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Functional Anatomy of the Lower Limb

Bill Sellers

Email: wis@mac.com

This lecture can be found at:

http://mac-huwis.lut.ac.uk/~wis/lectures/

Following on from my lecture on the upper limb I would now like to treat the lower limb in a similar fashion: moving distally from the pelvic girdle to the foot.

Functional Anatomy of the Lower Limb Bill Sellers Email: wis@mac.com This lecture can be found at:

Figure 1. Pelvic girdle [Aiello & Dean 1990]

The pelvic girdle has two joints: the sacroiliac joint dorsally and the pubic symphysis anteriorly (figure 1). The pubic symphysis is a secondary cartilaginous joint (bone, cartilage, fibre, cartilage, bone) and is basically immobile although during pregnancy it does stretch to allow the pelvic outlet to enlarge during childbirth. The sacroiliac joint is an atypical synovial joint which does allow a small but significant movement. The main movement it allows is called nutation or nodding. This is a forward motion of the top of the sacrum that occurs as the weight of the trunk slides forward at the sacroiliac joint or due to the contraction of muscles like the hamstrings that can cause large rotational forces on the pelvis. It produces an inward motion of the iliac crests and an outward movement of the ischial tuberosities and so also leads to an increase in the diameter of the birth canal.

Figure 2. Muscles acting on the hip The hip joint is a classic ball-and-socket joint allowing

Figure 2. Muscles acting on the hip

The hip joint is a classic ball-and-socket joint allowing flexion, extension, adduction, abduction, and medial and lateral rotation. The hip joint is a much more stable joint than the shoulder since it has a much more substantial bony cup (acetabulum ) for the head of the femur and has a more restricted range of movement. Even so the short lateral rotators (obturator internus, the superior and inferior gemelli, piriformis, quadratus femoris) do have an important stabilisation rôle. The prime movers can be grouped into four compartments: anterior, posterior, medial (adductor) and buttock, and their actions assigned accordingly as flexors, extensors, adductors and abductors. There is of course some overlap with several muscles having multiple actions: for example gluteus maximus acts as a hip extensor when the hip is flexed; and adductor magnus is also a hip extensor as well as an adductor. In addition muscles in the hamstring group (biceps femoris, semitendinosus and semimembranosus ) are also knee flexors and the quadriceps muscles (rectus femoris, vastus medialis, intermedius, lateralis) are knee extensors. Such muscles cross more than one joint and this seems to be important in the lower limb for energy transfer between segments and to keep the muscles operating and their optimal length.

Figure 2. Muscles acting on the hip The hip joint is a classic ball-and-socket joint allowing

Figure 3. Ligaments of the hip joint

The hip joint itself is also stabilised by the actions of the iliofemoral , ischiofemoral and pubofemoral ligaments (figure 3). These wind around the neck of the femur in such a way that they tighten in extension. This drives the head of the femur firmly into the acetabulum preventing dislocation and also limits hip extension. The pubofemoral ligament, because of its position, also limits abduction. Other movements of the hip (flexion and adduction) are

limited by muscle stretch. Flexion is limited by the hamstrings and since these are lax when the knee is flexed considerably more hip flexion is possible if combined with knee flexion. The hip joint is very stable and is almost never dislocated in a healthy adult. The one occasion where it can occur is in car accidents where the victim is sitting in the from seat and the force of the impact forces the femur posteriorly. The flexion of the hip means that the ligaments are lax, and the direction of the force pushes the head of the femur towards the weakest and shallowest part of the acetabulum.

limited by muscle stretch. Flexion is limited by the hamstrings and since these are lax when

Figure 4. Knee joint capsule

The knee joint is considerably more complex than the hip joint. It is generally described as a hinge joint but this does not do it justice! As can be seen from figure 4 the synovial membrane is a horseshoe shape with the gap posteriorly. Within the synovial cavity are two articular disks: both are attached to the surrounding joint capsule but the lateral meniscus is much more mobile. You can also see from figure 4 that there are a large number (approximately 15) of bursae associated with the knee joint. They act to reduce the friction between the various structures (tendons, muscles, bone) associated with the joint.

limited by muscle stretch. Flexion is limited by the hamstrings and since these are lax when

Figure 5. Cruciate ligaments

Within the joint capsule are two important intracapsular ligaments: the cruciate ligaments (figure 5). These are names by their relative origins on the tibia and cross before inserting in the opposite order between the femoral condyles. The anterior cruciate (which is the one that is most commonly injured) becomes taught during extension and posterior displacement of the femur thus is restricts these movements and can be injured in forced hyperextension. The posterior cruciate prevents the opposite movements: hyperflexion and anterior displacement of the femur.

