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Dr. Kaan Yücel
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Yeditepe Anatomy
CLINICAL ANATOMY OF THE LOWER LIMB
PART II
LEG & FOOT
13. March.2012 Tuesday
Gastrocnemius Strain
Gastrocnemius strain (tennis leg) is a painful acute injury resulting from partial tearing of the medial belly of
the gastrocnemius at or near its musculotendinous junction, often seen in individuals older than 40 years of age.
It is caused by overstretching the muscle by concomitant full extension of the knee and dorsiflexion of the ankle
joint. Usually, an abrupt onset of stabbing pain is followed by edema and spasm of the gastrocnemius.
Ruptured Calcaneal Tendon
Rupture of the calcaneal tendon is often sustained by poorly conditioned people with a history of calcaneal
tendinitis. The injury is typically experienced as an audible snap during a forceful push off (plantarflexion with
the knee extended) followed immediately by sudden calf pain and sudden dorsiflexion of the plantarflexed foot.
In a completely ruptured tendon, a gap is palpable, usually 1-5 cm proximal to the calcaneal attachment. The
muscles affected are the gastrocnemius, soleus, and plantaris.
Calcaneal tendon rupture is probably the most severe acute muscular problem of the leg. Individuals with this
injury cannot plantarflex against resistance (cannot raise the heel from the ground or balance on the affected
side), and passive dorsiflexion (usually limited to 20° from neutral) is excessive.
Ambulation is possible only when the limb is laterally (externally) rotated, rolling over the transversely placed
foot during the stance phase without push off. Bruising appears in the malleolar region, and a lump usually
appears in the calf owing to shortening of the triceps surae. In older or nonathletic people, non-surgical repairs
are often adequate, but surgical intervention is usually advised for those with active lifestyles.
Calcaneal Tendinitis
Inflammation of the calcaneal tendon constitutes 9-18% of running injuries. Microscopic tears of collagen
fibers in the tendon, particularly just superior to its attachment to the calcaneus, result in tendinitis, which
causes pain during walking, especially when wearing rigidsoled shoes. Calcaneal tendinitis often occurs during
repetitive activities, especially in individuals who take up running after prolonged inactivity or suddenly
increase the intensity of their training, but it may also result from poor footwear or training surfaces.
Fabella in Gastrocnemius
Close to its proximal attachment, the lateral head of the gastrocnemius contains a sesamoid bone, the fabella
(L., bean), which articulates with the lateral femoral condyle and is visible in lateral radiographs of the knee in
3-5% of people..
Superficial Fibular Nerve Entrapment
Chronic ankle sprains may produce recurrent stretching of the superficial fibular nerve, which may cause pain
along the lateral side of the leg and the dorsum of the ankle and foot. Numbness and paresthesia (tickling or
tingling) may be present and increase with activity.
Deep Fibular Nerve Entrapment
Excessive use of muscles supplied by the deep fibular nerve (e.g., during skiing, running, and dancing) may
result in muscle injury and edema in the anterior compartment. This entrapment may cause compression of the
deep fibular nerve and pain in the anterior compartment.
Pain occurs in the dorsum of the foot and usually radiates to the web space between the 1st and 2nd toes.
Because ski boots are a common cause of this type of nerve entrapment, this condition has been called the “ski
boot syndrome”; however, the syndrome also occurs in soccer players and runners and can also result from tight
shoes.
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Dr. Kaan Yücel
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Yeditepe Anatomy
Injury to Common Fibular Nerve and Footdrop
Because of its superficial position, the common fibular is the nerve most often injured in the lower limb, mainly
because it winds subcutaneously around the fibular neck, leaving it vulnerable to direct trauma. This nerve may
also be severed during fracture of the fibular neck or severely stretched when the knee joint is injured or
dislocated.
Severance of the common fibular nerve results in flaccid paralysis of all muscles in the anterior and lateral
compartments of the leg (dorsiflexors of ankle and evertors of foot). The loss of dorsiflexion of the ankle causes
footdrop, which is further exacerbated by unopposed inversion of the foot. This has the effect of making the
limb “too long”: The toes do not clear the ground during the swing phase of walking.
There are several other conditions that may result in a lower limb that is “too long” functionally, for example,
pelvic tilt and spastic paralysis or contraction of the soleus. There are at least three means of compensating for
this problem:

A waddling gait, in which the individual leans to the side opposite the long limb, “hiking” the hip.

