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Anatomy of nerve_injuries_lower_limb
MOB TCD

Anatomy of Nerve Injuries
Lower Limb
Professor Emeritus Moira O’Brien
FRCPI, FFSEM, FFSEM (UK), FTCD
Trinity College
Dublin
MOB TCD

Anatomy of Nerve Injuries
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•
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Dermatomes
Entrapment of Nerves
Pierce Muscle
Pierce Fascia
Repetitive Movements
MOB TCD

Anatomy of Nerve Injuries
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•
•
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•

Must know the course of nerve
Dermatomes
Entrapment of nerves
Pierce muscle
Pierce fascia
Repetitive movements
MOB TCD

Dermatomes and Myotomes
Nerves supply
• Skin
• Muscles (group)
• Tendons
• Bones
• Joints
• Blood vessels
MOB TCD

Extrinsic Factors
• External forces
• Fibro-osseous tunnels, tether
the nerve
• Oedema
• Callus formation as a result of a
fracture
• External compression due to
specific movements
• Mechanical compression
• Compartment syndromes
• The nerve is tender at the site
of compression
MOB TCD

Extrinsic Factors
• Fibrous bands
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•
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Accessory muscles
Spurs
Narrow notches
Anatomical variations of the nerve itself
MOB TCD

Lumbosacral Plexus
Entrapment Syndromes
in Lower Limb
• Affects branches of lumbar
or sacral plexuses
• Pierces muscle
• Pierces fascia
• Increase in compartment
pressure
• Compressed by external
pressure

MOB TCD
MOB TCD

Skin of Anterior Abdominal Wall
• Lower five intercostal nerves
• Subcostal nerve T12
• 10th intercostal nerves at the level
of the umbilicus
• Iliohypogastric nerve L1
• Ilioinguinal nerve L1
MOB TCD

Cutaneous Nerves of Thigh
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Subcostal nerve T12
Iliohypogastric nerve L1
Ilioinguinal nerve L1
Femoral branch of the
genitofemoral nerve L1,2
• Lateral cutaneous nerve of the
thigh L2,3
• Femoral nerve L2,3,4
• Obturator nerve L2,3,4
MOB TCD

Cutaneous Nerves
MOB TCD

Iliohypogastric Nerve L1
• Branch of lumbar plexus
• Lateral border of psoas
• Anterior to quadratus
lumborum
• Neurovascular plane between
internal oblique and
transversus
• Lateral cutaneous supplies
upper part of buttock
MOB TCD

Iliohypogastric Nerve
• Pierces internal oblique
above anterior superior
iliac spine
• Pierces aponeurosis of
external oblique an inch
above superficial ring
• Supplies skin over lower
part of rectus sheath
• Can be trapped piercing
aponeurosis
MOB TCD

Ilioinguinal Nerve
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•
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Ilioinguinal nerve
L1 branch of lumber plexus
Lateral border of psoas
Anterior to quadratus lumborum
Neurovascular plane between
internal oblique and transversus
MOB TCD

Ilioinguinal Nerve
• Pierces internal oblique
4 cm medial to
• Anterior superior iliac
spine
• Enters inguinal canal
• Leaves through
superficial ring
• Supplies the skin of the
medial part of the thigh
• Adjoining portion of the
scrotum and labia
MOB TCD

Ilioinguinal Nerve
• May be trapped post
surgery, due to adhesions
• Poor tone in abdominal
muscles
• Pain increased by
increased tension in the
anterior abdominal wall
• Hyperextension of hip
• Tenderness 4 cm from
anterior superior iliac spine
MOB TCD

Ilioinguinal Nerve Entrapment
• Pain increased
• Increased tension in the anterior
abdominal wall
• Hyperextension of hip
• Tenderness 4 cm medial to anterior
superior iliac spine
MOB TCD

Cutaneous Nerves
• Iliohypogastric in 5.6%
• Ilioinguinal 90.7%
• Union of branches of ilioinguinal
and genital branch of the
genitofemoral nerve 13%
• Genitofemoral passing through
superficial inguinal ring 35.2%
• Piercing inguinal ligament 5.6%
• Femoral branch 13%
Akita et al., 1999
MOB TCD

