Anatomy, Bony Pelvis and Lower Limb, Foot Muscles

Article Author:
Ryan Card
Article Editor:
Bruno Bordoni
Updated:
3/22/2019 11:38:21 PM
PubMed Link:
Anatomy, Bony Pelvis and Lower Limb, Foot Muscles

Introduction

There are 29 muscles associated with the human foot. (10 foot/ankle and 19 intrinsic) Ten of these muscles originate outside of the foot itself but cross the ankle joint to act on the ankle joint and help position the foot.  The other 19 muscles are referred to as intrinsic muscles of the foot and act only within the foot. The muscles covered in this article serve various roles in gait as well as posture. These muscles are also aided by the plantar fascia, managing the mechanical vectors of the foot. The muscles of the foot influence the posture and the shape of the foot, as well as providing the ability to transmit muscle tension not only towards the ground but also towards the whole body system.

Embryology

During gestation, the presence of the limbs appears at the 4th post-ovulatory week in the embryos (3-6 mm long - stage 13). Each limb develops in a proximal-distal direction and the foot appears at about 4.5 weeks (stage 15). The cartilaginous skeleton and the muscles become visible in a few days and soon after the fingers can be observed (stage 18-19). The skeletal elements are first seen as mesodermal condensations which then condense in a definite order; ossification, in the form of a periosteal collar in the tubular bones, occurs subsequently. Vascular invasion of the tarsal bones occurs during the fetal period, while endochondral ossification does not begin in some tarsal bones until after birth.

The limbs develop from proliferation of the mesoderm of the somatopleural in the lateral region of the body, which forms outgrowths in correspondence of the lumbar tract (3rd-5th lumbar somite) for the hind limbs.

Blood Supply and Lymphatics

The blood supply to the foot begins primarily with the popliteal artery. The popliteal artery branches off the large superficial femoral artery and gives rise to the three main branches supplying the lower leg and foot. The three branches from proximal to distal are the anterior tibial artery, peroneal artery, and posterior tibial artery.  The anterior tibial artery continues distally to supply the anterior and dorsal portions of the foot.  Once the anterior tibial artery passes under the extensor retinaculum, it becomes the dorsalis pedis.  This artery is commonly palpated for a pedal pulse. The dorsalis pedis continues under the extensor hallucis longus and passes between it and the extensor digitorum longus.  The dorsalis pedis has three lateral branches named the proximal and distal tarsal arteries and the arcuate artery, and two medial branches named the medial tarsal arteries. The arcuate artery branches at the level of the 1st tarsal-metatarsal joint and courses over the metatarsals 2 to 4 to give rise to the dorsal metatarsal arteries 2 to 4. The first dorsal metatarsal artery branches directly off the dorsalis pedis. The metatarsal branches supply the dorsal interosseous muscles of the foot. The peroneal artery supplies the muscles of the lateral leg and the posterior foot.  Finally, the posterior tibial artery supplies the posterior and lateral leg as well as the plantar surface of the foot.[1]

The venous system of the lower limbs is composed of deep veins (which run between the muscles) and superficial veins (which constitute a complex network just below the skin). The two systems are joined by transfascial valved communications that constitute a real system, that of the perforating veins. The perforating veins have the function of favouring the outflow of the blood that flows in the system superficial (about 10%) towards the deep system.

In the sole of the foot, there is a sort of sponge, consisting of a complicated intertwining of superficial and deep veins which, at each step, is emptied by compression on the ground. Thanks to this mechanism, the blood is pushed over the ankle up to the calf.

The venous system originates in the microcirculation from the arterial capillaries (afferent branch) to continue with the venous capillaries that converge in the collecting venules first and then in the collecting veins, thus constituting the initial efferent branch of venous macrocirculation.

In the anterior region the dorsal venous network of the foot through the intercapitular veins that pass through the interdigital spaces; the digital veins, joining two to two in the interdigital spaces, originate the metatarsal veins that are directed in the deep plantar venous arch, converging in the lateral plantar veins; these, after joining posteriorly with the medial plantar veins, originate the two posterior tibial veins. The anterior tibialis originate from the deep veins of the dorsal region of the foot. The medial marginal vein of the foot ascending anterior to the medial malleolus forms the internal saphenous vein or the great saphenous vein. The lateral marginal vein of the foot ascending anterior to the lateral malleolus forms the small saphenous vein.

