LEG AND FOOT – Dr.

Duenk
• Leg and foot are like arm and hand but they are meant to be weight bearing
• Bones of leg and foot
o Tibia - large weight bering
• Artic w/ fibia at 2 places and femur and with talas at ankle joint
• Condlyes - medial and lateral - art with femur at top and fibial laterally
• Intercond eminence - where lig attaches
Mountains at top intercon em - where important ligs attach - like ACL, PCL (ant/post cruciate lig)
CC- debilitating injury when pulled/torn in sports
• Medial malleolous - distal end - knob of ankle on the inside (medial)
• Tibial tuborsity - little projection past proximal end, where patellar tendon attaches,
 CC- is prominent, can pull off tendon - very clinically important - swelling/tenderness
 osgood-slaughters disease - boney overgrowth of tibial tub, more common in boys, more prom in
active teens, feel achy - treatment is to back off activity and rarely cast
• Interossesous membrane - strong fibrous connective tissue between two bones
 Anterior border
 Post - soleal (fish) line - follows contour of where soleus muscle is attached
• CC- tibia is often fractured, various types
• Ankle joint - made of tibia, fibula and talus. It’s a mortitis joint - 3 sided - hinge joint, very stable and firm
- tibia forms bulk of mortis joint
 Only tight and stable joint at 90 degrees
 It is unstable when on tippy toes (wearing high heels)
o Fibula - non weight bearing bone (test Q) that can transmit force
• Muscle attachment point
• Has lateral malleous
• Synovial joint superiorly, more of a fibrous joint inf
• Artics with tibia at 2 places
• Art at ankles with talus
• Fibular nerve branches off post and wraps around outside fibula and thus is very susceptible to injury and
disease - at this point is common fib nerve - divides later into superficial and deep
• CC - when looking at x-rays for broken ankle look for transmitted fracture in proximal end of fibula
(occassionally tibia)
o Talus - large bone,
• doesn't fuse well, sometimes see as 2 pieces
• Articulates w/ fibia and tibia proximally
 Primarilly bottom of tibia
• articulates w/ calcaneous and navicular distally
o Calcaneous - sustains talus at sustenatculum tali (talus rests on it)
• heel bone - bears 50% (normally) of weight
• Articulates w/ talus and cuboid
o Cuboid - laterally,
• Articulates with calcaneus, navicular, lateral cuneiform, 4&5 metatarsal
o Navicular - medial more superior,
• art with head of talus, cuboid, and 3 cuneiforms
• it has a palpable medial tuberosity - attachment point for muscle
o Cuneifroms - 3 - medial, middle, lateral
• Medial - by big toe
• Art w/ navicular and metatarsals
o Metatarsals - heads bear weight of body - bear about 50% (on both feet - calcaneus does other 50% )
• 2 sesamoid bones at base of big toe (1st metatarsal) - make a tunnel for flexor tendon - it runs in btw
sesamoid bones
• 2nd metatarsal has its own mortis joint on prox end- jammed in at 3 points -
 CC -can get stress fractures more commonly here at base - aka march fractures
• CC- if wearing high heels more like 80/20
o Phalanges - 3 for all except big toe (2)
• Axis of abduction/adduction is digit 2 in foot (it is 3 in hand) - understand when see interosseous muscles
• Joints of leg and foot
o Knee joint - see joint lecture
o Ankle joint - has a synovium - allows you to plantar flex and dorsi flex
• Plantar flex - stepping on gas - uses flexores
• Dorsi flexion - pick up foot - uses EXTENSORS
o Inversion/eversion
• Inversion - turn foot in (go up on pinky side)
 CC- most common ankle sprain
• Eversion - turn foot out (go up on big toe side)
 CC-catching foot when riding motorcycle, tear medial ligaments
o In ankle joint - deltoid ligaments is found medially, thus much stronger than laterally - not injured as much, if done
is by inversion
• Lateral joint
• More likely to injure ant/inf part of ankle - lateral ankle is much more commonly injured
• sprain ankle is when you injure tripartide ligs
o Transverse tarsal joint - where talus and calcaneous articulate with navicular and cuboid-
• doesn't allow you to move much
o Tarsal-metaltarsal joint - Lis franc joint (fractures can occur here)
o Metatarsal-phalangeal joint - MTP joint
o Interphalanegeal joint (DIP, PIP, IP)
• IP - only in big toe (only one it has)
• 2-5 have DIP and PIP
• Arches and ligaments
o Arches are shock absorbers - maintain balance btw weight bearing heads of metatarsals and calcaneous
