PT 514 LE Exam Study Guide

LE Muscle Quizlet LE Bones Bony Landmarks for tendon/ligaments ○ Crest- Narrow ridge ○ Epicondyle- process on a condyle ○ Line- Narrow ridge of bone, less prominent than crest ○ Trochanter- only in femur, larger rounded projection for muscle attachment...

LE Muscle Quizlet LE Bones Bony Landmarks for tendon/ligaments ○ Crest- Narrow ridge ○ Epicondyle- process on a condyle ○ Line- Narrow ridge of bone, less prominent than crest ○ Trochanter- only in femur, larger rounded projection for muscle attachment ○ Tubercle- small projection, often rough ○ Tuberosity- larger, often rough projection Wolff’s Law is a theory that describes how bones adapt to the mechanical stress placed on them Bony landmarks for joint articulation ○ Condyle- large, rounded articular projection ○ Facet- small, smooth, flat articular surface (seen in spine) ○ Head- bony prominence on a narrow neck ○ Ramus- adjoining bar of bone Depressions and openings in bone ○ Fissure: narrow opening ○ Foramen: round opening through bone ○ Fossa: shallow depression, not a full opening ○ Meatus: canal-like passageway, seen in the skull ○ Sinus: cavity within bone, skull landmark Steps to bony alignment (must be able to orient based on one of each) ○ Goal of orientation is to align a bone in anatomical position by identifying and orienting bony landmarks in three cardinal planes ○ Anterior/posterior, medial/lateral, and superior/inferior Important bone landmarks (use complete anatomy to review) ○ Innominate(no name) Articulates with the femur to create the hip joint. Referred to as the pelvis/hip bone. Iliac crest Posterior superior iliac spine(PSIS) Posterior inferior iliac spine(PIIS) Anterior superior iliac spine(ASIS) Anterior inferior iliac spine(AIIS) Acetabulum (including rim, lunate surface, acetabular fossa, acetabular notch) Where femur articulates by the femoral head  Obturator foramen Lesser sciatic notch Greater sciatic notch Ischial spine(separates notches) Iliac fossa Iliac tuberosity Auricular surface(ear-like) Ischial tuberosity Inferior pubic ramus Symphyseal surface Superior pubic ramus Ischial ramus is the adjoining bar of bone that creates small “bridge” of the lower border of the obturator foramen  Innominate bone is made up of Illium (superior), pubis (anterior), ischium (posterior). These connect at the acetabulum ○ Femur Greater trochanter (lateral) Specific to the femur Head Neck Lesser trochanter (posterior) Intertrochanteric line Shaft Adductor tubercle Medial and lateral condyles/epicondyles Patellar surface (Trochlear groove) Fovea (dot in middle of femoral head) Trochanteric fossa Intertrochanteric crest (front there is line, back there is crest) Gluteal tuberosity Linea aspera (long line which is major muscle site for thigh muscles) Popliteal surface ○ Patella(sesamoid bone) Base (rounded) Superior Apex (sharp) Inferior Articular surface Lateral articular surface is larger  Set patella down on the table, with apex away from you. Whichever way patella falls is how to tell which knee it is ○ Tibia Lateral and medial condyles Tibial plateau On top of the condyles Tibial tuberosity Anterior border Ridge at the front of the tibia Medial malleolus Only on tibia Soleal line Posterior line where Soleus attaches Shaft Tibial plateau articulates with lateral and medial femoral condyle Inferior articular surface of tibia articulates with the superior facet of trochlea of talus ○ Fibula Proximal end is rounded and the distal end is flatter Head Neck Shaft Lateral Malleolus Articular surface of lateral malleolus and articular surface of medial malleolus articulate with the talus Malleolar fossa ○ Foot Talus Superior facet of trochlea articulates with the inferior articular surface of tibia Articulates with articular surface of lateral malleolus and articular surface of medial malleolus Calcaneus Tarsal sinus Navicular Medial, lateral and intermediate cuneiforms Cuboid Metatarsals 1-5 Head, shaft and base  Proximal, middle and distal phalanx Tuberosity of 5th Metatarsal Sustentalculum tali Articulations ○ Hip joint- Head of femur articulates with acetabulum of innominate bone ○ Tibiofemoral joint- Lateral condyle of femur articulates with tibial plateau of lateral tibial condyle Medial condyle of femur articulates with tibial plateau of medial tibial condyle Normal for the femoral condyle to extend more distally than laterally See a normal anatomical alignment angle of 170-175 degrees (normal genu valgum) ○ Patellofemoral- Patellar surface/trochlear groove articulates with articular surface of patella Quad and patella tendon Superior aspect on lateral side is more superior than medial for better congruence In extension, patella is in more shallow trochlear groove, as knee flexes it goes deeper into trochlear groove Trochlear groove (sulcus angle) should be about 140 degrees Variation of patella can promote instability Patella importance Increases surface area, decreases stress, and increases quad moment arm Patellar retinacula support patella medially and laterally ○ Talocrural- Articular surface of lateral malleolus and articular surface of medial malleolus articulates with talus, inferior articular surface of tibia articulates with superior facet of trochlea Sinus tarsi- Space between the talus and the bone underneath Talus sits on top of the calcaneus Calcaneal tuberosity is a bony landmark for muscle attachment In front of the talus is the navicular bone, and then the cuneiforms (wedge shape) ○ Lateral side we have a cuboid bone  -Metatarsal bones -numbered from big toe down to the pinky -Proximal phalange, middle phalange, and distal phalange in 2-5 but in big toe there is only two phalanges(no middle phalange) -Tuberosity of 5th metatarsal -Sustentaculum tali (only visible from bottom surface of foot) Palpable landmarks -Iliac crest, ASIS, greater trochanter, pubic tubercle, pubic symphysis, ischial tuberosity -Patella, lateral femoral epicondyle, lateral tibial condyle, head of fibula, medial epicondyle, medial tibial condyle -Tibial tuberosity, medial surface of tibia - Lateral malleolus, tuberosity of 5th metatarsal, medial malleolus, navicular tuberosity, MTP joint, IP joints of the foot Nerves/lumbosacral Plexus Nerve plexus is a network of intersecting nerves Combine ventral rami of spinal nerves into one nerve ○ Contains both motor and sensory nerves Brachial plexus ○ Formed by nerves C5-T1 for Supplies upper extremity Lumbosacral plexus (T12) L1-S4 ○ Lumbar plexus formed by L1-L4 (runs anterior) ○ Sacral plexus formed by L4-S4 (runs posterior) Supplies lower limbs Lumbar plexus supplies nerves that run anteriorly ○ Iliohypogastric: T12-L1-transversus abdominis, internal oblique(the inferior portions of each) Anterior and lateral cutaneous branch ○ Ilioinguinal : L1-transversus abdominis, internal oblique(the inferior portions of each) Anterior scrotal nerves and labial nerves in females  ○ Genitofemoral: L1-L2- cremaster in males(genital branch), labia majora, scrotum Genital branch, femoral branch ○ Lateral femoral cutaneous: L2-L3- Lateral femoral cutaneous nerve ○ Obturator: L2-L4- obturator externus Cutaneous branch Anterior branch-adductor longus, adductor brevis, gracilis, -cutaneous branch Posterior branch- adductor magnus-cutaneous branch ○ Femoral: