Big Toe Research Articles

Changes in plantar pressure, contact area and contact time symmetry during the gait 4 weeks before and 12 and 24 weeks after unilateral total hip arthroplasty

BackgroundFoot to ground pressure changes in total hip arthroplasty patients' gait are not widely described, although they are sensitive to gait abnormalities and the distribution of plantar pressures may differ before and after the surgery. This study aimed to analyse longitudinally differences in plantar pressure during gait in total hip arthroplasty patients compared to healthy controls. MethodsEighteen males participated in this study. Eight males, who underwent unilateral total hip arthroplasty, participated at the data collection three times: 4 weeks before the surgery, 12 and 24 weeks after, and ten healthy controls. All participants were asked to walk over Emed platform. To compare differences between the affected and unaffected limbs, Kolmogorov-Smirnov test was used. Kruskal-Wallis test was used to compare the difference between total hip arthroplasty patients and healthy controls. FindingsStatistically significant differences between the affected and unaffected limb were observed only during the preoperative measurement in peak pressure at MH4 area and in the contact area at MH4 and big toe. When comparing total hip arthroplasty patients and controls, a difference in the contact time at MH2, MH3 and MH4 areas 12 weeks after surgery and at MH2 and MH4 24 weeks after the surgery were observed. InterpretationThe shorter contact time at forefoot areas may indicate an alteration in the propulsive phase of the gait of both the affected limb and unaffected limb in total hip arthroplasty patients as a result of decreased terminal hip extension during the stance phase described in previous studies.

Gordon's reflex. Auerbach (Zeit. f. ärz. Forth., 1922, No. 5)

The author draws attention to the importance in the diagnosis of many diseases of the central nervous system of the sign, first noticed, in 1904, by Gordon. The sign is that if you make a patient bend his leg and rotate his tibia slightly outward, press deeply with four (II-V) fingers of one or, even better, both hands on the most distal third of the calf muscles, then, as in the Babinsk's sign, you get a sluggish, isolated dorsal flexion of the big toe.

Metric variation in the postcranial skeleton of ostriches,Struthio(Aves: Palaeognathae), with new data on extinct subspecies

AbstractAs a result of numerous fossil and subfossil finds of ostriches, there is great demand for a comprehensive osteometric dataset for the living species and subspecies of the genus Struthio. We meet this demand by providing a set of > 100 measurements for a sample of 18 sexed skeletons, including all living and recently extinct species and subspecies of ostriches. We provide the first mensural data for two extinct subspecies, the hitherto questioned Struthio camelus spatzi from north-western Africa and the Arabian ostrich, Struthio camelus syriacus. The unique skeletal proportions of S. c. spatzi, with a relatively short wing, broad pelvis, short tarsometatarsus and big third toe, confirm the validity of this taxon and suggest an increased stability at the expense of cursoriality, which might have contributed to its extermination by humans. Our biometric analysis of the entire sample suggests a subtle sexual dimorphism in the ostrich skeleton, with females having more robust limb bones (especially wider and/or deeper at the ends) despite being on average smaller than males. If confirmed by further research, this size-independent dimorphism might reflect the independent regulation of the longitudinal and transverse dimensions of bones as revealed by several independent studies of morphological integration (covariance among morphological traits) in the avian skeleton.

Effect of Dual Task on Step Variability during Stepping in Place without Vision

Stepping in place without vision is a spatial orientation task that is associated with unperceived foot displacements. This study was aimed at determining whether foot displacement variability is modified by a concurrent cognitive task. Fourteen young adults stepped for 50 steps with their vision blocked and performed a continuous mental counting task. 3-D Kinematic data from both feet (heel and big toe) was recorded. The variability of foot displacements was either unchanged or slightly lower in dual task, while the foot displacements were significantly shorter (p < 0.05) in dual task than without the cognitive task. The results suggest that the concurrent cognitive task might have allowed a better control of the repetitive lower limb movements.

