Vol 2 Anatomie Oase Anul 1

Acland's DVD Atlas of Human Anatomy
Transcript for Volume 2

2007 Robert D Acland
This free downloadable pdf file is to be used for individual study only. It is
not to be reproduced in any form without the author's express permission.
ACLAND'S DVD ATLAS OF HUMAN ANATOMY VOL 2 PART 1 1
PART 1: THE HIP
BONES, LIGAMENTS AND JOINTS
00.00
Well look at the lower extremity in four sections. In this first section, well look at
the hip. After that well look at the knee; then well go down to the ankle, and
lastly well look at the foot.
00.13
Before we get started, theres a simple term we need to define: the leg. In
everyday speech, the leg means everything from the hip downwards. In
anatomy, only this part, from the knee to the ankle, is the leg, and this part , from
the hip to the knee, is the thigh.
00.30
In looking at the hip region, well start with the bones, then well look at the hip
joint and how it moves, then well look at the muscles which produce movement at
the hip joint, and lastly well look at the vessels and nerves. First, lets see the
bones.
00.47
Here are the lumbar vertebrae, the pelvis, and the two femurs. Well look at the
pelvis by itself.
00.56
The pelvis is made up of the two hip bones, or innominate bones, and the sacrum.
The fibrous joints which unite them, the two sacro-ilicac joints behind and the pubic
symphysis in front, permit almost no movement. Well look at the right hip bone
by itself.
01.20
The hip bone is formed by the fusion of three bones, the ilium, the ischium, and
the pubis. The names of these bones give rise to the names of the various
features of the hip bone. Lets look at these features.
01.37
This broad bony plate is the wing, or ala of the ilium. Its broad, roughened edge
is the iliac crest, an area where many important muscles attach. The iliac crest
ends in front at the anterior superior iliac spine, and behind at the posterior
superior iliac spine.
02.00
This is the ischial spine, with the greater sciatic notch above it, and the lesser
sciatic notch below it. This is the ischial tuberosity. The ischial tuberosity is
another area where many muscles attach. Its also the part of the hip bone that
we sit on.
02.17
The socket for the hip joint is called the acetabulum. This broad smooth area is
the articular surface. Well see it again in a minute with the articular cartilage
intact.
02.30
The big hole in the lower part of the hip bone is the obturator foramen. This is
the body of the pubis, this is the superior ramus of the pubis, and this is the
ischio-pubic ramus. This prominence is the pubic tubercle, to which the inguinal
ligament is attached
02.53
Its helpful to keep in mind that the upper part, and the lower part of the hip bone
face in different directions, like my hands. If we look at the hip bone from in front,
like this, were looking at the inner aspect of the ilium, and the outer aspect of the
pubis and ischium. Now that weve looked at the hip bone, lets bring the sacrum
back into the picture. Were looking at the bones as theyd be in the upright,
standing position, and its perhaps surprising to see the angle at which the sacrum
lies. Its pelvic surface is more nearly horizontal than vertical.
03.29
The sacrum is attached to the hip bone not only by the sacro-iliac joint, seen here
from behind, but also by two big ligaments, one going to the ischial spine, and one
going to the ischial tuberosity, as well see in a minute.
03.44
Now lets add the femur to the picture. The femur is the longest bone in the body.
Well be looking at its distal end in the next section. For now, lets look at the
features of the proximal end.
03.57
This is the head of the femur, this is the neck. Since the head is wide and the
neck is narrow, the head of the femur can go a long way in this axis, and in this
axis, before bone hits bone.
04.16
This prominent lump is the greater trochanter, and this one is the lesser
trochanter. The greater and lesser trochanters are important muscle insertions.
This line, the inter-trochanteric line, marks the insertion of a major ligament of the
hip joint, which well see in a minute. On the back of the femur this prominent
ridge, the inter-trochanteric crest, runs from the greater to the lesser trochanter.
This broad rough area is the gluteal tuberosity. This rough line running down the
shaft of the femur is the linea aspera. Many muscles have their origins or their
insertions on the linea aspera, on the gluteal tuberosity, and in this hollow in front
of the intertrochanteric crest.
05.10
Now that weve looked at the dry bones, lets see how they look in the living body.
The big gap between the sacrum and the ischium is bridged by two massive
ligaments. The sacro-spinous ligament goes to the ischial spine, the sacro-
tuberous ligament goes to the ischial tuberosity. Lets go round to the front and
see those two ligaments from the inside. Heres the sacro-spinous ligament,
heres the sacro-tuberous ligament. These two openings are the lesser sciatic
foramen, and the greater sciatic foramen. The sciatic nerve passes through the
greater sciatic foramen. The obturator foramen is largely closed by the obturator
membrane. The obturator nerve and vessels pass through a small tunnel here.
06.09
Now lets take a look at the hip joint. Well remove the femur for a moment., and
look at the acetabulum. Heres the broad, c-shaped articular surface, sometimes
called the lunate surface. This non-articular part of the acetabulum is the
acetabular fossa. Around the edge of the bony acetabulum this rim of
fibrocartilage, the acetabular labrum, adds to the depth of the acetabulum.
06.40
This is the cut end of the ligament of the head of the femur. Its other end is
attached here, on the center of the femoral head. Now lets go back to the intact
hip joint.
06.52
The capsule of the hip joint is a sleeve of ligaments. The capsule is thin on the
underside. Everywhere else its thick and strong. This part of the capsule behind is
called the ischio-femoral ligament. This anterior part of the capsule, which is the
thickest, is known as the ilio-femoral ligament. The fibers of these capsular
ligaments become tight when the joint is extended.
07.23
The capsule is attached to the hip bone all the way round the acetabular labrum.
On the back of the femur the capsule is attached about halfway along the femoral
neck. On the front of the femur the capsule is attached out here, on the inter-
trochanteric line.
07.43
Now let's take a look at the various different movements that occur at the hip joint.
Movement can occur in three different axes. Forward movement is flexion,
backward movement is extension. Movement out to the side is abduction,
movement in toward the midline is adduction. Rotation outward is lateral rotation,
rotation inward is medial rotation.
08.22
Rotation at the hip joint is accompanied by marked backward and forward
movement of the greater and lesser trochanter.
08.31
Now were almost ready to move on, to look at the muscles of the hip region.
Before we do that, lets take a minute to review what weve seen of the bones, and
of the hip joint. If youd like to use this review section to test yourself, turn off the
sound, and see how many of the structures you can name. Theres another blue
sign like this one, at the end of the review section.
08.53
BONE AND JOINT REVIEW
Heres the wing of the ilium, the iliac crest , the anterior superior iliac spine, the
posterior superior iliac spine, the ischial spine, the ischial tuberosity, the
acetabulum, the obturator foramen, the body of the pubis, the superior pubic
ramus, the ischio-pubic ramus, and the pubic tubercle.
09.28
On the femur heres the head, the neck, the greater trochanter, the lesser
trochanter, the inter-trochanteric line, the inter-trochanteric crest, the gluteal
tuberosity, and the linea aspera.
09.54
Here are the sacro-spinous ligament, the sacro-tuberous ligament, the ischio-
femoral ligament, the ilio-femoral ligament, and the obturator membrane.
10.10
MUSCLES
Now lets move on to look at the muscles that produce movement at the hip joint.
There are five muscle groups to look at: the short rotators, the flexors, the
adductors, and the extensors. Well look at the six short rotator muscles first,
because they lie deep to all the others.
10.33
The short rotator muscles arise from four different bony surfaces, the inner surface
of the sacrum, both the inner surface and the outer surface of the area around the
obturator foramen,and from the outer surface of the ischium. They all converge on
this small area on the back of the femur, just medial to the greater trochanter.
10.58
The one that arises from the sacrum is piriformis. Here it is. Piriformis arises from
here on the sacrum. It leaves the pelvis by passing through the greater sciatic
foramen, along with the sciatic nerve. Well go right round to the back to see
where it comes out. Heres piriformis emerging. It inserts here, high up on the
medial aspect of the greater trochanter.
11.32
Piriformis is an important muscle to understand, because its closely related a very
important structure, the sciatic nerve. Next well look at the two obturator muscles,
obturator internus and externus. They lie on each side of the obturator
membrane.
11.50
Heres obturator externus. It arises from the obturator membrane, and from the
adjoining edge of the ischio-pubic ramus
12.00
Obturator externus passes backwards just beneath the neck of the femur. Heres
its tendon, passing laterally , to reach its insertion here, below piriformis.
12.16
Next well see obturator internus, which comes around the back of the ischium here,
from inside the pelvis. Well go around this way to see where it arises. Heres
obturator internus. It arises from this wide area on the ilium and ischium, and from
the obturator membrane. It leaves the pelvis through the lesser sciatic foramen.
As it passes round the back of the ischium, obturator internus does a 90 turn.
12.54
As it makes the turn , its joined above and below by these two little muscles,
gemellus superior, and gemellus inferior. They arise from the ischium here, and
here. Along with obturator internus, theyre inserted here.
13.15
The last of the short rotators is quadratus femoris. Quadratus femoris arises from
the ischial tuberosity here, and inserts on the femur here, on the intertrochanteric
crest.
13.31
All these short rotator muscles have the same action: by pulling the back of the
femur medially, they produce lateral rotation at the hip joint. When the foot is on
the ground, the same muscle action produces what appears to be a different
movement: rotation of the trunk to the opposite side. So contraction of these
muscles has two possible effects, depending on whether the limb is free to move,
or whether its fixed. As well see, thats holds true for every muscle that
produces movement at the hip joint.
14.10
Now well move on to look at the groups of muscles which produce adduction, and
abduction at the hip. Well look at the five adductors first. There are three named
adductors, adductors magnus, brevis, and longus; and there are two other
muscles which adduct, pectineus and gracilis.
14.29
The adducting muscles all arise from this region on the pubis and ischium, and
theyre all inserted along this line, the lowest, gracilis, right down here on the tibia.
Lets start with the named adductors,
14.51
Heres the largest of the them, adductor magnus. Adductor magnus arises from
the outer border of the ischio-pubic ramus. Its insertion is in two parts, with a gap
in between. The upper part of adductor magnus inserts here, on the linea aspera.
The lower part inserts here, on the adductor tubercle of the femur
15.19
This gap is the adductor hiatus. The main blood vessels to the leg pass through
here, from the front of the thigh, to the back.
15.33
The other two named adductors, brevis and longus, sit in front of adductor
magnus. Heres adductor brevis. Heres adductor longus.
15.47
Brevis arises here on the body of the pubis, longus arises here. Theyre inserted
on the femur right next to adductor magnus, brevis above, longus below. The
insertion of adductor longus stops just short of the adductor hiatus.
16.08
The other two adducting muscles are a short muscle, pectineus, and a very long
muscle, gracilis
16.18
Pectineus is the shortest of the adductors. It arises from this line on the superior
pubic ramus. It inserts here, just in front of adductor brevis.
16.32
Gracilis is the most medial of all the thigh muscles. It arises here on the pubis,
and its inserted all the way down here, on the tibia.
16.44
The main effect of all these muscles, is to produce adduction at the hip joint.
16,52
The gracilis is the first muscle weve met which crosses both the hip joint, and the
knee joint. Well be meeting more muscles like it quite soon. A muscle that
crosses both the hip, and the knee can either act at the hip, at the knee, or at
both joints at once. The movement that it does produce is determined by what
other muscle groups are acting at the same time.
17.19
For now, when we look at a muscle that goes from above the hip to below the
knee, well just look at the way it acts at the hip. In the next section well take a
second look at each of these muscles, and see how it acts at the knee.
17.32
Now lets move on, and look at the three muscles which produce abduction at the
hip joint. The two important abductors are gluteus minimus, and gluteus medius.
Well go round to the back to look at them.
