Muscles of Lower Leg Ankle and Foot Pain

■ Tibialis Anterior Muscle (Figs. 19.119,19.120) Origin

• Lateral side of the tibia (proximal half)

• Interosseous membrane

Trigger Point Location

In the upper third of the muscle belly (transition from the proximal to the middle third of the lower leg)

Insertion

• Medial cuneiform bone (plantar side)

• Base of the metatarsal bone I

Action

• Dorsal extension

• Inversion of the foot

• Stabilization of the longitudinal arch of the foot Innervation

Referred Pain

• Ventromedial area of the upper ankle joint

• Dorsal and medial at the big toe

• A narrow band from the trigger point anteromedial through the lower leg to the big toe

Associated Internal Organs lliotibial tract

Vastus lateralis

Patella

Biceps femoris

Lateral head of the gastroc nemius

Peroneus longus

Peroneus brevis

Lateral malleoli

Achilles tendon

Extensor digitorum brevis

- Tibialis anterior

Patellar ligament

Extensor digitorum longus

Extensor hallucis brevis

- TP of the peroneus brevis

- Extensor hallucis longus

Peroneus tertius

Vastus medialis

Patella

Vastus lateralis

Tuberosity of the fibula tibialis lliotibial tract

Biceps-

femoris

of the fibula

Peroneus longus

TP of the

Extensor digitorum brevis anterior

Peroneus brevis

Extensor digitorum longus

Lateral malleolus

Attachment tendon of the peroneus brevis

Tuberosity of the metatarsal bone V

Peroneus tertius

Patellar lig.

Attachment tendons of the extensor digitorum longus

Soleus

Tibialis anterior

Extensor hallucis longus

— Medial malleolus

Extensor hallucis brevis

Biceps femoris lliotibial tract

Vastus lateralis

- Tibialis anterior

Vastus medialis

Head of the fibula

Vastus lateralis

Patella

Lateral head of the gastroc nemius

Tuberosity of the fibula

Patella tibialis

Medial head of the gastrocnemius

Soleus

Tibialis anterior

Patellar ligament

TP of the peroneus longus lliotibial tract

Biceps-

femoris

of the fibula

Patellar lig.

Superficial pes anserinus

Peroneus longus

Peroneus brevis

Lateral malleoli

Achilles tendon

Calca-neoustuber

Extensor digitorum brevis

Peroneus tertius

Peroneus longus

TP of the

Extensor digitorum brevis

Extensor hallucis longus

— Medial malleolus

Attachment tendons of the extensor digitorum longus

Extensor hallucis brevis

Extensor digitorum longus

Extensor hallucis brevis anterior

Peroneus brevis

Extensor digitorum longus

Lateral malleolus

Attachment tendon of the peroneus brevis

Tuberosity of the metatarsal bone V

Peroneus tertius

- TP of the peroneus brevis

- Extensor hallucis longus

Fig. 19.119

■ Tibialis Posterior Muscle (Figs. 19.121.19.122)

Origin

Backside of the tibia and fibula (between the medial crest, interosseous border, and interosseous membrane)

Action

• Plantar flexion

• Inversion of the foot

• Stabilization of the longitudinal arch of the foot

Innervation

Insertion

• Tuberosity of the navicular bone

• All tarsal bones (excepting the talus)

• Medial tarsal ligaments (e.g., deltoid ligament)

Fig. 19.120

Fig. 19.121

Fig. 19.122

Plantaris

Popliteus

Peroneus head of the gastrocnemius Popliteus

TP of the tibialis posterior

TP of the flexor digitorum longus

TP of the flexor hallucis longus

Tibialis — posterior

Tibialis -anterior

Peroneus longus

Peroneus brevis

Plantaris

Triceps surae

Peroneus brevis

Biceps femoris

Flexor — digitorum longus

Flexor -hallucis longus

Soleus

Tibialis posterior

Tibialis — posterior

Tibialis -anterior

Peroneus longus

Plantaris

Popliteus

Semimembranosus

TP of the flexor hallucis longus

Peroneus brevis

Plantaris

Triceps surae

Peroneus brevis

Medial head of the gastrocnemius head of the gastrocnemius Popliteus

Biceps femoris

TP of the tibialis posterior

TP of the flexor digitorum longus

Flexor — digitorum longus

Flexor -hallucis longus

Peroneus

Soleus

Tibialis posterior

Trigger Point Location

Lateral to the posterior rim of the tibia and in the proximal quarter of the interosseous membrane. It can only be palpated through the soleus.

