Posterior Of thigh

s a group, the muscles of the posterior compartment of the thigh are called the hamstrings. To be called a hamstring, the muscle must arise from the ischial tuberosity. The hamstrings are: biceps femoris (long head) semimembranosus semitendinosus hamstring part of the adductor magnus (not shown in the diagram)

Nerves

The muscles of the posterior compartment of the thigh are innervated by the tibial (medial) part of the sciatic nerve.  The short head of the biceps is innervated by a branch of the common peroneal nerve.

Arteries

The arteries of the posterior compartment of the thigh arise from two major arteries: inferior gluteal (upper posterior compartment) perforating branches of the profunda femoris

Table of Muscles

Muscle	Origin	Insertion	Action	Nerve Supply
biceps femoris, long head	ischial tuberosity	head of fibula	flexes and laterally rotates leg, extends thigh	tibial part of sciatic nerve
biceps femoris, short head	shaft of femur	head of fibula	flexes and laterally rotates leg	common peroneal nerve
semitendinosus	ischial tuberosity	upper part medial surface of tibia	flexes and medially rotates leg; extends thigh	tibial part of sciatic
semimembranosus	ischial tuberosity	medial condyle of tibia;  forms oblique popliteal ligament	flexes and medially roates leg; extends thigh	tibial part of sciatic
adductor magnus (hamstring part)	ischial tuberosity	adductor tubercle of femur	extends thigh	tibial part of sciatic

Popliteal Fossa

The popliteal fossa is an anatomical region behind the knee with certain identifiable boundaries.

Start by identifying the bony background of the popliteal fossa and then visualizing the boundaries. The bones of the popliteal fossa are: femur medial condyle lateral condyle tibia medial condyle lateral condyle The boundaries are: superior and medial - semitendinosus (ST) inferior and medial - medial head of gastrocnemius (MG) superior and lateral - biceps femoris (B) inferior and lateral - lateral head of gastrocnemius (LG)
The muscles and contents of the popliteal fossa are: Muscles semitendinosus biceps femoris medial head of gastrocnemius lateral head of gastrocnemius Arteries popliteal artery - continuation of femoral artery superior medial and lateral genicular arteries inferior medial and lateral genicular arteries Nerves tibial nerve common peroneal nerve
With the nerves and arteries removed and the muscles reflected, you now identify the structures making up the floor of the popliteal fossa: posterior surface of femur posterior surface of tibia oblique popliteal ligament popliteus muscle

Table of Muscles

HOME
Practice Examination 

Medial Thigh

Anterior Leg & Dorsum of Foot

Read more »

Proximal Entrapments of the Lower Extremity

Proximal Entrapments of the Lower Extremity

Iliohypogastric Nerve

Anatomy

The iliohypogastric nerve arises primarily from the ventral primary rami of L1 and occasionally with a twig from T12. This nerve has a pathway similar to that of the intercostal nerves in the thoracic region. The iliohypogastric nerve traverses the psoas major muscle, piercing the lateral border of the muscle anterior to the quadratus lumborum muscle and posterior to the kidney to traverse the lateral abdominal wall. The nerve penetrates the transverse abdominal muscle near the iliac crest, coming between it and the internal oblique musculature. The nerve supplies the lower fibers of the transverse abdominal muscle and the internal oblique, and divides into the lateral and anterior cutaneous branches.

The anterior cutaneous branch continues anteriorly between the internal oblique and transverse abdominal muscle, then pierces the internal oblique and becomes cutaneous through an opening in the fascial aponeurosis of the external oblique muscle, approximately 2-3 cm cephalad to the superficial inguinal ring. The distribution of the cutaneous sensation is a small region just superior to the pubis.

Etiology

The iliohypogastric nerve is rarely injured in isolation. The most common causes of injury are surgical procedures. These include transverse lower abdominal incisions, as in hysterectomies, or injuries from procedures such as inguinal herniorrhaphy and appendectomies. The injuries mainly occur if the incision extends beyond the lateral margin of the inferior rectus abdominis fibers. The damage can result from direct surgical trauma, such as passing a suture around the nerve and incorporating it into the fascial repair, or postoperative entrapment in scar tissue or neuroma formation. Sports injuries, such as trauma or muscle tears of the lower abdominal muscles, may also result in injury to the nerve. Injury may also occur during pregnancy, owing to the rapidly expanding abdomen in the third trimester. This is called the idiopathic iliohypogastric syndrome and is rare.

Clinical

Symptoms include burning or lancinating pain immediately following the abdominal operation. The pain extends from the surgical incision laterally into the inguinal region and suprapubic region. Discomfort may occur immediately or up to several years after the procedure, and may last for months to years. This discomfort is possibly because of the formation of scar tissue in the region. Occasionally, the pain may extend into the genitalia because of significant overlap with other cutaneous nerves. Loss of sensation is usually minimal and not problematic. Iliohypogastric nerve entrapment causing symptoms similar to trochanteric bursitis refractory to conventional therapy has been reported.

On examination, pain and tenderness are usually present in the area of scarring or entrapment. Hyperesthesia or hypoesthesia may occur in the area supplied by this nerve. Diagnosis is difficult, owing to the small area of cutaneous supply that this nerve provides. There may be overlap in sensory supply with the genitofemoral and ilioinguinal nerves.

Three major criteria are used to diagnose this nerve injury. The first is a history of a surgical procedure in the lower abdominal area, although spontaneous entrapment can occur. Pain can usually be elicited by palpating laterally about the scar margin, and the pain usually radiates inferomedially toward the inguinal region and into the suprapubic and proximal genital area. Second, a definite area of hypoesthesia or hyperesthesia should be identified in the region of supply of the iliohypogastric nerve. Third, infiltration of a local anesthetic into the region where the iliohypogastric and ilioinguinal nerves depart the internal oblique muscle and where symptoms can be reproduced on physical examination by palpation should provide symptomatic relief.

If no relief is obtained with injection, a different etiology should be sought for the discomfort. Alternate diagnoses include upper lumbar or lower thoracic nerve root pathology, or discogenic etiology of the pain. If the iliohypogastric nerve is identified clearly as the source of pain, and a favorable response is not obtained with local anesthetic injection, then surgical exploration and resection of the nerve should be considered. No reliable electrodiagnostic techniques are available to define the integrity of this nerve, although needle electromyography of the lower abdominal musculature may serve as an adjunct in the diagnosis.

