Lower Limb

1. The Foot
Dr M Idris Siddiqui

2. Foot

3. The Dorsum of the Foot

4. Skin
•The skin on the dorsum of
the foot is thin, hairy, and
freely
•mobile on the underlying
tendons and bones.

5. Cutaneus nerves
1. The sensory nerve supply
2. The superficial peroneal nerve
3. The deep peroneal nerve
4. The saphenous nerve
5. The sural nerve

6. Dorsal Venous Arch (or Network)
• The dorsal venous arch lies in the
subcutaneous tissue over the heads
of the metatarsal bones and drains
on the medial side into the great
saphenous vein and on the lateral
side into the small saphenous vein

9. Sole of the Foot

10. Sole of the foot
• Sole of the foot is the bottommost region of foot
where human foot comes in contact with the earth.
• In various ways the structure of foot and palm is
comparable and similar to the palm of human hand.
• The foot is meant for transfer of body weight and
movement of body.
• There are different parts of foot that are in contact
with the earth at different type of activities like
running, walking and standing.

11. SKIN
of the sole
• The skin of the sole presents the following features:
• It is thick and hairless.
• No sebaceous glands are present in it.
• It includes large number of sweat glands.
• It is bound to the underlying deep fascia (plantar
aponeurosis) by the many fibrous bands.
• The above features boost the efficiency of grip of
the sole on the earth.

12. Superficial fascia
• It contains subcutaneous fat in fibrous
meshwork formed by irregular septa. Fibrous
meshwork connect skin with deep fascia.
• Superficial fascia thick over some points of
sole like posterior tubercle of calcaneus,
heads of metatarsal bones and pulp of digits.
• These are weight bearing points of sole.

13. Cutaneous supply of sole

14. Deep fascia
• It is formed by bundles of collagen fibres
longitudinally arranged in sole.
• Divides sole into three parts central, medial and
lateral parts.
• Central part is very thick forming plantar
aponeurosis. Medial and lateral parts are thin,
forming plantar fascia.
– Central part covers flexor digitorum brevis,
– Medial part covers abductor hallucis and
– Lateral part covers abductor digiti minimi.

15. FIBROUS FLEXOR SHEATHS
• The inferior surface of every toe from the head of
metatarsal to the base of distal phalanx is provided
with a solid fibrous sheath originated from the deep
fascia of the toes. It is connected to the sides of
the phalanges.
• The proximal end of every sheath gets the deeper part
of the slickness of plantar aponeurosis. The distal end
of the sheath is closed and is connected to the base of
the distal phalanx.
• The sheath together with the inferior surfaces of the
phalanges and interphalangeal joints creates a blind
tunnel via which pass long flexor tendon/tendons of
the toes.

16. Plantar aponeurosis
• It is thick central part of deep fascia.
• It is triangular in shape and narrow posteriorly.
• Posterior part shows attachment on medial tubercle of
calcaneus proximal to flexor digitorum brevis.
• Anterior end divides into five bands one for each toe.
Transverse fibres held together five bands.
• Plantar digital vessels and nerves passes between
interval between bands protected by transverse fibres.
• Near head of metatarsal head digital bands divides into
superficial and deep slips. Superficial slip shows
attachment on skin and blends with superficial
transverse metatarsal ligaments.

17. Plantar aponeurosis
• Deep slip divides into two parts which embrace
flexor tendons. Then it blends with fibrous flexor
sheaths and deep transverse metatarsal ligaments.
• Lateral and medial intermuscular septa passes
vertically from medial and lateral aspect of central
part. Transverse septa arising from vertical septa
divides muscles of sole into four layers.
• Morphologically the plantar aponeurosis represents
the degenerated tendon of plantaris muscle, which
has been divided by the enlarging heel during
development.

19. Functions of plantar aponeurosis
• It fixes skin of sole.
• It maintains longitudinal arch of
foot.
– It helps to preserve the
longitudinal arches of the foot by
acting as tie beam.
• It protects vessels and nerves
from compression.
• It gives origin to muscles of first
layer of sole.
• It divide sole into different
compartments.

20. Clinical Significance
• Plantar fasciitis and calcaneal spur:
• The plantar aponeurosis is stretched during standing
position. Consequently, splitting or inflammation
(plantar fasciitis) frequently takes place in people who
do a lot of standing or walking, viz. traffic police staff.
• It causes pain and tenderness in the sole of the foot
particularly underneath the heel during standing.
• Continued episode of the plantar fasciitis results in
calcification in the posterior connection of the plantar
aponeurosis creating a calcaneal spur.

