Leg and foot Flashcards
What is the popliteal fossa and what is its role?
The popliteal fossa is a diamond shaped area located on the posterior aspect of the knee.
- It is the main path by which vessels and nerves pass between the thigh and the leg.
What are the borders of the popliteal fossa?
- Superomedial border – semimembranosus
- Superolateral border – biceps femoris
- Inferomedial border – medial head of the gastrocnemius
- Inferolateral border – lateral head of the gastrocnemius and plantaris
- The floor of the popliteal fossa is formed by the posterior surface of the knee joint capsule, popliteus muscle and posterior femur.
- The roof is made of up two layers: popliteal fascia and skin. The popliteal fascia is continuous with the fascia lata of the leg.
What are the contents of the popliteal fossa?
The popliteal fossa is the main conduit for neurovascular structures entering and leaving the leg. Its contents are (medial to lateral):
- Popliteal artery
- Popliteal vein
- Tibial nerve
- Common fibular nerve (common peroneal nerve)
What are the most superficial contents of the popliteal fossa?
Tibial and common fibular nerves (from the sciatic)
The common fibular nerve follows which route?
Follows the biceps femoris tendon, travelling along the lateral margin of the popliteal fossa
The small saphenous vein pierces the popliteal fossa and passes between the two heads of the gastrocnemius to empty into the…
Popliteal vein
What is the deepest structure in the popliteal fossa?
The popliteal artery
What is the tarsal tunnel and what is its role?
- The tarsal tunnel is a fibro-osseous space located on the posteromedial aspect of the ankle.
- It acts as a passageway for tendons, nerves and vessels to travel between the posterior leg and the foot.
What are the borders of the tarsal tunnel?
- The tarsal tunnel is formed by a bony floor and connective tissue roof.
- The floor is a concave surface formed by the medial aspect of the tibia, talus and calcaneus.
- It is converted into a tunnel by the flexor retinaculum, which spans obliquely between the medial malleolus and the medial tubercle of the calcaneus to form the roof. The flexor retinaculum is continuous with the deep fascia of the leg and foot.
What are the contents of the tarsal tunnel?
- The tarsal tunnel acts as a passageway for tendons, nerves and vessels to travel between the posterior leg and the foot. Its contents (anterior to posterior) are: • Tibialis posterior tendon • Flexor digitorum longus tendon • Posterior tibial artery and vein • Tibial nerve • Flexor hallucis longus tendon
• The mnemonic Tom, Dick and a Very Nervous Harry can be used to aid recall of these structures.
What is tarsal tunnel syndrome? Signs/symptoms and management?
It refers to the entrapment and compression of the tibial nerve as it passes through the tarsal tunnel.
- Patients experience altered sensation in the sensory distribution of the tibial nerve – the sole of the foot
- The motor function of the nerve can also be affected in severe disease, causing weakness and wasting of the intrinsic foot muscles
- Management can be conservative (physio, NSAIDs, corticosteroids) or surgical (tarsal tunnel release = cutting through the flexor retinaculum to decompress the tunnel)
What are the different landmarks of the PROXIMAL tibia?
- Tibial tuberosity
- Medial and lateral condyles
- Intercondylar tubercles - this is the main area for attachment of ligaments and menisci of the knee joint
- Soleal line
What are the landmarks of the DISTAL tibia?
- The distal end widens to assist with weight-bearing
- The medial malleolus is a bony projection continuing inferiorly on the medial aspect of the tibia, it articulates with the tarsal bones to form part of the ankle joint
- Laterally is the fibular notch, where the fibula is bound to the tibia – forming the tibiofibular joint
What is the fibula and what is its main function?
- The fibula is a bone located within the lateral aspect of the leg, its main function is to act as an attachment for muscles, and not as a weight-bearer.
What are the 3 main articulations of the fibula?
- Proximal tibiofibular joint
- Distal tibiofibular joint
- Ankle joint – articulates with the talus bone of the foot
On the posterior and lateral surface of the fibular neck, which nerve can be found?
Common fibular
What are the proximal tarsal bones?
Calcaneus (largest tarsal bone and lies underneath the talus where it constitutes the heel)
Talus (most superior of the tarsal bones & transmits the weight of the entire body to the foot - HIGH RISK OF AVASCULAR NECROSIS AS THE VASCULAR SUPPLY IS DEPENDENT ON FASCIAL STRUCTURES)
What are the bones of the midfoot (intermediate group)
Navicular bone
- On the plantar surface, there is a tuberosity for the attachment of part of the tibialis posterior tendon
What are the distal bones of the midfoot?
Cuboid
3x Cuneiforms
- They articulate with the metatarsals
- Cuboid is the farthest lateral, anterior to the calcaneus and behind the 4th and 5th metatarsals
How are the metatarsals numbered?
- They are numbered I-V (medial to lateral)
What are the different muscles found in the anterior compartment of the leg?
Tibialis anterior
Extensor digitorum longus
Extensor hallucis longus
Fibularis tertius
What is the role of the muscles in the anterior leg compartment?
Dorsiflexion and inversion of the foot at the ankle joint
- Extensor digitorum longus and extensor hallucis longus also extend the toes
The muscles in the anterior leg compartment are innervated by which nerve and artery?
Deep fibular nerve L4-S1
Anterior tibial artery
What is the origin & attachment, action and innervation of the tibialis anterior?
- Attachments: Originates from the lateral surface of the tibia, attaches to the medial cuneiform and the base of metatarsal I.
- Actions: Dorsiflexion and inversion of the foot.
