1. Osteology, ligaments, gluteal musculature
Lower Extremity
Osteology, ligaments, gluteal musculature

2. Which of the following is most likely pertaining to the two pelves depicted?
The left is male and the right is female
The right is male and the left is female
The left is from a younger person than the right
The right is from a younger person than the left A

3. LE Unit Overview Superficial fascia, veins, lymph
Skeletal structures / joint surfaces
Ligamentous support
Musculature / vasculature
Nerves
Forces and injuries
Again building from inside out
Potentially most important region / unit for physical therapists
Highest forces, mobility still essential for function -> precarious balance between stability and mobility
Injuries common
Also, nerve supply is farthest from the brain (the source)
Spinal cord injuries, nerve injuries, affect leg and mobility function

4. Objectives
Describe the gross anatomy for each system (circulatory, muscular, nervous, and skeletal) in the lower extremity.
Integrate the systems to discuss the lower extremity stability and mobility functions.
Analyze common injuries in the lower extremities.
For each muscle, describe how the attachment sites result in an action around a joint.
For each muscle, identify the innervation (peripheral nerve and nerve roots).
Pulled from syllabus

5. LE Overview
Joints:
hip – ball and socket (reinforced with ligament… tbd)
knee – modified hinge (hinge with rotation)
tibiotalar and talofibular (ankle) – hinge
names of joints and ligaments = tibia wins, talus comes in second, fibula loses
talocalcaneal (subtalar) – condyloid
Common understanding: ankle joint is commonly thought of as the tibiotalar, talofibular, and subtalar joints together.
Musculature:
extensors for each joint are powerful and essential
Neurovasculature:
tends to run on the flexion side for protection and reduced stretching
femoral artery and nerve anterior to hip
popliteal artery and sciatic branches posterior to knee
sciatic nerve is an exception – commonly in trouble!!
tibial nerve and posterior tibial artery are posterior to ankle
Line of force:
straight through each joint ideally – postural variations, skeletal variations, muscular strength/weakness may change the normal line of force (tbd)
hip flexors, ankle plantarflexors regularly active like the back extensors

6. For reference

7. Fascia latae, crural fascia
holds muscles in place, creates pressure for returning blood to the heart
Superficial veins – venous drainage of extremities is both superficial and deep
medium veins, with valves
not necessary for proper drainage – great saphenous is sometimes used in surgeries as a vessel replacement

8. Top is R leg, bottom is R leg
Intermuscular septa – bone to superficial fascia
Reduce muscles rubbing against each other, serve as attachment sites (short head of bicep for example), maintain pressure for each compartment
medial and lateral in thigh
anterior, posterior and transverse in leg

9. Superficial veins and lymphatic flow
Great saphenous dives deep in femoral triangle
Small saphenous dives deep in popliteal fossa

10. During development, three bones are very distinct
notice: separation between ilium and pubis/ischium, and femoral head growth plate

11. Coxae (Pelvis) Obturator Membrane Anatomical Position
Coxal joint, coxa vara, coxa valga
Obturator membrane is tough but thin and serves as an attachment site for two muscles: ??
obturator internus
obturator externus
Also allows passage of obturator nerve which innervates ???
adductors
Asis and pubic tubercle should vertically line up
Anatomical Position

12. True vs. false pelvis – true pelvis is cavity for reproductive organs, bladder, and rectum. False pelvis is actually in the abdominal region but serves as essential surface area for hip muscles – iliacus, glutes, TFL
Side note: angle of sacrum, sacral promontory

13. Sacroiliac Joint - Ligaments
Primary:
Anterior Sacroiliac
Interosseus
Short and long posterior sacroiliac
Secondary:
Sacrotuberous
Sacrospinous
Anterior sacroiliac – thickened joint capsule
this part of sacroiliac joint is also strengthened by piriformis and psoas
Interosseus ligament – short, strong fibers between sacrum and ilium along margins
strongest bond
Posterior sacroiliac ligaments (short and long)
short – extensive but thin, many fibers bind with interosseous
long – 3rd-4th sacral segments -> PSIS
Sacrotuberous – does not cross joint!
PSIS -> ischial tub
Sacrospinous – does not cross joint!
sacrum -> ischial spine (creates greater and lesser sciatic foramen for piriformis & sciatic, and obturator internus muscles)

14. Sacroiliac Joint - Motions
Anterior Tilt and Posterior Tilt
Nutation (sacral flexion) and Counternutation (sacral extension)
Stability vs. Mobility
Nutation is more stabilizing – stretches interosseous and sacrotuberous ligaments, compresses joint

15. Nutation and the effects of sacrotuberous and sacrospinous ligaments

16. None of these would be stretched
Your patient has significant posterior tilt in his pelvis but when palpating, you notice his sacrum is nutated. What ligament would be most stretched?
Posterior Sacroiliac
Anterior Sacroiliac
Sacrospinous
None of these would be stretched C

