MOB TCD

Anterior Thigh

Professor Emeritus Moira O’Brien

FRCPI, FFSEM, FFSEM (UK), FTCD
Trinity College
Dublin
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Cutaneous Supply
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Thigh
• Anterior muscle group:
supplied by femoral nerve
• Sartorius
• Quadriceps: rectus femoris, vastus
medialis, vastus intermedius and
vastus lateralis
• Pectineus
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Thigh
• Medial or adductor group:
adductor longus, adductor
brevis, adductor portion
adductor magnus and
gracillis are supplied by the
obturator nerve
• Posterior group: hamstring,
semimembranosus,
semitendinosus, biceps
femoris, adductor magnus,
below femoral hiatus
• Supplied by sciatic nerve
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Femoral Sheath

• Anterior wall formed by transversalis

fascia
• Posterior by fascia iliaca
• Three compartments
• Medial, short, is the femoral canal,
contains lymph gland
• Opens into abdomen via femoral ring,
site of femoral hernia
• Middle compartment contains femoral vein
• Lateral, femoral artery and femoral branch of genito-
femoral nerve
• Femoral nerve is outside sheath
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Quadriceps Femoris

• Rectus femoris
• Vastus medialis
• Vastus intermedius
• Vastus lateralis
• Forms the anterior portion of the
capsule of the knee joint
• The largest muscle group in the body
• Wastes rapidly if there is an effusion,
particularly the oblique portion of the
vastus medialis
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Rectus Femoris

• Tendinous origin from the upper part

of the anterior inferior iliac spine
(epiphysis) and the groove above the
acetabulum
• The most superficial portion of the
quadriceps
• The most frequently strained
• The only portion of the quadriceps
that crosses two joints
• Flexes hip, extends knee
• Femoral nerve
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Vastus Medialis

• Vastus medialis arises from the

lower half of the trochanteric line
• The spiral line
• The medial lip of the linea aspera
• The oblique (horizontal) fibres arise
from the lower portion of the
adductor magnus, helping to
stabilise the patella
• Separate branch from femoral nerve
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Vastus Lateralis
• Arises from the upper half of the
inter-trochanteric line
• The root of the greatertrochanter
• The lateral lip of the gluteal
tuberosity
• The lateral lip of the linea aspera
• The oblique portion of the muscle
arises from the iliotibial band
• Separate nerve supply
• Helps to stabilise the patella
• Lateralis is a common site for
muscle biopsies and for injections
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Vastus Intermedius
• Arises from the upper two
thirds of the anterior and
lateral aspect of the shaft of
the femur
• It is the deepest portion of the
quadriceps and is a common
site (with vastus lateralis) for
myositis ossificans, after a
direct blow to the thigh
• The articularis genu is inserted
into the upper part of the
suprapatellar bursa
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Quadriceps
• The rectus femoris forms the most
superficial lamina of the quadriceps,
passes anterior to the patella
• To form the anterior part of the
patellar ligament
• The fibres of the medialis and the
lateralis decussate cross in an
X-shape and lie in a plane posterior
to the rectus femoris
• Some of these fibres form the retinacular fibres
• Their oblique portions are inserted into the sides of
the patella
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Quadriceps Femoris
• The vastus intermedius is the most
posterior lamina, forms the main part
of the patellar ligament
• It is the most powerful extensor
• The patellar ligament is inserted into
the smooth upper portion of the tibial
tuberosity
• The quadriceps are the extensors of
the knee
• Only the rectus femoris portion arises
above the hip joint, and therefore is
also a flexor of the hip
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Weak Vastus Medialis Obliquus

• Lower most fibres of vastus medialis
• Partly arise from the adductor
magnus
• Straightens the pull on the quads
tendon and patella
• Controls patella tracking during
flexion/extension of the knee
• Fibres atrophy quickly after knee
injury (within 24 hours)
• 10-15 ml of effusion inhibit VMO
• VMO rehabilitation strength and
timing of contraction
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Abnormal Lower Limb Biomechanics

