Lec 17 - Lower Leg and Foot Flashcards
What are the superficial posterior lower leg muscles?
The triceps surae
gastrocnemius
soleus
plantaris
What are the deep muscles of the posterior lower leg
popliteus
flexor hallucis longus
flexor digitorum longus
tibialis posterior
Gastrocnemius
MA: plantarflexes ankle joint when knee is extended, raises heel during walking, flexes knee joint
PA:
- medial head: popliteal surface of femur
- lateral head: lateral femoral condyle
DA: calcaneus via calcaneal/achilles tendon
N: Tibial N S1, S2
Soleus
MA: Plantarflexes ankle joint independent of position of knee, stabilizes ankle joint
PA: posterior fibula, soleal line and medial tibia, tendinous arch between the bony attachments
DA: calcaneus via calcaneal/achilles tendon
N: Tibial N S1 S2
Plantaris
MA: weakly assists gastroc with plantar flexion
PA: lateral supracondylar line of femur, oblique popliteal ligament
DA: calcaneus via calcaneal / Achilles tendon
N: Tibial N S1 S2
Popliteus
MA: weakly flexes knee joint, UNLOCKS by rotating femur 5 degrees on fixed femur and medially rotates tibia of unplanted limb (open chain)
PA: lateral condyle of femur and lateral meniscus
DA: posterior tibia above soleal line
N: Tibial N L4 L5 S1
Flexor Hallucis Longus
MA: flexes great toes at all joints, weakly plantarflexes ankle, supports medial longitudinal arch of foot
PA: lower posterior surface of fibular and interosseous membrane
DAL Base of distal phalanx of great toe (hallux)
N: Tibial N S2 S3
Flexor Digitorum Longus
MA: Flexes lateral four digits, plantar flexes ankle joint, supports longitudinal arches of foot
PA: Posterior tibia inferior to soleal line by a broad tendon to fibula
DA: Bases of distal phalanges of digits 2-5
N: Tibial N S2 S3
Tibialis Posterior
MA: Plantarflexes ankle joint, inverts foot (medial side), maintains medial longitudinal arch (major arch tendon)
PA: interosseous membrane, posterior tibia inferior to soleal line posterior surface of fibula
DA: Tuberosity of navicular, cuneiform, cuboid, and sustentaculum tali of calcaneus
bases of 2nd, 3rd, and 4th metatarsals
N: Tibial N L4 L5
As we age, our foot arches naturally flatten. What tendon/muscles would be most affected?
Tibialis posterior can rupture
What muscles compose the lateral lower leg? What is special about their innervation?
Fibularis Longus
Fibularis Brevis
only two nerves inervated by superficial fibular nerve L5 S1 S2
Fibularis Brevis
MA: Everts subtalar joint and weakly plantarflexes foot
PA: inferior lateral fibula
DA: lateral side of 5th metatarsal
N: Superficial fibular nerve L5 S1 S2
Fibularis Longus
MA: eversion of subtalar joint and weakly plantarflexes ankle joint
PA: head and superior lateral fibula
DA: base of 1st metatarsal and medial cuneiform
N: Superficial fibular nerve L5 S1 S2
Why is the fibularis longus called longus
Becomes a tendon more proximal than brevis
brevis doesn’t become a tendon until malleolus
Do the fibularis longus and brevis go under the foot?
Brevis does no
Longus does!
What muscles compose the anterior leg (shin?)
tibialis anterior
extensor hallucis longus
extensor digitorum longus
fibularis tertius
Tibialis Anterior
MA: dorsiflexes ankle joint and inverts subtalar joint
PA: lateral condyle and superior half of tibia and interosseous membrane
DA: medial cuniform and base of 1st metatarsal
N: deep fibular nerve L4 L5
Extensor Hallucis Longus
MA: extends great toes and dorsiflexes ankle joint
PA: middle anterior fibula and interosseous membrane
DA: base of distal phalanx of great toe
N: Deep fibular nerve L5 S1
Extensor Digitorum Longus
MA: extend lateral 4 digits and dorsiflexes ankle joint
PA: lateral condyle of tibia and superior surface of fibular and interosseous membrane
DA: Middle and distal phalanges of lateral four digits
N: Deep fibular n L5 S1
Fibularis Tertius
MA: DF ankle joint and aids on eversion of STJ joint
PA: inferior anterior surface of fibular and interosseous membrane
DA: dorsum of base of 5th metatarsal
N: Deep fibular N L5 S1
What motion will a muscle perform if it goes over the malleolus? Under malleolus?
Under - plantarflexion
over - dorsiflexion
Which muscles of the lower leg attach to all 3 structures of the low leg?