- Innervation: Deep fibular nerve
What is the origin & attachment, action and innervation of the extensor digitorum longus?
- Attachments: Originates from the lateral condyle of the tibia and the medial surface of the fibula. The fibres converge into a tendon, which travels to the dorsal surface of the foot. The tendon splits into four, each inserting onto a toe.
- Actions: Extension of the lateral four toes, and dorsiflexion of the foot.
- Innervation: Deep fibular nerve.
What is the origin & attachment, action and innervation of extensor hallucis longus?
- Attachments: Originates from the medial surface of the fibular shaft. The tendon crosses anterior to the ankle joint and attaches to the base of the distal phalanx of the great toe.
- Action: Extension of the great toe and dorsiflexion of the foot.
- Innervation: Deep fibular nerve.
What is the origin & attachment, action and innervation of the fibularis tertius?
- Attachments: Originates with the extensor digitorum longus from the medial surface of the fibula. The tendon descends with the EDL, until they reach the dorsal surface of the foot. The fibularis tertius tendon then diverges and attaches to metatarsal V.
- Actions: Eversion and dorsiflexion of the foot.
- Innervation: Deep fibular nerve.
What is foot drop? Which nerve is damaged? What is the clinical manifestation of this?
- Footdrop is a clinical sign indicating paralysis of the muscles in the anterior compartment of the left leg
- Occurs as a consequence of damage to the common fibular (peroneal) nerve – from which the deep fibular nerve arises
- You get permanent plantarflexion, the limb can drag along the ground
What are the muscles found in the lateral compartment of the leg?
Fibularis longus
Fibularis brevis
What is the role of the muscles of the lateral leg compartment?
Eversion of the foot
Which nerve innervates the muscles of the lateral leg compartment?
Superficial fibular nerve
What is the origin & attachment, action and innervation of the fibularis longus?
- Attachments
The fibularis longus originates from the superior and lateral surface of the fibula and the lateral tibial condyle.
The fibres converge into a tendon, which descends into the foot, posterior to the lateral malleolus.
The tendon crosses under the foot, and attaches to the bones on the medial side, namely the medial cuneiform and base of metatarsal I.
- Actions: Eversion and plantarflexion of the foot. Also supports the lateral and transverse arches of the foot.
- Innervation: Superficial fibular (peroneal) nerve, L4-S1.
What is the origin & attachment, action and innervation of the fibularis brevis?
- Attachments:
Originates from the inferolateral surface of the fibular shaft. The muscle belly forms a tendon, which descends with the fibularis longus into the foot.
It travels posteriorly to the lateral malleolus, passing over the calcaneus and the cuboidal bones.
The tendon then attaches to a tubercle on metatarsal V.
- Actions: Eversion of the foot.
- Innervation: Superficial fibular (peroneal) nerve, L4-S1.
What is the clinical relevance of fibularis longus?
- It is an anatomical network for locating the common fibular nerve
- There is a small space between the parts of the fibularis longus that originate from the head of the fibula, and the neck of the fibula. The CFN passes through this gap and is easily identified.
- After passing through this gap, the nerve terminates by bifurcating into two terminal branches: the deep and superficial fibular nerve
The posterior compartment of the leg contains 7 muscles, organised into superficial and deep, what separates these two layers?
A band of fascia
What is the role of the muscles in the posterior leg compartment?
Plantarflexion and inversion of the foot
Which nerve innervates the muscles of the posterior leg compartment?
Tibial nerve, a terminal branch of the sciatic nerve
The superficial muscles of the posterior leg form the
‘calf’ shape, where do they insert into?
The calcaneus of the foot via the calcaneal tendon
The calcaneal reflex tests which spinal roots?
S1-S2
To minimise friction during movement, what is found associated with the calcaneal tendon?
Two bursae
- Subcutaneous calcaneal bursa - between the skin and the calcaneal tendon
- Deep bursa of the calcaneal tendon - between the tendon and the calcaneus
What are the superficial muscles of the posterior leg compartment?
Gastrocnemius - medial and lateral head
Soleus
Plantaris
What is the origin & attachment, action and innervation of the gastrocnemius?
- Attachments: The lateral head originates from the lateral femoral condyle, and medial head from the medial femoral condyle. The fibres converge, and form a single muscle belly. In the lower part of the leg, the muscle belly combines with the soleus to from the calcaneal tendon, with inserts onto the calcaneus (the heel bone).
- Actions: It plantarflexes at the ankle joint, and because it crosses the knee, it is a flexor there.
- Innervation: Tibial nerve.
What is the origin & attachment, action and innervation of the plantaris muscle?
- Attachments: Originates from the lateral supracondylar line of the femur. The muscle descends medially, condensing into a tendon that runs down the leg, between the gastrocnemius and soleus. The tendon blends with the calcaneal tendon.
- Actions: It plantarflexes at the ankle joint, and because it crosses the knee, it is a flexor there. It is not a vital muscle for these movements.
- Innervation: Tibial nerve.
The plantaris muscle is a small muscle with a long tendon, and therefore it can be mistaken for a nerve as it descends down the leg. It is absent in what percentage of people?
10%
What is the origin & attachment, action and innervation of the soleus?
- Attachments: Originates from the soleal line of the tibia and proximal fibular area. The muscle narrows in the lower part of the leg, and joins the calcaneal tendon.
- Actions: Plantarflexes the foot at the ankle joint.
- Innervation: Tibial Nerve
Which people are more likely to suffer from a ruptured calcaneal tendon?
Those with a history of calcaneal tendinitis