1. Lower Limb
The lower limb is subdivided by the hip joint, knee joint, &
ankle joint into regions:
• buttock (gluteal)
• thigh
• leg (crus)
• foot
Movements:
• Flexion & Extention: Knee Joint
• Dorsiflexion (Extention), Plantar flexion (Flexion),
inversion & eversion: ankle joint
• Movements at the hip joint are similar to those at the
shoulder joint: except their range is more limited.
• The toes have limited movement compared to the
movements of the fingers,
1
2. Study the lower limb in the following order:
• bones of the lower limb
• anterior region of the thigh
• medial region of the thigh
• gluteal region
• posterior region of the thigh
• anterior region of the leg and dorsal region of
foot
• lateral region of the leg
• posterior region of the leg
• sole of the foot
• ankle
• joints of the lower limb
2
3. Bones of the Lower Limb
There are 32 bones found in the lower limb:
• hip bone (1)
• femur (1)
• patella (1)
• tibia (1)
• fibula (1)
• tarsals (8)
• metatarsals (5)
• proximal phalanges (5)
• intermediate phalanges (5)
• distal phalanges (4)
• The big toe (hallux) only has 2 phalanges
• There are also 2 extra bones in the foot, called sesamoid bones.
These small bones develop within tendon of flexor hallucis longus m 3
5. Functions & Bones of Lower Limb
• A major function of the lower limb is to support the weight of the body
• A second major function is to move body thru space
• bones of gluteal region & thigh are pelvic bone & femur (femur is bone of the thigh).
• Femur, at its distal end, its major weight-bearing articulation is with tibia, but it also
articulates anteriorly with the patella (knee cap).
• patella is the largest sesamoid bone & is embedded in quadriceps femoris tendon.
• knee joint allows femur to rotate on tibia:
This rotation contributes to 'locking' of the knee when fully extended, particularly
when standing.
• The leg contains two bones: the tibia is medial in position, is larger than the laterally
positioned fibula, and is the weightbearing bone;
• tibia & fibula are linked along their lengths by an interosseous membrane, and at their
distal ends by a fibrous inferior tibiofibular joint.
• distal surfaces of tibia & fibula together form a deep recess: ankle joint is formed
by this recess & part of talus, which projects into the recess.
• ankle is most stable when dorsiflexed.
• bones of the foot consist of tarsal bones , metatarsals, & phalanges.
5
12. 12
Lower Limb
• The lower limb is divided into:
• The gluteal region,
• Thigh / femoral region
• Knee region
• Leg/ caff region,
• Ankle region &
• The foot
13. 13
• The lower limb: Major divisions:
The gluteal region,
Thigh / femoral region
Knee region
Leg/ caff region,
Ankle region &
The foot
14. Anterior Thigh
•After removing skin from anterior thigh,
cutaneous nerves & veins of the thigh
& fascia lata are identified.
•Fascia lata is a dense layer of deep
fascia surrounding large muscles of the
thigh.
• great saphenous vein reaches
femoral vein by passing thru fossa
ovalis which has a sharp margin called
falciform margin.
14
16. Fascia Lata
• thigh is completely
surrounded by a dense layer
of deep fascia called fascia
lata.
• fascia lata is thickened on
lateral aspect of thigh & is
named the iliotibial tract.
•This tract extends from the
iliac crest to the lateral
condyle of the tibia.
16
17. Anterior Thigh: Lymph Nodes & Cutaneous Nerves
superficial inguinal lymph nodes:
•high in the thigh, just below inguinal
ligament, usually arranged in a T-shape.
•receive lymph from entire lower limb &
superficial structures of perineum.
Cutaneous nerves:
• found piercing deep fascia are:
•lateral femoral cutaneous n,
(branch of Lumbar plexus: L2-L3)
•intermediate cutaneous n, &
•medial cutaneous n of the
thigh, branches of femoral nerve
17
19. Anterior Compartment of the
Thigh: Muscles
•anterior compartment contains a large
muscle, consisting of four heads, the
quadriceps femoris muscle:
This is a strong extensor of the knee.
• four heads of quadriceps femoris are:
•rectus femoris
•vastus lateralis
•vastus medialis
•vastus intermedius
•One other muscle of the anterior
compartment is the sartorius.
19
21. Anterior Compartment of Thigh: Muscles
Muscle Action
Nerve
Supply
sartorius flexes, abducts, laterally
rotates thigh; flexes &
medially rotates leg
at knee
femoral nerve
pectineus flexes and adducts
thigh
femoral nerve
rectus femoris extension of leg femoral nerve
vastus lateralis extension of leg femoral nerve
vastus medialis extension of leg femoral nerve
vastus
intermedius
extension of leg femoral nerve
21
22. Cross Section Through the Thigh
Cross sections:
• Three
dimensional
view
• Anatomical
relations of
structures
• This is the left
leg so medial
should be to
your left.
22
24. Femoral Triangle
• femoral triangle: an anatomical region of
upper thigh with the following boundaries:
•inguinal ligament
•sartorius
•adductor longus
•The floor of the triangle is made up of:
•iliopsoas muscle
•pectineus muscle
• contents of femoral triangle (from lateral
to medial):
•femoral nerve
•femoral artery
•femoral vein
•femoral ring (usually contains a lymph
node) 24
26. Femoral Triangle & Adductor Canal
adductor canal (subsartorial canal,
Hunter canal):
• extends from apex of femoral triangle,
(where sartorius crosses over adductor
longus), to adductor hiatus in the
tendon of adductor magnus.
• It provides an intermuscular passage
for femoral artery & vein, saphenous
nerve, & nerve to vastus medialis.
• it is bounded: anteriorly & laterally by
vastus medialis;
• posteriorly by adductor longus &
adductor magnus;
• medially by sartorius, forming roof of
the canal.
26
28. Femoral Sheath
Femoral sheath:
• sheath of deep fascia, extending
down from abdominal wall.
•contains the following structures,
from lateral to medial:
•femoral artery
•femoral vein
•femoral canal (usually containing
lymph node).
•femoral canal is site of femoral
hernia.
•femoral nerve is not in the
sheath.
28
30. Nerve of Anterior Compartment of Thigh
• femoral nerve (L2, L3,
L4) supplies muscles of
anterior compartment of
the thigh (quadriceps
femoris), including
pectineus muscle.
• psoas m. receives its
nerve supply from the
lumbar plexus.
30
31. Artery of Anterior Compartment of the Thigh
Femoral artery (1): principal supply to
anterior compartment of thigh & rest of
the lower limb.
Its branches are:
•superficial iliac circumflex (3): supplies
lower abdomen and upper thigh.
•Superficial epigastric: runs up to the
area of umbilicus
•external pudendal (2): supplies
superficial perineal structures (scrotum &
labia majora).
•profunda (deep) femoris (6):
•lateral femoral circumflex (5)
•medial femoral circumflex (4)
31
32. Arteries of the Thigh
•femoral artery: chief artery to lower limb
•continuation of external iliac artery distal
to inguinal ligament
•enters femoral triangle deep to midpoint
of inguinal ligament & lateral to femoral
vein
•Bisects femoral triangle & exits at its
apex to enter adductor canal, deep to
sartorius
•Exits adductor canal by passing thru
adductor hiatus (opening in adductor
magnus) & becomes popliteal artery
32
33. Artery of Anterior Compartment of the Thigh
•profunda (deep) femoris (6): arises 4 cm
below inguinal ligamentpasses medially
behind femoral vessels, along attached margin
of adductor magnus enters medial
compartmentterminates as 4th perforating
artery.
• chief artery to the thigh.
•arises from lateral or posterior side of femoral
artery in femoral triangle.
•In middle third of thigh, it is separated from
femoral artery & vein by adductor longus.
•gives off perforating arteries that wrap
around posterior aspect of femur & supply
adductor magnus, hamstring, & vastus lateralis
muscles.
33
34. Arteries of the Thigh
profunda (deep) femoris (6):
•At its origin, it gives off: lateral femoral
circumflex (5) & medial femoral circumflex
(4)Supplies most of the blood to the head &
neck of femur.
•lateral femoral circumflex (5): travels
around anterior surface of surgical neck of
femur & anastomoses with medial
femoral circumflex.
•medial femoral circumflex (4): travels
around posterior surface of surgical neck
of the femur.
34
35. Arteries of the Thigh
profunda (deep) femoris (6):
• during its course down, it gives off: 3
perforating branches (6a-6c).
•four perforating arteries: three arising in
anterior compartment & the fourth being
terminal branch
•gives off perforating arteries which pierce the
adductor magnus to enter the posterior
compartment and supply the hamstrings.
• near its termination, it gives off : superior
(descending) genicular (7)
35
38. Arteries of the Thigh
1. Trochanteric Anastomosis:
• Sourse of main blood supply to head of Femur
• The following take part in formation of the anastomosis:
– Superior gluteal (internal ileac artery)
– Inferior gluteal (internal ileac artery)
– Medial femoral circumflex (profunda femoris artery)
– Lateral femoral circumflex (profunda femoris artery)
2. Cruciate Anastomosis:
– Located at level of lesser trochanter of femur
– Formed by the following arteries:
1. inferior gluteal
2. Medial femoral circumflex
3. Lateral femoral circumflex
4. 1st perforating artery (profunda femoris artery)
38
39. Medial Compartment of Thigh
• The medial compartment of the thigh is frequently called
the adductor compartment because the major action of
this group of muscles is adduction of thigh.
except for hamstring portion of the adductor magnus
which performs as a hamstring and is supplied by a
different nerve sciatic nerve
• Sometimes pectineus included in this group but it really
belongs to the anterior compartment & is supplied by
the femoral nerve, nerve of the anterior compartment.
