Flexor Hallucis Brevis Trigger Points

Introduction

The flexor hallucis brevis (FHB) is a key foot muscle responsible for big toe flexion and arch support. When trigger points develop in this muscle, they can cause pain in the ball of the foot, big toe, and arch, often mimicking bunion pain, arthritis, or nerve compression.

Name and Area

  • Name: Flexor Hallucis Brevis (FHB)

  • Area: Located on the plantar surface (bottom) of the foot, running from the cuboid and cuneiform bones to the base of the big toe.

Indications

Flexor hallucis brevis trigger points may contribute to:

  • Pain in the Ball of the Foot (Mistaken for Metatarsalgia or Sesamoiditis)

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

  • Weakness in the Big Toe (Difficulty Pushing Off While Walking or Running)

  • Cramping or Tightness in the Big Toe (Especially After Long Periods of Standing or Walking)

  • Pain That Worsens When Wearing Tight Shoes or High Heels

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

Pain from this muscle is often mistaken for bunions, nerve compression, or toe joint arthritis.

Muscle Action

  • Flexes the Big Toe (Hallux): Bends the big toe at the metatarsophalangeal (MTP) joint.

  • Supports the Foot Arch: Assists other intrinsic foot muscles in stabilizing the medial arch.

The FHB is crucial for foot stability, balance, and push-off during walking and running.

Signs and Symptoms

Individuals with flexor hallucis brevis trigger points often report:

  • Pain in the Ball of the Foot, Near the Big Toe

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

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

  • Pain That Feels Worse After Long Periods of Walking or Standing

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

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

Perpetuating Factors

Common causes of flexor 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

  • Walking or Standing for Long Periods on Hard Surfaces (Retail Workers, Runners, Hikers)

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

Trigger Point Referral Pattern

Trigger points in the flexor hallucis brevis refer pain to:

  • The ball of the foot (Mistaken for Sesamoiditis or Metatarsalgia)

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

  • The inner arch of the foot (Can Be Misdiagnosed as Plantar Fasciitis or Nerve Pain)

Pain from this muscle is often confused with bunions, sesamoiditis, or arthritis.

Differential Diagnosis

Flexor 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 Ball of 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)

  • Metatarsalgia (Pain in the Ball of the Foot, Worsened by Walking or Running)

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

Associated Trigger Points

Flexor hallucis brevis trigger points often co-exist with:

  • Flexor Hallucis Longus (Big Toe Pain and Weakness in Toe Push-Off During Running and Walking)

  • Flexor Digitorum Brevis (Pain in the Arch and Toes, Affects Foot Stability and Control)

  • Tibialis Posterior (Pain Along the Inner Ankle and Foot, Affects Arch Support and Stability)

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

Anatomy and Innervation

Muscle Origin Insertion Innervation
Flexor Hallucis Brevis Cuboid and lateral cuneiform bones Base of the proximal phalanx of the big toe Medial plantar nerve (S1–S2)

The FHB is innervated by the medial plantar nerve, which also controls big toe flexion and foot stability.

Patient Examination

A comprehensive examination should include:

  • Palpation: Identify tender nodules along the ball of the foot and base of the big toe.

  • Big Toe Flexion Strength Testing: Assess pain and weakness when curling the big toe against resistance.

  • Gait Analysis: Look for abnormal foot movement patterns while walking or running.

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

Corrective Actions

Dry Needling

  • Dry needling can release trigger points in the flexor hallucis brevis, reducing muscle tightness and improving foot mobility.

Manual Therapy

  • Trigger Point Release: Apply direct pressure to tight spots in the ball of the foot and base of the big toe.

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

Stretching

  • Big Toe Flexor Stretch: Pull the big toe backward gently while keeping the foot relaxed.

  • Foot Arch Stretch: Roll a tennis ball or massage ball under the foot to loosen tight muscles.

Strengthening Exercises

  • Toe Gripping Exercises: Strengthens the flexor hallucis brevis and foot stabilizers.

  • Resistance Band Toe Flexion: Improves big toe control and push-off strength.

  • Short Foot Exercise: Helps activate the arch and improve foot stability.

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

Conclusion

The flexor hallucis brevis plays a crucial role in big toe flexion and arch support, but trigger points in this muscle can cause significant ball of foot, big toe, and arch pain. By incorporating dry needling, manual therapy, stretching, and strengthening exercises, individuals can reduce pain, improve mobility, and prevent future dysfunction.

➡️ 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.