Flexor Hallucis Longus Pain

This blog post will cover the best exercises and stretches to help fix Flexor Hallucis Longus pain.

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Flexor Hallucis Longus (FHL) is a muscle that is responsible for big toe flexion, foot stability and ankle plantarflexion.

Pain in this muscle is usually associated with “tendinopathy, tendinosis and/or tendinitis”.

Where Is the pain with a Flexor Hallucis Longus injury?

As the Flexor Hallucis Longus is a fairly long muscle, there are 3 main areas where pain may occur.

They are:

• Under The Foot
• Inner Side of Ankle (Tarsal Tunnel)
• Back of Calf (Outer side)

(This blog post will cover how to address all of these areas!)

What causes Flexor Hallucis Longus pain?

This injury is generally caused by overloading the muscle/tendon by excessively and/or repeatedly pushing off the big toe/foot. (Eg. When running, walking, jumping etc.)

How to tell if you have a Flexor Hallucis Longus Injury

a) Point Tenderness in these areas

If there is pain located anywhere along the pathway of this muscle, this suggests there may be an injury to the Flexor Hallucis Longus.

b) Pain with Loading

Instructions:

• Stand on the edge of a step on your injured leg.
• Hold onto something for balance.
• Push your big toe into the step.
• Bounce on your foot.

Results: If pain is reproduced in the areas of tenderness, this suggests you may have an injury to the Flexor Hallucis Longus.

c) Get a Scan

Ask your Primary Care Provider for a referral to get an Ultrasound and/or MRI scan of your ankle to determine if there are any structural abnormalities.

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How to Fix Flexor Hallucis Longus Pain

STEP 1: Avoid Aggravation
STEP 2: Reduce Inflammation
STEP 3: Releases
STEP 4: Stretches
STEP 5: Improve Circulation
STEP 6: Strengthening Exercises
STEP 7: Gradual Return To Activity
STEP 8: Big Toe Extension
STEP 9: Hindfoot Eversion

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STEP 1: Reduce Exposure to aggravating activities

Completely stop or reduce exposure to any aggravating activity until your symptoms have noticeably improved.

Activities that you will likely need to address:

(Basically – the following movements involve placing an increased amount of pressure through the big toe/foot.)

• Walking
• Squatting
• Hopping/Jumping
• Running

Persistent exposure to the activities/positions/movements that aggravate the pain in the Flexor Hallucis Longus will likely prolong the recovery time.

KEEP IN MIND – The aim is not to completely rest your injury as this could lead to unnecessary deconditioning. Aim to use your foot as much as possible without making it worse!

STEP 2: Reduce Inflammation

A significant amount of inflammation in the Flexor Hallucis Longus muscle can be very sensitive and painful.

This may limit the ability to perform the suggested exercises on this blog post.

Here are some simple ways to reduce inflammation:

a) Anti-Inflammatory Gel

Apply an anti-inflammatory gel to the areas of pain.

Do this 3 times per day.

b) Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

It is recommended that you take an anti-inflammatory medication consistently for at least 7-10 days.

Keep in mind – there are different strengths/types of NSAIDs and is best used if the prescribed medication is appropriate to the severity of the inflammation.

Note: Please consult your Primary Care Provider before taking any medication.

c) Cold Therapy

Apply an ice pack to the areas of pain for at least 10-15 minutes.

Do this 3-5 times per day.

Note: Do not apply the ice pack directly to the skin as you may develop an irritation on the skin.

d) Try Natural Products

It is suggested that taking turmeric, ginger, chia seeds and/or fish oil capsules are natural ways to help reduce the inflammation.

e) Cortisone Injection

The cortisone injection consists of a steroid (cortisone) and an analgesic substance.

The aim of the injection is to reduce the inflammation and reduce the pain by numbing the area.

Talk to your Primary Care Provider to see if the cortisone injection is appropriate for your shoulder injury.

STEP 3: Releases

Releasing the Flexor Hallucis Longus can help reduce tension in the muscle.

