9 - Foot and Ankle

Question 1

Label the following nerves and artery of the anterior leg.

Answer 1

Question 2

Label the following muscles and tendons.

Answer 2

Question 3

Label the following muscles of the leg.

Answer 3

Question 4

Fill in the labels for the nerves and add on labels for the veins and arteries.

Answer 4

Question 5

Label the following structures of the popliteal fossa.

Answer 5

Question 6

Label the following structures of the leg.

Answer 6

Question 7

Label the inferior view of the foot.

Answer 7

Question 8

Label the following.

Answer 8

Tom, Dick and A Very Nervous Harry

Question 9

Label what nerves supplying the following parts of the foot.

Answer 9

Question 10

Label what dermatomes supply each part of the foot.

Answer 10

Question 11

What are the three parts of the foot and the bones involved in each part?

Answer 11

- Hindfoot: Calcaneus and Talus

- Mid-foot: Navicular, Cuboid and Cuneiforms

- Forefoot: Metatarsals and Phalanges

Question 12

What are the three articulations of the talus?

Answer 12

- Ankle joint (talocrural): superior between talus, tibia and fibula

- Subtalar joint: inferior between talus and calcaneus

- Talonavicular joint: anteriorly between talus and navicular

Question 13

What is an issue with talus fracture and why?

Answer 13

• Avascular necrosis as no muscle attachments improving vascularity and blood supply is retrograde

Question 14

What are the different joints of the calcaneus?

Answer 14

- Subtalar: Superior

- Calcaneocuboid: Anterior

Takes full weight of body when heel is on the ground and is marked by the calcaneal tuberosity

Question 15

What are the different rows of the tarsals?

Answer 15

Proximal: Calcaneus and Talus

Intermediate: Navicular

Distal: Cuneiform and Cuboid

Question 16

What are the different joints in the forefoot?

Answer 16

• Tarsometatarsal
• Intermetatarsal
• Metatarsophalangeal

Question 17

Explain the makeup of the ankle joint and what movement occurs here?

Answer 17

• Only plantar and dorsiflexion
• Joint more stable in dorsiflexion as anterior part of talus is wider
• Synovial hinge joint

Question 18

What are the ligaments supporting the ankle joint?

Answer 18

Lateral:

- Anterior talofibular: between lateral malleolus and neck of talus

- Posterior talofibular: Between malleolar fossa and lateral tubercle of talus

- Calcaneofibular: Between lateral malleolus and lateral calcaneus

Medial:

- Deltoid: Fans from medial malleolus to talus, calcaneus and navicular. Stronger and resists eversion

Question 19

What muscles are involved in dorsiflexion and plantarflexion?

Answer 19

Dorsiflexion: Tibialis anterior, Extensor hallucis longus, extensor digitorum longus, peroneus tertius

Plantarflexion: Gatrocnemius, Soleus, Plantaris, Tibialis Posterior

Question 20

What joint does inversion and eversion of the foot occur in and what muscles allow this?

Answer 20

• Subtalar, calcaneocuboid and talocalcaneonavicular NOT ankle
• Mainly occurs in subtalar, no flexion whatsover only in/eversion here

- Eversion: Lateral muscles (brevis and longus) and peroneus tertius from anterior

- Inversion: Tibialis anterior and posterior

Question 21

What are the arches of the foot?

Answer 21

Question 23

What is the medial arch of the foot maintained by?

Answer 23

• Calcaneus, talus, navicular, three cuneiforms, spring ligament (plantar calcaneonavicular), tibialis anterior and peroneus longus tendons

- Muscle support: TA, PL, tibialis posterior, peroneus longus and flexor hallucis longus

Question 24

What is the lateral longitudinal arch maintained by?

Answer 24

- Formed: Calcaneus, Cuboid and lateral two metatarsals

- Support: Contraction of fibularis brevis

• Arch flattens when standing and bones lock together, ligaments binding so they become and immobile pedestal

Question 25

What muscles are in the anterior compartment of the leg, what are they innervated by and what is the blood supply?

