A 19-year-old male presents to the emergency department with a gunshot wound to the medial foot. The bullet entered the medial foot distal to the medial malleolus at the level of the calcaneus. The bullet grazed the undersurface of the calcaneus as it traveled to the lateral foot. The bullet then stopped just before exiting the skin on the plantar aspect of the foot.
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The bullet’s entry site on the medial ankle is closest to the tibialis posterior tendon or the posterior tibial tendon. The posterior tibial tendon courses posterior to the medial malleolus and inserts at the navicular and plantar aspect of foot. Injury to the posterior tibial tendon causes weakness with plantar flexion and inversion of the foot. Other structures at risk for injury include the flexor digitorum longus, flexor hallucis longus, posterior tibial artery, and posterior tibial nerve. Injury to the flexor digitorum longus causes weakness with flexion of the lateral 4 toes. Injury to the flexor hallucis longus causes weakness with flexion of the great toe. Tendons of the anterior foot include the anterior tibialis (dorsiflexes and inverts the foot), extensor hallucis longus (dorsiflexes and extends the great toe), and the extensor digitorum longus (dorsiflexes and extends the lateral 4 toes). Tendons of the lateral foot, including the peroneus brevis and longus tendons, evert and plantar flex the foot.
Dagan Cloutier, MPAS, PA-C, practices in a multispeciality orthopedic group in the southern New Hampshire region and is editor in chief of the Journal of Orthopedics for Physician Assistants (JOPA).
- Thompson JC. Netter’s Concise Orthopaedic Anatomy. Philadelphia, Pa.: Saunders Elsevier; 2002.