Anatomical anomalies
• Femoral torsion
• Genu valgum
• Increased Q angle
• High (Alta) patella
• Tibial torsion
• Overpronation
• Q angles
males 140 and females 170
> 200 greater problems
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The Q-angle

• The Q-angle is the angle formed by a

line drawn from the anterior superior
iliac spine to the centre of the patella
• And a line drawn upwards from the
attachment of the patellar ligament to
the tibial tubercle passing through this
point
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The Q-angle
• Functionally, on standing, the
normal angle is 10–15°
• With the knee at 90°of flexion, an
angle of 6°is normal, while greater
than 10°is abnormal
• Contraction of the quadriceps
tends to displace the patella
laterally in the femoral groove
• The oblique fibres of the vastus
medialis and the bony prominence
of the lateral femoral condyle resist
this
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Osgood Schlatter
• In young athletes, the
patellar ligament is
stronger than the bone
• Which can lead to a
traction apophysitis of the
tibial tuberosity, Osgood
Schlatter disease
• Jumpers’ knee is a lesion
at the apex of the patella
and the ligament
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Sartorius
• Sartorius arises from anterior superior illiac
spine
• Forms lateral boundary of femoral triangle
• Crosses adductor longus at apex
• Lies anterior to femoral artery
• Posterior to adductor longus lies the
profunda artery
• Knife injury at apex can injury both arteries
and the main blood supply to lower limb
• Sartorius lies on roof of subsartorial canal which
contains femoral artery
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Sartorius

• Inserted into upper third of medial

surface of tibia
• Anterior to gracillis and
semitendinosus, as part of the pes
anserinum
• Separated by tibial intertendinous
bursa
• Supplied by femoral nerve
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Adductor Muscles
• Adductor longus
• Adductor brevis
• Portion of adductor
Magnus
• Gracilis
• Supplied by obturator
Nerve L2,3,4
• Act with lower abdominals
to stabilise the pelvis
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Adductor Origins

lateral medial

inferior
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Adductor Longus
• Tendinous origin, pubic body,
has a variable shape
• Inserted into medial lip of
linea aspera
• Most frequently torn at
proximal musculo-tendinous
junction, which varies
• Or may tear at teno-periosteal
junction
• Site of junction varies, medial or lateral,
may be longer in some
• Anterior division obturator nerve
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Adductor Brevis
• Origin lower portion of body
of pubis
• Inferior pubic ramus
• Inserted into lower half of the
pectineal line
• Upper half of the linea
aspera
• Deep to adductor longus
• Separates two divisions of
obturator nerve
• Anterior division supplies it
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Adductor Magnus
• Triangular area of ischial tuberosity
• Ramus of ischium and inferior
ramus of pubis
• Inserted into medial lip of gluteal
tuberosity
• Lateral lip of linea aspera
• Medial supracondylar line
• Adductor tubercle
• Hiatus for popliteal vessels
• Origin of oblique fibres of vastus medialis
• Post division obturator nerve
• Sciatic nerve below hiatus for femoral vessels
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Gracilis
• Gracilis is the weakest, most medial and
superficial of the adductors
• Gracilis is the only one that crosses the
knee joint
• It arises from a thin aponeurosis, lower
half of the body and the inferior ramus of
the pubis and part of the ramus of the
ischium. It is strap like above
• It ends in a rounded tendon, inserted into
the upper portion of the medial surface of
the tibia between the sartorius and the
semitendinosus
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Gracilis

• Gracilis is separated from sartorius

and the semitendinosus by the tibial
intertendinous bursa (pes
anserinum)
• Gracilis is usually supplied by the
anterior division of the obturator
nerve, L2, 3, 4
• It adducts the hip and flexes and
medially rotates the leg
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The Tibial Intertendinous Bursa

• Inflammation of the tibial

intertendinous bursa
• Must be differentiated from injury to
the lower attachment of the medial
collateral ligament of the knee
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Adductors

• The adductors adduct the

femur and help to stabilise
and counteract the rotation
of the pelvis, particularly
during the double support
• When the anterior limb is
flexed and the posterior limb
is extended
Carlsoo, 1972
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Adductor Muscle - Tendon Strain

