11

ANKLE/LOWER LEG ANATOMYANKLE/LOWER LEG ANATOMY

KIN 191AKIN 191AAdvanced Assessment of Advanced Assessment of Lower Extremity InjuriesLower Extremity Injuries

22

INTRODUCTIONINTRODUCTION

ANATOMYANATOMY BONY STRUCTURESBONY STRUCTURES ARTICULATIONS ARTICULATIONS LIGAMENTSLIGAMENTS MUSCLES MUSCLES BURSAEBURSAE NEUROANATOMYNEUROANATOMY VASCULAR ANATOMYVASCULAR ANATOMY

33

Lower legLower leg TibiaTibia FibulaFibula

Ankle Ankle mortisemortise Distal tibia and fibular Distal tibia and fibular

&& TalusTalus

BONY STRUCTURESBONY STRUCTURES

44

Primary weight-Primary weight-bearing bone of the bearing bone of the lower leglower leg

Roof/medial border of Roof/medial border of ankle mortiseankle mortise

Medial malleolusMedial malleolus Attachment site of the Attachment site of the

deltoid ligamentsdeltoid ligaments

TibiaTibia

66

Attachment site of Attachment site of muscles and muscles and ligamentsligaments

Serve as a pulley to Serve as a pulley to increase the increase the efficiency of the efficiency of the muscles at that run muscles at that run posteriorly to it posteriorly to it

Lateral malleolusLateral malleolus

FibulaFibula

77

Lateral malleolus Lateral malleolus (cont.)(cont.) Extends farther distally Extends farther distally

than the medial than the medial malleolusmalleolus

Limiting eversion than Limiting eversion than the medial malleolus is the medial malleolus is at limiting inversionat limiting inversion

88

The amount of force transmitted through The amount of force transmitted through the fibula range from 0 to 12 % of BWthe fibula range from 0 to 12 % of BW

Serve as a pulley to increase the efficiency Serve as a pulley to increase the efficiency of the muscles at that run posteriorly to itof the muscles at that run posteriorly to it

The peroneal nerve The peroneal nerve The nerve courses subcutaneously just The nerve courses subcutaneously just

posterior to the fibular head posterior to the fibular head Innervates the lower leg’s anterior and lateral Innervates the lower leg’s anterior and lateral

compartmentcompartment

Fibula Fibula (cont.)(cont.)

99

The trochleaThe trochlea Quadrilateral in shapeQuadrilateral in shape Covered with articular cartilageCovered with articular cartilage Anterior surface > Posterior Anterior surface > Posterior

surfacesurface• PF instability and DF stabilityPF instability and DF stability

Medial border Medial border medial medial malleolusmalleolus

Lateral border Lateral border lateral lateral malleolusmalleolus

Superior surface Superior surface tibia tibia Inferior surface Inferior surface calcaneus calcaneus

TalusTalus

1010

HeadHead

BodyBody

NeckNeck

TalusTalus

1111

Related Bony StructuresRelated Bony Structures

CalcaneusCalcaneus Attachment site of tendons and ligamentsAttachment site of tendons and ligaments

NavicularNavicular Attachment site of muscle and ligamentsAttachment site of muscle and ligaments

Base of the 5Base of the 5thth metatarsal/cuboid metatarsal/cuboid Attachment site of muscles and Attachment site of muscles and ligamentsligaments

1212

ARTICULATIONSARTICULATIONS

Talocrural JointTalocrural Joint Interosseous MembraneInterosseous Membrane

Distal Tibiofibular SyndesmosisDistal Tibiofibular Syndesmosis Subtalar JointSubtalar Joint

1313

Talocrural JointTalocrural Joint

= Ankle joint = Tibiotalar joint= Ankle joint = Tibiotalar joint Hinge jointHinge joint

Movements are plantar flexion and Movements are plantar flexion and dorsiflexion only dorsiflexion only

Closed packed in DFClosed packed in DF Loose packed in PFLoose packed in PF

1414

Interosseous MembraneInterosseous Membrane A strong fibrous tissue A strong fibrous tissue Serves as part of the Serves as part of the

origin for many musclesorigin for many muscles Distally, the membrane Distally, the membrane

blends intoblends into Anterior/posterior Anterior/posterior

tibiofibular ligaments tibiofibular ligaments Support the distal Support the distal

tibiofibular syndesmosis tibiofibular syndesmosis jointjoint

1515

Subtalar JointSubtalar Joint

Articulation between calcaneus and talusArticulation between calcaneus and talus No muscle attach to the talus, the stability of No muscle attach to the talus, the stability of

the subtalar joint is derived from ligamentous the subtalar joint is derived from ligamentous and bony restraintsand bony restraints

