11/28/2016

Lecture 21: Lower Limb 2-Knee to Foot.

Hip Summary:

Gluteus Maximus: extensor of the hip

Psoas: flexor of the hip
Tensor Fascia Lata and Gluteus Maximus: abductors of the hip
Adductor Group (Magnus and Gracilis): adductors of the hip
Quadriceps: extensors of the knee
Hamstrings: flexors of the knee.

4 Muscle Groups Acting on the Hip Circumduction Ball and

Socket joint
1. Flexors iliopsoas
2. Extensors Gluteus Maximus
3. Adductors sartorius, gracilis, adductor group
4. Abductors gluteus maximus, tensor fascia lata

1) Flexors Iliopsoas

2) Extensors - Gluteal

4) Abductors
Gluteus maximus,
Tensor fascia lata

Ball and Socket

J oint

3) Adductors
Sartorius,
Gracilis,
Adductor Group

4 Muscle Groups Acting on Hip - Circumduction

Part 1: Lower Limb 2 the Knee to Foot

Overview:
The knee = one of the most complicated joints in the body
because it has adapted itself to be able to flex the knee, and yet
also bear the weight of the body.
There are two muscle groups acting on the knee (cross the hip and
knee joint), because it is a hinge joint (not capable of
circumduction).
o 1. Flexors Hamstrings (back)
o 2. Extensors - Quadriceps (front)
Note: the hamstrings (flexors) are still stronger than the
quadriceps (extensors)

1) Flexors Hamstrings

2) Extensors - Quadriceps

Hinge J oint
2 Muscle Groups acting on knee
1. Anterior Compartment: Extensors of the Knee (4 of them Quadriceps)

4 parts, all attach to the anterior surface of the tibia (the tibial
tuberosity).
All exert their force through a patella (kneecap) embedded in the
middle of the tendon (tendon continues on and attaches to tibial
tuberosity).
o Patella: an embedded bone that looks like a sesame seed,
used to protect the tendons as they go over a bony point.
Largest sesamoid bone in the body.
There are many sesamoid bones embedded in the
tendons (middle of it) of the hand and feet.
o In knee flexion/extension, the patella will appropriately move
over the joint in order to prevent the tendon from being
damaged.

Quadriceps Group: Four muscles, all come together to form the

quadriceps.
Origin: various
Insertion: one tendon distally.
Action: knee extension (and hip flexion during extreme
contraction)
o Will be stretched out during knee flexion by hamstrings, and
will contract to extend the knee.
Innervation: all innervated by femoral nerve (posterior division of
lumbar plexus).
o The nerve becomes a superficial cutaneous nerve and
innervates the medial aspect of the calf.
Muscles:
o 1. Rectus femorus runs straight up and down (most
superficial).
Origin: Only one originating in the pelvis.
Action: will also cause hip flexion (minor) in extreme
contraction (as goes across two joints).
o 2. Vastus lateralis most lateral
Origin: greater femoral trochanter.
o 3. Vastus intermedialis in between (deep to femoris).
Origin: greater femoral trochanter.
o 4. Vastus medialis - most medial
Origin: lesser femoral trochanter.
Patella: The patella guides the quadriceps tendon in a flexed position,
evenly moving it over the articular surface of the femur, in order to give you
a smooth, proper extension of the knee.

Problems with the patella may give rise to knee painone of the
quadriceps (either lateral or medialis) may not contract as
powerfully as one on the other side, and as a result, there may be
uneven pulling of the patella.
o Physiotherapist must thus give exercises to strengthen the
weakened quadriceps.

Anterior Compartment:
Extensors of knee
Patella:
sesamoid bone

Femoral
nerve

Quadriceps
Group

patella

patella
Tibial tuberosity

Tibial tuberosity

2. Posterior Compartment: Flexors of the Knee (Hamstring

Muscles)
They have very prominent tendons as split to form the diamond of
the popliteal fossa and thus cross from the thigh into the knee
o Popliteal fossa: diamond shaped area in between the
hamstring muscles and gastrocnemius (calf muscle with two
bellies)
Here you can find the popliteal artery pulse.
Why named Hamstrings? When you have a pig and you smoke
the pig in a smoke house, you hang the pig from these tendons to
put the rod through in order to hang the ham - where they get their
name.
Hamstring Muscles: 3 muscles named according to what their
tendons look like.
Overview (only learned about 1 and 2):
o Origin/Insertion: They arise from the ischial tuberosity
(bone you sit on) and insert onto the medial tibia.
o Action: knee flexion, minor hip extension (extreme
contraction).
Knee flexion: When they contract, they flex the knee.
Hip extension: Because they cross the hip joint and
the knee joint, in extreme flexion, they can be a minor
mover of the hip, as well.
Antagonists to quadriceps muscles.

