MOB TCD Posterior Compartment of Thigh Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin MOB TCD Posterior Compartment of Thigh • Buttock to back of knee • Separated from the extensor compartment by lateral intermuscular septum • Hamstrings MOB TCD Cutaneous Supply • Posterior cutaneous nerve of thigh S2 • Posterior branch of lateral cutaneous of thigh MOB TCD Hamstrings • • • • Fascia lata thin Iliotibial tract, thick Ischial tuberosity Quadrilateral and triangular • Sciatic nerve • Extends hip • Flexes knee MOB TCD Semimembranosus • Smooth upper lateral portion of ischial tuberosity • Origin long flat membrane for 15 cm • Rounded laterally • Sharp medial border • Deep to semitendinosus and biceps • Muscle appears half membranous MOB TCD Semimembranosus • Becomes tendinous • Inserted into the posterior surface of medial condyle of tibia • Three expansions MOB TCD Semimembranosus • Expansion downwards and medially along the medial surface of tibia • Upwards and laterally; oblique popliteal ligament • Which is pierced by middle genicular vessels and nerve, post division obturator nerve • Downwards and laterally as fascia covering popliteus MOB TCD Semimembranosus • The Semimembranosus bursa lies between the tendon of semimembranosus and • The medial condyle of the tibia and the medial head of gastrocnemius • May communicate with the bursa between the medial head of gastrocnemius and the fibrous capsule of the knee joint MOB TCD Semimembranosus • Extends hip • Flexes and medially and rotates knee • Tibial nerve MOB TCD Semitendinosus • Common origin with the long head of the biceps • Lower medial area of ischial tuberosity • Fleshy fibres of origin replaced by a tendon • Lies in the gutter of semimembranosus • Curves forward MOB TCD Semitendinosus • Inserted upper part of subcutaneous surface of tibia • Behind sartorius and gracilis • Tibial intertendinous bursa • Tibial nerve MOB TCD Semitendinosus • Develops from myotomes • There is a tendinous intersection at the junction of the upper and middle thirds of the muscle, which is a common site of tears Lee and O’Brien, 1988 MOB TCD Biceps • Long head has common origin with the semitendinosus • Lower medial area of ischial tuberosity • Short head from linea aspera • Upper part of lateral supracondylar line MOB TCD Biceps Femoris • Inserted into head of fibula in front of styloid process • Folded around lateral ligament of knee • Long head extends hip • Tibial nerve supplies long head • Short head by common peroneal nerve • Both heads flex and laterally rotates knee MOB TCD Biceps Femoris • 80% of hamstring strains occur in the occur in the long head of the biceps femoris muscle Koulouris & Connell, 2003 • Injuries may occur: • During the switch between late leg recovery and initial leg approach in the swing phase of sprinting Woods et al., 2004 • During the ground contact phase of running • Poor timing-intermuscular coordination and eccentric strength in the short head of the biceps femoris muscle Woods et al., 2004 MOB TCD Biceps Femoris • Lack of stiffness and eccentric strength in the short and long head of the biceps femoris muscle during the ground contact phase of running Bosch and Klomp, 2005 • Can be torn at origin from tuberosity • Middle of thigh • Prior hamstring injury is a very good indicator of potential for future injury Crosier, 2004 MOB TCD Hamstrings • Hamstrings act eccentrically in the swing phase of gait to resist hip flexion and knee extension • Extends the hip with the gluteus Maximus for propulsion forwards at the start of heel strike • The hamstrings contract with the quadriceps as the hip of the supporting leg moves over the foot MOB TCD Hamstrings • Avulsion of the epiphysis of the ischial tuberosity origin of the hamstrings • In young athletes, the whole of the ischial tuberosity and the attached origins of the hamstrings may be avulsed Ishikawa et al., 1988; Kurosawa et al., 1996 MOB TCD Hamstrings • Poor posture, stiff lumbar spine