17.44
Here are the short rotator muscles that weve seen already, quadratus femoris,
obturator internus and the gemelli, and piriformis. Now well add
gluteus minimus to the picture. Gluteus minimus arises from this part of the wing
of the ilium. Its inserted here, on the front of the greater trochanter.
18.12
Overlying gluteus minimus, is gluteus medius. Gluteus medius arises
from this part of the ilium. Its inserted here, on the outer aspect of the greater
trochanter.
18.30
Though gluteus medius is mainly an abductor as well see, its anterior part also
produces medial rotation at the hip
18.41
The last of the abductors is called the tensor fascia lata. Before we look at it, we
need to digress for a minute, and get acquainted with the structure that gives it its
name, the fascia lata.
18.51
The fascia lata is a continuous sheet of dense fibrous tissue that surrounds all the
muscles of the thigh. Along the outer aspect of the thigh theres a very marked
thickening of the fascia lata called the ilio-tibial tract. It extends all the way from
here on the ilium, down to here, on the tibia.
19.17
Heres the ilio-tibial tract by itself, with the rest of the fascia lata removed. These
muscles, in front of it and behind it, well be looking at in a minute. Between the
muscles is a strong fibrous septum, which attaches the ilio-tibial tract to the femur.
At its lower end, the ilio-tibial tract is attached down here on the tibia.
19.43
The ilio-tibial tract acts as the tendon of insertion of two muscles, a big one back
here, gluteus maximus, which well see later, and this one, which we were just
getting ready to look at, tensor fascia lata.
20.00
Tensor fascia lata arises from the iliac crest here. It inserts here on the ilio-tibial
tract.
20.10
The three hip abductors move the limb to the side. When the foot is on the
ground the hip abductors, pulling down on the ilium, raise the opposite side of the
pelvis up. This tilting of the pelvis happens in a small way each time we take a
step, making it easy for the opposite foot to move forward without touching the
ground.
20.38
Now lets move on to look at the muscles which produce flexion at the hip. There
are four, two that act only at the hip, and two that act at the hip and also at the
knee. The first two are the most important hip flexors - theyre called iliacus, and
psoas major.
20.57
Iliacus arises here from the iliac crest, psoas major from all the way up here, on
the lumbar spine.
21.06
Heres psoas major. Psoas major arises from the transverse processes of all five
lumbar vertebrae, and from the sides of the intervertebral discs and the adjoining
vertebral bodies. Well see its insertion in a moment.
21.24
Heres iliacus. It arises from almost all of the inner aspect of the wing of the ilium.
21.34
As they pass downward together, iliacus and psoas major pass over the superior
pubic ramus and under a structure here that we havent been introduced to yet, the
inguinal ligament.
21.52
The two muscles pass downward and backward, and insert together down here, on
the lesser trochanter. Contraction of the iliacus and psoas major produces flexion
of the hip joint.
22.10
When the limb is free to move, flexion brings the thigh forward. When the limb is
fixed, as it is here, flexion of both hips brings the body upright.
22.24
The other two muscles which help in hip flexion are rectus femoris, and sartorius.
Theyre more important for their actions at the knee, than for their actions at the
hip. Well look at them briefly here, and in more detail in the next section. Rectus
femoris is part of a huge muscle with four heads called quadriceps which well see
in a moment.
22.46
Here are the muscles that weve seen already: psoas major and iliacus, pectineus,
adductor brevis, longus, and magnus, and gracilis. Now lets add quadriceps to
the picture.
23.06
All this is quadriceps. Its the main muscle that extends the knee. The only part
of quadriceps which acts as a hip flexor is this part, rectus femoris. Its the only
part that arises from above the hip joint, which is here.
23.23
Rectus femoris arises by two heads here and here, just above the acetabulum.
Its final insertion, along with the other three heads of quadriceps, is right down
here on the tibia. Rectus femoris is quite a weak hip flexor.
23.43
Now well add the last hip flexor, sartorius. Sartorius is a very long narrow muscle
that lies outside all the others. It runs in a spiral, starting here on the anterior
superior iliac spine, and ending up all the way down here, on the tibia. Sartorius
helps to flex the hip. It can also produce lateral rotation at the hip.
23.12
Now lets move on to look at the four muscles that extend the hip. The first three,
which are known collectively as the hamstring muscles, act at the hip and at the
knee. The fourth one, gluteus maximus, acts only at the hip. Well come to it last
because it lies outside the others and covers them up
24.30
Heres the back of the thigh as we saw it last. Heres gluteus medius, here are all
the short rotators, heres adductor magnus, and heres the back of quadriceps.
24.43
The three hamstring muscles all arise from the ischial tuberosity. Here they are.
Two of them run down to the medial aspect of the leg, one runs to the lateral
aspect. The lateral one is biceps femoris. The two medial ones are
semimembranosus, and semitendinosus.
25.05
Heres semimembranosus by itself. It has a long flat membrane-like tendon of
origin, which arises from here on the ischial tuberosity. Its inserted here on the
back of the tibia.
25.22
Heres semitendinosus, lying behind semimembranosus. It has a long cord-like
tendon of insertion. It arises from here, next to semimembranosus. It inserts
down here on the medial aspect of the tibia, close to two other muscles that weve
seen already, sartorius and gracilis.
25.50
Now that weve seen these two, well add biceps femoris to the the picture. Biceps
femoris has two heads of origin, a long head, and a short head.
26.04
The long head arises from here on the ischial tuberosity, along with
semitendinosus. The short head arises from almost the whole length of the linea
aspera, and from this supracondylar line
26.22
The two heads of biceps femoris join together, forming a tendon that runs down
behind the lateral aspect of the knee, then runs forward to insert here, on the head
of the fibula.
26.33
Well be taking another look at the hamstring muscles, their insertions, and their
actions at the the knee, in the next section. Well look at their action at the hip in
a minute, but before we do that well add the last and largest of the hip extensors,
gluteus maximus, to the picture.
26.49
Heres the upper end of the hamstring muscles, here, overlying them, is gluteus
maximus. Its a thick, flat sheet of muscle. Gluteus maximus arises from here
on the back of the ilium, and from the side of the sacrum, and from the
sacrotuberous ligament.
27.09
The upper three quarters of gluteus maximus inserts into the ilio-tibial tract. The
lower one quarter of gluteus maximus passes more deeply, and inserts here on
the back of the femur, on the gluteal tuberosity.
27.25
Now lets look at the actions of the hip extensor muscles, starting with the
hamstring muscles. Contraction of the hamstring muscles can produce both knee
flexion, and hip extension. When knee flexion is held in check by the action of
quadriceps, the hamstrings just produce extension at the hip, which is the action
that propels us forward in normal walking.
27.54
Gluteus maximus isnt used in the gentle action of normal walking. It comes into
play when a powerful action is needed, especially an action that opposes the force
of gravity. The action of gluteus maximus extends the hip from a position of full
flexion, as in climbing stairs, or rising from a squatting or sitting position. The
same action, balanced against the force of gravity, controls the rate of hip flexion,
as we sit down.
28.24
Gluteus maximus is one of the two big anti-gravity muscles of the lower extremity.
The other one, acting at the knee, is quadriceps as well see in the next section.
28.33
Gluteus maximus has yet another set of actions when the lower extremity is fixed
and upright. Then the action of gluteus maximus pulls the back of the pelvis
downward, raising the body from a forward bend at the hips, or, when balanced
against gravity, controlling the rate of bending forward.
28.54
Now weve looked at all the muscles that produce hip movement. As weve seen,
several of them also have important actions at the knee, and well be looking at
these a second time in the next section. Were now almost ready to move on, to
look at the vessels and nerves of the hip region, but before we do that, lets review
what weve just seen of the muscles.
29.14
REVIEW
Heres gluteus maximus, biceps femoris, semitendinosus, and semimembranosus.
29.26
Heres gluteus medius, and gluteus minimus.
29.33
Heres piriformis, obturator internus, and quadratus femoris; and heres adductor
magnus, seen from behind.
29.43
On the front, heres tensor fascia lata, sartorius, and rectus femoris, psoas major,
and iliacus, pectineus, adductor brevis, adductor longus, and magnus, and gracilis,
and here again are piriformis, obturator internus, and obturator externus.
30.18
BLOOD VESSELS
Now we'll move on, and look at the blood vessels and nerves of the hip region.
We'll follow the course of the vessels and nerves from the inside of the body, to
the proximal part of the thigh. In the next section we'll follow them on down to
below the knee. To understand the course of the main blood vessels, the femoral
vessels, there's a structure we need to look at, that we saw before, the inguinal
ligament; and there's a space between muscles that we need to understand, called
the femoral triangle.
30.51
Here's the inguinal ligament. It's a strong, tight band that forms the lowest part of
the anterior abdominal wall. The inguinal ligament passes from the anterior
superior iliac spine, to the pubic tubercle. The inguinal ligament isn't an isolated
structure, it's the lower edge of this large sheet of tendon-like material, the
external oblique aponeurosis. Here's the inguinal ligament. The fascia lata, which
we've seen already, is attached to it along here.
31.22
Tha gap between the inguinal ligament and the superior pubic ramus is occupied
partly by the iliacus and psoas muscles, and partly, as we'll see, by the femoral
nerve, artery and vein, and the inguinal lymph nodes. The other muscle in the
picture here is obturator externus.
31.45
Now let's add all the other thigh muscle to the picture, and see the femoral
triangle. Here, the fascia lata has been left intact; here, it's been removed. The
femoral triangle is the name given to this deep hollow. It's bounded by sartorius
laterally, adductor longus medially, and the inguinal ligament above. Int the
depths of the triangle pectineus, psoas major and iliacus pass backward toward
their insertions.
32.19
Now that we understand the inguinal ligament and the femoral triangle, we can
move on and look at the blood vessels in the hip region, starting with a brief look
at the principal veins. Almost all the veins in the region run parallel to arteries of
the same name, so we won't need to look at them all separately. There's just one
important vein we do need to look at, that has no corresponding artery - the long
saphenous vein, also called the greater saphenous vein. With t he main vein
there's a change of name that we need to understand. Below the inguinal ligament
it's called the femoral vein. Above the inguinal ligament it's called the external
iliac vein. It's the same with the artery. The vessels themselves don't change, just
their names.
33.00
Here's the thigh with just the skin removed. The anterior superior iliac spine is
here. Here's the long saphenous vein, which starts at the ankle, and passes up
the medial side of the knee, and up to the top of the thigh. We'll remove all the
subcutaneous fat to see it better. The inguinal ligament runs from here to here.
Here's the fascia lata. Superficial veins from other parts of the region join the
upper end of the long saphenous vein which passes through an opening in the
fascia lata, the saphenous hiatus. Here, near the top of the saphenous vein are
two of the inguinal lymph nodes. The main lymphatic vessels draining the lower
extremity pass under the inguinal ligament here.
33.55
To see where the saphenous vein goes, we'll remove the fascia lata, and the
underlying fat. Here are the main blood vessels to the leg - the femoral vein, and
artery, and this is the femoral nerve. The long saphenous vein ends by joining the
femoral vein here.
34.16
The femoral vein passes beneath the inguinal ligament. To see where it goes,
we'll remove the abdominal wall, leaving just the inguinal ligament. This is the
inguinal ligament, this is the top of the pubis. Here the vein is called the femoral
vein, here above the inguinal ligament it's the external iliac vein; it's all the same
vessel. To see where it goes, we'll remove the artery.
34.45
This muscle is the psoas major muscle. The external iliac vein is joined by the
internal iliac vein to form the common iliac vein The right and left common iliac
veins join in the midline to form the inferior vena cava.
35.03
Now we'll remove all the veins from the picture so that we can look at the arteries.
