Page 1 of 54

ABRIDGED ANATOMY OF THE LOWER LIMB

References; Gray’s Anatomy 3rd Edition (majorly) & Textbook of Anatomy by
Vishram Sigh 7th Edition.
September 14th 2019.

-By K. Willis

”It was not raining when Noah built the ARK”

-Howard Ruff.
 Page 2 of 54

Functions

1. Support of the body weight with minimal expenditure of energy.

 In an erect position, the centre of gravity lies anterior to the edge of the SII vertebra in the pelvis.
The vertical line through the COG is slightly posterior to the hip joint, anterior to the knee and
ankle joints and directly over the almost circular support base formed by the feet on the ground
and holds the knee and hip joints in flexion.

 The organization of ligaments at the hip joint and knee joints together with the shape of the
articulating surfaces particularly the knee joint facilitates “locking” of these joints into position
when standing.

2. Locomotion

 To move the body through space which involves integration of movements at all joints in the
lower limb to position the foot on the ground and move the body over the foot.

Component Parts

 Bones and joints

 Pelvis

 Femur

 Tibia

 Patella

 Fibula

 Tarsal bones; calcaneus, Talus, navicular, 3 cuneiforms, and cuboid.

 Metatarsals

 Phalanges.

 The bones of the foot are arranged to form the lateral and medial longitudinal and the anterior
and posterior transverse arches. The arches are flexible in nature and are supported by muscles
and ligaments. They absorb and transmit forces during walking and standing.

 Muscles:

 Extensors, rotators and abductors of the gluteal region

 Flexors of the hip joint (iliopsoas)

 Adductors, extensors and flexors of the thigh

 Lateral compartment of the leg evert the foot.

 Anterior compartment dorsiflex the foot and extend the digits

 Page 3 of 54

 The posterior compartment plantar flex the foot and flex the digits

 The intrinsic muscles of the foot modify the forces produced by the tendons entering the
toes from the leg and provide dynamic support to the longitudinal arches of the foot.

Relationship to other Regions

There are four major entry and exit points between the lower limb and the abdomen, pelvis and
perineum:

 The gap between the inguinal ligament and pelvic bone

 The greater sciatic foramen

 The obturator canal (at the top of obturator foramen).

 The lesser sciatic foramen

Abdomen

 It communicates directly with the abdomen through the gap between the pelvic bone and the
inguinal ligament. The structures passing through this gap include:

 Muscles- psoas major, iliacus and pectineus

 Nerves- femoral and femoral branch of genitofemoral nerve and the lateral cutaneous
nerve of the thigh

 Vessels- femoral artery, vein and the lymphatic

 The gap between the pelvic bone and the inguinal ligament is a weak area in the abdominal wall
and often associated with the abnormal protrusion of the abdominal cavity and contents into
the thigh (femoral hernia). This type of hernia usually occurs where the lymphatic vessels pass
through the canal (the femoral canal).

Pelvis

Structures within the pelvis communicate with the lower limb through two major apertures.
Posteriorly, structures communicate with the gluteal region through the greater sciatic foramen and
include:

 A muscle- piriformis

 Nerves- sciatic, superior and inferior gluteal and pudendal nerve

 Vessels- superior and inferior gluteal arteries and veins and the internal pudendal artery.

Perineum

Structures pass between the perineum and gluteal region through the lesser sciatic foramen and
include:

 Tendon of the obturator internus muscle

 Page 4 of 54

 Internal pudendal artery and pudendal nerve

Innervation of the lower limb is by Lumbar (L1-L4) and Sacral (L4-S5) plexuses spinal nerves.

Nerves related to bone:

 Common peroneal branch of the sciatic nerve curves laterally around the neck of the fibular
when passing from the popliteal fossa into the leg to supply the anterior and lateral
compartments of the leg.

Superficial veins

 The great saphenous vein which passes through the medial side of the leg, knee and the thigh to
pass through an opening in the deep fascia covering the femoral triangle (saphenous opening
a.k.a. fossa ovalis) to join with the femoral vein.

 The small saphenous vein passes behind the distal end of fibular (lateral malleolus) and back of
the leg to penetrate deep fascia and join the popliteal vein posterior to the knee.

 Perforating veins; connect the superficial veins with the deep veins.

 Clinical correlation; Varicose veins; caused by incompetence of valves in perforating

veins*

Regional Anatomy

Bony Pelvis (OS innominatum)

 Formed by three bones ilium(superior), ischium(posteroinferior) and pubis (anteroinferior). The

ilium articulates with the sacram and the pelvis is further anchored to the end of the vertebral
column by sacrotuberous and sacrospinous ligaments which attach to a tuberosity and spine on
the ischium.

 Ilium:

 It has an iliac crest which extends anteriorly as the ASIS and posteriorly as the PSIS. A
prominent lateral expansion of the crest just posterior to the anterosuperior iliac spine is
the tuberculum of the iliac crest. The iliopubic eminence is the raised area of bone where
the ilium fuses with the pubis.

 The gluteal surface of the ilium is curved and marked by three lines; the anterior, posterior
and inferior gluteal lines

 Ischial tuberosity

 Associated with mainly the hamstring muscles of the posterior thigh

 Ischiopubic ramus and pubic bone

 Page 5 of 54

 The external surfaces of the ischiopubic ramus anterior to the ischial tuberosity and the
body of the pubis provide attachment for muscles of the medial compartment of the thigh,
which include adductor longus, adductor brevis, adductor magnus, pectineus and gracilis.

Acetabulum

 The large cup shaped acetabulum for the articulation with the head of femur is on the lateral
surface of the pelvic bone in the region where the three bones fuse.

 The margin of the acetabulum is marked inferiorly by a prominent notch (acetabular notch)

 The wall of the acetabulum consist of nonarticular and articular parts:

 The nonarticular part is rough and forms a shallow circular depression (the acetabular
fossa) in central and inferior parts of the acetabular floor- the acetabular notch is
continuous with the acetabular fossa.

 The articular surface is broad and surrounds the anterior, superior and posterior margins of
the acetabular fossa. The articular surface is termed the lunate surface.

 The acetabular fossa provides attachment for the ligament of the head of the femur
(ligamentum teres femoris), whereas blood vessels and nerve pass through the acetabular
notch.

Proximal femur

 Characterized by head and neck and two large projections the greater and lesser trochanters.
The head of femur is spherical and articulates with the acetabulum of the pelvic bone. It is
characterized by a nonarticular pit (fovea) on the medial surface for the attachment of the
ligament of the head.

 The neck of the femur is a cylindrical strut of bone that connects the head to the shaft of the
femur. It projects superomedially from the shaft of the femur at an angle of 125° (coxa noma) to
increase the range of movement of the hip joint.

 The upper part of the shaft bears the greater and lesser trochanter which are attachment sites
for muscles that move the hip joint.

 The greater trochanter bears the trochanteric fossa(posteriorly) with the lateral wall
lodging a distinct depression for attachment of the obturator externus muscle.

 The lesser trochanter is smaller than the greater trochanter. It is the attachment site for the
iliopsoas which are the chief flexors of the hip joint.

 Extending between the two trochanters and separating the shaft from the neck of the
femur are the intertrochanteric line and intertrochanteric crest.

 Intertrochanteric line- ridge of bone on the anterior surface of the upper margin of the
shaft that descends medially from a tubercle on the anterior surface of the base of greater
trochanter to position just anterior to the base of the lesser trochanter. It is continuous
 Page 6 of 54

with the pectineal line (spiral line) which will merge with the medial margin of the linea
aspera on the posterior margin of femur.

 The intertrochanteric crest is on the posterior surface of the femur and descends medially.
It is broad smooth ridge of bone with prominent tubercle (the quadrate tubercle) which
provides attachment for the quadratus femoris.

Shaft of Femur

 The posterior margin is broad and forms a prominent raised crest (the linea aspera). It is a major
site for muscle attachments in the thigh. In the proximal third of femur, the medial and lateral
margins of the linea aspera diverge and continue superiorly as the pectineal line and gluteal
tuberosity, respectively:

 The pectineal line curves anteriorly under the lesser trochanter and joins the
intertrochanteric line.

 The gluteal tuberosity is a broad linear roughening that curves laterally to the base of the
greater trochanter. The gluteus maximus is attached to the gluteal tuberosity.

 Femoral neck fractures; can interrupt the blood supply to the femoral head.

 Intertrochanteric fractures; runs from the greater trochanters to the lesser trochanters and does
not involve the femoral neck and therefore preserve the femoral neck blood supply and do not
render the femoral head ischemic.

 Femoral shaft fractures; appreciable amount of energy is needed to fracture the femoral shaft. It
is therefore accompanied by damage to the surrounding soft tissues, which include the muscle
compartments and the structures they contain.

Hip Joint

 Synovial articulation between the head of femur and the acetabulum of the pelvic bone. It is a
multiaxial ball and socket joint designed for stability and weight bearing at the expense of
mobility.

 Thee articular surfaces of the hip joint are:

 The spherical head of femur

 The lunate surface of the acetabulum of the pelvic bone

 The lunate surface and the head of femur are covered by hyaline cartilage. The rim of the
acetabulum is raised slightly by fibrocartilaginous collar (the acetabular labrum). Inferiorly, the
labrum bridges across the acetabular notch as the transverse acetabular ligament and converts
the notch into foramen.

 The ligament of the head of femur is a flat band of delicate connective tissue that attaches at
one end to the fossa on the head of femur and at the other end to the acetabular fossa,
transverse acetabular ligament and margins of acetabular notch. It carries a small branch of the
obturator artery which contribute to the blood supply to the head of the femur.

 The synovial membrane attaches to the articular surfaces of the femur and acetabular ligament
 Page 7 of 54

Ligaments

Three ligaments reinforce the external surface of the fibrous membrane and stabilize the joint

 The iliofemoral ligament- is anterior to the hip joint and is triangular shaped. Its apex is attached
to the ilium between the AIIS and the margin of the acetabulum and its base is attached to the
intertrochanteric line of the femur. Parts of the ligament attached above and below the
intertrochamteric line are thicker than the part attached to the central part of the line. This
results to its Y appearance

 The pubofemoral ligament is anteroinferior to the hip joint . It is also triangular in shape, with its
base attached medially to the iliopubic eminence, adjacent bone, and obturator membrane.
Laterally it blends with the fibrous membrane and with the deep surface of the the iliofemoral
ligament.

 The ischiofemoral ligament reinforces the posterior aspect of the fibrous membrane. It is
attached medially to the ischium, just posteroinferior to the acetabulum, and laterally to the
grater trochanter deep to the iliofemoral ligament.

The fibres of the ligaments are oriented in a spiral fashion around the hip joint so that they become
taut when the joint is extended which stabilizes the joint and reduce the amount of muscle energy
required to maintain a standing position.

Vascular supply to the hip joint

 It is predominantly through branches of the obturator artery, medial and lateral circumflex
femoral arteries, superior and inferior gluteal arteries and the first perforating branch of the
profunda femoris artery. The articular branches of these vessels forms a network around the
joint.

Trochanteric Anastomosis

 The neck of the femur is vascularized by the anastomosing branches from the profunda femoris
artery ( a branch of the femoral artery.) The profunda femoris gives off a lateral circumflex and a
medial circumflex femoral artery. The lateral circumflex trifurcates, giving rise to the ascending,
descending and transverse branches. The acscending branch travels superiorly in the anterior
aspect of the femoral neck, just medial to the greater trochanter.

 The ascending branch of the medial circumflex femoral artery also travels superiorly, but along
the trochanteric line in the posterior aspect of the neck of feur. They both meet with the inferior
division of the deep superior gluteal artery in the trochanteric fossa. The inferior gluteal artery (a
terminal branch of the internal iliac artery) also joins the trochanteric anastomosis along the
neck of femur.

 The medial circumflex femoral artery also forms an anastomosis with the posterior branch of the
obturator artery (a terminal branch of internal iliac artery) as it courses along the inner margin of
the ramus of the ischium (in the obturator foramen). The obturator artery also gives off anterior
and acetabular branches as it enters the obturator foramen, posterior to the superior pubic
ramus. The anterior branch of the obturator artery follows the inner margin of the inferior pubic
ramus to anastomose with the posterior branch.
 Page 8 of 54

The Cruciate Anastomosis

 It is formed at about the midpoint of the lesser trochanter. In the anterior compartment of the
thigh, the transverse branch of the lateral circumflex femoral artery travels laterally and courses
around the greater trochanter. In the posterior aspect of the thigh, the transverse branch of the
medial circumflex femoral artery also travels laterally to meet with corresponding branch of the
lateral circumflex femoral artery. The descending branch of of the inferior gluteal artery joins the
anastomosis from above, while the first perforating branch of of profunda femoris recurs to join
the anastomosis from below.

