JOINTS OF LOWER LIMB

Dr Yasrul Izad Abu Bakar

Faculty of Medicine, UniSZA
 Early morning MVA
• Unable to abduct the
thigh

• Affected limb appears

shorter

• Medially rotated
 Learning outcome
• Describe the joints of the lower limb ( Hip joint, knee
joint, tibiofibular joints, ankle joint and joints of foot)
with regards to the:

i. Bones forming the joint

ii. Ligaments of the joint
iii. Important relations of the joint
iv. Movements at the joint and muscles producing them
v. Nerve and blood supply of the joint

• Discuss the clinical aspects.

 Outline
1. Hip joint

2. Knee joint

3. Tibiofibular joints

4. Ankle joint

5. Joints of the foot

 Classification of joint

Structural Classification Functional

• Presence of joint cavity Classification
• Type of connective tissue that Degree of movement
binds the joint
Synarthrosis
(Immovable)
Fibrous joint Synovial joint
- No cavity - Has a cavity Amphiarthrosis
- Bound by - Bound by (Partially movable)
fibrous tissue articular capsule Diarthrosis
(Freely movable)
Cartilaginous joint
- No synovial cavity
- Bound by cartilage
Hip Joint
 Hip joint
Forms connection
between pelvic girdle &
lower limb
Structural classifications:
• SYNOVIAL JOINT (ball &
socket)
Functional classifications:
• DIARTHROSIS (multi-
axial)
The 2nd most movable
joint after shoulder joint.
 Hip Joint: Articulations
Synovial articulation
between: Head of femur Acetabulum

Head of femur

Acetabulum of
hip bone
 Articulation surface
Head of femur:
Fovea capitis

• Forms approximately 2/3

of sphere

• All covered with hyaline

cartilage except at fovea
capitis (pit for ligament of femoral
head)
Ligament of
femoral head
 Articulation surface Lunate surface

Acetabulum: Acetabular
labrum
• Hemispherical hollow on lateral part of hip
bone
• Formed by fusion of ischium, ilium, pubis

Tranverse
• Lunate surface: semilunar articular part (lined acetabular
by hyaline cartilage) ligament

• Acetabular labrum: fibrocartilagenous collar Lunate surface

attaches to the acetabular rim
Acetabular
 Deepens the acetabulum
rim
 Prevent the head of the femur to slip out of place
(subluxation of the femur)

• Acetabular notch: bridged by transverse

acetabular ligament Acetabular
fossa

• Acetabular fossa: non-articular part Acetabular

notch
 Hip Joint: Joint capsule
• Hip joints are enclosed by strong Fibrous capsule
+ ligaments
joint capsule

Joint capsule:
• Formed by fibrous layer Synovial
membrane
(external) & synovial membrane
(internal)

Proximal attachment -
a. Just peripheral to acetabular
rim
b. Transverse acetabular ligament

Distal attachment
a. Intertrochanteric line
b. Root of greater trochanter
 Hip Joint: Ligaments
• 5 ligaments:

1. Iliofemoral ligament

2. Pubofemoral ligament

3. Ischiofemoral ligament

4. Transverse acetabular ligament

Anterior view
5. Ligament of the head of femur
 Iliofemoral Ligament
• Lies anterior & superiorly

Iliofemoral
• Strongest ligament in the body ligament

• Aka Y-shaped ligament of

Bigelow

• Prevent trunk from falling

backward (hyperextension of hip Anterior view

joint) when standing

 Pubofemoral Ligament

• Lies anterior &

inferiorly Anterior view

• Prevent over-abduction
of hip joint

Pubofemoral ligament
 Ischiofemoral Ligament
Ischiofemoral ligament
• Covers the joint
posteriorly

• Weak compared to
others

Posterior view
 Ligament of femoral head
• Laterally attached to fovea
capitis

• Medially attached at
transverse acetabular
ligament & acetabular
notch

• Little importance in
strengthening the hip joint

*Transmits acetabular branch of

obturator artery to the head of
femur
Ligament of femoral
head (Cut)
 Transverse acetabular ligament
• Part of acetabular
labrum that bridges the Transverse
acetabular notch acetabular
ligament

• Transverse acetabular
ligament converts
acetabular notch into
foramen:
Transmit acetabular
vessels & nerves to the
joint
 Hip Joint: Blood supply

1. Obturator artery

2. Circumflex femoral arteries:

1. Medial circumflex femoral artery
2. Lateral circumflex femoral artery
Forms cruciate
3. Gluteal arteries: anastomosis

1. Superior gluteal artery

2. Inferior gluteal artery
 Hip Joint: Blood supply
Retinacular
• Medial & lateral circumflex arteries

femoral arteries:

Arise from deep artery of the

thigh Medial
circumflex
femoral a.
Form a circle around the neck
of femur
Lateral Deep artery
circumflex of thigh
Gives rise to retinacular femoral a.

arteries that supply the intra-

capsular part of the neck &
major part of the head
 Hip Joint: Blood supply
Area near the fovea
capitis is supplied by:

Acetabular branches
of obturator artery Obturator
artery
 Cruciate anastomosis
• Anastomosis at the upper Anastomosis

part of the back of femur

• Formed by:
1. Medial circumflex femoral a.
2. Lateral circumflex femoral a.
3. 1st perforating a.
4. Inferior gluteal a.
 Hip Joint: Innervations

Hilton’s law :

• Nerves supplying muscles extending directly

across / moving the joint also innervate the
joint
 Hip Joint: Important relations
• Anteriorly:
illiopsoas
1. Pectineus muscle
Pectineus
2. Iliopsoas Rectus
femoris
3. Rectus femoris

4. Femoral vein

5. Femoral artery

6. Femoral nerve
 Hip Joint: Important relations
• Posteriorly:

1. Deep group of Piriformis

gluteal muscles

Gamelli
2. Sciatic nerve

OI
 Hip Joint: Relations
• Superiorly:
Gluteus minimus &
medius

• Inferiorly:
Medial thigh muscles
 Superior

Posterior
Anterior

Inferior
 Femoral
nerve
Hip Joint: Innervations
1. Anterior aspect: femoral
nerve
Obturator
nerve

2. Posterior aspect: nerve to

quadratus femoris
Superior
gluteal
3. Inferior aspect: obturator nerve

nerve
Nerve to
4. Superior aspect: superior quadratus
femoris
gluteal nerve
 Hip joint: movements
• Diarthrosis

• Movement in 3 axis (multi-axial):

Flexion-Extension (transverse axis)
Abduction-Adduction (AP axis)
Lateral & medial rotation (vertical axis)
Circumduction
 Hip joint: Muscles involve in movements
Movement Chief muscles
Flexion 1. Psoas major (strongest)
2. Anterior thigh muscles
Extension 1. Gluteus maximus (mainly from flexed to standing position)
2. Hamstrings (further extends from standing position)

Adduction Adductors (longus, magnus, brevis)

Abduction 1. Gluteus medius

2. Gluteus minimus

Medial rotation 1. Anterior part of gluteus medius & minimus

2. Tensor fascia latae

Lateral rotation Deep group of gluteal muscles

 Clinical applications
• Dislocation of hip joint:
 Uncommon because articulation is
very strong
 Acquired occurs in MVA (if femoral
head forced out of acetabulum)
 Unable to abduct the thigh
 Affected limb appears shorter
 Posterior dislocation more
common
 Congenital case occurs in 1.5 per
1000 live births

• Femoral neck fractures:

 #NOF
 High-energy impacts e.g dashboard
injury
 Common in >60yo (because of
osteoporosis)
 Often disrupt blood supply to head
& neck of femur – lead to avascular
necrosis
`
 Clinical
application
• Avascular
necrosis
is death of bone
tissue due to a
lack of blood
supply
aka osteonecrosis
can lead to tiny
breaks in the
bone & collapse
KNEE JOINT
 Knee joint - introduction
• Largest synovial joint in the
body

Structural classification:
• Synovial joint:
 Primarily, hinge type (but combined
with gliding, rolling, rotation about a
vertical axis)

Functional classification:
• Diarthrosis
 Knee joint : Articulations
• 3 Articulations: MC femur

LC femur
1. Lateral femorotibial:
Between lateral condyle of femur
& lateral condyle of tibia

2. Medial femorotibial:
Between medial condyle of MC tibia
LC tibia
femur & medial condyle of tibia

3. Femoropatellar :
Between femoral condyle &
patella

*Fibula is not involved in knee

joint
 patella
Femoropatellar:

• Between femoral
condyle & patella
Femoral
condyle
 Knee joint : capsule
• Consist of typical external
fibrous layer & internal
synovial membrane
Synovial
• Loose & thin membrane

Fibrous capsule attachment:

• Superiorly, 1 cm above the
articular margin of condyle
(femur)

• Inferiorly, 1cm beyond the Fibrous

margin of superior articular capsule
surface of tibia (tibia plateu)
 Fibrous capsule
• Anteriorly replaced by:

1. Quadriceps femoris Quadriceps

femoris
tendon tendon

2. Patella Patella

3. Patellar ligament
(Ligamentum patellae)
Ligamentum
patellae
 Knee joint : Ligaments
• Extra-capsular/capsular ligaments (external ligaments)
1. Patellar ligament
2. Tibial (medial) collateral ligament
3. Fibular (lateral) collateral ligament
4. Oblique popliteal ligament
5. Arcuate popliteal ligament

