1. Lower Limb, part II Barbara Kraszpulska, Ph.D. Neuroscience, Cell Biology, and Physiology

2. Popliteal fossa Small saphenous vein Popliteal artery and vein Superior medial genicular a. Superior lateral genicular a. Gastrocnemius m. Biceps femoris Semimembranosus m. Semitendinosus m. Gracilis m. Sartorius m. Plantaris m. Tibial nerve Common fibular nerve Lateral sural cutaneous n. Medial sural cutaneous n. Common fibular gives rise to lateral sural Tibial nerve gives rise to medial sural cutaneous n. Superior genicular artery (one on lateral and one on medial side) -Superior lateral genicular a. - Superior medial genicular a.

3. Popliteal Fossa The popliteal fossa is a space or shallow depression located at the back of the knee joint. The boundaries of the fossa are: * superior and medial: the semimembranosus m., lateral to which is the semitendinosus m. * superior and lateral: the biceps femoris m. * inferior and medial: the medial head of the gastrocnemius m. * inferior and lateral: the lateral head of the gastrocnemius m. The contents of the politeal fossa include the: * termination of the small saphenous vein * popliteal arteries and veins and their branches and tributaries * tibial and common fibular nerves * popliteal lymph nodes and lymphatic vessels Vein lies more anteriorly Artery lies deeper in popliteal fossa

4. Knee joint This is condylar type of synovial joint (between two condyles of the femour and tibia), in addition it includes a saddle joint between the femur and the patella! Functionally this a hinge type of synovial joint – the main movement is flexion and extension, but there is also rotation when the knee is flexed ! The fibula is NOT involved in the knee joint!!!!!!!!!!! Extracapsular ligaments( external ligaments): * patellar lig. * tibial collateral lig. * fibular collateral lig. * oblique popliteal lig. * popliteus tendon Intracapsular ligaments: * anterior cruciate lig. * posterior cruciate lig. * medial meniscus * lateral meniscus Bursae – there are at least about 12 bursae around knee joint! Quadriceps tendon becomes the patellar ligament Tibial and fibular collateral ligaments are like the ulnar and radial collateral ligaments.

5. Right Knee – Cruciate and Collateral Ligaments Anterior view Posterior view 1 – medial condyle 2 – lateral condyle 3 – medial meniscus 4 – lateral meniscus 5 – anterior cruciate lig. 6 – posterior cruciate lig. 7 – tibial collateral lig. 8 –fibular collateral lig. 1 1 2 2 77 88 5 6 6 5 4 4 3 3 9 9 – tendon of popliteus m.

6. Function of the Cruciate ligaments Anterior cruciate ligament Prevents anterior displacement of the tibia relative to the femur Posterior cruciate ligament Prevents posterior displacement of the tibia relative to the femur

7. Medial meniscus Lateral meniscus Anterior cruciate lig. Posterior cruciate lig. Infrapatellar fat pad Menisci of the knee joint Which meniscus is more frequently torn in injures and why???

8. 1.“Unhappy triad " 2. Bursitis in the knee region a.Tibial collateral lig. b.Medial meniscus c.Anterior cruciate lig.

9. Genicular anastomoses around the knee Four genicular branches 1 & 2. Superior medial and lateral loop over respective femoral condyles 3. Inferior medial parallels superior edge of popliteus 4. Inferior lateral crosses popliteus

10. 4 branches of genicular arteries – which are derived from the Popliteal artery: -Superior lateral genicular arteries - loops over lateral femoral condyle - Superior medial genicular arteries - loops over medial femoral condyle - Inferior medial genicular artery - parallels superior edge of popliteus - Inferior lateral genicular artery - crosses popliteus

11. Right knee Pes anserinus Vastus medialis Vastus lateralis Quadriceps femoris tendon Patellar ligament Iliotibial tract Medial patellar retinaculum Lateral patellar retinaculum Semitendinosus Gracilis Sartorius }

