HAND OUT OF THE LECTURES OF THE LOWER LIMB

DR NAHED KOURA
Muscles of the lower limb
Front of the thigh
Name Origin Insertion action Nerve
supply
Quadriceps femoris (4 The four heads unite Entire Branches
heads) at the distal part of quadriceps of femoral
1- Rectus femoris 2 tendons; one the thigh to form a extends the nerve.
anterior inferior iliac
strong tendon leg (knee
spine; the other from
a rough area above joint).
the acetabulum
The rectus
2- Vatus lateralis Greater trochanter Which is inserted Femoris flexes
and linea aspera of into base of the thigh (hip
the of femur joint)
3- Vastus medialis Medial lip of linea Patella and form the
aspera ligamentum
4- Vastus intermedius Ventral and lateral Patellae, which
surfaces of the body extends to tibial
of the femur. tuberosity
Sartorius Anterior superior iliac Upper medial Flexes the Femoral
spine surface of shaft of thigh rotates it nerve
tibia laterally and
flexes leg
 Medial side of the thigh

Adductor longus Body of pubis medial In the middle ⅟3 of Adduction of Obturator

to pubic tubercle linea aspera hip joint nerve
Adductor brevis Inferior ramus of Upper ⅟3 of linea Adduction of Obturator
pubis aspera hip joint nerve

Adductor magnus The side of the pubic 1-Pubic part from Pubic part Pubic part
arch and lower lateral gluteal tuberosity, makes by
part of ischial linea aspera and adduction obturator
tuberosity medial supra- while ischial and
condylar ridge part makes ischial
2-Ischial part from extension of part by
the adductor hip joint sciatic
tubercle nerves
Gracillis Inferior ramus of the Upper part of shaft Adduct the
pubis and ramus of of tibia on medial hip, flex and obturator
ischium surface medial rotate nerve
the knee
 The gluteal region and back of the thigh

Gluteus maximus Ilium behind posterior ¼ in gluteal Extension and Inferior

gluteal line, back of tuberosity, ¾ in ilio- lateral rotation gluteal
sacrum, coccyx and tibial tract of the hip nerve
sacro- tuberous joint; extend
ligament the knee
Gluteus medius Between anterior and Superior and lateral Abduction and Superior
posterior gluteal lines surface of the medial gluteal
of ilium greater trochanter rotation of hip nerve
of femur joint

Gluteus minimus Between anterior and Anterior surface of Abduction and Superior
inferior gluteal lines of the greater medial gluteal
the ilium trochanter of femur rotation of hip nerve
and capsule of hip joint
joint.

Biceps femoris Long head from upper By a tendon into the Extends the Sciatic
medial part of ischial head of the fibula, hip, flexes the nerve;
tuberosity the fibular collateral knee and long head
Short head from linea ligament splits it rotates the leg by tibial
aspera and lateral laterally part and
supracondylar ridge short by
common
peroneal
part
semitendinosus A common origin with Upper part of Extend the hip Sciatic
long head of biceps medial surface of and medially nerve
from ischial tuberosity the shaft of the tibia rotate knee

Semimembranosus Upper lateral part of Flattened tendon Extends the Sciatic

ischial tuberosity into the back of the hip, flexes and nerve
medial condyle of medially
the tibia rotates the leg
at knee joint
 Anterior compartment of the leg

Name of a muscle Anatomy of a muscle

Tibialis anterior
Origin: Upper 2/3 of the lateral surface of the tibia
Insertion: Medial cuneiform and base of the 1st metatarsal
Action: Dorsiflexion of the ankle joint and inversion of the
subtalar joint. It holds up the medial longitudinal arch.
Nerve supply: Deep peroneal nerve

Extensor digitorum longus

Origin: Upper ¾ 0f the ant. Surface of the tibia
Insertion: By 4 tendons into the middle and terminal phalanges
of the lateral 4 toes through the
extensor expansion
action: Dorsiflexion of the ankle joint and extension of
all joints of the lateral 4 toes and everts the foot.
nerve supply: Deep peroneal nerve

Extensor hallucis longus

Origin: Middle 2/4 of the anterior surface of the fibula
Insertion: Base of the terminal phalanx of the big toe
Action: Extension of all joints of the big toe and dorsiflexes the
ankle joint. It inverts the foot.
Nerve supply: Deep peroneal nerve.

