NERVE AND BLOOD SUPPLY

OF THE
LOWER EXTREMITY
Mark David S. Basco, PTRP
Department of Physical Therapy
College of Allied Medical Professions
University of the Philippines Manila
OBJECTIVES
 Describe the Lumbar and Sacral Plexus in
terms of:
 Roots,Divisions, and Branches
 Pathway
 Motor and Sensory distribution
OBJECTIVES
 Describe the Arterial and Venous Circulation
in terms of:
 Vessels
 Pathway
 Distribution
 Function
 Decribe the lymphatic circulation of the lower
extremity
NERVES OF THE
LOWER EXTREMITY
LUMBAR Plexus
SACRAL Plexus
IMPORTANT FUNCTIONS
 Sensory innervation to the skin and joints
 Motor innervation to the muscles

 Autonomic innervation to the

LUMBOSACRAL PLEXUS
 The nerves of the lower
limb originate from the
lumbar plexus and the
sacral plexus
LUMBAR PLEXUS
 Formed by:
 Anteriorrami of L1 to L4
 May have contributions
from T12

 Branches emerge from

the anterior, lateral,
and medial borders of
the psoas muscle
ILIOHYPOGASTRIC NERVE
 T12, L1
 MOTOR and SENSORY

 MOTOR
 Musclesof the
abdominal wall
 SENSORY
 Suprapubic region
 Lateral aspect of the
buttocks
ILIOINGUINAL NERVE
 L1
 MOTOR and SENSORY

 MOTOR
 Musclesof the
abdominal walll
 SENSORY
 Upper medial part of
thigh
 Anterior part of scrotum
 Mons pubis and labium
majus
GENITOFEMORAL NERVE
 L1, L2
 MOTOR and SENSORY

 MOTOR
 Genital branch
 Cremater muscle
 SENSORY
 Skkin over femoral
triangle
GENITOFEMORAL NERVE
 Cremasteric reflex
 Efferent stimulation of the skin of the upper
medial thigh in males causes a reflex contraction
of the cremaster muscle
 RESPONSE
 Drawing upward of the ipsilateral testes within
the scrotum
LATERAL FEMORAL CUTANEOUS
NERVE
 L2, L3
 SENSORY
 Skin over the Anterior
and Lateral surface of
the thigh and knee
 Lower lateral
quadrant of buttocks
LATERAL FEMORAL CUTANEOUS
NERVE
 Meralgia Paresthetica
 Entrapment of the
lateral femoral
cutaneous nerve

 Commonly at the
level of the inguinal
ligament

 Complains of pain and

paresthesia in the
area supplied by the
nerve
OBTURATOR NERVE
 L2, L3, L4
 SENSORY and MOTOR

 SENSORY
 Cutaneous branch
 Subsartorial plexus to
supply the medial thigh
 MOTOR
 Gracilis
 Adductor longus
 Adductor brevis
 Adductor magnus
 Pectineus
 Obturator externus
OBTURATOR NERVE

 MOTOR
 Gracilis
 Adductor longus
 Adductor brevis
 Adductor magnus
 Pectineus
 Obturator externus
FEMORAL NERVE
 L2, L3, L4
 Largest branch of the
lumbar plexus
 Enters the thigh via the
femoral triangle
 Supplies all the mucles
of the anterior
compartment of the
thigh
 MOTOR and SENSORY
FEMORAL NERVE
Anterior Division
 Cutaneous branch
 Medial cutaneous nerve of
the thigh
 Intermediate cutaneous
nerve of the thigh
 Motor branch
 Sartorius, Iliacus, Pectineus
 Other branch
 Articularbranch to the
knee joint
FEMORAL NERVE
Posterior Division
 Cutaneous branch
 Saphenous nerve
supplies the medial
surface of the leg, foot
up to ball of big toe
 Motor branch
 Rectus femoris, Vastus
mm
FEMORAL NERVE
PATELLAR Plexus
 Located in front of the knee

 Formed by the terminal branches of the

 LATERAL, INTERMEDIATE,and MEDIAL cutaneous nerve of
the thigh
 INFRAPATELLAR branch of saphenous nerve
FEMORAL NERVE
SUBSARTORIAL Plexus
 Found underneath the sartorius mm

 Formed by the cutaneous branches of:

 FEMORAL
 OBTURATOR
SACRAL PLEXUS
 Lies on the posterior wall
(in front of the piriformis)
 Formed by the:
 Anterior rami of L4 – S3
 Branches leave the pelvis
through the greater sciatic
foramen
BRANCHES TO PELVIC
MUSCLES, PELVIC VISCERA,
AND PERINEUM
PUDENDAL NERVE
 S2 – S4
 MOTOR and SENSORY

 MOTOR
 External anal / urethral
sphincter and muscle

 Cutaneous branch
 Perineum
NERVE TO PIRIFORMIS
 S1 – S2
 MOTOR
 Piriformis
PELVIC SPLACHNIC NERVE
 S2 – S4
 MOTOR and SENSORY
 Pelvic Viscera
 Erection, GI Mobility,
Micturition, Pain from
cervix, bladder,
urethra
LUMBAR PLEXUS

