Long flexors of the fingers and toes. Extensor and flexor of the big toe long Flexor of the big toe long

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Feet

Feet The feet are another part of the body that allows you to get in touch with and use the somatic mind. We don't usually think of our feet as an important part of our nervous system, but they have a significant impact on how we function and interact with our surroundings.

Feet

Feet In Japan, feet are perhaps the most important element of female beauty. In the novel The Life of a Woman in Love (1686), a young girl who was intended as a geisha for a high-ranking official is described as follows: “Her feet were hardly more than 20 cm in length; big

FEET

FEET In Japan, feet are perhaps the most important element of female beauty. In the novel The Life of a Woman in Love (1686), a young girl who was intended as a geisha for a high-ranking official is described as follows: “Her feet were hardly more than 20 cm in length; big

Flexor digitorum longus
Flexor of the foot

Long flexors fingers and feet and stress points
Left: flexor digitorum longus
Right; flexor longus

LONG FLEXORS flex all toes and feet together, helping to maintain balance as the weight of the body is transferred to the forefoot. In addition, they secure the ankles while walking and are activated during upward jumps.

Stress points are caused by running on uneven and soft surfaces and by poor shoes that do not provide enough support to the foot and ankle. Hard shoes can also cause them. Since both muscles run deep, they are difficult to feel.

Flexor digitorum longus attached at one end at the back tibia, runs deep under the gastrocnemius and solitary muscles along the entire length of the tibia on the back side, crosses the talus and is attached at the other ends on the underside of the foot to each of the four small toes. If stress points are present in the flexor digitorum, pain occurs in the sole of the foot and under the toes.

To find stress points in this muscle, sit in a chair and place the ankle of your affected leg on the knee of your other leg. Locate the sharp protrusion on the front side of the tibia. Run your hand along it towards the back of your shin. The flexor digitorum muscle is located 8 cm down from the knee between the tibia and the gastrocnemius muscle. Press on the back of the bone and then on the outside of the shin to find tender spots.

Flexor of the foot attached at one end at the back fibula, runs along the back of the leg, crosses the talus on the inside and is attached to the bottom of the foot to the big toe. If there are stress points in the plantar flexor, pain will occur in the big toe and forefoot. When you stand still, the pain gets worse. When this muscle becomes stiff, finger diseases develop.

The plantar flexor cannot be detected directly. To find it, you need to feel deeply through the thick single muscle, pressing your thumb on the shin at a distance of 2/3 down from the knee joint. The flexor is located there, at the beginning of the Achilles tendon. To find sensitive spots in it, press on the outside of the shin.

Stretching is very important to relax the toe and toe flexors.

Flexor digitorum longus stretch

Stretching: Sit on the floor and extend your leg forward. Grasp your toes with your hand and pull towards you. Relax your ankle so that it also flexes as you stretch. Maintain this position for 15-20 seconds, repeat the exercise many times a day to achieve complete relaxation.

In location, action and number, the muscles of the toes are almost similar to the muscles of the fingers of the hand, but, as already indicated, depending on the little developed activity of the toes, the muscles of the dorsum of the foot are more related to movement in the ankle joint, and the muscles of the plantar side are involved in strengthening the arch of the foot.

Extensors and flexors of the toes

Between the extensors of the fingers (dorsal flexors) and their flexors (plantar flexors) we find long and short extensors, as well as long and short flexors. The first are located on the front surface of the lower leg and on the back of the foot, the second - on the back surface of the lower leg and on the sole.

Among the extensors we have the extensor digitorum longus and the extensor pollicis longus, which have already been described above; we only have to look at the short extensor digitorum muscles.

Extensor digitorum brevis(m. extensor digitorum brevis, Fig. 72-11) begins on the dorsum of the calcaneus; its innermost part stands out under the name of the short extensor hallucis brevis (m. extensor hallucis brevis, Fig. 72-22). At the level of the metatarsal bones, the muscle fibers pass into the tendons of the first four toes. All of them obliquely approach (from the outside inward) to the outside of the long extensor tendons and merge with them at the base of the first phalanx, except for the tendons of the thumb. The extensor pollicis brevis tendon attaches directly to the first phalanx.

