546189

research-article2014

FAIXXX10.1177/1071100714546189Foot & Ankle InternationalDalmau-Pastor et al.

Topical Review

Extensor Apparatus of the Lesser

Toes: Anatomy With Clinical
ImplicationsTopical Review

Foot & Ankle International

113
The Author(s) 2014
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DOI: 10.1177/1071100714546189
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Miquel Dalmau-Pastor1, Betlem Fargues1, Enric Alcolea1, Nerea Martnez-Franco1,

Patricia Ruiz-Escobar2, Jordi Vega3, and Pau Golan1,4

Abstract
Lesser toe deformities are one of the most common conditions faced by orthopedic surgeons. Knowledge of the anatomy
of the lesser toes is important for ensuring correct diagnosis and treatment of deformities, which are caused by factors
such as muscle imbalance between the extensor apparatus and flexor tendons. However, this apparatus has not received
sufficient attention in the literature. In addition, the large number of inaccurate and erroneous descriptions means that
gaining an understanding of these structures is problematic. The objective of the present article is to clarify the anatomy
of the extensor apparatus by means of a pictorial essay, in which the structures involved will be grouped and discussed in
detail. The most relevant clinical implications will be addressed.
Level of Evidence: Level V, expert opinion.
Keywords: anatomy, extensor apparatus, orthopedic surgery, lesser toe deformities.

Introduction
Lesser toe deformities are a common condition faced by the
orthopedic foot and ankle surgeon, with a reported incidence that ranges from 2% to 20%.12,17 These deformities
are more frequent in females, and their incidence increases
with age.11,27,44 The causes of lesser toe deformities include
anatomic factors, neuromuscular disease, connective tissue
disorders, congenital anomalies, trauma, constricting footwear, or poor foot biomechanics.25,27,29 These can result in
an imbalance between the extensor and flexor muscles of
the toes, which leads to lesser toe deformities.5,9 Lesser toe
deformities are complex and involve the interphalangeal
joints, metatarsophalangeal joints, and associated tendons
and ligaments.29 Depending on the joints affected, the
deformity is classified as claw toe, hammer toe, and mallet
toe, all of which can appear as flexible or fixed deformities.27 Once the cause of the deformity is determined, the
surgeon can decide which deforming force has to be neutralized so that the appropriate procedure can be chosen.29
Lesser toe deformities can be corrected using techniques
applied to both soft tissue and bone.11,25,27,29
The extensor apparatus of the toes is an important structure in the etiology of lesser toe deformities and therefore
the object of the surgical procedures used to correct the
deformity.27 Anatomy is the basis of orthopedic surgery,43
and knowledge of the morphologic and functional anatomy
of the extensor apparatus of the toes is necessary before

performing surgical procedures to correct lesser toe

deformities.10,21,26,27,29,32
However, despite the importance of a sound knowledge
of these structures, classic anatomy textbooks and chapters
on lesser toe deformities in surgery textbooks reveal a lack
of detail, inaccuracies, or even errors in the descriptions of
the extensor apparatus.
The objective of this article was to present an anatomical description of the components of the extensor apparatus of the lesser toes based on a thorough literature review
and the dissections performed in our dissecting room. The
fifth toe has been excluded from this study because the
extensor brevis muscle does not reach it, the fact that it has
proper intrinsic muscles, and that with high frequency it is
a biphalangic toe. We present the anatomical features of
these complex structures and examine their role in clinical
and surgical practice in order to enhance the orthopedic
foot and ankle surgeons knowledge and understanding of
lesser toe deformities. Finally, the lack of high-quality
1

University of Barcelona, Barcelona, Spain

Private practice, Balearic Islands, Spain
3
Unit of Foot and Ankle Surgery, Hospital Quirn, Barcelona, Spain
4
University of Pittsburgh, Pittsburgh, PA, USA
2

Corresponding Author:
Jordi Vega, MD, Unit of Foot and Ankle Surgery, Hospital Quirn,
Barcelona, Spain. Plaza Alfonso Comn 5, 08023 Barcelona, Spain.
Email: jordivega@hotmail.com

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Foot & Ankle International

Figure 1. Anatomical dissection of the dorsum of the foot showing the main components of the extensor apparatus. Neurovascular
structures were removed. (A) Dorsal view. (B) Lateral view. (1) Extensor digitorum longus tendons. (2) Middle or central slip. (3)
Lateral slips. (4) Terminal tendon. (5) Extensor digitorum brevis tendons. (6) Extensor sling. (7) Triangular lamina. (8) First dorsal
interosseous. (9) Extensor hallucis longus tendon. (10) Peroneus tertius tendon. (11) Abductor digiti minimi tendon.

images of the extensor apparatus of the foot led us to present this article as a pictorial essay that will provide readers
with an up-to-date visual portrayal of the anatomy of this
structure.