Origin: upper surface of the calcaneum

Extensor digitorum brevis Insertion: in the proximal phalanx of the hallux by a separate slip
And into the extensor expansion of 2,3.,4 toes.
Action: extend toes
Nerve supply: Deep peroneal nerve
 Lateral compartment of the leg

Name of a muscle Anatomy of a muscle

Peroneus longus
Origin: Upper 2/3 of the lateral surface of the
fibula
Insertion: Medial cuneiform and the planter
surface of the base of the 1st
metatarsal
Action: planter flexion of the ankle joint and
eversion of the subtalar joint. It
supports the lateral longitudinal
and transverse arches of the foot.
Nerve supply: Superficial peroneal nerve

Peroneus brevis
Origin: Lower 2/3 of the lateral surface of the
fibula
Insertion: Tuberosity of the base of the 5th
metatarsal bone
Action: Planter flexion of the ankle joint and
eversion at the subtalar joint. It
supports lateral longitudinal arch.
Nerve supply: Superficial peroneal nerve
 Posterior compartment of the leg

Name of a muscle Anatomy of a muscle

Gastrochnemius Origin: medial head arises from the popliteal
surface above the medial condyle of
the femur while lateral head arises
from the lateral surface of the lateral
condyle of the femur
insertion: By a tendon joins the tendon of
soleus to form tendo-calcaneus
which is inserted into the
intermediate part of the back of
the calcaneus
insertion: flexor of the knee joint and
powerful planter flexion of the
ankle joint. It flexes the knee joint.
nerve supply: Tibial nerve
Soleus
Origin: 1- Soleal line and middle 1/3 of the
medial border of tibia.
2-back of the head and upper 1/3 of
the posterior surface of the fibula
3-fibrous arch between tibia and
fibula
insertion: By a tendon joins the tendon of
gastrochnemius to form
tendocalcaneus which is inserted
into the intermediate part of the
back of the calcaneus
action: powerful planter flexion of the ankle
joint and provides propulsive force in walking and running.
It has a role in return of venous blood from lower limbs as
muscle pump.
Nerve supply: Tibial and posterior tibial nerve
Name of a muscle Anatomy of a muscle
Flexor hallucis longus
Origin: Lateral part of Posterior surface of the fibula below the
origin of the soleus
Insertion: Planter surface of the base of the terminal phalanx
of the big toe
Action: Flexion of the joints of the big toe and assists in planter
flexion of the ankle. It supports the
medial longitudinal arch of the foot.
Nerve supply: Posterior tibial nerve
Popliteus
origin: A tendon from the anterior part of a groove in the
lateral surface of lateral condyle of the femur
and from the back of the lateral meniscus
insertion: into the posterior surface of the tibia above the
soleal line
action: When the leg is free it rotates the tibia medially on the
femur but when the leg is on the ground
it laterally rotates the femur on the tibia (unlocking at
the start of knee flexion)
nerve supply: Posterior tibial nerve
Name of a muscle Anatomy of a muscle
Flexor digitorum longus
Origin: Medial part of the posterior surface
of the tibia distal to the soleal line
Insertion: Four tendons into the terminal
phalanges of the lateral 4 toes
Action: Flexion of all joints of the lateral 4
toes and assists in planter flexion of
the ankle joint. It supports lateral and
medial longitudinal arches of the
foot.
nerve supply: Posterior tibial nerve
Tibialis posterior
Origin: lateral part of the posterior surface of
the tibia below the soleal line;
interosseous membrane and the
medial part of the posterior surface
of the fibula below the origin of
soleus.
insertion: tuberosity of navicular bone and all
tarsal bones except the talus;
bases of the second, third and
fourth metatarsals
action: planter flexion of the ankle and
inversion of the subtalar joint. It
supports the medial longitudinal
arch.
nerve supply: Posterior tibial nerve.
Nerves of the lower limb

LUMBAR PLEXUS
Femoral nerve:
Origin and course:
It arises from the lumbar plexus (posterior divisions of L 2,3 and 4). It
emerges at the
lateral border of psoas major muscle in the abdomen. It passes downward
between iliacus and psoas muscles. It enters the femoral triangle deep to
the inguinal ligament and lateral to femoral sheath. It has a short trunk and
divides into anterior and posterior divisions.
Branches:
1- main trunk gives iliacus and pectineus muscles.
2- The anterior division gives sartorius, hip joint, medial and intermediate
cutaneous nerves of the thigh.
3- The posterior division gives the saphenous nerve and muscular branches to
quadriceps muscle.
N.B.:
The saphenous nerve is a cutaneous branch, crosses the femoral artery from
lateral to medial. It pierces the deep fascia at the medial side of the knee between
tendons of gracilis and sartorius. It descends on the medial side of the leg, in front
of medial malleolus and along the medial border of the foot to terminate into the
ball of the big toe. In front of the medial malleolus the saphenous nerve lies just
anterior to the great saphenous vein.
Obturator nerve:
Origin and course:
It arises from the lumbar plexus (anterior divisions of L2, 3 and 4).
It emerges from the medial border of psoas major in the abdomen. It
passes on the lateral wall of the pelvis and leaves the pelvis through the
obturator canal where it divides into anterior and posterior divisions. The
anterior division lies in front of the obturator externus deep to
adductor longus. The posterior division pierces the obturator externus
muscle and passes behind adductor brevis and terminate by passing
through adductor hiatus to supply the knee joint
branches:
1- The anterior division gives muscular branches to gracilis, adductor
longus, adductor brevis and pectineus, articular branches to hip joint,
small branch to patellar plexus to the skin on the medial side of the
thigh and terminates as small nerve to femoral artery.