Referred Pain

• Achilles tendon (primary pain)

• From the trigger point caudal into the middle of the lower leg through the heel and sole referring to toes 1-5

Associated Internal Organs

None

■ Peroneus Longus, Brevis, and Tertius

Peroneus Longus Muscle Origin

• Lateral fascia of the tibia (proximal two-thirds)

• Tibiofibular articulation

Insertion

• Base of the metatarsal bone I

• Medial cuneiform bone

Action

• Plantar flexion

• Eversion of the foot

• Stabilization of the transverse arch of the foot Innervation

Superficial fibular nerve (L5-S1)

Peroneus Brevis Muscle (Fig. 19.123) Origin

Lateral fascia of the tibia (distal two-thirds) Insertion

Tuberosity of the metatarsal bone V Action

• Dorsal flexion

• Eversion of the foot

• Stabilization of the transverse arch of the foot Innervation

Trigger Point Location

• Trigger point of the peroneus longus: 2-4 cm distal from the fibula head above the fibula shaft

• Trigger point of the peroneus brevis: at the border between the middle and distal thirds of the lower leg, on both sides of the tendon of the peroneus longus

Referred Pain

• Lateral malleolus, also cranial, caudal, and posterior thereof

• Middle third of the lateral lower leg

Associated Internal Organs

None

Superficial fibular nerve (L5-S1)

Fig. 19.123

Peroneus Tertius Muscle (Fig. 19.124) Origin

Anterior border of the fibula (distal third)

Insertion

Metatarsal bone V

Action

• Dorsal flexion

• Eversion of the foot

Innervation

Deep fibular nerve (L5-S1) Trigger Point Location

Slightly distal and anterior from the peroneus brevis trigger point (see also Fig. 19.119)

Referred Pain

• Ventrolateral on the upper ankle joint and on the back of the foot

Posterior from the lateral malleolus running towards the lateral heel

Associated Internal Organs

None

Gastrocnemius Muscle (Figs. 19.125, 19.126)

Origin

Medial and lateral condyle of the femur Insertion

Calcaneal tuber (above the Achilles tendon) Action

• Plantar flexion Knee flexion

Fig. 19.124

Trigger Point Location

TP1 and TP2 About proximal to the middle of the muscle bellies, one trigger point each in the medial and lateral head of the gastrocnemius

TP3 and TP4 In the medial and lateral heads of the gastrocnemius, in the vicinity of the condyles (see also Fig. 19.117)

Referred Pain

TP1 Medial on the sole of the foot Posteromedial lower leg Back of the knee and partly up the posterior thigh

TP2-TP4 The referred pain of these three trigger points can be found locally around each trigger point.

Associated Internal Organs

None

Innervation

Tibial nerve (S1-S2)

Fig. 19.125

■ Soleus and Plantaris Muscles (Fig. 19.127)

Soleus Muscle Origin

• Posterior fascia of the tibia (middle third)

• Neck and posterior fascia of the fibula (proximal third)

Insertion

Calcaneal tuber (above the Achilles tendon) Action

Plantar flexion

Innervation

Tibial nerve (S1-S2)

Fig. 19.126

Trigger Point Location

TP1 2-3 cm distal from the gastrocnemius heads and slightly medial from the center line TP2 Near the fibula head (lateral on the calf) TP3 Further proximal than TP1 and lateral from the center line

Referred Pain

TP1 Achilles tendon

Heel posterior and plantar Sole of the foot

Slightly proximal to the trigger point TP2 Upper half of the calf TP3 ISJ ipsilateral

Fig. 19.127

Fig. 19.127

Plantaris Muscle Origin

Lateral epicondyle of the femur (proximal to the gastrocnemius head)

Insertion

Achilles tendon (medial, below the tendon of the gastrocnemius)

Action

• Plantar flexion

Innervation

Tibial nerve (S1-S2)

Trigger Point Location

In the middle of the back of the knee

Referred Pain

Back of the knee and calf up to about the middle of the lower leg

Associated Internal Organs

■ Extensor Digitorum Longus and Hallucis

Extensor Digitorum Longus Muscle Origin

• Fibula (ventral proximal two-thirds)

