Fascia of the thigh

1. The superficial fascia:

- It is formed of two layers: superficial fatty layer and deep membranous layer.
- Both layers are continuous above with the corresponding layers of the anterior
abdominal wall.
- The deep membranous layer is firmly attached to the deep fascia of the thigh
along a line one inch below the inguinal ligament
2. The deep fascia (fascia lata) (Fig. 1):
- It extends from the root of the limb (above) to the bony prominences around
the knee (below).
- It is shows two important features:
a. It is thickened laterally to form the ilio-tibial tract.
b. It contains the saphenous opening anteriorly
c. It gives 3 intramuscular septa

Figure (1): Fascia lata

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 Iliotibial tract (Fig. 2)
Definition: It is a thickened band of fascia lata (1-2 inches) on the lateral aspect
of the thigh.
Attachment:
- Above: tubercle of the iliac crest
- Below: Lateral border of patella and the lateral condyle of tibiaStructures
attached to the iliotibial tract:
- Tensor fasciae latae: into its anterior border.
- Superficial 3/4 of gluteus maximus: into its posterior border.
The Saphenous opening (Fig. 3)
Definition: It is an It is an oval opening in the fascia lata in the upper part of the
front of the thigh
Site: Three cm below and lateral to the pubic tubercle
Size: 3 cmx 1.5 cm
Overlying fascia: It is closed by a thin layer of fascia called cribriform plate
fascia

Figure (2): Iliotibil tract Figure (3): Saphenous opening

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 Compartments of the thigh (Fig. 4)
- The thigh is divided into three compartments by three intermuscular septa
- extend from the deep surface of the fascia lata to the linea aspera
- The three compartment are:
Anterior Medial Posterior
compartment compartment compartment
Group of It contains the It contains the It contains the
muscles extensors of the adductors of the flexors of the
knee thigh knee
Nerve supply femoral nerve Mainly obturator sciatic nerve
nerve

Figure (4): Compartments of the thigh

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 Muscles of the front of the thigh
A. Muscles of iliac region
[Link] major (Fig. 5):
Origin:
- From sides of bodies of last thoracic and all lumbar vertebrae
- Inter vertebral discs
Insertion:
- It leaves the abdomen deep to the inguinal ligament
- Together with the iliacus they form the iliopsoas tendon, which is inserted into
the lesser trochanter of femur.
Nerve supply:
Lumbar nerves (L1, 2, 3) in the abdomen.
B. Iliacus (Fig. 5):
Origin:
From the iliac fossa and adjoining part of ala of the scacrum
Insertion:
Through the tendon of psoas major, into the lesser trochanter of femur
Nerve supply:
Femoral nerve
Action of iliopsoas:
- Acting from its origin: flexion .
- Acting from its insertion:
• Both iliopsoas: flexion of the vertebral column as in raising from the
recumbent position.
• One iliopsoas: lateral flexion of vertebral column.

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 Muscles of anterior compartment of the thigh
[Link] (Fig. 6) :
It is the longest muscle in the body having parallel fibers (strap muscle).
Origin:
Anterior superior iliac spine
Insertion:
Upper part of the medial surface of the shaft of tibia (in front of the insertion of gracilis and
semitendinosus (SGS).)
Nerve supply:
Femoral nerve
Action:
1- Flexion, abduction and lateral rotation of the hip.
2- Flexion and medial rotation of the knee (Tailor’s leg position).
3- Steady the pelvis on the femur (together with the guy rope muscles: gracilis
and semitendinosus).

Figure (6): attachment of Sartorius muscle 5

 Quadriceps femoris

Figure (7): The four heads of quadriceps femoris muscle

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Origin: four parts of quadriceps femoris
1. Rectus femoris:
It arises by two heads:
- Straight head: from the anterior inferior iliac spine.
- Reflected head: from a depression just above the acetabulum
-

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2. Vastus lateralis :
Lateral lip of linea aspera + some extensions up and down (up to the base of
greater trochanter .
3. Vastus medialis:
Medial lip of linea aspera + some extensions up and down (up to the lower end of
intertrochanteric line and down to the medial supracondylar line).
4. Vastus intermedius:
From the upper 2/3 anterior and lateral surfaces of the femur.

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Insertion:
The four heads unite to form a single tendon, which is inserted into:
- Base of patella.(sesamoid bone)
- Tuberosity of tibia through ligamentum patellae.

Figure (9): Insertion of quadriceps femoris muscle

Nerve supply:
Femoral nerve; each head separate branch
Action:
1. Main extensor of knee joint
2. Rectus femoris helps flexion of hip joint
3. Lower part of vastus medialis is inserted in the medial border of patella to
prevent its lateral dislocation by the action of the iliotibial tract

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 Muscles of medial compartment of the thigh
General remarks (Fig. 10):
- They are five muscles; gracilis is the most medial muscle. It forms V-shaped
interval with the shaft of the femur.
- The other four muscles fill the V-shaped interval in three layers:
a. Anterior layer: contains adductor longus and pectineus
b. Middle layer: contains of adductor brevis
c. Posterior layer: contains adductor magnus
- All are inserted into the back of the femur except gracilis in the tibia
- All are supplied by obturator nerve except pectineus by femoral nerve
And ischial part of adductor magnus by sciatic nerve
- All are adductors of the hip joint

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A. Gracilis :
Origin:
From the body of the pubis near middle line
Insertion:
Into the upper part of the medial surface of the shaft of tibia
(between the insertion of sartorius and semitendinosus)
Nerve supply:
Obturator nerve (anterior division)
Action:
1. Adduction of the thigh.
2. Flexi and medial rotation of the leg .
3. Steady the pelvis on the femur.

B. Pectineus (Fig. 11):

Origin:
From pectineal line and pectineal surface of superior pubic ramus
Insertion:
Pectineal line of femur
(line extending from the lesser trochanter to the linea aspera).
Nerve supply:
Femoral nerve
Action:
- Adduction of the thigh
- Flexion of the hip joint

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.[Link] longus (Fig. 11):
Origin: By rounded tendon from the body of the pubis
(below the pubic tubercle.)
Insertion:
Middle part of linea aspera
Nerve supply:
Obturator nerve (anterior division).
Action:
- Adduction of the thigh.

- Medial rotation of the thigh.

[Link] brevis (Fig. 11):

Origin:
Body of the pubis and inferior pubic ramus (below the origin of adductor longus)
Insertion: Lower 1/2 of pectineal line
Upper ½ of linea aspra
Nerve supply:
Obturator nerve
Action:
- Adduction of the thigh.
- Medial rotation of the thigh.

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E. Adductor magnus (Fig. 12):
It is formed of two parts with two double origin, insertion, nerve supply and
action.

Pubic part Ischial part

Origin outer surface of pubic arch lower part of the ischial
tuberosity
Insertion medial lip of linea aspera adductor tubercle
and medial supracondylar
line.

Nerve supply obturator nerve sciatic nerve

Action adduction and medial extension of the hip joint
rotation of the thigh
N.B. Adductor hiatus:
It is an opening in the adductor magnus, which lies between the insertion of the
pubic and ischial part of adductor magnus. It allows passage of femoral vessels

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Attachment of adductor magnus muscle
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 Femoral triangle
Definition and Site:
It is an inverted triangular depression in the upper third of the front of the thigh,
below the inguinal ligament.
Boundaries:
It has two borders, base, apex, floor and roof.
Lateral border: formed by medial border of sartorius.
Medial border: formed by medial border of adductor longus.
Base (upper border): formed by the inguinal ligament.
Apex: it is directed downwards and is formed by the overlap between sartorius
and adductor longus. It is continuous below with the adductor canal.
Floor: From medial to lateral it is formed by adductor longus, pectineus, psoas
major and iliacus muscles.

Figure (13): Boundaries and floor of femoral triangle

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Roof:
- It is formed by skin, superficial fasica and deep fascia.
- The superficial fascia of the roof contains:
• Cutaneous nerves: femoral branch of genito-femoral nerves
• Vein: the upper part of great saphenous vein and its tributaries.
• Arteries: the three superficial branches of the femoral artery
• Superficial inguinal lymph nodes: vertical group, along the great saphenous
vein and horizontal group, below and paralled to the inguinal ligament.
- The deep fascia contains saphenous opening

Figure (14): Roof of femoral triangle

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Contents of femoral triangle:
- Femoral nerve (lateral to the femoral artery)
- Lateral cutaneous nerve of thigh
- Femoral branch of genito-femoral nerve
- Femoral artery (between femoral nerve and femoral vein)
- Femoral vein (medial to the femoral artery)
- Femoral sheath: a funnel shaped sheath which surrounds the upper 3 - 4 cm of
the femoral artery and femoral vein
- Deep inguinal lymph nodes: on the medial side of the femoral vein.

Figure (15): Contents of femoral triangle

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 Femoral sheath
Definition:
A funnel shaped extension of the deep fascia of the lower abdomen. It surrounds
the upper 3-4 cm of the femoral vessels.
Compartments:
The femoral sheath is divided by two antero-posterior septa into three
compartments:
- The lateral compartment: contains the femoral artery and the femoral branch of
genito-femoral nerve.
- The intermediate compartment: contains the femoral vein.
- The medial compartment (femoral canal): It contains a lymph node, lymph
vessels and some fat.

