Hallux Saltans
Other Names
- Hallux Saltans (HS)
- Trigger Toe
- FHL Stenosing Tenosynovitis
- Flexor Hallucis Longus Tendon Triggering
- Flexor Hallucis Longus Tendinopathy (Trigger Variant)
- Stenosing Tenosynovitis of the Great Toe
- FHL Entrapment Syndrome
Background
- This page refers to Hallux Saltans or FHL Stenosis Tenosynovitis, often caleld "Trigger Toe"
History
Epidemiology
- Rare disease, limited to case reports
Introduction
General
- Rare clinical condition characterized by compression and triggering of the flexor hallucis longus (FHL) tendon
- Characterized by the big toe being stuck in the bent position, brought back into extension manually with a "click" sound
- Due to rarity of condition, diagnosis is often missed or delayed
- Treatment can be surgical or conservative depending on the underlying etiology
Etiology
- In dancers
- The 'demi pointe' movement is performed, the overload on FHL tendon causes this injury[5]
Pathophysiology
- Repeated excessive joint movements in the foot and ankle result in irritation, inflammation and hypertrophy of the FHL tendon
- This can lead to intra-tendon partial tears, nodules and trigger finger formation
- Entrapment can occur at:
- Entrapment commonly occurs at the fibrous bone tunnel below the sustentaculum tali[6]
- Os Trigonum
- Hallux Sesamoids
- Knot of Henry[7]
Anatomy of the Flexor Hallucis Longus
- Origin: Fibula (distal 2/3, posterior surface), Interosseous Membrane of the Leg, Tibialis Posterior Muscle (fascia)
- Anatomic Course
- Muscle belly runs in deep posterior compartment of the leg
- Tendon passes posterior to the ankle, deep to the Achilles Tendon
- Enters fibro-osseous tunnel between talus and calcaneus (retrotalar pulley)
- Courses into plantar foot and crosses the FDL at the Knot of Henry
- Travels between the medial and lateral sesamoids of the first metatarsal head
- Insertion: Base of distal phalanx of great toe
- Function: plantar flexion, inversion of foot; flexion of MTP and IP joints of great toe
Risk Factors
Sports
Differential Diagnosis
Differential Diagnosis Hallux Saltans
- Flexor Hallucis Longus Tendinopathy
- FHL tendon tear or partial rupture
- FHL tendon entrapment at the posterior talus or retrotalar pulley
- FHL tenosynovitis without triggering
- Os Trigonum Syndrome
- Stenosing tenosynovitis at the sesamoids
- Sesamoiditis
- Turf Toe (1st MTP joint sprain)
- Hallux Rigidus
- Hallux valgus with mechanical irritation
- Plantar plate injury of the 1st MTP joint
- Gout affecting the 1st MTP
- Osteoarthritis of the 1st MTP joint
- Intersection syndrome of the FHL with other tendons
- Posterior ankle impingement syndrome
- Ganglion cyst or fibroma along the FHL tendon sheath
Differential Diagnosis Foot Pain
- Fractures & Osseous Disease
- Traumatic/ Acute
- Stress Fractures
- Other Osseous
- Dislocations & Subluxations
- Muscle and Tendon Injuries
- Ligament Injuries
- Plantar Fasciopathy (Plantar Fasciitis)
- Turf Toe
- Plantar Plate Tear
- Spring Ligament Injury
- Neuropathies
- Mortons Neuroma
- Tarsal Tunnel Syndrome
- Joggers Foot (Medial Plantar Nerve)
- Baxters Neuropathy (Lateral Plantar Nerve)
- Arthropathies
- Hallux Rigidus (1st MTPJ OA)
- Gout
- Toenail
- Pediatrics
- Fifth Metatarsal Apophysitis (Iselin's Disease)
- Calcaneal Apophysitis (Sever's Disease)
- Freibergs Disease (Avascular Necrosis of the Metatarsal Head)
- Kohlers Disease (Avascular Necrosis of the Navicular)
Clinical Features
History
- Patients will report "triggering" or the big toe getting stuck in flexion
- May describe it as snapping, catching or locking
- Pain can be provked by activities that load the FHL tendon
- Including walking, running and classically, ballet dancing
- It is often accompanied by retromalleolar pain
- Often insidious following repetitive strain or microtrauma
Physical Exam
- Hallmark is visible or palpable triggering or snapping of the hallux as the patient actively flexes and extends the toe
