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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From A Practical Guide to Clinical Medicine
University of California, San Diego
Region of the lower limb
Superior surface (dorsum of foot) Inferior surface (sole)
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.
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Neurogenesis in the dentate gyrus of the rat hippocampus enhanced by tickling stimulation with positive emotion.
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.
Midfoot and forefoot
Medial compartment of the sole
Central compartment of the sole
Lateral compartment of the sole
interosseous compartment of the foot
Dorsal compartment of the foot
between dorsal fascia of the foot & tarsal bones & dorsal interosseous fascia of the midfoot and forefoot
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.
Attaches above to medial malleolus below to calcaneus
2 compartments on the posterior surface of medial malleolus for tibialis posterior& flexor digitorum longus tendons
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
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
Attached to lateral side of calcaneus
Extensor digitorum longus &
fibularis tertius tendons
Dorsalis pedis artery
Extensor hallucis longus tendon
tibialis anterior tendon
pass under extensor 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
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
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.
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.
OF THE FOOT
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
Organized into four layers
From superficial to deep
or plantar to dorsal
Medial to lateral
Flexor digitorum brevisAbductor digiti minimi
Quadratus plantae Lumbrical muscles
Flexor hallucis brevis
Flexor digiti minimi brevis
Dorsal & plantar interossei
Medialplantarnerve (S2, S3)
Lateralplantarnerve (S2, S3)
Assistsflexordigitorumlongus in flexinglateralfourdigits
Flexproximalphalanges, extendmiddle& distalphalanges of lateralfourdigits
Adductdigits (2-4) andflexmetatarsophalangealjoints
Abductdigits (2-4) andflexmetatarsophalangealjoints
Flexordigit minimi brevissuperficialbranch
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
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
OF THE FOOT
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
Dorsalvenous network of thefoot
Dorsalvenousarch of thefoot
OF THE FOOT
Enters the foot through
posterior to medial malleolus
Lateral to posterior tibial artery
Medial calcaneal branchesheel
medial malleolus & heel
large Medial plantar nerve
smaller Lateral plantar nerve
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.
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.
Skin of theplantaraspects of thelateraloneand a halfdigits, thedorsal skin and nail beds of theirdistalphalanges, and skin of the sole proximaltothem.
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
Emerges as a cutaneous nerve about two thirds of the way down the leg
Skin on the anterolateral aspect of leg
Medial and intermediate dorsal cutaneous nerves
Most of the skin on the dorsum of the foot
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.
Saphenous nervedistally to the head of 1st metatarsal
Superiorly (dorsum of foot)
Deep fibular nerves
Inferiorly (sole of foot)
Medial & lateral plantar nerves
Medial & lateral calcaneal branches of tibial & sural nerves, respectively
OF THE FOOT
medialside of the dorsum& sole of thefoot
Lateralsuperficial lymphatic vessels
lateralside of the dorsum& sole of thefoot