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The Anatomy of the Lower Limb

Dr. Akram M. Asbeutah, Ph.D

Faculty of Allied Health Sciences

Kuwait University

Dr. Akram Asbeutah

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OBJECTIVES• The anatomy of the lower limb is discussed in relation to common

clinical conditions

• A general description of the bones, joints, and actions of muscles is given. Emphasis is placed on the functions of the muscles, and only the briefest coverage of their attachment is provided

• The basic anatomy of the vascular supply, lymphatic drainage, & distribution of the nerves is reviewed

• Lower limb problems are the most common dealt with by the health professionals, whether working in general practice, surgery, an emergency department, physiotherapy, or radiology

• Common diseases affecting the lower limb such as arthritis, varicose veins, vascular deficiencies, fractures, dislocations, lacerations, knee effusions, leg pain, ankle injuries, and peripheral nerve injuries are few of the conditions that you see as a physiotherapists or radiologists

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Organization of the Lower Limb

• It is divided into:The Gluteal regionThe thighThe kneeThe legThe ankleThe foot

• The thigh and the leg have compartments with its own muscles that perform group functions and its own distinct nerve & blood supply

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The Gluteal Region

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Lymph Vessels

• It drains into the lateral group of the superficial inguinal nodes

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Fascia of the Buttock

• The superficial fascia is thick, especially in women, and it is impregnated with large quantities of fat. It contributes to the prominence of the buttock

• The deep fascia continuous below with the fascia lata (deep fascia) of the thigh. In the gluteal region, it splits to enclose the gluteus maximus muscle. Above the gluteus maximus muscle, it continue as a single layer that covers the outer surface of the gluteus medius and is attached to the iliac crest

• On the lateral surface of the thigh, the fascia is thickened to form a strong, wide band, the iliotibial tract. The iliotibial tract extend from the tubercle of the iliac crest to the lateral condyle of the tibia

• It forms a sheath for the tensor fasciae latae muscle and receives the greater part of the insertion of the gluteus maximus

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Pelvic Girdle and Hip Bones

• Pelvic girdle = two hipbones united at pubic symphysis– articulate posteriorly with sacrum at sacroiliac joints

• Each hip bone = ilium, pubis, and ischium– fuse after birth at acetabulum

• Bony pelvis = 2 hip bones, sacrum and coccyxDr. Akram Asbeutah

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Bones of the Gluteal Region• Ilium

Iliac crest Anterior superior & inferior iliac spines Posterior superior & inferior iliac spines Greater sciatic notch

• Ischium Body Ramus Ischial spine Ischial tuberosity Greater & lesser sciatic notches/foramina

• Pubis Body Superior & inferior rami Symphysis pubis Obturator foramen/membrane Pubic crest/tubercle

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Ilium

• Iliac crest and iliac spines for muscle attachment• Iliac fossa for muscle attachment• Gluteal lines indicating muscle attachment• Sacroiliac joint at auricular surface & iliac tuberosity• Greater sciatic notch for sciatic nerve

Dr. Akram Asbeutah

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Ischium and Pubis• Ischium

– ischial spine & tuberosity

– lesser sciatic notch

– Ramus

• Pubis– body

– superior & inferior ramus

– pubic symphysis is pad of fibrocartilage between 2 pubic bones

Dr. Akram Asbeutah

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Bones of the Gluteal Region

• AcetabulumAcetabular notch: deficient inferior part of the acetabulumAcetabular fossa: nonartciular floor of the acetabulum

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Lower Extremity• Each lower limb = 30 bones

– femur and patella within the thigh– tibia & fibula within the leg– tarsal bones in the foot– metatarsals within the forefoot– phalanges in the toes

• Joints – hip, knee, ankle – proximal & distal tibiofibular– Intertarsal– tarsometatarsal– Metatarsophalangeal– Interphalangeal

Dr. Akram Asbeutah

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Femur

• Femur (thighbone)

– longest & strongest bone in body

– head articulates with acetabulum (attached by ligament of head of femur)

– neck is common fracture site

– greater & lesser trochanters, linea aspera, & gluteal tuberosity-- muscle attachments

– medial & lateral condyles articulate with tibia

– patellar surface anteriorly between condyles

Dr. Akram Asbeutah

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Femur• Femur

Head: fovea capitis Neck: 125° with shaft and less in females Greater & lesser trochanters: gluteal

tubersoisty below the greater trochanter for gluteux maximus attachment

Intertrochanteric line anteriorly and intertrochanteric crst with quadrate tubercle on it posteriorly

Shaft; smooth anteriorly but has a ridge posteriorly (linea aspera)

Medial & lateral suprachondylar ridges Politeal surafce Medial & lateral femoral epicondyles Medial & lateral femoral condyles

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Pelvis• Pelvis = sacrum,

coccyx & 2 hip bones• Pelvic brim

– sacral promontory to symphysis pubis

– separates false from true pelvis

– false pelvis holds only abdominal organs

• Inlet & outlet• Pelvic axis = path of

babies head Dr. Akram Asbeutah

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Female and Male Skeletons• Male skeleton