The hip joint is innervated by articular branches from the femoral, obturator and superior gluteal
nerves and the nerve to the quadratus femoris.

Gateways to the Lower Limb

There are four major routes by which structures pass from the abdomen and pelvis into and out of
the lower limb. These are the obturator canal, the greater sciatic foramen, the lesser sciatic foramen
and the gap between the inguinal ligament and the anterosuperior margin of the pelvic bone.

1. Obturator canal

 The obturator canal is almost verically oriented passageway at the anterosuperior edge of the
obturator foramen. It bordered:

 Above by a groove (obturator groove) on the inferior surface of the superior ramus of pubic
bone

 Below by the upper margin of the obturator membrane, which fills most of the obturator
foramen and by muscles (obturator internus and externus) attached to the inner and outer
surfaces of the obturator membrane and the surrounding bone.

 It connects the abdominopelvic region with the medial compartment of the thigh. The obturator
nerve and vessels pass through the canal.

2. Greater sciatic foramen

 Formed on the posterolateral pelvic wall and is the major route for structures to pass between
the pelvis and the gluteal region of the lower limb. The margins of the foramen are formed by:

 The greater sciatic notch

 Parts of the upper borders of the sacrospinous and sacrotuberous ligaments

 The lateral border of sacrum

 The piriformis opasses out of the pelvis into the gluteal region through the greater sciatic
foramen and separates the greater sciatic foramen into two parts, a part above (suprapiriformis)
and part below (infrapiriformis)

 The superior gluteal nerve and vessels passes through the greater sciatic foramen above
the piriformis.

 The sciatic nerve, inferior gluteal nerve and vessels, pudendal nerves and internal pudendal
vessels, posterior cutaneous nerve of the thigh, nerve to the obturator internus and
 Page 9 of 54

gemellus superior, and nerve to the quadratus femoris and gemellus inferior pass through
the greater sciatic foramen below the muscle.

3. The lesser sciatic foramen

 Is inferior to the greater sciatic foramen on the posterolateral pelvic wall. It is also inferior to the
lateral attachment of pelvic floor muscles (levator ani and coccygeus) to the pelvic wall and
therefore connects the gluteal region with the perineum:

 The tendon of the obturator internus passes from the ateral pelvic wall through the lesser
sciatic foramen into the gluteal region to insert on the femur.

 The pudendal nerve and internal puudendal vessels, which first exit the pelvis by passing
through the greater sciatic nerve below the piriformis muscle, enter the the perineum
below the pelvic floor by passing around the ischial spine and sacrospinous ligament and
medially through the lesser sciatic foramen.

4. Gap between the inguinal ligament and pelvic bone.

 The psoas major, iliacus and the pectineus muscles

 The major blood vessels (femoral artery and vein) and lymphatics of the lower limb

 Femoral nerve

 Femoral branch of the genitofemoral nerve, lateral cutaneous nerve of the thigh

Nerves

 The lumbar plexus is formed by the anterior rami of spinal nerves L1 to L3 and part of L4 the rest
of the anterior ramus of L4 and L5 combine to form the lumbosacral trunk, which enters the
pelvic cavity and joins with the anterior rami of S1 to S3 and part of S4 to form the sacral plexus.

 The major nerves originating from the lumbosacral plexus are femoral nerve, obturator nerve,
superior gluteal, inferior gluteal nerve, sciatic; mino nerves; lateral cutaneous nerve of the thigh,
nerve to obturator internus, nerve to quadratus femoris, posterior cutaneous nerve of the thigh,
perforating cutaneous nerve and branches of the ilioinguinal and genitofemoral nerve.

Branches of the Lumbosacral plexus associated with the lower limb

Branch Spinal Motor Function Cutaneous (sensory) Function

segments

Ilio-inguinal L1 No motor function in lower limb, Skin over anterolateral part of

but innervates muscles of the upper thigh and adjacent skin of
abdominal wall perineum

Genitofemoral L1,L2 No motor function in the lower Femoral branch innervates skin
limb, but genital branch on anterior central part of upper
 Page 10 of 54

innervates cremaster muscle in thigh; the genital branch

the wall of of spermatic cord in innervates the skin in anterior
men part of perineum (anterior
scrotum in men, and mons pubis
and anterior labia majora in
women)

Femoral L2-L4 All muscles in the anterior Skin over the anterior thigh,
compartment of the thigh; in the anteromedial knee, medial side
abdomen, also gives rise to of the leg and the medial side of
branches that supply iliacus and the foot.
pectineus

Obturator L2-L4 All the muscles in the medial Skin over upper medial aspect of
compartment of thigh (except the thigh
pectineus and part of adductor
agnus attached to the ischium);
also innervates the obturator
externus

Sciatic L4-S3 All muscles in the posterior

compartment of thigh and part of
adductor magnus attached to the
ischium; all muscles in the leg and
foot

Superior L4-S1 Muscles of the gluteal region

gluteal (gluteus medius, gluteus minimus,
tensor fasciae latae

Inferior L5-S2 Muscles of the gluteal region

gluteal (gluteus maximus)

Lateral L2,L3 Parietal peritoneum in iliac

cutaneous fossa; skin over anterolateral
nerve of the thigh
thigh

Posterior S1 to S3 Skin over gluteal fold and upper

cutaneous medial aspect of thing and
nerve of the adjacent perineum, posterior
thigh aspect of the thigh and upper
posterior leg

Nerve to L4 to S1 Muscles of the gluteal region

quadratus (quadratus femoris and gemellus
femoris inferior)

Nerve to L5 to S2 Muscles of gluteal region

obturator (obturator internus and gemellus
internus superior)

Perforating S2,S3 Skin over medial aspect of the

cutaneous gluteal fold.
nerve
 Page 11 of 54

Arteries

 Femoral artery

 Is the continuation of the external iliac artery in the abdomen. It becomes femoral artery as
the vessel passes under the inguinal ligament to enter the femoral triangle in the anterior
aspect of the thigh. Its branches supply the thigh and the entire leg and foot.

 Superior and inferior gluteal arteries and obturator artery

 The superior and inferior gluteal arteries originate in the pelvic cavity as branches of the
internal iliac artery. The superior gluteal artery leaves the pelvis through the greater sciatic
foramen above the priformis muscle and the inferior gluteal artery leaves through the same
foramen but below the piriformis muscle.

 The obturator is also a branch of the internal iliac artery and passes through the obturator
canal to enter and supply the medial compartment of the thigh.

Veins

 There are groups of veins

 Superficial veins which include:

 Great saphenous vein- originates form the medial side of the dorsal venous arch
and then ascends up the medial side of the leg, knee and thigh to connect with
the femoral vein just inferior to the inguinal ligament through the saphenous
opening.

 Small saphenous vein- originates from the lateral side of the dorsal venous arch,
ascends up the posterior surface of the leg, and then penetrates deep fascia to
join the popliteal vein posterior to the knee which proximally becomes the
femoral vein.

 Deep veins

 Perforating veins

 Clinical correlation

 Varicose veins

 Deep vein thrombosis (DVT) described by the classic triad (venous stasis, injury to the
vessel wall and hypercoagulable states) which precipitates thrombosis.

 Lymphatics

 Most vessels drain in the deep and superficial inguinal nodes located in the fascia just
inferior to the inguinal ligament.

 Superficial inguinal lymph nodes

 Are approximately 10 in number and, are located in the superficial fascia and
parallel the course of the inguinal ligament in the upper thigh. They are
categorized into the horizontal group and the vertical group extending inferiorly
along the terminal part of great saphenous vein
 Page 12 of 54

 They receive lymph from the gluteal region, lower abdominal wall, perineum and
superficial regions of the lower limb. They drain via vessels that accompany the
femoral vessels into the external iliac nodes associated with the external iliac
artery in the abdomen.

 Deep inguinal lymph nodes

 Are up to three in number and medial to the femoral vein in the femoral canal.
The deep inguinal lymph nodes receive lymph from deep lymphatic associated
with the femoral vessels and from glans penis (or clitoris) in the perineum. They
interconnect with the superficial inguinal nodes and drain into the external iliac
nodes via vessels that pass along the medial side of the femoral vein as it passes
under the inguinal ligament. The space through which the lymphatic vessels pass
under the inguinal ligament is the femoral canal.

 Popliteal nodes

 Receive lymph from the superficial vessels, which accompany the small
saphenous vein and from deep areas of the leg and foot. They ultimately drain
into the deep and superficial inguinal nodes.

Deep Fascia and the Saphenous Opening

Fascia Lata

 The outer layer of deep fascia in the lower limb forms a thick like stocking-like membrane which
covers the limb and lies beneath the superficial fascia. It is particularly thick in the thigh and
gluteal region and is termed fascia lata.

 Its superior line of attachment include bony structures and soft tissues which include; inguinal
ligament, iliac crest, sacrum, coccyx, sacrotuberous ligament, inferior ramus of the pubic bone,
body of the pubic bone and superior ramus of the pubic bone. Inferiorly, the fascia lata ia
continuous with the deep fascia of the leg (fascia crura).

Iliotibial tract

 The fascia lata is thickened laterally into a longitudinal band which descends along the lateral
margin of the limb from the tuberculum of iliac crest to a bony attachment just below the knee.

 The superior aspect of fascia lata in the gluteal region splits to anteriorly to enclose the tensor
fascia lata and posteriorly to enclose the gluteus maximus.

 The tensor fascia latae muscle is partially enclosed by and inserts into the superior and
anterior aspects of the ITT.

 Most of the gluteus maximus muscle inserts into the posterior aspect of the iliotibial tract.

 The tensor fascia latae and gluteus maximus working through their attachments to the ITT, hold
the leg in extension once the knee extensors have extended the knee.

 ITT and its two associated muscles also stabilizes the hip joint by preventing lateral displacement
of the proximal end of the femur away from the acetabulum.
 Page 13 of 54

Saphenous Opening

 The fascia lata has one prominent aperture on the anterior aspect of the thigh just inferior to the
medial side of the inguinal ligament. It allows the great saphenous vein to pass from the
superficial fascia through the deep fascia to connect with the femoral vein. Its margin is formed
by the free medial edge of the fascia lata as it descends from the inguinal ligament and spirals
around the lateral side of the great saphenous vein and medially under the femoral vein to
attach to the pectineal line (pecten pubis) of the pelvic bone.

Femoral Triangle

 Is a wedge shaped depression formed by muscles in the upper thigh at the junction between the
anterior abdominal wall and the lower limb.

 Boundaries;

 The base is formed by the inguinal ligament

 The medial border is formed by the medial margin of the adductor longus muscle in the
middle compartment of the thigh.

 The lateral margin is formed by the medial margin of sartorius muscle in the anterior
compartment of the thigh.

 The floor is formed medially by the pectineus and adductor longus muscles in the medial
compartment of the thigh and laterally by iliopsoas muscle descending from the abdomen
so as to attach to the lesser trochanter.

 The apex ofthe triangle is continuous with a fascial canal (adductor canal) which descends
medially down the thigh and posteriorly through and aperture in the lower end of adductor
magnus muscle (adductor hiatus).

 Note:

 The femoral nerve, artery and vein and lymphatics pass between the abdomen and lower
limb under the inguinal ligament and the femoral triangle. The femoral artery and vein pass
inferiorly through the adductor canal and become the popliteal vessels behind the knee
where they meet and are distributed with the branches of the sciatic nerve, which descend
through the posterior thing from the gluteal region.

Major structures within the Femoral Triangle

 From Lateral to medial;

 Femoral nerve

 Femoral artery

 Femoral vein

 Lymphatic vessels

Femoral Sheath
 Page 14 of 54

 Is a funnel shaped sleeve of fascia which encloses the femoral artery, the femoral vein and the
associated lymphatic vessels and is continuous superiorly with the transversalis fascia and the
iliac fascia of the abdomen and merges inferiorly with connective tissue associated with the
vessels.

 Each of the three structures surrounded by the sheath is contained within a separate fascia
compartment with artery occupying the lateral, vein occupying the intermediate compartment
and the lymphatics within the femoral canal occupying the medial compartment.

 The opening of the femoral canal is a potential weak point in the lower abdomen and is the site
for the femoral hernias.

 The femoral nerve is lateral to the artery and is not contained within the femoral sheath.

Vascular access to the lower limb

 Femoral artery and vein can be accessed below the inguinal ligament for catheterization of the
femoral artery or vein.

GLUTEAL REGION

 The gluteal region lies posterolateral to the bony pelvis and the proximal end of the femur.

 Muscles of the gluteal region;

 A deep group of small muscles, which are mainly lateral rotators of the femur at the hip
joint and include the piriformis, obturator internus, gemellus superior, gemellus inferior
and quadratus femoris.

