The knee, leg, ankle and foot part 3

Question 1

Describe the anatomy of the ankle joint and the movements it allows

Answer 1

The ankle joint is synovial in type and involves the talus of the foot and the tibia and fibula of the leg

The ankle joint mainly allows hinge-like dorsiflexion and plantarflexion of the foot on the leg.

Question 2

Describe weight bearing at the ankle joint

Answer 2

The weight-bearing at the ankle joint is by talus via it’s superior articulation with tibia. Fibula is not weight-bearing, but it’s distal lateral malleolus, with tibia’s medial malleolus, forms the square socket of the ankle joint.

Question 3

Describe the anatomy of the socket of the ankle joint

Answer 3

The distal end of the fibula is firmly anchored to the larger distal end of the tibia by strong ligaments. Together, the fibula and tibia create a deep bracket-shaped socket for the upper expanded part of the body of the talus:

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The roof of the socket is formed by the inferior surface of the distal end of the tibia.

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The medial side of the socket is formed by the medial malleolus of the tibia.

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The longer lateral side of the socket is formed by the lateral malleolus of the fibula.

Question 4

Describe the anatomy of the articular surface of the talus and the consequences of this for stability of the ankle joint

Answer 4

The articular surfaces are covered by hyaline cartilage.

The articular part of the talus is shaped like a short half-cylinder tipped onto its flat side with one end facing lateral and the other end facing medial. The curved upper surface of the half-cylinder and the two ends are covered by hyaline cartilage and fit into the bracket-shaped socket formed by the distal ends of the tibia and fibula.

When viewed from above, the articular surface of the talus is much wider anteriorly than it is posteriorly. As a result, the bone fits tighter into its socket when the foot is dorsiflexed and the wider surface of the talus moves into the ankle joint than when the foot is plantarflexed and the narrower part of the talus is in the joint. The joint is therefore most stable when the foot is dorsiflexed.

Question 5

Summarise the stability of the ankle joint

Answer 5

The articular cavity is enclosed by a synovial membrane, which attaches around the margins of the articular surfaces, and by a fibrous membrane, which covers the synovial membrane and is also attached to the adjacent bones.

The ankle joint is stabilized by medial (deltoid) and lateral ligaments.

Question 6

Summarise the collateral ligaments of the ankle joint

Answer 6

The broader and tougher tibiocalcaneal ligament is less often damaged. This ligament is also called the deltoid ligament.

The lateral ligaments (3 parts) are commonly damaged by over-inversion.

Question 7

Summarise the medial deltoid ligament

Answer 7

Less prone to damage

The medial (deltoid) ligament is large, strong (Fig. 6.98), and triangular in shape. Its apex is attached above to the medial malleolus and its broad base is attached below to a line that extends from the tuberosity of the navicular bone in front to the medial tubercle of the talus behind.

Question 8

Describe the different parts of the medial deltoid ligament

Answer 8

The medial ligament is subdivided into four parts based on the inferior points of attachment:

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The part that attaches in front to the tuberosity of the navicular and the associated margin of the plantar calcaneonavicular ligament (spring ligament), which connects the navicular bone to the sustentaculum tali of the calcaneus bone behind, is the tibionavicular part of the medial ligament.

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The tibiocalcaneal part, which is more central, attaches to the sustentaculum tali of the calcaneus bone.

▪
The posterior tibiotalar part attaches to the medial side and medial tubercle of the talus.

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The fourth part (the anterior tibiotalar part) is deep to the tibionavicular and tibiocalcaneal parts of the medial ligament and attaches to the medial surface of the talus.

Question 9

Describe the lateral ligament

Answer 9

The lateral ligament of the ankle is composed of three separate ligaments, the anterior talofibular ligament, the posterior talofibular ligament, and the calcaneofibular ligament (Fig. 6.99):

▪
The anterior talofibular ligament is a short ligament, and attaches the anterior margin of the lateral malleolus to the adjacent region of the talus.

▪
The posterior talofibular ligament runs horizontally backward and medially from the malleolar fossa on the medial side of the lateral malleolus to the posterior process of the talus.

