LOWER LIMB

CUTANEOUS INNERVATION
OF THE LOWER LIMB
GLUTEAL REGION
GLUTEAL REGION

Gluteal region is described as the posterior

part of the pelvis, extending between the
iliac crest and the inferior border of the
gluteus maximus muscle
GLUTEAL REGION (continued)

Gluteus maximus muscle

• Outer surface of ilium, dorsal surface of sacrum and coccyx,
sacrotuberous ligament
• Iliotibial tract (attaches to the lateral condyle of tibia),
gluteal tuberosity of femur
• Extends and laterally rotates thigh at the hip; through
iliotibial tract it extends knee joint
• Innervated by the inferior gluteal nerve
GLUTEAL REGION (continued)

• Deep fascia of the thigh is called the fascia lata

• Fascia lata postero-superiorly divides into two
layers covering the superficial and deep surfaces of
the gluteus maximus muscle
• At the inferolateral part of the thigh the fascia lata
forms a thickening called the iliotibial tract, which
inserts to the lateral condyle of tibia
GLUTEAL REGION (continued)

Gluteus medius muscle

• Outer surface of ilium
• Greater trochanter of femur
• Abducts (most powerful) and medially rotates the thigh at
the hip joint, tilts pelvis when walking
– During walking, when one foot is raised, the gluteus medius and
minimus of the opposite side contracts and keep the pelvis tilted
and prevents its sagging to the raised side
• Innervated by the superior gluteal nerve
GLUTEAL REGION (continued)

Gluteus minimus muscle

• Outer surface of ilium
• Greater trochanter of femur
• Abducts and medially rotates the thigh at the hip joint,
tilts pelvis when walking (as described for gluteus
medius)
• Innervated by the superior gluteal nerve
CLINICAL NOTE

Injury to the superior gluteal nerve

• Abduction and medial rotation of the thigh is weakened
• When the patient is asked to raise the foot of the opposite side,
the pelvis sags on that side
– i.e. When the right gluteal nerve is damaged and the patient is asked to
raise the left foot, the left pelvis sags
• The above sign is known as the “positive Trendelenburg sign”
• In order to compansate the sagging and prevent the foot
rubbing the floor, during walking, these patients lean away
from the sagging side or raise the foot higher than normal
Functioning gluteus
med. & min.
Pelvis is kept from dipping to
the left by the right gluteus
med. & min. thus allowing
the left limb to clear the
ground during the swing
phase of gait (walking)

Rt Lt
Non- functioning
gluteus med. & min.
Non- functioning right
gluteus med. & min. cannot
support pelvis when left
limb is off the ground, thus
the pelvis falls or dips to the
left during the swing phase
of gait (walking)
Rt Lt
Trendelenburg Sign vs. Trendelenburg Test
(hip abductors) (competency of vein valves)
GLUTEAL REGION (continued)

Tensor fascia lata muscle

• Anterior superior iliac spine and iliac crest
• Iliotibial tract (attaches to the lateral condyle of tibia)
• Abducts, medially rotates and flexes the thigh; by tensing
the iliotibial tract, helps to keep the knee extended as in
during standing
• Superior gluteal nerve
GLUTEAL REGION (continued)

Priformis muscle
• Anterior surface of sacrum and sacrotuberous ligament
• Greater trochanter of femur
• Laterally rotates the extended thigh and abducts the
flexed thigh
• Nerve to priformis

Passes through the greater sciatic foramen and divides it

into suprapriform and infrapriform parts
GLUTEAL REGION (continued)

Obturator internus muscle

• Pelvic surface of obturator membrane and surrounding bone
• Passes through the lesser sciatic foramen and insert to the
greater trochanter of femur
• Lateral rotator of the thigh
• Nerve to obturator internus
GLUTEAL REGION (continued)

Gemellus superior and gemellus inferior muscles

• Superior: spine of ischium, Inferior: ischial tuberosity
• Trochanteric fossa of femur
• Both gemelli are lateral rotators of the thigh
• Nerves to gemellus superior and inferior respectively
GLUTEAL REGION (continued)

Quadratus femoris muscle

• Lateral border of ischial tuberosity
• Quadrate tubercle on the intertrochanteric crest of femur
• Lateral rotator of the thigh
• Nerve to quadratus femoris
GLUTEAL REGION (continued)

Obturator externus muscle (lies deep at the medial thigh region)

