KNEE, ANKLE AND FOOT

Regional Anatomy Fall 2010 Chantelle Drobot, ND

THE POPLITEAL FOSSA

A diamond shaped hollow posterior to the knee Boundaries y Superolateral biceps femoris y Superomedial semimembranosus & semitendinosus y Inferolateral and inferomedial both heads of gastrocnemius

THE POPLITEAL FOSSA

CONTENTS Contents include fat, popliteal vessels, tibial and peroneal nerves, small saphenous vein, and popliteal lymph vessels

THE POPLITEAL FOSSA

THE POPLITEAL FOSSA

POPLITEAL ARTERY  Extension of the femoral artery, divides into anterior and posterior tibial arteries

POPLITEAL VEIN
 Runs beside the popliteal artery,

originates at the anterior and posterior tibial veins then drains into the femoral vein SCIATIC NERVE  divides at the superior end of the fossa into tibial and peroneal nerves

THE KNEE
BONES  Femur  Tibia  Patella knee cap JOINTS Tibiofemoral  Joint between femur and tibia Patellafemoral  Between patella and femur

THE KNEE
ARTICULAR CAPSULE Strong fibrous capsule  Deficient on the lateral condyle to allow passage of the popliteus out of the joint

LIGAMENTS OF THE KNEE

Capsule strengthened by 5 intrinsic ligaments Patellar ligament  Central portion of the quadricepts femoris tendon Tibial collateral/medial collateral (MCL)  Medial side of knee Fibular collateral/lateral collateral  Lateral side of knee Oblique Popliteal ligament  Broad flat fibrous band  Posterior femur to posterior margin of tibia
Realism - 87

LIGAMENTS OF THE KNEE

Arcuate ligament (arc shaped ligament)  Y shaped ligament Cruciate ligaments Anterior Cruciate ligment  Weaker of the two ligaments  Prevents anterior displacement of the tibia Posterior Cruciate Ligament  Stronger of the two  Prevents posterior displacement of the tibia

LIGAMENTS OF THE KNEE

THE KNEE
SYNOVIAL MEMBRANE  Lines inner fibrous capsule  Most extensive in the body therefore creating the largest joint space MENISCI  C-shaped plates of fibrocartilage on the articular surface of the tibia  Allows for a deeper articulation and acts as a shock absorber

BURSAE OF THE KNEE Front compartment

Suprapatellar between anterior surface of femur and deep surface of quadiceps femoris Subcutaneous infrapatellar between patella and skin Deep infrapatellar between upper part of tibia and patellar ligament Medial compartment Anserine medially between MCL and the sartorius, gracillis and semitendinosus Semimembranosa medially between MCL and semimembranosis Gastrocnemius medial between gastrocnemius and joint capsule

BURSAE OF KNEE
Lateral compartment Gastrocnemius lateral between gastrocnemius and joint capsule Posterior compartment Popliteal bursae back part of knee can get inflamed and called a Bakers cyst

THE LEG
TIBIA Tibial plateau Medial and lateral condyles Intercondylar eminence Tibial tuberosity Interosseous border Medial malleolus Articular surface FIBULA Head Interosseous border Lateral malleolus
These two bones are joined by an interosseous membrane

MUSCLES OF THE ANTERIOR COMPARTMENT

Muscles Tibialis anterior Extensor hallucis longus Extensor digitorum longus Peroneus tertius Nerve Deep peroneal nerve Artery Anterior tibial artery

TIBIALIS ANTERIOR
O Lateral condyle of the tibia upper half and lateral surface interosseous membrane, deep fascia, lateral intramuscular septum I First cuneiform medial plantar surface, base of first metatarsal A Dorsiflexion of foot at ankle, inversion of foot N Deep peroneal nerve
Realism 217

EXTENSOR HALLUCIS LONGUS

O Fibula anterior surface and middle 1/2 adjacent interosseous membrane I Base of distal phalanx of great toe dorsal surface A Extension of great toe, assists in dorsiflexion of foot at ankle, assists inversion of foot N Deep Peroneal nerve (L4, L5, S1)
Realism - 228

