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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Perforating Peroneal Artery
Perforating peroneal artery Pierces interosseus membrane
Enters anterior compartment
May replace dorsalis pedis
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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
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Lateral Compartment of Calf
Between anterior and posteriorintermuscular septa
Peroneus longus
Peroneus brevis
Superficial peroneal nerve
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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
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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
Superficial peroneal nerve
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
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MOB TCD
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Peroneus Longus and Brevis
Plantar flexors andevertors
Longus support the lateral
longitudinal arch
Superficial peroneal nerve
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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
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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
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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
Medial and Lateral HeadsMOB 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
Medial and Lateral Heads
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
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MOB TCD
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May be absent
May rupture
Used in tendon grafts
Sudden dorsiflexionof ankle
Ballet dancing
Gymnastics
Basketball
Sprinting
Plantaris
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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
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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
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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
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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
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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
Medial and Lateral HeadsMOB TCD
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Medial and Lateral Heads
of Gastrocnemii
Sprinting Jumping
Hopping
Skipping
Stretched with knee
extended and ankle
dorsiflexed
Tibial nerve
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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
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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
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Very extensive fibularorigins of FDL
FHL
Fibular origin of FDL
FDL
Hislop M, 2003
Flexor Digitorum Longus
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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
Flexor Digitorum Longus
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
Flexor Digitorum Longus
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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
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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
Flexor Hallucis Longus
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Tibial nerve Plantar flexes ankle
Flexes big toe
Supports medial longitudinal arch
Take off muscle
Flexor Hallucis Longus
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
Tibi li P t iMOB TCD
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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
Tibi li P t iMOB TCD
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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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BMJ Publishing Group Limited (BMJ Group) 2012. All rights reserved.
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