FOURTH EDITION
AIDS TO THE
EXAMINATION
,
OF THE PERIPHERAL
NERVOUS SYSTEM
,
Iw. B. SAUNDERS I
On hc:half of the l,U.JrJ,nlOn of Brain
FOURTH EDITION
AIDS TO THE
EXAMINATION
OF THE PERIPHERAL
NERVOUS SYSTEM
~ W.B. SAUNDERS
EDINBURGH • LONDON • NEW YORK • PHILADELPH IA • ST LOUIS • SYDNEY • TORONTO 20 0 0
W. B. SAUNDERS
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PREFACE
In 1940 Dr George Riddoch was Consultant Neurologist to the Army. He realised the
necessity of providing centres to deal with peripheral nerve injuries during the war. In
collaboration with Professor J. R. Learrnonth, Professor of Surgery at the University of
Edinburgh, peripheral nerve injury centres were established at Gogarburn near
Edinburgh and at Killearn near Glasgow. Professor Learmonth wished to have an
illustrated guide on peripheral nerve injuries for the use of surgeons working in general
hospitals. In collaboration with Dr Ritchie Russell, a few photographs demonstrating the
testing of individual muscles were taken in 1941. Dr Ritchie Russell returned to Oxford in
1942 and was replaced by Dr M. J. McArdle as Neurologist to Scottish Command. The
photographs were completed by Dr McArdle at Gogarburn with the help of the
Department of Medical Illustration at the University of Edinburgh. About twenty copies in
loose-leaf form were circulated to surgeons in Scotland.
In 1943 Professor Learmonth and Dr Riddoch added the diagrams illustrating the
innervation of muscles by various peripheral nerves modified from Pitres and Testut,
(Les Neufs en Schemas, Doin, Paris, 1925) and also the diagrams of cutaneous sensory
distributions and dermatomes. This work was published by the Medical Research
Council in 1943 as Aids to the Investigation of Peripheral Nerve Injuries (War Memorandum
No.7). It became a standard work and over the next thirty years many thousands of
copies were printed.
It was thoroughly revised between 1972 and 1975 with new photographs and many new
diagrams and was republished under the title Aids to the Examination of the Peripheral
Nervous System (Memorandum No. 45), reflecting the wide use made of this booklet by
students and practitioners and its more extensive use in clinical neurology, which was
rather different from the war time emphasis on nerve injuries.
In 1984 the Medical Research Council transferred responsibility for this publication to
the Guarantors of Brain for whom a new edition was prepared. Modifications were made to
some of the diagrams and a new diagram of the lumbosacral plexus was included.
Most of the photographs for the 1943, 1975 and 1986 editions show Dr McArdle, who
died in 1989, as the examining physician. A new set of colour photographs has been
prepared for this edition, the diagrams of the brachial plexus and lumbosacral plexus have
been retained, but all the other diagrams have been redrawn.
ACKNOWLEDGEMENIS
The Guarantors of Brain are very grateful to:
Patricia Archer
PhD
for the drawings of the brachial plexus;amld~ JIlIkMm;
Ralph Hutchings for the photography
Paul Richardson for the artwork and diagrams
Michael Hutchinson
MB BDS for
advice on the neum-anatomy
Sarah Keer-Keer (Harcourt Publishers) for her help and ~1t..
CONTENTS
Introduction
1
Spinal accessory nerve
Brachial plexus
4
Musculocutaneous nerve
Axillary nerve
Radial nerve
Median nerve
Ulnar nerve
12
14
16
24
30
Lumbosacral plexus
37
Nerves of the lower limb
Dermatomes
3
38
56
Nerves and root supply of muscles
Commonly tested movements
62
60
INTRODUCTION
This at las is intended as a guide to t he exami natio n of pat ients with lesion s of periph eral
nerves and nerve roots.
These examinations sho uld, if pos sible , be co nduc te d in a qu iet room where pat ien t
and examiner will be free fro m distracti on . For both moto r and sen so ry testing it is
important th at the patient sho uld first be warm. The nature and object of th e tests sh ould
be explained to th e patient so t ha t his in teres t and co-op erat ion are sec ure d. If e it her
shows signs of fatig ue, t he session sho uld be discont in ued a nd resum ed late r.
Motor testing
Amuscle may act as a prime mover, as a fixator, as an antagonist, o r as a synergist. Thus, flexor
carpi ulna ris acts as a prime mover when it flexes and ad du c ts t he wrist; as a fixator when it
immobilises the pisiform bone du ring contractio n of th e adductor d igit i mini mi; as an
antagonist when it resist s extens ion of th e wrist; and as a synergist when th e digits, but not
the wrists, are extended.
As far as possible the acti o n o f ea ch muscle sho uld be obse rved se pa rate ly and a not e
made of th ose in whic h power has be en re tai ne d as well as of th ose th a t are wea k o r
paralysed. It is usual to examine th e power of a muscle in relatio n to th e movement of a
single joint. It has lon g been customary to use a 0 to 5 sca le for recordi ng muscle powe r,
but it is gene rally recogn ised th at su bd ivisio n of grade 4 may be help ful.
o
1
2
3
4
5
No co ntraction
Flicker or t race of co nt raction
Active movement, with gravity eliminate d
Active moveme nt against gravity
Active movement against gravity and resistan ce
Normal powe r
Grades 4-, 4 and 4 +, may be used to ind icat e movem ent aga ins t slight. mod erat e an d
strong resistan ce respec t ively.
