Dr. Sangeeta Kotrannavar Assistant Professor Dept. of Anatomy USM-KLE IMP, Belagavi
Describe the bony landmarks of tibia and fibula Describe the osteology of tibia, fibula, tarsals, metatarsals and phalanges State the anterior, posterior and lateral compartments of the leg Describe the attachments, actions and innervations of the muscles in each compartment
Describe the blood supply and nerve supply in each compartment
Describe the tarsal tunnel and its contents State the four layers of muscles in the sole of the foot Describe the blood supply and innervation of the sole of the foot Explain the arches of the foot and its significant Describe the applied anatomy of the foot Leg is between the knee and ankle joint – bones tibia & fibula Foot is distal to the ankle joint
Lat. Medial
Tibia is large, weight-bearing shin bone Medially placed, Long bone Equivalent to radius Parts Upper end, Lower end, Shaft
• Upper end - med. & Lat. Condyles, intercondylar area (non articular), tibial tuberosity • Condyles articulates with condyles of femur. • Intercondylar area—attachment fro before backwards: Ant. Horn of med. Miniscus, ant. Cruciate lig., ant. Horn of lat. Miniscus. post. Horn of lat. Miniscus, post. Horn of med. Miniscus, post. Cruciate lig. • Med. Condyle - post - semimembranosus. Ant. - sartorius, gracilus, semitendinosus. • Tibial tuberosity - ligamentum patellae. • Lower end - medial malleolus – tip - deltoid lig. • Shaft - triangular. Borders - ant., med., lat • Shaft - Surfaces - anteromedial (subcutaneous), anterolat. (extensor Tibialis anterior), post.(flexor) • Post. Surface divided by soleal line into upper(soleus) &lower. Lower area is divided by vertical line into med.(flexor digitorum longus) &lat. (Tibialis posterior)
femoral condyles
talus
Articulates with the femoral condyles superiorly the talus inferiorly the fibula laterally at its proximal and distal ends
fibula anterior view
Tibial tuberosity
Laterally placed, Long bone head The slender fibula lies posterolateral to the tibia and serves mainly for muscle
attachment shaft The fibula is not directly involved in weight bearing Equivalent to ulna Parts - Upper &lower end, shaft
Lower end
A –medial aspect B – Post.aspect C – lat. View of lower end
Upper end—Head, neck, styloid process Lower end—Lat. Malleolus; lower than med. Malleolus Shaft—Borders - anterior, inetrosseous, & poterior Shaft— surfaces – med., lat., & post. • The shafts of the tibia and fibula are connected by an interosseous membrane throughout most of their lengths
• Two apertures in the interosseous membrane allow vessels to pass between the anterior and posterior compartments
posterior tibiofibular • This expanded end of the interosseous ligaments membrane is reinforced by anterior and posterior tibiofibular ligaments anterior tibiofibular ligaments Tibial # at narrowest at middle & inferior junction Fibular # at proximal to lateral malleolus
Skin Superficial fascia Contains great saphenous vein & small saphenous vein Deep fascia Muscles Bones
Small saphenous opens into Popliteal vein. Provided 7 to 13 valves Applied aspect Varicose vein - Veins become tortious, dilated. Complications – Skin pigmented, ulcers. Deep fascia
Divided into Anterior/ extensor compartment Lateral / peroneal compartment Posterior compartment By Ant. & post. intermuscular septa & an interosseous membrane
Nerve - Deep peroneal nerve Action - dorsiflexor (extensor) compartment) TS of leg
Between—Introsseous membrane & deep fascia, medially extensor surface of tibia &laterally extensor surface of fibula. Contents Muscles: Four muscles (tibialis anterior, extensor hallucis longus, extensor digitorum longus, and peroneus tertius). Artery: Anterior tibial artery. Nerve: Deep peroneal nerve (anterior tibial nerve).
