Lower Extremity-Hip, Thigh, and Pelvis

Basic Areas/Regions Gluteal-of or relating to or near the gluteal muscles Femoral-of or relating to the femur or thigh Pelvis-of or relating to the pelvis

The pelvic girdle (pelvis) is made up of the ischium, the ilium and the pubis. On each side, the bones are fused together at the acetabulum. The two sides connect anteriorly at the pubic symphysis and posteriorly at the sacrum at the sacroiliac joints.

Bones of the Pelvic Girdle Bone Landmarks Atlas Ilium 1. Iliac crest 2. Iliac tuberosity 3. Iliac fossa 4. Gluteal surface 5. Gluteal lines 6. Auricular surface 7. Arcuate line 8. Greater sciatic notch 9. Acetabulum 10. Acetabular rim 11. Acetabular notch 12. Anterior superior iliac spine (ASIS) 13. Anterior inferior iliac spine (AIIS) 14. Posterior superior iliac spine (PSIS) 15. Posterior inferior iliac spine (PIIS)

Ischium 1. Ischial tuberosity 2. Ischial spine 3. Ischial ramus 4. Body of ischium 5. Lesser sciatic notch 6. Obturator foramen

Pubis 1. Pubic tubercle 2. Superior pubic ramus 3. Inferior pubic ramus 4. Pubic symphysis 5. Symphyseal surface 6. Pectineal line 7. Body of pubis

Femur 1. Head 2. Neck 3. Fovea capitus 4. Greater trochanter 5. Lesser trochanter 6. Intertrochanteric crest 7. Intertrochanteric line 8. Trochanteric fossa 1

9. Shaft of femur 10. Gluteal tuberosity 11. Pectineal line 12. Linea aspera 13. Adductor tubercle 14. Medial condyle 15. Lateral condyle 16. Medial epicondyle 17. Lateral epicondyle 18. Intercondylar notch 19. Intercondylar line 20. Patellar surface 21. Popliteal surface 22. Medial supracondylar line 23. Lateral supracondylar line

Joints and Ligaments of the Hip and Pelvic Girdle Remember that joints are bone to bone. Synovial joints have a joint capsule with synovial fluid inside that acts to lubricate the joint. Remember that ligaments connect bone to bone. Joint Ligaments Bones that ligaments connect Atlas Femoralacetabular (Hip) 1. Ligamentum teres (ligament 1. Acetabulum to fovea • Head of femur and to the head of the femur) capitis acetabulum 2. Iliofemoral ligament 2. AIIS to inter- • Ball and socket joint (Y ligament) trochanteric line • Synovial (diarthrotic) 3. Pubofemoral ligament 3. Superior pubic ramus joint to intertrochanteric line 4. Ischiofemoral ligament 4. Ischium to intertrochanteric line Pubic Symphysis 1. Interpubic disc 1. Pubic bone to pubic • Pubic symphyseal bone surface and pubic symphyseal surface • Immovable • Joint by fibrocartilage disc

Sacroiliac 1. Sacrotuberous ligament 1. Sacrum to ischial • Sacrum and ilium 2. Sacrospinous ligament tuberosity • Modified plane joint 3. Anterior/posterior sacroiliac 2. Sacrum to ischial spine (immovable) ligaments 3. Sacrum to ilium • Synovial (ampiarthrotic) joint

Additional Ligaments 1. Inguinal ligament 1. ASIS to pubic tubercle 2. Iliolumbar ligament 2. Iliac crest to transverse processes of lumbar vertebrae

Muscles of the Hip, Pelvis, and Thigh You are responsible for understanding names of muscles, their origin, insertion, innervations, vascularization, and functional movements they create. This manual is based off your required textbook and is meant to be a guide for what you are responsible for knowing. DO NOT simply memorize, make sure you truly understand the information. Some reminders and tips for understanding include: • Due to the nature of the muscle fibers, muscles are able to change length. The contraction is when it is shortening. • Origin-the immovable part of the muscle • Insertion-the moveable part of the muscle • Function-the origin stays fixed and the insertion is the moving part… the insertion will move towards the origin. • A muscle will move the bone that it inserts on. (ex. If insertion is on humerus, the humerus moves; if insertion is on scapula, scapula moves) • If a muscle crosses more than one joint, it will move more than one joint (ex. Biceps brachii crosses the shoulder and the elbow, therefore it moves both the shoulder and the elbow) • Note the angle/direction of the muscle fibers. It often dictates the function. Notice what happens when the muscle shortens • Always palpate from origin to insertion 4

Anterior Hip Region (Hip flexors) -Iliopsoas Muscle Origin Insertion Function Atlas Psoas Major Bodies, Transverse Lesser Trochanter Hip Flexion Processes, and Intervertebral Disks T12-L5 Psoas Minor Vertebral Bodies and Iliopectineal Arch Pelvis Upward Rotation Intervertebral Disks T12-L1 Iliacus Iliac Fossa Lesser Trochanter Hip Flexion

