MOB TCD

Anterior and Lateral and Posterior

Compartments of Calf
Professor Emeritus Moira OBrien
FRCPI, FFSEM, FFSEM (UK), FTCD
Trinity College
Dublin

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Cutaneous Supply of Calf

Saphenous first branch is
infrapatellar branch it
Supplies medial side of the
calf and
Medial side of foot to ball of
the hallux
Lateral cutaneous of calf
Superficial peroneal
Sural, lateral border of foot
Deep peroneal first cleft

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Fascial Compartments in Calf

Subcutaneous surface of tibia
Fascia anterior and posterior
intermuscular septa
Anterior compartment
Lateral compartment
Posterior compartment
Divided
Superficial
Deep
Deep posterior

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Extensor Retinacula

Superior retinaculum
Thickening deep fascia
Tibialis anterior pierces
Other tendons pass posterior
Inferior extensor retinaculum
Inferior stem attached to calcaneus
Upper limb to medial malleolus
Lower limb plantar aponeurosis

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Anterior Compartment of Calf

Tibialis anterior
Extensor hallucis longus
Extensor digitorum longus
Peroneus tertius
All muscles supplied by the
deep peroneal nerve
Dorsi flexors
Anterior tibial and
perforating peroneal arteries

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Tibialis Anterior
Upper two thirds
Lateral surface of tibia and
adjoining area of
interosseous membrane
And deep fascia
Inserted
Medial aspect of medial
cuneiform
And adjoing base of first
metatarsal

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Tibialis Anterior
Synovial sheath
Passes under superior and
both limbs of inferior
extensor retinaculum
Dorsi flexor and invertor
Eccentric pays out, prevents
foot slapping down
Supports medial arch
Deep peroneal nerve

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Extensor Hallucis Longus

Middle two fourths

Anterior surface of fibula
Interosseous membrane
Base of distal phalanx of
hallux
Dorsiflexor big toe and
ankle
Deep peroneal nerve
Test for L5

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Extensor Hallucis Longus

Upper three quarter anterior
surface of fibula
Except the area for the
extensor hallucis longus
Anterior intermuscular
septum
Passes under retinacula
Divides into four tendons
Joined by slips from brevis
Lumbricals and interossei
muscles

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Extensor Digitorum Longus

Main extensor tendon inserted into
base of middle phalanx, of the
lateral four toes
Collateral slips formed by lumbricals
and interossei inserted into distal
phalanx
Dorsiflexor ankle
Extends proximal phalanx lateral four
toes

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Peroneus Tertius
Lower quarter of anterior surface of
the fibula
Inserted into base and dorsum of
shaft of fifth metatarsal
Dorsiflexor and evertor

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Extensor Digitorum Brevis

Fleshy origin from calcaneus

Stem of inferior retinaculum
Divides into four tendons
First is extensor hallucis brevis
Other three join extensor
expansion of second, third and
fourth toes
Deep peroneal nerve

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Deep Peroneal Nerve

Branch of the common peroneal at neck of
fibula
Pierces anterior intermuscular septum
Runs between extensor digitorum longus and
tibialis anterior
Then tibialis anterior and extensor hallucis
longus

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Deep Peroneal Nerve

In anterior compartment
Supplies
Tibialis anterior
Extensor hallucis longus
Extensor digitorum longus
Peroneus tertius
Extensor digitorum brevis
Skin first cleft

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Anterior Tibial Artery

Branch of popliteal
Enters above interosseous
membrane
Only supply of tibialis
anterior
Becomes dorsalis pedis at
ankle joint

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Dorsalis Pedis

Gives off
First dorsal metatarsal artery
Arcuate artery gives off
2-4th dorsal metatarsal
arteries
At base of first
intermetatarsal space
Enters sole of foot
Joins lateral plantar artery to
complete plantar arch

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Blood Supply of Dorsum

Arcuate artery
Dorsal metatarsal arteries
Posterior and anterior perforating
branches from metatarsals
Communicate plantar arch
And its digital branches
Perforating veins drain into dorsal
venous arch

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Perforating Peroneal Artery

Perforating peroneal artery

Pierces interosseus membrane
Enters anterior compartment
May replace dorsalis pedis

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Venous and Lymph Drainage of Foot

Dorsal venous arch
Medial, long saphenous
vein
Anterior to medial
malleolus
Short saphenous vein
Posterior to lateral
malleolus
Lymphatics follow
superficial veins

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Lateral Compartment of Calf

Between anterior and posterior
intermuscular septa
Peroneus longus
Peroneus brevis
Superficial peroneal nerve