• Outer surface of obturator membrane surrounding bone
• Trochanteric fossa of femur
• Lateral rotator of the thigh
• Obturator nerve
GLUTEAL REGION (continued)

Greater sciatic foramen

• Bordered by
– Greater sciatic notch,
– Sacrospinous ligament
– Sacrotuberous ligament

• Priformis muscle further divides the greater schiatic

foramen into suprapriform and infrapriform parts
GLUTEAL REGION (continued)

• Structures passing through the suprapriform foramen

– Superior gluteal artery and vein
– Superior gluteal nerve
GLUTEAL REGION (continued)

• Structures passing through the infrapriform foramen

– Inferior gluteal artery and vein
– Inferior gluteal nerve
– Sciatic nerve ( largest nerve in the body)
– Posterior femoral cutaneous nerve
– Internal pudendal artery and vein
– Pudendal nerve
GLUTEAL REGION (continued)

Lesser sciatic foramen

• Bordered by
– Lesser sciatic notch,
– Sacrospinous ligament
– Sacrotuberous ligament

• Structures passing through the lesser sciatic foramen are

– Internal pudendal artery and vein
– Pudendal nerve
GLUTEAL REGION (continued)

• Internal pudendal vessels and the pudendal nerve leave the

pelvis through the greater sciatic foramen and reenter
through the lesser sciatic foramen

• In the pelvis these structures pass through the pudendal canal

(Alcock’s canal)

• Pudendal canal lies in the lateral wall of the ischiorectal

fossa; it is between the obturator internus muscle and the
fascia covering its medial surface

• Contents of the pudendal canal are

– Internal pudendal vessels
– Pudendal nerve
– Nerve to obturator internus muscle
CLINICAL NOTE

Intramuscular injections to gluteal region

• Gluteal region is a common site for intramuscular injections,
as the muscles here are large and provide a large surface area
for absorbtion of the given medication

• The safest area for IM injections is above the horizontal line

passing through the greater trochanter of femur and upper
lateral quadrant of the buttock

• Other regions may be dangerous, as a number of vessels and

nerves are present
 Injections
Upper lateral quadrant = safe for injection

Sciatic n.

lower quadrants = unsafe for injection

ANTERIOR THIGH
ANTERIOR THIGH (continued)

• Fascia lata (deep fascia of the thigh) superiorly

attaches to the inguinal ligament

• Inguinal ligament extends between the anterior

superior iliac spine and the pubic tubercle
– It is the most inferior part of the aponeourosis of the
external oblique muscle (one of the muscles of the
anterolateral abdominal wall)
ANTERIOR THIGH (continued)

• The opening on the fascia lata inferior to the

inguinal ligament is called the saphenous
opening which is covered by a fascia called
the cribriform fascia
– Great saphenous vein penetrates this fascia and
passes through the hiatus saphenus to drain into
the femoral vein
ANTERIOR THIGH (continued)

In general, the functions of the muscles in this

region are to flex the thigh at the hip joint and
extend the knee

Six muscles are considered here

– Pectineus muscle
– Psoas major muscle
– Iliacus muscle
– Psoas minor muscle
– Quadriceps femoris muscle
– Sartorius muscle
ANTERIOR THIGH (continued)

Pectineus muscle
• Superior ramus of pubis
• Pectineal line of femur
• Flexes and adducts thigh assist in its medial rotation
• Femoral nerve
ANTERIOR THIGH (continued)

Iliopsoas muscle
• Psoas major, psoas minor and iliacus muscles are
collectively referred as the iliopsoas muscle
• Psoas major and iliacus muscles act together in flexing the
thigh and laterally rotating it
• When the lower limb is fixed, contracting bilaterally, all
three muscles can flex the trunk
• Psoas major muscle is also a postural muscle that helps to
control the deviation of the trunk and active during standing
ANTERIOR THIGH (continued)

Psoas major muscle

• Bodies and transverse processes of T12 – L5 vertebrae and
the intervertebral discs between them
• Lesser trochanter of femur
• Innervated by direct branches from the lumbar plexus
ANTERIOR THIGH (continued)

Psoas minor muscle

• Bodies of T12 – L1 vertebrae and the intervertebral discs
between them
• Pectineal line of pubic bone and iliopubic eminence
• Innervated by direct branches from the lumbar plexus
ANTERIOR THIGH (continued)

