UPPER LIMB

Attachment of latissimus dorsi: “Lady Between Two Majors”

Latissimus dorsi attaches to the humerus between pectoralis major and teres major.

Rotator cuff muscles: SITS

● Supraspinatus
● Infraspinatus
● Teres minor
● Subscapularis

See our guide to the intrinsic muscles of the shoulder.

Structure of the brachial plexus: “Reach To Drink Cold Beer”

● Roots
● Trunks
● Divisions
● Cords
● Branches (nerves)

See our overview of the brachial plexus.

Contents of the cubital fossa: “Really Need Beer To Be At My Nicest”

From lateral to medial:

● Radial Nerve
● Brachial Tendon
● Brachial Artery
● Median Nerve

Muscles involved in elbow flexion: “Three Bs Bend the Elbow”

● Biceps brachii
● Brachialis
● Brachioradialis

Carpal bones: “Some Lovers Try Positions That They Can’t Handle”

Starting from the thumb:

 ● Scaphoid
● Lunate
● Triquetral
● Pisiform
● Trapezium
● Trapezoid
● Capitate
● Hamate

See our guides to the bones of the hand and the wrist joint.

Median nerve supply to the hand: LOAF

● Lateral two lumbricals

● Opponens pollicis
● Abductor pollicis brevis
● Flexor pollicis brevis

Actions of the interosseous muscles of the hand: PAD DAB

● Palmar interossei: ADduction

● Dorsal interossei: ABduction

Introduction

The intrinsic muscles of the shoulder form the scapulohumeral group, mainly originating from the
scapula and inserting onto the humerus.1

The intrinsic muscles can be further divided into the deltoid muscle, teres major and the rotator
cuff muscles; supraspinatus, infraspinatus, subscapularis and teres minor.2

This article will primarily highlight the origin, insertion, innervation and function of the intrinsic
muscles of the shoulder.

Deltoid

The deltoid forms the rounded contour of the shoulder and is comprised anterior, intermediate
and posterior fibres.1
Origin and insertion

The anterior (or clavicular) fibres originate from the lateral third of the clavicle. The intermediate
(or acromial) fibres originate from the acromion process of the scapula. The posterior (or spinal)
fibres originate from the spine of the scapula.

All fibres converge toward their insertion on the deltoid tuberosity on the middle of the shaft of
the humerus.

Innervation

The deltoid is innervated by the axillary nerve (C5-6).

Function

The functions of the deltoid muscle can be categorised based on the groups of fibres involved:

● Anterior fibres: shoulder flexion and internal rotation.

● Intermediate fibres: abduction of the shoulder (these fibres take over from
supraspinatus which initiates shoulder abduction).
● Posterior fibres: shoulder extension and external rotation.
 Figure 1. Deltoid muscle.3

Teres major

Teres major is a thick muscle which is positioned superiorly to latissimus dorsi.4

Origin and insertion

Teres major originates from the posterior aspect of the inferior angle of the scapula and inserts
onto the medial lip of the bicipital groove (intertubercular sulcus) of the humerus.4

Innervation

The majority of teres major is innervated by the lower subscapular nerve and a small portion is
innervated by the thoracodorsal nerve (C5-8).4

Function

Teres major acts to adduct the humerus as well as assisting in extension and internal rotation of
the shoulder.4
 Figure 2. Teres major.4

Rotator cuff muscles

All four rotator cuff muscles originate from areas of the scapula and insert onto the humeral
head.2

The glenohumeral (GH) joint is highly mobile, allowing a large range of movement, but this comes
at the cost of stability. The resting tension of the rotator cuff muscles provides the primary
stabilizing force on the GH joint.1,2

Supraspinatus

Supraspinatus arises from the scapula and runs beneath the cover of the acromion.5

Origin and insertion

Supraspinatus originates from the supraspinous fossa and the muscle’s tendon inserts onto the
superior facet of the greater tubercle of the humerus.5

Innervation

Supraspinatus is innervated by the suprascapular nerve (C5).5

Function

Supraspinatus acts to initiate abduction of the arm (especially between the first 15 degrees of
movement) and then acts to assist the deltoid muscle (15-90 degrees of movement).5

Clinical relevance: impingement syndrome

Impingement syndrome is caused by rotator cuff tendonitis as the tendons pass beneath the
acromion. The supraspinatus muscle’s tendon is most commonly affected.

Impingement syndrome typically presents with pain, weakness and restricted shoulder
movement. Patients with impingement syndrome often complain of pain when their arms are
raised (this is particularly common in mechanics and manual labourers who work with their arms
overhead). When the arm is raised, the subacromial space narrows, which can result in
impingement of the supraspinatus muscle tendon leading to an inflammatory response.

Clinical examination

Typical findings on clinical examination in supraspinatus impingement syndrome include:

● Pain experienced between 60-120° of shoulder abduction (known as a ‘painful arc’).

● Weakness and pain experienced when the supraspinatus muscle is isolated using the
‘Empty can/Jobe’s test

For more information, see the Geeky Medics shoulder examination guide.
 Figure 3. Supraspinatus.5

Infraspinatus

Infraspinatus is a thick triangular muscle. The spine of the scapula acts to separate the origin of
the supraspinatus muscle from the infraspinatus muscle.6

Origin and insertion

The infraspinatus muscle originates from the infraspinous fossa of the scapula, passing over the
lateral border of the spine of the scapula before inserting onto the middle facet of the greater
tuberosity on the humerus.6

Innervation

Infraspinatus has the same innervation as supraspinatus – the suprascapular nerve (C5).6
Function

Infraspinatus acts to externally rotate the arm.6

Figure 4. Infraspinatus.6

Subscapularis

Subscapularis is another large triangular-shaped muscle.7

Origin and insertion

It originates from the subscapular fossa (ventral surface) and inserts onto the lesser tuberosity of
the humerus (this is the only rotator cuff muscle which doesn’t attach to the greater tuberosity).7

Innervation

Subscapularis is innervated by the upper and lower subscapular nerves (C5-6).7

Function

Subscapularis acts to internally rotate and adduct the arm.7

Figure 5. Subscapularis.7

Teres minor

Teres minor is a narrow elongated muscle which is superior to teres major.8

Origin and insertion

Teres minor originates from the lateral border of the scapula, before inserting onto the inferior
facet of the greater tubercle on the humerus.8

Innervation

Teres minor is innervated by the axillary nerve (C5-6).8

Function

Teres minor acts to externally rotate the arm.8

Mnemonic: SIT
SIT is a mnemonic to remember the superior to inferior attachments of the rotator cuff muscles
onto the greater tubercle of the humerus.5

● Supraspinatus
● Infraspinatus
● Teres minor

Figure 6. Teres minor.8

Summary

Muscle Origin Insertion Innervation Action

 Anterior fibres:
Flexion &
Deltoid Lateral ⅓ Deltoid Axillary nerve internal rotation
clavicle + tuberosity
acromion & the
spine of the
scapula Intermediate
fibres: major
abductor, takes
over from
supraspinatus

Posterior fibres:
extension &
external rotation

Adducts &
extends at the
Teres major Inferior angle of Medial lip Lower shoulder
the scapula of bicipital subscapular
groove nerve

Internally
rotates the arm

Rotator cuff muscles

 Initiates
abduction
Supraspinatus Supraspinous
fossa
Greater Suprascapular
tubercle nerve (0-15 degrees) &
assists deltoid
for 15-90
degrees

Infraspinatus Infraspinous Externally

fossa rotates

Subscapularis Subscapular Lesser Upper and lower

Fossa tubercle subscapular
nerves Internally
rotates arm

Externally
rotates
Teres minor Lateral border Greater Axillary nerve
of the scapula tubercle

Introduction
The brachial plexus is a complex intercommunicating network of nerves formed by spinal nerves C5,
C6, C7, C8 and T1. The brachial plexus, frequently appears in examination questions.

This guide will cover the brachial plexus and includes a summary diagram. One of the best ways to
memorise the brachial plexus is by drawing it.

If you’d like to put your knowledge of the brachial plexus to the test, take a look at the Geeky Medics
brachial plexus quiz.

You might also be interested in our Anatomy Flashcard Collection which contains over 2000 anatomy

flashcards in addition to advanced features such as spaced repetition.

Overview of the brachial plexus

The brachial plexus is a complex intercommunicating network of nerves formed by spinal nerves C5,
C6, C7, C8 and T1.

It supplies all sensory innervation to the upper limb and most of the axilla, with the exception of an
area of the medial upper arm and axilla, which is supplied by the intercostobrachial nerve T2.

It supplies all motor innervation to the muscles of the upper limb and shoulder girdle, with the
exception of the trapezius, which is supplied by the spinal accessory nerve XI.

It also supplies autonomic innervation to the upper limb by intercommunicating with the stellate
ganglion of the sympathetic trunk at the level of T1, where it gains sympathetic fibres which supply
specialist functions:

● Vasomotor: stimulates vasoconstriction of arteries, arterioles and capillaries resulting in

skin pallor and coldness
● Pilomotor: stimulates contraction of arrector pili muscles within hair follicles, making hairs
stand on end
● Sudomotor or secretomotor: stimulates the production of sweat from sweat glands
Outline of the brachial plexus

The brachial plexus begins as the anterior rami of five spinal nerve roots C5-T1, which emerge from the
intervertebral foramen of their respective vertebrae to lie in the posterior triangle of the neck between
the anterior and medial scalene muscles.

The five spinal nerves quickly unite to form superior, middle and inferior trunks, which continue to
pass laterally between the anterior and medial scalene muscles and cross the base of the posterior
triangle of the neck, where they can be found behind the subclavian artery. They pass over the apex of
the lung and the first rib towards the clavicle.

