Praxis für Physiotherapie Torsten Husemann

30/09/2025

Hot off the press 🔥

The Broken Wing Sign🦅: A New Clinical Test to Detect Gluteus Medius Pathology with and without Fatty Infiltration

🦵 Gluteus medius pathology, including tendon tears and fatty degeneration, is a major cause of lateral hip pain, limp, and functional impairment (Kenanidis et al., 2020; Pianka et al., 2021). These lesions are common in patients with hip osteoarthritis and after total hip arthroplasty (THA) and can significantly impact surgical outcomes (Whiteside & Roy, 2019; Howell et al., 2001; Bunker et al., 1997). While magnetic resonance imaging (MRI) remains the gold standard for evaluating tendon integrity and fatty infiltration (Bogunovic et al., 2015; Engelken et al., 2014), it is not always readily available preoperatively. Clinical tests such as the Trendelenburg sign and resisted abduction are widely used, but they suffer from limited sensitivity and practical constraints (Bird et al., 2001; Ortiz-Declet et al., 2019). Therefore, novel physical examination maneuvers that correlate with MRI and intraoperative findings are needed for early and accurate detection of hip abductor insufficiency.

📘 Sierra et al. (2025, https://pubmed.ncbi.nlm.nih.gov/40938961/) introduced the “broken wing sign”, a new clinical test designed to detect gluteus medius tears and muscle atrophy. In a prospective study of 59 patients (75 hips; mean age 69.5 years), the maneuver was performed in a prone position with the knee flexed at 90°, requiring active hip extension (figure below). A positive sign was defined as ≥10° of compensatory external rotation, with ≥30° considered “highly positive.”

🩻 MRI and intraoperative findings served as reference standards.

✅ The test demonstrated strong diagnostic performance, with 81.8% sensitivity, 80.0% specificity, and a diagnostic odds ratio of 17.8 for detecting any tear.

✅ For massive tears, the negative predictive value reached 96.1%.

✅A ≥30° threshold yielded 100% specificity and positive predictive value for tendon tears.

✅The degree of external rotation correlated with fatty infiltration severity, showing 88% sensitivity for Goutallier grade ≥3 and 100% sensitivity for grade 4.

💡 Compared to the Trendelenburg sign, which was often unfeasible due to pain or poor balance, the broken wing sign was easier to perform and maintained comparable diagnostic accuracy. The authors conclude that this maneuver provides a reliable, accessible, and clinically valuable tool to guide MRI utilization, preoperative planning, and management of abductor pathology.

📸 Fig. 1-A The patient is positioned prone on the examination table with the right knee flexed to 90°. While actively extending the right hip, the leg is lifted straight upward, maintaining the thigh in neutral rotation. No excessive internal or external rotation is observed, indicating a negative broken wing sign (normal finding).

📸 Fig. 1-B In the same position, weakness of the contralateral gluteus medius allows the hip to drift into external rotation, causing the foot to move inward toward the midline. This compensatory motion indicates a positive broken wing sign.



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📚 References

• Bird, P. A., Oakley, S. P., Shnier, R., & Kirkham, B. W. (2001). Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome. Arthritis & Rheumatism, 44(9), 2138–2145.

• Bogunovic, L., Lee, S. X., Haro, M. S., Frank, J. M., Mather, R. C. III, Bush-Joseph, C. A., & Nho, S. J. (2015). Application of the Goutallier/Fuchs rotator cuff classification to the evaluation of hip abductor tendon tears and clinical correlation with outcome after repair. Arthroscopy, 31(11), 2145–2151.

• Bunker, T. D., Esler, C. N., & Leach, W. J. (1997). Rotator-cuff tear of the hip. Journal of Bone and Joint Surgery (Br), 79(4), 618–620.

• Engelken, F., Wassilew, G. I., Köhlitz, T., Brockhaus, S., Hamm, B., Perka, C., & Diederichs, G. (2014). Assessment of fatty degeneration of the gluteal muscles in patients with THA using MRI. Journal of Arthroplasty, 29(1), 149–153.

• Howell, G. E., Biggs, R. E., & Bourne, R. B. (2001). Prevalence of abductor mechanism tears of the hips in patients with osteoarthritis. Journal of Arthroplasty, 16(1), 121–123.

