Lower limb

Bones, ligaments and joints ........................................................................................................2

Pelvic bone ........................................................................................................................................................................................ 2
Sacrum ................................................................................................................................................................................................ 3
Hip joint .............................................................................................................................................................................................. 4
Femur .................................................................................................................................................................................................. 5
Patella.................................................................................................................................................................................................. 7
Knee joint........................................................................................................................................................................................... 7
Tibia ..................................................................................................................................................................................................... 9
Fibula ................................................................................................................................................................................................... 9
Ankle joint (talocrural joint)...................................................................................................................................................... 9
Calcaneal bone .............................................................................................................................................................................. 10
Talus bone ...................................................................................................................................................................................... 10
Talocalcaneonavicular joint .................................................................................................................................................... 10
Muscles.................................................................................................................................... 11
Muscles of pelvis .......................................................................................................................................................................... 11
Six lateral hip rotators............................................................................................................................................................... 12
Gluteus muscles ........................................................................................................................................................................... 13
Thigh muscles ............................................................................................................................................................................... 14
Medial compartment of the thigh ............................................................................................................................................. 14
Posterior compartment of the thigh ........................................................................................................................................ 16
Anterior compartment of the thigh ......................................................................................................................................... 16
Leg muscles.................................................................................................................................................................................... 17
Anterior extensor compartment of the leg ........................................................................................................................... 17
Lateral everter compartment of the leg ................................................................................................................................ 18
Superficial posterior flexor compartment of the leg – 3 muscles .............................................................................. 18
Deep posterior flexor compartment – 4 muscles ............................................................................................................... 19
Foot muscles.................................................................................................................................................................................. 19
First layer ............................................................................................................................................................................................. 19
Second layer ........................................................................................................................................................................................ 20
Third layer ........................................................................................................................................................................................... 20
Fourth layer ........................................................................................................................................................................................ 21
Fascia ....................................................................................................................................... 22
Fascial compartments of the leg ............................................................................................................................................... 22
Fascial compartments of the foot ............................................................................................................................................. 22
Anatomical areas ..................................................................................................................... 23
Greater sciatic foramen ............................................................................................................................................................ 23
Lesser sciatic foramen............................................................................................................................................................... 24
Inguinal triangle (Of hasselbach) ......................................................................................................................................... 24
Femoral triangle (of scarpa) .................................................................................................................................................. 24
Adductor canal (Hunter’s canal, subsartorial canal) .................................................................................................... 25
Popliteal fossa ............................................................................................................................................................................... 25
Arteries .................................................................................................................................... 28
Anastomosis at hip joint ........................................................................................................................................................... 29
Blood supply to the head of femur ....................................................................................................................................... 30
Obturator artery .......................................................................................................................................................................... 30
Popliteal artery............................................................................................................................................................................. 30
Anterior tibial artery ...................................................................................................................................................................... 30
 Posterior tibial artery .................................................................................................................................................................... 31
Peroneal (fibular) artery .............................................................................................................................................................. 31
Veins........................................................................................................................................ 32
Great saphenous vein ................................................................................................................................................................ 32
Lesser (short) saphenous vein .............................................................................................................................................. 32
Nerves ..................................................................................................................................... 33
Lumbar plexus .............................................................................................................................................................................. 33
Obturator nerve ................................................................................................................................................................................ 34
Femoral nerve .................................................................................................................................................................................... 34
Sacral plexus.................................................................................................................................................................................. 35
Posterior femoral cutaneous nerve .......................................................................................................................................... 36
Sciatic nerve (L4-S3) ....................................................................................................................................................................... 36
Cutaneous sensation over leg................................................................................................................................................. 39
Muscle attachment groups ....................................................................................................... 41
Clinical ..................................................................................................................................... 42
Myotomes of lower limb .......................................................................................................... 42

Bones, ligaments and joints

Pelvic bone
 Prior to puberty, three pelvic bones are separated by triradiate
cartilage. Fuses at 15-17 to form acetabulum complete by 25
 ASIS and pubic symphysis are in same vertical plane Greater
 Acetabulum = 2/5 ilium, 2/5 ischium and 1/5 pubis Sciatic
Notch

Ilium
 Wing / ala of ilium = lies immediately superior to acetabulum. Has two surfaces
 Iliac surface - inner concave containing the iliac fossa, is origin for iliacus
 Gluteal surface - external convex, attachment for gluteal muscles
 Iliac crest is thickened superior margin of the wing, from ASIS to PSIS
 Auricular surface of ilium – The part that connects with the sacrum
 Arcuate line is a continuation of pectineal line and is immediately below the iliac fossa.
Forms part of pelvic inlet margin
 Greater sciatic notch – formed between PIIS and the ischial spine

Ischium
 Has a body (central), super ramus and inferior ramus
(medial)
 Ischial tuberosity – bears load when seated
 Ischial spine – forms the lesser sciatic notch
(equivalent of PIIS)
 Ramus of ischium articulates with inferior rami of pubic bone to help make obturator
formaen

Pubis
 Two rami which form the obturator foramen
 Superior rami forms part of acetabulum
 Inferior rami joins the ischium
 Pectineal line – from pubic tubercle to iliopubic eminence then continues as arcuate line
 Pubic symphysis, pubic tubercle and pubic crest in that order
 Linea terminalis – Pubic crest, pectineal line and arcuate line all combined

Superior pelvic aperture / pelvic inlet – Pubic crest, pectineal line, arcuate
line, sacral ala and promonetry of sacrum. Forms an angle of 50-60 degrees
with the horizontal from posterior to anterior

Inferior pelvic aperture / outlet

Pubic symphysis, ischiopubic ramus, ischial
tuberosity, sacrotuberous ligament, coccyx.
Dimensions taken from tip of sacrum due to
mobility of coccyx

Sacrum
 Base articulates with L5
 Apex articulates with coccyx
 Auricular surface articulates with the ilium (SIJ)
 Sacral hiatus – Termination of the central canal at the level of S4
 Sacral ala – Large and triangular on either side of the body of base of sacrum
 Support psoas major + lumbar and sacral
plexus
 Origin of some of iliacus
 Promontary of the sacrum – the part that sits
anterior most and has ala either side
 Dorsal surface of sacrum
 Median sacral crest - Central ridge of
bone from fusion of S1-3 spinous
processes, gives rise to the supraspinous ligament,
 Intermediate sacral crest – fusion of sacral articular
processes (S1 and S5 are not fused, S1 articular process
articulates with L5 and S5 with coccyx, called coccygeal
cornu / sacral cornu
 Lateral sacral crest – Transverse processes fused,
attachment of sacroiliac and sacrotuberous ligament.
 Fusion not complete, allows posterior sacral foramen to
transmit nerves
 Pelvic (anterior) surface of sacrum
  Has four transverse ridges where the discs used to lie
 Sacral promontory superiorly
 Four anterior sacral foramina

Key ligaments
Sacrospinous ligament (blue) connects PIIS to sacrum and coccyx to form the greater sciatic
foramen. Sits anterior and medial to sacrotuberous. Lesser sciatic
Sacrotuberous ligament connects the ischial tuberosity to sacrum +
coccyx. Forms greater sciatic foramen between the greater sciatic
notch (L shaped) and the ligament with help from sacrospinous
ligament

Hip joint
Capsule: Very strong. Extends to intertrochanteric line anteriorly over neck, and posteriorly
extends 1.25cm short of the intertrochanteric rest. Above it is to the base of neck, below to the
lower neck near the lesser trochanter.
Has two fibers: Circular around neck (zona orbicularis) and longitudinal