My Big Toe and Your Big Toe

My Big Toe and Your Big Toe

Tattoos as a window onto cross-linguistic differences in scalar implicature

This paper addresses the question of how to predict which alternatives are active in scalar implicature calculation, and the nature of this activation. It has been observed that finger implicates 'not thumb', and a Manner-based explanation for this has been proposed, predicting that if English had the simplex Latin word pollex meaning 'thumb or big toe', then finger would cease to have the implicature 'not thumb' that it has. It has also been suggested that this hypothetical pollex would have to be sufficiently colloquial in order to figure in scalar implicature calculation. This paper makes this thought experiment into a real one by using a language that behaves in exactly this way: Spanish has pulgar 'thumb' (&lt; pollex), a non-colloquial form. We first use a fill-in-the-blank production task with both English and Spanish speakers to guage the likelihood with which a speaker will produce a given form as a way of describing a given digit. Production frequency does not perfectly track complexity, so we can then ask whether comprehension follows production frequency or complexity. We do so using a forced choice comprehension task, which reveals cross-linguistic differences in comprehension tracking production probabilities. A comparison between two RSA models -- one in which the speaker perfectly replicates our production data and a standard one in which the speaker chooses based on a standard cost/accuracy trade-off -- illustrates the fact that comprehension is much more closely tied to production probability than to the mere existence of sufficiently simple alternatives.

First clinical experience of a new surgical technique including correction of bony alignment of first foot ray combined with reconstruction of muscle balance in case of adolescent hallux valgus

BACKGROUND: Hallux valgus deformity of the big toe in adolescents accounts for 22%44% of all relevant cases. Despite a relatively large number of surgical treatment methods proposed to correct this deformity, treatment results are not always satisfactory. The problem of imbalance between the external traction of the abductor hallucis muscle and the contracted adductor muscle in hallux valgus remains controversial and is not covered in the literature.&#x0D; AIM: This study aimed to examine the results of hallux valgus deformity treatment, following the suggested combined technique.&#x0D; MATERIALS AND METHODS: Eight teenage patients (10 feet), aged 15 years on average, were assessed. Patients were undergoing treatment in the department of pediatric orthopedics of the Dana Hospital, Tel Aviv, within the period from 2015 to 2019. The average postoperative observation period was 30 months. This study suggested a new combined technique, including (1) modified oblique Chevron osteotomy with a V-shaped cut in the distal aspect of the first metatarsal with the dorsal wedge excision performed at the apex of its angulation, (2) valgus osteotomy of the medial cuneiform bone with the insertion of the V-shaped bone allograft, and (3) transfer of the dorsal portion of the pre-split tendon of abductor hallucis muscle to the base of the triangular medial capsular flap of the first metatarsophalangeal joint (MPJ). The tendon received optimal tension to restore the muscular balance.&#x0D; RESULTS: This surgical technique provided safe and stable correction of the hallux valgus deformity, restored muscular balance, avoided movement restriction of the first MPJ, and restored the function and strength of the abductor halluces muscle that prevented the recurrence of the deformity. The number of good and excellent results was much greater than those in published reports.&#x0D; CONCLUSIONS: Despite a relatively small group of patients, the suggested technique has shown improvements in hallux valgus deformity in adolescents.

Adolph Seeligmüller (1837-1912) and the first graphic illustration of the "toe phenomenon" (later called "Babiński sign") in the medical literature.

The "toe phenomenon" refers to the extension (dorsiflexion) of the great toe, which occurs instead of the normal flexion following stimulation of the foot sole. Its clinical significance was not fully appreciated until Joseph Jules François Félix Babiński (1857-1932) described it in 1896. In 1881, Ernst Strümpell (1853-1925) had described a continuous (tonic) extension of the big toe, a finding that years later the French neurologist Jean-Athanase Sicard (1872-1929) recognized as an equivalent of the "toe phenomenon", also indicating pyramidal tract dysfunction. Previously, this phenomenon had been mentioned in patients only passingly and without providing a picture of it. In 1887, the German neurologist Adolph Seeligmüller (1837-1912) mentioned the tonic extension of the big toe among the characteristic clinical features of spastic infantile hemiplegia-a condition first described by the Austrian physician Moritz Benedikt (1835-1920) in 1868. Seeligmüller incorrectly attributed the tonic extension of the big toe to spastic contracture of the extensor hallucis longus muscle. However, he put great emphasis on this sign and considered it worth being illustrated. Adolph Seeligmüller therefore provided the very first graphic illustration of the (tonic) "toe phenomenon" in the medical literature. Of note, the first photographic illustration of this sign made by Babiński appeared only in 1900, when it had already been adopted by neurologists all over the world.

