11/28/2016

Lecture 20: Lower Limb Part 1-Hip to

Knee (MSK 7)
While the lower limb is similar to the upper limb, there are a few odd
things:
Odd Thing 1: Internal Rotation (see slide 18)
The upper and lower limbs undergo internal rotation during embryo
development more defined in the lower limb (this continues until
after you are born)
o Over the period of year that babies learn to walk, the muscle
compartments are in the right locations.
Internal Rotation of the lower limb stretches the dermatomes and
shifts the position of the muscle compartments.
o Extensors that were at the back get rolled around to the front
and flexors get rolled to the back.
o Also, the flexors will become the adductors of the thigh.
o This shifts the position of the muscular compartments and
results in three muscular compartments.
These are adaptations for us walking on two feet. Very unusual as it
puts us off balance.
Odd Thing 2: Thigh-3 Muscle Compartments (Not 2):
The muscles found within the thigh have three compartments (and
not the usual 2):
o 1. Extensors of the knee: front of the thigh (the
quadriceps).
Femoral nerve.
o 2. Flexors of the knee: back of the thigh (the hamstrings).
Tibial nerve.
Thus, hamstrings are antagonists to quadriceps.

Note: hamstrings named because the tendons here are

very prominent (like in a pig, so these are what are
used in a smokehouse to make a ham).
o 3. Adductors of the hip: located medially.
Obturator nerve.
Note:
These were the old flexors (before the rotation
occurred).
There are also abductors (because you need 4
muscles for circumduction) which will put these
out and enable then to contract to adduct the hip.
o Thus, not only are there 3 compartments, but the flexors and
extensors are switched.
This makes sense: in the UL, you have greater ability to
move knee back (flex) than forward (extend).
In fact it can be argued that the only purpose of
extensors is to bring the knee joint back to anatomical
position after flexing occurs.

Thigh 3 Muscle Compartments (not 2)

Anterior

Extensors of Knee
(quads; femoral nerve)
Adductors of Hip
(obturator nerve)
Lateral

Medial

Flexors of Knee
(hams; tibial nerve)
Posterior

Lumbo-Sacral Plexus-innervation of the Lower Limb

Overview:
o Little simpler than UL, but still joining together of spinal levels
o Posterior (flexor) and anterior (extensor) divisions will almost
immediately separate out after they have divided.
o There are 2 plexuses and 4 nerves: 2 for muscles above the
knee (Lumbar Plexus) and 2 for muscles below the knee
(Sacral Plexus).
Each plexus has the posterior extensor division, and the
anterior flexor division.
Lumbar Plexus: arising from the lumbar nerves in the lumbar
vertebrae
Anterior division: made up of the obturator nerve divisions
coming out and running around the rim of the pelvis and coming
out through the obturator foramen
o Obturator nerve: innervates the adductors of the hip (old
flexors).
Made up of ventral rami of L2,L3,L4.
o Obturator foramen: a little hole in the front of the pelvis
that is covered by a ligament, specifically an interosseous
membrane.
The hole is here just to make the pelvis a little bit
lighter (created by ischium and pubis bones)
This is a tiny hole that allow for the obturator nerve,
artery and vein to come out through
o The adductor muscles of the hip arise from that bone and
interosseous membrane of the obturator foramen.
Posterior division: made up of the femoral nerve runs forward
along the pelvis and goes out underneath the inguinal ligament
o Femoral nerve: innervates the extensors of the knee
(quads).
Very large (relative to obturator), also arising from
ventral rami of L2-L4, but located more posteriorly.
o Inguinal ligament: extends between the anterior superior
iliac spine and the pubic tubercle of the pelvis).
Anterior superior iliac spine is the bony point that holds
up your pants.

The inguinal ligament is the end of the anterior

abdominal wall, and allows for arteries, muscles, veins,
and nerves to go out from the abdomen to the lower
limb.
Femoral nerve will thus go out underneath
inguinal ligament and innervate the extensors of
the knee.
Note: thus, the lumbar plexus will innervate everything ABOVE the
knee except the true flexors (the hamstrings), which are innervated
by the sciatic nerve of the sacral plexus.

Sacral Plexus: formed by the nerves arising from the sacral foramina.
Gives rise to 2 mixed nerves (tibial and fibular nerve, named after bones)
innervating muscles below the knee:
Sciatic Nerve (L4-S3): The 2 nerves stay together when they
come out of the sacral foramina forming the sciatic nerve, which is
actually the two nerves just stuck together. This will exit via the
back of the pelvis through the greater sciatic foramina.
o 1. The tibial nerve innervates the flexors at the back of your
calf (plantar flexors)
Anterior flexor division (located posteriorly however).
o 2. The fibular nerve (common peroneal) innervates the
muscles of the anterolateral compartments, or the extensors
of the foot and ankle (dorsiflexors)
Posterior extensor division (located anteriorly however)
Thus, these branches (tibial/fibial) dont do anything until they get
to the knee (they stay as the sciatic until then), at which point they
split into posterior extensor and anterior flexor divisions.
o However, sciatic nerve will innervate the hamstrings above
the knee.
Note: remember sciatica, which is irritation of the sciatic nerve
caused by problems in the lower back (e.g. disk herniation,
spondylolisthesis, etc).

