gluteal region: region between iliac crest and gluteal fold

-deep/ superficial layers of muscles

-deep muscles: small, little muscles (lateral rotators of the hip)
-superficial group: mainly extensor and adductor of femur of the hip
Superficial: #3 muscles
-gluteus maximus: origin: ileum, posterior lower part of sacrum and coccyx
insertion: posterior aspect of iliotibial tract, gluteal tuberosity of
femur
-extend the thigh
-stabilize hip and knee joint
innervation: inferior gluteal nerve
-gluteus medius: (lie underneath the superior part of gluteus maximus)
-abduct the femur, hip joint
fan-shaped
origin: ileum
insertion: greater trochanter
-innervation: superior gluteal nerve
-gluteus minimus: (lie underneath the gluteus maximus, gluteus medius)
-work tgt with gluteus medius to abduct the femur at hip joint
origin: external surface of ileum
insertion: anterolaterally on greater trochanter
innervation: superior gluteal nerve
-tensor fasciae latae muscle: origin: iliac spine (behind ASIS)
insertion: iliotibial tract (anterior aspect)
-stabilize hip joint (stabilize femur and acetabulum)
-stabilize knee in knee extension
innervation: superior gluteal nerve
-iliotibial tract: origin: tubercle of crest of ilium

Deep: (top to bottom)

gap above piriformis: superior gluteal nerve and vessels passing through
gap below piriformis: sciatic nerve (above sacrospinous ligament) and vessels passing
through
-piriformis: origin: anterolateral surface of sacrum
insertion: greater trochanter of femur
runs through the greater sciatic foramen
-extend femur at hip joint
-laterally rotate
 {greater sciatic notch of pelvis
ischial spine of pelvic bone}
-innervation: branches from S1 S2

sacrospinous ligament: runs from ischial spine to sacrum

grater sciatic foramen: above grater sacrospinous ligament
space between greater sciatic notch and sacrospinous and
sacrotuberous ligaments
sacrotuberous ligament: posterior to sacrospinous ligament
runs vertically from ischial tuberosity to sacrum
-superior gemellus: origin: ischial spine
insertion: greater trochanter, border of superior aspect of
obturator internus tendon
-extend femur at hip joint
-lateral rotate, abduct
-innervation: nerve to the obturator femoris
-obturator internus: origin: the medial surface of obturator membrane
bend 90 degrees
insertion: femur and greater trochanter
-extend femur at hip joint
-lateral rotate, abduct
-innervation: nerve to the obturator femoris
-inferior gamellus: insertion: inferior aspect of obturator internus tendon, greater
trochanter
-extend femur at hip joint
-lateral rotate, abduct
-innervation: nerve to quadratus femoris
-quadratus femoris: origin: lateral aspect of ischium (anterior to ischial tuberosity)
insertion: femur between greater and lesser trochanter
-only lateral rotation of femur
-innervation: nerve to quadratus femoris

Thigh: three compartments, separated by intermuscular septa

anterior compartment: extensor compartment by femoral nerve
#5 quadricep femoris + satorius

@anterior, superior compartment: seeing part of iliopsoas muscles (the terminal

end) inserted into lesser trochanter of femur

Psoas major: iliacus

origin : T12-L5 origin: iliac fossa
insertion: lesser trochanter insertion: lesser trochanter
innervation: anterior rami of L1 L2 L3 innervation: femoral nerve
 flex femur at hip joint

Quadriceps femoris: insert by quadriceps tendon onto patellar bone

Patella bone insert onto tibia by patellar ligament

 quadricep tendon: common insertion on patella bone

rectus femoris (most superficial muscle) + vastus muscles
origin (two heads): iliac fossa (AIIS) straight head
reflected head (originate superior to acetabular fossa)
because originate pelvis: flex hip, thigh
vastus muscles: cant do that because originate on femur
only do knee extension

vastus lateralis: originate from femur, insert onto patella by quadricep femoris
tendon
vastus medialis : teardrop-shaped muscle
inserted by quadricep femoris tendon by patella
all vastalis muscles: all originate on femur
insert onto patella by quadriceps femoris tendon
for extending the leg at knee joint