The lymph drained from the lower limb reaches the external and common iliac lymph node chains. The fingers and the sole of the foot are rich in superficial lymphatic vessels, which gather in the medial and lateral collectors. The lymph drained deeply from the foot, concerns above all the articular area, bone and muscle and aponeurosis; the lymph gathers in the popliteal and femoral collectors.

Nerves

There will be discussion regarding innervation of the various muscles in greater detail in the sections that follow.  The initial nerve that gives rise to most of the innervation of the lower extremity is the sciatic nerve.  The sciatic nerve makes its way out of the lumbosacral plexus and passes under the piriformis muscle before traveling distally.  Around the distal third of the femur, the sciatic nerve branches to give rise to the common fibular nerve and the tibial nerve.  The tibial nerve continues distally to give rise to the medial calcaneal branches, the medial sural cutaneous nerve, and the medial and lateral plantar nerves.  The common peroneal nerve gives rise to two main branches, the superficial peroneal and the deep peroneal nerves. The superficial peroneal nerve primarily gives rise to cutaneous branches that receive sensory information from the skin.  The deep peroneal nerve supplies motor function to many of the muscles responsible for dorsiflexion of the foot.[2][3]

Muscles

To simplify the organization of the muscles, the following will break them up into those that act upon the foot and ankle and those classified as intrinsic.[4][5][6]

Foot and Ankle

Peroneus Longus

  • The peroneus longus is one of the three muscles that span the lateral leg - peroneus may also be interchanged with fibular, referring to the lateral bone of the lower leg running deep to the peroneal muscles
  • Origin: The peroneus longus muscle originates on the head of the fibula and the upper half of the fibular shaft - this muscle crosses the ankle joint and courses deep into the foot and passes into a groove of the cuboid bone.
  • Insertion: the posterolateral aspect of the medial cuneiform bone and the lateral portion of the base of the first metatarsal
  • Action: The peroneus longus acts to evert the foot, plantarflex the ankle and adds support to the transverse arch of the foot
  • Blood Supply: Anterior tibial artery
  • Innervation: Superficial peroneal nerve

Peroneus Brevis

  • The peroneus brevis is another of the three muscles spanning the lateral leg and may also be called fibularis brevis, referring to the fibula
  • Origin: The peroneus brevis originates on the inferior two-thirds of the lateral fibula and courses posteriorly to the lateral malleolus of the fibula ultimately
  • Insertion: The styloid process of the fifth metatarsal
  • Action: The primary action of the peroneus brevis is to evert the foot and plantar flex the ankle
  • Blood Supply: Peroneal artery
  • Innervation: The superficial peroneal nerve innervates the peroneus brevis muscle

Peroneus Tertius

  • The peroneus tertius is the third and final muscle of the lateral peroneus or fibular muscles
  • Origin: The peroneus tertius originates from the middle fibular shaft
  • Insertion: The dorsal surface of the fifth metatarsal
  • Action: Dorsiflex, evert, and abduct the foot
  • Blood Supply: The peroneus tertius primarily receives its blood supply from the anterior tibial artery
  • Innervation: Peroneus tertius innervation comes from the deep peroneal nerve, an innervation different than its similarly named peroneal counterparts

Anterior Tibialis

  • The anterior tibialis is the most prominent muscle in the anterior leg and is often visible during dorsiflexion of the foot
  • Origin: The lateral condyle of the tibia and the proximal half to two-thirds of the tibial shaft.
  • Insertion: Occurs after passing under the extensor retinaculum and is on the medial and plantar surfaces of the medial cuneiform and base of the 1st metatarsal.
  • Action: Dorsiflex the ankle and invert the hindfoot
  • Blood Supply: Anterior tibial artery
  • Innervation: Comes from the deep peroneal nerve

