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Anatomy review sheet exam #4

Blood Vessels of LE

- Most of the arteries and veins travel together & take same path
Arteries:
- At L4 ascending aorta branches into right & left common iliac

- Common iliac branches into the internal & external iliac


- External iliac gives inferior epigastric artery & then becomes Femoral
Artery after inguinal ligament
- Internal iliac dives into pelvis
Femoral Artery
- Travels with the femoral vein

- Travels deep to inguinal ligament with the vein and nerve


- Found in sheet sitting on top of pectineus (on floor of femoral triangle)
- First branch off femoral artery is the deep femoral artery (profunda femoris)
- Provides majority of the blood supply to the thigh
- Deep gives off lateral & medial circumflex femoral artery which surround
the neck of the femur
- Massive bleed tunicate on femoral artery to stop all blood flow

- Femoral artery continues distally & then dives deep to sartorious & vastus
medialis
- Enters the adductor canal along side the femoral vein and saphenous nerve

- Femoral artery & vein then pass through the adductor hiatus
- Pass adductor hiatus emerge posteriorly in the popliteal fossa
- Once in fossa becomes femoral artery & vein become popliteal artery &
vein
Popliteal Artery (and vein)
- Gives off branches that anastomose around the knee to perfuse the knee:

Superior medial geniculate artery


Superior lateral geniculate artery
Inferior medial geniculate artery
Inferior lateral geniculate artery

- Popliteal artery continues, leaves the popliteal fossa, passes the


gastrocnemius:
- Splits into anterior and posterior tibial arteries
*Term Genu refers to knee

Anterior Tibial Artery:

- Goes to anterior compartment


- Travels alongside the deep fibular nerve & anterior tibial vein
- Pierces through the interosseous membrane between the tibia and fibula
into anterior compartment of leg, deep to tibialis anterior muscle, then
dives superficially & courses along dorsum of ankle
- As it enters the foot becomes dorsalis pedis artery (to dorsal aspect of
foot)
- Can be found between the tendons of extensor hallicus longus &
extensor digitorum longus
- Can usually take pulse here, quite superficial

- Important to check in diabetic people to make sure there is perfusion of

the foot (wont know they nicked foot, decreased blood supply which
compromises healing, and bacteria feasts on blood sugar, making it more
difficult)

Posterior Tibial Artery:


- Dives deep into the posterior compartment of the leg (deep to soleus &
gastro)
- Travels along side the tibial nerve in posterior compartment of leg

- Found superficial to posterior tibialis muscle


- Quickly gives off proximal branch fibular artery
- Fibular Artery
- Travels with the superficial fibular nerve
- Perfusion of lateral compartment of leg
- Terminates at calcaneus
- Posterior tibial artery then travels posterior to medial malleolus through the
Tarsal Tunnel (with tibial nerve)
- Posterior tibial artery is major blood supply to the foot

- Dives deep inferior to the sustentaculum tali (on calcaneous) & splits in the
foot:
- Medial plantar artery perfuse medial base of foot

- Lateral plantar artery perfuse lateral base of foot


Internal Iliac Artery:
- Gives off the obturator artery, which gives off acetabular branch
- Also known as the artery to ligamentum teres
- Travels through acetebular notch, through acetebular fossa of hip joint

- Surrounded by ligamentum teres (protects it) & heads to fovea of femoral


head
- Early in life: this is the major blood supply to the femoral head

- With age becomes secondary to the circumflex femoral arteries


- Many do not actually receive any perfusion from acetabular branch
(artery to ligamentum teres) because it is not needed, it can become
occluded
- Realize there is no blood supply when fracture occurs at femoral neck,
no perfusion via the acetabular branch could lead to avascular neurosis
of the femoral head

Veins:
- Follow the same course as the arteries (except for two superficial veins)

- The dorsal venous network in foot will drain into the great & lesser
saphenous veins
Greater Saphenous Vein:
- Superficial drainage to the entire length of the lower extremity

- Begins in the dorsal foot, travels along side antero-medial aspect of LE


- Pierces through opening in fascia lata at level of femoral triangle
(saphenous hiatus)

- Longest vein in your body!


- Drains directly into femoral vein
- Surgeons can use this vein for coronary artery bypass grafts/surgeries
(stents are more popular now, they open up area), plaque occluded
coronary artery & a vein graft can bypass occlusion so blood goes around
conflicted area
Lesser Saphenous Vein:
- Found superficial in posterior aspect leg

- Travels alongside the sural nerve


- Dives into popliteal fossa

- Drains directly into popliteal vein (then to femoral & external iliac)

Bony Landmarks of the Lower Extremity


Each innominate consists of 3 fused bones: site of fusion found in the
acetabulum
-Ileum: superiorly
-Pubis: anterior & inferior
-Ischium: posterior & inferior
Innominate/Ox Coxa:
Acetabulum: concavity on lateral aspect, in which the femoral head will
articulate; it accepts the convex femoral head

-Lunate surface: articular surface found superiorly; lined with hyaline


cartilage, increases congruency & reduces friction (C shaped), comes
in contact with femoral head,
-Acetabular fossa: non-articular, where lunate surface is incomplete,
deeper surface
-Acetabular notch: where the lunate surface is incomplete, (in-situ
there is a transverse acetabular ligament, which covers the acetabular
notch)
The artery to ligamentun teres (acetabular branch) enters under this
ligament through notch into fossa & articulates with head/fovea of
femur
If femoral head actually came in contact tare artery, Important this
does not articulate, at least early in life
- Obturator Foramen: has the obturator membrane, obturator nerve
pierces it
Ischium:
-Ischial tuberosity: the sacro-tubris ligament attaches there &
hamstrings originate here
-Ischial spine: the sacro-spinous ligament attaches to the ischial
spine
-Greater sciatic notch: closed off & becomes greater sciatic
foramen
-Lesser sciatic notch: closed off & becomes lesser sciatic foramen
-Ischial ramus: projection of bone, inferior & lateral to the
obturator foramen

Pubis:
-Symphyseal surface: has the pubic symphysis

-Pubic crest: superior angulation lateral from the pubic symphysis


-Pubic tubercle: the apex; highest point of the pubic crest
-Superior pubic ramus: projection of bone, superior to the
obturator foramen
-Inferior pubic ramus: projection of bone,inferior to the obturator
foramen
-Pectineal line: line on the superior pubic ramus; pectinues
muscle attaches
* Ischial ramus and the inferior pubic ramus becomes the ischial-pubic
ramus
Ilium:
-Iliac crest: most superior portion of the ileum, lines up between
L4 & L5
-Iliac tubercle: widened thickened portion projects from the
middle of the iliac crest, origin point for the ilio-tibial band
(ilio-tibial band: thick dense lateral portion of the fascia latta that
is dense & significantly thicker than the rest of the fascia latta)
-Iliac tuberosity: posterior auricular surface, iliolumbar ligaments
attaches
-ASIS: iliac crest anterior & superior projection
-AIIS: projection inferior & medial to the ASIS; origin point: rectus
femoris
-PSIS: iliac crest posterior and superior projection; lines up with
S2
-PIIS: projection inferior to the PSIS
-Iliac fossa: iliacus muscle found here & lateral femoral
cutaneous nerve
-Auricular (articular surface: articulates with the sacrum
- Gluteal surface: gluteal lines; demark the specific areas along
the ilium that the gluteal muscles will attach to; gluteus

mimimus & medius have strong attachments, gluteus maximus


has a weak attachment

Femur (on anterior):


