flexor digitorum longus

4

Is your 5th toe curled under ? What do you do when “this little piggy” can’t go wee wee wee all the way home.

Have a look at the 4 photos above.  You will see this curling of the lesser toes quite often in your practice, and when you know what it means it can help to guide your thinking, both from a diagnostic and treatment perspective.  

You should have noticed in the photos that the 4th and 5th toes curl under and are hyper-flexed, and this is at rest.  So, what does this mean ?

It means that the long flexors are overactive, the extensors are underactive, and the adduction pull of the long flexors is unopposed by the under appreciated quadratus plantae muscle.

Look at the clinical drawing. The quadratus plantae has 2 heads, a medial head and a lateral head.  Being able to clinically test these two heads will give you much insight into the function of the foot and when you see these outer two toes curling under, as you see in the photo, you will always see weakness of the lateral head of the quadratus plantae.  

The quadratus plantae arises from two heads separated from each other by the long plantar ligament. The medial head is larger and more muscular, attached to the medial calcaneus;  the lateral head is smaller and more tendinous, attaching to the lateral border of the inferior surface of the calcaneus and the long plantar ligament.  The two portions join and end in a flattened band which inserts into the lateral, upper and under surfaces of the tendons of the flexor digitorum longus, usually the second, third, and fourth toes.

But this time, if you have studied the drawing, you should notice the oblique line of pull of the long flexors.  This should in fact create this undesirable curling effect of the lateral two toes since they are so far out on the oblique line of pull. However, if you look at the insertion of the lateral head of the quadratus plantae you should be able to conclude that this head is designed to offset this oblique pull of the outer two long flexor tendons.  The quadratus creates a posterior pull on the outer long flexor tendons ensuring that the curling effect (as seen in the photo) is nullified. Thus, we have a clinical presentation of a weak lateral head of the quadratus plantae (and probably a few others which we will not discuss here so as to not dilute the purpose of today’s post). Now you just have to figure out why it is weak or if there is a biomechanical reason for its insufficiency

  • is there a foot type presenting itself that makes it difficult for this muscle to create sufficient posterior pull to offset the tremendous leverage of the long flexors? Maybe a forefoot varus, which gives the flexor tendons a mechanical advantage or a forefoot valgus which puts the quadratus plantae at a mechanical disadvantage? (Taking our National Shoe Fit Certification Program will help you get closer to understanding many of these issues.)
  • Are their other anatomical variants like an increased forefoot width or bunions (medial or tailor’s)
  • is there excessive rear or midfoot pronation?
  • Shoe choice problem ?

Some folks do have adequate function of the quadratus plantae. Note the lovely feet in the last picture … .  they must have strong lateral quadratus plantae and abductors of the lateral foot and toes ! And, they have great toe separation, thus great intrinsic interossei muscles, and nice flat toes (great balance between flexors and extensors).

So, what do you do?

  • you could do a surgery, amputate or fuse some of the joints to make them look better. Extreme for a problem like this
  • you could ignore the issue and hope it goes away. (in all likelihood it will worsen)
  • you could give them long flexor, toe scrunching Towel-curling, marble-grasping exercises , like you see all over the internet…and give the flexor digitorum longus even more of a mechanical advantage, and make the problem worse
  • you could give them exercises to increase the function of the long extensors, which would increase the mechanical advantage of the quadratus plantae. like the shuffle walk; lift, spread and reach and tripod standing exercises (hmm…sounding better)
  • be a real clinician and in addition to looking at the foot, look north of the foot to see what might be causing the problem (loss of ankle rocker, insufficient gluteal activity, loss of internal rotation of the hip, etc) Hmmm; sounding like a good idea too…

The Gait Guys. Hammering it home, day after day, about the importance of gait and giving you clues to be a better _________ (insert athlete, coach, trainer, clinician, shoe fitter, rehab specialist…).

Anatomy Mnemonics

Below are some old Anatomy Mnemonics someone once gave me that I found in my hard drive. Hopefully they’ll come in handy for someone else.



BONES

6 cranial bones

Old People From Texas Eat Spiders.

Parietal, Ethmoid, Sphenoid, Temporal, Occipital, Frontal.



Leg Bones

TIBia is the Thick Inner Bone, and Fibula is Finer, Fluted, and Lateral.



8 facial bones

Common Love gone Zip?(Abbr. CMMNLVZP)

conchae, mandible, maxilla, nasal, lacrimal, vomer, zygomaticus, palatine.



