Clinically Oriented Anatomy, 5th Edition - 5. Lower Limb

Ovid: Clinically Oriented Anatomy
Page 1 of 155
Author s: Mo or e, Keit h L. ; Da lley, Ar thur F.

T itle: Cl inica lly Orie nted Ana tomy, 5th E di tio n
C op yri gh t 2 0 06 L ip pi nco tt Wi lli am s & Wilk in s
> T a b l e o f C o n t en t s > 5 - L o we r L im b
5
Lowe r Lim b
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O v e rv ie w o f t h e L ow e r Lim b
T h e l ower lim b s (extr em iti es) ar e exten sion s fr om th e tru n k sp ecial ized to su pp or t b od y w eig h t, fo r loco mo tion , th e abi lity to m ove
f r om on e pl ace t o an ot her a nd m ai nt ain b alan ce.
I t is cu sto ma ry wh en d escri bi ng th e low er li mb s t o i ncl ud e reg ion s tha t ar e tran si tion al be tween the tr un k an d the fr ee lo we r
l imb s (t he m ob ile pa rt of th e l im bs exten di ng f r om th e tru n k), su ch as t he gl ute al reg ion (G. glo ut os , b utto cks). Th e low er li mb
h as six m ajor p ar ts o r re gio ns (Fig . 5. 1 ):
1. G luteal r eg ion (L. r eg io gl ute alis). Th is tran sit ion al re gio n be tween the tr un k an d fr ee l owe r lim b in clu d es tw o par ts of th e
l ow er lim b : th e ro un de d, p ro m in ent po ster ior r eg ion , th e b utto cks (L. n ates, cl un es), a nd th e later al , usu al ly l ess p r om in ent
hi p (L. coxa) or hip r eg io n (L. reg io coxa e), wh ich o ver lies th e h ip j oin t and g r eater tr och an ter of th e fem u r. Note th at the
w id th of th e hi ps in co mm on term i no log y i s a ref er en ce to on e's tr ansv erse di m ensi on s at th e l evel of th e g r eater
t ro chan ter . T he gl ute al reg ion is b ou n ded su p eri or ly b y the il iac crest, med ia lly by th e i nte rg lutea l (nat al) clef t (L. na tus,
t o b e bor n ), an d in fer io rly b y th e s kin f old (g ro ove) un d erl yin g the b utt ock, th e g lute al f ol d (L. sul cus gl ute alis). Th e g lu teal
m u scles con stitu te th e b u lk o f thi s r eg ion .
2. T hig h or femo ra l r eg io n (L. reg io f emo ri s). Th is par t/r egi on o f the fr ee low er li mb l ies bet ween t he gl ute al, ab d om in al, an d
p er in eal r egio ns p roxi m ally an d th e kn ee re gio n di stall y. It con tai ns m ost o f th e f emur (th ig h b on e), wh ich con nect s th e h ip
a nd kn ee.
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T h e tr an siti on b etwee n th e tr u nk an d fr ee l ow er lim b i s ab ru p t an ter io rly an d m edi all y. Th e b ou n dar y betw een th e thi gh and
a bd om in al re gio ns is dem ar cated b y the in gu in al li ga men t an teri or ly and t he isch io pu bi c r am us of th e hi p bon e (par t of th e
p elv ic g ir dl e o r skeleto n of th e p elv is) m ed ial ly. T he ju n ction of th ese r eg ion s i s th e in gu in al re gio n or g ro in .
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Fig ure 5.1. Reg io ns and b ones of lo w er li mb. T h e p elvi c g ird le, con sistin g of th e sacr um and r ig h t an d le ft hi p bon es
un it ed by th e p ub ic sym ph ysis, a ttach es th e app en di cul ar skel eton o f t he fr ee low er li mb t o th e axia l ske leton and
tra nsf er s w eig ht fr om t he axia l ske leton to the lo wer l im bs.
3. Knee (L. gen u ) or knee r eg io n (L. reg io g enu s). T hi s p art /reg ion in clu des th e p ro mi ne nces (con dy les) of th e d istal f em ur
a nd p r oxim al tib ia , the h ead of th e fi bu la, a nd th e pat ella (kn ee cap, w h ich li es a nter io r to the d istal en d of th e fem u r) as
w ell as th e j oin ts betw een th ese bo ny str uctu r es. Th e po ster io r pa rt of the k ne e (L. po pl es) i ncl ud es a w ell-d ef in ed, f atf il led h oll ow, tra nsm itt in g neu r ovascu lar stru ctu re s, call ed the p opl itea l f ossa.
4. L eg (L. cr u s) or l eg r egi on (L. r eg io cru r is). Al th ou gh l aype rson s ref er in cor r ectly to the en tir e l ow er lim b as th e le g,
t he leg i s th e par t t hat li es b etw een th e kn ee an d th e r ou n ded m ed ial an d lat eral p ro mi ne nces (m all eoli ) th at fla nk th e a nkl e
j oin t. T h e le g con tain s t he tib ia (shi n b on e) an d fi bu la (L . bu ckle) an d con n ects th e kne e an d f oot. T h e cal f (L. su r a) o f the
l eg is th e p oster ior pr om in en ce cau sed b y th e tri ceps su rae m u scle, f ro m wh ich t he calca nea l (A ch ill es) ten d on exte nd s to
r each the h eel.
5. Ankl e (L. tar su s) o r talo crur al re gi on (L. r egi o t alocr u ra lis). T hi s i ncl ud es t he n arr ow , di stal pa rt of th e l eg an d th e
m al leo li; the an kle (tal ocr ur al) joi nt is lo cated b etween the m all eoli .
6. Fo ot (L. pes) or f oo t r eg ion (L. r eg io ped is ). T h e f oot is the d istal p art of th e low er li mb co nta in in g the tar su s, m etatar su s ,
a nd p h alan g es (to e b on es). Th e sup er ior su r face is th e d or sum o f the f oo t an d th e in fer ior , g ro un d-c on tactin g su rf ace is th e
s ole or p la ntar re gi on. T he toe s ar e t he d ig its o f the f oo t. Th e gr eat toe (L. h al lu x), li ke th e thu m b, has on ly two
p h alan g es (d ig ital b on es); th e oth er d igi ts h ave th ree .
D e ve lo p m e n t of th e Lo w e r L im b
Deve lop m ent of th e low er li mb i s il lu str ated, expl ain ed , an d con tra sted wi th th at o f the u pp er li mb in Fig ur e 5. 2 . In iti all y, th e
d evel op men t of th e l owe r lim b is sim il ar to th at o f the u pp er li mb , al tho ug h occu r ri ng a bou t a w eek later . Du ri ng th e 5th week,
l ow er lim b b ud s b u lg e f ro m th e l ater al aspect of th e L2 S2 segm en ts of th e tr u nk (a br oad er ba se th an f or th e up pe r lim b s) (Fig .
5 . 2A). B oth l im bs in itia lly exten d fr om the tr un k wit h th eir d evelo pin g th u mb s a nd g re at to es d ir ected su p eri orl y a nd th e pal ms

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a nd so les di rected ant eri orl y. Bo th li mb s t hen un d erg o tor sion a rou n d th eir l on g axes, b ut in o pp osite d ir ection s (Fi g. 5 . 2B D ).
T h e m ed ial r otati on an d th e p er ma ne nt pr on ati on of th e low er li mb e xpla in (1 ) h ow th e kne e, u nl ike the jo in ts su p eri or to it,
e xten ds an teri or ly a nd f lexe s p oster ior ly, a s d o t he jo in ts in f eri or to th e kn ee (e. g. , in ter ph al ang eal jo in ts o f the toe s); (2 ) h ow
t he fo ot beco mes or ien ted w ith th e gr eat toe on th e me dia l si de (Fig . 5. 2D ), wh er eas th e ha nd (i n th e an ato m ical po sitio n)
b ecom es or ien ted w ith th e thu m b on t he late ral sid e; an d (3) th e b arb er -po le patt ern o f the seg m enta l i nn er vati on of th e
s kin (d erm ato m es) of t he low er li m b (see C u tan eou s I nn er vatio n of th e Low er L im b, in th is cha pter ). T he tor sion an d
t wist in g of th e l ower l im b is still i n pr og ress at bi rth ( not e th e way ba bie s' f eet ten d to m eet sol e to sol e w h en th ey a re br ou gh t
t oge the r, l ike clap pin g ). C om ple tion of th e p ro cess co in cide s w ith th e ma steri ng o f wal kin g skill s.
L o w er L i m b I n j u r i e s
Kn ee, l eg, a nd f oot in ju r ies are th e m ost com m on l ow er lim b in j ur ies. I n ju ri es to th e hi ps ma ke u p <3 % of l ower l im b in ju r ies. I n
gen er al, m ost in ju r ies resu lt fr om acu te tr au m a d u rin g con tact sp or ts su ch as ho ckey a nd f oot bal l a nd f ro m over u se d u rin g
end u ran ce spo rts su ch as m ar ath on r aces. Ad olescen ts ar e m ost vu ln era ble to th ese i nj ur ie s b ecau se o f t he de ma nd s o f s por ts on
the ir slo wly m atu ri ng m u scu loskel etal system s. T he car tila gi no us mo del s o f the bo ne s in the d evelop in g lo wer l im bs ar e
tra nsf or me d in to b on e by end och on d ral ossi fi catio n (see B on e Devel op me nt in t he In tr od ucti on ) (Fig . 5 .2E & F). Beca use th e
pr ocess is not com p leted u n til ear ly ad ul tho od , cart ilag in ou s e pip h ysial p lates stil l e xist du ri ng th e teen ag e yea rs wh en p hysi cal
activi ty o ften p eaks an d in vol vem ent in co m peti tive spo rts is mo st co mm on . Du ri ng g ro wth spu rts, bon es actu all y g ro w faster tha n
the atta ched m u scle. Th e co mb in ed str ess o n th e ep ip h ysial pl ates resu lt in g fr om p hy sical acti vity and r ap id g ro wth m ay re sul t i n
ir rit ation an d in ju ry of th e p lat es an d d evelo pin g b on e (o steoch on dr osi s).
B on e s o f th e L ow e r L im b
T h e skel eton o f th e lo wer l im b (in fer io r ap pen di cul ar skel eton ) m ay be d ivid ed in to two f un ctio na l co m pon en ts: the pe lvic gi rd le
a nd t he bo nes of th e fr ee l ow er lim b (Fig . 5 .1 ). T he p elvic gi rd le (b on y p elvi s) is a bon y ri ng co mp osed o f the sacr u m an d ri gh t
a nd l eft h ip bo ne s jo in ed an ter ior ly at the pu b ic sy mp h ysis. I t at tach es th e fr ee l owe r lim b to th e a xial skel eton , th e sa cru m b ein g
c om mo n to th e axi al skelet on an d th e p elvi c g ir dle . Th e p elv ic g ir dl e al so ma kes u p th e ske leton of th e l ower par t o f th e tr u nk. I ts
p r otecti ve an d su pp or tive fu n ctio ns ser ve th e abd om en , pe lvis, a nd p er in eum as w ell as th e l ower lim b. Th e b on es of th e f ree
l ow er lim b ar e con tain ed w ith in an d sp ecif icall y ser ve th at p ar t o f t he li mb .
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Fig ure 5.2. D evelo pm ent of l ow er li mb . A D . T he u pp er an d low er li mb s devel op f rom lim b b ud s th at ar ise fr om th e
late ral b ody w all du r in g the 4 th an d 5 th we eks, r especti vely. Th ey th en e lon ga te, d evelop f lexu r es, an d r otate in o pp osite
di recti on s. Seg m en tal in ne rvat ion i s m ain tai ne d, th e der m atom al p atter n r efl ectin g th e el on gati on an d spir alin g o f t he lim b . E
and F. Fut ur e b on es devel op f rom car tilag e mo del s, de mo nstr ated a t th e end o f th e 6 th w eek (E ) a nd b egi n ni ng o f t he 7 th
week (F).
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A r ra n g e m e n t o f L o w e r L im b B on e s
B od y w eig h t is tr an sfer red f r om th e verte br al colu m n th ro ug h th e sa cro ili ac j oin ts (s ee C h apte r 4) to th e p elvi c g ird le an d fr om t he
p elv ic g ir dl e th r ou gh th e hi p joi nt s to th e f em ur s (L. f em or a) (Fig . 5 .3A ). To su pp or t th e erect b ipe dal p ostu re b etter , th e f em ur s
a re ob liq u e (d ir ected in f ero me dia lly) wi thi n th e th ig h s so th at w h en stan di ng the kn ees a re ad jacen t and a re pl aced d ir ectly
i n fer ior t o th e tru n k, r etu rn in g th e cen ter o f gr avity to th e ve rti cal lin es o f th e su pp or tin g leg s a nd f eet (Fi gs. 5 . 1 , 5. 3 , an d 5 .4 ).
C om p ar e th is ob liq u e p ositi on o f t he fem u r s wi th th at of qu ad ru p eds, in wh om th e f em ur s a re ver tical an d th e kn ees ar e ap ar t,
w ith the tr un k ma ss su spen d ed be tween the li mb s (Fi g. 5 . 3B ). Th e fem u rs of f ema les are sli gh tly m or e ob li qu e tha n tho se o f
m al es, r efl ectin g th e g re ater w idt h of th eir p elves. At the kn ees, th e dist al end o f each f em ur a rti cul ates w ith the pa tell a an d ti bia
o f th e cor r espo nd in g leg . Wei gh t i s tr an sfer r ed fr om th e kne e j oin t t o th e an kle joi nt by th e t ibi a. Th e fi bu la do es n ot ar ticu late
w ith the fe mu r an d
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P. 5 6 1
d oes n ot bear o r tr ansf er w eig ht, bu t i t p ro vid es f or m u scle attach m ent an d con tr ib utes to th e f or ma tion o f th e an kle jo in t.
Fig ure 5.3. Pel vic G ir dl e and Rel ated J oints , D emo nstra ting Tr ansf er of We ig ht. A. T he w eig ht of th e u p per b od y,
tra nsm it ted cen tra lly th rou g h th e ver teb ra l co lu m n, i s d ivid ed an d d ire cted late ral ly by me an s of th e bon y ar ch for m ed b y th e
sacr um and i lia . Th ick po rti on s of th e ili a tr an sfe r the w eig ht to the f emu r s. Th e pu bi c r am i for m str u ts o r br aces tha t
he lp m ain tai n the in teg ri ty o f th e ar ch . B. T h e ar r ang em en t o f the lo wer l im b bo nes of b ip eds is com par ed to th at of
qu ad ru p eds. T he d iag on al di sposi tion of th e f em ur r ecen ter s su p por t dir ectl y in f eri or to th e tr u nk (b ody m ass) t o m ake b ipe dal
stan di ng m or e eff icien t an d to ena ble b ipe dal w alkin g , in w hi ch th e f u ll wei gh t i s b or ne alt ern atel y b y e ach li mb . I n
qu ad ru p eds, th e tru n k i s su spe nd ed b etween essen tial ly v erti cal lim b s, re qu ir in g sim u ltan eou s su p po rt fr om ea ch sid e.

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Fig ure 5.4. B ones of lo w er lim b. A a nd B . I nd ivi du al bo ne s an d bo ny fo rm ati on s ar e id enti fi ed. T h e f oot is in f ul l
pl ant arf lexi on . Th e hi p joi nt is di sarti cul ated (B ) to d em on stra te th e acetab u lu m of th e hi p bon e, w h ich r eceives th e h ead o f
th e f em ur .
A t the an kle, t he wei gh t bor n e b y t he tib ia is tra nsf err ed to th e t alu s. Th e talu s i s th e keyston e of a lon gi tu din al ar ch f orm ed b y
t he tar sal an d m etatar sal bo ne s of ea ch fo ot t hat d istr ibu tes th e w eig ht even ly be tween the h eel an d the f ore foo t w he n stan di ng ,
c reat in g a f lexi ble b ut stab le pla tfo rm t o su p por t the b ody.
H ip B on e
T h e m atu r e hip b o ne (L. os coxae), o nce cal led the in no mi na te (u n na med ) b on e, i s th e l ar ge, f lat p elvic bo ne fo rmed b y th e fu sio n
o f th ree pr im ar y b on es il iu m , isch iu m, an d pu bi s at t he en d of th e te ena ge year s. E ach of th e thr ee bo nes is fo rm ed f rom its
o wn p r im ary cen ter of o ssif icati on ; fi ve se con dar y c ente rs of ossi fica tion a pp ear la ter. At bi rth , th e t hr ee prim ar y b on es a re joi ne d
b y hya lin e ca rti lag e; i n ch ild re n, th ey ar e i nco mp lete ly o ssif ied (Fig . 5 .5 ). A t p ub er ty, th e th r ee b on es are stil l separ ated by a Y s hap ed tr ir ad iate car tila ge cen ter ed in th e acetab ul um , a lth ou gh t he two p art s of th e isch iop u bic r am i f u se b y th e 9th year (Fig .
5 . 5B). T he b on es b egi n to fu se b etw een 1 5 an d 1 7 year s o f age ; f usi on is com pl ete betw een 2 0 an d 2 5 year s of ag e. Li ttle or n o
t race of th e lin es of fu sio n of th e p r im ar y b on es i s visi bl e i n old er ad u lts (Fi g. 5 . 6). A lth ou g h th e b on y co mp on en ts a re ri gid ly
f u sed, t hei r na me s ar e still u sed in a du lts to descr ib e th e th ree pa rts of th e h i p bon e.
B ecau se mu ch o f the m edi al aspe ct of t he h ip bo ne s/bon y pel vis is p ri m ari ly con cern ed w ith p elvi c an d p eri nea l st ru ctu res an d
f u ncti on s (C h apte r 3) or th ei r un io n wi th th e ver teb ra l co lu m n (Ch ap ter 4 ), it is descr ib ed m or e th or ou g hl y in tho se ch ap ter s.
A spe cts o f t he h ip bo ne s con cer ne d wit h low er li mb st ru ctu res an d fu n ction s, m ai nl y in vol vin g th eir l ater al aspect s, ar e d escri bed
i n th is chap ter .
I l iu m
T h e i lium com po ses th e lar gest p art of th e hi p bon e an d con tri bu tes the su per io r par t of th e ac etabu lu m (Fi g. 5 . 5B ). Th e ili um ha s
t hi ck m ed ial po rti on s (co lu mn s) for w eig h t b ear in g an d thi n, win g -like, post ero later al po rti on s, th e a lae (L. w in gs), tha t p ro vid e
b r oad su rf aces fo r the fl esh y att ach men t of m uscl es (Fi g. 5 . 3). T h e b od y o f the il ium joi ns the p ub is an d isch iu m to fo rm t he
a cetab ul um . A nt eri or ly, th e i liu m h as stou t a nteri or sup er ior an d anteri or i nf er io r ili ac sp ines th at pr ovid e attach m ent fo r
l ig am ent s an d ten do ns of l ower l im b m uscl es (Fi g. 5 . 6). B eg in ni ng a t th e ant eri or su per io r ili ac sp in e (A SI S), t he lon g cu rv ed an d
t hi cken ed sup er ior b or der of th e al a o f the il iu m, the il iac crest , exten ds po ster ior ly, ter m in ati ng at th e p o ster ior sup er io r ili ac
s pi ne (PS IS ). Th e crest ser ves a s a pr otect ive b u mp er a nd i s an i m por tan t site of ap on eur oti c at tach men t fo r thi n, shee tl ike m uscl es an d d eep fa scia. A p ro mi ne nce on t he exter n al lip of t he cre st, th e tub er cle o f the i liac cre st (i liac tu ber cle), lies
5 6 cm po steri or to th e A SI S. T h e p oste ri or inf er ior i lia c sp ine ma rks th e su pe rio r en d of th e g re ater scia tic no tch.

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Fig ure 5.5. Par ts of hip b ones. A. A n an ter op oster ior r ad iog ra ph o f an in fa nt' s h ip s sh ow s th e thr ee par ts of th e
in com pl etely ossi fie d hi p bon es (ili um , i schi um , an d p ub is). B . T he ri gh t hi p bon e of a 13 -yea r-ol d dem o nstr ati ng th e Y-sh ap ed
tri ra dia te ca rti lag e ext end in g th ro ug h th e a cetab ul um , u n itin g th e thr ee pr im ar y p ar ts of t he bo ne, an d the ossi fie d epi ph yses
alo ng th e ili ac cr est an d isch ial tu ber osi ty. Th ese bo ny pa rts fu se to f or m th e on e-par t ma tur e hi p bon e of th e a du lt bet ween
th e 1 6 th an d 1 8th year s.
T h e l ater al sur fa ce of t he ala of th e ili um ha s th re e r ou gh cu r ved li nes t he po ster ior , an ter ior , an d in fer io r gl uteal lines t ha t
d em ar cate the p ro xim al attach m en ts o f t he th ree la rg e g lu teal m u scles (glu tei ). Medi ally , each al a h as a l ar ge, sm oo th d epr essio n,
t he il iac f os sa (Fi g. 5 . 6B ), th at pr ovid es pr oxim al att achm en t for t he il iac mu scle (L . ili acus ). Th e b on e for m in g th e su per io r pa rt
o f th is f ossa m ay b ecom e th in an d tr an slu cent, especi all y in old er wo m en wi th osteo po ro sis. Po steri or ly, th e med ia l a spect of th e
i liu m h as a r ou g h, e ar-sh ap ed ar ticu lar a rea cal led th e auri cular sur face (L. au ri cul a, a littl e e ar) an d an even rou g he r ili ac
t ub er os it y
P. 5 6 2
s up eri or to it fo r syn ovial an d syn de smo tic art icu lati on wi th th e r eci pr ocal su rf aces of th e sacr u m at th e sacr oi liac jo in t (see
C h ap ter 4 ).

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Fig ure 5.6. Rig ht hip b o ne of a dult in a na tomi cal po sitio n. In thi s p osit ion , th e a nter io r sup er ior i lia c sp in e (A SI S) an d
th e an ter ior aspect of th e pu bi s l ie in th e sa me cor on al pl an e. A. Th e lar ge h ip bo ne is con str icted in the m id dl e an d exp an ded
at its su p eri or an d in fe ri or en ds. B . T he sym ph ysia l su r face of th e pu bi s ar ticu la tes w ith t he cor re spon d in g sur fa ce o f t he
con tra later al h ip b on e. Th e aur icu la r sur fa ce o f the il iu m ar ticu late s w ith a cor resp on d in g sur fa ce of th e sacr um to f or m th e
sacr oil iac join t.
I s ch iu m
T h e i schium f or ms th e p oster oi nf er ior p ar t o f t he h ip bo ne . Th e su p eri or p art of th e bo d y of the ischium fu ses w ith the pu b is
a nd i liu m , fo rm in g th e post ero in fer ior a spect of th e acetab ul u m. T h e r amus o f the is chium j oin s t he in fer io r ra mu s o f th e p ub is
t o f or m a bar of bo ne, the ischi op ubi c r amus (Fi g. 5 . 6A ), wh ich con stitu tes the in fe ro med ia l b ou n dar y o f the ob tu ra tor fo ra men .
T h e p oster io r bor d er of th e i schi u m fo rm s t he in fer io r m arg in o f a d eep in d ent atio n call ed the g re ater scia tic no tch. Th e l ar ge,
t ri angu lar i schial sp ine a t th e in fer ior ma rg in of th i s n otch p ro vid es l iga me nto us attach m en t. Th is sh arp d em ar catio n sep ara tes
t he gr eate r sciati c n otch f ro m a m ore in f eri or, sma ller , r ou nd ed , an d smo oth -su rf aced in d enta tion , th e lesser s ciatic notch. T he
l esser sci atic no tch s er ves a s a tro chl ea or pu ll ey f or a m uscl e t hat em er ges fr om t he bo ny pe lvis he re. T h e r ou gh bon y pr oje ction
a t th e ju nct ion o f the in fe ri or en d of th e b od y o f the isch iu m an d it s r am us is the la rg e i schial tube ro sity. T he b ody' s w eig ht
r ests on th is tu ber osi ty w he n sitti ng , an d it pr ovi des th e p ro xim al, t end in ou s a ttach me nt of p oster ior thi gh m u scles.
P u b is
T h e p ubi s f or m s th e a nte rom ed ial p ar t of t he h ip bo ne , con tri bu tin g th e a nte ri or pa rt of th e a cetab ul um , and p ro vid es p ro xim al
a ttach m ent fo r m uscl es o f the m edi al th igh . T he pu b is is d ivi ded i nto a fl atten ed b ody an d two r am i, su pe ri or an d in fer io r (Fig.
5 . 6 ). Th e r am i ar e str on g yet re lativ ely lig ht skel etal stru ts (br aces) th at m ai nta in th e arch com pose d of th e sacr u m an d th e
t wo ili a, b y w hi ch axia l w eig h t i s d ivid ed an d tr ansf er red l ater all y to th e l im bs wh en sta nd in g an d to th e isch i al tub er ositi es w he n
s ittin g (Fig . 5 .3 ). Med iall y, th e sym p h ysial su rf ace of th e b od y o f the p ubi s ar ticu la tes w ith t he cor re spon d in g sur fa ce o f t he bo dy
o f th e con tr ala tera l p u bi s b y m ean s o f the p ubi c symp hysis. T he an ter osu per io r bo rd er of th e un ited b od ies an d sym ph ysis for m s
t he p ub ic cr est, wh ich pr ovid es attach m en t f or ab do mi na l m u scles. S m all p roj ectio ns at the la tera l e nd s o f t hi s cr est, th e p ub ic
t ub er cles, are im p or tan t l andm ar ks of th e in gu in al r egi on s. Th e t ub er cles p r ovid e a ttach m ent fo r th e m ai n par t of th e i ng u in al
l ig am ent an d th er eby in di rect m uscl e a ttach me nt. Th e p oster io r ma rg in o f the sup eri or r amus of th e p ub is h as a sh arp rai sed
e dg e, th e p ecten pub is, w h ich f or ms pa rt of th e p elvi c b ri m (see Ch ap ter 3 ).
O bt u r at o r Fo r am en
T h e o btur ato r fo ra men i s a lar ge ova l o r ir reg u lar ly tri ang u lar a per tu re in th e hi p bo ne. It is b ou n ded b y t he pu b is a nd i schi um
a nd t hei r ra mi . Ex cept fo r a sm al l p assag ew ay f or th e obtu r ator n er ve and v essels (the ob tu ra tor can al), the ob tu rat or fo ram en is
c losed b y th e th in , stro ng o btu r ator m em b ran e (see C h ap ter 3 ). Th e pr esen ce o f t he fo ram en mi ni mi zes b on y ma ss (w eig ht) wh il e
i ts cl osu re by th e o btu r ator m em b ran e still p ro vid es ext ensi ve su r face ar ea on b oth si des for flesh y mu scl e att achm en t.

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A c e ta b u lu m
T h e ace tabu lu m (L . sh all ow vin eg ar cu p) is t he lar g e cu p-sh ap ed cavi ty o r socket on th e later al asp ect o f the h ip b on e th at
a rti cul ates wit h th e h ead of t he fem u r to fo rm the h ip jo in t (Fig . 5 .6A ). All th r ee p r im ary b on es f or mi ng th e hi p bo ne con tr ibu te to
t he fo rm ati on of t he acetab u lu m. Th e m ar g in of th e acetab u lu m is in com pl ete i nf er ior ly at the aceta bu lar n otch , w hi ch m akes the
f ossa r esem ble a cup w ith a p iece of it s li p mi ssin g. T h e r ou gh dep ressi on i n th e f loo r of th e ace tabu lu m e xten din g su pe rio rl y f ro m
t he aceta bu lar n otch is t he aceta bu lar f ossa. T h e ace tabu la r no tch an d fo ssa a lso crea te a d efici t i n th e sm oo th lu n ate sur fa ce of
t he aceta bu lu m, wh ich a rti cul ates with the h ead of th e fem u r. Th e ace tabu lu m i s d iscu ssed fu r th er in r elat ion to th e hi p joi nt.
T h e B o t to m L i n e
Fo rm ed b y th e un io n of th r ee p ri m ary bo ne s (il iu m , isch iu m, and pu bi s), th e h ip b on es a re joi ne d to t he sacr um post eri or ly a nd to
each ot her a nte rio rl y (at th e p u bi c sym ph ysi s) to fo rm the pe lvic gi rd le. E ach h ip b on e is sp ecia lized to r ecei ve h alf t he wei gh t of
the u pp er b ody wh en st and in g an d all of i t p er iod ical ly d u ri ng w alki ng . T hi ck p art s of th e bo ne tr ansf er w eig ht to th e f em ur . Th in
par ts of th e b on e p ro vid e a b roa d sur fa ce f or att achm en t of po wer fu l m uscl es th at m ove the f emu r . Th e pel vic g ir dl e e nci rcle s an d
pr otects pe lvic viscer a, p ar ticu lar ly th e r epr od u ctive or gan s.
A n at o m i cal P os it io n of th e H ip B on e
S u rf aces, b or der s, an d r elati on shi ps of th e h ip b on e are de scri bed assu m in g th at the bo dy is in th e ana tom ical p ositi on (see
I n tro du ctio n). To pl ace a n isol ated h ip b on e o r bo ny pel vis in th is po sitio n, s itu ate it so th at th e:
A SI S an d th e an ter osu pe rio r asp ect o f the p ub is lie in th e sam e ver ti cal pla ne.
S ym ph ysia l su r face of th e pu bi s i s ver tica l, pa ra llel to th e m ed ian pla ne (Fig . 5. 6 ).
I n th e ana tom ical p ositi on , th e:
l
l
l
A cetab u lu m fa ces i nf ero later al ly, w ith th e acetab ul ar n otch d ir ected i nf eri or ly.
Ob tu ra tor f ora me n lie s in f ero med ia l to th e acetab u lu m.
I n ter nal asp ect of th e b od y o f the pu b is faces alm ost d ire ctly sup er ior ly (it essen tiall y f or m s a flo or on wh ich th e ur in ar y
b la dd er re sts).
T h e su pe ri or pe lvic ap ertu r e (p elvi c in le t) is m or e ver ti cal tha n ho ri zon tal; in th e an tero po steri or (A P) vi ew, t he tip o f t he
c occyx a pp ear s n ear i ts cen ter (Fig . 5 . 3).
P. 5 6 3
I nj u r i e s o f t h e H i p B o n e ( P e lv i c I n j ur ie s )
Fr actu r es o f the h ip bo ne ar e co m mo nl y r efe rr ed to as p elv ic f ra ctur es (see cl in ical cor r elati on [b lu e] b ox Pelvi c Fr actu res,
in C ha pter 3). T h e ter m h ip f ra ctur e is m ost com m on ly ap pli ed (u nf or tun ate ly) t o f ra ctur es of th e f em or al hea d, n eck, o r
tro cha nter s.
Avul sio n fr actur es o f th e h ip b on e m ay occu r du r in g spo rts th at r eq ui re su dd en accel era tion o r de celer atio n fo rces, s uch a s
spr in tin g or ki ckin g in f ootb al l, soccer , h u rd le ju mp in g , bask etbal l, an d m ar tial ar ts (Fi g. B 5 .1 ). A sm all p ar t of b on e w ith a p iece
of a tend on o r lig am en t a ttach ed is avu lsed (to rn a way). T h ese f ra ctur es occu r at a po p hys es (b on y p ro jecti on s th at lack
secon da ry ossif icati on cen ter s). Av ul sion f ra ctur es occu r wh er e m u scles are att ache d: ant eri or su per io r an d in fer ior i lia c sp in es,
isch ial tu ber osi ties, a nd i schi opu b ic ram i.

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Fig ure B5. 1
Femu r
T h e femur is the lo ng est an d hea viest bo ne in th e bo dy. I t t ran sm its bo dy wei gh t f ro m th e h ip b on e to t he tib ia wh en a p erso n is
sta nd in g (Fig . 5. 4 ). I ts le ng th is ap pr oxim at ely a q ua rte r of th e p er son 's h eig h t. Th e fem u r con sists of a shaft (b od y) an d tw o
e nd s, su per ior or pr oxi m al and i nf er ior o r di stal (Fig. 5. 7 ). Th e sup er ior (p ro xim al) en d of th e f em ur co ns ists o f a h ead , n eck, an d
tw o tro cha nte rs (gr eater a nd l esser ). Th e r ou n d head o f the fem ur ma kes u p tw o th ir d s of a sp her e tha t is cover ed w ith ar tic ul ar
ca rti lag e, excep t f or a m edi all y p laced d ep ressi on or p it, the fo vea fo r the li ga ment o f the head . In ear ly l ife , th e li ga men t gi ves
p assag e t o a n ar tery su pp lyin g th e epi ph ysis of th e h ead . Th e neck o f the f emur is tra pezo id al, w ith i ts n ar ro w end su p por tin g
th e he ad an d its br oad er b ase b ein g con ti nu ou s w ith t he sh aft. I ts aver age di am eter i s th re e q ua rter s tha t of th e fem or al h ead .
T h e p ro xim al fem u r is ben t (L-sh ap ed) so tha t th e lon g axis of th e hea d an d neck pr oj ects s up ero m edi ally at an an g le t o
th at of th e obl iq uel y o ri ente d sha ft (Fi g. 5 . 7A & B). Th is obtu se ang le o f incli natio n is gr eate st (m ost ne arl y str ai gh t) a t b ir th
a nd g ra du all y d im in ish es (beco mes m or e acu te) u nti l t he ad ul t an g le is r each ed (1 1 5 1 4 0 , a vera gi ng 1 2 6 ) (Fig. 5. 7C E ).
T h e an g le i s l ess i n fem al es b ecau se o f the in cr eased w id th bet ween t he aceta bu la (a co nse qu en ce o f a w id er lesser p elvi s) a nd th e
g r eater ob li qu ity of th e s haf t. T he an gl e o f i ncl in atio n all ow s g reat er m obi lit y of th e fem u r at the h ip jo in t b ecau se it p lace s th e
h ead a nd n eck mo re p erp en dic ul ar to the acet abu lu m i n th e n eu tra l p osi tion . T he ab du ctor s an d r otat ors of th e thi gh a ttach m ain l y
to th e ape x of th e an gle (th e gr eater tr och an ter ) so th ey a re pu ll in g on a leve r (the sh or t l im b of th e L ) th at is m ore la tera lly th an
ve rti cally d ire cted. Th is p r ovid es i ncr ease d lever ag e f or th e a bd uct ors an d ro tator s of th e th ig h an d all ow s th e co nsi der ab le ma ss
o f the ab du ctor s of th e th ig h to be p laced su pe ri or to th e f em ur (i n th e g lu teal r egi on ) in stea d of late ral to it, fr eein g th e l ater al
a spect of th e fem or al sha ft to pr ovid e in crea sed ar ea f or f lesh y a ttach me nt of th e exten sor s of th e kne e. Th e an gle als o al low s th e
o bl iqu it y of th e fem u r wi thi n th e th ig h , wh ich p er m its t he kn ees to b e a dj acen t an d in f eri or to th e tr u nk, as exp lai ne d pr evio usl y.
A ll of th is is adva nta geo us fo r bip ed al wal kin g; ho weve r, i t i mp oses con sid era ble str ain o n th e n eck of th e f em ur . C on seq uen tly ,
f ra ctur es of th e f em or al neck can o ccur i n ol der p eop le as a r esu lt o f a sl ig ht stu mb le if th e neck h as b een w eaken ed b y
o steop or osis.
T h e to rsio n of th e pr oxim al l ower l im b (fe mu r ) th at occu rr ed d ur in g de velop m en t d oes no t con cl ud e w ith t he lon g axi s o f t he
su p eri or en d of th e fem u r (he ad an d neck ) p ara llel to th e t ran sver se a xis of th e i nf eri or en d (fe mo ral co nd yles). Wh en t he fem u r is
vi ewe d sup eri or ly (so th at on e is l ooki ng a lon g th e l on g axis of th e sh af t), it is app ar en t th at th e tw o axes l ie at a n an gl e (th e
to r sion angl e, or a ngl e o f d ecl inatio n), th e m ean of wh ich is 7 i n m ales an d 12 i n fem al es. Th e tor sion ang le, com bi ned
w ith t he an gl e o f i ncl in atio n, allo ws ro tator y m o vem ents of th e fem or al h ead wi th in th e o bl iqu el y p laced a cetab ul um t o co nve rt in to
f lexi on an d
P. 5 6 4
P. 5 6 5
e xten sion , ab du ctio n an d add u ction , an d r otat ion al m ovem en ts o f the th ig h.

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Fig ure 5.7. Rig ht f emur . A and B. T h e b on y f eatu re s of a n adu lt f emu r ar e sho wn . Fun cti on ally an d m or ph olo gi cally, the
bo ne con sists of h ig hl y m od if ied su per io r an d in fer ior end s a nd a n in ter veni ng cy lin dr ica l sh af t. Th e nu tr ien t for am en (B ) i s
dem o nstr ated en ter in g th e f em or al sha ft ne ar th e l in ea a sper a. AE . Th e f em ur is b en t so th at the lo ng a xis o f the
he ad an d ne ck li es a t an a ng le (an gl e o f i ncl in atio n) to th at o f the sh aft . When the m assive f emo ra l co nd yles r est o n a
ho ri zon tal su rf ace, th e f em u r assu mes its ob liq u e an ato mi cal po sitio n in w h ich th e ce nte r of th e r ou n d fem or al h ead li es
di rectl y su p eri or to th e i nte rcon d ylar f ossa. C E. T he an gl e o f in clin ati on d ecrea ses (b ecom es mo re acu te) with age,
resu lt in g in g rea ter str ess at a tim e wh en b on e m ass is r ed uce d. Wh en th e fem u r is view ed alo ng th e lon g axi s of th e fem or al
sha ft, so th at th e p ro xim al en d is su p eri mp osed o ver th e d ista l e nd (F), i t can be seen th at th e axi s o f the h ead an d n eck o f
th e f em ur f or ms a 12 a ng le wit h th e tr an sver se axi s o f the fe mo ral co nd yles (an gl e of t orsi on ).
W her e the n eck j oin s t he fem o ral sh af t ar e two lar g e, bl un t eleva tion s ca lled t roch an ter s (Fig . 5 . 7A , B, & F). Th e abr u pt, con ical
a nd r ou n ded l esser tr ocha nte r (G. a r u nn er ) ext end s m ed ial ly fr om th e post ero me dia l p ar t o f the ju n ction of th e n eck an d shaf t
t o g ive ten di no us attac hm en t to th e pr im ar y f lexo r of th e th ig h (th e ilio pso as). Th e gr eate r tro chanter is a lar ge, later all y p lace d
b on y ma ss th at pr oje cts su pe rio rl y an d p oster ior ly wh er e t he n eck j oin s th e fem or al sh aft , pr ovi din g att achm en t and lever ag e f or
a bd uct ors an d ro tato rs of th e th ig h . Th e si te wh ere th e n eck an d sha ft joi n is in dica ted by th e i ntert ro chanter ic l ine, a
r ou g hen ed r id ge fo rm ed b y th e attach m en t o f a p owe rf ul li ga men t (ili ofe mo ral l iga me nt), tha t r un s fr om th e gr eater tr och an ter a nd
w in d s ar ou nd the lesse r tro cha nter to co nt in ue po ster ior ly and in fer ior ly as a le ss d istin ct ri dg e, th e sp ir al li ne. A sim ila r bu t
s mo oth er an d m or e p ro mi nen t ri dg e, th e i ntert ro chanter ic cr est, j oin s t he tr och ant ers po steri or ly. T he r ou nd ed ele vatio n on th e
c rest is the q uad rate tub ercl e. In an teri or an d po ster ior vi ews (Fig. 5. 7A & B ), th e g re ater tr och an ter is in l in e w ith th e fem or al
s haf t. I n po steri or an d su per io r view s (Fig . 5 .7B & F), it over ha ng s a de ep dep r ession med ia lly, th e tro chanter ic f o ssa.
T h e shaf t o f the f emur is slig h tly bow ed (con vex) an teri or ly. T hi s con vexi ty m ay in cr ease ma rked ly, p r oceed in g later al ly a s w ell
a s an ter io rly , if th e sh af t i s w eaken ed by a loss of cal ciu m, as o ccur s i n ri ckets. Most of th e shaf t is sm oo th ly r ou n ded , p rov idi ng
f lesh y or igi n to exten sor s o f the kn ee, excep t post eri or ly w h ere a br oad , ro ug h l in e, th e l inea a spe ra, pr ovid es apo neu r otic
a ttach m ent fo r ad du ctor s o f the th ig h. T h is ve rti cal ri dg e i s esp ecial ly pr om in en t i n th e m id dl e th ir d of th e fem or al sh aft, wh ere it
h as med ial an d la tera l l ip s (m ar gi ns). Su per io rly , the la tera l l ip b len ds wi th th e b ro ad, ro ug h g luteal tube ro sity, a nd th e me dia l
l ip con ti nu es as a n arr ow , r ou gh sp ir al lin e. T he sp ir al lin e e xten ds towa rd th e lesser tr och an ter b u t th en p asses to t he an ter ior
s ur face of th e fem u r, wh ere it is con tin u ou s w ith th e in tertr och an ter ic lin e. A p ro mi ne nt in ter me dia te r id ge, the p ectineal li ne,
e xten ds fr om th e cen tral p ar t of t he lin ea asp era to th e b ase of th e l esser tr och an ter . In fer io rl y, th e l in ea a sper a divi des in to
m ed ial an d l ater al supr aco nd yla r lines, wh ich l ead to th e sp ir all y cu rve d me dia l a nd l ater al con dyl es (Fig . 5 .7B ).
T h e med ia l a nd l ater al femo r al co nd yles ma ke u p n ear ly t he en tir e i nf er ior (d istal ) en d of th e fem u r. Th e tw o con dyl es ar e on
t he sam e ho rizo nt al level w hen the bo ne is in i ts an ato m ical po sitio n, so th at if an isol ated fe mu r is p laced u pr ig h t w ith b oth
c on dyle s con tacti ng the fl oor o r tab letop , th e fem or al sh aft wi ll assu me th e sa me ob li qu e p osi tion i t o ccup ies in th e livi ng b od y
( abo ut 9 fr om v erti cal in m ale s an d sli gh tly gr eate r in f em ales). T he f emo ra l co nd yles ar ticu late w ith m en isci (cr escent ic p lat es
o f car tila ge) an d tib ial con dyl es t o f or m th e kn ee joi n t (Fig . 5 .4 ). T he m en isci an d tib ial con dyl es g li de as a u ni t a cross th e i nf er ior

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a nd p oster io r asp ects o f the fe mo ral co nd yles du r in g fle xion a nd ex tensi on . Th e con vexity of th e arti cul ar su rf ace of th e co nd yles
i n crease s as it descen d s th e an teri or su rf ace, co veri ng t he in fer io r en d, an d th en asce nd s p oster io rl y. Th e con dyle s ar e se par ated
p oste ri orl y an d i nf eri or ly b y an inter co nd yla r fo ssa (in terco nd yla r no tch) bu t me rg e a nter io rl y, fo rm in g a sha llo w l on gi tud in al
d ep ressi on , th e p atel lar sur fa ce (Fig . 5 . 7), w h ich ar ticu la tes w ith th e pat ella . Th e l ater al sur f ace o f the la tera l co nd yle h as a
c entr al p roj ectio n call ed th e l ater al epi con dyl e. Th e med ia l su r face of th e med ia l co nd yle h as a lar g er an d mo re p rom i nen t me dia l
e pico nd yle, sup er ior to w hi ch an oth er el evatio n, t he ad ducto r tub ercl e, fo rm s in r elati on to a ten do n attach m en t. Th e
e pico nd yle s p rov ide p rox im al attach m en t f or th e co lla tera l l ig am ents of th e kne e jo in t.
Th ro ug h evo lu tion a nd d evel opm en t, o ur l arg est bo ne, the fe mu r , ha s d evelo ped a b end (a ng le of in cli na tion ) a nd h as twi sted
(me dia l r ota tion and t orsi on so th at the kn ee a nd a ll joi nt s in fe ri or to it fle x p oster ior ly) to accom m od ate ou r ere ct p ostu re an d to
ena bl e b ip edal w alki ng an d r un n in g. Th e an g le of in cli nat ion a nd at tach men t of th e a bd uct ors an d ro tator s to th e gr eate r
tro cha nter allo w in crea sed lever ag e, su per io r pl acem ent of th e abd u ctor s, an d ob liq ue or ien tat ion o f the fe mu r in the th ig h.
Co mb in ed w ith th e tor sion a ng le, o bl iqu e ro tator y m o vem ents at th e h ip j oin t a re con ver ted in to m ovem en ts o f flex ion exten sio n
an d abd u ction ad du ctio n (in th e sagi ttal an d cor on al pl an es, re specti vely) as w ell as of r otati on .
P. 5 6 6
C oxa Vara an d C ox a V alga
Th e a ng le of in cli na tion b etw een th e l on g axis of th e fem or al n eck an d th e fem or al sh aft (Fig. 5. 7C E ) vari es w ith a ge, se x, an d
devel op me nt of th e f em u r (e.g . , a co ng en ital d efe ct in the ossi fica tion of th e f em ora l n eck). It ma y al so ch an g e w ith an y
path ol og ical pr oce ss th at weake ns th e n eck of th e f em ur (e .g ., rick ets). Wh en th e a ng le of in cli nat ion i s d ecre ased, the con d itio n
is co xa var a (Fig . B 5. 2A); wh en it is in cre ased, it i s co xa va lg a (Fi g. B 5. 2B). C oxa var a cau ses a m ild sh or ten in g of th e low er
lim b an d li mi ts p assive ab du ctio n of th e hi p.
D i s l o c a te d ( Sl i p p e d ) E p i p h y si s o f th e Fe m o r a l H e a d
In o lde r chi ld ren a nd a dol escen ts (1 0 1 7 year s o f a ge), t he ep iph ysis of th e fem or al h ead m ay slip aw ay fr om th e fem or al n eck
beca use of a wea kene d epi ph ysial p late . Th is in ju ry m ay b e ca use d by acu te tr au m a o r rep eti tive mi cro tra um as th at p lace
in crea sed she ari ng st ress on th e epi ph ysis, e speci ally wi th ab du ctio n an d late ral r otati on o f t he th ig h. T he ep ip hysi s o ften
disl ocate s (sli ps) slow ly an d resu lts in a p ro gr essive coxa var a. T he com m on i ni tial sym pto m of th e in ju ry is hi p di scom for t tha t
ma y b e r ef err ed to th e kn ee. R ad iog r aph ic exam in ati on of th e sup er ior e nd o f the fe mu r is u sual ly req u ir ed to con fir m a di ag no sis
of a disl ocated epip h ysis of th e h ead o f the fe mu r .
Fig ure B5. 2.
Fe m o r a l Fr a ct u r e s
De spite it s la rg e si ze an d str en gth , th e fem u r is com mo nl y f ra ctur ed . Th e type of f ract ur e su stai ne d is f re qu en tly age- an d even
sex-re lated . Th e ne ck of th e fem u r is m ost f re qu en tly fr actu red b ecau se it is th e na rr ow est a nd w eakest pa rt of th e b on e and it
lies at a m ar ked an g le to th e lin e of we igh t bea ri ng (p ul l of gr avi ty). It be com es i ncr easi ng ly vul n erab le wi th ag e, esp ecial ly in
fem al es, secon da ry to osteo por osi s. Fract ur es o f the p ro xim al fem u r occu r at sever al loca tion s; t wo exam p les a re tr ans-c ervi cal
(mi dd le of n eck) a nd i nte rtr och an ter ic (Fi g. B 5. 3 ). Th ese fr actu r es u su ally occu r as a r esu lt of in di re ct tr au m a (stu m bl in g or
stepp in g d own h ar d, as o ff a cur b or st ep). B ecau se o f th e an g le o f in clin ati on , th ese f ra ctur es are in h er entl y u n stab le a nd
imp actio n (ov err id in g of fr ag m ent s r esul tin g in f or esh or teni ng o f th e li m b) occu rs. Mu scle spa sm also con tr ib ut es to th e
sho rten in g of t he lim b . In tr acap su lar f ractu r es (o ccur r in g wit hi n th e h ip j oin t ca psu le), a re com p licate d by deg en era tion of th e
fem or al h ead ow in g to vascu lar tr au m a (see cli ni cal cor rel atio n [bl ue] bo xes Fr actu res of th e Fe mo ral N eck ( H ip
Fr actu r es ) an d Su r gi cal Hip R ep lacem en t, b oth l ater i n th is ch ap ter ).
Fr actu r e o f t he gr eate r tro cha nte r an d fem or al sh aft usu al ly resu lt fr om dir ect tra um a (di rect b low s su stain ed b y th e bo ne
resu lti ng fr om f alls or b ein g h it) an d are m ost com mo n d ur in g th e m or e active year s. Th ey fr eq uen tly occu r d ur in g m otor vehi cle
accid en ts an d sp ort s su ch as skiin g an d cli mb in g . In so me cases, a sp ir al fr actu re of th e fem or al sh aft occu rs, resu lti ng i n
for esh or ten in g as th e fr ag me nts over r ide, or th e f ra ctur e ma y b e co mm i nu ted (b ro ken in to sever al pi eces), w ith th e fr agm en ts
disp la ced in var io us di rect ion s a s a resu lt of m u scle pu ll an d d epen d in g on th e l evel of th e fr actu re. Uni on of t hi s ser iou s type of
fr actu re m ay t ake u p to a year .
Fr actu r es o f the di stal fem u r m ay be com pl icated b y separ ati on of th e con dyl es, r esul tin g in m isa lig n men t of th e a rti cul ar su rf aces
of th e kn ee joi nt , or b y h em or rh ag e f ro m th e l arg e pop li teal ar ter y th at ru n s d ir ectly on th e sur fa ce of th e bo ne, wh ich
com pr om ises th e b loo d sup p ly t o th e leg (an occu rr en ce th at sho ul d alw ays be con sid ered i n kn ee f r actu res d islo catio ns).

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Fig ure B5. 3
T ib ia a n d F ib u la
T h e ti bia an d fi bu la ar e t he bo nes of th e leg (Fig s. 5 .4 and 5 . 8 ). Th e t ibi a a rti cul ates with the con d yles of th e f em ur su p eri or ly a nd
th e talu s in fer ior ly an d in so d oin g tr an smi ts th e bod y's wei gh t. T he fi bu la m ain ly fu n ction s as an attach m en t f or m us cles, b ut it is
a lso im po rta nt fo r the stab il ity of th e an kle jo in t. Th e sha fts (bo die s) of th e tib ia an d fib u la are con n ected b y a de nse in ter osseou s
m em b ran e com po sed of str on g ob liq u e f ibe rs.
T ib i a
L ocat ed on th e ant ero me dia l si de of th e l eg, nea rl y p ara llel to th e fib u la, th e tib ia (shi n bo ne ) is th e seco nd l arg est bo ne in th e
b od y. It f lar es o utw ar d at b oth end s t o p ro vid e an in crea sed ar ea f or ar ticu la tion and w eig h t tr an sfer . T he su per ior
P. 5 6 7
(p r oxim al ) en d wi den s t o f or m med ial an d l ater al co nd yles tha t ov erh an g th e sh af t m ed ial ly, la tera lly, a nd p oster io rl y, fo rm in g a
r ela tivel y f lat supe ri or ar ticula r surf ace, o r tib ial p latea u. Th is pla teau co nsi sts of t wo sm ooth a rti cul ar su rf aces (the m edi al
o ne sli gh tly con cave an d the la tera l o ne sli gh tly con vex) tha t ar ticu la te w ith t he lar ge con d yles of th e f em ur . T he ar ticu lar su r face s
a re sepa rat ed by an i nte rco ndyl ar eminence fo rm ed b y tw o inter cond ylar tub er cles (m edi al an d later al) fl an ked by r elati vely
r ou g h anterior and p o ster ior i nterc ond ylar ar eas. Th e tu b ercl es f it in to the in ter con dyl ar fo ssa b etw een th e fem or al con dyl es
(Fi g. 5 . 7B ). Th e in ter con dyla r tu ber cles an d are as p ro vid e at tach me nt fo r the m en isci an d pr in cip al lig am en ts o f the kn ee, w hi ch
h ol d th e f emu r an d ti bia to geth er , m ain tai ni ng co nta ct b etwe en th eir ar ticu la r sur fa ces. Th e an tero later al asp ect of th e l ater al
ti bi al con dyl e b ear s an antero la tera l ti bi al t ub er cle (Gerd y tub er cle) in fer ior t o th e ar ticu lar su r face (Fig . 5. 8 ), wh ich pr ovid es
th e di stal attach m en t f or a den se th icken in g of th e f ascia cov eri ng th e later al th ig h, add in g stab ili ty to th e kne e jo in t. Th e late ral
co nd yle also b ear s a fi bul ar ar ticula r facet po ster olat era lly on it s in f eri or asp ect f or th e he ad of th e f ib ul a.
Fig ur e 5. 8. Rig ht tib ia and f ib ula. T ib iof ibu la r syn desm oses, in clu din g th e den se in tero sseou s m em b ran e, ti gh tly con n ect
the tib ia an d fi bu la. Th e i nte rosse ou s m em br an e p r ovid es a dd itio na l su r face ar ea for mu scu lar a ttach me nt. T h e an ter io r tib ial

08-May-15
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vessels tr aver se th e ope ni ng i n th e m em br an e to e nte r the an ter ior co m par tm en t of t he leg (Fig . 5 .1 0 ).
U nl ike tha t o f the fe mu r , th e shaf t o f the tib ia is tr ul y ver tica l w ith in t he leg a nd so mew h at tr ia ng u lar in cro ss secti on , ha vin g
t hr ee sur fa ces an d b or der s: m ed ial , late ral /in ter osseou s, an d p oster ior . T he anter io r bo rd er o f the tib ia is th e m ost pr om in en t
b or de r; it and the ad jacen t an teri or su rf ace are su bcu tan eou s thr ou g ho ut th eir le ng th s an d ar e co m mo nl y kn ow n as the sh in
o r shi n bo ne ; th eir per iost eal cover in g an d over lyi ng ski n is vul ne rab le to br u isin g. At the su per io r end o f th e an ter ior
b or de r, a b roa d, o bl ong tib ial tube ro sity pr ovid es dist al attach m ent f or th e p atel lar l iga men t, w h ich str etch es b etw een th e
i n fer ior m ar g in of th e pat ella an d th e ti bi al tub er osity. Th e ti bi al sha ft is th in n est at th e ju n ction o f its mi dd le an d dist al thi rd s.
T h e d istal en d of th e tib ia is sm al ler th an t he pr oxi m al e nd , fl ar in g on ly m ed ial ly; the m ed ial exp ansi on ext end s i nf er ior to th e rest
o f th e sh af t as th e med ia l ma lleo lus. T he in f eri or su rf ace of th e sh af t an d th e l ater al su rf ace o f the m ed ial m alle olu s a rti cul ate
w ith the tal us an d are cove red w ith a rti cul ar car til age (Fig . 5. 4 ). Th e inter osse ous b o rd er o f t he tib ia is sha rp w her e it give s
a ttach m ent to th e i nte rosse ou s m em br an e t hat u ni tes t he two l eg bo nes. I n fer io rly, the sh ar p bor d er is rep laced b y a g ro ove, th e
f ib ular no tch, th at
P. 5 6 8
a ccom m oda tes a nd p ro vid es f ib ro us attach m en t to th e d ista l e nd o f the fi bu la.
O n the p oster ior su r face of th e pr oxi ma l p ar t o f t he tib ial sh af t is a ro ug h di ag on al rid g e, call ed th e so leal li ne, wh ich ru n s
i n fer om edi all y to th e m ed ial b or der ; i t i s f or med i n r elati on shi p to the ap on eur ot ic o ri gin of th e so leu s m u scle app ro xim atel y o ne
t hi rd o f t he wa y d own the sh aft. Im m edi ately d istal to th e so leal li ne is an ob li qu ely di rect ed vascu lar g ro ove, w h ich lea ds to a
l ar ge nutri ent fo r amen. Fro m it, the n utr ie nt can al ru n s in f eri or ly i n th e ti bi a b efo re it op en s in to th e m ed ul lar y (m ar r ow) cavi ty.
F i b u la
T h e sl end er f ib ula lies po ster olate ral to th e t ibi a a nd i s f ir ml y at tach ed to it b y the tib io fib u lar syn de smo sis, w hi ch in clu des th e
i n tero sseou s m em b ran e (Fi g. 5 . 8 ). Un like th e co mp ar abl e b on es of th e f or ear m (ra diu s an d ul na), wh ich ar e joi ned t o en ab le
m o bil ity (pr on ati on and su pin ati on ), th e l eg is fixe d in a per m an en tly p r on ated p ositi on th at pl aces t he gr eat toe m edi all y an d
d ir ects the sol e o f the fo ot in fer ior ly, towa rd th e gr ou n d. T he fi bu la h as n o fu n ction in w eig ht bea ri ng ; i t ser ves ma in ly for m u scle
a ttach m ent , pr ovi din g d istal atta chm en t (in serti on ) f or on e mu scle an d p rox im al attach m en t (or ig in ) f or ei gh t mu scles. Th e f ib ers
o f th e ti bio fi bu lar syn d esm osis ar e ar r ang ed to r esist the r esul tin g n et d ow nw ar d pu ll on t he fi bu la.
T h e d istal en d en lar g es an d is pr ol on ged l ater all y an d in fe ri orl y as th e l ater al mall eol us . Th e m al leol i for m th e ou ter wa lls of a
r ecta ng ul ar socke t (m or tise), wh ich i s th e su p eri or com p on en t of t he an kle joi nt (Fig . 5 .4A), a nd p r ovid e a ttach me nt fo r th e
l ig am ent s th at stab iliz e th e joi nt. T h e l ater al ma lleo lu s is m or e p ro mi ne nt an d po steri or th an th e m edi al ma lleo lu s an d exten d s
a pp ro xim atel y 1 cm mo re di stall y. Th e pr oxi ma l en d of t he fi bu la con sists of an e nl arg ed head a nd sm al ler neck ; th e hea d ha s a
p oi nte d ap ex f or m ed in r elat ion sh ip to a t end in ou s a ttach m ent. Th e h ead a rti cul ates with the fi bu la r facet on t he po ster olat eral ,
i n fer ior a spect of th e later al tib ial con d yle. T h e shaf t o f the fi bu la is twi sted an d m ark ed by th e si tes o f mu scu lar at tach me nts.
L ike th e sh af t o f the tib ia , it is tr ia ng u lar in cro ss secti on , ha vin g th ree bo rd er s (an ter ior , in ter osseo us, and poste ri or) an d th ree
s ur face s (m ed ial, post eri or, and later al).
Our se con d lar gest bo ne , th e ti bia , is a ver tica l co lu m n bea ri ng th e wei gh t o f all su per io r to it. T he slen de r fib u la do es n ot bea r
wei gh t b u t, alo ng w ith t he in ter osseou s me mb ra ne th at bin d s it to th e ti bi a, is accessor y to t he tib ia in p ro vid in g an ad di tion al
sur fa ce ar ea fo r fle shy m uscl e at tach me nt an d in f or mi ng th e socket of th e ankl e j oin t. T hr ou g h evol uti on an d d evelo pm en t, th e
two b on es h ave beco me p erm an en tly pr on ated t o a ccom mo dat e b ip edal ism .
P. 5 6 9
T i b i a l F r a c t ur e s
Th e ti bi al sha ft is n ar ro west at th e j un ctio n of it s m id dle an d in fe ri or th ir ds, w hi ch is th e m ost fr eq uen t site of fr actu r e.
Unf or tu na tely, th is ar ea of th e b on e a lso ha s th e p oo rest bl ood su p ply . Becau se its an teri or su rf ace is sub cut ane ou s, th e ti bia l
sha ft is th e m ost co m mo n site fo r a co mp ou n d fr actu re (Fig . B5 . 4A ). C om po un d tib ia l f ra ctur es ma y al so r esu lt fr om d ir ect tra um a
(e.g . , a b u mp er f ractu r e ca use d wh en a car b um p er stri kes t he leg ). Fra ctur e of th e ti bi a th r ou gh th e nu tr ien t cana l
pr edi spo ses th e pati en t to n on -un io n of th e bon e fr ag men ts res ul tin g fr om d am ag e to th e n u tr ien t ar ter y.
Tr an sverse str ess (march ) f ract ur es o f the in f eri or th ir d of th e ti bi a (Fig . B 5. 4B) ar e com m on i n pe opl e w h o ta ke l on g hi kes b efo re
the y ar e con diti on ed fo r th is a ctivit y. Th e st rai n m ay f ra ctur e the an ter ior cort ex o f t he tib ia. I n di rect vio len ce a pp lied t o th e tib ial
sha ft wh en th e b on e tur n s w ith th e foo t f ixed d u rin g a fa ll ma y p ro du ce a f ract ur e (e .g ., wh en a per son i s ta ckled in foo tba ll). I n
add iti on , sever e to rsi on d ur in g skii ng m ay pr od u ce a di ago na l f r actu re (Fig. B5 .4C ) o f the tib ial sh af t at th e j un cti on of th e m idd le
an d in fer ior t hi rd s as wel l as a fr actu r e o f t he fi bu la. Di ago na l f ra ctur es are of ten asso ciate d with lim b sh or ten in g cau sed by
over ri di ng o f t he fr actu r ed en ds. Fr equ en tly du r in g skiin g , a f ra ctur e resu lt s f rom a h ig h -speed f or war d f all, wh ich an g les the leg
over th e ri gid ski b oot , pr od uci ng a bo ot-to p fr actu re (Fig . B5 . 4D ).
Becau se of its exten sive su bcu tan eou s locat ion , th e a nte rio r tib ia is accessib le fo r obt ain in g pi eces o f bo ne fo r gr aft in g in ch ild r en;
it is a lso used a s a site fo r in tra me du lla ry in fu sio n in d eh ydr ated /sh ocked ch ild r en.
Fr a ct u r e s I n v o l v in g t h e E p i p h y s i a l P l a te s
Th e p ri m ary ossi fica tion c ente r for t he su per ior end o f the tib ia ap pea rs sho rtl y a fter b ir th an d jo in s th e s haf t o f the ti bia d ur in g
ado lescen ce (usu al ly a t 1 6 18 year s of a ge). T ib ial fr actu r es i n chi ld ren are m or e ser io us if th ey i n volve th e ep ip h ysial pl ates
beca use con tin u ed no rm al g ro wth o f the b on e m ay be jeo par di zed . Th e t ibi al tu ber osit y u sua lly fo rm s b y in fer ior b on e gr ow th fr om
the su per io r epi ph ysia l cen ter a t ap p rox im ately 1 0 year s o f age, bu t a sep ar ate c ente r for t he tib ial tu b ero sity ma y ap pea r at
app r oxim atel y 1 2 yea rs of ag e. Disr up tio n of th e e pip h ysial p late at the tib ia l tu b ero sity ma y cau se in fl am ma tion o f the tu be rosi ty
an d chr on ic recu r ri ng p ain du ri ng a dol escen ce (Osg o od -Schlatt er di sease), especi all y in you ng a thl etes.
Fi b ul a r F r a c tu r e s
Fi bu lar fr actu res com m on ly occu r 2 6 cm pr oxi m al to t he di stal en d of th e l ater al ma lleo lu s an d ar e ofte n associ ated w ith
fr actu re d isl ocati on s of th e an kle join t, w h ich ar e co m bin ed w ith ti bi al fr actu res (Fig . B5 . 4F). Wh en a p erso n slip s a nd th e fo ot
is f or ced in to an exce ssively in ver ted p ositi on , th e an kle li gam en ts tear , fo rci bly til tin g th e ta lu s ag ain st the lat era l m al leol us an d

08-May-15
Page 14 of 155
s hea rin g it of f (Fig. B5 .4G). Fr actu res of th e l ater al an d m edia l m al leo li are r elati vely com m on in soccer an d b asketb all p layer s.
Fi bu lar f r actu res can b e p ain f ul ow in g to di sru pte d mu scle atta chm en ts; wal kin g is c om pr om ised b ecau se o f th e b on e's rol e i n
a nkl e st abi lity.
Fig ure B5. 4
B on e Graft s
I f a par t of a m aj or b on e i s d estr oyed b y in j ur y o r di sease, th e lim b b ecom es u sel ess. R epl acem ent of th e aff ected seg m en t b y a
b on e tra nsp lan t ma y avo id am p uta tion . T he fi bu la is a co mm o n sou rce of b on e f or g ra ftin g . Ev en af ter a segm en t o f sha ft has b een
r em ove d, w alki ng , r un n in g, a nd j um p in g can b e n or m al. Fr ee va scul ari zed fi bu la s h ave been used t o r estor e skeleta l i nt egr ity to
u p per a nd l owe r lim b s in wh ich co ng en ital b on e d efec ts exi st an d to r epl ace se gm en ts o f bon e afte r tra um a or exci sion o f a
m al ig na nt tu mo r (Fig. B5 .5 ). T he r em ain in g pa rts of th e f ib ul a u su all y d o no t r ege ner ate be cause th e p er ioste um and n u tr ien t
a rte ry are g ene ral ly rem ove d wit h the p iece of bo ne so th at t he gr af t w ill r em ain a live an d gr ow w hen tra nsp lan ted to an oth er si te.
S ecu re d in its n ew site, th e fi bu lar se gm en t r estor es the b loo d sup pl y of t he bo ne to wh ich it i s n ow att ache d. H eali ng p r oceed s as
i f a f r actu re ha d occu rr ed at each o f its e nd s.
A wa ren ess of th e l ocati on of th e nu tr ien t for am en i n the f ibu la is im p ort ant w hen p er fo rm in g fr ee vascu lar ized f ib ul ar tr an sfer s.
B ecau se the n ut rie nt fo ram en is l ocated i n th e m id dl e t hi rd of th e fi bu la in m ost cases, t hi s seg m ent of th e bon e is used f or
t ran sp lan tin g wh en t he gr af t m u st i ncl ud e a b loo d sup pl y to th e ma rr ow cavi ty as we ll as to th e com pa ct b on e o f t he su rf ace ( via
t he pe rio steu m ).

08-May-15
Page 15 of 155
Fig ure B5. 5
P. 5 7 0
B on e s o f t h e F o ot
T h e b on es o f the fo ot in clu de th e tar su s, m etatar su s, an d phal ang es. T he re ar e 7 ta rsal b on es, 5 m etat arsa l b on es, an d 1 4
p h alan g es (Fig s. 5 .1 , 5 . 4, and 5 . 9 ). Alt ho ug h kn owl edg e of th e ch ar acter isti cs of i nd ivi du al bo nes is ne cessar y f or an
u n der stan d in g of th e str u ctur e of th e f oot , it is i mp or tan t t o stu d y th e skeleto n of th e foo t as a wh ole an d to id ent ify its pr in cip al
b on y l an dm ar ks i n th e l ivin g fo ot (see S ur fa ce A na tom y o f the B on es of th e Foot, later i n th is c hap ter ).
T ar su s
T h e tar sus (post eri or or p ro xim al fo ot; hi nd fo ot) con sists o f seven b on es (Fi g. 5 . 9A & B): talu s, cal can eu s, cub oi d, n avicu la r, a nd
th r ee cun eif or m s. Onl y o ne bo ne, the tal us, a rti cul ates wit h th e le g bon es.
T h e tal us (L . an kle, a nkl e b on e) h as a b od y, n eck, an d h ead (Fig . 5 .9C ). The sup er ior su r face, o r tr ochlea of the talus, i s
g r ipp ed b y th e two m all eoli (Fig . 5 .4 ) and r ecei ves th e wei gh t o f the b ody fr om the tib ia . It tra nsm it s th at wei gh t i n tu rn , d ivid in g
i t b etw een th e ca lcan eu s, on w hi ch th e ta lar b od y r ests, a nd th e for ef oot, via an osseo lig am en tou s h am m ock' tha t r eceiv es
th e ro un d ed an d an tero me dia lly di rect ed tala r he ad. Th e h am m ock (spr in g lig am en t) i s su spe nd ed acr oss a g ap b etwee n the tal ar
sh el f (a b rac ket-lik e la ter al pr oject ion o f the cal cane us) an d the n avicu la r bon e, w h ich li es a nte rio rl y (Fig . 5 .9B & D). T h e ta lu s is
th e on ly tar sal bon e tha t h as no m u scul ar or te nd in ou s at tach men ts. Mo st of i ts su r face is cover ed wi th ar ticu la r cart ilag e. T he
ta lar b od y b ear s th e tro chl ea su p eri or ly a nd n ar ro ws in to a p os teri or p r ocess th at featu r es a g ro ove fo r the tend on of the
f lex or hal lucis long us (Fi g. 5 . 9D ), f lan ked b y a pr om in en t l ater al tuber cle an d a less pr om in en t me di al tub er cle (Fig . 5. 9A).
T h e cal caneus (h eel b on e) i s th e lar gest an d str on gest bo ne in t he fo ot (Fi g. 5 . 9). When stan din g , th e cal can eus tr an smi ts th e
m aj or ity of th e b od y's w eig h t f ro m th e ta lu s to th e g ro un d . Th e ant eri or tw o th ir d s of th e calcan eu s's sup er ior su r face ar ticu lat es
w ith t he talu s an d its a nte ri or su rf ace a rti cul ates wit h th e cu bo id . Th e l ater al sur f ace o f the cal cane us ha s an obl iq ue ri dg e (Fi g.
5 . 9C ), th e fi bula r tro chlea, tha t an ch or s a ten do n pu ll ey f or th e ever tor s of th e foo t (m u scles th at m ov e th e sole of th e f oot aw ay
f ro m th e m ed ian pla ne). On th e m ed ial sid e, th e t alar shel f (L. su sten tacu lu m ta li), t he sh elf-l ike sup p ort of th e talu s, p ro jects
f ro m th e su p eri or b or der o f the m edi al sur fa ce o f the calca ne us an d par tici pat es in sup po rti ng t he tal ar he ad (Fig . 5. 9 B & D ). T he
p oster io r pa rt of th e ca lcan eu s h as a m assiv e, wei gh t-b ear in g pr om in en ce, th e ca lcaneal tub ero sity (L. tub er cal can ei), w hi ch
h as med ial , later al , an d anter ior tub er cles. Onl y th e m ed ial tu b ercl e co nta cts th e gr ou nd d u ri ng sta nd in g.
T h e navic ul ar (L . lit tle shi p) is a f latten ed , bo at-sh ap ed bo ne loca ted be tween the tal ar h ead po ster ior ly an d the th re e cu n eifo rm s
a nte rio rl y (Fig . 5 .9 ). T he m edi al sur f ace o f the n avicu la r pr oje cts in f eri or ly t o f or m th e navi cular tub er osi ty,
P. 5 7 1
a n im po rta nt site fo r ten do n attach m en t b ecau se t he m edi al bor d er of th e f oo t d oes no t r est o n th e g ro un d , as does th e l ater al
b or der . I nst ead, it f or m s a lon g itu di nal ar ch o f t he fo ot, w hi ch m ust be su pp or ted cen tr ally. If th is tub er osity is too p rom i nen t, i t
m ay pr ess aga in st th e me dia l p ar t o f the sh oe and cause fo ot pai n.

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Fig ure 5.9. B ones of r ig ht fo ot. AD . Th e seven b on es o f the tar su s m ake u p the p oster ior h al f of th e f oot (h in df oot). T h e
talu s and ca lcan eu s o ccup y th e po steri or tw o t hi rd s of t he h in df oot, a nd th e cub oi d; na vicu lar ; an d m ed ial, later al, and
in ter me dia te cu n eif or ms occu py th e an ter io r th ird . On ly the tal us ar ticu late s w ith th e leg b on es. Th e met atar sus con n ects th e
tar sus po ster ior ly wit h the p ha lan ges an ter ior ly. T og eth er, t he m etatar su s an d p ha lan ges m ake up th e an teri or h alf o f the fo ot
(fo ref oot). Site s of m u scle attach m en t ar e sho wn i n pa rts A, B, a nd D . Pr oxi ma l a ttach m ents ar e sh ow n in s alm on co lor an d
di stal attach m en ts i n bl ue.
T h e cub oi d, a pp ro xim atel y cu bi cal in sh ap e, is th e m ost late ral b on e i n th e d istal r ow of th e tar sus (Fig. 5. 9 A & C ). An ter io r to the
t ub er os ity o f the cub oid o n th e l ater al an d in fer ior sur fa ces of t he bo ne is a g r oo ve f or the tendo n o f the fi bul ari s l ong us
m uscle.
T h e th r ee cu n eif or ms (Fig . 5. 9A, C , & D) ar e th e m edia l ( 1st), i n term ed iate (2 nd ), an d la tera l (3 r d). T h e med ia l cunei fo rm is the
l ar gest bo ne , an d the inter med ia te cuneif or m is th e sm alle st. Ea ch cu nei for m (L . cu ne us, w ed ge sha ped ) ar ticu la tes w ith t he
n avi cul ar p oster ior ly an d th e b ase of its app r opr ia te m etat arsa l a nte rio rl y. Th e later al cuneif or m a lso ar ticu lates wi th th e cu b oid .
P. 5 7 2
M et ata rs u s
T h e meta tar sus (an ter io r or d istal fo ot, f or efo ot) co nsi sts o f five m etata rsal s th at ar e n u mb er ed fr om t he m edi al sid e of th e fo ot
( Fi g. 5 . 9A ). I n the ar ticu la ted skelet on of th e foo t (Fig s. 5 . 1, 5 . 4 , an d 5. 9 ), th e ta rsom eta tar sal joi nts fo rm an ob liq u e
t arso metata rsa l l ine joi ni ng th e mi dp oin ts of th e m ed ial an d sh or ter lat era l b or der s of th e f oot; th us th e m etat arsa ls a nd

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p h alan g es a re loca ted in th e an teri or h alf (f or efo ot) a nd th e tar sals ar e in the p oster ior h al f (hi nd fo ot) (Fi g. 5 . 9A i nset & B).
T h e 1st metatar sal is sh ort er an d stou ter th an th e oth ers . Th e 2nd meta tar sal is t he lon g est. E ach m etata rsal h as a b ase
p r oxim al ly, a sh aft, a nd a h ead d istal ly (Fi g. 5 . 9C ). T he ba se o f each m etata rsal i s th e l ar ger , pr oxi m al end . Th e ba ses of t he
m et atar sals art icu late wi th th e cu n eif or m an d cub oi d bon es, a nd th e he ads ar ticu late wi th th e p r oxim al p hal an ges. T h e b ases of
t he 1 st an d 5 th m etata rsal s h ave lar g e tu be ro sities th at p r ovid e f or te nd on at tach men t; th e tub er osit y of the 5th metatar sal
p r oject s la tera lly over th e cub oi d. On t he pl an tar su rf ace of th e h ead o f the 1 st m eta tarsa l a re pr om in en t m ed ial an d la ter al
s esam oid b on es (n ot sh own ); the y ar e emb ed ded i n th e ten d on s p assin g al on g the pl an tar su rf ace (see B on es o f the Foot in
t he fo llo win g secti on on Su rf ace An atom y).
P h al an g es
T h e 1 4 p h ala ng es ar e as fo llo ws: the 1 st d ig it (gr eat toe) ha s 2 p h alan ge s (p ro xim al an d dis tal); the oth er f ou r di gi ts h ave 3
p h alan g es ea ch: pr oxi ma l, m id dl e, an d di stal (Fig. 5. 9A & C ). E ach p halanx h as a b ase (pr oxi ma lly), a shaf t, an d a he ad
( dista lly). Th e p h alan ge s of th e 1st d igi t a re sho rt, br oad , an d str on g. T he m id dle an d d istal ph al an ges of th e 5 th d ig it m ay b e
f u sed in el der ly pe opl e.
Th e m an y bon es of th e f oot f orm a f u ncti on al un it th at allo ws wei gh t to b e d istr ib u ted to a w id e p latf or m to m ain tai n bal an ce w he n
stan din g , en abl e co nf or m ation an d adj ustm en t to terr ain var iatio ns, and per fo rm sh ock ab sor pti on . Th ey also tr ansf er w eig ht fr om
the h eel to the f ore foo t as r equ ir ed in w alki n g and r u nn in g .
P. 5 7 3
P. 5 7 4
P. 5 7 5
P. 5 7 6
P. 5 7 7
Su r f a c e A na t o m y o f t he L o w e r L im b B o ne s
Bon y lan dm ar ks are h elp fu l du ri ng p h ysical exa mi na tion s a nd su r ger y b ecau se the y can b e used t o ev alu ate no rm al d evelo pm en t,
dete ct an d assess fr actu r es an d d islo catio ns, a nd l ocate str uctu r es su ch as n erves an d bl ood ve ssels.
P e lv i c G ir d l e a nd Fe m ur
When you r ha nd s a re on yo ur h ip s, th ey rest on yo ur i lia c cr ests, th e cur ved su pe rio r bo rd er s of th e alae or w in gs of th e ili a
(sin gu lar = i liu m ) (Fig . S A5 .1A ). Th e a nte ri or th ir d of th e cr ests is e asily p alp ated b ecau se th e crest s ar e su b cuta neo us (Fig .
SA 5. 1 C & D ). T he po ster ior tw o thi rd s o f the cr ests a re m ore d iff icu lt to pal pa te b ecau se t hey ar e u su all y cove red w ith f at. T he
ili ac cr est end s a nte rio rl y at th e r ou n ded a nteri or sup er ior i lia c sp ine, w hi ch is easy to pal pate b y tr acin g th e ilia c cr est
an tero in fer ior ly. Th e A SI S is o fte n visib le in th in in div idu al s. In o bese p eop le t hese sp in es ar e cover ed wi th fa t an d m ay be
dif fi cul t to l ocate; ho weve r, th ey ar e ea sier to pa lp ate w h en th e p er son is sitti ng a nd th e m uscl es at tach ed to them ar e r elaxe d.
Th e i lia c tub ercl e , 5 6 cm p oster io r to t he AS IS , m ark s th e w id est p oi nt of th e ili ac cr est. T o p alp ate th e i liac tu ber cle , pl ace
you r th um b on the AS IS an d m ove you r f in ger s p oster io rl y al on g the exter n al lip o f the il iac crest (Fig . SA 5. 1B). Th e i liac tu ber cle
lies at the le vel of th e sp in ou s p ro cess o f L5 ver teb ra .
Ap pr oxim at ely a h an d' s w idth in fer ior to t he u mb il icu s, the b od ies an d sup eri or r ami of the pub ic bo nes m ay be p alp ated (Fig .
SA 5. 1 C). P alp atio n of th e pu bi c tu be rcle s w as d iscu ssed in C h ap ter 2 . Th e i lia c cr est e nd s p oster io rl y at th e sh ar p poster ior
super io r il iac s pi ne (Fig . SA 5 .1 D ), wh ich m ay be diff icu lt to pal pa te; h ow ever , its po sitio n is easy t o l ocate be cause it li es at th e
bot tom o f a ski n di mp le, a pp ro xim atel y 4 cm later al to th e m id li ne (see Ch ap ter 4 ). Th e di mp le exists be cause th e s kin an d
un d erl yin g fasci a a ttach to th e P SI S. T he ski n d imp les ar e u sefu l lan d ma rks wh en p alp ati ng th e are a o f t he sacr oil iac joi nts in
sear ch of ed em a (sw ell in g) or lo cal tend er ne ss. Th ese dim p les also in d icate th e ter m in ati on of th e ili ac cr ests fr om w hi ch bo ne
ma rr ow an d p ieces of bo ne fo r gr af ts can be ob tain ed (e. g. , to r epa ir a fr actu red t ibi a).
Th e i schial tube ro sity is easily p alp ated in the in fe ri or pa rt of th e b u ttock wh en th e thi gh i s f lexed (Fi g. S A5 . 1E ). T he bu tto ck
cover s an d ob scu res th e tu b ero sity wh en th e thi gh i s exte nd ed (Fig . SA 5. 1D). Th e g lutea l f ol d (sulcus) co in cide s wi th th e
in fer ior bor d er of th e g lu teu s m axi m us an d in dica tes t he sepa rat ion o f the b utto ck f ro m th e th ig h .
Th e cen ter o f th e f emor al head ca n be pa lpa ted de ep to a p oin t ap pr oxim ate ly a th u mb 's br ead th in fe rio r to th e m id po in t o f t he
in gu in al li gam en t (Fi g. S A5 . 1C ). T he sh aft of th e f emu r is co ver ed wit h m uscl es an d is n ot u su all y p alp ab le. On ly th e su pe rio r an d
in fer ior end s o f the f emu r ar e pal pab le. Th e l ater ally p laced g r eater tr ochante r pr oje cts su pe rio r to th e ju n ctio n of th e sh af t w ith
the fe mo ra l n eck an d can b e p alp ated on the la tera l si de of th e thi gh a pp ro xim ately 1 0 cm i nf eri or to th e i lia c cr est (Fi g. S A5 . 1B ).
Th e g re ater tr och an ter f orm s a p r om in ence an ter ior t o th e ho llo w on th e later al sid e o f the b utto ck. The pr om in en ces o f the
gr eater t roch an ter s a re no rm al ly resp on sib le for t he wi dth o f the ad u lt p elvi s. Th e po steri or ed ge of th e gr eater tr och an ter i s
rel ative ly u n cover ed an d m ost easil y p alp ated w hen the li mb i s n ot wei gh t bear in g . Th e ant eri or an d late ral p ar ts of th e tro ch ant er
are n ot easy t o p alp ate be cause th ey are cover ed b y f ascia an d m uscl e. Be cau se it li es cl ose to t he skin , th e g r eater tr och an ter
cau ses d iscom f ort w hen you li e o n you r sid e o n a har d su rf ace. I n th e a nat om ical p ositi on , a l in e j oin in g th e t ips of th e gr eater
tro cha nter s no rm all y p asses thr ou g h th e p ub ic tu ber cles an d th e cen ter o f the fe mo ral h ead s. Th e lesser tr o chanter is
in dist in ctly pal pab le su per ior to t he late ral en d of th e gl utea l f ol d.
Fig ure SA5. 1
Th e f emo ral co ndyl es ar e sub cu tan eou s an d easi ly pal pat ed wh en th e knee is fl exed or e xten ded (Fig . SA 5 .1F). At th e ce nte r of
the la tera l a spect of each con dyl e is a pr om in en t ep ico nd yle t hat is easi ly p alp ab le. T he p atell ar su rf ace of th e f em ur i s w her e the
pa tella sli des du r in g fl exion and e xten sion o f the leg a t th e kne e j oin t. T he late ral an d m ed ial m arg in s o f th e p atell ar su rf ace can
be pa lpa ted wh en th e leg is fl exed . Th e a dd ucto r tub er cle, a sm al l p ro m in ence of b on e, m ay be fel t at th e su p eri or p art of th e
me dia l f em or al con dyl e b y p u shi ng yo ur t hu m b in fer io rly al on g the m edi al sid e of t he th ig h un til i t en cou n ter s th e t ub ercl e.
T i b i a a nd Fi b ul a
Th e ti bi al tuber o sity, an o val eleva tion on th e a nte rio r su rf ace o f th e ti bia , is easil y p alp ated ap pr oxi ma tely 5 cm d istal to th e
apex of th e pat ella . Th e su b cuta neo us, fla t anter o med ial surf ace of the ti bi a i s al so easy t o p alp ate. Th e ski n cover in g th is

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s ur face is fr eel y m ovab le. Th e ti bi al cond yles can b e p alp ated an ter io rl y at th e si des of th e p atel lar l iga me nt, especi all y w hen the
k nee is fl exed. Th e hea d of the f ib ula is pr om in en t at th e l evel of th e sup er ior p ar t of t he tib ial tu be rosi ty b ecau se the kn ob -like
h ea d is su b cuta neo us at the p oster ola tera l a spect of th e knee . Th e ne ck o f t he fi bul a ca n be pa lpa ted ju st dist al to t he late ral
s ide of th e hea d. Doi ng so m ay evoke a mi ld ly u n pl easan t se nsa tion b ecau se of th e p re sence of a n erve p assin g th ere.
T h e med ia l ma lleo lus, th e pr om in en ce o n th e m ed ial sid e of th e an kl e, is also su bcu tan eou s a nd p r om in ent (Fig . SA 5. 1G & H).
N ote th at its i nf er ior en d is b lu nt an d do es n ot exten d as far d ista lly as th e late ral m all eol us. T he m ed ial m all eolu s l ies
a pp ro xim atel y 1 . 25 c m pr oxi ma l to th e level of th e tip o f t he late ral m al leol us. On ly th e d ista l q u art er of th e sh af t o f the fi bu la is
p al pab le. Fee l yo ur l ater al mall eol us, no tin g th at i t i s su bcu tan eo us an d tha t i ts in f eri or en d is sha rp (Fig . SA 5 .1 G & I). Note th at
t he tip o f the la tera l m al leol us exten d s f arth er d ista lly an d mo re po ster ior ly tha n do es th e tip of t he m edi al ma lleo lu s.
B o n e s o f th e Fo o t
T h e tal ar head i s p alp ab le ant ero med ia l to th e pr oxim al p ar t of t he late ral m all eol us wh en th e foo t i s in ver ted an d an ter ior t o th e
m ed ial m al leol us wh en th e foo t i s ever ted (Fig . S A5 .1G). E ver sion o f the f oot m akes t he tala r he ad m ore p ro mi nen t as i t m ove s
a way fr om the n avicu lar . T he h ead occu p ies t he spa ce b etw een th e ta lar sh elf a nd th e na vicu lar tu b ero sity. I f th e tal ar h ead is
d if fi cul t to p alp ate, d ra w a l in e f ro m th e ti p of th e m ed ial m all eolu s to the n avicu lar tub er osity; th e ta lar h ead l ies d eep to th e
c ente r of th is l in e. Wh en th e foo t is p lan tar fle xed, t he su per ior sur face of th e bo dy of th e ta lu s can be pal pat ed on th e ant eri or
a spect of th e an kle, an ter io r to t he in fe rio r en d of th e ti bi a.
T h e w eig ht- bear in g med ial tub er cle o f the cal caneus o n th e p lan tar su r face of th e foo t i s b ro ad an d lar ge (Fig . SA 5. 1J), b ut
o fte n it is n ot pa lp abl e b ecau se o f the ove rly in g skin an d su bcu tan eou s tissu e. Th e tala r shelf is th e o nl y p art of th e me dia l
a spect of th e calcan eu s th at m ay b e pal pat ed as a sm all p ro mi ne nce ap pr oxim at ely a f in ger 's br ead th d istal to th e ti p of th e m ed ial
m al leo lu s. Th e e nti re lat eral su r face of th e calcan eu s i s su bcu tan eou s. T he f ib ul ar tr ochle a, a sma ll later al exte nsi on of th e
c alcan eu s, m ay b e detec tabl e as a sma ll tu ber cle on th e later al asp ect o f th e cal can eus, ant ero in fer ior t o th e tip o f t he late ral
m al leo lu s.
U sua lly, p alp ati on of bon y p r om in en ces on the p lan tar su rf ace of the f oot is di ff icu lt becau se of th e t hi ck ski n, f ascia , an d pad s o f
f at. T h e m ed ial an d late ral ses amoi d bo nes i nf er ior to th e hea d of th e 1 st me tatar sal can b e f elt to slid e wh en th e g r eat t oe i s
m o ved pa ssively. Th e hea ds of the m etatar sal s can b e pal pat ed by pl acin g th e th u m b on th eir p lan tar su r face s an d th e i nd ex
f in g er on th eir dor sal su rf aces. I f call osi ties (callu ses), t hi ckeni ng s of th e ker ati n layer of th e ep id erm i s, ar e p rese nt, t he
m et atar sal hea ds are d iff icu lt to pal pa te.
T h e tub er osi ty of the 5th metatar sal f or ms a pr om in en t l and m ar k on the la tera l a spect of th e f oo t (Fig . SA 5 .1 I & J), wh ich ca n
e asily b e p alp ated at th e m i dp oin t o f th e la ter al bor de r of th e f oot . Th e s ha fts of the me tatar sals and p ha lang es can be f elt on
t he do rsu m o f the fo ot betw een th e exten sor ten d on s. Th e cub o id can be fel t on the la tera l a spect of th e foo t, po ster ior to th e
b ase of th e 5th met atar sal. T he med ia l cuneif or m can b e p alp ated b etw een th e tu b ero sity of th e n avi cul ar an d th e b ase of th e
1 st m etatar sal (Fig . SA 5. 1H). T h e head o f the 1st metatar sal fo rm s a p ro m in ence on t he m edi al aspe ct of th e fo ot. T he
t ub er os ity o f the navicul ar is easil y seen an d pal pate d on th e m ed ial asp ect of th e f oot (Fig . SA 5 .1H), in fer oan ter ior t o th e tip
o f th e m ed ial m all eolu s. T he cu boi d an d cun ei for m s ar e dif fi cul t to i den tif y i nd ivi du all y b y p alp ati on .
C a l c a n e a l F r a c tu r e s
A h ar d fa ll on to the h eel, f ro m a lad der for e xam ple , ma y f ra ctur e the calca neu s in to sever al pie ces, pr od uci ng a com m inu ted
f r actu re (Fig. B5 .6A ). A calcan eal f ra ctur e is u su all y d isab lin g b ecau se i t d isr up ts the su btal ar (tal ocal cane al) joi nt, w h ere th e
t alu s a rti cul ates w ith the calca ne us.
F r a c t u r e s o f t h e T a la r N e c k
Fr actu r es of th e tala r ne ck (Fig . B5 . 6B ) m ay occu r d ur in g sever e d or sif lexi on of th e an kle (e.g . , wh en a pe rson is p r essin g
e xtre mel y h ar d on th e br ake ped al of a veh icle d ur in g a hea d-on coll ision ). I n som e cases, th e bod y of th e ta lu s d isloc ates
p oste ri orl y.
F r a c t u r e s o f t h e M e ta t a r s a l s
Met atar sal fr actu re s occu r w hen a h eavy ob ject fal ls on th e f oo t, fo r exam pl e o r wh en it is ru n o ver by a hea vy o bje ct su ch as a
m et al wh eel (Fig. B5 .6C ). Metata rsal f ract ur es a re also co mm on in d ance rs, esp ecia lly fem al e b all et dan cer s w ho u se t he dem i p oi nte tech n iq ue. Th e d an cer' s f ract ur e u su all y o ccur s w he n th e d an cer lose s b alan ce, p u ttin g th e f ul l b od y w eig h t on the
m et atar sal an d fr actu ri ng th e bo ne. Fat igu e fr actu re s of th e me tatar sals m ay r esu lt fr om p ro lon g ed wal kin g. Th ese f ra ctu res,
u su all y tr an sver se, r esul t f ro m r epea ted str ess on the m etata rsal s.
W hen the fo ot is su d den ly an d viol en tly in verte d, th e tub er osit y of th e 5t h me tatar sal m ay b e avul sed b y th e t end on o f the
f ib u lar is b r evis mu scle . Avu lsi on fr actu r es o f the 5 th m etatar sal tu be rosi ty (Fi g. B 5. 6C ) ar e co mm o n in b asketb all an d ten n is
p la yers. Par t of th e tu ber osit y is pu ll ed of f, p ro du cin g p ain an d ed em a a t th e base of th e 5th me tatar sal.