o Innervation: the sciatic nerve, which is conveniently located

between the hamstring muscles and eventually crosses the
popliteal fossa where it splits into its tibial and fibular
branches
Runs right down in between the heads of the
hamstrings.
Innervated by the tibial nerve (anterior flexor division of
the sciatic) as the hamstrings are the flexors of the
knee.
Muscles: action is common, innervation is common (except for 4,
not a hamstring)
o 1. Semitendinosus
Origin: ishial tuberosity
Insertion: medial tibial surface.
Tendon located on the medial aspect of the
popliteal fossa (round and typical tendon).
Innervation: tibial
o 2. Semimembranosus
Origin: ishial tuberosity
Insertion: medial tibial condyle
Tendon is broad and membranous; if you push
behind the semitendinosus, you will feel the
semimembranosus underneath
Innervation: tibial
o 3. Biceps Femoris-long head (Extra)
Origin: ishial tuberosity
Insertion: lateral fibular head (common tendon with
short head)
Innervation: tibial
o Extra: Biceps Femoris-short head (Extra)Not part of
the hamstrings.
Origin: lateral supracondylar femoral line.
Insertion: lateral fibular head (common tendon with
long head)
Innervation: fibular (common peroneal)

Note:
There is a muscle with two heads: the biceps femorus (long head
is part of the hamstrings), which ends in a common tendon in the
lateral side of the knee.
o When you feel the lateral side of your knee, you feel the
single tendon of the biceps.

The purpose of the sciatic nerve is to innervate the musculature below

the knee, but here the sciatic nerve is innervating the hamstrings above the
knee whats the deal?
Really, there is no such thing as the sciatic nerve. It is just the tibial
and fibular nerves glued together. Sowhich branch is responsible for
innervating this?
Sciatic nerve is made up of an anterior flexor nerve (the tibial) and
a posterior extensor nerve (the fibular). The hamstrings are flexors
of the knee, so we can conceptually say that the tibial division of
the sciatic nerve innervates them.

Posterior Compartment:
Flexors of knee
Nervebranches
fromTibial
branch of
sciatic nerve

Hamstringgroup

Popliteal
fossa

L: yellow=ishial
tuberosity.
Balance: Sartorius, Gracilis, Semitendinosis
Pes anserinus: On the medial side of your knee, the tendons of
sartorius, gracilis and semitendinosus come together, and insert into one
common spot on the proximal tibia that looks like a gooses footthus its
called the pes anserinus.
These three muscles originate from the furthest parts away in the
pelvis (ASIL, pubic symphysis, and ishial tuberosity), and come
down like an inverted tripod to insert into the medial aspect of the
tibia.
Purpose: because of this arrangement, they are critical for
maintaining balance.
Note: these make up the medial side of the knee, whereas the
biceps femoris is on the lateral side.
Pes anserine bursa: located on the medial aspect of the junction
between the tibia and femur (medial tibial plateau), between the bones and
the pes anserine tendons.
Whenever you bend the knee (extension/flexion), there is a lot of
movement in these tendons (rub around medial tibial plateau) so it
would be a good idea to have a bursa in there.
Pes anserine bursitis: inflammation of this bursa.
o Anybody who runs or who does continuous flexion of the
knee, we can expect irritation to occur within that synovial
membrane as tendons are rubbing up against the bone,
giving rise to pain on the medial aspect of the knee
o Very common in runners or in painters or tile masons, as the
tendons rub on the sharp edges of the medial epicondyle of
the femur.

Muscles Involved in Balance (EXTRA, but IMPORTANT)

You are in a constant position of sway and the muscles of your thigh
are constantly fighting gravity from pulling you over. To help you stand up,
there are three muscles that form an inverted pyramid: the
semitendinosus (hamstring group), gracilis (adductor group) and
sartorius, which come together to form the pes anserine on the medial
tibia. These three muscles act to keep us balances and standing up.
Bones bear weight of the body, and the muscles fine-tune to minimize
the sway and maintain upright posture.

Adductor Hiatus
Hiatus is at the distal end of the adductor hiatus muscle.
The femoral artery gets to the back of the knee through the
adductor hiatus, when it becomes a popliteal artery.
o Note: it passes through the subsartorial canal to get to the
hiatus.
How can you tell if there is entrapment of this artery in the
adductor hiatus?
o Patient will most likely be experiencing a cold foot, pins and
needle in the foot whenever they exercise.
o Take a femoral pulse (medial aspect of the thigh, near the
Sartorius) and then a popliteal pulse (back of knee, press
inwards).
Compare the two pulses. If popliteal is weak then you
may have entrapment of the artery in the adductor.
Note: common for nerve/artery entrapment to occur whenever a
nerve/artery passes through a bony opening or muscular opening.