Within the joint capsule are two important intracapsular ligaments: the cruciate ligaments (figure 5). These are

Figure 6. Extracapsular structures.

Figure 6 shows the extracapsular structures. This includes two other important ligaments, the medial and lateral collateral ligaments, that stabilise the joint against lateral movements. Once again the tendons of the various muscles that cross the joint are also important in stabilisation.

Within the joint capsule are two important intracapsular ligaments: the cruciate ligaments (figure 5). These are

Figure 7. The shapes of the articular surfaces of the knee joint

When we look in detail at the shapes of the articular surfaces we can begin to see why the knee cannot be described as a simple hinge joint (figure 7). The lateral femoral condyle is smaller than the medial condyle and its articulation with the corresponding tibial condyle is more circular. The cross-section of the femoral condyles is not uniformly circular with a rounded posterior surface but a flattened anterior surface. The medial tibial condyle is described as more “ball and socket-like”.

Figure 8. The knee locking mechanism These features interact to produce the locking mechanism of the

Figure 8. The knee locking mechanism

These features interact to produce the locking mechanism of the knee. This mechanism means that the knee can remain in full extension with no muscular activity which makes standing much more comfortable and energy efficient. In figure 8 we can see how it works. As we start to extend a flexed knee initially both the medial and lateral femoral condyles are able to roll on the tibia plateau. However because the lateral condyle is smaller the flattened anterior part of the articular surface comes into contact sooner on this side. The movement there becomes a sliding movement and 30° before full extension the joint becomes close packed on the lateral side. The only way the knee can continue to extend is for the tibia to laterally rotate allowing the medial condyle of the femur to continue to rotate and then slide itself when its own flattened surface comes into contact with the tibia. The end result of this rotation is that the anterior crucitate is tightened and the knee joint is locked into extension with the flat part of the femoral condyles tightly pulled onto the tibia. The knee is stable in this extended position and in fact the tibia needs to be medially rotated by a small muscle called popliteus before flexion can occur. Note in this description popliteus unlocks the knee joint by medially rotating the tibia. This could equally well be described as laterally rotating the femur if the tibia was fixed which would be the case in normal walking for example.

Figure 8. The knee locking mechanism These features interact to produce the locking mechanism of the

Figure 9. Medial aspect of the leg

Moving distally we can start to see similarities between the leg and the arm musculature. Figure 9 shows the medial aspect of the leg and we can see the flexor and extensor compartments. During development the leg is rotated 180° in the thigh region such that in the anatomical position the distal flexors are now on the dorsal aspect (flexors of the knee and

ankle joints). Arm flexors are always ventral. In an attempt to avoid confusion flexion and extension of the ankle have alternative names: plantarflexion and dorsiflexion.

ankle joints). Arm flexors are always ventral. In an attempt to avoid confusion flexion and extension

Figure 10. Lateral aspect of the leg

There is also an additional compartment on the lateral side (figure 10) containing the peroneal muscles (peronius longus, brevis and tertius).

ankle joints). Arm flexors are always ventral. In an attempt to avoid confusion flexion and extension

Figure 11. Anterior aspect of the leg

As can be seen in figure 11 the peroneal muscles laterally and the tibialis muscles medially produce two new movements known as eversion and inversion . These are not really equivalent to supination and pronantion even though they do all involve rotation around the longitudinal axis of the limb. Supination and pronantion would have to occur by movement of the tibia and fibula which does not occur. Evertion and invertion take place between the bones of the foot and are more equivalent to the small amount of rotation that can take place at the midcarpal joint.