– larger and heavier

– larger articular surfaces

– larger muscle attachments

• Female pelvis– wider & shallower

– larger pelvic inlet & outlet

– more space in true pelvis

– pubic arch >90 degrees

Dr. Akram Asbeutah

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Female Male

Dr. Akram Asbeutah

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Ligaments of the Gluteal Region

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Sacrotuberous Ligament

• It connects the back of the sacrum to the ischial tubersoity

• It stabilize the sacrum and prevent its rotation at the sacroiliac joint by the weight of the vertebral column

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Sacrospinous Ligament• It connects the back of

the sacrum to the ischial spine

• It stabilize the sacrum and prevent its rotation at the sacroiliac joint by the weight of the vertebral column

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Greater Sciatic Foramen• It is formed by the greater sciatic notch

of the hip bone and the sacrotuberous & sacrospinous ligaments

• It provides exit from the pelvis into the gluteal region for the following structures:

Piriformis m Sciatic nerve Posterior cutaneous nerve of the thigh Superior & inferior gluteal nerves Nerves to the obturator internus & qudratus

femoris Pudendal nerve Superior & inferior gluteal vessles Internal pudendal vessels

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Lesser Sciatic Foramen• It is formed by the greater sciatic notch of

the hip bone and the sacrotuberous & sacrospinous ligaments

• It provides an entrance into the perineum from the gluteal region for the following structures:

Tendon of the obturator internus m Nerve to obturator internus m Pudendal nerve Internal pudendal vessels

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Arteries of the Gluteal Region

• Superior gluteal artery: a branch of the internal ilaic artery & enters the gluteal region through the upper part of the greater sciatic foramen above the piriform m

• Inferior gluteal artery: a branch of the internal ilaic artery & enters the gluteal region through the lower part of the greater sciatic foramen below the piriform m

• The trochanteric anastomosis: main blood supply to the femoral head. The nutrient arteries pass along the femoral neck beneath the capsule. The arteries that take part in anastomais are: Superior & inferior gluteal arteries and the medial & lateral femoral cricumflex arteries

• The cruciate anastomosis: at the level of the lesser trochnater and together with the trochanteric anastomosis provides a connection between the internal iliac & femoral arteries. The arteries that take part in anastomosis are: the inferior gluteal, medial & lateral femoral circumflex, and the first perforating artery which is a branch of the profunda artery from the femoral artery

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Abdominal Aorta

• Splits into common iliacaa at 4th lumbar vertebrae

– external iliac aa supplylower extremity

– internal iliac aa supplypelvic viscera

Dr. Akram Asbeutah

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The Front & Medial Aspects of the Thigh

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Superficial Veins

• The Great saphenous vein & small saphenous veins and their tributaries• They are of great clinical importance• Perforating veins connect the superficial to deep veins• The great saphenous vein drain into the common femoral vein in the

femoral traingle and receives three tributaries that are: the superficial circumflex iliac vein, the superficial epigastric veins, & the superficial external pudendal vein

• The small saphenous vein drian into the popliteal veins at the popliteal fossa

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Veins of the Lower Limb

• Drain blood from entire body & return it to right side of heart• Deep veins parallel the arteries in the region• Superficial veins are found just beneath the skin• All venous blood drains to either superior or inferior vena cava or coronary

sinusDr. Akram Asbeutah

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Dr. Akram Asbeutah

Veins of the Lower Limb

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Superficial Inguinal Lymph Nodes• Horizontal group: below & parallel to the

inguinal ligament. The medial members of the group receives superficial lymph vessels from the anterior abdominal wall below the level of the umbilicus and from perineum, lymph vessels from the urethra, the external genitalia of both sexes but not the testes, and the lower half of the anal canal are drained by this route. The lateral members receives from the back from below the iliac crest

• Vertical group: lies along the terminal end of the great saphenous vein & receives lymph vessels from the lower limb

• The superficial joins the deep inguinal nodes the through the saphenous opening

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Deep Inguinal Lymph Nodes

• It is located beneath the deep fascia and along the medial side of the femoral vein

• They pass to the abdomen through the femoral canal along the external iliac artery

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Superficial Fascia of the Thigh• The membraneous layer of the

superficial fascia of the anterior abdominal wall extends into the thigh and is attached to the deep fascia (fascia lata) below the inguinal liagment

• The fatty layer of the superficial fascia on the anterior abdominal wall extends into the thigh and continues down over the lower limb without interruption

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Deep Fascia of the Thigh• It encloses the thigh like a trouser leg and

attached above to pelvis & inguinal ligament

• On the lateral aspect is thickened to form the iliotibial tract (insertion for gluteus maximus & tensor fasciae latae

• Saphenous opening is a gap in the deep fascia in front of the thigh just below the inguinal ligament. It is only 1.5 inch lateral to pubic tubercle It transmits the great saphenous vein, some small branches of the femoral artery, & lymph vessels

• The lower lateral border of the opening is called the falciform margin which lies anterior to the femoral vessels

• The spahenous opeining is filled with loose connective tissue called the cribriform fascia

