Lower Limb

The only anatomic structure with a bottom at its

top.
Regions of the Lower Limb
1. Gluteal Region
1. Buttocks –intergluteal cleft, gluteal
fold/crease
2. Hip
2. Femoral Region
1. Inguinal region
3. Knee Region (genu)
1. Popliteal fossa
2. Patella
4. Leg Region (crus)
5. Ankle region (talocrura)
6. Foot (pes)
1. Tarsus, metatarsus, phalanges
Surface Anatomy of the Lower Limb
Thigh
• Femoral Triangle
• Gracilis m.
• Adductors
• Sartorius
• Quadriceps
• Tensor fascia latae
Leg
• Fibularis m.
• Tibialis anterior m.
• Gastrocnemius
• Soleus
Sensory Pathways
1. Dorsal Column-Medial Lemniscal Tract
• Carries general touch sensation
• Ascends ipsilaterally and crosses at the
medulla oblongota
2. Spinothalamic Tract
• Carries temperature and pain sensation
• Crosses immediately in the spinal cord
to the contralateral side.
3. Spinocerebellar tract
• Carries proprioception information
from golgi tendon organs and muscle
spindles in the torso and legs.
• Does not cross
• Function: Coordination of muscles
 Motor Pathways
Motor neurons (2).
• Upper motor neuron crosses at the
pyramids in the medulla to control the
movement of the muscle on the
contralateral side of the body.
• Lower motor neuron extends from
the Anterior horn to the muscle or organ.
Tracts:
1. Lateral Corticospinal Tract
• Controls muscles of the limbs and
some organs. Especially fine motor
control.
2. Anterior Corticospinal Tract
• Controls the axial and girdle
muscles and some gross movement
of the appendicular muscles.
Innervation of the Lower Limb
Development of the Lower Limb

4th week 7th

week
Talipes Equinovarus – Club Feet

Ponseti Method
 Cutaneous innervation of the Lower Limb

Foerster map Keegan and Garrett Map

Clinical Developmental
 Os –Lt. bone
Os Coxa (pl. ossa coxae) – aka. Pelvic bone Coxa – Lt. hip
Os Coxae
 Growth and Development of the Hips

Infants hip X-ray showing three distinct parts of the Os Coxae

Growth and development of the pelvis (pictured from the front, top row; and from above,
bottom row) from birth to 80 years of age. The opening in the pelvis widens during puberty
then narrows again later in life.
IMAGE COURTESY OF MORPHOLAB, UNIVERSITY OF ZURICH SCIENCE APR 2016
Fusion of the iliac crest epiphysial plate
 Transfer of weight through the pelvic girdle
1. Body weight is transferred
from the vertebral column
through the sacroiliac joints
to the pelvic girdle.
2. Weight is divided and
directed laterally through the
bony arch.
3. Thick portions of the ilia
transfer the weight to the
femurs.
4. The pubic rami form “struts”
or braces that help maintain
the integrity of the arch
5. The femur angles medially to
recenters support directly
inferior to the body mass to
make bipedal standing
possible.
 Femoral Angle of Inclination:

Femurs of females are slightly

more oblique than those of the
males reflecting the greater width
of their pelvis

Sexual dimorphism
Femur: The Angle of Inclination

• The angle of inclination is the

angle between the neck and
the shaft of the femur.
• Note that the line of gravity
aligns between the head of the
femur and the intercondylar
fossa.
• The AOI is sexually dimorphic
• Changes through your lifetime.
• The angle decreases with
age and with the overall
weight of the person.
 Arrangement of the
Lower Limb.
• The femur transfers weight from the
acetabulum to the tibia.
• The tibia transfers weight to the talus
in the ankle.
• The fibula does not bear weight but
acts as a muscle attachment and a
stabilizer for the ankle joint.
• The talus is the keystone of the
longitudinal arch formed by the
tarsal and metatarsal bone
distributing the weight between the
heel and the forefoot.
 Ligaments of pelvic girdle.

Ligaments of pelvic girdle. The sacrotuberous and sacrospinous ligaments convert the greater and lesser
sciatic notches into foramina.
Tension and Compression Lines of the Femur
Acetabular Fracture of the Pelvis
Osteoporosis
is a bone
disease that
develops when
bone mineral
density and
bone mass
decreases, or
when the
quality or
structure of
bone changes.
This can lead to
a decrease in
bone strength
that can
Pelvic Fractures increase the
Fracture of the neck of the femur.
Injuries of the Hip Bone.
• Avulsion fractures of the hip
bone may occur during
sports that require sudden
acceleration or deceleration
forces, such as sprinting or
kicking in football, soccer,
hurdle jumping, basketball,
and martial arts.
• A small part of bone with a
piece of a tendon or ligament
attached can be “avulsed”
(torn away).
Anatomy of the Femur
 Surface Anatomy of the Pelvic Girdle and Femur

Bony landmarks are helpful during physical examinations and surgery because they can be used to
evaluate normal development, detect and assess fractures and dislocations, and locate the sites of
structures such as nerves and blood vessels.
 Femoral Fractures
• The neck of the femur is most frequently fractured because it is the
narrowest and weakest part of the bone and it lies at a marked angle to
the line of weight bearing (pull of gravity). It becomes increasingly
vulnerable with age, especially in females, secondary to osteoporosis.
• Distal fractures often require traction, intermedullary nailing and/or
external fixators. Because they are often associated with significant
trauma and may take months to heal.