• the obturator nerve supplies the muscles of the medial
compartment (adductor compartment).
39
40. Medial Compartment of Thigh
The superficial
layer of adductor
muscles are:
•gracilis
•adductor longus
40
41. Medial Compartment of Thigh
•pectineus & adductor longus are
reflected the second layer of muscles can
be identified:
adductor brevis
•obturator nerve exits pelvis by passing thru
a small canal in upper part of the obturator
foramen.
It then pierces obturator externus m. &
splits (on either side of adductor brevis m.) as
an anterior and posterior branch.
It then supplies the adductor muscles.
• anterior division of obturator nerve lies on
anterior surface of adductor brevis muscle.
•(posterior division lies posterior to adductor
brevis & on adductor magnus)
41
42. Medial Compartment of Thigh
•Adductor magnus: deepest &
largest muscle in the medial
compartment.
•Most of Adductor magnus
inserts along the linea aspera
of femur.
•one part inserts into adductor
tubercle of femur: this part is
called hamstring portion of
Adductor magnus
thus, supplied by tibial part of
sciatic nerve: and functions
with hamstrings in posterior
compartment of the thigh.
42
45. Muscles of Medial Compartment of Thigh
Muscle Action
Nerve
Supply
gracilis adducts thigh;
Flexes Leg
obturator nerve
adductor longus adducts thigh and
assists
in lateral rotation
obturator nerve
adductor brevis adducts thigh and
assists in
lateral rotation
obturator nerve
adductor magnus adducts thigh and
assists in
lateral rotation.
Hamstring part
extends thigh
obturator nerve
and tibial part of
sciatic
45
46. Cross Section Through the Thigh
Cross sections:
• Three
dimensional
view
• Anatomical
relations of
structures
• This is left thigh
so medial
should be to
your left as you
examine it.
46
48. 48
The gluteal region
• Gluteal region (hip & buttocks) is the
prominent area posterior to pelvis.
• The shape is formed by a mass of
gluteal muscles & a layer of fat
covers these muscles.
Boundaries:
• Superiorly: iliac crest & extends
laterally to posterior margin of
greater trochanter
• Inferiorly: gluteal fold
• Intergluteal cleft separates the
buttocks
50. 50
Gluteal Ligaments
• Hip bones, are bound together by
dense ligaments
• posterior sacroiliac ligament is
continuous inferiorly with
sacrotuberous ligament.
• sacrotuberous ligament extends
across sciatic notch of hip bone,
converting the notch into a
foramen
• further subdivided by
sacrospinous ligament & ischial
spine, creating the greater &
lesser sciatic foramina.
51. 51
• greater sciatic foramen is
the passageway for
structures entering or
leaving the pelvis:
Example: Sciatic nerve
• lesser sciatic foramen is
the passageway for
structures entering or
leaving the perineum:
Example: Pudendal nerve
Gluteal Ligaments
53. Gluteal Region of Lower Limb
Superficial Nerves
•After skin of gluteal region has been
removed, you should be able to identify
cutaneous nerves in gluteal area:
•Cutaneous nerves in gluteal area are:
•branches of subcostal nerve: T12
•dorsal rami of lumbar nerves
•dorsal rami of sacral nerves
•inferior cluneal nerves
•posterior femoral cutaneous n.
53
54. Muscles of the Gluteal Region
Muscles of gluteal region are responsible
for extension, abduction, lateral rotation and
slight medial rotation of hip joint.
•Starting from superficial and going deep
identify the following muscles:
•gluteus maximus (most powerful
extensor of the thigh)
•gluteus medius
•gluteus minimus
•piriformis
•superior gemellus
•obturator internus
•inferior gemellus
•obturator externus
•quadratus femoris
•Tensor fscia lata
54
56. Muscles of the Gluteal Region
56
•Muscles of gluteal region
consist predominantly of
extensors, rotators, &
abductors of the hip joint.
•Major flexor muscles of the
hip (iliopsoas:-psoas major
& iliacus) do not originate in
the gluteal region or the thigh:
originate from posterior
abdominal wall & descend thru
the gap b/n inguinal ligament
& pelvic bone to attach to
proximal end of femur
60. Muscles of the Gluteal Region
•The tensor fascia latae is
seen from the lateral side of the
gluteal region.
60
61. Muscles of the Gluteal Region
Muscle Action Nerve
Supply
gluteus maximus -extends & laterally
rotates thigh at hip;
-thru iliotibial tract
(tensor fascia lata) it
extends knee joint.
(muscle used to stand up
from sitting position)
inferior gluteal
nerve
gluteus medius Powerfully abducts
thigh at hip; tilts
pelvis when walking
superior gluteal
nerve
gluteus minimus abducts thigh at
hip; anterior fibers
medially rotate thigh.
superior gluteal
nerve
61
62. 62
Muscles of the Gluteal Region
• piriformis muscle: most superior of deep group of mm.
• Supplied by Branches of anterior rami of S1, S2
• Is a muscle of pelvic wall & of the gluteal region.
• In addition to its action on the hip joint, the piriformis is an
important landmark,
• It divides the greater sciatic foramen into two regions,
one above and one below the piriformis.
• The superior gluteal nerves and vessels pass through the greater
sciatic foramen above piriformis;
• All other vessels and nerves passing between the pelvis and the
gluteal region, including the sciatic nerve, pass through the
greater sciatic foramen below the piriformis.
63. 63
Muscles of the Gluteal Region
Piriforms:
Origin: anterior surface of sacrum;
sacrotuberous ligament
Insertion: Superior border of greater
trochanter of femur.
Innervation: anterior rami of S1, S2
Action:
• Laterally rotates the extended femur at hip
joint;
• Abducts flexed femur at hip joint
64. 64
Muscles of the Gluteal Region
• The obturator internus muscle, like the piriformis muscle, is a
muscle of pelvic wall & gluteal region
• obturator internus forms:
• anterolateral wall of pelvic cavity ;
• lateral wall of the ischio-anal fossa in the perineum
• tendon of obturator internus, which bends 90° around ischium &
passes thru lesser sciatic foramen to enter gluteal region.
• it attaches to medial surface of superior margin of greater
trochanter just inferior to attachment of piriformis muscle.
65. 65
Muscles of Gluteal Region
obturator internus:
Origin:
• Pelvic surface of obturator membrane & surrounding bones
Insertion:
• Medial side of greater trochanter of femur.
Innervation:
• Nerve to obturator internus (L5,S1)
Action:
• Laterally rotates the extended femur at hip joint;
• Abducts flexed femur at hip joint
67. Arteries of Gluteal Region
•*There are three arteries
coming into the gluteal
region through the greater
sciatic foramen:
•superior gluteal
•inferior gluteal
•internal pudendal
•*These arteries are
branches of the internal iliac
artery which lies inside the
pelvis.
67
69. Nerves of Gluteal Region
*Nerves of gluteal region are branches of
lumbosacral plexus.
*Seven nerves enter gluteal region from
pelvis thru greater sciatic foramen.
1. superior gluteal
• (only branch that comes thru superior
part of greater sciatic foramen).
• Supplies gluteus medius &
minimus & tensor fasciae latae m.
2. inferior gluteal
3. sciatic
4. posterior femoral cutaneous
5. pudendal
6. nerve to quadratus femoris and
inferior gemellus muscles
7. nerve to obturator internus and
superior gemellus muscles
69
71. Gluteal Region : Relations
Areas of communication B/n Lower Limb & true pelvis:
• Three apertures in pelvic wall communicate with lower
limb:
(i). the obturator canal;
(ii). the greater sciatic foramen
(iii). the lesser sciatic foramen.
1. obturator canal is formed in superior aspect of obturator
foramen, b/n bone, a connective tissue membrane &
muscles that fill the foramen.
• obturator canal forms a passageway b/n pelvic cavity &
adductor region of the thigh,
obturator nerve & vessels pass thru it from pelvic cavity
to the thigh
71
72. Gluteal Region : Relations
2. The greater sciatic foramen:
• is a major route of communication b/n pelvic cavity & lower
limb.
• It is formed by greater sciatic notch, sacro-tuberous &
sacrospinous ligaments & spine of ischium.
• piriformis muscle passes thru it, dividing it into two parts:
superior (above piriformis) & inferior (below piriformis)
parts:
superior gluteal nerves & vessels pass thru superior
part
• Passing thru inferior part are: inferior gluteal nerves &
vessels, sciatic nerve, pudendal nerve, internal pudendal
vessels, posterior femoral cutaneous nerves, nerves to
obturator internus & quadratus femoris muscles.
72
73. Gluteal Region : Relations
3. Lesser sciatic foramen:
• formed by lesser sciatic notch, ischial spine, sacrospinous
& sacrotuberous ligaments.
• tendon of obturator internus muscle (pelvic wall) passes
thru lesser sciatic foramen to enter gluteal region of lower
limb.
• because it lies below attachment of pelvic floor, provides
communication b/n gluteal region & perineum:
pudendal nerve & internal pudendal vessels pass
b/n the pelvic cavity & perineum, by first passing out of
pelvic cavity thru greater sciatic foramen, pass thru
lesser sciatic foramen to enter the perineum.
73
75. Posterior Compartment of Thigh
Muscles:
•muscles of posterior compartment of the
thigh are called the hamstrings.
