Illustrated Essentials of Musculoskeletal Anatomy [5th Edition] 978-0935157079

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ust rated Essentia ls of

Musculoskeletal

Anatomy Fifth Edition

KayW. Si€9, Ph.D.

Sandra P. Adams, Ph.D.

\11

,nn

Gainesville, Florida 2009

Copyright

@

2009 by Megabook,Inc.

Third printing October 2010 Fifth Edition Previous editions copyrighted @ 1977, 1985,1996,2002by Megabooks Inc.

All rights reserved. This book is protected by copyright. No part of this book may be reproduced in any form or by any means, including photocopying, or utilized by any iniormation storage and retrieval system without written permission from the copyright owner.

Libra ry of Congress Control Number 2009924259

lsBN 978-0-93s 1 s7-07-9

Printed in the United States of America

MegabooksrM is the trademark of Megabooks, Inc.

4,^^

/v1€GABOOKS Published

by: Megabooks, Inc. 2937 NE 19 Drive Gainesvil le, FL 32609-3348

With admiration and affection to

BARRETT ADAMS for his enduring courage in the face of more challenges than we can imagine

tfl

iv

PREFACE TO 5TH EDITION As in previous editions of lllustrated Essentials

of Musculoskeletal Anatomy,thisfifth edition provides anatomical information about the bones, skeletal muscles and peripheral nerves of ihe human body. Siudents use the manual to learn anatomy for the first time; practitioners use it to update and refresh their knowlldge of musculoskeletal anatomy; and instructors use it to teach anatomy basics. Key features of the fifth edition as well as prior editions include clean, clear illustrations of bones, muscles, and nerves; a single bone, muscle or nerve on a page; brief descriptions of bone and muscle palpation; and m-uscle group actions. Basic muscle information includes the origin, insertion, action, innervation and palpation of individual muscles and how these muscles work together to perform joint movements. As in prior editions, content is organized into three sections of the book upper limb; lower limb; and head and trunk.

lmproved features from prior editions include updated anatomical terminology and improved content accuracy functional groups such as muicles thai attach the scapula to the humerus. The information on motions of the body and the peripheral nerves have improved and expanded a.nd clarity. Muscles are presented in anatomically

illustrations. Bone and muscle palpations are revised and expanded.

New features in the fifth edition include 1 7 additional muscles. New muscle pages illustrate and describe deep neck muscles and muscles of the pelvic floor. For the head, neck, and trunk musiles, new sections include group actions and motor and cutaneous innervation. The cervical plexus and cranial nerves are also illustrated.

Commitment to students, instructors, and practitioners remains our goal. As anatomy instructors, we originally developed this manual to help students to dev_elop a working knowledge of musculoskeletal anatomy. To this end, we distilled and focused the content in a user-friendly and simplified foimat as a supplement, or an aliernative, to weighty and detailed anatomy texts. Our hope for the instructor is that this manual eases your teaching of basic anatomy content; our hope for the student or practitioner is that this manual helps you to increase and maintain your knowledge of anatomy. Ultimately, a better understanding of the musculoskeletal system can impact the application of this knowledge towards enhancing human mou6ment and promoting health and well-being. Kay W. Sieg, Ph.D.

Sandra

P.

Adaffis, Ph.D.

Gainesville, Florida

VI

TABLE OF CONTENTS Dedication

ill

Preface to 5th Edition Table of Contents

V

vii

Instructions for Use of Manual

SECTION 1: UPPER LIMB A. Motions

B.

2 2

Humerus Elbow, Forearffi, Wrist, Digits

4

Bones

3

5 5

6

Scapula

7

Humerus

8

Radius, Ulna Hand

9 10

Palpation Sites

11

c. Muscles

14

Shoulder girdle Arm Forearm Hand

D. Muscle Group

14

28 31

Wrist Structures

Actions

49 59

61

Scapula

61

Humerus Elbow

64

Forearm

Wrist Thumb, Digits

Nerves

68 69 70 72

74

Brachial Plexus Musculoskeletal Nerve

74

Axil lary, Radial Nerves

76 77 78

Median, Ulnar Nerves Cutaneous Nerves

SECTION 2: LOWER LIMB

A.

1

Scapula

Skeleton Sternurn, Clavicle, Rib

E.

ix

Motions FemuL Knee Ankle, Toes

B. Bones Pelvis

Femur Tibia, Fibula Foot Palpation Sites

75

79 80 80 81

82 82 83 84 85 86

vil

TABLE OF CONTENTS SECTION 2: LOWER LIMB Cont'd

C.

Muscles Anterior Thigh

MedialThigh Gluteal

Foot

116

Muscle Group Actions

'a2,'a

Knee

Ankle, Foot

124 126

Toes

127

SECTION 3: HEAD ANDTRUNK

Motions Mandible, Neck Trunk, Pelvis

Bones Skull Spine, Vertebrae

Palpation Sites

c. Muscles

D.

E.

128 ",28 'a29

130 131

132

133 134 134 135

136 136 137 138

140

Head

'140

Anterior Neck Thoracic Wall

148 152

Abdominal Wall

157

Intrinsic Neck, Back Pelvic Floor

162

Muscle Group Actions

167

169

Mandible

'a69

Neck

Trunk

170 172

Nerves

173

Cervical Plexus Cranial Nerves Spinal Nerves Cutaneous Nerves

vlll

121

Hip

Lumbosacral Plexus ObturatoL Femoral Nerves Sciatic, Tibial Nerves Fibular Nerves Cutaneous Nerves

B.

89 93 97

102 104

E. Nerves

A.

89

Leg

Posterior Thigh

D.

88

173

174 175

176

REFERENCES

177

INDEX AUTHORS, ACKNOWLEDG EM ENT, CONTACT

182

179

INSTRUCTIONS FOR USE OF MANUAL This manual has three sections: Upper Limb; Lower Limb; and Head, Neck,Trunkthat include information A-E

described below.

A. MOTIONS Motions of the major joints of the human body are ilfustrated and labeled. In learning the motions, it is helpful to recall that the starting position for these motions is the anatomical position: head, eyes, and toes facing' forward; arms at sides with palms facing front; legs together with feet parallel (see position of skeleton Fig I B.t p.5).

B. BONES Majgr bony landmarks are illustrated for individual bones. Palpation instructions explain how to locate the landmark on the body surface. C. MUSCLES

lllustrations: Individual muscle illustrations show the location of the muscle on the skeleton. Observing the direction of the muscle fibers is helpful in appreciating the action of the muscle. Muscles are typicaliy illustrated on the right side of the body.The perspective of the view being shown is indicated below each drawing: i.e., "posterio4 right" means posterior view, right side. Qrigln,lnsertion, Action, Nerve: Individual muscle information includes the attachments, motions, and innervation and is presented as:

O I A N

Origin

Inseftion Action Nerve (spinalsegments)

Pglpatlon (P).' Palpation is described for most muscles. Palpation of the muscle belly and/or tendon can be done during active contraction of the muscle. Adding resistance to the motion may-be helpful in locating the specific muscle. Biceps Brachii muscle and tendon of insertion example:

P

Palpate muscle belly on the anterior surface of humerus during active elbow flexion. Distaltendon is palpated in cubitalfossa.

Comments: Memorization tips and/or notes of interest are highlighted for individual muscles. Text boxes provide general information about muscle groups such as the SITS muscles of the shoulder (see p.2t). Terminology: Terminology reflects current usage in the literature and international anatomical standards AnatomicalTerminology, 1998). When newer terms are used, the traditional terms are shown in parentheses, for example, Adduction (Retraction) of the scapula and Fibularis Tertius (FCAT - Federal Commiftee on

(Peroneus Tertius).

The classic anatomical terms of "origin" and "insertion" are used for systematic clarity in learning basic muscle anatomy, although the term "attachment" has been suggested to replace the terms origin and fnsertion since "they change with function" (FCAI, p.33). For example, the biceps brachii muscle brings the radius (insertion/ distal attachment) towards the scapula (origin/proximal attachment) to flex the elbow, but if the radius is stabilized by resting the elbow on a tabletop, the biceps may move the proximal (scapula) towards the distal (radius) attachment. Learning origins and insertions provides a sound reference for understanding such situational variations in muscle function. (continued next page)

IX

INSTRUCTIONS FOR USE OF MANUAL' Cont'd D. MUSCLEGROUPACTIONS In the sections on muscle group actions, muscles that serve as prime movers for a particular

joint action are

listed first. Muscles that assist in that action are in italics. An example follows: Flexors of the Elbow 1. Biceps Brachii (prime mover of elbow flexion) 2. Brachialis (prime mover of elbow flexion)

3. Brachioradialis (prime mover of elbow flexion) 4. Pronator teres (assists in elbow flexion) E.

NERVES

In the sections on nerves, illusgations of plexuses and individual peripheral nerves include the list of muscles

supplied by the nerve as well as the spinal segment for a given muscle. Cutaneous distributions of peripheral nerves are summarized in additionaldrawings. ABBREVIATIONS USED IN MANUAL action of a muscle

Forearm APL

a, as

artery, arteries

BR

ant

anterior

ECRB

c

ECRL

I

cervical coccygeal carpometacarpal joint distal interphalangealjoint in hand, foot insertion of a muscle

inf

inferior

EPB

IP

interphalangeal joint in hand, foot

EPL

L

lumbar

FCR

lat

lateral muscle, muscles medial metacarpophalangeal joint in hand metatarsophalangeal joint in foot innervation of a muscle nerve, nerves origin of a muscle palpation of a muscle proximal interphalangeal joint in hand, foot

FCU

post

posterior

AdP

S

sacral

APB

sup

superior

DI

s5 T v, vs

spinal segment

FDM

General

A

Co

CM, CMC DIP

m, mS

med MP, MCP

MB MTP N

n, nS

o P

PIP

PQ

Brachioradialis Extensor Carpi Radialis Brevis Extensor Carpi Radialis Longus Extensor Carpi Ulnaris Extensor Digitorum Extensor Digiti Minimi Extensor Indicis Extensor Pollicis Brevis Extensor Pollicis Longus Flexor Carpi Radialis Flexor Carpi Ulnaris Flexor Digitorum Superficialis Flexor Digitorum Profundus Flexor Pollicis Longus Palmaris Longus Pronator Quadratus

PT

Pronator Teres

ECU ED

EDM EI

FDS FDP FPL PL

Hand

ADM

thoracic

FPB

vein, veins

ODM OP

Digits l st digit

2nd digit 3rd digit

4th digit sth digit

Fingers

Toes

thumb index finget 2nd

great toe 2nd toe, 1 st of 4 lateral toes 3rd toe, 2nd of 4lateral toes 4th toe, 3rd of 4lateral toes 5th toe,4th of 4lateral toes

finger

middle finger, 3rd finger ring finger,4th finger little finger,5th finger

Abductor Pollicis Longus

PI

Abductor Digiti Minimi Adductor Pollicis Abductor Pollicis Brevis Dorsal Interossei Flexor Digiti Minimi Brevis Flexor Pollicis Brevis

Opponens Digiti Minimi Opponens Pollicis Palmar Interossei

A. MOTIONS

Posterior Forearm Compartment F:ftensor Supinator Muscles

Scapula

Humerus Elbow, Forearm, Wrist Thumb, Fingers

B.

BONES Skeleton Sternum, Clavicle, Rib

Supinator

Scapu la

Extensor Indicis

Humerus

Abductor Pollicis Longus

Radius, Ulna

Extensor Pollicis Longus Extensor Pol licis Brevis

Wrist, Hand Palpation of Bony Landmarks

C. MUSCLES

Intrinsic Muscles of Hand

Axioappendicular Muscles - Stabilize Scapula on Trunk Attoch Scapula to Vertebral Colu mn Trapezius Levator Scapula Rhomboids Major Rhomboids Minor

Rotator Cuff "SITS" M uscles

14

Flexor Pollicis Brevis

'14

Opponens Pollicis

Hypothenar

53

Flexor Digiti Minimi Brevis Opponens Digiti Minimi

Abductor Digiti Minimi

Palmar '49

Wrist

Structures

59

Dorsal Expansion of Digits Wrist Cross Section Tendons of the Wrist and Digits

21

Teres Minor

56

Lumbricals (1-4) Palmar Interossei (1 -4) Dorsal Interossei (l -3)

Supraspinatus Infraspinatus

D. MUSCLE GROUP ACTIONS-

Subscapularis

Scapula

Teres Major

61 61

Elevators, Depressors of Scapula Adductors (Retractors), Abductors (Protractors) of Scapula

Deltoids Coracobrachialis

Arm

Medial (Downward), Lateral (Upward) Rotators, Anterior, Posterior Tilt of Scapula

2g

Humerus

Biceps Brachii Brachialis

64

Flexors, Extensors of Humerus

Adductors, Abductors, Scaption of Humerus Medial, Lateral Rotators of Humerus Horizontal Adductors, Abductors of Humerus

Triceps Brachii Anconeus

Muscles of Forearm, Wrist,

49

Abductor Pollicis Brevis Adductor Pollicis

Serratus Anterior

Pectoralis Minor Subclavius Axioappendicular Muscles - Attach Trunkto Humerus Pectoralis Major Latissimus Dorsi Scapulohumeral Muscles - Attach Scopula to Humerus -

49

Thenar

14

Muscles of Shoulder Girdle and Upper Arm

Muscles of

38

Brachioradialis Extensor Carpi Radialis Longus Extensor Carpi Radialis Brevis Extensor Carpi Ulnaris Extensor Digitorum Extensor Digiti Minimi

Hand

Anterior Foreorm Compartment - Flexor Pronotor Muscles Flexor Carpi Radialis Flexor Carpi Ulnaris Palmaris Longus Pronator Teres

Pronator Quadratus Flexor Digitorum Superficialis Flexor Digitorum Profundus Flexor Pollicis Longus

Elbow Forearm, Wrist,

3l

Digits

68

Flexors, Extensors of Elbow

3l

Supinators, Pronators of Forearm Flexors, Extensors of Wrist Adductors, Abductors of Wrist Flexors, Extensors, Opposers of Thumb, Digits Abductors, Adductors of Thumb and Digits

E.

NERVES

74

Brachial Plexus Musculocutaneous Nerve Axillary and Radial Nerves Median and Ulnar Nerves Cutaneous Nerves

Serfion 'l : Upper l-imb

Scapular Motions

Depression

Elevation

Fig 1A.1 Elevation, depression of scapula Posterior; right scapula active, left scapula neutral

Neutral

Anterior Anteriorttilt

Fig 1A.3 Anterior tilt of scaPula Lateral, right

Abduction Adduction Fig 1 A.2 Adduction (retraction), abduction (protraction) of scapulae

In anterior tilt of the scapula, the coracoid process moves anteriorly and inferiorly and the inferior angle moves posteriorly and superiorly; in posterior tilt, the scapula moves in the opposite direction.

Posterior

Neutral

Lateral (upward)

Medial (downward)

rotation

rotation

Fig 1A.4 Lateral (upward), medial (downward) rotation of scapula Posterior; right scapula active in rotation, left scapula neutral

New Term Adduction Abduction

Scapular motions terminology New Term Traditional Term Lateral rotation Retraction Medial rotation Protraction

lllustrated Essentials of Musculaskeletal Anatomy

Traditional Term Upward rotation Downward rotation

l'lumeral Motions

Extension

Abduction

Flexion

Adduction

Fig 1A.5 Flexion, extension of humerus

Fig 1A.6 Abduction, adduction of humerus

Lateral, right

Anterior, right

Neutral

Medial rotation

Lateral rotation

Fig 1 A.7 Medial, lateral rotation of humerus Anterior, right

Horizontal abduction

:f

-'---': td-"t:.:::- -'-',:-' ,

-'

Horizontal adduction

Fig 1A.9 Horizontal adduction, abduction of humerus Anterior, right

Fig 1A.8 Scaption of humerus Anterior, right

Scaption refers to elevation of humerus in the plane of the scapula, 45o between the frontal and sagittal planes of the body.

Serrion I A : Upper Limb - Motions

EIb

ot

ltr.

Fo rea,rrnr,.llUri 5t,,D,i,g

it Motions

Supination

Extension

+\ J

Anterior

Pronation

Posterior

Fig 1A.1 1 Supination, pronation of forearm Right

Fig 1A.10 Flexion, extension of elbow Lateral, right

Extension

Fig 1A.1 2 Flexion, extension of wrist

Fig 1A.13 Adduction (ulnar deviation), abduction (radial deviation)

Lateral, right

Anterior, right

/q

Abduction*

Extension*

Flexion

\(

Adduction Opposition

Fig 1A.14 Flexion, extension of thumb

of thumb Lateral, right * also "palmar abduction"

Anterior, right abduction"

Anterior Anterior

Anterior, right

Finger

Flexion of MP joints with lP extension

Extension

Flexion

Fig 1A.16 Opposition, reposition of thumb and sth finger

Fig 1A.15 Adduction, abduction

* also "radial

Reposition

abduction

Thumb extension

Extension of MP and lP joints Medial

Fig 1 A.17 Flexion, extension of fingers Right

Adduction Fig 1A.18 Adduction of fingers and thumb; Abduction of fingers, extension of thumb Anterior, right

lllustrated Essentials of Musculoskeletal Anatomy

,

Skgfeton

Clavicle

Vertebrae

Scapula

Sternum

Humerus

Pelvis Ulna Radius

Metacarpals

Phalanges

Patella

fibia

Metatarsals

Phalanges

Fig

I8.1

Skeleton

Anterior

Axial skeleton - 80 bones: gkull; vertebral column; thoracic cage Appendicular skeleton - 126 bones: pectoral girdle; upper linib; pelvic girdle; lower limb Anatomical position -. H9ad, eyes, and toes faling fonru'ard; arms at sides with palms facing front; legs together with feet parallel Section

IB

: Upper Limb - Bones

Sternum, Thorax' Clavicle Sternum 1. Manubrium 2. Clavicular notch

Vertebrae (c6, c7, Tl

)

Clavicle 11

3. Body 4. Xiphoid process 5. Jugular (suprasternal)

l st Rib

8

;,T2ndRib

notch

Rib

6. Head 7. Tubercle

8. Body

Sternum

9. Costal angle (see Fig 18.3b) 10. Costal cartilage

Scapula

Clavicle 1

1. Sternal end

12.

Acromial end

Fig 18.2 Sternum, ribs, right clavical Anterior, right Vertebrae, scapula included for anatomical relationships; described p.7,

p.\37

T.l T-2 T.3

T4 T-5

T-6 T.7

T.8 T-9 T.lO T.'l'l T.'12

Fig 18.3a Thorax

Fig 18.3b Thorax

Anterior, right

Posterior, right

The 12 pairs of ribs are attached posteriorly to_thoracic vertebrae. Ribs 1-7 attach anterioily to the sternum by costal cartilagbg Ribs 8-10 attach.anterior,ly to each other by'costal cartilages. "'Floating" ribs 11-12 have no anterior attachments. lllustrated Essential s of Musculaskeletsl Anatamy

Sc,'gpulp

\4

Fig 1B.4a Scapula Posterior, right

1.

9.

Vertebral (medial) border Axillary (lateral) border

2, 3. Acromion 4. Coracoid process 5. Inferior angle 6. Superior angle 7, Glenoid cavity (fossa) 8. Infraglenoid tubercle

10. 1

1.

12. 13. 14, 15.

