THE LEG, ANKLE & FOOT

• Distal ends of tibia & fibula articulate with the bones of the ankle.

Shaft of the tibia:

• Shaft of the tibia has a very sharp anterior border – subcutaneous so easy to palpate
• Laterally, facing the fibula, there is another sharp border – interosseous border.
• ∆ transverse section of tibia is triangular in shape

Fibula:
• Has a head at proximal end
• Head articulates with the lateral tibial condyle at the proximal tibiofibular joint.
• Below head of fibula is a narrow neck
• Thin shaft
• Shaft has an interosseous border which faces that of the tibia

• The interosseous borders of the tibia and fibula are united by interosseous membrane
o Provides site for muscle attachment (as in the forearm)
o Fibres slope obliquely downwards: tibia  fibula
o Hole in upper membrane, which transmits anterior tibial artery from popliteal fossa 
front of leg.

• Soleal line is only notable landmark on back of tibia

Femur = linea aspera
Tibia = soleal line

Distal ends of the tibia & fibula:

• Distal ends of the tibia & fibula are joined by the
distal tibiofibular joint
• This is a strong fibrous joint
• The bones are linked further by the:
o Anterior tibiofibular ligament
o Posterior tibiofibular ligament

• Posterior tibiofibular ligament is particularly strong –

projects low over back of ankle joint.

• Lower surface of tibia = quadrilateral articular surface

• Medially, tibia projects downwards as medial malleolus

• Laterally, the fibula projects downwards as the lateral malleolus:

o Projects lower than the medial malleolus
o Posterior to the medial malleolus

• Both medial and lateral malleoli can be palpated easily.

Mortise:
• The mortise is the articular surface formed by the:
o Lateral & medial malleoli
o Inferior surface of tibia
o Posterior tibiofibular ligament
• The mortise articulates with the ankle bone.
• The distal tibiofibular joint must be v. strong to maintain integrity of mortise – or else ankle bone
would ride up between tibia & fibula during running etc.

BONES OF THE FOOT:

• The tarsal bones are more irregularly arranged than the mobile carpal bones of the wrist.
• Tarsus refers to bones between the tibia/fibula and the metatarsals
• Arrangement allows for stability – essential for upright bipedal locomotion.

• Nav Cubed Turnips Cautiously

• Talus sits at summit of the foot – fits into the ankle mortise to form the ankle joint
• Talus is mounted on the calcaneus – the heel bone.
• Joint between talus & calcaneus = subtalar joint

• Along lateral edge of foot, the calcaneus articulates with the cuboid via the calcaneocuboid joint

• Medial edge of foot is raised off of the floor by 4 bones:

o Talus  navicular: talonavicular joint
o Navicular  cuneiforms (medial, intermediate, lateral)
• This arrangement of bones has primative mammalian origins

THE ARCH OF THE FOOT:

• The arrangement of the tarsal bones ensures that body weight is transmitted in an even manner
• Talus transmits weight through itself to two boney pillars – rays - which rest on the ground; thus
it acts like the keystone of a roman arch:
• Posterior ray: calcaneus
• Anterior ray: navicular + 3 cuneiforms
• The arch formed is the medial longditudinal arch of the foot
• Arch is maintained by:
o Shape of bones
o Small muscles
o Ligaments & tendons

• During running, arch is compressed 1cm ↓ downwards ground

• This stretches the ligaments spanning the arch:
o Long plantar ligament
o Short plantar ligament
• These ligaments store elastic potential energy, and release 70% of it when foot leaves the
ground.

LATERAL RAY:
• The lateral ray of the foot is composed of:
o Cuboid
o 4th + 5th metacarpal
• Lies in gentle contact with ground on standing (as no arch here)
• Lateral ray doesn’t bear much weight – only briefly when walking
• More important for balance.

RAY
DISTRIBUTION OF WEIGHT OVER FOOT WHILST WALKING:
1. Heel strike – weight of body passes through heel
2. Weight spreads along lateral aspect of foot  head of metatarsals
3. Weight rolls across ball of foot  1st metatarsal
4. Toe off – powerful big toe, the hallux, propels the body forwards.