Behind the middle third of the clavicle, each trunk splits into an anterior division and a posterior
division. These continue to pass downwards behind the clavicle to enter the axilla.

The six divisions combine to form lateral, posterior and medial cords. These are distributed around
and named according to their relationship with the second part of the axillary artery, which is located
behind the pectoralis minor muscle.

The cords travel laterally with the axillary artery towards the arm. The artery and cords are ensheathed
by an extension of the prevertebral fascia known as the axillary sheath, this is a target for brachial
plexus nerve blocks.

The cords divide around the third part of the axillary artery into their five terminal branches: the
musculocutaneous, axillary, radial, median and ulnar nerves.

Vascular supply

The brachial plexus gets its blood supply from various branches of the subclavian artery along its
length, including:

● Roots: vertebral artery, anterior and posterior spinal arteries

● Trunks and divisions: ascending and deep cervical arteries, superior intercostal artery
● Cords: axillary artery

Structure of the Brachial Plexus

Figure 1 summarises the structure and branches of the brachial plexus.

Figure
1. Brachial plexus diagram

The brachial plexus is easier to understand once broken down into its component segments: these are
roots, trunks, divisions, cords and terminal branches.

Roots

There are five nerve roots from C5-T1, which give three nerve branches:

● Dorsal scapular nerve

● Long thoracic nerve
● First intercostal nerve

It is important to remember that C5 also gives fibres which join fibres from C3 and C4 to form the
phrenic nerve, which is not shown in the diagram.
Trunks

The five nerve roots combine to form three trunks:

● The superior trunk is formed from C5 and C6

● The middle trunk is formed from C7
● The inferior trunk is formed from C8 and T1

The superior trunk gives rise to two nerve branches: the suprascapular nerve and the nerve to
subclavius. The middle and inferior trunks do not give off any extra branches.

Divisions

There are six divisions in total, comprising of an anterior division and a posterior division from each of
the three trunks:

● Anterior division fibres usually supply flexor muscles

● Posterior division fibres usually supply extensors
● There are no extra nerve branches arising from the divisions

Cords

The divisions combine to form three cords, which are distributed around the axillary artery:

● The lateral cord is formed from the anterior divisions of the superior and middle trunks. It
gives one extra nerve branch: the lateral pectoral nerve.
● The posterior cord is formed from the posterior divisions of the superior, middle and inferior
trunks. It gives three nerve branches: the upper subscapular nerve, the thoracodorsal nerve
and the lower subscapular nerve.
● The medial cord is formed from the anterior division of the inferior trunk. It gives three nerve
branches: the medial pectoral nerve, the medial cutaneous nerve of the arm (also known as
the medial brachial cutaneous nerve) and the medial cutaneous nerve of the forearm (also
known as the medial antebrachial cutaneous nerve).
Terminal branches

The three cords branch to form five terminal nerve branches which supply the upper limb:

● The lateral cord gives rise to the musculocutaneous nerve and the lateral root of the median
nerve
● The posterior cord gives rise to the axillary nerve and the radial nerve
● The medial cord gives rise to the medial root of the median nerve and the ulnar nerve

Identifying structures

It is easy to panic when given a diagram or prosection of the brachial plexus to label in exams. The key
is to look for the “M” shape formed around the axillary artery by the musculocutaneous, median and
ulnar nerves.

This is an easy landmark to find and will give you your bearings. Once you have found this, you should
be able to confidently identify those three nerves. You will then be able to identify the small axillary
nerve and large radial nerve originating from the posterior cord behind the axillary artery.

The medial cutaneous nerves of the arm and forearm can be found travelling down the arm below the
ulnar nerve. The three branches from the posterior cord should also be easy to spot, you will see the
two small subscapular nerves and the large thoracodorsal nerve between them, which forms a bundle
with the thoracodorsal artery and vein to supply latissimus dorsi.

Anatomical variations

There are many recognised anatomical variations to this structure, which may affect over 50% of
people. The most significant ones include:

● Pre-fixed brachial plexus: contributing nerve roots all moved up one, therefore the plexus is
derived from C4-C8
● Post-fixed brachial plexus: contributing nerve roots all moved down one, therefore the
plexus is derived from C6-T2
● Individual nerves may also arise from different cords, intercommunicate with others or be
completely absent.
Nerve branches from the roots

Dorsal scapular nerve (C5)

Origin

C5 nerve root of the brachial plexus

Sensory supply

None

Motor supply

Levator scapulae (elevates scapula)

Rhomboid major and rhomboid minor (stabilise, retract and medially rotate scapula)

Long thoracic nerve (C5/C6/C7)

Origin

C5, C6 and C7 nerve roots of the brachial plexus

Sensory supply

None

Motor supply

Serratus anterior (protracts and stabilises scapula)

Clinical significance: long thoracic nerve

An injury to the long thoracic nerve, for example as a result of a sports injury or damage during axillary
surgery, results in winging of the scapula on examination.

The deformity may be visible at rest, and a classic way to elicit or exaggerate it is by asking the patient
to push against a wall and looking for abnormal posterior protrusion of the scapula on the affected
side.

First intercostal nerve (T1)

Origin

T1 nerve root of the brachial plexus

Sensory supply

A narrow strip of skin over first intercostal space

Motor supply

First intercostal muscles (elevate and depress the rib cage during inspiration and expiration)

Nerve branches from the trunks

Suprascapular nerve (C5/C6)

Origin

Superior trunk of the brachial plexus

Sensory supply

Glenohumeral and acromioclavicular joints

Motor supply

Supraspinatus (stabilises and abducts shoulder) and infraspinatus (stabilises and externally rotates
shoulder)

Nerve to subclavius (C6)

Origin
Superior trunk of the brachial plexus

Sensory supply

None

Motor supply

Subclavius (depresses clavicle and elevates the first rib)

Branches from the cords

Lateral pectoral nerve (C5/C6/C7)

Origin

Lateral cord of the brachial plexus

Sensory supply

None to the skin, but it is thought to play an important role in the sensation of chest wall pain, for
example after mastectomy or breast implant insertion, and is, therefore, a target for regional nerve
blocks

Motor supply
Upper clavicular part of the pectoralis major (flexes, adducts and internally rotates shoulder)

Upper subscapular nerve (C5/C6)

Origin

Posterior cord of the brachial plexus

Sensory supply

None

Motor supply

Subscapularis (stabilises and internally rotates shoulder)

Lower subscapular nerve (C5/C6)

Origin

Posterior cord of the brachial plexus

Sensory supply

None
Motor supply

Subscapularis (stabilises and internally rotates shoulder) and teres major (adducts and internally
rotates shoulder, protracts and depresses scapula)

Thoracodorsal nerve (C6/C7/C8)

Origin

Posterior cord of the brachial plexus

Sensory supply

None

Motor supply

Latissimus dorsi (extends, adducts and internally rotates shoulder, externally rotates trunk)

Clinical significance: thoracodorsal nerve

The thoracodorsal nerve is vulnerable to injury during axillary dissection, for example during lymph
node clearance for breast cancer.

This results in shoulder movement weakness, which is best elicited on examination by asking the
patient to place the dorsum of their hand on the opposite buttock to test extension, adduction and
internal rotation.
Most patients do not suffer from significant loss of function in terms of day-to-day activities, but
elderly people may struggle to pull themselves up from a sitting position, and young climbers or
bodybuilders are likely to notice significantly reduced performance on the affected side.

Medial pectoral nerve (C8/T1)

Origin

Medial cord of the brachial plexus

Sensory supply

None to the skin, but may have a role in the sensation of chest wall pain following breast surgery

Motor supply

Pectoralis minor (stabilises scapula, raises ribs during inspiration)

Lower sternocostal part of the pectoralis major (extends, adducts and internally rotates shoulder)

Medial cutaenous nerve of the arm (T1)

Origin

Medial cord of the brachial plexus

Sensory supply
Skin of the lower third the of the medial arm

Motor supply

None

Medial cutaneous nerve of the forearm (C8)

Origin

Medial cord of the brachial plexus

Sensory supply

Skin over biceps muscle, antecubital fossa and medial forearm

Motor supply

None

Terminal branches

For more information on the terminal branches, see the Geeky Medics guide to the nerve supply to the
upper limb.
Musculocutaneous nerve (C5/C6/C7)

Origin

Lateral cord of the brachial plexus

Sensory supply

Lateral forearm

Motor supply

Anterior compartment of the arm:

● Biceps (flexes elbow, supinates forearm)

● Brachialis (flexes elbow)
● Coracobrachialis (adducts shoulder, flexes elbow)

Clinical significance: musculocutaenous nerve

Musculocutaneous nerve injuries are rare, but result in very weak elbow flexion and weak forearm
supination which can be very disabling.

Axillary nerve (C5/C6)

Origin
Posterior cord of the brachial plexus

Sensory supply

“Sergeant’s patch” over the lower deltoid

Motor supply

Deltoid (abducts, flexes and extends shoulder) and teres minor (stabilises and externally rotates
shoulder)

Clinical significance: axillary nerve

The axillary nerve may be injured by shoulder dislocations or proximal humeral fractures, resulting in
numbness over the sergeant’s patch and profound weakness of shoulder abduction from 15-90°.

Other examination findings include deltoid wasting and weakness of shoulder flexion, extension and
external rotation.

Radial nerve (C5/C6/C7/C8/T1)

Origin

Posterior cord of the brachial plexus

Sensory supply

The radial nerve supplies sensation to:

● Posterior arm and forearm

● Lateral ⅔ of the dorsum of the hand
● Proximal dorsal aspect of lateral 3½ fingers

Motor supply

The radial nerve supplies the posterior compartment of the arm, which contains triceps (extends and
adducts shoulder, extends elbow).

