FOURTH EDITION

AIDS TO THE
EXAMINATION
, ,
OF THE PERIPHERAL
NERVOUS SYSTEM
Iw. B. SAUNDERS I
On hc:half of the l,U.JrJ,nlOn of Brain
FOURTH EDITION
AIDS TO THE
EXAMINATION
OF THE PERIPHERAL
NERVOUS SYSTEM
~ W.B. SAUNDERS
EDINBURGH LONDON NEWYORK PHILADELPHIA STLOUIS SYDNEY TORONTO 2000
W. B. SAUNDERS
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PREFACE
In 1940 Dr George Riddoch was Consultant Neurologist to the Army. He realised the
necessity of providing centres to deal with peripheral nerve injuries during the war. In
collaboration with Professor J. R. Learrnonth, Professor of Surgery at the University of
Edinburgh, peripheral nerve injury centres were established at Gogarburn near
Edinburgh and at Killearn near Glasgow. Professor Learmonth wished to have an
illustrated guide on peripheral nerve injuries for the use of surgeons working in general
hospitals. In collaboration with Dr Ritchie Russell, a few photographs demonstrating the
testing of individual muscles were taken in 1941. Dr Ritchie Russell returned to Oxford in
1942 and was replaced by Dr M. J. McArdle as Neurologist to Scottish Command. The
photographs were completed by Dr McArdle at Gogarburn with the help of the
Department of Medical Illustration at the University of Edinburgh. About twenty copies in
loose-leaf form were circulated to surgeons in Scotland.
In 1943 Professor Learmonth and Dr Riddoch added the diagrams illustrating the
innervation of muscles by various peripheral nerves modified from Pitres and Testut,
(Les Neufs en Schemas, Doin, Paris, 1925) and also the diagrams of cutaneous sensory
distributions and dermatomes. This work was published by the Medical Research
Council in 1943 as Aids to the Investigation of Peripheral Nerve Injuries (War Memorandum
No.7). It became a standard work and over the next thirty years many thousands of
copies were printed.
It was thoroughly revised between 1972 and 1975 with new photographs and many new
diagrams and was republished under the title Aids to the Examination of the Peripheral
Nervous System (Memorandum No. 45), reflecting the wide use made of this booklet by
students and practitioners and its more extensive use in clinical neurology, which was
rather different from the war time emphasis on nerve injuries.
In 1984 the Medical Research Council transferred responsibility for this publication to
the Guarantors of Brainfor whom a new edition was prepared. Modifications were made to
some of the diagrams and a new diagram of the lumbosacral plexus was included.
Most of the photographs for the 1943, 1975 and 1986 editions show Dr McArdle, who
died in 1989, as the examining physician. A new set of colour photographs has been
prepared for this edition, the diagrams of the brachial plexus and lumbosacral plexus have
been retained, but all the other diagrams have been redrawn.
ACKNOWLEDGEMENIS
The Guarantors of Brainare very grateful to:
Patricia Archer PhD for the drawings of the brachial plexus;amld~ JIlIkMm;
Ralph Hutchings for the photography
Paul Richardson for the artwork and diagrams
Michael Hutchinson MB BDS for advice on the neum-anatomy
Sarah Keer-Keer (Harcourt Publishers) for her help and ~ 1 t . .
CONTENTS
Introduction 1
Spinal accessory nerve 3
Brachial plexus 4
Musculocutaneous nerve 12
Axillary nerve 14
Radial nerve 16
Median nerve 24
Ulnar nerve 30
Lumbosacral plexus 37
Nerves of the lower limb 38
Dermatomes 56
Nerves and root supply of muscles 60
Commonly tested movements 62
INTRODUCTION
This at las is intended as a gui de to t he exami nation of pat ient s with lesion s of periph eral
nerves and nerve roots.
These examinations sho uld, if possibl e, be conducte d in a qu iet room where pat ient
and examiner will be free from distracti on . For both mot or and sen sory testing it is
important th at the patient sho uld first be warm. The nature and object of the tests should
be explained to the patient so t hat hi s interes t and co-operat ion are sec ure d. If eit her
shows signs of fatigue, t he session sho uld be discont inued a nd resumed later.
Motor testing
Amuscle may act as a prime mover, as a fixator, as an antagonist, or as a synergist. Thus, flexor
carpi ulna ris acts as a prime mover when it flexes and addu cts t he wrist; as a fixator when it
immobilises the pisiform bone du ring contraction of th e adductor digit i mini mi; as an
antagonist when it resist s extension of th e wrist; and as a synergist when th e digits, but not
the wrists, are extended.
As far as possible the acti on of each muscle should be obse rved sepa rately and a not e
made of those in whic h power has be en retai ned as well as of th ose that are wea k or
paralysed. It is usual to examine the power of a muscl e in relatio n to th e movement of a
single joint. It has lon g been customary to use a 0 to 5 sca le for recordi ng muscle power,
but it is generally recognised that subdivision of grade 4 may be helpful.
o No cont raction
1 Flicker or t race of cont raction
2 Active movement, with gravity eliminate d
3 Active movement against gravity
4 Active movement against gravity and resist an ce
5 Normal power
Grades 4-, 4 and 4+, may be used to indicat e movement aga inst slight. moderat e an d
strong resistance respect ively.