• Kenanidis, E., Kyriakopoulos, G., Kaila, R., & Christofilopoulos, P. (2020). Lesions of the abductors in the hip. EFORT Open Reviews, 5(8), 464–476.

• Ortiz-Declet, V., Chen, A. W., Maldonado, D. R., Yuen, L. C., Mu, B., & Domb, B. G. (2019). Diagnostic accuracy of a new clinical test (resisted internal rotation) for detection of gluteus medius tears. Journal of Hip Preservation Surgery, 6(4), 398–405.

• Pianka, M. A., Serino, J., DeFroda, S. F., & Bodendorfer, B. M. (2021). Greater trochanteric pain syndrome: Evaluation and management of a wide spectrum of pathology. SAGE Open Medicine, 9, 20503121211022582.

• Sierra, R. J., Guarin Perez, S. F., Restrepo, D. J., Howe, B. M., & Tai, T.-W. (2025). The broken wing sign: A new clinical test to detect gluteus medius pathology with and without fatty infiltration. Journal of Bone and Joint Surgery (Am), 00, 1–6. https://doi.org/10.2106/JBJS.25.00427

• Whiteside, L. A., & Roy, M. E. (2019). Incidence and treatment of abductor deficiency during total hip arthroplasty using the posterior approach. Bone & Joint Journal, 101-B(6_Supple_B), 116–122.

29/09/2025

02/09/2025

🔥👉 Übertragene Schmerzmuster bei zervikalen Facettengelenksschmerzen

a. Diagramm der Schmerzverteilung der zervikalen Facettengelenke (1).

b. Hauptmuster der übertragenen Schmerzen (Referral Patterns) für die Facettengelenke von C0/1 bis C7/T1 sowie für die dorsalen Rami von C3 bis C7 (2).

c. Zusammengesetzte Darstellung der Übertragenen Muster aller Probanden, basierend auf der minimalen Reizschwellenstimulation des rechten dritten Okzipitalnervs und der medialen Äste von C3 bis C8 (3).

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01/09/2025

😍 Great illustration of the neurological examination of the upper extremity according to Miller & Thompson

📘 Reference: Thompson, Stephen R., and Mark D. Miller, eds.
Miller's Review of Orthopaedics E-Book. Elsevier Health Sciences, 2025, https://www.eu.elsevierhealth.com/millers-review-of-orthopaedics-9780443112140.html

10/08/2025

👀🫵Kennst Du den Unterschied zwischen indirekter und direkter Frakturheilung?

Die Heilung von Frakturen kann durch zwei verschiedene Prozesse erfolgen: indirekte (sekundäre) Heilung und direkte (primäre) Heilung. Jeder dieser Prozesse unterscheidet sich erheblich im Bezug auf die biologischen Mechanismen, die mechanischen Bedingungen und die strukturellen Ergebnisse.

👉Indirekte (sekundäre) Frakturheilung

Indirekte Frakturheilung tritt in Situationen auf, in denen ein gewisses Maß an Bewegung oder Instabilität zwischen den gebrochenen Knochenfragmenten besteht.

👉Direkte (primäre) Frakturheilung

Die direkte Frakturheilung tritt ein, wenn die gebrochenen Knochenfragmente in unmittelbarem Kontakt zueinander stehen und durch eine starre Fixation mechanisch stabilisiert sind.

👉Jetzt die genauen Vorgänge auf physiomeets.science lesen! 🥳💪

02/08/2025

Aetiology of Piriformis Syndrome

🔍 Anatomic Anomalies

Anatomic anomalies such as bipartite piriformis muscle or the sciatic nerve course/branching variations with respect to the piriformis muscle as seen in >80% of the population, the sciatic nerve courses deep to and exits inferiorly to the piriformis muscle belly/tendon.

It is also known to occur in early (proximal) divisions of the sciatic nerve into its tibial and common peroneal components can predispose patients to piriformis syndrome, with these branches passing through and below the piriformis muscle or above and below the muscle.

💥 Buttock Pain

Piriformis syndrome causes radiating pain originating in the buttock which may radiate down the leg.