A Zigzag Flap for Correcting a Nail Deformity Caused by Subungual Schwannoma

Subungual schwannoma is quite rare and often causes nail deformity and difficulty in wearing shoes. Complete tumor excision is the treatment of choice, and we advocate that restoring the nail appearance should be considered at the same time. We present the case of 43-year-old man with a big toe subungual schwannoma. We designed a zigzag incision method to excise the tumor and also corrected nail-bed deformity. The patient had a smooth recovery, and the nail plate regrew with a good appearance.

Application of IARTI and Ameliorating Principles to Improve Compliance and Completion of Treatment in General Dental Practice

Introduction: Many General Dental Practitioners run single handedly a mini-hospital. Practice administration, delivery of treatment and financial stewardship are all demanding with consequent induction of uncertainty, distress, and diminished performance, loss of satisfaction and unwelcome depression and anxiety. Aim: This contribution describes moderation of stresses in general dental practice by applying amelioration policies. Discussion: This advisory is targeted at all dentists involved in extensive dental therapy. The stress and anxiety of practice management is improved by applying newly established principles of practice, namely the Initial Assessment and Ranking of Treatment Index (IARTI) and What arrangements Have you made to meet your Oligations (WAHUM TOMYO), Immediate Payment Therapy (IPP) and Big Toe Philosophy (BTP). Conclusion: By applying these fundamental principles into general dental practice, much anxiety is relieved, challenges and problems are avoided or resolved and successful practice of dentistry is realized. A much higher frequency of failures will occur if these principles are not applied. Success does depend on applying IARTI and WAHUM TOMYO, IPP and BTP.

A new surgical strategy for reconstruction of claw nail deformity

Claw nail deformity is common in patients with fingertip injury. The optimal reconstruction remains unclear. We devised a unique strategy for reconstruction of claw nail deformity. We divided the approach into three parts: soft tissue reconstruction, bone graft and nail bed graft. In the soft-tissue reconstruction, a reverse digital arterial finger flap for the finger or an extended palmar flap advancement with V-Y plasty for the thumb was selected. A part of the distal phalanx of the second toe including periosteum was harvested as a bone graft. A nail bed graft from the big toe was performed. We reconstructed in 11 cases of claw nail deformity using our strategy. All cases achieved significant improvement with no recurrence of the claw nail deformity. Moreover, there was no donor site morbidity.

Assessment of Different Technique of Eliciting the Planter Reflex in Term Neonates

Background: Planter reflex is still an essential part of the neurological examination. The usual plantar reflex involved bending of the big toe or no response. There is a positive Babinski signal with corticospinal dysfunction, which involves big toe dorsal flexion and the accompanying fanning of the other toes. It’s one of the infant reflexes that disappers as the infant nervous system grows. The plantar reaction is primarily extensive in stable, term neonates. Many have researched this reflex's accuracy but very few studies have analyzed the various techniques of the planting reflex.&#x0D; Objective: To assess the five different technique of eliciting the plantar reflex in newborn babies.&#x0D; Materials and Methods: In this cross-sectional study, the eligible healthy newborn will be given the different methods for the elicitation of the plantar reflex i.e. Oppenheim sign, Gordon sign, Gonda’s sign, Chaddock sign, and Schaefer sign. During this procedure, we will record the baseline RR, HR, and SpO2 before, and after the procedure. Three pediatric residents of the different years will be selected for examining the newborn reflexes throughout the study period.&#x0D; Results: After completion of the study, we will come to know the negative likelihood ratio, negative predictive value, positive predictive, specificity, positive likelihood ratio, and sensitivity of the Oppenheim sign, Gordon sign, Gonda’s sign, Chaddock sign, and Schaefer sign.&#x0D; Conclusion: The study will probably give us information about the sensitivity and specificity of the Oppenheim sign, Gordon sign, Gonda’s sign, Chaddock sign, and Schaefer sign for the elicitation of the plantar reflex in the neonates.