 A more superficial group of larger muscles, which mainly abduct and extend the hip and
include the gluteus minimus, gluteus medius and gluteus maximus. The tensor fascia latae
is also part of this group and it stabilizes the knee in extension by acting on the ITT.

 Many of the important nerves lies in the plane between the superficial and deep groups of
muscles.

Muscles of the gluteal region

Muscles Origin Insertion Innervation Function

Piriformis Anterior surface of Medial side of The nerve to Laterally rotates the
the sacrum between superior border piriformis extended femur at
the anterior sacral of greater which are hip joint; abducts
foramina. trochanter. branches from flexed femur at hip
S1 and S2 joint.

Obturator Anterior wall of true Along the length Nerve to Laterally rotates the
internus pelvis; deep surface of superior obturator extended femur at
of obturator surface of the hip joint; abducts
 Page 15 of 54

membrane and obturator internus (L5,S1) flexed femur at hip

surrounding bone internus tendon joint
and into the the
medial side of
greater
trochanter of
femur with
obturator
internus tendon

Gemellus External surface of Along length of Nerve to Laterally rotates the

superior ischial spine superior surface obturator extended femur at
of the obturator internus (L5, the hip joint;
internus tendon S1) abducts the flexed
and into the femur at hip joint
medial side of of
greater
trochanter of
femur with
obturator
internus tendon.

Gemellus Upper aspect of the Along length of Nerve to Laterally rotates the
inferior ischial tuberosity inferior surface of quadratus extended femur at
the obturator femoris (L5,S1) hip joint; abducts
internus tendon flexed femur at hip
and into the joint
medial side of of
the greater
trochanter of
femur with
obturator
internus tendon

Quadratus Lateral aspect of the Quadrate Nerve to Laterally rotates the

femoris ischium just anterior tubercle on the quadratus femur at the hip
to the ischial intertrochanteric femoris (L5,S1) joint
tuberosity rest of the
proximal femur

Gluteus External surface of Linear facet on Superior gluteal Abducts the femur
Minimus the ilium between the anterolateral nerve (L4,L5,S1) at hip joint; holds
inferior and anterior aspect of the the pelvis secure
gluteal lines greater over stance leg and
trochanter prevents pelvic drop
on the opposite side
during walking;
medially rotates the
thigh

Gluteus External surface of Elongate facet on Superior gluteal Abducts femur at

Medius ilium between the the lateral surface nerve (L4,L5,S1) hip joint; holds the
anterior and of the greater pelvis secure over
posterior gluteal trochanter stance leg and
 Page 16 of 54

lines prevents pelvic drop

on the opposite
swing side during
walking; medially
rotates thigh

Glutues Fascia covering the Posterior aspect Inferior gluteal Powerful extension
Maximus gluteus medius, of ITT of fascia nerve (L5,S1,S2) of flexed femur at
external surface of lata and gluteal hip joint; lateral
ilium behind the tuberosity of stabilizer of hip joint
posterior gluteal line, proximal femur and knee joint;
fascia of erector laterally rotates the
spinae, dorsal thigh
surface of lower
sacrum, lateral
margin of coccyx,
external surface of
sacrotuberous
ligament

Tensor fascia Lateral aspect of ITT of fascia lata Superior gluteal Stabilizes the knee
latae crest of ilium nerve (L4,L5,S2) in extension
between ASIS and
tubercle of iliac crest

 The piriformis is an important landmark because it divides the greater sciatic foramen into a
supra and infra piriformic compartments.

 Trendelenburg’s sign;

 Occurs in people with weak or paralyzed abductor muscles (gluteus medius and gluteus
minimus)

 The sign is demonstrated by asking the patient to stand on one limb. When the patient
stands on the affected limb, the pelvis severely drops over the swing limb.

 Positive signs are typically found in patients with damage to the superior gluteal nerve,
pelvis fractures, paralysis of the gluteus maximus and gluteus minimus muscles, fracture of
the neck of femur, subsequent hip surgeries.

Nerves of the Gluteal region

 Superior gluteal nerve

 Passes through the greater sciatic nerve above the piriformis muscle.

 It supplies branches to the gluteus minimus and the gluteus medius and terminates by
innervating the tensor fascia latae muscle.

 Sciatic nerve
 Page 17 of 54

 Enters the gluteal region through the greater sciatic foramen inferior to the piriformis
muscle. It innervates all the muscle of the leg and foot and a large area of skin on the lower
limb.

 Nerve to quadratus femoris

 Enters the gluteal region through the greater sciatic foramen inferior to the piriformis
muscle and between the posterior cutaneous nerve of the thigh and the pudendal nerve.

 Supplies gemellus superior and the obturator internus

 Posterior cutaneous nerve of the thigh

 Enters the gluteal region through the greater sciatic nerve through the greater sciatic
foramen below the piriformis and immediately medial to the sciatic nerve.

 Pudendal nerve

 Enters through the greater sciatic foramen inferior to the piriformis muscle and medial to
the sciatic nerve and exits through the lesser sciatic foramen to enter the perineum.

 Inferior gluteal nerve

 Enters through the greater sciatic foramen inferior to the piriformis muscle. It supplies the
gluteus maximus muscle.

 Perforating cutaneous nerve

 Leaves the sacral plexus by piercing the sacrotuberous ligaments to enter the gluteal
region.

Intramuscular injections

 The safest place to inject is the upper outer quadrant of either gluteal region (the gluteus medius

anterosuperior to themargin of gluteus maximus.

Arteries

 Inferior gluteal artery

 Originates from the anterior trunk of the internal iliac artery in the pelvic cavity. It leaves
the pelvic cavity with the inferior gluteal nerve through the greater sciatic foramen inferior
to the piriformis muscle.

 Superior gluteal artery

 Originates from the posterior trunk of the internal iliac artery in the pelvic cavity. It leaves
the pelvic cavity with the superior gluteal nerve through the greater sciatic foramen above
the piriformis muscle.

 It divides into a superficial branch and a deep branch

 The superficial branch passes onto the deep surface of the gluteus maximus muscle.
 Page 18 of 54

 The deep branch passes between the gluteus medius and minimus muscles.

Veins

Inferior and superior gluteal veins follow the inferior and superior gluteal arteries into the pelvis
where they joint pelvic plexus of veins.

Lymphatics

Deep lymphatic vessels of the gluteal region accompany the blood vessels into the pelvic cavity and
connect the internal iliac nodes. Superficial lymphatics drain into the superficial inguinal nodes on the
anterior aspect of the thigh.

THE THIGH

Introduction

 The inguinal ligament and the gluteal fold marks the anterior and the posterior boundaries of the
thigh.

 Structures leave the top of the thigh through three routes; posteriorly the sciatic nerve,
anteriorly; the thigh communicates with the abdominal cavity through the aperture between the
inguinal ligament and the pelvic bone with the major structures passing include iliopsoas muscle,
pectineus, the femoral nerve, artery, vein and the lymphatics to the lower limb.

 Medially the obturator nerve and associated vessels pass between the thigh and the pelvic cavity
through the obturator canal.

 The thigh is divided into three compartments by intermuscular septa;

 The anterior compartment contains muscles that mainly extend the leg at the knee joint.

 The posterior compartment contains muscles that mainly extend the thigh at the hip joint

 The medial compartment of the thigh consist of muscles that mainly adduct the thigh at the
hip joint.

 The sciatic nerve innervates the muscles in the posterior compartment, femoral nerve innervates
the muscles in the anterior compartment with the obturator nerve innervating the muscles of
the medial compartment.

 Major artery, vein and lymphatic channels enter the thigh anterior to the pelvic bone and pass
through the femoral triangle inferior to the inguinal ligament which in turn will pass to the leg
through the popliteal fossa.

Bones

The femur is the skeletal support for the thigh.

Shaft and the distal end of femur

 Page 19 of 54

 The shaft of the femur is obliquely oriented from the neck to the distal end. As a consequence of
this orientation, the knee is close to the midline under the body’s centre of gravity. The posterior
border of the femur forms a broad roughened crest-the linea aspera which forms the posterior
surface of femur at the distal end of the femur and its margin form the lateral and medial
supracondylar lines.

 The medial suoracondylar lines ends at a prominent tubercle, the adductor tubercle where the
adductor magnus (hamstring part) terminates.

 The distal end of femur is characterized by two large condyles, which articulate with the
proximal head of the tibia. The condyles are separated posteriorly by the intercondylar fossa and
joined anterioly where they articulate with the patella.

 The walls of the intercondylar fossa bear two facets for the superior attachment of the cruciate
ligaments, which stabilizes the knee joint.

 The wall formed by the lateral surface of the medial condyle has a large oval facet, which covers
most of the inferior half of the wall, for attachment of the proximal end of the posterior cruciate
ligament.

 The wall formed by the medial surface of the of the lateral condyle has a posterosuperior smaller
oval facet for attachment of the proximal end of the anterior cruciate ligament.

 The epicondyles of femur provide attachment sites of the collateral ligaments of the knee.

 Two facets separated by a groove are just posterior to the lateral epicodyle. The upper facet is
for the attachment of thelateral head of gastrocnemius muscle. The inferior facet is fro the
attachment of the popliteus muscles with its tendon lying in the groove separating the two
facets.

Patella

 Is the largest sesamoid bone ( a bone formed within a tendon of a muscle)

 The patella is triangula:

 The apex is pointed inferiorly for the attachment of the patellar ligament which connects
the patella to the tibia.

 Its base is broad and thick and for the attachment of the quadriceps femoris muscle from
above.

 Its posterior surface articulates with the femur and has medial and lateral facets. The
lateral facet is larger than the medial facet for articulation with the larger corresponding
surface on the lateral condyle of the femur.
 Page 20 of 54

Proximal end of Tibia

 Is the bone which articulates with the femur at the knee joint. The proximal end is expanded in
the transverse plane for weight bearing and consist of medial and lateral condyle, which are
both flattened in the horizontal plane and overhang the shaft.

 The articular surfaces of the medial and lateral condyles and the intercondylar fossa form the
tibial plateau which articulates and is anchored to the distal end of femur.

 The tibial tuberosity exist inferior to the condyles of on the proximal part of the shaft of tibia.

Tibial condyles and intercondylar areas

 The tibial condyles are thick horizontal discs of bone attached to the top of the tibial shaft. The
medial condyle is larger than the lateral condyle and is better supported over the shaft of tibia.

 The knee menisci are made of fibrocartilage. The intercondylar region of the tibial plateau lies
between the articular surfaces of the medial and lateral condyles. It is narrow centrally where it
is raised to form the intercondylar eminence, the sides of which are elevated further to form
medial and lateral intercondylar tubercles.

 The intercodylar region bears six distinct facets for the attachment of menisci and cruciate
ligaments. The anterior ntercondylar area widens anteriorly and bears three facts;

 The most anterior facet is the attachment for the anterior end (horn) of medial meniscus.

 Immediately posterior to the most anterior facet is a facet for the attachment of the
anterior cruciate ligament.

 A small facet for the attachment of the anterior end (horn) of the lateral meniscus is just
lateral to the site of attachment of the anterior cruciate ligament.

 The posterior intercondylar area also bears three attachment facets;

 The most anterior is for attachment of the posterior horn of the lateral meniscus.

 Posteromedial to the most anterior facet is the site of attachment for the posterior horn of
the medial meniscus.

 Behind the site of attachment for the posterior horn of the medial meniscus is a large facet
for the attachment of the posterior cruciate ligament.

Tibial tuberosity.

 Is a palpable inverted triangular area on the anterior aspect of the tibia below the site of
junction between the two condyles. It is the site for attachment of for the patellar ligament
which is a continuation of the quadriceps femoris tendon below the patella.
 Page 21 of 54

Shaft of Tibia

 Triangular in cross-section and has three surfaces (posterior, medial, and lateral) and three
borders (anterior, interosseous and medial). The posterior surface of the tibia, between the
interosseous and the medial borders is the widest superiorly where it is crossed by a roughened
oblique line (the soleal line)

Proximal end of the Fibula

It is much smaller than the tibia and has a small proximal head and narrow neck and delicate shaft,
which ends as the lateral malleolus at the ankle. The common peroneal nerve lies against the
posterolateral aspect of the shaft. It has three borders (anterior, posterior and interosseous) and
three surfaces (lateral, posterior and medial).

 The anterior border is sharp mid shaft and begins superiorly from the anterior aspect of the
head .

 The posterior border is rounded and descends from the region of the styloid process of the head.

 The interosseous border is medial in position. The three surfaces of fibular are associated with
the three muscular compartments of the leg viz. (anterior, lateral and posterior).

Muscles

 Muscles of the thigh are arranged into three compartments separated by intermuscular septa.