The models employed in t his work were not chosen becau se th ey showed unusual
muscular development; the ease wit h whic h the co nt rac tio n of muscl es is ide nt ified varies
with the build of t he pat ient, and it is essent ial th at th e examiner should both look for an d
endeavour to feel the contracti on of an accessi ble muscle and/or th e movement of it s
tendon. In most of the illustrati ons the opti mum point for palpation has been marked.
Muscles have been arranged in the order of the origin of their mot or supply from nerve
trunks, which is conveni ent in many examinati ons. Usually only one met hod of test ing
each muscle is shown but, whe re necessa ry, mult iple illust rat ion s have been include d if a
muscle has more than one impo rta nt act ion. The examiner should apply the tes ts as t hey
are illustrated, becau se th e techniques shown will eliminate many of t he tr ap s for t he
inexperienced provided by ' t rick' movemen t s. It sho uld be noted that each of th e method s
used tests, as a rule, the acti on of muscles at a si ngle joi nt.
When test ing a movement, th e limb should be firmly supporte d proximal to the rel evant
joint, so that th e test is confi ned to the chosen muscle group and does not require th e
patient to fix the limb proximally by muscle cont ract ion. In this book, thi s principle is
SPINAL ACCESSORY NERVE
Fig. 1 Trapezius (Spinal accessory nerve and 0 , ( 4)
The pat ient is elevati ng t he shoul der against resistance.
Arrow: t he thi ck upper part of t he muscle can be seen and f elt .
Fig.2 Trapezius (Spinal accessory nerve and O . ( 4)
The pat ient is pushing the palms of the hands hard against a wall with t he elbows fully
extended. Arrow: th e lower f ibres of t rapezius can be seen and f elt .
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BRACHIAL PLEXUS 5
fig.4 The approximate area wit hin which sensory changes may be found in complet e
lesions of t he brachial plexus (5. (6, (7. C8, T1).
Hg.5 The appr oximate area within which sensory changes may be fou nd in lesions of t he
upper roots ( 5.(6) of t he brachial plexus.
6 BRACHIAL PLEXUS
Fig.6 The approxi mate area wi t hin which sensory changes may be found in lesionsof the
lower roots (C8. T1) of t he brachial plexus.
BRACHIAL PLEXUS 7
Fig.7 Rhomboid s (Dorsal scapul ar nerve; ( 4, (5)
Thepatient is pressing the palm of hi s hand backwards against th e examiner's hand.
Arrow: t he muscle bel lies can be felt and some times seen.
Fig.8 Serratus a nterior (long t horacic nerve; (5, e6, 0 )
The patient is pushing against a wall. The left serratus ante rior is pa ralysed and t here is
winging of the scapula.
8 IlRACHIAL PLEXUS
Fig. 9 Pecto ralis Major: Clavicular Head {lateral pectoral nerve; ( S, (6)
The upper a rm is above th e horizonta l and t he patien t is pushing forward agai nst the
examiner's hand. Arrow: t he clavicular head of pect oralis major can be seen and fel t .
Fi g. 10 Pectoralis Major: Sternocostal Head (latera l and medial pectoral ne rves; (6, ( 7,
C8)
The patient is adduct ing the upper arm against resistance .
Arrow: the sterno-costal head can be seen and felt.
BRACHIAL PLEXUS 9
f ig. 11 Supraspinat us (Suprascapular nerve; (S, ( 6)
The patient is abduct ing the upper arm aga inst resist ance.
Arrow: t he muscle belly can be f elt and somet imes seen.
Fig. 12 Inf raspinatus (Suprascapular nerve; (5. ( 6)
The patient is ext ernall y rotating the up per arm at t he sho ul der agai nst resist ance. The
examiner's right hand is resist ing t he movement and sup port ing t he forearm wit h t he
elbow at a ri ght angle; his left hand is supporti ng the elbow and prevent ing abduction of
t he arm. Arrow: the muscle bell y can be seen and felt .
10 BRACHIAL PLEXUS
..
Fig.13 lat issimus Dorsi (Thor acod orsal nerve; ( 6, C7, C8)
The upper ar m is hor izont al and t he pat ient is addueting it agai nst resista nce. Lower
arrow: t he muscle belly can be seen and felt. The upper arrow points to teres major.
Fig. 14 latissimus Dorsi (Thoracod orsal ne rve; (6, C7, C8)
The Muscle bell iescan be f elt t o cont ract when the patient coughs.
HKACl IIAL PLEXUS 11
Fig.1 5 Teres Major (Subscapular nerve; (S, (6, 0)
The patient is adducting the elevated upper arm against resistance.
Arrow: the muscle belty can be seen and felt .