2- The posterior division gives muscular branches to obturator externus,

pubic part of adductor magnus and knee joint.
LUMBAR AND SACRAL PLEXUSES
Sciatic nerve:
Origin and course:
It arises from the sacral plexus L4,5 and S1,2,3) the anterior divisions form
the tibial part while the posterior divisions form the common peroneal
part of the sciatic nerve. It emerges in the gluteal region at the lower
border of piriformis and runs obliquely on the tendon of obturator
internus, two gemelli and quadratus femoris to reach the back of
adductor magnus. It is related to posterior cutaneous nerve of the thigh,
gluteus maximus and long head of biceps posteriorly. In the lower third of
the back of the thigh it divides into tibial and common peroneal nerve. The
nerve may be divides at a higher level.
Branches:
It gives muscular branches to the long head of biceps, semitendinosus,
semimembranosus and ischial part of adductor magnus from its tibial part
except the short head of biceps from the common peroneal part of the
nerve
common peroneal nerve
origin and course:
one of the terminal branches of the sciatic nerve in the popliteal fossa
It passes at the medial border of biceps to the back of the head of the fibula
turns lateral to neck of fibula deep to peroneus longus to divide into
superficial and deep peroneal nerve
Branches:
1. Lateral cutaneous nerve of the calf
2. Sural communicating nerve
3. Superior and inferior lateral genicular and recurrent genicular.
Effect of injury:
1. Drop foot. EXPLAIN?
2. Sensory loss of the antero-lateral part of the leg and dorsum of the
foot
Deep peroneal nerve
1. It arises from common peroneal nerve under cover peroneus longus
2. It enters into the anterior compartment of the leg
3. It passes deep to extensor retinaculum at the ankle to enter the dorsum
of the foot between the tendons of the extensor digitorum longus and
extensor hallucis longus
4. On the dorsum of the foot, it divides into medial branch and lateral
branch. The medial branch gives the 1st dorsal interosseous muscle and
the 1st interdigital space. The lateral branch gives the extensor
digitorum brevis and the surrounding joints.
5. The nerve supplies the muscles of the anterior compartment of the leg
(tibialis anterior, extensor digitorum longus, extensor hallucis longus,
peroneus tertius.
Superficial perineal nerve
1. It arises from common peroneal nerve on the lateral side of the neck of
the fibula and descends in the peroneus longus. Then passes at the
anterior border of the peroneus brevis. It pierces the deep fascia at the
lower 1/3 of the leg by dividing into medial and intermediate
cutaneous branches.
2. It supplies the Peroneus longus, peroneus brevis the skin of the
dorsum of the foot and most of the dorsal surfaces of the toes.
Tibial nerve
1. It is the large branch of Sciatic nerve
2. It descends vertically in popliteal fossa.
3. It passes under the fibrous arch of soleus to enter the posterior
compartment of the leg.
4. In the popliteal fossa it supplies the gastrochnemius, soleus, popliteus
and plantaris. It gives the sural nerve. It gives the superior, middle and
inferior medial genicular branches to the knee joint.
5. The injury of the tibial nerve leads to paralysis of the muscles of the back
of the leg and sole. Sensory loss of the lower part of the posterior surface
of the leg and sole of the foot.