Adductor Hiatus
Adductor
group

Femoral
pulse

Femoral
artery

Popliteal
pulse

Poplital
artery

Joint Capsule of the Knee

Dissect away hamstring and quadriceps muscles.
o These act as stabilizers of the knee, because they cross the
joint and are very big and powerful, with thick tendons.
Removing all of these muscles gets you right down to the CT of the
joint capsule that crosses the knee (jumping from periosteum of the
femur to that of the tibia/fibula, but mainly the tibia).
Note: the bursaes will be on top of the CT of the joint capsule.
Anterior View:
Patella and quadriceps tendon and pes anserine bursa
Posterior View:
Cut edges of the gastrocnemius muscle, and more distally the cut
edges and tendons of the hamstrings

J oint Capsule of Knee

Anterior view

Posterior view

Interior of Knee Joint

Quadriceps muscle and tendon can be seen at the front.
Overview:
The tibial surface is very flat (the tibial plateau), while the femoral
surface is round.
o So essentially, we have a ball sitting on a table, which is very
unstable on its own.
o Tibial plateau: smooth bony surface of a condyle of the tibia
which articulates with the corresponding condylar articulating
surface of the femur (femoral condyles)
Also, note that the two sides of the knee are very different: lateral
side can move (tendons are separated), while the medial side is
stuck together and cannot move.
Cartilage:

Articular cartilage: makes up the ends (surface) of the tibia and

femur (not completely ossified)present on tibial plateau and
femoral condyles.
Joint meniscae (disks): Pieces of cartilage that have a C-shape,
where the bottom surface is flat and the top surface is
curved/round so that it can match/articulate with the two shapes of
the bones (flat tibial plateau, round femoral condyle).
o Disks:
Lateral meniscus: can move, smaller.
Medial meniscus: cannot move, larger.
There are ligaments gluing this down to the
middle of the plateau.
o Purpose: increase the stability of the knee koint, as it is
essentially like a ball (femur) rolling on a table (tibia).

Synovial membrane: rich vascular membrane lining the entire joint

capsule (especially the front)seen in red.
The entire joint is enveloped in connective tissue and is thickened in
certain areas. Underneath that is the synovial membrane lining
the interior of the joint capsule.
o Sometimes the joint synovial membrane is continuous with
bursas, lining the entire inside of the joint with a synovial
membrane.
At the back, the synovial membrane diverges from the joint capsule
and dives inward in order to exclude/separate the cruciate
ligaments found at the interior of the knee
o Thus, there is nothing inside joint capsule except for menisci
Note (Extra): the synovial membrane does NOT cover the
articulating surface of the tibia and femur (this is the articulating
cartilage).
o The articulating cartilage will meet up with the synovial
membrane at the sides).
o If the synovial membrane did cover this articulating surface,
then its blood vessels would be crushed.
Cruciate Ligaments: stabilize the knee and preventing anterior (ACL)
and posterior displacement (PCL) of those two bones.
The cruciate ligaments are inside the knee, or joint capsule
(intracapsular), but outside the synovial membrane
(extrasynovial).

Ligaments: They cross over one another inside of the joint, and
check anterior and posterior displacement of the knee, as well as
rotational movements of the knee.
o ACL: antero medial to posteo lateral.
Responsible for preventing anterior displacement of the
tibia (e.g. can't pull tibia straight out and away from
knee joint)
More oblique than PCL.
o PCL: postero lateral to antero medial.
Prevents posterior displacement of tibia
Note:
o Make a model for their origins and insertions for both knees
by crossing your fingers over (only one way will be
comfortable).
o PCL is twice as thick as ACL.

Joint capsule: will encase the entire knee joint (full 360, can be seen
in grey).
Collateral Ligaments: thickening of the CT of joint capsule at the
side, and serve to stabilize the joint at the side.
Medial Collateral Ligament (MCL): medial side, firmly attached
to the joint capsule, and thus part of it (medial meniscus, ACL)
Lateral Collateral Ligament (LCL): lateral side, dissociated from
joint capsule and is kind of free-floating (looks more round)
o Note: there is a bursa on the outside of this here for the
tendons of popliteus which creates the separation on the
lateral side of the knee.
Note: these ligaments are nowhere near menisci (looks like a
thickening of joint capsule)
Medial vs. Lateral sides of the knee:
Medial Side: everything is glued together, immobile
o MCL, attached to medial meniscus, which is attached o the
tibia (tibial plateau)
Lateral Side: separation of most things, very mobile
o Lateral meniscus is not attached to LCL OR the tibia.
o Purpose: This allows it the lateral meniscus to move on the
inside of the knee (slide back and forth), allowing for the knee
to change its shape.
When the knee is in the extended position, there is no
way to fit the large femoral condyles in the joint.

It will only fit if you contract a muscle (popliteus) to

expand the joint, by pulling backwards on the lateral
meniscus and rotating it backwards to expand the size
of the tibia to accommodate the large femoral condyles.
This is what needs to be done in order to flex the knee.

