Physical Therapy in Sport 10 (2009) 101–104

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Physical Therapy in Sport

journal homepage: www.elsevier.com/ptsp

Original research

Extensor hallucis longus tendon injury in taekwondo athletes

Kyung Tai Lee a, Yun Sun Choi b, Young Koo Lee c, *, Jeong Pil Lee d, Ki Won Young a, Shin Yi Park a
a
Foot and Ankle service, Department of Orthopedic Surgery, Eulji Hospital, Eulji University, School of Medicine, Seoul, Republic of Korea
b
Department of Radiology, Eulji Hospital, Eulji University School of Medicine, Seoul, Republic of Korea
c
Department of Orthopedic Surgery, Soonchunhyang University, Bucheon Hospital, 4 Jung-Dong, Wonmi-Gu, Bucheon-Si, Gyeonggi-Do, 420-767, Republic of Korea
d
Laboratory of Sports Medicine, Korea National Sport University, Seoul, Republic of Korea

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: Extensor hallucis longus (EHL) tendon injuries can occur in taekwondo athletes when per-
Received 30 January 2009
forming hyperplantarflexed barefoot kicking exercises. A state of full excursion of the extensor tendon is
Received in revised form
used to strike opponents in which the metatarsal bone and the proximal phalanx area is in contact with
12 May 2009
Accepted 19 May 2009 the opponent. The purpose of this study is to examine the incidence of extensor hallucis longus tendon
injury in taekwondo athletes.
Keywords: Design: Case–control study.
Taekwondo Participants: 50 Athletes from the Korean taekwondo national team and a control group of 50 healthy
Extensor hallucis longus tendon subjects.
Ultrasound
Main outcome measures: History of sports participation, the American Orthopaedic Foot and Ankle
Incidence
Society (AOFAS) score and ultrasound imaging of the EHL.
Results: Difference in the AOFAS scores were noted with the control group at 92.95  9.18, and the
experimental group score at 88.45  10.93 (p < 0.01). Only one person (one tendon) from the control
group demonstrated changes on sonography (2%), whilst 10 subjects from the taekwondo group dis-
played changes in 16 tendons (20%). EHL thickness of the experimental group (1.52  0.16 mm) was
greater and the control group (1.46  0.11 mm) (p < 0.01).
Conclusion: Taekwondo athletes have a higher incidence of changes on sonographic imaging of the EHL
compared to non-taekwando participating healthy subjects.
Ó 2009 Elsevier Ltd. All rights reserved.

1. Introduction with ‘‘Poomsae’’ being an emphasis towards mental concentration

Injury to the Extensor Hallucis Longus (EHL) tendon is
uncommon with most cases caused by either direct penetrating
trauma or indirect repetitive overuse (Kass, Palumbo, Mehl, &
Camarinos, 1997; Poggi & Hall, 1995; Skoff, 1988). It has been sug-
gested that repetitive movements in athletes, without enough rest
time, may lead to minor trauma with the subsequent possibility of
a tear (Cha, Kim, Chumg, Yoo, Park, & Kim, 2007).
Taekwondo is the national martial art of Korea and also an
official Olympic category. It involves a combination of motions,
* Corresponding author. Tel.: þ82 32 621 5272; fax: þ82 32 621 5018.
E-mail addresses: lkt2408@hanmail.net (K.T. Lee), cys0128@eulji.ac.kr
(Y.S. Choi), brain0808@hanmail.net (Y.K. Lee), leejpkata@yahoo.co.kr (J.P. Lee),
youngkw1@hanmail.net (K.W. Young), parksini@naver.com (S.Y. Park).
and defensive movements using the whole body. ‘‘Gyorugi’’ is more
attacking orientated using the fist and the feet to hit and stomp. The
stepping motions normally involve barefoot for maneuvering. As
a result, taekwondo athletes tend to have injuries involving the
lower extremity and foot (Stricevic, Patel, Okazaki, & Swain, 1983;
Zemper & Pieter, 1989). As with many other martial arts where little
or no protective gear is permitted, large contact forces are gener-
ated in the lower leg and foot (Schwartz, Hudson, Fernie, Hayashi, &
Coleclough, 1986).
Several case reports have documented EHL and interphalangeal
injuries in Taekwondo athletes (Cha et al., 2007; Gong, Kim, & Park,
2007; Lee et al., 2006; Shin, Choi, & Rhee, 2008). Lee et al. (2006)
reported EHL rupture in 2 cases. One case involved the rupture at
the 1st metatarsal midshaft portion, while the other involved
rupture at the insertional site with reactions from the proximal
portion to the level of the ankle joint. Cha et al. (2007) reported 2
cases of extensor hallucis longus dysfunction involving taekwondo

