Lower Limb

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The Sole of the Foot
(the planter aspect of the foot)
Dr. Zeenat Zaidi
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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

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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

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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

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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

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• 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.
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• 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.

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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.

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• From superficial to deep
• The muscles of the first layer are
• Abductor hallucis
• Flexor digitorum brevis
• Abductor digiti minimi

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• The muscles of the second layer are
• Accessory flexor (quadratus plantae)
• Lumbricals
• Tendons of the flexor digitorum longus from which
  the lumbricals arise

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• The muscles of the third layer are
• Flexor hallucis brevis
• Adductor hallucis
• oblique head
• transverse head
• Flexor digiti minimi brevis

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• The muscles of the fourth layer are
• Dorsal interossei
• Plantar interossei
• Tendon of the peroneus longus
• Tendon of the tibialis posterior

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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.

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• 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)
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• 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.

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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 distal ends are closed and are attached to
the base of the distal phalanges
Their proximal ends receive the deeper parts of
the slips of plantar aponeurosis
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• 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
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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

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• 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

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• 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.

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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

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• 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
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• 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
• At the proximal end of the first intermetatarsal
  space joins the dorsalis pedis artery

Gives numerous muscular, cutaneous articular
branches and plantar digital arteries to the toes.
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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.

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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.

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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

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• 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

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• 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.

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• 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

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• 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

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• 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.

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• 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

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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

N
CU
N
CA
CA
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• 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.

N
CA
This ligament is also know as the spring ligament
since it is believed to give a spring-like action
to the foot when walking.
T
N
CA
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• Soles are the site of the planter (Babinskis)
  reflex
• 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
• Normal response is planterflexion (flexion) of
  the toes. (Negative Babinski's response)
• Abnormal response is dorsiflexion of the big toe
  and often a fanning of the other toes (Positive
  Babinski's response)
• Under 2 years of age, extension of the toes is
  the normal response

D
Under 2 years toes are extended
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