Gross Anatomy Final Exam

Gross 1 Final Exam Info

Hip Joint

Forms connection between the lower extremity and the pelvis

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Wide range of motion

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Stable

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Ligaments of Hip Joints

Capsular

Iliofemoral

Pubofemoral

Ischiofemoral

Transverse and Acetabular Ligament

Capitis Femoris Ligament

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Capsular Ligament of the Hip Joint

Strong, fairly loose capsular ligament permits free movement at the joint but cannot maintain the integrity of the joint without reinforcing ligaments.

Iliofemoral

Very strong ligament which reinforced the capsular ligament anteriorly and inferiorly

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Considered to be the strongest ligament in the body

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Attaches to the anterior inferior iliac spine (superiorly) and to the intertrochanteric line (inferiorly)

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Ligament become light upon full extension of the femur and thus provides a mechanism for one to stand upright with the hip joint being supported by this ligament; the ligament literally “screws” the head of the femur into the acetabulum.

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If someone bends backward or forward, too much strain is put on the ligament and muscles come into play to support the joint in the extended position.

When bending backward, the anterior hip and abdominal muscles are brought into action and prevent the body from falling backward.

When bending forward, the gluteal, hamstring, and spinal muscles are brought into play and prevent the body from falling forward.

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The ligament is extrinsic and acts like a rope

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The nerve supply to the joint is the **femoral**, **obturator**, and **sciatic** nerves.

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Pubofemoral

Reinforces the capsule anteriorly and inferiorly

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Attaches from the superior ramus of the pubis (superiorly) to the intertrochanteric line (inferiorly)

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It prevents abduction at the joint

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It is extrinsic and acts like a rope.

Ischiofemoral

Reinforces the capsule posteriorly

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Runs from the body of the ischium (superiorly) to the neck and greater trochanter of the femur (inferiorly)

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Prevents hyperextension and abduction at the joint

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it is extrinsic and acts like a rope

Transverse Acetabular Ligament

An intrinsic ligament which is formed by the acetabular labrum as it bridges the acetabular notch

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The ligament converts the notch into a tunnel through which blood vessels and nerves enter the joint

Capitis Femoris Ligament (Ligament of the Head of the Femur)

A weak, intrinsic ligament which functions mainly to conduct a blood vessel to the head of the femur (ligament is hollow)

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It is of little importance in strengthening the joint

Movement and the Hip Joint

Has a wide range of movements, but less so than the shoulder joint.

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Some of the movements have been sacrificed in order to provide strength and stability.

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When the leg is flexed at the knee joint, flexion at the hip joint is limited by the anterior surface of the thigh coming into contact with the anterior abdominal wall.

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When the leg is extended at the knee joint, flexion at the hip is limited by the tendon of the hamstring muscles

Developmental Dysplasia (Congenital Dislocation)

Term used to describe an ongoing process which is variable in its manifestations and not always detectable at birth.

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Hip joints that are found to be normal at birth (and even in the first few months of life) can subsequently be abnormal later.

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This condition is found in about 1.5 per 1000 live births and is bilateral in about 50 per cent of cases.

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More common in females (8x more common in females)

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Majority of children with this condition have ligamentous laxity, which causes the hip to become unstable and slip out of position

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Majority of infants with the condition were in a breech position during the birth process

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If the condition is not corrected:

Pain, abnormal gait, unequal leg length, osteoarthritis (condition in adults caused by having this as a child), twisting of the femur (femoral anteversion aka knock knee), contracture of the hip muscles

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Treated conservatively -

Tripple diaper, harness if needed

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\*In birth process, maternal hormones that cause pubic symphasis to expand, cross placenta to fetus, female fetuses more prone to accepting it, more ligaments elasticity in female fetuses.

Acquire or Traumatic Dislocations

Rare - due to articulation being so strong and stable

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Dislocations may occur during trauma (ex. auto accident)

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Posterior dislocations are the most common, which allows the femoral head to pass through a tear in the capsular ligament and over the acetabulum, ending up on the ilium - may compromise the **sciatic nerve**

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Anterior dislocations can also occur, which allows the head of the femur to end up in the obturator foramen, these types of dislocations may compromise the **obturator nerve**

Knee Joint

Largest and most superficial joint in the body

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Formed from the articulation of the Femur, Tibia, and Patella

*Fibula is NOT involved*

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During development 3 separate joints become continuous with each other and form a single, large knee joint cavity


1. Between the patella and femur
2. Between the lateral condyles of the femur and tibia
3. Between the medial condyles of the femur and tibis

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The articulating surfaces of the tibial condyles are often referred to as the **lateral and medial tibial plateaus**

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The joint between the femur and tibia is classified as a ginglymus (hinge) with some degree of rotation when the joint it flexed.

