Neurovascular

Distribution in
the Plantar
Foot
Lower Extremity Anatomy
Temple University School of Podiatric Medicine
Griffin
 NEUROVASCULAR
DISTRIBUTION IN
THE PLANTAR FOOT
Digital nerve blocks are most often administered
in the following clinical contexts:

• Provide surgical anesthesia in preparation for

repair of e.g., laceration, tendon, fracture
• Provide postoperative pain relief after a
surgical procedure

Your patient requires a complete block (i.e., both

dorsal and plantar aspects) of her second toe as
indicated by the shaded green area in the
picture.
Branches from what major nerves supply the entire skin of second digit?

• Dorsomedial side of proximal digit: Deep Fibular Nerve

• Dorsolateral side of proximal digit: Superficial Fibular Nerve
• Distal dorsum & plantar aspect of digit: Medial Plantar Nerve
Specifically, anesthesia would block which nerve branches
innervating the skin of the second digit?
• Dorsomedial side of proximal digit: 1 Proper Dorsal Digital N.
• Dorsolateral side of proximal digit: 1 Proper Dorsal Dig. N.
• Distal dorsum & plantar aspect of digit: 2 Proper Plantar Dig. Ns.
Administration of Digital Block

• 2 proper dorsal digital

nerves lie along the phalanx
at the 2 & 10 o’clock
positions

• 2 proper plantar digital

nerves lie along the phalanx
at the 4 & 8 o’clock
positions

 Needle is inserted adjacent to base of toe that will be blocked

 While slowly injecting, needle is advanced inferiorly/plantarly
 After the needle is removed, pressure is placed on injection site to prevent
the formation of a hematoma
MEDIAL
PLANTAR

LATERAL
PLANTAR
MEDIAL PLANTAR NERVE (L4-S3)
What four intrinsic muscles of the foot are innervated by this
nerve?
L First Lumbrical
A Abductor hallucis
F Flexor hallucis brevis
F Flexor digitorum brevis

All the rest of the INTRINSIC muscles of the

PLANTAR foot are innervated by the LATERAL
PLANTAR NERVE.
FLEXOR DIGITORUM BREVIS CAN RECEIVE ADDITIONAL INNERVATION FROM THE LATERAL PLANTAR NERVE.
 MEDIAL PLANTAR NERVE (L4-S3)
• Larger of two terminal
branches
• Innervates 4 intrinsic muscles
• Innervates much of the skin of
the sole, medial three toes and
medial side of 4th toe. Then
branches make their way onto
the dorsum of those same 3 ½
toes
 MEDIAL PLANTAR
NERVE (L4-S3) COURSE
 Courses deep to the AbH to enter sole

 Travels between the fascial plane btw AbH

& FDB

 As AbH and FDB diverge, gives off the

PROPER PLANTAR DIGITAL NERVE TO THE
MEDIAL SIDE OF THE HALLUX/GREAT TOE

 Terminates at the MT bases by dividing into

 3 COMMON PLANTAR DIGITAL NERVES
• Each one gives off 2 PROPER
PLANTAR DIGITAL NERVES
 LATERAL PLANTAR NERVE (S1-S3)
• Innervates most of the intrinsic
plantar muscles
• Innervates some of the skin on the
lateral side, half of the skin on the
plantar aspect of the 4th toe and all
of the plantar skin of the 5th. Then
branches make their way onto the
dorsum of those same 1 ½ digits.
 LATERAL PLANTAR
NERVE (S1-S3) COURSE
 Courses deep to AbH
 Pierces medial intermuscular septum
 Runs distally and laterally btw FDB & QP
 Pierces lateral intermuscular septum
 Just proximal to MT 5 base divides into:
o Deep Branch (hidden by QP)
o Superficial Branch
 Proper Plantar Digital Nerve to
lateral side of 5th toe
 Common Plantar Digital Nerve
• Communicating Branch
• 2 Proper Plantar Digital
Nerves
BAXTER’S NERVE (aka inferior calcaneal nerve)

Often the first branch off the lateral plantar nerve

• Motor Innervation: FDB, QP, & AbDM
• Sensory Innervation: calcaneal periosteum & long plantar ligament

Brown et. al 2016

BAXTER’S NERVE (aka inferior calcaneal nerve)

AbDM QP QP

AbH
FDB
PA
MP
BAXTER’S NERVE (aka inferior calcaneal nerve)

Two primary sites of entrapment:

#1: lateral turn btw QP &
thick fascia of AbH due to
e.g., AbH hypertrophy
which is common in
runners. Also, increased
foot pronation can put
traction on nerve AbDM QP QP

#2: anterior course towards

medial process which can
develop a spur AbH
FDB
PA
MP
Brown et. al 2016
Sagittal MRI
of patient
with
Baxter’s
Neuropathy

What clues tell us where this slice is taken?

What structure is indicated by the 3 arrows?
Why is this structure hyperintense?
 What muscles are innervated by the deep
division/branch of the lateral plantar nerve?