JOINTS OF THE TARSAL REGION:

 4 important joints to consider

Ankle joint
 Synovial
 Hinge joint
 Artciulation:
o Mortise of tib & fib
o Trochlea (the upper artciular surface of talus)
o Trochlea articulates with:
 Lower tibial surface
 Medial & lateral malleoli
 The malleoli clamp either side of the trochlea – holding it in place.
 In some, the trochlea of the talus narrows towards the back.

 Neutral position of ankle joint: foot right angles to the leg.

 Plantar flexed: toes point downwards
 Dorsiflexed: toes pointed upwards

 People with a trochlea which narrows towards the back – plantarflexion brings the narrow bit of
the trochlea between the malleoli.
 BUT the joint is not loose: the inferior tibiofibular ligaments can strech & the fibula can bend,
such that the narrow part is held firm, and then as the foot is returned to the neutral postion,
the malleoli separate a few mm to accommodate the larger part of the trochlea.

The fibrous capsule of ankle joint:

 Strong
 Attached to the articular margins
 Strengthed at the back by the posterior tibiofibular ligament
 Also strengthed by ligaments on either side.

 SM covers all non-articular surfaces.

Subtalar joint
 Joint between talus & calcaneus
 Synovial
 Calcaneous has 3 articular surfaces for the talus: anterior + middle + posterior
 Articular surface of the calcaneus is dome shaped & curved – ensure particular movement of the
calcaneus under the talus:
 Abduction of foot away from midline  lateral edge of foot raised off ground; eversion
 Adduction of foot towards mideline  medial edge of foot raised off ground; inversion
 Abduction-eversion
 Adduction-inversion
 Due to shape of articular surfaces of subtalar joint.
 In these movements, the talus is stationary and the calcaneus
swings beneath it.
 Inversion / eversion of the ankle happens at the level of the
subtalar joint

Talonavicular joint
 Between talus and navicular
 Synovial
 Ball & socket
 Connection of talus to the medial ray
 Ball: head of talus
 Socket:
o Navicular
o Sustentaculum tali (boney platform on medial side of calcaneus)
 Between the navicular and the calcaneus is the spring ligament (called plantar calcaneonavicular
ligament in grays)
 Although this is a ball and socket joint, it doesn’t show much mobility.
 Movement is resricted to the tarsus swinging beneath the talus
o Abduction-eversion
o Adduction-inversion
Calacenocuboid joint:
o Between calcaneus & cuboid
o Synovial
o Articular surfaces are flat – movements are sliding.

o TRANSVERSE TARSAL JOINT: talonavicular joint + calcaneocuboid joint

LIGAMENTS AROUND THE TARSAL JOINTS:

Medial ligament (aka deltoid ligament)

• Triangular shaped (hence ‘deltoid’)
• Apex: medial malleolus
• Base: talus, navicular, calcaneum
• ∆ spans the ankle joint, supporting it.
• Part of the base also inserts into the calcaneus bone at the sustentaculum tali.
• ∆ spans the subtalar joint as well.

• Part of the base also inserts into the spring ligament & navicular.
• ∆ spans the talonavicular joint as well – giving it support

Lateral ligament
• Strong, but often strained in ankle injuries
• Has 3 fibrous bands

• Anterior band:
o Lateral malleolus  anterior talus
• Posterior band:
o Lateral malleolus  posterior talus
 ∆ anterior & posterior bands both strengthen the ankle joint

• Middle band:
o Lateral malleolus  calcaneus
o Orientation is downwards & backwards.
 ∆ middle band strengthens both the ankle and subtalar joints

Long plantar ligament:

• Sole of foot
• Origin: inferior surface of calcaneus
•  extends under surface of cuboid
• Inserts: base of metatarsals
• ∆ supports the calcaneocuboid joint

• The other tarsal bones are united by synovial joints as well as the 4 described above, but these
are less important.
• The other joints of the foot are also synovial:
o Tarsometatarsal
o Metatarsophalangeal
o Interphalangeal

• The metatarsophalangeal joint (MTP) of the big toe is clinically important.