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The joints between the patella and the femur is of the plane gliding variety.

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Nerve supply to the joint is supplied by the **femoral, obturator, common fibular, and tibial nerves.**

Ligament of the Knee joint

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Capsular Ligament

Forms a loose fibrous investment of the joint, completely surrounding it.

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There are a number of openings found in the anterior aspect of the capsular ligament, which allows the synovial membrane to pass through and form several bursae, which are clinically significant.


1. Subcutaneous Prepatellar - lies between the patella + skin
2. Subcutaneous Infrapeteller - lies between tibial tubercle + skin
3. Deep Infrapetellar - found between ligamentum patella and tibial tubercle
4. Suprapatellar - lies between the femur and the common tendon of insertion of the quadriceps

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Extrinsic Ligaments of the Knee Joint

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Ligamentum Patella

This is the anterior ligament of the joint and represents the original distal common tendon of insertion of the quadriceps.

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Runs from the apex of the parella to the tibial tubercle

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It plays an important role in maintaining the alignment of the patella relative to the articular surface of the femur.

Extrinsic Ligaments of the Knee Joints

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Collateral Ligaments

These ligaments are taut when the joint is fully extended and this contribute to stability when standing.

Extrinsic Ligaments of the Knee Joint

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Lateral (Fibular) Collateral

Located on the lateral side of the joint

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Is superficial and separate from the articular capsule of the joint.

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Attaches from the lateral epicondyle of the femur (proximally) to the head of the fibula (distally)

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It functions as a wall and prevents lateral movement (abduction) at the joint

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Can also prevent abduction by acting as a rope

Extrinsic Ligaments of the Knee Joint

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Medial (Tibial) Collateral

Is located on the medial side of the joint

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It blends with the articular capsule and is directly attached to the medial meniscus

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It attaches to the medial epicondyle of the femur (proximally) and the medial side of the tibia, just below the medial condyle (distally)

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It functions as a wall and prevents medial movement (adduction) at the joint.

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Can also prevent abduction by acting like a rope

Extrinsic Ligaments of the Knee Joint

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Oblique and Arcuate Popliteal

Found on the posterior aspect of the joint.

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They both function as walls to prevent hyperextension of the joint

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They also stabilize the posterior aspect of the joint

Intrinsic Ligaments of the Knee Joint

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Cruciate Ligaments

These are two very strong ligaments which cross each other like an “x” in the center of the joint

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They are names anterior and posterior according to their tibial attachments

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They are the main bonds between femur and tibia

Intrinsic Ligaments of the Knee Joint

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Anterior Cruciate Ligaments

The weaker of the two and runs from the lateral condyle of the femur (proximally) to the anterior intercondylar area of the tibia (distally)

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It prevents anterior displacement of the tibia under the femur and thus functions like a rope

Intrinsic Ligaments of the Knee Joint

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Posterior Cruciate Ligament

The stronger of the two and runs from the medial condyle of the femur (proximally) to the posterior intercondylar area of the tibia (distally)

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The ligament prevents posterior displacement of the tibia under the femur and functions like a rope

Intrinsic Ligaments of the Knee Joint

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Menisci or Semilunar Cartilages

The menisci have a well developed blood supply from the time of birth until about 18 months of age.

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Once the infant begins to walk, the menisci loose about 75% of their vascular supply

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As one ages the vascular supply continues to diminish, thus the peripheral portions of the menisci are well supplied by vascular tissue, but the central portions are avascular and will not heal properly after an injury.

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Nutrition is supplied to the menisci of an adult through blood vessels in the peripheral portion and by diffusion from the synovial fluid for the central portion of the menisci

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The main function of the menisci are to:


1. Deepen the articulating surface
2. Act as a shock absorber
3. Act as a mechanoreceptor (type of proprioceptor) to increase positional sense of the knee joint.

Intrinsic Ligaments of the Knee Joint

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Medial Meniscus

Is “C” shaped and firmly adheres to the tibial collateral ligament

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Its less mobile on the surface of the tibia

Intrinsic Ligaments of the Knee Joint

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Lateral Meniscus

Nearly circular in shape and smaller than the medial meniscus

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More freely movable on the surface of the tibia

Intrinsic Ligaments of the Knee Joint

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Coronary Ligaments

Associated with the menisci

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Are a portion of the joint capsular ligament which attaches to the edge of the menisci and helps to hold them in place.

Intrinsic Ligaments of the Knee Joint

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Transverse Ligaments of the Knee

Joins the anterior edges of the medial and lateral menisci and allows them to work together

Movements of the Knee Joint

Mainly flexion and extension, but some rotation occurs when the joint is in a flexed position

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When the knee is fully extended, the knee “locks” because of lateral rotation of the tibia

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This “locked” position most of the ligaments of the knee are very tight or taut and this makes the lower extremity a solid column and more adaptable for weight bearing.