Fig 18.4b Scapula Costal (anterior), right

Supraglenoid tubercle Spine Root of spine Infraspinous fossa Supraspinous fossa Subscapular fossa Scapular notch

Fig 18.4c Scapula Medial, right

Section 1B: Upper Limb - Bones

Humerus

1. Head 2. Anatomical neck 3. Surgical neck 4. Greater tubercle 5. Lesser tubercle 6. Bicipital groove (l

ntertu bercu

la r g

roove)

7. Deltoid tuberosity 8. Groove for radial nerve (Spiral groove)

9. Lateral supracondylar ridge 10. Lateral epicondyle 1

1.

Medial epicondyle Medial supracondylar ridge

12. 13. Radial fossa 14, Capitulum 15. Coronoid fossa 16. Trochlea 17. Olecranon fossa

1

-1 14

16

Fig 1B.5a Humerus Anterior, right

lll ustrated

Essentials of Musculoskeletal Anatomy

Fig 18.5b Humerus Posterio6 right

Radius**U,lna

11

12

Radius

1. Head 2. Neck 3. Tuberosity 4. Anterior oblique line 5. Posterior oblique line 6. Interosseous border 7. Styloid process 8. Dorsal tubercle Ulna 9. Olecranon process 10. Trochlear notch (Semilunar notch) 11. Coronoid process 12. Radial Notch 13. Tuberosity

14. Interosseus border 15. Styloid process 16.

Head

17. Supinator crest 18. Posterior (su bcuta neous)

border

ts

8 Radius

Ulna

Ulna

Radius

Fig 18.6a Radius, ulna

Fig 18.6b Radius, ulna

Anterior, right

Posterior, right

Secti*n

1B :

Upper Limb - Bones

Distal

l

Phatanees

I Proximal

j

Metacarpals

Ulri

i. I

t

Fig 1 B.7a Carpals, metacarpals, phalanges Dorsal (posterior), right

Carpals Proximal Row:

1. Scaphoid 2. Lunate 3. Triquetrum 4. Pisiform

Distal Row:

5. Trapezium 6. Trapezoid 7. Capitate 8. Hamate (hoo k of hamate on anterior surface)

..,

,t

Metacarpals I through V

9.

Base

10.

Shaft

1.

Head

i

Fig 18.7b Carpals, metacarpals, phalanges Pal mar (anterior), right

10

lllustrated

Essen

tials of Musruloskeletal Anatomy

1

Phalanges

12. Base 13. Shaft 14. Head

Bone

Fig 18.8 Thorax and upper limb polpation sites Anterior, right

Anteriorthorar upper limb bone palpations 1.

Clavicle - Palpate tollar bone" from jugular notch of sternum to acromion of scapula.

2. Jugular (suprasternal) notch - Palpate indentation at superior end of manubrium between medial ends of the two clavicles. 3. Coracoid process of scapula - Palpate bony knob lying inferior to lateral part of clavicle.

9.

Bicipital groove - Palpate groove for long biceps tendon on anterolateral side of proximal humerus between greater and lesser tubercles.

10 Deltoid tuberosity - Palpate small bump midway down on lateral humerus. 1

1.

Lateral supracondylar ridge of humerus - Palpate superficial ridge on lateral side of distal end of

humerus, proximal to lateral epicondyle. 4.

Sternum - Palpate "breast plate'i the flat bone in midline of anterior thorax.

12. Medial supracondylar

ridge of humerus - Palpate medial ridge on medial side of distal end of humerus, proximal to medial epicondyle.

5. Xiphoid process - Palpate "sword-like" pointed tip at inferior end of sternum.

13.

Lateral epicondyle of humerus - Palpate bump on lateral side of distal end of humerus.

6.

Ribs - Palpate lateral thorax.

7.

Greater tubercle of humerus - Palpate round prominence on lateral side of proximal humerus, inferior and lateral to acromion of scapula.

14. Medial epicondyle

8.

Lesser tubercle of humerus - Palpate small

15 Head of radius - Palpate bony knob on proximal

prominence on lateral side of proximal humerus, anterior to greater tubercle and separated from it by the bicipital groove.

of humerus - Palpate bump on medial side of distal end of humerus ("funny bone"); larger than lateral epicondyle.

radius, just distal to lateral epicondyle of humerus (with elbow extended, it can be felt rolling during supination and pronation). Section lB : Upper Limb - Bones

1

1

Bo n g Pa I pa

-t i

o,11

qr,,Co n -ttd,*

Vertebra prominens (see Fig 38.8 p.139)

Fig

l.B9

Upper limb bone palpation sites Posterior, right

Posterior uppel limb bone palpations 1.

7,

Spinous processes of vertebrae - Palpate line of bumps down midline of back.

2. Spine of scapula - Palpate ridge across posterior

8. Olecranon fossa of humerus - Palpate distal end

scapula.

of posterior humerus between medial and lateral epicondyles.

3. Acromion process of scapula - Palpate lateral end of spine of scapula that forms top of shoulder.

9. Olecranon process of ulna - Palpate point of elbow at proximal end of posterior ulna between medial and lateral epicondyles.

4. Vertebral border of scapula - Palpate vertebral (medial) border of scapula that runs parallel to vertebral column.

10. 5.

Inferior angle of scapula - Palpate angle at inferior end of vertebral border of scapula (protrudes when arm placed behind the back).

Axillary border of scapula - Palpate axillary (lateral) border from inferior angle to axilla (armpit).

1

Posterior border of ulna - Palpate sharp dorsal margin of ulna for entire length of forearm.

1. Styloid process of ulna - Palpate prominent on distal end of posterior ulna

6. Superior angle of scapula - Palpate angle at superior end of vertebral border of scapula.

12.

lllustrated Essentials of Musculoskeletal Anatomy

1

knob

.Bl 1 p.l3).

Styloid process of radius - Palpate bony knob on distal end of lateral radius (it is slightly more distal

than styloid process of ulna) (see Fig 1.Bl 1 p.l3).

'a2

(see Fig

,Bo,n

e.Palpa t ign

sr',,Sgn t'

d

5. Metacarpal

heads

Capitate Trapezoid 4. Hamate 3.

Trapezium

1. Pisiform

Lunate Styloid process: ulna

2. Scaphoid

Styloid process: radius

Fig 1.810 Carpal bones palpation sites Pal mar (anterior), right

Anterior carpal bones palpations 1.

Pisiform - Palpate prominent, pea-shaped carpal bone on medial side of anterior wrist, just distal wrist flexor skin crease.

2. Scaphoid tubercle - Palpate bony knob on palmar surface of scaphoid on lateral side of anterior wrist, just distal to flexor skin crease. 3. Trapezium - Palpate carpal bone on lateral side of palm, just distal to scaphoid tubercle and proximal to the thumb metacarpah difficult to distinguish from the scaphoid.

4. Hamate and hook of hamate - Palpate carpal bone with small projection ("hook") on medial palm, just distal and lateral to the pisiform.

Hamate

Trapezoid

Pisiform

Trapezium

1.

4. Scaphoid

Triquetrum

2. Lunate

Styloid process: radius (see p.t 2)

Styloid process: uf na gee p.l2)

Fig 1.Bl 1 Carpa[ metacarpal, wrist bone palpation sites Dorsal (posterior), right

Posterior carpal, metacarpal, wrist bone palpations 1. Triquetrum - Palpate carpal bone on ulnar side of dorsal wrist just distal to styloid process of

the ulna; protrudes when wrist is abducted; located posterior to pisiform. 2.

Lunate - Palpate carpal bone in middle of dorsal wrist on ulnar side of scaphoid, just distal to medial end of radius; protrudes when wrist is flexed.

3. Capitate - Palpate carpal bone just distal to lunate and proximal to the base of 3rd metacarpal on dorsal wrist when wrist is flexed.

4. Scaphoid - Palpate carpal bone on dorsolateral side of wrist, just distal to styloid process of radius; protrudes when wrist is adducted; forms floor of "anatomical snuffbox" (see note p.47). 5. Metacarpal heads - "Knuckles" - Palpate large distal ends of the 5 metacarpal bones; prominent when hand is fisted. Section

IB

: Upper Limb -

Eones

13

{.t

ranezluS -F--'

rI r

Ligamentum nuchae (base of skull to C7)

O.

Upper:

l.

Upper:

Upper trapezius

External occi pital protuberance Ligamentum nuchae Middle: C7 -T3 spi nous processes Lower: T4-T1 2 spinous processes

5

6

Middle

7

trapezius

Lateral third of clavicle Acromion of scapula

Middle: Spine of scapula Lower: Root of spine of scapula

T1

2 3

A. Upper:

4

Elevation Lateral (upward) rotation of scapula Middle: Adduction (retraction) of scapula Lower: Depression Lateral (upward) rotation of scapula

=

5

6 7

8 9

N. Accessory n (CNXI) spinal part (motor) C3, 4 spinal ns P.

Upper: Palpate superior surface of shoulder

L1

between curvature of neck and lateral third of clavicle during active scapular elevation. Middle: Palpate area medial to the vertebral border

2 3

of scapula between thoracic vertebrae T1-5 and the root of spine during active scapular add uction (retraction).

a Fig

1C.l

Trapezius

Lower:

Posterior

Palpate triangular area between lower

thoracic vertebrae T6- 12 and root of spine of scapula during active scapular depression and lateral (upward) rotation.

,

Trapezius has three parts: upper, middle, and lower. This large, triangular shaped muscle, when paired, forms a trapezium and is the mo.sf sup erficial muscle of the

back.

riit: jil;rjilti;riiii:l:,ii:;.;::i

14

lllustrated Essentials of Musculoskeletal Anatamy

i

,:i'

Levator

O.

l.

S,(a,pu,la

C1-4 (transverse processes)

Vertebral border of scapula from superior angle to root of spine

A. Elevation Medial (downward) rotation of scapula N. Dorsal scapular n (C5) C3, 4 spinal ns P.

Palpate lateral neck region in triangular area formed by upper trapezius and

sternocleidomastoid during elevation of the scapula. Palpate distal attachment on posterior surface of upper back just off the

superior angle of scapula during elevation of the scapula.

Fig 1 C.2 Levator scapula Posterior

Scapulothoracic Joint Muscles attaching to the scapula move the scapula upon the thorax at the scapulothoracic joint, gliding the scapula in elevation, depressioh, adduction, abduction, medial and lateral rotatioo, and anterior and posterior tilt motions.

Position the hand behind the back to minimize the action of the trapezius.

Shrugging the shoulder rapidly and repeatedly in a small range of motion will help distinguish the levator scapula from the overlying trapezius.

Levator scapula is an elevator (L-evato). Together with the upper trapezius, this muscle shrugs your shoulders. Section I C : Upper Limb - Muscles

15

Rhomboids Major and Minor

o. Rhomboid minor: C7 and T1 (spinous processes)

Rhomboid major: T2-T 5 (spi nous processes) l. Rhomboid minor: Root of spine of scapula

Rhomboid

minor Rhomboid

Rhomboid major: Vertebral border of scapula from root of spine to inferior angle

major

A. Add uction (retraction) Medial (downward) rotation of scapula

N. Dorsal scapular P.

Posterior

* + j;:,:

'ti :]4 ,:td

e{iUiiiiil,ii:ririiiiirriiliti':li

16

lllustrated Essentiols of Musculoskeletal Anatomy

Palpate area medial to the vertebral border of scapula near the inferior

angle during active scapular adduction and medial rotation (retraction and downward rotation).

Fig 1C.3 Rhomboids maior and minor

Ihese rhomboidal-sha ped m usclet ,' when paired, form a chevron shape " due to the oblique and downward ', direction of their fibers.

n (C4, 5)

Serratus Anterior

o. Lateral surface of upper 8 ribs (by fingerlike slips)

l. Vertebral border of scapula - anterior su rface A. Abd uction (protraction) Lateral (upward) rotation of scapula Stabilizes scapula against chest wall Depression of scapula (lower fibers) Assists forced exha lation

N. Long thoracic n (C5, 6,7) P.

Palpate below lateral end of clavicle on anterior chest wall, just inferior and medial

to coracoid process of scapula, during active scapular abduction (protraction). Fig 1C.4a Serratus anterior

Anterior

from of

; Serratus anterior deriyes its name the serrated origin. The lower fibers $ the origin interdigitate with the external $ oblique. lt is the strongesf abductor $ the scapula and holds the scapula against the chesf wall to provide a fixed $ for muscles acting on the $ 'ii

of

Fig 1C.4b Serratus anterior costal origin, medial border of scapula insertion Anterolateral

origin humerus.

--3:,-:o,:.::r:r:.:,:,,_j.--.-1-.T,.?::-::::k# Section lC:UpperLimb-

Muscles

'17

Pectora I is M in,o,rr. Su bcl avius

i

Pectoralis minor

Subclavius

Pectoralis Minor O. Anterior surface of ribs 3, 4,5 near costal cartilages

l. A.

Coracoid process of scapula (medial border of superior surface)

Abduction (protraction) Depression Medial (downward) rotation

Anterior tilt of scapula Assists forced i n ha lation

N.

Medial pectoral n (C8, T1)

P. Difficult to palpate. Position arm with the hand behind the back to relax pectoralis major. Place palpating fingertip on coracoid process and lay finger just in front of anterior border of deltoid. Palpate pectoralis minor as the hand is actively lifted away from the back during scapular a bd uction (protraction).

Fig 1C.5 Pectoralis minor, Subclavius Anterior

Subclavius O. 1st rib costocartilage junction

l.

Inferior shaft of clavicle - middle 1/3

A. Depresses Sta bi I izes

N.

clavicle sternoclavicu lar joi nt

Subclavian n (C5, 6)

P. Difficult to differentiate from overlying pectoralis major. Subclavius prevenfs extreme elevation and protraction of the clavicle.

18

lll

ustrated Essential s of Musculoskeletal Anatomy

Maj,or

q

O. Clavicular head: Medial half of clavicle Sternocostal head: Sternum Cartilages of superior 6 ribs Aponeurosis of external oblique muscle

Clavicular head Sternocostal head

l. Lateral lip of bicipital (intertubercular) groove of humerus A. Adduction Horizontal adduction Medial rotation of humerus Clavicular head: Flexion of humerus Sternocostal head: Extension of humerus Assists anterior tilt of scapula N. Clavicular head: Lateral and medial pectoral ns (C5, 6) Sternocostal head:

Medial pectoral n P.

Fig 1C.6 Pectoralis major Anterior

two hr;;;, ;,;;;i;:d for their origins. This large chesf muscle forms Pectoralis

major

the anterior wall

,8,T1)

Palpate anterior chest wall between clavicle and 6th rib during resisted adduction of the

humerus at the shoulder joint. Clavicular head: Palpate just inferior to medial half of clavicle on anterior chest wall during resisted horizontal adduction of the humerus. Sternocostal head: Palpate the lower anterior border of the axilla during resisted extension and horizontal adduction of the humerus from a flexed starting position.

has

of

(CZ

i

the axilla (armpit). ,ii,

Sertion lC : Upper Limb

-

Muscles

19

Dorsi

o. Thoracol u m ba r a poneu rosi s Lower 6 thoracic spinous processes Sacrum lliac crest of ilium

Lower3to4ribs Inferior angle of scapula l. Bicipital (intertubercular) groove of humerus A. Extension Medial rotation Adduction of humerus Medial (downward) rotation of scapula Assists depression of scapula

N. #.H tro

P.

rtb --l

ET, \J C,

xe

Thoracodorsal n (C6, 7,8) Palpate along posterolateral surface of rib cage toward its insertion on the humerus during resisted extension of the humerus.

=|! F

)< f

'r\

Fig 1 C.7 Latissimus dorsi Posterior

20

lllustrated Essentials of Musculoskeletal Anatomy

Latissimus means widest and dorsi means back (Latin); it is the widest muscle of the back. A powerful extensor of the flexed humerus, it is active in forcef ul movemenfs suc h as swimming, chopping with an axe, and pulling the shoulder girdle down when using crutches or doing a depression transfer. This muscle lies inferior to feres major and together they form the posfe rior border of the axilla by their attachmenfs fo the humerus.

Supraspinat,us

O.

Supraspinous fossa of scapula

l. Greater tubercle of humerus (superior facet) A. Abduction Scaption of humerus Stabilization of head of humerus

N.

Suprascapular n (C4,5,6)

P.

Palpate above the spine of scapula near the acromion during the first 1 5' of abduction of the humerus. The

overlying upper trapezius can be relaxed by laterally flexing the neck prior to initiating the motion to help differentiate the supraspinatus.

Fig 1C.8b Supraspinatus insertion Posterior

(acromion removed)

Rotator cuff "SITS" Muscles Su.praspinatus, Infraspinatus and Teres minor insert, respectively on the superior; middle, and inferior facets of the greater tubercle of the humeral head and the Subscapularis inserts on the lesser tubercle of the humeral head. These four muscles can be recalled by the first letter of their names as the 'SITS' muscles. The " S|TS " muscles comprise the " rotator cuff muscles " that reinforce the capsule of the shoulder joint and stabilize the head of the humerus in the glenoid fossa of the scapula for movements of the humerus.

Tl.

Supraspinatus pulls the head of the humerus into the glenoid fossa and is a crucial initiator for the first | 5" of humeral abduction. As one of the "SITS rotator cuff" muscles, it is an effective stabilizer for humeral abduction and a reinforcer of the shou lder joint capsule. '!r;:l

r

ji,r j,i:::irt.:rilri*i:itt! j

r

Section lC: Upper Limb - Muscles

21

lnfraspinatus

O.

l.

Infraspinous fossa of scapula Greater tubercle of humerus (middle facet)

A. Lateral rotation Extension of humerus

N. P.

Suprascapular n

(C5

,6)

Palpate below the spine of scapula during active lateral rotation of the humerus. Seated with trunk leaning forward and arm hanging down to passively protract scapula, palpate inferior to the posterior

deltoid.

Fig 1C.9 lnfraspinatus Posterior

lnfraspinatus is the "1" of the "SITS rotator cuff" muscles (see note p.2t), assisting in reinforcement of the shoulder ioint capsule and stabilization of the head of the humerus in the glenoid fossa of the scapula for movements of the humerus. 22

tllustrated Essentials of Musculoskeletal Anatamy

Te1eF*M,i,;lgr

O.

l. A.

Upper 2/3 of axillary border of scapula Greater tubercle of humerus (inferior facet) Lateral rotation Extension of humerus

N.

Axillary n (C5,6)

P.

Palpate along lateral border of scapula just inferior to the infraspinatus during active

lateral rotation of the humerus. Teres minor performs the same actions as

the infraspinatus and may be difficult to differentiate.

Fig 1C.10 Teres minor Posterior

minor is the "T" of the "SITS" muscles (see note p.2t). lt reinforces the capsule of the shoulder joinf as one of the 'rotator cuff" muscles and helps stabilize the head of the humerus in the glenoid fossa for movements of the humerus. Teres

iti tl',

Section tC : Upper Limb

-

Muscles

23

Subsca,pularis

O.

l.

Subscapular fossa of scaPula Lesser

tubercle of humerus

A. Medial rotation Adduction of humerus

N. Upper and lower subscapular ns (C5, 6,7) P.

Palpate deep in axilla along the lateral border of costal surface of the scapula toward its insertion during medial rotation of

the humerus. Subscapularis is difficult to differentiate from the overlying latissimus dorsi and teres major muscles which form the posterior Fig 1C.l 1a Subscapularis Anterior

border of the axilla and perform the same actions.

pularis asstsfs tn various sho ulder actions, depending on the position of the humerus.Subsca pularis is the last of the "5/I5 " muscles (see note p.21); it inserts on the /esser tubercle and the other 3 5/I5 muscles insert on the greater tubercle.