- Compartments of femoral sheath

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 Femoral hernia
Definition:
It is the abnormal protrusion of a peritoneal sac (containing a loop of intestine)
through the femoral canal.
Incidence:
It is more frequent to occur in females because their femoral ring is wider due to
a wider pelvis.

Direction of femoral hernia

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 Adductor canal
(Subsartorial canal, canal of Hunter)
Definition:
It is an intermuscular tunnel on the medial aspect of the middle 1/3 of the thigh
under cover of the sartorius muscle.
Position:
- It begins at the apex of the femoral triangle and ends at the adductor hiatus.
- It connects the femoral triangle on the front of the thigh to the popliteal fossa
on the back of the knee.

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Boundaries:
The canal is triangular in cross section having the following walls:
1. Antero-medial wall: is formed by sartorius.
2. The posterior wall (floor): is formed by the adductor longus (above) and the
adductor magnus (below).
3. The antero-lateral wall: is formed by the vastus medialis.

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Contents:
Femoral artery:
It enters the adductor canal through its upper end and it leaves the canal through
its lower end (adductor hiatus) to enter the popliteal fossa.
Femoral vein:
It enters the canal through the adductor hiatus and it leaves the canal at the apex
of the femoral triangle.
Saphenous nerve:
It leaves the canal by piercing the lower end of its roof and emerges on the medial
side of the knee.
Nerve to vastus medialis: ends by supplying the vastus mediali muscle.

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 Lumber plexus
Formation: It is formed by:
• The anterior 1ry rami of the upper 3 lumbar nerves, and
• The upper ½ of the anterior ramus of the 4th lumbar nerve.
- Site: it lies in the substance of the posterior part of the psoas major
muscle, inside the abdomen.
- Mode of formation and distribution of its branches:
(A) The 1st lumbar nerve divides into:
- A large division, giving:
1. Ilio-hypogastric nerve (L1): supplies the skin of the anterior abdominal
wall above the pubis.
2. Ilio-inguinal nerve (L1): supplies the skin of the external genitalia and
the upper part of the medial side of the thigh.
- A small division joins a branch from (L2) to form the genito-femoral
nerve (L 1,2) which divides into:
a. genital branch: supplies skin of the external genitalia
b. femoral branch: supplies the skin of the roof of femoral triangle.
(B)The 2nd, 3rd and 4th lumbar nerves divide into ventral and dorsal
divisions to form the following nerves:
1. Lateral cutaneous nerve of thigh: from dorsal divisions of (L2,3). It
supplies the skin of lateral side of thigh.
2. Femoral nerve: from dorsal divisions of (L2,3,4).
[Link] nerve: from ventral divisions of (L2,3,4)

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 Femoral Nerve
It arises from the lumbar plexus in the abdomen, from the dorsal divisions of the
anterior primary rami of the 2nd, 3rd and 4th lumbar nerves.

Course and relations:

- It appears at the lateral margin of the psoas major muscle between it and the
iliacus, a short distance above the inguinal ligament.
- It descends in the groove between the two muscles
- It enters the thigh deep to the inguinal ligament and lateral to the femoral
sheath
- It ends 2cm below the ligament by dividing into a number of branches.
Branches:
A- Muscular branches: to
- Iliacus:the branch arises in the abdomen.
- Pectineus: in the femoral triangle
- Sartorius
Quadriceps femoris:
B- Cutaneous branches:
1. Saphenous nerve: to the skin of the medial side of knee, leg and foot.
2. Medial cutaneous nerve of thigh: to the skin of the medial side of thigh
down to the knee.
3. Intermediate cutaneous nerve of thigh: to the skin of the intermediate
area of front of thigh down to the knee.

4.

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C- Articular branches: to
- The hip joint
- The knee joint.

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Effects of injury of the femoral nerve:
- Motor effect: paralysis of the quadriceps muscle leading to loss of knee
extension. However it could be extended passively with help of iliotibial tract.
- Sensory effect: loss of sensation on the front and medial sides of the thigh,
and on the medial sides of leg and foot.
Saphenous nerve
It is the longest cutaneous nerve in the body.
It arises from the femoral nerve in the femoral triangle.
In the femoral triangle, it descends lateral to the femoral artery.
- In the adductor canal, it lies at first lateral to the artery then crosses it
superficially to lie medial to it in the lower part of the canal. It leaves the canal
by piercing its roof. Here, it gives its infra-patellar branch.
- In the leg, it pierces the deep fascia to descend along the medial side of the
knee and leg together with the great saphenous vein.
- In the foot, it passes in front of the medial malleolus and continues on the
medial side of the foot as far as the first metatarso-phalangeal joint.
Distribution : to the skin of the medial side of knee, leg and foot as far as 1st
metatarso-phalyngeal joint

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 Obturator nerve
It is a branch of the lumbar plexus in the abdomen. It originates from the ventral
divisions of the anterior primary rami of the 2nd, 3rd, and 4th lumbar nerves.
- Course:
• It appears at the medial side of psoas major muscle. It descends on the side of
the pelvis in company with the obturator vessels. It passes through the obturator
canal to reach the medial compartment of the thigh where it divides into:
∗ Anterior division: passes in front of the adductor brevis between it and the
adductor longus.
∗ Posterior division: passes behind the adductor brevis between it and the
adductor magnus.
- Branches:
• The anterior division gives:
1-Muscular branches to adductor longus, adductor brevis and gracilis. (may be
an additional branch to pectineus).
2- Articular branch to the hip joint.
3- Cutaneous branch: to a limited part of the skin of the medial side of the thigh.
• The posterior division gives:
1- Muscular branches: to obturator externus, adductor brevis and pubic part
of adductor magnus
2- Articular branch to the knee joint.

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 THE GLUTEAL REGION

BOUNDRIES
superiorly by the iliac crest,
Inferiorly by the gluteal fold,
Posteroir by the natal cleft
Anteroior by a line drawn from the anterior superior iliac spine to the greater

Trochanter

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 Ligaments of Gluteal Region

1. The sacro-spinous ligament: extends from the ischial spine to last piece
of sacrum and first piece of coccyx.
2. The sacro-tuberous ligament: extends from the medial border of the
ischial tuberosity to the posterior iliac spines and lateral parts of sacrum and
coccyx.

Greater sciatic foramen::

- Boundaries:
• Lesser sciatic notch.
• Sacro-spinous ligament.
• Sacro-tuberous ligament.
Lesser sciatic foramen
- Boundaries:
1- Greater sciatic notch
2- Sacro-spinous ligament.
3- Sacro-tuberous ligament.

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 Muscles of the Gluteal Region

1-Tensor fascia lata

- Origin: from the outer lip of the iliac crest between the anterior superior iliac
spine and the iliac tubercle.
- Insertion: into the anterior border of the ilio-tibial tract.
- Nerve supply: superior gluteal nerve.
- Action: It tightens the ilio-tibial tract to assist in stability of the knee

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 2- Gluteus maximus
It is the largest muscle in the body.
- Origin: from
1- The outer gluteal surface of the ilium, behind the posterior gluteal line.
2- The posterior surface of sacrum and coccyx.
3- The back of the sacro-tuberous ligament.

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- Insertion: the fibers pass downwards and laterally.
Its superficial 3/4: inserted into the posterior border of the upper part of the
ilio- tibial tract.
Its deep 1/4: inserted into the floor of the gluteal tuberosity.

- Nerve supply: inferior gluteal nerve.

- Action:
1. It is the main extensor of the hip joint
2. Lateral rotator of the hip joint.
3. It tightens the ilio-tibial tract to assist in keeping the knee extended
N.B.:
− The great thickness of the gluteus maximus muscle makes it ideal for intramuscular
injections. To avoid injury to the underlying sciatic nerve, the injection should be given on
the upper outer quadrant of the buttock.

3-

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 3-Gluteus medius
− Origin: from the outer surface of the ilium [between posterior gluteal line
(behind) and anterior gluteal line (below)].
− Insertion: Inserted into the oblique ridge on the lateral surface of the
greater trochanter.

Gluteus medius Gluteus mediu

4-Gluteus minimus
− Origin: from the outer surface of the ilium between the anterior and inferior
gluteal lines.
− Insertion: inserted into the anterior surface of the greater trochanter.
− Nerve supply of gluteus medius and minimus: superior gluteal nerve.
− Action of gluteus medius and minimus:
1. Abduction of the hip joint.
2. Medial rotation of the thigh (the anterior fibers).
[Link] muscles prevent sagging of the pelvis when the opposite leg is off the
ground.

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N.B:
− In paralysis of both muscles on one side: the patient shows a limping gait.
− On both sides: the patient shows a waddling gait.

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 Six lateral rotators of hip joint
[Link]
- Origin: from the front of the middle three sacral vertebrae in the pelvis;
- Insertion: it leaves the pelvis through the greater sciatic foramen to enter
the gluteal region .inserted into the tip of the greater trochanter.
- Nerve supply: branches from the sacral plexus (S1, 2).
- Action:lateral rotation of the thigh at the hip joint.