Treatment

Treatment includes local injection of an anesthetic (as noted above), oral medications, or physical therapy. The oral medications may include antiseizure medications, such as gabapentin (Neurontin), carbamazepine (Tegretol), or lamotrigine (Lamictal), as well as nonsteroidal anti-inflammatory drugs (NSAIDs), tricyclic antidepressant medications (amitriptyline [Elavil], doxepin), capsaicin cream, topical lidocaine (Lidoderm patches), or tramadol (Ultram). With physical therapy, cryotherapy or a transcutaneous electrical nerve stimulation (TENS) unit may be tried. When conservative measures are not successful, surgical excision may result in relief of pain with few potential complications. Potential complications include possible neurolysis of the nerve in refractory cases. Surgical excision is more invasive but has had good outcomes in several reports. Krahenbuhl and colleagues reported an endoscopic approach.^[1]

Ilioinguinal Nerve

Anatomy

The ilioinguinal nerve arises from the fusion of T12 and L1 nerve roots and emerges from the lateral border of the psoas muscle; it traverses the anterior abdominal wall to the iliac crest just inferior to the hypogastric nerve. Adjacent to the anterior margin of the iliac crest, the nerve pierces the transversus abdominis and internal oblique muscles (providing neural branches to these) and sending neural branches to the iliohypogastric nerve. The nerve then supplies sensory branches to supply the pubic symphysis, the superior and medial aspect of the femoral triangle, and either the root of the penis and anterior scrotum in the male or the mons pubis and labia majora in the female.

Etiology

Causes of injury include lower abdominal incisions (Pfannenstiel), pregnancy, iliac bone harvesting, appendectomy, inguinal herniorrhaphy, inguinal lymph node dissection, femoral catheter placement, orchiectomy, total abdominal hysterectomy, and abdominoplasty. Nerve injury can also occur idiopathically. The prevalence of injury with surgery has declined, owing to the use of laparoscopic procedures. Tearing of the lower external oblique aponeurosis may also cause injury to this nerve. This injury has been reported in hockey players.

Clinical

Symptoms may include hyperesthesia or hypoesthesia of the skin along the inguinal ligament. The sensation may radiate to the lower abdomen. Pain may be localized to the medial groin, the labia majora or scrotum, and the inner thigh. The characteristics of the pain may vary considerably. Patients may be able to associate their pain clearly with a traumatic event or with the surgical procedure.

Pain and tenderness may be present with application of pressure where the nerve exits the inguinal canal in up to 75% of patients. Sensory impairment is common in the above-noted distribution of the nerve supply. Symptoms usually increase with hip extension (patients walk with the trunk in a forward-flexed posture). Pain may also be reproduced with palpation medial to the anterosuperior iliac spine (ASIS).

The diagnosis can be made on the basis of local infiltration of anesthetic with or without steroid, which should result in relief within 10 minutes. Unfortunately, no electrodiagnostic techniques are readily available to test this nerve. Abdominal needle electromyography may be helpful in determining the severity of nerve injury, but electromyography is not sensitive or specific.

Treatment

Treatment includes local injection of an anesthetic, physical therapy, or oral medications. Types of medications may include antiseizure medications, such as gabapentin (Neurontin), carbamazepine (Tegretol), or lamotrigine (Lamictal), as well as NSAIDs, tricyclic antidepressant medications (amitriptyline [Elavil], doxepin), capsaicin cream, topical lidocaine (Lidoderm patches), or tramadol (Ultram). Ice or possibly a TENS unit may be used with physical therapy. When conservative measures are not successful, surgical excision may result in relief of pain with few potential complications.

Genitofemoral Nerve

The genitofemoral nerve or its branches (genital or femoral branches) can be entrapped throughout its course. Nerve injury occurs most commonly as a complication of lower abdominal surgeries.

Anatomy

The genitofemoral nerve arises from the L1 and L2 ventral primary rami, which fuse in the psoas muscle. The nerve then pierces the anterior surface of the psoas major muscle at the level of L3-4 and descends on the fascial surface of the psoas major muscle past the ureter. It then splits into the genital and femoral branches near the inguinal ligament.

The genital branch continues along the psoas major to the deep inguinal ring and enters the inguinal canal. It supplies the cremaster muscle, spermatic cord, scrotum, and adjacent thigh in males. In females, it travels with the round ligament of the uterus and provides cutaneous sensation to the labia majora and adjacent thigh. The femoral branch lies lateral to the genital on the psoas major and travels lateral to the femoral artery and posterior to the inguinal ligament to enter the proximal thigh. There, it pierces the sartorius muscle distal to the inguinal ligament and supplies the proximal portion of the thigh about the femoral triangle just lateral to the skin that is innervated by the ilioinguinal nerve.

Etiology

Nerve injury may result from hernia repair, appendectomy, biopsies, and cesarean delivery. Injury may also result from intrapelvic trauma to the posterior abdominal wall, retroperitoneal hematoma, pregnancy, or trauma to the inguinal ligament. Fortunately, injury to this nerve is rare, even with open herniorrhaphy.

A prospective study was performed to evaluate the genitofemoral nerve electrophysiologically in children with inguinal hernia repair. Latency of the genitofemoral nerve was found to be prolonged after inguinal hernia repair possibly because of surgical-related injury.^[2]

Clinical

Injury to the femoral branch causes hypoesthesia over the anterior thigh below the inguinal ligament, which is how it is distinguished from the iliohypogastric and ilioinguinal nerve. Groin pain is a common presentation of neuralgia from nerve injury or entrapment. The pain may be worse with internal or external rotation of the hip, prolonged walking, or even with light touch. Differential diagnoses include injury to the ilioinguinal and genitofemoral nerves as well as L1-2 radiculopathies. Some anatomic overlap may exist with the supply of the ilioinguinal and genitofemoral nerves, which makes the diagnosis somewhat difficult to establish.

Unfortunately, no reliable electrodiagnostic test exists that can be used for diagnosis of injury to this nerve. Oh has discussed a side-to-side sensory comparison study, but this test is technically difficult to perform.^[3] Diagnosis typically is made using anesthetic nerve blocks. Injection of the ilioinguinal and iliohypogastric nerves anteriorly should leave the pain or abnormal sensation unchanged. A block of the L1 and L2 roots should then result in relief. This should help to determine the diagnosis and to prevent unnecessary surgical exploration of an uninjured nerve.