Extensor Apparatus
Current knowledge of the anatomy and function of the
extensor apparatus of the lesser toes is limited. Most studies focus on the extensor apparatus of the hand, with less
attention being paid to that of the foot. In their description
of the extensor apparatus of the lesser toes, most anatomy
textbooks refer us to the extensor apparatus of the
fingers.
A search of the literature on the extensor apparatus of the
lesser toes reveals only 2 articles that provide an overview
of its anatomy.15,38 The 1969 work by Sarrafian and
Topouzian38 provides the most complete description of the
components of the extensor apparatus and will be used as a
reference in our description. Given the lack of a specific
nomenclature for this structure in the International
Anatomical Terminology of the Federative International
Committee on Anatomical Terminology16 and the indiscriminate use of various terminologies, we will use the
nomenclature proposed by Sarrafian and Topouzian.38
Extension of the toes is the result of the combined action
of the extensor digitorum longus, extensor digitorum brevis, interossei muscles, and lumbrical muscles, all of which
converge to form a tendinofibroaponeurotic structure
known as the extensor apparatus (Figure 1).

In order to better understand the extensor apparatus, and

following the structure established by Sarrafian and
Topouzian,38 we identified 3 basic components: the extrinsic
contribution, which is formed by the extensor digitorum longus; the intrinsic contribution, which is formed by the extensor digitorum brevis, lumbrical muscles, and interossei
muscles; and a third component, which we term the stabilizing ligaments, comprising the extensor sling, extensor wing,
and triangular lamina. As their names indicate, the main
function of these ligaments is to ensure that the extrinsic and
intrinsic contributions remain in their appropriate anatomic
location (Figure 2 and 3).

Extrinsic Contribution
Extensor Digitorum Longus
The extensor digitorum longus is a muscle of the anterior
compartment of the leg. It provides 4 tendons for the second to fifth toes. These tendons reach their respective
metatarsophalangeal joints, where they meet the extensor
apparatus and thus form their main axis. At the level of the
metatarsophalangeal joints, the extensor tendons are
attached to the digital axis using a fibroaponeurotic structure known as the extensor sling, which is a stabilizing
ligament. At this level, the extensor digitorum longus tendon divides into 3 tendinous components known as slips:
a middle or central slip and 2 lateral slips, medial or lateral
depending on their anatomic location (Figure 4).38 The
middle slip inserts into the dorsal area of the base of the

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Dalmau-Pastor et al.

Figure 2. Main drawing of the extensor apparatus and its components based on the drawings of Sarrafian and Topouzian.35 (A)
Dorsal view. (B) Lateral view. (C) Medial view. (1) Extensor digitorum longus tendons. (2) Middle or central slip. (3) Lateral slips. (4)
Terminal tendon. (5) Extensor digitorum brevis tendons. (6) Lumbrical muscle and tendon. (7) Interosseous muscles. (8) Extensor
sling. (9) Extensor wing. (10) Triangular lamina. (11) Deep transverse metatarsal ligament. (12) Flexor digitorum longus tendon. (13)
Flexor digitorum brevis.

Figure 3. Extension of the toes is the result of the combined action of the extensor digitorum longus, extensor digitorum brevis,
interossei muscles, and lumbrical muscles. All of which converge to form a tendinobroaponeurotic structure known as the extensor
apparatus.

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Foot & Ankle International

Figure 5. Sagittal section of the third toe. (1) Extensor

digitorum longus tendon. (2) Middle or central slip. (3) Lateral
slip. (4) Terminal tendon. (5) Metatarsal head. (6) Proximal
phalanx. (7) Middle phalanx. (8) Distal phalanx. (9) Flexor
digitorum tendon. (10) Flexor digitorum longus tendon. (11)
Plantar plate.

Figure 4. (A) Dorsal view of the anatomical dissection showing

the trifurcation of the tendon of the extensor digitorum longus
muscle. (B) Main drawing of the extensor apparatus in dorsal view
in which the contribution of extensor digitorum brevis muscle is
highlighted. (1) Extensor digitorum longus tendons. (2) Middle or
central slip. (3) Lateral slips. (4) Terminal tendon. (5) Extensor
sling. (6) Triangular lamina. (7) Extensor digitorum brevis.

middle phalanx and into the capsule of the proximal interphalangeal joint. After receiving contributions from the
intrinsic muscles, the 2 lateral slips run distally over the
dorsum of the middle phalanx before gradually inserting
into the dorsum of the distal phalanx via a single tendon
known as the terminal tendon. The triangular space
between both lateral slips is occupied by an aponeurotic
structure known as the triangular lamina (Figure 4 and
5).37 When the proximal interphalangeal joint is flexed,
the middle slip is compressed against the head of the proximal phalanx, which acts as a pulley. For this pulley mechanism to function, the middle slip has a sesamoid
fibrocartilage at its plantar side at the level of the proximal
interphalangeal joint, just proximal to the insertion of the
central slip into the middle phalanx.30

Although most authors6,8,20,21,27,29,31,34-36,41 agree with the

description by Sarrafian and Topouzian,38 a review of the
literature reveals divergence in many aspects. For example,
there are several versions of the location of the trifurcation
of the tendon of the extensor digitorum longus muscle, as
well as of the nomenclature used to describe its components, or slips. Sarrafian and Topouzian state that this division occurs at the level of the metatarsophalangeal joint,
whereas other authors have reported this division to occur
at the level of the diaphysis of the proximal phalanx.6,21,27,29,31,36,41 Gosling,20 however, makes no mention
of where this trifurcation is formed, and some authors even
refer us to the section on anatomical descriptions of the
extensor apparatus of the hand.35
The trifurcation of the extensor digitorum longus has
received several names, which, while morphologically referring to the same structure, cause confusion in the study of
the extensor apparatus. Although we find the terms parts35
and bands,31 slips is the most widely used,6,8,27,
29,34,36,38,39,41,44
and thus, the nomenclature that is used in this
review.