Intermedullary nailing
Image: American Academy of Orthopedic Surgeons
 Patella

• The patella is a sesamoid bone that is formed in the tendon of the quadriceps femoris muscle after birth.
• It articulates with the patellar surface of the femur with the central ridge keeping it centered in the intercondylar groove
of the femur giving the quadriceps mechanical advantage.
• How can you determine right vs left and medial vs later articular surface?
 Patellar Fracture

Patellar repair – open

reduction-internal fixation

Transverse patellar fractures may result from a blow to the knee or sudden contraction of the
quadriceps The proximal fragment is pulled superiorly with the quadriceps tendon, and the
distal fragment remains with the patellar ligament.
Tibia and Fibula
 Tibia
• Medial and lateral condyles make a platform (superior
articular surface) for bearing the weight of the body.
• Intercondylar eminence fits into the intercondylar
fossa of the femur.
• Anterolateral tibial tubercle (Gerdy tubercle) – attaches
to the iliotibial tract.
• Tibial tuberosity – attaches to the Patellar ligament
• Pes anserinus – attaches to the Medial side of tibia.
Muscles: gracilis, semitendinosus and sartorius.
• Soleal line – posterior (not shown)
• Interosseous border attaches to the interosseous
membrane.
• Medial malleolus – stabilizes the ankle
• Fibular notch – attachment of the fibula.
 Tibial Fractures

Most tibial fractures are combined with fibular

fracture.
Fibula
• No function for bearing the weight of the body.
• Head attaches to the proximal tibia in the articular facet.
• Interosseous border attaches to the interosseous
membrane.
• Lateral malleolus – stabilizes the ankle and forms the
lateral border of the socket (mortise).
• What attaches to the fibula?
 Fibular Fractures

eversion
• Fibular fractures commonly occur 2–6 cm proximal
to the distal end of the lateral malleolus and are often
associated with fracture–dislocations of the ankle
joint,
– may be combined with tibial fractures.
• When a person slips and the foot is forced into an
excessively inverted position, the ankle ligaments
tear, forcibly tilting the talus against the lateral
malleolus, causing it to shear off.

inversion
• The fibula is also exposed to blows to the lateral leg
and therefore susceptible to fracture.
Surface Anatomy of the Tibia and Fibula – Ankle and Heel
Bones of the Foot
Tarsus (7)
• Talus
• Calcaneous
• Navicular
• Cuboid
• Cuneiforms 1-3
Metatarsus (5)
Phalanges
• Proximal
• Middle (not in 1st digit)
• Distal
Bones of the Foot
Surface Anatomy
Fractures of the Foot

1. Calcaneal Fracture -common in falls

from height.
2. Talar Fracture - occur during severe
dorsiflexion
3. Metatarsal Fracture – Occurs
when heavy objects fall on feet or
in dancers on point.

An avulsion fracture of the tuberosity of the

5th metatarsal is common in basketball and
tennis players. This injury produces pain and
edema at the base of the 5th metatarsal and
may be associated with a severe ankle
sprain.
Os Trigonum – secondary ossification center does not unite on the
talus. (may cause pain in the ankle and/or reduced plantar flexion).
Sesamoind Bones – shown in the flexor hallicus longus
Evan Seamons 2015
 Fascia and Compartments of the
Lower Limb.
• Fascia lata (L. Broad) or deep fascia of the
thigh.
• Iliotibial tract
• Tensor Fascia latae and gluteus
maximus
• Inserts on the Ant. Lat. Tibial
tubercle or Gerdy tubercle
• Crural fascia or deep fascia of the leg
• Extensor retinacula of the foot
• Fascial Compartments of the leg and
thigh.
• Share common functions and
innervations.
 Compartments of the Thigh and Leg

Fascia lata

Crural Fascia
Saphenous Opening and Superficial veins of the Lower Limb

Falciform – curved like a sickle, hooked

Superficial veins of the
Lower Limb
Deep Veins of the Lower Limb
Lymphatic Vessels of the Lower Limb

Lymphedema
Femoral Artery

Profunda femoris or deep femoral artery is the largest branch of the femoral
artery and the chief artery to the thigh
Arteries of the Knee

Arterial anastomoses around knee. In addition to providing collateral circulation, the genicular arteries
of the genicular anastomosis supply blood to the structures surrounding the joint as well as to the joint
itself (e.g., its joint or articular capsule). Compare these views with the anterior view in Figure 5.93B.
Arteries of the Leg
Muscles of the Anterior Thigh: Flexors of the Hip Joint

Iliopsoas is the most powerful flexor of the thigh with the longest range. It is
also a powerful fixator of the thigh. The rectus femoris (not shown) can also
act as a flexor of the thigh.
MUSCLES OF ANTERIOR THIGH: FLEXORS OF HIP
JOINT
Muscles of the Anterior Thigh: Extensors of the Knee

Note: the rectus femoris crosses both the hip and knee joint and therefore has action at both as a
hip flexor and knee extensor.
MUSCLES OF ANTERIOR THIGH: EXTENSORS OF KNEE
Suprapatellar bursa and articularis genu muscle.