*Applying the first-3-letters rule to the facial bones, I came up with

Con Man

Max and Pal



Bones of the Wrist

Some Lovers Try Positions That They Cannot Handle

Scaphoid, Lunate, Triquetrum, Pisiform, Trapezium, Trapezoid, Capitate, Hamate



Never Lower Tillie’s Pants, Mama Might Come Home.

navicular, lunate, triquetrum, pisiform, greater and lesser multangular, capitate, and hamate.



*To remember that the carpals are bones of the wrist and not the foot, Lunate, Triquetrum, remember that CARPenters use their hands.



7 types of bone fractures

C3-PO Breaks his Bones


Greenstick, Open, Complete, Closed, Comminuted, Partial, and Others.



MUSCLES

Muscles in gluteal region: from top to bottom: P-GO-GO-Q

 Piriformis

 Gemellus superior

 Obturator internus

 Gemellus inferior

 Obturator externus

 Quadratus femoris


Muscles whose tendons attach at the pes anserinus (medial tibia): SGT
(“Sargent”)

 Sartorius

 Gracilis
semiTendinosus



Four abdominal muscles –

TIRE: (deepest to most superficial)

Transversus abdominis, Internal abdominal oblique, Rectus abdominis, and External abdominal oblique



Functions of the Interossei muscles

 PAD – Palmar ADduct

 DAB – Dorsal ABduct



Attachments of Pectoralis Major, Teres Major and Latissimus Dorsi

 A lady between two majors.

 Pectoralis major attaches to lateral lip of bicipital groove.

 Teres major attaches to medial lip of bicipital groove.

 Latissimus dorsi attaches to the floor of bicipital groove.

 The “lati” is between two “majors.“

 A lady between two majors.



Four muscles which control the mandible

masseter, temporal, lateral and medial pterygoids

form the letters MTPP, which could be read as "Empty Peepee” which could be construed as a command (or wish) to empty one’s peepee via…oh we’d better not say it.



Four abdominal muscles
Spare TIRE

transversus, internal oblique, rectus, and external oblique


 
On the floor of the mouth are two muscles
Doctor on the Floor?

mylohyoid and digastric – MD.


Muscles which regulate breathing

You Will DIE! If you don’t have'em

Diaphragm, Inner costal, and External costal



The SITS muscles make up the rotator cuff:

 Supraspinatus

 Infraspinatus

 Teres Minor

 Subscapularis



NERVES

Radial n. innervates the BEST!!!!

 Brachioradialis

 Extensors

 Supinator

 Triceps



Hand muscles innervated by the Median nerve

LOAF

 Lumbricals 1 + 2

 Opponens pollicis

 Abductor pollicis brevis

 Flexor pollicis brevis 


Innervation of phrenic nerve
 c345 keeps the phrenic alive 
 c345 keep the diaphragm alive

Innervation of the penis:

 Parasympathetic puts it up; sympathetic spurts it out

 Point , Shoot, Score! (erection, emmision ,ejaculation)

 Parasympathetic, Sympathetic ,Somatomotor


 
Innervation of the penis by branches of the pudental nerve

"S2, 3, 4 keep the penis off the floor”, derived from spinal cord levels
S2-4


 
Long thoracic nerve innervates serratus anterior 
 c5-6-7 raise your arms to heaven



Lateral and Medial Pectoral Nerve

Lateral is less, medial is more.

Lateral pectoral nerves goes through pectoralis major while medial pn goes though both pectoral major and minor.



12 Facial Nerves

"At the OIL FACTORY, the OPTICIAN looked for the OCCUPANT of the TRUCK. He
was searching because 3 GEMS had been ABDUCTED by a man who was hiding his FACE and EARS. A GLOSSY PHOTOGRAPH has been taken of him, but it was too VAGUE to use. He appeared to be SPINELESS and HYPOCRITICAL.“


In order, the oil factory is the olfactory nerve; the optician is the optical nerve; the occupant is the occulomotor nerve; the truck represents the trochlear nerve; the 3 gems are the trigeminal nerve; abducted is really the abducens;
face is facial; ears really means auditory; glossy photograph is glosso-pharyngeal; spineless relates to the spinal
accessory nerve; and hypocritical is the hypoglossal nerve.



Wrist Nerves and Prohibition

RUM, for radial, ulnar, and medial symptoms of nerve troubles are wrist drop, claw hand, and tunnel syndrome …

represented by the letters WCT (Women’s Christian Temperance Union).