L2-L4- iliopsoas, pectineus, sartorius, quadriceps, femoris Saphenous: L4 Anterior cutaneous branches, saphenous nerve Sacral plexus supplies nerves that run posteriorly ○ Superior gluteal: L4-S1-gluteus medius, gluteus minimus, tensor fascia latae- Posterior femoral cutaneous nerve ○ Inferior gluteal: L5-S2- gluteus maximus- Posterior femoral cutaneous nerve ○ Sciatic: L4-S3- semitendinosus(Tib), semimembranosus(Tib), biceps femoris(long head=TIb, short head= Fib), adductor magnus(Tib), medial part Common fibular: L4-S1 (S2) Deep fibular: L4-S1- Tibialis anterior, extensor digitorum longus, extensor digitorum brevis, extensor hallucis longus, extensor hallucis brevis, fibularis tertius ○ Lateral cutaneous nerve of the big toe, medial cutaneous nerve of the second toe Superior fibular: L4-S1- Fibularis longus, fibularis brevis ○ Medial dorsal cutaneous nerve, intermediate dorsal cutaneous nerve Tibial: L4-S3-triceps surae, plantaris, popliteus, tibialis posterior, flexor digitorum longus, flexor hallucis longus- Medial sural cutaneous nerve, lateral and medial calcaneal branches, lateral dorsal cutaneous nerve Lateral plantar: S1-S2- flexor hallucis brevis lateral head, quadratus plantae, abductor digiti minimi, flexor digiti mini brevis,  third and 4th lumbricals, 1-3 plantar interossei, 1-4 dorsal interossei, adductor hallucis ○ Proper plantar digital nerves Medial plantar: (L4) L5-S1- abductor hallucis, flexor digitorum brevis, flexor hallucis brevis medial head, first and second lumbricals ○ Proper plantar digital nerves Medial sural: S1 Medial calcaneal: S1 Lateral sural: L5 Proper sural(from medial and lateral Sural):L5-S1 ○ Posterior femoral cutaneous: S1-S3 ○ Pudendal: S2-S4 Important to know segmentation for potential disc herniation and radiculopathy ○ Disc herniation causes compression of spinal nerve  ○ Pattern on one side of the body is known as radiculopathy Myelopathy would be compression of the whole spinal cord that would result in bilateral symptoms Lower extremity blood supply Aorta is a huge artery that comes out of the left ventricle. As it descends the body it is renamed a couple of times ○ Thoracic aorta, Abdominal aorta, split into common iliac arteries Common iliac artery is split again so that it can provide blood to the pelvic region itself ○ Internal iliac artery External iliac artery provides blood down to the leg Blood supply path for anterior body: ○ Common iliac to external iliac ○ Passing under inguinal ligament (ligament on the pelvis that connects the iliac crest to the pubic bone) it becomes femoral artery ○ Femoral artery splits to profunda femoris (deep femoral artery)  ○ Profunda femoris (deep femoral artery) has lateral and medial circumflex arteries Circumflex arteries gives collateral circulation for the femoral head Potential branching variants ○ Femoral artery becomes popliteal artery after crossing under adductor canal and adductor magnus Profunda femoris provides thigh with blood Femoral artery is major blood supply to entire lower leg and foot but NOT thigh ○ Profunda femoris is major blood supply to thigh One major superficial vein is the long saphenous vein ○ Runs around the medial part of the knee joint ○ Brings blood all the way down from your toes, traveling up around the medial knee, and then bringing that blood into a specific area called the femoral triangle ○ Landmark to work back up and find the femoral triangle ○ Short saphenous vein is in back of calf area ○ Dumps blood into the deep vein Deep veins ○ Femoral, Popliteal, Anterior and Posterior tibial Femoral triangle ○ Borders are: Superior: Inguinal ligament, ASIS Medial: Adductor longus Lateral: Sartorius Floor: Iliopsoas and pectineus Roof: Fascia latae ○ Contains NAVEL Femoral nerve, artery, vein, canal (ring) Saphenous nerve Profunda femoris and branches E= empty space Lymph nodes Be able to draw the femoral triangle Knee articulations ○ Tibiofemoral Joint Articulation between medial and lateral condyles Medial tibial condyle is larger Fibula articulates with lateral tibial condyle and NOT femur Medial femoral condyle extends more distally than does lateral  Contributes to anatomical alignment deviation from vertical Normal anatomical alignment: 170-175 degrees external angle ○ Normal genu valgum Tibial articulation is made more concave by menisci Supporting structures surround the joint ○ Patellofemoral Patella Sesamoid bone embedded in the quadriceps tendon Articulates with femur Quadriceps tendon Patellar tendon Large medial and lateral facets ○ Form a V to articulate in the trochlear/intercondylar groove Function: ○ Increase surface area ○ Decrease stress ○ Increased moment arm for quadriceps Trochlear groove Superior aspect is more shallow than inferior aspect ○ Better congruency in flexion Lateral femoral condyle is more anterior than medial Trochlear groove ~140 degrees Variation in size and shape of medial and lateral patellar facets and trochlea of femur ○ Patellar instability Extension: Patella in shallow trochlear groove Flexion: Patella drops into deeper trochlear groove Deep flexion: Quadriceps tendon contacts articular groove Supporting structures of the knee ○ Articular hyaline cartilage ○ Joint capsule ○ Fibrocartilage: Menisci ○ Ligaments: Extrinsic, Intrinsic, and Capsular ○ Patella, Iliotibial band, Retinacula ○ Bursae Lubricate, increase contact area Located under muscle bellies and subcutaneous  Found in following areas: Anterior and medial ○ Suprapatellar ○ Subcutaneous prepatellar ○ Subcutaneous infrapatellar ○ Deep infrapatellar ○ Pes anserinus bursa Posterior ○ Gastrocnemius ○ Popliteus ○ Semimembranosus tendon ○ Fibrous Joint capsule Fibrous sleeve that creates knee joint cavity Fibrous membrane attaches to margins of articular surfaces Reinforced by ligaments for stability Excludes the cruciate ligaments Inner lining is the synovial membrane that makes synovial fluid Lubrication Contains blood vessels that provide blood supply for the meniscus ○ Fibrocartilage is the menisci ○ Extrinsic, intrinsic and capsular ligaments ○ Also supported by patella, iliotibial band, joint capsule, and retinacula Menisci ○ Two fibrocartilage pads that increase concavity of tibial plateau Medial and lateral menisci Anterior and posterior horns ○ Function: Improve congruence Movement of menisci during tibiofemoral motion is needed to improve congruence and distribute forces Distribute weight bearing force ○ Medial meniscus Insertion sites are far apart C shaped Both MCL and joint capsule attach into medial meniscus ○ Lateral meniscus Insertion sites close together, More circular  Coronary attaches meniscus to tibia, allow for movement of lateral meniscus Meniscal ligaments ○ Coronary Attaches menisci to tibia Looser laterally Allows more movement of lateral meniscus ○ Transverse Attaches anterior meniscus to anterior meniscus ○ Meniscofemoral Attaches posterior horn of lateral meniscus to medial femoral condyle Posterior and anterior named based on relative location to posterior cruciate ligament ○ Intercondylar Attaches meniscus horns to intercondylar eminence Blood supply comes from capillaries within synovial membrane and joint capsule ○ Goes lateral to medial, making lateral edges most likely to heal if damaged Be able to draw site of attachment for menisci