Ligamentous supports – 3 external to capsule, one internal

1. Iliofemoral ligament – strongest in human body. V shaped with a deficiency anteriorly
 Base of V arises from AIIS and rim of acetabulum
 Limbs of V extend to upper and lower parts of intertrochanteric line anteriorly
 Two parts: Transverse above runs parallel to axis of femoral neck, strongest. Second part
is vertical band running parallel to femoral shaft
 Function: Limits extension of extension
2. Ischiofemoral ligament
 The posterior ligament – Attach to intertrochanteric
crest – crest is the posterior.
3. Pubofemoral ligament
 From obturator crest and superior ramus of pubic
bone to blend with capsule inferiorly with the vertical
band of iliofemoral
 Transverse acetabular ligament – Runs
across the inferior margin of the
acetabulum, extension of the labrum that
has no cartilage. Crosses the acetabular
notch, forming foramen for nutrient vessels
to enter joint
Posterior view Anterior view
ischiofemoral ligament Iliofemoral ligament
Lunate surface of acetabulum – the inside
surface of the acetabulum that articulates with the femur, much like the glenoid of the scapula

Ligament of head of femur / round ligament / teres – the feeder nutrient artery remnants
that enter head of femur within acetabulum

Femur
Proximal
 Head = Round ligament / ligament of the head of
the femur
 During development, cartilage separates head
and neck. Hence need for two blood supplies
 Fovea capitis – Contains ligamentum teres
which transmits a branch of obturator artery.
 Obliterates when developed
 Neck of femur supplied by circumflex femoral
artery (femoral artery)
 Neck – makes an angle with the shat of 125
degrees
 Intertrochanteric crest: From greater to lesser trochanter, obliquely, on the posterior of
the femur
 Intertrochanteric line: From greater to lesser trochanter, obliquely, on the anterior of
the femur (LA = Line is anterior)
 Quadrate tubercle – 1/3 below greater trochanter along intertrochanteric crest. For
quadratus lumborum
 Trochanteric fossa (red) – posterior surface, immediately below greater trochanter
 Angle of inclination / angle of head to neck of femur = 125 degrees
 Angle of torsion = horizontal plane through the condyles versus the angle to the head and
neck = 12 degrees

Shaft
 Pectineal line – from lesser trochanter to linea aspera (orange)
 Gluteal tuberosity – also merges with pectineal line to form linea aspera
(green) – attachment for gluteus maximus
 Linea aspera – Long vertical line down middle posterior of femur
 Popliteal fossa – triangular fanning of linea aspera inferiorly (purple)
 Medial and lateral supracondylar ridges (red)
 Adductor tubercle (blue) – medial continuation of medial lip of linea aspera before it
becomes medial epicondyle – adductor magnus

Distal
 Medial and lateral condyle (knuckles) that sit on top of tibia to form joint
 Medial and lateral epicondyles
 Trochlear groove on anterior of femur (for patella)
 Intercondylar fosa – depression posteriorly on femur between to condyles
 Attachment for anterior and posterior cruciate ligaments

Condyle and epicondyle

Intercondylar fossa/notch – seen on the posterior surface as the condyles project more
posteriorly than anteriorly. Is the area of attachment for the cruciate ligaments
On the anterior side is the patella fossa
Adductor tubercle – medial continuation of the medial lip of the linea aspera which becomes
the medial epicondyle – for insertion of adductor magnus
Patellar surface
Groove on anterior side of lateral condyle for popliteus

Ossification of the femur

 Mid-shaft appears at eight weeks and lower shaft at 9 months of foetal life (birth)
 Lower shaft is the growth section of the bone. Epiphysis fuses at 20 years
 Upper epiphyses fuse with shaft at 18 years
 Head of femur begins at 1 year
 Greater trochanter at 3 years
 Lesser trochanter at 12 years

Fascia lata

Anterior to pectineus
muscle
Patella
Begins ossification between 3-6 years, fuse at puberty
Patella ligament is vertical, but the pull of quadriceps is oblique in line with the shaft of the
femur. This would normally cause the patella to move laterally. Things that prevent it from
doing so (bone, ligament, tendon)
 Anterior prominence of the lateral femoral condyle
 Medial patella retinaculum (blended with Sartorius and vastus medialist) is especially
tense
 Vastus medialis has oblique fibers at its insertion (VMO) which pulls the patella medially
and also is important to enable full extension of the knee
Retinacula is not a tendon, but a thickening of fascia that attaches to the tendons either side
of the knee to help support the patella.

Patellar plexus – network of communicating twigs in subcutaneous tissue around patella

 Medial and intermediate cutaneous nerves of the thigh (from femur)
 Lateral femoral cutaneous nerve of the thigh’s anterior branch
 Infrapatellar branch of the saphenous nerve

Menisci Medial

Knee joint
Menisci – fibrocartilage that sit on top of the tibia.
Lateral = circle, medial = C shaped
 Thick at outer edge, thin at inner edge
 Attaches to the ‘intra-articular area’ of the tibia

Cruciate ligaments
The way I remember:
 They form an X, so if the ligament starts medial on femur, it attaches lateral on tibia and
vice versa. I refer to the ligaments based on their femoral attachment

LAMP: Lateral origin for Anterior cruciate ligament (on femur), Medial origin for Posterior
cruciate ligament (on femur)
->Therefore, the anterior cruciate ligament attaches
medial on tibia, the posterior cruciate ligament attaches
lateral on the tibial

 Both ligaments originate from the intercondylar area

of the femur, and insert into the intercondylar area of
the tibia.
 Posterior prevents forward movement.
 Anterior prevents backwards movement
Collateral ligaments – Tight during knee extension
 Fibula-collateral ligament – Lateral epicondyle of femur to fibula head.
Doesn’t blend with joint capsule and isn’t attached to lateral meniscus
 Tibia-collateral ligament – medial epicondyle to anteromedial aspect
proximal tibia with firm attachment to edge of medial meniscus. Blends with
joint capsule Tibial
collateral

Oblique popliteal ligament - Runs as an expansion of semimembranosus tendon insertion,

obliquely, laterally and superiorly to blends with the capsule superior to the lateral condyle.
Pierced by retinacular branches for the joint.

Bursa of the knee joint

Tibial plateau showing the attachments of synovium. Note the

menisci are within the synovium, the cruciate ligaments are
outside of.

Bursae associated with bone

Suprapatellar - top (under quadriceps)
Prepatellar (housemaid’s, middle)
Infrapatellar superifical (clergymans)
Infrapatellar deep

Bursa associated with ligaments

1 – Sartorius, gracilis and Semitendinosis
2 – Medial head of gastroc (often into joint)
3 – Lateral head of gastroc (sometimes into joint)
4 – Fibula / lateral collateral ligament
5 – Under popliteus into joint
6 - Semimembranosus

Bursa communicating with the joint cavity include:

 Suprapatellar
 Medial gastroc often (2)
 Lateral gastroc sometimes (3)
 Popliteus bursa (5)

Capsular reinforcements of knee joint

Anterior – patellar tendon + retinacular fibers (3)
Lateral – popliteus, biceps femoris, iliotibial tract
Medial – Short internal (medial) ligament attaches to medial
collateral on its outside and to medial meniscus on its inside
(1)
Posterior – Oblique popliteal ligament from
semimembranosus with popliteus inside it (2)
Also medially - pes anserinus tendons (Sartorius, gracilis, then bursa and semitendinosus)
GOOSES’ FOOT tendinous insertions from anterior to posterior
 Say grace before tea SGBsemiT

Knee joint vascular anastomosis

Popliteal artery – Five genicular arteires
 Superior (medial and lateral)
 Middle
 Inferior (medial and lateral)