Treatment

The above-mentioned blocks are diagnostic and therapeutic. Avoidance of aggravating activities should be emphasized. Treatment may also consist of antiseizure medications, such as gabapentin (Neurontin), carbamazepine (Tegretol), or lamotrigine (Lamictal), as well as tricyclic antidepressant medications (amitriptyline [Elavil], doxepin). Other medications include capsaicin cream, topical lidocaine (Lidoderm patches), NSAIDs, or, possibly, tramadol (Ultram). A trial with a TENS unit may also be beneficial.

If conservative treatment fails, surgical excision of the nerve is the treatment of choice. Some authors describe a transabdominal approach to the nerve (Magee and Lyon) with satisfactory results.^{[4, 5]} The complications of this procedure include hypoesthesia of the scrotum or labium majus and of the skin over the femoral triangle, as well as loss of the cremasteric reflex. This usually will not result in notable morbidity. According to Harms and colleagues, an extraperitoneal approach should result in fewer operative complications.^[6]

Lateral Femoral Cutaneous Nerve

Injury or entrapment of the lateral femoral cutaneous nerve is also known as meralgia paresthetica. It is derived from the Greek word meros, meaning thigh, and algo, meaning pain. It is a syndrome of paresthesia and pain in the lateral and anterolateral thigh. This syndrome is seen most commonly in individuals aged 20-60 years, but it can occur in people of all ages.

Anatomy

This nerve arises from the ventral primary rami of L2-4 where they divide into anterior and posterior branches. The dorsal portions fuse to form the lateral femoral cutaneous nerve in the midpelvic region of the psoas major. The nerve then courses over the iliacus toward the ASIS. The nerve travels posterior to the inguinal ligament and superior to the sartorius muscle at the iliac crest region and divides into anterior and posterior branches. The anterior branch comes off 10 cm distal to the inguinal ligament in line with the ASIS, and supplies cutaneous sensation to the lateral thigh, including just proximal to the patella. It then communicates with cutaneous branches of the femoral nerve and saphenous nerve to form the patellar plexus. The posterior branch pierces the fascia lata posteriorly and laterally, and divides into multiple, small branches that supply the skin from the greater trochanter to the midthigh.^[7]

Etiology

Entrapment usually occurs at the inguinal ligament. The peak incidence for this condition is in middle age. Differential diagnoses include lumbar radiculopathies and discogenic or nerve root problems at L2 and L3. The entrapment may be from intrapelvic causes, extrapelvic causes, or mechanical causes. Intrapelvic causes include pregnancy, abdominal tumors, uterine fibroids, diverticulitis, or appendicitis. Injury has been described in cases of abdominal aortic aneurysm. Examples of extrapelvic causes include trauma to the region of the ASIS (eg, from a seatbelt in a motor vehicle accident), tight garments, belts, girdles, or stretch from obesity and ascites. Mechanical factors include prolonged sitting or standing and pelvic tilt from leg-length discrepancy. Diabetes can also cause this neuropathy in isolation or in the clinical setting of a polyneuropathy.

Clinical

Symptoms include anterior and lateral thigh burning, tingling, and/or numbness, that increase with standing, walking, or hip extension. Symptoms may also increase with lying prone. Symptoms usually are unilateral but may be bilateral in rare cases. The symptoms usually improve with sitting unless compressive forces, such as tight belts or garments, remain.

Physical examination findings may be completely normal. Findings may include hyperesthesia over the lateral thigh (usually in a smaller area than the symptoms). Pain can be produced by pressure medial to the ASIS. A positive Tinel sign may be present over the ASIS or inguinal ligament.

Diagnosis of this entrapment may again be based on an injection of local anesthetic near the inguinal ligament or ASIS. Spontaneous recovery usually is expected. Electrodiagnostic testing may be performed for diagnosis. With nerve conduction studies, the technique includes using a bar electrode for recording and reference. This can be performed with either antidromic (conduction against the direction of sensory fiber conduction) or orthodromic (conduction in the direction of nerve conduction) methods. The antidromic study is usually easier to perform, although response may be absent bilaterally on occasion. The response is small and difficult to obtain in obese patients.

A needle stimulation electrode may needed. The sensory response is absent in 71% of patients with meralgia paresthetica and is prolonged in 24% of patients with this condition. Electromyographic test results with needle are normal in patients with this diagnosis, which may help to differentiate it from an upper lumbar radiculopathy. Technically, the sensory test is a difficult study and a response must be present on the opposite side to determine entrapment. It may be nearly impossible to obtain a response in an obese patient or a patient with a large abdomen without using a needle for stimulation. Unfortunately, the test may be difficult for the patient to tolerate because of the large amount of current (with respect to more peripheral nerves) that is required to stimulate a nerve that lies under adipose tissue.

Treatment

Treatment may include the injection of local anesthetic agents, as previously noted. A steroid can also be used to prolong the effects of the local anesthetic and reduce inflammation. Oral medications, such as NSAIDs, antiseizure medications (gabapentin [Neurontin]), tricyclic antidepressants, and tramadol may be used, as may capsaicin cream and topical lidocaine. One must also instruct patients on ways to prevent further irritation of the nerve. These may include avoidance of hip extension, prolonged standing, and compressive garments. The use of ice and a TENS unit may also be helpful. Surgical exploration may be required if the above treatment options are not helpful. This includes transection of the nerve, or decompression with or without neurolysis. Anatomical variations of the nerve and neuromas can occur and lead to recurrence.^[8]

Femoral Nerve

Anatomy

The femoral nerve arises from the posterior divisions of the ventral primary rami of L2, L3, and L4 within the psoas major muscle. These nerves join to form the largest branch of the lumbar plexus. The nerve emerges from the lateral border of the psoas muscle and courses inferiorly in the intermuscular groove between this muscle and the iliacus muscle. It then passes under the inguinal ligament lateral to the femoral artery and vein. It then divides into multiple branches within the femoral triangle. In the proximal thigh it divides into sensory branches that innervate the upper and anterior thigh, and muscular branches that innervate the quadriceps muscle. One of the major branches is the lateral femoral cutaneous nerve, as discussed previously.^[9]

Another branch is the medial femoral cutaneous nerve, which originates just distal to the inguinal ligament, descends on the sartorius muscle, and penetrates the deep fascia about the distal third of the thigh to split into 2 terminal nerve branches. One branch innervates the skin covering the medial aspect of the distal thigh and knee joint region. The second branch supplies the skin superior to the patella and shares several communicating branches with the saphenous nerve. The posterior branch of the medial cutaneous nerve travels along the medial border of the sartorius muscle and pierces the deep fascia about the knee to also communicate with the saphenous nerve in providing cutaneous sensation to the patellar region. The best-known cutaneous nerve arising from the femoral nerve is the saphenous nerve (discussed below).