Cranial Nerves

I-Optic

II-Olfactory

III-Oculomotor

IV-Trochlear

V-Trigeminal,

VI-Abducens

VII-Facial

VIII-Acoustic (Vestibulocochlear),

IX-Glossophrayngeal,

X-Vagus,

XI-Spinal Accessory,

XII-Hypoglossal

On Old Olympus Towering Tops, A Finn And German Viewed Some Hops 


Branches of the Facial Nerve (CN VII):

To Zanzibar by Motor Car

Ten Zebras Bought My Car

Temporal, Zygomatic, Buccal,
Masseteric,Cervical 


Brachial Plexus:

Roots, Trunks, Divisions, Cords, Branches
Robert Taylor Drinks Cold Beer. (or Richard Tucker Drinks Cheap Beer :-) )



Innervation of Extraocularmotor Muscles: LR6 SO4 Others 3

 LR6–Lateral rectus - VI abductens

 SO4–Superior Oblique - IV Trochlear

 Others 3–The remaining 4 eyeball movers = III Oculomotor


For the order of nerves that pass through the superior orbital fissure:

"Lazy French Tarts Lie Naked in Anticipation.” 
(Lacrimal, Frontal, Trochlear, Lateral, Nosociliary, Internal, Abducens)


9 branches of the abdominal portion of the aorta

"Celia Smith’s Supra Rams Green Impala Past Stop Light"

Celiac, Supra mesenteric, Supra-renal, Renal, Gonadal, Inferior mesenteric, Phrenic, Sacral, and Lumbar.



VESSELS
Structures passing posterior to the medial malleolus of the foot:

 Tom, Dick, And Harry

Tibialis posterior tendon, flexor Digitorum longus tendon, post. tibial Artery and tibial nerve, and 
flexor Hallucis longus tendon. (i.e. Tibialis, Digitorum, Artery & nerve, and Hallucis) 



Carotid Sheath– VAN

 Internal Jugular Vein

 Common carotid Artery

 Vagus Nerve



Arteries as they come off the external carotid:

Superior thyroid, Ascending pharyngeal, Lingual, Facial, Occipital, Post Auricular, Superficial temporal, Maxillary

Some Angry Lady Figured out PMS



ABC’S of the aortic arch!

Aortic arch gives off the Brachiocephalic trunk, the left Common Carotid, and Left Subclavian artery



Branches of the aorta artery in the lower torso

Transsexuals Remember the Aorta

"Come on In Ex-Female, Pop And Prance Past Doors and Planters".

Common iliac, Internal iliac, External iliac, Femoral, Popliteal, Anterior tibia, Posterior tibia, Peroneal, Dorsalis, medial and lateral Plantars.



Branches of the axillary artery

 Sally Thompson Loves Sex And Pot pie 
Superior Thoracic, Thoracoacromial, Lateral thoracic, Subscapular, Anterior circumflex humeral, Posterior circumflex humeral, and Profunda brachii.



Arteries off the External Carotid

They are buried in the phrase Some Loser F*cked My Sister

Superior Thyroid, Lingual, Facial, Maxillary, Superficial Temporal 



Vessels joining the inferior vena cava

"He Commonly Lumbers in the Viet Cong ReGion".

A Vietnamese Lumberjack’s Heart:

 Hepatic, Common iliac, Lumbar, Vena Cava, Renals, Gonadals.


Stroke versus Aneurysm

STRoke is caused by arterial reSTRiction, and aneurysm is AN Erupting artery.



MISCELLANEOUS

checklist of factors causing back troubles

Dr. O. VESALIUS

O - Osteomyelitis

V - Vertebral fracture

E - Extraspinal tumour

S - Spondylolisthesis

A - Ankylosing spondylitis

L - Lumbar disk disease

I - Intraspinal tumour

U - Unhappiness

S - Stress

Cranial sutures

cranial sutures have CLASS!

Coronal, Lambdoid, Squamous, Sagittal.


five visceral sensors

Low TEMPeratures have BARe-CHEsted cOSMO-girls kNOCking.
temperature, barometric, chemical, osmotic, nociceptors



Femoral Sheath (lateral to medial) order of things in thigh

NAVEL

 Femoral Nerve,

 Femoral Artery,

 Femoral Vein,

 Empty Space,

 Lymphatics (or Lacunar Ligament)


 
Pelvic Diaphragm – PICOLO(A) -Posterior to anterior

 PIriformis

 COccygeus

 Levator Ani


 
Location of Thoracic duct:

The duck is between two gooses (duck = thoracic duct)

2 gooses = azyGOUS and esophaGOUS


Structures perforating the diaphragm

 “At T8 you see, perforates the IVC” (inferior Vena Cava) the “EsoVagus” pierce T10 (esophagus, vagus nerve) 
 T12 - red, white and blue (aorta,thoracic duct,azygous vein)


Course of Ureters

Water runs under the bridge (uterine a. and ductus deferens)