Presentation on theme: "FOOT IN 30 QUESTIONS Exam of the Lower Extremities"— Presentation transcript:
1 FOOT IN 30 QUESTIONS Exam of the Lower Extremities From A Practical Guide to Clinical MedicineUniversity of California, San DiegoFOOTIN 30 QUESTIONSKaan Yücel M.D., Ph.D.
2 INTRODUCTION TO FOOT Region of the lower limb distal to ankle joint Subdivided intoAnkleMetatarsusDigitsSuperior surface (dorsum of foot) Inferior surface (sole)
3 INTRODUCTION TO FOOT Body's point of contact with the ground Provides a stable platform for upright stance.Supports the body weight and provides leverage for walking and running.Unique -constructed in the form of arches, adapt its shape to uneven surfaces.Serves as a resilient spring to absorb shocks, such as in jumping.
5 The subcutaneous tissue is loose deep to the dorsal skin 1…skin of the footSkin of the dorsum of the foot thinner and less sensitive than that of the soleThe subcutaneous tissue is loose deep to the dorsal skinEdema most marked on the dorsal skinespecially anterior to and around the medial malleolusEntire sole is sensitive (“ticklish”), especially the thinner-skinned area underlying the arch of the foot.Neurosci Res Dec;68(4):285-9.Neurogenesis in the dentate gyrus of the rat hippocampus enhanced by tickling stimulation with positive emotion.Ticklish?gargalesis
6 2. Deep fascia of the foot & Plantar fascia Thin where it is continuous proximally with the inferior extensor retinaculum.Over the lateral and posterior aspects of the foot continuous with the plantar fascia, the deep fascia of the sole.Plantar fascia holds the parts of the foot together, helps protect the sole from injury, and helps support the longitudinal arches of the foot.
7 3. Compartments by the deep fascia Midfoot and forefoot Medial compartment of the soleCentral compartment of the soleLateral compartment of the soleForefoot4th compartmentinterosseous compartment of the footDorsal compartment of the foot5th compartmentbetween dorsal fascia of the foot & tarsal bones & dorsal interosseous fascia of the midfoot and forefootTransverse section of the foot: 1, lateral compartment; 2, central compartment; 3, medial compartment;4, interosseous compartment. Arrows indicate the high-pressure areas that often lead to foot ulceration.
8 Overlying flexor retinaculum 4. Tarsal tunnelFormed on the posteromedial side of the ankle by:A depression formed byMedial malleolus of tibia Medial &posterior surfaces of talusInferior surface of sustentaculum tali Medial surface of calcaneusOverlying flexor retinaculumContents from ant. to post.(Tom Dick ANd Harry)Tibialis posterior tendonFlexor digitorum longus tendonPosterior tibial arteryTibial nerveFlexor hallucis longus tendon
9 5. Flexor retinaculumAttaches above to medial malleolus below to calcaneus2 compartments on the posterior surface of medial malleolus for tibialis posterior & flexor digitorum longus tendonsLaterallyposterior tibial artery ,veins & tibial nerve through tarsal tunnel into sole of footLateral to tibial nervetendon of flexor hallucis longusPulse of posterior tibial artery through flexor retinaculum midway between medial malleolus and calcaneus
10 Prevent tendon bowing during extension of the foot and toes 6. Extensor retinaculaPrevent tendon bowing during extension of the foot and toesSuperior extensor retinaculum Superior to the ankleAttached to anterior borders of the fibula & tibiaInferior retinaculumY-shapedAttached to lateral side of calcaneusExtensor digitorum longus &fibularis tertius tendonsMediallyDorsalis pedis arteryExtensor hallucis longus tendontibialis anterior tendonpass under extensor retinacula
11 Superior fibular retinaculum Inferior fibular retinaculum 7. Fibular (Peroneal) retinaculaBind the tendons offibularis longus & fibularis brevisto lateral side of the footSuperior fibular retinaculumBetween lateral malleolus & calcaneusInferior fibular retinaculumAttaches to lateral surface of calcaneus around fibular trochlea
12 8. Plantar aponeurosisA thickening of deep fascia in the sole of the footA thick central partWeaker medial and lateral partsTougher, denser, and elongated than palmar aponeurosisAnchored to the medial process of calcaneal tuberositySupports the longitudinal arch of the foot & protects deeper structures in the sole
13 9. Fibrous sheaths of toes Flexor digitorum longus, flexor digitorum brevis, & flexor hallucis longus tendons enter fibrous digital sheaths on plantar aspect of digits.Formed by fibrous arches & cruciate (cross-shaped) ligamentsHold the tendons to the bony plane and prevent tendon bowing when the toes are flexed.
