HUMAN ANATOMY

First Year MBBS

Note: Underlined and bold
words are important and
often asked by teachers in
vivas. Some frequently
asked questions are also
mentioned here.

These are maximum clinicals

of lower limb put together
from different books and
internet by Umer Shehroz
Khan (Kemcolian)

Lower limb:
BONES OF LOWER LIMB:
Hip fractures:

Q. What is the most common type of hip fracture?

A. Intertrochanteric and femoral neck fractures are the most common types of hip fracture. Femoral head
fractures are extremely rare and are usually the result of a high-velocity event.

Types of hip fractures:

Hip fractures are classified according to their anatomical location as:
1) Intracapsular, which involves the femoral head and neck
2) Extracapsular, which includes intertrochanteric, trochanteric, and subtrochanteric fractures.
 Hip Bone:
 Avulsion fracture of hip bone:

An avulsion fracture occurs when a small chunk of bone attached to a tendon or ligament gets pulled away from
the main part of the bone. (The hip, elbow and ankle are the most common locations for avulsion fractures in the
young athlete.) These fractures occur where
1) muscles are attached
2) apophyses (that lack secondary ossification center).

 Weavers Bottom:
The inflammation of bursa over ischial tuberosity is called weavers bottom. It is also called as ischial bursitis or
ischiogluteal bursitis. It causes pain in buttock. It is caused by sitting for too long.
OR
It is the Inflammation of the bursa that separates the gluteus maximus muscle of the buttocks from the underlying
bony prominence of the bone that a person sits on (ischial tuberosity).

Q. Which region of hip bone is used for taking bone marrow biopsy?
A. Iliac crest. (it is done in case of anemia or leukemia)

Femur:
 Femoral head fracture:
It is caused by posterior dislocation of hip joint and can be treated by hip replacement. It results in shortening of
lower limb with medial rotation.
Note: joint replacement is possible.

 Avascular necrosis of femoral head:

The head of femur is supplied by retinacular arteries (branches of medial circumflex femoral artery) and branch
of obturator artery along ligamentum teres. During intracapsular fracture, they get damage and cause avascular
necrosis of head.

 Femoral neck fracture:

The neck of femur can be considered to have two distinct areas, which are described relative to the joint capsule:

 Intra-capsular fracture – which occur inside the capsule of hip joint. It has 2 types:
1) subcapital fracture: It is the fracture of femoral head or neck near the head.
2) Trans-cervical fracture: It is the fracture of the femoral neck, immediately proximal to the trochanters
 Extra-capsular fracture – outside the capsule, subdivided into 3 types:
1) Inter-trochanteric fracture, which occur between the greater trochanter and the lesser trochanter
2) Sub-trochanteric fracture, which occurs at area 5cm distal to the lesser trochanter.
3) Pertrochanteric fracture, is a femoral fracture through the trochanters. The pull of the quadriceps femoris,
adductors, and hamstring muscles may produce shortening and lateral rotation of the leg. It is common in
elderly women because of an increased incidence of osteoporosis.

 Femoral shaft fractures:

The most common types of femoral shaft fractures include:

1) Transverse fracture. In this type of fracture, the break is a straight horizontal line going across the femoral
shaft.
2) Oblique fracture. This type of fracture has an angled line across the shaft.
3) Spiral fracture. The fracture line encircles the shaft like the stripes on a candy cane. A twisting force to
the thigh causes this type of fracture.

 Pillion fracture:

It is a T shaped fracture of the distal femur with displacement of the condyles. It may be caused by a blow
to the flexed knee of a person riding pillion on a motor cycle.

 In fracture of the middle third of the femoral shaft, the proximal fragment is pulled by the quadriceps and the
hamstrings, resulting in shortening, and the distal fragment is rotated backward by the two heads of the
gastrocnemius.

Patella:

 Transverse patellar fracture:

It results from a blow to the knee or from

sudden contraction of the quadriceps muscle.
The proximal fragment of the patella is pulled
superiorly with the quadriceps tendon, and the
distal fragment remains with the patellar
ligament.
 Tibia:
 The tibia is commonly fractured at the junction of upper two thirds and lower one third of the shaft as the
shaft is slenderer here.
 The upper end is one of the commonest sites for acute osteomyelitis.