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Fig ure B5. 6
O s T r ig o n u m
Du r in g ossif icati on of th e talu s, th e secon da ry ossif icati on cen ter , wh i ch beco me s th e l ater al tu ber cle of th e t alu s, occasi on all y
f ail s to u n ite with the b ody of th e talu s. T hi s f ailu r e m ay be caused b y ap pl ied str ess ( for cefu l p lan tar fle xion ) d u ri ng th e ear ly
t een s. Occasio nal ly, a p artl y o r even f ul ly ossif ied cen ter m ay fr actu re an d p rog r ess to n on -un io n. Ei the r even t m ay resu l t in a
b on e (accessor y o ssicle ) kn ow n as a n os tri go num, wh ich occu rs in 1 4 25 % of ad u lts, m or e co m mo nl y b ila tera lly (Fig . B5 . 7). I t
h as an i ncr eased p r evalen ce am on g soccer p layer s and b al let dan cer s. Pati en ts w ith an os tr ig on u m m ay b e symp tom at ic o r pai n
f r ee. R adi on ucl id e b on e sca nn in g, wh ich p ro vid es p hy siolo gi cal as w ell as an atom ica l ev ide nce, is u sef ul in dist in gu ish in g
s ymp tom ati c an d asym p tom ati c ossi cles. (L aw son , 19 9 4 )
Fig ure B5. 7
F r a c t u r e o f th e Se s a m o id B o ne s
T h e sesa mo id b on es of t he gr eat toe in th e ten do n of th e f lexo r ha llu cis lon g us bea r th e w eig ht of th e bod y, esp ecial ly du r in g the
l atter p ar t o f the stan ce ph ase of wa lkin g (see Postu r e an d Gait , in th is ch apte r). T he sesam o ids de velop b ef ore b ir th an d
b eg in to ossi fy du r in g late ch ild ho od . Fr actu r e o f the sesam oi ds m ay r esu lt fr om a cr ush in g in ju r y (e. g ., w he n a h eav y ob ject fa lls
o n th e g r eat t oe).
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F a sc ia , Ve s se ls, a n d Cu t a n e o u s N e rv e s of th e Lo w e r Lim b
S u b cu t a n e ou s Tis su e a n d F a sc ia
T h e sub cutaneo us tissue (sup erf ici al fasci a) l ies dee p to t he skin (Fi g. 5 . 10 ) and co nsi sts o f loo se co nn ectiv e ti ssue th at
c on tain s a var iab le amou n t of f at, cu tan eou s ner ves, su p erf icia l v ein s (g rea t an d sm all sap h en ou s vei ns and the ir tr ibu tar ie s),
l ym ph ati c vessel s, an d lym ph no des. T h e su bcu tan eo us tissu e o f th e h ip an d th ig h is con tin u ou s wi th th at of th e i nf er ior p ar t of th e
a nte ro later al ab dom i nal w all an d b utto ck. At th e kn ee, the su bcu tan eou s t issu e l oses i ts f at an d ble nd s w ith th e dee p fasci a, bu t
f at is aga in p resen t di stal to the kn ee i n th e su b cuta neo us tissu e of th e l eg.
T h e d eep f ascia of t he low er li m b is esp ecia lly str on g, i nvest in g the li mb l ike an el astic stocki ng (Fig . 5 .1 0A & B ). Th e dee p fasci a
l im its ou twa rd exp an sion of con tr actin g m uscl es, m akin g m u scul ar con tr actio n m ore ef fici en t i n com pr essin g vei ns to pu sh b loo d
t owa rd th e hea rt. T h e d eep fa scia of th e th ig h is call ed fa scia lata (L. lata, br oad ). It is con tin u es i nf eri or to th e k nee as the d eep
f asci a of t he leg .
T h e f ascia lat a at tach es to /is co nt in uo us wit h:
T h e i ng ui na l l ig am ent , pu bi c ar ch , bo dy of p ub is, a nd p ub ic tu ber cle su per ior ly; th e m em b ran ou s layer o f sub cu tan eou s ti ssue
( Scar pa fa scia) of th e i nf er ior ab d om in al wal l a lso attach es to the fa scia lata ap pr oxi ma tely a f in ger 's br ead th in f eri or to th e
i n gu in al lig am en t.
T h e i liac cre st l ater ally an d po ster ior ly.
T h e sacr u m , coccyx, sac rot ub ero us li gam en t, an d isch ia l t ub er osity po steri or ly.
E xp osed p ar ts of b on es aro un d th e k nee an d th e d eep f ascia of th e l eg di stall y.
T h e f ascia lat a i s su bsta nti al beca use it en closes th e l arg e thi gh m u scles, e speci ally la tera lly wh er e i t is th icken ed an d
s tren g the ned b y a dd itio na l r ei nf or cin g lon gi tu din al f ibe rs to for m th e ili otib ia l tr act (Fig. 5. 1 0B ). Th is b roa d ban d of f ib ers is the
c on join t ap one ur osi s of th e ten sor of f ascia lat a an d g lu teu s m axim u s m u scles. Th e i lio tib ial tr act ex tend s f r om th e ilia c tu b ercl e to
t he an ter olat era l ti bi al tub er cle.
T h e th ig h m u scles a re sep ara ted in to th ree com p artm en ts an ter io r, m ed ial , an d post eri or . Th e w all s of t hese com p art men ts ar e
f or m ed by th e f ascia la ta an d th r ee f ascia l i nte rm u scul ar sep ta t hat ar ise fr om i ts d eep asp ect an d attach to th e lin ea asp era of th e
f em u r (Fi g. 5 . 1 0D ). T he late ral inte rmuscula r sep tum is esp ecial ly st ron g ; th e oth er two sep ta ar e r elati vely wea k. Th e later al
i n term u scu lar sep tu m exten d s d eepl y f ro m th e i lio tib ial tr act to th e later al li p of th e l in ea a sper a and l ater al su pr acon dy lar li ne of
t he fe mu r . Th is septu m o ff ers a welco m e in ter n erv ou s p lan e to su r geo ns ne edi ng w id e exp osu re of th e fem u r.
T h e sa pheno us op eni ng in th e f ascia la ta (Fi g. 5 . 10A ) is a gap o r hi atu s in the f ascia lata in f eri or to th e m ed ial p art of th e
i n gu in al lig am en t, ap pr oxi ma tely 4 cm in f ero later al to th e p u bic tu ber cle. Th e sap h en ou s op en in g is usu all y a pp rox im ately 3 .7 5 cm
i n len g th an d 2 .5 cm in b rea dth , an d its lo ng ax is i s ver tica l. I ts m ed ial m ar gin is sm oo th b ut its sup er ior , la tera l, an d in f eri or
m ar g in s f orm a sh ar p cr escen tic e dg e, th e f alci fo rm mar gi n. Th is m arg in i s j oin ed at its me dia l m ar g in b y f ibr of atty tissu e, th e
c ri br if or m f ascia (L. cri br u m, a si eve). Th is sieve -like fa scia is a lo cali zed m em br an ou s la yer of su bcu tan eou s tissu e th at sp read s
o ver th e sa ph en ou s o pen in g, closi ng i t. Th is layer of spo ng y co nn ecti ve ti ssu e is pi er ced by nu m er ou s op en in gs (th us its na me ) fo r
t he pa ssage of ef fer en t l ym ph ati c vessel s f ro m th e su pe rf icia l i ng u in al lym ph n od es and b y the g reat sap he no us vein a nd i ts
t ri bu tar ies. A fter p assi ng th r ou gh th e sap hen ou s ope ni ng an d cr ib ri for m f ascia, the gr eat sap he no us
P. 5 7 9
P. 5 8 0
v ein en ter s th e fem or al vei n (Figs. 5. 1 0A a nd 5 . 11A) . Th e l ym ph atic vessel s en ter th e deep i ng u in al lym ph no des.

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Fig ure 5.10. Fasci a, inter muscular sep ta, a nd f asci al comp ar tments o f low e r limb . A. Th e ant eri or skin and
sub cu tan eou s ti ssue h ave been rem ove d to revea l t he de ep fasci a o f the th ig h (fa scia lata) an d leg (cr u ral f ascia). B . T he
fasci a l ata is rei nf or ced late ral ly with lon gi tu din al f ibe rs to for m th e ili otib ial tr act, w hi ch al so ser ves as a n ap on eur osi s f or
th e g lu teu s m axim u s a nd te nso r of fa scia lata m uscl es. C a nd D. T he fa scial com p art men ts of th e t hi gh an d le g, co nta in in g
m uscl es sh ar in g com m on f un ctio ns an d in ne rvat ion , ar e d em on str ated in tran sver se section s.
T h e d eep f ascia o f the leg , th e c rur al fasci a (L. cr us, leg ), attach es to the an ter ior a nd m ed ial b or der s o f the tib ia, wh ere it is
c on tin uo us wi th its perio steu m. Th e d eep f ascia of th e l eg is thi ck i n th e p ro xim al pa rt of th e a nte rio r asp ect o f the leg , w her e it
f or m s p art of th e pr oxi ma l a ttach me nts of th e un de rly in g mu scle s. Alt ho ug h th in ne r di stally , the d eep fa scia of th e l eg for m s
t hi cken ed ban d s b oth su pe ri or an d an ter ior to th e ank le j oin t, th e extenso r re tinacula (Fig . 5 .1 0A). Anter io r an d poster ior
i nter muscular sep ta pass fr om the d eep su rf ace o f the la tera l d eep f ascia of th e leg an d atta ch to the cor r espo nd in g m arg in s o f
t he fi bu la. Th e i nte rosse ou s m em br an e a nd th e in ter mu scu lar se pta di vid e th e leg in to th re e com p ar tm ents: an ter ior (d or sif lexor ),
l ater al (fi bu lar ), an d p oster ior (p la nta rf lexor ) (Fi g. 5 . 10C ). Th e m uscl es in the p oster ior co m par tm en t ar e sub di vid ed in to
s up erf ici al and deep p ar ts b y th e tra nsverse inter muscula r sept um.
Th e l owe r lim b is in vested b y su b cut ane ou s tissu e an d deep f asci a. Th e for m er in su lates, stor es f at, an d p rov ide s p assag e f or
cuta neo us n erve s an d su per fi cial vessel s (l ymp h atics an d vein s). Th e dee p fasci a o f the th ig h (fasci a l ata) an d leg (cr ur al f ascia)
(1) su rr ou nd t he th ig h an d leg , resp ecti vely, l im itin g ou tw ar d bu lg in g of m uscl es a nd f acil itati ng ve no us ret ur n in deep ve in s; (2 )
sepa rate m us cles w ith sim ilar fu nct ion s a nd i nn er vatio n in to com pa rtm en ts, an d (3 ) su r rou n d in di vid ua l m u scles, a llo win g th em to
act i nd ep end en tly. Mo dif icat ion s o f the d eep fa scia in clu de op eni ng s t hat al low th e p assag e of n eur ova scul ar str uctu r es (e. g ., t he
saph en ou s o pen in g ) an d th icken in g s th at reta in ten d on s clo se to th e joi nts th ey a ct on (reti na cul a).
V e n o u s Dr a in a g e o f th e L ow e r L im b
T h e l ower lim b h as su p erf icia l a nd d eep vei ns; th e su p erf icia l ve in s ar e i n th e su b cuta neo us tissu e, a nd th e deep v ein s ar e deep to
( ben eath ) t he de ep fasci a a nd a ccom pan y all m ajo r art eri es. Su p erf icia l a nd d eep vei ns h ave va lves, w h ich ar e m o re nu m er ou s in
d eep ve in s.
S u p erfi ci al V ei n s of t h e L ow er L im b

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T h e tw o ma jor su p erf icia l ve in s in the lo wer l im b ar e th e gr eat an d sma ll saph en ou s ve in s (Fig . 5 .1 1 A & B ). Most of th eir
t ri bu tar ies are u nn am ed .
T h e g r eat sa pheno us vein is for m ed b y th e u n ion of th e d or sal vei n of the g r eat toe an d the d or sal venous ar ch of th e foo t.
T h e g re at sa ph en ou s vei n:
A scen ds an ter ior to th e med ia l m al leol us.
P asses post eri or to th e m ed ial con d yle of th e f em ur (a bou t a h an d 's b rea dth poste ri or to th e m ed ial bo rd er of t he pa tella )
( Fi g. 5 . 12 in set).
A n astom oses fr eel y w ith th e sma ll sap hen ou s vein .
T r aver ses th e saph en ou s o pen in g in t he fa scia lata.
E m p ties in to t he fem o ral vei n.
T h e g rea t sap h en ou s vei n ha s 1 0 12 v alves, w h ich ar e m o re nu m er ou s in the le g tha n in th e thi gh . T hese val ves ar e usu al ly
l ocate d ju st i nf eri or to th e p er for ati ng ve in s (Fig . 5 .1 1A). T he p erf or atin g vei ns also h ave valves. Veno us val ves ar e cusp s (f lap s)
o f en dot hel iu m wi th cu p-l ike valvu lar si nu ses th at f il l f ro m ab ove. Wh en th ey ar e f ul l, th e valve cu sps occlu de th e l um en of th e
v ein , th ere by pr even tin g re flu x of bl ood d ista lly, m aki ng f lo w un id ir ectio nal . Th e valvu la r me chan ism also b rea ks th e co lu m n of
b lo od in t he sap hen ou s vein i nto sh or ter seg m ent s, red u cin g back pr essu r e. Bo th eff ects ma ke i t ea sier f or th e m u scu loven ou s
p u m p to o ver com e th e for ce of gr avi ty to r etu rn t he bl ood to th e hea rt.
A s i t a scend s i n th e l eg an d thi gh , th e gr eat saph en ou s ve in r eceives n um er ou s tr ib u tari es a nd co mm u n icates in sev eral l ocati on s
w ith the sm all sap h eno us vein . T ri bu tar ies fr om th e me dia l a nd p oster io r aspe cts o f t he th ig h fr equ en tly u ni te to f or m an
a ccesso ry sap he nous vei n (Fig . 5 .1 1B). Wh en p r esen t, th is ve in b ecom es t he m ain co mm u n icati on b etwee n the g rea t an d th e
s mal l saph en ou s ve in s. Also , fa ir ly l ar ge vessels, t he late ral a nd anter io r cutaneo us veins, ari se f ro m n etwo rks of vei ns in th e
i n fer ior p ar t o f the th ig h an d en ter th e g re at sa ph en ou s vei n sup er ior ly, j u st b efo re it ent ers th e f em or al vein . Nea r its
t erm in ati on , th e g re at sa ph en ou s vei n also r eceives th e su p erf icia l ci rcu m fl ex i lia c, sup er fici al epi ga stri c, an d exter na l p u den da l
v ein s (Fig . 5 .1 1A).
T h e sma ll sap he nous vei n ar ises on th e late ral sid e of th e f oot fr om the u ni on of th e do r sal vein o f the li ttle toe wit h th e
d or sal ven ou s a rch (Fig . 5 .1 1 B). Th e sm al l sa ph en ou s vei n:
A scen ds po ster ior to th e l ater al m alle olu s a s a con tin u atio n of th e l ater al ma rg in al vein .
P asses alon g th e later al bo rd er of th e calcan eal te nd on .
I n clin es to the m id lin e of th e f ib ul a an d p ene tra tes th e deep f ascia .
A scen ds bet ween t he h eads of th e gastr ocn em iu s m u scle.
E m p ties in to t he po pl iteal vei n in th e po pli teal fo ssa.
A lth ou g h m any tr ib uta rie s ar e recei ved by th e sa ph en ou s vei ns, thei r di am eter s r em ain r em ar kabl y u n if orm as th ey ascen d th e
l im b. Th is is p ossi ble b ecau se th e blo od r eceived b y the sap he no us vein s i s co nti nu ou sly sh un ted f ro m th ese su p erf ici al vein s i n
t he su bcu tan eou s t issu e to th e d eep ve in s b y m ean s o f ma ny pe rf or atin g vein s.
T h e p er fo ra ting veins pen etr ate th e d eep f ascia close to th eir o ri gin fr om th e sup er fici al vein s a nd co nta in val ves th at all ow
b lo od to fl ow on ly fr om t he su per fi cial vein s to t he de ep vein s. Th e per f ora tin g vein s p ass th rou g h th e d eep f ascia at an ob liq u e
a ng le so tha t w he n mu scl es con tr act an d the pr essu r e
P. 5 8 1
P. 5 8 2
P. 5 8 3
i n crease s in sid e the d eep fasci a, th e per fo rat in g vein s ar e com pr essed . C om pr essio n of th e p er for ati ng ve in s al so p re vent s b loo d
f r om f low in g fr om th e dee p to t he su per fi cial vein s. T hi s p atter n of ve no us bl ood f low fr om su p erf ici al to d eep is im po rtan t for
p r ope r ven ou s r etu rn f ro m th e l owe r lim b b ecau se i t en ab les m uscu lar con tract ion s to p ro pel b loo d tow ard th e he art ag ain st t he
p u ll of g rav ity (m u scu loven ou s pu m p; see t he In tr od ucti on ).

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Fig ure 5.11. V eins o f lo we r limb . Th e vein s a re su bd ivid ed in to su per fi cial (A and B ) a nd d eep (C and E) gr ou ps. T h e
sup er fi cial vein s, u su ally u na ccom pan ie d, co ur se w ith in the su bcu tan eou s t issu e; th e deep v ein s ar e in tern al to th e d eep
fasci a a nd u su all y acco mp an y a rter ie s. A, i nset. Th e pr oxi ma l e nd s o f t he fe mo ral an d g rea t sap h eno us vein s are op en ed an d
spr ead ap ar t to sh ow th e valves. Alth ou g h dep icte d as si ng le vein s i n p arts C a nd E , th e d eep vei ns u sual ly occu r as d u pli cate
or m u ltip le accom p an yin g vein s. D . Mul tip le p er fo rati ng v ein s p ier ce th e dee p fasci a to sh u nt bl ood f ro m th e su p erf icia l v ein s
(e. g. , th e g re at sa ph en ou s vei n) to the d eep vein s (e.g . , the p oster ior t ibi al an d fib u lar ve in s).

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Fig ure 5.12. Super f icia l vei ns and lymp hati cs o f l ow er l imb . A. Th e g re at sa ph en ou s vei n ascen ds th e m ed ial asp ect o f
th e li m b, p assin g an ter ior t o th e m edi al ma lleo lu s an d ap pr oxi ma tely a h an d' s b rea dth p oste rio r to th e p atell a (k nee cap )
(inset). T h e su pe rf icial l ymp h atic vessels fr om the m edi al foo t, an ter om ed ial leg , an d th ig h con ver ge tow ard a nd acco m pan y
th e g rea t sap h eno us vein , d ra in in g in to the in fe ri or (ver tical ) g ro up o f sup er fici al in gu in al lym p h no des. B. S up er fic ial
lym ph ati c vesse ls o f the la tera l f oo t an d p oster ola tera l l eg accom p an y th e lesser sap h eno us vein an d dr ain i ni tial ly in to t he
po pli teal lym p h n ode s, wh ich l ie deep t o th e po pli teal fa scia. T he ef fer en t vesse ls f ro m th ese no des joi n oth er d eep
lym ph ati cs, wh ich accom pa ny th e f em or al vessels to dr ain i nt o th e dee p in gu in al lym p h no des. C. Lym p h fr om t he su per fi cial
an d deep i ng u in al lym ph no des tra verse s th e e xter nal an d com m on i lia c n od es b efo re en ter in g the la tera l a ort ic l ym ph n od es
an d the lu m ba r lym ph ati c tr u nk.
D eep V ein s of th e L ow er L im b
T h e d eep vei ns accom p an y al l th e m ajor a rte rie s (L . ven ae co m itan tes) and thei r br an ch es. In stea d of occu rr in g as a si ng le vein in
t he li mb s (a lth ou gh th ey ar e f req u en tly i llu str ated a s on e an d are of ten r efer r ed to as a sin g le vein ), th e d eep vei ns usu al ly occu r
a s p air ed , fr equ en tly in ter con ne ctin g vein s t hat fl an k th e art ery th ey acc om pan y (Fi g. 5 . 1 1C & E ). Th ey are con tai ned w ith in the
v ascul ar sh eath w ith t he ar ter y, wh ose pu lsa tion s a lso he lp com p ress an d mo ve b lo od in t he vein s.
A lth ou g h th e d or sal veno us ar ch dr ai ns pr im ar ily via th e sup erf ici al saph en ou s ve in s, per fo ra tin g vein s p en etr ate the de ep fasci a,
f or m in g an d con tin ua lly su pp lyin g an a nte rio r tib ial vei n in th e an teri or le g. M edi al an d later al p lantar vei ns f ro m th e p lan tar
a spect of th e foo t f or m th e p o steri or ti bi al an d fib ula r ve ins p oste rio r to the m ed ial an d late ral m all eol i (Fig . 5 . 11C E). A ll
t hr ee deep v ein s f ro m th e l eg flo w in to the p op li teal vein p oster io r to the kn ee, w hi ch be com es th e femo r al ve in i n th e th ig h.
V ein s accom pa nyi ng t he per f ora tin g ar teri es o f the d eep ar tery of th e thi gh dr ain b lo od fr om t he th ig h mu scl es an d ter m in ate in
t he d eep vein of the thi gh (L. ven a pr of un d a f em or is), w hi ch joi ns th e te rm in al p ort ion o f the fe mo ral vei n . Th e f em or al vein
p asses de ep to the in g ui nal l iga me nt to beco me th e e xter nal i liac vein of th e tr u nk.
B ecau se of th e ef fec t of g ra vity, b lo od fl ow is slow er wh en a p erso n stan ds qu ie tly. Du ri ng ex erci se, bl ood r ecei ved fr om t he
s up erf ici al vein s b y th e dee p vein s i s p ro pel led b y m u scul ar con tr actio n to the fe mo ral an d th en th e exter na l i lia c vei ns. Fl ow in
t he re verse d ir ection aw ay fr om th e hea rt or f ro m th e d eep to th e su p erf icia l ve in s is p r even ted if th e veno us valv es ar e
c om pete nt (cap abl e o f p er fo rm in g th eir f un cti on ). Th e d eep vei ns ar e m or e var iab le a nd a na stom ose mu ch m or e fr equ en tly th an
t he ar ter ies t hey accom p an y. Bo th su per fi cial an d d eep vein s ca n be li gate d wit h im pu n ity if n ecessar y.
Th e ve in s of th e low er li mb i ncl ud e bot h sup er fi cial (in th e sub cu tan eou s ti ssue ) an d de ep (in ter na l to th e deep f ascia ) vei ns. T h e
sup er fici al gr eat an d lesser sa ph en ou s vei ns m ain ly dr ain the in teg um en t or skin and , via m an y p er for ati ng ve in s, con tin u ou sly
shu n tin g bl ood to th e deep ve in s acco mp an yin g th e a rter ies. Dee p vein s a re sub ject to m uscl e co mp r ession (mu scu love no us pu m p)
to a id ven ou s r etu r n. A ll lo wer l im b vein s h ave val ves to ove rco me th e ef fe cts of g r avity.
V a r i c o s e V e i n s , T hr o m b o s i s, a n d T h r o m b o p h l e b i t is
Fr eq ue ntl y, th e g re at sa ph en ou s vei n an d its tri bu tar ies beco me var ico se (d il ated so th at t he cu sps of th eir val ves d o no t cl ose).
Var icose vei ns ar e co mm on in th e p oste rom ed ial p ar ts of th e low er li mb and m ay cau se con side rab le di scomfo rt (Fig. B5 .8 ).
Var ico se vei ns fo rm w h en th e va lves tha t u su ally p reven t bl ood f low f ro m th e d eep vei ns th rou g h th e p er for ati ng vei ns to th e

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s up erf ici al vein s ar e in com pet ent . When the val ves w ith in t he gr eat sap hen ou s vein i tself ar e in com pete nt, the pu ll o f gr avity on
t he u ni nte rr up ted co lu mn o f bl ood r esu lts in a hi gh er in tr alu m in al pr essu re , wh ich a lso exacer ba tes va ri cositi es. As a r esu lt, t he
s up erf ici al vein s b ecom e tor tuo us an d di lated .
T h e vei ns of th e low er li mb a re sub ject to venous thro mb osis (b loo d clotti ng ) a fter a b on e f ra ctur e. V enous stasis (stag n atio n)
i s a n im po rta nt cau se o f thr om b us fo rm ati on . Ven ou s st asis can b e cau sed b y:
Fig ure B5. 8
I n com pet ent , loo se f ascia th at f ail s to r esist m uscl e exp an sion , d im in ish in g th e e ffe ctiven ess of th e m u scul oven ou s p u mp .
E xter n al pr essu re on t he vein s fr om b edd in g du r in g a p r olo ng ed h ospi tal stay or f ro m a t igh t cast o r ba nd ag e.
Mu scu lar i na ctivity (e. g. , d ur in g an o verse as f lig h t).
V en ou s i nf lam m atio n wi th th ro mb u s f or ma tion (thr o mbo phl eb itis) m ay d evel op ar ou nd th e vein . A th ro m bu s th at br eaks fr ee
f r om a low er li m b vein an d tr avel s to th e l un g s con sti tute s a pul monar y thr omb o embo li sm (o bstr u ction o f a p u lm on ary ar ter y).
A l ar ge em bol us m ay o bstr u ct a m ain p u lm on ar y ar ter y a nd cau se dea th (see Ch ap ter 1 ).
S a p he n o u s V e i n G r a f t s
T h e g re at sa ph en ou s vei n is com mo nl y u sed f or cor on ar y ar ter ial b ypa sses b ecau se (1 ) it is r ead ily accessi bl e, (2 ) su ff icien t
d ista nce occu r s b etwee n th e tr ib ut ari es an d th e per fo rat in g vein s so th at usa ble len g ths can b e h ar vested , an d (3 ) i ts w all con tai ns
a h ig he r per cen tag e of m u scu lar an d el astic fi ber s th an d o oth er su per fi cial vei ns. S ap he no us vein g r afts ar e u sed to by pass
o bstr u ction s in b loo d vessels (e. g. , in a n in tra cor on ary th ro mb u s; see C hap ter 1 ). Wh en p ar t of th e gr eat sap hen ou s vein i s
r em ove d for a b ypass, the vein is r ever sed so th at the val ves d o no t ob str uct bl ood f lo w i n th e g ra ft. B ecau se ther e are so m an y
o th er leg vei ns, rem ov al of th e g rea t sap h eno us vein rar el y p ro du ces a sig n ifi can t p ro bl em in th e low er li m b or ser iou sly af fects
c ircu la tion , p ro vid ed th e d eep vein s are in tact. In f act, r em oval of th is vein ma y f acil itate th e su p erf icia l to d eep d rai na ge pa ttern
t o ta ke a dvan tag e of th e m u scul oven ou s p u mp .
S a p he n o u s C ut d o w n a n d S a p he n o u s N e r v e I n j ur y
E ven wh en it is no t vi sib le i n in fa nts, in ob ese peo ple , or in pati en ts i n sho ck w ho se ve in s ar e co lla psed , th e g re at sa ph en ou s vei n
c an alw ays be loca ted by m akin g a skin i nci sion a nte rio r to th e m ed ial m all eolu s (Fi g. 5 . 11A ). Th is pr oced ur e, ca lled a sap henou s
c utd o w n, is u sed to in ser t a can n ul a f or p ro lon g ed adm in i strat ion o f blo od , pl asm a exp an de rs, el ectr olyte s, or d ru gs. Th e
s aph en ou s n er ve a ccom pan ie s th e g r eat s aph en ou s vei n an ter ior to th e me dia l m al leol us . Sh ou ld th is ne rve be cu t d ur in g a
s aph en ou s cu td own or cau gh t by a l ig atu re du r in g closu r e of a su rg ical w ou nd , th e pati en t m ay com pl ain o f pai n or n u mb n ess
a lon g th e m ed ial b or der o f the f oot.
P. 5 8 4
L y m p h a t ic D ra in a g e of th e Lo w e r L im b
T h e lo wer l im b h as su pe rf icia l a nd d eep lym p ha tic vessels. T h e sup er fic ial lymp hatic vessels con ver ge on a nd acco m pan y the
sa ph en ou s vei ns an d th eir tr ib uta ri es (Fig . 5 .1 2A). T h e ly mp h atic vessels accom p an yin g the g rea t sap h eno us vein end i n th e
ve rti cal gr ou p of sup erf ici al ingui nal l ymp h nod es. Most lym p h fr om th ese n ode s p asses d ir ectly to th e ex ter na l i lia c lymp h
no de s , loca ted alo ng t he exter n al ili ac vei n; bu t lym ph ma y al so p ass to the d eep ing uinal lymp h no des. Th ese n od es lie u nd er
th e dee p fasci a o n th e m ed ial asp ect o f the f emo ra l ve in . Th e l ym ph atic vessel s acco mp an yin g th e sm al l s aph en ou s vei n en ter th e
p o pl iteal lymp h no des , wh ich su r ro un d th e p op lite al vein i n th e f at o f the p opl itea l f ossa (Fig . 5. 1 2B ). T he d eep lymp hatic
ves sels fr om th e leg acco m pan y deep ve in s an d en ter th e pop li teal lym ph no des. Mo st l ymp h f rom th ese n od es a scend s t hr ou gh
d eep l ymp h atic vessels to th e d eep in g ui nal l ymp h n od es. Ly mp h f rom the d eep n ode s p asses t o th e exter na l a nd co mm o n ili ac
l ym ph n od es a nd i s th en r eceive d by th e lumb ar l ymphati c tr unks (Fi g. 5 . 12C ).
T he B o t to m L i n e
Mo st l ymp h f rom th e lo wer l im b dr ai ns via lym p hat ics th at fo llo w the su per fi cial vei ns to the su per f icial in g ui na l n od es. S om e
l ym ph ati cs f ollo w dee p vein s to d eep in gu in al n od es. L ymp h d rai na ge fr om t he low er li m b then passe s d eep to th e exte rn al an d
c om mo n ili ac n od es of th e tr u nk.
E nl a r g e d I n g ui n a l L ym p h N o d e s

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L ym ph no des en lar ge wh en d isea sed. Ab r asio ns an d mino r sep sis, ca used b y path og en ic mi cro org an ism s or th eir to xin s i n the
b lo od or o the r tissu es, m ay pr od uce sli gh t en l arg em en t of t he su per fi cial in gu in al ly mp h n od es (l ym phad eno pat hy) in o the rw ise
h ea lth y p eop le. B ecau se t hese en lar ge d no des ar e lo cated i n th e su bcu tan eo us tissu e, th ey are easy to pal pa te i n he alth y p eop le.
T h ose wh o a re u naw ar e o f thi s m ay be con cer ned w h en th ey f eel th ese n od es beca use th ey a ssum e the y h ave a ser io us ge ni tal
d isea se, fo r exam p le. Wh en in g ui na l l ym ph n od es a re en lar ged , th eir e nti re fi eld of d r ain ag e the tr un k in fer io r to the u mb il icu s,
i n clu din g th e p er in eu m, as w ell as the en tir e l ow er lim b sho ul d be exam in ed to d eter mi ne th e ca use of th ei r enl ar gem en t. I n
f em ale p atien ts, th e po ssibi lity of m etast asis of can cer fr om the u ter us sho ul d also b e co nsi der ed b ecau se som e lym p hat ic
d r ain ag e f ro m th e u ter in e f u nd us m ay f lo w alon g lym p ha tics accom pa nyi ng t he ro un d li ga men t of th e u ter u s th ro ug h th e in gu in al
c ana l t o r each th e sup er fi cial in gu in al ly mp h n od es (see C ha pter 3 )
P. 5 8 5
C u t a n e o u s I n n e r v a tio n o f t h e Lo w e r Lim b
C u tan eou s n er ves i n th e su b cuta neo us tissu e sup pl y th e skin o f the lo wer l im b (Tab le 5 .1 ). Th ese n erve s, excep t f or som e pr oxi ma l
u n iseg m enta l n er ves ari sin g fr om th e T1 2 or L1 sp in al n erves, are b ran ch es o f the lu m ba r an d sacra l p lexu ses (see Ch ap ters 3 an d
4 ). T he ar eas of skin su p pl ied b y th e i nd ivi du al sp in al ner ves, i ncl ud in g th ose con tri bu tin g to th e p lexu ses, a re call ed
d er mato mes. T he de rm ato ma l (seg m en tal) pat tern of skin i nn er vati on is re tain ed th ro ug h ou t l ife bu t is disto rt ed by lim b
l en gth en in g an d the tor sio n of th e l im b th at o ccu rs du ri ng d evel opm en t (Fig. 5 . 1 3). A lth ou g h sim pl if ied in to di stin ct z on es in
d er ma tom e m ap s, ad jace nt de rm ato mes over la p, exce pt at t he axi al line, th e lin e of ju n ction of de rm ato mes su pp lied f r om
d isco nti nu ou s spin al le vels. Der ma tom es L1 L5 exten d as a ser ies of b and s f r om th e p oste ri or m id lin e o f th e tr u nk in to the
l im bs, p assi ng l ater ally an d in fe rio rl y ar ou n d th e li m b to i ts a nte rio r an d m edia l a spects , ref lecti ng t he m edi al ro tatio n th at o ccur s
d evel opm en tal ly. Der ma tom es S 1 an d S2 pass in fe rio rl y d ow n th e p oster ior aspect of th e lim b , sepa rat in g nea r the an kle to pa ss to
th e late ral an d m ed ial m arg in s o f the f oot. T h e cu tan eou s n er ves of th e l ower lim b ar e i llu str ated an d th eir o ri gi n (in clu di ng
co ntr ib u tin g spi na l n er ves), cou r se, an d di stri bu tio n ar e l isted i n Tab le 5 .1 .
Fig ur e 5. 13. De rma tomes of lo w er li mb. T h e d erm at om al or seg me nta l p atter n o f d istr ib u tion o f sen sory n erv e f ibe rs
per sists des pite th e m er g in g of spi na l n er ves i n p lexu s f or ma tion d u ri ng d evel opm en t. T wo di ff ere nt de rm ato me m aps ar e
com m on ly u sed . A and B . Th e der m atom e pat tern of th e l ower l im b accor d in g to Fo erste r (19 3 3 ) is pr ef err ed b y m an y b ecau se
of its cor rel atio n wi th cli ni cal fin d in gs. C and D. Th e d er ma tom e p atter n of t he low er li m b accor di ng to K eeg an an d Garr ett
(19 4 8 ) is pr ef err ed b y ot her s f or i ts ae sthet ic u n if orm i ty an d ob vio us cor re latio n wi th d evelop m en t. Al tho ug h d epi cted as
dist in ct zo nes, adj acen t d er ma tom es o verl ap con sid er abl y, excep t a lon g th e ax ial lin e.
P. 5 8 6
Tab le 5.1. Cutaneo us Ner ves o f the L ow er L i mb

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Or ig in (co ntr ib uting

Nerve
Su bco stal
Il ioh ypo ga stri c
Il ioi ng ui na l
Geni tof em ora l
sp inal ne rves )
T 1 2 an teri or r am us
Co urs e
D istr ib utio n in L o we r Li mb
C ou rses alo ng i nf er ior b or de r of 1 2th

r ib ; la tera l cu tan eou s br an ch
La tera l cu tan eo us br an ch
su pp lies skin o f hi p reg io n
d escen ds over il iac cre st
in ter ior to an ter io r ili ac cr est an d

an ter ior to g rea ter tr och an ter
Par al lels il iac crest; di vid es i nto

la tera l a nd a nter io r cut ane ou s
La tera l cu tan eo us br an ch
su pp lies su per ola tera l q u adr an t
b ran ch es
of b utt ock
L u mb ar p lexu s (L 1 ;
Pas ses th r ou gh i ng ui na l ca na l;
Fem ora l b r anch sup pl ies skin
o ccasion al ly T1 2)
d ivid es i nt o f em or al an d scrot al or
la bia l b r anch es
over m ed ial f em ora l t ria ng le
L u mb ar p lexu s
(L 1 L2 )
Descen ds an ter ior su r face of p soas

m ajo r; di vid es i nto g eni tal an d
Fem ora l b r anch sup pl ies skin

over l ater al fem or al tr ian g le;
f emo ra l b ra nch es
gen it al br an ch su pp lies an ter ior

scro tu m or la bi a m aj ora
L u mb ar p lexu s (L 1 ;
o ccasion al ly T1 2)
Lat era l cu tan eou s

ne rve of th ig h
L u mb ar p lexu s
(L 2 L3 )
Pas ses d eep to in gu in al li gam en t,

2 3 cm m ed ial to an ter ior su p eri or
il iac spi ne
Su pp li es ski n on a nter io r an d
late ral asp ects of th ig h
An ter ior cu tan eo us

br an che s
L u mb ar p lexu s vi a
f em or al ner ve
A rise in fem or al tr ian gl e; p ier ce

f ascia lata al on g path of sar tor iu s
Su pp ly skin o f an teri or an d
m edi al aspect s of th ig h
(L 2 L4 )
m u scle
Cu tan eo us br an ch
Foll ow in g its descen t betw een
Ski n of m id dl e p ar t of m ed ial
of ob tu rat or n erve
o btu r ator n er ve, an t.

b ra nch (L2 L4 )
ad du ctor s lon gu s and b r evis,

an ter ior d ivi sion of ob tur ato r ne rve
th igh
p ier ces f ascia lat a to r each ski n of

th ig h
Poste rio r
cut ane ou s n erv e
of th ig h
S acr al ple xus

(S 1 S3 )
E nt ers gl ute al reg ion via

in f rapir if orm po rti on of g re ater
Ter m in al br an ch es p ier ce f ascia

lata to su pp ly skin o f p oste rio r
scia tic for am en d eep to gl ut eus

m axim u s; t hen descen d s d eep to
th igh an d pop li teal fo ssa

08-May-15
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f ascia lata
Sap h eno us n erve
Tr ave rses add u ctor can al b ut do es
Ski n on m ed ial sid e of leg an d
f em or al ner ve
(L 3 L4 )
n ot pass th ro ug h ad du ctor h ia tus;

cr ossin g m edi al sid e o f knee d eep to
fo ot
sar tor iu s te nd on
Su pe rf icial f ib ul ar
C om m on f ib ul ar
C ou rses th ro ug h la tera l
Ski n of an ter ola tera l l eg an d
ne rve
n er ve (L 4 S1 )
com p art me nt of leg ; after sup pl yin g

f ibu la r mu scle s, per f ora tes cr u ral
do rsu m o f f oo t, exclu d in g web

bet ween g r eat and 2 n d toes
f ascia
De ep fi bu lar n er ve
Su ra l n er ve
A fter su p plyi ng m u scles on d or su m
Ski n of w eb betw een g r eat a nd
n er ve (L 5 )
of f oot, pie rces de ep fasci a su p eri or

to h ead s of 1 st and 2 n d m etatar sal s
2 nd to es
T ib ial an d com m on
f ib ul ar n erve s
Med ial su ral cu tan eou s b r an ch of

tib ia l n er ve a nd l ater al sur al
Ski n of p oster ola tera l l eg an d

late ral m ar gi n of f oot
(S 1 S2 )
cu tan eou s b r anch of fi bu lar n er ve

m er ge at v aryi ng l evels on p oster io r
le g
Medi al pla nta r
T ib ial n erve
Pas ses b etwe en fi rst an d secon d
Ski n on m ed ial sid e of sole an d
ne rve
(L 4 L5 )
la yers of p lan tar m u scles; the n

b etwee n m edi al and m i dd le mu scles
sid es, pl an tar asp ect, an d n ail

bed s of m edi al 3 to es
of f ir st l ayer
Lat era l p lan tar

ne rve
Ca lcan eal n erve s
T ib ial n erve
(S 1 S2 )
T ib ial an d su ral
n er ves (S 1 S2 )
Pas ses b etwe en fi rst an d secon d

la yers of p lan tar m u scles; the n
Ski n on l ater al sid e of so le an d

sid es, pl an tar asp ect, an d n ail
b etwee n m idd le an d late ral m u scles

of f ir st l ayer
bed s of late ral 1 toe s
L ater al an d med ia l b ra nch es of tib ial

an d su ral n er ves, r espect ively, over
Ski n of h eel
cal cane al tub er osity
Su pe rio r clu n ial
L 1 L3 p oster io r
Pen etr ate th or acod or sal fasci a;
Ski n over lyi ng su p eri or an d
ne rves
r am i
cou r se l ater ally an d in fe rio rl y i n

su bcu tan eou s tissu e
cen tra l p ar ts o f bu ttock
Medi al clu ni al
ne rves
S 1 S3 p oster ior
r am i
E m erg e f ro m d orsa l sa cra l f or am in a;

d ir ectly ent er over lyi ng
Ski n of m ed ial bu tto ck an d

in ter gl utea l cl eft
su bcu tan eou s tissu e
In fe rio r clu n ial
P oster ior cu tan eo us
A rise d eep to gl ute us ma xim u s;
Ski n of in f eri or b utto ck
ne rves
n er ve o f thi gh
(S 2 S3 )
em er ge fr om b en eath i nf er ior b or der

of m u scle
(over lyi ng g lu teal f old )
P. 5 8 7
Th e cu tan eou s in ne rvati on o f the lo wer l im b ref lects bo th th e o ri gi nal seg m en tal in ner vati on o f t he skin v ia separ ate spi na l n er ves
in it s d erm ato ma l p atte rn a nd th e resu lt of p lexu s f or m atio n in th e dist ri bu tion of m ul tiseg m enta l p erip her al n erv es. Most
in ner vati on o f t he th ig h is s up pl ied b y la ter al and p oste rio r cu tan eou s n er ves o f t he th ig h an d an teri or cu tan eou s b r anch es of th e
fem or al n erve , the n am es o f wh ich d escr ibe th eir d istr ib ut ion . Th e latt er br an che s al so su p ply m ost of th e m ed ial asp ect of th e
thi gh . T he in n erva tion o f the le g and d or su m of th e foo t i s su pp lie d by saph en ou s (a nte rom ed ial l eg), su r al (pos tero later al leg ),
an d fib u lar n er ves (an ter ol ater al leg an d d orsu m o f foo t). Th e pl an tar asp ect (so le) of th e f oot is sup p lied b y ca lcan eal b ran ch es o f
the tib ia l a nd su r al ner ves (hee l r eg ion ) a nd th e m edi al and l ater al pl an tar n erve s; th e a rea s of d istr ib ut ion o f the la tter ar e
dem ar cated b y a li ne b isectin g th e 4th toe.
Re g i o n a l A n e s th e ti c Ne r ve B lo ck s o f t he L o w e r L im b s
Th e i lio hyp og astr ic a nd i lio in gu in al n erve s can b e blo cked by in je ctin g an an esth etic ag ent 4 6 cm p oster io r to the AS IS , alo ng
the la tera l a spect of th e exter nal l ip of th e ilia c cr est (see C h apte r 2). Th is is w he re th ese n er ves p er fo rate th e t ran sver se
abd om in al (L . tra nsver su s ab d om in is) m u scle. Th e f em or al ner ve (L2 L 4) can b e b lock ed 2 cm in f eri or to th e i ng u in al lig am en t,
app r oxim atel y a fi ng er 's b r eadt h later al to th e f em or al art ery. Par esthesia (tin g lin g , bu r ni ng , tickl in g) ra dia tes to th e kne e an d

08-May-15
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o ver th e m ed ial si de of th e l eg if th e saph en ou s n er ve (te rm in al b ran ch o f f em or al) is aff ected .

V a r i a t io ns o f t he C u ta n e o u s N e r ve s
V ar iati on s of t he cu tan eou s n er ves ar e com m on . Fo r exam p le, th e ili oh ypog astr ic an d ili oin gu in al n er ves m ay ar ise fr om a com m on
t ru n k of va ri abl e l eng th , or th e ili oin gu in al n er ve m ay joi n th e i lio hyp og astr ic n er ve at th e ili ac cr est. I n th e l atter ca se, th e
i lio hy pog astr ic ner ve sup p lies th e cu tan eou s b r an ches fo r bo th ne rves. When the ob tu rat or n erve h as a la rg e cu tan eou s br an ch,
t he m edi al an teri or cu tan eou s b r anch es of th e f em or al ne rve ar e co rr espo nd in g ly sm al l.
A b n o r m a l i t ie s o f S e ns o r y F u nc t io n
I n m ost in stan ces, a pe rip h era l n er ve s ensi tizin g an area of sk in r epr esen ts m o re th an on e se gm en t o f the spin al cord . T her ef or e,
t o i nte rp ret ab n orm al itie s of p er iph er al sen sor y f un ctio n, per ip he ral n er ve d istr ib uti on o f the m ajo r cuta neo us n erve s m u st b e
i n terp re ted as ana tom ical ly dif fe ren t fr om d erm at om e d istr ib uti on o f t he spi na l co rd se gm en ts (Fig . 5 .1 3 ). Ne igh b or in g
d er m atom es ma y ove rl ap. P ain sen sati on i s teste d by usi ng a sh ar p obj ect and a skin g th e p atien t if p ain i s fe lt. I f the re is no
s ensa tion , th e s pin al cor d seg me nt(s) in vol ved can b e d eter m in ed.
P. 5 8 8
P o st u re a n d Ga it
T h e lo wer l im bs fu n ction pr im ar ily in sta nd in g an d wa lkin g. Typ icall y th e actio ns of th e low er lim b m u scles ar e d escri bed a s if th e
m u scle wer e actin g in i sola tion , w hi ch ra rel y o ccur s. In thi s b ook, in clu din g th e com me nts in th e tab les, th e ro le o f each m u scle (or
o f the f un ctio na l g ro up o f wh ich i t i s a m emb er ) i s d escri bed i n typ ical activ ities, especi all y stan d in g an d wal kin g. I t i s i mp or tan t to
b e fam il iar w ith l owe r lim b m ovem en ts and co nce ntr ic an d eccen tri c con tr acti on s of m u scles, a s d escri bed i n th e I nt rod u ction , an d
to h ave a basi c u nd er stan di ng o f the pr oce sses of st and in g an d wa lkin g .
S ta n d in g a t Ea se
Wh en a p erso n is stan din g at ease wi th th e f eet slig h tly apa rt an d ro tated la tera lly so the toe s p oin t o ut war d, on ly a f ew of th e
b ack an d low er li mb m u scles ar e acti ve (Fi g. 5 . 14 ). T he m ech an ical ar ran g em ent of th e joi nts an d m uscl es a re such tha t a
m in im u m o f m u scu lar act ivity is req u ir ed to keep fr om fal lin g . In th e stan d-ea sy p ositi on , th e h ip a nd kn ee joi nt s ar e e xten ded an d
a re in th ei r mo st sta ble p ositi on s (m axi ma l co nta ct o f a rti cul ar su rf aces for w eig h t tr an sfer , w ith su pp or tin g li gam en ts tau t). Th e
a nkl e j oin t is l ess sta ble th an th e hi p an d knee jo in ts, an d th e l in e o f g r avity fa lls betw een th e two li m bs ju st an ter io r to the axi s
o f ro tatio n of th e a nkl e j oin ts. C on seq uen tly , a te nd en cy to f all fo rw ar d (for wa rd sw ay) m u st be cou nte red p er iod ical ly by bil ater al
co ntr acti on of ca lf muscl es (p lan tar f lexio n). T h e sp re ad an d spl ay o f the fe et i ncr ease late ral stab il ity. H ow ever, wh en la tera l sw ay
o ccur s, it is cou n tere d by the h ip ab du ctor s (actin g th ro ug h th e i lio tib ial tr act); f ib ul ar col later al li gam en t of th e kn ee joi nt ; an d
th e ever tor m u scles of on e si de acti ng w ith th e th igh add u ctor s, tib ial col later al li gam en t, an d in ver tor m u scles of th e con tral ater al
si de.
Fig ur e 5. 14. Relax ed stand ing . A. Th e r elat ion sh ip of th e lin e of gr avi ty to th e t ran sver se r ot ation al axe s of th e pel vis and
low er li mb i n th e r ela xed stan di ng (sta nd -easy) po sitio n is dem on str ated . On ly m i no r po stur al ad ju stm ent s, ma in ly by the
exten sor s of t he ba ck an d th e p lan tar f lexor s o f an kle, ar e nec essary to m ain tai n thi s p osit ion b ecau se the li gam en ts of th e h ip
an d knee ar e b ein g ti gh tly stre tche d to p r ovid e p assi ve su pp or t. B . A bi ped al pl atfo rm is f or m ed by th e f eet du ri ng r ela xed
stan din g . Th e wei gh t o f the b ody is sym me tri cally di str ibu ted a rou n d th e cen ter o f gr avity , wh ich f all s in the p oster ior th i rd of
a m ed ian p la ne bet ween t he sli gh tly par ted a nd l ater ally r otated f eet, a nte rio r to th e r otati on al axes of th e a nkl e j oin ts.

08-May-15
Page 30 of 155
P. 5 8 9
W a lkin g : Th e G a it C y cle
L o como tio n is a com ple x f un ctio n. Th e m ove me nts of th e l ow er lim b s d ur in g w alkin g on a l evel sur f ace m ay be d ivid ed in to
a lter n atin g swi ng a nd sta nce ph ase s (Ta bl e 5 . 2). T h e g ait cycle con sists of on e cy cle o f swi ng an d stan ce by on e l im b. Th e sta nce
p hase b egi ns wi th heel stri ke, w he n th e h eel str ikes the g rou n d an d beg in s to a ssum e th e b ody 's f ul l weig h t (l oad in g resp on se),
a nd e nd s w ith p ush o ff f ro m th e f or efo ot a resu lt of p lan tar fl exio n. T he sw ing p hase be gin s after pu sh of f wh en th e toes leave
t he gr ou n d an d end s w h en th e h eel str ikes th e g ro un d . Th e sw in g p hase occu p ies app ro xim atel y 4 0 % o f th e w alki ng cycl e an d th e
s tan ce p ha se, 6 0% . Th e stan ce p ha se of w alk in g is l on ger th an the swi ng p h ase becau se it beg in s a nd en d s w ith r elat ively sh or t
p er iod s (e ach 1 0% o f t he cycle) of d ou bl e su pp or t (b oth feet ar e co nta ctin g th e g ro un d) as the w eig ht is tra nsf err ed f ro m on e si de
t o th e oth er , wi th a m o re exten de d per iod of sin gl e su pp or t (on ly o ne fo ot on th e gr ou nd b ear in g all b od y w eig ht) in b etw een as
t he con tr alate ral li m b swin g s f or war d. I n r un n in g, t her e is n o pe rio d of d ou ble su pp or t; co nseq u en tly, th e tim e a nd p er centa ge of
t he ga it cycle rep re sent ed by th e stan ce ph ase ar e r edu ced .
W alkin g is a rem ar kab ly eff icien t activi ty t akin g ad van tage of g ra vity an d mo me ntu m so th at a m in im u m o f p h ysical exer tio n is
r eq ui re d. Most en erg y is u sed (1 ) i n th e ecce ntr ic con tr action of th e d or sif lexor s d u ri ng th e beg in n in g (load in g ) p hase of sta nce as
t he h eel is l ow ered t o th e gr ou n d fol low in g he el stri ke an d (2 ) es peci ally at the en d of stan ce as t he pl an tar flex ors con cen tri call y
c on tract , pu sh in g the fo re foo t (m etat arsa ls a nd p ha lan ge s) d own to p r odu ce pu sh of f, thu s p r ovid in g m ost of th e p ro pu lsi ve f or ce.
Du r in g the las t p art of th e stan ce p h ase (p u sh of f), th e toes flex to gr ip t he gr ou n d an d aug m en t th e pu sh of f in itia ted fr om the
b al l o f the fo ot (sole u nd er lyin g th e h ead s o f the m ed ial two m etat arsa ls). Th e lon g f lexor s a nd i nt rin sic m uscl es o f the f oot
s tabi lize th e f or efo ot and t oes so th at th e ef fect of p lan tar fl exio n at the an kle an d fl exion of th e to es i s m axim i zed.
T h e sw in g ph ase also in vol ves flexi on o f the h ip so th at th e lim b acce ler ates faster tha n the f orw ar d m ovem en t o f t he bo dy.
I n itia lly, t he kn ee f lexe s al mo st si mu lta neo usl y, ow in g to mo m entu m (w ith ou t expen d itu re of en er gy), fol low ed by d orsi fl exion
( lif tin g th e f or efoo t u p ) at th e an kl e jo in t. Th e latte r two m ovem en ts hav e th e eff ect o f sho rten in g th e fr ee l im b so tha t it w ill clea r
t he gr ou n d as i t sw in gs fo rw ar d; by mi dsw in g, kn ee exten sio n is add ed to th e f lexi on an d m om en tu m of th e t hi gh to r eali ze
a nte ri or swi ng f u lly. T h e exte nso rs of th e h ip a nd f lexo rs of th e kn ee con tr act ecce ntr ica lly at the en d of sw in g to d ecel erat e th e
f or wa rd m ovem en t, w hi le exten sor s o f t he kn ee (q u adr icep s) co nt ract as nec essary to exten d th e l eg fo r th e d esir ed len g th of
s tri de an d to p osi tion the fo ot (pr esen t th e he el) f or h eel str ike. C on tr actio n of th e knee exten so rs is m ai nt ain ed th ro ug h h eel
s tri ke i nto th e load in g ph ase to ab sorb sho ck an d keep th e kne e f ro m bu ckli n g un til it r each es f ul l exten sion . B ecau se th e
u n su pp or ted sid e o f the h ip ten ds to dr op d ur in g th e swin g p hase (w hi ch wo ul d neg ate th e ef fect of l im b sho rte ni ng ), ab du ctor
m u scles on t he su pp ort ed sid e co ntr act stro ng ly du r in g the sin g le sup po rt pa rt of th e st ance p has e, pu ll in g on th e fixe d fem u r to
r esi st th e tilti ng a nd ke ep the p elvis leve l. T hese sam e mu scle s al so r ota te (ad van ce) the con tr alat eral si de of th e p elvi s f or war d,
c on cur re nt wi th th e sw in g of its fr ee lim b .
O f co ur se, a ll the se act ion s a lter na te f ro m sid e to si de wi th each ste p. T he exten sor s of th e h ip n or m ally m ake on ly m i no r
c on tri bu tion s to level wa lkin g . Pr im ar ily, th e hi p is passi vely exten de d by mo m entu m d u ri ng sta nce, except wh en a cceler ati ng o r
w alk in g fast, and b ecom es in cre asin gl y act ive with in crea se in slop e (st eepn ess) du r in g wal kin g up h ill or u p stai rs. C on cen tr ic h ip
f lexi on an d kn ee exten sion are u sed du r in g th e sw in g ph ase of leve l w alki ng a nd so ar e no t w eig ht-b ear in g acti on s; h ow ever, the y
a re ef fected b y b od y w eig h t w hen the ir eccen tr ic co nt racti on i s n ecessar y f or d eceler ati on or wal kin g dow n hi ll or d own stair s
S tab ili zatio n an d re sili ence ar e i mp or tan t du ri ng l ocom ot ion . Th e in ver tor s an d ever tor s o f the fo ot are p ri nci pal stab il izer s of t he
f oo t d ur in g th e st ance p hase . Th eir l on g ten do ns, p lu s th ose of th e fl exor s of th e di gi ts, also h elp su pp or t t he ar che s of th e foo t
d u ri ng th e stan ce p h ase, assi stin g th e i ntr in sic m uscl es of t he sole .
Ab s e nc e o f P l a n ta r f l e x i o n in W a l k i n g
If th e m u scles of th e calf ar e p ar alyze d or th e ca lcan eal ten do n is ru p tur ed , a m u ch le ss ef fecti ve a nd ef fi cien t p u sh of f (fr om th e
mi df oot) can sti ll be acco mp li shed b y t he actio ns of th e glu teu s ma xim us an d h am stri ng s i n exten di ng t he th ig h at t he h ip jo in t
an d the qu ad r icep s in e xten din g th e knee . Beca use pu sh o ff fr om the f ore foo t i s n ot possi bl e (i n fact , the an kle wi ll be p assivel y
dor sif lexe d as th e bod y's wei gh t mo ves a nter io r to the fo ot), th ose atte mp tin g to wa lk i n th e a bsen ce of pl an tarf lexi on o ften r ota te
the fo ot as f ar la tera lly (exter n ally ) as po ssibl e d u rin g th e stan ce p ha se to d isab le passi ve d or sif lexi on an d all ow a mo re ef fecti ve
pu sh of f th rou g h h ip an d kn ee ext ensi on exe rted a t th e mi df oot.
T h ig h a n d G lu te a l Re gio n
I n evo lu tion , th e deve lop me nt of a pr om in en t g lu teal r eg ion i s clo sely associ ated w ith th e assum p tion of bi ped al ism an d an e rect
p ostu r e. Th e pr om in en t g lu teal r egi on i s u ni qu e to h u m an s. Modi fica tion of th e sh ap e o f the fe mu r n ecessar y f or b ip eda l w alki ng
a nd r u nn in g (sp ecif icall y th e ben di ng of th e b on e, cr eatin g th e ang le of i ncl in ation an d the tr och an ters, as d iscu ssed ear li er
i n th is chap ter ) a llow s t he su per ior pla cem ent of th e abd u ctor s of th e th igh in to t he gl ute al reg io n. T he r em ain in g th igh mu scle s
a re or ga ni zed in to thr ee com pa rtm en ts by in ter mu scu lar sep ta th at p ass deep ly bet ween t he m uscl e g ro up s f r om th e i n ner su r face
o f th e f ascia lata to th e l in ea asper a of th e f em ur (Fi g. 5 . 10D ). Th e
P. 5 9 0
P. 5 9 1
c om par tm en ts ar e anteri or or e xten sor , me dia l o r addu ctor , an d po ster ior o r flex or, so n am ed o n the b asis of th eir l ocatio n or
a ction at th e kn ee j oin t. Gen er ally , the an ter ior g r ou p is i nn er vated b y t he fem o ral n er ve, th e m ed ial g ro up b y th e ob tur ato r
n er ve, an d th e post eri or gr ou p b y th e tib ial po rti on o f t he sciat ic n er ve. A lth ou gh th e com pa rtm en ts v ary in a bsol ut e an d r elati ve
s ize dep en din g on level , the an ter ior com par tm en t i s la rg est o ver all an d in clu des th e f em ur .
T ab le 5. 2. Muscl e Actio n d uri ng the Gai t Cycle

08-May-15
S TA NC E
PH AS E
Page 31 of 155
Phase o f Gai t
Me chanical Go als
Heel str ike

(in it ial con tact)
L ow er f or ef oo t to gr o und
A nk le d or sif lexo rs
(ecc entr ic con tr action )
T ib iali s anter io r
C on tin ue de celer atio n

(re verse f orw ar d swi ng )
H ip exte nso rs
Glu teu s m axi m us
Pr eser ve l on git ud in al ar ch
of f oot
I n tri nsi c m u scles of fo ot
Flexo r di gi tor um b r evis
L on g ten do ns of f oot
T ibi ali s an ter ior
Accep t w eig ht
K n ee ex tens ors
Quad ri cep s
Deceler ate m ass (sl ow
A nk le p la nta rf lexor s
L oa di ng
r esp onse (fl at
f oot)
Active M uscle Gr oup s
do rsi fle xion )
Stab ili ze p elvi s
E xamp les
T rice ps sur ae (sole us an d

g astr ocn emi us )
H ip ab du cto rs
Gl uteus med ius and

mini mus; te nso r of
f ascia lata
of f oot
T ibi ali s p oster ior ; l on g

f lexor s o f di git s
M id stance
Sta bil ize kn ee
K n ee ex tens ors
Qu ad rice ps
C on tro l d or sif lexio n

(pr eser ve mo me ntu m )
(ecc entr ic an d
T rice ps sur ae (sole us

con tr actio n)
g astr ocn em iu s)
H ip ab du cto rs

mini mus, tensor o f
f ascia lata
of f oot

T ermi nal
Acceler ate mass
stance (h eel
of f)
T ri ceps sura e (s ole us
(co nce ntr ic con tra ction )
and g astr ocnem ius)
H ip ab du cto rs

mini mus, tensor o f
f ascia lata

08-May-15
Pr eser ve ar ch es o f foo t; f ix
fo ref oot
Page 32 of 155
A dd ucto r h allu cis

S WIN G
Preswing (toe
PH AS E
of f)
Accel er ate m ass
L on g fl exor s o f dig its
Flexo r h allu cis lon g us;

f lexor d ig ito ru m lo ng u s
Pr eser ve ar ch es o f foo t; f ix
A dd ucto r h allu cis

Deceler ate th ig h; pr ep are

fo r swi ng
Fle xor of h ip (ecce ntr ic

co ntr acti on )
I lio psoa s; r ectu s f em ori s
Acceler ate thig h, vary

cad ence
Fl exo r of hip
( concentr ic
Il io pso as; re ctus f emor is
fo ref oot
I ni tial sw ing
co ntra ctio n)
Clea r fo ot
Ankl e d or sif lex or s
M id swing
Clea r fo ot
T ermi nal
Deceler ate th ig h
sw ing
Deceler ate leg
H ip exte nso rs (eccen tri c
Glu teu s m axi m us;
co ntr acti on )
h am str in gs
K n ee f lexo rs (eccen tri c
H am stri ng s
co ntr acti on )
Po sitio n f oo t
T ibi ali s an ter ior
Ex tend knee to p la ce f oo t
(co ntro l s tri de) ; p r ep are
Knee extenso rs
Qu ad rice ps
fo r conta ct
T o faci lita te co nti n ui ty an d f ollo w an ap pr oa ch com m on ly u sed i n di ssectio n cou rses, the an ter ior a nd m ed ial th ig h is add r essed
i n itial ly, f oll owe d by con tin u ou s exam i nat ion o f the p oster ior a spect of th e p r oxim al li m b: glu tea l r eg ion , p oster ior t hi gh , an d
p op li teal fo ssa
A n t e rio r T h ig h Mu sc le s
T h e l arg e anteri or co mp artm ent of the thig h con tai ns th e anter io r thig h muscle s, th e f lexo rs of th e h ip a nd ext enso rs of th e
kn ee (Fig . 5. 1 5 ). For atta chm en ts, n er ve su pp ly, and m ai n acti on s of th ese m uscl es, see Tab le 5. 3 . Th e an teri or th ig h m usc les
i n clu de the p ectin eu s, ili op soas, sa rto riu s, an d q ua dr icep s f em or is. 1 Th e m aj or m us cles o f th e anter ior com par tm en t te nd to
a tro ph y (d im in ish ) rap id ly wi th di sease, an d p hysi cal th era py is o ften nece ssary to re stor e str en gth , to ne, and sy mm etr y with the
o pp osi te l im b afte r im m obi liza tion of th e th ig h or l eg.
P ec t in eu s
T h e p ectine us is a f lat q uad r ang u lar m u scle loca ted in th e an teri or p ar t of th e sup er om edi al asp ect o f the th ig h. I t o fte n app ear s
t o b e com pose d of two l ayer s, sup er fici al an d dee p, an d th ese are g ene ral ly in ner vated b y two di ff ere nt n erves . Becau se of th e
d u al ne rve su pp ly a nd th e m uscl e's a ction s (the p ectin eu s ad du cts an d fle xes th e thi gh a nd a ssists i n m edi al ro tatio n of th e t hi gh ),
i t i s act ual ly a tr an siti on al mu scle b etwee n th e an ter ior and t he m edi al com par tm en ts.
I l io ps o a s
T h e i lio ps oas is the ch ief f lexor o f th e th ig h, the m ost po wer fu l of th e h ip f lexo rs wi th th e l on gest ra ng e. A lth ou gh i t i s on e of th e
b od y's mo st p ow erf u l m u scles, i t i s r elat ively h idd en , wi th m ost of its m ass l ocated i n th e p oster io r wal l o f th e ab do m en an d
g r eater p elvi s. Its br oa d later al pa rt, the il iacus, an d it s lo ng m ed ial p ar t, th e p soa s maj or , ar ise fr om th e ili ac f ossa an d lu m bar
v erte br ae, r espe ctivel y (T abl e 5 . 3C ). T hu s i t i s th e on ly m u scle attach ed to th e verte br al colu m n , pel vis, an d f em ur . It is in a
u n iq ue p ositi on n ot on ly to p r odu ce mo vem en t b ut to stab ili ze (f ixat e). Ho wever , it can a lso per p etua te a nd ev en con tr ibu te to
d ef or mi ty a nd d isab ili ty w h en it is ma lfo rm ed (esp ecia lly if it is sho rte ned f or va rio us r eason s), d ysfu n ction al, or d iseased .
C on cen tr ic con tract ion o f the il iop soas typ icall y m ove s th e f re e l im b, p ro du cin g fl exio n at the h ip to li ft the li mb a nd i ni tiate its

08-May-15
Page 33 of 155
f or wa rd sw in g du r in g wal kin g (i. e., du ri ng th e pr esw in g and i ni tial sw in g ph ases, a s th e opp osi te l im b accep ts w eig ht; Ta ble 5 .2 )
o r to eleva te th e lim b d ur in g
P. 5 9 2
c lim bi ng . H owe ver, i t i s al so ca pab le of m ovi ng th e tru n k. B ilate ral co ntr acti on in iti ates fle xion o f th e tr u nk at the h ip on t he fi xed
t hi gh as wh en (in cor r ectly) do in g sit-u ps an d in cr eases th e lu m ba r cur vatu r e o f the ver teb ral col um n . I t i s acti ve d u rin g
w alk in g dow n hi ll, i ts ecce ntr ic con tra ction resi stin g accele rat ion . Th e ili op soas is a lso a p ostu r al mu scle , active du r in g stan di ng i n
m ai nt ain in g n orm al l um b ar lor d osis (an d in di rectl y th e com pen sato ry th or acic kyph osi s; see C hap ter 4 ) a nd r esist in g
h yp er exten sion o f th e h ip j oin t (Fi g. 5 . 14 ). Un il ater al wea kness or sp asti city m ay b e a fa ctor in the de velop m en t of sco lio sis.
Fig ure 5.15. Muscl es o f anter ior thi gh. A. Th e sur f ace a nat om y o f t he an ter ior th ig h m u scles is sh ow n . In B C, ski n,
sub cu tan eou s ti ssue , an d deep f ascia h ave been rem ov ed to expo se th e an teri or th ig h m uscl es, th e l ayer s o f w h ich ar e
dem o nstr ated b y r em ovi ng th e m uscl es seq u ent iall y, fr om sup erf ici al (B-r ig ht sid e) t o d eep (C-l eft sid e).
S art o ri u s
T h e sa rto ri us, th e tai lor 's mu scle (L . sar tu s, pat ched o r rep ai red ), is lon g an d r ibb on -li ke. It p asses o bl iqu el y (la ter al to
m ed ial ) acr oss th e su p ero ant eri or p art of th e thi gh (Fi g. 5 . 15 ; Tab le 5. 3D). Th e sa rto riu s lies su per fi cial ly i nsi de th e an ter io r
c om par tm en t, wi thi n its ow n re lati vely dist in ct f ascial sh eath . T hi s m u scle d escen d s in f eri orl y a s f ar as t he sid e o f the kn ee. T he
s arto ri us, t he lon g est m u scle in th e bo dy, a cts acr oss two jo in ts. I t f lexes th e h ip j oin t a nd p ar ticip ates in f lexi on of t he kn ee j oin t.
I t also we akly abd u cts th e thi gh a nd l ater all y r otate s it. Th e a ction s o f bo th sar tor iu s m u scles br in g th e lo wer l im bs in to th e cr ossl egg ed si ttin g po sitio n. N on e o f th e acti on s o f the sar tor iu s i s str on g; th eref or e, it is m ain ly a syn er gi st, acti ng w ith o the r thi gh
m u scles th at pr odu ce th ese m ov eme nts.
Q u ad ri ce ps F em or is
T h e q uad ri cep s f emor is (L. f ou r -hea ded f em or al mu scle ) fo rm s the m ain bu lk of th e an ter io r th igh mu scles an d col lective ly
c on stitu tes t he lar g est an d on e of th e m os t p owe rf ul m u scles in th e b od y. I t m ay be th ree tim es stro ng er th an i ts an tag on isti c
m u scle gr ou p , th e h am str in gs. I t co vers alm o st al l t he an ter ior asp ect an d sid es of t he fem u r. Th e q u adr icep s f em or is (qu ad rice ps)
c on sists o f fou r p ar ts: (1 ) r ectu s f em or is, (2 ) va stus lat era lis, (3 ) vastu s in ter m edi us, and (4 ) vastu s m ed ial is. C oll ectivel y, th e
q u adr ice ps is a tw o-jo in t m u scle capa ble of p ro du cin g acti on at bo th th e h ip a nd th e kn ee. Th e two m ajo r com po nen ts of th e
q u adr ice ps (rectu s fem or is an d vasti) ar e d iscu ssed sep ara tely late r in th is cha pter .
T h e q ua dr icep s i s th e gr eat exten sor of th e leg . C on centr ic con tr actio n of th e q u adr icep s t o ext end t he kn ee a gai nst gr avi ty i s
i m por tan t du ri ng r isi ng f r om sit tin g or sq uat tin g, d u ri ng cl im bi ng an d w alki ng u p stai rs, a nd f or accel era tion and
P. 5 9 3
p r oject ion (r u nn in g an d ju m pi ng ). I n level w alki ng , it beco m es act ive du ri ng th e ter mi na tion of th e sw in g ph ase, p r epar in g th e
k nee to accep t w eig h t (T abl e 5 . 2). I t is p r im ari ly resp on sib le for abso rb in g th e j arr in g sh ock of he el stri ke, an d its activi ty
c on tin ues as the we igh t is assum ed d u ri ng th e ear ly st ance p ha se (lo ad in g resp on se). I t al so fu ncti on s m u ch of th e tim e a s a
f ixa tor d ur in g be nt-kn ee spo rts, such a s ski in g and t enn is, and co nt ract s eccen tr ical ly d u ri ng d ow nh il l w alki ng a nd d escen di ng
s tair s.
T abl e 5. 3-I. M uscles of the Anter io r Thig h: Flexo rs of the Hi p Jo int

08-May-15
M us cle
Pecti neu s
Pr ox imal Attachment
S u per ior r am u s o f p u bi s
(A & B )
Page 34 of 155
D ista l Attachme nt
Inner vati on a
Pectin eal l in e of
Fem or al ne rve (L 2,
Ad d ucts an d fl exes
fem u r, j ust in f eri or

to l esser tr och an ter
L 3); m ay r ecei ve a
b ran ch f ro m ob tu rato r
th ig h; assists wi th
m edi al ro tatio n of
n erv e
th ig h
Il iop soas (A & C )
Psoas
major
S id es o f T1 2 L 5 ver teb ra e
a nd d iscs betw een th em ;
Act con jo in tly in
Lesser tro chan ter o f

femu r
tr an sver se p r ocesses of all

l um b ar ver teb rae
Psoas
m in or
Il iacu s
S id es o f T1 2 L 1 ver teb ra e
a nd i nte rver teb ra l d isc
Mai n Actio n
A nter io r ra mi of
lu m ba r ne rves (L 1,
fl exin g th ig h at hi p
jo in t an d in stab iliz in g
th is joi nt b
L 2, L3 )
Pectin eal l in e,
ili ope ctin eal
A nter io r ra mi of
lu m ba r ne rves (L1 ,
em in ence via
ili ope ctin eal ar ch
L 2)
I li ac cr est, i liac fo ssa, ala of

sa cru m , an d an teri or
Ten do n of p soas
ma jor , lesse r
Fem or al ne rve (L 2,
L 3)
sa croi lia c li ga men ts
tro cha nter , an d

fem u r di stal to it
Sar tor iu s
A n teri or su per io r ili ac sp in e
Su per io r par t of
Fem or al ne rve (L2 ,
Flexes, abd u cts, an d
(A & D )
a nd su p eri or pa rt of n otch
i nf er ior to it
me dia l su r face of
tib ia
L 3)
la tera lly ro tates thi gh

at hi p joi nt ; f lexes leg
at kn ee j oin t c
Th e spi nal co rd seg m ent al in ner vati on is in d icated (e. g ., L 1 , L2 , L 3 m ean s th at th e n er ves su p ply in g the p soas
m ajor a re de riv ed fr om th e fi rst th ree lu m bar se gm en ts o f the sp in al cord ). N um b ers in b old fa ce (L 1, L 2) in d icate th e
m ain seg m en tal in ner vati on . Dam age to on e o r m or e of th e list ed spi nal co rd seg m ent s or t o th e mo tor n er ve r oo ts ar isi ng
fr om th em resu lts in p ar alysi s of t he m uscl es co ncer n ed.
T he pso as m aj or is also a po stu ral m u scle tha t h elp s co ntr ol th e devi atio n of th e t ru nk an d is active d ur in g stan di ng .
T he fo ur a ction s of th e sar tor iu s (L. sar tor , tai lor ) p r odu ce th e on ce com m on cr oss-le gg ed sitti ng p osit ion u sed b y ta ilo rs,
he nce th e n am e.
T h e ten d on s of t he fo ur p ar ts o f the q uad r icep s u ni te i n th e d ista l p or tion of th e th ig h to fo rm a si ng le, st ron g , br oad q uad r icep s
t endo n (T abl e 5 . 3E ). T he p atell ar li game nt (L. lig am en tum pa tella e), attach ed to th e tib ial tu ber osi ty (Fig . 5 .1 5B), is th e
c on tin ua tion o f the q uad r icep s ten d on in wh ich th e pate lla is em bed de d. T he pa tell a i s th u s th e l ar gest sesamoi d bon e in th e bod y.
T h e m ed ial an d lat eral va sti m u scles also at tach in d epen d ent ly to th e pat ella an d fo rm apo neu r oses, th e med ial an d late ral
p ate llar r eti nacula, w hi ch r ein for ce th e jo in t ca psu le of th e kn ee on e ach sid e o f the p atell a en ro ute to attach m en t to th e
a nte ri or bo rd er of th e tib ial p latea u. T h e r etin acu la also p lay a r ol e i n keep in g the p atell a a lig ne d over th e pate llar a rti cul ar
s ur face of th e fem u r.
T h e p atel la pr ovi des a b on y su r face th at is a ble to wi th stan d the com p ressi on p laced o n th e q ua dr icep s te nd on
P. 5 9 4
d u ri ng kn eel in g an d the f rict ion o ccur r in g wh en th e k nee is fl exed an d exten de d du ri ng r u nn in g . Th e pate lla also p ro vid es
a dd iti on al lever ag e f or th e q u adr icep s i n pl acin g th e t end on m or e an teri or ly, f art her f ro m th e j oin t's axi s, cau sin g it to a pp ro ach
t he tib ia fr om a p ositi on o f g r eater m ech an ical ad van tag e. Th e in fer io rly d ire cted ap ex o f the pa tell a i nd icate s th e l evel of th e joi nt

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p la ne of th e knee wh en t he leg i s exte nd ed an d th e p atel lar li ga men t is tau t.
Tab le 5.3-I I. M us cles o f the Anter io r Thig h: E xtenso rs of the Knee
Musc le
Pr o ximal Attachment
Inner vatio n a
Ma in Actio n
Qua dr icep s
fem or is (fi g.
E H )
Rect us
fem or is
Vastu s
later al is
A nte rio r in fer io r ili ac

sp in e a nd i liu m
V ia com mo n ten di no us (qu ad ri ceps

ten d on ) an d in de pen d ent atta chm en ts
Fe mo ral
ner ve (L2 ,
E xten d leg a t
kn ee joi n t; r ectu s
su pe rio r to
ac et abu lu m
to ba se o f pate lla; in di rect ly v ia

p atell ar li gam en t to t ibi al tu ber osit y;
L3, L 4)
f em or is a lso
ste adi es h ip j oin t
Gr eater tr och an ter

an d la tera l l ip of
m ed ial an d late ral vast i a lso attach t o

tib ia an d pa tell a vi a a pon eu ro ses
a nd h elp s
i lio psoa s f lex
(m ed ial an d late ral p atell ar r etin acu la)
th ig h
li ne a asp er a o f fem u r
Vastu s
I nte rtr och an ter ic l in e
m edi alis
an d m ed ial lip o f
li ne a asp er a o f fem u r
Vastu s
in ter me diu s
A nte rio r an d later al

su rf aces of sh aft of
f emur
a Th e
spi nal co rd seg m ent al in ner vati on is in d icated (e. g ., L 1 , L2 , L 3 m ean s th at th e n er ves su p ply in g the
qu ad ri ceps fem or is ar e d er ived f rom th e f ir st th r ee l um b ar seg men ts of th e sp in al cor d). Nu mb er s i n bo ldf ace (L3, L 4)
in di cate the m ain se gm en tal in n erva tion . Dam ag e to on e or m or e o f the li sted spi na l co rd se gm en ts o r to the m otor n er ve
ro ots ari sin g fr om th em resu lts in p ar alysi s of th e m uscl es co ncer n ed.
T estin g th e qu ad rice ps is p er for m ed w ith th e p er son i n th e su pi ne p ositi on w ith th e knee p artl y f lexed . T he pe rson exten ds th e
k nee ag ain st resi stan ce. Dur in g th e te st, con tr actio n of th e r ectu s f em or is sh ou ld b e obse rvab le an d pa lpa bl e if t he m uscl e i s
a ctin g n orm al ly, i nd icati ng t hat its n erve su pp ly is in tact.
R ec t u s F em o ri s
T h e r ectus f emo ri s r eceive d its nam e be cause it r un s st rai gh t d ow n th e th ig h (L . re ctus, strai gh t). B ecau se o f its attach m ent s to
t he h ip bo ne an d tib ia, the r ectu s fe mo ri s cr osses two jo in ts; h en ce i t i s cap ab le of fl exin g th e th ig h at th e h ip j oin t and e xten din g
t he leg a t th e knee jo in t. Th e rect us fem or is is the on ly pa rt of th e q u adr ice ps tha t cr osses the h ip jo in t, an d as a h ip f lexo r it acts
w ith and l ike th e i liop soa s d ur in g th e p re swin g an d in iti al swi ng p ha ses o f wal kin g (Tab le 5. 2 ). Th e abi lit y of th e rect us fem or is to
e xten d the kn ee is co mp r om ised d ur in g h ip f lexio n, b u t i t d oes con tri bu te to the exten sio n fo rce du r in g the to e of f ph ase, wh en th e
t hi gh i s exte nd ed. It is p ar ticu lar ly ef fici en t in mo vem ent s com b in in g kn ee ext ensi on an d h ip f lexio n fr om a p ositi on o f hi p
h yp er exten sion a nd kn ee fl exion , a s in t he pr ep ar ator y p osit ion f or ki ckin g a so ccer ba ll. T h e r ectu s f em ori s, th e ki ckin g
m u scle, is suscep tib le to in ju ry an d avu lsio n fr om the an ter ior i nf er ior i liac spi ne d ur in g kicki ng . A lo ss of f u ncti on of t he re ctus
f em or is ma y r edu ce th igh flex ion str en gt h by as m u ch as 1 7% (Mar khe de an d Sten er , 1 98 1 ).
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V as tu s M u sc le s
T h e n am es of th e th r ee l arg e vastus muscl es (va sti) in dica te th ei r pos itio n ar ou nd th e fem or al sh aft (Fig . 5. 1 5 ; Ta bl e 5 . 3-I I):
V astus late ral is, th e lar ges t com p on en t of th e qu ad ri ceps, l ies on th e later al sid e o f th e th ig h.
V astus med ial is co ver s th e m ed ial si de of th e t hi gh .
V astus inter med ius lies dee p to the r ectus fe mo ri s, betw een th e vastu s m ed ial is a nd th e vastu s l ater ali s.
I t is d if fi cul t to iso late th e f un cti on of th e thr ee vastu s m u scles.