Intrinsic Contribution
Extensor Digitorum Brevis
The extensor digitorum brevis muscle, which is the only
muscle of the dorsum of the foot, arises on the anterior
superior process of the calcaneus and runs obliquely to the
medial and anterior area before dividing into 4 fleshy fascicles, each of which finishes in a flattened tendon. The
tendons of the extensor digitorum brevis are generally

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Dalmau-Pastor et al.

Figure 6. (A) Dorsolateral view of the extensor tendons of

the toes on the dorsum of the foot. The image shows how
the lateral slip is formed exclusively by the extensor digitorum
brevis and is more apparent the more lateral the toe is (black
arrows). (B) Lateral view of the main drawing in which the
contribution of extensor digitorum brevis muscle of the
extensor apparatus is highlighted. (1) Extensor digitorum brevis
tendons. (2) Extensor digitorum longus tendons. (3) Middle or
central slip. (4) Medial slip. (5) Lateral slip. (6) Terminal tendon.
(7) Extensor sling. (8) Triangular lamina.

thinner than those of the extensor digitorum longus, deeper

and more oblique in direction. These tendons reach the
metatarsophalangeal joint and contribute to the extensor
apparatus from the first to the fourth toe.
Most descriptions of the incorporation of these 4 extensor tendons into the extensor apparatus state that they are
incorporated on the lateral aspect of the extensor digitorum longus,6,29,34-36,38,39,41 thus countering the oblique
direction of the tendons of the long extensor of the toes.
Therefore, from a functional viewpoint, the action of both
muscles is considered a single action.29,41 This description
is corroborated by Sarrafian and Toupouzian,38 although the
authors state that the extensor digitorum brevis sometimes
runs independently, without joining the extensor digitorum
longus, and thus forms the lateral slip by itself. Our dissections generally confirm this description. The lateral slip is
formed exclusively by the extensor digitorum brevis, and

Figure 7. Plantar view of the lumbrical muscles and

surrounding structures. (1) Flexor digitorum longus tendon.
(2) Tendon to the second toe. (3) Tendon to the third toe.
(4) Tendon to the fourth toe. (5) Tendon to the fifth toe. (6)
First lumbrical muscle. (7) Second lumbrical muscle. (8) Third
lumbrical muscle. (9) Fourth lumbrical muscle. (10) Flexor
hallucis longus. (11) Chiasma plantare. (12) Quadratus plantae
muscle.

this is more apparent the more lateral the toe under study is,
except for the fifth toe, which does not have extensor brevis
tendon (Figure 6). We consider this anatomic detail to be
crucial for our understanding and treatment of lesser toe
deformities. We stress the importance of this structure, since
the extensor digitorum brevis muscle is omitted or poorly
addressed in the description of the extensor apparatus in
chapters on lesser toe deformities in surgery textbooks7,8,44
and in common anatomy textbooks.31

Lumbrical Muscles
The lumbrical muscles, which are numbered 1 to 4 medial
to lateral, are found at the bifurcation of the tendons of the
flexor digitorum longus muscle and arise from the neighboring tendons, except for the first lumbrical, which arises
from the flexor tendon of the second toe (Figure 7). From

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Foot & Ankle International

their point of origin, the lumbrical muscles run distally and

diverge slightly to reach the medial side of the metatarsophalangeal joints of the second to fifth toes. At this point,
they are already in the form of their insertion tendon and run
plantar to the deep transverse metatarsal ligament, thus
forming part of the extensor apparatus.
Sarrafian and Topouzian38 and other authors6,29,33,36 state
that the lumbrical muscles insert into the extensor apparatus
(medial and middle slip) via a triangular structure formed by
oblique fibers known as the extensor wing (Figure 8). Some
authors report that the lumbrical muscles can also insert via
tendinous fibers on the phalangeal tuberosity, at the base of
the proximal phalanx.29,37,38 Our dissections occasionally
show that the lumbrical muscle itself forms the medial slip of
the extensor apparatus (Figure 9). However, the terminology
used in many chapters on lesser toe deformities and anatomy
textbooks is often confusing, thus making it difficult to
understand the insertion of the lumbrical muscles.8,29,31,41
Given their plantar location with respect to the axis of
rotation of the metatarsophalangeal joint, these muscles act
as flexors of the metatarsophalangeal joint by countering
the extensor action of the extensor digitorum longus muscle. They act on the extensor apparatus by means of their
expansion, or extensor wing, thus contributing to the extension of the interphalangeal joints.21,23,31

