Flexor Hallucis Longus Tendinopathy and Hallux Saltans:

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

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 Hills 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

Frequently Asked Questions

When should I see a podiatrist?

If symptoms persist past 2 weeks, affect your normal activity, or are accompanied by red-flag symptoms (warmth, redness, swelling, inability to bear weight).

What does treatment cost?

Most diagnostic visits and conservative treatments are covered by Medicare and major insurers. Out-of-pocket costs vary by your specific plan.

How quickly can I get an appointment?

Most non-urgent cases see us within 5 business days. Urgent cases (sudden pain, possible fracture) typically same or next business day.

What is Foot pain?

Foot pain is a common foot/ankle condition that affects mobility and quality of life. Understanding the underlying cause is the first step in successful treatment. Our podiatrists at Balance Foot & Ankle perform a hands-on biomechanical exam, review your activity history, and use diagnostic imaging when appropriate to identify the root cause—not just treat the symptom. Many patients have been told to “rest and ice” without a deeper diagnostic workup; our approach is different.

Symptoms and warning signs

Common signs of foot pain include pain that worsens with activity, morning stiffness, swelling, tenderness when palpated, and difficulty bearing weight. If you experience sudden severe pain, inability to walk, visible deformity, numbness or color change, contact our office the same day or visit urgent care—these can signal a more serious injury such as a fracture, tendon rupture, or vascular compromise. Diabetics with any foot wound should seek same-day care.

Conservative treatment options

Most cases of foot pain respond to non-surgical care: structured rest, supportive footwear changes, custom orthotics, targeted stretching and strengthening protocols, anti-inflammatory medications when medically appropriate, and in-office procedures such as ultrasound-guided injections. We also offer advanced therapies including MLS laser therapy, EPAT/shockwave, regenerative injections, and image-guided procedures. Treatment is sequenced from least invasive to most invasive, and we explain the rationale at every step.

When is surgery considered?

Surgery is reserved for cases that fail 3-6 months of well-structured conservative care, when there is structural pathology (severe deformity, complete tear, advanced arthritis), or when imaging shows damage that will not heal without intervention. Our surgeons have performed 3,000+ foot and ankle procedures and prioritize minimally-invasive techniques whenever appropriate. We discuss recovery timelines, return-to-activity milestones, and realistic outcome expectations before any procedure is scheduled.

Recovery timeline and prevention

Recovery from foot pain varies based on severity and chosen treatment path. Conservative cases often improve within 4-8 weeks with consistent adherence to the protocol. Post-procedural recovery may range from a few days (in-office procedures) to several months (reconstructive surgery). Long-term prevention involves footwear assessment, activity modification, structured strengthening, and regular check-ins with your podiatrist if you have a history of recurrence. We provide written home-exercise plans and digital follow-up support.