• Longitudinal along line of foot
 Medial portion is what people think as arch - does not touch ground
 Lateral - does touch ground
 CC- Flat feet, can see hole foot print, more prone to foot probs
• Transverse arch (See pic in notes)
o Ligaments - sup to deep
• Plant aponeurois - superficial
• Long and short plant
 Long = lateral
 Short = calcaneocuboid liagement, lateral
 Short is deep
 Both go from calcaneous to cuboid
• Spring lig - Calcaneous to medial navicular - most important at maintaining arches
 = calcaneounavicular ligament, medial
• CC - Foot injuries
o Halux valgus - lateral deviation of big toe at MTP joint - occurs when squish feet is small shoes
o Hammer toes - one goes up, one goes down - same cause as above
• Usually 2nd toe - at MTP joint, MTP joint is hyperextended
o Plantar Fasciitis - fascia and ligament get irritated and inflamed
• No arch support in shoes -
• can result in bone spurs growing off anterior part of calcaneous (doesn't cause the pain - is a result of
plantar fasciitis which caused growth and the pain)
• Occurs more with flat feel
o Ankle sprain, fractures - if walking on unstable ankle (ie high heels) more likely to injure it
o Ingrown toenail - no where to grow if no space - grows inward
o Corn/calluses - reaction of rubbing of shoes
o Bunion - extreme corn/cal
• Classic bunion is at MTP joint on big toe due to shoes rubbing on widest part of foot- here it shows
buionette
o Back probs - walking funny effects back
o Morton's neuroma - squish toes get a fibroma around nerve sheath
• Nerve swelling due to rubbing - usually btw toes 3/4
 o Tinea pedis - fungal infection in btw toes - need to change socks, smells bad (fungus likes it where it is warm, dark,
and wet)
o Patient education -
• Trace foot and then take shoe and put it on top and then patient can see clearly why they have probs

• Leg - general
o Arteries
• Popliteal artery main artery that supplies leg comes through popliteal fossa -has many branches
 Anterior tibial comes off popliteal first and it goes between tibia and fibia in interosseous
membrane - is in anterior compartment
 Goes down leg and becomes dorsalis pedis artery at shoestring line of foot
• CC- need to know where pulses are to see where blood clots are. Can palpitate pulses at:
• Dorsalis pedis
• (note: coming off it laterally is medial maleolar artery - on parts list)
• Posterior Tibial artery - supplies entire post compartment - runs more medially on - ultimately goes post to
medial malleolus and then subdivides to form plantar arteries
• Fibular artery - supplies blood to lateral compartment (through additional artery) BUT it is in the
POSTERIOR compartment - it is a communicational artery
• CC- diabetics and smokers are particularly prone to peripheral vascular disease
 Diabetics often have nerve probs and thus can't feel they aren't getting good circulation (due to
cholesterol plaques) - leads to gangrene
o Veins -
• Superficial veins
 Great saphenous - goes behind knee, comes medially, and then goes anterior to medial malleolous
• Used to do cut downs in order to give IV fluids here
• Gets blood from dorsal venous arch
• drains into deep veins popliteal area
 Small saphenous - goes all the way to inguinal region - also gets blood from dorsal venous arch
• Deep - run parallel to major arteries -don't name deep veins (vena comitantes)
• CC- Varicose vein - ballooning out of superficial vein do to inc pressure - occurs due to pregnancy or
prolonged standing over time and the valves that help get blood get back up become incompetent and get
varicose veins - leads to pain
 Not as dangerous as when you get clots in deep veins - can be deadly - most commonly occur
beneath knees - BUT deep vein blood clots (thrombosis) above knee are more likely to break off
and go to lungs and cause probs (pulmonary embilous)
• Inc risk w/: Birth control, family history (protein coagulation disorders), smokers - treat
with blood thinners
o Nerves
• Motor: Tibial nerve is continuation of sciatic nerve
 Goes inferior to medial malleolous
 Branch off it is common fib nerve - superficial to lateral comp and deep fib to post comp
• Deep fib nerve - only a certain part of foot - btw toes 1/2
• Superficial supplies rest of foot
• Cutaneous:
 Saphenous (femoral branches, medial)
 Sural (Fibular branches, lateral)
o Lymphatics
