Medically reviewed by Dr. Tom Biernacki, DPM — Board-certified foot & ankle surgeon, 3,000+ surgeries performed. Updated April 2026 with current clinical evidence. This article reflects real practice experience from Balance Foot & Ankle Specialists in Howell and Bloomfield Hills, Michigan.
Quick Answer
Most foot and ankle problems respond to conservative care — proper footwear, supportive inserts, activity modification, and targeted stretching — within 4-8 weeks. Persistent pain beyond that window, or any symptom that prevents walking, warrants a podiatric evaluation to rule out fracture, tendon tear, or systemic cause.
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Medically reviewed by Dr. Tom Biernacki, DPM — Board-Certified Podiatric Surgeon — Balance Foot & Ankle, Howell & Bloomfield Hills, MI. Last updated April 2026.
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Medically Reviewed by Dr. Tom Biernacki, DPM — Board-Certified Podiatrist, Balance Foot & Ankle Specialists, Michigan. Last updated April 2026.
The flexor hallucis longus (FHL) tendon runs from the posterior lower leg through a fibro-osseous tunnel behind the medial malleolus to insert at the base of the distal phalanx of the great toe. It is the primary plantarflexor of the hallux — a function critically important in ballet dancers (who rely on it for pointe work), runners, and gymnasts. FHL tendinopathy is underdiagnosed in non-dancer populations, often labeled as posterior ankle pain or Achilles pathology without specific FHL examination.
Anatomy and Mechanism of Injury
The FHL has two critical zones of potential pathology: the fibro-osseous tunnel behind the medial malleolus and sustentaculum tali where it is compressed during maximum ankle plantarflexion, and the knot of Henry at the plantar midfoot where it crosses the flexor digitorum longus. In ballet dancers, repeated forced plantarflexion compresses the FHL against the posterior talar process — producing stenosing tenosynovitis analogous to trigger finger in the hand. In runners and hikers, hypertrophic muscle belly extending too distally into the tunnel creates impingement. A low-lying FHL muscle belly is an important anatomical variant detectable on MRI that predisposes to this impingement pattern.
Clinical Presentation
FHL tendinopathy presents with posteromedial ankle pain provoked by hallux dorsiflexion and active great toe plantarflexion against resistance. Triggering or crepitus with great toe motion — a “trigger hallux” phenomenon — is pathognomonic when present. Tenderness is maximal posterior to the medial malleolus and along the FHL tunnel, distinct from the Achilles insertion or plantar fascia origin. Nodular tendon thickening may be palpable. Importantly, passive great toe dorsiflexion (the “Silfverskiold-modified FHL stretch test”) reproduces posterior ankle pain in the majority of affected patients.
Diagnostic Imaging
Musculoskeletal ultrasound demonstrates FHL tendon thickening, peritendinous fluid, and dynamic assessment of triggering or impingement in real time. MRI provides superior characterization of FHL intrasubstance tears, tunnel stenosis, and the presence of a low-lying muscle belly. Posterior ankle impingement from os trigonum or posterior talar process hypertrophy frequently co-exists with FHL pathology and must be identified as it may require simultaneous surgical management.
Treatment
Conservative management includes activity modification, FHL stretching (dorsiflexing the great toe with the ankle in neutral), physical therapy targeting eccentric FHL loading, and ultrasound-guided corticosteroid injection into the FHL tendon sheath for tenosynovitis. Custom orthotics with forefoot posting may reduce FHL demand in functional hallux limitus. Surgical FHL tendon sheath release is indicated for stenosing tenosynovitis refractory to 3–6 months of conservative care and produces reliable, rapid return to activity. Dr. Biernacki at Balance Foot & Ankle provides comprehensive evaluation and treatment of FHL tendinopathy including diagnostic ultrasound and surgical release when needed. Call (810) 206-1402 for an evaluation at our Bloomfield Hills or Howell office.
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Our board-certified podiatrists treat this condition at two convenient locations. Same-day appointments often available.
When to See a Podiatrist
Many foot conditions can be managed conservatively at home, but some require professional evaluation. See a podiatrist promptly if you experience:
- Pain that persists for more than 2 weeks despite rest
- Swelling, redness, or warmth that isn’t improving
- Numbness, tingling, or burning in the feet
- A wound or sore that is not healing within 2 weeks
- Any foot concern if you have diabetes or poor circulation
- Nail changes that suggest fungal infection or other problems
At Balance Foot & Ankle, our three board-certified podiatrists — Dr. Tom Biernacki, Dr. Carl Jay, and Dr. Daria Gutkin — provide comprehensive foot and ankle care at our Howell and Bloomfield Township offices. Most insurance plans are accepted.
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Board-certified podiatrists Dr. Tom Biernacki, Dr. Carl Jay, and Dr. Daria Gutkin see patients daily at our Howell and Bloomfield Township, MI offices.
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FHL Tendon Specialists — The Dancer’s Tendon
Flexor hallucis longus tendinopathy is known as “dancer’s tendinitis” because of its prevalence in ballet. Our podiatrists provide expert diagnosis and treatment for this challenging condition.
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Clinical References
- Hamilton WG, Geppert MJ, Thompson FM. Pain in the posterior aspect of the ankle in dancers. J Bone Joint Surg Am. 1996;78(10):1491-1500.
- Michelson J, Dunn L. Tenosynovitis of the flexor hallucis longus: a clinical study of the spectrum of presentation and treatment. Foot Ankle Int. 2005;26(4):291-303.
- Lo LD, Schweitzer ME, Fan JK, Wapner KL, Hecht PJ. MR imaging findings of entrapment of the flexor hallucis longus tendon. AJR Am J Roentgenol. 2001;176(5):1145-1148.
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Howell Office
3980 E Grand River Ave, Suite 140
Howell, MI 48843
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Bloomfield Hills Office
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Book Your AppointmentIn-Office Treatment at Balance Foot & Ankle
If home care isn’t resolving your your foot or ankle concern, a visit with a board-certified podiatrist is the fastest path to accurate diagnosis and a personalized plan. At Balance Foot & Ankle Specialists, Dr. Tom Biernacki, Dr. Carl Jay, and Dr. Daria Gutkin offer same-day and next-day appointments at both our Howell and Bloomfield Hills offices. We perform on-site diagnostic ultrasound, digital X-ray, conservative care, advanced regenerative treatments, and minimally invasive surgery when indicated.
Call (810) 206-1402 or request an appointment online. Most insurance plans accepted, including Medicare, Blue Cross Blue Shield, Aetna, Cigna, and United Healthcare.
Most Common Mistake We See
The most common mistake we see is: Waiting too long before seeking care. Fix: any foot pain lasting more than 4 weeks, or any sudden severe symptom, deserves a professional evaluation rather than more rest.
Warning Signs That Need Same-Day Care
Seek immediate evaluation at Balance Foot & Ankle if you experience any of the following:
- Unable to bear weight
- Severe swelling with skin colour change
- Fever with foot pain (possible infection)
- Diabetes plus any new foot symptom
Call (810) 206-1402 — same-day and next-day appointments at our Howell and Bloomfield Hills offices.
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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.
- Plantar Fasciitis: Diagnosis and Conservative Management (PubMed)
- Plantar Fasciitis (APMA)
- Diagnosis and Treatment of Plantar Fasciitis (PubMed / AAFP)
- Heel Pain (APMA)
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