Genitofemoral Nerve
• Lumbar plexus L1,2
• Anterior aspect of the psoas
• Genital branch enters the deep
inguinal ring
• Femoral branch lies on the
lateral side of femoral artery in
the femoral sheath
MOB TCD

Femoral Branch Genitofemoral
• Enters thigh on lateral aspect
of femoral artery in femoral
sheath
• Pierces anterior wall of the
sheath
• Supplies skin a hands breath
below the inguinal ligament
MOB TCD

Genitofemoral Nerve
• Union with ilioinguinal nerve
on anterior aspect of
spermatic cord
• Supplies ventral aspect of
scrotum and adductor region
• Cutaneous branch on the
dorsal-caudal aspect
• May also supply dorsal
scrotum
Akita et al., 1999
MOB TCD

Genitofemoral Nerve
Lateral Cutaneous Nerve
of Thigh L2,3
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Lumbar plexus in psoas
Lateral aspect of psoas
Pierces inguinal ligament
Lies in fibrous tunnel
Divides into two
Pierces deep fascia

MOB TCD
MOB TCD

Lateral Cutaneous Nerve of Thigh
• A centimeter medial to
anterior superior iliac
spine
• Crosses the lateral angle
of femoral triangle
• Divides into two
• Pierces deep fascia
• Anterolateral aspect of the
thigh
• Anterior portion of gluteal
region

LCN
MOB TCD

Lateral Cutaneous Nerve of Thigh
• Entrapment in the fascial tunnel
• Injured in the thigh by
asymmetric bars in gymnastics
• Causes meralgia paraesthetica
• Post laparoscopic surgery
MOB TCD

Femoral Nerve L2,3,4
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Largest branch of the lumbar plexus
Lateral aspect of psoas
Passes under the inguinal ligament
Outside femoral sheath
2 cm below
Divides into terminal branches
Muscular
Articular
Cutaneous
MOB TCD

Femoral Nerve
Muscular branches
•Rectus femoris
•Vastus medialis,
•Vastus lateralis
•Vastus intermedius
•Sartorius, pectineus
Cutaneous
•Medial cutaneous nerves of thigh
•Intermediate cutaneous nerves of thigh
•Saphenous
Articular branches to hip and knee joints
MOB TCD

Femoral Nerve
• Dancers may stretch the
nerve by prolonged
hyperextension of the hip
• Compress the nerve under
the inguinal ligament
• Nerve may also be
compressed due to a
haematoma following a
partial tear of the iliacus
O’Brien, 1997
MOB TCD

Femoral Nerve

Femoral nerve

Saphenous
MOB TCD

Obturator Nerve L2,3,4
• Lumbar plexus in psoas
• Medial aspect of psoas
• Side wall of pelvis under
peritoneum
• Leaves through obturator foramen
• Divides into anterior and posterior
divisions
MOB TCD

Obturator Nerve
• Supplies the parietal
peritoneum on side wall of the
pelvis
• Is related to the ovary
• Pathology in the ovary or
endometriosis may result in
referred pain to the hip, knee or
medial side of the high
MOB TCD

Anterior Division Obturator
• Anterior division of
the obturator
leaves pelvis
• Anterior to
obturator externus
• Descends in front
of adductor brevis
• Behind pectineus
and adductor
longus
Obturator nerve
MOB TCD

Anterior Division Obturator
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•
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•

Adductor longus
Adductor brevis
Gracilis
It gives an articular twig to
the hip joint
• Skin on the medial side of
the thigh
MOB TCD

Obturator Nerve
MOB TCD

Posterior Division Obturator
• It may be entrapped as it leaves the pelvis
• Pierces and supplies the obturator externus
• Causing spasm of the adductor muscles
MOB TCD

Posterior Division Obturator
• Supplies adductor portion of adductor
magnus, above hiatus
• Articular twig to knee joint and cruciate
ligaments
• Causing spasm of the adductor muscles
• It may be entrapped as it leaves the pelvis or
between fascial planes
MOB TCD