Subsca Fig 1C.l 1b Subscapularis, thorax removed to reveal origin on costal (anterior) surface of scapula Anterior

24

tllustrated Essentials of Musculoskeletal Anatomy

grtes-fvl,ilor Teres Maior

o.

Inferior angle of scapula (dorsal surface) Lower third of axillary border of scapula

l.

Medial lip of bicipital groove of humerus

A. Extension Medial rotation Adduction of humerus t'

N.

Lower subscapular n

P.

Palpate muscle belly just lateral to the inferior angle of scapula toward its

(C5

,6)

insertion during resisted extension of the humerus.

Fig 1 C.12

Teres

major

Posterior

major lies superior to, and inserts near; latissimus dorsi which it joins fo form the posterior border of the axilla and shares the same actions. Together with infraspinatus and feres minor; it pulls downward to help stabilize the head of the humerus during Teres

'

abduction

Section lC:UpperLimb-

Muscles

$ $

25

Deltoids O. Anterior: Lateral third of clavicle

Middle: Acromion of scapula - lateral surface Posterior: Spine of scapula

Fig 1C.13a Anterior deltoid Anterior

l.

Deltoid tuberosity of humerus

A.

Anterior: Flexion Horizontal adduction Medial rotation of humerus Middle: Abduction of humerus to 90 degrees Posterior: Extension

Posterior

Anterior Middle

Horizontal abduction Lateral rotation Scaption of humerus

N. Axillary n (C5,6) P. Anterior: Palpate anterior surface of upper arm in shoulder area just below acromion during

Fig 1C.l3b Middle deltoid Lateral

horizontal adduction of the humerus. Middle: Palpate lateral surface of upper arm in shoulder area just below acromion during

abduction of the humerus.

Posterior

Posterior: Palpate posterior surface of upper arm in shoulder area just below the acromion

during horizontal abduction of the humerus.

Fig 1C.l3c Posterior deltoid Posterior

26

tllustrated Essentials of Musculoskeletsl Anatamy

The deltoids form the rounded muscle bulk over the shoulder joint. A strong abducto7 the muscle cannot initiate that movement because the angle of putl is parallel to the humerus when the arm is

by the side

(see supraspinatus, p.21).

Coracobrachialis

O. Coracoid process of scapula

l.

Middle 1/3 of medial surface of humeral shaft

A. Flexion Adduction of humerus

N.

Musculocutaneous n (C5, 6,7)

P. Palpate slender muscle belly on anteromedial surface of proximal humerus, medial to short head of bic€ps, during resisted flexion and adduction of the humerus.

Fig

1

C.l4

Coracobrochialis

Anterior

Coracobrachialis is named for its origin and insertion. Secfrcn

"f

{ : Upper Limb

- Muscles

27

Brachii

o. Short head: Coracoid process of scapula Long head: Supraglenoid tubercle of scapula

l. Tuberosity of radius Bicipital aponeurosis A. Flexion of elbow Supination of forearm Short head: Flexion of humerus

Long head

N. P.

Musculocutaneous n (C5, 6) Palpate muscle belly on anterior surface of

humerus during active elbow flexion with

Bicipital aponeurosis

forearm supinated.

Fig 1C.l5a Biceps brachii Anterior

Distal tendon is palpated in cubital fossa on anterior surface of elbow joint.

'

Fig 1C.1 5b Biceps brachii origins; tendon of long head in bicipital groove Anterior

28

lllustrated Essentiols of Musculoskeletal Anatomy

:

' ,

Biceps means two heads and brachium means arm (Latin). The long head travels through the capsule of the shoulder joint and the bicipital (intertubercular) eroove. The short head originates on the coracoid process along with the origin of the coracobrachialis and the insertion of the pectoralis minor.

Brachialis

O.

l.

Lower half of anterior shaft of humerus Tuberosity of ulna Coronoid process of ulna

A.

Flexion of elbow

N.

Musculocutaneous n (C5, 6)

P.

Palpate on either side of the biceps

tendon on anterior surface of distal humerus, just proximal to the cubital fossa, during active flexion of the elbow

with forearm pronated (to relax biceps). Palpate tendon of insertion deep in

cubital fossa just medial to biceps tendon. Fig 1C.l6 Brachialis

Anterior

..

flexor.

Brachialis is the strongest elbow

fi ,t

Secfion lC : Upper Limb

-

Muscles

29

I.r*i-*_,-----c.'--q*

Brachii and Anconeus Triceps Brachii O. Long head: Infraglenoid tubercle of scapula Lateral head: Posterior humerus above spiral groove Medial head: Posterior humerus below spiral groove l. Olecranon process of ulna Medial head

A. Extension of elbow Long head: Extension of humerus

N. Radial n (C6, 7 ,8) P.

extension. Long head: Palpate posteromedial surface of proximal humerus, just inferior to the posterior deltoid, during resisted elbow

Fig 1 C.17 Triceps brachii Posterior

extension. Medial head: Palpate posterior surface of distal humerus, proximal to olecranon process

Fig 1C.l8 Anconeus Posterior

of ulna, on either side of triceps tendon during resisted elbow extension. lt lies deep to the long and lateral heads.

Anconeus

O.

Lateral head: Palpate posterolateral surface of mid humerus during resisted elbow

Lateral epicondyle of humerus

l. Olecranon process and upper posterior surface of ulna A. Assists extension of elbow N. Radial n P.

30

(C7

,8, T1 )

Palpate small area just distal to elbow joint between lateral epicondyle of humerus and olecranon process of ulna on posterolateral surface of proximal forearm. Difficult to palpate because it lies deep to tendinous sheath of triceps brachii. lllustrated Essentials of Musculoskeletal Anatomy

Triceps means three heads (Latin). lt is the only muscle on the posfe rior arm. ', The long head of the triceps originafes ',, from the infraglenoid tubercle, whereas the long head of the biceps originafes from the supraglenoid tubercle.

, ,

Flexor

O.

l.

Medial epicondyle of humerus (common flexor tendon) Bases

of 2nd and 3rd metacarpals

A. Flexion Abduction of wrist (radial deviation)

N.

Median n (C6,7)

P. Palpate tendon on anterior surface of wrist at base of 2nd metacarpal, just lateral to palmaris longus tendon (if present), during active wrist flexion. Palpate muscle belly on anterior surface of proximal forearffi, just medial and superficial to pronator teres muscle,

during active wrist flexion with radial deviation to differentiate it from other wrist flexors.

Fig 1C.l9 Flexor carpi radialis Anterior

Acting alone, flexor carpi radialis (FCR) flexes the wrist with some abduction. Flexor carpi radialis and extensor carpi radialis longus function ,

,,.tog,,'' Section

|

{ : Upper Limb - Muscles

31

Fl

exo r,Ca rpi,,,U Ina,ri,s

o. Humeral head: Medial epicondyle of humerus (common flexor tendon) Ulnar head: Proximal posterior ulna Olecranon process of ulna

l. Pisiform carpal bone Hamate carpal bone Base of 5th metacarpal

Humeral head

A. Flexion Adduction of wrist (ulnar deviation)

N. P.

Ulnar n (C7,8) Palpate tendon on anterior surface of wrist, just proximal to the pisiform carpal bone, during active wrist flexion. Palpate muscle belly on medial side of anterior forearm, just anterior to proximal shaft of ulna, during active wrist flexion with

ulnar deviation. Alternate wrist adduction and abduction with wrist slightly flexed to differentiate it from other wrist flexors.

Fig 1C.20a Flexor carPi ulnaris Posterior

Fig 1C.20b FCU insertion

Anterior

,

Acting alone, flexor carpi ulnaris (FCU) flexes the wrist in an ulnar direction. ', Flexor carpi ulnaris and extensor carpi t ulnaris function together to adduct the ' wrist. The ulnar nerve passes between ' the ulnar and humeral heads to enter I the forearm. :,

"''i:t$;jii::r.,,: ::ili:ijirr:1t:'#i1d,.i:liit!r.ie:f:'ii

32

tllustrated Essentials of Musculoskeletal Anatomy

#'"1l

i*,.iiirc*f5;,;:i:v,l*lr.1i{{i.ijr.ii.s;.ili*'.1ii{i;i' 1*:iiigl'itr.i''il

*iroJi

Pa I m,a,ri s',Lo n,g,fl,s

o. Medial epicondyle of humerus (common flexor tendon)

;,-

l. Palmar aponeurosis Flexor retinaculum

A.

Assists flexion of wrist

N.

Median n (C7,8)

P.

Palpate tendon, if present, in midline of anterior surface of wrist on ulnar side of flexor carpi radialis tendon when the wrist is flexed against resistance or when

the fingertips and thumbpad are brought tightly together.

!1ffi, ^\

Fig 1C.21 Palmaris longus

Anterior

'1 {:ii

Palmaris Brevis Palmaris brevis, a small muscle lying in

the fascia of the hypothenar eminehce, may be present in some persons.

The lengthy tendon of palmaris longus (PL) is often used for tendon repair. Palmaris longus is sometimes absent on one or both forearms.

fi *9

$ ilf

i'{i

ii

rt#ttiit if itjJljini{ri,,;'. *ii{Strj$t*f S$iifjrl,,niij?;#*,r.,r,,O.r*r*.rr*#

Section lC : Upper Limb -

frluscles

33

Pronator Teres and Pronator Quadratus ,i,

:

' :. .

:j:

Pronator Teres O. Humeral head: Medial epicondyle of humerus Ulnar head: Coronoid process of ulna

l.

Middle of lateral shaft of radius

A. Pronation of forearm Assists in flexion of elbow

W

N. Median n (C6, 7) P.

Palpate medial side of anterior surface of proximal forearm just medial to biceps

tendon and cubital fossa during resisted pronation of the forearm.

Pronator teres fibers run from origin to insertion diagonally across the proximal half of the anterior forearm resulting in rotation of the radius over the ulna.

%

Pronator Quadratus O. Distal fourth of anterior ulna

l.

Distal fourth of anterior radius

A. Pronates forearm N. Median n (C8, T1 )

Fig 1 C.22 Pronator teres; Pronator quadratus Anterior

P.

Cannot palpate due to its deep location. Pronator quadratus functions in resisted and non-resisted pronation. lt has more fibers in cro.ss section than pronator feres.

34

lllustrated Essentials of Musculoskeletal Anatomy

Flexor

D

igitoru m,Superficialis

o. Humeroulnar head: Medial epicondyle of humerus (common flexor tendon) Coronoid process of ulna Radial head:

Anterior oblique line of radius

Humeroulnar head T.

Sides of shafts of middle phalanges of 4

fingers A. Flexion of 4 fingers at PIP joints Assists flexion of wrist

N.

Median n (C7,8, Tl )

P.

Palpate common tendon on anterior wrist between palmaris longus tendon and

flexor carpi ulnaris tendon during resisted flexion of the 4fingers at PIP joints. Palpate individual tendons on palmar surface of proximal phalanx of each of the

4fingers during resisted flexion of the PIP joints. lsolation of little finger PIP flexion from DIP flexion may not be possible.

The median nerve and ulnar

Fig 1 C.23 Flexor digitorum superficialis

Anterior

artery pass beneath the origin of flexor digitorum superficialis (FDS). At the wrist the tendons to the middle and ring fingers are superficial to the tendons of the index and little fingers (see Fis 1c.48, p.se). Each of the four FDS tendons divides at the proximal phalanx to allow the flexor digitorum profundus (see p.36) to pass through to the distal phalanx (see Fig 1C.47,

p.59; Fig 1D.25, p 72).

Section I C : Upper Limb - Muscles

35

Flexor Pigitor u m Profundus

O.

l.

Proximal3/4 of anterior ulna lnterosseous membrane Bases of distal phalanges

of 4fingers

rt,lllll,l

A.

Flexion of 4frngers at DIP joints Assists flexion of wrist

N. Radial 2 fingers: Median n (C8, T1) Uf na r 2fingers: Ulnar n (C8, T1) P.

Palpate individual tendons on the palmar surface of the middle phalanx of each of the 4frngers during resisted DIP flexion. Stabilize the PIP joint of the finger being palpated to isolate DIP flexion.

Fig 1 C.24 Flexor digitorum profundus Anterior

As the flexor digitorum profundus (FDP) flexes the DIP joints of the fingers, its continued action flexes the PIP and MP and wrist joints. Profundus means deep (Latin). The profundus tendons pass through the tendons of the flexor digitorum superficialis 6ee p.35; Fig 1C.47, p.59; and Fig 1D.25, p.72 ).

36

lll ustrated

Essentials of Musculoskeletal Anatomy

Flexor Pollicis Longu,s

O.

Middle of anterior radius Interosseous membrane

l.

Distal phalanx of thumb

A.

Flexion of thumb at lP joint

N.

Median n (C8, T1 )

P.

Palpate tendon on anterior surface of proximal phalanx of thumb during active

flexion of the

lP

joint.

As the flexor pollicis longus (FPL) flexes the lP its continued action flexes MP and CM joints of the thumb. This muscle originafes near the flexor digitorum profundus, and the muscle bellies are adjacent. The tendon passes through a synovial sheath and attaches fo the distal phalanx of the thumb in a manner similar to the flexor digitorum profundus in the fingers.

joint, Fig 1 C.25 Flexor pollicis longus

Anterior

Section I C : Upper Limb - Muscles

37

Brachioradialis

O.

l.

Lateral supracondylar ridge of humerus

Styloid process of radius

A. Flexion of elbow with forearm in mid-position (halfway between supination and pronation)

N.

Radial n (C5, 6,7)

P. With forearm in mid-positiol'1,

Pdlpate prominent tubular-shaped muscle on proximal foreafln, just lateral to the biceps tendon as it crosses the elbow joint, during resisted elbow flexion.

7Di

Fig 1 C.26 Brachioradialis Posterior

38

lll ustrated

Essentials of Musculoskeletal Anatarny

Brachioradialis derives its name from its origin and insertion. lt flexes the elbow with the forearm in mid-position, whereas the biceps flexes fhe elbow in supination and the brachialis flexes the elbow in all positions. Brachioradialis functions when the elbow flexes rapidly or against reststa nce. Acting alone, this muscle would tend to bring the forearm to mid-position from either a supinated or pronated position as it flexes the elbow.

Extensor c a,rn,i-*ff # d in,l tt,t. g,l].1

O.

l. A.

Lateral supracondylar ridge of humerus Lateral epicondyle of humerus Base

of 2nd metacarpal

Extension

Abduction of wrist (radial deviation)

N. Radial n (C6,7) P.

Palpate muscle belly on posterior surface of proximal forearm adjacent

to brachioradialis during active wrist extension with radial deviation (abduction). Radially deviating the extended wrist will differentiate the muscle belly from other wrist extensors. Palpate tendon on dorsal surface of wrist at the base of the 2nd metacarpal.

Fig 1 C.27 Extensor carpi radialis longus Posterior

, Acting alone, extensor carpi radialis longus

, (ECRL) extends the wrist in a radial direction. '

'iiiiiii;lli$i.+lliti,riiifi++,tqb::.,.rr*;:'..$lij;:l,rrc,iit:p{i,,rd.

'i;

ff $ iif

ir:rr#p+r 1r.r:,iirr.lir,;jiiLi4t"tf;l;{+r!

Section lC : Upper Limb

-

Muscles

39

Extensor Carpi Radialis Brevis

o. Lateral epicondyle of humerus (common extensor tendon)

l. Base of 3rd metacarpal A. Extension of wrist N. Radial n (C6,7) P.

Difficult to differentiate, but muscle belly may be palpated just distal to extensor carpi radialis longus on posterior forearm during active wrist extension. Tendon is palpated on dorsal surface of wrist at base of 3rd metacarPal.

Fig 1C.28 Extensor carpi radialis brevis Posterior

Acting alone, extensor carpi radialis brevis (ECRB) muscle extends the wrist in the midline.

40

tllustrated Essentials of Musculoskeletal Anatomy

Extensor Carpi Ulnaris i..,----,r1 ,r (..'

O.

:,,r.

I+

.., s.i,rif.i::rrtrit:ltri::ia|:i:t:ii::*ltl!ilri,iilii:::itt:.r:ii:.;i;j:iit,:tl

Humeral head: Lateral epicondyle of humerus (common extensor tendon) Ulnar head (deep to humeral head): Posterior proximal ulna - subcutaneous

border

l. A.

Base of

5th metacarpal

Extension

Adduction of wrist (ulnar deviation)

N. Radial n (C7,8) P.

Palpate tendon on ulnar side of dorsal surface of wrist, just distal to the styloid process of ulna and proximal to the 5th

metacarpal, during active wrist extension with ulnar deviation (adduction). Palpate slender belly along ulnar border of posterior surface of forearm.

Fig 1 C.29 Extensor carpi ulnaris Posterior

Acting alone, extensor carpi ulnaris (ECU) extends the wrist in an ulnar direction. The tendon runs through a groove between the head of the ulna and the styloid process of the ulna.

I

i

If

$

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Section lC:UpperLimb-

Muscles

41

Extensor Digitorum

O.

l.

Lateral epicondyle of humerus (common extensor tendon) Extensor expansion of 4 fingers

A. Extension

of 4 fingers at MP joints Assists extension of wrist

N.

Radial n (C6, 7 ,8)

P. Palpate muscle belly in middle of posterior forearm during forceful extension of the MP joints of the 4fingers, Ets in making a "claw hand". Palpate the 4 tendons on the dorsal surface of the metacarpals on dorsum of hand.

Fig 1C.30 Extensor digitorum Posterior

Extensor digitorum (ED) divides into the four prominent tendons on the dorsum of the hand. The tendons run down to the base of the middle phalanges where they flatten out and spread into the extensor expansion to each finger (see Fis 1c.47, p.5e; Fis 1D.24, p.72). The muscle itself cannot extend the distal phalanges; extension of the tP joinfs is due to the lumbricals and intero.ssei (see p.56-58). lf contraction of ED is continued past finger extension, the wrist will also

extend.

42

lllustrated Essentials of Musculoskeletal Anatomy

l :ii

Hxtensor Digiti Mlnimi

O.

l.

Lateral epicondyle of humerus (common extensor tendon) Extensor expansion of little (5tn1 finger

A.

Extension of little (5th) finger at MP joint Assists extension of wrist

N.

Radial n (C7,8)

P.

Palpate tendon on ulnar side of extensor digitorum tendon on dorsal surface of 5th metacarpal and proximal phalanx of

little finger during resisted extension of the MP joint.

Extensor

expansion

Fis 1c'31

';':::i,;lisiti

minimi

Extensor digiti minimi (EDM) joins the extensor dig,itot,ru,r

ii

,,,,r,

Section ?{ : Upper Limb - Muscles 43

O.

Lateral epicondyle of humerus

Annular ligament of radius Radial collateral ligaments Proximal ulna at supinator crest

l.

S

Lateral surface of proximal 1/3of radius between anterior and posterior oblique lines

N

A.

Supination of forearm

N. Radial n (C7, 8) P. Ulna

Palpate distal to lateral epicondyle of humerus and head of radius on postero-

lateral side of proximal foreaftrl, pushing relaxed overlying extensor muscles to the side and palpating under them, during

Radius

Fig 1C.32a Supinator origins Posterior

resisted supination of the forearm.