Profunda femori – descending branch

Tibia
Anteromedial surface is directly adjacent to skin
Medial condyle
Lateraly condyle
Two articular surfaces bridged by an intra-articular ridge
Tibial tubercle – Anterior and central just below the condyles. Insertion for
quadriceps tendon
Medial malleolus = medial protrusion of ankle joint

Proximal tibiofibular joint = synovial

Distal tibiofibular joint = fibrous
 Anterior and posterior tibiofibular ligament holds together

Fibula
Doesn’t contribute to knee joint
Lateral malleolus is lateral protrusion of ankle joint, meets talus

Proximal tibiofibular joint – Synovial joint

Distal tibiofibular joint – Fibrous joint (not synovial or cartilaginous)

Ankle joint (talocrural joint)

The articulation of the tibia and fibula with the talus
 Tibial body, medial malleolus and lateral malleolus articulate with talus
 Synovial joint

Supports
 Capsular – loose on front and back to allow for dorsi / plantar flexion
 Ligamentous
 Laterally = posterior talofibular ligament + anterior talofibular ligament
 Medially = Deltoid ligament – Attaches over talus, navicular and calcaneus
Calcaneal bone

Sustenaculum tali – Horizontal shelf from the medial side of talus bone
which articulates with the talus and has many ligamentous attachments
 Spring ligament partial attachment
 Deltoid ligament partial attachemnt
 Supports head of the talus

Talus bone
Talus articulates with:
 Tibia
 Fibula
 Navicular
 Calcaneum
 Posterior tibiofibula ligament
 Inferior calcaneonavicular ligament
*Does not articulate with long plantar ligament

Talocalcaneonavicular joint
Two parts
1. Subtalar joints - total of three
facets
1. Talonavicular joint

Subtalar joint – allows inversion and

eversion of the foot
1. Anteriorly is talocalcaneal, has two
facets here
2. Posterior is talocalcanean
Midtarsal joint – not part of the talocalcaneonavicular joint
1. Calcaneocuboid joint – Calcaneus and cuboid bone (laterally)
2. Talonavicular part of the talocalcaneonavicular joint

Ligamentous supports
Medial

Deltoid ligament - Four heads that spread out from medial

malleolus and attach to: Talus, sustenaculum tali, spring
ligament and navicular

Spring ligament (6) – From sustenaculum tali to the navicular

Lateral ligaments
Didn’t learn – too many

Muscles
Muscles of pelvis

Pelvis diaphragm
Coccygeus
 Origin: Coccyx + distal sacrum
 Insertion: Ischial spine
 Action: Vestigial

Levator ani
 Origin: Body of pubis anteriorly, ischial
spine posteriorly, tendinous arch
between the two
 Course: Fibers pass downwards,
backwards, medially to meet in midline of
opposite side
 Continuous with external anal sphincter Urogenital hiatus
on the understide of the muscle
 Tethered to the ano-coccygeal ligament by its posterior fibers

Said to have three heads

 Puborectalis fibers
 Pubococcygeus fibers
 Iliococcygeus fibers are most lateral and thing
Perineum - Bound by coccyx, ischial tuberosities and pubic symphysis

Muscles of pelvic diaphragm from below

Six lateral hip rotators

All muscles which travel obliquely or transversely from the pelvis to the posterior portion of
the femur

Piriformis - 1
 Origin: Anterolateral sacrum between and laterally to
anterior sacral foramina 2-5
 Insertion: Greater trochanter
 Course: Passes out through the greater sciatic foramen.
Has the sciatic nerve running along its inside edge
medially
 Innervation: Nerve to piriformis L5, S1 and S2
 Action: Lateral rotator

Gemellus superior - 2
 Origin: Ischial spine
 Insertion: Greater trochanter + Obturator internus
tendon inferiorly
 Innervation: Nerve to obturator internus

Obturator internus - 3
 Origin: Covering the obturator foramen, originates
from obturator membrane + ilium + ischium
 Insertion: Greater trochanter
 Course: Fans into a single tendon within the pelvic
cavity to then pass 90 degrees around and out
through lesser sciatic foramen
 Action: Laterally rotates femur + abduction
 Covered by a thick layer of fascia – tendinous fascia
 Innervation: Nerve to obturator internus (L5-S2 from
sacral plexus

Tendinous fascia – Sits on top of obturator internus. Has a thickening in the middle arching
from lower part of pubic symphysis to ischial spine called Tendinous arch, which is
important as it joints pubocervical fascia that covers the anterior vaginal wall. If it fails, the
ipsilateral vagina sinks down = incontinence. Levator ani also arises from tendinous arch

Gemellus inferior - 4
 Origin: Tuberosity of the ischium
 Insertion: Greater trochanter + inferior margin of obturator internus tendon
Quadratus femoris - 5
 Origin: Ischial tuberosity
 Insertion: Intertrochanteric crest
 Action: Laterally rotates femur

Gluteus muscles
Gluteus maximus
 Quadrangular shaped muscle
 Origin: Iliac crest + posterior lower sacrum +
tuberosacrous ligament
 Insertion: Upper ¾ inserts into iliotibial tract
posteriorly, to enable it to exert force onto the tibia. Also ¼ into gluteal tuberosity on
femur (below greater trochanter)
 Innervation: Inferior gluteal nerve
 Action: Extension of hip, or when feet are fixed, raises torso upright when bent forward +
lateral rotation of femur

Gluteus medius
 Triangular fan shaped muscle
 Origin: gluteal surface of ilium
 Insertion: Greater trochanter
 Innervation: Superior gluteal nerve
 Action: Hip abduction + medial rotation during flexion + lateral rotation during extension.
Support pelvis when the leg is raised in the air (trendelenburg)

Gluteus minimis
 Triangular shaped
 Origin: External surface of gluteal ilium
 Insertion: Anterior greater trochanter
 Innervation: Superior gluteal nerve
 Action: Hip abduction + medial rotation during flexion + lateral rotation during extension.
Support pelvis when the leg is raised in the air (trendelenburg)

Tensor fascia lata

 Origin: Iliac crest posterior to ASIS
 Insertion: Iliotibial tract
 Action: Stabilises the knee in extension and stabilizes the hip joint
 Innervation: Superior gluteal nerve
Iliotibial tract – runs from tubercle of crest of ilum to tibia, is a lateral thickening of fascia lata
Fascia lata – Fibrous fascia that wraps around all thigh muscles

Iliacus
Origin: Inside wing of ilium
Insertion: Lesser trochanter
Course: Over Pubic ramus but under inguinal ligament, down and backwards
Function: Flexion of hip + bends torso when legs fixed
Innervation: Femoral nerve

Psoas major
Origin: Transverse processes of L1-5 + lateral intervertebral disc of same distribution
Insertion: Lesser trochanter
Course: Over Pubic ramus but under inguinal ligament, with femoral nerve and artery resting
anterior to its tendon
Function: Flexion of hip + bends torso when legs fixed
Innervation: Anterior branches of L1-3 nerve roots (lumbar plexus)

Thigh muscles

Medial compartment of the thigh

Mostly supplied by the obturator nerve (L2-4). Superficial to deep

Obturator externus - 6
 Origin: Obturator membrane + adjoining ischiopubic ramus
 Insertion: intertrochanteric crest
 Course: Runs from anterior pelvis to posterior aspect inserting onto greater trochanter
 Innervation: Posterior obturator
 Function: Lateral rotation of femur + adduction of thigh

Pectineus
 Origin: Superior pubic rami
 Insertion: Medial to adductor brevis, medial x2 to linea aspera
 Sits anterior to all other adductors
 Innervation: Femoral nerve but 20-30% have accessory obturator nerve (passes anterior
to pubic rami, more like accessory femoral nerve)
 Function: adductor

Gracilus
 Origin: From the aponeurosis on lower half of pubic symphysis and the pubic arch
 Insertion: immediately below the medial condyle of the tibia above semitendinosus
 Innervation: Anterior obturator
 Used to be called custodian virginalis – muscle that is active during rape

Adductor longus
 Origin: Body of pubis
 Insertion: Medial to linea aspera, stopping just short of adductor hiatus
 Innervation: Anterior obturator

Adductor brevis
 Origin: Body of pubis
 Insertion: Medial to linea aspera
 Innervation: Anterior obturator

Adductor magnus
Has two heads.