• Intra- articular ligaments (internal ligaments)

1. Anterior cruciate ligament
2. Posterior cruciate ligament
3. Menisci
 External ligament: Patellar ligament
Patellar ligament:

• Continuation of the quadriceps

femoris tendon (central part) Quadriceps
inferior to patellar femoris
tendon

• Attachment:
 Superiorly : apex of patella
 Inferiorly : tibial tuberosity

• Related to: Patellar

 Superficial & deep infrapatellar ligament
bursae
 Infrapatellar fat pad
 Patellar ligament

Superficial
(subcutaneous)
infrapatellar bursa

Infrapatellar Deep
fat (subtendineous)
pad infrapatellar bursa
 External ligament: MCL
Medial (tibial) Collateral
ligament:

• Both collateral ligaments are

tighly stretched in fully flexed
knee

• Attachments:
Superiorly:
medial epicondyle of
femur
Inferiorly: MCL
medial tibia
 behind the attachment of
sartorius, gracilis &
semitendinosus tendons
Posterior view
External ligament: MCL

MCL

Semitendinosus

Gracilis

Sartorius
 External ligament: LCL
Lateral (fibular) Collateral
ligament (LCL):
LCL

• Attachments:
Superiorly:
Lateral epicondyle of femur

Inferiorly :
Head of fibula
Separated from lateral
meniscus by tendon of Popliteus
popliteus tendon

Posterior view
 External ligament: OPL
Oblique popliteal
ligament (OPL):
• Expands from OPL
semimembranosus
tendon
Semimembrinosus
tendon
• Attached to the:
Lateral condyle of
the femur

Posterior view
 External ligament: APL
Arcuate popliteal Posterior view
ligament (APL):

• Arise from head of fibula 

APL
arches over the tendon of
popliteus  attached to
the posterior border of the
intercondylar area of tibia

• Strengthens joint capsule

posterolaterally

Popliteus muscle
 Internal ligament: Cruciate ligaments
• Crisscross within the knee joint Cruciate ligaments
capsule

• Maintain anteroposterior stability

of knee joint

Include:
1. Anterior cruciate ligament (ACL)
2. Posterior cruciate ligament (PCL)

• Cruciate = cross-shaped
Anterior view
Internal ligament: Cruciate ligaments
• Named according to PCL
attachment on tibia

• Ant. Cruciate Ligament:

Anterior part of intercodylar
area (tibia) to posterior part
of lateral condyle of femur

• Post. Cruciate Ligament: ACL

Posterior part of
intercondylar area (tibia) to
anterior part of medial
condyle of femur
ACL PCL ACL

ANTERIOR VIEW
POSTERIOR VIEW
 Internal ligament:
Menisci
• Fibrocartilaginous C-shaped
disc
Lateral
• Functions: meniscus
Medial
Shock absorber meniscus

Help lubricating the joint

cavity
Give propioceptive
impulse because it has
nerve supply

• 2 menisci:
1. Medial meniscus
2. Lateral meniscus
Interior of knee - superior view
 Medial Meniscus

• Attached to the joint MCL

capsule & medial

collateral ligament

Medial
meniscus

Interior of knee - superior view

 Lateral Meniscus
• Nearly circular
Popliteus tendon

LCL
• Unattached to joint capsule
& lateral collateral ligament
(separated by tendon of
popliteus)

• More mobile than medial

meniscus Lateral
meniscus

Interior of knee - superior view

Menisci
Menisci are interconnected anteriorly
by transverse ligament of knee

Transverse ligament
Knee joint : Blood supply
• Anastomoses around knee
joint:
Descending
branch Descending
1. Femoral artery (FA) of LCFA genicular
 Descending branch of of FA

lateral circumflex femoral

artery (LCFA)
 Descending genicular
artery Genicular
branches of
PA
2. Genicular branches of
popliteal artery (PA)
Anterior tibial a.
3. Anterior tibial artery
 Knee joint : Nerve
supply
• 3 nerves:

1. Femoral nerve

2. Obturator nerve

3. Tibial & common

fibular nerve
 Knee joint : Movement
Movement Muscles involved
Flexion 1. Hamstring muscles
2. Sartorius, gracilis
3. Gastrocnemius

Extension Quadriceps femoris

Locks knee into full extension Gluteus maximus

(by way of iliotibial tract)
(The last 30 degree of extension 
medial rotation occur)

Unlocks full extension and 1. Tensor fasciae latae

start flexion 2. Popliteus
(pulls on lateral condyle of femur causing it
(Initial stage of flexion  lateral rotation to rotate laterally)
occur)
 Knee joint : Locking & unlocking
• During standing: knee joint is locked into
position (thus, reduce amount of muscle effort to maintain the standing
position)