The models employed in this work were not c hose n becau se th ey showe d unusual
muscular developm en t; th e ease wit h whic h the co nt rac tio n of muscles is ide nt ified varies
with the build of the pat ien t, and it is essent ial th at th e examiner sho uld both look for an d
endeavour to feel the contraction of an accessible mu scle and/or th e movement of its
tendon. In most of the illustrations the opti mu m point for palpation has been marked.
Muscles have been arranged in the order of th e origin of th eir mot or supply from nerve
trunks, whic h is co nvenie nt in many exam inations. Usu ally o nly one met hod of test ing
each muscle is shown but, whe re ne cessa ry, mult iple illust rat ion s ha ve been include d if a
muscle has more th an one impo rta nt act io n. Th e examiner sho uld apply th e tes ts as they
are illustrated , becau se th e techniques show n will eliminate man y of t he tr ap s for t he
inexperience d provided by 'trick' movem en ts. It sho uld be noted that each of th e method s
used tests, as a ru le, the acti on of mu scles at a single joint.
When testing a movement, th e limb sh ould be firmly su pporte d proximal to the rel evant
joint, so that th e test is confi ned to the chose n muscle group and do es not require th e
patient to fix the limb proximally by mu scle co nt ract ion. In this book, thi s principle is
SPINAL ACCESSORY NERVE
Fig. 1 Trapezius (Spinal accessory nerve and 0 , ( 4 )
The pat ient is elevati ng t he shoul der against resistan ce.
Arrow: t he thick u pp er part of t he mu scle can be seen and felt .
Fig.2 Trapezius (Spinal accessory ne rve a nd O . ( 4)
The pat ient is pushing th e palms of the hands hard against a wall with t he elbows fu lly
extended. Arrow: th e low er f ibres of t rapezius can be seen and felt .
-::lY
'
-e
r
-
CY
~
_ _
Fig. 3
~~~
,":";'i
1
~ \\
Diagram of t he brachial plexus, it s bra nche s and t he muscles whic h th ey su pply.
t o lat issi m u s d o rsi - - - - - - - - - - - - - - - - - - -_--'
'rh o rec c c c r se r nerve
M ed ial c u t aneous n er v e 0 1a rm
M ed ia l c u t an eous ner ve of fo rea rm
ULN AR NERVE -
an d t er es m ajor
t o su bsc apular is
Su bsca p u la r nerve s
><
cCIl
T2
~::r::
J->
r
MEDIAN NE RVE
--------
I~
I
O::!
L'1
."
LA TERAL CO RD
RA DI AL N ERV E -.......-......
A x illary n erv e
Mu scu lo c u ta neous n~rve ~
POS TE RIO R CO RD
Sup ra scapul ar ne rve to su p ras pi n at us and i nfras pi n at us
l on g th or ac ic ne r ve t o serr at us an t erior
D orsa l sc ap u l ar ne rve t o rh om boids
BRACH IAL PLEXUS
5
fig.4 The approximate a rea wit hin which sensory cha nges ma y be fo und in complet e
lesions of t he bra chia l plexus «(5. (6, (7. C8, T1).
Hg.5 The appr oximate area within which se nsory changes ma y be fou nd in lesions of t he
upper roots «( 5.(6) of t he brach ial plexus.
6
BRACH IAL PLEXUS
Fig.6 The approximate area wi t hin which sensory chang es may be found in lesions of th e
lower roo ts (C8. T1) of t he brachial plexus.
BRAC HIAL PLEXUS
Fig.7
7
Rhomboid s (Dorsal scapul ar nerve; ( 4, (5)
The patient is pressing the p alm of his hand backwards against th e examiner's han d.
Arrow: t he muscle bel lies ca n be felt a nd some times seen.
Fig. 8 Serratus a nterior (long t horacic ne rve ; (5, e6, 0 )
The patient is pushing against a w all. The left se rratus a nte rior is pa ra lysed a nd t he re is
winging of the scapula.
8
IlRACHIAL PLEXUS
Fig. 9 Pecto ralis Majo r: Clavicular Head {lateral pectora l nerve; ( S, (6)
The upper a rm is above th e ho rizonta l a nd t he pa tien t is push ing fo rwa rd agai nst the
examiner's hand. Arrow: t he clavicular head of pect oralis major can be seen and fel t .
Fig. 10 Pecto ralis Majo r: Ste rnocostal He ad (latera l and media l pe cto ral ne rves; (6, ( 7,
C8)
The patie nt is a dd uct ing the uppe r a rm ag a inst resistan ce .
Arrow: the sterno-costal head ca n be seen a nd fe lt.
BRACHIAL PLEXUS
f ig . 11
9
Suprasp inat us (Sup rascapular nerve; (S, ( 6)
The patient is abduct ing the uppe r arm aga inst resist a nce.
Arrow: t he muscle belly can be f elt and somet imes seen.
Fig. 12
Inf raspinatus (Suprascapular nerve; (5. ( 6)
The patient is ext ernall y rotating the up pe r arm at t he sho ul d er ag ai nst resist a nce. The
examine r's rig ht hand is re sist ing t he movement and sup port ing t he forearm wit h t he
elbow at a rig ht angle; h is left hand is sup porti ng the elbow and preventin g abd uction o f
the arm . A rrow: the m uscle bell y can be seen and felt.
10
BRACH IAL PLEXUS
..
Fig.13 lat issimu s Dorsi (Thor acod orsal ne rve ; ( 6, C7, C8)
The upper ar m is hor izontal and t he pat ient is addueting it against resista nce. Lo w er
arro w : t he muscle belly ca n be see n and felt. The upper a rrow points to teres major.