21. The muscles acting on the foot
• The muscles acting on the foot can be divided into
two distinct groups; extrinsic and intrinsic muscles.
• The extrinsic muscles arise
from the anterior, posterior and lateral
compartments of the leg. They are mainly
responsible for actions such as eversion, inversion,
plantarflexion and dorsiflexion of the foot.
• The intrinsic muscles are located within the foot
and are responsible for the fine motor actions of
the foot, for example movement of individual digits.

22. DEEP TRANSVERSE METATARSAL LIGAMENTS
• All these are 4 short, flat bands of fibrous
tissue, which attach the plantar ligaments of
the adjoining metatarso-phalangeal joints.
• They are linked dorsally to interossei, and
ventrally to lumbricals and digital nerves and
vessels.

23. Plantar Aspect of foot
• There are 10 intrinsic muscles located in
the sole of the foot.
• They act collectively to stabilise the
arches of the foot, and individually to
control movement of the digits.
• All the muscles are innervated either by
the medial plantar nerve or the lateral
plantar nerve, which are both branches
of the tibial nerve.

24. MUSCLES OF THE SOLE OF THE FOOT
• There are 18 intrinsic muscles and 4 extrinsic tendons
in the sole of the foot. The muscles of the sole are
described in 4 layers from superficial to deep.
• The muscles of the sole are primarily concerned with
supporting the arches of the foot. The short and
long muscles of the foot serve as synergists.
• There are 2 neurovascular planes between the muscle
layers of the sole:
– Superficial neurovascular plane between the first and 2nd
layers.
– Deep neurovascular plane between the 3rd and fourth
layers.

25. Layer Muscles Features
First
layer
1. Flexor digitorum brevis.
2. Abductor hallucis.
3. Abductor digiti minimi
They cover whole of the sole
Second
layer
1.Flexor digitorum accessories
2.Four lumbricals.
3.Two tendons (tendon of flexor digitorum
longus and tendon of flexor hallucis longus)
Flexor digitorum accessorius and
lumbricals are attached to the
tendon of flexor digitorum longus
Third
layer
1. Flexor hallucis brevis.
2. Flexor digiti minimi brevis.
3. Adductor hallucis
1. They are confined to the
metatarsal region of the sole.
2. Two of these muscles act on the
big toe and one on the little toe
Fourth
layer
1. Interossei (3 plantar interossei and 4 dorsal
interossei).
2. Tendon of tibialis posterior.
3. Tendon of peroneus longus
They fill up the intermetatarsal
spaces
There are 2 neurovascular planes between the muscle layers of the sole

26. Interossei
• Mnemonic: Plantar interossei ADduct
(PAD) the toes and originate from single
metatarsal as unipennate muscles;
• On the other hand Dorsal
interossei ABduct (DAB) the toes and
originate from 2 metatarsals as
bipennate muscles.

27. First Layer

29. Second Layer

31. Third Layer

33. Fourth Layer

35. Neurovascular planes of the sole
There are 2 neurovascular planes between the
muscle layers of the sole.
1. Superficial neurovascular plane between the first and 2nd layers.
In the superficial neurovascular plane is located the trunks of medial
and lateral plantar nerves, and the arteries.
2. Deep neurovascular plane between the 3rd and fourth layers.
In the deep neurovascular plane is located the deep branches of the
lateral plantar nerve and artery.

36. First Layer
• The first layer of muscles
is the most superficial to
the sole, and is located
immediately underneath
the plantar fascia.
• There are three muscles
in this layer.

37. Abductor Hallucis
• The abductor hallucis muscle is located on the
medial side of the sole, where it contributes to a
small soft tissue bulge.
• Attachments: Originates from the medial tubercle
of the calcaneus, the flexor retinaculum and the
plantar aponeurosis. It attaches to the medial base
of the proximal phalanx of the great toe.
• Actions: Abducts and flexes the great toe.
• Innervation: Medial plantar nerve.

39. Flexor Digitorum Brevis
• The flexor digitorum brevis muscle is
located laterally to the abductor hallucis. It sits in
the centre of the sole, sandwiched between the
plantar aponeurosis and the tendons of flexor
digitorum longus.
• Attachments: Originates from the medial tubercle
of the calcaneus and the plantar aponeurosis. It
attaches to the middle phalanges of the lateral four
digits.
• Actions: Flexes the lateral four digits at the proximal
interphalangeal joints.
• Innervation: Medial plantar nerve.

40. Abductor Digiti Minimi
• The abductor digiti minimi muscle is located on the
lateral side of the foot. It is homologous with the
abductor digiti minimi of the hand.
• Attachments: Originates from the medial and
lateral tubercles of the calcaneus and the plantar
aponeurosis. It attaches to the lateral base of the
proximal phalanx of the 5th digit.
• Actions: Abducts and flexes the 5th digit.
• Innervation: Lateral plantar nerve.

