Organization of the Lower Limb - Ohio University

Organization of the Lower LimbAudrone Biknevicius, Ph.D.

Dept. Biomedical Sciences, OU HCOM at DublinClinical Anatomy Immersion 2015

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LIMB FUNCTION

Mobility versus Body weight supportDexterity Locomotion

Equilibrium & Stability

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Pectoral Girdle Pelvic Girdle

Mobility versus Body weight supportDexterity Locomotion

Equilibrium & Stability

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Arm – forearm – hand Thigh – leg – foot

The upper and lower limbs are innervated by:

A. Posterior (dorsal) rami of spinal nn.B. Anterior (ventral) rami of spinal nn.

5Poste

rior (d

orsal) r

ami of s

pin..

Anterior (v

entral) r

ami o

f sp...

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CORRECTED SLIDE #5

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Week 5

RULE #1Limbs are outgrowths of the ventral body wall

Upper limb: C5-T1 trunk segments

Lower limb: L2-S3 trunk segments(morphogenesis ~1-2 days later)

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RULE #1 (continued)Limbs are outgrowths of the ventral body wall that undergo distal growth, differentiation and rotation

Week 7

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Before rotation

• Pollex and hallux both preaxial • Anteriomedially-directed palms and soles

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Upper limb rotates 90◦ laterally:-Extensor mm. on posterior surface-Future elbow directed posteriorly-Supine hand in anatomical position-Pollex positioned laterally

Lower limb rotates 90◦ medially:-Extensor mm. on anterior surface-Future knee directed anteriorly-Foot fixed in prone position-Hallux positioned medially

Post rotation

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Spinal nerveDorsal primary ramusVentral primary ramus (L2-S3)

Anterior (ventral) divisionPosterior (dorsal) division

limb axisStern Essential of Gross Anatomy

RULE #2: Innervation of lower limb mm. established in early embryogenesis – resulted in dedicated nerve-compartment relationships

Brachial Plexus(right side; simplified)

TerminalBranches

“Roots of BP” (=ventral rami)

C5C6

C7

C8

T1

Trunks

U

M

L

Cord

LatPost

Med

Divisions

Anterior (ventral) division

Posterior (dorsal) division 11

Stern E

ssential of Gross A

natomy

Radial n.

Musculocutaneous n.

Median n.

Ulnar n.

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Ventral divisionDorsal division

Lumbosacral trunk (to sacral plexus)Obturator Nerve

(L2,3,4)

Lumbar Plexus

Ventral divisionDorsal division

Sacral Plexusaccessphysiotherapy.m

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As a result of the opposite rotation of the lower limb, in which compartment will the developmentally dorsal muscles be located?

A. Anterior compartmentB. Posterior compartment

14Anterio

r compartm

ent

Posterio

r compartm

ent

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Week 7

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Forearm

Hand

Arm

Leg

Foot

Thigh

Upper Limb Lower Limb

Ant

Post

MedLat

Developmentally ventral vs. dorsal mm.S

tern Essential of G

ross Anatom

y

Hence, posterior division nn. serve anterior compartments in LL

The fact that the anterior compartment muscles are innervated by posterior division nerve is …

A. Functionally relevantB. Downright confusing

16Functi

onally re

levant

Downright c

onfusing

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Palmar

Dorsum

LatMed

Dorsum

Plantar

MedLat

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Leg

Foot

Thigh

Compartments: Anterior Posterior Medial Lateral

Upper Limb Lower Limb

Ant

Post

MedLat

Limb Muscle Compartments

MP

A

ALP

A

P

APForearm

Hand

Arm

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No motor distribution distal to knee*pectineus usually innervated by femoral n.

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Leg

Foot

Thigh


Ant

Post

MedLat

Lower Limb Muscle Compartments

Compartments: Dorsum Plantar

Femoral n.

Obturator n.

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The Sacral Plexus

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Leg

Foot

Thigh


Ant

Post

MedLat



Femoral n.

Obturator n.

Tibial n.

Tibial n.

Tibial n.

Including Adductor magnus (hamstring part)

Common fibular n.: Biceps femoris short head

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The Sacral Plexus

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Lateral compartment

Anteriorcompartment

dorsum of foot!“Peroneal” = “Fibular”

Deep fibular n.

Superficial fibular n.

Common fibular n.

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Leg

Foot

Thigh


Ant

Post

MedLat



Femoral n.

Obturator n.

Tibial n.

Tibial n.

Tibial n.

Deep fibular n.Superficial fibular n.

Deep fibular n.

Including Adductor magnus (hamstring part)

Common fibular n.: Biceps femoris short head

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Compartmental Organization of the Thigh

Fascia lata (& intermuscular septa)

Anterior – Femoral n.

Medial – Obturator n.(exception: Femoral n. –adductor magnus, hamstring part)

Posterior – Tibial n.(exception: Common fibular n. – biceps femoris, short head)

Primary functions: Hip & Knee

medical-dictionary.thefreedictionary.com

Medial compartmentAdductors of thighObturator n.

Posterior compartmentExtensors of thigh Tibial n.