 The anterior compartment of the thigh- contains sartorius and the four large quadriceps
femoris muscles (rectus femoris, vastus lateralis, vastus medialis and vastus intermedius).
All are innervated by the femoral nerve. Also present in this compartment are terminal
ends of psoas major and iliacus muscles which pass into the upper part of the anterior
compartment of the thigh. The muscles are innervated by branches directly from the
anterior rami of L1, L2 and L3 (psoas major) or from femoral nerve (iliacus) as it passes
down the abdominal wall.

 The medial compartment of the thigh- contains six muscles (gracilis, pectineus, adductor
longus, adductor brevis, adductor magnus and obturator externus). All except the pectineus,
which is innervated by the femoral nerve, and part of adductor magnus, which is
innervated by the sciatic nerve, are innervated by the obturator nerve.

 The posterior compartment of the thigh- contains three large muscles termed “hamstrings”.
All are innervated by the sciatic nerve

Compartment Syndrome
 Page 22 of 54

 Occurs when their is a swelling within fascial enclosed muscle compartment in the limbs. Typical
causes include; limb trauma, intracompartment hemorrhage and limb compression. As pressure
within a compartment elevates, capillary blood flow and tissue perfusion is compromised, which
can ultimately to neurovascular damage if nor treated.

Anterior Compartment

 Muscles in the anterior compartment acts on the hip and knee joints:

 The psoas major and iliacus acts on the hip joint.

 The sartorius and rectus femoris act on both the hip and knee joints

 Vastus muscles acts on the knee joint

Muscle Origin Insertion Innervation Function

Psoas major Posterior Lesser trochanter Anterior rami Flexes the thigh at
abdominal wall of femur (L1,L2,L3) the hip joint
(lumbar
transverse
processes,
intervertebral
discs and
adjacent bodies
from TXI to LVV
and tendinous
arches between
these points

Iliacus Posterior Lesser trochanter Femoral nerve Flexes the thigh at

abdominal wall of femur (L2,L3) the hip joint
(iliac fossa)

Vastus medialis Femur- medial Quadriceps Femoral nerve Extends the leg at
part of femoris tendon, the knee joint
(L2,L3,L4)
intertrochanteric lateral margin of
line, pectineal patella, and
line, medial lip of medial border of
linea aspera and patella
medial
supracondylar
line

Vastus Femur- upper Quadriceps Femoral nerve Extends the leg at

intermedius two-thirds of femoris tendon, (L2,L3,L4) the knee joint
anterior and lateral margin of
lateral surfaces patella and lateral
condyle of tibia

Vastus lateralis Femur-lateral Quadriceps Femoral nerve Extends the leg at

part of femoris tendon
 Page 23 of 54

intertrochanteric and lateral part of (L2,L3,L4) the knee joint

line, margin of patella
greater
trochanter, lateral
margin of gluteal
tuberosity, lateral
lip of the linea
aspera

Rectus femoris Straight head Quadriceps Femoral nerve Flexes the thigh at
originates from femoris tendon (L2,L3,L4) the hip joint and
the anterior extends the leg at
inferior iliac spine the knee joint
(AIIS);reflected
head originates
from the ilium
just superior to
the acetabulum

Sartorius Anterior superior Medial surface of Femoral nerve Flexes the thigh at
iliac spine (ASIS) tibia just (L2,L3) the hip joint and
inferomedial to extends the leg at
tibial tuberosity the knee joint.

Discussion:

 Iliopsoas

 Is a powerful flexor of the thigh at the hip joint and can also contribute to lateral rotation of
the thigh.

 Quadriceps femoris- vastus lateralis, vastuus medialis, vastus intermedius and rectus femoris

 The rectus femoris component assist in the flexion of the thigh at the hip joint. Because the
vastus muscles insert into the margins of the patella as well as into the quadriceps tendon,
they stabilize the position of the patella during knee joint movement.

 A tiny muscle originates mainly from the femur just inferior to the origin of the vastus
intermedius and inserts into the suprapatellar bursa associated with the knee joint. It pulls away
the suprapatellar bursa away from the knee joint during extension.

 The patellar ligament is functionally the continuation of the quadriceps femoris tendon below
the patella and is attached above to the apex and margins of patella and below to the tibial
tuberosity.

 The sartorius, gracilis and semitendinosus muscles attach to the tibia in a three-prolonged
pattern on the tibia with the combined insertion being called pes anserinus. In the upper one
third of the thigh the sartorius forms the medial margin of the femoral triangle and in the middle
one third it forms the anterior wall of the adductor canal.
 Page 24 of 54

The medial compartment of the thigh

There are six muscles in the medial compartment of the thigh.

Muscle Origin Insertion Innervation Function

Gracilis A line on the Medial surface of Obturator nerve Adducts the thigh
external surfaces the proximal shaft (L2,L3) at hip joint and
of the body of the of tibia flexes leg at the
pubis, the inferior knee joint.
pubic ramus and
the ramus of
ischium

Pectineus Pectineal line Oblique line Femoral nerve Adducts and

(pecten pubis) extending from (L2,L3) flexes thigh at hip
and adjacent base of lesser joint.
bone of pelvis trochanter to
linea aspera on
the posterior
surface of
proximal femur

Adductor longus External surface Linea aspera on Obturator nerve Adducts and
of body of pubis middle one third (anterior division) medially rotates
(triangular of shaft of femur (L2,L3,L4) the thigh at hip
depression joint
inferior to the
pubic crest and
lateral to pubic
symphysis)

Adductor brevis External surface Posterior surface Obturator nerve Adducts and
of body of pubis of proximal femur (L2,L3) medially rotates
and inferior pubic and upper one the thigh at hip
ramus third of linea joint
aspera

Adductor magnus Adductor Posterior surface Obturator nerve Adducts and

part-ischiopubic of proximal (L2,L3,L4) medially rotates
ramus femur, linea the thigh
aspera, medial
supracondylar
lines

Adductor tubercle
and the medial
Hamstring supracondylar
Sciatic nerve
part-ischial line
(tibial division)
tuberosity
(L2,L3,L4)

Obturator External surface Trochanteric Obturator nerve Laterally rotates

 Page 25 of 54

externus of obturator fossa (posterior thigh at hip joint

membrane and division) (L3,L4)
adjacent bone

 The pectineus muscle forms part of the floor of the medial half of the femoral triangle. It adducts
and flexes the thigh at the hip joint.

 The adductor longus insert by an aponeurosis to the middle one third of the linea aspera. It
contributes to the floor of the femoral triangle and its medial margin forms the medial border of
the femoral triangle. It also forms the proximal posterior wall of the adductor canal.

 Adductor magnus muscle forms the distal posterior wall of the adductor canal. The adductor
magnus muscle has a large circular gap between the hamstring part and the adductor part
known as the adductor hiatus which allows the femoral artery and associated veins to pass
between the adductor canal on the anteromedial aspect of the thigh and the popliteal fossa
posterior to the knee.

Posterior compartment of the thigh

There are three long muscles;the biceps femoris, semimembranosus and semitendinosus which are
collectively known as the hamstrings. All except the short head of biceps femoris cross the hip and
knee joints.

Muscle Origin Insertion Innervation Function

Biceps femoris Long Head of fibula Sciatic nerve Flexes the leg at
head-inferomedial (L5,S1,S2) knee joint;
part of the upper extends and
area of the ischial laterally rotates
tuberosity thigh at hip joint
and laterally
Short head-lateral
rotates the leg at
lip of linea aspera
the knee joint.

Semi tendinosus Inferomedial part Medial surface of Sciatic nerve Flexes the leg at
of the upper area proximal tibia (L5,S1,S2) knee joint and
of the ischial extends the thigh
tuberosity at hip
joint;medially
rotates thigh at
hip joint and leg
at knee joint

Semimembranosus Superolateral Groove and Sciatic nerve Flexes leg at knee

impression on the adjacent bone on (L5,S1,S2) joint and extends
ischial tuberosity medial and thigh at hip
posterior surface joint;medially
of medial tibial rotates thigh at
 Page 26 of 54

condyle hip joint and leg

at knee joint

 The long head of biceps femoris is innervated by the tibial division of the sciatic nervewhile the
short head is innervated by the common peroneal division of the sciatic nerve.

Arteries

 Three arteries enter the thigh; femoral, obturator and the inferior gluteal artery. The three
arteries contribute to the anastomotic network of channels around the hip joint.

 Femoral artery

 Is a continuation of the external iliac artery and it begins as external iliac artery passes
under the inguinal ligament to enter the femoral triangle

 It gives a cluster of small branches-superficial epigastric artery, superficial circumflex iliac

artery, superficial external pudendal artery and the deep external pudendal artery in the
femoral triangle and supply the cutaneous regions of the upper thigh, lower abdomen and
perineum.

 The deep artery of the thigh i.e. The Profunda femoris artery

 Originates from the lateral side of the femoral artery in the femoral triangle and
is the major source of blood supply to the thigh

 The deep artery of thigh has lateral and medial circumflex femoral branches,
three perforating branches and a terminal branch

 The Lateral circumflex femoral artery

 Gives off three terminal branches

 Ascending branch which supplies the neck and head of femur

 Descending branch which connects with a branch of the popliteal artery to

contribute to the genicular anastomosis.

 The transverse branch which forms the cruciate anastomosis together with
branches from the medial circumflex femoral artery, the inferior gluteal
artery and the first perforating artery.

 Medial circumflex femoral artery

 Gives of an articular branch which enters the hip joint trough the acetabular
notch to anastomose with the acetabular branch of the obturator artery.

 The main trunk passes over the superior margin of the adductor magnus and
divides into two major branches deep to the quadratus femoris muscle

 Ascending branch to the trochanteric fossa and connects with branches of

the gluteal and lateral circumflex femoral arteries.

 The transverse branch passes laterally to participate with branches of the

lateral circumflex femoral artery, the inferior gluteal and the first
 Page 27 of 54

perforating branch in forming the anastomotic network of vessels around

the hip.

 Perforating arteries

 The three perforating arteries branch from the deep artery of the thigh as it
descends anterior to the adductor brevis muscle with the first originating above
the muscle, second originating anterior to the muscle while third originates
below the muscle.

 All the three penetrate through the adductor magnus muscle near its attachment
to the linea apera to enter and supply the posterior compartment of the thigh.
Here, the vessels have ascending and descending branches, which interconnect
to form longitudinal channel which participates above in forming an anastomotic
network of vessels around the hip and inferiorly anastomoses with branches of
the popliteal artery behind the knee.

 Obturator artery

 Originates as a branch of the internal iliac artery in he pelvic cavity and enters the medial
compartment of the thigh through the obturator canal. As it passes through the can it
bifurcates into an anterior branch and a posterior branch which together form a channel
that circles the margin of the obturator membrane and lies within the attachment of the
obturator externus muscle.

 Vessels arising from the anterior and posterior branches supply the adjacent muscles and
anastomose with the inferior gluteal and medial circumflex femoraal arteries.In addition,
ana acetabular vessel originates from the posterior branch, enters the hip joint through the
acetabular notch and contributes to the supply of the head of femur.

Peripheral vascular disease

Is often characterized by reduced blood flow to the legs which may be caused by stenoses (narrowing)
and/or occlusions (blockages) in the lower aorta and the iliac, femoral, tibial and fibular arteries.

 Chronic leg ischemia

 Acute on chronic ischemia

 Critical limb ischemia

Veins

Consist of superficial and deep veins. The largest of the superficial veins is the great saphenous vein
which originates from a venous arch on the dorsal aspect of the foot and ascends along the medial
side of the lower limb to the proximal thigh. It then passes through the saaphenous opening in the
cribiform fascia (deep fascia) covering the anterior thigh to connect with the femoral vein in the
femoral triangle.

Nerves
 Page 28 of 54

There are three major nerves in the thigh and each is associated with one of the three compartments.
Femoral nerve is associated with the anterior compartment, the obturator nerve with the medial
compartment and the sciatic nerve with the posterior compartment of the thigh.

 Femoral nerve

 Branches of the femoral nerve include

 Motor branches to iliacus and pectineus muscles

 Anterior cutaneous branches, which penetrate deep fascia to supply the skin on
the front of the thigh and knee

 Numerous motor nerve which supply the quadriceps femoris muscles and the
sartorius muscles.

 One long cutaneous nerve, the saphenous nerve which supplies the skin as far
distally as the medial aspect of the medial side of the foot.

 The saphenous nerve accompanies the femoral artery through the adductor canal, but does
not pass through the adductor hiatus with the femoral artery. It penetrates directly through
connective tissue near the end of the canal to appear between the sartorius and gracilis
muscles on the medial side of the leg and foot, and supplies skin on the medial aspect of
the knee leg and foot.