Etiology

The femoral nerve can have several entrapment locations or causes of injury, including intrapelvic injury or injury in the inguinal region. Diabetic amyotrophy is the most common cause of femoral nerve neuropathy. Open injuries can occur from gunshots, knife wounds, glass shards, or needle puncture in some medical procedures. The most worrisome complication of major trauma to the femoral triangle region is an associated femoral artery injury. The nerve can be injured at the time of the trauma or inadvertently sutured during repair of this injury. Large-blade, self-retaining retractors used during pelvic operations can cause injury to the nerve due to compression.^[10]

Conduction of the femoral nerve was measured in diabetic patients without clinical signs of femoral nerve involvement, and there was a statistically significant difference between diabetics and healthy individuals in terms of both femoral nerve motor latency and amplitude. The authors observed that these abnormalities became more evident as the polyneuropathy of the patients became more serious.^[11]

Most entrapment neuropathies occur below the inguinal ligament. After passing beneath the inguinal ligament, the femoral nerve is in close proximity to the femoral head, the tendon insertion of the vastus intermedius, the psoas tendon, the hip, and the joint capsule. The femoral nerve does not have significant protection in this area.

Heat developed by methylmethacrylate during a total hip arthroplasty can injure the femoral nerve. Pelvic procedures that require the lower extremity to be positioned in an acutely flexed, abducted, and externally rotated position for long periods can cause compression by angling the femoral nerve beneath the inguinal ligament. The nerve may be compromised by pressure from a fetus in a difficult birth. Pelvic fractures and acute hyperextension of the thigh may also cause an isolated femoral nerve injury. Pelvic radiation, appendiceal or renal abscesses, and tumors can cause femoral nerve injuries as well. The nerve can also be injured by a compartment-like compression from a hemorrhage (caused by a hemorrhagic disorder or by anticoagulant use).

Clinical

The symptoms of a femoral neuropathy may include pain in the inguinal region that is partially relieved by flexion and external rotation of the hip, and dysesthesia over the anterior thigh and anteromedial leg. Patients complain of difficulty in walking and of knee buckling, depending on the severity of the injury. The nerve gives rise to the saphenous nerve in the thigh; therefore, numbness in this distribution can be present. Anterior knee pain may also be present because the saphenous nerve supplies the patella.

On examination, patients may present with weak hip flexion, weak knee extension, and impaired quadriceps tendon reflex, as well as sensory deficit in the anteromedial aspect of the thigh. Pain may be increased with hip extension and relieved with external rotation of the hip. If compression occurs at the inguinal region, no hip flexion weakness is present. Sensory loss may occur along the medial aspect of the leg below the knee (saphenous distribution).

Electrodiagnostic testing typically is performed for diagnosis, but is also important to determine the extent of the injury and the prognosis for recovery. With electrodiagnostic testing, either surface or needle electrodes lateral to the femoral artery in the inguinal region are used for stimulation. The stimulation can be performed above and below the inguinal ligament. Disk electrodes from the vastus medialis are used to record stimulation.

A saphenous nerve sensory study may also be performed (continuation of the sensory portion of the femoral nerve over the medial aspect of the leg and ankle). Needle examination should be completed for the paraspinal muscles as well as for the iliopsoas (also L2-3) and hip adductors supplied by the obturator nerve, to determine the presence of root or plexus injury versus peripheral nerve injury. Needle electromyography is usually the most revealing portion of the electrodiagnostic test. The examiner must look not only for denervation potentials but also for any active motor units.

Treatment

Treatment may be based on symptoms only, or it may be more invasive and include surgical intervention, depending upon the severity of the injury. Quadriceps weakness may be treated with a locking knee brace to prevent instability, and the patient may require an assistive device for walking. Good recovery has been reported in up to 70% of patients with a femoral neuropathy and may take up to a year. The recovery may even occur in the setting of a fairly severe injury, as determined through electrodiagnostic testing and by physical examination. Patients with severe axonal loss have some recovery of function, although it is usually incomplete.

Saphenous Nerve

Anatomy

The saphenous nerve, the terminal branch of the femoral nerve, is the femoral nerve's longest branch. It is a pure sensory nerve that is made up of fibers from the L3 and L4 spinal segments. Because of its long course, it can become entrapped in multiple locations, from the thigh to the leg. It branches from the femoral nerve just distal to the inguinal ligament and courses with the superficial femoral artery to enter the adductor (Hunter's) canal in the distal third of the thigh. This canal extends proximally from the apex of the femoral triangle to the inferomedial aspect of the thigh in the adductor magnus tendon, just proximal to the femoral condyle. The canal is somewhat triangular and lies between the vastus medialis laterally and the adductor magnus and longus muscles medially.

The roof of the canal is a dense bridge of connective tissue extending between these muscle groups. The saphenous nerve exits the canal by piercing the roof, and becomes subcutaneous about 10 cm proximal to the medial epicondyle of the femur. The nerve may also pierce the sartorius muscle. Once it becomes subcutaneous, the nerve branches to form the infrapatellar plexus, while the main branch continues along the medial leg and foot.

Etiology

The saphenous nerve can become entrapped where it pierces the roof of the adductor canal. Inflammation results from a sharp angulation of the nerve at its exit and from the dynamic forces of the muscles in this region, which cause contraction and relaxation of the fibrous tissue that impinges on the nerve. The nerve can also be injured as a result of an improperly protected knee or leg support during surgery. It may be injured by a neurilemoma, entrapment by femoral vessels, direct trauma, pes anserine bursitis, varicose vein operations, and medial knee arthrotomies and meniscus repairs.^[12]

Clinical

Symptoms of entrapment may include a deep aching sensation in the thigh, knee pain, and paresthesias in the cutaneous distribution of the nerve in the leg and foot. The infrapatellar branch may also become entrapped on its own. This is because it passes through a separate foramen in the sartorius muscle tendon. It may also be exposed to trauma where courses horizontally across the prominence of the medial femoral epicondyle. Patients report paresthesias and numbness about the infrapatellar region that is worse with flexion of the knee or compression from garments and braces.

