Massage_connection

Chapter 4—Muscular System 227 Iliotibial tract Gastrocnemius, medial head Plantaris Quadratus femoris Gastrocnemius, Biceps Gracilis lateral head femoris Semimembranosus Soleus Fibularis Semitendinosus Tibialis posterior (peronues Sartorius longus) Origin Popliteus Insertion Extensor Tibialis anterior Flexor hallucis longus digitorum longus Flexor digitorum longus Extensor hallucis longus Fibularis (peroneus) brevis Fibularis (peroneus) tertius Fibularis (peroneus) brevis Extensor digitorum brevis Fibularis For tendo calcaneus (peroneus) bursa brevis Fibularis (peroneus) tertius Extensor hallucis brevis Tendo calcaneus (Achilles tendon) Extensor hallucis longus Extensor digitorum longus CD FIGURE 4.34., cont’d Muscles That Move the Leg. C, Bones, Showing Origin and Insertion of Muscle (An- terior View, Dorsal Aspect of Foot); D, Bones, Showing Origin and Insertion of Muscle (Posterior View) Shinsplints Shinsplints is a rather loose term that describes pain in the shin caused by activities such as running. The tugging of the medial border of the tibia by the fascia covering the soleus, gastrocnemius muscles, and other muscles, causes the periosteum to rise up from the bone with resultant inflammation.

Two head of gastrocnemius (cut) Popliteus muscle Gastrocnemius Popliteus Tibialis Peroneus muscle posterior longus A Soleus muscle Tibialis posterior Soleus Gastrocnemius Flexor Flexor Flexor muscle (cut) digitorum hallucis digitorum longus longus longus Achilles Achilles Peroneus Peroneus tendon tendon longus brevis (calcaneal tendon tendon) Calcaneus Peroneus brevis C Calcaneus B D FIGURE 4.35. Muscles That Move the Foot and Toes. A, Posterior View (Superficial Muscles); B, Posterior View (Second Layer); C, Posterior View (Third Layer); D, Posterior View (Deepest Layer) (continued)

Peroneus Tibia Gastrocnemius Patellar ligament longus (lateral head) Gastrocnemius Tibia Tibialis muscle Soleus Gastrocnemius anterior Soleus muscle Extensor Tibialis Soleus Peroneus hallucis anterior Calcaneal tendon brevis longus Tibialis anterior Peroneus Flexor digitorum Extensor Superior Inferior longus longus tendon digitorum extensor extensor Flexor hallucis retinaculum retinaculum Peroneus longus tendon longus brevis Flexor reticulum Tibialis anterior Extensor Extensor tendon hallucis digitorum longus longus E Calcaneal tendon Inferior extensor retinaculum FG Chapter 4—Muscular System H FIGURE 4.35., cont’d Muscles That Move the Foot and Toes. E, Anterior View (Superficial); F, Anterior View (Deep); G, Lateral View; H, Medial View 229

230 The Massage Connection: Anatomy and Physiology “Tom, Dick, and Harry” Muscles Adductor and Iliopsoas Strains The tendon of the tibialis posterior crosses the ankle and midtarsal joints with the tendon of the flexor digitorum These strains occur in the belly of adductor longus or ad- longus and the flexor hallucis longus and functions with ductor magnus and are a result of forced abduction or re- them at these joints. These three muscles are often re- sisted adduction. It is a common injury in football. ferred to as the Tom, Dick, and Harry muscles. Tom for tibialis posterior; Dick for flexor digitorum longus; and Injury to the iliopsoas muscle is commonly referred to Harry for flexor hallucis longus. as a groin strain. Because the belly of psoas major ex- tends up to its attachments into the transverse process of the lumbar vertebra, a strain here may result in abdomi- nal pain and tenderness on deep palpation. Tendon of Extensor Lumbricales peroneus brevis retinaculum Abductor hallucis Lateral malleolus of fibula Tendon of Extensor tibialis anterior digitorum longus tendons Tendon of Flexor digitorum extensor brevis Extensor hallucis longus digitorum brevis Abductor A hallucis Lumbricales Abductor digiti minimi Flexor B digitorum longus Hallucis longus Quadratus plantae Flexor hallucis C brevis FIGURE 4.36. Intrinsic Muscles of the Toes. A, Dorsal View; B, Plantar View; C, Planter View (Deep Layer)