41. Second Layer
• The second layer contains
two muscles –
• Quadratus plantae, and
• Lumbricals .
• In addition, the tendons of
the flexor digitorum
longus (an extrinsic
muscle of the foot) pass

42. The quadratus plantae
• The quadratus plantae muscle is located superior to
the flexor digitorum longus tendons. It is separated
from the first layer of muscles by the lateral plantar
vessels and nerve.
• Attachments: Originates from the medial and
lateral plantar surface of the calcaneus. It attaches
to the tendons of flexor digitorum longus.
• Actions: Assists flexor digitorum longus in flexing
the lateral four digits.
• Innervation: Lateral plantar nerve.

43. Lumbricals
• There are four lumbrical muscles in the foot. They
are each located medial to their respective tendon
of the flexor digitorum longus.
• Attachments: Originates from the tendons of flexor
digitorum longus. Attaches to the extensor hoods of
the lateral four digits.
• Actions: Flexes at the metatarsophalangeal joints,
while extending the interphalangeal joints.
• Innervation: The most medial lumbrical is
innervated by the medial plantar nerve. The
remaining three are innervated by the lateral
plantar nerve.

44. Third Layer
• The third layer contains three
muscles.
• Flexor hallucis brevis and
• Adductor hallucis are
associated with movements of
the great toe.
• Flexor digiti minimi brevis,
moves the little toe.

45. Flexor Hallucis Brevis
• The flexor hallucis brevis muscle is located on the
medial side of the foot. It originates from two
places on the sole of the foot.
• Attachments: Originates from the plantar surfaces
of the cuboid and lateral cuneiforms, and from the
tendon of the posterior tibialis tendon. Attaches to
the base of the proximal phalanx of the great toe.
• Actions: Flexes the proximal phalanx of the great
toe at the metatarsophalangeal joint.
• Innervation: Medial plantar nerve.

47. Adductor Hallucis
• The adductor hallucis muscle is located laterally to the
flexor hallucis brevis. It consists of an oblique and
transverse head.
• Attachments: The oblique head originates from the
bases of the 2nd, 3rd and 4th metatarsals. The
transverse head originates from the plantar ligaments
of the metatarsophalangeal joints. Both heads attach to
the lateral base of the proximal phalanx of the great
toe.
• Actions: Adduct the great toe. Assists in forming the
transverse arch of the foot.
• Innervation: Deep branch of lateral plantar nerve.

48. Flexor Digiti Minimi Brevis
• The flexor digiti minimi brevis muscle is located on
the lateral side of the foot, underneath the
metatarsal of the little toe. It resembles the
interossei in structure.
• Attachments: Originates from the base of the fifth
metatarsal. Attaches to the base of the proximal
phalanx of the fifth digit.
• Actions: Flexes the proximal phalanx of the fifth
digit.
• Innervation: Superficial branch of lateral plantar
nerve.

49. Fourth Layer
• The plantar and dorsal
interossei comprise
the fourth and final
plantar muscle layer.
• The plantar interossei
have a unipennate
morphology, while the
dorsal interossei are
bipennate.

50. Plantar Interossei
• There are three plantar interossei, which are
located between the metatarsals. Each arises from a
single metatarsal.
• Attachments: Originates from the medial side of
metatarsals three to five. Attaches to the medial
sides of the phalanges of digits three to five.
• Actions: Adduct digits three to five and flex the
metatarsophalangeal joints.
• Innervation: Lateral plantar nerve.

51. Dorsal Interossei
• There are four dorsal interossei, which are located
between the metatarsals. Each arises from two
metatarsals.
• Attachments: Originates from the sides of
metatarsals one to five. The first muscle attaches to
the medial side of the proximal phalanx of the
second digit. The second to fourth interossei attach
to the lateral sides of the proximal phalanxes of
digits two to four.
• Actions: Abduct digits two to four and flex the
metatarsophalangeal joints.
• Innervation: Lateral plantar nerve.

53. Clinical Relevance
• Contusion of Extensor Digitorum Brevis
• Tearing of the extensor digitorum brevis muscle fibres
will result in a haematoma. This produces a
characteristic swelling anteromedial to the lateral
malleolus – differentiating it from a sprained ankle (for
which it is often confused).
• Medial Plantar Nerve Entrapment
• The medial plantar nerve can become compressed and
irritated as it passes deep to the abductor
hallucis muscle. This can cause aching, numbness and
paraesthesia on the medial side of the sole of the foot.
The muscle can become compressed during
repetitive eversion of the foot, which may occur in
some sports such as gymnastics.