Posterior Tibialis

  • Origin: The superior two-thirds of the medial posterior surface of the tibia
  • Insertion: The tendon courses distally, splitting into two at the calcaneonavicular ligament, to insert on the tuberosity of the navicular bone (superficial slip) and the plantar surfaces of the metatarsals two to four (deep slip)
  • Action: The posterior tibialis is the primary inverter of the foot but also adducts, plantar flexes, and aides in supination of the foot
  • Blood Supply: Sural, peroneal, and posterior tibial arteries
  • Innervation: Tibial nerve

Extensor Digitorum Longus

  • Origin: Lateral tibial condyle and continues distally to split into four tendons after the level of the extensor retinaculum
  • Insertion: Dorsum of the middle and distal phalanges
  • Action: Extend the second through fifth digits and dorsiflex the ankle
  • Blood Supply: anterior tibial artery
  • Innervation: deep peroneal nerve

Flexor Digitorum Longus

  • Origin: Posterior surface of the tibia distal to the popliteal line
  • Insertion: Continues distally to split into four individual tendons which insert on the plantar surfaces of the bases of the second through fifth distal phalanges
  • Action: Flex the digits two through five and may aid in plantar flexion of the ankle
  • Blood Supply: Posterior tibial artery
  • Innervation: Tibial nerve

Flexor Hallucis Longus

  • Origin: inferior two-thirds of the posterior fibula
  • Insertion: The plantar surface of the base of the distal phalanx of the great toe
  • Action: Flex the great toe but may minimally supinate and plantar flex the ankle
  • Blood Supply: Peroneal and posterior tibial artery
  • Innervation: Tibial nerve 

Gastrocnemius

  • The gastrocnemius is the most superficial calf muscle
  • Origin: femoral condyles
  • Insertion: thick Achilles tendon inserting on the calcaneus. 
  • Action: Plantarflex the ankle. 
  • Blood Supply: Sural branch of the popliteal artery
  • Innervation: Tibial nerve 

Soleus

  • The soleus is the deep muscle of the posterior leg and makes up most of the bulk of the calf
  • Origin: Upper quarter of the posterior fibula and the middle third of the posterior tibial shaft
  • Insertion: The soleus eventually joins the gastrocnemius to for the Achilles tendon to insert on the calcaneus
  • Action: The action is to plantarflex the ankle
  • Blood Supply: Posterior tibial, peroneal, and sural arteries
  • Innervation: Tibial nerve

Intrinsic

Dorsal

Extensor Digitorum Brevis

  • Origin: Dorsal surface of the calcaneus
  • Insertion: The base of the proximal phalanx of digits two through four
  • Action: Extend the toes
  • Blood Supply: Dorsalis pedis
  • Innervation: Deep peroneal nerve

Dorsal Interosseus

  • The dorsal interossei muscles (3) exist between digits two through five - the two adjacent muscles form a central tendon and act to abduct the metatarsal-phalangeal joints and innervation comes from the lateral plantar nerve

Extensor Hallucis Brevis

  • Origin: Dorsal surface of the calcaneus
  • Insertion: The base of the proximal phalanx of the great toe
  • Action: Extend the great toe
  • Blood Supply: Dorsalis pedis.
  • Innervation: Deep peroneal nerve 

Plantar

1st layer

Abductor Hallucis

  • Origin: Calcaneal tuberosity
  • Insertion: Base of the great toe and the proximal phalanx.
  • Action: Abduct the great toe
  • Blood Supply: Medial plantar artery
  • Innervation: Medial plantar nerve

Flexor Digitorum Brevis

  • Origin: Calcaneal tuberosity
  • Insertion: The middle phalanx of digits two thorugh five
  • Action: Flex the digits two through five
  • Blood Supply: Medial plantar artery
  • Innervation: Medial plantar nerve 

Abductor Digiti Minimi

  • Origin: Calcaneal tuberosity 
  • Insertion: Base of the fifth metatarsal
  • Action: Abduct the 5th digit
  • Blood Supply: Lateral plantar artery
  • Innervation: Lateral plantar nerve lateral plantar artery