The sciatic nerve becomes impinged by the Piriformis muscle, deep in the buttocks resulting in (1) Buttock pain which may (2) may radiate down the back of the thigh and may extend into the calf muscles.

📉 Prevalence & Causes

Piriformis syndrome is not very common as it causes only about 0.3% to 6% of lower back pain.

It may be a painful musculoskeletal condition which may be caused by stretched Piriformis muscle, leading to inflammation of soft tissue, muscle spasms, or both, resulting in nerve compression.

🎯 Trigger Points

Myofascial trigger points may be single like medial piriformis trigger point lies along the piriformis line about an inch outside the edge of the sacrum which is a large, triangular bone at the base of the spine

Or double which refer pain and tenderness to the sacroiliac joint, gluteal, and hip regions.

🧬 Predisposing Anatomic Variants (6 Types)

Type A: typical pattern with the Sciatic Nerve (SN) passing below the Piriformis Muscle (PM) , undivided

Type B: the Common Peroneal Nerve (CPN) exits through the PM and Tibial Nerve (TN) exits below the PM

Type C: the CPN exits above the PM and TN and below the PM

Type D: the SN exits through the PM, as a single trunk

Type E: the CPN exits above the PM and TN through the PM

Type F: the SN passes undivided above the PM as seen in the (Figure)

🧠 Other Causes of Sciatic-like Pain

🔹 Secondary to laminectomy leading to Acute Sciatic Neuritis

🔹 Bursitis of the Piriformis muscle: It can also occur in the buttocks when it is called ischial bursitis wic can be symptomatic and seen as pain when sitting or lying down or pain at the back of the thigh or swelling with redness in the affected area

🔹 Degenerative disc disease: This happens with due to age and may cause pain in the buttocks and thighs at times with numbness and tingling in the legs which increases on sitting, lifting or bending

🔹 Pilonidal cyst which may be found in the cleft between a person’s buttocks and differs in containing tiny bits of hair and skin

🔹 Perianal abscess which may be infected and filled with pus

🔹 Sacroiliac joint dysfunction resulting in pain in the lower back, buttocks, and upper legs

🔹 Arthritis of the hips giving rise to raditing pain in te lower back, hips and thighs

🔹 Vascular disease may experience pain radiating in the buttocks due to blockage of blood vessels

👇👇👇👇👇

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29/07/2025

🏃‍♂️ Multi-Tissue Coordination of Acute Exercise Metabolism

⏱️ Immediate Onset of Exercise (0–30 s at >100% max)

💪 Muscle-centric energy provision

Rapid utilization of skeletal muscle glycogen stores

Production of allosteric regulators: ADP, AMP, Pi, and Ca²⁺

Increased production of lactate

⚡ ATP production dynamics

0–6 s: Predominantly supplied by PCr hydrolysis and glycolysis

15–30 s: Contribution of oxidative phosphorylation begins to increase

~

🕒 Prolonged Exercise (0–240 min at

20/06/2025

📌 Common Movement Strategy Anterior and Posterior pelvic tilt

The movement strategy, e.g., coupled lumbar flexion and anterior pelvic rotation, illustrates the most commonly used strategy for bending, lifting, and reaching activities.

The strategy of combining movements of the spine and pelvis appears to maximize the range of motion.

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🔄 Alternative Strategy

It is possible to implement a different strategy that utilizes primarily pelvic control, i.e., anterior or posterior tilt.

This creates apparent paradoxical lumbar movements compared to the movement pattern just described above.

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📉 Less Common but Illustrative

The sequence of movements described are not typically observed in normal daily activities.

They are presented as an example of an alternative illustration of the coupling dynamics of the hip joint, pelvis, and lumbar spine.

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🦴 Anterior Pelvic Rotation Mechanism

Activation of the erector spinae and hip flexors (primarily iliopsoas) creates a force couple.

This anteriorly rotates the pelvis and accentuates lumbar lordosis (i.e., increases lumbar extension).

The approximate axis of rotation is through both hip joints.

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⚠️ Consequences of Increased Lordosis

Accentuation of lumbar lordosis:

Decreases the diameter of the intervertebral foramen.

Places lumbar segments in a more extreme extension position.

