• Tibialis posterior is the largest of the tendons that lie in the medial aspect of the ankle.
• Lies in close proximity to flexor digitorum
• The third medial tendon is flexor hallucis longus.
• This is some distance from the other two tendons but the three are considered together
• and remembered by the mnemonic Tom, Dick and (a very nervous) Harry
• Tibialis posterior and flexor digitorum longus are contained within the tarsal tunnel
• bounded laterally by the flexor retinaculum.
• other important structures within the tunnel are the tibial neurovascular bundle.
• Abnormalities of each of these structures can contribute to medial ankle pain.
• The anatomy of the medial ligaments is complex. Three layers are recognised:
• superficial layer (tibio calcaneal, tibiospring and tibionavicular ligaments)
• deep layer (tibiotalar (occasionally divided into anterior and posterior))
• and a transverse layer. The spring ligament
There are two ligaments in the deep layer passing between the tibia and the os calcis. One lies anterior and the other posterior. Injuries are relatively common but usually heal without sequelae. There are three ligaments in the superficial layer named for their origin and insertion. Two of these run between bony structures. The anterior ligament is the tibionavicular and the posterior is the tibiocalcaneal ligament. The largest of these three ligaments runs between the tibia and the spring ligament and consequently is named the tibiospring ligament. The transverse component of the medial ligament complex is the spring ligament.
The calcaneonavicular ligament complex plays an important role in stabilisation and maintenance of the medial longitudinal arch. The most important part is the superomedial calcaneonavicular or spring ligament. The spring ligament is so named as it is reputed to have some elastic properties, however histologically there is no evidence of either elastic fibres or properties, so the name is now considered a misnomer
The peroneii are a pair of set of tendons arising from the peroneal muscles in the posterolateral calf.
Peroneus longus is a larger and more posterior of the two main tendons, peroneus brevis is the smaller and anterior.
In the mid foot, peroneus longs passes beneath the cuboid and traverses the plantar aspect of the tarsal bones to insert in the base of the first metatarsal.
Peroneus brevis lies more anteriorly at the level of the lateral malleolus and follows a more direct course to insert at the base of the fifth metatarsal.
They are positioned posterior to the lateral malleolus is maintained by a combination of concavity in the distal fibula and the peritoneal retinaculum.
Just below the lateral malleolus, the two tendons are separated by a bony prominence lateral aspect of the os calcis called the peroneal tubercle
• There are two group of lateral ligaments
• High ankle sprain involves the tibiofibular ligament (AiTFL) and syndesmosis ligaments
• Low ankle sprain involves the talofibular and calcaneofibular ligaments predominantly
The Achilles tendon is formed from the gastrocnemius and soles muscle. The principle contribution comes from the medial and lateral heads of gastrocnemius with a tendon forming on their dorsal aspect and uniting in mid calf to form the Achilles tendon which runs along the dorsal aspect of the soleus muscle. The central tendon of the soleus muscle eventually joins on the anterior aspect of the gastric tendon, and the combined tendon continues to its insertion on the posterosuperior aspect of the os calcis. Prior to its insertion, the Achilles tendon is separated from the underlying bone by the pre-Achilles bursa and a fibrocartilagenous enthesis. It is separated from the posterior tibia and flexor hallucis muscle bellies by a triangle of fat called Kagers Fat Triangle.
Arises from the upper two thirds of the lateral aspect of the tibia.
It has a high musculotendinous junction and a strong distal tendon, which is constrained by a transverse superior and an oblique inferior retinacular band.
The relationship of tibialis anterior to the retinacula is complex.
The superior retinaculum is band like and lies at the level of the distal tibia below the musculotendinous junction.
This retinaculum represents the anterior portion of a circumferential band of tissue that includes
• the tarsal retinaculum, overriding the tarsal tunnel,
• the superior peroneal retinaculum laterally.
In cross section, there may be two components, superficial and deep, with the tibialis anterior tendon passing in a tunnel between them.
This tunnel may also separate tibialis anterior from the other extensor tendons.
The oblique inferior retinaculum comprises two bands, a superomedial and an inframedial which unite to form a single lateral attachment.
The tibialis anterior tendon passes deep to the oblique inferomedial ligament just prior to its insertion into the medial cuneiform.
The tendon insertion is quite far medial onto a facet of the medial cuneiform and base of the first metatarsal.
