The Innervation of the Joints of the Foot’

ERNEST GARDNER AND D. J. GRAY

Departments of Anatomy, W a y n e State University School o f Medicine,
Detroit, Michigan, and Stanford Universitg School o f Medicine,
Stanford, California

ABSTRACT The nerve supply of the ankle joint and of the joints of the foot was
studied in dissections of fetal and adult feet and in serial sections of fetal feet stained
with silver.
The ankle joint was supplied by the tibial, saral, deep peroneal, and saphenous
nerves, and by the accessory deep peroneal nerve when present.
The tarsal joints were supplied on their plantar aspects by the medial or lateral
plantar nerves, and on their dorsal aspects chiefly by the deep peroneal nerve. The
joint between the lateral and intermediate cuneiform received branches from the
intermediate dorsal cutaneous nerve also. The lateral dorsal cutaneous nerve and
the accessory deep peroneal nerve when present provided additional branches to the
subtalar and calcaneocuboid joints.
The tarsometatarsal joints were supplied on their plantar aspects by the medial
or lateral plantar nerves. Most of them were supplied on their dorsal aspects by the
deep peroneal nerve, but the cuboid-metatarsal joints received their supply from the
intermediate dorsal cutaneous nerve. The intermetatarsal joints had a similar but
sparser supply. The joint between the fourth and fifth metatarsal received branches
from the intermediate dorsal cutaneous nerve.
The plantar digital nerves provided the main supply to the metatarsophalangeal
joints. The dorsal aspect of the first metatarsophalangeal joint was supplied by the
deep peroneal and the medial dorsal cutaneous nerves, of the second metatarsopha-
langeal joint by the deep peroneal nerve, and of the fourth and fifth metatarsopha-
langeal joints by the lateral dorsal cutaneous nerve. The interphalangeal joints did
not receive articular branches from the dorsal digital nerves, except in the case of the
interphalangeal joint of the big toe, which was supplied by the deep peroneal and
the medial dorsal cutaneous nerves.

Relatively few reports on the nerve sup- scriptions of the distribution of the nerves
ply of the joints of the foot have been pub- of the foot. However, serial sections of five
lished, and the studies that have been re- fetal feet provided the material for detailed
ported were based mostly upon dissections. studies. These sections had been stained
Riidinger (1857) described branches to with Bodian’s activated protargol method,
many of these joints. The information that and then counterstained with a modified
he provided was the most detailed and Masson’s method. The feet studied com-
comprehensive available until recently, prised the left foot of a fetus 58 mm in
when Lippert (’62) described and illus- crown-rump length, both feet of a fetus 61
trated their innervation. mm crown-rump, and both feet of a fetus
In 1897, Bryce discovered a nerve 150 mm crown-rump. Although the tech-
hitherto undescribed in man. He again nique employed did not make possible the
found and reported this nerve upon two observation and identification of intra-
later occasions, and named it the “deep ac- articular endings, the nerve fibers could
cessory peroneal nerve,” because of its ap- be traced to and often within the capsules
parent homology with a nerve found and of the various joints. In cases in which the
so named by Ruge (1878) in certain other origin of a nerve fiber was doubtful, it
mammals. Winckler (’34, ’36) has pro- could be traced in serial sections to its par-
vided a more detailed account of this nerve ent trunk and thereby identified. The value
and its distribution, as well as its com- of using serial sections of fetal joints to
parative anatomy.
1 This investigation was supported by research
MATERlALS AND METHODS grants HD 00377 from the National Institute of Child
Health and Human Development and AM 6705 from
Several fetal and adult feet were dis- the National Institute of Arthritis and Metabolic Dis-
eases of the Nahonal Inshtutes of Health, Public
sected in order to confirm the usual de- Health Service.