• Often the site of:
o Arthritis
o Gout

• NOTE, unlike the finger MCP joint, the MTP joint of the toe can only actively perform flexion &
extension.
• The other movements of adduction, abduction & circumduction can be produced in the
metatarsophalangeal joints, but only passively.
MUSCLES OF THE LEG & FOOT
• Below knee joint – muscles of the leg are for movement of ankle & toes.
• Lower leg is divided into an anterior & posterior compartment by osseofascial septum:
o Tibia 
o Interosseous membrane 
o Fibula 
o Posterior intermuscular septum
• Osseofascial septum divides the lower leg into:
o Anterior compartment
o Posterior compartment

• Anterior compartment:
o Dorsiflexion of ankle
o Extend toes

 Medial group of anterior compartment:

o Adduction-inversion
 Lateral group of anterior compartment:
o Abduction-eversion

• All muscles of anterior compartment: innervated by common peroneal nerve (of sciatic)

• Posterior compartment:
o Plantar flexion of ankle
o Flexion of toes
• Tendons of these muscles pass to heel and into sole of foot
• One muscle also performs adductor-inversion
• All muscles of posterior compartment: innervated by tibial nerve (of sciatic)

MUSCLES OF THE ANTERIOR COMPARTMENT OF LOWER LEG

 Central muscles of this group:
o Primarily: extension of the toes
o Secondarily: dorsiflexion of ankle

 Extensor digitorum longus

 Extensor hallucis longus

 As both muscles pass over the front of the ankle, they are held down by thickenings in the deep
fascia – extensor retinacula
 The extensor retinacula is composed of superior retinacula and inferior retinacula.

 Superior extensor retinacula:

o Extends between tibia & fibula

 Inferior extensor retinacula:

o ‘Y’-shaped
o Stem attached to lateral calcaneus
o Upper limb attached to medial malleolus
o Lower limb attached to medial border of foot,
blending with deep fascia of the sole.

Extensor digitorum longus:

 Origin: fibula
 Passes down leg towards ankle
 Becomes a tendon which passes beneath the extensor
retinacula.
 Covered by synovial sheath as it passes beneath the
extensor retinacula.
 Divides in 4 tendons, which pass to the 4 lateral toes.

 Over the proximal phalanges the tendons form

extensor expansion (similar to those in the fingers).

 Central slip then gains insertion into middle phalynx

 2 collateral slips insert into base of distal phalynx.

 Action of extensor digitorum longus:

o Extension of lateral 4 toes:
 Metatarsophalangeal joints
 Interphalangeal joints
 Nerves supply is from the deep
peroneal nerve

Extensor hallucis longus:

 Origin: mid-fibular shaft + interosseous membrane
 Passes under extensor retinacula – surrounded by its own synovial sheath
 Strong tendon
 Inserts into distal phalanx of big toe

 Action: extend the big toe joints:

o Metatarsophalangeal
o Interphalangeal

 Supplied by deep peroneal nerve

 Tendon of extensor hallucis longus can be ruptured in injury  impossible to extend big toe – it
stays in a flexed position.
  difficult to walk without shoes – flexed big toe trips patient up.

Extensor digitorum brevis & extensor hallucis brevis

 The extensor digitorum and hallucis longus are assisted in extension by a short
muscle on the dorsum of the foot:
o Extensor digitorum brevis / hallucis brevis
 The muscle arises from the upper surface of the calcaneus
 Divides into 4 tendons:

o Most medial tendon: extensor hallucis brevis

 Passes to the proximal phalynx of big toe

o Lateral 2nd, 3rd & 4th tendons: extensor digitorum brevis

o Insert into the extensor expansions of the toes

 The muscle is supplied by the deep peroneal nerve

LUMBRICAL & INTEROSSEOUS MUSCLES:

 As in the hand
 But play a much less important role than those in the hand

 Lumbricals:
o Arise: long flexor tendons in the sole of the foot
 Interossei:
o Arise: metatarsal bones
 The tendons of both insert into the extensor expansions of 2nd, 3rd, 4th & 5th toes.