Posterior Hip Region (Gluteals and Rotators) Muscle Origin Insertion Function Atlas Gluteus Maximus Sacrum, Posterior Iliotibial Tract Hip Extension Ilium, Thoracolumbar Gluteal Tuberosity Fascia, Sacrotuberous Ligament Gluteus Medius Posterior Ilium under Greater Trochanter Hip Abduction Iliac Crest Hip Extension Gluteus Minimus Posterior Ilium, Greater Trochanter Hip Abduction beneath Gluteus Hip Extension Medius Tensor Fascia Latae Anterior Superior Iliac Iliotibial Tract Hip Abduction Spine Piriformis Pelvic surface of Superior Greater Hip External Rotation Sacrum Trochanter Adduction Extension Obturator Internus Obturator Membrane Medial Greater Hip External Rotation (within Foramen) Trochanter Adduction Extension Gemellus Superior Ischial Spine Medial Greater Hip External Rotation Trochanter Adduction Extension Gemellus Inferior Ischial Tuberosity Medial Greater Hip External Rotation Trochanter Adduction Extension Quadratus Femoris Lateral Ischial Intertrochanteric Hip External Rotation Tuberosity Crest Adduction Medial Thigh -Superficial Muscle Origin Insertion Function Atlas Pectineus Superior Pubic Ramus Pectineal Line Hip Adduction External Rotation Adductor Longus Superior Pubic Linea Aspera Hip Adduction Ramus, Ant. Symphysis 5

Adductor Brevis Inferior Pubic Ramus Linea Aspera Hip Adduction Gracilis Inferior Pubic Ramus Pes Anserine Hip Adduction (Superior, Medial Flexion Tibia)

-Deep Muscle Origin Insertion Function Atlas Obturator Externus Obturator Membrane Trochanteric Fossa Hip Adduction External Rotation Adductor Magnus Imferior Pubic Ramus, Linea Aspera Hip Adduction Ischial Tuberosity Adductor Tubercle

Anterior Thigh -Quadriceps/Hip Flexors Muscle Origin Insertion Function Atlas Sartorius Anterior Superior Iliac Pes Anserine Hip Flexion, Abduction Spine (Superior, Medial External Rotation Tibia) Knee Flexion Internal Rotation Rectus Femoris Anterior Inferior Iliac Tibial Tuberosity via Hip Flexion Spine Patellar Tendon Knee Extension

Vastus Medialis Linea Aspera Medial Tibial Knee Extension Intertrochanteric Line Condyle via Medial Longitudinal Retinaculum, Tibial Tuberosity via Patellar Tendon Vastus Lateralis Linea Aspera, Greater Lateral Tibial Knee Extension Trochanter Condyle via Lateral Longitudinal Retinaculum, Tibial Tuberosity via Patellar Tendon Vastus Intermedius Anterior Femoral Tibial Tuberosity via Knee Extension Shaft Patellar Tendon Posterior Thigh -Hamstrings/Hip Extensors Muscle Origin Insertion Function Atlas Biceps Femoris -SH -Linea Aspera Head of Fibula Hip Extension - LH -Ischial Tuberosity Knee Flexion External Rotation Semimembranosus Ischial Tuberosity Medial Tibial Hip Extension Condyle Knee Flexion Internal Rotation Semitendinosus Ischial Tuberosity Medial Tibial Hip Extension Condyle, Pes Knee Flexion Anserine Internal Rotation

Bursas of the Hip Bursas are found between bones and ligaments or muscles. They are fluid filled sacs that help to reduce friction and lubricate the joint Bursa Location Atlas Greater trochanteric Bursa Over the greater trochanter Ischial Bursa Over the ischial tuberosity

Lower Extremity-Knee, Tibia and Fibula

Basic Areas/Regions Femoral-of or relating to the femur or thigh Patellar-of or relating to the patella Popliteal-of or relating to the popliteal fossa

Bones of the Knee and Lower Leg and Foot Bone Landmarks Atlas Femur 1. Adductor tubercle 2. Medial condyle 3. Lateral condyle 4. Medial epicondyle 5. Lateral epicondyle 6. Intercondylar notch 7. Intercondylar line 8. Patellar surface 9. Popliteal surface 10. Medial supracondylar line 11. Lateral supracondylar line

Patella 1. Base 2. Apex 3. Anterior surface 4. Articular surface

Tibia 1. Tibial plateau 2. Tibial tuberosity 3. Medial condyle 4. Lateral condyle 5. Gerdy’s tubercle 6. Intercondylar eminence 7. Soleal line 8. Medial malleolus 9. Mallolar groove 10. Tibial shaft

Fibula 1. Head 2. Neck 3. Shaft 4. Lateral malleolus

Tarsal bones 1. Calcaneous -sustentaculum tali -calcaneal tuberosity 2. Talus -talar dome 3. Navicular 4. Cuboid 5. Lateral cuneiform 6. Intermediate cuneiform 7. Medial cuneiform 9