Interossei Muscles
The 7 interossei muscles (3 plantar and 4 dorsal) arise on
the metatarsal aspects that delimit the corresponding intermetatarsal spaces. The plantar muscles are found in the
second, third, and fourth intermetatarsal spaces and arise
on the medial aspect of the delimiting metatarsal bones in
its inferior segment. The dorsal muscles, which are larger
than the plantar muscles, are found in all the intermetatarsal spaces (Figure 10).
The tendons from both the plantar and dorsal interossei
muscles course distally before running dorsal to the deep
transverse metatarsal ligamentin contrast with the lumbrical muscles, which do so plantarlyto reach the metatarsophalangeal joint and insert in the plantar area of the proximal
phalanx and plantar plate.8,15,27,31,33,36,38,39 At their insertion,
they are covered by the extensor sling (Figure 11).37,38
According to the description of the extensor apparatus proposed by Sarrafian and Topouzian,38 the tendons of the interossei muscles are closely associated with the capsule, into
which some fibers insert. The remaining fibers extend distally
and insert into the base of the proximal phalanx. Some of
these fibers insert into the deep side of the extensor sling and
occasionally extend until they reach the extensor wing.
The vast majority of authors report that the interossei
muscles insert at the phalangeal tuberosity on the base of
the proximal phalanx.8,15,27,31,33,36,41 The area of greatest

Figure 8. (A) Medial view of the anatomical dissection of the

second toe showing the anatomical relationships of the first
lumbrical muscle. (B) Same anatomical image in which the extensor
wing (black arrows) and the extensor sling (white arrows) have
been identified by software (Adobe PhotoShop). (C) Medial view
of the main drawing showing the anatomy of the lumbrical muscle.
(1) First lumbrical muscle. (2) Lumbrical tendon. (3) Extensor
wing. (4) Flexor digitorum longus tendon. (5) Medial slip. (6) Deep
transverse metatarsal ligament and plantar plate (cut). (7) Extensor
digitorum longus tendon (cut). (8) Extensor sling. (9) First dorsal
interosseous muscle. (10) Second dorsal interosseus muscle.
(11) Vertical septum of plantar fascia. (12) Shaft of the second
metatarsal bone. (13) Annular pulley of the fibrous sheath of the
flexor tendons. (14) Toenail. (15) Nail matrix.

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Dalmau-Pastor et al.

Figure 9. Dorsal view of the anatomical dissection of the

extensor apparatus of the second toe showing a case in which
the lumbrical muscle itself forms the medial slip of the extensor
apparatus. (1) First lumbrical muscle. (2) Extensor digitorum longus
tendon. (3) Middle slip. (4) Lateral slip. (5) Medial slip. (6) Extensor
wing. (7) Extensor sling. (8) Extensor digitorum brevis tendon.
(9) First dorsal interosseous muscle. (10) Medial terminal branch
(sensitive) of the deep peroneal nerve. Figure reproduced with
kind permission from De Prado et al.13

Figure 10. Schematic drawing of the anatomical disposition of

the interosseous muscles (D, dorsal; P, plantar) at the level of the
intermetatarsal spaces.

Figure 11. Anterior-dorsal view of the anatomical dissection of

the second intermetatarsal space. (1) Second dorsal interosseous
muscle. (2) First plantar interosseous muscle. (3) Deep transverse
metatarsal ligament. (4) Second lumbrical tendon. (5) Extensor
digitorum longus tendon. (6) Extensor digitorum brevis tendon.
(7) Middle slip. (8) Medial slip. (9) Extensor sling. (10) First dorsal
interosseous muscle.

confusion is the direct contribution of the tendons of the

interossei muscles to the extensor apparatus. Some authors
describe this contribution without specifying how it is produced.6,8,27,36,41 Other authors state that the interossei muscles make no contribution to the extensor apparatus and
only insert into the base of the proximal phalanx.15,31,33
Consistent with Fahrer and Chapius,15 our dissections
show that the interossei muscles only insert at the base of
the proximal phalanx. We are unable to establish the
existence of fibers that extend distally to this insertion
point and contribute to the formation of the extensor
apparatus, thus corroborating the findings of previous
studies (Figure 12).3,15,23
Given their location plantar to the axis of rotation of the
metatarsophalangeal joint, the interossei muscles flex the
joint by countering the extensor function and stabilizing
the extensor apparatus.8 Given the lack of insertion at the
level of the extensor apparatus, the interossei muscles have
no function at the level of the interphalangeal joints.
Therefore, the lumbrical muscles and the extensor

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Foot & Ankle International

Figure 13. Lateral view of the anatomical dissection of the

second toe showing the extensor sling and its anatomical
relationships. (1) Extensor sling. (2) Extensor digitorum longus
tendon. (3) Extensor digitorum brevis tendon. (4) Deep
transverse metatarsal ligament (cut). (5) Plantar plate. (6) Second
dorsal interosseous muscle. (7) Phalanx tubercle. (8) Vertical
septum of the plantar fascia (cut) inserted into the plantar plate.
(9) Flexor digitorum longus tendon. (10) Flexor digitorum brevis
tendon. (11) Annular pulley of the fibrous sheath of the flexor
tendons. (12) Metatarsal tubercle.

