back of leg of human

1. BACK
OF
LEG
MRS NIDHI SHARMA

2.  The posterior compartment of the leg contains
seven muscles, organised into two layers –
superficial and deep. The two layers are
separated by a band of fascia.
 The posterior leg is the largest of the three
compartments. Collectively, the muscles in
this area plantarflex and invert the foot. They
are innervated by the tibial nerve, a terminal
branch of the sciatic nerve.
INTRODUCTION

3. SUPERFICIAL MUSCLES
 The superficial muscles form the characteristic ‘calf’
shape of the posterior leg. They all insert into the
calcaneus of the foot (the heel bone), via
the calcaneal tendon. The calcaneal reflex tests
spinal roots S1-S2.
 To minimise friction during movement, there are
two bursae (fluid filled sacs) associated with the
calcaneal tendon:
 Subcutaneous calcaneal bursa – lies between the
skin and the calcaneal tendon.
 Deep bursa of the calcaneal tendon – lies between
the tendon and the calcaneus.

4.  Tibia
 Medial
mallelous
 Fibula
 Lateral
mallelous
 Talus
 Calcaneous

5. Ligaments
Lateral aspect
Anterior tibiofibular
Posterior tibiofibular
Anterior talofibular
Posterior talofibular
Calcaneofibular

6.  Medial aspect
 deltoid
 Tendons
 Achilles
 Peroneus longus
 Peroneus brevis
 Anterior tibialis
 Tibialis posterior
 Flexor digitorium
 Flexor hallicus longus

7.  Muscles
Gastrocnemius
Soleus
Tibialis anterior
Tibialis posterior
Flexor digitorium longus
Flexor hallicus longus
Peroneus longus
Peroneus brevis

9.  These muscles connect the tibia or fibula to
the femur or pelvic girdle.
 The muscles either flex or extend the knee.
 The muscles include the hamstring group and
the quadriceps femoris group.

10. superficial/
calf: gastrocnemius, soleus, plantaris

11. Gastrocnemius -is a very
powerful superficial
muscle .It runs from its two
heads just above the knee
to the heel, and is involved
in standing, walking,
running and jumping.
Along with the soleus
muscle it forms the calf
muscle.
Its function is plantar
flexing the foot at the ankle
joint and flexing the leg at
the knee

12. . The Lateral Head originates
from the Lateral Condyle of
the femur, while the Medial
Head originates from the
Medial Condyle of the femur.
Its other end forms a common
tendon with the soleus
muscle; this tendon is known
as the calcaneal tendon or
Achilles Tendon and inserts
onto the posterior surface of
the calcaneus, or mountain
bone.
NERVE SUPPLY :
The nerve supply of the gastrocnemius
muscle is the tibial nerve (S1, S2).
ACTION :
The gastrocnemius and soleus muscle act
together as plantar flexors of foot at the
ankle joint. The gastrocnemius also act as
the flexor of the knee.

13. PLANTARIS
The plantaris is a small muscle with a long tendon,
which can be mistaken for a nerve as it descends
down the leg. It is absent in 10% of people.
•Attachments: Originates from the lateral
supracondylar line of the femur. The muscle
descends medially, condensing into a tendon that
runs down the leg, between the gastrocnemius and
soleus. The tendon blends with the calcaneal
tendon.
•Actions: It plantarflexes at the ankle joint, and
because it crosses the knee, it is a flexor there. It is
not a vital muscle for these movements.
•Innervation: Tibial nerve.

14.  the soleus is a
powerful muscle in
the back part of the
lower leg (the calf). It
runs from just below
the knee to the heel,
and is involved in
standing and walking.
It is closely connected
to the gastrocnemius
muscle.

15.  ORIGIN :
 The soleus muscle has a
dome-shaped origin from:
 back of head and upper
one-fourth of the posterior
surface of the shaft of the
fibula
 soleal line and middle one-
third of the medial border
of the shaft of the tibia
 the tendinous soleal arch
that stretches between the
tibia and the fibula.