Tibialis posterior
Extensor Digitorum Longus
What spinal cord segments are associated with the quadriceps (knee jerk) myotatic reflex
What about the calcaneal (Achilles; ankle jerk)?
quad - L3/L4
Achilles - S1 S2
Myotomes for inversion and eversion
Inversion L4
Eversion S1
at the subtalar joint
Myotomes for Toe extension and flexion
extension L5
Flexion S2
Review myotomes for the other joints
What is special about the dermatomes of leg? Describe their general pattern starting with posterior side
Corresponds with myotomes
What dermatomes exist at the lateral and medial malleolus?
Lateral - S1
Medial - L4
The soleal line is on the front or back of tibia?
Posterior
Where is the nutrient foramen?
Small opening to allow blood vessels to enter and exit
mid way down posterior tibia
Where is the groove for tibialis posterior tendon?
Know where the tibial plafond is as well
right above the medial malleolus of tibia on posterior side
area by medial malleolus
Describe the articulation of the proximal and distal tibiofibular joint
what kind of joint?
what movements?
proximal - fibular head on tibia
distal - lateral malleolus on fibular notch
synovial joints
responsible for IR and ER of lower leg (proximal) and invilved with talocrural DF/pF
What is syndesmosis?
two lower leg bones + interosseous membrane
What ligaments are associated with the tibiofibular joint
anterior and posterior tibiofibular ligaments
Superior (proximal)
Inferior (distal)
Screw home
open chain - unlock = medial tibia, lock = lateral tibia
closed chain - unlock = lateral femur, lock = medial femur
What is the longest tendon in the body?
Plantaris
What are common injuries that occur at the 5th metatarsal
Avulsion - fibularis brevis is stronger than the bone and pulls on bone too much, eventually breaking the bone
jones fracture - fall
stress fracture
KNOW THEIR LOCATIONS
Avulsion most proximal, jones, then stress
List the bones of the foot in their proximal, intermediate and distal categories
proximal - talus, lateral tubercle and calcaneus
intermediate - navicular
distal - cuneiforms and cuboid
What metatarsals are lined up with the cuboid?
4th and 5th
Where is the superior groove for fibularis longus
Plantar cuboid
Where is the tarsometatarsal joint?
between cuneiforms and cuboid and the metatarsals
Where is the transverse tarsal joint?
between the talus/calcaneus and the cuboid and navicular
Locate navicular tuborosity, sustentaculum tali, lateral tubercle, medial tubercle
What and where are the sesamoid bones?
plantar side of big toe, between the metatarsal and proximal phalange
medial and lateral sesamoid
Flexor Hallucis brevis
Locate the body, neck and head of the talus bone
Locate the groove for fibularis longus - where is it and what fxn does it serve?
Locate Groove for flexor hallucis longus
Groove for fibularis longus is on lateral side between cuboid and 5th metatarsal, FL wraps around bottom of foot and becomes pulley
groove for flexor hallicus longus is on MEDIAL side, under the sustentaculum tali
Forefoot vs Midfoot
forefoot - metatarsals and phalanges, 1/2 foot
midfoot - cuboid, navicular and cuneiforms 1/3 foot
(hindfoot - calcaneos and talus)
Talocrural joint articulations and movements
end of the tibia and medial malleolus and end of fibular with lateral malleolus articulate with talus bone
pivotal hinge joint
dorsiflexion and plantarflexion
ankle joint
*anterior surface of talus is narrow posteriorly and wide anteriorly
where is the sinus tarsi?
cave on the lateral side between talus and calcaneal
problem site
Where is the deltoid ligament? What movements does it resists? Injury with what movement?
medial side
starts on medial malleolus, connects to navicular (tubercle), sustentaculum tali of calcaneus bone and talus
4 portions
resists eversion
Injury with forced eversion
dont worry too much, not as common of injury site
Why are lateral ankle injuries more common?
More inversion mobility vs eversion
What ligaments exits at the lateral ankle? (Talocrual joint)
Posterior talofibular ligament
*Anterior talofibular ligament (1 most injured)
Calcaneofibular ligament (2nd most injured)
What movements cause a lateral ankle sprain? What ligament is primarily involved?
inversion and plantar flexion
anterior talofibular ligament
What structures are injured in a high ankle sprain? What movements cause it?
tibiofibular syndesmosis and anterior TIBIOfibular ligament
Lower leg “forced into” ER with dorsiflexion
When is an ankle x-ray required?
an ankle x ray is required only if there is any pain in the laaeolar zone and any
- bone tenderness at A (posterior edge or tip of lateral malleolus)
- bone tenderness at B (posterior edge or tip of medial malleolus)
- inability to weight bear and walk 4 steps
When is a foot x-ray required?
only if there is pain un midfoot zone and any
- bone tenderness at C (base of 5th metatarsal)
- bone tenderness at D (navicular)
- inability to weight bear and walk 4 steps
Explain the difference between an isolated lateral/medial malleolar fracture, a bimalleolar fracture and trimalleolar fracture
These are common with what injury?