The use of multi-site photoplethysmography (PPG) as a screening tool for coronary arterial disease and atherosclerosis

Objective. We present the design and validation of a non-invasive smart-phone based screening tool for atherosclerosis and coronary arterial disease (CAD), which is the leading cause of mortality worldwide. Approach. We designed a three-channel photoplethysmography (PPG) device that connects to a smart phone application for measuring pulse transit time (PTT) and pulse wave velocity (PWV) using PPG probes that are simultaneously clipped onto to the ear, index finger, and big toe, respectively. Validation was performed through a clinical study with 100 participants (age 20 to 77) at a research hospital in Nagpur, India. Study subjects were stratified by age and divided into three groups corresponding to the disease severity: CAD, hypertensive (‘Pre-CAD’), and Healthy. Main results. PWV measurements derived from the Ear-Toe probe measurements yielded the best performance, with median PWV values increasing monotonically as a function of disease severity and age, as follows: 14.2 m s−1 for the older-patient CAD group, 12.2 m s−1 for the younger-patient CAD group, 11.6 m s−1 for the older-patient Pre-CAD group, 10.2 m s−1 for the younger-patient Pre-CAD group, 9.7 m s−1 for the older healthy controls, and 8.4 m s−1 for the younger healthy controls. Using just two simple features, the PTT and patient height, we demonstrate a machine learning prediction model for CAD with a median accuracy of 0.83 (AUC). Significance. This work demonstrates the ability to predict atherosclerosis and CAD using a single simple physiological measurement with a multi-site PPG tool that is electrically powered by a mobile phone and does not require any electrocardiogram reference. Furthermore, this method only requires a single anthropometric measurement, which is the patient’s height.

The Effect of Transcutaneous Application of Gaseous CO2 on Diabetic Symmetrical Peripheral Neuropathy—A Double-Blind Randomized Clinical Trial

Aim: Diabetic symmetrical peripheral neuropathy is a common complication of diabetes mellitus. Patients treated with transcutaneous CO2 application for chronic wounds reported an improvement in peripheral sensations. This study aimed to evaluate the effect of transcutaneous application of gaseous CO2 on diabetic symmetrical peripheral neuropathy. Methods: A prospective randomized, double-blind study was performed at the University Medical Center Ljubljana between September 2019 and September 2020. Sixty consecutive patients with diabetes with a unilateral chronic wound were randomized into either a study group that received transcutaneous CO2 therapy or a control group that received placebo treatment with air. Results: Vibration, monofilament sensation, and temperature of the big toe improved significantly in the study group (p &lt; 0.001, for vibration sensation, monofilament test and temperature of the big toe), but not in the control group (p = ns for all evaluated outcomes). Conclusion: According to our results, a transcutaneous application of gaseous CO2 shows promising results in treating diabetic symmetrical peripheral neuropathy. Considering the major consequences of sensory loss leading to foot ulceration and possibly amputation, we believe this treatment approach deserves future attention and investigation as a treatment modality of diabetic symmetrical peripheral neuropathy.

Effects of running-induced fatigue on plantar pressure distribution in runners with different strike types.

Running induced-fatigue is an important factor in running related injuries. Runners with different strike types have different running mechanics and suffer from different injury patterns. Underlying mechanism of this difference is not well understood. The aim of this study was to examine the effects of running-induced fatigue on plantar pressure distribution in runners with different strike types. 30 rearfoot (age = 21.56 ± 2.28 years; height = 1.67 ± 0.08 m; mass = 61.43 ± 11.57 kg; BMI = 21.77 ± 2.9 kg∙m-2) and 30 forefoot (age = 19.73 ± 1.68 years; height = 1.71 ± 0.08 m; mass = 65.7 ± 13.45; BMI = 22.53 ± 3.39 kg∙m-2) strike male and female recreational runners were recruited to this study. Participants ran in 3.3 m/s barefoot along the plantar pressure measuring device (Footscan®, Rsscan International) before and after running-induced fatigue. Fatigue protocol was performed on a treadmill. Peak plantar pressure and peak plantar force (% body weight), contact time and medio-lateral force ratio were calculated while running. Repeated measures ANOVA test was used to investigate the effect of running-induced fatigue on plantar pressure variables (p ≤ 0.05). After running-induced fatigue, in the rearfoot strike group, increases in loading of medial and lateral portions of the heel, first metatarsal and big toe was observed, and in lesser toes and in the forefoot push off phase, the medio-lateral force ratio decreased. While, in the forefoot strike group first to third metatarsals loading increased and fifth metatarsal loading decreased after fatigue, and medio-lateral force ratio in the foot flat and forefoot push off phase increased. In both groups contact time increased after fatigue. Our data indicate that running-induced fatigue has different effects on plantar pressure distribution pattern in runners with different strike type. These different effects reflect different adaptation strategies in runners with different strike types, and could explain existence of different injury patterns in runners with different strike types.