Pubofemoral / adductor portion

 Origin: Ischopubic ramus (outer)
 Insertion: Linea aspera + Adductor tubercle of
femur (medial continuation of linea aspera)
 Innervation: Posterior branch of obturator
nerve

Ischiocondylar / hamstring portion

 Origin: Tuberosity of the ischium
 Insertion: Adductor tubercle
 Innervation: Sciatic / tibial nerve

Has multiple osseoaponeurotic openings as it inserts

onto the femur. The first few are small and transmit
the perforating arteries from profunda femoris. The
last is known as the adductor hiatus, which
transmits the femoral vessels
Posterior compartment of the thigh
Sciatic nerve innervates all + hamstring portion of adductor magnus

Semitendinosus
 Origin: Ischial tuberosity
 Insertion: Medial tibia, posterior to Sartorius and gracilis
 Action: Knee flexion + hip extension (if knee is locked into extension by quadriceps). If
knee locked into flexion, produce medial rotation
 Course: Runs medial in posterior thigh and is most superficial

Semimembranosus
 Origin: Ischial tuberosity
 Insertion: posterior tibia
 Action: Knee flexion + hip extension (if knee is locked into extension by quadriceps). If
knee locked into flexion, produce medial rotation
 Course: Runs medial in posterior thigh and is deep

Biceps femoris
 Origin: Two heads. Long head from ischial tuberosity, short from whole length of linea
aspera + lateral supracondylar line
 Insertion: Head of fibula (wraps from posterolateral to lateral
 Action: Knee flexion + hip extension (if knee is locked into extension by quadriceps). If
knee locked into flexion, produce lateral rotation
 Course: Runs to lateral part of leg
 Innervation: Long head tibial nerve, short head from common fibular nerve

Anterior compartment of the thigh

Supplied by the femoral nerve

Sartorius
 Origin: ASIS
 Insertion: medial aspect of tibia
 Course: Lateral to medial and is most anterior of muscles
 Action: Flexion of hip + lateral rotation

Rectus femoris
 Origin: Two origins – AIIS + anterosuperior acetabulum
 Insertion: Tibial tubercle
 Two tendinous origins: Straight (from AIIS) and reflected (from
acetabulum)

Vastus Intermedius
 Origin: Antero-lateral femur and greater trochanter
 Insertion: Converge onto common quadriceps tendon


Vastuc medialis
 Origin: Medial edge of linea aspera + Intertrochanteric line
 Insertion: Converge onto common quadriceps tendon
 Lowermost fibers are almost horizontal directed laterally, inserting into medial
patella
 Has fleshy fibers extending lower than vastus lateralis

Vastus lateralis
 Origin: lateral edge of linea aspera + intertrochanteric line
 Insertion: Converge onto common quadriceps tendon

*Adductors all insert in the space between the medialis and lateralis muscles posteriorly

Leg muscles

Anterior extensor compartment of the leg

Bound between the interosseous membrane and the and the extensor surface of tibia
medially, + anterior intermuscular septum laterally which connects to fibula
Innervation: Deep fibula nerve. From common fibula (peroneal) nerve – wraps around
lateral head of gastrocnemius, to the neck of the fibula then dives into the gap between
plantaris’ head of attachment and divides

Components of anterior compartment from medial to lateral

The Hamptons Are Never Dull Parties
From medial malleolus
 Tibialis anterior
 Origin: Medial tibia and medial interosseous membrane
 Insertion: 1st cuneiform medially and 1st head of metatarsal medially
 Action: Ankle dorsiflexion + inversion
 Extensor Hallucus longus
 Origin: Medial fibula and interosseous membrane
 Insertion: Dorsal surface, base of distal phalanx, big toe
 Anterior tibial artery + vein
 Nerve (deep peroneal)
 Extensor digitorum longus
 Origin: Lateral condyle of tibia anteriorly, shaft of fibula, superior ¾ of interosseous
membrane
 Insertion: Base of middle + distal phalanges of 2-5 digits, dorsal surface
 Peroneus tertius
 Origin: Distal fibula
 Course: Under extensor retinaculum
 Insertion: Base of 5th metatarsal dorsal surface
 Action: Eversion + helps dorsiflexion
Lateral everter compartment of the leg
 Peroneus longus
 Origin: Proximal half fibula, up to head with a gap just below head
 Insertion: insert into base of first metatarsal plantar surface + medial
cuneiform
 Has deep peroneal nerve running between head and shaft of fibula
 Course: Under perineus retinaculum, posterior to brevis then under sole of
foot
 Peroneus brevis (deep)
 Origin: Distal half fibula
 Course: Pass under perineus retinaculum, anterior to longus
 Insertion; Base of 5th metatarsal plantar surface

Note: Peroneus tertius is part of anterior compartment

Superficial posterior flexor compartment of the leg – 3 muscles

GSP
 ‘Gastrocnemius – two heads
 Medial origin – Just above medial condyle and a little higher on femoral shaft
 Bursa between medial head and knee capsule, which communicates with the joint
and may also communicate with semimembranosus bursa
 Lateral origin – Just above lateral condyle
 Bursa between lateral head a knee capsule, may or may not communicate with joint
 Insertion – Achilles ligament on calcaneal tuberosity
 Action: Bursting power for plantarflexion. Works best when a flexed knee is extended,
because soleus overcomes inertia of the body weight, then gastrocnemius greatly
increases speed of movement above and beyond
 Soleus
 Origin - Soleal line (posterior head + superior posterior body of fibula) and middle
third of medial tibia
 Insertion – Achilles ligament
 Action – Anti-gravity plantarflexion muscle. Slow activation
but constant, forceful contraction.
 Has a fibrous arch between fibia and tibial origins for the
popliteal vessels
 Plantaris
 Origin - Lateral supracondylar line of femur + oblique
popliteal ligament
 Insertion – into achilles tendon
 Action: Assists gastroc in plantarflexion
 Vestigial muscle, similar to palmaris longus in the hand
  Long and tendinous, looks like a nerve and commonly misidentified!

