Lower Limb

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Lower Limb

Conceptual overview

General introduction

The lower limb is directly anchored to the axial skeleton by a sacroiliac joint and by strong ligaments, which link the pelvic bone to the sacrum. It is separated from the abdomen, back, and perineum by a continuous line (Fig. 6.1), which:

The lower limb is divided into the gluteal region, thigh, leg, and foot on the basis of major joints, component bones, and superficial landmarks (Fig. 6.2):

The femoral triangle and popliteal fossa, as well as the posteromedial side of the ankle, are important areas of transition through which structures pass between regions (Fig. 6.3).

The femoral triangle is a pyramid-shaped depression formed by muscles in the proximal regions of the thigh and by the inguinal ligament, which forms the base of the triangle. The major blood supply and one of the nerves of the limb (femoral nerve) enter into the thigh from the abdomen by passing under the inguinal ligament and into the femoral triangle.

The popliteal fossa is posterior to the knee joint and is a diamond-shaped region formed by muscles of the thigh and leg. Major vessels and nerves pass between the thigh and leg through the popliteal fossa.

Most nerves, vessels, and flexor tendons that pass between the leg and foot pass through a series of canals (collectively termed the tarsal tunnel) on the posteromedial side of the ankle. The canals are formed by adjacent bones and a flexor retinaculum, which holds the tendons in position.


Support the body weight

A major function of the lower limb is to support the weight of the body with minimal expenditure of energy. When standing erect, the center of gravity is anterior to the edge of the SII vertebra in the pelvis (Fig. 6.4). The vertical line through the center of gravity is slightly posterior to the hip joints, anterior to the knee and ankle joints, and directly over the almost circular support base formed by the feet on the ground and holds the knee and hip joints in extension.

The organization of ligaments at the hip and knee joints, together with the shape of the articular surfaces, particularly at the knee, facilitates “locking” of these joints into position when standing, thereby reducing the muscular energy required to maintain a standing position.


A second major function of the lower limbs is to move the body through space. This involves the integration of movements at all joints in the lower limb to position the foot on the ground and to move the body over the foot.

Movements at the hip joint are flexion, extension, abduction, adduction, medial and lateral rotation, and circumduction (Fig. 6.5).

The knee and ankle joints are primarily hinge joints. Movements at the knee are mainly flexion and extension (Fig. 6.6A). Movements at the ankle are dorsiflexion (movement of the dorsal side of the foot toward the leg) and plantarflexion (Fig. 6.6B).

During walking, many anatomical features of the lower limbs contribute to minimizing fluctuations in the body’s center of gravity and thereby reduce the amount of energy needed to maintain locomotion and produce a smooth, efficient gait (Fig. 6.7). They include pelvic tilt in the coronal plane, pelvic rotation in the transverse plane, movement of the knees toward the midline, flexion of the knees, and complex interactions between the hip, knee, and ankle. As a result, during walking, the body’s center of gravity normally fluctuates only 5 cm in both vertical and lateral directions.

Component parts

Bones and joints

The bones of the gluteal region and the thigh are the pelvic bone and the femur (Fig. 6.8). The large ball and socket joint between these two bones is the hip joint.

The femur is the bone of the thigh. At its distal end, its major weight-bearing articulation is with the tibia, but it also articulates anteriorly with the patella (knee cap). The patella is the largest sesamoid bone in the body and is embedded in the quadriceps femoris tendon.

The joint between the femur and tibia is the principal articulation of the knee joint, but the joint between the patella and femur shares the same articular cavity. Although the main movements at the knee are flexion and extension, the knee joint also allows the femur to rotate on the tibia. This rotation contributes to “locking” of the knee when fully extended, particularly when standing.

The leg contains two bones:

The tibia and fibula are linked along their lengths by an interosseous membrane, and at their distal ends by a fibrous inferior tibiofibular joint, and little movement occurs between them. The distal surfaces of the tibia and fibula together form a deep recess. The ankle joint is formed by this recess and part of one of the tarsal bones of the foot (talus), which projects into the recess. The ankle is most stable when dorsiflexed.

The bones of the foot consist of the tarsal bones, the metatarsals, and the phalanges (Fig. 6.9). There are seven tarsal bones, which are organized in two rows with an intermediate bone between the two rows on the medial side. Inversion and eversion of the foot, or turning the sole of the foot inward and outward, respectively, occur at joints between the tarsal bones.

The tarsal bones articulate with the metatarsals at tarsometatarsal joints, which allow only limited sliding movements.

