Transcript Muscular-Anatomy-Handoutx

Simplifying Muscular
Anatomy
Muscular Anatomy
• The neck is very complex
anatomically…
• Muscular anatomy here is vast.
• Origins, Insertions, Nerve Supply
and Action information is provided,
but will not be discussed in depth
Aims:
• Apply muscle anatomy knowledge
to assessment & diagnosis
• Explore palpation techniques
(Hansen 2009)
Before we begin –
Myofascial Trigger Points (MTrP’s)
• Highly debated topic
• No clear definition of what
MTrP’s are
• Essentially its a tender point that
when pressed can trigger pain
locally or referred
• Pain not present if palpation
moves
• Maybe it’s a neurologically
driven protective mechanism
Posterior Muscles
Layer 1
Trapezius
Origin
Medial superior nuchal line, external occipital
protuberance, ligamentum nuchae and the spinous
process of C7-T12
Insertion
Posterior aspect of the lateral clavicle, medial acromion
and the upper border of the spine of the scapula
Action
Upper fibres- elevation, neck extension, ipsilateral
lateral flexion, upward rotation of the scapula
Middle fibres- shoulder retraction
Nerve
Supply
(Palastanga, Field et al. 2006)
Lower fibres- depression, upward rotation of the
scapula, posterior tilt of the scapula
Accessory nerve (11th Cranial Nerve)
Trapezius
• Key Points
• All fibres of trapezius aid in
scapular upward rotation
• Fibres of upper trapezius are very
thin
• Lower fibres of trapezius are
perpendicular to rhomboids
(Brookbush 2014)
Rhomboid Major
(Palastanga, Field et al. 2006)
Origin
Spinous processes of T2 to T5
Insertion
Medial border of scapula
Action
Scapular retraction, downward scapular rotation
Nerve Supply
Dorsal Scapular Nerve
Rhomboid Minor
(Palastanga, Field et al. 2006)
Origin
Spinous processes of C7-T1
Insertion
Medial border of scapula
Action
Scapular retraction, downward scapular rotation
Nerve Supply
Dorsal Scapular Nerve
Rhomboids
• Palpation
• Side lying, with arm hanging over
edge of the bed to abduct the scapula
• Palpation obliquely downwards and
lateral from spinous process to
medial scapula border
• Key Points
• Rhomboid fibres run almost
perpendicular to lower fibres of
trapezius
• Rhomboids aid in scapular downward
rotation
• If hypertonic can resist scapular
upward rotation, altering mechanics
potentially leading to pain
Levator Scapulae
(Palastanga, Field et al. 2006)
Origin
Transverse process of C1-4
Insertion
Medial margin of the scapula between superior angle and
spine of scapula
Action
Elevation, shoulder retraction, neck extension, ipsilateral
lateral flexion, downward scapular rotation
Nerve Supply
Ventral rami of C3-4
Levator Scapulae
• Palpation
• Supine, ipsilateral cervical rotation,
hand behind back
• Palpate anterior to upper trapezius
fibres and follow down onto superior
angle of the scapula
• Key Points
• Levator Scapulae aids in downward
rotation of the scapula
• Can restrict upward rotation if
hypertonic
• Restriction of upward rotation during
shoulder movements can lead to neck
pain
• Can be a source of pain if hypertonic
Key Learning Points
• Trapezius is a big but thin muscle
• All fibres of trapezius aid in
scapula upward rotation
• Levator Scapulae and
Rhomboids aid in scapula
downward rotation
• Levator Scapulae and Rhomboid
hypertonicity can alter scapula
mechanics causing neck pain
(Brookbush 2014)
Key Learning Points
• Trapezius is a big but thin muscle
• All fibres of trapezius aid in
scapula upward rotation
• Levator Scapulae and
Rhomboids aid in scapula
downward rotation
• Levator Scapulae and Rhomboid
hypertonicity can alter scapula
mechanics causing neck pain
(Brookbush 2014)
Posterior Structures
Layer 2
Splenius Capitis
(3D4Medical 2013)
Origin
Lower half of ligamentum nuchae and the spinous process
of C7-T4
Insertion
Posterior aspect of the mastoid process of the temporal
bone
Action
