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TOES
FLEXION OF METATARSOPHALANGEAL JOINTS OF TOES
Muscles Tested:
1. Lumbricals (4 small muscles):
- Origins:
a) From medial of first Flexor digitorum longus tendon.
b) From adjacent sides of first and second Flexor digitorum longus tendons.
c) From adjacent sides of second and third Flexor digitorum longus tendons.
d) From adjacent sides of third and fourth Flexor digitorum longus tendons.
- Insertions:
a) Medial side of proximal phalanx.
b) Dorsal expansion of the extensor digitorum longus tendon of the 2nd, 3rd, 4th and 5th
digits.
- Nerve Supply:
a) Lumbricals 1: Tibial Nerve: L4, L5, S1.
b) Lumbricals 2, 3, 4: Tibial Nerve: L4, L5, S1.
- Actions:
a) Flex the metatarso-phalangeal joints.
b) Extend the inter-phalangeal joints of the 2nd, 3rd, 4th and 5th digits.
2. Flexor Hallucis Brevis
- Origin:
a) Medial part of plantar surface of cuboid bone.
b) Adjacent part of lateral cuneiform bone.
c) From prolongation of tendon of tibialis posterior.
- Insertion: Medial and lateral sides of the base of the proximal phalanx of the great toe.
- Nerve Supply: Tibial Nerve: L4, L5, S1.
- Action: Flexes the metatarso-phalangeal joint of the great toe.
 Accessory Muscles
1. Dorsal and palmar interossei.
2. Flexor digitorum brevis.
3. Flexor digitorum longus.
4. Flexor digitorum brevis.
Range of Motion:
The range of motion of the metatarso-phalangeal joints flexion is of 25o to 35o.
This range of motion may be limited by:
a) Tension of the extensor muscles tendons.
b) Contact of soft parts.
Test Procedures:
1. Metatarsophalangeal joint flexor muscles of the four toes (Lumbricals Muscles):
- Patient Starting Position: Back lying, affected leg extended.
- Therapist Position and Grasps: Standing beside the table at the level of the patient feet.
The proximal hand grasps the patient’s forefoot to stabilize the metatarsal bones.
Resistance for testing “Grades 4 and 5” will be given by the distal hand beneath the
proximal row of phalanges.
- Command: “Push your lateral four toes down, Relax”.
Note: Individual testing of the toes is often desirable as they vary in strength.
2. Metatarso-phalangeal joint of Hallus (big toe flexor muscle):
Same procedures as for the other toes are used. Grades below “4 and 5” may be
difficult to determine as the joint motion is often limited and muscle and tendon cannot
be palpated. If range of motion appears normal, a grade of “Fair; 3” may be given for
completion of full motion. A “Poor; 2” grade is given for partial range.
Effect of weakness of the metatarso-phalangeal joints flexor muscles of the toes:
Weakness results in hyperextension of the metatarso-phalangeal joints caused by
the sole activity of the flexor digitorum longus muscles. The distal joints flex causing a
“hammer toe” position. Muscular support of the transverse arch is decreased.
Hammer toe
FLEXION OF METATARSOPHALANGEAL JOINTS OF TOES
Grade 3: Fair
Grade 4, 5: Grade good and Normal
FLEXION OF INTERPHALANGEAL JOINTS OF TOES
Muscle Tested:
1. Flexor Digitorum Longus:
- Origin:
a) Middle 3/5 of posterior surface of body of tibia.
b) From fascia covering the tibialis posterior.
- Insertion: Bases of distal phalanges of second through fifth digits.
- Nerve Supply: Tibial Nerve: L5, S1.
- Actions:
a) Flexes the inter-phalangeal and metatarso-phalangeal joints of the 2nd through 5th
digits.
b) Assists in plantar flexion of the ankle joint and inversion of the foot.
2. Flexor Digitorum Brevis:
- Origins:
a) Medial process of tuberosity of calcaneus.
b) Part of planar aponeurosis and adjacent inter-muscular septa.
- Insertion: Middle phalanx of 2nd through 5th digits.
- Nerve Supply: Tibial Nerve: L4, L5, S1.
- Action:
a) Flexes the proximal inter-phalangeal joints of the toes (second through fifth).
b) Assists in the flexion of the metatarso-phalangeal joints of the 2nd through 5th toes.
3. Flexor Hallucis Longus:
- Origins:
a) Posterior surface of distal 2/3 of tibia.
b) Interosseus membrane and adjacent inter-muscular septa and fascia.
- Insertion: Base of distal phalanx or great toe.
- Nerve Supply: Tibial Nerve: L5, S1, S2.
- Actions:
a) Flexes the inter-phalangeal joint of the great toe.
b) Assists in flexion of the metatarso-phalangeal joint.
c) Assist in plantar flexion of the ankle joint.
d) Assist in inversion of the foot.
