Kin191 A. Ch.5. Ankle. Lower Leg. Anatomy. Fall 2007

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Kin191 A. Ch.5. Ankle. Lower Leg. Anatomy. Fall 2007

  1. 1. ANKLE/LOWER LEG ANATOMY KIN 191A Advanced Assessment of Lower Extremity Injuries
  2. 2. INTRODUCTION <ul><li>ANATOMY </li></ul><ul><ul><li>BONY STRUCTURES </li></ul></ul><ul><ul><li>ARTICULATIONS </li></ul></ul><ul><ul><li>LIGAMENTS </li></ul></ul><ul><ul><li>MUSCLES </li></ul></ul><ul><ul><li>BURSAE </li></ul></ul><ul><ul><li>NEUROANATOMY </li></ul></ul><ul><ul><li>VASCULAR ANATOMY </li></ul></ul>
  3. 3. <ul><li>Lower leg </li></ul><ul><ul><li>Tibia </li></ul></ul><ul><ul><li>Fibula </li></ul></ul><ul><li>Ankle mortise </li></ul><ul><ul><li>Distal tibia and fibular </li></ul></ul><ul><ul><li>& </li></ul></ul><ul><ul><li>Talus </li></ul></ul>BONY STRUCTURES
  4. 4. <ul><li>Primary weight-bearing bone of the lower leg </li></ul><ul><li>Roof/medial border of ankle mortise </li></ul><ul><li>Medial malleolus </li></ul><ul><ul><li>Attachment site of the deltoid ligaments </li></ul></ul>Tibia
  5. 6. <ul><li>Attachment site of muscles and ligaments </li></ul><ul><li>Serve as a pulley to increase the efficiency of the muscles at that run posteriorly to it </li></ul><ul><li>Lateral malleolus </li></ul>Fibula
  6. 7. <ul><li>Lateral malleolus (cont.) </li></ul><ul><ul><li>Extends farther distally than the medial malleolus </li></ul></ul><ul><ul><li>Limiting eversion than the medial malleolus is at limiting inversion </li></ul></ul>
  7. 8. <ul><li>The amount of force transmitted through the fibula range from 0 to 12 % of BW </li></ul><ul><li>Serve as a pulley to increase the efficiency of the muscles at that run posteriorly to it </li></ul><ul><li>The peroneal nerve </li></ul><ul><ul><li>The nerve courses subcutaneously just posterior to the fibular head </li></ul></ul><ul><ul><li>Innervates the lower leg’s anterior and lateral compartment </li></ul></ul>Fibula (cont.)
  8. 9. <ul><li>The trochlea </li></ul><ul><ul><li>Quadrilateral in shape </li></ul></ul><ul><ul><li>Covered with articular cartilage </li></ul></ul><ul><ul><li>Anterior surface > Posterior surface </li></ul></ul><ul><ul><ul><li>PF instability and DF stability </li></ul></ul></ul><ul><ul><li>Medial border  medial malleolus </li></ul></ul><ul><ul><li>Lateral border  lateral malleolus </li></ul></ul><ul><ul><li>Superior surface  tibia </li></ul></ul><ul><ul><li>Inferior surface  calcaneus </li></ul></ul>Talus
  9. 10. Head Body Neck Talus
  10. 11. Related Bony Structures <ul><li>Calcaneus </li></ul><ul><ul><li>Attachment site of tendons and ligaments </li></ul></ul><ul><li>Navicular </li></ul><ul><ul><li>Attachment site of muscle and ligaments </li></ul></ul><ul><li>Base of the 5 th metatarsal/cuboid </li></ul><ul><ul><li>Attachment site of muscles and ligaments </li></ul></ul>
  11. 12. ARTICULATIONS <ul><li>Talocrural Joint </li></ul><ul><li>Interosseous Membrane </li></ul><ul><ul><li>Distal Tibiofibular Syndesmosis </li></ul></ul><ul><li>Subtalar Joint </li></ul>
  12. 13. Talocrural Joint <ul><li>= Ankle joint = Tibiotalar joint </li></ul><ul><li>Hinge joint </li></ul><ul><ul><li>Movements are plantar flexion and dorsiflexion only </li></ul></ul><ul><li>Closed packed in DF </li></ul><ul><li>Loose packed in PF </li></ul>