16.  INSERTION :
 The tendon of this muscle fuses with
the tendon of gastrocnemius to form
tendoachilles, which is inserted into
the middle one-third of the posterior
surface of the calcaneum.
 NERVE SUPPLY :
 The nerve supply of the soleus muscle
is the tibial nerve (S1, S2).
 ACTION :
 The soleus and gastrocnemius act as
plantar flexors of the foot, at the
ankle joint. The soleus is more
powerful than gatrocnemius but is
slow acting than the gastrocnemius.
Soleus is chiefly a postural muscle, to
steady the leg on the foot.

18. DEEP MUSCLES
 There are four muscles in the deep
compartment of the posterior leg. One muscle,
the popliteus, acts only on the knee joint. The
remaining three muscles (tibialis posterior,
flexor hallucis longus and flexor digitorum
longus) act on the ankle and foot.

19. The popliteus is located superiorly
in the leg. It lies behind the knee
joint, forming the base of
the popliteal fossa.
There is a bursa (fluid filled sac)
that lies between the popliteal
tendon and the posterior surface
of the knee joint. It is called the
popliteus bursa
POPLITEUS

20.  Attachments: Originates
from the lateral condyle of
the femur and the
posterior horn of the
lateral meniscus. From
there, it runs
inferomedially towards
the tibia and inserts above
the origin of the
soleus muscle.
 Actions: Laterally rotates
the femur on the tibia –
‘unlocking’ the knee joint
so that flexion can occur.
 Innervation: Tibial nerve.

21.  Tibialis Posterior
 The tibialis posterior is the
deepest out of the four muscles. It
lies between the flexor digitorum
longus and the flexor hallucis
longus.
 Attachments: Originates from the
interosseous membrane between
the tibia and fibula, and posterior
surfaces of the two bones. The
tendon enters the foot posterior to
the medial malleolus, and attaches
to the plantar surfaces of the
medial tarsal bones.
 Actions: Inverts and plantarflexes
the foot, maintains the medial arch
of the foot.
 Innervation: Tibial nerve.

22.  Flexor Digitorum Longus
 The FDL is (surprisingly)
a smaller muscle than the
flexor hallucis longus. It
is located medially in the
posterior leg.
 Attachments: Originates
from the medial surface
of the tibia, attaches to the
plantar surfaces of the
lateral four digits.
 Actions: Flexes the lateral
four toes.
 Innervation: Tibial nerve.

23.  Flexor Hallucis Longus
 The flexor hallucis longus
muscle is found on the
lateral side of leg. This is
slightly counter-intuitive, as
it is opposite the great toe,
which it acts on.
 Attachments: Originates
from the posterior surface of
the fibula, attaches to the
plantar surface of the
phalanx of the great toe.
 Actions: Flexes the great toe.
 Innervation: Tibial nerve.

25.  The calf muscles do the work for movements like running, walking and
cycling as it provides the initial propulsion for these movements. Most
of the people train calf for aesthetic purposes. But calf muscle plays
more important role than just to flaunt. Calf muscle is often called as the
pseudo or periphery heart because of its very important function which
is to return the blood from leg and foot to the heart. Blood flow from
the lower body to heart has to work against the gravity, so the
contraction of calf muscle builds up an external pressure that propels
the blood through the veins to the heart.
 The gastrocnemius muscle is used more during dynamic, higher force
activities and soleus muscle is more active during postural and static
contractions. As the gastrocnemius crosses knee and ankle, the position
of the knee during the plantar flexion resistance exercise affects activity
of the muscle. At 90 degree of knee flexion, the gastrocnemius
experiences passive insufficiency and hence less active. During calf raise
exercise keeping knee 90 degree flexed to focus on soleus and zero
degree flexed to focus on gastrocnemius.