and cruciate ligaments Knee ligaments by area ○ Anterior knee Patella, patellar tendon, quadriceps tendon ○ Medial knee MCL, medial patellar retinacula ○ Lateral knee LCL, iliotibial band, lateral patellar retinacula, arcuate popliteal ligament ○ Posterior knee Oblique popliteal ligament Derived from the semimembranosus tendon Attaches medial tibial condyle to lateral femoral condyle Arcuate popliteal ligament Attaches lateral femoral and tibial condyle to head of fibula ○ Intrinsic knee ACL, PCL Stabilizing ligaments resisting rotation and anterior/posterior translation of the tibia Also resist varus and valgus stress Named based on tibial attachment  MCL ○ Thickening of the capsule ○ Attaches medial epicondyle of femur to the medial aspects of the proximal tibia ○ Broad and long ○ Superficial and deep layers blend with medial meniscus ○ Resists valgus stress Most effective in extension because it is taut Carries large load when knee is flexed Valgus is the aBduction of the tibia LCL ○ Extracapsular, extrinsic ligament ○ Attaches lateral femoral epicondyle to fibular head ○ Rope like ○ Deep to biceps femoris tendon and superficial to popliteus tendon ○ Resists varus stress Varus is the adduction of the tibia IT band ○ Reinforces knee laterally ○ Formed proximally by fascia investing tensor fascia latae and gluteus maximus ○ Inserts distally into tibial condyle Oblique popliteal ligament ○ Derived from semimembranosus tendon ○ Attaches medial tibial condyle to lateral femoral condyle Acruate pop. ligament ○ Attaches lateral femoral tibial condyle to head of fibula Cruciate ligaments ○ Stabilize to resist rotation and anterior/posterior translation of tibia ○ ACL Attaches medial aspect of lateral femoral condyle to anterior intercondylar fossa Anteromedial and posterolateral bundle Resists anterior tibial translation and internal tibial rotation Also resists varus and valgus stress ○ PCL Attaches intercondylar surface of medial femoral condyle to posterior intercondylar fossa Similar orientation to meniscofemoral ligaments  Meniscofemoral ligaments run from posterior horn of lateral meniscus to lateral wall of medial femoral condyle Resists posterior translation of tibia and anterior translation of femur Also resists varus and valgus stress Knee extensors ○ Anterior compartment of the thigh Quadriceps Vastus lateralis Vastus medialis Vastus intermedius Rectus femoris Sartorius ○ Posterior compartment of the thigh Hamstrings ○ Medial compartment of the thigh Gracilis ○ Posterior compartment of the leg Gastrocnemius Popliteus Vasti Intermedius O: Anterior femur Lateralis O: Lateral lip of linea aspera Medialis O: Medial lip of linea aspera All of these: Insert at tibial tuberosity via patellar tendon Innervated by femoral nerve Extend knee Rectus femoris O: Anterior inferior iliac spine I: Tibial tuberosity via patellar tendon Innervated by femoral nerve Action: extend knee, flex hip  Knee Flexors ○ Anterior thigh Sartorius Gracilis ○ Posterior thigh Semitendinosus Semimembranosus Biceps femoris Long and short head ○ Posterior leg Gastrocnemius Plantaris Popliteus Sartorius ○ O: Anterior superior iliac spine, ASIS ○ I: Medial to the tibial tuberosity via the pes anserinus ○ Innervated by the femoral nerve ○ Action: flex knee, internally rotate knee, flex hip, aBduct hip, externally rotate hip Gracilis ○ O: Inferior pubic ramus ○ I: Medial to the tibial tuberosity via the pes anserinus ○ Innervated by the obturator nerve ○ Action: flex knee, internally rotate knee, flex hip, adduct hip Hamstrings ○ Biceps femoris long head Same origin as semimembranosus Inserts at the head of the fibula Innervated by the tibial nerve Action: flex knee, externally rotate knee, extend hip ○ Semimembranosus Same origin as biceps long head Inserts at the medial tibial condyle Innervated by the tibial nerve Action: flex knee, internally rotate knee, extend hip  ○ Semitendinosus Originates at ischial tuberosity Inserts medial to the tibial tuberosity via the pes anserinus Innervated by the tibial nerve Action: flex knee, internally rotate knee, extend hip ○ Biceps femoris short head Originates at the lateral lip of linea aspera Inserts at the head of the fibula Innervated by the common peroneal nerve Action: flex knee, externally rotate knee, no hip action Pes anserinus ○ Common tendon insertion Sartorius Gracilis Semitendinosus ○ Common actions at the knee Flex Internally rotate ○ Different innervation Sartorius- Femoral nerve Gracilis- Obturator nerve Semitendinosus- Tibial nerve SGT-FOT Gastrocnemius ○ O: Medial and lateral femoral epicondyles ○ I: Calcaneal tuberosity via achilles tendon ○ Innervated by tibial nerve ○ Action: flex knee, plantar flex ankle, invert IT Plantaris ○ O: Lateral femoral epicondyle ○ I: Calcaneal tuberosity via achilles tendon ○ Innervated by tibial nerve ○ Action: small contribution Flex knee, plantar flex ankle, invert IT Popliteus ○ O: Lateral femoral condyle ○ I: Proximal posterior tibial surface ○ Innervated by the tibial nerve ○ Action: flex knee, internally rotate knee  Internally rotate tibia Externally rotate femur Motor Innervation Femoral nerve ○ Quadriceps ○ Sartorius Obturator nerve ○ Gracilis Common fibular nerve ○ Biceps femoris(short head) Tibial nerve ○ Biceps femoris(long head) ○ Semimembranosus ○ Semitendinosus ○ Gastrocnemius ○ Plantaris ○ Popliteus Knee Neurovascular Femoral triangle ○ Borders are: Superior: Inguinal ligament, ASIS- Pubic tubercle Medial: Adductor longus Lateral: Sartorius Floor: Iliopsoas and pectineus Roof: Fascia latae ○ Contains NAVEL Femoral nerve, artery, vein, canal (ring) Femoral sheath(artery, vein, canal) Saphenous nerve Profunda femoris and branches Lymph nodes  Know how to draw thigh cross section Adductor canal ○ Borders are Superior: Apex of femoral triangle Inferior: Adductor hiatus (opening posterior intermuscular septa) Posterior/medial: Adductor magnus (superior) and magnus (inferior) Anterior/lateral: Vastus medialis Roof: Sartorius ○ Contains the femoral artery and vein and saphenous nerve Popliteal fossa ○ Borders are Superior and lateral: Biceps femoris Superior and medial: Semitendinosus and semimembranosus Inferior medial and lateral: Gastrocnemius Floor: Posterior joint capsule  Roof: Deep fascia ○ Contains popliteus, popliteal artery/vein, genicular arteries, tibial nerve, common peroneal (fibular) nerve, and sural cutaneous nerve (medial/lateral) Genicular arteries ○ Knee joint anastomosis Superior medial and lateral Inferior medial and lateral Middle Cruciate ligaments Hip Articulation of head of femur and acetabulum of innominate Synovial, ball and socket joint ○ Three planes of motion Supports the head, arms, and trunk Three bones of the innominate/pelvic bone and fuse together at the Acetabulum ○ Ilium that is superior ○ Ischium that is posterior ○ Pubis that is anterior ER v IR of hip ○ In ER, the greater trochanter and posterior hip move closer together ○ In IR, the greater trochanter and anterior hip move closer together Angle of inclination ○ The line of alignment for femoral shaft and neck Hip joint capsule ○ Surrounded by synovial membrane and fibrous membrane around neck of femur from intertrochanteric line to acetabular Acetabular labrum ○ Fibrocartilage ring that improves bony fit, increases