Logan Steele
The flexor hallucis longus (FHL) is a powerful muscle located in the posterior aspect of the fibula. It is one of three deep muscles in the posterior compartment of the leg, the others being the flexor digitorum longus and the tibialis posterior. The FHL is responsible for flexing the big toe, also known as the great toe or hallux. This muscle is particularly important for dancers, gymnasts, and runners, who make excessive use of toe flexion. However, overuse of the FHL can lead to tendonitis, causing pain and stiffness in the big toe.
| Characteristics | Values |
|---|---|
| Name of muscle that flexes the big toe | Flexor hallucis longus (FHL) |
| Location | Posterior aspect of the fibula below the deep fascia of the calf |
| Tendon passes through | Tarsal tunnel |
| Tendon wraps around | Lower end of the tibia, back of the talus, and the sustentaculum tali on the calcaneus |
| Tendon lies above | Lateral side of the tendon of the flexor digitorum longus |
| Muscle innervation | Tibial nerve |
| Muscle attachments | Plantar surface of the phalanx of the great toe |
| Muscle function | Flexing the great toe, maintaining the medial longitudinal arch |
| Common issues | FHL tendinitis, fractures of the sustentaculum tali, hallux saltans |
| Treatment options | Rest, ice, ultrasound therapy, physical therapy, splints, anti-inflammatory medication, surgery |
| Related muscles | Extensor hallucis longus (EHL), flexor digitorum longus, tibialis posterior |
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What You'll Learn
Flexor hallucis longus (FHL)
The flexor hallucis longus (FHL) is a powerful muscle located on the posterior aspect of the fibula, below the deep fascia of the calf. It is one of the three deep muscles of the posterior compartment of the leg, alongside the flexor digitorum longus and the tibialis posterior. The FHL arises from the inferior two-thirds of the posterior surface of the fibula, with fibres passing obliquely downward and backward.
The FHL tendon passes downwards, deep into the flexor retinaculum, crossing the posterior ankle joint. It wraps around the lower end of the tibia, the back of the talus, and the inferior surface of the sustentaculum tali on the calcaneus. The sustentaculum tali is a bony landmark, and friction at this site can cause pain and inflammation, leading to a condition known as "dancer's tendinitis". This condition is common in ballet dancers, gymnasts, and runners due to excessive use of toe flexion.
As the tendon enters the sole of the foot, it passes forward deep into the tendon of the flexor digitorum longus and enters the fibrous sheath of the great toe. It inserts at the base of the distal phalanx of the great toe, flexing it. The FHL is responsible for producing the final thrust from the foot in the toe-off phase of the gait cycle. It also helps to supinate the ankle and contributes to maintaining the medial longitudinal arch.
Injuries to the FHL are typically managed through conservative treatment, including rest, ice, ultrasound therapy, physical therapy, and anti-inflammatory medication. More severe or chronic injuries may require surgery to repair tears and remove debris. Rehabilitation exercises for the FHL include towel grip exercises, balance exercises, and walking or running on different surfaces.
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Extensor hallucis longus (EHL)
The Extensor hallucis longus (EHL) is a key muscle located in the anterior compartment of the lower leg. It is responsible for extending the big toe at both the metatarsophalangeal and interphalangeal joints. The EHL passes deep to the extensor retinaculum before inserting at the base of the distal phalanx of the big toe. It extends the metatarsophalangeal and interphalangeal joints of the big toe and assists in the inversion of the foot and dorsiflexion of the ankle.
The EHL is the only muscle for the extension of the interphalangeal joint. Weakness in the EHL diminishes an individual's ability to control the descent of the medial portion of the foot, especially the big toe. Patients with EHL weakness report that the toe tends to fold under the foot when they are putting on socks or shoes, and it can cause tripping. EHL weakness can also cause the toe to be pulled into extension, leading to a claw toe deformity.
The EHL muscle is a thin skeletal muscle, situated between the tibialis anterior and the extensor digitorum longus. It ends as a tendon of insertion, which passes through a distinct compartment in the inferior extensor retinaculum of the foot. The EHL's tendon is situated along the medial side of the dorsum of the foot. Opposite the metatarsophalangeal articulation, the tendon gives off a thin prolongation on either side, to cover the surface of the joint.
The EHL can be strengthened through exercises such as the Big Toe Lift, where the big toe is raised while keeping the other toes flat on the floor. Another exercise is the Big Toe Extension with Heel Raises, where heel raises are performed while keeping the big toe extended. A third exercise is the Short Foot Exercise, where the base of the big toe is pulled towards the heel to create an arch, while keeping the toes flat.
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FHL injuries
The flexor hallucis longus (FHL) is a muscle located on the posterior aspect of the fibula below the deep fascia of the calf. It is responsible for flexing the big toe. The FHL tendon is susceptible to various injuries, including lacerations, ruptures, longitudinal splits, and stenosing tenosynovitis. Friction at the site of the sustentaculum tali, a bony landmark, can cause FHL tendinitis, commonly referred to as "dancer's tendinitis." This is often seen in ballet dancers, gymnasts, and runners due to excessive use of toe flexion, resulting in inflammation and irritation.
