MOB TCD Posterior Compartment of Thigh Professor Emeritus

MOB TCD Posterior Compartment of Thigh Professor Emeritus Moira O’Brien FRCPI, 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 S 2 • 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 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 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