MUSCULOCUTANEOUS NERVE
Coracobrachi ali s ----1111
MUSCULOCUTANEOUS
NERVE - - - - - + 1
Brachialis
lateral cutaneous nerve \
altha forearm --II
Fig. 16 Diagram of t he musculocut aneous nerve, it s majo r cut aneous branch and t he
muscles which it supplies.
MUSCULOTANEQUSNERVE 13
Fig. 17 The approximate ar ea wi thin which sensory changes may be found in lesions of
the musculocutaneous nerve. (The distribution of t he lat eral cutaneous nerve of t he
forearm.)
Fig.1 8 Biceps (Musculocutaneous nerve; (S. (6)
The pat ient is flexing the supinated forearm against res ist ance.
Arrow: t he muscle belly can be seen and felt .
AXILLARY NERVE
AXILlARY NERVE
UPPER CUTANEOUS
NERVE OF THE ARM - - ----.......,
\J'-- - -i-- - - - RADIAL NERVE
minor
Fig_19 Diagram of the axillary nerve, its major cutaneous branch and the muscleswh ich
it suppnes.
o
f ig_20 The approximate area within which sensory changesmay be f ound i n lesions of
t he axillary nerve.
AXILLARY NERVE 15
Fig. 21 Deltoi d (Axillary nerve; {S. ( 6)
The pat ient is abducting the upper ar m against resistance.
Arrow: t he anterior and mi ddl e f ibres of t he muscle can be seen and f elt .
Fig.22 Deltoi d (Axillary nerve; { 5, (6)
The pat ient is ret ract ing t he abducted upper arm against resist ance.
Arrow: the posterior fibres of delt oid can be seen and felt .
RADIALNERVE
AXIUARY NERVE -----:.,-- 7'''':
Triceps . long head - - - - - -1
Triceps . lateral head
------- Triceps, medtal head
1--1- - - - - - - - RADIAL NERVE
Brachiol'adaall$ --------1
Extensor carpi radaalis longus ----Il-'l
Extensor carpi radialiSbrevis
Supinator
Extensor carpi utnans ------Il.....
Extensor digllorum -------r;:- ,
Extensor digiti mlnl mi -----:i
Abduct or polliCis longus ~
Extensor polllClS Ioogus ------\l""
Extensor polliCiS brevis -----;;,..-
Extensor indios
POSTERIOR INTEROSSEOUS
NERVE (deep branch)
SUPERFICIAL RADIAL NERVE
Fig.23 Diagram of t he radial nerve, it s major cutaneous branch and the muscles which it
suppli es.
RADIALNERVE 17
Fig.24 The approximate area within which sensory changes may be found in high lesions
of the radi al nerve (above th e origi n of t he posterior cutaneous nerves of th e arm and
forearm). The average area is usuallyconsiderably smaller. and absence of sensory changes
has been recorded.
Fig.2S The approximat e area within which sensory cha nges may be found in lesions of
the radial nerve above the elbow joint and below the ori gi n of the posterior cutaneous
nerve of the f orearm. (The distr ibut ion of the superfici al t erminal br anch of th e rad ial
nerve.) Usual area sha ded, wi th dark blue line; light blue lines show small and large ar ea s.
18 KAlJIAL NEKVE
Fig.26 Triceps (Radial nerve; cs. C7, (8)
The patient is extending t he for ea rm at the elbow against resistance .
Arro ws: the long and lateral heads of the muscle (a n be seen and felt .
Fi g. 27 Ext ensor Carpi Radial i s l ongus (Radial nerve; (5. ( 6)
The patient is extending and abdu ct ing th e ha nd at t he wrist against resist ance.
Arrows: t he muscle belly and t endon (a n be felt and usuallysee n.
RADI AL NERVE 19
A

/
Fig_28 Brachioradial is (Radi al nerve; (5, (6)
The pat ient is flexing the forearm against resist ance with the forearm midway between
pronation and supination. Arrow: the muscle belly (an be seen and felt .
20 RADI AL NERVE
Fig.29 Supinat or {Radial nerve; ( 6. 0)
The patient is supinating t he forearm against restst ence with t he forearm extended at the
elbow.
RADIAL NERVE 21
Fig. 30 Ext ensor Carpi Ulnar is {Poster ior int erosseous nerve; (7, ( 8)
The pat ien t is extendi ng and adducti ng the hand at t he wrist against resist ance.
Arrows: th e muscle belly and t he tendon (an be seen and felt .
Fig. 31 Ext ensor Digitorum (Post eri or interosseous nerve; (7, C81
The patient' s han d is firmly supported by the exa miner's right ha nd. Ext ension at t he
metacarpopha langea l joints is ma intained agai nst the res ist ance of the fingers of t he
exemtner's left ha nd. Arr ow: t he muscle bell y can be see n and felt .
22 RADI AL NERVE
Fig. 32 Abductor Pollicis Longus (Posterior inte rosseous nerve; O . (8)
The pat ient is abducti ng t he t humb at t he carpo-metece rpet joi nt in a plane at right
angles to the palm. Arrow: t he tendon can be seen and felt ante rior and close ly adjacent
t o t he tendon of extensor pctncrs br evis (d . Fig. 34).