▪
The calcaneofibular ligament is attached above to the malleolar fossa on the posteromedial side of the lateral malleolus and passes posteroinferiorly to attach below to a tubercle on the lateral surface of the calcaneus.

prone to injury (sprain) upon over inversion

Question 10

What is an inversion ankle sprain

Answer 10

The mechanism of injury for an inversion ankle sprain generally involves plantar flexion and inversion of the ankle. The injury usually first involves the talofibular ligament followed by the calcaneofibular ligament and finally the posterior talofibular ligament if the injury is severe enough. In addition to a ligament injury, an inversion ankle sprain may also cause a fracture of the lateral or medial malleolus, or an injury to the peroneal tendon.

Question 11

Describe the signs and symptoms of an inversion ankle sprain

Answer 11

A patient with an inversion sprain may present with the following signs and symptoms: pain with palpation of the lateral ligaments (anterior talofibular, calcaneofibular, and posterior talofibular), swelling and discoloration of the lateral ankle and foot, painful gait with limping, limited passive plantar flexion with inversion, painful active eversion against resistance, and positive anterior drawer and medial talar tilt tests.

Question 12

Describe the anterior drawer test

Answer 12

The anterior drawer test determines the integrity of the anterior talofibular ligament. It is performed by placing the patient’s foot over the edge of the table with the knee straight on the table and the ankle in relaxed dorsiflexion. The physical therapist stabilizes the distal tibia and fibula with one hand and grasps the posterior calcaneus with the other hand. The physical therapist then applies an anterior force on the calcaneus attempting to translate the talus on the fibula. The degree of motion and the presence of an endpoint determine the integrity of the anterior talofibular ligament.

Question 13

Describe the medial talar tilt test

Answer 13

The medial talar tilt test determines the integrity of the calcaneofibular ligament. It is performed in the same position as the anterior drawer test except the physical therapist’s second hand grasps the plantar surface of the calcaneus. The physical therapist then performs a medial tilt of the calcaneus. The amount of tilt available during this test determines the integrity of the calcaneofibular ligament. If more movement is available on one foot versus the other, it can be concluded the calcaneofibular ligament has been compromised.

Question 14

What is an eversion spain

Answer 14

The mechanism of injury for an eversion ankle sprain is typically excessive abduction of a planted foot or excessive pronation, both caused by an external force on the lateral leg. This injury usually involves the medial ligament,but may also involve the distal tibio-fibular interosseus membrane (see high ankle sprain). If the injury is more severe, the calcaneal insertion of the medial ligament may fail, causing an avulsion fracture of the bone. For this reason, it is important to know that the patient had a negative radiograph. This type of ankle sprain is less common than the inversion sprain based on the strength of the medial ligament as well as the bony stability of the distal fibula, making it difficult for the ankle to roll medially.

Question 15

Describe the signs and symptoms of an eversion ankle sprain

Answer 15

A patient with ans eversion sprain will have pain with palpation over the medial ligament as well as swelling and discoloration of the medial ankle, and may also have tenderness over the tibiofibular ligament and interosseus membrane. The patient will have decreased dorsiflexion and eversion accompanied by pain and may exhibit weak and painful resisted inversion. The patient will have positive anterior drawer and Kleiger tests

Question 16

Describe the Kleiger test

Answer 16

The Kleiger test is performed by positioning the patient in neutral dorsiflexion with the knee flexed to 90°. The physical therapist then externally rotates the ankle in an attempt to reproduce the mechanism of injury. Pain during this movement indicates a positive test.

Question 17

How can a high ankle sprain occur

Answer 17

The patient states that while he was kneeling to stand following a tackle another player fell on his heel causing his foot to fall into external rotation while his knee was fixed on the ground. Following the injury, he was unable to walk and described severe lateral ankle pain.

Question 18

Describe the clincial findings of a high ankle sprain

Answer 18

Upon examination, the patient reports pain during palpation to the region of the distal tibiofibular joint and with passive dorsiflexion. He exhibits negative anterior drawer and talar tilt tests, excluding the diagnosis of lateral ligament injury. The patient does show positive Kleiger (external rotation test) and distal tibia-fibula compression tests.