•To be called a hamstring, the muscle must
arise from the ischial tuberosity.
•The hamstrings are:
•biceps femoris (long head)
•semimembranosus
•semitendinosus
•hamstring part of the adductor
magnus (not shown in the diagram)
75
78. Muscles of Posterior Compartment of the Thigh
Muscle Action Nerve Supply
biceps femoris,
long head
Extends Thigh;
flexes and laterally
rotates leg.
tibial part of
sciatic nerve
biceps femoris,
short head
flexes and laterally
rotates leg. common peroneal
nerve
semitendinosus
Extends thigh;
flexes and medially
rotates leg;
tibial part of
sciatic
semimembranosus Extends Thigh.
flexes and medially
roates leg;
tibial part of
sciatic
adductor magnus
(hamstring part)
extends thigh tibial part of
sciatic 78
79. Nerves of Posterior Compartment
Nerves:
• Muscles of posterior
compartment of the
thigh are innervated
by the tibial (medial)
part of sciatic nerve.
•Short head of
biceps is innervated
by a branch of
common peroneal
nerve.
79
80. Arteries of Posterior Compartment
Arteries
• Arteries of the posterior
compartment of the thigh arise
from two major arteries:
1. inferior gluteal (upper
posterior compartment)
2. perforating branches of the
profunda femoris
80
81. Popliteal Fossa
•The popliteal fossa is an anatomical
region behind the knee with
boundaries.
•Identify the bony background and the
boundaries of the popliteal fossa.
•Bones of the popliteal fossa are:
•Femur:
•medial condyle
•lateral condyle
•tibia:
•medial condyle
•lateral condyle
81
82. Popliteal Fossa
•The boundaries are:
•superior & medial: -
semitendinosus (ST)
•inferior & medial: - medial
head of gastrocnemius
(MG)
•superior & lateral: - biceps
femoris (B)
•inferior & lateral - lateral
head of gastrocnemius
82
83. Popliteal Fossa
•With nerves and arteries
removed & muscles reflected,
identify the structures making
up floor of the popliteal
fossa:
•posterior surface of femur
•posterior surface of tibia
•oblique popliteal ligament
•popliteus muscle
83
84. muscles & contents of popliteal fossa
Muscles:
•semitendinosus
•biceps femoris
•medial head of gastrocnemius
•lateral head of gastrocnemius
Arteries:
•popliteal artery - continuation of
femoral artery
•superior medial and lateral
genicular arteries
•inferior medial and lateral
genicular arteries
Nerves:
•tibial nerve
•common peroneal nerve
84
86. Anterior Compartment of Leg
Muscles:
•The anterior compartment
contains muscles that are
basically extensors of the
ankle & toes:
•tibialis anterior
•extensor digitorum
longus
•extensor hallucis
longus
86
88. Muscles of Anterior Compartment of Leg
Muscle Action Nerve
Supply
tibialis anterior extends the foot at ankle;
inverts foot at subtalar &
transverse tarsal joints
helps to maintain the medial
longitudinal arch of foot
deep peroneal
nerve
extensor digitorum
longus
extends toes; dorsiflexes
(extends) foot
deep peroneal
nerve
peroneus tertius dorsiflexes (extends) foot;
everts foot at subtalar and
transverse tarsal joints
deep peroneal
nerve
extensor hallucis longus extends big toe; dorsiflexes
foot;
deep peroneal
nerve
extensor diditorum
brevis
Extends toes deep peroneal
nerve
extensor hallucis brevis extends big toe
deep peroneal
nerve
88
89. Nerves
•The nerve of the anterior
compartment of the leg is the
deep peroneal nerve.
• This nerve terminates b/n
the big toe & second toe and
can be tested at this point.
•it supplies skin b/n big toe
& second toe.
89
90. Anterior Compartment of Leg
Arteries:
• artery of the anteriorcompartment
of the leg is anterior tibial
artery (a branch of popliteal
artery).
•Its terminal branch, the dorsalis
pedis, can be palpated on the
dorsum of the foot between the
1st and 2nd metatarsal bones.
90
91. Cross Section of a Leg
•This is a cross-
section of the left
leg.
•As you look at it,
medial will be to
your left.
91
92. Lateral Compartment of Leg
•The lateral crural
compartment, also called the
peroneal compartment, is
made up of two muscles
whose tendons cross the
ankle joint posterior to and
under the lateral malleolus.
• This makes them evertors
of the foot. These muscles
are the:
•peroneus longus
•peroneus brevis
92
95. Muscles of Lateral Compartment of Leg
Muscle Action Nerve
Supply
peroneus
longus
plantar flexes (flexes)
foot; everts foot at
subtalar & transverse
talar joints;supports
lateral longitudinal arch
& transverse arch of foot
superficial
peroneal
nerve
peroneus
brevis
plantar flexes (flexes)
foot: everts foot
at subtalar & transverse
talar joints; holds up
lateral longitudinal arch
superficial
peroneal
nerve
95
96. Nerves of Lateral Compartment of Leg
•The superficial peroneal
nerve branches from the
common peroneal nerve
near the neck of the fibula
and passes b/n peroneus
longus & brevis muscles,
at which point they supply
the muscles.
•The superficial branch
then continues onto the
dorsum of the foot to
supply the skin there.
96
97. Arteries of the Lateral Leg
Arteries:
• The arteries to the tissues in the lateral
compartment are from both the anterior
and posterior tibial branches of the
popliteal artery.
97
98. Posterior Compartment of the Leg
• posterior compartment of leg is
subdivided into superficial and
deep parts.
•The superficial structures to
identify are:
•small saphenous vein
•peroneal communicating
branch of common peroneal n
•medial cutaneous nerve of the
calf (medial sural cutaneous)
•Sural Nerve
98
99. Posterior Compartment of the Leg
•The superficial part of the
posterior compartment of
the leg is made up of three
muscles:
•gastrocnemius
•plantaris
•soleus
99
101. Posterior Compartment of the Leg
•The deepest layer of
muscles includes the:
•tibialis posterior
•flexor digitorum longus
•flexor hallucis longus
101
104. Muscles of Posterior Compartment of Leg
Superficial Group
Muscle Action Nerve
Supply
gastrocnemius plantar flexes
(flexes) foot;
flexes knee
tibial
nerve
plantaris plantar flexes
foot; flexes knee
tibial
nerve
soleus with gastrocnemius,
a powerful plantar
flexor of ankle;
main propulsive
force in walking
and running
tibial
nerve
104
105. Muscles of Posterior Compartment of Leg
Deep Group
Muscle Action Nerve
Supply
flexor
digitorum
longus
flexes distal phalanges of lateral
four toes; plantar flexes foot;
supports lateral longitudinal arch
of foot
tibial nerve
flexor hallucis
longus
flexes distal phalanx of big toe;
plantar flexes foot; supports
medial longitudinal arch of foot
tibial nerve
tibialis
posterior
plantar flexes foot; inverts foot
at subtalar and transverse tarsal
joints; supports medial
longitudinal arch of foot
tibial nerve
105
106. Nerves of Posterior Compartment of Leg
• muscles of the
posterior
compartment of
leg are all
supplied by
tibial nerve.
106
107. Artery of Posterior Compartment of Leg
• posterior tibial artery
supplies tissues of posterior
compartment of leg.
•It is one of the terminal
branches of popliteal artery.
107
115. Sole of the Foot
•This is the sole of the left foot.
•When standing, foot touches the ground mainly
at calcaneus bone & heads of metatarsals (H).
•Note two small bones, sesamoid bones (S)
under the head of the 1st metatarsal.
These small bones develop in the tendons of
flexor hallucis brevis muscle & probably serve
as a fulcrum for the muscle to act more
strongly.
•During walkiing, our main lift off is at the big toe.
115
116. Sole of the Foot
• sustentaculum tali: a shelf-like
extension of calcaneous, supports
head of talus when standing.
• spring ligament (plantar calcaneo-
navicular Ligament), one of the
more important ligaments of foot,
crosses under head of talus adding
more support.
• Note the major joints for eversion &
inversion of the foot:
• subtalar joint (ST)
• transverse tarsal joint (TT)
116
117. Plantar Aponeurosis
Plantar Aponeurosis:
• Formed by central part of
palmar fascia.
• Consists of longitudinally
arranged band of dense
connective tissue.
• Support longitudinal arch
& hold parts of the foot
togather.
118. Sole of the Foot
•Once the skin of the sole of
the foot has been removed
plantar aponeurosis.
•Plantar aponeurosis: dense,
organized layer of deep fascia
that runs down the middle of
the sole.
•it helps maintain the medial
longitudinal arch of the foot.
118
119. Intrinsic Muscles of the Foot
Intrinsic Muscles of
Dorsum of the Foot:
• Extensor digitorum
brevis
• Extensor hallucis
brevis
119
120.
121. Muscles of Sole of the Foot: I-Layer
Muscles in I – Layer:
• Abducter hallucis
• Flexor digitorum brevis
• Abductor digiti minimi
121
123. Muscles of Sole of the Foot
• When the flexor digitorum
brevis is removed, the
muscles of the second
layer can be seen:
1. accessory flexor
(quadratus plantae)
2. lumbricals
3. tendons of the flexor
digitorum longus from
which the lumbricals arise
123
125. Muscles of Sole of the Foot: III-Layer
The muscles of the third
layer include the:
1.flexor hallucis brevis
2.adductor hallucis
• oblique head
• transverse head
3.flexor digiti minimi
brevis
125
127. Sole of the Foot
• The fourth layer of muscles:
1. dorsal interossei (dab)
meaning dorsal abduct
2. plantar interossei (pad)
meaning plantar adduct
• Note tendon of peroneus
longus crossing sole of the foot.
