Anterior lateral and_posterior_compartments_of_calf

1. Anterior and Lateral andAnterior and Lateral and
Posterior Compartments ofPosterior Compartments of
CalfCalf
By- Dr. Armaan Singh

2. Cutaneous Supply of Calf
 Saphenous first branch is
infrapatellar branch it
 Supplies medial side of
the calf and
 Medial side of foot to ball
of the hallux
 Lateral cutaneous of calf
 Superficial peroneal
 Sural, lateral border of
foot
 Deep peroneal first cleft

3. Fascial Compartments in Calf
 Subcutaneous surface of
tibia
 Fascia anterior and posterior
intermuscular septa
 Anterior compartment
 Lateral compartment
 Posterior compartment
Divided
 Superficial
 Deep
 Deep posterior

4. Extensor Retinacula
 Superior retinaculum
 Thickening deep fascia
 Tibialis anterior pierces
 Other tendons pass posterior
 Inferior extensor retinaculum
 Inferior stem attached to calcaneus
 Upper limb to medial malleolus
 Lower limb plantar aponeurosis

5. Anterior Compartment of Calf
 Tibialis anterior
 Extensor hallucis longus
 Extensor digitorum longus
 Peroneus tertius
 All muscles supplied by the
deep peroneal nerve
 Dorsi flexors
 Anterior tibial and
perforating peroneal
arteries

6. Tibialis Anterior
 Upper two thirds
 Lateral surface of tibia
and adjoining area of
interosseous membrane
 And deep fascia
Inserted
 Medial aspect of medial
cuneiform
 And adjoing base of first
metatarsal

7. Tibialis Anterior
 Synovial sheath
 Passes under superior
and both limbs of inferior
extensor retinaculum
 Dorsi flexor and invertor
 Eccentric pays out,
prevents foot slapping
down
 Supports medial arch
 Deep peroneal nerve

8. Extensor Hallucis Longus
 Middle two fourths
 Anterior surface of fibula
 Interosseous membrane
 Base of distal phalanx of
hallux
 Dorsiflexor big toe and
ankle
 Deep peroneal nerve
 Test for L5

9. Extensor Hallucis Longus
 Upper three quarter
anterior surface of fibula
 Except the area for the
extensor hallucis longus
 Anterior intermuscular
septum
 Passes under retinacula
 Divides into four tendons
 Joined by slips from
brevis
 Lumbricals and
interossei muscles

10. Extensor Digitorum Longus
 Main extensor tendon inserted
into base of middle phalanx, of
the lateral four toes
 Collateral slips formed by
lumbricals and interossei
inserted into distal phalanx
 Dorsiflexor ankle
 Extends proximal phalanx
lateral four toes

11. Peroneus Tertius
 Lower quarter of anterior
surface of the fibula
 Inserted into base and
dorsum of shaft of fifth
metatarsal
 Dorsiflexor and evertor

12. Extensor Digitorum Brevis
 Fleshy origin from calcaneus
 Stem of inferior retinaculum
 Divides into four tendons
 First is extensor hallucis
brevis
 Other three join extensor
expansion of second, third
and fourth toes
 Deep peroneal nerve

13. Deep Peroneal Nerve
 Branch of the common peroneal at
neck of fibula
 Pierces anterior intermuscular septum
 Runs between extensor digitorum
longus and tibialis anterior
 Then tibialis anterior and extensor
hallucis longus

14. Deep Peroneal Nerve
 In anterior compartment
 Supplies
 Tibialis anterior
 Extensor hallucis longus
 Extensor digitorum longus
 Peroneus tertius
 Extensor digitorum brevis
 Skin first cleft

15. Anterior Tibial Artery
 Branch of popliteal
 Enters above
interosseous membrane
 Only supply of tibialis
anterior
 Becomes dorsalis pedis
at ankle joint

16. Dorsalis Pedis
 Gives off
 First dorsal metatarsal
artery
 Arcuate artery gives off
 2-4th
dorsal metatarsal
arteries
 At base of first
intermetatarsal space
 Enters sole of foot
 Joins lateral plantar artery
to complete plantar arch

17. Blood Supply of Dorsum
 Arcuate artery
 Dorsal metatarsal arteries
 Posterior and anterior perforating
branches from metatarsals
 Communicate plantar arch
 And its digital branches
 Perforating veins drain into dorsal
venous arch

18. Perforating Peroneal Artery
 Perforating peroneal artery
 Pierces interosseus membrane
 Enters anterior compartment
 May replace dorsalis pedis

19. Venous and Lymph Drainage of Foot
 Dorsal venous arch
 Medial, long
saphenous vein
 Anterior to medial
malleolus
 Short saphenous
vein
 Posterior to lateral
malleolus
 Lymphatics follow
superficial veins

20. Lateral Compartment of Calf
 Between anterior and posterior
intermuscular septa
 Peroneus longus
 Peroneus brevis
 Superficial peroneal nerve