Positive Kleiger test
Positive tibula-fibula compression test

Question 19

Describe the tibula-fibula compression test

Answer 19

The tibia-fibula compression test is performed by the physical therapist placing one hand on the medial and one hand on the lateral aspect of the lower leg, just proximal to the lateral and medial malleolus. Compression is then applied to this area. Pain during this maneuver indicates a positive test. v

Question 20

Explain the movements of the intertarsal joints

Answer 20

The numerous synovial joints between the individual tarsal bones mainly invert, evert, supinate, and pronate the foot:

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Inversion and eversion is turning the whole sole of the foot inward and outward, respectively.

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Pronation is rotating the front of the foot laterally relative to the back of the foot, and supination is the reverse movement.

Pronation and supination allow the foot to maintain normal contact with the ground when in different stances or when standing on irregular surfaces.

Question 21

Which joints make up the intertarsal joint

Answer 21

The major joints at which movements occur include the subtalar, talocalcaneonavicular, and calcaneocuboid joints (Fig. 6.100). The talocalcaneonavicular and calcaneocuboid joints together form what is often referred to as the transverse tarsal joint.

Intertarsal joints between the cuneiforms and between the cuneiforms and the navicular allow only limited movement.

The joint between the cuboid and navicular is normally fibrous.

Question 22

Describe the anatomy of the subtalar joint

Answer 22

The subtalar joint is between:

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the large posterior calcaneal facet on the inferior surface of the talus, and

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the corresponding posterior talar facet on the superior surface of the calcaneus.

The articular cavity is enclosed by synovial membrane, which is covered by a fibrous membrane.

The subtalar joint allows gliding and rotation, which are involved in inversion and eversion of the foot. Lateral, medial, posterior, and interosseous talocalcaneal ligaments stabilize the joint. The interosseous talocalcaneal ligament lies in the tarsal sinus

Question 23

What is the talocacaneonavicular joint

Answer 23

The talocalcaneonavicular joint is a complex joint in which the head of the talus articulates with the calcaneus and plantar calcaneonavicular ligament (spring ligament) below and the navicular in front

The talocalcaneonavicular joint allows gliding and rotation movements, which together with similar movements of the subtalar joint are involved with inversion and eversion of the foot. It also participates in pronation and supination.

Synovial

Question 24

Describe the anatomy of the talocalcaneonavicular joint

Answer 24

The parts of the talocalcaneonavicular joint between the talus and calcaneus are:

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the anterior and middle calcaneal facets on the inferior surface of the talar head, and

▪
the corresponding anterior and middle talar facets on the superior surface and sustentaculum tali, respectively, of the calcaneus (Fig. 6.102B).

The part of the joint between the talus and the plantar calcaneonavicular ligament (spring ligament) is between the ligament and the medial facet on the inferior surface of the talar head.

The joint between the navicular and talus is the largest part of the talocalcaneonavicular joint and is between the ovoid anterior end of the talar head and the corresponding concave posterior surface of the navicular.

Question 25

Describe the ligamentous reinforcement of the talocalcaneonavicular joint

Answer 25

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posteriorly by the interosseous talocalcaneal ligament,

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superiorly by the talonavicular ligament, which passes between the neck of the talus and adjacent regions of the navicular, and

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inferiorly by the plantar calcaneonavicular ligament (spring ligament)

Question 26

Describe the lateral reinforcement of the talocalceonavicular joint

Answer 26

The lateral part of the talocalcaneonavicular joint is reinforced by the calcaneonavicular part of the bifurcate ligament, which is a Y-shaped ligament superior to the joint. The base of the bifurcate ligament is attached to the anterior aspect of the superior surface of the calcaneus and its arms are attached to:

▪
the dorsomedial surface of the cuboid (calcaneocuboid ligament), and

▪
the dorsolateral part of the navicular (calcaneonavicular ligament).

Question 27

Describe the plantar calcaneonavicular ligament

Answer 27

The plantar calcaneonavicular ligament (spring ligament) is a broad thick ligament that spans the space between the sustentaculum tali behind and the navicular bone in front (Fig. 6.102B,C). It supports the head of the talus, takes part in the talocalcaneonavicular joint, and resists depression of the medial arch of the foot.

Question 28

Describe the calaneocuboid joint

Answer 28

The calcaneocuboid joint is a synovial joint between:

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the facet on the anterior surface of the calcaneus, and

▪
the corresponding facet on the posterior surface of the cuboid.

