Flexor Hallucis Longus Tendinopathy and Hallux Saltans:

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

Flexor hallucis longus (FHL) tendinopathy is an underappreciated cause of medial ankle and plantar forefoot pain, particularly in dancers, runners, and patients with prior posterior ankle pathology. The FHL runs in a fibro-osseous tunnel behind the medial malleolus, passes under the sustentaculum tali, and inserts on the distal phalanx of the great toe — producing great toe plantarflexion. Its unique anatomy creates two distinct pathology zones: behind the ankle (posteromedial FHL tendinopathy) and beneath the forefoot (subhallucal FHL tendinopathy/sesamoid groove stenosis).

Posteromedial FHL Tendinopathy

The FHL is the most medially positioned structure in the posterior ankle — running between the medial and lateral tubercles of the posterior talus in its fibro-osseous canal. This canal is the narrowest point of FHL excursion; tendon thickening from tendinopathy at this level produces triggering — a snapping or locking sensation during active great toe flexion or extension — termed hallux saltans (triggering hallux). Examination findings: tenderness behind the medial malleolus, pain with resisted great toe plantarflexion, and reproducing the triggering by passively flexing and extending the hallux while palpating the posterior ankle. Posterior ankle impingement (os trigonum syndrome) frequently coexists with FHL tendinopathy because both conditions arise from the same posterior ankle compartment anatomy.

Conservative and Surgical Management

Conservative management: activity modification reducing repetitive ankle equinus (relevant in dancers — modified training, avoiding extreme relevé), anti-inflammatory medications, ultrasound-guided corticosteroid injection around the FHL in its tendon sheath (avoiding intratendinous injection), and physical therapy focused on eccentric FHL strengthening and posterior ankle flexibility. For refractory posteromedial FHL tendinopathy with triggering — surgical release of the FHL retinaculum at the posterior ankle (arthroscopic or open) provides reliable relief, with concurrent os trigonum excision when posterior impingement coexists. For subhallucal FHL stenosis at the sesamoid groove level — local corticosteroid injection combined with metatarsal padding is first-line; surgical FHL tendon sheath release at the sesamoid level is reserved for refractory cases. Dr. Biernacki at Balance Foot & Ankle evaluates FHL tendinopathy and posterior ankle pathology with clinical examination and diagnostic ultrasound. Call (810) 206-1402 at our Bloomfield Township or Howell office.

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In-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 appointments at both our Howell and Bloomfield Township 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.

Frequently Asked Questions

Can bunions be corrected without surgery?

Bunion correctors and orthotics cannot reverse a bunion, but they can significantly reduce pain, slow progression, and improve function. Surgery is the only way to permanently correct the deformity — but conservative care often manages symptoms effectively for years.

How long does bunion surgery recovery take?

Recovery varies by procedure. Most patients are in a surgical boot for 4–6 weeks, return to regular shoes at 8–12 weeks, and are fully recovered with normal footwear at 3–6 months. Minimally invasive techniques often have faster recovery.

Do bunions come back after surgery?

Recurrence rates are low with modern surgical techniques (5–10%). Risk is reduced by wearing appropriate footwear after surgery and using custom orthotics to correct the underlying biomechanics that caused the bunion.

Need Treatment at Balance Foot & Ankle?

Dr. Tom Biernacki, Dr. Carl Jay, and Dr. Daria Gutkin see patients at our Howell and Bloomfield Township offices.

Book Online or call (810) 206-1402

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

More questions patients ask

What is a bunion?

A bunion (hallux valgus) is a progressive bony deformity where the big toe joint shifts outward, creating a visible bump. It results from an unstable metatarsal bone, not simply tight shoes. Bunions affect approximately 23% of adults and can cause significant pain, difficulty wearing shoes, and secondary problems like hammertoes. Dr. Biernacki specializes in both conservative management and advanced surgical correction including Lapiplasty 3D bunion correction.

What is Lapiplasty bunion surgery?

Lapiplasty is an advanced 3D bunion correction procedure that addresses the root cause of bunions by correcting the unstable metatarsal bone in all three dimensions. Unlike traditional bunionectomy, Lapiplasty patients can bear weight within days and has a recurrence rate under 3% compared to 12-15% for traditional procedures. Dr. Biernacki is a fellowship-trained Lapiplasty surgeon serving SE Michigan.

Still have a question about coverage or cost? Book online and we will check your benefits before your visit: Book in Howell · Book in Bloomfield Township. Prefer to talk it through first? Call (810) 206-1402.