Lower limb :

Bone, Muscles, Nerves and vessels

Lecturer: Dr. M. Samsam

University of Central Florida, Orlando,
Pictures from Platzer atlas and textbook
of human anatomy and K. Moore anatomy
And Netter atlas of human body
Hip bone:
Study the bones from book and
lab manual.

*Bone marrow biopsy and

Transplantation.

*Bone grafting from iliac crest

Pelvic ligaments:
8- iliolumbar ligament
11- sacrotuberous ligament
12- sacrospinous ligament
13- obturator membrane
19- greater sciatic foramen
20- lesser sciatic foramen
24- inguinal ligament
27- lacunar ligament
30- iliopectineal arch
 Differences between a
male and a female pelvis:
Types of pelvis and
Pelvic Diameters:

Pelvic inlet:
1- transverse diameter (13.5-14 cm)
2- Oblique diameter I (12-12.5 cm)
3- Oblique diameter II (11.5-12 cm)
4- Anatomical conjugate (12 cm)
5- True conjugate (11.5 cm)
6- Diagonal conjugate (13 cm)

Pelvic outlet:
7- Straight conjugate (9.5-10 cm)
8- median conjugate (11.5 cm)
*interspinous diameter
(not less than 9.5 cm)

Others:
10- intercristal distance 29 cm

External conjugate (20 cm)

Femur:
*Angle of Inclination

*Rickets and Osteomalacia

*Hip fracture due to osteoporosis in

elderly (fracture causes the person to fall).

*Congenital dislocation of the hip:

Common birth defect, more in female
infants.
Either the acetabulum fails to form
completely or the ligaments of the hip
joint are loose.
Treatment: splint or harness of straps to
hold femur in its proper position
Fibula
Used sometimes for bone
grafting

Mid-shaft fractures of tibia +

fibula are common distal
fractures in Skiers
Metatarsals and
phalangeal bones:

Metatarsal stress fractures:

As a result of repetitive stress
on foot.
2nd and 3rd metatarsals are
mostly affected
Treatment: rest and wearing
stiff or well cushioned shoes.
Lumbosacral plexus

Sacral plexus:
Sciatic nerve (roots):
L4
L5
S1
S2
S3
*Sciatic nerve is the thickest nerve of body.
*It is composed of Common Peroneal and
Tibial nerves.
*Com. Peroneal: composed of dorsal rami
Tibial: composed of ventral rami

*L4+L5= Lumbosacral trunk

3- Lumbosacral trunk
4- Sciatic nerve
5- common peroneal N.
6- tibial N.
12- posterior femoral cutaneous nerve
13- pudendal nerve
14- superior gluteal nerve
Dorsal Hip muscles:
1- Tensor fascia lata:
Origin: anterior superior iliac spine (2), extends
to greater trochanter , into iliotibial tract (3)
which has >2cm width (It is thickened deep
fascia of the thigh).
Insertion: lateral tibial condyle
Innervation: superior gluteal nerve (L4-L5).
Function: Abduction, medial rotation and flexion
of the thigh, protects the knee joint.
Gluteal region has 3 important muscles:
Gluteus Maximus, Medius and minimus.
Gluteus Maximus (4)
Origin: superficial and deep: Iliac crest (5),
post. sup. Iliac spine (6), sacrum (7), coccyx,
ilium, posterior to posterior iliac line (9) and
sacrotuberous ligament (10).
Insertion: mostly to iliotibial tract and only about
25% to gluteal tuberosity (11) of femur.
Innervation: Inferior gluteal N. (L5- S2)
Function: powerful extensor of hip joint,
lateral rotator, active in rising, sitting, climbing
Dorsal Hip muscles:
(gluteal region)
13- Gluteus Medius:
Origin: external surface of ilium (ala), between
anterior and posterior gluteal lines (14).
Insertion: greater trochanter of femur (16).
Innervation: superior gluteal N. (L5-S1)
Function: Abduction, medial rotation of thigh,
It keeps pelvis level when opposite leg is raised.
17- Gluteus minimus:
Origin: ala of ilium between anterior and inferior
Gluteal lines (18).
Insertion: greater trochanter of femur (19).
same Innervation and function as the
Gluteus medius.
*Superior gluteal artery gives the blood supply
of these 2 muscles while the inf. Gluteal artery
gives the blood supply of gluteus maximus.