 Bumper fracture:
A bumper fracture is a fracture of the lateral tibial plateau
caused by the bumper of a car coming into contact with the
outer side of the knee when a person is standing. Common
peroneal nerve can damage here.

 Boot top fracture:

Boot top fracture is a spiral fracture in which the tibia gets fractured close to the boot top. It results from high
speed forward fall.

 Transverse March or stress fracture:

It is a fracture of inferior third of tibia occur in people who take long hikes.

Fibula:
 Bone grafting:
Sometimes a surgeon takes a piece of bone from one part of the body and uses it to repair a defect in some other
part. This is called bone grafting. The medial aspect of tibia & shaft of fibula are commonly used for bone grafting.

 Potts fracture:
Pott’s fracture also called Dupuytren’s fracture is a trimalleolar fracture of the lower end of the fibula (lateral
malleolus), accompanied by fracture of the medial malleolus & distal end of tibia. It causes rupture of the deltoid
ligament. It is caused by forced eversion of the foot.
  Foot drop:
The facture of neck of fibula damages the
common peroneal nerve and causes the
paralysis of muscles of anterior and lateral
compartment of leg and loss of their related
movements. This is called foot drop

Foot:
 Fracture of neck of talus is common and it is caused by forced dorsiflexion.
 Fracture of sustantaculum tali is common which is caused by forced inversion.
 Talus is devoid of any muscular attachment.
 March fracture:
The fracture of 2nd ,3rd ,4th and 5th metatarsal bones is called march fracture. It is common in soldiers, policemen
and female ballet dancers. It is also called as stress fracture.

Joints of lower limb

Hip joint:

 Dislocation of hip joint:

A hip dislocation is when the thighbone (femur) separates from
the hip bone (pelvis).

Anterior,
Types
posterior

Causes Trauma

Confirmed by
Diagnostic method
X-rays

Hip fracture,
Differential diagnosis
hip dysplasia
 Types of dislocation:
1. Posterior dislocation:
Posterior dislocations are when the femoral head lies posteriorly after dislocation. It is the most common pattern
of dislocation accounting for 90% of hip dislocations. Posterior dislocation of the hip joint occurs through a
posterior tearing of the joint capsule, it results in probable rupture of both the posterior acetabular labrum and
the ligamentum capitis femoris and usually injury of the sciatic nerve. It results in the affected lower limb being
shortened. The sciatic nerve may be injured in posterior dislocations of hip joint.

2. Anterior dislocation:
Anterior dislocations are when the femoral head lies anteriorly after dislocation. Anterior dislocations are
subdivided into two types being inferior (obturator) dislocation and superior (iliac or pubic) dislocation. The
affected limb is slightly flexed, abducted, and laterally rotated.

3. Medial dislocation:
Medial (central or intra-pelvic) dislocation of the hip joint occurs through a medial tearing of the joint capsule,
and the dislocated femoral head lies medial to the pubic bone. This may be accompanied acetabular fracture
and rupture of the bladder.

 Coxa valga (increase in angle):

Coxa valga is a deformity due to an increase in the angle between the head and neck of the femur and its shaft
(normally 135 degrees).so that the angle exceeds 135 degrees and, thus, the femoral neck becomes straighter.

 Coxa vara (decrease in angle):

Coxa vara is the opposite a decreased angle between the head and neck of the femur and its shaft.so that the
angle is less than 135 degrees and, thus, the femoral neck becomes more horizontal.
 Anteversion of the femur (inward twisting) can create coxa valga.
 Angle of wiberg is angle between ilium and femoral head. Decrease in angle shows joint instability.

 Referred pain:
The pain of hip joint is referred in knee joint because of the common nerve supply (obturator nerve)

 The length of the lower limb is measured from anterior superior iliac supine of hip bone to the medial
malleolus of tibia.