- Tenderness along the anatomic course of the FHL tendon
- Less commonly, a palpable nodule is found
- Swelling along the course of the FHL tendon can be seen
- Passive range of motion may reprorduce triggering
Special Tests
- Flexor Hallucis Longus Stretch Test: passively stretch FHL in plantarflexion and dorsiflexion
Evaluation
Radiographs
- Standard Radiographs Foot
- Typically normal
- Useful to exclude osseous pathology
Ultrasound
- Dynamic ultrasound is the imaging modality of choice[14]
- Can directly visualize FHL tendon triggering
- Associated tenosynovitis during active/assive movement
- Potential findings
- Nodular thickening of the trapped FHL tendon
- Tendon tears
MRI
- Complimentary study if ultarsound is inconclusive or suspicion for additional pathology
- Provides excellent soft tissue evaluation
- Evaluates for other etiology of hallux pain
- Potential findings[15]
- Tenosynovitis
- Tendon thickening
- Other causes of pain
Classification
- Not applicable
Management
Nonoperative
- Indications
- Vast majority of cases
- Activity modification
- Footwear modification
- Shoes with a wider or deeper toe box to reduce pressure on the hallux and FHL tendon[16]
- Orthotics[17]
- Both prefabricated and custom insoles, metatarsal pads, and molded forefoot orthoses
- Can help offload pressure, improve pain, and restore function
- Physical Therapy[18]
- Stretching, home exercise programs, manual therapy, and taping for flexible deformities
- Effective for pain reduction and functional improvement
- Also consider
- Night Splint
- Toe separators
- Other padding techniques
- NSAIDS
Procedures
- Ultrasound guided corticosteroid injection[19]
- Consider Platelet Rich Plasma, Botox
Operative
- Indications[20]
- Persistent or significant symptoms despite conservative management
- Technique[21]
- FHL Tenotomy
- FHL Tendon lengthening
- Capsular or ligamentous release
- Excision of fibrous bands or adhesions
- Arthroscopic approach
Rehab and Return to Play
Rehabilitation
- General principles[22]
- Emphasizing stretching, joint mobilization, flexor hallucis strengthening
- Gait retraining to restore normal biomechanics and reduce recurrence
Return to Play/ Work
- RTP Milestones[22]
- Full, pain-free range of motion
- Restored strength
- Normalized, non-antalgic gait
- Typical return-to-play timeline ranges from 2 to 6 months with conservative management[23]
Prognosis and Complications
Prognosis
- General[24]
- Prognosis is generally favorable when condition is recognized early, managed appropriately
- Most patients will experience symptom resolution
Complications
- Chronic pain and functional limitation
- Progression to flexor hallucis longus (FHL) tendon degeneration or rupture
- Adhesion formation or recurrence of triggering
- Iatrogenic injury
- Stiffness or loss of range of motion
- Post operative complications (wound healing, infection, etc)
See Also
References
- ↑ Lewin, Philip. "The foot and ankle: their injuries, diseases, deformities and disabilities." The foot and ankle: Their injuries, diseases, deformities and disabilities. 1941. 665-665.
- ↑ MCCARROLL, JOHN R., MERRILL A. RITTER, and TED E. BECKER. "Triggering of the Great Toe: A Case Report." Clinical Orthopaedics and Related Research (1976-2007) 175 (1983): 184-185.
- ↑ Tokgöz, Mehmet Ali, et al. "Endoscopic treatment of bilateral hallux saltans in an ordinary woman." Joint Diseases and Related Surgery 30.3 (2019): 322-324.
- ↑ CHEMELLO, SARA, and HOSSEIN ANSARIPOUR. "Finite element analysis of socket optimization in accordance with the deformation of external surface of the stump." (2017).
- ↑ Tudisco C, Puddu G. Stenosing tenosynovitis of the flexor hallucis longus tendon in a classical ballet dancer. A case report. Am J Sports Med 1984;12:403-4.
- ↑ Purushothaman, Rajesh, et al. "Hallux saltans due to flexor hallucis longus entrapment at a previously unreported site in an unskilled manual laborer: a case report." The Journal of foot and ankle surgery 51.3 (2012): 334-336.