*Positive Trendelenberg sign.

*Waddling gate
*Lurching gate (one sided defect)
Dorsal Hip muscles:
(gluteal region continued)

Deep muscles in the gluteal region:

There are a few muscles deep to gluteus Max.

These are: Piriformis, obturator internus,

superior and inferior gemellus and
quadratus femoris.

Piriformis Muscle (20):

Origin: as several slips from anterior surface
of sacrum (21) and sacro-tuberous ligament.
Insertion: greater trochanter of femur (22).
Innervation: nerve to piriformis (sacral plexus)
S1-S2.
Function: lateral rotator and abductor of the
thigh, keeps femur head in acetabulum.
*The muscle may partially or totally be absent.
Ventral hip muscles:
Function as lateral rotators, are stronger than
medial rotators and control the balance***.

1- Obturator internus
Origin: inner surface of hip bone, around the
Obturator foramen.
It passes through the LESSER Sciatic Foramen.
Insertion: Trochanteric fossa (2).
Innervation: N. to obturator internus (L5-S1)
3- Superior gemellus, arises from ischial
spine (4) and inferior gemellus (5) from
ischial tuberosity (6).
Both insert to trochanteric fossa.
Innerv, Sup. Gemellus: N. to Obturator int.
Innerv, inf. Gemellus: N. to quadratus femoris.

7- Quadratus femoris: from ischial

tuberosity to Intertochanteric crest.
Innervation: Nerve to quadratus femoris

All function: lateral rotator of the thigh when

It is extended and, abductor of the thigh when
flexed.
Posterior thigh muscles:
Hamstring muscles:
Long head of biceps, Semitendinous,
Semimembranous, Adductor mag (ischial part).

All innervated by tibial branch of sciatic nerve.

Charactristic of hamstring muscles:

1- originate from ischial tuberosity
2- innervated by tibial nerve
3- Flexors (strong) of the knee joint
4- Extensors (weak) of hip joint
5- insert around bones of the knee joint
Posterior thigh muscles:
Hamstring muscles:
1- Biceps femoris:
Long head origin: Ischial tuberosity (3)
Short head origin: linea aspera (lateral lip)
Insertion: head of fibula (encircles collateral lig)
Innervation: long head: tibial N. (L5-S2)
short head: common peroneal nerve (S1-S2).
Function: Long head: extension at hip.
It is a flexor and lateral rotator at knee joint.
*Short head may be absent.
4- Semitendineous: Origin: ischial tuberos (3)
Insertion: shaft of tibia medially (upper part)
Pes Anserinus Superficialis (8),
+gracilis (9), + Sartorius (10).
Function: extension at hip, flexion and medial
rotation at knee. Innervation: tibial Nerve (L5-S2).
11- Semimembraneous:
Origin: Ischial tuberosity (3). Insertion: near semi/
Tendineous (Pes Anserinus Profundus)
It’s extension is the oblique popliteal ligament
Innervation: tibial N.,
Function: hip extensor, knee flexor, medial rotator
Adductor Magnus (4):
Origin: inferior ramus of pubis (6),
Inferior ramus of ischium (7) and
ischial tuberosity (8)
Insertion:
Linea Aspera (medial lip) 10.
Adductor tubercle (12) at medial epicondyle.

Function: powerful adductor, lateral rotator

(part inserted to linea aspera), medial rotator
at knee joint. Extensor at hip joint,
13- Hiatus tendineus
Innervation: Tibial nerve to the part inserted
to linea aspera.
obturator nerve to the part inserted to adductor
tubercle (puberty and conception).