Chapter 4—Muscular System 231 An Overview of Lower Limb Innervation tenosynovitis, and low back pain. It reduces swelling, increases blood flow, relieves pain and muscle spasm, The muscles of the lower limb are innervated by and mobilizes fibrous tissue, and also improves mus- nerves that arise from the lumbar (with contribution cle action and induces a state of general relaxation. from T12, L1–L4) and sacral (L4–L5, S1–S3) segments Early institution of massage not only decreases pain of the spinal cord. These nerves initially form a net- but also accelerates the rate of functional recovery. work known as the lumbosacral plexus (see page 328). Of the many nerves that arise from this plexus The gradual compression produced by strokes (see Figure 4.37), the sciatic nerve (L4–L5, S1–S3) is such as effleurage reduces muscle tone and induces a the largest (it is the largest nerve in the body). The sci- general state of relaxation that relieves muscle atic nerve, with its two main divisions—tibial and spasm.7 The relaxation is produced by the localized common peroneal nerves—supplies the skin of most stretch effect that lengthens sarcomeres in the imme- of the leg and foot, muscles of the posterior thigh, and diate vicinity of the applied pressure. Strokes that in- all the muscles of the leg and foot. volve application of firm pressure accelerate blood and lymph flow and improve tissue drainage. Knead- Muscular System and Aging ing promotes the flow of tissue fluid and causes reflex vasodilation and marked hyperemia; this reduces The slower movement, weakness, and altered physi- swelling and helps resolve inflammation. Vigorous cal appearance are largely a result of changes in the kneading decreases muscle spasm and can stretch tis- muscular and skeletal system.1 sues shortened by injury. Petrissage is particularly useful for stretching contracted or adherent fibrous With age, the muscles decrease in size as a result tissue and will relieve muscle spasm. Acting deeper of loss of muscle fibers and atrophy of individual than kneading, petrissage also promotes the flow of muscle fibers. There is also a loss of motor units. body fluids and resolves long-standing swelling. Sub- There is greater loss of fast twitch fibers, partly a re- stances released by ischemic tissue that sensitize sult of aging and partly a result of disuse. The vascu- pain receptors are also dispersed, relieving pain. Fric- larity decreases and more fat is deposited in the mus- tion massage2 breaks down scars and prevents scar cle. The atrophied muscles are replaced with fibrous tissue from matting muscle fibers together. tissue, reducing elasticity. Changes in muscle, as well as the nervous system, slow movement and decrease Postexercise effleurage reduces subsequent muscle strength and endurance. The rate of loss of strength soreness by rapidly reducing lactate concentration in and endurance can be significantly reduced by resis- the muscle cells. This has been shown to be a more tance exercise. Changes in the vertebral column, stiff- effective treatment than either rest or a conventional ening of ligaments and joints, and hardening of ten- active warm-down program.8-11 Massage can also be dons result in mild flexion of the vertebrae, hips, used to prevent denervated muscle from losing both knees, elbows, wrists, and neck. bulk and contractile capability, assisting subsequent rehabilitation.12 Massage has been successfully used The changes in muscle function may be partly at- for prevention of delayed-onset muscle soreness13 tributed to effects of age on the nervous system. The and as an adjuvant therapy for conditions such as extrapyramidal system (see page 361) is impaired and carpal tunnel syndrome,14 low back pain (not involv- this results in mild tremors at rest. There is a decline ing nervous dysfunction),15-17 and joint sprains.18 in the number of spinal cord axons and in nerve con- duction velocity. Voluntary responses that involve re- Heat is often used during massage.19 Local heat action and/or movement are slower; however, the de- can be applied by immersion in hot water, hot towels, cline is less in those who maintain an active lifestyle. paraffin wax baths, electrically heated pads, infrared lamps, or infrared lasers. The latter have the capacity Muscular System and Massage to penetrate deep tissue. Heat causes local vasodila- tion, increased cell metabolism, pain relief, relax- Most of the therapist’s work is likely to be related to ation of muscle spasm, increased range of motion, the muscular system. There are too many muscle-re- and decreased stiffness.19 Some of the effects of heat lated problems, however, and they cannot all be dis- on deeper structures is believed to be a result of reflex cussed in this section. mechanisms. By stimulating other afferent fibers, heat reduces the number of impulses carried to the Massage is beneficial in treating many muscu- brain by pain fibers (gate-control theory).19,20 Muscle loskeletal problems,2-6 such as tendinitis, sprain, relaxation may be produced by a reduction of gamma motor neuron and alpha motor neuron activity.19 Heat also increases the extensibility of collagen. By increasing blood flow, it speeds the removal of pain- causing substances. Before the application of heat,