12. Anterior (extensor) compartment Action: 1. they all extend (dorsiflex) the foot (ankle joint) 2. Tibialis anterior- inverts the foot 3. Extensor. digit. long. – extend digits (toes), everts foot 4. Extensor hallucis long. – extend great toe, inverts foot Innervation: Deep fibular nerve (L5,S1) Blood supply: Anterior tibial artery (terminal branch of popliteal a.) Tibialis anterior M. 1 2 Tibia Extensor hallucis longus m. Extensor digit. longus m. 1 2 1. Sup. extensor retinaculum 2. Inf. extensor retinaculum

13. Actions of the anterior extensor compartment: -Tibialis anterior: -Extend (dorsiflexion) of foot at ankle joint - inverts foot - Extensor digitorum longus -Extends the foot at the ankle joint -Everts foot -extend digits “Odd man out is ED” Extensor hallucis longus Extends the foot at ankle joint Inverts foot Extend great toe Innervation: -Deep fibular nerve (L5, S1) Blood supply: -Anterior tibial artery (Terminal branch of popliteal a.)

14. Lateral (eversion) compartment Action: 1. They both evert the foot (elevate the lateral margin of the foot) 2. They weakly flex (plantarflex) the foot (because they pass posterior to the transverse axis of the ankle) Innervation: Superficial fibular nerve (L5-S2) Blood supply: Perforating branches of the anterior tibial and fibular artery (posterior tibial artery Tendon of fibularis longus (1) Fibularis Longus (1) Fibularis Brevis (2) (1) (2)

15. The lateral compartment is supplied by both the anterior and posterior tibial arteries (the fibular artery, in this case). However, they are perforating branches. Unlike the anterior compartment (deep branch, L5- S1), the lateral compartment is innervated by the superficial branch (L5-S2) Fibularis longis (lateral compartment, supplied by perforating branches of anterior tibial and fibular arteries) wraps under the flexor digitorum brevis

16. Common fibular N Superficial fibular N Deep fibular N Lateral sural cutaneous n. Superficial fibular n. Deep fibular n. Sural n. (lat. dorsal cutaneous branch)

17. Causes include: *Compressed nerve root, usually in the lower spine, due to a ruptured lumbar disk *Pressure or injury to the peroneal nerve in your lower leg, such as from sitting with your legs crossed for long periods *Peripheral nerve disorder (neuropathy) *Muscle disorders (myopathies) *Tumor or stroke affecting the areas of the brain that control movement of the legs *Disorders of the spinal cord such as tumors or multiple sclerosis Injury to the common fibular nerve Footdrop is due to weakness or paralysis of the muscles involved in lifting the front part of your foot. This can cause inability to stand on heels and walk with a foot slap. Footdrop isn't a disease but a sign of an underlying problem. Depending on the cause, footdrop can be temporary or permanent. Treatment depends on the underlying cause but may include a brace (orthotic) worn on the ankle and foot to hold the foot in the normal position.

18. Footdrop is a sign of injury to the common fibular nerve (also known as the peroneal nerve) -Result of compression of nerve root, injury to nerve itself, peripheral nerve disorder, muscle disorder, tumor or stroke, disorder of spinal cord -(Basically, damage to nerve, damage to brain, damage to spinal cord or muscle itself)

19. T ibialis posterior Flexor D igitorum longus Posterior tibial artery and vein Tibial nerve Flexor H allucis longus Flexor retinaculum Achilles tendon (calcaneal tendon) Posterior (plantarflexion) compartment Superficial group: Gastrocnemius Soleus flex the foot plantaris Deep group: TOM DICK HARRY Soleus Lateral to medial: Tom Dick VAN Halen Calcaneal tendon is also known as the Achilles tendon

20. Tibialis posterior tendon Flexor digitorum longus Posterior tibial A and Tibial nerve Flexor hallucis longus TOM – T ibialis posterior DICK- Fl. D igitorum longus HARRY- Fl. H allucis longus The tarsal tunnel is a narrow space that lies on the inside of the ankle next to the ankle bones. Tarsal tunnel syndrome is a compression, or squeezing, on the posterior tibial nerve that produces symptoms anywhere along the path of the nerve. The posterior tibial nerve runs along the inside of the ankle into the foot. Tarsal tunnel Tarsal tunnel syndrome Flexor retinaculum

21. Tarsal tunnel syndrome (TTS), also known as posterior tibial neuralgia, is a painful foot condition in which the tibial nerve is impinged and compressed as it travels through the tarsal tunnel.tibial nervetarsal tunnel

22. Tibial nerve Popliteus muscle Flexor digitorum longus M. Flexor hallucis longus M. Tibialis posterior M. Sural nerve Common fibular (peroneal) nerve Soleus Muscle (cut) Gastrocnemius muscle (cut) Innervation: Tibial nerve (L4-S3) Blood supply: Posterior tibial artery and also fibular artery (branch of posterior tibial a.)

