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Anatomical Localization of Motor Points of The Original Article Ann Rehabil Med 2017;41(4):589-594 pISSN: 2234-0645 • eISSN: 2234-0653 https://doi.org/10.5535/arm.2017.41.4.589 Annals of Rehabilitation Medicine Anatomical Localization of Motor Points of the Abductor Hallucis Muscle: A Cadaveric Study Asayeon Choi, MD1, Na Yeon Kwon, MD1, Kyeongwon Kim, MD1, Youngkook Kim, MD2, Jeehae Oh, MD3, Hyun Mi Oh, MD1, Joo Hyun Park, MD, PhD1 1Department of Rehabilitation Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul; 2Rhin Hospital, Yongin; 3Department of Rehabilitation Medicine, Eulji General Hospital, Seoul, Korea Objective To identify the anatomical motor points of the abductor hallucis muscle in cadavers. Methods Motor nerve branches to the abductor hallucis muscles were examined in eight Korean cadaver feet. The motor point was defined as the site where the intramuscular nerve penetrates the muscle belly. The reference line connects the metatarsal base of the hallux (H) to the medial tubercle of the calcaneus (C). The x coordinate was the horizontal distance from the motor point to the point where the perpendicular line from the navicular tuberosity crossed the reference line. The y coordinate was the perpendicular distance from the motor point to the navicular tuberosity. Results Most of the medial plantar nerves to the abductor hallucis muscles divide into multiple branches before entering the muscles. One, two, and three motor branches were observed in 37.5%, 37.5%, and 25% of the feet, respectively. The ratios of the main motor point from the H with respect to the H–C line were: main motor point, 68.79%±5.69%; second motor point, 73.45%±3.25%. The mean x coordinate value from the main motor point was 0.65±0.49 cm. The mean value of the y coordinate was 1.43±0.35 cm. All of the motor points of the abductor hallucis were consistently found inferior and posterior to the navicular tuberosity. Conclusion This study identified accurate locations of anatomical motor points of the abductor hallucis muscle by means of cadaveric dissection, which can be helpful for electrophysiological studies in order to correctly diagnose the various neuropathies associated with tibial nerve components. Keywords Cadaver, Tibial nerve, Abductor hallucis, Motor point, Electromyography Received October 12, 2016; Accepted December 21, 2016 Corresponding author: Joo Hyun Park Department of Rehabilitation Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho- gu, Seoul 06591, Korea. Tel: +82-2-2258-2822, Fax: +82-2-2258-2825, E-mail: [email protected] ORCID: Asayeon Choi (http://orcid.org/0000-0002-4666-5185); Na Yeon Kwon (http://orcid.org/0000-0001-7694-361X); Kyeongwon Kim (http://orcid. org/0000-0001-6185-0058); Youngkook Kim (http://orcid.org/0000-0003-3964-026X); Jeehae Oh (http://orcid.org/0000-0001-6933-8788); Hyun Mi Oh (http://orcid.org/0000-0001-5493-4691); Joo Hyun Park (http://orcid.org/0000-0001-9257-8704). This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright © 2017 by Korean Academy of Rehabilitation Medicine Asayeon Choi, et al. INTRODUCTION medial plantar nerve were identified and traced to their penetration point into the abductor hallucis muscle. The Electrodiagnostic studies are powerful tools to use most distal point, where the motor branch entered the with patients who have neuromuscular disorders. Since muscle belly, was designated as the anatomical motor electrophysiological studies are sensitive tests that are point in this study [7]. susceptible to subtle changes, imprecisely recorded For each foot, three bony landmarks were defined as compound muscle action potential (CMAP) can lead to the reference points: the metatarsal base of the hallux incorrect diagnoses. The tibial motor-nerve conduction (H), the medial tubercle of the calcaneus (C), and the na- to the abductor hallucis muscle is commonly studied in vicular tuberosity (N). The reference line was defined as electrophysiology. However, there is still a lack of con- the line connecting the metatarsal base of the hallux and sensus among the textbooks on where an active electrode the medial tubercle of the calcaneus (H–C line). The x co- (E1) should be placed on the navicular tuberosity in tibial ordinate was defined as the horizontal distance from the motor conduction studies. All the authors recommended motor point to the perpendicular line from the navicular placing E1 below the navicular tuberosity, but some pro- tuberosity. The y coordinate was defined as the perpen- posed placing it anterior to the navicular tuberosity [1,2], dicular distance from the motor point to the