Flexor Hallucis Longus Tendinitis Injury

Overview

Flexor hallucis longus tendinitis injury is a musculoskeletal condition that affects one of the most important tendons in the foot, the flexor hallucis longus (FHL) tendon. This tendon originates from the lower two-thirds of the fibula, travels down the back of the leg, passes behind the medial malleolus (the bony prominence on the inner ankle), and finally inserts into the base of the distal phalanx of the big toe. The FHL tendon plays a crucial role in foot biomechanics, as it not only flexes the big toe but also stabilizes the medial arch of the foot during walking, running, and jumping. Additionally, it provides essential push-off strength, enabling propulsion during activities that require explosive movements such as sprinting, ballet pointe work, gymnastics, football, and other sports involving repetitive toe-off actions.

When this tendon undergoes excessive stress, repetitive microtrauma, or degenerative changes, it may become inflamed, irritated, or weakened, resulting in a flexor hallucis longus tendinitis injury. This condition is most commonly observed in athletes and individuals who engage in repetitive foot-intensive activities. Dancers, in particular, are prone to this injury, which is often referred to as “dancer’s tendinitis” due to the extreme load placed on the tendon during en pointe and jump maneuvers. Similarly, runners and sportspeople who repeatedly push off the big toe are at higher risk of developing this injury, which can cause pain, swelling, and functional limitations in the foot and ankle.

At DMPhysios, a premier clinic in Noida specializing in spine and sports conditions, the management of flexor hallucis longus tendinitis injury emphasizes patient-centered rehabilitation. Each treatment plan is carefully tailored to the individual’s needs, combining evidence-based physiotherapy techniques, manual therapy, strengthening exercises, and movement retraining. This holistic approach ensures not only the reduction of pain and inflammation but also the restoration of full function, mobility, and long-term tendon health, allowing patients to safely return to their sports and daily activities.

Symptoms

Patients with this injury commonly present with:

Pain along the inner back of the ankle extending to the big toe.
Swelling and tenderness along the course of the tendon.
Pain aggravated by walking, running, jumping, or pushing off the toes.
A “catching” or “snapping” sensation in severe cases.
Stiffness in the big toe, especially in the morning or after rest.
Weakness during push-off phase in walking or sports activity.
Discomfort during movements requiring ankle plantarflexion (e.g., tiptoe standing).

These symptoms often interfere with daily activities and athletic performance if not treated promptly.

Types of Flexor Hallucis Longus Tendinitis Injury

Though not formally divided into strict types, clinicians describe flexor hallucis longus tendinitis injury in categories based on severity and presentation:

Acute Tendinitis – Sudden inflammation due to an overuse episode or trauma, leading to sharp pain and swelling.
Chronic Tendinitis – Long-standing irritation and microtears resulting from repetitive loading, common in professional athletes.
Stenosing Tenosynovitis – Thickening of the tendon sheath leading to a “triggering” or locking sensation of the big toe.
Partial or Complete Tear – Severe cases where tendon fibers are disrupted, often requiring prolonged rehab or surgical consultation.

Causes

The main causes include:

Overuse and repetitive stress (e.g., running, dancing, gymnastics).
Sudden increase in training intensity or frequency.
Biomechanical issues such as flat feet or overpronation.
Improper footwear lacking arch and ankle support.
Trauma or ankle sprains that overstretch the tendon.
Muscle imbalances in the calf or intrinsic foot muscles.
Tight calf muscles (gastrocnemius and soleus) increasing load on the FHL tendon.

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Risk Factors

Certain groups are more prone to developing flexor hallucis longus tendinitis injury:

Ballet dancers (especially en pointe work).
Sprinters, runners, and jumpers.
Gymnasts and football players.
Individuals with poor ankle stability.
People with flat feet or overpronation.
Occupations requiring long hours of standing on toes.
Previous history of ankle injuries.

Awareness of these risk factors helps in early diagnosis and prevention.

Treatment

Management typically begins with conservative approaches:

Rest and activity modification to reduce tendon overload.
Ice therapy to reduce swelling and pain.
Nonsteroidal anti-inflammatory drugs (NSAIDs) as prescribed.
Footwear modification with cushioned insoles and arch support.
Immobilization in severe cases using a walking boot.
Surgical intervention in rare cases (chronic stenosis or tendon rupture).

However, the cornerstone of recovery lies in physiotherapy rehabilitation, which ensures safe return to activities and long-term tendon health.

Physiotherapy Treatment

At DMPhysios, physiotherapy for flexor hallucis longus tendinitis injury is individualized and patient-centered, focusing on reducing pain, restoring strength, and preventing recurrence. Below is a detailed approach:

1. Pain Management

Ice packs and cryotherapy.
Ultrasound or laser therapy for deep tissue healing.
Manual therapy to reduce soft tissue tightness around the tendon.

2. Range of Motion (ROM) Exercises

Gentle toe flexion and extension movements.
Ankle circles to mobilize the joint.
Big toe towel curls (gripping towel with toes).

3. Stretching Exercises

Calf stretches (gastrocnemius and soleus) to relieve tension.
Plantar fascia stretch using a towel or band.
Toe stretches to gently mobilize the FHL tendon.

4. Strengthening Exercises

Toe curls with a resistance band.
Marble pickups with toes to strengthen intrinsic foot muscles.
Heel raises (progressed to single-leg).
Eccentric strengthening of the calf and toe flexors to improve tendon resilience.

5. Proprioception and Balance Training

Single-leg balance on stable and unstable surfaces.
Bosu ball or wobble board training for ankle control.

6. Gait and Movement Correction

Analyzing walking and running patterns.
Correcting overpronation with orthotics.
Re-educating proper push-off mechanics.