The extensor digitorum brevis primarily acts on the first phalanges. The oblique arrangement of its tendons allows for the ability to abduct the fingers outward in the metatarsophalangeal joint. Acting simultaneously with the extensor digitorum longus, the extensor digitorum brevis produces pure extension of the fingers at the metatarsophalangeal joint. The tendon of the short extensor of the first finger, attaching directly to the first phalanx, produces its extension.

Innervation: deep peroneal nerve (n. peroneus profundus, L IV-V and S I).

Among the flexors of the fingers, they are distinguished: the long flexor of the thumb and the common long flexor of the fingers with an accessory head starting from the calcaneus, the quadratus plantae muscle and the short common flexor of the fingers. In addition, there is a flexor brevis for both the thumb and little finger.

Flexor digitorum longus(m. flexor digitorum communis longus, Fig. 66-7) is located in the deepest layer of the lower leg. It begins from two-thirds of the posterior surface of the tibia, in addition, part of its fibers originates from the tendinous arch formed by the fascia of the tibial muscle.

Thus, the beginning of its muscle fibers reaches the fibula. The tibialis posterior muscle, coming under the formed long flexor tendon, crosses it and is located directly near the medial malleolus. The tendon of the long flexor of the fingers, going down, is located closer to the midline of the lower leg and passes to the sole. On the sole, it receives a tendinous pedicle from the long flexor pollicis and, in addition, from the lower and inner surface of the calcaneus, another short accessory head is attached to it - quadratus plantaris(m. quadratus plantae, s. sago quadrata Sylvii, Fig. 66-23). Then, at the level of the base of the metatarsal bones, the common tendon of the long common flexor of the fingers splits into four bundles, which immediately, upon their division, give rise to the so-called worm-shaped muscles, extending from the inner (from the side of the first finger) side of its tendons. Moving further forward, each tendon of the common long flexor lies in a canal formed by the bifurcation of the corresponding tendon of the short flexor, just as it was on the hand of the superficial and deep flexor of the fingers. Located together with the short common flexor of the fingers in the osteofibrous sheath of the fingers, the tendons of the long flexor end, attaching to the third (ungual) phalanges of the fingers.

The long common flexor digitorum bends the third phalanges over the second and the second over the first; at its maximum contraction, it can slightly bend the first phalanx over the metatarsal bone; in addition, it imparts a slight inward deviation to the fourth and fifth fingers, which is especially evident in the position of their nail phalanges. This last action is explained by the oblique (inside out) direction of the tendons of the IV and V fingers on the sole. If the action of the general long flexor of the fingers is joined by the action of its accessory head and the action of the short general flexor of the fingers, then this deviation is destroyed.

Duchesne and Poirier completely deny the action of the long common flexor of the digitorum on the ankle joint during upper support. Braus believes that with upper support, the common long flexor of the fingers can produce plantar flexion, supination (turning the sole medially) and medial abduction (from the midline of the foot), and supination is most pronounced, plantar flexion is the least, and medial abduction corresponds to the action tibialis posterior muscle. When a person is standing, the flexor digitorum longus strengthens the arches of the feet and can extend the lower leg (plantar flexion) when raising the torso on the toes.

Innervation: tibial nerve (n. tibialis, L V and S I).

Flexor digitorum brevis(m. flexor digitorum communis brevis, Fig. 74) starts from the lower surface of the tubercle of the calcaneus, from the posterior third of the upper surface of the plantar aponeurosis and from the intermuscular septa. At the level of the base of the metatarsal bones, it forms four tendons, which at the level of the first phalanges split longitudinally and, passing the corresponding tendons of the long

the common flexor of the fingers, pass through the osteofibrous sheath and are attached to the sides of the second phalanges, reaching their articulations with the third. Their relationship and structure are quite consistent with the relationship and structure of the superficial and deep flexor of the fingers, which were described above. The flexor tendon of the fifth finger is sometimes very thin and is not pierced by the tendon of the common long flexor digitorum, sometimes it is completely absent.