Lumbo- Sacral Plexus

Femoral nerve

Extensors of knee

Obturator nerve
Adductors of hip
(fexor)

Sciatic nerve
Tibial nerve

Obturator foramen

Fibular nerve
(Common Peroneal)

Major Nerves: There are two nerves above the knee

(obturator/femoral) and two nerves below the knee (fibular/tibial):
Above the Knee: accounting for the three compartments
1. Femoral nerve (L2-L4)Extensor Compartment

Posterior division of the lumbar plexus (extensors of the knee

(quads)).
Motor: Comes along pelvis and goes underneath the inguinal
ligament and becomes deep muscular nerve to innervate extensors
of the knee, the quadriceps
Sensory: It becomes a superficial cutaneous nerve (saphenous
nerve) and supplies medial aspect of the thigh, knee, and leg (thus
goes below the knee).
o This cutaneous branch of the femoral called the saphenous
nerve.

Femoral Nerve

Extensors
of knee
(quadriceps)

Muscular distribution

Cutaneous distribution

2. Obturator Nerve (L2-L4)Adductor Compartment

Anterior flexor division of lumbar plexus (adductors of the hip).
Path: Arises from anterior division of lumbar plexus and goes
through obturator foramen

Motor: Innervates the complex set of muscles that are responsible

for adducting the hip (some of which come from the obturator
foramens membrane).
Sensory: Superficial cutaneous branch is a small patch on the
medial side of the thigh

Obturator Nerve

Adductors of hip

Muscular distribution

Cutaneous distribution

*Sciatic NerveFlexor Compartment

Path: Comes out of the greater sciatic foramen BEHIND the pelvis
to get to the back of the hip. Sciatic nerve goes through an
opening in the pelvis to get to the back of the hip
Motor: Travels down the back of the thigh between the hamstring
muscles (flexors of the knee), innervating them (3 tibial, 1 fibular).
o Tibial nerve: innervates most of the hamstrings as it is the
flexor division of sacral plexus.
Will also innervate the plantar flexors of the foot.
o Fibular: one hamstring (see below for more specific).
Sensory:
o Sciatic:

Posterior aspects of thigh and gluteal regions.

Entire lower leg (except for medial aspect):
Divided between tibial and fibular nerves.
Red=tibial (cant really see fibular).

Sciatic Nerve

Hamstrings:
fexors of
knee
Tibial nerve:
plantar fexors

Muscular distribution

Fibular nerve:
dorsifexors
extensors

Cutaneous distribution

Below the Knee

Sciatic knee will split into the tibial and fibular nerves at the
popliteal fossa
Tibial nerve:
Path: innervates plantar flexors, then wraps around medial
malleolus, and then gives off superficial cutaneous (Sole of foot)
Motor:
o Innervates plantar flexors (muscles of the calf)
o Innervates intrinsic flexors of the foot:
Then wraps around the medial malleolus, using it as a
sort of pulley, to get into the bottom of the foot to
innervate the intrinsic flexors of the foot: abductors
and adductors of the toes.

Sensory: Supplies skin over the calf and the medial side of the foot
(as well as the sole of the foot (pink)).
o Note: feel funny sensation if push on backside of medial
malleolus (this is where tibial nerve is), as well as the
pulsations of the tibial artery (also here).

Sciatic nerve

Common
peroneal
nerve

Tibial Nerve

Plantar
fexors

Medial
malleolus
Cutaneous distribution
Muscular distribution

Intrinsic fexors
of foot

Fibular nerve (common peroneal): dorsiflexors extensors

Path (Contrast to tibial nerve): Wraps around the head/neck of
the fibula to get into the anterolateral extensor compartment, then
gives off superficial cutaneous branches.
o Can also feel this nerve (put fingers on top of fibula)same
idea as the ulnar nerve.
Motor: anterolateral extensor compartment
o Innervates dorsiflexors of the ankle, everters of the foot, and
the extensors ofyour toes.
Sensory: anterolateral compartment (anterolateral calf, top of foot,
esp. big toe/adjacent toe).

o After giving off its deep muscular branches, it becomes a

superficial cutaneous nerve supplying the skin on the
anterolateralcompartment (all along its length).

Sciatic nerve

Fibular Nerve
(Common Peroneal)

neck of
fbula

Dorsifexors
of ankle

Everters
of foot

Extensors
of foot

Muscular distribution

Cutaneous distribution

Note: each leg has two malleoluses (bony prominences) at the

ankle:
Medial malleolus: end of tibia.
Lateral malleolus: end of fibula.
Dermatomes of the Lower Limb
Dermatomes look like twisted stripes.
o If you took the foot and externally rotated it, all of the stripes
would be straightened out.
o However, because of the internal rotation, we not only have
the muscles changing their rotations, but we have these
twisting dermatomes (essentially a reflection of the rotation).
Pattern: As you go out the limb, dermatomes become straighter.

o The L5 dermatome (the Mounty stripe) is the first one that

runs straight up and down
It goes straight down the side of the pant, and out onto
the top of the foot.
Helps to determine which dermatome is which.
Immediately behind is S1 and S2.
Note that S2 and S3 can go up to the genitalia
(hence pedundal nerve).

Dermatomes of Lower Limb

L5The mountie stripe

Myotomes of Lower Limb

Pattern: Further down the limb you go, the further down the
lumbosacral plexus (i.e. upper plexus levels supply proximal
musculature).
o Flexion and extension of the hip: L2, L3, L4, (a bit of 5)
o Knee: L3, L4, L5, S1 (Patellar Reflex)
o Ankle: L4, L5, S1, S2 (Achilles Reflex)
o Everson and Inversion of the Foot: L4, L5, S1
These match up with the reflexes that we have seen before.

