Mid-foot pain is a common presentation in long-distance runners. One less common cause of mid-foot pain is Knot of Henry pain, an inflammation of foot tendons crossing at the mid-foot. What is Knot of Henry pain, and how do you make a diagnosis?
Knot of Henry Space
This space is located under the surface of the mid-foot. The two tendons of the foot—flexor hallucis longus and flexor digitorium longus—cross over in this space. This crossover space is prone to repetitive friction from running, leading to tendon inflammation.
Knot of Henry pain
Runners with Knot of Henry pain generally report localised pain at the undersurface of the mid-foot, distal to the heel and inside the ankle. Running usually aggravates the pain, which improves with rest.
How to make a diagnosis
In general, pain is localised at the undersurface of the mid-foot. Careful assessment by your doctor reveals localised tenderness at the tendon crossover. Also, resisted first-toe flexion will often reproduce pain.
Your doctor must exclude other causes of mid-foot pain, including:
- Navicular stress fracture
- Accessory navicular
- Tibilais posterior tendonitis
- Subtalar joint arthritis
- Tarsal coalition
- Jogger’s Foot
Generally, we use an MRI scan to confirm the diagnosis and exclude other causes of mid-foot pain. Findings on the MRI scan include swelling of the FHL tendon sheath combined with tendonitis or a partial tear.
Knot of Henry treatment
First, we start with simple treatments. Anti-inflammatory measures such as ice and oral NSAIDs will reduce inflammation and pain at the tendon crossover. A podiatry review is essential to assess whether orthotic inserts will help reduce friction at the tendon crossover. Physiotherapy to strengthen the calf and foot intrinsics and to improve heel and mid-foot control can also help.
Next, we consider a guided cortisone injection at the crossover. Generally, we recommend ultrasound guidance to improve accuracy and reduce injection-related side effects.
Finally, in intractable cases, we consider the surgical release of the tendons at the Knot of Henry. Generally, we suggest endoscopic rather than open surgical release to reduce downtime and complication rates.
Final word from Sportdoctorlondon regarding Knot of Henry pain
We should consider Knot of Henry pain in runners with localised pain tenderness in the undersurface of the mid-foot. However, excluding other causes of mid-foot pain, including stress fractures and mid-foot arthritis, is essential.
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