Deep posterior flexor compartment – 4 muscles

PTH-D
 Popliteus
 Origin: Posterior superior body of tibia
 Insertion: Anterior notch on the lateral epicondyle of femur
 Action: Laterally rotates the femur unlocking the knee joint
 Tibialis posterior – deepest muscle!
 Origin: posterior tibia, fibula and interosseous
membrane
 Course: behind medial malleolus, through flexor
retinaculum
 Insertion: Fan shaped. navicular, 1st cuneiform, base
of 2-4th metatarsals plantar surface
 Action: Inverts and plantarflexes the foot. Maintains
medial arch
 Innervation: Tibial nerve
 Flexor digitorum longus – smaller than flexor hallucus longus! Found medial posterior leg
 Origin: Posterior Medial surface of tibia
 Insertion: Base of distal phalanx for lateral 4 digits
 Action: Flexes the lateral 4 toes
 Innervation: Tibial nerve
 Flexor hallucis longus – found lateral posterior leg (despite acting on the toe!)
 Origin: Posterior fibula
 Insertion: plantar surface base of distal phalanx of great toe
 Action: Flexes big toe
 Innervation: Tibial nerve
 Comments:
 Passes deep to flexor digitorum longus in second layer of sole of foot
 Does not groove the medial malleolus – use mnemonic Tom Dick and Very Nervous
Harry (halluces longus is most posterior in flexor retinaculum, away from
malleolus)
 Grooves the posterior aspect of the talus

Foot muscles

First layer
Abductor hallucis
 Origin: Tuberosity of calcaneus
 Insertion: Medial base 1st phalanx of big toe
 Innervation: Medial plantar nerve
Flexor digitorum brevis
 Origin: Calcaneus
 Insertion: Base of middle phalanges of toes 2-5
 Split to allow FDL to perforate. Have decussating fibers deep (see picture)
 Innervation: Medial plantar nerve

Abductor digiti minimi (foot)

 Origin: Tuberosity of calcaneus
 Insertion: Lateral side of base of 5th proximal phalanx
 Innervation: Lateral plantar nerve

Second layer
Tendon of flexor digitorum longus (from posterior deep
compartment)
 Origin: Middle half of posterior tibia
 Insertion: Base of distal phalanx digits 2-5
 Innervation: Tibial nerve
 Comments:
 Receives flexor accessorius, responsible for pulling FDL
tendon laterally to ensure tendon pulls straight. Innervated by
lateral plantar nerve
Flexor
 Gives off lumbricals like in hand Accessorius
 Receives two slips from flexor hallucis longus

Tendon of flexor hallucis longus FHL

 Origin: Posterior fibula
 Insertion: plantar surface base of distal phalanx of great toe
 Action: Flexes big toe
 Innervation: Tibial nerve

Flexor accessories
Lateral plantar artery superficial to flexor accessorius
Medial plantar artery

Third layer

Flexor hallucis brevis

Two heads, one is more medial, other lateral
 Origin: Cuboid, lateral cuneiform and medial
side of first metatarsal
 Insertion: Medial and lateral sides of
proximal phalanx of big toe
 Innervation: Medial plantar nerve
 Often has a sesamoid bone appearing in it on
X-ray
Adductor hallucis
Origin: Base of metatarsals 2-5 (via two heads)
Insertion: Lateral side of base of proximal phalanx
Innervation: Lateral planter nerve deep branch

Flexor digiti minimi brevis

All the ligaments mentioned in picture (never learnt)

Fourth layer
Muscles described earlier
Tibialis anterior tendon

Fibularis longus tendon

Tibialis posterior tendon

Interossei
 Much like with hand, PAD DAB – plantar
adduct, dorsal abduct
 The axis is shifted to second metatarsal
(rather than middle finger)
 Planter interosseus arises from the
metatarsal bone of its own toe
 Adduct towards second toe
 Big toe has its own – adductor halluces
oblique+transverse heads
 Each insert into the tibial sides at base of proximal
phalange
 Run dorsal to the deep transverse ligament of the
metatarsal heads
 Dorsal interosseus arises from two heads from the two
metatarsals between which it lies
 Each digit gets abducted away from second toe
 First interosseus inserts into big toe side of second digit
 Second-fourth insert into the little toe side of their digits
 Insert into proximal phalange, gives an extension to dorsal
extensor expansion
 Big and little toe have their own abducting muscles

*All interossei are supplied by the lateral planter nerve

-Those of the fourth space are supplied by superficial branch,
rest deep branch
Fascia

Fascial compartments of the leg

Four compartments separated by fascia
 Interosseous membrane between tibia and fibula
 Anterior intermuscular septum – separates anterior from lateral compartment,
connects from fibula to fascia lata
 Transverse intermuscular septum (deep transverse fascia) – Between the superficial
and deep posterior compartments, connected at the tibia and fibula on each side
 Continuous with flexor retinaculum
 Posterior intermuscular septum – Connects from fibula to
fascia lata and transverse intermuscular septum

A = Anterior compartment
B = Lateral (peroneal) compartment
C = Deep posterior
I = Superficial posterior

Compartment syndrome
Two incisions made:
1. Posteromedial incision – behind the superficially places
tibia, starting in the superficial posterior and
extending to deep posterior (red line)
2. Anterolateral incision – Lateral to the
anterior border of tibia, extending laterally to
the lateral compartment

Fascial compartments of the foot

Flexor retinaculum
 Tip of medial malleolus to medial calcaneal process
 Continuous with deep fascia above
 Continuous with plantar aponeurosis below + fibers
of abductor halluces muscles below

Order of tendons from anterior to posterior “Tom Dick

and Very Nervous Harry
 Tibialis posterior
 Flexor digitorum longus
 Artery, vein, nerve
 Flexor hallucis longus

Extensor retinaculum
Superior extensor retinaculum– formed by transverse
crural ligament, thickening of the deep fascia which does
not encircle the leg inferiorly, but instead attaches to the
subcutaneous border of the fibula above the
lateral malleolus.
-Tibialis anterior pierces the inferior section of
this superior extensor retinaculum!

Inferior extensor retinaculum

 Arises from the anterior upper calcaneal
tendon on the lateral border of dorsum of
the foot
 Stem diverges into two limbs with two
attachments
 Upper limb = medial malleolus
 Lower limb = Blends with plantar aponeurosis3

Order from medial to lateral of tendons in the extensor retinaculum “Timothy has a very
nasty diseased foot
 Tibialis anterior
 Extensor hallucus longus
 Artery (anterior tibial), vein, nerve (deep peroneal)
 Extensor digitorum
 Fibularis tertius (peroneus tertius)

Superior peroneal retinacula - Lateral malleolus to lateral superior calcaneum

Inferior peroneal retinacula -
Longus is more lateral, surprisingly

Anatomical areas

Greater sciatic foramen

Formed between the greater sciatic notch of the ilium and the sacrotuberous + sacrospinous
ligaments. Most of volume is filled with piriformis muscle

Superior to piriformis
 Superior gluteal vessels and superior gluteal nerve (L4-S1
Inferior to piriformis
 Inferior gluteal vessels
 Internal pudendal artery
 Inferior gluteal nerve
 Pudendal nerve
 Sciatic nerve
 Posterior femoral cutaneous nerve
 Nerve to quadratus internus
 Nerve to quadratus femorus

PIN and PINS mneumonic for remembering all below piriformis muscle
Posterior femoral cutaneous nerve, Inferior gluteal vessels, nerve to quadratus femorus,
pudendal nerve, internal pudendal artery, nerve to quadratus internus, sciatic nerve

Lesser sciatic foramen

Formed from the lesser sciatic notch, sacrospinous ligament and sacrotuberous ligament
Contents
 Pudendal nerve
 Internal pudendal vessels
 Nerve to obturator internus
 Tendon of obturator internus
PINT

Inguinal triangle (Of hasselbach)

 Inferior: Inguinal ligament
 Medial: Lateral margin of rectus sheath (linea semilunaris)
 Lateral: Inferior epigastric
 Significance: Location of direct inguinal hernias as posterior canal only has transversalis
fascia

Femoral triangle (of scarpa)

 Seen when the femur is abducted, flexed and
medially rotated
 Superior border = inguinal ligament
 Medial = adductor longus
 Lateral = sartorius
 Floor = Iliopsoas laterally, adductor longus and
pectineus medially
 Contents (M to L)
 Femoral sheath, femoral vein + tributaries
great saphenous and deep femoral, femoral
artery
 Femoral nerve
 Deep inguinal lymph nodes
Femoral sheath / ring / canal
 Continuation of transversalis fascia anteriorly and iliacus fascia posteriorly that enters
into thigh under inguinal ligament
 Femoral nerve does not travel inside it, as it arises from lumbar plexus posterior to psoas
fascia
 Femoral canal is a small area medial to the femoral
vein, lateral to lacunar ligament that transmits
lymphatics from cloquets canal and provides space
for expansion of femoral vein
 Location of femoral hernia

