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Anatomy
Subject: Done by: Doctor: Date:
Muscles of the Lower Limb (1) Hala Shawareb Rashed Jomard Sunday, 25/9/2011

Anatomy - Lecture 9 Sunday, 25-9-2011 Done by: Hala Shawareb

Muscles of the lower limbs

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We are here to achieve our goals Do you have any question about the muscles of the lower limbs? Because we are in a university we dont repeat whats in the book. We analyze and discuss difficult areas. Okay? Now, why do we do that? Because we have to answer this question Where is the Disease? Most doctors count on ignorance of the patients and that is a big problem. Now what if you have an intelligent patient and he has a problem and he asks you Where is my disease? It is one of the most important duties to explain to patients Look your problem is in this part and Im going to do this and that but most people count on ignorance of the patients. Patients are suffering, therefore they are not in the mood for asking but youre supposed to tell them.

Lower Limb:
This lecture does not include everything you need to know, it only includes difficult areas (general outline), so you have to refer to the book. Now, why do we have muscles in the lower limb? We have muscles there so that we can move joints.
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I would like to group muscles according to function, so when I want to study muscles of the lower limb I have to study the joints first. We have the hip joint, knee joint, ankle joint and then a group of small joints that are close to each other that are the tarsal joints, sub tarsal joints, metacarpopharangeal joints (should be metatarsophalangeal joint) and interpharangeal joints (these are the joints that Im supposed to move in the lower limb) For example, one of the movements of the hip joint is Flexion (decreasing the angle) and this is done by a group of muscles. There are extra pluses on iliopsoas. So if we lose one of these muscles we can still do flexion of the hip but if we lose the iliopsoas muscle were going to lose a good part of flexion. Then extension of the hip joint (back to normal anatomical position) and hyperextention. We use this movement a lot, we stand up we do extension, we climb stairs we do extension, we move and push our body forward we do extension, so it is one of the most useful movement of the hip. Abduction and adduction we dont use them as frequently as flexion and extension but still they are being done by two important muscles; gluteus medius and minimus plus some other joints so we dont really worry of losing a movement of a joint. Adduction is also being done by a group of muscle. Rotation (lateral and medial) is also done by a group of muscles and then circumduction (combination of all these movements) and I need muscles to move the hip joint in these groups.

Knee joint, I need to do flexion which is also done by a group of muscles but the hamstrings are the most important ones. Extension, flexion, locking and unlocking. You see, I cant do adduction and abduction at the knee joint because of the tight or type (not sure) of the joint. Locking is a very important movement, when I move especially in walking, one of the stages of walking is straight up with one leg flying, so in order to prevent the knee from bending flexion I have to lock the knee so that the thigh and the leg are fixed in position so it can bear the weight.
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Locking is done by medial rotation; when Im standing on one leg, the foot is being fixed and the body is the moving part so I do medial rotation of the thigh on the tibia and I lock it. Now when I take off the leg I have to unlock it, and this is done by a muscle called the poplliteus muscle. Some people cant lock their knee because of: 1. Weakness of the muscle 2. Problem in the nerves supplying these muscles If you stand up at the gate of the university and start watching how the people walk, youll find different ways of walking, different problems during walking. When you go and read the book, you will not find many books like writing that one of the movements of the knee is medial and lateral rotation; medial rotation of the femur on the tibia and lateral rotation back to the normal anatomical position, these are another names for locking and unlocking.

For the ankle, it is dorsiflexion or plantarflexion. These are important movements in walking because when one of the legs is on the ground and I want to lift the other one, I dont want the foot to drop; because
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when it drops it shovels, I want to lift it (dorsiflexion). Because the angle between the foot and the leg becomes smaller, they call this flexion. Some people call it extension but it is dorsiflexion and the foot down is plantarflexion or extension. I have very important muscles in plantarflexion because I force myself forward because of the extension. How do I push myself forward? I extend the hip joint and I want to take it off the ground so I plantarflex the foot and this is done by gastrocnemius and soleus plus other muscles. Now Im not going to give you the ankle joint or the joints of the foot but I would like just to mention that for the ankle it is Plantarflexion and Dorsiflexion. More peripheral joints, tarsal and subtarsal joints plus metatarsal pharangeal joint. Therefore, we are going to have different groups of muscles to do different movements. Now what do you think gluteal muscles do? They are at the back of the hip; so when they come down and insert on the femur what do they do? Extend it, plus medial rotation and lateral rotation, but usually lateral rotation. Now theres another important movement during walking, (you are lucky we dont teach you walking because its complex). When Im having one leg on the ground, the other leg is flying, what happens to the pelvis? It drops. How do I stabilize it? A group of muscles on the landing site should contract to bring the pelvis straight these are abductors and these are the gluteus medius and minimus. How do I flex my hip? I must bring muscles anterior to the hip joint so that they flex the hip joint. How do I Adduct? I have to bring muscles
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from the medial side and insert them on the femur, so that when they contract I have adduction. Other people say: we are going to divide muscles not in relation to the movement of the joints but in groups. For example, muscles of the thigh that are around the femur, they are divided into anterior muscles, medial muscles and back muscles. As well as muscles of the leg; they are divided in the same manner. What do usually anterior muscles of the leg do? If they come anteriorly they do dorsiflexion, if they are swipping around the medial malleolous, they do plantarflexion. So you know now what the mechanics of these groups of muscles are. What do you think posterior muscles of the leg do? They do plantarflexion. You see because of confusion, we are not going to use extension and flexion in the ankle, let us use dorsiflexion and planterflexion.

