Management of Flexor Digitorum Longus Tendinosis
The most effective treatment for flexor digitorum longus tendinosis consists of relative rest, cryotherapy, eccentric strengthening exercises, and short-term analgesics for 3-6 months before considering more invasive interventions. 1
Initial Conservative Management
- Relative rest is essential to decrease repetitive loading of the damaged tendon while maintaining some activity to prevent muscle atrophy 1
- Cryotherapy (ice application for 10-minute periods through a wet towel) provides acute pain relief 1, 2
- Eccentric strengthening exercises focusing on the flexor digitorum longus muscle are effective and can reverse degenerative changes in the tendon 1, 2
- Oral or topical NSAIDs can be used for short-term pain relief, though they don't affect long-term outcomes 1, 2
- Topical NSAIDs may be preferable due to fewer systemic side effects 2
Diagnostic Considerations
- Normal inflammatory markers are consistent with tendinosis rather than an inflammatory condition, confirming this is likely not a rheumatological issue 1
- MRI confirmation of flexor digitorum longus tendinosis is appropriate and helps rule out other causes of ankle pain 1
- Physical examination typically reveals well-localized tenderness that reproduces the pain experienced during activity 1
- The presence of multiple symptomatic tendons should prompt consideration of rheumatic disease, but with normal inflammatory markers and isolated FDL involvement, this is less likely 1
Secondary Treatment Options
- If symptoms persist after 4-6 weeks of initial conservative management, consider:
- Local corticosteroid injections may provide better acute pain relief than oral NSAIDs but do not improve long-term outcomes 2
- Ultrasonography therapy may decrease pain and increase collagen synthesis, though evidence is limited 2
- Extracorporeal shock wave therapy (ESWT) is a safe and effective option but can be costly 2
Surgical Management
- Surgical evaluation is justified only if pain persists despite 3-6 months of well-managed conservative treatment 1, 2
- Surgical techniques generally involve excision of abnormal tendinous tissue and longitudinal tenotomies to release areas of scarring and fibrosis 2
Prognosis and Follow-up
- Most patients with overuse tendinopathies (approximately 80%) recover completely within 3-6 months with appropriate conservative treatment 1
- Regular follow-up is recommended to monitor progress and adjust treatment as needed 1
Important Pitfalls to Avoid
- Direct injection into the tendon substance should be avoided as it can inhibit healing and reduce tensile strength 2
- Complete immobilization for prolonged periods should be avoided as it can lead to muscle atrophy and deconditioning 1, 2
- Misdiagnosis as an inflammatory condition ("tendonitis") rather than degenerative tendinosis can lead to inappropriate treatment focus 1