127
130. Muscles of Sole of the Foot: First Layer
Muscle Origin Insertion Action Nerve
Supply
abductor
hallucis
medial tubercle
of calcaneum
medial side,
base proximal
phalanx big toe
flexes, abducts
big toe.
Supports
medial
longitudinal
arch
medial plantar
flexor
digitorum
brevis
medial tubercle
of calcaneum
middle phalanx
of four lateral
toes
flexes lateral
four toes.
Supports
medial & lateral
longitudinal
arches
medial plantar
abductor
digiti minimi
medial and
lateral
tubercles of
calcaneum
lateral side
base proximal
phalanx fifth
toe
flexes, abducts
fifth toe.
Supports lateral
longitud. arch
lateral plantar
130
131. Muscles of Sole of the Foot: II-Layer
Muscle Origin Insertion Action Nerve
Supply
Second Layer
accessory
flexor
(quadratus
plantae)
medial and
lateral sides
of
calcaneum
tendon
flexor
digitorum
longus
aids long
flexor
tendon to
flex lateral
four toes
lateral plantar
nerve
lumbricals tendons of
flexor
digitorum
longus
dorsal
extensor
expansion
of lateral
four toes
extends
toes at
interphal
angeal
joints
I- lumbrical-
med plantar;
remainder-
deep branch
lateral plantar
131
132. Muscles of Sole of the Foot: III-Layer
Muscle Origin Insertion Action Nerve
Supply
Third Layer
flexor hallucis
brevis
cuboid, lateral
cuneiform;
tibialis posterior
insertion
medial and lateral
sides of base of
proximal phalanx
of big toe
flexes
metatarsophalang
eal joint of big
toe; supports
medial
longitudinal arch
medial plantar
adductor
hallucis, oblique
head
bases second,
third, fourth
metatarsal
bones
lateral side base
proximal phalanx
big toe
adducts big toe,
supports
transverse arch
deep branch
lateral plantar
adductor
hallucis,
transverse head
capsules 3, 4, 5
metatarsophalan
geal joints
lateral side of base
of proximal
phalanx, big toe
adduct big toe deep branch
lateral plantar
flexor digiti
minimi brevis
base of fifth
metatarsal
lateral side base of
proximal phalanx
small toe
flexes little toe lateral plantar
132
133. Muscles of Sole of the Foot: IV-Layer
Muscle Origin Insertion Action Nerve
Supply
Fourth Layer
dorsal
interossei (4)
adjacent sides of
metatarsals
bases of
phalanges and
dorsal expansion
of corresponding
toes
abduct toes,
using second toe
as reference
flex
metatarsophalan
geal joints;
extend
interphalangeal
joints
lateral plantar
plantar
interossei (3)
3rd, 4th, 5th
metatarsals
bases phalanges
and dorsal
expansion 3rd,
4th, 5th toes
adduct toes using
second toe as
reference
flex metatarso
phalangeal
joints; extend
interphalangeal
joints
lateral plantar
133
134. Nerves of Sole of the Foot
•Medial & lateral plantar nerves,
branches of tibial nerve, supply
muscles & skin on sole of the foot.
• medial plantar nerve supplies:
•abductor hallucis muscle
(first layer)
•flexor digitorum brevis (first
layer)
•1st lumbrical (second layer)
•flexor hallucis brevis (third
layer)
134
135. Nerves of Sole of the Foot
• lateral plantar nerve supplies the
remaining muscles in sole of the foot:
•abductor digiti minimi (first layer)
•accessory flexor (quadratus
plantae): (2nd layer)
•adductor hallucis (third layer)
•flexor digiti minimi brevis (third
layer)
•interossei (fourth layer)
•lumbricals 2, 3, & 4.
lateral plantar nerve is similar to the
ulnar n. which supplies most of the small
muscles of the hand.
135
136. Nerves of the Sole of the Foot
•The medial & lateral plantar nerves
supply muscles & skin of sole of the
foot.
•medial plantar nerve gives rise to
digital branches which then give rise
to common digital branches & then,
terminal branches.
•medial plantar nerve supplies skin of
the medial three & one half digits.
•lateral plantar nerve gives rise to
motor branches, a deep branch &
finally branches to the skin of the
lateral one & one-half digits.
136
138. Nerves of the foot
• Medial plantar N, Lateral plantar N., Sural N.,
• Saphenous N., Superficial & deep Peroneal nerves.
139.
140.
141.
142. Nerves of the Lower Limb
• Somatic motor & general
sensory innervation of lower
limb is by peripheral nerves
from lumbar & sacral plexuses
on posterior abdominal & pelvic
walls.
• These plexuses are formed by
anterior rami of L1 to L3 &
most of L4 (lumbar plexus) &
L4 to S5 (sacral plexus).
• Nerves originating from lumbar
& sacral plexuses & entering
lower limb carry fibers from
spinal cord levels L1 to S3
• Nerves from lower sacral
segments innervate the
perineum.
142
144. Nerves of the Lower Limb
• lumbar & upper sacral nerves are tested
clinically by examining the lower limb.
• Dermatomes in lower limb that can be
tested for sensation & are reasonably
autonomous (have minimal overlap) are:
• over the inguinal ligament: -L1;
• lateral side of the thigh: -L2;
• lower medial side of the thigh: -L3;
• meidal side of great toe (digit 1): -L4;
• meidal side of digit 2: -L5;
• little toe (digit 5): -S1;
• back of the thigh: -S2;
• skin over the gluteal fold: -S3.
• dermatomes of S4 & S5 are tested in
the perineum.
144
145. Nerves of the Lower Limb
• Selected joint movements are used to test myotomes :
example: flexion of hip is controlled primarily by L1 & L2;
• extension of knee is controlled mainly by L3 & L4;
• knee flexion is controlled mainly by L5 to S2;
• plantarflexion of the foot: controlled by S1 & S2;
• adduction of the digits is controlled by S2 & S3.
• In an unconscious patient, both somatic sensory &
somatic motor functions of spinal cord levels can be
tested using tendon reflexes: a 'tap' on patellar ligament
at the knee tests predominantly L3 & L4;
• a tendon tap on calcaneal tendon posterior to the ankle
(tendon of gastrocnemius & soleus) tests S1 & S2.
145
147. Nerve
Origin
(contributing spinal
nerves) Course Distribution in Lower Limb
Subcostal T12 anterior ramus Courses along inferior border of
12th rib; lateral cutaneous branch
descends over iliac crest
Lateral cutaneous branch
supplies skin of hip region
interior to anterior iliac crest
and anterior to greater
trochanter
Iliohypogastric Lumbar plexus (L1;
occasionally T12)
Parallels iliac crest; divides into
lateral and anterior cutaneous
branches
Lateral cutaneous branch
supplies superolateral
quadrant of buttock
Ilioinguinal Lumbar plexus (L1;
occasionally T12)
Passes through inguinal canal;
divides into femoral and scrotal or
labial branches
Femoral branch supplies skin
over medial femoral triangle
Genitofemoral Lumbar plexus (L1-
L2)
Descends anterior surface of psoas
major; divides into genital and
femoral branches
Femoral branch supplies skin
over lateral femoral triangle;
genital branch supplies
anterior scrotum or labia
majora
Lateral cutaneous
nerve of thigh
Lumbar plexus (L2-
L3)
Passes deep to inguinal ligament,
2-3 cm medial to anterior superior
iliac spine
Supplies skin on anterior and
lateral aspects of thigh
Anterior
cutaneous
branches
Lumbar plexus via
femoral nerve
(L2-L4)
Arise in femoral triangle; pierce
fascia lata along path of sartorius
muscle
Supply skin of anterior and
medial aspects of thigh
Cutaneous
branch of
obturator nerve
Lumbar plexus via
obturator nerve, ant.
branch (L2-L4)
Following its descent between
adductors longus and brevis,
anterior division of obturator nerve
pierces fascia lata to reach skin of
thigh
Skin of middle part of medial
thigh
148. Nerve
Origin (contributing
spinal nerves) Course Distribution in Lower Limb
Saphenous
nerve
Lumbar plexus via
femoral nerve (L3-L4)
Traverses adductor canal but does not
pass through adductor hiatus; crossing
medial side of knee deep to sartorius
tendon
Skin on medial side of leg
and foot
Superficial
fibular nerve
Common fibular nerve
(L4-S1)
Courses through lateral compartment of
leg; after supplying fibular muscles,
perforates crural fascia
Skin of anterolateral leg and
dorsum of foot, excluding
web between great and 2nd
toes
Deep fibular
nerve
Common fibular nerve
(L5)
After supplying muscles on dorsum of
foot, pierces deep fascia superior to
heads of 1st and 2nd metatarsals
Skin of web between great
and 2nd toes
Sural nerve Tibial and common
fibular nerves (S1-S2)
Medial sural cutaneous branch of tibial
nerve and lateral sural cutaneous branch
of fibular nerve merge at varying levels on
posterior leg
Skin of posterolateral leg and
lateral margin of foot
Medial plantar
nerve
Tibial nerve (L4-L5) Passes between first and second layers
of plantar muscles; then between medial
and middle muscles of first layer
Skin on medial side of sole
and sides, plantar aspect,
and nail beds of medial 3½
toes
Lateral plantar
nerve
Tibial nerve (S1-S2) Passes between first and second layers
of plantar muscles; then between middle
and lateral muscles of first layer
Skin on lateral side of sole
and sides, plantar aspect,
and nail beds of lateral 1½
toes
Calcaneal
nerves
Tibial and sural nerves
(S1-S2)
Lateral and medial branches of tibial and
sural nerves, respectively, over calcaneal
tuberosity
Skin of heel
Superior clunial
nerves
L1-L3 posterior rami Penetrate thoracodorsal fascia; course
laterally and inferiorly in subcutaneous
tissue
Skin overlying superior and
central parts of buttock
151. Arteries of the Sole of the Foot
• arteries of sole of the foot are derived
from posterior tibial artery.