Fig.33 Extensor Pollicis l ongus (Posterior int erosseous nerve; 0 , (8)
The pat ient is ext end ing the thumb at the interphalangeal joint against resistance.
Arrow: the tendon can be seen and felt .
RADIAL NERVE 23
Fig_34 Extensor Poll ids Brevis (Posterior int erosseous nerve; C7. C8)
Thepatient is extending the thu mb at the metacarpophalangeal joint aga inst resistance.
Arrow: t he tendon can be seen and felt (d . Fig. 32).
MEDIAN NERVE
1-- - - - - - - - - - MEDIAN NERVE
Sensory
)
Flexor poIhcis longus
IlL
I
h '-- - ANTERIOR INTEROSSEOUS NERVE
'd 't-- Flexor retinaculum

1\+ - - Palmar branch
Firstlumbrical ------!'-J---'!ll!
Pronator quadratus ------+_
Motor
Abductor pomos
Flexor pollicis brevis _
Opponens poll icis --- - tV
Pronal or teres -------1
Flexor carpi radialis - - - - - -tr;
Palmans longus -------1
Flexor d1gitorum superliciahs
Second lumbr ical --'
Fig.35 Diagr am of t he median nerve. its cut aneous branches an d the muscl es which it
supplies . Note: th e white rectangle signifies that the muscle indicat ed receives a part af its
nerve supply f rom another per ipheral nerve (d. Figs. 45. 57 and 58).
MEDIAN NERVE 25
A

Fig.36 The app rox imate areas within which sensory changes may be found in lesions of
the median nerve in: A t he fo rearm. B the carpal tunnel.
26 MEDIAN NERVE
Fig_37 Pronator Teres (Median nerve; ( 6, 0 )
The patient is pronat ing the forear m aga inst resistance.
Arr ow: the muscle belly can be fe lt and somet ime seen.
Fig. 38 Flexor Carpi Radial is (Median nerve; ( 6 , 0 )
The pat ient is f lexing and abd uct ing t he hand at t he wrist against resist ance.
Arrow: t he tendon (an be seen and felt .
MEDIAN NERVE 27
Fig_39 fl exor Digi to rum Superf ici al is (Median nerve; C7, C8, Tt)
The pati ent is f lexing the f inger at th e proximal int erphal ageal joint against resistance
with t he proximal phalanx fixed. This t est does not el iminate th e possibility of f lexion at
the pr oximal inter phal angeal j oint being prod uced by f lexor digit orum profundus.
Fig.4O Flexor Digitorum Profundus I and II (Anterior interosseous nerve; ( 7, (8)
The patien t is flexing the distal phalanx of the index finger agai nst resistance with the
middle phalanx fixed.
28 MEDIAN NERVE
Fig_41 Flexor Pol lid s l ongus (Anterior int erosseous nerve; 0. C8)
The patient is flexing the di stal phalanx of the t humb against resist ance while t he
proximal phalanx isf ixed.
Fig_42 Abduct or Polli cis Brevis (Medi an nerve; C8, 11)
The pat ient is abduct ing the thumb at fight angles t o the palm against resist a nce.
Arrow: t he muscle can be seen and felt.
MlJIAN NERVE 29
/
Fig.43 Opponens Pollicis (Median nerve; ca, T1)
The pat ien t is touching t he base of t he littl e finger wit h t he t humb agai nst reslstence.
Fig. 44 lst lumbrical-Interosseous Muscle (Median and ulnar nerves; C8, 11)
The pati ent is extendi ng the f inger at t he proximal interphalangeal j oint against
resistance wit h t he metacar pophalangeal joint hyperextended a nd fixed.
ULNAR NERVE
I
I
-----ULNAR NERVE
Sensory
I
Dorsal cutaneous
branch
Palmar cutaneous ,
branch
Deep motor branch
Superficial terminal
branches
---MEDIAL CUTANEOUS
NERVE OF THE ARM
--- - Flexor carpi ulnaris
I 11-- - - - Flexor digilorum
profundus III & IV
11-- - - MEDIAL CUTANEOUS
NERVE OFTHE
FOREARM
Four th lumb rical
} digiti minimi
Flexor

Thi rd lumbrical ----------1'<'
Mot or
Adductor ponies - - - - - - - - - - -0<.
Flexor pollicis brevis
t st Palmar interosseous -----/
1st Dorsal interosseous
Fig.4S Diagram of t he ulnar nerve, it s cut aneous branches and the muscles whi ch it
supplies.
ULNAR NERVE 31
A
B
c
Fig_46 The approximate areas within which sensory changes may be found in lesions of
the ulnar nerve: A above the origin of t he dorsal cutaneous branch, Bbelow the origin of
the dorsal cutaneous branch and above the origin of the palmar branch, Cbelow the
origin of t he palmar branch.
32 ULNARNERVE
Fig.47 The approxi mat e area wi t hi n which sensory changes may be found in lesions of
the medi al cut aneous nerve of the forearm.