21. Peroneus Longus
 Upper two thirds lateral surface
of fibula
 Adjoining area of interosseous
membrane
 Passes under superior and
inferior peroneal retinaculum

22. Peroneus Longus
 May have a sesamoid bone
 Runs in groove in the cuboid
 Inserted into
 Lateral aspect of medial
cuneiform
 And adjoing base of first
metatarsal

23. Peroneus Longus
 Plantar flexor and evertor
 Supports lateral arch
 Superficial peroneal nerve
 Cuboid syndrome
 Torn peroneal retinacula
 Snapping tendons

24. Peroneus Brevis
 Lower two thirds
 Lateral surface of fibula in front
of longus
 Passes under superior and
inferior peroneal retinacula
 Above peroneal trochlea on
calcaneus
 Inserted into base of fifth
metatarsal

25. Peroneus Longus and Brevis
 Plantar flexors and
evertors
 Longus support the
lateral longitudinal
arch
 Superficial peroneal
nerve

26. Superficial Peroneal Nerve
 Branch common peroneal
 Neck of fibula
 Supplies peroneus longus and brevis
 Pierces deep fascia
 Dorsum of foot supplies
 Medial side of big toe
 All clefts except first and lateral side
of little toe

27. Sensory Supply to
Posterior Aspect of Calf
 Posterior cutaneous nerve of thigh
 Lateral cutaneous of calf
 Sural nerve
 Saphenous nerve
 Medial calcaneal

28. Dermatomes

29. Posterior Surface of the Calf
 Short saphenous vein
 Posterior to lateral
malleolus pierces the roof
of popliteal fossa to enter
popliteal vein
 Deep fascia thickened
medial between medial
malleolus and calcaneum
 Bursa anterior to achilles

30. Medial and Lateral Heads
of Gastrocnemii
 Medial head arises from
popliteal surface of femur
above medial condyle
 Lateral is shorter, arises
from posterior part of the
lateral surface of the lateral
femoral condyle and capsule
of knee
 Fabella is a sesamoid bone
in lateral head

31. Medial and Lateral Heads
of Gastrocnemii
 Bursa deep to the two heads
 Medial belly is longer
 Unite to form a tendinous raphe
 Unites with soleus to form
achilles
 Fast twitch fibres
 Flex knee and plantar flex ankle

32. Plantaris
 Short fleshy origin from
 The popliteal surface of
femur above the lateral
femoral condyle
 Long tendon passes
between gastronemii and
soleus
 Inserted medial border of
achilles
 Tibial nerve

33. Plantaris
 May be absent
 May rupture
 Used in tendon
grafts
 Sudden dorsiflexion
of ankle
 Ballet dancing
 Gymnastics
 Basketball
 Sprinting

34. Soleus
 Broad flat pennate muscle
 Arises from head and upper
fourth of posterior surface
of the fibula
 Fibrous arch
 Soleal line of tibia
 Middle third of medial
border of tibia

35. Soleus
 Two aponeurotic lamellae
 Bulk of vascular multipennate muscle
fibres
 Deepest of achilles
 Slow twitch fibres
 Perforating veins from great
saphenous enter soleus
 Acts as a peripheral pump

36. Achilles Tendon
 Extent of the fusion between the
gastronemii and soleus varies
 Inserted into middle of posterior
surface of the calcaneus
 Tendon twists
 Gastronemii form the lateral and
posterior part of the tendon

37. Achilles Tendon
 Rotation occurs above
where the soleus tends
to join
 Rotation is greater if
minimal fusion
 Stress marked 2-5 cm
above insertion
 Plantar flexor of ankle
 Eccentric lower heels

38. Achilles Tendon
 The achilles tendon is
subjected to the highest loads
in the body
 Tensile loads up to eight and
ten times body weight are
experienced during running
jumping hopping and skipping
 The achilles tendon is
subjected to stress when
running up and downhill
 A tight achilles tendon also
limits dorsiflexion of the ankle

39. Achilles Tendon
 Superficial bursa may be
found posterior to
achilles between it and
the deep fascia
 The retrocalcaneal bursa
is just proximal to the
insertion
 Between the tuberosity
on the posterior surface
of the calcaneus and the
achilles tendon

40. Achilles Test

41. Medial and Lateral Heads
of Gastrocnemii
 Sprinting
 Jumping
 Hopping
 Skipping
 Stretched with
knee extended and
ankle dorsiflexed
 Tibial nerve

42. The Retrocalcaneal Bursa
 The area of fibro cartilage on the
tendon forms the posterior wall
 The anterior wall of the
retrocalcaneal bursa is the 0.5 to
1 mm thick cartilaginous layer on the
posterior aspect of the calcaneus
 The proximal wall of the synovial lined sac
consists of folds, or villus synovial projections
 Allows alterations in its form, produced by
varying degrees of pressure on the fat above it
during flexion and extension of the ankle

43. Flexor Digitorum Longus
 Posterior surface of tibia
 Below soleal line
 Medial to vertical line
 Variable origin by an
aponeurosis from fibula