EXTENSOR DIGITORIUM LONGUS

O Lateral condyle of the tibia and superior of fibula, interosseous membrane and intramuscular septum I Bases of middle and distal phalnages dorsal surface via 4 slips to extensor expansion of lateral 4 digits A Extension of 2nd through 5th digits, assists dorsiflexion of foot at ankle, eversion of foot N Deep peroneal nerve
Situated on lateral side of front of the leg
Realism - 223

PERONEUS TERTIUS
O Fibula anterior margin and distal 1/3, interosseous membrane I Base of 5th metatarsal dorsal surface A Dorsiflexion of foot at ankle, eversion of foot N Deep Peroneal nerve (L5, S1)
Realism - 227

MUSCLE TIBIALIS ANTERIOR

ORIGIN Lateral condyle of the tibia upper half and lateral surface interosseous membrane, deep fascia, lateral intramuscular septum Fibula anterior surface and middle 1/2 adjacent interosseous membrane Lateral condyle of the tibia and superior of fibula, interosseous membrane and intramuscular septum Fibula anterior margin and distal 1/3, interosseous membrane

INSERTION

ACTION

INNERVATION

First cuneiform Dorsiflexion of foot Deep peroneal medial plantar at ankle, inversion nerve surface, base of first of foot metatarsal

EXTENSOR HALLUCIS LONGUS

Base of distal Extension of great phalanx of great toe toe, assists in dorsal surface dorsiflexion of foot at ankle, assists inversion of foot Bases of middle and distal phalanges dorsal surface via 4 slips to extensor expansion of lateral 4 digits Base of 5th metatarsal dorsal surface Extension of 2nd through 5th digits, assists dorsiflexion of foot at ankle, eversion of foot

Deep Peroneal nerve (L4, L5, S1)

EXTENSOR DIGITORIUM LONGUS

Deep peroneal nerve

PERONEUS TERTIUS

Dorsiflexion of foot Deep Peroneal at ankle, eversion of nerve (L5, S1) foot

DEEP PERONEAL NERVE

Deep Peroneal Nerve Also called deep fibular nerve Supplies Anterior compartment of leg Begins at bifurcation of common fibular nerve between fibula and peroneus longus, passes deep to extensor digitorum longus and comes into relation with anterior tibial artery Descends with tibial artery until ankle joint where it divides into medial and lateral terminal branches

ANTERIOR TIBIAL ARTERY

Anterior Tibial Artery
Supplies anterior compartment and dorsum of foot Arises from popliteal artery Accompanied by Tibial vein

LATERAL COMPARTMENT OF LEG

Muscles Peroneus longus Peroneus brevis Nerves Superficial peroneal nerve Arteries Perforating branches from both anterior tibial and fibular arteries along with their veins supply this compartment

PERONEUS LONGUS
O head of the fibula upper 2/3s and lateral surface, intramuscular septum I first cuneiform lateral aspect, base of 1st metatarsal plantar surface A Plantar flexion of foot at ankle and eversion N Superficial peroneal nerve  The common peroneal nerve runs between the peroneus longus and the fibula  Ends in a long tendon that runs around the lateral malleolus of the fibular
Realism - 220

PERONEUS BREVIS
O Fibula lateral surface and distal 2/3s, adjacent intramuscular septum I Tuberosity on 5th metatarsal lateral aspect A Plantarflexion of foot at ankle, eversion of foot N Superficial peroneal nerve (L4, L5, S1)
Realism - 225

MUSCLE

ORIGIN

INSERTION

ACTION

INNERVATION

PERONEUS LONGUS

head of the fibula upper 2/3s and lateral surface, intramuscular septum

first cuneiform lateral aspect, base of 1st metatarsal plantar surface

Plantar flexion of foot at ankle and eversion

Superficial peroneal nerve

PERONEUS BREVIS

Fibula lateral surface and distal 2/3s, adjacent intramuscular septum

Tuberosity on 5th metatarsal lateral aspect

Plantarflexion of foot at ankle, eversion of foot

Superficial peroneal nerve (L4, L5, S1)

SUPERFICIAL PERONEAL NERVE

y Also called the superficial fibular

nerve y Passes between the peroneus muscles and the extensor digitorum longus y Divides into the medial dorsal cutaneous nerve and intermediate dorsal cutaneous nerve

