Foot and Ankle Surgery 13 (2007) 165–166

www.elsevier.com/locate/fas

Editorial

Hallux adductor or abductor muscle?

Abstract

Anatomists classify the muscle located medially to the plantar region that passes from the posterior tuberosity of the calcaneus to the base
of the hallux as either an adductor or an abductor according to whether reference is made to the sagittal plane or the body or the axis of the
second digital ray of the foot, respectively.
Clinicians, on the other hand, always refer to the sagittal plane: hallux valgus, metatarsus primus varus, hallux varus, metatarsus adductus
(or varus), etc.
Definition of an axis intrinsic to the foot is a reference, by analogy, to the hand, whereas it is more logical to refer to the sagittal axis and
classify this muscle as an adductor.
# 2007 Published by Elsevier Ltd on behalf of European Foot and Ankle Society.

Keywords: Hallux adductor muscle; Hallux abductor muscle

The muscle that lies medially to the sole of the foot,
originates from the medial aspect of the tuber calcanei, the
superficial layer of the ligamentum laciniatum, the medial
malleolus, the medial tubercle of the navicular and the plantar
surface of the 1st cuneiform, and inserts on the medial
sesamoid and at the base of the great toe is called as adductor
by some workers, whereas most writers, especially English-
speaking authors, call it as abductor. Since this difference may
sometimes hinder immediate understanding, its origin is a
matter of interest. An opinion may also be expressed with
regard to whether one classification is more correct than the
other in relation to the more logical axis or plane of reference.
The subject of axes or planes of reference was raised by
Valenti [1] owing to the disagreement among anatomists
concerning the natural position of the upper limb in death, and
hence on the dissecting table, with a frontal view of the
extensor or the flexor surface of the hand. It is obvious that the
movement described as adduction in the first case becomes
abduction in the second and vice versa. At the same time,
Antonelli [2] declared: ‘‘Since there are still anatomists who
refer movements of the digits to the median plane of the body
and others who refer them to the median axis of the hand and
the foot, some inevitably describe as an abductor a muscle
which others regard as an adductor. This is especially true with
regard to the ring finger, the little finger and the great toe’’.
Examination of the meanings acquired by these terms
shows that abduction (and, conversely, adduction) refers to a
movement whereby any part of the body, and above all the
limbs and their segments, moves away from a defined plane
of reference. Reference was initially made to the median or
sagittal plane of the body. This, however, impeded precise
definition of the movements of the fingers in view of the
already mentioned disagreement among the anatomists as to
the basic position in which the hand should be studied [3].
It was for this reason, therefore, that some anatomists
defined an imaginary axis of reference running along the
centre of the middle finger: abduction thus became a
movement of a digit away from this finger, and adduction a
movement towards it. The middle finger, of course, could
neither move towards nor away from itself: its movement in
either direction, whether ulnar or radial, was equally a
departure from the reference axis (abduction).
Selection of the middle finger as the reference axis was
related to the function of the three small, triangular palmar
interossei. These arise from the ulnar aspect of the 2nd
metacarpal and from the radial aspects of the 4th and 5th
metacarpals, respectively, run along the dorsal surface of the
transverse carpal ligament to the corresponding surfaces of
the 2nd, 4th and 5th fingers and insert into the triangular
expansion of the extensor communis tendon and dorsum of
the proximal phalanx so as to bring the 2nd, 4th and 5th
fingers to the middle finger, which thus acts as the reference
axis for abduction and adduction of the fingers.
A median axis has been defined for the toes. Here,
however, it must be pointed out that the natural position of the
foot and hence on the dissecting table has never been the

