CHAPTER I3

TFIE PTANTAR SKIN AND SOFT TISSUE,S:

Private Surgical Anatomy Review
Tlcom,as F. Smitb, DPM

Plantar surgical approaches are feared clue to a specialized aspects of the subcutaneous tissues or
concern for symptomatic scarring. There should be fat pzrds will be reviewed with emphasis on
a respect for the plantar skin and associated exposure and visualization.
subcutaneous tissues, but not fear. To avoid the
possibility of a painful scar, it has been THE SKIN
recommended that plantar incisions be placed on
the non-u.eightbearing areas of the plantar skin. The histology of skin is impoment to review. Skin is
Incisions can likewise be piacecl plantarly in areas of composed of tu.o basic layers, the epidermis on the
potential non-weightbearing w'here a sesamoicl or surface and the cleeper dermis. The epidermis is
metatarsal is to be resectecl. A non-rvei5lht- composed of the stratified squalnous epithelium.
bearing xea plantariy is in essence created from a The major ce1l of the epiclermis is the keratinocyte.
weightbearing area. A more complete approach to Other cells of the epidermis include melanocl,tes.
the plantar scar is to orlent the scar to not only Melanocyes are not nllmerolls in plantar skin and
consider the weightbearing status of the skin but little melanin pigment is formed. Plantar skin gets its
neuroyasclllar concerns, relaxed skin tension lines, characteristic yel1ow-golden color from the pigment
and adequacy of exposure.'l carotene that exists in the subcutaneous fat, not the
The plantar skin and soft tissues are very more translucent skin. The pink coloration of the
specialized to provide the suppleness and padding plantar foot comes from the oxlrhemoglobin in the
neecled for absorbing the forces of weightbearing. highly vascular plantar dermis. Langhans's cells in
The plantar soft tissues possess the strength to resist the epidermis play a role in immunologic fr-rnction.
ground reactive forces whether walking shod or Merkel's cells present in the plantar epidermis are
unshod. Special techniques of surgical approach, thought to sen,e as mechanoreceptors.s
repair, zrnd postoperative management are The dermis is primarily made r-rp of collagen
urarranted. Plantar approaches are \rery reasonable fibers and a protein matrix network that strengthens
to consider, and do not necessarily result in plin or and binds the epidermis to the subcutaneous tissue.
problems of scar hypertrophy. Callous formation or Cel1s in this layer are primarily fibroblasts. The outer
loss of padding and protectir.e function are not papillary lzryer of the dermis is loosely arranged. The
common place following p1'.rntar incisions.'1 ' inner reticuiar layer is composed of denser
Nlany surgical procedures require a plantar connective tissue. There is a rich network of
approach. Advances in nerve and odrer soft tissue neurovascular and lymph structures within the
and osseous techniques related to the foot open dermis, feeding and nourishing the epidermi.s.
new vistas for reconstruction, if plantar zrpproaches The dermis has trvo viscoelastic properties that
can he utilized with conficlence. Plantar incisions can be utilized surgically to expand coverage of
should not be fezrred. but respected zrnd jucliciously defects.' The first is termed creep. Creep
r,rtilized. A ful1 understanding of topographical represents the ability of skin stretchecl at a constant
and local plantar anatomy is required. Special tension to expand in surface area. Creep can occur
understanding of the nenrovascular supply ancl by two mechanisms. Biological creep is not the
associated subcutaneous tissues of the plantar foot stretching of skin, but the expansion or grou,th of
are importzrnt. The plantar foot anatomy will be additional skin over slow insidior-rs expanding
revieu,'ed as an introclr:ction to plantar foot sr-rrgery forces. Biological crecp occurs in pregnancy zrnd
in general. Emphasis rvill be placed on the skin and subcutaneous tllmor growth. Mechanical creep of
derrnal neurovascul'ar supply as it impacts the clermis is the zrctr:a1 stretching of skin over a
plantar incision placement consiclerations. The much shorter time beyond the limits of its ability to
 CHAPTER 13 69