Interior of knee joint

anterior

J oint capsule
Femur
Synovial
membrane

Femoral
condyles

Cruciate Intracapsular/
ligaments extrasynovial
Tibial plateau

Lateral
collateral
ligament

posterior

patella

Synovial membrane
lining interior of joint
capsule

Medial
collateral
ligament
Tibial plateau
anterior

Posterior
cruciate
ligament

femur

tibia

Anterior
cruciate Femoral condyles
ligament

tibia
fbula
fbula

Posterior view

Anterior view

Assembly of the Knee Joint: see MSK 8, 33:25

Flat tibial plateau (yellow bottom)
Curved femoral condyles (yellow top)
Meniscus in between, allowing for a nice fit between the two
Cruciate ligaments intracapsular/extrasynovial
Collateral ligaments
Patella: Protects the quadriceps tendon, especially during knee
flexion.

Note: can see how joint capsule thickens, and how the popliteal
tendon is underneath this.
Movements of the Knee:
Since the width of the femur varies (small at front, large at back),
the shape of the knee will change as you go from extension
(accommodate small femoral width) to flexion (accommodate
larger femoral width).
Knee in Extension:
Locked position: small knee, lateral meniscus in the anterior
rotated position (pushed up forward) to accommodate the smaller
portion of the femoral condyles.
Normally in the extended position, the knee is locked so it can bear
the weight of the body.
Knee in Flexion:
Unlocked Position: Pull the knee backwards, expand and widen
the joint, so that large femoral condyles (at the back) are able to be
accommodated
o The popliteus muscle will contract and pull the lateral
meniscus backwards, and externally rotate the femur to allow
for the expansion of the joint to accommodate the condyles
Very unstable, can buckle underneath of you in the unlocked
position.

Knee in extension

Knee in fexion

Femoral
condyles

Tibial
plateau
lateral

medial

Medial Meniscus Fixed; Lateral Menisus A/P Movement

The medial meniscus is more shaped like a C and anchored in place
to MCL
The lateral meniscus is more round, and only attached by two small
ligaments, allowing for movement.
See MSK 8, 37:23
Unlocking the Knee
The muscle that you need to contract before you can unlock the knee
is a muscle located at the back of the knee in the popliteal fossa and is
therefore called the popliteus.
Popliteus muscle:
Origin: It arises medially and has a tendon that sticks underneath
of the free LCL (thus tendon is underneath CT of joint capsule).
Insertion: lateral meniscus (few branches going in here), lateral
femoral condyle.

Action: external rotation of femur, drawing lateral meniscus

backwards.
o When it contracts, it pulls back on the lateral meniscus,
externally rotates the knee, unlocks it and allows for
expansion of the joint, essentially allowing for flexion of the
joint.
o External rotation of femur needed, because it is usually
angled outwards, so rotating it in will make it align with tibia
and will allow for straight flexion (My understanding, not in
lecture).
o See MSK 8, 38:28.
Innervation: tibial nerve (L5-S1).

Note: one reason LCL not attached to anything else because it has to
allow for popliteus tendon to pass underneath it.

Unlocking the knee

Lateral
collateral
ligament

medial

lateral
External
rotation of
femur
Draws
lateral
meniscus
backward

Note: left diagram, green=synovial membrane, then popliteus tendon

over this; right diagram: origin and insertion of popliteus.
Damage to ACL
Responsible for checking rotational movements, as it is a little bit
more oblique (the PCL still does this too).
o The knee is a hinge joint, so it doesnt like to have a lot of
rotation.
ACL Tears: ACL is thus usually injured (torn) in rotational
movements (as it is thinner than PCL).
o May happen when foot firmly placed on floor, and then there
is a twisting action on the body (e.g. playing basketball).
o Arthroscopic view: When you look with a small tube into
the knee, you see that ACL is just like a rope that has been
pulled and frayed.
Anterior Drawer Test: check for ACL tear by pulling tibia forward
and noting the displacement of it.
o Involves grabbing onto the patients tibia while their legs are
hanging over the edge of the examining table, and trying to
pull the tibia out, or open the drawer, which shouldnt
happen in a normal knee.
o If you have anterior displacement of the tibia (as in, the
ACL doesnt check and prevent it from being pulled out of
place), that means you have a damaged ACL.

Damage to PCL
Is less damaged because of its thickness, but may be damaged in a
hyperextension injury .
o E.g. 1. May be caused by stepping into a hole, and you
continue moving forward, so the whole weight of your body
coming down and pushing on the back of the knee, tearing
the PCL.
o E.g. 2. It can also be caused by a blow to the tibial tuberosity
(e.g. in sports), which forces the tibia back away from the
femur, which should be blocked by the PCL if force is to
great, it can result in PCL tearing.
Posterior Drawer Test: checks for PCL tear by pushing tibia
backwards (while stabilizing the foot) and noting displacement.
o Push the tibia back, which shouldnt be able to be forcefully
done in a normal person.