Figure 12. (A) Lateral view of the anatomical dissection of

the second toe, showing the insertion of the second dorsal
interosseous muscle in the phalanx tubercle. (B) Main drawing
showing the anatomy of the interosseous muscle, which has been
highlighted in the drawing. (1) Second dorsal interosseous muscle
and tendon. (2) Phalanx tubercle. (3) Vertical septum of the plantar
fascia, plantar plate, and deep transverse metatarsal ligament (cut).
(4) Extensor sling. (5) Extensor digitorum longus tendon. (6)
Extensor digitorum brevis tendon. (7) Middle slip. (8) Lateral slip.
(9) Flexor digitorum brevis tendon. (10) Flexor digitorum longus
tendon. (11) Shaft of the second metatarsal bone.

digitorum brevis are the only intrinsic muscles with an

extensor function at the level of the interphalangeal joints.23
The second toe is anatomically unique because it has 2
dorsal interossei muscles and no plantar interossei muscles.
Consequently, it could be more prone to dorsomedial dislocation,10,22 thus explaining why the second toe is dislocated
more often than the others.1,2,18,19,37,45

Stabilizing Ligaments
Extensor Sling
The tendons of the extensor apparatus are anchored on the
dorsum of the metatarsophalangeal joint and on the proximal phalanx by a fibroaponeurotic structure known as the

extensor sling.6,36,38,39,41 This aponeurosis is formed by

transversely oriented fibers at the level of the metatarsophalangeal joint and covers the extensor digitorum brevis
and extensor digitorum longus tendons. From this point, it
runs in a plantar direction and covers the insertion tendons
of the interossei muscles, before reaching the plantar plate,
deep transverse metatarsal ligament, and the fibrous synovial sheath of the flexor digitorum longus and flexor digitorum brevis tendons. This reinforcement extends distally
to the base of the proximal phalanx. In our dissections, we
constantly observed this structure at the level of the metatarsophalangeal joint, although it was somewhat difficult to
clearly identify its insertions in the plantar region (Figure
13 and 14).
As mentioned previously, the extensor digitorum longus
does not insert into the proximal phalanx. The proximal
phalanx extends via the pull exerted by the extensor digitorum longus on the extensor sling, which Sarrafian and
Topouzian37 described as a sling mechanism (Figure 15).
Furthermore, this extensor sling prevents the extensor tendon excursion from being used exclusively in metatarsophalangeal extension, and in so doing enables extension of
the interphalangeal joints. Injury to this structure and others
allows the extensor digitorum longus to exert its entire
excursion on the metatarsophalangeal joint, thus favoring
hyperextension. Extensor action on the interphalangeal
joints disappears, and the flexor force predominates, leading to lesser toe deformity.

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Dalmau-Pastor et al.

Figure 14. (A) Drawing of the extensor apparatus in proximal-superior view showing the anatomical relationship of the extensor
sling based on the drawings of Oukouchi et al.30 (B) Lateral view of the main drawing showing the highlighted extensor sling. Medial
view of the main drawing showing the highlighted extensor sling. (1) Extensor sling. (2) Extensor digitorum longus tendon. (3) Middle
slip. (4) Lateral slips. (5) Terminal tendon. (6) Entensor digitorum brevis tendon. (7) First lumbrical muscle. (8) Extensor wing. (9)First
dorsal interosseous muscle. (10) Second interosseous muscle. (11) Triangular lamina. (12) Deep transverse metatarsal ligament.
(13)Flexor tendons. (14) Metatarsal bone (cut).

Extensor Wing
The extensor wing, or extensor hood, is an aponeurosis situated distal to the extensor sling. It is composed of obliquely
oriented fibers and is triangular in shape.6,27,36,38,39 The
extensor wing unites the tendinous fibers of the intrinsic
muscles with the 3 slips of the extensor digitorum longus
(Figure 16).38 According to Sarrafian and Topouzian,38 the
extensor wing is situated on both sides of each toe. The
superior border of each triangle inserts into each of the lateral slips corresponding to the trifurcation of the extensor
digitorum longus muscle. Some fibers extend toward the
dorsum of the proximal interphalangeal joint and join the
middle slip. The proximal border is continuous with the distal margin of the extensor sling, and the inferior border runs
obliquely, distally, and dorsally. Observed in a medial view,
the tendon of the lumbrical muscleafter passing plantar to
the deep transverse metatarsal ligamentruns dorsally to
form the oblique border of the extensor wing.6,29,33,36,38,39
Although most of the authors who discuss the extensor
wing29,36 agree with the description proposed by Sarrafian and
Topouzian,37 our dissections confirm that on the medial side,
the extensor wing is evident, owing to the presence of the lumbrical muscle. However, we did not observe a structure

comparable to the extensor wing on the lateral side of the lesser

toes. Therefore, our illustration differs in this detail from the
original drawing by Sarrafian and Topouzian (Figure 17).

Triangular Lamina
The triangular lamina occupies the space between the lateral
slip and the medial slip at the dorsum of the middle phalanx.37
This structure comprises a fine, almost transparent lamina of
tissue that is pearl in color and extends until it becomes the
terminal extensor tendon. The triangular lamina was a constant finding in our dissections (Figure 18). Although we do
not discuss its function, we think that the triangular lamina
helps to maintain the lateral and medial slips in their original
anatomic position, thus avoiding their plantar displacement.
If this happens, the slips function as flexors rather than extensors of the proximal interphalangeal joint.

