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Institute of Anatomy, First Faculty of
Medicine
Paul Mozdziak
Visiting Professor
Muscles, osteofascial
compartments,
vessels, and nerves of
the lower limb
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Muscle is Important
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Regional Anatomy
Surface Anatomy
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General Structure of Muscle-Review
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Overview of muscle groups
• Muscles of the hip joint (3 groups)
• Thigh muscles (3 groups)
• Muscles of the leg (3 groups)
• Muscles of the foot (2 groups)
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Muscles of the hip joint (musculi coxae)
• Anterior group (flexors)
• Posterior group:- gluteal (superficial)- pelvitrochanteric (deep)
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Muscles of the hip joint (musculi coxae)
• Anterior group muscles:-iliacus-psoas major-(psoas minor)
• Function: flexors
• Innervation: lumbar plexus (Th12 - L4)
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Muscles of the hip joint (musculi coxae)
• Posterior group muscles – gluteal group- gluteus maximus- gluteus medius-abduction- gluteus minimus-abduction- tensor fasciae latae
• Function: abductors, extensors, rotators
• Innervation: sacral plexus (L4 - S2), directly or via gluteal nerves
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GX
G
NG
D
SRIP
OI
P
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Muscles of the hip joint (musculi coxae)
• Posterior group muscles - deep (aka. pelvitrochanteric) muscles- piriformis- mm. gemelli (superior and inferior)- obturator internus (tendon - landmark)- quadratus femoris
• Function (aka): small lateral rotators
• Innervation: sacral plexus (L4 - S2)
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Thigh muscles (musculi femoris)
• Ventral (anterior) group (quadriceps, sartorius -knee extensors)
• Medial group (adductors)
• Posterior (dorsal) group (knee flexors)
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Thigh muscles (musculi femoris)• Ventral (anterior) group
- m. sartorius - tailor’s muscle- quadriceps femoris (4 heads):
rectus femorisvastus medialis, intermedius,lateralis
• Innervation: femoral nerve (L2 - L4)
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Thigh muscles (musculi femoris)
• Medial group muscles (inner thigh):- pectineus- gracilis- adductor longus, brevis, magnus- obturatorius externus
• Innervation: obturator nerve (L2 - L4); pectineus and add. magnus bineural
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Thigh muscles (musculi femoris)
• Posterior group muscles (hamstring):- biceps femoris- semitendinosus- semimembranosus
• Innervation: sciatic nerve (n. ischiadicus, L4 -S2)
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Leg muscles (musculi cruris)
• Anterior group (digit and foot extensors and foot supinators)
• Lateral group (supplemental foot flexors and pronators)
• Dorsal (calf) group (foot and digit flexors)
• Tough fascial compartments - compartment syndrome!
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Leg muscles (musculi cruris)
• Anterior group- tibialis anterior- extensor hallucis longus - extensor digitorum longus
• Innervation: deep peroneal nerve (n. peronaeusprofundus, L4 - S1)
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Leg muscles (musculi cruris)
• Lateral group- peronaeus longus- peronaeus brevis
• Inervation: n. peronaeus superficialis (L5 - S1)
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Leg muscles (musculi cruris)
• Posterior group- superficial layer:
- triceps surae, - plantaris
– deep layer:- popliteus- tibialis posterior- flexor digitorum longus- flexor hallucis longus
• Innervation: n. tibialis (L4 - S2)
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Tight heel cord
• Clinically important that gastrocnemius crosses the knee joint
• Soleus does not cross the knee joint
• Can be used to determine the cause of a tight knee cord
• Silfverskiöld test– Ankle Joint
– Flex Knee Relaxes Gastrocnemius
– If more dorsiflexion of ankle is possible with knee flexed, cause of tightness is gastrocnemius
– If no change in dorsiflexion regardless of position of knee, soleus is responsible
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Silfverskiöld test
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Foot muscles (musculi pedis)
• Plantar muscles:- muscles of the big toe (medial compartment)- muscles of the little toe (lateral compartment)
- central compartment- mm. interosseiInervation: n. plantaris medialis et lateralis via n. tibialis (S1-S2)
• Muscles of the dorsum of the foot (extensors)- ext. digitorum brevis and ext. hallucis brevisInervation: n. peronaeus profundus (L4-S1)
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Foot muscles (musculi pedis)
- medial (big toe) compartment -
• M. abductor hallucis
• M. flexor hallucis brevis
• M. adductor hallucis
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Foot muscles (musculi pedis)
- lateral (little toe) compartment -
• M. abductor digiti minimi
• M. flexor digiti minimi brevis
• M. opponens digiti minimi
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Foot muscles (musculi pedis)
- central compartment -
• M. flexor digitorum brevis
• Mm. lumbricales
• M. quadratus plantae
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Foot muscles (musculi pedis)
- musculi interossei -
• Mm. interossei plantares (3 ; 3., 4., 5. toe)
• Mm. interossei dorsales (4; axis = 2. toe)
• M. quadratus plantae
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PlantarDorsal
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Foot Arch
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Factors
Affecting
The
Arches
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Supporting Foot Arch
• Foot arch Medial is supported by ligaments
– Staples
• Short Plantar
• Long Plantar
• Spring Ligament
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Muscles Supporting the Medial Foot Arch
• Longitudinal muscles (“tie beam”):- flexor digitorum longus-Medial portion- flexor hallucis longus- abductor and flexor hallucis brevis
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Muscles Supporting the Medial Foot Arch
• Tibialis Anterior
• Tibialis Posterior
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Lateral Longitudinal• Tie Beams
– Abductor Digiti minimmi, Flexor Digitii minimmi
– Lateral portion of Flexor Digitorum
• Sling
– Tendon of Peroneus Brevis
– Peroneus longus—long course, underneath foot.