Hyperextension
of knee
Posterior Drawer Test
Blow to tibial
tuberosity

Damage to posterior cruciate ligament

Damage to MCL:
Everything in the medial side of the knee is attached to one
another.
Thus, any rotation or blow to lateral side of the knee will stretch the
medial aspect of the knee (checked by MCL), thus tearing it.
o Hard to get force on medial side as someone would have to
be on the inside of your legs.
Unhappy (Terrible Triad): tearing of MCL will also usually tear the
medial meniscus (as it is attached to MCL) and pull it right out of
the joint capsule, as well as an ACL tear (as there is rotational
forces).

Summary of Knee Joint

Slight rotation of femur takes place during flexion and extension of
knee joint
o Rotation is accomplished by slight movements of the lateral
meniscus to accommodate for this movement
o Popliteus muscle aids in movement of meniscus (designed to
unlock knee from full extension)
Patella aids in extension of knee joint
o Increases the leverage that the patellar tendon can exert on
the femur by increasing the angle at which it acts

Leg to Foot: Compartments

Overview: muscles in the thigh responsible for action on the knee
(knee joint), whereas muscles in the leg (below the knee) responsible for
action on the foot/toes (ankle joint)
1. Knee Joint:
o Quadriceps muscle is on the front of your thigh --> extensor
after rotation of knee joint has taken place
Innervated by femoral nerve
o Hamstring muscles are flexors of the knee
Innervated by tibial nerve (flexor division of sciatic)

2. Ankle Joint:
o Like the knee, the ankle is more of a hinge joint with primarily
up-and-down motion (plantar flexion and dorsiflexion)
However, more stability at ankle because we bear most
of our weight on the bones of our feet
Foot can move on the tibia
o Muscles in leg (not thigh) are responsible for movement of
the ankle
There are two compartments of the leg, acting on the
foot/toes
1. Posterior: Posterior flexors (plantar
flexors)
2. Anterior: Anterior extensor (dorsiflexors).

Posterior Compartment of the Leg (Flexor): Plantar

Flexors/Inverters (Superficial), Flexors of Toes (Deep)
Note: Tibial nerve innervatesboth superficial and deep flexors (as tibial
artery, vein, and nerve come into flexor compartment of calf)
Plantar Flexors: (Superficial): 3 muscles, flexors of the ankles
3 superficial muscles of calf ending at the calcaneous, called the
triceps group: gastrocnemius (two heads), soleus (directly
underneath gastrocnemius), plantaris (in between)
Triceps Group:
o Gastrocnemius and soleus: known as the triceps surae
(triceps of the calf), and sometimes referred to as one muscle
because they share a tendon (calcaneal tendon).
Arrangement: Gastrocnemius is superficial, soleus is
underneath, and they form the bottom of the popliteal
fossa.
Both come together distally to form the calcaneal
tendon (Achilles tendon).
Action: plantar flexion (move sole of foot downwards).
Innervation: tibial nerve.
o Plantaris comes from back of popliteal fossa, very tiny
muscle (less than one inch wide) with long skinny tendon that
contributes to calcaneal tendon
O/I: Runs down the medial side of the leg, with a
tendon similar to palmaris longus in the forearm, and
inserts into calcaneal tendon (medial side).

Action: does not really do much (often used as a 'spare

part' to fix other parts of body, e.g. tendon repair)
Muscle is responsible for flexion at ankle (plantar
flexion)
Innervation: tibial nerve (S1-S2).

Inverters/Flexors of Toes: 3 muscles, deep to the triceps group

(analogous to muscles on flexor side of forearm)
O/I: Arise from tibia, interosseous membrane, and fibula, and go
all the way down around the medial malleolus (tendons that you
feel around the medial malleolus are coming from these muscles)
Action: Responsible for flexion (curling) of toes
Muscles: tibialis posterior, flexor digitorum longus/hallicus.
o Tibialis posterior is most lateral muscle of calf, but tendon
crosses medially and diagonally across back of calf so that it
is the first tendon you feel around the medial malleolus & first
to enter foot
Origin: interosseous membrane.
Action:
Helps triceps surae in plantar flexion
Inversion of foot (foot moves inwards,similar to
supination) because of its oblique course.
o Flexors of toes: include flexor digitorum longus (4 toes) and
flexor hallicis longus (big toe) located medially to tibialis
posterior
Uses medial malleolus as a sort of pulley
Action: flex the toes and big toe, respectively.
May also assist in plantar flexion.

"Tom, Dick, And Not Harry" = Tibialis posterior, flexor Digitorum

longus, posterior tibial Artery, posterior tibial Nerve, flexor Hallicis
longus
o This is the order that they are in at the medial malleolus
(lateral to medial)
o Tibial vein is assumed to be with tibial artery (it wraps around
it).