We'll look first at the internal and external iliac arteries. Then we'll look at the
femoral and deep femoral arteries which supply almost all of the lower extremity;
then we'll look at the gluteal arteries which supply the gluteal or buttock area.
35.23
Here's the abdominal aorta, dividing to give off the left and right common iliac
arteries. The common iliac divides, into the internal iliac and external iliac arteries.
The external iliac passes under the inguinal ligament, emerging as the femoral
artery.
35 44
The femoral artery gives off two small branches and one large branch. The small
branches are the superficial circumflex iliac, which runs laterally, and the external
pudendal, which runs medially. The large branch is the deep femoral artery, which
we'll look at in a minute. The femoral artery itself runs downward, and passes
beneath the sartorius muscle. We'll follow its further course in the next section of
this tape.
36.10
Below the point where it gives off the deep femoral, the femoral artery is often
referred to as the superficial femoral. It supplies everything from about here
downward, but the main artery that supplies the thigh is the deep femoral.
36.24
To follow the deep femoral artery, we'll remove the femoral artery. We'll also
remove the sartorius muscle and the femoral nerve.
36.34
Early in its course, the deep femoral gives off two large branches, the medial
circumflex femoral, and the lateral circumflex femoral. It then passes behind
adductor longus, which we'll remove.
36.48
Here's pectineus, adductor brevis, adductor magnus, rectus femoris. The deep
femoral artery runs down in front of adductor brevis and adductor magnus, giving
off numerous muscle branches, including several which run backward through
adductor magnus to supply the posterior thigh muscles.
37.11
Now we'll go up to the internal iliac artery again, to look at the gluteal vessels,
which provide the blood supply for the buttock.
37.20
The left side of the pelvis has been removed to give us a better view. Here's the
internal iliac artery. Its branches which go to the pelvic viscera have been divided.
Here, arising from the internal iliac, are the superior gluteal and inferior gluteal
arteries. They both pass backward through the greater sciatic foramen, one above
and one below the piriformis muscle, which is here. To see where they emerge,
we'll go right round to the back, and remove gluteus maximus.
37,56
Here's piriformis, here's gluteus medius. Again, all the veins have been removed
to simplify the picture. Here's the superior gluteal artery, and here's the inferior
gluteal artery, branching to supply the muscles of the buttock region.
38.17
NERVES
Now that we've looked at the blood vessels of the hip region, we can move on to
look at the nerves. We'll look first at the femoral nerve and the obturator nerve,
which supply the front and the medial aspect of the thigh, then we'll look at the
gluteal nerves and the sciatic nerves, which supply the buttock and the back of the
thigh. All the nerves of the lower extremity come from the anterior rami of the
second to the fifth lumbar nerves, and the first, second and third sacral nerves. To
see where these arise, let's take a look at the lumbar spine and the sacrum.
38.52
Below each vertebra theres an intervertebral foramen. An anterior ramus emerges
through each foramen. The anterior rami of the sacral nerves emerge from the
anterior sacral foramina. Each anterior ramus is numbered according to the
vertebra, or the sacral segment, thats above it. Here's the third lumbar vertebra,
here's where the L3 ramus emerges.
39.19
Well start by looking at the femoral nerve, and the obturator nerve. This is the
femoral nerve, this is the obturator nerve. The white structure between them is the
psoas major tendon. Both these nerves arise from the lumbar plexus, which lies
up here within the thickness of the psoas major muscle.
39.40
The femoral nerve emerges lateral to psoas major, the obturator nerve medial to
it. Well follow the femoral nerve. It runs across the iliacus muscle, and passes
under the inguinal ligament just lateral to the femoral artery. Below the inguinal
ligament the femoral nerve breaks up into several branches.
40.01
The femoral nerve supplies iliacus, all four heads of quadriceps, and also
pectineus, and sartorius.
40.14
Now lets look at the obturator nerve. Emerging below the medial border of psoas
major, it crosses the wing of the sacrum, then runs along the back of the ischio-
pubic ramus. It leaves the pelvis by passing forward through the obturator canal,
just above obturator internus. To see where it emerges, well remove pectineus.
40.41
Heres the obturator nerve, emerging over the top of obturator externus. Its
branches run down between the adductor muscles. The obturator nerve supplies
obturator externus, adductor brevis, and longus, and the anterior part of adductor
magnus.
41.04
Now well look at the two gluteal nerves, the superior and the inferior, and at the
largest nerve of the lower extremity, the sciatic nerve, which supplies the posterior
thigh muscles, and also almost everything below the knee. The gluteal and sciatic
nerves arise from the sacral plexus.
41.24
Heres the sacral plexus. Its formed by the anterior rami of L4 and 5, and S1.2
and 3. The sacral plexus overlies the piriformis muscle.
41.39
This is the sciatic nerve. It arises from L4 through S3. This is the superior gluteal
nerve. The inferior gluteal nerve arises out of sight behind the sciatic nerve. All
three nerves leave the pelvis through the greater sciatic foramen. To see where
they come out, well go round to the back, and remove gluteus maximus
42.02
Here, the vessels have been removed to simplify the picture. Heres piriformis.
Heres the sciatic nerve, heres the inferior gluteal nerve, and heres the superior
gluteal nerve, disappearing beneath gluteus medius. The superior gluteal nerve
supplies gluteus medius, gluteus minimus, and tensor fascia lata. The inferior
gluteal nerve supplies gluteus maximus.
42.33
The sciatic nerve runs down the middle of the thigh. Deep to it are quadratus
femoris, and lower down, adductor magnus. This is the long head of biceps
femoris which crosses over the nerve obliquely, and covers it up. Well follow the
sciatic nerve further, in the next section of this tape.
42.55
In the thigh, the sciatic nerve supplies semitendinosus, semimembranosus, and
also biceps femoris, and the posterior part of adductor magnus.
43.09
Lastly, there are a few hip muscles which have their own individual nerve supply.
Psoas major is supplied by several small branches of the lumbar plexus. Small
separate branches of the sacral plexus supply piriformis, obturator internus, and
quadratus femoris
43.32
Now lets review the vessels and nerves of the hip region.
43.37
REVIEW
Heres the long saphenous vein, and the femoral vein, becoming the external iliac
vein.
43.50
Heres the common iliac artery, the internal iliac, giving off the superior gluteal and
inferior gluteal arteries. Heres the external iliac, becoming the femoral artery.
44.06
Heres the superficial circumflex iliac, and the external pudendal. Heres the deep
femoral, giving off the lateral circumflex femoral, and the medial circumflex
femoral arteries.
44.20
Now the nerves: the femoral nerve, the obturator nerve, the sciatic nerve, the
inferior gluteal nerve, and the superior gluteal nerve.
44.37
That brings us to the end of this section on the hip region.
In the next section well look at the knee.
END OF SECTION 1
PART 2: THE KNEE
00.00
In this section, well look at the knee. First well look at the bones, then the knee
joint and how it moves, then the muscles that move it, and lastly the vessels and
nerves. Lets see the bones, starting with the femur.
00.21
We saw the proximal end of the femur in the last section. Now lets look at the
distal end.
00.28
The two smoothly curved surfaces are the lateral condyle and the medial condyle.
The deep notch which separates them is the intercondylar notch. Above the two
condyles are the epicondyles, lateral and medial. The sharp corner on the medial
epicondyle is the adductor tubercle. This prominent ridge is the medial
supracondylar line, this one is the lateral supracondylar line. Now well add the
tibia and the fibula to the picture.
01.12
The tibia and the fibula are fixed to each other firmly by two joints, the proximal,
and distal tibio-fibular joints. Theres almost no movement at either of these
joints. Lets take a look at the proximal end of the tibia.
01.33
This is the medial condyle, this is the lateral condyle. On top of the two condyles
are two quite separate articular surfaces. Theyre much flatter than those on the
femur. The rugged expanse between the articular surfaces is the inter-articular
area. This prominent lump on the front, the tibial tubercle, is the final insertion of
the quadriceps tendon. The small facet under here is for the fibula, which we'll
add.
02.06
This is the head of the fibula, this is the neck. The head of the fibula is the point
of attachment of a major ligament of the knee joint, as well see.
02.15
The space on each side of the knee between the femoral condyle and the tibial
condyle is occupied by a crescent shaped piece of cartilage, a meniscus, which well
see shortly. The space in the middle, the intercondylar notch is occupied by the
two cruciate ligaments. The intercondylar notch and its contents divide the knee
joint into two almost separate halves.
02.42
Theres one more bone to add to the picture, the patella, or kneecap. The
patella, as well see, is embedded within the quadriceps tendon, which comes from
up here, and inserts on the tibia down here on the tibial tubercle. On the back of
the patella the articular surface is divided into facets. These articulate either with
the femoral condyles when the knee is flexed, or with this central articular area
when its extended.
03.16
Now that weve seen the bones of the knee joint, lets see how the joint looks in
the living body.
03.22
In building up our picture of this quite complicated joint, there are several
structures that we need to understand: first the two joint cartilages or menisci,
then the ligaments, the two cruciate ligaments and the two collateral ligaments,
then the patella and the quadriceps tendon on the front, and lastly the capsule
which encloses the joint.
03.44
Here are the two articular surfaces of the tibia. The two menisci sit on top of them.
Here are the menisci. Theyre made of flexible fibrocartilage. Theyre shaped a
little differently, the lateral one is almost a circle, the medial one is more C-
shaped. In cross section, each meniscus is thick at the outer edge and thin at the
inner edge. The two ends of each meniscus are attached to the inter-articular area
of the tibia, the medial ones far apart, the lateral ones close together.
04.26
In addition each meniscus is attached all the way round its edge, both above and
below, to the joint capsule. Heres part of the joint capsule. Well see more of it
later.
04.41
The lateral meniscus is much more mobile than the medial one, partly because its
two ends are attached close together, partly because of a big difference in the
mobility of the joint capsule around the edge.
04.56
By filling in the spaces between the femoral and tibial condyles, the menisci
produce an even distibution of synovial fluid, to nourish and lubricate the articular
cartilage of the femur and tibia. Now lets look at the two pairs of ligaments which
hold the bones together at the knee joint - the two cruciate ligaments on the
inside, and the two collateral ligaments on the outside.
05.21
Well look at the cruciate ligaments first. Theyre the important structures which
prevent forward and backward movement of the femur on the tibia. Their name
comes from the fact that they form a cross like this.
05.36
Heres the anterior cruciate ligament, seen from in front. Heres the posterior
cruciate ligament, seen from behind. To get a better look at them, well remove
the lateral condyle of the femur.
05.53
Now we can see the whole of the anterior cruciate ligament. Te anterior cruciate
ligament goes from here on the tibia, to here on the femur, on the inner aspect of
the lateral condyle. The anterior cruciate ligament prevents the femur from moving
backward in relation to the tibia.
06.21
Now well look at the posterior cruciate ligament. Well remove the anterior
cruciate ligament to see it better. The posterior cruciate ligament goes from here
on the femur, to here on the back of the tibia. The posterior cruciate ligament
stops the femur from moving forward on the tibia.
06.42
By preventing backward and forward movement, the cruciate ligaments ensure that
the condyles of the femur stay in one place, as they roll on the condyles of the
tibia. Without them, the femur would roll off the back of the tibia in flexion, and
would roll off the front of it in extension.
07.04
Now lets look at the two collateral ligaments, the fibular collateral ligament on the
lateral side, and the tibial collateral ligament on the medial side. The tibial
collateral ligament goes from the medial epicondyle of the femur, to the
anteromedial aspect of the proximal tibia.
07.26
The tibial collateral ligament blends with the capsule of the knee joint behind, and
also in front. On its inner aspect, its firmly attached to the edge of the medial
meniscus, which is here. Now lets look at the rather different fibular collateral
ligament. It goes from the lateral epicondyle of the tibia, to the head of the
fibula.
07.54
The fibular collateral ligament stands out from the side of the knee joint. Unlike
its tibial counterpart, it doesnt blend with the joint capsule. Its not attached to
the meniscus.
08.07
When the knee joint is extended, both the collateral ligaments are tight. When its
flexed, they become less tight. The function of the collateral ligaments is to keep
the femoral and tibial condyles together,and thus to prevent the knee joint from
bending from side to side like this, or like this.
08.34
In addition to the obvious knee movements - flexion and extension - its also
possible for the tibia to rotate a little on the femur, like this. This rotation can
happen only when the knee is flexed - when its extended the tightness of the
collateral ligaments makes rotation impossible. The next structure we need to add
in building up our picture of the knee joint is the quadriceps tendon, and along with
it, the patella.
09.02
Heres the distal end of the quadriceps muscle, which well see in more detail later
in this section. Heres the quadriceps tendon. The patella, which is here, is
enfolded within the tendon. The part of the tendon below the patella is known as
the patellar ligament. On the medial side, and on the lateral side, the tendon is
continuous with the capsule of the knee joint.
09.32
Between the quadriceps tendon and the femur is an extension of the knee joint
cavity, the quadriceps bursa. Its lined with synovial membrane. This lubricated
pocket enables the quadriceps tendon to slide easily on the femur.
09.49
Now well complete our picture of the knee joint by adding the fibrous capsule which
encloses it.
09.56
Heres the knee joint with the joint capsule intact. On the medial side the thin
capsule is continuous with the tibial collateral ligament, but on the lateral side the
capsule is separated from the fibular collateral ligament. On the back of the joint
the capsule is thick and strong. The thickened posterior capsule prevents
hyperextension of the knee joint.
10.26
Here weve divided the fibrous capsule to see its inner surface. Its lined on the
inside with synovial membrane all the way round the joint, except at the back. At
the back, as well see if we remove the capsule, the thin synovial membrane (here
it is) passes forwards around the cruciate ligaments, covering them on the front.
10.54
Besides being the largest joint in the body, the knee joint is also much the most
complicated! Before we move on to look at the muscles which produce knee
movement, lets review what weve seen of the bones, and of the knee joint.
11.06
REVIEW
On the femur, heres the lateral condyle, and epicondyle; the medial condyle, and
epicondyle; the adductor tubercle, and the intercondylar notch.
11.28
On the tibia, heres the lateral condyle, the medial condyle, the tibial tubercle, and
the facet for the fibula.
11.40
Heres the head of the fibula, the neck of the fibula, the proximal tibio-fibular joint,
and the patella.
11.54
Heres the medial meniscus, the lateral meniscus, the anterior cruciate, and
posterior cruciate ligaments. The fibular collateral ligament, the tibial collateral
ligament, the quadriceps tendon, the patellar ligament, and the joint capsule.
12.24
MUSCLES
Now well move on to look at the muscles which produce movement at the knee
joint. Weve met most of them already. The one muscle that extends the knee is
the massive quadriceps. We saw it briefly in the last section. Well take a better
look at it now. The main flexors of the knee are the so-called hamstring muscles,
semi-membranosus, semitendinosus, and biceps femoris. Besides flexing the
knee, the hamstring muscles also extend the hip. We took a good look at them in
the last section. Here, well just re-visit their insertions. In addition well look at
three muscles at the back of the knee that we havent yet seen - popliteus,
gastrocnemius, and plantaris.
13.12
Well start with quadriceps. Its name comes from the fact that it has four heads.
Oddly, these are named as though they were separate muscles. Three of the
heads arise from the femur. Theyre all called vastus intermedius, vastus
medialis, and vastus lateralis. The fourth head, rectus femoris, arises from the hip
bone. All four heads converge on the quadriceps tendon, which weve seen. Well
start with the deepest of the heads, vastus intermedius.
13.43
Here it is. It forms a bulge on the front of the femur. Vastus intermedius arises
from this broad area around the lateral aspect and front of the femur.
13.56
Wrapped around the outside of vastus intermedius are vastus medialis, and
vastus lateralis. These two cover vastus intermedius almost completely. Their
fibers run obliqely, all the way round to the back. Heres lateralis, heres medialis,
almost meeting it.
14.23
Vastus lateralis arises from the lateral edge of the linea aspera, and from the side
and front of the greater trochanter. Vastus medialis arises from the medial edge
of the linea aspera, and from just below the lesser trochanter. The thin strip of
bone between these two lines of origin provides the insertion of all the adductor
muscles, and also the origin of the short head of biceps.
14.53
Now lets add rectus femoris to the picture. Here it is. Rectus femoris arises from
the ilium just above the hip joint. Its tendon of origin has two parts, a posterior or
reflected part and an anterior or straight part. The anterior part arises from this
prominence, the anterior inferior iliac spine. The posterior part arises from just
above the acetabulum.
15.28
All four heads of quadriceps converge on the quadriceps tendon. The lowest fibers
of vastus lateralis and medialis insert into the sides of the patella.
15.40
The principal action of the quadriceps muscle is to extend the knee. When the
foot is off the ground, that action simply straightens the leg, and holds it straight.
When the foot is on the ground, the action of quadriceps has several important
effects.
15.58
In normal walking, quadriceps straightens the leg as the foot reaches the ground,
then keeps the leg straight while the hamstring muscles extend the hip.
16.09
Quadriceps is also one of the two big anti-gravity muscles of the lower extremity.
Its partner, which weve seen already, is gluteus maximus. Acting together,
quadriceps at the knee and gluteus maximus at the hip, lift the body upward, when
we climb uphill, when we rise from a sitting position, and when we jump. The
same muscle actions propel us forward when were pushing a heavy load.
16.47
In addition to these actions, when quadriceps and its partner gluteus maximus act
in balance with the force of gravity, they control our rate of descent as we sit down.
and also when we walk downhill.
17.04
We need to digress for a moment to look at a structure called the adductor canal,
which lies between vastus medialis, and the adjoining adductor longus muscle.
The adductor canal is important because the femoral vessels run through it, in their
course from the front of the thigh to the back.
17.23
Heres vastus medialis, here are the adductor muscles, magnus behind, longus in
front, with brevis up here. The adductor canal is formed by the groove between
adductor longus and vastus medialis, and by this sheet of fascia, called the roof of
the adductor canal, which bridges over between the muscles. The adductor canal is
covered over by the sartorius muscle.
17.53
Well see the adductor canal again when we look at the blood vessels. Now lets
move on to look at the muscles which produce flexion at the knee joint. Well
revisit the main flexors, the three hamstring muscles, and two minor flexors,
sartorius and gracilis.
18.11
Here are the hamstring muscles again. On the medial side, here are semi-
membranosus and semi-tendinosus. As weve seen, they both arise from the
ischial tuberosity and insert on the medial side of the knee, semimembranosus
here, semitendinosus here.
18.31
On the lateral side, heres biceps femoris. It arises both from the ischial tuberosity,
and from the femur, and inserts down here, on the head of the fibula.
18.44
Weve already seen that these three muscles, which usually act together, can
produce either extension of the hip, or flexion of the knee. Whether they do one,
the other, or both, is determined by what other muscles are acting in opposition to
them at the time. When flexion of the knee is resisted by quadriceps, the
hamstring muscles produce extension at the hip. When extension of the hip is
resisted by the hip flexors, the hamstring muscles produce flexion of the knee.
19.18
In addition, the hamstring muscles, acting separately, produce medial rotation and
lateral rotation at the knee joint. As weve seen, these movements can only
happen when the knee is flexed. The two semi- muscles produce medial rotation,
biceps femoris produce lateral rotation.
19.41
The other two minor knee flexors that weve seen already are sartorius, and
gracilis. Heres sartorius, which arises up here. Heres gracilis, arising here.
These two insert close to semitendinosus. sartorius here, gracilis here.
20.07
Weve already seen the actions of these two muscles at the hip. At the knee, they
help to produce flexion. Now well complete our picture of the muscles around the
knee by looking at three muscles at the back that we havent met yet, popliteus,
gastrocnemius and plantaris.
20.25
Heres the popliteus muscle. It arises from this area on the back of the tibia, and
inserts up here on the lateral epicondyle of the femur. The tendon of popliteus
passes through the capsule of the knee joint to reach its insertion. Popliteus is a
minor flexor of the knee, and it can also produce medial rotation of the tibia.
20.52
Lying on top of popliteus is the small plantaris muscle. Its a vestigial structure.
It arises from the lateral epicondyle of the femur. The tiny tendon of plantaris
runs down on the back of this big muscle, soleus. Well see where it ends up in the
next section.
21.16
Lying on top of the two small muscles that weve just seen, is the much larger
gastrocnemius muscle. Gastrocnemius arises by two heads, from the back of the
medial and lateral condyles of the femur.
21.31
Gastrocnemius runs downward, and joins with the underlying soleus muscle, which
well see in the next section, to form the calcaneal tendon, or heel cord.
Gastrocnemius has a slight flexing action at the knee, but its main action, by far, is
at the ankle joint: well see it again in the next section.
21.51
Now that weve seen all the muscles that arise or insert at the knee joint, lets see
how they all fit together.
21.58
REVIEW
You can use this overview as a brief review section.
Here on the front are quadriceps. sartorius, and gracilis. On the back, here are
semitendinosus, and semimembranosus. Heres biceps femoris. and heres
gastrocnemius, Heres plantaris, and popliteus.
22.29
VESSELS
Now well move on, to look at the principal veins, arteries and nerves in the region
of the knee. Well begin where we saw them last, just below the hip. Well follow
them to just below the knee.
22.49
With the main artery and vein, theres a change of name that we need to
understand. In the upper and middle thigh, theyre known as the femoral vessels,
but below the adductor hiatus theyre called the popliteal vessels. The same
vessels, just a different name.
23.03
Heres the thigh, with the skin removed, and a strip of subcutaneous fat taken out
so that we can see the long saphenous vein. Here its in the middle of its course
from the ankle to the top of the thigh. To see the femoral vessels well remove
the superficial fat, and deep fascia.
23.22
Here are the femoral artery and vein at the point where we saw them last,
disappearing beneath the sartorius muscle. To follow their course, well remove
sartorius, and also gracilis.
23..36
Heres vastus medialis, heres adductor longus, with adductor magnus behind it.
The femoral vessels pass beneath the roof of the adductor canal, and through the
adductor hiatus. To see where they emerge, well remove semi-membranosus and
semi-tendinosus, and go round to the back. Here are the vessels emerging
behind adductor magnus. Theyre now known as the popliteal artery and vein.
24.04
A little above the knee the popliteal vessels are joined by the sciatic nerve. At the
back of the knee, the popliteal artery lies deep to the nerve, and to the popliteal
vein. To see the artery better, well go to a different dissection in which the
muscles are intact, and the nerve and the vein have been removed.
24.22
Above the knee, which is just here, the popliteal artery gives off these two superior
genicular arteries, lateral, and medial. At the knee it gives off these branches, to
the two heads of gastrocnemius; and below the knee it gives off these two inferior
genicular arteries, medial, and lateral. The popliteal artery then disappears deep
to the two heads of gastrocnemius. Well see where the vessels go from there, in
the next section.
25.00
NERVES
Now lets look at the nerves. In the last section we looked at three major nerves -
the obturator, the femoral, and the sciatic. Well follow the sciatic nerve in a
minute. The obturator nerve and the femoral nerve we dont need to follow any
further, except to remind ourselves of the muscles that they supply.
25.17
As weve seen before, the obturator nerve supplies obturator externus, adductor
brevis, and longus, and the anterior part of adductor magnus. The femoral nerve
supplies iliacus, pectineus, all four heads of quadriceps, and sartorius.