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Fascial Compartments of the Thigh• Three fascial septa pass from the

inner aspect of the deep fascial sheath of the thigh to the linea aspera of the femur. By this means, the thigh is divided into three compartments:

AnteriorMedialPosterior

• Each having muscles, nerves, & vessels

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Cross-Section through Thigh

• 3 compartments of muscle with unique innervation– anterior compartment is quadriceps femoris innervated by femoral

nerve

– medial compartment is adductors innervated by obturator nerve

– posterior compartment is hamstrings innervated by sciatic nerveDr. Akram Asbeutah

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Femoral Triangle• It is a triangular depressed area situated in the upper

part of the medial aspect of the thigh just below the inguinal ligament

• Boundaries: Superior: inguinal ligament Lateral: sartorius m Medial: adductor longus m

• Floor: it is gutter and formed from lateral to medial by the iliopsoas,the pectineus, and the adductor longs

• Roof: it is formed by the skin & fasciae of the thigh

• Contents: terminal part of the femoral nerve & its branches femoral sheath femoral artery & its branches femoral vein & its tributaries deep inguinal lymph nodes

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Adductor (Subsartorial) Canal• It is an intermuscular cleft situated on the medial aspect of the

middle third of the thigh beneath the sartorius muscle

• It commences above at the apex of the femoral triangle and ends below at the opening in the adductor magnus

• In cross section it is triangular, having the following walls

The anteromedial wall: it is formed by the sartorius muscle & fascia

The posterior wall: it is formed by adductor longus & magnus

The lateral wall: it is formed by the vastus medialis

• Contents: Terminal part of the femoral artery Femoral vein Deep lymph vessels Saphenous nerve Nerve to vastus medialis Terminal part of the the obturator nerve

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Femoral Sheath

• It is a downward protrusion into the thigh of the fascial envelope lining the abdominal walls. Its anterior wall is continuous with the fascia transversalis, & its posterior wall with the fascia iliaca

• The sheath surrounds the femoral vessels & lymphatics for 1 inch below the inguinal ligament. Te structures from lateral to medial is the femoral artery, femoral vein, & lymphatic. They are separated by fibrous septa

• The most medial small part is the femoral canal, and its upper opening is the femoral ring (antterior to ring is the inguinal ligament; posterior: superior pubic ramus, laterally: femoral vein; & medially: lacunar ligament. It is potential for femoral hernia. It lies very close to saphenous opening in the deep fascia of the thigh

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Blood supply of the Anterior Fascial Compartment of the Thigh-Femoral Artery

• It enters the thigh behind the inguinal ligament as a direct continuation of the external iliac artery

• It is the main artery of the lower limb. It descends vertically toward the adductor tubercle of the femur and ends by passing through the adductor canal to become the popliteal artery in the popliteal fossa

• Relations Anterior: superficial in the upper part and in the lower

part of thigh it passes behind the sartorius m Posterior: it lies on the psoas (separated it from the hip

joint), pectineus, & adductor longus Medial: feomral vein in the upper part Lateral: femoral nerve & its branches

• Branches Superficial circumflex iliac a Superficial epigastric a Superficial external pudendal a Deep external pudendal a Profunda femoris a: medial & lateral femoral circumflex

arteries, gives three perforating arteries and ends by becoming the fourth perforating artery

Descending genicular a

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Arteries of the Lower Extremity

• External iliac artery become femoral artery when it passes under the inguinal ligament & into the thigh– femoral artery becomes popliteal artery behind the knee

Dr. Akram Asbeutah

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Dr. Akram Asbeutah

Femoral Vein

• It enters the thigh by passing through the adductor canal as a continuation of the popliteal vein

• It lies first lateral to the femoral artery, then posterior, and finally on its medial side

• It leaves the thigh through the intermediate compartment of the femoral sheath beneath the inguinal ligament to become the external ilaic vein

• Tributaries: great saphenous veins and veins that correspond to the branches of the femoral artery

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Lymph Nodes of the Anterior Fascial Compartment of the Thigh

• The deep inguinal lymph nodes are variable in numbers

• They are commonly three groups

• They lies on the medial side of the femoral vein

• The receives the efferent vessels from the superficial lymph nodes & lower limb

• They drain into the abdominal cavity through the femoral canal to the external iliac nodes

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Medial Fascial Compartment of the Thigh

• Muscles: gracilis, adductor longus, adductor brevis, adductor magnus, obturator externus

• Blood supply: profunda femoris artery & obturator artery

• Nerve supply: obturator nerve

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Blood Supply of the Medial Fascial Compartment of the Thigh• Profunda femoris artery: it is a largest branch of the

femoral artery below the inguinal ligament. It arise from the lateral side of the femoral artery and it descends in the interval between the adductor longus & brevis and then lies on the adductor magnus, where it ends as the fourth perforating artery.