3,4 knock on the door Patellar Reflex, and 1,2, buckle

my shoe Achilles Reflex

Myotomes of Lower Limb

Hip L2 L3 L4 L5

Ankle L4 L5 S1 S2

Knee L3 L4 L5 S1

Foot L4 L5 S1

True Pelvis and False Pelvis (not covered in lecture, BUT

important)
All of the weight from our body needs to be transmitted to the
lower limb, and many strong ligaments between the bones of the
pelvis are needed to increase stability.
Important things to know that are seen here:
o The iliac crest is where the anterior abdominal wall muscles
attach.
o Sacrum
o Holes:
Obturator Foramen
Greater and lesser sciatic foramen.
o Ischial tuberosity we sit on it
o Acetabulum where the femur sits

o Note:
When hung on the skeleton, the anterior superior iliac
spine and pubic tubercle must be in the same plane
(not always seen in the lab, usually tilted forward)
Inguinal ligament is anterolateral (femoral nerve goes
through here), while the greater/lesser sciatic foramen
are more posterior (sciatic nerve passes through).
True vs. False Pelvis: Inside of the pelvis is quite flared - the
groove on the inside of the pelvis makes a sort of bucket, covered
over by the pelvic diaphragm. This basin is referred to as the true
pelvis. The flared upper portion is called the false pelvis.
o True pelvis: everything under pubic symphysis (bottom
bound by pelvic diaphragm).
Makes up the pelvic cavity.
o False pelvis: everything above pubic symphysis, bound on
each side by the illium (there is nothing in the front, as this is
occupied by the abdomen).
Generally considered part of the abdominal cavity
(hence, false pelvis).

Look for sciatic foramina

(left) and inguinal ligament foramina (right).

Sacroiliac Joint (Also not in lecture, BUT very important)

Sacroilliac joint: the joint between the illium of the pelvis and the
sacrum.
o The pelvis articulates with the axial skeleton (the sacrum)
using ligaments thus, the joint is called the sacro-iliac
joint.
o It is a synovial joint with associated sacroiliac ligaments
going from the sacrum to the illium.
Why synovial? Because the pelvis has to be able to
open up to allow a CHILD to go through the birth
canal...so ithas to be an articulating joint, instead of a
firm one)
o Strong, weight-bearing joint.
This is where the weight of the body is being
transferred from the vertebrae onto your two lower
limbs.
Motions: will occur because of the amount of weight being put on
the joint (two types)
o Gliding motion: pushes the sacrum down (w.r.t to pelvis) as
the force of the weight of the body is distributed along the
pelvis.
o Rotational motion: backwards rotation (tilting) of the
sacrum will also occur when this weight is put on the lower
limbs
Solution: to prevent these types of motions, the sacroiliac joint
must have many strong ligaments to stabilize it in so it doesnt
move to much and doesnt flip out towards the back too much.
o There must also be two types of ligaments (to prevent the
two types of motions):
The (sacroiliac) associated ligaments (prevent gliding).
The rotational ligaments (prevent rotation).
Most powerful stabilizers of the joint.

Note: rotational and associated ligaments are those

that I made up (do NOT use on tests/bellringers).

Ligaments Stabilizing the Sacroilliac Joint: see MSK 7, 33:41

1. Sacroilliac Ligaments (associated ligaments): prevent
downwards gliding of sacrum.
2. Rotational Ligaments: prevent backwards rotation of sacrum
(important in prevent it from flipping out backwards).
o 2 ligaments extending from the sacrum to the bones at the
front of the pelvis, or the ischium.
Sacro-spinous ligament: from the sacrum to the ishial
spine (superior).
Sacro-tuberous ligament: from the sacrum to the ishial
tuberosity (inferior).
o Important Purposes:
1. These are the most powerful stabilizers of the
sacroiliac joint.
2. These create 2 holes:
The greater sciatic foramen (top), and the
lesser sciatic foramen (bottom).
Greater sciatic foramen: above the level
of the pelvic diaphragm, so it provides a
good exit point for any artery/nerve that
needs to exit the pelvis (as they dont have
to pierce the diaphragm).

o If the diaphragm is pierced, you may

get prolapse (herniation) through the
muscles of the pelvic diaphragm.
o Divided by piriformis: upper=superior
gluteal nerve; lower=inferior gluteal
nerve, pedundal nerve, sciatic nerve.
Lesser sciatic foramen: good re-entry
point into the pelvis for things (may hook
around sacro-spinous ligament)
o E.g. pedundal.
o Summary: in addition to being important hip stabilizers,
these ligaments also form important landmarks for nerves
and arteries to enter/exit the pelvis.

Hip Joint
Ball and Socket Joint=Freedom of Movement (MSK 7, 35:32)
The hip is a ball and socket joint: the head of the femur
articulates withthe acetabulum in the pelvis.
o It is also a synovial joint, and as such there is an inner
synovial membrane and an outer joint capsule.
Arrangement:
o On top of the arteries is periosteum, then the synovial
membrane, then the joint capsule.
o This joint capsule needs to be thickened called ligaments.
The thickenings here are named based on the bones they are
attaching.
There are three: pubo-femoral, ilio-femoral and
ischio-femoral ligaments.