A swing-out gait, in which the long limb is swung out laterally (abducted) to allow the toes to clear the
ground.

A high-stepping steppage gait, in which extra flexion is employed at the hip and knee to raise the foot as
high as necessary to keep the toes from hitting the ground.
Because the dropped foot makes it difficult to make the heel strike the ground first as in a normal gait, a
steppage gait is commonly employed in the case of flaccid paralysis. Sometimes an extra “kick” is added as the
free limb swings forward in an attempt to flip the forefoot upward just before setting the foot down.
Injury to Tibial Nerve
Injury to the tibial nerve is uncommon because of its deep and protected position in the popliteal fossa;
however, the nerve may be injured by deep lacerations in the fossa. Posterior dislocation of the knee joint may
also damage the tibial nerve.
Complete division results in the following clinical
features:
Motor: All the muscles in the back of the leg and the sole of the foot are paralyzed. The opposing muscles
dorsiflex the foot at the ankle joint and evert the foot at the subtalar and transverse tarsal joints, an attitude
referred to as calcaneovalgus.
Sensory: Sensation is lost on the sole of the foot; later, trophic ulcers develop.
Posterior Tibial Pulse
The posterior tibial pulse can usually be palpated between the posterior surface of the medial malleolus
and the medial border of the calcaneal tendon. Because the posterior tibial artery passes deep to the flexor
retinaculum, it is important when palpating this pulse to have the person invert the foot to relax the retinaculum.
Failure to do so may lead to the erroneous conclusion that the pulse is absent.
Both arteries are examined simultaneously for equality of force. Palpation of the posterior tibial pulses is
essential for examining patients with occlusive peripheral arterial disease. Although posterior tibial pulses are
absent in approximately 15% of normal young people, absence of posterior tibial pulses is a sign of occlusive
peripheral arterial disease in people older than 60 years. For example, intermittent claudication, characterized
by leg pain and cramps, develops during walking and disappears after rest. These conditions result from
ischemia of the leg muscles caused by narrowing or occlusion of the leg arteries.
Varicose Veins
A varicosed vein is one that has a larger diameter than normal and is elongated and tortuous. Varicosity
of the esophageal and rectal veins is described elsewhere. This condition commonly occurs in the superficial
veins of the lower limb and, although not life threatening, is responsible for considerable discomfort and pain.
Varicose veins have many causes, including hereditary weakness of the vein walls and incompetent
valves; elevated intraabdominal pressure as a result of multiple pregnancies or abdominal tumors; and
thrombophlebitis of the deep veins, which results in the superficial veins becoming the main venous pathway
for the lower limb. It is easy to understand how this condition can be produced by incompetence of a valve in a
perforating vein. Every time the patient exercises, high-pressure venous blood escapes from the deep
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Yeditepe Anatomy
veins into the superficial veins and produces a varicosity, which might be localized to begin with but becomes
more extensive later.
The successful operative treatment of varicose veins depends on the ligation and division of all the main
tributaries of the great or small saphenous veins, to prevent a collateral venous circulation from developing, and
the ligation and division of all the perforating veins responsible for the leakage of high-pressure blood from the
deep to the superficial veins. It is now common practice to also remove or strip the superficial veins. Needless
to say, it is imperative to ascertain that the deep veins are patent before operative measures are taken.
Deep Vein Thrombosis andLong-Distance Air Travel
Passengers who sit immobile for hours on long-distance flights are very prone to deep vein thrombosis
in the legs. Preventative measures include stretching of the legs every hour to improve the venous circulation.,
Occlusions of the Popliteal, Anterior, and Posterior Tibial Arteries
Popliteal artery occlusion occurs just below the beginning of the artery (just below the opening in the
adductor magnus muscle). In some cases the occlusion extends distally to involve the origins of the anterior and
posterior tibial arteries and even the peroneal artery. Symptoms include intermittent claudication, night cramps,
and rest pain caused by ischemic neuritis. Signs include impaired or absent arterial pulses, lowered skin
temperature, color changes, muscle weakness, and trophic changes.
Morton's neuroma
A Morton's neuroma is an enlarged common plantar nerve, usually in the third interspace between the
third and fourth toes. In this region of the foot the lateral plantar nerve often unites with the medial plantar
nerve. As the two nerves join, the resulting nerve is typically larger in diameter than those of the other toes.