Fig . 14
latissimus Dorsi (Thoracod orsal ne rve; (6, C7, C8)
The Mu scle bell ies can be f elt to cont ract w hen the patient coug hs.
HKACl IIA L PLEXUS
Fig.1 5 Teres Major (Subscapular nerve; (S, (6, 0)
The patient is adducting the elevated upper arm against resistance.
Arrow: the muscle belty can be seen and felt .
11
MUSCULOCUTANEOUS NERVE
Coracobrachi alis
----1111
MUSCULOCUTANEOUS
NERVE
- - - - - +1
Brachialis
lateral cutaneous nerve
altha forearm
Fig. 16
--II
\
Diagram of t he musculo cut aneous nerve, it s majo r cut aneous b ranch an d t he
muscles w h ich it supplies.
M USCULOTANEQUS N ERVE
13
Fig. 17 The ap proximate ar ea wi thin w hic h sensory cha nges may be found in lesions o f
the musculocutaneous nerve. (The distribution o f t he lat eral cutaneous nerve of t he
forearm.)
Fig.1 8
Biceps (Musculocutaneous nerve ; (S. (6)
The pat ient is flexing the supinated forearm against res ist a nce.
Arrow: t he muscle belly ca n be seen and felt .
AX ILLARY NERVE
AXILlARY NERVE
------)~~~~~r;;::::==:: :
UP PER CUTANEOUS
NE RVE OF THE ARM -
-
----.......,
\J'-- - -i-- - - -
RADIAL NERVE
~_o-+------- Teres minor
Fig _19 Diagram of the axillary nerve, its major cutaneous branch and the muscles wh ich
it suppnes.
o
f ig_20 The app ro xima te area w ithin w hich sensory changes may be fou nd in lesions of
the axillary nerve.
AXILLA RY NERVE
Fig. 21 Deltoid (Ax illary nerve; {S. ( 6)
The pat ient is abducting the upper ar m against resistance.
Arrow: the anterior and mi d dle f ibres of t he muscle can be seen and f elt .
Fig.22 Deltoi d (Axillary nerve; { 5, (6)
The patient is ret ract ing t he abducted upper a rm ag ainst resist ance.
Arrow: the posterior fibres of delt oid can be seen and felt.
15
RA DIA L NERVE
AX IUARY NERVE
- - - - -:.,-- 7'''':
Triceps . long head
- - - - - -1
Triceps . lateral head
- - - - - - - Trice ps, medtal hea d
1--1- - - - - - - Brachiol'adaall$
RADIAL NERVE
- -- -- ---1
Extensor carpi radaalis longus
- ---Il-'l
Exten sor ca rpi radialiS b revis
Supinator
Extensor ca rpi utnans
Extensor digllorum
- - - - --Il.....
POSTERIOR INTEROSS EOUS
NERV E (dee p branch )
-------r;:- ,
Exte nsor digiti mlnl mi
-----£:i
Abd uct or polliCis longus
Exten sor polllClS Ioogus
~
- - - ---\l""
Exten sor polliCiS brevis - - - --;;,..Extensor indios
SUPERFICIAL RADIAL N ERVE
Fig.23
suppli es.
Diagram of t he radial nerve, it s major cutaneous branch and the muscles w hich it
RADIAL NERVE
17
Fig.24 The a pp ro xima te a rea within which sensory cha nges ma y be found in hig h les io ns
of the radi al nerve (above th e origi n of t he posterior cutaneou s nerves o f th e arm and
forearm). The ave rage area is usua lly considera bly smaller. and absence of sensory cha nges
has been recorded .
Fig.2S The approximat e a re a w ithin which se nso ry cha nges may be fo und in lesions of
the radial nerve above the elbo w joint and below the ori gi n of the posterior cutaneo us
nerve of the forearm. (The distr ib ut ion of the su perfici al t ermin al br anch of th e rad ial
nerve.) Usual a rea sha ded, with dark blue line; lig ht blue lines show small and large ar ea s.
18
KAlJIAL N EKVE
Fig.26 Trice ps (Radia l ne rve; cs. C7, (8)
The patient is extending t he for ea rm at the e lbo w against res ista nce .
A rro ws: the long and la te ra l heads of the muscle (a n be se e n and felt .
Fig. 27
Ext ensor Carpi Radialis l o ng us (Radia l nerve; (5. ( 6)
The patient is extending an d abdu ct ing th e ha nd at t he wrist against resist a nce.
Arrows: t he muscle be lly a nd t endon (a n be fe lt and usua lly see n.
RA DI AL N ERVE
19
A
•
/
Fig _28
Brachiorad ialis (Radi al nerve; (5, (6)
The pat ient is flexing the forea rm against resist ance with the fo rearm midway between
pronation and supination. Arrow: the muscle belly (an be seen and felt.
20
Fig.29
RA DI AL N ERVE
Supinat or {Rad ial nerve ; ( 6. 0)
The patient is su pinating t he forearm aga inst restst e nce w ith t he forearm extended at the
elbow.
RAD IAL N ERVE 21
Fig. 30
Extensor Carp i Uln ar is {Poste r ior int ero sseous nerve; (7, ( 8)
The pat ien t is e xte ndi ng an d a dd ucti ng the ha nd a t t he wrist against resist an ce .
Arro ws: th e muscle belly and t he te ndon (a n be see n a nd felt .
Fig. 31
Ext ensor Digitoru m (Po st eri or intero sseous nerve; (7, C81
The patien t' s han d is firmly suppo rted by the exa mine r's rig ht ha nd. Ext e nsion at t he
metacarpopha langea l joints is ma intained a gainst the res ist a nce o f the fingers of t he
exemtner's left ha nd. A rr o w: t he muscle belly ca n be see n an d felt .