-Fovea capitis/femoris: top of head of femur; depression accepts
lligamentum teres
-Head: (superior aspect, contains the fovea), neck, shaft
-Greater trochanter: large projection of bone laterally
-Lesser trochanter: small projection medially; psoas major & illiacus
attachment
-Intertrochanteric line: slight rise in bone from the greater trochanter
lesser trochanter; the joint capsule of hip joint attaches anteriorly
-Patellar surface: depression where the patella (sesamoid bone) should
sit & glide, sometimes known as trochlea of femur
Femur (on posterior):
-Intertrochanteric crest: large projection of bone between the two
trochanters; the joint capsule of the hip joint will also attach posteriorly
-Intertrochanteric fossa: lip to the greater trochanter, on undersurface;
lateral rotators of the hip insert here
-Gluteal tuberosity: superior & lateral to linea aspera; attachment for
some gluteus maximus fibers (not all)
-Linea aspera: along posterior aspect of the shaft; medial & lateral lip
to it; site for vastis medialis & vastis lateralis attachment (found on the
anterior aspect of thigh; originate posteriorly but function anteriorly)
-Pectineal line of the femur: medial & proximal linea aspera; pectinues
muscle

-Medial condyle: longer than the lateral condyle of the femur (most
inferior)
-Medial epicondyle: superior to the medial condyle
-Lateral condyle: shorter than medial condyle (most inferior)
-Lateral epicondyle: superior to the lateral condyle
-Adductor tubercle: sits on top of medial epicondyle; adductor magnus
has fibers that attach to the adductor tubercle as well as linea aspera
-Popliteal surface: posterior surface (behind knee)
-Intercondylar notch/fossa: between the medial & lateral condyle;
anterior & posterior cruciate ligament here

Tibia:
- Medial (large bone of the leg)
-Tibial tuberosity: on superior & anterior aspect; common insertion
point for all four heads of quadriceps femoris
*Osgood Schlaters disease: skeletal system is growing too fast for the
muscles to keep up with increase force/tension placed on tibial
tuberosity & it becomes enlarged (Wolfs Law)
- Gerdys tubercle: lateral to tibial tuberosity, also called lateral
tubercle of tibia; insertion point for the ilio-tibial band (thickened
portion of the fascia latta)
(Origin point for the ilio-tiboal band is iliac tubercle)
-Pes anserinus: flattened area medial to tibial tuberosity aspect; (goose
foot) common insertion point for three muscles: Sartorius (most
anterior), gracillis (intermediately) & semitendinosous (most posterior)
remember: SGT*
-Medial malleolus: large projection of bone along the inferio-medial
aspect
-Fibular notch: fibula fits into the tibia here

-Medial condyle: medial condyle of tibia is longer to fit in w/ longer


medial condyle of the femur
-Lateral condyle: shorter than medial condyle
-Intercondylar eminence: between the 2 condyles
-Medial & lateral intercondylar tubercles: in b/w the intercondylar
eminence
-Superior & medial articular surfaces for talus: tibia and fibula bone
articulates with the superior aspect of the talus; the lateral articular
surface is formed by the fibula
-In the anterior view dense interosseous membrane between the
tibia & fibula; syndesmosis joint

Fibula:
- Lateral bone in leg
-Apex: most superior aspect of the fibula; pointed portion of the fibular
head
-Head, neck: narrow portion of the fibula, shaft
-Lateral malleolus: large projection of bone on the inferior aspect of the
fibula
*Equilateral triangle on the apex of fibula & right triangle on the
inferior aspect of the fibula; most distal point of the lateral malleolus is
more anterior & angulation will taper posteriorly
-Lateral articular facet for talus: articulate with superior aspect of talus
Talus:

- Tibia & fibula articulate with the talus


-Dome/trochlea: two facets of the dome of the talus should be easily
palpated; the anterior portion of the dome of the talus is wider &
tapers more posteriorly
-Neck: the talus narrows here
-Head: most distal portion of the talus; articulates with the navicular
bone
Calcaneus:
-Articulates with the talus inferiorly & posteriorly (forms heel)
-Sustentaculum tali: flat area forms a shelf, has a groove, the tibial
nerve & the flexor halicus longus run through it (forms an anatomical
pulley), origin for calcaneo-navicular ligament/spring ligament
-Medial calcaneal tubercle & Lateral calcaneal tubercle: attachment
point for the plantar fascia/aponeurosis, medial calcaneal tubercle is
the main attachment
-Fibular trochlea/tubercle: attachment point for calcaneo-fibular
ligament
-Anterior, middle & posterior talar articular surfaces: three surfaces
articulating between talus & calcaneus, which limits the amount of
mobility in that joint (sub-talar joint)

Navicular:
- Navicular tubercle: on the apex of the medial longitudinal arch;
anterior to the talus, articulating with the head of the talus; insertion
point for calcaneo-navicular ligament/spring ligament
*Spring ligament maintains the medial longitudinal arch
*Flat foot: the spring ligament is elongated, & arch drops down (pes
planis)

Pes cavis: extremely high arch; shortened spring ligament


*Navicular drop test to test flat foot: navicular height during weight
bearing vs. not
Cuboid:

- Anterior to the calcaneus & lateral to the navicular, cubed shaped


bone
- Groove of cuboid: fibularis longus runs through here & then sweeps
around the plantar surface of the foot & attaches to the base of the
1st metatarsal
Cuneiforms:
- Distal to the navicular & lateral to the cuboid
- Medial, lateral, & middle cuneiforms
- Middle cuneiform: shortest & smallest than the others, & set back
further
- The 2nd metatarsal is embedded in all 3 cuneiforms, midline b/c less
mobility
Metatarsals (5):
-Head (convex), shaft, base (concave)
-Tuberosity of 5th metatarsal: large bony growth; insertion point for
fibularis brevis (sprained ankle bump, wolfs law)
-1st metatarsal the medial cuneiform
-2nd metatarsal the middle cuneiform & wedged between medial and
lateral
-3rd metatarsal the lateral cuneiform
-4th and 5th metatarsals cuboid

Phalanges (14) (tarsals):

- Head (convex), shaft, base (concave)