Quadriceps femoris muscle

• Has four heads. Origins of the heads are
– Rectus femoris: Anterior inferior iliac spine and ilium just above the
acetabulum
– Vastus lateralis: Greater trochanter and linea aspera
– Vastus medialis: Intertrochanteric line and linea aspera
– Vastus intermedius: Anterior and lateral surfaces of the the body of femur
• All heads insert to the base of the patella via the quadriceps
tendon; some fibers extend as the patellar ligament and inserts to
the tibial tuberosity
• Extend the knee, rectus femoris helps the flexion of the thigh
• All heads are innervated by the femoral nerve
ANTERIOR THIGH (continued)

Iliacus muscle
• Iliac fossa
• Lesser trochanter of femur
• Innervated by the femoral nerve
ANTERIOR THIGH (continued)

Sartorius muscle
• Anterior superior iliac spine
• Superior part fo the medial srface of tibia
• Flexes, abducts and laterally rotates the thigh at the hip
joint; flexes the leg at the knee joint
• Femoral nerve
MEDIAL THIGH
MEDIAL THIGH (continued)

The muscles in this region are called the adductor

group of muscles

Four muscles are considered here

• Adductor longus muscle
• Adductor brevis muscle
• Adductor magnus muscle
• Gracilis muscle
MEDIAL THIGH (continued)

Adductor longus muscle

• Body of pubis inferior to the pubic crest
• Middle third of linea aspera
• Adducts the thigh and assists
in lateral rotation
• Obturator nerve
MEDIAL THIGH (continued)

Adductor brevis muscle

• Inferior ramus of pubis
• Posterior surface of the body of femur
• Adducts the thigh and assists in flexion
• Obturator nerve
MEDIAL THIGH (continued)

Adductor magnus muscle

Has two parts

• Origin
– Adductor part : Inferior ramus of pubis and ramus of
ischium
– Hamstring part: Ischial tuberosity
• Insertion
– Adductor part : Gluteal tuberosity, linea aspera, medial
supracondylar line
– Hamstring part: Adductor tubercle of femur
MEDIAL THIGH (continued)
Adductor magnus muscle (continued)

• Function
– Adductor part : Adducts and flexes the thigh
– Hamstring part: Adducts and extends the thigh
• Innervation
– Adductor part : Obturator nerve
– Hamstring part: Tibial nerve

• The gap between attachments of the adductor and hamstring

parts is called the adductor hiatus
– The adductor hiatus transmits the femoral artery and vein as they pass
through the adductor canal to the popliteal fossa
MEDIAL THIGH (continued)

Gracilis muscle
• Inferior ramus of pubis
• Superior part of medial surface of tibia
• Adducts the thigh, flexes the leg
• Obturator nerve
 FEMORAL TRIANGLE

• This triangle lies at the upper part of the anterior thigh

• Borders of the femoral tringle

– Superior : Inguinal ligament
– Medial : Medial margin of the adductor longus muscle
– Lateral : Medial margin of the sartorius muscle
– Floor : Medially the adductor longus and pectineus muscles,
laterally the iliopsoas muscle
– Roof : Deep and superficial faciae, and skin
FEMORAL TRIANGLE (continued)

Contents of the femoral triangle (from lateral to medial)

– Femoral nerve (and its branches)
• Saphenous nerve (sensory branch of the femoral nerve)
– Femoral artery (and its several branches) a continuation of
external iliac artery.
• Deep femoral artery (deep artery of the thigh) and its branches in this
region; medial and lateral circumflex femoral arteries and perforating
branches
– Femoral vein (and veins draining to its proximal part such as
the great saphenous vein and deep femoral vein), continous
of external iliac vein.
– Deep inguinal lymph nodes
 MUSCULAR AND VASCULAR
COMPARTMENTS

• The passageway posterior to the inguinal ligament

is divided into two compartments by a septum
– Muscular comparment (lateral)
– Vascular compartment (medial)

• The above mentioned septum is a thickening of the

iliac fascia (deep fascia covering the anterior
surface of the iliacus muscle)
– This thickening extends between the posterior surface of
the inguinal ligament and the iliopubic eminence
MUSCULAR AND VASCULAR COMPARTMENTS (continued)

• Contents of the muscular comparment (lacuna)

– Iliacus and psoas muscles
– Femoral nerve

• Contents of the vascular compartment (lacuna)