 Action:
o Flex metatarsophalangeal joint
o Weakly extend interphalangeal joint

 Most medial (& superficial) muscle of anterior compartment:

Tibialis anterior:
 Large
 Origin:
o Tibia (this is a medial muscle)
 o Interosseous membrane

 Passes deep to extensor retinacula – covered with its own synovial sheath

 Insertion: medial side of foot:

o Medial cuneiform
o First metatarsal

 Action:
o Dorsiflexion of the foot
o Adductor-inversion (points toes towards midline and raises medial foot)

 Tibialis anterior is supplied by the deep peroneal nerve

 Most lateral muscle of the anterior compartment:

Peroneal muscles:
• Peroneus longus
o Origin: upper part of fibula
• Peroneus brevis
o Origin: lower part of fibula

• Both curl around the lateral malleolus  lateral aspect of ankle

• Held in place by 2 retinacula:

o Superior peroneal retinacula
 Lateral malleolus  calcaneus
o Inferior peroneal retinacula
 Attached to lateral calcaneus at both ends
• The 2 peroneus tendons pass beneath the peroneal retinacula:
o Surrounded by common sheath beneath the superior retinacula
o Surrounded by separate individual sheaths beneath inferior retinacula

• Peroneus brevis: inserts into peroneal tubercle at base of 5th metatarsal

• Peroneus longus:
o Sweeps around to sole of foot – held in groove on cuboid by long plantar ligament –
surrounded by synovial sheath.
o Inserts into same bones as tibialis anterior on the medial side of the foot:
 Medial cuneiform
 1st metatarsal
• The tendons of peroneus longus (lateral origin) and tibialis anterior (medial origin) thus pull in
opposite directions:
o Tibialis anterior: adduction-inversion
o Peroneus longus: abduction-eversion

• Both peroneal muscles are supplied by superficial peroneal nerve.

• Blood supply from peroneal branch of posterior tibial artery (all the rest of the anterior
compartment is supplied by the anterior tibial artery).

• Peroneus tertius is a small muscular slip

• Actually slip of extensor digitorum longus, arising from lower fibula
• Tendon is delicate and doesn’t pass through the peroneal retinacula – instead passes deep to
the extensor retinaculum.
• Should be considered with the muscles which pass beneath the extensor retinaculum
• Inserts into base of 5th metatarsal (like peroneus brevis)
• Supplied by: deep peroneal nerve
• Action: weak dorsiflexion.
NEUROVASCULAR SUPPLY TO THE FRONT OF THE LEG:
• Muscles of the front of the leg are supplied by:
o Common peroneal branch of the sciatic nerve (grays calls it fibular nerve)
o Anterior tibial branch of the popliteal artery
(Except peroneal muscles – supplied by peroneal branch of the posterior tibial artery)

• Common peroneal branch was identified leaving the popliteal fossa

• Runs beneath the head of the fibula
• Comes to lie on neck of fibula on lateral side of knee (can be rolled beneath the skin here)
• Divides into:
o Deep peroneal branch
o Superficial peroneal branch
• Mixed nerves – supply all muscles and skin on the front of the leg

Deep peroneal branch:

• Passes onto the front of the interosseous membrane
 o Can be seen here by seperating the tibialis anterior from the extensor digitorum longus
& extensor hallucis longus.
• At ankle it is crossed by tendon of extensor hallicus longus (as the tendon passes to big toe)
• On dorsum of foot it lies between the tendons of extensor digitorum longus & extensor hallucis
longus.
• It passes beneath the extensor retinacula
• Then divides into lateral and medial branches.
• Lateral division: supplies extensor digitorum brevis
• Medial division: cutaneous – supplies 1st cleft skin.

• Whilst in the front of the leg, the deep peroneal branch supplies all the muscles of the anterior
compartment except the peroneal muscles:
o Extensor digitorum longus
o Extensor digitorum brevis
o Extensor hallucis longus
o Extensor hallucis brevis
o Tibialis anterior
o Peroneus tertius

Superficial peroneal branch:

• From the posterior aspect of the neck of the fibula, the
superficial branch passes immediately into the
substance of the peroneus longus & peroneus brevis
• The superficial branch supplies only these 2 peroneal
muscles.