Sartorius: strap-like muscle

from ASIS to medial surface of proximal tibia (wind obliquely descend)
-insertion point: anterior to insertion pt. of gracilis and semitendinosus
muscle
-insertion point behind sartorius: hamstrings and gracilis
flex thigh at hip joint
flex thigh at knee joint
 vastus medialis, vastus intermedius (under rectus femoris), vastus lateralis
rectus femoris: originate on pelvis
flexion of hip joint
extension of knee joint
vastus muscles: knee joint extension

medial compartment: adductor compartment by obturator nerve

#6 adduct femur, thigh at hip joint
origin: body of pubis and ischiopubic ramus of pelvic bone
gracilis: vertically down to medial aspect of pelvis on body of pubis medial aspect
of proximal tibia (insert between insertion pt. of sartorious muscle)
most medially
-adduct thigh
-flex the knee

semitendinosus: (tendon insert behind the insertion of gracilis muscle)

insertion pt. of gracilis: between insertion pt. of Sartorius and semitendinosus
adduct thigh
flex knee at knee joint

Pectineus muscle: rectangular muscle

innervate by femoral nerve
adduct, flex thigh at hip joint
insertion: pectineal line on femur
forming part of medial floor of femoral triangle
Adductor longus: superficial layer in femoral triangle
(underneath: adductor brevis, magnus)
origin: pubis
insertion: middle third of shaft of femur
adduct femur
medially rotate

Adductor brevis: origin: pubis

insertion: upper third of femur
adduct the thigh at hip joint
(lies behind pectineus and adductor longus muscle)
Adductor magnus: (deeper than other two adductor) biggest adductor muscle
adductor part (lateral) + hamstring part(medial)
origin: ischiopubic ramus origin: ischial tuberosity
insertion: posterior surface of femur
insertion: adductor tubercle on medial condyle of femur
adduct, medial rotate
tibial branch of sciatic nerve (only hamstring part)
Adductor hiatus: allow femoral artery, veins pass through popliteal fossa
Obturator externus: fan-shaped muscle
origin: lateral/ external surface of obturator membrane
lateral rotate femur
insertion: trochanteric fossa (oval depression)
innervation: obturator nerve
Obturator internus: medial side of obturator foramen

posterior compartment: flexor compartment by sciatic nerve

#3
-sciatic nerve: emerge underneath the piriformis muscle in greater sciatic foramen
posterior compartment
all posterior muscles act at hip and knee joint (except short head of biceps femoris)
extend hip joint, flex knee joint
deep gluteal muscles: superior, inferior gemellus, obturator internus muscles
origin: ischial tuberosity
(removed: see origin of hamstring muscles)
Hamstring muscles: semitendinosus + semimembranosus + bisceps femoris
insertion: ischial tuberosity
bisceps femoris: lies laterally
origin: long head: ischial tuberosity
short head (beneath long head): lateral
lip of linea aspera on femur
 run obliquely across ischial tuberosity and insert onto head of fibula
flex leg at knee joint
extend, lateral rotate thigh at hip joint
lateral rotate leg at knee joint when knee joint is slightly flexed
innervation: long head: tibial branch of sciatic nerve
short head: common fibular branch of peroneal nerve
semitendinosus: origin: ischial tuberosity
 insertion: behind insertion pt. of gracilis and sartorius muscle on
medial aspect of upper tibia
extend hip joint
flex knee joint
medial rotate hip joint and knee joint (work with
semimembranosus)
innervation: tibial branch of sciatic nerve

semimembranosus: lies medially

under semitendinosus
origin: ischial tuberosity
insertion: medial condyle of femur, medial condyle of tibia
blend with joint capsule of knee
fascia surround knee joint: fibers from the tendon blend/ join
fascia that surround the knee/ contribute to some ligaments around the knee
flex knee joint
extend thigh at hip joint
medially rotate at hip and knee joint
act tgt with semitendinosus
[semitendinosus: sit on the top of semimembranosus, superficially
semimembranosus: medially
bisceps femoris: tendon formed by converge of both heads and
insert into head of fibula