Answer 25

Question 26

What are the origins and insertions of the muscles in the anterior compartment? (all passing under extensor retinacula)

Answer 26

**- TA:** origin at lateral surface of anterior tibia, and inserts on medial cuneiform and base of first metatarsal **- EDL:** origin lateral condyle of tibia, medial fibula and interosseous membrane and inserts on middle and distal phalanges of dorsal four toes **- EHL:** origin at medial fibula and crosses anterior to ankle joint to insert on base of distal phalanx of great toe **- Fibularis Tertius:** origin at medial fibula, inferior to EDL, and inserts on base of 5th metatarsal

Question 27

What are the muscles in the lateral compartment of the leg, the blood supply, the nerve supply and the action of the muscles?

Answer 27

- Fibularis longus (superficial) and Fibularis brevis (deep) **- Nerve:** Superficial peroneal nerve **- Blood:** Fibular artery **- Action:** Both evert the foot and prevent excess inversion. Longus plantarflexes and supports medial and transverse arches. Brevis supports lateral arch.

Question 28

What is the innervation and blood supply of the posterior muscles of the leg, and the action they have?

Answer 28

**- Tibial nerve** **- Posterior tibial artery** - Collectively plantarflex and invert the foot - Superficial and deep compartment separated by fascia

Question 29

What are the muscles of the superficial posterior compartment, what are their actions, origins and insertions?

Answer 29

**- Plantaris:** origin at lateral supracondylar line of femur and blends to calcaneal tendon. Can be harvested to use for a tendon elsewhere **- Gatrocnemius:** origin from each femoral condyle and blends to calcaneal tendon to insert on calcaneal tuberosity **- Soleus:** origin at tibial soleal line and proximal fibula, inserting to calcaneal tendon

Question 30

What is the anatomy of the calcaneal tendon?

Answer 30

- Formed from blending of tendons of superficial posterior muscles - Deep and superficial bursae

Question 31

What are the muscles of the deep posterior compartment of the leg, their innervation, blood supply, action and origin/insertion?

Answer 31

- Posterior tibial artery ## Footnote **- Popliteus**: origin at posterior tibia and inserts on lateral femoral condyle **- TPL:** origin at posterior interosseous membrane and inserts on plantar surface of navicular and medial cuneiform **- FHL:** origin at posterior fibula and inserts on distal phalanx of great toe **- FDL:** origin at medial surface of tibia and inserts onto base of distal phalanc for each four toes

Question 32

What is the anatomy of the tarsal tunnel?

Answer 32

- Located at the medial malleolus where all the structures run posteriorly to get to sole of foot - Tom Dick and A Very Nervous Harry

Question 33

What is the structure of the popliteal fossa, including borders and what runs through it? What is the clinical relevance of it?

Answer 33

- Protective passageway for neurovascular structures to pass through knee joint to lower limb

Question 34

What is the course of the tibial nerve in the leg and what does it innervate? (L4 to S3)

Answer 34

**- Innervates:** skin of posterolateral leg, lateral foot and sole of the foot. Innervates posterior muscles too - Passes through popliteal fossa and gives off branch that becomes **sural nerve** (skin of leg and foot) and a branch to posterior muscles - At ankle passes through flexor retinaculum behind medial malleolus and divides into **medial and lateral plantar nerves** to supply sole of foot

Question 35

What are the sensory branches of the tibial nerve, and what else does it innervate apart from the posterior muscles of the lower limb?

Answer 35

**- Medial sural cutaneous nerve** (joins with lateral sural cutaneous nerve from common peroneal to form sural nerve) **- Medial calcaneal branch** **- Medial and lateral plantar nerve** (motor to intrinsic muscles of foot) - Also supplies intrinsic muscles of the foot

Question 36

What areas does the common peroneal nerve innervate and what does it split off into?