- Sesamoid bones: on the plantar surface of the 1st metatarsal;
embedded in the tendon of flexor halicus brevis; maintains the tendon
of flexor halicus longus where it travels in between them; we weight
bear everytime we push off we are pushing off on the sesamoid
bones, weight bearing surfaces on plantar aspect of foot
- 1st digit has only 2 phalanges; the rest have 3 phalanges
- Calcaneus & talus: hind foot
- Cuneiform, navicular & cuboid: form mid foot
- Metatarsals & on: will form the fore foot
Joints of LE
Acetabulo-femoral/Coxa-femoral Joint (Hip Joint)
- Ball & socket joint, synovial

- 3 DOF: Flexion/Extension, Abduction/Adduction, IR/ER (ability to


circumduct)
- Acetabulum & femoral head: closely the same size provides
increased stability with decreased mobility (1:1 ratio)
Angle of inclination:
-Medial angle, normal, but if it approaches a straight line (180 degrees)
medial angle increased (valgus, coxa valga)
- Medial angle decreases (closer to 90 degrees) varus, coxa vara
- Decreases as you begin to weight bear, in geriatric years prolonged
weight bearing decreased angle (straighter orientation to femur),
due to wolfs law
- Coxa Valga: medial angle larger than suppose to be at that age
(relevant to age)
- Cant compare a 1 year old to a 90 year old
- Looking at coronal plane: difference of proximal aspect of femur to
distal aspect
Angle of torsion:
- Look from top of femur downward: proximal differing from distal
aspect
- Now looking in transverse plane

- Head/neck angled slightly (aprox. 30 degrees) when looking down at


femur

- Head & neck is not parallel to condyles (angled slightly)

- Angle increases antiversion, distal portion of femur points


medially, (knees are pointing together, knock-knee)
- Angle decreases retroversion, distal portion of femur points
laterally, (bowlegged)
Joint capsule of hip joint: quite strong but loose for some amount of
mobility
Transverse acetabular ligament:
- Part of acetabulum, closes off acetabular notch

- Artery to ligamentum teres goes through here


Acetabular labrum:
- Continuous with joint capsule, contributes to congruency/stability

- Vacuum in joint further increases stability. If Torn decrease stability


-3 major Ligaments of the hip:
1. Iliofemoral (Y ligament of Bigalow) anterior
2. Pubofemoral - anterior
3. Ischiofemoral posterior
- The first two attach from intertrochanteric line of femur anteriorly

- Ischiofemoral ligament attaches from intertrochanteric crest of femur


posteriorly
- All attach from femur to ilium, pubis, & ischium respectively (by
name)
- Ligaments and capsule are most taught & provide most amount of
restriction/stabilization in: hip extension, abduction, & IR
- Joint surfaces have maximum articulation in flexion, abduction, & ER
(FABER)
- Cant dislocate hip from just standing, hip is fairly taught in extension
alone
- Dislocations generally: flexed, adducted, & IR (posterior dislocation)
- Ligaments are intra-capsular (blend in with the joint capsule)
Closed pact position:
Position of joint where ligaments & joint capsule are most taught
& joint surfaces are most congruent, where there is the most
match-up
This is not the case for the hip; this is not with the most
congruency!

Congruent: flexion abduction & ER (FABER), taught: extension,


abduction, IR
Closed pact position for hip is just when it is taught, not
congruent
Total hip replacement: replace end of femur, postero-lateral
approach, cut through: posterior lateral joint capsule &
iliofemoral ligament, restrictions/ total hip precautions: flexion,
adduction, IR. Probably dislocate hip if do so.
Child born with mal-formed femoral head: harness into FABER to
keep head in acetabulum & hopefully femoral head shapes into
right form when removed from harness

Tibio-femoral Joint (Knee):


-Bi-condyloid joint, 1 DOF primary (flex/ext), but can abd/add in weight
bearing
- Flex/ext: sagittal plane, abd/add: coronal plane
- 2 condyles of femur articulating with 2 condyles on tibia
Screw home mechanism:
- Knee into terminal extension (last 30 degrees) tibia ER on femur
This is because medial condyle Is longer, continue to move on
medial condyle & tibia goes out laterally (ER)
Allows for energy efficiency, locks tibia into femur & you dont
have to utilize muscle force, occurs in transverse plane
Unlock knee with IR
Joint capsule:
Surrounds entire joint, but synovial membrane folds in at
intercondylar fossa
Synovium doesnt completely engulf the whole joint
Therefore, ACL & PCL are not supplied with synovial fluid,
because they are extra-synovial but still intra-capsular, dont
receive nutrition from synovial fluid wont repair themselves if
they are torn (need surgery)
Synovial Plica:

Synovial membrane has natural folds (redundancies)


Can become irritated with reduced friction or overuse

Medial and lateral menisci:


2 fibrocartilageneous support structures
Form concavity for femur to articulate with, increase congruency
& disperse force, increases articulation
Concentrated into small surface area, so menisci allow force to
be displaced over greater amount of area, reducing strain,
disperse force
Tear in meniscus smaller area to disperse force & increase
likelihood of osteoarthritis (decrease ability of meniscus to
disperse force, more stress)
Medial meniscus needs to cover larger area, has more of C shape
Medial meniscus is less mobile b/c of multiple attachments
(commonly torn)
Lateral meniscus covers smaller area, almost complete ring
Semimembranous: attachment to posterior aspect of medial
meniscus
Popliteus: attachment to posterior aspect of lateral meniscus.
Muscular attachment to menisci prevent impingement of the
menisci when the 2 bones come in flexion & pulls them taught
(meniscus doesnt get stuck)
Muscular attachment also ensures the menisci are drawn
posteriorly & there is always meniscus in contact with tibia &
femur through full ROM
Bound to tibial plateau by coronary ligaments (mensco-tibial)
Attached loosely to femur via menisco-femoral ligaments
Ligaments of knee joint include:
Anterior Cruciate Ligament
Posterior Cruciate Ligmanet
Medial Collateral Ligament
Lateral Collateral Ligmanet
Arcuate Ligament
Oblique Popliteal Ligament
Posterior Oblique Ligament
ACL & PCL
- Found in intercondylar fossa
- Cross one another (cruciate), resist excessive IR of the tibia
* Remember LAMP: lateral ACL medial PCL (condyle attachments on
femur)
- ACL: resist anterior translation of the tibia, resists if femur moves
posteriorly

