Medically reviewed by Dr. Tom Biernacki, DPM — Board-Certified Podiatric Surgeon — Balance Foot & Ankle, Howell & Bloomfield Hills, MI. Last updated April 2026.

What Is the Extensor Hallucis Longus Tendon?

The extensor hallucis longus (EHL) is the muscle and tendon that lifts the big toe upward (dorsiflexion). It runs from the fibula and interosseous membrane in the lower leg, across the top of the foot, and inserts at the base of the big toe’s distal phalanx. EHL tendon injuries — including tendinopathy, partial tears, and complete ruptures — cause pain on the dorsum (top) of the foot along the tendon’s course, weakness lifting the big toe, and occasionally a visible gap in the tendon. At Balance Foot & Ankle in Howell and Bloomfield Hills, Michigan, Dr. Tom Biernacki, DPM evaluates and treats EHL injuries with both conservative and surgical approaches. Call (810) 206-1402.

Causes of EHL Tendon Injury

EHL tendon injuries most commonly result from: direct trauma (lacerations on the top of the foot — stepping on glass, a blade injury, or a crush injury); acute forceful dorsiflexion against resistance (a tackle or jump landing); tight shoe laces or ski boot pressure creating chronic impingement over the tendon; and repetitive overuse in runners who toe-strike or carry significant forefoot load. In our clinic, EHL lacerations from glass or garden tool injuries are the most common presentation requiring surgical repair, while runners most commonly present with EHL tendinopathy from shoe pressure or training load.

Symptoms — EHL Tendinopathy vs. Complete Tear

EHL tendinopathy produces: aching or burning pain along the top of the foot and/or ankle; tenderness directly over the tendon; pain with resisted big toe dorsiflexion; and often swelling and crepitus along the tendon sheath. Big toe strength is preserved. Complete EHL rupture produces: inability to lift the big toe off the floor; a visible or palpable gap in the tendon; acute pain and swelling after a traumatic event; and a distinctive gait change with the big toe dragging during swing phase. MRI confirms the diagnosis and quantifies tear extent.

Conservative Treatment for EHL Tendinopathy

For EHL tendinopathy without tear, conservative management includes: activity modification and temporary avoidance of the offending shoe or activity; MLS laser therapy to reduce tendon inflammation; orthotic modification to reduce dorsal pressure from shoe upper; physical therapy with eccentric loading protocol; and a brief period of CAM boot immobilization for acute presentations. Most EHL tendinopathy resolves within 6–10 weeks with consistent conservative management. Cortisone injection near tendons is performed cautiously — injection within the tendon sheath can weaken tendon substance.

EHL Tendon Repair — When Is Surgery Required?

Complete EHL rupture in active patients typically requires surgical repair to restore big toe lifting function. The surgery involves tendon-to-tendon repair (primary repair) if performed within 3–4 weeks of injury, or tendon transfer/graft if repair is delayed. EHL rupture that goes unrepaired in active individuals produces a “floppy toe” gait and can lead to secondary toe deformities over time. In elderly or lower-demand patients, non-operative management with an ankle-foot orthosis (AFO) or toe-lifting insole may be appropriate. Recovery from surgical repair involves 4–6 weeks in a boot followed by gradual rehabilitation.

Differential Diagnosis — Other Causes of Top of Foot Pain

Top of foot pain has important differentials: metatarsal stress fracture (point tender along a metatarsal, positive X-ray after 7–10 days or MRI — most common); ganglion cyst (soft, fluctuant, transilluminates); extensor digitorum tendinopathy (same mechanism, affects lesser toes); tarsal coalition (rigid foot, pain in adolescence); midfoot osteoarthritis (older patients, diffuse dorsal aching); and Lisfranc injury (midfoot pain with instability — do not miss in trauma). Accurate diagnosis prevents months of ineffective treatment.

Red Flags

Seek immediate evaluation for: inability to lift the big toe after a traumatic event (possible complete EHL rupture requiring timely repair); a laceration on the top of the foot with visible tendon or loss of toe function; severe midfoot pain after a twisting injury (rule out Lisfranc fracture-dislocation); or spreading warmth and redness suggesting infection. Early surgical repair of EHL rupture has significantly better outcomes than delayed reconstruction.

EHL Tendon Treatment in Howell & Bloomfield Hills Michigan

Dr. Tom Biernacki, DPM provides comprehensive evaluation of top-of-foot pain and tendon injuries at Balance Foot & Ankle — serving all of Metro Detroit, Livingston County, and Southeast Michigan. Diagnostic ultrasound and X-ray are available in-office; MRI is coordinated with same-week turnaround for urgent cases. Book your evaluation online or call (810) 206-1402.

Extensor Hallucis Longus Tendon Injury Treatment in Michigan

EHL tendon injuries cause pain on the top of the foot and inability to lift the big toe. Our podiatrists diagnose these injuries with physical examination and imaging, then provide targeted treatment from immobilization to surgical repair for complete tears.

Explore Our Tendon Treatment Options → | Book Your Appointment | Call (810) 206-1402

Clinical References

1. Anzel SH, et al. Disruption of muscles and tendons: an analysis of 1,014 cases. Surgery. 1959;45(3):406-414.
2. Floyd DW, et al. Observations on the extensor hallucis longus tendon. Foot Ankle. 1983;3(5):269-273.
3. Kannus P, Józsa L. Histopathological changes preceding spontaneous rupture of a tendon. J Bone Joint Surg Am. 1991;73(10):1507-1525.

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Dr. Tom Biernacki, DPM

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Dr. Tom Biernacki, DPM

Dr. Tom Biernacki, DPM is a double board-certified podiatrist and foot & ankle surgeon at Balance Foot & Ankle Specialists in Southeast Michigan. With over a decade of clinical experience, he specializes in heel pain, bunions, diabetic foot care, sports injuries, and minimally invasive surgery. Dr. Biernacki is a member of the APMA and ACFAS, and his patient education content on MichiganFootDoctors.com and YouTube has reached over one million views.