ANAT. REC., 161: 141-148. 141

142 ERNES T GARDNER A N D D. J. GRAY

determine more exactly the distribution of The term “accessory deep peroneal
nerves to joints has been established by nerve” has been given to the downward
Gardner (’48). continuation of the branch of the superfi-
cial peroneal nerve that supplies the
OBSERVATIONS peroneus brevis muscle. When present,
The usual descriptions of the distribu- this nerve usually passes behind the lateral
tion of the nerves of the foot were con- malleolus into the foot, where it helps to
firmed by dissection. The plantar digital supply the extensor digitorum brevis and
nerves reached the tips of all toes. Unlike may send articular twigs to some of the
the dorsal digital nerves of the hand, only intertarsal joints.
some of which extend to the tips of the Lateral plantar nerve (fig. 1). Before
fingers, in most cases the dorsal digital giving off its deep branch, the lateral
nerves of the foot reached the tips of the plantar nerve supplied, on their plantar
toes. In most specimens, the lateral dorsal aspects, the calcaneocuboid joint, the cu-
cutaneous nerve was a continuation of the boid-navicular joint, the joints between
sural nerve. It sometimes communicated the navicular and lateral cuneiform, be-
with the intermediate dorsal cutaneous tween the cuboid and fifth metatarsal, and
nerve, or with one of the branches of the between the bases of the fourth and fifth
intermediate dorsal cutaneous. metatarsals, the tarsometatarsal joints be-

Fig. 1 Schematic representation of the articular distribution of the medial and lateral
plantar nerves. The word plantar was misspelled on the original drawings.
 NERVES TO JOINTS O F FOOT 143

tween the lateral cuneiform and the fourth, and the medial side of the joints of the
third, and second metatarsals, and the fourth.
joint between the lateral and intermediate Deep peroneal nerve (fig. 3 ) . The deep
cuneiforms. The deep branch of the lateral peroneal nerve had a wide distribution to
plantar nerve supplied the joints between the joints of the tarsus on the dorsum of
the third and fourth, and between the sec- the foot. It supplied the talonavicular joint,
ond and third metatarsals, and sent long the calcaneocuboid joint, all joints between
filaments to supply the second, third, and the navicular and cunejforms, both inter-
fourth metatarsophalangeal joints (fig. 2). cuneiform joints, the joints between the
The proper plantar digital nerves supplied three cuneiforms and the metatarsals, the
all joints of the fifth toe on both medial joint between the cuboid and the lateral
and lateral sides, and all joints of the cuneiform, and those between the second
fourth toe on the lateral side. and third, and between the third and
Medial plantar nerve (fig. 1). The me- fourth metatarsals. The proper digital
dial plantar nerve supplied, on their branches sent twigs to the metatarsopha-
plantar aspects, the subtalar joint, and the langeal and interphalangeal joints of the
joints between the navicular and medial first and second toes.
cuneiform and between the navicular and Medial dorsal cutaneous nerve (fig. 3 ) .
intermediate cuneiform. Branches to the The medial dorsal cutaneous nerve sup-
joints between the medial and intermediate plied the metatarsophalangeal and inter-
cuneiform and between the intermediate
phalangeal joints of the big toe on the
cuneiform and the second metatarsal arose
after the medial plantar gave off the proper medial side.
plantar digital to the medial side of the big Intermediate dorsal cutaneous nerve
toe. A branch to the joint between the me- (fig. 3 ) . The intermediate dorsal cutane-
dial cuneiform and first metatarsal arose ous nerve supplied the joint between the
from the common plantar digital between intermediate and lateral cuneiforms, the
the first and second toes. Digital branches joints between the cuboid and fourth
froim the medial plantar supplied both metatarsal and between the cuboid and
sides of the metatarsophalangeal and in- fifth metatarsal, and the joint between the
terphalangeal joints of the first three toes fourth and fifth metatarsals. Although the

Fig. 2 Fibers from an articular branch of the lateral plantar nerve entering the plantar pad of
the fourth metatarsophalangeal joint of a 150 rnm fetus. X 610.
144 E R N E S T GARDNER A N D D. J. GRAY

Fig. 3 Schematic representation of the articular distribution of the superficial peroneal, deep
peroneal, and accessory deep peroneal nerves, and of the lateral dorsal cutaneous nerve.