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To “unlock” the knee, the *Popliteus Muscle* must contract to rotate the tibia medially and thus cause flexion at the knee joint

Bursitis

Several different types of bursitis are associated with the bursae of the knee joint

Prepatellar (Housemaid’s) Bursitis

Caused by friction between the skin and the patella

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It may also occur from a direction below or falling on a flexed knee

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If the condition becomes chronic, the bursae will become distended with fluid and form a swelling anterior to the knee.

Subcutaneous Infrapatellar Bursitis

Caused by excessive friction between the skin and the tibial tubercle

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This was once known as “clergyman’s knee” but is now common in roofers and floor tilers, who will wear knee pads to avoid the condition.

Suprapatellar Bursitis

Caused by bacteria from an abrasion or penetrating wound

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The infection may spread to the knee joint cavity, causing local redness and pain as well as enlarged lymph nodes.

Clinical Aspects of the Knee Joint

Knee joint injuries cause more problems for individuals who are active in sports than injuries to any other joint

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The joint being mobile and weight bearing makes it very susceptible to injury.

Ligament Sprains

Very common, especially when the foot is fixed on the ground

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If a force is applied against the knee, when the foot cannot move, the ligaments are likely to be injured

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*Unhappy Triad* is a term that refers to a blow to the lateral aspect of the joint while it is in weight brearing that can cause damage to the **medial collateral,** **anterior** **cruciate**, and **medial meniscus**.

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\*also known as O’Donoghue’s Triad

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Damage to the Medial Collateral

Probably most commonly injured ligament of the joint

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Can occur not only by a lateral blow to the joint, but also by rotational forces during trauma.

Damage to the Medial Meniscus

More vulnerable to injury than the lateral meniscus

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Patients with this type of injury will complain of their knee “clicking”, locking up, pain when going up stairs or getting up from a chair (especially a low one)

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Small tears can sometimes repair themselves with 4 to 6 weeks of physical therapy

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Larger tears need to be repaired surgically

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If large parts of the menisci are removed, forces are now transmitted to the condyles of the tibia and can lead to damage of the articular cartilage and to osteoarthritis

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*You really want to save menisci if at all possible*

Damage to the Anterior Cruciate

Can be damaged in sports that require twisting or jumping

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At the time of injury the patient will often complain of hearing a pop and there is the sensation that their knee has “given out”

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Within a few hours of the injury, the knee becomes swollen, as blood fills the joint cavity

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This type of injury will produce a condition in which the tibia can be pulled excessively forward under the femur (positive drawer test)

Damage to the Posterior Cruciate

Is injured much less commonly than the anterior cruciate

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With this type of injury, the tibia can be pulled or moved excessively backward under the femur (positive posterior drawer test).

Knee Replacements

Are used to replace the major diseased portions of the knee joint (both femoral and tibial portions)

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Knee replacement may be total or partial

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The two main criteria for this type of surgery is that the pain cannot be controlled or the individual is functionally disabled (ex. cannot walk up or down stairs)

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With a complete replacement, the artificial knee will consist of a metal and plastic component that are cemented in both ends of the joint.

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This combination of metal and plastic mimics the smoothness of cartilage on cartilage and produces fairly good results in “low demand” individuals (relatively sedentary life styles)

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In “high demand” individuals who are very active, the bone cement may break down

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The “life span” of a knee prosthetic is about 15-20 years

Tibia (aka Shinbone)

Large medial bone of leg

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Functions in weight bearing

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It articulates with the condyles of the femur and head of the fibula (proximally) and with the talus and distal end of the fibula (distally)

Ossification of the Tibia

From 4 ossification centers

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A primary ossification center for the shaft and 3 secondary ossification centers for the proximal end, distal end, and the tibial tuberosity/tubercle

* Shaft - Ossification begins during the 7th-8th week of development
* Proximal End - Just before birth
* Distal end - Ages 1-2
* Tibial Tuberosity - Around puberty
* Distal End Fuses - 14.5(females)-16.5(males)
* Proximal End Fuses - 15 (females) - 17.5(males)

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Osgood-Schlatter’s Disease

Disruption of the epiphyseal plate of the tibial tuberosity that occurs around puberty in active adolescents

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It is an example of what is known as an apophyseal injury or a traction apophysitis

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An apophyses is a secondary ossification center that develops with growth

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The condition is commonly seen in adolescents and teenagers that participate in running and jumping sports

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Bilateral in half of those affected

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Patients complain of localized pain in the area of the tibial tubercle and usually occurs with activity

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Avulsion fractures of the tubercle are common

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The condition is usually self-limiting, but can take one or two years to run its course.

