Lower Limb 0809

Lower Limb
Muscles, fascia, joints &

regions
2008/2009
Haytham Bayadsi
Lower Limb
Muscles
Haytham Bayadsi, 2008/09

Muscle Origin Insertion Innervation
Dorsal Hip
Anterior Group
Iliopsoas
2 parts:
 Psoas major - Lateral surfaces of T12-
Lesser Trochanter
L5 vertebrae and IV
of femur.
disks & costal processes
(after Iliacus Lumbar Plexus
of L1-L5.
inserts on tendon (L1-L3)
of Psoas major)
 Iliacus - Iliac fossa & crest of
sacrum.
Iliopubic
Lateral surfaces of T12-
Psoas Minor eminence,
L1 and IV disk.
Pectineal line
Dorsal Hip
Posterior Group
Gluteus Maximus
 Superficial - Iliac crest, PSIS,

fibers Thoracolumbar fascia, Inferior Gluteal
sacrum and coccyx. Gluteal tuberosity nerve
and Iliotibial (L5-S2)
 Deep fibers - Wing of Ilium behind tract.
Post. Gluteal line and
sacrotuberal ligament.
Wing of ilium between Greater

Gluteus Medius Ant. and Post. Gluteal Trochanter (lat.
lines and iliac crest. surface)
Wing of ilium between Greater
Superior
Gluteus Minimius Ant. and Inf. Gluteal Trochanter (ant.
Gluteal nerve
lines. surface)
(L5-S1)
Iliotibial tract,
ASIS, anterior part of
Tensor Fascia Latae inserted on lateral
iliac crest
condyle of tibia.
Pelvic surface of sacrum Greater
Sacral plexus
Piriformis lateral to foramina, Trochanter
(L5-S2)
sacrotuberal ligament. (Sup. Surface)
Ventral Hip
Nerve to
Pelvic surface of
Trochanteric Obturator
Obturator Internus Obturator membrane and
fossa of femur internus
bones around it
(L5-S1)

Superior Gamellus Ischial spine Trochanteric Sacral plexus
Inferior Gamellus Ischial tuberosity fossa of femur (L5-S2)
Intertrochanteric
Sacral plexus
Quadratus Femoris Ischial tuberosity crest and quadrate
(L5-S1)
tubercle
External surface of
Trochanteric Obturator nerve
Obturator Externus Obturator membrane and
fossa of femur (L2-L4)
surrounding bone
Adductors of
Thigh
Pes Anserinus
Body & inferior pubic Superficialis, on
Gracilis
ramus medial surface of
tibia
Iliopubic eminence, Pectineal line of
Pectineus
pectin pubis femur
Proximal (upper)
Adductor Brevis Inferior ramus of pubis 1/3 of medial lip
of Linea Aspera Obturator nerve
Middle 1/3 of (L2-L4)
Adductor Longus Superior ramus of pubis medial lip of
Linea Aspera Hamstring part
of Adductor
Adductor Magnus Magnus
receives from
2 parts: Tibial nerve
 Muscular - Inferior ramus of pubis, - Medial lip of (L4-L5)
(adductor) part: ramus of Ischium. Linea Aspera and
supra condylar
line.
 Tendinous
(Hamstring) part: - Ischial tuberosity - Adductor
tubercle of femur.
Inferior ramus of pubis Medial lip of
Adductor Minimus
Linea Aspera
Anterior Thigh
muscles
Quadriceps Femoris
Common
4 parts: Quadriceps
 Rectus Femoris - ASIS & Supra- tendon onto
Acetabular groove. Patella, and distal Femoral nerve
 Vastus Intermedius - Anterior & Lateral to Patella as (L2-L4)
surface of shaft of femur. Patellar ligament
 Vastus medialis - Medial lip of Linea inserted on Tibial
Aspera tuberosity.
 Vastus Lateralis - Lateral lip of Linea
Aspera & Gr. trochanter

Pes Anserinus
ASIS Superficialis, Femoral nerve
Sartorius
medial surface of (L2-L4)
tibia.
Posterior Thigh
Muscles
Long head
Biceps Femoris
Tibial nerve
(L5-S2)
Short head
 Long Head: - Ischial tuberosity Head of Fibula
common
 Short Head: - Middle 1/3 of lateral lip
Peroneal nerve
of Linea Aspera
(S1-S2)
Pes Anserinus
Superficialis,
Semitendinosus Ischial tuberosity
medial surface of
tibia
Pes Anserinus
Tibial nerve
Porfundus, ( as
(L5-S2)
medial Tibial
Semimembranosus Ischial tuberosity condyle, fascia of
popliteus and
oblique Popliteal
ligament)
Anterior Leg Muscles,
Extensor compartment
Plantar surface of
Medial
Tibialis Anterior Lateral surface of tibia &
Cuneiform bone
(TA) interossious membrane
& Base of 1st
metatarsal
Lateral condyle of tibia,
head and superior 3/4 of Middle and distal
Extensor Digitorum
medial surface of fibula phalanges of 2nd –
Longus (EDL) Deep Peroneal
and interossious 5th digits (toes)
nerve (L4-S1)
membrane
Dorsal aspect of
Extensor Hallucis Medial surface of fibula base of distal
Longus (EHL) & interossious membrane phalanx of great
toe
Inferior 1/3 of fibula & Dorsum of base
Peroneus Tertius interossious membrane or of 5th metatarsal
from EDL
Anterior Leg Muscles,
Peroneal compartment
Tuberosity of 1st
Superficial
Head of fibula, superior metatarsal and
Peroneus Longus Peroneal nerve
2/3 of fibula medial cuneiform
(L5-S1)
(Crosses foot)

Superficial
Lateral surface of Fibula Tuberosity of 5th
Peroneus Brevis Peroneal nerve
(Inferior 2/3) metatarsal
(L5-S1)
Posterior Leg Muscles,
Superficial layer (Triceps Surae)
Head and upper 1/3 of
Soleus fibula & Soleal line of
tibia (Tendinous arch)
Gastrocnemius
Calcaneal tendon
of Achilles on Tibial nerve
 Medial head - Medial femoral condyle
calcaneal (S1-S2)
tuberosity
 Lateral head - Lateral femoral condyle
Oblique Popliteal
Plantaris ligament, lateral femoral
condyle
Posterior Leg Muscles,
Deep layer
- Thicker medial
part on tuberosity
Interossious membrane
Tibialis Posterior of Navicular bone
and adjacent surfaces of
(TP) - Weaker lateral
tibia and fibula
part on 3
cuneiform bones
Inferior 2/3 of posterior Base of distal Tibial nerve
Flexor Hallucis
surface of fibula and phalanx of great (L4-S1)
Longus (FHL)
interossious membrane toe
Bases of distal
Flexor Digitorum
Posterior surface of tibia phalanges of 2nd –
Longus (FDL)
5th toes
Lateral femoral Posterior Tibial
Popliteus
epicondyle surface
Intrinsic muscles of the foot,
Dorsum of foot
Dorsal
Extensor Digitorum Calcaneus, near calcaneal
aponeurosis of 2nd
Brevis (EDB) sulcus
– 4th digits Deep Peroneal
Dorsal nerve (S1-S2)
Extensor Hallucis
Splits from EDB aponeurosis of 1st
Brevis (EHB)
toe (great)
Intrinsic muscles of the foot,
Sole of foot (plantar region)
Base of proximal
Medial process of phalanx of great
Medial plantar
Abductor Hallucis calcaneal tuber & plantar toe and medial
nerve (L5-S1)
aponeurosis sesamoid bone

- Medial head:
medial sesamoid
bone and
Medial cuneiform bone,
Flexor Hallucis proximal phalanx Medial plantar
long plantar ligament, TP
Brevis - Lateral head: nerve (L5-S1)
tendon
lateral sesamoid
bone and
proximal phalanx
Adductor Hallucis
 Oblique Head: - Cuboid & Lateral

cuneiform bone and Lateral sesamoid Lateral plantar
bases of 3rd-4th bone of great toe nerve (S1-S2)
metatarsals
 Transverse Head: - Metatarsophalangeal
joint's capsules of 3rd-5th
digits
Long plantar ligament &
Opponens Digiti 5th metatarsal
Tendinous sheath of
Minimi shaft
Peroneus longus
Base of 5th metatarsal
Base of 5th
Flexor Digiti Minimi bone, long plantar
proximal phalanx
ligament
Lateral plantar
Lateral process or
nerve (L5-S2)
Calcaneal tuber,
Abductor Digiti Base of 5th
tuberosity of 5th
Minimi proximal phalanx
metatarsal and plantar
aponeurosis
Medial & Lateral margin Lateral margins
Quadratus Plantae of plantar surface of of tendons of
Calcaneus FDL
Split tendons on
Flexor Digitorum Plantar surface of Medial plantar
middle phalanx of
Brevis calcaneal tuberosity nerve (S1-S2)
2nd – 5th toes
Medial margin of Medial 1:
proximal Medial plantar
Medial surfaces of phalanges of 2nd – nerve (L5-S1)
Lumbricals (4)
Tendons of FDL 5th toes + Radiate Lateral 3:
into extensor Lateral plantar
aponeurosis nerve (L5-S2
Interossious (7)
 Dorsal Interossei - 2 heads, Adjacent sides - 1st: Medial side

Lateral plantar
(4) of 1st-5th metatarsals of proximal
nerve (L5-S1)
phalanx of 2nd toe
2nd-4th: lateral
sides of 2nd-4th
toes

 Plantar Interossei - Medial side of 3rd – 5th - Medial sides of
(3) metatarsals bases of
phalanges of 3rd-
5th toes
 ASIS – Anterior superior iliac spine

AIIS – Anterior Inferior iliac spine
PSIS – Posterior superior iliac spine
PIIS – Posterior inferior iliac spine
 Triceps Coxae: Gamellus superior & Inferior + Obturator internus.

