Lateral posterior leg and sole of the foot

Question 1

Fibularis longus

Answer 1

Origin: proximal 2/3 of the lateral fibula
Insertion: lateral aspect of the medial cuneiform and the first metatarsal
Innervation: superficial fibular nerve L4-S1
Action: eversion and plantar flexion

Question 2

Fibularis brevis

Answer 2

Origin: distal 2/3 of the lateral fibula
Insertion: tuberosity of the 5th metatarsal
Innervation: superficial fibular nerve L4-S1
Action: eversion and plantar flexion

Question 3

Gastrocnemius

Answer 3

Origin: lateral head- lateral femoral condyle, medial head- medial femoral condyle
Insertion: posterior aspect of the calcaneus via the Achilles tendon
Innervation: tibial nerve S1, S2
Action: knee flexion and ankle plantar flexion

Question 4

Soleus

Answer 4

Origin: posterior aspect of the entire tibia and fibular head
Insertion: posterior aspect of the calcaneus via the Achilles tendon
Innervation: tibial nerve S1, S2
Action: ankle plantar flexion

Question 5

Plantaris

Answer 5

Origin: lateral supracondylar line of the femur
Insertion: posterior aspect of the calcaneus via the Achilles tendon
Innervation: tibial nerve S1, S2
Action: assists with ankle plantar flexion (do not need this muscle)
Sometimes runners rupture their plantaris tendon, they get this huge bruising and bleeding in the back of the calf, nobody does anything about it.

Question 6

How do we stretch the gastroc? The soleus?

Answer 6

If you want to isolate the gastroc to stretch it, you need to have your knee straight (extended) to include its action at the knee.
If you only want to stretch the soleus and knock out the gastroc, then you put the knee in flexion

Question 7

What type of muscle is the gastroc?

Answer 7

Type II muscle (or phasic or FG), used for power and short bursts, predominantly burns energy via anaerobic metabolism

Question 8

What type of muscle is the soleus?

Answer 8

Type I muscle (or tonic or SO), anti-gravity/postural muscle, predominantly burns energy via oxidative phosphorylation. Fires all day while you stand, ground reaction forces are posterior, anterior to your ankle so always putting you in light dorsiflexion so soleus always has to fire to balance it out so you don’t fall backward

Question 9

What type of muscle is plantaris?

Answer 9

A lot of muscle spindles - intrafusal fibers that are sensitive to changes in length, there for protective reasons

Question 10

Flexor hallucis longus

Answer 10

Origin: posterior aspect of the fibula and interosseous membrane
Insertion: distal phalanx of the great toe plantarly
Innervation: tibial nerve S1, S2
Action: big toe flexion all joints, can assist with plantar flexion

Question 11

Flexor digitorum longus

Answer 11

Origin: posterior aspect of the tibia and interosseous membrane
Insertion: distal phalanges digits 2-5
Innervation: tibial nerve S1, S2
Action: flexes digits 2-5, can assist with plantar flexion

Question 12

Tibialis posterior

Answer 12

Origin: posterior aspect of the fibula, tibia, and interosseous membrane
Insertion: navicular, cuneiforms, cuboid, and metatarsals 2, 3, 4
Innervation: tibial nerve S1, S2
Action: plantar flexion and inversion

Question 13

Popliteus

Answer 13

Origin: lateral condyle of femur, lateral meniscus
Insertion: posterior surface of the tibia superior to the soleal line
Innervation: tibial nerve L4, L5, S1
Action: unlocks knee; flexes it

Question 14

4 layers in the sole of the foot

Answer 14

Layer 1: 2 AB 1 FLEXOR
Layer 2: Lumbricals, Quadratus plantae, tendons: FDL, FHL, TP
Layer 3: 2 FLEXORS 1 ADD
Layer 4: DABS and PADS 
Total 18 muscles in the sole of the foot

Question 15

Abductor hallucis

Answer 15

Layer 1
Origin: medial tubercle of the calcaneus, flexor retinaculum, plantar aponeurosis
Insertion: medial aspect proximal phalanx digit
Innervation: medial plantar nerve S2, S3
Action: abducts digit 1, helps with flexion of digit 1

