Anterior and Lateral and Anterior and Lateral and Posterior Compartments of Posterior Compartments of

CalfCalf

By- Dr. Armaan Singh

Cutaneous Supply of Calf Saphenous first branch is

infrapatellar branch it Supplies medial side of

the calf and Medial side of foot to ball

of the hallux Lateral cutaneous of calf Superficial peroneal Sural, lateral border of

foot Deep peroneal first cleft

Fascial Compartments in Calf Subcutaneous surface of

tibia Fascia anterior and posterior

intermuscular septa Anterior compartment Lateral compartment Posterior compartmentDivided Superficial Deep Deep posterior

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

Anterior Compartment of Calf Tibialis anterior Extensor hallucis longus Extensor digitorum longus Peroneus tertius All muscles supplied by the

deep peroneal nerve Dorsi flexors Anterior tibial and

perforating peroneal arteries

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 first

metatarsal

Tibialis Anterior Synovial sheath Passes under superior

and both limbs of inferior extensor retinaculum

Dorsi flexor and invertor Eccentric pays out,

prevents foot slapping down

Supports medial arch Deep peroneal nerve

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

Extensor Hallucis Longus Upper three quarter

anterior surface of fibula Except the area for the

extensor hallucis longus Anterior intermuscular

septum Passes under retinacula Divides into four tendons Joined by slips from

brevis Lumbricals and

interossei muscles

Extensor Digitorum Longus Main extensor tendon inserted

into base 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

Peroneus Tertius

Lower quarter of anterior surface of the fibula

Inserted into base and dorsum of shaft of fifth metatarsal

Dorsiflexor and evertor

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

Deep Peroneal Nerve

Branch of the common peroneal at neck of fibula

Pierces anterior intermuscular septum Runs between extensor digitorum

longus and tibialis anterior Then tibialis anterior and extensor

hallucis longus

Deep Peroneal Nerve

In anterior compartment Supplies Tibialis anterior Extensor hallucis longus Extensor digitorum longus Peroneus tertius Extensor digitorum brevis Skin first cleft

Anterior Tibial Artery

Branch of popliteal Enters above

interosseous membrane Only supply of tibialis

anterior Becomes dorsalis pedis

at ankle joint

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

to complete plantar arch

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

Perforating Peroneal Artery

Perforating peroneal artery Pierces interosseus membrane Enters anterior compartment May replace dorsalis pedis

Venous and Lymph Drainage of Foot

Dorsal venous arch Medial, long

saphenous vein Anterior to medial

malleolus Short saphenous

vein Posterior to lateral

malleolus Lymphatics follow

superficial veins

Lateral Compartment of Calf

Between anterior and posterior intermuscular septa

Peroneus longus Peroneus brevis Superficial peroneal nerve

Peroneus Longus

Upper two thirds lateral surface of fibula

Adjoining area of interosseous membrane

Passes under superior and inferior peroneal retinaculum

Peroneus Longus

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 Longus

Plantar flexor and evertor Supports lateral arch Superficial peroneal nerve Cuboid syndrome Torn peroneal retinacula Snapping tendons

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

Peroneus Longus and Brevis

Plantar flexors and evertors

Longus support the lateral longitudinal arch

Superficial peroneal nerve

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

Sensory Supply to Posterior Aspect of Calf

Posterior cutaneous nerve of thigh Lateral cutaneous of calf Sural nerve Saphenous nerve Medial calcaneal

Dermatomes

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 medial between medial malleolus and calcaneum

Bursa anterior to achilles

Medial and Lateral Heads of Gastrocnemii

Medial head arises from popliteal surface of femur above medial condyle

Lateral is shorter, arises from posterior part of the lateral surface of the lateral femoral condyle and capsule of knee

Fabella is a sesamoid bone in lateral head

Medial and Lateral Heads of Gastrocnemii

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

Plantaris

Short fleshy origin from The popliteal surface of

femur above the lateral femoral condyle

Long tendon passes between gastronemii and soleus

Inserted medial border of achilles

Tibial nerve

Plantaris May be absent May rupture Used in tendon

grafts Sudden dorsiflexion

of ankle Ballet dancing Gymnastics Basketball Sprinting

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

Soleus

Two aponeurotic lamellae Bulk of vascular multipennate muscle

fibres Deepest of achilles Slow twitch fibres Perforating veins from great

saphenous enter soleus Acts as a peripheral pump

Achilles Tendon

Extent of the fusion between the gastronemii and soleus varies

Inserted into middle of posterior surface of the calcaneus

Tendon twists Gastronemii form the lateral and

posterior part of the tendon

Achilles Tendon

Rotation occurs above where 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 The achilles tendon is

subjected to 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 Superficial bursa may be

found 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 Test

Medial and Lateral Heads of Gastrocnemii

Sprinting Jumping Hopping Skipping Stretched with

knee extended and ankle dorsiflexed

Tibial nerve

The Retrocalcaneal Bursa

The area of fibro cartilage on the tendon forms the posterior wall

The anterior wall of the retrocalcaneal bursa is the 0.5 to 1 mm thick cartilaginous layer on the posterior 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 varying degrees of pressure on the fat above it during flexion and extension of the ankle

Flexor Digitorum Longus

Posterior surface of tibia Below soleal line Medial to vertical line Variable origin by an

aponeurosis from fibula

Very extensive fibular origins of FDL

FHL

Fibular origin of FDL

FDL

Hislop M, 2003

Flexor Digitorum Longus

Flexor Digitorum Longus

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

In the foot the tendon passes through birfurcation of brevis

Inserted into distal phalanges Plantar flexes ankle Plantar flexes lateral four toes Supports medial arch Tibial nerve

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

Flexor Hallucis Longus

Grooves posterior process of talus Sustentaculum tali Crossed in foot by flexor digitorum

longus to which it gives two slips Inserted base of distal phalanx

Flexor Hallucis Longus

Tibial nerve Plantar flexes ankle Flexes big toe Supports medial longitudinal

arch Take off muscle

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

Tibialis Posterior

Crossed by flexor digitorum longus in calf

Posterior to medial malleolus grooves bone, type II collagen,

tends to have poor blood supply Most anterior under the flexor

retinaculum Inserted into tuberosity of navicular All bones of the tarsus except talus Base of middle three metatarsals

Tibialis Posterior

Plantar flexor ankle Invertor of foot Supports medial arch Avascular area behind

medial malleolus Tibial nerve

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

Posterior Tibial Artery 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

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

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

Causes of Compartment Syndromes

May be acute or chronic

Sudden increase in exercise

Haematoma Callus Fracture

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

FasciotomyOr Posterior or lateral compartments

Posterior Compartment Posterior compartment Posterior border of tibia Posterior intermuscular

septum

Divided Superficial Deep Deep posterior

Posterior Compartment

Superficial compartment Posterior intermuscular

septum Posterior border of tibia

Superficial Posterior Compartment

Medial and lateral gastrocnemii Plantaris Soleus Forming the achilles tendon Tibial nerve

Deep Posterior Compartment

Popliteus Flexor digitorum longus Flexor hallucis longus Deepest is tibialis

posterior

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 Compartment Syndrome (CECS)

The fibular origin of FDL can partially (or sometimes almost completely) compartmentalize TP and acts to resist increases in intracompartmental volume and therefore cause increased pressure

The presence and extent of a fibular origin of FDL may act as an anatomical predisposition to the development of CECS