Lower

Limb
-Lecture 9-
Ms S Singh
The Leg:
✓ Deep Post. compartment
✓ Neurovascular supply – Leg
Foot:
✓ Skin & Subcutaneous tissue

Moore: p.759-769; 783

 Aims & Outcomes for lecture:
1. To know the deep posterior muscles of the leg.
2. To understand the neurovascular supply of the
posterior leg.
3. To understand the structures of the soft tissue
& compartments of the foot.

Lower Limb: Outcomes 33., 34., 36 to 41.

 Deep posterior compartment - leg:
Deep (anterior) to transverse IM septum in posterior compartment.
Contains all vessels & nerves for posterior compartment & foot.
Prone to serious compartment syndrome.
Separate compartments for each m., n. a. deep to flexor
retinaculum.
Smaller size muscles, closer to axis of ankle→produce 7%
plantarflexion (not enough to lift body’s weight)
Two criss-crossed muscles:
❖ Flexor Hallucis Longus m.
❖ Flexor Digitorum Longus m.
Posterior compartment - Leg:
 Deep Posterior
Compartment - muscles

• M. popliteus
• M. flexor digitorum longus
• M. flexor hallucis longus
• M. tibialis posterior

Table 7.13-II, p.757

 M. Popliteus:
▪ Triangular m. in floor of popliteal fossa (inferior)
▪ Fleshy belly emerges from knee joint capsule
▪ Popliteus bursa deep to its tendon
PA: Lateral aspect of lateral condyle of femur
(tendinous attachment); lateral meniscus
DA: Posterior surface tibia, superior to soleus line
(fleshy)
Nn.: Tibial n. (L4,5, S1)
 Posterior view:

M. Popliteus:
 M. Popliteus:
Function:
✓ Insignificant flexor of the knee
✓ Pulls lateral meniscus posteriorly during flexion
→ protects against injury
✓ Prevents anterior displacement of femur during partial
flexion of knee (with posterior cruciate ligament)
✓ Rotates femur 5° laterally when knees locked to enable
flexion
✓ Rotates tibia medially when foot is lifted & knee is flexed
(assists medial hamstrings)
M. Flexor hallucis longus:
 M. Flexor hallucis longus:
FHL: tendon passes posterior to distal end of tibia & posterior surface talus
→ talar shelf
Tendon between two sesamoid bones (FHB) → distal phalanx
(protect from pressure of head - 1st MT)
PA: Inferior ⅔, posterior surface fibula;
inferior part interosseous membrane
DA: Base – distal phalanx of big toe (hallux)
Nn.: Tibial n. (S2,3)
Talar shelf

Function:
✓ Powerful flexor – all joints of big toe
(final thrust for toe-off – pre-swing phase)
✓ Weak plantar flexor of ankle
✓ Supports medial longitudinal arch of foot
Testing - M. Flexor hallucis longus:
➢ Distal phalanx of big toe flexed against resistance.
➢ Tendon seen & palpated on plantar surface of big toe.
 M. Flexor
digitorum longus:
 M. Flexor digitorum longus:
FDL: smaller than FHL
Passes diagonally to sole, superficial to FHL
(quadratus plantae m. realigns its line of pull)
PA: Medial part, posterior surface tibia (inf. to soleus
line); fibula (by a broad tendon)
DA: Bases of distal phalanges – lateral 4 toes
Nn.: Tibial n. (S2,3)
Function:
✓ flexes lateral 4 digits
✓ plantar flexion of ankle
✓ supports longitudinal arches of foot
 Testing - M. Flexor digitorum longus:

Distal phalanges of lateral 4 digits flexed against resistance.

M. Tibialis posterior:
 M. Tibialis posterior:
Tibialis posterior m. is deepest - between FDL & FHL
PA: Posterior surface tibia (inferior to soleus line);
posterior surface fibula; IO membrane
DA: Tuberosity navicular bone; cuneiforms; cuboid; talar shelf,
bases of 2nd-4th metatarsals
Nn.: Tibial n. (L4,5)
Function:
✓ 1° role: maintain medial longitudinal & transverse arch of foot
during weight bearing (standing)
✓ Balance when standing on one foot
(with TA → depress lateral side of foot, pull leg medially)
✓ Invertor of foot - assists TA (when foot off ground)
✓ Plantar flexion of ankle
 Testing - M. Tibialis posterior:
Foot in slight plantarflexion.
Foot then inverted against resistance.
Tendon seen & palpated posterior to medial malleolus.
Tendons – TP, FDL, FHL:
Plantar surface of foot - Tendons:
 Neurovascular
structures:
Post. Compartment -
Leg
 Posterior compartment - Nerves:
Tibial nerve (L4,5, S1-3)
Popliteal fossa → post. compartment deep to tendinous arch
of M. soleus
Ankle: between tendons of FHL &FDL
Post-inf. to medial malleolus → terminal branches
Branches:
➢ Motor to all muscles in post. compartment
➢ Medial sural cutaneous n. → sural n.
➢ Articular branches – knee joint
➢ Calcaneal branches – skin of heel
➢ Medial & lateral plantar nn. Table 7.11, p.752
 Tibial n.