Also, it is in a relatively subcutaneous position, just above the fat pad of the foot close to the artery and the
vein. Above the nerve is the deep transverse metatarsal ligament, which is a broad strong structure holding the
metatarsals together. Typically, as the patient enters the "push off" phase of walking the interdigital nerve is
sandwiched between the ground and the deep transverse metatarsal ligament. The forces tend to compress the
common plantar nerve, which can be irritated, in which case there is usually some associated inflammatory
change and thickening. Typically, patients experience pain in the third interspace, which may be sharp or dull
and is usually worsened by wearing shoes and walking. Treatment may include injection of anti-inflammatory
drugs, or it may be necessary to surgically remove the lesion.
Tarsal tunnel syndrome
Tarsal tunnel syndrome (TTS), also known as posterior tibial neuralgia, is compression neuropathy and
a painful foot condition in which the tibial nerve is impinged and compressed as it travels through the tarsal
tunnel.
Patients complain typically of numbness in the foot, radiating to the big toe and the first 3 toes, pain,
burning, electrical sensations, and tingling over the base of the foot and the heel. Depending on the area of
entrapment, other areas can be affected. If the entrapment is high, the entire foot can be affected as varying
branches of the tibial nerve can become involved. Ankle pain is also present in patients who have high level
entrapments.
Plantar Fasciitis
Plantar fasciitis, which occurs in individuals who do a great deal of standing or walking, causes pain
and tenderness of the sole of the foot. It is believed to be caused by repeated minor trauma. Repeated attacks of
this condition induce ossification in the posterior attachment of the aponeurosis, forming a calcaneal spur.
Clinical Problems Associated With the Arches of the Foot
Of the three arches, the medial longitudinal is the largest and clinically the most important. The shape of
the bones, the strong ligaments, especially those on the plantar surface of the foot, and the tone of muscles all
play an important role in supporting the arches. It has been shown that in the active foot the tone of muscles is
an important factor in arch support. When the muscles are fatigued by excessive exercise (a long-route march
by an army recruit), by standing for long periods (waitress or nurse), by overweight, or by illness, the muscular
support gives way, the ligaments are stretched, and pain is produced.
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Yeditepe Anatomy
Pes planus (flat foot) is a condition in which the medial longitudinal arch is depressed or collapsed. As
a result, the forefoot is displaced laterally and everted. The muscles and tendons are permanently stretched. The
causes of flat foot are both congenital and acquired.
Pes cavus (clawfoot) is a condition in which the medial longitudinal arch is unduly high. Most cases are
caused by muscle imbalance, in many instances resulting from poliomyelitis.
Plantar Reflex & Babinski Reflex
Stroking the lateral part of the sole of the foot with a fairly sharp object produces plantar flexion of the
big toe; often there is also flexion and adduction of the other toes. This normal response is termed the flexor
plantar reflex.
In some patients, stroking the sole produces extension (dorsiflexion) of the big toe, often with extension
and abduction ("fanning") of the other toes. This abnormal response is termed the extensor plantar reflex, or
Babinski reflex.
The muscles taking part in a fully developed response include extensor hallucis longus, tibialis anterior,
extensor digitorum longus, hamstring group of muscles and tensor faciae latae. The characteristic
response is dorsiflexion (extension) of the big toe, which precedes all other movements. It is followed by
fanning out and extension of the other toes, dorsiflexion of the ankle and flexion of the hip and knee joint. This
response represents ‘positive’ Babinski sign. There is no such thing as a ‘negative’ Babinski sign.
The plantar reflex is a nociceptive segmental spinal reflex that serves the purpose of protecting the sole
of the foot. The clinical significance lies in the fact that the abnormal response reliably indicates metabolic or
structural abnormality in the corticospinal system upstream from the segmental reflex. Thus the extensor reflex
has been observed in structural lesions such as hemorrhage, brain and spinal cord tumors, and multiple
sclerosis, and in abnormal metabolic states such as hypoglycemia, hypoxia, and anesthesia.
Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Walker HK, Hall WD,
Hurst JW, editors. Boston: Butterworths; 1990.Chapter 73The Plantar Reflex
H. Kenneth Walker.http://www.ncbi.nlm.nih.gov/books/NBK397/
The Babinski Sign - A Reappraisal
http://www.sheddonphysio.com/babinski.pdf
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