NAVEL from lateral to medial

Nerve, artery, vein, empty, lympatics

Saphenous opening / foramen ovalis

A defect in the femoral sheath that allows the greater saphenous vein to drain into the femoral
vein. It is loosely covered by the cribiform fascia, which has many openings (like a sieve)

Adductor canal (Hunter’s canal, subsartorial canal)

 Found between vastus medialis and adductor longus + magnus. Extends from the apex of
the femoral triangle to the adductor hiatus
 Lateral: Adductor longus + magnus more inferiorly
 Medial: Vastus medialis
 Roof / Anterior: Sartorius muscle and subsartorial
plexus of nerves: Anterior branch of obturator,
medial cutaneous nerve of the thigh (from femoral)
and saphenous nerve.
 Contents: Femoral artery, vein, saphenous nerve
and nerve to vastus medialis
 Become popliteral artery and vein when they
exit adductor hiatus
 Artery always between femoral vein and
saphenous nerve
 Vein starts medial and spirals posteriorly down along the canal

Popliteal fossa
Diamond shaped
 Upper medial SemiTendinosus
 Upper lateral = Biceps femoris
 Lower medial + lateral = heads of gastroc
 Roof posteriorly: Fascia lata
 Floor: Femur, condyles, capsule, popliteus muscle
 Contents: Medial to lateral: Pop art (more ant), vein (posterior), tibial nerve (lateral),
more lateral wrapping around fibula head = peroneal nerve
 Exiting the popliteal fossa: Sural nerve and sural communicating nerve
 Entering = short saphenous vein and posterior femoral cutaneous nerve of the thigh
Popliteal artery: Starts medial to tibial nerve, ends lateral and pierces soleus to divide. 8
inches long. Vein runs between artery and nerve always

Dissected specimen quiz of popliteal fossa

47=Sartorius tendon
48=Gracilis tendon
49=Semtendinosis
50=Medial head of gastrocnemius
52=Lateral head of gastrocnemius
54=Semimembranosus
55 = Common peroneal nerve
56 = Tibial nerve
57 = Lateral cutaneous nerve of the calf
58 = Sural nerve + short saphenous vein
59 = Great saphenous vein
Arteries
Brief summer of external iliac
Deep circumflex iliac artery
Inferior epigastric artery – anastomosis with superior
epigastric artery from internal thoracic artery
Femoral artery is terminal branch

Femoral artery – three small branches immediately as it

passes under inguinal ligament followed by one larger
branch. Then continues down under sartorius muscle /
adductor canal through adductor hiatus

Superficial branches
 Superficial circumflex iliac artery – Pierces fascia lata
lateral to saphenous opening, passes below inguinal
ligament to anastamose at ASIS
 Superficial epigastric artery – Emerges through saphenous opening, over inguinal
ligament to supply umbilicus
 Superficial external pudendal artery – through saphenous opening then medially in
front of spermatic cord to supply skin of scrotum

Deep femoral artery (profunda femoris) – supplies most of the proximal thigh. Gives off
two branches immediately, medial+lateral circumflex
 Runs anteriorly to adductor brevis and magnus (?but posterior to adductor longus)
 Four perforating branches through adductors to supply posterior thigh muscles
 First goes above adductor brevis and sends a branch to cruciate anastamosis
 Second goes through adductor brevis
 Third and fourth go below adductor brevis

Medial circumflex femoral artery

 Most important for blood supply to weight bearing portion of femoral head
 Course: Often arises above (and medial) to the lateral circumflex. Passes backwards
between pectineus and psoas tendon. Two branches
 Ascending branch: trochanteric anastomosis
 Transverse branch: Cruciate anastamosis

Lateral circumflex femoral artery – this splits the femoral nerve.

 Course: Passes between branches of femoral nerve and passes from femoral triangle to lie
under rectus femoris. Breaks up into three branches
 Ascending branch: Runs up vastus lateralis where it gives a branch to the trochanteric
anastomosis. Passes towards ASIS and anastomoses with superficial and deep circumflex
iliac arteries, superior branch of superior gluteal artery and an iliac branch of the
iliolumbar artery
 Transverse branch: Passes over vastus lateralis and winds around femur to form a branch
of the cruciate anastomosis
 Desending branch: Slopes down in the groove between vastus lateralis and intermedius
and anastomosis around the knee

Anastomosis at hip joint

 Three arteries come from profunda femoris: Medial + lateral circumflex femoral arteries +
ascending branch of first perforator
 Medial + lateral circumflex both contribute an ascending and a transverse branch to
the trochanteric and cruciate anastomosis respectively
 Ascending profunda branch to cruciate anastomosis only
 *Two from inferior gluteal – one to each anastomosis
 *One from superior gluteal – trochanteric anastomosis only

1. Trochanteric anastomosis – at greater trochanter

a. Ascending branches from medial and lateral circumflex femoral artery
b. Branch from inferior gluteal artery
c. Descending branch from superior gluteal artery
2. Cruciate anastomosis – at lesser trochanter
a. Transverse branches of medial and lateral circumflex femoral artery
b. Branch of inferior gluteal artery
c. Ascending branch of the 1st perforating artery

Upper anastomosis does not receive branch form lowest artery

Lower anastomosis does not receive branch from highest artery
I.E the trochanteric anastomosis doesn’t get a branch from the perforator of profunda
femoris. The cruciate anastomosis doesn’t get a branch from the superior gluteal
Blood supply to the head of femur
Arises from the trochanteric anastomosis – ascending Epiphyseal branches
from medial + lateral circumflex femoral, superior fibers Retinacular
gluteal and inferior gluteal. Medial circumflex fibers
Extracapsular
femoral provides the greatest contribution anastomosis

MCFA
1. Trochanteric anastomosis
2. Extracapsular anastomosis
3. Retinacular fibers
4. Epiphyseal fibers
Medial circumflex femoral is most important
contributor

Obturator artery
Emerging from the obturator foramen
 Divides to medial and lateral branches that encircle obturator externus and anastomose
with each other + medial circumflex femoral artery
 The lateral branch sends a twig to the acetabulum, which passes through the
acetabular notch


Popliteal artery
 8 inches long
 In the adductor canal, the artery is
anterior and lateral to vein
 In the popliteal fossa, the artery
crosses over vein anteriorly to lie
medial. The nerve is lateral, the vein is
between the two
 Passes through a hole in the insertion
of soleus

Branches of popliteal
 Anterior tibial
 Fibular (peroneal)
 Posterior tibial

Anterior tibial artery

 Passes through to anterior compartment via the interosseous membrane
 Runs between tibialis anterior (medially) and
extensor digitorum longus (laterally)
 Extensor hallucus longus crosses over it
 Gives off anterior medial and anterior lateral
malleolar branches
 Becomes the dorsalid pedis artery after it
gives off its malleolar branches and passes under
extensor retinaculum
 Gives off medial and lateral tarsal arteries to
anastomose around tarsal bones
 Branch to 1st dorsal metatarsal
 Continues as the arcuate artery, which gives
branches to dorsal metatarsals 2-5
*Can be likened to the radial artery in the hand– Anterior tibial artery
dorsal surface artery)
*Can be palpated between extensor hallucis longus and extensor digitorum longus