– Femoral artery
– Femoral vein
– Femoral branch of the genitofemoral nerve
– Lymph vessels
 FEMORAL SHEATH

• Transversalis fascia of the abdominal wall and iliac

fascia forms a tubular sheath that encloses the
vascular lacuna

• This tubular sheath is called the femoral sheath

FEMORAL SHEATH (continued)

Two septa divides femoral sheath into three

compartments

– Lateral compartment for the femoral artery

– Intermediate compartment for the femoral vein
– Medial compartment is an opening called the femoral
canal
 FEMORAL CANAL
• Femoral canal is the smallest of the three compartments of
the femoral sheath
• It is approximately 1-1.5 cm long
• The canal contains loose connective tissue, fat and usually a
deep inguinal lymph node
• Femoral canal is actually a potential canal, which is
normally closed with the above given tissues
FEMORAL CANAL (continued)

• The proximal opening of the femoral canal is called the

femoral ring
• Femoral ring is closed by extraperitoneal fatty tissue which
is referred as the femoral septum

• The borders of the femoral ring

– Femoral vein (laterally)
– Lacunar ligament (medially)
– Inguinal ligament (anterior)
– Pectineus muscle and its fascia (posterior)
CLINICAL NOTE

Femoral hernia
• The protrusion of any abdominal organ (usually a part of small intestine) is
called a femoral hernia
• Femoral ring is a weak area of the lower part of the anterior abdominal
wall
• A hernia passing through the femoral canal, reaches to the femoral
triangle, where usually is palpable as a tender mass
• After reaching the femoral triangle, the hernia may pass through the
saphenous opening to the subcutaneous tissue
• Femoral hernias are more common in females, as the femoral ring is
usually larger in females
• Strangulation of the hernia may occur, which will interfere with the blood
supply of the intestine and leads to the necrosis of that part of the intestine
 ADDUCTOR (SUBSARTORIAL) CANAL
• A long canal (app. 15 cm long) extending within the middle
third of the anterior thigh
• Extends between the apex of the femoral triangle and
adductor hiatus
• Adductor hiatus is a gap between the two heads of the
adductor magnus muscle
• Boundaries of the adductor canal
– Vastus medialis (antero-lateral)
– Sartorius muscle, vastoadductor fascia (antero-medial)
– Adductor longus and adductor magnus muscles (posterior)
ADDUCTOR (SUBSARTORIAL) CANAL (continued)

Following structures pass through the adductor canal

• Femoral artery and femoral vein
– Femoral artery and vein pass through the adductor hiatus to reach the
popliteal fossa, where they become the popliteal artery and vein
• Saphenous nerve (sensory br. of femoral nerve)
– Does not pass through the adductor hiatus
– Penetrates the vastoadductor fascia and becomes superficial at the
medial part of the knee joint
• Nerve to vastus medialis (br. of femoral nerve)
– Does not pass through the adductor hiatus
POSTERIOR THIGH
POSTERIOR THIGH (continued)

Three muscles are considered in this region

• Semitendinosus muscle
• Semimembranosus muscle These muscles are
also known as the
• Biceps femoris hamstring muscles
 Gluteus Medius
Gluteus
Maximus
Gluteus Minimus
Tensor
Piriformis Fascia Lata
Sciatic n.

Hamstrings 2
3 1
1) Biceps Femoris Tibial n.
2) Semimembranosus
Common fibular n.
3) Semitendinosus
POSTERIOR THIGH (continued)

Semitendinosus muscle
• Ischial tuberosity
• Medial surface of tibia on its upper part
• Flexes and medially rotates the flexed leg, extends the thigh
• Innervated by the tibial nerve ( a medial branch of sciatic
nerve and common perineal nerve also a lateral branch of
sciatic nerve)
POSTERIOR THIGH (continued)

Semimembranosus muscle
• Ischial tuberosity
• Posterior part of medial condyle
– Reflected part of its inserting tendon forms the oblique popliteal
ligament
• Function is exactly same with the semitendinosus muscle
• Innervated by the tibial nerve
POSTERIOR THIGH (continued)

Biceps femoris muscle

• Long head: ischial tuberosity, Short head: linea aspera and
lateral supracondylar line of femur
• Both heads insert to the fibula
• Flexes the leg and laterally rotates it when flexed, extends
the thigh (e.g. starting to walk)
• Long head is innervated by the tibial nerve, short head by
the common peroneal nerve