 Obturator nerve

 It supplies most of the adductor muscles and skin on the medial aspect of the thigh. As the
obturator nerve enter the thigh it divides into two branches, an anteerior branch and a
posterior branch, which are separated by the adductor brevis muscle:

 The posterior branch descends behind the adductor brevis muscle and on the
anterior surface of the adductor magnus muscle, and supplies the obturator
externus and adductor brevis muscles and the adductor part of the adductor
magnus.

 The anterior branch descends on the anterior surface of the adductor brevis
muscle and is behind the pectineus and adductor longus muscle- it supplies
branches to the adductor longus, gracilis and adductor brevis muscles and often
contribute to the supply of the pectineus muscle and cutaneous branches to
innervate the skin of the medial side of the thigh.

 Sciatic nerve

 Innervates all the muscles of the posterior compartment of the thigh. It lies on the adductor
magnus muscle and is crossed by the long head of biceps femoris. It later divides into two,
the common peroneal nerve and the tibial nerve. These nerves travel verically down the
thigh and enter the popliteal fossa posterior to the knee where they meet the popliteal
vein and artery

 Tibial division

 It supplies all the muscles in the posterior compartment of the thigh except the
short head of biceps femoris which is supplied by the common peroneal part

 It descends through the popliteal fossa, enters the posterior compartment of the
leg and continues into the sole of foot.
 Page 29 of 54

 It innervates;

 All muscles in the posterior compartment of the leg

 All intrinsic muscles in the sole of foot including the two dorsal interossei
muscles, which also may receive innervation from the deep fibular nerve.

 Skin on the posterolateral side of the lower half of the leg and lateral side of
the ankle, foot and little toe and skin on the sole of foot and toes.

 Common peroneal division

 Innervates the short head of biceps femoris muscle in the posterior compartment
of the thigh and then continues into the lateral and anterior compartment of the
leg and onto the foot. It innervates;

 All muscles in the anterior and lateral compartments of the leg

 One muscle (extensor digitorum brevis) on the dorsal aspect of the foot

 The first two dorsal interossei muscles in the sole of foot

 Skin over the lateral aspect of the leg ankle and over the dorsal aspect of
the foot and toes

THE KNEE JOINT

 The largest synovial joint in the body and consist of;

 The articulation between the femur and tibia, which is weight bearing.

 The articulation between the patella and the femur, which allows the pull of the quadriceps
femoris muscle to be directed anteriorly over the knee to the tibia without tendon wear.

 The fibrocartilage menisci, one on each side between the femoral condyles and tibia
accommodate changes in the shape of the articular surfaces during the joint movements. The
knee joint is a hinge joint and reinforced by collateral ligaments, one on each side of the joint. In
addition, two very strong ligaments (the cruciate ligaments) interconnect the adjacent ends of
the femur and tibia and maintain their opposed positions during movements.

 The knee joint being weigh bearing has an efficient locking mechanism to reduce the amount of
muscle energy required to keep the joint in extension.

Articular surfaces

 Are covered by hyaline cartilage. The major surfaces involved include:

 The two femoral condyles

 The adjacent surfaces of the superior aspect of the tibial condyles

 The surfaces of the femoral condyles that articulate with the tibia in flexion of the knee are
curved or round, whereas the surfaces that articulate in full extension are flat.

 The articular surfaces between the femur and the patella are v-shaped trench on the anterior
surface of the distal femur where the two condyles join and the adjacent surfaces on the
posterior aspect of the patella.

 The joint surfaces are enclosed within a single articular cavity, as are the intraarticular menisci
between the femoral and tibial condyles.
 Page 30 of 54

Menisci

 There are two menisci which are fibrocartilaginous C-shaped, in the knee joint, one medial
(medial meniscus) and the other lateral (lateral meniscus) which are both attached to facets at
each end in the intercondylar region of tibial plateau.

 The medial meniscus is attached to around its margin to the capsule of the joint and to the tibial
collateral ligament and this forms the basis of the unhappy triad. Whereas the lateral collateral
ligament is unattached to the capsule making the lateral meniscus more mobile.

 The menisci are interconnected anteriorly by a transverse ligament of the knee. The lateral
collateral ligaments is also connected to the tendon of the popliteus muscle which passes
superolaterally between the meniscus and the capsule to insert onto the femur.

 The menisci improve the congruency between the femoral and tibial condyles during the joint
movement where the surfaces of the femoral condyles articulating with the tibial plateau change
from small curved surfaces in flexion to large flat surfaces in extension.

Synovial membrane

 Attaches to the margins of the articular surfaces and to the superior and inferior margins of the
menisci. The two cruciate ligaments which attach in the intercondylar fossa lie outside the
articular cavity, but enclosed within fibrous membrane of the knee joint.

 Anteriorly, the synovial membrane is separated from the patellar ligament by an infrapatella fat
pad and on each side of the pad, the synovial membrane forms a fringed margin (an alar fold),
which project into the articular cavity.

 The synovial membrane of the knee joint forms pouches in two locations to provide low-friction
surfaces for the movement of tendons associated with the joint.

 Subpopliteal recess which lies between the lateral meniscus and the tendon of the
popliteus muscle, which pass through the joint capsule.

 Suprapatellar bursa which is a continuation of the articular cavity superiorly between the
distal end of the shaft of the femur and the quadriceps femoris muscle and tendon. The
apex of this bursa is attached to the small articularis genu muscle which pulls the bursa
away from the joint during extension of the knee.

Other bursae associated with the knee but not normally communicating with the articular cavity
include;

- subcutaneous prepatellar bursae

- deep infrapatellar bursae

- subcutaneous infrapatellar bursae

 Page 31 of 54

The prepatellar bursae is subcutaneous and anterior to the patella. The deep and subcutaneous
infrapatellar bursae are on the deep and subcutaneous sides of the patellar ligament respectively.

Fibrous Membrane

Is extensive and partly formed and reinforced by extensions from the tendons from the surrounding
muscles. It encloses the articular cavity and the intercondylar region:

 On the medial side of the knee joint, the fibrous membrane blends with the tibial collateral
ligament and is attached to on its internal surface to the medial meniscus.

 Laterally, the external surface of the fibrous membrane is separated by a space from the fibular
collateral ligament and the internal surface of the fibrous membrane is not attached to the
lateral meniscus.

 Anteriorly, the fibrous membrane is attached to the margins of the patella where it is reinforced
with tendinous extensions from the vastus lateralis and vastus medialis muscles, which also
merge above with the quadriceps femoris tendon and below with the patellar ligament.

 The fibrous membrane is reinforced anterolaterally by a fibrous extension from the iliotibial tract
and posteromedially by an extension from the tendon of the semimembranosus (the oblique
popliteal ligament), which reflects superiorly across the back of the fibrous membrane from
medial to lateral.

Ligaments of the Knee

 The major ligaments are the patellar ligament, the tibial (medial) and fibular (lateral) collateral
ligament and the anterior and posterior cruciate ligaments.

 Patellar ligament

 Is the continuation of the quadriceps femoris tendon inferior to the patellar and
is attached to the margins and the apex of the patella and below to the tibial
tuberosity.

 Collateral ligaments

 One n each side of the joint, stabilize the hinge-like motion of the knee.

 The cord like fibular collateral ligament is attached superiorly to the lateral
femoral epicondyle just above the groove for the popliteus tendon and inferiorly
to a depression on the lateral surface of the fibular head. It is separated from the
fibrous membrane by a bursa.

 The broad and flat tibial collateral ligament is attached by much of its deep
surface to the underlying fibrous membrane. It is anchored superiorly to the
medial femoral epicondyle just inferior to the adductor tubercle and descends
anteriorly to attach to the medial margin and medial surface of tibia above and
behind the attachment of the sartorius, gracilis and semitendinosus tendons.

 Cruciate ligaments

 The two cruciate ligaments are in the intercondylar region of the knee and
interconnect the femur and tibia
 Page 32 of 54

 The anterior cruciate ligament attaches to a facet on the anterior part of the
intercondylar area of the tibia and ascends posteriorly to attach to a facet at the
back of the lateral wall of the intercondylar fossaa of the femur.

 The posterior cruciate ligament attaches to the posterior aspect of the

intercondylar area of the tibia and ascends anteriorly to attach to the medial wall
of the intercondylar fossa of the femur.

 The anterior cruciate ligament crosses the lateral to the posterior cruciate
ligament as they pass trough the intercondylar region. The anterior cruciate
ligament prevents anterior displacement of the tibia relative to the femur and
the posterior cruciate restricts the posterior displacement.

Locking Mechanism of the Knee

 When standing, the knee joint is locked into position, thereby reducing the amount of muscle
work needed to maintain the standing position.

 One of the components of the locking mechanism is the change in the shape and size of the
femoral surfaces that articulate with the tibia.

 In flexion, the surfaces are curved and rounded areas on the posterior aspects of the
femoral condyles

 As the knee is extended, the surfaces move to be broad and flat area on the inferior aspects
of the femoral condyles and consequently the joint surfaces become large and more stable
in extension.

 There is also medial rotation of the femur on the tibia during extension. The medial
rotation and full extension tightens all the associated ligaments and is done by the rectus
femoris muscle.

 The body’s center of gravity is positioned along a vertical line that passes anterior to the
knee joint. The popliteus muscle unlocks the knee by initiating the lateral rotation of the
femur on the tibia.

Vascular supply and innervation

The vascular supply to the knee joint is predominantly through the descending and genicular branches
of the femoral artery, popliteal, and lateral circumflex femoral arteries in the thigh and the circumflex
fibular artery and recurrent branches from the anterior tibial artery in thee leg. These vessels form an
anastomotic network of vessels known as the genicular anastomosis. The joint is innervated by
branches from the obturator, femoral, tibial and common peroneal nerve according to Hilton’s Law.

Vessels forming the genicular anastomosis

1. Descending branch of the lateral circumflex femoral artery

2. Descending genicular artery

3. Superior lateral and inferior lateral genicular artery

4. Superior medial and inferior medial genicular artery

 Page 33 of 54

5. Saphenous branch of the descending genicular artery

6. Circumflex fibular artery

7. Recurrent branch of anterior tibial artery

Clinical correlation

Degenerative joint disease/osteoarthritis* read more about rheumatoid arthritis and osteoarthritis.

Note: Also present in the knee is the anterolateral ligament of the knee between the fibular collateral
ligament and the ITT (iliotibial tract) attachment. Also, note the presence of oblique ligament of the
knee as a continuation of the tendon of semimembranosus muscle.

Tibiofibular joint

 It is synovial in type and allows very little movements.

 The joint capsule is reinforced by anterior and posterior ligaments.

THE POPLITEAL FOSSA

Is an important area of transition between the thigh and leg and is the major route by which
structures pass from one region to the other.

 The popliteal fossa is a diamond shaped space behind the knee joint formed in the posterior
compartments of the thigh and leg.

 The margins of the upper part of the diamond are formed medially by the distal ends of
semitendinosus and semimembranosus muscles and laterally by the distal end of the biceps
femoris.

 The margins of the smaller lower part of the space are formed medially by the medial head of
the gastrocnemius muscles and laterally by the plantaris muscle and the lateral head of the
gastrocnemius muscle.

 The floor of the fossa is formed by the capsule of the knee joint and adjacent surfaces of the
femur and tibia, and more inferiorly, by the popliteus muscle.

 The roof of the fossa is formed by deep fascia, which is continuous above with the fascia lata of
the thigh and below with deep fascia of leg.

Contents

 Popliteal artery

 Popliteal vein

 Tibial nerve

 Common peroneal nerve

 Page 34 of 54

The tibial and common peroneal nerve are the most superficial neurovascular structures in the fossa
with the popliteal artery being the deepest located structure in the fossa.

 The tibial nerve descends vertically through the popliteal fossa and exits deep to the margin of
the plantaris muscle to enter the posterior compartment of the leg.

 The common peroneal nerve exits by following the biceps femoris tendon over the lower lateral
margin of the popliteal fossa, and continues to the lateral side of the leg where it swings around
the neck of the fibula and enters the lateral compartment of the leg.

 The popliteal artery and vein

 Is the continuation of the femoral artery in the anterior compartment of the thigh, and
begins as the femoral artery passes posteriorly through the adductor hiatus in the adductor
magnus muscle. It descends obliquely through the fossa with the tibial nerve and enters the
posterior compartment of the leg where it ends just lateral to the midline of the leg by
dividing into anterior and posterior tibial arteries.

 It gives branches which supply adjacent muscles and a series of geniculate arteries which
contribute to the vascular anastomosis around the knee.

 The popliteal vein is superficial to and travels with the popliteal artery. It exits the fossa
superiorly to become the femoral vein by passing through the adductor hiatus.