• Branches: Medial & lateral circumflex arteries Four perforating arteries

• Profunda femoris vein receives tributaries that correspond to the branches of the artery. It drains into the femoral vein

• Obturator artery: it is a branch of the internal iliac artery. It passes forward on the lateral pelvic wall with the obturator nerve and passes through the obturator foramen. It divided into medial and lateral branches. It gives off muscular & an articular branch to the hip joint

• The obturator vein receives tributaries that correspond to the branches of the artery. It drains into the internal iliac vein

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The back of the Thigh

• Superficial veins: great & samll saphenous veins

• Lymph vessels: it drains into the vertcial group of the superficial inguinal lymph nodes

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The Posterior Fascial Compartment of the Thigh

• Muscles: Biceps femoris, semitendinosus, semimembranosus, & a samll part of the adductor magnus (hamstring muscles)

• Blood Supply: branches of the profunda femoris artery

• Nerve supply: Sciatic nerve

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Blood Supply of the Posterior Fascial Compartment of the Thigh

• Profunda femoris artery• Profunda femoris vein

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Hip Joint• Articulation: it is between the hemispherical femoral

head & the cup-shaped acetabulum of the hip bone (acetabular notch, acetabular labrum, transverse acetabular ligament). The articular surface are covered with hyaline cartilage

• Type: Synovial ball-and-socket• Capsule: encloses the joint and medially is attached

to the labrum & laterally is attached to the intertrochanteric line of the femur in front and to half of the femoral neck posteriorly. Retinacula accompanied by vessels to supply head & neck of the femur

• Ligaments: iliofemoral, pubofemoral, ichiofemoral, transverse acetabular, & ligament of the head of the femur

• Synovial membrane: lines the capsule & is attached to the margin of the aricular surfaces

• Nerve supply: femoral, obturator, & sciatic nerves, & the nerve to the quadratus femoris

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Hip Joint

• Acetabular labrum• Articular capsule• Ligament of the head of the femur Dr. Akram Asbeutah

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Hip Joint

• Dense, strong capsule reinforced by ligaments– iliofemoral ligament

– ischiofemoral ligament

– pubofemoral ligament

• One of strongest structures in the bodyDr. Akram Asbeutah

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Hip Joint• Movements:

Flexion: iliopsoas, rectus femoris, sartorius, & adductors Extension: gluteus maximus & hamstring muscles Abduction: gluteus medius & minimus, assissted by the

sartorius, tensor fasciae latae, & piriformis Adduction: adductor longus & brevis & adductor part of the

adductor magnus. They are assisted by pectineus & the gracilis Lateral rotation: piriformis, obturator internus & externus,

superior & inferior gemelli, & quadratus femoris, assisted by the gluteus maximus

Medial rotation: anteror fibers of gluteus medius & minimus and the tensor fasciae latae

Circumduction: a combination of all the above movements

• N.B The extensor group and lateral rotators group are more powerful than the flexor & medial rotators group of muscles.

• Important relations: Anterior: iliopsoas, pectineus, & rectus femoris muscles. The

iliopsoas & pectineus separate the femoral vessels & nerves from the hip oint

Posterior: the obturator internus, the gemelli, & the quadratus femoris muscles separate the joint from the sciatic nerve

Superior: piriformis & gluteus minimus Inferior:obturator externus tendon Dr. Akram Asbeutah

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Dr. Akram Asbeutah

Bones of the Leg-Patella

• Trinagular sesamoid• Largest sesamoid bone in the body• Increases leverage of the qudriceps femoris tendon

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Bones of the Leg -Tibia and Fibula

• Tibia– medial & larger bone of leg– weight-bearing bone– lateral & medial condyles– tibial tuberosity for patellar lig.– proximal tibiofibular joint– medial malleolus at ankle

• Fibula– not part of knee joint– muscle attachment only– lateral malleolus at ankle Dr. Akram Asbeutah

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Bones of the Foot -Tarsus

• Proximal region of foot (contains 7 tarsal bones)• Talus = ankle bone (articulates with tibia & fibula)• Calcaneus - heel bone• Cuboid, navicular & 3 cuneiforms

Dr. Akram Asbeutah

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Bones of the Foot- Metatarsus and Phalanges

• Metatarsus– midregion of the foot– 5 metatarsals (1 is most medial)– each with base, shaft and head

• Phalanges– distal portion of the foot– similar in number and arrangement to the hand– big toe is hallux

Dr. Akram Asbeutah

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Popliteal Fossa• It is a diamond-shaped intermuscular space

situated at the back of the knee• The fossa is most prominent when the knee joint is

flexed• Contents

Popliteal vessels Small saphenous vein Common peroneal & tibila nerves Posterior cutaneous nerve of the thigh Genigular branch of the obturator nerve Connective tissue & lymph nodes

• Boundaries Lateral: biceps femoris, lateral head of gastocnemius

& plantaris Medial: semimembranosus & semitendinosus and

medial head of gastrocnemius• Floor: femur, popliteus muscle & posterior

ligamnet of knee• Roof: skin, superifical fascia, & deep fascia of the

thigh

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Popliteal Artery• It is deeply placed and enters the popliteal

fossa through the opening in the adductor magnus (adductor canal), as a continuation of the femoral artery