In anatomical position, the ligaments run straight up

and down.When they are moved into the flexed or
extended position, they are able to change their shape,
based on the way they are oriented.
o There is an articulating cartilage acting as a buffer between
bones.
o Ligamentum teres: There is also another round ligament
(ligamentum teres) that extends from the femur to the
acetabulum here that is not present in the ball and socket
joint in the shoulder.
This is because the hip needs to hold more weight.
An artery will go through this ligament (not important)
o Acetabular labrum: Additionally, there is a rim of cartilage
(labrum, or lip) that surrounds the acetabulum (outside of
yellow) and helps to deepen the bone for extra
support/stability for the head of the femur.
Without this, the joint would be shallow (like the
Glenohumeral joint).
Movements: Abduction of the hip, hip flexion, some hip extension,
hip lateral and medial rotation is all possible.
o With this range of motion means you can expect 4 groups of
muscles wrapping around this joint causing its movement.
o Outline: see MSK 7, 36:27
Abduction: move hip out (away from body).
Adduction: move hip back in to anatomical position.
Flexion: move hip forward.
Extension: move hip backwards.
Lateral rotation: rotate hip outwards.
Internal rotation: rotate hip inwards.
Thus, circumduction.

*Red is ligamentum teres with the artery going through it (goes right
into the head of the femur).
Innervation:
There are blood vessels (femoral artery) supplying the head of the
femur, but they have to enter into the bone below the joint capsule
to avoid getting crushed/strangulated by the movement of the joint
(as the joint capsule will tighten up).
To the elbow we go and from the knee we flee
o From the knee we flee: Head of the femur receiving most
of its blood supply through nutrient arteries that are going
inside through the marrow of the bone in order to reach it.
The arteries that supply the head of the femur are
fleeing the knee, and are located lower than you would
expect.

The articulating branches of the femoral artery wrap

around the neck of the femur and then wrap
underneath of the joint capsule in order to penetrate
the bone in the diaphysis (through the nutrient
foramina).
Then it travels through the spongy bone of the
epiphysis in order to supply that part of the spongy
bone (the head) with nutrients.
o Thus, femoral (hip) fracture of the neck (where its thinnest)
will compromise the head of the femur (may cause necrosis of
the head of the femur).

Muscles acting on the Hip

There are 4 muscle groups acting on the hip (hence,

circumduction).
1. Flexors: illiopsoas
2. Extensors: Gluteal
3. Adductors: Sartorius, gracilis, adductor group.
o Medial surface of the thighs.
4. Abductors: gluteus maximus, tensor fascia lata (and gluteus
medius).
o Act through the illiotibial tract/band (superficial fascia).
Note: 1 and 2, then 3 and 4 are antagonists.

So how do these 4 muscle groups have an action on the hip?

*For reference w.r.t

origins/insertions.
1. Flexors of the Hip:

1. Quadratus lumborum: square muscle in lumbar region of the

spine
o Located quite high up in the lumbar region, in front of the
transverse processes of the lumbar vertebrae,
o Origin: arises from the anterior surfaces of lumbar transverse
processes.
o Insertion: bottom of pelvic brim (internal lip of iliac crest)
o Action: stabilizes the pelvis when contracts (weak stabilizer)
When you are walking, when one leg lifts up, the pelvis
on that side would drop, as it is only supported on the
other side, so the quadratus lumborum on that same
side contracts to pull it back up.
Thus, maintains a steady pelvis on the side with
the lifted leg.
Your left and right quadratus lumborum muscles
Contract in sequence (alternatively) as you walk to keep
your pelvis from dropping.
o Innervation: innervated by the ventral rami of the mixed
spinal nerves, making it part of the lower limb, not a back
muscle (not segmentally innervated).
o Note:
Called the bartenders muscle. Why?
This is the area of your back that hurts if you walk
all day long, because the quadratus lumborum is
continuously contracting to try and keep your
pelvis stabilized.
Thus, the brass rod (bar) underneath the bar is
there so that you can alternate resting your legs
on it to rest your quadratus lumborum muscles,
which is a weak stabilizer of the hip (hence why
you have to rest it to stay at the bar longer...).
Why is this muscle important?
Because we walk on two feet, instead of four, we
are unbalanced. While walking, there is a period
of time when you are balancing on one foot.
Without the bilateral stability created by the two
legs, you need muscles to suspend the pelvis
from the back in order to prevent it from falling
down on the unsupported side.
Muscles: quadratus lumborum and gluteus
medius.
2. Iliopsoas: most powerful flexor of the hip

o Origin:
Made up of two muscles: both also important hip
stabilizers
Psoas: major and minor (see MSK 7, 41:15)
Origin: arises from the transverse
processes/vertebral bodies (T12, L1-L5),
BUT is superficial to quadratus lumborum.
Iliacus: see MSK 7, 41:04
Origin: arises from the inside surface of the
pelvis itself (iliac fossa).
These two muscles will travel anteriorly and pass
under the inguinal ligament, at which point they
will join together to form the iliopsoas muscle.
o Insertion: attaches to the femur (lesser trochanter,
proximally near the head).
o Action: most powerful hip flexor when it contracts.
o Innervation (Extra):
Psoas: direct branches of anterior rami (L2-L4);
Iliacus: femoral nerve (also L2-L4).

Flexors of Hip
Quadratus
Lumborum
Stabilizer
of pelvis
Psoas
iliacus

iliopsoas

The origin and insertion of Psoas muscles can be reversed.