Roof of the popliteal fossa

 Is covered superficial fascia and skin. The most important structure in the superficial fascia is the
small saphenous nerve. Another structure that passes through the superficial fascia is the
posterior cutaneous nerve of the thigh, which descends through the roof of the popliteal fossa,
and then continues inferiorly with the small saphenous nerve to innervate skin on the upper half
of the leg.

THE LEG

 Proximally, most major structures pass between the thigh and leg through or in relation to the
popliteal fossa behind the knee.

 Distally, structures pass between the leg and the foot mainly through the tarsal tunnel on the
posteromedial side of the ankle, the exceptions being the anterior tibial artery and the ends
terminal parts of the deep and superficial fibular nerves, which enter the foot anterior to the
ankle joint.

 The bone s of the leg include the tibia and the fibula. The fibula is much smaller and does
not take part in the formation of the knee joint. The distal end of the fibula is firmly
anchored to the tibia by a fibrous joint and forms the lateral

 The tibia is the weight bearing bone of the leg and is much large than the tibia. It takes
part in the formation of the knee joint and below it forms the medial malleolus.

 The leg is divided into anterior (extensor), posterior (flexor) and lateral (fibular) compartments
by:

 An interosseous membrane which links adjacent borders of the tibia and fibula along most
of their lengths.
 Page 35 of 54

 Two intermuscular septa, which pass between the fibula and deep fascia surrounding the
limb

 Direct attachment of the deep fascia to the periosteum of the anterior and medial borders
of the tibia.

 The muscles in the anterior compartment of the leg dorsiflex the ankle, extend the toes and
invert the foot. Muscles in the the posterior compartment plantarflex the ankle, flex the toes
and invert the foot. Major nerves and vessels supply or pass through each compartment.

Bones

Shaft and distal end of tibia

The shaft of tibia is triangular in cross-section and has anterior, interosseous and the medial borders
and medial, lateral and posterior surfaces:

 The anterior and medial borders and the entire medial surface are subcutaneous.

 The interosseous border of the tibia is connected, by the interosseous membrane, along its
length to the interosseous border of the fibula.

 The posterior surface is marked by an oblique line (the soleal line).

The distal end of the tibia is shaped like a rectangular box (mortise tendon) with a bony protuberance
on the medial side forming the medial malleolus. The upper part of the box is continuous with the
shaft of the tibia while the lower surface and the medial malleolus articulate with one of the tarsal
bones (talus) to form a large part of the ankle joint.

 The posterior surface of the box-like distal end of tibia is marked by a vertical groove, which
continues inferiorly and medially onto the posterior surface of the medial malleolus. The groove
is for the tendon of the tibialis posterior muscle.

 The lateral surface of the distal end of the tibia is occupied by a deep triangular notch (the
fibular notch) to which the distal head of the fibular is anchored by a thickened part of
interosseous membrane.

Shaft and distal end of fibula

 The fibular is enclosed by muscles except for the ends. The shaft has three borders and three
surfaces for the attachment of muscles, intermuscular septa and ligaments. The interosseous
border of the fibula is attached to the interosseous border of tibia by the interosseous
membrane. Intermuscular septa attach to the anterior and posterior borders. Muscles attach to
the three surfaces.

 The narrow medial surface faces the anterior compartment of the leg, the lateral surface faces
the lateral compartment and the posterior surface faces the posterior compartment of the leg.
 Page 36 of 54

 The posterior surface is marked by vertical crest (medial crest), which divides the posterior
surface into two parts each attached to a different flexor muscle. The distal end of the fibula
expands to form the spade-shaped lateral malleolus.

 The medial surface of the lateral malleolus bears a facet for articulation with the lateral surfaces
of the talus forming the lateral part of the ankle joint. The malleolar fossa is the attachment site
for posterior talofibular ligament. This firm linking together of the distal ends of the tibia and
fibula is essential to produce the skeletal framework for articulation with the foot to form the
ankle joint

Posterior compartment of the leg

Muscles

The muscles in the posterior compartment of the leg are organized into two groups, superficial and
the deep group separated by a layer of deep fascia. The muscles mainly plantarflex and invert the foot
and flex the toes. All are innervated by the tibial nerve.

 Superficial group

 It consist of three muscles- the gastrocnemius, plantaris and soleus- all of which insert onto
the heel (calcaneus) of the foot and plantarflex the foot at the ankle joint.

 As a unit these muscles are large and powerful because they propel the body forward off
the planted foot during walking and can elevate the body upwards onto the toes when
standing (antigravity muscles).

 Two of muscles (gastrocnemius and plantaris) originate on the distal end of the femur and
can flex the knee.

Muscle Origin Insertion Innervation Function

Gastrocnemius Medial Via calcaneal Tibial nerve Plantarflexes the

head-posterior tendon to (S1,S2) foot and flexes
surface of the posterior surface the knee
distal femur just of calcaneus
superior to
medial condyle;
lateral head-
upper
posterolateral
surface of the
lateral femoral
condyle

Plantaris Inferior part of Via calcaneal Tibial nerve Plantarflex foot

lateral tendon to (S1,S2) and flex the knee
supracondylar posterior surface
line of femur and of calcaneus
oblique popliteal
 Page 37 of 54

ligament of the
knee

Soleus Soleal line and Via calcaneal Tibial nerve Platarflexes the
medial border of tendon to (S1,S2) foot.
tibia; posterior posterior surface
aspect of fibular of calcaneus
head and
adjacent surfaces
of neck and
proximal shaft;
tendinous arch
between tibial
and fibular
attachments

Achilles tendon rupture

Often related to sudden or direct trauma and frequently occurs in a normal healthy tendon. Certain
conditions may predispose the tendon to rupture which are tendinopathy (due to overuse, or
age-related degenerative changes) and previous Achilles tendon intervention such as injections of
pharmaceuticals and the use of certain antibiotics.

Deep Group

There are four muscles in the deep posterior compartment of the leg- the popliteus, flexor hallucis
longus, flexor digitorum longus and tibialis posterior.

 The popliteus muscle acts on the knee and is the smallest and most superior of all the muscles in
the deep group. It unlocks the extended knee at the initiation of flexion and stabilizes the knee
joint by resisting lateral(external) rotation of the tibia on the femur.

Muscle Origin Insertion Innervation Function

Popliteus Lateral femoral Posterior surface Tibial nerve (L4 to Stabilizes the
condyle of the proximal S1) knee joint (resist
tibia lateral rotation of
tibia on femur),
unlocks knee joint
(laterally rotates
the femur on
fixed tibia)

Flexor hallucis Posterior surface Plantar surface of Tibial nerve Flexes the great
longus of fibular and distal phalanx of (S2,S3) toe
adjacent surfaces great toe.
of interosseous
membrane

Flexor digitorum Medial side of the Plantar surfaces Tibial nerve Flexes lateral four
longus posterior surface of bases of distal (S2,S3) toes
 Page 38 of 54

of the tibia phalanges of the

lateral four toes

Tibialis posterior Posterior surfaces Mainly to Tibial nerve Inversion and

of interosseous tuberosity of (L4,L5) plantarflexion of
membrane and navicular and foot; support of
adjacent regions adjacent region of the medial arch of
of tibia and fibula the medial the foot during
cuneiform walking.

 Arteries

 Popliteal artery

 Divides into anterior and posterior tibial arteries within the leg. Two large sural
arteries, one on each side, branch from the popliteal artery to supply
gastrocnemius, soleus and plantaris muscles. It also gives branches that
contribute to a collateral network of vessels around the knee joint (genicular
anastomosis).

 Anterior tibial artery

 Passes forward through the aperture in the upper part of the interrosseous
membrane and enters and supplies the anterior compartment of the leg.

 Posterior tibial artery

 Supplies the posterior and the lateral compartment of the leg and continues into
the side of the leg. It descends in the posterior leg and passes through the tarsal
tunnel behind the medial malleolus and into the sole of the foot.

 In the leg the leg, the posterior tibial artery supplies the adjacent muscles and
bone and has two major branches, the circumflex fibular artery and fibular
artery.

 The circumflex fibular artery passes laterally through the soleus muscles and
around the neck of fibula to connect with the anastomotic network of vessels
surrounding the knee.

 The fibular artery parallels the course of the tibial artery , but descends along the
lateral side of the posterior compartment adjacent to the medial crest on the
posterior surface of the fibular, which separates the attachments of the tibialis
posterior and flexor hallucis longus muscles. The fibular arteries supplies the
adjacent muscles and bone in the posterior compartment of the leg and also has
branches that pass laterally through the intermuscular septum to supply the
fibularis (peroneus) muscles in the lateral compartment of the leg.

 Veins

 Deep veins in the posterior compartment generally follow the arteries.

 Nerves

 Tibial nerve
 Page 39 of 54

 Is a major branch of the sciatic nerve that descends through the popliteal
fossa into the posterior compartment of the leg.

 It leaves the posterior compartment of the leg at the ankle by passing

through the tarsal tunnel behind the medial malleolus into the foot to
supply most of the intrinsic muscles of the foot.

 In the leg, it gives rise to branches that supply all the muscles in the
posterior compartment of the leg and two cutaneous branches, the sural
nerve and medial calcaneal nerve.

Lateral compartment of the Leg

Muscles

There are two muscles in the lateral compartment of the leg; fibularis longus (peroneus longus) and
fibularis brevis (peroneus brevis).

 Both the muscles evert the foot(turn the sole outward) and are innervated by the superficial
fibular nerve which is a branch of the common fibular nerve.

Muscle Origin Insertion innervation Function

Fibularis longus Upper lateral Undersurface of Superficial fibular Eversion and

surface of fibula, lateral sides of nerve (L5,S1,S2) plantarflexion of
head of fibula, the distal end of foot
and occassionally medial cuneiform
the lateral tibial and base of
condyle metatarsal I

Fibularis brevis Lower two-thirds Lateral tubercle at Superficial fibular Eversion of foot
of lateral surface the base of nerve (L5,S1,S2)
of the shaft of metatarsal V
fibula

The fibularis longus everts and plantarflex the foot. The fibularis longus, tibialis anterior and tibialis
posterior muscles, which all insert on the undersurface of bones on the medial side of the foot,
together act as a stirrup to support the arches of the foot. The fibularis longus supports mainly the
lateral and transverse arches.

Arteries

 No major artery passes vertically through the lateral compartment of the leg. It is supplied by
branches (mainly from the fibular artery in the posterior compartment of the leg) that penetrate
into the lateral compartment of the leg.

 The deep veins generally follow the arteries.

 Page 40 of 54

Nerves

Superficial fibular nerve

 Originates as one of the two major branches of the common peroneal (fibular) nerve, which
enters the lateral compartment of the leg from the popliteal fossa. The common fibular nerve
originates from the sciatic nerve in the posterior compartment of the thigh or in the popliteal
fossa, and follows the medial margin of the biceps femoris tendon over the lateral head of
gastrocnemius muscle and towards the fibular. Here it gives origin to two cutaneous branches,
which descend int the leg

 The sural communicating nerve, which joins the sural branch of the tibial nerve and
contributes to innervation of skin over the lower posterolateral side of the leg.

 The lateral cutaneous nerve, which innervates the skin over the upper lateral leg.

 The common fibular nerve continues around the neck of fibular and enters the lateral
compartment by passing between the attachments of the fibularis longus muscle to the head
and shaft of the fibula. Here the common peroneal nerve divides into its two terminal branches;

 The superficial fibular nerve

 The deep fibular nerve

 The superficial fibular nerve descends in the lateral compartment deep to the fibularis longus
and innervates the fibularis longus and brevis. It then penetrates the deep fascia in the lower leg
and enters the foot where it divides into medial and lateral branches, which supply the dorsal
areas of the foot and toes except for

 The web space between the great and second toes, which is supplied by the deep fibular
nerve.

 The lateral side of the little toe, which is supplied by the sural branch of the tibial nerve.

 The deep fibular nerve passes anteromedially through the intermuscular septum into the
anterior compartment of the leg which it supplies.

The Anterior compartment of the leg

Muscles

There are four muscles in the anterior compartment of the leg- the tibialis anterior, extensor hallucis
longus, extensor digitorum longus and fibularis tertius (peroneus tertius). Collectively they dorsiflex
the foot at the ankle joint, extend the toes and invert the foot. All are innervated by the deep fibular
nerve.

Muscle Origin Insertion Innervation Function

Tibialis anterior Lateral surface of Medial and Deep fibular Dorsiflexion of

tibia and adjacent inferior surfaces nerve (L4,L5) the foot at the
interosseous of medial ankle
membrane and cuneiform and joint;inversion of
deep fascia adjacent surfaces foot; dynamic
on the base of support of the
 Page 41 of 54

metatarsal I medial arch of

foot.