- PCL: resist posterior translation of tibia, resists if femur moves


anteriorly
- Femur moves anteriorly: PCL resists, femur moves posteriorly: ACL
resists
- ACL posterior on lateral condyle of femur run anteriorly onto tibia
- ACL also attaches to medial meniscus & MCL
- PCL: anterior on medial condyle of femur run posteriorly onto tibia
MCL:
- Medial epicondyle of femur blend in w/ medial meniscus pes
anserenus
- Resist valgus force at knee
- geno-valgum: MCL is elongated & medial angle larger (Knock-knee)
- Intra-capsular (blends in with joint capsule)
LCL:
- Lateral epicondyle of femur fibular head.
- Completely extra-capsular
- Resist varus force at knee, medial angle is decrease
geno-varo: medial angle is shorter (bow-legged)
LCL & MCL: also resist ER of tibia
Unhappy triad:
ACL, medial meniscus, MCL all torn
Because they are all united, tend to get injured together
The 3 can still be torn separately
Last 3 ligaments:
Along posterior capsule of knee, reinforce joint capsule
Assist in resisting excessive hyperextension of knee genurecurvatul
- Arcuate ligament: more lateral near fibular head
- Oblique popliteal & posterior oblique ligaments: more posteromedially
- All 3 also assist in resisting valgus & varus forces at the knee
Patello-femoral Joint:
-Plane synovial joint, between patella & patella surface of femur
Facets on posterior aspect of patella:
- Lateral, medial & odd (most medial facet)
-Lateral facet is largest (most lateral), odd facet is the smallest
- Articulate with patellar surface of femur

Patella is a sesamoid bone imbedded within the tendon of the


quadriceps femoris:
- Superior to patella is quadriceps tendon
- Inferior to patella is patellar tendon or ligament
- Patella acts to change the angle of pull of the quadriceps
Patellar tendon:
Connects patella to tibial tuberosity
Continuous with tendon of quadriceps
Can also be called ligament because it connects bone to bone
Patella:
Helps to protect acl & pcl (which are right behind it)
An anatomical pulley & changes direction/angulation of force of
quad
Ligaments binding the patella:
1. Lateral & medial patello-femoral ligaments: attach patella to femur
2. Lateral & medial patello-tibial ligaments: attach patella to tibia
- Lateral ligaments collectively lateral patellar retinacula
- Medial ligaments collectively medial patellar retinacula
liotibial band:
Iliac tubercle on illiac crest lateral aspect of thigh gurdeys
tubercle on antero-lateral aspect of tibia
Crosses knee & blends in with lateral retinculum
Ilio-patello ligament: fibers which are continuous with the lateral
retinculum
Tension on band pull patella laterally because of physical
connection
Q-angle:
Estimation of line of pull of quad femoris muscle, not definitive
measurement
Measure from ASIS mid patella tibial tuberosity
Make assumption that wider pelvis quad will pull more laterally
Make assumption that narrow pelvis quad will pull more
superiorly
Assumption not always true, can have wide pelvis & no knee
tracking issues
Patella should be able to:
Tilt & rotate medially & laterally
Glide superiorly/inferiorly & medially/laterally

Proximal Tibio-fibular Joint:


Union between head of fibula & tibia
Plane synovial joint
Anterior and posterior tibio-fibular ligaments
Very little movement, movement serves to accommodate ankle
motion
Accommodates for movement distally
Fusion here ROM limitations at ankle
Superior and inferior translation as well as rotation
Distial Tibio-fibular Joint:
- Syndemsosis, interosseous membrane found here
- Anterior & posterior tibio-fibular ligaments
- Very stable & strong joint, supported by ligaments & interosseous
membrane
- Fibro-adipose tissue separates distal tibia & fibula, no true articulation
- High ankle sprain: separation of distal tibia & fibula (torn interosseous
membrane)
Talocrural Joint:
Joint found amongst the talus as well as distal tibia & fibula
Crural means leg
- Distal tibia & fibula are thought to create a mortise, which grips the
talus
- Essentially a synovial hinge joint: dome of talus is larger anterior than
posteriorly
- Lateral malleolus extends inferior & posteriorly relative to the medial
malleolus
-Primary motion: dorsiflexion & plantarflexion
- Dorsiflexion wider portion of talus into distal tibo-fibial joint, not a
lot of movement there so proximal tibio-fibial joint has to move also
Lateral Collateral Ligaments:
Resist inversion of ankle, usually injured when sprain ankle
1. Anterior Talo-fibular ligament (ATFL)
Sits on top of sinus tarsi
Most commonly injured ligament of the ankle
Stressed in plantar flexion & pushed into inversion
Lateral malelous anterior aspect of talus
2. Calcaneo-fibular ligament (CFL)
Posterior to AFTL, stressed in neutral inversion
Lateral malleolus calcaneous
3. Posterior Talo-fibular ligament (PTFL)
Most posterior, stressed when in dorsiflexion & pushed into
inversion

Posterior talus lateral malleolus


Least commonly injured lateral collateral ligament

Medial Collateral Ligaments:


Resist eversion of the ankle
Commonly called deltoid ligaments, strong band of ligaments
Uncommonly injured because you pull ligament off bone before
tearing actual ligament
1. Anterior Tibio-talar ligament
Medial malleolus anterior aspect of talus
- Stressed in plantar flexion & pushed into eversion
2. Tibio-navicular ligament
Medial malleolus navicular tubercle
Stressed in plantar flexion & pushed into eversion
3. Tibio-calcaneal ligament
- Stressed when neutral & then eversion
- Medial malleolus medial aspect of calcaneous
4. Posterior Tibio-talar ligament
- Stressed in dorsiflexion & pushed into eversion
- Medial malleolus posterior aspect of talus
Subtalar Joint:
- Union of the talus & the calcaneus
- Primary motion: Supination & pronation
- However, we commonly think of joint as moving into inversion &
eversion as that is a large component of the motion
(supination/pronation: combo of 3 movements)
- Supination: elevation of navicular & the medial longitudinal arch
- Pronation: depression of navicular & the medial longitudinal arch
- Movement is a complex twisting motion due to the concave posterior
facet & convex anterior & middle facets
- Supported by the MCL and LCL
- Also specifically by the cervical ligament & interosseous talocalcaneal
ligament
- These ligaments attach to both the talus & calcaneous, giving further
support
Sinus tarsi:
Cone shaped opening/space found between the talus &
calcaneus
Wider laterally and narrow medially (hardly see on medial side)

ATFL sits on sinus tarsi


Common site for edema collection during any ankle injury (fluid
taking path of least resistance & fill up this space)
Depression on lateral side, but runs horizontally across the ankle

Transverse tarsal joint:


Articulation proximately of talus and calcaneus posteriorly
Articulation distally of the navicular and cuboid anteriorly
Effect on supination & pronation of foot
Movement drastically limited by the orientation of the joint
surfaces
Similar to the subtalar joint but even more severely
Movement contributes to supination and pronation but the joint
motion is often thought of as abduction & adduction
The rays 1-5:
- Rays consist of phalanges, metatarsal, & cuneiform or cuboid
depending
- The 2nd ray is the least mobile, serves as the axis of movement
around which the other rays rotate (2nd ray is midline)
- MTPs are condyloid (2DOF, abd/add & flex/ext)
- IPs are hinges (flex/ext
- Deep transverse metatarsal ligament prevents excessive abduction of
metatarsals
- 1st ray: medial cuneiform, 1st metatarsal & 2 phalanges (one
functional unit)
- 2nd ray: middle cuneiform, 2nd metatarsal & 3 phalanges
- 3rd ray: Lateral cuneiform, 3rd metatarsal & 3 phalanges
- 4th ray: Cuboid, 4th metatarsal & 3 phalanges
- 5th ray: Cuboid, 5th metatarsal & 3 phalanges
Deep transverse metatarsal ligament:
Binds metatarsals in hand
Limits excessive abduction of metatarsals
Arches:
- Medial longitudinal arch: apex is navicular bone, on medial aspect of
foot
- Lateral longitudinal arch: smaller in amplitude, on lateral aspect of
foot
- Transverse arch: running horizontally across metatarsal heads
Other ligaments:
- Calcaneo-navicular ligament (Spring): support medial longitudinal
arch

