Session 25 Anatomy 1.

The arrangement of the muscles, blood vessels, and nerves in the planar surface of the foot, (pp. 596-607): 4 muscular layers and 2 neurovascular layers i) 1st layer (1) abductor hallucis (a) origin: medial tubercle of tuberosity of calcaneus, flexor retinaculum, and plantar aponeurosis (b) insertion: medial side of base of proximal phalanx of 1 st digit (c) innervation: medial plantar nerve (S2,3) (d) action: abducts and flexes 1st digit (2) flexor digitorum brevis (a) origin: medial tubercle of tuberosity of calcaneus, plantar aponeurosis, and intermuscular septa (b) insertion: both sides of middle phalanges of lateral four digits (c) innervation: medial plantar nerve (S2,3) (d) action: flexes the four lateral toes (3) abductor digiti minimi (a) origin: medial and lateral tubercles of tuberosity of calcaneus, plantar aponeurosis, and intermuscular septa (b) insertion: lateral side of base of proximal phalanx of 5 th digit (c) innervation: lateral plantar nerve (S2,3) (d) action: abducts and flexes the small toe ii) neurovascular plane (1) plantar digital nerves from the medial and lateral plantar nerves nerves from medial plantar nerve supplies the three and a half medial digits; nerves the lateral plantar nerve supplies the one and a half lateral digits (2) plantar digital arteries and veins supply adjacent digits; arteries come from plantar metatarsal arteries iii) 2nd layer (1) quadratus plantae (a) origin: medial surface and lateral margin of plantar surface of calcaneus (b) insertion: posterolateral margin of tendon of flexor digitorum longus (c) innervation: lateral plantar nerve (S2,3) (d) action: assists flexor digitorum longus in flexing lateral four digits (2) tendons of the flexor hallucis longus and flexor digitorum longus (3) lumbricals (a) origin: tendons of flexor digitorum longus (b) insertion: medial aspect of expansion over lateral four digits (c) innervation: medial one medial plantar nerve (S2,3): lateral three lateral plantar nerve (S2,3)

(d) action: flex proximal phalanges and extend middle and distal phalanges of lateral four digits iv) 3rd layer (1) flexor hallucis brevis (a) origin: plantar surfaces of cuboid and lateral cuneiforms (b) insertion: both sides of base of proximal phalanx of 1 st digit (c) innervation: medial plantar nerve (S2,3) (d) action: flexes proximal phalanx of 1st digit (2) adductor hallucis (a) origin:oblique head bases of metatarsals 2-4; transverse head plantar ligaments of metatarsophalangeal joints (b) insertion: tendons of both heads attach to lateral side of base of proximal phalanx of 1st digit (c) innervation: deep branch of lateral plantar nerve (S2,3) (d) action: adducts 1st digit; assists in maintaining transverse arch of foot (3) flexor digiti minimi brevis (a) origin: base of the 5th metatarsal (b) insertion: base of proximal phalanx of 5 th digit (c) innervation: superficial branch of lateral plantar nerve (S2,3) (d) action: flexes proximal phalanx of 5th digit, thereby assisting with its flexion v) neurovascular plane (1) medial plantar nerve larger terminal branch of tibial nerve; passes distally in foot between abductor hallucis and flexor digitorum brevis and divides into muscular and cutaneous branches; supplies skin of medial side of sole of foot and sides of first three digits; also supplies abductor hallucis, flexor digitorum brevis, flexor hallucis brevis, and first lumbrical (2) lateral plantar nerve smaller branch of tibial nerve; passes laterally in foot between quadratus plantae and flexor digitorum brevis muscles and divides into superficial and deep branches; supplies quadratus plantae, abductor digiti minimi, and flexor digiti minimi brevis; deep branch supplies plantar and dorsal interossei, lateral three lumbricals, and adductor hallucis; supplies skin on sole lateral to a line splitting 4th digit (3) lateral plantar artery derived from posterior tibial artery; runs laterally and anteriorly, initially deep to the abductor hallucis and then deep to the flexor digitorum brevis; runs into the deep plantar arch; the arch gives off four plantar metatarsal arteries and three perforating branches th vi) 4 layer (1) plantar interossei (3 muscles) (PAD) (a) origin: bases and medial sides of metatarsals 3-5 (b) insertion: medial sides of bases of proximal phalanges of 3 rd-5th digits