22
RADIAL NERVE
Fig. 32 Abductor Pollicis Longus (Posterior inte rosseou s ne rve; O . (8)
The pa t ient is ab ducting t he t humb at t he carpo -metece rpe t joint in a plan e at right
a ngles to the palm . Arrow: t he te nd on ca n be seen a nd felt an te rior a nd close ly adjacent
t o t he tendon of extensor
pctncrs br evis (d . Fig . 34).
Fig.33 Extensor Pollicis l ongus (Posterior int e rosseo us nerve; 0 , (8)
The pat ie nt is ext end ing the thumb at the interphalangeal joint against resistance.
Arro w: the tendon can be seen and felt.
RADIAL N ERVE
23
Fig_34 Extensor Poll id s Brevis (Posterior int erosseous nerve; C7. C8)
The patient is extending the thu mb at the metacarpophalangea l joint aga inst resistance.
Arrow: t he tendon ca n be seen and felt (d . Fig. 32).
MED IAN NERVE
1-- - - - - - - - - -
Pronal or teres
MED IAN NERVE
----- --1
- - - - - -tr;
Palman s longus -------1
h '-- -
Flexor carpi radialis
ANTERIOR INT EROSS EOU S NERVE
Flexor d1gitorum superliciahs
IlL
I
Flexor poIhcis longus
)
Pronator quadratus
------+_
1\+ - Motor
Abductor pomos breVI"'-===E~~~
Flexor pollicis brevis _
Opponens poll icis
Firstlumbrical
- -- - tV
'd 't--
Palmar branc h --I--~
Flexor retinaculum
Sensory
~Irt\
------!'-J---'!ll!
Second lumbr ica l
--'
Fig.35 Diagr am of t he median nerve. its cut aneous branches an d the muscles which it
su pplies . Note: th e white rectangle signifies that the muscle ind icat ed receives a part af its
nerve supply f rom another per ipheral nerve (d. Fig s. 45. 57 and 58).
MEDIAN NERVE
25
A
•
Fig.36 The app rox imate areas with in w h ich sensory changes may be fo und in lesion s of
the median nerve in: A t he fo rearm. B the carpal tunnel.
26
Fig _37
MEDIAN NERVE
Pronator Teres (M edia n nerve; ( 6, 0 )
The patien t is pro nat ing th e forear m aga inst resistance.
Arr ow: th e muscle belly ca n be fe lt a nd somet ime seen .
Fig. 38
Flexor Carp i Radial is (Me dian nerve; ( 6 , 0 )
The pat ien t is f lexing and abd uct ing t he hand at t he w rist aga inst resist ance.
Arrow : t he tendon (a n be seen and felt.
MEDIAN NERVE 27
Fig_39 fl exor Digi to ru m Superf icialis (M edian nerve ; C7, C8, Tt)
The pati ent is f lexing the f inger at th e proxima l int erphalageal joint against resistance
with t he proximal phalanx fixed . This test does not eliminate th e possibility of f lexion at
the pr oxim al inte r phalang eal jo in t being prod uced by flexor digit oru m profundus.
Fig.4O
Flexor Digitoru m Pro fundus I and II (Anterior interosseous nerve; ( 7, (8)
The patien t is flexing the distal pha la nx of the ind ex finge r agai nst resista nce with the
middle phala nx fixed .
28
Fig_41
MEDIAN NERVE
Flexor Pol lid s l ongu s (Ante rior interosseou s nerve; 0. C8)
The patient is fle xing the distal phalan x of the t hu mb aga inst resist ance w hile t he
proximal phalanx is f ixed.
Fig _42 Abductor Polli cis Brevis (M edi an nerve; C8, 11)
The pat ie nt is abducting the thum b at fight ang les t o the palm aga inst re sista nce .
Arrow: t he muscle can be seen and fe lt.
M £lJIAN NERVE
29
/
Fig.43 Oppo nens Pollicis (Median nerve; ca, T1)
The pat ien t is touching t he base of t he little finger wit h t he t hu mb against reslstence.
Fig. 44
lst lumb rical-Interosseous Muscle (Median and u lnar nerves; C8, 11 )
The pati ent is extendi ng the f inge r at t he p ro xim al inte rphalangeal joint aga inst
resista nce wit h t he metacar po phalange a l joint hyperextended a nd fixed .
ULNAR NERVE
I
I
- - - - - ULN AR NERVE
- - - MEDIAL CUTA NEOUS
NERVE OF THE ARM
Sensory
I
Dorsal cutaneous
branch
,
Palmar cutaneous
branch
Deep m otor branch
- -- -
Flexor carpi ulnaris
Superficial terminal
branches
I 11-- - - -
11-- - -
Flexor digilorum
profund us III & IV
MEDIAL CUTANEOUS
NERVE OFTHE
FOREARM
Mot or
- - - - - - - - - - -0<.
Adductor ponies
Flexor pollicis brevis
-,<;,,~
~~==
~~:nl~~s
~
Flexor
1st Dorsal interosseous
t st Palmar interosseous - - - - -/
Thi rd lumbrical
----------1'<'
i~
} digiti minimi
Four th lumb rical
Fig.4S Diag ram of t he ulnar nerve, it s cut aneous bra nches and the mu scles which it
supplies.
ULNAR NERVE
31
A
B
c
Fig_46 The approximate areas within which sensory changes may be found in lesions of
the ulna r nerve : A above the origin of t he do rsal cutaneous bran ch, B be low the origin of
the dorsal cutaneous branch and abo ve the origin of the pa lmar branch, C below the
origin of th e palmar b ranch.