return to the original surface area, not the additional glands, but not apocrine glands." The excretions to
FJrowth of skin. the sole are more watery than oily in character.
The second viscoelastic propefiy of the clermis The sweat function is controlled by the sympathetic
is stress relaxation. Stress relaxation represents the nelvous system as is plantar skin lvrinkling in
propefiy that as skin is stretched, the amount of response to water exposllre.
tension required to maintain the stretch is decreased Numerous creases ancl line systems have been
()vcr a f,actor ol timc. clescribed within the skin. Dermographic patterns
The skin of the sole of the foot is thickened fbr are finger and foot prints unique to each individual.
a protective function. It is thickest at the heel and Foot or finger prints have no surgical significance.
lateral plantar margin of the fbot. The plantar pedal Flexion skin creases or folds in plantar skin are
skin is tighter and more fkecl than the clorsal pedal nllmerous (Figure 1) Flexion creases plantzrrly
skin that is more mobile. Surgical exposllre represent the flxed and resilient natLrre of this skin,
plantarly may require longer or more varied shapes as well as the aclaptable and mobile qualities of the
of incisions to provide a similar degree of exposure plantar foot needecl to permit joint motion. Flexion
as shofier linear dorsal foot incisions. Accuracy of creases can hicle scars u,'hen placed within theil
placement for specific areas of visualization on the depths. This technique is most commonly exploited
plantzrr aspect of the fbot is more critical and leaves on the face not the plantar foot.
Iess room for error. The plantar skin is much more Cleavage lines, as described Lry Cox, la1n
resistant to abrasion. Plantar skin has a higher' longitudinally in a proximal ancl distal orientation on
pain threshold to altrasion when compared with the plantar foot.'' There is a slight convex clifl/ature
thigh skin. These two characteristics of elevatecl pain on the fibuiar side and a circumferential orientation
threshold and abrasion resistance attest to the ability about the posterior plantar heel area (Figure 2).
of the plantar skin to avoid pain and injury in Cleavage lines were based on studies originally
barefoot u.alking.''' done by Langer. Cleavage lines were determinecl
The dermis contains numerolts appenclages by skin hole orientation following awl pLrnctures
that may have their origin in tl-ie subcutaneous tissue in fresh cadaver skin. Langer's lines generally tencl
just beneath the dermis. The plantar skin does not to follow in the direction of muscle pr-rl1 throughout
contain hair follicles. Sebaceous gland function and the body, cleavage lines do not.'3 Cox's and Langer's
excretions do not exist without hair follicles. Sweat lines vary in orientation on the foot dorsally, but
function does exist on the plantzrr skin as eccline not plantarly.

Figure 1. Flexion creases on the plantar aspect of Figurc 2. Clcar.age lines on the plantar aspect of
tlie lirot. the foot.
70 CHAPTER 13

Relaxed skin tension lines (RSTL) were subcutaneous padding and be problematic, yet not
described by Borges and Alexander.'a They be considered hypetrophic. Pefiaps this tendency
determined the tension on the skin with respect to of plantar scars not to hypertrophy is a function of
elasticity of the skin, stretch of the skin as related to the rigid nature of the plantar skin that splints and
muscle pull, and 1oca1 anatomy considerations. protects the scaq as well as the pressure of weight
These lines have proven to be more effective in bearing that is therapeutic in adding compression
determining orientation of scars to prevent forces to the plantar scar.
hypertrophy. Incisions parallel to RSTL do not gap as
much as those perpendicular to RSTL. Incisions BLOOD SUPPLY
paral1el to RSTL have much less tension on them
after closure. The tension demonstrated by RSTL is As a general rule, one thinks of afierial outflow
constant, whether the wound is dressed, placed in a and venoLrs retlrrn in a proximal and distal
cast, of suppoted by suture. Scars are much less orientation (Figure ,t). This is accurate in most areas
likely to hypertrophy when parallel to RSTL due of the body. The deep arterial flow to the plantar
to the lessened degree of tension on the wound. aspect of the foot follorvs this orientation from the
RSTL run transversely across the plantar aspect of posterior tibial artery to the medial and lateral
the foot (Figure 3). plantar arteries dista1ly. The medial and lateral
RSTL vary fiom cleavage lines plantarly by plantar afieries continue distally within the central
90 clegrees. RSTL run lransversely whereas cleavage compaftment of the sole of the foot deep to the
lines mn longitudinally on the plantar aspect ol plantar fascia to the cligits.
the foot. Incisions, however, in either line system The blood flow through the plantar skin within
of the plantar foot are said to show little tendency the subdermal plexus follows a different orientation.
to hypertrophy. The arterial flow to the skin and related soft tissues
The incidence of hypertrophic scars or keloids of the sole of the foot is rich and plentiful. The
on the plantar skin is minimal, whether RSTL or vessels reach the skin through a perforating system
cleavage lines are followed. Scars in either direction from principally the larger lateral piantar artery and
on the plantar skin whether transverse or the smaller medial plantar afiery deep in the central
longitudinal in
orientation show 1ittle signs of compafiment of the foot. The vessels must perforate
hypertrophy.a Plantar scars can still be sensitive, the deep fascia towards the plantar skin (Figure 5).
have keratotic thickening, or have atrophy of the This perforating system occurs along either side of