T h e sm al l, fl at arti cular muscl e o f the knee (L. arti cul ar is g en us), a d er ivati ve o f t he vastu s i nt erm ed iu s (Fig . 5 .1 6 ), u sua lly
c on sists o f a va ri abl e n u mb er of m u scu lar sl ips th at a ttach
P. 5 9 6
s up eri or ly to t he in fer io r pa rt of th e a nter io r asp ect o f t he fem u r an d in fe rio rl y to th e syno vial m em br an e o f the kn ee join t an d the
w all o f the su pr ap atell ar bu r sa (T ab le 5. 3A). T hi s m u scle pu lls th e syn ovi al m em br an e su pe rio rl y d ur in g exte nsi on of th e leg ,
t her eb y p re vent in g fol ds of th e m em b ran e fr om b ein g com p resse d betw een th e fem u r an d the p atell a w ith in t he kn ee j oin t.
Fig ure 5.16. Supr ap atel lar b ursa and ar ticul ar muscle of knee . A and B. T h e l arg e su p ra patel lar b u rsa, no rmall y a
po ten tial spa ce ex tend in g b etwee n the q ua dr icep s an d th e f em u r, i s d epi cted as if in jecte d with latex. C. In t hi s d eep
di ssection of th e kn ee re gio n, the pr oj ected ou tl in e of t he fem u r is in di cated b y a re d br oken l in e an d th e exten t o f the
sup r apa tella r bu r sa i s in d icated b y a b lu e b ro ken li ne. A C . Th e arti cu lar m u scle of th e kn ee is sh ow n as exten di n g fr om th e
di stal fem u r to attach to t he bu r sa. Th is m uscl e b len d s w ith th e deep a spect of th e v astu s in ter m edi us.
Th e l arg e an teri or com p art me nt of th e t hi gh i ncl ud es t he fl exor s o f t he h ip an d exten sor s o f the kn ee, w ith m ost m uscl es
in ner vate d by the f emo ra l n er ve. T he qu ad ri ceps fe mo ri s acco un ts for m ost of th e ma ss of t hi s com p art me nt. I t sur ro un d s th e
fem u r on th r ee si des an d ha s a com m on ten d on of a ttach me nt to th e ti bia , wh ich i ncl ud es the p atell a a s a sesam oid b on e. Maj or
mu scle s of th is com p artm en t atr oph y rap id ly wit h di sease or d isu se, re qu ir in g ph ysica l th er ap y to r etain or r estor e f un cti on .
Hi p a n d T hi g h C o n t us i o n s
Sp or ts b ro adca sters an d tra in ers re fer to a hi p po in ter, wh ich i s a con tu sion o f the il iac crest th at usu al ly o ccur s at i ts
an teri or p art (e. g. , wher e the sar tor iu s a ttach es to th e ASI S). This i s o ne of th e mo st co mm on in ju ri es to the h ip r eg ion , u su ally
occu rr in g in a ssociat ion w ith co lli sion sp or ts, su ch as the var io us fo rm s o f foo tba ll, i ce h ocke y, an d voll eyba ll. Co ntusio ns cau se
ble edi ng f ro m r up tu red ca pil lar ies an d in fil tr ation of bl ood i nto th e mu scle s, ten don s, a nd o ther soft tissu es. T he ter m h ip p oin ter
ma y al so r ef er to avu lsio n of b on y m u scle attach m en ts, fo r exam pl e, of th e sart ori us or r ectu s f em or is t o th e an teri or il iac spi nes,

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o f th e h am str in gs fr om th e isch iu m (see clin ica l co rr ela tion [b lu e] box Ha mstr in g I nj ur ies, in th is cha pter ), or of th e
i lio pso as f ro m th e l esser tr och an ter of th e fem u r). H ow ever , th ese i nj ur ies sh ou ld be cal led avu lsi on f ract ur es.
A n oth er ter m com m on ly use d is ch ar ley ho rse , wh ich m ay r efer e ith er to th e cr am pi ng o f an in di vid ua l t hi gh m u scle beca use
o f isch em ia or to con tu sion and r u ptu r e o f blo od vessel s su ff icie nt en ou gh t o f or m a hem at om a. Th e in ju ry is usu al ly the
c on sequ en ce o f tear in g of fi ber s o f the r ectu s f emo ri s; so met im es th e qu ad ri ceps ten do n is a lso pa rti ally tor n . Th e mo st co mm on
s ite of a t hi gh h em ato ma is in th e qu ad ri ceps. A ch ar ley h orse is associ ated w ith l ocali zed pa in an d /or m uscl e sti ff ne ss an d
c om mo nl y f oll ows di re ct tr au ma (e. g ., a stick sla sh in h ockey or a tackl e i n fo otba ll).
P so a s A b sc e s s
T h e p soas m ajor ari ses i n th e ab do m en fr om t he in ter ver tebr al di scs, th e si des of th e T 1 2 L 5 ver teb ra e, an d the ir tr an sverse
p r ocesses. T h e m ed ial ar cua te l iga me nt of th e dia ph ra gm a rch es obl iq uel y o ver th e p ro xim al pa rt of th e p soa s m ajo r (see C h ap ter
2 ). T h e tr an sver salis fa scia on th e i nt ern al ab do mi na l w all is con tin u ou s w ith th e pso as f ascia, wh ere it fo rm s a f ascia l co veri ng f or
t he pso as m aj or th at accom p an ies t he m uscl e i nto th e ant eri or r egi on of th e th igh .
T h ere is a r esu rg en ce o f tu ber cul osis (TB ) i n Af ri ca, Asi a, an d else wh er e. A ret rop er iton eal p yog enic (p us-f or mi ng ) i nf ectio n in t he
a bd om en or gr eater p elvi s, ch ara cteri stical ly occu rr in g in a ssociati on w ith T B of th e ve rteb r al colu m n, o r secon d ary to re gio na l
e nte rit is o f the il eu m (Cr oh n d isease ), ma y r esu lt in th e f or m atio n of a psoa s ab scess. Wh en th e absce ss p asses b etw een th e psoa s
a nd i ts f ascia to th e i ng u in al and p r oxim al th ig h re gio ns, sever e p ain m ay be r efer r ed to the h ip , th igh , o r knee jo in t.
C on seq u entl y, a pso as ab scess sho ul d alw ays b e con side red w he n ede ma occu r s in the p rox im al par t of th e th ig h . Su ch an a bscess
m ay b e p alp ated o r obse rved i n th e i ng u in al reg ion , j ust in fe rio r or su pe ri or to th e in g ui na l l ig am ent , an d ma y b e m ista ken f or an
i n dir ect in gu in al h ern ia or a f emo ra l h er n ia, an enl arg em en t o f the in g ui nal l ymp h n od es, or a sap he no us var ix (s ee cl in ical
c orr ela tion [blu e] bo x Sa ph en ou s V ari x, in thi s ch ap ter). Th e l ater al bo rd er of th e psoa s is com m on ly visib le in r ad iog ra ph s
o f th e ab do m en; an o bscu red p soa s sh ado w m ay b e a n in di catio n of ab do mi na l p ath ol ogy.
P a r a l ys i s o f th e Qu a d r i ce p s
A p er son w ith a pa ral yzed q ua dr icep s can n ot exten d th e le g aga in st r esista nce an d usu al ly pr esses o n th e d ista l en d of t he th igh
d u ri ng w alki ng t o p re vent in ad ver ten t f lexio n of th e knee jo in t. Weakn ess of th e va stus m edi ali s or v astu s la tera lis, r esu lti ng f ro m
a rth r itis or tr au m a to th e kne e j oin t, f or exam p le, can resu lt in a bn or m al pate llar m o vem ent an d loss of j oin t st abi lity.
C h o n d r o m a la c i a P a te l l a e
C ho ndr o malac ia p atel lae (r un n er' s kn ee) is a com m on k nee p rob lem for ma rath on ru n ner s. S uch o ver stressi ng o f the kn ee can
a lso occu r in r u nn in g sp or ts su ch as bask etba ll. T he sor en ess a nd ac hi ng ar ou n d or d eep to th e p atel la r esu lts fr om q u adr ice ps
i mbal an ce. C hon d ro ma lacia p atell ae ma y r esu lt f r om a bl ow to th e p atell a o r extr em e f lexi on of th e kne e (e. g ., d u rin g sq ua ttin g
w h en po wer l if tin g).
P a te l l a r Fr a ct u r e s
A d ir ect blo w to the p atell a m ay fr actu r e it in two or m or e fr agm en ts. T ran sver se pate llar f r actu res m ay r esu lt fr om a bl ow to th e
k nee or su d den co nt racti on o f the qu ad r icep s (e. g. , w hen on e sl ips an d attem p ts to p reve nt a backw ar d fal l). T he pr oxi ma l
f r agm en t is p u lled su p eri or ly w ith t he qu ad ri ceps ten do n, and t he di stal fr ag me nt re ma in s wi th th e p atel lar l ig am ent.
A b n o r m a l O s s if i c a ti o n o f t he P a t e ll a
T h e p atel la is ca rti lag in ou s at bi rth . I t b ecom es ossif ied d u ri ng th e 3r d 6th year s, fr equ en tly fr om mo re th an on e ossif icati on
c ente r. A lth ou gh thes e cen ter s u su all y coa lesce an d for m a sin gl e b on e, th ey ma y r em ain se par ate on o ne or b oth si des, g ivi ng r ise
t o a b ip ar tite or tr ip ar tite p ate lla (Fig . B5 . 9). A n u nw ar y o bser ver m ig h t in ter pr et th is co nd iti on on a r ad iog ra ph o r CT as a
p atel lar f ra ctur e. Ossi fica tion abn or m ali ties are n ear ly alw ays b ila tera l; t her ef or e, di agn ost ic i ma ges sho ul d be exam in ed f ro m bo th
s ides . If th e def ects a re bi later al , the ab n orm al itie s ar e l ikel y o ssifi catio n abn or m ali ties.
Fig ure B5. 9
P a te l l a r T e n d o n R e f le x
T ap pi ng th e pate llar lig am en t w ith a re fle x h am m er no rm al ly elici ts th e pa tella r ref lex (kn ee jer k). Th is m yotati c (d eep ten d on )
r ef lex is rou ti nel y test ed du r in g a p hy sical exam in ati on b y h avi ng th e per son si t w ith l egs da ng lin g . A fi rm st rik e on the li gam en t
w ith a r efl ex h am m er u su ally cau ses t he leg to exte nd . I f t he re fle x is n orm al , a han d on the p erso n' s q uad r icep s sh ou ld f eel the
m u scle con tr act. T hi s ten do n r efle x test s th e i nt egr ity of th e f em or al ne rve an d th e L 2 L 4 sp in al cor d segm en ts. T app in g th e
l ig am ent acti vates muscl e sp in dl es in the q uad r icep s; af fer en t i m pu lses fr om th e spi nd les tra vel in th e fem or al n erve to th e
L 2 L4 segm en ts o f the sp in al cor d. Fr om h er e, eff er en t im p ul ses a re tra nsm i tted via m otor fib er s in the fe mo ral n er ve to th e
q u adr ice ps, r esu ltin g in a j erk-l ike con tra ction of th e m u scle an d exten sion o f th e le g at th e kn ee j oin t. D im in u tion or ab sen ce of
t he pa tell ar ten do n ref lex m ay r esu lt fr om a ny lesi on th at in ter ru pts th e i nn er vati on of th e qu ad ri ceps (e.g . , per ip h era l n er ve
d isea se).
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M e d ia l T h ig h Mu s cle s
T h e m ed ial th ig h m uscl es, col lectiv ely calle d the ad d ucto r g ro up, a re in th e m edi al com par tm en t o f the th ig h, i nn er vated
p r im ar ily by th e o btu ra tor n er ve (Fig s. 5 .1 5 a nd 5 . 17 ). T he ad du ctor gr ou p of th ig h m uscl es con si sts of th e ad du ctor l on gu s,
a dd uct or b revi s, ad ductor m ag nu s, g ra cili s, an d ob tur ato r externu s. I n ge ner al, the y atta ch pr oxi ma lly to th e an ter oi nf eri or
e xter ior o f t he bo ny p elvis (pu b ic b on e, i schi opu b ic r am u s, an d isch ial tu be ro sity) a nd a dj acen t ob tu ra tor m em br an e a nd d istal ly to
t he li nea asp er a o f t he fem u r (Ta bl e 5 . 4A ). Al l a dd ucto r m uscl es, excep t t he ha mstr in g p art of t he ad du ctor m ag n us p lu s
p ar t o f the p ectin eu s ar e su pp li ed by th e ob tu ra tor n er ve (L 2 L4 ). Th e pecti ne us is sup pl ied b y th e fem or al n erve (L 2 L 4 ),
a nd t he ha ms tri ng p ar t of t he ad du ctor m ag n us is su p pl ied b y th e tib ial pa rt of th e sci atic n erve (L 4). T h e d etail s o f t hei r
a ttach m ent s, ne rve sup p ly, an d acti on s of th e m uscl es ar e pr ovid ed in Tab le 5. 4 . Wh ile col lectiv ely these m u scles are th e
a dd uct ors of th e thi gh , th e action s of som e of th ese m u scles ar e m or e com ple x.
A d d u ct o r Lo n g u s
T h e ad d uctor l ong us is a lar ge, fan -sh aped m u scle an d is the m ost an teri or ly pla ced of th e a dd ucto r gr ou p . Th is tri an gu lar l on g
a dd uct or ar ises by a st ron g ten d on f ro m th e an ter io r aspec t of th e bo dy of th e p u bis ju st in fer ior t o th e pu b ic tu b ercl e (a pex of
t ri ang le) an d exp and s t o a ttach to th e l in ea asper a of th e f em ur (base of tr ian g le); in so do in g it cover s th e an teri or asp ects of th e
a dd uct or b revi s an d m id dl e of th e ad du ctor m ag nu s.
A d d u ct o r B r ev is
T h e ad d uctor b r evis, o r sho rt ad du ctor , li es d eep to th e p ectin eu s a nd a dd ucto r lon g us wh er e i t ar ises fr om the b ody an d in fer io r
r am u s o f the pu b is. I t w id ens as it p asses di stall y to att ach to th e u pp er mo st p ar t o f the li nea asp er a. As th e o btu ra tor n er ve
e me rg es f ro m th e o btu r ator can al to en ter th e me dia l co mp ar tm en t of th e th igh , i t sp lits in to an an ter io r an d a p oster io r div ision ,
t he two d ivi sion s p assin g an ter ior and p oste rio r to th e ad du cto r br evis. T h is u n iq ue re lati on shi p is u sef ul in id enti fyi ng th e m uscl e
i n d issectio n an d in an ato m ical cr oss sect ion s.
A d d u ct o r M ag n u s
T h e ad d uctor ma gnus is th e lar ge st (m ost po wer fu l) an d m ost p oste rio r m uscl e i n th e ad du cto r gr ou p. T h is l arg e add u ctor is a
c om posi te, tr ian g ul ar m uscl e w ith a th ick, m ed ial m ar gi n th at h as an ad du cto r par t and a h am stri n g p ar t. T he two p ar ts d iff er in
t hei r attach m en ts, n erve su pp ly, a nd m ai n actio ns (Ta ble 5 .4 ). T he ad du ctor p ar t f an s o ut wi del y f or ap on eu rot ic d ista l a ttach me nt
a lon g th e e nti re len g th of th e l in ea aspe ra of th e f em u r, ext end in g in fe rio rl y o nto th e med ia l su p raco nd yla r ri dg e. Th e ham str in g
p ar t h as a t end in ou s d ista l a ttach m ent to th e ad du cto r tub er cle.
P. 5 9 8
Fig ure 5.17. Femo ral tr iang le. A. T he b ou nd ar ies and co nt ents of th e fem or al tr ian gl e ar e sho wn . Ob serve th e str u ctu res
th at b ou n d the tr ian gl e: th e in gu in al li gam en t sup er ior ly, th e add u ctor lo ng u s m ed ial ly, an d th e sa rto riu s later al ly. S up eri or ly,
th e f em ora l n er ve and v essels ent er th e b ase of th e tr ian g le; in fer ior ly, they exi t f rom its ape x. B. I n th is dee per d issecti on ,
sectio ns ha ve b een r em oved f ro m th e sa rto ri us an d the f emo ra l ve ssels and n er ve. Ob serv e th e mu scles fo rm in g th e flo or of
th e f em ora l t ria ng le: th e i liop soa s la tera lly an d the p ectin eu s m ed ial ly. Of th e n eu r ovascu lar st ru ctu res at the ap ex o f the
fem or al tr ian gl e, th e t wo an ter ior vesse ls (f em or al ar tery an d vein ) and t he two n er ves en ter t he ad du ctor ca nal (an ter io r to
add u ctor l on gu s), an d th e tw o post eri or vessel s (d eep ar ter y an d vei n of th ig h) pa ss d eep (po ster ior ) to th e add u ctor lo ng u s.
G ra ci lis
T h e g r acili s (L . sle nd er) is a l on g, st rap -li ke m u scle an d is th e m ost m ed ial m u scle of th e th ig h . It is the m ost sup er fi cial of th e
a dd uct or g rou p an d th e w eakest m em ber . I t i s th e o nl y o ne of th e gr ou p to cros s th e kn ee jo in t as wel l as th e hi p joi nt, joi ni ng
w ith two oth er tw o-jo in t m u scles fr om t he oth er tw o com par tm en ts (th e sart ori u s an d sem iten d in osu s m u scles. T hu s the th ree
m u scles ar e i nn er vated b y th r ee dif fer en t n er ves). T he y h ave a co mm on ten din ou s in serti on , th e p es anser inus (L . g oose's fo ot),
i n to th e up p er pa rt of th e m ed ial su rf ace of th e ti bi a. Th e gr acil is is a syn er gist in a dd uct in g the th ig h, f lexi ng t he kn ee, an d
r ot atin g th e l eg me dia lly wh en th e kn ee i s f lexed . It acts wi th the o ther p es anse rin u s m u scles to ad d stabi lity to th e m ed ial
a spect of th e exten ded k nee, mu ch as th e g lu teu s m axi mu s an d tens or of th e fasci a l ata do via th e i lio tib ial tr act o n th e l ater al
s ide.

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O bt u r at o r Ext er n u s
T h e o btur ato r exter nus i s a fl at, r elati vely sm all, fan -sh aped m u scle th at is d eep ly pla ced in th e sup er om edi al par t of th e th ig h .
I t exten ds fr om th e exter n al sur fac e of th e ob tur ato r me mb r ane an d su rr ou n din g b on e o f t he pe lvis to the p oster ior a spect of th e
g r eater tr och an ter , pa ssin g di rectl y u n der th e acetab u lu m an d n eck o f t he fem u r .
A c ti on s of th e A dd u c t or M u sc le G r ou p
Fr om t he an atom ic al posi tion , th e ma in acti on o f t he ad du ctor m u scle gr ou p is to pu ll th e th ig h m ed iall y, tow ar d or p ast t he
m ed ian pl ane . Th re e ad du cto rs (lon gu s, b re vis, an d m ag nu s) a re u sed in al l m o vem ent s in w h ich th e thi gh s a re ad du cted (e. g. ,
p r essed tog eth er wh en r id in g a ho rse). Th ey a re use d to st abi lize th e sta nce wh en st and in g on both feet, to co rr ect later al sw ay o f
t he tr un k, or wh en th er e is a sid e-to-sid e shi ft of th e su r face on w h ich on e is st and in g (r ockin g a bo at, stan d in g on a bal an ce
b oa rd ). Th ey are al so u sed i n kickin g w ith th e me dia l si de of th e foo t i n soccer an d in swim m in g . Fin ally, they con tr ib ute to fl exio n
o f th e exte nd ed th ig h an d exten sion of th e f lexed t hi gh w he n ru n ni ng o r ag ain st r esist ance .
T h e ad d ucto rs as a g ro up co nsti tut e a lar g e m u scle ma ss. Alt ho ug h th ey a re im po rt ant in m an y activi ties, i t h as bee n sho wn th at a
r ed uct ion o f as m u ch as 70 % in t hei r fu n ction w il l r esu lt in o nl y a slig h t to m od era te i mp ai rm en t o f hi p fu nct ion (Mar kh ede an d
S ten er , 19 8 1 ).
T estin g of t he m edi al thi gh m u scles is per fo rm ed w hi le the p erso n is lyin g su pi ne wi th th e kn ee str aig ht. Th e p er son ad du cts the
t hi gh a gai nst re sistan ce, an d if th e ad du ctor s ar e no rm al , th e p ro xim al en ds of th e g ra cili s an d ad du ctor l on gu s ca n easil y b e
p al pate d.
P. 5 9 9
T ab le 5. 4. Muscle s o f the Med ia l T hig h: Ad ducto rs of the Thig h
Muscl e a
Pr ox imal
Attachment
Addu ctor
lon g us (E &
B ody of p ub is
in f eri or to pu b ic
G)
cr est
Di stal Attachment
Mi dd le th ird o f lin ea
asper a of fe mu r
I nnervat ion b
Obt ur ato r ner ve, b ra nch
of an ter io r div isio n (L2 ,
M ain Acti on
A dd ucts th ig h
L 3, L4 )
Addu ctor
B ody an d in fer io r
Pectin eal l in e an d
Obt ur ato r ner ve (L2 , L 3,
A dd ucts th ig h; to
br evis (F &
G)
r am us of p ub is
pr oxim al p ar t of l in ea
asper a of fe mu r
L4 ), b r anch of an ter ior

di visi on
som e exten t flex es it
Addu ctor
m agn u s (C ,
A dd ucto r pa rt:
in f eri or r am us of
Ad du ctor p ar t: g lu teal
tub er osity, lin ea aspe ra,
Ad du cto r par t: obt ur ator

n erve (L 2, L 3, L 4),
A dd ucts th ig h
A dd ucto r pa rt: fl exes
D, & G)
p ub is, r am u s of
is ch iu m
med ia l su p raco nd yla r lin e

Ham str in gs pa rt:
br an ch es o f post eri or
di visi on
th ig h
H am stri ng s p ar t:
H am stri ng s p ar t:
isch ia l t ub ero sity
add u ctor tu be rcle of

femu r
Ha mst rin g s p ar t: ti bia l

pa rt of scia tic ner ve (L4 )
exte nd s th ig h
B ody an d in fer io r
r am us of p ub is
Su per io r par t of m edi al

sur fa ce of t ibi a
Obt ur ato r ner ve (L2 , L 3 )
A dd ucts th ig h; fl exes
le g; hel ps ro tate it
Graci lis (H)
m ed iall y

08-May-15
Obtu rator
exter nu s
Mar gi ns of ob tu rat or
f ora me n an d
Page 40 of 155
Tr och an teri c f ossa of

femu r
Obt ur ato r ner ve (L3 , L 4)
ob tu ra tor m em br an e
L ater all y r otate s

th ig h; stead ies h ead
of f em ur in
ac et abu lu m
a C oll ectivel y,
th e f ive mu scl es li sted ar e t he ad du ctor s o f the th ig h, b u t th ei r actio ns ar e m or e co m ple x (e. g. , th ey act a s

fl exor s of th e hi p joi nt d ur in g fl exio n of th e kn ee jo in t an d ar e a ctive du r in g wal kin g).
T he spi na l co rd se gm en tal in ne rvat ion i s i nd icate d (e.g . , L2 , L3 , L 4 m ean s tha t th e n er ves sup pl yin g th e ad du cto r
lon g us ar e d eri ved fr om the secon d to f ou rth l um b ar seg me nts of th e spin al cor d ). Nu m ber s i n bo ld face ( L 3) in d icate th e
P. 6 0 0
Th e m u scles of th e m edial co mp ar tm ent of th e thi gh a ttach p ro xim all y to th e ant ero in fer ior b on y pel vis a nd d ista lly to the li nea
aspe ra of th e f em u r. T he y ar e a dd uct ors of th e thi gh , in n er vated p ri mar il y b y th e ob tur ato r ne rve. U se o f t hese m u scles a s p ri me
mo ver s is re lativ ely lim ite d.
A d d u ct o r H iat u s
T h e ad d uctor hia tus is an o pen in g or g ap b etwe en th e ap on eu ro tic dist al attach m en t of th e ad du ctor p ar t of t he ad du ctor m ag nu s
a nd t he ten di no us di stal attach m en t o f the h am stri ng p ar t. Th e add u ctor h iatu s tra nsm its th e f em or al art ery an d vein f ro m th e
a dd uct or can al in th e th igh to t he po pl iteal f ossa post eri or to th e kn ee (Tab le 5 .4 ). T he op en in g is l ocated j u st la tera l a nd su p eri or
t o th e ad du ctor tu b ercl e o f the fe mu r .
T r a n s p l a n ta t i o n o f t h e G r a c i li s
Becau se th e g ra cilis is a r ela tivel y w eak mem b er of th e add u ctor g ro up o f mu scles, it can be r em oved w ith ou t n oti ceab le l oss of its
actio ns on th e leg . Hen ce, su r geo ns of ten tr an spla nt th e g ra cili s, or p art of i t, wi th its n erve an d bl ood ve ssels t o r ep lace a
dam ag ed m u scle i n th e h an d, for e xam pl e. Once th e m u scle is tra nsp lan ted , it soo n pr od uces g ood d ig ital fl exio n an d exten sion .
Fr eed f ro m its di stal attach m en t, th e m u scle h as al so been r el ocated a nd r epo siti on ed to crea te a r epla cem ent f or a no n-f un cti on al
exter na l a nal sp hi nc ter.
G r o in P u ll
Sp or ts b ro adca sters re fer to a pu ll ed gr oin or g roi n in ju r y. Th ese ter ms m ean th at a st rai n, stretch in g , an d pr ob abl y
som e te ari ng o f the p rox im al attach m en ts of t he an ter om edi al thi gh m u scles h as o ccur r ed. T he in ju r y u su ally in vol ves t he fl exor
an d add u ctor th ig h m uscl es. Th e pr oxim al at tach me nts of th ese mu scle s ar e i n th e i ng u in al reg ion (gr oin ), th e ju nct ion o f the
thi gh a nd tr u nk . Gr oi n pu ll s u su ally occu r in spor ts tha t r equ ir e qu ick star ts su ch as sh ort -dist ance r acin g (e. g. , a 60 -m sp r in t),
base steal in g in b aseb all , an d qu ick star ts i n bask etbal l.
I nj u r y to t h e A d d u c to r L o n g u s
Mu scle str ain s o f th e ad du cto r lon gu s ma y occu r i n ho rseb ack ri der s a nd p ro du ce pai n (ri der 's str ain ). Ossif icati on som eti m es
occu rs in th e ten don s of th ese m u scles beca use th e h or seb ack r id er s acti vely ad du ct th ei r thi gh s to ke ep fr om f all in g fr om th ei r
an im als. T he ar eas of th e o ssifi ed ten do ns ar e so met im es ca lled r id ers' b on es.
N e u ro v a s cu la r S tr u ct u re s a n d R e la t ion sh ip s in th e A n t e ro m e d ia l Th ig h
F em o ral T ri an g le
T h e f em or al tri ang le, a su bf asci al space, is a tr ian gu la r lan d ma rk usef u l i n di ssectio n an d in u n der stan di ng r el ation sh ip s i n the
g r oin . (Fig s. 5 .1 5A & B , an d 5. 1 7 , 5. 1 8 an d 5 .1 9 ). In livi ng p eop le it app ear s a s a tr ian gu lar dep res sion i nf er ior to th e i n gu in al
l ig am ent w hen the th ig h is flex ed, a bd ucte d, an d la ter ally r otated . (Fig . 5 .1 5A) Th e f em or al tri an gle is bo un d ed:
l
l
S u per io rly b y th e i ng u in al lig am en t (th e th icken ed in fe rio r m arg in o f the exte rn al ob liq u e ap on eu ro sis) t hat fo rm s the b ase o f
t he fem o ral tr ian g le.
Med ia lly by th e ad du cto r lon g us.
L ater al ly b y the sar tor iu s; th e ape x is wh er e t he late ral b or der o f the sar tor iu s cr osses th e m ed ial b or der o f the ad du ctor
l on gu s.
T h e m u scul ar fl oor o f th e f em ora l t ria ng le is for m ed by th e i lio pso as l ater ally an d th e p ectin eu s m ed ial ly. T he r oof of th e fem or al
t ri ang le is for m ed b y th e f ascia la ta a nd cr ib ri fo rm f ascia , sub cu tan eou s ti ssue , an d skin .
Dee p to t he in gu in al li gam en t, th e subi nguina l sp ace (cr eated as th e i ng ui na l l ig am ent sp ans th e g ap b etwe en th e tw o bon y
p r om in en ces to w hi ch it is a ttach ed, the AS IS a nd p ub li c tu be rcl e) is an i mp or tan t p assag eway co nn ecti ng th e
t ru n k/abd om in op elvi c cav ity t o th e low er li mb . T he in gu in al li ga men t actu all y ser ves as a fl exor r etin acu lu m , r etain in g str uct ur es
t hat p ass a nter io r to the h ip jo in t a gai nst th e j oin t du ri ng f lexi on of t he th igh . T he p assag eway po ster ior to th e lig am en t is di vid ed
i n to tw o com pa rtm en ts, or lacu na e, by a thi cken in g of th e i lio psoa s f ascia, the il iop ecti neal arch (Fig . 5. 1 9) , wh ich p asses
b etw een th e deep su r face of th e in gu in al li gam en t a nd th e ili op ub ic em in ence (Fig . 5 .6B). Late ral to th e a rch i s th e mu scu lar
l acu na , th rou g h wh ich the il iop soas mu scl e an d f emo ra l n er ve p ass fr om th e gr eater pelv is i nto th e an teri or th ig h; m edi al to the
a rch , th e vascu lar la cun a all ows pa ssage of th e ma jor va scul ar str uctu r es (ve in s, art ery, and l ym ph atics) b etween the g rea ter
p elv is a nd th e fem or al tr ian gl e o f the an ter ior t hi gh . As th ey en ter t he fem o ral tr ian g le, th e nam es of th e vessels cha ng e f r om

08-May-15
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e xter nal i liac to fem oral .

T h e co nten ts of th e f em or al tri an gle , fr om l ater al to me dia l, ar e t he:
Fem o ral n er ve an d it s (ter m in al) br an che s.
Fem o ral sh eath a nd i ts co nten ts:

l
Fem o ral ar ter y a nd seve ral of i ts b ra nch es.
Fem o ral vei n an d its pr oxim al tr ib u tari es (e. g ., t he gr eat sap he no us an d deep f em or al vein s).
Dee p in gu in al lym ph no des an d associ ated lym p ha tic vessels.

P. 6 0 1
Fig ure 5.18. D issecti on o f femo r al s he ath in femo r al tr ia ng l e. Th e falc ifo rm m ar g in of th e saph en ou s o pen in g in the
fasci a l ata is cut an d ref lect ed. N ote th at th e fem or al n erv e is exter n al an d later al to th e f em or al shea th, w h erea s th e fem or al
ar tery an d vein occu py the sh eath .
Fig ure 5.19. Structur e a nd contents o f fem or al sheath. Th is di ssectio n is of th e su p eri or en d of th e a nte rio r asp ect o f the
ri gh t t hi gh . No te th e com pa rtm en ts with in the fe mo ra l sh eath . T he p rox im al end (a bd om in al op en in g) of th e f em or al cana l i s
th e f em ora l r in g .

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Page 42 of 155
P. 6 0 2
T h e f em or al tri ang le is bi sected b y th e f em or al ar tery an d vein , w hi ch pa ss to an d fr om the ad du ctor ca na l i nf er ior ly at i ts a pex
( Fi g. 5 . 17A ). Th e a dd uct or can al is an in tr am uscu la r passa gew ay by wh ich th e m ajor n eu r ovascu lar b u nd le of th e thi gh tr aver ses
i ts m i dd le thi rd (Fig s. 5 .1 7B an d 5 .2 0 ).
F em o ral N er v e
T h e f emor al ner ve (L 2 L4 ) i s th e lar gest br an ch of t he lu m bar p lex us. T he n erv e or ig in ates in th e ab dom en w ith in the pso as
m aj or an d d escen ds po stero later al ly t hr ou gh the pe lvis to app r oxim atel y th e m idp oi nt of th e i ng u in al lig am en t (Fig s. 5 . 17A, 5. 1 8
a nd 5 . 1 9). I t t hen passes d eep to thi s l iga me nt an d en ters th e f em or al tri an gle , later al to th e f em or al vessels. A fte r ent eri ng th e
t ri ang le, the fe mo ral n er ve d ivi des in to sever al br an ches to th e an ter io r thi gh m u scles. It also sen ds ar ticu lar b r anch es to the h ip
a nd kn ee jo in ts an d p ro vide s sever al cu tan eou s b ra nch es to the an ter om edi al sid e o f the th ig h (Tab le 5 .1 ). T he ter mi na l cu tan eo us
b r an ch of th e f em or al ner ve, t he sap henous ne rve, d escen d s th ro ug h th e fem or al tr ian gl e, lat eral to th e fem or al sh eath
c on tain in g th e f em or al vessels (Fig. 5. 1 7B a nd 5 . 19 ). T he sap he no us ne rve accom p an ies the fe mo ral ar ter y a nd ve in th ro ug h th e
a dd uct or can al an d beco m es su pe rf icial b y p assin g b etwe en th e sar tor iu s and t he gr aci lis wh en th e fem or al vessels tr aver se th e
a dd uct or h iatu s a t th e di stal end o f th e can al . It ru n s an ter oi nf eri or ly to su p pl y th e skin an d fa scia on th e ant ero me dia l a spects of
t he kn ee, le g, an d f oot.
F em o ral S h e at h
T h e f emor al sheath is a f un n el-sh ap ed fa scial tu be of var yin g len g th (u sua lly 3 4 cm ) th at passes d eep to the in g ui na l
l ig am ent , lin in g th e v ascul ar la cun a of th e su b in gu in al spa ce. It ter mi n ates i nf er ior ly by bl en din g w ith th e adven ti tia of th e f em or al
v essels. T he sh eath en cl oses p r oxim al p art s of th e fem or al vessel s an d cr eates the f emo ra l ca nal m ed ial to th em (Fig s. 5 .1 8 an d
5 . 1 9). T h e sh eath is f or m ed by an in f eri or p rol on ga tion o f tra nsver sal is a nd i lio psoa s f ascia fr om t he ab dom en /g rea ter pe lvis (see
C h ap ter 2 ). Th e fem oral sh eath d oes no t en clo se th e fem or al n erve b ecau se i t p asses thr ou gh the m usc ul ar lacu n a. Wh en a lon g
f em or al she ath occu r s (w he n it exten ds far th er d istal ly), its m edi al wal l is p ier ced b y th e gr eat saph en ou s ve in an d lym p ha tic
v essels (Fi g. 5 . 1 8). T h e f em ora l s hea th all ows th e f em or al art ery an d vein to g lid e deep t o th e in gu in al li gam en t du ri ng m ov eme nts
o f th e h ip j oin t.
T h e f em or al shea th is sub di vid ed in ter na lly in to thr ee com pa rtm en ts by vert ical sep ta o f extra per ito ne al con necti ve t issu e th at
e xten d fr om th e abd om en a lon g th e f em or al vessels (Fig. 5. 1 9). Th e co mp ar tm ent s of th e fem or al sh eath ar e th e:
L ater al com p ar tme nt fo r the f emo ra l a rter y.
I n ter med ia te co mp ar tm ent fo r th e f em or al vein .
Med ia l co mp ar tm ent , wh ich co nsti tu tes th e fem or al can al.
T h e f emor al canal is th e sm al lest of th e th r ee com par tm en ts. It is sh ort (ap pr oxi ma tely 1. 2 5 cm ) a nd co ni cal and l ies betw een
t he m edi al edg e o f th e f em ora l sh eat h an d the f emo ra l ve in . Th e f em or al can al (Fi g. 5 . 1 9):
l
l
E xten d s d istal ly to t he leve l o f the proxi m al edg e o f the sap he no us op eni ng .

A ll ows th e f em or al vein to exp an d wh en ven ou s retu r n fr om the lo wer l im b is i ncr ease d or wh en i ncr ease d in tra-a bd om in al
p r essur e cau ses a tem po ra ry stasis in th e vein (a s
P. 6 0 3
d u ri ng a Va lsal va m an eu ver , i. e., takin g a br eath a nd h ol di ng i t, of ten wh il e b ear in g do wn ).
Fig ure 5.20. Add ucto r canal in med ia l p ar t o f m id dl e thir d of thi gh. A. Or ien tatio n dr aw in g sho wi ng th e can al
fo rm ed b etwee n th e th r ee th ig h m u scles and t he level o f the secti on sh own in p art B . B. T hi s tr an sver se sect ion o f the
th igh sho ws the m uscl es b ou n din g th e add u ctor can al an d its ne ur ovascu la r con ten ts.
C on tai ns lo ose con necti ve t issu e, fa t, a f ew lym p ha tic vessels, a nd so met im es a d eep in gu in al lym p h n ode (C loq u et n od e).
T h e b ase of th e f em or al cana l, f orm ed b y t he sm all (ap pr oxi ma tely 1 cm w id e) p ro xim al op eni ng a t i ts ab do mi n al end , is th e o val
f emo ra l r ing . Th is op en in g is cl osed b y ext rap er iton eal f atty tissu e th at fo rm s the tr an sverse ly o ri ent ed femo r al s eptum (Fig .
5 . 1 8). T h e ab d om in al sur fa ce o f t he sep tum is co ver ed by par ie tal per ito neu m (se e C h apte r 2). T h e f em or al septu m i s p ier ced by

08-May-15
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l ym ph ati c vessel s con n ectin g th e in gu in al an d exter na l i lia c lym p h n od es.

T h e b ou nd ar ies of th e f em or al ri ng a re
L ater al ly, th e verti cal sept um b etw een th e fem or al can al an d the f emo ra l ve in .
P oster io rly, the su per io r ram u s o f the p ub is cover ed by th e p ecti neu s and i ts f ascia .
Med ia lly, th e lacu n ar li gam en t.
A n teri or ly, th e med ia l p ar t o f the in gu in al l iga men t.
F em o ral A rt er y
Deta ils con cer ni ng th e or igi n, cou rse, a nd d istr ib u tion o f the ar ter ies of th e th ig h ar e descr ib ed in T abl e 5 . 5 .
T h e f emor al ar ter y, th e co nti nu ati on of t he exter n al ilia c ar ter y d ista l to th e in gu in al li gam en t, is th e ch ief a rter y to t he lo wer
l im b (Fig s. 5. 1 7 , 5. 1 8 , 5. 1 9 an d 5 .2 0 ). It en ter s th e fem or al tr ian gl e d eep to th e m id p oin t o f th e in g ui na l l ig am ent (m id way
b etw een th e ASI S an d th e p ub ic tu ber cle), l ater al to th e f em ora l ve in (Fig . 5 .2 0A). I ts p u lsati on s ar e pal pab le wi thi n th e tr ia ng le
b ecau se of its re lati vely sup er fici al po sitio n dee p (post eri or ) to th e f ascia lat a, wh er e i t l ies and d escen d s on the ad jacen t bor d ers
o f th e il iop soas an d pe ctin eus th at ma ke u p th e f loo r of th e t ria ng le. T h e su pe rf icia l ep ig astr ic arte ry, su p erf ici al (and so m etim es
t he de ep) cir cum f lex ili ac ar ter ies, a nd t he su per fi cial an d dee p exter na l p u den da l a rte rie s ar ise fr om t he an ter ior asp ect of th e
p r oxim al p art of th e fem or al ar ter y.
T h e d eep ar ter y o f the thig h (L. ar ter ia pr of un da f em ori s) i s th e l ar gest br an ch of th e fem or al ar ter y an d th e chi ef art ery to the
t hi gh . It ar ises fr om t he late ral o r post eri or sid e o f th e f em ora l a rter y in th e f em or al tri an gl e. In t he m id dle th ir d of th e th i gh ,
w h ere it is sepa rate d fr om th e fem or al ar ter y an d vei n by th e ad d ucto r lon g us (Figs. 5. 1 7B a nd 5 . 20B ), it gi ves o ff pe rf or atin g
a rte rie s th at wr ap ar ou nd t he po ster ior asp ect of th e f em ur . T he pe rf or atin g ar ter ies su p pl y m u scles of all th r ee f ascial
c om par tm en ts (ad d ucto r m agn u s, ha mst ri ng s, an d vastu s l ater ali s).
T h e ci rcu m fle x f em ora l a rter ies en cir cle the u pp er mo st sh af t o f t he fem u r an d an astom o se w ith ea ch oth er an d oth er ar ter ies,
s up pl yin g the th ig h m uscl es a nd th e sup er ior (p ro xim al) en d of th e f em u r. T he med ial cir cumf lex femo r al a rte ry is e speci ally
i m por tan t beca use it sup p lies m ost o f the b loo d to t he h ead an d th e n eck of th e f em ur vi a i ts b r anch es, th e po ster io r re tinacular
a rte ri es. Th e reti na cul ar ar ter ies are of ten to rn w he n th e f em ora l n eck is fr actu red o r th e h ip j oin t is d isl ocated . Th e later al
c ir cumf le x f emor al ar ter y, less abl e to su pp ly th e f em or al hea d and n eck as it p asses late ral ly acro ss th e thi ckest p ar t o f the
j oin t cap sul e of th e hi p joi nt , m ain ly sup pl ies mu scle s on the lat era l si de of th e t hi gh .
O bt u r at o r Ar te ry
T h e o btu ra tor ar ter y h elp s the de ep ar tery of th e thi gh su p pl y t h e a dd uct or m uscl es vi a a nte rio r an d po steri or b ran ch es, w hi ch
a na stom ose (Tab le 5 .5 ). T he po ster ior b ra nch g ive s of f an acet abu lar br an ch th at su p pli es t he he ad of th e f em u r.
P a lp a t io n, C o m p r e s s i o n , a nd C a nn u l a ti o n o f th e F em o r a l A r te r y
Th e i ni tial p art of th e fem or al ar ter y, pr oxi ma l t o th e br an chi ng o f th e d eep ar ter y of t he th igh , i s su per f icial in po sitio n, m aki ng i t
especi all y acce ssibl e a nd u sef ul fo r a nu m ber o f clin ica l p r oced ur es. S om e vas cul ar su rg eon s r efe r to thi s p art of th e fem or al
art ery as t he com m on f em or al arte ry an d to its co nt in uat ion d ista lly as t he su per fi cial fem o ral ar ter y. Th is ter m in olo gy is n ot
reco mm en d ed by th e Fed era tive In ter na tion al C om m ittee on A n atom ical T erm i no log y an d is n ot used i n th is b oo k b ecau se th ese
term s m ay cau se m isu nd er stan din g . An ter ior t o th e in iti al par t o f the f emo ra l a rter y are th e ski n, sub cu tan eou s ti ssue, sup er fici al
in gu in al lym p h no des, sup er fici al cir cum f lex ili ac ar ter y, cr ib rif or m f ascia, a nd th e an teri or p ar t of th e fem or al sh eath (Fig s. 5 . 10 ,
5. 1 2, and 5. 1 8).
With th e per son l yin g in th e sup in e posi tion , th e fem or al p ul se is pa lp ated m id way be tween the AS IS an d th e pu bi c sym p hysi s (Fig .
B5 .1 0A & B ). B y p lacin g th e tip of th e litt le f in ge r (of th e r ig ht h an d wh en d eali ng w ith t he ri gh t side ) on the AS IS an d th e tip of
the th u mb o n th e p ub ic tu ber cle, t he fem o ral p ul se can be pa lpa ted wi th th e m id p alm j ust in fe rio r to th e m id po in t o f t he in gu in al
lig am en t b y p re ssin g fir m ly. N or ma lly th e p ul se i s str on g; h owe ver, i f th e com m on o r exter n al ili ac ar ter ies ar e p ar tiall y o cclu ded ,
the p ul se m ay be di m in ish ed.
Co mp r ession o f th e f em ora l a rter y ma y al so b e accom pl ish ed at thi s si te b y p r essin g di rectl y p oster io rl y ag ain st the su per io r pu bi c
ram u s, p soas ma jor , an d fem o ral h ead (Fig . B 5. 1 0C ). C om pr essi on at th is p oi nt wi ll red u ce b loo d fl ow th ro ug h th e f em or al art ery
an d its b r anch es, su ch a s th e d eep ar ter y o f the th ig h.
Th e f em or al art ery m ay b e cann u late d ju st i nf eri or to th e m i dp oin t of th e in g ui na l l ig am ent . In l eft car dia l (ca rd iac) an gi ogr ap hy, a
lon g, slen der cath eter is in ser ted in to the ar ter y an d p assed u p th e exte rn al il iac arte ry, co m mo n ili ac a rter y, an d ao rta to th e l eft
ven tri cle o f th e h ear t (see C ha pter 1).

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Page 44 of 155
Fig ure B5. 10
T h is sa me ap pr oach via the f emo ra l a rter y ma y b e u sed to visu al ize the cor on ar y ar ter ies in co ro nar y arte ri ogr ap hy.
L a c e r a t io n o f t h e F e m o r a l A r t e r y
T h e su pe rf icia l p osi tion o f the f emo ra l a rter y in th e f em or al tri an gle al so m ake s it vu ln era bl e to tr au ma tic in ju ry, e speci ally
l acer atio n. Com m on ly, bot h the f emo ra l a rter y and v ein ar e lacer ated i n an ter ior th ig h w ou nd s b ecau se t hey li e clo se t oget her . I n
s om e case s, an ar ter iove no us shu n t o ccur s a s a re sul t of co m mu n icati on b etwe en th e i nj ur ed vessel s. Wh en it is nece ssary to
l ig ate the fe mo ral ar ter y, an asto mo sis of br an ch es of t he fem o ral ar ter y w ith o the r art eri es th at cro ss th e hi p joi nt, ma y su pp ly
b lo od to th e l ower lim b . How ever , th e cr u ciate an astom o sis, con sisti ng o f a f ou r-w ay com m on m eeti ng o f t he m edi al an d later al
c ircu m fl ex f em or al art eri es w ith th e in fer io r glu tea l a rter y sup er ior ly an d the fi rst p erf or atin g ar ter y in f eri or ly p oste rio r to th e
f em u r, o ccur s l ess co mm o nl y th an i ts f req u ent d escri pti on in textb ooks an d dep icti on in atlases im p lies.
R e p l a ce d o r A cc e s s o r y O b t u r a to r Ar te r y
A n en lar g ed pu b ic b ra nch of th e i nf eri or ep ig astr ic a rter y eith er take s th e p lace of th e ob tur ato r art ery (re pla ced ob tur ato r ar tery)
o r jo in s it as an accesso ry ob tur ato r ar tery in a pp ro xim atel y 2 0 % o f peo ple . Th is art ery ru n s cl ose to o r acr oss t he fem or al r in g to
r each the ob tu rat or fo ra men and wou ld b e cl osel y r elate d to t he n eck o f a f em ora l h er n ia. C on seq uen tl y, th is a rter y cou ld be
i n volved i n a stra ng ul ated f em ora l h er n ia. S ur g eon s p laci ng sta ple s d ur in g en do scopi c r epa ir of b oth i ng u in al an d fem or al h ern ia s
m u st also be vig il ant con cer n in g the po ssib le pr esen ce o f thi s com m on arte ria l v ari an t.
P. 6 0 4
P. 6 0 5
P. 6 0 6
F em or al V ei n
T h e f em ora l ve in is th e co nti nu ati on of t he po pl iteal vei n pr oxi ma l t o th e add u ctor h iatu s. A s i t asce nd s th r ou gh th e add u ctor
ca nal , th e f em or al vein l ies post ero later al an d th en po ster ior to th e fem or al ar ter y (Fig s. 5 .1 7A & B an d 5 .1 9 ). T he fem o ral vei n
e nter s the fe mo ral sh eath later al to th e f em ora l ca na l a nd en d s p oster ior to th e in gu in al li gam en t, w he re it beco me s th e e xter nal
i lia c vei n. I n th e i nf er ior p ar t o f the fe mo ral tr ian g le, th e fem or al vein rece ives the de ep vein o f the th ig h, the g reat sap he no us
ve in , an d oth er tr ib uta rie s. Th e d eep vei n of th e thi gh , f orm ed b y t he u ni on of th r ee o r fo ur p er for ati ng vei ns , ent ers th e f em ora l
ve in ap pr oxi ma tely 8 cm i nf eri or to th e i ng u in al lig am en t an d ap pr oxi m ately 5 cm i nf er ior to th e t erm in ati on o f t he gr eat
sa ph en ou s vei n.
T ab le 5. 5. Ar ter ies of the Ante ri or and M edi al Thig h

08-May-15
Ar ter y
Femo ra l
Or ig in
Page 45 of 155
Cour se
D istr ib ution
C on tin u ation of exter n al
Desce nd s th r ou gh f em or al tri an gle
Br an ches su pp ly ant eri or an d
il iac art ery di stal to

in g ui nal l iga me nt
bise ctin g it; the n cou rses th ro ug h

add u ctor can al; ter m in ates a s it
an tero me dia l a spects of th ig h
trav erses ad du ctor h ia tus, wh ere its

nam e bec om es p op litea l a rte ry
De ep ar tery
of th ig h
Fem or al art ery 1 5 cm

in f eri or to in gu in al
Passes deep ly be tween pecti neu s

and a dd uct or lo ng us; de scend in g
Th ree to fo ur per fo rati ng b r an ches

pass th ro ug h ad du ctor m ag n us
li gam en t
poste ri or to latt er on m ed ial sid e o f

femu r
mu scle , win d in g ar ou nd f em ur t o
sup pl y m u scles in m ed ial, post eri or ,
an d later al pa rt of an ter ior
com par tm en ts
Medi al
cir cum f lex
Deep ar ter y o f thi gh ;

m ay ari se f ro m fe mo ral
Passes me dia lly an d po steri or ly

betw een p ectin eu s a nd i liop soa s;
Su pp lie s m ost of b lood t o h ead a nd

neck of f em ur ; t ran sver se b r anch
fem or al
ar ter y
ente rs gl utea l r eg ion and g ives r ise

to p oste rio r re tin acu lar ar ter ies;
takes par t in cr uci ate ana stom osi s of

thi gh ; a scend in g b ran ch j oin s
then term i nat es b y d ivi din g in to

tran sver se and a scen din g b ran ch es
in fer ior glu tea l a rter y
Lat era l
cir cum f lex
Deep ar ter y o f thi gh ;

m ay ari se f ro m fe mo ral
Passes later al ly d eep to sar tor iu s

and r ectu s f em or is, d ivid in g in to
Ascen di ng b r an ch sup pl ies an teri or

par t of gl ute al reg ion ; tra nsver se
fem or al
ar ter y
ascen din g , tr ansve rse, a nd

descen d in g art eri es
br an ch wi nd s a rou n d fem u r ;
descen d in gb ra nch j oin s gen icu la r
per iar ticu la r an astom osi s
Obtu rator
I nter n al ili ac a rter y or

(in ~ 2 0 %) as a n
Passes thr ou g h ob tur ato r for am en ;

ente rs me dia l co m par tm en t o f t hi gh
An ter ior b ra nch sup pl ies obtu r ator

exter nu s, p ectin eu s, ad du ctor s o f
accesso ry or r ep laced
ob tu rat or ar ter y f ro m
and d ivi des in to an teri or an d

poste ri or br an ch es, wh ich pass on
thi gh , an d g raci lis; po ster ior b ra nch

sup pl ies mu scle s att ache d to i schi al
th e i nf er ior ep ig astr ic
ar ter y
resp ective sid es of ad du ctor b re vis
tub er osity
P o t e nt i a ll y L e t ha l M i s n o m e r
Cl in ical staf f, so me vascu la r lab or ator ies, a nd ev en som e text a nd r ef eren ce bo oks u se th e ter m su per f icial f em ora l v ein
wh en r efer r in g to the fe mo ral vei n be for e it i s j oin ed b y th e accom pa nyi ng ve in s of th e dee p arte ry of th e t hi gh (d eep f emo ra l

08-May-15
Page 46 of 155
v ein s). So me p rim ar y care p hysi cian s m ay n ot h ave b een tau g ht an d/o r ma y n ot re alize th at the so-ca lled su p erf icia l f em or al vein
i s a ctua lly a d eep vei n an d th at a cute th ro mb osi s of th i s vessel is po ten tial ly lif e th r eatenin g. Th e a dje ctive sup er fici al sho ul d no t
b e used b ecau se it im pl ies t hat th is vein i s a su per fi cial vein . Most p ul mo na ry em bol i ori gi na te i n dee p vein s, n ot i n su per fi cial
v ein s. Th e ri sk of emb oli sm can b e gr eatly r edu ced b y an tic oag ul ant tr eatm en t. Th e use of i mp r ecise lan guag e h er e cr eat es th e
p ossi bi lity th at a n acu te t hr om bo sis of th is t ru ly deep v essel cou ld b e ove rl ooked a s an a cute cli ni cal issu e, an d a lif e-th rea ten in g
s itu atio n crea ted. An atom ica l t erm in ol og y u sed in cl in ical r epo rts m ust be accu r ate to a void p ossib le li fe-th r eaten in g situ ati on s.
S a p he n o u s V a r ix
A l ocal ized d ila tion o f the ter m in al par t of th e g re at sa ph en ou s vei n, ca lled a sap heno us var ix (L. d il ated vei n), m ay cau se e dem a
i n th e f em or al tri an gle . A saph en ou s va ri x m ay be con fu sed w ith o ther gr oin sw ell in gs such as a p soas abscess (see clin ica l
c orr ela tion [blu e] bo x Pso as A bscess, in th is cha pter ); ho wever , a var ix sh ou ld be con sid ered w h en var icose vei ns are
p r esen t i n oth er p arts of th e low er lim b .
L o c a t io n o f t h e F e m o r a l V e i n
T h e f em or al vein i s n ot usu al ly p alp ab le bu t i ts p osi tion ca n be lo cated in f eri or to th e i ng ui n al l ig am ent b y f eeli ng th e pu lsat ion s o f
t he fe mo ral ar ter y, w hi ch is im me dia tely later al to th e ve in . In th in peo ple , th e f em ora l v ein m ay be close to th e su r face an d m ay
b e mi staken f or th e gr eat sap hen ou s v ein . It is im po rta nt th ere for e to kn ow t hat th e f em or al vein h as no tr ib ut ari es a t th is level ,
e xcept fo r th e g rea t sap h en ou s vei n th at j oin s i t a pp ro xim ately 3 cm i n fer ior t o th e in gu in al li gam en t. I n var icose vein ope rat ion s,
i t i s o bvio usl y i mp or tan t t o i den tif y t he gr eat sap hen ou s vein co rr ectly an d n ot t ie o ff th e fem or al vein by mi stake.
C a n n u la t i o n o f th e Fe m o r a l V e i n
T o secu re bl ood sam p les an d take pr essu re re cord in g s f rom the ch am ber s of th e r ig ht sid e o f the h ear t an d /or f rom the p ul mo na ry
a rte ry an d to p er fo rm r ig h t car di ac a ng iog r aph y, a lo ng , slen d er cath eter i s in ser ted in to th e f em or al vein a s it pa sses th r ou gh t he
f em or al tri an gl e. Un der f lu or oscop ic con tr ol, th e cath eter is pa ssed su per ior ly th ro ug h th e e xtern al an d com m on i lia c vei ns in to the
i n fer ior ve na cava an d ri gh t atri u m of th e h ear t. Fem or al ven ou s p u nctu r e m ay also b e u sed f or th e a dm in istr ati on of f lu id s.
Fig ure B5. 11
F e m o r a l He r ni a
T h e f em or al rin g is a weak ar ea in th e a nte ri or ab do mi na l w all th at no rm al ly i s o f a si ze su ff icie nt to ad mi t th e tip of th e litt le
f in g er. T h e f em ora l r in g is th e u su al or igi na tin g site of a fem or al h ern ia , a p r otr usi on of a bd om in al viscer a (ofte n a l oop o f sma ll
i n testin e) t hr ou gh the fe mo ral r in g in to th e f em ora l c ana l. A fe mo ral h er ni a a pp ear s as a m ass, ofte n ten der , in the fe mo ral
t ri ang le, in fer ola tera l t o th e pu bi c tu b ercl e (Fig . B 5. 1 1). Th e h er ni a i s b ou nd ed b y th e fem or al vein later all y a nd th e lacu n ar
l ig am ent m ed iall y. Th e her n ial sac com pr esses th e con ten ts of th e f em or al can al (loose con n ective tissu e, f at, a nd l ymp h atics) an d
d iste nd s th e wal l of th e can al . In iti all y, th e h er ni a i s sm all b ecau se i t i s con tai ne d with in the can al; bu t it can en lar ge b y p assin g
i n fer ior ly th ro ug h th e sa ph en ou s op en in g in to the su bcu tan eou s tissu e o f the th ig h. Fem o ral h er ni as ar e mo re com m on i n fem al es.
S tr an gu lati on of a f emo ra l h er ni a m ay occu r b ecau se o f the sh arp , r ig id bo un d ar ies o f the f emo ra l r in g , par ticu la rl y th e con cave
m ar g in of th e lacu n ar li gam en t. S tra ng ul atio n of a fem o ral h er ni a i nter f eres wi th th e b lo od su pp ly t o th e he rn iat ed in testin e. T hi s
v ascul ar im p air m ent m ay result in d eath of th e ti ssues.
P. 6 0 7
A d d u ct o r Can al
T h e ad d uctor canal (su b sarto ri al can al; Hu nt er can al) is a lo ng (a pp ro xim atel y 1 5 cm ), n ar row p assag ewa y i n th e m id dl e th ir d of
th e th igh . I t ex tend s fr om th e apex of th e fem or al tr ian gl e, wh er e t he sar tor iu s cr osses over th e add u ctor l on gu s, to th e addu cto r
h ia tus in th e ten do n of th e a dd ucto r m agn u s (Fig . 5 .2 0 ). Th e ad du ctor can al p ro vid es an i n term u scu lar p assag e f or th e f em or al
a rter y and v ein , th e sap h eno us n erve , an d the n erv e to vastu s me dia lis, d eli veri ng t he fe mo ral vesse ls to th e pop li teal fo ssa w h ere
th ey be com e th e pop li teal vessel s.
T h e ad du cto r cana l i s b ou n ded :
A n teri or ly a nd l ater all y b y th e vastu s m ed iali s.
P oster ior ly by th e a dd ucto rs lon g us an d m agn u s.
Med ial ly by the sar tor iu s, w hi ch over lie s th e g r oove be tween the ab ove mu scl es, fo rm in g th e r oo f of th e can al .

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I n th e in fer ior t hi rd to h alf o f the can al, a to ug h su bsar tor ia l o r vastoa dd uct or fa scia span s betw een th e add u ctor lo ng u s an d th e
v astu s m ed iali s m u scles, f or mi ng t he an ter ior w all of th e can al deep t o th e sar tor iu s. Beca use th is f ascia h as a d isti nct sup er ior
m ar g in , no vices di ssectin g in t hi s ar ea com m on ly a ssum e wh en th ey see th e fem or al vessel s p ass d eep to th is fasci a t hat th ey are
t rave rsi ng th e add u ctor h iatu s. T he ad du ctor h ia tus , ho wever , is lo cated at a mo re in fer io r level , ju st p r oxim al to th e m ed ial
s up ra con dyla r ri dg e. Th is h iatu s i s a ga p betw een th e ap on eur oti c ad du cto r an d the ten di no us h am stri ngs a ttach me nts of th e
a dd uct or m agn u s.
Th e p ri m ary n eur ova scul ar bu n dl e o f the th ig h, l ike th at o f the ar m , is pla ced on th e me dia l si de of th e lim b fo r pr ote ction . I n th e
up pe r thi rd o f the th ig h, t he bu n dl e i s m ost sup er fi cial as it e nter s deep to th e in gu in al li gam en t. T hi s r elati vely su per fi cial
posi tio n is i m por tan t for cl in ical p ro cedu r es. Al tho ug h th ey are essen tia lly ad jacen t, th e fem or al n erve tr aver ses th e mu scu lar
lacu n ae o f the su bi ng ui na l s pace, wh ere as th e fem or al vessel s tr aver se t he vascu lar l acu na e w ith in th e fem or al sh eath . Th e
fem or al vessel s b isect the f emo ra l tr ia ng le, w h ere th e p ri m ary vessel s of th e th igh , th e deep a rter y an d vein o f t he th ig h, a rise
an d term in ate , resp ecti vely. T he f emo ra l n er ve p er se ter mi na tes w ith in t he tr ian gl e. Ho wever , tw o of its br an che s, a m o tor
br an ch (n erve to vastu s m ed ial is) and se nso ry br an ch (sap he no us ne rve), a re pa rt of th e n eu r ovascu lar b u nd le th at t rave rses th e
add u ctor can al in t he m id dle th ir d of th e th ig h . Th e vascu lar str u ctur es the n pass th ro ug h th e a dd uct or h iatu s, b ecom in g po pl iteal
in n am e a nd l ocati on in the di stal th ig h/p oster io r kne e r egi on .
H ip a n d Bu t to cks : T h e Glu t e a l R e g ion

A lth ou g h th e d em arca tion of tru n k a nd l im b is abr u pt an teri or ly at th e in gu in al li gam en t, p oster io rly th e g lu teal r egi on i s a lar ge
t ran sit ion al zon e betw een tr u nk an d lim b . Ph ysical ly par t of th e tr u nk, f u ncti on all y th e glu tea l r eg ion i s d efi ni tely pa rt of th e l im b.
T h e g lu teal r egi on is th e p ro m in ent ar ea post eri or to th e p elvi s an d in fe ri or to th e l evel of th e i liac cr ests (th e bu ttock s) an d
e xten din g l ater ally an d an ter ior ly to the g reat er tro cha nte r accor di ng to so me de fin it ion s a nd to th e ASI S accor d in g to o th ers (Fig.
5 . 2 1). T h e i nter g lu teal clef t sep ar ates th e b utt ocks f r om each oth er. Th e g lu teal m u scles
P. 6 0 8
( glu teu s m ax im us, m ed iu s, an d m in im u s an d ten sor o f the fa scia lata) fo rm the b ul k of th e reg io n. T h e g lu teal fo ld d em arca tes th e
i n fer ior b ou n dar y of th e b ut tock a nd th e sup er ior b ou n dar y of th e th ig h .
Fig ure 5.21. Gl ute al reg io nb utto cks ar ea. Th e in ter glu tea l cl eft sep ara tes th e bu ttock s (r igh t an d lef t g lu teal r egi on s or
pr om in en ces). T he gl ute al fol d (sul cus) m ar ks th e low er lim i t of th e bu tto ck an d th e u p per l im it of th e th ig h .
G lu t eal L ig am en t s
T h e p ar ts of t he bo ny pe lvis h ip b on es, sacr u m, and c occyx ar e b ou n d tog eth er by den se lig am en ts (Fi g. 5 . 22 ). T he
s acro tub ero us a nd sa cro sp inous lig aments con ver t th e sciati c n otch es in th e h ip b on es in to t he gr eate r an d lesser sci atic
f or am in a. T he g rea ter scia tic f or amen is the pa ssage way fo r stru ctu re s en ter in g or le avin g th e p elvi s (e. g. , sci atic ne rve),
w h ere as th e lesser s ciatic fo r amen i s th e passag ew ay f or str u ctur es ent eri ng o r leavi ng t he pe rin eu m (e. g ., p u den d al ner ve). I t
i s h elp fu l to th in k of t he gr eate r sciati c f ora me n as t he do or th ro ug h w hi ch all lo wer l im b ar ter ies a nd n er ves l eave th e
p elv is a nd en ter t he gl ute al reg ion . T he p ir ifo rm is (Tab le 5 .6 ) also en ters th e g lu teal r egi on th r ou gh th e gr eater sciatic fo ra men
a nd a lm ost fil ls it.
G lu t e a l Mu s cle s
T h e g lu teal m us cles (Fi g. 5 . 23A , C, & D ) sh ar e a com m on co mp ar tm en t b ut ar e o rg an ized i nto tw o l ayer s, su per fi cial an d de ep:
T h e su pe rf icia l l ayer con sist s of th e thr ee lar ge g lu tei (ma xim u s, me diu s, an d m in im u s) an d th e ten sor of th e fasci a l ata.
T h ese m u scles all h ave pr oxi ma l a ttach me nts to th e p oster ola tera l (e xter nal ) su r face an d m arg in s o f the al a o f t he il iu m an d
a re m ain ly exten sor s, ab du ctor s, an d m edi al ro tator s o f th e th ig h.
T h e d eep la yer con sists of sm all er m uscl es (p ir if orm i s, ob tur ato r in tern u s, exter n us ge me lli, an d qu adr atu s fem or is) cover ed
b y the in fe ri or h alf of th e gl uteu s ma xim u s. Th ey a ll ha ve d ista l a ttach me nts on o r adj acen t t o th e in ter tro chan ter ic cre st of
t he fem u r . Th ese mu scle s ar e l ater al ro tator s of th e th ig h b ut th ey al so stabi lize th e h ip join t, w or kin g wi th th e str on g
l ig am ent s of th e hi p joi nt to stead y t he fem o ral h ead in the acet abu lu m .
Fo r the att achm en ts, i nn er vatio n, and m ai n acti on s of th ese m uscl es, see Tab le 5 .6 .

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G lu t eu s M a xim u s
T h e g luteus maxim us is th e m ost su per fi cial g lu teal m uscl e. It is th e la rg est, h eavi est, an d m ost coar sely fi ber ed m uscl e o f the
b od y. T he gl ute us m axim u s cov ers all of th e oth er g lu teal m uscl es (Fig s. 5 .2 3A & C and 5 . 2 4A ) exce pt for the an ter osu per io r thi rd
o f th e g lu teu s m ed iu s. Th e i schi al tu ber osit y can be fel t on deep p al pati on th r ou gh th e in fer ior par t o f th e m u scle, j ust su per ior to
t he m edi al par t of th e g lu teal f old . Wh en th e th ig h is fl exed , the in f eri or bo rd er of t he gl ute us m axim u s m oves su per ior ly, leavi ng
t he isch ial tu b ero sity sub cu tan eou s. Yo u do n ot sit on you r g lu teu s m axim u s; y ou sit on th e fat ty f ib rou s tissu e a nd th e isch ial
b u rsa th at lie be tween the isch ial tu b ero sity an d the skin .
Fig ure 5.22. L ig aments o f pe lvic gi rd le. Th e sac rot ub ero us an d sacr osp in ou s li gam en ts pass fr om t he isch ial tu b ero sity an d
isch ial sp in e, r especti vely, t o th e sid e o f the sacr um an d coccyx. T hese li gam en ts con vert th e g r eater an d le sser sciati c
no tch es in to f ora mi na . Th e gr eater sci atic fo ram en i s th e doo rw ay of th e tr u e p elvi s; th e lesser sci atic for am en , th e e ntr an ce
to the p eri neu m .
P. 6 0 9
Ta bl e 5. 6. M uscles of G luteal Reg ion: Abd ucto rs and Rotato r s o f the Thig h
Muscl e
Pr oxi mal Atta chment
D istal Attachment
Inner vatio n a
M ain Acti on
Glu teu s
Ili um post eri or to
Mo st f ib ers en d in
I n fer ior g lu teal n er ve
E xten d s th ig h (esp ecial ly
m axim u s (A
& C)
poste ri or gl ut eal
lin e; d or sal su rf ace
ili otib ial tr act, w h ich

in sert s in to lat eral
(L 5, S1, S2)
f r om f lexed p osit ion ) a nd

a ssists in it s la tera l
of sacr um and
coccyx;
con dyl e of t ibi a; so m e

fib er s i nser t on g lu teal
r ota tion ; stead ies thi gh

a nd a ssists in r isin g fr om
sacro tub er ou s
lig am en t
tub er osity
si ttin g p ositi on

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Glu teu s
m edi us (A,
Exte rn al su rf ace o f
iliu m b etw een
Lat eral su r face of

gr eater t roch an ter o f
C, & E )
ant eri or an d
poste ri or gl ut eal
femu r
S u per ior g lu teal

n er ve (L 5 , S 1)
A bd u ct an d m ed ial ly
r ota te t hi gh ; kee p pel vis
l evel wh en i psi later al li mb
i s w eig ht b eari n g and
lin es
a dvan ce op pos ite

(u n su pp or ted) sid e d u rin g
Glu teu s
Exte rn al su rf ace o f
An ter ior su r face of
m in im us
(A D )
iliu m b etw een

ant eri or an d in fer io r

femu r
i ts sw in g ph ase
glu tea l l in es
Ten sor o f
An ter ior su pe ri or
Ili oti bia l tr act, wh ich
fasci a l ata
(J)
ilia c sp in e; a nter io r
par t o f ili ac cr est
attach es to l ater al
con dyl e of t ibi a
Pir if or mi s
(F & G)
An ter ior su r face of

sacru m ;
Su per io r bo rd er of
sacro tub er ou s
lig am en t
femu r
Pelvi c su rf ace of
obtu r ator m em b ra ne
Me dia l su r face of g re ater

tro cha nter (tro chan ter ic
and su r ro un d in g
bon es
fossa ) of f em ur b
Su per io r: isch ial

spin e In fe rio r: isch ial
Me dia l su r face of g re ater

tro cha nter (tro chan ter ic
Obtu rator
in ter nu s (H )
Su pe rio r
an d in fer ior
gem el li (H)
tub er osity
fossa ) of f em ur
B ra nch es of an ter ior

r am i of S1, S2
L ater al ly r ota te e xten ded

t hi gh a nd ab du ct fl exed
t hi gh ; ste ady fem o ral
h ea d in aceta bu lu m
N er ve to ob tu ra tor
i nte rn u s (L 5, S1)
S u per ior g em ell us:

sa me n erve su pp ly as
o btu r ator i nte rn u s
I n fer ior g em ell us:
sa me n erve su pp ly as
q u adr atu s f em or is
Qua dr atu s
Late ral b or der o f
Qua dr ate tub er cle on
N er ve to q ua dr atu s
L ater al ly r ota tes th i gh ; c
fem or is (I)
isch ial tu ber osi ty
in ter tro chan ter ic cres t of

fem u r an d ar ea i nf er ior
f em or is (L 5 , S1 )
st eadi es f em or al he ad in
a cetab ul um
to it
Th e spi nal co rd seg m ent al in ner vati on is in d icated (e. g ., S 1, S2 m ea ns tha t th e ner ves sup p lyin g th e p ir if or mi s ar e
der ive d fr om th e fir st two sacr al segm en ts of th e sp in al cor d). N u mb er s in bol df ace (S1 ) in di cate the m ain se gm en tal
in ne rvat ion . Dam age to on e or m or e o f t he li sted spi na l co rd seg m en ts or to t he m otor n er ve roo ts a risi ng f r om th em
resu lt s in par aly sis o f the m uscl es co nce rn ed .
b T he ge mel li m uscl es b len d w ith th e tend on o f the ob tu ra tor in ter n us as i t a ttach es to th e gr eater tr och an ter o f the fe mu r .
c
T her e are six lat eral r otat ors of th e thi gh : p ir if or mi s, ob tur ato r in ter nu s, su pe rio r an d in fer io r gem el li, q u adr atu s f em or is,
an d obt ur ator exter nu s. T hese m us cles a lso stab ili ze th e hi p joi nt.
P. 6 1 0
T h e g lu teu s m axi mu s slop es i nf er olate ral ly at a 4 5 an gl e f ro m th e p elvi s to th e b u ttock. T he f iber s of th e su pe ri or an d lar ge r
p ar t o f the g lu teu s m axim u s a nd su p erf icia l f ib ers of th e in fer ior par t i nse rt in to the il ioti bi al tract (Fig . 5 .2 3A, C , & D). S om e deep
f ib er s of th e in fer io r par t of th e m u scle (ro ug hl y th e dee p ant eri or an d in fer io r qu ar ter ) att ach to th e g lu teal tu ber osi ty o f the
f em ur. T he in f eri or g lu teal ne rve an d vessels en ter th e d eep su r face of th e glu teu s m ax im us at its cente r. I t i s su pp li ed by bo th
t he in fe rio r an d sup er ior g lu teal ar ter ies. I n th e s up eri or p ar t of i ts co ur se, th e sciatic n erve p asses d eep to th e glu teu s ma xim us
( Fi g. 5 . 24A ).
T h e m ai n actio ns of th e g lu teu s m ax im us ar e ext ensi on an d la tera l r ota tion of th e th ig h . When the g lu teu s m axim u s i s f ixed
p r oxim al ly, th e mu scle exten d s th e tru n k on the lo wer l im b. A lth ou g h it is t he str on gest exten sor o f the h ip, it acts m ost ly w h en
f or ce i s n ecessar y (rap id m ove me nt or m ovem en t aga in st r esista nce) an d fu n ction s pr im ar ily be tween the fl exed an d stan d in g
( strai gh t) posi tion s of th e th ig h , as w h en r isin g fr om the sitti ng p osi tion , str aig h ten in g fr om th e ben d in g posi tio n, w alki ng u p hi ll
a nd u p stai rs, a nd r u nn in g . It is used on ly b r iefl y d u rin g casu al w alkin g an d u sua lly n ot a t al l wh en stan d in g mo tion le ss. Par alysi s
o f th e g lu teu s m axim u s d oes n ot s eri ou sly a ff ect w alki ng o n leve l g ro un d . Ver if y th is by p lacin g you r h an d on yo ur b u ttock wh en
w alk in g slow ly. T he gl u teus m axim u s co ntr acts on ly br ief ly du ri ng t he ear lie st p art of th e stan ce p h ase (f ro m h eel str ike t o w h en
t he fo ot is f lat on t he gr ou n d, to r esist fu r the r fle xion a s w eig ht is assu med b y the pa rti all y f lexed l im b) (Tab le 5 .2 ). I f you cli m b
s tair s an d p ut you r h an d on yo ur b u ttock, yo u wi ll feel th e glu teu s ma xim us con tr act st ron g ly.
B ecau se the il ioti bi al trac t cr osses the kn ee and a ttach es to th e an tero later al tib ia l tu b ercl e (Fig . 5 . 23C & D; Ta ble 5 .6 ),
P. 6 1 1
t he gl ut eus m axim u s an d ten sor o f the f ascia lata to geth er ar e also ab le to a ssist in m akin g th e exten ded kn ee stab le, b u t th ey are
n ot u sua lly call ed on to d o so d u rin g n or m al stan din g . Beca use th e i lio tib ial tr act a ttach es to th e fem u r via th e l ater al

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i n term u scu lar sep tu m, it d oes n ot h ave th e f r eedo m n ecessar y to p ro du ce m ot ion a t th e knee .
Fig ure 5.23. Muscl es o f gl ut eal reg io n and p ost eri or co mpa rtme nt of thig h. Su p erf ici al and d eep d issecti on s o f t he
gl ute al reg ion (A) an d th e p oster io r com par tm en t o f the th ig h (B) ar e d em on str ated . Also sh ow n ar e su pe rf icia l (C) an d dee p
(D) view s o f the la tera l m u scu lof ib rou s com pl ex f or me d by the ten sor o f the fa scia lata an d gl ut eus m axim u s m u scles an d
th eir sh ar ed apo ne ur oti c ten d on , the il ioti bi al tra ct. Th e ilio tib ial tr act is co nti nu ou s (po steri or ly a nd d eep ly) with the d ense
late ral in ter m uscu la r sept um , b y w hi ch th e tr act is attach ed to th e l in ea a sper a of th e f em ur .
T estin g th e glu teu s ma xim us is per fo rm ed w he n th e p erso n is pr on e w ith t he lo wer l im b stra igh t. T he p erso n tig ht ens th e b u ttock
a nd e xten ds the h ip jo in t as th e ex am in er ob serve s an d pa lp ates t he gl ut eus m axim u s.
G lu t eal B u r s ae
G luteal b ursa e (L . p ur ses) se par ate th e g lu teu s m axi mu s fr om ad ja cent str uctu r es (Fi g. 5 . 25 ). B ur sae ar e m em br an ou s sa cs li ne d
b y a syn ovi al m emb r ane con tai ni ng a cap ill ar y la yer of sl ipp er y f lu id r esem bl in g egg w hi te. B ur sae ar e lo cated i n ar eas su b ject to
f r ictio n (e. g. , wh er e t he ili oti bia l tr act cro sses t he gr eate r tro cha nter ); thei r pu r po se is to re du ce f r ictio n an d per m it fr ee
m o vem ent . Usu ally th ree b ur sae are asso ciated w ith t he gl ut eus m axim u s:
1. T h e tr ocha nte ri c b ursa sep ara tes su p eri or f ibe rs of th e g lu teu s m axi mu s fr om th e gr eater tr och an ter . Th e tro cha nte ric bu r sa
i s co mm on ly th e l ar gest of th e b u rsa e f or med i n r elati on to b ony p rom i nen ces an d is p r esen t at bi rth . Oth er su ch b ur sae
a pp ear to f orm as a r esu lt o f pos tna tal mo vem en t.
2. T h e i schial bur sa sepa rat es th e in fer ior par t o f the g lu teu s m axim u s f ro m th e i schi al tu ber osit y; it is of ten ab sen t.
3. T h e g luteo fe mor al bur sa sepa rate s th e i lio tib ial tr act f r om th e sup eri or p ar t of th e pr oxi ma l a ttach me nt of th e vastu s

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l ater ali s, a thi gh m u scle.
P. 6 1 2
G lu t eu s M e di u s an d G lu t eu s M in i m u s
T h e sm al ler g lu teal m uscl es, g luteus me di us an d g luteus mi nimus, ar e fan sh ap ed , an d thei r fi ber s co nv erg e i n th e sam e
m an n er tow ar d essen tial ly the sam e targ et (Figs. 5. 2 3A , 5 .2 4A, 5 . 2 5, a nd 5 . 26D ). Th ey sha re th e sa me acti on s an d n erve su pp ly
( Tab le 5. 6 ) an d ar e sup pl ied b y th e sam e b loo d vessel, t he su perior glu tea l a rter y. T he gl ut eus m in im us and m ost of th e g lu teu s
m ed iu s l ie deep to th e gl ute us m axim u s on the exter n al sur fa ce o f the il iu m. Th e g lu teu s m ed iu s an d m in im u s ab du ct th e th ig h an d
r ot ate i t m ed ial ly (Fi g. 5 . 26 ; Tab le 5. 2 ).
T estin g th e glu teu s med iu s a nd m in i mu s i s p er for m ed wh il e th e per son i s p ro ne wi th th e l eg fl exed to a ri gh t a ng le. T he p erso n
a bd uct s th e t hi gh a gai nst re sistan ce. T he gl ut eus m edi us can b e p alp ated i nf er ior to th e ili ac cr est, p oster io r to the ten sor o f the
f asci a l ata, w hi ch is also con tr actin g d ur in g ab du ctio n of th e th ig h .
T en s o r of th e F as ci a L at a
T h e tenso r of the fasc ia l ata (L. te nso r fasci ae l atae) is a f u sifo rm mu scle ap pr oxi ma tely 15 cm lon g th at is encl osed b etwe en
t wo laye rs of fa scia lata (Fig . 5. 1 7B). I ts a ttach me nts, i n ner vati on an d acti on ar e pr ovid ed in Tab le 5. 6 . Th e ten sor an d th e
s up erf ici al and ant eri or pa rt of th e glu teu s m ax im us sh are a com mo n d istal atta chm en t t o th e an tero late ral ti bia l co nd yle via th e
i lio tib ial tr act, w hi ch acts as
P. 6 1 3
P. 6 1 4
P. 6 1 5
a lo ng apo neu r osis fo r the m u scles. H owe ver, u n lik e th e glu teu s ma xim us, the ten sor i s ser ved b y th e su p eri or g lu teal
n eu r ovascu lar bu nd le. Desp ite its gl ut eal in ne rvat ion a nd sh ar ed attac hm en t, th e t enso r of th e f ascia la ta i s p ri ma ri ly a f lexor of
t he th ig h beca use of it s an ter ior locati on ; h ow ever , it gen er all y d oes no t act in d epen d ent ly. To p ro du ce flex ion , th e te nso r of th e
f asci a l ata a cts i n con cer t w ith th e ili opso as a nd r ectu s f em or is. Wh en th e i lio pso as i s p ara lyzed , th e te nso r of th e f ascia la ta
u n de rg oes hyp er tro ph y i n an at tem pt to com pen sate . It also w ork s in c on ju ncti on w ith o ther abd uc tor /med ia l r ota tor m uscl es
( glu teu s m ed iu s a nd m in im u s) (Fi g. 5 . 26 ). I t l ies too far ant eri orl y to b e a str on g ab du ctor an d th u s p ro bab ly con tri bu tes pr im ar ily
a s a syn erg ist or f ixato r.

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Fig ure 5.24. D issecti on o f gl uteal reg io n and a bd uctor s a nd ro tator s of thig h. A. In th is de ep di ssection , th e
ne ur ovascu la r stru ctu r es of t he gl ute al reg io n an d pr oxim al p oster io r thi gh a re re vealed . Most of th e g lu teu s m axi m us an d
m edi us are r em oved , an d segm en ts of th e h am str in gs are exci sed. E xcep t f or th e sup er ior g lu teal ar ter y a nd n er ve, th e
ne ur ovascu la r stru ctu r es su pp lyi ng o r tra versi ng the gl ut eal reg io n an d po steri or th ig h em er ge fr om th e pel vis via the g rea ter
sciati c f or am en in fer io r to the p ir ifo rm is; h oweve r, ex cepti on s occu r (Fig . 5 .2 8 ). Th e sciati c n er ve r u ns dee p (an teri or ) to an d
is pr otected b y the over lyi ng g lu teu s m ax im us in iti ally an d th en th e b icep s f em or is. B . Th is di ssectio n sho ws som e o f the
late ral r otato rs of th e t hi gh : th e pi rif or m is (d ista l t end in ou s a ttach me nt on ly), t he exter n al and i nt ern al ob tu rat ors (ar isin g
fr om o pp osite sid es of th e o btu ra tor m em br an e), an d th e g em ell i mu scles. Note th at the com p on ent s of th e tri ceps coxa e
sha re a com mo n atta chm en t ad jacen t to tha t of th e ob tur ato r exter nu s in to th e t roch an ter ic foss a.

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Fig ure 5.25. Gl ute al mus cles and bur sae. T h ree bu r sae (tro chan ter ic, g lu teo fem or al, and i schi al) usu al ly separ ate th e
gl ute us ma xim u s f rom un d erl yin g bo ny pr om in en ces, al low in g fr ee mu scu lar co nt racti on o r ten don mo vem ent . Th e b u rsa of th e
ob tur ato r in ter nu s a llo ws t he ten do n of th e o btu r ator i nt ern u s to g lid e f re ely over th e lesser sci atic no tch of th e hi p bon e,
wh ich t he m uscl e u ses as a tr och lea (pu ll ey), ch an gin g it s d ir ection of pu ll b y m or e tha n 90 b ef ore th e g em ell i m u scles
beco m e att ache d to i t.
Fig ure 5.26. Actio n of ab d uctor s/m edi al ro tato rs of thig h w hen w al king . AC. Th e ro le o f the ab du ctor s (glu teu s
m edi us an d mi ni m us, te nso r of fa scia lata) is dem on str ated . Wh en th e w eig h t is on b oth feet (A), th e p elvi s is even ly
sup p ort ed an d doe s n ot sag. When the we igh t is b or n e b y o ne li mb (B ), th e mu scles on t he su pp ort ed sid e f ix the p elvis so
th at i t d oes no t sag t o th e un su pp or ted sid e. K eep in g the p elvis leve l en ab les th e n on -we igh t-b ear in g lim b to cle ar th e g ro un d
as i t i s b ro ug ht f orw ar d du r in g the swi n g ph ase. Wh en th e ri gh t a bd ucto rs ar e p ar alyzed (C), owi ng t o a lesi on o f t he ri gh t
sup er ior g lu teal n er ve, fi xatio n by th ese mu scle s is lost an d th e p elvi s ti lts to t he un su pp or ted le ft side (p ositi ve
Tr en del enb u rg si gn ). Th e ne t ef fect is th at th e lim b b ecom es to o lon g f or th e h ip h eig h t, r equ ir in g a com pen sato ry lim p
to pr even t th e fo ot f r om h itti ng th e gr ou n d du ri ng sw in g ph ase . DF. T h e r ole of th e ro tator s o f the th ig h is dem on str ated .
In t he late ral (D ) a nd su pe ri or (E) view s, n ote tha t m ost ab du ctor s th e te nso r of th e f ascia la ta, g lu teus m in im u s, an d mo st
(th e an ter io r fib er s) of th e gl ute us m edi us l ie a nt eri or to th e l ever pr ovi ded b y the axi s of th e he ad, n eck, a nd g re ater

08-May-15
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tro cha nte r of th e f em ur t o r ota te th e thi gh a ro un d th e ve rti cal axis tra versi ng t he fem o ral h ead . Th e sup er ior vi ew of th e r ig h t
hi p joi nt (E) in clu d es th e sup er ior p ub ic ra mu s, ace tabu lu m , an d il iac crest; th e i nf er ior p ar t of t he ili um ha s b een r em oved to
rev eal the h ead an d n eck o f the f emu r . Th e lin es of pu ll of t he ro tator s of th e h ip ar e in dica ted by ar ro ws, d em on str atin g th e
an tago ni stic rel atio nsh ip r esu lti ng f ro m th eir p osit ion s r ela tive to the lev er an d the cen ter of r ota tion (fu lcr um ). T he m edi al
ro tator s p u ll th e g rea ter tr och an ter an ter ior ly an d the la tera l r ota tor s p ul l t he tr och ant er po steri or ly, r esu ltin g in rot atio n of
th e th ig h ar ou nd t he ver tical axi s. No te th at all of t hese m uscl es a lso pu ll th e h ead and n eck of th e f em u r me dia lly in to the
acetab u lu m, stren g the ni ng th e joi nt. In w alki ng (F), t he sam e m u scles th at act u n ila tera lly du r in g the stan ce ph ase (pl ant ed
lim b ) to keep t he pel vis level vi a ab du cti on can si m ul tan eou sly pr od uce m edi al ro tatio n at the h ip jo in t, ad van cin g the
op posi te u n su pp or ted sid e o f the pe lvis (au gm en tin g ad van cem ent of th e fr ee l im b). Th e l ater al ro tator s o f the ad van cin g
(fr ee) lim b act du r in g the sw in g ph ase to keep th e f oot pa ral lel to th e d ir ectio n (lin e) of ad van cem ent .
T h e ten sor of th e f ascia lat a al so tense s th e f ascia la ta a nd i lio tib ial tr act, th er eby h elp in g sup po rt th e f em ur o n th e ti bi a w he n
s tan din g . Beca use th e i lio tibi al tr act i s att ache d to t he fem u r via th e later al in ter mu scu lar s eptu m , th e te nso r pr od uces li ttle if an y
m o vem ent of th e leg (Fig . 5 .2 3D). How ever , wh en th e kn ee i s f ul ly e xten ded , it con tr ibu tes to (in crea ses) th e exten di ng f or ce,
a dd in g stab ili ty. Wh en th e kn ee is fle xed by oth er m u scles, th e ten sor can syn er gi stical ly aug m en t f lexi on an d lat eral r otat ion o f
t he leg .
T h e ab d ucto rs/m ed ial r otato rs of th e h ip j oin t pl ay an essen tial r ole du r in g loco mo tion , a dvan cin g an d p reven ti ng th e sagg in g of
t he u nsu p por ted si de of th e p elvi s d ur in g w alkin g , as illu str ated a nd exp la in ed in Fig u re 5. 2 6 . Th e su p po rti ve an d acti on -pr od uci ng
f u ncti on s o f the ab du ctor s/m edi al ro tator s d ep end s o n n or ma l:
Mu scu lar a ctivity an d in n erva tion fr om th e sup er ior g lu teal n erv e.
A r ticu lati on of th e hi p joi nt com p on ent s.
S tr eng th an d an g ul atio n of th e f em or al ne ck.
P ir if or m i s
T h e n ar ro w, p ear -sha ped p ir if or mis (L. pi ru m, a p ear ) i s lo cated p ar tly on th e p oste rio r wa ll of th e l esser pe lvis an d par tly
p oste ri or to th e h ip j oin t (Fi gs. 5 . 23A , 5. 2 4 A, an d 5 .2 5 ; T ab le 5 . 6 ). Th e p ir if or mi s l eaves the pe lvis th ro ug h th e g re ater scia tic
f or am en , alm ost f illi ng i t, to r each its atta chm en t t o th e sup er ior b or de r of th e g re ater tr och an ter. Becau se of its key po sitio n in
t he bu tto ck, th e p ir if orm i s is th e l and m ar k of th e gl ute al reg ion . T he p iri fo rm is pr ovi des th e key to un d erst and in g r elati on shi ps in
t he gl ut eal reg io n beca use it de term in es th e n am es o f th e b loo d vessels an d ner ves:
T h e su pe ri or gl ut eal vessels and ne rve em er ge sup erior to i t.
T h e i nf eri or g lu teal vessel s an d n erve em er ge in fe rio r to it.
T h e su r face m arki n g of th e su pe rio r bo rd er of th e pi rif or m is i s i nd icate d by a l in e j oin in g th e ski n di m ple f orm ed b y t he

p oste ri or su per ior ili ac sp in e to th e sup er ior b or der of th e g rea ter tr och an ter of th e fem u r (Fig. S A5 . 2G).
O bt u r at o r In t er n u s a n d G em ell i
T h e o btur ato r inter nus an d th e s up er io r an d inf eri or g emel li (L. g em in us , sma ll twi n) fo rm a tr ici pita l (t hr ee-h ead ed) m uscl e,
t he tr icep s coxa e (tr icep s o f th e h ip ), wh ich o ccu pies th e g ap b etwe en th e p ir ifo rm is an d th e q u adr atu s f em or is (Fi gs. 5 . 23A an d
5 . 2 4A & B; Tab le 5 .6 ). T he com m on ten d on of t hese m uscl es l ies ho ri zon tall y in the b utto ck a s it pa sses to th e gr eater tr och an ter
o f th e f em ur .
T h e o btu ra tor in ter n us is loca ted pa rtl y in the p elvis, w h ere it cover s mo st of t he late ral w all of th e lesser p elvi s (Fig . 5 .2 4B; Tab le
5 . 6 ). It lea ves th e pel vis t hr ou gh the lesse r sciati c f ora me n, m ake s a ri gh t-an gl e tu r n (Fig . 5 .2 6E), b ecom es ten di no us, a nd
r ecei ves th e di stal attach m en ts o f the ge me lli be for e attach in g to th e m ed ial su rf ace of th e g re ater tr och an ter (tr och an teri c f ossa).
T h e sm al l g em ell i a re na rr ow , tri an gu lar extra pel vic rei nf or cem ents of th e obt ur ator in tern u s. Al th oug h th e in fer ior gem ell us
r ecei ves se par ate in ne rvat ion f ro m th e n er ve to t he qu ad ra tus fem o ris, it is m or e rea listi c to con sid er th ese thr ee m uscl es as a
u n it (i. e. , as th e tri ceps coxa e) b ecau se th ey ar e i ncap ab le of in de pen d ent acti on . Th e b ur sa o f the o btur ato r inter nus all ow s
f r ee m ove me nt of th e m u scle over t he po ster ior b or der o f the isch iu m , w her e the bo rd er f or ms th e l esser sciat ic n otch and the
t ro chl ea o ver wh ich the ten do n gl id es as it tu rn s (Fi g. 5 . 25 ).
Q u ad ra tu s Fe m o ri s
T h e q uad ra tus fe mor is is a sh or t, f lat qu ad ran g ul ar m uscl e l ocated i nf er ior to th e obt ur ato r in tern u s a nd g em elli (Fig s. 5 .2 3A an d
5 . 2 5). T r ue to its na me, the q uad r atu s f emo ri s is a recta ng u lar m u scle; it is a str on g later al r otato r of th e t hi gh .
O bt u r at o r Ext er n u s
B ased o n its loca tion (p oste rio r to th e p ectin eu s an d th e sup er ior en d s of th e add u ctor m u scles) an d its i nn er vati on (ob tu ra tor
n er ve), th e ob tur ato r exter nu s was descr ib ed ear li er in th is ch apte r with the m ed ial th igh mu scle s (T abl e 5 . 4). H ow ever , it
f u ncti on s as a later al r otato r of th e th ig h , an d its dis tal attach m en t is visi bl e on ly d ur in g di ssectio n of th e g lu teal r egi on (Fig .
5 . 2 4B ) o r hi p joi nt. Th us it is me nti on ed ag ain i n th is co nte xt. It li es d eep in the pr oxi m al thi gh , w ith it s ten do n pa ssin g dee p to
t he qu ad ra tus fe mo ri s on the wa y to its atta chm en t t o th e tro cha nte ri c fo ssa o f th e f em ur (Fig . 5 .2 4A). Th e o btu r ator exte rn u s,
w ith oth er sh ort m u scles a ro un d th e h ip j oin t, sta bi lizes th e h ead o f the fe mu r in the aceta bu lu m (Fig . 5 .2 6E) . It is mo st ef fect ive
a s a late ral r otat or of th e thi gh w h en th e h ip j oin t is f lexed .