Saphenous nerve entrapment is a frequently overlooked cause of persistent medial knee pain in patients who experience trauma or direct blows to the medial aspect of the knee. As this is a purely sensory nerve, weakness should not be noted with an isolated injury of this nerve. If weakness is present, look for an injury of the femoral nerve or possibly an upper lumbar radiculopathy, particularly if thigh adduction is present (obturator nerve).

Deep palpation proximal to the medial epicondyle of the femur may reproduce the pain and complaints. Some weakness may be present because of guarding or disuse atrophy from pain, but no direct weakness will result from the nerve impingement. Sensory loss in the saphenous distribution may be present on examination. No weakness should be present in the quadriceps muscles or in the hip adductors.

The diagnosis may be made on the basis of injection of local anesthetic along the course of the nerve and proximal to the proposed site of entrapment. Nerve conduction techniques are available to assess neural conduction in the main branch of the saphenous nerve or in the terminal branches. The routine tests may be disappointing in persons with subcutaneous adipose tissue or swelling. A side-to-side comparison of the nerve should be made, and must demonstrate a lesion consistent with the patient's complaints. A somatosensory evoked potential (SSEP) test can also be performed and the results compared with those of the contralateral side for diagnosis, although this test may be cumbersome and time-consuming.

No findings should be present on needle examination of the muscle during electromyography. Needle examination should include the quadriceps muscle and the adductor longus to assess for femoral and obturator nerve injury. If findings are present in both of these muscles, then paraspinal muscles definitely should be examined to rule out radiculopathy.

Treatment

Entrapment in the adductor canal usually is treated conservatively with an injection of anesthetic (with or without corticosteroid) at the point of maximal tenderness (usually 10 cm proximal to the medial femoral condyle). The injection may need to be repeated periodically. Avoiding aggravating activities and using proper body mechanics will also be helpful. If this approach fails, surgical decompression may be needed. In patients who have had a direct blow to the medial knee who have persistent medial knee pain despite conservative trials for treatment, a neurectomy or neurolysis of the infrapatellar branch may be helpful.

Next Section: Obturator Nerve Entrapment

Read more »

complications of diabetes

What are the Complications?
How does diabetes affect the body? If the blood sugar (glucose) is not controlled, it can lead to a number of complications:

• Eye problems
• Heart disease
• Stroke
• Kidney failure
• Nerve damage
• Loss of limbs
• Tooth and gum problems

Diabetes injures the blood vessels that serve a number of key body organs. This can go on to damage your vision, your heart, your kidneys. It can delay or prevent tissues from healing. If wounds do not heal, it can lead to amputation.
Blood vessel injury can lead to:

• Heart attacks and heart failure
• Stroke
• Loss of vision, even blindness
• Poor kidney function, even kidney failure
• Poor wound healing, including minor injuries
• Poor circulation
• Amputation, usually of toes, feet or lower legs, can result from poor circulation and poor wound healing

Poor circulation

• Poor circulation prevents nutrients and oxygen from reaching the cells to help heal wounds and infections.
• Cells without oxygen or nutrients die.
• The affected area becomes numb or tingly or sometimes painful.
• Sometimes the poor, slow circulation causes blockage in a blood vessel. Blood that cannot flow through an artery can become a clot which can cause a heart attack, stroke or other blockage.

Poor circulation and infections

• A cut or wound will not heal well or quickly if there is high blood sugar The germs feed off the sugar and multiply.
• The damaged blood vessels are not able to transport enough infection-fighting cells, natural antibodies, antibiotic medicine or nutrition to the wound to heal well.

Complications: Heart disease
Heart disease is one of the most common complications of diabetes. Diabetes causes increased risk of:

• chest pain (angina)
• coronary artery disease (blockages of arteries in the heart)
• heart attack
• congestive heart failure

Factors which increase the risk of heart disease in diabetics:

• high blood sugar
• igh blood pressure
• high cholesterol

Diabetes and high blood pressure

• One of the common illnesses that develops when you have diabetes is high blood pressure.
• The high pressure with each beat of the heart damages the heart and blood vessels.
• Eventually it can weaken the heart muscle, causing congestive heart failure.
• If the pressure becomes really high, it can also cause a stroke.

Diabetes and cholesterol

Cholesterol damages arteries, too.
• It plugs them up with fatty deposits.
• This narrows the openings and slows down blood flow.
• This increases the likelihood of heart attacks, strokes and poor circulation to the legs.
• Smoking makes all of this worse by further narrowing the arteries.

Complications: Kidney

• The kidney acts as a filter for bloodpassing small waste into the urine and keeping large nutrients (protein and sugar) for bodys use.
• When blood sugar is not controlled, the high sugar in the blood damages the kidneys, leaving holes in the tiny filters that make up the kidney.
• When filters are damaged, it lets protein and sugar cells into the urine.
  • The presence of protein in the urine can mean there is kidney damage.

Kidney failure

• End stage renal disease (ESRD) is the medical term for kidney failure (when the kidneys can no longer function).
• Kidney dialysis is then used to do the work formerly done by the kidneys.
• Many persons with ESRD must use dialysis about three times a week to clean their blood.

Renal (kidney) dialysis

• A special machine is used to remove waste from the bloodlike a kidney does.
• Smaller machines might also be used at home by some patients who are trained and can do their own dialysis.
• A family member might also be trained to do this dialysis at home.

Complications: Vision

• Retinopathy (blurred vision/blindness) occurs when the tiny blood vessels that nourish.
• Weakened blood vessels can break and bleed, causing blindness.
• Laser treatments are often used to repair weakened or broken blood vessels.
• Timely eye exams and laser treatments can prevent blindness.

Complications: Nerve damage

• Neuropathy (damage to the nerves) is a common complication of diabetes, especially when the blood sugar is not controlled.
• Blood vessels that feed the cells are tiny and have very narrow passages.
• When blood vessels become damaged from the high sugar levels, oxygen and nutrients cannot be delivered to the cells, damaging the nerve cells.