(c) innervation: lateral plantar nerve (S2,3) (d) action: adduct digits 2-4 and flex metatarsophalangeal joints (2) dorsal interossei (DAB) (a) origin: adjacent sides of metatarsals 1-5 (b) insertion: first medial side of proximal phalanx of 2 nd digit; second to fourth lateral sides of 2nd to 4th digits (c) innervation: lateral plantar nerve (S2,3) (d) action: abduct digits 2-4 and flex metatarsophalangeal joints 2. Transverse and longitudinal arches of the foot and the ligaments which support them, (pp. 637-40): the tarsal and metatarsal bones are arranged in longitudinal and transverse arches that add to the weightbearing capabilities and resiliency of the foot a. Longitudinal arch composed of medial (higher and more important) and lateral parts; medial is composed of the calcaneus, talus, navicular, 3 cuneiforms, and 3 metatarsals the talar head is the keystone of this arch; medial arch is supported by fibularis longus tendon; lateral part is composed of the calcaneus, cuboid, and lateral 2 metatarsals b. Transverse arch runs from side to side; formed by cuboid, cuneiforms, and bases of the metatarsals; supported by fibularis longus tendon c. The integrity of the bony arches is maintained by the shape of the interlocking bones, strength of the plantar ligaments (especially the spring ligament and the long and short plantar ligaments), the plantar aponeurosis, and the adjacent muscles d. Long plantar ligament e. Calcaneonavicular (spring) ligament 3. Major joints of the foot, (pp. 637, Table 5.16, p. 638): a. Intertarsal i. Transverse tarsal (calcaneocuboid and talonavicular)1. calcaneocuboid anterior end of calcaneus articulates with posterior surface of cuboid; supported by dorsal calcaneocuboid ligament, plantar calcaneocuboid ligament, and long plantar ligament; involved with inversion and eversion of foot; blood supply is anterior tibial artery via lateral tarsal artery 2. talonavicular (talocalcaneonavicular) head of talus articulates with calcaneus and navicular bones; supported by plantar calcaneonavicular ligament; involved with gliding and rotatory movements are possible; blood supply is anterior tibial artery via lateral tarsal artery ii. Subtalar (talocalcaneal) inferior surface of body of talus articulates with superior surface of calcaneus; supported by medial, lateral, and posterior talocalcaneal ligaments, interosseous talocalcaneal ligament binds bones together);

involved with inversion and eversion of the foot; blood supply is posterior tibial and fibular arteries b. Tarsometatarsal arterior tarsal bones articulate with bases of metatarsal bones; supported by dorsal, plantar, and interosseous ligaments; blood supply is lateral tarsal artery c. Intermetatarsal bases of metatarsal bones articulate with each other; supported by dorsal, plantar, and interosseous ligaments; blood supply is lateral metatarsal artery d. Metatarsophalangeal heads of metatarsal bones articulate with bases of proximal phalanges; supported by collateral ligaments and plantar ligament; involved in flexion, extension, some abduction, adduction, and circumflexion; blood supply is lateral tarsal artery e. Interphalangeal (DIP and PIP) head of one phalanx articulates with bse of one distal to it; supported by collateral and plantar ligaments; involved in flexion and extension; supplied by digital branches of palmar arch 4. Comparison of the anatomy of the hand and foot - Appendix I!!. 5. Clinical correlates: a. Plantar fasciitis (p. 596) straining and inflammation of the plantar aponeurosis; caused by running and high impact aerobics, especially when inappropriate footwear are worn; causes pain on the plantar surface of the heel and the medial aspect of the foot, pain is most severe after sitting and when beginning to walk in the morning; point tenderness is located at the proximal attachment of the aponeurosis; if a calcaneal spur protrudes from the medial calcaneal tubercle, the plantar fasciites may product the heel spur syndrome- a bursa develops at the end of the spur that may become inflamed and tender b. Plantar reflex (p. 601) a deep tendon reflex (L4, L5, S1, and S2 nerve roots) that is routinely tested during neurological examinations; the lateral aspect of the sole is stroked with a blunt object, beginning at the heel and crossing to the base of the great toe; normal response: flexion of the toes; slight fanning of the lateral four toes and dorsiflexion of the great toe is an abnormal response indicative of brain injury or cerebral disease, except in infants c. Hallux valgus and bunions (p. 641) a foot deformity characterized by lateral deviation of the great toe; caused when the sesamoids under the head of the 1st metatarsal are displaced between the heads of the 1st and 2nd metatarsals causing the 1st metatarsal bone to shift laterally while the sesamoid bones shift medially; often this causes the surrounding tissues to swell and form a bursa, when is called a bunion when tender and inflamed d. Hammer toe (p. 641,2) deformity where the proximal phalanx is permanently flexed at the metatarsophalangeal joint and the middle phalanx is plantarflexed at the PIP joint; results from weakness of

the lumbricals and interossei; often causes callosity (callus) to form because raised surface of toe will rub against shoes e. Claw toes (p. 641-2) deformity characterized by hyperextension of the metatarsophalangeal joints and flexion of the DIP joints; usually all the lateral four toes are involved; often causes callosities f. Pes planus or flat feet (p. 642) deformity characterized by fallen arches, usually the medial parts of the longitudinal arches; results when the plantar ligaments and plantar aponeurosis become unusually stretched (by long periods of standing); because the plantar calcaneonavicular ligament can no longer support the head of the talus, it becomes displaced inferomedially and becomes prominent this results in flattening of arch and lateral deviation of the forefoot; the appearance of flat feet is normal in infancy, the arches will not be obvious until the infant has walked a few months