• The suprapatellar bursa, normally a potential space extends between the quadriceps and the femur
(exaggerated for schematic purposes in C).
• The articularis genu muscle pulls the synovial membrane superiorly during extension of the leg, preventing
folds of the membrane from being compressed between the femur and the patella within the knee joint.
Adductors of the Thigh
 MUSCLES OF MEDIAL THIGH: ADDUCTORS OF THIGH

• Collectively, the five muscles listed are the adductors of the thigh, but their actions are more complex
(e.g., they act as flexors of the hip joint during flexion of the knee joint.
• All adductor muscles, except the “hamstring part” of the adductor magnus and part of the pectineus, are
supplied by the obturator nerve (L2–L4).
• The hamstring part of the adductor magnus is supplied by the tibial part of the sciatic nerve (L4).
Pes anserinus
• The gracilis is a synergist in
adducting the thigh, flexing the
knee, and rotating the leg medially
when the knee is flexed.
• It acts with the other two “pes
anserinus” muscles to add stability
to the medial aspect of the extended
knee, much as the gluteus maximus
and tensor fasciae latae do via the
iliotibial tract on the lateral side.
• Muscles:
Goose Foot
– Gracilis
– Semitendinosus
– Sartorius
Femoral Triangle

Borders:
1. Inguinal ligament
2. Sartorius
3. Adductor Longus
4. Muscle floor –
Iliopsoas/pectinius
5. Fascia lata roof.
Femoral Triangle
Femoral Triangle
Contents:
Femoral sheath
1. Femoral artery
2. Femoral vein
3. Femoral canal
• Deep inguinal lymph
nodes and vessels
Muscular compartment
4. Femoral nerve
• Outside of the
femoral sheath
Femoral sheath in femoral triangle.
Femoral Hernias

The femoral ring is a weak area in the anterior abdominal wall that normally is of a size sufficient to
admit the tip of the little finger. The femoral ring is the usual originating site of a femoral hernia. A
femoral hernia appears as a mass, often tender, in the femoral triangle, inferolateral to the pubic tubercle.
Myotomes: segmental innervation of muscle groups and
movements of lower limb
Posture and Gait
Standing at Ease Position:
• The line of gravity falls between the
two limbs, just anterior to the axis of
rotation of the ankle joints.
• -Only minor postural adjustments,
mainly by the extensors of the back
and the plantar flexors of the ankle,
are necessary to maintain this
position because the ligaments of the
hip and knee are being tightly
stretched to provide passive support.
Walking: The Gait Cycle
Abnormal Gaits
1. Hemiplegic Gait
• Circumduction of the foot –usually due to stroke on one side of the brain thus
hemiplegic (one sided paralysis, weakness, spasticity, loss of motor control)
• Hand is generally flexed up (Flexor hypertonia of the upper limb)
• Extensor hypertonia of the lower limb - foot drop.
• More distal weakness but less proximal weakness.
2. Parkinsonian Gait
• Festinating gait – fr. Marche de petits paw (march of little steps)
• General flexion of joints and with tremor.
3. Cerebellar Gait
• Broad stance and wide staggering quality.
• Fall toward the side of their illness
• Tilting/swaying while standing still (titubation)
4. Stamping Gait.
• Loss of proprioception in feet – stomping in the dark to get vibration up the limb
so that is can be detected.
Abnormal Gaits
5. Diplegic Gait or the cerebral palsy gait.
• Extensor spasm in both legs / medial gait or scissor gait.
• Walking on tip toes.
6. Myopathic Gait or “Waddling Gait”
• Falling hip or hip drop- compensating for weak pelvic muscles.
• Trendelenburg sign – hip falls so you compensate by leaning away from
the side of weakness.
7. Neuropathic gait (Equine or Steppage gait)
• High stepping gait to compensate for foot drop.
• Weak dorsiflexors often due to a damaged deep fibular nerve that feed the
anterior compartment.
8. Choreiform gait
• Already have writhing movements when sitting that continue when
walking.
Gait Examination
Following a major operation, a patient was placed on a course
of antibiotics which were to be delivered via intramuscular
injection to his buttocks.
After one of these injections, the patient complained of more
pain than usual in the region of the injection.
Later, as the patient was taking his afternoon walk in the hall,
the nurse noticed that he was walking with a limp that had not
been present before. His left hip dropped every time he lifted
his left foot off the floor, but on the right side, his pelvis
remained level when he lifted-up his right foot.

What could be the cause of the patient’s hip drop?