2- Obturator internus
- Origin:
• From the inner surface of the obturator membrane.
• From the margins of the obturator foramen and lateral wall of pelvis.
- Insertion:
• Its tendon passes through the lesser sciatic foramen laterally across the back
of hip joint to be joined by the two gemelli (superior and inferior) to form a common tendon.
medial surface of the greater trochanter.
• It is inserted into the
- Nerve supply: nerve to obturator internus
- Action: Lateral rotation of the thigh at the hip joint.

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 3. Superior gemellus
- Origin: from the upper margin of the lesser sciatic notch.
- Insertion: into the upper border of the tendon of obturator internus.
- Nerve supply: nerve to obturator internus (from the sacral plexus).
- Action: lateral rotation of the hip joint.
4. Inferior gemellus
- Origin: from the lower margin of the lesser sciatic notch.
- Insertion: into the lower border of the tendon of obturator internus.
- Nerve supply: nerve to quadratus femoris (from the sacral plexus).
- Action: lateral rotation of the hip joint.
5- Quadratus femoris
- Origin: from lateral margin of ischial tuberosity.
- Insertion: into the quadrate tubercle.
- Nerve supply: nerve to quadratus femoris.
- Action: lateral rotation of the thigh at the hip joint.

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 6- Obturator externus

Origin: from outer surface of obturator membrane and from margins of obturator
foramen.
- Insertion: The tendon passes below then behind the hip joint to become
inserted into the floor of the trochanteric fossa.
- Nerve supply: posterior division of obturator nerve (from lumbar plexus).
- Action: lateral rotation of the thigh at the hip joint.

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 Nerves of Gluteal Region
All arise from the sacral plexus inside the pelvis.
- Sciatic nerve (L 4, 5, S1, 2 ,3):
• It leaves the pelvis through the greater sciatic foramen below the piriformis
to enter the gluteal region. (see later)
- Superior gluteal nerve (L4,5,S1):
• It leaves the pelvis through the greater sciatic foramen above the piriformis .
• It supplies gluteus medius, minimus and tensor fascia lata muscles.
- Inferior gluteal nerve (L5, S1,2):
• It enters the gluteal region through the greater sciatic foramen below the
piriformis. It supplies the gluteus maximus only.
- Pudendal nerve(S2,3,4)and nerve to obturator internus(L5,SI, 2):
• They enter the gluteal region through the greater sciatic foramen below the
piriformis with the internal pudendal artery in between. Then they enter the
lesser sciatic foramen.
• The nerve to obturator internus supplies the obturator internus and the
superior gemellus muscles.
Nerve to quadratus femoris (L4, 5, S1):
• Leaves the pelvis through the greater sciatic foramen below the piriformis.
• It descends deep to the sciatic nerve.
• It supplies the quadratus femoris and the inferior gemellus muscles.

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- Posterior cutaneous nerve of thigh(S1, 2, 3):

39
• It enters the gluteal region via the greater sciatic foramen below the
piriformis.
• It descends on the posterior surface of the sciatic nerve and deep to the
gluteus [Link] descends in the back of thigh dowen to the upper
half of back of thigh
Branches:
− To skin of gluteal region and perineum.
− To skin of the back of thigh, popliteal fossa and upper half of back of leg.

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Greater sciatic foramen:
• Boundaries:
-Anterior :Greater sciatic notch
-Below :Sacro-spinous ligament.
- Behind :Sacro-tuberous ligament.
• Structures passing through it:
1. Piriformis muscle.
2. Structures above the piriformis: Superior gluteal nerve and vessels.
3. Structures below the piriformis:
a. Inferior gluteal nerve and vessels.
b. Sciatic nerve.
c. Nerve to quadratus femoris (deep to sciatic nerve).
d. Posterior cutaneous nerve of thigh (superficial to sciatic nerve).
e. Nerve to obturator internus.
f. Internal pudendal vessels. [Link] nerve.
Lesser sciatic foramen:
- Boundaries:
-Anterior : Lesser sciatic notch.
-AboveSacro-spinous ligament.
-Behind:Sacro-tuberous ligament.
- Structures passing through it:
[Link] of obturator internus emerging from the pelvis to the gluteal region
[Link] structures emerging from the greater sciatic foramen to the lesser
sciatic foramen (from medial to lateral):
a. Pudendal nerve on the sacro-spinous ligament.
b. Internal pudendal vessels on the tip of the ischial spine.
c. Nerve to obturator internus on the ischial spine.

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 Sacral plexus
Roots: It is formed of five roots:
- Lumbo-sacral trunk (L4, 5):Made by the union of the lower part of ventral ramus
of L4 and ventral ramus of L5.
• Ventral rami of upper 3 sacral nerves (S1, S2, S3).
• Upper part of ventral ramus of S4.
- Formation:
• The lumbo-sacral trunk leaves the psoas major muscle at its medial border below
the obturator nerve.
• It descends over the ala of sacrum to the pelvis.
ry
• The anterior 1 rami of upper 4 sacral nerves emerge through the anterior sacral
foramina where S1,2,3 and upper part of S4 unite with the lumbo-sacral trunk.
- Site: in front of the sacrum and the piriformis muscle

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Branches:
1- Nerve to piriformis (S1,2)

2- Pelvic splanchnic Two pelvic nerves (from roots of plexus.

(parasympathetic) nerves
(S2,3,4)

3- Superior gluteal nerve(L4,5 &

S1) Two gluteal nerves (from posterior
4- Inferior gluteal nerve (L5 & S1,2) surface of plexus).

5- Nerve to quadratus femoris

(L4,5& S1). Two muscular nerves (from anterior
6- Nerve to obturator internus surface of plexus).
(L5& S1,2)

7- Perforating cutaneous nerve

(S2, 3).
8- Posterior cutaneous nerve of Two cutaneous nerves.
thigh (S1, 2, 3).

9- Sciatic nerve (L4,5& S1,2,3)

Two “terminal” branches
10- Pudendal nerve (S2,3,4)

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44
 Muscles of back of thigh
Hamstring muscles
They are:
− All arise from the ischial tuberosity except the short head of biceps.
− All are supplied by the sciatic nerve.
− All are flexors of the knee and extensors of the hip joint.
1- Biceps femoris
− Origin: this muscle arises by 2 heads:
The long head: arises from the lower medial area of the upper quadrangular part
of the ischial tuberosity in common with the semitendinosus muscle.
The short head: arises from the lateral lip of linea aspera and the upper
part
of the lateral supracondylar line
− Insertion: common tendon is inserted into the head of the fibula.
− Nerve supply:
− The long head: is supplied by the tibial part of the sciatic nerve.
− The short head: is supplied by the common peroneal part of the sciatic
nerve.
− Action:
1- Flexion and lateral rotation of the leg at the knee joint.
2- Extension of the hip joint by the long head of biceps alone.

45
hamstring muscles and the lateral rotators of the thigh

46
 2- Semitendinosus
It is so called as half of its length is made of a long tendon.
− Origin: it arises in common with the long head of biceps from the lower
medial area of the upper quadrangular part of the ischial tuberosity.
− Insertion: into the upper part of the medial surface of tibia behind the
insertion of sartorius and gracilis (S.G.S).
− Nerve supply: from the tibial part of the sciatic nerve.
− Action:
[Link] and medial rotation of the leg at the knee joint.
[Link] of the hip joint.

[Link]
Its upper part is formed of a wide membrane, hence its name.
− Origin: from the upper lateral area of the upper quadrangular part of the
ischial tuberosity.
− Insertion:
-to the groove on the back of the medial condyle of the tibia
-the capsule of the knee joint by oblique popliteal ligament
− Nerve supply: from the tibial part of the sciatic nerve.
− Action:
1. Flexion and medial rotation of the leg at the knee joint.
2. Extension of the thigh at the hip joint.

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48
 Sciatic nerve
It is the thickest nerve in the body.
− Origin:It arises from the sacral plexus (from the anterior and posterior divisions

of (L4, 5, SI,2,3) in the pelvis.

− Course:

• It leaves the pelvis through the greater sciatic foramen

below the piriformis to enter the gluteal region.

..It descends on the back of the ischium and enters the

back of the thigh midway between the greater
trochanter and the ischial tuberosity.
• It ends a little below the middle of the thigh by dividing

into its two terminal branches; the common peroneal and

the tibial nerves.

49
− Relations:

∗ In the gluteal region:

∗ Superficially: gluteus maximus thigh.