Extensor hallucis Middle one-half Dorsal surface of Deep fibular Extension of the
longus of medial surface distal phalanx of nerve (L5,S1) great toe and
of fibular and great toe dorsiflexion of
adjacent surface foot
of interosseous
membrane

Extensor Proximal one-half Via dorsal digital Deep fibular Extension of

digitorum longus of medial surface expansions into nerve (L5,S1) lateral four toes
of fibula and the bases of distal and dorsiflexion
related surfaces and middle of foot
of lateral tibial phalanges of
condyle lateral four toes

Fibularis Distal part of Dorsomedial Deep fibular Dorsiflexion and

(peroneus tertius) medial surface of surface of base of nerve (L5,S1) eversion of foot
fibula metatarsal V

Arteries

Anterior tibial artery

 Originates from the popliteal artery in the posterior compartment of leg and passes forward into
the anterior compartment through an aperture in the interosseous membrane.

 It descends through the anterior compartment on the interosseous membrane. It leaves the leg
leg anterior to the distal end of tibia and ankle joint and continues onto the dorsal aspect of the
foot as dorsalis pedia artery.

 It supplies adjacent muscles and is joined by the perforating branch of the fibular artery, which
passes forward through the lower aspect of the interosseous membrane from the posterior
compartment of the leg.

 Distally, the anterior tibial artery gives rise to an anterior medial malleolar artery and an anterior
lateral malleolar artery, which passes posteriorly around the distal ends of the tibia and fibular
and connect with vessels from the posterior tibial and fibular arteries to firm anastomotic
network around the ankle.

 Deep veins follow the arteries.

Nerves

Deep fibular nerve

 It originates from the lateral compartment of the leg as one of the divisions of the common
peroneal nerve.

 It passes anteromedially through the intermuscular septum that separates the lateral from the
anterior compartments of the leg and then passes deep to the extensor digitorum longus. It
reaches the anterior interosseous membrane where where it meets and descends with the
anterior tibial artery:
 Page 42 of 54

 The deep fibular nerve:

 Innervates all the muscles in the anterior compartment of the thigh

 Continues into the dorsal aspect of the foot where it innervates the extensor
digitorum brevis, contributes to the innervation of the first two dorsal interossei
muscles and supplies the skin between the great toe and second toe.

Clinical correlation

Foot Drop

 Is the inability to dorsiflex the foot. Patients with foot drop have a characteristic steppage gait.
As the patient walks, the knee of the affected limb is elevated to an abnormal height during the
swing phase to prevent the foot from dragging. At the end of the swing phase, the foot slaps the
ground.

 A typical cause of foot drop is damage to the common fibular nerve. Other causes include disc
protrusion compressing the L5 nerve root, disorders of the sciatic nerve and the lumbosacral
plexus, and pathologies of the spinal cord and brain.

THE FOOT

 It is distal to the ankle joint and is subdivided into the ankle, the metatarsus and the digits. There
are five digits of the medially positioned great toe (digit I) and four more laterally placed digits,
ending laterally with the little toe (digit V).

 The foot has a superior surface (dorsum of the foot) and the inferior surface (sole or plantar
surface)

 Abduction and adduction of the toes are defined with respect to the long axis of the second digit.
The foot provides a stable platform for upright stances. It also levers the body forward during
walking.

Bones

There are three groups of bones in the foot

 The seven tarsal bones, which form the skeletal framework for the ankle;

 Metatarsal (I to V), which are the bones of the metatarsus

 The phalanges, which are the bones of the toes- each toe has three phalanges except the great
toe which has two.

Tarsal bones

 The tarsal bones are arranged in a proximal group and a distal group with an intermediate bone
between the two groups on the medial side of the foot

 The proximal group consist of two large bones, the talus and the calcaneus
 Page 43 of 54

 Intermediate bone on the medial side of the foot is the navicular (boat shaped). It
articulates behind with the talus and articulates in front and on the lateral side with the
distal group of the tarsal bones.

 From lateral to medial, the distal groups of tarsal bones consist of

 The cuboid which articulates posteriorly with the calcaneus, medially with the
lateral cuneiform and anteriorly with the bases of the lateral two metatarsals.
The tendon of fibularis longus muscle lies in a prominent groove on the anterior
plantar surface, which passes obliquely forward across the bone from lateral to
medial.

 Three cuneiforms- the lateral and medial cuneiforms which articulate with each
other, articulate posteriorly with the navicular bone and anteriorly with the
bases of the medial three metatarsals.

Metatarsals

 There are five metatarsals in the foot (I-V) from medial to lateral. Each metatarsal has a head at
the distal end, an elongate shaft in the middle and a proximal base. The head of each metatarsal
articulates with the proximal phalanx of a toe and the base articulates with one or more of the
distal group of tarsal bones.

 The plantar surface of the head of metatarsal I also articulates with two sesamoid bones.

 The lateral side of the base of metatarsal V has a prominent tuberosity, which projects
posteriorly and is the attachment site for the tendon of the peroneus brevis muscle.

Phalanges

The phalanges are the bones of the toes. Each toe has three phalanges (proximal, middle and distal)
except for the great toe which has two (proximal and distal). Each phalanx consist of a base, a shaft
and a distal head.

 The base of each proximal phalanx articulates with the head of the related metatarsal

 The head of each distal phalanx is nonarticular and flattened into a crescent-shaped plantar
tuberosity under the the plantar pad at the end of the digit.

Joints

Ankle Joint

 Is of synovial type and involves the talus of the foot and the tibia and fibula of the leg. It allows
hinge like dosrsiflexion and plantarflexion of the foot on the leg. The distal end of fibula is firmly
anchored to larger distal end of the tibia by strong ligaments. Together, the fibular and tibia
create a deep bracket-shaped socket (mortise) for the upper expanded part of the body of talus.

 The roof of the socket is formed by the inferior surface of the distal ens of tibia.

 The medial side of the socket is formed by the medial malleolus of the tibia.

 The loner lateral side of the socket is formed by the lateral malleolus of the fibula.

 The articular surfaces are covered by hyaline cartilage

 Page 44 of 54

 Fracture of the talus- the blood supply to the bone is vulnerable to damage. It is supplied by the
branches of the posterior tibia artery and the dorsalis pedis artery. Also branches from the
fibular artery supply a small portion of of the lateral malleolus. Fractures of the neck of talus
often interrupt the blood supply to the talus, so making the body and posterior aspect of the
talus susceptible to osteonecrosis, which may in turn lead to premature osteoarthristis which
may require extensive surgery.

 Mid foot fractures which usually occur when heavy weights have been dropped on the feet or
when the feet has been ran over by a vehicle.

 The ankle joint is more stable during dorsiflexion. The articular cavity is enclosed by synovial
membrane, which attaches around the margins of the articular surface, and by fibrous
membrane, which covers the synovial membrane and is attached to the adjacent bones. The
ankle joint is stabilized by medial (deltoid) and lateral ligaments.

Ligaments

Medial ligament (Deltoid ligament)

 It is large and strong and triangular in shape. Its apex is attached above to the medial malleolus
and its broad base is attached below to a line extending below to a line that extends from the
tuberosity of the navicular bone in front to the medial tubercle of the talus behind. It is
subdivided into four parts based on the inferior points of attachment:

 The part that attaches to in front to the tuberosity of the navicular and associated margin
of the plantar calcaneonavicular ligament (spring ligament), which connects the navicular
bone to the sustentaculum tali of the calcaneus bone behind, is the tibionavicular part of
medial ligament.

 The tibiocalcaneal part, which is more central, attaches to the sustentaculum tali of the
calcaneus bone

 The posterior tibiotalar part attaches to the medial side and medial side and medial
tubercle of the talus

 The anterior tibiotalar part is deep to the tibionavicular and tibiocalcaneal parts of the
medial ligament and attaches to the medial surface of the talus.

Lateral ligament

It is composed of three separate ligaments, the anterior talofibular ligament, the posterior talofibular
ligament and the calcaneofibular ligament.

 The anterior talofibular ligament is a short ligament and attaches to the anterior margin of the
lateral malleolus to the adjacent region of the talus.

 The posterior talofibular ligament runs horizontally backward and medially from the malleolar
fossa on the medial side of the lateral malleolus to the posterior process of the talus.

 The calcaneofibular ligament is attached above to the malleolar fossa on the posteromedial side
of the lateral malleolus and passes posteroinferiorly to attach below the tubercle on the lateral
side of the calcaneus.
 Page 45 of 54

Intertarsal joints

The numerous synovial joints between the individual tarsal bones mainly invert, evert, supinate and
pronate the foot.

Pronation and supination allow the foot to maintain normal contact with the ground when in
different stances or when standing on irregular surfaces. The major joints at which movements take
place include the subtalar, talocalcaneonavicular and calcaneocuboid joints. The
talocalcaneonavicular and calcaneocuboid joints are referred to as the transverse tarsal joint. The
subtalar joint is stabilized by lateral, media, posterior and interosseous talocalcaneal ligaments. The
talocalcaneonavicular joint (is a complex joint in which the head of the talus articulates with the
calcaneus and plantar calcaneonavicular ligament (spiring ligament) below and the navicular infront),
is reinforced:

 Posteriorly by the interosseous talocalcaneal ligament

 Superiorly by the talonavicular ligament, which passes between the the neck of the talus and
adjacent regions of the navicular.

 Inferiorly by the plantar calcaneonavicular ligament or the spring ligament.

 The calcaneocuboid joint is reiforced by the bifurcate ligament and by the long plantar ligament
and the plantar calcaneocuboid ligaments (short plantar ligament).

Tarsometatarsal joints

These are plane joints and allow limited sliding movements.

Metatarsophalangeal joints

These are elipsoid synvisl joints between the sphere-shaped heads of the metatarsals and the
corresponding bases of the proximal phalanges of the digits. The joint capsules are reinforced by
medial and laterall collateral ligaments and by the plantar ligaments. They allow for extension and
flexion and limited abduction, adduction, rotation and circumduction.

Deep transverse metatarsal ligaments

Four deep transverse metatarsal ligaments link the heads of the metatarsals together and enable the
metatarsals to act as a single unified structure. The ligaments blend with the plantar ligaments of the
adjacent metatarsophalangeal joints. The great toe is non-opposable to provide principle support to
the foot during walking and for efficient transfer of weight.

*Bunions- significance protuberance of bone that may include the soft tissue around the medial
aspect of the first metatarsophalangeal joint.
 Page 46 of 54

Interphalangeal joints

Are hinge joints that allow mainly flexion and extension. They are reinforced by by medial and lateral
collateral ligaments and by plantar ligaments.

Tarsal tunnel, retinacula and arrangement of major structures at the ankle

 The tunnel is formed on the posteromedial side of the ankle by:

 Depression fromed by the medial malleolus of the tibia, the medial and posterior surfaces
of the talus, the medial surface of the calcaneus and the inferior surface of the
sustentaculum tali of calcaneus.

 An overlying flexor retinaculum

Flexor retinaculum

 Is a strap like layer of connective tissue that spnas the bony depression formed by thee medial
malleolus, the medial and posterior surfaces of the talus, the medial surface of the calcaneus
and the inferior surfaces of the sustentaculum tali. It attaches above to the medial malleolus and
below and behind to the inferomedial margin of the calcaneus.

 It is continuos above with the deep fascia of the leg and below with the deep fascia (plantar
aponeurosis) of the the foot.

 Septa from the flexor retinaculum convert the grooves on the bones into tubularconnective
tissue channels for the tendons of the flexor muscles as they pass into the sole of the foot from
the posterior compartment of the leg. Free movement of the tendons is facilitated by the
synovial sheaths, which surround the tendons.

 Two compartments on the posterior surface of the medial malleolus are for the tendons of the
tibialis poaterior and the flexor digitorum longus, the posterior tibial artery with the associated
veins and the tibial nerve passes through the tarsal tunnel into the sole of the foot. The pulse of
the posterior tibial artery can be felt through the flexor retinaculum midway between the medial
malleolus and the calcaneus.

 Lateral to the tibial nerve is the compartment on the posterior surface of the talus and the under
surface of the sustentaculum tali for the tendon of the flexor hallucis longus.

Extensor retinacula

 Strap the tendons of the extensor muscles to the ankle region and prevent tendon bowing
during extension of foot and toes.

 A superior extensor retinaculum is thickening of the deep fascia in the distal leg just
superior to the ankle joint and attached to the anterior borders of the fibula and tibia.