 Osteoarthritis, the most common disease of the hip joint in the adult, causes pain, stiffness, and deformity.
 Congenital dislocation is more common in the hip joint than in any other joint of body.

 Shenton line:
It is seen in an x-ray. It is a continuous curve formed by the upper border of the obturator foramen and the
lower border of the neck of the femur. In the case of femoral neck fracture, this line becomes abnormal.

Knee joint:

Q. Why knee joint is a week joint?

A. The knee joint is a week joint because:
1. The articular surfaces are not congruent.
2. The tibial condyles are too small and shallow to hold
the large, convex femoral condyles in place.
3. The femorapatellar articulation is also insecure.

Q. Which factors provide stability to knee joint?

A. There are various factors:
1. The cruciate ligaments provide anteroposterior support.
2. The collateral ligaments provide side to side support.
3. Various other ligaments strengthening the capsule.
4. The iliotibial track also provide stability to knee joint.

 Drawer sign:
Anterior drawer sign is a forward sliding of the tibia on the femur due to a rupture of the anterior cruciate
ligament
Posterior drawer sign is a backward sliding of the tibia on the femur caused by a rupture of the posterior cruciate
ligament.
 The medial meniscus is more frequently torn in injuries than the lateral meniscus because of its strong
attachment to the tibial collateral ligament.

 Unhappy triad or O’Donoghue’s triad: (Imp)

It may occur when a football player’s cleated shoe is planted firmly in the turf and the knee is struck from the
lateral side. It is indicated by a knee that is markedly swollen, particularly in the suprapatellar region, and results
in tenderness on application of pressure along the extent of the tibial collateral ligament. It is characterized by

(a) rupture of the tibial collateral ligament, as a result of excessive abduction

(b) tearing of the anterior cruciate ligament, as a result of forward displacement of the tibia

(c) injury to the medial meniscus, as a result of the tibial collateral ligament attachment.

 Baker’s cyst:
A Baker's cyst (or Baker cyst), also known as a popliteal cyst, is a swelling in the popliteal space, the space behind
the knee. It causes stiffness and knee pain. It is caused by osteoarthritis of knee joint. The synovial membrane
protrudes through a hole in the posterior part of the capsule of knee joint. It impairs flexion and extension of the
knee joint, and the pain gets worse when the knee is fully extended, such as during prolonged sanding or walking.
It can be treated by draining and decompressing the cyst

 Genu valgum:
Genu valgum, known as knock-knees, is a knee misalignment that turns your knees inward. It is a deformity in
which the leg is abnormally abducted because tibia is bent or twisted laterally. It may occur as a result of collapse
of the lateral compartment of the knee and rupture of the medial collateral ligament.

 Genu varum:
Genu varum (also called bow-leg, bandy-leg, and tibia vara) is a deformity marked by (outward) bowing at the
knee, which means that the lower leg is angled inward (medially) in relation to the thigh's axis, giving the limb
overall the appearance of an archer's bow. It may occur as a result of collapse of the medial compartment of
the knee and rupture of the lateral collateral ligament.

 Patellar tendon reflex: a tap on the patellar tendon elicits extension of the knee joint. Both afferent
and efferent limbs of the reflex arc are in the femoral nerve (L2–L4).
 A portion of the patella ligament may be used for surgical repair of the anterior cruciate ligament of the
knee joint. The tendon of the plantaris muscle may be used for tendon auto grafts to the long flexors of
the fingers.

Bursas of Knee:

 Prepatellar bursitis (housemaid knee):

It is an inflammation of the bursa in the front of the kneecap (patella). It occurs when the bursa becomes
irritated and produces too much fluid, which causes it to swell and put pressure on the adjacent parts of the
knee.
 Infrapatellar bursitis (Vicar's knee, clergyman's knee):
It is inflammation of the superficial infrapatellar bursa (located between the patellar ligament and the skin) or
deep infrapatellar bursa (which lies between the patellar ligament and the tibia). Symptoms may include knee
pain, swelling, and redness just below the kneecap.
 Patellofemoral syndrome:
It is a condition that describes pain in the front of the knee and around the kneecap, known as the patella. It is
also called as “jumper's knee” or “runner's knee.” This Pain results from abnormal tracking of patella relative to
femur. It may also result from direct blow to patella or osteoarthritis.