• It ends at the level of the lower border of the popliteus muscle by dividing into anterior and posterior tibial arteries

• Relations: Anterior: femur, knee joint, & popliteus muscle Posterior: popliteal vein & tibial nerve, fascia &

skin

• Branches:• Muscular & articular branches to the knee• Arterial anastomosis around the knee

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Popliteal Vein• It is formed by the junction of the venae comitantes

of the anterior & posterior tibial arteries at the lower border of the popliteus muscle on the medial side of the popliteal artery

• As it ascends through the fossa, it crosses behind the popliteal artery so that it comes to lie on its lateral side

• It passes through the adductor canal to become the femoral vein

• It is medial to the femoral artery at the femoral triangle

• The tributaries are the veins that correspond to branches given off by the popliteal artery and the small saphenous vein

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Popliteal Lymph Nodes• About six lymph nodes are

embedded in the fatty connective tissue of the popliteal fossa

• They receive superficial lymph vessels from the lateral side of the foot & leg which accompany the small saphenous vein into the popliteal fossa

• They also receive lymph from the knee joint and from deep lymph vessels accompanying the anterior & posterior tibial arteries

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Fascial Compartments of the Leg

• Two intermuscular septa pass from its deep aspect to be attached to the fibula. These together with the interosseous membrane, divide the leg into three compartments

Anterior Lateral Posterior

• Each having its own muscles, blood supply, & nerve supply

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Interosseous Membrane

• It binds the tibia & fibula together• It provides attachment for neighboring muscles

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Superior Extensor Retinaculum• The retinacula are

thickenings of the deep fascia that keep the long tendons around the ankle joint in position & act as pulleys

• The superior extensor retinaculum is attached to the distal ends of the anterior borders of the fibula & tibia

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Inferior Extensor Retinaculum

• It is a Y-shaped band located in front of the ankle joint• Fibrous bands separate the tendons into compartments,

each of which is lined by a synovial sheath

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Flexor Retinaculum

• It extends from the medial malleolus downward & backward to be attached to the medial surface of the calcaneum

• It binds the tendons of the deep muscles of the back of the leg to the back of the medial malleolus as they pass forward to enter the sole of the foot

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Superior Peroneal Retinaculum

• It connects the lateral malleolus to the lateral surface of the calcaneum

• It binds the tendon of the peroneus longus & brevis muscles to the back of the lateral malleolus

• The tendonsare provided with a common synovial sheath

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Inferior Peroneal Retinaculum

• It binds the tendon of the peroneus longus & brevis muscles to the lateral side of the calcaneum

• The tendons each posses a synovial sheath

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Anterior Fascial Compartment of the Leg

• Superifical veins: it drains into the great saphenous vein

• Lymph vessels: along the great (inguinal) & small (popliteal) spahenous veins

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Contents of the Anterior Fascial Compartment of the Leg

• Muscles: the tibialis anterior, extensor digitorum longus, extensor digitorum brevis, peroneus tertius, & extensor hallucis longus

• Blood supply: anterior tibial artery

• Nerve supply: deep peroneal nerve

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Arteries of the Anterior Fascial Compartment of the Leg

• It is the smaller terminal branch of the popliteal a• It arises at the level of the lower border of the

popliteus m and passes forward into the anterior compartment of the leg through an opening in the upper part of the interosseous membrane

• It lies in front of the interosseous membrane together with the deep peroneal nerve

• In it upper course is deep to muecles and its lower part is superifical, it has the tendon of the extensor hallucis longus on its medial side and the tendon of the extensor digitorum longus and the deep peronral nerve on its lateral side. Here it is called dorsalis pedis artery

• Branches: muscular: anastomotic branches

• The venae comitantes of the ATA join those of the PTA in the popliteal fossa to form the popliteal vein

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Contents of the Lateral Fascial Compartment of the Leg

• Muscles: peroneus longus & brevis

• Blood supply: peroneal artery

• Nerve supply: superficial peroneal nerve

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Artery of the Lateral Fascial Compartment of the Leg

• It is a branch from the posterior tibial artery that pierces the posterior fascial septum and supply the peroneal muscles

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Posterior Fascial Compartment of the Leg

• Cutenous nerves: The posterior cutaneous nerve of the thigh descends on the back of the thigh and supplies the skin over the popliteal fossa and upper part of the back of the leg; & lateral cutaneous nerve , a branch from the common peroneal nerve supplies the skin in the upper posterolateral surafce of the leg. Also from sural nerve (tibial & common peroneal), and saphenous (femoral N) supplies the skin of posterior leg lateral & medial side

• Superifical veins: it drains intothe small saphenous vein• Lymph vessels: along the great (inguinal) & small (popliteal) spahenous veins

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Contents of the Posterior Fascial Compartment of the Leg

• Muscles: Superficial group: gastrocnemius, plantaris, & soleus; Deep group: tibialis posterior, flexor digitorum longus, flexor hallucis longus, & popliteusThe deep transverse fascia of the leg is a septum that divides

the muscle of the posterior compartment into superficial & deep groups

• Blood supply: posterior tibila artery

• Nerve supply: tibial nerve

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Artery of the Posterior Fascial Compartment of the Leg• It is one of the popliteal aretry branches