Figure 12. Sole of the foot The muscles of the lower leg are equivalent to the

Figure 12. Sole of the foot

The muscles of the lower leg are equivalent to the extrinsic muscles of the hand and within the foot itself are the equivalents of the intrinsic muscles. In fact, as shown in figure 12, there are as many intrinsic muscles in the foot as in the hand and the movements they produce are equivalent (flexion, extension, abduction and adduction of the toes). However the degree of movement available and the independent control is much less although with training the dexterity of the feet can be greatly enhanced.

Figure 12. Sole of the foot The muscles of the lower leg are equivalent to the

Figure 13. Tibiofibular joints

Figure 13 shows the tibiofibular joints – equivalent but much less mobile than the radioulnar joints. The proximal joint is actually synovial and allows a small degree of rotation although there are no muscles directly producing this action. It occurs to accommodate movements in the talus at the tibiocrural (tibiotalal) joint. The inferior tibiofibular joint is a largely immobile fibrous joint.

Figure 14. Tibiocrural joint The ankle joint, much like the wrist joint is a complex of

Figure 14. Tibiocrural joint

The ankle joint, much like the wrist joint is a complex of several synovial joints. The movements can however be more easily assigned to specific bones. The tibiocrural joint (figure 14) between the distal end of the tibia and the talus (with a small contribution from the fibula on the lateral side) is where most of the flexion and extension takes place. It is stabilised by medial and lateral ligaments. The lateral ligaments are weaker and therefore more commonly damaged in sprains. The anterior part of the talar trochlear (the articular surface of the talus is wider than the posterior part. This means that in dorsiflexion the tibia and fibula are pushed apart tightening the tibiofibular ligaments and stabilising the joint. In plantar flexion these ligaments are lax and the joint is less stable. Ankle injuries often occur when the ankle is fully flexed.

Figure 14. Tibiocrural joint The ankle joint, much like the wrist joint is a complex of

Figure 15. Subtalar joint

The subtalar (talocalcaneal) joint is between the talus and calcaneus and is where the actions of inversion and eversion take place as shown in figure 15. The range of movement is quite small but important for walking and standing on uneven ground.

There are a number of other named joints between tarsal bones (midtarsal joint, transverse tarsal joint, intertarsal joints) and the tarsametatarsal joints but these show relatively little movement. They are a collection of synovial sliding joints with tight ligaments that allow

small movements of the tarsal and metatarsal bones to accommodate uneven grounds. The Metatarsophalageal joints and the various interphalangeal joints are largely equivalent to their homologous counterparts in the hand. The MTP joints allow rather more extension than flexion (the opposite to the hand) but the IP joints allow more flexion than extension exactly as in the hand.

small movements of the tarsal and metatarsal bones to accommodate uneven grounds. The Metatarsophalageal joints and

Figure 16. The arches of the foot [Snell 1986]

One important feature of the foot are the arches. The bones of the foot do not lie flat on the substrate but are maintained as arches with only the ends of the arch in contact with the ground. Anatomically three arches have been described and these are illustrated in figure 16 but only the medial arch (and perhaps to some extent the lateral arch) has any real function. The arches of the foot convert the foot from a rigid lever to a sprung platform and this has noticeable effects on running efficiency and performance since it allows the foot to store elastic energy from one stride to the next.

small movements of the tarsal and metatarsal bones to accommodate uneven grounds. The Metatarsophalageal joints and

Figure 17. Mechanisms to maintain the arches

There are several anatomical mechanisms that act to maintain the arches of the foot illustrated in figure 17. The first is the shape of the bones and the orientation of the joints which forces them into an arch shape. This interlocking has to be maintained by external

ligaments both close to the joint (such as the so-called spring ligament between the calcaneus and the navicular) and as a truss acting at the base of the arch. This truss is also helped by the plantar aponeurosis. The centre of the arch is also actively supported by the direct action of certain muscles. If these mechanisms fail then the person is described as having fallen arches or flat feet.

Bibliography

Aiello L, Dean C. An introduction to human evolutionary anatomy. 1990 London: Academic Press.

Snell RS. Clinical anatomy for medical students. 1986 Boston: Little, Brown.