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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
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)
● 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
● soft tissue work, strengthening and stretching
● operative mx :
○ fasciotomy
○ excision: if no response to fasciotomy OR
haemorrage/ necrosis on MRI
Popliteal Artery
1. Btw heads of gastroc
2. Posterior to popliteus
● 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
○ 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
● Lateral ankle pain or instability
● Subluxation/ tearing due to overcrowding peroneal retinaculum
Accessory FDL
Incidence: 2-8%
Variable origins:
flexor retinaculum
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
● Passes obliquely through popliteal
fossa, anterior to popliteal vessels
● Compresses popliteal neurovascular
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”
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,
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 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