T1 Iliohypogastric
2
L1 ILIonguinal

L2 Genitofemoral

L3 Lateral Femoral
Cutaneous

L4
Obturator

Femoral
BRANCHES TO THE LOWER
EXTREMITY
SUPERIOR GLUTEAL NERVE
 L4, L5, S1
 Leaves the greater sciatic
foramen above the piriformis
 MOTOR

 SUPERIOR branch
 Gluteus minimus
 TFL
 INFERIOR branch
 Gluteus medius
 TFL
INFERIOR GLUTEAL NERVE
 L5, S1, S2
 Leaves the greater
sciatic foramen
below the piriformis

 MOTOR
 Supplies the gluteus
maximus
NERVE TO QUADRATUS FEMORIS
 L4, L5, S1
 MOTOR
 INFERIOR
GEMELLUS
 QUADRATUS FEMORIS

 Articular branch to hip joint

NERVE TO OBTURATOR INTERNUS
 L5, S1, S2
 MOTOR
 SUPERIORGEMELLUS
 OBTURATOR INTERNUS
POSTERIOR FEMORAL CUTANEOUS
NERVE
 S1, S2, S3
 SENSORY
 Lower medial aspect of buttock
 Back of thigh and upper leg
SCIATIC NERVE
 L4, L5, S1, S2, S3
 Largest branch of
lumbosacral plexus
 Largest peripheral nerve

 Emerges from the

piriformis and courses
downward on the red
carpet mm
 Passess deep into the
long head of the biceps
femoris
 Divides into tibial and
common peroneal
SCIATIC NERVE
 Sciatic nerve can be
entrapped by the
piriformis
 PIRIFORMIS
Syndrome, Fat wallet
syndrome
 Sciatic nerve can also
be injured by injection
at the wrong site
TIBIAL NERVE
 Larger than the common
peroneal nerve
 Enters the popliteal fossa

 Passes behind the medial

malleolus
 Divides into lateral and medial
plantar nerves
TIBIAL NERVE
 MOTOR and SENSORY
 SENSORY
 Sural nerve – posterolateral leg
 Medial calcaneal branch
 Articular branch to knee joint
 MOTOR
 Soleus
 Gastrocnemius
 Flexor digitorum longus
 Flexor hallucis longus
 Tibialis posterior
MEDIAL AND LATERAL PLANTAR
NERVES
 Medial plantar nerve
 ABDuctor hallucis
 FLEXor hallucis brevis
 1st lumbrical
 Flexor digitorum brevis
 Lateral Plantar nerve
COMMON PERONEAL NERVE
 Winds around the neck of the
fibula
 MOTOR and SENSORY

 MOTOR
 Short head of Biceps femoris
 SENSORY
 Suralcommunicating
 Lateral cutaneous nerve of calf
 Articular branch to knee and
proximal tibiofibular joint
SUPERFICIAL AND DEEP PERONEAL
NERVE
SUPERFICIAL PERONEAL NERVE
 SENSORY and MOTOR

 SENSORY
 Dorsum of the foot,
 MOTOR
 Peroneus longus
 Peroneus brevis
DEEP PERONEAL NERVE
 SENSORY and MOTOR

 SENSORY
 1st dorsal webspace
 MOTOR
 TA
 EHL
 EDL
 PT
BLOOD SUPPLY OF THE
LOWER EXTREMITY
Arterial
Venous
Lymphatic
FEMORAL ARTERY
ANTERIOR TIBIAL ARTERY
DORSALIS PEDIS ARTERY
POSTERIOR TIBIAL ARTERY
PLANTAR ARCH
 Composed of:
 Lateral Plantar Artery
 Dorsalis pedis artery

 Gives off plantar digital arteries

TROCHANTERIC ANASTOMOSIS
 Main blood supply to femoral head

 Composed of:
 Superior gluteal artery
 Inferior gluteal artery
 Medial femoral circumflex artery
 Lateral femoral circumflex
CRUCIATE ANASTOMOSIS
 At the level of greater trochanter
 Connects the internal and femoral arteries

 Composed of:
 Inferior gluteal artery
 Medial femoral circumflex artery
 Lateral femoral circumflex artery
 First perforating artery
VENOUS DRAINAGE
 Deep veins (venae
commitantes)
 Superficial veins

 Perforating veins
LYMPHATIC DRAINAGE
REFERENCES
 Moore, K.L., & Dalley, A.F. (2006). Clinically oriented
anatomy. Philadelphia: Lippincott Williams & Wilkins.
 Chung, K.W., & Chung, H.M. (). BRS Gross anatomy.
Philadelphia: Lippincott Williams & Wilkins.
 Tank, P.W. (2005). Grant’s dissector. Philadelphia: Lippincott
Williams & Wilkins.
 Moore, K.L., & Dalley, A.F. (2006). Clinically oriented
anatomy. Philadelphia: Lippincott Williams & Wilkins.
 Drake, R.L., Vogl, W., & Mitchell, A.W.M. (2007). Gray’s
anatomy for students. Philadelphia: Elsevier
 Standring, S. (ed.). (2008). Gray’s anatomy. London:
Churchill Livingstone.
 Gomez, M.Z.A. (2008). OTPT102 Archives.