Medial plantar nerve

The medial plantar nerve is one of the two terminal branches of the tibial nerve, the other being the lateral plantar nerve. It is located in the foot, arising from the tibial nerve after it passes through the tarsal tunnel, a space behind the medial malleolus (the inner ankle bone). The medial plantar nerve runs along the medial side of the foot, beneath the abductor hallucis muscle, and travels anteriorly toward the sole. It provides innervation to the medial portion of the sole, as well as the first three and a half toes. The nerve also branches to supply some intrinsic muscles of the foot.

Structure and Anatomy

The medial plantar nerve is one of the two terminal branches of the tibial nerve, and it plays a significant role in providing motor and sensory innervation to the medial aspect of the foot. It courses through the foot, supplying both muscles and skin. Below is a detailed description of the anatomy of the medial plantar nerve.

Origin

The medial plantar nerve originates from the tibial nerve, which is a continuation of the sciatic nerve. The tibial nerve bifurcates into the medial and lateral plantar nerves after passing through the tarsal tunnel, a passageway located posterior to the medial malleolus. The tarsal tunnel also contains the posterior tibial artery and the tendons of muscles that contribute to foot movement.

Course and Pathway

• Proximal Course: After branching from the tibial nerve, the medial plantar nerve runs beneath the flexor retinaculum alongside the medial plantar artery. It enters the sole of the foot by passing deep to the abductor hallucis muscle. The nerve follows a medial course, running along the sole between the abductor hallucis and the flexor digitorum brevis muscles.
• Midfoot: As the nerve continues along the medial side of the sole, it travels in close proximity to the medial plantar artery, providing both sensory and motor innervation along its path. It remains relatively superficial, making it more accessible for diagnostic or surgical procedures.
• Distal Course and Branching: The medial plantar nerve branches as it approaches the midfoot and forefoot into smaller sensory and motor branches. These branches serve the medial part of the sole, as well as several muscles that control toe movements. As the nerve moves forward, it divides into digital branches, which provide sensation to the medial toes.

Branches of the Medial Plantar Nerve

The medial plantar nerve gives off several motor and sensory branches as it travels through the foot:

Motor Branches:

• Abductor Hallucis: The nerve innervates the abductor hallucis muscle, which is responsible for the movement of the big toe.
• Flexor Digitorum Brevis: The medial plantar nerve also supplies the flexor digitorum brevis, which is involved in flexing the middle phalanges of the lateral four toes.
• Flexor Hallucis Brevis: This nerve provides motor innervation to the flexor hallucis brevis, a muscle responsible for flexing the big toe.
• First Lumbrical: The first lumbrical muscle, which assists in the flexion of the metatarsophalangeal joint and extension of the interphalangeal joints of the toes, is also innervated by the medial plantar nerve.

Sensory Branches:

• The medial plantar nerve gives rise to sensory branches that provide innervation to the medial portion of the sole of the foot.
• It also provides digital branches that innervate the medial three and a half toes (the big toe, second, third, and medial side of the fourth toe), allowing for sensation in these areas.

Relationship to Neighboring Structures

• Medial Plantar Artery: The medial plantar nerve runs alongside the medial plantar artery, which provides the vascular supply to the medial part of the foot. The close proximity of the nerve and artery is important in foot surgeries and in conditions like tarsal tunnel syndrome, where both structures can be compressed.
• Muscles of the Sole: The medial plantar nerve courses between and innervates several intrinsic muscles of the foot, including the abductor hallucis and flexor digitorum brevis. These muscles contribute to the movement and stabilization of the toes, especially the big toe.
• Flexor Retinaculum: The medial plantar nerve passes beneath the flexor retinaculum, a thick band of connective tissue that helps secure the tendons, nerves, and blood vessels as they pass through the tarsal tunnel behind the medial malleolus.

Sensory Distribution

The sensory fibers of the medial plantar nerve are responsible for providing sensation to the medial portion of the sole and the medial three and a half toes. The sensory coverage extends from the heel to the forefoot, including the plantar surface of the big toe and adjacent toes. The digital branches of the medial plantar nerve ensure tactile sensation and proprioception, which are crucial for balance and foot coordination during walking.

Motor Distribution

The motor fibers of the medial plantar nerve innervate key muscles responsible for controlling the movement of the toes. These muscles include the abductor hallucis, flexor digitorum brevis, flexor hallucis brevis, and the first lumbrical. By controlling these muscles, the medial plantar nerve contributes to the flexion, abduction, and adduction of the toes, particularly the big toe, which plays a major role in foot stability and propulsion during walking.

Branching Patterns

The medial plantar nerve has a relatively consistent branching pattern. It typically divides into:

• Superficial Branches: These branches provide sensory innervation to the skin of the medial sole and the medial three and a half toes.
• Deep Branches: The deep branches of the medial plantar nerve supply the motor innervation to the muscles in the sole of the foot.

Anatomical Variations

There are some anatomical variations in the exact course and branching pattern of the medial plantar nerve. These variations can include differences in the location where the nerve divides into its terminal branches or slight differences in the areas supplied by its sensory and motor branches. These variations are important to consider in surgical procedures involving the foot and during the diagnosis of nerve injuries or entrapment syndromes.