Posterior tibial artery

 Tibial nerve runs posterior to it and crosses over it
 Runs deep to soleus, between tendons for
FDL and FHL
 Gives off a calcaneal branch prior to flexor
retinaculum
 Goes under flexor retinaculum
 Gives off medial and lateral plantar branches
 Gives off
 Medial plantar artery
 Lateral plantar artery (bigger)

Medial plantar artery

Sends a branch to 1st toe
Doesn’t anastomose with the plantar arch

Lateral plantar artery

 Lies superficial to flexor accessorius
Posterior tibial artery
 Passes obliquely forward and lateral to 5th
metatarsal
 Then turns medial and completes the Plantar arch anastomosing with the arcuate artery
(deep plantar) from dorsalid pedis artery

Peroneal (fibular) artery

 Arises at the bifurcation of the tibio-fibular trunk (whereas some sources say that it is
simply a branch off the posterior tibia
 Runs in posterior compartment, medial to fibula
 Sends communicating branch to anterior tibial artery
 Provides nutrient artery to the fibula
 Supplies the evertor (lateral) compartment

Veins
Great saphenous vein
 Begins as continuation of medial marginal vein of the foot (from dorsal venous arch)
 Anterior to medial malleolus
 Is always superficial to deep fascia of the leg – runs in fat.
 Runs up medial border of tibia, posterior to sartorious,
running with saphenous nerve below knee level
 Communicates extensively with the lesser saphenous vein,
particularly at the knee with a named vein “Boyd
perforator” and in the thigh “Dodd perforator”
 Enters through cribriform fascia of saphenous opening (aka
fossa ovalis), 3.5cm below and lateral to pubic tubercle
 Up to four tributaries drain into the vein before it enters the
femoral vein:
 Superficial external pudendal – receives the superficial
dorsal vein of the penis
 Deep external pudendal
 Superficial circumflex iliac artery
 Superficial epigastric
 Superficial external pudendal artery may run over the top of
the greater saphenous veins
 Has multiple perforating branches that run from greater saphenous into the deep veins of
the calf. One below medial mal, one above and one 10cm above

Lesser (short) saphenous vein

 Drains from the lateral side of the dorsal venous arch
 Lies behind the lateral malleolus and runs with the sural nerve
 Passes up midline of calf and pierces deep fascia anywhere from midcalf to the roof of the
popliteal fossa
 Communicates with the great saphenous vein

Deep veins
Accompany the arteries and are named as such. All drain into popliteal vein
 Anterior tibial vein
 Posterior tibial vein
 Fibular (peroneal) vein
Nerves

Lumbar plexus
Located within the substance of psoas major muscle
Originates from L1-L4 with contribution from T12
*The ventral rami form anterior and posterior divisions for flexor and extensor compartments
respectively

I (twice) Get Laid On Fridays

2 from 1 2 from 2 2 from 3
Two nerves come from one nerve root
Two nerves come from two nerve roots
Two nerves come from three nerve roots

*All nerves except genitofemoral, obturator

and lumbosacral trunk arise lateral to
psoas major
-Genitofemoral emerges anterior to psoas
-Obturator emerges medial to psoas major
-Lumbosacral trunk emerges medial to psoas
major to join sacral plexus
*Occasionally, additional accessory obturator
nerve from L3-4 which supplies pectineus
*The very base of the lumbar plexus is the lumbosacral trunk,
from L4/L5

More detail..
Iliohypogastric nerve (L1)
 Course: Runs over top of quadratus lumborum to iliac crest
 Pierces transversus abdominis and runs under internal
oblique
 Sends off an ilioinguinal nerve.
 Innervates: Internal oblique and transversus abdominis.
Sensory: Posterolateral gluteal skin and pubic region

Ilioinguinal nerve
 Course: Follows same course and function initially as iliohypogastric nerve. Pierces
internal oblique to join into the inguinal canal between internal oblique and external
oblique.
 Innervates: Transversus abdominis, internal oblique and combined the conjoint tendon.
 Here it helps contract the conjoint tendon, severing it leads to a direct inguinal hernia.
 Purely sensory when it enters into inguinal canal. Become s anterior scrotal nerve
supplying anterior 1/3 of scrotum and supplied upper medial thigh
Genitofemoral nerve L1-2
Two branches
 Genital branch – passes through deep inguinal ring into the inguinal canal and supplies the
cremaster muscle
 Femoral branch – Passes under inguinal ligament adjacent to the artery and supplies
upper anterior skin of thigh, for the sensation of the cremaster reflex
 Femoral branch is afferent, genital branch is efferent for cremaster
reflex

Lateral cutaneous nerve (of the thigh) L2-3, considered an extensor

compartment muscle
 responsible for myralgia paraesthetica

Obturator nerve
Course: From lumbar plexus, appears medial to the psoas major tendon and
on top of the sacral ala (medial to SIJ joint), to then move directly to the obturator canal where
it divides

Posterior obturator nerve

 Supplies obturator externus then pierces it along
its upper border
 Runs on the anterior side of adductor magnus and
supplies its pubic part (ischial side is supplied by
sciatic nerve)
 Sends off a fine branch to joint the femoral nerve
which supplies the knee joint

Anterior obturator nerve

 Passes over the top of obturator externus
 Supplies the hip joint
 Runs anterior to adductor brevis but deep to
adductor longus and pectineus. Supplies adductor
brevis, longus, gracilis.
 Sends a cutaneous branch to supply medial thigh

Femoral nerve
*L2-4 Extensor compartment, therefore posterior divisions

Course:
 From lumbar plexus posterior division, emerges laterally to psoas
 Gives twigs to iliacus
 Goes under inguinal ligament, lateral to femoral sheath and into femoral triangle. Is deep
to psoas fascia
 Provides articular branches to knee and hip joint
 Branches begins around the lateral circumflex femoral artery

Deep branch of femoral nerve – Runs from lateral to medial

down the adductor canal in front of the femoral artery.
 Becomes the saphenous nerve after it gives off its twig to
vastus medialis in the lower 2/3 of adductor canal
 Gives an infrapatella branch then pierces fascia lata in medial
knee between tendons of sartorious and gracilis
 Innervates:
 Hip joint
 Quadriceps (all)
 Knee
 Saphenous nerve - Continuation of femoral vein after vastus
medialis twig given, Runs with great saphenous vein,
beginning behind sartorious in medial knee.
 Gives off a infrapatellar branch which pierces fascia lata and supplies infront of patella
 Continues down and supplies skin to the medial calf (known as medial crural
cutaneous branches)
Superficial branch of femoral nerve – Innervates pectineus and Sartorius and divides into
two branches which are collectively known as the anterior cutaneous nerve of the
thigh:
 Medial cutaneous nerve of thigh
 Intermediate cutaneous nerve of the thigh – pierces fascia lata 7.5cm below inguinal
ligament.
*Medial cutaneous nerve of the thigh, intermediate cutaneous nerve of the thigh and the
infrapatella branch of the saphenous nerve all communicate to form patella plexus supplying
skin over the patella

Sacral plexus
Arises anterior to the piriformis muscle but beneath the
sacral fascia
Originates from L4-S4

Six nerves that start with P arise from the roots

1. Posterior femoral cutaneous nerve (S1-3)
2. Perforationg cutaneous nerve of the thigh (S2-3)
3. Pudendal nerve (S2-4)
4. Nerve to piriformis (S1-2)
5. Perineal branch of S4 (to levator ani) – see pelvis
notes
6. Pelvic splanchnics (S2-4) – parasympathetics for
bladder, hind gut. Sensation for bladder, lower
uterus, lower colon and rectum
Three nerves arise from the anterior division
 Nerve to quadratus femoris (L4,5,S1)
 Nerve to obturator internus (L5,S1-2) – paradoxically arises lower in plexus than
quadratus femoris
 Tibial portion of sciatic nerve (L4-S3)