It also supplies the entirety of the posterior compartment of the forearm. This consists of:

● Brachioradialis (flexes elbow)

● Anconeus (extends elbow, stabilises elbow joint)
● Supinator (supinates forearm)
● Extensor carpi radialis longus and brevis (extend and abduct wrist)
● Extensor carpi ulnaris (extend and adduct wrist)
● Extensor digitorum
● Extensor pollicis longus and brevis
● Extensor indicis
● Extensor digiti minimi
● Abductor pollicis longus (abducts thumb)

Clinical significance: radial nerve

Radial nerve injuries are commonly due to compression, for example by leaning or lying on the arm for
extended periods, excessively tight plaster casts or prolonged tourniquet use. It can also be damaged
by fractures of the humerus or radius, or by stab wounds.
Radial nerve injury results in loss of innervation to the muscles of the posterior compartments of the
arm and forearm. This manifests as numbness in the radial nerve distribution and a “wrist drop”
deformity with very weak extension of the elbow, wrist and fingers.

Median nerve (C5/C6/C7/C8/T1)

Origin

Lateral and medial cords of the brachial plexus

Sensory supply

The median nerve supplies sensation to:

● Thenar eminence, the lateral ⅔ of the palm of the hand

● Palmar aspect of lateral 3½ fingers
● Dorsal fingertips of lateral 3½ fingers

Motor supply

All muscles of the anterior compartment of forearm except flexor carpi ulnaris and the medial two parts
of flexor digitorum profundus.

The median nerve, therefore, supplies pronator teres, flexor carpi radialis, palmaris longus, flexor
digitorum superficialis, the lateral two parts of flexor digitorum profundus, flexor pollicis longus and
pronator quadratus.

These forearm muscles flex the wrist, the proximal interphalangeal joints of all four fingers and the
distal interphalangeal joints of the index and middle fingers. They also pronate the forearm and abduct
the wrist.

The median nerve also supplies the LOAF muscles of the hand:

● Lateral two lumbricals

 ● Opponens pollicis
● Abductor pollicis brevis
● Flexor pollicis brevis

The lumbricals flex the MCPJs and extend the IPJs of the index and middle finger.

The muscles of the thenar eminence flex, abduct and oppose the thumb.

Clinical significance: median nerve

The median nerve is most commonly damaged by compression within the carpal tunnel at the wrist,
resulting in numbness of the median nerve distribution to the hand, wasting of the thenar eminence,
weak grip strength and a “hand of benediction” deformity due to an inability to flex the index or middle
fingers.

It can also be injured by supracondylar fractures of the humerus and stab wounds or lacerations to the
forearm or wrist.

Ulnar nerve (C8/T1)

Origin

Medial cord of the brachial plexus

Sensory supply

The ulnar nerve supplies sensation to:

● Hypothenar eminence
 ● Medial ⅓ of the palm of the hand
● Palmar aspect of the medial 1½ fingers
● Medial ⅓ of the dorsum of the hand
● Dorsal aspect of the medial 1½ fingers

Motor supply

The ulnar nerve supplies just two muscles in the anterior compartment of the forearm:

● Flexor carpi ulnaris, which flexes and adducts the wrist

● The medial two parts of flexor digitorum profundus, which flex the distal interphalangeal
joints (DIPJs) of the ring and little fingers.

It also supplies the intrinsic muscles of the hand except the LOAF muscles supplied by the median
nerve. These can be remembered as the HILA muscles:

● Hypothenar eminence
● Interossei
● Medial two lumbricals
● Adductor pollicis

The hypothenar eminence consists of opponens digiti minimi, flexor digiti minimi brevis and abductor
digiti minimi, which oppose, flex and abduct the little finger respectively.

The palmar interossei adduct the fingers, whilst the dorsal interossei abduct them.

The medial two lumbricals flex the MCPJs and extend the IPJs of the ring and little fingers.

Adductor pollicis adducts the thumb. This muscle does not form part of the thenar eminence and
actually lies deep beneath it as a separate structure.

Clinical significance: ulnar nerve

The ulnar nerve may be injured by supracondylar fractures of the humerus, medial epicondylar
fractures, stab wounds to the forearm or wrist, or compression at either the cubital tunnel in the elbow
or Guyon’s canal in the wrist.

This results in numbness in the ulnar distribution to the hand, wasting of the hypothenar eminence
and intrinsic muscles of the hand, a “claw hand” deformity due to an inability to extend the ring and
little fingers, and weak finger abduction and adduction.

Prosected specimen

This labelled prosection specimen sums up the parts of the brachial plexus.

Figure
2. Labelled prosection showing the parts of the brachial plexus
Brachial plexus injuries

It is possible for the brachial plexus to be injured at the level of the cervical nerve roots or trunks in the
neck, causing a syndrome of neurological deficits and clinical features.

The most common injuries are Erb’s palsy, Klumpke’s palsy and Horner’s syndrome.

Brachial plexus injuries are rare, but are often appear in exams to test anatomical knowledge.

Types of brachial plexus injury

There are several different types and pathologies of nerve injuries:

● Neurapraxia: the nerve is stretched and damaged but not torn

● Rupture: the nerve is torn at a point along its length
● Axonotmesis: the nerve fibre is partially severed: the axon and myelin sheath are
torn but the surrounding epineurium, perineurium and connective tissues are
preserved. Natural recovery is possible through axonal regeneration, so these
injuries can often be managed conservatively.
● Neurotmesis: the nerve fibre completely severed. There is no prospect of natural
recovery, so this type of injury requires surgery to restore function.
● Avulsion: the nerve root is torn off the spinal cord at its origin
● Post-traumatic neuroma: a growth of scar tissue at the site of a previous nerve injury, which
leads to compression

Upper brachial plexus injury: Erb’s palsy

Site of the injury

Superior trunk of the brachial plexus (C5/C6) – occasionally the middle trunk (C7) is also involved

Mechanism

Traction injury due to excessive lateral neck flexion towards the contralateral side, or excessive
shoulder depression, resulting in violent stretching +/- tearing of the upper portion of the brachial
plexus

Causes

The classical cause is a traction injury during difficult or obstructed childbirth, such as shoulder
dystocia requiring emergency forceps delivery, or breech presentations with the arms raised above the
head.

The stretching mechanism can also be caused by falls onto the neck/shoulder or excessive traction on
the arm, for example during sports (often known as “burner syndrome”), motorbiking accidents or
attempts to reduce a shoulder dislocation.

It can also result from direct trauma by clavicle fractures, gunshot wounds or stab injuries.

Nerves injured

● Musculocutaneous nerve
● Axillary nerve
● Suprascapular nerve
● Nerve to subclavius

Clinical features

Erb’s palsy results in loss of sensation to the skin over the “sergeant’s patch”, lateral arm and lateral
forearm.

There is wasting of the deltoid, supraspinatus and infraspinatus muscles and the anterior
compartment of the arm, with loss of shoulder abduction and external rotation, elbow flexion and wrist
supination. This results in a “waiter’s tip” deformity characterised by a limp, adducted, internally
rotated shoulder, an extended elbow and a pronated wrist.

The biceps reflex is absent. Wrist flexion, wrist extension and finger movements are usually preserved.
If C7 is involved, elbow and wrist extension will also be diminished and the wrist may be held in fixed
flexion.

Severely affected untreated babies may be left with stunted arm growth, joint contractures and
circulatory problems.

Lower brachial plexus injury: Klumpke’s palsy

Site of injury

Inferior trunk of the brachial plexus (C8/T1)

Mechanism

Traction injury due to excessive force placed on an abducted shoulder results in violent stretching +/-
tearing of the lower portion of the brachial plexus

Causes

Klumpke’s palsy is the rarest brachial plexus syndrome. The most common cause is a traction injury
during difficult childbirth, such as an arm presentation requiring force on the arm to successfully
deliver the rest of the baby.

The same mechanism can also be caused by a falling person grabbing onto something (e.g. grabbing a
branch when falling from a tree), or by other causes of excessive abduction such as motorbiking
accidents.

Direct trauma can result from clavicle fractures, gunshot wounds or stabbings.
It can also be caused by compression of the lower plexus by a mass in the root of the neck, such as
lymphoma or lung cancer.

Nerves injured

Median and ulnar nerves

Clinical features

Klumpke’s palsy results in loss of skin sensation in the median and ulnar distributions of the hand, the
sensory supply to the lateral dorsum of the hand is preserved as this comes from the radial nerve.
There is also loss of sensation in medial forearm and arm.

The injury affects the motor nerve fibres to all small intrinsic muscles of the hand. There is therefore
generalised wasting of hand muscles with a loss of MCPJ flexion, IPJ extension, finger abduction and
adduction, and opposition.

The anterior compartment of the forearm is also affected, resulting in loss of wrist flexion. This results
in a “claw hand” deformity affecting all four fingers, characterised by IPJ flexion and MCPJ
hyperextension at rest, and an inability to extend the fingers. The wrist is classically held supinated.

Shoulder and movements are usually preserved. T1 injuries may be associated with Horner’s
syndrome, and there may be associated superior/middle trunk injuries.