What muscles are innervated

by the superficial
division/branch of the lateral
plantar nerve?
WHAT IS MORTON’S (Plantar Digital) NEUROMA?

o Not a true “oma” or tumor

o Interdigital nerve entrapment causing enlargement

– most often reported in 3rd common digital branch

o Thought to be caused by repetitive irritation of the

nerve possibly due to e.g., compression from
adjacent MT heads, MTPJs or deep transverse
metatarsal ligament during ambulation

o From Dr. Khan’s FPP2 Lecture: “Authors agree that

etiology is from entrapment but disagree as to the
mechanism of entrapment.”

o May have radiating, burning pain in forefoot;

numbness/tingling between affected digits

o Can be aggravated by activity or restrictive shoes

o May feel as if one is walking on a marble, hot

pebble or with a rolled -up sock
Mulder’s Test

 Simultaneous compression of forefoot while applying direct pressure to the

affected area
• Right Hand: squeezing MT heads together
• Left Thumb: applying direct pressure at the affected web space where
patient feels pain.
 The nerve thickening is pushed inferiorly by compression from MT heads and
observer and/or patient may feel a click
 AXIAL T1 MRI AXIAL T2 w/ fat suppression
Treat

• Black arrow in each image points to location of neuroma

• Clearer on T1
• MRI can rule out other pathology, but generally not necessary for
diagnosis
 Morton’s Neuroma: Hypoechoic (low level echoes) mass

Click here for ultrasound video (start at 32:23)

https://www.educationaldimensions.com/
Neuroma Excision

 Dorsal or plantar surgical approach

 If dorsal (more common), then must go through deep transverse metatarsal ligament
Neuroma Excision

Thomas et al 2009
 NEUROVASCULAR
DISTRIBUTION IN
THE PLANTAR FOOT
POSTERIOR TIBIAL ARTERY
BRANCHES

Posterior Tibial A.
Nutrient Artery Fibular A.
of the Tibia

Communicating Branch

Posterior medial malleolar

artery
Medial calcaneal branches
ALL OF THE INTRINSIC MUSCLES OF THE PLANTAR
FOOT ARE SUPPLIED BY BRANCHES OF THE
LATERAL PLANTAR ARTERY EXCEPT FOR 3 WHICH
ARE SUPPLIED BY THE BRANCHES OF THE MEDIAL
PLANTAR ARTERY:

• ABDUCTOR HALLUCIS

• FLEXOR DIGITORUM BREVIS

• FIRST DORSAL INTEROSSEOUS

 LATERAL PLANTAR ARTERY
 Courses deep to AbH
 Pierces medial intermuscular septum
 Runs laterally and distally btw FDB & QP
 Pierces lateral intermuscular septum
 Can give off PROPER PLANTAR DIGITAL A.
TO THE LATERAL SIDE OF THE 5TH TOE*
 At MT 5 base, curves & becomes the DEEP
PLANTAR ARCH (btw AdH obl. & Interossei)
 3 POSTERIOR PERFORATING A.
 4** PLANTAR METATARSAL A.
o 1 ANTERIOR PERFORATING A.
each
o 2 PROPER PLANTAR DIGITAL A.
each
o 1 digital branch or twig (from 1ST
PLANTAR MT A. only)

* Can come off 4th MT A. instead

** 1st Plantar MT A. is formed by DP Arch & Deep Plantar A.
MEDIAL PLANTAR ARTERY
 Courses deep to the AbH
 Runs btw AbH & FDB
 At MT 1 base provides the PROPER
PLANTAR DIGITAL A. which joins the
digital branch or twig FROM THE 1ST
PLANTAR MT A. to form:
 PROPER PLANTAR DIGITAL A. TO THE
MEDIAL SIDE OF THE HALLUX

 SUPERFICIAL BRANCHES join the 1st-3rd

PLANTAR MT As.

** Lateral Plantar A. and branches (except

digital branch or twig) are in gray**
Dorsal Arterial Map Plantar Arterial Map
• Dorsal MT arteries lie in the intermetatarsal
spaces; the plantar MT arteries usually lie
along midline of MT shaft

• Posterior dorsal perforating arteries come off

the dorsal MT arteries; Posterior plantar
perforating arteries come off deep plantar arch
Forefoot Anastomoses (e.g., 3rd Digit)

There are
Proper Dorsal Digital Dorsal
anastomoses Arcuate
among digital Artery Metatarsal
Artery
arteries of Artery
toes

Anastomosis btw
dorsal and plantar
anterior perforating
arteries Proper Plantar Deep Plantar
Digital Artery Arch
Plantar
Anastomosis btw
Metatarsal
dorsal and plantar
Artery
posterior perforating
arteries
 Neurovascular Relationships

LATERAL to the
The medial plantar nerve lies__________
medial plantar artery.

MEDIAL to the
The lateral plantar nerve lies__________
lateral plantar artery.

OR

THE ARTERY LIES ON THE OUTSIDE

OF THE SAME NAMED NERVE
 QUIZ
YOURSELF!

Note:
• Muscles innervated by LPN: superficial , deep or early branches? Know this.
THE
END

PotaTOES