VASCULARIAZATION OF THE FOOT

Describe the general aspects of the superficial veins on the dorsum of the foot.
S or P

They course in the superficial fascia. They do not have corresponding arteries. They have valves. They connect to the deep veins by perforating veins. They connect to other superficial veins. Considerable variability in the pattern of superficial veins. They are commonly accompanied by cutaneous nerves.

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VASCULARIAZATION OF THE FOOT

Describe the dorsal venous arch.

The dorsum of each toe is drained by dorsal digital veins and a median digital vein:
Dorsal digital veins drain the sides of the toe. The median digital vein drains the center of the toe and the nail matrix.

S or P

Great Saphenous Vein

The median digital veins drain into the dorsal digital veins on the sides of the toes. Dorsal digital veins from adjacent sides of toes unite with an intercapitular vein from the plantar cutaneous venous arch to form a common digital vein. Common digital veins, the dorsal digital vein from the dorsomedial aspect of the hallux and the dorsal digital vein from the dorsolateral aspect of the digiti minimi flow into the dorsal venous arch.

Medial Marginal Vein

Lateral Marginal Vein L M Dorsal Venous Arch

Common Digital Vein

Dorsal Digital Veins

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VASCULARIAZATION OF THE FOOT

Describe the dorsal venous arch.
S or P

The dorsal venous arch flows medially into the medial marginal vein and laterally into the lateral marginal vein. It lies in the superficial fascia at the distal aspect of the metatarsal shafts. It is located superficial to the cutaneous nerves. There is a irregular network of superficial veins proximal to the dorsal venous arch that flows into the dorsal venous arch, the medial marginal vein, and the lateral marginal vein.

Great Saphenous Vein

Medial Marginal Vein

Lateral Marginal Vein L M Dorsal Venous Arch

Common Digital Vein

Dorsal Digital Veins

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VASCULARIAZATION OF THE FOOT

Describe the medial marginal vein.
S or P

The dorsal digital vein on the dorsomedial aspect of the hallux and the dorsal venous arch unite to form the medial marginal vein. The medial marginal vein courses along the medial aspect of the foot and receives branches from the irregular network and the plantar surface of the foot. The saphenous nerve courses with the medial marginal vein. The medial marginal vein courses anterior to the medial malleolus and becomes the great saphenous vein which courses up the leg and thigh and courses through the saphenous opening below the inguinal ligament to drain into the femoral vein.

S or P S or P

M A P L M

A or D D or S

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VASCULARIAZATION OF THE FOOT

Describe the lateral marginal vein.
S or P S or P

The dorsal digital vein on the dorsolateral aspect of the fifth toe and the dorsal venous arch unite to form the lateral marginal vein. The lateral marginal vein courses along the lateral aspect of the foot and receives branches from the irregular network and the plantar surface of the foot. The lateral dorsal cutaneous nerve courses with the lateral marginal vein. The lateral marginal vein courses posterior to the lateral malleolus and becomes the small saphenous vein which courses up the leg and pierces the popliteal fascia to drain into the popliteal vein. The lateral marginal vein may be absent. When absent the small saphenous vein is formed from superficial veins on the lateroplantar aspect of the foot.

A or D S or P

P or P D or S

A or D

P or P P or I P or I

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VASCULARIAZATION OF THE FOOT

Describe the superficial veins on the plantar surface of the foot.
A or D

A plantar cutaneous venous arch lies in the superficial fascia in the region of the MTP s. It receives superficial branches from the toes. It gives off four intercapitular veins to the dorsum of the foot. It is continuous over the sides of the foot with the medial and lateral marginal veins. There is a plantar cutaneous network of superficial veins proximal to the plantar cutaneous venous arch that flows into the arch, the medial marginal vein, and the lateral marginal vein. The superficial veins are less organized on the plantar surface of the foot.

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VASCULARIAZATION OF THE FOOT

Describe the general aspects of the arteries on the dorsum of the foot.