∗ Deeply: back of ischium, nerve to quadratus femoris, tendon of obturator

internus with the two gemelli and the quadratus femoris separating the
nerve from hip joint.
∗ In the back of the thigh:
 Superficially: long head of biceps femoris.
 Deeply: adductor magnus

50
 − Branches:
1. Tibial (medial popliteal) nerve:.
2. Common peroneal (lateral popliteal)
3. Muscular branches:
a- From the tibial part to:
* Long head of biceps femoris. * Semitendinosus.
* Semimembranosus. *Ischial part of adductor magnus.
b- From the common peroneal part to:
∗ Short head of biceps femoris.
4. Articular branches: to the hip joint.
Clinical points related to sciatic nerve:
− Sciatic nerve injury:
Causes of injury of sciatic nerve:
1. Posterior dislocation of the hip joint with fracture in the acetabulum.
2. Wrong intramuscular injection

Effects of injury of sciatic nerve:

∗ Motor effects: paralysis of hamstrings and all muscles of leg and foot.
∗ Sensory effects: loss of cutaneous sensation below the knee in the leg and foot except
on the medial side (supplied by saphenous nerve) and on the back of the calf muscles
(supplied by posterior cutaneous nerve of thigh).
∗ Deformity: drop foot. (High step gait)

− Sciatica:
- It is the pain felt along the sensory distribution of the sciatic nerve which can be caused
by prolapse of an intervertebral disc, with pressure on one or more of the roots. nerve

51
 Popliteal fossa
Shape and site:
it is a diamond-shaped intermuscular space present behind the knee joint.
Boundaries:
Above and lateral:
biceps femoris.
Above and medial:
Semi-tendinosus and semimembranosus.-
Below and lateral:
lateral head of gastrocnemius and plantaris (if present).
Below and medial:
medial head of gastrocnemius

52
Roof:
1. Skin.
2. Superficial fascia containing the terminal parts of the short
saphenous vein and the posterior cutaneous nerve of thigh.
3. Deep fascia called popliteal fascia (part of fascia lata).

Floor:
1. Popliteal surface of femur.
2. Capsule of knee joint.
3. Popliteus muscle and its covering fascia

53
Contents: (
1. Popliteal artery: deepest structure in the fossa.
[Link] vein: crosses the artery posteriorly from medial to lateral.
[Link] nerve: descends centrally crossing the popliteal vessels posteriorly
from lateral to medial.
[Link] peroneal nerve: descends laterally along the medial border of
biceps femoris.
[Link] lymph nodes: 6-7 in number.
6.A rich amount of fat.

54
 LEG
Deep Fascia of the Leg
(fascia cruris)
- The leg is surrounded by a strong tight layer of deep investing fascia called
fascia cruris (crus = leg).
- It is particularly thickened around the knee and ankle joints to form 5 bands of
deep fascia called retinaculae which hold the tendons and vessels entering
the foot.
- It gives 2 intermuscular septa which are attached to the anterior and posterior
borders of the fibula respectively.
- The 2 (anterior and posterior) intermuscular septa and the interosseus
membrane (present between tibia and fibula) divide the leg into 3 muscular
compartments (anterior, posterior and lateral).

55
 [1] Muscles of the Anterior (Extensor)
Compartment of the Leg
Four muscles:
1- Tibialis anterior.
2- Extensor digitorum longus.
3- Extensor hallucis longus.
4- Peroneus tertius.
Nerve supply: common nerve supply by anterior tibial nerve
[Link] anterior
- Origin:
• Upper 2/3 of lateral surface of shaft of tibia.
• Interosseus membrane.
-Insertion:
• The medial side of the medial cuneiform bone.
• The base of the 1st metatarsal bone.
- Nerve supply: anterior tibial nerve (deep peroneal).
- Action:
1- Dorsiflexion (extension) of the ankle
2- Inversion of the foot(at subtalar joint.
3- Supports the medial longitudinal arch of foot

56
- 2-Extensor Digitorum Longus
- Origin:
• Upper ¾ of anterior surface of shaft of fibula.
• Interosseus membrane.
- Insertion: the tendon of the muscle divides into 4 tendons for the lateral 4
toes
- .Each tendon expands on the dorsum of the proximal phalanx forming
an extensor expansion
Each expansion divides into 3 slips:
• The middle slip inserts into the bases of the middle phalanges of the lateral 4 toes.
• The 2 collateral slips unite and insert into the bases of the terminal phalanges of the lateral 4 toes.

- Nerve supply: anterior tibial nerve.

- Action:
• Extension of all joints of the lateral 4 toes.
• Dorsiflexion of ankle joint.

57
 4- Extensor Hallucis Longus
Origin:
 Middle 2/4 of anterior surface of shaft of fibula.
 Interosseus membrane.
Insertion:
The base of the terminal phalanx of the big toe (or hallux).
- Nerve supply: anterior tibial nerve.
- Action:
• Extension of all joints of big toe.
• Dorsiflexion of ankle.

4-Peroneus (fibularis) Tertius

- Origin:
• Lower ¼ of anterior surface of shaft of fibula.
• Interosseus membrane.
- Insertion: into the dorsal surface of the base of the 5th metatarsal bone.
- Nerve supply: anterior tibial nerve.
- Action:
• Dorsiflexion of ankle joint.
• Eversion of foot (at subtalar joint).
• Supports the lateral longitudinal arch of foot

58
59
 [2] Muscles of the Lateral Compartment of the Leg
[Link] (fibularis) Longus
Origin:
• From upper 2/3 of lateral surface of shaft of fibula.
Insertion: the tendon crosses the sole transversely (from lateral to medial) to
become inserted (in the 4th layer of sole) into the lateral aspect of the medial
cuneiform bone and the base of the 1st metatarsal bone.
Nerve supply: musculo-cutaneous nerve (superficial peroneal).
Action:
1. Eversion of foot (at subtalar joint).
2. Plantar-flexion of foot (at ankle joint).
3. Supports the lateral longitudinal, and the transverse arches of foot.

60
 2. Peroneus (fibularis) Brevis
Origin:
 From lower 2/3 of lateral surface of shaft of fibula.
Insertion: the tendon is inserted into the tuberosity on the base of the 5th
metatarsal bone.
Nerve supply: musculo-cutaneous nerve (superficial peroneal).
Action:
1. Eversion and plantar flexion of foot.
2. Supports the lateral longitudinal arch of foot.

61
 Common Peroneal Nerve(Lateral popliteal nerve)
Origin, course and end:
• It is the smaller of the two terminal branches of the sciatic nerve.
• It begins at the lower 1/3 of the back of the thigh.
• It enters the popliteal fossa through its upper angle and runs downwards
and laterally.
• It leaves the fossa through its lateral angle by crossing superficial to the
plantaris and lateral head of gastrocnemius muscles.
• It curves behind the head of the fibula then close to the lateral aspect of its
neck.
• It ends by piercing the peroneus longus muscle and divides inside its
substance into its two terminal branches (superficial and deep peroneal nerves).

62
- Branches in the popliteal fossa:
1- Cutaneous branches:
a- Sural communicating nerve: arises in the upper part of the fossa, and
runs inferomedially to join the sural nerve.
b- Lateral cutaneous nerve of calf: arises on the lateral head of
gastrocnemius and supplies the upper 1/3 of the anterolateral side of
the leg.
2. Articular branches to the knee joint: Superior and inferior lateral
genicular and recurrent genicular nerves
3. Terminal branches:
a- Superficial peroneal (musculo-cutaneous) nerve.
b- Deep peroneal (anterior tibial) nerve.
N.B.: The common peroneal nerve has no muscular branches in the popliteal fossa.
Injury of common peroneal nerve:
a) Causes of injury: fracture of head or neck of fibula or pressure from casts or
splints.
b) Results of injury:
Motor effects:
1- Foot drop: due to paralysis of all extensor muscles of front of leg.
2- Loss of eversion of foot: due to paralysis of the 3 peroneal muscles.
This deformity is called talipes equinovarus.
Sensory effects:
Loss of skin sensation:
1- On the upper lateral side of leg (supplied by lateral cutaneous nerve of
calf).
2- On the front of the lower part of leg and dorsum of foot (supplied by
superficial and deep peroneal nerves).

63
 Nerve of the lateral compartment of leg.
Musculo–cutaneous (Superficial Peroneal) nerve
Begins: as one of the 2 terminal branches of the lateral popliteal (common peroneal)
nerve, at the lateral side of neck of fibula, in the substance of peroneus longus muscle.
Course and relations:
- it runs in the substance of peroneus longus muscle then it runs between peroneus
longus and brevis muscles.
-At the junction of the middle and lower 1/3 of leg, it pierces the deep fascia and
lies in the superficial fascia.
- Then descends to enter the dorsum of the foot.
Ends: on the dorsum of foot, where it divides into medial and lateral cutaneous
branches (each then splits into 2 dorsal digital branches).
Branches:
• Muscular: to peroneus longus and brevis.
• Cutaneous: to
∗ Skin of lower 2/3 of leg (anterior and lateral aspects).
∗ Skin of dorsum of foot and toes except:
 Cleft between 1st and 2nd toes → supplied by anterior tibial nerve.
 Lateral side of foot and little toe → supplied by sural nerve.
 Medial side of foot as far as the head of 1 metatarsal → supplied by
st

saphenous nerve.

64
65
 Anterior Tibial (deep peroneal) Nerve
Begins:
as one of the 2 terminal branches of the lateral popliteal (common peroneal) nerve,
at the lateral side of the neck of fibula, in the substance of peroneus longus muscle.
Course and relations:
a- At the lateral side of neck of fibula:
The nerve enters the anterior compartment of the leg.
b- It then descends deeply on the interosseus membrane between tibialis
anterior
(medially) and extensor digitorum longus (laterally) accompanied by the
anterior
tibial artery (lateral-anterior - lateral.) Then passes in front ankle joint to
reach the
dorsum of the foot.
Ends: on the dorsum of the foot by dividing into medial and lateral terminal
branches.
Branches of the anterior tibial nerve:
1. Muscular branches: to all 4 muscles of anterior compartment of leg.
2. Articular branches: to ankle joint.
3. Terminal branches:
• The medial terminal branch: gives:
st nd
∗ Cutaneous branches to the skin of the cleft between the 1 and 2

toes.
• The lateral terminal branch: gives:
∗ Muscular branches: to extensor digitorum brevis

Injury of the anterior tibial nerve:

Damage of this nerve leads to paralysis of the muscles of the anterior
compartment of
leg and the extensor digitorum brevis muscle.
Motor loss:
- Loss of dorsiflexion of ankle leading to →foot-drop.
- Loss of extension of all toes.
Sensory loss:
Minimal and limited to skin of cleft between 1st and 2nd toes.