232 The Massage Connection: Anatomy and Physiology Lumbar plexus L1 Obturator N. (cut) Psoas minor L1 Femoral N. (cut) Psoas major L2 Sup. gluteal N. Femoral N. L2 Gluteus med. Iliacus Gluteus min. L3 Ten. fas. latae Pectineus L3 Sartorius Inf. gluteal N. L4 Gluteus max. Rectus femoris L4 Vast. med. Peroneal N. Vast. lat. L5 (See ant. view) Vast. inter. L5 Tibial N. Vastus med. Obturator N. Sacral plexus Plantaris Piriformis Gastrocnemius Superficial (Pectineus) Popliteus peroneal N. Obturator ext. Gemellus sup. Soleus Peroneus long. Obturator int. Tibialis post. Add. brevis Gemellus inf. Flex. digit. I. Peroneus brev. Add. longus Quad. fem. Flex. hall. I. Add. magnus Sciatic N. Gracilis Biceps, l.h. Semitendin. Add. magnus Semimembran. Biceps, s.h. Green: Peripheral nerves and posterior divisions from which they arise. Yellow: Peripheral nerves and anterior divisions from which they arise. Deep peroneal N. Tibialis anterior Ext. hall. longus Tibialis anterior Ext. digit. longus Peroneus tertius Ext. digit. brevis Medial plantar N. Lateral plantar N. Flex. dig. brev. Abd. dig. min. Lateral plantar N. Abd. hallucis Quad. plantae Dorsal interossei Flex. dig. min. Flex. hall. brev. Opp. dig. min. Lumbricalis l Add. hall. obl. Plantar interossei Lumb. II, III, IV Add. hall. trans. A B Dorsal interossei (see dorsum) FIGURE 4.37. Nerves to the Lower Limb. A, Motor Supply (Anterior View); B, Motor Supply (Posterior View) (continued)

Chapter 4—Muscular System 233 Subcostal Ilioinguinal nerve Iliohypogastric nerve (T12) (L1) Sacral nerve nerve (T12) Genitofemoral nerve (L1, L2) (S1, S2, S3) Lumbar nerve (L1, L2, L3) Lateral femoral cutaneous nerve Lateral femoral (L2, L3) cutaneous nerve (L2, L3) Anterior femoral cutaneous nerve Obturator nerve (L2, L3) L2, L3 Posterior femoral cutaneous nerve (S1, S2, S3) Medial antebrachial L4, L5, S1 cutaneous nerve, (C8, T1) Common peroneal Saphenous nerve nerve (L5, S1, S2) (L3, L4) Sural nerve (S1, S2) Superficial peroneal Tibial nerve nerve (L4, L5, S1) (S1, S2) Sural nerve Deep peroneal nerve Medial plantar Lateral plantar nerve (S1, S2) (L4, L5) (L4, L5) (S1, S2) C D FIGURE 4.37., cont’d Nerves to the Lower Limb. C, Sensory Supply (Anterior View); D, Sensory supply (Posterior View) therapists must ensure that the client has normal (55–65°F), and very cold if it is below 12.8°C (55°F). temperature and pain perception to determine a safe Substances may be used in solid forms (ice, carbon level of heat. Therapists should also make sure that dioxide, snow), liquid forms (water), or gaseous forms the local circulation is not impaired. Deep heat (e.g., (ethyl chloride, alcohol, ether; they extract heat dur- infrared, ultrasound) should be avoided in areas that ing evaporation) for eliciting cold sensations. contain large amounts of fluid, such as the eye, joints, and acutely inflamed tissue because high thermal en- Although it sounds unappealing, application of ergy can build up. Deep heat should also be avoided cold (cryotherapy) is a more effective way of produc- over tissue containing metallic objects. ing deep vasodilation than heat. Application of cold also has a pain-relieving effect and reduces muscle Cold may also be used therapeutically.21 The term spasm.22 Cooling produces analgesia by reducing the cold refers to removal of heat (i.e., one feels a sensa- rate of conduction through nerves. When the skin is tion of cold if the temperature is lower than that of cooled, it initially causes local vasoconstriction; how- the body area to which it is applied). The temperature ever, after 5 to 10 minutes, the blood flow through su- is described as tepid if it is 26.7–33.9°C (80–93°F); cool perficial and deep tissue increases and then oscillates. if it is 18.3–26.7°C (65–80°F); cold if it is 12.8–18.3°C The increased blood flow raises the temperature and