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Transverse Arch
• Tie Beams
– Tendon of Peroneus longus
– Tendon of Tibialis posterior
• Sling
– Tibialis anterior medially
– Peroneus brevis and tertius laterally
• Factors that maintain the longitudinal arches
also maintain the transverse arch
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Coming up next time:
Vessels and nerves of the lower
limb
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Lower limb vessels
• Arteries - femoral artery and its branches
• Veins:- deep system (accompanies arteries)
• Popliteal and femoral
– superficial system - great and small saphenous vv. -varices, by-pass grafts
• Lymphatic vessels
• Embryology-Time Permitting
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Femoral Artery• Femoral artery is the
continuation of the
external iliac artery:
– Begins deep to the inguinal
ligament.
– Enclosed within the femoral
sheath
• transversalis fascia anteriorly
and the iliac fascia posteriorly;
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Femoral Artery
• Superficial epigastric
artery:• Passes through or close to the
saphenous hiatus.
• Crosses inguinal ligament
toward the umbilicus.
• Anastomoses with inferior
epigastric artery.
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Femoral Artery
• Superficial circumflex iliac
artery:
– Passes through or close to
the saphenous hiatus.
– Passes along inguinal
ligament toward the ASIS.
– Anastomoses with deep
circumflex iliac artery.
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Femoral Artery
• External pudendal
artery:
– Passes through or
close to the saphenous
hiatus.
– Passes medially
toward external
genitalia.
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Deep Femoral Artery
• Medial femoral circumflex.
• Lateral femoral circumflex.
• Perforating arteries (3).
• Descending genicular.
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Deep Femoral Artery
– Arises from deep side of femoral artery within femoral triangle.
– Largest branch.
– Passes posterior to adductor longus muscle.
– Medial and lateral
– Perforating arteries.
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Medial femoral circumflex
– Leaves femoral triangle between the
iliopsoas and pectineus muscles.
– Ascending branch anastomoses with
inferior gluteal artery.
– Transverse branch anastomoses with
lateral femoral circumflex artery.
– Supplies hip joint, muscles of upper
thigh, gluteal region.
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Lateral femoral circumflex
– Ascending branch anastomoses with
superior gluteal artery.
– Transverse branch anastomoses with medial femoral circumflex artery.
– Descending branch anastomoses with genicular arteries.
– Supplies hip joint, muscles of upper thigh, gluteal region.
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Descending genicular
• Arises in adductor canal.
• Musculoarticular branch:
– Part of genicular anastomosis.
• Saphenous branch:
– Runs with saphenous nerve.
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• Profunda femoris + rami perforantes I-III
• Circumflexa femoris medialiset lateralis
Femoral angiography
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• Deep Femoral + perforating arteries
• A. poplitea and anastomoses around the knee joint
• Topography in the popliteal fossa:
AVeN!
(from deep to superficial)
Blood supply to the
posterior thigh
muscles
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Popliteal Artery
• Continuation of femoral artery.
• Begins at adductor hiatus.
• Ends at inferior border of popliteus muscle:– Branches into anterior and
posterior tibial arteries.
• Most anterior structure in popliteal fossa.
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• A. poplitea and anastomoses around the knee
• A. tibialis anterior
• A. tibialis posterior et a. fibularis
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Posterior Tibial Artery
• Terminal branch of popliteal artery.
• Begins at inferior border of popliteus muscle.
• Accompanied by tibialnerve.
