FHL tendinopathy can cause pain behind the inside ankle, under the arch, or near the big toe. It often affects dancers, runners, and jumping athletes who rely on repeated forefoot push-off.

The flexor hallucis longus tendon helps you push off when you walk, run, jump, or rise onto your toes. When load rises too fast, the tendon may become sore, stiff, and less able to cope.

FHL tendon pain can overlap with other foot pain conditions, ankle pain, and broader tendinopathy patterns. A physiotherapist can assess the tendon, check your training load, and guide a safe return to running, dance, work, or sport.

What Is FHL Tendinopathy?

FHL tendinopathy is irritation or overload of the flexor hallucis longus tendon. This tendon runs behind the inside ankle, under the foot arch, and into the base of the big toe.

The FHL tendon supports balance, toe grip, and push-off. It works hard during walking, running, jumping, and ballet pointe work. It can become painful when training load, footwear, foot control, or recovery are not well matched.

You may also hear the term FHL tenosynovitis. This describes irritation around the tendon sheath. Tendinopathy and tenosynovitis can occur together, especially when repeated big toe and ankle movement keeps irritating the tendon.

Where Does FHL Tendon Pain Usually Occur?

FHL tendon pain usually occurs behind the inside ankle, through the arch, or near the base of the big toe. Some people feel one main pain spot. Others notice symptoms along the tendon path.

• Pain behind or below the inside ankle bone.
• Arch pain during push-off or toe gripping.
• Pain near the base of the big toe.
• Stiffness when first walking after rest.
• Clicking, catching, or creaking behind the ankle.

These symptoms can overlap with posterior ankle impingement, tarsal tunnel syndrome, plantar fasciitis, and foot stress fracture. Assessment helps confirm the likely pain source.

Who Gets FHL Tendinopathy?

FHL tendon pain is most common in people who repeatedly load the forefoot, big toe, and calf. It can affect athletes, dancers, active adults, and workers who spend long periods on their feet.

• Ballet dancers doing demi-pointe, pointe work, jumping, and repeated turns.
• Runners, including distance runners, sprinters, and hill runners.
• Jumping athletes, gymnasts, football players, skaters, and divers.
• Dancers with recurrent ballet injuries or broader dance injuries.
• People returning to sport after illness, injury, holidays, or a training break.
• Workers who stand or walk for long shifts on firm surfaces.

The key issue is not just the activity. It is whether the tendon has enough current capacity for the load being asked of it.

What Causes FHL Tendinopathy?

FHL tendinopathy usually develops when tendon load rises faster than tendon capacity. Common triggers include sudden training spikes, repeated pointe work, hills, jumps, sprinting, footwear changes, or poor recovery.

Training and activity factors

• Rapid increases in running distance, speed, hills, or sprint work.
• Extra pointe work, rehearsals, jumps, or performance blocks.
• Hard, uneven, or slippery surfaces.
• Too little recovery between sessions.
• Returning to sport or dance too quickly after time away.

Body and movement factors

• Reduced calf strength or endurance.
• Weak foot control during single-leg work.
• Limited ankle or big toe range.
• Flat feet or poor foot posture control.
• Previous ankle sprains, foot injuries, or calf overload.

Footwear and support factors

• Worn or unsupportive shoes.
• Sudden footwear changes.
• Dance shoes, spikes, or work shoes that increase forefoot load.
• Not enough support during a painful training phase.

Good care looks at the whole load picture. It may include footwear advice, active foot posture correction exercises, stretching exercises, and a staged strength plan.

How Is FHL Tendinopathy Diagnosed?

FHL tendinopathy is usually diagnosed through your symptom history and a physical examination. Your physiotherapist will check the painful tendon area, big toe movement, ankle movement, calf strength, and activity-specific control.

Your assessment may include:

• Palpation along the FHL tendon behind the inside ankle and under the foot.
• Big toe flexion strength and movement tests.
• Ankle range, calf strength, and single-leg balance tests.
• Heel raise, hopping, walking, running, or dance-specific movement review.
• Foot posture and footwear assessment.

Imaging such as ultrasound or MRI may help when symptoms are unclear, severe, persistent, or linked with locking, swelling, or suspected tendon sheath irritation. Many cases, however, do not need a scan before starting a clear management plan.

How Can Physiotherapy Help FHL Tendinopathy?

Physiotherapy can help by calming pain, reducing overload, and rebuilding tendon capacity. Treatment should match your symptoms, activity goals, and response to load.

Load management

Your physiotherapist may adjust running volume, hills, speed, pointe work, jumping, rehearsals, gym work, or long standing tasks. The aim is to keep you active while reducing the tendon’s most painful triggers.

Exercise and tendon loading

Progressive strengthening is central to tendon care. Your programme may include calf strengthening, big toe flexor work, foot control drills, balance work, and staged return to hopping, running, or dance. Our tendon healing guide explains why load progressions matter.

Hands-on treatment and muscle care

Hands-on care may help settle calf, foot, and ankle muscle tension. This may include soft tissue work, joint mobilisation, stretching, and advice on self-care tools such as a foam roller or massage ball. Some people also benefit from soft tissue massage when calf or foot tightness adds to symptoms.