Muscular branches

Sural n.
Medial plantar n.

Lateral plantar n.
 Posterior compartment - Arteries:
Posterior tibial a. from popliteal a. (distal border of m. popliteus)
Deep to tendinous arch of M. soleus → accompanies tibial n.
Posterior to medial malleolus
Fibular

Inferior to medial malleolus: between FHL & FDL artery

Branches: Posterior tibial

✓ Fibular a. lateral & parallel to posterior tibial a.

artery

✓ Circumflex fibular a. (knee)

✓ Nutrient a. of tibia
✓ Lateral & medial plantar aa.
Table 7.12, p.753
Post. compartment –
Arteries:
Anterior tibial a.

Fibular a.

Posterior tibial a.

Perforating branch

Medial plantar a.
Lateral plantar a.
 Fibular a.:
Largest branch of posterior tibial a.
In deep posterior compartment with FHL
Branches:
➢ Muscular to M. popliteus and other
muscles(posterior & lateral compartments)
➢ Nutrient a. of fibula
➢ Perforating branch → dorsum of foot
/ lateral compartment
➢ Lateral malleolar branch
➢ Lateral calcaneal branch
 Posterior tibial a. - Pulse:

Palpated between the posterior

surface of the medial malleolus &
medial border of calcaneal
tendon
 Ankle –
Transverse
section:
Distal to ankle joint The Foot:
3 parts:
• Hindfoot = talus & calcaneus
• Midfoot = navicular bone, cuboid, cuneiforms
• Forefoot = metatarsals, phalanges
Sole / plantar region – contact ground
Dorsum – directed superiorly
Heel – part underlying the calcaneus
Ball of foot – part underlying heads of medial 2 metatarsals
Big toe (hallux) = 1st toe
 The Foot – Skin & Fascia:
Dorsum of foot:
▪ Skin thinner, less sensitive to that of sole
▪ Subcutaneous tissue loose
→ oedema (swelling) noticeable on dorsum
Sole of foot:
▪ Skin thick (weight bearing), hairless, numerous
sweat glands, very sensitive
▪ Subcutaneous tissue fibrous
→ septa (skin ligaments) divide tissue into
fat-filled areas for shock absorption
→ skin ligaments - anchor skin to deep fascia for grip
 The Foot – Deep Fascia:
Dorsum of foot:
- thin, continuous with inf. extensor retinaculum
Lateral & posterior aspect of foot:
- continuous with plantar fascia
Sole (plantar fascia):
- weak medial + lateral parts
- thick centrally = plantar aponeurosis
→ holds parts of foot together
→ protects sole from injury
→ supports longitudinal arches of foot
- calcaneus→ fibrous digital sheaths (5 bands)
- superficial transverse metatarsal ligament - heads MT’s
The Foot – Fascia:
 The Foot – Compartments:
Mid- & forefoot: intermuscular septa from plantar aponeurosis
→ to 1st & 5th MT’s
→ forms 3 compartments in foot
Medial compartment of sole:
- thin medial plantar fascia
- AbH, FHB, tendon FHL, medial plantar a. v. & n.
Central compartment of sole:
- dense plantar fascia
- FDB, tendons FHL, FDL, QP, lumbricals, AdH, lateral plantar a. v. & n.
Lateral compartment of sole:
- thin lateral plantar fascia
- AbDM, FDMB
The Foot – Compartments:
 The Foot – Compartments:
Interosseous compartment:
- only forefoot between plantar & dorsal IO fascia
- metatarsals, interosseous muscles, deep plantar & metatarsal blood
vessels
- dorsal IO mm. & MT’s, blood vessels → located intermediate between
plantar / dorsal aspects of foot
Dorsal compartment:
- dorsal fascia → tarsals, dorsal IO fascia of mid- & forefoot
- EHB, EDB, dorsal neurovascular structures
Inflammation plantar Plantar fasciitis:
aponeurosis
E.g. running, high-impact
aerobics (inappropriate footwear)
Pain – plantar aspect of heel &
medial side of foot
Pain most severe when starting
to walk after rest
Point of tenderness: proximal
attachment of plantar
aponeurosis – medial tubercle of
calcaneus