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CLINICAL ANATOMY OF the LOWER LIMB PART II. 13.March.2012 Tuesday. Kaan Yücel M.D., Ph.D. CLINICAL ANATOMY OF THE LEG. Gastrocnemius Strain Tennis leg.
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CLINICAL ANATOMY OF the LOWER LIMB PART II • 13.March.2012 Tuesday • Kaan Yücel M.D., Ph.D.
CLINICAL ANATOMY OF THE LEG
GastrocnemiusStrain Tennisleg Painfulacuteinjuryresultingfrompartialtearing of themedialbelly of thegastrocnemius at ornearitsmusculotendinousjunction Individualsolderthan 40 @ risk Causedbyoverstretchingthemusclebyconcomitantfullextension of thekneeanddorsiflexion of theanklejoint
RupturedCalcanealTendon Poorlyconditionedpeoplewith a history of calcanealtendinitis. Audiblesnapduring a forcefulpushoff (plantarflexionwiththekneeextended) followedimmediatelybysuddencalfpainandsuddendorsiflexion of theplantarflexedfoot. Ina completelyrupturedtendon, a gappalpable, 1-5 cm proximaltocalcanealattachment.
CalcanealTendinitis Inflammationof thecalcanealtendonconstitutes 9-18% of runninginjuries. Oftenoccursduringrepetitiveactivities Especiallyin individualswhotakeuprunningafterprolongedinactivitysuddenlyincreasetheintensity of theirtraining, Alsoresultfrompoorfootwearortrainingsurfaces.
Fabella in Gastrocnemius Close toitsproximalattachment, lateralhead of thegastrocnemiuscontains a sesamoidbone Fabella(L. bean) Articulateswiththelateralfemoralcondyle Visiblein lateralradiographs of theknee in 3-5% of people
SuperficialFibularNerveEntrapment Chronicanklesprainsmayproducerecurrentstretching of thesuperficialfibularnerve Pain alongthelateralside of thelegandthedorsum of theankleandfoot. Numbnessandparesthesia (ticklingortingling)
DeepFibularNerveEntrapment Excessiveuse of musclessuppliedbythedeepfibularnerve (e.g., duringskiing, running, anddancing) mayresult in muscleinjuryandedema in theanteriorcompartment. Compressionof thedeepfibularnerveandpain in theanteriorcompartment. Painoccurs in thedorsum of thefootandusuallyradiatestothe web spacebetweenthe 1st and 2nd toes.
InjurytoCommonFibularNerve& Footdrop Superficialcoursearoundfibularneck Mostinjurednerve in thelowerlimb Flaccidparalysis of allmuscles in theanteriorandlateralcompartments of theleg dorsiflexorsof ankleandevertors of foot Lossof dorsiflexion of theankle footdrop furtherexacerbatedbyunopposedinversion of thefoot
InjurytoCommonFibularNerve& Footdrop • Becausethedroppedfootmakes it difficulttomaketheheelstrikethegroundfirst as in a normal gait, steppagegait • Sometimesan extra “kick” is added as thefreelimbswingsforward in an attempttofliptheforefootupwardjustbeforesettingthefootdown.
Injurytotibialnerve Motor: Allthemuscles in theback of thelegandthe sole of thefootareparalyzed. Theopposingmusclesdorsiflexthefootat theanklejointandevertthefootat thesubtalarandtransversetarsaljoints, an attitudereferredto as calcaneovalgus. Sensory: Sensation is lost on the sole of thefoot; later, trophiculcersdevelop.
PosteriorTibialPulse Between posteriorsurface of medialmalleolus & medialborder of calcanealtendon Posteriortibialartery passesdeeptoflexorretinaculum Whenpalpatinghavetheperson invertfoottorelaxtheretinaculum Absenceof posteriortibialpulses Signof occlusiveperipheralarterialdisease in peopleolderthan 60 years Intermittentclaudicationcharacterizedbylegpainandcramps, duringwalking
VaricoseVeins A varicosedvein Largerdiameterthannormal, elongated & tortuous Commonlyoccurs in thesuperficialveins of thelowerlimb Responsibleforconsiderablediscomfortandpain Every time thepatientexercises, high-pressurevenousbloodescapesfromthedeepveinsintothesuperficialveinsandproduces a varicosity, andgetsworseby time.