1466-853X/$ – see front matter Ó 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ptsp.2009.05.002
102 K.T. Lee et al. / Physical Therapy in Sport 10 (2009) 101–104
Fig. 1. Transverse sonogram at the junction of 1st metatarsal head and neck shows
a hyperechoic extensor hallucis tendon (T) at the medial side of the dorsal digital
vessels (v). The tendon thickness was measured from the ventral outer margin of the
tendon to the dorsal outer margin (denoted by arrows).
athletes. Shin et al. (2008) reported 7 cases of an open lateral
collateral ligament injury of the 1st interphalangeal joint during
Taekwondo in adolescents. Gong et al. (2007) also reported a case of
varus instability of the hallux interphalangeal joint in a taekwondo
athlete.
The aim of this study was to evaluate any changes in the EHL
tendon using ultrasound imaging in taekwando athletes compared
to a control group.
2. Materials and methods
2.1. Materials and methods
The study was performed prospectively between May 2008 and
October 2008 with institutional review board approval and
included 50 taekwondo athletes from the Korean national team
(experimental group) and 50 non-athletes (control group). Inclu-
sion criteria for the experimental group were being a member of
the national team and winning at least one medal in an interna-
tional stage competition. Subjects were recruited from the
University for the control group and were included if they had no
history of pain/injury in either lower limb.
Questionnaires were given to all 100 participants. The purpose
of the research was described in the questionnaire. Information on
age, gender, history of foot injury/pain and dominant foot prefer-
ence was collected. Additional questions included the degree of
contact with a sandbag (in taekwondo, kicking the sandbag with
the dorsum of the foot is a training exercise), years of martial arts
experience and current skill level. Taekwondo skill is graded based
on 10 different degrees. Athletes improve based on their skill and
mental ability. As a result, high degree taekwondo athletes gener-
ally have more skill and better mental ability. All subjects
Fig. 2. Long axis sonogram (A) of extensor hallucis longus tendon (T) on 1st proximal phalanx (PP) and short axis sonogram (B) on the base of 1st distal phalanx (DP) show
a thickened, hypoechoic tendon (arrows) on the insertion portion.
completed the American Orthopaedic Foot and Ankle Society
(AOFAS) hallux metatarsophalangeal interphalangeal scale and
scores were given to both feet.
Ultrasound evaluation of the EHL tendon was performed with
a linear 5–17 MHz transducer (iU 22; Philips Medical Systems,
Bothell, WA) by an experienced musculoskeletal radiologist who
was blinded to the subject groups. The continuity, echogenicity and
thickness of the tendon from the musculotendinous junction at the
ankle joint and the insertion portion of the distal phalanx base were
evaluated. The surrounding soft tissue of the joint capsule and
ligaments were also evaluated. The tendon thickness was evaluated
twice for both the experimental and control groups, with the
average data saved for analysis (Fig. 1). The thickest part of tendon
taken from the metatarsal head and neck junction was evaluated
and then compared to the average data.
2.2. Statistic analysis
All statistical analyses were conducted with SAS version 9.1
software (SAS institute Inc., Cary, North Carolina). Differences in
means and proportions were tested by using the student’s t-test,
chi-square test or the Fisher’s exact test, as appropriate. For all
tests, a p value of 0.05 or less was considered statistically
significant.
3. Results
The experimental group consisted of 38 men and 12 women,
while the control group included 39 men and 11 women. The
average age for the experimental group and control groups were
22.4 years and 23.4 years, respectively.
The experimental group consisted of 7 subjects with a third
degree, 41 subjects with the fourth degree, and 2 subjects with the
fifth degree skill level, respectively. The number of years of taek-
wondo experience included 1 subject with 0–3 years, 5 subjects
with 4–6 years, 7 subjects with 7–9 years, 17 subjects with 10–12
years, and 20 subjects with greater than 13 years experience. Also, 7
subjects reported 0–10 h of weekly practice, 11 subjects 11–20 h, 18
subjects 21–30 h, 11 subjects 31–40 h, 2 subjects 41–50 h, and 1
subject underwent more than 50 h of weekly practice. Ten subjects
(20%) demonstrated changes on ultrasound imaging compared to
just one (2%) in the control group (p ¼ 0.004). There were no
apparent differences between the dominant and non-dominant
feet between the two groups (p ¼ 0.57), but when the EHL thick-
nesses of the experimental group (1.52  0.16 mm) and the control
groups (1.46  0.11 mm) were compared, statistical differences
were noted (p ¼ 0.0015). According to the AOFAS score, there were
no differences between the dominant foot (90.56  10.16) and the
non-dominant foot (90.96  10.68) in the experimental group and
control group (p ¼ 0.79), but there were differences between the
 K.T. Lee et al. / Physical Therapy in Sport 10 (2009) 101–104 103

