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Concept: Toe


People have long speculated whether the evolution of bipedalism in early hominins triggered tool use (by freeing their hands) or whether the necessity of making and using tools encouraged the shift to upright gait. Either way, it is commonly thought that one led to the other. In this study, we sought to shed new light on the origins of manual dexterity and bipedalism by mapping the neural representations in the brain of the fingers and toes of living people and monkeys. Contrary to the ‘hand-in-glove’ notion outlined above, our results suggest that adaptations underlying tool use evolved independently of those required for human bipedality. In both humans and monkeys, we found that each finger was represented separately in the primary sensorimotor cortex just as they are physically separated in the hand. This reflects the ability to use each digit independently, as required for the complex manipulation involved in tool use. The neural mapping of the subjects' toes differed, however. In the monkeys, the somatotopic representation of the toes was fused, showing that the digits function predominantly as a unit in general grasping. Humans, by contrast, had an independent neurological representation of the big toe (hallux), suggesting association with bipedal locomotion. These observations suggest that the brain circuits for the hand had advanced beyond simple grasping, whereas our primate ancestors were still general arboreal quadrupeds. This early adaptation laid the foundation for the evolution of manual dexterity, which was preserved and enhanced in hominins. In hominins, a separate adaptation, involving the neural separation of the big toe, apparently occurred with bipedality. This accords with the known fossil evidence, including the recently reported hominin fossils which have been dated to 4.4 million years ago.

Concepts: Finger, Hand, Locomotion, Toe, Dinosaur, Hominina, Hominid, Bipedalism


The tips of mammalian digits can regenerate after amputation, like those of amphibians. It is unknown why this capacity is limited to the area associated with the nail. Here we show that nail stem cells (NSCs) reside in the proximal nail matrix and that the mechanisms governing NSC differentiation are coupled directly with their ability to orchestrate digit regeneration. Early nail progenitors undergo Wnt-dependent differentiation into the nail. After amputation, this Wnt activation is required for nail regeneration and also for attracting nerves that promote mesenchymal blastema growth, leading to the regeneration of the digit. Amputations proximal to the Wnt-active nail progenitors result in failure to regenerate the nail or digit. Nevertheless, β-catenin stabilization in the NSC region induced their regeneration. These results establish a link between NSC differentiation and digit regeneration, and suggest that NSCs may have the potential to contribute to the development of novel treatments for amputees.

Concepts: Developmental biology, Stem cell, Regeneration, Amputation, Gangrene, Toe


A composite graft for reattachment of an amputated fingertip is a very controversial and challenging procedure. An osteocutaneous composite graft is rarely conducted and has a low success rate following fingertip amputation. A 21-year-old male patient was referred to our emergency clinic with dorsal oblique amputation of the middle, ring and small fingers of the left hand through the distal interphalangeal joint and middle phalanx. The amputated parts of the middle and ring fingers were reattached with osteocutaneous composite grafts. The amputated part of the small finger was revascularised to the ulnar palmar digital artery of the small finger. The composite grafts of the middle and ring fingers and the revascularised small finger survived completely. We suggest that careful patient selection will allow an osteocutaneous composite graft to become an acceptable method for the treatment of fingertip amputation. A large-scale study of osteocutaneous graft of amputated fingertips is required to improve the survival rate.

Concepts: Bone, Surgery, Finger, Ring finger, Hand, Toe, Phalanx bones, Finger protocol


