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Anatomical Variants of the lower
limb & Shank Pain
Dr Eloise Matthews
MP Sports Physicians Registrar
Anatomical Variants & Shank Pain
•
•
•
•
Accessory Soleus
Popliteal Artery Anomalies
PAES
Other Accessory Muscles
Accessory Soleus
● Rare anatomical variant – 1-5%
○ bilateral in 10%
● Soft tissue mass bulging medially btw
distal tibia and Achilles tendon
● Asymptomatic in 25%
● Supplied by post tibial nerve
● Contained in own fascial sleeve with own blood supply
● Insertion variable: achilles / medial calcaneus / superior calcaneus.
● Associations: CECS/ Post tibial Nerve Compression (tarsal tunnel)
Investigation
● X-ray : soft tissue swelling btw deep compartment & Achilles
– obliterates Kager’s triangle on lateral x-ray
● MRI confirms normal muscle & rules out tumor
● Compartment pressure testing
Management
● soft tissue work, strengthening and stretching
● operative mx :
○ fasciotomy
○ excision: if no response to fasciotomy OR
haemorrage/ necrosis on MRI
Popliteal Artery
Anatomical
Variations
Normal:
1. Btw heads of gastroc
2. Posterior to popliteus
50%
Presentation:
PAES
● Deep ache / cramp like pain in the calf or shank
● Pain can be worse walking: running (contraction phase)
● Paresthesias in tibial nerve distribution
● Pain disappears with exercise cessation
● Unaffected by consecutive days of exercise
● Severity related to intensity
Examination: (unreliable for dx)
● 10% signs of acute or chronic lower limb ischemia
● Pop artery bruit / Pulses may be weak or absent following exercise
PAES Investigation
● Doppler U/S Dynamic and symptomatic
● MRI/MRA:
○ relationship between structures
● Angiography
● CT Angiography:
○ site of occlusion/ ddx/ anat variants.
PAES Management
Chronic entrapment can lead to endothelial damage ??? accelerating arthrosclerosis
● Surgery
○ Undamaged popliteal artery : division of abnormal muscle / tendon to
release the popliteal artery (Geurgioitis, 2008).
○ Degeneration of popliteal artery: arterial reconstruction (Macedo, 2003).
● Untreated - intraluminal stenosis / aneurysm formation (Frontera et al, 2006).
RTP: 6-8 months postop
Peroneus quartus
● Incidence : 6-22%
● Origin: Distal lateral fibula
● Descends medial and posterior to the other peroneals
● Insertions:
○
○
○
Retrotrochlear eminence of the calcaneus (most common)
5th metatarsal
Peroneal tendons
○
○
Lateral retinaculum of the ankle
Cuboid
● Lateral ankle pain or instability
● Subluxation/ tearing due to overcrowding peroneal retinaculum
Accessory FDL
●
Incidence: 2-8%
●
Variable origins:
○
flexor retinaculum
○
tibia
○
fibula
○
soleus
○
fhl
●
Posterior and superficial to tibial nerve
●
Beneath flexor retinaculum through tarsal tunnel
●
Leads to tarsal tunnel syndrome, FHL tenosynovitis
Accessory popliteus
● Common origin with lateral head
gastroc
● Passes obliquely through popliteal
fossa, anterior to popliteal vessels
● Compresses popliteal neurovascular
bundle
Tensor fascia suralis
●
Soft tissue mass
popliteal fossa
●
Very Rare
●
“muscular slip
passing from one of
the hamstrings to
the fascia of the
back of the leg”
References
Anderson & Read, 2008, Popliteal Artery Entrapment Syndrome, Atlas of Imaging in Sports Medicine, Chapter 6, pgs 525- 526.
Barry D. Bothroyd JS, Tensor Fasciae Suralis, J Anat. 1924 Jul; 58(Pt 4): 382–383.
Brukner et al, 2012, Popliteal Artery Entrapment, Clinical Sports Medicine, Chapter 36, pgs 770 - 771
Carroll J, Accessory Muscles of the Ankle, MRI Web Clinic — November 2008, http://radsource.us/accessory-muscles-of-the-ankle/#sthash.K41B4Fey.dpuf
Christodoulou A, Terzidis I, Natsis K, Gigis I, Pournaras J, Soleus accessorius, an anomalous muscle in a young athlete: case report and analysis of the literature, Br J
Sports Med 2004;38:e38 doi:10.1136/bjsm.2004.012021
Frontera, Herring, Micheli, Silver, 2006, Neurovascular Causes of Leg Pain, Clinical sports medicine: medical management and rehabilitation, Chapter 32, page
451, retrieved from http://www.mdconsult.com/das/book/pdf/443857492-2/978-1-4160-2443-9/4-u1.0-B978-1-4160-2443-9..50035-0..DOCPDF.pdf?isbn=978-14160-2443-9&eid=4-u1.0-B978-1-4160-2443-9..50035-0..DOCPDF on 21/4/14
Gourgioitis, Aggelakas, Salemis, Elias, Georgiou, 2008, Diagnosis and surgical approach of popliteal artery entrapment syndrome: a retrospective study, Vascular
Health Risk Management, 4 (1), pgs 83-88.
Macedo, Johnson, Hallett, Breen, 2003, Popliteal Artery Entrapment Syndrome: Role of Imaging in Diagnosis, American Journal of Roentgenology, Volume 181,
Number 5, pgs 1259-1265, Retrieved from DOI: 10.2214/ajr.181.5.1811259