Which muscle/nerve might be involved?
• The nerve that innervates the gluteus medius and minimus muscles and the tensor faciae latae
is the superior gluteal nerve.
• Nerve roots L4, L5 and S1 supply the superior gluteal nerve.
• Damage results in Trendelenburg gate – weakness in the abductors of the thigh
The neurovascular structures of the gluteal region and proximal posterior thigh.
 Intragluteal Injections

• The gluteal region (buttocks) is a common site for intramuscular (IM) injection of drugs. Gluteal IM
injections penetrate the skin, fascia, and muscles.
• Injections into the buttocks are safe only in the superolateral quadrant of the buttocks or superior to a line
extending from the PSIS to the superior border of the greater trochanter (approximating the superior border of the
gluteus maximus).
 Gluteal Region: Buttocks and Hip

Buttocks is posterior to the pelvis and inferior to the level of the iliac crests and extending
laterally to the posterior margin of the greater trochanter.
Hip region overlies the greater trochanter laterally, extending anteriorly to the ASIS.
Intergluteal cleft (natal cleft) is the groove that separates the buttocks.
Gluteal fold demarcates the boundary between the buttocks and the the thigh.
Muscles of gluteal region: superficial and deep dissections.
Muscles of gluteal region:
Abductors and Lateral rotators of the thigh.
Gluteus maximus and tensor fasciae latae.
• Aka. the lateral musculofibrous complex is formed by the tensor fasciae latae and gluteus maximus muscles
and their shared aponeurotic tendon, the iliotibial tract.
• The iliotibial tract is continuous posteriorly and deeply with the dense lateral intermuscular septum attaching
directly to the femur. Aponeurosis Gk. apo – away, neuron - sinew
Gluteal muscles and bursae.
Gluteal muscles and bursae.
Muscles:
1. Gluteus medius
2. Gluteus minimus
3. Piriformis
4. Superior gemellus
5. Obturator internus
6. Inferior gemellus
7. Quadratus femoris

Three bursae:
8. Trochanteric,
9. Gluteofemoral,
10. Ischial
These usually decrease friction between the
gluteus maximus and the underlying bony
prominences.
4. Bursa of the obturator internus
Underlies the tendon of the obturator internus
as it crosses the lesser sciatic notch
The lateral rotators of the thigh.

Triceps Coxae:
1. Superior Gemellus
2. Obturator Internus
3. Inferior Gemellus
Obturator Externus

• The components of the triceps

coxae share a common
attachment into the trochanteric
fossa adjacent to that of the
obturator externus.
• They are lateral rotators of the
thigh.
The neurovascular structures of the gluteal region.
• Sciatic n.
• Muscles of the posterior thigh.
• Superior gluteal n.
• Gluteus Medius, Minimus and
tensor fascia latae
• Inferior gluteal n.
• Gluteus maximus
• Nerve to the obturator internus.
• Superior gemellus, obturator
internus
• Nerve to the quadratus femoris.
• Inferior gemellus and quadratus
femoris
Movements of the Thigh: Medial and Lateral Rotation.
Muscles of posterior thigh: extensors of hip and flexors of knee.
Muscles of posterior thigh: extensors of hip and flexors of knee.
Muscles and fascial compartments of thigh.

• The three compartments of

the thigh:
– Anterior
• Femoral nerve
– Posterior
• Sciatic nerve
– Medial
• Obturator nerve
• Each has its own nerve supply
and functional group(s) of
muscles.
Nerves of the gluteal and posterior thigh regions.

Sciatic
• Innervates muscles of
the posterior
compartment of the
thigh.
• Leg
• Tibial
• Common Fibular
• Deep Fibular
• Superficial
Fibular
Nerves of the anterior thigh regions.

Femoral Nerve
• Superficial Division
• Motor to Sartorius
• Sensory to the skin of the
anterior and medial thigh.
• Deep Division
• Motor branches to the
quadriceps muscles.
• Sensory to the medial knee,
surface of the medial leg
and dorsum of the foot
Relationship of sciatic nerve to piriformis.

A. The sciatic nerve usually emerges from the

greater sciatic foramen inferior to the
piriformis.
B. In 12.2% of 640 limbs the sciatic nerve
divided before exiting the greater sciatic
foramen; the common fibular division
(yellow) passed through the piriformis.
C. In 0.5% of cases, the common fibular
division passed superior to the muscle, where
it is especially vulnerable to injury during
intragluteal injections.
Arteries of the gluteal and posterior thigh regions.
Surface anatomy of the hip region and lateral thigh.
 Surface anatomy of the gluteal
region and posterior thigh.

A. Surface projection of piriformis and

sciatic nerve.
B. The hip and knee joints are extended
with muscles actively tensed following
exercise, to provide muscle definition.
C. Weight is being borne by the right limb
while the hip, knee, and
metatarsophalangeal joints are in a
flexed position.
THE KNEE
Popliteal Fossa

Superficial popliteal region.

The diamond-shaped gap in the roof of the popliteal fossa, formed by the overlying muscles, is outlined.
What are the borders of the popliteal fossa?
Nerves of the Popliteus
Nerves of Popliteal Fossa.

• Sciatic nerve: separates into the common

fibular nerve and tibial nerve at the apex of
the popliteal fossa (or higher).
• Common fibular nerve: courses along the
medial border of the biceps femoris.
• Tibial Nerve: All of the motor branches
arising from the tibial nerve, except one, arise
from its lateral side; consequently, in surgery it
is safer to dissect on the medial side.
• Medial sural cutaneous nerve and sural
communicating branch merge to form the
sural nerve. The sural nerve runs down the
mid calf to the ankle and along the skin from
the mid-posterior popliteal fossa to just behind
the lateral malleolus and then under the
malleolus and forward along the lateral aspect
of the foot
Deep dissection of popliteal fossa.
The popliteal artery runs on the floor of
the fossa, formed by the popliteal surface
of the femur, the joint capsule of the
knee, and the investing fascia of the
popliteus.
Genicular anastomosis.