14 10. Extensor hoodsExtensor digitorum longus, extensor digitorum brevis, and extensor hallucis longus expand over the proximal phalanges to form complex dorsal digital expansions ("extensor hoods").Many of the intrinsic muscles of the foot insert here.This allows the forces from these muscles to be distributed over the toesto cause flexion of the metatarsophalangeal joints while at the same time extending the interphalangeal joints.
16 20 individual muscles of the foot 14 located on the plantar aspect2 on the dorsal aspect4 intermediate in positionPlantar muscles function primarily as a group during the support phase of stance, maintaining the arches of the footFew delicate functions compared to hand musclesConcerned with supporting the arches of the foot
17 Muscles in the dorsumExtensor digitorum brevisAttached to a roughened area on the superolateral surface of the calcaneus lateral to the tarsal sinusExtensor hallucis brevisThe part of the muscle associated with the great toeDeep fibular nerve
18 Organized into four layers From superficial to deep Muscles in the soleOrganized into four layersFrom superficial to deepor plantar to dorsalFirst layerMedial to lateralAbductor hallucisFlexor digitorum brevis Abductor digiti minimiSecond layerQuadratus plantae Lumbrical musclesThird layerFlexor hallucis brevisAdductor hallucisFlexor digiti minimi brevisFourth layerDorsal & plantar interossei
19 1st layer 2nd layer 3rd layer 4th layer Functions & innervations of the muscles of the foot1st layerMedial plantar nerve (S2, S3)Abductor hallucisFlexor digitorum brevisAbductor digiti minimiLateral plantar nerve (S2, S3)2nd layerAssists flexor digitorum longus in flexing lateral four digitsQuadratus plantaeFlex proximal phalanges, extend middle & distal phalanges of lateral four digitsLumbricals3rd layer4th layerPlantar interossei (three muscles)Adduct digits (2-4) and flex metatarsophalangeal jointsDorsal interossei (four muscles)Abduct digits (2-4) and flex metatarsophalangeal jointsFlexor hallucis brevisAdductor hallucisdeep branchFlexor digit minimi brevis superficial branch
21 Posterior tibial artery Supply of the footTerminal branches ofanterior tibial artery & posterior tibial arterydorsalis pedis artery & plantar arteriesPosterior tibial arteryin the sole divides intolateral & medial plantar arteriesLateral plantar artery +Dorsalis pedis arteryDeep plantar arch
22 Lateral & medial plantar arteries Lateral plantar arteryMajor branches of the deep plantar archDigital branch to lateral side of little toe4 plantar metatarsal arteries3 perforating arteriesMedial plantar arteryPasses deep to the abductor hallucisEnds by joining the digital branch of the deep plantar archSuperficial branch
23 Dorsalis pedis arteryMajor source of blood supply to forefootContinuation of anterior tibial arteryBegins midway between malleoliRuns deep to inferior extensor retinaculum between extensor hallucis longus & extensor digitorum longus tendons on the dorsum of the foot
24 Dorsalis pedis arteryPasses inferiorly asdeep plantar arteryJoins deep plantar arch in the sole of the foot.Brancheslateral and medial tarsal branchesarcuate arteryfirst dorsal metatarsal artery
26 As in the rest of the lower limb, there are both superficial and deep veins in the foot. Unlike the leg and thigh, however, the venous drainage of the foot is primarily to the major superficial veins
27 Dorsal metatarsal veins Dorsal digital veinsDorsal metatarsal veinsDorsal venous network of the footDorsal venous arch of the footMedial sideLateral sideGreat saphenous veinSmall saphenous vein
29 Tibial nerveDeep fibular nerveSuperficial fibular nerveSural nerveSaphenous nerveAll intrinsic muscles of the foot except for the extensor digitorum brevis, innervated by the deep fibular nerveDeep fibular nerve often also contributes to innervation of the first and second dorsal interossei.
