Muscles
Flexor Hallucis Brevis
Symptom Area: Leg, Ankle and Foot
Short flexor of the big toe; trigger points cause pain under the first metatarsal head and the ball of the foot.
Overview
Flexor hallucis brevis lies in the plantar forefoot, running from the cuboid and cuneiforms to the base of the great toe with two heads containing the sesamoid bones. It flexes the big toe at the metatarsophalangeal joint and helps with push-off.
Trigger point locations
Points in the medial plantar forefoot, along the shaft of the first metatarsal proximal to the sesamoids.
Referred pain pattern
Pain under the head of the first metatarsal and the ball of the foot, sometimes into the great toe; often confused with sesamoiditis.
Palpation & testing
With the foot supported, press with the thumb along the plantar surface of the first metatarsal; a taut band that reproduces the forefoot pain confirms involvement.
Common causes
High heels and stiff-soled shoes, prolonged standing and push-off loading, running on hard surfaces, hallux valgus and limited big-toe extension.
Self-care & clinical treatment
Ball rolling on the plantar forefoot, big-toe mobility and intrinsic foot strengthening, wider and lower-heeled footwear, metatarsal padding when indicated. Clinically: manual release or needling, plus assessment of first-ray mechanics.
Treatment protocol
Evidence-based options, dosage and safety limits for this muscle. Educational content — not a substitute for individual clinical assessment.
Manual trigger point release
Position Flexor Hallucis Brevis in a shortened, fully supported position, locate the taut band across the fibres and hold the most tender nodule between finger and thumb (pincer grip) or against the underlying bone (flat palpation).
Apply sustained pressure release at an intensity the person rates 4-6/10, holding 30-60 seconds until the discomfort fades by roughly half, then release slowly. Repeat 2-3 times per point, once or twice a day. Follow each release with slow active movement through the full available range rather than stopping at the pressure itself.
Manual release, ischaemic compression and soft tissue technique reduce trigger point pain and pressure-pain threshold in systematic reviews, with effect sizes comparable to needling in the short term; combining manual work with movement retraining is what maintains the gain.
Charles 2019 · Simons & Travell · Shah 2015
Stretch, heat and movement dosage
Warm the area for 10-15 minutes (shower, hot pack) before stretching Flexor Hallucis Brevis: warm tissue tolerates the lengthening better and the post-release window is when range is easiest to gain.
Hold each stretch 30 seconds, 3 repetitions, 5-7 days a week, to the first firm resistance and never into referred pain. Add low-load isometrics or slow controlled repetitions in the newly gained range on the same day, then progress load once the daily pain pattern has settled.
Reassess after 2 weeks. If the trigger point keeps returning to the same spot, the driver is usually postural load, sustained shortening or an unaddressed perpetuating factor rather than the point itself.
Simons & Travell · Fernández-de-las-Peñas 2019
Dry needling and injection (clinician only)
Clinician onlyTrigger point dry needling of Flexor Hallucis Brevis is performed only by a clinician licensed for it, with clean-needle technique and informed consent. The taut band is fixed between the fingers and the needle advanced into the nodule; eliciting local twitch responses is associated with the largest immediate drop in pain and in spontaneous electrical activity.
Typical dosage in the trials is 1-2 sessions per week for 3-6 sessions, reassessing function each time, rather than open-ended treatment. Meta-analyses in upper-quarter and multi-region myofascial pain show reduced pain and improved pressure-pain threshold in the short and medium term compared with sham or no treatment.
Injection with local anaesthetic gives comparable pain relief to dry needling with less post-needling soreness; corticosteroid is not required for myofascial trigger points. Expect 24-72 hours of local soreness after needling and tell the person so in advance.
Kietrys 2013 · Gattie 2017 · Boyles 2015 · Cagnie 2013 · Hong 1994
Precautions and contraindications
In the calf, ankle and foot the tibial nerve and posterior tibial vessels in the deep posterior compartment, the common peroneal nerve at the fibular neck and the plantar neurovascular bundle guide needle placement. Post-treatment soreness in the calf must be distinguished from vascular or compartment symptoms.
Do not press or needle over broken or infected skin, an acute haematoma, a suspected fracture, a joint replacement approach, a tumour site, lymphoedema or an area with lost sensation. Anticoagulation, bleeding disorders, needle phobia, pregnancy, uncontrolled diabetes and immunosuppression all require the technique to be modified or avoided.
Documented adverse events after dry needling are mostly mild (bleeding, bruising, post-needling soreness, brief autonomic symptoms); serious events are rare and almost always relate to depth and direction in a thoracic or vascular field. Stop and seek urgent assessment for new breathlessness or chest pain, spreading numbness or weakness, fever, or a rapidly expanding swelling.
This page is educational and does not replace an individual clinical assessment. Progressive night pain, unexplained weight loss, cancer history, recent trauma or bladder and bowel change need medical evaluation before any trigger point treatment.
Halle 2016 · Boyce 2020
Sources for this protocol
- Effectiveness of dry needling for upper-quarter myofascial pain: a systematic review and meta-analysis — J Orthop Sports Phys Ther 2013;43(9):620-34
- The effectiveness of trigger point dry needling for musculoskeletal conditions by physical therapists: a systematic review and meta-analysis — J Orthop Sports Phys Ther 2017;47(3):133-49
- Effectiveness of trigger point dry needling for multiple body regions: a systematic review — J Man Manip Ther 2015;23(5):276-93
- A systematic review of manual therapy techniques, dry cupping and dry needling in the reduction of myofascial pain and myofascial trigger points — J Bodyw Mov Ther 2019;23(3):539-46
- Physiologic effects of dry needling — Curr Pain Headache Rep 2013;17(8):348
- Trigger point dry needling for the treatment of myofascial pain syndrome: current perspectives within a pain neuroscience paradigm — J Pain Res 2019;12:1899-911
- Myofascial trigger points then and now: a historical and scientific perspective — PM R 2015;7(7):746-61
- Pertinent dry needling considerations for minimizing adverse effects — Int J Sports Phys Ther 2016;11(5):651-62
- Adverse events associated with therapeutic dry needling — Int J Sports Phys Ther 2020;15(1):103-13
- Lidocaine injection versus dry needling to myofascial trigger point: the importance of the local twitch response — Am J Phys Med Rehabil 1994;73(4):256-63
- Myofascial Pain and Dysfunction: The Trigger Point Manual (2nd ed.) — Williams & Wilkins, Baltimore
Primary Symptoms
Secondary Symptoms
Related muscles in this region
References
- • triggerpoints.net — reference
Medically reviewed by: Physio Energy clinical team — physiotherapists specialised in myofascial pain · Last reviewed:

