2. MOB TCD
Anterior and Lateral and Posterior
Compartments of Calf
Professor Emeritus Moira O’Brien
FRCPI, FFSEM, FFSEM (UK), FTCD
Trinity College
Dublin
3. MOB TCD
Cutaneous Supply of Calf
• Saphenous first branch is
infrapatellar branch it
• Supplies medial side of the
calf and
• Medial side of foot to ball of
the hallux
• Lateral cutaneous of calf
• Superficial peroneal
• Sural, lateral border of foot
• Deep peroneal first cleft
4. MOB TCD
Fascial Compartments in Calf
• Subcutaneous surface of tibia
• Fascia anterior and posterior
intermuscular septa
• Anterior compartment
• Lateral compartment
• Posterior compartment
Divided
• Superficial
• Deep
• Deep posterior
5. MOB TCD
Extensor Retinacula
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Superior retinaculum
Thickening deep fascia
Tibialis anterior pierces
Other tendons pass posterior
Inferior extensor retinaculum
Inferior stem attached to calcaneus
Upper limb to medial malleolus
Lower limb plantar aponeurosis
6. MOB TCD
Anterior Compartment of Calf
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Tibialis anterior
Extensor hallucis longus
Extensor digitorum longus
Peroneus tertius
All muscles supplied by the
deep peroneal nerve
• Dorsi flexors
• Anterior tibial and
perforating peroneal arteries
7. MOB TCD
Tibialis Anterior
• Upper two thirds
• Lateral surface of tibia and
adjoining area of
interosseous membrane
• And deep fascia
Inserted
• Medial aspect of medial
cuneiform
• And adjoing base of first
metatarsal
8. MOB TCD
Tibialis Anterior
• Synovial sheath
• Passes under superior and
both limbs of inferior
extensor retinaculum
• Dorsi flexor and invertor
• Eccentric pays out, prevents
foot slapping down
• Supports medial arch
• Deep peroneal nerve
9. MOB TCD
Extensor Hallucis Longus
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Middle two fourths
Anterior surface of fibula
Interosseous membrane
Base of distal phalanx of
hallux
• Dorsiflexor big toe and
ankle
• Deep peroneal nerve
• Test for L5
10. MOB TCD
Extensor Hallucis Longus
• Upper three quarter anterior
surface of fibula
• Except the area for the
extensor hallucis longus
• Anterior intermuscular
septum
• Passes under retinacula
• Divides into four tendons
• Joined by slips from brevis
• Lumbricals and interossei
muscles
11. MOB TCD
Extensor Digitorum Longus
• Main extensor tendon inserted into
base of middle phalanx, of the
lateral four toes
• Collateral slips formed by lumbricals
and interossei inserted into distal
phalanx
• Dorsiflexor ankle
• Extends proximal phalanx lateral four
toes
12. MOB TCD
Peroneus Tertius
• Lower quarter of anterior surface of
the fibula
• Inserted into base and dorsum of
shaft of fifth metatarsal
• Dorsiflexor and evertor
13. MOB TCD
Extensor Digitorum Brevis
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Fleshy origin from calcaneus
Stem of inferior retinaculum
Divides into four tendons
First is extensor hallucis brevis
Other three join extensor
expansion of second, third and
fourth toes
• Deep peroneal nerve
14. MOB TCD
Deep Peroneal Nerve
• Branch of the common peroneal at neck of
fibula
• Pierces anterior intermuscular septum
• Runs between extensor digitorum longus and
tibialis anterior
• Then tibialis anterior and extensor hallucis
longus
15. MOB TCD
Deep Peroneal Nerve
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In anterior compartment
Supplies
Tibialis anterior
Extensor hallucis longus
Extensor digitorum longus
Peroneus tertius
Extensor digitorum brevis
Skin first cleft
16. MOB TCD
Anterior Tibial Artery
• Branch of popliteal
• Enters above interosseous
membrane
• Only supply of tibialis
anterior
• Becomes dorsalis pedis at
ankle joint
17. MOB TCD
Dorsalis Pedis
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Gives off
First dorsal metatarsal artery
Arcuate artery gives off
2-4th dorsal metatarsal
arteries
• At base of first
intermetatarsal space
• Enters sole of foot
• Joins lateral plantar artery to
complete plantar arch
18. MOB TCD
Blood Supply of Dorsum
• Arcuate artery
• Dorsal metatarsal arteries
• Posterior and anterior perforating
branches from metatarsals
• Communicate plantar arch
• And its digital branches
• Perforating veins drain into dorsal
venous arch
20. MOB TCD
Venous and Lymph Drainage of Foot
• Dorsal venous arch
• Medial, long saphenous
vein
• Anterior to medial
malleolus
• Short saphenous vein
• Posterior to lateral
malleolus
• Lymphatics follow
superficial veins
21. MOB TCD
Lateral Compartment of Calf