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Peroneus Longus
Upper two thirds lateral surface of fibula
Adjoining area of interosseous
membrane
Passes under superior and inferior
peroneal retinaculum

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Peroneus Longus

May have a sesamoid bone

Runs in groove in the cuboid
Inserted into
Lateral aspect of medial cuneiform
And adjoing base of first metatarsal

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Peroneus Longus

Plantar flexor and evertor

Supports lateral arch
Superficial peroneal nerve
Cuboid syndrome
Torn peroneal retinacula
Snapping tendons

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Peroneus Brevis
Lower two thirds
Lateral surface of fibula in front of
longus
Passes under superior and inferior
peroneal retinacula
Above peroneal trochlea on calcaneus
Inserted into base of fifth metatarsal

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Peroneus Longus and Brevis

Plantar flexors and
evertors
Longus support the lateral
longitudinal arch
Superficial peroneal nerve

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Superficial Peroneal Nerve

Branch common peroneal

Neck of fibula
Supplies peroneus longus and brevis
Pierces deep fascia
Dorsum of foot supplies
Medial side of big toe
All clefts except first and lateral side of little
toe

Sensory Supply to
Posterior Aspect of Calf

Posterior cutaneous nerve of thigh

Lateral cutaneous of calf
Sural nerve
Saphenous nerve
Medial calcaneal

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Dermatomes

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Posterior Surface of the Calf

Short saphenous vein
Posterior to lateral malleolus
pierces the roof of popliteal
fossa to enter popliteal vein
Deep fascia thickened medial
between medial malleolus
and calcaneum
Bursa anterior to achilles

Medial and Lateral Heads

of Gastrocnemii
Medial head arises from popliteal
surface of femur above medial
condyle
Lateral is shorter, arises from
posterior part of the lateral surface
of the lateral femoral condyle and
capsule of knee
Fabella is a sesamoid bone in
lateral head

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Medial and Lateral Heads

of Gastrocnemii

Bursa deep to the two heads

Medial belly is longer
Unite to form a tendinous raphe
Unites with soleus to form achilles
Fast twitch fibres
Flex knee and plantar flex ankle

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Plantaris
Short fleshy origin from
The popliteal surface of femur
above the lateral femoral
condyle
Long tendon passes between
gastronemii and soleus
Inserted medial border of
achilles
Tibial nerve

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Plantaris

May be absent
May rupture
Used in tendon grafts
Sudden dorsiflexion
of ankle
Ballet dancing
Gymnastics
Basketball
Sprinting

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Soleus
Broad flat pennate muscle
Arises from head and upper
fourth of posterior surface of the
fibula
Fibrous arch
Soleal line of tibia
Middle third of medial border of
tibia

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Soleus

Two aponeurotic lamellae

Bulk of vascular multipennate muscle fibres
Deepest of achilles
Slow twitch fibres
Perforating veins from great saphenous enter
soleus
Acts as a peripheral pump

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Achilles Tendon
Extent of the fusion between the
gastronemii and soleus varies
Inserted into middle of posterior surface of
the calcaneus
Tendon twists
Gastronemii form the lateral and posterior
part of the tendon

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Achilles Tendon
Rotation occurs above
where the soleus tends to
join
Rotation is greater if minimal
fusion
Stress marked 2-5 cm above
insertion
Plantar flexor of ankle
Eccentric lower heels

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Achilles Tendon
The achilles tendon is subjected
to the highest loads in the body
Tensile loads up to eight and
ten times body weight are
experienced during running
jumping hopping and skipping
The achilles tendon is subjected
to stress when running up and
downhill
A tight achilles tendon also
limits dorsiflexion of the ankle

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Achilles Tendon
Superficial bursa may be
found posterior to achilles
between it and the deep
fascia
The retrocalcaneal bursa is
just proximal to the insertion
Between the tuberosity on
the posterior surface of the
calcaneus and the achilles
tendon

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Achilles Test

Medial and Lateral Heads

of Gastrocnemii

Sprinting
Jumping
Hopping
Skipping
Stretched with knee
extended and ankle
dorsiflexed
Tibial nerve

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The Retrocalcaneal Bursa

The area of fibro cartilage on the
tendon forms the posterior wall
The anterior wall of the
retrocalcaneal bursa is the 0.5 to
1 mm thick cartilaginous layer on the
posterior aspect of the calcaneus
The proximal wall of the synovial lined sac consists of
folds, or villus synovial projections
Allows alterations in its form, produced by varying
degrees of pressure on the fat above it during flexion
and extension of the ankle

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Flexor Digitorum Longus

Posterior surface of tibia

Below soleal line
Medial to vertical line
Variable origin by an
aponeurosis from fibula