The dorsum of the foot is vascularized by the dorsalis pedis artery which is a continuation of the anterior tibial artery. The arteries on the dorsum of the foot are much smaller than on the plantar surface. There is considerable variation in the arteries on the dorsum of the foot. The arteries are accompanied by deep veins of the same name. The deep veins course with the arteries and are usually paired forming venae comitantes (accompanying veins). The description of a deep vein is the reverse of an artery (i.e. distal to proximal).

S or P

S or P

A or D A or D

VASCULARIAZATION OF THE FOOT

Describe the dorsalis pedis artery. Begins at the articular capsule of the ankle joint as a continuation of the anterior tibial artery. Courses deep to the deep fascia. Courses over the neck of the talus, navicular, and second cuneiform. At the proximal aspect of the first interspace it terminates by dividing into the first dorsal metatarsal artery and the deep plantar artery. Some textbooks consider the dorsalis pedis artery to terminate as the deep plantar artery and the first dorsal metatarsal artery is a branch. The tendon of extensor hallucis longus is located on the medial side of the dorsalis pedis artery. The tendon of extensor hallucis brevis crosses the dorsalis pedis artery near its termination. Major branches are:
Artery of the sinus tarsi Lateral tarsal artery Medial tarsal arteries Arcuate artery First dorsal metatarsal artery Deep plantar artery
S or P

A or D

VASCULARIAZATION OF THE FOOT

Describe the artery of the sinus tarsi. Describe the lateral tarsal artery. Describe the medial tarsal arteries. Artery of the sinus tarsi:
Branches from the dorsalis pedis artery at the level of the neck of the talus (it may branch from the lateral tarsal or perforating artery). It provides the major vascular supply to the talus. It terminates by anastomosing with the artery of the tarsal canal from the posterior tibial artery.
S or P

Lateral tarsal artery:

Branches from the dorsalis pedis artery at the level of the neck of the talus or navicular. It courses laterally deep to EHB and EDB (which it vascularizes) with the lateral terminal branch of the deep peroneal nerve. It terminates by anastomosing with the anterior lateral malleolar, perforating, and arcuate arteries (lateral malleolar network).
L M

Medial tarsal arteries:

Usually two or three branches that vascularize structures on the medial aspect of the foot and then anastomose with the medial malleolar network.

A or D

VASCULARIAZATION OF THE FOOT

Describe the arcuate artery and the second, third, and fourth dorsal metatarsal arteries.
S or P

Arcuate artery:
Branches from the dorsalis pedis artery near the second metatarsal base. Courses laterally over the metatarsal bases deep to the tendons of EDL, EHB and EDB and gives off the Second, third, and fourth dorsal metatarsal arteries. It terminates by anastomosing with the lateral malleolar network.

A or D

VASCULARIAZATION OF THE FOOT

Describe the arcuate artery and the second, third, and fourth dorsal metatarsal arteries.
A or D

Second, third, and fourth dorsal metatarsal arteries:

Each courses distally on its respective dorsal interosseous muscle. Each terminates by dividing into two dorsal proper digital arteries at the cleft of the toes for the adjacent sides of the digits. Each receives at its distal aspect an anterior perforating artery from its respective plantar metatarsal artery. Each receives at its proximal aspect a posterior perforating artery from the plantar arch. The fourth dorsal metatarsal artery gives off a dorsal proper digital artery to the dorsolateral aspect of the fifth toe.

P or P

VASCULARIAZATION OF THE FOOT

Describe the first dorsal metatarsal artery. Describe the deep plantar artery. First dorsal metatarsal artery:
Terminal branch of the dorsalis pedis artery. Courses distally on the first dorsal interosseous muscle. Terminates at the cleft of the toes by dividing into two dorsal proper digital arteries to the adjacent sides of the hallux and second toe. Gives off a dorsal proper digital artery which courses deep to the tendon of EHL to the dorsomedial aspect of the hallux. Receives an anterior perforating artery from the first plantar metatarsal artery.
S or P

The dorsal metatarsal arteries (1-4) vascularize the metatarsals, the sesamoids, the MTP s, and the interossei muscles. Deep plantar artery:
Terminal branch of the dorsalis pedis artery. Courses plantarly through the first dorsal interosseous muscle between the first and second metatarsal bases. Unites with the plantar arch portion of the lateral plantar artery to complete the plantar arch.

