Extensor Hallucis Longus (EHL) Tendon Rupture

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Extensor Hallucis Longus (EHL) Tendon Rupture

A patient guide by Mr Matthew Welck, Consultant Orthopaedic Foot & Ankle Surgeon, London and North London

The extensor hallucis longus (EHL) tendon runs over the top of the foot and lifts the big toe. It is most often cut when a knife, piece of glass or mirror is dropped on a bare foot, and the injury is often missed when the wound is first treated. Without this tendon working, the big toe droops and can catch on the ground when you walk. Surgery to repair it usually works well, even if treatment is delayed. This guide explains the injury and the treatment options available in London and North London.

At a Glance: EHL Tendon Rupture

Key factEHL tendon rupture
What it isA cut or tear of the tendon that lifts the big toe
Who it affectsAnyone with a cut on the top of the foot; tears without a cut are rare
Main symptomsNot being able to lift the tip of the big toe, a drooping toe, catching the toe when barefoot
Key testsExamination by a specialist; an ultrasound or MRI scan; an X-ray to check for glass or bony spurs
Non-surgical optionA toe splint for 4–6 weeks for partial tears, or cuts near the tip of the toe
SurgeryStitching the tendon ends back together; using another tendon to bridge the gap if the ends cannot meet; occasionally fusing (stiffening) a toe joint
RecoveryAbout 6 weeks in a splint and cast, then a boot and physiotherapy
EvidenceStudies of groups of patients; around 95% can lift the toe again after repair

01

What Is an EHL Tendon Rupture?

The EHL muscle sits at the front of the shin. Its tendon (the tough cord that attaches muscle to bone) passes across the front of the ankle under a band of tissue that holds the tendons in place, then runs along the top of the foot to the end of the big toe. Its job is to lift the big toe. This helps your foot clear the ground when you walk and keeps the toe straight.

A second, smaller tendon (extensor hallucis brevis) lifts the big toe where it joins the foot. So after an EHL injury, the toe may still lift a little at its base while the tip droops. This is one reason the injury can be easy to miss.

02

How Common Is It?

Injuries to the tendons that lift the toes are not rare. In a well-known study of more than 1,000 muscle and tendon injuries, these tendons made up 11% of injuries in the leg and foot.

In one study of 20 patients who had surgery, the tendon injury had been missed at their first A&E visit in 65% of cases (about two in three). Tears that happen without a cut are rare: a 2012 review of published research found only around 20 reported cases.

03

What Causes EHL Rupture?

  • Cuts: a knife, glass, a mirror, a tile or another sharp object dropped on a bare foot
  • The toe being forced downwards: or pressure from tight ski or skate boots
  • Bony spurs: a small lump of extra bone at the front of the ankle can rub on the tendon and wear through it
  • Steroid injections and inflammatory conditions: conditions that cause inflammation in the body can weaken tendons
  • Nearby surgery: occasionally after bunion surgery or keyhole ankle surgery (arthroscopy)

04

What Are the Symptoms?

  • Not being able to lift the tip of the big toe
  • A big toe that droops or curls downwards
  • Catching or stubbing the toe, especially when barefoot or on stairs
  • A wound on the top of the foot, or a gap you can feel along the line of the tendon
  • Mild pain or swelling over the top of the foot

A cut on the top of the foot?

If you cut the top of your foot on glass or a knife, the strength of your big toe should be checked before the wound is stitched or closed. If your toe still droops after a wound has healed, ask for a specialist assessment: it is often still possible to repair the tendon later.

05

What Investigations Might You Need?

  • An examination, where the specialist checks the tip and the base of your toe separately
  • An ultrasound scan to confirm the tear and see how far apart the tendon ends have pulled
  • An MRI scan if there was no cut, or if the diagnosis is unclear
  • X-rays to look for any glass left in the foot or a bony spur

06

Non-Surgical Treatment Options

Some injuries can be treated without surgery.

  • Partial cuts: a splint holds the toe straight for 4–6 weeks
  • Cuts near the tip of the toe: the toe often still works well
  • Tears caused by wear and tear (without a cut): in less active people, who may be happy to live with a mild droop
  • Supportive shoes and advice on activity

If the tendon is completely cut and you are active, surgery is usually recommended. This is because the cut ends pull apart and will not heal back together on their own.

07

Surgical Options for EHL Rupture

The aim of surgery is to repair the tendon so your big toe can lift and sit straight again. The type of operation depends on how long ago the injury happened and how far apart the tendon ends are.

Direct Repair

The wound is made slightly longer so the surgeon can find both ends of the tendon. The ends are tidied and then sewn together with strong stitches. Even when the ends have pulled apart (by an average of 3.3 cm in one study), gently stretching them usually brings them back together: in that study, 80% could still be stitched directly. If the injury is under the band of tissue at the front of the ankle, this band is partly opened and then repaired.

Tendon Transfer or Graft

If the ends cannot be brought together, the tendon that lifts the second toe can be moved across and joined to the EHL. Its loose end is attached to the tendon of the third toe, so the second toe can still lift. Another option is to bridge the gap with a piece of tendon (a graft) taken from the second toe, the back of the thigh (hamstring) or elsewhere. If a bony spur caused the tear, the spur is removed and the tendon is repaired or joined to a neighbouring tendon.

Big Toe Joint Fusion

If only the tip of the toe droops and catches, a simple and reliable option is to fuse (permanently stiffen) the small joint near the tip of the big toe.

