Transcript 45-sole of the foot

(the planter aspect of the foot)
Skin
• Thick & hairless, lacks pigmentation
• Possesses abundant sweat glands
• Firmly bound down to the underlying
deep fascia by numerous fibrous
bands
• Shows few flexor creases at the sites
of skin movement.
• The subcutaneous tissue contains a
lot of fat, especially in the heel
• Extremely sensitive to touch due to a
high concentration of nerve endings.
This makes the sole sensitive to
surfaces that are walked on
Cutaneous Nerve Supply
• Medial side of the heel:
• Medial calcaneal branch of
the tibial nerve
• Medial 2/3 of the sole:
• Branches from the medial
plantar nerve
• Lateral 1/3 of the sole:
• Branches from the lateral
plantar nerve
• Along the Medial border:
• Saphenous nerve
• Along the Lateral border:
• Sural nerve
Deep Fascia
• Lies beneath the
subcutaneous tissue and
surrounds the intrinsic
foot muscles
• Much thicker in the
central part and thinner
where it covers the
intrinsic muscles of big
toe and little toe
• The central thicker part
forms triangular planter
aponeurosis
Planter Aponeurosis
• A triangular thickening of the deep fascia
that protects the underlying nerves, blood
vessels, and muscles.
• Apex is attached to the medial and lateral
tubercles of the calcaneum.
• Base divides into five slips that pass into
the toe
• Each slip further divides into the:
• Superficial band to the skin
• Deep band passing to the root of the
toes, where it divides into two,
diverging along the flexor tendons and
fusing with the fibrous sheath and the
deep transverse ligaments
• The medial and
lateral borders of the
thick aponeurosis
are continuous with
the thinner deep
fascia covering the
abductors of the big
and little toes.
From each of these borders, fibrous septa
pass superiorly into the sole and take part in
the formation of the fascial spaces of the sole.
• Functions
 To give a firm
attachment to the
overlying skin
 To protect the
underlying
vessels, nerves
and tendons and
their synovial
sheaths
 To assist in
maintaining the
arches of the foot.
Muscles of the Sole
• The sole contains both Extrisic & Intrinsic muscles
• These muscles:
 Help to flex, extend, abduct, and adduct the toes
 Enable the toes to lift and curl.
 Support the arches of the foot
 Are supplied by branches of tibial nerve
 Are supplied by branches of posterior tibial artery
 Are arranged in four layers.
• From superficial to
deep
• The muscles of the
first layer are:
 Abductor hallucis
 Flexor digitorum
brevis
 Abductor digiti
minimi
• The muscles of the
second layer are:
• Accessory flexor
(quadratus plantae)
• Lumbricals
• Tendons of the
flexor digitorum
longus from which
the lumbricals arise
• The muscles of the
third layer are:
• Flexor hallucis
brevis
• Adductor hallucis
 oblique head
 transverse head
• Flexor digiti minimi
brevis
• The muscles of the
fourth layer are:
• Dorsal interossei
• Plantar interossei
• Tendon of the
peroneus longus
• Tendon of the tibialis
posterior
Long Tendons of the Sole of the Foot
• Flexor Digitorum Longus Tendon
• Enters the sole by passing:
 behind the medial malleolus
 beneath the flexor retinaculum.
• Passes forward across the medial
surface of the sustentaculum tali
• Then crosses the tendon of flexor
hallucis longus, from which it receives a
strong slip.
• It is here that it receives on its lateral
border the insertion of the quadratus
plantae muscle.
• The tendon now divides
into its four tendons of
insertion, which pass
forward, giving origin to
the lumbrical muscles.
• The tendons then enter
the fibrous sheaths of
the lateral four toes
Each tendon perforates the corresponding tendon
of flexor digitorum brevis and passes on to be
inserted into the base of the distal phalanx
(compare with the insertion of the flexor digitorum
profundus in the hand)
• Flexor Hallucis Longus Tendon
• Enters the sole by passing:
 behind the medial malleolus
 beneath the flexor retinaculum.
• It runs forward below the
sustentaculum tali and crosses
deep to the flexor digitorum longus
tendon, to which it gives a strong
slip.
• It then enters the fibrous sheath of
the big toe and is inserted into the
base of the distal phalanx.
Fibrous Flexor Sheaths
• The inferior surface of
each toe (from the head of
the metatarsal bone to the
base of the distal
phalanx), is provided with
a strong fibrous sheath,
which is attached to the
sides of the phalanges.
Their proximal ends
receive the deeper
parts of the slips of
plantar aponeurosis
Their distal ends are
closed and are
attached to the base of
the distal phalanges
• The fibrous sheath,
together with the
inferior surfaces of
the phalanges and
the interphalangeal
joints, forms a blind
tunnel for the flexor
tendons of the toes
Synovial
sheath
Fibrous
sheath
Flexor
tendon
Phalanx
Synovial Flexor Sheaths
• The tendons of the flexor muscles are
surrounded by synovial sheaths
The synovial sheath of the flexor
hallucis longus extends:
• Upwards behind the medial
malleolus above the flexor
retinaculum
• Ends distally at the base of
the first metatarsal bone.
