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Anatomy

Lower Limb

Question 62 of 180

A 21 year old man sustains an injury to his left leg during a judo match. He is complaining of loss of sensation over the sole of his foot and weakness of flexion of his toes. Which of the following nerves has most likely been damaged:

Answer:

The medial and lateral plantar nerves, branches of the tibial nerve, innervate the intrinsic foot muscles in the sole of the foot, and supply skin over the sole of the foot.

The tibial nerve is a branch of the sciatic nerve receiving nerve fibres from L4 - S3.

Table: Anatomical Overview of the Tibial Nerve

Nerve Tibial
Nerve roots L4 – S3
Motor supply All muscles in the posterior compartment of the leg and the intrinsic muscles in the sole of the foot
Sensory supply Skin on the posterolateral side of the lower leg, the lateral side of the ankle, foot and little toe, the medial side of the heel and the sole of the heel, foot and toes
Injury Motor Loss: Weakness of flexion at knee, loss of plantarflexion at ankle and flexion of toes, weakness of foot inversion

Sensory Loss: Loss of sensation to the skin on the posterolateral side of the lower leg, the lateral side of the ankle, foot and little toe, the medial side of the heel and the sole of the heel, foot and toes

Anatomical Course

It arises at the apex of the popliteal fossa before descending in the leg to enter the popliteal fossa posterior to the knee. The tibial nerve then passes under the tendinous arch formed by the two heads of the soleus muscle and then descends through the deep region of the posterior compartment of the leg. The tibial nerve passes through the tarsal tunnel, posterior to the medial malleolus to enter to foot.

By Henry Vandyke Carter [Public domain], via Wikimedia Commons

Tibial Nerve. (Image by Henry Vandyke Carter [Public domain], via Wikimedia Commons)

Branches

Table: Branches of the Tibial Nerve

Branch Supply
Muscular branches Posterior compartment of leg
Sural nerve Skin on lower posterolateral leg, lateral side of ankle, foot and little toe
Medial calcaneal nerve Skin on medial surface and sole of heel
Plantar nerves Intrinsic muscles in sole of foot, skin over sole of foot and toes

Through its muscular branches, the tibial nerve innervates all of the muscles in the posterior compartment of the leg.

The tibial nerve gives rise to the sural nerve in the proximal leg which supplies skin on the lower posterolateral surface of the leg, and the lateral side of the ankle, foot and little toe, and the medial calcaneal nerve in the distal leg which supplies skin on the medial surface and sole of the heel.

In the foot the tibial nerve divides into the medial and lateral plantar nerves which innervate all of the intrinsic muscles of the sole of the foot and supply skin over the medial and lateral sole of foot and toes respectively.

Function

The table below details the motor function of the tibial nerve.

Table: Motor Supply of the Tibial Nerve

Muscle Function
Gastrocnemius Plantarflexion of foot and flexion of leg
Plantaris Plantarflexion of foot and flexion of leg
Soleus Plantarflexion of foot
Flexor digitorum longus Flexion of lateral four toes
Flexor hallucis longus Flexion of great toe and plantarflexion of foot
Tibialis posterior Plantarflexion and inversion of foot, support of medial arch

Modified by FRCEM Success. Original by Henry Vandyke Carter [Public domain], via Wikimedia Commons

Cutaneous Innervation of Lower Limb. (Image modified by FRCEM Success. Original by Henry Vandyke Carter [Public domain], via Wikimedia Commons)

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  • Biochemistry
  • Blood Gases
  • Haematology
Biochemistry Normal Value
Sodium 135 – 145 mmol/l
Potassium 3.0 – 4.5 mmol/l
Urea 2.5 – 7.5 mmol/l
Glucose 3.5 – 5.0 mmol/l
Creatinine 35 – 135 μmol/l
Alanine Aminotransferase (ALT) 5 – 35 U/l
Gamma-glutamyl Transferase (GGT) < 65 U/l
Alkaline Phosphatase (ALP) 30 – 135 U/l
Aspartate Aminotransferase (AST) < 40 U/l
Total Protein 60 – 80 g/l
Albumin 35 – 50 g/l
Globulin 2.4 – 3.5 g/dl
Amylase < 70 U/l
Total Bilirubin 3 – 17 μmol/l
Calcium 2.1 – 2.5 mmol/l
Chloride 95 – 105 mmol/l
Phosphate 0.8 – 1.4 mmol/l
Haematology Normal Value
Haemoglobin 11.5 – 16.6 g/dl
White Blood Cells 4.0 – 11.0 x 109/l
Platelets 150 – 450 x 109/l
MCV 80 – 96 fl
MCHC 32 – 36 g/dl
Neutrophils 2.0 – 7.5 x 109/l
Lymphocytes 1.5 – 4.0 x 109/l
Monocytes 0.3 – 1.0 x 109/l
Eosinophils 0.1 – 0.5 x 109/l
Basophils < 0.2 x 109/l
Reticulocytes < 2%
Haematocrit 0.35 – 0.49
Red Cell Distribution Width 11 – 15%
Blood Gases Normal Value
pH 7.35 – 7.45
pO2 11 – 14 kPa
pCO2 4.5 – 6.0 kPa
Base Excess -2 – +2 mmol/l
Bicarbonate 24 – 30 mmol/l
Lactate < 2 mmol/l

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