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Treatment: If pain, ibuprofen

Fibula

Lies Parallel to the tibia and is a very long and slender bone

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It is not weight-bearing but functions to give attachment to muscles

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It is part of the articulation of the ankle joint, as well as the proximal and distal tibiofibular joints.

Ossification of the Fibula

Is from three ossification centers

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A primary for the shaft and secondary ossification centers for the distal and proximal ends of the bone.

* Shaft - begins around 8th week of development
* Distal end - during first year of life
* Proximal end - during the 3rd or 4th year
* Proximal end fuses - 14.5 (females) 16.5 (males)
* Distal end fuses - 15.5 (female) 17 (male)

Fractures of the Tibia and Fibula

These type of fractures are common

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Fortunately, if only one bone is fractures, the other can act as splint and there is minimal displacement

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Fractures of the medial and/or lateral malleoli can occur in contact sports, especially those played on hard surfaces (ex. basketball)

Fractures of the Tibia

Because the shaft is unprotected along its medial aspect, the tibia is a commonly fractures bone of the lower extremity.

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Compound fractures are common from direct trauma (bumper fracture)

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The Tibia has a relatively poor blood supply and even undisplaced fractures may take up to several months to heal.

Fractures of the Fibula

Usually fracture just proximal to the lateral malleolus or just distal to the head of the bone

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Fractures to the area below the head (neck) may damage the common fibular nerve which can lead to atrophy and paralysis of the anterior and lateral leg musculature

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Fractures can be very painful due to the disruption of muscle attachments and locomotion may be compromised due to the bone’s role in stability of the ankle joint.

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You can get fractures of the malleolus -- proper ankle support shoes are important!

Bones of the Foot

The bones of the foot are similar in their arrangement to the bones of the hand.

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Include:

* 7 tarsal bones
* 5 metatarsals
* 14 phalanges

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The bones are shaped so that there is relatively little movement between individual bones, thus there is maximum stability between them.

Tarsal Bones

Comparable to the carpal bones of the hand, but they are more modified and specialized

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Function in locomotion and support.

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Calcaneus (heel)

Largest and strongest of the tarsals

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Important muscles and ligaments attach to the bone

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Articulates with the talus and the Cuboid

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Calcaneal Tuberosity is the large prominence and allows for the insertion of the tendon calcaneus (Achilles Tendon)

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Fibular Trochlear, found on lateral side of the bone, separates the tendons of the fibularis longus and brevis from each other

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Sustentaculum Tali prominent “ledge” on the medial aspect of the bone that has articular facets associated with it

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Calcaneal Sulcus is a deep groove which separates the articular facets of the bone

Talus (ankle)

The only tarsal bones that articulates with the tibia and fibula to form the ankle joint

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Also articulates inferiorly with the calcaneus to form the subtalar joint

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Consist of a head, neck, body

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Articulates anteriorly with the navicular

Os Trigonum

During ossification of the talus, under certain circumstances a secondary ossification center may develop for the lateral tubercle of the bone

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When this occurs, the lateral tubercle will not fuse with the bone when ossification is completed

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This may be due to applied stresses (forceful plantar flexion) to the bone at puberty or during trauma

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Seen commonly in teenage soccer players or ballet dancers

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In most cases it is asymptomatic, but may be mistaken for a fracture on an x-ray

Navicular

Found on the medial side of the foot

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Has projection on its medial side (navicular tuberosity) which is very palpable

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The bone articulates posteriorly with the talus, anteriorly with the three cuneiform bones, laterally with the cuboid

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Cuboid

So named because of its cuboidal shape

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It is situated on the lateral border of the foot

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It articulated posteriorly with the calcaneus, anteriorly with the 5th metatarsal and medially with the lateral cuneiform and navicular

Cuneiforms (wedge shaped)

3 Small bones

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They are named the first (medial - largest), second (intermediate - smallest), third (lateral)

Ossification of the Tarsal Bones

Unlike carpal bones, the tarsal bones begin to ossify before birth

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Each bone normally has a single center of ossification, except the calcaneus which has a secondary ossification center for the calcaneal tuberosity

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Calcaneus - 6th fetal month (secondary ossification for the tuberosity \~8-10 yrs)

Talus - 7th fetal month

Cuboid - at birth

1st Cuneiform - during 1st year

2nd Cuneiform - 3rd year

3rd Cuneiform and Navicular - 4th year

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*Bones are completely ossified by puberty*

What are the two most common fractures of the foot?

Fractures of the Talus

Fractures of the Calcaneus

Fractures of the Talus

Fractures usually occur through the neck during severe dorsal flexion at the ankle (ex. when a person is pressing extremely hard on the brake pedal during a collision)

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In some fractures of the talus, the blood supply may become compromised and lead to avascular necrosis of the head of the bone.