The calcaneocuboid joint allows sliding and rotating movements involved with inversion and eversion of the foot, and also contributes to pronation and supination of the forefoot on the hindfoot.

Question 29

Describe the plantar calcaneocuboid ligament

Answer 29

The plantar calcaneocuboid ligament (short plantar ligament) is short, wide, and very strong, and connects the calcaneal tubercle to the inferior surface of the cuboid (Fig. 6.103A). It not only supports the calcaneocuboid joint, but also assists the long plantar ligament in resisting depression of the lateral arch of the foot.

Question 30

Describe the long plantar ligament

Answer 30

The long plantar ligament is the longest ligament in the sole of the foot and lies inferior to the plantar calcaneocuboid ligament (Fig. 6.103B):

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Posteriorly, it attaches to the inferior surface of the calcaneus between the tuberosity and the calcaneal tubercle.

▪
Anteriorly, it attaches to a broad ridge and a tubercle on the inferior surface of the cuboid bone behind the groove for the fibularis longus tendon.

More superficial fibers of the long plantar ligament extend to the bases of the metatarsal bones.

The long plantar ligament supports the calcaneocuboid joint and is the strongest ligament, resisting depression of the lateral arch of the foot.

Question 31

Describe the tarsometatarsal joint

Answer 31

The tarsometatarsal joints between the metatarsal bones and adjacent tarsal bones are plane joints and allow limited sliding movements

The range of movement of the tarsometatarsal joint between the metatarsal of the great toe and the medial cuneiform is greater than that of the other tarsometatarsal joints and allows flexion, extension, and rotation. The tarsometatarsal joints, with the transverse tarsal joint, take part in pronation and supination of the foot.

Question 32

Describe the metatarsal- phalangeal joints

Answer 32

The metatarsophalangeal joints are ellipsoid synovial joints between the sphere-shaped heads of the metatarsals and the corresponding bases of the proximal phalanges of the digits.

The metatarsophalangeal joints allow extension and flexion, and limited abduction, adduction, rotation, and circumduction.

The joint capsules are reinforced by medial and lateral collateral ligaments, and by plantar ligaments, which have grooves on their plantar surfaces for the long tendons of the digits

Question 33

Describe the interphalangeal joints of the foot

Answer 33

The interphalangeal joints are hinge joints that allow mainly flexion and extension. They are reinforced by medial and lateral collateral ligaments and by plantar ligaments

Collateral joints aid flexion/extension

Question 34

Describe the deep transverse metatarsal ligaments

Answer 34

Four deep transverse metatarsal ligaments link the heads of the metatarsals together and enable the metatarsals to act as a single unified structure (Fig. 6.104). The ligaments blend with the plantar ligaments of the adjacent metatarsophalangeal joints.

Question 35

Why is the range of motion of the big toe not as free as the thumb

Answer 35

The metatarsal of the great toe is oriented in the same plane as the metatarsals of the other toes and is linked to the metatarsal of the second toe by a deep transverse metatarsal ligament. In addition, the joint between the metatarsal of the great toe and medial cuneiform has a limited range of motion. The great toe therefore has a very restricted independent function—unlike the thumb in the hand, where the metacarpal is oriented 90° to the metacarpals of the fingers, there is no deep transverse metacarpal ligament between the metacarpals of the thumb and index finger, and the joint between the metacarpal and carpal bone allows a wide range of motion.

Question 36

What is a bunion

Answer 36

A bunion occurs on the medial aspect of the first metatarsophalangeal joint. This is an extremely important area of the foot because it is crossed by tendons and ligaments, which transmit and distribute the body’s weight during movement. It is postulated that abnormal stresses in this region of the joint may produce the bunion deformity.
Clinically, a bunion is a significant protuberance of bone that may include soft tissue around the medial aspect of the first metatarsophalangeal joint. As it progresses, the toe appears to move toward the smaller toes, producing crowding of the digits.
This deformity tends to occur among people who wear high-heeled or pointed shoes, but osteoporosis and a hereditary predisposition are also risk factors.
Typically the patient’s symptoms are pain, swelling, and inflammation. The bunion tends to enlarge and may cause problems in obtaining appropriate footwear.
Initial treatment is by adding padding to shoes, changing the type of footwear used, and taking anti-inflammatory drugs. Some patients may need surgery to correct the deformity and realign the toe.