• It lies deep to gastrocnemius & soleus muscles & the deep transverse fascia of the leg

• It lies on the posterior surface of the tibialis posterior muscle above & posterior surface of the tibia below

• It lies beneath the skin in its lower part after passing beneath the flexor retinaculum and terminates by dividing into medial & lateral plantar arteries

• Branches: Peroneal artery Muscular branches Nutrient artery to the tibia Anastomotic branches around the ankle joint Medial & lateral planatar arteries

• Venae comitantes of the posterior tibial artery join that of the ATA to form the popliteal vein in the popliteal fossa

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The Region of the Ankle• Before learning the anatomy of the foot, it is essential that

you should have a sound knowledge of the arrangement of the tendons, arteries, and nerves in the region of the ankle joint

• You should identify the structures from medial to lateral and vise versa

• You should examine your own ankle and identify as many of the structures as possible

• From a clinical standpoint, the ankle is a common site for injury

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Anterior Aspect of the ankle• Structures that pass anterior to the extensor

retinacula from medial to lateral

Saphenous nerve & great saphenous vein (in front of the medial malleolus)

Superfical peroneal nerve (medial & lteral branches)

• Structures that pass beneath or through the extensor retinacula from medial to lateral

Tibilais anterior tendon Extensor hallucis longus tendon Anterior tibial artery with venae comitantes Deep peroneal nerve Extensor digitorum longus tendons Peroneus tertius

• Structures that pass in front of the medial malleolus

Saphenous nerve & great saphenous vein

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Posterior Aspect of the ankle• Structures that pass behind the lateral

malleolus superficial to the superior peroneal retinaculum

The sural nerve Small saphenous vein

• Structures that pass behind the lateral malleolus beneath the superior peroneal retinaculum

Peroneus longus & brevis tendons with one common synovial sheath and below the inferior peroneal retinaculum they have separate sheaths

• Structures that lie directly behind the ankle

The fat & the large tendo calcaneus (Achill’s tendon)

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The Foot

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The Foot• It supports the body weight & provides

leverage for walking & running

• It is unique in that it is constructed in the form of arches, which enable it to adapt its shape to uneven surfaces

• It serves as a resilient spring to absorb shocks, such as jumping

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The Sole of the Foot• Skin• It is thick & hairless• It is bound down to the underlying deep fascia by

numerous fibrous bands• The skin shows many flexure creases• Sweat glands are presents in large numbers• The sensory nerve supply to the skin is derived from

medial calcaneal branch, medial plantar nerve, & lateral plantar nerve of the tibilal nerve

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Deep Fascia of the Sole of the Foot• The plantar aponeurosis is a

triangular thickening of the deep fascia that protects the underlying nerves, blood vessels, & muscles

• Its apex is attached to the medial & lateral tubercles of the calcaneum

• The base of the aponeurosis divides into five slips that pass into the toes (plantar fasciitis/calcaneal spur)

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Fibrous Flexor Sheaths & Synovial Flexor Sheaths

• Fibrous flexor sheaths: the inferior surface of each toe, from the head of the metatarsal bone to the base of the distal phalanx, is provided with a strong fibrous sheath, which is attached to the sides of the phalanges. The firbrous sheath, together with the inferior surface of the phalanges and interphalangeal joints, forms a blind tunnel in which lie the flexor tendons of the toe

• Synovial flexor sheaths: the tendons of the flexor hallucis longus & flexor digitorum longus are surrounded by synovial sheaths

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Arteries of the Sole of the Foot

• Medial plantar artery: it is the smaller terminal branch of the PTA. It arises beneath the flexor retinaculum and passes forward deep to the abductor hallucis muscle. It ends by supplying the medial side of the big toe. It give soff muscular, cutaneous , & aricular branches

• Lateral plantar artery: It is the larger terminal branch of PTA. It arises beneath the flexor retinaculum & passes deep to the abductor hallucis & flexor digitorum brevis. At the base of the 5th metatarsal bone, it curves medially to form the plantar arch and at the proximal end of the first intermetatarsal space joins the dorsalis pedis artery. It gives muscular, cutenous, & articular branches. The plantar arch gives off plantar digital arteries to the toes

• Medial & lateral planatr veins accompany the corresponding arteries, and they unite behind the medial malleolus to form the PT venae comitantes

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Arteries of the Lower Extremity

Dr. Akram Asbeutah

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Dorsal Venous Arch of the Foot

• It lies in the subcutaneous tissue over the heads of the metatarsal bones

• It receives digital veins, communicating veins from the sole of the foot

• On the medial side drains into the great saphenous vei and on the lateral side into the small saphenous vein

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Artery of the Dorsum of the Foot

• It is a direct continuation of the ATA in front of the ankle joint• It terminates by passing downward into the sole of the foot between the two

heads of the first interosseous muscle, where it joins the lateral plantar artery and completes the plantar arch

• It is superifical in position and is crossed by the inferior extensor retinaculum and the first tendon of the extensor digitorum brevis

• On its lateral side lie the terminal part of the deep peroneal nerve & the extensor digitorum longus tendons. On its medial side lies the tendon of extensor hallucis longus (you can its pulse here!!)

