Anterior lateral and_posterior_compartments_of_calf

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2. MOB TCD
Anterior and Lateral and Posterior
Compartments of Calf
Professor Emeritus Moira O’Brien
FRCPI, FFSEM, FFSEM (UK), FTCD
Trinity College
Dublin

3. 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
MOB TCD

4. Fascial Compartments in Calf
•Subcutaneous surface of tibia
•Fascia anterior and posterior
intermuscular septa
•Anterior compartment
•Lateral compartment
•Posterior compartment
Divided
•Superficial
•Deep
•Deep posterior
MOB TCD

5. Extensor Retinacula
•Superior retinaculum
•Thickening deep fascia
•Tibialis anterior pierces
•Other tendons pass posterior
•Inferior extensor retinaculum
•Inferior stem attached to calcaneus
•Upper limb to medial malleolus
•Lower limb plantar aponeurosis
MOB TCD

6. 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
MOB TCD

7. Tibialis Anterior
•Upper two thirds
•Lateral surface of tibia and
adjoining area of
interosseous membrane
•And deep fascia
Inserted
•Medial aspect of medial
cuneiform
•And adjoing base of first
metatarsal
MOB TCD

8. •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
Tibialis Anterior
MOB TCD

9. Extensor Hallucis Longus
•Middle two fourths
•Anterior surface of fibula
•Interosseous membrane
•Base of distal phalanx of
hallux
•Dorsiflexor big toe and
ankle
•Deep peroneal nerve
•Test for L5
MOB TCD

10. •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 Hallucis Longus
MOB TCD

11. 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
MOB TCD

12. Peroneus Tertius
•Lower quarter of anterior surface of
the fibula
•Inserted into base and dorsum of
shaft of fifth metatarsal
•Dorsiflexor and evertor
MOB TCD

13. Extensor Digitorum Brevis
•Fleshy origin from calcaneus
•Stem of inferior retinaculum
•Divides into four tendons
•First is extensor hallucis brevis
•Other three join extensor
expansion of second, third and
fourth toes
•Deep peroneal nerve
MOB TCD

14. 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
MOB TCD

15. •In anterior compartment
•Supplies
•Tibialis anterior
•Extensor hallucis longus
•Extensor digitorum longus
•Peroneus tertius
•Extensor digitorum brevis
•Skin first cleft
Deep Peroneal Nerve
MOB TCD

16. Anterior Tibial Artery
•Branch of popliteal
•Enters above interosseous
membrane
•Only supply of tibialis
anterior
•Becomes dorsalis pedis at
ankle joint
MOB TCD

17. Dorsalis Pedis
•Gives off
•First dorsal metatarsal artery
•Arcuate artery gives off
•2-4
th
dorsal metatarsal
arteries
•At base of first
intermetatarsal space
•Enters sole of foot
•Joins lateral plantar artery to
complete plantar arch
MOB TCD

18. Blood Supply of Dorsum
•Arcuate artery
•Dorsal metatarsal arteries
•Posterior and anterior perforating
branches from metatarsals
•Communicate plantar arch
•And its digital branches
•Perforating veins drain into dorsal
venous arch
MOB TCD

19. Perforating Peroneal Artery
•Perforating peroneal artery
•Pierces interosseus membrane
•Enters anterior compartment
•May replace dorsalis pedis
MOB TCD

20. 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
MOB TCD

21. Lateral Compartment of Calf
•Between anterior and posterior
intermuscular septa
•Peroneus longus
•Peroneus brevis
•Superficial peroneal nerve
MOB TCD

22. Peroneus Longus
•Upper two thirds lateral surface of fibula
•Adjoining area of interosseous
membrane
•Passes under superior and inferior
peroneal retinaculum
MOB TCD

23. •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
MOB TCD

24. •Plantar flexor and evertor
•Supports lateral arch
•Superficial peroneal nerve
•Cuboid syndrome
•Torn peroneal retinacula
•Snapping tendons
Peroneus Longus
MOB TCD

25. Peroneus Brevis
•Lower two thirds
•Lateral surface of fibula in front of
longus
•Passes under superior and inferior
peroneal retinacula
•Above peroneal trochlea on calcaneus
•Inserted into base of fifth metatarsal
MOB TCD