contact area, reduce compression stress Ligament of head of femur (Ligamentum teres femoris) ○ Intrinsic ligament Does not actually support the hip joint or provide stability to the joint itself ○ Attaches acetabular rim to femoral head and supports foveolar artery  Transverse ligament ○ Intrinsic ligament ○ Attachment spans acetabular notch ○ Creates foramen Rotational ligaments ○ All are capsular ○ All limit hyperextension ○ Iliofemoral ligament Y ligament (inverted) attaching from AIIS and acetabular rim down to the intertrochanteric line Intertrochanteric line: anterior between the two trochanters. ○ Limits hyperextension- An anterior ligament is likely going to limit extension Limits adduction Adduction: femur moving in towards midline of the body Individuals who have weak hip extensors hang out on their Y-ligament. They are using the passive stability of that iliofemoral ligament when standing upright instead of using their extensor muscles Strongest of the ligaments ○ PuBofemoral Attaches superior pubic ramus and inferior neck of neck of femur Both anterior ligaments Limits aBduction ○ Ischiofemoral Attaches ischial acetabular rim to intertrochanteric line Limits Internal rotation Wraps around anteriorly to limit hyperextension even though it attaches posteriorly at the ischium ○ Each of the three bones of the pelvis have ligaments Ilio Ischio Pubofemoral Hip ligaments draw femoral head into acetabulum during extension  Ligaments twist during extension to create additional bony stability These sites tend to be a little more vulnerable to dislocation Pelvic girdle and ligaments ○ Pelvic ring Formed by the two innominate bones Anteriorly they connect and form an anterior articulation called the pubic symphysis ○ Symphysis=fibrocartilage joint Sacrum Posteriorly these innominate bones articulate with the sacrum to create sacroiliac (SI) joints Sacroiliac Joint(SI) joint Gliding, synovial joint Connector between what’s happening at the hip between the femur and the innominate bones, and then the spine itself ○ Connection from head, arms, and trunk, and into the pelvis and down to the hip joint Pretty tight connection but there is some movement ○ Allow a baby to move through the pelvic girdle ○ Ligaments able to loosen Anterior sacroiliac ligaments ○ Capsular ○ Attachment: The auricular margins of the sacrum and ilium Posterior sacroiliac ligaments ○ Capsular ○ Attachment: PSIS and auricular margin of the ilium and then to the auricular surface, or the auricular margin of the sacrum. Iliolumbar ○ Extrinsic ○ Stabilizes the lumbar spine ○ Attachment: Transverse process of the lumbar region, L4 and L5, the very bottom-most inferior, or caudal, of the vertebrae. Then attaches down to the iliac crest and anterior sacroiliac ligament  Sacrospinous ligament ○ Extrinsic ○ Attachment: Anterior sacrum to the ischial spine Sacrotuberous ligament ○ Extrinsic ○ Attachment Anterior sacrum to ischial tuberosity These two ligaments together make the sacrum and pelvis move together, move in coordination with one another ○ Supporting the SI joint, even though they’re not specifically crossing like the capsular ligaments ○ They also create foramen Greater sciatic foramen ○ Boundaries Greater sciatic notch, the sacrospinous ligament, and the sacrum Lesser sciatic foramen ○ Boundaries Lesser sciatic notch, the sacrotuberous ligament, and the sacrospinous ligament Sacrotuberous, sacrospinous ligaments are attached anteriorly to the sacrum, go to the ischium in different locations, and also create these foramen Hip muscle group Function ○ Iliofemoral, ischiofemoral, and pubofemoral all wrap anterior, therefore they limit hip hyperextension ○ Sagittal Plane Muscle Control Muscles whose line of pull is Anterior to the axis of rotation would contribute to hip flexion and anterior pelvic tilt ○ Anterior pelvic tilt= pulling your ASIS anteriorly Muscles whose lines of pull are Posterior to the axis rotation are going to contribute to hip extension and posterior pelvic tilt Tucking your tailbone= posterior pelvic tilt ○ Transverse Plane Muscle Control  Muscles whose line of pull is Anterior to the axis of rotation Internal rotation Muscles whose lines of pull are Posterior to the axis of rotation External rotation ○ Frontal Plane Muscle Control Muscles whose line of pull is Superior/Lateral to the axis of rotation Hip abduction Muscles whose line of pull is Inferior/Medial to the axis of rotation Hip adduction Movement of Hip Joint ○ Pelvic tilt Anterior pelvic tilt Rotation of superior aspect of pelvis anteriorly Associated with hip flexion, lumbar extension Cat move in yoga Posterior pelvic tilt Rotation of superior aspect of pelvis posteriorly Associated with hip extension, lumbar flexion Cow move in yoga ○ Superior and lateral line of pull are aBductor muscles ○ Inferior and medial line of pull are adductor muscles ○ Trick for discovering the agonist in an isometric contraction is imagining what would happen if you let go of the position ○  ○ Hip flexors ○ Anterior hip flexors Psoas Major Difficult to see in cadaver lab because it’s actually deep to the intestinal organs Attaches to lateral surfaces of T12-L4 vertebral bodies (also discs) Inserts on the lesser trochanter Innervation comes directly from branches L1-L3 of the lumbar plexus ○ This is because psoas major is so close to the spine that those spinal nerves are coming out and just directly innervate this muscle Action is to flex the hip ○ Lesser trochanter towards the lumbar vertebrae is going to bring hip into a flex position Also externally rotates the hip (small line of pull) Flexes the lumbar spine and ipsilateral lateral flex spine ○ Contract right psoas major and get a trunk side bend to the right Iliacus O: Iliac fossa I: Lesser trochanter Innervated by the femoral nerve ○ Sitting right next to it in the femoral triangle Action is to flex the hip and externally rotate the hip (small) Iliacus and psoas major come together to form a common tendon called the iliopsoas tendon  This is because they have the same insertion: the lesser trochanter Sartorius O: Anterior superior iliac spine I: Medial to the tibial tuberosity via pes anserinus Innervated by the femoral nerve Action is to flex the hip, abduct the hip, externally rotate the hip, flex knee, and internally rotate knee ○ Sagittal and transverse plane hip function Flex and externally rotate Psoas major, Iliacus, Sartorius Rectus Femoris One of the quadriceps muscles that crosses the hip joint O: Anterior inferior iliac spine (AIIS) I: At the tibial tuberosity via the patellar tendon Innervated by the femoral nerve Action is to flex the hip and extend the knee Tensor Fasciae Latae(TFL)-runs all the way down past the knee joint, crossing the knee joint. Tenses the fasciae latae. Originates at the anterior superior iliac spine (ASIS) Inserts into the iliotibial tract ○ Lateral stabilizer of the knee joint Innervated by the superior gluteal nerve Action is to flex the hip (line of pull), aBduct hip (lateral to the axis of rotation), internally rotate hip, and tenses fascia latae Hip flexors: Adductors ○ Gracilis ○ Pectineus ○ Adductor longus ○ Adductor brevis ○ Adductor magnus (anterior fibers) Longus on top, brevis, and then magnus Just anterior fibers of adductor magnus contribute