How Important is the Big Toe?: Functional Anatomy of Hallux Flexion

Introduction Bipedalism is a unique characteristic of homo sapiens allowing us the ability to stand and walk. Many muscles required for bipedalism have been studied with a focus on large superficial leg muscles. However, the functional anatomy of deeper muscles with unique foot function have not been explored. The flexor hallucis longus (FHL) of the posterior leg and flexor hallucis brevis (FHB) of the foot function to flex the big toe, are required for optimal locomotion, and have an important role in upright balance and gait. Furthermore, the FHL has been used in tendon transfers such as Achilles reconstruction. The loss of function of the FHL, including impairments in balance and walking, have been noted but not comprehensively explored. Thus, the purpose of this study was to assess the relative activation of these muscles (FHL and FHB) in toe flexion and postural movements by using indwelling electromyography (EMG) recordings. Methods In six healthy participants to date (4 males and 2 females) ages 22-25 years, indwelling fine wires were inserted into each of the following muscles of the dominant limb: FHL, FHB, soleus and tibialis anterior (TA), to record intramuscular EMG activity. Ultrasound imaging was used to ensure optimal placement of the fine wires within each muscle. After two familiarization sessions, participants were placed in a custom-built toe dynamometer to record maximal voluntary contractions (MVC) of the big toe flexors (ankle, knee, and hip were maintained at 90 degrees). Additionally, plantar flexion and dorsiflexion MVCs were recorded using a custom ankle dynamometer. Participants were then asked to perform functional tasks including standing quietly for 60 seconds, sitting and standing from a seated position, bilateral calf-raises, standing on one foot, and swaying anteriorly to their limit of stability (before requiring a step to stop falling). Data were analyzed offline using Spike2 software. EMG (root mean squared – RMS) activity from the various tasks for each muscle was normalized to the maximal EMG obtained from the MVC tasks and expressed as a percentage (%). Results Average toe flexion strength was ~174N of force. When standing on two feet the FHL was ~1% active relative to its MVC while the FHB was ~6% active. During sitting and standing from the seated position the FHL had ~3% activity while the FHB had ~10%. FHL and FHB had ~36% and 39% activity, respectively, during the body weight calf raise. When standing on one foot the FHL was ~6% active while the FHB was ~30% active. The greatest activity for these muscles within the functional tasks was during the anterior forward tilt with ~50% and 75% for the FHL and FHB, respectively. While performing toe flexion MVCs there was ~65% co-activation in the TA and ~4% in the soleus. Conclusion These results illustrate the importance of the FHL and FHB during balance (forward sway) compared with their activity during plantar flexion and other tasks, although the FHB was more active in these than the FHL. The large degree of co-activation in the TA to optimize toe flexion illustrates an important synergy required for optimal toe and foot function. In addition to providing a better understanding of the functional anatomy and biomechanics of the foot, these results also indicate consideration of the functional relevance of these big toe muscles in clinical interventions.

Clinical analysis of Pseudomonas aeruginosa-positive and -negative green nail syndrome cases: A single center retrospective analysis.

Green nail syndrome (GNS) is a paronychial infection mainly due to Pseudomonas aeruginosa, characterized by green discoloration of the nail plate. Although the diagnosis of GNS may be straightforward with its distinctive color change, the clinical management of the disease can be sometimes confusing, especially when the bacterial culture result is inconsistent. There is, however, a paucity of comprehensive reviews regarding the treatment of GNS in the actual clinical setting. In this retrospective review of 34 patients, we found that GNS mostly occurs on a single digit (79.4%) on the big toe or thumb (85.3%) with frequent concurrent fungal infection (67.6%). The prevalence of inconsistent bacterial culture result with no evidence of P.aeruginosa was unexpectedly high (n=22, 64.7%), in which case coagulase-negative staphylococci were most frequently detected. The P.aeruginosa-negative group did not demonstrate any statistically significant differences compared with the P.aeruginosa-positive group, and it still responded well to the typical topical and/or oral fluoroquinolone treatment. GNS without the evidence of P.aeruginosa may be a more common occurrence than reported in the literature, and it can be managed successfully with the same strategy employed to treat P.aeruginosa-positive cases. It may result from the low detection rate of P.aeruginosa due to the limited sensitivity of the test, or inadequate amount and/or contamination of the sample, warranting close scrutiny by clinicians.