Fig.48 Flexor Carpi Ulnaris (Ulnar nerve; a . C8. Tt )
The patient is abducti ng t he little finger against resist ance. The tendon of uexcr car pi
ulnar is can be seen and felt (ar ro w) as t he muscle comes int o act ion to f ix the pisiform
bone from which abd uctor digiti minimi ar ises. If flexor carpi utnens is int act , the tendon is
seen even when abductor digit i minimi is paral ysed (see also Fig. 49).
ULNAR NERVE 33
Fig.49 Flexor Carpi Ul naris (Ulnar nerve; 0 , C8, T1)
The patient is flexing and adducting the hand at the wrist against resistance.
Arrow: the tendon can be seen and felt .
Fig. SO Flexor Digitorum Prof undus III and IV (Ulnar nerve; 0 , C8)
The patient is flex ing the distal interphalangeal j oint against resistance while the middle
phalanx is fixed.
34 ULNARNERVE
Fig. 51 Abduct or Digit i Minimi (Ulnar nerve; C8, 11)
The patient is abduct ing t he litt le finge r against resist ance.
Ar row: t he muscle bell y can be felt and seen.
Fig.52 Flexor Digit i Minimi (Ulnar nerve; C8, 11)
The patient is flexing t he litt le f inger at t he metacarpophalangeal joint aga inst resist ance
with t he finge r extended at bot h interpha langeal joints.
ULNAR NERVE 3S
Fig_53 r trst Dorsal Interosseous Muscle (Ul nar nerve; C8, 11)
The patient is abduct ing the index finger against resistance.
Arrow. the muscle belly can be felt and usually seen.
Fig. S4 Second Palmar Interosseous Muscle (Ulnar nerve; C8, T1)
The pat ient is adduct ing the index finger against resistance.
36 ULNARNERVE
Fig. 55 Adductor Polltcls(Ulnar nerve; C8. T1)
The patient is adducting the thumb at right angles t o th e palm against the resistance of
t he examiner's f inger.
LUMBOSACRAL PLEXUS
Perineal nerve
Dor sal ner ve of
penis or cli lori s

l.'. H20
... \
10
levat or a ni and
e xternal s phl m::le,
branches t o
______ Obtura to r e l l e rn us
Adductor l ongus
Adduct or brevi S
Adductor magnus
/ ----- Gr acili s
/ - - - - Cuta ne ous
NERVE
Rectus t emcr ta -----J.
VI SluS l . t eralis - - - - - \-J
Yul us i nl er medius ----\, - >.

.. c ut an.ous
V. Sl uS me d iali s
ne, v. 01 t hig h

To lUaeus
SCIATIC NERVE- - _ ,
Psoas muscle
Supe rior and
int erior gluteal
Ner ve 10
s.rto ri us mu s cle
Cutaneous nerv es
ot Ihigh
Genito le mo ra l nerve
Ner ves 10 quadriceps
f EMORAL NER ve <,
Iliohypog as t ric l'Ierv. - - -"
Ili o inguina l ner ve - - _,
SCIATIC NERVE
I-HI-- - - - - - - - - - - - Common peroneal
I+l-- - - - - - - - - - - - - Ti blal
Saphenous nerve -----:--\,--\li t "\-'
Fig.56 Diagram of t he lumbosacral plexus, its branches and t he muscles which t hey supply.
NERVES OF THE LOWER LIMB
Adductor magnus
Cutaneous branch

Adductor brevis
MEDIAL CUTANEOUS
NERVe QFTHE THIGH
1t-!lI-- - - - - - Adductor longus
Iliacus
{
Rectus femoris
Quadriceps vastcs l.ateraIiS.
semens vastcs Intermedi us --/Y' L" .I I ' . - - - - - - - - - Gracilis
vastcs medi alis 1\,
INTERMEOI ATE CUTANEOUS
NERVe OF THE THI GH ------;
LATERAL CUTANEOUS
NERVE OFTHETHI GH ----1 \
FEMORAL NERVE - - - - - + ---1:-1..... " ""'=,---__
... OBTURATOR NERVE
( /
/
COMMON PERONEAL NERVE 'I,
SUPERFICIAL PERONEAL NERVE - -
Peroneus longus
Deep PERONEAL NERVE
)-Ii}+ - - - - - - - - Tibial is anterior
Peroneus brevis ---------
Extensor digilofum longus
LATERAL CUTANEOUS
NERVE OF THE CALF ------/ 11
Peroneusterlius - - - - - - - - -
-t- - - - - Extensor hallucis longus
SAPHENOUS NERVE
Fig. 57 Diagram of the nerves on t he anterior aspect of t he lower l imb, their cutaneous
branches and t he muscles whi ch t hey supply.