navicular and others suggested placing it posterior to the navicular tuberosity (Fig. 1). The x and y coordinates of the motor tuberosity [3,4]. This disagreement might have confused electromyographers. False motor points can be produced when the record- ing electrode is placed over sites other than the end-plate zone and are characterized by marked delayed onset la- tencies due to flattening of the initial segment and phase transition in motor-nerve conduction studies [5]. Reduc- ing false motor points is important for improving the ac- curacy of motor-nerve conduction studies, because false motor points can lead to misdiagnosis of various periph- A B eral neuropathies defined by the prolongation of distal motor latencies [6]. A few studies have located the motor point of the abductor hallucis muscle, although there has been no consensus about E1 location. This study was conducted to identify the location of the anatomical mo- tor points of the abductor hallucis muscles in terms of 1 Y coordinate N the anatomical landmarks. 2 3 Abductor hallucis H C MATERIALS AND METHODS Motor point X coordinate Eight feet from four fresh Korean adult cadavers were Distance (D') C dissected (3 men and 1 woman, ranging in age from 52 to 79 years). There were no deformed or injured feet, and all Fig. 1. Motor branches of the medial plantar nerve to the limbs were positioned with neutral ankle alignment. The abductor hallucis were dissected. (A) Multiple branches skin and subcutaneous tissues were dissected to expose for the abductor hallucis muscle (arrow). (B) Enlarged the medial plantar nerve and abductor hallucis muscle image of multiple branches to the abductor hallucis mus- cle (arrow). (C) Schematic of the anatomical landmarks from the tarsal tunnel to the first metatarsal base along and nerves (H, metatarsal base of the hallux; C, medial the medial aspect of the foot. We carefully removed the tubercle of the calcaneus; N, navicular tuberosity; 1, pos- subcutaneous tissues and held onto the nerves with just terior tibial nerve; 2, medial plantar nerve; 3, branch for enough tension to avoid injury. Then the branches of the the abductor hallucis). 590 www.e-arm.org Motor Points of Abductor Hallucis Muscle points were measured, and the ratio of the coordinates to The mean length of the H–C line was 15.5±1.00 cm the length of the H–C line was calculated. The number of (mean±standard deviation). The main motor point was motor points (the number of branches to the muscle) was located at 10.63±0.74 cm, with a ratio of 68.79%±5.69%, also counted. from the H point of the H–C line. The second mo- tor point was located at 11.4±0.43 cm, with a ratio of RESULTS 73.45%±3.25%, from the H point of the H–C line. The mean x coordinate from the main motor point was The intramuscular penetrations of the medial plantar 0.65±0.49 cm (4.14%±2.25%). The mean y coordinate nerves were divided into multiple branches before they from the main motor point was 1.43±0.35 cm. All the entered the abductor hallucis muscles in 62.5% (5 of 8) motor points of the abductor hallucis were consistently of the feet (Fig. 2). Two motor branches were observed found inferior and posterior to the navicular tuberosity in 37.5% (3 of 8) of the feet and three motor branches (Fig. 3). in 25.0% (2 of 8) of the feet. The thickest branch of each medial plantar nerve was designated as the main motor DISCUSSION point and the others as the minor motor points. One ca- daver showed multiple motor points on both feet, while This study was designed to identify the anatomical three cadavers showed multiple motor points on only motor points in the abductor hallucis muscle. We found one foot. multiple motor points in the abductor hallucis muscle Fig. 2. Anatomic dissection showed the medial plantar nerve branch entering the abductor hallucis muscle. The ana- tomical motor point was defined as the most distal point at which the motor branch entered the muscle (arrow). www.e-arm.org 591 Asayeon Choi, et al. During this study, we identified the exact anatomical locations of the motor points in the abductor hallucis N muscles by using landmarks, such as the navicular tuber- 0.5 1.0 1.5 0.5 osity. Interestingly, all the anatomical motor points of the 1.0 1.5 abductor hallucis were consistently found to be inferior 2.0 and posterior to the navicular tuberosity. As mentioned earlier, many textbooks have suggested various loca- tions for E1 on the abductor halluces. Dumitru et al. [1] N 0.51.0 1.5 0.5 1.0 and Liveson and Ma [2] proposed placing it anterior and 1.5 2.0 inferior to the navicular tuberosity, while Lee et al.
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