DeepVeinThrombosis& Long-DistanceAir Travel Passengerswho sit immobileforhours on long-distanceflightsareverypronetodeepveinthrombosis in thelegs. Preventativemeasuresincludestretching of thelegseveryhourtoimprovethevenouscirculation. Prevention of deep vein thrombosis associated with flying ArchInternMed. 2003;163:2766-2770. Incidence of airtravel-relatedpulmonaryembolism at the Madrid-Barajasairport. Pérez-Rodríguez E, Jiménez D, Díaz G, Pérez-Walton I, Luque M, Guillén C, Mañas E, Yusen RD.
Popliteal, Anterior, & PosteriorTibialArteries Poplitealarteryocclusionjustbelowthebeginning of theartery justbelowtheopening in theadductormagnusmuscle Insomecasesextendsdistally originsof theanterior& posteriortibialarteries,evenperonealartery. intermittentclaudication, nightcramps, and rest paincausedbyischemicneuritis. trophicchanges impairedorabsentarterialpulses, lowered skin temperature, colorchanges, muscleweakness, andtrophicchanges
CLINICAL ANATOMY OF THE FOOT
Morton'sneuroma Enlargedcommonplantarnerve @ thirdinterspace betweenthird &fourthtoes 3rd interspace, lateralplantarnerveoftenuniteswithmedialplantarnerve. "Pushoff" phase of walkinginterdigitalnervesandwiched betweenground & deeptransversemetatarsalligamentabove Compressingcommonplantarnerve Painin thethirdinterspace
Tarsaltunnelsyndrome Posteriortibialneuralgia Compressionneuropathy& a painfulfootconditionwheretibialnerve is compressedthroughthetarsaltunnel Numbnessin thefoot, radiatingtothebigtoeandthefirst 3 toes, pain, burning, electricalsensations, andtinglingoverthebase of thefootandtheheel.
PlantarFasciitis Occursin individualswho do a greatdeal of standingorwalking, painandtenderness of the sole of thefoot. Believedto be causedbyrepeatedminortrauma. Repeatedattacks of thisconditioninduceossification in theposteriorattachment of theaponeurosis, forming a calcanealspur.
ClinicalProblemsAssociatedWithArchesof theFoot • Mediallongitudinalarch • largest &clinicallythemostimportant • Intheactivefootthetone of muscles • an importantfactor in archsupport. • Musclesarefatigued • excessiveexercise • standingforlongperiods • overweight • illness • muscularsupportgivesway, theligamentsarestretched, andpain is produced.
Pes planus(Flatfoot) Mediallongitudinalarch is depressedorcollapsed. Forefootis displacedlaterallyandeverted. Themusclesandtendonsarepermanentlystretched. Congenital & acquired
Pes cavus(Clawfoot) Conditionin whichmediallongitudinalarch is undulyhigh. Mostcasesarecausedbymuscleimbalance, in manyinstancesresultingfrompoliomyelitis.
PlantarReflex & BabinskiReflex Plantarreflex Strokinglateralpart of the sole of thefootwith a fairlysharpobjectproducesplantarflexion of thebigtoe; oftenthere is alsoflexion& adduction of theothertoes. Babinskireflex Strokingthe sole producesextension(dorsiflexion) of thebigtoe, oftenwithextensionandabductionof theothertoes The Babinski Sign - A Reappraisal
Plantarreflex protectingthe sole of thefoot Abnormalresponse Metabolicorstructuralabnormality in corticospinalsystemupstreamfromthesegmentalreflex Structurallesionssuch as hemorrhage, brainandspinalcordtumors, andmultiplesclerosis Abnormalmetabolicstatessuch as hypoglycemia, hypoxia, andanesthesia
Pathways Afferent:Nociceptiondetected in the S1 dermatomeandtravelsupthetibialnervetosciaticnervetoroots of L5,S1andsynapse in theanteriorhorntoelicitthe motor response. Efferent:Motor responsebackthroughthe L5,S1 rootstothesciaticnervetoitsbifurcation. Toeflexorsareinnervatedbytibialnerve. Toeextensors (extensorhallicuslongus, extensordigitorumlongus) areinnervatedbythedeepperonealnerve.