• Descends on posterior surface of tibialis posterior muscle.
• Medial plantar artery.
• Lateral plantar artery.
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• posterior tibial artery
passes behind the
medial malleolus
• arterial arch
analogous to palmar
• individual variations
• lower limb ischemia
in diabetes:
gangrene
=>amputation
Arteries of the foot -
plantar view
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Anterior Tibial Artery• Terminal branch of popliteal
artery:– Inferior border of popliteus
muscle.
• Accompanied by deep peroneal (fibular) nerve.
• Anterior compartment of leg.
• Branches:– Anterior tibial recurrent
– Lateral malleolar artery.
– Medial malleolar artery.
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• A. dorsalis pedis
• palpable between the tendons
• m. extensor hallus longus
• extensor digitorum longus
Arteries of the foot -
dorsal view
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Veins of the lower limb
• Deep system (follows the
arteries).
• Superficial network great and
small saphenous vein
– varices (in valvar insufficiency)
– potentially redundant => material for
by-pass (of clogged coronary
arteries)
– deep venous thrombosis => lung
embolism
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Femoral vein and its
tributariesGreat saphenous vein
Relationship of structures in Femoral Triangle under the inguinal ligament:
(Clo)VAN
significance: catheterization of femoral artery and vein
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Lymphatic drainage of the lower limb
• Follows the course of veins– Superficial
– Medial vessels• Great saphenous vein.
– Lateral Vessels• Small saphenous vein
• Popliteal nodes
– Deep• Fewer than superficial counterparts.
• 3 main groups:
– Anterior tibial, posterior tibial and peroneal.
» Entering the popliteal lymph nodes.
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Lymphatic vessels of the lower limb• Superficial Inguinal Nodes
– Below the inguinal ligament
– Receive lymph from the penis, scrotum,
perineum, buttock and abdominal wall.
• Superficial Sub-Inguinal Nodes
– Proximal section of the great saphenous
vein.
• Deep Sub-Inguinal Nodes
– Medial aspect of the femoral vein
• Knowledge of the lymphatic system is
necessary to understand tumor
spreading.
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Nerves of the lower limb
• Thigh:
- Anterior group – Femoral nerve (L2-L4)
- Adductors – Obturator nerve (L2-L4)
- Posterior group - sciatic (L4-S2)
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Nerves of the thigh
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Nerves of the lower limb
• Leg:
- anterior group – Deep peroneal nerve.
- lateral group – Superficial peroneal nerve
- posterior group – Tibial nerve.
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Nerves of the leg
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Nerves of the lower limb
• foot:- plantar muscles – n. plantaris medialis
– lateralis• via n. tibialis
– Extensors• Deep peroneal nerve
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Embryology of the Lower Limb
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Embryology Development-Muscles
• Somites– L1-L5, S1-S2
– at the limb bud site
• Sequence of Events (wk5)– migration – mesoderm from
somites (myotomes) migrates into the limb bud forming posterior and anterior condensations
– condensation – mesoderm condenses and differentiates into myoblasts; condensations split into recognizable muscles
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Bone Development• Lateral plate mesoderm
(LPM)
– primary ossification centers-
femur and tibia
• Rotation takes place as
the limb extends ventrally
– medial 90° rotation on the
longitudinal axis
– Future knee becomes
ventral; extensor muscles
anterior
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Vascular Development• Umbilical a.
– Axis a.
• anterior tibial
• mostly regresses
– Terminal plexus
• (but for deep plantar
arch
• External Iliac a.
– femoral artery
• profunda femoris a.
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Innervation of the Limbs• Lumbosacral Plexus - Ventral Primary Rami
(L2-L5, S1-S3)
• Motor Axon from the Spinal cord innervate limb
tissues
– Local cues guide axons
– Sensory axons use motor axons for guidance
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Muscle groups and their nerves
• Dorsal group - extensors:-dorsal hip joint group (glutei mm. and nn.)-anterior group of the thigh (femoral n.)-anterior and lateral group of the leg (peroneal n.)-dorsum of the foot (deep peroneal n.)
• Ventral group - flexors:-posterior group of the thigh (hamstrings, sciatic n.)-medial group of thigh (adductors, obturator n.)-calf muscles (tibial nerve)-muscles of the sole of the foot (branches of tibial n.)
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References
• Cihák: Anatomie 1, 3
• Netter: Anatomical atlas (CD version)
• Sobotta: Atlas of anatomy
• Grim M, Druga R et al.: Základy anatomie 5. Anatomie krajin těla
• Snell’s Clinical Anatomy
• Grey’s Anatomy
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