66
67
68
 [3] Muscles of the Posterior Compartment of the Leg (Flexor)
- It is formed of 2 (superficial and deep) groups

Superficial Flexor Group

(Superficial Calf Muscles)
1) Gastrocnemius
(Most superficial of the 3 calf muscles
Origin: arises by 2 heads:
Lateral head : from femur above the lateral epicondyle.
Medial head :from back of femur above the medial condyle
Insertion: the 2 heads end in a tendon which joins the tendon of
soleus muscle forming the tendo-calcaneus or tendo-Achilles which is
inserted into the middle of the posterior surface of calcaneus.
- Nerve supply: tibial (medial popliteal) nerve (by a separate branch to each head).

69
 2-Soleus
(Lies deep to gastrocnemius)
a. Origin: horse-shoe shape
Tibial origin: from
- Middle 1/3 of medial border of shaft of tibia.
- Soleal line on the back of tibia.
Fibular origin: from
- Back of head of fibula.
- Upper 1/3 of posterior surface of shaft of fibula.
From fibrous tendinous arch: (between tibia and fibula)

70
- Nerve supply:by 2 branches from tibial neve:
1. A superficial branch from the tibial nerve (in popliteal fossa): supplies its
superficial surface.
2. A deep branch from the tibial nerve (in back of leg): supplies its deep
surface.
-
-

71
- Action of gastrocnemius and soleus muscles:
• They are powerful plantar flexors of the ankle joint during walking and
running and rising on tip toes.
• Gastrocnemius alone is also a flexor to the knee joint .
• Soleus: acts as a muscle pump during standing.

[Link]
- A very small muscle, which may be absent.
- Its tendon is used in surgical autograft to repair severed flexor tendons of
fingers.
- Origin:
• From lower part of lateral supracondylar line of femur.
- Insertion: It has a long slender tendon which runs obliquely between
gastrocnemius and soleus to reach the medial side of tendo-calcaneus and
inserts in tendo-calcaneus or in posterior surface of calcaneus.

M L

- Nerve supply: tibial (medial popliteal) nerve.

- Action: weak flexion of knee and ankle joints.

Clinical Points:

Plantaris Tendon: which is often missing, it can be used for tendon autografts in repairing
flexor tendons of the fingers 72
 Deep Flexor Group
(Deep Calf Muscles) Includes 4 muscles:
[Link]
- Origin: from popliteal sulcus on lateral surface of lateral condyle of femur
below the lateral epicondyle (intra-capsular).
- Insertion: the tendon of origin comes from the back of the capsule of the knee
joint, it then expands to form the fleshy fibres which become inserted into the
posterior surface of tibia above the soleal line.
- Nerve supply: a branch from tibial nerve (in popliteal fossa).
- Action:
• Flexion of knee joint.
• It produces unlocking at the beginning of flexion of a fully extended knee
.

73
 2) Flexor Hallucis Longus
- Origin:
• From lower 2/3 of back of fibula
• From back of interosseus membrane.
- Insertion:
• The tendon of the muscle lies in groove on the back of the lower end of tibia,
nd
• Then it runs in the 2 layer of the sole to insert into the base of the
terminal phalanx of the big toe.
- Nerve supply: posterior tibial nerve.
- Action:
1- Flexion of all joints of big toe 2. Helps in plantar flexion of foot.
3-Supports the medial longitudinal arch of foot.

- (3) Tibialis Posterior

- Origin:
• From back of tibia (below soleal line, lateral to the vertical line).
• From back of interosseus membrane ., Back of fibula.
- Insertion:
• In the distal part of leg: the tendon of the muscle passes on the back of the
medial malleolus then deep to the flexor retinaculum.
• It enters the foot: where it becomes inserted into:
∗ The tuberosity of navicular bone (main insertion).
∗ Into all tarsal bones (except the talus).
nd rd th
∗ Bases of 2 , 3 , and 4 metatarsal bones
- Nerve supply: posterior tibial nerve.
- Action:
1- Plantar flexion of foot (at the ankle joint).
2- Inversion of foot (at the subtalar joint). [Link] medial longitudinal arch

74
 3) Flexor Digitorum Longus
- Origin: from back of tibia below the soleal line medial to the vertical line.
- Insertion:
• The tendon of the muscle passes behind the medial malleolus, lateral to the
tendon of tibialis posterior .
• Then it enters the sole of foot and divides into 4 tendons to insert into the
bases of the terminal phalanges of the lateral 4 toes.
- Nerve supply: posterior tibial nerve.
- Action:
1. Flexion of all joints of the lateral 4 toes
2. Plantar flexion of foot
3. Supports the lateral and medial longitudinal arches.

75
76
-

Tibial Nerve in popliteal fossa

(Medial popliteal nerve)
It is the larger of the two terminal branches of the sciatic nerve.
• It begins at the lower 1/3 of the back of the thigh.
• It enters the popliteal fossa at the superior angle and descends vertically,
superficial to the popliteal vessels and crossing them from lateral to medial ..
It ends at the lower border of the popliteus by becoming the posterior tibial
nerve.
- Branches in the popliteal fossa:
1. Cutaneous branch: Sural nerve:
• It joins the sural communicating branch of the common peroneal nerve.
• It descends between the two heads of gastrocnemius accompanying the
small saphenous vein. Then behind lateral malleolus to reach foot .
• It supplies the skin of the lower part of the back of the leg and lateral
side of foot.
2. Muscular branches: to both heads of gastrocnemius, plantaris, soleus
and popliteus muscles.
3. Articular branchesto the knee joint:superior and inferior medial genicular
and middle genicular nerves .

77
-

Sural nerve

78
 Tibial nerve in the posterior compartment of leg
(Posterior tibial nerve )
- Begins: at the lower border of popliteus muscle as the continuation of the
tibial (medial popliteal) nerve.
- Course:
• It enters the back of the leg, deep to the tendinous arch of soleus
(extending between tibia and fibula).
• It descends in the leg between superficial and deep flexors of the
posterior compartment (accompanied by posterior tibial vessels).
- Ends:
behind the ankle joint by dividing into medial and lateral plantar nerves
which enter the sole of foot.
- Branches:
• Articular: to ankle joint.
∗ Muscular:to soleus, tibialis posterior, flexor hallucis longus and flexor
digitorum longus.
∗ Cutaneous: medial calcanean branches supplies the skin of heel and
medial side of sole of foot.
∗ Terminal branches: medial and lateral plantar nerves.
Injury of tibial nerve:
a) Motor loss: Muscles of back of leg and sole of foot paralysed leading to
dorsiflexion and eversion of foot.
b) Sensory loss: in skin of sole of foot

79
80
81
82
83
84
 THE FOOT
The only muscle present on the dorsum of foot.
Extensor Digitorum Brevis muscle

- Origin: from dorsal surface of calcaneus.

- Insertion:
• It breaks into 4 tendons which pass to the medial 4 toes.
st
• The 1 tendon is called extensor hallucis brevis and inserts into the base of
the proximal phalanx of the big toe.
• The other 3 tendons join the lateral side of the corresponding expansion of
the extensor digitorum longus.
- Nerve supply: anterior tibial nerve (lateral terminal branch).
- Action: extension of toes

85
The Sole of the Foot
The deep fascia of the sole is thickened in its central part forming the plantar
aponeurosis.
Plantar aponeurosis: it is formed of 3 parts:
1. Central part(thick):
- It is triangular in shape, attached by its apex to the medial tubercle of
calcaneus; its base splits into 5 slips (at the heads of metatarsals) which
fuse with the deep fascia of toes.
2. Medial part (thin): it covers the abductor hallucis.
3. Lateral part (thin): it covers the abductor digiti minimi.
Function:
 It protects the nerves and vessels of the sole.
 It helps to maintain both the medial and lateral longitudinal arches.