Tom, Dick, and Not Harry

Actions- Plantar Flexion, Flexion of Toes
1. Plantar flexors attach at calcaneus (heel)
o Triceps surae: 2 heads of gastrocnemius and soleus muscle.
2. Inverter:
o Tibialis posterior
Origin: originates form interosseous membrane
between tibia and fibula and attaches to tarsals of foot
Action: plantar flexion, inversion.
Assists in inversion of foot (raising medial side of
foot) and plantar flexion
Foot is not capable of supination and
pronation because fibula doesn't rotate
(unlike ulna in forearm)
Note: helped by tibialis anterior.
3. Flexors of toes do not attach to calcaneus, but use the medial
malleolus instead (as a pulley)
o Lateral malleolus is formed by fibula, medial by tibia

o Origin from tibia, interosseus membrane, and fibula

o 1. Flexor Digitorum Longus (long flexors of the toes):
Origin: tibia.
Action: toe flexion, help with plantar flexion.
When these muscles in the calf contract (flexor
digitorum longus), they pull on the 4 toes through
a long tendon(attaches at end of toes)
Can also assist triceps surae in plantar flexion
(extreme contraction).
o 2. Flexor hallucis longus is an independent muscle because
you can flex big toe independently of other toes
Origin: Arises from fibula, crosses over the course of
the medial malleolus
Action: Its contraction results in flexion of big toe, can
assist in plantar flexion

Calf Muscles
Deep
Tibialis Posterior (inverter)
Long Flexors of
toes

Superficial
Triceps Surae:
Gastrocnemius
Soleus

Calcaneus

Medial malleolus

Anterior Compartment of the Leg (Extensor):

Dorsiflexors/extensors of toes/everters of foot
These are the muscles at the front of the calf, in the anterolateral
compartment.
o Muscles do not entirely cover front part of shaft of tibia, and
are instead off to one side --> muscles are therefore in the
anterolateral flexor compartment
o The medial side is covered by calf muscles (from the back).
There are 3 muscles, and roughly only one layer, all innervated by
fibular nerve.
o Tibialis anterior is most medial (immediately next to tibia),
then extensor digitorum (longus/brevis) in between, and then
finally, peroneus longus on the most lateral side.
o There is also extensor hallicus longus
Muscles:
o 1. Tibialis anterior : ankle extensor,
I/O: immediately adjacent to tibial shaft.
During dorsiflexion of foot, you can see the
tendon of this muscle stick out near where it
attaches to the front of the tarsal bones
Action: dorsiflexion and inversion.
Primary dorsiflexors of ankle.
Antagonistic to tibialis posterior (+
gastrocnemius and soleus).
Can assist tibialis posterior in inversion due to
attachment on medial side
Thus, inversion is both as a result of tibialis
anterior and tibialis posterior.
Note: Tibialis anterior and posterior provide ankle with
equivalent medial deviation as seen at wrist

o 2. Extensor digitorum (longus and brevis): extensors of

toes, and dorsiflexors (in extreme contraction)
Extensor Digitorum longus: long extensors of toes,
I/O: between tibia and fibula and next to tibialis
anterior, goes out into each of the toes
Action: toe extension
Toe extension (upwards)
o Antagonizes flexors in sole of foot
Also assists in dorsiflexion.
Extensor digitorum brevis: Little pad of muscle on
lateral aspect of foot (underneath tendons of longus)
helps to redirect fibres of toe extensors
I/O: top of foot.
This is different than in the arm, where you only
have extensor digitorum.
Extensor hallucis longus antagonizes flexor hallucis
longus
I/O: from fibula to big toe
Muscle on top of foot that goes to big toe
Action: halluces extensor.
Note: extensor retinaculum will hold down tendons of extensor
digitorum and tibialis anterior (so they wont buldge out during
dorsiflexion.
3. Peroneal group on lateral side (eversion of foot, help with
plantarflexion)
o If you feel behind lateral malleolus, you will feel some
tendons which are part of the peroneal group of muscles
(small portion of extensor compartment).
o There is both a peroneus longus and brevis.
Brevis stops at middle of foot and tendon goes
underneath it to attach to big to.
Peroneus (fibularis) longus is particularly important:
I/O: Arises from shaft of fibula, goes all the way
around the lateral malleolus and connects to up
5th metatarsal and base of big toe (1st metatarsal)
Action:
Eversion of foot (uses lateral malleolus as a
pulley)
May also help with plantar flexion.
Creates longitudinal arch of foot by pulling
bones of the foot.

*Middle: Yellow/green is the origin and insertion of extensor

digitorum brevis
*Right: can see both peroneus longus and brevis.