25.47
The obturator and femoral nerves also have sensory branches, some of whch go
below the knee. Well leave these out. Well go on now to look at the sciatic
nerve. We saw the sciatic nerve a minute ago, with the hamstring muscles absent.
To see the whole picture, well add the hamstring muscles.
26.06
Here are semimembranosus and semitendinosus, heres biceps femoris. Here are
the two heads of gastrocnemius. The space thats bounded by these muscles is
called the popliteal fossa. As we saw in the previous section, the sciatic nerve
passes deep to biceps femoris. Here it is emerging. Here are the popliteal
vessels, coming in beneath the semi muscles, and passing deep to the nerve.
Above the knee the sciatic nerve divides into two major nerves - the tibial nerve,
and the common peroneal nerve.
26.45
The tibial nerve runs downward in the midline, and passes between the two heads
of gastrocnemius, along with the popliteal vessels. The common peroneal nerve,
diverges laterally, running just behind the tendon of biceps femoris.
26.69
It passes around the neck of the fibula, heres the fibula, and passes into this
muscle, peroneus longus. Well follow the further course of both these nerves in
the next section.
27.11
Of the muscles that weve seen in this section, the tibial nerve supplies popliteus,
gastrocnemius, and plantaris.
27.22
Well conclude this section by briefly reviewing what weve seen of the vessels and
nerves of this region.
27.29
REVIEW
Here's the femoral vein, and artery; the superior genicular arteries, lateral, and
medial and the inferior genicular arteries, medial and lateral. Here's the popliteal
artery, and vein.
Heres the sciatic nerve, the tibial nerve, and the common peroneal nerve.
28.13
That brings us to the end of this section on the knee. In the next section well
look at the leg, the ankle, and the joints of inversion and eversion of the foot.
END OF PART 2
PART 3: THE LEG AND ANKLE
00.00
In this section well go from the knee, to a little below the ankle. Well start by
looking at the bones, and the joints of the the ankle region. Then well look at
the muscles which produce movements at those joints. Lastly well look at the
blood vessels and nerves of the region.
00.21
Before we start, we need to understand the meaning of some anatomic terms
regarding the foot and its movements. The upper and lower surfaces of the foot
are called the dorsal surface, and plantar surface. This part of the foot is called
the tarsus, these bones are the tarsal bones. The long bones in front of them are
the metatarsals.
00.48
Well be looking at two sets of movements, which happen in two different places.
The upward and downward movements, that occur at the ankle joint itself, are
called dorsi-flexion, and plantar flexion.
01.03
The side to side rocking movements that occur at the joints just below the ankle
are called eversion, for turning outward, and inversion, for turning inward. Lastly,
speaking of definitions, recall that the leg in anatomy means just the part of
the lower extremity that's between the knee and the ankle.
01.23
Now lets look at the bones. Well start by taking a further look at the two long
bones of the leg, the tibia and the fibula. The tibia is much the larger of the two
bones.
01.35
The shafts of the two bones are covered by muscles, except for the anteromedial
aspect of the tibia, which lies directly beneath the skin all the way from the knee to
the ankle.. The proximal end of the fibula doesnt form part of the knee joint, but
its distal end forms an important part of the ankle joint, as well see.
02.01
The tibia and fibula are held together throughout their length by the strong
interosseous membrane. Above and below there attached at the two tibio-fibular
joints. The proximal tibio-fibular joint is a synovial joint, the distal one is a fibrous
joint. Theres very little movement at either of these joints. Distally the two bones
are strongly held together by the anterior tibio-fibular ligament, and the posterior
tibio-fibular ligament..
02.37
The projecting ends of the tibia and fibula, which stick out on either side of the
ankle, are called the medial malleolus, and the lateral malleolus.
02.53
The articular surface for the ankle joint is a broad notch, formed by the curved
undersurface of the tibia, and the inner surfaces of the medial malleolus, and the
lateral malleolus.
03.08
Now lets look at the bone that articulates with the tibia and fibula to form the
ankle joint - the talus. This is the talus. The bone below and behind it is the
calcaneus, or heel bone. The bone in front of the talus is the navicular bone.
Well meet the remaining tarsal bones shortly. Now we'll go round to te lateral view
to see the talus by itself.
03.31
This is the head of the talus, this is the neck. The talus has three articular
surfaces, one on the head, and one on the underside for the two joints of inversion
and eversion, and one on top for the ankle joint.
03.52
Heres the ankle joint. Lets see how it looks in the living body. Here the loose
parts of the joint capsule have been removed, leaving these thickened parts, which
are the ligaments of the joint. Heres the front of the joint in plantar flexion,
heres the back of the joint in dorsiflexion.
04.28
On the lateral side, the joint is held together by the posterior talo-fibular
and anterior talo-fibular ligaments. On the medial side its held together by this
massive ligament, the deltoid ligament, which attaches not only to a broad area on
the talus but also to the adjoining bones below and in front, as well see shortly.
The ligaments of the ankle joint ensure that the talus cant rock from side to side
like this, or move backward or forward like this, relative to the tibia and fibula.
05.12
Heres the ankle joint with its joint capsule intact, and with the rest of the bones in
place. The capsule of the ankle joint is loose on the front, and its also loose on
the back. This looseness allows for a full range of dorsiflexion and plantar flexion.
05.37
Now well move on, to look at the two joints of inversion and eversion. Theres one
directly beneath the main part of the talus, called the subtalar joint; and theres
one below and in front of the head of the talus that has an unwieldy name, the
talo-calcaneo-navicular joint. Well call it the T.C.N. joint for short.
05.56
To understand these joints we need to get acquainted with the remaining tarsal
bones. We already know the talus, the calcaneus, and the navicular. In front of
the navicular are the three cuneiform bones, first, second, and third. Lastly, the
bone in front of the calcaneus is the cuboid bone.
06.18
Now let's look at the calcaneus by itself. The posterior part of the calcanueus
forms the heel. The massive calcaneal tendon, also called the Achilles tendon, is
attached here. Here on the medial side theres a projecting shelf which the medial
part of the talus sits on, called the sustentaculum tali.
06.42
On the front of the calcaneus theres an articular surface for the cuboid bone. On
the upper aspect of the calcaneus there are two articular surfaces for the talus, a
small one in front, a larger one behind.
07.01
The larger of these two surfaces, together with the corresponding surface on the
underside of the talus, forms the subtalar joint. The head of the talus fits into a
socket, which well see by taking the talus away. The socket is formed by this
surface of the calcaneus, this surface of the navicular bone, and by a strong
ligament here which well see in a minute. These surfaces, together with the head
of the talus, form the talo-calcaneo-navicular joint.
07.41
Heres what these joint surfaces look like in the living body: the surface for the
subtalar joint, and the two surfaces for the T.C.N. joint. This structure in between,
which forms part of the TCN joint, is the upper surface of the strong calcaneo-
navicular ligament, also misleadingly called the spring ligament, which helps to
hold up the head of the talus. It goes from here on the calcaneus to here on the
navicular.
08.11
The movement that happens at the subtalar and T.C.N joints is a rocking motion,
that takes place around an obliquely placed axis.
08.20
This rod shows the position of the axis: its oblique to the long axis of the foot
both in this plane, and in this plane. Heres eversion...heres inversion. Again,
eversion...and inversion
08.43
Several strong ligaments hold the malleoli, the talus, the calcaneus and the
navicular bone together. On the medial side, which well see first, theres one
extensive ligament to look at, the deltoid ligament. Weve seen part of it already,
009.01
Now heres the whole of the deltoid ligament. This is the part we saw before, going
from from the medial malleolus to the talus. In addition, parts of the deltoid
ligament fan out below onto the sustentaculum tali of the calcaneus, and in front
onto the navicular bone, so that the deltoid ligament holds all four of these bones
together.
09.25
On the lateral side there are two important ligaments, the calcaneo-fibular
ligament which goes from the lateral malleolus to the side of the calcaneus, and
this strong ligament, the interosseous talo-calcaneal ligament, which goes from
here on the calcaneus, to here on the talus.
09.49
To see that ligament better, well remove the talus. The interosseous talo-
calcaneal ligament lies between the subtalar joint and the T.C.N. joint..
10.02
Now that weve seen the ankle joint and the joints of inversion and eversion, well
look very briefly at the remaining joints of the tarsus. Between the navicular and
its neighbors, the cuneiform bones and the cuboid bone, theres hardly any
movement. But there is a small amount of rotation here between the cuboid and
the calcaneus, which lets the front part of the foot invert and evert a little,
independently of the calcaneus.
10.29
Well see more of the bones and ligaments of the foot in the next section. For now,
weve seen enough to understand how the joints of the ankle region move. Before
we move on to look at the muscles that produce those movements, we need to
take a look at some important pulley-like structures that are attached to the bones
of the ankle region. These are called retinacula, the singular of which is
retinaculum. Each retinaculum guides and keeps in place a set of tendons that
pass from the leg to the foot. Theres a retinaculum on the front of the ankle,
and one on each side of the ankle, behind and below each malleolus.
11.06
Here on the front are the upper part and the lower part of the extensor
retinaculum. These arent isolated structures, theyre localized thickenings of this
layer of investing deep fascia, which well meet later. Four tendons, a nerve and an
artery pass under the extensor retinaculum.
11.31
On the lateral aspect, behind the malleolus, heres the peroneal retinaculum. It
accommodates the tendons of two peroneal muscles as they pass around the
lateral malleolus.
11.46
On the medial side the flexor retinaculum fans out from the back of the medial
malleolus. The space beneath the flexor retinaculum is divided into four separate
tunnels. Three tendons, and the posterior tibial vessels and nerve, pass through
these tunnels as they pass around the ankle and into the foot.
12.09
Now lets review what weve seen of the bones, joints and pulleys of the ankle
region. Then well move on to look at the muscles of the leg.
12.17
REVIEW
Heres the tibia, the fibula, the medial malleolus, the lateral malleolus, the
talus, and the ankle joint.
12.34
Heres the interosseous membrane, the proximal tibio-fibular joint, the distal tibio-
fibular joint, the posterior tibio-fibular, and talo-fibular ligaments, the anterior
tibio-fibular, and talofibular ligaments, and the deltoid ligament. Here's the
calcaneus, the cuboid, the three cuneiform bones, and the navicular,
13.13
Here are the surfaces for the subtalar joint, and for the T.C.N. joint. Heres the
calcaneo-navicular ligament, the calcaneo-fibular ligament, and the interosseous
talo-calcaneal ligament. Heres the extensor retinaculum, the peroneal
retinaculum, and the flexor retinaculum.
13.49
MUSCLES
Now well move on to look at the muscles that produce movement at the joints of
the ankle region. In doing this, well meet most but not all of the muscles that are
in the leg.
14.05
There are four muscles that in the leg, the long flexors and extensors of the toes,
that well leave out of the picture till the next section. These are the long flexors
and the long extensors of the toes. Along with the muscles, well meet the various
layers and partitions of deep fascia which divide the muscles of the leg into rather
distinct compartments.
14.23
Well start with the muscles that produce dorsiflexion and plantar flexion at the
ankle joint; next well look at the fascial layers and compartments, lastly well look
at the muscles of inversion and eversion.
14.35
First, then, the dorsiflexors and plantar flexors. Dorsiflexion involves just lifting
the foot. Plantar flexion involves lifting the whole body. So its not surprising that
the muscles for plantar flexion are much larger than the ones for dorsiflexion.
14.52
Theres one muscle on the front of the leg for dorsiflexion, tibialis anterior. There
are three on the back of the leg for plantar flexion, gastrocnemius, soleus, and
plantaris. Heres tibialis anterior. Tibialis anterior arises from the lateral surface of
the upper tibia, and from the interosseous membrane.