digital branches could usually be followed was found in most specimens. It often
to the tips of the toes, in most cases sent branches to the subtalar joint and
branches of these nerves could not be sometimes reached the calcaneocuboid
traced to the metatarsophalangeal and in- joint.
terphalangeal joints. Ankle joint. Although the ankle joint is
Lateral dorsal cutaneous nerve (fig. 3 ) . not included in any of the diagrams, its
The lateral dorsal cutaneous nerve sup- nerve supply was included in this study. It
plied branches to the subtalar and calcane- received branches from the tibial (fig. 5),
ocuboid joints, and to the joints between the sural, the deep peroneal, the saphenous
the cuboid and fourth metatarsal and be- (fig. 6), and the accessory deep peroneal
tween the cuboid and fifth metatarsal. It when present.
supplied the metatarsophalangeal joints of Table 1 shows a composite of the nerve
the fourth and fifth toes, but branches to supply of the various joints in the five feet
the interphalangeal joints of these toes studied with the use of serial sections.
were inconstant. Figure 4 is a composite drawing represent-
Accessory deep peroneal nerve (figs. 3, ing the distribution of the nerves con-
4). The accessory deep peroneal nerve cerned.
 NERVES TO JOINTS OF FOOT 145

Fig 4 Schematic composite representation of the nerve supply of the joints of the foot. The
word plantar was misspelled on the original drawings.
DISCUSSION In general, the joints of the foot are sup-
A study of the innervation of the joints pried by nerves reaching them on their
of the wrist and hand (Gray and Gardner, plantar and dorsal aspects. Some joints,
'65) revealed that all of the nerves reach- however, are supplied by only one nerve
ing the wrist and hand had articular from one aspect. For example, the inter-
branches. Some joints were supplied by phalangeal joints of the little toe receive
only one nerve, but many joints received their supply from the superficial branch of
their supply from two or more nerves. In the lateral plantar nerve only.
the case of certain joints, the number and The larger tarsal joints are supplied by
origin of the nerves supplying them vaned two or more nerves. For example, the
from one specimen to another. Some joints, calcaneocuboid joint receives articular fi-
however, always received a branch from bers from the lateral plantar, the deep
a specific nerve. peroneal, and the lateral dorsal cutaneous
A similar pattern of articular nerve sup- nerves, and from the accessory deep per-
ply was revealed by the present study. All oneal nerve when present.
nerves reaching the foot contain articular Most of the metatarsophalangeal joints
fibers that reach joints by way of branches receive a multiple innervation. The second
that vary in origin and number, depending metatarsophalangeal joint, for example, is
on the joint concerned. supplied by the medial plantar, the deep
146 ERNEST GARDNER AND D. J. GRAY

branch of the lateral plantar, and the deep

peroneal nerves.
It is possible that as growth continues,
a specific articular nerve might develop a
wider distribution than that shown in the
present study, However, a s judged from
the studies of other joints using both fetal
and adult material (Gardner, '48), it is un-
likely that such a change would be signifi-
cant.
The present study provides detailed in-
formation concerning the total distribution
of articular nerves to a degree that cannot
be achieved by dissection. It reveals that
the joints of the foot, like all other synovial
joints that have been studied, receive a
significant nerve supply, usually from
many sources. It gives no evidence about
types of fibers or of intra-articular endings,
but it is reasonable to suppose that the
types present in the foot are similar to
Fig. 5 A few thin nerve fibers from an articu-
lar branch of the tibia1 nerve curving through those of other Joints and that they have a
the capsule of the ankle joint. From a 150 mm Similar physiological importance. Stilweu
human fetus. X 350. ('57) described proprioceptive triads in