Common in soccer is
adductor muscle-
tendon strain.
Be aware of:
• Rectus Femoris
• Sartorius
• Rectus Abdominus
• Pectineus
• Adductor Magnus
• Gracilis
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Adductors
• If the hip is flexed, the adductors
rotate the hip medially
• When the hip is extended the
adductors can laterally rotate
• They can also flex the extended
hip and extend the flexed hip
• At the beginning of the swing
phase of walking they work
synergistically with the iliopsoas
• At the end of the swing phase, they work with the
hamstrings, which contract to prevent further hip
flexion
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Pectineus

• The pectineus muscle is a short

flat muscle, which forms part of the
floor of the femoral triangle
• It arises from the anterior aspect of
the superior ramus of the pubic
bone and the fascia covering it
• It is inserted into the upper half of a
line drawn from the lesser
trochanter to the linea aspera and
lies posterior to the femoral sheat
• It is supplied by a branch from the femoral nerve or
the accessory obturator (L2, 3)
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Pectineus
• The pectineus is mainly a flexor of the thigh
and a weak adductor
• There may occasionally be some fusion
between the adductor longus and brevis or
with the pectineus
• Doubling of the origin of the adductor
longus or brevis may also take place
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Psoas Major
Origin
• Intervertebral discs, adjoining
bodies of T12-L5 vertebrae
• Medial half, anterior aspect of five
lumbar transverse processes
• Fibrous arches on the sides of the
bodies of the four upper four
lumbar vertebrae, over four lumbar
arteries
• Inserted into the lesser trochanter
of femur
• Nerve L2,3,4
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Psoas Minor

• Minor
• Origin
• T12 –L1
• Insertion
• Arcuate line
• Iliopubic eminence
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Psoas Major Muscle and Fascia

• The psoas is covered by fascia

which is attached medially to the
lumbar vertebrae
• To the fibrous arches
• Medially along the brim of the
pelvis to the arcuate and
pectineal lines
• Laterally, the fascia is attached to
the transverse processes of the
lumbar vertebrae
• Medial Arcuate Ligament is a thickening
of fascia over the Psoas
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Psoas
• Flexes the hip when acting
from above
• Lumbar plexus is formed inside
the substance of psoas
• A strain of the psoas muscle
may be the cause of chronic
groin pain, and you must take
care not to mistake it for an
adductor strain
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Psoas
 Psoas bursa, between
psoas and capsule of hip
joint, may communicate
with the synovial
membrane of the joint
 Psoas abscess will
present in the groin
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The Iliopsoas
• The iliacus
• Origin: iliac fossa and iliac crest
• Inserted into the lateral aspect of the psoas
and into the femur below the lesser trochanter
• Nerve L2,3
• The iliopsoas is an active postural or stabilising muscle
of the hip which helps to prevent hyperextension of the
hip while standing
• Acting from above, the iliopsoas flexes the hip and may
be either a medial or a lateral rotator; acting from
below, psoas flexes spine
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The Iliopsoas
• In walking, the iliopsoas is used
to start swinging the leg
forwards
• On level ground the leg moves
forwards like a pendulum to
complete the swing
• Stronger contraction of the
iliopsoas is required when
running or walking up a hill
• When climbing stairs, the
iliopsoas lifts the leg and places
the foot on the stair above
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The Iliopsoas
• When preparing to stand
from sitting, the iliopsoas
pulls the trunk forwards as
the femur is fixed
• The trunk leans forwards
and, before standing
upright, the centre of gravity
of the trunk moves over the
feet
• In sitting up from lying, the iliopsoas pulls on the pelvis
and the lower vertebrae in order to pull the trunk up
Tyldesley & Grieve, 1989
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The Iliopsoas
• Running with the legs lifted high,
helps to develop the iliopsoas
• The iliopsoas is also used in the
downbeat of freestyle swimming
• The iliopsoas is the main muscle
involved in straight leg sit-ups
• These, however, should never be
done as they put stress on the
lumbar vertebrae and do nothing
for the abdominal muscles
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