to hip flexion and adduction motion ○ Gracilis Originates at the inferior pubic ramus Inserts medial to the tibial tuberosity via pes anserinus Pes anserinus= goose’s foot ○ Common tendons for the sartorius, gracilis, semitendinosus Innervated by the obturator nerve Within medial compartment innervated the medial thigh muscles Action is to adduct the hip, flex hip, flex knee, and internally rotate knee Anterior to the axis of rotation for the hip joint, but is posterior to axis of rotation for the knee joint Contributes to hip flexion and knee flexion ○ Pectineus Originates at the superior pubic ramus Inserts at the pectineal line Line inferior to the lesser trochanter Innervated by the femoral nerve Femoral nerve also innervates quadriceps Action is to adduct the hip, flex hip, internally rotate hip ○ Adductor longus Most superficial of these adductor muscles. Lying a little bit distal to the pectineus. Fibers run in more of a diagonal direction compared to the pectineus Originates at the superior pubic ramus Inserts at the medial lip of linea aspera Linea aspera also insertion site for biceps femoris short head, vastus lateralis and medialis Innervated by the obturator nerve Action is to adduct the hip, flex hip (up to 70 degrees), and internally rotate hip ○ Adductor brevis Muscle is just deep to adductor longus. Fibers more similar to the pectineus Originates at the inferior pubic ramus, ischial ramus Inserts at the medial lip of linea aspera Same place longus attaches Innervated by the obturator nerve Anterior branch runs on top of adductor brevis Posterior branch runs underneath adductor brevis Action is to adduct hip, internally rotate hip, and flex hip  ○ Adductor magnus (anterior fibers) Originate at the inferior pubic ramus, ischial ramus Inserts at the medial lip of the linea aspera Innervated by the obturator nerve Action is to adduct hip, internally rotate hip, and flex hip ○ Adductor magnus (posterior fibers) Originate at the inferior pubic ramus, ischial tuberosity Inserts at the adductor tubercle of femur Medial structure on the medial part of the femur and being just superior to the medial epicondyle Innervated by the tibial nerve Part of the sciatic nerve running in the posterior part of the leg Action is to adduct hip, externally rotate hip, and extend hip ○ Adductor magnus is self-antagonistic Anterior fibers internally rotate and flex the hip Posterior fibers externally rotate and extend the hip Muscles are innervated at the level of the fascicle Common innervation of hip flexors ○ Femoral nerve Iliacus Rectus femoris Sartorius Pectineus ○ Obturator Nerve Gracilis Adductor longus Adductor brevis Adductor magnus(anterior fibers- flex) Obturator externus* (not a flexor) ○ Superior gluteal nerve Tensor fasciae latae Gluteus medius (anterior fibers- flex) Gluteus minimus (anterior fibers- flex) Hip joint posterior muscles/Hip extensor muscles ○ Gluteus Maximus Very wide origin. It originates at the sacrum, thoracolumbar fascia (both), posterior iliac crest (upper), sacrotuberous ligament (lower) Inserts at the iliotibial tract (upper), gluteal tuberosity (lower)  Innervated by the inferior gluteal nerve Only innervates gluteus maximus Action is to extend hip, externally rotate hip Upper fibers only: aBduct Lower fibers only: adduct ○ Self antagonistic only in frontal plane ○ Gluteus Medius Deep to gluteus maximus Originates at the superior gluteal surface of ilium Inserts at the greater trochanter Innervated by the superior gluteal nerve Superior gluteal nerve also innervates gluteus minimus as well as TFL Action is to aBduct hip Anterior fibers: Flex and internally rotate hip Posterior fibers: Extend and externally rotate hip ○ Self-antagonistic in sagittal and transverse planes ○ Gluteus Minimus Deep to gluteus medius Originates at the inferior gluteal surface of ilium Inserts at the greater trochanter Innervated by the superior gluteal nerve Superior gluteal nerve runs right between medius and minimus and reaches around to TFL Action is to aBduct the hip. Anterior fibers: Flex and internally rotate hip Posterior fibers: Extend and externally rotate hip ○ Self-antagonistic in sagittal and transverse planes ○ These muscles only cross the hip joint so they don't have action at the lumbar spine or at the knee joint: Only function at the hip joint! ○ Gluteus Medius and Minimus Anterior fibers: Flex and internally rotate hip Posterior fibers: Extend and externally rotate hip ○ Hamstrings All hamstrings originate at the ischial tuberosity Ischial tuberosity: sit bone Insertions: Biceps femoris, long head: Head of fibula Semimembranosus: Medial tibial condyle Semitendinosus: Medial to the tibial tuberosity via pes anserinus  ○ Biceps femoris short head does not cross the hip Innervated by the tibial nerve Action is to extend the hip and flex the knee Semimembranosus and semitendinosus: Internally rotate knee Biceps femoris long head: Externally rotate knee No transverse plane or frontal plane motion at the hip. Just hip extensors Hip external Rotators/Small external hip rotators ○ Piriformis Key to this area Because of the neurovascular structures that are coming out below and superior to the piriformis Originates at the anterior surface of the sacrum No other muscles besides glut. max attach to the sacrum Inserts at the greater trochanter Innervated by the L5-S2 direct branches from the sacral plexus Action is to externally rotate the hip, aBduct hip, and extend hip Superior/lateral to axis of rotation: Hip aBduction Posterior on the axis of rotation: Hip extensor ○ Obturator Internus Inferior to the piriformis Originates at the inner surface of obturator membrane Inserts at the medial greater trochanter Innervated by the L5, S1 direct branches from sacral plexus Action is to externally rotate hip and extend hip Adduct hip when hip is 30 degrees aBducted ○ Gemelli Gemellus superior and gemellus inferior Obturator foramen separates these two muscles Superior originates at the ischial spine Inferior originates at the ischial tuberosity Same origin as hamstring muscles Inserts at the medial greater trochanter Innervated by the L5, S1 direct branches from the sacral plexus Action is to externally rotate hip and extend the hip Adduct hip when hip is 30 degrees aBducted Order: Piriformis. Gemellus superior. Obturator internus. Gemellus inferior. Quadratus femoris ○ Quadratus femoris Originates at the ischial tuberosity Superior portion Inserts at the intertrochanteric crest Inferior of greater trochanter Innervated by L5, S1 direct branches from sacral plexus Action is to externally rotate hip, adduct hip It is inferior and medial fibers that will pull the femur towards the pelvis, pull it towards midline/adduction ○ Obturator externus Hard to see in lab Running from outer surface of obturator membrane, going to trochanteric fossa, so it’s really a deep muscle Hard to see without removing other rotator muscles Originates at the outer surface of the obturator membrane Inserts at the trochanteric fossa Innervated by the obturator nerve Unlike the other muscles Action is to externally rotate hip and adduct hip Not an extensor like the other muscles ○ Same plane as axis of rotation ○ Sagittal and Transverse plane hip function Extend and externally rotate Gluteus maximus