Muscle Origin Insertion Tibialis Upper 2/3 of lat. Base of 1st anterior Surface of shaft of metatarsl, med. tibia, introsseous cuneiform membrane Extensor Middle 2/4th of Base of terminal hallucis extensor surface of phalanx of great longus fibula toe Extensor Upper 3/4th of Middle & digitorum extensor surface of terminal phalanx longus fibula introsseous by dorsal digital membrane expansion Fibularis Lower ¼ th of ext. Base of 5th tertius surface of fibula metatarsal
Muscle Innervation Function Tibialis Dorsiflexes ankle joint; anterior inversion of foot; Supports medial Deep fibular / longitudinal arch of foot Extensor peroneal nerve Extension of great toe and hallucis Dorsiflexes ankle joint longus Extensor Extension of lateral four digitorum digits and Dorsiflexes ankle longus joint Fibularis Dorsiflexion and eversion tertius of foot
Eversion of foot Superficial fibular nerve
Boundaries Anterior: Anterior intermuscular septum. Posterior: Posterior intermuscular septum. Medial: Lateral surface of the fibula. Lateral: Deep fascia of the leg. Muscle Origin Insertion Fibularis Head & Base of first (peroneus) superior two metatarsal and longus (FL) thirds of lateral medial surface of fibula cuneiform Fibularis Inferior two Dorsal surface of (peroneus) thirds of lateral tuberosity on brevis (FB) surface of fibula lateral side of fifth metatarsal
Muscle Innervation Function Fibularis Superficial fibular Eversion and plantar (peroneus) /peroneal nerve flexion of foot; longus [L5,S1,S2] supports arches of foot Fibularis Eversion of foot (peroneus) brevis
Tibial nerve Plantar flexion
Contents Muscles: Superficial; gastrocnemius, plantaris, and soleus deep groups of the muscles Arteries: Tibial and peroneal arteries. Nerve: Tibial nerve.
Lies between anteriorly posterior surfaces of the tibia, fibula, interosseus membrane, and posterior intermuscular septum. Posterior: Deep fascia of the leg
Muscle Origin Insertion Gastrocn Lateral head: lateral aspect of Posterior surface Plantaris emius lateral condyle of femur of calcaneus via Medial head: popliteal surface of calcaneal tendon
femur, superior to medial Soleus condyle Soleus Posterior aspect of head of fibula, superior fourth of gastrocne mius posterior surface of fibula, soleal line, and medial border of tibia
Achilles Plantaris Inferior end of lateral On the posterior Tendon supracondylar line of femur and surface of oblique popliteal ligament calcaneus medial to tendocalcaneus Muscle Innervation Function Gastrocnemi Tibial nerve Plantar flexes foot, flexes us [S1,S2] knee, provides rapid movements of foot during running & jumping Soleus Plantar flexes foot Peripheral heart Plantaris Plantar flexes the foot and flexes knee
You stroll with soleus but win long jump with gastronemius Muscle Origin insertion Popliteus Lateral surface of lateral Posterior surface of condyle of femur & lateral tibia, superior to meniscus soleal line Tibialis Interosseous membrane; Tuberosity of posterior posterior surface of tibia navicular, cuneiform, inferior to soleal line; cuboid, & posterior surface of fibula sustentaculum tali of calcaneus; bases of 2nd, 3rd, and 4th metatarsals Flexor Inferior two thirds of Base of distal hallucis posterior surface of fibula; phalanx of great toe longus inferior part of interosseous (hallux) membrane Flexor Medial part of posterior Bases of distal digitoru surface of tibia inferior to phalanges of lateral m longus soleal line; by a broad tendon four digits to fibula Muscle Innervation Function Popliteus Tibial nerve Unlocks knee joint [L4 to S1] (laterally rotates femur on fixed tibia) Tibialis Tibial nerve Inversion and plantar posterior [L4,L5] flexion of foot; support of medial arch of foot Flexor Tibial nerve Flexes great toe, weak hallucis [S2,S3] plantar flexion, longus support of medial arch of foot Flexor Flexes lateral four toes, digitorum weak plantar flexion, longus support of medial arch of foot OSPE
5 6 1 3 2
4 anterior compartment ms Muscles in the anterior dorsiflexion compartment of leg dorsiflex the posterior ankle, extend the toes, and invert the compartment ms foot
Muscles in the posterior plantar flexion compartment plantarflex the ankle, flex the toes, and invert the foot
anterior compartment lateral compartment Muscles in the lateral compartment evert the foot
inversion eversion
Tarsus-7 Metatarsus-5 (I-V) Phalanges-14
Regions of foot Plantar (sole)-part contacting ground Dorsal- part directing superiorly Heel – sole underlying calcaneus
Calcaneus (Latin w. for heel) Talus (Latin w. for ankle) Cuboid Navicular Three cuneiforms