l)-"*'---
7-l--' _*--::
FOREFOOT

MIDFOOT

Figr-rre J, ITSTL on the plantar aspect of the lbot Figure 4. Arterral blood flow to the plantar aspect
of the fbot.
 CHAPTER 13 71

the strong central portion of the plantar fascia to the abundance of the plantar
clorsal skin attests
through the medial and lateral plantar su1ci.'' skin blood supply. Lacerations or incisions in this
Curtin has shown through infrarecl photo- marginal skin may require substantial hemostasis.
graphy that the distribution of vessels in the plantar These superficial veins then drain dorsally into the
skin follou,'s a more transverse orientation, not large saphenous system medially, and the small
longitudinal.'6 The flow originates laterally and saphenous system latera1ly.
medially and proceeds toward the plantar central
aspect of the sole of the foot. This is a critical I\I-ERYES
concern n'hen designing plantar surgical approaches
or assessing the viability of plantar skin after lacera- The nerves to the plantar skin zlnd related soft
tions. Parallel plantar incisions or longitudinally- tissues reach the sole of the foot in the midfoot
oriented lacerations could result in a compromise to region much in the same manner as the arterial
the tissue between them (Figure 6). Parallel incisions system. The major plantar nelves of the midfbot and
transversely oriented would not be as prone to forefoot are the large meclial plantar nerve and
avascularity. Large medially or laterally based skin smaller lateral plantar nen'e. These nerves course
flaps that cross into and transect the blood flon, from deep to the plantar fascia within the central
the opposite direction can result in significant tip compartment of the foot. The clltaneous nen/e
necrosis (Figure 7). Skin flap and plastic surgical extensions pierce the deep fascia along the meclizrl
techniques on the plantar skin must respect the and laterai margins of the planlar fascia w-ithin the
deep and superficial variations in ar-terial blood flow. medial ancl lateral sulci in the midfoot region."'The
Viability of the skin would outweigh concerns clrtaneous nerves branch ttansversely w'ithin the
of scarring, given the choice of surgical wound neurovascular arcade to inneruate the skin.
orientation options. The plantar heel skin nen e supply originrtes
The deep venous flow runs from distal to from two sources. The sural nerve innelates the
proximal through the posterior tibial veins (Figure lateral heel area plantarly. The medial heel is inner-
B). The subdermal nelwork of veins frorn the skin vated by the medial calcaneal nefl/e as a branch of
and related soft tissues flows olttward from the the tibial nerve. The cutaneous perfbrating branches
central plantar foot in a meclial and lateral direction. to the plantar heel are variable in presentation, and
The multitude of superficial veins about the difficult to rrisualize and identifv.
periphery of the foot where the plantar skin joins the

Figure 5. Topographical idcntitlcetion of the Figure 6. Sl<in necrosis befileen two p:rrallei
medi:rl ancl iateral sulci on the plantar aspect of plantar incis:ions.
the tirot.
 72 CHAPTER 13