Obturator Nerve

Obturator nerve

Fascial planes
MOB TCD

Howship Rhomberg Sign
• Pressure on obturator
nerve
• Pain on inner aspect of
thigh relieved by flexion of
hip
• Increased by extension,
adduction and medial
rotation
MOB TCD

Obturator Nerve
MOB TCD

Psoas Muscle
MOB TCD

Sacral Plexus
MOB TCD

Pudendal Nerve
MOB TCD

Pudendal Nerve
• Compression of pudendal nerve in
cyclists due to saddle
• History of change of saddle
• Compressing dorsal nerve of penis
Sciatic Nerve
Posterior Cutaneous Nerve Thigh

MOB TCD
MOB TCD

Sciatic Nerve L4,5, S1,2,3
• Is the largest nerve in
diameter in the body
• It passes out of the pelvis
below piriformis and
descends between the
greater trochanter of the
femur and the ischial
tuberosity
• Passes deep to gluteus
maximus
• More distally it lies on
adductor magnus
MOB TCD

Sciatic Nerve
• Is crossed by the long head
of biceps femoris
• Divides in middle of thigh
• Tibial and common peroneal
nerves
• Common peroneal may
pierce piriformis if divides in
pelvis
• Supplies hamstrings
• Adductor magnus below
hiatus
MOB TCD

Sciatic Nerve
• Occasionally it divides in the
pelvis
• Then the common peroneal
portion may pierce the piriformis
muscle to enter the thigh
• Recurrent injury to the
hamstring muscles produces
inflammation and possible
scarring which could interfere
with the normal mobility of the
sciatic nerve and produce
clinical signs of adverse neural
tension
MOB TCD

Tibial Nerve
• The larger terminal branch of the
sciatic nerve
• Crosses popliteal fossa
• Passes deep to soleus
• In posterior compartment between
flexor digitorum longus flexor
hallucis longus
• Passes deep to flexor retinaculum
• Gives off medial calcaneal nerve
which pierces retinaculum
• Divides into medial and lateral
plantar nerves
MOB TCD

Tibial Nerve
• The tibial nerve supplies all the muscles of the
posterior compartment of calf
• In popliteal fossa gives off
• Superomedial, middle and inferomedial
genicular branches
• Nerve to medial and lateral heads of
gastronemii
• Plantaris
• Popliteus
• Soleus
• Sural nerve
MOB TCD

Obturator Nerve L2,3,4
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•
•
•

Medial side of psoas
Side wall of pelvis
Obturator canal
Divides anterior posterior
division
MOB TCD

Sural Nerve
• Sural nerve is joined by sural
communicating from
commom peroneal
• Pierces deep fascia
• Supplies posterior and lateral
portion of calf
• Lateral border of foot
• Entrapment occurs most
frequently in runners with a
history of ankle sprain
MOB TCD

Sural Nerve
MOB TCD

Flexor Retinaculum
• Deep fascia from medial malleolus to
medial margin of calcaneus
Anterior to posterior
• Tibialis posterior
• Flexor digitorum longus
• Posterior tibial artery
• Tibial nerve
• Both give off medial calcaneal artery and nerve
• Then both divide into medial and lateral plantar
branches
• Flexor hallucis longus
MOB TCD

Tibial Nerve
• Gives off the medial calcaneal nerve under
cover of the retinaculum
• It then pierces the flexor retinaculum to
supply the posterior and medial aspect of
the heel
MOB TCD

Medial and Lateral Plantar Nerves
• Tibial divides into the medial and lateral
plantar nerves
• They enter two tunnels separated by a
fascial septum
• Stretching from the calcaneus to the deep
fascia of the abductor hallucis
MOB TCD

Medial Plantar Nerve
• Passes under the abductor hallucis
• Then runs on the plantar surface of
the flexor digitorum longus
• Dividing into its digital branches
• Sensory to the plantar aspect of the
medial three and a half toes
MOB TCD