- Long plantar ligament: on lateral aspect of foot calcaneous


metatarsals
- Short plantar ligament (Plantar calcaneo-cuboid lig) calcaneous
cuboid
- Both support lateral longitudinal arch
Plantar Aponeurosis:
- Thick connective tissue
- Medial (majority of fibers) & lateral calcaneal tubercles on calcaneous
bound to metatarsal heads proximal phalanges
- Extend digits stretch aponeurosis
-Superficial transverse metatarsal ligament:
- Hold plantar aponeurosis down to metatarsal heads
3 groups of retinacula around the ankle:
- With superior and inferior components for each (superior & inferior
band)
1. Extensor retinaculum: bands on anterior aspect of ankle,
bind extensor tendons down to prevent bowstringing (dont
lift away from body)
2. Flexor retinaculum: bands on medial aspect of ankle,
closes off tarsal tunnel
3. Fibular retinaculum: bands on lateral aspect of ankle,
closes off fibular tunnel
Nerves of LE
Know terminal branches found in LE, nerve roots involved & the
courses of nerves throughout LE
Lumbo-sacral plexus spans from L2-S4
1.

Femoral Nerve
Emerges lateral to psoas major & travels to anterior thigh
Roots: L2, L3, L4
Dives deep to inguinal ligament alongside femoral artery & vein
Femoral nerve in entirety found superficial to the iliopsoas
muscle
This region where you find femoral nerve as a whole is femoral
triangle
Little branches innervate the muscles past Sartorius/femoral
triangle
Sartorius, quadriceps femoris, illiacus, & portion of pectineus
Innervates entire anterior thigh, all muscles except tensor fascia
lata

Gives off a cuteanous branch: anterior femoral cutaneous nerve


(L2,L3), gives you sensation to anterior thigh (remember: more
distal, doesnt include groin)

The femoral triangle: Has femoral nerve, artery, & vein


1- Superior boundary: Inguinal ligament (ASIS pubic tubercle)
2- Inferior boundary: Sartorius (tailor, Longest muscle in the body)
3- Medial boundary: adductor longus
Floor of femoral triangle: pectineus (medially) & iliopsoas (laterally)
Fascia lata:
Covers all parts of thigh
Tensor fascia lata has a purpose to tense this fascia
2. Saphenous Nerve
- Majority of femoral nerve terminates at level of knee
- One branch that will continue past the knee the saphenous nerve
(L3, L4)
- Provide you with cutaneous sensation inside the knee, to the medial
aspect of the leg & the medial longitudinal arch (commonly known as
inseam).
- Travels within the same sheath as the femoral artery and vein, deep
to vastus medialis muscle, through the adductor canal (all 3 structures)
- Adductor canal will eventually meet up with opening adductor
hiatus.
- Saphenous nerve does not travel into hiatus, but dives into knee joint.
- Saphenous nerve emerges from knee joint at level of pes anserinus &
will continue distally to medial leg.
Adductor hiatus:
- Line of demarcation between anterior thigh & posterior knee
- Small portion of adductor magnus with no muscle fiber (opening)
- Femoral artery & femoral vein travel through here to become
posterior structures
3. Obturator Nerve
Emerges at level of pelvis, through obturator foramen, medial to
psoas major
Innervates medial thigh, Contributions from L2, L3, L4
Pierces obturator membrane, which covers obturator foramen.
Provides innervation to all muscles & cutaneous sensation in
medial thigh
Muscles of medial thigh are adductors

Innervation to: Adductor longus, adductor brevis, portion of


adductor magnus, a portion of pectineus, obturator externis &
gracilis.

4. Lateral Femoral Cutaneous nerve:


- Within pelvis, sits on iliacus, Contributions from L2, L3
- Dives anterior to ASIS before diving into lateral aspect of thigh
- Provides sensation to lateral thigh.
Remember:
- Genitofemoral innervates genitals & groin
- Femoral portion innervates groin within femoral triangle (&
ilioinguinal nerve)
- Genital portion innervates genitals
- Subcostal & iliohypogastric nerves will supply some sensation to
posterior lateral thigh, they terminate here
5. Gluteal Nerves:
2 large gluteal nerves: Superior & Inferior Gluteal Nerves
Piriformis: sacrum intertrochanteric fossa of the femur
Courses through the greater sciatic notch
piriformis splits greater sciatic foramen into inferior & superior
cavities
Both the superior & inferior gluteal nerves emerge through
greater sciatic foramen
suprapirform: any structure traveling superior to piriformis
infrapiriform: any structure traveling inferior to piriformis
Superior gluteal nerve:
- Travels suprapiriform
- Receives contribution from L4, L5, S1
- Innervates gluteus medius, gluteus minimus, & tensor fascia lata
Inferior gluteal nerve:
- Travels infrapiriform
- Receives contribution from L5, S1, S2
- Only innervates gluteus maximus
Cluneal nerves: Sensation to gluteal region
Sciatic notches: concavities around ischial spine
Sacrospinous ligament: sacrum ischial spine
Sacrotuberous ligament: sacrum ischial tuberosity
The 2 Ligaments close off notches, making a greater & lesser
sciatic foramen

Greater sciatic foramen then is divided by piriformis.

