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The Last Leg

A Partial Survey of the Bones, Joints, Muscles, Nerves, Arteries and Veins of the Anatomical Leg and the Foot
Part I: Bones
A. Distal Tibia The distal region of the tibia has a styloid process similar to that found in the radius and ulna, but it has another name, the medial malleolus (malleolus means little hammer or, perhaps, more literally, little bad thing. If youve ever twisted you ankle, the meaning of the name is perfectly clear. The medial malleolus forms the bone of the medial ankle and supports the leg on the first tarsal bone, the talus. B. Distal Fibula The distal fibula also has a malleolus, the lateral malleolus. This process forms the lateral ankle bone and also supports the leg on the talus. C. Tarsal Bones Tarsal bones are akin to the carpals of the wrist. There are seven in all; two large and five small. Lets look at the largest tarsals first, the talus, and the calcaneous. The most superior tarsal bone is the talus. The term talus means ankle. Both of the medial and lateral malleoli rest on its sides, holding the leg and foot together. This bone is easily recognized by the smooth articulating surfaces, particularly its superior region. It is like the kingpin for all the tarsal bones. Below the talus is the largest of the tarsal bones, the calcaneous. The term calcaneous means heel, and, as you have guessed, it is the bone that forms the heel of the foot. The calcaneal tendon of the gastrocnemius and soleus muscles inserts at the posterior region of this bone. Some people think this bone resembles a wooden shoe. Some people believe in the tooth fairy. Now lets examine the five small tarsal bones. These bones articulate with either the calcaneous or the talus. The largest is the cuboid bone (its name is self explanatory). The cuboid rests on the lateral side of the foot and atriculates with the anterior region of calcaneous. Articulating medially with the posterior of the cuboid is a little bone that resembles a fat little boat called the navicular. Indeed this word is the Latin for little ship. Articulating from the navicular are the three cuneiform bones: Mamma, Pappa, and Baby cuneiform. No, its not that simple, and my little joke is probably not that helpful, but lets work with it a bit and see what happens. In reality, the bones are the lateral cuneiform, the intermediate cuneiform, and the medial cuneiform. Cuneiform means wedge, and indeed these bones are wedged together forming the apex and medial aspects of the foot. Getting back to the names, note that the largest of the cuneiforms is the most medial. Big Daddy cuneiform articulates with the metatarsal of the big toe, so hes got to be pretty solid. Now the lateral cuneiform actually rests at the apex of the foot (Pappa puts Mamma on a pedestal). This cuneiform is tough to remember because it is not even close to the lateral edge of the foot. Recall that the cuboid bone resides there. However, as cuneiforms go, this one is the most lateral, hence the name. Baby cuneiform is wedged in the middle of the lateral and medial cuneiforms. Its called the intermediate cuneiform. Its not that small; it is wider but shorter than the lateral cuneiform. Its

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the fat kid in the family. The articulations of these last two cuneiforms are straight forward. The lateral cuneiform articulates with the third metatarsal and the intermediate cuneiform articulates with the second metatarsal. Some texts merely number the cuneiforms to match the metatarsals. Thats simpler than keeping track of position, I think, and if you want to learn them that way, be my guest. That brings us to the metatarsals. Hey, were nearly home. D. Metatarsals & Phalanges Just as there are five metacarpals, there are five metatarsals, numbered one through five. Lets look at their distal articulations first. Metatarsal number one articulates with the proximal phalanx of the big toe (hallux). Thats right., the toes are also phalanges! Metatarsal number two articulates with the proximal phalanx of the second toe, and so it goes through number five. Now lets look at the articulations at the proximal ends of the metatarsals. Metatarsals five and four articulate at their proximal ends with the cuboid bone. As mentioned above, three, two and one articulate at the proximal ends with their corresponding cuneiforms. One final point., As with the thumb, the hallux has only two phalanges, one proximal and one distal. Now before we go onto the joints, I have a surprise. Remember the patella? That was a sesamoid bone. The surprise is we also have sesamoid bones and even semsamoid cartilages imbedded in the tendons of the muscles that extend the toes. They are associated with the distal ends of the metatarsals. Im not sure why they are there. Perhaps they give a little more support for the ball of the foot. Although their purpose is not obvious, remember we can never argue with anatomy. We must accept it as it is, and like it or not, there they are.