Triceps Surae: Soleus + Gastrocnemius + Plantaris.
Quadriceps Coxae: Obturator Externus + Obturator internus + 2 Gemelli.
Hamstrings: Semimembranosus + Semitendinosus + Biceps Femoris
 Intermuscular Speta: in the thigh we have the lateral and medial femoral
Intermuscular septa between the different compartments of the thigh (flexors,
extensors), and the broad Adductor Magnus forms also the border and separation
between the extensor and flexors.
 In the leg, we have 2 Intermuscular speta, dividing leg into 3 compartments,

together with the fibula, tibia and interossious membrane:
- Anterior Intermuscular septum of leg
- Posterior Intermuscular septum of leg

Lower Limb
Joints

Lower Limb Joints:
In the lower limb we have to distinguish between:

- Pelvic Girdle (formed by 2 hip bones and the sacrum).
- Free lower limb (Femur, Tibia, Fibula, Patella, Tarsals, Metatarsals and Phalanges).
In the pelvic girdle, the pubic symphysis unites the 2 hip bones anteriorly, and the sacroiliac
joints unite them posteriorly with the sacrum and unite them together with he lumbosacral joint
to the axial skeleton (skeleton of trunk and vertebral column).
The pelvis is divided into Greater (false) and Lesser (True) pelvises by the oblique plane of the
Pelvic inlet (superior pelvic aperture). The pelvic inlet is defined by the Pelvic Brim:
 Sacral promontory, sacral crests, arcuate line, Iliopubic eminence, pectin pubis, pubic
tubercle, pubic crest and pubic symphysis.
Pubic arch is formed by the ischiopubic rami (inferior rami of pubic and Ischium) of 2 sides.
Subpubic angle is defined by the inferior border of the pubic arch.
Pubic Outlet is bounded by:
 Pubic arch Anteriorly  Ischial tuberosites laterally
 Sacrotuberous ligament posterolaterally  Tip of coccyx posteriorly
The Greater pelvis is:

- Superior to the pelvic inlet
- Bounded by the wings of ilium laterally and the antero-superior aspect of S1 vertebra
posteriorly.
- Occupied by abdominal viscera
The Lesser pelvis is:

- Between pelvic inlet and pelvic outlet
- Bounded by pelvic surface of hip bones, sacrum and coccyx
- Includes the true pelvic cavity and deep parts of perineum & ischioanal fossa
 The Inguinal (Poupart) ligament: is formed by the inferior border of the aponeurosis of the
external abdominal oblique muscle. It extends from the Anterior Superior Iliac Spine to the
Pubic tubercle.
It has a medial point of attachment that spreads out as a broad surface known as Lacunar
ligament (Gimbernat ligament).
Laterally passing from this ligament along the Pectineal line of pubis is the strong fibrous
Pectineal ligament (Inguinal ligament of Coopers).
Between the inguinal ligament and the Iliopubic eminence is the Iliopectineal arch, that
separates the space between the inguinal ligament the anterior surface of hip bone into lateral
neuromuscular and medial vascular compartments.

Joints & Ligaments of the Pelvic Girdle:
1) Sacroiliac Joints:
- Composed of 2 parts:
 Anterior Synovial joint (Amphiarthrosis) between the auricular surfaces of
sacrum and ilium, the joint capsule is very taut and encloses the almost immobile
joint and reinforced by ligaments.
 Posterior Syndesmosis between the tuberosities of sacrum and ilium
- Transmit the weight of most of the body to the hip bones. From axial skeleton to the ilia
and then to the femur during standing, and ischial tuberosities during sitting.
- Ligaments:  Anterior Sacroiliac ligaments: thin and cover the anterior part
of the joint capsule.
 Posterior Sacroiliac ligaments: on the posterior external surface.
 Interossious Sacroiliac ligaments: Abundant, between the tuberosities
of the sacrum and ilium (forming the Syndesmosis).
 Sacrotuberous ligament: from posterior ilium, lateral sacrum and
coccyx to ischial tuberosity. It transforms the sciatic notch into sciatic
foramen.
 Sacrospinous ligament: from lateral sacrum and coccyx to ischial
spine, subdivides the sciatic foramen into Greater and Lesser sciatic
foramina.
2) Pubic Symphysis:
- Fibrous cartilaginous joint consists of a fibrocartilaginous interpubic disc.

- Between the Symphysial surfaces of the 2 hip bones in median plane.
- The disc is generally wider in women, containing a small Non-Synovial cavity.
- Ligaments:  Superior Pubic ligament: superior aspects of the pubic bodies &
interpubic disc
 Inferior Pubic ligament: thick arch of fibers, connects inferior
inferior aspect of joint, forming the apex of Pubic arch and angle
3) Lumbosacral Joints:
- 3 joints:  Anterior Intervertebral Joint (IV) by the IV disc between the bodies
of S1 & L5
 Posterior 2 Zygapophysial joints (vertebral facet joints), between the
the Inferior articular processes of L5 and the Superior articular
process of S1
- The facets of S1 face posteriomedially, while the facets of L5 face anterolaterally. This
will prevent the lumbar vertebra from sliding anteriorly down the incline of sacrum.
- Ligaments:  Iliolumbar ligaments: fan-like, from transverse processes of L4-

L5 to the ilia. Strengthens the joint

4) The Hip Joint:
- Ball & Socket (Spheroidal) Multiaxial free moving type of joint.

- The round head of femur articulates with the cup-like Acetabulum at the Lunate surface.
- The acetabulum is a hollow hemisphere cavity formed by fusion of 3 bones, bordered by
the Acetabular rim. The Lunate surface and the Acetabular rim forms 3/4 of a circle,
missing the inferior part which is the Acetabular notch.
- Fibrocartilage Acetabular labrum (lip): attaches to the Acetabular rim and increase
surface contact area by 10%, and together with the Lunate surface, they cover 2/3 of the
femoral head. Hyaline cartilage covers the articular surfaces (Head of femur and Lunate
surface).
- Transverse Acetabular ligament: continuation of the femoral labrum inferiorly, bridges
the Acetabular notch.
- Acetabular fossa: centrally deep non-articular part, thin walled and continuous inferiorly
with the Acetabular notch.
- Joint capsule, strong yet loose, has an external fibrous layer and an internal Synovial
membrane. Proximally it attaches around the Acetabular rim and transverse Acetabular
ligament, and distally it attaches to the femoral neck only at the Intertrochanteric line
anteriorly, but posteriorly it crosses the neck to attach to the Intertrochanteric crest.
- Ligaments: 4 extracapsular ligaments of hip joint, and 1 intracaspular one.

Muscles and ligaments around the hip joint are reciprocally balanced. The
medial flexors, located anteriorly, are fewer and weaker, but the anterior
ligaments are the strongest, whereas the ligaments are weaker posteriorly,
but the medial rotators are abundant, stronger and more mechanically
advantaged.
 Zona Orbicularis: collar like, circular fibers of the fibrous layer of the
joint capsule pass circularly around the neck of femur, other ligaments
radiate into it. Holds the head of femur inside the cavity like a button in a
buttonhole
 Iliofemoral (Biglow) ligament: inverted Y-shaped Anterio-superior

ligament, strongest ligament in the body. Arises from ASIS & rim of
acetabulum and extends to the Intertrochanteric line. Have a strong
Transverse part and a weaker Descending part. Specifically prevents
Hyperextension & abduction of hip joint during standing by screwing the
femoral head into Acetabulum via screwing mechanism.
 Ischiofemoral ligament: Posteriorly located, arises from ischial part of

Acetabular rim horizontally until attachment of lateral part of Iliofemoral
ligament. Prevents excessive Medial rotation of thigh
 Pubofemoral ligament: Anteriorly and inferiorly positioned, arises

from Obturator crest and membrane, and radiates into the joint capsule,
specifically to Zona Orbicularis. Prevents Over-Abduction of the hip

 Ligament of Head of Femur: Intracaspular ligament which is actually
a Synovial fold containing a small artery to the head of femur. Have a
wide end that attaches to the transverse Acetabular ligament and a narrow
end that attaches to the fovea for ligament of the head of femur. It is found
in the Acetabular fossa, covered with fat pad & lined with a Synovial
membrane.
- Bursae:  Iliopectineal Bursa: large bursa between the Iliopsoas muscle

and the hip joint anteriorly
 Obturator Externus Bursa: a Synovial protrusion beyond the
margin of joint capsule into the posterior aspect of the femoral
neck. For the tendon of Obturator Externus
 Obturator Internus Bursa
 Gluteus Maximus, Medius and Minimus Bursae: Also called
Trochanteric Bursae, found between tendons and greater and
lesser trochanters
- Movements: Free moving, Multiaxial joint, 3 axes:

 Anteversion (Flexion) / Retroversion (Extension), at a transverse axis through
the head of femur
 Abduction / Adduction, at an Anterior-Posterior (Sagittal) axis through the
head of femur
 Medial / Lateral Rotation, at a vertical axis through the head of femur and the
medial femoral condyle
 Combined movements of the above produce Circumduction
** Note: the degree of flexion/extension possible at the hip joint depends on the
position of the knee. If the knee is flexed (hamstring muscles are relaxed), the
thigh can be actively flexed until it reaches the anterior wall of abdomen.
Extension is very limited due to the strong Iliofemoral ligament.
Lateral rotation is more powerful than medial rotation.
- Blood Supply: Medial & Lateral circumflex femoral arteries that give the Retinacular
arteries (branches of femoral artery) + Artery to the head of femur (branch of Obturator).
- Nerve Supply: Femoral nerve, Obturator nerve, Superior Gluteal nerve.
Movements of the Hip Joint and the muscles acting upon them:
Anteversion Retroversion Abduction Adduction Lateral Rot. Medial Rot.

(With flexed knee (15°, with (50°, in (10°, in (15°, in (30°, in
Max. 130-140°) abduction 45°) flexion 80°) flexion 30°) flexion 60°) flexion 40°)
Iliopsoas Gluteus Maximus Gluteus Medius Adductor Magnus Gluteus Maximus Gluteus Medius
Ventral part
Rectus Femoris Semimembranosus Gluteus Minimus Adductor Longus Gluteus Medius Gluteus Minimus
Dorsal part Ventral part
Pectineus Semitendinosus Tensor Fascia L Adductor Brevis Gluteus Minimus Adductor Longus
Dorsal part
Sartorius Biceps Femoris Pectineus Obturator internus Iliopsoas
Long Head Piriformis
Gracilis Quadratus Femoris

**Note: In balancing the body weight in erect position against tilting:
Forward: gluteus max. (Post.-inf. part)
Backward: ilio-, pubo-, Ischiofemoral ligaments.
Contralateral (standing in one foot, or walking):
To the opposite side contralateral: gluteus med., min.

