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Exam of the Lower Extremities From A Practical Guide to Clinical Medicine University of California, San Diego. FOOT. IN 30 QUESTIONS. Kaan Yücel M.D., Ph.D. INTRODUCTION TO FOOT. R egion of the lower limb distal to ankle joint S ubdivided into Ankle Metatarsus D igits

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slide1

Exam of the Lower Extremities

From A Practical Guide to Clinical Medicine

University of California, San Diego

  • FOOT
  • IN 30 QUESTIONS
  • Kaan Yücel M.D., Ph.D.
slide2

INTRODUCTION TO FOOT

Region of the lower limb

distaltoankle joint

Subdivided into

Ankle

Metatarsus

Digits

Superior surface (dorsum of foot) Inferior surface (sole)

slide3

INTRODUCTION TO FOOT

  • Body's point of contact with the ground
  • Provides a stable platform for upright stance.
  • Supports the body weight and provides leverage for walking and running.
  • Unique -constructed in the form of arches, adapt its shape to unevensurfaces.
  • Serves as a resilient spring to absorb shocks, such as in jumping.
slide4

SKIN

&

SUBCUTANEOUS TISSUE

  • IN 10 QUESTIONS
slide5

1…skin of the foot

Skin of the dorsum of the foot thinner and less sensitive than that of the sole

The subcutaneous tissue is loose deep to the dorsal skin

Edema most marked on the dorsal skin

especially anterior to and around the medial malleolus

Entire sole is sensitive (“ticklish”), especially the thinner-skinned area underlying the arch of the foot.

Neurosci Res. 2010 Dec;68(4):285-9.

Neurogenesis in the dentate gyrus of the rat hippocampus enhanced by tickling stimulation with positive emotion.

Ticklish?

gargalesis

slide6

2. Deep fascia of the foot & Plantar fascia

Thin where it is continuous proximally with the inferior extensor retinaculum.

Over the lateral and posterior aspects of the footcontinuous with the plantar fascia, the deep fascia of the sole.

Plantar fascia holds the parts of the foot together, helps protect the sole from injury, and helps support the longitudinal arches of the foot.

slide7

3. Compartments by the deep fascia

Midfoot and forefoot

Medial compartment of the sole

Central compartment of the sole

Lateral compartment of the sole

Forefoot

4th compartment

interosseous compartment of the foot

Dorsal compartment of the foot

5th compartment

between dorsal fascia of the foot & tarsal bones & dorsal interosseous fascia of the midfoot and forefoot

http://home.comcast.net/~wnor/soleoffoot.htm

Transverse section of the foot: 1, lateral compartment; 2, central compartment; 3, medial compartment;

4, interosseous compartment. Arrows indicate the high-pressure areas that often lead to foot ulceration.

slide8

4. Tarsal tunnel

  • Formed on the posteromedial side of the ankle by:
  • A depression formed by
  • Medial malleolus of tibia Medial &posterior surfaces of talus
  • Inferior surface of sustentaculum tali Medial surface of calcaneus
  • Overlying flexor retinaculum
  • Contents from ant. to post.
  • (Tom Dick ANdHarry)
  • Tibialis posterior tendon
  • Flexor digitorumlongus tendon
  • Posterior tibial artery
  • Tibial nerve
  • Flexor hallucislongus tendon
slide9

5. Flexor retinaculum

Attaches above to medial malleolus below to calcaneus

2 compartments on the posterior surface of medial malleolus for tibialis posterior& flexor digitorum longus tendons

Laterally

posterior tibial artery ,veins& tibial nerve through tarsal tunnel into sole of foot

Lateral to tibial nerve

tendon of flexor hallucis longus

Pulse of posterior tibial artery through flexor retinaculum midway between medial malleolus and calcaneus

slide10

6. Extensor retinacula

Prevent tendon bowing during extension of the foot and toes

Superior extensor retinaculum Superior to the ankle

Attached to anterior borders of the fibula & tibia

Inferior retinaculum

Y-shaped

Attached to lateral side of calcaneus

Extensor digitorum longus &

fibularis tertius tendons

Medially

Dorsalis pedis artery

Extensor hallucis longus tendon

tibialis anterior tendon

pass under extensor retinacula

slide11

7. Fibular (Peroneal) retinacula

Bind the tendons of

fibularis longus &fibularis brevis

to lateral side of the foot

Superior fibular retinaculum

Between lateral malleolus & calcaneus

Inferior fibular retinaculum

Attaches to lateral surface of calcaneus around fibular trochlea

slide12

8. Plantar aponeurosis

A thickening of deep fascia in the sole of thefoot

A thick centralpart

Weaker medial and lateralparts

Tougher, denser, andelongatedthanpalmaraponeurosis

Anchored to the medial process of calcanealtuberosity

Supports the longitudinal arch of the foot & protects deeper structures in the sole

slide13

9. Fibrous sheaths of toes

Flexor digitorum longus, flexor digitorum brevis, & flexor hallucis longustendons enter fibrous digital sheaths on plantar aspect of digits.