The short common flexor of the fingers bends the second phalanges and almost does not show its action on either the first or third phalanges. With lower support, its main action is to strengthen the longitudinal arch of the foot (Fig. 74) and the plantar aponeurosis.

Innervation: plantar internal nerve (n. plantaris medialis, L V and S I).

Flexor pollicis longus(m. flexor hallucis longus, Fig. 66-19, 15) is the outermost muscle of the deep posterior muscular layer of the leg; it begins on the middle lower third of the posterior surface of the fibula; going down and inward, it passes into the tendon, located in the groove located on the posterior surface of the talus, fits under the internal process of the calcaneus (sustentaculum tali) and goes to the inner edge of the foot.

On this path, the tendon of the flexor pollicis longus intersects with the tendon of the long common flexor of the fingers, is connected to it by a tendon bundle and then, passing between both parts of the short flexor pollicis and both sesamoid bones of the metacarpophalangeal joint of the thumb, reaches its nail phalanx, where is attached (Fig. 74-4).

The flexor hallucis longus strongly flexes the second phalanx and has a weak effect on the metatarsophalangeal joint. Duchenne completely rejects its influence on the ankle joint. According to Braus, the flexor hallucis longus plays an important role in pushing the foot off the ground. It is also necessary to note its significance in relation to the movements of the entire foot. It is primarily a plantar flexor, but at the same time, with upper support, it abducts the foot medially and supinates it. With inferior support, the flexor hallucis longus strengthens the arch of the foot in the longitudinal direction and counteracts the formation of a flat sole (pes planum).

Innervation: tibial nerve (n. tibialis, L V and S I-II).

Flexor pollicis brevis(m. flexor hallucis brevis, Fig. 74-2; 75-1) is divided into two parts. Both of its parts begin from the sphenoid bones, from the ligamentous apparatus connecting the plantar surface of the heel and metatarsal bones, and from the plantar aponeurosis. Heading towards the thumb along the metacarpal bone, the short flexor pollicis is divided into two parts and attached to the tubercle of the first phalanx: one on the outside, the other on the inside. Both tendons contain sesamoid bones.

Rice. 75. Deep muscles of the foot. (Poirier.) 1 - flexor pollicis brevis, 2 - transverse head of the adductor pollicis muscle, 2" - oblique head of the adductor pollicis muscle, 3 - flexor pollicis brevis, 4 - opposable V finger muscle, 5 - peroneus longus tendon - its movement along the plantar surface and attachment

The flexor pollicis brevis flexes the big toe at the metatarsophalangeal joint, which is especially important when standing on your toes. Acting with separate heads, the flexor hallucis brevis can abduct the first phalanx in one direction or the other (from the midline of the foot). Starting from the deep ligamentous apparatus of the foot and to the side of the plantar aponeurosis, it strengthens, together with other muscles, the internal longitudinal arch of the foot.

Flexor digitorum brevis(m. flexor digiti quinti, Fig. 75-3) starts from the fibrous sheath of the peroneus longus muscle, from the crest of the lower surface of the cuboid bone, from the base of the metatarsal bone of the fifth finger and is attached to the base of the first phalanx of the fifth finger. It flexes the fifth finger at the metatarsophalangeal joint, and also strengthens the outer longitudinal arch of the foot through the plantar aponeurosis.

Innervation: external plantar nerve (n. plantaris lateralis, S I-II).

Muscles that abduct the toes are located three to three feet away from the midline of the foot

The abduction possible in the metatarsophalangeal joints is accomplished in the same way as in the hand, through the interosseous and lumbrical muscles, and in the big and small fingers, also with special abductor muscles. Only the opponsus pollicis muscle is missing; As for the same muscle of the fifth finger, it is sometimes observed. On the foot, as well as on the hand, there should be 10 abductor and adductor muscles in this group. Of these, the muscles that abduct and adduct the thumb, as well as the abductor pollicis, are located on the sole, and the rest are located between the metatarsal bones, which is why they, similar to the muscles of the hand, are called interosseous. The vermiform muscles, which were mentioned when describing the long common flexor of the digitorum, located on the inside of its tendons, also take part in the abduction of the second finger and the adduction of the third, fourth and fifth fingers.