«
Complications: Dental

• The poor circulation can also affect the blood vessels that supply oxygen and nutrients to the gums and bone which hold the teeth in place.
• Gums and jawbone that are unable to get the nutrients and oxygen are more likely to develop infection or become loose.
• Loose gums can mean lost teeth.
• Gum infections make blood sugar control very difficult.

Complications: Amputation

• Most amputations occur when wounds are not healing and become life threatening.
• It becomes life threatening because the infection can spread and affect the body's total blood stream and important organs like the heart, the brain, etc.
• When the wound becomes serious, tissues become damaged and infection can't be controlled, it becomes necessary to remove the affected part to save the life.

Amputations

• Depending on the size and location of the incurable infection or wound, the surgery may mean removing one toe or up to the ankle, it may mean removing the foot, etc.
• Special shoes or a special prosthesis may be used to help with walking.
• A wheel chair may be used if the amputation removes much of the leg and no artificial limb is possible for medical or personal reasons.

Complications: Sexual dysfunction

• Because nerves and blood vessels are damaged by high blood sugar, diabetes can lessen sexual desire.
• Both men and women can be affected
• Diabetes can also lead to impotence (also called erectile dysfunction or ED). This is when the man is unable to have an erection (the penis can't get hard enough to allow intercourse to occur). Medicine may be helpful for this.
• Many native people do not talk about this, but they should feel okay about talking to their doctors about this concern.

Complications and Smoking

• Smoking is a known cause of heart disease and stroke..
• Smoking (nicotine) causes the small blood vessels everywhere in the body to constrict (get narrow), which decreases oxygen to tissues.
• Smoking also makes the blood sludgy, making it more likely to clot and cause heart attacks and strokes.
• Smoking (even without diabetes) also causes gum disease
• Smoking worsens all the negative effects of diabetes on the body.

Read more »

symptoms of diabetes

While talking about symptoms of diabetes, you must keep in mind that there are no clear real symptoms, and not all the individuals present all them.

Diabetes symptoms vary from person to person making observations as difficult as comparing life insurance quotes in a time besot by financial crisis. The best thing you can do is to learn more about these symptoms and weigh how many of them applies to you.


The most common symptoms of diabetes that one can experience are as follow:

• Constant excessive thirst and Unusual increased urination
If you have diabetes,due to high sugar blood level, fluid comes out from cells to blood stream in order to adapt to this new situation. This cause dehydration of body cell, they suffer lack of fluid.
But here interfere your body thirst center which makes you to drink a lot of water or other juices. When you take lots of juices, you may experience frequent urination daily and nights.

• Increase hunger and weight gain as common symptoms of diabetes
When you have diabetes, you lose too much fluid and too much sugar. Your body needs to compensate them by craving sweets or other foods as well.
This experience of increase hunger causes you a fast weight gain. But this is not good for you body, and diabetes and weight gain
is not a 'good-impact' link. It has a negative influence on your diabetes course too.

• Vision changes
If you have diabetes, you may experience sudden vision changes, such as blurred vision. This is caused because, due to diabetes changes in your eye tissues, they tend to pull out from your lenses.
This makes you disable to focus, but if you take appropriate treatment, this can be restored. But, in serious cases of diabetes, these vision disorders can be prolonged, and maybe it leads you to blindness.

• Not healing skin infections
During diabetes, your body process of healing is hindered due to high sugar blood level. Mostly, you can experience recurrent skin infection.
Or, if you are a woman, you may have problems due to no properly recovery from vaginal and bladder yeast infections.
So, you must pay attention to all these kinds of recurrent infections, because they are a signal for you : you might have diabetes.
On the other hand you should know about diabetes skin care
to avoid future severe skin injuries.

• Tingling or Numbness
While you experience diabetes, your high sugar blood level damages your nerves and your nerves blood vessels too. This leads to some specific symptoms such as tingling or numbness in your hands or feet.
Maybe, you can also, experience some burning sensation in hands, arms, legs or feet.

• Gums disorders
Another symptom you can experience during diabetes, are several gums disorders. During diabetes your gums may be tender, swollen or red. Your teeth may be loose due to gums pulling away from your teeth.
There might be present, also, gum infections and several gum diseases. You may try an alternative to protect your gums, and at the same time a no-carbohydrates sweetener at all.

• Some other common symptoms of diabetes
Diabetic people may suffer from feeling very tired, weak, fatigue most of the time. Also, they may experience loss of appetite, dry skin, stomach pains, nausea, vomiting, or even hair loss.
If you want to know more about what can you do for diabetes and hair loss, click here.

These are some common symptoms for diabetes that you may experience. You must keep in mind, that you may not experience all the symptoms. They vary from one individual to another.
Also, you must remember that you may have diabetes symptoms, but you are not aware of them, because they can be unnoticed.
What do you have to do if you notice to have them?
You can make a simple sugar blood test yourself, and immediately consult your doctor for further follow up.

Read more »

DIABETES -EXCESSIVE THIRST

Thirst - excessive

Excessive thirst is an abnormal feeling of always needing to drink fluids.

Considerations

Drinking lots of water is usually healthy. However, the urge to drink too much may be the result of a physical or emotional disease. Excessive thirst may be a symptom of high blood sugar (hyperglycemia). It can be an important clue in detecting diabetes.

Excessive thirst is a fairly common symptom. It is often the reaction to fluid loss during exercise, or to eating salty foods.

Causes

• A recent salty or spicy meal
• Bleeding enough to cause a significant decrease in blood volume
• Diabetes
• Diabetes insipidus
• Drugs such as anticholinergics, demeclocycline, diuretics, phenothiazines
• Excessive loss of water and salt (possibly due to not drinking enough water, profuse sweating, diarrhea, or vomiting)
• Loss of body fluids from the bloodstream into the tissues due to:
  • Conditions such as severe infections (sepsis) or burns
  • Heart, liver, or kidney failure
• Psychogenic polydipsia, the result of a mental disorder

Home Care

Because thirst is usually the body's signal to replace water loss, it is usually appropriate to drink plenty of liquids.

A very strong, constant urge to drink may be a sign of a psychological problem, which may mean psychological help is needed.

For thirst caused by diabetes, follow the prescribed treatment to properly control blood sugar levels.