Increases the closed-packed position of the facet joints.

Elevates joint surface compression loads.

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📚 Disc and Annulus Effects

Increased compression of the posterior IVD causes the posterior annulus to buckle.

This forces the nucleus pulposus anteriorly, inducing annular bulging.

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🔁 Posterior Pelvic Tilt Mechanism

Posterior tilting of the pelvis is induced by:

Coupling of the abdominal muscles (primarily re**us abdominis and external obliques).

Hip extensors (gluteus maximus and hamstrings).

This reverses the effect on the lumbar spinal segments.

🔘Read the full article and source :in the com-ments. 👇

31/05/2025

Hot off the Press 🔥

The resisted levator scapulae test: a clinical test for C4 radiculopathy

✅ Background and Rationale

Painful cervical radiculopathy, first described by James Parkinson in 1817, typically presents with arm pain, paresthesia and weakness corresponding to specific dermatomes and myotomes of with clear dermatomal and myotomal symptoms described for C2-3 (Occipitalgia), and C5-8 roots (Brachalgia) [1,6].

C4 radiculopathy, however, is less recognized due to its non-brachial presentation, with symptoms including pain or paresthesia in the posterior neck, trapezial, clavicular, medial shoulder, interscapular, and suboccipital regions [3,7].

These symptoms often mimic musculoskeletal shoulder pathology or facet joint-mediated pain, leading to frequent misdiagnosis [2,8]. Existing tests, such as Spurling’s test, shoulder abduction test, Valsalva maneuver, and traction test, lack sensitivity or specificity for isolated C4 radiculopathy, and electromyography often fails to detect C4-specific abnormalities [4,9].

The resisted levator scapulae (RLS) test was designed to isolate the levator scapulae muscle, innervated by the C4 nerve root, to provide a non-invasive screening tool for this condition [5].

Study Design and Methods 🔬

Peters et al. [5, https://pubmed.ncbi.nlm.nih.gov/40423794/] conducted a diagnostic accuracy study in a private spine clinic following STARD guidelines [10].

👫 Participants with clinical suspicion of C4 radiculopathy, based on symptoms like posterior neck pain, trapezial pain, or suboccipital headaches exacerbated by extension or ipsilateral rotation, were recruited.

👉 The test group (n=25) consisted of patients with radiographic evidence of C3/4 foraminal stenosis on MRI or CT, who underwent a CT-guided C4 nerve root block as the reference standard.

👉 The pragmatic control group (n=298) included patients without C3/4 stenosis, who were not eligible for the nerve block and were classified as reference standard negative based on imaging alone.

📸 The RLS test (picture) involved positioning the patient supine to minimize postural muscle recruitment, with the examiner instructing the patient to elevate the ipsilateral shoulder and laterally flex the cervical spine toward the same side. The examiner applied gentle isometric resistance to the mandible while the patient maintained contact between the elevated shoulder and head. A positive test was defined by notable asymmetry in strength, indicated by the patient’s inability to maintain the test position.

Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and odds ratio (OR) were calculated using 2x2 contingency tables.

Results 📊

👫 The test group included 25 participants (12 male, 13 female; median age 69), and the pragmatic control group included 298 participants (192 male, 106 female; median age 56).

👫 In the test group, 10 participants (37.5%) had isolated C4 radiculopathy confirmed by CT-guided nerve block, while 15 (62.5%) had multilevel involvement including C4. The pragmatic control group had no radiographic evidence of C3/4 stenosis. The RLS test yielded 21 positive and 4 negative results in the test group, with 9 positive results in the control group.

✅ Primary Analysis (Test Group Only):
▶️ Sensitivity: 90% (9/10 participants with isolated C4 radiculopathy tested positive).

▶️ Specificity: 20% (3/15 participants without isolated C4 radiculopathy tested negative).

▶️ PPV: 43% (9/21 positive RLS tests were true positives).

▶️ NPV: 75% (3/4 negative RLS tests were true negatives).

▶️ Odds Ratio: 2.25 (95% CI: 0.2–25.4).

✅ Expanded Analysis (Test and Control Groups Combined):

▶️ Sensitivity: Remained 90%.

▶️ Specificity: Increased to 93% (292/313 participants without isolated C4 radiculopathy tested negative).