Leg:
three compartments
-separated by intermuscular septa and interosseous membrane between tibia and
fibula

posterior compartment:
-plantar flexion of foot
-flexion of digits
-inversion of foot
 #2 muscles can flex at the knee because they are attached on femur
 gastrocnemius and plantaris
-innervation: tibial branch of sciatic nerve
#2 layers: #7 muscles
 superficial layer: #3
-gastrocnemius: most superficial layer
2 heads (medial head, lateral head)
origin: medial head insert on medial condyle of femur
lateral head insert on lateral condyle of femur
insertion: calcaneus via calcaneal tendon (Achilles tendon)
-plantarflex the foot
-flexion at the knee joint
-plantaris: under medial head of gastrocnemius
short muscle belly and very long tendon (wind round down the medial
side of leg)
origin: lower part of supracondylar ridge
join oblique popliteal ligament
insertion: calcaneus via calcaneal tendon (with gastrocnemius and soleus
muscle)
-plantarflex ankle joint
-flexion at knee
-soleus: under plantaris and gastrocnemius
origin: proximal ends of tibia and fibula
insertion: calcaneus via calcaneal tendon
-plantarflex ankle joint

deep layer: #4
-popliteus: -most superior layer
insertion: posterior surface of proximal tibia (above soleal line???)
origin: lateral surface of lateral femoral condyle (penetrate the joint
capsule of knee, passing between lateral meniscus and fibrous membrane
to reach condyle) insert inferolaterally on lateral femoral condyle
-unlock knee (when lock in extension) by lateral rotate femur on tibia
standing: leg fully extend: locked

-flexor hallucis longus: in lateral position relatively

origin: posterior surface of lower tibia, adjacent interosseous
membrane
insertion: distal phalanx of the great toe
sustentaculum talus: where the tendon of flexor hallucis longus
passing through the groove on the talus pass
underneath  base of distal phalanx
-flexor digitorum longus: in medial position relatively
origin: posterior surface of medial tibia
wind round behind a shallow groove in medial
malleoluspass inferiorly to flexor hallucis longus tendon bases of lateral four
insertion: base of the lateral four phalanges, and plantar
surface
-flex lateral four digits

-tibialis posterior: middle of the two muscles

origin: between tibia and fibula on interosseous membrane,
adjacent surface of tibia and fibula
insertion: tuberosity of navicular (mainly) and medial cuneiform
-plantarflex ankle joint
-invert the foot
-support medial arch of foot

common fibular nerve branch after passing though neck of fibula

-superficial branch -deep branch
Anterior compartment:
-dorsiflexion
-extension of digits
-inversion
-innervation: deep branch of common fibular nerve
#4
-tibialis anterior: most superficial
origin: lateral side of tibia, adjacent interosseous membrane
insertion: lower surface of medial cuneiform and adjacent base of
first metatarsal
-inversion
-dorsiflexion
-support for arch of foot
-extensor digitorum longus: origin: proximal, medial surface of proximal fibula
(superiorly to extensor longus muscle), lateral tibial condyle
split into 4 tendons
insertion: bases of intermediate and distal phalanges
-extension of lateral 4 digits
-dorsiflexion at ankle
-extensor hallucis longus: origin: medial half of fibula, interosseous membrane
insertion: base of distal phalanx of great toe
-extend big toe
-dorsiflexion the ankle
-extensor retinaculum: superior and inferior
hold extensor tendon in place
medial: tibialis anterior
middle: extensor hallucis longus
lateral: extensor digitorium longus
-fibularis tertius: origin: distally on medial surface of fibula
-considered as part of the extensor digitorium longus (sometimes
join tgt)
insertion: base of fifth metatarsal
-eversion of foot
-assist dorsiflexion
Lateral compartment:
#2
-evert the foot
-innervation: superficial branch of common fibular nerve
-fibularis longus: origin: upper lateral surface of fibia and lateral surface of head of
fibula
tendon: runs down behind lateral malleolus, descends, cross
forward on lateral side of calcaneus ,pass underneath foot
(pass groove in cuboid bone)  medially at the distal end of
medial cuneiform bone, at the base of first metatarsal
-eversion
-assist plantarflexion
-support lateral and transverse arches of foot
-fibularis brevis: origin: lower two-third of lateral surface of shaft of fibula
winds behind lateral malleolus, curve round and insert into base of
fifth metatarsal
-eversion
Sciatic nerve bifurcate into two branches once enter popliteal fossa: tibial nerve and
common fibular (peroneal) nerve
common fibular nerve wind around head and neck of fibula
-fracture of leg easily affect the blood supply (vulnerable to damage)