234 The Massage Connection: Anatomy and Physiology improves tissue nutrition. Ice applied for short peri- Trigger points are locations in tissue that are hy- ods causes vasoconstriction and reduces bleeding. persensitive and painful when compressed. Thera- Prolonged application will cause vasodilation by tis- peutic work on trigger points of various muscles24 sue injury and increase tissue hemorrhage. Melting seems to have a positive outcome, and it is worth- ice is the most effective way to chill the skin. while to master the techniques needed to identify and treat these regions. The therapist must remember that muscle is made up of different kinds of tissue. Although the bulk of the Many problems related to muscle may be a result muscle is muscle tissue, the tension produced in the of the occupation of the client or a result of bad pos- muscle is transmitted to the bone via connective tissue ture. An important element of therapy should be in the form of fascia, tendons, and aponeurosis. The proper history taking and physical assessment. De- pressure, stretching, friction, and movement exerted tails of occupation and work-related stresses and during a therapeutic session can make this connective strains that may be the cause of the ailment should tissue more pliable and have a beneficial effect. be obtained, and client education and strategies should be planned accordingly. All connective tissue exhibits thixotropy.23 This is the property by which connective tissue becomes Lastly, but most importantly, the therapist should more fluid and pliable when exposed to heat, friction, ensure that the techniques and posture used by them- and/or movement and becomes more solid when ex- selves during a massage are ergonomically healthy in posed to cold and/or is unused. This inherent prop- order to prevent problems such as musculotendinous erty is a result of the ground substance and collagen, and nerve impingement injuries.25 elastic, and reticular fibers it is made of. The applica- tion of heat and cold in therapy capitalizes on this REFERENCES property of connective tissue. 1. Kenney RA. Physiology of Aging: A Synopsis. 2 Ed. Chicago: As in any tissue, when injury occurs, it is followed Year Book Medical, 1989. by inflammation and healing. While healing, the con- nective tissue fibers/fascia of adjacent muscles may 2. Chamberlain GJ. Cyriax’s friction massage: A review. J Or- adhere (stick) to each other. These adhesions, other thoped Sports Physic Ther 1982;4:16–22. than restricting movement of muscle, may trap nerves and blood vessels supplying the muscle, pro- 3. Clews W. Effects of massage in athletes with rotator cuff ten- ducing further complications. Appropriate applica- dinitis. 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236 The Massage Connection: Anatomy and Physiology Wu L, Jin Y. Application of finger pressure to ankle sprains. J Trad 4. The connective tissue that surrounds the most Chin Med 1993;13(4):299–302. muscle tissue is A. endomysium. Yackzan L, Adams C, Francis KT. The effects of ice massage on de- B. perimysium. layed muscle soreness. Am J Sports Med 1984;12:159–165. C. epimysium. Yang Z, Hong J. Investigation on analgesic mechanism of acupunc- 5. Of the following, the smallest structure is the ture finger-pressure massage on lumbago. J Trad Chin Med A. myofibril. 1994;14(1):35–40. B. muscle fascicle. C. myofilament. Ylinen J, Cash M. Sports Massage. London: Stanley Paul, 1988. D. muscle fiber. Yu C. 55 cases of lumbar muscle strain treated by massage. Intern 6. If the motor nerve to a muscle is injured, the J Clin Acupuncture 1999;10(2):189–190. muscle Yurtkuran M, Kocagil T. TENS, electroacupuncture and ice mas- A. loses tone. B. atrophies. sage: comparison of treatment for osteoarthritis of the knee. C. hypertrophies. Am J Acupuncture 1999;27(3-4):133–140. D. A and B are correct. Zelikovski A, Kaye C, Fink G, et al. The effects of the modified in- E. A and C are correct. termittent sequential pneumatic device (MISPD) on exercise performance following an exhaustive exercise bout. Br J Sport 7. When muscle length is 75% of optimal, the force Med 1993;27:255–259. of the muscle contraction would be A. maximal. Review Questions B. less than maximal. Multiple Choice 8. The cause of staircase phenomenon can be ex- Choose the best answer to the following questions: plained by A. availability of calcium in the sarcoplasm. 1. A motor unit consists of B. a more rapid action potential. A. a skeletal muscle and all of its supplying C. an increased number of acetylcholine neurons. receptors. B. a nerve and all of the skeletal muscles sup- D. more myofibrils. plied by the nerve. C. a neuron and all of the skeletal muscle fibers 9. During aerobic metabolism, a molecule of glu- that it stimulates. D. all of the skeletal muscles that accomplish a cose can yield ATP. single movement. A. 2 2. Consider the list of actions below. Which would classify as isotonic contractions? B. 36 A. Pushing against a stationary wall B. Chewing gum C. 30 C. Writing a letter D. B and C D. 40 E. All of the above 10. Paralysis of which of the following would make 3. During moderate levels of exercise, the process an individual unable to flex her knee? that provides the richest supply of ATP for mus- A. Hamstrings cle contraction is B. Gluteal muscles A. the use of creatine phosphate. C. Soleus B. anaerobic glycolysis. D. Gastrocnemius C. aerobic respiration. E. Quadriceps D. the use of ATP storage in muscle.

