Anterior Lateral and Posterior Compartments of Calf BMJ

7/28/2019 Anterior Lateral and Posterior Compartments of Calf BMJ

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MOB TCD

Anterior and Lateral and PosteriorCompartments of Calf

Professor Emeritus Moira OBrien

FRCPI, FFSEM, FFSEM (UK), FTCD

Trinity College

Dublin


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Cutaneous Supply of Calf

Saphenous first branch isinfrapatellar branch it

Supplies medial side of the

calf and

Medial side of foot to ball ofthe hallux

Lateral cutaneous of calf

Superficial peroneal

Sural, lateral border of foot Deep peroneal first cleft

MOB TCD


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Fascial Compartments in Calf

Subcutaneous surface of tibia

Fascia anterior and posteriorintermuscular septa

Anterior compartment

Lateral compartment

Posterior compartment

Divided

Superficial

Deep Deep posterior

MOB TCD


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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

MOB TCD


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Anterior Compartment of Calf

Tibialis anterior

Extensor hallucis longus

Extensor digitorum longus

Peroneus tertius

All muscles supplied by thedeep peroneal nerve

Dorsi flexors

Anterior tibial and

perforating peroneal arteries

MOB TCD


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Tibialis Anterior

Upper two thirds Lateral surface of tibia and

adjoining area of

interosseous membrane

And deep fasciaInserted

Medial aspect of medial

cuneiform

And adjoing base of firstmetatarsal

MOB TCD


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Synovial sheath

Passes under superior andboth limbs of inferiorextensor retinaculum

Dorsi flexor and invertor

Eccentric pays out, preventsfoot slapping down

Supports medial arch

Deep peroneal nerve

Tibialis AnteriorMOB TCD


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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

MOB TCD


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Upper three quarter anteriorsurface of fibula

Except the area for theextensor hallucis longus

Anterior intermuscular

septum Passes under retinacula

Divides into four tendons

Joined by slips from brevis

Lumbricals and interosseimuscles

Extensor Hallucis LongusMOB TCD


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Extensor Digitorum Longus

Main extensor tendon inserted intobase 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

MOB TCD


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Peroneus Tertius

Lower quarter of anterior surface ofthe fibula

Inserted into base and dorsum of

shaft of fifth metatarsal

Dorsiflexor and evertor

MOB TCD


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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

MOB TCD


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Deep Peroneal Nerve

Branch of the common peroneal at neck offibula

Pierces anterior intermuscular septum

Runs between extensor digitorum longus and

tibialis anterior Then tibialis anterior and extensor hallucis

longus

MOB TCD


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In anterior compartment Supplies

Tibialis anterior

Extensor hallucis longus

Extensor digitorum longus Peroneus tertius

Extensor digitorum brevis

Skin first cleft

Deep Peroneal NerveMOB TCD


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Anterior Tibial Artery

Branch of popliteal Enters above interosseous

membrane

Only supply of tibialis

anterior Becomes dorsalis pedis at

ankle joint

MOB TCD


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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 tocomplete plantar arch

MOB TCD


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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

MOB TCD


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Perforating Peroneal Artery

Perforating peroneal artery Pierces interosseus membrane

Enters anterior compartment

May replace dorsalis pedis

MOB TCD


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Venous and Lymph Drainage of Foot

Dorsal venous arch Medial, long saphenous

vein

Anterior to medialmalleolus

Short saphenous vein

Posterior to lateralmalleolus

Lymphatics followsuperficial veins

MOB TCD


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Lateral Compartment of Calf

Between anterior and posteriorintermuscular septa

Peroneus longus

Peroneus brevis

Superficial peroneal nerve

MOB TCD


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Peroneus Longus

Upper two thirds lateral surface of fibula Adjoining area of interosseous

membrane

Passes under superior and inferior

peroneal retinaculum

MOB TCD


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May have a sesamoid bone Runs in groove in the cuboid

Inserted into

Lateral aspect of medial cuneiform

And adjoing base of first metatarsal

Peroneus LongusMOB TCD


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Plantar flexor and evertor Supports lateral arch


Cuboid syndrome

Torn peroneal retinacula Snapping tendons

Peroneus LongusMOB TCD

MOB TCD


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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

MOB TCD

MOB TCD


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Peroneus Longus and Brevis

Plantar flexors andevertors

Longus support the lateral

longitudinal arch


MOB TCD

MOB TCD


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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