*Perforating arteries (3-4) usually pierce this

muscle from deep femoral artery in anterior
femoral region to posterior thigh region to
give blood to the dorsal muscles.
Adductor hiatus may be considered as the 5th
hiatus, its content: Popliteal artery and vein
Posterior leg muscles,
Superficial layer:
The Triceps Surae, consisting of Soleus (1),
Gastrocnemius (2) and Plantaris (3) muscles.
1- Soleus muscle:
Origin: head and upper fibula (4), soleal line of
Tibia (5).
Insertion: into tuber calcanei (8), Achilles T (7).
Active in hard and sustain motion (red fiber type).
Gastrocnemius (2) muscle:
Origin: by 2 heads (9, 11) proximal to femoral
Condyles (10).
Insertion: tuber calcanei (8).
Active for fast movements (white fiber types)
Plantaris muscle (3): slight and delicate, long
Tendon. Originates from lateral femoral condyle
Insertion is to the tuber calcanei (8).
May disappear by evolution.
Innervation: All 3 muscles, tibial nerve (S1-S2).
Function: best plantar flexors, active in Walking.
Achilles tendon (calcaneal tendon) is the
most powerful tendon and important in walking.
Poaterior leg muscles
Deep group,
Tibialis posterior (1) muscle:
Origin: tibia (3), fibula (4) and interosseous
membrane (2).
Insertion: navicular bone (7) and 3 cuneiform
bones (8). May extend to 2,3,4 metatarsal bones.
Innervation: tibial nerve (L4-L5).
Flexor Hallusis longus (9):
Origin: fibula (10), interosseous membrane (11).
Insertion: base of terminal phalanx,1st digit (14).
Innervation: tibial nerve (S1-S2).
Flexor digitorum Longus (15):
Origin: tibia (16)
Insertion: by 4 tendons to base of terminal
Phalanx of 2nd to 5th digits (18).
Innervation: Tibial nerve (S1-S3).
*The tendon of all 3 muscle pass beneath
the Flexor retinaculum (13).
Function: all 3 are active in plantar flexion
and Supination of the foot.
Poaterior leg muscles
Deep group,
Popliteus (19) muscle:
Origin: lateral femoral epicondyle (20).
Insertion: tibia (21), above soleal line.
Function: Flexion of the knee, unlocking
of the Knee joint, protection of lateral
meniscus.

Innervation: tibial nerve (L4- S1).

Peroneal group of muscles

1-Peroneus longus: has a long tendon.

Origin: head and proximal parts of fibula (2).
*The tendon runs behind the lateral malleolus
Passing in tendon groove of cuboid bone (8).
Insertion: tuberosity of 1st metatarsal (6)and
the medial cuneiform bone (7).

Peroneus brevis (3): short tendon

Origin: lateral surface of fibula (9).
Its tendon pass beneath the superior (4) and
Inferior (5) peroneal retinaculum with the
tendon Peroneus longus.
Insertion: tuberosity of 5th metatarsal bone (10).
Function: they are strongest pronator of the
foot.
That is Eversion at the subtalar and talocalca-
-neonavicular joints (standing on medial margin
of the foot while lateral margin is up).
Innervation of both muscles:
Superficial peroneal nerve (L5-S1).
Deep gluteal region:

Greater sciatic foramen

Lesser sciatic foramen

Greater sciatic foramen

is divided by Piriformis muscle (2).
Suprapiriformis hiatus:
sup. Gluteal vessels (3, 4, 5)
Infrapiriformis hiatus:
Inferior Gluteal vessels (8,9)
Internal pudendal artery and vein (10)
Pudendal nerve (11)
Posterior Cutaneous N. of the thigh (14)
Sciatic nerve (15)
Nerve to obturator internus (not shown)
[18- inf. Clunial N., and 19- perineal N. are
branches of posterior cutaneous N. of the thigh.]
Int. pudendal artery, pudendal nerve and nerve to
Obturator int. reenter the pelvis through lesser
Sciatic foramen.
Lesser Sciatic Foramen:
Int. pudendal vessels. Pudendal nerve. Nerve to
Posterior femoral region

Division of sciatic nerve

Perforating vessels (artery and vein)
Popliteal region (superficial)

1- greater Saphenous vein (medially)

2- Saphenous nerve (medially)
3- Small saphenous vein
4- medial sural cutaneous nerve
5- branches of post. Femoral cutaneous N.
Popliteal fossa:

Diamond shape.
Walls:
Inferiorly:
Gastrocnemius (medial and lateral heads) M.
Superiorly:
Semitendinosus and semimembranosus (medial)
Biceps femoris (lateral)

Its floor is composed of:

Popliteal surface of femur, knee joint and upper
Tibial bone, oblique popliteal ligament and
Popliteal muscle with its covering fascia.