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Page 55 of 155
B ecau se the f emu r i s b ent at th e an g le o f in clin ati on , th e r ela tively tr an sverse lev er fo rm ed b y th e pr oxim al f em ur a llow s su p eri or
p la ceme nt of th e abd u ctor s of th e thi gh a nd p r ovid es m ech an ical ad van tag e f or th e deep er m ed ial an d lat eral r otat ors of th e thi gh .
T h is i s cr iti cal for b ip ed al locom o tion . T hu s, d espi te th ei r desi gn ati ons , the ab du ctor s/m ed ial ro tator s (the su per fi cial g lu teal
m u scles) ar e m ost acti ve d u ri ng th e stan ce p ha se w he n th ey si mu lta neo usl y el evate an d ad van ce th e con tral ater al u nsu pp or ted
s ide of th e pel vis d u ri ng a mb u lati on . Th e l ater al ro tator s (d eep g lu teal m u scles) of th e u n sup po rted si de r otate th e f ree li m b
d u ri ng th e swi ng p ha se so th at the f oot rem ai ns p ara llel to th e l in e o f adva ncem en t.
I sc h i a l B ur si t is
R ecu r ren t mi cro trau m a resu lt in g fr om r epe ated str ess (e .g ., as f ro m cycli ng , r owi ng , or o the r activi ties in volv in g rep etiti ve h ip
e xten sion w h ile seated ) m ay over w hel m th e i schi al bu r sa's a bi lity to di ssipa te a pp lied st ress. T h e r ecu rr en t tr au m a r esu lts in
i n fla mm ati on of t he bu r sa (i schial b ur si tis). I schi al bu r sitis is a f ri ctio n b ur si tis r esu lti ng f ro m excessi ve f ri ction betw een th e
i sch ial bu r sae a nd t he isch ial tu be ro sities. Loca lized p ai n occu rs over t he bu r sa, an d th e p ain in crease s w ith m ovem en t of th e
g lu teu s m ax im us. C al cifi catio n m ay o ccur in th e b u rsa wi th ch ro ni c b ur siti s. Beca use th e i schi al tu ber osit ies b ear t he bo dy wei gh t
d u ri ng si ttin g, the se p ressu r e p oin ts m ay l ead to pr essu re sor es in d ebi lita ted peo pl e, pa rti cul arl y p ar apl egi c p er son s wi th p oor
n u rsi n g care.
T r o c h a n te r i c B u r s i ti s
I n fla mm at ion o f the tr och an teri c b u rsae, or tr ochanter ic bur siti s, m ay r esu lt fr om r ep etiti ve a ction s su ch a s cli mb in g stai rs wh il e
c arr yin g h eavy obj ects or r un n in g on a steep ly elevat ed tre adm il l. T hese m ovem en ts in volve th e g lu teu s m axi mu s an d mo ve th e
s up eri or ten d in ou s f ibe rs rep eate dly ba ck an d f or th over th e bu r sae o f the g rea ter tr och ant er. T ro cha nte ri c b ur siti s cau ses deep
d if fu se pai n in th e later al th ig h r egio n. Th is type of f ri ction b u rsi tis i s ch ar acter ized b y p oi nt ten de rn ess o ver th e g r eat t roch an ter ;
h ow ever , th e p ain rad ia tes al on g th e i liot ibi al tra ct th at exten ds fr om the il iac tub er cle to the tib ia (Fig s. 5. 2 3C an d 5. 2 6D ). T hi s
t hi cken in g of th e f ascia lat a r eceive s ten d in ou s r ein fo rcem en ts fr om th e tenso r of th e fasci a l ata and t he gl ute us m axim u s. Th e
p ai n fr om a n in fl am ed tro cha nte ric bu r sa, u sua lly lo calize d ju st p oster io r to t he gr eate r tro cha nte r, i s g ene ral ly elici ted by
m an u all y r esisti ng a bd uct ion a nd l ater al ro tatio n of th e th ig h w hi le the p erso n is lyin g on t he u naf fe cted sid e.
P. 6 1 6
P o st e rio r T h ig h Mu s cle s
T h e att achm en ts, i nn er vatio n, and a ction s of th e p oster io r thi gh m u scles ar e p ro vid ed in T abl e 5 . 7 . Th re e of th e fo ur m u scles in
th e po steri or asp ect of th e th ig h ar e ha mstri ngs (Fig . 5. 2 7A & B ): (1 ) sem i tend in osu s, (2 ) se mi me mb ra no sus, and (3 ) bi ceps
f em or is (l on g h ead). Th e h am str in gs sha re com m on f eatu re s:
P ro xim al attach m en t to th e i sch ial tu ber osi ty d eep to th e g lu teu s m axi mu s.
S pa nn in g an d acti ng o n two jo in ts: ex tensi on at th e h ip j oin t an d fle xion a t th e knee .
I n ner vati on b y th e tib ial di visi on of th e sciati c n er ve.
T h e lo ng h ead o f th e b icep s m eets all th ese con di tion s, b ut th e sh or t h ea d of th e b icep s, th e f ou rth mu scle of th e po steri or
co mp ar tm en t, fai ls to m ee t an y of th em. Th e h am str in gs re ceived th eir nam e bec ause it is com m on to tie h am s (p or k th ig h s) u p for
cu r in g an d/or smo kin g wi th a h oo k a rou n d th ese m u scle ten do ns. T h is a lso expl ain s t he exp ressi on h am stri ng in g th e en em y
b y sl ash in g th ese te nd on s l ater al and m ed ial to th e knee s.
T h e tw o a ction s of th e h am str in gs can no t b e p er for m ed m axim al ly a t th e sam e ti me : f ul l f lexi on of th e kn ee r eq ui res so mu ch
sh or ten in g of th e ham str in g s th at the y can n ot pr ovid e the ad di tion al con tr actio n th at w ou ld b e n ecessa ry for sim ul tan eou s f ul l
e xten sion o f the th ig h; sim il arl y, fu ll exte nsi on of th e hi p sho rte ns th e h am str in gs so t hey can no t f u rth er con tr act to act f ul ly on
th e kn ee. Wh en th e th ig h s an d le gs are fi xed , the h am stri ng s ca n h elp exten d th e tru n k at th e h ip j oin t. T he y ar e active in th ig h
e xten sion u n der a ll situ ati on s excep t f u ll fl exion of th e kn ee, i ncl ud in g m ain ten an ce o f the r elaxed s tan din g p ostu re (stan di n g at
e ase). A pe rso n wit h par al yzed h am stri ng s te nd s to f all fo rw ar d beca use th e g lu teu s m axi mu s mu scles can n ot m ai nt ain th e
n ecessa ry m uscl e to ne to stan d stra ig ht.
T h e h am str in gs are th e h ip e xten sors in vol ved in w alki ng o n fl at g r ou nd , wh en t he gl ute us m axim u s d em on stra tes m in im al acti vity.
H ow ever , rat her t han pr od uci ng e ith er h ip exten sio n or kn ee fle xion p er se du r in g no rm al w alkin g , th e h am str in gs dem on str ate
m ost acti vity wh en th ey are eccen tr ical ly co nt ract in g, r esisti ng (d ecel erat in g) hi p fle xion a nd kn ee exten sio n du r in g term i nal sw in g
(b etw een m id swi ng an d h eel str ike) (Tab le 5. 2 ).
T h e le ng th of th e ha mst rin g s var ies, bu t t hi s is u sual ly a m att er of con d itio ni ng . In som e p eop le, t hey ar e n ot lon g en ou g h to allo w
th em to t ou ch th eir toe s w hen the kn ees a re exten d ed. R ou tin e stre tch exer cise can le ng th en th ese m u scles an d ten do ns.
T o test t he h am stri ng s th e per son f lexe s th e l eg ag ain st r esist anc e. Nor m all y, th ese m u scles e speci ally th eir te nd on s o n each
si de of th e pop li teal fo ssa sho ul d be pr om i nen t as th ey ben d th e knee .
S e m it en d i n o su s
A s i ts n am e in dica tes, th e se mitend inos us m u scle i s sem i tend in ou s. T hi s m u scle has a fu sif orm bel ly tha t is u sua lly in ter ru pt ed
b y a ten d in ou s in ter secti on an d a lon g, cord -li ke te nd on th at be gin s app ro xim atel y tw o thi rd s o f the wa y d ow n the th ig h. Di stall y,
th e ten do n attach es to the m edi al sur fa ce o f the su per io r par t of th e ti bia as pa rt of th e p es anse ri nu s
P. 6 1 7
f or m ation in con ju n ctio n wi th th e ten d in ou s i nser tio ns of th e sarto ri us an d gr acil is (discu ssed ea rl ier in thi s ch ap ter).
Tab le 5.7. M us cles o f the Po ster io r Thig h: E xtenso rs of the Hi p, Fl exo rs of the Knee
M us cle a
P ro xima l
Attachment
D ist al Atta chme nt
Inner vatio n b
M ain Acti on

08-May-15
Sem it end in osu s
Is hch ial tu b ero sity
Sem im em b ran osu s
Page 56 of 155
Me dia l su r face of
sup er ior p ar t o f tibi a
T ib ial d ivisi on of sci atic

n er ve p ar t o f tib ia (L5,
E xten d th igh ; fle x

le g and r ota te i t
S1 , S 2)
m ed iall y w he n kne e
is fl exed ; wh en t hi gh
Poster io r par t of
me dia l co nd yle of
an d leg a re fl exed ,
th ese mu scle s can
tib ia; ref lecte d

attach m en t f or ms
exte nd tr u nk
ob liq ue p opl iteal

lig am en t (to la tera l
fem or al con dy le)
Bi ceps fem or is
L on g hea d: isch ial
Lat eral si de of h ead of
L on g h ead: tib ial
Flexe s leg a nd
tu ber osi ty
Sh or t hea d: lin ea
fib u la; ten don is sp li t

at t hi s site b y f ib ul ar
d ivi sion o f sciati c n er ve

(L 5, S1, S2 ) S ho rt
r otate s it lat eral ly

w hen knee is fl exed ;
asp era an d la tera l

su pr acon d ylar l in e
coll ater al lig am en t o f

kne e
h ead : co m mo n fi bu lar
d ivi sion o f sciati c n er ve
exte nd s th ig h (e. g. ,
w hen start in g to
(L 5, S1, S2 )
w alk)
of f em ur
a C oll ectivel y
b
th ese th ree m uscl es ar e kno wn a s h am stri n gs.

T he spi na l co rd se gm en tal in ne rvat ion i s i nd icate d (e.g . , L5 , S1 , S 2 m ean s th at th e n er ves su p pl yin g the
sem iten di no sus ar e d er ived f ro m th e f ift h lu m bar se gm en t an d f ir st tw o sa cra l seg m en ts of t he spi na l co rd ). Nu m be rs in

bo ldf ace (L5, S1) i n dica te th e ma in seg m ent al in ner vati on . Dam age to on e o r m ore of th e liste d spi nal co rd seg m ent s or
to the m oto r ner ve ro ots a ri sin g fr om th em r esu lts in p ar alysi s of th e mu scl es con cer n ed.
S e m i m em br an o s u s
T h e sem imemb r anosus is a b ro ad m uscl e th at is also ap tly na med b ecau se of th e f latt ened mem b ra no us fo rm o f its pr oxim al
a ttach m ent to th e i schi al tub er osity (Fig . 5 .2 7A). T he ten do n of th e semi m em br an osu s f orm s ar oun d th e mi dd le of th e th ig h an d
d escen d s to th e p oster io r par t of th e m ed ial tib ia l co nd yle. Its ten don div ide s d istall y i nto th r ee p ar ts: (1 ) a d ir ect a ttach m ent to
t he po ster ior as pect of th e m ed ial ti bia l co nd yle , (2) a par t t hat b len ds wi th th e p op lite al fasci a, an d (3 ) a ref lecte d par t tha t
r ei nf or ces th e in terc on dyla r par t of th e j oin t capsu le of th e knee as th e o bl iq ue p op li teal lig ament (Fig s. 5. 2 3B a nd 5 . 60 ).
W hen the kn ee i s f lexed to 9 0 , the ten do ns of th e me dia l h am str in gs or sem i- m uscl es (se mi ten din osu s and
s emi m emb r ano sus ) p ass to th e med ial si de of th e t ibi a; i n th is p osi tion , co ntr acti on of th e me dia l h am str in gs (an d of syn er gist s
i n clu din g th e g r acili s, sar tor iu s, an d po pl iteu s) p ro du ces a l im ited am o un t (abo ut 1 0 ) of m edi al rot atio n of th e ti bi a a t th e knee .
T h e tw o me dia l h am str in gs ar e n ot as a ctive as t he lat eral h am str in g, th e bi ceps fem or is, wh ich is th e w or kho rse of
e xten sion a t th e hi p (Ham il l and K n ut zen, 19 9 5).
P. 6 1 8

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Page 57 of 155
Fig ure 5.27. Muscl es and f asci al co mp ar tments o f thi gh. A. T he gl u teus m axim u s h as been ref lecte d to r evea l th e sciati c
ne rve en ter in g the pr oxi m al thi gh a nd th e attach m en ts o f t he h am stri ng s. Th e level of th e sectio ns sh own i n p arts B an d C i s
indi cated. B. A n an ato mi cal tra nsve rse sectio n th rou g h th e m id dl e th ig h , 1 0 1 5 cm in fer ior t o th e in gu in al li gam en t. C. T h e
th ree com p artm en ts of th e th ig h ar e sho wn . No te th at each h as its own ner ve sup pl y a nd f un cti on al gr ou p(s) of m uscl es. D .
Th is tra nsver se MRI of t he ri gh t thi gh i nd icat es th e mu scle s of ea ch com pa rtm en t. (C ou rt esy o f Dr . W. K uch ar czyk, C h air o f
Medi cal Im ag in g, Facu lty of Med icin e, U ni versi ty o f Tor on to an d Cl in ical Dir ector o f the Tr i-H osp ital R eson an ce C en tr e,
Tor on to, Onta ri o, C an ada. )
P. 6 1 9
B ic ep s F em o ri s
A s i ts n am e in dic ates, th e f u sifo rm bi cep s fe mor is ha s tw o h ea ds: a l on g hea d and a sh or t h ead (Fi g. 5 . 23A & B). I n th e i nf eri or
p ar t o f the th ig h, the lo ng h ead b ecom es ten di nou s an d is j oin ed b y th e sho rt h ead. Th e r ou n ded co mm on ten don attach es to t he
h ea d of th e f ib ul a an d can e asily b e seen an d felt as it passe s th e kn ee, especi all y w hen the kn ee i s f lexed a gai nst r esistan ce (see
S ur f ace A n atom y o f th e Glu teal R egi on an d T hi gh , in thi s ch ap ter ). Th e l ong head o f the b icep s f emo ri s cr osses an d
p r ovid es p r otecti on f or th e sci atic ne rve af ter it desce nd s f ro m th e g lu teal r egi on i nto th e p oste ri or asp ect o f the th ig h (Fig . 5. 2 7) .
W hen the sciat ic n er ve d ivi des in to its ter mi na l b ra nch es, th e later al b ran ch (co mm on fib u lar n er ve) co nt in ues th is r ela tion sh ip ,
r u nn in g w ith th e bi ceps ten don .
T h e sho rt head o f the bi cep s f emor is ar ises fr om th e later al li p of th e i nf er ior th ir d of th e lin ea asp era an d su pr acon dy lar r id ge
o f th e f em ur . Wh ere as th e ha mstr in g s h ave a co mm o n ne rve sup p ly f ro m th e t ibi al di visio n of th e sci atic n erve , the sh or t h ead o f
t he bi ceps is in ne rvat ed by th e f ib ul ar di visio n (Ta ble 5 .7 ). B ecau se e ach of th e two h eads of th e bice ps fem or is ha s a di ff eren t
n er ve sup pl y, a wou n d in th e post eri or th ig h wi th n erve in ju r y m ay pa ral yze o ne h ead an d n ot the oth er .
W hen the kn ee i s f lexed to 9 0 , the ten do ns of th e later al h am stri ng (b icep s) a s w ell as the il ioti bia l t ract p ass to th e later al sid e
o f th e ti bia . In t hi s p ositi on , con tra ction of th e b icep s an d ten sor of th e f ascia lata p ro du ces a bo ut 4 0 l ater al ro tatio n of th e tib ia
a t th e kne e. Ro tati on of th e fle xed kn ee i s esp ecial ly im po rtan t in sn ow ski in g.
Alth ou g h th ey h ave on ly ab ou t tw o t hi rd s th e stren g th of th e gluteu s ma xim us, the h am stri ng s a re th e m ai n exten sor s o f t he h ip
used i n n or ma l w alki ng . T hey ar e tw o-j oin t m u scles, and t hei r con cen tri c con tr actio n pr od u ces ei the r exten sion of th e h ip o r
fle xion o f the kn ee. H owe ver, in wa lkin g th ey are m ost active in e ccent rica lly con tr actin g to dece ler ate hi p fle xion a nd kn ee
exten sion du ri ng t erm in al sw in g. T he h am stri ng s a lso ro tate the fl exed kn ee. I f re sistan ce t o h ip e xten sion i s in cr eased , or m or e

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v igo ro us exten sio n is req u ire d, th e glu teu s ma xim us is call ed in to actio n.
H a m st r i n g I n ju r i e s
H am str in g stra in s (p ul led an d /or tor n h am str in gs) are com m on i n in di vid ua ls w ho r u n an d/or kick h ar d (e. g. , in ru n ni ng , ju m pi ng ,
a nd q u ick-star t spor ts such a s b aseb all, baske tbal l, f ootb all , an d soccer ). Th e viol en t m u scul ar exer tio n req u ir ed to excel in th ese
s por ts ma y tea r par t of th e p ro xim al ten di no us attach m en ts o f the h am stri ng s to th e isch ial tu ber osi ty. Ha mst ri ng str ain s are tw ice
a s com m on as q ua dr icep s str ai ns (Leva nd ow ski and Di fio ri , 19 9 4 ).
U sua lly th igh stra in s ar e a ccom pan ie d by con tu sion a nd tea ri ng o f mu scle fi ber s, r esu ltin g in ru ptu r e o f the b lood vessels sup pl yin g
t he m uscl es. Th e resu lt ant h em atom a is con tain ed b y th e den se stockin g -like fa scia lata. Tear in g of h am str in g fib er s is of ten so
p ai nf ul w he n the ath le te m ove s or st retch es the le g tha t h e o r she f alls an d wr ith es in p ain . Th ese in ju r ies o ften resu lt fr om
i n adeq u ate war m in g up b efo re p racti ce o r com pe titio n. Avu lsio n of th e i schi al tu ber osit y (see cli ni cal corr el ation [blu e] bo x
I n ju ri es of t he Hi p Bon e (Pelvi c I nj u rie s), in th is ch apt er) at the pr oxi m al attach m ent of th e bi ceps fem or is an d
s emi ten di no sus ( hu r dle r's in ju r y ) m ay res ul t f rom fo rcib le fl exio n of th e h ip w ith t he kn ee ex tend ed (e. g. , ki ckin g a
f oo tbal l).
N e u ro v a s cu la r S tr u ct u re s o f t h e Glu t e a l R e g ion a n d Po s te r ior T h ig h

S ever al im po rta nt n erve s ar ise fr om th e sacr al ple xus an d eith er su pp ly th e g lu teal r egi on (e. g. , su pe ri or an d in fer io r gl ute al
n er ves) o r pa ss th r ou gh i t to su pp ly the p eri neu m a nd th ig h (e. g. , th e pu de nd al an d sciati c n er ves, r especti vely). Tab le 5. 8
d escr ib es th e ori gi n, co ur se, a nd d istr ib uti on o f the n erve s of th e gl utea l r eg ion and p oste rio r th igh .
C lu n i al (S u p erfi ci al G lu t ea l) N er v es
T h e ski n of th e g lu teal r egi on is r ich ly i nn er vated b y super io r, mid dl e, an d inf eri or cl uni al ne rves (L. clu ne s, bu ttocks) . Th ese
su p erf icia l n er ves sup pl y th e skin o ver th e i liac cre st, bet ween the po ster ior su p eri or il iac spin es an d over th e ili ac tu b ercl es.
C on seq ue ntl y, th ese n er ves are vu ln era bl e to in ju r y w he n bo ne is taken f ro m th e i liu m f or g raf tin g .
D eep G lu t eal N er v es
T h e d eep gl ut eal ne rves ar e th e sup er ior a nd i nf eri or g lu teal n erve s, sciati c n er ve, n erve to qu ad ra tus fe mo ri s, po steri or cu tan eou s
n er ve o f th e th ig h, ner ve to obt ur ator in tern u s, an d pu d end al n erve (Fig . 5 .2 4 A; Tab le 5. 8 , fi gu r e). Al l o f the se n er ves a re
b r anch es of th e sa cral p lexu s a nd l eave the p elvis th ro ug h th e g r eater sci atic for am en . E xcept f or th e su p eri or g lu teal ne rve, they
a ll em erg e i nf er ior t o th e pi rif or m is.
S u p eri or G lu t eal N er v e
T h e sup er ior g lutea l ner ve ru n s la tera lly be tween the gl u teus m edi us an d m in im us wi th th e d eep b ran ch o f the su per io r gl utea l
a rter y. I t d ivi des in to a su p eri or b ran ch th at sup p lies th e g lu teu s m ed iu s an d an i nf er ior b ra nch tha t con ti nu es to p ass betw een th e
g lu teu s m ed iu s an d th e glu teu s mi ni mu s to sup pl y b oth m u scles an d the ten sor o f the fa scia lata .
I n fer io r G l u t eal N erv e

T h is i nfer io r gl uteal nerve lea ves th e pel vis thr ou gh the g rea ter sciati c f or am en, in fer ior to t he pi ri for m is and su p erf ici al to t he
sci atic n erve, accom pa ni ed by m ul tip le br an ches of th e in fer ior glu teal ar ter y a nd ve in . It
P. 6 2 0
P. 6 2 1
a lso di vide s in to sever al br an ch es, wh ich pr ovid e mo tor in n er vatio n to the ove rly in g glu teu s ma xim us.
Ta bl e 5. 8. Ner ves of Gl uteal Re gi on a nd Poster io r Thi gh
Nerve
Or ig in
Co urse
D is tri butio n

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Cl un ia l
Su per io r
As later al
Pass in fe rol ater all y acr oss ili ac cr est
cut ane ou s b ran ch es

of po ster ior r am i of
Su p ply skin of sup er ior b u ttock as

fa r as tu b ercl e o f ili ac cr est
L1 L 3 spi na l
ne rves
Midd le
As later al
cut ane ou s b ran ch es
E xit thr ou g h po steri or sacr al fo ra mi na

an d pa ss la tera lly to gl ute al reg ion
Su p ply skin over sacr u m an d

ad jacen t are a of b u ttock
Poster io r cut ane ou s
E me rg es f ro m in fe ri or bo rd er of g lu teu s
Su p pli es ski n of in f eri or h alf o f
ne rve of th ig h
(an teri or r am i of
m axim u s a nd asce nd s su p erf icia l t o i t
bu tto ck as fa r as g re ater tr och an ter
Sacr al pl exu s
(an teri or an d
E nte rs gl utea l r eg ion via gr eater sci atic

fo ra men in fer ior to p ir if or mi s an d d eep
Su p pli es n o m uscl es i n gl ute al

re gio n; su pp lies all m u scles of
po steri or d ivisi on s
of an ter ior r am i of
to gl ut eus m axim u s; d escen ds in

p oster ior th ig h d eep to bi ceps fe mo ri s;
po ster ior co mp ar tm ent of th ig h

(tib ial d ivisi on su pp li es al l bu t sh or t
L4 S3 spi nal
ne rves)
b ifu r cates in to t ibi al an d com m on fi bu la r

n erve s at ap ex o f pop li teal fo ssa.
h ead of b icep s, wh ich i s su p pli ed by

com m on f ib ul ar di visio n)
Poste rio r
cut ane ou s
Sacr al pl exu s
(an teri or an d

Su p pli es ski n of in f eri or h alf o f

bu tto ck (th r ou gh i nf eri or cl un ial
ne rve of
th igh
po steri or d ivisi on s
S1 S3 spin al
to gl ut eus m axim u s, em erg in g f rom

in fe ri or bo rd er of l atter ; d escen ds in
p oster ior th ig h d eep to fa scia lata
n erves) , skin o ver po steri or th ig h

an d po pli teal fo ssa, an d skin of
late ral p eri ne um and u p per m ed ia
of po ster ior r am i of
S1 S3 spin al
ne rves
Inferio r
S2 S3 spin al
ne rves)
Sci atic
ne rves)
th ig h (via its per in eal b ran ch ).
Su pe rio r
Sacr al pl exu s
In n erv ates g lu teu s m ed iu s, g lu teu s
gl ute al
(po steri or d ivisi on s

fo ra men sup er ior to p ir ifo rm is; cou r ses

la tera lly bet ween g lu teu s m ed iu s a nd
m in im us, and tenso r of f ascia lata

m uscl es
L4 S1 spi nal
ne rves)
m in im u s as far as ten sor of fasci a l ata
Sacr al pl exu s
(po steri or d ivisi on s

L5 S2 spi nal
to in fer io r pa rt of gl u teus m axim u s,

d ivid in g in to sever al br an che s
Infe rio r
gl ute al
Su p pli es g lu teu s m axi mu s
ne rves)
Ner ve to
Sacr al pl exu s
In n erv ates h ip join t, i nf er ior
qu ad ra tus
fem or is
(an teri or d ivisi on s

fo ra men in fer ior to p ir if or mi s, de ep

(an ter ior ) t o sci atic ne rve
ge mel lu s, an d qu ad ra tus fem o ri s
L4 S1 spi nal
ne rves)
S ci at ic N er ve
T h e sci atic nerve is th e la rg est n er ve in th e b od y a nd i s th e con tin ua tion o f the m ain par t o f th e sacr al p lexu s. Th e ram i con ver ge
a t th e in fer io r bor d er of th e p ir if or mi s to f orm the scia tic ner ve, a th ick, f latt ened ban d ap pr oxi ma tely 2 cm w ide . Th e sci atic n erve
i s th e mo st l ater al stru ctu r e em er gi ng th r ou gh t he gr eate r sciati c f or ame n in fer io r to the p iri fo rm is. Med ial to it ar e t he in fer io r
g lu teal n er ve a nd ves sels, th e in tern al p ud en dal vesse ls, an d th e p u den da l n er ve. T he sciat ic n er ve ru ns in fe rol ater all y u n der co ver
o f th e g lu teu s m axim u s, m id way b etwee n the g rea ter tr och ant er an d isch ial tu be rosi ty. Th e ne rve re sts o n the isch iu m a nd th en
p asses po ster ior to th e obtu r ator i nt ern u s, qu ad ra tus fe mo ri s, an d add u ctor m ag nu s m u scles. Th e sci atic ne rve is so l ar ge tha t i t
r ecei ves a n am ed br an ch of th e in fer io r gl utea l a rter y, th e ar tery to the scia tic ner ve (L. a rter ia com ita ns n ervi isch ia di ci).
T h e sci atic ne rve sup p lies n o str u ctu res in th e glu tea l r eg ion . I t su pp li es th e pos teri or th ig h m uscl es, all l eg an d foo t m u scles, a nd
t he skin o f m ost o f the leg and t he fo ot. I t al so sup pl ies the ar ticu lar br an ches to all jo in ts o f the lo wer l im b.
T h e sci atic ne rve is rea lly two n erv es, th e ti bi al ner ve, d er ived f rom an teri or (p rea xial ) d ivisi on s of th e an teri or r am i, an d th e
c om mo n fi bu lar n er ve, d eri ved f rom po steri or (p ostaxi al) div isio ns of th e a nter io r ra mi , wh ich a re lo osely bo un d tog eth er in the

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s ame con n ective tissu e she ath (Fig . 5 .2 8A). P ero ne is Greek fo r th e f ib ul a; b ecau se o f the clo se r ela tion sh ip of th e ne rve to the
f ib u lar n eck, it s n am e h as bee n cha ng ed in ter n ation al ly fr om com m on per on eal to com m on f ib ul ar. T h e ti bia l a nd co mm o n fi bu lar
n er ves usu al ly se par ate ap pr oxim ate ly h al fw ay o r m ore d own the th ig h (Fig. 5. 3 3); h owe ver, i n ap pr oxi ma tely 12 % of p eop le, th e
n er ves separ ate as the y le ave the pe lvis (Fig. 5. 2 8B ). I n th ese ca ses, th e ti bia l n er ve passes in fe rio r to th e p ir ifo rm is, and t he
c om mo n fi bu lar n er ve pie rces th is m u scle or p asses sup er ior to it (Fig . 5 .2 8C).
N e rv e to Q u ad rat u s F em or is
T h e ner ve to the quad r atus f emo ri s le aves t he pe lvis an teri or to th e sci atic n erve an d ob tu rato r in ter nu s and p asses over t he
p oste ri or su rf ace o f th e h ip j oin t. I t su pp li es an arti cu lar b ran ch to th is joi nt an d in n erva tes t he in fer io r gem el lu s an d q uad r atu s
f em oris.
P o st er io r Cu t an eou s N e rv e of th e T h ig h
T h e p os teri or cutaneo us ner ve o f the thig h su p pli es m or e skin th an a ny oth er cu tan eou s n er ve. I ts f ib ers fr om the an ter ior
d ivi sion s of S2 a nd S 3 su pp ly the skin of th e p er in eum . S om e o f th e f ibe rs fr om th e po steri or d ivisi on s of t he an ter ior r am i of S1
a nd S 2 su pp ly th e ski n of th e i nf er ior p ar t of t he bu tto ck (vi a th e in fer ior clu ni al ner ves); oth er s con tin u e i nf er ior ly in b ra nch es
t hat su pp ly th e ski n of th e p oster io r th igh and p r oxim al p art of th e leg . Un like m ost ner ves bea ri ng th e na me cu tan eou s, th e m ai n
p ar t o f thi s n er ve l ies deep t o th e dee p fasci a (f ascia lat a), wi th on ly its ter mi na l b r anch es pen etr ati ng th e sub cu tan eou s ti ssue fo r
d istr ib u tion to t he skin .
P u d en d a l N er v e
T h e p ude ndal ner ve i s th e mo st m ed ial str uct ur e t o ex it t he pe lvis th rou g h th e g rea ter scia tic f or am en in f eri or to th e p ir if orm i s
m u scle. It descen d s p oster ol ater al to t he sacr osp in ou s li gam en t and ente rs the p eri neu m t hr ou gh the lesse r sciati c f ora me n to
s up pl y str u ctur es in th e p er in eu m (see Ch ap ter 3 ); i t su pp li es n o stru ctu re s in the g lu teal reg io n or p oster ior thi gh .
N e rv e to O b t u r at or I n t er n u s
T h e ner ve to the ob tura tor inte rnus ari ses f ro m th e an ter io r di visio ns of th e a nte rio r ra mi o f the L5 S 2 n erves an d pa ral lel s
t he cou r se of th e pu d end al n erve . As it p asses ar ou nd th e ba se of t he isch ial sp in e, it su pp lies th e su p eri or g eme llu s. Af ter
e nte rin g th e per in eu m via th e l esser scia tic for am en , it sup p lies th e o btu ra tor in ter n us m uscl e.
I nj u r y to t h e S u p e r i o r G l ut e a l N e r v e
In ju ry to th e su p eri or g lu teal ne rve re sul ts i n a ch ar acter isti c m oto r loss, resu lti ng i n a disa bl in g glu teu s m ed iu s l im p, to
com pen sate fo r wea ken ed abd u ction of th e th ig h b y th e glu teu s med iu s a nd m in im u s, an d /or a glu tea l g ait , a co mp en sator y list of
the b ody to th e w eaken ed g lu teal sid e. Th is com p ensa tion pla ces th e cent er of g ravi ty o ver th e su p por ting l ower l im b. Me dia l
ro tatio n of th e th ig h i s al so sev erel y i mp air ed . Wh en a per son i s asked to st and o n on e l eg, the g lu teus m edi us an d m in im us
no rm al ly co ntr act as soon a s th e co nt ral ater al fo ot l eaves th e f loo r, p re vent in g tip pin g of th e pel vis to t he u nsu p por ted si de (Fig.
B5 .1 2A). When a p ers on wh o h as su ff er ed a l esio n of th e su p eri or g lu teal n erve is asked to stan d on on e le g, th e pel vis on th e
un su pp or ted sid e d escen ds (Fig . B5 . 12B ), in di catin g th at the gl ut eus m edi us an d m in im us on th e sup po rt ed sid e ar e weak or n on fu nct ion al. Th is o bser vati on i s r efer r ed to clin ical ly as a p osi tive T r endel enbur g test. Ot her ca use s of th is sig n in clu de f ractu r e
of th e g re ater tr och an ter (th e d ista l a ttach me nt of g lu teu s m ed iu s) an d di sloca tion of th e h ip j oin t.

08-May-15
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Fig ure 5.28. Rela tionshi p of scia tic ner ve to p ir if or mis. A. T h e scia tic ner ve usu al ly e mer g es f ro m th e g re ater scia tic
fo ram en i nf er ior to th e pir if or m is. B . In 1 2 . 2% of 6 4 0 li mb s st ud ied , th e sci atic ne rve di vid ed bef or e e xitin g th e gr eater
sciati c f or am en, the com m on f ib ul ar di visio n (yell ow ) p assed th ro ug h th e p ir if or mi s. C. I n 0. 5 % of cases, th e com m on f ibu la r
di visio n pa ssed sup er ior to th e mu scle , wh er e i t is esp ecial ly v ul ner ab le to in ju ry du r in g in tra glu tea l i nj ectio ns.
W hen the pe lvis desce nd s o n th e u n sup po rted side , the lo wer l im b beco m es, in ef fe ct, too lo ng an d d oes no t cl ear th e g r ou nd w he n
t he fo ot is b r oug h t f or war d in t he swi ng p h ase o f wal kin g. T o com pen sate , the in d ivid u al lean s a way fr om t he u nsu p por ted si de,
r ai sin g the p elvis to all ow ad equ ate r oom f or th e foo t to cl ear th e g ro un d as it swi ng s f or war d. Th is resu lts in a ch ar acter istic
w ad dli ng or g lu teal ga it. Oth er w ays to com p en sate is to l ift th e f oot h ig her a s it is br ou g ht fo rw ard , r esu ltin g in t he soc alled s tepp ag e g ait, o r to swi ng th e foo t o utw ar d (later al ly), th e so-call ed swi ng -ou t g ai t. Th ese sam e g aits ar e a dop ted to
c om pen sate fo r th e f ootdro p th at r esu lts fr om co mm o n fib u lar n er ve p ar alysi s (see cli ni cal cor rel atio n [bl ue] bo x I nj ur y t o th e
C om m on Fi bu lar N er ve a nd Foo tdr op , in t hi s ch ap ter), wh ich al so m ak es th e lim b too l on g.
A n e s th e t ic B l o c k o f t he S ci a t i c N e r v e
S en satio n con veyed b y th e sciati c n er ve ca n be bl ocked b y th e in jecti on of a n an esth etic age nt a f ew cen tim eter s in fer ior t o th e
m i dp oin t of th e l in e j oin in g th e P SIS a nd th e sup er ior b or der of th e g rea ter tr och an ter. Par esth esia ra dia tes to th e foo t b ecau se o f
a ne sthesi a o f th e p lan tar n er ves, w hi ch are ter m in al br an che s of th e tib ial n erv e d eri ved fr om the scia tic n er ve.

08-May-15
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Fig ure B5. 12
I nj u r y t o t he S c ia t i c N e r v e
A p ain in th e bu ttock m ay r esu lt fr om co mp r ession of th e sci atic ner ve by th e p ir ifo rm is m uscl e (p ir if or mis synd ro me).
I n di vidu al s i nvo lved in spor ts tha t r eq ui re excessive u se o f the g lu teal m uscl es (e. g ., i ce ska ters, cyclists, and r ock cli mb er s) an d
w om en a re m ore li kely to deve lop th is syn dr om e. I n app r oxim ate ly 5 0 % of cases, t he case hi stor ies in dica te t rau m a t o th e bu tto ck
a ssocia ted wi th h yper tr oph y an d spasm of th e p ir if orm i s. In th e ap pr oxim ate ly 1 2 % of p eopl e i n wh om the com m on f ib ul ar d ivisi on
o f th e scia tic ner ve passe s th ro ug h th e pir if or m is (Fig . 5 . 28B), thi s m u scle ma y co mp re ss th e n er ve.
C om p lete secti on of th e sciati c n er ve i s u nco mm o n. Wh en t hi s occu r s, th e le g is u sel ess b ecau se e xten sion o f the h ip is im pa ir ed,
a s i s fl exio n of th e l eg. All an kle an d fo ot mo vem ent s ar e a lso lost . In com p lete sectio n of th e sci atic ne rve (e.g. , from stab
w ou n ds) ma y al so in volve th e i nf er ior g lu teal an d/o r th e p oster io r fem or al cu tan eou s n er ves. R ecover y f r om a sciati c l esion i s sl ow
a nd u su all y i nco mp lete .
W ith r espe ct to th e sci atic n erve, the b utto ck h as a si de of saf ety (its l ater al sid e) a nd a sid e o f dan g er (its m edi al side ). Wou nd s
o r su rg ery on t he m edi al sid e of th e bu tto ck ar e l iab le to in ju re th e sci atic ne rve an d its br an che s to th e h am str in gs
( semi ten di no sus, se mi me mb ra no sus, and b icep s f em or is) on th e p oste rio r asp ect o f the th ig h. P ara lysis of th ese mu scl es r esu lts i n
i m pai rm en t o f th igh exten sion a nd l eg fl exion .
I nt r a g lu t e a l I n j e ct i o n s
T h e g lu teal r egi on is a com mo n site fo r in tr am uscu lar in jectio n of d ru g s. Glu teal in tra mu scu lar i nj ectio ns pe netr ate th e ski n,
f asci a, an d m uscl es. Th e glu tea l r eg ion i s a fa vor abl e i nj ection site beca use th e m u scles ar e th ick an d lar ge ; con seq ue ntl y, th ey
p r ovid e a su bst ant ial vol um e for a bso rp tion of in jecte d sub stan ces b y in tram u scu lar vei ns. It is im por tan t to be awa re of th e
e xten t o f t he gl ut eal reg io n an d the saf e r eg ion f or g ivin g in j ection s. S om e p eop le re stri ct th e are a o f t he bu tto ck to th e m o st
p r om in en t p art , wh ich m ay be d an ger ou s b ecau se t he sciat ic n er ve l ies deep t o th is ar ea (Fi g. B 5 .1 3A).
I n jecti on s in to th e b u ttock ar e saf e o nl y i n th e su pe rol ater al qu ad ra nt of th e b u ttock or su pe rio r to a l in e ex tend in g f rom the PS IS
t o th e sup er ior b or de r of th e g re ater tr och an ter (ap pr oxi ma ting th e su per io r bo rd er of th e glu teu s ma xim us). In tr am uscu lar
i n jectio ns can al so be gi ven saf ely in to the an ter ola tera l p ar t o f the th ig h, w h ere th e n eed le en ters th e te nso r of th e f ascia lat a
( Fi g. 5 . 23C ) a s it exten d s d istal ly f r om th e i lia c cr est a nd A SI S. T he in d ex f in ger is p lace d on th e A SI S, a nd th e fi ng er s ar e sp r ead
p oste ri orl y al on g th e i liac cre st u n til th e tu b ercl e o f t he cre st i s fe lt b y the m id dle f in ger (Fig . B 5. 1 3B ). A n in tra glu tea l i nj ectio n
c an be m ad e saf ely in th e tri an gu lar a rea b etwee n th e f in ger s (j ust an ter ior t o th e pr oxi ma l j oin t of th e m id dl e f in ge r) beca use it is
s up eri or to th e sci atic n erve . Co mp li catio ns of im p ro per te chn iq ue in clu d e n er ve i nj ur y, h em atom a, and a bscess fo rm ati on .

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Fig ure B5. 13.
B ecau se it over lies th e m aj or d oor way (th e g r eater sci atic for am en ) b y w h ich d eri vative s of th e sacr al ple xus exit th e b on y p elvi s,
t he gl ut eal reg io n in clu des a disp r opo rti on ate nu m be r of n erves of al l sizes, b oth m ot or an d sen sor y. Fort un atel y, m ost are p laced
i n th e i nf er om edi al qu ad ran t; th us pr op erl y ad m in ister ed in tr am u scul ar in jecti on s av oid th ese stru ctu r es. Beca use th e sci atic n erve
i n clu des fib er s f ro m th e L 4 S3 sp in al ne rves, it i s af fe cted by th e m ost com m on n er ve co m pr ession synd r om es (e. g .,
r ad icu lop ath ies of th e L4 a nd L 5 sp in al ner ve ro ots; s ee C h apte r 4). Even tho ug h occu r ri ng o utsi de th e l owe r lim b p er se, th ese
s ynd ro m es r esu lt i n sciat ica p ain th at r adi ates dow n th e l ow er lim b al on g the cou r se o f the n erve an d its ter m in al br an ches. Pain
e xper ien ced i n th e lo wer l im b m ay n ot n ecessar ily ar ise fr om a p rob lem in th e lim b !
P. 6 2 2
P. 6 2 3
P. 6 2 4
A r ter ie s of th e G l u t eal Re gi on an d Po st er io r Th ig h
T h e ar ter ies of th e g lu teal r egi on ar ise, dir ectl y or in dir ectl y, fr om t he in ter na l i liac ar ter ies, b ut th e p atte rn s o f ori gi n of th e
a rter ies ar e va ri abl e (Fig . 5 .2 4 A; Tab le 5 .9 ). T he m ajo r br an che s of th e in ter nal i liac ar tery th at sup pl y o r tra verse th e g lu teal
r eg ion a re th e (1 ) su p eri or g lu teal ar ter y, (2 ) in fe ri or gl ut eal art ery, and (3 ) in ter nal p ud en da l a rter y. A fter b ir th , th e p oster io r
co mp ar tm en t of th e th igh has n o m aj or ar ter y ex clu sive to t he com p artm en t; it recei ves b lo od fr om mu lti pl e so ur ces: i nf er ior
g lu teal , m edi al cir cum fl ex f em or al, p er for ati ng , an d p opl iteal ar ter ies.
S u p eri or G lu t eal Ar t er y
T h e sup er ior g lutea l a rter y is th e lar ge st b ran ch o f the in ter n al ilia c ar ter y a nd p asses post eri or ly b etw een th e lu mb osacr al tr un k
a nd th e S1 n er ve. T he su per ior glu tea l ar ter y l eaves th e p elvi s th ro ug h th e gr eater sci atic fo ram en , su pe rio r to th e p ir ifo rm is, and
d ivi des im m edi ately in to su per fi cial an d de ep br an che s. Th e su p erf ici al br an ch sup p lies th e g lu teu s m axi mu s a nd ski n over the
p r oxim al atta chm en t of th is m u scle; th e d eep b ran ch su pp li es th e gl uteu s me diu s, g lu teu s m in im u s, an d ten sor of t he fa scia lata.
T h e su per io r gl ute al arte ry an astom ose s wi th th e i nf er ior g lu teal an d m ed ial cir cum f lex fem or al ar ter ies.
I n fer io r G l u t eal Ar t ery

T h e inf er ior g lute al a rte ry ari ses f ro m th e i nt ern al il iac arte ry an d passe s p oster ior ly th ro ug h th e p ar ietal p elvi c f ascia, b etw een
th e S1 a nd th e S2 (o r S2 a nd S 3 ) n erv es. Th e in fer ior g lu teal ar ter y l eaves th e p elvi s th ro ug h th e gr eater sci atic fo ram en , in f eri or
to th e pi rif or m is. I t en ter s th e gl utea l r eg ion deep to th e gl uteu s ma xim us an d de scend s m ed ial to th e sci atic n erve .
T h e in f eri or g lu teal ar tery su pp lie s th e g lu teu s m axi m us, o btu r ator i nte rn u s, qu ad rat us fem or is, and su p eri or p art s of th e
h am str in gs. I t ana stom oses wi th th e su p eri or gl ut eal ar tery an d fr eq uen tl y p art icip ates in th e cru ciate an asto mo sis o f th e th ig h,
i nvo lvin g th e fir st per fo rat in g arte ri es of th e dee p art ery of th e t hi gh an d th e med ia l a nd l ater al cir cum f lex fem or al ar teri es (T ab le
5 . 5) . Whet her t he cr uci ate a na stom osis is for m ed or n ot, the se vessel s al l par tici pat e in sup pl yin g th e str u ctur es of th e p ro xim al
p oster io r th igh .
Devel op me nta lly, th e in fer io r gl utea l a rte ry is t he m ajo r art ery of th e p oste rio r com pa rtm en t, tr aver sin g its len g th an d beco m in g
co nti nu ou s wit h th e p op litea l a rter y. T hi s p ar t of th e ar tery di m in ish es, h owev er, p er sistin g p ostn atal ly as th e art ery to the scia tic
n er ve.
I n t er n al Pu de n d al Ar t ery
T h e inte rnal p udend al ar ter y ar ises fr om th e in ter nal i liac ar ter y an d li es an ter io r to the in fe ri or gl ut eal art ery. Its cou rse
p ar all els t ha t of th e pu d end al n erve, ent eri ng th e gl ute al r eg ion thr ou gh the g rea ter sciati c f or am en in fe ri or to th e p ir ifo rm is. Th e
i nte rn al pu d en dal ar ter y l eaves the g lu teal reg io n im m edi ately b y cr ossin g th e i sch ial spi ne /sacro spi no us lig am en t an d en ter s th e
p er in eum th rou g h th e l esser sciat ic f or am en . Li ke th e pu de nd al ne rve, it su p pl ies t he skin , exte rn al ge ni talia , an d mu scl es in the
p er in eal re gio n. It doe s n ot sup pl y an y stru ctu r es in the g lu teal re gio n or p oster io r thi gh .
P er for at in g Ar t eri es
T h ere ar e u su ally f our p erf or ati ng art eri es o f the d eep ar ter y o f the thig h, th ree ar isin g in the an ter ior co mp ar tm en t an d th e
f ou rt h bei ng t he ter mi na l b r anch of th e d eep ar ter y i tself . Th e per fo rat in g arte rie s ar e lar ge vessels, un u sua l i n th e l im bs for thei r
tr an sver se, in ter com partm en tal cou r se. S ur geo ns op er atin g in the po steri or com p ar tme nt ar e ca ref ul to iden tif y th em t o av oid
i na dver ten t i nj u ry. T he y p erf or ate the ap on eu ro tic p or tio n of th e d ista l a ttach m ent of th e add u ctor m ag nu s t o en ter t he po ster ior
co mp ar tm en t. With in t he po steri or co mp ar tm ent, the y typ ical ly give r ise to m u scu lar b ra nch es to t he h am stri ng s a nd an asto m otic
b r anch es th at a scend o r desce nd to u n ite with tho se a risi n g sup eri or ly or in fe rio rl y f ro m th e o the r per fo rat in g art eri es or the
i nf er ior g lu teal an d p opl iteal ar ter y. A con tin u ou s a nast om otic ch ain th u s exte nd s f ro m th e g lu teal to p opl itea l r eg ion s, w hi ch gi ves
r ise to ad dit ion al br an ch es to m u scles a nd t o th e sciati c n er ve. Af ter g ivin g of f th eir p oster ior com par tm en t b ra nch es, th e
p er for ati ng a rter ies pi er ce th e later al in ter m uscu lar septu m to en ter th e an teri or com p ar tme nt, wh ere th ey sup pl y th e vastu s
l ater ali s m u scle.
P. 6 2 5
Tab le 5.9. Ar teri es o f the Gl uteal Reg ion and Post eri or T hi gh

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Arter y a
Page 64 of 155
Cour se
Di stri buti on
Su pe rio r
E n ter s g lu teal re gio n th ro ug h g reat er sciati c f or am en su per ior to
Su p erf icia l b r an ch: sup pl ies
gl ute al
p ir if orm i s; d ivid es i n to su p erf icia l a nd d eep b ra nch es; ana stom oses
w ith i nf er ior g lu teal an d m edi al cir cum f lex art eri es (n ot sh own i n
gl u teus m axim u s
Deep b ran ch : r u ns betw een
f ig ur e)
gl u teus m edi us an d m in im us an d
su pp lie s th em an d ten sor o f
fa scia lata
Infe rio r
E n ter s g lu teal re gio n th ro ug h g reat er sciati c f or am en in fer io r to
Su p pli es g lu teu s m axi m us,
gl ute al
p ir if orm i s; d escen ds on m ed ial sid e o f sciati c n erv e; an asto mo ses

w ith su p eri or g lu teal ar tery an d pa rti cip ates in cr uci ate ana stom osis
ob tu rat or in ter nu s, q ua dr atu s

fe mo ri s, an d sup er ior p ar ts o f
o f thi gh , in vol vin g fi rst pe rf ora tin g ar tery of d eep f emo ra l a nd m ed ial
a nd l ater al cir cum fl ex a rte rie s (n ot sho wn i n fi gu re )
h am stri ng s
E n ter s g lu teal re gio n th ro ug h g reat er sciati c f or am en; de scend s

p oster io r to isch ial spi n e; en ter s p er in eum thr ou g h lesser sci atic
Su p pli es e xtern al g en itali a a nd

m uscl es i n pe rin eal r eg ion ; d oes
f or am en
n ot sup pl y g lu teal r egi on
E n ter s p oster ior co m par tm en t b y p er for ati ng ap on eu ro tic por tio n of
Su p pli es m aj or ity (cen tral
a dd ucto r m agn u s at tach men t an d me dia l i nt erm u scul ar sep tu m; aft er

p ro vid in g m uscu lar br an ches to ha mst rin g s, con tin u es o n to an teri or
po rt ion s) o f ham str in g m uscl es,

th en con tin u es t o su p ply vastu s
co mp ar tm ent b y p ier cin g late ral in ter m uscu l ar sept um
lat era lis in an ter ior com par tm en t
In ter na l
pu d end al
Per forati ng
Al l o f th ese ar ter ies ar ise fr om th e in tern al il iac ar tery (see Tab le 5 .5 f or a n an teri or vi ew).
V ein s o f t h e G l u te al Reg i on an d P o st er io r Th i g h
T h e g lu teal vein s are tr ib uta ri es of t he in ter na l i lia c vei ns th at d ra in b loo d fr om th e gl utea l r eg ion . T he sup eri or and i nfer io r
g l ute al ve ins a ccom pan y the cor r espo nd in g ar teri es th r ou gh t he gr eate r sciati c f or am en, su p eri or an d in f eri or to th e p ir ifo rm is ,
r esp ective ly (Fi g. 5 . 29A ). Th ey co m mu n icate wi th tr ib uta ri es of t he fem o ral vei n, t her eb y p ro vid in g alter n ate rou tes fo r th e r etu rn
o f bl ood f ro m th e l ower lim b if th e fem or al vein is o cclu ded o r h as to b e l iga ted. Th e i nternal p ude nd al veins accom p an y th e
i n tern al p ud en dal ar ter ies an d joi n to for m a sin g le v ein th at en ters th e i nte rn al ili ac v ein . Th ese vein s d r ain b loo d fr om th e
e xter nal g en ital ia or pu d en du m (L . pu de re, t o b e a sha me d). Pe rf or atin g vein s accom pa ny th e ar ter ies of th e sa me n am e to d ra in
b lo od fr om the p oster ior co m par tm en t of th e th igh in to the de ep vein o f the th ig h. Th e p er for ati ng vei ns, like th e a rter ies, usu all y
a lso com m un ica te i nf er ior ly wit h the p opl itea l ve in an d su per io rly wi th th e i nf er ior g lu teal vei n.
L y m p h a ti c Dr ai n ag e o f t h e G lu tea l R eg io n an d T h ig h
L ym ph fr om th e deep t issu es o f t he bu tto cks f oll ows th e g lu teal vessel s to th e s up eri or an d in f eri or g luteal lymp h no des an d
f r om th em to th e in tern al , exter n al, an d com m on i lia c lymp h no de s (Fig . 5 .2 9 A) an d fr om th em t o th e later al
P. 626
a or tic lumb ar (cava l/l ymph) nod es. L ym ph fr om th e sup er fici al tissu es o f the g lu teal re gio n en ter s th e su p erf ici al in gu in al
l ym ph n od es, w hi ch also r eceive lym p h fr om the th ig h. A ll th e su p erf icia l i ng u in al no des sen d eff er ent lym p ha tic v essels to the
e xter nal i liac lym p h no des.

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Fig ure 5.29. L ymphati c d r ainag e o f gl uteal reg io n and thi gh. A. L ymp h f rom th e d eep tissu es of th e g lu teal r egi on en ter s
th e p elvi s al on g the gl ut eal vein s, d rai ni ng t o th e sup er ior a nd i nf er ior g lu teal lym p h n ode s; f rom th em, it p asses to th e il iac
an d later al lu m ba r (caval/a or tic) l ym ph n od es. B . Ly mp h fr om sup er fici al tissu es o f th e g lu teal r egi on p asses i ni tial ly to th e
sup er fi cial in gu in al n od es, wh ich also re ceive lym ph fr om th e thi gh . L ym ph f ro m all th e sup er fici al in gu in al n ode s p asses v ia
eff er ent lym p h vessel s to th e ext ern al an d com m on i liac an d ri gh t and l eft lu m ba r (caval/a or tic) l ym ph n od es, d rai n in g via
lu m bar l ym ph atic tr un ks to t he ch yle cister n.
Ar ter ies a nd ve in s ser vin g th e g lu teal r egi on an d th e p r oxim al p art of th e post eri or com p art me nt of th e t hi gh ar e br an che s an d
tri bu tar ies of th e i nte rn al il iac arte ry an d vein th at pa ss to an d fr om the r egi on via th e gr eater sci atic fo ram en . A ll bu t t he
sup er ior g lu teal vessel s exi t th e fo ram en i nf er ior to th e pir if or m is m u scle. A lth ou g h the p ud en dal vesse ls f oll ow th e sa me r ou te,
the y tr aver se t he gl ute al reg io n on ly br ief ly e n ro ute to an d fr om t he pe rin eu m vi a th e lesser sci atic fo ram en . T he po ster ior
com par tm en t o f the th ig h do es n ot h ave a m ajo r ar tery cou r sin g thr ou g h it wit h pr im ar y r esp on sibi lit y f or th e co mp ar tm en t.
Rat her , b ran ch es a re sen t f ro m sever al ar ter ies i n oth er co mp ar tm ent s to su pp ly it.
I n ter m s o f the vascu lar sup pl y to th e l ow er lim b as a wh ole, the m ajo ri ty o f t he ar ter ial bl ood co mi ng t o th e lim b an d m ost of th e
v eno us bl ood a nd l ymp h exi tin g fr om i t p ass alon g th e mo re pr otect ed an tero m edi al aspect of th e lim b . Flexor aspect s ar e
g en er ally b etter p ro tected th an ar e exten sor asp ects, th e latte r bei ng exp osed a nd t her ef ore vu ln er abl e i n th e f lexed , de fen sive
p osi tion.
P. 6 2 7
P. 6 2 8
P. 6 2 9
P. 6 3 0
P. 6 3 1
Su r f a c e A na t o m y o f t he G l u t ea l R e g i o n a n d T h i g h
Th e ski n of th e glu tea l r eg ion i s u su ally th ick an d cou rse, e speci ally in m en , w he reas th e ski n of th e thi gh i s r elat ively th in an d
loo sely attach ed to th e u n der lyi ng su b cuta neo us tissu e. A l in e j oin in g th e h ig h est p oin ts of th e i lia c cr ests (Fi g. S A5 . 2A ) cr osses
the L 4 L 5 in ter ver tebr al (I V) disc an d is a u sef ul la nd m ark wh en a lu m ba r pu n ctur e is p er fo rm ed (see Ch ap ter 4 ), in d icati ng th e
mi dd le of th e l um b ar ciste rn (Fig . S A5 .2A D). T h e i nte rg lutea l cl eft, b eg in ni ng i nf er ior to th e apex of th e sacru m , is th e d eep
gr oove b etwee n th e b utt ocks. I t exte nd s a s f ar sup er ior ly as the S3 or S4 segm en t. T he coccyx is pal pab le in t he su per ior p ar t o f
the in ter gl ut eal clef t. Th e po ster io r s up er io r ili ac sp ine s ar e l ocate d at th e po steri or extr em iti es o f the il iac crests an d m ay b e
dif fi cul t to p alp ate; ho weve r, th ei r posi tio n can al ways be lo cated at th e b otto m of th e per m ane nt skin d im p les app ro xim atel y 3 . 75
cm fr om mi dli n e (Fig . SA 5 .2B). A l in e j oin in g th ese di mp les, o ften mo re visi bl e in wom en t han in m en , pa sses th r ou gh th e S2
spin ou s pr ocess, i nd icat in g the lev el o f th e lo west li mi t o f the du r al sac o r lu m bar ci ster n, t he m idd le of th e sacro ili ac j oin ts, a nd
the b ifu r catio n of th e co m mo n ili ac a rter ie s.
Fig ure SA5. 2
Th e l ocati on of o nl y tw o of th e g lu teal m uscl es ca n be ob ser ved. T h e g lu teu s m axim u s co ver in g mo st str u ctur es in th e glu tea l
reg io n can b e f elt to con tra ct w hen strai gh ten in g u p fr om b en di ng o ver. T h e i nf eri or ed ge of th is lar ge m u scle is l ocated j ust
sup er ior to th e gl ut eal fo ld , wh ich co nta in s a var iab le am ou nt of su bcu tan eo us fat (Fig . SA 5. 2A & C ). T he gl ut eal fol d di sapp ear s
wh en th e h ip join t is flex ed. T he d egr ee of pr om in en ce of th e g lu teal fo ld ch an ges in ce rtai n ab no rm al con d itio ns, su ch a s atr op hy
of th e g lu teu s m axi mu s. A n im ag in ar y li ne d raw n fr om the coccyx to th e i schi al tub er osity in d icates th e in f eri or ed ge of th e
glu teu s ma xim us (Fig . SA 5. 2B). A n oth er lin e dr aw n fr om th e PSI S to a p oi nt sli gh tly sup er ior t o th e gr eater tro chan ter i nd ica tes
the su per io r edg e of th is m u scle.
Th e g lutea l sul cus, th e ski n crea se i nf er ior to th e glu teal f old , d elin eate s th e bu ttock fr om t he po ster ior asp ect of th e th ig h (Fig .
SA 5. 2 A & C ). Wh en th e th ig h is exten d ed as i n th e f ig ur es, th e ischia l tub er osi ty is cover ed b y th e in fer ior p ar t o f the g lu teu s
ma xim us; h owe ver, the tu ber osi ty i s easy to pa lpa te w h en th e th ig h is fl exed b ecau se th e glu teu s ma xim us sli ps sup er ior ly off th e

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t ub er osity, wh ich is th en su bcu tan eou s. Feel th e isch ial tu ber osi ty as you b en d to sit. T he su per io r par t of th e g lu teu s m ed iu s can
b e pal pat ed betw een th e sup er ior p ar t o f the g lu teu s m axim u s a nd th e ili ac cr est (Fi g. S A5 . 2E & F). T he gl ut eus m edi us of on e
b u ttock can b e f elt wh en al l the b ody we igh t shi fts on to the ip sil ater al lim b (th e o ne on the sam e side ).
T h e g r eater tr ochante r , th e mo st l ater al bo ny po in t i n th e g lu teal r egi on , ma y b e f elt on th e later al asp ect of th e h ip , esp ecial ly
i ts i nf er ior p ar t (Fig . S A5 .2A C). I t i s ea sier to p alp ate wh en you passi vely abd u ct yo ur l owe r lim b to r elax th e g lu teu s m ed iu s
a nd m i ni mu s. T he top o f the tr och an ter li es ap pr oxi ma tely a h an d 's b re adth in fer ior to t he tu ber cle of th e i lia c cr est. T he
p r om in en ce of t he tr och ant er in cre ases w he n a d isl ocated h ip ca use s atr op hy of th e glu tea l m u scles an d di spla cem ent of th e
t ro chan ter . A li ne dr aw n fr om the AS IS to th e isch ial tu ber osi ty (N l aton l in e), p assin g over t he late ral asp ect of th e h ip r eg ion ,
n or m all y p asses over o r nea r th e to p of th e g rea ter tr och an ter (Fig . SA 5. 2D). Th e tr och an ter can be fel t su pe ri or to th is l in e i n a
p er son w ith a d isloca ted h ip or a fr actu r ed fem o ral n eck. T he les ser tro chanter i s p alp abl e w ith d if fi cul ty f ro m th e p oster io r
a spect wh en t he th igh is e xten ded an d r otat ed me dia lly.
T h e sci atic ner ve, t he m ost im por tan t stru ctu re in f eri or to th e p ir if orm i s, is r ep rese nte d by a l in e th at exten d s fr om a p oin t m idw ay
b etw een th e gr eater tr och an ter an d th e isch ial tu ber osi ty (Fig . S A5 .2G) d ow n th e m id d le o f the p oster ior a spect of th e thi gh (Fi g.
S A5 . 2H). T he leve l o f the b ifu r catio n of th e sci atic ne rve in to th e ti bia l a nd co mm o n fi bu lar n er ves v ari es. Th e sepa rati on u su all y
o ccu rs in th e i nf er ior t hi rd of th e th igh , b ut th e d ivi sion of th e sci atic ner ve m ay o ccur a s it pa sses th r ou gh t he sciati c f or am en.
T h e ti bi al n er ve bise cts th e pop li teal fo ssa, an d th e co mm on fib u lar n er ve f oll ow s th e b icep s f em or is, w hi ch cover s i t. Th e sciati c
n er ve stret ches wh en th e th igh is f lexed and t he kn ee i s exte nd ed, and it r ela xes w h en th e th ig h is exten d ed an d the kn ee i s
f lexe d.
T h e hams tri ng s can b e f elt as a g rou p as th ey a rise f rom th e isch ia l t ub er osity an d exten d alo ng t he late ral an d p oster ior a spects
o f th e th ig h (Fig . SA 5. 2E) . Th e i lio tib ial tr act, th e fib r ou s b and t hat r ein fo rces th e f ascia lat a l ater ally, can b e ob ser ved on th e
l ater al asp ect o f the th ig h as i t p asses to the la tera l t ibi al con dyl e. Wh ile sitti ng d ow n wi th you r lo wer l im b exten de d, r aise you r
h eel o ff th e f loo r an d feel th e an teri or b or der o f the il ioti bia l t ract p assin g a f in ge r's br ead th p oster io r to t he lat eral b or der o f the
p atel la (Fig. SA 5. 2E & F). N ote th at th e ili otib ial tr act is pr om in en t an d tau t wh en th e hee l i s r aised a nd i nd isti nct wh en th e he el is
l ow ered . T he ten do ns of th e h am str in gs can b e o bser ved an d p alp ated at th e b or der s of th e p op litea l f ossa (Fig . SA 5. 2 I & J). T h e
b i ceps fe mor is t endo n is on th e late ral sid e of th e f ossa. T h e m ost late ral ten d on on the m edi al sid e w he n the kn ee is f lexe d
a gai nst r esistan ce is the semi memb rano sus tend on. Wh i le si ttin g on a ch air w ith you r kne e f lexed , pr ess you r h eel aga in st th e
l eg of th e cha ir an d fee l yo ur b icep s fem or is ten don later all y a nd tr ace it to the h ead of th e fib u la. A lso fee l th e na rr ow an d m or e
p r om in en t semi tend inosus tendo n m ed ial ly, w hi ch pu ll s aw ay fr om th e sem im em br an osu s ten d on th at attach es to t he
s up ero m edi al par t o f th e ti bia .
I n f air ly mu scu lar i nd ivi du als, som e o f the bu lk y an ter ior thi gh m u scles can b e o bser ved . Th e pr om in en t m u scles are th e
q uad r icep s a nd sa rto ri us, wh er eas later al ly th e ten sor of th e fasci a l ata is pal pab le as is th e ili otib ial tr act to wh ich th is m uscl e
a ttach es (Fi g. S A5 . 2F). T hr ee of th e f ou r pa rts of th e q u adr ice ps are visi bl e or can be ap pr oxi ma ted (Fig . SA 5. 2J & K); th e f ou rth
p ar t (v astu s in ter m edi us) is deep a nd a lm ost hi dd en by th e o th er m uscl es an d can n ot be pal pa ted. (Fi g. S A5 . 2K & L). Th e r ectus
f emo ri s m ay be easi ly obse rved a s a ri dg e p assin g d own the th ig h wh en th e low er li mb i s r aised f r om th e flo or wh il e si ttin g.
O bser ve t he lar g e b ul ges fo rm ed b y th e vastu s l ater alis an d m edi alis at the kn ee (Fi g. S A5 . 2J). Th e p atel lar l ig ament i s ea sily
o bser ved , esp ecial ly i n th in p eop le, a s a th ick b an d ru n n in g fr om th e pate lla to th e ti bia l t ub er osity. Y ou ca n also p alp ate the
i nfr ap atel lar f at p ad s, th e m asse s of l oose fa tty ti ssue on e ach sid e o f th e p atell ar li gam en t.
O n the m ed ial asp ect o f the in fe ri or pa rt of th e t hi gh , th e g r acil is a nd sa rto ri us mu scl es f or m a w ell -m arke d pr om in en ce, wh ich is
s epar ated b y a d epr essio n fr om the la rg e b ul ge fo rm ed b y th e vastus me di alis (Fig . SA 5. 2K). De ep in th is dep r essed ar ea, th e
l ar ge tend on o f the ad d uctor mag nus ca n be pa lp ated as it passe s to its attach m en t to th e add u ctor tu be rcle of th e fem u r.
Mea sur em en ts o f the lo wer l im b ar e take n to dete ct sh or ten in g (e. g. , re sul tin g fr om a f emo ra l f ra ctur e). T o ma ke su ch
m ea sur em en ts, com p are th e a ff ected li mb w ith t he cor resp on d in g lim b . Rea l l im b sh ort eni ng i s d etected b y c om par in g th e
m ea sur em en ts f ro m th e A SI S to the di stal tip o f the m edi al m alle olu s o n bo th sid es. To d eter m in e if t he sh ort eni ng i s i n the th ig h,
t he m easu rem en t is t aken f ro m th e to p of th e A SI S to t he di stal ed ge of th e l ater al fem or al con d yle on b oth sid es. K eep in mi nd
t hat sm all d if fer en ces b etwe en th e tw o side s such as a di ff ere nce of 1 . 25 cm in to tal len gt h of th e l im b m ay be n or ma l.
T h e p ro xim al two th ir ds of a li ne dr aw n fr om t he m idp oi nt of th e in gu in al lig am en t t o th e ad ducto r tuber cle w hen the th ig h is
f lexe d, ab d ucte d, an d r otate d later all y r ep resen ts th e cou r se o f the fe mo ra l a rter y (Fi g. S A5 . 2L ). Th e pr oxi ma l th ir d of th e lin e
r ep res ents th is arte ry as i t p asses thr ou g h th e f em ora l t ria ng le, w h ere as th e mi dd le th ird r ep rese nts th e ar ter y w h ile it is in th e
a dd uct or can al. Ap pr oxim ate ly 3 . 7 5 cm al on g thi s li n e d istal to th e i ng u in al lig am en t, th e d eep ar ter y o f the th ig h ar ises f r om th e
f em or al ar tery . Th e f em or al vein i s
Med ia l to th e fem or al ar ter y at th e b ase of th e f em or al tri ang le (in d icated b y i ng u in al lig am en t).
P oster io r to t he fem o ral ar ter y a t th e apex of th e fem or al tr ian gl e.
P oster ol ater al to t he ar tery in the ad du ctor ca nal .
T h e f emor al tr iang le, i n th e su p ero an teri or asp ect of th e th ig h , is n ot a pr om in en t su r face fe atu re in m ost pe opl e. Wh en som e
p eop le sit cro ss-leg ged , th e sarto ri us an d ad du ctor l on gu s sta nd o ut, del in eatin g th e f em or al tri an gle . Th e su r face an ato my of th e
f em or al tri an gl e is cli ni cally im p or tan t b ecau se o f its con tent s. Th e f em or al ar tery can b e f elt pu ls atin g ju st i nf er ior a t th e
m i din g ui na l p oi nt. W hen y ou p alp ate the fe mo ral p ul se, th e f em or al vein i s j ust m edi al, th e fem or al n erv e is a fin g er' s b rea dth
l ater al, and t he fem o ral h ead is ju st post eri or . Th e f em or al art ery ru n s a 5 -cm su per fi cial cou r se th r ou gh t he fem o ral tr ian g le
b ef or e it is cover ed b y th e sart ori us in t he ad du ctor can al .
T h e g rea t sap h en ou s vei n en ters th e th ig h p oster ior t o th e m edi al fem or al con dyl e a nd p asses sup er ior ly alo ng a li ne fr om t he
a dd uct or tu ber cle to th e sa pheno us op eni ng . T he cen tra l p oi nt of th is op eni ng , w her e the g rea t sap h eno us vein ente rs the
f em or al vein , is lo cated 3 .7 5 cm in fer ior and 3 . 7 5 cm la tera l t o th e pu bi c tu b ercl e.
P. 6 3 2
P o p lit e a l F os s a
T h e p op li teal fo ssa is a m ostl y f at-fi lle d com par tm en t o f the lo wer l im b. S up er fi ciall y, wh en th e kn ee i s f lexed , th e p op lite al fossa
i s evi den t as a d iam on d-sh ap ed d epr essio n po steri or to th e kn ee jo in t, bo un d su per io rl y b y th e div erg in g h am stri ng s an d i nf eri or ly
b y t he con ver gi ng h ead s o f the ga stro cne mi us an d pl ant ari s (Fig . 5 .3 0 ). Th e size of th is gap b etw een m u scles i s m isl ead in g,

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h ow ever , in term s of th e act ual si ze a nd ext ent of th e pop li teal fo ssa. Deep ly, it is m uch l ar ger th an t he su per fi cial de pr essio n
i n dica tes b ecau se t he h eads of th e gastr ocn em iu s f or m in g the in f eri or b ou nd ar y su per f icial ly for m a r oof ove r the in f eri or h alf of
t he de ep par t. Wh en th e kne e i s exten d ed, t he fa t w ith in th e fossa p ro tru de s th r oug h th e gap b etw een m u scles, p ro du cin g a
r ou n ded e levati on f lan ked b y sh all ow lo ng itu d in al gr ooves over lyi ng t he h am stri ng te nd on s. In disse ction , if t he h eads of th e
g astr ocn em iu s a re sepa rat ed an d retr acte d (Fi g. 5 . 31 ), a m u ch lar ger space is rev ealed .
S u per fi cial ly, th e p op lit eal fossa is b ou nd :
S u per ol ater ally by th e b icep s f em or is (sup er olate ral b or der ).
S u per om ed ial ly b y t he sem im em br an osu s, la tera l to w hi ch is th e sem ite nd in osu s (su p ero me dia l b or de r).
Fig ure 5.30. Super f icia l p op li teal re gi on. A. Nu m ber s on th e su r face an ato my re fer to str u ctur es ide nti fie d in p art B .
Th e d ia mo nd -sh aped g ap i n th e r oof o f the po pl iteal f ossa, f or me d by the ove rl yin g mu scle s, is ou tlin ed . B. S u per fi cial
di ssection of th e p op lite al reg ion sho win g th e mu scles th at cover m ost of th e p op lit eal fo ssa. Th e me dia l su r al cuta ne ou s
ne rve an d th e su ra l co m mu n icati ng b r anch of th e co mm on fib u lar n er ve u n ite at vari ou s l evels to for m th e sur al n erve . In
th is sp ecim en , th e u n io n occu rs in fer io r to the leve l o f thi s d issecti on . C om par e thi s w ith th e hi gh u n ion with in the
po pli teal fo ssa i n th e sp ecim en sh ow n in Fi gu r e 5 . 31 .
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Fig ure 5.31. Ex po sure of p op li teal fo ssa and nerve s of f oss a. Th e two h eads of th e gastr ocn em iu s mu scle h ave been
sepa rat ed an d are b ein g ret racte d. T he scia tic n er ve separ ates in to its com po ne nts at the ap ex o f the p opl itea l f ossa (or
hi gh er ; Fig . 5 .2 8B). T h e co mm on fib u lar n er ve co ur ses alon g th e m ed ial b or der o f the b icep s f emo ri s. Al l t he m otor
br an che s ar isi ng f ro m th e ti bi al ner ve, ex cept on e, ar ise fr om t he late ral si de; con sequ en tly, in su rg er y it is saf er to
di ssect o n th e m ed ial sid e. T he leve l a t w hi ch th e m ed ial an d late ral su ra l n er ves me rg e to f or m th e su ra l
ne rve o ccur r in g hi gh h er e is qu ite var iab le; it m ay eve n occu r at the le vel of th e an kle .
I n fer ol ater ally an d in fer om ed ial ly by the la tera l a nd m ed ial h ead s of th e ga stro cnem iu s, r esp ectivel y (i nf ero late ral an d
i n fer om edi al bo rd er s).
P oster io rly b y skin an d pop li teal fasci a (r oo f).
D eep ly, t he su per ior bou n da rie s ar e f or m ed by th e d iver gi ng med ial an d l ater al sup ra con dyl ar lin es of th e f em ur . T he in fe rio r
b ou n dar y is f or m ed by th e so leal li ne of th e tib ia (Fi g. 5 . 4B ). T hese b ou nd ar ies su r ro un d a rel ativ ely lar ge di am on d-sh ap ed fl oor
( ant eri or wa ll), f or m ed by th e p op li teal surf ace of th e f em u r sup er ior ly, th e po steri or cap su le of th e kn ee joi nt cen tra lly, and t he
p op li teus fa scia cover in g th e p op liteu s mu scle in f eri orl y (Fig . 5 . 60 ).
T h e co nten ts of th e p op lit eal fossa (Fig s. 5 .3 0B, 5 . 3 1, a nd 5 . 32 ) in clu de th e:
T er mi na tion of th e sm al l sa ph en ou s vei n.
P op litea l a rter ie s an d vein s an d thei r br an ch es an d tr ib uta ri es.
T ib ial an d com m on f ib ul ar n erve s.

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Fig ure 5.32. D eep d issecti on o f po p litea l f ossa . Th e pop li teal ar tery r un s o n th e f loo r of th e f ossa, for m ed by th e
po pli teal su rf ace of th e f em ur , th e j oin t capsu le of th e kn ee, an d th e p op liteu s fasci a. Th e fl oor o f t he fo ssa, wh ich
exten ds su per ior ly to th e d iver gi ng su p ra con dyla r lin es of th e f em ur a nd i nf er ior ly to the sol eal lin e of (su per io r
attach m en t o f t he sol eus to) th e ti bia , is mu ch l arg er th an th e gap b etw een th e o ver lyin g m us cles (o ut lin ed in Fi gu re
5. 3 0 A), of ten m ist aken as re pr esen tin g th e ext ent of th e fossa . Nu m ber s r ef er to the su rf ace an atom y s how n in Fi gu r e
5. 3 0 A.
P oster io r cuta neo us n erve of th ig h (T abl e 5 . 1B ).
P op litea l l ym ph n od es a nd l ym ph atic vessel s (Fig . 5 .1 3B).
F a sc ia of th e P o p lite a l F o ss a
T h e su bcu tan eo us tissu e over lyin g th e p op lit eal fos sa (Fig . 5 .1 0B) con tain s the sm all sap h eno us vein (un less it h as p en etra ted th e
d eep f ascia at a m o re in fer io r level ), an d thr ee cu tan eou s n er ves: th e ter mi na l b ra nch (es) of th e p oster io r cut ane ou s n erv e of th e
t hi gh an d th e me dia l a nd l ater al sur al cu tan eou s n er ves. Th e dee p po pl iteal f ascia is a stro ng sh eet of d eep fa scia, co nti nu ou s
s up eri or ly with the fa scia lata an d in fe rio rl y w ith th e deep fasci a o f t he leg . Th e po pli teal fa scia for m s a p rot ective cover in g fo r
n eu r ovascu lar stru ctu res pa ssin g fr om th e th igh thr ou g h the p opl itea l f ossa to th e le g and a r elat ively lo ose b u t f un cti on al
r eta in in g r eti nacu l um for t he h am stri ng te nd on s. Ofte n it is p ier ced b y th e sm all sap hen ou s vein . Wh en th e l eg exten ds, the
f at wi thi n th e f ossa is rel ativel y co mp r essed as t he po pl iteal f ascia be com es ta ut, a nd th e sem im em br an osu s m ove s la tera lly,
p r ovid in g fu r the r pr otecti on to th e con tent s of th e po pli teal fo ssa. T he con ten ts, m ost im po rta nt th e p op litea l a rte ry an d lym ph
n od es, a re m ost e asily pa lp ated wi th th e k nee in se mi fle xion . B ecau se o f the de ep fasci al ro of an d osseo fib r ous fl oor , th e pop li teal
f ossa is a r el ativel y co nf in ed spa ce. Man y d isor de rs pr od uce swe lli ng o f t he fo ssa, m akin g kn ee exten sion pai nf ul .
N e u ro v a s cu la r S tr u ct u re s a n d R e la t ion sh ip s in th e P o p lit e a l F os s a
A ll im p or tan t n eu ro vascu lar str u ctur es tha t p ass f r om th e t hi gh to th e leg d o so b y tr aver sin g th e p op lit eal fossa .
P. 6 3 5
P ro gr essin g fr om sup er fici al to deep (p oster io r to an teri or ) w ith in th e fossa , as i n di ssectio n, t he n erve s ar e e nco un ter ed fi rst,
t hen the vei ns. T he ar ter ies lie de epest , dir ectl y o n the su rf ace of th e f em ur , j oin t ca psu le, a nd p op lite al fasci a f or mi ng t he fl oor o f
t he fo ssa.
N e rv es i n t h e Po p lit ea l F o ss a
T h e sci atic ner ve usu al ly end s a t th e sup er ior an g le of th e p op lite al fossa b y d ivid in g in to th e ti bia l a nd co mm o n fi bu lar n er ves
( Fi gs. 5 . 30B , 5 .3 1 an d 5 .3 2 ). Th e tib ial ner ve i s th e m ed ial , lar g er ter mi na l b r anch of th e sci atic ne rve de riv ed fr om an ter io r
( pr eaxia l) d ivi sion s o f the an ter ior ram i of th e L4 S3 spin al n erv es. Th e tib ial n erve is th e m ost su per fi cial of th e thr ee m ain

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c entr al com p on ent s of th e po pli teal fo ssa (i .e ., n er ve, vei n, a nd a rter y); ho wever , it is stil l i n a deep a nd p ro tected p ositi on . Th e
t ibi al ne rve bi sects t he fo ssa a s it pa sses f ro m its su per ior to i ts i nf er ior an g le. Wh il e i n th e f ossa, th e tib ial n erve g ives br an ches
t o th e sole us, g astr ocn em iu s, pl an tar is, an d po pl iteu s m u scles. T h e med ia l sur al cutaneo us ner ve is also d er ived f rom th e ti bia l
n er ve in th e p op li teal fo ssa an d is jo in ed by th e sur al communi cating b ra nch of th e c om mo n fi bu lar n er ve at a h ig hl y var ia ble
l evel to fo rm t he su ral n er ve. Th is n erve su pp lies th e l ater al sid e o f t he leg a nd an kl e.
T h e co mmon fib ula r ne rve is the la tera l, sm all er ter m in al br an ch of th e sci atic n erve d eri ved fr om p oste rio r (po staxia l) d ivi sion s
o f th e an ter io r ram i of th e L4 S2 spin al n er ves. It b egi ns at t he su per ior ang le of th e pop li teal fo ssa an d f oll ows clo sely the
m ed ial b or der o f th e b icep s f em ori s an d it s ten d on al on g the su per ol ater al bou n da ry of th e p op lite al fossa . Th e co m mo n fi bu lar
n er ve leaves th e f ossa by pa ssin g sup er fici al to the la tera l h ead o f th e g astr ocn em iu s an d th en p asses o ver th e p oster io r asp ect o f
t he h ead of th e fib u la. T he com m on f ib ul ar n erve w in ds aro un d th e fib u lar n eck and d ivi des in to its term i nal b ra nch es.
T h e m ost in fe rio r br an ch es of t he po ster ior cu tan eou s ner ve of th e th ig h su pp ly th e ski n tha t o verl ies the p opl iteal f ossa. T h e
n er ve tra verses m ost of th e l eng th o f t he po ster ior co mp ar tm ent of th e thi gh d eep to th e fasci a l ata; on ly i ts te rm in al b ran ch es
e nte r the su bcu tan eou s tissu e a s cu tan eou s n er ves p er se.
B lo od V es sel s in th e P op l it eal F os s a
T h e p op li teal ar ter y, the con tin u atio n of th e fem or al ar ter y (Fig . 5 .3 2 ), be gin s wh en th e l atter p asses th rou g h th e ad d ucto r
h i atu s. Th e p op lit eal art ery pa sses i nf ero later al ly t hr ou gh the fo ssa a nd e nd s at th e i nf er ior b or der of th e p op liteu s by di vidi ng i n to
t he an ter ior a nd p oster io r tib ial ar ter ies. T he de epest (m ost an teri or ) str uct ur e i n th e f ossa, the po pl iteal ar ter y, r un s i n clo se
p r oxim it y to th e j oin t capsu le of th e kne e as it spa ns the in ter con dy lar f ossa. Five g eni cul ar b ran ch es o f the p opl itea l a rter y sup pl y
t he cap sul e an d l iga men ts of th e kn ee jo in t. Th e gen icu lar arte ri es ar e the sup eri or l ater al, sup er ior me di al, mi dd le, i nfer io r
l ater al, and i nfer io r med ial g enicular a rte ri es (Fig . 5 .3 3 ). Th ey pa rti cipa te i n th e f or ma tion of th e p eri ar ticu lar g enicul ar
a nastom osis , a n etw or k of v essels sur r oun d in g th e kn ee tha t p ro vid es co llate ral ci rcu lati on cap ab le of m ain tai ni ng b loo d sup p ly t o
t he leg d u ri ng f ul l k nee fl exio n, w h ich m ay kin k th e po pli teal ar ter y. Oth er con tri bu tor s to t hi s im p or tan t an asto mo sis are th e:
Fig ure 5.33. Geni cular anast omo sis. T he m an y ar ter ies m akin g u p the pe ri arti cul ar an asto mo sis a ro un d th e kn ee pr ovi de
an im p or tan t co llat eral ci rcu lati on f or b ypas sin g the po pl iteal ar ter y w h en th e kn ee ha s b een m ain tai ne d too lon g in a f ul ly
fl exed po sitio n or w he n th e vesse ls a re na rr ow ed or occl ud ed .
Desce nd in g gen icu la r br an ch of th e fem or al ar ter y, sup er om ed iall y.
Desce nd in g br an ch of th e later al fe mo ra l ci rcu m fl ex ar ter y, su per ol ater all y.
A n teri or ti bia l r ecu rr en t b r an ch of th e a nter io r tib ial ar ter y, in fe rol ater all y.
Mu scu lar b ra nch es of th e p op lite al art ery sup p ly t he h am stri ng , ga stro cne mi us, so leu s, an d p lan tar is m u scles. Th e su p eri or
m u scu lar b ra nch es of th e p op lite al arte ry ha ve cl in ical ly i mp or tan t ana stom oses wi th th e ter m in al pa rt of th e d eep f em or al and
g lu teal ar ter ies.
T h e p op li teal vein beg in s a t th e dista l b or de r of th e p op lite us as a con ti nu ati on of th e po steri or tib ia l ve in (Fig . 5 .3 2 ).
T h ro ug ho ut its cou r se, th e vei n li es clo se t o th e po pli teal ar ter y, lyi ng su pe rf icia l to i t an d in t he same f ib ro us sh eath . Th e
p op li teal vein i s i ni tial ly p oster om ed ial to th e a rter y an d later al to th e ti bia l n er ve. Mor e sup er ior ly, th e po pli teal vein lies
p oste ri or to th e ar ter y, b etwee n thi s ves sel a nd th e over lyi ng ti bi al ner ve. S up er ior ly, t he po pl iteal vei n, w h ich h as severa l v alves,
b ecom es th e f em or al vein as it tr aver ses th e add u ctor h iatu s. T he sm all sap h eno us vein p asses fr om the po ster ior a spect of th e
l ater al m alle olu s t o th e po pli teal fo ssa, w her e it p ier ces th e d eep po pl iteal f ascia an d en ters th e p op lite al vein .
P. 6 3 6
P o p li t e a l A b s c e s se s a n d T u m o r s
Becau se th e d eep p opl iteal f ascia is stro ng a nd l im its expa nsi on , pa in fr om an ab scess o r tu mo r in th e pop li teal fo ssa i s u su ally
sever e. Pop li teal ab scesses te nd to sp rea d sup er ior ly an d in fer ior ly be cause of th e tou gh n ess o f the p opl itea l f ascia . A pop li teal
cyst (B aker cyst), a sap h en ou s var ix, a nd a n an eur ysm o f the p opl iteal ar ter y sh ou ld b e con side red i n th e d if fer en tial d iag no sis o f
ma sses w ith in th is spa ce (see cli ni cal cor rel atio n [bl ue] bo xes P opl itea l C ysts, S ap hen ou s V ar ix, a nd Po pl iteal

08-May-15
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A n eur ysm a nd H em or rh ag e, in thi s ch ap ter).