Formed by fibrous arches & cruciate (cross-shaped) ligaments

Hold the tendons to the bony plane and prevent tendon bowing when the toes are flexed.

slide14

10. Extensor hoods

Extensor digitorum longus, extensor digitorum brevis, and extensor hallucis longusexpand over the proximal phalanges to form complex dorsal digital expansions ("extensor hoods").

Manyof the intrinsic muscles of the foot insert here.

Thisallows the forces from these muscles to be distributed over the toes

to cause flexion of the metatarsophalangeal joints while at the same time extending the interphalangeal joints.

slide15

MUSCLES

OF THE FOOT

  • IN 4 QUESTIONS
slide16

20 individual muscles of thefoot

  • 14 located on the plantaraspect
  • 2 on the dorsalaspect
  • 4 intermediate in position
  • Plantar muscles function primarily as a group during the support phase of stance, maintaining the arches of the foot
  • Few delicate functionscomparedtohandmuscles
  • Concerned with supporting the arches of thefoot
slide17

Muscles in the dorsum

Extensor digitorum brevis

Attached to a roughened area on the superolateral surface of the calcaneus lateral to the tarsal sinus

Extensor hallucis brevis

The part of the muscle associated with the great toe

Deepfibularnerve

slide18

Muscles in the sole

Organized into four layers

From superficial to deep

or plantar to dorsal

First layer

Medial to lateral

Abductor hallucis

Flexor digitorum brevisAbductor digiti minimi

Second layer

Quadratus plantae Lumbrical muscles

Third layer

Flexor hallucis brevis

Adductor hallucis

Flexor digiti minimi brevis

Fourth layer

Dorsal & plantar interossei

slide19

Functions & innervations of the muscles of the foot

1st layer

Medialplantarnerve (S2, S3)

Abductorhallucis

Flexordigitorumbrevis

Abductordigiti minimi

Lateralplantarnerve (S2, S3)

2nd layer

Assistsflexordigitorumlongus in flexinglateralfourdigits

Quadratusplantae

Flexproximalphalanges, extendmiddle& distalphalanges of lateralfourdigits

Lumbricals

3rdlayer

4th layer

Plantarinterossei (threemuscles)

Adductdigits (2-4) andflexmetatarsophalangealjoints

Dorsalinterossei (fourmuscles)

Abductdigits (2-4) andflexmetatarsophalangealjoints

Flexorhallucisbrevis

Adductorhallucis

deepbranch

Flexordigit minimi brevissuperficialbranch

slide20

ARTERIES

OF THE FOOT

  • IN 5 QUESTIONS
slide21

Supply of the foot

Terminal branches of

anterior tibial artery &posterior tibial artery

dorsalis pedis artery&plantar arteries

Posterior tibial artery

in the sole divides into

lateral & medial plantar arteries

Lateral plantar artery +Dorsalis pedis artery

Deep plantar arch

slide22

Lateral & medial plantar arteries

  • Lateral plantar artery
  • Major branches of the deep plantar arch
  • Digital branch tolateralside of little toe
  • 4 plantar metatarsal arteries
  • 3 perforating arteries
  • Medial plantar artery
  • Passes deep to the abductor hallucis
  • Ends by joining the digital branch of the deep plantar arch
  • Superficial branch
slide23

Dorsalis pedis artery

Major source of blood supply toforefoot

Continuation of anteriortibialartery

Begins midway betweenmalleoli

Runsdeeptoinferior extensor retinaculum betweenextensor hallucis longus& extensor digitorum longus tendons on the dorsum of thefoot

slide24

Dorsalis pedis artery

  • Passesinferiorly as
  • deepplantarartery
  • Joinsdeep plantar arch in the sole of the foot.
  • Branches
  • lateral and medial tarsalbranches
  • arcuateartery
  • first dorsal metatarsalartery
slide25

VEINS

OF THE FOOT

  • IN 2 QUESTIONS
slide26

As in the rest of the lower limb, there are both superficial and deep veins in the foot.