Joints and Ligaments of the Knee and Lower Leg Remember that joints are bone to bone. Synovial joints have a joint capsule with synovial fluid inside that acts to lubricate the joint. Remember that ligaments connect bone to bone. Joint Ligaments Bones that ligaments connect Atlas Tibiofemoral (knee) 1. Medial collateral ligament 5. Medial epicondyle of • Condyles of femur and (MCL) femur to medial tibia tibial plateau 2. Lateral collateral ligament 6. Lateral epicondyle of • Hinge joint (LCL) femur to head of fibula • Synovial (diarthrotic) 3. Anterior cruciate ligament 7. Medial anterior tibia joint (ACL) to posterior lateral condyle of femur 10

4. Posterior cruciate ligament 8. Posterior tibia to (PCL) anterior medial condyle of femur

Patellofemoral 1. Patella tendon 2. Quadriceps to tibial • Posterior patella with tuberosity (patella is condyles of femur imbedded in the tendon)

Proximal tibiofibular 1. Anterior/Posterior ligament 4. Tibia to head of fibula • Head of fibula and of fibular head 5. Entire length of tibia lateral condyle of tibia 2. Interosseous membrane and fibula • Synovial (ampiarthrotic) joint

Additional Ligaments 1. Transverse ligament 3. Anterior medial 2. Oblique popliteal ligament meniscus to anterior 3. Arcuate popliteal ligament lateral meniscus 4. Posterior menisco-femoral 4. Lateral femur to ligament medial tibia (posterior) 5. Oblique ligament to head of fibula 6. Lateral meniscus to medial intercondylar notch

Additional Information about the Ligaments • MCL o Attached to the joint capsule and the medial meniscus o Prevents a valgus force (force on the outside –lateral aspect of the leg); valgus stress test • LCL o Is located outside the joint capsule o Prevents a varus force (force on the inside -medial aspect of the leg); varus stress test • ACL o Prevents anterior translation of the tibia o Frequently torn with rotation and valgus force; can be contact or non-contact injury; anterior drawer and Lachman’s tests • PCL o Prevents posterior translation of the tibia o Torn with fall on flexed knee (posterior force on the femur) and with hyperextension; posterior drawer test • “Unhappy triad” o ACL, MCL, and medial meniscus tears in 1 injury

Additional Structures • Iliotibial band o Runs down length of the femur over the lateral epicondyle and inserts on Gerdy’s tubercle • Meniscus-fibrocartilage disc on tibial plateau that provide cushion and shock absorption; torn with rotation; poor healing capabilities due to being mostly avascular; complaints of locking, catching, giving way o Medial- “C” shaped; is attached to the MCL o Lateral- “O” shaped • Patella tendon o Common tendon of the quadriceps muscles; inserts into the tibial tuberosity • Medial and lateral longitudinal patellar retinaculum o Vastus medialis and vastus lateralis to tibia • Medial and lateral transverse patellar retinaculum o Runs horizontally under the longitudinal retinaculum

Bursas of the Knee Bursas are found between bones and ligaments or muscles. They are fluid filled sacs that help to reduce friction and lubricate the joint Bursa Location Atlas Suprapatellar Bursa Between the femur and quadricps tendon Prepatellar bursa Between skin and patella Superficial Infrapatellar bursa Between the skin and the patella tendon Deep infrapatellar bursa Between tibia and patellar tendon

Muscles of the Knee and Lower Leg You are responsible for understanding names of muscles, their origin, insertion, innervations, vascularization, and functional movements they create. This manual is based off your required textbook and is meant to be a guide for what you are responsible for knowing. DO NOT simply memorize, make sure you truly understand the information. Some reminders and tips for understanding include: • Due to the nature of the muscle fibers, muscles are able to change length. The contraction is when it is shortening. • Origin-the immovable part of the muscle • Insertion-the moveable part of the muscle • Function-the origin stays fixed and the insertion is the moving part… the insertion will move towards the origin. • A muscle will move the bone that it inserts on. (ex. If insertion is on humerus, the humerus moves; if insertion is on scapula, scapula moves) • If a muscle crosses more than one joint, it will move more than one joint (ex. Biceps brachii crosses the shoulder and the elbow, therefore it moves both the shoulder and the elbow) • Note the angle/direction of the muscle fibers. It often dictates the function. Notice what happens when the muscle shortens • Always palpate from origin to insertion

Keys to Help with Lower Leg Muscles • Anterior muscles are dorsiflexors and toe extensors • Posterior muscles are plantarflexors, inverters and toe flexors • Lateral muscles are Peroneal (fibularis) muscles that originate on the fibula and are everters • Hallucis muscles go to the big toe • Digitorum muscles go to the toes • Longus muscles are longer • Brevis muscles are shorter • MTP-Metatarsalphalangeal, IP-Interphalangeal, PIP-Proximal Interphalangeal, DIP-Distal Interphalangeal Compartments of the Lower Leg -The lower leg is divided into 4 compartments by thick walls of fascia. All of the muscles as well as the bones, arteries and nerves are contained within each of the four compartments.