Genicular anastomosis.
The many arteries making up
the peri-articular anastomosis
around the knee provide an
important collateral circulation
for bypassing the popliteal
artery when the knee joint has
been maintained too long in a
fully flexed position or when the
vessels are narrowed or
occluded.
Bones of knee joint.
Bones of knee joint.
External aspect of joint capsule of knee.

The fibrous layer of the joint capsule is relatively thin in some places and thickened in others to form reinforcing intrinsic (capsular)
ligaments. A. Modifications of the anterior aspect and sides of the fibrous layer include the patellar retinacula, which attach to the sides
of the quadriceps tendon, patella, and patellar ligament, and incorporation of the iliotibial tract (laterally) and the medial collateral ligament
(medially). B. The hamstring and gastrocnemius muscles and the posterior intermuscular septum have been cut and removed to expose the
adductor magnus, lateral intermuscular septum, and the floor of the popliteal fossa. Posterior modifications of the fibrous layer include the
oblique and arcuate popliteal ligaments, and a perforation inferior to the arcuate popliteal ligament to allow passage of the popliteus
tendon.
Cruciate ligaments of knee joint.
• Superior aspect of the superior articular
surface of the tibia (tibial plateau), showing
the medial and lateral condyles (articular
surfaces) and the intercondylar eminence
between them.
• Anterior and posterior cruciate
ligaments attachments are colored yellow
or green.
– The ACL prevents anterior
displacement of the tibia relative to
the femur.
– The PCL prevents posterior
displacement of the tibia relative to
the femur.
Cruciate ligaments of knee joint.
• The posterior cruciate ligament
resists anterior displacement of the
femur on the tibial plateau.
• The anterior cruciate ligament
resists posterior displacement of the
femur on the tibial plateau.

Bursae and Articular Cavity

• The articular cavity is continuous
with the various bursae of the knee
and the reflections and attachments
of the complex synovial membrane.
Deep dissection of popliteal fossa and posterior knee joint .
Collateral ligaments and bursae of knee joint.

1. Fibular collateral ligament.

• The FCL or lateral collateral ligament
extends from the lateral epicondyle of the
femur to the tibia.
• It is slender and splits the biceps femoris
tendon.
2. Tibial collateral ligament
• The TCL or medial collateral ligament
extends from the medial epicondyle of the
femur to the medial condyle of the tibia
3. Suprapatellar bursa
• Extends superiorly deep to the quadriceps.
• It is attached to the artcularis genu muscle
that pulls it up and out of the way during
knee extension.
Collateral ligaments and bursae
of knee joint.
1. Fibular collateral ligament.
• The attachment sites of the FCL
(green) and related muscles
(red, proximal; blue, distal) in
figure C.
2. Tibial collateral ligament
• Tibial collateral ligament
(isolated from the fibrous layer
of the joint capsule, of which it
is a part).
• The attachment sites of the TCL
and related muscles in Figure E.
3. Suprapatellar bursa
• extends superiorly deep to the
quadriceps.
• Attached to the artcularis genu
that pulls it up and out of the
way during knee extension.
Joint capsule of knee:
• All internal surfaces of the joint capsule of
the knee are covered with articular
cartilage (blue) and are lined with synovial
membrane (mostly purple).
• The synovial membrane has two layers:
1. Fibrous layer
2. Synovial layer

• The bottom image shows the attachments of

the fibrous layer (blue dashed line) and
synovial membrane (red dashed line) of the
joint capsule on the tibia.

• The layers part company centrally to

accommodate intercondylar and infra
patellar structures that are intracapsular
(inside the fibrous layer) but extra-articular
(excluded from the articular cavity by
synovial membrane).
Menisci of knee joint.
• The menisci form a figure 8 shaped plate on
the articular surfaces of the knee.
• They are wedge shaped with the outer
borders being thicker than the inside
stabilizing and cushioning the joint.
• The meniscus attaches to the intercondylar
area of the tibia, surrounding the cruciate
ligaments.
• The band-like tibial collateral ligament is
attached to the medial meniscus.
• The cord-like fibular collateral ligament is
separated from the lateral meniscus.
• The posterior menisco-femoral ligament
attaches the lateral meniscus to the medial
femoral condyle.

The numbers on the MRI study refer to the structures

labeled in the corresponding anatomical coronal
section.
Knee injury.
Image courtesy of
Travis Eddy (2020)
with special thanks to
his sister for tearing
her ACL and lateral
meniscus just so
Travis could get extra
credit.
Tests for ACL and PCL injuries.
ACL Repair
THE LEG
Compartments of Leg
• Anterior compartment (dorsiflexor
or extensor comp)
– 4 extensor muscles (the fibularis
tertius lies inferior to the level of this
section).
– Deep Fibular Nerve
• Lateral (fibular) compartment
– 2 evertor muscles.
– Superficial Fibular Nerve
• Posterior (plantar-flexor or flexor)
compartment,
– 7 plantar flexor muscles,
• subdivided by the transverse
intermuscular septum (TIS)
into:
1. superficial group of 3
2. deep group of 4.
Posterior Tibial Nerve
 Compartments of leg

Deep Fibular Nerve

4
(not shown)