Gluteus medius posterior fibers Gluteus minimus posterior fibers Piriformis  Gemellus posterior Gemellus inferior Obturator internus Adductor magnus posterior fibers Extend and internally rotate NONE! ○ Common innervation Small external rotators Direct branches from sacral plexus L5-S1 ○ Obturator internus ○ Gemellus superior ○ Gemellus inferior ○ Quadriceps femoris Direct branches from sacral plexus L5-S2(inferior gluteal nerve) ○ Piriformis Pelvic and Femoral Blood supply  ○ Pelvic blood supply ○ Internal iliac artery Superior and inferior gluteal arteries Run with nerves that have the same name Obturator artery Runs with obturator nerve Provides blood supply down to obturator foramen and membrane ○ Hole in pelvis and membrane covering foramen Anterior branch ○ Supplies anterior medial thigh muscles Posterior branch ○ Gives off foveolar artery Both anastamose around hip Internal pudendal artery Runs with pudendal nerve Loops around: comes off internal iliac. Alcock’s canal Small visceral arteries Rectum Bladder Reproductive organs   Sciatic Foramen ○ Greater sciatic foramen Boundaries: Greater sciatic notch, sacrospinous ligament, sacrum Piriformis Key feature: things coming out above and below Sciatic nerve Comes out below the piriformis Superior and inferior gluteal nerve and artery Superior comes out above piriformis Inferior comes out below piriformis Internal pudendal artery and vein Comes out below piriformis Pudendal nerve Comes out below piriformis Posterior femoral cutaneous nerve Comes out below piriformis ○ Lesser sciatic foramen Boundaries: Lesser sciatic notch, sacrospinous ligament, sacrotuberous ligament Obturator internus Running right between the gemelli Internal pudendal artery and vein Exit out of greater sciatic foramen and then re-enter through lesser sciatic foramen Pudendal nerve Exit out of greater sciatic foramen and then re-enter through lesser sciatic foramen  ○ Sciatic Nerve variants ○ For the most part, exits below the piriformis ○ Sciatic nerve is made up of two nerves Common fibular nerve and tibial nerve Common fibular portion exits right within the piriformis muscle Sometimes we have one of those nerves exiting above the piriformis ○ This is less common  Cutaneous Innervation of the thigh in the gluteal region ○ Focus on peripheral nerves innervating the skin, rather than focusing on the dermatomes Posterior hip cutaneous innervation ○ Superior cluneal: Dorsal rami L1-L3 Dorsal rami go directly into the skin ○ Middle cluneal: Dorsal rami S1-S3 Dorsal rami go directly into the skin ○ Inferior cluneal: from posterior femoral cutaneous, S1-S3  Hip joint movement neutralization chart ○ Neutralization Specific recruitment of agonists that counteract unwanted movements in other planes at a given joint Activation of a variety of muscles in order to eliminate unwanted movements so that the desired movement is uni-planar or occurs at a single joint FOOT & ANKLE Ankle region Joints ○ Tibiofibular joint ○ Talocrural joint ○ Intertarsal joints Subtalar joint Transverse tarsal joint ○ Tarsometatarsal joint ○ Metatarsophalangeal joint ○ Interphalangeal joint Tibiofibular Joints ○ Three separate joints Superior: Articulation between the posterior-lateral aspect of tibia and head of fibula Synovial, plane joint Supported by anterior and posterior ligaments of fibular head ○ Attachments: Anterior and posterior aspects of fibular head to lateral condyle of tibia Middle: Between shafts of tibia and fibula Syndesmosis joint ○ Slightly movable articulation where bony surfaces are united by the interosseous membrane ○ Fibrous joint Inferior: Fibrous union between concave facet of tibia and convex facet of fibula Syndesmosis joint Supported by anterior and posterior tibiofibular ligaments ○ Attach to distal aspects of fibula and tibia ○ Talocrural or Ankle joint Synovial, hinge joint Ankle mortise Crus refers to leg Medial side contains the deltoid ligament ○ Named after uppercase delta greek letter ○ Made up of multiple parts: Anterior tibiotalar, tibionavicular, tibiocalcaneal, posterior tibiotalar All attach at the medial malleolus and fan out to different tarsal bones  Talus Head of talus is anterior ○ Larger diameter anterior Relates to bony fit: Dorsiflexion leads to tibia and fibula articulating with the wider area of the talus ○ Sprains of ligaments When a ligament becomes taut, when the origin and insertion of the ligament separates and it overly extends leading to a sprain Inversion sprain ○ The plantar surface of the foot is moving inward Inversion ○ Excessive inversion of the foot could potentially sprain those lateral ligaments ○ More common Lateral malleolus extends further distally(fibula is longer) than the medial malleolus does, leading to bony stability Medial deltoid ligament restricts eversion Eversion sprain ○ The deltoid ligament could be sprained through an eversion sprain Foot joints ○ Intertarsal joints (joints between tarsal bones) Seven tarsal bones Synovial, plane joints Subtalar ○ Articulation between talus and calcaneus/navicular Talonavicular Calcaneocuboid Cuneocuboid Intercuneiform Cuneonavicular ○ Sinus Tarsi (Tarsal sinus) Space separating anterior and posterior subtalar joint Ligamentous complex within Talocalcaneal ligament Attaches to inferior part of the talus and the superior calcaneus  ○ Binds talus and calcaneus Separates the subtalar joint ○ Head of the talus articulates with the navicular here and calcaneus. Anterior portion of ligament articulates with part of navicular as well then ligament divides the inferior articulation of talus and calcaneus Subdivisions of foot Hindfoot Talus Calcaneus Midfoot Navicular Cuboid 3 Cuneiforms Forefoot Metatarsals Phalanges ○ Transverse tarsal joint Talonavicular and calcaneocuboid Joints between hindfoot and midfoot Helps increase movement of subtalar joint Allows forefoot to stay on ground, while the hind foot is able to move separately Allows for our foot to be able to move over a rocky surface Tarsometatarsal joints ○ Synovial, plane joints, gliding joints ○ The first metatarsal articulates with the medial cuneiform ○ The second metatarsal articulates with the intermediate or middle ○ The third metatarsal articulates with the lateral ○ The fourth and fifth metatarsals articulate with the cuboid Metatarsophalangeal joint ○ Synovial, condyloid ○ Biplanar Flexion/extension of toes Abduction/adduction of toes ○ Make up ball of foot ○ Hallux valgus(bunion) Chronic adduction of first metatarsophalangeal joint Exacerbated by aBductor hallucis and flexor tendons  Muscle bellies in the back of the leg- exacerbate because of the angulation; rather than pull straight back, they add an additional angle More common in females/tighter shoes and very low incidence in unshod population of South atlantic island Interphalangeal joint ○ Synovial,hinge joints (flexion/extension only) ○ Toes 2-5 Proximal interphalangeal(PIPs) Distal interphalangeal(DIPs) ○ Hallux (refers to the big toe) One Interphalangeal joint Does not have a middle phalange Arches of the foot ○ Wedging of tarsals for three arches of the foot Bones form the arches Ligaments support them ○ Function: Dampen shock of the body coming down and making contact with the ground every time you take a step or do any other movement ○ Medial