On the foot, the midline, towards which adduction (adductio) will occur and towards which abduction (abductio) will occur, coincides with the midline of the second toe. Thus, only the second finger will have two interosseous muscles that abduct in both directions from the midline, while the remaining fingers will have interosseous muscles that abduct from the midline and lead to it.

At the thumb we have an independent muscle, the abductor pollicis and the independent adductor.

Abductor pollicis muscle(m. abductor hallucis, Fig. 74-3) lies superficially under the fascia on the inner edge of the foot and forms the eminence of the big toe. The abductor muscle begins directly from the lower part of the inner surface of the tubercle of the calcaneus, as well as from the ligamentous apparatus of the foot and the plantar aponeurosis; it is attached by a well-developed tendon to the inner edge of the first phalanx, fused with the tendon of the inner head of the short flexor pollicis. Sometimes the abductor pollicis muscle sends a tendon extension to the extensor pollicis tendon. It abducts the big toe from the midline of the foot, in which it is partly helped by the internal head of the flexor hallucis brevis.

The abductor pollicis muscle can be classified as a static type: feathery arrangement of fibers (powerful tendon). Its main significance is strengthening the inner arch of the foot. Abduction of the thumb is weakly expressed.

Innervation: internal plantar nerve (n. plantaris medialis, L V and S I).

Adductor pollicis muscle(m. adductor hallucis, Fig. 75-2, 2") consists of two heads. One of them, obliquely located, starts from the cuboid bone, from the third wedge-shaped, second and third metatarsal bones, as well as from the fibrous sheath of the peroneus longus muscle and goes obliquely from the middle of the foot to the first toe. The second head, located transversely, starts from the head of the metatarsal bone of the fourth toe and on the way to the first toe crosses the heads of all other metacarpal bones in the transverse direction, receiving separate muscle bundles from them and from the intermetatarsal ligaments.

The obliquely located head, approaching the first toe, fuses with the outer head of the flexor hallucis brevis and together with it will bring the big toe to the midline of the foot. The transversely located head of the adductor pollicis muscle is more independent than was observed on the hand, and some (Lebuk) even indicate that on the first phalanx this muscle has an independent attachment: on the one hand, it sends a continuation to the back of the thumb to its extensor , on the other hand, part of the fibers, passing through the attachment of the oblique head of the adductor pollicis and its flexor brevis, ends on the osteofibrous sheath of the thumb. The oblique head has the strongest adductor effect on the first phalanx of the big toe and, as Duchesne points out, is an active ligament that prevents the divergence of the metatarsal heads, and thus strengthens the transverse arch of the foot.

Innervation: internal and external plantar nerves (n. n. plantares medialis et lateralis, S I-II).

Abductor fifth digit muscle(m. abductor digiti quinti, Fig. 74-5), like the abductor pollicis muscle, is located superficially, but only on the outside. The abductor digit V muscle begins from the lower surface of the posterior external tubercle of the calcaneus, from the inward-facing surface of the plantar aponeurosis and from the intermuscular septum separating it from the flexor digitorum brevis muscle. Moving forward along the metacarpal bone of the fifth finger, it ends on the outer surface of the base of the first phalanx of the fifth finger and on the lower surface of the bursa ligament of the metatarsophalangeal joint.

In most cases, the abductor V finger muscle is only a flexor of the first phalanx, and only in children can it produce abduction. Located on the outer side from the heel to the main phalanx of the fifth finger, it, of course, has a great influence on strengthening the outer arch.

Innervation: external plantar nerve (b. plantaris lateralis, S I-II).

Abduction and adduction of the remaining fingers is accomplished with the help of the interosseous muscles; they are located like the interosseous muscles of the hand, on the one hand, in the deepest layer on the sole (interosseous internal muscles), on the other, on the back of the foot (interosseous external muscles). As on the hand, there are three internal interosseous muscles on the foot, four external ones; the internal ones will lead to the midline of the foot, the external ones will lead away from the midline; you just need to remember that the midline of the foot passes through the second toe and therefore two abductors will be at the second toe, and not at the third, as we saw on the hand.