Question 16

Abductor digiti minimi

Answer 16

Layer 1
Origin: med/lat tubercles of calcaneus, plantar aponeurosis
Insertion: lateral aspect proximal phalanx digit 5
Innervation: lateral plantar nerve S2, S3
Action: abducts digit 5, help flex digit 5

Question 17

Flexor digitorum brevis

Answer 17

Layer 1
Origin: medial tubercle of calcaneus, flexor retinaculum, plantar aponeurosis
Insertion: both sides middle phalanges lateral 4 digits
Innervation: medial plantar nerve S1, S2
Action: flexes digits 2-5

Question 18

Quadratus plantae

Answer 18

Layer 2
Origin: medial/lateral aspect of plantar surface of calcaneus
Insertion: tendons of FDL (posteriolat)
Innervation: lateral plantar nerve S2, S3
Action: flexes digits 2-5 with the FDL
Corrects the pull of the FDL. FDL tendons run on an angle, quadratus plantae and the FDL work synergistically to give you pure sagittal plane toe flexion so it doesn’t deviate to one side.

Question 19

Lumbricals (4)

Answer 19

Layer 2
Origin: tendons of the FDL
Insertion: medial aspect of the extensor expansions of digits 2-5
Innervation: L1 medial plantar nerve, L2-L4 lateral plantar nerve
Action: flexion MTP, extension IP joints
Lumbrical 1 is uni-pennate; Lumbrical 2-4 bi-pennate

Question 20

Which tendons are in layer 2 of the sole of the foot?

Answer 20

TP: 1st compartment of flexor retinaculum
FDL: 2nd compartment flexor retinaculum
FHL: 4th compartment flexor retinaculum

Question 21

Flexor digiti minimi brevis

Answer 21

Layer 3
Origin: base of 5th metatarsal
Insertion: base of proximal phalanx digit 5
Innervation: lateral plantar nerve S2, S3
Action: flexes digit 5

Question 22

Flexor hallucis brevis

Answer 22

Origin: plantar surface of cuboid and lateral cuneiform
Insertion: both sides of bases proximal phalanx digit 1
Innervation: medial plantar nerve S2, S3
Action: flexes proximal phalanx of digit 1
Has a medial and lateral head which act as a tunnel so that the tendon of the FHL goes through it and is well protected and doesn’t come out until it hits the ITP joints and makes its insertion on the distal phalanx.

Question 23

Adductor hallucis

Answer 23

Layer 3
Origin: oblique head- bases of metatarsals 2-4; transverse head- ligaments of MTP
Insertion: tendons of both heads attach to the lateral side of proximal phalanx digit 1
Innervation: lateral plantar nerve S2, S3
Action: adducts digit 1

Question 24

DABS (4)

Answer 24

Layer 4
All bi-pennate
Origin: adjacent sides of metatarsals 1-5
Insertion: D1 medial side proximal phalanx digit 2; D2-D4 lateral sides digits 2-4
Innervation: lateral plantar nerve S2, S3
Action: abducts digits, flexes MTP joints

Question 25

PADS (3)

Answer 25

Layer 4 All bi-pennate Origin: medial sides metatarsals 3-5 Insertion: medial side of proximal phalanges 3-5 Innervation: lateral plantar nerve S2, S3 Action: adducts digits, flexes MTP joints

Question 26

Saphenous nerve

Answer 26

Innervates the entire medial side of the leg in the front (anterior)

Question 27

Lateral sural cutaneous nerve

Answer 27

Innervates the lateral aspect of the lower leg

Question 28

Sural nerve

Answer 28

Innervates posterior, lateral, inferior aspect of the leg

Question 29

Peroneal retinaculum

Answer 29

On lateral aspect of lower leg and foot. Superior peroneal retinaculum - from back of fibula to calcaneus, fibularis longus/brevis have same tendon sheath. Inferior peroneal retinaculum - calcaneus, tendons here have separate sheaths

Question 30

Through trauma the retinaculum can

Answer 30

Become torn and the tendon can snap in and out of the retinaculum becoming painful and starting a pretty vicious inflammatory process, would eventually need to be surgically repaired

Question 31

Nerve of the lateral compartment

Answer 31

Superficial to the fibula nerve

Question 32

Artery of the lateral compartment

Answer 32

Fibula/peroneal artery

Question 33

When is the fibularis longus/brevis important for dynamic stability?