•It splits into medial & lateral plantar
arteries.
•medial plantar artery passes along
the medial part of sole of the foot &
terminates by branching into digital
branches.
•lateral plantar artery becomes the
plantar arterial arch which
anastomoses by way of a perforating
artery with the dorsal pedis artery.
The arch gives rise to several
metatarsal branches which split into
digital branches.
151
158. Ligaments of the Sole of the Foot
• The long plantar ligament
& plantar calcaneocuboid
ligament lie deep to the
muscles of the fourth layer.
• long plantar ligament
stretches from calcaneum to
cuboid and to the bases of
2nd, 3rd & 4th metatarsal
bones.
• plantar calcaneocuboid
ligament, extends from
calcaneum to the cuboid on
the deep aspect of the long
plantar ligament.
158
159. Ligaments of the Sole of the Foot
• plantar calcaneo- navicular
ligament extends from
calcaneus to navicular bone
& prevents the head of talus
from pushing down b/n
calcaneus & navicular
bones.
plantar calcaneonavicular
ligament is known as spring
ligament since it is believed
to give a spring-like action to
the foot when walking.
159
160. Arches of the Foot
• All bones of the foot are held
together by ligaments.
• The three most important strongly
implicated in maintaining the
arches of the foot are:
1. long plantar ligament
2. calcaneocuboid ligament
3. calcaneonavicular ligament
• Functions of muscles of the foot:
1. responsible for movement
made during walking
2. help maintain the arches of
the foot.
160
161. Arches of the Foot
•Arches of the foot are arranged
longitudinally & transversely, and are
caused:
•*primarily by conformation of
bones of foot & ligaments which bind
them together,
• *secondarily by muscles which act
upon the bones.
• longitudinal arch of the foot is higher
on medial side, where it forms the
instep as can be seen on a foot-print
medial longitudinal arch
161
162. Arches of the Foot
• medial longitudinal arch is made up of
1st three digits & their metatarsals,
cuneiforms, navicular bone & talus.
• lateral longitudinal arch is made up of
digits 4 & 5 and their metatarsals, the
cuboid & calcaneum.
•It is much shallower than the medial arch.
• transverse arch is primarily formed by
bases of 5 metatarsal bones, cuboid &
the 3 cuneiform bones.
162
164. Arches of the Foot
• Every ligament that connects bones of foot plays a part in
maintenance of the arches, but some which pass across two or
more joints are especially important:
• long plantar ligament, plantar calcaneo- cuboid ligament
& plantar calcaneonavicular ligament.
• small intrinsic muscles also play an important role in keeping
the arches intact,
But, the long muscles which are inserted by tendons into
bones of the foot have more important role:
These are tendons of: tibialis anterior muscle, tibialis
posterior, peroneus longus & of flexor hallucis longus &
flexor digitorum longus muscles.
more superficially, plantar aponeurosis also plays an
important part in maintaining the medial longitudinal arch.
164
165. Maintaining Arches of the Foot
Maintenance of the Medial Longitudinal Arch:
1. Shape of the bones
2. Inferior edges of the bones are tied together: by plantar
ligaments. the plantar calcanionavicular lig. is most
important
tendons of tibialis anterior & posterior also play
important role.
3. The ends of the arch are tied together: by plantar
aponeurosis, flexor digitorum brevis, abductor hallucis,
flexor hallucis longus, flexor digitorum longus & flexor
hallucis brevis.
4. The arch is suspended from above by tibialis anterior &
postirior and medial ligament of ankle joint
165
166. Maintaining Arches of the Foot
Maintenance of the Lateral Longitudinal Arch:
1. Shape of the bones
2. Inferior edges of the bones are tied together: by
long & short plantar ligaments and short muscles of
the foot
3. The ends of the arch are tied together: by plantar
aponeurosis, abductor digiti minimi, flexor
digitorum longus & brevis.
4. The arch is suspended from above by peroneus
longus & brevis
166
167. Maintaining Arches of the Foot
Maintenance of the Transverse Arch:
1. Shape of the bones.
2. Inferior edges of the bones are tied together: by deep
transverse ligaments, the very strong plantar
ligaments, plantar muscles, dorsal interossei,
transverse head of adductor hallucis are important.
3. The ends of the arch are tied together: by peroneus
longus tendon.
4. The arch is suspended from above by peroneus longus
tendon & peroneus brevis
167
168. Ankle
• Over ones life time, the lower limb receives much trauma
from walking & carrying around weight of the body.
• Add to that any athletics and exercise
• One area of the lower limb that receives the trauma is
the ankle.
• The ankle also needs to be as stable as possible.
• stability of the ankle depends on the tendons of very
strong muscles that cross the ankle joint & on ligaments
around the ankle joint.
168
169. The Ankle
•On medial side of the ankle
identify the:
1. structures passing
anterior to medial malleolus:
•tendon of tibialis anterior
2. structures passing
posterior to medial malleolus
(Tom, Dick & Harry):
•tibialis posterior (T)
•flexor digitorum longus
(D)
•flexor hallucis longus (H)
169
170. The Ankle
• For flexor & extensor tendons
to perform properly, they must
be kept close to bones of the
ankle.
• The structures that keep them
close are the retinaculae:
1. superior extensor
retinaculum
2. flexor retinaculum
3. inferior extensor
retinaculum
170
171. The Ankle
• On lateral side, tendons of
muscles passing behind
lateral malleolus are:
1. peroneus longus
2. peroneus brevis
• Structures passing anterior
to the ankle:
1. peroneus tertius
2. tendons of the extensor
digitorum longus
3. tendon of the extensor
hallucis longus
4. tendon of tibialis anterior
171
172. Joints of the Lower Limb
The Hip Joint
•The hip joint is an
articulation b/n the
hemispherical head of the
femur & the cup-shaped
acetabulum of the hip
bone.
172
173. Hip Joint
•The acetabular notch at
the lower part of the
acetabulum is bridged by
the transverse ligament
of acetabulum.
173
174. Hip Joint
•acetabular labrum a
fibrocartilaginous ring, firmly
attached to the rim of the
acetabulum deepens the
acetabulum & clasps head
of the femur to form a more
stable joint.
•round ligament of head of
femur is attached to the
transverse acetabular
ligament & extends to the
fovea centralis on the head
of the femur.
174
175. Hip Joint
• articular capsule of hip joint from has
attachment to the intertrochanteric line & to
bases of greater & lesser trochanters.
•the iliofemoral ligament is the strongest
of ligaments of the capsule
• it is Y-shaped, & prevents
overextension during standing
•Note that its apex is attached to the ilium
b/n the two heads of rectus femoris muscle.
Identify the two limbs of the ligament,
one passing to base of greater trochanter
& other to the base of lesser trochanter.
175
176. Hip Joint
• the pubofemoral ligament is
triangular shape, found on the
inferomedial aspect of the capsule.
• pubofemoral ligament: limits
extension & abduction
•attachment of the ligament is to
base of lesser trochanter & its
wide attachment to superior
ramus of the pubis, just above
the obturator foramen.
•this capsular ligament is thinner
than the iliofemoral ligament.
176
177. Hip Joint
• the ischiofemoral ligament in posterior
aspect of hip joint, sweeps over neck of femur
• attached to ischium & neck of femur.
• ischiofemoral ligament: limits extension
• capsule of hip joint is very loose as it covers
posterior aspect of neck of the femur & does not
cover neck completely: Posterior Dislocation more.
• The hip joint receives its blood supply from small
vessels which reach it by running up the neck of
the bone.
arteries that supply branches to hip joint are:
1. medial circumflex
2. lateral circumflex
3. obturator
4. inferior gluteal
177
178. Hip Joint
Movements at the Hip Joint:
• Movements which take place at the hip joint are:
• flexion, mainly due to contraction of the iliopsoas
muscle, with help from sartorius, rectus femoris &
pectineus.
• extension, chiefly by the gluteus maximus muscle with
help by the hamstrings
• adduction, by the adductors longus, brevis, magnus
and the gracilis
• lateral rotation, by gluteus maximus, quadratus
femoris, piriformis, obturator internus and externus,
gemelli.
• medial rotation, by anterior part of the gluteus
minimus and medius and tensor fasciae latae
muscles
178
179. Hip Joint
Nerves to hip joint:
• The hip joint is supplied by the:
1.femoral
2.obturator
3.sciatic
4.nerve to quadratus femoris
direct branches of sacral plexus
179
180. The Knee Joint
•The knee joint is an articulation b/n
condyles of femur & of tibia as well as
the lower end of the femur & the patella.
•It is a synovial joint
•articulation b/n femur & tibia is a hinge
joint with a very small amount of rotation
possible.
• articulation b/n femur & patella is a
synovial plane joint where the patella
glides on the femur.
•The condyles of the tibia are separated
by the intercondylar eminence.