ARTERIES OF THE LATERAL COMPARTMENT OF THE LEG

y Perforating branches of

the anterior tibial and fibular arteries y Also veins

POSTERIOR COMPARTMENT OF LEG

Muscles Gastrocnemius Soleus Plantaris Popliteus Flexor hallucis longus Flexor digitorum longus Tibialis posterior Nerves Tibial nerve Arteries Posterior tibila artery Peroneal artery Nutrient artery to the tibia

GASTROCNEMIUS
O Medial head femur-posterior surface, medial condyle, underlying capsule of knee joint Lateral head femur posterior surface, lateral condyle, underlying capsule of knee joint I Calcaneus via achilles tendon A Plantar flexion of foot at ankle, assists in flexion of leg at knee N Tibial nerve (S1, S2)
Realism - 216

SOLEUS
O Head of fibula posterior surface, body of fibula proximal 1/3, soleal line, tibia posterior and upper surface, tendinous arch between tibia and fibula I Calcaneus via Achilles tendon A Plantar flexion of foot at ankle N Tibial nerve (S1, S2)
Realism - 221

MUSCLE

ORIGIN

INSERTION Calcaneus via achilles tendon

ACTION

INNERVATION

GASTROCNEMIUS MH femur-

posterior surface, medial condyle, underlying capsule of knee joint LH femur posterior surface, lateral condyle, underlying capsule of knee joint

Plantar flexion of Tibial nerve (S1, foot at ankle, assists S2) in flexion of leg at knee

SOLEUS

Head of fibula Calcaneus via posterior surface, Achilles tendon body of fibula proximal 1/3, soleal line, tibia posterior and upper surface, tendinous arch between tibia and fibula

Plantar flexion of foot at ankle

Tibial nerve (S1, S2)

PLANTARIS
O Femur superior to lateral condyle, oblique popliteal ligament of knee I Calcaneus via Achilles tendon A Plantarflexion of foot at ankle, assists in flexion of leg at knee N Tibial nerve (L4, L5, S1)
Realism - 221

POPLITEUS
O Lateral condyle of femur I Posterior shaft of tibia superior to soleal line A Medial rotation of tibia of femur with thigh/origin fixed as when sitting upright: flexion of leg at knee With leg/insertion fixed as when standing: flexion of leg at knee Lateral rotation of femur on tibia, to unlock knee joint N Tibial nerve (L4, L5, S1)
Realism - 222

FLEXOR HALLUCIS LONGUS

O Posterior fibula distal 2/3s, interosseous membrane, adjacent intrmuscular septum I Base distal phalanx of great toe plantar surface A Flexion of great toe, inversion of foot, assists plantarflexion of foot at ankle N Tibial nerve (L5, S1, S2)  Deep muscles of the posterior compartment of leg  Fibular side of leg
Realism - 233

FLEXOR DIGITORIUM LONGUS

O Tibia medial posterior surface I Bases of 2nd, 3rd, 4th and 5th distal phalanges of digits plantar surface A Flexion of proximal and distal phalanges of lateral 4 digits, assists plantarflexion of foot at ankle, assist inversion of foot N Tibial nerve (L5, S1)  On tibial side of leg  Deep muscle of the posterior

compartment
 Realism - 229

TIBIALIS POSTERIOR
O Interosseous membrane, posterior fibula medial surface, posterior tibia lateral surface I Tuberosity of navicular bone, calcaneus plantar surface, cuneiform, cuboid, bases of 2nd, 3rd, and 4th metarsals A Plantarflexion of foot at ankle, inversion foot N Tibial nerve (L5, S1)  Deep muscle of posterior compartment
Realism - 231

MUSCLE PLANTARIS

ORIGIN
Femur superior to lateral condyle, oblique popliteal ligament of knee Lateral condyle of femur

INSERTION
Calcaneus via Achilles tendon

ACTION
Plantarflexion of foot at ankle, assists in flexion of leg at knee Medial rotation of tibia of femur Flexion of great toe, inversion of foot, assists plantarflexion of foot at ankle

INNERVATION
Tibial nerve (L4, L5, S1)

POPLITEUS

Posterior shaft of tibia superior to soleal line Base distal phalanx of great toe plantar surface Bases of 2nd, 3rd, 4th and 5th distal phalanges of digits plantar surface

Tibial nerve (L4, L5, S1) Tibial nerve (L5, S1, S2)

