Lower Limb 5
Tibialis Anterior Strain(shin splint)
Dan's car broke down. He was jogging to school. However he did not warm up. He developed a mild form of anterior compartment syndrome that resulted from small tears in the periosteum covering the shaft of the tibia and/or of fleshy attachments to the overlying deep fascia of the leg. What is he condition equally referred to as?
a Y-shaped band of deep fascia, attaches laterally to the anterosuperior surface of the calcaneus. It forms a strong loop around the tendons of the fibularis tertius and the extensor digitorum longus muscles
Describe the inferior extensor retinaculum.
Gastrocnemius strain (tennis leg)
During a particularly intense tennis match Adam deliver a perfect serve down the middle of the court. In order to return the serve, Kurt fully extends the knee and dorsiflexes the ankle joint. Despite his efforts Kurt misses the ball completely and falls to the ground experiencing an abrupt onset of stabbing pain and subsequent edema and spasm of the gastrocnemius. Luckily Veronica and Amanda were serving as ball girls and rushed over to Kurt and properly diagnosed Kurt with what?
Calcaneal Bursitis (retroachilles bursitis) results from inflammation of the bursa of the calcaneal tendon located between the calcaneal tendon and the superior part of the posterior surface of the calcaneus
Having once again missed the bus, Kurt decides to run to school in his brand new running shoes. After a few miles Kurt beings to experience pain posterior to the heel. Coincidentally, Amanda was driving by and decided to give Kurt a ride to school. After explaining his pain, Amanda correctly diagnoses Kurt with what?
Calcaneal tendinitis Inflammation of the calcaneal tendon constitutes 9-18% of running injuries Calcaneal tendinitis often occurs during repetitive activities, especially in individuals who take up running after prolonged inactivity or suddenly increase the intensity of their training,
Having slept in for the last week, Kurt has begun to routinely run to catch his bus. After his most recent sprint, Kurt notices pain superior to his calcaneous on a walk to Proctors. What is your diagnosis?
Deep fibular nerve entrapment (ski boot syndrome)
Kurt and Dan were out dancing all night.(homo) When Kurt developed pain in the dorsum of his foot that radiated to the webspace between his first and second toes. This resulted from excessive use of the muscles supplied by his deep(no homo) fibular nerve. This condition is equally referred to as?
fasciotomy
Loss of distal pulses is an obvious sign of arterial compression, as is a lowering of the temperature of tissues distal to the compression. A ____ (incision of the overlying fascia or a septum) may be performed to relieve the pressure in the compartment(s) concerned.
Ruptured Calcaneal Tendon
Once again Kurt sleeps in and is late for his bus. As he sprints out the door, he makes a sharp left turn and his foot slips on the tile. Kurt hears an audible snap and experiences immediate sudden calf pain and sudden dorsiflexion. Luckily, for some unknown reason, Adam emerges from Kurt's front door and is able to call and ambulance and diagnose what?
Individuals with this injury cannot plantarflex against resistance (cannot raise the heel from the ground or balance on the affected side),
Once at the hospital, the Dr. Okorie is able to confirm Adam's diagnosis when Kurt is unable to perform which movement against resistance?
popliteal fossa
Suppuration (formation of pus) from purulent (pus-forming) infections in the lateral compartment of the leg, can ascend proximally into the _____.
False! laterally over the neck of the fibula to the anastomoses around the knee.
T/F? The circumflex fibular artery arises from the origin of the anterior or posterior tibial artery at the knee and passes medially over the neck of the fibula to the anastomoses around the knee.
compartment syndrome
The anterior compartment is relatively small, therefore it is most susceptible to ___ syndrome.
dorsiflexor (extensor) compartment
The anterior compartment of the leg is equally referred to as:
knee and ankle
The bones of the leg connect the ___ and the ___.
perforating branches
The lateral compartment does not have an artery coursing through it. _____ and accompanying veins supply blood to and drain blood from the compartment.
The tibial nerve and posterior tibial and fibular vessels supply both parts of the posterior compartment but run in the deep subcompartment deep (anterior) to the transverse intermuscular septum.
The plantarflexor compartment is ivided into superficial and deep subcompartments/muscle groups by the transverse intermuscular septum. What nerve and vessels supply supply both parts of the posterior compartment but run in the deep subcompartment deep (anterior) to the transverse intermuscular septum?
Anterior tibial artery
This artery Passes between tibia and fibula into anterior compartment through gap in superior part of interosseous membrane and descends this membrane between tibialis anterior and extensor digitorum longus
Popliteal artery
This artery Passes through popliteal fossa to leg; ends at lower border of popliteus muscle by dividing into anterior and posterior tibial arteries
Dorsal artery of foot (L. dorsalis pedis)
This artery distributes to Muscles on dorsum of foot; pierces first dorsal interosseous muscles as deep plantar artery to contribute to formation of plantar arch
Fibular artery
This artery distributes to the posterior compartment of leg: perforating branches supply lateral compartment of leg.