A or D

VASCULARIAZATION OF THE FOOT

Describe the dorsal proper digital arteries.
A or D

There are two dorsal proper digital arteries for each digit, one on the dorsomedial side and one on the dorsolateral side. The dorsal proper digital arteries vascularize the phalanges, and interphalangeal joints.

P or P

VASCULARIAZATION OF THE FOOT

Describe the general aspects of the arteries on the plantar aspect of the foot.
A or D S or P

The plantar surface of the foot is vascularized by the medial and lateral plantar arteries which are the terminal branches of the posterior tibial artery. The branching of the posterior tibial artery occurs in the porta pedis which is the area deep to the abductor hallucis muscle (between the abductor hallucis and the calcaneus). The arteries are accompanied by deep veins of the same name. The deep veins course with the arteries and are usually paired forming venae comitantes (accompanying veins). The description of a deep vein is the reverse of an artery (i.e. distal to proximal).

I or P or D

P or P

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VASCULARIAZATION OF THE FOOT

Describe the medial plantar artery.
A or D

Branches from the posterior tibial artery between the calcaneus and abductor hallucis muscle (porta pedis). Courses distally between the abductor hallucis and flexor digitorum brevis muscles to the base of the first metatarsal. Terminates along the medioplantar aspect of the hallux as a plantar proper digital artery. During its course it gives off a superficial digital branch which trifurcates and anastomoses with the first three plantar metatarsal arteries. The medial plantar artery vascularizes the abductor hallucis and flexor digitorum brevis muscles.

A or D

P or P

P or P Gray s Anatomy Elsevier

VASCULARIAZATION OF THE FOOT

Describe the lateral plantar artery.
Branches from the posterior tibial artery between the calcaneus and abductor hallucis muscle (porta pedis). Courses obliquely anteriorly and laterally between the flexor digitorum brevis and quadratus plantae muscles. Becomes more superficially located between flexor digitorum brevis and abductor digiti minimi. Near the base of the fifth metatarsal it gives off a plantar proper digital artery to the lateroplantar aspect of the fifth digit. The lateral plantar artery then turns medially as the plantar arch (plantar arch portion of the lateral plantar artery). It courses on the bases of the metatarsals between the interossei muscles and the oblique head of the adductor hallucis muscle. It terminates by uniting with the deep plantar artery in the first interspace. Major branches are:
Posterior perforating arteries (3) Plantar metatarsal arteries (4)
A or D

Vascularizes the abductor digiti minimi, quadratus plantae, flexor digiti minimi brevis, and oblique head of adductor hallucis.
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VASCULARIAZATION OF THE FOOT

Describe the plantar metatarsal arteries. There are four plantar metatarsal arteries (first, second, third, and fourth). Each courses distally on its respective interossei muscles. Each terminates by dividing into two plantar proper digital arteries at the cleft of the toes for the adjacent sides of the digits. Each gives off at its distal aspect an anterior perforating artery to anastomose with its respective dorsal metatarsal artery. The first plantar metatarsal artery gives off a plantar proper digital artery to the medioplantar aspect of the hallux. Plantar metatarsal arteries vascularize the metatarsals; the sesamoids; the MTP s; and the interossei, flexor hallucis brevis, lumbricals, and transverse head of adductor hallucis.
A or D

M L

P or P

VASCULARIAZATION OF THE FOOT

Describe the posterior perforating arteries.

There are three posterior perforating arteries, each anastomoses with its respective dorsal metatarsal artery. The deep plantar artery serves the same function as a posterior perforating artery in the first interspace.

A or D

P or P

VASCULARIAZATION OF THE FOOT

Describe the plantar proper digital arteries.
A or D

There are two plantar proper digital arteries for each digit, one on the medioplantar side and one on the lateroplantar side. The two plantar proper digital arteries terminate on the distal aspect of a digit by forming a terminal tuft or terminal arborization which is a major communication between these arteries. The two dorsal proper digital arteries anastomose with the terminal tuft. The plantar proper digital arteries vascularize the phalanges, and interphalangeal joints.