Content of popliteal fossa:

Popliteal artery
Popliteal vein
Tibial N.
Common peroneal N.
Genicular arteries and veins
Posterior region of the leg

1- triceps surae m.
2- gastrocnemius
3- soleus
4- calcaneal tendon
5- saphenous nerve
6- great saphenous vein
7- small saphenous vein
9- medial sural nerve
10- communicating branch (lateral sural N.)
11- sural nerve
12- lateral dorsal cutaneous nerve
15- common peroneal nerve
16- posterior tibial artery
17- peroneal (fibular artery
18- popliteal artery
19- anterior tibial artery
20- perforating branch of fibular artery
Medial retromalleolar region:

1-2, the Flexor retinaculum

3- greater saphenous vein
5- saphenous nerve

Structures passing beneath the

Flexor retinaculum
(from medial to lateral):
Tibialis posterior tendon (7)
Flexor digitorum longus (8)
Posterior tibial artery and veins (10, 11)
Tibial nerve (12)
Flexor Hallucis longus (9)
Arteries of the leg

4-5: lateral and medial superior genicular aa.

6-7:lateral and medial inferior genicular aa.
8- medial (middle) genicular artery (piercing
the oblique popliteal ligament to reach
inside the knee joint).
1- Anterior tibial artery
2- posterior tibial artery
20- fibular artery
12- Dorsalis pedis artery
Lumbosacral plexus

Lumbar plexus (T12- L4):

1- Obturator nerve (L2-L3-L4)

2- Femoral nerve (L2-L3-L4)
3- Lumbosacral trunk (L4-L5)
7- subcostal nerve (T12)
8- iliohypogastric N. (T12-L1)
9- ilioinguinal N. (L1)
10- genitofamoral N. (L1-L2)
11- lateral cutaneous N. of the thigh (L2-L3)
 Diaphragm and posterior abdominal wall:
The psoas major and minor muscles, the quadratus lumborum
muscle. The lumbar plexus and its related nerves.
Adductors of the thigh:
All are innervated by Obturator nerve
except the pectineus muscle.

1- Gracilis muscle:
Origin: inferior ramus of pubis (2).
Insertion: medial tibial condyle (pes anserinus).
Function: adductor of the thigh, flexor at hip
and flexor at knee joints

5- Pectineus muscle
Origin: pecten of pubis (6), iliopubic eminence
Insertion: Pectineal line of femur (8)
Function: adductor of thigh and flexor of
hip joint.
Innervation:
Femoral nerve (L2-L3) and Obturator nerve

10- Adductor brevis muscle:

Origin: inferior ramus of pubis (11)
Insertion: upper part of linea aspera (9)
Function: adductor of thigh and flexor of hip joint.
Innervation: Obturator nerve (L2-L4).
Adductor Longus (1):
Origin: superior ramus of pubis (2),
Insertion: middle 1/3 of linea aspera (3).
It lies on the adductor magnus (4).
Adductor brevis (5) is interposed between them.
Function: Adduction of thigh, hip flexion
NN: Obturator nerve
Adductor Magnus (4):
Origin: inferior ramus of pubis (6),
Inferior ramus of ischium (7) and
ischial tubrosity (8)
Insertion:
Linea Aspera (medial lip) 10.
Adductor tubercle (12) at medial epicondyle.
Function: powerful adductor, lateral rotator
(part inserted to linea aspera), medial rotator
at knee joint. Extensor at hip joint,
13- Hiatus tendineus
Innervation: Tibial nerve to the part inserted
to linea aspera.
Obturator nerve to the part inserted to adductor
tubercle (puberty and conception).
Adductor minimus (14):
Incompletely separated division of adductor
Magnus. Origin: inferior ramus of pubis (6)
Insertion: upper part of linea aspera
Function and innervation:
same as adduct. Magnus.
13- Adductor hiatus
16- Vasto-adductor membrane
Anterior Thigh region:

Iliopsoas muscle:
Composed of Psoas major (1) and Iliacus (4)
muscles.
Psoas major originates from body (2) and
Transverse processes (3) of 1st-4th lumbar
Vertebrae and
The Iliacus originates from ala of the ilium (7).
Insertion: lesser trochanter of femur (6).
Function: chief flexor of the hip
Innervation: lumbar plexus to psoas (L1-L3)
and femoral nerve to iliacus (L2-L4)
Anterior thigh muscles:

Quadriceps femoris muscle:

Consist of 4 parts:
Rectus femoris (1): originates from ant inf
Iliac spine (2)
Vastus intermedius (3), vastus medialis (5)
and vastus lateralis (7), all originating from
femur.
Insertion: by a common tendon (tendon of
the quadriceps femoris) to patella (9).
Inferior to patella, the tendon continues as
the patellar ligament (10) to insert on tibial
tuberosity (11).
Function: Chief extensor of the knee joint
Rectus femoris also flexes the hip joint.
Innervation: femoral nerve (L2-L4).
Sartorius muscle (12):
Origin: anterior superior iliac spine (13)
Insertion: pes anserinus superficialis (14)
Function: acts on 2 joints: flexes at both hip
and knee joints.
Innervation: femoral nerve (L2-L4).
Anterior thigh region (deep)
The femoral triangle
Borders: Sartorius laterally
Adductor longus, medially and also the floor
Ilioinguinal ligament superiorly.
Floor: iliopsoas m., pectineus m., and
adductor longus.

Content:
A- lateral femoral cutaneous nerve
B- Femoral nerve
C- Structures inside the femoral sheath
*Content of Femoral Ring:
Femoral artery and genitofemoral N. (fem)
Femoral vein
Lymph nodes and areolar tissue (femoral
Canal), the Rosenmuller node (they drain the
Glans penis and clitoris)
*Femoral hernia: painful, more in female,
below and lateral to pubic tubercle.
Femoral hernia:
Arteries to the pelvis

The internal iliac artery and it’s branches

Arteries of the pelvis and the thigh

5- abdominal aorta
4- common iliac artery
1- internal iliac artery
15- external iliac artery
19- femoral artery
24- deep femoral artery
25- medial circumflex femoral artery
27- lateral circumflex femoral artery
30- terminal branches of deep femoral
artery, the perforating arteries.
33- descending genicular artery
Subinguinal region

9- external pudendal vessels

10- superficial epigastric vessels
11- superficial circumflex iliac vessels
Saphenous hiatus
Anterior thigh region (deep)
Subsartorius (adductor, Hunter’s) canal:

*Starts distal to femoral triangle.

Content:
Femoral artery and vein, saphenous nerve,
nerve to Vastus medialis, small branches of
Obturator nerve and great saphenous
vein
Anterior leg: Extensor group

1-2: Tibialis anterior

Origin: tibia and interosseous memb (2)
Its tendon passes beneath the extesor RT (3)
Insertion: medial cuneiform (5) and
1st metatarsal (6).
Function: dorsiflexion and supination; with
Peron. L., keep the transverse arch of the foot
Innervation: deep peroneal N. (L4-L5).

7-8: extensor digitorum longus

Origin: tibial condyle, fibula, interosseous M.
Insertion: Base of distal phalanx (2nd-5th).
Function: Dorsiflexion of the foot
Innervation: deep peroneal N. (L5-S1).

Peroneus Tertius: Extensor digitorum’s

additional part which may extend to the
base of 5th metatarsal (9). It may even be a
muscle and have a separate origin.
NN: Deep peronael nerve
10-11: Extensor Hallucis longus
Origin: fibula, inteosseous membrane (11)
Insertion: terminal phalanx of the big toe (12)
Function: first toe dorsiflexion
Innervation: deep peroneal N. (L4- S1).
Muscles of the dorsum of the foot:
Tendon of the long extensors of the foot, lie
superficial to these muscles and they form a
dorsal aponeurosis into which the short
Extensors of the digits, plantar and dorsal
Interosseous muscles radiate.

Extensor digitorum brevis (6):

Origin: Calcaneus (7)
Insertion: with 3 tendons to dorsal
aponeurosis (8).
Function: dorsiflexion of these digits
Innervation: Deep peroneal nerve (S1-S2).

Extensor Hallucis brevis (9):

Origin: Calcaneus
Insertion: Dorsal aponeurosis of 1st digit
Function: Dorsiflexion of 1st digit
Innervation: Deep peroneal nerve (S1-S2).

10- tibialis anterior tendon

11- Peroneus tertius
Muscles of the sole of the foot:

1- Plantar Aponeurosis
Consist of longitudinal and transverse fibers.
It maintains the longitudinal arch of the foot
and protects the vessels and nerves there.