• The superficial nerve then divides into lateral & medial

branches.
• These branches pass superficial to the extensor
retinacula (unlike the deep branch)
• Supplies skin of dorsum of foot and
toes.
Anterior tibial artery
• Branch of popliteal artery
• Pierces interosseous membrane to enter front of leg
• Accompanies the deep peroneal nerve down the leg.
• Supplies blood to muscles on front of leg (except peroneus longus & brevis)
• Passes deep to the extensor retinacula
• Like the deep peroneal nerve, it lies between the tendons of the extensor digitorum longus &
extensor hallucis longus.
• Can be easily palpated in this region
• (The tendon of extensor hallacis longus is particularly visible if the toe is bent).
• At the ankle it gives off the medial and lateral malleolar arteries
• At the foot it gives off the medial and lateral tarsal arteries

• As the anterior tibial artery passes onto the dorsum of the foot it is renamed the dorsalis pedis

• On the dorsum of the foot the dorsalis pedis runs to the 1st web space with the medial branch of
deep peroneal nerve
• Passes into sole of foot

• On the dorsum of the foot the dorsalis pedis also gives off:
o First dorsal metatarsal artery
o Arcuate branch which supplies the metatarsals and toes by means of:
 Dorsal metatarsal branches
 Digital branches

 Note it is the peroneal branch of the posterior tibial artery which supplies the peroneal muscles.
MUSCLES OF THE BACK OF THE LOWER LEG
• Plantar flexion of ankle
• Flexion of toes

• All muscles on the back of the leg are supplied by the tibial nerve

• The muscles are arranged in 3 layers:

o Deepest layer: tibialis posterior
 Origin: tibia + fibia + interosseous membrane
 Insertion: sole of foot
o Middle layer: long flexors of the toes
 Insertion: toes
o Superficial layer: platar flexors of ankle
 Insertion: heel

• The deep and middle layers reach the sole of foot and toes by curling
beneath the medial malleolus (tibia malleolus).
• The outermost layer (platarflexors) insert into the calcaneous tendon.
• Flexor retinaculum is thickening of deep fascia here, holding these
tendons in place.
• Flexor retinaculum: medial malleolus  calcaneus

DEEPEST LAYER OF MUSCLES ON BACK OF LEG:

• Tibialis posterior
• Origin:
o Tibia
o Fibula
o Interosseous membrane
• Tendon passes deep to the flexor retinaculum – surrounded by synovial sheath
• In sole, sends fibrous insertions to nearly all bones of sole
• Main insertion: navicular

• Action:
o Plantar flexion
o Adduction-inversion (as it pulls on medially placed navicular)

• Innervation: tibial nerve

MIDDLE LAYER OF MUSCLES ON BACK OF LEG:

• Flexor digitorum longus
• Flexor hallucis longus
• Next layer of “onion” out from the tibialis posterior – so must have an origin further out.

• Flexor digitorum longus

o Origin: tibia
o Inserts: divides into 4 tendons which insert into terminal phalanges of lateral 4 toes.

• Flexor hallucis longus

 o Origin: fibula
o Inserts: single tendon which inserts into terminal phalanx of big toe.

• Both pass deep to the flexor retinaculum – are covered with separate synovial sheaths.

• Action: flexion of metatasophalangeal joint & interphalangeal joint.

• Innervation: tibial nerve

NOTE the order of the tendons of the deep and middle layers as
they pass beneath the flexor retinaculum:

Tom Dick And a Very Naughty Harry

Tibialis posterior, flexor Digitorum longus, Artery, Vein, Nerve, flexor Hallucis
longus

• As the tendons of flexor digitorum longus & flexor hallicus longus travel along the plantar suface
of the toes, they are held in place by fibrous flexor sheaths.
• ∆ are also surrounded by synovial sheaths

• NOTE the tendons of the flexor digitorum longus would exert a v. oblique pull on toes – as they
travel from medial malleolus and spread to the toes.
• To correct this, a small muscle – flexor accessorius – arises from calcaneus to insert into the
tendon of flexor digitorum longus (note in grays diagrams, called quadratus plante)

• A lumbrical muscle arises from medial side of each tendon of the flexor digitorum longus.
• The muscle winds around to front of metatarsal & insert into extensor expansion
• Assist in flexion of metatarsophalangeal joint – but not as important as in the hand.