2nd Layer

Quadratus Plantae

  • Origin: Plantar surface of the calcaneus
  • Insertion: Flexor digitorum longus tendon
  • Action: Help flex the distal phalanges
  • Blood Supply: Lateral plantar artery
  • Innervation: Llateral plantar nerve 

Lumbricals

  • There are four muscles referred to as lumbricals in the foot
  • Origin: Flexor digitorum longus tendon
  • Insertion: Extensor digitorum longus tendon
  • Action: Flex the metatarsophalangeal joints and extend the interphalangeal joints
  • Blood Supply: Medial and lateral plantar arteries
  • Innervation: Medial and lateral plantar nerve 

3rd layer

Flexor Hallucis Brevis

  • Origin: The cuboid and the lateral cuneiform
  • Insertion: Proximal phalanx of the great toe
  • Action: Flex the great toe
  • Blood Supply: Medial plantar artery
  • Innervation: Medial plantar nerve 

Oblique and Transverse Head of Adductor Hallucis

  • The adductor hallucis has two heads, an oblique head, and a transverse head
  • Origin: The oblique head originates at the proximal ends of the metatarsals two thourgh four, and the transverse head originates via MTP ligaments of digits three through five
  • Insertion: inserts at the proximal phalanx of the great toe
  • Action: The primary action is to adduct the great toe
  • Blood Supply: First plantar metatarsal artery
  • Innervation: Deep branch of lateral plantar

Flexor Digiti Minimi Brevis

  • Origin: Base of the fifth metatarsal
  • Insertion: Proximal phalanx of the fifth metatarsal
  • Action: The primary action is to flex the fifth digit
  • Blood Supply: Lateral Plantar artery
  • Innervation: Lateral plantar nerve

4th layer

Plantar Interosseous

  • The plantar interossei (3)
  • Origin: medial aspect of the individual metatarsals of digits three through five
  • Insertion: The proximal phalanges
  • Action: Adduct the digits
  • Blood Supply: Plantar metatarsal artery
  • Innervation: Lateral plantar nerve

Compartments of the Foot

The muscles of the foot are divided up into nine compartments encompassed by fascia.  The medial compartment contains the abductor hallucis, flexor hallicus brevis, and the flexor hallucis longus tendon.  The lateral compartment contains the abductor digiti minimi and the flexor digiti minimi.  The superficial central compartment contains the flexor digitorum brevis, the four lumbricals, and the flexor digitorum longus tendons.  The deep central (aka calcaneal) compartment contains the quadratus plantae and the posterior tibial neurovascular bundle. The deep central compartment also communicates with the deep posterior compartment of the lower leg. The adductor compartment contains the adductor hallucis muscle. There are four interosseous compartments; the first is between the first and second metatarsals and includes the first dorsal interosseous muscle, the second is between the second and third metatarsal and includes both the dorsal and plantar interosseous muscles. The two compartments between the third and fourth as well as the fourth and fifth metatarsals also include the dorsal and plantar interosseous muscles.[7][8][1][9]

Physiologic Variants

Recent studies have shown variability in the insertion of the tibialis anterior tendon insertion, which may be significant because different points of insertion may have different distributions of force distribution on the foot and ankle. These differences become important during anterior tibialis tendon ruptures when it may be important for biomechanics to match up the previous tendon type.[4]

Accessory peroneal muscles

Peroneus quartus is an accessory muscle found to be present in anywhere from 6 to 22% of people depending on the study you read.  It typically arises from the peroneus brevis muscle but has been found to originate from the peroneus tertius and longus muscles as well. This muscle has been found to have different insertions including the cuboid, the lateral tubercle of the calcaneus, the apophysis of the cochlea of the calcaneus or the retrotrochlear eminence of the calcaneus. In some instances this muscle belly will give rise to a tendon that inserts on a phalanx of the fifth digit, thus earning the name peroneus digiti quinti. The peroneus digiti quinti may, in this case, help to extend the fifth digit.[10]

Several studies have shown the association of the presence of a peroneus quartus muscle and the presence of associated pathology. Several studies have shown symptomatology in the form of ankle pain even without any signs of trauma to the lateral ankle.  Other pathology noted includes peroneal subluxation, tendinous calcification, and hypertrophy of the retrotrochlear eminence of the calcaneus causing pain.[11]