6. Posterior Femoral Cutaneous nerve


- Derives from S1, S2, S3
- Emerges from greater sciatic foramen, infrapiriform
- Is not always distinguishable, because skin is removed (dangling &
not attached)
- Provides sensation to posterior thigh
- Inferior gluteal nerve also emerges here, but can be recognized
because it is attached to gluteus maximus
- Travels parallel to sciatic nerve (also infrapiriform)
7. Pudendal nerve
- Arises from L4, L5, S1, S2, S3, S4
- Emerges though greater sciatic foramen into the gluteal region,
infrapiriform
- Unlike other nerves it dives back into lesser sciatic foramen
- Doesnt innervate LE
- Provides control over external sphincters of rectum/bladder & genital
innervation
- Anesthesia during birth needle toward ischial tuberosity to numb
this nerve
8. Sciatic Nerve
- Largest nerve in body, 2x larger than radial nerve
- From gluteal region (dives deep to proximal hamstrings) distal foot
- Arises from L4, L5, S1, S2, S3 (infrapiriform)
- 2 nerves bundled together: tibial nerve & common fibular nerve
- 2 nerves held loosely together by fascia
- Split occurs at popliteal fossa
Popliteal Fossa boundaries:
- Inferior: 2 heads of gastrocnemius (medial & lateral)
- Supero-laterally: biceps femoris
- Supero-medially: semimembranosus & semitendinous
Tibial Portion Of Sciatic Nerve:
- Medial, derives from L4, L5, S1, S2, S3
- Innervates majority of musculature in posterior thigh:
semimembranosus, semitendinosus, posterior adductor magnus,
long head of biceps femoris

Common Fibular Portion of Sciatic Nerve:


-

Laterally, Derives from L4, L5, S1, S2 (Fibular=peroneal)


Innervates Short head of biceps femoris

Remember:
Infrapiriform nerves:
- Sciatic Nerve, Posterior femoral cutaneous, Inferior Gluteal nerve,
Pudendal
Suprapiriform nerve:
- Superior gluteal nerve
3 compartments of thigh: anterior, medial, posterior (fascia closes off
these areas)
3 compartments of leg: posterior: anterior, lateral, posterior
Sural Nerve:
- Branches reconvene together, form sural nerve together
- Medial sural cutaneous nerve: comes off tibial nerve (medial aspect of
distal popliteal fossa)
- Lateral sural cutaneous nerve: comes off the common fibular nerve
(lateral aspect of distal popliteal fossa)
- Superficial & sensory, distal aspect of popliteal fossa
- Provides sensation to posterior aspect of leg
- Dives posterior to the lateral malleolus through the fibular tunnel
- Provides sensation to lateral foot
*Saphenous nerve provides medial innervation to foot
Tibial
-

nerve:
After popliteal fossa, to posterior compartment
Dives deep to gastrocnemius
Sits right on top of tibialis posterior along with posterior tibial
artery & vein
Innervates all muscles in posterior thigh
Travels posterior to medial malleolus through tarsal tunnel
(concavity in tarsal bones)
Tarsal tunnel syndrome: effects tibial nerve
Passes tarsal tunnel gives off calcaneous branches (numbness
on heel)
Passes sustentaculum tali splits forming lateral & medial
plantar nerves

Medial Plantar Nerve: medial plantar muscles & skin on plantar surface
Lateral Plantar Nerve: lateral plantar muscles & skin on plantar surface

Sustentaculum tali: medial lip on calcaneous

Common fibular nerve:


- Main portion travels toward fibular head (bony notch on lateral
leg)
- Travels laterally
- At level of fibular head split into superficial & deep fibular
nerve
Superficial fibular nerve:
- Innervates lateral compartment of leg (fibularis longus & fibularis
brevis)
- Then will pierce through fibularis longus very superficially on
lateral aspect of leg en route to dorsal aspect of foot
- Cutaneous innervation to dorsal foot, except web between digits
1&2
- Also innervates the two intrinsic muscles on dorsum of foot
(extensor digitorum brevis & extensor halicus brevis)
Deep Fibular nerve:
- Anterior compartment with anterior tibial artery & anterior tibial
vein
- Innervates all muscles in anterior leg (dorsiflex)
- Then enters dorsal foot: contributes to innervation of intrinsic
muscles in dorsal foot (extensor digitorum brevis & extensor
halicus brevis) & cutaneous innervation to web space between
digits 1 & 2
Dermatomes:
L1 superior lateral thigh along the iliac crest
L2 anterior mid thigh
L3 medial aspect of knee
L4 medial leg near medial malleoulus
L5 lateral leg near fibular head & in web space b/w digits
1&2
S1 inferior to lateral malleolus
S2 medial aspect of popliteal fossa
S3, S4, S5 Perineal region: bulls eye in between butt
cheeks (no sensation here & no bowel/bladder control can
occur)

Myotomes:
L2, L3 hip flexion
L3, L4 knee extension
L4, L5 ankle dorsiflexion or inversion
L5, S1 hip extension, knee flexion, or ankle eversion or
great toe extension
S1, S2 ankle plantar flexion
DTRs:
L2, L3, L4 knee jerk (quad tendon)
L5, S1 medial hamstring reflex
S1, S2 ankle jerk (achilles tendon/reflex)

Pelvis & Gluteal Region


- Iliac tubercle: widened part on iliac crest
True pelvis vs. false pelvis
- On floor of true/lesser pelvis: pelvis floor muscles

- Openings for anus & urethra


Boundaries of Pelvic Floor
Lateral: Obturator internis
Anterior surface of ilium, ischium & obturator membrane greater
trochanter via intertrochanteric fossa
Innervation: Nerve to obturator internis, Action: ER @ hip
Posterolaterally:: Piriformis
Anterior surface of sacrum S2-S4, pass through greater sciatic notch,
sacrotuberous ligament greater trochanter via intertrochanteric
fossa
Innervation: anterior rami of sacral plexus S1, S2, Action: ER @ hip
Pelvic Floor: Coccygeus and Levator Ani
Coccygeus
Ischial spine anterior/inferior sacrum coccyx
Innervation: Anterior rami of sacral plexus S4, S5
Action: Supports pelvic viscera, coccygeal flexion
Levator Ani (3 parts)
1. Iliococcygeus: lateral
2. Pubococcygeus: posterior
3. Puborectalis: form sling around orifices
Innervation: Nerve to levator ani (S4), inferior anal nerve, coccygeal
plexus

Action: Support pelvic viscera, assist in bowel & bladder continence


- External anal and urethra sphincters: innervated by pudendal nerve
(S2, S3, S4)
*Sacral plexus: most important for bowel & bladder function
Gluteal Region
Superficial
1. Gluteus maximus:
Posterior aspect of sacrum & coccyx, posterior aspect to iliac crest &
sacrotuberous ligament, fibers extend inferior laterally iliotibial band
(majority), & gluteal tuberosity (minority)
Innervation: inferior gluteal nerve
Action: extends hip & ER
2. Gluteus medius:
Gluteal surface of ilium, posterior iliac crest greater trochanter of
femur on supero-lateral aspect
Innervation: superior gluteal nerve
Action: when extended hip abduction & IR
3. Gluteus minimus:
Gluteal surface of ilium greater trochanter of femur on supero-lateral
aspect
Innervation: superior gluteal nerve
Action: when extended hip abduction & IR
Deep
1. Piriformis:
- Inferior to gluts, ER of hip
2. Superior gemelus
3. Obturator internus: inferior & superior gemelus insert into its
tendon
4. Inferior gemelus
5. Quadratus Femoris (4 sides to it)
a. ischial tuberosity greater trochanter

- All inferior to piriformis, ER of hip


- Nerve to obturator internus also innervates superior gemelus
- Nerve to quadratus femoris also innervates inferior gemelus
6. obturator externus
- Sacrotuberous ligament & sacrospinous ligament found in gluteal
region
Superior gluteal neurovascular bundle:

- Nerve, artery & vein all emerge superior to piriformis (head to glut
med & min)
Inferior gluteal neurovascular bundle:
- Nerve, artery & vein all emerge inferior to piriformis (head to glut
max)
Sciatic nerve: splits (medial branch: tibial portion, lateral branch:
common fibular)
Posterior femoral cutaneous nerve: comes straight down & attaches to
skin
Pudendal neurovascular bundle
- Nerve artery & vein emerge inferior to piriformis & come back in

Anterior, Medial, Posterior Thigh


Anterior thigh: think femoral nerve!
- The entire thigh is covered in fascia known as Fascia Lata
Function: contain structures which improves efficiency of muscular
contractions
- The fascia lata thickens laterally & is known as the iliotibial band

- IT band can assist in knee flexion (when closer to flexion, slides

posterior to knee joint) & extension (when closer to extension, it is


more anterior to knee joint)
Muscles:
1. Tensor fascia: asis, iliac crest IT band
- Innervation: superior gluteal nerve. Actions: hip flexor,
abduction, IR
2. Sartorius: asis pes anserinus, tailor muscle
Actions: abduction, ER & flexion. Crosses knee joint: knee flexion,
IR of tibia
3. Pectineus: pectineal line on superior pubic ramus pectineal line
on femur

- Femoral vein & artery are superficial (palpation..)


- Located between anterior & medial thigh dual innervation:
femoral & obturator nerves
- Actions: hip flexion/adduction
Quadriceps
1. Rectus femoris: AIIS (crosses hip joint, does hip flexion)
2. Vastus lateralis: lateral lip of linea aspera
3. Vastus medialis: medial lip of linea aspera
4. Vastus intermedius: anterior aspect of shaft of femur
- All 4 heads insert into quadriceps tendon to patellar tendon which
inserts into tibial tuberosity & extend knee
- Vastus medialis oblique: vmo (triangular portion distally)
Pre-patellar bursa: most superficial, anterior to patella, inflammation if
falls on knee
Supra-patellar bursa: deep to quadriceps tendon, ensures it moves
smoothly
Infra-patellar bursa: deep to patellar tendon, ensures it moves
smoothly
Articularis Genu: pocket of muscle, prevents bursa from being trapped
under patella, puts tension on it, attaches to supra-patellar bursa
-Deep femoral artery, Saphenous nerve, Great saphenous vein also in
anterior thigh

Medial thigh: think obturator nerve (found in b/w adductor longus &
brevis)
1. Gracilis:
- Most medial muscle, pubic symphysis pes anserinus

- Function: hip adduction, knee flexion & IR tibia.

2. Adductor longus:
- Pubic tubercle linea aspera posteriorly. Action: hip adduction
3. Adductor brevis:
- Deep to longus, inferior pubic ramus pectineal line of femur

4. Adductor magnus
- Deep to adductor brevis, hip extension & adduction

- Adductor portion (anterior): innervated by obturator nerve

a. Inferior pubic ramus, linea asprea adductor tubercle


-Hamstring portion (posterior): innervated by tibial portion of sciatic
nerve.
a. Ischial tuberosity adductor tubercle
5. Pectineus (pectineal line pectineal line)
Innervation: femoral & obturator nerve,
- Anterior and posterior branches of the obturator nerve
Posterior thigh: think sciatic nerve!
- Contains hamstring group (ischial tuberosity is common origin)
Medial hamstrings: IR of tibia
a. Semitendonosus : more superficial, attach to anteriormedial tibia at pes anserinus
b. Semimembranosus: deeper & wider, attaches to medial
meniscus & posterior aspect of tibia
c. Adductor magnus (posterior portion) is deep to
semimembranous
Lateral Hamstrings: ER of tibia
a. Biceps femoris Short head: linea asprea blends in w/
biceps femoris fibular head
b. Biceps femoris Long head: ischial tuberosity head of
fibula
All hamstring muscles: hip extension & knee flexion (except adductor
magnus)
Sciatic nerve: Tibial & Common Fibular nerves
With medial & lateral sural cutaneous branches as well as Sural nerve
Popliteal fossa
Borders: Biceps femoris, Semimembranosus, medial/lateral heads of
gastrocnemius
Contents: Popliteal artery and vein
Politeus:
- Behind knee, lateral condyle of femur medial aspect of tibia,

- Knee flexion & IR of tibia, unlocks the knee (opposite of screw home
mechanism)
The Leg & Foot

The leg:
- The fascia of the leg is known as crural fascia (crural=leg)
- Fascia is dense (no give), invaginates into clearly defined
compartments
It separates the leg into compartments:
Anterior (deep fibular nerve & anterior tibial artery & vein)
Lateral (superficial fibular nerve, fibular artery & vein)
Superficial posterior
Deep Posterior
Compartment syndrome vs. shin splints:
- Shin splits: overuse injury, compartment overused begins to pull
periosteal irritation, force becomes so large you start to tare
away from the bone
- Compartment syndrome: pain in leg, depending on
compartment, fascia in leg is so dense & does not allow for
expansion, pressure increases in one of the compartments
(vascular component swelling)
- Acute compartment syndrome: trauma, swelling but do not tare
actually fascia, medical emergency because nerve & vasculature
compression (nerve: lose sensation & function distal to
compression) (vascular issue: avascular necrosis structures in
foot supplied by that vessel will die & need to be amputated)
- Chronic compartment syndrome: not a medical emergency,
increase in pressure in compartment due to activity (pumping
action of muscle), feel pain/weakness/numbness, as soon as they
stop pressure normalizes, can be controlled by stopping
activity
- To diagnosis compartment syndrome: probe in leg & run on
treadmill to track pressure
- Pes anserinus: antero-medial aspect of tibia, insertion point for
Sartorius, gracillis & semitendinous, pes anserinus bursa underneath.
Chronic overuse of tendons bursitis
- Gerdys tubercle: proximal lateral aspect of tibia, in between tibial
tuberosity & head of fibula, Insertion for IT band.
- Tibial tuberosity: patellar tendon attaches here (infrapatellar bursa
posteriorly & prepatellar bursa anteriorly & quadriceps tendon
superiorly, with suprapatellar bursa posteriorly to it (articularis genu
pulls on it)

Anterior Compartment of the Leg:


Extensor group of the leg:
- Anterior compartment
- Bound by deep investing fascia anteriorly & interosseous
membrane posteriorly
1. Tibialis anterior
- Most medial
- Tibia/interosseous membrane base of 1st metatarsal & medial
cuneiform
- Dorsiflexion & inversion
2. Extensor hallucis longus
- Tibia/interosseous membrane distal phalange of first digit
- Runs along dorsum of first ray
- Dorsiflexion & inversion & extends great toe
3. Extensor digitorum longus
- Fibula/interosseous membrane distal phalanges of digits 2-5
- Dorsiflexion & eversion & extension of digits 2-5
4. Fibularis tertius
- Most lateral (3rd fibular muscle)
- Fibula/Interosseous membrane base of the 5th metatarsal
(does not extend down to toes)
- Dorsiflexion & eversion
- All of these muscles are innervated by deep fibular nerve
- Anterior tibial artery & vein in this anterior compartment
- Superior & inferior extensor retinacula prevents these muscles from
bowstringing