32
ULNAR N ERVE
Fig.47 The app roxim at e area w it hi n w h ich sensory chang es may b e found in lesions of
the me di al cut aneous nerve of the fo rearm.
Fig.48
Flexor Carpi Ulnaris (Uln ar nerve;
a . C8. Tt )
The patient is abducti ng t he little finger against resist a nce. The tendon of uexc r car pi
ulnar is can be see n a nd felt (ar ro w) as t he muscle comes int o act ion to f ix the pisiform
bone from which abd uctor d igiti min im i ar ises. If flexor carp i utnens is in t act, the tendon is
seen even w hen abductor dig it i minimi is paral ysed (see also Fig. 49).
ULNAR NERVE
Fig.49
33
Flexor Carpi Ul naris (Ulnar nerve; 0 , C8, T1)
The patient is flex ing and adducting the hand at the wrist against resistance.
Arrow:the tendon can be seen and felt .
Fig. SO
Flexor Digitorum Prof un dus III and IV (Ulnar nerve; 0 , C8)
The patient is flex ing the distal inte rphalangeal joint against resistance while the middle
phalanx is fixed.
34
Fig . 51
ULNAR NERVE
Abduct or Digit i M inim i (Ulnar nerve; C8, 11)
The patient is a bducting t he litt le finge r against resist a nce.
Ar row: t he muscle bell y can be fe lt and seen.
Fig .52
Flexor Dig it i M in im i (Uln ar nerve; C8, 11 )
The patie nt is flexing t he litt le f inge r at t he metacarpophalangeal joint aga inst resist a nce
w ith t he finge r extended at bot h interpha langeal jo ints.
ULNAR NERVE
Fig _53 r trst Dorsal Interosseous Muscle (Ul nar nerve; C8, 11)
The patient is abducting the index finger aga inst resistan ce.
Arrow. the muscle belly can be felt and usually see n.
Fig . S4 Second Palmar Interosseous Muscle (Ulnar nerve; C8, T1)
The pat ient is adduct ing the index finger against resistance.
3S
36
ULNAR NERVE
Fig. 55 Adductor Polltcls (Ulnar nerve; C8. T1)
The patient is adducting the thumb at right angles to th e pa lm against the resistan ce of
t he exam iner's f inger.
LUMBOSACRAL PLEXUS
~
l.'.·...
H20\
Ilioh ypo g as t ric l'Ierv. - - - "
Ili o inguina l ne r ve - - _ ,
P so as muscle
To lUaeus ------~,
Ge n ito le mo ra l nerve ~
f EMO R AL NER ve <,
I~~~:::;;;~:-;N erve 10
levator a ni a nd
e xte rna l s p hl m::le,
Su pe rio r a n d
int erior gluteal
Perineal ne rve
SCIATIC NERVE -
-
_
Dor sa l ner ve of
penis or c li loris
,
Ner ve 10
s. rto rius mu s cle
Cutaneous nerv es
ot Ih igh
I\~"-~-{\\:~~""'- O B TU A "'TO R NERVE
branch es t o
______ Obtu ra to r e l le rn us
Medl.I ----=:::::=:'I;::=~
~ Addu ctor l ongu s
iJ~--1,~:'----: Adduct or brevi S
Ner v e s 10 quadric e p s
Rectu s tem cr ta
Addu ctor m a gnu s
-----J.
/ - - - --
VI Slu S l . t e ralis - - - - - \-J
Yu lus i n l er me dius
V. Sl u S me d ia li s
Sa p he nous nerve
/ - - - -
----\, - >.
..
------T---\\tit\-~k_---=--_1----:p~o~.~~rior
c ut0an
ne,v.
1 t.ou
hig sh
-----:--\,--\li t "\-'
SCIATIC NERVE
I-HI-- - - - - - - - - - - I+l --
Fig.56
Gr ac ili s
C uta ne o us
-
-
-
-
-
-
-
-
-
Comm o n peron eal
- - Tiblal
Diagram of t he lumbosacral plexus, its branches a nd t he muscles which t hey supp ly.
NERVES OF THE LOWER LIMB
Iliacus
FE MORAL NERVE
- - - - - + ---1:-1..... "••
""'=,---__
...
LATERAL CUTA NEOUS
NERVE OFTHETHIGH
OBTU RATOR NERVE
- - --1 \
Cu taneous branch
\c-~I~t::===-;;;;;;I
Adductor brevis
MEDIAL CUTA NEOUS
NERVe QFTHE T HIGH
Adductor longus
1t-!lI-- - - - - Rectus femoris
Quadriceps
semens
1
\,
vas tcs l.ateraIiS.
{
vastcs Intermedius
I'. - - - - - - - - -
- -/Y' L" .I
vastcs medi alis
INTERMEOI ATE CUTANEOUS
Gracilis
Add uctor mag nus
NERVe O F TH E THI GH - - - - - -;
COMMON PERONEAL NERVE
SUPERFICIAL PERONEAL NERVE -
/
'I,
(
-
Peroneus longus
/
Deep PERONEAL NERVE
)-Ii}+ - - - - - - - -
Extensor digilofum longus
Peroneus brevis - - - - - - - - LAT ERAL CUTANEOUS
NERVE OF THE CALF
- - - - - -/ 11
T ibial is anterior
-t- - - - -
Extensor hallucis longus
SAPHENOUS NE RVE
Peroneus terlius - - - - - - - - -
Fig. 57 Diagram of the nerves on t he anterior aspect of t he lower limb, their cutaneous
branches and t he muscles w hich t hey supply.