Medial Plantar Nerve
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•

Motor to the abductor hallucis
Flexor hallucis brevis
Flexor digitorum brevis
First or unipennate lumbrical
MOB TCD

Medial Plantar Nerve
• Crosses the sole of the foot deep to the
•
•
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abductor hallucis, flexor digitorum brevis
and the abductor digiti minimi
To the base of 5th metatarsal
Superficial to flexor hallucis longus, flexor
digitorum longus and flexor accessorius
Lateral plantar nerve supplies the lateral
one-and-a-half toes
Supplies all the other intrinsic muscles of
the foot
MOB TCD

Tarsal Tunnel Syndrome
• The tibial nerve may be
compressed in the proximal
portion of the tunnel before it
divides
• More distally, either the medial
or lateral plantar nerves may be
involved
• Hyper dorsiflexion, external
rotation and eversion can
produce symptoms of tarsal
tunnel syndrome
MOB TCD

Tarsal Tunnel Syndrome
• Pain worse if foot is
pronated
• Tender over flexor
retinaculum
• Pain in heel, if medial
calcaneal is involved
• Pain in sole of foot if
plantar nerves involved
MOB TCD

Tarsal Tunnel Syndrome
• Orthotics may help if marked
pronated foot
• Anti-inflammatories
• Splint at night
MOB TCD

Tarsal Tunnel Syndrome
MOB TCD

Morton’s Metatarsalgia
• Depressed
transverse arch in
runners and ballet
dancers with mobile
first ray
• Neuroma on digital
nerve to the second
cleft or third cleft

Morton’s Foot

morton neuroma.jpg
MOB TCD

Medial Plantar
• Pronated foot
• Depressed transverse
arch at heads of
metatarsals
• Pain worse with tight
shoes on
• Relieved by removing
shoes
Common Peroneal Nerve
L4,5, S1,2,3
• If sciatic nerve divides inside
the pelvis
• Common peroneal nerve
pierces the piriformis
• May be entrapped
• In popliteal fossa
• The common peroneal nerve
lies between the tendon of
biceps femoris and the lateral
head of gastrocnemius

MOB TCD
MOB TCD

Common Peroneal
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•
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•
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•
•
•
•

In popliteal fossa gives off
Lateral cutaneous of calf
Sural communicating
Superior lateral, inferior lateral
genicular nerves
Leaves fossa at lateral angle
Crosses neck of fibula deep to
peroneus longus
Gives off recurrent genicular, deep
and superficial peroneal
Vulnerable to injury as it winds around neck of fibula
Foot drop, plantar flexed, inverted
MOB TCD

Compartments in Calf
• Nerves can be
compressed in
compartments
• Anterior compartment
deep peroneal nerve
• Lateral compartment
superficial peroneal
• Posterior compartment
tibial nerve
MOB TCD

Deep Peroneal Nerve
• Branch of the common peroneal
at the neck of the fibula
• Pierces the lateral intermuscular septum to enter the
anterior compartment
• Supplies all muscles in
anterior compartment tibialis
anterior, extensor hallucis
longus, extensor digitorum
longus, peroneus tertius and
extensor digitorum brevis
MOB TCD

Deep Peroneal Nerve
• Skin of cleft between first and second toes
• The nerve may be compressed due to anterior
compartment syndrome
• Muscle most at risk is tibialis anterior
• Entrapment occurs most frequently in runners.
It also occurs in soccer players, dancers and
skiers
• It occurs most often under the inferior extensor
retinaculum. Repetitive ankle sprains, tight
fitting shoes or trauma may also cause
entrapment
MOB TCD

Superficial Peroneal Nerve
• Runs in the lateral
compartment of the calf
• Between the peroneus longus
and brevis supplying both
these muscles
• Pierces the deep fascia
10–12 cm above the lateral
malleolus supplies most of
the dorsum
MOB TCD

Nerve Supply of Dorsum
• Divides 6 cm above the lateral
malleolus into branches, which
supply the dorsum of the foot
• The first cleft is supplied by the
deep peroneal
• The lateral border is supplied by
the sural nerve
• Medial border to ball of big toe
saphenous
• Rest superficial peroneal
MOB TCD

Superficial Peroneal Nerve
• Entrapment occurs where the
superficial peroneal pierces
the deep fascia
• Particularly if there is
herniation of the muscle due
to fascial defects
• Chronic ankle strains also
stretch the nerve
MOB TCD

Ankle Injuries
• Grade III ankle injuries have a high
incidence of traction injuries to both the
peroneal and posterior tibial nerves
Taunton & Fricker, 1996
“BMJ Publishing Group Limited (“BMJ Group”) 2012. All rights reserved.”