26.  The calves also act as a deceleration tool for the body. While doing a
sprint when one need to stop or change directions quickly the calves
absorb up to 10 to 12 times the body-weight. Trained calves are
therefore required to bear this load and ensure the deceleration takes
place safely to avoid injury caused by the eccentric phase of any
exercise.
 The calves also stabilise the knees which is important for jumping
exercises where unstable knees can result in poor form and injury. Here,
a strong set of calves protect the joints.
 Well trained calves result in increased vertical jumping power. With the
gastrocnemius mainly composed of fast-twitch muscle fibres, the calves
can execute quick and explosive movements, such as those required
during high jumps, squat jumps and sprints. Although genetics
determine the amount of fast-twitch muscle fibres every person has,
strengthening the calves helps everyone perform these power
movements

27. soleus

30.  The tibial nerve is a branch of
the sciatic nerve. The tibial
nerve passes through the
popliteal fossa to pass below
the arch of soleus.
 In the popliteal fossa the nerve
gives off branches to
gastrocnemius, popliteus,
soleus and plantaris muscles,
an articular branch to the knee
joint, and a cutaneous branch
that will become the sural
nerve. The sural nerve is joined
by fibres from the common
fibular nerve and runs down
the calf to supply the lateral
side of the foot.

31.  Lateral plantar nerve
 The lateral plantar nerve supplies
quadratus plantae, flexor digiti
minimi, adductor hallucis, the
interossei, three lumbricals. and
abductor digiti minimi. Cutaneous
innervation is to the lateral sole and
lateral one and one half toes

33.  The posterior tibial
artery –it is the large
terminal branch of
popliteal artery begins at
the lower border of the
Popliteus, opposite the
interval between the
tibia and fibula; it
extends obliquely
downward, and, as it
descends, it approaches
the tibial side of the leg,
lying behind the tibia,

.

34.  and in the lower part of its course is
situated midway between the
medial malleolus and the medial
process of the calcaneal tuberosity.
Here it divides beneath the origin
of the Adductor hallucis into the
medial and lateral plantar arteries.

35.  In anatomy, the
fibular artery (also
known as the
peroneal artery)
supplies blood to
the lateral
compartment of the
leg and is typically
a branch of
posterior tibial
artery

37.  when a strain occurs, muscle fibers are torn to some degree.
 a pulled calf muscle happens when your internal muscles are
overstretched from exercise. this is a common injury, especially
among athletes and walkers. symptoms of a pulled calf muscle can
depend on the severity of the injury. a mild strain can leave you with
pain and feelings of pulling within the lower half of your leg. you can
still walk with a mild strain, but it may be uncomfortable.
 other signs of a pulled calf muscle include:
1.mild swelling
2.redness
3.bruising
4.inability to stand up on the ball of your foot.
 a severe pull in your calf muscles can leave you with feelings of sharp
pain. it can also affect your mobility, making you unable to walk.
pulled calf muscles may be chronic from long-term injury or acute
from brief over pulling .

38.  Achilles Tendon Stretching
 A tight heel cord may limit dorsiflexion and may
predispose athlete to ankle injury
 Should routinely stretch before and after practice
 Stretching should be performed with knee extended
and flexed 15-30 degrees
 Strength Training
 Static and dynamic joint stability is important in
preventing injury
 A balance in strength throughout the range,
incorporating all muscles of the lower leg is critical

40.  Ankle Fractures/Dislocations
 Cause of Injury
 Number of mechanisms – often similar to those seen in
ankle sprains
 Signs of Injury
 Swelling and pain may be extreme with possible
deformity
 Care
 Splint and refer to physician for X-ray and examination
 RICE to control hemorrhaging and swelling
 Once swelling is reduced, a walking cast or brace may be
applied, w/ immobilization lasting 6-8 weeks
 Rehabilitation is similar to that of ankle sprains once
range of motion is normal

44. Post reduction

47.  Acute Leg Fractures
 Cause of Injury
 Result of direct blow or indirect trauma
 Fibular fractures seen with tibial fractures or as the result
of direct trauma
 Signs of Injury
 Pain, swelling, soft tissue insult
 Leg will appear hard and swollen (Volkman’s
contracture)
 Deformity – may be open or closed
 Care
 X-ray, reduction, casting up to 6 weeks depending on the
extent of injury