Fig. 6 Articular branches (upper right and lower left arrows) of the saphenous nerve to the
ankle joint. The middle arrow indicates a developing pacinian corpuscle. From a 150 mm
human fetus. X460,
 NERVES T O JOINTS O F FOOT 147
TABLE 1
The nerues of the foot and the joints supplied b y these nerues
Medial plantar Lateral plantar Lateral plantar (deep branch)
Subtalar Calcaneocuboid Mt 2-Mt 3
Talonavicular Cuboid-navicular Mt 3-Mt 4
Navicular-medial cuneiform Navicular-lateral cuneiform MtPh 4
Navicular-intermediate Cuboid-Mt 5 MtPh 3
cuneiform
Medial cuneiform-intermediate Mt 4-Mt 5 MtPh 2
cuneiform
Intermediate cuneiform-Mt 2 Lateral cuneiform-intermediate
cuneiform
Medial cuneiform-Mt 1 Lateral cuneiform-Mt 2
MtPh 1 Lateral cuneiform-Mt 3
IPh 1 Lateral cuneiform-Mt 4
MtPh 2
P IPh 2
D IPh 2
MtPh 3
P IPh 3
D IPh 3
MtPh 4
P IPh 4
D IPh 4
Lateral plantar (superficial Deep peroneal Accessory deep peroneal
branch)
MtPh 5 Calc aneocuboid Subtalar
P IPh 5 Talonavicular Calcaneocuboid
D IPh 5 Cuboid-navicular
MtPh 4 Cuboid-lateral cuneiform
P IPh 4 Navicular-medial cuneiform
D IPh 4 Navicular-intermediate
cuneiform
Lateral cuneiform-intermediate
cuneiform
Lateral cuneiform-Mt 3
Mt 3-Mt 4
Lateral cuneiform-Mt 4
Medial cuneiform-intermediate
cuneif o m
Mt 2-Mt 3
Intermediate cuneiform-Mt 2
Medial cuneiform-Mt 2
Medial cuneiform-Mt 1
MtPh 1
IPh 1
MtPh 2
Medial dorsal cutaneous Intermediate dorsal cutaneous Lateral dorsal cutaneous
MtPh 1 Lateral cuneiform-intermediate Subtalar
cuneiform
IPh 1 Cuboid-Mt 4 Calc aneocuboid
Cuboid-Mt 5 Cuboid-Mt 4
Mt 4-Mt 5 Cuboid-Mt 5
MtPh 4
MtPh 5
Mt, metatarsal; MtPh, metatarsophalangeal; P IPh, proximal interphalangeal; D IPh, distal interphalangcal.

joint capsules, flexor tendon sheaths, and tissues of the foot, especially in joint cap-
retinacula of the feet of monkey and man, sules and periosteum.
and emphasized their importance in kines- LITERATURE CITED
thesis and in reflex activities. He also de- Bryce, T. H. 1897 A long muscular branch of
scribed free-ending, small-diameter fibers, the niusculo-cutaneous nerve of the leg. J.
probably associated with pain, in all deep Anat., 31: v-xii.
148 ERNEST GARDNER AND D. J. GRAY

Gardner, E. 1948 The innervation of the knee Ruge, G. 1878 Untersuchungen uber die Ex-
joint. Anat. Rec., 101: 109-130. tensorengruppe a m Unterschenkel und Fuss der
Saugetiere. Morph. Jahrb., 4: 592-643.
Gray, D. J.9 and E. GXdner 1965 The i n n e ~ ~ a -Stawell, D. L., Jr. 1957 The innervation of
tion Of the joints Of the wrist and hand- Anat- deep structures of the foot. Am. J. Anat., 101:
Rec., 151: 261-266. 59-74.
Lippert, H. 1962 Zur Innervation der mensch- Winckler, G. 1934 Le nerf pkronier accessoire
lichen Fussgelenke. Zeit. Anat. EntwGesch., profond* Etude d'anatomie cornparbe. Arch
123: 295-308. Anat., Strasbourg, 18: 181-219.
Rudinger, N. 1857 Die Gelenknerven des men-
- 1936 Contribution a l'etude de l'inner-
vation de la face dorsale des articulations du
schlichen Korpers. Erlangen. Verlag von Ferdi- pied chez l'homme. Arch. Anat., Strasbourg,
nand Enke. 23: 39-54.