  13. 14. Interosseous Membrane <ul><li>A strong fibrous tissue </li></ul><ul><li>Serves as part of the origin for many muscles </li></ul><ul><li>Distally, the membrane blends into </li></ul><ul><ul><li>Anterior/posterior tibiofibular ligaments </li></ul></ul><ul><ul><li>Support the distal tibiofibular syndesmosis joint </li></ul></ul>
  14. 15. Subtalar Joint <ul><li>Articulation between calcaneus and talus </li></ul><ul><li>No muscle attach to the talus, the stability of the subtalar joint is derived from ligamentous and bony restraints </li></ul>
  15. 16. LIGAMENTS <ul><li>Lateral ligaments </li></ul><ul><ul><li>Anterior talofibular (ATF) ligament </li></ul></ul><ul><ul><li>Cacaneofibular (CF) ligament </li></ul></ul><ul><ul><li>Posterior talofibular (PTF) ligament </li></ul></ul><ul><li>Medial ligaments </li></ul><ul><ul><li>Deltoid ligaments (4 components) </li></ul></ul><ul><li>Syndesmosis ligaments </li></ul><ul><ul><li>Distal anterior tibiofibular ligament </li></ul></ul><ul><ul><li>Distal posterior tibiofibular ligament </li></ul></ul><ul><ul><li>(Interosseous membrane) </li></ul></ul>
  16. 17. Lateral Ligaments <ul><li>ATF </li></ul><ul><ul><li>Restricts anterior translation of talus on tibia and talar inversion during PF </li></ul></ul><ul><li>CF </li></ul><ul><ul><li>Restricts talar inversion during “neutral” position </li></ul></ul><ul><li>PTF </li></ul><ul><ul><li>Restricts posterior translation of talus on tibia – strongest of 3 </li></ul></ul>
  17. 18. ATF CF PTF
  18. 19. Deltoid Ligaments <ul><li>Anterior tibiotalar (ATT) ligament </li></ul><ul><li>Tibionavicular (TN) ligament </li></ul><ul><li>Tibiocalcaneal (TC) ligament </li></ul><ul><li>Posterior tibiotalar (PTT) ligament </li></ul><ul><li>Restricts talar eversion </li></ul>
  19. 20. TN T C PTT ATT
  20. 21. MUSCLES <ul><li>ANTERIOR C. </li></ul><ul><ul><li>Tibialis anterior </li></ul></ul><ul><ul><li>Extensor digitorum longus </li></ul></ul><ul><ul><li>Extensor hallucis longus </li></ul></ul><ul><ul><li>Peroneus tertius </li></ul></ul><ul><li>LATERAL C. </li></ul><ul><ul><li>Peroneus longus </li></ul></ul><ul><ul><li>Peroneus brevis </li></ul></ul><ul><li>SUPERFICIAL POSTERIOR C. </li></ul><ul><ul><li>Gastrocnemius </li></ul></ul><ul><ul><li>Soleus </li></ul></ul><ul><ul><li>Plantaris </li></ul></ul><ul><li>DEEP POSTERIOR C. </li></ul><ul><ul><li>Tibialis posterior </li></ul></ul><ul><ul><li>Flexor digitorum longus </li></ul></ul><ul><ul><li>Flexor hallucis longus </li></ul></ul>
  21. 22. Compartment of the Leg
  22. 23. Anterior Compartment <ul><li>Tibialis anterior </li></ul><ul><li>Extensor digitorum longus </li></ul><ul><li>Extensor hallucis longus </li></ul><ul><li>Peroneus tertius </li></ul>
  23. 24. Tibialis Anterior <ul><li>O: Lateral tibial condyle and shaft </li></ul><ul><li>I: Medial/plantar 1 st cuneiform and metatarsal </li></ul><ul><li>N: Deep peroneal </li></ul><ul><li>A: DF and Inversion </li></ul>