Extension of the head and neck, ipsilateral lateral flexion,
ipsilateral rotation
Nerve Supply
Posterior primary rami of C3-5
Splenius Capitis
• Palpation
• Locate upper fibres of trapezius
• Isolate the lateral edge with cervical
extension
• Palpate lateral to trapezius and
medial to sternocleidomastoid on
mastoid process
• Key Points
• Splenius muscles are often hypertonic
when a painful facet joint is
underneath
• Splenius capitis trigger points can
refer into the head
Splenius Cervicis
(3D4Medical 2013)
Origin
Spinous process of T3-6
Insertion
Posterior tubercles of the transverse process of C1-4
Action
Ipsilateral lateral flexion, extension
Nerve Supply
Posterior primary rami of C5-7
Splenius Cervicis
• Palpation
• Supine with contralateral rotation
• Palpable in the lamina groove of
upper cervical vertebrae with
splenius capitis
• Palpated indirectly as it is deep to
levator scapulae and trapezius
• Key Points
• Splenius muscles are often hypertonic
when a painful facet joint is
underneath
• Splenius cervicis trigger points can
refer into the head
Key Learning Points
• Spleni muscles can be a source
of headaches
• Often hypertonic to protect an
irritable facet joint
• Palpation can be difficult as deep
to other structures
(Simons, Travel et al. 1999)
Key Learning Points
• Spleni muscles can be a source
of headaches
• Often hypertonic to protect an
irritable facet joint
• Palpation can be difficult as deep
to other structures
(Simons, Travel et al. 1999)
Posterior Muscles
Layer 3
Semispinalis Capitis
(3D4Medical 2013)
Origin
Transverse and articular processes of the vertebrae C3
– T6
Insertion
Posterior occipital bone below the superior nuchal line
Action
Extension and lateral flexion of the cervical and
thoracic spine and head
Nerve
Supply
Dorsal primary rami of the spinal nerves C1 – T12
Semispinalis Capitis
• Palpation
• NA as deep to many other
structures
• Key Points
• Often has MTrPs in Whiplash
Associated Disorders
(Ettlin, Schuster et al. 2008)
• Another source of headaches
(Simons, Travel et al. 1999)
Posterior Muscles
Layer 4
Semispinalis Cervicis
(3D4Medical 2013)
Origin
Transverse processes of the vertebrae T1- T6
Insertion
Spinous process of the C2 – C5 vertebrae
Action
Extension and rotation of the cervical and thoracic
spine and head
Nerve
Supply
Dorsal primary rami of the spinal nerves C1 – T12
Semispinalis Cervicis
• Palpation
• NA
• Key Points
• Fatty deposits develop in the deep
cervical extensors in WAD
(Elliott, Jull et al. 2006)
• Change in size in neck pain, although no
consensus whether its an increase or
decrease
• Decrease activation in neck pain
(Schomacher and Falla 2013)
• Activation can be increased by resisting
extension with the hand over the
vertebrae arch of C1
(Schomacher, Erlenwein et
al. 2015)
(Schomacher, Erlenwein et al. 2015)
Multifidus
(Schomacher and Falla 2013)
Origin
Sacrum and the transverse processes of the C2 –
L5 vertebrae
Insertion
Spinous process of the vertebrae superior to their
origins
Action
Extension, ipsilateral flexion and contralateral
rotation
Nerve
Supply
Dorsal primary rami of the spinal nerves C1 – L5
Multifidus
• Palpation
• NA
• Key Points
• Change in size in neck pain, although no consensus whether its an increase or
decrease
• Decrease activation in neck pain
(Schomacher and Falla 2013)
Suboccipital Extensors
Rectus Capitis Posterior Major: Spinous process of the axis (C2)
Rectus Capitis Posterior Minor: Posterior tubercle of the atlas
Origin
Superior Oblique: Transverse process of the atlas (C1)
Inferior Oblique: Spinous process of the axis (C2)
Rectus Capitis Posterior Major: Medial aspect of the inferior
nuchal line of the occipital bone
Rectus Capitis Posterior Minor: Medial aspect of the inferior
nuchal line of the occipital bone
Insertion
Superior Oblique: Superior and inferior aspect of the nuchal line