Superficial Fibular Nerve

2
Popliteus (not shown)

Tibial Nerve
7
 Compartments of the Leg

Anterior – Deep Fibular Lateral – Superficial Posterior – Tibial Nerve

N. Fibular
Tibialis anterior Fibularis Longus Popliteus
Fibularis tertius Fibularis Brevis Tibialis Posterior
Ex. Digitorum Fl. Digitorum
Ex. hallucis Fl. Hallucis
Transverse Intermuscular
Septum
Gastrocnemius
Soleus
Plantaris
Fascia of the Foot.
• Retinacula of the foot and ankle
retain the tendons as they cross the
ankle.
• Include:
1. Superior extensor
retinaculum.
2. Inferior extensor retinaculum
3. Fibular retinaculum

• At the ankle, the vessels and the

deep fibular nerve lie midway
between the malleoli and between
the tendons of the long dorsiflexors
of the toes.
• Synovial sheaths surround the
tendons as they pass beneath the
retinacula of the ankle.
Muscles of anterior and lateral compartments of leg.
Muscles of the Anterior and Lateral Compartments of the Leg
 Nerves of leg.

What nerve is damaged in foot drop?

Injury to Common Fibular Nerve and Footdrop

Because of its superficial position, the common fibular nerve is the nerve most often injured in the lower limb,
mainly because it winds subcutaneously around the fibular neck, leaving it vulnerable to direct trauma. This nerve
may also be severed during fracture of the fibular neck or severely stretched when the knee joint is injured or
dislocated. Severance of the common fibular nerve results in flaccid paralysis of all muscles in the anterior and
lateral compartments of the leg (dorsiflexors of ankle and evertors of foot). The loss of dorsiflexion of the ankle
causes footdrop, which is further exacerbated by unopposed inversion of the foot. This has the effect of making
the limb “too long”: the toes do not clear the ground during the swing phase of walking
Superficial (calf) muscles of posterior compartment of leg.

1. Gastrocnemius
2. Soleus
Which of these can act as flexors of the knee?
3. Plantaris
Which muscles do not?
Deep muscles of posterior compartment of leg.

1. Popliteus Where do these muscles attach?

2. Tibialis Posterior What are their actions?
3. Flexor Digitorum longus
4. Flexor Hallucis Longus
Plantar flexion tendons
Arteries of the Leg
Popliteal artery branches:
• Superior genicular circumflex a.
– medial and lateral
• Inferior genicular circumflex a.
• Anterior tibial artery
– Circumflex Fibular a.
– Medial Malleolar a.
– Dorsal Pedis a.
• Posterior tibial artery
– Fibular artery
• Lat. Malleolar a.
– Medial Plantar a.
– Lateral Plantar a.
 Arteries of the Leg.

What is claudication?
Popliteal arteriogram.
The Popliteal artery begins at the
site of the adductor hiatus (where it
may be compressed), and then lies
successively on the distal end of
the femur, joint capsule of the knee
joint, and popliteus muscle (not
visible) before dividing into the
anterior and posterior tibial
arteries at the inferior angle of the
popliteus fossa. The fibular artery
branches laterally from the
posterior tibial artery.
Posterior Tibial Pulse

Both arteries are examined simultaneously for equality of force.

Absence of posterior tibial pulses is a sign of occlusive peripheral arterial disease.

Intermittent claudication, characterized by leg pain and cramps, develops during walking and
disappears after rest. These conditions result from ischemia of the leg muscles caused by
narrowing or occlusion of the leg arteries.
Anterior Tibial Pulse
THE FOOT
The Foot

Surfaces, parts, bones, and retinacula of ankle and foot.

The disposition of the bones of the foot and the superior and inferior extensor and fibular
retinacula relative to surface features are demonstrated.
Fascia and compartments of foot.
The deep plantar fascia
• thick plantar aponeurosis
• thinner medial and lateral
plantar fascia.
The bones and muscles of the
foot are surrounded by the
deep dorsal and plantar fascia.