Radial collateral ligament

Annular ligament of radius

Radius

N

Ulna

Fig 1C.32c Radial, annular ligaments supinator attachments

N

Anterior

Radius Fis 1c'32b

4

Ulna

;:i::;:r

insertion

For slow, non-resisted supination and for supination with the elbow extended, the supinator is sufficient. When speed or resistance is required, the stronger supinatof biceps brachii, is recruited. The radial nerve passes betvveen the superficial and deep layers of the supinator.

lllustrated Essentials of Musculoskeletal Anatomy

Hxtensor lndicis

O.

Posterior ulna Interosseous membrane

l.

Extensor expansion of index (2nd) finger

A. Extension

of index finger at MP joint Assists extension of wrist

N.

Radial n (C7,8)

P.

Palpate tendon on dorsal surface of 2nd metacarpal on ulnar side of extensor

digitorum tendon near the MP joint during resisted extension of the index finger at the MP joint.

Interosseous membrane

Fig 1C.33 Extensor indicis Posterior

Four deep muscles originafe on the poste rior radius, ulna and interosseous membrane. From proximal to distal in origin, they are abductor pollicis longus (APL), extensor pollicis brevis (EPB), extensor pollicis longus (EPL), and extensor indicis

(El)

$ ili

Section lC : Upper Limb - {rrtuscles 45

Abductot Pollicis Longus

O.

l.

Posterior radius Posterior ulna lnterosseous membrane Base

of l st metacarpal

A.

Abduction of thumb at CM joint Assists wrist abduction

N.

Radial n (C7, 8)

P.

Palpate tendon at base of 1st metacarpal on radial side of the extensor pollicis brevis

tendon during active abduction of the thumb. lnterosseous membrane

Fig 1C.34 Abductor pollicis longus Posterior

Acting alone, abductor polticis longus (APL) abducts the thumb in a radial direction f and some sources describe this action as extension of thumb at CM ioint. By

lllustrated Essentials of Musculoskeletal AnatCImy

Extensor Pollicis Lon,gus

O.

l.

Posterior ulna - middle 1/3 Interosseous membrane Base of distal phalanx of

thumb

A.

Extension of thumb at lP joint Assists wrist abduction

N.

Radial n (C7, 8)

P. Palpate tendon on dorsal surface of l st metacarpal and proximal phalanx of thumb during active extension of the thumb lP joint. This tendon forms the ulnar side of the "anatomical snuffbox".

Interosseous membrane

Fig 1C.35 Extensor pollicis longus Posterior

Anatomical Snuffbox The " anatomical snuffbox " is a depression on the dorsum of the 1st metacarpal reputedly used to hold snuff for sniffing by genteel persons in the 1800's. The scaphoid carpal bone forms the floor of the snuffbox and the extensor pollicis brevis (EPB) tendon forms the lateral (radial) border while the extensor pollicis longus (EPL) tendon forms the medial (ulnar) border (see pp.t3, 4B).

Section

7

C:

Upper Limb - Muscles

47

Extensor Pollicis Brevis I

O.

Posterior radius Interosseous membrane

l.

Base

of proximal phalanx of thumb

A. Extension

of thumb at MP joint Assists wrist a bd uction

N. P.

Radial n (C7,8) Palpate tendon adjacent to the abductor pollicis longus tendon at the base of the 1 st metacarpal and on dorsal surface of l st metacarpal during active extension of the thumb MP joint. Keep lP joint slightly flexed

to differentiate from the tendon of extensor pollicis longus.

Fig 1C.36 Extensor pollicis brevis Posterior

Extensor pollicis brevis (EPB) tendon forms the radial border of the "anatomical snuffboX, " while extensor pollicis longus (EPL) forms the medial

bordel tllustrated Essentials of Musculoskeletal Anatomy

6ee note p.47).

Abductor Pollicis Brevis

o. Flexor retinaculum Trapezium carpal bone Scaphoid carpal bone l. Base of proximal phalanx of thumb radial side

A.

Abduction of thumb at CM joint

N.

Median n (C8, T1 )

P. Palpate

bulky muscle on palmar surface of l st metacarpal during active abduction of the thumb. lt forms the radial side of the thenar eminence.

Fig 1 C.37 Abductor pollicis brevis

Anterior

Thenar Eminence Flexor pollicis brevis, abductor pollicis brevis, dnd opponens pollicis form the thenar eminence, the fleshy pad on the radial side of the palm. "Thenar" is Greek for palm (and sole).

', Abductor pollicis brevis brings the thumb i a way from the palm (perpendicular to it) ' to work with opponens pollicis (see p sD in ' thumb opposition. '

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il E

$ i1f 4i

**

Section lC : Upper Limb - Muscles 49

Adductor Pollicis

o. Transverse head: Anterior shaft of 3rd metacarpal Oblique head: Base of 2nd and 3rd metacarpals Capitate carpal bone Trapezoid carpal bone Trapezium carpal bone l. Base of proximal phalanx of thumb medial side

S

A.

Adduction of thumb at CM joint

N.

Ulnar n (C8, T1 )

P. Palpate deep in palmar surface of

:?a

Transverse head

web space between the l st and 2nd metacarpals during resisted adduction of the thumb against the lateral side of the index finger.

Oblique head

Fig 1C.38 Adductor pollicis

Anterior

Adductor pollicis forms fhe bulk of the thumb web space on the anterior surface (opposite the first dorsal inferosseous on the posterior surfac€ - see p sB). lt significantly contributes to the power of grasp.

50

lllustrated Essentials of Musculoskeletal Anatomy

Flexor Pollicis Brevis

o. Superficial head: Flexor retinaculum Trapezium carpal bone Deep head: Trapezoid carpal bone

Capitate carpal bone l. Base of proximal phalanx of thumb radial side

A. Flexion of thumb at MP joint N.

Superficial head: Median n (C8, Tl Deep head: Ulnar n (C8, Tl

P. Palpate anterior

)

surface of 1st

metacarpal on ulnar side of thenar eminenc€, medial to abductor pollicis brevis, during active MP flexion of the thumb. Keep lP joint extended to avoid substitution by flexor pollicis longus.

Superficialhead

1_;Q-4

)

(deep head lies beneath)

Flexor

retinaculum

Fig 1C.39 Flexor pollicis brevis Anterior

The deep head of flexor pollicis brevis is sometimes considered as a palmar i

nterosseous

(see

p. 57).

Secfion 7C: Upper Limb - Muscles

51

Opponens Pollicis

O.

l.

Flexor retinaculum Trapezium carpal bone Lateral shaft of l st metacarPal

A.

Opposition of thumb at CM joint

N.

Median n (C8, T1 )

P. Palpate along

lateral shaft of 1st just lateral to abductor metacarpal, pollicis brevis, during active thumb

opposition.

g Fig 1C.40 Opponens pollicis Anterior

Thumb opposition is the combined movement of abduction, flexion, and medial rotation of the CM ioint of the thumb that occurs simultaneously as the opponens pollicis contracts.

52

Illustrated Essentials of Musculoskeletal AnatomY

Minimi

Filexor

o. Flexor retinaculum Hook of hamate carpal bone

l. Base of proximal phalanx of little (5th) finger A. Flexion of little (5th) finger at MP

joint N. Ulnar n (C8, Tl P.

)

Palpate palmar surface of 5th metacarpal during resisted MP

flexion of the little finger.

Flexor

retinaculum

Fig 1 C.41 Flexor digiti minimi brevis Anterior

Hypothenar Eminence Flexor digiti minimi brevis, abductor digiti minimi, anq opponqns digiti minimi form the hypothenar eminence, the fleshy pad on the ulnar side of the palm opposite to the thenar eminence of the thumb.

Secficn IC : Upper Limb

-

Muscles

53

Opponens Dlgiti Minimi

O.

Flexor retinaculum Hook of hamate carpal bone

l. A.

Ulnar border of 5th metacarpal

Opposition of little (5th) finger at CM

N.

joint

Ulnar n (C8, T1 )

P. Difficult to differentiate but muscle belly may be palpable on palmar surface of the 5th metacarpal, deep to abductor digiti minimi, during resisted opposition of the little

finger to the thumb.

retinaculum

Fig 1 C.42 Opponens digiti minimi

Anterior

the and

Opponens digiti minimi rotafes sth metacarpal so the liXle finger thumb 6ee p.52) can meet in opposition.

54

lll ustrated

Essentials of ll/lusculoskeletal Anatomy

"i.

i. 1

t,

Abductor D igi,ti--fvti,mm,i

O.

l. A.

Pisiform carpal bone

of proximal phalanx of little (sttr) finger - ulnar side Base

Abduction of little (5th) finger at MP

joint

N.

Ulnar n (C8, Tl

)

P. Palpate

ulnar border of 5th metacarpal during active abduction of the little finger at the MP joint.

Fig 1 C.43 Abductor digiti minimi Anterior

Abduction of the little finger is a motion parallel to the palm, whereas abduction of the thumb is perpendicular to the palm. Section

1C :

Upper Limb - Muscles

55

Lumb,rigals (4),

O.

Flexor digitorum profundus tendons

l.

Extensor expansion of index, middle, ring, and little (2nd, 3rd, 4th and 5th) fingers at proximal phalanges -

radial side A. Flexion of fingers at MP joints Extension of fingers at PIP and DIP joints N.

1st and 2nd lumbricals (radial 2

fingers): Median n (C8, T1) 3rd and 4th lumbricals (ulnar 2 fingers): Ulnar n (C8, T1) P.

Fig

1C.4

Difficult to palpate because of deeP location in palm of hand, however, lumbricals may be tested for function by resisting MP flexion with lP extension of 4 fingers.

Lumbricals

Anterior

Simultaneous flexion of the MP ioints and extension of the lP joinfs (see Fis 1A.17, p.4) characterizes the actions of the lumbricals.

56

tllustrated Essentials of Musculoskeletol Anatomy

Palmar Intergffej*tl)

o. Shaft of 2nd, 4th and 5th metacarpals palmar surface l. Base of proximal phalanges to extensor expansion of index, ring, and little (2nd, 4th and 5th) fingers A. Adduction of the ind€X, ring, and little (2nd,4th, and 5th) fingers at MP joints Assists lumbricals in MP flexion and PIP and DIP extension of index, middle, and ring (2nd, 3rd, and 4th) fingers

N. Ulnar n (C8, T1 ) P. Difficult to palpate

because of lying deep to lumbricals, but palmar

interossei may be tested for function by adducting the index, ring and little fingers toward the middle finger from an abducted starting position. Alternately, normal function can be quickly checked by flicking the distal phalanx of each of the 3 fingers in the direction of abduction and observing whether it rebounds or "snaps back". Fig 1C.45 Palmar interossei Anterior

The action of palmar intero.ssei is remembered as PAD since Palmar interosse i ADduct the fingers (see dorsal interossei p.s8). The deep head of

the flexor pollicis brevis (see p.st) is sometimes considered as an additional intero.sseous muscle, and when this is the case, there would be four palmar interossei. Section lC:UpperLimb-

Muscles

57

Dorsal Interossei t4)

e-rirl

o.

.i ' '

Each interosseous has 2 heads arising

from adjacent dorsal surfaces of metacarpals l. Base of proximal phalanges to extensor expansion of index, middle, and ring (2nd, 3rd and 4th) fingers: Radial side of 2nd and 3rd Ulnar side of 3rd and 4th A. Abduction of index and ring (2nd and 4th) fingers at MP joints Abduction and adduction of middle (3rd) finger at MP joint Assists lumbricals in MP flexion and PIP and DIP extension of ind€X, middle, and ri ng (2hd, 3rd, and 4th) fingers

N.

Ulnar n (C8, T1 )

P. 1st interosseous: Palpate along radial side of

2nd metacarpal during active abduction of index finger. 2nd, 3rd, 4th interossei: Pal pate between metacarPals Fig 1 C.46 Dorsal interossei Posterior

on dorsal surface during active abduction of middle and ring finger.

Since Dorsal infeross ei ABduct the fingers, the action is recalled by the contraction DAB, while the Palmar interossei (see p'57) action of ADduction is differentiated as PAD.

58

lllustrated Essentials of Musculoskeletal Anatomv

Dorsal ExpaJlsion, Wrist Cross Section

1. Dorsal (extensor) expansion 2. Dorsal (extensor) hood 3. Extensor digitorum 4. Dorsal interosseous 5. Lumbrical 6. Flexor digitorum superficialis 7. Flexor digitorum profundus 5

Fig 1 C.47 Dorsal exponsion, tendons inserting on digits Ventral (palmar) Flexor retinaculum

12*

13

Thenar ms

1. Abductor pollicis longus

Palmar carpal ligament

Median n*

2. Extensor pollicis brevis 3. Extensor pollicis longus 4. Extensor carpi radialis longus 5. Extensor carpi radialis brevis 6. Extensor indicis 7. Extensor digitorum 8. Extensor digiti minimi 9. Extensor carpi ulnaris

Ulnar h, o Ulnar tunnel Carpal tunnel

Hypothenar ms 3 Radial h, o

10. Flexor digitorum profundus* 1

7 Dorsal (posterior)

Fig 1C.48 Wrist cross-section at distal row of carpol bones Right

1.

12. 13. * Carpal

Flexor digitorum superficialis* Flexor pollicis longus* Flexor carpi radialis tunnel structures

Wrist Retinacula (Fig 1C.48) The flexor retinaculum (transverse carpal ligament) spans the anterior wrist from the scaphoid and tra.pezium laterally,-to the pisiform and hook of the hamate medially to form the carpal tunnel, a passageway for nine flexor tendons (FDP, FDS, and FPL)and median nerve. The flexor retinaculum and the palmar carpal ligament form, on the ulnar side of the wrist, the ulnar tunnelfor p-assage of the ulnar nerve and artery. The flexor retinaculum splits to form, on the radial side of the wrist, a passageway for the flexor carpi radialis tendon. Thenar and hypothenar muscles attach to the flexor retinaculum gee pp.49, st-s4). The extensor retinaculum straps the extensor tendons and attaches to the distal radius and medially to the ulna, triquetrum and pisiform. Gxtensor retinacutum is not ittustrated - it is proximatto structures in above image.)

Section

IC

: Upper

Limb - Muscles

59

Tendons of the Wrist and

D

i

g,,f=,..1;,,',,,,,,,,,,,,,,,,,,,,,,,

Dorsal Tendons 1. Abductor pollicis longus 2. Extensor pollicis brevis 3. Extensor pollicis longus 4. Extensor carpi radialis longus 5. Extensor carpi radialis brevis 6. Extensor digitorum

7. Extensor indicis 8. Extensor digiti minimi 9. Extensor carpi ulnaris

Fig 1 C.49 Tendons of wrist and digits Dorsal (posterior), rig ht

Palmar Tendons 1. Abductor pollicis longus 2, Flexor carpi radialis 3. Flexor pollicis longus

4.

Palmaris longus tendon (cut away to reveal deeper structures) Flexor digitorum superficialis

5. 6. Flexor digitorum profundus 7. Flexor carpi ulnaris

Fig 1C.50 Tendons of wrist and digits Pal mar (anterior), right

lllustrated Essentials of Musculoskeletal Anatomy

.,E

levato rsr,Depressqfs of*Scaprlla

Elevators of the Scapula 1. Upper trapezius

2. Levator scapula

Fig

1D.l

Elevators of scapula Posterior, right

Depressors of the Scapula 1. Pectoralis minor 2. Serratus anterior (lower fibers) 3. Lower trapezius

4. Latissimus dorsi*

I\\ /\\\ Fig 1D.2a Depressors of scapula Anterior, right

Fig 1 D.2b Depressors of scapula Posterior, right

Muscles in italics assist the oction *Nof illustrated

Section l D : Upper Limb - Group Actions

61

I

llrLttrrttr.t

I

I

J.r{r[

|

r!

]r

r,,i'rr.,prr,r

rr!---r--rr-

i,

Ad"*;|-c*f*g-r.l-(Bg,$'9-gt-o-J,--1,-LAF-C*u-s$offi,,(Rr-9tJ,.n,gtg.-Hl,gl,*Sse*llq**

Adductors (Retractors) of the Scapula

1. Middle trapezius 2. Rhomboids

Fig 1D.3 Adductors of scapula Posterior, right

Abductors (Protractors) of the Scapula 1. Pectoralis minor 2. Serratus anterior

Fig 1D.4 Abductors of scapula Anterior, right 62

I

llustrated Essentials of Musculoskeletal Anatomy

-Jl-g"d,iel*[P*9..!y-.]=tLlta""r"dh"l-.n-tRmltHpJm-r"C).,S--g--!.a."!"=o-rs, -AJttr-T,i-1["gf#*q#ff*tl-?

Medial (Downward) Rotators of the Scapula

1. Levator scapula 2, Rhomboids 3. Pectoralis minor Latissimus dorsi*

Anterior Tilt of the Scapula 3. Pectoralis minor Pectoralis major Fig 1 D.5 Medial rotators of scapula Posterior, right

(sternocostal head)*

Fig 1D.6 Medial rotator, Anterior tilt of scapula Anterior, right

Lateral (Upward) Rotators of the Scapula 1. Upper trapezius 2. Lower trapezius 3. Serratus anterior

Fig 1 D.7 Lateral rotators of scapula Posterior, right

Muscles in italics assist the oction *Not illustrated

Section I D : Upper Limb - Group

Actions

63

Flexors-, Extensors of Humerus

Flexors of the Humerus 1. Anterior deltoid 2, Pectoralis major (clavicular head)

3. Coracobrachialis 4. Biceps brachii (short head)

Fig 1D.8 Flexors of humerus Anterior, right

Extensors of the Humerus 1. Latissimus dorsi 2. Teres major 3. Posterior deltoid 4. Infraspinatus 5. Teres minor 6. Triceps brachii (long head) 7. Pectoralis major (sternal head)

% vt

t/2

g-i\-

i-= -\\ -\_ i-\ :\

ts\ i-.-

7/

N

N \'..

m

.\

t, / t'/

Fig 1D.9a Extensors of humerus Posterior, right

64

lllustrated Essentials of Musculoskeletal Anatomy

Fig 1 D.9b Extensors of humerus Anterior, right

Adductors, Abductors

Adductors of the Humerus

1. Pectoralis major 2. Coracobrachialis 3. Latissimus dorsi 4, Teres major 5. Subscapularis

,-

Thorax removed

Fig 1 D.l0a Adductors of humerus

Fig 1 D.l0b Adductors of humerus

Anterior, right

Posterior, right

Abductors of the Humerus

1. Supraspinatus 2. Middle deltoid Scaption of the Humerus 1. Supraspinatus Posterior deltoid* Fig 1D.l 1 Abductors, Scaption of humerus Posterior, right *Nof illustrated

Section I D : Upper Limb - Group Actions

65

Medial, Lateral Rotators of Humerus Medial Rotators of the Humerus 1. Anterior deltoid

2. Pectoralis major 3. Subscapularis 4. Teres major 5. Latissimus dorsi

Fig

1

D.l2b Medial rotators Posterior, right

Fig 1D.l2a Medial rotators of humerus Anterior, right

Lateral Rotators of the Humerus 1 . Infraspinatus 2. Teres minor 3. Posterior deltoid

Fig

66

1

D.l3

Lateral rotators of humerus Posterior, right

lllustrated Essentials of Musculaskeletal Anatomy

of humerus

hf

orizontal Adductors, Abductors of Humerus

Horizontal Adductors of the Humerus 1. Anterior deltoid

2

Fig

1

Pectoralis major

D.l4 Horizontal adductors of humerus Anterior, right

Horizontal Abductor of the Humerus 1. Posterior deltoid

Fig

1

D.l5 Horizontal abductor

of humerus

Posterior, right

Section l D : Upper Limb - Group

Actions

67

Extensors of Elbow

Flexors of the Elbow 1. Biceps brachii 2. Brachialis 3. Brachioradialis 4. Pronator Teres

Extensors of the Elbow 1. Triceps brachii

Fig 1 D.16 Flexors of elbow Anterior, right

2. Anconeus

Fig 1 D.17 Extensors of elbow Muscles

68

in italics assist the action

lllustrated Essentials of Musculoskeletal Anatomy

Posterior, right

Pronators,of Forearm

Supinators of the Forearm

1. Biceps brachii 2. Supinator

Fig

1

D.l8

Supinators of forearm

Anterior, right

Pronators of the Forearm

1. Pronator teres 2. Pronator quadratus

Fig

1

D.l9

Pronators of forearm

Anterior, right Section I D : Upper Limb - Group Actions

69

Flexors, Extenso,rs,, of Wrist

Flexors of the Wrist 1. Flexor carpi radialis 2. Flexor carpi ulnaris 3. Palmaris longus Flexor digitoru m su perficialis* Flexor digitoru m profu ndus*

'

Muscles fo the fingers with tendons thaf cross the anterior aspect of the wrist can asslst tn flexion of the wrist.