Question 37

Describe the tarsal tunnel

Answer 37

The tarsal tunnel is formed on the posteromedial side of the ankle by:
▪
a depression formed by the medial malleolus of the tibia, the medial and posterior surfaces of the talus, the medial surface of the calcaneus, and the inferior surface of the sustentaculum tali of the calcaneus; and
▪
an overlying flexor retinaculum

Question 38

Describe the contents of the tarsal tunnel from medial to lateral

Answer 38

Tendon of tibialis posterior 
Tendon of flexor digitorum longus 
Posterior tibial artery 
Tibial nerve 
Tendon of flexor hallucis longus  

The pulse of the posterior tibial artery can be felt through the flexor retinaculum midway between the medial malleolus and the calcaneus.

Question 39

What is the flexor retinaculum of the foot

Answer 39

The flexor retinaculum is a strap-like layer of connective tissue that spans the bony depression formed by the medial malleolus, the medial and posterior surfaces of the talus, the medial surface of the calcaneus, and the inferior surface of the sustentaculum tali (Fig. 6.105). It attaches above to the medial malleolus and below and behind to the inferomedial margin of the calcaneus.
The retinaculum is continuous above with the deep fascia of the leg and below with the deep fascia (plantar aponeurosis) of the foot.

Question 40

Describe the role of septa from the flexor retinaculum

Answer 40

Septa from the flexor retinaculum convert grooves on the bones into tubular connective tissue channels for the tendons of the flexor muscles as they pass into the sole of the foot from the posterior compartment of the leg (Fig. 6.105). Free movement of the tendons in the channels is facilitated by synovial sheaths, which surround the tendons.

Question 41

Describe the anatomy of the extensor retinacula

Answer 41

Two extensor retinacula strap the tendons of the extensor muscles to the ankle region and prevent tendon bowing during extension of the foot and toes (Fig. 6.106):
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A superior extensor retinaculum is a thickening of deep fascia in the distal leg just superior to the ankle joint and attached to the anterior borders of the fibula and tibia.
▪
An inferior retinaculum is Y-shaped, attached by its base to the lateral side of the upper surface of the calcaneus, and crosses medially over the foot to attach by one of its arms to the medial malleolus, whereas the other arm wraps medially around the foot and attaches to the medial side of the plantar aponeurosis.

Question 42

Which structures pass under the extensor retinacula

Answer 42

The tendons of the extensor digitorum longus and fibularis tertius pass through a compartment on the lateral side of the proximal foot. Medial to these tendons, the dorsalis pedis artery (terminal branch of the anterior tibial artery), the tendon of the extensor hallucis longus muscle, and finally the tendon of the tibialis anterior muscle pass under the extensor retinacula.

Question 43

What are the fibular retinacula

Answer 43

Fibular (peroneal) retinacula bind the tendons of the fibularis longus and fibularis brevis muscles to the lateral side of the foot (Fig. 6.107):
▪
A superior fibular retinaculum extends between the lateral malleolus and the calcaneus.
▪
An inferior fibular retinaculum attaches to the lateral surface of the calcaneus around the fibular trochlea and blends above with the fibers of the inferior extensor retinaculum.

At the fibular trochlea, a septum separates the compartment for the tendon of the fibularis brevis muscle above from that for the fibularis longus below

Question 44

What is important to remember about the orientation of the foot

Answer 44

The bones of the foot do not lie in a horizontal plane. Instead, they form longitudinal and transverse arches relative to the ground (Fig. 6.108), which absorb and distribute downward forces from the body during standing and moving on different surfaces.

Question 45

Describe the longitudinal arch

Answer 45

The longitudinal arch of the foot is formed between the posterior end of the calcaneus and the heads of the metatarsals (Fig. 6.108A). It is highest on the medial side, where it forms the medial part of the longitudinal arch, and lowest on the lateral side, where it forms the lateral part.