Posterior Knee Muscle Origin Insertion Function Atlas Popliteus Lateral Femoral Posterior, Proximal Knee Flexion Condyle, Lateral Tibial Surface Internal Rotation Meniscus Lower Leg -Anterior Compartment Muscle Origin Insertion Function Atlas Tibialis Anterior Proximal Lateral Medial Cuneiform Dorsiflexion Tibia, Interosseous (medial and plantar Inversion Membrane surface), medial base 1st metatarsal Extensor Hallucis Medial Fibula, Base of Distal 1st Dorsiflexion Longus Interosseous Phalanx Extension of MTP, IP of Membrane big toe Extensor Digitorum Head of Fibula, Base of Distal Dorsiflexion Longus Lateral condyle tibia, Phalanx 2-5 Eversion Interosseous Memb. Extension MTP, IP 2-5

Peroneal (Fibularis) Distal Fibula Base of 5th Metatarsal Dorsiflexion Tertius Eversion

-Lateral Compartment Muscle Origin Insertion Function Atlas Peroneal (Fibularis) Head of Fibula Plantar Medial Plantar Flexion Longus Lateral Fibula Cuneiform Eversion Base of 1st Metatarsal Supports Arch Peroneal (Fibularis) Distal Lateral Fibula Tuberosity on Base Plantar Flexion Brevis of 5th Metatarsal Eversion

-Superficial Posterior Compartment Muscle Origin Insertion Function Atlas Gastrocnemius Medial/Lateral Calcaneal Tuberosity Plantar Flexion Epicondyles of Femur via the Achilles Knee Flexion Tendon Soleus Posterior Head of Calcaneal Tuberosity Plantar Flexion Fibula, Soleal Line of via the Achilles Tibia Tendon Plantaris Lateral Epicondyle of Calcaneal Tuberosity Too small for function Femur-Proximal to via the Achilles (may prevent Lateral Head of Tendon compression) Gastrocnemius -Deep Posterior Compartment Muscle Origin Insertion Function Atlas Tibialis Posterior Interosseus Medial Navicular Plantar Flexion Membrane, Medial Cuneiforms (Plantar Inversion Proximal Fibula, Aspect) Supports Arch Lateral ProximalTibia Plantar Bases of Metatarsals 2-4 Flexor Digitorum Longus Posterior Tibia Base of Distal Plantar Flexion Phalanges 2-5 Inversion Flexion of MTP and IP joints 2-5 Flexor Hallucis Longus Posterior Fibula Base of 1st Distal Plantar Flexion Phalanx Inversion Flexion of MTP and IP of 1st Digit

Contents of The Compartments of the Lower Leg Anterior Compartment Lateral Compartment Superficial Post. Comp. Deep Post. Comp. Tibialis anterior Peroneal longus Gastrocnemius Tibialis posterior Extensor hallicus longus Peroneal brevis Soleus Flexor hallucis longus Extensor digitorum longus Plantaris Flexor digitorum longus Peroneal tertius Deep peroneal N. Superficial peroneal N. Tibial N. Tibial N.

Anterior tibial A. Peroneal A. Sural branches of Posterior tibial A. Popliteal A. Peroneal A. 15

Lower Extremity-Ankle and Foot

Basic Areas/Regions Peroneal-of or relating to the outer side of the lower leg Crural-of or relating to the leg Sural-of or relating to the calf Tarsal-of or relating to the tarsus (mid bones in the foot) Calcaneal-of or relating to the heel Pedal-of or relating to the foot or feet Hallux-of or relating to the big toe

Bones of the Ankle and Foot Bone Landmarks Atlas Tibia 1. Medial malleolus 2. Mallolar groove 3. Tibial shaft

Fibula 1. Shaft 2. Lateral malleolus

Tarsal bones 1. Calcaneous -sustentaculum tali -calcaneal tuberosity 2. Talus -talar dome 3. Navicular 4. Cuboid 5. Lateral cuneiform 6. Intermediate cuneiform 7. Medial cuneiform

Metatarsals (base and head) 1. 1 (big toe side) 2. 2 3. 3 4. 4 5. 5 (little toe side )

Phalanges 1. 1 (proximal and distal) 2. 2 (proximal, middle and distal) 3. 3 (proximal, middle and distal) 4. 4 (proximal, middle and distal) 5. 5(proximal, middle and distal)

Joints and Ligaments of the Ankle and Foot Remember that joints are bone to bone. Synovial joints have a joint capsule with synovial fluid inside that acts to lubricate the joint. Remember that ligaments connect bone to bone. Joint Ligaments Bones that ligaments connect Atlas Distal tibiofibular 1. Interosseous membrane 6. Entire length of tibia • Distal tibia and distal 2. Anterior/posterior and fibula fibula tibiofibular ligaments 7. Distal tibia and distal • Fibrous joint fibula