NERVES OF THE LOWER LIMB 39
)f- - - - - - - - - Biceps, long head
)l- - - - - - - - - Biceps. short head
I f\-''f-- - - - POSTERIOR CUTANEOUS
NERVE OF THE THI GH
f '. \"-, "',f-- - - - - - - - Gluteus maximus

[' Gluteus minimus
____ GLUTEAL NERVE
Semimembranosus -------11-'
Semi tendi nosus
SCI ATIC NERVE
Adductor magnus -------j
Pir iformis
SUPERIORGLUTEAL _
Tensor fasciae latae
,
)
COMMON PERONEAL NERVE
Gastrocnemius. medial head
Soleus
,I'i!-- - - - - - Gastrocnemius, lateral head
Tibialis posterior
Flexor digilorum longus
------It'l -;t-------- Flexor hallucis longus
TIBIALNERVE --------1
SURAL NERVE
CALCANEAL BRANCH ------1 'i-'l-- - -
, LATERAL PLANTAR NERVE to:
MEDI AL PLANTAR NERVE to' ----"''\ Abduc tor digiti minimi
Abductor nauccs Flexor digiti mini mi
Flexor digitorum brevis Adductor hallucis
Flexor hallucis brevis Interossei
Cutaneous branches Cutaneous branches
Fig. 58 Diagram of the ne rves on the posterior aspect of the lower limb, their cutaneous
branches an d the muscles which they suppl y.
40 NERVES OF THE LOWERLIMB
..
Fig.59 The ap proxi mate area within which sensory changes may be found in lesions of
t he lateral cut aneous nerve of the thigh. Usua l area sha de d. wit h dark blue line; large
area indicated with light blue line.
...
Fig_60 The approximate area within which sensory changes may be found in lesions of
the femoral nerve. (The distribution of the intermed iate and medial cutaneous nerves of
the t high and the saphenous nerve.)
NERVES OFTHE W WER LIMB 41
Fig. 61 The approximate area within whi ch sensory changes rna)' be found in lesions of
the obturator nerve.
Fig.62 The approximat e area within which sensory changes may be found in lesions of
t he post erio r cutaneous nerve of the th igh.
42 NERVES OF THE WWERLIMB
Fig. 63 The approximat e area within which sensory changes may be found in lesions of
t he trunk of t he sciat ic nerve. (Modif ied from M.R.e. Special Report No. 54, 1920.)
Fi g.64 The approximate ar ea within which sensory cha nges may be found in lesions of
bot h the sciat ic and the posterior cutaneous nerve of the t high.
NERVES OFTIIE LOWER LIMB 43
Fig. 65 The approximat e area wit hin which sensory changes may be found in lesions of
the common peroneal nerve above the or igi n of the superficial peron eal nerve. (Modified
from M.R.C. Special Report No. 54, 1920.)
J
Fig. 66 The approximate area wit hin which sensory changes may be found in lesions of
the deep peroneal nerve.
44 NERVES OF THE LOWER LIMB
Fig. 61 The approximate area within which sensory changes may be found in lesions of
t he sural nerve.
Fig.68 The approximate area within which sensory changes may be found in lesions of
the t ibial nerve. (Modified f rom M.R.C. Special Report No. 54, 1920.)
NERVES OFTHE LOWERLIMB 45
SURAL NERVE -----i
LATERAL PLANTAR
NERVE
---MEDIAL PLANTAR
NERVE
y'-- - - SAPHENOUS NERVE
+- - - - - CALCANEAL NERVE
Fig. 69 The approximate areassupplied by the cutaneousnervesto the sale of the foot.
46 NERVES OFTHE LOWER LIMB
J
}
Fig.70 Iliopsoas (Branches from l 1, 2 and 3 spinal nerves and femoral nerve; l l , L2, l3)
The pat ient is fl exing the th igh at t he hip against resist ance wi t h th e leg fl exed at the
knee and hip.
Fig. 71 Quadriceps Femoris(Femoral nerve; 12. L3, L4)
The patient is extending t he leg against res istance wit h the limb flexed at the hip and
knee. To detect slight weakness. t he leg should be fully flexed at t he knee.
Arrow: t he muscle belly of rect us femor is can be seen and felt .
NERVES OF TI lE LOWER LIMB 47
,
I
Fig.72 Adduct ors (Obt urator nerve; L2, l3, L4)
The patient lies on his back wi t h t he leg exte nded at t he knee. and is adduct ing the l imb
against resist ance. The muscle be llies can be fel t .

I
Fig.73 Glut eus Med ius and Min imus (Super ior glut eal nerve; L4. lS. 51)
The pat ient lies on his back and is internally rotating the thigh against resistance with the
limb flexed at t he hip and knee.
48 NERVES OFTHE LOWER LIMB
Fig. 74 Gluteus Medius and Minimus and Tensor FasciaeLat ae (Superi or gluteal nerve; l 4,
LS, 51)
The pat ien t lies on his back wit h the leg extended and is abduct ing the limb against
res istance. Arrows: t he muscle be llies can be felt and sometimes seen.
Fig.7S Gluteus Maximus (Inf er ior gluteal nerve; l S. $1. 52)
The patient lies on his back wit h t he leg ext ended at the knee and is extending t he limb at
t he hip ag ai nst resist ance.