NERVES OF THE LOWER LIMB
39
1~~~r=========-(G, uteuSmediUS
['
SUPERIOR GLUTEAL
Gluteus minimus
NERVE -~--';~(<,,!-~
_
Tensor fasciae latae
Pir iformis
SCI ATIC NERVE
____~--'~L'\t_---'--',-- I N F E R IOR GLU TEAL NERVE
f '. \"-," ',f-- - - - - - - - Glu teus maximus
I f\-''f-- - - - POSTERIOR CUTANEOUS
Semitendi nosus
NERVE OF THE THI GH
Semim embranosus
Adduc tor ma gnus
-------11-'
- - - - - --j
)f- - - - - - - - -
)l- - - - - - - - -
,
Biceps, long head
Biceps. short head
COMMO N PERON EAL NERVE
)
Gastrocnemius. medial head -~~\
,I'i! -- - - - - - Gas trocne mius , lateral head
Soleus
Tibialis posterior
Flexor digilorum long us
TIBIAL NERVE
------It'l -;t-------- Flexor hallucis longus
- - - - - - --1
SURAL NERVE
CALCA NEAL BRANC H
- - - ---1
MEDI AL PLANTAR NERVE to' - - --"'' \
Abd uctor nauccs
Flexor digitorum b revis
Flexor hallucis brevis
Cutaneous branches
'i-'l-- ,
LATERAL PLANTAR NERVE to :
Abduc tor digiti minimi
Flexor digiti mini mi
Ad ducto r hallucis
Interossei
Cutaneous branches
Fig. 58 Diagram of the ne rves on the posterior aspect of the lowe r limb, th eir cutaneous
branches an d th e muscles which they suppl y.
40
NERVES OF TH E LOWER LIMB
.
Fig.59 The ap proxima te area within which se nsory changes may be found in lesion s of
t he la te ral cut an eous nerve of the th igh. Usua l area sha de d. wit h dark blue line; la rge
a rea indicated with light blue line .
..
Fig _60 The approximate area w ith in which sensory cha nges may be found in lesions of
the femoral nerve. (The distribution of the intermed iate and medial cutaneous nerves of
the t high and the saphenous nerve.)
NERVES OFTHE W WER LIMB
41
Fig. 61 The app roximate area within w hich sensory changes rna)' be found in lesio ns of
the obturator nerve.
Fig.62 The approximat e area w ithin w hich sensory changes may be found in lesions of
the post erio r cutaneous nerve o f the th igh.
42
NERVES OF THE WWER LIMB
Fig. 63 The app ro ximate area within w hich sensory changes may be found in lesions of
t he trun k of t he sciat ic nerve. (Mo dif ied from M.R.e. Special Report No. 54, 1920.)
Fig.64 The approximate ar ea within w hich sensory cha nges may be found in lesions of
bot h th e sciat ic and th e posterior cutaneous nerve of the t high.
NERVES OFTIIE LOWER LIM B 43
Fig. 65 The app roximat e area wit hin which sensory chan ges may be found in lesions of
the comm on peronea l nerve above the or igi n of the superficia l peron eal nerve. (Modified
from M.R.C. Special Report No. 54, 1920.)
J
Fig. 66 The approximate area wit hin which se nsory changes may be found in lesions of
th e deep peronea l nerve.
44
NERVES OF THE LOWER LIMB
Fig . 61 The approximate area within which sensory chan ges may be found in lesions of
t he su ral nerve.
Fig.68 The approximate a rea within w hich sensory cha nges may be found in lesions of
the t ibial nerve. (Modified f rom M.R.C. Specia l Report No. 54, 1920.)
NERVES OF TH E LOWER LIMB
45
- - - MED IAL PLANTAR
NE RVE
SURAL NE RVE
- ----i
LATERAL PLANTAR
NERVE
y'-- - -
+- - - - -
SAPH ENO US NERVE
CALCANEAL NERV E
Fig . 69 The approximate areas supplied by the cutaneous nerves to the sale of th e foot.
46
NERVES OF THE LOWER LIM B
J
}
Fig .70
Ilio psoas (Bra nches from l 1, 2 and 3 spinal nerves a nd femo ra l ne rve; l l , L2, l3)
The pat ient is fl exing the th igh at t he hip against resist ance wi t h th e leg fl exed at the
knee and hip .
Fig . 71 Qu adriceps Fem oris (Femoral nerve; 12. L3, L4)
The patie nt is extending t he leg against res istance wit h the limb flexed a t the hip an d
knee. To detect slig ht weakness. t he leg should be fully flexed at t he knee.
Arrow: t he muscle belly of rect us femor is ca n be seen and felt .
NERVES OF TI lE LOWER LIMB
47
,
I
Fig .72
Addu ct ors (Obt u rator nerv e; L2, l3, L4)
The patient lies on his back wi t h t he leg exte nded at t he knee. and is adducting th e limb
aga inst resist an ce. The muscle be llies can be felt .
•
I
Fig .73
Glu t eu s M ed ius an d M in im us (Super io r g lut ea l nerve; L4. lS . 51)
The pat ie nt lies o n his back and is internally rotating the thigh against resistance with the
limb flexed at t he hip and knee.
48
Fig. 74
LS, 5 1)
NERVES OFT HE LOWER LIM B
Gluteus Medius and Minimus and Tensor Fasciae Lat ae (Superior gluteal nerve; l 4,
The pa t ien t lies o n his ba ck wit h the leg extended and is abducting the limb against
res istance. Arrows: t he muscle be llies can be felt and sometimes seen.