1268-7731/$ – see front matter # 2007 Published by Elsevier Ltd on behalf of European Foot and Ankle Society.
doi:10.1016/j.fas.2007.06.001
166 Editorial / Foot and Ankle Surgery 13 (2007) 165–166
subject of disagreement. The frontal view of its extensor
surface means that its adduction and abduction and those of
the toes are intuitively referred to the sagittal axis of the body.
The middle toe could not be selected as the intrinsic axis
by analogy with the middle finger because of the dissimilar
anatomical arrangement and function of the corresponding
three small, fusiform plantar interossei. These arise from the
medial aspects of the 3rd, 4th and 5th metatarsals. Their long
tendons run across the dorsal surface of the transverse
metatarsal ligament and insert into the medial tubercle of the
proximal phalanx of the last three toes to bring them to the
2nd toe, which thus acts as the reference axis for the foot, as
has been recently emphasised by Maestrò [4]: ‘‘If for the
forefoot the 2nd metatarsal is taken as the reference for
movements of the toes, then approximation to M2 becomes
adduction and departure from M2 becomes abduction’’.
This wish to carry over the idea of an intrinsic reference
axis from the hand to the foot has been the cause of
confusion in the actual definition of the intrinsic axes for the
hand (3rd ray) and the foot (2nd ray).
If the 2nd ray is the reference for the foot, it is obvious that
the muscle set medially to the plantar region and inserted on
the great toe must be called an abductor, since it draws the
digit away from the axis. In this case, however, we should
apply the term ‘‘hallux varus’’ to the common deformity
known as ballux valgus, and ‘‘valgus’’ to the concomitant
metatarsus primus varus; in clinical practice, the deformity is
evidently referred to the sagittal plane. And the 2nd toe,
whether medially or laterally turned aside from the frontal
plane, must always be referred to as abducted, since it can in
no way adduce itself to its own self as the reference line.
Hallux valgus has been historically described in this way
on account of its double abduction and pronation. As
Lelièvre [5] says: ‘‘The hallux is not truly valgus except in
serious deformities in which, when turning on its long-
itudinal axis, it presents its plantar surface outwards. Until
this point is reached, it is a hallux abductus’’. Once again,
therefore, the clinician refers the component in abduction to
the sagittal plane.
In the same way, congenital hallux valgus and hallux
varus are clinically thus defined on account of the deviation
of the great toe in abduction and adduction, respectively with
reference to the median (midsagittal) plane.
In conclusion, therefore, it can be said, as currently used,
the clinical terms and the anatomical terms are not the same.
Clinical language is used to define hallux derangements in
which varus, valgus are referred to the sagittal plane of the
body (hallux varus, hallux valgus and hallux abductus).
Anatomical language refers to the axis of the 2nd toe in its
application of the term ‘‘abductor’’ to a muscle that opposes
the said displacements of the hallux in abduction. This is an
evident anachronism. Everything becomes clear if this
muscle is called an adductor and its anatomical description
and function are expressed in clinical terms. Priority in
temporal terms, indeed, can be claimed for the clinical
expression. The 17th-century physician Laforest [6], Louis
XVI’s doctor, referred the deformity known as hallux valgus
to the sagittal plane of the body.
Disagreement among anatomists over how the hand
should be studied has since been the source of misunder-
standings. If, by analogy with the foot, whose extensor
surface has always accepted as frontal, this surface had been
adopted for the hand with reference to the sagittal plane of
the body when defining the movements of the fingers, it
would not have been necessary to define an intrinsic axis for
the hand and then assign an intrinsic axis to the foot. The
muscle that lies medially to the sole of the foot would thus
have been described as an adductor, as in the Continental
European literature [7–10].
References
[1] Valenti G. Abduzione—Enciclopedia Medica. Milano: Ed. Vallardi;
1880.
[2] Antonelli L. Piede: anatomia—Enciclopedia Medica. Milano: E.
Vallardi; 1880.
[3] Theile quoted by Antonelli [2].
[4] Maestrò M. Biomécanique de l’avant-pied—Chirurgie de l’avant pied.
Elsevier; 2005.
[5] Leliévre J. Pathologie du pied. Parigi: Ed. Masson; 1961.
[6] Laforest quoted by da Leliévre [5].
[7] Viladot A. Patologia del antepié. Barcelona: Ed. Toray; 1974.
[8] Kapandji IA. Fisiologia articolare. Roma: Demi; 1974.
[9] Pisani G. Trattato di chirurgia del piede, Ist ed., Torino: Minerva
Medica; 1990.
[10] Regnauld B. The foot. Pathology, aetiology, semiology clinical inves-
tigation and therapy. Springer-Verlag; 1986.
G. Pisani*
Centro di Chirurgia del Piede ‘‘Prof. G. Pisani’’,
c/o Casa di Cura ‘‘Fornaca di Sessant’’,
C. so Vittorio Emanuele II 91, 10128 Torino, Italy
*Tel.: +39 011 55 74 111; fax: +39 011 55 74 399
E-mail address: info@chirurgiapiede-pisani.it
9 May 2007