44. Very extensive fibular
origins of FDL
FHL
Fibular origin of FDL
FDL
Hislop M, 2003
Flexor Digitorum Longus

45. Flexor Digitorum Longus
 Crosses tibialis posterior in calf
 Flexor hallucis longus in foot
 Foot receives insertion flexor
accessorius and two slips from
flexor hallucis longus
 Divides four tendons
 Give origin to four lumbricals

46. Flexor Digitorum Longus
 In the foot the tendon passes
through birfurcation of brevis
 Inserted into distal phalanges
 Plantar flexes ankle
 Plantar flexes lateral four toes
 Supports medial arch
 Tibial nerve

47. Flexor Hallucis Longus
 Bulkiest and most powerful,
multipennate
 Arises from posterior
surface of fibula
 Posterior to medial crest
 Beef to heel
 Most posterior under
retinaculum

48. Flexor Hallucis Longus
 Grooves posterior process of talus
 Sustentaculum tali
 Crossed in foot by flexor digitorum
longus to which it gives two slips
 Inserted base of distal phalanx

49. Flexor Hallucis Longus
 Tibial nerve
 Plantar flexes ankle
 Flexes big toe
 Supports medial longitudinal
arch
 Take off muscle

50. Tibialis Posterior
 Deepest
 Posterior surface of tibia
 Below soleal line
 Lateral to vertical line
 Interosseous membrane
 Arises from posterior
surface of fibula
 Anterior to medial crest

51. Tibialis Posterior
 Crossed by flexor digitorum longus
in calf
 Posterior to medial malleolus
grooves bone, type II collagen,
tends to have poor blood supply
 Most anterior under the flexor
retinaculum
 Inserted into tuberosity of navicular
 All bones of the tarsus except talus
 Base of middle three metatarsals

52. Tibialis Posterior
 Plantar flexor ankle
 Invertor of foot
 Supports medial arch
 Avascular area behind
medial malleolus
 Tibial nerve

53. Posterior Tibial Artery
 Branch popliteal
artery
 Lower border of
popliteus
 Under fibrous
arch of soleus
 Between flexor
digitorum longus
and flexor hallucis
longus
 Vena commitans

54. Posterior Tibial Artery
 In the calf gives off
 Nutrient artery to tibia
 Peroneal artery
 Nutrient artery to fibula
 Perforating peroneal
 Passes under flexor retinaculum
 Gives off medial calcaneal artery which
pierces flexor retinaculum
 Then ends under flexor retinaculum
 Dividing into medial and lateral plantar
arteries

55. Tibial Nerve
 Leaves the popliteal fossa
 Runs in middle of calf
 Deep to soleus
 Accompaning artery
 Branches to soleus
 Flexor digitorum longus and flexor
hallucis longus
 Tibialis posterior

56. Flexor Retinaculum
 Medial malleolus to calcaneus
 Anterior to posterior
 Tibialis posterior
 Flexor digitorum longus
 Posterior tibial artery
 Medial calcaneal artery pierces retinaculum
 Divides into medial and lateral plantar arteries
 Tibial nerve
 Gives off medial calcaneal nerve which accompanies
artery
 Divides into medial lateral plantar nerves
 Flexor hallucis longus

57. Causes of Compartment Syndromes
 May be acute or
chronic
 Sudden increase in
exercise
 Haematoma
 Callus
 Fracture

58. Compartment Syndromes
 Mainly anterior compartment
 Tibialis anterior main muscle
affected as only supplied by anterior
tibial, other muscles also supplied by
perforating peroneal
 Increasing pressure causes loss of
sensation of first cleft due to
pressure on deep peroneal nerve
 Fasciotomy
Or
 Posterior or lateral compartments

59. Posterior Compartment
 Posterior compartment
 Posterior border of tibia
 Posterior intermuscular
septum
Divided
 Superficial
 Deep
 Deep posterior

60. Posterior Compartment
 Superficial compartment
 Posterior intermuscular
septum
 Posterior border of tibia

61. Superficial Posterior Compartment
 Medial and lateral gastrocnemii
 Plantaris
 Soleus
 Forming the achilles tendon
 Tibial nerve

62. Deep Posterior Compartment
 Popliteus
 Flexor digitorum longus
 Flexor hallucis longus
 Deepest is tibialis
posterior

63. Chronic Exertional Compartment
Syndrome (CECS)
• Significant morbidity/limitation activity to
athletes
• Activity related, reversible, myofascial
intracompartmental pressure increase
• Results in decreased tissue perfusion and
neuromuscular function abnormalities
• Predilection for the lower leg

64. Chronic Exertional Compartment
Syndrome (CECS)
 The fibular origin of FDL can
partially (or sometimes almost
completely) compartmentalize
TP and acts to resist increases
in intracompartmental volume
and therefore cause increased
pressure
 The presence and extent of a
fibular origin of FDL may act as
an anatomical predisposition to
the development of CECS