5) The Knee Joint:
- Trochoginglymus type of joint, mainly a hinge joint (Ginglymus) combined with gliding
and rolling and with rotation (Torchoid) about a vertical axis, 2 axes joint.
- The articular surfaces are large sized, complicated & incongruent shapes. We have to
distinguish 3 articulations in the knee joint:
 2 Femortibial articulations (lateral & medial) between the lateral and the
medial femoral and Tibial condyles
 1 Intermediate Femoropatellar articulation between patella and the femur
 The fibula is not involved in the joint
The knee joint is the biggest and most superficial joint in the body; it's mechanically a
weak joint due to the incongruence of the articular surfaces (like placing 2 balls on the
table!) but the stability of it arises from the muscles around it (especially the quadriceps
Femoris) and the ligaments (and cartilage) between the femur and tibia. The extended
erect position is the most stable position of the knee joint, because contact is maximized
between the articular surfaces, and the ligaments are taut.
The femoral condyles diverge to some extent; the lateral condyle is wider in the front
than in the back, the medial condyle has constant width. This morphology with allow the
hinge function of the joint to occur accompanied with rotation of the femoral condyle on
the Tibial plateau to maintain balance and correct positioning of the joint.
- Joint capsule has 2 layers, external fibrous layer and internal Synovial membrane. The
fibrous layer is thin and incomplete but has thickened parts that make up the intrinsic
ligaments.
* Superiorly the capsule attaches proximal to the margins of the femoral condyles
* Posteriorly it encloses the condyles and the intercondylar fossa, and has an
opening here on the lateral Tibial condyle to allow the tendon of popliteus muscle
to pass out
* Inferiorly it attaches to the margins of the superior articular surface (Tibial
plateau)
* Anteriorly it is replaces by the tendon of the Quadriceps Femoris, Patella &
Patellar ligament.
The Synovial membrane lines all surfaces not covered by cartilage. Also covers the
Infrapatellar fat-pad and Cruciate ligaments which creates the Median Infrapatellar
Synovial fold, occupying the intercondylar region, and dividing the articular cavity into
left and right femorotibial articular cavities.
Above the patella, the joint cavity extends deep to the Vastus Intermedius as the
Suprapatellar bursa. (~5cm) (It has a special articular muscle of the knee that retracts
this big bursa during extension of the knee)

- Ligaments: In the knee joint we have 2 types of ligaments, Extracapsular &
Intra-Articular.
Extracapsular ligaments (Capsular or external) strengthen the joint capsule:
o Patellar ligament: distal part of quadriceps muscle, thick fibrous band passing
from apex of patella to the Tibial tuberosity. On both sides it receives the lateral
and medial patellar retinacula (expansions of Vastus muscles and overlying
fascia) which make up the joint capsule on both sides of the patella. Maintain the
patella in appropriate articular position with the femur.
o Tibial Collateral ligament (medial collateral ligament): strong, flat capsular band
that extends from medial epicondyle of femur to the medial condyle of tibia (&
medial superior surface). Its deep fibers are strongly attached and fused to the
medial meniscus and joint capsule. It is weaker than the fibular collateral
ligament and more often damaged.
o Fibular collateral ligament (lateral collateral ligament): cord-like strong

extracapsular ligament from lateral epicondyle of femur to the lateral surface of
head of fibula. It is separated from the lateral meniscus and capsule by the
tendon of popliteus and it splits the tendon of Biceps Femoris into 2.
o Oblique Popliteal ligament: expansion of the tendon of Semimembranosus that

reinforces the joint capsule posteriorly. Arises posterior to the medial Tibial
condyle and passes superolaterally toward the lateral femoral condyle.
o Arcuate Popliteal ligament: from posterior aspect of fibular head, passes

superiorly above the tendon of popliteus and spreads on the posterior surface of
knee joint. Strengthens the joint Posteriorly
Intra-Articular ligaments: Cruciate ligaments & Menisci
o Cruciate Ligaments (2) (cross ligaments): crisscross obliquely like X within the
joint capsule, but outside the Synovial cavity.
During medial rotation of knee they Wind around each other and limit this
movement to 10° only, but during lateral rotation of the knee they unwind and
then it's available to rotate up to 40° -60° (during flexed knee). Due to their
oblique orientation, in every possible movement of knee, at least one of the
cruciate ligaments is taut
 Anterior Cruciate Ligament: weaker, from anterior intercondylar area of

tibia, extend superiorly posteriorly and laterally and attaches to the medial side
of lateral condyle of femur. Prevents hyperextension of knee joint, posterior
displacement of femur on tibia and limits posterior rolling of femoral condyles on
the Tibial plateau during flexion.
 Posterior Cruciate Ligament: stronger, from posterior intercondylar are of

tibia, passes superiorly and anteriorly and attaches to lateral surface of the

medial condyle of femur. Limits anterior Rolling of femoral condyles on the
Tibial plateau during extension, prevents anterior displacement of femur from
tibia and Hyperflexion of knee joint. Stabilizes the knee joint in weight bearing
flexed knee (like when walking downhill).
o Menisci of knee joint: crescentic plates of fibrocartilage on the articular surface of

the tibia that deepen the surface and play a role in shock absorption. They are
thicker at the external margins and become thinner medially. They are attached
firmly to the intercondylar are of the tibia.
The Coronary ligaments are portions of the joint capsule that extend between the
margins of the menisci and the Tibial condyles on the edges.
The Transverse ligament of the knee is a thin fibrous band joining the anterior
edges of the menisci.
 Medial Meniscus: C-shaped, wider posteriorly than anteriorly. Firmly

attached to the Tibial collateral ligament, so it's less mobile on the Tibial plateau
than the lateral meniscus, it is relaxed in medial rotation
 Lateral Meniscus: almost circular, smaller and more freely movable than the
medial one, it is joined to the posterior cruciate ligament and medial femoral
condyle by the Anterior & Posterior Meniscofemoral ligaments
- Bursae: There are at least 12 bursae around the knee joint because most tendons run
parallel to the bones and have friction with them during knee moves. Some
are communicating some are non-communicating. The Main bursae are:
Bursae Location Notes

Suprapatellar Between Femur & Tendon of Held by the articular knee muscle,
Quadriceps Femoris communicates freely with Synovial
cavity of joint.
Popliteus Between popliteus tendon & lateral Communicates with Synovial cavity.
condyle of tibia
Anserine Separates the Pes Anserinus from the Communicates with Synovial cavity.
tibia and collateral ligament
Gastrocnemius At the origin of the tendons of the An extension of the Synovial cavity
(Medial & Lateral) Gastrocnemius Of knee joint.
Semimembranosus Between medial Gastrocnemius head Communicates with Synovial cavity
And Semimembranosus tendon
Subcutaneous Between skin & anterior surface of Allows free movement of skin over
Prepatellar patella pattela
Subcutaneous Between skin and Tibial tuberosity Helps knee withstand pressure while
Infrapatellar kneeling
Deep Infrapatellar Between patellar ligament & Anterior Separated from knee joint by
Surface of tibia infrapatellar fat pad

- Blood Supply: the Periarticular Genicular anastomosis around the knee. Superior
lateral, Superior medial, Inferior lateral, Inferior medial, middle and Descending -
Genicular arteries
- Nerve Supply: Femoral, Tibial & Common fibular nerves branches. ( + Obturator &
saphenous supply cutaneous innervation on medial side)
- Movements: Trochoginglymus joint that allows 2 types of movements in 2 axes:
 Flexion / Extension of knee joint, at a Transverse axis through the femoral

condyles
 Lateral / Medial Rotation of knee joint, at a vertical long axis of leg, possible
only in the flexed knee position & impossible during extended knee.
** Very Important Note: in the case of rotation of knee, we have to distinguish

between Obligatory Terminal Rotation (Passive rotation, Closure rotation) and
Active Rotation of knee.
During the extension of knee joint towards maximum, the femoral condyles glide
over the Tibial condyles. During the last 10° of extension before completion, the
Obligatory Terminal Rotation of 5° occurs Medially due to the stretching of the
Anterior Cruciate Ligament which is permitted by the shape of the medial femoral
condyle (constant, while the Lateral condyle is wider anteriorly) assisted by the
Iliotibial tract. This Passive lock or screwing home movement during maximal
extension makes the lower limb a solid column and adapts it for weight bearing and
relaxes the thigh muscles partially. (The collateral ligaments are taut, and the cruciate
ligaments are relaxed)
To unlock the knee, the popliteus muscle must contract to rotate the femur laterally
about 5° on the Tibial plateau so the flexion of knee can occur.
The Active rotation occurs during the flexed position of knee, after unlocking the
knee joint. Because the collateral ligaments are loose during flexion and the cruciate
ligaments are taut, the rotation is controlled by the cruciate ligaments. During medial
rotation of knee they Wind around each other and limit this movement to 10° only,
but during lateral rotation of the knee they unwind and then it's available to rotate up
to 40° -60° (during flexed knee)
Movements of Knee Joint and the muscles acting upon them:
Flexion Extension Lateral Rot. Medial Rot.

(Max. 130°) (Max. 180°) (40°-60°) (10°)
Semimembranosus Quadriceps Femoris Biceps Femoris Semimembranosus
Semitendinosus Tensor fasciae Latae Tensor fasciae Latae Semitendinosus
Biceps Femoris Sartorius
Gastrocnemius Gracilis
Sartorius

6) Tibiofibular Joints:
- 2 joints:
 1. Superior Tibiofibular joint: Plane type of Synovial joint that is almost

immobile (Amphiarthrosis), between the flat articular facet of head of Fibula and
the articular facet located posterolaterally on the lateral Tibial condyle.
Tense joint capsule, surrounds margins, Reinforced by:
 Anterior / Posterior Fibular Head ligaments
The tendon of popliteus crosses the joint posteriorly, and between them the
popliteus bursa.
During Maximal Dorsiflexion of the ankle (talocrural joint), there is an expansion
of the Malleolar Mortise as a result of wedging of trochlea of talus, this expansion
results in compensatory movement in the Superior Tibiofibular joint, that’s why
this joint is also known as the Compensatory Joint.
Blood Supply: Inferior Lateral Genicular + Anterior Tibial recurrent arteries

Nerve Supply: Common fibular nerve
 2. Tibiofibular Syndesmosis: compound fibrous joint, consisting of the union

between fibula and tibia by the Interossious membrane (shafts) and the Anterior,
Interossious & Posterior Tibiofibular ligaments.
The Posterior Tibiofibular ligaments make up the Inferior Tibiofibular joint by

its deep transverse fibers between the distal ends of the tibia (medial malleolus)
& the fibula (lateral malleolus). The rough triangular area on medial surface of
the inferior end of the fibula articulates with the facet of the inferior end of the
tibia.
The deep interossious tibiofibular ligament continues superiorly with the
interossious membrane & forms the principal connection between tibia and fibula
that fixes them to each other.
During Ankle Dorsiflexion, slight movement of the joint occurs due to the slight
extensibility of the Anterior & Posterior Tibiofibular ligaments, allowing slight
displacement of the bones from each other.
Blood Supply: Perforating branch of the fibular artery & medial Malleolar
branches.
Nerve Supply: Deep fibular, Tibial & Saphenous nerves

7) Upper Ankle (Talocrural) (Ankle) Joint:
- Hinge type Synovial joint. 1 axis of movement.

