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Flexor Hallucis Longus (FHL) & Flexor Digitorum Longus (FDL) Audio

Integrated functional anatomy of the flexor hallucis longus and flexor digitorum longus. Attachments, nerves, palpation, joint actions, arthrokinematics, fascia, triggerpoints, and behavior in postural dysfunction. Common exercises, foam rolling, and stretches for the toe flexors.

Flexor Hallucis Longus (FHL) & Flexor Digitorum Longus (FDL)

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I have been following Brent Brookbush for nearly a decade- back when I was a personal Trainer and now as a Physical Therapist. BBI is an incredible resource for any movement nerds and corrective exercise specialists! The information is thorough with multiple real world applications. I am looking forward to an in-person Manual Therapist course the second they do one a little bit closer to Virginia ;)

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We learn principles in academia, we learn cool new modalities via whatever specialty certification, but BBI really concentrates on the nuances of passive treatment and they do a fantastic job. The format in which BBI instructs soft tissue specialists (DPTs, Chiros, ATs) like myself feels like almost like an apprenticeship. You get a thoroughly detailed explanation of the “why’s”, and a visual comprehension of how to apply. Personally, I believe application is where the good and the great are distinguished.

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This course describes the anatomy and integrated function of the flexor hallucis longus and flexor digitorum longus muscles (a.k.a. hallucis longus and digitorum longus muscles, flexor hallucis and digitorum muscles, FHL and FDL muscles). These muscles are likely composed primarily of type II fibers (based on the composition of the peroneus longus, hallucis brevis, and digitorum brevis muscles). They are located deep to the soleus in the posterior compartment of the lower leg, the flexor hallucis longus tendon, and flexor digitorum longus tendon course behind the medial malleolus, through the tarsal tunnel, and invest into the plantar surfaces of the toes. These muscles cross and contribute to ankle (talocrural) plantar flexion and inversion, transverse tarsal joint flexion and supination, the FHL contributes to great toe flexion, and the FDL to metatarsophalangeal joint flexion of toes 2-5. This course also describes the role of the FHL and FDL in ankle and foot arthrokinematics, fascial integration, postural dysfunction, and subsystem integration. Sports medicine professionals (personal trainers, fitness instructors, physical therapists, massage therapists, chiropractors, occupational therapists, athletic trainers, etc.) must be aware of these deep compartment muscles of the lower leg and foot for detailed analysis of human movement, and the development of sophisticated exercise programs and therapeutic (rehabilitation) interventions. Further, this course is essential knowledge for future courses discussing injury prevention and physical rehabilitation including tendinopathy (a.k.a. hallucis longus tendon inflammation, flexor hallucis longus tendonitis, FHL tendon dysfunction, FHL & FDL tendonitis, etc.), as well as foot ankle dysfunctions (e.g. posterior ankle pain, hallux rigidus, tarsal tunnel syndrome, plantar nerve pain, plantar fasciitis, Achille’s tendonitis, shin splints, etc.) and FHL and FDL exercises and techniques (e.g. long toe flexor muscle or plantar flexor muscle release, mobilizations, lengthening and integration techniques).

Human Movement Specialist (HMS) Certification

Pre-approved for Continuing Education Credits for:

Brookbush Institute’s most recommended techniques for the Toe Flexors (see videos below):

Flexor Hallucis Longus & Flexor Digitorum Longus Static Manual Release

Talonavicular and Cuneonavicular Joint Manipulation

Dissection of the toe flexor muscles including flexor hallucis longus and flexor digitorum longus

 Course Description: Toe Flexor

Flexor - 1610s, Modern Latin, short for musculus flexor "a bending muscle," agent noun from past participle stem of Latin 

Hallucis - mid 19th century: modern Latin alteration of medieval Latin 

Dissection of the flexor hallucis longus and flexor digitorum longus muscles on the foot

Dissection of the deep posterior compartment of the lower leg - https://upload.wikimedia.org/wikipedia/commons/d/d2/Slide2ACA.JPG

Attachment of the flexor digitorum longus on the tibia

Attachment & Innervations: Flexor Hallucis Longus and Flexor Digitorum Longus

Flexor hallucis longus and flexor digitorum longus tendons 

The tendinous sheath enveloping the FHL, FDL, and Tibialis posterior tendons

Where are the Toe Flexor Muscles Located

Palpating the FHL and FDL

Introduction to the Toe Flexors

Phalanges: flexion of the interphalangeal joint of the great toe and assists in flexion of the metatarsophalangeal joint (15, 16, 17).

In most individuals, fascial slips connect the FHL to the FDL tendons of the 2nd toe, and in many individuals the 3rd and 4th toe. This implies that the FHL may be an important synergist for flexion on 2 - 4 toes during the toe-off phase of gait (16, 17)

Ankle: Plantar flexion of the foot, as well as, a weak invertor of the foot and ankle (11)

Phalanges: Flexion of the 2nd through 5th metatarsophalangeal joints, and proximal and distal interphalangeal joints.