NERVES OFTHE LOWER LIMB 49
Fig. 76 Hamstring Muscles (Sciatic nerve. Semitendinosus. semimembranosus and biceps;
L5. S1. S2)
The pa tient lies on his back with t he limb flexed at the hip and knee and is flexing t he leg
at the knee against resistance.
Fig.77 Hamst ring Musd es (Sdetic nerve . Semitendinosus, semimembranosus and biceps;
l5, 51. 52)
The pat ient lies on his face and is flelCing the leg at t he knee against resistance.
Arrows : t he t endons of t he biceps (laterally) and semi tendinosus (medi ally) can be felt
and usua lly seen.
SO NERVES OFTHE LOWERLI MB

I
Fig. 78 Gastrocnemius (Tibial nerve; 51, 52)
The patient lies on his back with the leg extended and is plantar-flexing the foot against
resist ance. Arrow: the muscle bell ies can be seen an d felt. To detect slight weakness. the
patient shoul d be asked t o st and on one foot. raise the heel fr om the gr ound and
ma int ain t his position.
Fig. 79 Soleus (Tibial ne rve; 51, 52)
The patient lies on his ba ck with th e limb flexed at the hip and knee and is plantar-flexing
the foot agai nst resistance. The muscle be lly can be felt and some times see n.
Arrow: t he Achilles t endon.
NERVES OF THE LOWERLIMB 51
f ig.80 Tibialis Post erior (Tibial nerve; l4. lS)
The patient is inve rting t he foot aga inst resist ance.
Arrow: the tendo n can be seen and felt .
Fig. 81 Flexor Digitor um l ongus. Flexor Hettuos Longus (Tibi al nerve; l 5, 51, 52)
The pat ient is flexing the toes against resistance.
52 NERVES OFTHE LOWER LIMB
Fig.82 Small muscles of th e f oot (medial and lat eral plantar nerves; 51, 52)
The pat ient iscuppi ng t he sole of t he f oot; the small muscles can be f elt and someti mes
seen.
f ig.83 Tibialis Anterior (Deep peroneal nerve; L4, LS)
The pat ient is dorsiflelCing the foot against resist ance.
Arrows: the muscle belly and its t endo n can be seen and fe lt.
NERVES OF TIlE LOWERLIMB 53
Fig. 84 Ext ensor Digit orum Longus(Deep peroneal nerve; l 5, 51)
The patie nt is dorsifl exing t he toes ag ainst resistance. The ten dons passing to the lateral
four toescan be seen and felt .
54 NERVES OF THE WWER LIMB
Fig.85 Extensor Hattucts Longus (Deep peroneal nerve; L5, S1)
The patient is dorsiflexing the distal phalanx of the big toe against resistance .
Arrow: the tendon can be seen and felt .
NERVESOF TIl E LOWER LIMB 55
Fig.86 Ext ensor Digi t orum Brevis (Deep peroneal nerve; LS, 51)
The patient is dorsiflexing the proxima l phalanges of the toes against resistance .
Arrow: the muscle belly can be felt and sometimes seen.
(
Fig.87 Peroneus l ongusand Brevis (Superficial peroneal nerve; r s. 51)
The pati ent is evert ing th e f oot against resist ance. Upper arr ow: th e t endon of peroneus
brevis. Lower arrow: t he t endon of peroneus longus.
C 6 , - _ ~
DERMATOMES
C'
T2
13
T'
T5
T7
T6
T9
TID
T11
Ll
T12
Fig. 88 Approximate distribut ion of dermatomes on the anter ior aspect of t he upper
limb.
Fig. 88-91 show t he approximat e cut aneousareas supplied by each spina l root . There is
considerable variat ion and overlap between der mat cmes, so t hat an isolated root lesion
result s in a much smaller area of sensory impai rment than is indicated in t hese di agrams.
This var iation also applies t o t he innervat ion of t he f inger s, but th e t humb is usuall y
supplied by (6 and the little finger usually by (8 (see Inouye and Bucht hal ( 1977) Bra;n
100: 131- 748).The heavy axial lines are usuall y mor e consist ent, showing the boundary
between non consecutive dermat omes.
DERMATOMES 57
C4
T12
,/ ~
L1
Fig.89 Approximate dist ribut ion of der matomes on t he post erior aspect of t he upper
limb.
58 DERMArOMES
Tt o
Tll
Tt 2
LI
L2
I
SSr:>'
SJ
l3
l3
S2
I
l5
I
S2
S,
l4
l4
l5
Fig_90 Approximat e distribution of dermat omeson the lower limb.
52
L3
53
L2 L2
53
DERMATOMES 59
L3
52
L2
Fig. 91 Approximate distr ibution of dermatomeson the perineum
NERVES AND MAIN ROOT SUPPLY OF MUSCLES
The list given be low does not include a ll t he muscles inne rvated by th ese nerves, but only
those more commonly tested, eit he r clinicallyo r electr ica lly, and shows the order of
innervation.