180
181. Knee Joint
•There are anterior
and posterior
condylar areas of
the tibia that serve
as attachments to
the anterior &
posterior cruciate
ligaments,
respectively.
181
182. Knee Joint
•The quadriceps femoris attaches
into the patella & from that into the tibia
via the patellar ligament.
•The vastus lateralis & medialis part
of this muscle strengthens the capsule
of the knee joint.
•If part of the capsule is removed, you
can identify the tibial (medial)
collateral capsular ligament.
This tibial collateral ligament is
fixed to medial meniscus & thus
more prone to certain sports injuries.
182
184. Knee Joint
•Note that there is a fairly large
fat pad beneath the patella
• Usually this will provide
freedom of movement b/n the
patellar ligament and the
bony knee structures allowing
for compression &
decompression in this area.
184
185. Knee Joint
LATERAL VIEW of Knee Joint:
•Note attachment of very strong
iliotibial tract, tensed by
tensor fasciae latae muscle.
• also identify tendon of the very
strong biceps femoris muscle,
inserted into head of fibula.
• fibular (lateral) collateral
ligament: is free from capsule
of knee joint &, thus, not likely to
be injured in knee injuries
occurring during games such as
american football. 185
186. Knee Joint
POSTERIOR VIEW:
•Identify the arcuate popliteal
ligament arches upwards &
medially over popliteus from head of
fibula.
• tendon of popliteus arises from
lateral condyle of femur, within the
capsule of knee joint
•its tendon separates lateral
meniscus from fibular (lateral)
collateral ligament.
• removal of the two heads of
gastrocnemius m & vessels & nerves
in the area, oblique popliteal
ligament can be identified.
186
187. Knee Joint
•When patella is cut away from
quadriceps muscle & reflected
downwards, internal makeup of the
knee joint is seen.
• Note articularis genu muscle, a
small muscle originating from lower
anterior surface of femur & attaches
into upper part of the joint capsule.
•the synovial infrapatellar fold is
also visiblenotice liying deep to
patella.
187
188. Knee Joint
•inner structures making up knee
joint can be identified when knee
is flexed & various synovial folds
removed :
•anterior cruciate ligament
•posterior cruciate ligament
•lateral meniscus
•medial meniscus - firmly
attached to the tibial collateral
ligament
•transverse ligament
•fibular (lateral) collateral
ligament
•tibial (medial) collateral
ligament
188
191. Ligaments of the knee joint
• major ligaments associated with
the knee joint are:
1. patellar ligament,
2. tibial (medial) & fibular (lateral)
collateral ligaments,
3. anterior & posterior cruciate
ligaments.
1. patellar ligament:
• is continuation of quadriceps
femoris tendon inferior to
patella.
• attached above to margins &
apex of patella & below to tibial
tuberosity.
191
192. Ligaments of the knee joint
2. Collateral ligaments:
• one on each side, stabilize
the hinge-like motion of knee
.
(i). fibular collateral ligament:
• cord-like, & superiorly
attached to lateral femoral
epicondyle.
• Inferiorly, to a depression on
lateral surface of fibular head.
• It is separated from the
fibrous membrane by a
bursa.
192
193. Ligaments of the knee joint
2. Collateral ligaments:
(ii) tibial collateral ligament:
• Is broad & flat; attached to
medial meniscus &
underlying fibrous
membrane.
• is anchored superiorly to
medial femoral epicondyle
& attaches to medial
margin & medial surface of
tibia above & behind
attachment of sartorius,
gracilis, & semitendinosus
tendons.
193
194. Ligaments of the knee joint
3. Cruciate ligaments:
• are in the intercondylar region of
the knee & interconnect femur &
tibia
• They are termed 'cruciate' (Latin
for shaped like a cross) because
they cross each other b/n their
femoral & tibial attachments:
anterior cruciate ligament
attaches to anterior part of
intercondylar area of tibia &
ascends posteriorly to attach to a
facet at the back of lateral wall of
intercondylar fossa of femur.
194
195. Ligaments of the knee joint
3. Cruciate ligaments:
• the posterior cruciate
ligament attaches to
posterior aspect of
intercondylar area of
tibia & ascends anteriorly
to attach to medial wall
of the intercondylar fossa
of femur.
• anterior cruciate
ligament crosses lateral
to posterior cruciate
ligament as they pass
thru the intercondylar
region.
195
196. Ligaments of the knee joint
Extra Capsular Ligaments:
1. Patellar Ligament:
• Attached to lower border of patella (above) & to tuberosity of tibia (below)
• Is a continuation of common tendon of quadruceps femoris m
• Separated from the synovial membrane by intrapatellar fat pad
2. Lateral collateral ligament:
• Attached above to lateral condyle of femur & below to head of fibula
• Popliteus tendon intervene b/n it & lateral meniscus
Not tightly held to lateral meniscus mobility not limited.
3. Medial Collateral Ligament:
• Attached to medial condyle of femur & to medial surface of shaft of Tibia
• Firmly attached to edge of medial meniscus mobility limited
4. Oblique popliteal ligament:
• Derived from semitendinosus m.
• Strengthens posterior aspect of the capsule
196
198. Ligaments of the knee joint
Intra Capsular Ligaments:
I. Cruciate Ligaments:
• Two very strong intracapsular
ligaments, which cross each other
within joint cavity.
• They are named Anterior &
Posterior according to their Tibial
attachments
• They are the main bond b/n femur
& tibia
198
199. Ligaments of the knee joint
1. Anterior Cruciate Ligament:
• Attached to anterior intercondylar area of Tibia
• Passes upward, backward & laterally to be attached
to posterior part of medial surface of lateral condyle
of femur.
• It is slack when knee is flexed but taut when knee is
fully extended
• prevents posterior displacement of femur on Tibia.
• With knee joint flexed, anterior cruciate ligament
prevents tibia from being pulled anteriorly
199
200. Ligaments of the knee joint
2. Posterior Cruciate Ligament:
• Attached to posterior intercondylar area of Tibia
• Passes upward, forward & medially to be attached to
anterior part of lateral surface of medial condyle of
femur.
• Anterior fibers become slack when knee is extended,
but become taut in flexion
• Posterior fibers are taut in extension.
• Posterior Cruciate Ligament prevents anterior
displacement of Femur on Tibia
• With knee joint flexed, Posterior Cruciate Ligament
prevents the Tibia from being pulled posteriorly
200
202. Ligaments of the knee joint
II. Menisci (Semilunar
Cartilages):
• C-shaped fibrocartilage
• Peripheral border is thick &
convex & attached to the
capsule
• Inner border is thin & concave
and forms a free edge.
• Menisci’s function is to
deepen the articular surfaces
of Tibial condyles to receive
the convex Femoral condyles
• They also serve as cushions
b/n Tibia & Femur
202
203. Ligaments of the knee joint
1. Medial Meniscus:
• Nearly semicircular
• Anterior horn attached to anterior
intercondylar area of Tibia &
Posterior horn attached to posterior
intercondylar area
• Also connected to lateral meniscus
by Transverse Ligament
• Peripheral border attached to the
Capsule & to Medial Collateral Lig.
• because of this, Medial Meniscus
is relatively fixed mobility limited
more prone to injury
203
204. Ligaments of the knee joint
2. Lateral Meniscus:
• Nearly circular
• Anterior horn attached to
anterior intercondylar area of
Tibia & Posterior horn attached
to posterior intercondylar area
• Peripheral border is separated
from the Lateral Collateral
Ligament by popliteus tendon
• because of this, Lateral
Meniscus is less fixed than
Medial Meniscus mobility
unlimited less prone to injury
204
206. Movements of the Knee Joint
• The main movements at the knee joint: flexion and
extension.
• when knee is bent with foot on the ground, some rotation
of distal end of femur is possible on upper end of tibia.
Such rotation is possible only when the joint is flexed
because this is the only position in which tibial collateral,
fibular collateral & cruciate ligaments are not tense.
When knee is flexed & the ligaments are loose, knee has a
tendency to fall off the tibia if it weren't for the cruciate
ligaments which prevent this movement:
posterior cruciate prevents movement of femur forward
on tibia (anterior dislocation) & the anterior cruciate
prevents the movement of the femur backward (posterior
dislocation of femur).
• Tears of anterior cruciate ligament are more common
206
207. Knee Joint
• There are several muscles that flex the leg at the knee joint:
– hamstring muscles
– sartorius
– gracilis
– gastrocnemius
The main extensor is the quadriceps femoris muscle.
muscle that lock the knee into full extension are the tensor fasciae
latae & gluteus maximus by way of the iliotibial tract.
To break full extension and start flexion (unlocking the knee joint),
the popliteus muscle is called into action.
popliteus m pulls on lateral condyle of femur causing femur to
laterally rotate on tibia. (popliteus m. is innervated by Tibial nerve).
• During normal stages of walking, the knee is extended during the
swing thru phase & flexed during the push off phase.
When knee is extended during walking, foot is laterally rotated.
This makes sense because if the foot rotated medially, you would trip
over your own feet.
207
208. Knee Joint
Locking mechanism:
• during standing, knee joint is 'locked' into position,
thereby reducing the amount of muscle work needed to
maintain the standing position.
• in flexion, articular surfaces b/n femur & tibia are
reduced & in extension articular surfaces are increased.
• joint surfaces become larger & more stable in extension.
• Medial rotation & full extension tighten all associated
ligaments.
• Another feature that keeps the knee extended when
standing is body's center of gravity
• popliteus muscle unlocks the knee by initiating lateral
rotation of femur on tibia.