The ball of the foot anc'l cligits are suppliecl peripheral nelves. Careful study ancl memorization
primarily by the mecli:Ll, and to a lesser degree. the of these dermzrtomal maps is required. Some
lateral plantar nen/e. These t\vo neta,es overlap at variability exists and the distribution patterns are not
the third intermetatarsal space where both sencl a zrbsolr-rte. Complicating rhe situation is the finding
brzrnch that sr-rpplies the lateral aspect of the third that texts ancl afticles represent these clermatom:1l
toe and medial aspect of the fourth toe, ancl is distribution maps differently. Representative
involr.ed in the classic Morton,s neuroma. These c1ermatomal maps zrre proviclecl here for rer,,iew,
mzrjor plantar nel1.es are axon extensions of cells study, ancl comparison (Figures 9-11).
whose ce11 b<xly and nucleus 1ie in the sensory
dorsal root ganglion of the spine. The nerv,e root
levels of L5 and 51 are the spinal origin of the nelves
SUBCUTANEOUS TISSI]ES
to the plantar aspect of the foot.
The plantar subcutaneous tissues are specifically
The plantar cligital nen es are protectecl from
aclaptecl, both structurally ancl biochemically, to act
the eff-ects of rnor.ement and weight bearing by as a cushion for weight bearing. The subcutaneous
the fat boclies plantarly. The fat bodies are tissues can be clivicled into three distinct and uniqtie
accumulations of adipose tissLte enclosecl by fibrous
arezls. These are2ls inclucle tf ie heel. arch and
fascial septa betw,een the metatzrrs:r1 heacls. As the
forefoot subclltaneous tissues. A closecl-cell structure
cligital nen/es progress beyond the metatarsal heacls,
they become rather sr-rperficial in the digital sulcus
of tl-re aclipose tissue in the heel ancl forefoot
pror.ides for w'eight-lrcaring force transmission and
area plantariy. Sr,rrgical approaches to the cligital
absorption. As zln example, normal heel fat pacls tencl
nefl/es at the non-r,eight be:lring sulcus arc:t l.equire
to broadly disperse u,.eight-bearing forces. Atropllic
less exposure than more proximally at the metatarsal
heel fat pads tend to have more concentratecl peak
head level tlrrough the fat Lroclies. The curaneous presslrre distribution.,- The septal walls of atr-ophic
nerves to the ball :rrea of the foot exit ancl perforate
heels tend to be fragmented and wider than normal
tow-arc1s the skin at variours ler.els along the course
with fibrosis. The stn-rctllre of fat ce1ls is similar in
of the digital nelves. The digital nelves end in the normal and atrophic heels, but a smaller mean cell
cutaneolls fat of the ti,rfts of the toes.
area has been noted.,3 Higher percentzrges of
The dermatomal distribution of innelarion to unsaturzrtecl fatty acids and lower percentages of
the sole of the foot can be vieu,ed as spinal or
salurated fatty acicls are found jn normal heel fat than

Shori l-cng
Saphenous
Vein
Syslem
@*@ Saphenous
Vein
System

Figurc 7. Skin riect-osis at the clistal tip of the skin Figru'e B. Venoris blood f'lor,,. fron the pl:rntar
flap that ertcndecl ir-rto ancl tr:rnscctecl bloocl flou. aspect of thc fbot.
fioni the opposite sicle of t1-re firot.
 CHAPTER 13 73

Saphenous
Nerua

Figr,rre !. Largc peripheral ner-ve innervation to Figure 10. Small peripheral nefl/e inneruation to
the plantar foot. the plantar fbot,

other bodily fatty tissues. The increased unsaturated

fatty acid rutio may decrease triglyceride viscosity
and enhance biomechanical efficiency. No difference
in this fatty acid ratio is found when comparing
normal or atrophic heel fat pads.re
The thickness of the subcutaneolrs tissue of the
heel can be 2 cm. Fibrous septa are oriented in a
spiral fashion through the subcutaneous tissue to
hold the heel fat about the calcaneus in chambers
plantarly.'n The septa form a precise system of
chambers that retains the adipose tissue (Figure 72).
The hydrodynamics of these chambers provide for
the effective absorption and distribution of body
weight through the weight-bearing process. The
most plantar and superficial spiral septal system
originates medially on the calcaneus. The septa
spiral posterior and lateral.. A second more proximal
spiraling system of septa, originates on the laterai
calcaneus. These septa spiml posteriorly, but end
more medial-ward in the subcutaneous tissues. A Figure 11. Spinal nerve root inneruation to the
plantar lbot.
third converging septal system runs from the anterior
calcaneus and curves lateral and forward. The more
anterior septa on the l-reel run anterior towards the
plantar skin. The more posterior septa run relatively
posterior as they course towards the plantar skin. A
complex of multiple smaller chzlmbers is created,
which gives the strength to the overall system to
 74 CHAPTER 13

t*.i .l \
.-..1 tt : I
t| l. 9,:'-. ,. t

/t.:,.,1!- ,t ..*-. li
,.i..
l,a1
t:

':l
I
t
tt
l,tll '
1
1,-
{ 1'
l t!
i 1i.,.-,
t
, it .,... ...-, ::#
t t\-
, 1-..&
t
la

I
r, ,{ a& I
gil"Jliv\
\*, I il
:, @^&
., I

':1 **8
ttt
,,/

Figure 12A. Diagrenmtatic reprcsentation of the Figure 12ts. Thc seconclan'spiral septal svstem
prim2rr\. fibrolrs sepral svsrem of thc heel originates ntore lateral ancl spir:rls posterior end
sllllcut:lneolls tissr-Le layer that odginatcs mecliall,v encls n'rore rneclial.
on thc c:rlc:rneLls end spirals postcriot :1nai lateral.

