Extensor Hallucis Brevis Trigger Points

Introduction

The extensor hallucis brevis (EHB) is a small but important foot muscle that helps in extending the big toe and stabilizing the foot during walking and running. When trigger points develop in this muscle, they can cause pain on the top of the foot and near the big toe, often mimicking arthritis, nerve compression, or metatarsalgia.

Name and Area

  • Name: Extensor Hallucis Brevis (EHB)

  • Area: Located on the dorsum (top) of the foot, spanning from the calcaneus (heel bone) to the base of the big toe.

Indications

Extensor hallucis brevis trigger points may contribute to:

  • Pain on the Top of the Foot, Near the Big Toe (Mistaken for Arthritis or Nerve Pain)

  • Pain That Radiates Toward the Big Toe Joint (Can Mimic Gout or Hallux Rigidus)

  • Tightness or Cramping in the Big Toe (Especially With Walking or Running)

  • Pain That Increases When Wearing Tight or Restrictive Shoes

  • Big Toe Weakness, Leading to Difficulty Pushing Off When Walking or Running

  • Pain When Extending the Big Toe (E.g., Pushing Off While Running or Walking Barefoot)

Pain from this muscle is often mistaken for bunions, nerve entrapment, or osteoarthritis of the big toe.

Muscle Action

  • Extends the Big Toe (Hallux): Lifts the big toe upward.

  • Assists in Foot Stabilization: Helps support balance and weight distribution during walking and running.

  • Works With the Extensor Hallucis Longus: Controls big toe movement and foot dorsiflexion.

The EHB is essential for proper foot mechanics and efficient movement during activities that involve toe-off motion.

Signs and Symptoms

Individuals with extensor hallucis brevis trigger points often report:

  • Pain on the Top of the Foot, Near the Big Toe Joint

  • Difficulty Extending the Big Toe (Pain When Pushing Off While Walking or Running)

  • Burning or Tingling Sensation in the Foot (Mistaken for Nerve Pain or Neuropathy)

  • Pain That Feels Worse When Wearing Tight Shoes or High Heels

  • Cramping or Tightness in the Big Toe, Especially After Activity

Pain worsens with prolonged walking, running, or wearing restrictive footwear.

Perpetuating Factors

Common causes of extensor hallucis brevis trigger points include:

  • Wearing Tight or Narrow Shoes (E.g., High Heels, Cleats, or Dress Shoes)

  • Overuse From Running, Sprinting, or Jumping

  • Foot Instability Due to High Arches or Flat Feet

  • Prolonged Standing or Walking on Hard Surfaces

  • Toe-Curling Movements or Foot Strain from Certain Sports (Dancing, Ballet, or Soccer)

Trigger Point Referral Pattern

Trigger points in the extensor hallucis brevis refer pain to:

  • The top of the foot, especially near the big toe

  • The first metatarsophalangeal (MTP) joint (Big Toe Joint)

  • The dorsum of the foot (Can Resemble Arthritis or Nerve Pain)

Pain from this muscle is often confused with bunions, nerve entrapment, or osteoarthritis.

Differential Diagnosis

Extensor hallucis brevis trigger points may be mistaken for:

  • Hallux Rigidus (Stiffness and Pain in the Big Toe Joint, Worsens with Movement)

  • Bunion Pain (Pain on the Inner Side of the Big Toe, Different from Dorsal Foot Pain)

  • Morton’s Neuroma (Pain Between the Toes with a "Pebble in the Shoe" Sensation)

  • Tarsal Tunnel Syndrome (Burning Pain and Numbness in the Foot and Toes)

  • Stress Fractures in the First Metatarsal (Pain That Worsens with Impact Activities)

A thorough foot examination is necessary to rule out these conditions.

Associated Trigger Points

Extensor hallucis brevis trigger points often co-exist with:

  • Extensor Hallucis Longus (Big Toe Pain and Foot Drop Symptoms)

  • Extensor Digitorum Longus (Pain in the Foot and Lower Leg, Affects Toe Control)

  • Tibialis Anterior (Shin and Foot Pain, Weak Foot Dorsiflexion)

  • Peroneus Longus and Brevis (Lateral Foot and Ankle Pain, Can Affect Balance and Gait)

Anatomy and Innervation

Muscle Origin Insertion Innervation
Extensor Hallucis Brevis Calcaneus (Heel Bone) Base of the proximal phalanx of the big toe Deep fibular (peroneal) nerve (L5–S1)

The EHB is innervated by the deep fibular nerve, which also controls toe extension and foot dorsiflexion.

Patient Examination

A comprehensive examination should include:

  • Palpation: Identify tender nodules along the top of the foot, near the big toe joint.

  • Big Toe Extension Strength Testing: Assess pain and weakness when lifting the big toe upward against resistance.

  • Gait Analysis: Look for toe-off weakness or abnormal foot movement patterns while walking or running.

  • Footwear Assessment: Determine if improper shoes are contributing to symptoms.

Corrective Actions

Manual Therapy

  • Trigger Point Release: Apply direct pressure to tight spots along the top of the foot.

  • Massage Therapy: Helps improve circulation and reduce foot tension.

Stretching

  • Big Toe Extension Stretch: Pull the big toe upward gently while keeping the foot relaxed.

  • Foot Dorsiflexion Stretch: Stretch the shin and top of the foot by pressing the toes downward while standing.

Strengthening Exercises

  • Toe Raises: Strengthens the extensor hallucis brevis and foot stabilizers.

  • Resistance Band Toe Extensions: Improves big toe control and foot endurance.

  • Tibialis Anterior Strengthening: Prevents overuse of the EHB in dorsiflexion movements.

Postural and Footwear Adjustments

  • Wear Supportive Shoes With a Wide Toe Box

  • Use Custom Orthotics to Improve Foot Alignment

  • Avoid Excessive Barefoot Walking on Hard Surfaces

Summary Table: Extensor Hallucis Brevis Trigger Points

Field Details
Name & Area Extensor Hallucis Brevis; Top of the foot, spanning from the calcaneus to the big toe
Indications Foot and big toe pain, weakness in toe extension, discomfort while walking
Muscle Action Extends the big toe, stabilizes the foot, assists in walking and running
Signs & Symptoms Pain on the top of the foot, difficulty extending big toe, tightness in the foo
Perpetuating Factors Tight shoes, excessive running, foot instability, prolonged standing
Trigger Point Referral Dorsum of the foot, big toe, metatarsal region
Differential Diagnosis Hallux rigidus, bunion pain, Morton’s neuroma, tarsal tunnel syndrome, stress fractures
Associated Trigger Points Extensor hallucis longus, extensor digitorum longus, tibialis anterior, peroneus longus/brevis
Anatomy & Innervation Deep fibular (peroneal) nerve (L5–S1)
Corrective Actions Manual therapy, stretching, strengthening, footwear modifications

➡️ Learn more about Trigger Points

Sources:

  • Travell, J. G., & Simons, D. G. (1983). Myofascial Pain and Dysfunction: The Trigger Point Manual (2nd ed.). Williams & Wilkins.

  • Simons, D., & Travell, J. (1999). The Trigger Point Manual, Volume 2: The Lower Extremities. Williams & Wilkins.