86
 1-The First Layer of the Sole
-
1. Abductor hallucis, (medially):
- Origin: from medial tubercle of calcaneus
- Insertion: medial side of base of proximal phalanx of big toe.
- Nerve supply: medial plantar nerve.
- Action: abduction of big toe away from the 2nd toe (axis for adduction and abduction).
2. Abductor digiti minimi, (laterally):
- Origin: from lateral and medial tubercles of calcaneus
- Insertion: lateral side of the base of proximal phalanx of little toe.
- Nerve supply: lateral plantar nerve.
- Action: abduction of little toe away from 2nd toe.
3. Flexor digitorum brevis, (in between):
- Origin: from medial tubercle of calcaneus.
- Insertion: by 4 tendons into the middle phalanx of the lateral 4 toes Nerve supply:
medial plantar nerve.
- Action: flexion of lateral 4 toes(at M/P and proximal I/P joints).
-

87
 The Second Layer of the Sole
- Two tendons:
1- Flexor digitorum longus.
2- Flexor hallucis longus.
- Two muscles:
1. Flexor digitorum accessorius:
- Origin: from medial and lower surfaces of calcaneus.
- Insertion: into the lateral margin of tendons of flexor digitorum longus.
- Nerve supply: lateral plantar nerve.
- Action: it corrects the oblique direction of the tendon of flexor digitorum longus
2. Four lumbrical muscles:
- Origin: from adjacent sides of the 4 tendons of flexor digitorum longus.
- Insertion: into the extensor expansion of the lateral 4 toes.
- Nerve supply:
st
1- The 1 lumbrical is supplied by the medial plantar nerve.
2- The lateral 3 lumbricals are supplied by the lateral plantar nerve.
- Action: flexion of metatarso-phalangeal joints

88
 The Third Layer of the Sole
1. Flexor hallucis brevis (medially):
- Origin: from cuboid ..
- Insertion: by 2 small tendons, one on either side of the base of proximal phalanx of big toe.
- Nerve supply: medial plantar nerve.
- Action: flexes the metatarso-phalangeal joint of the big toe.
2. Flexor digiti minimi brevis (laterally):
- Origin: from the base of 5th metatarsal bone.
- Insertion: in the lateral side of the base of proximal phalanx of little toe.
- Nerve supply: lateral plantar nerve.
- Action: flexes the metatarso-phalangeal joint of the little toe.
3. Adductor hallucis (in between):
- Origin: by 2 heads:
a- Oblique head: from the bases of the 2nd, 3rd and 4th metatarsal bones.
b- Transverse head: from the capsule of the lateral 4 metatarso-phalangeal joints.
- Insertion: into the lateral side of the base of proximal phalanx of big toe.
- Nerve supply: lateral plantar nerve.
- Action: adduction of big toe.
-

89
- The Fourth Layer of the Sole
- Two tendons:
1- Peroneus longus. 2- Tibialis posterior.
- Two groups of muscles:
1- Dorsal interosseous muscles: 4 in number. (No dorsal interosseus muscles for
the big and little toes, as they have their own abductors).
• Origin: from adjacent sides of the metatarsal bones.
• Insertion: the tendon of each interosseous muscle joins the extensor
expansion on the dorsum of the proximal phalanx of the corresponding toe.
• Nerve supply: lateral plantar nerve.
nd rd th
• Action: abduct the 2 , 3 and 4 toes.
2- Plantar interosseous muscles: 3 in number. No plantar interosseus muscles
for :
- The big toe (as it has its own adductor).
- The 2nd toe (as it is not adducted but it is only abducted on either sides).
rd th th
• Origin: arise from the shafts of the 3 , 4 and 5 metatarsal bones.
• Insertion and nerve supply: the same as for dorsal interosseous muscles.
nd
• Action: adduct the lateral 3 toes towards the 2 toe.

N.B.:
-Abduction and adduction of toes is according to the middle line of the 2nd toe.

90
 Planter nerves
The medial and lateral plantar nerves are the 2 terminal branches of the
tibial nerve; they begin behind the ankle.
Medial plantar nerve
- Course and relations:
• It passes between the abductor hallucis and flexor digitorum brevis muscles
• It ends at the base of the 1st metatarsal bone by dividing into 4 plantar digital
nerves.
- Branches:
a- Muscular branches: to 4 muscles:
1- Abductor hallucis.
2- Flexor hallucis brevis.
3- Flexor digitorum brevis.
4- 1st lumbrical muscle.
b- Cutaneous branches:
• To the skin of the medial 2/3 of the sole.
• To the skin of the plantar surface of the medial 3 ½ toes.
c- Articular branches: to the tarsal and metatarsal joints.

Lateral Plantar Nerve (smaller)

- Course and relations: it runs forwards and laterally between the 1st and 2nd layers
of sole to the base of 5th metatarsal bone, accompanied by the lateral plantar
artery, where it divides into superficial and deep divisions:
st nd
• Superficial division: passes forwards between the 1 and 2 layers of sole to
the lateral 1½ toes.
rd th
• Deep division: curves medially between the 3 and 4 layers of sole and
supplies most of the muscles of the sole.
- Branches:
a) Muscular branches: to 14 muscles (most of the muscles of the foot).
st
∗ Abductor digiti minimi (in 1 layer).
∗ Flexor digitorum accessorius.
(in 2nd layer)
∗ Lateral 3 lumbricals.
∗ Flexor digiti minimi brevis.
∗ Adductor hallucis.
(in 3rd layer)
th
∗ All 7 interosseous muscles (in 4 layer).
b) Cutaneous branches:
∗ To skin of lateral part of sole.
∗ To skin of plantar surface of lateral 1 ½ toes.
c) Articular branches: to tarsal and metatarsal joints.

91
-

92
 The Hip joint

- Type: synovial, polyaxial joint.

- Variety: ball and socket.
- Articulating bones: (Fig. 83)
a- Head of femur (rounded ball).
b- Acetabulum of hip bone (cup-like socket).

93
Fibrous capsule: (Fig.):a strong capsule surrounding the joint completely.
Attachments:
- To hip bone:
• To the margins of acetabulum
• To the transverse acetabular ligament.
- To neck of femur:
• To the intertrochanteric line and bases of greater and lesser trochanters,
anteriorly.
• To the middle of the back of neck of femur, posteriorly.
N.B.:
∗ Some fibres arising from the capsule, called retinacula extend along the neck of femur
towards its head. They carry blood supply to the head and neck of femur and also keep
the segments of the fractured neck in posit

94
Ligaments
- The capsule of the hip joint is strengthened by
Three extra-capsular ligaments.
[Link]-femoral ligament:
a- Attachments:it is an inverted Y-shaped ligament; its stem is attached to
the anterior inferior iliac spine while its 2 limbs are attached to the 2 ends
of the intertrochanteric line.
b- Function:
- It is the strongest ligament of the hip joint which reinforces the
anterior aspect of its capsule.
- It limits over extension
[Link]-femoral ligament:
a- Attachments: a triangular ligament, attached to superior pubic ramus
and ilio-pubic eminence of the hip bone and blended to the medial part
of the capsule.
b- Function: limits over abduction of the joint.
[Link]-femoral ligament:
a- Attachments:
- It is attached to the body of ischium below the acetabulum and is
blended to the back of the capsule.
b- Function:
- It supports the posterior part of the capsule and limits excessive medial
rotation of the hip joint

95
Three intracapsular ligaments
4) Round ligament of the head of femur: (Ligamentumteres)(Fig. 86)
a. Attachments:
- A weak triangular band lying inside the cavity of the hip joint
- Its apex is attached to a pit (fovea) on the head of femur.
- Its base is attached to both sides of acetabular notch and to the
transverse acetabular ligament.
b. Function:
- It allows the passage of arterial branches to the head of femur.
5) Transverse acetabular ligament:
- Attached to both ends of acetabular notch converting it into a foramen
through which vessels and nerves enter the hip joint.
6) Labrum acetabulare:
- It is a fibrocartilagenous rim attached to the margins of the acetabulum
to blend with transverse acetabular ligament.

96
- Stability of the hip joint: a very stable joint due to:
• Bony factor: (shape of articular surfaces): the femoral head fits well in the
deep socket of the acetabulum.
• Ligamentous factor: strong capsule and ligaments surround the joint
(especially the ilio-femoral ligament).
• Muscular factor: many strong muscles surround the joint.
- Movements of the hip joint and muscles acting on it:
 Flexion: done mainly by iliopsoas, assisted by sartorius and rectus

femoris.
 Extension: done mainly by gluteus maximus, assisted by hamstrings and
ischial part of adductor magnus.
 Abduction: done mainly by gluteus medius and minimus, assisted by
tensor fasciae latae.
 Adduction: done mainly by the adductors, assisted by gracilis and
pectineus.
 Medial rotation: done by gluteus medius and minimus (anterior fibres only).
 Lateral rotation: done by the small lateral rotators of the thigh: (obturator
internus and externus, 2 gemelli, quadratusfemoris and piriformis),
assisted by gluteus maximus and sartorius.
 Circumduction: a combination of flexion, abduction, extension and finally
adduction movements.

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 - Nerve supply of hip joint: by branches from femoral, anterior division of
obturator, sciatic and nerve to quadratusfemoris muscle.
- Arterial supply of hip joint:
From gluteal, circumflex and obturator arteries.
- Clinical Points related to the hip joint:
a) Fractures of the neck of femur:
- Very common in old age, especially in females due to osteoporosis.
b) Dislocation of the hip joint: May be congenital or traumatic.
- Congenital dislocation.
- Traumatic posterior dislocation occurs in car accidents, may injury sciatic nerve
c) Pain from the hip joint may be felt at the knee region:
- This is due to the rich nerve supply of the hip joint from the femoral and obturator
nerves which also supply the knee joint.
- So, referred pain at the knee may be of hip origin.

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 Knee joint
- Type: synovial joint.
- Variety: modified hinge: as it allows some medial and lateral rotation added
to flexion and extension (actions done by any hinge joint).