  24. 25. Extensor Digitorum Longus <ul><li>O: Lateral tibial condyle, proximal ¾ of anterior fibula </li></ul><ul><li>I: Via 4 tendons into distal phalanges of 2 nd -5 th toes </li></ul><ul><li>N: Deep peroneal </li></ul><ul><li>A: Extension of 2 nd -5 th MTP joints, assists with eversion and DF </li></ul>
  25. 26. Extensor Hallucis Longus <ul><li>O: Middle 2/3 of anterior fibula </li></ul><ul><li>I: Base of distal 1 st phalanx </li></ul><ul><li>N: Deep peroneal </li></ul><ul><li>A: Extension of 1 st MTP and IP joints </li></ul>
  26. 27. Peroneus Tertius <ul><li>O: Distal 1/3 of anterior fibula </li></ul><ul><li>I: Dorsal base of 5 th metatarsal </li></ul><ul><li>N: Deep peroneal </li></ul><ul><li>A: Eversion of foot, assists in PF </li></ul>
  27. 28. Video
  28. 29. I am thinking…
  29. 30. Lateral Compartment <ul><li>Peroneus longus </li></ul><ul><li>Peroneus brevis </li></ul>
  30. 31. Peroneus Longus <ul><li>O: Lateral tibial condyle, fibular head, upper 2/3 of lateral fibula </li></ul><ul><li>I: Lateral base of 1 st metatarsal, lateral and dorsal aspect of 1 st cuneiform </li></ul><ul><li>N: Superficial peroneal </li></ul><ul><li>A: Eversion of the foot, assists with PF </li></ul>
  31. 32. Peroneus Brevis <ul><li>O: Distal 2/3 of lateral fibula </li></ul><ul><li>I: Styloid process at base of 5 th metatarsal </li></ul><ul><li>N: Superficial peroneal </li></ul><ul><li>A: Eversion of the foot, assists with PF </li></ul>
  32. 33. Superficial Posterior Compartment <ul><li>Gastrocnemius </li></ul><ul><li>Soleus </li></ul><ul><li>Plantaris </li></ul>
  33. 34. Gastrocnemius <ul><li>O: Medial head – posterior medial femoral condyle, Lateral head – posterior lateral femoral condyle </li></ul><ul><li>I: Calcaneus via Achilles tendon </li></ul><ul><li>N: Tibial </li></ul><ul><li>A: PF, assists knee flexion </li></ul>
  34. 35. Soleus <ul><li>O: Posterior fibular head, upper 1/3 of posterior fibular, soleal line on posterior tibial shaft, middle 1/3 of medial tibial border </li></ul><ul><li>I: Calcaneus via Achilles tendon </li></ul><ul><li>N: Tibial </li></ul><ul><li>A: PF </li></ul>
  35. 36. Plantaris <ul><li>O: Distal supracondylar line of lateral femoral condyle, femoral popliteal surface </li></ul><ul><li>I: Calcaneus via Achilles tendon </li></ul><ul><li>N: Tibial </li></ul><ul><li>A: PF, assists knee flexion </li></ul>
  36. 37. Deep Posterior Compartment <ul><li>“ T om, D ick, A N H arry” </li></ul><ul><li>T ibialis posterior </li></ul><ul><li>Flexor d igitorum longus </li></ul><ul><li>Flexor h allucis longus </li></ul><ul><li>A N </li></ul><ul><ul><li>Tibial A rtery </li></ul></ul><ul><ul><li>Tibial N erve </li></ul></ul>
  37. 38. Tibialis Posterior <ul><li>O: Posterior/lateral tibia, upper 2/3 of medial fibula </li></ul><ul><li>I: Navicular tuberosity, via slips into sustentaculum tali, cuneiforms, cuboid and bases of 2 nd -4 th metatarsals </li></ul><ul><li>N: Tibial </li></ul><ul><li>A: Inversion of the foot, assists with PF </li></ul>
  38. 39. Flexor Hallucis Longus <ul><li>O: Posterior/distal 2/3 of fibula </li></ul><ul><li>I: Plantar surface of 1 st proximal phalanx </li></ul><ul><li>N: Tibial </li></ul><ul><li>A: Flexion of 1 st IP joint, assists with flexion of 1 st MTP joint, foot inversion and PF </li></ul>