When to Contact a Medical Professional

• Excessive thirst is persistent and unexplained
• Thirst is accompanied by other unexplained symptoms, such as blurry vision and fatigue
• You are passing more than 5 quarts of urine per day

What to Expect at Your Office Visit

The health care provider will get your medical history and perform a physical examination.

Medical history questions may include the following:

• How long have you been aware of having increased thirst?
• Is it consistent during the day?
• Is it worse during the day?
• Did it develop suddenly or slowly?
• Are you eating more salty or spicy foods?
• How much salt do you have each day?
• Did you change your diet?
• Have you noticed an increased appetite?
• Have you noticed an unintentional weight gain?
• Have you noticed an unintentional weight loss?
• Has your activity level recently increased?
• What other symptoms are happening at the same time?
• Have you recently suffered a burn or other injury?
• Are you urinating more or less frequently than usual?
• Are you producing more or less urine than usual?
• Have you noticed any bleeding?
• Are you sweating more than usual?
• Is there any swelling in your body?
• Do you have a fever?

A psychological evaluation may be recommended if the health care provider suspects a psychological compulsive thirst. Your fluid intake and output will be closely watched.

Diagnostic tests that may be performed include the following:

• Blood glucose level
• CBC and blood differential
• Serum calcium
• Serum osmolality
• Serum sodium
• Urinalysis
• Urine osmolality

Alternative Names

Increased thirst; Polydipsia; Excessive thirst

Read more »