SUPERFICIAL LAYER OF MUSCLES ON BACK OF LEG:

• Platar flexion of ankle
• Soleus
• Gastrocnemius
• Plantaris
• All 3 muscles insert as a common tendon into calcaneus
Soleus
• Is the deepest of the 3 muscles
• Origin:
o Tibia: soleal line
o Fibula
• Forms a fibrous arch between these 2 origins.
• Ends in a tendon at the ankle which inserts into common tendon into calcaneus.

Gastrocnemius
• Arises as 2 heads:
o One from lateral femoral condyle
o One from medial femoral condyle
• Makes up most of the muscle mass of the calf
• Inserts into common tendon into calcaneus

Plantaris
• Delicate muscle – mainly exists as tendon
• Arises from femur on medial side of lateral gastrocnemius head
• Plantaris tendon is stretched during running / walking like elastic
• Can return 90% of the elastic potential energy stored
• (important in animals like kangeroos for locomotion)

• Near the ankle, the tendons of gastrocnemius & plantaris fuse with the soleal tendon
• The 3 tendons combined make up the tendo calcaneus – aka achilles tendon.
• Tendo calcaneus inserts into the calcaneus
• Easily palpated on back of ankle.
• Tendo calcaneus is seperated from underlying bone by a small bursa.
• All 3 muscles of the superficial layer are:
o Plantar flexors
o Innervated by the tibial nerve
TENDONS ON THE SOLE OF THE FOOT:
• Deepest layer:
o Tibialis posterior
  navicular (+other bones of sole)
o Peroneus longus (aka fibularis longus)
  medial border of foot: medial
cuneiform + base of big toe metatarsal
 Same insertion as tibialis anterior

• Peroneus longus passes obliquely beneath the long

plantar ligament

• Interossei
o Arise as 2 groups (like those in the hand)
o Insert into the extensor expansions
o Flex the metatarsophalangeal joints
 o Much less precise & important than those in the hand

Summary of deepest layer of sole:

o Metatarsals + their interossei
o Tibialis posterior
o Peroneus longus
o Long plantar ligament

• Superficial to this deep layer on the sole of the foot is:

o Flexor digitorum longus (+ flexor accessorius muscle)
o Flexor hallucis longus

Small muscles form 2 further layers:

Most superficial
• Abductor hallucis
• Abductor digiti minimi
o Arise from the calcaneus
o Insert into the proximal phalanx of the big
and little toe

• Flexor digitorum brevis:

o Between the 2 short abductors
o Arises from calcaneus
o Splits into 4 tendons
o Insert into fibrous flexor sheaths of middle
phalanges of lateral 4 toes
 o Split on the middle phalanges to allow the tendon of the flexor digitorum longus to
reach the terminal phalanges.

Deeper layer of small muscles:

• Short flexors of big toe & toe 5:
o Flexor hallucis brevis
o Flexor digiti minimi
o Insert into the proximal phalanges of big toe & toe 5
• Adductor hallicus:
o Akin to adductor pollicis of hand
o Origin: metatarsals
o Insertion: proximal phalanx of big toe

SEE SEPARATE SUMMARY SHEET FOR LAYERS OF SOLE OF FOOT

NEUROVASCULAR STRUCTURES OF LEG & SOLE OF FOOT
• Sciatic nerve divides in the popliteal fossa
o Common peroneal nerve
o Tibial nerve

• Tibial nerve is responsible for the nerve supply to muscles on back of leg & sole of foot.

• Tibial nerve leaves lower angle of popliteal fossa

• Immediately passes deep to the fibrous arch formed by origin of soleus (superficial layer muscle)
• ∆ lies beneath the superficial layer of muscles on the back of the leg
• Passes down the leg between the muscles of the middle stratum:
o (tibia) Flexor digitorum longus – tibial nerve – flexor hallucis longus (fibia)
• Curls around medial malleolus at ankle, along with the tendons of these muscles (T, D, ANd H)
• Passes beneath the flexor retinaculum

• Under the flexor retinaculum, it divides into 2 terminal branches:

o Medial plantar nerve
o Lateral plantar nerve
• Make comparisons with the nerves of plam of hand:
o Medial plantar nerve (median nerve of hand)
o Lateral plantar nerve (ulnar nerve of hand)

Medial plantar nerve Median nerve

Short muscles of big toe Short muscles of thumb
Most medial lumbrical Lateral 2 lumbricals
Flexor digitorum brevis Counterpart is ‘flexor digitorum superficialis’
which originates in forearm, & is supplied here.

