Innervation.—A branch of the lateral division of the tibial nerve passes deep to the posterior head of M. flexor perforans et perforatus digiti II and enters the posteromedial edge of M. flexor perforans et perforatus digiti III.
Individual Variation.—In both legs of one specimen, the part arising from the femorofibular fascia appears as a distinct but short accessory head. There is no significant individual variation in T. cupido or P. p. jamesi.
M. Flexor Perforatus Digiti IV, [Figs. 14], [16]
T. pallidicinctus
General Description and Relations.—On posterolateral aspect of shank deep to M. gastrocnemius pars externa; bounded medially by medial head of M. flexor perforatus digiti III, anterolaterally by posterior head of M. flexor perforans et perforatus digiti II, and anteriorly by M. flexor digitorum longus; divided into three heads—medial (largest), lateral, and anterolateral (smallest); tendon of insertion of M. extensor iliofibularis passing between medial and lateral heads; proximal and anteroproximal parts of lateral head an extremely thin, flat tendon; anterodistal part of tendon fused to lateral surface of fleshy part of underlying lateral head of M. flexor perforatus digiti II; proximal part of tendon fused indistinguishably to tendinous part of underlying lateral head of M. flexor perforatus digiti II; fleshy part of anterolateral head anterodistal to lateral head; proximal part of former a long slender tendon anterior to lateral head; anterior surface of anterolateral head (both fleshy and tendinous parts) fused to tendon of anterolateral head of M. flexor perforatus digiti III; deep surface fused to underlying anterolateral head (fleshy) of M. flexor perforatus digiti II; common tendon of anterolateral heads of M. flexor perforatus digiti IV and M. flexor perforatus digiti III passing medial to tendon of insertion of M. extensor iliofibularis, to peroneal nerve, and to fibular arm of guide loop for M. extensor iliofibularis; tendon of M. ambiens inserting on anterolateral surface of this common tendon; medial head entirely fleshy; medial surface fused to medial head of M. flexor perforatus digiti III; deep surface fused to medial edge of underlying medial head of M. flexor perforatus digiti II; medial and lateral heads joined, forming bipinnate belly (pinnate structure most evident on deep surface); anterolateral head joined to distolateral part of belly.
Origin.—The medial head attaches fleshily to the proximal part of the popliteal area proximal (adjacent) to the origin of M. flexor hallucis longus and distolateral to the distal end of the origin of M. femorocruralis; the attachment extends laterally onto the posterolateral surface of the femur proximal (adjacent) to the common attachment of M. gastrocnemius pars externa and the distal arm of the guide loop for M. extensor iliofibularis; the medial edge of the origin is fused with part of the tendinous origin of the medial head of M. flexor perforatus digiti III.
The broad flat common tendon of the lateral head and the lateral head of M. flexor perforatus digiti II fuses to the superficial surface of the fibular arm of the guide loop for M. extensor iliofibularis and contributes to the femorofibular fascia; consequently the ultimate origin would be the external femoral condyle and the head of the fibula.
The slender common tendon of the anterolateral head and the anterolateral heads of Mm. flexor perforatus digiti II and flexor perforatus digiti III passes deep to the insertional tendon of M. extensor iliofibularis and to the fibular arm of the guide loop for the latter muscle (to which it partly fuses); the tendon attaches to a narrow line on the head of the fibula adjacent to the attachment of the fibular arm of the guide loop and to the deep part of the femorofibular fascia.
Insertion.—The slender ossified tendon becomes flexible before it passes posterior to the tibial cartilage deep to the tendon of M. gastrocnemius, lateral to the tendon of M. flexor perforans et perforatus digiti III, and superficial to the lateral half of the tendon of M. flexor perforatus digiti III; a thin sheet of connective tissue covers the tendon and attaches by its edges to the underlying tendon of M. flexor perforatus digiti III (thus the latter tendon forms a sheath for the tendon of M. flexor perforatus digiti IV; this sheath is separate from a similar sheath surrounding the tendon of M. flexor perforans et perforatus digiti III); the tendon is again ossified where it passes along the posterolateral surface of the tarsometatarsus posterolateral to the tendon of M. flexor perforans et perforatus digiti III; near the distal end of the tarsometatarsus the tendon becomes flexible and expands greatly in width and thickness, and sends a small slip dorsally, medial to the underlying tendons, that attaches to the subarticular cartilage ventral to the trochlea for digit IV; sometimes this slip is continuous with the retinaculum ventral to the tendon at the level of the proximal end of the digit. Several more or less distinct sheets of tough connective tissue lie ventral to all of the flexor tendons at the level of the trochleae and the proximal end of the digits, holding them in place. The tendon narrows as it passes onto the ventral surface of digit IV and soon divides into three branches; the tendon of M. flexor digitorum longus emerges between the medial and middle branches. The lateral branch attaches to the subarticular cartilage ventral to the first interphalangeal joint and is also bound by connective tissue to the ventrolateral surface of the first phalanx. A dorsal slip arises at the point of divergence of the lateral and middle branches and attaches to the subarticular cartilage of the first interphalangeal joint. The middle branch attaches to the subarticular cartilage of the second joint. The medial branch, after sending dorsal slips to each of the first two subarticular cartilages, attaches to the subarticular cartilage of the third interphalangeal joint.
Innervation.—The posterior division of the tibial nerve sends a branch into the posterior edge of the medial head, then passes between the latter and the medial head of M. flexor perforatus digiti III; as it extends distally it gives off twigs to the medial surface of the medial head, to the deep surface of the lateral head, and to the deep surface of the anterolateral head.