P or P P or P

A or D

VASCULARIAZATION OF THE FOOT

Describe the anastomoses in the forefoot and rearfoot. Anastomotic connections in the rearfoot region:
Artery of the sinus tarsi and artery of the tarsal canal. The arteries involved with the medial and lateral malleolar networks.
A or D

Anastomotic connections in the forefoot region:

Deep plantar artery between the dorsalis pedis artery and the plantar arch. Anterior perforating arteries between the dorsal and plantar metatarsal arteries, Posterior perforating arteries between the plantar arch and dorsal metatarsal arteries. Terminal tuft between the dorsal proper digital and plantar proper digital arteries. Superficial branch of the medial plantar artery between the medial plantar and the plantar metatarsal arteries.
L

P or P

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VASCULARIAZATION OF THE FOOT

Arteries in the first interspace of the right foot.

D or S

A or D

P or P

P or I

VASCULARIAZATION OF THE FOOT

Arteries in the second, third, or fourth interspace of the right foot.

D or S

A or D

P or P

P or I

LYMPHATICS OF THE FOOT

Describe the superficial lymphatic drainage of the foot.
S or P S or P

The lymphatic vessels of the lower extremity consist of superficial and deep vessels. Their distribution is very similar to the superficial and deep veins. Both sets of vessels have valves and communicate with each other. The superficial are greater in number but smaller in size than the deep.

M L M

A or D

I or P or D

LYMPHATICS OF THE FOOT

Describe the superficial lymphatic drainage of the foot.

Superficial lymphatic vessels:

Most abundant on the plantar aspect of the foot. The dorsal and plantar regions of the foot drain into a medial and lateral group of collecting vessels.
Medial group of collecting vessels:
Larger and more numerous than the lateral group, course with the great saphenous vein up the leg and thigh and drain into the lower group (vertical group) of superficial inguinal lymph nodes.

S or P S or P

M L M

Lateral group of collecting vessels:

Course anterior and posterior to the lateral malleolus. Those coursing anterior drain into the medial group and those passing posterior accompany the small saphenous vein and drain into the popliteal lymph nodes.

Superficial lymphatic vessels of the leg and thigh flow into those accompanying the great and small saphenous veins.

A or D

I or P or D

I or P or D

LYMPHATICS OF THE FOOT

Describe the deep lymphatic drainage of the foot.

In the foot the deep lymphatic vessels course with the dorsalis pedis, medial plantar, and lateral plantar arteries and veins. In the leg they course with the anterior tibial, posterior tibial, and peroneal arteries and veins to drain into the popliteal lymph nodes.

S or P

S or P

I or D

A or D

INNERVATION OF THE FOOT

S or P

Sciatic nerve division into common peroneal nerve and tibial nerve. Branches of the tibial and common peroneal nerves. Formation of the sural nerve.

I or P

INNERVATION OF THE FOOT

Describe the deep fibular (peroneal) nerve.
S or P

Branch of the common peroneal nerve. Innervates the anterior compartment of the leg. Courses deep to the deep fascia with the anterior tibial vessels. On the dorsum of the foot it divides into a medial and lateral terminal branch. Medial terminal branch:
Follows the course of the dorsalis pedis artery. Becomes superficial as it pierces the deep fascia at the distal aspect of the first interspace. It divides into two dorsal proper digital nerves for the adjacent side of the hallux and second toe. The medial terminal branch communicates with the dorsal proper digital branch of the medial dorsal cutaneous nerve.

S or P

Lateral terminal branch:

Follows the course of the lateral tarsal artery. Innervates the extensor hallucis brevis and extensor digitorum brevis.

A or D

A or D

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INNERVATION OF THE FOOT

Describe the superficial fibular (peroneal) nerve.
S or P S or P

Branch of the common peroneal (fibular) nerve. Innervates the lateral compartment of the leg. Pierces the deep fascia in the lower one-third of the leg and innervates the skin on the lower anterolateral aspect of the leg. Proximal to the malleoli it divides into a medial dorsal cutaneous nerve and an intermediate dorsal cutaneous nerve.