Psoas may reverse origin and insertion (i.e. action) during hip
flexion or lumbar spine flexion.
In both cases, the part of the body that is stable (immovable) will
result in action across the joint to a part of the body that is not
stabilized (movable):
o 1. Hip Flexion: When you flex your hip by moving your leg
and keeping yourupper body stationary, the origin of psoas
are in the spine and the insertion is in the femur, so when
they contract, they bring the leg up.
o 2. Lumbar Spine Flexion: If you are lying down and keep
your legs stationary (hip is stabilized), but move your upper
body (sitting up), the origin is then in the femur and the
insertion is on the spinal vertebrae. So, contraction of psoas
will allow us to do sit-ups.
Hip usually stabilized if someone holds down your feet,
and knees in arched position.
See MSK 7, 41:44.
2. Extensor and external rotators of the hip:
Located at the back of the hip and are antagonists to iliopsoas
(which are located deep, but at the front).
Gluteus maximus: largest extensor (similar to deltoids in the
shoulder)most powerful extensor.
o Origin: posterior aspect of inner upper illium border (the
pelvis.
o Insertion: 2 insertions (one on bone, one not on bone)

1. Iliotibial tract (band of fascia lata): upper and

larger fibers/superficial fibers (passes across the
greater trochanter) insert into the posterior edge of
iliotibial tract.
For hip abduction.
2. Shaft of the femur (gluteal tuberosity):
deeper/lower fibers.
For extension.
o Action: extensor of the hip (antagonist to iliopsoas),
abductor of the hip (see MSK 7, 44:33).
Note: when it has fully extended the hip, it will also
laterally (externally) rotate the hip.
Innervation: Inferior gluteal nerve.
Deep gluteal muscles: external rotators of the hip.
o Underneath the gluteus maximus muscle is what looks like
the rotator cuff of the shoulder. These are the deep gluteal
muscles, which are responsible for external rotation of the
hip.

Note:
Gluteal muscles:
o Gluteus maximus, gluteus minimus, gluteus medius, tensor
fasciae latae (thus this is part of the gluteal muscles).
Maximus is most superficial, then minimus, then medius
CHECK

Gluteus maximus

Gluteus
medius
Deep
gluteal
muscles

(abductor,
hip stabilizer)
Gluteus maximus

Extensors and external rotators of Hip

REVIEW
3. Abductors of the hip:
At the side of the hip, there are no muscles there, so what
can abduct the hip? It is nothing but bone (shaft of femur)!
o The muscles are located to the side (not laterally), and they
do not insert onto the bone.
o Specifically, there are two muscles, one from the front and
one from the back, which actually attach to the iliotibial tract
of the superficial fascia (fasci lata):
The gluteus maximus at the back and the tensor
fascia latta at the front.
Contraction of upper fibers of gluteus maximus, and
tensor fascia lata=hip abduction.
o Note: you can also feel the greater trochanter as it angles
inward to articulate with the acetabulum (but this is not
important).
The iliotibial tract of superficial fascia (of the thigh): There is
dense connective tissue underneath the skin (superficial fascia). In
the thigh, it is thickened, especially at the side, so it is called the
iliotibial tract of superficial fascia. In human beings, it has been
turned into a kind of ligament or tendon into which these muscles
can attach.
o The iliotibial tract originates from the ilium of the pelvis and
inserts onto the lateral aspect of the tibia (hence it cause
abduction).
o The gluteus maximus is at the back and the tensor fascia lata
is at the front (both insert here).
When contracted together, there is abduction of the hip.
Abductors:
1. Gluteus maximus: described above.
o Insertion: Upper fibers insert into the posterior portion of the
Iliotibial tract.
2. Tensor fascia latta: see MSK 8, 5:33
o Origin: outside of iliac crest
o Insertion: anterior portion iliotibial tract in the thigh.
o Action: hip abduction.
o Innervation: superior gluteal nerves (check/EXTRA).
3. Gluteus medius and minusMild Abductors
o Overview:

Abduction: all fibres of gluteus medius and minimus

abduct the hip (milder than the first 2).
Internal rotation: anterior fibers of gluteus
medius/minimus internally rotate the hip.
o Gluteus medius: may also help in abduction; good stabilizer
of the hip.
Origin: outer surface of illium (iilliac crest)extra.
Insertion: greater trochanter of femur.
Action:
Hip stabilizer (compliments quadratus
lumborum)
But it can also have its insertion reversed so
instead of pulling the hip upwards, it can
pull the pelvis downwards.
THIS IS THE MOST IMPORTANT ACTION.
It is the STRONGEST stabilizer of the hip.
Hip abductor (assists gluteus maximus).
Internal Rotator
Innervation: Superior gluteal nerve
o Gluteus minimus: also abduction and internal rotation.
Origin: outside of illium
Insertion: greater trochanter.
Action: also abduction and internal rotation.
Innervation: Superior gluteal nerve
Note: located underneath of gluteus medius.
Note:
o 1 and 2 are major hip abductors, 3 (min/medius) are minor.
o Gluteus maximus inserts into the posterior edge of the
iliotibial tract, while the tensor fascia lata matches it and
inserts into the anterior edge of the iliotibial tract.These two
muscles work together to abduct the hip.

Gluteus
maximus

Tensor fascia lata

Iliotibial
tract of
superfcial fascia

Abductors of hip

tibia

Gluteal Muscles
Gluteus maximus, gluteus minimus, gluteus medius, tensor fasciae
latae (thus this is part of the gluteal muscles).
o Maximus is most superficial, then medius, then minimus
CHECK

Gluteal Nerves
Gluteal nerves innervate these gluteal muscles. .
Pathway: They come directly out of the lumbar plexus (very early
off of it), and exit the pelvis through the greater sciatic foramen
(along with the sciatic nerve), instead of going through the pelvis
diaphragm and weakening it.
Nerves:
o Inferior gluteal nerve innervates the gluteus maximus
o Superior gluteal nerve innervates the gluteus medius and
minimus.
Note: The pyriformis muscle divides the spot where
the superior and inferior gluteal nerves exit the greater
sciatic foramen.
Inferior exits below, and superior exits above.
Pedundal Nerve:
There is another nerve that comes out from the greater sciatic
foramen that wraps around the sacrospinous ligament and then reenters the pelvis, underneath the sacrotuberous ligament and
comes forward to innervate the muscles in the genital diaphragm
and also the skin in the perineum.
This nerve is the pudendal nerve (S 2, 3, 4, keeps the penis off
the floor...). The pudendal nerve also avoids piercing the pelvic
diaphragm.