Part II: Joints

There are numerous joints in the foot and most of them are beyond the scope of this class. But lets look at a few. The foot has flexor and extensor retinacula like the wrist. The flexor retinaculum is in heel and posterior ankle region; the extensor retinaculum covers the anterior ankles and crosses the apex of the foot forming a Z (see Calais-Germain, page 257). In addition, there is also a lateral retinaculum, the peroneal retinaculum that will be discussed with the peroneal muscles. Another ligament worth mentioning is the spring ligament, or the calcaneonavicular ligament. This highly elastic structure is a deep ligament, and rarely illustrated. Even without a picture, I think its worth mentioning because it helps put spring in the step. Thats particularly important for us bipeds. I should also mention that there is an interosseous membrane between the tibia and fibula, similar to the one found between the radius and ulna. Besides keeping the bones bound together, this interosseous membrane also acts as a point of origin for a number of muscles that we will discuss below. Its time for muscles!

Part III: Musculature

4 A. Muscles of the Knee 1. Popliteus (Calais-Germain, page 230) [Model: Flexed 28; Extended 26]. Recall that the region behind the knee is called the popliteal region. When you think of it this way, the name popliteus makes sense because this muscle resides exactly where we would expect it, behind the knee joint. The muscle originates from the side of the lateral condyle of the femur, crosses the fibula and tibia, and inserts below the medial condyle of the tibia on the proximal diaphysis. The popliteus muscle is small, so its simply a synergist to the main knee flexors, the biceps femoris, semitendinosus and semimembranosus, and the gastrocnemius. 2. Gastrocnemius (Calais-Germain, page 230) [Model: Flexed 24 & 25; Extended 24]. The name gastrocnemius means belly of the knee joint. If you think about it cne sounds like knee. I dont know whos responsible for silent letters, but I suspect the French. Anyway, were stuck with them. Furthermore, the body of all muscles, that is the region between the tendons, is often called the belly. Maybe the belly of the knee makes sense after all. The gastrocnemius is a superficial muscles originating from the posterior region of the femur just above the condyles of the femur and inserting into the Achilles tendon (more appropriately named the calcaneal tendon). Achilles was one of those characters in Greek mythology who was half God and half human and could only be killed by shooting an arrow through the tendon of his heel. Lopping his head off just wouldnt do it I guess. Anyway, nobody tried. The calcaneal tendon inserts on the posterior most aspect of the calcaneus. It is a common tendon for the soleus muscle, a calf muscle that lies deep to the gastrocnemius, which we will discuss shortly. The actions of the gastrocnemius are flexion of the knee and plantar flexion (planting the toes and raising the heel). We plantar flex when we walk, run and jump. Remember, Achilles was a great athlete. One more thing before we leave the gastrocnemius. This muscle is primarily white fibered, which means that it has few mitochondria and little blood supply. Taking a step into biochemistry, this design means that the gastrocnemius doesnt use much oxygen when it works, but it creates a toxin, lactic acid, instead. Why would we want that? White twitch fibers are fast twitch fibers, which means that contract and relax very rapidly. In other words, it makes us fast. Sprinters use their gastrocnemius muscles very effectively, but they cant sprint long distances. This is because the lactic acid builds up in the muscle, which results in fatigue. The gastrocnemius, therefore, has little stamina. I guess the same can be said of Achilles. I mean if a little arrow through the heel can do you in, what good are you? B. Extrinsic Anterior Muscles 1. Tibialis Anterior (Calais-Germain, page 258) [Model: Flexed 20; Extended 19]. The tibialis anterior is an easy muscle to find, and so it makes a great landmark. You can see part of the

5 anterior medial tibial bone resting right next to it. Thats right. Its just the bare bone with no muscles covering it. The origin of the tibialis anterior is the lateral condyle of the tibia as well as the proximal lateral region of the diaphysis of the tibia. The tibialis anterior inserts on the medial cuneiform (Big Daddy). Its actions include dorsiflexion, which is pointing the foot up (the opposite of plantar flexion) and inversion, medial rotation of the foot. The tendon of the tibialis anterior crosses under the extensor retinaculum. This holds the tendon in place. Because this muscle inserts on a cuneiform, contraction moves the whole foot. As such, it is a chief muscle in dorsiflexion. 2. Extensor digitorum longus (CalaisGermain, page 258) [Model: Flexed 21; Extended 21]. All toes except the hallux are extended and hyperextended by the extensor digitorum longus. Its origin is the lateral condyle of the tibia, as well as the diaphysis of the fibula and the accompanying interosseous membrane. The tendon of the extensor digitorum longus crosses extensor retinaculum and then splits into four separate tendons each inserting on the phalanges. There is also an extensor hallucis longus that extends and hyperextends the hallux. Because it is a deep muscle and not visible on the models, we will not deal with it in this class. If you would like to study it see Calais-Germain, page 258. C. Extrinsic Lateral Muscles 1. Peroneus longus (Calais-Germain, page 260) [Model: Flexed 22; Extended 22].