1616

LIGAMENTSLIGAMENTS Lateral ligamentsLateral ligaments

Anterior talofibular (ATF) ligamentAnterior talofibular (ATF) ligament Cacaneofibular (CF) ligamentCacaneofibular (CF) ligament Posterior talofibular (PTF) ligamentPosterior talofibular (PTF) ligament

Medial ligamentsMedial ligaments Deltoid ligaments (4 components)Deltoid ligaments (4 components)

Syndesmosis ligamentsSyndesmosis ligaments Distal anterior tibiofibular ligamentDistal anterior tibiofibular ligament Distal posterior tibiofibular ligamentDistal posterior tibiofibular ligament (Interosseous membrane)(Interosseous membrane)

1717

Lateral LigamentsLateral Ligaments ATFATF

Restricts anterior translation of talus on Restricts anterior translation of talus on tibia and talar inversion during PFtibia and talar inversion during PF

CFCF Restricts talar inversion during “neutral” Restricts talar inversion during “neutral”

positionposition PTFPTF

Restricts posterior translation of talus on Restricts posterior translation of talus on tibia – strongest of 3tibia – strongest of 3

1818

ATFATF

CFCF

PTFPTF

1919

Deltoid LigamentsDeltoid Ligaments

Anterior tibiotalar (ATT) ligamentAnterior tibiotalar (ATT) ligament Tibionavicular (TN) ligamentTibionavicular (TN) ligament Tibiocalcaneal (TC) ligamentTibiocalcaneal (TC) ligament Posterior tibiotalar (PTT) ligamentPosterior tibiotalar (PTT) ligament

Restricts talar eversionRestricts talar eversion

2020

TNTN

TTCC

PTTPTTATTATT

2121

MUSCLESMUSCLES

ANTERIOR C.ANTERIOR C. Tibialis anteriorTibialis anterior Extensor digitorum longusExtensor digitorum longus Extensor hallucis longusExtensor hallucis longus Peroneus tertiusPeroneus tertius

LATERAL C.LATERAL C. Peroneus longusPeroneus longus Peroneus brevisPeroneus brevis

SUPERFICIAL SUPERFICIAL POSTERIOR C.POSTERIOR C. GastrocnemiusGastrocnemius SoleusSoleus PlantarisPlantaris

DEEP POSTERIOR C.DEEP POSTERIOR C. Tibialis posteriorTibialis posterior Flexor digitorum longusFlexor digitorum longus Flexor hallucis longusFlexor hallucis longus

2222

Compartment of the LegCompartment of the Leg

2323

Anterior CompartmentAnterior Compartment

Tibialis anteriorTibialis anterior Extensor digitorum longusExtensor digitorum longus Extensor hallucis longusExtensor hallucis longus Peroneus tertiusPeroneus tertius

2424

Tibialis AnteriorTibialis Anterior

O: O: Lateral tibial Lateral tibial condyle and condyle and

shaftshaft I: I: Medial/plantar Medial/plantar

11stst cuneiform and cuneiform and metatarsalmetatarsal

N: N: Deep peroneal Deep peroneal A:A: DF and DF and

InversionInversion

2525

Extensor Digitorum LongusExtensor Digitorum Longus

O: O: Lateral tibial Lateral tibial condyle, proximal condyle, proximal ¾ ¾ of anterior fibulaof anterior fibula

I: I: Via 4 tendons into Via 4 tendons into distal phalanges of distal phalanges of 22ndnd-5-5thth toes toes

N: N: Deep peroneal Deep peroneal A:A: Extension of 2Extension of 2ndnd-5-5thth

MTP joints, assists MTP joints, assists with eversion and with eversion and

DFDF

2626

Extensor Hallucis LongusExtensor Hallucis Longus O: O: Middle 2/3 of Middle 2/3 of

anterior fibulaanterior fibula I: I: Base of distal Base of distal

11stst phalanxphalanx N: N: Deep peroneal Deep peroneal A:A: Extension of 1Extension of 1stst