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Anatomy of nerve_injuries_lower_limb

  • 2. MOB TCD Anatomy of Nerve Injuries Lower Limb Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin
  • 3. MOB TCD Anatomy of Nerve Injuries • • • • • Dermatomes Entrapment of Nerves Pierce Muscle Pierce Fascia Repetitive Movements
  • 4. MOB TCD Anatomy of Nerve Injuries • • • • • • Must know the course of nerve Dermatomes Entrapment of nerves Pierce muscle Pierce fascia Repetitive movements
  • 5. MOB TCD Dermatomes and Myotomes Nerves supply • Skin • Muscles (group) • Tendons • Bones • Joints • Blood vessels
  • 6. MOB TCD Extrinsic Factors • External forces • Fibro-osseous tunnels, tether the nerve • Oedema • Callus formation as a result of a fracture • External compression due to specific movements • Mechanical compression • Compartment syndromes • The nerve is tender at the site of compression
  • 7. MOB TCD Extrinsic Factors • Fibrous bands • • • • Accessory muscles Spurs Narrow notches Anatomical variations of the nerve itself
  • 9. Entrapment Syndromes in Lower Limb • Affects branches of lumbar or sacral plexuses • Pierces muscle • Pierces fascia • Increase in compartment pressure • Compressed by external pressure MOB TCD
  • 10. MOB TCD Skin of Anterior Abdominal Wall • Lower five intercostal nerves • Subcostal nerve T12 • 10th intercostal nerves at the level of the umbilicus • Iliohypogastric nerve L1 • Ilioinguinal nerve L1
  • 11. MOB TCD Cutaneous Nerves of Thigh • • • • Subcostal nerve T12 Iliohypogastric nerve L1 Ilioinguinal nerve L1 Femoral branch of the genitofemoral nerve L1,2 • Lateral cutaneous nerve of the thigh L2,3 • Femoral nerve L2,3,4 • Obturator nerve L2,3,4
  • 13. MOB TCD Iliohypogastric Nerve L1 • Branch of lumbar plexus • Lateral border of psoas • Anterior to quadratus lumborum • Neurovascular plane between internal oblique and transversus • Lateral cutaneous supplies upper part of buttock
  • 14. MOB TCD Iliohypogastric Nerve • Pierces internal oblique above anterior superior iliac spine • Pierces aponeurosis of external oblique an inch above superficial ring • Supplies skin over lower part of rectus sheath • Can be trapped piercing aponeurosis
  • 15. MOB TCD Ilioinguinal Nerve • • • • • Ilioinguinal nerve L1 branch of lumber plexus Lateral border of psoas Anterior to quadratus lumborum Neurovascular plane between internal oblique and transversus
  • 16. MOB TCD Ilioinguinal Nerve • Pierces internal oblique 4 cm medial to • Anterior superior iliac spine • Enters inguinal canal • Leaves through superficial ring • Supplies the skin of the medial part of the thigh • Adjoining portion of the scrotum and labia
  • 17. MOB TCD Ilioinguinal Nerve • May be trapped post surgery, due to adhesions • Poor tone in abdominal muscles • Pain increased by increased tension in the anterior abdominal wall • Hyperextension of hip • Tenderness 4 cm from anterior superior iliac spine
  • 18. MOB TCD Ilioinguinal Nerve Entrapment • Pain increased • Increased tension in the anterior abdominal wall • Hyperextension of hip • Tenderness 4 cm medial to anterior superior iliac spine
  • 19. MOB TCD Cutaneous Nerves • Iliohypogastric in 5.6% • Ilioinguinal 90.7% • Union of branches of ilioinguinal and genital branch of the genitofemoral nerve 13% • Genitofemoral passing through superficial inguinal ring 35.2% • Piercing inguinal ligament 5.6% • Femoral branch 13% Akita et al., 1999
  • 20. MOB TCD Genitofemoral Nerve • Lumbar plexus L1,2 • Anterior aspect of the psoas • Genital branch enters the deep inguinal ring • Femoral branch lies on the lateral side of femoral artery in the femoral sheath