The term peroneus means fibula. Some books are starting to call these muscles the fibularis muscles, so be aware of this potential name change. Needless to say, the longest of the peroneus muscles is the peroneus longus. It originates on the lateral side of the fibula just below the head. Its tendon covers quite a distance, traveling first behind the lateral malleus, under the peroneal retinaculum, and then inserting into bump on the lateral region of the calcaneous, just below the fibula. This bump on the calcaneous is the peroneal tubercle. But still the tendon goes on. Its final insertion is on the first metatarsal, forming a sling with the tendon of the tibialis posterior which comes from the opposite side. This sling helps support the lower arch of the foot. So far in this lab, we have slings and we have arrows. Perhaps we can skip the misfortune bit, if thats OK with you. The peroneus longus helps to evert the foot and plantar flexes the ankle. 2. Peroneus brevis (Calais-Germain, page 260) [Model: Flexed 23; Extended 23]. If peroneus longus is long, then peroneus brevis must be short. Peroneus brevis rests below peroneus longus. Its origin is the mid-distal lateral diaphysis of fibula. It, too, passes under the peroneal retinaculum but it inserts on metatarsal five. The actions of peroneus brevis are identical to peroneus longus, plantar flexion and eversion, but it does not help to support the arch. I suppose when youre short, life has its limitations. D. Extrinsic Posterior Muscles

6 1. Flexor digitorum longus (CalaisGermain, page 262) [Model: Flexed 29; Extended 27]. As you might guess, flexor digitorum longus flexes the toes, but not the hallux. Its origin is the posterior medial surface of the tibia, and its insertion is on the inferior surfaces of distal phalanges II-V. This is a muscle that is easily confused with flexor hallicus longus because they appear to be in the wrong places. Flexor digitorum longus is on the medial side of the tibia, and its tendon crosses at a lateral angle under the flexor retinaculum, splitting to accommodate the digits. The opposite is true with flexor hallicus longus as we will soon see. 2. Tibialis posterior (Calais-Germain, page 263) [Model: Flexed 31; Extended 28]. This deep muscle is barely visible on the models, but it is an important one. Tibialis posterior helps to plantar flex the ankle, the opposite action of its anterior cousin. However, these muscles can be synergistic to each other as both work to invert the foot. The origin of tibialis posterior is the interosseus membrane and the corresponding diaphyses of the tibia and fibula. It inserts on the tarsal and the second, third and fourth metatarsal bones, coming from the opposite direction as peroneus longus. As previously mention, the tendons of these muscles form a supporting sling for the inferior arch of the foot allowing the foot to bear more weight. Exceptionally heavy people are often flat footed. 3. Flexor hallucis longus (CalaisGermain, page 264) [Model: Flexed 30; Extended 29]. As the name implies, flexor hallicus longus helps flex the big toe (hallux). Again, this muscle is easy to confuse with flexor digitorum longus. This is because flexor hallicus longus is found in middle of the posterior region of the leg, a place you might associate with the digits. Once again, the tendon of this muscle must cross in the flexor retinaculum to be directed to its proper place of insertion, the inferior surface of the hallux. The origin for flexor hallicus longus is the posterior surface of the fibula. 4. Gastrocnemius revisited (CalaisGermain, page 265-66) [Model: Flexed 24 & 25; Extended 24]. Yes, the gastrocnemius is back! Partly because its an extrinsic posterior muscle, and partly because I neglected to tell you that it has two heads. While these heads usually work together, each head has one distinct action. The medial head of the gastrocnemius inverts the foot; the lateral head everts the foot. Sometimes the soleus, described below, is included with the gastocnemius. Then the three are called the triceps surae. I prefer to keep the muscles separate. Three bellies are more than I can stomach. 5. Soleus (Calais-Germain, page 265-66) [Model: Flexed 27; Extended 24c]. Deep to the gastrocnemius lies the soleus muscle, so named because it resembles a fish. The sole is actually the same shape as this muscle, so they werent that far off with the name.

7 Unlike the gastrocnemius, the soleus is red fibered, rich in blood and mitochondria, and is the muscle of choice for long distance runners. Its origin is the posterior and proximal surfaces of the tibia and fibula; its shares the calcaneal tendon with the gastrocnemius as a point of insertion. Like the gastrocnemius, its chief purpose is plantar flexion. It does not flex the knee, however, having its origin below the knee joint.