Foot: #2 plantar group and dorsal group

dorsal group: #1 muscle
extensor digitorium brevis: origin: superior and lateral surface of calcaneus
insertion: base of proximal phalanges of the first 4 digits
innervation: deep fibular nerve
often considered as including extensor hallucis brevis
-extend metatarsophalangeal joint (MTP joint)
plantar group: #4 layers
First layer: #3 muscles (most superficial layer)
flexor digitorium brevis: origin: medial process of calcaneus
insertion: medial phalanx of lateral four digits
-flex the lateral four digits at proximal interphalangeal joint
(PIP joint)
innervation: medial plantar nerve
(flexor digitorium superficials: insertion: sides of the middle phalanx
allow flexor digitorium longus muscle to pass
through

abductor hallucis muscle: (medial)

origin: medial process of calcaneal tuberosity
insertion: medially at the base of proximal phalanx of great
toe
-flex and abduct at 1st MTP joint
innervation: medial plantar nerve
abductor digiti minimi: (lateral)
origin: medial and lateral process of calcaneal tuberosity
insertion: laterally on base of proximal phalanx
-abduct little toe at MTP joint
innervation: lateral plantar nerve

Second layer: #2 muscles

flexor digitorium longus: pass through flexor digitorium brevis
insertion: distally on lateral four phlanges
quadratus plantae: (lies posteriorly)
2 heads (medial and lateral)
origin: medial head: medial process of calcaneal tuberosity
lateral head: lateral process of calcaneal tuberosity
insertion: lateral side of flexor digitorium longus tendon
-help flexor digitorium longus to flex the lateral toes (2 to 5)
 innervation: lateral plantar nerve

first two dorsal interossei muscles: innervation: deep fibular nerve

rest of the intrinsic muscles: branches of tibial nerve (medial and lateral plantar
nerves
tibial nerve: running medial behind the middle malleolus  enter flexor retinaculum
 tarsal tunnel  split after entering plantar surface of foot
lumbricals: #4 origin: sides of the 4 tendons of flexor digitorium longus
(lumbrical of the second digit: one origin: medial side to the tendon to
the second toe; others: 2 origins: adjacent sides of flexor digitorium longus tendons
insert into extensor hood of the lateral 4digits
-bipennate muscles
flex the MTP joint
extend interphalangeal joint
innervation: first lumbrical: medial plantar nerve
other three: lateral plantar nerve

Third layer: #3muscles

flexor digiti minimi brevis: (little toe)
flexor hallucis brevis: (great toe)
lies under flexor hallucis longus tendon
2heads, 2 origins: cuboid bone
one of the tendon(medial): originate from tibialis posterior
tendon
insertion: medial and laterally on base of proximal phalanx of
great toe
innervation: medial plantar nerve
-flex big toe at MTP joint
adductor hallucis muscle: transverse head, oblique head
transverse head: runs horizontally
origin: deep transverse metatarsal ligament
insertion: base of proximal phalanx
oblique head: origin: bases of metatarsals two to four,
fibularis longus tendon
insertion: base of proximal phalanx of great
toe
-adduct great toe on MTP joint
-innervation: lateral plantar nerve
flexor digiti minimi brevis: origin: base of the fifth metatarsal, fibularis longus tendon
insertion: base of the proximal phalanx of little toe
-flex little toe
-innervation: lateral plantar nerve

