What structures are located near the medial malleolus?

Anatomical Structures Near the Medial Malleolus

The medial malleolus is surrounded by several critical neurovascular and musculoskeletal structures that are important to identify during clinical examination and surgical procedures.

Neurovascular Structures

Posterior Tibial Artery and Vein

• Located posterior to the medial malleolus, running in the tarsal tunnel
• The posterior tibial artery divides into medial and lateral plantar arteries distal to the medial malleolus 1
• Forms part of the medial malleolar network, which includes anastomoses with the anterior medial malleolar artery, medial tarsal arteries, and branches from the medial plantar artery 2
• Palpable behind the medial malleolus - an important pulse point for vascular assessment 1

Posterior Tibial Nerve

• Runs alongside the posterior tibial artery in the tarsal tunnel
• Protected by the tendons of tibialis posterior and flexor digitorum longus 3
• Divides into medial and lateral plantar nerves distal to the medial malleolus

Saphenous Nerve and Vein

• The saphenous nerve has larger anterior and smaller posterior branches in the perimalleolar area 2
• The great saphenous vein passes anterior to the medial malleolus

Musculotendinous Structures

Tibialis Posterior Tendon

• Runs in a groove behind the medial malleolus
• Has a hypovascular region starting approximately 2.2 cm proximal to the medial malleolus and extending for about 1.5 cm 4
• Receives vascular supply from vessels entering approximately 4.5 cm proximal and 2.0 cm distal to the medial malleolus 4
• Dysfunction of this tendon is a common disorder leading to pain and deformity 4

Flexor Digitorum Longus Tendon

• Located posterior to the medial malleolus
• Runs alongside the tibialis posterior tendon
• Helps protect the neurovascular bundle 3

Flexor Hallucis Longus Tendon

• Runs in the most posterior groove behind the medial malleolus
• Located lateral to the flexor digitorum longus tendon

Ligamentous Structures

Deltoid Ligament Complex

• Originates from the medial malleolus
• Consists of superficial and deep components
• Provides medial stability to the ankle joint
• Components include:
  • Tibionavicular ligament
  • Tibiocalcaneal ligament
  • Superficial and deep posterior tibiotalar ligaments
  • Anterior tibiotalar ligament

Clinical Significance

Examination Points

• The posterior tibial artery pulse should be palpated behind the medial malleolus during vascular assessment 1
• Point tenderness over the medial malleolus is one of the Ottawa Ankle Rules criteria for obtaining ankle radiographs after trauma 1
• Palpation pain at the medial malleolus is included in several clinical decision rules for acute ankle injuries 1

Surgical Considerations

• During arthroscopic procedures, the posteromedial portal is located 5 mm behind the posterior crest of the medial malleolus, typically 2 cm above its posterior tip 3
• Medial malleolar osteotomy techniques must consider the posterior tibial tendon to avoid injury 5
• An accessory portal 7 cm proximal to the medial malleolus enables complete posterior tibial tendon exploration during tendoscopy 6

Understanding these anatomical relationships is essential for proper clinical assessment, surgical planning, and avoiding iatrogenic injury when working near the medial malleolus.