Posterior tibial artery
This artery passes through posterior compartment of leg and terminates distal to flexor retinaculum by dividing into medial and lateral plantar arteries
-tibialis posterior -innervation: tibial nerve L4, L5 -inverts foot
This muscle is part of the same compartment as flexor digitorum longus, flexor hallucis longus and popliteus. What is the muscle? What is its innervation? Does it invert or evert foot or neither inver nor evert foot?
Deep fibular nerve
This nerve Supplies anterior muscles of leg, dorsum of foot, and skin of first interdigital cleft; sends articular branches to joints it crosses.
Superficial fibular nerve
This nerve Supplies fibularis longus and brevis and skin on distal third of anterior surface of leg and dorsum of foot.
Sural nerve
This nerve descends between heads of gastrocnemius and becomes superficial at middle of leg; descends with small saphenous vein and passes inferior to lateral malleolus to lateral side of foot. It supplies skin on posterior and lateral aspects of leg and lateral side of foot
Saphenous nerve
This nerve descends with femoral vessels through femoral triangle and adductor canal and then descends with great saphenous vein and it supplies skin on medial side of ankle and foot.
Common fibular nerve
This nerve forms as sciatic bifurcates at apex of popliteal fossa and follows medial border of biceps femoris and its tendon; passes over posterior aspect of head of fibula and then winds around neck of fibula deep to fibularis longus, where it divides into deep and superficial fibular nerves.
Tibial nerve
This nerve forms as sciatic bifurcates at apex of popliteal fossa; descends through popliteal fossa and lies on popliteus; runs inferiorly on tibialis posterior with posterior tibial vessels; terminates beneath flexor retinaculum by dividing into medial and lateral plantar nerves and supplies posterior muscles of leg and knee joint
what is tibial nerve
This nerve innervates the muscles of the posterior compartment of the LEG:
Posterior Tibial Pulse
This pulse can usually be palpated between the posterior surface of the medial malleolus and the medial border of the calcaneal tendon .
L4, 5 S1-3
Tibial nerve roots
S1
Upon damage to which nerve root will the ankle reflex be virutally absent?
fibularis brevis
Violent inversion of the foot may cause avulsion of the tuberosity of the 5th metatarsal, the distal attachment of _____. This avulsion fracture is associated with a severely sprained ankle. Injury to the associated superficial fibular nerve causes inversion of the foot because of paralysis of the fibular muscles in the lateral compartment.
Muscles of the posterior compartment produce -plantarflexion at the ankle, -inversion at the subtalar and transverse tarsal joints, -flexion of the toes.
What 3 actions do muscles in the posterior compartment of the leg produce?
anterior, lateral, posterior
What are the three compartments of the leg?
The fibular artery
What artery gives off a perforating branch, terminal lateral malleolar and calcaneal branches.?
the medial malleolus,
What bony structure does the tibial nerve run posterior to?
the medial sural cutaneous nerve
What branch of the tibial nerve is usually joined by the sural communicating branch of the common fibular nerve to form the sural nerve to supply the skin of the lateral and posterior part of the inferior third of the leg and the lateral side of the foot.
The fibular artery
What gives muscular branches to the popliteus and other muscles in both the posterior and the lateral compartments of the leg and is the largest branch of the tibial artery?
1. Innervation by Tibial nerve s1, s2 2. Distal attachment of the posterior surface of calcaneus via calcaneal tendon 3. action common to all: plantarflexing ankle
What is common about the 3 superficial muscles of the posterior compartment of the leg (Gastrocnemius, soleus and plantaris)?
A venous plexus deep to the triceps surae
What is involved in the return of blood from the leg?
Accessory soleus
What is present in approximately 3% of people, and usually appears as a distal belly medial to the calcaneal tendon, and may be associated with pain and edema during prolonged exercise.
extensor digitorum longus
What is the arrow point to?
extensor hallucis longus
What is the arrow pointing to?
crosses the ankle joint and prevents it from bowstringing anteriorly during dorsiflexion of the joint
What is the function of the superior extensor retinaculum and the inferior extensor retinaculum?
Posterior tibial artery
What is the larger and more direct terminal branch of the popliteal artery, that provides the blood supply to the posterior compartment of the leg and to the foot?
plantarflexor compartment
What is the largest compartment of the leg?
-Soleus -Plantarflexes ankle INDEPENDENT OF POSITION OF KNEE; steadies leg on foot -Posterior aspect of head of fibula; superior quarter of posterior surface of fibula soleal line, medial border, and of tibia
What is the muscle seen in the picture (arrow)? What action does it cause? What is its origin?