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Flexor Digitorum Longus

Very extensive fibular
origins of FDL
Hislop M, 2003

FHL

Fibular origin of FDL

FDL

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Flexor Digitorum Longus

Crosses tibialis posterior in calf
Flexor hallucis longus in foot
Foot receives insertion flexor accessorius
and two slips from flexor hallucis longus
Divides four tendons
Give origin to four lumbricals

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Flexor Digitorum Longus

In the foot the tendon passes through
birfurcation of brevis
Inserted into distal phalanges
Plantar flexes ankle
Plantar flexes lateral four toes
Supports medial arch
Tibial nerve

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Flexor Hallucis Longus

Bulkiest and most powerful,
multipennate
Arises from posterior surface of
fibula
Posterior to medial crest
Beef to heel
Most posterior under retinaculum

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Flexor Hallucis Longus

Grooves posterior process of talus
Sustentaculum tali
Crossed in foot by flexor digitorum longus to
which it gives two slips
Inserted base of distal phalanx

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Flexor Hallucis Longus

Tibial nerve
Plantar flexes ankle
Flexes big toe
Supports medial longitudinal arch
Take off muscle

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Tibialis Posterior

Deepest
Posterior surface of tibia
Below soleal line
Lateral to vertical line
Interosseous membrane
Arises from posterior surface of
fibula
Anterior to medial crest

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Tibialis Posterior
Crossed by flexor digitorum longus in calf
Posterior to medial malleolus
grooves bone, type II collagen, tends to
have poor blood supply
Most anterior under the flexor
retinaculum
Inserted into tuberosity of navicular
All bones of the tarsus except talus
Base of middle three metatarsals

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Tibialis Posterior

Plantar flexor ankle

Invertor of foot
Supports medial arch
Avascular area behind
medial malleolus
Tibial nerve

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Posterior Tibial Artery

Branch popliteal
artery
Lower border of
popliteus
Under fibrous arch
of soleus
Between flexor
digitorum longus
and flexor hallucis
longus
Vena commitans

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Posterior Tibial Artery

In the calf gives off

Nutrient artery to tibia
Peroneal artery
Nutrient artery to fibula
Perforating peroneal
Passes under flexor retinaculum
Gives off medial calcaneal artery which
pierces flexor retinaculum
Then ends under flexor retinaculum
Dividing into medial and lateral plantar
arteries

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Tibial Nerve

Leaves the popliteal fossa

Runs in middle of calf
Deep to soleus
Accompaning artery
Branches to soleus
Flexor digitorum longus and flexor hallucis
longus
Tibialis posterior

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Flexor Retinaculum

Medial malleolus to calcaneus

Anterior to posterior
Tibialis posterior
Flexor digitorum longus
Posterior tibial artery
Medial calcaneal artery pierces retinaculum
Divides into medial and lateral plantar arteries
Tibial nerve
Gives off medial calcaneal nerve which accompanies artery
Divides into medial lateral plantar nerves
Flexor hallucis longus

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Causes of Compartment Syndromes

May be acute or chronic

Sudden increase in exercise
Haematoma
Callus
Fracture

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Compartment Syndromes
Mainly anterior compartment
Tibialis anterior main muscle
affected as only supplied by
anterior tibial, other muscles also
supplied by perforating peroneal
Increasing pressure causes loss
of sensation of first cleft due to
pressure on deep peroneal nerve
Fasciotomy
Or
Posterior or lateral compartments

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Posterior Compartment
Posterior compartment
Posterior border of tibia
Posterior intermuscular septum
Divided
Superficial
Deep
Deep posterior

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Posterior Compartment
Superficial compartment
Posterior intermuscular septum
Posterior border of tibia

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Superficial Posterior Compartment

Medial and lateral gastrocnemii

Plantaris
Soleus
Forming the achilles tendon
Tibial nerve

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Deep Posterior Compartment

Popliteus
Flexor digitorum longus
Flexor hallucis longus
Deepest is tibialis posterior

Chronic Exertional Compartment

Syndrome (CECS)
Significant morbidity/limitation activity to athletes
Activity related, reversible, myofascial
intracompartmental pressure increase
Results in decreased tissue perfusion and
neuromuscular function abnormalities
Predilection for the lower leg

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Chronic Exertional Compartment

Syndrome (CECS)
The fibular origin of FDL can
partially (or sometimes almost
completely) compartmentalize
TP and acts to resist increases
in intracompartmental volume
and therefore cause increased
pressure
The presence and extent of a
fibular origin of FDL may act as
an anatomical predisposition to
the development of CECS

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