isolated - just one side fractured
bi - both medial and lateral malleolus fractures
tri - both and PLAFOND
Rolling ankle injury
Subtalar joint
talus and calcaneus
hindfoot inversion and eversion
obliques axis of movmement
Transverse Tarsal Joint - whats another name for it? what joints compose it?
chopart joint - commonly deformed
calcaneocuboid joint
talocalcaneonavicular joint
Talocalcaneonavicular joint (describe the articulation)
rounded head of talus to posterior navicular and anterior calcaneus
What ligaments exist with the talocalcaneonavicular joint?
plantar clacaneonavicular or “spring ligament” - important for high arch
plantar calcaneocuboid ligament (short plantar ligament)
long plantar ligament
all help support arches of foot and foot shape
Metatarsophalangeal joint - what is this joint important for?
GAIT
big toe guides walking
metatarsals and phalanges
Where does a Lisfranc injury occur? Where is the lisfranc ligament?
midfoot - metacarpal fracture, lisfranc ligament rupture, dislocation
happens due to foot twisting
ligament connects medial cuneiform to the second metatarsal
Where is the tarsal tunnel located? What are its contents? What problem might particularly impact
structures/contents run inferior and posterior to the medial malleolus
think 1st ray
Tom Dick and Very Nervous Harry
Tibialis Posterior, Flexor Digitorum Longus, Tibial artery, Tibial Vein, Tibial Nerve, Flexor Halluces Longus
Problem with flat arches
What is the technical term for a Bunion? What position is the great toe in? Who is it more common in?
hallux valgus, the great toe is adducted, more common in females because shoes
What is a consequence of bunions?
reduces medial longitudinal arch
Name the three retinaculum and what injuries they are involved with
superior extensor retinaculum - high ankle sprain
inferior extensor retinaculum - lateral ankle sprain (splits like a Y)
Flexor retinaculum - medial border, creates tarsal tunnel
What is the pulse on the top of the foot from?
Dorsalis pedis artery
netween first and second cunieforms/metatarsals
What are the two fibular retinaculum - what tendon do they hold in place?
inferior and superior fibular retinaculum
tendons of fibularis brevis and longus
What is meant by the fact that arches are supported dynamically and passively?
tendons = active support
ligaments = passive support
List the ligaments that passively support the medial longitudinal arch (review their locations!)
plantar calcaneonavicular “spring” ligament
long plantar ligament
short plantar ligament
plantar aponeurosis
What tendons dynamically support the medial longitudinal arch?
tibialis posterior
tibialis anterior
flexor hallucis longus
fibularis longus
intrinsic plantar muscles
What tendons support the transverse arch of the foot?
tibialis posterior and fibularis longus create a “stirrup”
integrity of the arches maintained by passive and active stretches
cuboid pulley?
where do the spring, short and long ligaments attach?
spring - calcaneus (sustentacular tali) to navicular
short - calcaneus to cuboid
long - calcaneus to base of metatarsals
Where does the plantar aponeurosis start? What other ligament runs perpendicular to it?
starts at the medial process of calcaneal TUBEROSITY
superficial transverse metatarsal ligaments
The forces through the extensor hoor create what movements? What do they prevent?
create MTP flexion and PIP extension and prevent the opposite motions
think sock puppet with foot
What are the intrinsic muscles on the dorsal side of the foot?
What nerve are they?
Extensor digitorum brevis (digits 2-4)
Extensor hallucis brevis (digit 1)
deep fibular nerve L5 S1
What muscles is the floor of sinus tarsi?
extensor digitrum brevis
What are the superficial veins of the lower led?
great saphenous (goes to medial arch)
small saphenous
dorsal venous network (top of foot)
Deep layer of veins on lower leg
anterior tibial, posterior tibial and plantar venous arch
Describe the arterial supply of the leg starting with the external iliac artery
external iliac to femoral artery when passing under the inguinal ligament
femoral to popliteal as it goes through adductor hiatus
popliteal splits below the popliteus into the posterior tibial artery and anterior tibial artery which comes back to the front
fibular artery comes off the posterior tibial artery
Name the parent structures for
Anterior tibial artery
fibular artery
posterior tibial artery
ATA - popliteus
fibular - PTA
PTA - popliteal
Arteries on the plantar surface of the foot (what’s there parent structure?)
posterior tibial artery branches into:
medial plantar artery
lateral plantar artery
deep plantar arch
Dorsal arterial supply
anterior tibial artery
dorsalis pedis artery
Arcuate
lateral tarsal artery - arcua
What ligament runs under the sustentaculum tali?
Flexor Hallucis longus
On its way the plantar medial cuneiform and 1st MT
Hind foot, mid foot , forefoot vs proximal intermediate and distal of tarsal bones