Adductor internal interosseous muscles(m. m. interossei interni, Fig. 76) start from the posterior third of the lower edge of each of the last three metacarpal bones (V, IV and III) and from the lower surface of their base. They lie more superficial than the interosseous spaces themselves, so that they completely cover the lower surface of the metacarpal bones. They end in a completely different way than the internal interosseous muscles of the hand: in most cases they are attached only to the lateral inner (from the side of the thumb) part of the first phalanx and to the bursa ligament of its joint; they do not give continuations to the extensor tendon of the fingers.

According to their location and attachment, the internal interosseous muscles are the muscles leading to the midline of the foot III, IV and V fingers; the second toe does not have an adductor muscle, since it lies on the midline of the foot, and the big toe has its own adductor, described above (Fig. 75-2).

Innervation: deep branches of the external plantar nerve (rami profundi n. plantaris lateralis, S I-II).

Abductor external interosseous muscles(m. m. interossei externi, Fig. 77) are located on the back of the foot, filling all the spaces between the metacarpal bones. They are two-headed and begin from the lateral parts of the metacarpal bones facing each other, from the lower surface of their bases and the dorsal interosseous fascia. Starting from two opposite sides, they form pennate muscles, the tendons of which are attached to the base of the first phalanges and to the bursa ligament of the joint on the outside of the third and fourth fingers and on both sides of the second finger. They do not give continuation to the extensor tendon of the fingers; rather, continuations can be found to the cartilaginous thickenings of the metatarsophalangeal joint bursa.

The interosseous muscles of the IV, III and II fingers are abductors from the midline of the foot. These movements in the foot are very limited, as they are constantly constrained by shoes, and are most noticeable in children or people who do not wear shoes. Approaching the first phalanx from both sides, more from the plantar surface, and combining their action with the action of the internal interosseous muscles, the external interosseous muscles of the IV, III and II fingers produce flexion of the first phalanx; the same movement is produced by the abductor V finger in combination with the internal interosseous V finger.

Innervation: deep branches of the external plantar nerve (n. plantaris lateralis, S I-II).

Vermiform muscles(m. m. lumbricales,) mentioned above when describing the long common flexor of the fingers, from the tendons of which they begin, also take part in abducting the fingers. Located on the inner side of each tendon of the II, III, IV and V fingers, they are attached to the inner side of the first phalanges of the same fingers, and, therefore, will contribute to the work of the interosseous muscles that produce abduction in their direction. In the second finger they will produce abduction from the midline, and in the remaining (III, IV and V) fingers - adduction to the midline.

The lumbrical muscles, to a certain extent, can participate in the flexion of the first phalanges.

Innervation: internal plantar nerve (n. plantaris medialis); external plantar nerve (n. plantaris lateralis to the first, third and fourth, L V and S I-II).

To the muscles of the foot we must also add the non-permanently existing muscle that opposes the fifth toe.

Opponder V finger muscle(m. opponens digiti quinti, Fig. 75-4). A person does not have an opponor muscle of the thumb, since the thumb, being one of the main points of support, has lost all significance for grasping. The opposing muscle of the fifth finger is important for adapting the sole to uneven soil. Even in cases where it exists, it is poorly developed and is not completely separable from the flexor brevis and abductor V digitorum muscles. It differs from the mentioned muscles only in that it is attached not to the first, but to the metacarpal bone of the fifth finger. During its contraction, the muscle opposing the fifth toe pulls the metacarpal bone somewhat inward (towards the midline of the foot) downwards.

The long flexor hallucis longus tendon is about 10-12 cm long and can be used to repair large Achilles tendon defects. When the tendon is transposed, the normal balance of the muscles acting on the ankle joint is also maintained - i.e. there is a transfer of the plantar flexor to the plantar flexor. However, athletes showed a decrease in pushing force due to the fact that there were problems in the area of ​​the big toe during sprinting.