Footwear, taping, and supports

Your physiotherapist may suggest taping, temporary supports, orthotic advice, or footwear changes. These tools can reduce tendon load while you rebuild strength and confidence.

Medical review when needed

Your GP or sports doctor can advise on medicines, topical anti-inflammatory options, or injections when appropriate. Surgery is uncommon and usually reserved for long-standing cases that have not improved with high-quality conservative care.

How Long Does FHL Tendinopathy Take to Improve?

Many people notice improvement over 6 to 12 weeks when they reduce aggravating load and follow a structured strength plan. Long-standing tendon pain can take longer, especially if symptoms have been ignored for months.

Recovery is usually not a straight line. Small flare-ups can happen when activity increases too fast. Regular review, load monitoring, and staged return-to-sport planning can help you progress with more confidence.

Can You Prevent FHL Tendinopathy?

You cannot remove every risk, but you can reduce tendon overload by building load gradually, improving calf and foot strength, wearing suitable footwear, and planning recovery.

• Increase running, jumping, and pointe work gradually.
• Build calf, foot, and hip strength across the week.
• Warm up before harder sessions and cool down afterwards.
• Rotate load across heavy, light, and rest days.
• Replace worn shoes and review footwear if symptoms return.
• Use warm-up routines before sport, dance, or faster running.

These habits may also help reduce recurrence of other foot and ankle overload problems.

When Should You See a Physiotherapist?

You should see a physiotherapist if FHL tendon pain lasts more than two weeks, limits walking, running, dance, work, or sport, or keeps returning when you increase load.

Book sooner if you notice swelling, catching, locking, limping, night pain, sudden severe pain, or pain after a direct injury. You can also read our guide on when to worry about foot or ankle pain.

Related Foot, Ankle and Tendon Articles

1. Common Tendon Injuries – tendon symptoms, causes, and treatment options.
2. Foot Pain Conditions – common causes of foot pain and when to seek care.
3. Ankle Pain Conditions – ankle injury and overload information.
4. Tendon Healing Guide – practical advice on load, pain, and recovery.
5. Active Foot Posture Correction Exercises – exercises for foot and ankle control.
6. Running Injuries – common running overload patterns and prevention tips.
7. Ballet Injuries – foot, ankle, and dance-specific load advice.
8. Sports Physiotherapy – injury assessment, rehab, and return-to-sport planning.

For a broader clinical overview, see the American Family Physician review of foot and ankle tendinopathies.

FHL Tendinopathy FAQs

Is FHL tendinopathy serious?

FHL tendinopathy is usually manageable with physiotherapy and load changes. It can become more persistent if you keep training through worsening pain, swelling, catching, or altered movement.

Can I keep running with FHL tendon pain?

You may be able to keep running if pain stays mild and settles quickly. Reduce hills, speed, distance, or frequency if symptoms build, change your stride, or last into the next day.

What makes FHL tendon pain worse?

FHL tendon pain often worsens with strong forefoot push-off. Common triggers include hills, sprinting, jumping, hopping, pointe work, repeated calf raises, and unsupportive footwear.

Do I need a scan for FHL tendinopathy?

Not always. Many cases are diagnosed through history and physical testing. Ultrasound or MRI may help if symptoms are unclear, persistent, severe, or linked with locking or swelling.

How long does FHL tendinopathy take to heal?

Many people improve within 6 to 12 weeks with a structured plan. Long-standing cases may take longer because tendon strength, calf capacity, and sport-specific loading need time to rebuild.

Can FHL tendinopathy affect ballet pointe work?

Yes. FHL tendon pain can affect demi-pointe and pointe work because these positions place high load through the big toe flexor tendon, calf, and inside ankle.

What To Do Next

If pain behind your ankle, under your arch, or near your big toe is limiting walking, running, dancing, or work, book a physiotherapy assessment. A clear plan can help you settle symptoms and rebuild load safely.

Your physiotherapist can check your tendon, footwear, strength, foot control, and activity demands. They can then guide a staged return to the activities that matter most to you.

Helpful Foot and Ankle Products

Some people with FHL tendinopathy use simple home tools such as ice or heat packs, massage balls, arch supports, or braces. Ask your physiotherapist which products suit your symptoms, activity level, and stage of recovery.

References

• Mikkelsen P, Andersen A, Shih HJS, Rowley KM, Kulig K. Flexor hallucis longus tendon morphology in dancers clinically diagnosed with tendinopathy. J Ultrasound. 2024;27:41-49.
• Michelson JD, Bernknopf JW, Charlson MD, Merena SJ, Stone LM. What is the efficacy of a nonoperative program including a specific stretching protocol for flexor hallucis longus tendonitis? Clin Orthop Relat Res. 2021;479(12):2667-2676. doi:10.1097/CORR.0000000000001867
• Deu RS, Deu SA. Tendinopathies of the foot and ankle. Am Fam Physician. 2022;105(5):479-488.
• Scott A, Squier K, Alfredson H, et al. ICON 2019: International Scientific Tendinopathy Symposium Consensus: clinical terminology. Br J Sports Med. 2020;54(5):260-262.