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Joints of the Lower Limb

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Knee Joint• It is the largest & most

complicated joint in the body

• It consists of two condylar joints between the medial & lateral condyles of the femur & the corresponding condyles of the tibia (tibial plateau), and a gliding joint, between the patella and patellar surface of the femur

• The fibula is not directly involved in the joint

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Knee Joint• Articulation: between femur, tibia and patella

• Type: hinge joint between tibia and femur; gliding joint between patella and femur

• Capsule: it is mostly ligaments & tendons and is attached to the margins of the articular surfaces & surrounds the sides & posterior aspect of the joint. On front is absent, permitting the synovial membrane to pouch up beneath the quadriceps tendon, forming the suprapatellar bursa. On each side of the patella, the capsule is strengthened by expansions from the tendons of vastus lateralis & medialis. Behind the joint the capsule is strengthened by expansion of the semimembranosus muscle called the oblique popliteal ligament. Opening in the caspule behind the lateral tibial condyle permits the popliteus tendon to emerge

• Ligaments: Extracapsular ligaments: ligamentum patellae,

lateral & medial collateral (attached to medial meniscus) ligaments, & oblique popliteal ligament

Intracapsular ligaments: the anterior & posterior cruciate ligaments, medial (c-shape) & lateral (circle) menisci (articular discs)

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External Views of Knee Joint

• Extracapsular ligaments: ligamentum patellae, lateral & medial collateral (attached to medial meniscus) ligaments, & oblique popliteal ligament

Dr. Akram Asbeutah

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Intracapsular Structures of Knee

• Medial meniscus– C-shaped fibrocartilage

• Lateral meniscus– nearly circular

• Posterior cruciate ligament

• Anterior cruciate ligamentDr. Akram Asbeutah

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Knee Joint• Synovial membrane: it lines the capsule & is attached to the

margins of the articular surfaces. It forms the suprapatellar bursa and held by position by small part of vastus intermedius called (aricularis genus). Popliteal bursa deep to the popliteus tendon at the back of the knee. A semimabranosus bursa between the medial head of gastrocnemius & the medial femoral condyle. Other bursae are prepatellar, superficial & deep infrapatellar bursae

• Nerve supply: femoral, obturator, common peroneal, & tibial nerves

• Movements: Flexion: biceps femoris, semitendenosus & semimembranosus,

assissted by sartorius, gracilis & popliteus. It is limited by the contact of the back of the leg with the thigh

Extension: qudriceps femoris. It is limited by tension of all the major ligaments of the joint

Medial rotation: sartorius, gracilis, & semitendenosus Lateral rotation: biceps femoris

• The tone of the muscles is the most important, and it is te job of the physiotherapist to build up the strength of these muscles, especially the qudriceps muscle, after injury to the knee joint Dr. Akram Asbeutah

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Knee Joint

• Important Relations:Anterior: prepatellar bursaPosterior: popliteal vessels, common peroneal & tibial nerves,

lymph nodes, muscles forming the popliteal fossa boundaries Medial; sartorius, gracilis, semitendinosus musclesLateral: common peronral nerve & biceps femoris muscle

Dr. Akram Asbeutah

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Proximal (Superior) TibioFibular Joint

• Articulation: lateral condyle of tibia & the head of the fibula

• Type: synovial plane/gliding

• Capsule: surround the joint & is attached to the margins of the articular surfaces

• Ligaments: anterior & posterior ligaments & the interosseous membrane

• Synovial membrane: it lines the capsule & is attached to the margins of the articular surfaces

• Nerve supply: common peroneal nerve

• Movements: a small amount of gliding movement takes place during movements at the ankle joint

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Distal (Inferior) TibioFibular Joint

• Articulation: between the fibular notch of tibia & lower end of the fibula

• Type: Fibrous joint• Capsule: No capsule• Ligaments: anterior & posterior ligaments,

the interosseous ligament, & inferior transverse ligament

• Nerve supply: Deep peroneal nerve & tibial nerves

• Movements: a small amount of gliding movement takes place during movements at the ankle joint

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Ankle Joint

• Articulation: Tibia & fibula with talus

• Type: Synovial hinge joint

• Capsule: surround the joint & is attached to the margins of the articular surfaces

• Ligaments: medial (deltoid) ligament & lateral ligament (weak) and consists of three bands [anterior talofibular, calcaneofibular, & posterior talofibular]

• Synovial membrane: it lines the capsule

• Nerve supply: deep peroneal & tibial nerves

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Ankle Joint• Movements:•

Plantarflexion (toes pointing up): it is performed by tibialis anterior, extensor digitorum longus extensor hallucis longus, peroneus tertius. It is limited by the tension of the Achill’s tendon, the posterior fibers of the medial ligament, & calcaneofibular ligament