• The lateral plantar nerve is counterpart of ulnar nerve in hand

• Both divide into superficial & deep branches
• The superficial branches supply similar cutaneous segments
• The deep lateral plantar nerve supplies all the short muscles of the foot not supplied by the
medial plantar nerve.

BLOOD SUPPLY TO BACK OF LEG & SOLE OF FOOT

• Popliteal artery
• At lower border of popliteus muscle, popliteal artery
divides into 2 terminal branches:
o Anterior tibial artery
o Posterior tibial artery

Anterior tibial artery:

• Immediately pierces interosseous membrane
• Supplies musculature on front of leg

Posterior tibial artery:

• Larger – as has a greater muscle mass to supply
• Gives off peroneal branch
o Passes deep to soleal bridge  lateral side of leg
o Supplies peroneal muscles

• Posterior tibial artery then continues with the tibial nerve

• Deep to the flexor retinaculum it divides into:
o Medial plantar artery
o Lateral planter artery
• Accompany nerves of the same name (derived from tibial
nerve)

• Lateral plantar artery

o Follows deep branch of lateral plantar nerve into
depths of sole – the plantar arch.
• Both medial plantar arteries & lateral plantar arteries then
give of metatarsal & digital vessels.
VENOUS DRAINAGE OF LOWER LIMB:
o Upright position  considerable hydrostatic pressure for venous blood to overcome.
o Venous return aided by:
• Skeletal muscle pump
• Valves
• Proximity of veins to arteries – pulsation of arteries massages blood up the veins. Especially
true for venae comitantes.

o In leg blood is drained from superficial & deep tissues.

o Superficial veins: outside deep fascia
o Deep veins: inside sheath of deep fascia

o Deep veins:
o Accompany (below + their branches)
 Tibial artery
 Popliteal artery
 Femoral arteries
o Blood flows  external iliac vein
o Blood flows efficiently in the deep veins as are surrounded by muscle & pulsating arteries, &
have valves.

o Superficial veins:
o Have no muscular surround
o Travel in subcutaneous fat, and often have no surrounding arteries.
o They do have valves
o Superficial veins pierce deep fascia  drain into deep veins.
o Valves at the point of perforation ensure that blood drains from superficial  deep (and not
other way round).
o Superficial veins are not good at dealing with engorgement as surrounded by fat: excess blood
extends them and stagnates.

o 2 important superficial veins:

• Great saphenous vein
• Small saphenous vein
o Blood of the foot drains through veins between the
metatarsals into venous arch on dorsum of foot (similar to
hand).
o Why this venous arch structure?
• Pressure on dorsum of foot when walking (& palm
when gripping).
• Venous arch between the boney struts of the foot
allows pressure-free escape-route for blood.
o The venous arch runs into:
• Medially: great saphenous vein
• Laterally: small saphenous vein

Great saphenous vein:

• Runs up over anterior surface of medial malleolus
• Runs through subcutaneous tissue of medial side of leg
• Several important perforations to the deep veins at the
level of the ankle and lower leg.

• Reers posteriorly to negotiate the knee

•  front of the thigh
• Recieves several tributaries in upper part of thigh

• Terminates just below medial end of the inguinal

ligament by perforating the deep fascia through the
saphenous opening.
• Surrounded by cribriform fascia as it passes through
the saphenous opening.
• As with all superficial venous perforations, there is a
valve as the great saphenous vein passes through
the deep fascia.

Small saphenous vein:

• Lateral side of foot  lateral side of ankle 
midline of back of lower leg
• Perforates deep fascia (popliteal fascia) in popliteal
fossa
• Enters the popliteal vein.

LYMPHATIC DRAINAGE OF THE LOWER LIMB

General rule:
o Superficial lympatics follow veins
o Deep lymphatics follow arteries
Superficial lymphatics
• Most lympathics drain along great saphenous vein  vertical inguinal lymph nodes of groin

• Not much lymph drains along the small saphenous vein.

• Since lymph drains from the foot & leg  inguinal nodes, infections of the foot or lower leg lead
to enlarged inguinal lymph nodes.