Fractures of the Calcaneus

Fracture of the bone occurs from a hard fall on the tuberosity (heel)

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The bone may fracture into several pieces (comminuted)

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These fractures are usually quite disabling and may disrupt the subtalar joint.

Metatarsals

5 long bones of the foot

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They are numbered medial to lateral with the great or bog toe (hallux) being digit one.

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The 1st metatarsal is the largest and strongest and plays an important role in supporting the body weight

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The 2nd tarsal is the longest

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The 5th metatarsal has a prominent tuberosity on its base, which is for the attachment of the fubularis brevis and tertius muscles.

Stress Fractures

These are fine, hairline fractures that appear without evidence of soft tissue damage

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Often difficult to diagnose, initially on xray and may bot become visible for several weeks after the fracture has occurred

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The fractures are commonly found on the:

* Shaft of Tibia
* 2nd, 3rd, 4th metatarsals
* Navicular bone

2 Types of Stress Fractures

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aka fatigue fractures

1. The bone is normal, but is overloaded as a result of a sudden increase in activity
2. The bone is abnormal as a result of osteoperosis, drugs, or some other metabolic disorder (pathalogical fracture)

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Most common symptom of stress fracture, regardless of type (1 or 2) is pain, which may appear suddenly or increase over several days

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Swelling may also accompany a stress fracture

Phalanges

Bones of the digits

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Each toe is comprised of 3 phalanges (proximal, middle, and distal) with the exception of the 1st (Hallus) toe which only has a proximal and distal phalange associated with it.

Fascia of the Leg

Crural fascia is the term used to designate the deep and superficial fascia of the leg

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In the region of the ankle joint, the crural fascia thickens to form a series of retinacula which function to keep tendons that cross the ankle joint in place.

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1. Superior and Inferior Extensor Retinacula - Bind the tendons of the anterior leg muscles and prevent the tendons from bowstringing when the foot is dorsal flexed
2. Fibular Retinacula - Which bind down the tendons from bowstringing when the foot is dorsal flexed
3. Flexor Retinaculum - Which binds down the tendons of the deep posterior leg muscles

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Interosseous Membrane

Thin, strong ligament which connects the interosseous borders of the Tibia and Fibula

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Large opening is found in the upper portion of the membrane to permit the anterior tibial artery to enter the anterior compartment of the leg

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The functions of the interosseous membrane include:


1. Serves as an attachment for muscles
2. Stabilizes the tibia and fibula

Movements of the Foot and Ankle Joint

Plantar Flexion - Carried out when the heel is raised off the ground, the dorsum of the foot is moved away from the anterior aspect of the leg

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Dorsal Flexion - Carried out when the toes are raised off the ground, the dorsum of the foot and the anterior aspect of the leg are brought closer together.

Movements of the Foot at the Subtalar Joint

1. Eversion (Pronation) - Carried out when the lateral aspect of the foot is elevated (plantar surfaces of the foot face laterally)
2. Inversion (Supination) - Carried out when the medial aspect of the foot is elevated (plantar surfaces of both feet face each other)

Arches of the Foot

Medial Longitudinal

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Lateral Longitudinal

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Transverse

Anterior Leg Compartment

The muscles in this group include:


1. Tibialis Anterior
2. Extensor Digitorum Longus
3. Fibularis Tertius
4. Extensor Hallucis Longus

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All muscles in the compartment are supplied by the deep fibular nerve.

Tibialis Anterior

This is the most medial muscle of the anterior leg

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It lies among the surface of the lateral aspect of the shaft of the Tibia

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O - Shaft of the Tibia, interosseous membrane, lateral condyle of Tibia

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I - Medial Cuneiform, 1st metatarsal

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A - 1. Dorsal Flexion of the foot


2. Inversion of the foot
3. Supports the medial longitudinal arch

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N - Deep Fibular Nerve

Extensor Digitorum Longus

Muscle lies lateral and partly deep to the Tibialis Anterior

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In the region of the ankle, it gives off 4 separate tendons which pass to the lateral 4 digits

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O - Lateral Condyle of the Tibia, shaft of the Fibula, interosseous membrane

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I - Middle and Distal Phalanges of Digit 2-5

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A - 1. Dorsal flexion of the foot


2. extends digits 2-5

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N - Deep Fibular Nerve

Fibularis Tertius

Muscle is a separate portion of the extensor digitoum longus, found on it’s lateral aspect

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Variable muscle, missing in a small percentage of the population

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O - Shaft of the Fibula

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I - 5th metatarsal

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A - 1. Dorsal flexion of the foot


2. Eversion of the foot

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N - Deep Fibular Nerve

Extensor Hallucis Longus

Muscle is found deep to and in between the tibialis anterior and the extensor digitorum longus