Talocrural (true ankle joint) 1. Anterior/posterior 7. Talus and fibula • Tibia and fibula with talofibular ligaments (ATF 8. Calcaneous and fibula the talus and PTF) 9. Tibia to talus,

• Hinge joint 2. Calcaneofibular ligament navicular and (CF) calcaneous • Synovial (diarthrotic) 3. Deltoid ligament (4 parts) joint Subtalar • Talus and calcaneous • Plane joint • Synovial (diarthrotic) joint Intertarsal joints 1. Dorsal and plantar tarsal 1. Between tarsals on • Calcaneocuboid ligaments dorsal and plantar • Talonavicular 2. Calcaneonavicularr (spring) aspect ligament 2. Calcaneous to • Cuneonavicular 3. Long plantar ligament navicular (medial • Cuneocoboid aspect) • Intercuneiform 3. Calcaneous to metatarsals 2-5

Tarsometatarsal • Tarsal bones with base of metatarsals Metatarsalphalangeal (MTP) 1. MTP Collateral ligaments 1. On the medial and Joints 2. Deep transverse metatarsal lateral side of each • Metatarsals 1-5 with ligaments MTP joint proximal phalanx 2. Metatarsal to

• Condyloid joints metatarsal

Interphalangeal (IP) Joint 1. IP Collateral ligaments 1. On the medial and • 1st proximal phalanx lateral side of the IP with 1st distal phalanx joint • Hinge joint Proximal Interphalangeal (PIP) 1. PIP Collateral ligaments 1. On the medial and Joints lateral side of the PIP • Proximal phalanx 2-5 joints with middle phalanx • Hinge joints Distal Interphalangeal (DIP) 1. DIP Collateral ligaments 1. On the medial and Joints lateral side of the DIP • Middle phalanx 2-5 joints with distal phalanx

Retinaculum of the Ankle Retinaculum are thck fibrous structures that help hold tendons in place Retinaculum Location Flexor Retinaculum (long flexor Behind medial malleolus tendons) Superior/Inferior Extensor Anterior ankle Retinaculum (long extensor tendons) Superior/Inferior Peroneal Lateral ankle Retinaculum (peroneal tendons)

Inversion Ankle Sprain • Lateral ligaments damaged- ATF (most often), CF and PTF • Plantarflexion and inversion mechanism

Eversion Ankle Sprain • Medial ligaments damaged-Deltoid ligament • Eversion and dorsiflexion mechanism

Syndesmostic (High) Ankle Sprain • Anterior and posterior tibiofibular ligaments damaged • Dorsiflexion and external rotation mechanism

Arches of the Feet • Longitudinal Arch (medial and lateral) o End of calcaneous to head of metatarsals o Highest on medial aspect and lowest on lateral aspect o Supported passively by plantar calcaneonavicular (spring) ligament, long plantar ligament, plantar fascia, and flexor hallucis longus and flexor digitorum longus tendons o Supported actively by abductor hallucis, flexor hallucis brevis, flexor digitorum brevis, quadrates planae, abductor digiti minimi • Transverse Arch o Horizontally across the bases of the metatarsals and the distal tarsal bones o Supported passively by deep transverse metatarsal ligaments o Supported actively by personal longus and tibialis posterior tendons and transverse head of adductor hallucis

Muscles of the Ankle and Foot You are responsible for understanding names of muscles, their origin, insertion, innervations, vascularization, and functional movements they create. This manual is based off your required textbook and is meant to be a guide for what you are responsible for knowing. DO NOT simply memorize, make sure you truly understand the information. Some reminders and tips for understanding include: • Due to the nature of the muscle fibers, muscles are able to change length. The contraction is when it is shortening. • Origin-the immovable part of the muscle • Insertion-the moveable part of the muscle • Function-the origin stays fixed and the insertion is the moving part… the insertion will move towards the origin. • A muscle will move the bone that it inserts on. (ex. If insertion is on humerus, the humerus moves; if insertion is on scapula, scapula moves) • If a muscle crosses more than one joint, it will move more than one joint (ex. Biceps brachii crosses the shoulder and the elbow, therefore it moves both the shoulder and the elbow) • Note the angle/direction of the muscle fibers. It often dictates the function. Notice what happens when the muscle shortens • Always palpate from origin to insertion Keys to Help with Lower Leg Muscles • Anterior muscles are dorsiflexors and toe extensors • Posterior muscles are plantarflexors, inverters and toe flexors • Lateral muscles are Peroneal (fibularis) muscles that originate on the fibula and are everters • Hallucis muscles go to the big toe • Digitorum muscles go to the toes • Digiti minimi muscles go to the little toe • Longus muscles are longer • Brevis muscles are shorter • MTP-Metatarsalphalangeal, IP-Interphalangeal, PIP-Proximal Interphalangeal, DIP-Distal Interphalangeal Foot -Dorsal Intrinsic Muscle Origin Insertion Function Atlas Extensor Digitorum Calcaneus (Dorsal Bases of Middle Extension of MTP and Brevis Aspect) Phalanges, Dorsal PIP joints 2-4 Aponeurosis 2-4 Extensor Hallucis Brevis Calcaneus (Dorsal Proximal Phalanx Extension of MTP- 1st Aspect) and Dorsal Digit Aponeurosis 1st Digit