Fourth layer: #2 muscles PAD DAB

plantar interossei muscles: (lie inferior to dorsal interossei muscles)
#3
origin: medial side of metatarsals 3-5
-unipennate muscles
insertion: base of proximal phalanges of extensor
expansion of digit three to five
-adduct toe 3-5 at MTP joint
innervation: lateral plantar nerve

dorsal interossei muscles: #4

-bipennate muscles
base of proximal phalanges two to four
-abduction of toe 2-4 at MTP joint
innervation: lateral plantar nerve
(first two dorsal interossei muscles also receive innervation
from deep fibular nerve)
Second toe can be abducted on either side because the first dorsal interossei muscle
attach medially on the second toe

plantar aponeurosis: attach to medial process of calcaneal tuberosity

extend and expand  form longitudinal bands of fibers
support longitudinal arches of foot
superficial transverse metatarsal ligament
deep transverse metatarsal ligament

extensor retinaculum: (lies anteriorly on the distal leg)

superior extensor retinaculum: attachment: anterior margins of tibia, anterior
margin of fibula
hold extensor tendons in place
inferior extensor retinaculum: Y-shaped, upper arm and lower arm
attachment: calcaneus
upper arm: medial malleolus
lower arm: plantar aponeurosis

flexor retinaculum: hold flexor tendons in place

overlies tarsal tunnel
origin: medial malleolus
insertion: runs inferomedial on calcaneus, blends with plantar
aponeurosis
flexor tendons: behind medial malleolus, inside tarsal tunnel, under flexor
retinaculum
structures running through tarsal tunnel
medially behind medial malleolus: tibialis posterior
extensor digitorium longus
posterior tibial artery (palpate posterior tibial
pulse)
posterior tibial vein
tibial nerve
flexor hallucis longus (pass through
sustentaculum talus)

superior fibular retinaculum: attachment: lateral malleolus, calcaneus

hold fibular tendons in place, fibularis longus, fibularis
brevis
inferior fibular retinaculum: blend with inferior extensor retinaculum

tarsal bones: #7 proximal, distal group

proximal group: #2 talus and calcaneus (calcaneus above talus, cuboid bone)
distal group: #4 articulate with metatarsals
cuneiforms (lateral, intermediate, medial)
cuboid (articulate with the lateral two metatarsals)
navicular: intermediate bone between distal and proximal rows
anteriorly articulate with cuneiform

Each metatarsal: head shaft base

proximal middle distal phalanx
femur medially rotates the tibia  lock joint , have collateral ligaments which tighten
to lock the joint in position

unlock the joint: femur is laterally rotated the tibia

femoral condyles articulate with superior aspect of tibial condyle
intercondylar fossa: where anterior and posterior cruciate ligament have proximal
attachment
epicondyle: site for proximal attachment of the medial and lateral collateral
ligaments, tibial and fibular collateral ligament

lateral, medial tibial condyle intercondylar region, where menisci of knee joint attach,
attachment site for anterior and posterior cruciate ligament
whole superior surface: tibial plateau: superior surfaces of lateral, medial tibial
condyles and intercondylar region
intercondylar eminence: lateral, medial intercondylar tubercle
meniscus: crescent-shaped, shock absorber, fibrocartilages
medial, lateral meniscus
transverse ligament: connecting the two meniscus

medial meniscus: attached medially to the tibial collateral ligament / blend with
fibers of the tibial collateral ligament, capsule of joint of knee
lateral meniscus: no these attachment (more mobile)