P o p l i te a l P u ls e
B ecau se the p opl iteal ar ter y i s d eep , it ma y b e d if ficu lt to fe el t he po pl iteal p ul se. Pal pat ion o f thi s p ul se i s com m on ly pe rf or med
w ith the p erso n in th e pr on e p osi tion w ith t he kn ee f lexe d to r ela x th e pop li teal fa scia and h am str in gs. Th e p u lsatio ns ar e b est fel t
i n th e i nf er ior p ar t o f t he fo ssa w h ere th e p op lite al arte ry is r el ated to th e ti bi a. Weaken in g or loss of th e p op lite al pu lse is a si gn
o f a f em or al ar tery ob stru cti on .
P o p l i te a l A ne u r y s m a n d H e m o r r h a g e
A p o pl iteal aneur ysm (a bn or m al dil atio n of al l o r pa rt of th e p op lite al art ery) usu al ly cause s ed em a a nd p ain in th e p op lit eal
f ossa. A pop li teal an eu rysm m ay b e d istin g ui she d fr om ot her m asse s b y p alp ab le p u lsati on s (th r ills ) an d ab no rm al ar ter ial sou n ds
( br ui ts) d etectab le wi th a steth oscop e. B ecau se th e ar tery li es d eep to th e ti bi al ner ve, an an eur ysm m ay str etch th e n er ve o r
c om pr ess i ts b loo d sup p ly (va sa va sor um ). Pa in f rom such ner ve com pr essio n is usu al ly ref err ed , in th is case to the skin over lyin g
t he m edi al aspe ct of t he calf , an kle or f oot. Becau se the ar ter y i s clo sely app li ed to the p opl itea l su r face of th e fem u r an d the jo in t
c apsu le, fr actu res of th e d ista l f em u r or d isloc ation s of th e kn ee m ay r u ptu r e th e arte ry, r esu lti ng i n he mo rr h age. Fu r the rm or e,
b ecau se of th eir p ro xim ity an d con fi nem en t with in the f ossa, an in ju ry of th e a rter y an d vein m ay resu lt in an ar t er iove no us
f istul a (co m mu n icati on b etwee n an ar ter y a nd a vein ). Fai lu re to reco gn ize th ese occu rr en ces an d to act pr om p tly ma y r esu lt i n
t he lo ss of th e leg an d f oot. I f th e f em or al arte ry mu st be li gate d, b loo d can b ypass th e o cclu sion t hr ou gh the ge ni cul ar
a na stom osis an d re ach th e p op lite al art ery di stal to the li gat ion .
I nj u r y t o t he T i b ia l N e r v e
I n ju ry to th e ti bia l n er ve is u n com m on b ecau se o f its d eep an d p ro tected p ositi on i n the p opl itea l f ossa; h owev er, th e ne rve m ay
b e in ju red b y deep l acer atio ns in th e pop li teal fo ssa. Po steri or d islo catio n of th e kn ee joi nt m ay also da ma ge th e ti bia l n er ve.
S ever an ce o f the tib ia l n er ve p r odu ces par al ysis o f the f lexor m u scles in th e leg an d th e in tri nsi c m u scles in th e so le of th e f oot .
P eop le wit h a ti bi al ner ve in ju ry ar e u n ab le t o p lan tar fl ex t hei r an kle or f lex thei r toes. Loss of sen sati on al so o ccur s o n th e so le of
t he fo ot.
L y m p h N od es i n t h e Po p lit ea l F o ss a
T h e sup er fici al po p litea l l ymph no d es a re usu al ly sma ll an d lie in th e sub cu tan eou s ti ssue . A lym ph n od e lies at the ter m in atio n
o f the sm all sap h eno us vein and r ecei ves l ym ph f ro m th e l ymp h atic vessels th at accom pa ny th is v ein (Fig . 5 .1 2B). T h e d eep
p o pl iteal lymp h no des su rr ou n d the vessel s an d r eceive lym p h fr om t he jo in t cap su le of th e kn ee an d the lym p ha tic vessels tha t
a ccom pan y the d eep vein s of th e l eg. T he lym p h atic vessels fr om t he po pl iteal lym p h n od es f oll ow th e f em ora l v essels to the de ep
i ng u in al lym ph n od es.
T h e p op litea l f ossa is a f at-f ill ed an d rel ative ly co nf in ed com p ar tme nt po ster ior to th e knee th at is t rave rsed b y a ll ne ur ovascu la r
s tru ctu res pa ssin g betw een t he th igh an d the leg . T he sciati c n er ve b if ur cates at the ap ex of th e f ossa, w ith th e com m on f ibu la r
n er ve passi ng l ater all y al on g the b icep s ten d on . Th e t ibi al ne rve, p op lit eal vein , an d p opl iteal ar ter y b isect th e f ossa i n th at
o rd er , fr om su p erf ici al (post eri or) to dee p (an teri or ). Geni cul ar b ran ch es o f the p opl iteal ar ter y f or m a per ia rti cul ar ge ni cul ar
a na stom osis ar ou nd t he kn ee, p rov idi ng co lla tera l ci rcu la tion t o m ai nta in b loo d flo w in al l p osi tion s of th e kn ee.
Leg
T h e b on es o f the leg (ti bi a a nd f ib ul a) th at con n ect th e kne e an d an kle, an d the th ree f ascial com p ar tme nts (an ter ior , lat eral , an d
p oster io r com pa rtm en ts of th e le g ), f or me d by the an ter ior and p oste rio r in ter mu scu lar se pta, the in ter osseo us m emb r ane , an d the
tw o leg b on es to w hi ch th ey a ttach , wer e disc ussed a t th e beg in ni ng o f th is ch ap ter an d ar e i llu str ated i n cro ss-sectio n in Fig u re
5 . 34 . I t w as poi nt ed ou t th at th e m u scles of each co m par tm en t sh ar e co mm o n fu n ction s a nd i nn er vati ons .
P. 6 3 7
C o m p a r tm e nt I n f e ct i o n s a n d S y nd r o m e s i n th e L e g
T h e f ascial co mp ar tm ent s of th e lim b s ar e gen er ally clo sed spa ces, en di ng p ro xim all y an d d istal ly at th e joi nts. In fl am ma tion s
w ith in the an ter ior a nd p oster io r com pa rtm en ts sp r ead ch ief ly i n a dist al dir ecti on . Su pp u rat ion (f or m ation of pu s) fr om p ur u len t
( pu s-fo rm in g) in fe ction s i n th e l ater al com pa rtm en t o f th e le g, h ow ever , can asce nd p ro xim all y i nto th e pop li teal fo ssa.

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Fig ure 5.34. Comp ar tments of leg at mid cal f level in tr ansver se anatom ical sectio n. A. Th e a nte rio r (do rsi fle xor or
exten sor ) co mp ar tm ent con tai ns fo ur m u scles (th e f ib ul ari s ter tiu s lies in fer io r to the le vel of th is sec tion ). T he late ral
(fi bu lar ) co mp ar tm en t con tai ns tw o eve rto r mu scl es. Th e poste ri or (pl an tar fle xor or f lexo r) com pa rtm en t, con tai ni ng se ven
m uscl es, is sub di vid ed by an i ntr aco mp ar tm enta l t ran sver se i n term u scu lar sep tu m in to a su p erf ici al gr ou p of th ree (tw o o f
wh ich a re com m on ly tend in ou s/ap on eu ro tic a t th is level ) an d a de ep gr ou p of f ou r. T he p opl iteu s (p ar t o f the d eep gr ou p ) li es
sup er ior t o th e level of th i s secti on . B. Ove rvi ew of com p artm en ts of leg . C. MR I of th e l eg. A bb r eviati on s ar e def in ed in th e
lab els fo r par ts A an d B.
T r aum a to m uscl es an d /or vessel s i n the com p ar tme nts m ay p r odu ce hem o rr ha ge, e dem a, a nd i nf lam m ati on of th e mu scle s.
B ecau se the sep ta and d eep f ascia of th e leg f orm i ng th e bou n da ri es of th e leg co mp ar tm ent s ar e st ron g , th e i ncr eased vo lu me
c on sequ en t to an y of th ese p r ocesses in crea ses i ntr acom p ar tme nta l p r essur e. Wi th ar teri al bl eedi ng , th e pr essu re m ay r each l evels
h i gh en ou g h to com pr ess st ru ctu res sig ni fi can tly i n th e co mp ar tm en t(s) con cer n ed. S tr uctu r es d istal to th e com pr essed ar ea ma y
b ecom e isch em ic an d per m ane ntl y i nj ur ed (e. g. , l oss o f mo tor f un ctio n in m u scles wh ose bl ood su p pl y an d/ or in n erva tion i s
a ff ected ). Th ese con dit ion s, in w h ich in cr eased p re ssur e i n a con fin ed an ato m ical spa ce ad ver sely aff ects the cir cu lati on an d
t hr eaten s the f un ctio n an d viab ili ty o f tissu e w ith in or di stall y, con stitu te comp ar tment synd r ome s. Lo ss of d ista l p u lses i s an
o bvi ou s si gn o f a rte ria l co m pr ession , as is a l ow eri ng o f the tem p erat ur e o f tissu es d ista l t o th e com pr essio n. A f asci oto my
( in cision of th e o verl yin g fas cia or a septu m ) m ay be p erf or me d to r el ieve the p ressu r e i n th e com p ar tme nt(s) con cer ned .
P. 6 3 8
A n t e rio r C om p a r tm e n t of t h e Le g
T h e anter io r comp ar tment, o r do rsif lexo r (extensor ) co mp ar tm en t, is locat ed an teri or to th e i nte ro sseou s m em br an e, b etwe en
th e late ral su rf ace of th e ti bi al sha ft an d the m edi al sur fa ce o f the fi bu la r shaf t, an d an ter ior to t he in ter mu scu lar se ptu m th at
co nn ects th em . Th e a nte rio r com pa rtm en t is b ou n ded an ter io rl y b y th e deep f ascia of th e leg an d ski n. T he d eep fa scia of th e l eg
o verl yin g th e a nter io r com pa rtm en t i s d en se su pe ri orl y, p rovi di ng p ar t o f the pr oxi m al attach m en t of th e m uscl e im m ed iatel y d eep
to i t. With u n yiel di ng str u ctur es on th r ee si des (th e tw o bon es an d the in ter osseo us m emb r an e) an d a den se fasci a o n th e
r em ain in g sid e, th e rel ative ly sm al l ant eri or com p art men t is especi ally con f in ed an d the ref or e m ost su scepti bl e to com p ar tme nt
syn d ro me s. In fer io rl y, two b an d-li ke t hi ckeni n gs of th e f ascia fo rm reti na cul a th at bi nd t he ten do ns of th e a nte rio r com pa rtm en t
m u scles bef or e a nd a fter th ey cro ss th e an kle joi nt, p r even tin g th em fr om bow str in gin g an ter io rly d ur in g do rsi fle xion o f the jo in t
(Fi g. 5 . 35 ):
1. T h e sup er ior e xtensor r eti naculum i s a str on g, b ro ad ba nd o f deep f ascia , pa ssin g fr om th e fib u la to the tib ia, pr oxim al to
th e m alle oli.
2. T h e inf er ior e xtenso r reti naculum, a Y-sh ap ed ba nd o f deep f ascia , attach es later al ly to th e an tero sup er ior su r face of th e
ca lcan eu s. It fo rm s a str on g lo op ar ou nd th e ten do ns of th e f ib ul ar is te rti us an d the exte nso r dig ito ru m l on gu s m u scles.

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M u sc les of th e A n te ri or C om p art m en t
T h e f ou r m uscl es i n the an ter ior com par tm en t ar e the ti bia lis an teri or , exten sor d ig itor u m lo ng u s, exten sor h all uci s l on gu s, an d
f ib u lar is t erti us (Fig . 5. 3 4A & B ; Ta bl e 5 .1 0 ). T hese m uscl es p ass an d in sert an ter ior to th e tra nsver sely or ien ted a xis o f the an kle
( talocr u ra l) j oin t and , th er efo re, a re do rsi fle xor s of th e an kle joi nt, e levati ng t he fo ref oot an d d epr essin g th e h eel . Th e l on g
e xten sor s al so p ass alon g an d atta ch to the d or sal aspect of th e di git s an d ar e th u s ext enso rs (eleva tor s) of t he toes.
A lth ou g h it is a r elat ively wea k an d sh or t m ov eme nt o nl y ab ou t a q ua rte r the str en gth o f pla nta rf lexi on (So der b erg , 1 98 6 ), w ith
a r an ge of ab ou t 2 0 f rom ne utr al d or sif lexi on is activ ely used i n th e sw in g ph ase of w alki ng , wh en co ncen tr ic con tra ction
k eeps th e f or efo ot e levate d to cl ear th e gr ou nd a s th e f r ee l im b swi ng s f or war d, and i m me dia tely afte r in th e stan ce p ha se, as
e ccent ric con tr actio n con tr ols the lo wer in g of th e for ef oot to the fl oor f ol low in g hee l st rik e (T abl e 5 . 2). Th e l atter i s im p or tan t to a
s mo oth g ait an d is im por tan t to decel era tion (br akin g) r elati ve to r un n in g an d wal kin g do wn h ill . Du r in g stan di ng , th e d or sif lexor s
r ef lexi vely pu ll th e l eg (an d th us th e cen ter o f gr avity) an ter iorly on th e fixe d foo t w he n th e b od y star ts to l ean (th e cen ter of
g r avity be gin s to sh if t too far ) p oste ri orl y. Wh en de scend in g a slop e, esp ecial ly if th e su r face is loo se (sa nd , gr avel o r sno w),
d or sif lexi on is u sed to d ig i n on e's he els.
T ib i ali s An t er io r
T h e ti bi alis anter io r (TA ), th e m ost m edi al an d sup er fici al do rsif lexo r, is a slen d er m uscl e th at li es ag ain st th e la tera l su r face of
t he tib ia (Fig s. 5. 3 4 an d 5 .3 6 ). Th e lon g ten do n of th e TA be gin s ha lfw ay dow n th e l eg an d desc end s a lon g th e an ter io r sur fa ce o f
t he tib ia. Th e ten d on passes with in its own syno vial sh eath d eep to th e su p eri or an d in fe rio r exten sor r eti nacula (Fig . 5 .3 5 ) to it s
a ttach m ent on t he m edi al sid e of th e fo ot. I n so doi ng , it s ten do n is loca ted fa rth est fr om th e axis of th e a nkl e j oin t, g ivin g it th e
m o st m ech an ical ad van tag e an d m akin g i t th e st ro ng est d or sif lexo r. A lth ou gh ant ago ni sts at th e a nkl e j oin t, th e TA an d th e ti bi alis
p oste ri or (fr om the po ster ior co mp ar tm ent ) b oth cr oss the su bta lar an d tr an sverse tar sal jo in ts to att ach to th e m ed ial b ord er o f
t he fo ot and t hu s a ct syn er gi stical ly t o i nve rt th e f oot.
T o test the TA , th e i nd ivi du al is asked to stan d on t he h eels or d orsi fl ex th e foo t a gai nst re sistan ce; if n orm al , its ten do n can b e
s een an d pa lpa ted.
E xt en s o r Di gi t or u m Lo n g u s
T h e ex tensor d ig ito rum lo ng us (EDL ) is th e m ost la tera l o f the an ter ior l eg m uscl es (Fig s. 5 . 34 , 5 . 35 a nd 5 . 36 ). A sm al l p ar t o f
t he pr oxi m al attach m ent of th e mu scl e is to th e l ater al tib ial con dyl e; h ow ever , m ost of it attach es to the m edi al sur f ace o f the
f ib u la and t he su per ior par t o f the an ter ior sur face of th e in ter osseou s mem b ra ne (Ta ble 5 .1 0A). T h e m u scle beco me s ten di no us
s up eri or to th e a nkl e, fo rm in g f ou r ten do ns tha t at tach to th e p h alan g es of t he late ral f ou r toes. A co mm on syno vial sh eath
s ur ro un d s th e fou r ten d on s of th e EDL (p lu s th at of th e f ib ul ar is te rti us) as t hey di ver ge on th e dor su m of th e foo t a nd p ass to
t hei r di stal attach m en ts (Fig . 5 . 35B).
P. 6 3 9
P. 6 4 0
P. 6 4 1
P. 6 4 2
E ach tend on f or m s a m em br an ou s exten sor expa nsi on (d orsa l a po neu r osis) over th e do rsu m of th e pr oxi ma l p h alan x of th e to e,
w h ich d ivid es in to t wo late ral b an ds an d on e cen tr al ban d (Fig . 5 .3 5A). T h e cen tr al ban d in ser ts i nt o th e base of th e m idd le
p h alan x, a nd th e later al sli ps con ver ge to in sert in to th e b ase of th e d istal p ha lan x.

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Fig ure 5.35. D issecti ons o f fo ot. T h ese d issecti on s d em on stra te th e con tin u ation of th e an ter io r an d later al leg m u scles in to
th e f oot. T h e th in n er po rti on s o f t he de ep fasci a o f the le g have b een r em oved , leavi n g the th icker p or tio ns tha t m ake u p the
exten sor an d f ib ul ar re tin acu la, w hi ch re tain th e ten do ns as t hey cr oss th e an kle. A. T he vessel s an d n erv es ar e cut sh ort . At
th e an kle , the vessel s an d th e deep f ib ul ar n erv e li e m id wa y b etwe en th e m al leol i a nd b etw een th e t end on s o f the lo ng
do rsi flex ors of th e toes. B . Syn ov ial sh eath s su rr ou n d th e ten d on s as th ey p ass ben eath the r etin acu la of th e a nkl e.
Tab le 5.10. Muscl es o f the Anter ior a nd La tera l Co mp artm ents o f the L eg

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M uscle a
Page 75 of 155
Pr o ximal Attachment
Di stal Atta chment
I n ne rv ati on b
Mai n Actio n
An ter ior
com pa rtm en t
Tib ia lis
an teri or (1 )
L ater al con dyl e a nd su p eri or
Med ial an d in fer io r
Deep fi bu la r
Dor sifl exes ank le
h alf o f later al su rf ace of tib ia

an d in ter osseo us m em br an e
su rf aces of m edi al
cu ne ifo rm and b ase of
n erve (L 4, L5 )
an d in ver ts f oot
1 st m eta tar sal
Ext enso r
di git oru m l on gu s
( 2)
L ater al con dyl e o f tib ia and
Mid dl e an d d istal
Deep fi bu la r
E xten ds later al f ou r
su pe ri or th ree q uar ter s o f

m ed ial su rf ace of fi bu la an d
p ha lan ges of la tera l

f ou r dig its
n erve (L 5, S 1 )
d igi ts an d
d orsi fl exes a nkl e
i nter osse ou s m em br an e
Mid dl e p ar t o f ant eri or
Dor sal aspe ct o f b ase
Deep fi bu la r
E xten ds gr eat toe
ha llu cis lon g us

( 3)
Ext enso r
su r face of f ibu la an d
of d ista l p h alan x o f
g rea t to e (h all ux)
n erve (L 5, S 1 )
an d do rsi fle xes

an kle
Fi bu la ris
ter tiu s (4 )
I nf er ior th ir d of a nter io r
su r face of f ibu la an d
Dor sum of ba se o f 5th

m etata rsal
Deep fi bu la r
n erve (L 5, S 1 )
Dor sifl exes ank le

an d aid s i n
in ver sion of fo ot
Lat era l
com pa rtm en t
H ead an d su per io r two th ir ds
B ase o f 1st m etatar sal
Su p erf ici al
E vert s f oot an d
lon g us (5 )
Fi bu la ris
o f l ater al su rf ace o f fib u la
an d m edi al cun ei for m
fi bu la r ner ve
(L 5, S1, S 2 )
we ak ly
p lan tar fle xes an kl e
Fi bu la ris b revi s
( 6)
I nf er ior tw o th ird s o f later al

su r face of f ibu la
Dor sal sur f ace o f

tu be rosi ty o n lat eral
Su p erf ici al
fi bu la r ner ve
E vert s f oot an d
we ak ly
sid e of ba se of 5 th
m etata rsal
(L 5, S1, S 2 )
p lan tar fle xes an kl e
a
b
Nu m ber s ref er to th e f ig ur e, p ar ts A an d B.
T he spi na l co rd se gm en tal in ne rvat ion i s i nd icate d (e.g . , L4 , L5 m ean s th at the n er ves su pp lyi ng th e tib ial is
an teri or ar e der ived f ro m th e f ou rt h an d fif th l um b ar seg men ts of th e sp in al cor d). Nu mb er s in bol df ace (L4 ) in di cate the

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Fig ure 5.36. D issecti ons o f anter io r and later al comp ar tments of leg . A. Th i s d issectio n sh ows th e m u scles of th e
an tero late ral le g and dor su m of th e foo t. Th e com m on fi bu la r ner ve, co ur sin g su bcu tan eou sly acr oss the lat era l a spect of th e
he ad an d ne ck of th e fi bu la, i s th e mo st co mm on ly in ju r ed pe rip h era l n er ve. B . In thi s d eepe r di ssection of th e an ter io r
com pa rtm en t, th e mu scles an d in fe rio r exten sor r etin acu lu m a re ret ract ed to disp lay th e a rter ie s an d n erve s.
T o test the E DL , th e l ater al fo ur to es a re do rsif lexe d aga in st r esista nce; if acti ng nor m all y, th e te nd on s can be seen an d p alp ated .
F i b u lar is T er ti u s
T h e f ib ular is terti us (FT ) is a separ ated p ar t o f the E DL , w hi ch sh ares its syn ovia l sh eath (Fi gs. 5 . 3 5 an d 5. 3 6 ). Pr oxim al ly, th e
a ttach m ent s an d fl esh y p art s of th e EDL an d FT ar e co nti nu ou s; how ever , d istal ly, th e FT ten d on is sep ara te a nd at tach es to th e
5 th m et atar sal, n ot to a p h alan x (Tab le 5. 1 0F). Alth ou g h th e FT d oes co nt rib u te (w eakl y) to d orsi fl exion , i t al so a cts at th e
s ub tala r an d tran sver se tars al join ts, co nt rib u tin g to pr on atio n (ever sio n) of th e f oot . It m ay p lay a speci al pr op rio cept ive rol e i n
s ensi ng su d den i nv ersi on an d th en con tr actin g r efl exivel y to p ro tect th e an ter ior ti bi ofi bu lar l ig am ent , the m ost com m on ly s pr ain ed
l ig am ent of th e bo dy. T he FT is no t al ways pr esen t.
E xt en s o r Ha llu cis L o n g u s
T h e ex tensor hal lucis lo ng us (EH L) is a th in mu scle th at lies dee ply b etween the T A a nd th e EDL at its su per ior attach m ent to
t he m id dle h alf of t he fi bu la an d in ter osseou s mem b ra ne. Th e E HL r ise s to th e su r face in th e di stal th ird o f th e le g, p assin g d eep to
t he exten sor r eti nacu la (Fig s. 5 .3 5 a nd 5 . 36 ). I t co ur ses dist ally alo ng t he cre st of t he do rsu m o f t he fo ot to t he gr eat toe.
T o test the E HL , th e g rea t to e i s d ors ifl exed ag ain st resi stan ce; i f n or m al, its e nti re ten do n can b e see n an d pal pa ted.
N e rv e of th e A n t eri or C om p art m en t
T h e d eep f ib ular ner ve is th e ne rve of th e a nte ri or com p artm en t (Fi gs. 5 . 3 4A an d 5 . 36B; Ta ble 5 .1 1 ). I t is on e of th e tw o
t erm in al b ran ch es o f th e com m on f ib u lar n er ve, ar isin g b etwee n the f ibu la ri s lo ng u s m u scle and t he n eck o f t he fi bu la. Aft er its
e ntr y in to t he an ter ior co mp ar tm ent , the d eep fi bu lar ner ve accom pa ni es th e an teri or ti bia l a rter y, f ir st b etw een th e T A an d the
E DL an d th en be tween the TA a nd th e EH L. It the n exits th e co mpar tm ent , con tin ui ng a cro ss th e ankl e j oin t to sup pl y i ntr in sic
m u scles an d a sma ll are a o f t he skin o f th e f oot. A l esion of th is n er ve resu lts in a n in ab ilit y to dorsi fl ex (f ootd r op).
A r te ry i n t h e An t er io r Co m p ar t m en t
T h e ante ri or tib ia l ar ter y su p pli es st ru ctu res in th e an teri or com p ar tm ent (Fig s. 5. 3 4A and 5 . 3 8B ;, Ta ble 5 .1 2 ). Th e sm alle r
t erm in al b ran ch o f the p opl iteal ar ter y, th e a nt eri or tib ial ar ter y, b egi ns at the in fe rio r bo rd er of th e po pli teu s m u scle (i. e., a s th e
p op li teal ar tery pa sses d eep to th e t end in ou s a rch o f the sol eus) an d im m edi atel y p asses a nte ri orl y th r ou gh a g ap in th e sup er ior
p ar t o f the in ter osseo us m em br an e to d escen d on th e a nte ri or su rf ace of th is m em b ran e betw een th e TA an d th e E DL m uscl es. At
t he an kle joi nt , mi dw ay betw een th e ma lleo li, t he an ter ior ti bi al art ery cha ng es nam es, becom i ng th e do rsal ar ter y o f the fo ot (L.

08-May-15
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a rte ria d or salis pe dis).

T i b i a l is A nt e r i o r S t r a i n ( S hi n Sp l in t s)
Shi n sp lints ed em a an d pai n in th e are a o f the di stal two -th ir ds of th e ti bia resu lt fr om rep etit ive mi cro tra um a of th e T A,
wh ich cau ses sm all tear s i n th e p er iosteu m co ver in g the sh aft of th e tib ia and /or o f fle shy attach m en ts to th e over lyin g d eep
fasci a o f the leg . S hi n spl in ts ar e a m il d for m o f the an ter ior co m par tm en t syn dr om e. S h in sp lin ts com mo nl y o ccur d u ri ng
tra um ati c in ju r y o r ath leti c ove rexe rti on of m u scles in th e ant eri or com p art men t, e speci ally th e T A, b y u n tr ain ed pe rson s. Of ten
per son s w h o l ead sed ent ary li ves d evelo p shi n sp lin ts w h en th ey p ar ticip ate in w alk- a-th on s (lo ng -di stan ce w alks). Sh in sp lin ts
also occu r in trai ne d ru n ner s w h o d o no t w ar m u p and co ol do wn su f fici ent ly. Mu scles in th e a nte ri or com p artm en t swel l f ro m
sud de n over us e, an d the ed em a a nd m u scle ten d on in f lam m atio n re du ce t he bl ood f low to th e mu scle s. Th e sw ol len m u scles are
pai nf u l a nd ten d er to pr essu re .
D e e p F i b u l a r N e r v e E nt r a p m e n t
Exce ssive use of m u scles sup pl ied b y th e deep f ib ul ar n erv e (e. g. , d ur in g ski in g, r un n in g, and d an cin g) m ay r esu lt in m u scle in ju ry
an d edem a in th e an teri or com p ar tme nt. Th is e ntr ap m ent m ay ca use com p ressi on of t he dee p fib u lar n er ve a nd p ain i n th e
an teri or com p art me nt. C om p ress ion o f the n erve b y ti gh t-fi ttin g ski bo ots, f or exam p le, m ay occu r wh er e t he n erve p asses d eep to
the in f eri or exten sor r eti na cul um a nd th e exten sor h al lu cis b re vis. Pa in occu r s i n the d or sum o f th e f oot an d usu al ly r ad iate s to
the we b space b etwee n the 1 st a nd 2 n d toes. B ecau se ski b oo ts ar e a co mm on cau se of t hi s typ e o f ner ve en trap m en t, th is
con dit ion h as bee n call ed th e ski bo ot synd ro m e ; h ow ever , th e syn d ro me also o ccur s i n soccer p laye rs an d ru n ner s a nd ca n
resu lt fr om tig ht sh oes.
Th e a nter io r com pa rtm en t, con f in ed by m ostly u nyi eld in g bo nes an d m em br an es, is susce ptib le to com pa rtm en t synd ro m es. Th e
con tain ed m u scles are an kle do rsi fle xor s/toe exten sor s th at are acti ve i n wa lkin g as the y (1 ) co ncen tr ical ly con tra ct to r aise th e
for ef oot to clear t he gr ou n d du ri ng the swi ng p h ase o f th e g ait cycle an d (2) eccen tr icall y co ntr act to low er th e f or efo ot to t he
gr ou nd a fter t he h eel stri ke o f the stan ce ph ase. T he d eep fi bu lar n er ve and a nte ri or tib ial ar ter y co ur se wit hi n an d sup pl y th e
com par tm en t. I nj ur y o f the com m on o r dee p fib u lar n er ve r esu lts in f ootd r op (see clin ical co rr elat ion [b lu e] b ox, I n ju ry to the
Co mm on Fi bu la r Ner ve a nd Foo tdr op , in thi s ch ap ter) .
P. 6 4 3
Ta bl e 5. 11. Ner ves of the L eg
Ner ve
Sap h eno us
Or ig in
Fem or al ner ve
Co urse
Di str ib ut ion in L eg
Desce nd s w ith f em or al vessels th rou g h fem o ral

t ria ng le an d ad du ctor can al an d th en d escen ds wit h
Su p pl ies sk in on med ial si de of

an kle an d fo ot
g r eat saph en ou s vei n
Su ra l
Usu all y ar ise s
Desce nd s b etwe en h eads of g astr ocn em iu s an d
Su p pl ies sk in on poste ri or an d

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Tib ia l
Page 78 of 155
fr om bot h tib ial

an d com m on
b ecom es su per fi cial at m idd le of le g; descen d s w ith

sm al l saph en ou s ve in an d pa sses i nf er ior to la tera l
la tera l a spects of le g and

la tera l si de of f oot
fi bu la r ner ves
m al leo lu s to lat eral si de of fo ot
Sci atic n erve
Fo rm s a s scia tic bif u rcat es at ap ex o f pop li teal
Su p pl ies p oste rio r m uscl es o f
f ossa; de scend s t hr ou gh pop li teal fo ssa a nd l ies o n

p op lit eus; r un s i nf er ior ly on ti bia lis po steri or w ith
leg a nd kn ee jo in t
p oste rio r tib ial vessel s; te rm in ates be nea th fl exor

r eti na cul um b y div idi ng i nt o m ed ial an d lat era l
p la nta r ner ves
Co mm o n
Sci atic n erve
fi bular
Fo rm s a s scia tic bif u rcat es at ap ex o f pop li teal
Su p pl ies sk in on later al pa rt of
f ossa an d fo llo ws med ia l b or der o f bi ceps fem or is

a nd i ts te nd on ; p asses over p oster io r aspect of
p oster ior a spect of le g via its

b ran ch (l ater al sur al cu tan eou s
h ead of fi bu la an d the n wi nd s ar ou n d ne ck of f ib ul a
d eep to f ibu l ari s lo ng u s, wh er e i t d ivid es in to deep
n erve ); al so su p pl ies k nee

jo in t vi a i ts ar ticu la r br an ch
a nd su p erf icia l f ib ul ar n er ves
Su pe rf icial
C om mon
A r ises b etw een f ibu la ri s lo ng u s an d n eck o f fib u la
Su p pl ies f ib u lar is l on gu s a nd
fi bular
fi bu la r ner ve
a nd d escen ds in l ater al com pa rtm en t o f leg ; p ier ces

d eep f ascia at di stal th ird o f leg to b ecom e
b revi s an d skin on d istal th ir d

of an ter io r sur fa ce o f leg an d
su b cut ane ou s
d orsu m o f foo t
De ep
C om mon
A r ises b etw een f ibu la ri s lo ng u s an d n eck o f fib u la;
Su p pl ies a nte ri or m uscl es o f
fi bular
fi bu la r ner ve
p asses th ro ug h exten sor d ig ito ru m lo ng u s an d

d escen d s on i nt ero sseou s m em b ran e; cro sses d istal
leg , d or sum of fo ot, an d skin

of f ir st i nter d igi tal clef t; se nd s
e nd o f tib ia and e nter s dor su m of f oot
ar ticu lar br an ches to joi nt s it

cr osses
P. 6 4 4
Tab le 5.12. Arte ri es o f the L eg
Ar ter y
Pop lit eal
Or ig in
Cour se
D istr ib utio n in Leg
C on tin u atio n of
Passes th rou g h po pl iteal f ossa to l eg; en ds
Su p eri or, mi dd le, a nd i nf er ior
f em or al arte ry at
ad d ucto r hi atu s i n
at l ow er bo rd er of p op liteu s mu scle b y
div idi ng i nt o a nter io r an d po steri or tib ia l
ge ni cul ar ar teri es t o b oth

late ral an d m ed ial asp ects o f

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ad d ucto r m agn u s
An ter ior
P opl iteal
tib ial
Page 79 of 155
art eri es
kn ee
Passes betw een t ibi a a nd f ib ul a i nto
An ter ior com par tm en t o f leg
an teri or com p ar tme nt th ro ug h ga p in

sup er ior p ar t o f i nt ero sseou s m em b ran e
an d descen d s th is me mb r ane b etwee n
tib iali s an ter io r an d exten sor d ig itor u m
lon gu s
Do ra l a rter y
C on tin u atio n of
De scend s a nte rom ed ial ly to f ir st
Muscl es o n do rsu m o f f oo t;
of fo ot (L.
do rsal is
an ter io r tib ial ar ter y

d istal to in f eri or
in tero sseou s sp ace an d di vide s in to

pla nta r an d arcu ate ar ter ies
pi erce s f irst d or sal in tero sseou s

m uscl es a s d eep pl an tar ar ter y
ped is )
ext enso r re tin acu lu m
Poste rio r
tib ial
P opl iteal
to con tri bu te to for m atio n of

pl an tar ar ch
Passes th rou g h po ster ior co mp ar tm ent of

leg an d ter m in ates dist al to f lexo r
Post eri or an d late ral

com p artm en ts of leg ;
reti na cul um by di vid in g in to m ed ial an d

later al p lan tar ar ter ies
cir cum f lex fi bu lar b r anch joi ns

an astom ose s ar ou n d knee ;
n utr ien t art ery pa sses to ti bia
Fibu la r
P oster ior ti bi al
De scend s i n po ster ior co mp ar tm ent
Post eri or com p art men t of leg :
adj acen t to p oster io r in term u scu lar

septu m
pe rf or atin g br an ch es su pp ly
late ral co mp ar tm ent of l eg
L a t e ra l C om p a rtm e n t o f t h e L e g
T h e l ater al comp ar tment o r ever tor com p ar tme nt, i s th e sma llest (n ar row est) of th e l eg com pa rtm en ts, b ou nd ed b y th e later al
s ur face of th e fi bu la, t he an ter ior an d p oster ior in term u scu lar sep ta, a nd th e deep f ascia of th e leg (Fig . 5 .3 4A & B ; T ab le 5 . 1 0).
T h e co mp ar tm ent en ds in fer io rl y at th e sup er io r fib ula r reti naculum, w hi ch spa ns bet ween t he di stal tip o f the fi bu la an d th e
c alcan eu s (Fig . 5 .3 6A). H er e th e ten don s of th e tw o mu scle s of th e late ral com p ar tme nt en ter a com m on syn ovia l sh ea th to
a ccom m oda te th ei r passa ge bet ween t he su per ior fib u lar r etin acu lu m an d th e later al
P. 6 4 5
m al leo lu s, usi ng t he latt er as a tr och lea as the y cr oss the an kle jo in t.
M u sc les in t h e La te ral C om pa rt m en t
T h e l ater al com par tm en t co nta in s th e fib u lar is lon gu s and b r evis mu scle s. Th ese mu scle s h ave the ir fl esh y b elli es i n th e l ater al
c om par tm en t b ut ar e t end in ou s a s th ey exit the com p ar tme nt wi thi n th e co mm on syno vial sh eath d eep to th e sup er ior f ib ul ar
r eti na cul um . B oth m u scles are ever tor s of th e f oot, e levati ng t he lat eral m ar gi n of th e foo t. Develo pm en tall y, th e f ib ul ari s m u scles
a re po staxia l m u scles, recei vin g in n erva tion f r om th e p oste rio r di visio ns of th e spin al n er ves, wh ich con tri bu te to t he sciati c n er ve.
H ow ever , beca use th e f ib ul ar is l on gu s a nd b re vis p ass po steri or to th e tr an sver se a xis o f th e an kle (tal ocr ur al) jo in t, th ey
c on tri bu te t o p lan tar fl exio n at the an kle u n lik e th e posta xial m u scles of th e an ter io r com par tm en t (i ncl ud in g th e f ib ul ar is
t erti us), wh ich ar e do rsif lexo rs.
A s e verto rs, the fi bu lar is m uscl es a ct at th e su b talar a nd tr an sver se ta rsa l j oin ts. Fr om th e neu tr al po sitio n, on ly a f ew deg re es of
e versi on ar e poss ibl e. In pr actice , the p ri ma ry fu n ction o f the ever tor s of th e f oot is no t to el evate the la tera l m ar g in of th e foo t
( the com m on d escr ipt ion o f evers ion ) b u t to d epr ess o r fi x th e med ia l m ar gi n of th e foo t i n sup p ort of th e toe off p h ase o f wal kin g
a nd , esp ecial ly, r u nn in g an d to resi st i na dver ten t o r excessi ve i nver sio n of th e f oo t (th e posi tion in w hi ch th e an kle is m ost
v ul ner ab le to in ju ry). Wh en st and in g (an d pa rti cul ar ly w h en ba lan cin g on o ne fo ot), th e fib u lar is mu scle s con tr act to r esis t m ed ial
s way (to recen ter a li n e of g r avity, w h ich h as sh if ted m ed iall y) b y p u lli ng l ater all y on the leg w h ile de pr essin g th e m ed ial m ar gin
o f th e f oot.
T o test the fi bu lar is lon g us an d br evis, the fo ot is e verte d stro ng ly aga in st r esista nce ; if act in g no rm al ly, th e m u scle ten do ns can
b e seen an d p alp ated in f eri or to th e l ater al ma lleo lu s.
F i b u lar is L o n g u s
T h e f ib ular is long us (FL ) i s th e lon ge r and mo re su per fi cial of th e two fi bu lar is m uscl es, ar isin g m u ch m ore su per io rl y on the
s haf t o f th e f ibu la (Fig s. 5 .3 4 an d 5 . 36A;, Tab le 5. 1 0 ). Th e n ar r ow FL exten ds fr om t he h ead of th e fib u la to t he sole of th e fo ot.
I ts ten don can be p alp ated an d ob ser ved pr oxi ma l a nd p oster io r to the la tera l m al leol us. Di stal to the su per io r fi bu lar r eti nacu lu m ,
t he com m on sh eath shar ed b y th e fib u lar m u scles spl its to e xten d thr ou g h sepa rate com p ar tme nts dee p to the inf eri or f ib ular
r eti naculum (Fi gs. 5 . 35A an d 5 .3 6 ). Th e FL p asses th ro ug h th e i nf er ior co mp ar tm ent in fer ior t o th e fi bu lar tr och le a o n the
c alcan eu s an d en ters a gr oove on t he an ter oin fer io r asp ect o f t he cu boi d bo ne (Fig . 5. 9C ). It th en cro sses t he sole of th e foo t,
r u nn in g ob li qu ely an d di stall y to r each it s att achm en t to t he 1 st m etat arsa l a nd m ed ial cu ne ifo rm bon es (see Fi g. 5 . 9B ). Wh en a
p er son sta nd s o n on e f oot , the FL h elp s stea dy the leg o n th e f oot .
F i b u lar is B rev i s
T h e f ib ular is br evis (FB) is a f usi fo rm m u scle th at l ies deep t o th e FL and , tr u e to its n am e, th e FB is sh ort er th an its pa rtn er i n
t he lat eral co mp ar tm ent (Fig s. 5 .3 4 an d 5 .3 6A; Tab le 5 .1 0 ). It s b roa d ten don gr oove s th e p oste rio r asp ect o f the la tera l m al leol us

08-May-15
Page 80 of 155
a nd ca n be pa lp ated in fe ri or to it. T he n ar row er ten d on of th e FL lies on th at of th e FB a nd d oes no t co nta ct th e later al m all eolu s.
T h e ten d on of t he FB tra verses th e su p eri or com p art men t of th e i nf er ior f ib ul ar r etin acu lu m, passi ng su p eri or to th e f ib ul ar
t ro chl ea o f the cal cane us; it can b e ea sily tra ced to its dist al attach m ent to th e b ase of th e 5 th m eta tarsa l ( Fi g. 5 . 9C ). T he ten do n
o f th e f ibu la ri s ter tiu s, a slip of m uscl e f ro m th e ext enso r di git oru m l on gu s, of ten m er ges wi th th e t end on o f the FB (Fig. 5. 3 6A ).
O ccasion al ly, h ow ever , the f ibu la ri s ter tiu s p asses an ter ior ly to attach d ir ectly to th e p ro xim al ph al anx of th e 5th di git.
N e rv es i n t h e Lat er al Co m p ar t m en t
T h e sup er fi cial fi bul ar nerve , a t erm in al b ran ch o f t he com m on f ib ul ar n erve, is t he n erve of th e later al com p artm en t (Figs.
5 . 3 4A an d 5 . 36A; Ta ble 5 .1 1 ). Af ter su p plyi ng t he FL an d FB , th e su p erf ici al fib u lar n er ve co nti nu es as a cu tan eou s n er ve,
s up pl yin g the ski n on th e dist al par t o f the an ter ior sur fac e of th e leg an d n ear ly all th e d or sum of th e f oot .
B lo od V es sel s of t h e L at er al Co m p ar t m en t
T h e l ater al com par tm en t d oes no t h ave an a rter y c ou rsin g th r ou gh i t. In stead , p erf or atin g b ran ch es a nd a ccom pan yi ng vei ns
s up pl y b loo d to and d r ain b loo d fr om th e com pa rtm en t. Pr oxi ma lly, per fo rati n g br an ches of th e ant eri or tib ial ar ter y p en etr ate the
a nte ri or in ter m uscu lar septu m . In f eri or ly, p erf or atin g b ran ch es o f th e f ibu la r ar tery pe netr ate th e p oste rio r in ter mu scu lar se ptu m ,
a lon g w ith th eir a ccom pan yi ng vei ns (L . ven ae co mi tan tes) ( Tab le 5. 1 2).
Th e sm al l l ater al com pa rtm en t con tain s th e pr im ar y e verto rs of th e f oo t an d th e su p erf ici al fib u lar n er ve th at su pp lies th em .
Becau se no ar ter y co ur ses wit hi n th e com p ar tme nt, per fo rati ng br an ches fr om t he an ter ior ti bi al an d fib u lar ar ter ies (an d the ir
accom pa nyi ng v ein s) p en etra te th e in ter mu scu lar sep ta to sup pl y (a nd d ra in ) b loo d. E ver sion is u sed to su pp or t/de pr ess th e
me dia l f oot d ur in g th e to e o ff of th e stan ce p h ase a nd to r esist in ad verte nt in ver sion , p rev enti ng i nj u ry.
P. 6 4 6
T h e F i b u l a r i s M u sc l e s a n d E vo lu t io n o f t h e H u m a n Fo o t
Wher eas th e f eet of an th rop oi ds (hi gh er p ri ma tes) ar e in ver ted so tha t th ey wal k on the ou ter b or der of th e f oot, f eet of h um an s
are r elati vely ever ted (p ron ate d) so th at th e so les lie m or e f ul ly o n th e g ro un d . Th is pr on ati on is th e r esu lt, at lea st i n par t, to th e
me dia l m ig r atio n of th e d ista l a ttach me nt of th e fib u lar is l on gu s acro ss th e sole of th e f oot an d th e d evel opm en t of a fib u lar is
tert iu s th at is a ttach ed to th e b ase of th e 5 th m etat arsa l. Th ese fea tur es ar e u n iqu e to the h um an f oo t.
I nj u r y to t h e C o m m o n F ib u la r N e r ve a n d F o o t d r o p
Becau se of its su per fi cial p ositi on , th e com m on f ib u lar is th e n erve m o st of ten i nj ur ed in the lo wer l im b, m ai nl y b ecau se i t w in ds
sub cu tan eou sly aro un d th e f ib ul ar n eck, le avin g it vu ln erab le to di rect tr au ma . Th is ne rve m ay a lso be sever ed du r in g fr actu re of
the fi bu la r neck or se verel y str etch ed w hen the kn ee join t is in ju red o r di slocat ed. S ever an ce o f the com m on f ib ul ar n erve r esul ts
in f laccid p ar alysi s o f a ll m uscl es i n the an ter ior and l ater al com pa rtm en ts of th e l eg (do rsif lexo rs of th e a nkl e a nd eve rto rs of th e
foo t). Th e loss of d ors ifl exion of th e an kl e cau ses foo tdr op , wh ich is f u rth er exa cerb ated b y u n op po sed in vers ion o f the fo ot. T hi s
ha s th e e ffe ct o f m ak in g the li mb to o l on g : Th e toes do n ot clear th e gr ou n d du ri ng th e swi ng p h ase o f wal kin g (Fig.
B5 .1 4A).
Th ere ar e s evera l o th er con di tion s tha t m ay resu lt in a lo wer l im b th at i s to o l on g fu n ction al ly, f or exam p le, p elvi c ti lt (Fi g.
5. 2 6C ) an d spasti c p ar alysis or co ntr acti on of t he sole us. T h ere ar e at le ast th r ee m ea ns of com p ensa tin g fo r thi s p ro bl em:
1 . A wad dl in g gai t, in w h ich th e i nd ivi du al lea ns to the sid e opp osi te th e lon g li mb , h ikin g th e hi p (Fi g. B 5 .1 4B).
2 . A swin g -ou t g ait, i n wh ich the lo ng l im b is swu ng o ut la tera lly (abd u cted ) to all ow th e to es to cl ear th e g r ou nd (Fig . B 5. 1 4C ).
3 . A hi gh -step pin g step pa ge ga it, in wh ich ext ra fl exion is e mp loy ed at t he h ip an d kn ee to r aise th e f oot as hi gh a s n ecessar y
to k eep th e to es f ro m h ittin g th e gr ou nd (Fi g. B 5. 1 4D).
Becau se th e d ro pp ed fo ot m ak es it d iff icu lt to ma ke th e he el s tri ke th e gr ou nd f ir st a s in a n or m al gai t, a stepp ag e g ait is
com m onl y em p loy ed in th e case o f fla ccid p ara lysis. S om etim es an ext ra kick is add ed as th e f ree li mb sw in gs fo rw ar d in an
attem pt to fl ip th e f or efo ot up wa rd j ust bef or e se ttin g th e f oot do wn . I n add iti on , th e b ra kin g actio n n orm al ly pr od uced b y
eccen tri c con tr actio n of th e dor sif lexo rs is also lost in fla ccid pa ral ysis foo tdr op . Th er efo re, the fo ot is n ot lo wer ed to th e g ro un d
in a con tro lle d ma nn er af ter h eel str ike bu t i nst ead slap s t he gr ou n d sud de nl y, pr od u cin g a d isti ncti ve cl op an d gr eatl y i ncr easi ng
the sh ock bot h rece ived b y th e for ef oot an d tra nsm itt ed up t he tib ia to the kn ee. I nd ivi du als wi th a fib u lar n er ve i nj ur y ma y al so
exper ie nce a vari abl e l oss of sen satio n on th e ant ero later al asp ect o f the le g and t he do rsu m o f the fo ot.
Su p e r f i ci a l Fi b ul a r N e r v e E n tr a p m e n t
Ch r on ic a nkl e sp ra in s m ay pr od uce re cur re nt str etch in g of th e su pe rf icia l f ib ul ar n erve , wh ich m ay cau se p ain alon g th e later al
side of th e leg an d th e dor su m of th e ank le a nd f oot . Nu m bn ess a nd p ar esth esia (tickl in g or tin g lin g ) m ay be pr esen t a nd i ncr ease
wit h activi ty.
Av u l si o n o f t he T u b er o s i ty o f th e 5t h M e t a ta r s a l
Vio len t i nve rsi on of th e foo t m ay cau se a vul sion o f th e tu be rosi ty o f the 5 th m etata rsal , th e d istal at tach me nt of f ibu la ri s b revi s.
Th is avu lsion fr actu re is associ ated w ith a sever ely spr ain ed an kl e. In ju r y to th e a ssocia ted su per fi cial fi bu lar ner ve cau ses
in versi on o f t he fo ot becau se of p ara lysis of th e f ib ul ar m us cles i n th e l ater al com pa rtm en t.

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Fig ure B5. 14
P. 6 4 7
P o st e rio r Co m p a r tm e n t of th e Le g
T h e p oste ri or co mpa rtment (pl an tar flexo r com p artm en t, i s th e l ar gest of th e thr ee leg com p ar tme nts (Fig . 5. 3 4A). T he po ster ior
co mp ar tm en t an d th e ca lf m uscl es w ith in i t a re di vid ed in to sup er fici al an d deep su b com par tm en ts/m uscl e g ro up s b y the
tr ansver se inter muscular sep tum. T he tib ial n er ve a nd p oster io r tib ial an d fi bu lar ve ssels sup pl y b oth p ar ts o f the po ster ior
co mp ar tm en t b ut r un i n th e d eep su bco mp ar tm ent d eep (an ter ior ) to th e tra nsver se in ter mu scu lar sep tu m . Th e l ar ger su p erf icia l
su b com par tm en t i s th e least con fi ned co m par tm en tal ar ea. Th e sm aller deep su b com par tm en t, li ke th e an teri or com p ar tm ent, is
b ou n ded b y th e two le g bon es an d the in ter osseo us m em br an e th at bi nd s th em toge the r plu s the tr an sverse in ter m uscu la r sept um ;
th er ef ore , the d eep su bcom p ar tme nt is qu ite tig h tly con fin ed . Beca use th e n er ve and b lo od vessel s su pp lyi ng th e ent ir e p oster ior
co mp ar tm en t an d th e so le of th e f oot p ass th r ou gh th e dee p sub com pa rtm en t, w hen swel lin g occu r s it lea ds to a com p ar tme nt
syn d ro me th at has ser iou s co ns equ en ces.
I n fer ior ly, the de ep sub com p art men t tap ers as t he m uscl es i t co nta in s b ecom e t end in ou s. Th e tra nsve rse in ter mu scu lar se ptu m
e nd s as r ein for cin g tr an sverse f ibe rs tha t ext end b etw een th e t ip of th e med ia l m al leol us an d th e cal can eus to fo rm t he fl exor
r eti nacu lu m . T he re tin acu lu m is sub di vid ed dee ply , for m in g sep ara te co mp ar tm ent s fo r each te nd on o f the d eep m uscl e g ro up , as
w ell as fo r the tib ia l n er ve a nd p oster io r tib ial ar ter y as th ey b en d ar ou nd th e me dia l m al leol us.
Mu scles of th e poste ri or com p artm en t pr od uce pl an tar fle xion a t the ank le, in ver sio n at the su btal ar an d tr ansverse tar sal jo in ts,
a nd f lexi on of th e toes. P lan tar fl exion is a p ower f ul m ovem en t (fou r ti mes str on ger th an dor sif lexi on ) p ro du ced over a r elat ively
l on g ra ng e (a pp ro xim ately 5 0 fr om n eu tr al) by mu scl es th at pass po ster ior to th e tra nsver se axis of th e a nkl e j oin t. T he
m ov eme nt de velop s th r ust , app li ed pr im ar ily at th e b all of th e foo t, th at is u sed to p ro pel th e b od y f or war d an d u pw ard a nd i s th e
m aj or com p on en t of th e fo rces gen er ated d u ri ng th e pu sh -off (h eel of f an d toe off ) p ar ts o f the stan ce ph ase of wa lkin g an d
r u nn in g (T abl e 5 . 2).
S u p erfi ci al M u s cl e G r ou p in t h e P os t er io r Co m p ar t m en t
T h e su per f icial g ro up o f calf m u scles in clu des th e g astr ocn em iu s, soleu s, an d p lan tar is. Detai ls con cern in g th eir a ttach m ents,
i nn er vati on an d acti on s ar e p r ovid ed in T ab le 5. 1 3. Th e tw o-h ead ed ga stro cnem i us an d soleu s shar e a co mm o n ten do n, th e
ca lcan eal ten do n, wh ich at tach es to th e ca lcan eu s. C olle ctivel y th ese two m uscl es m ake u p th e th r ee-h eade d tri ceps sur ae (L.
su r a, cal f) (Fi g. 5 . 37 ). T hi s p ow erf ul m u scul ar m ass tug s o n th e l ever pr ovi ded b y the calc ane al tub er osity, elevat in g the h eel an d
th u s d ep ressi ng th e fo ref oot, gen er atin g as mu ch a s 9 3% o f the pl an tar fle xion f or ce. Th e lar ge size of th e gast roc nem iu s an d
so leu s m u scles is a h u ma n cha ract eri stic tha t is di re ctly rel ated to ou r u pr ig ht stan ce. T he se m u scles are str on g an d hea vy b ecau se
th ey lif t, p ro pel , an d acceler ate th e w eig h t of th e bo dy wh en w alki ng , r un n in g, j um p in g, o r stan di ng o n th e to es.
T h e cal caneal tend on (L. ten d o ca lcan eu s, Ach il les tend on ) i s th e mo st p ow erf u l (th ic kest a nd str on ge st) ten d on in the b ody.
A pp r oxim atel y 1 5 cm in len g th, it i s a con tin u atio n of th e fla t ap on eu ro sis, f orm ed h al fw ay d ow n th e cal f wh er e th e bel lies of th e
g astr ocn em iu s ter m in ate. T h e ap on eu ro sis r ecei ves f lesh y fib er s of th e sole us di rectl y o n its deep su r face p rox im all y b ut th icken s
a s th e so leu s f ib ers be com e te nd in ou s i nf er ior ly. T he ten do n th us be com es th icke r (dee per ) b ut n ar row er as it desce nd s u n til it
b ecom es essen tial ly rou n d in cr oss-sect ion su p eri or to th e ca lcan eu s. It th en exp an ds as i t in ser ts ce ntr al ly o n th e p oster io r
su r face of th e calcan eal tu b ero sity. I t typ ica lly spi ral s a qu ar ter tu r n (9 0 ) du ri ng i ts d escen t, so th at th e ga stro cnem i us fib er s
a ttach la ter ally an d th e so leal fi ber s attach m ed ial ly. T hi s ar r ang em en t i s th ou gh t to be sig ni fica nt to th e ten d on 's el astic ab ili ty to
a bsor b en er gy (sho ck) an d r ecoi l, r eleasi ng t he en erg y a s p art of th e pr op ul sive fo rce it exer ts. Al tho ug h th ey shar e a co mm o n
te nd on , th e tw o m uscl es of t he tr icep s su ra e ar e capab le of act in g alon e, a nd o ften d o so: Y ou str ol l w ith t he sol eus bu t win
th e lon g ju m p wi th th e g astr ocn em iu s.
A su b cuta neo us calca nea l b u rsa, locat ed betw een th e skin a nd th e calcan eal ten d on , all ows th e ski n to m ove over th e tau t ten d on ,
a nd a d eep bu r sa o f the calca ne al tend on (r etr ocal can eal bu r sa), lo cated b etwee n th e ten d on an d th e ca lcan eu s, all ows th e te nd on
to g lid e over th e bon e.
T o test t he tr icep s su ra e, th e f oot is pl ant arf lexed a gai nst r esistan ce (e.g . , by stan di ng o n th e to es, in wh ich case b ody
w eig h t [g rav ity] pr ovid es resi stan ce). If n or m al, th e calca nea l te nd on an d tr icep s su r ae c an be seen a nd p alp ated .
G ast r oc n em iu s
T h e g astr ocnemi us i s th e m o st su per f icial m u scle in th e poste ri or com p artm en t an d for m s th e pr oxim al , m ost pr om in en t p ar t of
th e calf (Fig . 5 .3 7 ; T ab le 5. 1 3). It is a f usi for m , two -he aded , tw o-jo in t m u scle wi th th e m ed ial h ead sli gh tly lar g er an d exten di ng
m or e di stally th an i ts la tera l p ar tn er. T h e h ead s co me tog eth er at th e i nf eri or m ar gi n of th e p op lit eal fossa , wh er e th ey fo rm t he

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i n fer ola tera l a nd i nf ero m edi al bou n da rie s of th is fo ssa. B ecau se i ts f ibe rs are m ain ly ver tical , an d lar ge ly o f the w hi te, fa st-twi tch
( type 2 ) var iety , con tra ction s of th e g astr ocn em iu s p rod u ce r ap id m ovem en ts du ri ng r u nn in g an d ju m pi ng (T ab le 5. 1 3). I t is
r ecr u ited in to acti on on ly in ter m itten tly du r in g sym me tri cal stan din g . Th e gastr ocn em iu s cr osse s an d is capa bl e of a ctin g on b oth
t he kn ee a nd th e an kle joi nts; h owev er, i t ca nn ot exer t i ts f ul l p ow er on b oth joi nts at the sam e tim e. I t f un cti on s m ost eff ective ly
w h en th e kn ee is exten ded (a nd i s m axi ma lly activa ted wh en kn ee exten sio n is com bi ned w ith d or sif lexi on , as i n th e sp ri nt star t).
I t is i nca pab le of p ro du cin g pl an tarf lexi on w he n th e kn ee is f u lly fl exed.
S ol eu s
T h e so leus is locat ed deep t o th e ga stro cnem iu s an d is co nsi der ed to b e th e w or kh orse o f p la nta rf lexio n. It is a la rg e
m u scle, fla tter th an th e gastr ocn em iu s, th at is n am ed f or it s r esem bl anc e to a sole t he fl at f ish t hat r eclin es on it s sid e on th e
s ea f loo r. T h e sol eu s h as a con ti nu ou s p r oxim al att achm en t in th e s hap e of an in ver ted U to th e p oster ior aspect s of th e fib u la an d
t ibi a a nd a ten d in ou s ar ch b etwee n the m, the tend inous ar ch of the sole us (L. ar cus ten di neu s
P. 6 4 8
s oleu s) (Fi g. 5 . 38A ). Th e p op lit eal art ery an d tib ial n erv e exi t th e po pli teal fo ssa b y p assi ng th r ou gh th is ar ch, the p opl iteal ar ter y
s im ul tan eou sly bif u rcat in g in to i ts t erm in al b ran ch es, th e a nte ri or an d po steri or ti bia l a rte rie s. Th e so leu s ca n be pa lp ated on e ach
s ide of th e gastr ocn em iu s wh en th e i nd ivi du al is stan di ng o n th e ti ptoe s.

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Ta bl e 5. 13- I. Sup erf ici al M uscles of the Poste rio r Co mpar tment of the L eg
Muscl e a
Pr oxi mal Atta chment
Di stal
Attachment
Inner vatio n b
Ma in Actio n
Gastro cne mi us
L ater al he ad: late ral asp ect of
Po ster ior su r face
Ti bi al ner ve
Pl an tarf lexe s an kle wh en
( 1)
la tera l co nd yle of f em ur
Med ial h ead : p opl iteal su r face
of ca lcan eu s vi a
cal can eal ten don
(S1 , S 2 )
kn ee is e xten ded ; r aise s

h eel du r in g wal kin g; fl exes
Sol eu s (2 )
of f em ur , su pe rio r to m edi al
con d yle
le g at kn ee jo in t
Po ster ior asp ect of h ead of

f ibu la ; su pe rio r qu ar ter of
Pl an tarf lexe s an kle

in d epen d en t of p osi tion o f
p oster ior sur face of f ib ul a

sol eal li ne, m ed ial b or der , an d
kn ee; stead ies leg on f oo t
of ti bi a
Pla nta ris (3 )
a
b
I nf er ior en d of l ater al
Weak ly a ssists
su pr acon d ylar l in e o f fem u r;

ob li qu e p op lit eal lig am en t
g astr ocn em iu s in
p lan tar fl exin g an kle
N u mb er s r efer t o th e fi gu re , par t A.
Th e sp in al cor d seg men tal i nn er vatio n is in di cated (e. g. , S1 , S 2 m ean s th at th e n er ves su p pl yin g the se m u scles
ar e d eri ved fr om the fi rst an d secon d sacr al seg men ts of th e sp in al cor d). Da ma ge to on e or mo re of th e l isted sp in al cor d
segm en ts or to th e m oto r n erve r oots ar isin g fr om them resu lt s in par aly sis o f the m uscl es co nce rn ed .
T h e so leu s m ay act with the g astro cne mi us in p lan tar fl exin g th e a nkl e j oin t; it ca nn ot act on th e kne e jo in t a nd ac ts al on e w he n
t he kn ee i s f lexed . Th e fi ber s o f the sol eus slo pe po steri or ly a nd i nf er om edi ally . Whe n th e f oot is pla nte d, i t p ul ls p oste ri orl y o n
t he bo ne s of th e leg . Th is is im po rtan t to stan din g b ecau se th e lin e of gr avi ty p asses an teri or to th e l eg' s b on y axi s. Th e soleu s is
t hu s a n an tig ra vity mu scle (th e p r edo mi na nt pl an tarf lexo r fo r stan di ng an d str oll in g), wh ich con tr acts an tago ni stical ly bu t
c oop era tivel y (al tern ate ly) w ith the do rsi fle xor m u scles of th e le g to ma in tain b ala nce. Co mp osed l arg ely of r ed, fati gu e-r esistan t,
s low -twi tch (typ e 1 ) m u scle fi ber s, it is a str on g b ut re lati vely slow p lan tar fl exor o f the an kle joi nt , capa bl e of su stai ne d
c on tract ion . E lectr om yog ra ph y (E MG) stu d ies sho w t hat d ur ing sym m etri cal stan di ng , th e so leu s i s con ti nu ou sly activ e.
P la n t ari s
T h e p lanta ri s is a sma ll m uscl e w ith a sh or t b elly an d a lon g ten do n (Figs . 5. 3 1 an d 5 .3 4A; Tab le 5. 1 3 ). Th is vestig ial m u scle is
a bsen t in 5 1 0% of p eop le an d is
P. 6 4 9
h i gh ly vari ab le i n size an d fo rm wh en p resen t (mo st co mm o nl y a tap eri ng sl ip ab ou t th e size of th e sm al l fin g er). I t acts w ith t he
g astr ocn em iu s b u t i s in sig n ifi can t as eith er a fl exor o f the kn ee or a pla nta rf lexo r of th e an kl e. It h as b een co nsi der ed to be an
o rg an o f pr op rio cept ion f or th e lar ger p la nta rf lexor s, as it ha s a h igh den sity of m u scle spin d les (recep tor s for p ro pr io cepti on ). Its
l on g, sl en der te nd on i s easi ly mi staken f or a n erve (an d h en ce d ub be d by som e th e fr esh ma n's n erve ). It r un s d ista lly

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b etw een th e gastr ocn em iu s a nd th e sole us (Fig. 5. 3 4A ) a nd o ccasion al ly su d den ly r up tu res wi th a pai nf ul p op d ur in g acti vitie s su ch
a s r acq uet spo rt s. Becau se of its m in or r ole, the p lan tar is t end on ca n be r emo ved fo r gr af tin g (e. g. , du r in g rec ons tru ctive su rg er y
o f th e ten d on s of th e ha nd ) w ith ou t causi ng d isa bil ity.
Ta bl e 5. 13- II . D eep M uscles of the Poste ri or Co mpa rtment of the L eg
Muscl e a
Pop lit eus
Pr ox imal Attachment
Di stal Attachment
I n ne rv ati on b
Ma in Actio n
L ater al su rf ace of late ral
Poste rio r su rf ace o f
Tib ial n er ve
We akly fl exes kn ee an d
co nd yle of f em ur an d
l ater al me ni scus
tib ia, su p eri or to sol eal

lin e
(L4 , L 5, S 1 )
u n lock s it by r otati ng f em ur
5 o n fi xed tib ia; m edi ally
r ota tes ti bi a o f un pl an ted
l im b
Flexor
ha llu cis
I n fer ior t wo th ir ds of
p oster io r sur f ace o f fib u la;
Base of d ista l p h alan x

of g rea t toe (h all ux)
Tib ial n er ve
(S2 , S3 )
Fl exes g r eat t oe a t al l
j oin ts; wea kly p la nta rf lexes
lon g us (4 )
i nf er ior p ar t of
i nte ros seou s m em br an e
Flexor
di git oru m
Med ial p ar t of p oster io r

su r face of ti bia in f eri or to
Base s of d ista l
ph al ang es of late ral
Fl exes l ater al fo ur d ig its;

p lan tar flex es an kle ;
lon g us (5 )
so leal li ne ; b y a br oad
te nd on to f ibu l a
fo ur d ig its
su p po rts lon g itu di nal ar ch es

o f foo t
Tib ia lis
I n tero sseou s m em b ran e;
Tu be ros ity o f na vicu lar ,
Tib ial n er ve
P lan tar fl exes a nkl e; i nve rts
po steri or
( 6)
p oster io r sur f ace o f tib ia

i nf er ior to sol eal li ne;
cun ei for m , an d cu boi d;

ba ses of 2 n d, 3 r d, and
(L4 , L 5)
f oo t
p oster io r sur f ace o f fib u la
4 th m etatar sals
a nkl e; su p por ts me dia l

l on gi tud in al ar che s of f oot

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a
b
Page 85 of 155
N u mb er s r efer t o th e fi gu re , par t A.
Th e sp in al cor d seg men tal i nn er vatio n is in di cated (e. g. , S2 , S 3 m ean s th at th e n er ves su p pl yin g the f lexor
ha llu cis lon g us ar e d eri ved fr om the seco nd an d th ir d sacr al segm en ts of th e sp in al cor d). Dam ag e t o o ne or m or e of th e
liste d spi nal co rd seg m ent s or to th e mo tor n er ve r oo ts ar isi ng f ro m th em r esu lts i n pa ra lysis of th e m u scles con cer ned .
Fa b e l la i n t h e G a st r o cn e m i u s
Cl ose to i ts p ro xim al atta chm en t, th e later al h ead of th e gastr ocn em iu s co nt ain s a sesam oi d bo ne, the fa bel la (L. b ean ), wh ich
art icu lates wi th th e l ater al fem or al con dy le a nd i s vi sibl e i n late ral r ad iog ra ph s o f t he kn ee i n 3 5% of p eop le (Fig . B5 . 15 ).
C a lc a n e a l T e n d in i ti s
In fl am ma tion o f th e cal can eal ten don con stitu tes 9 1 8 % of ru n n in g in ju ri es. Micr oscop ic tear s of co lla gen f ib ers in th e ten do n,
par ticu la rl y ju st sup er ior to i ts att ach men t to the cal cane us, r esu lt in ten d in itis, wh ich cau ses pai n d ur in g wa lkin g, especi all y w hen
wear in g r ig id-so led sh oes. C al can eal ten din it is o ften occu rs du ri n g rep etiti ve a ctivit ies, esp ecia lly in i nd ivid u als wh o take up
ru n ni ng a fter p ro lon g ed in activi ty o r su dd enl y i ncr ease th e i nte nsi ty of t hei r tra in in g, b u t it m ay also r esul t f ro m po or f ootw ear or
tra in in g sur fa ces.
Fig ure 5.37. Supe rf icia l d iss ectio n of p oste ri or asp ect of leg . E xcep t f or th e reti na cul a i n th e an kle r egi on , th e d eep
fa scia has be en r emo ved to re veal th e n er ves an d m u scles. V isib le n erves in clu d e th e tib ial an d com m on f ibu la r ne rves an d
th eir con tr ib ut ion s to th e for m atio n of th e sur al n erve. Th e th r ee h ea ds of th e tr icep s su r ae m u scle atta ch di stall y to th e

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calcan eu s v ia the sp ira lin g fi ber s of th e cal can eal ten do n.
Fig ure 5.38. D eep d issecti on o f po ster io r asp ect o f ri ght l eg and knee jo int. A. Th e g astr ocn em iu s a nd m ost of th e
sole us are r em oved , leav in g on ly a h or sesh oe-sh ape d section of th e so leu s cl ose t o i ts p ro xim al attach m en ts a nd th e di stal
par t of th e ca lcan eal ten do n in th e sup er fici al pa rt of th e p oster io r com pa rtm en t Th e tr an sver se i nte rm u scul ar sep tum ha s
bee n spl it t o r eveal th e deep mu scles, vessels, a nd n er ves. B . Th e pop li teu s ten do n atta ches in p ar t to th e later al m en iscu s
an d is se par ated f ro m th e p r oxim al en d of th e tib ia by the p opl iteu s b u rsa.
Fig ure B5. 15
R u p tu r e d C a l c a n e a l T e n d o n
R u ptu r e o f the cal cane al ten don is o ften susta in ed by po or ly co nd iti on ed peo pl e w ith a h istor y of calca nea l te nd in iti s. Th e i nj u ry is
t ypi cally exp eri en ced as a n au di ble sn ap du r in g a f or cefu l pu sh o ff (p lan tar fl exion with the kn ee e xten ded ) f oll owe d im m edi ately by
s ud den calf p ain an d su dd en d or sif lexio n of th e p la nta rf lexed f oot. In a com p letel y r up tu re d tend on , a ga p is p alp ab le, u su all y
1 5 cm pr oxi ma l to th e calcan eal at tach men t.
C al can eal ten don ru pt ur e i s p ro bab ly th e m ost sever e acut e m u scul ar pr ob lem of th e l eg. I n div idu al s w ith th is in ju ry can n ot
p la nta rf lex aga in st r esista nce (can no t r aise th e heel f ro m th e g ro un d or bal ance on the af fected side ), an d passi ve d or sif lexio n
( usu all y l im ited to 2 0 fr om neu tr al) is excessive. Am bu la tion i s p ossib le on ly wh en th e lim b is exter n ally r otated , r oll in g over th e
t ran sver sely pl aced f oot du r in g the stan ce ph ase wi tho ut pu sh o ff . Br ui sin g ap pear s in th e m al leol ar r egi on , an d a l um p u su ally

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a pp ear s i n the cal f owi ng to sh or ten in g of th e t ric eps sur ae. I n ol der o r n on -ath letic pe opl e, n on -sur g ical re pai rs ar e of ten
a deq u ate, b ut su rg ical in ter ven tio n is usu al ly a dvi sed for tho se w ith a ctive lif estyle s.
Calcan eal Ten d on R eflex
T h e an kl e (je rk) re flex , the cal cane al ten don ref lex, i s a m yotati c r efl ex e lici ted wh il e th e per son 's leg s ar e dan gl in g over t he sid e
o f th e exa mi ni ng ta bl e. Th e calcan eal ten d on is str uck br iskl y w ith a r efl ex h am m er ju st p r oxim al to th e ca lcan eu s. Th e no rm al
r esu lt is pla nta rf lexi on of th e an kle joi nt. Th e cal can eal ten do n re flex tests th e S 1 an d S2 n er ve roo ts. I f t he S1 ner ve ro ot i s
i n ju red o r com pr essed , th e an kl e r efl ex i s vi rtu all y a bsen t.
G a s tr o c ne m iu s St r a i n
Ga stro cnem iu s stra in (ten n is l eg) is a p ai nf ul acu te in ju ry r esul tin g fr om the pa rti al tear in g of th e m ed ial b elly of th e
g astr ocn em iu s a t or nea r its mu scu lote nd in ou s j un cti on , oft en seen i n in di vid ual s o lde r tha n 4 0 year s o f a ge. I t is ca used b y
o ver stret chi ng th e mu scl e b y co nco mi tan t f ul l e xten sion o f the kn ee and d or sif lexi on of th e an kle joi nt. U sua lly, a n ab ru pt on set of
s tabb in g pa in is fo llo wed b y e dem a an d spasm of th e g astr ocn em iu s.
C a l c a n e a l B ur si t is
C al can eal bu r sitis (re tro achi lle s b ur siti s) r esu lts f r om in f lam m atio n of th e b u rsa of th e calcan eal ten d on lo cated b etwe en th e
c alcan eal ten d on an d th e su p eri or p art of th e post eri or su rf ace of th e cal can eus (Fig . B5 . 16 ). C alca nea l b u rsi tis cause s p ain
p oste ri or to th e h eel an d occu rs qu it e co mm on ly du r in g lon g -di stan ce r un n in g, basket bal l, an d ten n is. I t is cau sed b y excessi ve
f r ictio n on th e bu rs a as th e te ndon co nti nu ou sly sli des over i t. In f lam m atio n of th e su b cuta neo us calca nea l b u rsa al so r esu lts fr om
r ep etiti ve m i crot rau m a fr om th e backs of sh oes, u su all y n ew on es.
V e n o u s R e t ur n f r o m th e L e g
A ve no us pl exu s d eep to th e tr icep s su r ae i s i nvo lved in the r etu rn o f blo od f rom th e le g. Wh en a pe rso n is st and in g , th e ven ou s
r etu r n fr om t he leg d ep end s l arg ely on t he m uscu la r activi ty o f the tr icep s su r ae (see Ve no us Dr ai nag e of th e L ow er Li mb ,
e arl ier i n th is ch ap ter ). Co nt racti on o f the calf m u scles pu m ps bl ood su p eri or ly i n th e d eep vei ns. T h e ef fi cien cy o f the cal f p u mp i s
i m pr oved b y th e dee p fasci a th at in vests the m u scles like an el astic stocki ng . No rm al ly, b loo d is p r even ted fr om f lo win g in to th e
s up erf ici al vein s b y th e valve s in the pe rf or atin g vein s. I f th ese va lves are in com p eten t, bl ood i s f or ced in to the su per f icial vei ns
d u ri ng co ntr acti on of t he tr icep s su ra e an d b y h ydr osta tic pr essu re wh en str ain in g or stan din g . As a co nse qu en ce, th e vess els
b ecom e di lated and t ort uo us var icose vein s.
Fig ure B5. 16
A c c e s so r y S o l e u s
A n accesso ry sol eus is pr esen t i n ap pr oxim at ely 3% of p eop le (Fig. B5 .1 7 ). Th e accessor y mu scle u sua lly ap pear s as a di stal be lly
m ed ial to th e calcan eal ten d on . Cl in ical ly, an a ccessor y so leu s m ay be associ ated w ith p ain and e dem a du r in g pr olo ng ed exer cise.

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Fig ure B5. 17
P. 6 5 0
P. 6 5 1
P. 6 5 2
P. 6 5 3
D eep M u sc le G r ou p in th e P os t er io r Co m p ar tm en t
Fou r m u scles ma ke u p th e d eep g ro up i n th e p oster io r com pa rtm en t o f th e le g (Fi gs. 5 . 3 4, 5 . 3 8, 5 . 39 an d 5. 4 0): po pl iteu s, f lexor
d ig ito ru m lo ng u s, fl exor h all uci s lo ng u s, an d tib ial is p oster io r. Deta ils con cern in g th e attach m en ts, in ne rvat ion , an d acti on s of
th ese m uscl es a re pr ovi ded i n Tab le 5 .1 3 . Th e pop li teu s acts on th e kne e j oin t, w her eas th e o ther mu scle s p lan tar fle x th e ankl e
a nd f lex th e to es. Ho wever , b ecau se o f the ir sm all er size an d the clo se p ro xim ity of th eir tend on s t o th e axis of th e a nkl e j oin t, th e
n on -tr icep s p lan tar fl exor s co llect ively pr od u ce on l y ab ou t 7 % of th e total f orce of p lan tar fl exio n, a nd i n th is t he fi bu lar is
l on gu s a nd b re vis a re m ost sign if ican t. Wh en th e calca nea l te nd on i s r up tu red , th ese mu scle s can n ot gen er ate the p ower neces sary
to l ift th e b od y's weig h t (i .e. , to stan d on the toes) .
Fig ur e 5. 39. Di ssectio n d emo ns trat ing continuat ion of p lantar fl exo r tendo ns acr o ss ank le j oint. T h e f oot is rai sed as
in th e pu sh-o ff p ha se o f w alk in g. Ob ser ve th e sesam oid b on e actin g as a f oot stool f or th e 1st m etata rsal , gi vin g it
extr a h eig h t an d p ro tectin g th e f lexo r ha llu cis lon g us ten do n.
T h e tw o m u scles of th e post eri or com p artm en t tha t p ass to th e toes ar e cr iss-cr ossed th at i s, th e m u scle attach in g to th e m ed ial
(g r eat) t oe (f lexo r h allu cis lo ng us) ar ises later al ly (f r om th e f ib u la) in th e d eep su bco m par tm en t, an d th e m u scle attach in g to th e
l ater al fo ur to es (f lexo r di git oru m l on gu s) a ri ses m ed iall y (f ro m th e ti bi a) (Fig . 5 . 40 ). T hei r ten do ns cro ss in the sol e o f the fo ot.
P o pl it eu s

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T h e p op li teus i s a th in , tr ian gu la r mu scle th at for m s th e in fer ior par t o f th e f loo r of th e p op lite al fossa (Fig s. 5 .3 1 , 5 .3 2 , an d
5 . 3 8B ). Pr oxi ma lly, i ts ten d in ou s at tach men t to the la tera l a spect of th e l ater al fem o ral con d yle an d its br oad er atta chm en t t o th e
l ater al m eni scus occu r b etwee n th e f ibr ou s layer a nd th e syno vial m em br an e o f th e j oin t ca psu le of th e k nee. Th e a pex of its fl esh y
b ell y em er g es f ro m th e j oin t ca psu le of th e k nee jo in t. It h as a f lesh y d istal at tach men t to the tib ia th at is co vere d by po pli teal
f asci a r ein fo rced b y a f ib rou s expa nsi on f rom th e sem im em b ran osu s mu scle .
P. 6 5 4
Fig ure 5.40. D issecti on d emo nstra ting conti nua tion of p lantar f lexo r tend ons i n seco nd layer o f sol e of f oo t. Th is
layer of fo ot m u scles in clu de s th e t end on s o f the f lexor h al lu cis l on gu s and f lexo r di gi tor um l on gu s, th e fou r lu m br ica l (L .
lu m br icu s, ear th wor m ) m u scles, a nd th e qu ad rat us pl ant ae.
T h e p op liteu s is i nsi gn if ican t as a fl exor o f the kn ee joi nt per se; b ut d ur in g fl exion at t he kn ee, it assist s in p u lli ng th e late ral
m en iscu s post eri or ly, a m ovem en t o ther w ise p r odu ced p assive ly b y com pr essio n (as i t i s f or th e m ed ial m en iscu s; so me h ave
c laim ed th is is par t of th e r easo n the la tera l m en iscu s is i nj ur ed l ess of ten ). Wh en a per son i s sta nd in g wi th th e kn ee pa rtl y f lexed ,
t he po pl iteu s co ntr acts to assist th e p oster io r cru ciat e l iga me nt (PC L) in p rev enti n g ant eri or di spl acem en t o f t he fem u r on t he
i n clin ed tib ial p late au.
T h e p op li teus b urs a l ies deep to th e pop li teu s ten d on (Fig . 5 .3 8 B). Wh en sta nd in g wi th th e kn ees loc ked in th e fu lly exten d ed
p osi tion , th e pop li teu s acts to ro tate the f emu r l ater ally 5 on t he tib ial p latea us (see T ib ia, earl ier i n th is ch ap ter ),
r el easin g th e kn ee fr om i ts cl ose-p acked or locked p osi tion so th at fl exion can occu r . Whe n th e f oot is off th e gr ou n d and t he kn ee
i s f lexed , th e pop li teus can a id th e m ed ial h am stri ng s (t he sem im uscl es ) in r otati ng t he tib ia m edi ally be nea th th e f em or al
c on dyle s.
F l exo r Ha llu ci s Lo n g u s
T h e f lexo r hall ucis l ong us (FH L) is a p owe rf ul f lexor o f all of th e joi nts of th e gr eat toe. I m me dia tely afte r the tr icep s su r ae h as
d eli ver ed th e th r ust of p lan tar fl exion to t he ba ll of th e f oot (th e p r om in ence of th e sole u nd er lyin g th e h ead s o f th e 1 st a nd 2 n d
m et atar sals), th e FHL d elive rs a f in al th ru st v ia flex ion o f the g reat toe f or th e p re swin g p ha se (to e of f) of th e gai t cycl e (T abl e
5 . 2 ). Whe n ba ref oot, thi s th r ust is del iver ed by th e g r eat t oe; b u t w ith so led sh oes on , it beco m es p ar t of th e th ru st o f
p la nta rf lexio n de livered b y th e for ef oot. Th e ten d on of t he FHL p asses poste ri or to th e d istal en d of th e tib ia an d occu pie s a
s hal low g ro ove on th e post eri or su rf ace of th e ta lu s, wh ich i s con ti nu ou s w ith the gr oo ve o n th e p lan tar su r face of th e talar shel f
( Fi gs. 5 . 39 an d 5. 4 0). Th e te nd on th en cr osses de ep to the ten do n of th e flex or di gi tor um lon gu s in th e sole of th e f oo t. As it
p asses to th e d istal p ha lan x o f the g reat toe , th e FHL t end on r u ns bet ween two sesam oid b o ne s in the ten d ons of th e fle xor
h al lu cis br evis (Fig. 5. 4 0). T h ese b on es pr otect th e ten d on f ro m th e p ressu r e o f the h ead of th e 1st m etata rsal b on e.
T o test the FHL , th e d istal p h alan x o f th e g rea t to e i s fl exed ag ain st resi stan ce; i f no rm al , the ten d on can b e seen an d pa lp ated on
t he pl an tar asp ect of th e g rea t to e as it cro sses th e joi nt s of th e toe.
F l exo r Di g it or u m Lo n g u s
T h e f lexo r d ig ito rum l ong us (FDL) is sm aller tha n th e FHL , even tho ug h it m oves fo ur d ig its (Fi gs. 5 . 3 8A , 5 .3 9 , an d 5. 4 0 ). It
p asses di ago na lly in to th e sol e o f the f oot, su p erf icia l t o th e ten do n of th e FH L. H ow ever, its dir ecti on of p u ll is r eal ig ned b y t he
q u adr atu s pla nta e m u scle, w hi ch is attach ed to th e poste ro later al asp ect o f the FDL ten don as i t d ivid es in to f ou r ten do ns (Fig .
5 . 4 0), w h ich in tur n p ass t o th e di stal ph ala ng es of th e la ter al fou r d igi ts.
T o test the FDL , th e dista l p h alan g es o f the lat era l f ou r toes ar e f lexed a gai nst r esistan ce; if th ey a re actin g n or m ally, the ten do ns
o f th e to es can be seen an d p alp ated .
T ib i ali s Po st er io r

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T h e ti bi alis p oster io r (TP ), th e d eep est (m ost an ter ior ) m u scle in th e po steri or com p ar tme nt, lies bet ween t he FDL a nd th e FHL in
t he sam e pla ne as the tib ia an d fi bu la wi thi n th e d eep su bco mp ar tm en t (Fig s. 5 .3 8A, 5 . 39 , a nd 5 . 40 ). Dista lly, t he TP atta che s
p r im ar ily to the n avicu la r bon e (in cl ose p r oxim it y to th e h ig h p oin t of th e m ed ial lo ng itu di na l a rch o f the f oot) bu t has
a ttach m ent s to oth er ta rsal an d m etata rsal b on es (Fig s. 5 . 44D an d 5 .6 8A; Tab le 5 .1 3 ).
T h e T P i s tr ad itio na lly descr ib ed as an in ver tor o f the f oot. I n deed , w hen the fo ot is o ff th e gr ou nd , it can a ct syn er gist icall y w ith
t he TA to in ver t the fo ot, th ei r oth erw ise an tag on istic fu n ction s cance lin g each o th er ou t. Ho weve r, th e pr im ar y r ol e of t he TP is to
s up po rt or m ain tai n (fi x) th e me dia l l on gi tud in al ar ch d ur in g wei gh t bear in g ; con seq ue ntl y, th e m u scle con tra cts sta tical ly
t hr ou gh ou t the stan ce ph ase of g ait (Fi g. 5 . 6 9C & E ; T abl e 5 . 2). In so d oin g, it a cts i nd ep end en tly of th e T A beca use, on ce th e
f oo t is fl at on th e g r ou nd af ter h eel str ike, th at m uscl e i s r elaxe d du ri ng t he stan ce ph ase (the d orsi fl exion t ha t occu r s as th e b od y
p asses over t he pl an ted fo ot is p assive ), un le ss b rak in g req ui re s its eccen tr ic co nt racti on . Wh ile stan di ng (e speci ally on o ne f oot),
P. 6 5 5
h ow ever , th e t wo m uscl es m ay coop er ate to d ep ress th e l ater al sid e of th e fo ot a nd p u ll me dia lly on th e leg as n eede d to
c ou nter act late ral l ean in g for b ala nce .
T o test the tib ial is poste ri or, the fo ot is i nv erted agai nst r esistan ce wi th th e f oot in sl ig ht pl an tarf lexi on ; i f no rm al, the ten do n can
b e seen an d p alp ated p oster ior t o th e m edi al m al leo lu s.
N e rv es i n t h e Po st er io r Co m p a rt m e n t
T h e ti bi al n er ve (L4 , L 5, a nd S 1 S3 ) is th e l ar ger o f the two ter m in al br an ch es o f the sciat ic n er ve. I t r un s vert icall y th r ou gh th e
p op li teal fo ssa w ith th e po pli teal ar ter y, pa ssin g betw een th e hea ds of th e g astr ocn em iu s, th e tw o stru ctu re s exi tin g th e f ossa by
p assi ng d eep to th e te nd in ou s a rch o f the sol eus. Th e ti bi al ner ve sup pl ies all m u scles i n th e p oster io r com pa rtm en t of th e le g
( Fi gs. 5 . 34A an d 5 .3 8A; Tab le 5 .1 1 ). At th e a nkl e, th e n er ve l ies betw een th e ten don s of th e FH L and the FDL . Po ster oin fer io r to
t he m edi al ma lleo lu s, th e ti bi al ner ve di vide s in to th e m ed ial an d la tera l p lan tar ner ves. A b ra nch o f th e ti bia l n er ve, th e med ia l
s ur al cut ane ou s n er ve, is usu al ly j oin ed b y th e sur al com m u ni catin g br an ch of t he com m on f ib ul ar ne rve to fo rm t he sura l ner ve.
T h is n er ve sup pl ies the skin of th e l ater al and p oste rio r pa rt of th e i nf er ior th ir d of th e leg an d th e l ater al sid e o f the fo ot.
A r ticu lar b ra nch es of th e ti bi al ner ve sup pl y th e kne e j oin t, an d m edi al calca nea l b r anch es sup p ly th e skin o f the h eel.
A r te ri e s in th e P os t eri or C om p a r tm en t
T h e p os teri or ti bi al a rter y , th e lar ger a nd m or e di rect ter m in al br an ch of th e p op lit eal art ery, p r ovid es t he bl ood su p ply to th e
p oste ri or com p artm en t of th e l eg an d to the fo ot (Fi gs. 5 . 3 4A , 5 .3 8A, an d 5 . 41 ; Tab le 5. 1 2). It beg in s a t th e dist al bor d er of th e
p op li teus as the p opl iteal ar ter y p asses de ep to the ten di no us ar ch of th e soleu s a nd si m ul tan eou sly bif u rcate s in to its ter m in al
b r an ches. Cl ose t o i ts o rig in , th e poste ri or tib ial ar ter y g ives r ise t o i ts l arg est br an ch, the fi bu lar arte ry (see b elo w), w h ich r un s
l ater al an d pa ral lel to it, a lso wit hi n the d eep su bcom p ar tm ent. Du r in g its descen t, th e po steri or ti bia l a rter y is a ccom pan ie d by
t he tib ial n er ve an d vei ns. Th e ar ter y r u ns po ster ior to th e me dia l m al leol us, fr om w hi ch it is separ ate d by the ten d on s of th e
t ibi ali s p oster ior a nd f lexo r di git or um l on gu s. I nf er ior to th e med ia l m al leol us, it r u ns be tween the ten do ns of th e fle xor h allu ci s
l on gu s and f lexo r di gi tor um l on gu s. Deep to th e f lexo r re tin acu lu m an d th e o rig in o f th e ab du cto r hal lu cis, th e po steri or tib ia l
a rte ry di vide s in to m edi al an d later al p lan tar ar ter ies, th e ar teri es o f the sol e o f t he fo ot.
T h e f ib ular ar ter y, th e l ar gest an d mo st i mp or tan t br an ch of th e ti bi al art ery, ari ses i nf eri or to th e d ista l b or de r of th e p op lite us
a nd t he ten di no us ar ch of th e so leu s (Fig s. 5 . 38A an d 5 .4 1 ; T abl e 5 . 12 ). I t d escen ds ob liq u ely tow ard th e fi bu la an d passe s al on g
i ts m ed ial si de, u su all y w ith in th e FH L. Th e f ib ul ar ar ter y g ives mu scu lar b r anch es to the p opl iteu s and o th er m uscl es in bot h th e
p oste ri or an d th e l ater al com par tm en ts o f the leg . I t al so g ive s r ise to t he n utr ien t art ery of th e f ib u la ( Fi g. 5 . 41 ). Dista lly, the
f ib u lar ar ter y g ives ri se to a pe rf or atin g br an ch an d ter m in al later al m all eola r an d calcan eal b ra nch es. T he pe rf or atin g br an ch
p ier ces th e in ter osseo us m em br an e an d p asses to t he do rsu m o f t he fo ot, w he re it an astom oses wi th th e a rcu ate ar tery. Th e
l ater al calca nea l b r anch es sup p ly t he he el, an d th e later al m alle olar br an ch joi ns oth er m al leol ar br an ches to f orm a p er iar ticu lar
a rte ria l a na stom osis of th e ankl e.

