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LOCATION LOWER EXTREMITY Structures of Note • Femoral nerve • Femoral artery • Femoral vein • Inguinal lymph nodes • Sciatic nerve • Popliteal artery • Popliteal vein • Tibial nerve at popliteal fossa and tarsal tunnel • Common fibular nerve at popliteal fossa, distal to head of fibula • Small saphenous vein • Great saphenous vein Femoral Triangle The femoral triangle, bordered by the inguinal ligament, medial sartorius, and adductor longus, is a particularly rich area for vulnerable structures. The femoral artery and vein are both accessible here, as are the inguinal lymph nodes and the femoral nerve. Deep, specific work on the adductors must be conducted with special care to avoid damaging these structures (Image 5). Sciatic Notch The sciatic notch is located deep to the deep lateral rotators. To access it manually would require pressing in deeply and intimately in the medial buttocks—typically not an area where most massage therapists work. The sciatic nerve, about as thick as a thumb where it emerges from the lumbosacral plexus, runs through the sciatic notch, into the deep lateral rotators (sometimes bifurcating the piriformis), and down the back of the leg, where it splits into the common peroneal nerve and the tibial nerve. The sciatic nerve is difficult to pin or damage because the musculature surrounding it is so thick, but if the nerve is irritated for any reason it can become inflamed along its entire length, and careless massage may exacerbate the situation (Image 6). Popliteal Fossa The popliteal fossa (defined by hamstrings superiorly and the gastrocnemius and plantaris inferiorly) or "knee pit" holds several structures, including the small saphenous vein where it joins to the popliteal vein, the popliteal artery, and the lower extensions of the sciatic nerve: the tibial and common fibular nerves (Image 8). Great Saphenous Vein The great saphenous vein runs up the medial side of the calf where there is little to protect it from being pinned to the tibia. On the upper leg, the vein runs over the quadriceps along the edge of the sartorius. This area is bulky enough that pinning the great saphenous to the femur is not generally possible. The great saphenous vein is the most likely location for varicosities to develop. If the skin is healthy, then light, broad, flat pressure here moving distally to proximally can be appropriate. Anything more challenging than that may not be a good idea (Image 9). Tarsal Tunnel The tarsal tunnel is on the medial side of the ankle, between the medial malleolus of the tibia and the calcaneus. It is not considered by most people to be an endangerment site. But, because the posterior tibial nerve can become entrapped here, in a condition called tarsal tunnel syndrome, it's a good anatomical feature to keep in mind. The tibial artery and vein also run through the tarsal tunnel (Image 9). Small Saphenous Vein The small saphenous vein begins at the lateral ankle, and then wraps to the posterior side of the lower leg. It comes up between the heads of the gastrocnemius, and then dives into the popliteal fossa, where it joins the popliteal vein. The small saphenous vein is also prone to varicosities, and it's something we need to keep in mind when working deeply in this area to access the soleus or deep foot flexors (Image 8). Common Fibular Nerve The common fibular nerve is vulnerable for a short distance just inferior to the head of the fibula. Specific pressure or friction on the fibularis longus can sometimes irritate this nerve, which will send shock-like electrical sensations down into the foot (Image 10). IN CONCLUSION In conclusion, I want to reiterate two important points: • Any place on the body can become an endangerment site if the massage therapist is uneducated, careless, or inattentive. • An endangerment site is not a "no- go" area; it is an area where extra education and expertise are required to work safely if we're doing anything more than gentle effleurage. Remember, the target client for this discussion is someone who is fundamentally healthy and also not pregnant. Illness, recent surgery, injuries, and pregnancy obviously add to our list of cautions and concerns about potential endangerment sites. But, for most people, massage therapy is widely accepted as a remarkably safe intervention, especially compared to other ways people manage pain (e.g., with medications or surgery). We can each do our part to take the danger out of endangerment sites by knowing these areas well, getting advanced education to work here safely, and modifying our massage accordingly. If we do that, our insurance providers will thank us. And much more importantly, our clients will thank us. 54 m a s s a g e & b o d y w o r k m a y / j u n e 2 0 2 0