 Longitudinal tearing of menisci is called bucket handle tear.

Ankle joint:
 Ankle sprain:
A sprain occurs when your ankle is forced to move out of its normal position, which can cause one or more of
the ankle's ligaments to stretch, partially tear or tear completely.
 Acute sprains of lateral ankle when the foot is plantar flexed and excessively inverted. The lateral ligaments
of ankle joint are torn giving rise to pain and swelling.
 Acute sprains of medial ankle occur in excessive eversion leading to tear of strong deltoid ligament.

Ligaments of
ankle joint

Q. Why ankle joint is unstable in plantarflexion and usually dislocates in this position?
A. During plantar flexion the narrow posterior part (surface) of trochlea lies loosely in the wider anterior part
of the mortice. This makes the joint unstable. Thus ankle joint usually dislocates in this position especially
during walking in high heels.

Foot:

 Bunion and hallux valgus:

(Hallux valgus is a lateral deviation of big toe because of bunion which is a swelling on its medial side.) It is a
deformity of the joint connecting the big toe to the foot. Hallux valgus is a lateral deviation of the big toe and is
frequently accompanied by swelling (bunion) on the medial aspect of the first metatarsophalangeal joint due to the
development of adventitious bursa. Later on, osteoarthritic changes occur in the metatarsophalangeal joint,
which then becomes stiff and painful; the condition is then known as hallux rigidus.
 Hallux varus:
In hallux varus, there is a medial deviation of the big toe.

 Mallet toe:
It is a deformity characterized by hyperextension at proximal interphalangeal joint while there is flexion at
distal interphalangeal joint.

 Hammer toe:
A hammer toe is a toe that has an abnormal bend in its middle joint, making the toe bend downward to look like
a hammer. It is a Deformity in which proximal phalanx is extended at metatarsophalangeal joint, middle phalanx
is flexed at proximal interphalangeal joint & distal phalanx is hyperextended giving hammer like appearance.

 Claw toe:
It is a Deformity characterized by hyperextension of metatarsophalangeal joints & flexion of interphalangeal joints
giving the toes claw like position.

 Fractured toe is bandaged with the adjacent toe, this is called as buddy splint.

Gluteal region:
 Positive Trendelenburg sign:
Normally, when body weight is supported on one limb, the glutei of the supported side raise the opposite and unsupported
side of the pelvis. When this adductor mechanism becomes defective, the unsupported side of the pelvis drops. This is known
as positive Trendelenburg’s sign.
 Positive Trendelenburg’s sign is seen in

 fracture of the femoral neck

 dislocated hip joint (head of femur)
 weakness and paralysis of the gluteus medius
and minimus muscle, causing inability to abduct
the hip.

 Lurching gait:
When the Trendelenburg’s sign is positive i.e. the glutei medius and minimus of one side (e.g. right) are paralyzed the patient
cannot walk normally. He bends or waddles on that paralyzed side (e.g. right) in order to clear the opposite foot (i.e. left off the
ground) this is called lurching gait.

 Waddling gait (gluteal gait):

When glutei of both sides are paralyzed the patient waddles on both sides. This kind of gait is waddling gait. Its causes are
1) injury to superior gluteal nerve
2) paralysis of gluteus medius and minimus
3) fracture of greater trochanter
4) dislocation of hip joint

 The gluteal region is a common site for intramuscular injection of medications. Injection should always be made
in the superior lateral quadrant of the gluteal region to avoid injury to the underlying sciatic nerve and other
neurovascular structures in the medial and inferior quadrants. The injection is given in big gluteus medius
muscle.
 When poliomyelitis involves lower lumbar & sacral segments of spinal cord, gluteus medius & gluteus
minimus are paralyzed.
 Injury to the superior gluteal nerve causes a characteristic motor loss, resulting in weakened abduction of
the thigh by the gluteus medius, a disabling gluteus medius limp, and gluteal gait.
 Sciatic nerve block:

The site of needle insertion for blocking the sciatic nerve at the level of hip is 3 cm along the perpendicular that
bisects a line drawn between the greater trochanter and the posterior superior iliac spine.
  Piriformis syndrome:

Piriformis syndrome is a condition in which the piriformis muscle,

located in the buttock region, spasms and causes buttock pain.
The piriformis muscle can also irritate the nearby sciatic nerve and
cause pain, numbness and tingling along the back of the leg and into
the foot (similar to sciatic pain). It can be treated with progressive
piriformis stretching.