Chapter 4—Muscular System 237 Fill-In Complete the following: a. The following table compares the characteristics of skeletal, cardiac, and smooth muscle. Fill in the empty cells. Characteristics Skeletal Cardiac Smooth Striations (yes, no) Intercalated disks Appearance (cylindrical, branched, fusiform) Innervation (motor neuron, autonomic nerves) Location (attached to skeleton, etc.) Control (voluntary, involuntary) Complete the following: b. The following table compares the characteristics of fast twitch, slow twitch, and intermediate muscle fibers. Fill in the empty cells. Characteristics Fast Twitch Slow Twitch Intermediate Diameter (e.g., large) Glycogen content (e.g., large) Number of mitochondria Color Primary type of metabolism (aerobic, anaerobic) Capillaries (abundant, few) Myoglobin content

238 The Massage Connection: Anatomy and Physiology c. m. ADP and P are released when the myosin head pivots 1. One substance in muscle that stores oxygen un- til oxygen is needed by mitochondria is e. Name one or more muscle that is used to produce . the following actions: 2. During exercise lasting longer than 10 minutes, 1. To turn the palm so that it faces forward more than 90% of ATP is provided by the (aerobic, anaerobic) break- 2. To bend the elbow to touch the tip of the shoul- down of pyruvic acid. der 3. In general, (red, white) fibers 3. To flex the hip joint 4. To stand up tall (extend the vertebral column) are more suited for endurance exercise than for short bursts of energy. d. Arrange the following steps involved in muscle , 5. To breathe in contraction in the correct sequence. , 6. To plantar flex ,,,, True–False ,,,, (Answer the following questions T, for true; or ,,. F, for false): A Summary of the Steps Involved in Muscle Contraction a. Muscle spindles are spindle-shaped smooth muscles. a. This potential change is communicated directly into the sarcoplasm via the T tubules b. The Golgi tendon organ is a sensory receptor. b. ACh binds to ACh receptors on the sarcolemma c. Smooth muscles are found in respiratory and this results in opening of sodium channels bronchi. c. Action potentials or impulses from the central d. A second-class lever is the most common muscle nervous system come down the nerve axon of arrangement. the motor nerve when movement must occur e. The muscle fibers of the sartorius are bipennate. d. The rush of sodium into the sarcoplasm causes the inside of the cell to become positive as com- f. Oxygen debt is the amount of oxygen required pared to the outside to bring the muscle to its pre-exertion level. e. ATP provides the energy for the bound myosin g. The wheelbarrow is an example of a second- head to pivot towards the M line class lever. f. The cycle continues and the muscle fiber short- h. The hamstrings antagonize the action of ens as long as calcium is bound to troponin quadriceps. g. Calcium binds to troponin i. The peroneus longus, tibialis major, gracilis, and sartorius are all muscles located in the lower h. The impulse, on arriving at the myoneural junc- limb. tion, causes the ACh vesicles to fuse with the nerve cell membrane and release its contents j. The trapezius, pectoralis minor, teres minor, del- into the synaptic cleft toid, and sternocleidomastoid are all attached to the scapula. i. The sarcoplasmic reticulum releases calcium into the sarcoplasm as a result of the potential Matching change a. Match the following muscles that move the shoul- j. Myosin binds to the uncovered active site on actin der girdle with their actions: k. Binding of calcium to troponin causes troponin 1. _____ levator scapulae a. elevates to shift tropomyosin and uncover the active site 2. _____ serratus anterior b. depresses for myosin on the actin 3. _____ rhomboideus major c. abducts d. adducts l. Attachment of another ATP to the bound myosin and minor head causes it to release from the actin and bind 4. _____ pectoralis minor to another molecule of actin 5. _____ trapezius