Unlike the leg and thigh, however, the venous drainage of the foot is primarily to the major superficialveins

slide27

Dorsalmetatarsalveins

Dorsaldigitalveins

Dorsalvenous network of thefoot

Dorsalvenousarch of thefoot

Medialside

Lateralside

Great saphenousvein

Small saphenousvein

slide28

NERVES

OF THE FOOT

  • IN 8 QUESTIONS
slide29

Tibial nerve

  • Deep fibular nerve
  • Superficial fibular nerve
  • Sural nerve
  • Saphenous nerve
  • Tibial nerve
  • All intrinsic muscles of the foot except for the extensor digitorum brevis, innervated by the deep fibular nerve
  • Deep fibular nerve often also contributes to innervation of the first and second dorsal interossei.
slide30

Tibial nerve

Enters the foot through

tarsal tunnel

posterior to medial malleolus

Lateral to posterior tibial artery

Medial calcaneal branchesheel

Midway between

medial malleolus & heel

large Medial plantar nerve

smaller Lateral plantar nerve

slide31

Medialplantar nerves

Larger & moreanterior terminal branchArisesdeeptotheflexorretinaculum

Majorsensorynerve in thesole

Comparedtolateralplantarnerve, supplies more skin area but fewer muscles.

Its distribution to both skin and muscles of comparable to that of the median nerve in the hand.

Skin on most of theanteriortwo-thirds of the sole andadjacentsurfaces of themedialthreeandone-halftoes, whichincludesthegreattoe.

Fourintrinsicmuscles- abductorhallucis, flexordigitorumbrevis, flexorhallucisbrevis, andthefirstlumbrical.

slide32

Lateral plantar nerve

Smaller & more posterior terminal branch

Also courses deep to the abductor hallucis but runs anterolaterally between the 1st and 2nd layers of plantar muscles, on the medial side of the lateral plantar artery.

Ends @ lateral compartment, dividing into superficial and deep branches.

slide33

Lateral plantar nerve

Superficialbranch

Twoplantardigitalnerves

(onecommonandoneproper)

Skin of theplantaraspects of thelateraloneand a halfdigits, thedorsal skin and nail beds of theirdistalphalanges, and skin of the sole proximaltothem.

slide34

Deep fibular nerve

Passes deep toextensorretinaculum

Entersdorsal aspect of the foot on the lateral side of dorsalis pedis artery.

Muscles on dorsum of thefoot

Whenfinally emerges as a cutaneous nerve, so far distal in the foot ;

small area of skin remains available for innervation: web of skin between and contiguous sides of the 1st and 2nd toes

Divides into two dorsal digitalnerves

slide35

Superficial fibular nerve

Emerges as a cutaneous nerve about two thirds of the way down the leg

Skin on the anterolateral aspect of leg

Divides into

Medial and intermediate dorsal cutaneous nerves

Most of the skin on the dorsum of the foot

Terminal branches

Dorsal digital nerves

(common & proper)

Skin of the proximal aspect of the medial half of the great toe & that of the lateral three and a half digits.

slide36

Sural nerve

  • Cutaneous branch of tibial nerve Originates high in the leg
  • Sural nerve formation:
  • Medial sural cutaneous nerve (from the tibial nerve)
  • Sural communicating branch of common fibular nerve
  • Accompanies small saphenous vein Enters the foot posterior to the lateral malleolus
  • ankle joint &skin on the lateral side of the foot and dorsolateral surface of the little toe.
slide37

Saphenous nerve

  • Longest & most widely distributed cutaneous branch of the femoral nerve
  • Only branch to extend beyond the knee
  • Originates in the thigh
  • Skin and fascia on the anteromedial aspect of the leg,ankle joint
  • Skin along the medial side of the foot as far anteriorly as the head of the 1st metatarsal , medial side of the proximal foot
slide38

Cutaneous innervation of the foot

Medially

Saphenous nervedistally to the head of 1st metatarsal

Superiorly (dorsum of foot)

Superficial (primarily)

Deep fibular nerves

Inferiorly (sole of foot)

Medial & lateral plantar nerves

Laterally

Sural nerve

Posteriorly (heel)

Medial & lateral calcaneal branches of tibial & sural nerves, respectively

slide40

Medialsuperficial lymphaticvessels

medialside of the dorsum& sole of thefoot

Accompanygreatsaphenous vein

Lateralsuperficial lymphatic vessels

lateralside of the dorsum& sole of thefoot

Accompanysmallsaphenous vein

Deepinguinal lymphnodes

Iliaclymphnodes