Total/complete brachial plexus injury

Site of injury

Entire brachial plexus C5/C6/C7/C8/T1

Mechanism
Usually severe or complex traction injuries sustained during difficult childbirth

High-speed road traffic accidents, resulting in violent stretching +/- tearing of all nerve roots

Nerves injured

Entire brachial plexus

Clinical features

Totally limp, dangling, atrophied and numb upper limb with associated Horner’s syndrome

Horner’s syndrome

Site of injury

T1 nerve root

Mechanism

Any injury to the T1 nerve root associated with loss of sympathetic function

Causes

Acquired Horner’s syndrome may be due to a traction injury, direct trauma, cerebral pathology or
extrinsic compression. The classical cause is usually a Pancoast tumour in the apex of the lung.

Nerves injured
T1 nerve root, sympathetic trunk or stellate ganglion

Clinical features

Horner’s syndrome causes loss of sympathetic nerve supply to the face and neck. The key features are
ipsilateral partial ptosis (drooping eyelid), miosis (constricted pupil), anhidrosis (loss of sweating on
affected side of face), dilatation lag (slowly dilating pupil) and enophthalmos (eye appears sunken).

With traction injuries there may be associated Klumpke’s palsy. With nerve root compression there
may be associated hand/arm pain and wasting of the intrinsic muscles of the hand, this should trigger
alarm bells for an underlying malignancy.

Thoracic outlet syndrome

Site of injury

Trunks of brachial plexus, classically the inferior trunk but can affect any or all of the trunks

Mechanism

Compression of neurovascular structures at the level of the thoracic outlet between the root of the
neck and the upper thorax. The thoracic outlet is bounded by the scalene muscles, the first rib, and the
clavicle.

Causes

Causes of thoracic outlet syndrome include:

● Congenital fibrous tissue band

● Cervical rib
● Musculoskeletal abnormality
● Acquired pathology such as whiplash trauma, repetitive strain/sports injury
 ● Malunion of a clavicular fracture
● Underlying malignancy such as lymphoma or lung cancer.

Nerves injured

Classically, the ulnar nerve, but may affect any combination of nerves supplying the upper limb.

In about 5% of cases, compression may also affect the subclavian artery and/or vein which run with
the trunks through the thoracic outlet.

Clinical features

Thoracic outlet syndrome leads to a combination of neurological and vascular symptoms. Neurological
features include wasting of the intrinsic muscles of the hand with reduced grip strength, and some
patients may experience numbness or paraesthesia. Some patients report neuropathic pain affecting
the arm, shoulder and neck.

Vascular symptoms tend to be brought on or exacerbated by vigorous overhead activities, such as

lifting or throwing. Subclavian artery compression causes aching or painful claudication of the arm,
pallor and extreme cold; severe cases may lead to ischaemia with ulceration and gangrene. Subclavian
vein compression can result in diffuse arm pain and swelling, venous distension and cyanosis.

Venous obstruction may lead to thrombosis of the subclavian or axillary veins, which is known as
Paget-Schroetter syndrome.

Brachial neuritis / plexitis

Site of injury

Any part of brachial plexus – may affect individual nerves/cords or entire plexus

Mechanism
Inflammatory reaction against the nerves of the brachial plexus

Causes

Brachial neuritis may be idiopathic (Parsonage-Turner syndrome). Commonly recognised triggers

include bacterial, viral or parasitic infections, immunisations, trauma, childbirth, recent surgery or
radiotherapy, and systemic inflammatory disorders such as lupus, polyarteritis nodosa or other types
of vasculitis.

It may also occur as part of a polyneuropathy, such as Guillain-Barre syndrome or motor neurone
disease, or as a paraneoplastic syndrome associated with lymphoma.

Nerves injured

Any component of brachial plexus

Clinical features

Brachial neuritis classically starts with the sudden onset of excruciating shoulder and arm pain on the
affected side, followed by the development of paralysis and atrophy of affected muscle groups within a
couple of weeks.

The onset of symptoms may be preceded by prodromal symptoms of a systemic infection, or another
immunological trigger such as trauma, surgery or immunisation. The syndrome is particularly
associated with hepatitis E virus infection, occurring bilaterally in up to 10% of cases.

Patients usually present acutely due to the severity of the pain and tend to support the affected arm in
an adducted, internally rotated position. The phrenic nerve or lower cranial nerves may also be
affected in a minority of cases.

Summary diagram
Figure 3. Brachial plexus diagram

Introduction

The wrist joint connects the distal end of the radius to the carpal bones in the hand. It is a synovial joint,
meaning the bones are separated by a narrow cavity filled with synovial fluid.

The wrist joint is an articulation of the distal head of the radius, the articular disc that overlies the distal
ulna, and the proximal carpal bones of the hand (scaphoid, lunate and triquetrum). The carpal bones
are arranged in a convex formation, whereas the other articular surface is concave.

The main movements of the wrist are flexion and extension and to a lesser degree abduction and
adduction of the hand. Due to the radial styloid process extending more distal than the ulnar styloid, the
hand can be adducted more than it can be abducted.

Bony structure

The wrist joint involves the distal head of the radius, scaphoid, lunate and triquetrum. The ulna is not
directly involved as it is covered by a layer of cartilage which acts as the articulating surface.

Radius

Proximal articulation: capitulum of humerus

Distal articulation: scaphoid and lunate (carpal bones)

The radius is the site of insertion for several muscles of the forearm, which act to move the hand and
wrist.

Ulna

Proximal articulation: trochlea of the humerus

Distally, the ulna is covered by a layer of articular cartilage which then articulates with the carpal bones.

The ulna is not directly involved in the wrist joint but forms the distal radioulnar joint.
 Figure 1. The radius and ulna.1

Clinical relevance: Colles’ fracture4

Colles’ fracture is the most common type of distal radius fracture and is commonly caused by a fall on an
outstretched hand (FOOSH). This type of fracture is common in patients with osteoporosis. Young
patients sustain Colles’ fractures in high-impact trauma, such as contact sports.

On plain X-ray, Colles’ fracture can be diagnosed if there is a fracture of the distal radius with posterior
displacement of fragments. In up to 50% of cases, there is also a fracture of the ulnar styloid process.

Management of Colles’ fracture involves closed reduction and cast immobilisation, as well as
pharmacological bone protection for those at risk of osteoporosis. For more information, see the Geeky
Medics guide to wrist fractures.
Carpal bones

The scaphoid and lunate articulate with the radius. The triquetrum articulates with the layer of cartilage
that overlies the distal end of the ulna.

For more information, see the Geeky Medics guide to the bones of the hand.

Figure 2. X-ray of the hand and wrist.2

Clinical relevance: Scaphoid fractures3

The scaphoid is the most commonly fractured carpal bone, and fractures most commonly occur at the
waist of the scaphoid. This most commonly occurs following a fall onto an outstretched hand (FOOSH).

Scaphoid fractures are particularly common in the elderly, and those with osteoporosis. Symptoms
include pain and tenderness just below the base of the thumb and loss of pinch and grip strength.
Scaphoid fractures may be complicated by avascular necrosis, as the majority of its blood supply comes
from the radial artery. The artery enters the distal part of the bone to supply the proximal portion, and
therefore in fractures the blood supply to the proximal bone can become cut off, causing necrosis.

Movements of the wrist

Movement of the wrist is brought about by muscles in the forearm. For more information, see the Geeky
Medics guide to the muscles of the anterior forearm and muscles of the posterior forearm.

Table 1. An overview of the movements of the wrist.

Compartment Layer Muscle Action

Anterior Superficial Flexor carpi ulnaris Flexion and

adduction

Palmaris longus* Flexion

Flexor carpi radialis Flexion and

abduction

Pronator teres Pronation

 Intermediate Flexor digitorum Flexion
superficialis

Deep Flexor digitorum profundus Flexion

Pronator quadratus Pronation

Posterior Superficial Extensor carpi radialis Extension and

longus abduction

Extensor carpi radialis Extension and

brevis abduction

Extensor digitorum Extension

Extensor carpi ulnaris Extension and

adduction

Deep Supinator Supination

*This muscle is absent in approximately 15% of the population

The carpal tunnel

One of the most clinically important aspects of the wrist joint is the carpal tunnel. This is formed on the
anterior aspect of the wrist, by the flexor retinaculum superiorly and the deep arch of the carpal bones
inferiorly.

The bones that make up the deep arch include the hamate, capitate, trapezoid and trapezium.

The flexor retinaculum is a thick ligament made of connective tissue.

The carpal tunnel contains tendons of flexor digitorum superficialis (4), flexor digitorum profundus
(4) and flexor pollicus longus, which act to move the digits. The carpal tunnel also contains the median
nerve.

Figure 3. The Carpal Tunnel.3

Clinical relevance: Carpal tunnel syndrome

The carpal tunnel is a small space, meaning its contents can easily be compressed. Symptoms of carpal
tunnel syndrome are produced due to compression of the median nerve.

Carpal tunnel syndrome may be idiopathic, meaning there is no obvious cause, or may result due to
inflammation and swelling of the tendons and tendon sheaths. Common causes of carpal tunnel include
rheumatoid arthritis, pregnancy and repetitive use of the tendons.

Symptoms of carpal tunnel syndrome include pain and pins and needles in the hand, as well as
weakness of the thenar muscles. There are two important signs that help to identify carpal tunnel:
 ● Tinel’s sign: tapping over the area reproduces symptoms
● Phalen’s sign: symptoms are triggered by wrist flexion

Treatment of carpal tunnel syndrome includes wrist splinting, particularly at night, as well as
corticosteroid injections into the space.

Severe cases may be treated with decompressive surgery involving division of the flexor retinaculum. For
more information, see the Geeky Medics guide to carpal tunnel syndrome.

Other structures in the wrist

There are many other tendons, blood vessels and nerves that pass through the wrist into the hand.

Superficial to the flexor retinaculum, the ulnar nerve, ulnar artery, and palmaris longus tendon enter the
hand. Posteriorly to the carpal bones, the remaining tendons enter, along with the radial artery.