Independent movements of the metatarsals are restricted by deep transverse metatarsal ligaments, which effectively link together the distal heads of the bones at the metatarsophalangeal joints. There is a metatarsal for each of the five digits, and each digit has three phalanges except for the great toe (digit I), which has only two.

The metatarsophalangeal joints allow flexion, extension, abduction, and adduction of the digits, but the range of movement is more restricted than in the hand.

The interphalangeal joints are hinge joints and allow flexion and extension.

The bones of the foot are not organized in a single plane so that they lie flat on the ground. Rather, the metatarsals and tarsals form longitudinal and transverse arches (Fig. 6.10). The longitudinal arch is highest on the medial side of the foot. The arches are flexible in nature and are supported by muscles and ligaments. They absorb and transmit forces during walking and standing.


Muscles of the gluteal region consist predominantly of extensors, rotators, and abductors of the hip joint (Fig. 6.11). In addition to moving the thigh on a fixed pelvis, these muscles also control the movement of the pelvis relative to the limb bearing the body’s weight (weight-bearing or stance limb) while the other limb swings forward (swing limb) during walking.

Major flexor muscles of the hip (iliopsoas—psoas major and iliacus) do not originate in the gluteal region or the thigh. Instead, they are attached to the posterior abdominal wall and descend through the gap between the inguinal ligament and pelvic bone to attach to the proximal end of the femur (Fig. 6.12).

Muscles in the thigh and leg are separated into three compartments by layers of fascia, bones, and ligaments (Fig. 6.13).

In the thigh, there are medial (adductor), anterior (extensor), and posterior (flexor) compartments:

Muscles in the leg are divided into lateral (fibular), anterior, and posterior compartments:

Specific muscles in each of the three compartments in the leg also provide dynamic support for the arches of the foot.

Muscles found entirely in the foot (intrinsic muscles) modify the forces produced by tendons entering the toes from the leg and provide dynamic support for the longitudinal arches of the foot when walking, particularly when levering the body forward on the stance limb just before toe-off.

Relationship to other regions

Unlike in the upper limb where most structures pass between the neck and limb through a single axillary inlet, in the lower limb, there are four major entry and exit points between the lower limb and the abdomen, pelvis, and perineum (Fig. 6.14). These are:

Key points

Innervation is by lumbar and sacral spinal nerves

Somatic motor and general sensory innervation of the lower limb is by peripheral nerves emanating from the lumbar and sacral plexuses on the posterior abdominal and pelvic walls. These plexuses are formed by the anterior rami of L1 to L3 and most of L4 (lumbar plexus) and L4 to S5 (sacral plexus).

Nerves originating from the lumbar and sacral plexuses and entering the lower limb carry fibers from spinal cord levels L1 to S3 (Fig. 6.15). Nerves from lower sacral segments innervate the perineum. Terminal nerves exit the abdomen and pelvis through a number of apertures and foramina and enter the limb. As a consequence of this innervation, lumbar and upper sacral nerves are tested clinically by examining the lower limb. In addition, clinical signs (such as pain, pins-and-needles sensations, paresthesia, and fascicular muscle twitching) resulting from any disorder affecting these spinal nerves (e.g., herniated intervertebral disc in the lumbar region) appear in the lower limb.

Dermatomes in the lower limb are shown in Fig. 6.16. Regions that can be tested for sensation and are reasonably autonomous (have minimal overlap) are:

The dermatomes of S4 and S5 are tested in the perineum.

Selected joint movements are used to test myotomes (Fig. 6.17). For example:

In an unconscious patient, both somatic sensory and somatic motor functions of spinal cord levels can be tested using tendon reflexes:

Each of the major muscle groups or compartments in the lower limb is innervated primarily by one or more of the major nerves that originate from the lumbar and sacral plexuses (Fig. 6.18):

image Large muscles in the gluteal region are innervated by the superior and inferior gluteal nerves.

image Most muscles in the anterior compartment of the thigh are innervated by the femoral nerve (except the tensor fasciae latae, which are innervated by the superior gluteal nerve).

image Most muscles in the medial compartment are innervated mainly by the obturator nerve (except the pectineus, which is innervated by the femoral nerve, and part of the adductor magnus, which is innervated by the tibial division of the sciatic nerve).

image Most muscles in the posterior compartment of the thigh and the leg and in the sole of the foot are innervated by the tibial part of the sciatic nerve (except the short head of the biceps femoris in the posterior thigh, which is innervated by the common fibular division of the sciatic nerve).

image The anterior and lateral compartments of the leg and muscles associated with the dorsal surface of the foot are innervated by the common fibular part of the sciatic nerve.