15.17
The tendon of tibialis anterior passes under the extensor retinacula, and winds
around the medial side of the tarsus, to insert right down here, on the first
cuneiform bone, and on the base of the first metatarsal. The main action of
tibialis anterior is to produce dorsiflexion at the ankle.
15.49
Dorsiflexion is not the only action of tibialis anterior. It also has a role in
producing inversion, as well see shortly. Whats more, tibialis anterior is not the
only muscle that produces dorsiflexion. Its assisted in that, by the long extensor
muscles for the toes, which well see in the next section.
16.11
Well move on now to look at the muscles that produce plantar flexion. Two large
muscles, gastrocnemius and soleus, and one small muscle, plantaris, join together
to form the massive calcaneal tendon.
16.26
Heres gastrocnemius; here deep to it is soleus. Gastrocnemius has two heads, a
medial and a lateral. These arise, as weve seen, from the medial and lateral
condyles of the femur. The two heads of gastrocnemius unite, forming a flat
tendon. The gastrocnemius tendon in turn unites with the tendon of soleus to form
the calcaneal tendon. To look at soleus well remove gastrocnemius.
17.04
Heres the whole of soleus. Heres its medial border, heres its lateral border.
Heres the cut edge of the gastrocnemius tendon. Soleus arises from the medial
edge of the tibia, from this oblique line on the back of the tibia, and from this area
on the back of the fibula.
17.34
Between the fibular, and the tibial origins of soleus theres an arch of fibrous
tissue. The popliteal vessels, and the tibial nerve, pass beneath this arch. Here
are their divided ends.
17.50
For completeness, well add plantaris to the picture. Here it is. Plantaris arises
here on the lateral epicondyle of the femur. The long tendon of plantaris runs
almost to the ankle before uniting with the calcaneal tendon. The calcaneal tendon
is also known as the Achilles tendon or simply the heel cord. It inserts into a
broad area here, on the back of the calcaneus. In front of the calcaneal tendon
there's a pad of fat, which fills the gap between the tendon and the back of the
ankle joint
18.35
The action of soleus, gastrocnemius, and plantaris is to produce plantar flexion at
the ankle joint. Their action lifts us off the ground when we stand on tip-toe.
When balanced against gravity, the same action controls our rate of descent. In
addition, these muscles provide an important part of the propulsive force
in normal walking, in going uphill, in running, and in jumping.
19.16
Before we move on to see the muscles that produce inversion and eversion, we
need to digress for two minutes, to look at the layer of deep fascia that surrounds
all the muscles of the leg, and the three fibrous partitions, or septa that divide the
leg muscles into somewhat distinct compartments.
19.32
This outer layer is the investing deep fasica. It surrounds all the muscles of the
leg. The investing deep fascia is attached to the tibia here, and here . Its
attached to the fibula not directly, but indirectly by two fibrous septa here, and
here, that well see in a minute.
20.07
The investing deep fascia wraps around the back of the calcaneal tendon, like a
sling. Distally the investing deep fascia is continuous with the superficial part of
the flexor retinaculum, with the peroneal retinaculum, and with the two parts of the
extensor retinaculum.
20.27
Now well look at the fibrous septa, the singular of which is septum. There are
three of them. Together with the interosseous membrane, they divide the muscles
of the leg into four compartments, two on the front of the leg, and two on the back.
Well look at the back first. Well remove gastrocnemius and soleus, down to here.
20.50
Heres soleus, divided, heres the investing deep fascia, divided at a lower level.
In front of soleus, this transverse intermuscular septum crosses the back of the
leg. It runs from here on the tibia, to here on the fibula.
21.18
Three muscles that we havent seen yet lie between the transverse septum and the
bones. To see the transverse septum better, well remove the rest of soleus. The
transverse septum is thin up here, but toward the ankle it becomes thicker. At the
ankle, the transverse septum is continuous with the flexor retinaculum.
21.48
The other two septa have cumbersome names: theyre the anterior and the
posterior crural intermuscular septa. To see them, well remove the investing deep
fascia down to here, exposing several muscles that we havent met yet. Well be
meeting them soon. This is the posterior crural septum, lying just in front of the
soleus muscle. This is the anterior crural septum. These two septa are attached to
the fibula here, and here.
22.33
The anterior crural septum divides the muscles in front of and lateral to the two
bones into an anterior compartment, which contains four muscles including tibialis
anterior, and a more laterally placed peroneal compartment, which contains two of
the three peroneal muscles.
22.55
Now that weve seen these fascial structures, lets get back to the muscles, the
ones that produce inversion and eversion. There are two muscles that produce
inversion, tibialis anterior, which weve seen already, and tibialis posterior.
23.10
Heres tibialis posterior. Tibialis posterior arises from the back of the tibia, the
back of the fibula, and from the interosseous membrane in between. Its tendon
passes immediately behind the medial malleolus, through a fibrous tunnel thats
covered by the flexor retinaculum. Beyond the malleolus the tendon of tibialis
posterior fans out. It has a wide insertion, here, on the navicular and first
cuneiform bones and also under here, on the bases of the second, third and fourth
metatarsals. Heres the action of tibialis posterior: it inverts the foot
24.07
The other muscle that can act as a foot invertor is tibialis anterior, which inserts so
close to tibialis posterior that it has almost the same line of action. We looked at
tibialis anterior, in its role as an ankle dorsiflexor, earlier in this section.
24.28
Now well look at the three muscles that evert the ankle: peroneus longus, brevis,
and tertius. Heres peroneus brevis. Peroneus brevis arises from here on the
distal fibula.
24.48
Lying on top of peroneus brevis, is peroneus longus. Peroneus longus arises from
here on the proximal fibula. Its origin extends up onto the head of the fibula, with
a gap here.
25.10
The deep peroneal nerve passes under the upper end of peroneus longus here, as
well see. The other muscle in the picture here is tibialis anterior.
25,23
At the ankle, the tendons of peroneus longus and brevis pass behind the lateral
malleolus and beneath the peroneal retinaculum, longus behind, brevis in front.
Peroneus brevis runs forward to insert here, on the base of the fifth metatarsal. To
see the remarkable course of the peroneus longus tendon, we have to remove the
entire sole of the foot. Peroneus longus runs around the cuboid bone, and along
a deeply placed fibrous tunnel , to insert right over here, on the base of the first
metatarsal.
26.05
Lastly, in front of peroneus brevis and longus, heres peroneus tertius. Peroneus
tertius arises from here on the fibula. The tendon of peroneus tertius passes
under the extensor retinaculum, and in front of the lateral malleolus to insert
here, on the base of the fifth metatarsal, next to peroneus brevis. The action of
all three of the peroneal muscles is to evert the foot.
26.44
In addition, peroneus tertius, acting along with its anterior neighbors, can help to
dorsiflex the ankle. The muscles of inversion and eversion are important, because
they enable us to stay balanced and upright on a surface that tilts to one side, or
to the other.
27.03
Now that weve looked at the muscles that produce movement of the foot, were
nearly ready to move on to the vessels and nerves of this region. Before we do
that, lets review what weve seen of the muscles, and the associated fascial
structures.
27.19
REVIEW
Heres the investing deep fascia, heres the posterior crural septum, the anterior
crural septum, and the transverse intermuscular septum. Heres tibialis anterior,
heres gastrocnemius, soleus, and plantaris, and the calcaneal tendon. Heres
tibialis posterior, peroneus longus, peroneus brevis, and peroneus tertius.
28.15
VESSELS
Now well move on, to look at the vessels and nerves of the region. Well go from
the knee, where we saw them last, to just below the ankle. Well start with the
veins.
28.32
Heres the leg with the skin removed. To expose the two major superficial veins,
two strips of subcutaneous fat have also been removed. Heres the short
saphenous vein on the back, and the long saphenous vein on the front.
28.55
The long saphenous vein passes over the medial malleolus, which is here and runs
up the medial side of the leg. Weve seen its more proximal course in the
previous sections of this tape.
29.13
The short saphenous vein runs up between the calcaneal tendon and the lateral
malleolus. It goes up the back of the leg, and passes through the deep fascia
near the knee to join the popliteal vein.
29.30
To see some of the superficial veins in more detail, well remove the
subcutaneous fat from the back of the leg. The short saphenous vein, like the
long saphenous vein, is joined by a number of superficial branches The
saphenous veins are also joined by several perforating veins like this one, which
bring blood from the muscle compartments that lie deep to the investing deep
fascia.
29.54
In the last section we saw the principal deep vein of the leg, the popliteal vein.
here it is again. With the tibial nerve behind it and the popliteal artery in front of
it, it disappears between the two heads of gastrocnemius. In this section we wont
follow the deep veins any further, since their course is just the same as that of the
corresponding arteries.
30.19
Well look at the arteries next. The three main arteries which supply the leg and
ankle region are all branches of the popliteal artery. Theyre the anterior tibial,
the posterior tibial, and the peroneal. In the dissection that well see, all the veins
have been removed, to simplify the picture.
30.39
Heres the popliteal artery, passing between the two heads of gastrocnemius. Its
branches to gastrocnemius have been removed. To follow the popliteal artery, well
remove gastrocnemius. The popliteal artery runs down the back of the popliteus
muscle, then passes through the fibrous arch in the origin of soleus. Well remove
soleus.
31.03
At the lower border of the popliteus muscle, the popliteal atery gives off this major
branch, the anterior tibial artery, which runs forwards. Well follow it in a minute.
The popliteal artery then ends by dividing into the peroneal artery, and the
posterior tibial artery. Well follow the posterior tibial artery first. It runs down the
back of the leg, just behind the deep posterior muscles. Its covered by the
increasingly thick transverse intermuscular septum, which well remove.
31.37
As it passes toward the medial side of the ankle, the posterior tibial artery lies just
behind tibialis posterior. At the ankle, the artery passes through a tunnel beneath
the flexor retinaculum, part of which has been removed here. Within its tunnel, the
posterior tibial artery divides into the medial plantar, and lateral plantar arteries,
which well follow in the next section.
32.03
Next well look at the peroneal artery. The peroneal artery passes laterally, and
runs beneath a muscle that well be looking at at in the next section, flexor hallucis
longus. Well remove it. The peroneal artery runs down between the deep
posterior muscles, close to the fibula, which is here. It gives off numerous
branches to the surrounding muscles, and ends behind the lateral malleolus.
32.32
Lastly, well look at the anterior tibial artery. Heres where we saw the anterior tibial
artery last, arising from the popliteal artery. It immediately passes forward
through a gap in the interosseous membrane. Well go round to the front to follow
it. Here it is emerging. The anterior tibial artery runs down the leg on the
interosseous membrane, just lateral to tibialis anterior. The long toe extensors,
which have been removed in this dissection, lie lateral to the artery. At the ankle,
the anterior tibial artery passes beneath the extensor retinaculum. Heres the
artery emerging on the dorsum of the foot . Beyond this point its called the
dorsalis pedis artery. Well follow it further in the next section.
33.23
NERVES
Now well look at the nerves of this region, the tibial nerve, and the common
peroneal nerve. We saw them last at the knee, the tibial nerve disappearing,
along with the popliteal vessels, between the heads of gastrocnemius; the common
peroneal nerve disappearing underneath peroneus longus. Well look at the tibial
nerve first. To follow it, well remove two muscles which it supplies: gastrocnemius,
and soleus
The tibial nerve follows the same course as the posterior tibial artery. The nerve
passes beneath the flexor retinaculum just behind the artery. Beneath the flexor
retinaculum, the tibial nerve divides, into the medial plantar nerve, and the lateral
plantar nerve. Well see where these go in the next section.
34.19
In the leg, the tibial nerve supplies gastrocnemius, plantaris, soleus, and all three
of the deep flexor muscles, including tibialis posterior.