Lower limb

Lower limb
Contents of the femoral triangle: NAVEL

From lateral to medial:

● Nerve
● Artery
● Vein
● Empty space
● Lymphatics

Femoral triangle boundaries: SAIL

● Sartorius
 ● Adductor longus
● Inguinal Ligament

The intrinsic muscles of the foot

All intrinsic muscles of the foot originate and insert within it. They have two main
actions. The first is to stabilise the foot and support the arches to maintain foot
structure. The second is to aid the actions of the muscles of the lower leg to
produce fine movements of the toes.

All intrinsic muscles of the foot are innervated by branches of the tibial nerve
except for extensor digitorum brevis, which is innervated by the deep fibular
nerve. Blood supply is from branches of the posterior tibial and dorsalis pedis
arteries.

These muscles can be further subdivided into two groups, the dorsal and
plantar muscles of the foot.

Dorsal group muscles

The dorsal group consists of two muscles, extensor digitorum brevis and
extensor hallucis brevis. Both muscles act to extend the toes.

They originate on the superolateral surface of the calcaneus and pass

underneath the tendons of extensor digitorum longus as they pass over the
dorsal aspect of the foot. Both muscles are innervated by the deep fibular nerve
(S1, S2).

Extensor digitorum brevis

Extensor digitorum brevis originates on the superolateral surface of the
calcaneus.

The muscle belly then divides into three and runs along the dorsal surface of the
foot before forming three tendons.

These tendons insert onto the lateral aspect of the tendons of extensor
digitorum longus, which in turn insert on the base of the proximal phalanx of the
second, third and fourth toes.

Extensor hallucis brevis

Similar to extensor digitorum brevis, extensor hallucis brevis originates on the

superolateral surface of the calcaneus and runs along the centre of the dorsal
surface of the foot before inserting onto the base of the proximal phalanx of the
big toe.

Plantar group muscles

The plantar group consists of all the other intrinsic muscles of the foot and can be
subdivided into four layers, going from superficial (plantar) to deep (dorsal)
within the foot.

First layer

The first layer is the most superficial and consists of abductor hallucis, flexor
digitorum brevis and abductor digiti minimi. They lie immediately deep to the
plantar aponeurosis in the sole of the foot.
 Figure [Link] layer of the plantar group.1

Abductor hallucis
Abductor hallucis is the most medial muscle of the first layer and forms the
medial border of the foot.

It originates from the medial process of the calcaneal tuberosity and inserts as
a tendon on the medial side of the base of the proximal phalanx of the big toe.

As its name suggests, it acts to abduct and additionally flexes the big toe at the
metatarsophalangeal joint.

It is innervated by the medial plantar nerve, a branch of the tibial nerve derived
from nerve roots S1-3.

Flexor digitorum brevis

Flexor digitorum brevis lies centrally in the first layer. It originates as a tendon on
the medial process of the calcaneal tuberosity before becoming a muscle that
runs centrally over the plantar aponeurosis. It then divides into four tendon
branches.

These tendons split into two before running around the lateral aspects of each
tendon of flexor digitorum longus and inserting on the margins of the middle
phalanx.
It acts to flex the lateral four toes at the proximal interphalangeal joint and is
innervated by the medial plantar nerve, a branch of the tibial nerve derived from
nerve roots S1-3.

Abductor digiti minimi

Abductor digiti minimi is the most lateral of the muscles in the first layer.

It originates from several places: the medial and lateral aspects of the calcaneal
tuberosity, and a fibrous band of connective tissue which connects calcaneus to
metatarsal V.

Abductor digiti minimi forms a tendon that runs along the surface of metatarsal V
before inserting onto the lateral side of the base of the proximal phalanx on the
little toe.

It acts to abduct the little toe at the metatarsophalangeal joint and is innervated
by the lateral plantar nerve, a branch of the tibial nerve derived from nerve roots
S1-3.

Clinical relevance: Plantar fasciitis

The plantar aponeurosis is a thickening of the deep fascia that runs along the
sole of the foot. It acts to support the longitudinal arch of the foot and protects
deep foot structures.

Plantar fasciitis is a common injury in runners and is often presents in primary

care.

Clinical features include pain in the heel and the sole of the foot, typically worse
after long periods of rest or immediately after exercising.
Most cases of plantar fasciitis will improve with conservative management, such
as rest, non-steroidal anti-inflammatories and stretching.

Second layer

The second layer of the plantar group consists of two muscle groups, the
lumbricals and the quadratus plantae. These lie immediately deep to the first
layer and act on toes two to five.

Figure 2. Intermediate muscles of the left sole

(plantar view).1

Quadratus plantae
The quadratus plantae muscle has two origins, one head originates from the
medial surface, and the second from the lateral surface of the calcaneal
tuberosity.

It inserts onto the lateral side of each tendon branch of flexor digitorum longus
near where the tendons originate in the proximal half of the foot.
Along with the flexor digitorum longus, it acts to flex toes two to five and is
innervated by the lateral plantar nerve.

Lumbricals
The lumbricals are four muscles that originate from the tendons of flexor
digitorum longus and insert onto the medial aspect of the extensor hoods of
toes two to five.

First lumbrical:

● Origin: medial side of the tendon of flexor digitorum longus associated

with the second toe
● Insertion: medial side of the extensor hood of the second toe

Second lumbrical:

● Origin: medial side of the tendon of flexor digitorum longus associated

with the third toe
● Insertion: medial side of the extensor hood of the third toe

Third lumbrical:

● Origin: medial side of the tendon of flexor digitorum longus associated

with the fourth toe
● Insertion: medial side of the extensor hood of the fourth toe

Fourth lumbrical:

● Origin: medial side of the tendon of flexor digitorum longus associated

with the fifth toe
● Insertion: medial side of the extensor hood of the fifth toe

These muscles act to resist excessive extension of the metatarsophalangeal

joints and flex the interphalangeal joints during walking.

The first lumbrical is innervated by the medial plantar nerve, whilst the second,
third and fourth lumbricals are innervated by the lateral plantar nerve.
Third layer

The third muscle layer of the plantar group lies deep to the second layer, and
consists of three muscles: flexor hallucis brevis, adductor hallucis and flexor
digiti minimi brevis.

Figure 3. Deep muscles of the foot.1

Flexor hallucis brevis

Flexor hallucis brevis has two heads of origin:

● Medial head: originates from the tendon of tibialis posterior

● Lateral head: originates from the plantar surface of the cuboid bone

These heads converge to form the belly of the muscle, which in turn divides
forming two tendons for insertion on the medial and lateral side of the base of the
proximal phalanx of the big toe.

As its name would suggest, the muscle acts to flex the big toe at the
metatarsophalangeal joint and is innervated by the medial plantar nerve.

Adductor hallucis
Adductor hallucis also has two heads of origin, the transverse head and the
oblique head.

The transverse heads originate separately on the metatarsophalangeal joints of

the lateral three toes and run medially before converging and inserting onto the
lateral side of the base of the proximal phalanx of the big toe, along with the
oblique head.

The oblique head originates from the plantar surfaces of the bases of the
second to fourth metatarsals as well as the fibularis longus sheath. It runs
anterolaterally along the foot before converging with the transverse heads and
inserting onto the lateral side of the base of the proximal phalanx of the big toe.

These muscles act to adduct the big toe at the metatarsophalangeal joint and
are innervated by the lateral plantar nerve.

Flexor digiti minimi brevis

Flexor digiti minimi brevis originates from the base of the fifth metatarsal and
the adjacent sheath of the fibularis longus tendon. It inserts onto the lateral
side of the base of the proximal phalanx of the little toe.

It acts to flex the little toe at the metatarsophalangeal joint and is innervated by
the lateral plantar nerve.

Fourth layer

The fourth layer is the deepest of the plantar group and comprises the dorsal
and plantar interossei. Both groups act to resist extension of the
metatarsophalangeal joints and flex the interphalangeal joints, however have
opposite actions on the movement of the toes in the long axis.

Dorsal interossei
There are four dorsal interossei that run along with the metatarsal bones of the
second to fifth toes. They all act to abduct the toes.
The second toe is associated with two dorsal interossei and can therefore be
abducted to either side of its long axis.

The third and fourth toes are only associated with dorsal interossei on their
lateral border, and so can only be abducted in this direction.

Origins: sides of the adjacent metatarsals

Insertions: extensor hoods and bases of the proximal phalanges of the second
to fifth toes

Actions:

● Abduction of the third, fourth and fifth toes at the metatarsophalangeal

joints
● Resist extension of the metatarsophalangeal joints
● Flexion of the interphalangeal joints

Innervation:

● All are innervated by the lateral plantar nerve

● The first and second dorsal interossei are also innervated by the deep
fibular nerve (S2, S3)

Plantar interossei
The plantar interossei consist of four muscles that act together to adduct the
third, fourth and fifth toes.

Origin: medial sides of the third to fifth metatarsals

Insertion: extensor hoods and base of the proximal phalanx of the third, fourth
and fifth toes

Actions:

● Adduction of the third, fourth and fifth toes at the metatarsophalangeal

joints
● Resist extension of the metatarsophalangeal joints
● Flexion of the interphalangeal joints
Innervation: lateral plantar nerve (S2, S3)

Clinical relevance: Morton’s neuroma

Morton’s neuroma is an enlargement of the common plantar nerve. It is usually

found in the space between the third and fourth toes (the site where the medial
and lateral plantar nerves merge).

Typical clinical features include sharp or dull pain in the space between the third
and fourth toes, worsened by wearing shoes or walking.