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Fig ure 5.41. Arte ri es o f k nee, p oster io r leg , and so le o f fo ot. T h e p op litea l a rte ry bi fu rca tes i nto th e ant eri or an d
po steri or ti bia l a rter ie s; th e l atter g ives ri se t o th e fi bu lar a rter y and t erm in ate s as it ent ers th e f oot, b if ur cati ng i nt o th e
m edi al and l ater al pl an tar ar ter ies.
T h e ci rcumf lex fi bul ar ar tery ar ises fr om th e or igi n of th e an teri or or p oste rio r tib ial ar ter y at th e k nee an d pa sses l ater ally ove r
t he n eck o f the fi bu la to th e an asto m oses a ro un d th e kn ee.
T h e nutr ient a rter y o f the ti bi a, th e l arg est nu tr ien t arte ry in th e bod y, ar ises fr om the or ig in o f t he an ter ior o r po steri or tib ia l
a rte ry. I t p ier ces the tib ia lis po steri or , to wh ich i t su pp li es b ra nch es, an d en ter s th e nu tr ien t f or am en in the p rox im al thi rd o f the
p oste ri or su rf ace o f th e ti bia .
P o s te r io r T i b i a l P u l s e
Th e p oster io r tib ial p ul se can usu all y b e pal pate d betw een th e post eri or su rf ace of th e m ed ial m all eolu s an d the m edi al bo rd er of
the cal cane al ten don (Fi g. B 5 .1 8 ). Beca use th e p oster io r tib ial ar ter y p asses deep t o th e fle xor r etin acu lu m , it is i m por tan t wh en
pal pat in g thi s p ul se to h ave th e p erso n in ver t th e fo ot to r ela x th e r eti na cul um . Fail u re to do so ma y l ead to th e er r on eou s
con clu sion t hat th e p u lse is a bsen t. B oth ar ter ies ar e exa mi ne d sim ul tan eou sly fo r equ ali ty o f for ce. P alp atio n of th e p oster io r
tib ial pu lse s is essen tial f or exa mi ni ng p ati ents wi th occl usi ve p er iph er al ar ter ial di sease. A lth ou gh post eri or tib ial p ul ses a re
abse nt in ap p rox im ately 1 5% o f n or m al you n g peo ple , abse nce of p oster ior tib ial pu lse s is con sid ere d to b e a si gn o f occlu sive
per ip he ral ar ter ial d isease in p eop le old er th an 6 0 ye ars. Fo r exam pl e, in ter m itten t clau di catio n, ch ar acter ized by leg p ain an d
cram p s, de velop s d u ri ng w alki ng a nd d isap pe ars af ter re st. Th ese con di tion s r esu lt fr om i sche mi a o f the le g mu scles cau sed b y
na rr owi n g or occl usi on of th e leg ar ter ies.
Fig ure B5. 18
P. 6 5 6
P. 6 5 7

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T h e p oster io r or p lantar fle xor com p art me nt is sub di vid ed by th e tr an sver se i nte rm u scul ar sep tum in to sup er fici al an d deep
s ub com pa rtm en ts. I n th e su pe rf icia l su b com par tm en t, th e g astr ocn em iu s an d sol eu s m u scles (the tr icep s su ra e) sh ar e a com m on
t end on (t he calca nea l t end on , th e b od y's stro ng est tend on ). T he tr icep s su ra e p ro vid es th e pow er of p lan tar f lexio n th at p r ope ls th e
b od y i n wa lkin g an d pl ays a m aj or r ole in r u nn in g an d ju m pi ng vi a p u sh of f. T he de ep mu scl es au g men t th e acti on th r ou gh f lexi on
o f th e d ig its a nd su p por t of th e l on git ud in al ar ch of th e f oo t. Th e c ont ent s of th e com pa rtm en t a re su pp lied b y t he tib ial n er ve an d
t wo ar teri es, th e (m ed ial ) p oster io r tib ial an d fi bu lar a rte rie s. All th r ee st ru ctu res cou rse w ith in th e con fin ed d eep
s ub com pa rtm en t, w her e swel lin g m ay h ave p rof ou n d con sequ en ces f or th e en tir e p oster ior com par tm en t, th e d ista l l ater al
c om par tm en t, an d th e f oot.
S u r f a c e An a t o m y o f t he L eg
T h e ti bi al t ub er osi ty i s an e asily p alp abl e el evati on on t he an ter ior a spect of th e p r oxim al p art of th e tib ia, ap p rox im ately 5 cm
d ista l t o th e ape x of t he pa tella (Fig . SA 5 .3A). Th e ti bi al tub er osity in di cates th e le vel of th e h ead o f the fi bu la an d th e b if ur cati on
o f th e p op litea l a rter y in to t he an ter ior a nd p oster io r tib ial ar ter ies. T he p atell ar lig ame nt m ay be fel t as it exten ds fr om the
i n fer ior b or de r of th e ap ex of th e p atel la. I t i s m ost easi ly f elt wh en th e kn ee i s exte nd ed. When the kn ee f lexe s to a ri gh t a ng le, a
d ep ressi on m ay be fe lt o n each si de of th e pate llar l ig am ent . Th e j oin t cavity is sup er fic ial in th ese de pr ession s. T he head o f the
f ib ula is sub cu tan eou s a nd m ay be pa lp ated at th e p oster ola ter al aspect of th e kne e, at the leve l o f the ti bia l tu b ero sity. T h e neck
o f the f ib ula can b e p alp ated j ust di stal to th e h ead . Th e tendo n o f the b icep s f emor is m ay be tra ced by pa lpa tin g its di stal
a ttach m ent to th e l ater al sid e of th e he ad of th e f ib ul a. T hi s tend on an d th e n eck of th e f ib ul a g u ide th e e xam in in g fi ng er to th e
c ommo n fi bul ar ner ve (Fig . 5 .3 7 ). Th e ner ve is in dica ted by a lin e alon g th e bice ps fem or is ten don , p oster io r to the h ead of th e
f ib u la, an d ar ou n d the la tera l a spect of th e f ib u lar n eck t o i ts an ter io r aspe ct, ju st d ista l t o th e fi bu lar h ead . T he com m on f ibu la r
n er ve can u sua lly be pa lp ated ju st post eri or to th e f ib ul ar head an d ro lle d agai n st th e f ib u lar n eck w ith the fi ng er tip s.
T h e ante ri or b or d er of the ti bi a i s sh ar p, su b cut ane ou s, an d easil y f oll owed d ista lly by pa lp ation fr om th e tib ial tu ber osi ty to th e
m ed ial m al leol us (Fig . SA 5. 3A C ). It is n ot u su all y p erf ectl y str aig h t. Th e m ed ial su r face of th e shaft of the ti bi a i s al so
s ub cut ane ou s, excep t at its pr oxi ma l e nd . It s in f eri or th ir d is crosse d obl iq uel y b y t he gr eat sap hen ou s vein a s it pa sses p ro xim all y
t o th e m edi al aspect of th e kne e.
T h e ti bi alis anter io r lie s su per f icial ly and i s ea sily pa lpa ble ju st later al to th e a nter io r bo rd er of th e tib ia. A s th e foo t i s in ver ted
a nd d or sif lexed , th e l ar ge tendo n o f t he TA can b e seen and p al pate d as i t r un s dist ally an d sli gh tly m edi ally over t he an ter ior
s ur face of th e an kle joi nt to th e m ed ial sid e o f the f oot (Fig SA 5 .3C ). If th e 1st di gi t i s d orsi fl exed, the tend on o f the E HL can b e
p al pate d ju st l ater al to t he ten do n of th e t ibi ali s an ter ior . T he tend on o f the ext ensor hal lucis br evis m ay a lso be visi ble . As
t he toes ar e d or sif lexed , th e tend o ns of the ED L can b e p al pate d later al to th e exte nso r ha llu cis lon g us an d fol low ed to th e f ou r
l ater al di gi ts. Th e tendo n o f the FT ma y b e p alp ab le later al to th e ten d on s of t he E DL , esp ecial ly w h en th e f oot is do rsi fle xed an d
e vert ed.
Fig ure SA5. 3
T h e shaf t o f the f ib ula is su b cuta neo us on ly in i ts d istal p art , pr oxi ma l to th e later al m all eolu s; thi s p art is th e co mm on site of
f r actu res. T h e med ia l a nd l ater al mall eol i a re sub cu tan eou s a nd p ro mi ne nt. Palp ate th em, no tin g th at th e tip of t he late ral
m al leo lu s exten d s f art her d ista lly an d po steri or ly tha n th e m ed ial m all eolu s.
T h e f ib ular is long us i s su b cuta neo us th ro ug ho ut its cou r se (Fig . SA 5 .3B). Th e te nd on s o f thi s m u scle and the fi bul ar is b r evis
a re pa lp abl e w hen the f oot is evert ed as th ey pa ss ar ou n d the poster ior a spect of th e later al m all eolu s. T hese ten do ns m ay b e

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f ol low ed an ter ior ly alon g th e later al sid e o f the f oot. T h e ten d on of th e fi bu lar is lon g us ru n s as fa r an teri or ly a s th e cub oid a nd
t hen disa pp ear s b y tu r ni ng i nto th e sole of th e foo t. Th e tendo n o f the FB m ay b e trace d to its a ttach m ent to th e b ase of th e 5 th
m et atar sal.
T h e cal caneal tend on can b e easi ly fol low ed to its attach m en t to th e post eri or pa rt of th e calcan eu s. Th e an kle joi nt is fai rl y
s up erf ici al in th e d ep ressi on o n each si de of th e ca lcan eal ten do n. Th e hea ds of the g astr o cne mius a re easi ly r ecog n izab le in th e
s up eri or p ar t of th e calf o f t he leg (Fig . S A5 .3A & B). T he so leus can be p alp ated d eep to an d at the sid es o f the su per io r par t of
t he calca nea l t end on . T he tri cep s sur ae (soleu s and g astr ocn em iu s to get her ) i s ea sy to p alp ate wh en th e i nd ivi du al is stan di ng o n
t he toes. Th e so leu s can be di stin gu ish ed f ro m th e g astr ocn em iu s d ur in g sq uat tin g (fle xin g the kn ees wh ile stan d in g on toe s)
b ecau se fle xion o f th e kn ee to app ro xim atel y 9 0 m akes the g astro cne mi us fl accid ; p lan tar fl exio n in th is po sitio n is ma in tain ed
b y the sol eus. Th e d eep m u scles of th e p oster io r com par tm en t a re no t ea sily pa lpa ted, bu t t hei r ten don s can b e ob ser ved ju st
p oste ri or to th e m ed ial m all eolu s, esp ecia lly wh en th e foo t i s in ver ted an d th e t oes a re fl exed .
P. 6 5 8
F o ot
T h e cli ni cal im po rta nce of th e foo t i s in d icated b y t he con sidera bl e am ou n t o f tim e p r im ar y car e ph ysicia ns de vote to f oo t
p robl em s. Pod iatr y is th e speci ali zed fi eld th at dea ls w ith t he stu dy an d care of th e feet .
T h e an kle r efer s to th e na rr ow est an d m all eol ar pa rts of th e d ista l l eg, p r oxim al to th e d or su m an d he el o f the f oot, i ncl ud in g th e
a nkl e j oin t. T he fo ot, d istal to th e a nkl e, p rov ide s a pl atfo rm for su p por tin g th e bod y wh en stan d in g and h as an i mp or tan t r ol e in
l ocom ot ion . Th e skeleto n of th e foo t co nsi sts of 7 tar sals, 5 m eta tar sals, an d 1 4 p ha lan ges (Fig . 5. 4 2 ; Ta bl e 5 . 14 ). T he fo ot and i ts
b on es
P. 6 5 9
m ay be con sid er ed in te rm s o f thr ee an atom ica l a nd f un cti on al par ts:
Fig ur e 5. 42. Retinacul a o f a nkle and pa rts of f oo t. Th e disp osi tion o f th e b on es o f the fo ot and t he su per ior and i nf er ior
exten sor an d f ibu la r ret in acul a r ela tive to sur fa ce f eatu re s ar e d em on str ated .
Tab le 5.14-I . Muscl es o f the Foo t: 1st and 2nd La yers of the So le

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M uscle
Pr oxi mal At tachment
Page 94 of 155
D istal Attachment
I nnerva tion a
Ma in Actio n b
1st la yer
Abdu ctor
ha llu cis
Medi al tub er cle of

tu ber osit y of ca lcan eu s;
Media l s ide of b ase of

pr oxi mal p h alan x o f
fl exor r etin acu lu m ; p lan tar

apo ne ur osi s
1st d igi t
Fl exor
di git oru m
Medi al tub er cle of

tu ber osit y of ca lcan eu s;
Bot h sid es o f m i dd le
ph ala ng es o f later al
br evis
pl ant ar ap on eur osi s;

in ter mu scu lar se pta
fou r d ig its
Abdu ctor
di git i m in im i
Medi al and l ater al tu ber cles

of tu ber osi ty o f calcan eu s;
Lat eral si de of b ase

of pr oxi m al ph alan x
pl ant ar ap on eur osi s;

in ter mu scu lar se pta
of 5 th di gi t
Medi al sur fa ce an d la tera l

m arg in o f pla nta r sur f ace o f
Poster ol ater al m arg in

of ten do n of f lexor
calcan eu s
di gito ru m l on gu s
Med ial p lan tar

n er ve ( S2 , S3 )
Ab du cts a nd f lexes 1 st
dig it (gr eat toe, hal lu x)
Med ial p lan tar

n er ve ( S2 , S3 )
Fl exes l ater al fo ur d ig its
L ater al p lan tar

n er ve ( S2 , S3 )
Ab du cts a nd f lexes li ttle

toe (5th dig it)
L ater al p lan tar

n er ve ( S2 , S3 )
Assists fl exor d ig itor u m

lon gu s in f lexin g la tera l
2n d la yer
Qua dr atu s
pl ant ae
Lu m br ical s
fou r d igi ts (to es)
Ten d on s of f lexo r dig ito ru m
Media l a spect of
Med ial o ne:
Fl ex p ro xim al
lon g us
expa nsi on ove r

later al fo ur dig its
m ed ial p lan tar

n er ve ( S2 , S3 )
ph alan g es, exten d

mi dd le an d dist al
L ater al th re e:
l ater al pl an tar
ph alan g es o f later al
fou r d igi ts (to es)
n er ve ( S2 , S3 )
T h e sp in al cor d segm en tal in n erv ation is i nd ica ted (e. g. , S2 , S 3 m ean s th at th e n er ves su pp lyi ng t he ab du ctor
ha llu cis ar e d eri ved fr om the secon d an d th ir d sacr al segm en ts of th e sp in al cor d). Dam ag e t o o ne or m or e of th e l isted
spi na l co rd seg m en ts or t o th e m otor n er ve r oo ts ar isi ng f ro m th em r esu lts in p ara lysis of th e m u scles con cer ned .
b
De spite in d ivid u al actio ns, th e pr im ar y f u ncti on of th e in tri n sic m u scles of th e so le of th e f oot is to resi st f latt eni ng o r
m ain tain the ar ch of th e foo t.
T h e hind f oo t: ta lu s an d cal cane us.
T h e mi df oo t: nav icu lar , cu boi d, a nd cu n eif orm s.
T h e f or ef oo t: m eta tarsa ls a nd p h alan g es.
T h e p ar t/reg io n of th e f oot con tacti n g the fl oor o r gr ou n d is t he sole (L. pl ant a) o r pl ant ar re gio n (L. reg io pl an tar is), an d th e p ar t

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d ir ected su p eri or ly i s th e dor su m of th e foo t (L. d orsu m p ed is) o r d or sal reg io n o f the fo ot (L. reg io d orsa lis ped is ). T h e sol e o f
t he fo ot un de rl yin g the cal cane us is the h eel or heel r egi on (L. r eg io calcan ea) an d th e so le u n de rly in g the h ead s of th e me dia l
t wo m etatar sal s is th e b all of th e foo t. Th e gr eat toe
P. 6 6 0
( L. h all ux) is also th e 1st toe (L. dig itu s pr im u s); th e l ittl e to e (L. di gi tus m in im us) is also th e 5th toe (L. d ig itu s q u in tus ).
Ta bl e 5. 14- II. M uscles of the Fo ot: 3r d and 4th layer s of the So le
Pr oxi mal
M uscle
At ta chm en t
D istal Attachment
Inner vati on a
Mai n Actio nb
3r d la yer
Pla nta r sur f aces o f
Bo th sid es of ba se of
Medi al pl ant ar
Fle xes p ro xim al ph al an x of 1 st
ha llu cis
br evis
Fl exor
cu boi d an d later al
cu nei fo rm s
p roxi m al ph ala nx of
1 st d ig it
n erve (S2 , S 3)
d ig it
Addu ctor
ha llu cis
Obl iq ue h ead : b ases

of m etat arsa ls
Te nd on s o f both hea ds
atta ch to later al sid e
Deep br an ch of
lat eral p lan tar
T ra dit ion all y sai d to add u ct 1 st

d ig it; assists in tr an sver se
2 4
Tr an sver se h ead :
of b ase of pr oxi ma l
p hal an x of 1 st di git
n erve (S2 , S 3)
a rch o f foo t b y m eta tarsa ls

m ed ial ly
pl an tar li gam en ts of
m etatar sop ha lan ge al joi nts
Fl exor d ig it
Ba se o f 5 th
Ba se o f pr oxim al
Su p erf icia l
Fle xes p ro xim al ph al an x of 5 th
m in im i b r evis
m etatar sal
p hal an x of 5 th d ig it
br an ch of l ater al
pl an tar n erv e
d ig it, th er eby assi stin g wi th its

f lexi on
(S2 , S 3)
4t h layer
Plan tar
in ter ossei
Ba ses an d m ed ial
sid es o f me tatar sals
Medi al sid es o f bases

of p ha lan ge s of
(th ree
m uscl es)
3 5
3 rd 5 th di gi ts
Do rs a l
in ter ossei
Ad jace nt sid es o f
m etatar sal s 1 5
1 st: m ed ial sid e of

p roxi m al ph ala nx of
(fo ur
m uscl es)
La tera l p la nta r
n erve (S2 , S 3)
A dd u ct d ig its (2 4 ) a nd f lex
m eta tarso ph al ang eal jo in ts
La tera l p la nta r
n erve (S2 , S 3)
A bd u ct d ig its (2 4 ) a nd f lex
m eta tarso ph al ang eal jo in ts
2 nd d ig it; 2n d 4t h:
lat era l si des of
2 nd 4 th di gi ts
T h e sp in al cor d segm en tal in n erv ation is i nd ica ted (e. g. , S2 , S 3 m ean s th at th e n er ves su pp lyi ng t he fl exor

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ha llu cis br evis ar e d er ived f ro m th e seco nd a nd th ir d sacr al segm en ts of th e sp in al cor d). Dam ag e to o ne or m o re of th e
liste d spi nal co rd seg m ent s or to th e mo tor n er ve r oo ts ar isi ng f ro m th em r esu lts i n pa ra lysis of th e m u scles con cer ned .
b Desp ite in div idu al acti on s, th e p ri m ary fu n ction of th e i ntr in sic m uscl es o f the sol e of t he fo ot i s to r esist fl atten in g or
m ain tain the ar ch of th e foo t.
S kin a n d F a s cia o f th e F o ot
Ma rked va ri ation s occu r in th e thi ckn ess (str en gth ) and t extu re of skin , su bcu tan eo us tissu e (sup er fici al fasci a), an d de ep fasci a i n
r el ation sh ip to w eig ht bea ri ng a nd d istr ib uti on , gr ou n d con tact (gr ip , ab rasi on ), an d th e n eed f or con tai nm en t o r
c om par tm en tali zatio n.
S kin an d S u b cu t an e ou s T is s u e
T h e ski n of th e d or su m of th e foo t is m uch thi nn er a nd l ess sen siti ve t han skin on mo st o f the sol e. Th e sub cu tan eou s
P. 6 6 1
t issu e i s lo ose deep t o th e do rsal ski n; th eref or e, ed em a (G. o ide -m a, a sw elli ng ) i s m ost m ark ed over th is su rf ace, esp ecial ly
a nte ri or to an d ar ou nd th e me dia l m al leol us. Th e ski n over the m ajo r wei gh t-be ari ng a rea s of th e sole t he h eel, l ater al ma rg in ,
a nd b all o f the fo ot is th ick. T he su bcu tan eou s tissu e i n th e sol e i s m or e fib ro us th an in oth er ar eas of th e f oot. Fi br o us sep ta
( hi gh ly devel op ed skin l ig am ents, reti na cul a cu tis; see In tr odu cti on ) d ivid e t hi s ti ssue in to fat -fil led ar eas, m aki ng i t a sh ocka bso rb in g pad , esp ecial ly over th e hee l. Th e skin l ig am ents also an ch or th e skin to th e u n de rly in g deep f ascia (p lan tar
a po neu r osis), i m pr ovin g th e g ri p of th e sole. Th e ski n of th e so le is hai rl ess an d sw eat gla nd s a re nu m er ou s; th e enti re sol e
i s sen sit ive (tickli sh), especi all y th e thi nn er -skin n ed are a u n der lyi ng th e ar ch.
T ab le 5. 14-II I. M us cles of the Fo ot: Do r sum of the Foo t
M uscle
P ro xima l Attachment
Inner vatio n a
Ma in Actio n
Ext enso r
C al can eus (fl oor o f tarsa l
L on g fl exor
Deep f ib u lar
A id s th e e xten sor di gi tor um
di git oru m
br evis
si nu s); in tero sseou s

t aloca lcan eal li gam en t;
ten d on s of f ou r
m ed ial toe s (d igi ts
n er ve (L5 o r
S 1 , or b oth )
l on gu s i n exten di ng t he fo ur
m ed ial toe s at th e m etat ar-
st em of in f eri or exte nso r
2 5 )
so ph alan g eal an d

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r eti nacu lu m
i nter p hal an gea l j oin ts
Ext enso r
I n com m on w ith exten sor
Dor sal asp ect o f
A id s th e e xten sor h allu cis
ha llu cis
br evis
d ig ito ru m b revi s (ab ove )
b ase of pr oxi ma l
p ha lan x o f gr eat
l on gu s i n exten di ng t he gr eat
to e at th e m eta tar so-
to e (d ig it 1)
p ha lan ge al join t
T h e sp in al cor d segm en tal in n erv ation is i nd ica ted (e. g. , L5 o r S1 me ans th at the n erve su pp lyi ng th e exten sor
di git oru m b r evis is d er ived f ro m eith er th e fif th l um b ar seg men t or f irst sacr al seg men t of th e sp in al cor d). Da ma ge to
on e o r mo re of th e liste d spin al cor d seg m ents or to th e mo tor n er ve r oot s ar isi ng f ro m th em r esul ts i n pa ral ysis of th e
m uscl es con cer n ed.
P. 6 6 2
D eep F asc ia o f t h e F o o t
T h e d eep f ascia is thi n on th e do rsu m of th e fo ot, w her e it i s co nti nu ou s pr oxim al ly with the in f eri or exten sor r eti na cul um ( Fi g.
5 . 4 3A ). Over th e later al an d po ster ior asp ects of th e f oot , th e d eep fa scia is co nt in uo us wi th th e p lanta r fasci a, th e deep f ascia of
t he sol e (Fig . 5 .4 3B & C ). T he pl an tar fa scia ha s a th ick ce ntr al p art an d wea ker m edi al an d later al pa rts. Th e th ick, cent ral p art
f or m s th e stro ng p la nta r ap oneur osi s, lon g itu di nal ly arr an g ed bu n dle s of d en se f ib ro us con ne ctive tissu e i nve stin g th e cen tr al
p la nta r mu scle s. It re semb les th e p alm ar a po neu r osis of th e p alm of th e h an d (C ha pter 6 ) bu t i s to ug h er, d en ser , an d elon g ated .
T h e p lan tar f ascia h old s t he pa rts of th e f oot tog eth er , he lps p rot ect th e sole fr om in ju ry, a nd h elp s su p po rt th e lo ng itu d in al
a rch es of th e f oot.
T h e p lan tar a pon eu r osis ari ses p oster io rl y f ro m th e cal can eus an d fu n ction s like a sup er fici al lig am en t. Distal ly, th e lon gi tu din al
b u nd les of col lag en f ibe rs of th e a pon eu r osis div ide in to fi ve b an ds th at b ecom e con tin u ou s w ith th e fib ro us d igi tal she ath s th at
e ncl ose the fl exor te nd on s th at pa ss to th e t oes. A t th e ant eri or en d of th e so le, i nf er ior to th e hea ds of th e m etat arsa ls, th e
a po neu r osis is rei nf or ced by tr an sverse fi ber s for m in g th e sup er fici al tra ns verse metata rsa l l ig ament.
I n th e mi df oot an d fo ref oot, vert ical in ter mu scu lar se pta exten d d eepl y (su p eri or ly) f ro m th e m ar g in s of th e pl ant ar ap on eur osi s
t owa rd th e 1st an d 5 th m etatar sal s, for m in g th e th r ee co mp ar tm en ts of th e sole (Fig . 5 .4 3 C):
1. T h e med ia l co mp art ment of the sol e i s cove red su p erf icia lly by th in ne r me dia l p lan tar fasci a. It con tai ns th e
P. 6 6 3
a bd uct or h allu ci s, fle xor h all uci s b revi s, th e te nd on o f t he fl exor h all uci s l on gu s, an d th e m ed ial p lan tar n er ve a nd vesse ls.
Fig ure 5.43. Fasci a and co mpa rtme nts of f oo t. A. Th e sk in an d su bcu tan eou s t issu e h ave bee n rem o ved to
dem on str ate th e d eep f ascia of th e l eg an d do rsu m of t he fo ot. B . Th e deep p lan tar fasci a co nsi sts of t he th ick pla nta r
apo ne ur osi s an d th e th in n er m edi al an d later al p lan tar f ascia. Th e a pon eu ro sis con sists of lon g itu di na l b an ds of d ense
fi br ou s con n ective ti ssue. T h in ner par ts o f th e p lan tar f ascia h ave been r em ove d, r eveal in g the p lan tar d ig ital vessel s
an d ner ves. C. Th e b on es a nd m u scles of th e f oo t ar e sur ro un d ed by th e d eep d or sal and p la nta r fasci a. A lar g e cen tr al

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an d sma ller m ed ial an d la ter al com par tm en ts o f the sol e ar e crea ted by in ter m uscu lar septa th at exten d dee ply fr om the
pl ant ar ap on eur osi s.
2. T h e centr al comp ar tment of the so le is cover ed su per fi cial ly b y t he de nse pl an tar ap on eu rosi s. It con tai ns th e f lexo r
d ig ito ru m b rev is, th e te nd on s o f the fl exor h al lu cis l on gu s a nd f lexo r di git oru m l on gu s p lu s t he m uscl es a ssociate d wit h the
l atter , th e q u adr atu s pla nta e an d lu m br ica ls, an d th e a dd ucto r h allu cis. Th e l ater al pl ant ar ne rve an d vessels ar e a lso loca ted
here.
3. T h e l ater al c omp ar tment o f the sol e i s co vere d sup er fici ally b y th e thi nn er l ater al pla nta r fasci a a nd co nta in s th e a bd uct or
a nd f lexo r di git i m in i mi b revi s.
I n th e for ef oot on ly, a fo ur th co mp ar tm ent , the inter o sseous comp ar tment o f the f oo t, is sur r ou nd ed b y th e p la nta r and dor sal
i n tero sseou s f ascia s. It con tain s the m etatar sal s, th e d or sal an d pla nta r in ter osseou s m u scles, and t he de ep pl ant ar an d
m et atar sal vessels. Wh er eas th e p lan tar i nte rosse i a nd p lan tar m eta tar sal vessels ar e d istin ctl y p lan tar i n po sitio n, t he re ma in in g
s tru ctu res of th e com par tm en t a re loca ted in ter me dia te b etw een th e p la nta r and t he do rsa l a spects of th e f oo t.
A f if th com p art men t, th e do r sal comp ar tment o f the f oo t, lies be tween the d orsa l f ascia of t he fo ot a nd th e tar sal bo nes an d th e
d or sal in ter osseo us fasci a o f the m id fo ot a nd f or efo ot. I t co nta in s th e m u scles (exten sor s h al lu cis b r evis and exten sor d igi tor um
b r evis) an d neu r ovascu lar stru ctu re s of th e dor su m of th e foo t.
P la n t a r Fa sc i i ti s
Str ain in g an d in fl am m ation of th e p lan tar a pon eu r osis, a con ditio n call ed pl an tar fa sciiti s, m ay r esu lt fr om r u nn in g an d h igh im pact aer ob ics, esp ecia lly wh en i na pp ro pr iate fo otw ear is wo rn . Pl ant ar fasci iti s is th e m ost com m on h in d foo t p ro ble m in r u nn er s
(Mi dd leto n an d Ko lod on, 1 99 2 ). I t cau ses pai n on th e pl an tar su rf ace of th e h eel an d on th e me dia l a spect of th e foo t. Th e pai n is
ofte n m ost se vere af ter sitt in g and w h en be gin n in g to wal k i n th e m or n in g, b u t d issip ates aft er 5 1 0 m i nu tes of acti vity, o ften
recu r ri ng ag ai n fol low in g r est. Poi nt ten d ern ess is l ocated a t th e pr oxim al at tach me nt of th e a pon eu r osis to the m edi al tu ber cle of
the cal cane us an d on th e med ia l su r face of th is bo ne. Th e p ain in creas es w ith p assive exten sio n of th e gr eat toe and ma y b e
fu rth er e xacer bate d by dor sif lexi on of t he an kle an d/or weig h t b ear in g. I f a calcan eal sp ur (a bn or m al bon y pr ocess) pr otr u des
fr om th e me dia l t ub er cle, p lan tar f ascii tis i s l ikely to cau se p ain on th e m ed ial si de of th e f oot w hen wal kin g (Fi g. B 5 .1 9 ). Usu all y
a b u rsa dev elop s a t th e end o f the sp ur th at m ay a lso beco m e in f lam ed an d ten de r.
Fig ure B5. 19

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Fig ure 5.44. L ayer s o f p la ntar muscles. A. T he 1 st l ayer con si sts of th e ab du ctor s o f t he lar g e an d sm all to es, an d th e
sho rt fl exor o f the toes . B. T he 2 n d layer co nsi sts o f the lo ng f lexo r ten don s and a ssocia ted m uscl es: f ou r lu m br ical s an d th e
qu ad ra tus pl an tae. C. T he 3 rd l ayer con sis ts of th e fl exor of th e lit tle toe and t he fl exor an d ad du cto r of th e g re at to e. Al so
dem o nstr ated a re th e n eu ro vascu lar str u ctur es tha t co ur se i n a pla ne be tween the 1 st a nd 2 n d layer s. D . Th e 4th layer
con sists of th e d or sal an d pl ant ar in ter osseou s mu scle s.

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Fig ure 5.45. Arte ri es and muscl e la yers of f oo t. A and B . Th e p oste ri or tib ial ar ter y te rm in ates as it ente rs the f oot by
di vid in g in to t he m edi al an d later al pl an tar ar ter ies. Ob ser ve th e dis tal an astom oses of th ese vessels wi th th e d eep p lan tar
ar tery fr om the d orsa l a rter y of th e f oot an d th e p erf or ati ng b ra nch es to t he ar cua te ar ter y o n th e d or sum of th e f oot (Fig .
5. 4 7 ). Not e th at th e p lan tar ar ter ies en ter an d r un i n th e p lan e betw een th e 1st an d th e 2 n d layer s, w ith th e later al p lan tar
ar tery pa ssin g fr om m ed ial to la tera l. Th e dee p br an ches of th e art ery th en pa ss f rom late ral to m edi al bet ween t he 3 rd an d
th e 4 th la yers.
M u s cle s of th e Fo o t
O f t he 2 0 in di vid ual m u scles of th e f oot , 14 are lo cated on the p lan tar asp ect, 2 a re on th e do rsal asp ect, a nd 4 a re in ter me dia te
i n p ositi on . From the p lan tar asp ect, m u scles of th e so le are ar r ang ed in fou r la yers wi th in fo ur com par tm en ts. Th e mu scl es of th e
f oo t ar e ill ustr ated a nd th ei r attach m en ts, in n erva tion , an d acti on s ar e descr ib ed by com p artm en t an d by layer i n Fig ur es 5 . 4 3C ,
5 . 4 4, a nd 5 . 4 5B an d T abl e 5 . 14 .
Desp ite th eir co mp ar tm ent al and l ayer ed ar ra ng em en t, th e p lan tar m u scles fu n ction p r im ar ily as a g ro up d ur in g th e sup po rt ph ase
o f stan ce, m ain tai ni ng th e ar ches of th e foo t (T abl e 5 . 2). Th ey b asica lly re sist for ces tha t ten d to r edu ce the lo ng itu di na l a rch a s
w eig h t i s r eceived a t th e hee l (p oster io r en d of th e ar ch ) an d is th en tr an sfer re d to the ba ll of th e f oot an d g reat toe (an ter ior e nd
o f th e ar ch ). Th e mu scles b ecom e m ost acti ve i n th e l ater p or tion o f the m ovem en t to st abi lize th e f oot fo r pr op u lsion (pu sh of f), a
t im e w he n fo rces also t en d to fl atten t he fo ot's tra nsve rse ar ch. C on cu rr en tly, t hey ar e a lso abl e to r efi ne fu r t h er th e ef fo rts of th e
l on g m uscl es, pr od u cin g sup in ati on an d pr on ati on in ena bli n g the pl atf orm of th e f oot to ad ju st to u n even g ro un d. Th e m u scles of
t he fo ot are of l ittle im p or tan ce in d ivid u ally b ecau se f in e co ntr ol of th e in di vid ual to es i s n ot im po rta nt to mo st p eop le. R ath er
t han pr od uci ng a ctua l m ov eme nt, they ar e m o st acti ve i n fi xin g th e f oot or i n in crea sin g the p ressu r e ap p lied a gai nst th e g ro un d
b y vari ou s asp ects of th e so le or toe s to m ain tai n bal an ce.
A lth ou g h th e ad du cto r ha llu cis rese mb les a s im ilar mu scle of th e pal m th at add uct s th e t hu m b an d desp ite its n am e, th e
P. 6 6 4
P. 6 6 5
P. 6 6 6
a dd uct or h all uci s is pr ob ab ly m os t acti ve d u ri ng th e pu sh -off p h ase o f stan ce i n pu ll in g the la tera l f ou r m etatar sal s to war d th e
g r eat toe, f ixin g th e tran sver se arch of th e f oot, a nd r esist in g for ces tha t w ou ld sp read t he m etatar sal h ead s as wei gh t and f or ce
a re ap pl ied to th e f or efo ot (T ab le 5. 2 ).
I n T abl e 5 . 14 , n ote th at the:

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P lan tar i nte rosse i AD du ct (PAD) an d ar ise f r om a sin gl e m eta tarsa l a s u n ipe nn ate m uscl es.
D or sal in ter ossei AB du ct (D AB ) an d ar ise fr om tw o me tatarsals as bip en na te m u scles.
Page 101 of 155
T h ere ar e tw o ne ur ovascu la r pl ane s b etwee n th e m u scle layer s o f the sol e o f the fo ot (Fi gs. 5 . 4 4 an d 5. 4 5B): (1) a su p erf ici al on e
b etw een th e 1st an d th e 2 n d mu scu lar l ayer s, an d (2 ) a dee p on e b etwe en th e 3 r d and t he 4 th m uscu la r layer s. T he tib ial n er ve
d ivi des po ster ior to th e med ia l m al leol us in to th e m ed ial an d lat eral p lan tar n er ves (Fi gs. 5 . 38A an d 5 .4 6 ; T abl e 5 . 1 5). T h ese
n er ves sup pl y th e in tri nsi c m u scles of th e p lan tar a spect of th e foo t. Th e me dia l p lan tar ner ve cou rses wi thi n th e m ed ial
c om par tm en t o f t he sol e b etwe en th e 1 st and t he 2 nd m u scle layer s. I ni tial ly, th e later al pl an tar ar ter y an d n er ve r u n later al ly
b etw een th e mu scle s of th e 1st an d 2 nd l ayer s of p lan tar mu scles (Fig s. 5 .4 4C an d 5. 4 5B). T hei r de ep br an che s th en p ass m ed ial ly
b etw een th e mu scle s of th e 3r d an d 4 th lay ers (Fig. 5. 4 5B ).
T wo cl osely con n ected m uscl es o n th e d or sum of th e f oot ar e th e extenso r di g itor um b r evis (EDB ) an d exte ns or hall ucis
b r evis (E HB) (Fig s. 5 .3 5A & B an d 5 .3 6 A). T h ese th in , b ro ad m uscl es f or m a fle shy m ass o n th e l ater al par t o f th e d or sum of th e
f oo t, an ter ior to th e later al m all eolu s. T he E HB is actu all y p ar t of th e EDB . Its sm all fl esh y b elly m ay be fel t w he n the toe s ar e
e xtended.
Th e i ntr in sic m uscl es o f the p lan tar su rf ace of th e f oot ar e a rr an ged i n fo ur l ayer s an d d ivid ed in to fo ur fasci al com par tm en ts. A
tou gh p lan tar apo neu r osis over li es th e cent ral com p ar tme nt, passi vely con tri bu tin g to ar ch m ain ten an ce a nd , alo ng w ith fir m ly
bou n d fa t, pr otect in g the vessel s an d n erv es f ro m com pr essi on . Th er e is sim il ari ty t o th e ar ran g em ent of m u scles in th e p al m of
the h an d, b u t th e m u scles of th e foo t g en era lly resp on d as a g r ou p rath er th an in divi du al ly, acti ng to f ix the fo ot or p ush a p or tion
of it ha rd er ag ain st the gr ou n d to ma in tain b al ance . Th e m o vem ents of ab du cti on an d ad du ctio n pr od u ced by th e i nter ossei ar e
towa rd o r awa y f rom the 2 n d dig it. Th e f oot h as tw o in tri nsi c m uscles on it s d orsu m t hat au gm en t the lo ng e xten sor m uscl es. Th e
pla nta r in tri nsi c m u scles fu n ction t hr ou gh ou t the stan ce ph ase of g ait, f ro m h eel stri ke t o to e o ff , resi stin g fo rces th at t end t o
spr ead th e arch es of th e f oot. Th ey a re esp eciall y a ctive in f ixin g th e m ed ial f or efo ot f or th e pr op ul sive pu sh of f. T h e p lan tar
in tri nsi c m u scles are in n erv ated b y th e m ed ial an d la ter al pla nta r ner ves, w h erea s th e dor sal m uscl es a re in n erva ted by th e d eep
fib u lar n er ve.
Fig ure 5.46. Arte ri es o f f o ot: br anching and co mmunicati ng. A. T he ar teri es o f the m id fo ot a nd f or efo ot r esem b le tho se
of th e h an d in t hat (1 ) ar ch es o n th e tw o aspe cts g ive ri se to m etata rsal (m etaca rp al) ar teri es, w hi ch in tu r n gi ve r ise to
di git al arte ri es; (2 ) th e do rsal ar ter ies ar e exh au sted b efo re r each in g the d istal en ds of th e d ig its, so th e pla nta r (pa lm ar)
di git al arte ri es sen d b ran ch es d or sall y to su pp ly th e d istal d or sal aspect s of th e di git s, in clu di ng th e na il bed s; a nd (3 )
per fo ra tin g br an che s exte nd b etwe en th e m eta tarsa ls (m eta car pal s) f orm i ng an asto m oses betw een th e arch es of each si de. B.
Th e p ar en t n eu ro vascu lar str u ctur es gi vin g ri se to p lan tar vesse ls a nd n er ves p ass post eri or to th e m ed ial m all eolu s an d then
di vid e, th eir ter m in al pl an tar br an ch es en ter in g th e so le by passi ng d eep to th e abd u ctor h all uci s an d cou r sin g betw een th e
1st an d th e 2 n d m uscl e l ayer s of th e sole.
I nf e c t io ns o f t he F o o t
Fo ot in fecti on s ar e com mo n, especi all y in season s, cli m ates, an d cu ltu re s w her e sho es ar e less com mo nl y w or n. A n eg lected
pu n ctur e wou n d m ay l ead to an exte nsi ve d eep in f ection , r esu lti ng i n swel lin g, pai n, and f ever . Deep in fe ction s of th e f oot of ten
local ize wi thi n th e co mp ar tm ent s b etwee n the m u scul ar laye rs. A w ell -estab lish ed in fe ction in on e of th e en clo sed fa scial or
mu scu lar sp aces usu al ly req u ire s su rg ical i nci sion a nd d ra in age . Whe n po ssibl e, th e i nci sion is m ad e o n th e m ed ial sid e of th e f oot,

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p assi ng su p eri or to th e ab d ucto r ha llu cis to allo w visu ali zatio n of cr itica l n eu r ovascu lar st ru ctu res, wh ile avo idi ng p r odu cti on of a
p ai nf ul scar in a wei gh t-be ari ng a rea .
Ta bl e 5. 15. Ner ves o f the Fo ot
Ne rve a
Sap h eno us
( 1)
Or ig in
Fem or al n erve
Co urse
Ar ises in f em or al tri an gle an d
de scend s t hr ou gh thi gh a nd l eg;
Di stri buti on i n Foo t

Su pp li es ski n on m ed ial sid e of fo ot a s f ar
an ter ior ly as h ead o f 1st m etatar sal
accom p an ies gr eat saph en ou s v ein

an ter ior to m ed ial m all eolu s; end s
on m ed ial si de of fo ot
Su pe rf icial
Pie rces de ep fasci a i n di stal th ir d
Su pp li es ski n on d or sum of fo ot an d all di gi ts,
fi bu lar (2 )
n er ve
of l eg to beco me cu tan eou s; th en

sen ds br an ch es to f oot an d dig its
excep t l ater al sid e of 5 th a nd ad jo in in g sid es

of th e 1 st an d 2n d d ig its
Passe s d eep to exten sor

r etin acu lu m to en ter d orsu m o f
Su pp li es ext enso r di gi tor um b r evis an d skin

on co nti gu ou s si des of 1 st a nd 2 n d di gi ts
De ep fi bu lar
( 3)
fo ot
Medi al
L ar ger t erm in al
Passe s d istal ly i n fo ot betw een
Su pp li es ski n of m ed ial sid e o f sole of f oot
pl ant ar (4 )
b r anch of tib ial

n er ve
ab du ctor h al lu cis a nd f lexo r

di gi tor um br evis; di vid es i nto
m uscu la r an d cuta neo us br an ch es
an d sid es o f f ir st t hr ee dig its; also su pp li es

ab du ctor h all u cis, fl exor d ig itor u m b revi s,
fl exor h all uci s b rev is, an d fi rst lu m br ical
Lat era l
pl ant ar (5 )
S m alle r
te rm in al b ran ch
Passe s la tera lly in f oot be tween

qu ad r atu s p lan tae an d fle xor
Su pp li es q u adr atu s p lan tae , abd u ctor d ig iti

m in im i, d ig iti m in im i b r evis; deep b r anc h
o f tib ial n erve
di gi tor um br evis m uscl es; d ivid es

in to su per fi cial an d de ep br an che s
su pp lies pl an tar an d do rsa l i nte ro ssei, la tera l

th ree lu m br ical s, an d ad du ctor h all uci s;
su pp lies skin o n sol e la tera l t o a li ne sp litti ng
4 th di gi t
Su ra l (6 )
U sual ly ari ses

f ro m b oth ti bia l
Passe s in f eri or to th e l ater al

m all eolu s t o l ater al sid e o f f oo t
La tera l a spect of h in df oot an d m id foo t
Pass fr om dista l p ar t o f the

po ster ior a spect of le g to ski n on
Ski n of h eel
a nd co mm on
f ib ul ar n erve s
Ca lcan eal
br an che s (7 )
T ib ial an d su ral
n er ves
h eel
Nu m ber s ref er to th e f ig ur e.
C o nt u s io n o f t h e E x te n s o r D ig i to r um B r e v i s
Fu n ction al ly, th e EDB an d E HB m uscl es a re re lati vely un im p or tan t. Cl in ical ly, kn ow in g th e lo catio n of th e b ell y o f the E DB i s
i m por tan t for d isti ng u ish in g it fr om ab n or ma l e dem a. C on tu sion and tear in g of th e m u scle's fi ber s a nd a ssociat ed bl ood vessel s
r esu lt in a h em atom a, p ro du cin g ed em a a nter om ed ial to th e l ater al m alle olu s. Most peo pl e w ho h ave no t see n thi s i nf lam ed m u scle

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a ssum e th ey h ave a severe ly sp r ain ed an kle.

P. 6 6 7
P. 6 6 8
N e u ro v a s cu la r S tr u ct u re s a n d R e la t ion s h ip s in th e F o ot
N er v es o f t h e F oo t
T h e cu tan eou s i nn er vati on of th e foo t i s su pp li ed (Tab le 5 .1 5 ):
Med ial ly by the sap h eno us n erve, wh ich ext end s d ista lly to the h ead of 1 st me tatar sal.
S u per ior ly (do rsu m o f foo t) b y th e sup er fici al (pr im ar ily ) an d de ep fi bu lar n er ves.
I n fer ior ly (sol e of f oot ) b y th e med ia l a nd l ater al pla nta r ne rves; th e co mm on bor d er of th eir d istr ib ut ion e xten ds alon g th e
4 th m eta carp al an d di gi t. (Th is is sim ila r to t he pa tter n of in n erva tion of th e p alm ; see C h apt er 6. )
L ater all y b y t he su ral n er ve, in clu di ng p ar t o f the h eel.
P oster ior ly (h eel) by calcan eal b ra nch es of th e ti bi al and su r al ne rves.
S a p h en o u s N er ve
T h e sap h eno us n erve is th e la rg est (lon ge st an d m ost wi del y d istr ibu ted ) cu tan eo us br an ch of th e fem or al n erve ; it is th e on ly
b r anch to e xten d beyo nd th e kn ee (Fig . 5 .4 8 B; Ta ble 5 .1 ). I n ad di tion t o su p ply in g the skin and f ascia on the an ter om edi al asp ect
o f the leg , th e saph enou s n er ve p asses an ter ior to th e m ed ial m al leol us to th e d or sum of th e f oot, w h ere it su pp lies ar ticu lar
b r anch es to the an kle jo in t an d con ti nu es to su p ply skin alon g th e med ia l si de of th e f oo t as far ant eri orl y a s th e h ead o f th e 1 st
m eta tar sal (Tab le 5. 1 5) .
S u p erfi ci al an d D eep F i b u lar N er v es

A fte r cou rsi ng b etw een an d su pp lyin g th e f ib ul ar m u scles in th e l ater al com pa rtm en t o f th e le g, th e sup er fici al fi bu lar n er ve
e mer g es as a cuta neo us n erve ab ou t tw o thi rd s o f the w ay d ow n th e le g. I t th en su p pl ies t he skin o n th e a nter ol ater al aspe ct o f
th e leg an d d ivid es in to t he med ial an d inter med ia te d or sal cutaneo us ner ves, wh ich con tin ue acr oss the an kle to sup p ly m o st
o f the skin on th e d or su m of th e foo t. Its ter m in al br an ches ar e th e do rsal d ig ital n erv es (com m on a nd p r ope r) tha t su pp ly th e ski n
o f the p rox im al aspe ct of th e m edi al hal f of th e g r eat t oe a nd th at of th e later al th ree an d a ha lf di gi ts.
A fte r sup pl yin g th e m u scles of th e a nter io r com pa rtm en t o f th e le g, th e deep f ib ul ar n erv e p asses deep to th e exten sor r etin acu lu m
a nd su p pli es th e in tri nsi c m u scles on th e dor su m of th e foo t (ex tenso rs di gi tor um and h al lu cis l on gu s) and t he tar sal an d
ta rso me tatar sal joi nt s. Whe n it fin al ly e me rg es as a cuta neo us n erve , it is so f ar di stal in t he fo ot t hat on ly a sma ll are a o f skin
r em ain s avail abl e f or i nn er vatio n: th e w eb of ski n betw een a nd co nti gu ou s si des of th e 1st an d 2 nd to es. It in n erv ates t hi s ar ea as
th e 1st co mmon d o rsa l (a nd th en p r op er d or sal ) d ig ital ner ve(s) .
M e di al Pl an t ar N er v e
T h e med ia l p lanta r ne rve, the lar g er an d mo re an ter ior o f the tw o t erm in al b ran ch es o f the ti bia l n er ve, ar ises de ep to the fl exor
r eti nacu lu m a nd en ter s t he sole of th e fo ot b y p assi ng d eep to th e a bd ucto r h allu cis (Fig s. 5. 4 4 C an d 5. 4 6B ). I t th en r u ns
a nte rio rl y b etwe en th is m u scle an d th e f lexo r dig ito ru m b re vis, su pp lyi ng b oth w ith m o tor b ran ch es o n th e l ater al side of th e
m ed ial p lan tar ar ter y (Fi g. 5 . 44A an d C ). Af ter sen di ng m o tor b ran ch es to th e fle xor h all uci s b revi s an d 1 st l um b ri cal mu scl e, th e
m ed ial p lan tar n er ve te rm in ates n ear th e b ases of th e m et atar sals by di vid in g in to t hr ee senso ry br an ch es (co mm on pla nta r di git al
n er ves). T hese b ran ch es su p ply th e sk in of th e me dia l t hr ee and a h alf d ig its (in clu di ng th e dor sal skin an d nai l bed s o f thei r di stal
p h alan g es), an d th e ski n of th e so le pr oxim al to th em . C om par ed to th e oth er ter mi na l b r anch of th e ti bi al ner ve, th e m edi al
p lan tar ner ve sup pl ies mo re skin area b ut fe wer m u scles. I ts d istr ib u tion t o b oth sk in an d m uscl es o f the fo ot is co m par ab le to t hat
o f the m edi an n er ve i n th e h an d (Ch ap ter 6 ).
L at er al Pl an t ar N er v e
T h e la ter al p la nt ar nerve , the sm all er an d m or e p oster ior of th e tw o term in al b ran ch es of th e ti bia l n er ve, al so cou rses dee p to
th e ab du ctor h all uci s (Fig . 5 .4 6B) bu t ru n s an ter ol ater ally b etwee n the 1 st a nd 2 n d layer s of pl an tar m uscl es, on the m edi al sid e of
th e late ral p lan tar ar ter y (Fi g. 5 . 44C ). Th e later al p lan tar n er ve te rm in ates as it r each es the la tera l co m par tm en t, di vid in g in to
su p erf icia l a nd d eep b ra nch es (Tab le 5. 1 5 ). Th e su p erf icia l b r an ch di vid es, in tu r n, i nt o tw o pl ant ar di gi tal ne rves (on e co m mo n
a nd o ne pr op er ) th at sup pl y th e skin o f the pl an tar asp ects of th e l ater al on e an d a ha lf di gi ts, th e d or sal skin a nd n ail b eds of
th ei r di stal ph ala ng es, an d skin of th e so le pr oxim al to th em . Th e deep b r anch es of th e l ater al pl an tar n erve cou r se w ith th e
p lan tar arte ria l a rch b etw een th e 3r d an d th e 4 th m u scle layer s. T he su per fi cial an d de ep br an che s su pp ly all m uscl es o f the sol e
n ot su pp lie d by the m edi al pl an tar
P. 6 6 9
n er ve. C om pa red to th e latte r, th e later al p lan tar n er ve su p pli es l ess ski n ar ea b u t m or e in divi du al m u scles. I ts d istr ib uti on to b oth
ski n an d m uscl es o f the fo ot is co m par ab le to t hat of th e ul na r ner ve in th e han d (C h apte r 6). Th e m ed ial an d lat eral p lan tar
n er ves a lso pr ovi de in ne rvat ion to th e pl ant ar asp ects o f all th e j oin ts of th e f oot.
S u ra l N er v e
T h e su ra l n er ve i s f or me d by un io n of th e med ial su r al cuta neo us n erve (fr om the tib ia l n er ve) a nd su r al com m un icat in g br an ch of
th e com m on f ibu la r ne rve, resp ective ly (Fi g. 5 . 48 B ; Ta bl e 5 . 11 ). T he leve l o f ju ncti on o f t hese b ran ch es i s var ia ble ; it m ay be hi gh
(i n th e p op lite al fossa ) or l ow (p roxi m al to h eel ), an d som etim es th e b ra nch es do n ot join an d, th er efo re, no su ral n er ve i s f or med .
I n th ese peo ple , the ski n no rm al ly i nn er vated b y t he su ral n er ve i s su pp li ed by th e m ed ial an d late ral su ra l c uta neo us br an ch es.
T h e su ra l n er ve accom pa ni es th e sma ll saph en ou s v ein an d en ter s th e foo t p oster io r to the lat era l m al leol us to sup p ly t he an kle

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j oin t an d skin al on g th e la ter al ma rg in of th e fo ot (T ab le 5. 1 5).

Su r a l N e r v e G r a f t s
Pieces of th e sur al n erve ar e o ften used f or n er ve g r afts in p ro cedu r es su ch as re pai ri ng n er ve d ef ects r esu ltin g f ro m wo un ds . Th e
sur ge on is u sual ly abl e to l ocate th is n er ve i n r elati on to th e sm al l sa ph en ou s vei n (Fig . 5. 4 8B). B ecau se o f the var iat ion s i n th e
level of f or ma tion of th e su r al ner ve, th e sur g eon m ay ha ve to m ake in cisio ns in b oth leg s, an d the n select th e b etter sp ecim en .
An e s th e t ic B l o ck o f t he S u p e r f i c i a l F i b u l a r Ne r ve
Af ter th e su pe rf icia l f ib ul ar n erve p ier ces th e deep fasci a to b ecom e a cu tan eou s n er ve, i t d ivid es in to m ed ial an d in ter m edi ate
cuta neo us n erve s. In th in peo ple , th ese b ra nch es can of ten b e se en or f elt as r id ge s u nd er th e skin w hen the fo ot is p lan tar f lexed .
In jecti on s o f a n an esth etic age nt ar ou nd th ese br an ch es i n th e an kle r egi on , an ter ior to th e p al pab le po rti on of th e fi bu la,
an esthe tizes th e ski n on th e dor su m of th e foo t (exce pt th e w eb bet ween a nd a dja cent su rf aces of th e 1 st an d 2n d toe s) m or e
br oad ly an d eff ectivel y th an m o re loca l i nj ectio ns on th e do rsu m of th e fo ot f or su pe rf icia l su r ger y.
P la n t a r R e f le x
Th e p la nt ar re fle x (L 4 , L5 , S 1, a nd S 2 n erve r oots) is a m yot atic (dee p tend on ) r ef lex tha t i s r ou tin ely tested d u rin g n eu ro log ic
exam in atio ns. Th e l ater al aspe ct of t he sole of th e foo t i s str oked w ith a b lu nt ob ject, such a s a ton gu e dep r essor , beg in n in g at
the h eel an d cro ssin g to the ba se o f the gr eat toe . Th e m ot ion i s f ir m an d con tin u ou s b ut n eith er p ain fu l no r tickl ish . Flexio n of th e
toes is a n or m al resp on se. S lig ht fa nn in g of th e later al f ou r toes an d dor sif lexi on of th e gr eat toe is an ab no rm al r espo nse
(Bab in ski sign ), i nd icat in g br ain i nj ur y or cer ebr al d isease, e xcept in i nf an ts. B ecau se th e cort icosp in al tra cts a re no t f ul ly
devel op ed in n ew born s, a Bab in ski sig n is u su all y el icite d an d ma y b e p res ent u nti l chi ldr en ar e 4 year s o f age .
M e d ia l P l a nt a r N e r v e E n tr a p m e n t
Co mp r essive ir ri tatio n of th e m ed ial p lan tar n er ve a s it p asses d eep to th e f lexo r re tin acu lu m or cu r ves d eep to th e a bd ucto r
ha llu cis ma y cau se ach in g, b u rn in g, nu m bn ess, an d ti ng lin g (p are sthe sia) on th e m ed ial si de of th e so le and i n th e r eg ion o f the
na vicu lar tu b ero sity. Med ial p lan tar n er ve co mp re ssion m ay occu r d ur in g r epeti tive ever sion of th e f oot (e. g. , d ur in g gym n asti cs
an d ru n ni ng ). Be cause of i ts f req u ency in r u nn er s, th ese symp tom s ha ve b een cal led jo gg er 's f oot.
Mo st o f the d orsu m o f the f oot rece ives cuta neo us in n erva tion fr om th e sup er fici al fib u lar n er ve, th e e xcepti on b ein g th e ski n of
the we b betw een a nd th e adj acen t si des of th e 1 st an d 2n d to es. Th e latter recei ves i nn er vati on fr om the d eep fi bu lar n er ve afte r
it sup pl ies the m uscl es o n th e d or sum of th e f oot . Th e ski n of th e me dia l a nd l ater al sid es of th e fo ot i s i nn er vated b y th e
saph en ou s a nd su r al ner ves, r esp ectivel y. Th e pl ant ar asp ect o f the fo ot recei ves i nn er vati on f rom th e la rger m edi al an d sma ller
later al p lan tar n er ves, th e f or me r sup pl yin g m or e ski n (th e p lan tar asp ect of th e m ed ial th r ee a nd h alf to es a nd a dja cent sol e) b u t
few er m uscl es (th e m edi al hal lu x a nd 1 st lu mb ri cal m uscl es o nl y) th an th e latte r, w hi ch su pp lies th e r em ain in g m u scles and sk in of
the p lan tar asp ect. T he d istr ibu ti on of th e me dia l a nd l ater al pl an tar n erve s is com pa rab le to th at o f the m edi an an d u ln ar n erv es
in th e pal m.
A r te ri es of t h e F o ot
T h e ar ter ies of the f oo t ar e term in al b ra nch es of th e an ter io r and poste ri or tib ial ar ter ies (Figs. 5. 4 6B a nd 5 . 47 ), r esp ectivel y: th e
d or sal an d pl an tar ar ter ies.
D o rs a l Ar t er y of t h e F o ot
T h e d or sal ar ter y o f the fo ot (L. arte ria d or salis pe dis) o fte n a m aj or sou r ce o f blo od su pp ly to the fo ref oo t (e. g. , d ur in g
e xten ded p er iod s o f st and in g ) is t he di rect con tin u atio n of th e ant eri or tib ial ar ter y (Fi g. 5 . 47A ). Th e d or sal ar ter y b egi ns
m i dw ay b etw een th e m al leo li an d ru n s an ter om edi all y, de ep to the in fe ri or exten sor r eti nacu lu m b etw een th e exten sor h all uci s
l on gu s and t he exten sor d ig itor u m lo ng u s ten d on s on t he do rsu m o f the fo ot. T he d orsa l a rter y passe s to th e f ir st i nte rosse ou s
s pace, wh ere
P. 6 7 0
i t d ivi des in to the 1 st d or sal m etatar sal ar ter y an d a de ep p lantar ar ter y. Th e latte r passe s d eepl y b etwe en th e h ead s o f the fi rst
d or sal in ter osseo us m uscl e to en ter th e sole of th e f oo t, wh er e i t j oin s th e late ral p lan tar ar ter y t o f or m th e d eep p la nt ar ar ch
( Fi g. 5 . 47B ). Th e cou rse an d desti na tion of th e d or sal art ery an d its ma jor co nt in uat ion , th e d eep p lan tar a rter y, ar e com par ab le
t o th e ra dia l a rter y of th e h an d, wh ich co mp lete s a deep arte ria l a rch i n th e p alm (Ch ap ter 6 ).

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Fig ure 5.47. Arte ri es o f f o ot: over view . A. Ob serve th e a nte rio r tib ial ar ter y b ecom in g th e dor sal ar ter y of t he fo ot (L .
ar teri a d or sali s p edi s) an d th e a rcu ate ar ter y. B. Ob ser ve t he po ster ior ti bia l a rte ry an d its t erm in al b ran ch es, th e med ia l a nd
late ral p lan tar ar ter ies. T h e d eep p lan tar ar ch is fo rm ed b y th e late ral p lan tar ar ter y. N ote the an astom o ses b etwe en th e
do rsal an d th e pla nta r art eri es th r ou gh th e dee p pla nta r art ery an d per f ora tin g br an che s of th e dee p pla nta r ar ch.
T h e l ater al tars al a rter y, a br an ch of th e do rsal ar ter y o f the fo ot, r u ns late ral ly in an a rch ed cou r se b en eath th e exten sor
d ig ito ru m b rev is to su pp ly th is m u scle an d th e u n der lyi ng ta rsal s an d jo in ts (Fi g. 5 . 47A). It an astom oses wi th oth er b ra nch es, su ch
a s th e arcu ate ar ter y.
T h e 1st do rsa l me tatar sal ar tery di vid es i nto b ra nch es tha t su pp ly bo th sid es o f the g reat toe an d th e m ed ial sid e of th e 2 n d
t oe.
T h e ar cuate ar tery r un s l ater all y acr oss th e b ases of th e la ter al fou r m etata rsal s, de ep to the exten sor tend on s, to r each th e
l ater al asp ect o f the fo ref oo t w her e it ma y an asto mo se w ith th e late ral tar sal ar ter y to f or m an ar ter ial lo op . Th e a rcu ate ar tery
g ive s r ise to t he 2nd, 3r d, and 4th do rs al me tatar sal ar teri es. T hese vessel s r un di stally to th e cl efts of th e t oes a nd a re
c on necte d to t he pl an tar ar ch an d to th e p lan tar m eta tarsa l a rte rie s b y p erf or atin g b ran ch es (Fi gs. 5 . 45A & B, 5 . 46A , an d 5. 4 7B ).
Di stall y, each d or sal me tatar sal ar tery d ivid es i nt o tw o do r sal di gi tal a rter ie s f or th e d or sal asp ect o f the sid es of ad joi ni ng to es
( Fi g. 5 . 47A ); h ow ever, the se ar ter ies gen er all y en d p ro xim al to the d istal in ter ph al ang eal jo in t (Fi g. 5 . 46A) an d ar e r ep laced b y o r
r ecei ve r ep len ish m ent fr om dor sal b ran ch es o f the p lan tar d ig ital ar ter ies.
P a lp a t io n o f t he D o r s a l i s P e d i s P u l se
Th e p u lse of th e d or sal art ery of th e f oo t (r efer r ed to clin ica lly as t he d or sali s p ed is p ulse ) is eval uat ed du r in g a p hy sical
exam in atio n of th e per ip he ral vascu la r system . Dor salis pe dis p ul ses m ay be pa lpa ted wi th th e f eet slig h tly dor sif lexed . T he pu lse s
are u sua lly easy to pal pate b ecau se th e do rsal ar ter ies of th e f oot ar e su b cuta ne ou s an d pa ss al on g a l in e f ro m th e ex tenso r
reti na cul um to a p oin t ju st l ater al to the E HL ten d on s (S war tz, 2 0 02 ) (Fi g. B 5 .2 0 ). A di mi ni she d or ab sen t d or salis pe dis pu lse
usu al ly su g gests vascu lar in suf fici en cy r esu ltin g f rom ar teri al di sease. T he fi ve P sig ns o f acute a rter ia l o cclusio n ar e pai n,
pal lor , p are sthesi a, p ara lysis, and p u lsele ssness. Som e he alth y a du lts (an d even ch il dr en) h ave con gen ita lly no n-p alp ab le dor sal is
ped is pu lses; th e var ia tion is u su all y b ilat era l. In the se case s, the d or sal arte ry of th e f oot is re pla ced by an en la rg ed pe rf or atin g
fib u lar ar ter y.
Fig ure B5. 20
P. 6 7 1

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A r te ri es of t h e S o le of t h e F o ot
T h e so le o f th e f oot ha s a pr ol ifi c b loo d sup pl y th at is der ive d fr om th e post eri or tib ial ar ter y, w hi ch di vid es d eep to th e f lexo r
r eti na cul um (Fi gs. 5 . 44A , 5 .4 6B, an d 5 . 47B). Th e te rm in al b ran ch es p ass deep t o th e abd u ctor h all uci s as th e m ed ial an d lat era l
p la nta r art eri es, wh ich accom pa ny th e si mi lar ly na med n er ves.
M ed ial P lan t ar A rt er y
T h e med ia l p la nta r ar tery is the sm all er ter m in al br an ch of th e p oster io r tib ial ar ter y. It g ives rise to a deep b r an ch (or
b r an ches) th at su p pl ies m ai nl y m u scles of th e g r eat t oe. T he lar g er sup er fi cial br an ch of th e m edi al pla nta r art ery su pp lies th e ski n
o n th e m ed ial sid e of th e so le and h as di gi tal br an ches th at accom pa ny di gi tal br an che s of th e me dia l p la nta r ner ve, th e m ore
l ater al of w hi ch an astom ose wi th m ed ial pl an tar m etata rsal ar ter ies. Occa sion all y, a super f icia l p lanta r arch is for m ed wh en t he
s up erf ici al br an ch an astom ose s w ith th e later al pl an tar ar ter y or the (d eep) pl an tar ar ch.
L at er al Pl an t ar A rt er y
T h e l ater al pl antar ar ter y, mu ch l arg er th an th e m edi al pla nta r art ery, ari ses w ith a nd acco m pan ies th e n er ve o f the sam e na me
( Fi gs. 5 . 44C , 5 .4 5B, 5 . 4 6B , an d 5 .4 7B). I t r u ns late ral ly an d ant eri orl y, at fi rst dee p to t he ad du ctor h al lu cis a nd th en b etw een th e
f lexo r di gi tor um br evis an d qu ad ratu s pl ant ae (Fig s. 5 . 44C an d 5 .4 5B). Th e l ater al pl ant ar ar tery ar che s m ed iall y acr oss th e f oot
w ith the d eep br an ch of th e later al p lan tar n er ve to f or m th e d eep p lanta r arch, w h ich is com p leted b y u n ion with the d eep
p la nta r art ery, a b ran ch o f the d orsa l a rter y of th e f oot (Fig s. 5 .4 4C, 5 . 4 5, a nd 5 . 47B ). As it cro sses th e foo t, th e d eep p lan tar
a rch g ive s r ise to f ou r p lantar me tatar sal ar teri es; thr ee p erf or ati ng b r anches (Fi gs. 5 . 4 5, 5 . 4 6A , an d 5. 4 7B); and m an y
b r an ches to th e ski n, f ascia , an d mu scle s in the sol e. Th e pla nta r m etatar sal ar ter ies d ivi de n ear th e b ase of th e p ro xim al
p h alan g es to f or m th e p lanta r di gi tal arte ri es , su pp lyin g th e adj acen t d ig its; the m or e m ed ial m etata rsal ar ter ies ar e j oin ed b y
s up erf ici al dig ita l b r anch es of th e m ed ial p lan tar a rter y. T he pl an tar d igi tal ar ter ies t ypic ally pr ovi de m ost of th e b loo d rea chi ng
t he di stal toes, in clu din g th e nai l bed , via p erf or atin g an d do rsa l b ra nch es (Fig. 5 . 4 6A ) an ar r ang em en t th at also o ccur s i n th e
f in g ers.
He m o r r h a g i ng W o u n d s o f t he S o l e o f th e Fo o t
Pu nctu r e w ou nd s o f the sol e o f the fo ot in volvi ng t he de ep pl ant ar ar ch an d its br an ches u sua lly resu lt in sever e b leed in g, t ypic ally
fr om b oth en d s o f t he cu t ar ter y b ecau se of th e ab u nd an t a nast om oses. L ig atu re of th e a rch i s d if ficu lt b ec au se of i ts d ep th an d
the str uct ur es t hat su rr ou n d it.
P. 6 7 2
Th e d or sal an d pl ant ar ar teri es o f the f oot ar e ter m in al br an ch es of th e an ter ior an d p oster ior tibi al ar teri es, r espect ively. Th e
dor sal ar ter y o f the fo ot sup pl ies all of th e dor su m of th e foo t an d , via th e a rcu ate ar tery, the p rox im al dor sal asp ect of th e to es.
It also con tr ib ute s to fo rm ati on of t he pl an tar (ar ter ial) ar ch via its ter m in al deep p lan tar a rte ry. T he sm all er m edi al an d lar ger
later al p lan tar ar ter ies sup pl y th e pl ant ar asp ect o f the fo ot, th e latte r ru n ni ng i n vascu lar p la nes bet ween t he 1 st an d 2 n d and
the n, a s th e p la nta r arch , th e 3r d an d 4 th laye rs of th e i ntr in sic m uscl es. An asto m oses b etw een th e dor sal an d th e p lan tar a rte rie s
are ab un d an t an d im p or tan t f or th e h eal th of th e fo ot. E xcept f or th e sca rcit y of a su per f icial ar ch , th e ar ter ial p atter n of th e foo t
is si m ilar t o th at of th e han d .
V en o u s Dr ai n ag e o f th e F oo t
A s i n th e r est of th e l owe r lim b , the re ar e b oth su p erf icia l a nd d eep vei ns in th e fo ot. T he dee p vein s ta ke th e for m o f
i n tera nast om osin g p air ed vein s accom pa nyi ng a ll art eri es i nter n al to the d eep fa scia (Fi g. 5 . 4 8A ). Th e sup er fici al vein s a re
s ub cut ane ou s an d u na ccom pan ie d by art eri es (Fig . 5 .4 8B). Unl ike the le g and t hi gh , h owe ver, t he ven ou s d ra in age in t he fo ot is
p r im ar ily to the m ajo r sup er fi cial vein s, b oth f ro m th e d eep acco mp an yin g vei ns an d oth er sm all er sup er fi cial vein s. Pe rf or atin g
v ein s b egi n th e o ne-w ay shu n tin g of b loo d fr om su pe rf icia l to d eep vei ns, a p atter n essen tia l to o per atio n of th e mu scu love no us
p u m p (see V eno us Drai na ge of th e L ow er L im b, i n th is chap ter ), p roxi m al to t he an kle joi nt . Most b lo od is dr ain ed f ro m th e
f oo t th r ou gh th e sup er fici al vein s.
Do rsal d ig ital vei ns con tin ue p ro xim all y as do r sal metatar sal veins, wh ich al so r ecei ve b r anch es fr om p la nt ar di gi tal veins.
T h ese ve in s d rai n to th e d or sal venous ar ch of th e foo t, p rox im al to wh ich a d or sal venous ne two r k co vers th e r em ain d er of
t he do rsu m o f the fo ot. B oth th e ar ch an d the n etwo rk ar e l ocated i n th e su b cuta neo us tissu e. For t he m ain p ar t, su per fi cial vein s
f r om a pl antar veno us netw or k eith er d ra in ar ou n d the m edi al bo rd er of th e foo t to con ver g e w ith th e med ia l p ar t o f the do rsa l
v eno us ar ch an d ne twor k to f or m a med ial mar g inal vein, w hi ch beco m es th e gr eat saph en ou s ve in , or d rai n ar ou nd th e late ral
m ar g in to con ver ge wi th th e l ater al pa rt of th e d or sal ven ou s ar ch an d n etwo rk to fo rm t he late ral mar g inal vein, w hi ch be com es
t he sm all sap he no us vein (Fi g. 5 . 48B ). Per for ati ng ve in s f rom th e g rea t an d sm all sap h eno us vein s the n con tin u ou sly sh u n t b loo d
d eep ly as th ey ascen d to take ad van tage of th e mu scu lov eno us pu m p.
L y m p h a ti c Dr ai n ag e o f t h e F oo t
T h e l ymp h atics of th e f oo t b egi n in su b cuta neo us pl exu ses. Th e coll ectin g vessel s con sist of su pe rf icial an d d eep lym p ha tic vessels
t hat f ollo w th e su pe rf icial vei ns an d m ajo r vascu lar b un d les, r espectivel y. Su pe rf icia l l ym ph atic vessel s ar e m o st n um er ou s i n th e
s ole. T h e m ed ial su per fi cial lym p ha tic v essels, l arg er an d m or e n u m ero us th an th e l ater al on es, dr ai n th e m ed ial sid e o f the
d or su m an d sole of th e foo t (Fi g. 5 . 4). T h ese ve ssels co nv erg e o n th e g re at sa ph en ou s vei n an d accom p any it to th e ver tica l g r ou p
o f sup er fi cial in gu in al lym p h n ode s, loca ted alo ng th e vein 's ter mi na tion , an d th en to th e d eep in g ui na l l ym ph n od es a lon g th e
p r oxim al f em ora l ve in . Th e l ater al su per fi cial lym p ha tic ve ssels dr ain th e late ral sid e of th e d or sum an d sole of th e f oo t. Most of
t hese vessel s p ass p oste rio r to th e la tera l m al leo lu s an d accom p an y th e sma ll sap hen ou s vein to th e p op li teal fo ssa, wh er e th ey
e nte r the p opl iteal l ymp h n od es (Fig . 5 .1 2 ). T he de ep lym ph ati c vesse ls f ro m th e f oot fo llo w the m ain blo od vessel s: f ib ul ar,
a nte ri or an d po ster ior ti bi al; then pop li teal an d fem or al . Th e d eep vess els f r om th e f oo t al so d r ain i nto th e pop li teal lym p h no des.
L ym ph ati c vesse ls f ro m th em f oll ow th e f em or al vessels, ca rr yin g lym p h to the d eep in gu in al ly mp h n od es. Fro m th e d eep in g ui na l
n od es, a ll lym ph fr om th e low er lim b p asses deep t o th e in gu in al li gam en t to t he il iac no des.
L y m p ha d e n o p a t h y

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I n fecti on s o f t he fo ot ma y sp rea d pr oxim al ly, cau sin g en la rg em ent of p op lite al a nd i ng u in al lym ph no des (lym ph ad en op ath y).
I n fecti on s o n the la tera l si de of th e foo t i ni tial ly p r odu ce enl ar gem en t o f po pli teal lym p h n ode s (p op li teal lymp hade nop athy);
l ater , th e i ng u in al lym ph no des ma y en la rg e. Ing uinal lymp had enop athy with ou t po pli teal lym p ha den op ath y ca n resu lt f rom
i n fecti on of m ed ial sid e of th e f oot, l eg, or th ig h; h oweve r, en la rg em en t of t hese n ode s can a lso re sul t f ro m an in f ection or tu m or
i n th e vu lv a, pe ni s, scro tum , p er in eum , a nd g lu teal r egi on an d f rom ter mi na l p ar ts o f t he u reth r a, an al can al, a nd va gi na.
V en ou s d ra in age of th e foo t p ri m ari ly fol low s a su per fi cial r ou te, dr ai ni ng to th e dor su m of th e foo t an d th en m ed ial ly v ia the
g r eater o r later al ly vi a t he lesser saph en ou s ve in s. Fr om the se vei ns, blo od is sh un ted b y p er for ati ng vei ns to th e d eep vei ns of
t he leg a nd th ig h th at par tici pa te i n th e m u scul oven ou s p u mp . Th e lym ph ati cs car r yin g lym p h fr om th e foo t d r ain to war d an d th en
a lon g th e su p erf ici al vein s d ra in in g the fo ot. L ym ph f r om th e m ed ial f oot fo llo ws the g reat er sap hen ou s vein an d d rai ns d ire ctly to
s up erf ici al in gu in al lym p h no des. Lym ph fr om th e later al f oot fol low s th e lesser sa ph en ou s vei n an d dr ain s in itia lly to the p opl itea l
l ym ph n od es and t hen by deep l ym ph atic ch an nel s to th e d eep i ng u in al no des.
J o in ts of th e Lo w e r L im b
T h e jo in ts o f the lo wer l im b in clu de th e a rti cul atio ns of th e p elvi c g ir dl e lu m bosa cral j oin ts, sacr oi liac jo in ts, an d pu bi c
sym p hy sis, wh i ch are d iscu ssed in C h apt er 3. Th e r em ain in g jo in ts o f the lo wer l im b ar e th e hi p joi nt, knee jo in t, tib io fib u lar jo in ts,
a nkl e j oin t, an d f oot joi nt s (Fig . 5 .5 0 ).
P. 6 7 3
Fig ur e 5. 48. Ve ins o f leg and f oo t. A. Th e d eep vei ns accom p an y th e arte ri es an d th eir b r anch es (L. ve na e com i tan tes);
the y an asto mo se f re qu en tly and h ave n um er ou s va lves. B . T he m ain su p erf icia l ve in s ar e t he gr eat an d sm all sap he no us vein s,
wh ich d ra in in to th e d eep vei ns as the y ascen d th e lim b b y m ean s o f per fo rat in g vein s so th at mu scu lar co m pr ession can
pr op el blo od tow ar d th e h ear t a gai nst th e p u ll of gr avi ty. No te th at th e d ista l g re at sa ph en ou s vei n is accom pa ni ed by th e
saph en ou s n er ve, an d th e sm al l saph en ou s ve in is accom p an ied b y th e sur al ne rve an d its m edia l r oo t (m ed ial su ra l cu tan eo us
ner ve).
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Fig ure 5.49. L ymphati c d r ainag e o f fo ot. A. S up er fici al lym ph ati c vesse ls f ro m th e m ed ial f oot dr ain are jo in ed by th ose
fr om th e an ter om edi al leg in dr ain in g to th e su pe rf icia l i ng u in al lym ph n od es via lym ph ati cs th at accom p an y th e g r eater
saph en ou s v ein . B. Su per fi cial lym p ha tic vessels fr om t he late ral f oot joi n th ose fr om th e po stero later al le g, co nver g in g to
vessels accom p an yin g th e le sser sap hen ou s vein an d d ra in in g in to t he po pl iteal ly mp h n od es. Th e pop li teal lym p h no des dr ai n
via lym p hat ics a ccom pan yin g th e fem or al vein to t he de ep in gu in al lym p h n odes.
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Fig ure 5.50. Jo ints of lo w er lim b. T he jo in ts ar e tho se o f the p elvic gi rd le conn ectin g th e f ree lo wer l im b to the ver teb ral
colu m n , the kn ee, th e tib iof ib ul ar ar ticu lati on s, an d th e m an y j oin ts of th e f oot .
H ip J o in t
T h e hip j oi nt fo rm s the con n ectio n betw een th e low er li m b and t he pe lvic gi rd le. I t i s a str on g and s tabl e m u lti axial b all an d
s ocket type of syn ovi al joi nt. Th e f em or al hea d is t he ba ll, a nd th e acetab u lu m is the socke t (Fig . 5 .5 1 ). Th e hi p joi nt is desi gn ed
f or sta bi lity over a w ide r an ge of m ovem en t. Ne xt to th e gle no hu m era l (sh ou ld er ) j oin t, it is th e m ost m ovab le of al l j oin ts. Du ri ng
s tan din g , th e en tir e wei gh t o f the u pp er bo dy is tra nsm it ted th rou g h th e h ip b on es t o th e he ads an d ne cks of th e fem u rs.
A r ti cu l ar S u r fac es o f t h e Hi p J oi n t
T h e r ou n d hea d of th e f em ur a rti cul ates with the cu p-l ike acetab ul um of th e h ip b on e (Fi gs. 5 . 5 0, 5 . 5 1 an d 5. 5 2). Th e h ead o f the
f emu r for m s a pp rox im ately tw o th ir d s of a sp her e. E xcep t f or th e pit or f ovea fo r th e l iga me nt of th e f em or al he ad , a ll of th e h ead
i s co vere d with art icu lar car til age , wh ich i s th icke st ove r wei gh t-b eari ng a rea s. Th e a cetab ul um, a h em isph er ical h ol low on the
l ater al asp ect o f the h ip b on e, is for m ed by th e f u sion o f thr ee bo ny pa rts (Fig. 5. 5 ). Th e hea vy, pr om in en t rim of th e a cetab ul um
c on sists o f a se mi lu na r art icu lar p art cove red w ith a rti cul ar car tila ge, t he lunate surf ace of the a cetab ulum. Th e acetab u lar r im
a nd l un ate su rf ace for m ap p rox im ately th ree q ua rter s o f a ci rcl e; th e mi ssin g in fer io r segm en t of th e ci rcle is th e a cetab ular
no tch.
T h e f ib roca rti lag in ou s ac etab ul ar la br um (L. la br um, l ip) atta ches to th e ace tabu la r ri m, in creasi ng t he aceta bu lar a rti cul ar ar ea
b y nea rl y 1 0 %. Th e tra nsverse aceta bul ar lig ame nt, a co nti nu ati on of t he acetab u lar l abr u m, br id ges th e acet abu la r no tch. As a
r esu lt of th e h ei gh t o f the r im an d la br u m, m o re th an h alf of th e fem or al h ead f its w ith in the aceta bu lu m (Fig . 5 .5 2C). In o ther
w or ds, the aceta bu lar l ab ru m en ab les the aceta bu lu m to gr asp th e fem or al h ead b eyon d its equ ato r; th us du r in g di ssection ,
t he fe mo ral h ead m u st b e cu t fr om th e acetab u lar r im t o en ab le di sart icu lati on of th e joi nt. Cen tr all y a de ep no n-a rti cul ar pa rt,
c alled t he aceta bula r fo ssa, i s f orm ed m ai nl y b y th e isch iu m (Fig s. 5 .5 1 an d 5 .5 2C ). Th is fossa is th in w all ed (oft en tr ansl u cent)
a nd co nt in uo us in fer io rly wi th th e a cetab ul ar n otch .
B i p e d a l is m a n d C o ng r u i ty o f th e Ar ti c ul a r S u r f a c e s o f t h e H i p J o in t
Th e a cetab ul um is d ir ected in f eri or ly, la tera lly, and a nte ri orl y i n hu m an s. Th e wei gh t-b eari ng i lia c p or tion o f th e acet abu la r ri m
over lies th e f em or al hea d, w h ich is im po rta nt fo r tr ansf er of w eig h t to th e f em ur in th e e rect (stan di ng /wa lkin g ) p ositi on (Fig s.
5. 5 0A a nd 5 . 52C ). C on sequ en tly, o f the p ositi on s com m on ly assu m ed by h um an s, th e h ip join t is mech an ica lly m ost st abl e w he n a

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p er son i s b ear in g weig h t, as wh en li fti ng a h eavy ob ject, f or exa mp le. Decr eases in th e deg r ee to w hi ch th e i liu m ov erl ies the
f em or al he ad (de tectab le rad io gr aph ica lly as t he an gl e o f W ibe rg ) m ay in di cate j oin t in stab ili ty. Beca use of th e an teri or d ir ection
t he axis of th e acetab u lu m an d the p oster ior d ir ecti on of th e axis of th e f em or al hea d an d neck as it exten ds later al ly (o wi ng to th e
t or sion a ng le d iscu ssed ear li er in th is ch apte r), th er e i s an ang le of 3 0 40 b etw een th eir a xes (Fig . B 5. 2 1). Co nseq u ent ly,
t he ar ticu lar su r face s of th e he ad an d acetab u lu m ar e n ot fu ll y con g ru en t i n th e er ect (bi ped al) po stur e. T he an ter ior p ar t o f the
f em or al he ad is e xpo sed an d ar ticu lates m ostly wi th th e j oin t capsu le (Fig s. 5 .5 2B, 5 . 5 3A , an d 5. 5 6 ). Non eth el ess, ra rel y i s
< 4 0% o f t he avai lab le art icu lar su r face of th e f em or al he ad in co nta ct w ith th e sur fa ce o f t he aceta bu lu m in any p ositi on . Rel ative
t o o the r joi nts an d in vi ew of th e l ar ge size of th e h ip j oin t, th is is exten sive con tact, co nt rib u tin g con sid era bl y to th e j oin t's gr eat
s tabi lity.
Fig ure 5.51. Hip jo int. Th e hi p joi nt w as d isar ticu la ted by cu ttin g th e l iga me nt of th e h ead o f th e f em ur a nd r etr actin g th e
he ad fr om t he acetab u lu m . Th e tr an sver se a cetab ul ar li gam en t i s r etr acted su pe rio rl y to sh ow th e o btu r ator ca na l, wh ich
tra nsm it s th e o btu r ator n er ve a nd ve ssels passi ng f ro m th e p elvi c cav ity to th e m edi al thi gh .
Fig ure B5. 21
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Fig ure 5.52. Facto rs incr easing sta bi lity of hip jo int. A. Pa ral lel fi ber s l in kin g two d iscs resem b le th ose m aki ng up th e
tu be-l ike fib ro us lay er of th e h ip j oin t capsu le . Whe n on e d isc (the f emu r ) r otat es r elat ive to t he oth er (th e acetab ul um ), th e
fi ber s b ecom e in crea sin gl y ob li qu e a nd d ra w the tw o d iscs tog eth er. S im il arl y, exten sio n of th e hi p joi nt wi nd s (i ncr eases th e
ob liq ui ty o f) the f ibe rs of th e f ib ro us layer , p ul lin g th e h ead a nd n eck of th e f em u r tig htl y i nto th e acetab ul um , i ncr easi ng th e
stab ili ty o f t he jo in t. Flexio n u nw in ds th e f ib ers of th e ca psu le. B . T hi s tr an sver se secti on th r ou gh th e hi p joi nt de mo nst rate s
th e m ed ial an d re cipr oca l p u ll of th e p er iar ticu lar m u scles (m edi al an d later al r otato rs; red di sh b row n ar ro ws) an d in tri nsi c
lig am en ts o f the h ip jo in t (b lack ar ro ws) o n th e f em ur . R elat ive stren g ths ar e i nd icat ed by ar row w id th : An ter io rl y, th e
m uscl es ar e less abu n dan t bu t t he li gam en ts a re ro bu st; post eri or ly, th e m u scles pr ed om in ate. C. In th is cor on al sectio n of h ip
joi nt , the acet abu lar lab ru m an d tr an sverse acet abu la r lig am en t, spa nn in g th e a cetab ul ar n otch (an d in clu d ed in th e pl ane of
sectio n he re), e xten d the aceta bu lar rim so t hat a com pl ete socket is f or m ed. T h us th e acet abu la r com pl ex en g ul fs the h ead of
th e f em ur . Th e epi ph ysis of th e f em or al he ad is ent ire ly w ith in the jo in t cap su le. T he th ick wei gh t-be ari ng b on e of th e i liu m
no rm al ly lies di rectl y su p eri or to th e h ead o f the fe mu r f or ef fici en t tr an sfer o f wei gh t t o th e fem u r (Fig . 5. 3 ). Th e an gle of
Wib erg (se e text ) is u sed rad io gr ap hi cally to det erm in e th e d egr ee to wh ich th e acetab u lu m over h ang s the h ead of th e fem u r.
P. 6 7 8
T h e ar ticu la r sur f aces o f the aceta bu lu m an d f emo ra l h ead a re m ost con gr uen t wh en th e hi p is f lexe d 90 , ab du cted 5 , an d
r ot ated lat era lly 10 (t he po sitio n in w h ich th e a xis of th e ace tabu lu m a nd th e axis of th e f em or al he ad an d neck ar e a lig ne d),
w h ich is th e q u adr u ped p osit ion ! I n ot her w or ds, in assu m in g th e u pr ig h t p ositi on , a rel ativel y sm al l d eg ree of j oin t st abi lity wa s
s acri fice d to m ax im ize wei gh t b ear in g wh en er ect. E ven so, th e h ip j oin t is o ur mo st sta ble jo in t, ow in g also to its com pl ete bal l
a nd so cket con stru ctio n (de pth o f the socke t); th e stren g th of it s cap sul e; a nd th e attach m en ts o f m u scles cr ossin g th e j oin t,
m an y of wh ich are lo cated at som e dist anc e f rom th e cen ter o f mo vem ent (Pal astan g a et al. , 2 0 02 ).
J o in t Cap s u le of t h e H i p J oi n t
T h e h ip j oin ts are en close d with in stro ng ye t lo ose joi nt cap sules, for m ed of an exter nal f ib rou s layer (f ib ro us cap sul e) an d an
i n tern al syn ovia l m em b ra ne (Fig . 5. 5 2C ). P rox im ally , the f ibr ou s l ayer at tach es to th e acetab ul um , j ust p eri ph er al to t he ri m to
w h ich th e lab ru m is atta ched , an d to th e tr an sver se a cetab ul ar lig am en t (Fi gs. 5 . 51 , 5 . 52C , an d 5. 5 3 ). Distall y, th e f ib ro us laye r
a ttach es t o th e fem or al n eck o nl y an ter io rl y at th e i nte rtr och an ter ic l in e an d r oot of th e gr eater t roch an ter (Fig . 5 . 55B).
P oster io rly , the f ibr ou s l ayer cr osses th e n eck pr oxim al to th e i nt ertr och an ter ic crest bu t is no t att ache d to i t (Fig . 5 . 55C ).