▶️ PPV: Decreased to 30% due to additional false positives.

▶️ NPV: Increased to 99.6%.

✅ All 21 patients with a positive RLS test in the test group had either isolated C4 stenosis or multilevel involvement including C4, underscoring the test’s ability to detect C4-related pathology.

✅ False positives in the expanded analysis were associated with ipsilateral C3/4 facet joint arthropathy (2 cases), upper cervical facet arthropathy (3 cases), C2/3 foraminal stenosis (2 cases), and contralateral cervical dystonia (1 case). No adverse outcomes were reported.

💡 Discussion

➡️ The RLS test demonstrated high sensitivity (90%) in both analyses, indicating its effectiveness as a screening tool to identify C4 radiculopathy. The low specificity (20%) in the primary analysis reflects the test’s tendency to detect multilevel radiculopathy involving C4, which is more common than isolated C4 radiculopathy (estimated prevalence 7.7%) [5].

➡️ The expanded analysis improved specificity to 93%, enhancing the test’s reliability when combined with clinical history and imaging. Compared to existing tests like Spurling’s (30% sensitivity, 93% specificity) and the arm squeeze test (96% sensitivity for C5-T1 but untested for C4), the RLS test offers superior sensitivity for C4 radiculopathy [9,11]. Its design minimizes contributions from the trapezius and sternocleidomastoid muscles, distinguishing it from spinal accessory nerve testing [12].

🚫 Limitations include the small test group size, leading to low statistical power (11.2%), and potential misclassification bias in the pragmatic control group, as these patients did not undergo the reference standard nerve block. False negatives in the nerve block procedure due to anaesthetic spread to adjacent structures may also have affected results. The study’s single-center design and single examiner limit generalizability and inter-rater reliability.

Conclusion and Recommendations ✅

The RLS test is a promising bedside tool for detecting C4 radiculopathy, with high sensitivity and improved specificity in broader populations. It complements neurological examinations and should be integrated into standard clinical assessments for cervical radiculopathy to reduce misdiagnosis.

Future research should involve larger, multicenter studies with prospective designs, multiple examiners, and broader inclusion criteria to enhance power and generalizability. Comparative studies with other cervical radiculopathy tests and the use of ROC analysis could further validate its utility.

📒 References

1. Ellenberg MR, Horst JC, Treamor WJ. Cervical radiculopathy. Arch Phys Med Rehabil. 1994;75(3):342-352.

2. Caridi JM, Pumberger M, Hughes AP. Cervical radiculopathy: a review. HSS J. 2011;7(3):265-272.

3. Ross DA, Ross MN. Diagnosis and treatment of C4 radiculopathy. Spine. 2016;41(23):1790-1794.

4. Chang MC, Boudier-Revéret M. C4 radiculopathy misdiagnosed as myofascial pain syndrome in the upper trapezius. Ann Palliat Med. 2020;9(3):1275-1277.

5. Peters WR, Smith JTE, Zotti MG. The resisted levator scapulae test: a clinical test for C4 radiculopathy. Eur Spine J. 2025. https://doi.org/10.1007/s00586-025-08903-z.

6. Parkinson J. An essay on the shaking palsy. J Neuropsychiatry Clin Neurosci. 2002;14(2):223-236.

7. Bogduk N, Aprill C. On the nature of neck pain, discography and cervical zygapophyseal joint blocks. Pain. 1993;54(2):213-217.

8. Waxenbaum JA, Reddy V, Bordoni B. Anatomy, Head and Neck: Cervical Nerves. StatPearls Publishing, Treasure Island (FL); 2023.

9. Tong HC, Haig AJ, Yamakawa K. The Spurling test and cervical radiculopathy. Spine. 2002;27(2):156-159.

10. Bossuyt PM, Reitsma JB, Bruns DE, et al. STARD 2015: an updated list of essential items for reporting diagnostic accuracy studies. Radiology. 2015;277(3):826-832.

11. Gumina S, Carbone S, Albino P, Gurzi M, Postacchini F. Arm squeeze test: a new clinical test to distinguish neck from shoulder pain. Eur Spine J. 2013;22(7):1558-1563.