Trice ps
Upper limb
Spinal Accessory Nerve
Trapezius
Brachial Plexus
Rhomboi ds
Ser ratus anterior
Pectoralis ma jor
Clavicular }
Sterna l
Supraspin atus
Infr aspinat us
l at issimus dorsi
Teres majo r
Axill ary Nerve
Deltoid
Musculocutaneous Nerve
Biceps
8rachial is
Radial Nerve
!
l ong head ]
lateral he ad
Media l head
Brechioradialts
Extensor carpi rad ialis longus
Posterior Interosseous Nerve
Supinator
Extensor carpi ulnaris
Extensor dig itorum
Abduct or pollicis longus
Extensor pollicis longus
Ext ensor poll icis brevi s
Ext ensor indi cis
Median Nerve
Pronat or t eres
Hexer carpi radia lis
Flexor di git or um superf tctens
Abd uct or pollicis brevis
Hexor pollicis brevis"
Opponens pctncts
lumbricals I & II
Spinal Roots
0 .(4
( 4, ( 5
( 5, (6, C7
(5, ( 6
cs. (7, C8
(5, (6
(5. (6
( 6, 0. C8
(5, ( 6, C7
CS, C6
(5, ( 6
(5, (6
( 6, ( 7, C8
( 5. C6
( 5. ( 6
( 6, C7
C7, ( 8
C7, (8
(7, (8
(7, (8
(7, ( 8
(7, C8
( 6, (7
C6, (7
0 , C8, T1
C8, 11
C8, 11
C8, 11
C8, 11
NERVES AND MAI N ROOT SUPPLY OF MUSCLES 61
Quadriceps
femoris
Anterior Int erosseous Nerve
Pronat or quadratus
Flexor digitoru m profundus I & II
f lexor pollicis longus
Ulna r Nerve
Flexor carpi ulnaris
Flexor digi t orum profundus III & IV
Hypothenar muscles
Adduct or pall ids
Flexor palli cis brevis
Palmar int erossei
Dorsal int erossei
l umbr icals III & IV
l ower limb
Femoral Nerve
Iliopsoa s
Rect us f emori s ]
vestus taterehs
Vastus inte rmedius
Vast us media lis
Obturator Nerve
Adduct or longu5
Adductor magnus
Superior Gluteal Nerve
Gluteus medus and mi nimus
Tensor fasciae latae
Inferior Gluteaf Nerve
Gluteus maximus
O , C8
a , C8
a , ( 8
0 , C8, 11
C7, (8
C8, T1
C8, T1
C8, T1
C8, T1
C8, T1
C8, T1
Spina l Root s
u. 12, L3
L2. l3, l4
12. l3, l 4
l 4. L5, S1
l 5, 51, 52
Sciatic and Tibial Nerves
Semit end inosus
Biceps
Semimembranosus
Gastr ocnemius and soleus
Tibiali s post eri or
Flexor digitorum longus
Abductor hallu cis
Abduct or digiti minimi
Int erossei
Small muscles
of f oot
l5 , S1, S2
l5, 51, 52
l 5, 51, 52
51, 52
l4, l 5
i s , 51, 52
51, S2
Sciat ic and Common Peroneal Nerves
Tibi alis ant erior
Extensor digit orum longus
Extensor hatlucis longus
Exte nsor digit orum br evis
Perone us longus
Peroneus br evis
l 4, l5
l5, 51
l5, 51
l5, 51
l 5, 51
l5. 51
* Flexor pollicis brev is is often supplied wholly or partially by t he ulnar nerve.
COMMONLY TESTED MOVEMENTS
Movement UMN Root Refl e x Nerve Muscle
Upper /i mb
Shoul der abduction
++ C5 Axillary Delto id
Elbow f lexion (5/6
+
Musculocut aneous Biceps
C6
+
Radial arecbtor adtens
Elbow extension
+
C7
+
Radial Triceps
Radial wrist extension
+
C6 Radial Ext ensor car pi
rad ialis longus
Finger ext ensi on
+ C7 Poste ri or Extensor
int erosseus ner ve digit or um
communis
Finger f lexio n C8 + Anter ior Flexor polli ds
int er osseus nerve longus + Flexor
digit or um
pro f undus
(i ndex)
Uln ar Flexor dig it orum
prof undus
(ring + little)
Finger abduction
++ T1 Ulnar First do rsal
interosseous
T1 Medi an Abduct or po ll icis
brevis
Lower limb
Hip fl exion
++ L1 /2 Iliopsoas
Hip adducti on L2I3
+
Obturat or Adductors
Hip extension L51S1 Sciat ic Gluteus
ma ximu s
Knee f lexion
+
51 Sciat ic Hamstrings
Knee extensi on L3/4
+
Femoral Quadriceps
Ankle dorsifl exion
++
L4 Deep peroneal Tibial is anterior
An kle eversion LS151 Superf icial peroneal Per onei
Ankle plantarflexi on S1 152 + Tibial Gastrocnemius,
soleus
Big t oe exte nsion L5 Deep peroneal Extens or hellucis
longus
The t able shows some commonly t ested movements, the principal muscle i nvol ved wi t h its
roots and ner ve supply. The column headed UMN indicat es those movements which ar e
preferentially weak in upper motor neuron lesions.