Comparing the Main Treatment Options

OptionWhen it is usedWhat to expect
SplintPartial cut, or a cut near the tip of the toeGood function in selected cases
Direct repairMost complete cuts, even if delayedAround 95% can lift the toe again
Transfer or graftEnds cannot be brought togetherRestores lift; small effect on the toe the tendon is taken from
Toe joint fusionTip of the toe keeps droopingStops catching; tip of the toe no longer bends

Recovery After Surgery

After the repair, your toe is held in a splint in a slightly raised position. You will need to keep weight off your foot for about three weeks, then wear a cast for another three weeks, followed by a walking boot and physiotherapy. Most people return to normal footwear at around eight to ten weeks.

Results are usually good. In one study of 20 patients followed up for around five years, people scored on average 94% for everyday activities, 95% could lift their big toe again, and 15% had a complication (mainly stiffness or a mild droop of the toe).

08

Why Choose Mr Welck?

Mr Matthew Welck is a Consultant Orthopaedic Foot & Ankle Surgeon at the Royal National Orthopaedic Hospital (RNOH), Stanmore, and Honorary Associate Clinical Professor at University College London (UCL).

He has an exclusive specialist practice dedicated to the foot and ankle, with clinics in Central and North London. At the RNOH, one of the UK’s leading specialist orthopaedic hospitals, he regularly sees patients with tendon injuries of the foot, including EHL tears that were missed or treated late, and patients referred by other surgeons.

Sports injuries are a large part of his work. Where helpful, he uses a weight-bearing CT scan (a 3D scan taken while you stand) to show how the foot works under load and find the underlying cause of a tendon problem. His wider practice covers total ankle replacement, complex reconstruction and revision (repeat) surgery, so if a long-standing tendon problem has affected the joints, the whole picture can be managed in one place.

Mr Welck is research-active, with more than 50 published research papers, sits on the Education Committee of the British Orthopaedic Foot & Ankle Society (BOFAS) and teaches senior trainee surgeons how to manage tendon tears. Every treatment plan is agreed together with you, based on what matters most to you.

09

Frequently Asked Questions

How do I know if I have cut my big toe tendon?

If you cannot lift the tip of your big toe, or it droops after a cut on the top of the foot, the EHL tendon may be damaged. A specialist can test it properly.

Can the tendon heal without surgery?

Partial cuts and cuts near the tip of the toe can heal with a splint. A complete cut usually needs repair because the ends pull apart.

Is it too late to repair if the injury was missed?

Often not. Most tendons can still be stitched back together weeks after the injury. If not, another tendon can be used to bridge the gap and restore movement.

Can I walk normally without the EHL tendon?

Many people can walk, but the toe may catch or droop, especially when barefoot. Over time the toe can curl, which can be corrected with surgery.

How long will I be in a splint or cast?

Usually about six weeks in total, followed by a boot and physiotherapy. Most return to normal shoes at eight to ten weeks.

What are the risks of surgery?

Risks include stiffness, a mild droop of the toe, wound problems, numbness from damage to small nerves in the skin and, rarely, the tendon tearing again.

Can a bone spur really cause a rupture?

Yes. A bony spur at the front of the ankle can wear through the tendon over time. Removing the spur and repairing the tendon treats both problems.

Where can I see a foot and ankle surgeon in London for a toe tendon injury?

Mr Matthew Welck sees patients at HCA The Princess Grace Hospital in Central London, and at Spire Bushey, HCA The Wellington Hospital Elstree and the RNOH Private Patients Unit in North London.

10

Book a Consultation

If you think you may have an EHL tendon injury, or your big toe droops after a cut to the top of your foot, seeing a specialist early gives you the widest choice of treatment. Mr Welck sees private patients (insured and self-funding) and NHS patients at the following locations:

  • HCA The Princess Grace Hospital, Central London (outpatients at Nottingham Place, W1U 5NY and 30 Devonshire Street, W1G 6PU)
  • HCA The Wellington Hospital Elstree, North London
  • Spire Bushey, North London (0203 733 5665)
  • RNOH Private Patients Unit, Stanmore, North London

Telephone 07547 395 270, email secretary@matthewwelck.com or book a consultation online. Patients are seen from across London, Hertfordshire, the UK and overseas.

Written and medically reviewed by Mr Matthew Welck

MBChB FRCS (Tr&Orth), Consultant Orthopaedic Foot & Ankle Surgeon, RNOH Stanmore; Honorary Associate Clinical Professor, UCL. GMC 6074385.

Last reviewed: October 2026. Next review due: October 2027.

References

  1. Wong JC, Daniel JN, Raikin SM. Repair of acute extensor hallucis longus tendon injuries: a retrospective review. Foot Ankle Spec 2014;7:45–51. doi:10.1177/1938640013514271
  2. Al-Qattan MM. Surgical treatment and results in 17 cases of open lacerations of the extensor hallucis longus tendon. J Plast Reconstr Aesthet Surg 2007;60:360–7.
  3. Fadel GE, Alipour F. Rupture of the extensor hallucis longus tendon caused by talar neck osteophyte. Foot Ankle Surg 2008;14:100–2. doi:10.1016/j.fas.2007.11.004
  4. Lohrer H, Nauck T. Subcutaneous extensor hallucis longus tendon rupture: case report and literature review. Foot Ankle Int 2012;33:905–11. doi:10.3113/FAI.2012.0905
  5. Anzel SH, et al. Disruption of muscles and tendons: an analysis of 1,014 cases. Surgery 1959;45:406–14.
  6. Bastías GF, et al. Technique tip: extensor digitorum longus to extensor hallucis longus double loop transfer for EHL reconstruction. Foot Ankle Surg 2019;25:272–7.

This guide is for general information and does not replace an individual consultation. Treatment decisions should be made with a clinician who has examined you.

Written by: Matthew Welck | Consultant Orthopaedic Foot & Ankle Surgeon London — last updated 23 October 2026

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/ GMC No. 6074385