Extra Pictures:

Tibia

Tibialis Anterior
Calf
muscles

Long Extensors
of toes

Peroneal Group
(everters)
Lateral malleolus

Innervation of antero-lateral compartment (Fibular Nerve)

Sciatic nerve - splits in popliteal fossa into tibial nerve and fibular
nerve
o Tibial nerve goes straight down calf to innervate plantar
flexors and flexors of toes
o Fibular nerve (common peroneal): wraps around the neck of
the fibula and innervates the extensor division.
Supplies skin on top of the foot.
Can feel this nerve at the popliteal fossa by
holding it against the fibula
Fibular nerve is high risk for damage because it is lateral and
superficial
o Injury = inability to dorsiflexion the foot = foot drop/drag
Tibialis anterior will not be supplied, and this is
important for walking (first thing you do is dorsiflex so
heel can touch the ground), thus you have foot drag.
o Will also have problems with eversion and toe extension.

o Injury can also be caused by traction of the knee (adduction stretches nerve)

Blood Supply to Antero-Lateral Compartment

Popliteal artery will divide in popliteal fossa to form posterior and
anterior tibial arteries).
o Thus, there is no fibular artery, just the two tibial ones.
o This is unusual as the innervation for the anterolateral
compartment does not follow the nerve
Posterior tibial artery supplies posterior flexor compartment and
wraps around medial malleolus (A of tom, dick, AND not harry) to
supply bottom of the foot with blood
Anterior tibial artery goes through a hole (very narrow/tiny) in
the interosseous membrane between the tibia and fibula
o Adjacent to fibular nerve form anterior view of leg
o Opening is variable - different sizes in different people
o Shin splints: pain in anterolateral compartment. Two causes:
1. Vascular: Because of the variability of the hole, it
can sometimes be small and restrict blood flow, leading
to cramps resulting from muscle fatigue, especially
during exercise.

E.g. common in athletes/runners, who need a

bigger supply of blood for their muscles (for
nutrients/oxygen/sugar)
2. Mechanical:
Small tendons/muscles tear from interosseous
membrane.
Microfractures of the bone may be caused by
inappropriate footwear and running on hard
surfaces.
How to differentiate between the two causes of shin
splints? (vascular vs. mechanical)
Take a pulse! Ask aperson to exercise andcompare
popliteal pulse to tibial pulse at foot
If tibial pulse is weak in comparison, the cause is
vascular

Lower Limb: Part 3-Ankle and Foot

Overview:
Foot has to bear all of the weight of the body, and as such it is
designed more for structure and stability then mobility.

The bone that the tibia and fibula articulate with at the ankle is
called the talus
o Immediately above calcaneus
o Articulating surface of talus is reminiscent of other joints that
we've seen
Shape of joint is different in different parts of
articulating surface

Ligaments Stabilizing the Tibia and Fibula

Proximal: There is a synovial joint where the tibia and fibula meet
near the knee (proximal side) --> this joint is not really capable of
movement, surrounded by joint capsule
Distal: Ligaments at distal joint of tibia and fibula are much more
powerful
Anterior and posterior tibio-fibular ligaments
o Both are identical and are over the talus.
There is no supination and pronation here (unlike the forearm) as
they are bound together and fixed so that they dont move (have
slight movement).
Functional Mortise: Tibia and fibula form a 'functional mortise'
joint (fits like a peg into a hole)
o Talus is the peg in this analogy, and the posterior talus is
narrower than anterior talus.
The talus may also be viewed as the tenon.
o Thus, the as you flex or extend the foot, a different part of
the talus will be in the functional mortise, and this will
determine stability of the joint.
As you dorsiflex the foot, the functional mortise moves
towards wider end of talus --> less room on either side
--> less mobility (joint gets tighter & more stable as
you continue with dorsiflexion)
Also stretches the anterior & posterior tibiofibular
ligament, contributing to tightening of joint
o Comparison: see MSK 9, 11:11
Dorsiflexion: more stable (talus is wider), less
movement
When your foot is in dorsiflexed position, it is
difficult to move foot from side to side --> foot is
very stable in this position

Plantar Flexion: less stable (talus is narrower), more

movement.
Easier to do this in plantarflexion (evert/invert)
--> foot is less stable, and as a result, more
mobile
Narrower part of talus is in mortise.

Ligaments stabilizing ankle joint

tibia

tibia
fbula

Functional
Mortise

fbula
Posterior
tibio-fbular
ligament
talus

fbula

Anterior
tibio-fbular
tibia ligament

Posterior
talus

talus

Anterior
talus

calcaneus
calcaneus

Note: red=posterior/anterior tibio-fibular ligaments.

Ligaments Stabilizing Ankle Joint

We want to stabilize ankle joints the same way that the knee joint
was stabilized with collateral ligaments.
o There are ligaments on both medial and lateral sides but
medial is stronger.
Medial ligaments:
o Deltoid ligament: Broad triangular (deltoid) shaped
ligament on medial side of ankle (very strong)
Lateral Ligaments:
o On lateral side, we should theoretically have stronger
ligaments due to greater potential for injury, but this is not
the case --> ligaments are quite small and are weaker (all
attach to fibula).
Posterior talo-fibular ligament
Anterior talo-fibular ligaments
Calcaneo-fibular ligament
Inversion Sprain of ankle: rolling over of the ankle (inversion
injury), it's the weaker lateral ligaments which are most likely going
to be torn = ankle sprain
o Sprain of all three may occur (particularly ant/post talofibular).
o This inversion injury will most likely occur when in less stable
plantar flexed position (e.g. walking down the stairs, or high
heel shoes)
o Note: that the stronger ligaments (medial) are located in the
wrong spot to prevent this type of injury.