Anterior compartmentFlexors of thighFemoral n.

Many are biarticular muscles that also affect the knee joint

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Attached to ischial tuberosity: • Thigh extension, Leg flexion: Biceps femoris (long head)*,

Semitendinosus* & Semimembranosus* mm.• Thigh extension, Thigh adduction: Adductor magnus (hamstring part)* biarticular mm.

Tibial n.

Posterior compartment of thighHip extension; Knee flexion

Exception: Biceps femoris (short head); common fibular n.; knee flexion

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Adductor magnus

Hamstring part:-Attaches to ischial tuberosity-Tibial n.

Adductor part:-Attaches to pubis-Obturator n.

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Anterior Compartment of ThighHip flexion; Knee extension

Attached to ilium:• Thigh flexion: Iliopsoas• Thigh flexion, Leg flexion:

Sartorius*• Thigh flexion, Leg extension:

Rectus femoris m.*

• Leg extension (no action at hip) – remainder of Quadriceps femoris (vasti)

* biarticular mm.

Femoral n.

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Medial Compartment of ThighHip adduction; Hip flexion

Attachment to pubis:• Thigh adduction: Adductor

longus, Adductor brevis, Adductor magnus(pubofemoral part)

• Thigh adduction, Leg flexion: Gracilis

Obturator n.

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Pectineus – “the exception”

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Attaches to superior ramus of pubis

Pectineus m. mostly innervated by femoral n. (~25% by obturator n.)

All other mm. attaching to pubis are innervated by obturator n.

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Gluteal group (externally)Iliopsoas (internally)

Adductor grpHamstring & latrotator grp

Relative positions of muscles producing movements of hip joint

Adapted from Moore et al., Essential Clinical Anatomy

What are the actions of muscles attached to the anterior aspect of the hip?

A. Thigh extensionB. Thigh flexion

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extensio

n

Thigh

flexio

n

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Hip FlexorsFemoral n.: iliopsoas, sartorius, rectus femoris, pectineusSuperior gluteal n.: tensor fasciae lataeObturator n.: adductor longus, brevis & magnus (anterior), gracilis

Hip ExtensorsTibial n.: biceps femoris (long head), semitendinosis, semimembranosus, adductor magnus (posterior)Inferior gluteal n.: Gluteus maximus


What are the actions of muscles attached to the superolateral aspect of the hip?

A. Thigh adductionB. Thigh abduction

35Thigh

adducti

on

Thigh

abducti

on

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AdductorsObturator n.: adductor longus, brevis & magnus(anterior), gracilisTibial n.: adductor magnus (posterior)Femoral n.: Pectineus

AbductorsSuperior gluteal n.: gluteus medius & minimum, tensor fasciae latae


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Lateral RotatorsN. obturator internus: obturator internus, superior gemellusN. quadratus femoris: quadratus femoris, inferior gemellusObturator n.: obturator externusN. piriformis: piriformisInferior gluteal n.: gluteus maximus

Medial RotatorsSuperior gluteal n.: gluteus medius & minimum, tensor fasciae latae


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Compartmental Organization of the Leg

Crural fascia of leg (& intermuscular septa)

Anterior – Deep fibular n.

Lateral – Superficial fibular n.

Posterior – Tibial n.

(no medial compartment; tibial shaft)

Primary Actions: Ankle & Foot

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Primary Movements of Foot

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Subtalar joints

Ankle Joint (Talocrural Joint)

What is the likely action of the muscles of the anterior compartment at the ankle?

A. Foot dorsiflexionB. Foot plantarflexion

40Fo

ot dorsi

flexio

n

Foot p

lantarfle

xion

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plantarflexiondorsiflexion

What is the likely action of the muscles of the lateral compartment of the leg at the subtalar

joints?A. Foot eversionB. Foot inversion

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ot eve

rsion

Foot in

versi

on

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Medial malleolus

Lateral malleolus

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Anterior Compartment of LegDorsiflexor (extensor) Compartment

Also foot inversion:Tibialis anterior

Also foot eversion:Fibularis (peroneus) tertius

Also toe extension:Extensor hallicus longus Extensor digitorum longus

Deep fibular n.

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Lateral Compartment of LegEvertor Compartment

Fibularis (peroneus) longusFibularis (peroneus) brevis(also weak plantarflexors)


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Posterior Compartment of LegPlantarflexor Compartment

Superficial mm.:Gastrocnemius (also knee flexor)SoleusPlantaris

Deep mm.: Popliteus (unlocks knee) Flexor digitorum longusFlexor hallucis longusTibialis posterior (also inversion)

Tibial n.

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plantarflexiondorsiflexion

Dorsiflexion (flexion)Deep fibular n.: Tibialis anterior, EHL, EDL, fibularis tertius

Plantarflexion (extension)Tibial n.: gastrocnemius, soleus, plantaris, tibialis posterior

(Superficial fibular n.: weak fibularis longus & brevis)

* Triceps surae: medial and lateral gastrocnemius and soleus

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Inversion:Tibialis anterior (deep fibular n.)Tibialis posterior (tibial n.)