Dorsiflexion (toes pointing downward): it is performed by gastrocnemius, soleus, plantaris, peroneus longus & brevis, tibialis posterior, flexor digitorum longus, & flexor hallucis longus. It is limited by the tension of the opposing muscles, anterior talofibular ligament, & the anterior fibers of the medial ligament

• Inversion & eversion take place at the tarsal joints & not at the ankle joint

Dr. Akram Asbeutah

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Ankle Joint

• Important relations:Anterior: TA, EHL, AT vessels,

deep peroneal nerve, EDL, PTPosterior: Achill’s tendon &

plantarisPosterolateral: Peroni musclesPosteromedial: tibialis posterior,

flexor digitorum longus, posterior tibial vessels, tibial nerve, & flexor hallucis longus

Dr. Akram Asbeutah

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Tarsal Joints

• Subtalar, talocalcaneonavicular & calcaneocuboid are synovial of plane type joints. They perform inversion & eversion with gliding & rotary movements

• Cuneonavicular (synovial-gliding) joint, cuboideonavicular (fibrous) joint, intercuneiform & cuneocuboid (synovial-plane) joints

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Tarsometatarsal & Intermetatarsal Joints

• They are synovial joints of the plane type• They are connected by dorsal, plantar, & interosseous ligaments• The tarsometatarsal of the big toe has a separate joint cavity

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Metatarsophalangeal & Interphalangeal Joints

• They are synovial condyloid type• Adduction & abduction type of movement are possible but

minimal and take place from the midline of the second digit and the third as in the hand

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The Foot as a Weight-Bearer & lever• It support the body weight & to

serve as a lever to propel the body forward in walking & running

• It is pliable and can adapt itself to uneven surfaces

• The long flexor muscles and the small muscles of the foot can exert their action on the bones of the forepart of the foot and toes and greatly assist the forward propulsive action of the gastrocnemius & soleus muscles

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The Arches of the Foot• Function

– distribute body weight over foot– yield & spring back when weight is lifted

• Longitudinal arches along each side of foot (medial & lateral)• Transverse arch across midfoot region

– navicular, cuneiforms & bases of metatarsals

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The bones of the Arches• Medial longitudinal arch: it

consists of the calcaneum, the talus, the navicular, the three cuneiform bones, & the first three metatarsal bones

• Lateral longitudinal arch: it consists of the calcaneum, the cuboid, and the 4th & 5th metatarsal bones

• Transverse arch: it consists of the bases of the metatarsal bones and the cuboid and the three cuneiform bones

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Surface Anatomy of the Lower Limb

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The Gluteal Region & posterior aspect of the Thigh

• Gluteus maximus muscle

• Gluteus medius muscle

• Gluteal cleft

• Gluteal fold

• Ischeal tuberosity

• Greater trochanterDr. Akram Asbeutah

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Surface Markings in the Gluteal & the Front of the Thigh

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Surface Anatomy of the Anterior Thigh

• Surface features of the Thigh

– Sartorius muscle

– Quadriceps femoris muscle

– Adductor longus muscle

– Hamstring muscles

– Femoral triangeDr. Akram Asbeutah

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Surface Anatomy of the Knee• Surface Anatomy of the Knee

– Patella

– Patellar ligament

– Medial condyle of femur

– Medial condyle of thigh

– Lateral condyle of femur

– Lateral condyle of thigh

– Popliteal fossa Dr. Akram Asbeutah

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Surface features of the Popliteal Fossa, Leg, Ankle & Foot

• Tibial tuberosity

• Tibialis anterior muscle

• Tibia

• Peroneus longus muscle

• Gastrocnemius muscle

• Soleus muscle

Dr. Akram Asbeutah

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Surface Features of the Leg, Ankle & Foot

• Achilles (Calcaneal) tendon

• Lateral malleolus of fibula

• Medial malleolus of tibia

• Dorsal venous arch

• Tendons of extensor digitorum longus muscle

Dr. Akram Asbeutah

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Radiographic Appearances of the Lower Limb

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AP Projection of the Pelvis

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AP Projection of the Hip Joint

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Lateral (Frog Leg) Projection of the Hip Joint

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AP & Lateral Projections of the Knee

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AP & Lateral Projections of the Knee

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Lateral & Axial projections of the Patella

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Axial projection of the Patella

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Knee Arthrography

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Knee Arthrography

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Knee Arthrography

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AP & Lateral Projections of the Leg

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AP & Lateral Projections of the Ankle

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AP Projection of the Ankle

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Lateral projection of the Ankle & Foot

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Ap projection of the Ankle & Foot

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Lateral projection of the Foot

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Knee Arthrography

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Knee Arthrography

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Knee Arthrography

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MRI of the Knee

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MRI of the Knee

Hip Joint MRI

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Thigh MRI

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Thigh MRI

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Knee MRI

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Leg MRI

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Clinical Notes of the Lower Limb

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Hip Joint disorders

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Fractures of the Femur

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Total Hip Replacement

Dr. Akram Asbeutah

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Medial Meniscus Tears of the Knee Joint