23. Tibial nerve innervates the posterior plantarflexion compartment Roots? L4- S3 Muscles: -Popliteal - Gastrocnemius - Soleus - Tibial posterior - Flexor digitorum longus - Flexor hallucis longus Tarsal bones "Tall Cocky Navy Medical I nterns Lay Cuties": · In order (right foot, superior to inferior, medial to lateral): Talus Calcanous N avicular Medial cuneiform Intermediate cuneiform Lateral cuneifrom Cuboid

24. Foot Bones: Tarsals (7): talus, calcaneus, navicular, cuboid, and cuneiforms (3) Metatarsal – 5, Phalanges - 14 calcaneus talus cuboid navicular cuneiform bones Transverse tarsal joint Tarsometatarsal joint Function of the foot: *Provide a stable platform *Generate propulsion *Absorb shock calcaneus talus tibia Subtalar joint Ankle joint

25. Foot joints: 1. Ankle joint – between the distal end of the tibia and fibula and the superior part of talus. This is a hinge type joint! Movements: dorsiflexion ( extension) of the foot, plantarflexion (flexion) of the foot. 2. Subtalar joint articulation between talus and calcaneus 3. Transverse tarsal joint articulation between talus, navicular, calcaneus and cuboid bones Movements: inversion and eversion. Eversion- elevation of the lateral margin of the foot Inversion – elevation of the medial margin of the foot. extension Flexion

26. Posterior talofibular ligament Calcaneofibular ligament Anterior talofibular ligament (most commonly injured in ankle sprains) Lateral (collateral) ligament Fibularis longus tendon Fibularis brevis tendon Lateral collateral ligament -Contains 3 parts - torn under inversion

27. Inversion and eversion of the foot Inversion injury- Ankle sprains! Tibialis anterior AND tibialis posterior control inversion of the foot. -What else controls it? - Flexor hallucis longus Fibular

28. 1. Posterior tibiotalar part 2. Tibiocalcaneal part 3. TIbionavicular part 4. Anterior tibiotalar part DELTOID (medial) ligament SPRING LIGAMENT ( Plantar calcaneonavicular) Short plantar ligament Long plantar ligament Deltoid lig. stabilizes the ankle joint during eversion and prevents sublocation of the joint! 1 2 3 4

29. Although the lateral side (fibular side) is composed of 3 different ligaments, the medial side is considered one giant ligament. This ligament is known as the deltoid ligament. -Its components are similar to the lateral compartment, with the addition of the tibionavicular ligament. -Function? - Stabilizes the ankle joint during eversion and prevents sublocation of the jiont. -Also laterally, we have the spring ligament (plantar calcaneonvaciular

30. Ankle injuries A Pott fracture–dislocation of the ankle

31. Sole of foot Superficial dissection Plantar aponeurosis Medial plantar fascia Lateral plantar fascia First layer Abductor hallucis Flexor digitorum brevis Abductor digiti minimi Lateral plantar nerve(S2, S3) Medial plantar nerve(S2, S3) Medial plantar nerve(S2, S3)

32. Sole of foot Second layer Quadratus plantae Lateral plantar nerve(S2, S3) Lumbrical Lateral and medial plantar nerve(S2, S3) Third layer Adductor hallucis Lateral plantar nerve(S2, S3) Flexor digiti minimi brevis Lateral plantar nerve(S2, S3) Flexor hallucis brevis Medial plantar nerve(S2, S3)