A large central and smaller

medial and lateral
compartments of the sole are
created by intermuscular septa
that extend deeply from the
plantar aponeurosis.
Muscles of foot: 1st and 2nd layers of sole.
Muscles of foot: 3rd and 4th layers of sole.
Muscles of foot: dorsum of foot.
Layers of plantar muscles. A. The 1st
layer consists of the abductors of the
large and small toes and the short flexor
of the toes. B. The 2nd layer consists of
the long flexor tendons and associated
muscles: four lumbricals and the
quadratus plantae. C. The 3rd layer
consists of the flexor of the little toe
and the flexor and adductor of the great
toe. Also demonstrated are the
neurovascular structures that course in a
plane between the 1st and 2nd layers.
D. The 4th layer consists of the dorsal
and plantar interosseous muscles .
Arteries and muscle layers of foot. A and
B. The posterior tibial artery terminates as
it enters the foot by dividing into the
medial and lateral plantar arteries.
Observe the distal anastomoses of these
vessels with the deep plantar artery from
the dorsal artery of the foot and the
perforating branches to the arcuate artery
on the dorsum of the foot (see Fig. 5.73).
Note that the plantar arteries enter and run
in the plane between the 1st and the 2nd
layers, with the lateral plantar artery
passing from medial to lateral. The deep
branches of the artery then pass from
lateral to medial between the 3rd and the
4th layers.
Arteries of foot: branching and communicating.
A. Branching of the parent neurovascular structures
that give rise to plantar vessels and nerves. B. The
arteries of the midfoot and forefoot resemble those
of the hand in that (1) arches on the two aspects
give rise to metatarsal (meta carpal) arteries, which
in turn give rise to digital arteries; (2) the dorsal
arteries are exhausted before reaching the distal
ends of the toes or digits, so the plantar (palmar)
digital arteries send branches dorsally to supply the
distal dorsal aspects of the digits, including the nail
beds; and (3) perforating branches extend between
the metatarsals (metacarpals) forming anastomoses
between the arches of each side.
Nerves of foot.
Arteries of foot: overview. A. The anterior tibial artery becomes the dorsalis pedis artery when it crosses the
talocrural joint. B. The medial and lateral plantar arteries are terminal branches of the posterior tibial artery.
The deep plantar artery and perforating branches of the deep plantar arch provide anastomoses between the
dorsal and the plantar arteries.
Veins of leg and foot. A. The deep
veins accompany the arteries and
their branches; they anastomose
frequently and have numerous
valves. B. The main superficial
veins drain into the deep veins as
they ascend the limb by means of
perforating veins so that muscular
compression can propel blood
toward the heart against the pull of
gravity. The distal great saphenous
vein is accompanied by the
saphenous nerve, and the small
saphenous vein is accompanied by
the sural nerve and its medial root
(medial sural cutaneous nerve).
Lymphatic drainage of foot.
Lymphatic drainage from the sole
drains dorsally and proximally. A.
Superficial lymphatic vessels from the
medial foot drain are joined by those
from the anteromedial leg in draining
to the superficial inguinal lymph nodes
via lymphatics that accompany the
great saphenous vein. B. Superficial
lymphatic vessels from the lateral foot
join those from the posterolateral leg,
converging to vessels accompanying
the small saphenous vein and draining
into the popliteal lymph nodes.
Surface anatomy of the foot. A. Visible features. B. Underlying structures.
Surface anatomy of the foot. C and
D. Visible features. E. Underlying
structures. Numbers in parentheses in
(E) refer to structures identified in
(D).
Joints of lower limb.
The lower limb joints
are (A) those of the
pelvic girdle
connecting the free
lower limb to the
vertebral column, (B)
the knee and
tibiofibular joint, and
(C) tibiofibular
syndesmosis, ankle
joint, and the many
joints of the foot.
Hip joint. The joint was
disarticulated by cutting
the ligament of the head of
the femur and retracting the
head from the acetabulum.
The transverse acetabular
ligament is retracted
superiorly to show the
obturator canal, which
transmits the obturator
nerve and vessels passing
from the pelvic cavity to
the medial thigh.
Factors increasing stability of hip joint. A. This superior view of
the hip joint demonstrates the medial and reciprocal pull of the
peri-articular muscles (medial and lateral rotators; reddish brown
arrows) and intrinsic ligaments of the hip joint (gray arrows) on
the femur. Relative strengths are indicated by arrow width:
Anteriorly, the muscles are less abundant but the ligaments are
robust; posteriorly, the muscles predominate. B. Parallel fibers
linking two discs resemble those making up the tube-like fibrous
layer of the hip joint capsule. When one disc (the femur) rotates
relative to the other (the acetabulum), the fibers become
increasingly oblique and draw the two discs together. Similarly,
extension of the hip joint winds (increases the obliquity of) the
fibers of the fibrous layer, pulling the head and neck of the femur
tightly into the acetabulum, increasing the stability of the joint.
Flexion unwinds the fibers of the capsule. C. In this coronal
section of hip joint, the acetabular labrum and transverse
acetabular ligament, spanning the acetabular notch (and included
in the plane of section here), extend the acetabular rim so that a
complete socket is formed. Thus the acetabular complex engulfs
the head of the femur. The epiphysis of the femoral head is entirely
within the joint capsule. The thick weight-bearing bone of the
ilium normally lies directly superior to the head of the femur for
efficient transfer of weight to the femur (Fig. 5.3). The angle of
Wiberg (see text) is used radiographically to determine the degree
to which the acetabulum overhangs the head of the femur. D.
Several different lines and curvatures are used in the detection of
hip abnormalities (dislocations, fractures, or slipped epiphyses).
The Kohler line (red A) is normally tangential to the pelvic inlet
and the obturator foramen. The acetabular fossa should lie lateral
to this line. A fossa that crosses the line suggests an acetabular
fracture with inward displacement. The Shenton line (red B) and