What do you think lateral muscles do? Lateral muscles: if they go infront of the lateral malleolous, then they are dorsiflexors. If they go behind the lateral malleolous, then they are plantarflexors. Muscles of the foot are going to have their own lecture. Now we understand how muscles of lower limb are attached, we have a very important subject which is fascia of the lower limb.

Whats the difference between muscles of the upper limb and muscles of the lower limb? MUSCLES OF THE UPPER LIMB do not have very thick prominent fascia; they do not have thickening of the fascia strapping the tendons in flex because they are not weight bearing. While in muscles of lower limb, we have thick fascia (so we wear thick fascia in our lower limbs just like divers suit). Thick fascia cannot expand; it holds the muscles to the bones and holds muscles together. Fascia of the gluteal region is superficial and deep (No real clinical application). But fascia of the thigh is very important; fascia of the thigh is superficial and deep. The abdominal wall has 2 fascias; superficial and deep, The superficial comes from the anterior abdominal wall and becomes continuous with the lower limb (scarpas fascia). Now the deeper fascia of the abdominal wall which is the membranous fascia is not going down to the lower limb, its going to be inserted 1cm below the inguinal ligament. Now, the deep fascia of the thigh is called fascia lata, its very thick, it encloses the thigh as elastic stocking just like divers suit and therefore it prevents expansion. That is a big problem because inside this stocking we have the femur and blood vessels, if the femur is fractured and we have bleeding then this bleeding should produce swelling (like trauma at the back in the anterior abdominal wall and in the upper limb; we have swelling). Now, can the thigh and the leg swell? The answer is no because of the fascia lata. Since it does not swell, its going to compress blood vessels, therefore blood will be cut off for the lower limb, for the distal part of
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fracture and tissues will die in few hours therefore its very dangerous. Its life saving. Once we receive people coming in an ambulance from a car accident and we see different positions of the foot and the leg, we always immediately go to the thighs and look at them and feel them; because if we just look at them we dont see great difference between the good thigh and the injured one because expansion is going to be very little, so we feel them if one is soft and the other is hard that means there is bleeding and we have immediately to make incisions to relieve the pressure, so the blood can go to the peripheral part of the limb. Thats why we have to know that the lower limb has thick fascia called fascia lata, especially laterally it is very thick and its called the Iliotibial tract. Something which is read and not understood is the fascia here, so let me explain little bit details: Now here is the anterior superior iliac spine comes down attaches to the pubic tubercle, this is what? This is the inguinal ligament which has a fiber that will attach to the iliac crest which is pectineal ligament. Now, the inside of the abdominal cavity has a fascia lining the anterior abdominal wall which is fascia transversalis. The doctor started drawing; Fascia transversalis will come this way here, at the mid inguinal point will come down as femoral sheath and it has septa dividing it into compartments, this one is femoral canal, a hernia may come in this way, this is the femoral vein This is the femoral vein and the femoral artery is lateral and outside the sheath is the femoral nerve. So, theres an extension of the transversus fascia into the lower limb of the femoral sheath and the femoral sheath will stop and the blood vessel will continue.
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Now fascia lata attaches to the iliac crest and comes down and attaches to the inguinal ligament and comes down this way. Here it has an opening its called the saphenous opening. Look at the circle, this circle curves medially then up and then deeper to the superficial fascia; this is called saphenous opening. Its a little bit confusing when you read it in the book. We dedicate ourselves to muscles, which muscle are you interested in? Gluteal region (here the doctor was using his slides to explain so in order to understand what hes talking about, you can use GetBodySmart.com ) Now we look posteriorly, this is another way of studying muscles, which muscle is this? This is gluteus maximus coming from iliac crest. This is sacrum, this is coccyx and then ligaments and fibers will do what? Will come down posteriorly and laterally to be inserted in the Gluteal tuberosity and upper part of linea aspera, this is the great extensor. If we take off the gluteus maximus, we will see this muscle, coming from more anterior part of the iliac crest curling around the gluteus surface and inserts on gluteal tuberosity and what? Partly undercover of gluteus maximus. So if we take gluteus maximus reflected medially you will see most of gluteus medius then If we lift gluteus medius we will see this muscle; gluteus minimus. Gluteus minimus totally covered by gluteus medius,; you cannot see the minimus unless you reflect. And gluteus medius is partly covered by gluteus maximus. Now, when you go to the lab and you see a muscle here, most students will say this is gluteus maximus. This is not, this is gluteus medius.
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This is an extensor (the maximus), midius and minimus are the great abductors; the great stabilizers of the pelvis. In this area, gluteal muscles (Here the doc pointed at the three gluteal muscles) Then we have this muscle here, a very good land mark, it comes from the ant. surface of the sacrum and gets out of the pelvis; starts from the ant surface of the sacrum one on the right and one on the left comes out of the pelvis through the greater sciatic foramen and inserts on the greater trochanter. This is called the piriformis (from Latin piriformis = "pear shaped"). The function of this piriformis is abduction, whether it is lateral or medial rotator it depends on whether its inserted ant. or post. If it's inserted Ant. = medial rotator If it's inserted Post. = lateral rotator So thats a land mark we use it to identify the sciatic Nerve. There is another muscle for identifying the sciatic nerve which originates from the obturator membranem comes through sciatic notch and inserts on greater trochanter this is called obturator internus. We see a tondon here. This is the obturator internus, you see the sciatic nerve comes from below the piriformis muscle. This is the obturator internus and we have two muscles attached to obturator internus: sup. and inf. gemellus these are not very important. When you inject intramuscular injection in the gluteal region, you have to divide this region into four quadrants. You always inject in the upper outer quadrant; because if inject on the lower medial or at the point of transactional of these lines (the 2 lines that made the 4 quadrants), you will