• Interosseous membrane

• Tibiofibular articulation

Insertion

Dorsal aponeurosis of toes 2-5 Action

Dorsal extension of the toes and foot

Longus Muscles

Innervation

Deep fibular nerve (L5-S1) Trigger Point Location

Ca. 8 cm distal from the fibula head between the peroneus longus and tibialis anterior

Referred Pain

• Back of the foot, including toes 2-4

• Ventral lower leg (caudal half)

Associated Internal Organs

None

X1 TP of the „ extensor digitorum longus

Fi9- 19128 Fig. 19.129

lliotibial tract

TP of the extensor digitorum longus

Peroneus brevis

Extensor digitorum brevis

Peroneus tertius

Extensor digitorum longus

Extensor hallucis longus

-TP of the extensor hallucis longus

Extensor hallucis brevis

- Tibialis anterior

-TP of the extensor hallucis brevis

Sartorius

Tibialis anterior

Quadriceps femoris

Semimembranosus

Gracilis

Semi-tendinosus lliotibial tract

Extensoi digitorum longus

TP of the extensor digitorum longus

Peroneus brevis

Extensor hallucis longus

TP of the extensor digitorum brevis

Extensor digitorum brevis

-TP of the extensor hallucis longus

Extensor hallucis brevis

Peroneus tertius

- Tibialis anterior

Extensor digitorum longus

-TP of the extensor hallucis brevis

Sartorius

Tibialis anterior

Extensor Hallucis Longus Muscle Origin

Fibula (middle frontal area) Insertion

Base of the end phalanx of the big toe Action

• Dorsal extension of the big toe and foot

• Inversion of the foot

Innervation

Deep peroneal nerve (L5-S1)

Trigger Point Location

Slightly distal from the transition between the middle and caudal third of the lower leg and ventral to the fibula. It lies between the extensor digitorum longus and the tibialis anterior

Referred Pain

Back of the foot in the area of the first metatarsal bone and the big toe, sometimes referring in a small band to the trigger point

Associated Internal Organs

None

■ Flexor Digitorum Longus and Hallucis I

(Fig. 19.121, Figs. 19.130, 19.131, 19.132, 19.133)

Flexor Digitorum Longus Muscle Origin

• Posterior fascia of the tibia (distal to the line of the soleus)

• Fibula (above the tendinous arch)

igus Muscles

Flexor Hallucis Longus Muscle Origin

• Posterior fascia of the fibula (distal two-thirds)

• Intermuscular septum

• Aponeurosis of the flexor digitorum longus

Insertion

Base of the end phalanges of toes 2-5 Action

• Flexion of the toe end joints

• Plantar flexion

• Stabilization of the longitudinal arch of the foot

Innervation

Tibial nerve (SI-S2)

Trigger Point Location

By displacing the medial gastrocnemius belly, you can find the trigger point on the posterior side of the tibia in the proximal third of the medial calf area

Referred Pain

• Sole of the foot (mediolateral) up to toes 2-5 (primary pain)

• Medial malleolus and medial calf area up to the trigger point

Insertion

• Base of the proximal phalanx of the big toe

• Fibers to the two medial tendons of the flexor digitorum longus

Action

• Flexion of the base phalanx of the big toe

• Plantar flexion

• Stabilization of the longitudinal arch of the foot

Innervation

Tibial nerve (S2-S3)

Trigger Point Location

At the transition from the middle to the caudal third of the lower leg and slightly lateral to the center line on the dorsal side of the fibula. Palpate it through the superficial calf musculature

Referred Pain

Plantar side of the big toe and metatarsal bone I

Lumbrical muscle III

Lumbrical muscle IV

Flexor digiti minimi brevis

TP of the abductor digiti minimi

Calcaneal tuber

TPs of the flexor digitorum brevis

Plantar aponeurosis

Medial head of the flexor hallucis brevis

Attachment tendon of ie flexor hallucis longus

Abductor hallucis

TP of the abductor hallucis (example)

Flexor digitorum brevis

Lumbrical muscle II

Lumbrical muscle I

Lateral headof the flexor hallucis brevis

Fig. 19.130

TPs of the flexor digitorum brevis

Plantar aponeurosis

Lumbrical muscle III

Lumbrical muscle IV

Flexor digiti minimi brevis

Abductor digiti minimi

TP of the abductor digiti minimi

Calcaneal tuber

Medial head of the flexor hallucis brevis

Attachment tendon of ie flexor hallucis longus

Abductor hallucis

TP of the abductor hallucis (example)