FLEXOR HALLUCIS LONGUS

Post fibula distal 2/3s, interosseous membrane, adjacent intrmuscular septum

Tibia medial posterior FLEXOR DIGITORIUM surface LONGUS

Flexion of proximal Tibial nerve (L5, S1) and distal phalanges of lateral 4 digits, assists plantarflexion of foot at ankle, assist inversion of foot Plantarflexion of foot at ankle, inversion foot Tibial nerve (L5, S1)

TIBIALIS POSTERIOR

Interosseous membrane, posterior fibula medial surface, posterior tibia lateral surface

Tuberosity of navicular bone, calcaneus plantar surface, cuneiform, cuboid, bases of 2nd, 3rd, and 4th metarsals

TIBIAL NERVE
y Branch of the sciatic nerve y Goes through the popliteal fossa where it

innervates the gastrocnemius, soleus, plantaris and popliteus y Cutaneous branch becomes the sural nerve y Below the soleus, the tibial nerve lies close to the tibia and innervates the tibialis posterior, flexor digitalis longus and flexor hallucis longus y Runs medially over the medial malleolus and joins runs under the flexor retinaculum with the posterior tibial artery

ARTERIES OF THE POSTERIOR COMPARTMENT

Posterior tibial artery  Supplies blood to the posterior compartment of the leg and plantar surface of the foot  Arises from the popliteal artery and runs medially over the medial malleolus  Accompanied by the deep tibial vein Peroneal artery  Branch of the tibial artery, runs deep close to the fibula, laterally down the leg  Supplies lateral compartment of the leg Nutrient artery to the tibia  Largest nutrient artery in the body  Nutrient foramen is just inferior to soleal line

CROSS SECTION OF THE LEG

LYMPHATICS OF LOWER LEG

y Superficial lymph vessels from the lateral foot and

posterolateral leg follow the small saphenous vein and drain into the popliteal nodes. y Those on the medial foot and anteromedial leg follow the great saphenous vein and drain into the inguinal nodes

LYMPHATICS OF THE LOWER LEG

BONES OF THE FOOT

Bones Talus
y Head

Cuboid Navicular y Navicular tuberosity Calcaneus y Peroneal tubercle y Sustentaculum tali Cuneiforms y 1st, 2nd, 3rd/ medial, middle, lateral Metatarsals y 1st 5th Phalanges y 1st 5th y Proximal phalanx, middle phalanx, distal phalanx

JOINTS OF ANKLE AND FOOT

Joints
Talocrural ankle joint made up of distal tibia and fibula and talus Subtalar articulation of talus and calcaneus Tarsometatarsal articulation of the 1st, 2nd and 3rd cuniform as well as the cuboid with the metatarsal bones Metatarsophalangeal articulation between the metatarsal bones and the bones of the toes or phalanges Interphalangeal articulation between phalanges of the toes

LIGAMENTS OF THE FOOT

Ligaments: Deltoid medial ligament of the talocrual joint Anterior tibiotalar Posterior tibiotalar posterior fibres run backward and lateral and attach to inner side of talus Tibiocalcaneal middle of the deltoid Tibionavicular most anterior attaches to the navicular bone

LIGAMENTS OF THE FOOT

Ligaments Anterior talofibular anterior from the fibular malleolus to the talus bone Posterior talofibular runs horizontally from the medial part of the fibular malleolus to the posterior surface of the talus Calcaneofibular fibular malleolus downward and backward to the calcaneus

FASCIA OF THE FOOT

Fascia y It is thin on the dorsum of the foot Plantar fascia  along the centre is a thickening called the plantar aponeurosis. It helps support the longitudinal arches of the foot Arches Medial Lateral Transverse

MUSCLES OF THE FOOT

Muscles: Intrinsic Foot Muscles: Intrinsic Foot

Extensor digitorum brevis Abductor hallucis Flexor digiti brevis Abductor digiti minimi Quadratus plantae

Lumbricals Flexor hallucis brevis Adductor hallucis Flexor digiti brevis Dorsal interossei Plantar interossei

EXTENSOR DIGITORIUM BREVIS

O Anterior calcaneus superior lateral surface, lateral talocalcaneal ligament, inferior extensor retinaculum I Proximal phalanx of great toe dorsal surface, 2nd, 3rd, and 4th digits via extensor digitorum longus tendon A Extension of great toe, extension of 2nd, 3rd, 4th digits N Deep peroneal nerve (L5, S1)
Realism - 235