medial collateral ligament: proximal attachment: medial epicondyle of femur

distal attachment: tibia (a little bit above insertion pt. of
semitend., semimemb, Sartorius  pes anserinus)

lateral collateral ligament: proximal attachment: lateral epicondyle

distal attachment: lateral part of head of fibula

posterior cruciate ligament: proximal attachment: medial wall of intercondylar fossa

distal attachment: laterally on medial condyle
attach posteriorly ton tibia prevents tibia from sliding
backward
anterior cruciate ligament: proximal attachment: lateral wall of intercondylar fossa
distal attachment: medially on lateral condyle
attach anteriorly on tibia prevent tibia from sliding
forward
 cross over each other
 prevent anterior and posterior displacement of tibia and femur

Patella ligament: continuous with the tendon above the quadricep femoris tendon
attach around sides of the patella
attach distally to tibial tuberosity at base of patella
fibular bursa: separate fibular collateral ligament from joint capsule
oblique popliteal ligament: extension of semitendinosus tendon
reinforce posterior aspect of the joint capsule

synovial membrane not enclose cruciate ligament

suprapatellar bursa: above patella
subpopliteal recess: between popliteus tendon and lateral meniscus
infrapatellar fat pad: separate patella from synovial membrane
sit underneath the patella ligament and separate the ligament from synovial
membrane
prepatellar bursa: sit over the knee cap
deep infrapatellar bursa: sit underneath the patellar ligament
superficial infrapatellar bursa: top of patella ligament

Spring ligament (plantar calcaneonavicular ligament)

between talar shelf and inferior margin of posterior articular surface
of navicular (fill the wedge-shaped gap)
support head of talus

Short plantar ligament (plantar calcaneocuboid ligament)

@plane between plantar calcaneonavicular and long plantar
ligaments
extend from anterior aspect of the inferior surface of the calcaneus
to the inferior surface of cuboid

Long plantar ligament: from plantar surface of the calcaneus to the groove on cuboid
some fibers extend to base of metatarsals  forming tunnel
for tendon of peroneus longus
maintaining the longitudinal arch of foot
Talocalcaneonavicular joint: head of talus articulate with calcaneus and spring
ligament below and navicular in front
gliding and rotation movements
+ subtalar joint: inversion + eversion of foot

Subtalar joint (Agility joint): between large posterior calcaneal facet on inferior
surface of talus and corresponding posterior talar facet on superior surface of
calcaneus
articular cavity: enclosed by synovial membrane
(covered by fibrous capsule)
gliding and rotation (involved in inversion and eversion
of foot)
Small joints of foot:
Forefoot (all metatarsals and phalanges): IM joint, MP joint, IP joint
Midfoot (cuboid and 3 cuneiforms): tarsometatarsal joint (Lis Franc joint) distally
Mid-tarsal joint (of chopart) proximally
Hindfoot (talus and calcaneus): Subtalar joint
Talocalcaneonavicular joint

injury to tibial nerve: may due to posterior dislocation of knee joint

severance of tibial nerve: paralysis of flexor muscles of leg,
intrinsic muscles of sole of foot
cannot plantarflex ankle or flex toes
loss of sensation in sole of foot

septa and deep fascia of leg forming boundaries of leg compartments are strong,
increased volume  infection with suppuration (pus formation) 
intracompartmental pressure increase

inflammation within anterior and posterior compartment of leg spread in distal

direction

purulent (pus-forming) infection in lateral compartment: ascend proximally into

popliteal fossa, presumably along the course of the fibular nerve.
Fasciotomy (incision of fascia) may be necessary to relieve
pressure and debride (scrape away) pockets of infection.
Shin splints—edema and pain in the area of the distal
two thirds of the tibia—result from repetitive
microtrauma of the tibialis anterior
which causes small tears in the periosteum covering the shaft
of the tibia and/or of fleshy attachments to the overlying deep
fascia of the leg.
anterior compartment syndrome
occur during:
traumatic injury or athletic overexertion of muscles in the
anterior compartment, especially TA, by untrained persons
persons who lead sedentary lives develop shin splints
when they participate in long-distance walks.
Shin splints also occur in trained runners who do not warm
up and cool down sufficiently. Muscles in the anterior compartment
swell from sudden overuse, and the edema and muscle–
tendon inf ammation reduce the blood flow to the muscles. The
swollen muscles are painful and tender to pressure