Extensors of the Wrist 1. Extensor carpi radialis longus 2, Extensor carpi radialis brevis 3. Extensor carpi ulnaris Extensor digitorum* Extensor indicis* Extensor digiti minimi*

Fig 1 D.2O Flexors of wrist Anterior, right

, , :

Fig 1 D.21 Extensors of wrist Muscles

in itolics assist the action

Posterior, right

*Not illustrated

7O

lllustrated Essentials of Musculoskeletal Anatomy

Muscles to the fingers with tendons that cross the poste rior aspecf of the wrist can asslst tn exfe nsion of the wrist. :

:

rf

i..: .r..i \.

.)

Add u ctorsr Abd u ctors*of,Wri st

Adductors (Ulnar Deviators) of the Wrist

1. Flexor carpi ulnaris 2. Extensor carpi ulnaris

Fig 1 D.22a Adductors of wrist

Fig 1 D.22b Adductors of wrist

Anterior, right

Posterior, right

Abductors (Radial Deviators) of the Wrist

1. Flexor carpi radialis 2. Extensor carpi radialis longus Abd uctor pol I ici s I on gus'r

Extensor pol I ici s long us* Exten sor pol I i ci s brevis*

Thumb muscles with tendons that cross the lateral aspect of the wrist joint can assist in wrist abduction

Fig

1

D.23a Abductors of wrist Anterior, right

:

Fig 1 D.23b Abductors of wrist Posterior, right

Muscles in italics assist the action *Nof illustrated

Section

1D :

Upper Limb - Group Actions

71

F

I

exorsn Exte

n s,ors.

Opposers of Thumb, Digits Extensors of the Thumb and Digits** Thumb: MP

joint

1. Extensor pollicis brevis lP joint

2. Extensor pollicis longus Digits: MP joints

3. Extensor digitorum 4, Extensor indicis 5. Extensor digiti minimi DIP & PIP

10. 1

1.

12,

joints

Lumbricals Palmar interossei Dorsal interossei

Fig 1 D.24 Flexors, extensors of thumb, digits Posterior, right

Flexors of the Thumb and Digits** Thumb: lP

joint

6.

Flexor pollicis longus

MP joint

7, Flexor pollicis brevis Digits: PIP joints

8.

Flexor digitorum superficialis

DIP joints

9. MP

Flexor digitorum profundus

joints

10. Lumbricals 1

1.

12.

Flexor digiti minimi brevis* Palmar interossei Dorsal interossei

Opposers of the Thumb and 5th Digit** Thumb - CM joint: 13. Opponens pollicis Little (5th) finger - CM joint: 14. Opponens digiti minimi 72

lllustrated Essentials of Musculoskeletal Anatamy

Fig 1 D.25 Flexors, Opposition of thumb, digits Anterior, right

*Not illustrated **Refer to all above images for muscles listed Muscles in italics assisf the action

Abd uctorsr.,Ad ducto rs, of Th u m b and Digits

Abductors of Thumb and Digits* Thumb - CM joint: 1. Abductor pollicis longus 2. Abductor pollicis brevis Digits - MP joint: 3. Dorsal interossei 2nd,3rd, and 4th fingers 4. Abductor digiti minimi

Fig 1 D.26 Abductors of thumb, digits Posterior, right

---:

%

Adductors of Thumb and Digits* Thumb - CM joint: 5. Adductor pollicis Digits - MP joint: 6. Palmar interossei 2nd,4th, and 5th fingers 7. Dorsal interosseous 3rd finger (see Fig I D.26)

1

Fis 1D'27 *Refer to all above images for muscles listed

^X:i::::; ;;;iumb'

disits

Section I D : Upper Limb - Group Actions

73

Brachial Plexus

\ss \

"*'ry

):i \4 Fig

c5, c6,c7cg,T1 TRUNKS

1. Upper trunk 2. Middle trunk 3. Lower trunk DIVISIONS

4. Anterior divisions 5. Posterior divisions CORDS

6. Lateral cord 7. Posterior cord 8. Medial cord 74

Brachial plexus

Anterior, right

Roots, Trunks, Divisions, Cords ROOTS

1E.l

Terminal Nerves of Roots, Upper Trunk, Cords POSTERIOR CORD

ROOTS

DS LT

Dorsal scapular (C4) CS Long thoracic C5, 6,7

UPPER TRUNK

SC Subclavius C5,6 SS Suprascapular (Ca) C5,6 LATERAL CORD

LP MC

M

Lateral pectoral C5 ,6,7 Musculocutaneous C5, 6,7 Median (C5) C6,7

Segment in parentheses

lllustrated Essentials of Musculaskeletal Anatornv

(

) indicates inconsistent

US Upper subscapular C5, 6 (7) TD Thoracodorsal C6 ,7 , 8 LS Lower subscapular C5, 6 (7\

A Axillary C5,6 R

Radial

C5 ,

6,7 , 8 (T1 )

MEDIAL CORD MP Medial pectoral C7,8, T1 M Median Cg, T1 U Ulnar Cg, Tl contribution

Musculocutaneous Nerve C5, 6,7

ROOTS

Long thoracic n (C5, 6,71 1. Serratus anterior (C5, 6,7) Subclavian n 2 Lateral

pectoral n Musculocutaneous n

UPPER TRUNK

Subclavian n (C5,6) 2. Subclavius (C5 ,6) LATERAL CORD

Lateral pectoral n (C5 , 6,7) 3. Pectoralis major: clavicular head (C5,6) Musculocutaneous n (C5, 6,7) 4. Coracobrachialis (C5, 6,7) 5. Biceps Brachii (C5, 6) 6. Brachialis (C5, 6)

Fig 1E.2 Musculocutaneous n Anterior, right

Secrion

7E :

Upper

Limb-tVeryes

75

Axi l la ry. (C5,

6'1,,,Rad ia l ( C 5,,,,.,Q,r;,,,,7',1,

8, [T1]] Nerves Accessory n (Cranial Nerve Xl)" 1. Sternocleidomastoid 2. Trapezius BRACHIAL PLEXUS (C5, 6,7,9,T1

)

ROOTS

Dorsal scapular n [C4] (C5) Levator scapula (C5) Rhomboids (C4,5)

Accessory n

3. 4.

1

Suprascapular n

5,6

Dorsal

UPPER TRUNK

scapular n

314

Axillary n

Upper subscapular n

10, 11

Suprascapular n tG4l (C5,6) 5. Supraspinatus (C4, 5, 6)

6. Infraspinatus (C5, 6)

Lower subscapular n

7r8

POSTERIOR CORD

Thoracodorsal n

17 18 19 20 22 23

Fig 1E.3 Axillary, Radial ns Posterior, right

Nerve segment in brackets [ ] indicates inconsistent

76

contribution

lllustrated Essentials of Musculoskeletal Anatomy

1

5

1

6

Upper subscapular n (C5,61 tCTl 7. Subscapularis (C5, 6,7) Lower subscapular n (C5, 6) \CTI 7. Subscapularis C5, 6,7) 8. Teres major (C5,6)

Thoracodorsal n (C6 ,7 ,8) 9. Latissimus dorsi (C6 ,7 ,8) Axillary n (C5,6)

10.

Deltoid (C5 , 6) 1 1. Teres minor (C5, 6) Radial n (C5, 6,7,8,T1 ) 12. Triceps brachii (C6 ,7 ,8) 13. Brachioradialis (C5, 6,7) 14. Anconeu s (C7 ,8, T1 ) 15. Extensor carpi radialis longus (C6,7) 16. Extensor carpi radialis brevis (C0,17 17. Supinator (C7, 8) 18. Extensor digitorum (C6 ,7 , 8) 19. Extensor digiti minimi (C7, 8) 20. Extensor carpi ulnaris (C7, 8) 21 . Abductor pollicis longus (C7, 8) 22. Extensor pollicis brevis (C7, 8) 23. Extensor pollicis longus (C7,8) 24. Extensor indicis (C7,8) *see p.|73-l74

Nerves MEDIAL CORD

Medial pectoral n (CZ ,8,T1 ) 1. Pectoralis major: sternocostal head (C7 ,8, T1) 2. Pectoralis minor (C8, T1 ) FOREARM

Median n (C5, 6,7,8,T1)*

Medial pectoral n

3. Pronator teres (C6,7) 4. Flexor carpi radialis (C6,7) 5. Palmaris longus (C7, 8) 6. Flexor digitorum superficialis (C7 ,8,T1 ) 7. Flexor digitorum profundus (radial 2fingers)

Median n Ulnar n

(c8, T1 )

8. Flexor pollicis longus (C8, T1 ) 9. Pronator quadratus (C8, Tl ) Ulnar n (C8, T1 ) 10. Flexor carpi ulnaris (C7, 8) 11 Flexor digitorum profundus (ulna r 2 fingers)

10

.

11

(c8, T1 )

HAND

Median n (C5, 6,7,8,T1 )* 12. Abductor pollicis brevis (C8, T1 ) 13. Opponens pollicis (C8, T1 ) 14. Flexor pollicis brevis (superficial head) 15. l st and 2nd lumbricals (C8, T1 )

Median n

18 19

(C8, T1 )

Ulnar n (C8, Tl ) 16. Adductor pollicis (C8, T1 ) 17. Flexor pollicis brevis (deep head) (C8, T1) 18, Abductor digiti minimi (C8, T1 ) 19. Opponens digiti minimi (C8, T1 ) 20. Flexor digiti minimi brevis (C8, T1 ) 21 3rd and 4th lumbricals (C8, Tl ) D - Dorsal interossei (all 4) (C8, T1 ) P - Palmar interossei (all 3) (C8, T1)

.

Fig 1E.4 Median, Ulnar ns Anterior, right

*

median n - formed by lateral cord (C6, 7), medial cord (C8, Tl )

Section lE : Upper Limb -

Nerves

77

Cuta nqgus I nn gf.vatio n Un,ngn,lilnh Supraclavicular n

Supraclavicular n

Superior lateral

cutanious n of arm (cutaneous branches of

Medial cutaneous n of arm (and intercostobrachial n)

cutaneous n of arm

intercostals ns)

Inferior lateral cutaneous n of arm

Inferior lateral cutaneous n of arm

Medial cutaneous n of arm (and intercostobrachial n) Posterior cutaneous n of forearm

Medial cutaneous n of forearm

Medial cutaneous n of forearm

Lateral cutaneous n

of forearm

Lateral cutaneous n of forearm Radial n

Radial n

Ulnar n Median n

Median n

Fig 1E.5b Cutaneous innervation upper limb

Fig 1E.5a Cutaneous innervation upper limb Anterior, right

Posterior, right

Upper Limb Cutaneous ns - Source,Terminal Nerves, Spinal Segments CERVICAL PLEXUS

(see Fis 3E.1,

p.l73)

Supraclavicular n (C3, 4) BRACHIAL PLEXUS (C5-8,T1)

(see

Fis 1E.l, p.74)

Medial cutaneous n of arm Medialcutaneous n of forearm (C8,Tl) Axillary n Superior lateral cutaneous n of arm (C5, 6) Radialn lnferior lateral cutaneous n of arm (C5,6) Posterior cutaneous n of arm (C7) Posterior cutaneous n of forearm Musculocutaneous n

Lateralcutaneous n of forearm (C5) Radial n - Superficial branch (C6-8) Ulnar n - Deep cutaneous branch (C8, Tl Median n - Cutaneous branch (C6-8) 78

III u

strated

Es

senti a I s of M u scu

I os

kel eta I An

atomv

)

A. MOTIONS

80

Femur, Knee Ankle, Foot, Toes

B. BONES

Fi

82

Pelvis

Femur Tlbia, Fibula Ankle, Foot Palpation of Bony Landmarks

c. MuscLEs Muscles of Anterior, MedialThigh AnteriorThigh Muscles - Flexors of Femur

89 89 89

93

Muscles of Foot

116 116

'a'47

Abductor Hallucis Flexor Digitorum Brevis Abductor Digiti Minimi Second Layer Lumbricals Quadratus Plantae

Third Layer Flexor Hallucis Brevis

97

Gluteus Maximus Gluteus Medius Gluteus Minimus

Fourth Layer Dorsal Interossei (1 -4) Plantar Interossei (1 -3)

D. MUSCLE GROUP ACTIONS

121

Femur

121

Flexors, Extensors of Femur

Adductors, Abductors of Femur Medial, Lateral Rotators of Femur

Tensor Fascia Lata Six Deep Lateral Rotators:

Piriformis Gemellus Inferior Gemellus Superior Obturator Externus Obturator Internus Quadratus Femoris

Knee

124

Flexors and Extensors of Knee

Medial and Lateral Rotators of Knee

Ankle, Foot 102 102

126

Dorsiflexors and Plantarflexors of Ankle Invertors and Evertors of Foot Flexors and Extensors of Toes Adductors and Abductors of Toes

E. NERVES

Semimembranosus Semitendinosus

Anterior Compartment of Leg - Dorsiflexion Muscles Tibialis Anterior Extensor Digitorum Longus Extensor Hallucis Longus Fibuf aris Tertius (See eversion ms)

Popliteus

Adductor Hallucis Flexor Digiti Minimi Brevis

Gluteal Region Muscles - Abductors and Rotators of Femur 97

Muscles of Leg

Pla nta ris

91

Gracilis

Posterior Thigh Muscles - Hamstrings Group Extensors of Femur, Flexors of Knee Biceps Femoris

110

First Layer

Adductor Brevis Adductor Longus Adductor Magnus

Muscles of Posterior Thigh

bu la ris (Peroneus) Terti us

Fibularis (Peroneus) Longus Fibularis (Peroneus) Brevis Posterior Compartment of Leg - Plantarflexion Muscles Gastrocnemius

Dorsum of Foot Extensor Digitorum Brevis (Dorsal Interossei 1-4 - see Fourth Layer) Plantar Surtace of Foot

Pectineus

Muscles of Gluteal Region

107

Soleus

Major Minor

(see also pectineus with femur adductors) AnteriorThigh Muscles - Quadriceps Group Efrensors of Knee Rectus Femoris Vastus Intermedius Vastus Lateralis Vastus Medialis MedialThigh Muscles - Adductorc of Femur

- Evercion Muscles

Tibialis Posterior Flexor Digitorum Longus Flexor Hallucis Longus

Sartorius lliacus Psoas Psoas

LateralCompartment of Leg (See a nterior com partment)

128

Lumbosacral Plexus Obturator and Femoral Nerves

104 104

Sciatic and Tibial Nerves Fibular Nerves Cutaneous Nerves

Secficn 2: Low*r Limb

79

Femur, Knee Motions ,',i,i

Flexion

Extension Fig 2A.1 Flexion, extension of femur Lateral, right

Medial rotation

Adduction

Abduction

Lateral rotation

Fig 2A.2 Abduction, adduction of femur

Fig 2A.3 Medial, lateral rotation of femur

Anterior, right

Anterior, right

Extension Medial rotation

il

Neutral

Lateral rotation

Fig 2A.5 Medial, lateral rotation of knee (tibia) Anterior, right

Fig 2A.4 Flexion, extension of knee Lateral, right

80

lllustrated Essentials of Musculoskeletal Anatomy

Knee rotation refers to movement of the tibia when the knee is flexed and the foot is free so that tibia moves on fixed femur to rotate the leg.

An klg, Foo-r, Toe Mot,ions

l,

it

Dorsiflexion

i( I\ t\

\

\\

Plantarflexion

!

Eversion

:" Inversion

Fig 2A.6 Dorsiflexion, plantarflexion of ankle

Fig 2A.7 Eversion, inversion of foot

Lateral, right

Dorsal, right

Fig

2A.8 Extension of toes Lateral, right

Extension,

Flexion

Adduction Fig

Extension,

Abduction

2A.9 Extension, adduction, flexion, abduction of toes Dorsal, right

Section 2A : Lower Limb - Motions

81

Pelvis

A. llium 1

.

lliac crest

2. lliac fossa 3. Posterior (superior) 4.

5. 6.

\.,i

';

./ -

\= ):€ ?:S \l

firN',:X:fi

V -: /

N+=+q -:

,'.tN\\ ----r-

gluteal line Anterior (middle) gluteal line Inferior gluteal line Anterior superior iliac spine

--\\ 7-7.\l

(=w

A -

1

,\

\\rJ,,

A!,., '^/ l'

\

llrr.

\tY

(

)--- _ r

,

/

.

,4

(ASIS)

7. Anterior inferior iliac spine 8. Posterior superior iliac spine

28.1a Pelvis Anterior

(PSIS)

9.

Posterior inferior iliac spine

10. Greater sciatic notch 11. lliac tuberosity B. lschium 12. lschial tuberosity 13. lschial spine 14. Lesser sciatic notch 15. Ramus of ischium 15 + 20 = ischiopubic ramus

C.

Pubis 16. Pubic crest 17. Pubic symphysis 18. Body of pubis 19. Superior ramus of pubis 20. Inferior ramus of pubis

D. Acetabulum E. Obturator foramen

28.1b

Pelvis

Posterior

D

F. Sacrum 21

.

Sacral tuberosity

22.