Posterior tibial nerve

1. It lies in the back of the leg as a continuation of the tibial nerve
deep to soleus. It enters the sole of the foot deep to the flexor
retinaculum and divides into medial and lateral planter nerves.
2. It ends at the ankle joint deep to the flexor retinaculum. It supplies
tibialis posterior, flexor digitorum longus, flexor hallucis longus
and soleus.
3. It gives the medial calcanean branch, twigs to ankle joint.
The medial planter nerve:
Origin and course:
It is a terminal branch of the tibial nerve. It arises beneath the flexor
retinaculum, deep to abductor hallucis brevis.
Branches:
1. Muscular branches to abductor hallucis, flexor digitorum brevis, flexor
hallucis brevis and 1st lumbrical
2. Planter digital nerves to the medial 3½ toes

The lateral planter nerve:

Origin and course:
It arises as a terminal branch of tibial nerve beneath the flexor
retinaculum and deep to abductor hallucis. It runs with the lateral planter
artery till the base of the 5th metatarsal bone where it divides into
superficial and deep branches.
Branches:
1. From the trunk to quadratus plantae, abductor digiti minimi and skin of
the lateral part of the sole
2. Superficial branch supplies flexor digiti minimi, 4th interoseous muscles
and skin of lateral 1½ toes
3. Deep branch runs with the lateral planter artery. It supplies the rest of
the short muscles of the sole of the foot.
MEDIAL AND LATERAL PLANTER NERVES
 Handout of the JOINTS of the lower limb

Hip joint:
It is a synovial ball and socket joint. It is the articulation between the head of the femur and the
articular surface of the acetabulum of the hip bone. The cavity of the acetabulum is deepened
by labrum acetabular which becomes the transverse acetabular ligament across the acetabular
notch. The fibrous capsule is attached to the intertrochanteric line in front and to the middle of
the posterior surface of the femur from behind. The ligaments of the joint are iliofemoral,
pubofemoral, ischiofemoral and transverse acetabular. The iliofemoral ligament is a strong
ligament which prevents overextension of the hip joint during standing. The synovial
membrane protrudes between the iliofemoral and pubofemoral ligaments forming the psoas
bursa beneath the psoas tendon. The femoral nerve is anterior and sciatic nerve is posterior
relations to the joint.
Movements:
1- Flexion: iliopsoas and rectus femoris.
2- Extension: gluteus maximus and hamstring muscles.
3- Abduction and medial rotation: gluteus medius and minimus.
4- Adduction: adductor longus, adductor brevis and adductor magnus.
5- Lateral rotation: piriformis, obturator internus, two gemelli, quadratus femoris
and obturator externus.
HIP JOINT
Knee joint:
This is a synovial joint of hinge variety but some degree of rotatory movement is possible. The
joint between the patella and femur is synovial of plane variety. Basically, the knee joint is
formed of two condylar joints between the condyles of the femur and the tibia (tibial plateaus);
and plane joint between patella and femur. The articular surfaces of the joint are covered by
hyaline cartilage. There are medial and lateral menisci between femur and tibia. The fibrous
capsule is absent anterior and the ligamentum patellae replaces it. The extracapsular ligaments
of the joint are the ligamentum patellae, the lateral collateral ligament, the medial collateral
ligament and the oblique popliteal ligament. The intracapsular ligaments of the joint are
anterior and posterior cruciate ligaments in addition to the menisci. The tendon of popliteus,
the transverse ligament of the knee and infrapatellar fold of the synovial membrane are also
intracapsular structures. The medial meniscus is attached to the medial collateral ligament. The
lateral collateral ligament is separated from the lateral meniscus by the tendon of popliteus
which lies deep to the ligament. The lateral collateral ligament pierces the tendon of biceps and
splits it before its insertion into the head of fibula with and superficial to the ligament.
N.B.:
1. Anterior cruciate ligament is attached from the anterior intercondylar area of tibia
to the posterior part of the medial surface of the lateral condyle of the femur. The
ligament prevents anterior dislocation of the tibia during flexion of the knee.
2. Posterior cruciate ligament is attached from the posterior intercondylar area of
tibia and the anterior part of the lateral surface of the medial femoral condyle. The
ligament prevents posterior dislocation of the tibia with the knee joint flexed.
3. The medial and lateral menisci are fibrocartilages between femoral and tibial
condyles. The medial meniscus is relatively immobile.
4. The bursae related to the knee joint are suprapatellar, prepatellar, superficial
infrapatellar, deep infrapatellar, popliteal and semimembranosus bursae.
Movements of the knee joint:
1. Extension of the knee is associated with medial rotation of the femur on tibia
and tightening of the ligaments i.e. locked joint. This is done by quadriceps
femoris.
2. Flexion of the knee unlocking of the joint where ligaments be untwisted by
popliteus muscle where the femur rotates laterally on tibia.
The biceps also produce lateral rotation. The joint is flexed by biceps,
semimembranosus, semitendinosus, sartorius and gracilis.
3. Locking and unlocking of the knee
As the foot on the ground and the knee fully extended, the femur rotates
medially associated with tight stretching of ligaments of the knee. This is
termed locking of the joint. When the knee is extended and the foot is off the
ground the tibia rotates laterally and the joint locked.
If the joint is locked you cannot flex it unless it is unlocked by reversing the
rotation by the popliteus muscle and all the ligaments are untighten.