- Between the Malleolar Mortise (Formed by the Malleolar articular facet of tibia on
medial malleolus, Inferior articular surface of tibia & Malleolar articular facet of Fibula
on lateral malleolus) and the Trochlea of Talus with the Medial & Lateral Malleolar
facets.
So the tibia articulates with the talus in 2 places:
A. Inferior articular surface of tibia forms the roof of the Malleolar mortise,
articulating with the trochlea of talus, transferring the whole body weight to
the talus
B. The medial Malleolar facet of medial malleolus articulates with the medial
Malleolar facet of talus
The fibula articulates with the talus in 1 place:
The Malleolar articular facet of lateral malleolus of fibula articulates with the
lateral Malleolar facet of trochlea
The Malleolar mortise grips the trochlea very strongly, and maximum stabilization and
strength of the joint occurs during Dorsiflexion because the wider part of the trochlea is
brought back between the malleoli, spreading the crural bones a bit also (expansion of
Mortise due to wedging of trochlea of talus). The joint is weakest during Plantarflexion,
because the narrow posterior part of Talus is brought anteriorly and is relatively loose
within the mortise.
- Joint capsule is thin but reinforced by strong collateral ligaments. Attaches to the margins
of cartilaginous are of articular surfaces. Synovial membrane is loose and has anterior &
posterior Synovial folds.
- Ligaments:  Lateral Collateral Ligament of Ankle: compound structure consisting

of 3 separate ligaments:
1. Anterior Talofibular ligament: flat, weak band from the lateral
malleolus to the neck of talus.
2. Posterior Talofibular ligament: thick, strong band that runs
horizontally medially from lateral Malleolar fossa to the lateral
tubercle of posterior Talar process.
3. Calcaneofibular ligament: round cord, passes from tip of
lateral malleolus to the lateral surface of Calcaneus.
 Medial Collateral ligaments of Ankle (Deltoid Ligament): reinforces

the joint capsule medially, prevents subluxation (partial dislocation)
of the joint during Foot Eversion (Pronation). Has 4 parts:
1. Tibionavicular part: from medial malleolus to the Navicular
bone. Covers the anterior Tibiotalar part
2. Tibiocalcaneal part: from medial malleolus to the
Sustentaculum tali of Calcaneus.
3. Anterior Tibiotalar
4. Posterior Tibiotalar
- Blood Supply: Malleolar branches of the fibular, anterior & posterior Tibial arteries.
- Nerve Supply: Tibial nerve & deep fibular nerve.

- Movements: 1 transverse axis of movement that runs from the tip of medial malleolus
through the thickest part of lateral malleolus (which is 1cm lower).
 Plantarflexion / Dorsiflexion
Dorsiflexion Tibialis anterior Extensor Extensor Hallucis

(25-45°) Digitorum Longus longus
Plantarflexion Triceps Surae Flexor Hallucis Tibialis Posterior Flexor Digitorum
(30-60°) longus longus
8) Lower Ankle joint:
Compound joint, formed by 2 joints: Subtalar Joint and Talocalcaneonavicular Joint
 Subtalar (Talocalcaneal) Joint:

- Pivot type of joint. 1 rotatory oblique axis of movement
- Between the Posterior Calcaneal articular surface of Talus and the Posterior Talar
articular surface of Calcaneus
- Joint capsule is loose & thin, attaching to the margins of the bones.
- Ligaments: strengthen the joint capsule:
 Medial / Lateral Talocalcaneal ligaments
 Posterior Talocalcaneal ligament
 Interossious Talocalcaneal ligament: very strong, lies in the Tarsal
Sinus, separates the Subtalar from the Talocalcaneonavicular joint
 Talocalcaneonavicular Joint:
- The Talocalcaneal part is Plane type of joint, and the Talonavicular part is Spheroidal
(Ball & Socket) type of joint that functions as Pivot joint due to the many ligaments that
restricts it
- The Talocalcaneal part is between the Middle & Anterior calcaneal articular surfaces of
Talus and the Middle & Anterior Talar articular surfaces of Calcaneus. The
Talonavicular part is between the Head of Talus and the Talar articular surface on the
Navicular bone, and also there is an additional articular surface for the head of Talus on
the Plantar Calcanenavicular ligament (spring) that is covered by Hyaline cartilage.
- Joint capsule is attached on the edge of cartilage, and extends as far as the plantar
Calcanenavicular ligament (spring)
- Ligaments: Strengthens the joint capsule:
 Bifurcate Ligament: binds the Calcaneus with the Navicular & Cuboid
bones on the dorsal surface of foot\
- Movements: the 2 joints function together as special Pivot rotatory joint, around 1
oblique axis, permitting:
 Pronation (Eversion) / Supination (Inversion) of the foot
** Pronation involves Abduction, Dorsiflexion and Lateral rotation

** Supination involves Adduction, Plantarflexion and Medial rotation
Inversion (30°) Triceps Surae Tibialis Posterior Flexor Hallucis L. Flexor Digitorum L.
Eversion (30°) Peroneus Longus Peroneus Brevis Extensor Digitorum L. Peroneus Tertius

** Clinically, the term Subtalar joint is used to describe the anatomical Subtalar joint plus the
Talocalcaneal part of the Talocalcaneonavicular joint. Structurally, the anatomical Subtalar joint
is logical because it has a discrete own joint capsule and articular cavity. Functionally, however,
the clinical Subtalar joint is logical also because the 2 parts of the compound joint function as a
unit. By any definition, the majority of inversion & eversion of foot occurs in the Subtalar joint.
**  In summary the Upper Ankle joint (Talocrural) permits Hinge movements which are
Ginglymus. The Lower Ankle joint (Subtalar & Talocalcaneonavicular) permits Rotation
movements which are Trochoid.
Together the 2 joints function as Ankle joint which is Trochoginglymus.
9) Other Intertarsal Joints:
Involve the Calcaneocuboid, Intercuneiform, Cuneonavicular & Cuneocuboid joints.

- The Calcaneocuboid joint is Plane type of Synovial joint.
The anterior end of Calcaneus articulates with posterior surface of Cuboid
Joint cavity is part of the Chopart's Joint line. Participates in Inversion / Eversion of foot
and produces Circumduction also.
Have some ligaments that support the joint capsule such as: Dorsal / Plantar
Calcaneocuboid
- The other joints are also Plane type of Synovial joints. Small movements occur in these
joints. Reinforced and united by many ligaments such as:
 Dorsal Tarsal Ligaments:

 Dorsal Intercuneiform, Cuneocuboid ligaments
 Dorsal Cuboideonavicular, Cuneonavicular ligaments
 Plantar Tarsal Ligaments, on the plantar surfaces of tarsal bones:

 Long Plantar Ligament: from calcaneal tuberosity to the cuboid &
metatarsal bones. Maintains longitudinal arch of foot & form the tunnel
for the Peroneus longus tendon.
 Plantar Calcanenavicular ligament (Spring): stabilizes the foot, plays a
role in weight transmitting from talus & maintaining longitudinal arch of
foot (keystone)
 Plantar Calcaneocuboid (Short Plantar) ligament: also maintains
longitudinal arch of foot
 Plantar Cuneonavicular, Intercuneiform & Cuneocuboid ligaments
** Note: in the foot we have 2 Amputation lines:

 Chopart's Joint line (Transverse Tarsal Joint): Between Talus, Calcaneus Navicular &
Cuboid bones.
 Lisfranc's Joint line: Between Tarsals & Metatarsals
** The Transverse Tarsal or Midtarsal Joint is the Talonavicular part of the

Talocalcaneonavicular joint + the Calcaneocuboid joint together. It's just a functional clinical
naming for the joints since the Calcaneocuboid aids and assists in the inversion/eversion
movements of the foot produced by the Subtalar and Talocalcaneonavicular joints.

10) Tarsometatarsal Joints:
- Plane type of Synovial joints. Gliding or Sliding movements occur at them.

- Anterior tarsal bones articulate with the bases of the metatarsal bones.
- Have separate joint cavities & capsule that enclose each joint
- Ligaments : Dorsal / Plantar & Tarsometatarsal ligaments
11) Intermetatarsal Joints:
- Plane type of Synovial joints. Little individual movement occurs in them.

- Between the bases of the metatarsal bones that articulate with each other.
- Have a separate joint capsule that encloses each joint.
- Ligaments: Dorsal / Plantar & Interossious Tarsometatarsal ligaments
12) Metatarsophalangeal Joints:
- Spheroidal (Ball & Socket) anatomically shaped joints but restricted into 2 axes
(Condyloid or Ellipsoid functionally).
- Heads of metatarsal bones articulate with bases of proximal phalanges.
- Ligaments:  Collateral ligaments: supports capsule on each side
 Plantar ligament: supports plantar part of capsule
- Movements: 2 axes joint:
 Flexion / Extension
 Abduction / Adduction (Restricted by collateral ligaments)
 Combined Circumduction
13) Interphalangeal Joints of foot:
- Hinge type of Synovial joints.

- Head of one phalanx articulates with the base of the one distal to it.
- Ligaments:  Collateral ligaments: supports capsule on each side
 Plantar ligament: supports plantar part of capsule
- Movements: 1 axis joint:
 Flexion / Extension
Joint Blood Supply Nerve Supply

Subtalar Posterior Tibial & Fibular Planter aspect: Medial /
Arteries Lateral plantar nerves
Talocalcaneonavicular
Anterior Tibial artery via lateral Dorsal aspect: Deep
Calcaneocuboid
tarsal artery, a branch of Fibular nerve
Cuneonavicular Dorsalis Pedis artery
Tarsometatarsal Also Sural nerve
Intermetatarsal Lateral Metatarsal artery, a
Metatarsophalangeal branch of Dorsalis Pedis artery Digital nerves
Interphalangeal Digital branches of Plantar Arch

Muscles Acting on the Movement of the Big Toe (Hallux):
Plantarflexion Dorsiflexion Abduction Adduction

(40°) (55°)
Flexor Hallucis Longus Extensor Hallucis Longus Abductor Hallucis Adductor Hallucis
Flexor Hallucis Brevis Extensor Hallucis Brevis
Abductor Hallucis
Muscles Acting on the Movement of the 2nd – 5th Toes:
Plantarflexion Dorsiflexion Abduction Adduction

(40°) (55°)
Flexor Digitorum Longus Extensor Digitorum Longus Dorsal Interossious Plantar Interossious
Flexor Digitorum Brevis Extensor Digitorum Brevis Abductor Digiti Minimi Opponens Digiti Minimi
Lumbricals
Flexor Digit Minimi Brevis
** Note: The Abduction/Adduction and movements occur at the Metatarsophalangeal joints

(also Flexion/Extension). At the Interphalangeal (IP) joints Flexion/Extension occurs only. The
tendons of the Brevis act on the proximal IP joint, and the tendons of the Longus act on the distal
IP joint.