In addition to innervating major muscle groups, each of the major peripheral nerves originating from the lumbar and sacral plexuses carries general sensory information from patches of skin (Fig. 6.19). Sensation from these areas can be used to test for peripheral nerve lesions:

Nerves related to bone

The common fibular branch of the sciatic nerve curves laterally around the neck of the fibula when passing from the popliteal fossa into the leg (Fig. 6.20). The nerve can be rolled against bone just distal to the attachment of biceps femoris to the head of the fibula. In this location, the nerve can be damaged by impact injuries, fractures to the bone, or leg casts that are placed too high.

Regional anatomy

Bony pelvis

The external surfaces of the pelvic bones, sacrum, and coccyx are predominantly the regions of the pelvis associated with the lower limb, although some muscles do originate from the deep or internal surfaces of these bones and from the deep surfaces of the lumbar vertebrae, above (Fig. 6.22).

Each pelvic bone is formed by three bones (ilium, ischium, and pubis), which fuse during childhood. The ilium is superior and the pubis and ischium are anteroinferior and posteroinferior, respectively.

The ilium articulates with the sacrum. The pelvic bone is further anchored to the end of the vertebral column (sacrum and coccyx) by the sacrotuberous and sacrospinous ligaments, which attach to a tuberosity and spine on the ischium.

The outer surface of the ilium, and the adjacent surfaces of the sacrum, coccyx, and sacrotuberous ligament, are associated with the gluteal region of the lower limb and provide extensive muscle attachment. The ischial tuberosity provides attachment for many of the muscles in the posterior compartment of the thigh, and the ischiopubic ramus and body of the pubis are associated mainly with muscles in the medial compartment of the thigh. The head of the femur articulates with the acetabulum on the lateral surface of the pelvic bone.


The upper fan-shaped part of the ilium is associated on its inner side with the abdomen and on its outer side with the lower limb. The top of this region is the iliac crest, which ends anteriorly as the anterior superior iliac spine and posteriorly as the posterior superior iliac spine. A prominent lateral expansion of the crest just posterior to the anterior superior iliac spine is the tuberculum of the iliac crest.

The anterior inferior iliac spine is on the anterior margin of the ilium, and below this, where the ilium fuses with the pubis, is a raised area of bone (the iliopubic eminence).

The gluteal surface of the ilium faces posterolaterally and lies below the iliac crest. It is marked by three curved lines (inferior, anterior, and posterior gluteal lines), which divide the surface into four regions:

image The inferior gluteal line originates just superior to the anterior inferior iliac spine and curves inferiorly across the bone to end near the posterior margin of the acetabulum—the rectus femoris muscle attaches to the anterior inferior iliac spine and to a roughened patch of bone between the superior margin of the acetabulum and the inferior gluteal line.

image The anterior gluteal line originates from the lateral margin of the iliac crest between the anterior superior iliac spine and the tuberculum of the iliac crest, and arches inferiorly across the ilium to disappear just superior to the upper margin of the greater sciatic foramen—the gluteus minimus muscle originates from between the inferior and anterior gluteal lines.

image The posterior gluteal line descends almost vertically from the iliac crest to a position near the posterior inferior iliac spine—the gluteus medius muscle attaches to bone between the anterior and posterior gluteal lines, and the gluteus maximus muscle attaches posterior to the posterior gluteal line.

Ischial tuberosity

The ischial tuberosity is posteroinferior to the acetabulum and is associated mainly with the hamstring muscles of the posterior thigh (Fig. 6.23). It is divided into upper and lower areas by a transverse line.

The upper area of the ischial tuberosity is oriented vertically and is further subdivided into two parts by an oblique line, which descends, from medial to lateral, across the surface:

The lower area of the ischial tuberosity is oriented horizontally and is divided into medial and lateral regions by a ridge of bone:

When sitting, this medial part supports the body weight.

The sacrotuberous ligament is attached to a sharp ridge on the medial margin of the ischial tuberosity.


The large cup-shaped acetabulum for articulation with the head of the femur is on the lateral surface of the pelvic bone in the region where the ilium, pubis, and ischium fuse (Fig. 6.24).

The margin of the acetabulum is marked inferiorly by a prominent notch (acetabular notch).