Function

The medial plantar nerve plays a vital role in providing both motor and sensory innervation to the medial aspect of the foot. It is responsible for controlling the movement of specific muscles in the sole of the foot and for transmitting sensory information from the skin of the medial sole and toes. Below is a detailed explanation of its functions, categorized by motor and sensory roles.

Motor Function

The medial plantar nerve supplies several key muscles in the sole of the foot, which are involved in controlling toe movements, especially the big toe (hallux). These muscles contribute to foot stabilization, balance, and propulsion during walking.

• Abductor Hallucis Muscle: The medial plantar nerve innervates the abductor hallucis, a muscle located along the medial border of the foot. This muscle is responsible for abduction of the big toe, moving the toe away from the midline of the foot. This action helps maintain foot balance and medial arch support, particularly when standing or walking.
• Flexor Digitorum Brevis Muscle: The medial plantar nerve also innervates the flexor digitorum brevis, a muscle located in the sole of the foot. This muscle is responsible for flexing the middle phalanges of the second, third, and fourth toes. It plays an essential role in the push-off phase of walking by helping to bend the toes downward, allowing the foot to lift off the ground.
• Flexor Hallucis Brevis Muscle: The medial plantar nerve innervates the flexor hallucis brevis, which is responsible for flexion of the big toe at the metatarsophalangeal joint. This flexion is crucial during walking and running, as the big toe helps propel the body forward and maintain balance.
• First Lumbrical Muscle: The medial plantar nerve supplies the first lumbrical, a small muscle that is important for the coordination of toe movements. The first lumbrical assists in flexing the metatarsophalangeal joint and extending the interphalangeal joints of the second toe. This coordinated movement helps with the fine control of toe flexion and extension, ensuring stability during gait.

Sensory Function

The medial plantar nerve provides sensory innervation to the medial portion of the sole and the first three and a half toes. Its sensory role is essential for detecting touch, pressure, pain, and temperature, which are critical for maintaining balance and protecting the foot from injury.

• Medial Sole of the Foot: The medial plantar nerve supplies sensory fibers to the medial part of the sole, including the area under the arch of the foot. This region is important for tactile sensation, helping the body sense changes in pressure and surface texture, which aids in balance and posture during standing and walking.
• First Three and a Half Toes: The nerve provides sensory innervation to the first three and a half toes, including the big toe, second, third, and the medial half of the fourth toe. This sensory input allows for the detection of pressure and touch, which is essential for foot coordination during activities like walking, running, or jumping.
• Plantar Surface Sensation: The medial plantar nerve is responsible for transmitting sensory signals from the plantar surface (sole) of the foot. This includes the skin and deeper tissues in the medial part of the sole. The sensory information is crucial for protecting the foot from excessive pressure or harmful stimuli, such as sharp objects, which can cause injury.

Role in Gait and Balance

The medial plantar nerve is essential for maintaining proper foot mechanics during walking and standing. Its motor and sensory functions contribute significantly to balance, stability, and the propulsive phase of gait.

• Push-Off and Toe Flexion: The muscles innervated by the medial plantar nerve, particularly the flexor digitorum brevis and flexor hallucis brevis, allow for effective toe flexion during the push-off phase of walking. This flexion is essential for lifting the foot off the ground and propelling the body forward, ensuring smooth and efficient movement.
• Medial Arch Support: The medial plantar nerve’s control over the abductor hallucis helps maintain the medial longitudinal arch of the foot. This arch is crucial for absorbing shock and providing stability during weight-bearing activities, such as walking, running, or standing.
• Sensory Feedback for Balance: Sensory input from the medial sole and toes allows the body to detect changes in surface texture and foot pressure. This feedback helps the body adjust its posture and foot positioning to maintain balance, especially when walking on uneven surfaces or during quick directional changes.

Coordination with the Lateral Plantar Nerve

The medial plantar nerve works in conjunction with the lateral plantar nerve to provide comprehensive innervation to the sole of the foot. While the medial plantar nerve controls the medial aspect of the foot, the lateral plantar nerve supplies the lateral part of the sole. Together, these nerves ensure that the foot’s intrinsic muscles and skin are properly innervated for both motor and sensory functions.

Medial-Lateral Balance: The medial and lateral plantar nerves together allow for balanced foot movements, including abduction and adduction of the toes, which are necessary for foot stabilization and proper toe alignment during walking.

Reflexive Functions

The medial plantar nerve is involved in several autonomic reflexes that help maintain proper foot function and protect the foot from injury.

Withdrawal Reflex: When the skin of the medial sole or toes is exposed to harmful stimuli, such as excessive pressure or heat, the medial plantar nerve triggers a withdrawal reflex, causing the foot to pull away from the source of discomfort. This reflex helps prevent injury to the foot and toes.

Clinical Significance

The medial plantar nerve is crucial for both motor and sensory functions of the medial sole of the foot and the first three and a half toes. Injury or compression of this nerve can lead to conditions such as medial plantar neuropathy, which may result in symptoms like numbness, pain, tingling, or weakness in the affected areas. This can occur in activities involving repetitive foot stress, such as running, leading to what is often referred to as “jogger’s foot.”

Compression of the medial plantar nerve can also occur in tarsal tunnel syndrome, where the nerve is compressed as it passes through the tarsal tunnel near the ankle. This can cause discomfort in the medial foot and toes, and may affect gait and balance. Early diagnosis and treatment are important to prevent long-term damage and maintain foot functionality.