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Extensor Hallucis Longus (EHL), Extensor Digitorum Longus (EDL), and Fibularis Tertius Audio

Integrated Functional Anatomy of the Extensor Hallucis Longus and Extensor Digitorum Longus (and Fibularis Tertius). Attachments, nerves, palpation, joint actions, arthrokinematics, fascia, triggerpoints, and behavior in postural dysfunction. Common exercises, foam rolling, and stretches for the toe extensors.

Extensor Hallucis Longus (EHL), Extensor Digitorum Longus (EDL), and Fibularis Tertius

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Exercises and techniques for the toe extensors may contribute to the development of lower body (leg) and total body strength. The toe extensor muscles are located on the anterior side of the lower leg, cross the ankle and toe joints, and play a critical role in motion of the foot and ankle. The extensor hallicus longus (EHL), extensor digitorum longus (EDL), and fibularis tertius muscles can also play a role in injury, including hallux rigidus, plantar fasciitis, Achille's tendonitis, and shin splints. To get the most out of your strength training for lower body muscles, and to aid in the prevention of injuries, you will need more than just foot stretches. Sports medicine professionals should have knowledge of the functional anatomy of the toe extensor muscles, its role in posture (behavior in postural dysfunction and movement impairment), role in functional movement, and a repertoire of toe extensor exercises and techniques.

Brookbush Institute’s most recommended techniques for the Toe Extensor Muscles (see videos below):

 Tibialis Anterior Isolated Activation (With Cueing for EHL and EDL Inhibition)

Dissection of the toe extensor muscles of the foot

 Course Description: Toe Extensor

Extensor - early 18th century: from late Latin, from 

Hallucis - mid 19th century: modern Latin alteration of medieval Latin 

Attachment of the fibularis tertius

The tendons of the EHL, EDL, fibularis muscles, and tibialis anterior

Attachment & Innervations: Extensor Hallucis Longus and Extensor Digitorum Longus

Image of the fibularis tertius muscle of the foot

An Odd Ball: Fibularis Tertius

Where are the Toe Extensor Muscles Located

The fibularis brevis, fibularis longus, and extensor muscles

Palpating the EHL, EDL, and Fibularis Tertius

Introduction to the Toe Extensors

Extension of the first metatarsophalangeal and interphalangeal joints.

Dorsiflexion of the ankle, as well as, a weak invertor of the foot and ankle (8,11, 15)

Extension of the 2nd through 5th metatarsophalangeal and interphalangeal joints.

Dorsiflexion of the ankle, as well as, eversion/pronation of the foot and ankle (8, 11)

A cadaver dissection on the front of the foot

By Anatomist90 - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=25130279

Stabilizes the ankle (tibiotalar), transverse tarsal, tarsometatarsal, metatarsophalangeal and interphalangeal joints (19).

The EHL and EDL eccentrically decelerate flexion of the metatarsophalangeal and interphalangeal joints, as well as, eccentrically decelerate plantar flexion of the ankle. These muscles are active from heel strike to foot flat during gait, likely as synergists to the 

The EHL will eccentrically decelerate eversion and foot pronation, while the EDL will eccentrically decelerate inversion and foot supination.

The fibularis tertius will eccentrically decelerate inversion, supination, and plantar flexion.

The EHL and EDL (and fibularis tertius) work synergistically with the 

The EHL may also work synergistically with the t

 and posterior tibialis to invert, or eccentrically decelerate pronation during gait (8).

The EDL (and fibularis tertius) may work synergistically as an evertor of the ankle and pronator of the foot along with the Fibularis (Peroneal) muscles.

A more obvious synergistic relationship exists between the EHL, EDL, extensor hallucis brevis (EHB), and extensor digitorum brevis (EDB) in extending the metatarsophalangeal joints of all toes except toe 5.