Clinical Implications of the Extensor

Apparatus
The extensor apparatus of the lesser toes is a basic structure that must be addressed in order to correct lesser toe

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Foot & Ankle International

Figure 15. Anatomical images showing the sling mechanism

of the extensor sling. (A) Without action of the extensor
digitorum longus. (B) With action of the extensor digitorum
longus (black arrow). In this case, the extensor sling prevents
the extensor tendon excursion (its fibers in tension), allowing
the extensor digitorum longus extend all the toe joints. (1)
Extensor digitorum longus tendon. (2) Extensor sling. (Figure
reproduced with kind permission from De Prado M, Ripoll PL,
Golan P. Minimally Invasive Foot Surgery. Barcelona: About Your
Health; 2009: 221-38).13

deformities. Release of the extensor digitorum longus,

extensor digitorum brevis, metatarsophalangeal joint capsule or lengthening of the extensor digitorum longus tendon are common procedures aimed at eliminating the pull
of the extensor apparatus, thus avoiding hyperextension of
the proximal phalanx.5,13,25,27,29 A tenotomy decreases the
radiographic sagittal angulation of the toe.14 The correction
of these deformities is most effective if the deformity is
completely flexible and less effective if it is rigid.42 These
procedures, although described for correction of lesser
toes deformities, have not been documented in the literature as effective as isolated procedures. They can, however, be useful as adjunctive procedures in lesser toes
deformities.39,40 A detailed knowledge of the extensor

Figure 16. (A) Medial view of the anatomical dissection of

the second toe in which the anatomy of the extensor wing and
the limits are underlined by software (Adobe PhotoShop). (B)
Medial view of the main drawing showing the extensor wing. (1)
Extensor wing. (2) First lumbrical tendon (tensioned-arrow). (3)
Extensor digitorum longus tendon. (4) Middle slip. (5) Medial
slip. (6) Extensor sling. (7) Extensor digitorum brevis tendon.
(8) Phalanx tubercle. (9) First dorsal interosseous muscle. (10).
Plantar plate and deep transverse metatarsal ligament (cut). (11)
Shaft of the second metatarsal bone. (12) Metatarsal tubercle.

apparatus is key to an appropriate performance of these

procedures.
Most authors agree that both the extensor digitorum longus tendon and extensor digitorum brevis tendon should be
released.13,25,27 Joint capsule release, on the other hand,
depends on how fixed the deformity is. Additional release
of the lumbrical tendons has been suggested.24 Tendon
release at the level of the metatarsophalangeal joint prevents proximal displacement of the tendon ends, owing to
the attachment of the extensor sling. It is also possible to
perform dorsal release of the metatarsophalangeal joint
capsule through the same incision. Lengthening of the
extensor digitorum longus tendon could be performed
proximal to the extensor sling, since no proximal excursion

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Dalmau-Pastor et al.

Figure 18. Anterior view of the anatomical dissection of the

dorsal aspect of the middle phalanx showing the triangular
lamina anatomy (white arrows). (1) Triangular lamina. (2) Middle
slip. (3) Medial slip. (4) Lateral slip. (5) Terminal tendon.

Figure 17. Medial and lateral view of the anatomical dissection

of the extensor apparatus of the second toe intending to
demonstrate the absence of a structure comparable to the
extensor wing on the lateral side of the lesser toes. (A) Medial
view. (B) Lateral view. (1) Extensor wing. (2) First lumbrical
tendon. (3) Medial slip. (4) Flexor digitorum longus tendon.
(5) Extensor digitorum longus tendon. (6) Extensor digitorum
brevis tendon. (7) Extensor sling. (8) Phalanx tubercle. (9) Flexor
digitorum brevis tendon. (10) First dorsal interosseous muscle.
(11) Second dorsal interosseous muscle. (12) Vertical septum of
the plantar fascia (cut). (13) Shaft of the second metatarsal bone.
(14) Collateral ligaments of the proximal interphalangeal joint.

of the tendon is observed. There is no connection between

the extensor digitorum longus tendon and extensor digitorum brevis tendon at the metatarsophalangeal joint.
Consequently, when a lesser toe deformity is identified, the
extensor digitorum brevis tendon is displaced laterally and
plantar to the extensor digitorum longus. The surgeon has
to be aware of this fact, as both tendons should be cut.
Cutting only the extensor digitorum longus could lead to
incomplete correction of the deformity.
Lesser toe deformities can be caused by other pathological entities, such as spastic equinovarus deformity,
paralytic foot, or compartment syndrome (when affecting the lateral, deep posterior, or superficial posterior

compartments of the leg28). Release of the lumbrical tendons has been suggested when addressing lesser toe
deformities in patients with spastic equinovarus deformity.24 Release of the flexor digitorum longus and brevis
tendons alone can result in flexion deformity of the metatarsophalangeal joint because of the effect of the lumbricals tendons. Also in cases of paralytic foot, the paralysis
of the plantar intrinsic musculature of the foot leads to
claw toes and moreover causes a shift in distal direction
of the plantar fat pad below the metatarsophalangeal
joint, exposing the thinner part of the skin to pressure.4
Secondary toe deformities can develop in cases of peroneal nerve palsy, especially when tibialis anterior muscle
is affected, which can result in secondary recruitment
and overactivity of the extrinsic toe extensors to assist
ankle dorsiflexion.28