  39. 40. Flexor Digitorum Longus <ul><li>O: Posterior medial 2/3 of distal tibia </li></ul><ul><li>I: Plantar surface of base of 2 nd -5 th distal phalanges </li></ul><ul><li>N: Tibial </li></ul><ul><li>A: Flexion of 2 nd -5 th PIP/DIP/MTP joints, assists with foot inversion and PF </li></ul>
  40. 41. Plantar Flexion <ul><li>Gastrocnemius </li></ul><ul><li>Soleus </li></ul><ul><li>Plantaris </li></ul><ul><li>Peroneus Longus & Brevis </li></ul><ul><li>Tibialis Posterior </li></ul><ul><li>Flexor Hallucis Longus </li></ul><ul><li>Flexor Digitorum Longus </li></ul>
  41. 42. Dorsiflexion <ul><li>Tibialis Anterior </li></ul><ul><li>Extensor Digitorum Longus </li></ul><ul><li>Extensor Hallucis Longus </li></ul><ul><li>Peroneus Tertius </li></ul>
  42. 43. <ul><li>Tibialis Anterior </li></ul><ul><li>Tibilais posterior </li></ul><ul><li>Flexor Digitorum Longus </li></ul><ul><li>Flexor Hallucis Longus </li></ul><ul><li>Extensor Hallucis Longus </li></ul>Inversion & Adduction
  43. 44. <ul><li>Peroneus Longus </li></ul><ul><li>Peroneus Brevis </li></ul><ul><li>Peroneus Tertius </li></ul><ul><li>Extensor Digitorum Longus </li></ul>Eversion & Abduction
  44. 45. BURSAE <ul><li>Retrocalcaneal (subtendinous calcaneal) bursa </li></ul><ul><ul><li>Between the Achilles tendon and the calcaneus </li></ul></ul><ul><li>Subcutaneous calcaneal bursa </li></ul><ul><ul><li>Posterio r aspect of the calcaneus and skin </li></ul></ul>
  45. 46. NEUROANATOMY <ul><li>Anterior compartment </li></ul><ul><ul><li>Deep branch of peroneal nerve </li></ul></ul><ul><li>Lateral compartment </li></ul><ul><ul><li>Superficial branch of peroneal nerve </li></ul></ul><ul><li>Deep posterior compartment </li></ul><ul><ul><li>Tibial nerve </li></ul></ul><ul><li>Superficial posterior compartment </li></ul><ul><ul><li>Tibial nerve </li></ul></ul>
  46. 47. Deep Branch of Peroneal Nerve <ul><li>Branches from common peroneal nerve near fibular head </li></ul><ul><li>“ Dives” into anterior compartment </li></ul>
  47. 48. Superficial Branch of Peroneal Nerve <ul><li>Branches from common peroneal nerve near fibular head </li></ul><ul><li>Stays superficial and lateral in lateral compartment </li></ul>
  48. 49. Tibial Nerve <ul><li>Runs in fascial sheath between deep and superficial posterior compartments </li></ul><ul><li>Provides innervation to both, but not “in” either </li></ul>
  49. 50. VASCULAR ANATOMY <ul><li>Anterior compartment </li></ul><ul><ul><li>Anterior tibial artery </li></ul></ul><ul><li>Lateral compartment </li></ul><ul><ul><li>Peroneal artery </li></ul></ul><ul><li>Deep posterior compartment </li></ul><ul><ul><li>Posterior tibial artery </li></ul></ul><ul><li>Superficial posterior compartment </li></ul><ul><ul><li>Posterior tibial artery </li></ul></ul>
  50. 51. Anterior Tibial Artery <ul><li>Traverses similar path to deep peroneal nerve </li></ul><ul><li>Terminating as dorsal pedal artery </li></ul>
  51. 52. Peroneal Artery <ul><li>Branches off of posterior tibial artery </li></ul>
  52. 53. Posterior Tibial Artery <ul><li>Runs in fascial sheath between deep and superficial posterior compartments </li></ul><ul><li>Provides vascular supply to both, but not “in” either </li></ul>

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