Gluteal nerves
Inferior gluteal nervegluteus maximus

Superior
gluteal nervegluteus medius
& minimus

Greater
sciatic
foramen

Sciatic
nerve

Hip Stabilization during Walking: see MSK 7 45:14

Gluteus medius and quadratus lumborum both help stabilize the hip.
Quadratus lumborum on the same side contracts to pull the pelvis
up on the same side (the unsupported leg)
Gluteus medius muscles contracts and pulls the pelvis on the
opposite side (the supported leg) down, to further stabilize the hip
and even out the pelvis.
o This is its reversed origin/insertion.
Gluteal Nerve Lesion:
It is possible that the superior gluteal nerve gets impinged as it
comes out from the sciatic foramen, so the gluteus medius muscle
no longer has innervation.
The pelvis will tilt downwards on theunsupported leg, giving rise to
a condition called the PositiveTrendelenburgs sign.
You still have quadratus lumborum there, butit is much closer to the
fulcrum, so it is not enough force to stabilize the hip.

o Gluteus medius is farther away from the fulcrum, so it has a

much stronger ability to stabilize the hip, with less force.

Hip stabilization during walking

Quadratus
lumborum

Gluteus
medius
Unsupported
leg

Positive trendelenberg
Greater and Lesser Sciatic Foramina (see MSK 8, 0:56)
Greater Sciatic Foramen:
o Nerves passing through:
Gluteal nerves exit the greater sciatic foramen,
innervating the external rotators of the hip.
Sciatic nerve also passes through (goes down with the
tibial and fibular components in it).
Pedundal nerve: exits the greater sciatic foramen and
re-entering the pelvis below the pelvic diaphragm to get
to the perineum at the front.
o Muscles Passing through:
The pyriformis muscle is an external rotator and
abductor of the hip (looks like a pyramid)

Originates from inside of the sacrum and goes out

with the sciatic nerve to insert onto the femur.
The greater sacrotuberous ligament closes over the complex.

Surface Anatomy Localizing the Sciatic Nerve Intramuscular

Injections
Sciatic nerve runs right down the hip, so we can guess that it is close
to the head of the femur, so a hip dislocation could damage it. The gluteus
maximus muscle also covers the greater sciatic foramen where all of the
nerves exist, and the sciatic nerve is actually much higher up than we would
expect it would be.
When doing an intramuscular injection, you want to avoid hitting
the sciatic nerve, so the idea is that you can use your hand as a guide to put
the needle into the muscles in the gluteal region.
Remember that the muscular injection is not something you would
want to put in the vasculature (usually oil-based and not supposed
to be put into vascular system).
The sciatic nerve is also a very large structure, so when doing this
type of injection, you want to make sure you dont puncture it.
So, the area in which you want to make the injection is shown in the
picture the upper, outer quadrant of the butt. The injection is actually done
in the gluteus minimus.
You would put your hand on the buttocks with your fingers pointing
to the illium
You use this hand as a guide to insert the needle into the gluteal
region (i.e. the gluteus minimus)

o You give the injection obliquely into the underlying gluteus

medius.
o The injection is not into the gluteus maximus AT ALL. Why?
Two reasons:
1. Sciatic nerve runs right through the middle of the gluteus
maximus
2. The gluteus maximus muscle also has a huge venous plexus to
drain from the gluteus maximus muscle to the vascular system.
o IMJ has slow release component when injected into
vein/artery, so avoid giving these drugs into the vascular
supply.
o So, when doing this injection, you often see the doctors pull
out on the syringe before injecting, to make sure that no
blood comes out.

I ntramuscular injection

Gluteus medius

X
4. Adductors of the Hip-The Medial Compartments
Overview:
Located on the medial aspect of the thigh.
o When the hip is abducted, there is stretching of the these
muscles, and they contract to adduct the hip.
o Thus, these muscles are antagonists to the hip abductors
(gluteus maximus and tensor fascia lata).
Embryologically, these muscles used to be on the front (former
flexors), but they were internally rotated, so now those former
flexors are on the medial aspect of the leg.
Consist of Sartorius (NOT ADDUCTOR) and adductor muscle groups,
innervated by femoral nerve and obturator nerve respectively.
o 1. Sartorius: tailors table.
Most superficial, even over the quads.
o 2. Adductor magnus:

If you remove the sartorius muscle, you can see the

adductor group of muscles.
The largest one is called the adductor magnus. When
you look at the bottom end of the adductor magnus,
you can see an opening (adductor hiatus) where blood
vessels can get from the anterior compartment to the
posterior compartment at the back of the knee.
o 3. Gracilis: see below.