development of a fibularis
tertius that is attached to the base of the 5th metatarsal.
These features are unique to the human foot

common fibular
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 of the common fibular nerve
results in flaccid paralysis of all muscles in the anterior
and lateral compartments of the leg (dorsiflexors of ankle and
evertors of foot).
The loss of dorsiflexion of the ankle causes
footdrop, which is further exacerbated by unopposed inversion
of the foot making the limb “too
long”: The toes do not clear the ground during the swing
phase of walking
1. A waddling gait, in which the individual leans to the side
opposite the long limb, “hiking” the hip
2. A swing-out gait, in which the long limb is swung out
laterally (abducted) to allow the toes to clear the ground
3. A high-stepping steppage gait, in which extra flexion is
employed at the hip and knee to raise the foot as high as necessary
to keep the toes from hitting the ground
Because the dropped foot makes it difficult to make the
heel strike the ground first as in a normal gait, a steppage
gait is commonly employed in the case of flaccid paralysis

Individuals with a common

fi bular nerve injury may also experience a variable loss of
sensation on the anterolateral aspect of the leg and the dorsum
of the foot

Excessive use of muscles supplied by the deep fibular

nerve (e.g., during skiing, running, and dancing)
may result in muscle injury and edema in the anterior
compartment. This entrapment may cause compression
of the deep fi bular nerve and pain in the anterior compartment.

Pain occurs in the dorsum of the foot and

usually radiates to the web space between the 1st and 2nd
toes. Because ski boots are a common cause of this type of
nerve entrapment, this condition has been called the “ski
boot syndrome”; however, the syndrome also occurs in soccer
players and runners and can also result from tight shoes.
at nerve passes deep to the inferior
extensor retinaculum and the extensor hallucis brevis

Superficial fibular nerve entrapment

Chronic ankle sprains may produce recurrent
stretching of the superfi cial fi bular nerve, which may
cause pain along the lateral side of the leg and the
dorsum of the ankle and foot. Numbness and paresthesia

Fabella: sesamoid bone @ lateral head of gastrocnemius

 articulate with lateral femoral condyle
some ppl may not have

Calcaneal Tendinitis
occurs during repetitive
activities, especially in individuals who take up running

Chapter 5 • Lower Limb 607

after prolonged inactivity, or suddenly increase the intensity
of their training, but it may also result from poor footwear
calcaneal tendon rupture
Calcaneal tendon rupture is probably the most severe
acute muscular problem of the leg. Individuals with this injury
cannot plantarfl ex against resistance (cannot raise the heel
from the ground or balance on the affected side), and passive
dorsifl exion (usually limited to 20° from neutral) is excessive.
Ambulation (walking) is possible only when the limb is
laterally (externally) rotated, rolling over the transversely
placed foot during the stance phase without push off. Bruising
appears in the malleolar region, and a lump usually
appears in the calf owing to shortening of the triceps surae.
In older or non-athletic people, non-surgical repairs are
often adequate, but surgical intervention is usually advised
for those with active lifestyles, such as tennis players.

Calcaneal tendon reflex

plantarfl exion of the ankle
joint. The calcaneal tendon refl ex tests the S1 and S2 nerve
roots. If the S1 nerve root is injured or compressed, the ankle
refl ex is virtually absent.