• Between anterior and posterior
intermuscular septa
• Peroneus longus
• Peroneus brevis
• Superficial peroneal nerve
22. MOB TCD
Peroneus Longus
• Upper two thirds lateral surface of fibula
• Adjoining area of interosseous
membrane
• Passes under superior and inferior
peroneal retinaculum
23. MOB TCD
Peroneus Longus
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May have a sesamoid bone
Runs in groove in the cuboid
Inserted into
Lateral aspect of medial cuneiform
And adjoing base of first metatarsal
25. MOB TCD
Peroneus Brevis
• Lower two thirds
• Lateral surface of fibula in front of
longus
• Passes under superior and inferior
peroneal retinacula
• Above peroneal trochlea on calcaneus
• Inserted into base of fifth metatarsal
26. MOB TCD
Peroneus Longus and Brevis
• Plantar flexors and
evertors
• Longus support the lateral
longitudinal arch
• Superficial peroneal nerve
27. MOB TCD
Superficial Peroneal Nerve
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Branch common peroneal
Neck of fibula
Supplies peroneus longus and brevis
Pierces deep fascia
Dorsum of foot supplies
Medial side of big toe
All clefts except first and lateral side of little
toe
28. Sensory Supply to
Posterior Aspect of Calf
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Posterior cutaneous nerve of thigh
Lateral cutaneous of calf
Sural nerve
Saphenous nerve
Medial calcaneal
MOB TCD
30. MOB TCD
Posterior Surface of the Calf
• Short saphenous vein
• Posterior to lateral malleolus
pierces the roof of popliteal
fossa to enter popliteal vein
• Deep fascia thickened medial
between medial malleolus
and calcaneum
• Bursa anterior to achilles
31. Medial and Lateral Heads
of Gastrocnemii
• Medial head arises from popliteal
surface of femur above medial
condyle
• Lateral is shorter, arises from
posterior part of the lateral surface
of the lateral femoral condyle and
capsule of knee
• Fabella is a sesamoid bone in
lateral head
MOB TCD
32. Medial and Lateral Heads
of Gastrocnemii
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Bursa deep to the two heads
Medial belly is longer
Unite to form a tendinous raphe
Unites with soleus to form achilles
Fast twitch fibres
Flex knee and plantar flex ankle
MOB TCD
33. MOB TCD
Plantaris
• Short fleshy origin from
• The popliteal surface of femur
above the lateral femoral
condyle
• Long tendon passes between
gastronemii and soleus
• Inserted medial border of
achilles
• Tibial nerve
35. MOB TCD
Soleus
• Broad flat pennate muscle
• Arises from head and upper
fourth of posterior surface of the
fibula
• Fibrous arch
• Soleal line of tibia
• Middle third of medial border of
tibia
36. MOB TCD
Soleus
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Two aponeurotic lamellae
Bulk of vascular multipennate muscle fibres
Deepest of achilles
Slow twitch fibres
Perforating veins from great saphenous enter
soleus
• Acts as a peripheral pump
37. MOB TCD
Achilles Tendon
• Extent of the fusion between the
gastronemii and soleus varies
• Inserted into middle of posterior surface of
the calcaneus
• Tendon twists
• Gastronemii form the lateral and posterior
part of the tendon
38. MOB TCD
Achilles Tendon
• Rotation occurs above
where the soleus tends to
join
• Rotation is greater if minimal
fusion
• Stress marked 2-5 cm above
insertion
• Plantar flexor of ankle
• Eccentric lower heels
39. MOB TCD
Achilles Tendon
• The achilles tendon is subjected
to the highest loads in the body
• Tensile loads up to eight and
ten times body weight are
experienced during running
jumping hopping and skipping
• The achilles tendon is subjected
to stress when running up and
downhill
• A tight achilles tendon also
limits dorsiflexion of the ankle
40. MOB TCD
Achilles Tendon
• Superficial bursa may be
found posterior to achilles
between it and the deep
fascia
• The retrocalcaneal bursa is
just proximal to the insertion
• Between the tuberosity on
the posterior surface of the
calcaneus and the achilles
tendon
42. Medial and Lateral Heads
of Gastrocnemii
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Sprinting
Jumping
Hopping
Skipping
Stretched with knee
extended and ankle
dorsiflexed
• Tibial nerve
MOB TCD
43. MOB TCD
The Retrocalcaneal Bursa
• The area of fibro cartilage on the
tendon forms the posterior wall
• The anterior wall of the
retrocalcaneal bursa is the 0.5 to
1 mm thick cartilaginous layer on the
posterior aspect of the calcaneus
• The proximal wall of the synovial lined sac consists of
folds, or villus synovial projections