- ↑ Boruta, Peter M., and Gilbert D. Beauperthuy. "Partial tear of the flexor hallucis longus at the knot of Henry: presentation of three cases." Foot & ankle international 18.4 (1997): 243-246.
- ↑ Moorman 3rd, C. T., R. R. Monto, and F. H. Bassett 3rd. "So-called trigger ankle due to an aberrant flexor hallucis longus muscle in a tennis player. A case report." JBJS 74.2 (1992): 294-295.
- ↑ Cooper, MITCHELL E., and PRESTON M. Wolin. "Os trigonum syndrome with flexor hallucis longus tenosynovitis in a professional football referee." Medicine and science in sports and exercise 31.7 Suppl (1999): S493-6.
- ↑ Theodore, GEORGE H., GEORGE J. Kolettis, and LYLE J. Micheli. "Tenosynovitis of the flexor hallucis longus in a long-distance runner." Medicine and science in sports and exercise 28.3 (1996): 277-279.
- ↑ Olden, Theresa Rebecca, and Jacques Vallotton. "Endoscopic tenolysis of flexor hallucis longus tendon: surgical technique." Arthroscopy Techniques 9.9 (2020): e1269-e1273.
- ↑ 12.0 12.1 Pereira, Vinícius Felipe, et al. "Posterior ankle impingement syndrome in athletes: surgical outcomes of a case series." Scientific Journal of the Foot & Ankle 13.1 (2019): 15-21.
- ↑ Martinez-Salazar, Edgar Leonardo, et al. "Hallux saltans due to stenosing tenosynovitis of flexor hallucis longus: dynamic sonography and arthroscopic findings." Skeletal radiology 47.5 (2018): 747-750.
- ↑ Martinez-Salazar, Edgar Leonardo, et al. "Hallux saltans due to stenosing tenosynovitis of flexor hallucis longus: dynamic sonography and arthroscopic findings." Skeletal radiology 47.5 (2018): 747-750.
- ↑ Tafur, Monica, et al. "ACR Appropriateness Criteria® chronic foot pain." Journal of the American College of Radiology 17.11 (2020): S391-S402.
- ↑ Cooper, Minton Truitt. "Common painful foot and ankle conditions: a review." Jama 330.23 (2023): 2285-2294.
- ↑ Thomas, James L., et al. "Diagnosis and treatment of forefoot disorders. Section 1: digital deformities." The Journal of foot and ankle surgery 48.2 (2009): 230-238.
- ↑ Hurn, Sheree E., et al. "Effectiveness of nonsurgical interventions for hallux valgus: a systematic review and meta‐analysis." Arthritis care & research 74.10 (2022): 1676-1688.
- ↑ Erden, Yakup, Umut Güven, and Elif Selim Bahadır. "Trigger Hallux Due to Flexor Hallucis Longus Stenosing Tenosynovitis: Insights From Ultrasound Evaluation and Dynamic Imaging." Asia Pacific Journal of Pain (2025).
- ↑ Purushothaman, Rajesh, et al. "Hallux saltans due to flexor hallucis longus entrapment at a previously unreported site in an unskilled manual laborer: a case report." The Journal of foot and ankle surgery 51.3 (2012): 334-336.
- ↑ Mariano, Ashley A., and Lawrence M. Fallat. "Comparison outcomes of cheilectomy, hemi-implant arthroplasty and decompression osteotomy for the treatment of hallux rigidus: A retrospective study of 153 patients." The Journal of Foot and Ankle Surgery (2025).
- ↑ 22.0 22.1 Shamus, Jennifer, et al. "The effect of sesamoid mobilization, flexor hallucis strengthening, and gait training on reducing pain and restoring function in individuals with hallux limitus: a clinical trial." Journal of Orthopaedic & Sports Physical Therapy 34.7 (2004): 368-376.
- ↑ Sugimoto, Dai, et al. "Hallux sesamoid injury characteristics in young athletes presented to the sports medicine clinic." Clinical Journal of Sport Medicine 32.3 (2022): e276-e280.
- ↑ Martinez-Salazar, Edgar Leonardo, et al. "Hallux saltans due to stenosing tenosynovitis of flexor hallucis longus: dynamic sonography and arthroscopic findings." Skeletal radiology 47.5 (2018): 747-750.