We aimed to investigate the epidemiological determinants, clinical features, and genetic pattern of FOP in our country by evaluating the entire population of patients identified according to a combination of methods. To achieve this, 24 individuals were confirmed as FOP cases, 17 of whom were alive at the end of 2011 (point prevalence=0.36 × 10(-6)). The gender distribution (male/female ratio=13/11) and the concurrent range of ages (from 4 to 53 years; mean ± SD: 30.2 ± 13.8) are in agreement with similar reports. Twenty-one (87.5%) had characteristic congenital malformations of the big toe, and short thumbs were found in 65.2% of cases. In addition, other skeletal malformations such us fusion of the posterior elements of the cervical spine (89.0%), knee osteochondromas (71%), scoliosis (54.5%), and short and broad femoral neck (52.6%) were observed. All had developed mature ossicles of heterotopic bone in typical anatomic and temporal patterns, ranging in number from 1 to 17 (9.5 ± 3.9). Age at appearance of first ossifying lesion varied from 3 months to 15 years. Mean age at diagnosis was 7.3 ± 5.1 years and the average delay in reaching the correct diagnosis after the onset of heterotopic ossification was 2.7 years (range=0-12 years). Biopsy of the pre-osseous lesions was performed in 11 of 20 (55.0%), providing no useful information for the diagnosis of FOP. Seven of 18 (38.9%) reported some hearing loss, and 5 (27.8%) experienced diffuse thinning of the hair or were bald. No patient had relatives with a typical FOP clinical picture. Fourteen of the 16 cases which were genetically investigated displayed the single heterozygous mutation c.617G>A in exon 4 of the ACVR1 gene. One of the two patients who did not present with the canonical ACVR1 mutation showed a heterozygous mutation c.774G>C in exon 5 leading to the substitution of Arginine 258 with a serine. The other patient had a heterozygous c.774G>T substitution in exon 5 leading to the same amino acid change (p.Arg258Ser). These two patients had only nonspecific abnormalities of the great toe, lacked the typical anatomic and developmental pattern of heterotopic ossification, and shared a trend toward uncommon clinical features. These results provide new insight on the epidemiological and clinical traits of FOP, reinforcing the notion of its worldwide homogeneity. The molecular characterization of ACVR1 sequence variation will contribute to the understanding of the genetic profile of this devastating disease in different geographical areas.

Concepts: DNA, Genetics, Amino acid, Hallux, Fibrodysplasia ossificans progressiva, Congenital disorders, Toe, Heterotopic ossification


For crushing injury of the hand that involves 4-digit amputations sparing the thumb, lengthening of amputated stump and covering the defect are important for hand function. From March 2007 to September 2011, the authors performed “reverse on-top plasty” in 5 patients. The fifth metacarpal bone was disarticulated, turned over 180 degrees, and embedded in reverse direction so that the metacarpal base becomes the tip of new finger. Soft tissue defects were covered using anterolateral thigh free flap or reverse radial forearm flap.The mean follow-up period was 21.2 months, and major complications such as bony resorption did not occur. Static 2-point discrimination showed fair recovery of fingertip sense. Key pinch power was 76.4% of the uninjured hand. In conclusion, reverse on-top plasty is good in gaining more sufficient finger length and durability using cartilaginous portion of the fifth metacarpal bone than the previously used on-top plasty.

Concepts: Skeletal system, Injury, Finger, Hand, Metacarpus, Toe, Little finger, Boxer's fracture


A high proportion of flexor digitorum longus attachment is found at the posteromedial border of the tibia, which is the most common location of medial tibial stress syndrome (MTSS). Therefore, plantar flexion strength of the lesser toes could be related to MTSS; however, the relationship between MTSS and muscle strength of the hallux and lesser toes is not yet evaluated due to the lack of quantitative methods. This study investigated the muscle strength characteristics in runners with a history of MTSS by using a newly developed device to measure the muscle strength of the hallux, lesser toes, and ankle.

Concepts: Psychology, Foot, Hallux, Knee, Social sciences, Toe, Morton's toe, Musculoskeletal system


Quantifying the strength of the intrinsic foot muscles has been a challenge for clinicians and researchers. The reliable measurement of this strength is important in order to assess weakness, which may contribute to a variety of functional issues in the foot and lower leg, including plantar fasciitis and hallux valgus. This study reports 3 novel methods for measuring foot strength - doming (previously unmeasured), hallux flexion, and flexion of the lesser toes.