KNEE JOINT
Proximal tibiofibular joint:
It is a synovial plane gliding joint. It occurs between the lateral condyle of the tibia and head of
the fibula. The ligaments are anterior, posterior and interosseous membrane. Gliding
movement occurs during movements of the ankle.

Distal tibiofibular joint:

It is a fibrous joint. It occurs between the fibular notch of the tibia and lower end of the fibula.
The ligaments are interosseous ligament, anterior ligament, posterior ligament, inferior
transverse ligament and interosseous membrane. The movement is not appreciable.

Ankle joint:
It is a synovial hinge joint. It is between the inferior surface of the lower end of the tibia and the
two malleoli in which fitted the upper surface of the body of the talus. The collateral ligaments
of the ankle are medial or deltoid and lateral collateral ligament (3 bands; anterior talofibular,
posterior talofibular and middle called calcaneofibular). The deltoid ligament is triangular in
shape; its apex is attached to the tip of medial malleolus and the base below to navicular bone,
spring ligament, calcaneus and body of talus.
Movements:
1- Dorsiflexion: tibialis anterior, extensor digitorum longus and extensor hallucis
longus.
2- Plantarflexion: gastrocnemius, soleus, tibialis posterior, peroneus longus, flexor
digitorum longus, flexor hallucis longus.
Tarsal joints of eversion and inversion:
1- Subtalar: it is synovial plane. It is between the inferior surface of the body of the
talus and upper surface of the calcaneus.
2- Talocalcaneonavicular: it is synovial ball and socket. It is between the head of talus
and a socket formed of navicular bone, calcaneus and spring (planter calcaneo
navicular) ligament.
3- Calcaneocuboid: it is synovial plane. It is between the calcaneum and cuboid.
The calcaneonavicular and calcaneocuboid joints are together referred to as midtarsal or
transverse tarsal joints. The axis of eversion and inversion is directed forward upward and
medially through the head and neck of talus. In eversion the sole looks laterally while in
inversion the sole looks medially. The head of talus is fixed while calcaneum and navicular move
around the talus. The muscles of inversion are tibialis anterior and tibialis posterior while those
of eversion are peroneus longus and brevis.
Tarsometatarsal joints:
They are synovial plane joints. Each of the three medial metatarsals articulate with the
corresponding cuneiform. The lateral two articulates with the cuboid bone. The axis of
movements of these joints is at the 2nd toe.

The interphalangeal joints:

They are synovial hinge i.e. making flexion and extension

N.B.:
The joints of the foot are synovial except the cuboideonavicular is fibrous joint.
How the weight of the body is transmitted?
ANSWER
. From the vertebral column where it divides into two halves, each half passes to the
corresponding sacroiliac joint.
. Down to hip joints
. Through the head of the femur to femoral condyles
. through tibia to talus where it divides into two equal parts, one part passes to calcanean
tuberosity and the other part goes to the heads of metatarsal bones
what is the role of arches of the foot?
There are three arches formed in the foot medial and lateral longitudinal arches in addition to a
transverse arch. The wedged shape of bone and planter aponeurosis help in maintenance of the arches.
Their shape allows them to act as a spring bearing the weight of the body and absorbing shock produced
during locomotion. They facilitate walking and running.

Name medial longitudinal Lateral longitudinal transverse

Bones forming The Summit is talus The summit is cuboid It is formed by the 3
Anterior limb has The anterior limb has cuneiform and cuboid
navicular, 3 cuneiform cuboid and lateral 2 bones in addition to
and medial 3 metatarsal the bases of all
metatarsal The posterior limb is metatarsal bones
Posterior limb is calcaneus
formed by calcaneus
 Muscles acting Tibialis anterior, tibialis
posterior, flexor
digitorum longus,
flexor hallucis longus
and intrinsic muscles of
the foot
Ligaments of support Long planter, short
planter, spring and
deltoid ligaments
Mechanism of walking?
Peroneus (fibularis) Peroneus longus and
longus. flexor tibialis posterior
digitorum longus and
intrinsic foot muscles
Long planter, short Long planter, short
planter and spring planter, spring and
ligament deep transvers
metatarsal ligaments
Support of the non-moving leg by putting the heel of the foot on the ground while moving the other
foot off the ground and moving it forward, finally the heel of this other foot rests on the ground and vice
versa. Walking involves all the joints of the lower limb and is characterized by inverted pendulum
motion in which the body vaults over the non-moving limb.

What is the line of gravity?

THE FEMORAL TRIANGLE