and weak abdominals, will predispose to tight hamstrings • Tight hamstrings will shorten the stride • Resulting in a faster work rate over a given distance but a slower time • Hamstrings used in sprinting and hurdles MOB TCD Adductor Magnus • Triangular area of ischial tuberosity • Ramus of ischium • Inserted into medial lip gluteal tuberosity • Linea aspera • Medial supracondylar line • Inserted into adductor tubercle MOB TCD Adductor Magnus • Adductor portion supplied by posterior division of obturator nerve • Hamstring portion, below hiatus for femoral vessels • Supplied by tibial nerve • Gives origin to the oblique fibres of the vastus medialis MOB TCD Blood Supply • Inferior gluteal vessels • Perforating branches of the profunda artery • Popliteal artery MOB TCD Sciatic Nerve • Leaves through the greater sciatic foramen • Runs vertically down deep to the biceps on adductor magnus • Divides into tibial and common peroneal middle of thigh • If it divides in the pelvis common peroneal pierces piriformis MOB TCD Popliteal Fossa • • • • • • Diamond shaped space Superomedial boundary Semimembranosus Semitendinosis Superolateral boundary Biceps femoris MOB TCD Popliteal Fossa • • • • • Inferomedial boundary Medial head of gastronemius Inferolateral boundary Plantaris Lateral head of gastronemius lateral MOB TCD Popliteal Fossa • Roof • Fascia Lata reinforced by transverse fibres • Pierced by the posterior cutaneous nerve of the thigh • Short Saphenous vein • Superficial lymphatics from lateral and posterior part of leg MOB TCD Popliteal Fossa • • • • • Floor Superior to inferior Politeal surface of femur Oblique popliteal ligament Fascia covering the popliteus MOB TCD Contents of Popliteal Fossa • Popliteal artery and its branches • Superomedial, superolateral, inferomedial, inferolateral and middle genicular branches • Popliteal vein and tributaries • Short saphenous vein • Tibial nerve and branches • Common peroneal nerve and branches • Posterior division of Obturator nerve • Fat • Deep popliteal lymph glands MOB TCD Popliteal Artery • • • • Deepest structure which lies on floor Starts at the hiatus in the adductor magnus Ends at lower border of popliteus Divides into anterior and posterior tibial artery • Medial then lateral to tibial nerve, vein in between • Palpate artery and blood pressure in lower limb Genicular Branches of Popliteal Artery • • • • • Superolateral genicular Superolateral genicular Inferolateral genicular Inferomedial genicular Middle genicular pierces oblique popliteal ligament • Supplies cruciate ligaments • Branches crucify artery at the back of knee joint MOB TCD MOB TCD Dislocated Knee • Injury to blood vessels most serious • Loose all blood supply to areas below the knee • Test for artery first, nerves after MOB TCD Popliteal Vein • Union of vena commitans of anterior and posterior tibial arteries • Lower border of popliteus • Ends by becoming femoral vein at hiatus • Tributaries correspond to branches • Plus short saphaneous vein MOB TCD Tibial Nerve • Bisects middle of fossa superficial to vein and artery • Leaves deep to fibrous arch origin of soleus • Sural is cutaneous MOB TCD Tibial Nerve • Muscular to medial and lateral head of gastronemius • Plantaris • Soleus • Popliteus • Superior, inferior and middle genicular nerves MOB TCD Common Peroneal Nerve • May pierce piriformis • Enters fossa and runs on medial border of biceps • Leaves lateral angle • Sural communicating • Lateral cutaneous of calf • Inferolateral • Inferomedial genicular • Nerve to short head of biceps MOB TCD Deep Popliteal Lymph Glands • Superficial lymphatics drain lateral border of foot and posterior portion of calf • Area drained by the short saphenous vein • Afferent lymphatics pierce the roof to deep popliteal glands in the fossa • Then pass alongside the popliteal and femoral vessels to deep inguinal glands “BMJ Publishing Group Limited (“BMJ Group”) 2012. 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