Fig.7S Glu teus M aximu s (Inf er io r g luteal nerve; l S. $1. 52)
The patie nt lies on his back w it h t he le g ext e nded at the knee a nd is extending t he limb at
t he h ip ag ai nst resist an ce .
NERVES OF TH E LOWER LIMB
49
Fig. 76 Hamstring Muscles (Sciatic ne rve. Semitendinosus. semimem bra nosus and biceps;
L5. S1. S2)
The pa tien t lies o n his back w ith t he limb flexed at the hip a nd knee and is flexing t he le g
at the knee ag a inst resistance.
Fig.77 Ha mstring Musd es (Sdetic nerve . Sem iten d inos us, semime mbra nos us a nd bice ps;
l5, 51. 52)
The pat ient lies on his face and is flelCing the leg at t he knee aga inst resistance.
Arrows : t he t end ons of t he b icep s (laterally) and semitendinos us (medially) can be felt
an d usua lly see n.
SO NERVES O F THE LOWER LI MB
•
I
Fig. 78
Gastrocnem ius (Tib ial n erve; 51, 52)
The patient lies on his ba ck w ith th e leg extended a nd is plantar-flexing the foot aga inst
resist a nce . Arrow: the muscle bell ies ca n be seen an d felt. To detect slig ht wea kness. th e
patient should be asked t o st and on one foot. ra ise the he el fr om the gr ound and
ma int a in t h is position .
Fig. 79 Soleus (Tibia l ne rve; 51, 52)
The patient lies on h is ba ck with th e limb flexed at the h ip and knee and is plantar-flexing
the foot ag ainst resistance . The mu scle be lly ca n be felt and some tim es see n.
Arro w: t he Ach illes t e ndo n.
NERVES OF THE LOWER LIM B
f ig.80 Tibia lis Post e rior (Tibial ne rve; l4. lS)
The patient is inve rting t he foot aga inst resist a nce .
Arrow: the tendo n can be seen a nd fe lt.
Fig. 81 Flexor Dig itor um l o ng us. Flexor Hettuos Long us (Tibial nerve; l 5, 51, 52)
The pa t ie nt is flexing the toes against resistance.
51
52
Fig.82
NERV ES OFTHE LOWER LIMB
Small muscles of th e f oot (medial and lateral plantar nerves; 51, 52)
The pat ient is cuppi ng t he sole of t he foot; the small muscles can be felt and someti mes
seen.
f ig.83
Tibia lis An te rio r (Deep peronea l nerve; L4, LS)
The pat ient is dorsiflelCing the foot against resist a nce.
Arrows : the muscle be lly and its t e ndo n ca n be seen and fe lt.
NERVES OF TIlE LOWER LIM B
Fig. 84
53
Ext ensor Digit orum Longus (Deep peronea l nerve; l 5, 51)
The patie nt is dorsifl exin g t he toes ag ainst resistance . The ten dons passing to th e lateral
four toes can be seen and felt .
54
Fig.85
NERVES OF THE WWER LIMB
Extensor Hattucts Longus (Deep peroneal nerve; L5, S1)
The patient is dorsiflexing the distal phalanx of the big toe against resistance .
Arrow: the tendon can be seen and felt .
NERVES OF TIl E LOWER LIMB
Fig.86
55
Extensor Digit orum Brevis (Deep peroneal nerve; LS, 51)
The patie nt is dorsifle xing the proxima l phala nges of the toes against res istance .
Arrow: the muscle belly ca n be fe lt a nd som etimes seen.
(
Fig.87
Perone us l o ngus and Brevis (Sup erficial pero neal nerve; r s. 51)
The pati ent is evert ing th e foo t against resist ance. Upper arr ow : th e tendon of pero neus
brevis. Lower arrow: t he tendon of pero neus lon gu s.
DERMATOMES
C'
T2
13
T'
T5
T7
T6
T9
TID
C6 ,-_~
T11
T12
Ll
Fig . 88
limb.
Approximate d istribut ion o f d ermatomes on the anter io r aspect of t h e upper
Fig. 88-9 1 show t he approx imate cutaneous areas supp lie d by each spina l root . There is
conside rable variat ion and overlap between der mat c mes, so t hat an isolate d root lesion
results in a much smalle r area of sensory imp airment than is indicated in t hese di agrams.
Th is var iation also applies t o t he innerv at ion o f t he f inger s, b ut th e t hu mb is usuall y
supplied by (6 and the little finge r usua lly by (8 (see Inouye and Bucht hal ( 1977) Bra;n
100: 13 1- 748).The heavy axial line s are usuall y mor e consist ent, show ing the boundary
between non consecutive dermat omes.
DERMATOMES
57
C4
T12
,/
~
L1
Fig.89
limb.
App roximate dist ribut io n of der matomes on t he po st e rior aspect of t he up per
58
DERMArOMES
Tt o
Tll
Tt 2
LI
I
SS r:>'
SJ
L2
l3
S2
l3
S2
l4
l5
l4
I
l5
I
S,
Fig_90
Approximat e distribution of dermat omes on the lower limb.
DERMATOMES
L3
L3
52
52
53
53
L2
L2
Fig. 91
L2
Approximate d istr ibution of dermatomes o n th e perineum
59
NERVES AND MAIN ROOT SUPPLY OF MUSCLES
The list given be lo w does not include a ll t he muscles inne rvated by th ese nerves, but o nly
those mo re commonly tested , eithe r clinica lly o r e lectr ica lly, an d shows the o rde r of
innervation.