 Sciatica:

The pain that radiates along the course of sciatic nerve in the lower back and hip, also radiates down
the back of the thigh and into the lower back is called as sciatica. (The pain initially was attributed to sciatic nerve
dysfunction but now is known to be due to herniation of a lower lumbar intervertebral disk compromising nerve
roots.)
 Triceps coxae includes obturator internus, gemellus superior and inferior.

Anterior compartment of thigh:

Q. What is clinical significance of holden’s line?
A. When the urethra is injured in the perineum, urine may flow out or extravaste into the interval deep
membranous layer of superficial fascia. This urine can pass up into the anterior abdominal wall from where it
can enter into upper part of the thigh. However, the firm attachment of the membranous layer of the superficial
fascia to the deep fascia along the Holden’s line prevents urine from descending into the thigh beyond this line.

 Femoral hernia: (Imp)

Femoral canal is an area of potential weakness especially in females because of their wider femoral canal.
“Abdominal contents may bulge into femoral canal leading to femoral hernia”. It is never congenital.

 Parts: It consists of sac & neck. Coverings are various layers on the sac. Mostly the content of hernia sac is a
loop of bowel.
 Course: It passes downward through femoral canal, then anteriorly through saphenous opening and then moves
upwards. For reduction of such hernia, reversed course is followed.
 It is more common in females because of wider pelvis and the smaller size of the femoral vessels.
 Lacunar ligament is ligated to enlarge the femoral canal in order to treat femoral hernia.
 Q. During ligation of lacunar ligament what care should be
taken?
A. Sometimes, the abnormal obturator artery may lie along the
medial margin of the femoral ring i.e. along the free margin of
lacunar ligament. Such an artery is likely to be cut if an attempt
is made to enlarge the femoral ring by cutting the lacunar
ligament. So this artery should be kept in mind during
treatment.

Q. Difference between femoral and inguinal hernia?

A. These are:
1. The femoral hernia occurs in femoral canal while inguinal
hernia occurs in inguinal canal.
2. The femoral hernia is common in females and inguinal hernia
is common in males.

 Meralgia parasthetica:
Lateral cutaneous nerve of thigh may get entangled in inguinal ligament & this leads to pain on lateral side of leg,
which is known as meralgia parasthetica.

 The femoral artery is easily exposed and cannulated at the base of the femoral triangle just inferior to the
midpoint of the inguinal ligament. The superficial position of the femoral artery in the femoral triangle makes
it vulnerable to injury by laceration and gunshot wounds. When it is necessary to ligate the femoral artery, the
cruciate anastomosis supplies blood to the thigh and leg.
 Damage to the femoral nerve causes impaired flexion of the hip and impaired extension of the leg resulting from
paralysis of the quadriceps femoris.
 Apex of femoral triangle is such a point where femoral artery, femoral vein, profunda femoris artery & vein are
arranged in one line from before backwards.
 Psoas (pus accumulation) abscess:

Tuberculous infection of a lumbar vertebra can result in the extravasation of pus down the psoas sheath into the
thigh. The presence of a swelling above and below the inguinal ligament, together with clinical signs and symptoms
referred to the vertebral column, should make the diagnosis obvious.

 Femoral vessel catheterization:

1) The skin of the thigh below the inguinal ligament is supplied by the genitofemoral nerve; this nerve is blocked with
a local anesthetic.

2) The femoral pulse is palpated midway between the anterior superior iliac spine and the symphysis pubis, and the
femoral vein lies immediately medial to it.