• Allows alterations in its form, produced by varying
degrees of pressure on the fat above it during flexion
and extension of the ankle
44. MOB TCD
Flexor Digitorum Longus
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Posterior surface of tibia
Below soleal line
Medial to vertical line
Variable origin by an
aponeurosis from fibula
45. MOB TCD
Flexor Digitorum Longus
Very extensive fibular
origins of FDL
Hislop M, 2003
FHL
Fibular origin of FDL
FDL
46. MOB TCD
Flexor Digitorum Longus
• Crosses tibialis posterior in calf
• Flexor hallucis longus in foot
• Foot receives insertion flexor accessorius
and two slips from flexor hallucis longus
• Divides four tendons
• Give origin to four lumbricals
47. MOB TCD
Flexor Digitorum Longus
• In the foot the tendon passes through
birfurcation of brevis
• Inserted into distal phalanges
• Plantar flexes ankle
• Plantar flexes lateral four toes
• Supports medial arch
• Tibial nerve
48. MOB TCD
Flexor Hallucis Longus
• Bulkiest and most powerful,
multipennate
• Arises from posterior surface of
fibula
• Posterior to medial crest
• Beef to heel
• Most posterior under retinaculum
49. MOB TCD
Flexor Hallucis Longus
• Grooves posterior process of talus
• Sustentaculum tali
• Crossed in foot by flexor digitorum longus to
which it gives two slips
• Inserted base of distal phalanx
50. MOB TCD
Flexor Hallucis Longus
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Tibial nerve
Plantar flexes ankle
Flexes big toe
Supports medial longitudinal arch
Take off muscle
52. MOB TCD
Tibialis Posterior
• Crossed by flexor digitorum longus in calf
• Posterior to medial malleolus
grooves bone, type II collagen, tends to
have poor blood supply
• Most anterior under the flexor
retinaculum
• Inserted into tuberosity of navicular
• All bones of the tarsus except talus
• Base of middle three metatarsals
54. MOB TCD
Posterior Tibial Artery
• Branch popliteal
artery
• Lower border of
popliteus
• Under fibrous arch
of soleus
• Between flexor
digitorum longus
and flexor hallucis
longus
• Vena commitans
55. MOB TCD
Posterior Tibial Artery
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In the calf gives off
Nutrient artery to tibia
Peroneal artery
Nutrient artery to fibula
Perforating peroneal
Passes under flexor retinaculum
Gives off medial calcaneal artery which
pierces flexor retinaculum
• Then ends under flexor retinaculum
• Dividing into medial and lateral plantar
arteries
56. MOB TCD
Tibial Nerve
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Leaves the popliteal fossa
Runs in middle of calf
Deep to soleus
Accompaning artery
Branches to soleus
Flexor digitorum longus and flexor hallucis
longus
• Tibialis posterior
57. MOB TCD
Flexor Retinaculum
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Medial malleolus to calcaneus
Anterior to posterior
Tibialis posterior
Flexor digitorum longus
Posterior tibial artery
Medial calcaneal artery pierces retinaculum
Divides into medial and lateral plantar arteries
Tibial nerve
Gives off medial calcaneal nerve which accompanies artery
Divides into medial lateral plantar nerves
Flexor hallucis longus
58. MOB TCD
Causes of Compartment Syndromes
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May be acute or chronic
Sudden increase in exercise
Haematoma
Callus
Fracture
59. MOB TCD
Compartment Syndromes
• Mainly anterior compartment
• Tibialis anterior main muscle
affected as only supplied by
anterior tibial, other muscles also
supplied by perforating peroneal
• Increasing pressure causes loss
of sensation of first cleft due to
pressure on deep peroneal nerve
• Fasciotomy
Or
• Posterior or lateral compartments
60. MOB TCD
Posterior Compartment
• Posterior compartment
• Posterior border of tibia
• Posterior intermuscular septum
Divided
• Superficial
• Deep
• Deep posterior
64. Chronic Exertional Compartment
Syndrome (CECS)
• Significant morbidity/limitation activity to athletes
• Activity related, reversible, myofascial
intracompartmental pressure increase
• Results in decreased tissue perfusion and
neuromuscular function abnormalities
• Predilection for the lower leg
MOB TCD
65. Chronic Exertional Compartment
Syndrome (CECS)
The fibular origin of FDL can
partially (or sometimes almost
completely) compartmentalize
TP and acts to resist increases
in intracompartmental volume
and therefore cause increased
pressure
The presence and extent of a
fibular origin of FDL may act as
an anatomical predisposition to
the development of CECS
MOB TCD