longitudinal arch Supported by flexor hallucis longus tendon Runs right under the arch and goes all the way down to the big toe and the plantar calcaneonavicular(spring ligament) Peak is navicular bone ○ Proximal transverse arch Made up of tarsal bones Cuboid to cuneiform Middle cuneiform is peak ○ Distal transverse arch Made from the heads of the metatarsals Supported by adductor hallucis, transverse head(sit right underneath it) Ligaments of the foot ○ Spring ligament: Plantar Calcaneonavicular Ligament Attachments: Calcaneus to the proximal navicular Supported by tibialis posterior tendon Functions to support the head of talus, medial longitudinal arch, talonavicular joint (transverse tarsal joint)  Just below the talus- talar head is sitting on top of the spring ligament Talus sits on top of the sustentaculum tali ○ Long Plantar Ligament Attachments: Calcaneus to distal cuboid and base of lateral metatarsals Functions to support the calcaneocuboid joint(transverse tarsal joint) Creates tunnel for peroneus longus tendon Peroneus longus muscle is powerful evertor of the foot that runs underneath the long plantar ligament and attaches on the medial cuneiform ○ Short plantar ligament: Plantar Calcaneocuboid Ligament Deep to the long plantar ligament Attachments: Calcaneus to proximal cuboid Functions to supports longitudinal arch, calcaneocuboid joint ○ Plantar Aponeurosis/Fascia Plantar fasciitis would be inflammation of this fascia Attachments: Proximal calcaneus to proximal phalanges Functions to supports longitudinal arch Most superficial thing we see in plantar part of the foot White substance A lot of collagen, connective tissue ○ Deep Transverse Metatarsal Ligament Attachments: Adjacent metatarsal heads Functions to prevent separation of MTP joints Attachment site for adductor hallucis transverse head Looks like a 7 attaching to each of these deep transverse metatarsal ligaments Movements of Leg, Ankle, and Foot ○ Muscles of the Foot Intrinsic muscles Both attachments are within the foot Support the arches, contributes to joint movements of the foot, and pad the soles Smaller muscles “Brevis” muscles Extrinsic muscles Proximal attachment is outside the foot; distal attachment is within the foot Cross the ankle (have an effect there) “Longus” muscles  Talocrural Motion ○ Flexion/extension in sagittal plane Posterior compartment of leg is much bigger than anterior and lateral part because the muscles in the back of the leg are used in propulsion/plantarflexion ○ Anterior compartment contributes to dorsiflexion ○ Posterior/medial= plantarflexion, inversion ○ Anterior/lateral= dorsiflexion, eversion Subtalar Motion ○ Muscles further away from subtalar joint axis of rotation are better at producing torque ○ Eversion Sole of foot is pointed outward ○ Inversion Sole of foot is pointed inward Toes ○ Metatarsophalangeal Superior/dorsal muscles Extend ○ Extension goes to neutral Hyperextend MTP only ○ Getting on “tippy toes” Inferior/plantar muscles Flex ○ Interphalangeal joint Proximal interphalangeal joints Muscles that insert on middle or distal phalange ○ Muscles that insert onto the middle phalange will have action at the proximal interphalangeal joint, but not the distal Distal interphalangeal joints Muscles that insert on distal phalange ○ Toe motion Abduction and adduction Happens at the condyloid of the MTP joint Central digit is the second toe  ○ Second toe can move away from itself towards the pinky toe or away from itself towards the big toe Only abduct in two directions Superficial Posterior Leg muscles ○ Gastrocnemius Medial head originates at the medial epicondyle of femur Lateral head originates at the lateral epicondyle of femur Inserts at the calcaneal tuberosity via the achilles tendon Innervated by the tibial nerve Action Ankle: plantarflex Knee: flex Intertarsal(subtalar): invert ○ Soleus Just deep to the gastrocnemius No function at the knee Originates at the soleal line tibia, head/neck of fibula Inserts at the calcaneal tuberosity via achilles tendon Innervated by tibial nerve Action Ankle: plantarflex Intertarsal: invert ○ Plantaris Originates at the lateral epicondyle of femur Inserts at the calcaneal tuberosity via achilles tendon Innervated by the tibial nerve Big in cats because they can jump high Action Ankle:plantarflex Knee: flex Intertarsal: invert Deep Posterior Leg Muscles ○ Flexor Digitorum Longus(Dick) Extrinsic muscle with muscle belly medial on back of leg Originates at the middle posterior tibia Inserts at the base of distal phalanges digits 2-5 Innervated by the tibial nerve Action MTP 2-5: flex IP 2-5: flex  Ankle: plantarflex IT: invert Cruciform and annular ligaments support the tendon sheaths of the digits Cruciform=cross Annular= more parallel ○ Flexor hallucis Longus(Harry) Attaches laterally and then crosses medially Originates at the distal posterior fibula Inserts at the base of distal first phalanx(hallux) Innervated by the tibial nerve Action MTP 1: flex IP 1: flex Ankle: Plantarflex IT: inverts Supports longitudinal arch ○ Tibialis Posterior(Tom) Broad attachment site because it sits in between those two muscles Originates at the proximal posterior tibia, posterior fibula and IO membrane Inserts at the navicular medial, lateral, and intermediate cuneiforms; base of MT 2-4 Innervated by tibial nerve Action  Ankle: plantarflex IT: inverts (Supports longitudinal and transverse arches) ○ Flexor Retinaculum Connective tissue that is holding these three tendons down towards the ankle joint Prevents bowstringing Attachments: Medial malleolus to calcaneus ○ Tarsal Tunnel Under flexor retinaculum Runs closest to medial malleolus is tibialis posterior muscle(Tom) Next is flexor digitorum longus(Dick) Between is the tibial nerve and posterior tibial artery(and a very nervous) Wrapped back behind, wrapping around the sustentaculum tali is the flexor hallucis longus(Harry) Plantar Foot Muscles ○ First Layer(3) Flexor digitorum brevis ABductor hallucis ABductor digiti minimi ○ Second Layer(4) Flexor digitorum longus-extrinsic  Flexor hallucis longus-extrinsic Quadratus plantae Lumbricals ○ Third Layer(3) Flexor hallucis brevis Adductor hallucis Flexor digiti mini brevis ○ Fourth layer(4) Tibialis posterior- extrinsic Peroneus longus- extrinsic Dorsal interosseous Plantar interosseous First layer ○ ○ Flexor Digitorum Brevis Middle muscle Originates at the calcaneal tuberosity Inserts at the middle phalanges 2-5 Digitorum= 2-5 and not the big toe Innervated by the medial plantar nerve Medial plantar nerve only innervates a few things Action Flex MTP 2-5, Flex PIP 2-5 (not DIP because it does not cross the distal interphalangeal joint) ○ ABductor hallucis Originates at the medial calcaneus Inserts at the base of the 1st proximal phalange Innervated by the medial plantar nerve Action  ABduct 1st MTP Flex 1st MTP ○ ABductor Digiti Minimi Originates at the lateral calcaneal tuberosity Inserts at the base of 5th proximal phalange Innervated by the lateral plantar nerve Action ABduct 5th MTP Flex 5th MTP Second layer ○ ○ Extrinsic muscles Flexor digitorum longus insertion Base of distal phalanges 2-5 Flexor hallucis longus insertion Base of distal phalange 1 ○ Intrinsic muscles Quadratus plantae Originates at the calcaneal tuberosity Inserts at the