3) At a site about two fingerbreadths below the inguinal ligament, the needle is inserted into the femoral vein.
Groin injury or pulled groin is a strain, stretching, or tearing of the origin of the flexor and adductor of the thigh and
often occurs in sports that require quick starts such as a 100-meter dash and football.

 Corona mortis (crown of death):

It is defined as the vascular anastomoses between the obturator and external iliac systems. A vascular anastomosis
between pubic branches of the obturator artery and of the external iliac (or inferior epigastric) artery is called the
corona mortis

 Popliteal aneurysm:
It is a bulge in a popliteal artery behind your knee. The bulge occurs in a weak spot in the artery. This kind
of aneurysm is most common in older men. Blood clots can form in this type of aneurysm and block blood flow
in your leg. It results in edema and pain in the popliteal fossa. It is palpable &it has abnormal arterial sound. It may
stretch tibial nerve. Its treatment involves surgical ligation of femoral artery.

Medial compartment of thigh:

 The gracilis muscle is the most superficial muscle of the adductor compartment. This muscle is often used for
transplantation of any damaged muscle.
 Adductor magnus and pectinus are two hybrid muscles.
 Muscle strains of the adductor longus may occur in horseback riders and produce pain because the riders
adduct their thighs to keep from falling from the animal.
 Sesamoid bone in adductor longus tendon near its origin is called riders bone.
 Damage to the obturator nerve causes a weakness of adduction and a lateral swinging of the limb during
walking because of the unopposed abductors.

Back of thigh:
 Sleeping foot:
The sciatic nerve lies for a short distance on femur between the thin borders of quadratus femoris and adductor
magnus. When a person sits on the edge of the hard table or chair the sciatic nerve gets compressed between the
edge of table and femur. It results in numbness of lower limb but the sensation comes back when the foot is hit
on the ground. This is called sleeping foot.
 Damage to the sciatic nerve causes impaired extension at the hip and impaired flexion at the knee, loss of dorsi-
flexion and plantar flexion at the ankle, inversion and eversion of the foot, and peculiar gait because of increased
flexion at the hip to lift the dropped foot off the ground.
 Hamstring injury or strains (pulled or torn hamstrings) are common in persons who are involved in running,
jumping, and quick-start sports.
 Trochanteric bursitis (inflammation of trochanteric bursitis) results from climbing & running

Anterior compartment of leg:

 Anterior compartment syndrome (fresher’s syndrome):

It is characterized by ischemic necrosis of the muscles of the anterior compartment of the leg. It occurs
presumably as a result of compression of arteries (anterior tibial artery and its branches) by swollen muscles
following excessive exertion. It is accompanied by extreme tenderness and pain on the anterolateral aspect of
the leg.
 Foot drop:
The facture of neck of fibula damages the common peroneal nerve and causes the paralysis of muscles of anterior
and lateral compartment of leg and loss of their related movements. This is called foot drop.

There are 3 means of compensating foot drop

1) waddling gait
2) swing out gait (in which long limb is swung out laterally to allow toes to clear the ground)
3) steppage gait (in which extra flexion is employed at hip and knee to raise the foot as high to keep toes from hitting
ground)

 Shin splints (medial tibial stress syndrome):

It is an inflammation of the muscles, tendons, and bone tissue around your tibia. Pain typically occurs along the
inner border of the tibia, where muscles attach to the bone. Shin splint pain most often occurs on the inside edge
of your tibia (shinbone).

 The great saphenous vein accompanies the saphenous nerve, which is vulnerable to injury when collected
surgically. It is commonly used for coronary artery bypass surgery, and the vein should be reversed so its
valves do not obstruct blood flow in the graft. This vein and its tributaries become dilated.
 Sural nerve is used for nerve grafts to repair nerve defects.

 Thrombophlebitis is a venous inflammation with thrombus formation that occurs in the superficial veins in the
lower limb, leading to pulmonary embolism. However, most pulmonary emboli originate in deep veins, and the
risk of embolism can be reduced by anticoagulant treatment.