Lower Limb
Fascia

Fascia of the lower limb:
Fascia of the Thigh & Hip:
The Subcutaneous tissue (superficial fascia): lies deep to skin, consists of:
 Loose connective tissue
 Variable amount of Fat
 Cutaneous nerves
 Superficial Veins (Saphenous Greater, Lesser and tributes)
 Lymphatic vessels & nodes
The subcutaneous tissue of the hip & thigh is continuous with the inferior part of the
anterolateral abdominal wall & buttock.
In the iliac fossa there is the Iliopsoas Fascia, that begins with the Psoas fascia at the
Medial Arcuate ligament (of diaphragm) and descends as a tube covering the Psoas major
muscle and continues over the Iliacus muscle as the Iliac Fascia reaching the inguinal
ligament. There it will form the Iliopectineal arch (the separation between the muscular &
vascular compartments).
Below the inguinal ligament there is the Pectineus muscle covered with own Pectineal
fascia. Together with the iliac fascia, they form the connective tissue floor of the
Iliopectineal fossa.
The Deep fascia of the lower limb is especially strong, investing the whole lower limb. It
limits the expansion of the muscles, making the contraction more efficient, and compresses
the veins to push blood upward towards the heart.
The Deep fascia of the thigh is called  Fascia Lata (Broad fascia); inferior to the knee it
continues as deep crural fascia.
The attachments of the fascia lata are:
 Inguinal Ligament, pubic arch, pubis body, pubic tubercle superiorly. Sacarpa's
fascia (membranous layer of abdominal subcutaneous tissue) attaches to fascia
lata 1 cm under the inguinal ligament.
 Iliac crest lateral & Posteriorly
 Sacrum, coccyx, Sacrotuberous ligament & ischial tuberosity Posteriorly
 Exposed bones around knee, and deep crural fascia distally
The fascia Lata encloses the thigh muscles, and laterally it's strengthened and reinforced
longitudinally by the Iliotibial tract (broad fibrous band & conjoint aponeurosis of tensor
fascia lata and Gluteus Maximus muscles) which extends from iliac tubercle to the lateral
Tibial condyle, blending with the lateral patellar retinaculum.
Posteriorly the Gluteus Maximus is covered by a thin Gluteal fascia, that merges (or forms
the upper part) with the Fascia lata. Between the Gluteus Maximus & Medius there is the
strong Gluteal aponeurosis (origin of Gluteus Maximus)
The thigh muscles are separated into 3 compartments:

 Anterior Extensor Compartment
 Posterior Flexor Compartment
 Medial Adductor Compartment

This separation is done by the fascia lata and 3 Intermuscular septa that arise from the
fascia lata and insert on the Linea Aspera of the femur:
 The lateral Intermuscular septum is especially strong & broad, originates from
the Iliotibial tract and inserts on the lateral lip of Linea Aspera. It separates the
Vastus Lateralis from the short head of Biceps Femoris.
 The medial Intermuscular septum is thinner and separates the Vastus Medialis
from the adductor canal.
 The Posterior Intermuscular septum is really delicate and thin. It separates the
Adductor Magnus muscle from the flexors of the thigh. Sometimes the Adductor
Magnus muscles itself can be considered as the border between them.
On the anterior surface of the thigh, the Sartorius muscle possesses its own fascial
covering, overlying over the Vasto-adductor membrane. The Gracilis also can be in its own
fascia and separated from other fascias. But all thigh muscles have loose, delicate, thin
fascial covering or Perimysium (not only thigh muscle, all skeletal muscles in the body)
that enables the muscles to move against each other.
On the anterior surface of the thigh, below the inguinal ligament and medially over the
Iliopectineal fossa, there is porous (perforated) area of the fascia lata called the
Cribriform Fascia (membranous, spongy layer of subcutaneous tissue). This fascia here is
pierced by vessels, nerves & lymphatics (The Saphenous vein joins the femoral vein, and
the superficial lymphatic vessels join the deep inguinal lymph nodes. The nerves are
branches of the Ilioinguinal nerve)
If we remove this fascia we can expose the Saphenous Hiatus, which has a crescentic
shaped lateral, superior & inferior margins that form the Falciform Margin (Burn's or Hey's
ligament).
Fascia of the Leg & Foot:
The deep fascia of the Leg is known as Crural Fascia. It's thick superiorly and thinner
distally. It is a continuation of the fascia lata and its special Popliteal fascia. Encloses the
superficial muscles of leg, and sends septa to divide the leg into 3 compartments (see
below) together with the interossious membrane. Distally it becomes thickened and forms:
 The superior (crural) Extensor Retinaculum, anteriorly over the extensor tendons
 The superior & inferior Peroneal retinacula, laterally, above & under lateral
malleolus
 The Flexor Retinaculum (Deep & Superficial layers) medially, on the medial
Malleolar region
The crural fascia sends 2 Intermuscular septa:

 Anterior Intermuscular septum (from crural fascia to ant. Margin of fibula)
 Posterior Intermuscular septum (from crural fascia to post. Margin of fibula)

Together with the interossious membrane of the foot, the 2 speta divide the foot into 3
compartments:
 Anterior (Dorsiflexor compartment)
 Lateral (Fibular compartment)
 Posterior (Plantarflexor compartment)
o The muscles in the posterior compartment are further divided into
superficial (Triceps Surae) and deep (FHL, TA, FDL) parts by the
Transverse Intermuscular Septum (arises proximally from the
Tendinous arch of Soleus muscle & distally it form the thick fibers of
the deep layer of the flexor retinaculum medially)
Note: Plate 553 in the Netter atlas has a nice schematic drawing!!
On the dorsum of the foot, we find the thin Dorsal Fascia of foot, which makes the Inferior
(Plantar) Y-Shaped Extensor retinaculum proximally and covers the dorsal surface of the
foot and reaches the extensor aponeurosis of the digits.
The dorsal fascia of foot is continuous with the plantar fascia or the deep fascia of the
sole.
The plantar fascia (similar as in the palm) has a strong thick middle part  Plantar
aponeurosis and weaker medial & lateral parts  medial & lateral plantar fascia
Vertical Intermuscular septa extend deeply from the margins of the plantar aponeurosis
towards the 1st and 5th metatarsals, forming 3 compartments of the sole (same principle as
in the palm)
 Medial compartment of sole  covered by medial plantar fascia (thin),
contains the Abductor Hallucis, FHB, FHL tendon & Medial plantar nerve &
vessels
 Lateral compartment of sole  covered by lateral plantar fascia (thin), contains
Abductor & Flexor Digiti Minimi
 Central compartment of sole  covered by thick Plantar aponeurosis, contains
FDB, FDL, Quadratus Plantae, Lumbricals and Adductor Hallucis. Also
contains the lateral plantar nerve & vessels

Lower Limb
Regions &
Special
Formations

Lower Limb Regions:
1) Gluteal Region:
Borders:  Superior: Along the side of the Iliac Crest
 Lateral: Along the side of Greater Trochanter
 Inferior: Along the side of the Gluteal Sulcus
Skin Innervation:
 Superior Cluneal nerves (Dorsal Branches of L1-L3)
 Middle Cluneal nerves (Dorsal Branches of S1-S3)
 Inferior Cluneal nerves (from Post. Femoral Cutaneous nerve)
Before we start the discussion of the Gluteal region, we have to recall 2 important ligaments
here (that belong to the Sacroiliac Joint):
 Sacrotuberous ligament: from posterior ilium, lateral sacrum and coccyx to
ischial tuberosity. It transforms the sciatic notch into sciatic foramen.
 Sacrospinous ligament: from lateral sacrum and coccyx to ischial spine,
subdivides the sciatic foramen into Greater and Lesser sciatic foramina.
After the removal of the skin and the subcutaneous fatty tissue (thick), we find the Gluteus
Maximus muscle covered by a thin Gluteal fascia, that merges (or forms the upper part) with
the Fascia lata (of thigh). The Gluteal fascia sends many septa between the Gluteal Maximus
muscle fibers, so when we remove the fascia, we have to be careful not to damage the muscles
fibers.
We cut the gluteus Maximus muscle obliquely in the middle, and we reflect both parts to
expose the underlying structures (from superolaterally to inferomedially):
- Gluteus Medius
- Gluteus Minimus muscle (Under Gluteus Medius)
- Piriformis muscle
- Superior Gamellus
- Obturator internus muscle (or it's tendon mainly)
- Inferior Gamellus
- Quadriceps Femoris muscle
Between the Gluteus Maximus & Medius there is the Strong Gluteal aponeurosis (origin of
Gluteus Maximus), and we can see the Inferior Gluteal a/v/n (from IPH) running on the inner
surface of the Gluteus Maximus also and supplying it.
 The key muscle in this region is the Piriformis. Once you locate this i shaped muscle, you
can easily orientate in this region.
The Piriformis muscle originates from Pelvic surface of sacrum and Sacrotuberous ligament
and inserts on the Greater Trochanter. With this course, the muscle will pass through the
Greater Sciatic Foramen, and divides it in 2 parts or hiatuses (and each of the hiatuses
transmits different formations):
- Supra-Piriformis hiatus (SPH)
- Infra-Piriformis hiatus (IPH)

The structures that pass through the Supra-Piriformis hiatus are:
o Superior Gluteal Artery, Vein & Nerve
The structures that pass through the Infra-Piriformis hiatus are:

o Inferior Gluteal Artery, Vein & Nerve
o Posterior Femoral Cutaneous Nerve
o Pudendal Nerve
o Internal Pudendal Artery (from internal iliac artery)
o Sciatic nerve (Key structure also in this region for immediate recognition of IPH)
o Companion (Commitans) artery to Sciatic nerve
o Nerve to Quadriceps Femoris and Nerve to Obturator Internus
** The Pudendal nerve & the Internal Pudendal artery will emerge from the Infra-Piriformis
hiatus, but they will turn medially under the Sacrotuberous ligament to enter through the
Lesser Sciatic Foramen and reach the Ischiorectal fossa (via Alcock's Canal).
Under the Infra-Piriformis Hiatus (and the big sciatic nerve originating from it) we
immediately find the Superior and Inferior Gemelli muscles and between them runs the
Tendon of Obturator Internus (or the muscle itself sometimes) coming out of the Lesser
sciatic foramen.
Under the Inferior Gamellus muscle, we can see a quadrangular shaped muscle  Quadriceps
Femoris muscle, that stretches between the Ischial Tuberosity medially & the Greater
trochanter laterally (you can palpate these bony structures).
The Sciatic nerve immerges as a big, thick nerve (or sometimes it can be already split into
Common Fibular and Tibial nerves) from the Infra-Piriformis hiatus, and it reaches the thigh
down lying on the Gemelli muscles, tendon of Obturator Internus and the Quadriceps Femoris
together with the Posterior femoral cutaneous nerve (that immerges into the subcutaneous
tissue).

2) Subinguinal Region:
Borders:  Superior: A line along the inguinal ligament

 Lateral: A line from the anterior superior iliac spine (vertical line)
 Inferior: A line along the Gluteal sulcus (anteriorly)
 Medial: a vertical line from the pubic tubercle
Skin Innervation:
 Anterior Femoral cutaneous nerve (branches of Femoral nerve)
 Lateral Femoral cutaneous nerve (Lumbar plexus, 1 cm under ASIS)
 Femoral branch of Genitofemoral nerve (through lacuna Vasorum, then
pierces the fascia lata to become superficial)
 Ilioinguinal nerve
In the Subinguinal region, we have to recall some things from the osteofibrous structure of
the pelvis:
 The Inguinal (Poupart) ligament: is formed by the inferior border of the aponeurosis of
the external abdominal oblique muscle. It extends from the Anterior Superior Iliac Spine to
the Pubic tubercle.