Answer 33

After a lateral ankle sprain, loss of passive stability, these muscles are going to be very important to compensate for the torn ligament that’s not going to heal itself

Question 34

Men (5th decade of life) have a high likelihood of tearing

Answer 34

Achilles tendon, weekend warriors, needs to be surgically repaired

Question 35

Blood supply from femoral artery down through lower leg

Answer 35

Femoral artery becomes popliteal artery at the add magnus hiatus. Popliteal artery goes thru hiatus in soleus, splits into anterior tibial artery and posterior tibial artery. Anterior tibial artery brings blood supply to the anterior compartment. Posterior tibial artery brings blood supply to the posterior compartment. Posterior tibial artery runs down back of leg and gives off largest branch called the peroneal artery. Then it heads posterior to the medial malleolus and pierces the flexor retinaculum 4 compartments.

Question 36

4 compartments in flexor retinaculum

Answer 36

TOM = tibialis posterior (first comp - first tendon you run into behind medial malleolus) DICK = flexor digitorum longus (second comp - second tendon right below that) A very nervous = posterior tibial artery, posterior tibial vein, tibial nerve (third compartment has all vessels) Harry = flexor hallucis longus (fourth comp)

Question 37

Superficial posterior compartment is separated from deep posterior compartment by the

Answer 37

Transverse inter muscular septum

Question 38

Medial tibial stress syndrome (MTSS)

Answer 38

"Shin splints" Have to have pain on the medial posterior aspect of the tibia. Periostitis, periosteum around the tibia gets inflamed and begins to rip off the shaft of the tibia, burning searing hot pain that is extremely tender to palpation. Runners get this. Should not be encouraged to stop running first, there is a period of rest (cut mileage down in half) and then slowly bring them back up. Treat- manual therapy, tissue stretching, neuromuscular reeducation at the hip, taping.

Question 39

How can you tell if someone has a stress fracture?

Answer 39

If the pain starts the minute they start to run instead of miles into the run, then it’s a stress fracture. And they usually have bone tenderness, not soft tissue tenderness. And if you take a tuning fork and whack it and put it on the tibia it usually elicits the pain.

Question 40

Plantar aponeurosis

Answer 40

Dense CT (thick central portion, weaker med/lat bands) Holds the parts of the foot together Helps prevent injury to plantar aspect of the foot Helps support longitudinal arches of the foot

Question 41

Plantar fasciitis

Answer 41

Scarring and breakdown of the plantar fascia (not inflammation), can affect men or women at any age. People develop an insidious onset of foot pain on the sole of the foot that progressively gets worse and is the most painful with the first few steps of the morning upon wakening because they’ve been lying down all night in plantar flexion and they haven’t stretched out their calf and plantar fascia for several hours and until they get the juices going in the body the first few steps are very painful, then it eases off, then by the end of the day its painful again.

Question 42

Midline of the foot is

Answer 42

Digit 2

Question 43

Two bones at the MTP joint

Answer 43

Medial and lateral sesamoid bones. Ballet dancers sometimes get lots of pain on the plantar aspect of their first MTP joint. They could have flexor hallucis longus tendinitis, could have sesamoiditis, could have a fracture of one of these bones, could have flexor hallucis brevis tendonitis, could have a bunion, could have hallux valgus, could have hallux rigidtis (osteoarthritis of first MTP joint). Rest would be ideal in most of these cases to calm the inflammation, next goal would be to restore mobility in the first MTP joint and the entire first ray, improve intrinsic muscle control, and then look proximally for any impairments (all the way up to hip) that would have caused this in the first place.

Question 44

Blood supply sole of the foot

Answer 44

Posterior tibial artery in 3rd compartment of flexor retinaculum. Divides distal to the medial malleolus into the medial plantar artery and the lateral plantar artery. The lateral plantar artery will join the deep plantar artery of the dorsalis pedis artery. In the foot there is one arterial arch on the dorsum and one on the sole of the foot

Question 45

Tibial nerve

Answer 45

In 3rd compartment of flexor retinaculum. | Divides distal to the medial malleolus into the medial plantar nerve and the lateral plantar nerve