 Guy ropes:
The three muscles inserted into upper part of the medial surface of tibia are Sartorius, gracilis and
semitendinosus. They belong to three different compartments of thigh, correspond to three different elements
of hip bone and are supplied by three different nerves. They are called guy ropes because they are anchored
below at one point and spread out above to span the pelvis, like three strings of the tent. Due to this
arrangement they are called so.

 Anserine bursa:
The pes anserine bursa is a small, fluid-filled sac located 2 to 3 inches below the knee joint on the inside of the
lower leg. It separates the tendons of Sartorius, gracilis and semimembranosus at their insertion from one
another, from bony surface of tibia and from tibial collateral ligament. Its inflammation is called anserine
bursitis.

Posterior compartment of leg:

 Fabella is a sesamoid bone present in the tendon of origin of the lateral head of gastrocnemius.
 Brodie’s bursa is a bursa present deep to medial head of gastrocnemius and semimembranosus and may communicate
with the cavity of knee joint.
 The long tendon of plantaris is used for tendon transplantation (especially used to replace tendons of fingers).
 Tendo-calcaneus can rapture in tennis players 5cm above its insertion.
Q. Why soleus is called as peripheral heart or calf pump?
A. There are large, valveless, venous sinuses in the substance of soleus muscle. When the muscle contracts, the blood in these
sinuses is pumped upwards. When it relaxes, it sucks the blood from superficial veins through the perforators. Thus the soleus
is called as peripheral heart.

 Ankle jerk (Achilles reflex):

The ankle jerk reflex, also known as the Achilles reflex, the
foot gets plantar flexed on tapping the tendo-calcaneus
(Achilles tendon). It is a type of stretch reflex that tests the
function of the gastrocnemius muscle and the nerve that
supplies it.
 Restless legs syndrome is a sense of restless unpleasant discomfort inside the legs when sitting or lying down,
accompanied by an irresistible urge to move the legs. Movement like walking brings relief.
 Passengers who sit immobile for hours on long-distance flights are very prone to deep vein thrombosis in
the legs. Thrombosis of the veins of the soleus muscle gives rise to mild pain or tightness in the calf and calf
muscle tenderness. However, deep vein thrombosis can also occur with no signs or symptoms. When the
thrombus become dislodged, it passes rapidly to the heart and lungs, causing pulmonary embolism, which
is often fatal.

 Knee-jerk reflex (patellar reflex):

Knee jerk is a sudden kicking movement of the lower leg
in response to a sharp tap on the patellar tendon, which
lies just below the kneecap. It is used to check femoral
nerve.

 Calcaneal bursitis
Superficial calcaneal bursitis, also known as subcutaneous calcaneal bursitis or Pre-Achilles bursitis, is a form
of bursitis which affects the bursa located at the back of the heel, just underneath the skin.

 Posterior tibial pulse is palpated between posterior aspect of medial malleolus and medial border of
calcaneal tendon. While, dorsalis pedis pulse is palpated lateral to FHL tendon between two malleoli.

 Varicose veins:
Varicose veins are swollen, twisted veins that lie just under the skin (superficial veins)and usually occur in the legs.
Varicose veins are a common condition caused by weak or damaged vein walls and valves (mostly of perforating
veins). Varicose veins may form whenever blood pressure increases inside your veins.
Risk Factors: Old age; Pregnancy; Obesity
 Trendelenburg Test or Brodie–Trendelenburg test:
It is a test which can be carried out as part of a physical examination to determine the competency of the valves
in the superficial and deep veins of the legs in patients with varicose veins
{Technique (just for understanding)
The affected leg is raised so that the veins are emptied by gravity. Around the upper thigh region, a
tourniquet is applied, sufficiently tightly to constrict the saphenous vein. The femoral vein blood flow is not
obstructed. The subject is then asked to stand and the degree of filling of his saphenous vein is noted.

Interpretation
If the test is negative, with the tourniquet in place the veins fill within a period of 30 seconds, ad upon
removal of the tourniquet n increased rate of filling is observed. There is no retrograde flow taking place
through the saphenofemoral junction, and the filling occurs due to incompetency of the communicating
veins.