Part IV: Nerves (Martini, Figures 14.13 & 14.14, pages 367-368)
The sciatic nerve forms two branches just above the knee, these are the tibial nerve and the peroneal nerve. The tibial nerve travels down the leg as if it were

8 going to travel between the heads of the gastrocnemius muscle, but this nerve actually branches before it reaches the heads. By contrast, the common peroneal nerve travels laterally down the leg. The common peroneal nerve will branch into the deep peroneal nerve and a superficial peroneal nerve. We will discuss these nerves below Tibial nerve [Model: Flexed 42; Extended 64]. The tibial nerve branches into several smaller nerves prior to reaching the gap between the heads of the gastrocnemius muscle. This nerve and its branches innervate the popliteus, gastrocnemius, soleus, tibialis posterior and biceps femoris muscles. It is responsible for flexion of the knee and assists the superficial peroneal nerve in plantar flexion of the ankle. Damage to the tibial nerve is rare because the nerve is deep. When damage does occur, the foot is permanently dorsiflexed. 1. Common peroneal nerve [Model: Flexed 43; Extended 65]. The common peroneal nerve is the smaller branch of the sciatic nerve. It travels laterally to the head of the fibula and travels around the neck of the fibula to pierce the peroneus longus muscle. Here it divides into two branches, the superficial peroneal nerve and the deep peroneal nerve. Damage to this nerve causes the foot to be plantar flexed and inverted, a condition known as footdrop because the patient catches his/her toes on the ground while walking. 2. Deep peroneal nerve [Model: Flexed 43a; Extended 66]. The deep peroneal nerve lies deep to the extensor digitorum longus muscle. It begins laterally, and then crosses behind the muscle medially. It finishes its journey resting lateral to the anterior tibial artery discussed below. The deep peroneal nerve is responsible in part for plantar flexion. The muscles innervated by this nerve include the extensor hallicus longus, extensor digitorum longus, and the tibialis anterior. 3. Superficial peroneal nerve [Model: Flexed 43b; Extended: not numbered, but visible]. In contrast to the deep peroneal nerve, the superficial peroneal nerve travels between peroneus longus and brevis and eventually innervates the skin of the front of the leg and the dorsum of the foot. The superficial peroneal nerve assists the tibial nerve in dorsiflexion by innervating the peroneus longus and brevis muscles. Damage to this nerve includes numbness in the regions of the skin just described.

Summary of Muscular Innervation

1. Tibial nerve: all muscles of the leg and foot except for the muscles innervated by the peroneal (fibular) nerves. 2. Superficial peroneal (fibular): peroneus longus and brevis. 3. Deep peroneal (fibular): tibialis anterior, extensor hallucis longus,

9 extensor digitorum longus and brevis, and peroneus (fibularis) tertius (not discussed, but oh well).

Part V: Blood Vessels

A. Arteries (Martini, Figure 22.18, page 582) 1. Posterior tibial artery [Model: Flexed 54; Extended 56]. The posterior tibial artery and anterior tibial artery split from the popliteal artery just below the popliteal region of the knee joint. The posterior tibial branch passes between the heads of gastrocnemius, traveling deep to the soleus. It rests between the posterior surface of the tibia and the tibialis posterior muscle, crosses the medial malleolus, and flexor retinaculum, and ultimately branches into the medial and lateral plantar arteries. 2. Anterior tibial artery [Model: Flexed 56; Extended 57]. This artery is the small branch of the popliteal artery. It travels to the anterior region of the leg following the interosseous membrane where it forms a neural vascular bundle with the deep peroneal nerve. The anterior tibial artery then passes through the superior extensor retinaculum where it becomes the dorsalis pedis artery. 3. Peroneal artery [Model: Flexed 57; Extended 58]. The peroneal artery branches for the posterior tibial artery where it descends behind the fibula sometimes within and sometimes below the flexor hallicus longus muscle. It has numerous minor branches and ultimately joins other arteries in an anastomses at the ankle joint. 4. Dorsal arch (arcuate artery) The dorsal arch is formed by the union of the dorsalis pedis artery and the lateral tarsal artery. Both are branches of the anterior tibial artery is branch of the posterior tibial artery. Digital arteries as well as perforating arteries arise from this arch. See the illustration on the back page. 5. Plantar arch The medial and lateral plantar arteries both arise from the posterior tibial artery, forming an anastomosis at the base of the foot called the plantar arch. The plantar metatarsal and plantar digital arteries arise form this arch. See the illustration on the back page. B. Veins (Martini, Figure 22.25, page 590) 1. Great saphenous vein Recall that the longest vein in the body is the great saphenous vein. It travels superficially down the medial side of the thigh and leg. The great saphenous vein branches from the femoral vein just below the inguinal

10 ligament. It forms the dorsal venous arch with the small saphenous vein. 2. Small Saphenous vein The small saphenous vein rises from the popliteal vein traveling superficially down the posterior of the leg on the lateral side. Again, this vein joins with the great saphenous vein to form the dorsal venous arch. Digital veins drain into this arch. All other veins of importance travel with their corresponding arteries. As you might have guessed there is also a plantar venous arch. This arch is made by branches of the fibular and posterior tibial arteries. Simply knowing the dorsal arch will be fine for this class. Any more arches would only serve as a vain attempt to prolong this exercise.