-Plantar Intrinsic-Layer 1 Superficial Muscle Origin Insertion Function Atlas Abductor Hallucis Calcaneal Tuberosity Base of Proximal Flexion of MTP Joint1st Phalanx via Medial Digit Sesamoid- 1st Digit Abduct 1st Digit Supports Arch

Flexor Digitorum Brevis Calcaneal Tuberosity, Middle Phalanges 2-5 Flexion of MTP and PIP Plantar Aponeurosis Joints 2-5 Supports Arch Abductor Digiti Minimi Calcaneal Tuberosity, Base of 5th Proximal Flexion MTP 5th Digit Plantar Aponeurosis Phalanx, 5th Abducts 5th Digit Metatarsal Supports Arch -Plantar Instrinsic-Layer 2 Muscle Origin Insertion Function Atlas Quadratus Plantae Calcaneal Tuberosity Flexor Digitorum Redirects and Augments Longus Tendon the pull of Flexor Digitorum Longus Lumbricals (4 muscles) Flexor Digitorum Dorsal Aponeuroses- Flexes MTP Joints 2-5 Longus Tendons Toes 2-5 Extends IP Joints 205 Adducts 2-5 towards Great Toe

-Plantar Intrinsic Layer 3 Muscle Origin Insertion Function Atlas Flexor Hallucis Brevis Cuboid, Lateral Base of Proximal Flexion MTP Joint- 1st Cuneiform, Plantar Phalanx via Medial Digit Calcaneocuboid and Lateral Supports Arch Ligament Sesamoids- 1st Digit Adductor Hallucis Oblique Head- Bases Base of Proximal Flexion MTP- 1st Digit of Metatarsals 2-4 Phalanx via Lateral Adduct 1st Digit st Transverse Head- Sesamoid- 1 Digit Transverse Head- Supports Transverse MTP of 3-5, Deep Transverse Metatarsal Arch Ligament Oblique Head- Supports Longitudinal Arch Flexor Digiti Minimi Base of 5th Metatarsal, Base of Proximal Flexion of MTP- 5th Long Plantar Phalanx- 5th Digit Digit Ligament

-Plantar Intrinsic Layer 4 Muscle Origin Insertion Function Atlas Plantar Interossei (3 Medial Border Base of Proximal Flexion of MTP- 3-5 muscles) Metatarsals 3-5 Phalanx 3-5 Extension of IP Joints- 3- 5 Adduction 3-5 towards 2nd Digit Dorsal Interossei (4 Metatarsals 1-5 Base of 2nd proximal Flexion of MTP 2-4 muscles) Phalanx, Lateral Base Extension of IP 2-4 2-4 Proximal

Phalanges Abducts 3-4 from 2nd Digit

Lower Extremity Nerves Reminders: Spinal nerves come out of the spinal cord and carry signals to the periphery • Plexus-network of intersecting nerves that come from the same area and serve a common area • Motor Nerves-innervate a muscle • Cutaneous Nerve-innervates the skin Lumbosacral Plexus • Network of nerves originating from the spinal nerves L1-S4 Lumbar Portion (T12-L4) • L1- 2 branches 1. Superior branch-2 nerves ▪ Iliohypogastric N. (T12-L1) ▪ Ilioinguinal N. (L1) 2. Inferior branch (also comes from L2) ▪ Genitofemoral N. (L1-L2) • L2-L3- 1 branch 1. Lateral Femoral Cutaneous N. • L2-L4- 2 branches 1. Femoral N. ▪ Saphenous N. ▪ Anterior femoral cutaneous N. 2. Obturator N. Sacral Portion (L5-S4) • L4-S1- 1 branch 1. Superior Gluteal N. • L5-S2- 1 branch 1. Inferior Gluteal N. • L4-S3 -3 branches 1. Sciatic N. (splits into the Tibial N. and Common Fibular N. just superior to the knee) i. Tibial N. (L4-S3) (goes down the leg and into the foot) 1. Medial Sural Cutaneous N. 2. Medial Plantar N. 3. Lateral Plantar N. ii. Common Fibular N. (L4-S2) (splits right away and goes down the leg and into the foot) 1. Lateral Sural Cutaneous N. 2. Superficial Fibular N. 3. Deep Fibular N. • S1-S3- 1 branch 1. Posterior Femoral Cutaneous N. • L5-S2- 1 branch 1. N. to Obturator Internus • L4-S1-1 branch 1. N. to Quadratus Femoris • S1-S2- 1 branch 1. N. to Piriformis • S2-S4- 1 branch 1. Pudendal N.