  • 21. MOB TCD Femoral Branch Genitofemoral • Enters thigh on lateral aspect of femoral artery in femoral sheath • Pierces anterior wall of the sheath • Supplies skin a hands breath below the inguinal ligament
  • 22. MOB TCD Genitofemoral Nerve • Union with ilioinguinal nerve on anterior aspect of spermatic cord • Supplies ventral aspect of scrotum and adductor region • Cutaneous branch on the dorsal-caudal aspect • May also supply dorsal scrotum Akita et al., 1999
  • 24. Lateral Cutaneous Nerve of Thigh L2,3 • • • • • • Lumbar plexus in psoas Lateral aspect of psoas Pierces inguinal ligament Lies in fibrous tunnel Divides into two Pierces deep fascia MOB TCD
  • 25. MOB TCD Lateral Cutaneous Nerve of Thigh • A centimeter medial to anterior superior iliac spine • Crosses the lateral angle of femoral triangle • Divides into two • Pierces deep fascia • Anterolateral aspect of the thigh • Anterior portion of gluteal region LCN
  • 26. MOB TCD Lateral Cutaneous Nerve of Thigh • Entrapment in the fascial tunnel • Injured in the thigh by asymmetric bars in gymnastics • Causes meralgia paraesthetica • Post laparoscopic surgery
  • 27. MOB TCD Femoral Nerve L2,3,4 • • • • • • • • • Largest branch of the lumbar plexus Lateral aspect of psoas Passes under the inguinal ligament Outside femoral sheath 2 cm below Divides into terminal branches Muscular Articular Cutaneous
  • 28. MOB TCD Femoral Nerve Muscular branches •Rectus femoris •Vastus medialis, •Vastus lateralis •Vastus intermedius •Sartorius, pectineus Cutaneous •Medial cutaneous nerves of thigh •Intermediate cutaneous nerves of thigh •Saphenous Articular branches to hip and knee joints
  • 29. MOB TCD Femoral Nerve • Dancers may stretch the nerve by prolonged hyperextension of the hip • Compress the nerve under the inguinal ligament • Nerve may also be compressed due to a haematoma following a partial tear of the iliacus O’Brien, 1997
  • 30. MOB TCD Femoral Nerve Femoral nerve Saphenous
  • 31. MOB TCD Obturator Nerve L2,3,4 • Lumbar plexus in psoas • Medial aspect of psoas • Side wall of pelvis under peritoneum • Leaves through obturator foramen • Divides into anterior and posterior divisions
  • 32. MOB TCD Obturator Nerve • Supplies the parietal peritoneum on side wall of the pelvis • Is related to the ovary • Pathology in the ovary or endometriosis may result in referred pain to the hip, knee or medial side of the high
  • 33. MOB TCD Anterior Division Obturator • Anterior division of the obturator leaves pelvis • Anterior to obturator externus • Descends in front of adductor brevis • Behind pectineus and adductor longus Obturator nerve
  • 34. MOB TCD Anterior Division Obturator • • • • Adductor longus Adductor brevis Gracilis It gives an articular twig to the hip joint • Skin on the medial side of the thigh
  • 36. MOB TCD Posterior Division Obturator • It may be entrapped as it leaves the pelvis • Pierces and supplies the obturator externus • Causing spasm of the adductor muscles
  • 37. MOB TCD Posterior Division Obturator • Supplies adductor portion of adductor magnus, above hiatus • Articular twig to knee joint and cruciate ligaments • Causing spasm of the adductor muscles • It may be entrapped as it leaves the pelvis or between fascial planes
  • 38. MOB TCD Obturator Nerve Obturator nerve Fascial planes
  • 39. MOB TCD Howship Rhomberg Sign • Pressure on obturator nerve • Pain on inner aspect of thigh relieved by flexion of hip • Increased by extension, adduction and medial rotation
  • 44. MOB TCD Pudendal Nerve • Compression of pudendal nerve in cyclists due to saddle • History of change of saddle • Compressing dorsal nerve of penis
  • 45. Sciatic Nerve Posterior Cutaneous Nerve Thigh MOB TCD