However, more severe or chronic FHL injuries may require surgical intervention. Surgery typically involves repairing tears in the FHL, removing debris from the affected area, and addressing any underlying conditions causing similar symptoms, such as an os trigonum. Post-operative management includes the use of lower leg splints, partial weight-bearing exercises, and early range-of-motion exercises for the ankle and related joints.
To prevent FHL injuries, it is important to strengthen the muscle and improve foot strength in general. A common exercise involves sitting and placing a towel under the foot, then gripping the towel with the toes and pulling it towards the body. This can also be done using a theraband or wobble board for added challenge. Additionally, walking or running on different surfaces, such as grass or sand, can further enhance the function of the flexor hallucis longus.
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FHL tendinitis
The flexor hallucis longus (FHL) is a muscle that attaches to the plantar surface of the phalanx of the big toe, allowing for toe flexion. FHL tendinitis, also known as Dancer's tendinitis, is a common condition among ballet dancers, gymnasts, and runners. This is due to the repetitive and intense demands of their activities, which place significant stress on the tendons. Overuse of the FHL tendon can lead to inflammation and irritation, causing tendonitis.
Symptoms of FHL tendinitis include pain, especially on the inside of the ankle bone, swelling of the ankle, and pain that worsens when pushing off the toes. The pain often develops slowly over time rather than being the result of a single event. In more severe cases, triggering of the great toe may occur, resulting in an inability to relax the toe after full plantar flexion, leading to a locking sensation.
Clinical examination of a suspected FHL injury involves specific attention to four regions of the foot and ankle. The ankle and great toe are held in a neutral or dorsiflexed position to put the FHL under tension. Palpation of the muscle and tendon is performed in specific areas to assess for tenderness and swelling.
Treatment for FHL tendinitis typically involves conservative management, including rest, ice, ultrasound therapy, physical therapy, and anti-inflammatory medication. Physical therapy exercises and stretches can help rehabilitate the muscle and tendon, improving mobility and strengthening the FHL. In more severe or chronic cases, surgery may be indicated to repair tears and remove debris from the affected area.
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Exercises for foot strength
The flexor hallucis longus (FHL) is a muscle located on the posterior aspect of the fibula, and it is responsible for flexing the big toe. The extensor hallucis longus (EHL) is another muscle that extends the big toe at the metatarsophalangeal and interphalangeal joints.
Towel Scrunches
Sit on a chair and place a hand towel on the floor. Start with your toes at one edge of the towel and curl them so that the towel bunches up under your feet. Repeat this exercise two or three times with each foot. This exercise can also be done using a theraband around the big toe, providing more resistance.
Writing the Alphabet
Sit in a chair and raise one foot off the floor. Move your ankle in different directions to "write" each letter of the alphabet in the air with your big toe. Repeat this exercise with the other foot. This helps strengthen the muscles on the bottoms of your feet, supporting your arches.
Interlocking Fingers and Toes
Interlace the fingers of your right hand with the toes of your left foot and hold for 30 to 60 seconds. Slowly release and repeat with your right foot and left hand. Do this exercise only once with each foot.
Short Foot Posture
Stand on one leg and create a short foot posture by contracting the intrinsic muscles to raise the arch of your foot. Swing the non-stance leg forward and backward 15 times, then repeat the same movement left and right in front of your stance leg, again 15 times. Repeat this sequence without resting, then switch to the opposite leg.
Calf Raises to Big Toe Press
Do a traditional calf raise and finish by pressing onto your big toe. You can repeat this exercise 12 to 15 times and hold onto something for balance if needed.
Golf Ball Rolls
Grab a golf ball and place it under the arch of one foot. Roll the golf ball along the bottom of your foot for about two minutes, then switch and repeat with the other foot.
These exercises will help improve the strength and flexibility of the muscles, tendons, and ligaments in your feet, specifically targeting the big toe.
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Frequently asked questions
The flexor hallucis longus (FHL) muscle is responsible for flexing the big toe.
The FHL contributes to maintaining the medial longitudinal arch of the foot. It produces the final thrust from the foot in the toe-off phase of the gait cycle.
FHL tendonitis is inflammation of the FHL tendon, which is often caused by gradual wear and tear due to overuse. It is common in ballet dancers, gymnasts, and runners.
FHL tendonitis causes pain, particularly on the inside of the ankle, which may travel down to the big toe. It can also cause the big toe to become stiff and relatively immobile.
Rest, ice, and ultrasound therapy can help with the inflammation and pain of FHL tendonitis. Physical therapy exercises and stretches can also aid in rehabilitation. In more severe cases, surgery may be required to repair tears and remove debris from the affected area.