Deep lymphatics of lower limb:

• Follow arteries & drain into deep inguinal LNs
• Drain through lymph vessels in the femoral canal  abdominal cavity.
•  lymph vessels surrounding external iliac artery  surrounding aorta  thoracic duct

LYMPH NODES IN FEMORAL TRIANGLE

• LNs in femoral triangle are important in filtering lymph from lower limb.
• Arranged in superficial and deep groups.

• Superficial inguinal LNs:

• Arranged like letter ‘T’
• Horizontal: subcutaneous fat below inguinal ligament – receives lymph from lower abdominal
wall, back and perineum.
• Vertical: around great saphenous vein – receives lymph from the lower leg & foot which travels
up superficial lymphatics with the great sapenous vein.

• Deep inguinal LNs:

• Efferents from superficial inguinal LNs pass through the cribriform fascia into the deep inguinal
LNs.
• Deep LNs surround the upper end of the femoral vein
• One node is consistantly found in the femoral canal (medial to femoral vein in the femoral
sheath).

APPLIED ANATOMY OF THE ANKLE & FOOT

FRACTURE OF TIBIA & FIBULA
• Extremely common
• Pattern of fracture depends on force applied:
o Car bumper hitting leg: both tib & fib fracture @ same point
o Skiing accident (a twisting force): tib & fib fracture @ different levels.

• Pott’s fracture: both bones are broken at the level of the malleoli

SPRAINED ANKLE
• V. common
• Usually forced inversion
• Lateral ligament of ankle joint is partially/completely torn.
• Lateral ligament consists of 3 bands
• The bands usually damaged are the:
o Anterior band: talofibular
o Middle band: calcaneofibular
• The posterior band of the ligament ruptures only in severe injury.

MUSCLE / TENDON DAMAGE:

• Plantaris tendon can rupture spontaneously:
o  severe pain in the calf.

• Tendo calcaneus (achilles tendon) can also partially/completely rupture

• Poliomyelitis: often affects the dorsiflexors & evertors of the leg.

o Less common nowadays due to polio vaccine

PROBLEMS WITH NERVES:

• Pressure on common peroneal nerve  paralysis of muscles supplied by this nerve.
• Problem spot is where common peroneal nerve lies superficially on neck of femur.
o Bad positioning of patient on operating table
o Tight plaster of paris / torniquet

Foot drop:
• Permanent damage to common peroneal nerve as it winds around head of the fibula  foot
drop; inability to evert or dorsiflex the foot.
• Patient must walk with high step, so toes don’t hit floor first & trip patient up.

VASCULAR SUPPLY TO THE FOOT:

• Impaired blood supply to lower limb 
o Changes in skin
o Pain in muscles on walking
o Gangrene (death of tissue)
• Should therefore be able to palpate normal pulses in:
o Femoral artery
o Popliteal artery
o Dorsalis pedis
o Posterior tibial artery
• Blockage is often high in aorta / iliacs
• But sometimes localised to leg arteries; these blockages can be removed / bypassed.

Varicose veins
• Abnormally dilated veins in the leg
• Due to loss of function of valves in the perforators (superficial veins  deep veins through deep
fascia):
o At level of ankle
o At perforating terminations of great & small saphenous veins
•  accumilation of blood in the superficial veins
•  dilation of superficial veins
• Blood supply to skin & subcutaneous tissues suffers.

• Varicose veins of perforators on medial side of ankle 

o Skin discolouration
o Ulcers

CONGENITAL ABNORMALITIES
Club foot (talipes equinovarus):
• Baby’s foot is:
o Plantarflexed (toes point downwards)
o Adducted
o Inverted
• Special names for congenital deformities:
o Abnormal plantarflexion: equinis
o Abnormal adduction towards midline: varus

• Generic name for an abnormal ankle position:

talipes

• ∆ ‘club foot’ = talipes equinovarus

• Many congenital abnormalities at the time of birth lie in the soft tissues and so can be corrected
by manipulation.
• BUT if they are neglected, the bones ossify in the abnormal shape & ligaments & capsules
contract further  more drastic surgery needed.
• The same is true for congenital dislocation of the hip.