of the occipital bone
Inferior Oblique: Posterior aspect of the transverse process of
the atlas (C1)
(Anatomography 2013)
Suboccipital Extensors
(Anatomography 2013)
Action
Extension of the head on the neck
Nerve Supply
Posterior primary rami of C1
Suboccipital Extensors
• Palpation
• Supine, cradling the head with both
hands
• Slight upper cervical extension
• Palpate between superior nuchal line
and spinous process of C2
• Deep to trapezius and splenius capitis
• Key Points
• Sub occipitals are more like ligaments
• Source of headaches
(Biondi 2005, Page 2011, Fernandez-de-LasPenas and Courtney 2014)
Summary of the Posterior Structures
• Lots of muscles and layers
• Superficial muscles can alter
scapular mechanics
• Deeper layers can become
hypertonic to protect underlying
joints
• Can be a common source of
headaches
• Deep extensors show decrease
activity in neck pain
Anterior and Lateral Structures
Sternocleidomastoid
(Palastanga, Field et al. 2006)
Origin
Lateral surface of the mastoid process of the
temporal bone
Insertion
Superior anterior surface of the manubrium
sterni and medial clavicle
Action
Ipsilateral flexion, contralateral rotation, flexion
Nerve
Supply
Accessory Nerve (11th Cranial Nerve)
Sternocleidomastoid
• Palpation
• In supine, ipsilateral side flexion,
contralateral rotation. Palpate
between origin and insertion. Ask
client to actively raise head off
bed
• Key Points
• Hypertonicity/spasm can cause
torticollis
Scalenus Anterior
(Palastanga, Field et al. 2006)
Origin
Anterior tubercles of the transverse processes of
C3-6
Insertion
Scalene tubercle on the inner border of the first
rib
Action
Ipsilateral lateral flexion, flexion
Nerve
Supply
Anterior primary rami of C4-6
Scalenus Medius
(Palastanga, Field et al. 2006)
Origin
Transverse process of C1-2 and the posterior
tubercles of C3-7
Insertion
Lateral aspect of the 1st rib behind the
subclavian artery groove
Action
Ipsilateral lateral flexion
Nerve
Supply
Anterior primary rami of C3-8
Scalenus Posterior
(Palastanga, Field et al. 2006)
Origin
Posterior tubercles of the transverse process of
C4-6
Insertion
Outer surface of the 2nd rib posteriorly
Action
Ipsilateral lateral flexion
Nerve
Supply
Anterior primary rami of C6-8
Scalenes
• Palpation
• Anterior
• Palpation lateral border of
sternocleidomastoid at clavicle
• Increase contralateral rotation to move
sternocleidomastoid medially
• Move fingers laterally and resist
ipsilateral side flexion
• Medius
• As above but moving posterolaterally
to anterior
• Posterior
• As above but moving posterolaterally
to medius
Scalenes
• Key Points
• Involvement in breathing due to
rib attachment
• As the brachial plexus passes
through the scalenes it can
become compromised due to
scalene hypertonicity
• This can be one cause of Thoracic
Outlet Syndrome
(Hooper, Denton et al. 2010)
Longus Colli
Origin
Insertion
(Palastanga, Field et al. 2006)
Upper part- anterior tubercles of transverse
processes C3-5
Middle part- anterior bodies of C6-T3
Lower part- anterior bodies of T1-3
Upper part- anterior tubercle of the atlas
Middle part- anterior bodies of C2-4
Lower part- anterior transverse tubercles of
C5-6
Action
Flexion
Nerve
Supply
Anterior primary rami of C3-6
Longus Colli
• Palpation
• NA
• Key Points
• Longus muscle can provide
segmental stability
Muscular Anatomy – Simplified
You should now be able to:
•
•
•
•
List all of the muscles in the cervical spine
Describe their origins, insertions, actions and nerve supply
Explain key points regarding certain muscle groups
Confidently palpate muscles around the cervical spine
This will allow you to:
a) Perform a more specific objective assessment
b) Administer more effective treatment
c) Identify how to rehabilitate certain muscles within exercise programme
Cervical Spine – Simplified
1.