Cross-sectional view showing the muscles of the fibula and tibia

Henry Gray (1918) Anatomy of the Human Body (See "Book" section below)
Bartleby.com: Gray's Anatomy, Plate 440

The attachment of the extensor digitorum longus on the foot

Arthrokinematics

Toe Extensor Actions

My Fascial Hypothesis: Large fascial sheaths not only play a role in the transmission of mechanical force but may also play a role in dictating the function of muscular synergies. This is likely caused by reducing or increasing tone of invested musculature via reflex arcs formed between mechanoreceptors embedded in the connective tissue and the attached musculature. In this way my view of fascia differs slightly from noted expert on the subject Tom Myers. I think of these large fascial sheaths (specifically the thoracolumbar fascia, iliotibial band, and abdominal fascial sheath) as nature's "motherboard." A place for mechanical information to be communicated to the nervous system for more efficient recruitment of the muscular system. Despite having a slightly different philosophy it does not change the fact that fascia plays an important communicative role in the human body and we have Tom Myers to thank for his work.

Image of the fascial system of the body connecting muscles

Fascial Integration of the EHL, EDL, and Fibularis Tertius

I find it interesting that the EDL, an evertor/pronator of the foot/ankle shares an intermuscular septum with the fibularis longus, the primary evertors of the foot/ankle - while the EHL, an invertor/supinator of the foot/ankle shares the interosseous membrane with the posterior tibialis, a strong invertor/supinator of the foot ankle.

Tom Myers describes a "branch" of the "superficial front line" that continues from the iliotibial band to the anterior tibiofibular ligament to the anterior crural compartment (6), however, I think more specificity can be drawn from this line based on both anatomical relationships and common motor behavior in postural dysfunction. Commonly the 

 is most commonly under-active. The EHL, although commonly over-active, originates too distal to be anatomically linked. This leaves a potential fascial synergy between the TFL and EDL via the ITB. They have the highest likelihood of being fascially linked by the iliotibial band (ITB) via fascial slips of the ITB that invest in the tibial tuberosity and those that continue on to invest in the proximal anterior tibiofibular ligament - a.k.a. the origin of the EDL.

The fibularis tertius would share a fascial connection with the fibularis brevis via the tendinous insertion into the 5th metatarsal head. It may be worth exploring this relationship in those individuals who excessively pronate, and/or complain of pain in the lateral foot and 5th metatarsal head. Often pain emanating from this region is related to hypermobility of this joint and the release of fibularis muscles may reduce excessive motion.

A cadaver dissection of the EDL, EHL, and fibularis tertius

Notice the tendons of the EDL on the lateral aspect of the foot, contributing to eversion, and the fibularis tertius as a separate tendon extending from the same muscle mass - http://www.rvuanatomy.com/uploads/1/3/4/5/13457421/ac1a-animated.gif

Fascial Integration

These muscles fall into the weird category of long, but over-active. This is a relationship we usually note in 

, and that is precisely the role that the EDL and EHL play (The fibularis tertius would play a similar role).

 the EDL and EHL play no significant role.

Lumbo Pelvic Hip Complex Dysfunction (LPHCD)

, the EDL and EHL play no significant role.

Rule #5: Every inhibited prime mover will result in synergistic dominance of the ancillary movers for that joint action.

The EHL and EDL become synergistically dominant for an inhibited 

 That is to say that the overactive gastrocnemius/soleus complex results in altered reciprocal inhibition of the tibialis anterior and a relative increase in EHL and EDL activity to compensate. This increase in activity occurs despite the implication that a loss in dorsiflexion implies an increase in length of the EHL and EDL. This may also lead to arthrokinematic dyskinesis, as over-activity may lead to a superior glide of the metatarsophalangeal and interphalangeal joints. The change in arthrokinematics may limit flexion 

 of the toes. Particularly problematic is the loss of toe extension that may result in a compensation pattern that includes pronation (eversion) from heel-off to toe-off during the stance phase of gait, and pronation during any activity that requires an individual to move on the "balls" or their feet (baseball swing, golf, changing direction, jumping, etc.).