7. Sports-Specific Rehabilitation

Plyometric drills once pain-free.
Return-to-sport progression (jumping, sprinting, dancing).

DMPhysios in Noida incorporates all these techniques in a structured rehabilitation protocol, ensuring patients with flexor hallucis longus tendinitis injury not only recover but also return to their sport stronger and safer.

Prevention

Preventing recurrence is just as important as treating the condition. Key preventive measures include:

Gradual progression of training intensity.
Regular stretching of calf and foot muscles.
Strengthening intrinsic foot and ankle stabilizers.
Wearing supportive footwear with cushioned insoles.
Cross-training to avoid repetitive overload.
Addressing biomechanical issues with orthotics or corrective exercises.
Early management of ankle sprains and foot injuries.

By following these preventive steps, athletes and active individuals can protect themselves against repetitive flexor hallucis longus tendinitis injury.

Conclusion

Flexor hallucis longus tendinitis injury is a debilitating condition that can affect both athletes and active individuals, limiting daily function and sports performance. With proper diagnosis, structured treatment, and comprehensive physiotherapy rehabilitation, recovery is highly successful.

At DMPhysios, a specialized clinic in Noida for spine and sports conditions, the focus is always on patient-centered rehabilitation. By combining manual therapy, targeted exercises, and sports-specific retraining, DMPhysios ensures that patients with flexor hallucis longus tendinitis injury not only recover but also return to their activities stronger, safer, and more confident.

If you are struggling with persistent ankle or big toe pain, don’t let it hold you back. Book a consultation at DMPhysios today and begin your journey toward complete recovery.

Frequently Asked Questions

1. Can Flexor Hallucis Longus tendon issues cause pain in the arch of the foot?

Yes. The Flexor Hallucis Longus tendon runs along the inside of the ankle and under the arch before attaching to the big toe. Irritation or tendinopathy can cause pain that feels like an aching or sharp discomfort under the arch, especially during push-off while walking or running. This pain often increases with activities like walking barefoot, rising onto your toes, or climbing stairs. A physiotherapist can evaluate movement patterns to confirm if the arch pain originates from the FHL.

2. Are there specific activities that stress the FHL more than others?

Certain activities place greater load on the FHL tendon due to repetitive push-off or toe flexion. These include sprinting, dancing (especially ballet en-pointe), hiking on uneven terrain, uphill running, and sports involving sudden acceleration or direction changes. Wearing shoes with inadequate arch support or stiff soles can further increase stress. Activity modification and strengthening exercises tailored by a physiotherapist help reduce overload and prevent symptom worsening.

3. Can a tight Achilles tendon contribute to FHL pain?

Yes. The Achilles tendon and FHL share functional space within the foot and ankle. A tight or stiff Achilles can alter ankle mechanics, forcing the FHL to compensate during push-off and propulsion. This compensation increases tendon strain over time, especially in activities requiring strong toe off. Stretching and mobility work for the calf and Achilles, combined with FHL-specific strengthening, can improve mechanics and reduce tendon irritation.

4. Why might FHL discomfort worsen at the end of the day?

FHL tendon irritation often worsens as the day progresses because repeated weight-bearing and activity increase cumulative tendon load. By evening, the tendon may become more sensitive and inflamed from prolonged use. Foot swelling and stiffness also contribute to increased discomfort. Reducing high-impact activities, elevating the foot when resting, and using ice after activity help control symptoms and prevent end-of-day flare-ups.

5. Is numbness around the big toe linked with FHL problems?

While FHL issues primarily cause pain and muscular symptoms, numbness or tingling around the big toe may indicate associated nerve irritation (such as the medial plantar nerve). The close anatomical relationship means tendon inflammation sometimes affects nearby nerves. If numbness persists or spreads, it’s important to seek a clinical assessment to rule out neurologic involvement or nerve entrapment conditions.

6. Can foot structure, like high arches, influence FHL strain risk?

Yes. Structural factors like high arches (pes cavus) alter load distribution through the foot during walking and running. In high-arched feet, the weight may concentrate on the forefoot and big toe during push-off, increasing stress on the FHL tendon. Custom orthotic support and targeted strengthening can help redistribute forces and reduce excessive strain on the tendon and surrounding tissues.

7. Does improper footwear delay recovery from FHL injury?

Improper footwear can significantly delay healing. Shoes with poor arch support, inadequate cushioning, or limited motion control increase tendon load during daily activities. Tight toe boxes can also compress the tendon area and worsen symptoms. Choosing footwear with good arch support, room for toe movement, and appropriate cushioning reduces stress on the FHL and supports a smoother recovery.

8. How does FHL tendinopathy affect athletic performance?

FHL tendinopathy hinders push-off strength, toe flexion control, and ankle stability — all crucial for efficient running, jumping, and directional changes. Athletes may notice slower acceleration, reduced agility, or increased fatigue in the forefoot. Without proper management, altered mechanics to avoid pain can increase injury risk elsewhere, such as the knee or hip. A physiotherapist can create sport-specific rehabilitation plans to regain performance safely.

9. Are there nonsurgical treatments that help the FHL tendon heal?

Yes. Most FHL issues respond well to conservative management, including activity modification, eccentric strengthening exercises, manual therapy, taping techniques, and gait retraining. Shock-absorbing insoles or orthotics can offload the tendon during activity. Inflammatory control through ice and controlled rest is useful. Only in rare, persistent cases where conservative care fails would surgical options be considered.

10. Can flexibility of the toes affect FHL tendon health?

Absolutely. Limited toe or big toe extension alters foot mechanics and increases compensatory stress on the FHL tendon. When the big toe does not extend adequately during toe-off, other muscles and tendons (including FHL) work harder to push off the ground. Improving toe mobility through stretching, joint mobilisations, and functional exercises enhances gait mechanics and reduces undue strain on the FHL.