Chapter 4—Muscular System 239 b. Match the following muscles that move the iotherapist. The massage therapist decides to as- humerus with their actions: sess the shoulder of the client. A. What muscles are involved with movements 1. _____ pectoralis major a. abducts arm; flexes arm (ante- of the shoulder joint? 2. _____ deltoid rior fascicles) B. What are their origins, insertions, and actions? 3. _____ latissimus dorsi b. flexes; adducts; b. A therapist working at a sports clinic marvels at medially rotates the differences between the bodies of athletes involved in short-distance running and those c. extends; adducts; running marathons. medially rotates A. What is the difference in the structure of the muscles of these two groups of athletes? c. Match the following muscles that move the forearm B. How do muscles primarily obtain energy for with their actions: each of their activities? C. What are the factors that affect recovery of 1. _____ brachialis a. flexes and muscle in general? supinates D. What is muscle fatigue? 2. _____ biceps brachii forearm E. What are the different types of muscle fibers? 3. _____ triceps brachii 4. _____ flexor carpi radialis b. flexes forearm c. Some clients at the sports clinic are in wheel- c. flexes palm; chairs. The therapist noticed a dramatic differ- ence between the well-developed, hypertrophied, abducts palm firm muscles of the upper limb and the hardly d. extends forearm discernible muscles of the lower limb of some of the athletes with spinal cord injury. d. Match the following terms with their meaning: A. Why is there a difference in the muscles of the upper and lower limb? 1. _____ psoas a. in the wrist B. How do muscles contract? What are the 2. _____ deltoid b. loin region steps involved in muscle contraction? 3. _____ serratus c. groin region C. What is the role of nerves in the contraction 4. _____ carpi d. thumb of muscle? 5. _____ rectus e. saw-toothed D. What are the factors that affect muscle con- traction? 6. _____ inguinal appearance E. What is meant by atrophy, hypertrophy, and f. shaped like a spasticity? 7. _____ latissimus F. What is a motor unit? 8. _____ nuchal triangle G. What is the structure of a myoneural junction? 9. _____ pollicis g. big toe h. back of the neck 10. _____ hallucis i. parallel direction of muscle fascicles j. widest Short Answer Questions Answers to Review Questions 1. What are the effects of physical training on the cardiovascular system? Multiple Choice 2. What are the changes that occur in the skeletal muscle with aging? 1. C 3. What are the causes of muscle fatigue? 2. D 4. What are the factors that affect speed, direction, 3. C and force of contraction of muscle? 4. C 5. C Case Studies 6. D 7. B a. Mary is a 15-year-old swimmer, aspiring to reach 8. A the Olympics. She has been diagnosed with 9. B shoulder impingement syndrome and has been 10. A referred to a massage therapist and a local phys-

240 The Massage Connection: Anatomy and Physiology Fill-In Skeletal Cardiac Smooth a. Yes Yes No Yes No Characteristics Branched Fusiform Autonomic Autonomic Striations (yes, no) Around Heart Blood vessels; Involuntary bronchi; gut, etc. Intercalated disks No Involuntary Slow Twitch Appearance (cylindrical, Cylindrical Small Intermediate branched, fusiform) Motor neuron Small Intermediate Attached to skeleton Numerous Intermediate Innervation (motor neuron, Voluntary Red Some autonomic nerves) Aerobic Pale Abundant Both Location (attached to Large amounts Intermediate skeleton, etc.) Less Control (voluntary, involuntary) b. Fast Twitch Large Characteristics Large Diameter (e.g., large) Few Pale Glycogen content (e.g., large) Anaerobic Few Number of mitochondria Less Color Primary type of metabolism (aerobic, anaerobic) Capillaries (abundant, few) Myoglobin content c. e. 1. myoglobin 1. supinator 2. aerobic 2. biceps brachii 3. red 3. psoas major 4. erector spinae d. c; h; b; d; a; i; g; k; j; e; m; l; f 5. diaphragm 6. gastrocnemius

Chapter 4—Muscular System 241 True–False Case Studies a. false, they have skeletal muscle fibers. a. see Chapter Appendix Table 4.8 b. true b. see pages: c. true d. false, third class is most common. A. 195 (fast fibers/slow fibers) e. false B. See figure 4.16 f. true C. 193 (muscle recovery) g. true D. 194 (muscle fatigue) h. true E. 195 i. true c. see pages: j. false (sternocleidomastoid is not) A. 197 (hypertrophy), upper limb Matching 200 (atrophy), lower limb B. 181 (box: a summary of the steps involved in a. 1. a; 2. c; 3. d; 4. b; 5. a, b or d (depending on position) muscle contraction) b. 1. b; 2. a; 3. c C. 181 (excitation contraction-coupling) c. 1. b; 2. a; 3. d ; 4. c D. 184 (sentence: some factors that affect . . . ) d. 1. b; 2. f; 3. e; 4. a; 5. i; 6. c; 7. j; 8. h; 9. d; 10. g E. 200 (atrophy); 197 (hypertrophy); Short-Answer Questions 194 (spasticity) F. a motor neuron and all the muscle fiber it 1. see page 197 2. see page 231 innerates 3. see page 194 G. See figure 4.5 4. see page 184

Coloring Exercise Label the structures in the given diagrams, and color the structures, using the color code. a. In the diagram of a muscle fiber, label the marked structures. Using the color code, color the sarcoplasmic reticulum blue; t tubule pink; sarcoplasm yellow; myofibrils brown; mitochondria red and nucleus black. b. In the myoneural junction diagram, label the structures indicated. Color the nerve ending yellow and the muscle fiber brown, the synaptic cleft orange, and the acetylcholine vesicles purple. Outline the sarcolemma of the motor endplate in black.