Management of Morton’s neuroma includes non-steroidal anti-inflammatory

injections and surgical removal.

Key points
● The extrinsic muscles of the foot originate in the lower leg, whilst the
intrinsic muscles are contained within the foot itself.
● The intrinsic foot muscles act to stabilise the foot and support the
arches, as well as to produce fine movement of the toes.
● The intrinsic foot muscles can be divided into two main groups, plantar
and dorsal.
● The dorsal group consists of extensor digitorum brevis and extensor
hallucis brevis which both act to extend the toes.
● The plantar group consists of four muscle layers, going from superficial
(plantar) to deep (dorsal) within the foot.
 ● All of the muscles are innervated by branches of the tibial nerve (nerve
roots S1-3), except extensor digitorum brevis, which is innervated by
the deep fibular nerve.
● Vascular supply is derived from branches of the dorsalis pedis and
posterior tibial arteries.

Introduction
The ankle joint is a synovial hinge joint that connects the lower leg with the
foot. It is made up of three articulating points: the distal end of the tibia, the
distal end of the fibula, and the talus of the foot.

The primary movements of the ankle joint include plantarflexion and

dorsiflexion, with limited inversion and eversion. The joint is stabilised by
several ligaments.

Movement in the ankle is produced by muscles located in the lower leg. These
muscles are split into the anterior, lateral and posterior compartments of the
lower leg and each compartment is responsible for a different movement at the
ankle joint. For more detail, please see the Geeky Medics guide to the muscles
of the lower leg.

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Bony structure
The ankle joint consists of three bony surfaces: the distal end of the tibia, the
distal end of the fibula, and the superior surface of the talus in the foot.
Tibia

The tibia lies on the medial side of the lower leg and is larger than the fibula. It is
the main weight-bearing bone in the leg and has two articulating surfaces. At
the proximal end, the tibial condyles articulate with the medial and lateral
condyles of the femur to form the knee joint. At the distal end, the bone widens
and forms the medial malleolus on the medial aspect of the ankle.

The inside aspect of the medial malleolus articulates with the talus to form the
medial side of the ankle joint. On the lateral end of the tibia is the fibular notch,
which articulates with the distal end of the fibula. This forms the distal
tibiofibular joint.

Fibula

The fibula is the smaller of the two bones in the leg and lies on the lateral side. It
is not weight-bearing, and its primary function is to act as a site of muscle
attachment. The head of the fibula articulates proximally with the inferior lateral
tibial condyle, forming the proximal tibiofibular joint.

Similarly to the tibia, the distal end of the fibula expands to form the lateral
malleolus, the deep aspect of which articulates with the talus to form the lateral
ankle joint.

Talus

The talus is part of the proximal group of tarsal bones in the foot. It lies superior
to the calcaneus and posterior to the navicular bone. The superior surface is
elevated in order to articulate with both the tibia and fibula within the ankle joint.
The upper surface of this elevation articulates with the distal end of the tibia, the
lateral surface articulates with the lateral malleolus of the fibula and the medial
surface articulates with the medial malleolus of the tibia.
 Figure 1. The bony structure of the tibia and fibula.1

Clinical Relevance: ankle fractures

Ankle fractures are a common injury and are assessed using the Ottawa ankle
rules. These are highly specific and designed to identify clinically significant
injuries and reduce the use of unnecessary X-ray imaging. For more information
on X-ray interpretation, see the Geeky Medics guide to ankle X-ray interpretation.

An ankle X-ray is indicated if there is bony tenderness in any of the following

areas:

● The distal 6cm of the posterior tibia

● The distal 6cm of the posterior fibula
● Tip of the medial malleolus
● Tip of the lateral malleolus
AND an inability to weight bear immediately after the injury and in the
emergency department.

A foot X-ray is indicated if there is bony tenderness in any of the following areas:

● The base of the fifth metatarsal

● The site of the navicular bone

AND an inability to weight bear immediately after the injury and in the
emergency department.

Blood supply and innervation

The blood supply to the ankle joint is derived from the malleolar branches of the
fibular artery and the anterior and posterior tibial arteries.

The joint is innervated by branches of the tibial nerve and the deep fibular
nerve.

Ligaments

Distal tibiofibular joint

The distal aspects of the tibia and fibula are held together by a band of
connective tissue called a syndesmosis. This is a type of fibrous joint that
prevents the two bones from separating and therefore holds the talus in place
within the ankle joint. The function of the syndesmosis is, therefore, to strengthen
and stabilise the ankle joint and allow efficient weight-bearing.

Medial (deltoid) ligament

The medial side of the joint is supported by the medial (deltoid) ligament. This
is triangular in shape and originates just above the medial malleolus. It is
sub-classified into four parts based on the four inferior points of insertion:
tibionavicular, tibiocalcaneal, posterior tibiotalar and anterior tibiotalar.

Lateral ligament

Three ligaments form the lateral ligament of the ankle: anterior talofibular,
posterior talofibular, and calcaneofibular.

Figure 2. Ligaments of the ankle.2

Clinical Relevance: ankle sprains

Ankle sprains can be classified into either inversion or eversion sprains.

Inversion sprains are much more common and occur when the lateral supporting
ligaments are stretched or torn. The most commonly injured is the talofibular
ligament. In severe sprains, the ligament can rupture and may be associated
with distal fibular fractures.

Eversion sprains are less common and often occur following an awkward landing
from a jump. These result in damage to the deltoid ligament on the medial
aspect of the joint. In severe cases, this may lead to dislocation of the joint and
a bimalleolar (Pott’s) fracture.

The mainstay of treatment for ankle sprains is RICE: rest, ice, compression and
elevation. More severe injuries associated with fractures may require prolonged
immobilisation or surgery.

Muscles
The movement of the ankle joint is produced by muscles of the lower leg. The
table below summarises the muscles that act to move the ankle.

Table 1. Summary of the muscles that act to move the ankle joint.
Compartmen Muscle Action at ankle
t joint

Anterior Tibialis anterior Dorsiflexion,

inversion

Extensor hallucis longus Dorsiflexion

Extensor digitorum Dorsiflexion

longus

Fibularis tertius Dorsiflexion,

eversion

Posterior Gastrocnemius Plantarflexion

Soleus Plantarflexion
 Plantaris Plantarflexion

Tibialis posterior Plantarflexion,

inversion

Lateral Fibularis longus Plantarflexion,

eversion

Fibularis brevis Eversion

Introduction
The knee joint is the largest joint in the body and connects the thigh with the
lower leg. It is made up of two joints, the tibiofemoral joint (between the tibia
and the femur), and the patellofemoral joint (between the patella and the femur).

The primary movements at the knee joint include flexion and extension, with
limited internal and external rotation. The joint is stabilised by several of
ligaments.

There are many muscles responsible for movement at the knee joint which,
which are located in the thigh. These muscles are split into the anterior, medial
and posterior compartments of the thigh and each compartment is responsible
for a different movement at the knee joint.
 🔥
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Bony structure
The knee joint is a compound joint, consisting of two different articulation points
that combine to form the joint.

It may also be referred to as a bicondylar joint as movement primarily occurs in

one plane (flexion, extension). The two articulations in the knee are found
between the tibia and the femur (tibiofemoral) and the patella and the femur
(patellofemoral).

Figure 1. Knee joint anatomy.3

Articular surfaces
The distal end of the femur and the proximal end of the tibia are both covered by
a layer of hyaline cartilage, which allows the bones to slide over each other
easily.
The proximal end of the tibia is also covered by two menisci. Each meniscus is a
C-shaped piece of fibrocartilage. There are two menisci found on the proximal
tibia, the medial meniscus and the lateral meniscus which are connected by a
series of ligaments that run through the joint capsule.

The function of the menisci is to assist the movement of the bones over each
other, to deepen the tibial plateau and to act as a form of shock absorption.

Figure 2. Menisci of the knee joint

Clinical relevance: Meniscal tears

Injury to the menisci can occur secondary to sudden twisting of the knee (e.g. in
football) which tears the meniscal tissue. Typically symptoms of meniscal injuries
include sudden-onset pain, a popping sensation, locking and instability of
the knee joint.

Clinical relevance: Osteoarthritis of the knee

Osteoarthritis is a degenerative disease that primarily occurs in synovial joints. It

involves degeneration of the articular surfaces. Symptoms of severe
osteoarthritis include joint stiffness, reduced range of joint movement and
joint pain.
Typical X-ray findings of osteoarthritis include:

● Joint space narrowing

● Subchondral sclerosis: hardening of the bone beneath the joint surface
● Osteophyte formation: small bony growths around the edges of the joint
● Bony cyst formation

For more information, see the Geeky Medics guide to osteoarthritis.

Ligaments

Patellar ligament

The patellar ligament is a continuation of the quadriceps femoris tendon from

the anterior compartment of the thigh. It runs over the patella, attaching around
the margins of the bone, and inserts onto the tibial tuberosity.

Cruciate ligaments

Anterior cruciate ligament (ACL)

The ACL originates on the lateral condyle of the femur and inserts onto the
anterior intercondylar area. Its function is to prevent anterior displacement of
the knee. The ACL is the most commonly injured ligament of the knee.

Posterior cruciate ligament (PCL)

The PCL originates on the medial condyle of the femur and inserts onto the
posterior intercondylar area. It prevents posterior displacement of the knee.

Figure 3. Cruciate ligaments of the knee joint

Collateral ligaments

Medial collateral ligament (MCL)

The MCL, also known as the tibial collateral ligament, runs from the medial
epicondyle of the femur and inserts onto the medial condyle of the tibia. Its
function is to stabilise the knee by preventing medial movement (maintaining the
hinge-like properties of the joint). Without the MCL, the knee would have a
valgus deformity. The MCL is also connected to the medial meniscus.