Conclusion
The extensor apparatus of the lesser toes is an important
set of structures for the biomechanics of the toes that
involve an extrinsic contribution (extensor digitorum longus), an intrinsic contribution (extensor digitorum brevis,
lumbrical muscles, and interossei muscles), and stabilizing ligaments (extensor sling, extensor wing, and triangular lamina).
The action of the extensor and flexor muscles of the
lesser toes produce hyperextension of the metatarsophalangeal joint and plantarflexion of the proximal and distal
interphalangeal joint. Traction of the interossei muscles
flexes and stabilizes the metatarsophalangeal joint. The
lumbrical muscles plantarflex the metatarsophalangeal joint
and extend both of the interphalangeal joints. Thereby,
complete extension of the lesser toes is the result of the
combined forces between the extensor digitorum longus

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Foot & Ankle International

muscle and the intrinsic muscles, all of which converge to

form the extensor apparatus. The imbalance between the
extensor apparatus and the flexors of the toes leads to lesser
toe deformities. These deformities can often be corrected by
soft tissue procedures. Knowledge of these structures can
have great importance when performing these surgical procedures and in avoiding recurrence.
Acknowledgments
We thank Roser Torres for her valuable help with the drawings
presented in this paper. The authors are grateful to Thomas OBoyle
for editorial assistance. We thank Dr Cristina Manzanares for her
institutional support at the University of Barcelona.

Editors Note
This article is published in memory of Pau Golano, MD, who died
unexpectedly during the production phase of this outstanding scientific contribution.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.

Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.

References
1. Bade H, Tsikaras P, Koebke J. Pathomorphology of the hammer toe. Foot Ankle Surg. 1998;4:139-143.
2. Blitz NM, Ford LA, Christensen JC. Second metatarsophalangeal joint arthrography: a cadaveric correlation study. Foot
Ankle Surg. 2004;43(4):231-240.
3. Bojsen-Moller F. Anatomy of the forefoot, normal and
pathologic. Clin Orthop Relat Res. 1979;(142):10-18.
4. Brand PW. The insensitive foot (including leprosy). In: Jahss
MH, ed. Disorders of the Foot. Philadelphia: W. B. Saunders
Company; 1982:1266-1286.
5. Chadwick C, Saxby TS. Hammertoes/clawtoes: metatarsophalangeal joint correction. Foot Ankle Clin N Am.
2011;16(4):559-571.
6. Chan R. Anatomy of the digits. Clin Podiatr Med Surg.
1986;3(1):3-9.
7. Cooper PS. Disorders and deformities of the lesser toes. In:
Myerson MS, ed. Foot and Ankle Disorders. Philadelphia:
W.B. Saunders Company; 2000:308-358.
8. Coughlin MJ. Lesser toe deformities. In: Coughlin MJ, Mann
R, Saltzman CL, eds. Surgery of the Foot and Ankle. 8th ed.
Philadelphia: Mosby; 2007:363-464.
9. Coughlin MJ. Lesser-toe abnormalities. J Bone Joint Surg
Am. 2002;84(8):1446-1469.
10. Coughlin MJ. Subluxation and dislocation of the sec
ond metatarsophalangeal joint. Orthop Clin North Am.
1989;20(4):535-551.

11. Coughlin MJ, Dorris J, Polk E. Operative repair of the fixed

hammertoe deformity. Foot Ankle Int. 2000;21(2):94-104.
12. Cyphers SM, Feiwell E. Review of the Girdlestone-Taylor
procedure for clawtoes in myelodysplasia. Foot Ankle Int.
1988;8(5):229-323.
13. De Prado M, Ripoll PL, Golan P. Minimally Invasive Foot
Surgery. Barcelona: About Your Health; 2009:221-238.
14. Espinosa N, Myerson MS. Current concept review: metatarsalgia. Foot Ankle Int. 2008;29(8):871-879.
15. Fahrer M, Chapius PH. Proceedings: the functional anatomy
of the extensor apparatus of the second, third and fourth toes.
J Anat. 1973;116(3):478.

16.
Federative Committee on Anatomical Terminology.
International Anatomical Terminology. Stuttgart: Thieme; 1998.
17. Femino JE, Mueller K. Complications of lesser toe surgery.
Clin Orthop Relat Res. 2001;391:72-88.
18. Ford LA, Collins KB, Christensen JC. Stabilization of the
subluxed second metatarsophalangeal joint: flexor tendon
transfer versus primary repair of the plantar plate. Foot Ankle
Surg. 1998;37(3):217-222.
19. Fortin PT, Myerson MS. Second metatarsphalangeal joint
instability. Foot Ankle Int. 1995;16(5):306-313.
20. Gosling JA. Human Anatomy. Color Atlas and Textbook. 4th
ed. Philadelphia: Mosby; 2008.
21. Green DR, Brekke M. Anatomy, biomechanics, and pathomechanics of lesser digital deformities. Clin Podiatr Med Surg.
1996;13(2):179-200.
22. Holinka J, Schuh R, Hofstaetter JG, Wanivenhaus AH.