It has a lateral point of attachment that spreads out as a broad triangular surface known as
Lacunar ligament (Gimbernat ligament). Laterally passing from this ligament onto the
Pectineal line of pubis is the Pectineal ligament (Inguinal ligament of Coopers).
Under the inguinal ligament, we can find the Subinguinal space (hiatus), which is an
important passage way connecting the truck/abdominopelvic cavity to the lower limb. So we
can consider the inguinal ligament as a Flexor Retinaculum of thigh muscles.
Superficial Structures:
On the anterior surface of the thigh, below the inguinal ligament and medially over the
Iliopectineal fossa, there is porous (perforated) area of the fascia lata called the Cribriform
Fascia (membranous, spongy layer of subcutaneous tissue). This fascia here is pierced by
vessels, nerves & lymphatics (The Saphenous vein joins the femoral vein, and the superficial
lymphatic vessels join the deep inguinal lymph nodes. The nerves are branches of the
Ilioinguinal nerve)
If we remove this fascia we can expose the Saphenous Hiatus, which has a crescentic
shaped lateral, superior & inferior margins that form the Falciform Margin (Burn's or Hey's
ligament).
Through the Saphenous hiatus, a group of veins drain into the femoral vein, called the
Venous Star:
o Greater Saphenous vein
o Lateral accessory saphenous vein
o Superficial circumflex iliac vein
o Superficial epigastric iliac vein
o External Pudendal veins
Right beneath the skin, we have inguinal lymph nodes located into two lines: one parallel to
the inguinal ligament (superficial) and one superficial parallel to the Greater Saphenous vein
(and deep, parallel to the femoral vein and artery). So, the vertical line of the lymph nodes is
in two layers, one superficial and one deep. Both lines form a letter "T".
The lymph nodes parallel to the inguinal ligament collect lymph from: Anterior abdominal
wall (below the umbilicus), Gluteal region, Perineal region, External genitalia, Anal
opening, Vestibulum vaginae, and Fundus of the uterus.
The lymph nodes parallel to the veins and artery (the vertical line) collect lymph from the
lower limb.
Deep Structures:
Between the inguinal ligament and the Iliopubic eminence is the Iliopectineal arch (Arcuate
ligament), that separates the space between the inguinal ligament the anterior surface of hip
bone into lateral neuromuscular (Lacuna musculonervosum) and medial vascular (Lacuna
Vasorum) compartments.
 The Lateral Neuromuscular compartment transmits the Iliopsoas muscle and the femoral
nerve.

 The Medial Vascular compartment transmits the major vascular structures (Artery, veins
and lymphatics) between pelvis and femoral triangle of anterior thigh (discussed later). The
vascular compartment is lined by the femoral sheath, which is a fascial tube enclosing the
proximal part of the femoral vessels & creates the Femoral Canal. Proximally the sheath is
formed by the inferior prolongation of the trasversalis and Iliopsoas fascia, and distally it
blends with Tunica Adventitia of the vessels.
** The medial vascular compartment is subdivided by vertical septa of the femoral sheath
into 3 sub-compartments:
o Lateral Compartment for the Femoral artery
o Intermediate Compartment for the Femoral vein
o Medial Compartment, constitutes Lacuna Lymphatica (inlet of Femoral Canal)
 The femoral (Hernial) Canal:

Short, conical and lies medial to femoral vein. It extends distally to the level of the
proximal edge of saphenous hiatus, and allows the femoral vein to expand during
increased venous return or increased intra-abdominal pressure that causes
temporary stasis in the vein. The "canal" content is Connective tissue, fat and
Lymphatics only. Sometimes it includes the deep inguinal lymph node of Cloquet
(Rossenmuller's Gland).
The base of the canal (superiorly located) is an opening formed by an oval Femoral
Ring, and this opening/ring is not really a foramen or opening, because its covered
by a septum: the Femoral Septum, which is pierced by the lymph vessels passing
through the canal to the abdominal cavity.
So the boundaries of the Femoral Ring are:

o Laterally: the vertical septum between femoral canal & and the femoral vein
o Medially: the Lacunar ligament
o Posteriorly: the superior ramus of the pubis, covered by the Pectineus and its fascia
o Anteriorly: the Medial part of the inguinal ligament
BUT the WALLS of the Femoral Canal are:

o Lateral: Femoral Vein
o Medial & Posterior: Pectineus muscle and its fascia
o Anterior: Fascia Lata
o Inlet (entrance): Femoral Ring, covered by the Femoral septum
o Outlet (exit): Saphenous Hiatus (not really, but this the answer If you asked about
it)
The femoral canal is not a real canal. It is called a canal only if a hernia occurs through it.
Sometimes the enlarged Cloquet lymph node can be mistaken for a hernia.
 The Femoral Triangle: is a Subfascial space, bounded by:

o The Inguinal ligament superiorly
o The Adductor longus medially
o The Sartorius laterally. And the apex is the point where the Sartorius crosses the
adductor longus
o The floor is formed by the Iliopsoas laterally and the Pectineus medially
o The Roof is the fascia lata, Cribriform fascia, subcutaneous tissue and skin\

The femoral triangle contains the Iliopectineal fossa, and the contents from lateral to medial are:
o Femoral nerve and branches
o Femoral sheath and its contents:
 Femoral artery and some branches (Deep or Profunda Femoris, superficial
circumflex iliac, superficial Epigastric, external Pudendal)
 Femoral vein and proximal tributaries (Greater Saphenous, deep femoral
veins)
 Deep inguinal lymph nodes (Rossenmuller's, Cloquet) and hernial canal
 The superficial circumflex iliac artery is for the inguinal lymph nodes and integument of
that region; Sartorius and tensor fasciae Latae muscles
 The superficial epigastric artery is for the inguinal nodes and integument of lower abdomen
 The Deep or Profunda Femoris branch is the biggest and most important; it goes under
the adductor longus and gives 3 major branches in this region:
- Medial Circumflex femoral artery: anastomose with Obturator artery and together supply
the adductors and the head and neck of Femur. Has Ascending and Transverse branches
- Lateral Circumflex femoral artery: anastomose with Superior/Inferior Gluteal arteries
and supplies the extensors of thigh and hip. Has an Ascending, Transverse and
Descending branches.
- Perforating Branches: 3-4 branches that pierces the Adductor Magnus muscle, and reach
the flexor compartment of thigh to supply the flexor muscles.
The femoral nerve has anterior cutaneous branches that pierce the fascia lata and supply the
skin. It also has a long branch that goes inside the adductor canal called the saphenous nerve.
The adductor Brevis is

covered by the Pectineus and
the adductor canal.

3) Anterior Thigh (Femoral) Region:
Borders:  Superior: Anterior line parallel with Gluteal sulcus
 Lateral: A line from Greater Trochanter to Lateral epicondyle
 Inferior: 2-3 fingers above the patella
 Medial: a line from the Gluteal cleft to the medial epicondyle
Skin Innervation:
 Anterior Femoral cutaneous nerve (branches of Femoral nerve)
 Lateral Femoral cutaneous nerve (Lumbar plexus, 1 cm under ASIS)
 Obturator nerve (lower medial part)
Deep to the skin, we can find the fascia lata. Between the skin and the fascia, runs the
Greater Saphenous vein medially up to the Subinguinal region and saphenous hiatus,
cutaneous branches of the femoral nerve Anteriorly, and the lateral femoral cutaneous nerves.
The lateral femoral cutaneous nerve comes about 1 cm below the anterior superior iliac
spine, coming from the sacral plexus.
If you remove the fascia lata, be aware that the Sartorius muscle is unsheathed by the fascia
together with the Gracilis and the Tensor fasciae Latae. (Having their own fascia)
At the lateral side of the region is the Iliotibial tract, the thickened part of the Fascia Latae
(and a broad fibrous band & conjoint aponeurosis of tensor fascia lata and Gluteus Maximus
muscles) which extends from iliac tubercle to the lateral Tibial condyle, blending with the
lateral patellar retinaculum.

Deep Structures:
After removing the fascia, we will see the extensor muscles of thigh: Quadriceps Femoris
(Rectus Femoris, Vastus Lateralis, Vastus Intermedius, and Vastus Medialis). The adductor
group (Gracilis + Adductor Longus, Brevis & Magnus) is medial to the extensor muscles.
The adductor longus, together with the Sartorius and the inguinal ligament, form the femoral
or subinguinal triangle (previously discussed).
The Obturator nerve can be found under the Gracilis muscle coming from the Obturator canal
 The Adductor Canal is a space between the Vastus medialis and Adductor muscles. It is
converted into a canal by the overlying Sartorius muscle (in own fascia) and covered by the
Vasto-adductorial membrane (fascia) in the lower anterior 1/2.
The Vasto-Adductor membrane (fascia) is a dense fascial triangle extending from the inferior
medial border of the adductor Magnus muscle to the Vastus medialis muscle. Together with the
Sartorius muscle, this dense fascia forms the roof of the lower 1/2 of the adductor canal.
Borders of Adductor Canal:

o Roof and laterally: Sartorius muscle (upper 1/2), and Vasto-adductor membrane
(fascia) (lower 1/2)
o Floor and Medially: Adductor Magnus, Adductor Longus
o Outlet: Adductor Hiatus
o Inlet: Femoral Triangle
Contents of Adductor Canal:

- Femoral artery and vein spiraling around each other, the vein moves from medial
position (under inguinal ligament) to end up in lateral position when transmitted into
Popliteal fossa. (See the previous subinguinal hiatus for the branches of femoral
artery in this region)
- Saphenous nerve (branch of femoral nerve) is also a content, but it doesn't reach the
Popliteal fossa Posteriorly, instead it pierces the Vasto-adductorial membrane
anteriorly and goes onto the anterior surface of the leg medially around the knee
together with the Descending Genicular artery (branch of femoral) joining the Greater
Saphenous vein.
Although it belongs to the Popliteal Region, but the outlet of the Adductor Canal is the
Adductor Hiatus, which is an aperture in the aponeurotic insertion of the Adductor Magnus
muscle, transmitting the femoral vessels into the popliteal fossa from the Adductor canal
 Adductor Hiatus Borders:

o Femur bone lateral
o Tendinous insertion of Adductor Magnus Medially
o Membranous (muscular) insertion of Adductor Magnus Superiorly
So it's between the muscular part and the tendinous part of the adductor Magnus inserting on
the medial condyle and Linea Aspera of the femur.