Lateral collateral ligament (LCL)

The LCL, or fibular collateral ligament, runs from the lateral epicondyle of the
femur and inserts onto the head of the fibula. It is smaller in size compared to
the MCL and is more flexible due to not being connected to any other structures
within the knee joint. This flexibility makes the ligament less susceptible to
injury. Its function is to prevent lateral movement of the knee joint and to
prevent varus deformity.
 Figure 4. Collateral ligaments of the knee joint

Bursae
The knee is surrounded by a series of bursae which act to reduce friction within
the joint. Bursae are sacs filled with synovial fluid.

The largest bursae in the knee joint is the suprapatellar bursa, located above
the patella between the femur and the quadriceps femoris muscle. The function
of this bursa is to allow the quadriceps tendon to move freely over the femur. This
is a communicating bursa, meaning it is attached to the synovial membrane of
the joint capsule.

Other anterior knee bursae include the prepatellar bursa (between the patella
and the skin) and the superficial and deep infrapatellar bursae (between the
patellar ligament and the skin, and the patellar ligament and the tibia
respectively).

There are also four smaller bursae located in the posterior knee which function to
reduce friction between the joint capsule, ligaments and tendons of several
muscles in the leg (gastrocnemius, biceps femoris, popliteus).
 Figure 5. Ligaments and bursae of the knee joint.4

Blood supply and innervation

Blood supply of the knee joint

Blood supply to the knee originates from the femoral, popliteal and lateral
circumflex femoral arteries. In combination with smaller arteries from the leg,
they form an anastomotic network to supply the joint.

Figure 6. Arterial supply of the knee joint

Innervation of the knee joint

Innervation of the joint involves branches of the obturator, femoral, tibial and
common fibular nerves.

Muscles
There are three groups of muscles that act to move the knee. These muscles
originate from the anterior, posterior and medial compartments of the thigh.

Anterior compartment

The anterior compartment of the thigh acts to extend the knee joint. The
compartment contains the quadriceps muscles. There are seven muscles
located in this compartment, five of which act on the knee joint including:

● Vastus medialis
● Vastus intermedius
● Vastus lateralis
● Rectus femoris
● Sartorius

The vastus muscles and rectus femoris join distally to form the quadriceps
tendon which inserts onto the patella, stabilising it during movement.
 Figure 7. Muscles of the anterior thigh.4

Posterior compartment

The posterior compartment of the thigh contains three long muscles, collectively
known as the hamstrings. These muscles are biceps femoris,
semitendinosus, and semimembranosus.

The hamstrings contribute to flexion at the knee joint. As well as causing flexion,
biceps femoris acts to externally rotate the knee when partly flexed.
Semitendinosus and semimembranosus work together to internally rotate the
knee.

For more information, see the Geeky Medics guide to the muscles of the
posterior thigh.
Figure 8. Biceps femoris

Figure 9. Semitendinosus
 Figure 10. Semimembranosus

Medial compartment

The medial compartment of the thigh contains six muscles, however only the
gracilis muscle acts on the knee joint (the rest all act on the hip). This muscle
causes flexion of the knee and runs from the ischiopubic ramus on the pelvis to
the proximal tibia.
 Figure 11. Gracilis
Table 1. Summary of the compartments of the thigh, including the muscles and
relevant actions at the knee joint.

Compartment Muscle Action on the knee

Anterior Vastus medialis Extension

(quadriceps)

Vastus intermedius
 Vastus lateralis

Rectus femoris

Sartorius

Medial Gracilis Flexion

Posterior Biceps femoris Flexion

(hamstrings)

External rotation

Semitendinosus Flexion

Internal rotation
Semimembranosus
Introduction
The bones of the lower limb can be divided into two functional components; the
bones of the pelvic girdle and the bones of the free lower limb.

The bones of the free lower limb include the femur, tibia, fibula, patella and
bones of the foot.

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Femur
The femur is the longest and heaviest bone in the body, at approximately a
quarter of an individual’s height. It transmits weight from the hip bones to the tibia
during standing and is the origin and insertion of many muscles and ligaments.

The femur can be divided into three anatomical areas: the superior end, the
femoral shaft and the inferior end.

The superior end of the femur

The superior end of the femur, together with the acetabulum of the pelvis, forms
the hip joint.

The superior end of the femur consists of a head, a neck and greater and
lesser trochanters. Each plays an important role in the hip joint and serve as
origins and insertion points of several muscles.
Head of the femur
The round head of the femur is covered with articular cartilage, except centrally
where there is a depression known as the fovea where the ligamentum teres
attaches.

The neck of the femur

The neck of the femur is trapezoid in shape, with the narrower end supporting
the head and the wider base connecting to the shaft.

Where the femoral neck and shaft of the femur join, there are two large bony
prominences called trochanters. This site is demarcated by the
intertrochanteric line – an elevated rough ridge that runs from the greater
trochanter round the lesser trochanter to continue posteriorly and inferiorly as the
spiral line.

Greater trochanter
The greater trochanter is the larger of the two and sits laterally, projecting
superiorly and posteriorly. It provides attachment for several muscles; the
gluteus medius, the gluteus minimus and the piriformis.

Lesser trochanter
The lesser trochanter sits medially, projecting from the posteromedial aspect of
the neck-shaft junction, providing an attachment point for the tendon of the
iliopsoas muscle, the primary flexor of the thigh.

Intertrochanteric crest/ridge
The intertrochanteric crest/ridge joins the greater and lesser trochanters
posteriorly. It is smoother and more prominent than the intertrochanteric line.
There is a round prominence on the crest called the quadrate tubercle, to which
the quadratus femoris attaches.
 Figure 1. Anterior view of the right femur

The femoral shaft

The shaft of the femur connects the superior and inferior ends, transmitting the
body’s weight to the knee joint and tibia.

The majority of the shaft is smooth and rounded, except posteriorly where there
is a broad rough line called the linea aspera. This provides attachment for the
thigh adductors and splits inferiorly to form the medial and lateral
supracondylar lines. The popliteal surface is found between these medial and
lateral supracondylar lines. The medial supracondylar line terminates at the
adductor tubercle, the insertion site of the adductor magnus.

Proximally, the lateral border of the linea aspera becomes the gluteal
tuberosity, where the gluteus maximus attaches.

The shaft is slightly convex (bowed) in nature. This convexity acts to bring the
knee joint to lie medially in comparison to the hip joint and thus closer to the
body’s centre of gravity. This improves overall stability.
 Figure 2. Posterior view of the right femur

The inferior end of the femur

The medial and lateral femoral condyles make up the inferior end of the
femur. These are rounded prominences which articulate with the menisci
(crescentic plates of cartilage), the tibial condyles posteriorly and the patella
anteriorly to form the knee joint.

The two condyles merge anteriorly to form the patellar surface but are
separated posteriorly by an intercondylar fossa.

The patella surface is a shallow longitudinal depression which articulates with

the patella.

The intercondylar fossa is a deeper depression which contains facets for the
attachment of the anterior cruciate ligament (ACL) and the posterior cruciate
ligament (PCL). The anterior cruciate ligament (ACL) attaches to the medial
aspect of the lateral condyle and the posterior cruciate ligament (PCL) to the
lateral aspect of the medial condyle.

The medial and lateral epicondyles are bony projections that arise from the
non-articular areas of the condyles. The medial epicondyle is significantly larger
and lies superiorly to the adductor tubercle. These epicondyles provide
attachment for the medial and lateral collateral ligaments of the knee joint.

Figure 3. The lower extremity of the right femur,

viewed from below

Clinical relevance: Femoral fractures

Femoral fractures most commonly occur in the elderly population due to

increased falls risk and reduced bone mineral density.

The most common site of fracture is the neck of the femur due to being the
narrowest and weakest part of the bone. These fractures can be classified into
two main groups, intracapsular and extracapsular. Where the fracture occurs is
important for consideration of surgical treatment and the risk of avascular
necrosis (see our neck of femur fracture article for more details).

When fractures of the femur occur, the distal fractured bone is typically pulled
superiorly and rotated laterally, due to the action of muscles. This is exhibited
clinically as a shortened and externally rotated leg.
 Figure 4. Right hip fracture with leg
shortened and externally rotated.

Tibia and fibula

The tibia and fibula are the two bones of the leg. The tibia, which lies medially,
articulates with the femoral condyles superiorly and the talus bone inferiorly,
transmitting the body’s weight. The fibula lies laterally and is connected to the
tibia by an interosseous membrane.

While the tibia is the main weight-bearing bone in the leg, the fibula provides
stability to the ankle joint and acts as an attachment site for muscles.

Tibia

The tibia is the second largest bone in the body. It lies anteromedially in the leg
and flares outwards at either end to provide an increased area for articulation
and weight-bearing.
Superiorly these flares form the medial and lateral condyles, that together form
a flat articular surface, the tibial plateau. This articulates with the femoral
condyles to form the knee joint.

The tibial plateau’s articular surface is separated medially and laterally by the
intercondylar eminence formed by two intercondylar tubercles. These
tubercles fit into the intercondylar fossa between the femoral condyles and
provide attachments for the menisci and knee ligaments, which hold the knee
joint together.

The shaft of the tibia is shaped like a prism with three borders; anterior, posterior
and lateral, and three surfaces; medial, lateral and posterior.

The anterior border of the tibia is prominent in the leg, forming what is
commonly referred to as the shin. The patella ligament attaches to the tibial
tuberosity which lies at the superior aspect of the anterior border.