The wall of the acetabulum consists of nonarticular and articular parts:

The smooth crescent-shaped articular surface (the lunate surface) is broadest superiorly where most of the body’s weight is transmitted through the pelvis to the femur. The lunate surface is deficient inferiorly at the acetabular notch.

The acetabular fossa provides attachment for the ligament of the head of the femur, whereas blood vessels and nerves pass through the acetabular notch.

In the clinic

Pelvic fractures

The pelvic bones, sacrum, and associated joints form a bony ring surrounding the pelvic cavity. Soft tissue and visceral organ damage must be suspected when the pelvis is fractured. Patients with multiple injuries and evidence of chest, abdominal, and lower limb trauma should also be investigated for pelvic trauma.

Pelvic fractures can be associated with appreciable blood loss (concealed exsanguination) and blood transfusion is often required. In addition, this bleeding tends to form a significant pelvic hematoma, which can compress nerves, press on organs, and inhibit pelvic visceral function (Fig. 6.25).

There are many ways of classifying pelvic fractures, which enable the surgeon to determine the appropriate treatment and the patient’s prognosis. Pelvic fractures are generally of four types.

Other types of pelvic ring injuries include fractures of the pubic rami and disruption of the sacro-iliac joint with or without dislocation. This may involve significant visceral pelvic trauma and hemorrhage.

Other general pelvic injuries include stress fractures and insufficiency fractures, as seen in athletes and elderly patients with osteoporosis, respectively.

Proximal femur

The femur is the bone of the thigh and the longest bone in the body. Its proximal end is characterized by a head and neck, and two large projections (the greater and lesser trochanters) on the upper part of the shaft (Fig. 6.26).

The head of the femur is spherical and articulates with the acetabulum of the pelvic bone. It is characterized by a nonarticular pit (fovea) on its medial surface for the attachment of the ligament of the head.

The neck of the femur is a cylindrical strut of bone that connects the head to the shaft of the femur. It projects superomedially from the shaft at an angle of approximately 125°, and projects slightly forward. The orientation of the neck relative to the shaft increases the range of movement of the hip joint.

The upper part of the shaft of the femur bears a greater and lesser trochanter, which are attachment sites for muscles that move the hip joint.

Greater and lesser trochanters

The greater trochanter extends superiorly from the shaft of the femur just lateral to the region where the shaft joins the neck of the femur (Fig. 6.26). It continues posteriorly where its medial surface is deeply grooved to form the trochanteric fossa. The lateral wall of this fossa bears a distinct oval depression for attachment of the obturator externus muscle.

The greater trochanter has an elongate ridge on its anterolateral surface for attachment of the gluteus minimus and a similar ridge more posteriorly on its lateral surface for attachment of the gluteus medius. Between these two points, the greater trochanter is palpable.

On the medial side of the superior aspect of the greater trochanter and just above the trochanteric fossa is a small impression for attachment of the obturator internus and its associated gemelli muscles, and immediately above and behind this feature is an impression on the margin of the trochanter for attachment of the piriformis muscle.

The lesser trochanter is smaller than the greater trochanter and has a blunt conical shape. It projects posteromedially from the shaft of the femur just inferior to the junction with the neck (Fig. 6.26). It is the attachment site for the combined tendons of psoas major and iliacus muscles.

Extending between the two trochanters and separating the shaft from the neck of the femur are the intertrochanteric line and intertrochanteric crest.

Intertrochanteric crest

The intertrochanteric crest is on the posterior surface of the femur and descends medially across the bone from the posterior margin of the greater trochanter to the base of the lesser trochanter (Fig. 6.26). It is a broad smooth ridge of bone with a prominent tubercle (the quadrate tubercle) on its upper half, which provides attachment for the quadratus femoris muscle.

Shaft of the femur

The shaft of the femur descends from lateral to medial in the coronal plane at an angle of 7° from the vertical axis (Fig. 6.27). The distal end of the femur is therefore closer to the midline than the upper end of the shaft.

The middle third of the shaft of the femur is triangular in shape with smooth lateral and medial margins between anterior, lateral (posterolateral), and medial (posteromedial) surfaces. The posterior margin is broad and forms a prominent raised crest (the linea aspera).

The linea aspera is a major site of muscle attachment in the thigh. In the proximal third of the femur, the medial and lateral margins of the linea aspera diverge and continue superiorly as the pectineal line and gluteal tuberosity, respectively (Fig. 6.27):

The gluteus maximus muscle is attached to the gluteal tuberosity.