MTP and IP MTP and IP jointsjoints

2727

Peroneus TertiusPeroneus Tertius

O: O: Distal 1/3 of Distal 1/3 of anterior fibulaanterior fibula

I: I: Dorsal base of Dorsal base of 55thth metatarsalmetatarsal

N: N: Deep peronealDeep peroneal A:A: Eversion of foot, Eversion of foot,

assists in PFassists in PF

2828

VideoVideo

2929

I am thinking…I am thinking…

3030

Lateral CompartmentLateral Compartment

Peroneus longusPeroneus longus Peroneus brevisPeroneus brevis

3131

Peroneus LongusPeroneus Longus

O: O: Lateral tibial condyle, Lateral tibial condyle, fibular head, upper fibular head, upper 2/3 of lateral fibula2/3 of lateral fibula

I: I: Lateral base of 1Lateral base of 1stst metatarsal, lateral metatarsal, lateral and dorsal aspect of and dorsal aspect of 11stst cuneiform cuneiform

N: N: Superficial peronealSuperficial peroneal A:A: Eversion of the foot, Eversion of the foot,

assists with PFassists with PF

3232

Peroneus BrevisPeroneus Brevis

O: O: Distal 2/3 of Distal 2/3 of lateral fibulalateral fibula

I: I: Styloid process at Styloid process at base of 5base of 5thth

metatarsalmetatarsal N: N: Superficial peronealSuperficial peroneal A:A: Eversion of the foot, Eversion of the foot,

assists with PFassists with PF

3333

Superficial Posterior CompartmentSuperficial Posterior Compartment

GastrocnemiusGastrocnemius SoleusSoleus PlantarisPlantaris

3434

GastrocnemiusGastrocnemius

O: O: Medial head – Medial head – posterior posterior medial femoral medial femoral condyle, condyle, Lateral head – Lateral head – posterior posterior lateral femoral lateral femoral condylecondyle

I: I: Calcaneus via Achilles Calcaneus via Achilles tendontendon

N: N: TibialTibial A:A: PF, assists knee PF, assists knee

flexionflexion

3535

SoleusSoleus

O: O: Posterior fibular head, Posterior fibular head, upper 1/3 of posterior upper 1/3 of posterior fibular, fibular, soleal line on soleal line on posterior posterior tibial shaft, tibial shaft, middle 1/3 of middle 1/3 of medial tibial medial tibial borderborder

I: I: Calcaneus via Achilles Calcaneus via Achilles tendontendon

N: N: TibialTibial A:A: PFPF

3636

PlantarisPlantaris

O: O: Distal supracondylar Distal supracondylar line line of lateral femoral of lateral femoral condyle, femoral condyle, femoral popliteal popliteal surfacesurface

I: I: Calcaneus via Achilles Calcaneus via Achilles tendontendon

N: N: TibialTibial A:A: PF, assists knee PF, assists knee

flexionflexion

3737

Deep Posterior CompartmentDeep Posterior Compartment

““TTom, om, DDick, ick, AANN HHarry”arry”

TTibialis posterioribialis posterior Flexor Flexor ddigitorum longus igitorum longus Flexor Flexor hhallucis longusallucis longus

AANN Tibial Tibial AArteryrtery Tibial Tibial NNerveerve

3838

Tibialis PosteriorTibialis Posterior

O: O: Posterior/lateral tibia, Posterior/lateral tibia, upper upper 2/3 of medial fibula2/3 of medial fibula

I: I: Navicular tuberosity, via Navicular tuberosity, via slips into sustentaculum slips into sustentaculum tali, cuneiforms, cuboid tali, cuneiforms, cuboid

and and bases of 2bases of 2ndnd-4-4thth metatarsalsmetatarsals

N: N: TibialTibial A:A: Inversion of the foot, Inversion of the foot,

assists withassists with PF PF

3939

Flexor Hallucis LongusFlexor Hallucis Longus

O: O: Posterior/distal 2/3 of Posterior/distal 2/3 of fibulafibula

I: I: Plantar surface of 1Plantar surface of 1stst proximal phalanxproximal phalanx

N: N: TibialTibial A:A: Flexion of 1Flexion of 1stst IP joint, IP joint,

assists with flexion of assists with flexion of 11stst MTP joint, foot MTP joint, foot inversion inversion and PFand PF

