A patient lower extremity positioning system that is configured to facilitate easier use of surgical instruments during open and arthroscopic procedures of the lower extremity, including, but not limited to the hip joint, acetabulum, femur, femoral neck and femoral shaft is disclosed. The patient lower extremity positioning system may include one or more perineal pads configured to be supported adjacent to a patient torso support such that the perineal pad is positionable adjacent to a patient's perineum. The perineal pad may be formed from a perineal pad body coupled to a distal transition section extending distally from the perineal pad body. The distal transition section may have a distal tip with a cross-sectional area that is less than a cross-sectional area of the perineal pad body, thereby enabling a surgeon to more easily position surgical instruments during surgery without the perineal pad conflicting with the surgical instruments.