NOTE: If there is a significant amount of inflammation/pain, you may need to either:

• Reduce the amount of pressure being applied or
• Perform the releases around the area of pain (… as opposed to directly on top of it).

a) Under The Foot

Instructions:

• Locate the Flexor Hallucis Longus tendon by pulling the ankle and big toe backwards. The tendon will become more prominent underneath the arch of the foot.
• Place this region directly on top of a massage ball.
• Apply an appropriate amount of your body weight on top of the massage ball.
• Continue for 1-2 minutes.

b) Inner Side of Ankle

Instructions:

• Sit down on a chair.
• Place your ankle on top of the other knee.
• Locate the Flexor Hallucis Longus at the inner side of the ankle. (See above)
• Use your thumb to apply a firm pressure to the target area.
• Continue for 1-2 minutes.

c) Back of Calf

Instructions:

• Sit down on a chair.
• Locate the Flexor Hallucis Longus at the back of the calf.
• Keep your leg completely relaxed.
• Use your thumb/fingers to press firmly into the Flexor Hallucis Longus muscle.
• Make sure the cover the entire length of the muscle.
• Continue for 1-2 minutes

Note: Since this muscle is located deep within your calf region, you will need to press firmly when performing this release.

STEP 4: Flexor Hallucis Longus stretches

Here is a simple stretch for the Flexor Hallucis Longus muscle.

(Note: Make sure to only apply as much stretch that you can comfortably tolerate. Over stretching this muscle can make your symptoms worse! In some people – I would recommend completely skipping the stretch.)

a) Flexor Hallucis Longus Stretch

Instructions:

• Sit down on a chair.
• Place your ankle onto the other knee.
• Hold the big toe with your fingers.
• Pull your foot and big toe backwards.
• Aim to feel a stretch underneath your foot.
• Hold for 30 seconds.
• Repeat 3 times.

STEP 5: Encourage Blood Flow

In my opinion – your blood contains all the healing properties required to help with your recovery.

Try this gentle exercise to help improve the circulation to the injured area.

a) Toe Points

Instructions:

• Point your foot and toes forwards.
• Curve your foot inwards firmly.
• Aim to feel a muscular contraction on the inner side of the ankle.
• Hold for 5 seconds.
• Perform 30 repetitions.

Note: Don’t push too hard as it may cause a cramp in your foot!

STEP 6: Strengthening Exercises

The following Flexor Hallucis Longus strengthening exercises are arrange in order of difficulty.

Recommendation: Although it is not 100% necessary to do all of these exercises to get better, I do encourage you to at least try them all in the beginning. Feel how you respond to each of them. Focus on the exercises that activate your injured area the most without causing any significant increase in pain.

a) Isometric Strengthening Exercise

Instructions:

• Sit down on a chair.
• Place your ankle on top of the other knee.
• Place your finger underneath the tip of the big toe.
• Push your big toe into your finger as hard as you can comfortably tolerate.
• Hold for 30-45 seconds.
• Repeat 3 times.
• For best results – perform the exercise in the following different positions:
  • Ankle pointed
  • Ankle neutral
  • Ankle bent backwards

b) Towel Scrunches

Instructions:

• Sit down on a chair.
• Place a towel underneath your foot.
• Push your big toe into the towel as hard as you can comfortably tolerate.
• Scrunch the towel underneath your foot.
• Perform 30 repetitions.
• Repeat 3 times.

c) Heel Raise (with big toe emphasis)

Instructions:

• Stand with your feet shoulder-width apart.
• Push your big toe into the floor.
• Raise your heels.
• Hold for 2 seconds.
• Perform 20 repetitions.
  • (You can hold onto something for balance if required.)
• Repeat 3 times.
• Progression: Perform this exercise on one leg.

d) Bouncing

Instructions:

• Place your foot onto a step.
  • (The foot at the back will be targeted with this exercise.)
• Move the foot of the back leg onto the ball of the foot.
• Push your big toe into the ground.
• Bounce in this position.
• Continue for 30 seconds.
• Progression: Apply more body weight onto the back foot.