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Mo st f ib ers of th e f ib ro us laye r take a sp ir al cou rse fr om the h ip b on e to th e i nt ertr och an ter ic lin e, b ut som e deep fib er s p ass
c ircu la rl y ar ou n d the n eck, f orm i ng th e or bi cular zo ne. Th ic k p arts of th e fib r ou s la yer of th e capsu le fo rm the li gam ents o f the
hi p joi nt, wh ich p ass in a spi ra l f ash ion fr om th e pel vis t o th e fem u r. Exte nsi on wi n ds its sp ir ali ng l ig am ent s an d fi ber s mo re
t igh tl y, con str ictin g th e ca psu le an d dr awi ng the fe mo ral h ead ti gh tly in to th e ace tabu lu m (Fig . 5 . 52A). Th e ti gh ten ed f ibr ou s l ayer
i n crease s th e st abi lity of th e joi nt, bu t r estr icts exten sion of th e j oin t to 1 0 2 0 beyo nd th e ver tical p ositi on . Flexio n
i n creasi ng ly u nw in ds th e sp ir alin g l iga me nts an d fib er s. Th is pe rm its con sid era ble f lexio n of th e hi p joi nt wi th in cre asin g m obi lit y.
O f t he th ree in tr in sic lig am en ts of th e joi nt cap sul e b elo w it is th e fi rst on e th at r ein for ces an d stren g the ns th e j oin t:
A n teri or ly and su p eri or ly i s th e stro ng , Y-s hap ed il io femo ra l l ig ament (Big elo w lig am en t), wh ich a ttach es t o th e an teri or
i n fer ior i lia c sp in e an d th e acetab ul ar r im p ro xim all y an d th e in tertr och an ter ic lin e dist ally (Fig . 5. 5 3A & B ). Sai d to be th e
b od y's stro ng est lig am en t, th e i lio fem or al lig am en t sp ecif ical ly pr even ts h yp ere xten sion o f the h ip jo int d ur in g stan d in g by
s crew in g th e f em ora l h ead i nt o th e acetab u lu m via th e m ech an ism descr ib ed ab ove.
A n teri or ly and i nf er ior ly is the p ub o femo r al l ig ament, w hi ch ar ises fr om th e ob tur ato r crest of th e pu bi c b on e a nd p asses
l ater all y an d in f eri or ly t o m er ge wi th th e f ib ro us laye r of th e j oin t capsu le (Fig . 5 .5 3A). T hi s li ga men t bl end s w ith t he m edi al
p ar t o f the il iof em or al lig am en t an d ti gh ten s d ur in g b oth exte nsi on an d ab du ctio n of th e hi p joi nt. T h e p ub of em or al lig am en t
p r even ts o vera bd ucti on o f t he h ip jo in t.
P oster io rly is th e is chi of emo ral li ga ment, wh ich ari ses f ro m th e i schi al par t of th e a cetab ul ar ri m (Fig . 5 .5 3C). T h e w eakest
o f th e th r ee l iga me nts, it sp ir als su per ola ter ally to th e f em or al neck, med ia l to th e base of th e gr eater t roch an ter .
T h e r elat ive size, str en gth s, an d p ositi on s o f the th ree li gam en ts of th e h ip j oin t are sh own in Fig ur e 5. 5 2B. T he li gam en ts a nd
p er iar ticu la r mu scle s (th e m ed ial an d la ter al rot ator s o f t he th ig h) pl ay a vita l r ol e i n m ain tain in g th e stru ctu ra l i nte gr ity of th e
j oin t, a s d em on strat ed in th e abo ve f ig ur e. B oth m u scles an d lig am en ts p ul l the fe mo ral h ead m ed ial ly i nt o th e acetab u lu m, and
t hey ar e r ecip r ocall y b ala nced w h en do in g so. T he m edi al fle xor s, loca ted an ter ior ly, a re few er , weak er, a nd l ess m ech an ical ly
a dva nta ged , wh er eas the an ter ior l ig am ent s ar e st ron g est. C on ver sely, th e lig am en ts ar e weake r po steri or ly w h ere th e m ed ial
r ot ator s ar e abu n dan t, st ron g er, and m o re m echa ni cally ad van tag ed.
I n al l s yno vial jo in ts, syn ovia l m em b ran e lin es all in ter n al s ur face s of th e fi br ou s la yer as wel l a s an y in traca psu lar b on y sur fa ces
n ot li ne d with art icu lar car til age . Th u s in the h ip jo in t, wh er e th e fi br ou s la yer atta ches to th e f em ur d ista nt fr om t he ar ticu lar
c arti lag e co ver in g the fe mo ral h ead , th e syno vial memb r ane o f the hip jo int ref lects pr oxi ma lly alo ng t he fem o ral n eck t o th e
e dg e o f the fe mo ral h ead . L ong itu d in al synovia l f ol ds (r etin acu la) occu r in th e me mb r ane cove rin g th e fem or al n eck (Fig . 5 .5 2C ).
S u bsyn ovi al reti nacular a rter ie s (b ran ch es of th e m ed ial, and a f ew of th e l ater al, ci rcu m fl ex f em or al arte ry) th at su p ply th e
f em or al he ad an d ne ck cou r se w ith in t he syn ovial f old s (Fi g. 5 . 54 ).
T h e l ig ament o f the head o f the f emur (Fig s. 5. 5 1 , 5. 5 2C , a nd 5 . 54 ), p ri ma ri ly a syn ovi al fol d con du ctin g a bl ood vesse l, is
w eak an d of li ttle im po rta nce in st ren g then in g th e hi p joi nt. Its wid e end a ttach es to th e ma rg in s o f t he aceta bu lar n otch an d the
t ran sver se acetab ul ar li gam en t; its n ar r ow en d attach es to t he fo vea for th e lig am en t o f the h ead . Usu ally, the li gam en t con tain s a
s mal l art ery to the h ead of th e fem u r. A fat pa d in th e a cetab ul ar fo ssa f ill s th e par t of th e ace tabu la r fo ssa th at is no t occ up ied b y
t he li gam en t o f th e f em ora l h ead . B oth th e lig am en t an d th e f at-p ad ar e co ver ed wit h syn ovial m em br an e. T he m all eabl e n atu r e o f
t he fa t-pad p er m its i t to ch an ge sh ape to accom m od ate th e var ia tion s i n th e co ng ru it y of th e fem or al h ead an d aceta bu lu m as wel l
a s ch an ges in t he po sitio n of th e lig am en t of th e he ad du r in g joi nt m ovem en ts. A synovi al pr otr usio n b eyon d th e f r ee m ar gi n of
t he jo in t cap su le on to t he po ster ior asp ect of th e f em or al neck fo rm s a b u rsa fo r the ob tu ra tor exter n us ten do n. (Fi g. 5 . 53C )
M ov em en t s of t h e H ip Jo in t
H ip m ove me nts ar e f lexi on exten sion , ab du cti on add u ction , m ed ial l ater al ro tatio n, and ci rcu m du cti on (Fig . 5 .5 5 ).
Mo vem ent s of th e tru n k a t th e hi p joi nts ar e al so im por tan t, su ch as th ose occu rr in g wh en a p erso n lif ts t he tr un k f r om th e sup in e
p osi tion du ri ng si t-u ps or keep s th e pel vis level w hen o ne f oot is off th e gr ou n d.
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Fig ure 5.53. L ig aments o f pe lvis and hip jo int. A. Weig h t tr an sfer f r om th e v erte br al colu m n to th e p elvi c g ir dle is a
fu n ction of th e sacr oi liac li gam en ts. Wei gh t t ran sf er at the h ip jo in t i s acco mp li shed p r im ari ly by the d ispo siti on of th e bo nes,
wi th th e l iga me nts lim i tin g the r an ge of m ovem en t a nd a dd in g stab ilit y. B. Th e str on g, tri an gu lar i lio fem or al li gam en t attach es
at its a pex to th e r im o f the aceta bu lu m in f eri or to th e a nter io r in fer io r ili ac sp in e a nd a t it s b ase t o th e an teri or
in ter tro cha nter ic lin e of th e f em u r. T he p ub of emo ra l l ig am ent, a th icke ned p ar t o f the fi br ou s l ayer o f t he jo in t cap su le,
exten ds fr om the su per io r ram u s o f the p ub is to t he in ter tro cha nte ri c li ne of th e fem u r, p assin g d eep to th e i lio fem or al
lig am en t. C. T he isch io fem or al lig am en t, al so a th icken ed p ar t of th e fi br ou s la yer , passe s su per ol ater ally f rom the isch iu m
over th e ne ck of th e fem u r. Th e j oin t capsu le do es n ot atta ch to the p oster ior a spect of th e fem u r. T h us the syn ovi al
m emb r ane is ab le to p r otr ud e f r om th e j oin t capsu l e, fo rm in g th e o btu r ator ext ern u s b ur sa to faci lita te m ove men t of th e
ten do n of th e o btu r ator ext ern u s (sh ow n in p ar t B ) o ver th e b on e.
P. 6 8 0
Fig ure 5.54. B loo d sup pl y of head a nd ne ck o f femur . Br an ch es o f the m edi al an d later al cir cu mf lex fem o ral ar ter ies,
br an che s of th e dee p arte ry of th e t hi gh , an d th e ar ter y to th e fem or al h ead (a br an ch of th e obt ur ator a rte ry) sup pl y th e
he ad an d ne ck of th e fem u r. In th e adu lt, the m edi al cir cum f lex fem or al ar ter y is th e m ost im p or tan t sou r ce o f bl ood to th e

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fem or al h ead an d ad jacen t (pr oxi ma l) n eck.
T h e d egr ee of f lexio n an d exten sion po ssibl e a t th e h i p joi nt dep en ds on th e po sitio n of th e kn ee. If th e k nee is fl exed, rel axin g
t he h am stri ng s, th e t hi gh can be active ly f lexe d un til i t al mo st r each es the an ter ior a bd om in al wal l, an d can reach it via fu rth er
p assi ve f lexi on . Not al l th is m ovem en t o ccur s at th e hi p joi nt; som e resu lt s f rom fle xion o f the ver teb ral co lu mn . Du ri ng ext ensi on
o f th e h ip j oin t, th e f ib ro us laye r of th e j oin t capsu le , especi all y th e ili ofem o ral li ga men t, i s tau t; th eref or e, th e h ip c an u sual ly be
e xten ded o nl y sl ightly b eyon d th e ver tica l e xcept by m ovem en t o f th e b on y p elvi s (f lexio n of lu m ba r ver tebr ae).
Fr om t he an atom ic al posi tion , th e ran g e o f abd uc tion o f the h ip jo in t i s u su ally som ew ha t g rea ter th an f or ad du ctio n. A bo ut 6 0
o f abd u ction is p ossi ble w hen the th ig h is exten ded , an d m or e w he n it is f lexe d. L ater al ro tatio n is mu ch m or e po wer fu l tha n
m ed ial r otat ion . Th e m ain m u scles pr od uci ng m ov eme nts of th e hi p joi nt ar e l isted in Fi gu r e 5 . 55B . Note th at:
1. T h e i liop soa s is th e str on ge st f lexor of th e h ip .

2. I n ad di tio n to its f u ncti on as an ad d ucto r, t he ad du ctor m ag nu s also ser ves a s a fl exor (an ter io r or ap on eu rot ic p ar t) an d an
e xten sor (p oster ior o r ha mst ri ng s p ar t).
3. S ever al m uscl es p ar ticip ate in b oth f lexi on an d ad du cti on ( p ectin eu s an d g raci lis as well al l thr ee add u ctor m u scles).
4. I n ad di tio n to servi ng a s ab du ctor s, th e an teri or p ort ion s o f the g lu teu s m edi us an d m in im us ar e a lso me dia l r ota tor s.
5. T h e g lu teu s m axi mu s serves as the p ri mar y exten sor f ro m th e f lexed to th e stra igh t (stan di ng ) p osit ion ; a nd f ro m th is poi nt
p oste ri orl y, exten sio n is ach ieved p ri ma ri ly b y the h am stri ng s. T he gl ute us m axim u s is also a lat eral r otat or.
B lo od S u p p ly o f t h e Hi p J o in t
A r teri es su p plyi n g the h ip jo in t i ncl ud e (Fi g. 5 . 54 ) the fo llo win g :
T h e m ed ial an d lat eral ci rcu m fle x f em ora l a rter ie s, wh ich a re usu al ly br an ches of th e deep a rter y of th e th ig h bu t occasi on ally
a ri se as br an ch es o f the fe mo ral ar ter y.
T h e ar ter y to the he ad of the femur , wh ich is a b ran ch o f the ob tu rat or ar ter y of va ri abl e si ze; i t tr aver ses t he li gam en t o f
t he h ead.
T h e m ai n bl ood su pp ly of th e h i p join t is fr om th e reti na cul ar ar ter ies ari sin g as b r anch es of th e ci rcu m fl ex f em or al arte ri es.
R eti na cul ar ar ter ies a ri sin g fr om th e me dia l ci rcu m fl ex f em or al art ery ar e m ost ab un d ant , br in gi ng m or e bl ood to th e h ead and
n eck of th e fem u r beca use th ey a re ab le t o p ass ben eath the u na ttach ed po steri or b or der o f the jo in t cap su le. R etin acu la r art eri es
a ri sin g fr om th e later al cir cu mf lex fe mo ral m u st p en etr ate t he th ick i lio fem or al li gam en t an d are sm all er an d few er .
N e rv e S u p p ly o f t h e H ip J o in t
H il ton 's l aw states th at t he n erve s su pp lyi ng th e mu scle s exten d in g di rectl y a cross an d actin g at a gi ven jo in t al so i nn er vate th e
j oin t. A rt icu lar r am i ari se f ro m th e i ntr am u scul ar r am i o f the m u scul ar br an ch es an d d ir ectly fr om n am ed n er ves. A kn owl edg e of
t he n erve su pp ly of th e m u scles an d the ir r elati on shi p to the jo in ts can allo w on e to d edu ce th e n er ve su pp ly
P. 6 8 1
P. 6 8 2
o f m any jo in ts. Possi bl e d edu cti on s r ega rd in g th e h ip jo in t a nd i ts m u scul ar r elati on shi ps in clu de (Fig . 5. 5 5 ):

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Fig ure 5.55. Rela tions of hip j oint and muscles pr o ducing mo vements of jo int. A. Sag itt al section of th e h ip j oin t
sho wi ng th e mu scle s, vessels, and n er ves rel ated to it. Th e m u scles ar e col or cod ed to in d icate th eir f un ctio n(s). Ap plyi n g
Hi lton 's law , it is p ossi bl e to d edu ce the in n erva tion of th e h ip j oin t b y kno win g w hi ch m uscl es d ir ectly cro ss an d act on th e
joi nt an d th eir n er ve su p ply . B. T he r elati ve p osi tion s of th e m u scles pr od uci ng m ove me nts of th e h ip j oin t an d the d ir ection
of th e m ov eme nt ar e d em on stra ted.
Fl exor s i nn er vated b y th e fem or al n erve p ass a nter io r to the h ip jo in t; th e an teri or asp ect of th e h ip j oin t is i nn er vated b y t he
f em or al ne rve (di rect ly a nd vi a a rti cul ar r am i o f the mus cul ar br an ch es to th e p ecti neu s and r ectu s f em or is).
L ater al r otato rs pa ss in f eri or an d po ster ior to th e hi p joi nt; th e i nf eri or asp ect of th e j oin t is i nn er vated b y th e ob tur ato r
n er ve (dir ectl y an d via ar ticu la r ram i of th e m uscu lar br an ch to the ob tu rat or exter n us), and t he po ster ior asp ect is
i n ner vated b y the n erve to th e q u adr atu s f em or is.
A dd u ctor s i nn er vated b y th e sup er ior g lu teal n er ve p ass su p eri or to th e h ip j oin t; th e su per io r aspect o f the jo in t is
i n ner vated b y the su per io r glu tea l n er ve.
P ain p er ceived a s com in g f ro m th e h ip j oin t ma y b e m isl ead in g becau se pai n can b e r ef err ed f ro m th e ver teb ra l co lu mn .
Fr a ct u r e s o f th e Fe m o r a l N ec k ( H i p F r a c tu r e s )
Fr actu r es o f the n eck o f t he fem u r (u nf or tu nat ely ref er red to as fr actu re d hi ps, i mp lyi ng t hat th e h ip b on e is b r oken ) ar e
un com m on i n m ost con tact sp or ts b ecau se the p art icip an ts ar e usu al ly yo un g an d th e f em or al ne ck is str on g in p eop le <4 0 year s
of ag e. Wh en th ey d o occu r in th is ag e g ro up , th ese fr actu res u sual ly resu lt fr om hi gh -en erg y im pacts (e. g. , d ur in g r ace-car
accid en ts, skiin g , tr am pol in e, an d eq uest ria n even ts) w h en th e l owe r lim b is exten d ed an d the fo rce of th e im pact is tr ansm i tted to
the h ip jo in t, even i f app li ed at som e d istan ce fr om t he joi nt . For exam p le, i f t he fo ot is f ir m ly b r aced ag ain st t he car f loo r wit h
the kn ee locked , or i f the kn ee is b r aced ag ain st t he da shb oar d du r in g a h ea d-on colli sion , th e for ce of th e i mp act m ay b e
tra nsm itt ed sup er ior ly an d pr od uce a fem or al n eck f ra ctur e. T he se f ract ur es a re esp ecial ly co mm o n in i nd ivid u als >6 0 yea rs,
especi all y in wom en b ecau se the ir fe mo ra l n ecks are m or e o ften weak an d br itt le a s a re sul t of o steop or osis (Fig. B5 .2 2 ).
Fr actu r es o f the fe mo ral n eck are of ten in tr acap su lar , an d rea lig n men t of th e n eck fr ag men ts req u ir es i nte rn al skelet al fixa tion .
Fe mo ral n eck fr actu res ar e a mo ng th e m ost t rou b lesom e an d pr ob lem ati c of a ll fr actu res (Sa lter , 1 99 9 ).

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Fr actu r es of th e fem oral n eck o ften di sru pt th e b loo d su pp ly t o th e he ad of th e f em u r. Most of th e blo od to th e h ead a nd n eck of
t he fe mu r is su pp lied b y the m edi al cir cum f lex fem or al ar ter y (Fig . 5 .5 4 ). Th e reti na cul ar ar ter ies ari sin g fr om th is ar ter y ar e ofte n
t or n wh en th e fem or al n eck i s fr actu r ed or th e hi p joi nt is di slocat ed. Fol low in g som e fem or al n eck f ra ctur es, th e art ery to the
l ig am ent of th e fem or al h ead m ay be th e on ly r em ain in g sou rce of b loo d to the p rox im al fr agm en t. T hi s ar ter y i s f req u ent ly
i n adeq u ate for m ai nta in in g th e f em ora l h ead ; co nse qu en tly, th e fr ag men t m ay u n der go ase pti c vascu la r necr osi s.
Fig ure B5. 22
S u r g ic a l Hi p R e p l a ce m e nt
A lth ou g h th e h ip j oin t i s str on g an d stab le, i t i s su bj ect to seve re tra um ati c i nj ur y and d eg ene rati ve d isea se. Osteo arth r itis of th e
h i p join t, ch ar acter ize d by pai n, e dem a, l im itat ion o f mo tion , an d er osi on of ar ticu l ar car tila ge, i s a com m on cau se of di sab ili ty
( Fi g. B 5 .2 3 ). Dur in g h ip re pla cem ent , a m eta l p r osth esis anch or ed to th e p er son 's f em u r by bo ne cem en t r epl aces the f emo ra l
h ea d and n eck. A p last ic so cket c eme nted to th e hi p bo ne r epl aces th e acetab u lu m.
N e c r o si s o f th e F e m o r a l H e a d i n C h i ld r e n
I n ch il dr en, tra um ati c d islo catio ns of th e h ip j oin t di sru pt th e a rter y to t he h ead of th e fem u r. Fr actu res th at resu lt in se par atio n
o f th e su pe rio r fem o ral ep ip hysi s (th e gr ow th pl ate betw een th e fem or al h ead an d n eck) a re also li kely to resu lt in a n in ad equ ate
b lo od su pp ly to the fe mo ral h ead an d in post -tra um ati c ava scul ar n ecro sis o f the h ead . As a r esu lt, i nco ng r ui ty o f t he jo in t
s ur face s d evelo ps, an d g ro wth a t th e epi ph ysis is r eta rd ed. S u ch con di tion s, m ost com m on i n chi ld ren 3 9 y ears of ag e, p ro du ce
h i p pai n th at m ay ra di ate t o th e kne e (S alter , 1 9 99 ).
Fig ure B5. 23
D i s lo ca t i o n o f th e Hi p J o i nt
C on g en ital di sloca tion of th e h ip j oin t i s co mm on , o ccur ri ng i n ap pr oxi ma tely 1. 5 p er 1 00 0 l ive bi rth s; i t i s b ila tera l i n
a pp ro xim atel y h alf th e cases. Gir ls ar e af fect ed at least eig ht tim es m or e of ten th an b oys (Sa lter , 1 99 9 ). Dislo catio n occu rs wh en
t he fe mo ral h ead i s n ot pr op erl y l ocated i n th e ace tabu lu m . In ab il ity to a bd uct th e t hi gh i s ch ar acter istic of con g eni tal di sloca tion .
I n ad di tio n, th e aff ected l im b app ear s (a nd f u ncti on s as if ) sh or ter b ecau se th e disl ocate d fem or al h ead is mo re su per io r tha n on
t he n orm al si de, r esu lti ng i n a p osi tive Tr en del enb u rg si gn (h ip ap p ears to dr op o n on e si de du r in g wal kin g). A pp r oxim ate ly 2 5 % of
a ll cases of ar th rit is o f the h ip in a du lts ar e th e di rect re sul t of r esid u al def ects fr om co ng en ital d islo cation of th e h ip .
A cqu ir ed d islo catio n of th e h ip j oin t is un com m on b ecau se t hi s ar ticu la tion i s so str on g an d stab le. N evert hel ess, d isloca tion ma y
o ccu r du ri ng a n au tom ob ile acci den t w h en th e h ip i s f lexed , ad du cted , an d m edi ally r otated , th e u su al po sitio n of th e low er li mb
w h en a per son i s r id in g in a car . Poste rio r di sloca tion s a re m ost com mo n. A hea d-on coll ision tha t cau ses th e kn ee to stri ke th e
d ash bo ar d ma y d islo cate the h ip wh en t he fem o ral h ead i s fo rce d ou t of th e acetab u lu m (Fig . B5 . 24A) . Th e j oin t capsu le r up tu res
i n fer ior ly an d po steri or ly, al low in g th e f em ora l h ea d to p ass thr ou g h th e tea r in th e capsu le an d over t he po ster ior m ar gi n of th e
a cetab ul um on to the lat era l su r face of th e ili um , sh or tenin g an d me dia lly ro tatin g th e a ff ected li mb (Fi g. B 5 .2 4B). B ecau se o f the
c lose rel atio nsh ip o f th e scia tic ner ve to the h ip jo in t (Fig . 5 .5 6A), i t m ay be in ju r ed (str etch ed an d/or co m pr essed ) d ur in g

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p oste ri or di sloca tion s o r fr actu r e di slocat ion s o f the h ip jo in t. Th is kin d of i nj ur y m ay r esul t i n pa ral ysis of th e h am str in gs and
m u scles di stal to th e kn ee sup pl ied b y th e sciati c n er ve. Se nso ry cha ng es m ay al so o ccur i n th e ski n over t he po ster olate ral
a spects of th e leg an d ove r mu ch o f t he fo ot becau se of in ju r y to sen sor y b r anch es of th e sci atic n erve.
A n teri or d islo catio n of th e h ip j oin t resu lt s fr om a vi olen t in ju ry th at for ces the h ip in to exten sio n, a bd uct ion , an d lat eral r otat ion
( e.g ., catch in g a ski ti p wh en sn ow skii ng ). I n th ese ca ses, th e f em or al hea d is i nf er ior to th e acetab u lu m. Of ten , th e a cetab ul ar
m ar g in f ract ur es, p ro du cin g a f r actu re d islo catio n of th e hi p joi nt. Wh en t he fem o ral h ead d islo cates, i t u su ally car ri es th e
a cetab ul ar b on e f rag m en t an d aceta bu lar lab ru m w ith i t.
Fig ure B5. 24
P. 6 8 3
P. 6 8 4
T h e h ip j oin t is o ur st ron g est a nd m ost stab le joi nt . Its stab ili ty r esu lts fr om (1 ) t he m echa ni cal stre ng th of i ts b all an d (d eep)
s ocket con stru ctio n, allo wi ng ext ensi ve a rti cul ar su rf ace c ont act; (2 ) its stro ng j oin t capsu le; an d (3 ) its m an y su rr ou n di ng
m u scles. How ever , it re ma in s vu ln er abl e, esp ecial ly i n old er ag e, b ecau se o f the an g le o f th e f em ora l n eck (in clin ati on ) an d clo se
a ssocia tion o f th e b loo d sup pl y o f t he fem o ral h ead to th e neck. Th us fr actu r es r esu lt i n avascu la r ne cros is o f the fe mo ral h ead .
Ma jor m ove men ts ar e f lexio n an d exten sio n, p ossi bl e ove r a w id e r an ge; m edi al an d later al r otati on w ith ab du cti on ar e p ar t o f
e very step o f n or m al, bip ed al wal kin g.
K n e e J o in t
T h e knee jo int i s ou r l arg est an d mo st su pe rf icia l j oin t. I t i s p ri ma ril y a h in ge typ e of sy no vial jo in t, all owi ng f lexi on an d
e xten sion ; h ow ever , th e h in ge m ovem en ts are com b in ed wi th gl id in g an d rol lin g an d wi th r otati on ab ou t a ver tica l a xis. A lth ou gh
th e kn ee j oin t is w ell con str uct ed, i ts f un cti on is com m on ly im pai re d wh en it is hyp er exten de d (e.g . , in b od y con tact sp ort s, such
a s ice h ockey).
A r ti cu l at io n s , Ar t ic u lar S u rfac es , an d S t ab ili t y of t h e K n ee J o in t

R ele van t an ato mi cal det ails of th e in volved b on es, i ncl ud in g th eir ar ticu la tin g sur f aces, we re di scusse d in Bo ne s of th e Lo wer
L im b , ear lie r in th is cha pter . T he ar ticu lar su r face s of th e kne e j oin t a re ch ara cteri zed by th eir l arg e size an d thei r com pl icate d
a nd i nco ng ru ent shap es. T he kn ee j oin t consists of th ree ar ticu la tion s (Fi g. 5 . 56 ):
T wo f emor oti b ial ar ticulati ons (later al an d med ia l) b etw een th e l ater al an d the m ed ial fem o ral an d tib ia l co nd yles.
On e in ter med ia te f emor o pa tella r arti culati on b etw een th e pate lla an d th e f em ur .
T h e f ibu la is n ot in volved i n th e kn ee joi nt .

T h e kn ee joi nt is rel ative ly w eak m echa ni cally b ecau se o f t he in con gr u en ce of i ts a rti cul ar su rf aces, w hi ch ha s b een com p ar ed to
tw o bal ls sittin g on a w ar ped ta ble top . Th e st abi lity of th e knee jo in t d epe nd s o n (1 ) th e st ren g th an d actio ns of th e su r ro un d in g
m u scles an d th eir ten d on s an d (2 ) th e lig am en ts th at con ne ct th e fem u r an d tib ia. Of th ese sup po rts , the m u scles a re m ost
i mp or tan t; ther ef or e, m any sp ort in ju r ies are p reve nta ble th ro ug h ap pr op ri ate con di tion in g an d tr ain in g. Th e m ost im p ort ant
m u scle in sta bil izi ng th e kne e jo in t i s th e lar ge qu ad ri ceps fe mo ri s, par ticu la rl y th e in fer ior f ib ers of th e vastu s m ed ial is a nd
l ater ali s (Fig . 5 .5 7A). T he kn ee joi nt wi ll fu n ction su r pr isi ng ly wel l a fter a li gam en t stra in if th e qu ad ri ceps is well co nd iti on ed.
T h e er ect, ext end ed p ositi on is th e m ost stab le po sitio n of th e knee . In th is po siti on th e a rti cul ar su rf aces are m ost con gr ue nt
(co nta ct i s m in im ize d in al l o the r pos itio ns), th e pr im ar y l ig am ents of th e joi nt (col later al an d cru cia te l ig am ents) ar e ta ut, and t he
m an y ten don s sur ro un d in g th e jo in t p r ovid e a sp lin tin g ef fect.

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Fig ure 5.56. B ones o f knee joi nt. A Th e bon es ar ticu lati ng a t th e knee jo in t ar e sho wn . Th e hi p bo ne an d pr oxi ma l f em u r
ar e in clu d ed to dem o nstr ate th e Q-an g le, d eter m in ed du r in g ph ysical exa mi na tion to i nd icat e al ig nm en t o f th e f em ur an d ti bia
an d to evalu ate valg u s or varu s stress at th e kn ee. B . Th e bo nes an d bo ny fea tur es of th e p oster io r asp ect o f t he kn ee j oin t
an d kne e ar e sho wn .
J o in t Cap s u le of t h e K n ee Jo in t
T h e jo int caps ul e o f the knee jo int i s typ ical in con sistin g of a n exter na l f ib ro us laye r (fib r ou s cap sul e) a nd a n in ter nal
P. 6 8 5
s yno vial m em br an e th at li nes all in ter n al sur fa ces o f the ar ticu lar ca vity no t co vere d with art icu lar car til age . Th e f ib ro us laye r ha s
a f ew th icken ed pa rts th at m ake u p in tr in sic l ig ame nts bu t, f or th e ma in p art , it is th i n an d is a ctua lly in com pl ete in som e ar eas.
T h e f ib rou s layer a ttach es to th e fem u r su per ior ly, ju st p ro xim al to the ar ticu la r ma rg in s o f the con dy les. Po ster ior ly, th e fib r ou s
l ayer en clo ses th e con dyl es a nd th e in terc ond yla r fossa (Fig . 5 .5 7B). T h e f ib rou s layer h as an op en in g po ster ior to th e later al tib ial
c on dyle to all ow th e t end on o f the p opl iteu s t o p ass ou t of th e joi nt cap su le t o a ttach to th e ti bi a. I nf eri orly, th e fib r ous la yer
a ttach es t o th e m arg in o f the su per io r art icu lar su rf ace (tib ial p latea u) of th e t ibi a, excep t w h ere th e t end on o f the p opl iteu s
c rosse s th e b on e (Fi gs. 5 . 5 7A & B an d 5. 5 8A ). Th e qu ad ri ceps ten do n, p atel la, a nd p atel lar l iga me nt re pla ce th e fib r ou s la yer
a nte ri orl y th at i s, th e f ib ro us layer is co nti nu ou s wit h the la tera l a nd m ed ial m ar gi ns of th ese stru ctu re s, an d ther e is n o
s epar ate fi br ou s l ayer in the r egi on of th ese str uctu r es (Fig s. 5 . 57 A an d 5 .5 8A).

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Fig ure 5.57. Jo int ca ps ul e o f knee. T he exter n al aspect (f ibr ou s l ayer ) o f the jo in t cap su le is r ela tivel y th in i n som e pla ces
an d thi cken ed in o the rs to for m r ein fo rci ng i ntr in sic (cap sul ar) li gam en ts. A. Mod if icati on s of th e an teri or asp ect and si des of
th e f ibr ou s layer i ncl ud e the pa tell ar re tin acu la, w hi ch atta ch to the sid es o f th e q ua dr icep s ten d on , pa tella , an d pat ellar
lig am en t, an d in corpo rat ion o f the il ioti bi al tract (la tera lly) an d th e m ed ial col later al li gam en t (m ed ial ly). B . Th e ha mst rin g
an d gast rocn em iu s mu scles an d th e p oster io r in ter mu scu lar sep tu m h ave been cut an d re mo ved to expo se th e ad du ctor
m agn u s, late ral in ter m usc ul ar sept um , an d th e flo or of th e pop li teal fo ssa. Po steri or m od if icatio ns of th e fib r ou s la yer in clu de
th e ob li qu e a nd a rcu ate po pli teal li gam en ts an d a p erf or atio n in fe ri or to th e ar cu ate pop li teal lig am en t t o a llow p assag e of th e
po pli teu s ten d on .
T h e ext ensi ve syn ovi al m em br an e li ne s al l su r face s b ou nd in g th e ar ticu la r cavity (th e sp ace con tain in g syn ovi al flu id ) n ot cove red
b y arti cu lar car til age (Fig . 5 .5 8A & B ). Th u s it atta ches to th e p eri ph er y o f the ar ticu lar carti lag e co ver in g the fe mo ral an d ti bia l
c on dyle s; th e p oste rio r su rf ace o f the p atell a; a nd th e edg es of th e m en isci, the fi br ocar til ag in ou s d iscs b etw een th e t ibi al an d the
f em or al ar ticu lar su r faces. It lin es the in ter n al sur fa ce of t he fi br ou s l ayer la tera lly an d me dia lly, bu t cen tr all y i t b ecom es
s epar ated f r om th e f ib ro us laye r. Fr om th e po steri or asp ect of th e j oin t, th e syno vial m em br an e r ef lects an teri or ly i nt o th e
i n terco nd ylar reg ion , co veri ng t he cru cia te l ig am ents an d th e i nf r ap atell ar fa t-p ad , so tha t th ey are excl ud ed fr om the ar ticu lar
c avity. T h is cr eate s a me dia n inf rap ate llar s yno vial f old , a ver tical f old o f sy no vial m em bran e th at ap pr oach es the p oster ior
a spect of th e pate lla, occu pyi ng al l bu t th e m ost a nte rio r pa rt of th e i nt erco nd ylar reg ion . T hu s it a lm ost sub di vid es th e ar ticu lar
c avity in to ri gh t a nd l eft fem or oti bi al art icu lar cavi ties; in de ed, th is is ho w art hr osco pic su rg eon s co nsi der t he ar ticu lar
P. 6 8 6
P. 6 8 7
c avity. Fat -fil led la ter al and m edi al alar f ol ds cover the in n er su rf ace o f fat-p ad s th at occu py th e sp ace on eac h sid e of t he
p atel lar l ig am ent in ter n al to th e fi br ou s l ayer .

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Fig ure 5.58. L ayer s o f j oint cap sule, ar ticul ar cavity, and a rti cul ar sur face s of k nee jo int. A. Th e attach m en ts o f the
fi br ou s la yer an d syn ovia l m em b ran e to the tib ia ar e sh ow n . Note th at, a lth ou gh th ey ar e ad ja cent on e ach sid e, th ey par t
com pa ny cen tra lly to accom m od ate i n terco nd ylar and i nf r apa tella r stru ctu re s th at are in tr acap sul ar (in sid e the fi br ou s l ayer )
bu t extra -art icu lar (excl ud ed f ro m th e ar ticu la r cavity by syn ovi al mem b ra ne). B. T he jo in t cap su le was in cised tr an sver sely,
th e p atell a w as sawn t hr ou gh , an d th en th e kne e w as f lexed , op en in g th e ar ticu la r cavity. Th e i nf ra pate llar fol d of syn ovia l
m emb r ane en clo ses th e cru ciat e li ga men ts, ex clu din g th em f ro m th e j oin t cavity. All in ter n al sur fa ces n ot cover ed w ith or
m ade of ar ticu la r cart ilag e (blu e, o r gr ay in th e case o f the m en isci) ar e li ne d wit h syno vial m em br an e (mo stly pu rp le, bu t
tra nsp ar en t an d col or less w h ere it is cover in g n on -arti cul ar su rf aces of th e f em ur ).
S u per io r to t he pa tell a, th e kn ee joi nt cavi ty ext end s d eep to th e vastu s in ter m edi us as the su pr ap atell ar bu r sa (Fi gs. 5 . 57A an d
5 . 5 9A ). Th e syno vial m em br an e o f th e jo in t ca psu le is con tin uo us wi th th e syn ovi al lin in g of t hi s b ur sa. T hi s la rg e b u rsa u sua lly
e xten ds app r oxim atel y 5 cm su per ior t o th e pa tella ; h ow ever, it may exten d h alf wa y u p th e an ter io r aspe ct of th e fem u r. Mu scle
s lip s d eep to th e va stus in ter me diu s for m th e art icu lar m u scle of th e kn ee, w h ich atta ches to th e syn ovi al m emb r ane an d r etra cts
t he bu r sa d u ri ng ext ensi on o f t he kn ee (Fi gs. 5 . 16 and 5 . 5 7A ).
E xt r aca p su l ar L ig am e n t s of th e Kn ee J o in t
T h e j oin t ca psu le is stre ng th ene d by five extr acap su lar o r capsu la r (in tri nsi c) l iga me nts: pa tella r lig am en t, fi bu la r coll ater al
l ig am ent , tib ial col later al li gam en t, o bli qu e pop li teal lig am en t, an d ar cua te p op lit eal lig am en t (Fig . 5 .5 7A & B ). Th ey ar e
s om etim es calle d exter nal l iga me nts to di ff eren ti ate t hem fr om i nter n al lig am en ts, su ch as the cr uci ate lig am en ts.
T h e p atel lar li gam en t, th e di stal par t of th e q u adr icep s te nd on , is a st ron g , th ick f ib ro us ba nd p assin g f ro m th e ap ex and a dj oin in g
m ar g in s of th e pa tella to th e ti bi al tub er osity (Fig . 5 .5 7A). T he p atell ar li gam en t i s th e an teri or li gam en t of th e kn ee joi nt .
L ater al ly, it r eceives th e m ed ial an d la tera l p atel lar r etin acu la, apo neu r oti c exp an sion s o f the vastu s me dia lis an d later al is a nd
o ver lyin g d eep fa scia. T he r etin acu la ma ke u p th e j oin t capsu le of th e kn ee o n each si de of th e p atel la (Fi gs. 5 . 5 7A an d 5 . 58A) an d
p la y an i m por tan t ro le i n m ain tai ni ng al ig nm en t of th e p atell a r el ative to th e p atell ar ar ticu lar sur fa ce of t he fem u r. Th e o bl iqu e
p la ceme nt of th e fem u r an d/or lin e o f pu ll of th e qu ad ri ceps fem or is m uscl e r ela tive to the axi s of th e pat ellar tend on and t ibi a,
a ssessed cli ni call y as th e Q- an g le, f avor s l ater al di spla cem ent of th e pate lla (Fig . 5. 5 6 ).
T h e co llate ral l iga men ts of th e kn ee ar e ta ut wh en th e kne e i s fu ll y ex tend ed , con tr ibu ti ng to stab il ity wh ile stan d in g (Fi g. 5 . 5 9).
A s f lexi on p ro ceeds, the y b ecom e i ncr easi ng ly slack, per m itti ng an d li m itin g (ser vin g as check li gam en ts for ) r ota tion a t th e kne e.

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T h e f ib ular co lla tera l l ig ament ( FC L ; la tera l co lla tera l l ig am ent), a co rd -like extr acap su lar l iga me nt, i s str on g . It exten ds
i n fer ior ly fr om t he late ral ep ico nd yle of th e f em ur to t he late ral su rf ace of th e f ib ul ar h ead (Fig . 5 .5 9A & B ). Th e ten don of th e
p op li teus pa sses d eep to th e FC L, separ ati ng i t f ro m th e l ater al me ni scus. T h e ten d on of t he bi ceps fem o ris is spl it in to t wo pa rts
b y thi s l iga men t (Fig. 5. 5 9A ). Th e tib ial co llate ral li ga ment (T CL ; m ed ial co llate ral l iga me nt) is a str on g , fla t, in tr in sic
( capsu lar ) ban d th at exten ds fr om t he m edi al epi con dyl e of th e fem u r to th e m ed ial con d yle and t he su per ior par t o f the m ed ial
s ur face of th e tib ia (Fig. 5. 5 9C & D ). At its m idp oi nt, the d eep fi ber s o f the TC L ar e fir m ly attach ed to th e m ed ial m en iscu s. Th e
T C L, w eaker th an the FCL , is m or e o ften d am ag ed. A s a r esu lt, th e T C L and med ial m en iscu s a re com m on ly tor n du r in g con tact
s por ts such a s f ootb all an d ice h ockey.
T h e o bl iq ue p op li teal lig ame nt is a r ecu rr en t e xpan sio n of th e tend on o f the sem im em b ran osu s tha t r ein fo rces th e j oin t capsu le
p oste ri orl y as it spa ns th e i ntr acon d ylar f ossa (Fig. 5. 5 7B ). T he lig am en t a ri ses p oster ior to t he m edi al tib ial con dy le a nd p asses
s up ero late ral ly towa rd th e later al fe mo ral co nd yle, b len d in g wi th th e cen tr al par t of th e p oster io r aspe ct of t he joi nt cap su le.
T h e ar cuate po p litea l l ig ament also str eng th en s th e j oin t capsu le p oster ola tera lly. I t ari ses f ro m th e p oster io r aspe ct o f t he
f ib u lar h ead , pa sses su pe rom ed ial ly over th e ten don of th e p op liteu s, a nd sp re ads over th e po steri or su rf ace of th e kn ee jo in t. Its
d evel op men t app ear s t o b e i nv ersel y r ela ted to the p resen ce an d size of a fab ell a i n th e p ro xim al attach m en t o f the la tera l h ead o f
g astr ocn em iu s (se e cli ni cal cor rel atio n [bl ue ] b ox Fab ell a i n th e Gastr ocn em iu s, in thi s ch ap ter ). Bot h stru ctu r es ar e
t ho ug h t to con tr ib ute to po ster olate ral sta bil ity of th e kn ee.
G e n u V a lg u m a n d G e n u V a r u m
Th e f em ur is p lace d dia gon al ly with in the th ig h, w h ere as th e tib ia is a lm ost verti cal wi thi n th e l eg, cr eati ng a n an gl e at th e kn ee
betw een th e lon g axes of th e bon es (Fig. B5 .2 5A). T h e an g le betw een th e two b on es, re fer red t o cl in ical ly a s th e Q- ang le , i s
assessed b y d ra win g a lin e fr om th e AS IS to th e m id d le o f th e p atell a a nd ex trap ol atin g a secon d (ver tical ) li ne pa ssin g th rou g h
the m id dl e of th e pa tella an d tib ial tu b ero sity (Fi g. 5 . 5 6). T h e Q-an g le is ty pica lly gr eate r in ad ul t f em ales, owi ng to th ei r wid er
pel ves. Wh en n or ma l, th e a ng le of th e f em u r with in the th ig h pl aces the m id dle of th e kne e j oin t d ir ectl y in f eri or to th e h ead o f
the fe mu r w hen stan di ng , cen ter in g the we igh t-b ear in g lin e in th e in terco nd yla r reg io n of th e kn ee (Fig . B5 . 25A).
A med ia l a ng ul atio n of th e leg in r el ation to t he th ig h, i n wh ich the fe mu r is ab no rm al ly ve rti cal an d the Q-an gl e i s sm all , is a
def or mi ty ca lled g enu va rum (bow leg ) t hat cau ses un eq ual w eig ht b eari ng : Th e l in e of w eig h t b ear in g fal ls m ed ial to th e cente r of
the kn ee (Fi g. B 5 .2 5B). E xcess pr essu re is pl aced on th e m edi al aspect of th e kne e j oin t, w hi ch resu l ts in arthr o sis (destr uction
of kn ee ca rti lag es), an d th e f ib ul ar col later al li gam en t i s o verstr essed (Fi g. B .2 5D). A later al an gu la tion o f the le g (lar ge Q-an gl e,
>1 7 ) in r ela tion t o th e th igh (exag ger atio n of th e knee an gl e) i s cal led g enu val gum (kn ock-kn ee) (Fi g. B 5. 2 5C). B ecau se of
the exag g erat ed kne e ang le in g enu valg um , th e wei gh t-b eari ng l in e f all s l ater al to t he cen ter of th e kne e. C ons equ en tly, th e tib ial
coll ater al lig am en t i s over str etch ed, and t her e is e xcess str ess on th e l ater al m eni scus an d car tila ges of th e l ater al fem or al an d
tib ial con dy les. T he pa tella , no rm al ly pu lle d later all y b y t he ten do n of th e va stu s la tera lis, i s p ul led even far th er lat era lly wh en th e
leg is exten d ed in th e pr esen ce o f gen u val gu m so th at its a rti cul atio n wi th th e f em ur i s ab n or ma l. C hi ld ren co m mo nl y ap pe ar
bow leg ge d for 1 2 ye ars af ter star tin g to wa lk, an d kn ock-kn ees are fr eq ue ntl y o bser ved in chi ldr en 2 4 yea rs of ag e.
Per sisten ce o f th ese ab n or ma l kn ee an gl es i n late ch ild h ood u su ally m ean s co ng en ital d efo rm iti es exi st th at m ay r eq ui re
cor recti on . An y irr eg ul ar ity o f a j oin t even tua lly lea ds to w ear a nd tea r (ar thr osi s) of th e ar ticu lar car ti lag es.
P a te l l a r D i s l o c a ti o n
When the p atell a i s d islo cated , it nea rl y al ways di sloca tes l ater all y. Patel lar d isl ocatio n is m ore com m on i n wo me n, p r esum ab ly
beca use of th eir g r eater Q-an g le wh ich , in a dd itio n to rep r esen tin g the ob li qu e p lace me nt of th e f em u r rel ative to th e ti bi a,
rep re sent s th e a ng le of p ul l o f the q uad r icep s r elati ve t o th e axis of th e p atel la an d tib ia (the ter m Q- an g le was actu all y coi ne d in
ref er ence to th e an g le of pu ll o f t he qu ad ri ceps). Th e te nd en cy to war d lat eral d islo catio n is no rm al ly co un ter b alan ced b y th e
me dia l, m or e h or izo nta l p u ll of th e p ow erf u l v astu s m edi ali s. In a dd itio n, the m or e a nter io r pr oj ection of th e l ater al fem or al
con dyl e an d d eepe r slop e f or th e lar ger later al pa tella r face t p ro vid e a m echa ni cal dete rr en t to la tera l d isl ocati on . An i mb ala nce of
the la tera l p u ll an d the m ech an ism s r esisti ng i t r esu lt in ab n orm al tr acki ng o f t he pa tella w ith in th e pate llar gr oove an d ch ron ic
pate llar pai n, e ven if actu al d islo catio n do es n ot occu r.

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Fig ure 5.59. Col later al li ga ments o f knee j oint. A. T he fi bu lar colla ter al lig am ent is sh own . Pu r pl e l atex w as in jected i nt o
th e ar ticu la r cavity to dem o nstr ate th e ex tensi ve a nd co mp lex syn ovia l m em b ra ne su rr ou nd in g it. Th e ar ticu l ar cavity /syno vial
m emb r ane exte nd s su pe ri orl y d eep to th e q u adr icep s, f or mi ng th e sup r apa tella r bu r sa. B. Th e a ttach me nt sites of th e FC L
(gr een ) a nd r elat ed m uscl es (r ed, pr oxim al ; b lu e, d istal ) on t he late ral asp ect of th e b on es o f th e kn ee reg io n ar e in d icated .
Th e t end on o f the b icep s f emo ri s b if ur cates, i ts si te o f attach m en t em b raci ng t he in fer io r attach m en t o f the FCL . C. T he ba nd like p art of th e tib ial col later al li gam en t (i sola ted h ere fr om the fi br ou s l ayer of t he joi n t cap su le, of w h ich it is a p ar t)
attach es to the m edi al epi con dyl e (al m ost i n li ne wi th th e a dd ucto r m agn u s ten d on ); cr osses th e in ser tio n of th e
sem im em br an osu s m u scle; an d passes de ep to the p es an ser in u s, the com b in ed atta chm en t si tes o f th e ten d in ou s d istal
attach m en t o f the gr aci lis, se mi ten din osu s, an d sar tor iu s m u scles. D. T he atta chm en t sites of th e T CL a nd r ela ted m uscl es o n
th e m ed ial asp ect o f the b on es o f t he kn ee r eg ion a re in di cated .

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Fig ure B5. 25
P a te l l o f e m o r a l S y nd r o m e
P ain d eep to th e pate lla of ten r esul ts f ro m excessi ve r u nn in g , espe ciall y d ow nh il l; h en ce, th is type of p ain is o ften calle d
r u nn er 's k nee. Th e pai n resu lt s f rom rep eti tive mi cro tra um a cau sed by ab no rm al tr ackin g of th e pat ella r elati ve to th e
p atel lar su r face of th e fem u r, a con d itio n kn own as th e pa tello fe mor al syndr o me. Th is syn dr om e m ay also r esu lt fr om a di rect
b lo w to t he pa tell a an d f rom oste oar thri tis of the p atel lo femo ra l co mp ar tment (d ege ner ati ve w ear an d tear of ar ticu lar
c arti lag es). I n som e ca ses, str en gth en in g of th e va stus m edi ali s cor r ects p atel lof em ora l d ysf un ctio n. T h is m u scle ten ds to pr even t
l ater al di sloca tion o f th e p atell a r esu lti ng f ro m th e Q-a ng le beca use th e va stus m edi alis atta ches to an d pu ll s on the m edi al bo rd er
o f th e p atell a. H ence , weak ness of th e vastu s m ed iali s p red isp oses th e i nd ivid u al to the p atell ofe mo ral d ysfu n ction and patel lar
d isl ocati on.
P. 6 8 8
P. 6 8 9
P. 6 9 0
I n t r a-A rt ic u la r Li g am en t s o f t h e Kn ee J oi n t
T h e in tr a-ar ticu la r lig am en ts w ith in th e kne e jo in t co nsi st o f the cr uci ate lig am en ts an d m en isci. T h e p op litea l t end on i s al so i nt raa rti cul ar du r in g pa rt of its cou rse .
T h e cr uci ate lig am en ts (L. cr ux, a cr oss) crisscr oss wi thi n th e j oin t capsu le of th e joi nt bu t ou tsid e th e syno vial cavi ty (Fi gs. 5 . 60
a nd 5 . 61 ). T he cr uci ate lig am en ts ar e locat ed in th e cente r of th e j oin t and c ross each o th er ob liq ue ly, li ke t he lette r X. Du ri ng
m ed ial r otati on o f the tib ia on th e fem u r, the cr uci ate lig am en ts w in d aro un d each oth er; th us th e a mo un t of m edi al rot atio n
p ossi ble is lim i ted to abo ut 1 0 . B ecau se they b ecom e u n wo un d du r in g late ral r otati on , n ear ly 6 0 of l ater al ro tatio n is pos sibl e
w h en th e kn ee is flex ed >9 0 , the m ovem en t b ein g u lti ma tely lim ite d by th e T CL . Th e chi asm (p oin t of cro ssin g) of th e cr u ciate
l ig am ents ser ves a s th e p ivo t f or r otato ry m ovem en ts a t th e knee . Beca use of th eir o bl iqu e or ien tati on , in eve ry pos itio n on e
cr u ciate li gam en t, or par ts o f on e o r bo th lig am en ts, is ten se. I t is th e cr u ciate li gam en ts t hat m ain tai n con tact wi th th e f em or al
a nd ti bi al arti cul ar su rf aces du r in g flex ion o f the kn ee.
T h e anter io r cr uci ate lig ament (AC L), the we aker of th e two cr uci ate lig am en ts, ar ises fr om th e ant eri or in ter con dyl ar ar ea of
th e tib ia, j ust p oster ior t o th e attach m en t o f t he m edi al me ni scus (Fig. 5. 6 0A ). Th e AC L h as a r elati vely po or bl ood su p pl y. It

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e xten ds sup er ior ly, p os ter io rl y, an d later al ly t o a ttach to th e p os te rio r pa rt of th e m ed ial si de of th e l ater al con dyl e o f t he fem u r
( Fi g. 5 . 60C ). It li mi ts p oster io r ro lli ng (tu r ni ng a nd t rave lin g) of th e fem or al con dyl es o n th e ti bi al pla teau d ur in g f lexio n,
c on verti ng i t to sp in (tu r ni ng i n pl ace). I t a lso pr even ts p oster io r di spla cem ent of th e fem u r on th e tib ia an d hyp er exten sion of th e
k nee jo in t. Wh en th e j oin t is f lexe d at a r igh t an gle , th e ti bia can n ot be pu ll ed an teri or ly (like pu ll in g ou t a d raw er ) b ecau se i t is
h el d by th e A CL .
T h e p os teri or cr uciate lig ame nt (PC L), the str on ger o f th e tw o cr u ciate li gam en ts, ar ise s fr om the p oster ior i nt erco nd ylar area
o f th e ti bia (Fig . 5 .6 0A & D ). T he PC L pas ses su pe rio rl y an d an ter ior ly on t he m edi al side of th e AC L to attach to t he an ter ior p ar t
o f th e la ter al sur face of th e m edi al con dyle of th e fem u r (Fig . 5. 6 0B & C ). Th e PC L lim its an ter ior r ol lin g of th e fem u r on th e tib ial
p la teau d ur in g exten sio n, con vert in g it t o sp in . I t al so p r even ts an ter io r disp la ceme nt of th e fem u r on th e tib ia or po ster ior
d isp lace men t of th e t ibi a o n th e f em ur a nd h elp s p r even t h yp erf lexi on of th e kne e j oin t. I n th e w eig ht-b ear in g fl exed kn ee, th e PC L
i s th e ma in stab il izin g f actor f or th e fem u r (e.g . , wh en w alki ng d ow nh il l).
T h e meni sci o f the kne e jo int a re cre scent ic p lat es ( wa fer s ) of fi br ocar til age on th e ar ticu lar su r face of th e tib ia tha t
d eep en th e sur fa ce an d p lay a r ol e in sho ck ab sor pt ion (Fig . 5 . 61 ). T he m eni sci (G. men is ko s, cr escen t) ar e thi cker at th eir
e xter nal m ar gi ns an d tap er to thi n , un atta ched e dg es i n th e i nter io r of th e j oin t. Wed g e sh ap ed in tr an sver se sect ion , th e m en isci
a re fi rm ly atta ched a t th eir end s to th e in terc on dyla r are a o f the tib ia (Fig . 5. 6 0A). T hei r exter n al ma rg in s att ach to th e j oin t
c apsu le of th e knee . Th e co r onar y li ga ments a re po rti on s of t he joi n t cap su le e xten din g b etwe en th e m ar gi ns of th e men isci an d
m o st of t he per ip h ery of th e tib ial con dyl es (Fi g. 5 . 60B ). A slen der fib ro us ba nd , th e tr ansver se lig ament of the k nee j oin s the
a nte ri or ed ges of th e m en isci (Fig . 5 .6 1A), t ethe rin g th em to ea ch oth er d ur in g kn ee m o vem ents.
T h e med ia l me ni scus i s C sh ap ed, br oad er p oster ior ly th an an ter ior ly. I ts a nte ri or en d (ho rn ) is a ttach ed to the an ter ior
i n terco nd ylar area of t he tib ia, a nte rio r to th e att achm en t of th e A CL (Fi g. 5 . 60A ). Its po ster ior en d is attach ed to th e post eri or
i n terco nd ylar area , an ter ior to th e attach m ent of th e PC L. T he m ed ial m eni scus fi rm ly ad he res to the d eep su rf ace o f th e T CL (Fig s.
5 . 5 9C a nd 5 . 6 1). B ecau se of its wid esp rea d attach m en ts l ater ally to th e ti bi al i n terco nd ylar are a an d m ed iall y to th e TC L, th e
m ed ial m en iscu s i s l ess m ob ile on t he tib ial p latea u th an is th e l ater al men i scus.
T h e l ater al meniscus is n ear ly cir cul ar , sm aller , an d m or e f re ely mo vab le t han the m edi al m eni scus. Th e te nd on o f the po pl iteu s
h as two p ar ts p ro xim all y. On e p art atta che s to th e l ater al epi con dyl e of t he fem u r an d pa sses b etw een th e l ater al m eni scus an d
i n fer ior p ar t o f the la tera l ep ico nd ylar sur fa ce of
P. 6 9 1
P. 6 9 2
P. 6 9 3
P. 6 9 4
t he fe mu r (on the ten do n' s m ed ial asp ect) a nd th e FCL th at over li es it s la tera l a spect (Fig s. 5. 5 9A a nd 5 . 60B & D). Th e o the r,
m o re m edi al par t o f th e p op litea l t end on a ttach es to th e post eri or li mb o f the la tera l m en iscu s. A str on g ten di no us slip , th e
p o ster ior me niscof emo ra l l ig ament, jo in s th e later al m en iscu s to th e P CL a nd th e me dia l f em or al con dyl e (Fig s. 5 . 60 D an d
5 . 6 1B ).

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Fig ure 5.60. Cr uci ate lig aments of knee jo int. A. Su pe rio r asp ect o f the su per io r art icu lar su rf ace of th e ti bi a (ti bi al
pl ateau ) sh ow in g th e m ed ial an d la tera l co nd yles (ar ticu lar su r face s) an d th e i nt erco nd ylar e mi ne nce bet ween them . T he sit es
of atta chm en t of th e cr uci ate lig am en ts ar e colo red g re en; th ose of th e m ed ial m en iscu s, pu r pl e; an d th ose of th e l ater al
m eni scus, ora ng e. B . Th e q u adr icep s tend on h as be en sever ed an d th e p atel la (with in the ten do n an d its con tin u atio n, th e
pat ella r lig am en t) h as been ref lected i nf er ior ly. T h e kn ee is f lexe d to dem on str ate the cr uci ate lig am en ts. C. In the se la ter al
an d me dia l vi ews, the fe mu r h as been se ction ed l on gitu d in all y an d th e n ear hal f ha s b een r em oved w ith th e pr oxim al p art of
th e cor r espo nd in g cr uci ate l ig am ent . Th e l ater al view d em on stra tes h ow th e po steri or cr uci ate lig am en t r esists an ter ior
di spla cem ent of th e fem u r on th e tib ial p lateau . T he m edi al view d em on stra tes h ow th e an teri or cr uci ate lig am en t r esists
po steri or d isp lacem en t o f the f emu r o n the ti bia l p lat eau . D. B oth h ea ds of th e g astr ocn em iu s ar e r ef lected su p eri or ly, an d th e
bi ceps fem or is is ref lecte d in fer ior ly. Th e ar ti cul ar cavit y h as b een i nf lat ed wit h pu r ple la tex to d em on stra te i ts co nti nu ity wi th
th e var io us bu r sae a nd th e re flect ion s a nd at tach me nts of th e co m ple x syn ovi al mem b ra ne.

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Fig ure 5.61. Meni sci o f knee joi nt. A. T h e q ua dr icep s ten d on i s cu t, an d th e p atel la and p atel lar l ig am ent ar e r ef lected
in fer io rly an d an ter ior ly. T h e m en isci, the ir atta chm en ts t o th e in ter con dyla r ar ea o f the tib ia , an d the tib ial at tach men ts of
th e cr uci ate lig am en ts ar e sho wn . B . Th e b an d-l ike tib ial col later al li gam en t is a ttach ed to th e m ed ial m en iscu s. Th e co rd -li ke
fi bu lar co lla tera l l ig am ent is sepa rat ed fr om th e later al m en iscu s. Th e post eri or m en iscof em or al lig am en t att ache s th e l ater al
m eni scus to th e m ed ial fe mo ral co nd yle. C and D . Th e n u m ber s o n th e MR I stud y ref er to th e str u ctur es lab eled i n th e
cor resp on di ng a na tom ical cor on al secti on . (Par t C cou rt esy o f Dr . W. K uch ar czyk, C h air o f Me dica l I m agi ng , Un iver sit y of
Tor on to, an d Cl in ical Dir ector of T ri -Ho spit al Ma gn etic Re son an ce C en tre, Tor on to, On tar io , C ana da. )
M ov em en t s of t h e K n ee J o in t
Fl exion an d exten sion a re th e m ai n kn ee m ove men ts; som e r ota tion occu rs wh en th e knee is fl exed . When the kn ee is f u lly
e xten ded w ith th e fo ot o n th e g ro un d , th e kn ee passi vely locks b ecau se o f m ed ial r otat ion o f the f emo ra l co nd yles on th e
t ibi al pl ateau . T hi s p ositi on m akes th e l ower l im b a soli d colu m n an d m ore ad ap ted fo r wei gh t b ear in g. When the kn ee i s
l ocked , th e t hi gh an d le g mu scle s can r ela x b ri efl y w ith ou t m aki ng t he kn ee j oin t too un stab le. To un lo ck th e kn ee, th e
p op li teus con tr acts, r otati ng t he fem u r la tera lly ab ou t 5 on the tib ial p late au so tha t f lexi on of th e kne e can occu r. T he m ain
m o vem ent s of th e kne e j oin t, th e m u scles pr od u cin g the m, a nd r ele van t d etail s ar e pr ovid ed in Tab le 5. 1 6 .
Ta bl e 5. 16. M oveme nts of the Knee Jo int and the Muscl es P ro duci ng Them

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Muscles Pr od ucing Mo vement

Deg r ees
M oveme nt
P ossi bl e
Ext ensi on
Pr imar y
Qu ad ric eps fem or is
Seco nd ar y
We akly: ten sor
o f fasci a l ata
Factor s Li miting
(Check ing)
M oveme nt
C omments
A nt eri or ed ge of
l ater al me ni scus
A bi lity of
q u adr icep s to
co nta cts sh all ow

g ro ove bet ween
p ro du ce exten sion
i s m ost eff ective
ti bi al an d patel lar
su r faces of f em ora l
w he n hi p joi nt is
ext end ed ; f lexio n
co nd yles; an ter ior

cr u icate li gam en t
d im in ish es its
ef fi cien cy
co nta cts g ro ove in

i nte rcon d ylar f ossa
Flexio n
12 0 (h ip
exten de d);
H am stri ng s
(sem ite ndin osus,
Gr acil is,
sa rto ri us,
C al f o f leg con tac ts

th ig h ; le ng th of
N or ma lly, r ol e o f
g astr oc-n em iu s is
14 0 (h ip
fl exed);
semim em b ran osus,

lo ng h ead o f bi ceps);
g astr ocnem ius,

p op lit eus
h am str in gs is also a
f actor m or e kn ee
m in im al , bu t in
p re sence of a
16 0
pass ively
sh or t h ead o f bice ps
f lexi on is po ssib le
w he n hi p joi nt is
su p raco nd ylar
f ra ctur e, i t r otate s
f lexed ; ca nn ot fu ll y
f lex kn ee w he n hi p is
(f lexes) di stal
f ra gm en t o f fem u r
ex tend ed
Medi al
10 w ith
S emi ten di no sus an d
Gr acil is,
C ol later al li gam en ts,
Wh en ext end ed
ro tatio n
kn ee f lexed ;
5 wi th
sem im em b ran osu s

w hen knee is fl exed ;
sa rto ri us
l oose du r in g fl exion
w ith ou t r ot ation ,
kn ee is bear in g
w eig ht , actio n of
kn ee
exten de d
p op liteu s wh en n on b ear in g kne e is
b ecom e tau t at li mi ts
o f rot atio n
p op lite us later al ly
r otat es f em ur ;
exte nd ed
w he n no t b ear in g
w eig ht , po pli teu s
m ed ial ly r ota tes
p atel la
Lat era l
ro tatio n
30
B icep s f emo ri s w hen

kn ee is f lexe d
C ol later al li gam en ts
b ecom e tau t;
A t en d of r ota tion ,
w ith n o op pos itio n,
a nter io r cru cia te

l ig ame nt be com es
te nso r of fa scia
l ata can assi st in
w ou nd a ro un d
p oster io r cru cia te
m ai nta in in g
p osit ion
l ig ame nt
M ov em en t s of th e M en is ci
A lth ou g h th e r oll in g m ovem en t o f t he fem o ral con d yles du r in g flex ion a nd ext ensi on i s li mi ted (con ver ted to sp in ) b y th e cr u ciate
l ig am ent s, som e
P. 6 9 5
r ol lin g d oes occu r, an d th e poi nt of co nta ct b etwe en th e f em ur a nd th e tib ia mo ves p oste rio rl y w ith f lexi on an d r etu rn s a nter io rl y
w ith exten sion . Fu rth er m ore , du r in g ro tatio n of th e kn ee, on e f em ora l co nd yle m oves an teri or ly on th e co rr esp on din g ti bia l co nd yle
w h ile th e o the r fem or al con dy le m o ves p oster io rly , ro tatin g ab ou t th e chi asm o f t he cru ci ate l ig am ent s. Th e m en isci m u st b e a ble
t o m ig r ate on th e t ibi al pl ateau a s th e p oi nts of con tact b etwee n fem u r an d tib ia cha ng e.
B lo od S u p p ly o f t h e Kn ee J oi n t
T h e ar ter ies su pp lyin g th e kn ee jo in t ar e the 1 0 vessel s th at for m th e per iar ti cul ar gen icu la r an astom ose s ar ou n d the kn ee: t he
g en icu lar b r an ches of th e f em or al, p op lit eal, a nd an ter io r an d post eri or r ecur r ent b ran ch es o f the an ter ior t ibi al recu r re nt an d
c ircu m fl ex f ib ul ar ar ter ies (Fi gs. 5 . 6 2 an d 5. 6 3B ). T he m id dle g eni cul ar br an ch es o f the p opl iteal ar ter y p en etr ate the fi br ou s l ayer
o f th e j oin t ca psu le an d sup pl y th e cru cia te l iga me nts, syno vial m em br an e, an d pe ri ph era l m ar g in s of th e m eni sci.
I n n e rv at io n of th e Kn ee J o in t
R ef lecti ng H ilt on 's l aw, th e ne rves su pp lyin g th e m u scles cr ossin g (acti ng o n) th e kn ee joi nt also su pp ly th e j oin t ( Fi g. 5 . 63D );
t hu s a rti cul ar b ran ches f ro m th e f em or al (the b ran ch es t o th e vasti), tib ial, and co m mo n fi bu lar n er ves sup pl y it s an ter ior ,
p oste ri or, and l ater al asp ects, r especti vely. In ad di tio n, h ow ever, th e o btu r ator an d sap h eno us (cu tan eou s) n er ves su p ply ar ticu lar
b r an ches to its me dia l a spect.
B u rs ae ar ou n d t h e K n ee Jo in t
T h ere ar e a t le ast 1 2 b u rsae ar ou nd t he kn ee j oin t beca use m ost tend on s r u n pa ral lel to th e b on es a nd p u ll len gt hw ise acro ss th e

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j oin t du r in g kne e m ovem en ts. T he sub cutaneous pr ep atel lar an d i nf r ap atell ar bur sae ar e l ocated a t th e con vex su r face of th e
j oin t, a llo win g th e sk in to be ab le to mo ve f re ely du ri ng m o vem ents of th e knee (Fig s. 5 .5 8B an d 5. 5 9A ). Th e m ain b ur sae of th e
k nee ar e i llu str ated an d d escri bed i n Ta ble 5 .1 7 .
Fig ure 5.62. Arte ri al a nastomo ses aro und knee. I n ad di tion to p r ovid in g coll ater al cir cul atio n, t he ge ni cul ar ar ter ies o f the
gen icu la r an astom osi s su pp ly bl ood to th e stru ctu re s su rr ou n din g th e joi nt as w ell as to th e j oin t i tself (e. g ., i ts j oin t or
ar ticu lar cap su le). C om p are th ese view s w ith th e ant eri or view i n Fig ur e 5 . 6 3B .
Fo ur b u rsae com m u ni cate with the syn ovia l ca vity of th e kn ee jo in t: su pr ap atel lar b ur sa, p op lite us bu r sa (d eep to th e d ista l
q u adr ice ps), an ser in e b u rsa (d eep to th e ten d in ou s d istal atta chm en ts of th e sar tor iu s, g ra cili s, an d semi ten di no sus), a nd
g astr ocn em iu s b u rsa (Fig s. 5. 5 9A a nd 5 . 6 0D ). T he lar ge sup ra pa tella r bur sa (Fi gs. 5 . 5 7A an d 5 .5 9 A) is especi all y i mp or tan t
b ecau se an in f ection in it m ay spr ead to th e kn ee joi nt cavi ty. Al th ou gh i t d evelo ps sepa rate ly f r om th e k nee jo in t, th e b u rsa
b ecom es con tin u ou s w ith i t.
Kn e e J o i n t I n ju r i e s
Kn ee joi nt in ju r ies a re com m on b ecau se t he kn ee i s a low -pl aced , m obi le, w eig h t-bear in g jo in t, ser vin g as a f ul cru m b etw een tw o
lon g leve rs (thi gh and l eg). Its stab ilit y d epen d s al m ost e nti rel y o n its associa ted li gam en ts and su r ro un d in g mu scle s. Th e kn ee
joi nt is essen tial f or ever yda y act iviti es su ch as stan di ng , w alkin g , an d clim b in g stair s. I t i s al so a m ain join t fo r spor ts tha t
in volve r un n in g, j um p in g, ki ckin g, and ch an g in g di recti on s. To p erf or m th ese a ctivi ties, th e kne e jo in t m u st b e mo bi le; h ow ever ,
thi s m ob ili ty m ak es it su scept ibl e to i nj ur ies. T h e m ost com m on kn ee in ju ri es i n con tact spo rts ar e li ga men t spr ain s, w hi ch occu r
wh en th e f oo t is fi xed in t he gr ou n d (Fig. B 5 .2 6A). I f a for ce is a pp lied a gai nst th e kn ee wh en th e fo ot ca nn ot m ove, l iga me nt
in ju ri es ar e likel y to o ccur . Th e tib ial an d fi bu lar colla ter al lig am en ts (T CL an d FC L) are tig h tly stre tched wh en th e l eg is exten ded ,
no rm al ly p r even tin g di sru pti on o f the sid es o f the kn ee joi nt.

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Fig ure 5.63. Jo ints and neuro vascular s tructur es o f leg and f oo t. A. Th e t ibi of ibu la r art icu lati on s in clu d e th e syno vial
tib iof ib ul ar jo in t an d th e tibi of ibu la r syn desm osi s; th e latter i s m ad e u p of th e in ter osseou s mem b ra ne of th e leg an d th e
an teri or an d p oster ior t ibi of ibu la r lig am en ts. Th e ob liq ue d ire ction o f th e f ibe rs of th e i nte ross eou s m em br an e, p ri ma ril y
exten di ng i nf er olat era lly fr om th e tib ia, a llo ws sl ig ht u pw ard m o vem ent of th e fib u la bu t r esist s d own w ard p u ll on i t. B. T h e
ar teri al sup pl y o f the jo in ts o f the leg a nd f oot is dem o nstr ated . Per ia rti cul ar an astom ose s su rr ou n d the kn ee an d ankl e. C. Of
th e n in e m u scles atta ched to th e fib u la, a ll excep t on e exer t a do wn wa rd p ul l on th e f ib ul a. D . Th e ner ve sup pl y o f the leg a nd
fo ot i s d em on stra ted. S tar tin g wi th th e k nee an d pr og re ssin g dist ally in t he li mb , cu tan eou s n er ves b ecom e in cre asin gl y
in volv ed in p ro vid in g in ner vati on to jo in ts, taki ng o ver com p letel y in the d istal fo ot an d toes.
T abl e 5. 17. B ur sae a bo ut the Knee Jo int

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B ursa e
Su pr ap atel lar
Page 130 of 155
L ocati ons
Be tween fem u r an d ten don of qu ad ri ceps
fe mo ri s
Comm ents
H eld in posi tion by art icu lar is gen u m u scles;
com m u ni cates fr eely wi th (su per io r exten sion of)
syn ovi al cavity of kn ee joi nt
Pop lit eus
An ser in e
Be tween tend on o f po pli teu s an d la tera l
Op ens in to syn ovia l ca vity of kn ee j oin t in fer ior to
con dy le o f tib ia
la tera l m en iscu s
Sep ar ates ten do ns of sar tor iu s, gr aci lis,
A rea wh er e t end on s o f the se m u scles attach t o
an d sem iten d in osu s f rom tib ia an d tib ial

col later al li gam en t
ti bia ; r esem bl es a go ose's fo ot (L. p es a nser in u s)
Gastro cne mi us
Deep to pr oxi ma l a ttach m ent of ten d on of

m edi al he ad of g astro cne mi us
A n exten sion of syn ovia l ca vity of kn ee j oin t
Sem im em b ran osu s
Be tween med ia l h ead o f gastr ocn em iu s a nd

sem im em br an osu s t end on
R elat ed to dist al attach m ent of sem i mem b ra no sus
Su bcu tan eo us
prep atell ar
Be tween skin an d an ter ior su r face of

pa tell a
A llo ws f r ee m ove men t of skin over p atell a d u ri ng

m ovem en ts of leg
Su bcu tan eo us
Be tween skin an d tib ia l tu b ero sity
H elp s kn ee with stan d p ressu r e w h en kn eelin g
Be tween pate llar l ig am ent an d an ter ior
S epar ated f r om kn ee joi nt by in fr ap atel lar f at p ad
in fr ap atell ar
De ep in fr ap atell ar
su rf ace of tib ia
T h e f ir m atta chm en t o f the TC L to th e m ed ial m en iscu s i s of co nsi der ab le clin ica l si gn if ican ce becau se tear in g of th is lig am en t
f r equ en tly resu lt s in con com itan t tear in g of th e m ed ial m en iscu s. Th e in ju ry is fr equ en tly cau sed by a bl ow to the la tera l si de of
t he exten d ed kne e o r excessive lat era l tw isti ng o f the fl exed kn ee tha t d isr up ts the TC L an d con com it ant ly te ars an d/o r deta che s
t he m edi al me ni scus fr om t he jo in t cap su le (Fi g. B 5 .2 6A). T hi s in j ur y i s com m on in ath let es w ho tw ist the ir fl exed kn ees wh ile
r u nn in g (e. g ., i n ba sketba ll, th e var iou s f or m s of f oot bal l, an d vol leyb all ). Th e A C L, w hi ch ser ves a s a pi vot for r ota tor y
m o vem ent s of th e kne e an d is tau t d u ri ng f lexi on , m ay al so tear su bseq u en t to th e r u ptu r e o f t he TC L , crea tin g an u nh ap py
t ri ad of kn ee in ju ri es. Hyp er exten sion an d severe f orce d ir ected an ter ior ly ag ain st th e fem u r wi th th e kn ee sem if lexed (e. g ., a
c ross-b od y b lo ck in foo tba ll) ma y tea r the A CL . AC L r up tu res ar e al so com mo n kn ee i nj ur ie s in skiin g accid en ts. T hi s in ju r y cau ses
t he fr ee tibia to slid e a nter io rl y u n der th e fix ed fem u r, kno wn as the a nte ri or d ra w er sig n (Fig . B5 . 2 6B ). Th e AC L m ay te ar aw ay
f r om th e fem u r or tib ia ; h ow ever, tear s com m on ly occu r in t he m idp or tio n of th e l ig am ent .

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Fig ure B5. 26
A lth ou g h stro ng , PC L r up tu res m ay o ccur wh en a pl ayer la nd s o n th e ti bia l t ub ero sity wi th th e kn ee fl exed (e. g. , wh en k no cked to
t he fl oor i n ba sketba ll). P CL r u ptu r es u su ally occu r in con ju ncti on w ith ti bi al or fi bu la r lig am en t tea rs. T he se i nj ur ies can al so occu r
i n h ead -on col lisi on s w hen seat b elt s ar e n ot w orn and the pr oxi m al end o f the tib ia str ikes th e d ash boa rd . PC L ru p tur es all ow th e
f r ee ti bi a to sli de po ster ior ly un d er th e f ixed f em ur , kn ow n as t he p oster io r dr aw er s ig n (Fig . B5 . 26C ).
Men isca l t ear s u sua lly in volv e th e med ia l m en iscu s. T he lat eral m en iscu s d oes n ot u su all y tea r beca use of it s m ob ili ty. Pai n on
l ater al ro tatio n of th e tib ia on th e f em ur in dica tes i nj ur y of th e l ater al me ni scus (Fig. B5 .2 7A), w h erea s p ain o n m edi al ro tatio n of
t he tib ia on th e fem u r in di cates in ju ry of th e med ia l m en iscu s (Fi g. B 5. 2 7B). Most m en iscal tear s o ccur in con ju n ction wit h TC L or
A C L tear s. Per ip her al m en iscal tear s can of ten b e r ep air ed or m ay he al on th eir o wn b ecau se o f th e g ene ro us bl ood su pp ly to thi s
a rea . Meni scal tear s th at do n ot he al or can n ot b e rep air ed ar e usu all y r em oved (e. g ., b y arth r oscop ic sur g ery). Kn ee joi nts fr om
w h ich th e men is ci h ave be en re mo ved su ff er no l oss o f mo bi lity; h oweve r, th e kn ee m ay be less stab le an d the tib ial p late aus
o fte n un d erg o in fla mm at ory r eactio ns.

08-May-15
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Fig ure B5. 27
A r th r o s c o p y o f t h e K n e e J o i nt
Ar thr osco py is an en do scop ic ex am in ation tha t al low s vi sua liza tion o f the in ter io r of th e kn ee joi nt cavi ty w ith m in im al d isr up tio n
o f tissu e (Fi g. B 5 .2 8 ). Th e arth r oscop e a nd o ne (or m or e) add iti on al can ul a(e) a re in ser ted th ro ug h tin y in cisio ns, k no wn as
p or tal s. Th e se con d can ul a i s fo r pa ssage of sp ecial ized to ols (e. g. , m an ipu la tive pr ob es o r fo rcep s) o r equ ip m en t f or tr im m in g,
s hap in g, or r em ovin g da ma ged ti ssue . Th is tech ni qu e a llo ws rem ova l o f tor n m en isci, l oose bo di es in the jo in t (su ch as bo ne
c hi ps), an d d b ri dem en t (the exci sion o f devi tali zed ar ticu lar ca rti lag in ou s m ater ia l) i n ad van ced cases of ar thr iti s. Li gam en t
r ep air o r rep la ceme nt m ay a lso be pe rf or med u sin g an arth r oscop e. A lth ou gh g en er al ane sthe sia is u su all y p ref er abl e, kn ee
a rth r oscop y ca n be pe rf or me d usi ng l ocal or r eg ion al an esth esia. Du r in g arth r oscop y, th e arti cul ar cavi ty o f the kn ee m u st be
t rea ted essen tial ly as tw o sepa rate (m edi al an d later al ) f emo ro tib ial ar ticu lat ion s o win g to th e i m posi tion of th e syn ovi al fol d
a ro un d th e cr u ciate li gam en ts. For f u rth er in f or ma tion se e S oam es (19 9 5).
A s p ir a ti o n o f th e K ne e J o i n t
Fr actu r es of th e di stal en d of th e f em ur o r lacer ati on s of t he an ter ior th ig h m ay in volve th e su p rap atel lar b u rsa an d res ul t in
i n fecti on of th e kne e j oin t. Wh en th e k nee jo in t i s in f ected an d in fl am ed, t he am ou n t of syn ov ial fl ui d ma y in cr ease. J oi nt
e ff usio ns , the escap e of fl ui d fr om b loo d or ly mp h atic vessels, r esu lts in i ncr eased a mo un ts of fl ui d in th e joi nt cavit y. Beca use
t he su pr apa tell ar bu r sa co mm u n icates fr eel y w ith th e syno vial cavi ty o f the kn ee j oin t, f u lln ess o f th e th ig h in t he re gio n of th e
s up ra pate llar b u rsa m ay i n dica te i ncr eased syn ov ial fl ui d. T hi s b u rsa can b e a spir ated t o r em ove th e f lu id f or exam in ati on . Dir ect
a spi rati on o f the kn ee j oin t is u su all y p erf or m ed wi th th e p atie nt sitti ng o n a tabl e w ith th e kn ee f lexed . Th e joi nt is ap pr oach ed
l ater all y, u sin g thr ee bo ny po in ts as la nd m arks fo r ne edl e in ser tio n: th e an ter ol ater al tib ial (Gerd y) tub er cle, th e later al ep icon d yle
o f th e f em ur , an d th e ap ex of th e p atel la. I n ad di tion t o b ein g th e r ou te fo r aspi rat ion o f sero us an d san gu in eou s (blo od y) f lu id,
t hi s tr ian g ul ar ar ea a lso len ds itse lf to dr ug in jectio n fo r tre atin g pa tho log y o f th e kn ee joi nt.
Fig ure B5. 28
B u r s i ti s i n th e Kn e e R e g i o n
P rep atel lar b u rsi tis i s cau sed b y f ri ctio n betw een th e skin a nd th e pate lla; h owe ver, t he bu r sa m ay also b e i nj ur ed b y co mp r essive
f or ces r esu lti ng f ro m a di rect bl ow or f ro m fa lli ng o n th e f lexed kn ee (An d erso n et a l. , 2 00 0 ). If th e in fl am mat ion i s ch ro ni c, th e
b u rsa b ecom es d iste nd ed wi th fl ui d an d for m s a swe lli ng an ter io r to the kn ee. T hi s con d itio n h as b een cal led h ou sem aid 's
k nee (Fig . B5 . 2 9); ho weve r, o the r peo ple w ho wo rk on th ei r kne es w ith ou t kn ee pa ds, su ch as h ard wo od fl oor a nd r u g in stall ers,

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m ay al so d evel op pr ep atell ar b ur siti s.