• Barely mention b/c can't see it, palpable in inguinal region and in popliteal region only
o Compartments
• Three compartments - all have own nerve and artery
 Ant - ant tibular artery, deep fibular nerve
• 3 muscles -
• Tibialis anterior - most medial
• Extensor hallucis longus
• Ext digitorum longus
• Extensor retinaculum - across m
 Lateral - superficial fibular nerve - 2 muscles - has no artery in it - its artery is in post
  Post - biggest 2 parts : deep and superficial - tibial nerve
• 3 muscles in deep
• 3 in superficials
• Leg muscles
o Ant compartment MM: Medial to lat
• Tibialis ant - dorsi flex -
 Origin : lateral condyle
 Insertion: underside of medial cuneiform and 1st metatarsal
 Action: extend foot at ankle
• Extensor hallucis longus - in middle
 Origin : central half of medial fibula and interosseous membrane
 Insertion: by an extensor retinaculum to distal phalanx of big toe
 Action: extend big toe
• Extensor digitorum longus (includes peroneus tertius muscle) -
 Origin : lateral condyle of tibia, 3/4 of fibula, and interosseous membrane
 Insertion: on toes 2-5
 Action: extend toes
• Extensor retinaculum - restraining muscles, inferior and superior
o Lateral compartment muscles - eversion, dorsi flexion (extension)
• CC - Common fib nerve (supplies lateral and anterior compartment) injury results in foot drop - can be
caused by diabetes - foot catches on carpet
 Can be caused by Charcot-Marie Tooth disease which causes injury to common fibular nerve
• 2 muscles -
 fibularis longus -
• Origin - upper 2/3 of fib,
• Insertion - long tendon attaches to base of 1st meta tarsal
• Action - helps evert foor
 Fibularis brevis -
• Origin - lower 2/3 of fibula
• Insertion - at base of 5th met
• Action - evert foot, dorsi flexion
• CC-base of 5th metatarsal is commonly injured, can pull off part of fibularis brevis tendon, if it is a jones
fracture (ie further up ) - more complicated takes longer to heal
o Posterior Compartment: 2 parts: superficial and deep
• Superficial post compartment:
 Gastrocnemius
• Orgin: medial and lat cond of femur, thus has 2 heads
• Insertion: in achilles tendon (back end of calcaneus)
• Action: crosses 2 joints - helps plantar flex and cross knee and helps you jump and helps
flex knee
• Antigravity muscle
 (CC - Fabella - little bone about size of pea floating near head of Gastroc m - sometimes seen on
x-rays, just know it is there so you're not confused)
 Soleus - fish shaped -
• Orgin - from two points - soleal line of tibia and upper shaft of fibia
• Insertion: achilles tendon
• Action - plantar flex
 Plantaris - near popliteal fossa -
• origin - lateral femoral condyle
• Insertion - via long tendon (aka freshaman nerve) to achilles tendon
• Action - DO nothing muscle - can steal tendons from here
• Tendon of plantaris - under Gastroc m,
• looks like nerve, don't confuse it
 CC- when you think someone has rupture achilles tendon (no plantar flexion):
• Do Tonson test - check for passive and active plantar flexion
• Squeeze calf - and see if plantar flexion occurs
 • If not achilles tendon could be plantaris tendon or plantaris muscle rupture/injury
• Deep portion of Posterior Compartment
 Flexor hallucis longus - most lateral ,
• Orgin - inf 2/3 of fibula and interosseous membrane
• Insertion - via long tendon runs btw 2 sesamoid bones on distal phalanax
• Action - flex great toe and plantar flex
 Tibialis posterior - in middle - deepest
• origin - interosseous membrane and some of tibula and fibula
• Inserts via long tendon on tuberosity of navicular bone
• Action - plantar flexes ankle, inverts foot
 Flexor digitorum longus - medially -
• Orgin - medial portion of tibia
• insertion - via long tendonbases of distal phal 2-5
• Action - flex toes 2-5 and plantar flex ankle
 Popliteus - found at knee joint (unique), triangular shaped, bigger than plantaris
• Orgin - inside knee joint
• Inserts - on tibia above soleal line
• Action - unlock knee medially
 Flexor retinaculum - Keeps ligs in place

• Foot - general
o Functions: weight bearing,
o Many parallels with hand
• But no opposition in foot
o Arteries -Dorsal
• Anterior tibial A - becomes dorsalis pedis at ankle joint
• Dorsalis pedis A - has medial maleolar branch becomes Arcuate A -
 Arcuate A (arched A) has an anastomosis with Fibular A on lateral side of food and from the
arcuate itself you have metatarsal arteries
• Metatarsal arteries subdivide into dorsal digital arteries