4) Posterior Thigh (Femoral) Region:
Borders:  Superior: Gluteal line
 Lateral: A line from Greater Trochanter to Lateral epicondyle
 Inferior: 3 fingers above the popliteal sulcus
 Medial: a line from the Gluteal cleft to the medial epicondyle
Skin Innervation:
 Posterior Femoral Cutaneous nerve (Sacral plexus)
The fascia lata in this region surround the Posterior femoral cutaneous nerve, it’s the only
place where a cutaneous nerve is located inside the fascia
Below the fascia we can find the flexor muscles of thigh arising from the Ischial tuberosity
(except the short head of biceps Femoris arising from the lower 2/3 of lateral lip of Linea aspira):
o Biceps Femoris: runs laterally and inserts on the head of fibula
o Semitendinosus: found medially and more superficial, (note the long tendon of the
muscle) the tendon runs together with the Gracilis and Sartorius to insert on the medial
condyle of tibia as the Pes Anserinus Superficialis
o Semimembranosus: found medially below the Semitendinosus, inserts below the Pes
Anserinus Superficialis as the Pes Anserinus Profundus
So the Pes Anserinus Superficialis is combined tendinous expansions of the Sartorius,

Gracilis, and Semitendinosus muscles at the medial border of the tuberosity of the tibia, The
common function of these three muscles is medial rotation of the knee joint
The Pes Anserinus Profundus is formed the Semimembranosus, below the Superficialis
Deep Structures:
Between these muscles and below the long head of the Biceps Femoris and above the adductor
Magnus, we can find the Sciatic nerve, which gives branches innervating those muscles and
divides into the Common Peroneal & Tibial nerves. From the adductor Magnus we can see the
perforating branches of the deep femoral artery reaching the flexor compartment and supplying the
flexor muscles (since no direct artery supplying this compartment)
*Note: in thigh region, there is no interossious membrane, so there is no real border between
the extensor and flexor compartment. Instead, the adductor Magnus forms this border. The
deep femoral artery supplies the extensor compartment, while the perforating branches from it
through the adductor Magnus reach the flexor compartment and supplies it

5) Anterior Genicular (Knee) Region:
Borders:  Superior: 3 fingers above the Patella
 Lateral: A line along the Lateral epicondyle
 Inferior: 3 fingers below the Patella
 Medial: a line along the Medial epicondyle
Skin Innervation:
 Anterior Femoral Cutaneous nerve (Upper part) (Sacral plexus)
 Lateral Femoral cutaneous nerve (Lateral part)
 Obturator nerve (medial part)
 Saphenous nerve (inferior part)
There are three groups of bursae in this region:

a) Suprapatellar bursae
b) Prepatellar bursae
c) infrapatellar bursae
In the Prepatellar group, there is a bursa right beneath the skin called the subcutaneous
Prepatellar bursa (between the skin and the fascia).The next bursa is between the fascia and the
tendon and is called the Subfascial Prepatellar bursa. The third one is between the tendon and
the patella and is called the Subtendinous Prepatellar bursa (Check Knee joint for more details)
To see the suprapatellar bursa, you must open the joint
Beneath the skin, you will find the Quadriceps Femoris muscle (the common tendon). The
continuation of the tendons of the four heads of the quadriceps Femoris form the patellar
ligament and the medial and lateral patellar retinacula. The patellar ligament is inserted to the
tuberosity of the tibia and the medial and lateral retinacula, to the medial and lateral condyles of
the tibia.
The Adductor Magnus is inserted to the medial epicondyle (Adductor Tubercle), so at the medial
part of the region, you will see its tendon.
So, we will also see the descending Genicular artery (from the Genicular artery) coming from
the anterior femoral region, the Greater Saphenous vein, and the Saphenous nerve (Piercing the
Vasoadductorial membrane).
The Pes Anserinus is located at the medial part of the region

6) Popliteal Region:
Borders:  Superior: 3 fingers above the Popliteal sulcus
 Lateral: A line along the Lateral epicondyle
 Inferior: 3 fingers below the Popliteal sulcus
 Medial: a line along the Medial epicondyle
Skin Innervation:
 Posterior Femoral Cutaneous nerve (Upper part) (Sacral plexus)
 Lateral Sural cutaneous nerve (Common Peroneal)
 Medial Sural cutaneous nerve (Tibial)
The lateral Sural and medial sural cutaneous nerves meet to form the Sural nerve that
accompanies the lesser saphenous vein superficially, going behind the lateral malleolus and
entering the dorsum of foot giving:
 Lateral Calcaneal branches
 Lateral Dorsal cutaneous nerve  little toe
The lesser saphenous vein drains into the Popliteal vein in the Popliteal fossa between the 2
heads of Gastrocnemius after piercing the Popliteal fascia, which a continuation of the Fascia
Lata, covering the Popliteal fossa
Deep Structures:
 The Popliteal fossa: is a diamond shaped fossa covered by the popliteal fascia,
Borders:
 Base/floor: Popliteus muscle (below), posterior part of the articular capsule of
knee joint (middle) and femoro-popliteal fossa (above)
 Superomedial: Semitendinosus + Semimembranosus muscles
 Superolateral: Biceps Femoris muscle
 Inferomedial: Medial head of Gastrocnemius
 Inferolateral: Lateral head of Gastrocnemius
Contents:
 Popliteal artery & vein: exiting the adductor hiatus after performing a twist, the
artery comes to lay anteromedialy and the vein posterolaterally in the Popliteal
fossa (in the Subinguinal region, the artery is laterally)
 Tibial nerve: descends into the crural region between the 2 heads of
Gastrocnemius and gives the Medial Sural cutaneous nerve
 Common Peroneal (Fibular) nerve: gives the Lateral Sural nerve then goes
laterally and becomes superficial and turns around the neck of fibula between
the 2 heads of the Peroneal muscles (Brevis & longus) and divides into
Superficial & Deep Peroneal nerves
 Fat & Lymph nodes

** The Popliteal artery starts medial to the Tibial nerve at the upper part of the fossa and
while going down it goes laterally, but the vein keeps the same position the middle of the
fossa between the 2
The popliteus muscle is the deepest formation originating from the lateral epicondyle of
femur and inserts on the Popliteal line of tibia. The Plantaris muscle can be seen above the
popliteus muscles laterally

7) Anterior Crural Region:
Borders:  Superior: 3 fingers below the Patella
 Lateral: A line along the Lateral epicondyle & malleolus
 Inferior: a line connecting the medial & lateral malleoli
 Medial: a line along the Medial epicondyle & malleolus
Skin Innervation:
 Lateral Sural nerve (lateral part)
 Saphenous nerve (anterior)
 Obturator nerve (upper medial part)
 Superficial Peroneal nerve (lower lateral part)
Removing the skin, we will find the crural fascia. It gives a septum between the extensors and
Peroneus muscles (at the anterior margin of the fibula) and it also gives a septum at the posterior
margin of the fibula. These two are called the anterior and posterior intermuscular septa,
forming the Anterior Dorsiflexor compartment & Lateral Peroneal compartment

The Greater Saphenous Vein (at the medial part of the region) coming from the Dorsal venous
plexus of foot is in front of the medial ankle.
The Superficial Peroneal nerve, coming out from the peroneal compartment between the
middle and inferior third of the region and divides into medial and intermediate dorsal
cutaneous nerves
Deep structures: below the fascia,
Dorsiflexor Muscles (Extensors): Extensor Digitorum longus (most lateral), Tibialis anterior,
and extensor Hallucis longus muscles (deep to and between the first two). The Tibialis anterior
arises from the tibia and the Interosseous membrane, but the extensor Hallucis longus muscle
arises a little deeper than the extensor Digitorum longus and Tibialis anterior. So, at the
superior part of the region, only the Tibialis anterior and the extensor Digitorum longus will be
seen.
The deep Peroneal nerve and the anterior Tibial artery (with the two veins) between these two
muscles, The deep Peroneal nerve comes from the common Peroneal nerve and pierces through
the anterior Intermuscular septum (between Peroneal muscles and extensor Digitorum longus)
to enter the anterior compartment. In the inferior part of the region, the nerve, veins, and artery
are located between the extensor Hallucis longus and the Tibialis anterior muscles.
The anterior Tibial artery gives muscular branches and also recurrent branches to supply the
knee joint.
Peroneus muscles: Both originate from the lateral surface of the shaft of the fibula. The
Peroneus longus is superficial, has a shorter muscle body (but longer tendon), and inserts to the
base of the first metatarsal and the medial cuneiform. The Peroneus Brevis is deep, has a
broader, thicker muscle belly, and inserts to the base of the fifth metatarsal. They are
innervated by the superficial peroneal nerve, which runs between the peronei and the extensor
Digitorum longus.

8) Posterior Crural Region:
Borders:  Superior: 3 fingers below the Popliteal sulcus
 Lateral: A line along the Lateral epicondyle & malleolus
 Inferior: a line connecting the medial & lateral malleoli
 Medial: a line along the Medial epicondyle & malleolus
Skin Innervation:
 Medial & Lateral Sural cutaneous nerves (Upper Lateral part)
 Sural nerve (Lower lateral part)
 Saphenous nerve (Medial part)
Superficial structures:
Under the skin, the lesser Saphenous can be seen, formed in the dorsal venous reticulum of the
foot and ascending behind the lateral malleolus to the mid-posterior surface of the leg to reach
the popliteal fossa and drain into the popliteal vein
See in the discussion of fascia of leg the formation of the 3 compartments:

o Plantarflexor compartment posteriorly
o Dorsiflexor compartment anteriorly
o Peroneal compartment laterally
Under the fascia, we can find the Triceps Surae muscle made of:
The lateral & medial heads of Gastrocnemius muscle, below it the Soleus muscle arising from
the Tendinous arch between the tibia (Soleal line) and fibula) and between them the long thin
Plantaris tendon (freshman's nerve)  all 3 muscles insert as a common tendon on the
calcaneal tuberosity (Achilles' Tendon)
At this level the popliteal artery divides into:

o Anterior Tibial artery: goes into the Dorsiflexor compartment
o Posterior Tibial artery: for the Plantar flexor compartment, on the Tibialis
posterior muscle, between the flexor Hallucis & flexor Digitorum longus muscles
running together with the Tibial nerve to the sole behind the medial malleolus
o Peroneal artery: for the Soleus, Flexor Hallucis longs & Peroneal compartment,
from the posterior Tibial artery, has a perforating branch, a communicating branch
& lateral calcaneal branches
Below the Tendinous arch and under the Soleus muscle we can see the Tibial nerve and
Posterior Tibial artery & vein
Deep Structures:
The deep muscles of thigh (separated by the transverse Intermuscular septum from the triceps
Surae) are:
o Flexor Digitorum longus (most medial)
o Tibialis Posterior (Middle, deep)
o Flexor Hallucis longus (most lateral & big)
3 fingers above the medial malleolus, the Tibialis posterior & flexor Digitorum longus muscles
can be seen crossing each other as the Crural Chiasm, and by that the Tibialis posterior comes
to lie as the most medial structure in the medial malleolus region followed by the flexor
Digitorum longus in the mid-position