Question 46

Describe the transverse arch

Answer 46

The transverse arch of the foot is highest in a coronal plane that cuts through the head of the talus and disappears near the heads of the metatarsals, where these bones are held together by the deep transverse metatarsal ligaments

Question 47

Describe the ligament and muscle support of the arches

Answer 47

Ligaments and muscles support the arches of the foot (Fig. 6.109):
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Ligaments that support the arches include the plantar calcaneonavicular (spring ligament), plantar calcaneocuboid (short plantar ligament), and long plantar ligaments, and the plantar aponeurosis.
▪
Muscles that provide dynamic support for the arches during walking include the tibialis anterior and posterior and the fibularis longus.

Question 48

What is the plantar aponeurosis

Answer 48

The plantar aponeurosis is a thickening of deep fascia in the sole of the foot (Fig. 6.110). It is firmly anchored to the medial process of the calcaneal tuberosity and extends forward as a thick band of longitudinally arranged connective tissue fibers. The fibers diverge as they pass anteriorly and form digital bands, which enter the toes and connect with bones, ligaments, and dermis of the skin.
Fibres fuse with the fibrous flexor sheaths an the metatarsophalangeal joint capsules
Plantar fasciitis is a common painful inflammation of the fascia

Question 49

What connects the digital bands plantar aponeurosis

Answer 49

Distal to the metatarsophalangeal joints, the digital bands of the plantar aponeurosis are interconnected by transverse fibers, which form superficial transverse metatarsal ligaments.
The plantar aponeurosis supports the longitudinal arch of the foot and protects deeper structures in the sole.

Question 50

Describe the fibrous sheaths

Answer 50

The tendons of the flexor digitorum longus, flexor digitorum brevis, and flexor hallucis longus muscles enter fibrous digital sheaths or tunnels on the plantar aspect of the digits (Fig. 6.111). These fibrous sheaths begin anterior (as synovial sheaths) to the metatarsophalangeal joints and extend to the distal phalanges then as fibrous digital sheaths. They are formed by fibrous arches and cruciate (cross-shaped) ligaments attached posteriorly to the margins of the phalanges and to the plantar ligaments associated with the metatarsophalangeal and interphalangeal joints.

Question 51

What is the function of the fibrous sheaths

Answer 51

These fibrous tunnels hold the tendons to the bony plane and prevent tendon bowing when the toes are flexed. Within each tunnel, the tendons are surrounded by a synovial sheath.

Question 52

What are the extensor hoods formed by and describe their anatomy

Answer 52

The tendons of the extensor digitorum longus, extensor digitorum brevis, and extensor hallucis longus pass into the dorsal aspect of the digits and expand over the proximal phalanges to form complex dorsal digital expansions (“extensor hoods”)

Each extensor hood is triangular in shape with the apex attached to the distal phalanx, the central region attached to the middle (toes II to V) or proximal (toe I) phalanx, and each corner of the base wrapped around the sides of the metatarsophalangeal joint. The corners of the hoods attach mainly to the deep transverse metatarsal ligaments.

Question 53

What is thought to be the function of these extensor hoods

Answer 53

Many of the intrinsic muscles of the foot insert into the free margin of the hood on each side. The attachment of these muscles into the extensor hoods allows the forces from these muscles to be distributed over the toes to cause flexion of the metatarsophalangeal joints while at the same time extending the interphalangeal joints (Fig. 6.112). The function of these movements in the foot is uncertain, but they may prevent overextension of the metatarsophalangeal joints and flexion of the interphalangeal joints when the heel is elevated off the ground and the toes grip the ground during walking.

Question 54

Summarise the course of arteries in the region

Answer 54

Arteries:
Femoral artery passes through the adductor hiatus to become the popliteal artery
Popliteal splits at knee to form posterior and anterior tibial arteries
Anterior tibial artery passes through aperture in interosseous membrane to enter anterior compartment and travel with the deep fibular (peroneal) nerve, becoming the dorsalis pedis artery in the foot
Posterior tibial artery remains in the posterior compartment but forms the fibular (peroneal artery) for the lateral compartment

Question 55

Describe the popliteal artery

Answer 55

The popliteal artery appears in the popliteal fossa on the upper medial side under the margin of the semimembranosus muscle. It descends obliquely through the fossa with the tibial nerve and enters the posterior compartment of the leg where it ends just lateral to the midline of the leg by dividing into the anterior and posterior tibial arteries.
The popliteal artery is the deepest of the neurovascular structures in the popliteal fossa and is therefore difficult to palpate; however, a pulse can usually be detected by deep palpation near the midline.
In the popliteal fossa, the popliteal artery gives rise to branches, which supply adjacent muscles, and to a series of geniculate arteries, which contribute to vascular anastomoses around the knee.