-Gastrocnemius -Plantarflexes ankle WHEN KNEE IS EXTENDED; raises heel during walking; flexes leg at knee joint -tibial nerve s1, s2
What is the muscle seen in the picture (arrow)? What action does it cause? What nerve innervates it?
-flexor hallucis longus -inserts on base of distal phalanx of great toe -innervation: tibial nerve S2, S3 -has 3 actions -plantarflexion of ankle, weak -flexor digitorum longus, tibialis posterior and the superficial muscles of the posterior compartment of the leg also plantarflex ankle
What is the muscle seen in the picture? What is its insertion? What is its innervation? What muscles also perform an action that is the same as this muscle?
-flexor digitorum longus -supports longitudinal arches of foot -origin: medial part of posterior surface of tibia inferior to soleal line; by a broad tendon to fibula
What is the muscle shown in the picture? Which arch of the foot is it responsible for supporting? What is its origin?
proximal: lateral condyle of the tibia distal: middle and distal phalanges of lateral four digits innervation: deep fibular nerve (L5, S1) action: extends lateral 4 digits, dorsiflexs ankle
What is the proximal attachment, distal attachment, innervation, and main action of the extensor digitorum longus?
proximal: middle part of the anterior fibula distal: dorsal aspect of the base of the distal phalanx of the great toe (hallux) innervation: deep fibular nerve (L5, S1) action: extends great toe, dorsiflexes ankle
What is the proximal attachment, distal attachment, innervation, and main action of the extensor hallicus longus?
poximal: lateral condyle distal: Medial and inferior surfaces of medial cuneiform and base of 1st metatarsal innervation: deep fibular nerve (L4, L5) action: dorsiflexes ankle, inverts foot
What is the proximal attachment, distal attachment, innervation, and main action of the tibialis anterior?
-Plantaris -Weakly assists gastrocnemius in plantarflexing ankle
What muscle is indicated by the arrow? Which muscle does it work with to plantarflex the ankle?
-Popliteus -Weakly flexes knee and unlocks it by rotating femur on fixed tibia; medially rotates tibia of unplanted limb -Tibial nerve L4, L5, S1 -Deep muscle of the posterior compartment of the leg
What muscle is seen in the picture? What is its action? What is its innervation? What group of muscles is it part of?
fibularis tertius
What muscle is the arrow pointing to?
tibialis anterior
What muscle is the arrow pointing to?
L4-S3 -same as sciatic nerve from which it originates
What roots form the origin of the tibial nerve?
tibial nerve and veins.
What two structures accompany the posterior tibial artery during its descent?
The transverse intermuscular septum ends as reinforcing transverse fibers that extend between the tip of the medial malleolus and the calcaneus to form the flexor retinaculum.
Where does the transverse intermuscular septum end and what does it help to form?
located anterior to the interosseous membrane, between the lateral surface of the tibial shaft and the medial surface of the fibular shaft, and anterior to the intermuscular septum that connects them.
Where is the anterior compartment of the leg located?
The nutrient artery of the tibia,
Which artery pierces the tibialis posterior and enters the nutrient foramen in the proximal third of the posterior surface of the tibia?
Superficial fibular nerve
a terminal branch of the common fibular nerve, After supplying the Fibularis longus and Fibularis brevis continues as a cutaneous nerve, supplying the skin on the distal part of the anterior surface of the leg and nearly all the dorsum of the foot.
Because the nerve and blood vessels supplying the entire posterior compartment and the sole of the foot pass through the deep subcompartment.
when swelling occurs it leads to a compartment syndrome that has serious consequences. Why?
the knee joint, and the skin of the heel.
Articular branches and medial calcaneal branches of the tibial nerve supply?
Posterior inferior medial malleolus
At what land mark does the tibial nerve divides into the medial and lateral plantar nerves?
common fibular
Because of its superficial position, the _____ is the nerve most often injured in the lower limb, mainly because it winds subcutaneously around the fibular neck, leaving it vulnerable to direct trauma. This nerve may also be severed during fracture of the fibular neck or severely stretched when the knee joint is injured or dislocated. Severance results in flaccid paralysis of all muscles in the anterior and lateral compartments of the leg (dorsiflexors of the ankle and evertors of the foot). The loss of dorsiflexion of the ankle causes footdrop.
Superficial fibular nerve (Superficial fibular nerve entrapment)
Chronic ankle sprains may produce recurrent stretching of the ____ which may cause pain along the lateral side of the leg and the dorsum of the ankle and foot. Numbness and paresthesia (tickling or tingling) may be present and increase with activity.
Fabella in the Gastrocnemius
Close to its proximal attachment, the lateral head of the gastrocnemius contains a sesamoid bone which articulates with the lateral femoral condyle and is visible in lateral radiographs of the knee in 3-5% of people .