S u bcu tan eou s i nf r apa tella r bu rs itis is cause d by excessive f rict ion b etw een th e sk in an d th e ti bi al tub er osity; th e ed em a occu rs
o ver th e p r oxim al en d of th e tib ia. T hi s con d itio n wa s f orm er ly call ed cler gym an 's kn ee b ecau se of fr eq uen t gen u fl ectin g (L.
g en u , kne e); h ow ever , it occu rs m ore com m on ly in r oof er s an d f loor tiler s i f th ey d o no t w ear kn ee p ad s. D eep in fr ap atell ar
b u rsi tis resu lts in e dem a betw een th e pat ella r lig am en t an d th e tibi a, su pe rio r to the ti bia l tu b ero sity. T h e in f lam m atio n is usu al ly
c ause d by over use an d su bseq u ent fr icti on b etw een th e p atel lar te nd on an d th e stru ctu res po ster ior to i t, th e i nf rap atel lar f at-p ad
a nd t ibi a (A n der son et al ., 2 0 00 ). E n lar ge men t of th e d eep i nf rap atel lar b u rsa ob lite rat es th e dim p les no rm al ly o ccur r in g on each
s ide of th e pate llar lig am en t w hen the leg i s ext end ed .
Fig ure B5. 29
Fig ure B5. 30
A br asi on s or p en etr atin g wo un d s m ay resu lt in sup ra pate llar b u rsi tis, an in fecti on cau sed b y b acter ia en teri n g the bu r sa f r om th e
t or n skin . Th e in fecti on m ay spr ead to th e ca vity of th e kn ee jo in t, cau sin g loca lized r ed ne ss an d en lar ge d pop li teal an d in gu in al
l ym ph n od es.
P o p l i te a l C y st s
P op litea l cy sts (B aker cysts) ar e ab n or ma l f lu id -fil led sacs of syn ovi al me mb r ane in t he re gio n of th e pop li teal fo ssa. A po pl iteal
c yst is alm o st al ways a com pl icati on of ch r on ic kn ee jo in t ef fu sio n (Sla by et a l. , 19 9 4 ). Th e cyst m ay be a her n iati on of th e
g astr ocn em iu s o r sem im em br an osu s b ur sa th rou g h th e f ib rou s layer o f th e jo in t ca psu le in to the p opl itea l f ossa, co m mu n icati ng
w ith the syn ovia l ca vity of th e kn ee jo in t b y a n arr ow sta lk (Fi g. B 5. 3 0 ). Syn ovi al flu id m ay also esca pe fr om th e kn ee j oin t
( syno vial ef fu sion ) or a bu rsa ar ou n d the kn ee a nd co llect in the po pl iteal f ossa. H er e it f orm s a n ew syn ovi al-li ne d sac, or
p op li teal cyst. Po pli teal cysts ar e com m on i n ch ild re n bu t seld om cau se sym ptom s. I n ad u lts, p opl itea l cyst s can b e lar ge,
e xten din g as fa r as th e m idca lf, and m ay in ter fer e wit h kne e m ovem en ts.
K n e e Re p l a ce m e nt
I f a per son 's kne e is di seased , r esul tin g fr om o steoa rth r itis, f or exa mp le, an ar tif icia l kn ee joi nt m ay be in sert ed (total kn ee
r ep lacem en t art hr op lasty) (Fig . B5 . 31 ). T he ar tif icial kn ee joi nt con sists of p lasti c an d m etal com p on en ts th at ar e cem en ted to th e
f em or al an d tib ial b on e en ds af ter r emo val of th e d ef ective ar eas. T he com b in ation of m etal an d pl astic m im ics the sm ooth n ess o f
c arti lag e o n car tila ge an d pr od uce s g ood r esu lts i n low -de ma nd p eop le wh o h ave a r elati vely sed enta ry lif e. I n hi gh d em an d p eop le w h o a re activ e in spor ts, th e bo ne ce men t ju nct ion s m ay br eak do wn , an d th e a rti fici al kn ee co mp on en ts m ay
l oose n; ho weve r, i mp r ovem en ts i n bi oen gi nee rin g an d su rg ical tech n iq ue h ave pr ovid ed b etter r esu lts. For m or e in for m atio n see
S oam es (1 99 5 ).

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Fig ure B5. 31
P. 6 9 6
P. 6 9 7
P. 6 9 8
P. 6 9 9
P. 7 0 0
P. 7 0 1
T h e kn ee is a h in ge jo in t w ith a w ide r ang e of m otio n (pr im ar il y f lexio n an d exten sio n, w ith r ota tion in crea sin gly po ssib le wit h
f lexi on ). It is ou r m ost vul ne rab le joi nt ow in g to its in con gr uo us ar ticu lar su r face s an d th e m ech an ical d isad van tag e r esu ltin g f ro m
b ear in g th e b od y's weig h t p lu s m om en tu m w hi le servi ng a s a fu lcr u m bet ween t wo lon g le vers. Com p en satio n is attem pt ed by
s evera l f eatu r es, in clu di n g (1) stro ng i nt ri nsi c, extr acap sul ar, a nd i nt raca psu lar l ig am ents; (2 ) sp lin ti ng b y m an y sur ro un d in g
t end on s (i ncl ud in g th e i lio tib ial tr act); and (3 ) me ni sci t hat fi ll th e sp atia l v oid , pr ovi di ng m ob ile ar ticu la r sur fa ces. Of pa rti cul ar
c lin ical im p or tan ce a re (1) col later al li gam en ts tha t ar e tau t d ur in g (an d li mi t) ext ensi on an d ar e r el axed du r in g fl exion , al low in g
r ot ation for w h ich th ey serve as che ck li gam en ts; (2) cr uci ate l ig am ent s th at ma in tain t he joi nt d ur in g fl exio n, p r ovid in g th e p ivot
f or r ota tion ; a nd (3 ) the m edi al m eni scus th at i s at tach ed to the tib ia l co llat era l l iga me nt an d is fr equ en tly in ju re d beca use of th is
a ttachm ent .
T ib iof ib u la r J o in ts
T h e ti bia an d fi bu la ar e co nn ected by two jo in ts: th e sup er ior ti bi ofi bu lar j oin t an d the tib io fib u lar syn d esmo sis (in fer ior
ti bi ofi bu la r) joi nt. In ad di tio n, a n in ter osseou s m em b ra ne jo in s th e sh af ts o f the tw o b on es (Fi g. 5 . 63A ). Th e fib er s of th e
i nte ro sseou s m em br an e and a ll lig am en ts o f bot h tib iof ib ul ar ar ticu lati on s r u n in fer io rly fr om the tib ia to th e f ib ul a. Th u s th e
m em b ran e an d lig am en ts str on gl y r esist th e d ow nw ar d pu ll p laced o n th e f ibu la b y ei gh t o f th e n in e m u scles atta ched to i t (Fig .
5 . 63 C ). H oweve r, th ey all ow sli gh t u p war d m ovem en t o f the f ibu la th at occu rs wh en th e wid e (post eri or) en d of th e t roch le a o f the
ta lu s i s we dg ed bet ween t he m all eoli d ur in g do rsi fle xion a t th e an kle. Move men t at the su per io r tib iof ib ul ar joi n t is im p ossib le
w ith ou t mo vem ent at th e i nf eri or ti bio fi bu lar syn d esm osis.
T h e an ter ior tib ial vessel s p ass th r ou gh a h iatu s a t th e sup er ior en d of t he in ter osseou s me mb ra ne (Fig . 5 .6 3A & B ). At th e in f eri or
e nd o f t he m em br an e i s a sma ller hi atu s th ro ug h w hi ch th e p erf or atin g b ra nch o f the f ibu la r art ery pa sses.
S u p eri or T ib io fi bu lar J o in t
T h e sup er ior ti bi of ib ular jo int is a p lan e type of syn ovi al joi nt bet ween the fl at f acet on th e fi bu lar h ead a nd a sim il ar ar ticu lar
f acet loca ted po ster olate ral ly on th e l ater al tib ial con d yle (Fi gs. 5 . 6 1B & D an d 5 .6 3 A). A te nse joi n t cap su le su r ro un d s th e j oin t
a nd at tach es to th e mar g in s of th e ar ticu lar su r faces of th e fib u la and tibi a. T he jo in t cap su le is str en gth en ed b y an ter io r an d
p oster io r tib iof ib ul ar li gam en ts, w hi ch pa ss su per om ed ial ly fr om th e fib u lar h ead to th e l ater al tib ial con d yle (Fi g. 5 . 6 1B ). Th e joi nt
i s cr ossed p oster io rly b y th e tend on o f th e p op liteu s. A p ou ch of syn ovi al mem b ra ne fr om the kn ee j oin t, th e po pli teu s b ur sa (Tab le
5 . 17 ), p asses bet ween t he ten do n of th e p op lit eus an d th e la ter al con dyle of th e tib ia. A bo ut 2 0% of t he tim e, th e bu r sa al so
co mm u n icates wi th th e syn ov ial cavit y of th e tib iof ib ul ar jo in t, en abl in g tra nsm i gr atio n of in fl am m ator y p ro cesses betw een th e two
j oints.
M o v em e n t
S lig h t m ove men t of th e j oin t occu rs du r in g dor sif lexi on of t he fo ot a s a re sul t of w ed gin g of t he tr och lea of th e ta lu s b etwee n th e
m al leol i (see A rti cul ar Su r face s of th e An kle Join t, l ater i n th is ch ap ter ).
B lo od S u p pl y
T h e ar ter ies of th e su p eri or tib io fib u lar j oin t a re fr om the in fe rio r late ral g en icu lar an d an ter ior tibi al re cur re nt ar teri es (Fi gs.
5 . 62 A an d 5 .6 3 B).
N er v e S u p p ly
T h e n er ves o f t he tib iof ib ul ar jo in t a re fr om th e com m on f ibu la r ne rve an d th e n er ve to th e pop li teu s (Fig . 5 .6 3D).
T ib i ofi bu lar S y n d es m o s is
T h e tib io f ib ul ar synd esmosi s i s a com p ou nd f ib rou s joi nt. It is t he fi br ou s u n ion o f the ti bia an d fi bu la b y m ean s o f the

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i n tero sseou s m em b ran e (un iti ng t he sh afts) an d th e an ter io r, i nter osse ou s an d po ster ior ti bi ofi bu lar lig am ent s (th e l atter m aki ng
u p th e infe rio r tib io fi bul ar jo int, u ni tin g th e d istal en ds of th e bon es). T h e in teg r ity of th e i nf eri or ti bio fib u lar j oin t is e ssenti al
f or th e stab ili ty o f t he an kle joi nt b ecau se i t keep s t he lat eral m al leol us fi rm ly ag ain st th e late ral su rf ace of th e t alu s.
A r ti cu l ar S u r fac es an d Li ga m en t s
T h e r ou gh , tr ian g ul ar ar ticu lar a rea on the m edi al sur f ace o f the in fe ri or en d of th e f ib ul a a rti cul ates with a f acet on th e in fer ior
e nd o f the tib ia (Fig . 5. 6 3A). T he str on g deep i nter osseo us ti bi of ib ul ar li ga ment, con tin u ou s su pe rio rl y w ith th e in ter osseou s
m em b ra ne, for m s th e pr in cip al con nect ion b etw een th e ti bi a a nd th e fib u la. T he jo in t i s al so st ren g then ed a nter io rl y an d
p oste ri orl y b y th e stro ng e xter nal ante rior an d p oste rio r inf er ior ti bi of ib ular li g aments. T he di stal dee p con tin ua tion of th e
p oste ri or in fe rio r tib iof ib ul ar li gam en t, th e infe ri or
P. 702
t ransver se (tib io fi bul ar ) l ig ament, f orm s a st ron g con n ectio n be tween the d istal en ds of th e t ibi a (m ed ial m all eol us) an d the
f ib u la (later al m all eolu s). I t co nta cts th e talu s a nd f or ms th e p oster io r wal l o f a sq u are socke t (w ith th r ee d eep w alls an d a
s hal low o r op en an ter ior w all ), the mal leo lar mo rti se, f or th e t roch le a o f the tal us. T h e la tera l a nd m ed ial w alls of th e mo rti se
a re fo rm ed b y th e resp ecti ve m al leol i (Fi g. 5 . 64 ).
M ov e m en t
S li gh t m ov eme nt of th e joi nt occu rs to accom m od ate wed gi ng o f the wi de po rti on o f the tr och lea of th e t alu s b etwe en th e m al leol i
d u ri ng d or sif lexio n of th e foo t.
B lo od S u p p ly
T h e ar ter ies ar e f ro m th e p er for ati ng b ra nch o f th e f ibu la r ar tery an d fr om m ed ial m al leol ar br an ch es o f the an ter ior a nd p oster io r
t ibi al ar teri es (Fig . 5 . 63B ).
N e rv e S u p p ly
T h e n er ves to th e synd esm osi s ar e f ro m th e d eep f ib ul ar, tib ial, a nd sa ph en ou s n er ves (Fig . 5 .6 3D ).
Th e ti bi ofi bu lar joi nts in clu de a sup er ior syn ov ial joi n t an d th e ti bi ofi bu la r synd esm osis, con sistin g of a n in ter osseou s mem b ra ne
an d an in fe rio r tib iof ib ul ar jo in t w ith a nter io r, i nt ero sseou s, an d po steri or ti bio fi bu lar l ig am ents. Tog eth er th ey ma ke u p a
com pen sato ry system t hat al low s a slig h t u pw ar d m ovem en t o f the fi bu la ow in g to for ced tr an sver se exp an sion of th e m al leol ar
mo rti se (d eep sq ua re socket) du r in g m axim al d orsi fl exion of th e an kle . All f ib ro us tib iof ib ul ar con n ection s ru n d own w ard f ro m tib ia
to f ib u la, al low in g th is sl ig ht u pw ard m ov eme nt wh il e str on g ly r esist in g the d own w ard p u ll app li ed to the fi bu la b y th e con tract ion
of eig h t of th e ni ne m u scles attach ed to it.
Fig ure 5.64. Rad io gr ap h o f a nk le joi nt of a 14- year -o ld b oy. T he tr och lea of th e bod y o f th e tal us fi ts i nto th e mo rti se
fo rm ed b y th e med ia l a nd l ater al ma lleo li. E p ip hysi al (gr ow th) pl ates are evi den t a t th is ag e.
A n k le Jo in t
T h e ank le j oint (talo cr ural ar ticul atio n) is a h in g e-typ e syn ovi al joi nt. It is l ocated betw een th e dist al end s o f the tib ia an d th e
f ib u la and t he su per ior par t o f the tal us. Th e an kl e j oin t ca n be fe lt b etw een th e tend on s o n th e a nter io r sur f ace o f the an kle as a
s lig ht de pr essio n, a pp ro xim ately 1 cm pr oxim al to th e t ip of th e med ial m al leol us.
A r ti cu l ar S u r fac es o f t h e An kl e J o in t
T h e d istal en d s of th e tib ia an d fib u la (alon g w ith th e in fer ior tran sver se par t o f th e p oster ior tibi of ibu la r lig am en t) (Fig s. 5 . 63A
a nd 5 . 6 5B ) f or m a ma lleo lar m or tise in to wh ich t he pu ll ey-sh ape d tro chl ea o f the tal us fi ts (Fig . 5 .6 4 ). Th e tro chl ea (L. p u lley) is
t he ro un d ed su per ior arti cul ar su rf ace of th e ta lu s (T abl e 5 . 18A ). Th e m ed ial su rf ace of th e l ater al m alle olu s a rti cul ates with the
l ater al su rf ace o f the tal us. Th e ti bi a ar tic ul ates w ith the tal us in tw o pla ces:

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1. I ts in fer ior sur fac e f orm s th e r oof o f the m all eola r mo rti se, tr an sfer ri ng t he bo dy' s we igh t to the tal us.
2. I ts me dia l m al leol us ar ticu late s w ith th e med ia l su r face of th e talu s.
T h e m al leol i g r ip th e ta lu s ti gh tly as i t r ocks in th e mo rti se d u ri ng m ove men ts of th e j oin t. T he g ri p of th e m all eol i o n th e tr och lea
i s str on g est d u rin g d or sifl exio n of th e f oot (as wh en d igg in g in o ne 's h eel s w hen descen d in g a st eep slop e or d ur in g tu g-of w ar ) b ecau se t hi s m ovem en t for ces the wi der , an ter ior par t o f th e tr och lea p oster ior ly bet ween t he m alle oli , spr ead in g th e ti bia
a nd f ib ul a sl ig htl y ap ar t. T hi s sp read in g is lim i ted esp ecial ly b y t he str on g in tero sseou s ti bi ofi bu la r lig am en t as wel l as th e an teri or
a nd p oster io r tib iof ib ul ar li gam en ts tha t u n ite the tib ia an d fi bu la (Fig s. 5. 6 3A a nd 5 . 65 ). T h e in ter osseo us li gam en t i s d eep ly
p la ced betw een t he ne arl y co ng ru en t sur fa ces of th e tib ia an d fib u la; alth ou g h dem on str ated i n th e i nset fo r Figu r e 5 . 6 3A , th e
l ig am ent can a ctua lly be ob ser ved on ly by ru p tur in g it or i n a cr oss sectio n.
T h e an kl e jo in t i s r elat ively u nsta ble d ur in g p lan tar fle xion b ecau se the tr och lea is na rr ow er po steri or ly and , th er efo re, l ies
r el ativel y l oosel y w ith in th e mo rti se. I t is du r in g pl an tarf lexi on th at m ost in ju rie s of th e an kle occu r (usu al ly as a r esul t o f s ud den ,
u n exp ected and t her ef or e in ad eq uat ely resi sted i nve rsi on of th e foo t).
J o in t Cap s u le of t h e A n kl e J o in t
T h e j oin t ca psu le is thi n an ter ior ly an d po steri or ly b u t i s su pp or ted on e ach sid e b y stro ng co llat eral l iga me nts (Fig s. 5. 6 5 an d
5 . 6 6; th in ar eas of th e ca psu le ha ve b een r em oved i n Fig ur e. 5 .6 5 , le avin g on ly the r ein fo rced p ar ts th e l iga me nts a nd a
s yno vial fo ld ). Its fi br ou s l ayer is attach ed su p eri or ly to th e bo rd ers of th e arti cul ar su rf aces of th e ti bi a an d th e ma lleo li an d
i n fer ior ly to the tal us. Th e syn ovi al m emb r ane is lo ose a nd l in es th e fib r ou s la yer of th e capsu le. Th e syn ovi al cavit y of ten ext end s
s up eri or ly betw een th e tib ia and the fi bu la as far a s th e i nt ero sseou s ti bi ofi bu lar l ig am ent .
P. 7 0 3
Fig ure 5.65. D issecti on o f ankle jo int and j oints of inver sio n and eve rsi on. A and B . Th e foo t h as bee n in vert ed (no te
wed ge u nd er f oot) to dem on str ate th e ar ticu la r ar eas a nd th e later al li gam en ts tha t b ecom e tau t d ur in g in ver sion of th e f oot.
L ig a m en t s o f t h e An k le J o in t
T h e an kl e jo in t i s r ein fo rced l ater all y b y th e later al li ga ment of the ankle , a co m pou n d stru ctu r e con si stin g of th ree com p letel y
s epar ate li gam en ts (Fi g. 5 . 65A & B):
1. Anter io r talo fi bul ar li gam ent, a f lat , weak b and t hat exten d s an ter om ed ial ly f ro m th e l ater al m alle olu s to th e neck of th e
t alu s,
2. P oster io r tal of ib ul ar li ga ment, a t hi ck, fai rl y str on g b and t hat r un s h or izo nt ally m edi all y an d sli gh tly po ster ior ly fr om th e
m al leo lar f ossa to the lat eral tu b ercl e o f the tal us.
3. C alcaneo fi bul ar lig ame nt, a r ou n d cor d tha t p asses post ero in fer ior ly fr om t he tip o f the lat era l m al leol us to th e la ter al
s ur face of th e calcan eu s.
T h e j oin t ca psu le is rei nf or ced m edi all y b y th e lar ge, stro ng med i al l ig ament o f the ank le ( del toi d lig ament) th at a ttach es
p r oxim al ly to th e m edi al ma lleo lu s (Fig . 5 .6 6 ). Th e me dia l l ig am ent fa ns ou t f r om th e m al leo lu s, attach in g d istal ly t o th e talu s,

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c alcan eu s, an d n avicu lar vi a f ou r ad jacen t an d con tin uo us pa rts: th e ti bi onavi cul ar p ar t, the tib io cal caneal pa rt, a nd th e
a nteri or a nd p os teri or ti bi otal ar p arts . Th e m ed ial li ga men t stab ili zes th e an kle joi nt du r in g ever sion a nd p re vent s su bl uxa tion
( par tial d islo catio n) of th e joi nt.
P. 7 0 4
Ta bl e 5. 18. J oi nts of Fo ot
J oi nt
Typ e
Ar ticulati ng
Jo int
Surf aces
Cap sule
L ig aments
M ovements
Bl oo d
Nerve
Supp ly
Supp ly
Su bt alar
(talo calcan eal ,
Pla ne
syn ovial
Inf eri or
su rf ace o f
Fi br ou s
layer o f
Med ial , late ral ,

an d p oster io r
I nv ersi on an d
p oster io r of
Po ster ior
ti bia l a nd
Pla nta r
asp ect:
an atom ica l su b talar

joi nt )
joi nt
bo dy of
talu s
joi nt
capsu le is
ta local can eal

l iga me nt s
f oot
f ibu la r
ar ter ies
m edi al
or
(po ster ior

calca nea l
attach ed to
ma rg in s of
su p por t capsu le;

i nte rosse ou s
late ral
pl antar
ar ticu lar
fa cet)
arti cul ar
sur fa ces
ta local can eal

l iga me nt bi nd s
ne rve;
Dorsa l
b on es t oge ther
asp ect:
dee p
ar ticu late s
wi th
fi bular
ne rve
su per ior
su rf ace
(po ster ior
tala r
ar ticu lar
su rf ace) o f
calca neu s
Tal ocal cane on avicular
Ca lcan eocu b oid
Cu n eon avi cul ar joi nt
Syn ovi al
Hea d of
Join t
P lan tar
Gli di ng an d
A nte rio r
joi nt ;
talo na vicu lar
talu s
ar ticu late s
capsu le
in com pl etely
cal can eon avicu la r

(sp ri ng ) l ig am ent
r otat ory
m ove men t s
ti bia l
ar ter y vi a
pa rt is bal l
an d socket
wi th
calca neu s
encl oses
joi nt
su p por ts hea d of
ta lu s
p ossib le
la ter al
tar sal
typ e
an d
n avicu lar
ar ter y, a
b ran ch o f
bo nes
d or sal
ar ter y o f
Pla ne
An ter ior
Fi br ou s
Dor sal
I nv ersi on an d
syn ovial
joi nt (s)
en d of
calca neu s
capsu le
encl oses
cal can eocu bo id

l iga me nt, pla nta r
eve rsi on of
f oot;
ar ticu late s
wi th
joi nt
cal can eocu bo id ,

an d l on g pla nta r
ci rcu m du ctio n
po ster ior
su rf ace o f
l iga me nt s
su p por t joi nt
cuboi d
cap su le
An ter ior
Co mm on
Dor sal an d
L ittl e
n avicu lar
ar ticu late s
capsu le
encl oses
p lan tar
cu n eon avicu la r
m ove men t
o ccur s
f oot

08-May-15
Page 138 of 155
wi th ba ses
of
joi nts
l iga me nt s
An ter ior
tar sal
Sep ara te
joi nt
Dor sal, pla nta r,

an d i nter osseo us
bo nes
ar ticu late
capsu les
encl ose
ta rso met atar sal

l iga me nts bi nd
m edi al
an d
wi th ba ses
of
each jo in t
b on es t oge ther
late ral
pl antar
m etatar sal
bo nes
Tar som eta tarsa l
Gli di ng o r
sl idi ng
Deep
fi bu lar ;
m etatar sal
bo nes
ne rves;
su ral
ne rve
In ter m etatar sal
Pla ne
Ba ses of
Sep ara te
Dor sal, pla nta r,
L ittl e
L ater al
Digi tal
syn ovial
joi nt
m etatar sal
bo nes
joi nt
capsu les
an d i nter osseo us
ta rso met atar sal
i nd ivi du al
m ove men t
m etata rsal
ar ter y (a
ne rves
ar ticu late
wi th each
encl ose
each jo in t
l iga me nts bi nd
b on es t oge ther
o ccur s
b ran ch o f
d or sal
other
Metatar sop ha lan ge al
In ter ph al ang eal
ar ter y o f
f oot)
Co nd ylo id
Hea ds of
C ol later al
Fle xion ,
syn ovial
joi nt
m etatar sal
bo nes
l iga me nt s
su p por t capsu le
ext ensi on,

an d som e
ar ticu late
wi th ba ses
o n each si de;
p lan tar l ig am ent
abd ucti on,

add ucti on
of p ro xim al
ph al ang es
su p por ts pla nta r

p ar t o f ca psu le
an d
ci rcu m du ctio n
Hi ng e
syn ovial
Hea d of
on e
C ol later al an d
p lan tar l ig am ent s
Fle xion a nd
ext ensi on
joi nt
ph al anx
ar ticu late s
wi th ba se
su p por t joi nts
Dig ital
b ran ch es
of p lan tar
ar ch
of on e
di stal to it
P. 7 0 5
Fig ure 5.66. Ankle and tar sal joi nts. A. Th e f lexo r ten do ns, w h ich d escen d the po ster olat era l as pect of th e a nkl e r eg ion

08-May-15
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an d ent er th e f oot, are sh own as i s th eir r ela tion sh ip to th e m ed ial m all eol us an d talar shel f. E xcep t f or th e par t t eth eri ng th e
fl exor h all uci s lo ng u s ten d on , th e f lexor reti na cul um has b een r emo ved. B. T hi s d issecti on o f t he an kle an d tar sal joi nts
dem o nstr ates th e f ou r pa rts of th e m ed ial (d elto id) li gam en t o f th e an kle .
P. 7 0 6
M ov em en t s of t h e A n kl e J o in t
T h e m ai n mo vem en ts o f t he an kle joi nt ar e d or sif lexi on an d pl an tar flex ion o f the fo ot, w hi ch occu r ar oun d a tr an sver se ax is
p assi ng th r ou gh th e talu s (Tab le 5. 1 8A). B ecau se th e na rr ow en d of th e tro chl ea o f the tal us lie s lo osely b etwee n the m all eoli
w h en th e f oot is pl an tarf lexe d, so me wo bb le (sm all am ou n ts of a bd uct ion , ad du ctio n, i n versi on , an d ever sion ) i s p ossib le in
t hi s u nst abl e p osit ion .
D or sif lexi on of t he an kle is p r odu ced b y th e m uscl es i n the an ter ior com par tm en t o f the leg (T ab le 5 . 1 0). Do rsif lexi on i s
u su all y l im ited b y th e pa ssive resi stan ce o f t he tr icep s su ra e to str etch in g an d by ten sion i n th e m ed ial an d la tera l l ig am ents .
P lan tar fl exion of th e an kle is pr od u ced by th e m u scles in th e poste ri or com p artm en t of th e l eg (Tab le 5 .1 3 ). In toe dan cin g b y
b al let dan cer s, fo r exam pl e, th e d or su m of th e foo t i s in l in e w ith t he an ter ior su r face of th e leg .
B lo od S u p p ly o f t h e An k le Jo in t
T h e ar ter ies ar e d eri ved f rom ma lleo lar b ra nch es of th e f ib ul ar an d an ter ior a nd p oster io r tib ial ar ter ies (Fi g. 5 . 63B ).
N e rv e S u p p ly o f t h e An k le Jo in t
T h e n er ves a re der ive d fr om th e tib ial n erve an d th e d eep f ibu la r ne rve, a d ivisi on o f t he com m on f ib ul ar n erve (Fig . 5 .6 3D).
An k l e I nj u r i e s
Th e a nkl e i s th e m o st f req u ent ly i nj ur ed m aj or jo in t in the b ody . An kle spr ain s (tor n fib er s o f lig am ent s) ar e mo st co mm on . A
spr ain ed an kle is n earl y a lwa ys an i nv ersi on in ju r y, in vol vin g twi stin g of th e w eig h t-bea rin g p lan tar fl exed fo ot. T he p erso n step s
on an u n even su r face an d th e f oot is for cib ly in ver ted. Late ral li gam en t spr ain s occu r in sp or ts in wh ich r u nn in g an d ju m pi ng ar e
com m on, par ticu la rl y b asketb all (7 0 80 % of p layer s h ave h ad at least on e sp r ain ed an kle). Th e l ater al lig am en t i s in ju r ed
beca use it is mu ch w eaker th an t he m edi al lig am en t an d is th e l iga me nt th at r esi sts in ver sio n at the tal ocru r al joi nt . Th e a nte rio r
talo fib u lar li ga men t p ar t of t he late ral li ga men t i s m ost vu ln erab le an d m ost com mo nl y to rn d u ri ng a nkl e sp ra in s, eith er
par tia lly or com p letel y, r esul tin g in i nst abi lity of th e ankl e j oin t (Fi g. B 5 .3 2 ). Th e calcan eo fib u lar li ga men t ma y al so be tor n. In
sever e sp ra in s, the la tera l m al leo lu s of th e fib u la ma y b e f ra ctur ed . Sh ear in g in ju r ies fr actu re th e l ater al ma lleo lu s at or su pe ri or
to t he an kle joi nt . Avu lsi on fr actu r es b re ak th e m alleo lu s i nf er ior to th e a nkl e j oin t; a f ra gm en t o f bon e is pu lle d off b y th e
attach ed li gam en t(s).
A Pott fr actur ed islo catio n o f the ankl e oc cur s w he n th e f oot is for cib ly ever ted (Fig . B5 . 33 ). T hi s acti on p ul ls on th e
extr eme ly st ron g m ed ial li gam en t, of ten te ari ng o ff th e med ia l m al leol us. Th e ta lu s th en m oves lat era lly, sh ear in g of f th e la ter al
ma lleo lu s or , m or e com mo nl y, br eaki ng t he fi bu la su per io r to t he tib iof ib ul ar syn de smo sis. I f the tib ia is car rie d an teri or ly, th e
post eri or m ar gin of th e d istal en d of th e tib ia is also sh eare d off b y t he talu s, p ro du cin g a tri ma lleo lar f ract ur e. I n ap pl yin g
thi s ter m to th is in ju ry , the en tir e dist al e nd o f the tib ia is err on eo usl y con sid er ed to be a m al leol us.
T i b i a l N e r v e E n tr a p m e nt
Th e ti bi al ner ve leave s th e p oste rio r com p artm en t of th e l eg by pa ssin g deep t o th e fl exor r etin acu lu m in the in ter val be tween the
me dia l m al leol us an d th e cal can eu s (Fig . 5 .4 6B). E n tra pm en t a nd co mp re ssion o f the tib ia l n er ve (t arsa l tu n n el sy nd ro me) occu r s
wh en th er e i s ed em a an d ti gh tn ess i n th e an kle in vol vin g th e syn ovi al she ath s of th e ten don s of m uscl es i n th e p oster io r
com par tm en t o f the leg . T he ar ea i nv olved i s f ro m th e m ed ial m all eolu s to t he calca neu s, an d th e hee l p ain resu lts fr om
com pr essio n of th e t ibi al ne rve by th e f lexo r ret in acul um .

08-May-15
Page 140 of 155
Fig ure B5. 32
Fig ure B5. 33
P. 7 0 7
T h e an kl e (tal ocr ur al) jo in t i s com p osed of a su per io r m ort ise, f or med b y the we igh t-b ear in g in fer io r sur fa ce o f t he tib ia an d th e
t wo m alle oli , wh ich r ecei ve th e tro chl ea o f th e tal us. Th e j oin t is m ai nta in ed m edi ally b y a stro ng , m ed ial (de ltoi d) lig am en t, an d a
m u ch w eaker l ater al lig am en t. Th e later al li gam en t ( speci fica lly its an teri or tal ofi bu la r lig am en t com p on en t) i s th e m o st f req u entl y
i n ju red l iga me nt of th e bod y. I nj ur y occu rs pr im ar ily by in ad ver tent in ver sion of th e p lan tar fl exed , wei gh t-b eari n g foo t). Ab ou t
7 0 o f d or sif lexi on an d pl an tar fle xion i s p ossib le at the jo in t, in a dd itio n to wh ich sm al l am ou nts of w obb le occu r in t he less
s tabl e p lan tar fl exed p ositi on .
F o ot Jo in t s
T h e m an y j oin ts of th e f oot in vol ve th e tar sals, m eta tarsa ls, an d p hal an ges (Tab le 5 .1 8 ). Th e im po rta nt in ter tar sal joi nts ar e th e
su b talar (taloca lcan eal ) jo in t an d th e tran sver se tar sal join t (calca neo cub oid and t alon avi cul ar jo in ts). In ver sion an d eversi on o f
th e fo ot a re th e m ai n m ovem en ts i nvo lvin g th ese joi nts. T h e o ther in terta rsa l j oin ts (e.g . , in ter cun eif or m jo in ts) an d th e
ta rso me tatar sal an d in term et atar sal joi nts ar e r ela tivel y sm all an d ar e s o ti gh tly jo in ed by lig am en ts t hat on ly slig h t m ove me nt
o ccur s b etw een th em . I n the f oot, f lexi on an d exte nsi on occu r s in the fo re foo t at th e m eta tar soph al ang eal an d in ter ph al an geal
j oin ts (Tab le 5. 1 9 ) I nve rsio n is au gm en ted b y f lexio n of th e toes (especi all y th e g r eat and 2 n d toes), and e versi on b y th ei r
e xten sion (esp ecia lly of th e later al toes). All b on es o f the fo ot pr oxim al to th e m et atar soph al an geal j oin ts are u ni ted by d orsa l a nd

08-May-15
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p la nta r lig am en ts. Th e bon es of th e m eta tar soph al an geal an d in ter ph al an geal j oin ts are u ni ted by la tera l a nd m ed ial col later al
l ig am ent s.
T h e sub tala r joi nt occu r s w he re th e tal us r ests o n an d art icu lates wi th th e ca lcan eu s. Th e a na tom ical su bta lar j oin t i s a sin gl e
s yno vial jo in t b etwe en th e sl igh tl y con cave p oster ior ca lcan eal ar ticu lar sur fa ce of th e talu s and the con vex po steri or ar ticu la r
f acet of th e calcan eu s (T abl e 5 . 1 8). T h e j oin t ca psu le is weak bu t is sup po rted b y med ia l, la tera l, p oster ior , an d in ter osseo us
t aloca lcan eal li gam en ts (Fi g. 5 . 65 ). T he inter o sseous talo calca neal lig ament lie s w ith in th e tarsa l si nu s, w hi ch sep ara tes th e
s ub tala r an d taloca lcan eon avi cul ar jo in ts an d is esp ecial ly st ron g . Ort ho paed ic sur g eon s u se the ter m su bta lar j oin t f or th e
c om pou n d fu n ction al jo in t co nsi stin g of th e ana tom ical su bta lar j oin t plu s the tal ocal caneal pa rt of the ta lo calcaneo navicul ar
j oi nt. Th e tw o sepa rate el eme nts of th e c lin ical su bta lar j oin t strad d le t he talo calca nea l i nte ro sseou s li ga men t. S tr uctu r ally , the
a na tom ical d efi ni tion i s l ogi cal beca use th e a nat om ical su bta lar j oin t i s a di scre te j oin t, h avin g it s ow n jo in t cap su le an d arti cul ar
c avity. Fu n ction al ly, h ow ever, the cli ni cal def in iti on is log ica l b ecau se the tw o p ar ts o f t he com p ou nd j oin t f u ncti on as a un it; it is
i m possi bl e f or th em to f un ctio n in de pen d entl y. Th e sub tal ar jo in t (b y ei the r def in iti on ) is wh er e th e m ajor ity of i nver sio n an d
e versi on o ccur s, ar ou nd a n axis th at is o bli qu e.
T h e tr ansver se ta rsa l j oint is a co mp ou n d joi nt fo rm ed b y tw o sepa rate jo in ts al ig ned tran sver sely: th e ta lona vi cular
P. 708
P. 709
p ar t o f the tal ocal caneo na vicular j oint an d th e cal caneo cub o id jo int. A t th is joi nt, the m id foo t a nd f or efo ot r ota te a s a un it
o n th e h in d foo t ar ou n d a l on gi tud in al (AP ) axi s, au gm en tin g th e i nv ersi on an d ever sio n m ovem en ts o ccur ri ng a t th e clin ica l
s ub tala r joi nt. Tr ans ection acro ss th e tran sver se tar sal join t is a sta nd ar d me tho d for sur gi cal am pu tati on of th e foo t.
Tab le 5.19. Mo vements o f the J oints of the For efo ot and the M uscles Pro d ucing Them
Mo vement
Muscl es a
Metatar sop ha lan ge al joi nts
Fl exio n (A)
Flexo r d ig itor um b r evis

Lu mb r ical s
Inter oss ei
Flexo r hall ucis b r evis
Flexo r hall ucis l ong us
Flexor d ig it m in im i b r evis
Flexor d ig ito ru m lo ng u s
Ext ensi on (B )
Exte ns or hall ucis l ong us

Exte ns or d ig ito rum long us
Exte ns or d ig ito rum br evis

08-May-15
Ab du ctio n (C)
Page 142 of 155
Abd uctor hal lucis

Abd uctor d ig iti mini mi
Do rs al i nter ossei
Ad du ctio n (D)
Add uctor hal lucis

Planta r inter ossei
In ter ph al ang eal jo in ts
Fl exio n (fi g. A )
Flexo r hall ucis l ong us

Flexo r d ig itor um l ong us
Flexo r d ig itor um b r evis
Qua dr atu s p lan tae
Ext ensi on (f ig . B)
Exte ns or hall ucis l ong us

Exte ns or d ig ito rum long us
Exte ns or d ig ito rum br evis
a Muscl es
i n bo ld face ar e ch ief ly re spon sib le fo r th e m ovem en t; the oth er m u scles assist th em .
Fig ure 5.67. Pla nt ar lig ame nts . A and B. Deep disse ction o f the sol e o f the r igh t foo t sh ow in g th e at tach me nts of th e
lig am en ts a nd th e long ten do ns of th e lon g ever tor a nd i nver tor mu scles. Th e m ai n lig am en ts f ro m th is view ar e the pl an tar
calcan eo na vicu lar an d th e lon g an d sho rt pl an tar li gam en ts.

08-May-15
Page 143 of 155
M ajo r L ig am en t s of th e F o ot
T h e m aj or li gam en ts of th e p lan tar a spect of th e f oo t (Fig . 5 .6 7 ) ar e the :
P lantar ca lcaneo navicula r lig ament (spr ing l ig ament), w hi ch exten d s acr oss an d fil ls a w edg e-sh ape d gap b etw een th e
t alar sh el f a nd t he in fer io r m arg in o f the p oster ior a rti cul ar
P. 7 1 0
s ur face of th e na vicu lar (Fig . 5 . 67A & B ). T he spr in g li gam en t sup po rts th e h ead o f the tal us an d pl ays i mp or tan t r ol es i n th e
t ran sf er of w eigh t fr om t he talu s an d in m ain tai ni ng th e lon g itu di nal ar ch o f the fo ot, o f w h ich it is th e key ston e
( sup eri or mo st e lem en t).
L o ng pl antar li ga ment, wh ich p asses fr om the pl an tar su rf ace of th e ca lcan eu s to th e g ro ove on th e cub oid . S om e o f its
f ib er s exten d to th e b ases of th e m et atar sals, th er eb y f orm i ng a tu nn el f or th e te nd on o f t he fi bu laris lon g us (Fig . 5. 6 7 A).
T h e l on g pla nta r lig am en t i s im p or tan t i n ma in tain in g th e l on gi tud in al ar ch of th e foo t.
P lantar ca lcaneo cubo id li ga ment (sho rt p lantar li g ament), wh ic h is l ocate d on a pl ane b etwee n th e p lan tar
c alcan eon avi cul ar an d th e l on g pla nta r lig am en ts (Fig . 5 . 67B). It exten ds fr om t he an ter ior a spect of th e i nf er ior su r face of
t he calca neu s to the in fe rio r su rf ace o f the cu bo id. It is also in vol ved in m ai nta in in g the lo ng itu d in al arch o f th e f oot.
A r ch es of th e F oo t
I f th e f eet wer e m o re ri gi d stru ctu re s, each im p act wit h the gro un d wo ul d gen er ate extr em ely lar ge fo rces of sh or t d u rati on
( sho cks) th at wou ld b e pr op aga ted th rou g h th e ske letal system . B ecau se t he fo ot is co mp osed o f nu m er ou s b on es co nn ected b y
l ig am ent s, it ha s con sid er abl e f lexi bil ity th at a llow s i t to d efo rm with each g ro un d con tact, ther eb y ab sor bi ng m u ch of th e sho ck.
Fu r the rm or e, th e t arsa l a nd m eta tarsa l b on es are ar ra ng ed in l on gi tud in al an d tr an sverse ar che s p assivel y su pp or ted an d acti vely
r estr ain ed b y f lexi bl e ten d on s th at add t o th e wei gh t-b eari n g capab il itie s an d r esili ency of th e foo t. Th u s m u ch sm all er fo rces of
l on ger du ra tion a re tr ans mi tted th ro ug h th e sk eletal syste m.
T h e ar ch es d istr ib ut e w eig ht over the pe dal p latf or m (fo ot), act in g no t on ly as sho ck ab sor be rs bu t also as spr in gb oar ds fo r
p r ope lli ng i t d ur in g walkin g , ru n ni ng , an d ju m pi ng . T he re sili ent ar che s ad d to th e f oot' s ab ili ty to ad ap t to ch an ges in su r face
c on tou r. T he w eig ht of th e b od y i s tr an sm itted to th e talu s f ro m th e t ibi a. Th en i t i s tr an sm itted p oster io rly to th e ca lcan eu s an d
a nte ri orl y to th e b al l o f the fo ot (th e sesa mo ids of th e 1st m etatar sal an d th e h ead o f the 2 n d met atar sal), a nd th at
w eig h t/pr essu re is sha red l ater all y w ith th e hea ds of th e 3 r d 5 th m etat arsa ls a s n ecessar y f or b ala nce an d com fo rt (Fig. 5. 6 8).
B etw een th ese wei gh t-be ari ng p oi nts ar e th e rel ative ly e lasti c ar ch es of th e fo ot, w hi ch beco m e sli gh tly fl atten ed b y b od y w eig ht
d u ri ng sta nd in g. Th ey n or m all y r esu me th eir cur vatu re (r ecoil ) w hen bod y w eig h t i s r em oved .
T h e l ong itud inal ar ch of the fo ot is co mp osed o f me dia l a nd l ater al par ts (Fig. 5 . 6 9). Fu n ction al ly, b oth p ar ts act as a u n it wit h
t he tr an sverse ar ch of th e foo t, spr ead in g th e w eig ht in all di rect ion s. Th e med ial lo ngi tudi na l a rch is h ig h er an d m ore im p or tan t
t han the la tera l l on gi tud in al ar ch (Fig . 5. 6 9A & D ). Th e me dia l l on gi tud in al ar ch is com po sed of th e ca lcan eu s, tal us, n avi cul ar,
t hr ee cun eif or m s, an d thr ee m etatar sals . Th e ta lar h ead i s th e keyston e o f the m ed ial lon g itu di na l a rch . Th e tib ial is a nter io r,
a ttach in g to th e 1 st m eta tar sal and med ial cu n eif or m, h el ps stren g the n th e m ed ial lo ng itu di na l a rch . T he fi bu lar is lon g us ten do n,
p assi ng f ro m lat eral to m ed ial, also h elp s su pp or t th is ar ch (Fig . 5. 6 9A). T he lat eral l on gitu d in al ar ch is mu ch f latte r tha n th e
m ed ial p ar t of t he ar ch an d rest s on the gr ou n d du r in g stan di ng (Fig . 5 .6 9B & D ). I t i s m ad e u p of th e calcan eu s, cu bo id, and
l ater al two m etat arsa ls.
Fig ure 5.68. Weig ht-b ea ri ng a rea s o f f o ot. B ody we igh t is divi ded a pp ro xim atel y eq u ally be tween the h in df oot (calca neu s)
an d the f ore foo t (h ead s o f the m etatar sal s). Th e f or efo ot ha s f ive poi nts of co nta ct w ith th e gr ou nd : a la rg e m ed ial on e th at
in clu des th e tw o sesam oid b on es associa ted wi th th e h ead o f the 1 st m eta tar sal and t he h eads of th e later al fo ur m et atar sals.
Th e 1 st m etatar sal su pp or ts th e ma jor sh ar e o f th e lo ad, wit h the la tera l f or efo ot pr ovid in g b alan ce.
T h e tr ansver se a rch of the f oo t r u ns fr om si de to sid e (Fig . 5 . 69C ). It is for m ed b y th e cu b oid , cu ne ifo rm s, an d b ases o f th e
m et atar sals. T he m ed ial an d later al p art s of th e lon g itu di nal ar ch ser ve as p ill ar s f or th e tr an sver se a rch . Th e ten do ns of th e

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f ib u lar is l on gu s a nd ti bi ali s p oster ior , cr ossin g u nd er th e sole of th e f oo t li ke a sti rr up (Fi g. 5 . 69C ), h elp m ain tai n th e cu r vatu re of
t he tr an sverse ar ch. Th e i nte gr ity of th e b on y a rch es of th e f oot is ma in tain ed b y b oth p assive f actor s an d d yna mi c su p por ts (Fi g.
5 . 6 9E ).
P assive fa ctor s in vo lved in for m in g an d ma in tain in g th e a rch es of th e f oot in clu de
T h e sh ap e o f the u ni ted bo ne s (b oth ar ch es, bu t espe ciall y th e tra nsve rse ar ch).
Fo ur su ccessi ve l ayer s of f ib ro us tissu e t hat b owstr in g th e lon gi tud in al ar ch (su per fi cial to d eep):
1. P lan tar a pon eu ro sis.
2. L on g p lan tar l iga men t.
3. P lan tar ca lcan eocu bo id (sh or t p lan tar ) l ig am ent .
4. P lan tar ca lcan eon avi cul ar (spr in g ) li gam en t.
P. 7 1 1
Fig ure 5.69. Arches of f oo t. A and B . Th e m ed ial l on git ud in al ar ch is hi gh er th an th e later al lo ng itu di na l a rch , w hi ch m ay
con tact the g rou n d wh en sta nd in g er ect. C. T he tr an sverse ar ch is dem on str ated a t th e level of th e cun eif or m s, re ceivin g
stir ru p -like su pp or t f ro m a ma jor i nver tor (tib iali s p oster ior ) and e vert or (fi bu lar is lon g us). D. T he com p on ent s of th e m edi al
(dar k gr ay) a nd l ater al (lig h t g ray ) lo ng itu d in al arch es are in d icated . Th e calca neu s (med iu m g ra y) is com m on to b oth . Th e
m edi al arch i s p ri m ari ly weig h t b ear in g, w h erea s th e later al ar ch pr ovi des ba lan ce. E . Th e a ctive (red l in es) a nd p assive
(gr ay) sup po rts of th e lon gi tu din al ar ch es ar e rep re sent ed. T he re ar e f ou r layer s of pa ssive sup po rt (1 4).
P. 7 1 2
Dyn am ic su pp ort s in vol ved in m ai nt ain in g th e ar ch es o f the fo ot in clu de
A ctive (r efl exive) br acin g acti on o f in tri nsi c m u scles of fo ot (l on gi tud in al ar ch).
A ctive an d ton ic con tr actio n of m uscl es w ith l on g ten do ns exten di ng i nt o f oot:

l
Fl exor s h all uci s an d d ig itor u m lon g us fo r th e lo ng itu d in al arch .
Fi bu lar is lon g us an d tib ial is p oster io r fo r the tr an sverse ar ch .
O f t hese fa ctor s, th e p lan tar l ig am ents an d th e p lan tar a pon eu r osis bea r the g rea test str ess an d are m ost im po rta nt in m ai nta in in g
t he ar che s of th e foo t.
Fu n ctio nal ly, th er e a re th ree com p ou nd j oin ts in th e f oo t: (1 ) th e clin ica l su b tala r joi nt be tween the tal us an d the cal cane us,
wh er e in ver sio n an d ever sion o ccur a bo ut an ob li qu e a xis; (2) th e tr an sver se ta rsal j oin t, w her e the m id foo t an d f or efoo t r ota te as
a u n it on th e h in d foo t a rou n d a lon gi tu din al axi s, au gm en tin g in ver sion and e versi on ; an d (3 ) th e re mai n in g joi nts of th e f oo t,

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w h ich al low th e ped al pl atf orm (foo t) to f or m dyn am ic lo ng itu di na l a nd tr an sver se a rch es. T he ar che s p ro vide th e r esi lien ce
n ecessa ry fo r wal kin g, r u nn in g , an d ju m pin g , an d are m ain tai ne d by fou r l ayer s of p assive , fib r ou s su pp or t p lu s th e dyn am ic
s up po rt pr ovi ded b y th e in tri ns ic m u scles of th e f oot an d th e l on g fib u lar , tib ial , an d fl exor ten d on s.
H a l l ux V a l g u s
Hal lux valg us i s a foo t d efo rm i ty cau sed b y p re ssur e f r om f ootw ear an d d egen er ati ve j oin t d isea se; i t is ch ara cter ized b y la ter al
d evi ation of th e g re at to e (Fi g. B 5. 3 4 ). Th e L in val gu s i nd ica tes l ater al d eviati on . In som e p eop le, th e pa in fu l d evi ation is so
l ar ge th at th e gr eat toe over lap s t he 2 nd to e (Fig . B 5. 3 4A ), an d th ere is a decr ease in th e me dia l l on gi tud in al ar ch . Su ch de viati on
o ccu rs especi all y in fem al es, an d its fr equ en cy i ncr ease s wi th ag e. T hese in d ivid ua ls ca nn ot m ove th eir 1 st d ig it awa y f rom th eir
2 n d di gi t b ecau se t he sesam oi ds un d er th e h ead of t he 1 st m etat arsa l a re usu al ly disp lace d and lie in th e space b etwee n the h ead s
o f th e 1 st a nd 2 n d m etatar sals (Fig . B5 . 34B ). Th e 1 st m etatar sal sh ift s m edi all y an d th e sesam oid s sh if t l ater all y. Ofte n the
s ur ro un d in g tissu es sw ell an d th e r esu lta nt pr essu re an d fr icti on ag ain st th e sh oe cau se a su bcu tan eou s bu rsa to fo rm ; wh en
t end er an d in f lam ed , the b ur sa is ca lled a b union (Fig. B5 .3 4 A). Of ten h ar d cor ns (i nf lam ed a rea s of th ick skin ) also fo rm o ver
t he pr oxi m al in terp h alan g eal joi nts, especi all y th e littl e to e.
H am m er Toe
Ham mer toe is a f oot d efor m ity in w h ich th e p r oxim al p hal an x i s p erm an en tly an d ma rked ly do rsi fle xed (hy per exten d ed) at t he
m et atar soph al an geal j oin t and t he m idd le ph al an x str on gl y p lan tar fl exed at th e p ro xim al in ter ph ala ng eal jo in t. Th e di stal ph ala nx
o f th e d ig it i s o ften a lso hy per exten de d. T hi s g ives th e d ig it (u su all y th e 2n d ) a ha mm er -li ke ap p ear ance (Fig . B5 . 35A ). Th is
d ef or mi ty o f on e or mo re toes m ay r esu lt fr om w eakn ess of th e l um b rica l a nd i nt ero sseou s m u scles, w hi ch fl ex th e
m et atar soph al an geal j oin ts and e xten d the in ter ph al ang eal j oin ts. A cal losit y or c allu s, h ar d thi cken in g of th e ke rati n la yer of th e
s kin , oft en de velop s w h ere th e d or sal sur f ace o f the toe r epea tedl y r u bs on th e sh oe .
Fig ure B5. 34
Fig ure B5. 35
C l a w T o es
C law to es are ch ara cter ized b y h ype rext ensi on of th e m etatar sop ha lan ge al joi nts an d fl exion of th e d istal in ter p hal an gea l j oin ts
( Fi g. B 5 .3 5B). Usu al ly, th e later al fo ur t oes are in vol ved. Cal losi ties deve lop o n the d or sal sur fa ces of th e toes bec ause of p re ssur e
o f th e sh oe. T h ey m ay also f orm on th e pla nta r sur fa ces o f the m etata rsal h ead s an d th e t oe tips be cau se th ey bea r extra w eig ht
w h en claw t oes a re pr esen t.
P e s P l a n us ( F la t f e e t )

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T h e f lat ap pear an ce of th e f oot be for e age 3 is n orm al an d r esu lts f r om th e thi ck su bcu tan eo us fat -pad i n th e so le. A s ch ild r en get
o ld er, the fa t is lo st, an d a n or m al m edi al lon gi tu din al ar ch b ecom es v isib le (Fi g. B 5 .3 5C) . Fl atf eet ca n eith er b e f lexi bl e (f lat,
l ackin g a m edi al arch , w he n wei gh t b ear in g bu t no rm al in app ear an ce w he n no t b ear in g wei gh t [Fi g. B 5 .3 5D]) or r ig id (f lat even
w h en n ot bear in g w eigh t). T h e m or e co m mo n fl exib le fla tfeet r esul t f ro m lo ose or de gen er ated in tr in sic lig am en ts (i nad eq ua te
p assi ve ar ch su pp or t). Flex ibl e f latf oot is com m on i n chi ld ho od bu t usu al ly r eso lves with age as the li gam en ts gr ow an d m atu re.
T h e co nd iti on occa sion all y p er sists i nt o a du lth ood and m ay or m ay n ot b e symp tom at ic.
R ig id f latf eet wit h a h ist ory th at goe s b ack to ch il dh ood a re lik ely to resu lt fr om a b on e d efo rm ity (su ch as a f usi on o f a dj acen t
t arsa l b on es). A cqu ir ed fl atf eet ( f all en ar ches ) ar e likel y to b e seco nd ar y to d ysfu n ction of th e ti bi alis po ster ior (d yn am ic
a rch su p po rt) ow in g to t rau m a, d ege ner ati on wi th ag e, or d en er vatio n. I n th e a bsen ce of n or ma l p assive or d yn am ic sup po rt, t he
p la nta r calcan eo navi cu lar li gam en t fai ls t o su p por t the h ead of th e talu s. C on seq uen tly , the tal ar h ead d ispl aces in fer om ed iall y an d
b ecom es pr om in en t (Fi g. B 5 .3 5D, r ed ar r ow). As a r esu lt, som e fl atten in g of th e med ia l p ar t o f the lo ng itu di na l a rch o ccur s, al on g
w ith later al de viati on of th e fo ref oot. Fl atfe et a re com m on in old er pe opl e, p arti cu lar ly i f th ey u n der take m uch un accu stom ed
s tan din g or g ai n wei gh t r ap id ly, ad di ng st ress on th e mu scle s an d in cr easin g th e st rai n on th e lig am en ts su p por tin g th e a rch es.
C l u b f o o t ( T a li p e s)
C lubf oo t r ef ers to a f oo t th at is t wist ed ou t o f p osi tion . Of th e sever al types, a ll ar e co ng en ital (p resen t at b ir th ). Ta lip es
e qu in ovar u s, th e co mm on type (2 p er 1 00 0 l ive bir th s), in vol ves t he su btal ar jo in t; b oys are af fecte d twic e as of ten as gi rls. Th e
f oo t is in ver ted , the an kle is pl an tarf lexe d, an d th e for ef oot is add u cted (tu rn ed tow ar d th e m id lin e in an abn or m al ma nn er ) (Fig .
B 5 .3 6 ). Th e foo t a ssum es the p ositi on of a h or se's ho of, h en ce the p ref ix e qu in o (L. e qu in us , ho rse). I n h alf o f tho se
a ff ected , bo th fee t ar e ma lfo rm ed . A per son w ith an u nco rr ected cl ub fo ot ca nn ot pu t th e h eel an d sole fl at and mu st bear the
w eig h t o n the la tera l su r face of th e for ef oot. Co nseq u ent ly, w alkin g is pa in fu l. T he m ain abn or m alit y is sh or tness an d tig h tness of
t he m uscl es, ten do ns, lig am en ts, an d joi nt cap sul es o n th e m ed ial sid e and p oste rio r asp ect o f the fo ot an d ankl e.
Fig ure B5. 36
P. 7 1 3
P. 7 1 4
S u r f a c e An a t o m y o f t he A n k le a n d F o o t
T h e su r face an atom y of th e b on es o f th e f oot was pr esen ted ea rl ier in thi s ch ap ter (see Su rf ace An atom y of th e B on es o f the
Fo ot ).
I f th e f oot is activ ely in verte d, th e tendo n o f t he tib ial is po ster io r ma y b e p alp ated a s it p asses p oster io r an d di stal to the
m ed ial m al leol us, t hen sup er ior to th e talar sh el f, to r each i ts att achm en t to the tu ber osi ty o f the n avicu lar . H ence th e t ibi ali s
p oste ri or ten do n is the g ui de to the n avicu la r. T he ten do n of th e tib iali s p oster io r also in di cates th e sit e f or p alp atin g th e p oster io r
t ibi al pu lse (h alf way be tween the m edi al ma lleo lu s an d th e calcan eal ten d on ).
T h e tal ar shelf ( L. su sten tacu lu m tal i), ap pr oxi m ately 2 cm d ista l to th e tip of th e me dia l m al leo lu s, is b est fel t b y p alp ati ng i t
f r om b elow w h ere it is som ewh at ob scur ed b y th e tendo n o f the fl exo r di gi tor um lo ngus, wh ich cr osses it (Fi g. S A5 . 4B ). On th e
l ater al sid e, wh en t he fo ot is i nve rted , th e l ater al m arg in o f the anter io r surf ace of the c alcaneus is un cove red an d p alp ab le.
T h is i nd ica tes th e site of th e ca lcan eocu bo id jo in t. Wh en th e f oot is pl an tar flex ed, th e head o f the talus is expo sed. P alp ate it
d or sal to wh er e th e an teri or su rf ace of th e ca lcan eu s is fe lt. T he calca neal tendo n at th e p oster io r asp ect o f the an kle is easil y
p al pate d and t race d to i ts a ttach me nt to th e cal can eal tub er osity . In th e dep r ession on each si de of th e ten don , th e an kle join t is
s up erf ici al. Wh en th e joi nt is over fi lled w ith f lu id , th ese d ep ressi on s m ay be ob lit erat ed.
T h e ten d on s i n the an kle r egi on can b e ide nti fie d satisf actor il y on ly wh en t hei r m uscl es ar e actin g. Th e te nd on s o f the fi bu la ris
l on gu s and b r evis ma y b e f oll owe d dist ally, post eri or an d in fe rio r to th e la tera l m al leo lu s, an d the n an teri or ly alon g th e l ater al
a spect of th e foo t (Fig . S A5 .4C ). Th e fi bula ri s lo ngus tend on ca n be pa lp ated as far a s th e cub oid , an d th en it di sap pear s as i t
t ur n s in to th e so le. T he f ib ul ar is b r evis tendo n can easil y b e tr aced to i ts att achm en t to the do rsa l su r face of th e tub er osity on
t he ba se o f the 5 th m etatar sal . Th is tub er osity is loca ted at the m id dl e o f t he late ral b or der o f the f oot. Wi th toe s acti vely
e xten ded , th e sm al l f lesh y bel ly of th e ex tensor d ig ito rum br evis m ay be seen an d p alp ated an ter io r to t he late ral m al leol us. I ts
p osi tion sho ul d be ob serve d and p al pated so th at it m ay n ot be m istak en su bseq ue ntl y f or an a bn or m al edem a.
T h e meta tar sop hala ng eal jo int o f the g r eat to e l ies di stal to the kn uck le f or m ed by th e h ead o f the 1 st m etat arsa l (Fi g.
S A5 . 4A). Gou t, a m etab oli c d isor der , co mm on ly cau ses e dem a an d ten der n ess of t hi s jo in t, as doe s ost eoar th rit is (d eg ene rati ve
j oin t di sease). S ever e p ain i n th e 1 st me tatar sop ha lan gea l j oin t is c alled p od ag ra (fr om G. p ou s + G. a gr a, a seizu r e). Ofte n th e
1 st m etatar sop h alan ge al joi nt is the f irst on e aff ected b y ar th ri tis.
T h e ten d on s on the an ter ior a spect of th e an kle (fr om m ed ial to late ral sid e) are easi ly pal pat ed wh en th e foo t is d orsi fl exed.
T h e l arg e t endo n of the tib ial is a nteri or l eaves the cove r of th e su p eri or exten sor t end on (Fi g. S A5 . 4A ), fr om w h ich le vel
t he ten do n is in vested b y a con tin u ou s syn ovi al shea th; th e te nd on m ay be tr aced to its attach m en t to th e 1st cu nei fo rm a nd

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t he ba se o f the 1 st m etat arsa l.

l
T h e tend on of the e xtenso r ha lluci s lo ngus, o bvi ou s w hen the g reat toe is do rsi fle xed ag ain st r esist ance , ma y b e f oll ow ed
t o i ts at tach me nt to the b ase o f the d istal p ha lan x o f the gr eat toe .
T h e tend ons of the extenso r di gi tor um lo ngus m ay b e fol low ed easi ly t o th ei r attach m en ts to th e later al fo ur t oes (Fi g.
S A5 . 4C).
T h e tend on of the f ib ular is ter tius ma y al so b e trace d to i ts a ttach me nt to th e b ase of th e 5 th m etat arsa l. Th is m uscl e i s of
m i no r im po rta nce an d m ay b e a bsen t.
T h e tr an sver se ta rsal j oin t i s i nd icate d by a l in e f ro m th e p oster io r aspe ct of t he tu ber osi ty of t he n avicu lar t o a p oin t h al fw ay
b etw een th e later al m all eolu s a nd t he tu ber osi ty of t he 5 th m etatar sal (Ta ble 5 .1 8 ).
Fig ure SA5. 4
P. 7 1 5
P. 7 1 6
P. 7 1 7
M e d ic a l I m a g i n g o f t h e L o w e r L im b
R a d iogr aph y
P e lv i c G ir d l e a n d H i p J o in t

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R ad iog r aph s of th e p elvi s an d h ip sh ow bo ne an d jo in t ab n or ma liti es o r ma lali gn m en t. In the AP p ro jecti on of th e hi p joi nt sh own

i n Fig ur e 5. 7 0A , th e p ati ent is in th e sup in e p osi tion on th e r ad iog r aph ic tab le. T he cen tra l X -r ay b eam i s center ed ove r the h ip
j oin t (see ori en tatio n fi gu re s). Su per im p osed on the f emo ra l h ead i s th e post eri or r im of t he acetab u lu m (PR ). At th e j un cti on of
t he fe mo ral n eck and sh af t, th e g r eater an d l esser tr och ant ers m ay b e se en. Betw een th e tro cha nter s is a n ob liq ue li ne cast by th e
s up eri m pose d in tert roch an ter ic lin e an d crest (IC ).
W hen view in g a f ul l-size r adi og rap h of th e hi p joi nt (i. e. , on f ilm or a m on itor ), ob ser ve th e ar chi tectu re of th e t rab ecu lar b on e o f
t he h ead, neck , an d pr oxim al sh af t of th e fem u r. Th e str en gt h of th e a ng led b on e d ep end s o n th is stru ctu re. In a h ealth y fem u r
w ith ou t osteo por osi s, th e tr ab ecul ae corr esp on d to ten sion a nd p re ssur e l in es r ef lecti ng th e wei gh t-be ari ng f u ncti on of t hi s b on e.
T h e d en se co mp act bon e ap pear s t ran sp are nt (wh ite ), wh er eas t he less den se spo ng y b on e app ear s d ar k.
E xtr ap ola ted lin es an d cur ves sup er im po sed on th e rad io gr aph ic im ag e (e .g ., the K ohl er , Sh en ton , an d ili of emo ra l l in es i n Figu r e
5 . 7 0A ) i n speci fi c vie ws are u sed to assess no rm al ali gn m en t of bon y f eatu r es. In ter r up ted li ne s, ir reg u lar cu rv e or lack of
s ymm etr y betw een l eft an d ri gh t si des in di cates di slocati on s, fr actu r es, or sl ipp ed ep ip hyse s. To en sur e dete ction o f a f ra ctur e of
t he fe mo ral n eck, seve ral vi ews mu st be ob tain ed (Fig . 5 .7 0B).
K n ee Join t
Mu lti pl e r ad iog ra ph ic pr oje ction s (A P, l ater al, an d ob li qu e) are n ecessar y to eva lu ate t he kn ee p r ope rly. In a n AP pr oj ectio n of th e
k nee jo in t (Fig . 5 .7 1B), the pe rso n is i n th e su p in e p osit ion w ith th e kn ee ext end ed . Th e c entr al X -ray be am is di rect ed thr ou g h
t he jo in t cavi ty. Ou tli nes of th e f em or al an d tib ial con d yles and t he sh ado ws of th e p atell a a re su per im p osed over the di stal en d of
t he fe mu r . Th e j oin t cavity ap pea rs lar ge be cau se th e men isci ar e no t vi sib le. T he m eni sci can b e vi sual ized i f air or opa qu e f lu id i s
i n jected i nto th e joi nt cavit y. Th e a dd uct or tu ber cle is evid en t j ust su per ior to t he m edi al epi con dyl e of th e fem u r. Th e l ater al
f em or al epi con dyl e a pp ear s m or e p ro m in ent th an th e med ia l o ne. Th e i nte rcon d ylar f ossa is opp osi te th e m edi al and l ater al
t ub er cles of th e in ter con d ylar em in en ce of th e p ro xim al tib ia. T h e ar ticu la r sur f aces o f the con d yles of th e ti bi a ar e con cave i n an
A P view .
Fig ure 5.70. Rad io gr ap hs o f no rm al hi p joi nt. A. On the f emu r , ob serv e th e hea d, n eck, g re ater tr och an ter ,
in ter tro cha nter ic cre st (I C), and sh af t. On th e hi p bon e, o bser ve the lu n ate sur fa ce o f the aceta bu lu m , th e p oster ior rim of th e
acetab u lu m (PR ), th e a nter io r sup er ior i lia c sp in e (A SI S), th e isch ial sp in e, an d th e sacr oi liac jo in t. Seve ral d if fer en t li ne s an d
cur vatu r es a re use d in th e d etect ion o f hi p abn or m ali ties (disl ocati on s, fr actu r es or slip ped e pip h yses). Th e Ko hl er lin e (A) is
no rm al ly tan gen tia l to th e pel vic i nl et a nd t he ob tur ato r fo ram en . Th e acetab u lar f ossa sho ul d lie la tera l to th is li ne. A f ossa
th at cr osses th e l in e su gg ests an acet abu la r fr actu re wi th in wa rd d isp lacem en t. T he Sh en ton l in e (B ) a nd th e ili ofe mo ral l in e
(C) sh ou ld ap pea r in a no rm al A P r ad iog ra ph a s sm oot h, co nti nu ou s lin es tha t ar e bil ater all y sym m etr ical . Th e S h ent on li ne is
a r ad iog r aph ic in di catio n of th e a ng le of in cli na tion . B . In thi s vi ew the lef t t hi gh w as a bd uct ed. Ob ser ve th e acetab u lar f ossa,
an teri or in f eri or il iac spi ne (AI IS ), h ead of th e fem u r (H), n eck of th e f em u r (N), g rea ter tr och an ter (G), lesser tro chan ter (L ),
in ter tro cha nter ic cre st (I C), and sh af t o f fem u r (S).

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Fig ure 5.71. Knee jo int. A and B . T he or ien tati on d raw in g de pict s th e st ru ctu res visi ble in the AP r adi og rap h of t he ri gh t
kn ee j oin t.
I n th e later al pr oj ectio n of an a rth r ogr am of th e kn ee joi nt sh own in Fig ur e 5. 7 2, the kn ee is sl igh tl y f lexed . A con tr ast m ed iu m
w as in jected t hr ou gh the jo in t cap su le to sh ow t he joi nt cavi ty a nd th e exten t o f the syn ovia l m em b ra ne. T h e ar ticu la r car tilag e on
t he fe mo ral co nd yle is rad io lu cent an d th e f ib rou s layer o f th e jo in t ca psu le, l in ed wi th syn ovia l m em b ran e, i s d isti nct. T h e l arg e
s up ra pate llar b u rsa is con tin u ou s w ith th e joi nt cavity . Alt ho ug h MRI h as lar ge ly r ep laced a rth r ogr ap hy , it is so me tim es u sef ul f or
d etect in g loose ar ticu la r bod ies if th e MR I is in con clu sive.
A n k l e J o i nt a n d F o o t
T h e m ost com m on r ad iog ra ph ic view s of th e an kle joi nt an d fo ot a re lat eral an d A P. A lat eral r ad iog ra ph i s take n wi th th e l ater al
m al leo lu s p laced ag ai nst th e X -ra y d etector (Fi g. 5 . 73A ). In Fi gu re 5 .7 3 , th e a rti cul atio n of th e co nve x su rf ace of th e tr och le a of
t he tal us (T) wit h the m all eoli o f the tib ia an d fi bu la is app ar en t, an d sha dow s o f the m all eoli ar e visib le. T h e n eck (N) and h ead
( H) o f th e tal us, the d isc-sh aped n avi cul ar (Na ), an d th e tal on avicu la r joi nt can b e se en. Th e cal can eu s (C a) a nd cu b oid (C )
a rti cul ate at t he calca neo cub oi d joi nt. Th e ta rsal sin u s (T S), t he spa ce b etwe en th e cal can eu s an d tal us, co nta in s th e in tero sseou s
t aloca lcan eal li gam en t.
Fig ure 5.72. Arthr og r am o f knee joi nt . Co ntr ast m edi um was in jected i nt o th e syn ovial cavi ty. T he kn ee i s sli gh tly fl exed .
Th e l ar ge sup r apa tella r bu r sa co mm u ni cates wi th th e kn ee joi nt cavi ty.

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Fig ure 5.73. Rad io gr ap hs o f l ow er l eg, a nkle, and f oo t. A. Th e left f oot is s how n in a n eu tr al posi tion . B . Th e lef t f oot, in
slig h t p lan tar fl exion , i s sh ow n. C. Th e l eft an kle is s how n . C, cub oid ; C a, c alcan eu s; H , h ead of tal us; L , later al m all eolu s; M,
m edi al ma lleo lu s; N , neck of ta lu s; Na , n avicu lar ; T , tal us; TS , tar sal sin us (tu nn el ). (Par t C C ou rtesy of Dr . P. B obe chko an d
Dr . E . B ecker, Dep ar tm en t of Med ical I m agi ng , Un iver sity of T or on to, To ro nto , On tar io, C an ad a.)
I n th e dor sop lan tar p r oject ion , th e p ati ent is sup in e wit h the kn ee fle xed, a nd th e pl ant ar su rf ace o f the f oot is pla ced on th e X-r ay
d etect or (Fig . 5. 7 3B). T he cen tra l X -r ay b eam i s cen ter ed on the ba se o f the 3 rd m eta tarsa l. T hi s vie w d em on str ates the p hal an ges
a nd i nt erp ha lan ge al joi nts. H ow ever , beca use th e t oes a re in sl ig ht fl exion , th e in terp h alan g eal joi nt s of th e 2n d 5t h toes ar e
n ot cle ar. T h e sesa mo id s on t he pl an tar su rf ace of th e h ead o f the 1 st m etat arsa l a re evid en t, as is t he ar ticu lati on of t he ba se o f
t he 1 st m etat arsa l w ith t he m edi al cun eif or m an d th e b ase of th e 2 n d m etatar sal . Th e b ases of th e 2 n d 5 th m eta tar sals over lap ,
s o th e in ter met atar sal joi nts ar e ea sy to see. Th e ta rsal b on es o verl ap som ew ha t b ecau se o f the n or ma l cur vatu re of th e foo t.
C on seq u entl y, al l th e tar sal joi nts do n ot sho w clear ly. Onl y an ter ior par ts o f th e tal us an d calca neu s are visi bl e b ecau se o f the
o ver lap of th e m alle oli.
A n A P r ad iog ra ph i s take n wi th th e p er son in t he su pin e po sitio n wi th th e f oot do rsi fl exed to a r ig h t an g le and t he gr eat toe
p oi nte d slig ht ly m ed ial ly (Fi g. 5 . 7 3C ). T o vi sua lize all th e bo nes an d joi nt s of th e an kle and f oo t, oth er p ro jectio ns ar e r eq ui red .
A r t e r i o g r a p hy
V isu ali zati on of ar ter ies by X-r ay im ag in g afte r in jecti on of a r adi opa qu e co nt rast m edi um is a h elp fu l wa y of stu d yin g selecte d
a rte rie s to de term i ne th e exi sten ce o f abn or m ali ties such a s p op litea l a neu r ysm (cir cu m scrib ed d ila tion o f the p opl itea l a rter y). I n
a p op li teal ar teri og r am (Fi g. 5 . 74 ), th e rad io paq u e m ater ia l i s in je cted in to th e f em ora l a rte ry an d spr ead s th ro ug h th e pop li teal
a rte ry an d its br an ches, the tib ial an d f ibu la r ar teri es.
C o m p ut e d T o m o g r a p hy
C T u ses X -ra ys th at pa ss th ro ug h th e lim b at var iou s a ng les; h owev er, th e im ag es ar e crea ted by com p ute r reco nstr u ction s of th e
d ata . CT scan s can b e set to di spl ay so ft tissu es o r bo ne. Hyp od ense ar eas on C T scan s su gg est strai ns (swe lli ng ), an d h yper de nse
a rea s su gg est hem at om as. C T of th e kn ee (ar thr oto mo gr ap hy) pr ovi des a rel iab le assessm en t of t he cru cia te l ig am ents, me ni sci,
p atel lar ca rti lag e, an d loc alize s of o steoch on dr al d efects an d loo se b od ies.
M a g ne t i c R e s o n a n ce I m a g i ng
MR I pr od u ces i ma ges of exq ui site res olu tio n of li mb s w ith ou t the u se o f rad iat ion . MRI sca nn in g r equ ir es the in di vid ua l t o ke ep the
l im bs m otio nl ess f or 5 1 0 m in . MRI s sh ow m u ch m or e d etai l i n th e so ft tissu es th an do ra dio gr ap hs or C Ts (Fig s. 5. 7 5 , 5. 7 6,
5 . 7 7 an d 5. 7 8 ).
H i p J o i nt
I n Fig u re 5. 7 5 , ob serve th at the jo in t cap su le of th e j oin t is th ick n ear th e ilio fem or al li gam en t an d thi n po ster ior to th e p soa s
b u rsa an d ten do n. In secti on s at th is level , th e f em ora l sh eat h, w h ich en clo ses th e fem or al ar tery , vein , lym p h n ode , lym ph ati c
v essels, a nd f at, p ro tru d es in to th e su b cuta ne ou s tissu e. T h e lo ose con ne ctive tissu e n ear ly su rr ou nd s i t ex cept po ster ior ly wh er e,
b etw een th e ili opso as a nd th e pecti ne us, i t i s att ache d to the cap sul e o f the h ip jo in t. Th e fem or al ar ter y is sep ara ted fr om t he h ip
j oin t by th e i lio psoa s m u scle a nd /or te nd on . In the in ter val be tween the il iop soas, t he pe ctin eus, and the fe mo ral n er ve, th e
f em or al vein l ies bet ween t he ili op soas an d its f ascia .
Knee
MR Is ar e ex trem el y h elp fu l fo r dete rm in in g if th er e a re in ju ri es t o th e me ni sci, col late ral li gam en ts, a nd cr u ciate lig am en ts (Fi g.
5 . 7 6). I t is th e pr oced u re of ch oice fo r assessi ng i nte rn al der an g eme nts of th e k nee .

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Fig ure 5.74. Po pl iteal ar ter io gr am. T he p opl iteal ar ter y b eg in s at th e si te o f the ad du ctor h ia tus (wh er e i t m ay be
com pr essed ) an d th en l ies successi vely on th e di stal end o f th e f em ur , jo in t cap su le of th e kn ee joi nt , an d pop li teu s m us cle
(no t vi sib le) bef or e d ivid in g in to th e an ter io r an d post eri or tib ia l ar ter ies at the in f eri or an gl e o f the p opl iteu s f ossa. Her e i t i s
sub ject to en tra pm en t a s it p asses b en eath th e ten di no us ar ch of th e so leu s m u scle. (C ou r tesy o f Dr . K . Sn id er ma n, A ssoci ate
Pr ofes sor of Med ical Im ag in g , Un iver sity of To ro nto , To ron to , Onta ri o, C an ada )

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Fig ure 5.75. Sectio nal and ra di og ra phic anato my o f g lute al r eg io n and p ro xim al a nt eri or thig h at level o f hi p joi nt.
A and B . A descr ip tive dr aw in g an d tra nsver se (axia l MR I) stu dy of an an ato m ical sectio n of th e thi gh a re sh own . C. T he
or ien tati on d raw in g sh ows th e l evel of th e sect ion .
Fig ure 5.76. Sectio nal anatomy of knee jo int. A and B . Th e ori en tatio n dr aw in g dep icts th e str u ctur es visib le in th e
cor on al MR I of th e kn ee j oin t. (C ou rt esy o f Dr . W. K uch ar czyk, P rof essor a nd C h air o f Me dica l I m agi ng , Un ive rsit y of T or on to,
an d Cl in ical Dir ector o f Tr i-Ho spi tal Ma gn etic R eson an ce C en tre , Tor on to, Onta ri o, C an ada. )

08-May-15
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Fig ure 5.77. Tr ansver se MRIs of lo w er li mb, f ro m b elo w . A. Secti on s at th e m i d-th ig h leve l (A) an d mi d-l eg level (B ) ar e
sho wn .
Fig ure 5.78. Sectio nal anatomy of ankl e r eg io n. A and B. T h e or ie nta tion d r awi ng d epi cts t he str uctu r es vi sibl e i n th e MR I
of th e a nkl e. (C ou rtesy of Dr . W. Ku ch ar czyk, Pr of essor an d C ha ir of Med ical I ma gi ng , Un iver sity of T oro nt o, an d C lin ical
Di re ctor of T ri -Hosp ita l Mag n etic Reso na nce C ent re, T or on to, On tar io , Ca nad a. )
T hi g h, L e g , a n d A n k le
MR Is ar e h el pf ul fo r id en tify in g the sof t ti ssue (su ch as mu scle ) an d osseo us an d n eur ova scul ar an atom y of th e th ig h an d leg (Fi g.
5 . 7 7). I n th e coro na l MR I sh own in Fig ur e 5. 7 8, the tib ia r ests o n th e tal u s an d th e ta lu s r ests o n th e ca lcan eu s. Betw een th e
c alcan eu s an d th e skin , sever al en capsu la ted cush i on s of f at a re evid en t. I t is also cl ear ly se en th at th e late ral m all eol us desce nd s
m u ch f art her i nf er ior ly th an th e m ed ial m all eolu s. I n th e a nat om ical cor on al sectio n, the in ter osseo us ba nd b etw een th e ta lu s an d
c alcan eu s sep ar ates the su bta lar j oin t f r om th e taloca lcan eon avi cul ar jo in t. Bo th th e an ato m ical sectio n an d th e MR I dem on str ate
t he tal ar sh elf acti ng as a pu lle y f or th e f lexo r ha llu cis lon g us an d gi vin g attach m en t to th e calcan eot ibi al ban d of th e m edi al
l ig ament .
P. 7 1 8

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P. 7 1 9
P. 7 2 0
P. 7 2 1
P. 7 2 2
P. 7 2 3
P. 7 2 4
F o o tn o te
1 B ecau se of i ts a nter io r po sitio n, t he ten sor o f t he fa scia lata is oft en stu di ed wit h th e an ter ior thi gh m u scles fo r con ven ien ce (i .e. ,
w h en th e ca dave r is su p in e); h ow ever , it is actu ally pa rt of th e g lu teal g ro up , an d wi ll be in clu d ed wi th th at g r ou p in th is boo k.
R e f e r e n ce s a n d S u g g e st e d Re a d in g s
A n der son MK , Hal l SJ, Mar tin M: Sp or ts I nj ur y Ma na gem en t, 2 nd ed. B alti m ore , Li pp in cott Will iam s & Wil kin s, 2 00 0 .
B ir re r RB (ed ): S po rts Medi cin e f or th e Pri ma ry Ca re Ph ysici an, 2n d ed . Bo ca R ato n, FL , CR C P ress, 1 9 9 4.
C la y JH , Pou n ds DM: Basi c C li ni cal Me ssage Th er apy : I nteg r atin g An ato my an d Tr eatm en t. B alti mo re, Lip p in cott Will iam s &
Wi lkin s, 2 0 03 .
Foe rster O: Th e der m atom es in m an . Brai n 5 6:1 , 1 9 33 .
Fr ick H, L eon h ard t H, S tar ck D: H um an An atom y 1: Gen era l A na tom y, Sp ecia l A n atom y: Lim b s, Tr u nk Wall , Hea d and Neck.
S tu ttga rt, T h iem e, 1 9 91 .
Ger R , S edl in E : T he accesso ry sole us m uscl e. C lin Or th op 1 16 : 20 0 , 1 97 6 .
Gr oss A: Orth op edi c su r ger y a du lt. I n Gro ss A , Gro ss P, L an ge r B (eds): Su r ger y: A C om p lete Gui de for Patie nts an d Th eir
Fam il ies. T or on to, H ar per & C olli ns , 19 8 9 .
H am ill J, K n utz en KM: Bi om echa ni cal Basi s o f H u ma n Movem en t. Ba ltim or e, L ip pi nco tt Wi lli am s & Wilki ns, 19 9 5.
Je nki ns DB: H ol lin sh ead' s Fu nct ion al An ato my of th e Lim b s an d B ack, 8 th ed . Ph ila del ph ia, S au nd er s, 2 00 2 .
K ap an dj i I A: Th e P hysi olo gy of th e Jo in ts, Vo l. 2 . L ower Lim b , 5 th ed . Ed in bu r gh , UK , C hu r chi ll Li vin gsto ne , 19 8 7 .
K eeg an JJ, Gar r ett FD: T h e seg m ent al dist rib u tion of th e cu tan eou s ner ves in th e lim bs of m an . An at R ec 1 0 2:4 0 9 , 19 4 8 .
L aw son , JP: C li ni call y si gn if ican t r ad iol ogi c an ato m ic va ri ant s of th e skeleto n. Am J Ra di ol 16 3 :2 49 , 1 9 94 .
L evan d owski R , Dif ior i JP: T hi gh i nj ur ie s. In B ir re r RB (ed ): S po rts Medi cin e f or th e Pri ma ry Ca re Ph ysici an, 2n d ed . Bo ca
R ato n, FL , C RC P ress, 19 9 4.
Mar kh ede G, St ene r G: Fun cti on af ter r em oval of var io us h ip an d th igh mu scle s fo r extirp atio n of tu m ors. Acta Ort ho p Scan d
5 2 :3 73 , 1 9 81 .
Mi dd leton JA, K olo do n EL . Pl an tar fa sciiti s: H eel pai n in a thl etes. J Ath T r ain 2 7 :70 , 1 9 92 .
Mo ore K L, P ersau d T VN: Th e De velop in g Hu m an . C lin ical ly Orie nte d Em b ryo log y, 7 th ed ., P hi lad elp hi a, Sa un d ers, 2 0 0 3.
P alasta ng a N, Fiel d D, Soa mes R : A nat om y an d H um an Mo vem ent, 4th ed. , Oxf ord , UK , B utte rw or th-H ein em an n, 20 0 2 .
R ose J, Gam bl e JG: Hu m an Wal kin g , 2 n d ed. , B alti mo re, Lip pi nco tt Wi lli am s & Wilk in s, 19 9 4 .
S alte r RB : Or th ope dic su rg er y p edi atr ic. I n Gross A, Gr oss P, L an ger B (ed s): S u rg ery: A C om ple te Gu id e f or Pa tien ts a nd T he ir
Fam il ies. T or on to, H ar per & C olli ns , 19 8 9 .
S alte r RB : T extb ook of D isor der s and I n ju ri es o f t he Muscu lo skeleta l S ystem, 3 rd e d. B alti mo re , Li pp in cott Will iam s & Wil kin s,
1 9 9 9.
S lab y FJ, McC u ne SK , S um m er s R W: Gr oss A na tom y i n th e P racti ce o f Me dici ne . Bal tim or e, L ea & Feb ige r, 1 9 94 .

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S oam es RW: Ar th ro scopy of th e kne e. In Will iam s P H, B an ni ster LH , Be rr y MM, C oll in s P , Dyso n M, Dusse k JE , Ferg u son MWJ
(e ds): Gr ay's An ato my , 38 th e d. N ew Yor k, C h ur ch ill L ivin g ston e, 1 99 5 .
S od erb er g GL: Kin esi olo gy: Ap pli catio n to Path ol ogi cal Motio n. B alti m ore : Wil lia ms & Wi lki ns, 1 9 8 6.
S war tz MH: Textb ook of Ph ysica l D ia gn osi s, 4t h ed. P hi lad elp hi a, S aun d ers, 20 0 2 .
Wi lli am s PH , Ba nn ist er LH , Ber r y MM, C oll in s P, Dyso n M, Dussek JE , Ferg u son MWJ: Gr ay's An ato my, 38 th ed . Ne w Yor k,
C h ur ch ill L ivin g ston e, 1 99 5 .

08-May-15

Clinically Oriented Anatomy, 5th Edition - 5. Lower Limb

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Clinically Oriented Anatomy, 5th Edition - 5. Lower Limb

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Ovid: Clinically Oriented Anatomy

Author s: Mo or e, Keit h L. ; Da lley, Ar thur F.

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Ovid: Clinically Oriented Anatomy

S ym ph ysia l su r face of th e pu bi s i s ver tica l, pa ra llel to th e m ed ian pla ne (Fig . 5. 6 ).

I n th e ana tom ical p ositi on , th e:

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Fig ure B5. 1

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Fig ure B5. 2.

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Fig ure B5. 3

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Fig ure B5. 4

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Fig ure B5. 5

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Fig ure SA5. 1

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Ovid: Clinically Oriented Anatomy

Fig ure B5. 6

Fig ure B5. 7

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Ovid: Clinically Oriented Anatomy

T h e i liac cre st l ater ally an d po ster ior ly.

E xp osed p ar ts of b on es aro un d th e k nee an d th e d eep f ascia of th e l eg di stall y.

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Ovid: Clinically Oriented Anatomy

A scen ds an ter ior to th e med ia l m al leol us.

A n astom oses fr eel y w ith th e sma ll sap hen ou s vein .

T r aver ses th e saph en ou s o pen in g in t he fa scia lata.

E m p ties in to t he fem o ral vei n.

P asses alon g th e later al bo rd er of th e calcan eal te nd on .

I n clin es to the m id lin e of th e f ib ul a an d p ene tra tes th e deep f ascia .

A scen ds bet ween t he h eads of th e gastr ocn em iu s m u scle.

E m p ties in to t he po pl iteal vei n in th e po pli teal fo ssa.