Inner Ankle Pain

If your pain is located towards the inside ankle region, these exercises will help target this area more specifically.

a) Resistance Band Exercise

Instructions:

• Loop a resistance band around the base of the big toe.
• Hold the other end of the band with the hand on the same side.
• Hold your arm out to the side.
• Pull on the band to create tension.
• Point your foot and toes forwards.
• Curve your foot inwards firmly.
• Aim to feel a muscular contraction on the inner side of the ankle.
• Hold for 5 seconds.
• Perform 30 repetitions.
• Repeat 3 times.

b) Heel Raise with Ball

Instructions:

• Stand on the edge of a step.
• Place a small ball between the inner region of both heels.
• Squeeze and scoop up the ball between your ankles throughout this exercise.
• Aim to feel tension on the inner side of both ankles.
• Perform a heel raise.
• Repeat 30 times.
• Repeat 3 times.

c) Short Foot Exercise

Instructions:

• Stand with your feet facing forwards and shoulder width apart.
• Whilst keeping your toes relaxed, proceed to scrunch the under-surface of your foot.
  • Drag the base of your big toe backwards towards the heel.
• Keep the base of the big toe in contact with the ground to prevent this area from lifting.
• Gently push the tip of your big toe down onto the ground.
• Aim to feel a strong contraction of the muscles underneath your foot.
• Hold this for 5 seconds.
• Repeat 20 times.
• Repeat 3 times.
• Progression: Perform the exercise on one foot.

d) Step Through

Instructions:

• Have your feet in a staggered position.
• Activate short foot in your leading leg. (See previous exercise)
• Whilst maintaining short foot on the leading leg, step forward with the back leg.
• As the swinging leg is about to land on the ground, push off from the big toe.
• You should feel a contraction in your arch through movement.
• Return to starting point.
• Repeat 30 times.
• Progression: Instead of stepping to the front, try stepping in different directions whilst maintaining a strong short foot contraction.

STEP 7: Gradual return to Activity

As the symptoms start to improve with the exercises, you will want to gradually return the activities that were initially aggravating the Flexor Hallucis Longus.

This progression might look something like the following:

Slow walking > Walking longer distances > Walking quicker > Walking up hill > Slow jogging > Running

The goal here is to find the most stimulating activity that your injury can comfortably tolerate.

STEP 8: Increase Big Toe Extension

If your big toe is limited in its ability to bend backwards (also known as Big Toe Extension), it will likely impact how the Flexor Hallucis Longus functions during walking.

a) How much Big Toe Extension is ideal?

• 60-70 degrees

b) How to Check Big Toe Extension:

Instructions:

• Place your foot on the floor.
• Hold your big toe.
• Lift it up.
• Measure the angle of the big toe to the horizontal.

Exercises to Increase Big Toe Extension

Reclaiming the normal amount of big toe extension may help the Flexor Hallucis Longus muscle function more optimally.

a) Release Under The foot

Tightness in the Flexor Hallucis Longus can limit the amount of big toe extension.

Instructions:

• Locate the Flexor Hallucis Longus by pulling the ankle and big toe backwards. The tendon will become more prominent underneath the foot.
• Place this region on top of a massage ball.
• Apply an appropriate amount of your body weight on top of the massage ball.
• Continue for 1-2 minutes.

b) Big Toe Traction

Tightness in the big toe joint may reduce the amount of extension occurring in the big toe.