Concepts: Foot, Hallux, Muscle, Psychometrics, Muscular system, Thigh, Toe, Plantar fasciitis


Study Design Controlled laboratory study. Background Plantar heel pain is one of the most common foot and ankle conditions seen in clinical practice and many individuals continue to have persisting or recurrent pain after treatment. Impaired foot plantar flexor muscle performance is a factor that may contribute to limited treatment success, but reliable methods to identify impairments in individuals with plantar heel pain are needed. In addition, foot orthoses are commonly used to treat this condition, but the implications of orthosis use on muscle performance have not been assessed. Objectives To assess ankle plantar flexor and toe flexor muscle performance of individuals with plantar heel pain using clinically-feasible measures and to examine the relationship between muscle performance and duration of foot orthosis use. Methods The rocker board plantar flexion test (RBPFT) and modified paper grip test for the great toe (mPGTGT) and lesser toes (mPGTLT) were used to assess foot plantar flexor muscle performance in 27 individuals with plantar heel pain and compared to 27 individuals without foot pain that were matched according to age, sex, and body mass. Pain ratings were obtained before and during testing, and self-reported duration of foot orthosis use was recorded. Results Compared to the control group, individuals with plantar heel pain demonstrated lower performance in the RBPFT (P = 0.001), the mPGTGT (P = 0.037) and the mPGTLT (P = 0.022). Longer duration of foot orthosis use was moderately correlated to lower performance on the RBPFT (r = -0.52, P = 0.02), the mPGTGT (r = -0.54, P = 0.01), and the mPGTLT (r = -0.43, P = 0.03). Conclusion Ankle plantar flexor and toe flexor muscle performance was impaired in individuals with plantar heel pain and associated with longer duration of self-reported foot orthosis use. J Orthop Sports Phys Ther, Epub 3 Jul 2016. doi:10.2519/jospt.2016.6482.

Concepts: Foot, Hallux, Assessment, Flexion, Orthotics, Toe, Ankle-foot orthosis, Podiatry


Approximately 2 million people have had limb amputations in the United States due to disease or injury, with more than 185,000 new amputations every year. The ability to promote epimorphic regeneration, or the regrowth of a biologically based digit or limb, would radically change the prognosis for amputees. This ambitious goal includes the regrowth of a large number of tissues that need to be properly assembled and patterned to create a fully functional structure. We have yet to even identify, let alone address, all the obstacles along the extended progression that limit epimorphic regeneration in humans. This review aims to present introductory fundamentals in epimorphic regeneration to facilitate design and conduct of research from a tissue engineering and regenerative medicine perspective. We describe the clinical scenario of human digit healing, featuring published reports of regenerative potential. We then broadly delineate the processes of epimorphic regeneration in non-mammalian systems and describe a few mammalian regeneration models. We give particular focus to the murine digit tip, which allows for comparative studies of regeneration-competent and regeneration-incompetent outcomes in the same animal. Finally, we describe a few forward-thinking opportunities for promoting epimorphic regeneration in humans.

Concepts: Medicine, Human, Species, United States, Mammal, Amputation, Toe, Names of large numbers


Although recent studies have reported that the forefoot bones are longer in sprinters than in non-sprinters, these reports included a relatively small number of subjects. Moreover, while computer simulation suggested that longer forefoot bones may contribute to higher sprint performance by enhancing plantar flexor moment during sprinting, the correlation between forefoot bone length and sprint performance in humans has not been confirmed in observational studies. Thus, using a relatively large sample, we compared the length of the forefoot bones between sprinters and non-sprinters. We also examined the relationship between forefoot bone length and performance in sprinters. The length of forefoot bones of the big and second toes in 36 well-trained male sprinters and 36 male non-sprinters were measured using magnetic resonance imaging. The length of forefoot bones in the big and second toes was significantly longer in sprinters than in non-sprinters. After dividing the sprinters into faster and slower groups according to their personal best time in the 100-m sprint, it was found that the forefoot bone length of the second toe, but not that of the big toe, was significantly longer in faster group than in slower group. Furthermore, the forefoot bone length of the second toe correlated significantly with the personal best time in the 100-m sprint. The present study supported evidence that the forefoot bones are longer in sprinters than in non-sprinters. In addition, this is the first study to show that longer forefoot bones may be advantageous for achieving superior sprint performance in humans. This article is protected by copyright. All rights reserved.

Concepts: Foot, Hallux, Nuclear magnetic resonance, Magnetic resonance imaging, All rights reserved, Copyright, Toe, Morton's toe