Transposition of the flexor hallucis longus tendon was first performed by Wapner et al. The authors recommended performing the operation as follows. The patient lies on his back, and a pneumatic tourniquet is applied to the lower third of the thigh. A longitudinal incision is made along the medial edge of the foot from the first metatarsal to the navicular (Figure 93). By means of sharp dissection, the fascia covering m. abductor hallucis. The hook is used to move m. abductor hallucis together with m. flexor hallucis brevis downwards and expose the synovial sheaths of the tendons mm. flexor hallucis longus and flexor digitorum longus. The m tendon is identified. flexor hallucis longus and isolate it in such a way that after cutting it is possible to suture the distal tendon stump to the flexor digitorum longus tendon. The tendon of m. is crossed. flexor hallucis longus and suture the distal stump to that part of the flexor digitorum longus tendon that goes to the second finger. In this case, the big toe should be in a neutral position. The proximal stump of the flexor digitorum longus tendon is sutured with a strong thread.

Next, 1 cm medial to the Achilles tendon, a posteromedial incision is made from the musculotendinous junction of the gastrocnemius muscle and extended to a point 2-3 cm below the enthesis. Avoiding dissection of the subcutaneous fat, the paratenon is exposed and opened. The tendon is isolated in such a way as to preserve the vascular connections of the paratenon with the subcutaneous fat and skin. Having isolated the tendon, the fascia separating the posterior compartment of the leg is opened with a longitudinal incision and the tendon m. flexor hallucis longus, which is brought into the proximal wound. Just distal to the enthesis of the Achilles tendon, a channel is drilled into the calcaneus half the width of the bone in a medial to lateral direction. A second vertical channel is then drilled, starting immediately anterior to the Achilles tendon. A canal is developed in the bone with a curved instrument and the proximal stump of the m. tendon is pulled through it by a thread. flexor digitorum longus. Then the tendon stump m. flexor digitorum longus is reinforced in a zigzag manner to the Achilles tendon, suturing the graft with interrupted 1-0 Dacron sutures. At the surgeon's discretion, additional reinforcement with the m. tendon can be performed. plantaris or a reduced full-thickness or partial-thickness flap according to Chernavsky. The paratenon is sutured with absorbable suture, and the skin wound is closed in the traditional manner. After surgery, the limb is immobilized with a shortened splint with the foot plantar flexed at 15 degrees.

Figure 93 . Tendon repairm. flexor hallucis longus by Wapner et al.

The technique was used by the authors in seven patients who were followed for an average of 17 months. According to subjective questionnaires, excellent results were obtained in three patients, good in another three, and the result in one patient was assessed as poor. All patients had a functionally insignificant limitation in the range of motion in both the ankle joint and the first toe. Isokinetic tests revealed a 29.5% decrease in plantar flexion strength compared to the contralateral side. There were no secondary functional impairments associated with flexor hallucis longus harvesting. These results are similar to those reported in 1977, when Frenette and Jackson found no decline in function in ten young athletes who had ruptured the flexor hallucis longus tendon, four of which failed to heal.

M.W. Wong and V.W. Ng modified the flexor hallucis longus transposition technique by fixing the distal stump of the transposed tendon in a Pulvertaft tendon suture manner (Figure 94). The technique was used by the authors in 5 elderly patients (average age 52-71 years) with chronic untreated ruptures of the Achilles tendon with a large diastasis (5-7 cm). The results were followed over 28.8 months and improved from 64.4 to 94.4 points on the AOFAS scale. The study was uncontrolled.

Figure 94. Transposition of the flexor hallucis longus tendon according to M.W. Wong and V.W. Ng

The advantages of the flexor hallucis longus transposition include the presence of a long and strong tendon and the fact that the muscle of the transferred tendon is much stronger than other candidates for transposition, the flexor hallucis longus vector is closest to the Achilles tendon, and its contraction occurs during the same phases of gait as the calf contraction -soleus complex. The anatomical proximity makes the operation simpler without the need to open other compartments of the leg, and the muscle fibers provide additional vascularization of the proximal Achilles tendon stump.

We were able to find one biomechanical study in which the authors compared in vitro the tensile strength of the Achilles tendon after repair with the peroneus brevis and flexor hallucis longus tendons, which was equal to 348.8 ± 124.9 N and 241.5 ± 82.2 N, respectively. However, in vivo strength may be significantly different, so the results of this study cannot be interpreted as an indisputable advantage of peroneus brevis tendon repair.