ABDUCTOR HALLICUS
O Tuberosity of calcaneus, flexor retinaculum of ankle, plantar aponeurosis I Base of proximal phalanx of great toe medial side, medial sesamoid bone of great toe A abduction of great toe, assists in flexion of great toe N Medial plantar nerve (L4, L5)
Realism - 239

FLEXOR DIGITORUM BREVIS

O Tuberosity of calcaneus, plantar aponeurosis I both sides of middle phalanges of second through 5th digits A Flexion of lateral 4 digits N medial plantar nerve (L4, L5)
Realism - 237

ABDUCTOR DIGITI MINIMI

O Tuberosity of calcaneus, plantar aponeurosis I Proximal phalanx of 5ht digit lateral aspect A Abduction of 5th digit, assists flexion of 5th digit N Lateral plantar nerve (S1, S2)
Realism - 238

QUADRATUS PLANTAE
O Arises from 2 heads which are separated from each other by the long plantar ligament, the medial head attaches to the medial surface of the calcaneus, the lateral head arises from the lateral border of the inferior surface of the calcaneus and from the long plantar ligament I tendon of the flexor digitorum longus A flexion of the 2nd through 5th DIP joints N lateral plantar nerve (S1, S2)
Realism - 240

LUMBRICALS
O Tendons of flexor digitorum longus I Expansion of tendons to extensor digitorum longus on 2nd to 5th digits A Flexion of proximal phalanges of 2nd through 5th digits, extension of distal phalanges of 2nd through 5th digits N Medial plantar nerve (L4,L5), first lumbrical Lateral plantar nerve (S1, S2), second, third and 4th lumbricals
Realism - 240

FLEXOR HALLUCIS BREVIS

O Cuboid plantar surface, lateral cuneiform, and prolongation of tibialis posterior tendon I Base of proximal phalanx of great toe medial and lateral aspects A flexion of great toe N medial plantar nerve (L4, L5, S1)
Realism - 242

ADDUCTOR HALLUCIS
Made up of two heads O Oblique head Bases of 2nd, 3rd, and 4th metatarsal bones, tendionous sheath of peroneus longus - Transverse head Plantar metatarsophalangeal ligaments and transverse metatarsal ligaments of 3rd, 4th and 5th digits I base of phalanx of great toe lateral aspect A adducts hallux, assists in flexion N - Lateral plantar nerve (S1, S2)
Realism - 243

FLEXOR DIGITI BREVIS

O Base of Fifth metatarsal, adjacent tendinous sheath of peroneus longus I Base of proximal phalanx of 5th digit lateral aspect A Flexion of proximal phalanx of 5th digit N Lateral plantar nerve (S1, S2)
Realism - 241

DORSAL INTEROSSEI
O adjacent sides of each of the metatarsal bones I 1st interossei base of proximal phalanx of 2nd digit medial side 2nd to 4th base of proximal phalanx of 2nd to 4th digits lateral side All dorsal extensor expansion of respective digits A abduction of 2nd through 4th digtis, assists flexion and extension of lateral 4 digits N lateral plantar nerve
Realism - 236

PLANTAR INTEROSSEI
O 3rd, 4th and 5th metatarsal bones inferior and medial sides I base of proximal phalanx of corresponding digit medial side A adduction of 3rd, 4th, 5th digits toward 2nd digit, flexion of 3rd, 4th and 5th digits N Lateral plantar nerve (S1, S2)
Realism - 244

NERVES OF THE FOOT

Nerves Tibial nerve divides into:  Medial plantar nerve largest terminal branch  Lateral plantar nerve Sural nerve  supplies skin on lateral and posteroinferior 1/3 of leg Saphenous nerve  largest cutaneous branch of femoral nerve

ARTERIES OF THE FOOT

Arteries Dorsalis pedis artery
y Dorsum continuation of

anterior tibial artery

Medial and lateral plantar arteries

y Sole branches of posterior

tibial artery

VEINS OF THE FOOT

Veins:

Dorsal digital veins

y All veins of the foot

communicate and drain into the great and small saphenous veins