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O - Shaft of the Fibula, Interosseous Membrane

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I - Distal phalanx of digit one

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A - 1. Dorsal flexes foot

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N - Deep Fibular Nerve

Compartment Syndromes

These result from increased pressure within a myofascial compartment, resulting in ischemia and pain

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Muscles in the compartment will swell from overuse and the edema and muscle inflammation will reduce the blood flow to the muscles

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The muscles are painful and tender to pressure

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The condition may be either acute or chronic

Acute Compartment Syndrome

Most commonly occurs due to some trauma (ex. fractures, crush injuries, or severe burns)

Chronic Compartment Syndrome

Usually seen as exercise related soreness

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Often referred to as external compartment syndrome (ESC)

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Typically occurs in runners or walkers with no history of trauma

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Compartments of the leg most frequently affected are the anterior and deep posterior

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Patients with ECS usually complain of an aching, squeezing, or sharp pain in the anterior leg, which is almost always relieved with the cessation of activity.

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Neurological symptoms are rare, even in long standing chronic conditions

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Some precipitating factors for this disorder include:


1. Sudden increases in intensity and duration of exercise
2. More time spent on hard surfaces
3. Shoes

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The condition is diagnosed by measuring the compartmental pressure before and during exercise, a resting pressure of more than 12mm/hg and a one minute exercise pressure higher than 20mm/hg are usually diagnostic of this condition.

Shin Splints

An outdated catch all term for pain in the anterior aspect of the leg

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The most recent definition limits the term to pain along the tibia, usually involving the tibialis anterior muscle

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Recent literature is using the term medial tibial stress syndrome (MTSS) to refer to the condition

Common Fibular Nerve

This is the smallest of the two terminal branches of the sciatic nerve

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It contains fibers from L4, L5, S1, S2

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The nerve descends to the proximal part of the fibula where it winds around the neck (distal to the head)

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The nerves then divides into a superficial and deep fibular nerve.

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Branches of the nerve include:


1. Sural Communicating - Which joins the sural branch of the tibial nerve and helps to supply skin to the posterior aspect of the leg
2. Lateral Sural Cutaneous - Supplies skin on the proximal lateral posterior aspect of the leg
3. Articular - To the knee joint

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Because of it;s superficial position, it is one of the most commonly injured nerves of the lower extremity due to being in a very exposed position as it winds around the neck of the fibula

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The nerve may be injured by compression, traction, or lacerations and common ways to injure the nerve include:

Plaster casts, fractures at proximal end of fibula, prolonged kneeling and or squatting, prolonged kneeling with cross legs, stretch when knee joint is injured.

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When the nerve is injured, the following clinical problems may occur:


1. All anterior and lateral leg muscle may be involved
2. Loss of dorsal flexion of the foot causing foot drop
3. Loss of eversion of the foot
4. Loss of extension of the toes
5. Diminished foot inversion
6. Loss of sensation over the dorsum of the foot and lateral aspect of the leg.

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Deep Fibular Nerve

Found in the anterior compartment of the leg and is the medial terminal branch of the common fibular nerve.

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Contains fibers from L4, L5, S1

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Arises at the neck of the fibula and descend with the anterior tibial artery into the anterior compartment of the leg

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The nerve terminates at the front of the ankle into a medial and lateral branch found on the dorsum of the foot

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Branches of the nerve include:


1. Muscular - To muscles of the anterior compartment of the leg and the dorsum of the foot
2. Articular - To the inferior tibiofibular and ankle joints
3. Cutaneous - A small area of skin at the webspace between the 1st and 2nd digits.

Clinical Aspects of the Deep Fibular Nerve

*Ski Boot Syndrome* is the term that is used to indicate compression neuropathy of the nerve as it leaves the anterior compartment and become superficial at the anterior aspect of the ankle

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Due usually to tight fitting ski boots or other shoes

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Clinical features associated with compression of the nerve include:

Motor: Loss of dorsal flexion of foot and extension of toes diminished inversion of foot

Sensory: Loss of sensation to skin in the web space between digits 1 & 2

Anterior Tibial Artery

Supplies structures of the anterior compartment of the leg

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The vessel is the smaller terminal branch of the *popliteal artery*

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Begins at the lower portion of the *popliteal fossa* and passes through an opening in the proximal portion of the interosseous membrane

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The artery then descends along the anterior aspect of the interosseous membrane

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The vessel leaves the anterior compartment of the leg and as it becomes superficial and continues on the dorsum of the foot to become the *dorsal pedis artery*

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The artery cannot be directly palpated, so the best place to check for a pulse is to take a pulse of the *dorsal pedis artery*