Chapter 4—Muscular System 243 c. The following is a diagram of the scapula and humerus (anterior and posterior view). Shade the scapula yellow and the humerus orange. For the following muscles: Label the origins on the scapula: supraspinatus; infraspinatus; teres minor, teres major, deltoid; subscapu- laris, coracobrachialis; biceps brachii; triceps brachii (long head); deltoid Label the insertions on the scapula: trapezius, levator scapulae, rhomboideus minor, rhomboideus major, serratus anterior, pectoralis minor Label the insertions on the humerus: supraspinatus, infraspinatus, teres minor; deltoid. Shade all origins red and all insertions blue.

244 The Massage Connection: Anatomy and Physiology d. The following is a diagram of the arm (anterior and posterior views). Shade the humerus yellow; the ulna orange; and radius green. Label the origins: On the humerus: brachialis; brachioradialis; pronator teres On the radius: pronator teres On the ulna: pronator quadratus Label the insertions: On the humerus: coracobrachialis; teres major; pectoralis major; deltoid; latissimus dorsi; subscapularis; supraspinatus On the radius: biceps brachii; pronator teres; pronator quadratus; brachioradialis On the ulna: brachialis Shade the origins in red and the insertions in blue.

Chapter 4—Muscular System 245 e. The following is a diagram of the femur; and leg (anterior and posterior views). Shade the femur green; the tibia purple; and the fibula pink Label the origins: On the tibia: tibialis anterior On the fibula: extensor digitorum longus; extensor hallucis longus Label the insertion: On the tibia: semimembranosus; sartorius; patellar tendon; gracilis; semitendinosus On the fibula: biceps femoris. Shade the origins in red and the insertions in blue.

Table 4.1 Muscles Responsible for Facial Expressions Name Origin Insertion Action Nerve Supply VII Muscles in the cheek and lip region VII Orbicularis oris Alveolar border of maxillae Lips; most fibers into the Constricts the opening of VII and mandible; muscle deep surface of the skin the mouth; protrusion VII fibers of other muscles and mucous membrane; of the lips VII surrounding the mouth becomes continuous with VII muscles that insert into the VII lips VII VII Buccinator Alveolar processes of maxil- Skin and mucosa of the lips; Compresses cheek VII lae and mandible VII blends with orbicularis oris against teeth VII Depressor labii Mandible Skin of lower lip; blends with Depresses lip muscle fibers of lip VII VII Levator labii Maxillae Skin and muscle of upper lip Raises upper lip VII Mentalis Mandible Skin of chin Protrudes and raises lower lip Depressor anguli oris Anterolateral surface of Angle of mouth Depresses the angle of mandible the mouth Risorius Connective tissue around Angle of mouth Draws corner of mouth angle of mandible to the side Zygomaticus (major Zygomatic bone Angle of mouth; blends with Draws the corner of the and minor) muscle fibers of lip mouth back and up Depressor septi Maxilla superior to the cen- Nasal septum Widens the nasal opening tral incisor tooth Muscle in the eye region Orbicularis oculi Medial margin of orbit Skin around eyelid Closes eye (6 other muscles move the eyeball, which originate from the bones of the orbit and insert on the eyeball) Muscle in the nose region Nasalis (transverse and Maxilla Bridge of nose; corners of Compresses the bridge alar) nose and narrows the nasal opening (transverse); elevates corners and widens the nasal open- ing (alar) Muscles in the scalp region Occipitofrontalis (has Epicranial aponeurosis Skin of eyebrow and bridge Raises eyebrows; wrinkles two bellies; frontal (sheet of connective tissue of nose—frontal belly forehead transversely— and occipital) running over the scalp)— frontal belly frontal belly; Epicranial aponeurosis— occipital belly Pulls scalp posteriorly— Superior nuchal line of oc- occipital belly cipital bone and mastoid process of temporal bone—occipital belly Corrugator supercilii Medial end of the supercil- Skin above the supraorbital Draws the eyebrows to- iary arch of frontal bone margin (eyebrow) gether, resulting in ver- tical wrinkles in fore- head Procerus Fascia covering the inferior Skin over the inferior aspect Draws medial angle of part of the nasal bone and of the forehead, between the eyebrow inferiorly the superior portion of the eyebrows to wrinkle skin trans- the lateral nasal cartilage versely over the bridge of nose Muscle in the neck region Platysma Acromion of scapula and Inferior border of mandible; Tenses skin of neck; de- fascia covering the supe- skin and muscles of cheek; presses mandible; de- rior part of pectoralis ma- corner of mouth and lat- presses corner of jor and deltoid muscles eral half of lower lip mouth and lower lip (i.e., upper part of chest)