Instructions:

• Sit down on a chair.
• Place your ankle on top of the other knee.
• Hold onto the mid foot with one hand.
• Use the other hand to grip onto the base of the big toe.
• Pull the big toe away from the rest of the foot.
• Hold for 30 seconds.
• Repeat 3 times.

c) Advanced Stretch

Instructions:

• Kneel down on the floor.
• Make sure that the toes are bent backwards.
• Shift your body weight on top of your toes and forefoot.
• Aim to feel a stretch under the foot.
• Make sure that there is no pinching pain at the top of the base of the big toe.
• Hold this position for 2-5 minutes.
• Push the big toe into the floor for 30 seconds.
• Relax.
• Repeat

Note: If you have knee issues, please be careful with the kneeling position. You can place a pillow underneath the knees if required.

d) Big Toe Extension Strengthening

Instructions:

• Keep your foot on the floor.
• Lift up your big toe as high as you can.
• Aim to feel a contraction of the muscles at the top of your big toe.
• Hold for 5 seconds.
• Repeat 20 times.
• Progression: Apply additional resistance with your finger in this end range position.

e) Staggered Stance

This exercise will help with walking.

Instructions:

• Assume a lunge position. (see above)
  • The foot at the back will be the side targeted.
  • Make sure that your big toe is extended back as far as possible without compromising the alignment of your foot.
• Push the tip of your big toe into the ground as you point your foot against the ground.
  • Place as much of your body weight onto the back leg that you can comfortably tolerate.
• Return your weight back to the ball of the foot.
• Repeat 20 times.

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If your pain is specifically on the inner side of the ankle, you may need to address the following:

STEP 9: Address hindfoot eversion

Hindfoot eversion is where the heel collapses inwards as you place your weight through the foot.

The issue with this is that this movement may over stretch the Flexor Hallucis Longus tendon at the inner side of the heel (Tarsal Tunnel).

By minimizing the collapse, we can take pressure off the tendon.

Here are a few things that you can address to help with this (If relevant to you):

a) Address Flat Feet

Having flat feet involves the collapse of the inner arch of the foot.

To see my complete guide on how to address this issue:

See Post: Exercises for Flat Feet

b) Improve Ankle Dorsiflexion

Ankle Dorsiflexion is the movement where the ankle is bent in a backwards direction.

Limitations in this movement may result in changes in the walking pattern which can play more pressure on the Flexor Hallucis Longus.

To see my complete guide on how to address this issue:

See Post: How to Improve Ankle Dorsiflexion

c) Address Duck Feet Posture

Duck Feet Posture is where the feet are pointing outwards.

Walking with the toes pointing outwards may encourage more hindfoot eversion.

To see my complete guide on how to address this issue:

See Post: How To Fix Duck Feet Posture

d) Address Midfoot Stiffness

Stiffness in the midfoot can prevent normal foot movements during walking.

This may result in excessive hindfoot eversion.

Here are a few ways to loosen up the mid foot region:

a) Midfoot

Instructions:

• Sit down on a chair.
• Place your ankle on top of the other knee.
• Hold the midfoot with one hand.
• Using your other hand, place your thumb under the base of the big toe and the other fingers on top of the base of the pinky toe. (See image)
• Whilst anchoring the midfoot still, proceed to rotate the forefoot away from you.
• Perform 30 repetitions.

b) Arch Drop With Pivot

Instructions:

• Stand up.
• Activate the muscles of the arch.
• Try to keep as much of your body weight on this foot.
• Step to the side with your other leg.
• Allow the arch to drop as you step with the other foot.
• Perform 30 repetitions.

c) Medial Heel Wedge

A medial heel wedge is something that you can insert in your shoe to help minimize the amount of hindfoot eversion.

The aim of this is to encourage the midfoot to move normally during walking without the hindfoot compensating.

I do not recommend relying on external supports (including orthotics) in the long term!

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Conclusion

Pain associated with the Flexor Hallucis Longus can be located under your foot, inner side of the ankle and/or back of the calf.

In the initial stages of addressing this issue, it is important to minimize exposure to activities that make the symptoms worse and to reduce inflammation.

Perform the suggested exercises and stretches as mentioned in this blog post to fix your Flexor Hallucis pain.

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Disclaimer: The content presented on this blog post is not medical advice and should not be treated as such. It is not intended to be used as a substitute for professional advice, diagnosis or treatment. Use of the content provided on this blog post is at your sole risk. Seek guidance from a healthcare professional before attempting any exercise. For more information: Medical Disclaimer.