Lumbar Portion Nerve Level(s) Where the nerve travels Muscles/Location Innervating Iliohypogastric T12, L1 Pierces transverus abdominis Inferior Portions of Nerve Transversus Abdominus, Internal Obliques Ilioinguinal L1 Passes through inguinal canal; runs above and Inferior Portions of Nerve parallel to inguinal ligament Transversus Abdominus, Internal Obliques Genitofemoral L1, L2 Pierces psoas major and splits into a genital and Genitals and Skin of Nerve femoral branch Anterior Thigh Lateral Femoral L2, L3 Goes on top of iliacus and under the inguinal Skin of Anterior and Cutaneous ligament lateral Thigh Nerve Obturator Nerve L2-L4 Passes through the obturator canal and divides into Anterior Branch- an anterior and posterior branch Obturator Externus, Adductor Longus, Adductor Brevis, Gracilis, Pectineus Posterior Branch- Adductor Magnus Femoral Nerve L2-L4 Passes on top of iliacus and psoas major; goes under Iliacus, psoas major, psoas (splits into the inguinal ligament and through the femoral minor, Pectineus, cutaneous and triangle; splits into muscular and cutaneous Sartorius, Quadriceps (all muscular branches 4), cutaneous thigh branches)

Sacral Portion Nerve Level(s) Where the nerve travels Muscles/Location Innervating Superior Gluteal L4-S1 Runs above the piriformis muscle Gluteus Medius, Gluteus Nerve Minimus, Tensor Fasciae Latae Inferior Gluteal L5-S2 Comes out below the piriformis muscle Gluteus Maximus Nerve Sciatic Nerve L4-S3 Comes out over, through, or under the piriformis LH biceps femoris, muscle; travels down the posterior aspect and splits semimembranosus,

just above the knee semitendinosus, adductor magnus Tibial Nerve L4-S3 Goes deep down the posterior leg and wraps around Tibial Nerve- the medial malleolus; once in the foot, it splits into Gastrocnemius, Soleus, the medial and lateral plantar nerve Plantaris, Popliteus, Tibialis Posterior, Flexor

Digitorum Longus, Flexor Hallucis Longus Medial Plantar Nerve- Abductor Hallucis, Flexor Digitorum Brevis, Flexor Hallucis Brevis-medial head, 1st and 2nd Lumbricals Lateral Plantar Nerve- Flexor Hallucis Brevis Lateral Head, Quadratus Plantae. Abductor Digiti Minimi, Flexor Digiti Minimi, 3rd and 4th Lumbricals, 1st-3rd Plantar Interossei, 1st-4th Dorsal Interossei, Adductor Hallucis Common L4-S2 Wraps around the fibular head and splits into a Short Head Biceps Fibular Nerve superficial and a deep branch and continues down Femoris the leg Superficial Fibular Nerve- Peroneal Longus, Peroneal Brevis Deep Fibular Nerve- Tibialis Anterior, Extensor Digitorum Longus, Extensor Digitorum Brevis. Extensor Hallucis Longus, Extensor Hallucis Brevis, Peroneal Tertius Posterior S1-S3 Goes down the posterior thigh Skin of Posterior Thigh Femoral Cutaneous Nerve Nerve to L5-S2 Runs on the posterior side of the muscles (medially) Obturator Internus, Obturator Inferior and Superior Internus Gemelli Nerve to L4-S1 Runs on the anterior side of the muscles Quadratus Femoris Quadratus (underneath them) Femoris Nerve to S1-S2 Goes on the anterior side of the piriformis Piriformis Piriformis

Lower Extremity Vasculature Reminders • Arteries carry oxygen rich blood from the heart and distribute it throughout the body • Veins return the oxygen depleted blood to the heart • One exception- Pulmonary Artery carries oxygen deficient blood and Pulmonary Vein carries oxygen rich blood • Arteries are round and hollow

Arteries of the Lower Extremity Begins at the heart-artery branching down through the abdomen is the abdominal aorta Abdominal Aorta-split into 2 branches at the level of L4-the right and left Common Iliac arteries (the same on both sides) • Abdominal Aorta o Right/Left Common Iliac A.-each splits into 2 branches ▪ Internal Iliac A. ▪ External Iliac A. • Internal Iliac A. o Anterior trunk (also has some branches that go to the pelvis organs that we won’t worry about) ▪ Obturator A. (goes to the adductor compartment) ▪ Inferior gluteal A. (goes through the greater sciatic notch to the posterior gluteal region) o Posterior trunk ▪ Iliolumbar A. (goes to lumbar vertebrae) • Iliac branch • Lumbar branch ▪ Lateral sacral A. (goes to sacrum) ▪ Superior gluteal A. (goes under the piriformis to the posterior gluteal region)

• External Iliac A.-name changes to Femoral Artery once it passes under the inguinal ligament and into the femoral triangle***