MOB TCD

S S l tMOB TCD


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Sensory Supply to

Posterior Aspect of Calf

Posterior cutaneous nerve of thigh Lateral cutaneous of calf

Sural nerve

Saphenous nerve

Medial calcaneal

MOB TCD

MOB TCD


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DermatomesMOB TCD

MOB TCD


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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 medialbetween medial malleolus

and calcaneum

Bursa anterior to achilles

MOB TCD

Medial and Lateral HeadsMOB TCD


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Medial and Lateral Heads

of Gastrocnemii

Medial head arises from poplitealsurface of femur above medial

condyle

Lateral is shorter, arises from

posterior part of the lateral surfaceof the lateral femoral condyle and

capsule of knee

Fabella is a sesamoid bone in

lateral head

MOB TCD



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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


of Gastrocnemii

MOB TCD

MOB TCD


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Plantaris

Short fleshy origin from The popliteal surface of femur

above the lateral femoral

condyle

Long tendon passes betweengastronemii and soleus

Inserted medial border of

achilles

Tibial nerve

MOB TCD

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May be absent

May rupture

Used in tendon grafts

Sudden dorsiflexionof ankle

Ballet dancing

Gymnastics

Basketball

Sprinting

Plantaris

MOB TCD


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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

MOB TCD


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Two aponeurotic lamellae Bulk of vascular multipennate muscle fibres

Deepest of achilles

Slow twitch fibres

Perforating veins from great saphenous entersoleus

Acts as a peripheral pump

Soleus

MOB TCD


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Achilles Tendon

Extent of the fusion between thegastronemii and soleus varies

Inserted into middle of posterior surface of

the calcaneus

Tendon twists Gastronemii form the lateral and posterior

part of the tendon

MOB TCD


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Rotation occurs abovewhere 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

Achilles Tendon

MOB TCD


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The achilles tendon is subjectedto 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

Achilles Tendon

MOB TCD


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Superficial bursa may befound 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

Achilles Tendon

MOB TCD


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Achilles Test



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of Gastrocnemii

Sprinting Jumping

Hopping

Skipping

Stretched with knee

extended and ankle

dorsiflexed

Tibial nerve

MOB TCD


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The Retrocalcaneal Bursa

The area of fibro cartilage on thetendon forms the posterior wall

The anterior wall of the

retrocalcaneal bursa is the 0.5 to

1 mm thick cartilaginous layer on theposterior 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 varyingdegrees of pressure on the fat above it during flexion

and extension of the ankle

MOB TCD


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Flexor Digitorum Longus

Posterior surface of tibia Below soleal line

Medial to vertical line

Variable origin by an

aponeurosis from fibula

MOB TCD


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Very extensive fibularorigins of FDL

FHL

Fibular origin of FDL

FDL

Hislop M, 2003


MOB TCD


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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


MOB TCD


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In the foot the tendon passes throughbirfurcation of brevis

Inserted into distal phalanges

Plantar flexes ankle

Plantar flexes lateral four toes Supports medial arch

Tibial nerve


MOB TCD


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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

MOB TCD


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Grooves posterior process of talus Sustentaculum tali

Crossed in foot by flexor digitorum longus towhich it gives two slips

Inserted base of distal phalanx


MOB TCD


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Tibial nerve Plantar flexes ankle

Flexes big toe

Supports medial longitudinal arch

Take off muscle


Tibi li P t iMOB TCD


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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



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Crossed by flexor digitorum longus in calf Posterior to medial malleolus

grooves bone, type II collagen, tends tohave poor blood supply

Most anterior under the flexorretinaculum

Inserted into tuberosity of navicular

All bones of the tarsus except talus

Base of middle three metatarsals

Tibialis Posterior



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Plantar flexor ankle

Invertor of foot

Supports medial arch

Avascular area behind

medial malleolus Tibial nerve

Tibialis Posterior

P i Tibi l AMOB TCD


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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

P t i Tibi l A tMOB TCD


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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

Posterior Tibial Artery

Tibi l NMOB TCD


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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

Fl R ti lMOB TCD


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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

C f C t t S dMOB TCD


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Causes of Compartment Syndromes

May be acute or chronic

Sudden increase in exercise

Haematoma

Callus

Fracture

C t t S dMOB TCD


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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

P t i C t tMOB TCD


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Posterior Compartment

Posterior compartment

Posterior border of tibia

Posterior intermuscular septum

Divided

Superficial Deep

Deep posterior

P t i C t tMOB TCD


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Superficial compartment

Posterior intermuscular septum

Posterior border of tibia

Posterior Compartment

S perficial Posterior CompartmentMOB TCD


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Superficial Posterior Compartment

Medial and lateral gastrocnemii Plantaris

Soleus

Forming the achilles tendon

Tibial nerve

Deep Posterior CompartmentMOB TCD


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Deep Posterior Compartment

Popliteus

Flexor digitorum longus

Flexor hallucis longus

Deepest is tibialis posterior

Chronic Exertional CompartmentMOB TCD


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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

Chronic Exertional CompartmentMOB TCD


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The fibular origin of FDL canpartially (or sometimes almost

completely) compartmentalize

TP and acts to resist increases

in intracompartmental volumeand therefore cause increased

pressure

The presence and extent of a

fibular origin of FDL may act asan anatomical predisposition to

the development of CECS

Chronic Exertional Compartment

Syndrome (CECS)

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Anterior Lateral and Posterior Compartments of Calf BMJ

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