  • 46. MOB TCD Sciatic Nerve L4,5, S1,2,3 • Is the largest nerve in diameter in the body • It passes out of the pelvis below piriformis and descends between the greater trochanter of the femur and the ischial tuberosity • Passes deep to gluteus maximus • More distally it lies on adductor magnus
  • 47. MOB TCD Sciatic Nerve • Is crossed by the long head of biceps femoris • Divides in middle of thigh • Tibial and common peroneal nerves • Common peroneal may pierce piriformis if divides in pelvis • Supplies hamstrings • Adductor magnus below hiatus
  • 48. MOB TCD Sciatic Nerve • Occasionally it divides in the pelvis • Then the common peroneal portion may pierce the piriformis muscle to enter the thigh • Recurrent injury to the hamstring muscles produces inflammation and possible scarring which could interfere with the normal mobility of the sciatic nerve and produce clinical signs of adverse neural tension
  • 49. MOB TCD Tibial Nerve • The larger terminal branch of the sciatic nerve • Crosses popliteal fossa • Passes deep to soleus • In posterior compartment between flexor digitorum longus flexor hallucis longus • Passes deep to flexor retinaculum • Gives off medial calcaneal nerve which pierces retinaculum • Divides into medial and lateral plantar nerves
  • 50. MOB TCD Tibial Nerve • The tibial nerve supplies all the muscles of the posterior compartment of calf • In popliteal fossa gives off • Superomedial, middle and inferomedial genicular branches • Nerve to medial and lateral heads of gastronemii • Plantaris • Popliteus • Soleus • Sural nerve
  • 51. MOB TCD Obturator Nerve L2,3,4 • • • • Medial side of psoas Side wall of pelvis Obturator canal Divides anterior posterior division
  • 52. MOB TCD Sural Nerve • Sural nerve is joined by sural communicating from commom peroneal • Pierces deep fascia • Supplies posterior and lateral portion of calf • Lateral border of foot • Entrapment occurs most frequently in runners with a history of ankle sprain
  • 54. MOB TCD Flexor Retinaculum • Deep fascia from medial malleolus to medial margin of calcaneus Anterior to posterior • Tibialis posterior • Flexor digitorum longus • Posterior tibial artery • Tibial nerve • Both give off medial calcaneal artery and nerve • Then both divide into medial and lateral plantar branches • Flexor hallucis longus
  • 55. MOB TCD Tibial Nerve • Gives off the medial calcaneal nerve under cover of the retinaculum • It then pierces the flexor retinaculum to supply the posterior and medial aspect of the heel
  • 56. MOB TCD Medial and Lateral Plantar Nerves • Tibial divides into the medial and lateral plantar nerves • They enter two tunnels separated by a fascial septum • Stretching from the calcaneus to the deep fascia of the abductor hallucis
  • 57. MOB TCD Medial Plantar Nerve • Passes under the abductor hallucis • Then runs on the plantar surface of the flexor digitorum longus • Dividing into its digital branches • Sensory to the plantar aspect of the medial three and a half toes
  • 58. MOB TCD Medial Plantar Nerve • • • • Motor to the abductor hallucis Flexor hallucis brevis Flexor digitorum brevis First or unipennate lumbrical
  • 59. MOB TCD Medial Plantar Nerve • Crosses the sole of the foot deep to the • • • • abductor hallucis, flexor digitorum brevis and the abductor digiti minimi To the base of 5th metatarsal Superficial to flexor hallucis longus, flexor digitorum longus and flexor accessorius Lateral plantar nerve supplies the lateral one-and-a-half toes Supplies all the other intrinsic muscles of the foot