the iliofemoral line (red C) should appear in a normal AP
radiograph as smooth, continuous lines that are bilaterally
symmetrical. The Shenton line is a radiographic indication of the
angle of inclination (ASIS = anterior superior iliac spine).
Sectional and radiographic anatomy of
gluteal region and proximal anterior thigh
at level of hip joint. A and B. A descriptive
drawing and transverse (axial MRI) study of
an anatomical section of the thigh are shown.
Numbers in parentheses in (A) refer to
structures identified in (B). C. The
orientation drawing shows the level of the
section.
Ligaments of pelvis and hip
joint. A. Weight transfer from the
vertebral column to the pelvic
girdle is a function of the sacro-
iliac ligaments. Weight transfer at
the hip joint is accomplished
primarily by the disposition of the
bones, with the ligaments limiting
the range of movement and
adding stability. B. Articulating
surfaces of hip joint and sites of
attachment and tendinous
relationships of iliofemoral
ligaments and joint capsule. C.
Iliofemoral ligament. D. The
ischiofemoral ligament. Because
the joint capsule does not attach
to the posterior aspect of the
femur, the synovial membrane
protrudes from the joint capsule,
forming the obturator externus
bursa to facilitate movement of
the tendon of the obturator
externus (shown in part C) over
the bone.
Blood supply of head and neck of femur. Branches of the medial and lateral circumflex
femoral arteries, branches of the profunda femoris artery, and the artery to the femoral head (a
branch of the obturator artery) supply the head and neck of the femur. In the adult, the medial
circumflex femoral artery is the most important source of blood to the femoral head and
adjacent (proximal) neck.
Relations of hip joint and muscles
producing movements of joint. A.
Sagittal section of the hip joint showing
the muscles, vessels, and nerves related
to it. The muscles are color coded to
indicate their function(s). Applying
Hilton's law, it is possible to deduce the
innervation of the hip joint by knowing
which muscles directly cross and act on
the joint and their nerve supply. B. The
relative positions of the muscles
producing movements of the hip joint
and the direction of the movement are
demonstrated.
Arterial anastomoses around knee. In addition to providing collateral circulation, the genicular arteries
of the genicular anastomosis supply blood to the structures surrounding the joint as well as to the joint
itself (e.g., its joint or articular capsule). Compare these views with the anterior view in Figure 5.93B.
Joints and neurovascular structures of leg and foot. A. The tibiofibular articulations include the synovial
tibiofibular joint and the tibiofibular syndesmosis; the latter is made up of the interosseous membrane of the
leg and the anterior and posterior tibiofibular ligaments. The oblique direction of the fibers of the interosseous
membrane, primarily extending inferolaterally from the tibia, allows slight upward movement of the fibula
but resists downward pull on it. B. The arterial supply of the joints of the leg and foot is demonstrated. Peri-
articular anastomoses surround the knee and ankle.
Joints and neurovascular structures of leg and foot. C. Of the nine muscles attached to the fibula, all
except one exert a downward pull on the fibula. D. The nerve supply of the leg and foot is demonstrated.
Starting with the knee and progressing distally in the limb, cutaneous nerves become increasingly involved in
providing innervation to joints, taking over completely in the distal foot and toes.
Bursae around knee joint and proximal leg.
Ankle joint demonstrated radiographically. A. Left ankle (courtesy of Dr. P. Bobechko and Dr. E. Becker,
Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada.) B. Ankle joint of 14-year-
old boy. Epiphysial cartilage plates are evident at this age.
Sectional anatomy of ankle region. A and B. The orientation drawing depicts the structures visible in the
MRI of the ankle. (Courtesy of Dr. W. Kucharczyk, Professor and Neuroradiologist Senior Scientist,
Department of Medical Resonance Imaging, University Health Network, Toronto, Ontario, Canada.)
Dissection of ankle joint
and joints of inversion
and eversion. In (A), the
foot has been inverted (by
placing a wedge under the
foot) to demonstrate the
articular surfaces and
make the lateral ligaments
taut.
Tendons and ligaments
on medial aspect of ankle
and foot. A. The
relationships of the flexor
tendons to the medial
malleolus and
sustentaculum tali are
shown as they descend the
posterolateral aspect of the
ankle region and enter the
foot. Except for the part
tethering the flexor
hallucis longus tendon, the
flexor retinaculum has
been removed. B. The four
parts of the medial
(deltoid) ligament of the
ankle are demonstrated in
this dissection.
Joints of foot.
Movements of joints of forefoot.
Plantar ligaments. A and B. Sequential stages of
a deep dissection of the sole of the right foot
showing the attachments of the ligaments and the
tendons of the long evertor and invertor muscles.
Weight-bearing areas of foot. Body
weight is divided approximately
equally between the hindfoot
(calcaneus) and the forefoot (heads of
the metatarsals). The forefoot has five
points of contact with the ground: a
large medial one that includes the two
sesamoid bones associated with the
head of the 1st metatarsal and the
heads of the lateral four metatarsals.
The 1st metatarsal supports the major
share of the load, with the lateral
forefoot providing balance.
Arches of foot. A and B. The medial longitudinal arch is higher than the lateral longitudinal arch, which may
contact the ground when standing erect. C. The transverse arch is demonstrated at the level of the cuneiforms,
receiving stirrup-like support from a major invertor (tibialis posterior) and evertor (fibularis longus). D. The
components of the medial (dark gray) and lateral (light gray) longitudinal arches are indicated. The calcaneus
(medium gray) is common to both. The medial arch is primarily weight-bearing, whereas the lateral arch
provides balance.
Arches of foot. E. The active (red lines) and passive (gray) supports of the longitudinal arches are
represented. There are four layers of passive support (1–4).
Surface anatomy of the joints of the knee, leg, ankle, and foot.
Surface anatomy of the
joints of the knee, leg,
ankle, and foot.