2.
3.
4.
Rule out any Cervical Red Flags
Complete Structured Objective Assessment
Devise a Problem List
Treat:
• Do some talking therapy
• Do some hands on therapy
• Do some exercise therapy
5. Refer on where necessary.
References
•
3D4Medical (2013). Muscle System Pro III. D. M. Limited.
•
Anatomography (2013). Suboccipital muscles. BodyParts3D, Database Center for Life Science.
•
Biondi, D. M. (2005). "Cervicogenic headache: a review of diagnostic and treatment strategies." J Am Osteopath Assoc 105(4 Suppl 2): 16s-22s.
•
Brookbush, B. (2014). "Muscles of the Scapula." Retrieved May, 2014.
•
Drake, R. L., W. Vogl, A. W. M. Mitchell and H. Gray (2010). Gray's Anatomy for Students, Churchill Livingstone/Elsevier.
•
Elliott, J., G. Jull, J. T. Noteboom, R. Darnell, G. Galloway and W. W. Gibbon (2006). "Fatty infiltration in the cervical extensor muscles in persistent whiplash-associated disorders:
a magnetic resonance imaging analysis." Spine (Phila Pa 1976) 31(22): E847-855.
•
Ettlin, T., C. Schuster, R. Stoffel, A. Bruderlin and U. Kischka (2008). "A distinct pattern of myofascial findings in patients after whiplash injury." Arch Phys Med Rehabil 89(7): 12901293.
•
Fernandez-de-Las-Penas, C. and C. A. Courtney (2014). "Clinical reasoning for manual therapy management of tension type and cervicogenic headache." J Man Manip Ther 22(1):
44-50.
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Hansen, J. T. (2009). Netter's Clinical Anatomy, Elsevier Health Sciences.
•
Hooper, T. L., J. Denton, M. K. McGalliard, J. M. Brismee and P. S. Sizer, Jr. (2010). "Thoracic outlet syndrome: a controversial clinical condition. Part 1: anatomy, and clinical
examination/diagnosis." J Man Manip Ther 18(2): 74-83.
•
Page, P. (2011). "CERVICOGENIC HEADACHES: AN EVIDENCE-LED APPROACH TO CLINICAL MANAGEMENT." International Journal of Sports Physical Therapy 6(3): 254-266.
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Palastanga, N., D. Field and R. Soames (2006). Anatomy and Human Movement: Structure and Function, Butterworth Heinmann/Elsevier.
•
Schomacher, J., J. Erlenwein, A. Dieterich, F. Petzke and D. Falla (2015). "Can neck exercises enhance the activation of the semispinalis cervicis relative to the splenius capitis at
specific spinal levels?" Man Ther 20(5): 694-702.
•
Schomacher, J. and D. Falla (2013). "Function and structure of the deep cervical extensor muscles in patients with neck pain." Man Ther 18(5): 360-366.
•
Simons, D. G., J. G. Travell and L. S. Simons (1999). Travell & Simons' Myofascial Pain and Dysfunction: Upper half of body, Williams & Wilkins.