31 Medial plantar nervesLarger & more anterior terminal branch Arises deep to the flexor retinaculumMajor sensory nerve in the soleCompared to lateral plantar nerve, supplies more skin area but fewer muscles.Its distribution to both skin and muscles of comparable to that of the median nerve in the hand.Skin on most of the anterior two-thirds of the sole and adjacent surfaces of the medial three and one-half toes, which includes the great toe.Four intrinsic muscles- abductor hallucis, flexor digitorum brevis, flexor hallucis brevis, and the first lumbrical.
32 Lateral plantar nerveSmaller & more posterior terminal branchAlso courses deep to the abductor hallucis but runs anterolaterally between the 1st and 2nd layers of plantar muscles, on the medial side of the lateral plantar artery.lateral compartment, dividing into superficial and deep branches.
33 Two plantar digital nerves (one common and one proper) Lateral plantar nerveSuperficial branchTwo plantar digital nerves(one common and one proper)Skin of the plantar aspects of the lateral one and a half digits, the dorsal skin and nail beds of their distal phalanges, and skin of the sole proximal to them.
34 Deep fibular nervePasses deep to extensor retinaculumEnters dorsal aspect of the foot on the lateral side of dorsalis pedis artery.Muscles on dorsum of the footWhen finally emerges as a cutaneous nerve, so far distal in the foot ;small area of skin remains available for innervation: web of skin between and contiguous sides of the 1st and 2nd toesDivides into two dorsal digital nerves
35 Superficial fibular nerve Emerges as a cutaneous nerve about two thirds of the way down the legSkin on the anterolateral aspect of legDivides intoMedial and intermediate dorsal cutaneous nervesMost of the skin on the dorsum of the footTerminal branchesDorsal digital nerves(common & proper)Skin of the proximal aspect of the medial half of the great toe & that of the lateral three and a half digits.
36 Sural nerveCutaneous branch of tibial nerve Originates high in the legSural nerve formation:Medial sural cutaneous nerve (from the tibial nerve)Sural communicating branch of common fibular nerveAccompanies small saphenous vein Enters the foot posterior to the lateral malleolusankle joint & skin on the lateral side of the foot and dorsolateral surface of the little toe.
37 Saphenous nerveLongest & most widely distributed cutaneous branch of the femoral nerveOnly branch to extend beyond the kneeOriginates in the thighSkin and fascia on the anteromedial aspect of the leg, ankle jointSkin along the medial side of the foot as far anteriorly as the head of the 1st metatarsal , medial side of the proximal foot
38 Cutaneous innervation of the foot MediallySaphenous nerve distally to the head of 1st metatarsalSuperiorly (dorsum of foot)Superficial (primarily)Deep fibular nervesInferiorly (sole of foot)Medial & lateral plantar nervesLaterallySural nervePosteriorly (heel)Medial & lateral calcaneal branches of tibial & sural nerves, respectively
40 Medial superficial lymphatic vessels Accompany great saphenous vein medial side of the dorsum & sole of the footAccompany great saphenous veinLateral superficial lymphatic vesselslateral side of the dorsum & sole of the footAccompany small saphenous veinDeep inguinal lymph nodesIliac lymph nodes