12. Chan PK, Hems TE. Clinical signs of accessory nerve palsy. J Trauma Acute Care Surg. 2006;60(5):1142-1144.

26/05/2025

Continuum Model of Tendon Pathology 💡

👉 Cook et al. proposed the continuum pathology model in 2008, which has been widely recognized [https://pubmed.ncbi.nlm.nih.gov/18812414/, https://pubmed.ncbi.nlm.nih.gov/27127294/]. This model suggested that management may be optimized by tailoring interventions to the stage of pathology.

👉 They suggested that overload is the core factor driving tendinopathy and divided tendinopathy into three stages: reactive tendinopathy, tendon dysrepair and degenerative tendinopathy (s. graphic, https://pubmed.ncbi.nlm.nih.gov/37637777/).

1⃣ In the reactive tendinopathy, overload induced non-tendinogenic differentiation and proliferation of tendon cells [https://pubmed.ncbi.nlm.nih.gov/15336929/].

🫧The production of large proteoglycans (e.g., aggrecan, versican and hyaluronan), which have a strong ability to bind water, increases.

🗜️ At this stage, Col (collagen) arrangement and vascularization do not change significantly. Patients may complain of pain and tendon swelling associated with acute overload, which can be completely relieved with adequate rest. The rounded and enlarged tendon cells, increased extracellular matrix (ECM), and confined space lead to increased intratendinous resting pressure [https://pubmed.ncbi.nlm.nih.gov/19371780/]. The accumulation of hydrophilic glycoproteins and proteoglycans reduces matrix permeability, which increases the intra-tendinous dynamic pressure [https://pubmed.ncbi.nlm.nih.gov/36323498/].

2⃣ Persistent overload leads to further increase of proteoglycan production as well as Col structure destruction and Col arrangement disorder.

🔥The inflammatory response caused by overload induces angiogenesis [https://pubmed.ncbi.nlm.nih.gov/28119539/]. This stage is called tendon dysrepair. Soreness and stiffness may occur in the morning or after being still for a longer period of time. Imaging may reveal focal structural abnormalities (e.g., thickening) with or without increased vascularization. If the load is optimized, this stage is still considered reversible. If not optimized, overload may impair vascularization and cause hypoxia, which led to leaking vessel and negative feedback increased intratendinous pressure [https://pubmed.ncbi.nlm.nih.gov/36323498/].

3⃣ Finally, the transformation of tendon tissue into scar-like tissue, accompanied by tendon cells exhaustion and significant matrix abnormalities, marks the stage of degenerative tendinopathy.

🔽The tendon may have one or more focal nodules, with or without diffuse thickening. If the tendon is under high load or the lesion is extensive enough, it may rupture.

13/05/2025

Entrapment-Neuropathien des Nervus peroneus profundus (DPN) und anteriores Tarsaltunnelsyndrom 🔥🤯

Der DPN ist für die Motorik von entscheidender Bedeutung und innerviert Muskeln wie den Tibialis anterior und den Extensor digitorum longus im vorderen Unterschenkel. Er versorgt auch den Raum zwischen dem ersten und zweiten Zeh mit sensorischen Informationen und verläuft durch den vorderen Tarsaltunnel oberhalb des Talus. Er teilt sich in zwei Äste, einem für den Musculus extensor digitorum brevis und einem, der die Metatarsophalangealgelenke und das Sprunggelenk mit sensorischen Informationen versorgt, was für die Stabilität des Fußes unerlässlich ist, bevor er zwischen dem ersten und zweiten Zeh endet. (siehe Abbildung, 1,2).

Eine Verengung des Tarsaltunnels und eine Kompression des Nervs können durch verschiedene interne Faktoren verursacht werden, darunter Osteophyten, Synovialzysten, Ganglien, anomale Muskeln, Frakturen und Entzündungen. Externe Faktoren wie hohe Absätze, wiederholte Belastungen oder schlecht sitzendes Schuhwerk können den Zustand verschlimmern. Darüber hinaus können Neurome oder Aneurysmen den Tunnelraum einschränken, was häufig durch ein Fußtrauma oder eine Hypertrophie des Musculus extensor hallucis brevis ausgelöst wird.

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