On the posterior border, there is a rough diamond-shaped ridge, known as the

soleal line, which runs inferomedially. This line is the origin for the soleus
muscle: a member of the posterior muscle compartment in the leg.

The interosseous membrane is attached to the lateral border, connecting the

tibia and fibula. For this reason, the lateral border is often also referred to as the
interosseous border.

Inferior to the interosseous membrane at the distal end of the lateral border there
is a groove, the fibular notch, which accommodates the distal end of the fibula.
This is referred to as the distal tibiofibular joint. The syndesmosis present at
this joint is clinically important for the classification of ankle fractures.

As previously described, the tibia widens inferiorly to assist with weight-bearing

and articulates with the tarsal bones to form the ankle joint. The medial
malleolus is formed by the tibia, medially.
 Figure 5. Anterior and posterior view of the tibia and
fibula

Fibula

The fibula is a slender bone which lies posterolaterally to the tibia.

The proximal end of the fibula consists of a head, with a pointed apex and a
small neck. Superiorly, the head of the fibula articulates with the fibular facet on
the lateral tibial condyle; this forms the proximal tibiofibular joint.

The shaft of the fibula is twisted in nature and like the tibia is shaped like a
prism, with three borders and three surfaces; anterior, lateral and posterior. The
muscles of the leg are divided into compartments and each surface of the fibular
faces its retrospective compartment.

Inferiorly, the fibula sits in the fibular notch of the tibia medially, forming the
distal tibiofibular joint. The syndesmosis present at this joint is clinically
important for the classification of ankle fractures.
The fibula is prolonged laterally forming the lateral malleolus. This is more
prominent than the medial malleolus.

The fibula is connected to the tibia via the interosseous membrane, and unlike
the tibia has no role in weight-bearing.

The fibula’s main function is to serve as an attachment point for muscles,

providing insertion for one and origin for eight.

Clinical relevance: Tibial fractures

Fractures of the tibia and fibula are common, with fracture of one typically
associated with fracture of the other. However, if only one bone, either the tibia or
fibula is fractured, there is often minimal displacement because the other bone
acts as a splint.

As the anterior surface of the tibia is subcutaneous, the tibial shaft is the most
common site for a fracture. Compound fractures occur commonly due to direct
and indirect trauma.

Fracture examples:

● Direct trauma: a car bumper directly hits the tibial shaft, causing a
fracture.
● Indirect trauma: during a football tackle, the individual’s leg turns whilst
their foot remains fixed in position.

Fractures of the tibia can also occur proximally and involve the tibial plateau. In
these fractures, the tibial condyles may be broken and there is often
associated injury to the menisci and ligaments of the knee.
 Figure 6. A tibial plateau fracture

Clinical relevance: Fractures of the fibula

Fibular fractures commonly occur approximately 2-6cm from the inferior end
of the lateral malleolus. They are often associated with fractures of the distal
tibia and dislocation of the ankle joint.

When a patient slips and their foot is forced into an extreme inverted or everted
position, this can put strain on the distal fibula and lateral malleolus causing a
fracture.

The location of the fracture line in relation to the distal tibiofibular syndesmosis
(the connection between the distal ends of the tibia and fibula) is important for
management. Fibular fractures at the ankle joint can be classified into type A, B,
C, by the Danis-Weber classification (often known just as the Weber
classification).
 Figure 7. Danis-Weber classification of
ankle fractures (types A, B and C)

Patella
The patella bone, more commonly referred to as the kneecap, is found at the
anterior aspect of the knee joint.

It is triangular in shape with two surfaces: anterior and posterior.

On its posterior surface, the patella has two facets medial and lateral which
articulate with the medial and lateral condyle of the femur respectively.

The patella is held in place by two ligaments. Superiorly, at its base, it is

attached to the quadriceps tendon and inferiorly, at its apex, it is attached to
the patellar ligament.

Due to its suspension within the quadriceps tendon, the patella is classified as
a sesamoid bone.

The main function of the patella is to assist in leg extension, by increasing the
force the quadriceps tendon has on the femur. It also acts to protect the anterior
aspect of the knee joint.
 Figure 8. Anterior and posterior view of the patella

Clinical relevance: Patellar dislocation

The patella can be easily dislocated with forceful sudden twisting of the knee
(i.e. a twist of the femur on the tibia). This twisting motion causes the patella to
shift to the side due to the tibia shifting and the quadriceps muscle contracting
to maintain the stability of the body. The patella is pulled laterally because it
wants to remain in line with the muscle. Patellar dislocation typically presents
with intense pain and swelling.

Patellar dislocations are frequent occurrences, particularly in young female

athletes. Fortunately, the patella can often be relocated back into the groove with
assisted extension of the knee.

Introduction

Introduction
The hip joint connects the pelvis to the lower limb. It is a synovial ball and
socket joint made up of the head of the femur and the acetabulum of the
pelvis. The hip is designed to be highly stable and allows sufficient
weight-bearing, with limited mobility.

There are many movements at the hip including flexion, extension, adduction
and abduction, internal and external rotation, and circumduction. The joint is
stabilised by a series of muscles and ligaments.

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2000 anatomy flashcards in addition to advanced features such as spaced repetition.

Articular surfaces
The hip is a multiaxial ball and socket joint. The articulating surfaces are the
acetabulum of the pelvis and the head of the femur. Both of these surfaces are
covered by a layer of hyaline cartilage, which helps to reduce friction and aid
movement of the joint.

The acetabulum lies on the inferolateral aspect of the bony pelvis and forms a
‘cup’ for articulation with the head of the femur. The non-articular portion of the
acetabulum contains loose connective tissue.

Figure 1. Articulating surfaces of the hip.1

Clinical relevance: fractured neck of femur

A fractured neck of femur is usually caused by a fall, especially in older people.

However, it can be caused by other conditions such as cancer. Fractures can be
intracapsular or extracapsular depending on the location of the break, and
management is guided by this.

The leg is typically held in a shortened and externally rotated position and
patients are unable to weight bear.

Intracapsular fractures may be associated with avascular necrosis. This is

because the blood supply to the head of the femur runs retrospectively up the
femoral neck into the joint capsule, and can be disrupted following a fracture.

Figure 2. Right-sided sub-capital

fracture.2

Clinical relevance: osteoarthritis of the hip

Osteoarthritis is a degenerative disease that primarily occurs in synovial joints. It
involves degeneration of the articular surfaces. Symptoms of severe
osteoarthritis include joint stiffness, reduced range of joint movement and
joint pain.

Typical X-ray findings of osteoarthritis include:

● Joint space narrowing

● Subchondral sclerosis: hardening of the bone beneath the joint surface
● Osteophyte formation: small bony growths around the edges of the joint
● Bony cyst formation

Figure 3. Osteoarthritis of the hip.3

For more information, see the Geeky Medics guides to osteoarthritis and
interpreting a hip X-ray.

Ligaments
There are several ligaments which act to stabilise the hip joint.

The inferior aspect of the acetabulum is formed by the transverse acetabular

ligament and helps to stabilise the inferior part of the hip joint.
The fovea of the femoral head is connected to the acetabulum via the ligament
of the head of the femur (ligamentum teres). This ligament contains a branch of
the obturator artery, which supplies the head of the femur.

The iliofemoral, pubofemoral and ischiofemoral ligaments spiral around the

outer surface of the joint and act together to stabilise the hip.

Table 1. Ligaments of the hip

Location on Origin Insertion

the hip joint

Iliofemoral Anterior Between Intertrochanteric

ligament anterior line of the femur
superior iliac
spine (ASIS)
and acetabulum

Pubofemoral Anteroinferior Iliopubic Combines with

ligament eminence the deep
iliofemoral
ligament
Ischiofemoral Posterior Ischium Greater
ligament trochanter of the
femur

Figure 4. Ligaments of the hip joint.4

Bursae
Bursae are sacs filled with synovial fluid that act to reduce friction within the joint.
The two main bursae in the hip are the trochanteric and iliopsoas bursae.

Clinical relevance: bursitis

Bursitis involves inflammation of a bursa and commonly occurs in the hip as

trochanteric bursitis.

Patients commonly report a dull aching pain on the lateral aspect of their hip,
which is worse when they lie on the affected side. Treatment of simple bursitis is
rest, ice, and over-the-counter painkillers such as paracetamol or ibuprofen.

Blood supply and innervation

Blood supply to the hip joint

Arterial supply to the hip is mainly from the obturator artery, as well as the
medial and lateral circumflex arteries, branches of the femoral artery, and the
superior and inferior gluteal arteries. Branches of these arteries form an
anastomotic network around the joint.
Innervation of the hip joint

Nerves supplying the hip joint include branches of the femoral nerve, obturator
nerve and the superior gluteal nerve.

Muscles
There are several groups of muscles that act to move the hip joint. Movements
at the hip joint include flexion, extension, internal and external rotation, adduction
and abduction.

Table 2. Muscles acting on the hip joint.

Muscle group Muscle Action on the hip

Deep gluteal Piriformis External rotation,

abduction

Obturator internus

Gemellus superior +
inferior
 Quadratus femoris External rotation

Superficial gluteal Gluteus maximus Extension, internal

rotation, abduction

Gluteus medius Internal rotation,

abduction

Gluteus minimus

Anterior Psoas major Flexion

compartment of the
thigh

Iliacus

Sartorius

Rectus femoris
Medial compartment Gracilis Adduction
of the thigh

Pectineus Adduction, flexion

Adductor longus Adduction, internal

rotation

Adductor brevis

Adductor magnus

Obturator externus External rotation

Posterior Biceps femoris Extension, external

compartment of the rotation
thigh

Semitendinosus Extension, internal

rotation
Semimembranosus