Range of Motion:
The range of motion of the inter-phalangeal joints flexor muscles of the toes if of
50o to 90o. This range of motion may be limited by:
a) Tension of extensor muscle tendons of the toes.
b) Contact between soft parts of phalanges.
Test Procedures:
* Flexor Digitorum Longus:
- Patient Starting Position: Back lying or sitting with the legs extended on the table.
- Therapist Position and Grasps: Standing at the foot of the table. The proximal hand
grasps the middle row of phalanges of the lateral four toes. For testing of “Grades 4 and
5”, resistance is given by the distal hand beneath the distal or third row of phalanges of
the lateral four toes.
- Command: “Bend the end of your toes down, Relax”.
* Flexor Digitorum Brevis:
- Patient Starting Position: Same as for “Flexor Digitorum Longus”.
- Therapist Position and Grasps: Same as for “Flexor Digitorum Longus” but the
proximal hand stabilizes the proximal row of phalanges of the lateral four toes, plus the
resistance for “grades 4 and 5” is given by the therapist’s distal hand, beneath the middle
row of phalanges.
- Command: “Bend the middle part of your toes down, Relax).
* Flexor Hallucis Longus:
- Patient Starting Position: Same as for “Flexor Digitorum Longus and brevis” but the
proximal phalanx of hallus is stabilize by the proximal hand, plus the resistance is given
(for “Grade 4 and 5”) by the distal hand, beneath the second and distal phalanx of hallux.
Note: Joint motion may be limited. If range appears normal without resistance a “grade 3:
fair” may be given. A “grade poor: 2” is given for partial motion.
Effects of weakness of the inter-phalangeal flexor muscles of toes:
a) Weakness of the flexor digitorum longus muscle results in:
- A tendency toward hyper-extension of the distal inter-phalangeal joints of the four
lateral toes.
- It decreases the ability to invert the foot and plantar flex the ankle.
- In weight bearing, weakness permits a tendency toward a valgus position of the foot.
b) Weakness of the flexor digitorum brevis muscle results in:
- Decreased ability to flex the proximal inter-phalangeal joints of the four lateral toes.
- The muscular support of the longitudinal and transverse arches is diminished.
c) Weakness of the flexor hallucis longus muscle results in:
- Tendency toward hyperextension of inter-phalangeal joint.
- It decreases the strength of inversion of the foot and plantar flexion of the ankle.
- In weight bearing, it permits a tendency toward a valgus position of the foot.
EXTENSION OF METATARSOPHALANGEAL JOINTS OF TOES
AND INTERPHALANGEAL JOINT OF HALLUX

Muscle Tested:
1. Extensor digitorum longus:
- Origins:
a) Lateral condyle of tibia.
b) Proximal three fourths of anterior surface of fibula.
- Insertion: Extensor expansions into second and third phalanges of lateral 4 toes.
- Nerve Supply: Deep peroneal (L4, 5, S1).
2. Extensor digitorum brevis:
- Origin: Forepart of upper and lateral surfaces of calcaneus in front of grove for
peroneus brevis muscle.
- Insertion:
a) Medial division into dorsal surface of proximal phalanx of hallux at base (sometimes
called extensor hallucis brevis).
b) Three lateral divisions into tendons of extensor digitorum longus of second, third and
fourth toes.
Nerve Supply: Deep peroneal (L4, 5, S1).
3. Extensor hallucis longus:
- Origin: Middle 2 fourths of anterior surface of fibula.
- Insertion: Base of distal phalanx of hallux.
- Nerve Supply: Deep peroneal (L4, 5, S1).
Test Procedures:
* Extension of metatarso-phalangeal joints of lateral four toes (Extensor digitorum
longus and brevis):
From back lying, stabilize the metatarsal area. The patient extends lateral four
toes. Resistance is given on proximal phalanges of toes. For Trace and Zero grades,
tendons of extensor digitorum longus may be palpated on dorsal surface of metatarsals
and fibers of extensor digitorum brevis on lateral side of dorsum of foot anterior to
malleolus.
* Extension of metatarso-phalangeal joint of hallux (Medial division of extensor
digitorum brevis):
From back lying, stabilize first metatarsal. The patient extends metatarsophalangeal joint of hallux. Resistance is given over proximal phalanx.
* Extension of inter-phalangeal joint of hallux (Extensor hallucis longus):
From back lying, stabilize proximal phalanx of hallux. The patient extends distal
joint of hallux. Resistance is given on dorsal surface. For Trace and Zero grades, tendon
of extensor hallucis may be palpated on dorsal surface of 1st metatarso-phalangeal joint
and on a diagonal line across dorsum of foot to middle of anterior aspect of ankle.