208
209. Arteries of the Knee Joint
209
Vascular supply & innervation
•Vascular supply to the knee joint is mainly
thru descending & genicular branches
from femoral, popliteal, and lateral
circumflex femoral arteries in the thigh
and the circumflex fibular artery and
recurrent branches from the anterior
tibial artery in the leg.
•These vessels form an anastomotic
network around the joint
•The knee joint is innervated by branches
from obturator, femoral, tibial, and
common fibular nerves
210. The Ankle
Tarsal tunnel:
• is formed on posteromedial
side of the ankle by:
a depression formed by
medial malleolus,
medial & posterior
surfaces of talus,
medial surface of
calcaneus & inferior surface
of sustentaculum tali
an overlying flexor
retinaculum
210
213. Ankle Joint
The ankle joint is an
articulation between
the tibia, fibula and
talus.
•It is a synovial hinge
joint with only two
movements possible,
dorsiflexion
(extension) or
plantarflexion
(flexion).
213
214. Ankle Joint
Looking at the lateral
view of the ankle
joint, identify the
following ligaments:
•anterior talofibular
ligament
•calcaneofibular
ligament
•talocancaneal
ligament
•calcaneonavicular
ligament
214
215. Ligaments of the Ankle Joint
On the medial side
of the ankle joint,
identify the:
•deltoid ligament:
•Posterior
tibiotalar part
•tibionavicular
part
•tibiocalcaneal
part
215
217. Ligaments of the Ankle Joint
217
Ankle Sprain / Forced Inversion:
Results from rupture of calcaneofibular &
talofibular ligaments and a fracture of lateral
malleolus.
218. Acute sprain of lateral ankle:-
• lateral sprain is more common than medial
sprain,
• results from excessive inversion of the foot with
plantar flexion of the ankle.
• The antrior talofibular & calcaniofibular ligament
partially torn resulting in pain & local swelling
• The opposite (medial sprain) medially pulling
result in medial ligament & medial malleolus
injury.
Ligaments of the Ankle Joint
219. Ligaments of the Ankle Joint
•From the posterior
aspect of the ankle joint,
identify the:
•calcaneofibular
ligament
•posterior talofibular
ligament
•posterior tibiotalar part
of deltoid ligament
219
220. Joints of the Foot
In the sole of the foot,
identify the following
ligaments:
•long plantar ligament
•calcaneocuboid
ligament
•calcaneonavicular
(spring) ligament
220
222. Fracture of the Femur
• The upper end of the femur is
a common site for fracture in
the elderly.
• The neck may break
immediately beneath the head
(subcapital), near its midpoint
(cervical) or adjacent to the
trochanters (basal), or the
fracture line may pass
between, along or just below
the trochanters.
• Fractures of femoral neck
will interrupt completely blood
supply from the diaphysis
resulting in Avascular Necrosis
222
223. Fracture of femoral neck
A. sub capital fracture
• common in elderly & particularly in women
after menopause: caused as a result of
estrogen deficiency
• If considerable displacement occurs, the
strong muscles of the thigh (rectus femoris,
adductor muscles, & hamstring muscles)
pull the fragment upward:
shortened lower limb; & toes pointing
laterally.
• The gluteus maximus, piriformis, etc… rotate
the distal fragment laterally.
224. Trochanteric fracture
• Commonly occurs in young & middle
aged adults
• results in shortening & lateral
rotation of the leg.
• Fracture of Neck of Femur may damage
medial femoral circumflex artery
& interrupts blood supply local areas.
226. • Fractures of the femoral shaft
are accompanied by
considerable shortening of the
lower limb due to longitudinal
contraction of the extremely
strong surrounding muscles:
The proximal segment is
flexed by iliacus and psoas
and abducted by gluteus
medius and minimus, whereas
the distal segment is pulled
medially by the adductor
muscles.
Fracture of femoral shaft
227. i) Upper 3rd Fracture of shaft of femur:
• Proximal fragment flexed by iliopsoas
• Abducted by gluteus midius & minimus,
laterally rotated by gluteus maximus,
piriformis, obturator- internous, etc
ii) Fracture of middle 3rd:
• Distal fragment pulled up by hamstrings
& quadriceps femoris result in
considerable shortening of lower limb.
iii) Fracture of the distal 3rd:
• Displacement similar to middle 3rd
• since distal fragment is small,
gastrocnemius m may rotate backward
& may excert pressure on popliteal
artery & interfere in the blood supply of
the leg.
Fracture of femoral shaft
228. Normal angle of neck of femur
• Normal angle b/n neck & shaft in children 160% & in
adults 125%.
• angle: coxa valga (rare; occurs in congenital
hip dislocation; forced abduction fractures)
adduction of hip joint limited
• angle: is coxa vara, occurs in fracture of neck of
femur
• This may also result from adduction fractures, slipped
the femoral epiphysis or bone-softening diseases.
228
229. Dislocation of the hip
• The hip is usually dislocated
backwards and this is produced
by a force applied along the
femoral shaft with the hip in the
flexed position:
(e.g. the knee striking against
the opposite seat when a train
runs into the buffers).
230. Dupuytren’s Fracture /Pott’s racture
• Is a fracture of the
lower end of the
fibula, often
accompanied by a
fracture of the
medial malleolus or
rupture of the deltoid
ligament.
• Caused by forced
eversion of the foot.
231. Pilon Fracture:
Pilon Fracture:
• Is a fracture of the distal
metaphysis of the tibia
extending into the ankle joint.
March Fracture / Stress
Fracture:
• Is a fatigue fracture of one of
the metatarsals produced
from prolonged walking or
ballet dancing
Pilon Fracture
232. Other Clinical Conditions
• Flat foot (Pes Planus):
– weakened ligaments allow
bones of medial arch to
drop
• Claw foot (Pes Cavus) :
– medial arch is too
elevated
233. fracture associated with ligaments
Transverse Patellar Fracture:
• Results from a blow to the knee.
• The proximal fragment of the patella is pulled
superiorly with the quadriceps tendon and
the distal fragment remains with the patellar
ligament.
Ankle Sprain / Forced Inversion:
• Results from rupture of the calcaneofibular
and talofibular ligaments and a fracture of the
lateral malleolus.
234. fracture associated with nerves
1. Fracture of the Fibular Neck:
• May cause injury to common peroneal nerve which
laterally winds around the neck of the fibula.
• This results in paralysis of al muscles in the anterior &
lateral compartments of the leg and presents with Foot
Drop.
2 . Bumper Fracture:
• Is a fracture of the lateral tibial condyle, caused by an
automobile bumper, and is associated with a common
peroneal nerve injury
235. fracture associated with arteries
Dislocated Knee or Fractured Distal
Femur:
• May injure the popliteal artery because
of its deep position adjacent to the
femur and the knee joint capsule.
236. Piriformis Syndrome & Sciatica:
• Is a common condition in which the piriformis
muscle irritates and places pressure on the
sciatic nerve: Sciatica
pain across sensory distributor of sciatic
nerve
• Sciatica can be caused IVD prolapse, pressure
on one or more roots of sacral spinal nerves or it
can be intra-pelvic tumor or inflamation of sciatic
nerve or its terminal branches.
Piriformis Syndrome & Sciatica
238. Gluteal Gate / Gluteus Medius Limp
Is a tilting (dipping) or waddling gait characterized by the pelvis falling
toward the unaffected side when the opposite leg is raised. It results
from paralysis of the gluteus medius muscle, and damage to the
superior gluteal nerve.
Positive Trendelenburg’s Sign:
• Is seen in paralysis of gluteus medius, a fracture of the femoral neck or
in dislocated hip joint.
• If the right gluteus medius is paralyzed then:
1). the unsupported left pelvis will drop below horizontal level when the
patient is asked to stand on his right leg & raise his left leg clear of the
ground;
2). when the patient is asked to walk, he/she tilts to the right (paralyzed
side) to raise his left leg clear of the ground Tilting/Dipping Gait.
• If both the right & left gluteus medius are paralyzed, patient tilts to
both sides Waddling Gait
239. Nerve Injuries of Lower Limb
Tarsal Tunnel Syndrome:
• Results from compression of the tibial nerve in
the tarsal tunnel.
• May be caused by flat feet and excess weight.
Damage to Obturator Nerve:
• Causes a weakness of adduction and lateral
swinging of the limb, because adductor and lateral
rotator muscles of the thigh will be paralyzed.
240. Nerve Injuries of Lower Limb
Femoral nerve injury
• Motor - Quadriceps muscle paralyzed Causes
impaired flexion of the hip an impaired extension of leg
• Sensory- Skin sensation lost in anterior & medial side of
thigh, over medial side of leg & medial border of foot.
Injury to Superior Gluteal nerve:
• Weakened gluteus medius, gluteus minimus, tensor
fascia lata resulted in gluteal gate.
• It is also caused by fracture of greater trochanter &
hip joint dislocation
241. Gluteus maximus & injection
• To avoid injury of the underlying
sciatic nerve the injection should
given on upper outer quadrant of the
buttock on gluteus maximums
• Additionally acute or chronic trauma
of gluteus maximums muscle can
cause bursitis
242. Sciatic nerve injury
Motor- Hamstring muscles paralyzed, all
muscles below the kee are paralyzed
• Causes impaired extension at hip & impaired
flexion at the knee, loss of dorsi-flexion and
plantar flexion at the ankle , foot drop
• but week flexion of knee possible because
sartorius (femoral nerve) & gacilis (obturature
nerve).