17. Your female patient has anterior pelvic tilt due to excessive lumbar lordosis. Which of the following is TRUE?
She must be in nutation
She must be in counternutation
She is at risk for posterior disc herniation
None of these D

18. Femur line of force
Condyles are horizontally in line, shaft is angled inferomedially, force over time will impact the angle of inclination (of neck of femur)

19. Femur: Torsion Angle Averages: 7 degrees in males
12 degrees in females
Discussion question:
What effect does this difference have?
Angle of acetabulum matches torsion angle

20. Femur: Angle of Inclination
Change in bone structure over lifespan

21. The part of the femur that is most susceptible to fracture in conjunction with osteoporosis is:
mid-shaft.
medial condyle.
along the intertrochanteric line.
neck.
intercondylar area. D

22. In the following radiograph of the hip, the arrow points to the:
greater trochanter.
lesser trochanter.
ischial spine.
femoral neck. B

23. Coxa vara refers to:
an abnormal decrease in the angle between the shaft of the femur and the tibia.
an abnormal decrease in the angle between the head and neck of the femur and its shaft (angle of inclination).
an abnormally short distance between the anterior superior iliac spine and the center of the acetabulum.
an abnormally short distance between the iliac crest and the greater trochanter.
an abnormally short femur. B

24. Hip ligaments:
iliofemoral (Y) – covers anterior femoral head
ischiofemoral – covers posterior femoral head
pubofemoral – covers inferior femoral head
All resist distraction, medial rotation, and extension of hip
Strongest joint position is extended & medially rotated
Ligament of head of femur (carries an artery)
Subluxation of hip can result in avascular necrosis

25. Hip musculature Gluteal region Anterior hip Gluteus maximus Iliopsoas
Gluteus medius
Pectineus
Gluteus minimus
Sartorius
TFL
Rectus femoris
Piriformis
Obturator internus
Gemelli
Obturator externus
Quadratus femoris

26. Gluteus maximus
ilium, sacrum -> IT band (3/4) & gluteal tuberosity (1/4)
¾ of this muscle crosses the knee joint
strongest hip extensor from flexed position
Gluteus medius
ilium -> greater troch
hip abductor
line of pull – active during walking
Trendelenburg test, Trendelenburg gait
Gluteus minimus
ilium -> anterior greater troch
similar action to medius, also internally rotates in flexed position
TFL
anterior iliac crest -> IT band
counteracts glut max pulling posteriorly

27. Piriformis
anterior sacrum -> greater troch
through greater sciatic foramen
when tight and short, can impinge sciatic nerve in the greater sciatic foramen
Obturator internus
obturator membrane -> trochanteric fossa
Gemelli
superior: ischium above OI (spine) -> fossa
inferior: ischium below OI (tuberosity) -> fossa
Obturator externus
obturator membrane -> fossa
Quadratus femoris
ischial tuberosity -> intertrochanteric crest

28. Bursa Ischial Obturator internus Trochanteric Gluteofemoral
Bursa = sac of synovial fluid to reduce friction of muscles on bones or for cushioning from external forces

29. Iliopsoas
Psoas from lumbar vertebrae -> lesser trochanter
iliacus from iliac fossa -> lesser trochanter
strong hip flexors
cross sacroiliac & hip joints
psoas can cause low back pain if tight and short
Pectineus
adductor muscle – supports anterior hip
Sartorius
ASIS -> pes anserine
weak support for anterior hip joint
Rectus femoris
AIIS -> quad tendon
Hip flexion accomplished mostly with iliopsoas, Sartorius and rectus femoris.
Flexion and extension are vastly different

30. Important vasculature:
Femoral artery (no blood supply around posterior hip)
branches supply pelvis
Profunda Femoris artery
branches supply head of femur, trochanters, shaft of femur
Lateral and medial circumflex femoral arteries (both branch off profunda)
anastomosis – when arteries connect together to supply blood from multiple sources, insurance policy against reduced blood flow
Popliteal artery
Geniculate arteries – more anastomoses
Tibial arteries

31. The iliotibial tract is the conjoint distal aponeurotic attachment of which of the following pairs of muscles?
gluteus medius and minimus
gluteus medius and maximus
gluteus maximus and the tensor of the fascia lata
the tensor of the fascia lata and rectus femoris
rectus and biceps femoris C

32. Which of the following is incorrect pertaining to the great saphenous vein?
It passes posterior to the medial malleolus.
It passes posterior to the medial condyle of the femur.
It drains into the femoral vein.
It has a nearly uniform diameter because blood is shunted to deeper veins.
It traverses the saphenous opening in the fascia lata. A

33. For Monday
Readings in Moore
Study for lab quiz