Flexor digitorum brevis

Lumbrical muscle II

Lumbrical muscle I

Lateral headof the flexor hallucis brevis

Fig. 19.132

■ Superficial Intrinsic Foot Musculature

Extensor Digitorum Brevis Muscle (Fig. 19.134)

Origin

Calcaneus (dorsal side) Insertion

• Proximal phalanx of the big toe

• Toes 2-4 (through the long stretch tendons)

Action

Toe extensor

Innervation

Deep fibular nerve (L5-S1)

Trigger Point Location

In the first third of the muscle bellies

Referred Pain

Area on the medial back of the foot near the ankle joint

Associated Internal Organs

None

Fig. 19.133

Extensor Hallucis Brevis Muscle (Fig. 19.134) Origin

Dorsal side of the calcaneus Insertion

• Dorsal aponeurosis of the big toe

• Base of the proximal phalanx of the big toe

Action

Dorsal extension in the proximal joint of the big toe Innervation

Deep fibular nerve (L5-S1) Trigger Point Location

In the first third of the muscle belly (see also Fig. 19.128)

Referred Pain

Area of the medial back of the foot near the ankle joint

Associated Internal Organs

None

TP of the extensor hallucis brevis

TP of the extensor hallucis brevis

TP of the extensor digitorum brevis

Fig. 19.134

Abductor Hallucis Muscle (Figs. 19.130,19.135) Origin

• Medial process of the calcaneal tuber

• Flexor retinaculum

Insertion

Proximal phalanx of the big toe (medial) Action

• Abduction of the big toe

• Plantar flexion

Innervation

Medial plantar nerve (S1-S2) Trigger Point Location

Distributed in the muscle belly along the inside edge of the foot

Referred Pain

Inside of the heel and inside edge of the foot

Associated Internal Organs

None

Flexor Digitorum Brevis Muscle (Figs. 19.130, 19.136)

Origin

Calcaneal tuber (plantar) Insertion

Middle phalanges of toes 2-5 (split tendons) Action

• Stabilization of the arch of the foot

Innervation

Medial plantar nerve (S1-S2) Trigger Point Location

In the muscle belly in the proximal middle area of the sole of the foot

Referred Pain

Metatarsal heads 11—IV with only slight tendency to radiate further

Associated Internal Organs

None

Fig. 19.136

Fig. 19.137

Abductor Digiti Minimi Muscle (Figs. 19.130, 19.138)

Origin

Medial and lateral processes of the calcaneal tuber Insertion

• Base of the proximal phalanx of toe 5 (lateral)

• Metatarsal bone V

Action

• Stabilization of the longitudinal arch of the foot

Innervation

Lateral plantar nerve (S2-S3) Trigger Point Location

Distributed throughout the muscle belly along the outer edge of the sole of the foot

Referred Pain

Metatarsal head V with only slight tendency to radiate into the area of the lateral sole of the foot

Associated Internal Organs

None

Fig. 19.138

Calcaneous tuber

Calcaneous tuber

Abductor digiti minimi

Attachment tendons of the flexor digitorum longus

Attachment tendons of the flexor digitorum brevis

Lumbrical muscle III Lumbrical muscle IV-Flexordigiti minimi brevis

Attachment area of thequadratus plantae

Quadratus plantae

Abductor digiti minimi

Flexor digitorum brevis

Attachment tendon of the flexor hallucis longus

Lumbrical muscle II Lumbrical muscle I Lateral head of the flexor hallucis brevis Medial head of the flexor hallucis brevis