4040

Flexor Digitorum LongusFlexor Digitorum Longus

O: O: Posterior medial Posterior medial 2/3 of distal tibia2/3 of distal tibia

I: I: Plantar surface of Plantar surface of base of 2base of 2ndnd-5-5thth

distal phalangesdistal phalanges N: N: TibialTibial A:A: Flexion of 2Flexion of 2ndnd-5-5thth

PIP/DIP/MTP PIP/DIP/MTP joints, joints, assists with assists with foot foot inversion and inversion and PFPF

4141

Plantar FlexionPlantar Flexion GastrocnemiusGastrocnemius SoleusSoleus PlantarisPlantaris Peroneus Longus & Brevis Peroneus Longus & Brevis Tibialis PosteriorTibialis Posterior Flexor Hallucis LongusFlexor Hallucis Longus Flexor Digitorum LongusFlexor Digitorum Longus

4242

DorsiflexionDorsiflexion Tibialis AnteriorTibialis Anterior Extensor Digitorum LongusExtensor Digitorum Longus Extensor Hallucis LongusExtensor Hallucis Longus Peroneus TertiusPeroneus Tertius

4343

Tibialis AnteriorTibialis Anterior Tibilais posteriorTibilais posterior Flexor Digitorum LongusFlexor Digitorum Longus Flexor Hallucis LongusFlexor Hallucis Longus Extensor Hallucis LongusExtensor Hallucis Longus

Inversion & AdductionInversion & Adduction

4444

Peroneus LongusPeroneus Longus Peroneus Brevis Peroneus Brevis Peroneus TertiusPeroneus Tertius Extensor Digitorum LongusExtensor Digitorum Longus

Eversion & AbductionEversion & Abduction

4545

BURSAEBURSAE Retrocalcaneal (subtendinous calcaneal) Retrocalcaneal (subtendinous calcaneal)

bursabursa Between the Achilles tendon and the calcaneusBetween the Achilles tendon and the calcaneus

Subcutaneous calcaneal bursaSubcutaneous calcaneal bursa PosterioPosteriorr aspect of the calcaneus and skin aspect of the calcaneus and skin

4646

NEUROANATOMYNEUROANATOMY

Anterior compartmentAnterior compartment Deep branch of peroneal nerveDeep branch of peroneal nerve

Lateral compartmentLateral compartment Superficial branch of peroneal nerveSuperficial branch of peroneal nerve

Deep posterior compartmentDeep posterior compartment Tibial nerveTibial nerve

Superficial posterior compartmentSuperficial posterior compartment Tibial nerveTibial nerve

4747

Deep Branch of Peroneal NerveDeep Branch of Peroneal Nerve

Branches from common Branches from common peroneal nerve near peroneal nerve near fibular headfibular head

““Dives” into anteriorDives” into anterior compartmentcompartment

4848

Superficial Branch of Peroneal NerveSuperficial Branch of Peroneal Nerve

Branches from common Branches from common peroneal nerve near peroneal nerve near fibular headfibular head

Stays superficial and Stays superficial and lateral in lateral lateral in lateral compartmentcompartment

4949

Tibial NerveTibial Nerve

Runs in fascial Runs in fascial sheath between sheath between deep and superficial deep and superficial posterior posterior compartmentscompartments

Provides innervation Provides innervation to both, but not “in” to both, but not “in” eithereither

5050

VASCULAR ANATOMYVASCULAR ANATOMY

Anterior compartmentAnterior compartment Anterior tibial arteryAnterior tibial artery

Lateral compartmentLateral compartment Peroneal arteryPeroneal artery

Deep posterior compartmentDeep posterior compartment Posterior tibial arteryPosterior tibial artery

Superficial posterior compartmentSuperficial posterior compartment Posterior tibial arteryPosterior tibial artery

5151

Anterior Tibial ArteryAnterior Tibial Artery

Traverses similar Traverses similar path to deep path to deep peroneal nerveperoneal nerve

Terminating as Terminating as dorsal pedal arterydorsal pedal artery

5252

Peroneal ArteryPeroneal Artery

Branches off of Branches off of posterior tibial posterior tibial arteryartery

5353

Posterior Tibial ArteryPosterior Tibial Artery

Runs in fascial sheath Runs in fascial sheath between deep and between deep and superficial posterior superficial posterior compartmentscompartments

Provides vascular Provides vascular supply to both, but not supply to both, but not “in” either“in” either