- Articulating surfaces:
-2Condyles of: lower end of femur and of upper end of tibia.
-Back of patella

• Fibrous capsule:
Attachments:
∗ The capsule is attached to the sides of the patella and to the margins
of both femoral and tibial condyles
∗ The anterior wall of the capsule is completely absent where it is
replaced by the tendon of quadriceps femoris muscle, patella and
patellar ligament.

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-The posterior wall of the capsule is perforated by the tendon of
popliteus muscle which begins intracapsular.

- Ligaments of the knee joint:

Four extra-capsular ligaments (lying outside the capsule of the joint):
1-Oblique popliteal ligament: (posteriorly)
• It is an expansion from the tendon of insertion of

semimembranosus muscle.
• It passes upwards and laterally towards the lateral condyle of the

femur reinforcing the posterior aspect of the capsule.

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[Link] ligament: (Ligamentum patellae): (anteriorly).
• It is the downward continuation of the quadriceps femoris tendon.
• It extends from the apex of patella to the tibial tuberosity.
• It forms part of the anterior wall of the capsule of the knee joint.
3-Fibular (lateral) collateral ligament: (cord-like)
• It extends from the lateral epicondyle of the femur (above) to the
head of fibula (below).
• It reinforces the lateral aspect of the capsule.
• The tendon of popliteus muscle (inside the capsule) separates this
ligament from the lateral meniscus, which is therefore free and
mobile.
4-Tibial (medial) collateral ligament: (flattened band)
• It is attached to the medial epicondyle of femur (above) and to the
margin of medial condyle of tibia (below)
• It adheres to and reinforces the medial aspect of the capsule.
• It is firmly attached to the medial meniscus
•

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 Three intracapsular ligaments (lying inside the capsule of the joint):
1- Anterior cruciate ligament.
2- Posterior cruciate ligament.
3- Transverse ligament of the knee.
Intracapsular structures of the knee joint:
1. Two menisci (semilunar cartilages).
2. Two cruciate ligaments.
3. Transverse ligament of the knee which connects the anterior ends of the 2
menisci (has no bony attachment).
4. Tendon of origin of popliteus which perforates the back of the capsule to leave
the knee joint, accompanied by its synovial sheath.
5. Infrapatellar pad of fat
6. Synovial membrane
Semilunar Cartilages (Menisci):
Shape ,Structure ,Site and Attachment: :The meniscus is a curved plate of
fibrocartilage which lies on the upper surface of the corresponding condyle of tibia.
Each meniscus has an anterior and a posterior horns that attached to the
intercondylar area of the tibia.
Function :The menisci act as shock absorbers and help fitting of the convex femoral
condyles to the flat tibial condyles.
Medial Meniscus:
1- Shape: C-shaped, larger than the lateral meniscus.
2- Attachments:
- The anterior horn (end): is attached to the most anterior part of the
intercondylar area of tibia(in front of the anterior cruciate ligament).
- The posterior horn (end):is attached to the posterior part of the intercondylar
area (behind the posterior horn of the lateral meniscus and in front of the
posterior cruciate ligament).

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3- Mobility: it is less mobile as it is fixed to the tibial collateral ligament and the
capsule of the knee joint. So, it is more liable to be injured by becoming
compressed between the moving femoral and tibial condyles.
4- Function: it increases the concavity of the articular surface of the medial
condyle of tibia to adapt the shape of the femoral condyle.
Lateral Meniscus:
1- Shape: circular in shape, smaller.
2- Attachments: its 2 horns lie very close to each other:
- The anterior horn: it is attached to the anterior intercondylar area of tibia
just in front of the lateral intercondylar tubercle.
- The posterior horn: it is attached to the posterior intercondylar area of tibia
just behind the lateral intercondylar tubercle.
3- Mobility: it is more mobile, being separated from the capsule and the fibular
collateral ligament by the tendon of origin of popliteus muscle to which it is
attached; this arrangement makes it less liable to be injured.
4- Function: as the medial meniscus.

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104
Cruciate Ligaments:
Two strong ligaments (anterior and posterior) present inside the knee joint.
They cross each other in the form of the letter X.
Anterior cruciate ligament:
1) Attachments:
- To the anterior intercondylar area of the tibia between the anterior horns
of the 2 menisci.
- It then passes upwards, backwards and laterally to become attached to
the medial surface of the lateral condyle of femur.
2) Function: being stretched on extension of the knee, so:
- It prevents its hyperextension.
- It prevents anterior dislocation of the tibia during extension.

Posterior cruciate ligament:

1) Attachments:
- To the posterior intercondylar area of the tibia.
- It then passes upwards, forwards and medially to become attached to
the lateral surface of the medial condyle of femur.
2) Function: being stretched on flexion of the knee, so it prevents posterior
dislocation of the tibia during flexion.

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 Function of cruciate ligaments:
- Anterior cruciate ligament becomes tens with extension of knee
- so :
It prevents hyperextension of knee joint .
It prevents anterior dislocation of the tibia during extension.

- Posterior cruciate ligament becomes tens with flexion of knee

- so
It prevents posterior dislocation of the tibia during flexion
It prevents anterior dislocation of the femur during flexion

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 Movements of the Knee Joint:
Flexion and extension are the main movements of the knee:
1- Flexion: done mainly by the 3 hamstrings, assisted by popliteus,
sartorius and gracilis.
2- Extension: done by quadriceps femoris only.
3- Rotation:
-Slight degree of rotation can also occur at the knee
-It can only be performed in the semiflexed knee:
a. Lateral rotation: done by biceps femoris only.
b. Medial rotation: popletius. sartorius, gracilis, semitendinosus (S.G.S)
and semimembranosus

Locking of knee
- Mechanism: medial rotation of femur on tibia .or lateral rotation of tibia on femur
- Occurs: after full extension to make the knee a rigid structure and the lower limb a rigid
column in walking and standing. .
- Mechanism locking of the knee:
• The anterior cruciate ligament becomes tense before the end of extension stopping extension on the lateral
side while it continues or the medial side leading to rotation.
• This is helped by the fact that the anteroposterior diameter of the medial articular surfaces are longer than
those of the lateral.
- Muscle responsible: quadriceps femoris muscle.

Unlocking
- Mechanism: lateral rotation of femur on [Link] medial rotation of tibia on femur
- Occurs: at the beginning of flexion.
- Muscle responsible in unlocking of the knee:
• Popliteus

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- Nerve supply of the knee joint:
1- Three genicular nerves from tibial nerve.
2- Three genicular nerves from common peroneal nerve.
3- From femoral and obturator nerves (as the hip joint); that is why diseases of
the hip joint may lead to pain which may be referred to the knee joint.
Bursae around the knee joint:
a) Bursae on the anterior aspect of the joint:
1- Supra-patellar bursa: between tendon of quadriceps femoris and front of lower end of femur.
2- Infra-patellar bursa:
∗ Subcutaneous infra-patellar bursa: between skin and tuberosity of tibia.
∗ Deep infra-patellar bursa: between patellar ligament and front of upper end of tibia.
3- Subcutaneous pre-patellar bursa: between skin and patella. (This bursa is usually inflamed and becomes
swollen and painful from frequent kneeling, a condition called housemaid’s knee).
b) Bursae on the medial aspect of the joint:
1- Between medial head of gastrocnemius and capsule of the knee joint.
2- Between semimembranosus and medial condyle of tibia.
3- Between tendons of (S.G.S) and capsule of the joint.
c) Bursae on the lateral aspect of the joint:
1- Between the lateral head of gastrocnemius and the capsule of the joint.
2- Between the tendon of biceps and the fibular collateral ligament.
3- Between the tendon of popliteus and the lateral condyle of femur.

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Clinical points related to the knee joint:
Genu valgum:
• When the knee is hit hard from the lateral side while the foot is on the ground, the tibial
collateral ligament ruptures; the knee joint is opened on the medial side and the knee is
forced inwards, a condition known as “genu valgum”. This may tear the medial meniscus
and the anterior cruciate ligament.

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 Tibio-fibular Joints (T.F.J.)
1- Superior tibio-fibular joint: (Fig. 92)
A synovial joint of plane variety, between head of fibula and a rounded
facet on the inferior surface of the lateral condyle of tibia.

2- Middle tibio- fibular joint: (interosseus membrane)

- It is tense, so not allowing movements between tibia and fibula.
- Its fibres run obliquely downwards and laterally from tibia to fibula.

3- Inferior tibio-fibular joint: a fibrous joint (syndesmosis) between the

medial surface of the lower end of fibula and the fibular notch of tibia.

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 ANKLE JOINT
- Type and variety: synovial, uniaxial joint of the hinge variety.
- Articulating surfaces:
• Above and medially: lower end of tibia and its medial malleolus.
• Above and laterally : lateral malleolus of fibula.
• Below : trochlea of talus.
- Fibrous capsule:
• It is attached to the margins of the articulating surfaces.

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- Ligaments of ankle joint:
a) Medial ligament of ankle: (deltoid ligament):
It is triangular in shape (hence the name deltoid). It is attached by its apex
(above) to the tip of the medial malleolus, and by its base (below) to the neck
of talus, tuberosity of navicular bone, spring ligament, sustentaculumtali
and body of talus.
b) Lateral ligament of ankle:
Formed of 3 separate bands radiating from lateral malleolus of fibula.
1- Anterior talo-fibular ligament: from lateral malleolus to talus.
2- Posterior talo-fibular ligament: it extends horizontally from malleolar
fossa of fibula to talus.
3- Calcaneo-fibular ligament: it is a vertical middle band which extends
from the lateral malleolus to the lateral surface of calcaneus.