Ankle: Plantar flexion of the foot, as well as, a weak invertor of the foot and ankle (11).

Stabilizes the ankle (tibiotalar & subtalar joints), transverse tarsal, tarsometatarsal, metatarsophalangeal, interphalangeal joints.

The FDL and FHL eccentrically decelerate extension of the metatarsophalangeal and interphalangeal joints, as well as, eccentrically decelerate dorsiflexion and eversion of the ankle.

The FHL and FDL work synergistically with the 

 to eccentrically decelerate eversion during the mid-stance of gait (8), further, this muscle may assist in inversion along with the soleus, medial gastrocnemius, and plantaris.

The FHL and FDL may assist other plantar flexors including the soleus, gastrocnemius, plantaris, and 

 muscles - playing an important role in push-off and landing mechanics.

A more obvious synergistic relationship exists between the FHL, FDL, flexor hallucis brevis (FHB), and flexor digitorum brevis (FDB) in flexion of the toes.

A functional relationship may exist between the FHL, the 

 control posterior glide via the navicular, the FHL may control talar inversion via the groove in the talus and the sustentaculum tali of the calcaneus.

Arthrokinematics

Toe Flexor Actions

My Fascial Hypothesis: Large fascial sheaths not only play a role in the transmission of mechanical force but may also play a role in dictating the function of muscular synergies. This is likely caused by reducing or increasing tone of invested musculature via reflex arcs formed between mechanoreceptors embedded in the connective tissue and the attached musculature. In this way, my view of fascia differs slightly from noted expert on the subject Tom Myers. I think of these large fascial sheaths (specifically the thoracolumbar fascia, iliotibial band, and abdominal fascial sheath) as nature's "motherboard." A place for mechanical information to be communicated to the nervous system for more efficient recruitment of the muscular system. Despite having a slightly different philosophy it does not change the fact that fascia plays an important communicative role in the human body and we have Tom Myers to thank for his work.

Image of the fascial system of the body connecting muscles

The most obvious relationship exists between the posterior tibial fascia and the investing FHL and FDL, linking the deep posterior compartment muscles by function and fascia. These muscles play an important role in decelerating pronation during the stance phase of gait, including optimal arthrokinematic motion of the talus. Further, the tendon and tendinous slips of the FHL may distribute the load in the forefoot, especially during toe-off. This increases the weight-bearing on the forefoot and helps the FHL support the medial longitudinal arch of the foot (17).

Tom Myers places the FHL and FDL (along with the 

) in the "deep front line" that continues to include the 

, pelvic floor, diaphragm, etc. (6). Tom Myers states in Anatomy Trains, "Piecemeal experimentation with the myofascia of the Deep Front Line can produce mixed results. (6, 2nd Edition pg 183)." Speaking from a "movement impairment standpoint" - I can see why. These muscles, as a group, do not have a bias toward under-activity or over-activity, but rather play strong roles in opposition to one another. For example, the 

 is commonly long and under-active, with the FHL and FDL acting as over-active synergists, while the adductors are commonly short and over-active, etc.. Although further consideration should be given to fascial connections both proximally and distally, these muscles are well encapsulated by the soleus (existing in a compartment separate from even the 

), and distally these muscles course over all other plantar muscles to insert into a bone with only one other insertion - the functional antagonist (EHL and EDL) on the opposing side of the bone. Creative thinking is always welcome, but this may be a case where over-thinking will only result in over-reaching.

The Long Flexor Tendons - http://upload.wikimedia.org/wikipedia/commons/a/a3/Gray444.png

Fascial Integration

The FHL and FDL fall into the weird category of 

 - a relationship that implies these muscles act as overactive synergists.

 the FDL and FHL play no significant role.

Lumbo Pelvic Hip Complex Dysfunction (LPHCD)

, the FDL and FHL play no significant role.

HMS Rule #5: Every inhibited prime mover will result in synergistic dominance of the ancillary movers for that joint action.

These muscles are long due to excessive eversion at the subtalar joint and a varus tilt of the talus, but rather than resulting in a decrease in tone, the inhibition of prime movers results in over-use and hyper-facilitation of these synergistic muscles. The FHL and FDL become synergistically dominant for an inhibited 

 That is to say that the overactive fibularis muscles result in altered reciprocal inhibition of the tibialis posterior and a relative increase in FHL and FDL activity to compensate for a lack of force production in inversion (or decelerating pronation during gait). Further, there is evidence to suggest that the FHL and FDL may play a similar role at the metatarsophalangeal joints, compensating for inhibited short toe flexors.

This may also lead to arthrokinematic dyskinesis, as over-activity may lead to an inferior glide of the distal interphalangeal joint, most commonly combined with over-activity of the 

, the superior glide of the metatarsophalangeal joint, and potentially "claw toe deformity." The change in arthrokinematics and activity may limit 

 of the toes - a particularly problematic compensation pattern that generally leads to excessive pronation (eversion) from heel-off to toe-off during the stance phase of gait, and excessive pronation and tibial external rotation during any activity that requires an individual to move on the "balls" or their feet (baseball swing, golf, changing direction, jumping, etc.).