34.33
Now well follow the common peroneal nerve. As it passes under the peroneus
longus muscle, the common peroneal nerve divides, into the superficial peroneal
nerve, and the deep peroneal nerve. The superficial peroneal nerve runs down
beneath peroneus longus. It emerges here, and continues down to the foot as a
sensory nerve, as well see in the next section. The superficial peroneal nerve
supplies peroneus longus, and peroneus brevis.
35.08
The deep peroneal nerve runs under peroneus longus, here it is again, and then
under this adjoining muscle, which is extensor digitorum longus. Heres the deep
peroneal nerve emerging, just medial to the anterior tibial vessels, and medial to
tibialis anterior. The deep peroneal nerve follows the same course as the anterior
tibial vessels, as it runs down the leg, and under the extensor retinaculum.
35.41
Of the muscles that weve already seen in the leg, the deep peroneal nerve
supplies: tibialis anterior, and peroneus tertius.
35.53
Now lets review what weve seen of the vessels and nerves of the leg and ankle
region.
35.59
REVIEW
Heres the long sapheous vein, the short saphenous vein, and the popliteal vein.
Heres the popliteal artery, the peroneal artery, and the posterior tibial artery, the
medial plantar, and lateral plantar arteries, and the anterior tibial artery
36.37
Now the nerves: the tibial nerve, the medial plantar nerve, and the lateral plantar
nerve, the common peroneal, superficial peroneal, and deep peroneal nerves.
36.59
That brings us to the end of this section on the leg and ankle. In the next
section, well look at the foot.
END OF PART 3
PART 4: THE FOOT
00.00
In this section well look at the foot. As usual, well start with the bones.
After that well look at the joints and ligaments, the muscles, the blood
vessels and nerves, and lastly the skin.
00.20
We saw most of the bones of the foot in the last section. Here, we'll briefly
review the tarsal bones, then we'll look at the metatarsals and the bones of
the toes.
00.30
Heres the calcaneus, the talus, the navicular, the cuneiforms - first, second,
and third - , and the cuboid. Lets see the same bones again from beneath:
the calcaneus, the cuboid, the cuneiforms, the navicular, and the talus
again.
01.01
Now well look at the metatarsals. Like the toes, the metatarsals are
numbered one, through five. The first metatarsal is more massive than the
others. The second metatarsal is the longest. On the base of the fifth
metatarsal theres a prominent tubercle.
01.26
The metatarsals are slightly curved from end to end. The heads of the
metatarsals lie in one flat plane, but their bases form an arch from side to
side, as do the tarsal bones that they articulate with. These are the three
cuneiform bones, and the cuboid. These are the tarsometatarsal joints.
Theres very little movement at any of them.
02.02
The bones of the foot are arched in two planes, from side to side as weve
just seen, and also from end to end. Well be looking at the structures that
support the arches of the foot in a minute. To finish with the dry bones, lets
look at the toes.
02.22
The big toe has only two phalanges, a proximal, and a distal. The other
four toes have three phalanges, proximal, middle, and distal. These are the
metatarso-phalangeal joints, or MP joints for short. The joints between the
phalanges are the interphalangeal joints.
2.44
The bones of the toes are quite similar to the corresponding bones of the
fingers, which are shown in Volume 1 of this atlas. Now that weve seen the
dry bones of the foot, lets see what theyre like in the living body. Were
already familiar with the ligaments around the ankle. What well look at now
are the ligamentous structures that hold this apparently delicate arch of
bones together, and enable it to support the whole weight of the body.
03.12
Heres the foot with all the soft tissues removed, and all the joints and
ligaments intact. On the dorsum of the foot theres an almost continuous
layer of ligaments, connecting the tarsal bones both to each another and to
the metatarsals, and connecting the heads of the metatarsals together. The
ligaments on the dorsum of the foot are strong ligaments, but the truly
impressive ligaments, the ones which support the longitudinal arch, are on
the underside of the foot.
03.42
First, heres the short plantar ligament. It goes from here on the calcaneus,
to here on the cuboid bone. Just in front of the short plantar ligament is
the groove for the peroneus longus tendon. Lying directly beneath the short
plantar ligament is the long plantar ligament. The long plantar ligament
also starts here on the calcaneus, and goes all the way to the bases of the
third, fourth and fifth metatarsals.
04.20
The long plantar ligament bridges over, or rather under, the peroneus
longus tendon - heres the tendon, going to its insertion on the base of the
first metatarsal.
04.33
Theres another, even more impressive structure that supports the arch of
the foot - the plantar aponeurosis. The plantar aponeurosis is a massive
sheet of tendon-like tissue that runs the whole length of the foot. It starts
here on the calcaneus. It fans out as it runs forward. As it approaches the
MP joints, the plantar aponeurosis splits into five divisions. Most of the
fibers of each division pass into two slips, which pass forward and upward
toward the M.P. joint. Well see where they go in a minute.
05.19
To understand where the slips of the plantar aponeurosis insert, we first
need to look at the MP joints, and at some structures nearby: the flexor
tendon sheaths, the plantar ligaments of the MP joints, and the ligament
that connects the metatarsal heads, the deep transverse metatarsal
ligament.
05.42
Heres the deep transverse metatarsal ligament. It goes all the way from
the first MP joint, to the fifth. The flexor tendon sheaths, which well see in a
minute, are attached along these lines.
05.58
To take a look at a typical MP joint, and the structures around it, well look at
a toe and its metatarsal in isolation. Heres the MP joint with its capsule
intact. Here it is with the loose parts of the capsule removed. Theres a
broad collateral ligament on each side. The MP joint cant flex much beyond
a straight position, but it can extend all the way to here.
06.33
Heres an MP joint divided longitudinally. The joint capsule is thin on the
dorsal aspect, and massively thickened on the plantar aspect. This thick
part of the capsule is the plantar ligament of the MP joint, its fixed to the
proximal phalanx here, so when the joint is extended, the plantar ligament
is pulled forward.
06.57
Heres the plantar ligament in the intact joint. The tendon sheath is
attached to the plantar ligament here, and here. Heres a short piece of the
tendon sheath intact. It runs the whole length of the toe, as well see later.
Also attached to the plantar ligament of the MP joint is the deep transverse
metatarsal ligament: here's its attachment on one side, here it is on the
other side.
7.36
Heres the MP joint of the big toe, the first MP joint. Its much larger than
the other MP joints, and it has two additional structures, a pair of sesamoid
bones, which are enclosed within the plantar ligament. One of thems here,
the other ones here.
08.02
Now that weve looked at the MP joints and the structures around them, lets
go back to the plantar aponeurosis, and see how its inserted. As weve
seen, each division of the aponeurosis gives rise to two slips. These lie on
each side of the flexor tendons. The two slips are inserted here, and here,
on each side of the plantar ligament of the MP joint.
08.33
Since the plantar aponeurosis is inserted into a set of movable structures,
the plantar ligaments of the MP joints, its tightness varies depending on the
position of these joints. When the MP joints are straight, the plantar
aponeurosis is slack, but when there extended, it becomes much tighter.
08.57
The plantar aponeurosis acts as a continuation of the achilles tendon. When
its tight, as it is when the MP joints are extended, it enables the pull of the
calcaneal tendon be transmitted directly to the metatarsal heads. Thats
why the arch of the foot remains an arch, even at the moments when we
place the heaviest loads on it.
09.18
The plantar aponeurosis is the central part, and much the strongest part, of
a layer of fascia, the plantar fascia, which covers the entire sole of the foot.
Well see the whole of the plantar fascia when we've looked at at the
muscles of the foot, which were going to do shortly. Lets now review what
weve seen, of the bones, joints, and ligaments of the foot.
09.42
REVIEW
Here are the metacarpals, the proximal phalanges, the middle phalanges,
and distal phalanges, the tarso-metatarsal joints, the metatarso-phalangeal
joints, and the interphalangeal joints.
10.05
Here are the short plantar ligament, the long plantar ligament, and the
plantar aponeurosis. Heres the deep transverse metatarsal ligament, the
flexor tendon sheaths, and the plantar ligament of the MP joint.
10.33
MUSCLES
Now well look at the muscles which produce movement of the toes. Well
look at the extensor muscles first. There are two long extensors to the toes,
and two short ones. The long extensors are two of the four muscles that we
left out of the picture in the last section.
10.56
Heres extensor hallucis longus. Extensor hallucis longus arises from the
interosseous membrane, and from the adjoining fibula. Lying on top of
extensor hallucis longus is extensor digitorum longus. Extensor digitorum
longus has a long line of origin here on the fibula. This gap is for the
common peroneal nerve.
11.35
To see all the muscles of the anterior compartment together, well add
tibialis anterior to the picture, here it is. We saw tibialis anterior in the last
section. It almost covers up extensor hallucis longus. Well also add
peroneus tertius, which arises in continuity with extensor digitorum longus.
12.01
Here are the tendons of all these musces passing under the extensor
retinaculum: peroneus tertius, extensor digitorum longus, extensor hallucis
longus, and tibialis anterior.
12.19
The tendon of extensor hallucis longus inserts partly into the extensor
expansion of the first MP joint, and partly here, into the base of the distal
phalanx of the big toe.
12.32
The tendons of extensor digitorum longus insert, by way of the extensor
expansion of each toe, into the bases of the middle and distal phalanges.
The extensor expansion of the toe is quite similar to the extensor
expansion of the finger, which is described in some detail in Volume 1 of this
atlas. Heres the action of extensor hallucis longus: it extends both joints of
the the big toe. Heres the action of extensor digitorum longus: its action is
mainly at the MP joint.
13.09
The two long toe extensor muscles have another important action besides
extending the toes. Theyre also quite powerful dorsiflexors of the ankle.
13.22
Now lets add the short extensors to the picture. Here they are. They lie
beneath the tendons of the long extensors. Extensor hallucis brevis goes
to the big toe, the four slips of extensor digitorum brevis go to the four short
toes. The short toe extensors arise here, on the front of the calcaneus.
13.49
The tendons of the short extensors join the corresponding long extensor
tendons. The action of the short extensors is the same as that of the long
extensors, except that they dont dorsiflex the ankle.
14.02
Now well look at the muscles which flex the toes. First well look at the two
long flexors, flexor hallucis longus, and flexor digitorum longus. Theyre the
other two muscles that we left out of the picture in the last section.
14.19
Heres flexor hallucis longus. Flexor hallucis longus arises from here on the
back of the fibula. Medial to flexor hallucis longus is flexor digitorum
longus. Flexor digitorum longus arises from here on the back of the tibia.
This gap is for the tendon of tibialis posterior.
14.48
The relative position of these two muscles, this one for the big toe, this one
for the four small toes, is the reverse of what youd expect when you look at
where theyre going. As well see, their two tendons cross over just below the
ankl e.
15.05
To complete our picture of the deep posterior leg muscles, well add the third
one, tibialis posterior to the picture. We saw it in the last section. Its the
most deeply placed of the three muscles. Tibialis posterior, crosses beneath
flexor digitorum longus, and emerges in front of it, just above the ankle.
15.26
At the ankle, here are flexor hallucis longus, flexor digitorum longus, and
tibialis posterior, each passing beneath the flexor retinaculum in its own
fibrous tunnel. Emerging below the retinaculum, the two long toe flexors
cross over, flexor hallucis longus lying deeper.
15.47
The tendon of flexor hallucis longus passes forwards, and enters the fibrous
flexor tendon sheath of the big toe. The two sesamoid bones lie on each
side of it, here and here, as it passes beneath the MP joint. Flexor hallucis
longus is inserted here, on the base of the distal phalanx of the big toe.
Flexor digitorum longus divides into four tendons, one for each of the small
toes. These pass along the flexor tendon sheaths, and insert here on the
distal phalanges. Heres the action of flexor hallucis longus, heres the
action of flexor digitorum longus.