Absence of Plantarflexion
If the muscles of the calf are paralyzed/ the calcaneal tendon is ruptured/ normal push off is
painful,
much less effective and efficient push off (from the midfoot) can still be accomplished by:
actions of the gluteus maximus, hamstrings in extending the thigh at the hip joint
and the quadriceps in extending the knee.
push off from the forefoot is not possible (in fact, the ankle will be passively dorsiflexed as the
body’s weight moves anterior to the foot),
those attempting to walk in the absence of plantarflexion: rotate the foot as far
laterally (externally) as possible during the stance phase to disable passive dorsiflexion and
allow a more effective push off through hip and knee extension exerted at the midfoot

Gastrocnemius Strain (tennis leg): painful acute injury resulting from partial tearing
of the medial belly of the gastrocnemius at or near its musculotendinous junction (seen in
individuals > 40)
caused by overstretching the muscle by concomitant full extension of the knee and dorsiflexion of
the ankle joint. Usually, an abrupt onset of stabbing pain is followed
by edema and spasm of the gastrocnemius

Calcaneal bursitis: results from inflammation of the deep bursa of the calcaneal tendon, located
between the calcaneal tendon and the superior part of the posterior surface of the calcaneus
-causes pain posterior to the heel
-occurs commonly during long-distance running, basketball, and tennis
-caused by excessive friction on the bursa as the tendon continuously slides over it.

Contraction of
the calf muscles pumps blood superiorly in the deep veins.
The musculovenous pump is improved by the deep fascia
that invests the muscles like an elastic stocking

Accessory Soleus
present in approximately 3% of people
appears as a distal belly medial to the calcaneal tendon.
Clinically associated with pain and edema (swelling) during prolonged exercise.

Posterior tibial pulse

palpated
between the posterior surface of the medial malleolus
and the medial border of the calcaneal tendon
posterior tibial artery passes deep
to the fl exor retinaculum, it is important when palpating this
pulse to have the person invert the foot to relax the retinaculum
Palpation of the posterior tibial pulses is essential for examining patients with occlusive
peripheral arterial disease.
-absent in approximately 15% of normal young people,
could be a sign of occlusive peripheral arterial disease in people older than 60 years.
Intermittent claudication: characterized by
leg pain and cramps, develops during walking and disappears
after rest. result from ischemia of the leg muscles caused by narrowing or occlusion of
the leg arteries.
Gait cycle:
-Stance phase (from toe off to heel contact) 60% of gait cycle
Heel strike: foot hits the ground heel first

 Gluteus maximus: acts on the hip to decelerate the lower limb.

 Quadriceps femoris – keeps the leg extended at the knee and hip.
 Anterior compartment of the leg – maintains the ankle dorsiflexion,
positioning the heel for the strike.

Support: leading leg hits the ground, and the muscles work to cope with the
force passing through the leg
 Quadriceps femoris – keeps the leg extended, accepting the weight of
the body.
 Foot inverters and everters – contract in a balanced manner to stabilise
the foot.
 Gluteus minimus, medius and tensor fascia lata – abducts the lower
limb. This keeps the pelvis level by counteracting the imbalance created
from having most of the body-weight on one leg.

Toe-off: foot prepares the leave the ground – heel first, toes last
 Hamstring muscles – extends the leg at the hip.
 Quadriceps femoris – maintains the extended position of the knee.
 Posterior compartment of the leg – plantarflexes the ankle. The prime
movers include gastrocnemius, soleus and tibialis posterior.




-Swing phase
leg lift: Once the foot has left the ground, the lower limb is raised in
preparation for the swing stage.
 Iliopsoas and rectus femoris – flexes the lower limb at the hip, driving
the knee forwards.
 Hamstring muscles – flexes the lower limb at the knee joint.
 Anterior compartment of the leg – dorsiflexes the ankle.

Swing: the raised leg is propelled forward. This is where the forward motion
of the walk occurs.
 Iliopsoas and rectus femoris – keep the hip flexed, resisting gravity as it
tries to pull the leg down.
 Quadriceps femoris – extends the knee, positioning the foot for landing.
 Anterior compartment of the leg – maintains ankle dorsiflexion so that
the heel is in place for landing.