Attachment tendons of the flexor digitorum longus

Abductor hallucis

TP of thequadratus plantae

Attachment tendon of the flexor hallucis longus

Plantar aponeurosis

■ Deep Intrinsic Foot Musculature

Quadratus Plantae Muscle

Origin

Dual-headed from the edges of the calcaneus Insertion

Tendon of the flexor digitorum longus Action

Assists in the flexion of toes 2-5 Innervation

Lateral plantar nerve (S2-S3) Trigger Point Location

Can be palpated immediately in front of the heel through the plantar aponeurosis

Referred Pain

Plantar side of the heel

Associated Internal Organs

None

Dorsal Interossei Muscles Origin

Dual-headed from the insides of all metatarsal bones Insertion

■ Base of the proximal phalanges (toe 2: medial side, toes 2-4, lateral side) • Dorsal aponeurosis of the toes

adductor hallucis

Long plantar ligament

Abductor — digiti minimi

Flexor digitorum brevis

Calcaneal tuber

Attachment -

tendons of the flexor digitorum longus

Plantar ligaments

Plantar interossei muscles l-lll

Opponens -digiti minimi

Flexor digiti minimi brevi

Attachment tendon of the peroneus brevi

Quadratus plantae

Origin tendon of the abductor hallucis

TPs of the flexor hallucis brevis

Medial sesamoid bone

Medial head of the flexor hallucis brevis

- Lateral head of the flexor hallucis brevis

Oblique head of the adductor hallucis

Attachment tendon of the tibialis anterior

Attachment tendon of the peroneus longus

— Attachment tendon of the tibialis posterior

- Plantai calcaneonavicular ligament

Attachment tendon of the flexor hallucis longus

Attachment tendons of the flexor digitorum brevis

- Lateral sesamoid bone

adductor hallucis

Long plantar ligament

Abductor — digiti minimi

Flexor digitorum brevis

Calcaneal tuber

Attachment -

tendons of the flexor digitorum longus

Plantar ligaments

Attachment -tendon of the abductor digiti minimi Transverse head of the adductor hallucis

Quadratus plantae

Origin tendon of the abductor hallucis

Plantar aponeurosis

Plantar interossei muscles l-lll

Opponens -digiti minimi

Flexor digiti minimi brevi

Attachment tendon of the peroneus brevi

TPs of the flexor hallucis brevis

Medial sesamoid bone

Medial head of the flexor hallucis brevis

- Lateral head of the flexor hallucis brevis

Oblique head of the adductor hallucis

Attachment tendon of the tibialis anterior

Attachment tendon of the peroneus longus

— Attachment tendon of the tibialis posterior

- Plantai calcaneonavicular ligament

Attachment tendon of the flexor hallucis longus

Attachment tendons of the flexor digitorum brevis

- Lateral sesamoid bone

Attachment tendon of the abductor hallucis

Radiation of an interosseus muscle

Action

Abduction of toes 2-4 Innervation

Lateral plantar nerve (S2-S3)

Plantar Interossei Muscles Origin

One-headed from the metatarsal bones lll-V

Fig. 19.140

TP of the quadratus plantae

TP of an interosseus muscle

Insertion

• Base of the proximal phalanges of toes 3-5

• Dorsal aponeurosis of the toes

Action

Adduction of toes 3-5 Innervation

Lateral plantar nerve (S2-S3) Trigger Point Location

Between the metatarsal bones. Palpate from plantar and dorsal

Referred Pain

The referred pain of these trigger points is found along that side of the toes at which the tendon of the muscle is inserted. The pain can project to dorsal as well as to plantar

Associated Internal Organs

None

Adductor Hallucis Muscle (Fig. 19.142) Origin

• Oblique head: base of the metatarsal bones II—IV

• Transverse head: capsule ligaments of the proximal joints of toes 3-5 and transverse deep metatarsal ligament

Insertion

• Lateral sesamoid bone

• Proximal phalanx of the big toe (lateral)

Fig. 19.142 Action

• Adduction of the big toe

• Stabilization of the arch of the foot

Innervation

Lateral plantar nerve (S2-S3) Trigger Point Location

Palpable in the area of the metatarsal heads I—IV through the aponeurosis

Referred Pain

In an area around the metatarsal heads II—IV

Associated Internal Organs

None

Flexor Hallucis Brevis Muscle (Figs. 19.143, 19.144)

Origin

Fig. 19.143

Fig. 19.144 Insertion

Base of the proximal joint of the big toe (running with one tendon each lateral and medial across the sesamoid bones)

Action

• Stabilization of the arch of the foot

Innervation

Tibial nerve (S2-S3)

Trigger Point Location

At the medial inner edge of the foot roughly proximal to the metatarsal head I

Referred Pain

Plantar and medial around the metatarsal head I and including toes 1 and 2

Associated Internal Organs

None

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