The triangular area enclosed by the pectineal line, the gluteal tuberosity, and the intertrochanteric crest is the posterior surface of the proximal end of the femur.

In the clinic

Femoral neck fractures

Femoral neck fractures (Fig. 6.28) can interrupt the blood supply to the femoral head. The blood supply to the head and neck is primarily from an arterial ring formed around the base of the femoral neck. From here, vessels course along the neck, penetrate the capsule, and supply the femoral head. The blood supply to the femoral head and femoral neck is further enhanced by the artery of the ligamentum teres, which is generally small and variable. Femoral neck fractures may disrupt associated vessels and lead to necrosis of the femoral head.

Hip joint

The hip joint is a synovial articulation between the head of the femur and the acetabulum of the pelvic bone (Fig. 6.29A). The joint is a multiaxial ball and socket joint designed for stability and weight-bearing at the expense of mobility. Movements at the joint include flexion, extension, abduction, adduction, medial and lateral rotation, and circumduction.

When considering the effects of muscle action on the hip joint, the long neck of the femur and the angulation of the neck on the shaft of the femur must be borne in mind. For example, medial and lateral rotation of the femur involves muscles that move the greater trochanter forward and backward, respectively, relative to the acetabulum (Fig. 6.29B).

The articular surfaces of the hip joint are:

The acetabulum almost entirely encompasses the hemispherical head of the femur and contributes substantially to joint stability. The nonarticular acetabular fossa contains loose connective tissue. The lunate surface is covered by hyaline cartilage and is broadest superiorly.

Except for the fovea, the head of the femur is also covered by hyaline cartilage.

The rim of the acetabulum is raised slightly by a fibrocartilaginous collar (the acetabular labrum). Inferiorly, the labrum bridges across the acetabular notch as the transverse acetabular ligament and converts the notch into a foramen (Fig. 6.30A).

The ligament of the head of the femur is a flat band of delicate connective tissue that attaches at one end to the fovea on the head of the femur and at the other end to the acetabular fossa, transverse acetabular ligament, and margins of the acetabular notch (Fig. 6.30B). It carries a small branch of the obturator artery, which contributes to the blood supply of the head of the femur.

The synovial membrane attaches to the margins of the articular surfaces of the femur and acetabulum, forms a tubular covering around the ligament of the head of the femur, and lines the fibrous membrane of the joint (Figs. 6.30B and 6.31). From its attachment to the margin of the head of the femur, the synovial membrane covers the neck of the femur before reflecting onto the fibrous membrane (Fig. 6.31).

The fibrous membrane that encloses the hip joint is strong and generally thick. Medially, it is attached to the margin of the acetabulum, the transverse acetabular ligament, and the adjacent margin of the obturator foramen (Fig. 6.32A). Laterally, it is attached to the intertrochanteric line on the anterior aspect of the femur and to the neck of the femur just proximal to the intertrochanteric crest on the posterior surface.


Three ligaments reinforce the external surface of the fibrous membrane and stabilize the joint: the iliofemoral, pubofemoral, and ischiofemoral ligaments.

image The iliofemoral ligament is anterior to the hip joint and is triangular shaped (Fig. 6.32B). Its apex is attached to the ilium between the anterior inferior iliac spine and the margin of the acetabulum and its base is attached along the intertrochanteric line of the femur. Parts of the ligament attached above and below the intertrochanteric line are thicker than the part attached to the central part of the line. This results in the ligament having a Y appearance.

image The pubofemoral ligament is anteroinferior to the hip joint (Fig. 6.32B). It is also triangular in shape, with its base attached medially to the iliopubic eminence, adjacent bone, and obturator membrane. Laterally, it blends with the fibrous membrane and with the deep surface of the iliofemoral ligament.

image The ischiofemoral ligament reinforces the posterior aspect of the fibrous membrane (Fig. 6.32C). It is attached medially to the ischium, just posteroinferior to the acetabulum, and laterally to the greater trochanter deep to the iliofemoral ligament.

The fibers of all three ligaments are oriented in a spiral fashion around the hip joint so that they become taut when the joint is extended. This stabilizes the joint and reduces the amount of muscle energy required to maintain a standing position.

Vascular supply to the hip joint is predominantly through branches of the obturator artery, medial and lateral circumflex femoral arteries, superior and inferior gluteal arteries, and the first perforating branch of the deep artery of the thigh. The articular branches of these vessels form a network around the joint (Fig. 6.33).

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