Muscles of the Lateral Leg Compartment

Fibularis Longus

Fibularis Brevis

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Supplied by the Superficial Fibularis Nerve

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These two muscles were well developed in humans and can be notes in the way we walk slightly more everted

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This eversion is partly due to the medial migration of the insertion of the fibularis longus muscle across the plantar surface of the foot and the development of the *fibularis tertius muscle* - a feature unique to the human foot

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The feet of other primates are mostly inverted, so they walk more on the lateral border of their feet (due to the fact that they do not have well developed fibularis muscles)

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Fibularis Longus

Most superficial of the two muscles of the lateral leg compartment

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Long tendon of insertion of the muscle passes behind the lateral malleolus, curves around the lateral border of the foot (calcaneous bone) and passes obliquely across the plantar surface of the foot to its insertion

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O - Shaft and Head of Fibula

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I - Medial Cuneiform, 1st Metatarsal

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A - 1. Eversion of the foot


2. Plantar flexion of the foot
3. Support of the lateral longitudinal and transverse arches of the foot

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N - Superficial Fibular Nerve

Fibularis Brevis

Shorter and smaller of the two lateral leg muscles

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Its tendon of insertion descends with the tendon of the fibularis longus behind the lateral malleolus

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O - Shaft of the Fibula

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I - 5th metatarsal

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A - 1. Eversion of the foot


2. Plantar flexion of the foot
3. Supports lateral longitudinal arch of the foot

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N - Superficial Fibular Nerve

Superficial Fibular Nerve

The lateral terminal branch of the common fibular nerve

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Contains fibers from L4, L5, S1

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The nerve descends along the lateral aspect of the leg, between the fibularis longus and brevis muscles and the extensor digitorum longus muscle to the distal end of the leg

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Branches of the nerve include:

Motor - Supply the fibularis longus and brevis

Cutaneous - Distributed to the skin of the distal part of the anterior leg and the dorsum of the foot (except those areas supplied by deep fibular and sural nerves)

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Ankle sprains may cause a traction injury to the nerve, which may cause pain along the lateral side of the leg and the dorsum of the foot; paresthesia may be present and increase with activity.

Vascular Supply of the Lateral Leg

No blood vessels are found directly in the lateral leg compartment

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The muscles receive their vascular supply from branches of the anterior tibial artery and the fibular branch of the posterior tibial artery (which penetrate the connective tissue that surround the lateral leg compartment)

Muscles of the Superficial Posterior Leg

Muscles found in this compartment:


1. Gastrocnemius
2. Soleus
3. Plantaris (small belly, long tendon)

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Gastrocnemius and Soleus together form “Calf Muscle” aka Triceps Surae

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Their tendons fuse to form the prominent Achilles Tendon or Tendon Calcaneus, which is the thickest and strongest tendon in the human body and inserts on the Calcaneal Tuberosity

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All posterior leg muscles (superficial and deep) are supplied by the Tibial Nerve

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Gastrocnemius

“Stomach of the Leg”

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Is the most superficial of all posterior leg muscles

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Has two heads of origin - a medial, which is deep to the tendon of the semimembranosus and the lateral, which is deep to the tendon of the biceps femoris.

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O - Lateral and Medial Condyles and Epicondyles of the Femur

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I - Tuberosity of the Calcaneus

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N - Tibial Nerve

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A - 1. Plantar flexion of the foot (prime mover)


2. Flexion of the leg
3. Helps stabilize ankle to some degree

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*Fabella* - sesamoid bone which is found imbedded in the lateral head of the origin of the gastrocnemius and articulates with the lateral condyle of the Femur

Soleus

Comes from the Latin word Solea, a flat type of fish

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Broad, thick muscle, deep to the gastrocnemius

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O - Soleal line of the Tibia

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I - Tuberosity of the Calcaneus

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A - 1. Plantar Flexion of the foot (prime mover)


2. Helps stabilize ankle to some degree

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N - Tibial Nerve

Achilles Tendonitis

Microscopic tears in the collagen fibers of the tendons, usually just proximal to the attachment on the calcaneus

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Often occurs during repetitive activities and seen more commonly in those who participate in baseball, tennis, runners, dancers

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The most common symptoms of the disorder is pain, which develops while walking or running

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Individuals with flat feet are more prone to the condition, due to the fact that their foot is more hyper-everted.

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Other contributions:


1. Inappropriate footwear
2. Sudden increases in training intensities
3. Sudden changes in duration or frequency of activity
4. A quick return to activity after a prolonged break in training
5. Running on steeply inclined or uneven terrain

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Heel lifts and stretching may help to decrease symptoms.