9) Medial Malleolar Region:
Borders:  Located between the medial malleolus and Calcaneus
Skin Innervation:
 Saphenous nerve
The Greater Saphenous vein arising from the dorsal venous reticulum of foot runs anteriorly
the medial malleolus deep in the skin together with the saphenous nerve
The structures passing in this region are covered by the Flexor retinaculum, from the medial
malleolus towards the Calcaneus they are:
o Tibialis Posterior tendon
o Flexor Digitorum longus tendon
o Posterior Tibial artery & vein (Gives the medial calcaneal branches here)
o Tibial nerve
o Flexor Hallucis longus tendon

10) Lateral Malleolar Region:
Borders:  Located between the lateral malleolus and Calcaneus
Skin Innervation:
 Sural nerve
The Lesser saphenous vein arising from the dorsal venous reticulum runs under the lateral
malleolus together with the sural nerve as the superficial structures in this region, the Sural
nerve gives:
o Lateral Dorsal cutaneous nerve  on the lateral side of foot + lateral margin of
little toe
o Lateral calcaneal branches
Under the fascia, the Peroneus longs and Brevis muscles can be found + Peroneal artery, held
down by the Superior & Inferior Peroneal reticule, in a common Tendinous sheath and
innervated by the superficial branch of common Peroneal nerve that runs between them, and
becoming superficial at the distal part of the region to reach the dorsum of the foot
The Peroneus Brevis inserts on the base of 5th metatarsal
The Peroneus Longus inserts on the base of 1st metatarsal and medial cuneiform after crossing
the sole in the sulcus for Peroneus longus, covered by the long plantar ligament

11) Plantar Region (Sole of foot) Region:
Borders:  Superior (Posterior): Calcaneus
 Inferior (Anterior): root of toes
 Lateral: lateral border of sole
 Medial: medial border of sole
Skin Innervation:
 Medial Plantar nerve (from Tibial nerve)
 Lateral Plantar nerve (from Tibial nerve)
Under the skin we find the Plantar aponeurosis (from the calcaneal tuberosity sending
medial & lateral Intermuscular septa) forming 3 groups of muscles:
o Medial eminence covered by fascia (for small toe)
o Middle intermediate eminence
o Lateral eminence covered by fascia (for big toe)
* The Tibial nerve and posterior Tibial artery will give 2 branches each:
o Medial plantar nerve, artery & vein: running in the medial plantar groove 
Medial 7 toe sides (Analog to the median nerve in hand)
o Lateral plantar nerve, artery & vein: running in the lateral plantar groove 
lateral 3 toe sides (Analog to the ulnar nerve in hand)

The lateral & medial plantar nerves and arteries terminate as common then proper digital
branches
Deep Structures:
Under the plantar aponeurosis, we can dissect layer by layer the different structures in the
sole of foot:
o Layer 1: Flexor Digitorum Brevis, Abductor Hallucis and Abductor Digiti
Minimi muscles
o Layer 2: Tendons of Flexor Digitorum longus + 4 Lumbricals arising from the
tendons + Quadratus Plantae muscle inserting on the tendons of the FDL,
correcting it's movement + Flexor Hallucis longus tendon + Lateral & Medial
plantar artery, nerve and vein
o Layer 3: Adductor Hallucis muscle (Oblique, transverse heads) + Flexor Hallucis
Brevis (Lateral and medial heads) + Flexor Digiti Minimi Brevis
o Layer 4: Interossious muscles (3 plantar) + Tendon of Peroneus longus + Long
plantar ligament + Plantar arterial arch (under the oblique head of adductor
Hallucis)
In layer 2, we can see a Chiasm between the tendon of the Flexor Hallucis Longus and the
Flexor Digitorum Longus tendons, this is the Plantar Chiasm, and with it the flexor Hallucis
longus tendon comes from lateral position to reaches the big toe and the tendons of the flexor
Digitorum longus comes from medial position to reach the digits
The deep plantar arch is formed by the lateral plantar artery, goes under the oblique head of
adductor Hallucis muscle medially to be closed by the deep plantar artery from the Dorsalis
Pedis artery piercing the 1st interossial space from the dorsum of foot
The Lateral plantar nerve supplies:

- Abductor digit minimi
- Flexor digiti minimi Brevis
- Adductor Hallucis
- Quadratus Plantae
- Lateral head of flexor Hallucis Brevis
- All interossious muscles
- 3rd / 4th Lumbricals
- 1.5 toe side laterally
The medial plantar nerve supplies:

- Medial head of Flexor Hallucis Brevis
- Flexor Digitorum Brevis
- 1st / 2nd Lumbricals
- Abductor Hallucis
- 7.5 toe side medially

12) Dorsalis Pedis (Back of foot) Region:
Borders:  Superior (Posterior): a line connecting the medial and lateral malleoli.
 Inferior (Anterior): root of toes
 Lateral: a line from the lateral malleolus to the fifth toe or the lateral
margin of the foot
 Medial: a line from the medial malleolus to the first toe or the medial
margin of the foot
Skin Innervation:
 Lateral dorsal cutaneous branch of Sural nerve (later 0.5 of small toe)
 Intermediate Dorsal cutaneous branch of Superficial Peroneal nerve
(medial 0.5 of small toe, 3rd, 4th toes, lateral 0.5 of 2nd toe)
 Dorsal Digital branch of Deep Peroneal nerve (medial 0.5 of 2nd toe,
lateral 0.5 of 1st big toe)
 Medial Dorsal cutaneous branch of Superficial branch of Peroneal nerve
(medial 0.5 of big toe)
The Superficial Peroneal nerve enters the Dorsal Pedis region and divides into two branches:
the medial and intermediate dorsal cutaneous branches
The Deep Peroneal nerve becomes superficial from below the tendons of the extensor Hallucis
longus and Brevis.
Together with the cutaneous nerves, we have the Dorsal Venous Reticulum (Plexus) of Foot
from which the Greater & Lesser Saphenous veins drain blood.
Beneath the superficial structures, lie the Superior & Inferior (Y-shaped) Extensor
Retinacula. The superior extensor retinaculum is at the superior border of the region. The two
retinacula hold down the extensor tendons. The extensor tendons are the Extensor Hallucis
longus muscle, the Extensor Digitorum muscle, and the tendon of the Peroneus Tertius
(inserting to the base of the fifth metatarsal).
This region also includes the Extensor Digitorum Brevis and the Extensor Hallucis Brevis. The
tendons of the extensor Digitorum Brevis are inserted to the middle phalanges of the lateral 4
toes. The extensor Digitorum longus tendons are inserted to the distal phalanges of the lateral 4
toes.
An important structure in this region is the Dorsalis Pedis artery (Dorsal foot artery). It comes
from the midpoint of the line connecting the medial and lateral ankle toward the first interossial
space. (You can palpate the artery because it is on the cuneiform bone). The Dorsalis Pedis
artery will form the arcuate artery beneath the tendons which is closed by the lateral tarsal
artery (from the anterior Tibial). The Dorsalis Pedis artery pierces through the first interossial
space and closes the plantar arch (Formed by the lateral plantar artery). From the Anterior
Tibial artery, we have several Malleolar branches to supply the ankle joint:
- Anterior: Medial and lateral Malleolar arteries.
- Posterior: Medial and lateral Malleolar arteries.
From the Arcuate artery, the dorsal metatarsal arteries arise and will give the proper plantar
digital arteries. Beneath them, the dorsal 4 interossious muscles can be seen


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Lower Limb

Muscles, fascia, joints &

Haytham Bayadsi, 2008/09

 Superficial - Iliac crest, PSIS,

Wing of ilium between Greater

Haytham Bayadsi, 2008/09

Haytham Bayadsi, 2008/09

Haytham Bayadsi, 2008/09

Haytham Bayadsi, 2008/09

 Oblique Head: - Cuboid & Lateral

 Dorsal Interossei - 2 heads, Adjacent sides - 1st: Medial side

Haytham Bayadsi, 2008/09

 ASIS – Anterior superior iliac spine

 Triceps Coxae: Gamellus superior & Inferior + Obturator internus.

 In the leg, we have 2 Intermuscular speta, dividing leg into 3 compartments,

Haytham Bayadsi, 2008/09

Haytham Bayadsi, 2008/09

In the lower limb we have to distinguish between:

The Greater pelvis is:

The Lesser pelvis is:

Haytham Bayadsi, 2008/09

- Fibrous cartilaginous joint consists of a fibrocartilaginous interpubic disc.

- Ligaments:  Iliolumbar ligaments: fan-like, from transverse processes of L4-

Haytham Bayadsi, 2008/09

- Ball & Socket (Spheroidal) Multiaxial free moving type of joint.

- Ligaments: 4 extracapsular ligaments of hip joint, and 1 intracaspular one.

 Iliofemoral (Biglow) ligament: inverted Y-shaped Anterio-superior

 Ischiofemoral ligament: Posteriorly located, arises from ischial part of

 Pubofemoral ligament: Anteriorly and inferiorly positioned, arises

Haytham Bayadsi, 2008/09

- Bursae:  Iliopectineal Bursa: large bursa between the Iliopsoas muscle

- Movements: Free moving, Multiaxial joint, 3 axes:

Anteversion Retroversion Abduction Adduction Lateral Rot. Medial Rot.

Haytham Bayadsi, 2008/09

Haytham Bayadsi, 2008/09

 The fibula is not involved in the joint

Haytham Bayadsi, 2008/09

Extracapsular ligaments (Capsular or external) strengthen the joint capsule:

o Fibular collateral ligament (lateral collateral ligament): cord-like strong

o Oblique Popliteal ligament: expansion of the tendon of Semimembranosus that

o Arcuate Popliteal ligament: from posterior aspect of fibular head, passes

Intra-Articular ligaments: Cruciate ligaments & Menisci

 Anterior Cruciate Ligament: weaker, from anterior intercondylar area of

 Posterior Cruciate Ligament: stronger, from posterior intercondylar are of

Haytham Bayadsi, 2008/09

o Menisci of knee joint: crescentic plates of fibrocartilage on the articular surface of

 Medial Meniscus: C-shaped, wider posteriorly than anteriorly. Firmly

Bursae Location Notes

Haytham Bayadsi, 2008/09

- Movements: Trochoginglymus joint that allows 2 types of movements in 2 axes:

 Flexion / Extension of knee joint, at a Transverse axis through the femoral

** Very Important Note: in the case of rotation of knee, we have to distinguish

Movements of Knee Joint and the muscles acting upon them:

Flexion Extension Lateral Rot. Medial Rot.

Haytham Bayadsi, 2008/09

 1. Superior Tibiofibular joint: Plane type of Synovial joint that is almost

Blood Supply: Inferior Lateral Genicular + Anterior Tibial recurrent arteries

 2. Tibiofibular Syndesmosis: compound fibrous joint, consisting of the union

The Posterior Tibiofibular ligaments make up the Inferior Tibiofibular joint by

Haytham Bayadsi, 2008/09