26. Peroneus Longus and Brevis
•Plantar flexors and
evertors
•Longus support the lateral
longitudinal arch
•Superficial peroneal nerve
MOB TCD

27. Superficial Peroneal Nerve
•Branch common peroneal
•Neck of fibula
•Supplies peroneus longus and brevis
•Pierces deep fascia
•Dorsum of foot supplies
•Medial side of big toe
•All clefts except first and lateral side of little
toe
MOB TCD

28. Sensory Supply to
Posterior Aspect of Calf
•Posterior cutaneous nerve of thigh
•Lateral cutaneous of calf
•Sural nerve
•Saphenous nerve
•Medial calcaneal
MOB TCD

29. Dermatomes
MOB TCD

30. 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
MOB TCD

31. 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
MOB TCD

32. •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

33. 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
MOB TCD

34. •May be absent
•May rupture
•Used in tendon grafts
•Sudden dorsiflexion
of ankle
•Ballet dancing
•Gymnastics
•Basketball
•Sprinting
Plantaris
MOB TCD

35. Soleus
•Broad flat pennate muscle
•Arises from head and upper
fourth of posterior surface of the
fibula
•Fibrous arch
•Soleal line of tibia
•Middle third of medial border of
tibia
MOB TCD

36. •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
Soleus
MOB TCD

37. 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
MOB TCD

38. •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
MOB TCD

39. •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
MOB TCD

40. •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 Tendon
MOB TCD

41. Achilles Test
MOB TCD

42. Medial and Lateral Heads
of Gastrocnemii
•Sprinting
•Jumping
•Hopping
•Skipping
•Stretched with knee
extended and ankle
dorsiflexed
•Tibial nerve
MOB TCD

43. 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
MOB TCD

44. Flexor Digitorum Longus
•Posterior surface of tibia
•Below soleal line
•Medial to vertical line
•Variable origin by an
aponeurosis from fibula
MOB TCD

45. Very extensive fibular
origins of FDL
FHL
Fibular origin of FDL
FDL
Hislop M, 2003
Flexor Digitorum Longus
MOB TCD

46. •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

47. •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 Digitorum Longus
MOB TCD

48. Flexor Hallucis Longus
•Bulkiest and most powerful,
multipennate
•Arises from posterior surface of
fibula
•Posterior to medial crest
•Beef to heel
•Most posterior under retinaculum
MOB TCD

49. •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
MOB TCD

50. •Tibial nerve
•Plantar flexes ankle
•Flexes big toe
•Supports medial longitudinal arch
•Take off muscle
Flexor Hallucis Longus
MOB TCD

51. 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
MOB TCD

52. •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
MOB TCD

53. •Plantar flexor ankle
•Invertor of foot
•Supports medial arch
•Avascular area behind
medial malleolus
•Tibial nerve
Tibialis Posterior
MOB TCD

54. 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
MOB TCD

55. •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
MOB TCD

56. 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
MOB TCD

57. 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
MOB TCD

58. Causes of Compartment Syndromes
•May be acute or chronic
•Sudden increase in exercise
•Haematoma
•Callus
•Fracture
MOB TCD

59. 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
MOB TCD

60. Posterior Compartment
•Posterior compartment
•Posterior border of tibia
•Posterior intermuscular septum
Divided
•Superficial
•Deep
•Deep posterior
MOB TCD

61. •Superficial compartment
•Posterior intermuscular septum
•Posterior border of tibia
Posterior Compartment
MOB TCD

62. Superficial Posterior Compartment
•Medial and lateral gastrocnemii
•Plantaris
•Soleus
•Forming the achilles tendon
•Tibial nerve
MOB TCD

63. Deep Posterior Compartment
•Popliteus
•Flexor digitorum longus
•Flexor hallucis longus
•Deepest is tibialis posterior
MOB TCD

64. 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
MOB TCD

65. 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
Chronic Exertional Compartment
Syndrome (CECS)
MOB TCD

66. “BMJ Publishing Group Limited (“BMJ Group”) 2012. All rights reserved.”