• Deep plantar A - from arcuate too
 Plantar arteries are extions post tibial artery (some anastomosis w/ deep arteries)
• CC-Pulses
 behind medial medillus should be able to find post tibialis artery pulse
 Know that you can feel popliteal, femoral artery (pulses), and dorsal pedis
 CC- Arterial embolous - if you have a pateint with no feeling in foot (everything distal to artery
will die quickly if don't get blood to it)
 - check various pulses to see where occulsion could be - no fibular artery pulse (good test q -
where is the occulsion if a certain pulse is absent)
o Arteries - plantar
• Peroneal A (anastomosis w/ dorsal arcuate A)
• Post tibial A divides into medial and lateral plantar
 Medial becomes superficial arch
 Lateral becomes plantar arch which branches off into plantar metatarsal AA and then plantar
digital AA
• CC- digital block inject at base of finger or toe to numb up dig nerves - make sure you don't hit dig art
(draw back a little, nerves are slightly more medial)
 NEVER use epinephrine b/c it is a major vasoconstrictor and there are no anastomoses (thus ok in
other parts of body but don't use in END arteries - finger, nose, toes, penis)
o Cutaneous nerves of foot and leg: Various thus can't knock out sensation by knocking out one nerve
• Saphenous nerve - extension of femoral nerve
 Sensation to leg and foot on medial side
• Sural nerve - lateral posterior lower leg and foot
• Superficial fibular - anterior, dorsal foot (except one spot by deep fib nerve)
• Deep fibular n - btw dorsum of digits 1&2
 motor and spot of sensory btw digits 1 and 2
 • Plantar nn - also motor and sensory activity
 Medial plantar n - digits 1-3.5, plantum of foot, tibial n branch
 Lateral plantar n - 3.5-5, plantum of foot, tibial n branch
o Motor nerves
• Deep fibular n - supplies extensor digitorum brevis
• Tibial nerve becomes medial and lateral plantar nn
• Medial plantar nerve -
 4 muscles: abductor hallucis, flexor hallucis brevis, flexor digitorium brevis, most medial
lumbrical muscles)
• Lat plant - all others plantar muscles
• Foot Muscles:
o Dorsal - 1 layer
• Extensor digitorum brevis (includes extensor hallucis brevis m)
 Origin - lateral malleolus
 Insertion - prox phalanx of great toe and lateral side of tendons of other toes
 Nerve - deep peroneal
 Action - extend toes
• Dorsal expansion - like hand
• Dorsal interossei (considered under plantar muscles)
o Plantar - 4 layers
• first is plantar aponeurosis
• First muscle layer:
 Abductor hallucis - medial -
• Nerve - medial plantar n
• Action - abduct and 2nd flex
 Flexor digitorum brevis - 4 tendons,
• Insertion - inserts via 4 tendons to middle phalanx
• Nerve - medial plantar n
• Action - flexion
 Abductor digiti minimi -
• Nerve - lateral plantar n
• Action - abduct little toe
• 2nd layer - some tendons run through this layer that aren't of consequence now
 Flexor hallucis longus and flexor digitorum longus (leg muscles)
 Quadtratus plantae m - unique
• Origin - body of calcaneus
• Insertion - post margin of flexor digitorum longus
• Nerve - lateral plantar
• Action - It adjusts the pull of flexor digitorum so it pulls straight - changes vector so you
can curl toes straight
 Lumbricals (digits 2-5)
• Nerve - digit 2 -medial plantar; digits 3-5 lateral plantar
• Action - flex proximal phalanges, extend middle and distal phalanges of lateral 4 digits
(toes)
• Third layer
 Felox hallucis brevis - on medial side
• Origin- cuboid, lateral cuneiforms
• Insertion - inserts by 2 tendons at base of sesamoid bone
• Nerve - medial plantar
• Action - flex big toe
 Adductor hallucis -
• Origin - 2-4 metatarsals - 2 heads
• Insertion - big toe
• Nerve - lateral plantar
• Action - adduct big toe - adduct and flex big toe
 Flex digiti minimi brevis -
 • Origin - 5th metatarsal
• Insertion - proximal phalanx of 5th toe
• Nerve - lateral plantar
• Action - plantar flex of little toe
• Fourth Layer:
 Tendons of peroneus longus and tibialis posterior muscles (leg muscles)
 Interossei (DAB, PAD, plantar, 4 dorsal)
• DAB - dorsal int muscles - abduct - 4 muscles
• Origin - bases of metatarsals (medial)
• Insertion - prox phalanx
• Nerve - lateral plantar
• Action - abduct
• PAD - plantar int muscles - adduct - 3 muscles (dig 3-5) (remember axis is dig 2)
• Origin - bases of metatarsals (medial)
• Insertion - prox phalanx 3-5
• Nerve - lateral plantar
• Action - adduct