Uppe r limb
Sp inal Roots
Spinal Accesso ry Nerve
0 .(4
Trapeziu s
Brach ial Plexus
Rhomboi ds
Ser ratus an terior
Pectoralis ma jor
Clavicular }
Ste rna l
( 4, ( 5
( 5, (6, C7
(5, ( 6
cs. (7, C8
Supraspin atus
(5, (6
Infr asp inat us
l at issim us do rsi
(5. (6
Teres majo r
(5, ( 6, C7
( 6, 0. C8
Axill ary Nerve
Deltoid
CS, C6
M usculocu taneous Nerve
Biceps
(5, ( 6
8rachial is
(5, (6
Rad ial Nerve
l ong head ]
lateral he ad
Media l head
Brechioradialts
Trice ps
!
Extensor carpi rad ialis longus
Posterior Interosseous Nerve
Supinator
( 6, ( 7, C8
( 5. C6
( 5. ( 6
( 6, C7
C7, ( 8
C7, (8
Extensor carpi ulnaris
Extensor dig itorum
Abductor pollicis longus
Extensor pollicis longus
Extensor poll icis brevis
Extensor in dicis
(7, (8
(7, (8
(7, ( 8
(7, C8
M ed ian Nerve
Pron ator teres
Hexer carpi radia lis
Flexor di git or um superf tctens
Abd uctor po llic is brevis
Hexo r pollicis brevis"
Op ponens pctncts
lumbricals I & II
( 6, (7
C6, (7
0 , C8, T1
C8, 11
C8, 11
C8, 11
C8, 11
NERVES AN D M AIN ROOT SUPPLY OF MUSCLES
Anterior In t ero sseous Nerve
Pro nat o r q uadratus
Flexor digitoru m pro fund us I & II
f lexor pollicis longus
Ulna r Nerve
Flexor carpi u lna ris
Flexor dig it orum pro fundus III & IV
Hypothe nar muscles
O , C8
a , C8
a ,( 8
0 , C8, 11
C7, (8
C8,
C8,
C8,
C8,
C8,
Adductor pall ids
Flexor palli cis brevis
Palmar int e rosse i
Dorsal int erossei
l u mbr icals III & IV
T1
T1
T1
T1
T1
C8, T1
l ower limb
Spina l Ro ot s
Femoral Nerve
Iliopsoa s
Rectus femori s
u . 12, L3
]
vestus taterehs
Vastus inte rm ed ius
Vast us med ia lis
Quadriceps
fe mo ris
Obturator Nerve
Add uctor longu5
Adductor mag n us
L2. l3, l4
12. l3, l 4
Superior Gluteal Nerve
Gluteus med us and mi nimus
l 4. L5, S1
Te nsor fasciae latae
In ferior Gluteaf Nerv e
Gluteus ma ximus
Sciatic and Tibial Nerve s
Semit end in osus
Biceps
Semimem branosus
Gastr ocnem ius an d soleus
Tib iali s post eri or
Flexor digitorum longus
Abductor hallu cis
Abduct or digiti min imi
Intero ssei
l 5, 51, 52
l5 , S1, S2
l5, 51, 52
l 5, 51, 52
51, 52
l4, l 5
i s , 51, 52
Small mu scles
o f fo ot
Sciatic and Common Peron eal Nerves
Tibi alis ant erior
Extensor d ig it oru m longus
Exte nsor hatlucis lo ngus
Exte nsor d ig it orum br evis
Perone us long us
Peroneus br evis
51, S2
l 4, l5
l5,
l5,
l5,
l 5,
l5.
51
51
51
51
51
* Flexor pollicis brev is is often supplied w holly or partially by t he u lnar nerve.
61
COMMONLY TESTED MOVEMENTS
M o vem ent
UMN
Ro ot
++
C5
Refl e x
Nerve
Muscle
Axilla ry
Delto id
Uppe r /i mb
Shou lder abduction
Elbow f lexion
Elbow e xtension
Radia l wrist extension
Finger ext ension
(5/6
C6
+
+
Musculocutaneous
Radia l
Biceps
are cbtor adtens
+
C7
+
Radia l
Triceps
+
C6
Radial
Ext ensor car pi
Poste rior
rad ia lis lo ng us
Extensor
+
C7
C8
Fin g er f lex io n
+
int e rosse us ner ve
d igit or um
commu nis
A nter io r
Flexor polli ds
lo ngus + Flexor
d igit or um
pro f u nd us
(i ndex)
Flexo r d ig it oru m
int er osseu s nerve
Uln ar
prof und us
(ring + little)
Fin g er abd uction
++
T1
Ulnar
First do rsal
interosseous
T1
Medi an
Abduct or po ll icis
b revis
Low er limb
Hip fl exion
++
L1 /2
Hip adducti on
L2I3
Hip extensio n
L51S1
Iliopsoas
+
Obturat or
Addu ctors
Sciat ic
Gluteus
ma ximu s
51
Sciat ic
Hamstrings
L3/4
Fem oral
Quadriceps
L4
Deep peroneal
Tib ial is anterior
An k le eversion
LS151
Su pe rf icial peron eal
Per onei
Ankle p lantarflexi on
S1 152
Tib ial
Gastrocnemiu s,
soleus
Big t o e exte nsion
L5
Deep pe roneal
Extens or hellucis
longus
Knee f lexion
+
Knee extensi on
Ankle dorsifl exion
++
+
+
The t ab le shows some com mo n ly t ested movem ents, the principal muscle i nvo lved wi t h its
ro ots and ner ve su p ply. The colu m n he ad ed UMN indic at es those movements whic h ar e
preferentially w eak in uppe r motor neuron lesions.