The synovial sheaths of flexor digitorum longus extend:
• Above the flexor retinaculum
• Extend distally as far as the navicular bone
• Peroneus Longus Tendon
• Enters the foot from behind the
lateral malleolus
• Runs obliquely across the sole
to be inserted into the base of
the first metatarsal bone and
the adjacent part of the medial
cuneiform.
• The tendon grooves the
inferior surface of the cuboid
where it is held in position by
the long plantar ligament and
is surrounded by a synovial
sheath
• Tibialis Posterior Tendon
• Enters the foot from:
 behind the medial malleolus.
 beneath the flexor retinaculum
• Runs downward and forward
above the sustentaculum tali to be
• Inserted mainly into the tuberosity
of the navicular.
• Small tendinous slips pass to the
cuboid and the cuneiforms and to
the bases of the second, third,
and fourth metatarsals.
• The tendon is surrounded by a
synovial sheath.
Arteries of the Sole of the Foot
• Posterior tibial artery
enters the foot:
 Medially under the
medial malleolus
 Deeper to flexor
retinaculum
• Divides to give the
medial and lateral
plantar arteries
which supply the
sole
• Medial Plantar Artery
• The smaller of the terminal
branches of the posterior tibial
artery.
• Arises beneath the flexor
retinaculum and passes
forward deep to the abductor
hallucis
• Ends by supplying the medial
side of the big toe
Gives numerous
muscular, cutaneous
& articular branches
• Lateral Plantar Artery
• The larger of the terminal
branches of the posterior tibial
artery, arises beneath the flexor
retinaculum
• Passes forward deep to the
abductor hallucis and the flexor
digitorum brevis
• On reaching the base of the fifth
metatarsal bone, the artery
curves medially to form the
plantar arch
Gives numerous muscular,
• At the proximal end of the first
cutaneous & articular
intermetatarsal space joins the
branches and plantar
dorsalis pedis artery
digital arteries to the toes.
Planter Arch
• Formed by lateral plantar
artery
• Anastomoses with the dorsal
pedis artery by way of a
perforating artery which
pierces through the proximal
end of the first intermetatarsal
space
• The arch gives rise to several
metatarsal branches which
split into digital branches.
Veins of the Sole of the Foot
• Medial and lateral plantar veins
accompany the corresponding arteries,
and they unite behind the medial
malleolus to form the posterior tibial
venae comitantes.
Nerves of the Sole of the Foot
• Tibial nerve
enters the foot
medially:
 Under the medial
malleolus
 Deeper to flexor
retinaculum
• Divides to give the
medial and lateral
plantar nerves
which supply the
sole
• Medial Plantar
Nerve
• Runs forward deep to
the abductor hallucis,
with the medial plantar
artery
• Comes to lie in the
interval between the
abductor hallucis and
the flexor digitorum
brevis muscles
• Branches
• Muscular branches to the:
 Abductor hallucis
 Flexor digitorum brevis
 Flexor hallucis brevis
 First lumbrical muscle
• Cutaneous branches:
 Plantar digital nerves run to
the sides of the medial 3½
toes
 The nerves extend onto the
dorsum and supply the nail
beds and the tips of the toes.
• Lateral Plantar Nerve
• Runs forward deep to the
abductor hallucis and the
flexor digitorum brevis, in
company with the lateral
plantar artery
• On reaching the base of the
fifth metatarsal bone, it
divides into:
 Superficial
 Deep branches
• Branches
• From the main trunk
 Muscular branches to
the:
 Quadratus plantae
 Abductor digiti minimi
 Cutaneous branches to
the:
 skin of the lateral part
of the sole
• From the superficial
terminal branch
 Muscular branches to the:
 Flexor digiti minimi
 Interosseous muscles of
the fourth intermetatarsal
space
 Cutaneous branches
 Plantar digital branches
to the sides of the lateral
1½ toes.
 Extend onto the dorsum
and supply the nail beds
and tips of the toes.
• From the deep
terminal branch
 Muscular branches
to the:
• Adductor hallucis
• Second, third, and
fourth lumbricals
• All the interossei,
except those in the
fourth
intermetatarsal
space
Ligaments of the sole of foot
• Long plantar ligament
stretches from the
calaneum to the cuboid &
to the bases of the 2nd,
3rd & 4th metatarsal bones
• Short planter (plantar
calcaneocuboid)
ligament, connects the
calcaneum to the cuboid,
lies on the deep aspect of
the long plantar ligament
CU
N
N
CA
CA
• Plantar calcaneonavicular
ligament extends from the
calcaneus to the navicular
bone and prevents the head
of the talus from pushing
down between the
calcaneus and the navicular
bones.
This ligament is also know
as the spring ligament
since it is believed to give
a spring-like action to the
foot when walking.
N
CA
N
T
CA
• Soles are the site of the planter
(Babinski’s) reflex
A. When the sole of the foot is stroked
firmly on the outer side from the heel
to the front in persons over the age of
2 years
B. Normal response is planterflexion
(flexion) of the toes. (Negative
Babinski's response)
C. Abnormal response is dorsiflexion of
the big toe and often a fanning of the
other toes (Positive Babinski's
response)
D. Under 2 years of age, extension of
the toes is the normal response
D
Under 2 years: toes
are extended
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