Answer 36

- Root values: L4-S2 **- Innervates:** Short head of biceps femoris, skin of upper lateral leg, lateral sural cutaneous nerve supplying dorsum of foot

Question 37

What areas do each of the following nerves supply? - Sural Nerve - Deep Peroneal Nerve - Superficial Peroneal Nerve

Answer 37

- Formed from branches of tibial and common peroneal, passes behind lateral malleolus to supply skin over lateral dorsal foot. Can be harvested in reconstructive surgery as small area of parasthesia - L4-L5. Anterior leg muscles by piercing intermuscular septum. Lies adjacent to anterior tibial artery. Cutaneously supplies first webspace - L4 to S1. Lateral leg muscles then supploes anterolateral leg then middle dorsum of foot

Question 38

What do the anterior and posterior tibial arteries travel alongside?

Answer 38

- Anterior with the deep peroneal nerve - Posterior with the tibial nerve and two vena comitantes (tibial nerve)

Question 39

Describe the course of the main arteries from the knee downwards?

Answer 39

- After anterior tibial artery it is called the **tibioperoneal trunk** **- Anterior artery** goes though interosseous membrane to anterior compartment of the leg, passes under the extensor retinaculum and becomes **dorsals pedis** **-** **Posterior artery** bifurcates at inferior border of popliteus and descends in posterior compatment, passes behind medial malleolus to enter sole of foot via tatsal tunnel - **Peroneal artery** descends on medial sie of fibula in fibrous canal within deep posterior compartment, gives rise to perforating branches to penetrate IM septum to supply **lateral compartment**

Question 40

Explain the positions of each of the three main arteries of the leg.

Answer 40

Say which compartment each bundle is in and what muscles it runs between

Question 41

What is the blood supply to the foot?

Answer 41

**- Posterior tibial:** through tarsal tunnel and splits into lateral and medial plantar arteries, lateral contributing to supply of toes via plantar arch **- Dorsalis Pedis:** anterior into dorsum of foot. Deep branch between first and second metatarsals to sole of foot where it anastomoses with lateral plantar to make plantar arch

Question 42

Where are the pulses in the lower lumb?

Answer 42

**- Femoral pulse:** as enters femoral triangle, MIPA **- Popliteal artery:** hardest as deep in fossa. flex leg to relax fascia making easier to find **- Dorsalis pedis:** dorsum of foot lateral to extensor hallucis longus tendon **- Posterior tibial:** in tarsal tunnel below and behind medial malleolus

Question 43

Describe the course of the veins in the lower leg.

Answer 43

- Dorsal venous arch in foot drains into great and small saphenous vein at medial and lateral ends - Accompanying veins of dorsal venous arch continue to leg as AT vein to drain anterior compartment - Medial and lateral plantar veins from plantar venous arch to form PT vein. Pass behind medial malleolis and go into deep posterior compartment and drain the superficial and deep compartment **- Peroneal vein drains into posterior tibial vein at knee, which unites with anterior tibial vein to form popliteal vein.** - Popliteal enters thigh via adductor hiatus and becomes femoral vein

Question 44

What is the function of the extensor retinaculum?

Answer 44

The extensor retinacula bind down the tendons of the muscles in the antero-lateral compartments and prevent them from bowstringing during movements at the ankle.

Question 45

What are the surface markings of the great (long) and small (short) saphenous veins at the ankle?

Answer 45

The great (long) saphenous vein is sited anterior to the medial malleolus while the small (short) saphenous vein is sited posterior to the lateral malleolus.

Question 46

What is the differential diagnosis (list of possible causes that should be considered) for a mass (swelling) in the popliteal fossa? State four diagnoses.

Answer 46

- Popliteal aneurysm - Baker's cyst - Abscess - Popliteal lymphadenopathy - Thrombophlebitis of pop or short saphenous vein - Tumour of muscle, bone or tissue

Question 47

What is the transverse arch of the foot?

Answer 47

- Tarsals and base of metatarsals - Peroneus longus and brevis with TP - Talus is keystone