  • 60. MOB TCD Tarsal Tunnel Syndrome • The tibial nerve may be compressed in the proximal portion of the tunnel before it divides • More distally, either the medial or lateral plantar nerves may be involved • Hyper dorsiflexion, external rotation and eversion can produce symptoms of tarsal tunnel syndrome
  • 61. MOB TCD Tarsal Tunnel Syndrome • Pain worse if foot is pronated • Tender over flexor retinaculum • Pain in heel, if medial calcaneal is involved • Pain in sole of foot if plantar nerves involved
  • 62. MOB TCD Tarsal Tunnel Syndrome • Orthotics may help if marked pronated foot • Anti-inflammatories • Splint at night
  • 64. MOB TCD Morton’s Metatarsalgia • Depressed transverse arch in runners and ballet dancers with mobile first ray • Neuroma on digital nerve to the second cleft or third cleft Morton’s Foot morton neuroma.jpg
  • 65. MOB TCD Medial Plantar • Pronated foot • Depressed transverse arch at heads of metatarsals • Pain worse with tight shoes on • Relieved by removing shoes
  • 66. Common Peroneal Nerve L4,5, S1,2,3 • If sciatic nerve divides inside the pelvis • Common peroneal nerve pierces the piriformis • May be entrapped • In popliteal fossa • The common peroneal nerve lies between the tendon of biceps femoris and the lateral head of gastrocnemius MOB TCD
  • 67. MOB TCD Common Peroneal • • • • • • • • • In popliteal fossa gives off Lateral cutaneous of calf Sural communicating Superior lateral, inferior lateral genicular nerves Leaves fossa at lateral angle Crosses neck of fibula deep to peroneus longus Gives off recurrent genicular, deep and superficial peroneal Vulnerable to injury as it winds around neck of fibula Foot drop, plantar flexed, inverted
  • 68. MOB TCD Compartments in Calf • Nerves can be compressed in compartments • Anterior compartment deep peroneal nerve • Lateral compartment superficial peroneal • Posterior compartment tibial nerve
  • 69. MOB TCD Deep Peroneal Nerve • Branch of the common peroneal at the neck of the fibula • Pierces the lateral intermuscular septum to enter the anterior compartment • Supplies all muscles in anterior compartment tibialis anterior, extensor hallucis longus, extensor digitorum longus, peroneus tertius and extensor digitorum brevis
  • 70. MOB TCD Deep Peroneal Nerve • Skin of cleft between first and second toes • The nerve may be compressed due to anterior compartment syndrome • Muscle most at risk is tibialis anterior • Entrapment occurs most frequently in runners. It also occurs in soccer players, dancers and skiers • It occurs most often under the inferior extensor retinaculum. Repetitive ankle sprains, tight fitting shoes or trauma may also cause entrapment
  • 71. MOB TCD Superficial Peroneal Nerve • Runs in the lateral compartment of the calf • Between the peroneus longus and brevis supplying both these muscles • Pierces the deep fascia 10–12 cm above the lateral malleolus supplies most of the dorsum
  • 72. MOB TCD Nerve Supply of Dorsum • Divides 6 cm above the lateral malleolus into branches, which supply the dorsum of the foot • The first cleft is supplied by the deep peroneal • The lateral border is supplied by the sural nerve • Medial border to ball of big toe saphenous • Rest superficial peroneal
  • 73. MOB TCD Superficial Peroneal Nerve • Entrapment occurs where the superficial peroneal pierces the deep fascia • Particularly if there is herniation of the muscle due to fascial defects • Chronic ankle strains also stretch the nerve
  • 74. MOB TCD Ankle Injuries • Grade III ankle injuries have a high incidence of traction injuries to both the peroneal and posterior tibial nerves Taunton & Fricker, 1996
  • 75. “BMJ Publishing Group Limited (“BMJ Group”) 2012. All rights reserved.”

Editor's Notes

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