Treatment of Calcaneal Fracture by Calcaneal Plate

Background: Calcaneal fractures are not uncommon, accounting for 2% and 60.0% of all adult and tarsal fractures, respectively. Its treatment is still controversial. Aim of the work: To assess results and complications of calcaneal fractures treatment by fixation with calcaneal plate on clinical and radiological basis. Patients and Methods: A convenient sample of 20 patients, with calcaneal fractures and treated by calcaneal plate fixation were included. They were assessed in preoperative period in a systematic manner. Then, treated with a locking plate. Postoperatively, immediate X-rays, examination of the neurovascular status had been done. Anti-edematous, pain therapy, intravenous antibiotics and anticoagulation medication were administered. All patients had been followed up at 8, 16 weeks after operation and assessed for functional and anatomical state. RESULTS: According to the American Orthopedic Foot Ankle Society [AOFAS] Ankle-Hindfoot Score, the outcome was excellent [30.0%], good [40.0%], fair [20.0%] and poor [10.0%]. At the last follow‑up, Bohler’s angle was restored to normal [20°-40°] in 17 feet [85 %] while 3 feet [15 %] was less than normal. Wound infection was seen in [10%], each of varus heel deformity and flexion deformity of big toe was found in one patient [5.0%] and two case had reflex sympathetic dystrophy.Finally, there was no association between fracture type and subtalar arthritis. However, patients with subtalar arthritis had significantly lower AOFAS score when compared to patients with no subtalar arthritis [76.22±6.24 vs 87.0±6.05 respectively, p < 0.001]. Conclusion: Displaced calcaneal fractures treated surgically are associated with a relatively better functional outcome, provided that, Bohler's angle was restored to its normal or near normal values.

MINIMALLY INVASIVE TREATMENT OF INTRA-ARTICULAR CALCANEAL FRACTURES

Background: Calcaneal fractures have considerable debate of the appropriate methods of management and how to lessen potential complications. Objective: Evaluation of intra-articular calcaneal fractures that treated by minimally invasive methods. Patients and Methods: A prospective study has been conducted on twenty patients having intra-articular calcaneal fractures and were managed by minimally invasive methods of fixation at Al Azhar university hospitals, Cairo, Egypt, after that they have been followed up for 6 months. Results: According to the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hind foot Score. There was: excellent (5 feet (25%), good (11 feet (55%), fair (2 feet (10%) and poor (2 feet (10%). The average score was 83 with a range of 68 to 95. No patient in this series experienced any failure of hard-ware, or developed deep infections. Complications included: superficial pin tract infection, varus heel deformity, flexion deformity of the big toe, reflex sympathetic dystrophy, subtalar arthritis and painful heel. Conclusion: Management of calcaneal, intra-articular, fractures by minimally invasive techniques is a viable surgical alternate as it provides shorter time of surgery, nominal invasiveness, less serious wound problems, and no residual hardware (in case of pinning). Their drawbacks include technical issues and inadequate reduction fracture fragment.

Claw Toe: Anatomic Guide for Injection of Botulinum Toxin into Foot Muscles.

Poor response to injection of botulinum toxin (BoNT) into the flexor digitorum longus (FDL) muscle has been reported especially in patients with claw foot deformity. We previously advocated BoNT injection into the flexor hallucis longus (FHL) muscle in such patients. Here, we determined the functional and anatomical relationships between FHL and FDL. Toe flexion pattern was observed during electrical stimulation of FHL and FDL muscles in 31 post-stroke patients with claw-foot deformity treated with BoNT. The FHL and FDL tendon arrangement was also studied in five limbs of three cadavers. Electrical stimulation of the FHL muscle elicited big toe flexion in all 28 cases examined and second toe in 25, but the response was limited to the big toe in 3. FDL muscle stimulation in 29 patients elicited weak big toe flexion in 1 and flexion of four toes (2nd to 5th) in 16 patients. Cadaver studies showed division of the FHL tendon with branches fusing with the FDL tendon in all five limbs examined; none of the tendons was inserted only in the first toe. No branches of the FDL tendon merged with the FHL tendon. Our results showed coupling of FHL and FDL tendons in most subjects. Movements of the second and third toes are controlled by both the FDL and FHL muscles. The findings highlight the need for BoNT injection in both the FDL and FHL muscles for the treatment of claw-toe deformity.