Rupture of the Tendon Calcaneus

Typically occurs in poorly consitioned individuals with a history of Achilles Tendonitis

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Despite its thickness, the tendon can be ruptured during forceful plantar flexion (when knee is extended)

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The individual may hear an audible snap and feel intense pain (as if a stone has hit them)

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After a compete rupture, a palpable gap may be felt and the foot can be dorsal flexed to a greater extent than normal

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The individual will have difficulty carrying out plantar flexion of the foot

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In older or non-athletic individuals, non-surgical repairs are often adequate

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Surgical intervention is usually advised for those who are very active.

Calcaneal Tendon Reflex

This ankle reflex is elicited with the patient’s foot dangling over the side of the examination table

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The tendon is struck with a reflex hammer, just proximal to the calcaneal tuberosity

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The foot should reflexively fall into a plantar flexed position

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This tests for the segmental innervation of S1, S2

Wearing of High Heeled Shoes

Individuals who wear high heeled shoes a great deal may develop a shortening (contracture) of the calf muscles

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This occurs because the origin and insertion of the muscles are continually brought closer to each other

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When this occurs, calf pain may be experienced when walking in flat shoes or barefoot.

Plantaris

Small, variable muscle which is missing in about 5% of population

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When present, found between the lateral head of the gastrocnemius and the soleus

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Belly of the muscle is short and it’s long tendon descends along the medial border of the tendon - longest tendon of any other muscle in the body

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O - Lateral Supracondylar line (ridge) of the femur

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I - Tuberosity of the Calcaneus

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A - Plantar flexion of the foot

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N - Tibial Nerve

Muscles of the Deep Posterior Leg

Popliteus

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Flexor Hallicis Longus

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Flexor Digitorum Longus

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Tibialis Posterior

Popliteus

Small muscle, deep to the heads of the gastrocnemius, where it is obliquely placed

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Helps form the floor of the popliteal fossa

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O - Lateral condyle of the femur

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I - Shaft of the Tibia

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A - 1. Medially rotates the Tibia to unlock leg and allow flexion of the knee


2. Stabilize knee (prevent hyperextension)

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N - Tibial Nerve

Flexor Digitorum Longus

This is the most medial of the deep posterior leg muscles and is deep to the soleus

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It’s tendon passes behind the medial malleolus, between the tendons of the flexor hallucis longus and tibialis posterior

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Its tendon of insertion enters the plantar surface of the foot, where it divides into 4 separate tendons

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O - Shaft of the Tibia

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I - Distal Phalanges of Digits 2-5

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A - 1. Flexes digits 2-5


2. Plantar flexion of the foot
3. Supports both the medial and lateral longitudinal arches of the foot

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N - Tibial Nerve

Flexor Hallucis Longus

This is the most lateral of the deep posterior leg muscles

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O - Shaft of the Fibula, interosseous membrane

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I - Distal phalanx of digit one

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A - 1. Flexes digit 1


2. Plantar flexes foot
3. Supports the medial longitudinal arch of the foot

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N - Tibial Nerve

Tibialis Posterior

This muscle is found between the flexor digitorum longus and the flexor hallicus longus

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Its tendon passes behind the medial malleolus

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O - Shaft of the Fibula and Tibia, Interosseous Membrane

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I - Navicular; Cuneiforms; Cuboid; 2nd, 3rd, 4th metatarsals

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A - 1. Inversion of the foot


2. Plantar flexes the foot
3. Supports the medial longitudinal arch of the foot.

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N - Tibial Nerve

Tibial Nerve

This is the larger and more medial of the two terminal branches of the sciatic nerve

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It crosses the popliteal fossa, superficial to the popliteal artery and vein

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In the leg, the nerve descends deep to the Soleus and passes behind the medial malleolus, between the tendons of the flexor digitorum and the flexor hallicus longus.

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As the nerve enters the plantar surface of the foot, it divides into the medial and lateral plantar nerves

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The segmental innervation of the nerve is L4-S3

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Branches of the nerve include:


1. Motor supply to the posterior leg muscles
2. Sural nerve - cutaneous nerve which supplies skin on most of the posterior aspect of the leg and lateral plantar aspect of the foot.
3. Medial calcaneal - is a cutaneous branch which supplies the skin over the calcaneal tuberosity (heel)
4. Articular supply to the knee and ankle joints

Damage to the Tibial Nerve

The Tibial Nerve is not commonly injured because of it's protected position in the popliteal fossa and posterior leg

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It may be damaged by a deep laceration in the posterior leg or by a posterior dislocation of the knee joint

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If the nerve is damaged or compromised, the following may occur:

* unable to flex toes
* weakened plantar flexion -- *fibularis longus and brevis can still flex foot*
* Weakened inversion of the foot -- *Tibialis anterior is another inverter*

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There may also be a loss of sensation of the posterior aspect of the leg and plantar surface of the foot.