. This implies these muscles should be released, however, self-administered techniques have proven relatively ineffective. The major obstruction being the patient/client's ability to differentiate between the 

 and the EDL/EHL. It can be very frustrating to add "EHL/EDL Self-administered Release with Tennis Ball" to a home exercise program, only to find that the client/patient spent the week between appointments releasing their tibialis anterior resulting in no carry-over from session-to-session when re-assessing active dorsiflexion…. aaaaaaaahhhhhhhhh!

Where you will see the EHL and EDL mentioned during exercise programs in the 

Brookbush Institute of Human Movement Science

 content is in the cue "toes down" during 

. This cue is used to reciprocally inhibit the EHL and EDL to reduce the chance that these muscles will continue to be synergistically dominant during exercises aimed at improving recruitment, neuromuscular control, and conditioning of the tibialis anterior.

Peroneal nerve entrapment (at fibular head)

Achilles tendonitis (long term over-activity = rupture)

Signs of Altered Length/Tension and Tone:

Toes extend - Long/Over-active (This sign is not normally listed on the assessment template, but is worth noting)

Toe Extension < 70° (0° of extension of the IP's)

Toe Flexion < 90° (the distal phalanx forms a roughly 90° angle with the plane of the tarsal bones)

Palpation results in tenderness (trigger points or tender points) and may result in radiating symptoms along with the muscle and its tendons. Based on the theoretical model of trigger point development (8) it would seem likely that “trigger points” are dysfunctional at the “motor point” of a muscle. You may find the motor point map created by this research study helpful in directing patients/clients to the appropriate location – 

Common trigger points of the extensor muscles

Postural Dysfunction and the Toe Extensors

Equipment-Free, Variation: Standing Tibialis Anterior Activation

 Tibialis Anterior Activation on a Table (reinforcing Heel Strike Mechanics)

Heel Walks

Exercises and Techniques for the EHL, EDL, and Fibularis Tertius

Phillip Page, Clare Frank, Robert Lardner, 

Assessment and Treatment of Muscle Imbalance: The Janda Approach 

NASM Essentials of Corrective Exercise Training

NASM Essentials of Personal Training: 4th Edition

Diagnoses and Treatment of Movement Impairment Syndromes,

David G. Simons, Janet Travell, Lois S. Simons, 

Travell & Simmons’ Myofascial Pain and Dysfunction, The Trigger Point Manual, Volume 1. Upper Half of Body: Second Edition

Joint Structure and Function: A Comprehensive Analysis: Fifth Edition

Florence Peterson Kendall, Elizabeth Kendall McCreary, Patricia Geise Provance, Mary McIntyre Rodgers, William Anthony Romani

Fitness or Fiction: The Truth About Diet and Exercise

Carolyn Richardson, Paul Hodges, Julie Hides. Therapeutic Exercise for Lumbo Pelvic Stabilization – A Motor Control Approach for the Treatment and Prevention of Low Back Pain: 2nd Edition (c) Elsevier Limited, 2004

Bayer T, Kolodziejski N, Flueckiger G. (2014). The extensor hallucis capsularis tendon – a prospective study of its occurrence and function. Foot and Ankle Surgery. 20: 192-194.

Lui TH. (2011). Extensor tendoscopy of the ankle. 

Ma H, Zhao J, Yu B, Ye B. (2014). A gross anatomic study of distal tibia and fibula for single-incision approach. 

Journal of Orthopaedic Surgery and Research

Yildiz S, Yalcin B. (2012). A unique variation of the peroneus tertius muscle. 

Cimadoro G, Paizis C, Alberti G, Babault N. (2013). Effects of different unstable supports on EMG activity and balance. 

Bibliography

Questions, comments, and criticisms are welcome and encouraged

Extensor Hallucis Longus (EHL), Extensor Digitorum Longus (EDL), and Fibularis Tertius

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