Temporary Kirschner wire transfixation versus strapping
dressing after second MTP joint realignment surgery: a
comparative study with ten-year follow-up. Foot Ankle Int.
2013;34(7):984-989.
23. Jarrett BA, Manzi JA, Green DR. Interossei and lumbricales
muscles of the foot: an anatomical and functional study. J Am
Podiatry Assoc. 1980;70(1):1-13.
24. Keenan MA, Gorai AP, Smith CW, Garland DE. Intrinsic toe
flexion deformity following correction of spastic equinovarus
deformity in adults. Foot Ankle. 1987;7(6):333-337.
25. Kitaoka HB, Richardson EG. Realignment of lesser toe

deformities. In: Kitaoka HB, ed. The Foot and Ankle. 2nd ed.
Philadelphia: Lippincott Williams & Wilkins; 2002:147-168.
26. Knecht JG. Pathomechanical deformities of the lesser toes. J
Am Podiatr Assoc. 1974;64(12):941-954.
27. Mann RA, Coughlin MJ. Lesser-toe deformities. In: Jahss
MH, ed. Disorders of the Foot and Ankle. Medical and
Surgical Management. 2nd ed. Philadelphia: Saunders
Company; 1991:1205-1228.
28. Matuszak SA, Baker EA, Fortin PT. The adult paralytic foot.
J Am Acad Orthop Surg. 2013;21(5):276-285.
29. McGlamry ED, Jimenez AL, Green DR. Lesser ray deformities. In: McGlamry ED, Banks AS, Downey MS, eds.
Comprehensive Textbook of Foot Surgery. 2nd ed. Baltimore:
Williams & Wilkins; 1992:51-102.
30. Milz S1, Putz R, Ralphs JR, Benjamin M. Fibrocartilage
in the extensor tendons of the human metacarpophalangeal
joints. Anat Rec. 1999;256(2):139-145.
31. Moore KL, Dalley AF. Clinically Oriented Anatomy.

6th ed. Philadelphia: Lippincott Williams&Wilkins;
2010:509-669.

Downloaded from fai.sagepub.com by guest on April 6, 2016

13

Dalmau-Pastor et al.
3 2. Myerson MS, Shereff MJ. The pathological anat
omy of claw and hammer toes. J Bone Joint Surg Am.
1989;71(1):45-49.
33. Oukouchi H, Murakami T, Kikuta A. Insertions of the lumbrical and interosseus muscles in the human foot. Okijamas
Folia Anat Jpn. 1992;69(2-3):77-83.
34. Resch S. Functional anatomy and topography of the foot
and ankle. In: Myerson MS, ed. Foot and Ankle Disorders.
Philadelphia: W.B. Saunders Company; 2000:25-49.
35. Romanes GR. Cunninghams Manual of Practical Anatomy.
15th ed. Oxford: Oxford University press; 1986.
36. Samojla BG. Normal anatomy of the forefoot. In: Hetherington
VJ, ed. Hallux Valgus and Forefoot Surgery. New York:
Churchill Livingstone; 1994:7-37.
37. Sarrafian SK, Kelikian AS. Myology. In: Kelikian AS, ed.
Sarrafians Anatomy of the Foot and Ankle: Descriptive,
Topographic, Functional. 3rd ed. Philadelphia: Williams &
Wilkins; 2011:223-301.
38. Sarrafian SK, Topouzian LK. Anatomy and physiology

of the extensor paratus of the toes. J Bone Joint Surg Am.
1969;51(4):669-679.

39. Schuberth JM. Hammer toe syndrome. Foot Ankle Int.

1999;38(2):166-178.
40. Solan MC, Davies MS. Revision surgery of the lesser toes.
Foot Ankle Clin N Am. 2011;16:621-645.
41. Standring S, Borley NR. Grays Anatomy: The Anatomical
Basis of Clinical Practice. 40th ed. Philadelphia: Churchill
Livingstone; 2008.
42. Tamir E, Vigler M, Avisar E, Finestone AS. Percutaneous
tenotomy for the treatment of diabetic toe ulcers. Foot Ankle
Int. 2013;34(10):1-6.
43. Van Eck CF, Schreiber VM, Liu TT, Fu FH. The anatomic
approach to primary, revision and augmentation anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol
Arthrosc. 2010;18(9):1154-1163.
44. Watson AD, Anderson RB, Davis WH. Lesser toes deformities. In: Kelikian AS, ed. Operative Treatment of the Foot
and Ankle. New York: Appleton & Lange; 1999:99-116.
45. Yu GV, Judge MS, Hudson JR, Seidelmann FE. Predislocation
syndrome. Progressive subluxation/dislocation of the
lesser metatarsophalangeal joint. J Am Podiatr Med Assoc.
2002;92(4):182-199.

Downloaded from fai.sagepub.com by guest on April 6, 2016