Auricular (ear-like) lateral surface of sacrum and medial surface of ilium G. Coccyx Fig 2B.1c Pelvis

lnferior

82

lllustrated Essentials of Musculaskeletal Anatoftly

Fernur

1. Head 2. Neck 3. Greater trochanter 4, Lesser trochanter 5. Intertrochanteric line 6. Intertrochanteric crest 7. Trochanteric fossa 8. Quadrate tubercle 9. Gluteal tuberosity 10. Pectineal line 1

1. Linea aspera

12. Adductor tubercle 13. Medial epicondyle 14. Lateral epicondyle

15. Patellar surface 16. Medial supracondylar 17. Lateral supracondylar 18. Medial condyle 19. Lateral condyle 20. Popliteal surface 21

Fig 28.2a Femur Right, anterior

.

line line

Intercondylar notch

Fig 28.2b Femur Right, posterior

Section 28 : Lower Limb - BonEs

83

Tibia, Fibula

Fibula 1. Styloid process

2. Head 3. Neck 4. lnterosseous border 5. Lateral malleolus 6. Shaft of fibula Tibia

7. Medial condyle 8. Lateral condyle 9. Anterior intercondylar 10. 1

area

Posterior intercondylar area

1. Tibial tuberosity

12. Soleal line 13. Shaft of tibia 14. Interosseous border 15. Medial malleolus Patella

16. Base 17. Apex

16 17

Fibula

Tibia

Tibia

Fig 28.3b Tibia and fibula Right, posterior

Fig 28.3a Tibia and fibula Right, anterior

Fig2B.4 Patella Right, anterior

lllustrated Essentials of Musculoskeletal Anatomy

Fibula

Ta rsa,ls, M,gtata,rsa

Lateral

I

sr'.'

Ph

af.a,nggs

Navicular

cuneiform

Calcaneus

Navicular

Cuboid

tuberosity l st Metatarsal

Calcaneus

Fig 28.5b Tarsals, metatarsols, phalanges Right, posterior

Fig 28.5a Tarsals, metatarsals, phalanges Right, dorsal

Navicular

I

ntermediate

cu

neiform

Lateral cuneiform

Lateral malleolus

l st Metatarsal

Phalanges (Great Toe)

Calcaneus

5th Metatarsal Tuberosity of 5th metatarsal

Fig 28.5c Tarsals, metatarsals, phalanges Right, lateral

Section 28 : Lower Limb - Bones

85

Bone Palpatiglls

Anterior pelvis, lower limb bone palpations lliac crest - Palpate "hip bone" on superior edge of pelvis extending from anterior superior iliac spine (ASIS) to posterior superior iliac spine (PSIS).

1.

2. Anterior superior iliac spine (ASIS) - Palpate protuberance at the anterior end of the iliac crest on anterior ilium. 3. Anterior inferior iliac spine (Al15) - Palpate projection just inferior and slightly medial to ASIS; not as palpable as ASIS. 4. Greater trochanter of femur - Palpate large prominence on lateral side of proximal femur, anterior to hollow on lateral buttock when leg is in non-weightbearing position. 5.

Pubic crest - Palpate horizontal ridge on anterior pubis formed by the anterior superior pubic bones.

6. Adductor tubercle - Palpate small projection proximal to medial epicondyle on distal femur; often tender to the

touch. 7. Medial epicondyle of femur - Palpate large projection on medial side of distal femul proximal to medial condyle of femur and tibiofemoral joint. 8.

Lateral epicondyle of femur - Palpate knobby projection on lateral side of distal femur, proximal to the lateral condyle

of femur and head of fibula. 9.

Patella - Palpate "knee cap", the superficial, triangularshaped floating (sesamoid) bone on anterior aspect of knee.

10. 11

Fig 28.6 Lower body bone palpation sites

Anterior

86

lllustrated Essentials of Musculoskeletal Anatomy

.

12,

Head of fibula - Palpate superficial protuberance on lateral side of proximal fibula, at same level as tibial tuberosity.

Tuberosity of tibia (tibial tuberosity) - Palpate large projection in midline of anterior surface of proximal tibia, just distal to patella. Shaft of tibia - Palpate "shin bone'bn superficial anterior

border of tibia, from tibial tuberosity to medial malleolus.

B

one

?Elffi$r*-S-g-rlt,l,d

Posterior pelvis, lower limb bone palpations 1.

lliac crest - "hip bone"; Palpate superior edge of ilium extending from anterior superior iliac spine (ASIS) to posterior superior iliac spine (PSIS).

2.

Posterior superior iliac spine (PSIS) - Palpate projection at posterior end of iliac crest on posterior hip; sacroiliac joint is slightly inferior and medial to the PSIS and an observable dimple is landmark for joint.

2

3. Sacrum - Palpate curved, bumpy, triangular bone (five fused vertebrae), inferior to lumbar vertebrae. 4. Coccyx - Palpate "tailbone" (3 or 4 fused bones at caudal end of vertebral column) as a bumpy, inch-loh9, curved tip at inferior end of sacrum, located at superior end of gluteal cleft. 5. lschial tuberosity - Palpate blunt protuberance on inferomedial aspect of buttock when hip is flexed; takes weight of body when seated in upright position. 6.

Medial condyle of femur - Palpate large, rouhd, distal end of medial femur.

7.

Lateral condyle of femur - Palpate larg€, rouhd, distal end of lateral femur.

8. Medial condyle of tibia - Palpate large, proximal end of medial tibia just distal to the joint space on the medial side of the patellar tendon when the knee is flexed. 9.

Lateral condyle of tibia - Palpate large proximal end of lateral tibia on anterior surface just distal to the joint space on lateral side of the patellar tendon when the knee is

flexed.

Fig 28.8 Lower body bone palpation sites Posterior

10.

Medial malleolus of tibia - Palpate medial"ankle bone"on large distal end of tibia, medial side of ankle.

11.

Lateral malleolus of fibula - Palpate lateral"ankle bone"on distal end of fibula, more pointed and distal than medial malleolus.

12.

Calcaneus - Palpate "heel bone'i largest and most posterior

tarsal bone.

Section 28 : Lower Limb - Bones

87

Cont'd

Tarsal and metatarsal bone palpations

1 Talus - Palpate tarsal bone on dorsum of foot just distal to tibia when foot is plantar flexed; or on medial side of foot between navicular tuberosity and medial malleolus when foot is everted.

7. Metatarsal

heads

2. Navicular - Palpate (boat-shaped) tarsal bone on dorsomedial side of foot between talus and cuneiforms.

4. Cuneiforms 3.

6.

Tuberosity of navicular

2. Navicular 1.

Tuberosity of 5th metatarsal

5. Cuboid

3. Tuberosity of navicular - Palpate protuberance on medial side of navicular on medial border of foot, differentiated from talus when foot is inverted. 4.

Cuneiforms - Palpate 3 adjacent wedge-shaped tarsal bones in distal row of tarsals on dorsum of foot between the bases of the first 3 metatarsals and navicular.

5.

Cuboid - Palpate most lateral tarsal bone (cubeshaped) in distal row of tarsals on lateral side of foot between lateral malleolus and base of 5th metatarsal.

Talus

Talus Calcaneus (see #12 p.87)

F':s

28'

"';3:::i:, ;:!'ation

sites

6. Tuberosity of 5th metatarsal - Palpate protuberance on lateral side of base of l st metatarsah more distal than navicular tuberosity. 7.

88

lllustrated Essentials of Mu sculoskeletal Anatomy

Metatarsal heads - Palpate large distal ends of 5 metatarsal bones by curling toes downward. The l st metatarsal head is prominent and palpable on the dorsal, plantar and medial side of the fooU the 5th metatarsal head is palpable on the dorsal, plantar and lateral side of the foot.

Sartorius

O. Anterior superior

l. )--)_

)---

A.

iliac spine

Upper medial shaft of tibia Assists flexion of femur Assists abduction of femur

\-

Assists lateral rotation of femur Assists flexion of knee Assists medial rotation of tibia when knee is

flexed and foot is unweighted

N.

Femoral n (12,3)

P.

Palpate close to its origin, just below and slightly medial to anterior superior iliac

spine (ASIS), continuing diagonally across anterior thigh toward its insertion, during active flexioh, Etbduction and lateral rotation of the femur. t,

l I

Fig 2C.1 Sartorius

Anterior

The longest muscle in the body, it is the most superficial thigh muscle and forms the lateral border of the femoral triangle. lts name is derived from the Latin word for tailor; sartor; to indicafe ifs action of bringing the leg into a cross-legged sitting position. Not a powerful muscle, it only asslsfs in fhese actions. Section 2C: Lawer Limb - Muscles 89

Psoas Major and iliacus (iliopsoas)

ttl

O.

Psoas major:

Lumbar vertebrae Ll-5 - transverse processes T12-L5 vertebrae - bodies and intervertebral discs lliacus: lliac fossa of ilium

l.

Lesser

trochanter of femur

A. Flexion of femur Psoas major:

Flexion of trunk - lumbar spine Assists lateral flexion of trunk - lumbar spine

)-, ):f-

l-

Psoas major

N. Psoas major:

L2,3 spinal ns lliacus: Femoral n (12, 3)

lliacus

P.

waist, halfway between the anterior superior iliac spine (ASIS) and umbilicus, during active flexion of the femur.

I Fig2C.2

Palpate deeply on anterior abdomen just below the

Psoas major, lliacus

Anterior

facilitate palpation, relax overlying abdominal muscles by leaning forward in the seated position before flexing the femur by lifting the thigh off the

To

cha ir.

Minor minof (see Fig 3D.3b, p.t zz) is not present in most people. When present, it is a small muscle with a long tendon lying in front of psoas major, originating on the 12th thoracic vertebra, inserting on the pelvic rim, and innervated by L1 Psoas

Psoas

.

and iliacus are referred fo as the iliopsoas because of their common insertion and action. lliopsoas is the strongest hip flexor. lf the femurs are fixed, these muscles flex the lumbar spine such as when doing a sit-up Psoas major

,

+

i I

rri:

:tilt

+....r. .ii......1+.1 ., :

90

lllustrated Essentials of Musculoskeletal Anatomy

r.

,.

Quad riceps, Femoris

G

roup

Quadriceps Femoris Group The quadriceps femoris group is comprised of four large, anterior thigh muscles that insert below the knee and act to extend the knee. The three vasti lie deep to rectus femoris and two (vastus lateralis and vastus medialis) have their origins on the posterior femur. Individual descriptions are continued on the next page (see p.92).

Rectus femoris

Vastus intermedius Vastus medialis Vastus lateralis

N',

I

Fig 2C.3 Quadriceps femoris group

Anterior

Rectus Femoris O. Anterior inferior iliac spine llium at upper rim of acetabulum

l. Patella Tibial tuberosity via patellar ligament A. Extension of knee Assists flexion of femur Rectus femoris

N. Femoral n (L2 ,3,4)

P

Palpate large superficial muscle in midline of

anterior thigh during active knee extension.

Rectus femoris is the only muscle

Fig 2C.4 Rectus femoris Anterior

in the quadriceps

group that originafes on the pelvis and crosses both the hip and knee joints. lts combined actions bring the leg fonuard in walking. When the insertion is fixed, rectus femoris extends the knee as see n in jumping. The term, rectus, is derived from Latin word for straight, depicting this muscle that runs straight down the femur. Secfion 2C: Lower Limb - Muscles

91

Q.U-ad ri ge,ps, F,e m o r i s, G,ro

up (continued).,

Vastus Medialis Vastus Lateralis Vastus Intermedius O. Vastus medialis: Linea aspera of femur Intertrochanteric line of femur Vastus lateralis: Linea aspera of femur Greater trochanter of femur

Vastus medialis

Vastus intermedius:

Anterior and lateral femoral shaft

Vastus lateralis

l.

Patella

Tibial tuberosity via patellar ligament

A. Extension

of knee

N. Femoral n (L2,3,4) Fig 2C.5 Vastus medialis,

P. Vastus medialis:

Vastus lateralis

Palpate anteromedial surface of distal thigh, medial to the rectus femoris,

Anterior

during resisted knee extension. Vastus lateralis: Palpate lateral surface of anterior thigh, lateral to the rectus femoris, during resisted knee extension.

Vastus intermedius

Vastus intermedius: Deepest and difficult to palpate; may be palpable by pushing rectus femoris medially and palpating under it during resisted knee extension.

Fig 2C.6 Vastus intermedius

Anterior

92

lllustrated Essentials of Musculoskeletal Anatomy

Vastus is the Latin term for immense. Ihese three muscles of the quadriceps group derive their name from their size and position. Vastus lateralis is the largest of the group.

Pectineus

!

O.

Superior ramus of anterior pubis

---

9 --'

) -.,

)-

l.

Pectineal line of femur, inferior to lesser

trochanter

)Y

A.

Flexion of femur

Adduction of femur Assists medial rotation of femur

N.

Femoral n (L2,3)

P.

Palpate superficial part of muscle on medial side of anterior thigh, just lateral and slightly proximal to the prominent

adductor longus tendoh, during active adduction of the femur. lt may be difficult to differentiate from other adductors of the femur.

Fig 2C.7 Pectineus Anterior

Adductor group The adductor group includes medial thigh muscles that adduct the femur. Adductor magnus, brevis, and longus assist in medial or lateral rotation of the femur, depending upon the starting position of the femur in extension or flexion. Pectineus is the uppermost muscle of the group. Adductor magnus is the largest, deepest and most powerful of the group. Adductor brevis is superficial to adductor magnus and deep to adductor longus and pectineus. Adductor longus is the most anterior of the adductors and gracilis is the most medial and weakest of the group.

Pectineus is the only hip adductor supplied by the femoral nerve, a fact explained by it being considered an extension af the iliopsoas. Howevel like other hip adductors, it is sometimes supplied by a branch of the obturator nerve.

Section 2C: Lower Limb - Muscles

93

Add,u,cto,r,,Lgn,gus a

o. Adductor longus: Anterior pubis - body, inferior to pubic crest

l-

)-

Adductor brevis: Anterior pubis - body and inferior

)r

l.. l-

ramus

Adductor longus

l. Adductor longus: Linea aspera of femur - middle one third Adductor brevis: Linea aspera of femur - proximal part Pectineal line of femur A. Adduction of femur Assists flexion of femur

N.

Obturator n (L2, 3,4)

P. Adductor Fig 2C.8 Adductor longus

longus:

Palpate prominent cord-like tendon in groin area on proximal medial thigh

Anterior

during resisted adduction of the femur. It lies medial to the pectineus and lateral to the gracilis muscles. Adductor brevis: Located deep in medial thigh between adductor longus and pectineus muscles, adductor brevis is difficult to palpate with accu racy.

Adductor brevis

Fig 2C.9 Adductor brevis

Anterior lllustrated Essentials of Musculoskeletal Anatomv

Adductor longus forms the medial border of the femoral triangle that contains the femoral nerve, arterlq, and vein. Adductor longus is referred to as the " long adductor" and adductor brevis as fhe short adductor" "

.

Add uctor

Ma,g,nu,s

O. Anterior head: Inferior ramus of pubis Posterior head: lschial tuberosity Ramus of ischium

l. Anterior head: Linea aspera of femur Posterior head: Adductor tubercle of femur Anterior

(adductor) head

Posterior (hamstring) head

A. Adduction of femur Anterior head: Assists flexion of femur Assists medial rotation of femur Posterior head: Assists extension of femur Assists lateral rotation of femur

Adductor hiatus emergence of femoral artery and femoral vein

to popliteal fossa behind knee

N. Anterior head: Obturator n (12, 3,4) Posterior head: Sciatic n (14) P.

Ftg 2C.1O Adductor magnus

Anterior

Difficult to differentiate, but may be palpable on lower half of medial surface of thigh, posterior to the gracilis and anterior to the semimembranosus, during resisted adduction of the femur. Palpate tendon at its insertion on the

adductor tubercle of femur. The motions of the adductor magnus with its massiye size and extensive attachments

can vary depending upon which portion of the muscle is active and the starting position and direction of the movement of the femur. At most, adductor magnus is an assrfa nt in rotation. Section 2C: Lower Lirnb - Muscles 95

Gracilis

O.

l. A.

Inferior rarnus of anterior pubis Medial proximal tibia

Adduction of femur Assists flexion of knee Assists medial rotation of tibia when knee is flexed

N. Obturator n (12,3) P.

Palpate gracilis proximally a few inches below pubic bone on medial side of thigh, just posterior to adductor longus and

anterior to adductor magnus, during active adduction of the femur. Being the only hip adductor crossing the knee joint, gracilis can be differentiated from other adductors on the medial thigh during resisted knee flexion.

Fig 2C.1

1 Gracilis

Anterior

Tendon is palpated distally on medial side of posterior knee, medial to semitendinosus tendoh, during resisted knee flexion (see semitendinosus palpation, p 103).

Gracilis is the only muscle in the

adductor group to cro.ss fhe hip and knee joints. The femoral shaft and gracilis form the shape of the lefter "V".

the

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lllustrated Essentials of Musculoskeletal Anatomy

i

i

ri

Gluteus Maximus

o. Posterior sacrum llium (via sacrotuberous ligament) Posterior (superior) gluteal line of ilium l. Gluteal tuberosity of femur lliotibial tract (attaching to lateral condyle of tibia) A. Extension of femur Lateral rotation of extended hip

N. Inferior gluteal n (L5, S1 ,2) P. Palpate buttock lliotibial tract

between the sacrum and greater trochanter of femur during resisted extension of the femur.

Fig 2C.12 Gluteus maximus Posterior

Gluteal Group Gluteus is Greek for rump. The three gluteal muscles lie superficial to deep: gluteus maximus; gluteus medius; and g.luteus minimus. Gluteus maximus is used mostly for power; as in going upstairs., rising. from a sitting positioh, climbilg or running rather than walking. Similar to other lower extiemity muscles, the g-luteus maximus can move the femur against the pelvis (hip extension) or move the pelvis against the femur (posterior pelvic tilt).

Section 2C: Lawer Limb - Muscles 97

Gluteus Medius

O.

lliac crest of ilium llium - between posterior (superior) and anterior (middle) gluteal lines

l.

Greater trochanter of femur

A.

Abduction of femur Anterior fibers: Medial rotation of femur

N.

Superior gluteal n (15, Sl )

P. Palpate posterolateral

aspect of hip area between iliac crest and greater trochanter during active abduction of the femur.

Fig 2C.13 Gluteus medius Posterior

When standing on one foot, gluteus medius contracts on that side to help stabilize the pelvis and prevent it from tilting to the unsupported side. Paralysis of this muscle on one srde results in the "gluteus medius limp": the pelvis tilts towards the uninvolved side in walking.

98

lll ustrated

Essentials af Musculoskeletal Anatomy

Gluteus Minimus

o. Posterior ilium - between anterior (middle) and inferior gluteal lines

N

l. Anterior surface of greater trochanter of femur A. Abduction Medial rotation of femur

N.

Superior gluteal n (15, 51)

P.

Palpate along with overlying gluteus

medius during active medial rotation of the femur. Cannot differentiate gluteus minimus from gluteus medius.

Ftg

2CJ4 Gluteus minimus Posterior

Gluteus minimus works with anterior portion of gluteus medius to sfeady the pelvis during ipsilateral weight-bearing. Section 2C: Lower Limb - Muscles 99

Tensor of Fascia Lata

O.

Iliac crest - posterior to anterior superior iliac spine

l. A.

lliotibial tract (attaches to the lateral condyle of the tibia) Assists flexion of femur Assists abduction of femur Assists medial rotation of femur Assists stability of extended knee in

tliotibial

standing and ambulation Assists extension of knee

tract N.

Superior gluteal n (15, 51)

P.

Palpate muscle belly just distal and slightly lateral to anterior superior iliac

spine (ASIS) on anterolateral pelvis during resisted flexion of the femur. Fig 2C.1

5 Tensor of fascia lata Lateral

Palpate iliotibial tract on lateral aspect of distal thigh, just proximal to the knee

joint and anterior to the biceps femoris tendon.

of fascia lata (TFL) is enclosed in fascia of the lateral thigh (fasciae latae)

Tensor

band

that extends as the itiotibial (tract) to attach to the tibia. When TFL contracts, this tightens the fascia and helps stabilize the hip and knee ioints. 100

lllustrated Essentials of Musculaskeletal AnstamV

:

5ix Deep=,1-Atg,ral Rotators of the Femur O.