Anterior view Lateral view The foot and its bones may be considered in terms of three anatomical and functional parts
The hindfoot: talus and calcaneus The midfoot: navicular, cuboid, and cuneiforms. The forefoot: metatarsals and phalanges. Talocalcaneanavicular joint navicular
talus
calcaneus
Sagittal section of the foot showing talocrural and tarsal joints. (From Sobotta 2006.) There are five metatarsals in the foot, numbered I to V from medial to lateral
Metatarsal I, associated with the great toe, is shortest and thickest
Each metatarsal has a head at the distal end, an elongate shaft in the middle, and a proximal base
The head of each metatarsal articulates with the proximal phalanx of a toe
The base articulates with one or more of the distal group of tarsal bones The great toe (L. hallux) is also crescent-shaped called the 1st toe
head The little toe (L. digitus minimus) shaft is also called the 5th toe base head Consists of a base, a shaft, and a shaft distal head base
The head of each distal phalanx is non-articular and flattened into a crescent-shaped plantar tuberosity under the plantar pad at the end of the digit
The bones of the foot do not lie in a horizontal plane Instead, they form Longitudinal arch Transverse arch It absorb and distribute downward forces from the body during standing and moving on different surfaces Lateral view
is formed between the posterior end of the calcaneus and the heads of the metatarsals the medial part of the longitudinal arch is highest the lateral part is lowest
Anterior transverse arch is round shaped, formed by heads of 1-5 metatarsals, complete arch
Posterior transverse arch is wedge shaped, formed by navicular, 3 cuniforms, base & shaft of metatarsals, incomplete • Muscles that provide Ligaments and muscles dynamic support for support the arches of the foot the arches during Ligaments that support the walking include arches include – the tibialis anterior the plantar calcaneonavicular and posterior the plantar calcaneocuboidal – the fibularis longus the long plantar ligaments the plantar aponeurosis Extensor digitorum brevis This is a small muscle situated on the lateral part of the dorsum of foot, deep to the tendons of the extensor digitorum longus Nerve Supply- Lateral terminal branch of the deep peroneal nerve Actions Extensor digitorum brevis Extensor Extensor hallucis brevis - extends MTP joint of the hallucis great toe. brevis Extensor digitorum brevis - extend MTP and interphalangeal joints of the second, third and fourth toes, particularly in a dorsi-flexed foot It bind the tendons of the anterior compartment muscles
The superior extensor retinaculum is a strong, broad band of deep fascia, passing from the fibula to the tibia
The inferior extensor retinaculum, a Y-shaped band of deep fascia. The stem of the Y lies laterally, attached to the anterosuperior surface of the calcaneus and upper superior & band to medial malleolus and lower bands to plantar aponeurosis inferior extensor retinaculum The structures passing under cover of the extensor retinacula are muscles, nerve & artery of ant. compartment
Flexor retinaculum formed by deep fascia of post. Compartment Attached between tip of the medial malleolus & medial tubercle of the calcaneum
Peroneal retinaculum Superior peroneal retinaculum- It holds the peroneal tendons in place against the back of the lateral malleolus. It is attached between lateral malleolus & calcaneum Inferior peroneal retinaculum is situated anteroinferior to the lateral Flexor Sup. & inf.peroneal malleolus. retinaculum retinaculum- on the posteromedial side of the ankle a depression formed by the medial malleolus of the tibia, the medial and posterior surfaces of the talus and the medial surface of the calcaneus an overlying flexor retinaculum contains : vessels, flexor tendons and nerve
The plantar fascia holds the parts of the foot together, helps protect the sole from injury, and helps support the longitudinal arches of the foot. The thick, central part plantar fascia forms the strong plantar plantar aponeurosis aponeurosis The plantar aponeurosis arises posteriorly from the calcaneus and distally divides into 5 bands & continuous with the fibrous digital sheaths
Originate and insert in the foot
Of the 20 individual muscles of the foot, 14 are located on the plantar aspect, 2 are on the dorsal aspect, and 4 are intermediate in position.
all other intrinsic muscles are on the plantar side of the foot in the sole where they are organized into four layers.