Clinical Significance

The muscles that act directly on or around the foot are responsible for many of the actions that allow for normal gait as well as maintaining posture.  Injuries to these muscles can result in many conditions that may interfere with the ability to complete activities of daily living. Achilles tendon rupture, hammer toe, and pes planus (flat foot) are some of the more common conditions associated with the muscles of the foot.  Each of these affects patients in different ways and may come with other comorbidities as well.  Treatment of these conditions varies based on severity and even the age of the patient. Conservative non-operative management Achilles tendon rupture, for example, has shown to be non-inferior to operative management in cases of older patients.[12]

Other Issues

There is a direct relationship between the weakness of the foot muscles and the onset of pain when the foot is supported. Probably, the motivation is that the strength of the foot is not able to adequately manage the centre of mass, shifting the load to even weaker areas of the foot. Normally the centre of mass is managed by several different areas and at the same time, alternating. If the muscles are weak, this mechanism does not occur and pain arises.



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References

[1] Alagoz MS,Orbay H,Uysal AC,Comert A,Tuccar E, Vascular anatomy of the metatarsal bones and the interosseous muscles of the foot. Journal of plastic, reconstructive     [PubMed PMID: 18572002]
[2] Yablon CM,Hammer MR,Morag Y,Brandon CJ,Fessell DP,Jacobson JA, US of the Peripheral Nerves of the Lower Extremity: A Landmark Approach. Radiographics : a review publication of the Radiological Society of North America, Inc. 2016 Mar-Apr;     [PubMed PMID: 26871986]
[3] Taber KH,Duncan G,Chiou-Tan F,Patni P,Hayman LA, Sectional neuroanatomy of the lower limb II: leg and foot. Journal of computer assisted tomography. 2001 Sep-Oct;     [PubMed PMID: 11584247]
[4] Olewnik Ł,Podgórski M,Polguj M,Topol M, A cadaveric and sonographic study of the morphology of the tibialis anterior tendon - a proposal for a new classification. Journal of foot and ankle research. 2019;     [PubMed PMID: 30733832]
[5] Amis AA,de Leeuw PA,van Dijk CN, Surgical anatomy of the foot and ankle. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA. 2010 May;     [PubMed PMID: 20306016]
[6] Chiou-Tan F,Furr-Stimming E,John J,Harrell JS,Zhang H,Taber KH, Procedure-oriented sectional anatomy of the foot. Journal of computer assisted tomography. 2015 Jan-Feb;     [PubMed PMID: 25279850]
[7] Faymonville C,Andermahr J,Seidel U,Müller LP,Skouras E,Eysel P,Stein G, Compartments of the foot: topographic anatomy. Surgical and radiologic anatomy : SRA. 2012 Dec;     [PubMed PMID: 22638720]
[8] Orbay H,Kerem M,Unlü RE,Esmer AF,Cömert A,Tüccar E,Sensöz O, Vascular anatomy of plantar muscles. Annals of plastic surgery. 2007 Apr;     [PubMed PMID: 17413886]
[9] Kalin PJ,Hirsch BE, The origins and function of the interosseous muscles of the foot. Journal of anatomy. 1987 Jun;     [PubMed PMID: 3654378]
[10] Yammine K, The accessory peroneal (fibular) muscles: peroneus quartus and peroneus digiti quinti. A systematic review and meta-analysis. Surgical and radiologic anatomy : SRA. 2015 Aug;     [PubMed PMID: 25638531]
[11] Zammit J,Singh D, The peroneus quartus muscle. Anatomy and clinical relevance. The Journal of bone and joint surgery. British volume. 2003 Nov;     [PubMed PMID: 14653594]
[12] Zhou K,Song L,Zhang P,Wang C,Wang W, Surgical Versus Non-Surgical Methods for Acute Achilles Tendon Rupture: A Meta-Analysis of Randomized Controlled Trials. The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons. 2018 Nov - Dec     [PubMed PMID: 30368430]