\^*.E+,

)9-

v-

Gemellus superior: Obturator internus: Obturator externus: Gemellus inferior: Quadratus femoris:

Anterior sacrum Sacral ligament lschial spine Obturator foramen Obturator foramen lschial tuberosity lschial tuberosity

Piriformis: Gemellus superior: Obturator internus: Gemellus inferior: Obturator externus: Quadratus femoris:

Greater trochanter of femur Greater trochanter of femur Greater trochanter of femur Greater trochanter of femur Trochanteric fossa of femur Quadrate tubercle of femur

Piriformis:

Piriformis

l.

,l Obturator externus

Fig 2C.16 Piriformis, Obturator externus

A.

Lateral rotation of femur

N.

Piriformis: Gemellus sup: Obturator internus: Obturator externus: Gemellus inferior: Quadratus femoris:

Anterior

Piriformis

to piriformis (St ,2) N to obturator int (15, 51) N to obturator int (15, Sl ) Obturator n (13,4) N to quadratus femoris (15, 51) N to quadratus femoris (15, S1) N

Gemellus

superior P.

Obturator internus Gemellus

inferior Obturator externus

€/

Quadratus femoris

I

I

Fig2C.17

Lying deep to gluteus maximus, most of the six deep lateral rotators of the hip joint cannot be reliably palpated individually, but the group can be tested for function by resisting lateral rotation of the femur.

Piriformis is difficult to differentiate but may be palpable below the posterior superior iliac spine (PSIS) between the border of the sacrum and the greater trochanter, during active lateral rotation of the femur.

deep lateral rotators Posterior

Six

Six Deep Lateral Rotators of the Femur Six deep lateral rotators of the femur lie deep

to gluteus maximus and inferior to gluteus medius. The sciatic nerve lies between the rotators and piriformis and may be entrapped or compressed by piriformis. The first letter in the words of the phrase "Piece Goods Often Go On Quilts" denotes the anatomical order of these muscles from superior to inferior (piece goods = fabric sold by the yard). Secrion 2C: Lower Limb - Muscles

101

Biceps femoris

Semitendinosus Semimembranosus

Hamstrings Group The hamstring group is essential for hip extension for upright posture and may assist trunk extension at the hip joint when the thighs are fixed. All three of the hamstrings cross both the hip and knee joints. In order from lateral to medial their initials, BTM, indicate their arrangement on the "bottom" of the thigh: biceps femoris; semitendinosus; and semimembranosus. Difficulty touching the toes while keeping knees extended may be due to shortened hamstrings.

Fig 2C.18 Hamstrings group Posterior

Biceps Femoris O. Long head: lschial tuberosity Short head: Linea aspera

l.

Head of fibula - lateral aspect Lateral condyle of tibia

A. Flexion of knee Lateral rotation of tibia when knee is flexed

Biceps femoris Long head

Long head: Extension of femur

Biceps femoris Short head

N.

P.

Fig 2C.19 Biceps femoris Posterior

102

lllustrated Essentials of Musculoskeletal Anatomy

Long head: Sciatic n - tibial division (15, S1, 2) Short head: Sciatic n - fibular division (15, S1, 2) Palpate muscle belly on the lateral side of posterior thigh during resisted knee flexion.

Tendon is palpated on lateral side of posterior knee just proximal to its insertion on the fibula.

i ii :,

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Semitendinosus Semimembranosus O. lschial tuberosity

l.

Semitendinosus: Anterior proximal tibial shaft Semimembranosus: Posterior medial tibial condyle

A. Extension

of femur Flexion of knee Medial rotation of tibia when knee is flexed

Semitendinosus

N.

Sciatic n - tibial division (15, 51, 2)

P. Semitendinosus: Palpate muscle belly on the medial side of the posterior thigh during resisted knee

flexion. Tendon is palpated on the medial side of the posterior knee, just lateral to gracilis tendon

Ftg 2C.2O Semitend i nosus Posterior

(see gracilis palpation, p.96).

Semimembranosus: Difficult to differentiate but may be palpated on either side of semitendinosus tendon on the posterior thigh just proximal to the knee joint during resisted knee flexion.

Semimembranosus

a'nd sem i membra nosus insert medially at the knee while the ,, biceps femoris inserfs laterally. //'ls€ rtions account for the medial rotation ', of the tibia by the sem itendinosus sem imembrano.sus and lateral rotation the tibia by the biceps Sem itend i no.sus

Fig 2C.21 Semi membranosus Posterior

These

,

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Section 2C : Lower Limb - Muscles 103

Ti

bialis Anterior

o. Lateral condyle of tibia Lateral shaft of tibia Interosseous membrane \?l-

l. Base of 1st metatarsal - plantar surface Medial cuneiform tarsal bone - plantar surface A. Dorsiflexion of ankle Inversion of foot

N. P.

Deep fibular n (L4, 5) Palpate lateral side of tibia on anterior surface of lower leg during resisted dorsiflexion of the foot at the ankle joint.

Tendon is palpated on medial side of anterior surface of ankle.

Fig 2C .22a Tibialis anterior

Anterior

Fig 2C .22b Tibialis anterior insertion

Plantar

Tibialis anterior is the strongest dorsiflexor of the ankle and enables the foes to clear the ground in ambulation. Paralysis of this muscle causes foot drop. "Shin splints" result from overuse of this muscle.

104

tllustrated Essentials of Musculoskeletal Anatamy

Exte

O.

l.

n so.r, D

ig ito

f

m Longus ',11

Lateral condyle of tibia Proximal 2/3 of anterior shaft of fibula

Middle and distal phalanges of 4 lateral toes

A.

Extension of 4 lateral toes at MP joints Assists dorsiflexion of ankle

N. Deep fibular n (15, 51) P.

Palpate common tendon on anterior surface of ankle, just lateral to extensor hallucis

longus tendon, during active extension of the 4 lateral toes at the MP joints. lt divides into 4 tendons palpable on the dorsum of the foot.

Fig 2C.23 Extensor digitorum longus

Anterior

it;)

digitorum longus is comparable to the extensor digitorum in the hand and its tendons comprise the extensor Extensor

ff

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Extensor Hallucis Longus

O. Anterior shaft of fibula Interosseous membrane

l.

f''

^a

A.

Base of distal phalanx of

the great toe

Extension of great toe at lP joint Extension of great toe at MP joint Assists dorsiflexion of ankle

N. Deep fibular n (15, 51) P.

Palpate tendon on dorsum of foot just lateral to tibialis anterior tendon and on dorsal surface of 1st metatarsal during

extension of the great toe at the MP and lP joints.

Fig 2C.24 Extensor hallucis longus Anterior

Extensor hallucis longus rs comparable to

the extensor pollicis longus in the 106

ll

I

ustrated Essentials of Musculoskeletal Anatornv

hand.

;i

i ,I

Fibularis Tertius (Peroneus Tertius)

O. Anterior distal fibula (with extensor digitorum longus)

l.

Base of

5th metatarsal

A. Eversion of foot Assists dorsiflexion of

N.

foot

Deep fibular n (15, 51)

P. Tendon

is palpated lateral

to the extensor digitorum longus tendon on dorsum of foot at base of 5th metatarsal during active eversion of the foot.

Fig 2C.25 Fibularis tertius

Anterior

Foot Evertor Group The foot evertor muscles attach to the fibula (fibularis tertius, longus, and brevis) and were previously named peroneus tertius, longus, and brevis after the Latin word for fibula. Fibularis longus traverses the sole of the foot to meet the tibialis anterior tendon to form a stirrup for the foot. Due to the relative insertion sites on the ankle, fibularis tertius assists dorsiflexion of the ankle and fibularis longus and brevis assist plantar flexion of the ankle.

Fibularis tertius is considered to be a part of exfenso r digitorum longus. Fibularis tertius places the foot flat on the ground by raising the lateral border. lt contracts reflexively when the foot is over-inverted thus preventi ng ankle i njury. Section 2C : Lower Lirnb - Muscles '107

Fibularis ,,,Lo n g u s.j ,Pgr{)n eu s,,Lon g,u s)

O.

l.

Head and lateral shaft of fibula - upper 2/3

first metatarsal - plantar surface Medial cuneiform tarsal bone - plantar Base of

surface

A.

Eversion of foot Assists plantarflexion of ankle

N.

Superficial fibular n (L5, Sl )

P.

Palpate superficial muscle belly just distal

to head of fibula on lateral surface of proximal half of lower leg during active eversion of the foot.

Fig 2C.26b Fibularis

longus insertion Plantar

Fig 2C.26a Fibularis longus

Lateral

108

lllustrated Essentials of Musculoskeletal Anatomy

Tendon is palpated just proximal to the lateral malleolus and posterior to the fibularis brevis tendon as it wraps around the lateral malleolus before descending to insert on the plantar surface of the foot.

Fibularis Brevis (Pergneus Brevis)

O.

Lateral shaft of fibula - lower 2/3

l.

Base of

A.

5th metatarsal - lateral surface

Eversion of foot Assists plantarflexion of ankle

N.

Superficial fibular n (15, 51)

P.

Palpate tendon on the lateral side of the foot just distal to the lateral malleolus as it travels toward its insertion at the base of the 5th metatarsal during active eversion of

the foot. The muscle belly may be palpated on the lateral side of the distal leg, proximal to

the lateral malleolus on either side of the fi bularis longus tendon.

Fig 2C.27 Fibularis brevis Lateral

well when

The action of the foot evertors (as as invertors) rs esp ecially helpful walking or running on uneven surfaces. Sometimes the muscles "give out," and ra in e ,,

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Section 2C : Lower Limb - Muscles 109

Gastrocnemius

o. Medial head: Medial epicondyle of femur Lateral head: Lateral epicondyle of femur Medial head

N

Lateral head

N

l. Calcaneus via calcaneal tendon (tendo Achilles)

,\\

A. Plantarflexion of ankle Assists flexion of knee

N

N.

Tibial n

P.

Palpate medial and lateral heads on upper half of posterior lower leg during resisted

(S

1

,2)

plantarflexion of the ankle joint. Tendon is palpated as part of calcaneal (Achilles) tendon.

Fig 2C.28 Gastrocnem i u s Posterior

belly.

Gastro is the Greek term for Gastrocnemius can act on the knee i or the ankle separately, but not simultaneously. The "gastroc" raises l, the heel during running and jumping. i :

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10

lllustrated Essentials of Musculoskeletal Anatomy

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Soleus

o. Soleal line of tibia Posterior head of fibula Upper shaft of fibula

l. Calcaneus via calcaneal tendon (tendo Achilles)

A. Plantarflexion N. P.

of ankle

Tibial n (S 1 ,2) Palpate distal to gastrocnemius heads on medial and lateral sides of the calcaneal

tendon on posterior lower leg during active plantarflexion of the ankle joint.

Gastrocnemius tendon sectioned

Tendon is palpated as part of calcaneal (Achilles) tendon.

Fig 2C.29 Soleus Posterior

Calcaneal (Achil les) Tendon

The calcaneal tendon is the thick tendon of insertion of the triceps surae into the calcaneus, connecting the calf (soleus and gastrocnemius) muscles to the heel. lt is the strongest tendon in the body.

Soleus rese mbles the sole, a flat fish. Deep to gastrocnemius, so/eus is the stronger pla nta rflexor a nd is fatig ue-res6 ta nt. Together; the gastrocnemius and so/eus are referred to as the triceps surae and are powerful plantarflexors of the ankle for raising the heel in running and jumping.

Section 2C : Lower Limb - Muscles

111

Tibialis Posterior

o. Posterior tibia Posterior fibula Interosseous membrane

l. Navicular tarsal bone Adjacent tarsals and metatarsals on plantar surface A. lnversion of foot Assists plantarflexion of ankle

%

N.

Tibial n (1a,5)

P. Tendon is palpated just posterior to medial malleolus as it passes around it toward insertions on the plantar surface of medial side of foot during active inversion of the

foot. Muscle belly is deep to gastrocnemius and soleus and cannot be palpated. Fig 2C.30a Tibialis posterior Posterior

Fig 2C.30b Tibialis posterior insertion

Plantar

'l'12 lllustrated Essentials of Musculoskeletal

Anatomy

"Tom, Dick, and Harry" Posterior Calf Muscles The order of the three deep posterior calf muscles tendons that course around medial malleolus is remembered by the first letters in the names "Tom, Dick, and Harry". The most anterior and superficial tendon is tibialis posteriol being "Tom"; next is flexor digitorum longus tendon, being " Dick " ; and most posterior and deep is flexor hallucis longus tendon, being " Harry". Tibialis posterior is the deepest of the three muscles.

Ftexor Digitorum Longus

O.

l.

Posterior tibia Distal phalanges of 4lateral toes - plantar surface

A. Flexion of 4 lateral toes at lP joints of 4lateral toes at MP joints Assists plantarflexion of ankle Assists flexion

N.

Tibial n (S2, 3)

P. Difficult to differentiate but common tendon may be palpated behind the medial malleolus just posterior to the tendon of tibialis posterior during active flexion of the 4 lateral toes. Alternating inversion of the foot and flexion of the toes helps differentiate it from the tibialis posterior.

Fig 2C.31a Flexor digitorum longus Posterior

Fig 2C.31b Flexor digitorum longus insertion Plantar

Flexor digitorum longus is recalled as "Dick" of Tom, Dick and Harry calf muscles (see p.n 2). Flexor digitorum longus is comparable to the flexor digitorum profundus in the hand. i

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Secfron 2C: Lawer Limb - Muscles

113

Flexor Ha|Iucis Longus

O.

l.

Posterior fibula

Distal phalanx of great toe - plantar surface

A. Flexion of great toe at MP joint Flexion of great toe at lP joint Assists plantarflexion of ankle

N.

Tibial n (SZ, 3)

P.

Palpate tendon distally on the plantar surface of the proximal phalanx of the great toe during resisted flexion of the lP joint of the great toe.

Tendon may also be palpated in the area between the medial malleolus and calcaneal tendon, but it is difficult to differentiate from the flexor digitorum longus tendon as it goes around the medial malleolus.

Fig 2C 32a Flexor hallucis longus Posterior

Fig 2C.32b Flexor hallucis longus insertion Plantar

Flexor hallucis longus ts "Harry" of Tom, Dick and Harry calf muscles (see p.t t 2). Flexor hallucis longus plays an important role in fonuard propulsion by flexing the big foe to push off the ground when walking and running. 114

lllustrated Essentials of Musculoskeletal Anatomy

Plantaris and Popliteus Plantaris

O.

l.

Lateral epicondyle of femur Calcaneus via calcaneal tendon

A. Assists plantarflexion of ankle Assists flexion of knee N. Tibial n (S1,2)

Plantaris

P.

Difficult to differentiate but may be palpable just proximal and medial to the lateral head of gastrocnemius on the posterior knee during active plantarflexion of the foot with resisted flexion of the knee.

Plantaris is superficial on the posterior of the knee joint, lying between the soleus and gastrocnemius muscles. lt is the lower extremity counterpart of the palmaris longus of the hand and is absent in some persons. Gastrocnemius, soleus and plantaris share a common insertion, the calcaneal tendon (see note p.n t).

Popliteus

O.

Fig 2C.33 Plantaris Posterior

l. A.

Lateral condyle of femur

Posterior proximal tibial shaft Lateral rotation of the femur to "unlock" the extended knee to initiate knee flexion Assists medial rotation of tibia when knee is

flexed

N.

Popliteus

Tibial n (L4,5, S1)

P. Cannot palpate but can be tested for function by resisting medial rotation of the knee.

Fig 2C.34 Popliteus Posterior knee

', ',

Popliteus is the deepest muscle on the posfe rior of the knee joint. Because of its action in lateral rotation of the femur; poplifeus is remembered as "the key that unlocks the knee". lt is said to " reverse ifs origin and insertiofr", laterally rotating the femur on the tibi or medially rotating the tibia on the femur; depending upon which is fixed. Section 2C: Lower Limb - Muscles

1

15

Extensor Digitorum Brevis

O.

l. A.

Anterior calcaneus Extensor expansion of 4 medial toes Assists extension of 4 medial toes at MP

joints Assists extension of 4 medial toes at lP joints

N. P.

Deep fibular n (L5, 51) Palpate just anterior and distal

to lateral

malleolus on dorsolateral surface of the foot during extension of MP and lP joints of 4 medial toes.

The belly of exfenso r digitorum brevis (EDB) may be mistaken for swelling near Fig 2C.35 Extensor digitorum brevis

Anterior

Extensor Hallucis Brevis The portion of the extensor digitorum brevis to the great toe inserts on the base of the proximal phalanx and may be identified as the Extensor hallucis brevis. When identified as such, its action is to assist extension of the great toe at the metatarsophalangeal (MP) joint.

1

16

lllustrated Essentials of Musculoskeletal Anatomy

the lateral malleolus and, when the muscle it may become swollen and be mistaken for an ankle sprain.

is bruised,

It is not possible to extend the 4 lateral foes individually. The tendons of the EDB fuse with the tendons of the extensor digitorum longus (EDL), and both muscles contract simultaneously to produce extension of all 4 lateral foes. Howeve7 extension of the MP joint of the sth toe will not occur without EDL.

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Abductor Hallucis

O. Calcaneus

l.

A. N. P, Flexor

Abductor digiti minimi

digitorum brevis

of proximal phalanx of great toe Flexion of great toe at MP joint Abduction of great toe at MP joint Medial plantar n (S2,3) Palpate the medial border of the 1 st metatarsal during active abduction of the MP joint of the great toe. Base

Flexor Digitorum Brevis

O.

A.

Calcaneus Middle phalanges of 4lateral toes Flexion of 4lateral toes at lP joints

N.

Flexion of 4 lateral toes at MP joints Medial plantar n (S2, 3)

l.

P.

Palpate in middle of plantar surface of foot during active flexion of PIP joints of th e 4 lateral toes.

Abductor Digiti Minimi

O.

l.

A. N. P. Fig 2C.36 Muscles of the foot layer I Plantar, right -

,

i

Calcaneus Base of proximal phalanx of little toe Flexion of little (5th) toe at MP joint

Abduction of little (5th) toe at MP joint Lateral plantar n (S2, 3) Palpate the lateral surface of the 5th metatarsal during active abduction of the MP joint of the 5th toe.

ii

Abductor hallucis is comparable to the abductor pollicis brevis in the hand. Flexor digitorum brevis is comparable to flexor digitorum superficialis in the forearm. Most people cannot move one foe separately from another; nor separate MP from lP joint motions in individual foes.

il'lrili:ilirltiiiriiilrrl,iiiiij+!drx.,ir,ri#ir:ii:ij:l,i.i',iri;1*Li.d:l;iijjiiii.,irrti$.:it#*-"tttttltitj.,.!l#r.:.-q4

rli'r'ri

'lii

*r

:* ..ii

ii ,+ ii+ iil:!

# ;lli ti:r:

ui, lrll

iii i* !iil 1f

filit' ,*ro,iii

Section 2C: Lower Limb - Muscles 117

Muscles of the,Foot

;

LAyer 2

Lumbricals

O.

l.

Tendons of flexor digitorum longus Extensor expansion to 4 lateral toes*

A.