Question 56

Summarise the superficial veins of the region

Answer 56

Superficial veins
Dorsal venous arch
Long saphenous vein
Short saphenous vein
Perforating veins to the deep system (mainly in the calf)
Valves!

Question 57

Summarise the deep veins of the region

Answer 57

Deep calf veins – venae comitantes of arteries
Popliteal vein
Femoral vein
External iliac vein
Sapheno-femoral junction
Venae comitantes of the profunda femoris artery

Question 58

Describe the arteries of the foot

Answer 58

Dorsalis pedis – dorsal part of the foot and digits

Posterior tibial artery – sole of the foot (via the medial and lateral plantar arteries)

Question 59

What is the arch shaped artery on the dorsum of the foot

Answer 59

Arcuate artery

Question 60

Which small arteries supply the digits

Answer 60

Dorsal and plantar digital arteries

Question 61

What are the main superficial veins of the foot and le and where do they drain

Answer 61

Long saphenous vein (from the medial end of the dorsal venous arch, going 2 cm above and lateral to the medial malleolus and along the medial side of the leg) - It passes along the medial side of the leg and it drains into the femoral vein at the saphenofemoral junction
Short saphenous vein (from the lateral end of the dorsal venous arch, going behind the lateral malleolus) - It drains into the popliteal vein

Question 62

State the ankle motor nerve supplies

Answer 62

e. Ankle Dorsiflexors
L45
f. Ankle Plantarflexors
S12

Question 63

What is a good way for remembering the segmental sensory supply to the lower limb

Answer 63

L3 to the knee
L4 to the floor
L5 to the great toe
S1 to the lateral side and sole of the foo

Question 64

Summarise the motor peripheral supply

Answer 64

Femoral nerve : Knee Extensors
Sciatic Nerve : Hamstrings
Tibial nerve : Posterior Compartment and
				Foot intrinsics
Common Peroneal Nerve : Anterior and Lateral Compartments

Question 65

Summarise the tibial nerve

Answer 65

Posterior Compartment of the Leg
Passes behind medial malleolus to divide into:
Medial plantar nerve
Lateral plantar nerve
All intrinsics except extensor digitorum brevis

Question 66

Summarise the common peroneal nerve

Answer 66

Winds around the neck of the fibula
Deep Peroneal Nerve: anterior compartment
Superficial Peroneal nerve: lateral compartment

Question 67

What is the sural nerve made up of

Answer 67

A branch of the tibial nerve (medial sural cutaneous nerve) and a smaller branch of the common peroneal nerve (sural communicating branch)
NOTE: it can be used in nerve repair

Question 68

Describe the knee joint when standing

Answer 68

When standing, the knee joint is locked into position, thereby reducing the amount of muscle work needed to maintain the standing position

Question 69

Describe the features of the knee joint that contribute to its locking mechanism

Answer 69

One component of the locking mechanism is a change in the shape and size of the femoral surfaces that articulate with the tibia:
▪
In flexion, the surfaces are the curved and rounded areas on the posterior aspects of the femoral condyles.
▪
As the knee is extended, the surfaces move to the broad and flat areas on the inferior aspects of the femoral condyles.
Consequently the joint surfaces become larger and more stable in extension.
Another component of the locking mechanism is medial rotation of the femur on the tibia during extension. Medial rotation and full extension tightens all the associated ligaments.
Another feature that keeps the knee extended when standing is that the body’s center of gravity is positioned along a vertical line that passes anterior to the knee joint.

Question 70

What unlocks the knee joint

Answer 70

The popliteus muscle unlocks the knee by initiating lateral rotation of the femur on the tibia.