 An inferior extensor retinaculum whic is Y-shaped and attached by its base to the lateral
side of the upper surface of the calcaneus, and cross medially over the foot to attach by
one of its arms to the medial malleolus, whereas the other arm wraps medially around the
foot and attaches to the medial side of the plantar aponeurosis
 Page 47 of 54

 The tendons of the extensor digitorum longus and peroneus tertius pass through a
compartment on the lateral side of the proximal foot. Medial to these tendons, the dorsalis
pedis artery (terminal branch of the anterior tibial artery), the tendon of the extensor
hallucis longus, and the tendon of the tibialis anterior muscle passes under the extensor
retinacula.

Fibular retinacular

 Peroneal retinaculum bind the tendons of the peroneus longus and peroneus brevis muscles to
the lateral malleolus and the calcaneus.

 A superior fibular retinaculum extends between the lateral malleolus and the calcaneus

 An inferior fibular retinaculum attaches to the lateral surface of the calcaneus around the
fibular trochlea and blends above with the fibres of the inferior extensor retinaculum

Arches of the foot

The bones of the foot are arranged to form longitudinal and transverse arches relative to the ground,
which absorb and distribute downward forces from the body during standing and moving on different
surfaces.

Longitudinal arch

 Is formed between the the posterior end of the clacaneus and the heads of the metatarsals. It is
highest on the medial side, where it forms the medial part of of the longitudinal arch, and lowest
of the lateral side where it forms the lateral part.

Transverse arch

 It is highest in the coronal plane that cuts through the head of talus and disappears near the
heads of the metatarsals, where these bones are held together by deep transverse metatarsal
ligaments.

Ligament and muscle support

 Ligaments and muscles support the arches of the foot

 Ligaments that support the arches include the plantar calcaneonavicular (spring ligament),
plantar clacaneocuboid (short plantar ligament) and long plantar ligaments and the plantar
aponeurosis

 Muscles that provide dynamic support for the arches during walking include the tibialis
posterior and anterior and the peroneus longus.

Plantar aponeurosis

 Is a thickening of deep fascia in the sole of the foot. It is firmly anchired to the medial process of
the calcaneal tuberosity and extends forwards as thick band of longitudinally arranged
connective tissue fibres. The fibres diverge as they pass anterior to form digital bands, which
enter the toes and connect with bones, ligaments and dermis of the skin. Distal to the MTP joints,
the digital bands of the plantar aponeurosis are interconnected by transverse fibres, which form
 Page 48 of 54

superficial transverse metatarsal ligaments. The plantar aponeurosis supports the longitudinal
arches of the foot and protects neurovascular structures and deepers structures in the foot.

Fibrous sheaths of toes

 The tendos of the flexor digitorum longus, flexor digitorum brevis and flexor hallucis longus
muscles enter the fibrous digital sheaths or tunnels on the plantar aspect of the digits. They hold
the tendons to the bony plane and prevent tendon bowing when the toes are flexed.

Extensor hoods

 The tendons of the extensor digitorum longus, extensor digitorum brevis and extensor hallucis
longus pass into the dorsal aspect of the digits and expand over the proximal phalanges to form
complex dorsal digital expansions.

 Many of the intrinsic muscles of the foot insert into the free margins of the hood on each side.
This attachment allows the forces from these muscles to be distributed over the toes to cause
flexion of the MTP joints while at the same time extending the IPJ.

Intrinsic muscles of the foot

Intrinsic muscle of the foot originate and insert in the foot

 The extensor digitorum brevis and extensor hallucis brevis on the dorsal aspect of the foot;

 All other intrinsic muscles- the dorsal and plantar interossei, flexor digiti minimi brevis, flexor
hallucis brevis, flexor digitorum brevis, quadratus plantae (flexor accessorius), abductor digiti
minimi, abductor hallucis and lumbricals- are on the plantar side of the foot in the sole where
they are organized into four layers.

 The intrinsic muscles mainly modify the actions of the long tendons and generate fine
movements of the toes.

 All intrinsic muscles of the foot are innervated by the medial and lateral plantar branches of the
tibial nerve except for the extensor digitorum brevis, which is innervated by the deep fibular
nerve. The first two dorsal interossei also may receive part of their innervation from the deep
fibular nerve.

On the dorsal aspect of the foot

Extensor digitorum brevis and extensor hallucis brevis

Muscle Origin Insertion Innervation Function

Extensor Superolateral Lateral sides of Deep fibular Extension of toes

digitorum brevis surface of the the tendons of nerve (S1,S2) II to IV
calcaneus extensor
digitorum longus
of toes II to IV

Extensor hallucis Superolateral Base of the Deep fibular Extension of MTP

 Page 49 of 54

brevis surface of of proximal phalanx nerve (S1,S2) joint of the great

calcaneus of great toe toe.

In the Sole

The muscles in the sole of foot are organized into four layers. From superficial to deep or plantar to
dorsal, these layers are first, second, third and fourth.

First Layer

Muscle Origin Insertion Innervation Function

Abductor hallucis Medial process of Medial side of Medial plantar Abducts and
calcaneal base of proximal nerve from the flexes great toe at
tuberosity phalanx of great tibial nerve MTP joint.
toe (S1,S2,S3)

Flexor digitorum Medial process of Side of plantar Medial plantar Flexes lateral four
brevis calcaneal surface of middle nerve from the toes at proximal
tuberosity and phalanges of tibial nerve interphalangeal
plantar lateral four toes (S1,S2,S3) joint
aponeurosis

Abductor digiti Lateral and Lateral side of Lateral plantar Abducts little toe
minimi medial process of base of proximal nerve from the at the MTP joint.
calcaneal phalanx of little tibial nerve
tuberosity, and toe (S1,S2,S3)
band of
connective tissue
connecting
calcaneus with
base of
metatarsal V

The second layer

Muscles Origin Insertion Innervation Function

Quadratus Medial surface of Lateral side of the Lateral plantar Assists flexor
plantae calcaneus and tendon of flexor nerve from the digitorum longus
lateral process of digitorum longus medial nerve tendon in flexing
calcaneal in proximal sole (S1,S2,S3) toes II to V
tuberosity of the foot

Lumbricals First Medial free Fierst Flexion of MTP

 Page 50 of 54

Lumbrical-medial margins of lumbrical-medial joint and

side of tendon of extensor hoods of plantar nerve extension of IPJ
flexor digitorum toes I to V from the tibial
longus associated nerve, second,
with toes thrid and fourth
I;second, third lumbricals-lateral
and fourth plantar nerve
lumbricals- from the tibial
adjacent surfaces nerve (S2,S3)
of adjacent
tendons of flexor
digitorum longus

The Third Layer

Muscle Origin Insertion Innervation Function

Plantar surface of Lateral and Medial plantar Flexes MTP of the

cuboid and lateral medial side of nerve from tibial great toe
cuneiform;tendon base of proximal nerve (S1,S2)
of tibialis phalanx of the
posterior great toe

Adductor hallucis Transverse Lateral side of Lateral plantar Adducts the great
head-ligaments base of proximal nerve from tibial toe at MTP joint
associated with phalanx of great nerve (S2,S3)
MTP joint of the toe
lateral three toes;
oblique
head-bases of
metatarsal I to IV
and from sheath
covering fibularis
longus

Flexor digiti Base of Lateral side of Lateral plantar Flexes little toe at
minimi brevis metatarsal V and base of proximal nerve from tibial the MTP joint
related sheath of phalanx of great nerve (S2,S3)
the fibularis toe
longus tendon

The fourth layer

Muscle Origin Insertion Innervation Function

Dorsal interossei Sides of adjacent Extensor hoods Lateral plantar Abduction of toes
metatarsals and bases of nerve from tibial II to IV at the MTP
proximal nerve; first and joints; resist
phalanges of toes second dorsal extension of MTP
 Page 51 of 54

II to IV interossei also joints and flexion

innervated by of IPJ
deep fibular
nerve (S2,S3)

Plantar interossei Medial side of Extensor hoods Lateral plantar Adduction of toes
metatarsals of and bases of nerve from tibial III to V at MTP
toes III to V proximal nerve (S2,S3) joints; resist
phalanges of toes extension of the
III to V MTP joints and
flexion of the IPJ

Arteries

 Blood supply to the foot are from branches of the posterior tibial and dorsalis pedis artery which
is the terminal part of the anterior tibial artery. The posterior tibial artery enter the foot and
bifurcates into lateral and medial plantar arteries. The lateral plantar artery joins with the
terminal end of the dorsalis pedis artery (the deep plantar artery) to form the deep plantar arch.
Branches form this arch supplies the toes.

 The posterior tibial artery enter the foot through the tarsal tunnel on the medial aspect of the
ankle and posterior to the medial malleolus. The posterior artery bifurcates into a small medial
plantar artery and a much larger plantar artery.

 The lateral plantar artery forms the deep plantar arch which crosses the deep plane of the sole
on the metatarsal bases and the interossei muscles.

 Between the bases of metatarsal I and II, the deep plantar arch joins with the terminal branch
(deep plantar artery) of the dorsalis pedis artery, which enter the sole from the dorsal side of the
foot.

 Major branches of the deep plantar artery include;

 A digital branch to the lateral side of the little toe

 Four plantar metatarsal arteries, which supply digital branches to adjacent side
of of toes I to V and the medial side of the great toe.

 Three perforating arteries, which pass between the bases of metatarsals II to V to

anastomose with vessels on the dorsal aspect of the foot.

 Medial plantar artery

 Passes into the sole of foot by passing deep to the proximal end of the abductor hallucis
muscle. It supplies a deep branch to adjacent muscles and then passes forward in the
groove between the adductor hallucis and the flexor digitorum brevis muscles. It ends by
joining the digital branch of the deep plantar arch, which supplies the medial aspect of the
great toe.

 It gives rise to a superficial branch, which divides into three vessels that pass superficial to
the flexor digitorum brevis muscle to join the plantar metaatarsal arteries from the deep
plantar arch.
 Page 52 of 54

 Dorsalis pedis artery

 It is the continuation of the anterior tibial artery and begins as the anterior tibial artery
crosses the ankle. It passes anteriorly over the dorsal aspect of the talus, navicular and
intermediate cuneiform bones, and then pass inferiorly, as the deep plantar artery,
between the two heads of the first dorsal interosseous muscles to joint the deep plantar
arch in the sole of foot.

 Branches of the dorsalis pedis artery include lateral and medial tarsal branches, an arcuate
artery and first dorsal metatarsal artery.

 Veins

 The deep veins follow the arteries. Superficial veins drain into a dorsal venous arch on the
dorsal surface of the foot over the metatarsals.

 The great saphenous vein

 The small saphenous vein

 Nerves

 The foot is supplied by tibial, deep fibular, superficial fibular, sural and saphenous nerves.

 All the nerves contribute to cutaneous or general sensory innervation

 The tibial nerve innervates all intrinsic muscles of the foot except for the extensor
digitorum brevis, which is innervated by the deep fibular nerve.

 The deep fibular nerve often also contributes to the innervation of the first and second
dorsal interossei.

ARCHES OF THE FOOT

Introduction

 Functions of the foot are support and locomotion

 Adapted to perform these functions efficiently

 Many bones, plantigrade- Adapts to uneven surfaces

 Weight distributed by arches

 Pliable- gives spring to the step; can adapt to different surfaces

Arches- Classification

 The arches are identified according to position

 Medial longitudinal (complete)

 Lateral longitudinal (complete)

 Anterior transverse (incomplete)

 Posterior Transverse (complete)

Structure
 Page 53 of 54

Each arch has

 Bony factors- bones forming it: form ends, summit and pillars

 Intersegmental ties- Ligaments uniting the bones

 Beams- prevent flattening of the longitudinal arches

 Slings- tendons usually supporting the summit of the arch

Medial Longitudinal arch

Bones

 Calcaneus

 Talus (keystone)

 Navicular

 Cuneiforms

 Metatarsals 1, 2 & 3.

Intersegmental Ties

 Spring ligament (plantar calcaneonavicular ligament)

 Tibialis posterior tendon

 Other ligaments between the bones

Tie Beams

 Plantar aponeurosis

 Flexor Digitorum Brevis muscle

Slings

These offer support from above and suspend the apex

 Tibialis anterior

 Flexor Hallucis Longus

 Flexor Digitorum Longus

Lateral Longitudinal Arch

Bones- calcaneus, cuboid and lateral two metatarsals

Intersegemental ties- long plantar ligament

 Page 54 of 54

Short plantar ligament.

Tie beam and sling: Plantar aponesurosis

Flexor Digitorum Brevis

The sling is the Peroneus Longus

Transverse arches

Anterior: Heads of the five Metatarsals

It is a complete arch and supported by the plantar aponeurosis

Posterior: bones include Tarsals and metatarsals. It is incomplete thus completed by the one on the
opposite side and supported by the medial slings already mentioned above.

End