Flexion of 4 lateral toes* at MP joints

N.

Extension of 4lateral toes* at lP joints 2nd toe: Medial plantar n (S2, 3) 3rd, 4th, 5th toes: Lateral plantar n (S2, 3)

Quadratus plantae

Quadratus Plantae

O. Calcaneus

l.

Tendons of flexor digitorum longus Assists flexor digitorum longus in flexion

A.

of 4lateral toes* at lP joints

N.

Lateral plantar n (S2, 3)

All muscles in layes 2

Lumbricals

P. These muscles are too deep to palpate. *

4

lateral toes

-

2nd, 3rd, 4th, 5th toes

Tendons of flexor

digitorum longus

Ftg 2C.37 Muscles of the foot - layer 2 Plantar, right

Flexor Digitorum Accessorius

Quadratus plantae is also known as flexor digitorum accessorius, an assistant to the flexor digitorum longus.

1

18

lllustrated Essentials of Musculoskeletal Anatomy

Lumbricals are comparable to lumbricals in the hand. Quadrafus planfae has no counterpart muscle in the hand and may be absen t in some persons.

M

uscles of the',,f. ot,.;,,,1-f,,X er3

Flexor Hallucis Brevis O. Base of metatarsal of great toe l. Base of proximal phalanx of great toe A. Flexion of great toe at MP joint N. Medial plantar n (S2, 3)

Adductor Hallucis O. Oblique head: Base of 2nd, 3rd metatarsals

A.

Transverse head: 3rd, 4th, 5th MP joint capsules Base of proximal phalanx of great toe Adduction of great toe at MP joint

N.

Flexion of great toe at MP joint Lateral plantar n (S2, 3)

Flexor

digiti minimi brevis

l.

Adductor hallucis: Oblique head

Flexor

Transverse head

hallucis brevis

Flexor Digiti Minimi Brevis O. Cuboid tarsal bone Base of 5th metatarsal l. Base of proximal phalanx of 5th toe A. Flexion of 5th toe at MP joint N. Lateral plantar n (S2, 3)

All muscles in layer 3

P. These muscles

are too deep

to palpate.

Fig 2C.38 Muscles of the foot - layer 3 Plantar, right

Flexor hallucis brevis has tvvo heads and is comparable to adductor pollicis in the hand. Adductor hallucis is comparable to adductor pollicis in the hand. Flexor digiti minimi brevis is comparable to flexor digiti minimi brevis in the hand. Section 2C : Lawer Limb - Muscles

1

19

Muscles of

the*Foot;

Layer 4

Dorsalinterossei

Dorsal lnterossei (4) O. Adjacent metatarsals l. Extensor expansion of 2nd, 3rd, and 4th toes A. Abduction of 2nd, 3rd, and 4th toes at MP joints Adduction of 2nd toe at MP joint (4) Assists flexion of 2nd, 3rd, 4th toes at MP joints Assists extension of 2nd, 3rd, 4th toes at lP joints N. Lateral plantar n (S2,3) P. These muscles are too deep to palpate.

Fig 2C.39a Muscles of the foot - layer 4 Dorsal, right

Plantar interossei (3)

Plantar lnterossei (3) O. Medial side of 3rd, 4th and 5th metatarsals l. Extensor expansion to 3 lateral toes A. Adduction of 3rd, 4th, 5th toes at MP joints Assists flexion of 3rd, 4th, 5th toes at MP joints Assists extension 3rd, 4th, 5th toes at lP joints N. Lateral plantar n (S2, 3) P. These muscles are too deep to palpate.

Fig 2C.39b Muscles of the foot - layer 4 Plantar, right

120

lllustrated Essentials of Musculoskeletal Anotomy

Flexors, Extensors of Femur

Flexors of the Femur 1. Psoas major and lliacus 2. Pectineus 3. Tensor of fascia lata 4. Adductor brevis 5. Adductor longus 6. Adductor magnus (anterior head) Rectus femoris 8. Sartorius

7.

Fig 2D.1 Flexors of femur

Anterior, right

Extensors of the Femur 1. Gluteus maximus 2. Biceps femoris (long head) 3. Semitendinosus 4. Semimembranosus 5. Adductor magnus (posterior head)

Muscles

in italics assist the action

Fig 2D.2 Extensors of femur Posterior, right

Section 2D: Lower Limb - Graup Actions

121

Adductors, Abductors of Femur

Adductors of the Femur 1. Adductor brevis 2. Adductor longus 3. Adductor magnus

4. Gracilis 5. Pectineus

Fig 2D.3 Adductors of femur Anterior, right

N .\-.-

j^\ //\ - ),v

Abductors of the Femur

1. 2.

Gluteus medius Gluteus minimus Tensor of fascia lata

3. 4. Sartorius

Fig 2D.4a Abductors of femur

Anterior, right

Muscles

122

in italics assist the action

lllustrated Essentials of Musculoskeletal Anatomy

Fig 2D.4b Abductors of femur Posterior, right

M g d i a,lr* La t g ra,l,' B otato

r s,

o,t*tam,u r

Lateral Rotators of the Femur 1. Piriformis 2, Gemellus superior 3. Obturator internus 4. Gemellus inferior 5. Obturator externus 6. Quadratus femoris 7, Gluteus maximus (sectioned) Sartorius* Adductor magnus (posterior head)*

Fig 2D.5 Lateral rotators of femur Posterior, right

Medial Rotators of the Femur

1. Gluteus medius

2. 3.

Fig 2D.6a Medial rotators of femur Posterior, right

(anterior fibers) Gluteus minimus Tensor of fascia lata Adductor magnus (anterior head)* Pectineus*

Fig 2D.6b Medial rotators of femur Lateral, right

Muscles in italics ossist the action *Not illustrated

Section 2D : Lawer Limb - Group

Actions

,'123

FleXgrsr,,Extenp_ort

of Knee

Flexors of the Knee 1. Biceps femoris 2. Semitendinosus 3. Semimembranosus 4. Sartorius

5. Gracilis 6. Gastrocnemius 7. Plantaris Popliteus (deep to plantaris)*

Fig 2D.7 Flexors of knee

(see Fis

2D.s, #3)

Extensors of the Knee

Posterior, right

1.

Vastus lateralis

2. Vastus intermedius 3. Vastus medialis 4. Rectus femoris 5. Tensor of fascia lata Fig 2D.8 Extensors of knee

Anterior, right

Muscles in italics assist the action *Not illustrated

124

lllustrated Essentials of Musculoskeletal Anatomy

Med ia !r, Latera l, ffglators,of.,,KJl,ee

Medial Rotators of the Knee Rotates Tibia When Knee is Flexed

1. Semitendinosus 2. Semimembranosus 3. Popliteus 4. Gracilis 5. Sartorius Lateral Rotators of the Knee Rotates Femur When Knee is Extended 3. Popliteus

Fig 2D.9 Medial rotators of knee Posterior, right

Lateral Rotators of the Knee Rotates Tibia When Knee is Flexed 1. Biceps femoris

Fig 2D.10 Lateral rotators of knee Posterior, right

Muscles

in italics assist the action

Section 2D : Lower Limb - Group

Actions

125

Pp

f*

Dorsiflexors of the Ankle 1. Tibialis anterior 2. Extensor digitorum longus

3. Fibularis tertius 4. Extensor hallucis longus Plantarflexors of the Ankle

1. Gastrocnemius 2. Soleus 3. Plantaris 4. Fibularis longus 5. Fibularis brevis

6, Tibialis posterior 7. Flexor hollucis longus Flexor digitorum longus*

Fig 2D.1

1 Dorsiflexors of ankle Anterior, right

Fig 2D.12 Plantarflexors of ankle Posterior, right

lnvertors of the Foot 1. Tibialis anterior 2. Tibialis posterior Evertors of the Foot 1. Fibularis tertius 2. Fibularis longus

3. Fibularis brevis

Fig 2D,1 3a lnvertors of foot

Fig 2D.13b lnvertors of foot

Fig 2D.14 Evertors of foot

Anterior, right

Posterior, right

Lateral, right

126

Muscles in italics assist the action *Not illustrated

lllustrated Essentials of Musculoskeletal Anatomy

Abductors of Toes

'.''..u..'''.HXtensors'...H|...'gxorsf

6

9

Fig 2D.1

5 Extensors, adductors of toes

Fig 2D.1

Dorsal, right

5

Flexors, abductors of toes

Fig 2D.1

Plantar, right

5 Flexors, abductors of toes deep layer

Plantar, right

Extensors of the Toes** Flexors of the Toes** 1. Extensor hallucis longus 4. Dorsal interossei 2. Extensor digitorum longus 5. Lumbricals 3. Extensor digitorum brevis 6. Flexor digitorum longus 4. Dorsal interossei 7. Flexor hallucis brevis 5. Lumbricals 8. Flexor digitorum brevis

9.

Plantar interossei*

10. 1

1.

12,

Abductors of the Toes**

4, 1

Dorsal interossei

1. Abductor hallucis

12. Abductor digiti minimi Adductors of the Toes**

4.

Flexor hallucis longus Quadratus plantae

Abductor hallucis Abductor digiti minimi Flexor digiti minimi brevis*

Dorsal interossei

Adductor hallucis* Plantar interossei*

Plantar interossei* *Nof illustrated **Refer to all above images for muscles listed Muscles in italics assist the action

Section 2D: Lower Limb - Group Actions

127

T12

12th rib Subcostal n (T12)

lliohypogastric n (T1 2,LU lf

ioinguinal n (Tl 2,Ll) Genitofemoral n (Ll, 2) Lat femoral cutaneous n of

thigh (12, 3)

Branches to psoas (L2, 3),

quadratus lumborum (T12, Ll-4)

Ant cutaneous branch n (L2-a)

Obturator n (L2-4) Lumbosacral trunk (L4, 5)

Femoral n (L2,3,41

s1

V

Superior

gluteal n

Saphenous n (13,4)

(L4,5, 51)

v

Inferior gluteal n

s3

-e/

(15,

to piriformis

s4

-'--/ Yt

Sl, 2)

(sl,

2)

s

Col Coccygeal

plexus (S4, 5, Col

Sciatic n (L4,5, 51-3) ) N

to obturator internus Common fibular n

(L5, 51, 2)

Nto quadratus femoris (L4,5, 51)

(L4,

cutaneous n of thigh (s1-3)

Tibial n (L4,5, S1-3)

Fig 2E.1 Lumbosacral plexus Anterior, left

128

lllustrated Essentials of Musculoskeletal Anatomy

5,51,2)

Post

I I

Anterior division Posterior division

Obturatsn Femoral Nerves

99-9)Y

Obturator n 1. Obturator externus (L3, 4) 2. Adductor brevis (12, 3,4) 3. Adductor magnus (anterior head) (L2,3, 4. Adductor longus (12, 3,4)

U,2,,r,,,,,,,3,r,.,,,,4!

4)

5. Gracilis (L2,3)

F

9-

!:).)-

\t

Inguinal

ligament Fig 2E.2 Obturator n Anterior, right

Femoral n

1. Psoa s - L2,3 directly 2. lliacus (12, 3) 3. Pectineus (12, 3) 4. Sartorius (L2, 3) 5. Rectus femoris (L2 ,3, 4) 6. Vastus medialis (L2,3,4) 7. Vastus lateralis (L2,3, 4) 8. Vastus intermedius (L2,3,4)

il Fig 2E.3 Femoral n Anterior, right Section 2E: Lower Limb -

Nerves

129

Sciatir'l Tib ial Nerves

(L*t*5r,'S 1 , 2r ,.7,,,1

( I

Sciatic n:

Sciatic n Tibial Division 1. Biceps femoris (long head) (15, 51, 2) 2. Semitendinosus (L5, 51, 2) 3. Semimembranosus (L5, 51 ,2) 4. Adductor magnus (posterior head) (14)

Tibial division Fibular division

la

2: 3' 4

Fibular Division 1. Biceps femoris (short head) (L5, 51 ,2)

Common fibular n (L4, 5, 51 ,21

Tibial n (L4,5, Sl ,2,31

Tibial n

1. Plantaris (S1,2) 2. Popliteus (L4, 5, 51) 3. Gastrocnemius (S1, 2) 4. Soleus (S ,2) 5. Flexor digitorum longus (S2, 3) 6. Flexor hallucis longus (S2, 3) 7. Tibialis posterior (14, 5)

Fig 2E.4 Sciatic n Posterior, right

1

Tibial n

Lateral

plantar n

Medial

plantar n 13

8

15

12

17 16

9 17 10 Medial plantar n

Lateral Plantar n 12. Adductor hallucis (S2, 3) 13. Quadratus plantae (S2, 3)

14. Abductor digiti minimi (S2, 3) 15. Flexor digiti minimi brevis (S2, 3) 16. Plantar interossei (S2, 3) 17. Dorsal interossei (S2, 3) 18. Lumbricals (lateral 3) (S2, 3)

11

Lateral

plantar n

130

Medial Plantar n 8. Flexor digitorum brevis (S2, 3) 9. Abductor hallucis (S2, 3) 10. Flexor hallucis brevis (S2, 3) 1 1. Lumbrical (medial one) (S2, 3)

Fig 2E.5a Tibial, plantar ns

Fig 2E.5b Tibial, plantar ns

Posterior, right

Plantar, right

lllustrated Essentials of Musculoskeletal Anatomy

tibial n - innervates all muscles of posterior lower leg

Fibular Nerves L4r 5r,51

Common fibular n

Deep fibular n

Superficial fibular n

Superficial Fibular n

1. Fibularis longus (15, Sl ) 2. Fibularis brevis (15, S1) Deep Fibular n 3. Tibialis anterior (14, 5)

4. Extensor digitorum longus (15, 51) 5. Extensor hallucis longus (L5, S1) 6. Fibularis tertius (L5, 51) 7. Extensor hallucis brevis (15, 51) 8. Extensor digitorum brevis (15, Sl )

Deep fibular n

Fig 2E.6 Superficial fibular n Posterior, right

Fig 2E.7 Deep fibular n Anterior, right

Section 2E : Lawer Limb -

Nerves 1 31

I

-

l-

t

I

r

I

,

II

I

I

r

-!

|r

|I

I

r'rrrru-r

'

-

Cutaneous

,,,1

n lle r,ye,f_i gfl-'Lowg

r Limb Superior clunial n

lliohypogastric n

lliohypogastric n

Genitofemoral n Medial clunial n

k Lateral cutaneous n

llioinsuinal n

lnferior clunial n

Cutaneous branch of obturator n

of thigh

Lateral cutaneous n of thigh

Cutaneous bra of obturator n

4)

/

Anterior cutaneous branches of femoral n

\,4

$

Posterior cutaneous n of thigh

\Y Lateral sural

cutaneous n Lateral sural

cutaneous n

Medial sural cutaneous n

Saphenous n

Saphenous n

Lateral dorsal cutaneous n of foot

Calcaneal branches sural and tibial ns

Superficial

fibular n Medial plantar n Deep fibular n

Fig 2E.8 Cutaneous innervation lower limb Anterior, right

Fig

2E.9

Lateral plantar n

Cutaneous innervation lower limb Posterior, right

Lower Limb Cutaneous ns - Source,Terminal Nerves, Spinal Segments POSTERIOR (DORSAL) RAMIOF SPINAL

NERVES*

Superior clunial n (11-3) Medial clunial n (S1-3) LUMBAR PLEXUS

lliohypogastric n (11) llioinguinal n (12) Genitofemoral n (Ll, 2) Cutaneous branch of obturator n (L2-4) Lateral cutaneous n of thigh (12, 3) Femoral n (L2-4)

Ant cutaneous branches of femoral n (L2-4) Saphenous n (13, 4)

SACRAL PLEXUS

Posterior cutaneous n of thigh

lllustrated Essentials of Musculaskeletal Anotomy

-3)

Inferior clunial n (S2, 3) Sciatic n (L4,5, 51-3) Common fibular n (L4,5, S1,2) Lateral sural cutaneous n (14-Sl )* Superficial fibular n (15, Sl ) Deep fibular n (15) Tibial n (14,5, S1-3) Medial sural cutaneous n (15, 51, S2)** Calcaneal branches of sural and tibial n (S1,2) Medial plantar n (14, 5) Lateral plantar n (S1,2) Lateral dorsal cutaneous n of foot (L5, 51)*

*see image 3E.3, p.l75 **sural ns - arise from fibular and tibal ns; terminate as lateral dorsal cutaneous n of foot

132

(S1

t:

A. MOTIONS

134

Diaphragm Serratus Posterior Su perior Serratus Posterior I nferior Levatores Costarum Quadratus Lumborum

Mandible, Head, Neck Trunk, Pelvis

B.

136

BONES Skull

Muscles of Abdominal Wall

Vertebral Column Palpation of Bony Landmarks - Head

C. MUSCLES

External Oblique Internal Oblique

140

Muscles of Head

Transversus Abdominis

140

Eye Muscles

140

Superior Rectus Medial Rectus Lateral Rectus

Inferior Rectus Muscles of Facial Expression Au ricu la ris

Corregator Supercilii Compressor Naris Depressor Anguli Oris Depressor Labii I nferioris Depressor Septi Nasi

Muscles of Posterior Neck

Superior Oblique Inferior Oblique Dilator Pupillae Sphincter Pupillae

Spinotransverse Group

141

Platysma Procerus Risorius

Temporoparietalis Tygomaticus Major Zygomaticus Minor

lntrinsic Muscles of Posterior Neck, Back Eredor Spinae (Sacrospinalis) Grou p lliocostalis Longissimus Spinalis Transversospinalis Group Semispinalis

Levator Labii Superioris Levator Labii Superioris Alaque Nasi Levator Pa pebrae Su peroris Mentalis Occipitofronta lis Orbicularis Oculi I

of Mastication, Jaw and Lip Closure

Temporal Masseter Orbicularis Oris

of Deglutition - Larynx Elevotion, Depression Mylohyoid Thyrohyoid Geniohyoid Sternothyroid Stylohyoid Digastric

Muscles of Anterior Neck

164 164

165

Rotatores Interspina les Intertra nsversa rii

14

Perineurn, Pelvic Floor Muscles

167

Bulbospongiosus Coccygeus Transverse Perineal

External Anal Sphincter External Urethral Sphincter lschiocavernosus Levator Ani

146

Sternohyoid

Omohyoid

D. MUSCLE GROUP ACTIONS 148

Flexors, Extensors of Head, Neck Lateral Flexors, Rotators of Head, Neck

Scalenes

Prevertebral Muscles Longus Colli Longus Capitis Rectus Capitis Anterior Rectus Capitis Lateralis

150

Muscles of Thoracic Wall

152

169

Movers of Mandible Head, Neck

Sternocleidomastoid

External lntercostal Internal Intercostal Subcostal Transversus Thoracis

163

Multifidus

Buccinator Medial Pterygoid Lateral Pterygoid

Muscles

162 162

Splenius Capitis Splenius Cervicis Suboccipital Muscles Rectus Capitis Posterior Major Rectus Capitis Posterior Minor Obliquus Capitis Superior Obliquus Capitis I nferior

Dilator Naris Levator Anguli Oris

Muscles

157

Rectus Abdominis

Flexors, Extensors, Rotators of Trunk

E.

NERVES

173

Cervical Plexus Cranial Nerves Spinal Nerves Cutaneous Nerves

Secffcn 3: flead,lVecft,

Trunk

133

Mandible, Headr, Neck Motions

7

)/