Weight Distribution on Foot-Pressure Points:

Because of arch of foot, 50% of body weight goes to back to foot
(calcaneous) and 50% goes to front (heads of metatarsals)
o However, at the front, the distribution will split on either side
of arch

o 50% of weight will be evenly divided between heads of 1 st and

5th metatarsals (i.e. 25% big toe, 25% little toe).
This is why your footprint in sand is deepest at heel (calcaneus) and
below toes (heads of 1st and 5th metatarsals)
This type of weight distribution is due to the shape of the foot itself,
which is mainly created by the longitudinal (front & back) and
transverse (side to side) arches of foot

Ligaments and Tendons Maintaining Foot Arches

Two arches: longitudinal and transverse, maintained by ligaments
1. Longitudinal arch: extends from calcaneus to metatarsals.
o Maintained by the peroneus longus tendon
Comes around from peroneal group of muscles and
attaches to base of first metatarsal (thus covers the
entire length of the foot)
Thus goes from lateral to medial side
o Note: Tibialis posterior (to some degree) and peroneus
longus (primarily) form a 'sling' to maintain longitudinal arch
of foot (based on their actions).
2. Transverse arch: on side of the foot to the other.

o Maintained by the calcaneo-navicular ligament: extends

on medial side of the foot from calcaneus to navicular bone
(articulates with talus).
Referred to as the spring ligament (able to stretch):
foot spreads out while walking, but this ligament brings
it back together (shock absorber)
Maintains longitudinal arch.
o See MSK 9, 16:43
Flat Feet: People with 'flat feet' (fallen arches) have a permanently
stretched (sprung) calcaneo-navicular ligament (may happen when
born)
o They can walk, but they have to use the peroneus longus
muscle to maintain the longitudinal arch of the foot (more
important than transverse arch)
o Hard for them to walk and carry weights because they're
using muscles that fatigue to maintain the arch
Note: Ligaments are covered by the plantar fascia (the most
superficial thing on the bottom of the foot).

*Middle=calceno-navicular ligament; Right=peroneus longus tendon

(yellow)

Foot sling
Avascular Necrosis of Talus (Extra):
Nutrient arteries entering talus will do so away from the knee -->
distal segment of talus at risk for avascular necrosis
Intrinsic Flexors of Foot
Very weak, dont do much.
Superficial Layer:
o Flexor Digiotrum Brevis: short flexor of the toes.
I/O: Begins from calcaneous and goes into each of the
toes
Action: helps out with flexion of the toes.
Deep Layer: not very significant.
o Small muscles, same as those found in hand (e.g. lumbricals
and dorsal/ventral interossei).
o Help to abduction and adduction the toes, but our ability to do
this is limited (thus they dont do very much).
Foot is built for bearing body weight, not grasping
things so we have little ability to do this.
Note: both layers innervated by tibial nerve.

I ntrinsic Muscles of Foot

The foot is designed for weight bearing rather than movement

Tibial Nerve

Flexor
Digitorum
Brevis

Dorsal and ventral Interossei

Abductors and Adductors of Toes

Superfcial layer

Deep layer

Veins of Lower Limb: similar idea to UL, extra set (superficial and
deep plexus)
Two systems of veins:
o Superficial veins return blood to heart at rest, by draining
into deep system).
o Deep veins return blood to heart during exercise (have same
names as arteries) and at rest.
1. Superficial veins:
o Begin as dorsal venous plexus in the top of the foot (like
the back of the hand)no specific names as different.
o Lesser saphenous vein runs up back side of the calf
between heads of gastrocnemius and around lateral malleolus
Drains into (or becomes) the deep popliteal vein at
back of knee.
o Great saphenous vein runs up medial aspect of calf thigh
(drains into deep femoral vein).

Note: the femoral vein will form the iliac vein.

2. Deep Veins:
o When you exercise (e.g. running) action of muscle in deep set
pushes/squishes on vein and forces blood back to centre of
body (heart) to get more oxygen
Thus, use the musculature that needs the oxygen
supply as a pump to return veinous blood back to the
heart.

Varicose Veins:
Sedentary lifestyle (no exercise)= pooling of blood in superficial
veins = collapse of valves = varicose veins (dilated and engorged
veins).
o The valves (that force blood to move against gravity) will
become deficient and defective.
o The stagnant blood in these veins may coagulate, leading to
blood clots, and this may dangerous/fatal if these clots return
back to the body (can get embolism in either heart, lung, or
brain).
Solutions:
o Venous stripping: surgical approach (put catheter from one
end to the other, blowing up a balloon and pulling the whole
vein out through the superficial fascia).

Extra: Dorsalis pedis artery.

Continuation of the anterior tibial artery that supplies dorsal aspect
of the foot (top)
Accompanied by deep vein (dorsalis pedis vein).