pro\ride resiliency and shock absorption. It is

clifficult whether the plantar heel incision is
transverse or longituc'linal, not to violate this septal
system. A rather large subcalcaneal bursa is present
just beneath the w.eighr-bearing calcaneus to
provicle additional paclding.
The non-weight$earing arch sltbcutaneous
tissue varies little from other areas of the body.
Linear vefiical bands bind the fat 1oose1y. The
stlarcture is not nearly as formal as the heel or
ball lrea of the plantar foot (Figure 1, Tl-re
subcutaneolis tissr'te in the 21rch area ol the plantar
foot is r.ery thin. Scarring from the skin can readily
firrm adhesions to the deeper plantar fascia. plastic
surgical techniques that involve fr_r11-thickness
transf-er of skin and subcutaneous tissue from the
arch area to the weight-bearing areas may not
provide adeqlrate padcling against weight bearing.
The plantar subcutaneous tissue of the ball of
the fbot is retained and maintained by a complex Figure 12C. C:rclaveric r.ieu. of thc superficial
system of intersecting ligaments and fascial laver of the l'reel subcutancous tissues just belon-
the clermis. The scptal s_vstem lies deep to this
bands. The plantar fascia forms bands that are srrrface.
longitudinally oriented. The more transverse bands
are cal1ed transverse fhsciculi proximal to the
metatarsal heacls, and natatory ligaments more
distal1y. These longitudinal and transverse filtrous
structures clefine adipose deposits tenned fat bodies
 CI-IAPTER 13 75

that protect and cushion the neurovascular REFERENCES

structures betn'een the metatarsals. The sub-
Stapp \fD. I)lantal shin incisions: an clt'en.ict'. In \rickels \S.
cutaneous fat benezrth the metatarsai heads is termecl ecliicrr. necon-strtLctiue Su.rgetl' (t tlJe Foot ctrtcl Leg tipLl.tle '96
the submetatarsal cushion (Figure 74). The I.r.kc-'L, \,: l'nd...lr\ ln.litr tr: 1O'rli. p. lrrr-ll.
,\{:Lhan K'I . Plantar flbrclnalosis: srLrgic:rl col'rsicler:rtions. Il'r
submetatzrrsal cushion is confined medially ancl XIcGlamry ED. eclitor. Recotlstructiue Surgery- of'the Ft)ot .111.1 Le!.
laterally betn,een trv-o longitr-rdinal fascial bancls 1986. TLrcl<er (GA): Doctols Hospital Pocliatlic Eclucetion ancl
called the verlical fibers. The yerticai fibers arise Rescarch lnstitute: 1986. p. 161 1.
r\lahan KT. Phstic sllrgery ancl skin grafting. In trIcGl:rm1' fiD.
from the sides of the plantar piate and flexor sheath. tsenl<s AS. L)orlnel' \'IS. eclitors. Cot'ttprchusire
'lbxtbook ttf Frtot
They course piantarly from either side of the Sz.irgeil'2ncl ecl. Baltirtiore (r\ID): \\'illiarls & \\'ilkins; 1992:I2t6t6
Richar:dson EG. Rrotzman SB. Grares SC fhe plantar incision firr'
metatarsal head. The verllcal fibers form an arching proceclures ir-rrtrlr'ing the fbrefbot. .[ I]ctne Jrtlttt Strtg Attt
pattern beneath the metatarsal head to encase the 1gg 3;751726 31 .