, acting as overactive synergists. This implies these muscles should be released, and not stretched or activated. These trigger points in these muscles are often mistaken for gastrocnemius and soleus trigger points during 

self-administered release techniques for the calves

Where you will see the FHL and FDL mentioned during exercise programs in the 

Brookbush Institute of Human Movement Science

. This cue is used to reciprocally inhibit the FHL and FDL to reduce the chance that these muscles will continue to be synergistically dominant during exercises aimed at improving recruitment, neuromuscular control, and conditioning of the tibialis posterior.

Achilles tendonitis (long term over-activity = rupture?)

Signs of Altered Length/Tension and Tone:

Toe Extension < 70 - 80° (0° of extension of the IP's)

Toe Flexion < 90° (the distal phalanx forms a roughly 90° angle with the plane of the tarsal bones)

Gastrocnemius, soleus, and flexor complex trigger points

From top to bottom -
Lateral gastroc, soleus, and Flexor Hallucis Longus trigger points.

Palpation results in tenderness (trigger points or tender points) and may result in radiating symptoms along with the muscle and its tendons. Based on the theoretical model of trigger point development it would seem likely that “trigger points” are dysfunctional at the “motor point” of a muscle, and release will decrease tonicity via reflexive inhibition or ischemic pressure (8).

The common trigger points for the flexor hallucis longus and flexor digitorum longus

Postural Dysfunction and the Toe Flexors

Tibialis Posterior sports reconditioning (with cueing for FHL and FDL inhibition) - Hop Down to Stabilization:

Gastrocnemius and Soleus Self-administered Static Release

Seated Band Resisted Plantar Flexion and Inversion

Seated "Pigeon Toed" Calf Raise with Band Resisted Inversion

Dr. Brent Brookbush demonstrating a tibialis posterior activation exercise

 Standing "Pigeon Toed" Calf Raise with Band Resisted Inversion

Leaning Single Leg Calve Raise

Step Back to Soft Landing

Hop Down to Stabilization

Exercises and Techniques for the FHL and FDL

Phillip Page, Clare Frank, Robert Lardner, 

Assessment and Treatment of Muscle Imbalance: The Janda Approach 

NASM Essentials of Corrective Exercise Training

NASM Essentials of Personal Training: 4th Edition

Diagnoses and Treatment of Movement Impairment Syndromes,

David G. Simons, Janet Travell, Lois S. Simons, 

Travell & Simmons’ Myofascial Pain and Dysfunction, The Trigger Point Manual, Volume 1. Upper Half of Body: Second Edition

Joint Structure and Function: A Comprehensive Analysis: Fifth Edition

Florence Peterson Kendall, Elizabeth Kendall McCreary, Patricia Geise Provance, Mary McIntyre Rodgers, William Anthony Romani

Fitness or Fiction: The Truth About Diet and Exercise

Carolyn Richardson, Paul Hodges, Julie Hides. Therapeutic Exercise for Lumbo Pelvic Stabilization – A Motor Control Approach for the Treatment and Prevention of Low Back Pain: 2nd Edition (c) Elsevier Limited, 2004

Frank, RM, Hsu AR, Gross CE, Walton DM, Lee S. (2013). Open and arthroscopic surgical anatomy of the ankle. 

Edama M, Kubo M, Onishi M, et al. (2016). Anatomical study of toe flexion by flexor halluces longus. 

Mao H, Shi Z, Wapner KL, et al. (2015). Anatomical study for flexor halluces longus tendon transfer in treatment of Achilles tendinopathy. 

Lui TH. (2012). Flexor Digitorum Longus Tendoscopy. 

Precerutti M, Bonardi M, Ferrozzi G, Draghi F. (2014). Sonographic anatomy of the ankle. 

Bibliography

Questions, comments, and criticisms are welcome and encouraged

Flexor Hallucis Longus (FHL) & Flexor Digitorum Longus (FDL)

Related Courses:

Course Description: Toe Flexor

Introduction to the Toe Flexors
3 Sub Sections

Toe Flexor Actions
1 Sub Section

Fascial Integration

Postural Dysfunction and the Toe Flexors

Exercises and Techniques for the FHL and FDL
7 Sub Sections

Bibliography

Related Courses:

Comments

Guest

Flexor Hallucis Longus (FHL) & Flexor Digitorum Longus (FDL)

Related Courses:

Course Description: Toe Flexor

Introduction to the Toe Flexors3 Sub Sections

Toe Flexor Actions1 Sub Section

Fascial Integration

Postural Dysfunction and the Toe Flexors

Exercises and Techniques for the FHL and FDL7 Sub Sections

Bibliography

Related Courses:

Comments

Guest

Introduction to the Toe Flexors
3 Sub Sections

Toe Flexor Actions
1 Sub Section

Exercises and Techniques for the FHL and FDL
7 Sub Sections