HUMAN DIGESTIVE SYSTEM

Your Digestive System and How It Works On this page: Why is digestion important? How is food digested? How is the digestive process controlled? For More Information The digestive system. The digestive system is made up of the digestive tract—a series of hollow organs joined in a long, twisting tube from the mouth to the anus—and other organs that help the body break down and absorb food (see figure). Organs that make up the digestive tract are the mouth, esophagus, stomach, small intestine, large intestine—also called the colon—rectum, and anus. Inside these hollow organs is a lining called the mucosa. In the mouth, stomach, and small intestine, the mucosa contains tiny glands that produce juices to help digest food. The digestive tract also contains a layer of smooth muscle that helps break down food and move it along the tract. Two “solid” digestive organs, the liver and the pancreas, produce digestive juices that reach the intestine through small tubes called ducts. The gallbladder stores the liver’s digestive juices until they are needed in the intestine. Parts of the nervous and circulatory systems also play major roles in the digestive system. [Top] Why is digestion important? When you eat foods—such as bread, meat, and vegetables—they are not in a form that the body can use as nourishment. Food and drink must be changed into smaller molecules of nutrients before they can be absorbed into the blood and carried to cells throughout the body. Digestion is the process by which food and drink are broken down into their smallest parts so the body can use them to build and nourish cells and to provide energy. [Top] How is food digested? Digestion involves mixing food with digestive juices, moving it through the digestive tract, and breaking down large molecules of food into smaller molecules. Digestion begins in the mouth, when you chew and swallow, and is completed in the small intestine. Movement of Food Through the System The large, hollow organs of the digestive tract contain a layer of muscle that enables their walls to move. The movement of organ walls can propel food and liquid through the system and also can mix the contents within each organ. Food moves from one organ to the next through muscle action called peristalsis. Peristalsis looks like an ocean wave traveling through the muscle. The muscle of the organ contracts to create a narrowing and then propels the narrowed portion slowly down the length of the organ. These waves of narrowing push the food and fluid in front of them through each hollow organ. The first major muscle movement occurs when food or liquid is swallowed. Although you are able to start swallowing by choice, once the swallow begins, it becomes involuntary and proceeds under the control of the nerves. Swallowed food is pushed into the esophagus, which connects the throat above with the stomach below. At the junction of the esophagus and stomach, there is a ringlike muscle, called the lower esophageal sphincter, closing the passage between the two organs. As food approaches the closed sphincter, the sphincter relaxes and allows the food to pass through to the stomach. The stomach has three mechanical tasks. First, it stores the swallowed food and liquid. To do this, the muscle of the upper part of the stomach relaxes to accept large volumes of swallowed material. The second job is to mix up the food, liquid, and digestive juice produced by the stomach. The lower part of the stomach mixes these materials by its muscle action. The third task of the stomach is to empty its contents slowly into the small intestine. Several factors affect emptying of the stomach, including the kind of food and the degree of muscle action of the emptying stomach and the small intestine. Carbohydrates, for example, spend the least amount of time in the stomach, while protein stays in the stomach longer, and fats the longest. As the food dissolves into the juices from the pancreas, liver, and intestine, the contents of the intestine are mixed and pushed forward to allow further digestion. Finally, the digested nutrients are absorbed through the intestinal walls and transported throughout the body. The waste products of this process include undigested parts of the food, known as fiber, and older cells that have been shed from the mucosa. These materials are pushed into the colon, where they remain until the feces are expelled by a bowel movement. Production of Digestive Juices The digestive glands that act first are in the mouth—the salivary glands. Saliva produced by these glands contains an enzyme that begins to digest the starch from food into smaller molecules. An enzyme is a substance that speeds up chemical reactions in the body. The next set of digestive glands is in the stomach lining. They produce stomach acid and an enzyme that digests protein. A thick mucus layer coats the mucosa and helps keep the acidic digestive juice from dissolving the tissue of the stomach itself. In most people, the stomach mucosa is able to resist the juice, although food and other tissues of the body cannot. After the stomach empties the food and juice mixture into the small intestine, the juices of two other digestive organs mix with the food. One of these organs, the pancreas, produces a juice that contains a wide array of enzymes to break down the carbohydrate, fat, and protein in food. Other enzymes that are active in the process come from glands in the wall of the intestine. The second organ, the liver, produces yet another digestive juice—bile. Bile is stored between meals in the gallbladder. At mealtime, it is squeezed out of the gallbladder, through the bile ducts, and into the intestine to mix with the fat in food. The bile acids dissolve fat into the watery contents of the intestine, much like detergents that dissolve grease from a frying pan. After fat is dissolved, it is digested by enzymes from the pancreas and the lining of the intestine. Absorption and Transport of Nutrients Most digested molecules of food, as well as water and minerals, are absorbed through the small intestine. The mucosa of the small intestine contains many folds that are covered with tiny fingerlike projections called villi. In turn, the villi are covered with microscopic projections called microvilli. These structures create a vast surface area through which nutrients can be absorbed. Specialized cells allow absorbed materials to cross the mucosa into the blood, where they are carried off in the bloodstream to other parts of the body for storage or further chemical change. This part of the process varies with different types of nutrients. Carbohydrates. The Dietary Guidelines for Americans 2005 recommend that 45 to 65 percent of total daily calories be from carbohydrates. Foods rich in carbohydrates include bread, potatoes, dried peas and beans, rice, pasta, fruits, and vegetables. Many of these foods contain both starch and fiber. The digestible carbohydrates—starch and sugar—are broken into simpler molecules by enzymes in the saliva, in juice produced by the pancreas, and in the lining of the small intestine. Starch is digested in two steps. First, an enzyme in the saliva and pancreatic juice breaks the starch into molecules called maltose. Then an enzyme in the lining of the small intestine splits the maltose into glucose molecules that can be absorbed into the blood. Glucose is carried through the bloodstream to the liver, where it is stored or used to provide energy for the work of the body. Sugars are digested in one step. An enzyme in the lining of the small intestine digests sucrose, also known as table sugar, into glucose and fructose, which are absorbed through the intestine into the blood. Milk contains another type of sugar, lactose, which is changed into absorbable molecules by another enzyme in the intestinal lining. Fiber is undigestible and moves through the digestive tract without being broken down by enzymes. Many foods contain both soluble and insoluble fiber. Soluble fiber dissolves easily in water and takes on a soft, gel-like texture in the intestines. Insoluble fiber, on the other hand, passes essentially unchanged through the intestines. Protein. Foods such as meat, eggs, and beans consist of giant molecules of protein that must be digested by enzymes before they can be used to build and repair body tissues. An enzyme in the juice of the stomach starts the digestion of swallowed protein. Then in the small intestine, several enzymes from the pancreatic juice and the lining of the intestine complete the breakdown of huge protein molecules into small molecules called amino acids. These small molecules can be absorbed through the small intestine into the blood and then be carried to all parts of the body to build the walls and other parts of cells. Fats. Fat molecules are a rich source of energy for the body. The first step in digestion of a fat such as butter is to dissolve it into the watery content of the intestine. The bile acids produced by the liver dissolve fat into tiny droplets and allow pancreatic and intestinal enzymes to break the large fat molecules into smaller ones. Some of these small molecules are fatty acids and cholesterol. The bile acids combine with the fatty acids and cholesterol and help these molecules move into the cells of the mucosa. In these cells the small molecules are formed back into large ones, most of which pass into vessels called lymphatics near the intestine. These small vessels carry the reformed fat to the veins of the chest, and the blood carries the fat to storage depots in different parts of the body. Vitamins. Another vital part of food that is absorbed through the small intestine are vitamins. The two types of vitamins are classified by the fluid in which they can be dissolved: water-soluble vitamins (all the B vitamins and vitamin C) and fat-soluble vitamins (vitamins A, D, E, and K). Fat-soluble vitamins are stored in the liver and fatty tissue of the body, whereas water-soluble vitamins are not easily stored and excess amounts are flushed out in the urine. Water and salt. Most of the material absorbed through the small intestine is water in which salt is dissolved. The salt and water come from the food and liquid you swallow and the juices secreted by the many digestive glands. [Top] How is the digestive process controlled? Hormone Regulators The major hormones that control the functions of the digestive system are produced and released by cells in the mucosa of the stomach and small intestine. These hormones are released into the blood of the digestive tract, travel back to the heart and through the arteries, and return to the digestive system where they stimulate digestive juices and cause organ movement. The main hormones that control digestion are gastrin, secretin, and cholecystokinin (CCK): Gastrin causes the stomach to produce an acid for dissolving and digesting some foods. Gastrin is also necessary for normal cell growth in the lining of the stomach, small intestine, and colon. Secretin causes the pancreas to send out a digestive juice that is rich in bicarbonate. The bicarbonate helps neutralize the acidic stomach contents as they enter the small intestine. Secretin also stimulates the stomach to produce pepsin, an enzyme that digests protein, and stimulates the liver to produce bile. CCK causes the pancreas to produce the enzymes of pancreatic juice, and causes the gallbladder to empty. It also promotes normal cell growth of the pancreas. Additional hormones in the digestive system regulate appetite: Ghrelin is produced in the stomach and upper intestine in the absence of food in the digestive system and stimulates appetite. Peptide YY is produced in the digestive tract in response to a meal in the system and inhibits appetite. Both of these hormones work on the brain to help regulate the intake of food for energy. Researchers are studying other hormones that may play a part in inhibiting appetite, including glucagon-like peptide-1 (GPL-1), oxyntomodulin (+ ), and pancreatic polypeptide. Nerve Regulators Two types of nerves help control the action of the digestive system. Extrinsic, or outside, nerves come to the digestive organs from the brain or the spinal cord. They release two chemicals, acetylcholine and adrenaline. Acetylcholine causes the muscle layer of the digestive organs to squeeze with more force and increase the “push” of food and juice through the digestive tract. It also causes the stomach and pancreas to produce more digestive juice. Adrenaline has the opposite effect. It relaxes the muscle of the stomach and intestine and decreases the flow of blood to these organs, slowing or stopping digestion. The intrinsic, or inside, nerves make up a very dense network embedded in the walls of the esophagus, stomach, small intestine, and colon. The intrinsic nerves are triggered to act when the walls of the hollow organs are stretched by food. They release many different substances that speed up or delay the movement of food and the production of juices by the digestive organs. Together, nerves, hormones, the blood, and the organs of the digestive system conduct the complex tasks of digesting and absorbing nutrients from the foods and liquids you consume each day. [Top] For More Information American Dietetic Association 120 South Riverside Plaza, Suite 2000 Chicago, IL 60606–6995 Fax: 312–899–4739 Email: hotline@eatright.org Internet: www.eatright.org You may also find additional information about this topic by visiting MedlinePlus at www.medlineplus.gov. This publication may contain information about medications. When prepared, this publication included the most current information available. For updates or for questions about any medications, contact the U.S. Food and Drug Administration toll-free at 1–888–INFO–FDA (1–888–463–6332) or visit www.fda.gov. Consult your doctor for more information.

Read more »