Lateral Compartment of the Leg:


- Lies lateral to the fibula
- Separated from anterior & posterior compartments by deep
investing fascia
Muscles:
5. Fibularis longus
- Proximal 1/3 of fibula & fibular head course through fibular
tunnel course through groove of cuboid base of the 1st
metatarsal (start laterally & end medially)
- Plantar flexion & eversion
6. Fibularis brevis
- Distal 2/3 of fibula course through fibular tunnel insert into
tuberosity of 5th metatarsal
- Plantar flexion & eversion
-Superficial fibular nerve innervates these 2 muscles
- Fibular artery/vein in this lateral compartment
Superior & inferior fibular retinacula:
-Hold tendons in place & closes off fibular tunnel
- Make sure you can differentiate the distal ITB, LCL, biceps femoris
tendon, and common fibular nerve around the level of the fibular head
Posterior Compartment of the Leg:
- Deep investing fascia lies superficially along the superficial posterior
compartment
- Transverse intermuscular septum: separates deep & superficial
compartments
- Interosseous membrane: separates deep compartment & anterior
compartment
- Sural nerve & lesser saphenous vein sit superficial to & between
gastro heads
Superficial Muscles:
1. Gastrocnemius (medial and lateral heads)
- Condyles of the femur (medial & lateral) heads combine via
Achilles tendon insert into dome of calcaneous
- Knee flexion & plantar flexion
2. Plantaris

3.
-

Small muscle belly, long thin tendon


Lateral condyle of femur via Achilles tendon insert into dome
of calcaneous
Knee flexion & plantar flexion
Soleus
Fibula & tibia along soleal line & interosseous membrane via
Achilles tendon insert into dome of calcaneous
Plantar flexion (does not cross knee)

Triceps Surae: soleus & 2 heads of gastro, powerful plantar flexion


Deep Muscles:
1. Popliteus
- Lateral condyle of femur proximal medial tibia
- Also has attachment to lateral meniscus & draws it posteriorly
during knee flexion
- Found in popliteal fossa
- IR & flexion of the knee (unlocks knee)
2. Flexor digitorum longus
- Most medially in leg
- Tibia/interosseous membrane course through tarsal tunnel
distal phalanges of digits 2-5
3. Tibialis posterior
- From medial to lateral
- Interosseous membrane/tibia Plantar surface of base of 5th
metatarsal
4. Flexor hallucis longus
- Most lateral, bipennate
- interosseous membrane, distal 2/3rds of fibula through tarsal
tunnel, plantar surface of 1st ray; courses under sustentaculum
tali of calcaneus; b/w floating sesmoid bones; inserts into distal
phalange of 1st digit
-

Muscles in deep posterior compartment help maintain arch of


foot
Pes planis become elongated, pes cavis foot always
shortened

All found in deep posterior compartment of leg, sitting on tibilias


posterior:
- Tibial nerve (innervates all muscles in posterior compartment)
- Posterior tibial artery & vein located in posterior compartment
- Flexor retinaculum in the posterior compartment, holding down
tendons

Order of structures through the tarsal tunnel:


- Tibialis posterior (sit on top of medial malleolus)
- Immediately posterior: flexor digitorum longus
- Posterior tibial artery, posterior tibial vein, tibial nerve,
- Flexor hallucis longus (most posterior in tarsal tunnel)
*Tom, Dick and very nervous Harry*
For palpation: Feel around for tendons, in between palpate artery

Dorsal Foot:
2 intrinsic muscles of the dorsal foot:
1. Extensor digitorum brevis
- Lateral aspect of calcaneous middle phalanges of
digits 2-5
2. Extensor hallucis brevis
- Lateral aspect of calcaneous proximal
phalange of 1st digit
*Both innervated by superficial & deep fibular nerve
- Dorsalis pedis artery: in between extensor hallucis longus tendon &
extensor digitorum longus tendon
- Superficial fibular nerve & Deep fibular nerve
- Sinus tarsi: concavity, ATFL ligament sits here, space in between
calcaneous & talus
Plantar Foot:
Plantar aponeurosis:
- Most superficial structure in plantar foot
- Medial calcaneal tubercle (majority) & lateral calcaneal tubercle
just distal to metatarsal heads at proximal phalanges
- Superficial transverse metatarsal ligament: holds plantar
aponeurosis down to metatarsal heads
- Extend toes stretch & pull foot
1st Layer
1. Abductor halluces

Most medially
Abduct great toe
Medial plantar nerve
2. Flexor digitorum brevis
In the middle
Flex digits
Inserts middle phalanges
Medial plantar nerve
3. Abductor digiti minimi
Most laterally
Abduct 5th digit
Lateral plantar nerve

2nd Layer
- 2 muscles attach to the tendons of flexor digitorum longus
1. Lumbricals (4)
- Tendons of FDL on medial side of each tendon proximal
phalanges
- Flexion at MTP
- Medial 3: medial plantar nerve, Last lumbrical: lateral plantar
nerve
2. Quadratus plantae
- calcaneous tendon of flexor digitorum longus
- Normalize line of pull of flexor digitorum longus (without it, toes
would flex medially)
- Lateral plantar nerve
3rd Layer
-

1. Flexor hallucis brevis


Calcaneous proximal phalange of 1st digit
Medial & lateral heads, sesamoid bones embedded here
Medial plantar nerve
Flexion at MTPs
2. Adductor halluces
Usually medial plantar nerve, varies (can be lateral plantar
nerve)
3. Flexor digiti minimi brevis
Calcaneous proximal phalange of 5th digit
Flexion at MTPs

Lateral plantar nerve

4th Layer
Dorsal interosseous (4)
- Abduction
- Lateral plantar nerve
Plantar interosseous (3)
- Adduction
- Lateral plantar nerve
Medial and lateral plantar nerve, artery, vein all found in plantar foot
Calcaneo-navicular ligament:
- Spring ligament
- sustecaculum tali navicular tubercle
Long plantar ligament:
- Calcaneous metatarsals
Short plantar ligament:
- Calcaneous cuboid
The Foot:
Medial longitudinal arch:
- Medial aspect of foot
- Sensation: saphenous nerve
- Navicular=apex
- Flexor hallicus longus runs along this arch
- Flexor digitorum longus & tibialis posterior sweep across
Lateral longitudinal arch:
- Not as distinct, lateral aspect of foot
Transverse arch:
- Arch along metatarsal heads

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