Flexion
of hip

External
rotation

Adductor
group

Flexion
of knee

Adductors of hip- The medial Compartment

Note before starting: when some muscles undergo their complete
contraction, they may act as rotators (e.g. sartorius).
When we list the actions of the muscles below, it will happen in that
order for the strength of their contraction (only applicable for
this/when specified).
Medial Compartment Muscles:
1. Sartorius: tailors muscle

o Origin: anterior superior iliac spine (inferior to it)

o Insertion: proximal part of the tibia (goose
Tendon joins gracilis and semitendinosus (hamstring) to
form the pes anserinus.
o Action: hip flexion, knee flexion, hip external (lateral)
rotation, hip abduction (in that order).
Essentially creates turns your leg into a table.
See MSK 8, 8:12
o Innervation: femoral nerve.
o Pathway:
Crosses the hip joint and the knee joint and has an
action on both
Unusual as it crosses more than one joint (this is
why it can act on both hip and knee).
It also courses obliquely from lateral to medial on the
surface of the thigh.
o Note: Why Sartorius?
If you were a tailor, and you used this muscle, you
would have a table (out of your leg) that you could sew
on (The table has a hole in it (created by your leg)).
That is where this muscle got its name from: the
sartorius muscle! You look very sartorius (well
dressed) today!
2. Adductor magnus: located deep to the sartorius/gracilis
o Group of adductor muscles making a big sheet of muscle that
will attach to the entire shaft of the femur on the interior
medial side, and has a hole at the bottom.
Adductor hiatus: the opening at the end of the
adductor magnus.
While this is a hole in the muscle, it is not
actually one, but rather, it pushes the muscles to
the side, creating a hiatus (pause in the muscle
fibers).
o Origin: Bottom of the pelvis.
o Insertion: medial side of the femur.
o Action: adduction of the hip.
o Innervation: obturator nerve (check?).
3. Gracilis: Long and thin like a blade of grass.
o Origin: lower symphysis pubis (pubic tubercle)
o Insertion: medial part of the tibia, below the medial condyle
(as the pes ansirunus).
o Action: hip adductor (if hip was abducted).

In the order: knee flexion, medial rotation, then

adduction (in that order) medial rotation, high
flexion/knee flexion.
See MSK 8, 8:50
o Innervation: obturator nerve (check?)
o Structure/Arrangement:
Most superficial/medial muscle on medial side of the
thigh.

Vessels (Relating to the Medial Compartment):

Pathways: see MSK 8, 10:00
When the femoral vessels (artery and vein), which branch off of the
external iliac vessels go through the adductor hiatus to the back of
the knee, the vessel becomes the popliteal artery and vein.
o These vessels are all the same tube, but they are named
based on where they are.
Thus, the blood vessels (arteries/veins) is the same but will change
its name depending on which region its in.
o External iliac is when it is inside of the pelvis
o Femoral: when it goes through the inguinal ligament
o Popliteal: Once it passes through the adductor hiatus and is
at the back of the knee.

Pathology: Entrapped artery

As the artery and vein go through the adductor hiatus, there is a
possibility for them to be entrapped.
Distally, the patient would have a problem with the temperature in
their foot (inadequate circulation).
What could you do to determine if there was a problem with the blood
flow in this area?
Compare the pulse at the back of the knee (popliteal) to the pulse
in the thigh (femoral). If it is weaker at the popliteal, then there
must be a blockage in between the two areas.
Nerves (Relating to the Medial Compartment): see MSK
Obturator nerve (old flexor nerve) innervates the medial
compartment of muscles (adductors).
Nerve will exit in the tiny membrane in the obturator foramen (just
here to lighten bone), to descend and innervate these muscles.
Note: in this diagram (EXTRA) below can see:
Obturator externus muscle: rotator of the hip, weak adductor.
o O/I: posterior symphysis pubis to head of femur.

Hip Ligaments: Joint Capsule and Ligamentum Teres

Different joints will have a different balances between stability and
ability to move (freedom of movement).
In the pelvis (sacroilliac joint): high stability, less freedom of
movement.
o The sacroiliac joint is very important for stabilization of the
pelvis. Due to all of the force and weight on the pelvis and on
the lower limbs, we have to compromise range of movement
of the pelvis with stability, because the pelvis needs to be
stable in order for the lower limbs to function and hold the
body upright.
In the hip: has more freedom of movement, but is still bearing the
weight of the body; thus there must be a balance between stability
and movement.
Ligaments Stabilizing the Hip Joint: 4
Joint Capsule: 3 ligaments
Acetabulum made up of illium, ishium, and pubic bones, which fuse
together in the middle of the acetabulum (looks like a Mercedes
symbol).
There are 3 ligaments in the acetabulum binding it to the head of
the femur (one for each of these bones above, which are part of the
joint).
o Iliofemoral ligament (superior), ischiofemoral ligament
(back) and pubofemoral ligament (inferior)

These ligaments thicken the joint capsule, reinforcing it, and as

such increase joint stability.
The direction of the fibers also contributes to joint stability.
o Extension of the hip (anatomical position): more
stability, less movement.
Hip extension tightens (stretches) capsular ligaments,
and this will screw the head of the femur into the
acetabulum.
Thus, when you look at the pelvis in anatomical
position, the ligaments are fairly straight
(collagen fibers align).
o Flexion of hip: less stability, more movement.
If the hip was in the flexed position, the ligaments
loosen, decreasing stability but increasing freedom of
movement.
Happens when you sit down (why you will get hip
dislocation in car accidents).
Note: there is a bursa between the joint capsule and iliopsoas
muscle.