Muscles in the sole of the foot are organized into 4 layers:
1) First layer - contains abductor hallucis, flexor digitorum brevis, abductor digiti minimi
2) Second layer - contains quadratus plantae, lumbricals
3) Third layer – contains flexor hallucis brevis, flexor digiti minimi brevis, adductor hallucis
4) Fourth layer – contains dorsal interossei, plantar interossei
Muscle Innervation Action
Abductor Medial Abducts hallucis plantar n. great toe Flexor Flexes lateral digitroum 4 toes brevis Abductor Lateral Abducts Abductor digiti plantar n. little toe hallucis minimi Abductor digiti minimi Flexor Ab –Flexor-Ab digitorum brevis Lumbricals
Muscle Innervation Action
Quadratus Lateral plantar Assist flexor plantae n. digitorum longus in (flexor flexing the toes digitorum accessorium) Lumbricals 1st – medial Maintain extension of -4 plantar nerve lateral four digits at 2nd, 3rd, 4th – interphalangeal joints. lateral (toes do not buckle plantar nerve under during walking or running)
Quadratus plantae Muscle Innervat Action Adductor ion hallucis Flexor Medial Flexes proximal hallucis plantar n. phalanx of 1st brevis digit at MPJ Adductor Lateral Adducts great hallucis plantar n. toe at MPJ Flexor Flexes little toe digiti at MPJ Flexor hallucis minimi Flexor brevis brevis digiti minimi Flexor –AD-Flexor brevis MPJ = Metatarsophalangeal joint Plantar Muscle Innervatio Action interossei n
Plantar Lateral Adduct digits P-AD interossei plantar n. and flex (3 in no. at 3- MPJs th 5 toes) Dorsal Dorsal Abduct digits interossei D-AB interossei and flex (4 in no. at 2- MPJs 5th digit)
MPJ = Metatarsophalangeal joint Anterior tibial artery Anterior tibial artery Posterior tibial artery Fibular artery Medial plantar artery Lateral plantar artery
Fibular artery Posterior tibial artery
Ant. Tibial supplies anterior compartment
Branches Dorsalis pedis - Imp for artery pulsation in peripheral neuropathy
Originate from popliteal artery
Passes into anterior compartment through gap in superior part of interosseous membrane
Descends on this membrane between tibialis anterior and extensor digitorum longus
Distributed around the anterior compartment of leg is the continuation of the anterior tibial artery
begins as it crosses the ankle joint dorsalis pedis artery passes anteriorly over the dorsal aspect of the talus, navicular, and intermediate deep plantar artery cuneiform bones arcuate artery dorsal metatarsal arteries then it passes inferiorly, as the deep plantar artery, between the two heads of the first dorsal interosseous muscle to join the deep plantar arch in the sole of the foot dorsal digital arteries Imp artery pulsation in peripheral neuropathy
Branches
Posterior tibial artery supplies posterior and lateral compartments of leg
Posterior tibial artery bifurcates into a small medial plantar artery and a much larger lateral plantar artery Plantar arch is formed by the direct
continuation of the lateral plantar Deep plantar arch artery, and is completed medially by
the dorsalis pedis artery. lateral plantar artery Medial plantar artery lies between to third and fourth layers of the sole.
Arteries in the sole of the foot.
Popliteal artery It begins at the lower border of the popliteus, between the tibia and the fibula, deep to the gastrocnemius. Anterior tibial artery It enters the back of leg by passing deep to the tendinous arch of the soleus Fibular artery It terminates deep to flexor retinaculumPosterior tibial artery by dividing, into the lateral and medial plantar arteries Distribution:Posterior and lateral compartments of leg Branches The peroneal artery, Several muscular branches, Nutrient artery & anastomotic branches bifurcates into a small medial plantar artery and a much larger lateral plantar artery
The fibular artery arises from the posterior tibial artery
Descends in posterior compartment adjacent to posterior intermuscular septum
Distributed along the posterior compartment of leg: perforating branches supply lateral compartment of leg
Post comp
Lat. Comp Ant. Comp
The larger sciatic component Derived from the ventral branches (anterior division) of the L4 , L5 and S1 to S3 ventral rami It descends along the back of the thigh and popliteal fossa to the distal border of popliteus derived from the dorsal branches of the L4, L5 and S1, S2 ventral rami
It descends obliquely along the lateral side of the popliteal fossa to the fibular head
It lies between the bicipital tendon, to which it is bound by fascia, and the lateral head of gastronemius
The nerve then passes into the anterolateral muscle compartment through a tight opening in the thick fascia overlying tibialis anterior
It curves lateral to the fibular neck, deep to peroneus longus, and divides into superficial and deep peroneal nerves. Arises from division of common fibular nerve at the neck of fibula
Descends in the lateral compartment of the leg
Pierces deep fascia at distal third of the leg to become subcutaneous and supply the skin on the lateral side of the leg & dorsum of foot
It supplies: 1) Fibularis longus muscle 2) Fibularis brevis muscle one of the two terminal branches of the common fibular nerve, is the nerve of the anterior compartment
arises between the fibularis longus muscle and the neck of the fibula
after entering the compartment, the nerve accompanies the anterior tibial artery
innervates all muscles in the anterior compartments tibial nerve
The tibial nerve divides lateral plantar nerves posterior to the medial malleolus into medial plantar nerves the medial and lateral plantar nerves These nerves supply the intrinsic muscles of the foot, except for the extensor digitorum brevis and extensor hallucis brevis, which are supplied by the deep fibular nerve proper plantar digital nerve
Following an injury to the superficial peroneal nerve, the paralysis of the peroneal muscles and associated over activity of the invertor muscles of the foot produces a deformity of foot called talipes varus. The over activity of peroneal muscles following paralysis of the anterior tibial muscles (invertors of foot) produces a deformity of foot called talipes valgus. Self study
Forearm leg Flexor muscles Extensor muscles