Sensory – Sension below the knee except
medial, lower part of leg & medial border of
foot (saphenous from femoral nerve)
243. Damage to Common Peroneal Nerve
• The most injured nerve in the lower limb.
• May occur from fracture of fibula neck, knee joint injury or
dislocation
• Motor- muscles of anterior & lateral compartments of the leg
paralyzed, namely: (TA, EDL, EHL, EHB, EDB, & PT
supplied by deep peromeal nerve); and peroneus longus &
brevis (supplied by superficial peroneal nerve):
loss of dorsi flexion & eversion of foot results.
as a result, opposing muscles: (plantar flexors of flexion of
ankle joint & invertors at subtalar & transverse tarsal joints)
cause the foot to be plantar flexed (foot drop) & inverted: this
condition is known as Equinovarus.
• Sensory - Loss of sensation down the anterior & lateral
aspect of leg & dorsum of the foot & digits.
244. Damage to Superficial Peroneal
Nerve
• loss of eversion of foot because the lateral
compartment muscles (peroneus longus &
brevis) paralysed.
• But no foot drop
• Sensory - Loss of sensation down the
lateral aspect of leg & dorsum of the foot &
digits.
245. Damage to Deep Peroneal Nerve
Motor:
• Results in Foot Drop and a high stepping
gait, because muscles of anterior
compartment of the leg (tibialis anterior,
extensor digitorum longus & extensor
hallucis longus ) are paralyzed.
• Sensory:
• Loss of sensation of cleft b/n big toe & 2nd toe.
246. Damage to Tibial Nerve
• Motor: All muscles of posterior compartment of
leg & sole of the foot are paralysed: this causes
loss of plantar flexion of foot & impaired
inversion
• Foot is dorsiflexed at ankle joint & everted at
subtalar & transverse tarsal joints by opposing
muscles: this condition is known as calcaneo-
valgus.
• Sensory: loss of sensation of skin in sole of foot
247. Sympathetic innervation of arteries
Are from - lower 3 thoracic & Upper 2 or 3
lumbar segment of spinal cord
these nerves reach blood vessels of lower
limb thru femoral & obturator nerves and
common peroneal & tibial nerves.
• Femoral artery: from femoral & obturator
nerve.
• Distal arteries: thru common peroneal & tibial
nerve
248. Tendon reflexes of the lower limb
• Skeletal muscles receive segmental innervations:
• Innervated by specific spinal nerves from specific
spinal cord segments
• most muscles are innervated by 2, 3 or 4 spinal
nerves & spinal segmental cords:
Segmental innervation of lower limb muscle is
elicited by muscle reflexes:
1. Pattelar tender reflex (knee jerk reflex): elicited by
lumbar 2, 3 & 4 segments.
2. Achilles tendon reflex (plantar flexion of ankle):
by S1 & S2
249. A. Arterial Palpitation
• It is necessary to know the precise position
of main arteries within the lower limb.
• It may be necessary to arrest severe
hemorrhage, or palpate different parts of the
arterial tree in patients with arterial occlusion
1. Femoral artery: enters the thigh behind
the inguinal ligament at a point midway the
anterior superior iliac spine & symphysis
pubis
250. A. Arterial Palpitation
2. Politeal artery: felt by gentle palpation in depth
of popliteal space by flexion of knee
3. Dorsalis pedis artery: b/n the tendons of
extensor hallucis longus & extensor digitorum
longus, and midway b/n the medial & lateral
malleoli, on the front of the ankle.
4. Posterior tibialis artery: behind medial-
malleolus & beneath flexor retinaculum and lies
b/n flexor digitorum longus & extensor digitorum
longus
• pulsation b/n medial malleoli & heel
251. B. Arterial Injury
1. Injury to large femoral artery:
• can cause rapid exsanguination of the
patient.
• if the collateral circulation also is
inadequate & the vein around is
damaged: damage /necrosis/ to lower
limb occurs.
252. 2 . Arterial occlusive disease of the leg:
• is common in men; ischemia of the muscle
produce a cramp like pain
• with exercise, femoral artery obstructed,
supply of blood to the calf muscle is
inadequate, patient forced to limp or stop
walking after limited distance,
• with rest, the ischemia (O2 depletion) is
corrected & pain disappears: this is called
intermittent claudicaiton
B. Arterial Injury
253. 3. Anterior Tibial Compartment
Syndrome:
• Ischemic necrosis of the anterior
muscles.
• It results from a compression of the
anterior tibial artery by swollen
muscles.
B. Arterial Injury
254. veins
1 . Varicose vein:
• larger diameter than normal, elongated &
tortous
• occurs in superficial veins of lower limb
• caused by:
Hereditary
Weakness of vein wall
In competent valves
Increase intrabdominal pressures etc
258. 2. Great saphenous vein cut down:
Can be entered at ankle
side effect: phlebitis (inflamation of veins marked by pain
& swelling) common
At femoral triangle phlebitis relatively rare: thus,
mainly used for rapid infusion of large amounts of fluid
3 . Great saphenous vein:
• used in coronary by-pass in patients with coronary
disease caused by atherioschlerosis,
• graft taken from great saphenous vein is inserted by
reversing the segment
It is also used in replacement of brachial & femoral
arteries occlusion
veins
260. 1 . Acute sprain of lateral ankle-
• lateral sprain is more common than medial
sprain,
• results from excessive inversion of the foot with
plantar flexion of the ankle.
• The antrior talofibular & calcaniofibular ligament
partially torn resulting in pain & local swelling
• The opposite (medial sprain) medially pulling
result in medial ligament & medial malleolus
injury.
261. 2 . Fracture/ dislocation of ankle joint:
• Caused by forced external rotation & over eversion
of the foot
• talus externally rotated & forcibly against the
lateral malleolus of fibula: resulting in spiral
fracture & medial ligament of the ankle becomes
taut
3. Congenital dislocation of the hip joint:
• 10 x more common is female children
• three possible cause:
Generalized joint laxity
excessive laxity of the ligament of the hip joint
Breech position
Shallow actabulum
262. 4. Coxa Valga:
• Is an alteration of the angle made by the axis of the
femoral neck to the axis of the femoral shaft so that
the angle exceeds 135 degrees:
this pushes the femur laterally.
5. Coxa Vara:
• Is an alteration of the angle made by the axis of the
femoral neck to the axis of the femoral shaft so that
the angle is less than 135 degrees, this pulls the
femur medially.
6. Hemarthrosis:
This is blood in the joint which produces rapid
swelling of joint, mainly knee.
263. 7. Drawer Sign:
7.1 An anterior drawer sign (tibia sliding
forward):
• is due to rupture of anterior cruciate
ligament.
7.2 A posterior drawer sign (tibia sliding
backward):
• is due to a rupture of posterior cruciate
ligament.
264. 8. Unhappy Triad of the Knee
Unhappy Triad of the Knee:
• May occur when foot is firmly planted and knee is struck
from lateral side:-
a . Rupture of the tibial/medial collateral ligament:
excessive abduction of tibia.
b. Tearing of anterior cruciate ligament: forward
displacement of tibia.
c. Injury to medial meniscus. Knock-Knee/Genu Valgum:
– Is a deformity in which the tibia is bent or twisted
laterally.
– It may occur as a result of collapse of lateral
compartment of knee & rupture of tibial collateral
ligament.
265. 9. Bowleg / Genu Varum:
• a deformity in which the tibia is bent medially.
• It may occur as a result of collapse of the
medial compartment of the knee and rupture of
lateral collateral ligament.
10. Patellar Tendon & Achilles tendon Reflex:
1. Tap on the patellar tendon elicits extension
of the knee joint.
• elicited by L2, L3,& L4 lumbar segments.
2. Achilles tendon reflex (plantar flexion of
ankle): by S1 & S2
266. 11. Prepatellar Bursitis / Housemaid’s
Knee:
• Is inflammation and swelling of the
prepatellar bursa.
12. Poplitial / Baker’s Cyst:
• Is a firm swelling behind the knee
caused by herniation of synovial
membrane: this impairs flexion and
extension.
267. 13. Rupture of Achilles tendon:
• Thickest & strongest tendon
• Common tendon for insertion of
gastrocnimius & soleus into calcanius
• rapture disables the triceps surae
(gastrocnemius and soleus), and
cannot plantar flex the foot.
14. Forced Eversion of Foot:
• Avulses the medial malleolus and
ruptures the deltoid ligament
268. 15. Flat Foot / Pes Planus / Talipes Planus:
• Disappearance of the medial longitudinal arch with
eversion and abduction of the foot,
• stretches the plantar muscles and strains the spring
ligament.
16. Pes Cavus: Clubfoot / Talipes Equinovarus:
• Exhibits an exaggerated height of the medial
longitudinal arch.
• Foot is plantarflexed, inverted and adducted.
17. Hallux Valgus: common in females; badly fitting shoes.
• Is a lateral deviation of the big toe.
• Hallux Varus: is a medial deviation of the big toe
269. HERNIAS
1 . Femoral hernia:
• It is more common in females
• Femoral ring is a weak area in the anterior abdominal wall that
is sufficient to pass a tip of finger,
• usually abdominal structures pass thru.
2 . obturator hernia:
• develops through the canal where the obturator
nerve and vessels traverse the membrane covering the
obturator foramen.
• Pressure of a strangulated obturator hernia upon the nerve
causes referred pain in its area of cutaneous distribution, so
that intestinal obstruction associated with pain along the
medial side of the thigh should suggest obturator hernia.