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- Movements of the ankle joint: (Only two)
a) Plantar flexion:(moving the foot downwards):
Produced mainly by: gastrocnemius and soleus and helped by the
deep calf muscles (tibialis posterior, flexor hallucislongus and flexor
digitorumlongus).

b) Dorsiflexion (Extension):
(moving the foot upwards with the heel on the ground).
Produced by: muscles of anterior compartment of leg (tibialis anterior, extensor
digitorumlongus, extensor hallucislongus and peroneus tertius).

- Nerve supply of the ankle joint:branches from anterior and posterior tibial
nerves.

- Arterial supply of the ankle joint: from the anastomosis around the ankle
(around medial and lateral malleoli).

- Clinical points related to the ankle joint:

Sprain of ankle joint, occurs in:

• Excessive inversion of foot the anterior talo-fibular and calcaneo- fibular

ligaments are torn.
• Excessive eversion of foot the deltoid ligament is torn (less common).
In both conditions, local pain and swelling occur.

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 Intertarsal joints
[Link] (talo-calcanean) joint:
- Type: synovial joint. Variety: plane (or gliding).
- Articular surfaces: between inferior surface of body of talus and upper
surface of calcaneus.
- Movement: the subtalar joint allows inversion and eversion of foot.
[Link]-calcaneo-navicular joint:
- Type: synovial joint. Variety: complex ball and socket.
- Articular surfaces: between head of talus (a ball) which articulates with (a
socket) formed by calcaneus and navicular bones with the spring ligament
between them.
- Ligaments:
a) Spring (plantar calcaneo-navicular) ligament: it extends between the
sustentaculumtali of calcaneus to the tuberosity of navicular bone on the
plantar surface of foot.
b) Calcaneo-navicular ligament:
c) Talo-navicular ligament: connects the neck of talus to the navicular bone
and supports the capsule superiorly.
- Movements of the joint: It allows inversion and eversion of foot.

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 [Link]-cuboid joint:
- Type: synovial joint.

- Articular surfaces: anterior end of calcaneus articulates with posterior surface

of cuboid bone.
- Ligaments:
• Bifurcate ligament: it is a Y-shaped ligament which lies on the dorsal surface

of foot. It is formed of a stem and 2 limbs:

∗ The stem is attached to the upper surface of calcaneus.

∗ The 2 limbs are made of 2 ligaments:

 Dorsal calcaneo-cuboid ligament: attached to the medial side of cuboid

bone.
 Dorsal calcaneo-navicular ligament: attached to the dorsal surface
of navicular bone.
2- Cuneo-navicular joint:
- Type: synovial joint. Variety: plane.
- Articular surfaces: Anterior navicular bones articulate with posterior surface of

the 3 cuneiform bones.

3- Tarso-metatarsal joint:
- Type: synovial joint. Variety: plane.
- Articular surfaces: Anterior tarsal bones articulate with bases of metatarsal

bones.
4- Metatarsophalangeal joints:
- Type: synovial joint. Variety: condyloid
- Articular surfaces: Heads of metatarsal bones articulate with bases of proximal

phalanges.
- Movements: Flexion, extension, some abduction and adduction.

5- Interphalangeal joints:
- Type: synovial joint. Variety: Hinge
- Articular surfaces: Head of one phalanx articulates with base of one distal to it.

- Movements: Flexion and extension.

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116
 Inversion and Eversion

- In inversion: the sole turns medially (to inside).

- In eversion: the sole turns laterally (to outside).
These movements take place at the intertarsal joints:
1- Subtalar joint.
2- Talo-calcaneo-navicular joint.
Mechanism: the talus is fixed (by the 2 malleoli) while the calcaneus and
navicular bones swing around it carrying the other bones of the foot with
them.
Muscles acting in:

Inversion Eversion
• Tibialis anterior • Peroneus longus
• Tibialis posterior • Peroneus brevis
• Peroneus tertius

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 ARHCS OF THE FOOT
- The bones of the foot are arranged in longitudinal and transverse arches.
- The longitudinal arches extend from before backwards, while the
transverse arch extends from side to side.
Factors which help to maintain the arches of foot:
-The shape of the interlocking bones and the joints in between.
-The strength of the plantar ligaments of the tarsus and the plantar
aponeurosis (most important).
-The action of the muscles of leg and foot
Function of arches:
(1) They prevent pressure on the soft tissues of the sole in standing , walking
and balance.
(2) Falling of these arches (due to weak muscles or bone anomalies) leads to a
condition known as flat foot causing foot pain after walking due to excessive
stretch of the plantar muscles and ligaments.

118
[A] The longitudinal arches
1. Medial longitudinal arch:
It is made of 9 bones:
Calcaneus, talus, navicular, 3 cuneiforms and the medial 3
metatarsal bones.
The head of talus is the apex of the arch which receives the weight
of the body (the medial arch is higher than the lateral one).
Factors that maintain the medial arch:
1. Shape of bones.
2. Ligaments:
- Spring ligament (main supporter of the arch).
- Deltoid ligament.
- Plantar aponeurosis.
3. Muscles:
- Tibialis anterior and tibialis posterior tendons.
- Flexor hallucis longus tendon and medial tendons of flexor
digitorum longus.
- Short muscles of big toe.
Function of medial arch:
Helps elastic propulsion of the foot during walking and running
(kinetic arch).

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120
2. Lateral longitudinal arch:
It is made of 4 bones:
Calcaneus, cuboid and the lateral 2 metatarsal bones.
Factors that maintain the lateral arch:
1. Shape of bones.
2. Ligaments:
- Long and short plantar ligaments (main supporter of the arch).
- Plantar apon eurosis.
3. Muscles:
- Peroneus longus and brevis tendon.
- Lateral tendons of flexor digitorum longus.
- Short muscles of little toe.
- Function of lateral arch:
- Supports the body weight in standing position (static

121
122
[B] The transverse arch of foot:
- It runs from side to side.
- It is formed by the tarsals (cuboid and 3 cuneiform bones) and the bases of
all metatarsal bones.
Factors that maintain the transverse arch:
1- Shape of lateral and intermediate cuneiform bones which are wedge-
shaped.
2- Ligaments: dorsal and plantar interosseus ligaments.
3- Muscles:
- Peroneus longus tendon (traverses the sole transversely).
- Transverse head of adductor hallucis muscle.
- Dorsal interosseous muscles.
N.B.: In infants, these arches are normally present, but they are masked by the fat that
fills the concavity of the sole of foot. So, the foot of the young child appears flat.

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 Cutaneous Innervation of the Lower Limb
)
[I] Cutaneous nerves of the gluteal region and thigh:
From the lumbar plexus:
1. Ilio-inguinal nerve (L1): to skin of upper part of medial side of thigh
and skin of adjoining external genitalia.
2. Femoral branch of genito-femoral nerve (L1, 2): to skin of upper part
of front of thigh.
3. Lateral cutaneous nerve of thigh (L2, 3): to skin of lateral side of thigh.
From the femoral nerve:
a) Medial cutaneous nerve of thigh: to skin of medial side of thigh.
b) Intermediate cutaneous nerve of thigh: to skin of front of thigh.
c) Saphenous nerve: to skin of lower part of medial side of thigh
(infrapatellar branch)
From the obturator nerve: Its anterior division supplies the skin of the
lower part of medial side of thigh.
From the sacral plexus:
1. Perforating branch of sacral plexus (S3): to skin of gluteal region.
2. Posterior cutaneous nerve of thigh (S2): to skin of gluteal region and
skin of back of thigh.
[II] Cutaneous nerves of leg:
1. Saphenous nerve: (from femoral nerve) to skin of medial side of leg.
2. Lateral cutaneous nerve of calf: (from lateral popliteal nerve), to skin of
upper 1/3 of the anterolateral side of the leg.
3. Sural nerve: (from medial popliteal nerve), to skin of lower part of back
of leg.
4. Sural communicating nerve: (from common peroneal nerve) joins the
sural nerve.
5. Superficial peroneal nerve: to skin of lower 2/3 of the leg (anterolateral
aspect only).
6. Posterior cutaneous nerve of thigh: to skin of the upper part of back of
the leg.

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[III] Cutaneous nerves of foot:
(a) Sides of foot:
1. Saphenous nerve: to skin of medial side of foot as far as the 1st M/P
joint of big toe.
2. Sural nerve: to skin of lateral side of foot as far as the end of the
terminal phalanx of the little toe.
(b) Dorsum of foot:
1. Superficial peroneal nerve: to skin of most of dorsum of foot and toes
accept the adjacent sides of the 1st and 2nd toes (supplied by deep
peroneal nerve).
2. Deep peroneal nerve: to skin of adjacent sides of 1st and 2nd toes only.
(c) Sole of foot:
1- Medial plantar nerve: to skin of medial part of sole and plantar surface
of medial 3 ½ toes.
2- Lateral plantar nerve: to skin of lateral part of sole and plantar surface
of lateral 1 ½ toes.

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