Extensor Hallucis Longus Trigger Points

Introduction

The extensor hallucis longus (EHL) is a key lower leg muscle responsible for extending the big toe and dorsiflexing the foot. When trigger points develop in this muscle, they can cause pain in the shin, top of the foot, and big toe, often mimicking nerve compression, arthritis, or tendon injuries.

Name and Area

  • Name: Extensor Hallucis Longus (EHL)

  • Area: Located on the anterior lower leg, running from the fibula to the base of the big toe (hallux).

Indications

Extensor hallucis longus trigger points may contribute to:

  • Pain in the Shin and Top of the Foot (Mistaken for Shin Splints or Stress Fractures)

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

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

  • Weakness in Big Toe Extension (Difficulty Lifting the Toe While Walking)

  • Pain That Increases When Walking, Running, or Wearing Tight Shoes

  • Aching or Burning Sensation in the Lower Leg After Extended Standing or Activity

Pain from this muscle is often mistaken for nerve compression, foot arthritis, or extensor tendinitis.

Muscle Action

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

  • Dorsiflexes the Foot: Raises the foot, helping to prevent foot drop.

  • Assists in Foot Inversion: Helps slightly rotate the foot inward.

The EHL is essential for balance, walking, and running, ensuring proper toe-off mechanics.

Signs and Symptoms

Individuals with extensor hallucis longus trigger points often report:

  • Pain in the Shin and Top of the Foot, Near the Big Toe

  • Difficulty Lifting 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 With Running or Walking Long Distances

  • Big Toe Stiffness or Weakness, Especially in the Morning or After Activity

Pain worsens with repetitive walking, running, or prolonged standing.

Perpetuating Factors

Common causes of extensor hallucis longus trigger points include:

  • Running or Sprinting Without Proper Foot Support

  • Wearing Tight Shoes or Cleats (Common in Soccer, Football, and Ballet Dancers)

  • Overuse From Sports That Require Quick Toe Movements (Tennis, Basketball, or Gymnastics)

  • Walking or Standing for Long Periods on Hard Surfaces

  • Foot Drop or Weak Tibialis Anterior (Leading to Overuse of the EHL to Compensate)

Trigger Point Referral Pattern

Trigger points in the extensor hallucis longus refer pain to:

  • The shin and top of the foot (Mistaken for Shin Splints or Stress Fractures)

  • The big toe joint (Can Mimic Gout or Hallux Rigidus)

  • The front of the ankle (Mistaken for Ankle Sprains or Tendinitis)

Pain from this muscle is often confused with nerve compression, stress fractures, or overuse injuries.

Differential Diagnosis

Extensor hallucis longus trigger points may be mistaken for:

  • Shin Splints (Medial Tibial Stress Syndrome – Pain Along the Inner Shin, Rather Than the Front of the Leg)

  • Compartment Syndrome (Severe Tightness and Pain in the Lower Leg That Worsens With Activity)

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

  • Stress Fractures in the Tibia or Metatarsals (Pain That Worsens With Impact Activities)

  • Peripheral Neuropathy (Tingling, Numbness, and Burning Pain in the Feet and Toes)

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

Associated Trigger Points

Extensor hallucis longus trigger points often co-exist with:

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

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

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

  • Gastrocnemius and Soleus (Calf Tightness That Can Exacerbate Foot Weakness and Pain)

Anatomy and Innervation

Muscle Origin Insertion Innervation
Extensor Hallucis Longus Fibula, interosseous membrane Base of the distal phalanx of the big toe Deep fibular (peroneal) nerve (L5–S1)

The EHL 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 shin, near the ankle, and on top of the foot.

  • 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 shin and foot.

  • Massage Therapy: Helps improve circulation and reduce muscle tightness.

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 longus and foot stabilizers.

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

  • Tibialis Anterior Strengthening: Prevents overuse of the EHL 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 Longus Trigger Points

Field Details
Name & Area Extensor Hallucis Longus; Front of the shin, spanning fibula to the big toe
Indications Shin and foot pain, big toe weakness, discomfort while walking
Muscle Action Extends the big toe, dorsiflexes the foot, assists in foot inversion
Signs & Symptoms Pain in the shin and top of the foot, difficulty lifting the big toe, tightness in the foot
Perpetuating Factors Tight shoes, excessive running, foot instability, prolonged standing
Trigger Point Referral Shin, top of the foot, big toe, front of the ankle
Differential Diagnosis Shin splints, compartment syndrome, tarsal tunnel syndrome, stress fractures
Associated Trigger Points Tibialis anterior, extensor digitorum longus, peroneus longus/brevis, gastrocnemius/soleus
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.