0:00

Let's move now and we will talk about

0:03

the medial flexor tendons.

0:05

They are three in number tibialis posterior

0:09

flexor digitorum longus and flexor lysis longus.

0:14

They are involved in inversion of the foot along with the

0:18

tibialis anterior,

0:19

and they're shown here these three muscles.

0:24

Now when we look at them the way they line up in most

0:28

of the imaging planes, at least at the level

0:31

of the lower leg, ankle

0:34

and hind foot, they line up in such a fashion

0:37

that we can use this mnemonic Tom Dick and,

0:42

and for the neurovascular area, Harry.

0:46

So that is often the mnemonic we use

0:49

for the tibials posterior for the flexor digitor longest,

0:53

you can see that here.

0:54

And for the flexor lysis longus with the vessels

0:58

and nerves located here.

1:01

So here with transverse sections at the level

1:04

of the ankle joint, Tom, Dick

1:06

and Harry here at the level of the calcaneus,

1:10

again a transverse section.

1:12

Tom, Dick and Harry,

1:15

as we trace them down on this netter drawing, Tom

1:19

and Dick as well as Harry pass beneath

1:23

this particular structure, which is that flexor ulu.

1:28

We talked about its anatomy with respect

1:31

to the medial males.

1:33

And as we follow this further down, we see one point

1:36

of crossing known as the master knot of Henry, where Dick

1:41

and Harry Cross Dick being more plantar than Harry.

1:46

So that's one point of crossing of these tendons.

1:51

Now I wanna show you the posterior process of the talis.

1:56

Okay? This is typically

1:58

what it would look like in a transverse Mr image.

2:02

Here we can see the two cubicles.

2:04

This is the postal, uh, I'm sorry,

2:07

and we're looking, this is the postal lateral tubercle.

2:11

Okay? And you can appreciate here

2:13

that it is larger, okay?

2:16

It uh, may give rise to an a trigonum

2:20

and I've listed some of the things that may attach to it,

2:24

including some ligaments perhaps you have not heard of.

2:27

We won't be talking about those today.

2:30

This is the postal medial tubercle,

2:33

which typically is smaller, okay?

2:37

Between the two, the flexor lysis longest

2:41

tendon can be found.

2:43

Okay? So this is a classic place where we have a groove

2:46

between two cubicles of the posterior process.

2:52

And this is an area known as the fibrous tunnel

2:55

of the flexor lysis longest tendon.

2:59

Now, in some situations there is hypoplasia

3:03

or mal development of the medial tubercle,

3:07

and in those cases, as shown here,

3:10

there may be subluxation medially of the flexor lysis.

3:14

Long is tendon in this case

3:18

a second accessory muscle is shown.

3:20

This is a fairly common one, flexor digitor accessory,

3:25

longest muscle intimate with a neurovascular bundle,

3:29

sometimes producing neurologic compromise.

3:32

So be aware that the size of the cubicles, particularly that

3:37

postal medial tubical vary

3:39

and in some cases it is hypoplastic,

3:43

possibly allowing abnormal subluxation.

3:47

Let's go to the coronal plane.

3:48

You can see here the superficial

3:50

and deep portions of the deltoid ligament.

3:54

I'm showing you here the tibialis,

3:56

posterior flexor digitor flexor hallucis.

4:00

You'll see it here just beneath the sulu Tailie

4:04

of the calcaneus.

4:05

That by the way, is the middle facet of the calcaneus, Tom,

4:10

dick and par.

4:14

Now sometimes there are sesamoid bones that confuse us,

4:19

and that particularly is something

4:21

that occurs when we're dealing with a non ossified sesamoid.

4:27

And one of the ones that's fairly

4:29

commonly seen is the one I show you here.

4:32

This is a fibro cartilaginous nodule intimate

4:37

with the tibials posterior tendon, just proximal

4:41

to its navicular attachment.

4:43

You can see here that it's located

4:46

between the tibials posterior tendon, which is shown

4:50

the yellow arrow and the spring ligament shown

4:55

by the blue arrow with the nodule shown

4:58

by the orange arrows in these images.

5:01

Now there's another fibrocartilage nodule,

5:04

I'll show you a little bit later.

5:06

There are two places where these medial pendants cross

5:12

the anonymous would tell you these are chiasma.

5:15

There is the one we talked about, the master, not of Henry,

5:19

which is the distal one.

5:21

The fancy name is Chiasma planetary.

5:25

But there's another one

5:26

that occurs more approximately up here that is

5:30

the Chiasma cruel alley.

5:33

When we talk about the Chiasma cruel alley,

5:35

it is the crossing of Tom and Dick.

5:39

And it's not unusual as they cross

5:41

that you will see some focal areas of

5:45

or area of Teno synovial fluid that may not

5:49

indicate Teno synovitis.

5:51

And then as we go more distally down here,

5:55

this particular region

5:57

Where Dick and Harry Cross, again, it's not unusual

6:01

to get accumulations of teno synovial fluid in that area.

6:06

And you can see that nicely on the sagittal image,

6:09

the two areas of crossing proximal

6:13

cosmic corral, distal chiasma planetary,

6:18

or the master not of Henry.