Eversion:Fibularis longis & brevis (superficial fibular n.)Fibularis tertius (deep fibular n.)

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Central/Axial Lines3rd digit in hand 2nd digit in foot

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ikipedia.org

Dorsal interossei muscles

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Plantar (posterior) Compartment of Foot

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1st layer:Abductor hallucisFlexor digitorum brevisAbductor digit minimi

2nd layer:Quadratus plantaeLumbricals

3rd layer:Flexor hallucis brevisAdductor hallucisFlexor digit minimi brevis

4th layer:Plantar interosseiDorsal interossei

Tibial n.: medial and lateral plantar nn.

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Plantar (posterior) Compartment of FootMedial plantar n.(“median n. of foot”):Abductor hallucisFlexor hallucis brevis1st lumbrical

Flexor digitorum brevis

Lateral plantar n.(“ulnar n. of foot”):Abductor digiti minimiFlexor digiti minimi brevis

Dorsal interosseiPlantar interosseiAdductor hallucisRemaining lumbricals

Quadratus plantae

Upper roots of the lumbosacral plexus innervate proximal muscles (hip, knee)

Lower roots of the lumbosacral plexus innervate distal muscles (ankle, toes)

RULE #3: Proximal-to-Distal Rule

51Dorsiflexion-PlantarflexionInversion-Eversion

Patellar tendon reflex“Knee (jerk) reflex”

(predominantly L3, L4)

Deep Tendon Reflexes (DTR)

Achilles tendon reflex“Ankle (jerk) reflex”

(S1, S2)

“MIXED FUNCTIONAL MODALITIES”

Some terminal branches of the lumbosacral plexus are cutaneous nerves.

RULE #4A

What of the following functional modalities is NOT present in neurons contained within cutaneous nerves?A. Somatic motorB. Somatic sensoryC. Sympathetics

54So

matic m

otor

Somatic

senso

ry

Sympathetic

s

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Obturator Nerve (L2,3,4)

“MIXED FUNCTIONAL MODALITIES”

All terminal branches of the lumbosacral plexus are mixed fiber nerves:

1. Somatic motor and somatic sensory (prioprioception) to skeletal mm.

2. Then, cutaneous innervation with somatic sensory and sympathetics to skin

RULE #4 B

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Obturator n.

Cutaneous brs.

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Femoral n.

Anterior femoral cutaneous nn.

Saphenous n.

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Common Fibular n.

Lateral sural cutaneous n.


Dorsal digital nn.

Deep fibular n.

Dorsal digital nn.

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Tibial n.

Medial sural cutaneous n.

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Cutaneous Innervation of Foot

Dorsum – Superficial fibular n.(deep fibular between digits I & II)Plantar – Tibial n. (medial & lateral plantar nn.Medial – Saphenous n. (femoral n.)Lateral – Sural n.

L2-S3Lower Limb

RULE #5: Cutaneous Nerve vs. DermatomesDistribution

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Cutaneous Nerve Distribution vs. Dermatomesw

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Dermatome Mapsw

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Keegan & Garrett (1948) - DevelopmentFoerster (1933) - Clinical

65*Lower sacral cord largely confined to perineum

Dermatomes

Upper sacral cordMostly posterior aspect

Lumbar spinal cordAnterior & medial aspectsMost of lateral aspects

Autonomous Sensory Zones

S3

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L1: Over inguinal ligament

L2: Lateral side of thigh

L3: Lower medial side of thigh

L4: Medial malleolus, Medial side of foot(medial side of hallux)

L5: Medial side of digit II

S1: Lateral malleolus; Lateral side of foot(lateral side of little toe)

S2: Back of thigh

S3: Skin over gluteal fold

Radiculopathy

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brain

Cervical spinal nerve

Lumbar spinal nerves

Caudal equina

spin

al c

ord

Which dermatome is affected in a L4/L5 disk herniation?

A. L4B. L5C. S1

68L4 L5 S1

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Where will pain from a L4/L5 disk herniation radiate?

A. Medial aspect of leg, ankle (medial malleolus) & hallux

B. Lateral leg to dorsum of footC. Lateral aspect of ankle

(lateral malleolus) & lateral side of digit V

69Medial asp

ect of le

g, an

kle ...

Later

al leg

to dorsu

m of foot

Later

al asp

ect of a

nkle (la

ter..

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Dermatomes

Which deep tendon reflex will a longstanding L4/L5 disk herniation weaken?

A. Knee jerk/patellar tendonB. Ankle jerk/Achilles tendonC. Neither

71Knee j

erk/p

atellar

tendon

Ankle je

rk/Ach

illes t

endon

Neither

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CORRECTED SLIDE #71

IVD Root Sensory Loss Motor Weakness L3-L4 L4 Medial ankle Patellar tendon reflex

L4-5 l5 Dorsum of foot

L5-S1 S1 Lateral ankle Achilles tendon reflex

LOWER LIMB RADICULAR SYNDROMES

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Organization of the Lower Limb - Ohio University