M L M

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INNERVATION OF THE FOOT

Describe the medial dorsal cutaneous nerve.

Branches from the superficial peroneal (fibular) nerve in the lower leg region. On the dorsum of the foot it divides into a dorsal proper digital branch and a dorsal common digital branch. The dorsal proper digital branch innervates the skin on the dorsomedial aspect of the hallux. The dorsal proper digital branch communicates with the medial terminal branch of the deep peroneal nerve and the saphenous nerve. The dorsal common digital branch divides into two dorsal proper digital branches for the skin on the adjacent sides of the second and third toes. It innervates the skin on the dorsomedial side of the foot.

S or P

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INNERVATION OF THE FOOT

Describe the intermediate dorsal cutaneous nerve.
S or P

Also known as Lemont s nerve. Branches from the superficial peroneal (fibular) nerve in the lower leg region. On the dorsum of the foot it divides into a medial dorsal common digital branch and a lateral dorsal common digital branch. The medial dorsal common digital branch divides into two dorsal proper digital branches for the skin on the adjacent sides of the third and fourth toes. The lateral dorsal common digital branch divides into two dorsal proper digital branches for the skin on the adjacent sides of the fourth and fifth toes. The lateral dorsal common digital branch communicates with the lateral dorsal cutaneous nerve. It innervates the skin on the dorsointermediate side of the foot.

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INNERVATION OF THE FOOT

Describe the intermediate dorsal cutaneous nerve.
S or P

Clinical note: The intermediate dorsal cutaneous nerve may also branch from the sural nerve or the lateral dorsal cutaneous nerve.

P or P D or S

P or I

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INNERVATION OF THE FOOT

Describe the lateral dorsal cutaneous nerve.

Continuation of the sural nerve as it courses below the lateral malleolus. It courses along the dorsolateral side of the foot innervating the skin in this region. It terminates as a dorsal proper digital nerve to the dorsolateral side of the fifth toe. The lateral dorsal cutaneous nerve communicates with the lateral dorsal common digital branch of the intermediate dorsal cutaneous nerve. Some textbooks still call the lateral dorsal cutaneous nerve the sural nerve.

S or P

D or S

P or P P or I A or D

INNERVATION OF THE FOOT

Describe the saphenous nerve.
S or P S or P

Branch of the femoral nerve in the thigh. Courses with the great saphenous vein in the leg. Terminates on the dorsum of the foot by innervating the skin on the medial side of the foot up to the first MTP. The saphenous nerve is the only nerve of the foot that is not a branch of the sciatic nerve.

D or S

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INNERVATION OF THE FOOT

Describe the medial plantar nerve.
S or P A or D

Branch of the tibial nerve. Courses distally with the medial plantar vessels between the abductor hallucis and flexor digitorum brevis muscles. As it courses distally it gives off cutaneous, muscular and articular branches. It terminates by dividing into a plantar proper digital and three plantar common digital branches.

I or P or D Sobotta:Anatomy Elsevier GmbH Germany

P or P

INNERVATION OF THE FOOT

Describe the medial plantar nerve.
A or D A or D

Cutaneous branches:
Innervate the skin on the medioplantar aspect of the foot.

Muscular branches:
Innervate the abductor hallucis and flexor digitorum brevis muscles before the medial plantar nerve divides into plantar proper and plantar common digital branches.
L M L M

Articular branches:
Innervate joints on the medial portion of the tarsus.
P or P P or P

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INNERVATION OF THE FOOT

Describe the medial plantar nerve.
A or D

Plantar proper digital branch:

Innervates the flexor hallucis brevis and the skin on the medioplantar aspect of the hallux.

First plantar common digital branch:

Innervates the first lumbrical muscle and then divides into two plantar proper digital branches for the skin on the adjacent sides of the hallux and second toes.