lateral border FDL tendon Innervated by the lateral plantar nerve Action ○ Redirect and augment FDL pull  Lumbricals Named from medial to lateral similar to toes being numbered 1-5 Originates at the medial border FDL tendons Inserts at the dorsal aponeuroses 2-5 ○ Dorsal aponeurosis=extensor expansions Innervated by ○ 1st lumbrical: Medial plantar nerve ○ 2-4 lumbrical: Lateral plantar nerve Action ○ Flex MTP 2-5 ○ Extend IP 2-5 ○ Adduct MTP 3-5 ○ ABduct MTP 2 2nd toe can only aBduct Third layer- action at the metatarsophalangeal joints only ○ ○ Adductor hallucis, Oblique head Originates at the base of the MT 2-4, cuboid and lateral cuneiform Some similarity to the tibialis posterior insertion that it “exploded” in the bottom of the foot Inserts at the base of the 1st proximal phalanx Innervated by the lateral plantar nerve Action Adduct 1st MTP Flex 1st MTP ○ Adductor hallucis, Transverse head Originates at the deep transverse metatarsal ligament, MTP 3-5 Inserts at the base of 1st proximal phalanx Innervated by the lateral plantar nerve Action Adduct 1st MTP Support transverse arch ○ Flexor hallucis brevis, Medial head Originates at the medial cuneiform Inserts at the base of 1st proximal phalange Innervated by the medial plantar nerve Action Flex 1st MTP ○ Flexor hallucis brevis, Lateral head Originates at the intermediate(middle) cuneiform Inserts at the base of the 1st proximal phalange Innervated by the lateral plantar nerve Action Flex 1st MTP  ○ Sesamoid bones are sesame seed shaped bones that are embedded in these tendons Sesamoids of hallucis Medial side; abductor hallucis, medial head of flexor hallucis brevis Lateral side: adductor hallucis, both heads, and then lateral head of flexor hallucis brevis Between these two bones is the long tendon flexor hallucis longus ○ Flexor Digiti Minimi(Brevis) Originates at the base of the 5th metatarsal Inserts at the base of the 5th proximal phalange Innervated by the lateral plantar nerve Action Flex 5th MTP Fourth Layer ○ Extrinsic muscles ○ Tibialis posterior insertion Navicular, medial,lateral, intermediate cuneiform; base of MT 2-4 ○ Peroneus longus insertion Crossing all the way over/wrapping around medial part of foot and attaching laterally Medial cuneiform; base of MT 1 Plantar interossei(3) Adductors: PAD Originates at the medial border of MT 3-5  Inserts at the medial base of proximal phalange 3-5 Innervated by the lateral plantar nerve Action Plantar: adduct MTP 3-5(PAD) Dorsal interossei(4) ABductors: DAB Originates: Two heads form opposing sides of MT 1-5 Inserts at the first medial base of proximal phalanx; 2nd-4th lateral base proximal phalanx 2-4 Innervated by the lateral plantar nerve Action Dorsal: aBduct MTP 2-4 (DAB) Plantar Foot muscles: Movement Review  ○ ○ ○ Flexor digitorum longus is the only one that crosses over that distal interphalangeal joint and contributes to motion there Frontal plane motion  ○ ○ Anterior Compartment muscles of leg ○ Tibialis Anterior Closest one to the anterior border of tibia Originates at the proximal lateral tibia interosseous membrane Inserts onto the medial cuneiform Innervated by the deep fibular nerve Action Ankle: Dorsiflex IT: inverts ○ Extensor Digitorum Longus Extend the toes Originates at the anterior fibula-lateral tibial condyle; IO membrane Inserts at the base of the middle and distal phalanges 2-5 (dorsal aponeurosis) Innervated by the deep fibular nerve Action IP: extends 2-5  MTP: extends or hyperextends 2-5 Ankle: dorsiflex IT: everts ○ Peroneus Tertius Shares muscle belly with the EDL but ends early instead of extending all the way down to the toes Originates at the distal anterior fibula with extensor digitorum longus muscle Inserts at the dorsal border of 5th metatarsal Innervated by the deep fibular nerve Action Ankle: dorsiflex IT: evert ○ Extensor Hallucis Longus Between tibialis anterior and extensor digitorum longus(EDL) Originates at the medial fibula; IO membrane Inserts at the base of the 1st distal phalanx Innervated by the deep fibular nerve Action 1st IP: extends 1st MTP: extends (hyperextends) Ankle: dorsiflex IT: inverts/everts ○ Kind of special because it is very close to the axis of rotation leading to inversion/eversion of subtalar joint ○ Extensor Retinaculum Superior Attaching from medial-lateral maleoli Inferior Shaped like a Y Connective tissue preventing bowstringing: Lateral malleolus and calcaneus Connective tissue preventing bowstringing: Medial malleolus and navicular Lateral compartment muscles ○ Peroneus (Fibularis) Longus More superficial Originates at the proximal lateral fibula, fibular head Inserts at the medial cuneiform, base of 1st MT  Long plantar ligament creates tunnel Innervated by superficial fibular nerve Action Ankle: plantarflexion IT: everts ○ Peroneus (Fibularis) Brevis Originates at the distal lateral fibula; IO membrane Inserts at the tuberosity of 5th MT Innervated by the superficial fibular nerve Actions Ankle: plantarflex IT: everts ○ Fibular retinaculum Superior Attaching Lateral malleolus- calcaneus Inferior Continuous with inferior extensor retinaculum on calcaneus Neutralization  ○ Muscles of the dorsal foot ○ Extensor hallucis brevis Deeper. Closer to bones with long ligaments on top of EHB Originates at the dorsal surface calcaneus Inserts at the base of 1st proximal phalanx (1st dorsal aponeurosis) Innervated by the deep fibular nerve Action Extends 1st MTP ○ Extensor digitorum brevis Originates at the dorsal surface of calcaneus Inserts at the base of middle phalange 2-4 (dorsal aponeurosis of 2-4) Innervated by the deep fibular nerve Actions: Extends MTP 2-4 Extends PIP 2-4 Sagittal plane motion  ○ ○ ○ Blood supply of leg and foot ○ ○ ○  Plantar blood supply ○ Posterior tibial artery Medial plantar artery Lateral plantar artery Deep plantar arch ○ Anastomosis with dorsal: Deep plantar artery: Branch off of dorsalis pedis artery ○ Running off arch: Plantar metatarsal artery Split at MTP: Plantar digital artery Dorsal blood supply ○ ○ Anterior tibial artery Dorsal pedal artery (dorsalis pedis artery) Branch anastomoses with deep plantar arch: deep plantar artery Collateral circulation in this area is important Lateral tarsal artery Run right over tarsals ○ Arcuate artery Dorsal arch  Anastomosis of: Dorsalis pedal artery Lateral tarsal artery ○ Branches of anterior tibial artery Running off of arcuate: Dorsal metatarsal artery Dorsal digital artery Nerves of leg and foot ○ Sciatic nerve splits into top tibial and common fibula nerves Medial sural cutaneous nerves Branch of tibia Lateral sural cutaneous nerves Branch off common peroneal Sural nerves Lateral and medial sural combine Runs down midline of shank and pierces through the crural fascia and becomes subcutaneous ○ Tibial nerve innervates everything in the posterior compartment ○ Peroneal nerves Common peroneal splits at anterior intermuscular septa Deep peroneal nerve ○ Anterior compartment Superficial peroneal nerve ○ Lateral compartment running right between peroneus longus and peroneus brevis ○ Sciatic nerve  ○ Medial plantar nerve innervates: Abductor hallucis (first layer) Flexor digitorum brevis (first layer) First lumbrical (second layer) Flexor hallucis brevis, medial head (third layer) ○ Lateral plantar nerve Rest of intrinsic muscles