16.40
Now well move on, to look at the numerous small muscles on the plantar
aspect of the foot. The intricacy of these muscles reminds us that our
human foot has evolved from feet that had many other functions besides
that of being walked on. Since some of the smaller muscles are now almost
vestigial structures, well be looking at them quite briefly.
17.03
Well look at the small plantar muscles in four groups, first the interosseous
muscles; then the short muscles that occupy the middle of the foot; then the
short muscles for the big toe; and lastly the ones for the fifth toe.
17.19
Here are the interosseous muscles. There are seven of them, two for each
of the three middle toes, and one for the fifth toe. The interosseous muscles
arise from the shafts of the metatarsals, and insert into the bases of the
proximal phalanges. The action of the interosseous muscles is to flex the
toes at the MP joints.
17.52
Now well look at the middle group of muscles. These are all closely
associated with the tendon of flexor digitorum longus. The middle group
consists of the tiny lumbrical muscles, flexor accessorius, and, superficial to
them, flexor digitorum brevis, which well see again in a moment. The four
lumbricals are just like the lumbricals in the hand. We wont look at them in
detail.
18.25
Flexor accessorius, also called quadratus plantae, arises by two heads from
from here and here on the calcaneus. Flexor accessorius inserts here, into
the deep aspect of the tendon of flexor digitorum longus. Flexor accessorius
aids in flexing the toes.
18.52
Now well add flexor digitorum brevis to the picture - here it is again. Flexor
digitorum brevis arises from here on the calcaneus. Flexor digitorum brevis
divides to form four tendons. Each of these enters one of the tendon
sheaths, along with a tendon of flexor digitorum longus. Inside the tendon
sheath, which well remove, the brevis tendon splits into two halves, which
encircle the longus tendon. Flexor digitorum brevis inserts here, on the
bases of the middle phalanges. Flexor digitorum brevis assists in producing
flexion at the PIP and MP joints. Lying superficial to flexor digitorum brevis
is the plantar aponeurosis, which weve looked at already.
19.52
Now well look at the muscles for the big toe. To build up a picture of them,
well first take the middle group of muscles out of the picture so that were
again looking at just the interossei. The muscles for the big toe are flexor
hallucis brevis, adductor hallucis, and abductor hallucis. Well look at them
in that order.
20.21
Flexor hallucis brevis has two almost distinct parts, which arise here from the
cuboid and third cuneiform bones. Flexor hallucis brevis gives rise to two
tendons of insertion, which attach first to the medial and lateral sesamoid
bones, then to the base of the proximal phalanx of the big toe. The tendon
of flexor hallucis longus - which well add to the picture for a moment - runs
between the two halves of flexor hallucis brevis.
20.58
Heres adductor hallucis. It arises by two heads, an oblique head, and a
transverse head. The oblique head arises from the bases of the middle
three metatarsals, the transverse head arises from the deep transverse
metatarsal ligament.
21.20
These two heads converge, and merge with the medial head of flexor
hallucis brevis, sharing its insertion on the medial sesamoid bone, and on
the base of the proximal phalanx.
21.32
Medial to flexor hallucis brevis is abductor hallucis. Abductor hallucis is the
most medial of all the foot muscles. It arises here, on the medial side of
the calcaneus. The tendon of abductor hallucis merges with the medial
part of flexor hallucis brevis, and inserts with it here, on the medial
sesamoid bone, and on the base of the proximal phalanx.
22.03
The main action of all three of the short muscles of the big toe is to
produce flexion at the MP joint. In addition, adductor and abductor hallucis
brevis can produce adduction and abduction of the big toe.
22.23
Lastly, there are two short muscles for the fifth toe, a short flexor and an
abductor. Heres the flexor, flexor digiti minimi brevis. Its an outlying
interosseous muscle thats been given a long name. Heres the abductor,
abductor digiti minimi. It arises all the way back here, on the calcaneus.
Its inserted here, on the proximal phalanx of the fifth toe.
22.52
Now that weve seen the muscles for the big toe and the fifth toe, we need to
see how all these short muscles fit together. To do that, well put the long
flexor tendons, and then the central group of muscles back into the picture.
23.07
First well add flexor hallucis longus to the picture. Flexor hallucis longus
lies deep to abductor hallucis as it enters the foot. Heres flexor digitorum
longus, entering the foot along with flexor hallucis longus. The tendons of
flexor digitorum longus cover up adductor hallucis. Here are the lumbricals,
flexor accessorius, and last of all flexor digitorum brevis.
23.46
Now that weve seen all the muscles of the foot, lets get a complete picture
of the layer of deep fascia that encloses them all, the plantar fascia.
24.00
The central, thickened part of the plantar fascia is the plantar aponeurosis,
which weve seen already. The medial and lateral parts of the plantar fascia
extend on each side of the plantar aponeurosis. On the medial side the
plantar fascia covers abductor hallucis.
24.20
On the lateral side it covers abductor digiti minimi. Here on the lateral side
theres a marked thickening of the plantar fascia, called the lateral cord of
the plantar aponeurosis, which goes from here on the calcaneus, to here on
the base of the fifth metatarsal. The lateral cord of the plantar aponeurosis
helps to support the longitudinal arch of the foot, on the lateral side.
24.49
Weve seen all the muscles of the foot! Lets review them, before we move
on to look at the blood vessels and nerves of the foot.
24.59
REVIEW
Heres extensor digitorum longus, extensor hallucis longus, extensor
digtorum brevis, and hallucis brevis. On the back, heres flexor digitorum
longus, flexor hallucis longus,
25.31
Here are the interosseous muscles, the lumbricals, flexor accessorius, and
flexor digitorum brevis. Heres abductor hallucis, flexor hallucis brevis, and
adductor hallucis; and lastly here are abductor digiti minimi and flexor digiti
minimi brevis
26.09
VESSELS
Now well look at the blood vessels and nerves of the foot, starting with the
veins. The superficial veins of the lateral aspect of the foot join together to
form the short saphenous vein. The ones on the medial aspect of the foot
join together to form the long saphenous vein.
26.35
In addition, at a deeper level, the arteries, which well be looking at next,
are closely accompanied by concomitant veins, like these. From here on
well remove all the concommitant veins to simplify the picture.
26.51
We last saw the anterior, and posterior tibial arteries entering the foot,
beneath the extensor retinaculum and flexor retinaculum respectively.
Heres the anterior tibial artery at the ankle, passing beneath the extensor
retinaculum. Well remove the retinaculum.
27.13
As it passes in front of the ankle, the anterior tibial artery crosses beneath
extensor hallucis longus, emerging lateral to it. It gives off branches to the
tarsal region, then continues on to the dorsum of the foot. Beyond this
point its known as the dorsalis pedis artery.
27.32
The dorsalis pedis artery passes beneath the extensor hallucis brevis
muscle, gives off this first dorsal metatarsal artery, and ends by diving
through the first interosseous muscle to join up with the lateral plantar
artery which well see in a minute.
27.50
Now well look at the posterior tibial artery, or rather, at its two terminal
branches, the medial plantar, and lateral plantar arteries. Heres where we
saw them last, emerging from under the flexor retinaculum, the lower part
of which has been removed in this dissection. Also removed, are the
abductor hallucis muscle, here, and the plantar aponeurosis, here. This is
the distal end of the posterior tibial artery. This is the the lateral plantar
artery, this is the medial plantar artery.
28.26
The medial plantar artery is usually the smaller of the two. It crosses over
the tendons of the two long toe flexors, and runs along the medial side of
the foot. Its branches supply the adjoining muscles, and the underside of
the big toe.
28.41
Now well look at the lateral plantar artery. It passes deep to flexor
digitorum brevis, which well remove. After giving off this calcaneal branch,
the lateral plantar artery passes downwards and then laterally, across flexor
accessorius. When it reaches the base of the fifth metatarsal, which is here,
it curves around and passes deep to flexor digitorum longus and the
interosseous muscles, to join up with the dorsalis pedis artery.
29.15
NERVES
Now well look at the nerves of the foot. Well follow the nerves that we saw
in the last section: the superficial and deep peroneal nerves, and the medial
and lateral plantar nerves. There are two more nerves that well also look at
for completeness - the sural nerve, and the saphenous nerve. Well start
with the two peroneal nerves.
29.38
The superficial peroneal nerve runs down in front of the lateral side of the
ankle, and breaks up into several branches. These fan out to provide
sensation to this large area on the dorsum of the foot.
29.53
The deep peroneal nerve enters the foot along with the dorsalis pedis artery.
It gives off a motor branch, which supplies the short toe extensor muscles.
It continues distally as a sensory nerve, which supplies this small area
between the big and second toes.
30.13
Next well look at the medial and lateral plantar nerves. They follow the
same course as the medial and lateral plantar arteries. Heres the medial
plantar nerve. It gives off a motor branch which supplies flexor digitorum
brevis, abductor hallucis, and flexor hallucis brevis.
30.44
To follow the medial plantar nerve, well go round to the underside of the
foot. Distally, the medial plantar nerve breaks up into common plantar
digital nerves. These pass between the metatarsal heads, where each in
turn divides into two plantar digital nerves.
31.04
The median plantar nerve supplies the underside of the big toe, the second,
third and half of the fourth toes. It also supplies this medial area on the
sole of the foot
31.20
Now well look at the lateral plantar nerve. It runs just in front of the lateral
plantar artery. To follow it, we'll again go round to the underside of the foot.
Flexor digitorum brevis has been removed. The lateral plantar nerve gives
motor branches to flexor accessorius and abductor digiti minimi.
31.47
It then divides into a deep branch, which suppies all the interossei and
adductor hallucis, and a superficial branch, which supplies flexor digiti minimi
brevis, and provides sensation to the lateral part of the sole, the fifth toe
and half of the fourth toe
32.06
To complete our picture of the nerves that provide sensation to the foot,
well add two nerves that were passed over in the last section - the sural
nerve, and the saphenous nerve.
32.18
The sural nerve, which runs down the back of the leg, is formed by two
nerves which join together. One is the medial sural cutaneous branch of the
tibial nerve, the other is the sural communicating branch of the common
peroneal nerve.
32.34
The sural nerve runs down the lateral side of the ankle, behind the lateral
malleolus. The sural nerve supplies sensation to a variable area along the
lateral side of the foot.
32.46
The saphenous nerve, a branch of the femoral nerve, emerges at the knee,
from beneath the insertion of the sartorius muscle. It runs down the medial
side of the leg, and supplies a variable area on the medial side of the foot
and ankle.
33.06
Last of all, the heel area is supplied by calcaneal branches of the tibial
nerve, which are given off beneath the flexor retinaculum. Now lets review
what weve seen of the blood vessels and nerves of the foot.
33.22
REVIEW
Heres the start of the long saphenous vein, and the short saphenous vein.
Heres the dorsalis pedis artery, the lateral plantar artery, and the medial
plantar artery,
33.46
Heres the sural nerve, the superficial peroneal nerve, and the saphenous
nerve, the deep peroneal nerve, the medial plantar nerve, and the lateral
plantar nerve,
34.06
SKIN OF FOOT
Last of all, well look at the skin of the foot. On the dorsum of the foot, the
skin in thin and mobile. On the plantar aspect the skin is markedly
thickened, especially in the weight bearing areas. Theres a generous
padding of fat on the sole of the foot, especially on the heel.
34,42
The skin on the sole of the foot is tethered to the deeper tissues by
numerous firm strands of fibrous tissue. These strands arise from the
underlying bone, and plantar aponeurosis, and pass through the fat, into the
subdermis, keeping the weight bearing skin firmly in place.
35.01
That brings us to the end of Voume 2. In Volume 3, well look at the
musculo-skeletal system of the trunk, from the neck, to the pelvis.
END OF VOLUME 2

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