Fig. 3. Longitudinal extended field-of-view of extensor hallucis longus tendon (T) on
1st metatarsal bone (MT) shows a diffusely thickened, hypoechoic tendon (arrows).
experimental group (88.45  10.93), and the control group
(92.95  9.18) (p ¼ 0.0019).
In the experimental group, a total of 16 abnormalities were
identified in the 10 subjects. By contrast, just one abnormality was
identified in the single subject in the control group. In the experi-
mental group, tendon thickening and hypoechogenecity at the
insertion portion was identified in 10 feet (Fig. 2), tendon thick-
ening and hypoechogenecity at the metatarsal level was identified
in 4 feet (Fig. 3), and 2 feet had thickening and hypoechogenecity at
the proximal phalanx level. In addition, 3 feet showed signs of MTP
joint synovitis, 1 foot had medial capsular thickening at the MTP
joint, 2 feet had bony spurs, and 1 foot had a ganglion cyst (Table 1).
By contrast, only 1 foot in the control group was found to have
tendon thickening at the metatarsal level.
4. Discussion
Injury incidence in Taekwando athletes has been previously
reported in the 1997 Canadian national athletes (Kazemi & Pieter,
2004) and the 1988 American Olympic team (Zemper & Pieter,
1989). Injuries to the lower extremity and especially the feet were
the most frequent, with the head being the second most common
area. Foot pain and dysfunction was clearly demonstrated in the
current cohort of athletes with lower AOFAS scores 88.45  10.93
compared with the control group 92.95  9.18.
There are other martial arts such as Muay Thai kick boxing and
karate which also use the body to clash with their opponent. The
most frequent injury amongst these martial arts is soft tissue injury
followed by sprains and strains (Gartland, Malik, & Lovell, 2001).
These soft tissue injuries and sprains and strains, like taekwando,
happen mostly in the lower extremity areas of the body (Stricevic
et al., 1983; Zemper & Pieter, 1989).
Anzel et al. evaluated 1014 cases of tendon injury at the Mayo
Clinic and noted that 21 injuries involved the extensor to the toes
(EDL and EHL) mounting to a 2% incidence (Anzel, Covey, Weiner, &
Lipscomb, 1959). There is a paucity in the literature with regard to
EHL injury.
Spontaneous rupture of a tendon rarely occurs without the
presence of predisposing factors such as previous trauma, a chronic
disease process, or interruption of the blood supply to a portion of
the tendon, which may compromise the tendon’s intrinsic strength
(McMaster, 1933). Rupture due to rapid, powerful forced flexion of
the great toe against resistance (Menz & Nettle, 1989), due to
a dorsal osteophyte on the metatarsophalangeal joint (Poggi & Hall,
1995) and spontaneous rupture in a skier (Sim & Deweerd, 1977)
have all been reported in the literature.
The current study investigated the incidence of EHL injury
(evaluated by changes on ultrasound imaging and foot score
questionnaire) in a group of taekwando athletes. A 2% incidence
was reported in the control group, 10 taekwondo athletes out of
the 50 exhibited abnormalities indicating a 20% incidence in the
athlete group. Although the taekwondo athletes had no history
of trauma to the toe, the events surrounding the injury and the
ultrasound findings strongly suggest the presence of a pre-
existing degenerative process. In the current cohort, changes in
the EHL tendon occurred mostly at the insertional area, then at
the metatarsal level, followed by the proximal phalanx level
(Table 1). Associated findings signs included synovitis of the 1st
MTP joint, medial capsular thickening of the 1st MTP joint, bony
spurs, and a ganglion cyst. Six of the 10 athletes who demon-
strated changes, did so on both feet. This probably reflects the
nature of taekwando and the athletes requiring the ability to
strike with both feet.
In the current study, 1 subject of 3rd degree, 7 subjects of 4th
degree, and 2 subjects of 5th degree showed EHL tendinosis on
ultrasound. Based on the number of years in training, there was 1
subject of 4–6 years training, 4 subjects of 10–12 years training, and
5 subjects with more than 13 years training displayed tendinosis of
the EHL on ultrasound. However, there was no correlation between
an individual’s martial arts skill degree and presence of EHL