Three nerves arise from the posterior division

 Superior gluteal (L4,5,S1)
 Inferior gluteal (L5,S1-2)
 Common peroneal nerve (L4-S2)

Posterior femoral cutaneous nerve

 Emerges from the roots of S1-3
 Exits out of greater sciatic foramen below piriformis, lying superficial to the sciatic nerve
 Descends in the midline of the back of the thigh, superficial to the hamstrings but deep to
fascia lata, ending mid-way between knee and ankle over the heads of gastrocnemius
 Two branches
 Gluteal branches – Curles around lower border of gluteus maximum, supplies skin over
convexity of the gluteal region
 Perineal branch – winds medially and forward between fascia lata and gracilis to
supply posterior portion of scrotum or labium majus
 Clinical – as it arises from some of the same roots with pelvic splanchnics (S2-3), pelvic
disease can be referred along the skin of posterior thigh

Sciatic nerve (L4-S3)

*Supplied by blood from inferior gluteal. Has the ‘accompanying artery of the ischiadic
nerve’ running with it for a short distance then piercing it and supplying it internally (like the
central retinal artery does for the optic nerve)
Course
 Emerges from greater sciatic foramen below piriformis.
 Runs on top of superior/inferior gamellus, obturator internus tendon, quadratus femorus
and adductor magnus. Runs deep to biceps femoris
 Has the posterior femoral cutaneous nerve superficial to it
 Has the nerve to obturator internus deep to it
 Innervates: All hamstring from tibial portion, except short head biceps femoris from
peroneal portion. Also supplies hamstring portion of adductor
magnus

Tibial nerve–
Branches in the popliteal fossa
 Three genicular nerves – Upper medial, lower medial and middle to
supply knee joint – accompany the arteries
 Superficial posterior compartment: Gastrocnemius, Soleus,
plantaris
 Sural nerve – Formed from tibial nerve with a commuinicating branch from the peroneal
nerve.
 Runs in the groove between two heads of gastrocnemius
 Runs with the short saphenous vein
 Passes behind lateral malleolus to end at lateral side of little
toe.

In the leg: Plantar compartment

Motor:
 Deep posterior compartment: Flexor hallcus longus, flexor
digitorum longus, tibialis posterior, popliteus.

In the foot
 Medial plantar nerve– Medial toe muscles (Abductor halluces, flexor digitorum brevis,
flexor halluces brevis first lumbrical) + medial plantar surface of foot
 Can be likened to the median nerve of hand
 Passes between flexor digitorum brevis and adductor hallucis
 Lateral plantar – Lateral toe muscles
 Can be likened to ulnar nerve
 Medial calcaneal nerve – sensory to plantar surface of heel

Common peroneal –
Course
 Enters the apex of the popliteal fossa
 Moves laterally, lying on top of fat the popliteal fossa, crossing over: Plantaris, lateral head
of gastrocnemius, tendon of popliteus inside the knee capsule and fibular origin of soleus.
 Wraps around head of fibula then sinks into peroneus longus to run in what is known as
the peroneal tunnel. Emerges from peroneal tunnel then divides
Branches
 Upper and lower lateral genicular nerves – supply knee joint
 Peroneal lateral communicating nerve – joins sural nerve below gastrocnemius heads
 Lateral cutaneous nerve of the calf – Given off in lateral popliteal fossa. Supplies upper half
of lateral calf peroneal compartment.

Terminal divisions
 Deep peroneal – anterior compartment of leg
 Runs deep to extensor digitorum longus to lie on interosseous membrane
 Runs lateral to the vessels
 Tibialis anterior, extensor hallus longus, extensor digitorum longus, extensor hallus
brevis
 Superficial peroneal – lateral compartment of leg (everters)
 Peroneus longus and peroneus brevis
 Skin over antero-lateral aspect of leg and dorsal surface of foot (minus 1st web space)
Cutaneous sensation over leg

Pink upper thigh = lumbar plexus lateral femoral

cutaneous nerve of the thigh

Yellow in thigh = femoral nerve, anterior cutaneous nerve

of the thigh (combination of medial and intermediate
cutaneous femoral nerves)

Green in thigh = sacral plexus, posterior femoral

cutaneous nerve

Below knee

Medial calf = saphenous

Lateral calf and foot = Sural
Anterior calf + foot + medial foot = Superficial peroneal
Heel = Tibial
1st web space = Deep peroneal

Sole of foot
Heel = tibial’s medial calcaneal
Medial = Tibial’s medial plantar
Lateral = Tibial’s lateral plantar

Areas to remember
Thigh = 3 nerves, PCNT, LCNT, femoral’s ACNT
Calf = 4 nerves. Sural, saphenous, common peroneal +
superficial peroneal
Foot = 6 nerves. Medial calcaneal + medial and lateral
plantar nerves (from tibial), sural (peroneal and tibial), sup
and deep peroneal (common peroneal)

Repeatedly examined GSSE dermatomal segment

L4 nerve root ventral rami
 Extends over medial calf and medial big toe
 Skin over medial malleolus
 Does not involve the 1st and 2nd webspace (L5 does)
 Dorsiflexes ankle joint
 Invert the foot
 do not flex the knee joint

S4 = lateral malleolus

Better way to remember lower limb

dermatomes = look at bent over human
Muscle attachment groups
ASIS
 Sartorius - apex
 Iliacus - medial
 Tensor fascia latae – lateral

AIIS
 Rectus femoris
 Iliofemoral ligament

Ischial tuberosity
All hamstrings + adductor magnus hamstring portion
 membranosis, tendinosis, biceps femoris (short head comes from linea aspera)
 Adductor magnus

Adductor origins
Longus = Superior pubic ramus + body of pubis below pubic crest
Brevis = inferior pubic ramis
Gracilis – pubic symphysis
Pectineal line – Pectineus
ishiopubic ramus – Magnus

Greater trochanter
 Gluteus maximus, medius, minimis
 Obturator internus and externus
 Superior and inferior gemellae
 Piriformis
 Vastus intermedius

Lesser trochanter
 Psoas major
 Iliacus
 Upper part of adductor magnus

Linea aspera
 Vastus medialis and lateralis
 All adductors between the medialis and lateralis insertions
 Short head of biceps femoris

Intertrochanteric crest
Quadratus femoris

Intertrochanteric line (spiral line)

 Capsule of hip joint
 Vastus lateralis – upper half
 Vastus medialis

Medial cuneiform
 tibialis anterior
 Tibialis posterior - also base of 1st metatarsal
 Peroneus longus - also base of 1st metatarsal

Proximal phalanx of great toe

 Dorsally: Extensor hallucis longus, extensor digitorum brevis
 Medially: Abductor hallucis, Adductor hallucis two heads plantar


Clinical
 Inguinal hernias are always more common than
femoral
 Females are more likely to get a femoral hernia than a
male, but still more likely to get an inguinal hernia
than a femoral
 Richter type hernia is when only part of the intestinal circumference is within the hernia
sac, so no obstruction but more likely to get strangulation. Associated with femoral
hernias
 Inguinal hernias are more prone to recurrence than are femoral hernias
 Inguinal hernias are more likely to be indirect than a direct
 If the inguinal hernia extends into the scrotum, it is going to be an indirect hernia with the
sac anterior to the spermatic cord, as direct hernias don’t make it through the scrotal neck
(typically)

Myotomes of lower limb

 Hip
 Flex: L2,3
 Extension: L4,5
 Knee
  Extend: 3,4
 Flex: 5,1
 Ankle