• ***Femoral triangle*** o Upper boundary-inguinal ligament o Lateral boundary-sartorius o Medial boundary-adductor longus o Contents of the triangle ▪ Femoral A. ▪ Femoral V. ▪ Femoral N. Branches Off the Femoral Artery Femoral Artery-2 major branches (also has some smaller branches that we won’t worry about) (goes down anterior thigh) 1. Deep femoral A. (within the femoral triangle) a. Lateral femoral circumflex A. (goes to anterior neck of femur) b. Medial femoral circumflex A.(may be off the Femoral A.) (goes to posterior neck of femur) c. 3 perforating branches (named 1, 2, 3) and terminates with a 4th branch (goes through the adductor magnus to the posterior thigh and supplies hamstrings) 2. Descending genicular A. (just before the adductor hiatus) a. Articular branch (goes to knee joint) b. Saphenous branch (goes to upper part of lower leg) 28

**Femoral A.-name changes to Popliteal A. when it passes through the adductor hiatus (hole in adductor magnus) and goes to posterior aspect of the knee**

Popliteal Artery-gives off some branches to the knee joint itself and then splits into 2 major arteries 1. Superior medial genicular A. (to knee joint) 2. Superior lateral genicular A. (to knee joint) 3. Middle genicular A. (to posterior capsule) 4. Inferior medial genicular A. (to knee joint) 5. Inferior lateral genicular A. (to knee joint) Splits into: 6. Anterior tibial A. (goes anterior along interosseous membrane) 7. Posterior tibial A. (goes posterior)

Anterior Tibial A.-gives off 2 branches around the malleolus and then becomes the dorsalis pedis A. as it passes into the dorsum of the foot 1. Anterior medial malleolar A. (to medial malleolus ) 2. Anterior lateral malleolar A. (to lateral malleolus ) Becomes the: 3. Dorsalis Pedis A. a. Lateral tarsal A. (passes under and supplies the extensor digitorum brevis to the little toe) b. Medial tarsal A. (may be more than 1) c. Arcuate A. (forms arch with lateral tarsal A.) i. Gives off 3 dorsal metatarsal arteries (each splits into dorsal digital arteries) Splits into 2 terminal branches: d. Dorsal metatarsal A. e. Deep plantar A. (forms deep plantar arch with lateral plantar A.)

Posterior Tibial A.-quickly gives off Peroneal A. and then goes posterior down the leg and becomes the medial and lateral plantar A. 1. Peroneal A. (to lateral compartment) a. Posterior lateal malleolar A. 2. Posterior Medial malleolar A. Splits into: 1. Medial plantar A.(goes into the deep arch of the foot) 2. Lateral plantar A. (forms deep arch with deep plantar A.)

Deep Plantar Arch • Formed by the deep plantar A. and the lateral plantar A. • Gives off 4 plantar metatarsal arteries (each splits into 2 proper plantar digital arteries) and a proper plantar digital A.

Blood Supply of Muscles Arteries Muscles They Supply External Iliac Iliacus, Psoas Major, Psoas Minor Iliolumbar Psoas Major Superior Gluteal Tensor Fascia Latae, Gluteus Maximus, Gluteus Medius, Gluteus Minimus, Piriformis Obturator Gracilis, Pectineus, Adductor Brevis, Adductor Longus, Obturator Externus, Adductor Magnus Inferior Gluteal Gluteus Maximus, Piriformis, Gemellus Superior, Obturator Internus, Gemellus Inferior, Quadratus Femoris Femoral Adductor Longus, Adductor Magnus, Sartorius, Rectus Femoris, Vastus Medialis, Vastus Lateralis, Vastus Intermedius Deep Femoral (Profunda Femoris) Adductor Longus, Vastus Medialis, Biceps Femoris, Semitendinosus, Semimembranosus Lateral Circumflex Femoral Rectus Femoris, Vastus Intermedius, Vastus Lateralis Medial Circumflex Femoral Gemellus Superior, Obturator Internus, Gemellus Inferior, Quadratus Femoris, Gracilis, Pectineus, Adductor Brevis, Obturator Externus, Adductor Magnus Popliteal Popliteus, Gastrocnemius, Soleus, Plantaris ( last 3 via Sural Arteries) Anterior Tibial Tibialis Anterior, Extensor Hallucis Longus, Extensor Digitorum Longus, Peroneus Tertius Posterior Tibial Gastrocnemius, Plantaris, Soleus, Tibialis Posterior, Flexor Digitorum Longus, Flexor Hallucis Longus Peroneal/ Fibular Peroneus Longus, Peroneus Brevis, Soleus, Tibialis Posterior, Flexor Digitorum Longus, Flexor Hallucis Longus Dorsalis Pedis Extensor Digitorum Brevis, Extensor Hallucis Brevis Medial Plantar Adductor Hallucis, Flexor Digitorum Brevis, Quadratus Plantae, Lumbricals, Flexor Hallucis Brevis, Abductor Hallucis Lateral Plantar Abductor Digiti Minimi, Flexor Digitorum Brevis, Quadratus Plantae, Lumbricals, Flexor Hallucis Brevis, Adductor Hallucis, Flexor Digiti Minimi Deep Plantar Arch and Plantar Plantar Interossei Metatarsal Arteries Arcuate artery and Dorsal Metatarsal Dorsal Interossei Arteries