Hindfoot arthroscopy

Surgical Procedure

1. After the standard 2-portal posterior approach for ankle arthroscopy the posterior compartment of the ankle is inspected. In this picture an overview of important structures in the treatment of FHL pathology is given.
2. The soft tissue overlying the flexor retinaculum can be removed by the shaver to obtain a clear view of the retinaculum.
3. Inspection of FHL for pathology. The full tendon and distal part of the muscle belly become visible on passive plantar- and dorsiflexion of the hallux.
4. The FHL is stenosing on plantarflexion of the hallux.
5. The flexor retinaculum is released by detaching it from the posterior talar process with an arthroscopic punch. Subsequently the tendon sheath can be opened distally up to the level of the sustentaculum tali.
6. The flexor retinaculum is cut. When present length ruptures are debrided. The proximal part of the tendon and the distal part of the muscle belly are inspected and debrided if inflamed, thickened or if nodules are present. Adhesions and excessive scar tissue are removed. This can be done with a shaver and electrocautery.
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Pearls & Pitfalls

Surgical technique for treatment of FHL pathology

For the standard 2-portal hindfoot approach, please click here.

In the next procedure, the joint capsule and fatty tissue overlying the posterolateral aspect of the subtalar joint have already been removed. The posterior compartment is of the subtalar joint has been visualized and the ankle joint is opened. 

Bleeding is controlled by electrocautery at the end of the procedure. To prevent sinus formation, the skin incisions are sutured with 3.0 Ethilon. The incisions and surrounding skin are injected with 10 ml of a 0.5 % bupivacaine/morfine solution. A sterile compressive dressing is applied. Prophylactic antibiotics are not routinely given. 


Post-operative rehabilitation protocol

The patient can be discharged the same day of surgery and weightbearing is allowed as tolerated. The patient is instructed to elevate the foot when not walking to prevent edema. The dressing is removed 3 days postoperatively after which the patient is permitted to shower. Performing active range of motion exercises for at least 3 times a day for 10 minutes each is encouraged. Patients with limited range of motion are directed to a physiotherapist.



Create the posterolateral portal just proximal and lateral to the imaginary intersection of the horizontal line, perpendicular to the foot sole, from the tip of the lateral malleolus to the Achilles tendon with the ankle in the neutral position.

Leave some distance between portal and Achilles tendon to avoid Achilles tendon problems later on. 

The posteromedial portal is located at the same level as the posterolateral portal, just medial to the Achilles tendon.

Make vertical incisions to avoid nerve damage. 

Create the portals with the foot in neutral (90 degree) position. 

Use the arthroscopic shaft, inserted through the posterolateral portal and directed towards the interdigital webspace in between the first and second toe, as a guide to travel anteriorly with the instruments inserted through the posteromedial portal.

Introduce instruments with the foot in the 'relaxed', on other words, slightly plantarflexed position. In this position there is no tension on the nerves and vessels, iatrogenic damage is therefore better prevented. 

Use an arthroscopic punch to detach the flexor retinaculum from the posterior talar process and to release the tendon sheath in case of tendinopathy of the FHL. When using the punch, keep contact with the bone (os trigonum/ postrior talar process). In other words: detach the retinaculum at its insertion on the os trigonum (this avoids neurovascular damage).

Sufficient release of the tendon sheath can be performed all the way down towards the sustentaculum tali in case of isolated tendinopathy of the FHL; stay close to the tendon, with the blunt part of the resector on the tendon.

When releasing the tendon sheath with a bonecutter shaver, stay onto the tendon with the opening of the shaver away from the tendon.


When releasing the tendon sheath with a bonecutter shaver, stay onto the tendon with the opening of the shaver away from the tendon.



The crural fascia can be quite thick, this local thickening is called the ligament of Rouviere (see surgical technique 'standard 2-portal hindfoot approach'). This ligament needs to be partially excised of sectioned, using arthroscopic punch or scissors, to reach the level of the subtalar joint and/or ankle joint.

Stay lateral from the FHL tendon in order to prevent damage to the neurovascular bundle.

Be cautious while removing a hypertrophic posterior talar process with a chisel.

Only remove the infero-posterior part and remove the remnant with the bonecutter shaver in order to prevent removing too much bone at the level of the subtalar joint.

Surgeons not familiar with endoscopic surgery are advised to train themselves in a cadaveric setting.