33. First layer of the foot Flexor digitorum brevis Medial plantar nerve (S2, S3) Abductor hallucis Medial plantar nerve (S2, S3) Abductor digiti minimi Lateral plantar nerve (S2, S3) The lateral and medial plantar nerves are branches of the tibial nerve, which is itself a branch of the sciatic nerve Sole of foot: -First layer - Flexor digitorum brevis - Medial plantar n - Abductor hallucis - Medial plantar - Abductor digiti minimi - lateral plantar n. -Second layer - Quadratus plantae - lateral plantar n. - Lumbrical - lateral and medial plantar nerves -Third layer - Adductor hallucis - lateral plantar nerves - Flexor digit minimi brevis -Lateral plantar nerves - flexor hallucis brevis - medial plantar nerves

34. Muscles of the foot Plantar muscles function primarily as a group during the support phase of stance, maintaining the arches of the foot. The muscles of the foot are of a little importance individually because fine control of the individual toe is not important for most people. Rather than producing actual movement, they are most active in fixing the foot or in increasing the pressure applied against the ground by various aspects of the sole or toes to maintain balance. Nerves of the foot: Medial plantar nerve (S2, S3) Lateral plantar nerve (S2, S3) Both terminal branches of tibial nerve! Deep fibular- dorsum of the foot Arteries of the foot: Dorsalis pedis artery- terminal branch of the anterior tibial Medial plantar and lateral plantar- terminal branches of the posterior tibial

35. Arteries of the foot

36. Nerves of the Leg and Foot Sciatic nerve (L4-S3 ) Tibial nerve (L4-S3) Medial plantar nerve Lateral plantar nerve Superficial branchDeep branch Common fibular nerve (L4-S2)Superficial fibular nerve Deep fibular nerve Medial branch Lateral branch

37. Medial plantar nerve: flexor digitorum brevis abductor hallucis flexor hallucis brevis first lumbrical Lateral plantar nerve: abductor digiti minimi quadratus plantae lumbricals 2, 3 and 4 adductor hallucis flexor digiti minimi brevis dorsal and plantar interossei

38. Cutaneous nerves of Lower Extremity

39. Major ligaments of the foot (plantar aspect) Supports the longitudinal arch (Long plantar calcenocuboid ligament) Calcaneocuboid lig. Supports the Longitudinal arch Spring ligament!! 1.Supports the head of the talus 2. Transfers weight from the talus 3. Supports the longitudinal arch

40. Flexor hallucis longus supports the.. Dynamic support- -Major muscles that invert foot -Major muscles that evert foot -Intrinsic plantar muscles Passive support -On bottom of foot and ligaments - plantar aponeurosis - plantar calcaneonavicular lig - long plantar lig - short plantar lig

41. Arches of the foot Medial longitudinal arch – higher and more important Is composed of: calcaneus, talus, navicular, three cuneiforms, three medial metatrasal bones. This is arch is supported by: tendon of the flexor hallucis longus muscle and spring ligament

42. Arches of the foot Lateral longitudinal arch – much flatter. Is composed of: calcaneus, cuboid and lateral two metatarsalas. Supported by: Fibular (peroneus) longus tendon and long and short plantar ligaments.

43. Transverse arch of the foot – runs from side to side. Is composed of: cuboid, cuneiforms and bases of the metatarsals. Support by tendons of two muscles: Fibularis longus (FL) and tibialis posterior (TP), crossing under the sole of the foot. Arches of the foot FL TP

44. Factors involved in forming and maintaining the arches of the foot Passive factors: 1. the shape of the united bones 2. plantar aponeurosis 3. long plantar ligament 4. short plantar ligament 5. spring plantar ligament Dynamic factors: 1.Active action of the intrinsic muscles of foot 2.Active and tonic contraction of muscles with long tendons extending into foot: a. flexor hallucis longus and digitorum longus (longitudinal arch) b. fibularis longus and tibialis posterior (transverse arch)

45. Questions of the day! 1.What are the primary muscles that control eversion of the foot? 1.fibularis longis and brevis 2.If a patient cannot stand on his heel, which nerve is not functioning? 1.Common fibular (more specifically, that means we cannot extend, meaning deep fibular nerve… because extension is dorsiflexion 3.Nerves can frequently be compressed against bony structures in the lower limb. What nerve rests against the head and neck of the fibula? 1.Common fibular 2.Foot drop is a result