49.  Stress Fracture of Tibia or Fibula
 Cause of Injury
 Common overuse condition, particularly in those with
structural and biomechanical insufficiencies
 Result of repetitive loading during training and
conditioning
 Signs of Injury
 Pain with activity
 Pain more intense after exercise than before
 Point tenderness; difficult to discern bone and soft tissue
pain
 Bone scan results (stress fracture vs. periostitis)

50.  Care
 Eliminate offending
activity
 Discontinue stress
inducing activity 14 days
 Use crutch for walking
 Weight bearing may return
when pain subsides
 After pain free for 2 weeks
athlete can gradually
return to activity
 Biomechanics must be
addressed

51.  Medial Tibial Stress Syndrome (Shin Splints)
 Cause of Injury
 Pain in anterior portion of shin
 Stress fractures, muscle strains, chronic anterior
compartment syndrome, periosteum irritation
 Caused by repetitive microtrauma
 Weak muscles, improper footwear, training errors, varus
foot, tight heel cord, hypermobile or pronated feet and even
forefoot supination can contribute to MTSS
 May also involve stress fractures or exertional compartment
syndrome

53.  Achilles Tendonitis
 Cause of Injury
 Inflammatory condition involving tendon, sheath or
paratenon
 Tendon is overloaded due to extensive stress
 Presents with gradual onset and worsens with continued
use
 Decreased flexibility exacerbates condition
 Signs of Injury
 Generalized pain and stiffness, localized proximal to
calcaneal insertion, warmth and painful with palpation,
as well as thickened
 May progress to morning stiffness

55.  Achilles Tendon Rupture
 Cause
 Occurs w/ sudden stop and go; forceful plantar flexion
w/ knee moving into full extension
 Commonly seen in athletes > 30 years old
 Generally has history of chronic inflammation
 Signs of Injury
 Sudden snap (kick in the leg) w/ immediate pain which
rapidly subsides
 Point tenderness, swelling, discoloration; decreased
ROM
 Obvious indentation and positive Thompson test

56. Normal
Achilles Defect

58.  Achilles Tendon Rupture
 Etiology
 Occurs w/ sudden stop and go; forceful plantar flexion
w/ knee moving into full extension
 Commonly seen in athletes > 30 years old
 Generally has history of chronic inflammation
 Signs and Symptoms
 Sudden snap (kick in the leg) w/ immediate pain which
rapidly subsides
 Point tenderness, swelling, discoloration; decreased
ROM
 Obvious indentation and positive Thompson test
 Occurs 2-6 cm proximal the calcaneal insertion

60. Clinical Relevance: Ruptured Calcaneal Tendon
Rupture of the calcaneal tendon refers to a partial or
complete tear of the tendon. It is more likely to occur in
people with a history of calcaneal tendinitis (chronic
inflammation of the tendon).
The injury is usually sustained during
forceful plantarflexion of the foot. The patient will be unable
to plantarflex the foot against resistance, and the affected
foot will be permanently dorsiflexed. The soleus and
gastrocnemius can contract to form a lump in the calf region.
Treatment of a ruptured calcaneal tendon is usually non-
surgical, except in those with active lifestyles.

61.  Achilles Tendon Rupture (continued)
 Management
 Usual management involves surgical repair for
serious injuries (return of 75-80% of function)
 Non-operative treatment consists of RICE,
NSAID’s, analgesics, and a non-weight bearing
cast for 6 weeks, followed up by a walking cast for
2 weeks (75-90% return to normal function)
 Rehabilitation lasts about 6 months and consists of
ROM, PRE and wearing a 2cm heel lift in both
shoes

62.  Medial Tibial Stress Syndrome (Shin Splints)
 Etiology
 Pain in anterior portion of shin
 Catch all for stress fractures, muscle strains, chronic anterior
compartment syndrome
 Accounts for 10-15% of all running injuries, 60% of leg pain
in athletes
 Caused by repetitive microtrauma
 Weak muscles, improper footwear, training errors, varus
foot, tight heel cord, hypermobile or pronated feet and even
forefoot supination can contribute to MTSS
 May also involve, stress fractures or exertional compartment
syndrome