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injure the sciatic nerve and we dont want that because the sciatic nerve involves the muscles of the post. part of the thigh and all muscles below the knee.

Look at this muscle above, what is the shape of this muscle? (Quadrates) Its origin is ischial tuberosity and its insertion is quadrate tubercle near the greater trochanter and intertrochanteric crest of femur. This is the quadratus femoris. What does it do? It pulls the femur towards the acetabulum, so it is an adductor (also lateral rotator because its posterior).This is how we study the muscles. If you look at the gluteus muscles (mind map); there is the gluteus maximus (the great extensor). What does it do? >>> Extends >>> lateral rotator >> because its posterior. Gluteus medius and minimus abduct and medial rotation

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These are the quadratus femoris and the piriformis (reading from the mind map). Obturator interus is not a very important muscle. Tensor fascia lateral >> the thickest most lateral part of fascia lata is the iliotibial tract and it is attached to muscle. Anterior muscles of the thigh have two groups (Refer to getbodysmart.com). The great extensors of the knee (four muscles) they come collect together and insert on one tendon called quadriceps tendon, four muscles each has its own origin but they collect in one tendon called the quadriceps tendon. Inside this tendon theres the patella which is a sesamoid bone and then the tendon continues to be inserted into the tibial tuberosity and then its called patellar tendon (above the patella its called Quadriceps tendon below its called patellar tendon) This is the great extensor of the knee plus other muscles, for example, the Sartorius. This is not an extensor; it is a flexor because it inserts post. and it flexes the hip. It is called tailors muscle (because when tailors sit down and put a piece of cloth they sit like this >> flexion of the knee and flexion of the hip and lateral rotation of the hip<< *Medial rotation when the ant. becomes medial *Lateral rotation when the ant. becomes lateral The Sartorius muscle is important; it has sub-sartorial canal below it (femoral artery and femoral vein). And there is an opening of the big muscle adductor magnus, adductor magnus are going to show you this muscle. This is the place where the blood vessels change from the anterior part of the thigh to the posterior part.

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Now on the practical, you can put your hand behind the Sartorius and go down, you can feel the tendon of adductor magnus. What is this muscle? It comes from the ant. surface of the femur, medial side, lateral side and intermascular septae, comes down and insert to this tendon here which is Quadriceps tendon which includes the patella and then comes patellar tendon. This is one of the extensors of the knee. What about this muscle here? It originates from this interrupted line (Linea aspera) medial septum and joins the quadriceps tendon but at the same time it does not join here (the beginning of the tendon), it joins the tendon and THEN the medial side of the patella for a very good reason which I will be telling you in moments.

a. Vastus Medialis

b. Vastus lateralis
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This is the big muscle called vastus intermedias, here vastus medialis and here vastus lateralis. They join the quadriceps tendon. Look at the difference between vastus medialis and vastus lateralis, what do you find? You will find that the lower fibers of the vastus lateralis join the quadriceps tendon. While the lowest fibers of the vastus medialis joins the quadriceps tendon and the patella. You know why? Because when you apply pressure on the patella, the patella will go lateral, the patella must be in the midline to do its mechanical action in function of the knee, so to correct this lateral movement, you need to pull the patella medially. So what do you do? You extend the fibers of the vastus medialis lower down. Now there are people who are going (for some reasons) to have weak vastus medialis will come and say look when I walk my patella clicks lateral that is because they have a problem in the vastus medialis or its nerve supply. The last muscle is this one, which is quiet different because its bipennate. Its called rectus femoris. It takes origin from two points one point is above the acetabulum therefore physiologically it has a weak action on the hip and a very good action on the knee because of the distance. When you collect the up-mentioned 4 muscles together, they'll make the quadriceps muscle.

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This is the Origin and insertion of the rectus femoris

Doctors are men who prescribe medicines of which they know little, to cure diseases of which they know less, in human beings of whom they know nothing Voltaire

Done By: Hala Shawareb

Very special thanks to Dr. Islam Haddad for helping me

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