If the test is positive, While the patient stands with a tourniquet is placed, the varicosities will remain
collapsed throughout the 30second period. Once the tourniquet is removed the internal saphenous vein
rapidly fills with blood from above. This indicates that the valves of the saphenous vein at the
saphenofemoral junction are incompetent, but the valves of the communicating ve ins are still intact.

Doubly positive, If the veins rapidly fill on standing and again as the tourniquet is removed is there is further
distension of the veins. This indicates incompetency of the valves of both the saphenous and communicating
systems of veins.

Nil, the tourniquet is applied and even after removal there is only slow filling of the veins from below. This
indicates that both the saphenous veins and the communicating veins are competent. }

 Elephantiasis:

It is the enlargement and hardening of limbs or body parts due to tissue swelling. It is characterized by edema,
hypertrophy, and fibrosis of skin and subcutaneous tissues, due to obstruction of lymphatic vessels. It may affect
the genitalia.
 Foot:

 Plantar fasciitis:
It is one of the most common causes of heel pain. It involves inflammation of
a thick band of tissue that runs across the bottom of your foot and connects
your heel bone to your toes (plantar fascia). It occurs in policemen and
individuals who do a great deal of standing or walking due to stretching of the
plantar aponeurosis
 Morton's neuroma:
It is a benign but painful condition that affects the ball of the foot. It's also called an
intermetatarsal neuroma because it's located in the ball of the foot between 3rd and 4th metatarsal bones. It
happens when the tissue around a nerve that leads to a toe thickens from irritation or compression.

 Plantar reflex & Babinski sign:

Lateral aspect of sole of foot is stroked with a blunt object beginning at heel & crossing to the base of great toe. Flexion
of toes is normal response. Slight fanning out of lateral four toes and dorsiflexion of great toe is abnormal response
(Babinski sign) indicating brain injury or cerebral disease except in infants.

 Tarsal tunnel syndrome: (Imp)

It is a complex symptom resulting from compression of the tibial nerve or its medial and lateral plantar branches in
the tarsal tunnel, with pain, numbness, and tingling sensations on the ankle, heel, and sole of the foot. This tunnel is
found along the inner leg behind the medial malleolus. It may be caused by repetitive stress with activities, flat
feet, or excess weight.

 Pes cavus (claw foot):

It is also known as high arch in which patient exhibits an exaggerated height of the medial longitudinal arch of the
foot (may be seen in poliomyelitis).

 Pes planus (flat foot):

It is the loss of the medial longitudinal arch of the foot with eversion and abduction of the forefoot and causes
greater wear on the inner border of the soles and heels of shoes than on the outer border. In lay terms, it is a fallen
arch of the foot that caused the whole foot to make contact with the surface the individual is standing on.
Flat foot may be

1)flexible (flat, when weight bearing but normal when not bearing weight) It results from loose or degenerated
intrinsic ligament.

2) rigid (flat even when not bearing weight) it results from bone deformity. Acquired flatfoot (fallen arches) are
secondary to dysfunction of tibialis posterior owing to trauma, degeneration or denervation.

These five are important only.

 Talipes calcaneous is an abnormality in which foot is

dorsiflexed and person walks on heel (calcaneous).

 Talipes equinus is an abnormality in which foot is plantar

flexed and person walks on toes.
 Talipes varus is abnormality in which foot is
inverted and adducted and person walks on lateral
border of foot with medial border raised.
 Talipes valgus is an abnormality in which foot is everted
and abducted and person walks on medial border of foot
with lateral border raised.
 Club foot (talipes equinovarus):
In it, the foot points downward and inward i.e. the heel
is medial, the foot is plantar flexed and inverted with
high medial longitudinal arch.

 Great toe through its two sesamoid bones transmits double the weight than other toes.
Q. How plantar aponeurosis is different from palmar aponeurosis?
A. The plantar aponeurosis is different from palmar aponeurosis in way that it gives off an additional process to
the great toe, which restricts the movements of great toe in toe.