Ligamentum Teres: the 4th ligament

This is an unusual ligament on the inside of the hip, which is used
for increased stability.
o May be seen if you pull joint apart by severing the ligaments.
o It goes from the head of the femur into the acetabulum
(inside).
Obturator artery will accompany this ligament (branches of it)
o During development (before 20), the head of the femur needs
an extra blood supply as it cant enough from the femoral
arteries, which cannot get through the epiphyseal
cartilaginous plate to supply it.
o Thus, the obturator artery passes through the ligamentum
teres to feed the head of the femur.
o This artery sometimes goes away as you age.

ilium

Lateral
view of
pelvis

ishiofemoral
ishium

pubis

Ligamentum
teres

Anterior
posterior

Hip Ligaments:
J oint capsule &
Ligamentum Teres
Hip Stability (Review):
Hip Flexion: iliopsoas muscle
Pulls femur to the front, hip in flexion, ligaments loosen, less stable
Hip Extension: gluteus maximus
Pulls femur, hip in extension, ligaments tighter, more stable
(tightens the capsular ligaments and brakes the movement)

Hip Dislocation
Hip dislocation: when femur moves out of the acetabulum. Either
anterior or posterior:
o Anterior dislocation: knees will externally rotate, and head
of femur pops out in between pubofemoral and iliofemoral
ligaments.
o Posterior dislocation: knees will not externally rotate, and
the femur will be pushed BACKWARDS, and pops out in
between Iliofemoral and ischiofemoral ligaments.
o Note: majority are posterior (so the next section is
posterior).
Signs and symptoms:
o Sciatic nerve injury:
There is also a chance of injuring the sciatic nerve,
which is directly behind the femur (posterior
dislocation)
If this were to occur, there would be problems in both
extension and flexion of the ankle (because it hasnt
split into the tibial and fibular branches yet), leading to
foot drop.
o Internal rotation of hip.
Causes: More likely when the hip is in the flexed position (less
stable hip joint)
Example: most likely when sitting down (esp. car accident!)
o In a car accident, your body slides forward, the front of the
knee hits the dashboard, driving the femur back and
dislocating it from the hip.

Hip dislocation
Foot drop

Sciatic nerve

Posterior dislocation
in hip fexion

femur

Hip Dislocation vs. Hip Fracture

You can see a difference based on the kind of morphology that you see
the hip pulled into.
Hip Dislocation: internal rotation of hip (shortened leg).
In hip dislocation, the mechanism is the head of the femur is
popped out of its socket, and separated from the acetabulum.
Adductor muscles (front) can pull the hip medially, so you see that
the hip is pulled upwards and medially.
o Note: In anterior dislocation, harder for gluteal muscles and
abductors to exert action, as the bone is pulled to the front
Since its towards the front, adductors can pull it into
internal rotation.
The leg is also shorter (as femur doesnt articulate with acetabulum
and muscles pull it back) and pulled into internal rotation.
More common in youth.

Hip fracture: external rotation (foreshortened again).

In hip fracture, the head of the femur is fractured along its neck.
There is no movement posteriorly or anteriorly, and the bone just
sits there, so the powerful gluteal muscles will pull the femur into
external rotation.
o Also,you can see the muscles pulling the femur closer to the
pelvis(foreshortened foot again).
o Thus, gluteal muscles are predominant because of the
mechanism of injury.
More common in elderly.
o Osteoporosis (loss of calcium in the bones) will weaken the
bones.
o When elderly lose their balance (e.g. no proprioception), they
will fall, and they are more likely to break weakest/narrowest
part of femur (femoral neck).
Summary (Off LL, not sure if right): So apparently posterior dislocation
causes internal rotation and anterior dislocation displays the same symptoms
(aside from the breakage of the femoral neck) as hip feature.

Hip dislocation vs Hip fracture

Foreshortened
internal rotation

Hip dislocation

Foreshortened
external rotation

Hip fracture

Blood Supply to Proximal Femur (Head/Neck): Two different

arteries:
1. Obturator artery: enters proximally (ligamentum teres),
supplies femoral head.
o Gives off a branch that goes through the ligamentum teres
and supplies the head of the femur proximally
o Supplies femoral head proximally to epiphyseal plate.
2. Femoral artery: enters distally (flees knee), supplies femoral
neck.
o Branches from it enter in distal to the end of the joint capsule
Cant enter through the capsule as you cant pierce the
joint capsule because every time you would go to
extend the hip, you would squeeze and strangulate the
blood supply to the femoral head.

o Thus, the branches come off very far down, away from the
joint capsule and then flee the knee by coming back u
backwards through the bone marrow to supply the femoral
neck.
o Supplies femoral neck distally to epiphyseal plate.
Note: the epiphyseal plate sections off the area of supply for the
two arteries.

Blood Supply to Proximal Femur

acetabulum

Ligamentum teres

head

Obturator artery
Branches from
femoral artery

Cross section through

femoral head

Fracture to the Femoral Neck

Since the areas of blood supply are split up by the epiphyseal plate,
a fracture to the femoral neck may result in avascular necrosis of
the femoral head.
This depends on whether the obturator artery is still supplying the
femoral head (thus, older people who no longer have this artery will
be at risk).

o At risk: if the obturator artery in the ligamentum teres is not

in its normal position (i.e. not sufficient to supply head) or not
present.
Note: obturator artery may sometimes go away after
20 as it is not needed as much.
o Not at risk: if there is blood supply to the femoral head
through the ligamentum teres, and blood supply to the rest of
the bone from the other side (Like in this picture).
Fixing a Femoral Fracture:
To fix a fracture to the femoral neck, very strong machinery is needed
because this joint has to support the weight of the body. THIS IS EXTRA:
A large screw goes through the neck of the femur and is anchored
into the femoral head.
Another pin is attached adjacent to that to further stabilize it.
A large bar (approx. 6 inches long) attaches to the screw in the
femoral head with a nut, and then off of that bar are more screws
that go down along the femurs shaft to stabilize it.
Note: if there is avascular necrosis, then necrotic femoral head would
have to be removed/replaced with stainless steel ball prosthetic that will sit
into the acetabulum.

Avascular necrosis
of femoral head if
artery not present

X
X

X
Fracture to
femoral neck