5- Abductor Hallucis:
Origin: Tuber Calcanei (6), plantar aponeurosis (7).
Insertion: medial sesomoid bone (8) and base
of proximal phalanx of 1st toe (9).
Innervation: Medial plantar Nerve (L5-S1).

10- Fexor Hallucis Brevis:

Origin: medial cuneiform bone (11)
It has 2 heads. A medial head (12) which
extends to medial sesamoid bone (13) and
Its lateral head (15) extend to lateral sesamoid
bone (16) and inserted on proximal phalanx
of 1st toe.
Innervation: Medial Plantar Nerve (L5-S1).
Muscles of the sole of the foot:

11- Flexor digitorum Brevis:

Origin: tuber calcanei
Insertion: middle phalax of 2nd-4th digits
Innervation: Medial Plantar N (L5-S1).
1- Lumbriclas (4 ones)
Tiny muscles originating from tendon (2)
of the flexor digitorum longus (medial side).
Insertion: Dorsal aponeurosis of 2nd-5th digit.
Function: plantar flexion of these digits
Innervation: Medial Plantar N to 1, and
Lat Plantar N to 2, 3 and 4 (S2 and S3)
3- Quadratus Plantae:
Origin: by 2 heads from calcaneus
Insertion: lateral border of the tendon of the
Flexor digitorum longus.
Innervation: Lateral Plantar N. (S1-S2).
Muscles of the sole of the foot:

Plantar interossei MM (3), Blue

They have single head, Number 7
Originate from medial side of 3rd-5th
metatarsals bones.
Insertion: medial side of 3rd-5th digits.
Function: Adductors of the digits
Innervation: Lateral Plantar N (S2-S3).

Dorsal interossei MM (4), Red

They have 2 heads Number 9
Originate from opposing surface of all
metatarsals
Insertion: to base of 2nd-4th digits
Function: Abductors of the digits
Innervation: Lateral Plantar N (S2-S3).
Muscles of the sole of the foot:

1- Adductor Hallucis:
Has 2 heads:
oblique head (3) and the transverse head (9).
Innervation: Lateral Plantar N (S1-S2)

7- Long Plantar Ligament

12-Opponens digiti minimi,

Innervation: Lat Plantar N (S1-S2)

15-16: Flexor Digiti Minimi:

Innervation: Lateral Plantar N (S1-S2)

18- Abductor Digiti Minimi

Origin: calcaneus(20) and 5th metatarsal (21)
Insertion: Base of proximal phalanx of the
5th digit (22).
Innervation: Lateral Plantar N (S1-S2).

23- Quadratus Plantae

Arteries of the leg
4-5: lateral and medial superior genicular aa.
6-7:lateral and medial inferior genicular aa.
8- medial (middle) genicular artery (piercing
the oblique popliteal ligament to reach
inside the knee joint).
1- Anterior tibial artery
2- posterior tibial artery
20- fibular artery
*When the Anterior tibial artery (1) passes
Beneath the superior extensor retinaculum,
It is called dorsal artery of the foot or
Dorsalis Pedis artery (11).
12- shows where its pulsation can be felt.
Ant. Tibial artery or Dorsalis pedis may give
The lateral tarsal artery (13).
Together, the lateral tarsal and dorsalis pedis
Make the arcuate artery (14) giving rise to
Metatarsal (15) and dorsal digital (16) arteries.
*Dorsalis pedis gives a deep branch to join
The plantar arch.
Arteries of the leg

Posterior tibial artery(2) in the plantar region

gives the medial (21) and lateral (23)
Plantar arteries.

Lateral plantar artery makes most part of the

plantar arch (22) which give rise to plantar
Metatarsal arteries (24) and proper plantar
digital arteries (25).
The dorsal and plantar arches are connected
via perforating branches.

Pulsation of Dorsalis pedis artery may be lost

In some Peripharal vascular diseases such as
Burger’s disease or also in diabetes mellitus
Occlusion of blood vessels lead to gangrene
And even autoamputation of the first toe.
Scars on the skin may develop.
Plantar region superficial:

Plantar aponeurosis (1)

Plantar region deep:

Lateral plantar nerve (13) and

Medial plantar nerve (4), innervate the
muscles and skin of the plantar side.

Plantar arteries and veins (15,16, 3, 4)

are involved in blood supply and venous
drainage of the plantar region of the foot.