Question 71

Describe Lachman’s test

Answer 71

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Lachman’s test—the patient lies on the couch. The examiner places one hand around the distal femur and the other around the proximal tibia and then elevates the knee, producing 20° of flexion. The patient’s heel rests on the couch. The examiner’s thumb must be on the tibial tuberosity. The hand on the tibia applies a brisk anteriorly directed force. If the movement of the tibia on the femur comes to a sudden stop, it is a firm endpoint. If it does not come to a sudden stop, the endpoint is described as soft and is associated with a tear of the anterior cruciate ligament

Question 72

Describe the anterior drawer test

Answer 72

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Anterior drawer test—a positive anterior drawer test is when the proximal head of a patient’s tibia can be pulled anteriorly on the femur. The patient lies supine on the couch. The knee is flexed to 90° and the heel and sole of the foot are placed on the couch. The examiner sits gently on the patient’s foot, which has been placed in a neutral position. The index fingers are used to check that the hamstrings are relaxed while the other fingers encircle the upper end of the tibia and pull the tibia. If the tibia moves forward, the anterior cruciate ligament is torn. Other peripheral structures, such as the medial meniscus or meniscotibial ligaments, must also be damaged to elicit this sign.

Question 73

Describe the pivot shift test

Answer 73

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Pivot shift test—there are many variations of this test. The patient’s foot is wedged between the examiner’s body and elbow. The examiner places one hand flat under the tibia pushing it forward with the knee in extension. The other hand is placed against the patient’s thigh pushing it the other way. The lower limb is taken into slight abduction by the examiner’s elbow with the examiner’s body acting as a fulcrum to produce the valgus. The examiner maintains the anterior tibial translation and the valgus and initiates flexion of the patient’s knee. At about 20°–30° the pivot shift will occur as the lateral tibial plateau reduces. This test demonstrates damage to the posterolateral corner of the knee joint and the anterior cruciate ligament.

Question 74

Describe the posterior drawer test

Answer 74

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Posterior drawer test—a positive posterior drawer test occurs when the proximal head of a patient’s tibia can be pushed posteriorly on the femur. The patient is placed in a supine position and the knee is flexed to approximately 90° with the foot in the neutral position. The examiner sits gently on the patient’s foot placing both thumbs on the tibial tuberosity and pushing the tibia backward. If the tibial plateau moves, the posterior cruciate ligament is torn.

Question 75

Describe the peripheral sensory supply

Answer 75

Sensory branches of the femorla nerve (L2-4) supply the front of the thigh
The saphenous nerve, a branch of the femoral nerve, supplies a strip of skin along the inner border of the leg and ankle. This nerve accompanies the long saphenous vein.
The sural nerve- a branch of the tibial nerve in the popliteal fossa- supplies the lateral aspect of the leg and foot- accompanies the short saphenous vein
Superficial peroneal nerve- most of the dorsum of the foot
Deep peroneal nerve- a patch of skin on the dorsum of the foot at the base of the great and second toes
Medial and lateral nerves- the sole of the foot.

Question 76

Describe the stance phase of the gait cycle

Answer 76

§ Gait can be divided into the swing phase and stance phase.
o Stance phase:
1. Heel strike. Gluteus maximus, tibialis anterior.
2. Loading response. Quadriceps femoris.
3. Mid-stance. Triceps surae.
4. Terminal stance. Triceps surae.

Question 77

Describe the swing phase of the gait cycle

Answer 77

Swing phase:
1. Pre-swing. Rectus femoris, plantar flexors, flexors of toes, intrinsic foot.
2. Initial & mid-swing. Iliopsoas, rectus femoris, hip abductors.
3. Terminal swing. Hamstrings, tibialis anterior, quadriceps femoris.
§ The gluteal maximus and minimus remain contracted during the single support stages

Question 78

Describe the characteristics of the ligaments that help maintain the arches of the foot

Answer 78

Cannot change their tension, although they can become stretched
During gait (walking and running), muscles assume an important role since they can contract and vary the tension exerted by their tendons as required.
The important muscles are the intrinsic muscles of the foot, together with the tibialis anterior and posterior on the medial side and the peroneus longus and brevis on the lateral side.
Muscles tend to contract to raise the arches before they are loaded with body weight and then gradually relax as the ligaments start to take the load.