• Locking:
Due to medial rotation of femur during the last
stage of extension
When knee is locked:
Knee joint is rigid
All ligaments are taut
 Clinical application
• Injuries to meniscus:
 Occurs in slightly flexed knee
 Can be either separated from
the capsule / torn

 Medial meniscus is more

vulnerable to injury because:
It is fixed to MCL
Pain on medial rotation of
tibia (passive)

 Lateral meniscus:
Does not fixed to LCL
Protected by popliteus
Pain on lateral rotation of
tibia
 Clinical application
• Injuries to cruciate
ligaments:
Injury to ACL is
more common
ACL injury is due to :
violent
hyperextension of
the knee & anterior
dislocation of tibia
PCL injury due to
posterior
dislocation of tibia
 Tibiofibular joint

Superior tibiofibular joint – (synovial)

Inferior tibiofibular joint – (syndesmosis)
 Superior tibiofibular joint
• Synovial joint (plane)

• Articulation between:
 Head of fibula
 Lateral condyle of tibia

• Capsule strenghtened by : Sup.

 Ligament of fibular head Tibiofibular
joint

POSTERIOR VIEW
 Inferior tibiofibular joint
• Fibrous joint
(syndesmosis type)

• Fibrous made up from

the combination of: ATL

1. Interosseous
membrane
2. Anterior & posterior
tibiofibular ligament Inferior
view
(ATL & PTL)

PTL
Ankle (talocrural) joint

Structural classification:
Synovial joint (hinge)

Functional classification:
Diarthrosis
 Ankle joint: articulations
• Between the distal end of tibia ,
fibula & talus

• Upper articulation surface:

1) Lower end of tibia
2) Medial malleolus (tibia)
3) Lateral malleolus (fibula)
• Lower articulations surface:
4) Talus

• Movement: dorsiflexion &

plantarflexion
 Ankle joint: Medial (Deltoid) Ligament
• Joint capsule is reinforced medially Post. tibiotalar
by strong deltoid ligament
(medial ligament of ankle) Ant. tibiotalar

• The deltoid ligament proximally

attached to medial malleolus Tibionavicular

• Consists of:
1. Tibionavicular
2. Tibiocalcaneal
3. Posterior tibiotalar
Tibiocalcaneal
4. Anterior tibiotalar
 Ankle joint: lateral ligament
• Weaker than medial Ant. talofibular
• All attached to lateral malleolus Post.
talofibular
• Include:

1. Anterior talofibular ligament

(most frequently injured
ligament in the body)

2. Posterior talofibular ligament

3. Calcaneofibular ligament Calcaneofibular

 Ankle joint:
Innervations
1. Deep fibular nerve
(that supplies the
anterior
compartment Tibial Deep
muscles of the leg) n. fibular
n.

2. Tibial nerve (that

supplies the
posterior
compartment
muscle of the leg)
 Ankle joint: Movements

Movement Chief muscles

Dorsiflexion Tibialis anterior

(anterior compartment of the leg
muscles)

Plantarflexion Soleus (most powerful)

Gastrocnemius
(posterior compartment of the leg
muscles)
Joints of the foot
 Joints of the foot
• Foot joints involve the tranverse
tarsals, metatarsals & tarsal
phalanges joint

• Numerous & classified into: Tarso

metatarsal
1. Subtalar joint joint
2. Transverse tarsal joint
3. Tarsometatarsal joint
4. Intermetatarsal joint
5. Metatarsophalangeal
joint
6. Interphalangeal joint
 Joints of the foot Talus

Transverse tarsal joints: Calcaneus

tranverse
Compound joint formed by 2 tarsal
separate joints: joint

Cuboid
1. Talonavicular part of Navicular
talocalcaneonavicular joint
2. Calcaneocuboid joint

• Transected in standard
method of surgical
amputation of foot
 Foot joints
Subtalar joint:
Talus articulates with calcaneus (talocalcanean joint)
Majority of inversion & eversion occur

Talocalcanean joint:
-Between concave facet of inferior surface of body of
talus with convex facet of the superior surface of
calcaneus
 Clinical application
Club foot (Talipes)
• Congenital
• May involved
subtalar joint
• Foot is inverted
 Self study
• Hallux valgus
• Hammer toe
• Claw toes
• Pes planus
• Ankle sprain
 References
• Clinically Oriented Anatomy. 6th edition. 2010.
Keith L. Moore & Arthur F. Dalley. Lippincott
Williams & Wilkins.

• Gray’s anatomy for students. 2nd edition. 2010.

Richard L. Drake, A. Wayne Vogl & Adam W. M.
Mitchell. Churchill Livingstone Elsevier.

• Atlas of Human Anatomy. 5th edition. 2010. Frank

H. Netter. Saunders Elsevier.

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