Table 1
Ultrasound findings in taekwondo athletes.

Subject number Site Abnormalities of extensor hallucis longus tendon Additional findings
1 Left Thickening and hypoechogenecity on the 1st metatarsal body
2 Right Thickening and hypoechogenecity on the 1st metatarsal body
3 Right Thickening and hypoechogenecity on the body of 1st proximal phalanx 1st MTP joint synovitis
Left Thickening and hypoechogenecity on the body of 1st proximal phalanx
4 Right Thickening and hypoechogenecity on the insertion portion
Left Thickening and hypoechogenecity on the insertion portion 0.6 cm sized ganglion cyst
5 Right Thickening and hypoechogenecity on the insertion portion Medical capsular thickening of 1st MTP joint
Left Thickening and hypoechogenecity on the insertion portion
6 Right Thickening and hypoechogenecity on the 1st metatarsal body
Left Thickening and hypoechogenecity on the 1st metatarsal body
7 Right Thickening and hypoechogenecity on the insertion portion Traction spur at the insertion portion
Left Thickening and hypoechogenecity on the insertion portion 1st MTP joint synovitis
8 Right Thickening and hypoechogenecity on the insertion portion
Left Thickening and hypoechogenecity on the insertion portion 1st MTP joint synovitis
9 Left Thickening and hypoechogenecity on the insertion portion
10 Left Thickening and hypoechogenecity on the insertion portion Traction spur at the insertion portion

MTP: metatarsophalangeal.
104 K.T. Lee et al. / Physical Therapy in Sport 10 (2009) 101–104
tendinosis (p ¼ 0.059), or between years of training and presence of
tendinosis (p ¼ 0.686).
5. Conclusion
The incidence of extensor hallucis longus injury for the general
population is 2%, while taekwondo athletes have an incidence level
of approximately 20% in this cohort. People who practice martial
arts such as taekwondo which requires an individual to be barefoot
should be advised that repeated striking with hyperplantar flexion
of the ankle and hyperplantar flexion of the toe can be the cause of
extensor hallucis longus injury. Further study with larger athlete
numbers is required to establish if there is any consequence of
these changes found in the EHL on athlete training and/or
performance.
Conflict of Interest Statement
In the name of the authors of the manuscript Extensor Hallucis
Longus Tendon Injury in Taekwondo Athletes I declare that during the
research process were not a set of conditions in which professional
judgment concerning a primary interest, such as the validity of
research, were influenced by a secondary interest.
Ethical Statement
In the name of the authors of the manuscript Extensor Hallucis
Longus Tendon Injury in Taekwondo Athletes I declare that the
research was performed in accordance with the Declaration of
Helsinki and ethical approval for procedures was obtained from the
University of eulji Ethical Committee.
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