P or P

INNERVATION OF THE FOOT

Describe the medial plantar nerve.
A or D

Second plantar common digital branch:

Divides into two plantar proper digital branches for the skin on the adjacent sides of the second and third toes.
A or D

Third plantar common digital branch:

Divides into two plantar proper digital branches for the skin on the adjacent sides of the third and fourth toes. The third plantar common digital branch communicates with the plantar common digital branch of the superficial division of the lateral plantar nerve.
L M

P or P

Clinical note: The third plantar common digital branch is the common site of a Morton s neuroma.

P or P

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INNERVATION OF THE FOOT

Describe the lateral plantar nerve.
S or P A or D

Branch of the tibial nerve. Courses distally with the lateral plantar vessels. As it courses distally it gives off cutaneous, muscular and articular branches. It terminates by dividing into a superficial and deep branch.

P or P I or P or D Sobotta:Anatomy Elsevier GmbH Germany

INNERVATION OF THE FOOT

Describe the lateral plantar nerve.
A or D A or D

Cutaneous branches:
Innervate the skin on the lateroplantar aspect of the foot.

Muscular branches:
Innervate the abductor digiti minimi and quadratus plantae muscles before the lateral plantar nerve divides into a superficial and deep branch.

L L M

Articular branches:
Innervate joints on the lateral portion of the tarsus.

Clinical note: Entrapment of the first branch of the lateral plantar nerve to the abductor digiti minimi (Baxter s Nerve) causes heel pain due to its sensory innervation of the periosteum of the calcaneus in this area.
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P or P

INNERVATION OF THE FOOT

Describe the lateral plantar nerve.
A or D

Superficial branch:
Plantar proper digital branch:
Innervates the flexor digiti minimi brevis, fourth dorsal interosseous, and third plantar interosseous muscles; and the skin on the lateroplantar aspect of the fifth toe.

Plantar common digital branch:

Divides into two plantar proper digital branches for the skin on the adjacent sides of the fourth and fifth toes. The plantar common digital branch communicates with the third plantar common digital branch of the medial plantar nerve.
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INNERVATION OF THE FOOT

Describe the lateral plantar nerve.
A or D

Deep branch:
Courses with the plantar arch portion of the lateral plantar artery. Innervates the adductor hallucis; second, third, and fourth lumbricals; first, second, and third dorsal interosseous; first, and second plantar interosseous muscles.

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INNERVATION OF THE FOOT

Describe the medial calcaneal nerves. Describe the lateral calcaneal nerves.

Medial calcaneal nerves:

Branch of the tibial nerve. Innervates the skin on the plantar and medial aspect of the heel.

A or D

S or P

D or S

Clinical note: Entrapment of the medial calcaneal nerve is a common cause of heel pain. Lateral calcaneal nerves:
Branch of the sural nerve. Innervates the skin on the posterior and lateral aspect of the heel.

M P or P

A or D

P or I

P or P Sobotta:Anatomy Elsevier GmbH Germany

Sarrafian, S.K. Anatomy of the Foot and Ankle Lippincott

INNERVATION OF THE FOOT

Describe the dorsal and plantar proper digital nerves of each digit.
A or D

Dorsal proper digital nerves:

Branches of the medial dorsal cutaneous, medial terminal branch of the deep fibular, intermediate dorsal cutaneous, and lateral dorsal cutaneous nerves. Give off cutaneous and articular branches along their respective quadrant of a digit. Terminate around the base and sides of the nail.

M L

Plantar proper digital nerves:

Branches of the medial and lateral plantar nerves. Give off cutaneous and articular branches along their respective quadrant of a digit. Terminate in the area of the ungual tuberosity by sending branches to the distal end of the digit. At the level of the distal phalanx they send branches dorsally to the structures around the nail.

P or P D or S Tendon of EHL or EDL Dorsal Proper Digital Nerve and Artery M or L Plantar Proper Digital Artery M or L Tendon of FDL Tendons of FDB

Clinical note: For a digital block all four digital nerves are anesthetized.
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Plantar Proper Digital Nerves P or I

CUTANEOUS INNERVATION OF THE FOOT

INNERVATION OF THE FOOT

A or D A or D

P or P

P or P

INNERVATION OF THE FOOT

A or D A or D

M L M

P or P

P or P