I-clis G, Gatti A, Barn t-. et al Thc plantar:rpproach to heel

fatty tissr-re of the metatarsal cushion. Longitttclinzri srirge$,: a retrospective stuch . ./ -Fbol Szzrc 1 99 1 130: 5'i2-6.
incisions in the plantzrr forefoot tend not to violate Setterfielcl \iK, Joliv GP. A nen- nieihocl of crcision of palnl'lL1
planter fbreloot Icsions Llsing .1 rotation adlltncer cltt l1np .l Frxtt
this septal system. Longitudinal incisions help to Arrkle .Su:g 7991;331129 31.
avoid the w-eight-bearing areas and are parallel to Pelelman ClK. FigLrra \IA. Sanclbelg \S Thc rtreclirtl instep plalt-
the cleavage lines, but perpenclicr,rlar to the RSTL. tar fascicrtorlt-v. -/ Fortt Atrkle St;tg 1c)t)i:J1:i't'- 5 t-
8. l-ovelanc1 T,f . NlcClr-rr-e LP. P:rgc .lC. et al. Livirg skin ccluir-alents
ktue r Ex I tt:nt it.y 7t).c) 6 : 3 : 2 3 L -6.
9. Armstrong DG. Sotcr-ison .[C. RrLshtran T1l; lixpkriting thc:
CONCLUSION liscoelasric Propefiies of pecial skjn \\.ith lhe surt' closttrc skin
stretching tletice. J l'rtot Ankle 5L;.rg 199i:31:217 i3.
Plzrntar incisions are a safe methocl of zrccessing the 10. Robbins S. Goul'GJ. NlcClarar-i.1. cI:11. Protective sensation of thc
plantxr aspect of the foot. Foat Ankle 7t)t)3a11317-1f '
foot for surgical procedures. The speciahzecl 11. B:rtes IJ. A gulcle to Ph\:sice1 ExaminiLtion ancl History T:rkrng
piantar soft tissue and skin anzltomy aicls in Fitih ec1. Philadelphi:r (1'A): JR Lippincottrl99l. p. l'i0.
12.. Cor H'I . The cle:lr'agc lines of the skin. Brllrs'i./Si'//q [qxs:r):1t
L)

providing strength to resist t'eight bearing, y31 1i. l-angel K. tieber clie Spaltbelkcit cier Cutis. SitzrLnopll'd, K
cushioning for *'eight-bearing 1oac1s. The plantar Akaci.cl.N('issensch. trlath n:LttLny CL 'i3:23, 1861. Cited b1' 1(raissl
Clr 'fhe sclectlon of apl)roprirte liues for elcctive sr-rlgical
skin and soft tissue reaclill' senies this function' incisions. Pl.ts/ Re c o nsrr Szriig 1!5 1 :,3: -28. 1

Surgerl througl-r this area requires :Ln undet- 11. Borges AF, AleranclerJE. Relared skin tcnsion 1ines. z-plasties or.r
scar.s ancl firsifolm ercisiol'r of lcsions Br.l Plttst '\trrg
stancling of anatomy ancl function to yield the best 7962:15:21)-i1.
results u.ith the fell'est cornplications.

Figure li. A. Surgical exposllre o1' thc pl:rnter thscil in the arch area
[-ith the subcutaneous tissne l:r1'er rcteined to thc clemris fbr vascltlar
presefl':lticln o1'the skin f1aps.

F-igurc 1JB. Cad:rvelic r ies' of the sltpcrficilll

lar.er of the arch slLllcutlneous tisslles jtlst
lrc,rl Llrc tlr'ttnis. I lre 'l.l \ lllirn(uL' l:\\llr'' 'lle
fairlr.' contiguous throughout in the erch arer of
fhe frxrt.
76 CHAPTER 13

Figr-rre 1,1A. Diagramntatic representltion of the Figure f.iB. Scgtnentecl look in the fr-ontal pl:rne
subcutaneous tissues of the plantal' foreioot l-r
thc transve rse plane. Notc the scgmented
vari:rtion in tissuc character frorl beneath the
met.Ltersal hcacls ancl the fat pacl or sLlbmetatal-sal
cushion to between the metatarsal heads ancl the
fat bodies.

15. Curtin J\(/. Fibromatosis Of the plantar fascia. J Bone /oint Surg
/ i, I ,)()i;t-: lU{ ri d.
16. Sarrafian SK: ArtoLtomy cl' tbe Foot and Ankle philaclelphia: JB
Lippincon;1 !83.
17. Jahss MH, Kurrmer F, Michelson JD. Invcstigations into thc fat
pads of the sole of ti're fbot: heel pressure sttdtes. l.'oot Ankle
1992:73:22732.
1,3. Buschmann \VR, Jahss MtI. Kummer F, et al. Histologl. ancl
histonorphometric analysis of the norm:rl ancl atrophic heel lat
pad. Foctt Ankle 191)i;76:251-8.
19. Buschrnann IflR, Hudgins LC, Kummer F, et al. Fatty acicl
composit:ion of normal and atrophicd heel fat pad. Ictctt Ankle
7993:74:389-91.
20. tslechschmidt E. Die Alchitecktur cles Fcrsenpolsters. In
Gegenbaurs Morphologisches Jahrbuch, Leipzig, Akacl Vcrlag
MBH, 1933. p. 65-6

Figure 14C. NIore anatomic look in the liontal plane r,-ith the deeper
fat body in the intermetatarsal spaces and the more superticial fat pad
beneath t1're mctltarsal herrls.