Chapter 4—Muscular System 247 Table 4.2 Muscles of Mastication Name Origin Insertion Action Nerve Supply Lateral surface of mandibu- V Masseter Maxilla and zygomatic arch Elevates mandible lar ramus; coronoid (clenches teeth); pro- V Temporalis Along the temple (frontal, process of the mandible traction (superficial V Medial Pterygoid parietal, and temporal fibers) and retraction V Lateral Pterygoid bones) Coronoid process and ramus of mandible; minimal Suprahyoid muscles of mandible side-to-side movement V, VII Digastric Medial surface of lateral pterygoid plate of the Elevates and retracts VII Stylohyoid sphenoid bone; maxilla mandible V Mylohyoid Lateral surface of greater Medial surface of mandibular Elevates, protracts, and XII wing of sphenoid bone ramus and angle moves mandible from side to side Posterior belly: mastoid Condyle of mandible and process of the temporal temporomandibular joint Depresses jaw; protracts; bone moves mandible from side to side Anterior belly: base of the mandible, near midline Hyoid bone (The muscle Depresses mandible; ele- passes through a fibrous vates hyoid bone Styloid process of the tem- loop attached to the hyoid poral bone bone that changes the Elevates and retracts hy- course of the muscle.) oid bone Mandible Body of the hyoid bone Depresses mandible; ele- Geniohyoid Posterior aspect of the mid- vates the floor of dle of mandible Body of hyoid bone; connec- mouth and hyoid bone tive tissue (median fibrous raphe) from the middle of Elevates and protracts the mandible to the hyoid hyoid bone; depresses bone the mandible Anterior aspect of body of the hyoid bone

248 The Massage Connection: Anatomy and Physiology Table 4.3 Muscles in the Anterior Aspect of Neck Name Origin Insertion Action Nerve Supply XI (spinal); Sternocleidomastoid Superior margin of sternum Mastoid process of temporal If acting bilaterally: Flexes (sternal head) and medial bone the neck; draws head C2–C3 aspect of clavicle (clavicu- anteriorly and elevates lar head) chin; anterior: Bilaterally with inser- C4–C6 Scalenes (anterior, Transverse process of cervi- Superior surface of first two tion fixed: Draws ster- medius, and cal vertebrae ribs num superiorly during medius: posterior) deep inspiration; C3–C8 Unilaterally: Rotates head to opposite side; posterior: laterally flexes neck C6–C8 Flexes neck; ipsilateral C2–C7 neck lateral flexion; contralateral neck rota- C1–C3 tion; elevates the ribs C2–C3 Longus colli (inferior Inferior oblique: Anterior as- Inferior oblique: Anterior as- Flexes neck; contralateral oblique, superior pect of the bodies of pect of transverse neck rotation oblique, and vertical) T1–T3; processes of C5–C6; Superior oblique: Transverse Superior oblique: Anterior processes of C3–C6; arch of the atlas Vertical: Bodies of T1–T3 Vertical: Bodies of T1–T3 and and C5–C7 C5–C7 Longus capitis Transverse processes of Inferior surface of the occipi- Flexes head C3–C6 tal bone anterior to the foramen magnum Rectus capitis (anterior Anterior and superior as- Inferior surface of the basilar Flexes head; ipsilateral aspect of the occipital bone lateral flexion of the and lateralis) pect of the atlas (anterior to the occipital head (lateralis) condyle) The scalenes and sternocleidomastoid are brought into action in people with breathing difficulties (e.g., asthmatics).

Chapter 4—Muscular System 249 Table 4.4 Muscles in the Posterior Aspect of Neck Name Origin Insertion Action Nerve Supply Occipital bone (between infe- C2–T1 Semispinalis capitis Transverse processes of Bilaterally: Extends head; C2–T5 lower and upper thoracic rior and superior nuchal Unilaterally: Extends Capitis: C3–C6 vertebra line) and tilts head to one side C4–C8 Semispinalis cervicis Transverse processes of up- Spinous processes of C2–C5 per thoracic spine Extends vertebral col- C3–C8 Mastoid process of temporal umn; rotates to oppo- C3–T6 Splenius capitis Spinous processes of 7th bone and lateral part of su- site side C3–C5 Splenius cervicis cervical, upper three or perior nuchal line of occip- four thoracic vertebrae, ital bone Bilaterally: Extends head; C1 and lower part of liga- Unilaterally: Tilts and C1 mentum nuchae Transverse processes of rotates head to same C1–C3 side Spinous process of T3–T6 Mastoid process of temporal Bilaterally: Extends or hy- Longissimus capitis Articular processes of bone perextends head and (considered part of C5–C7 and transverse neck; Unilaterally: Lat- erector spinae) processes of T1–T5 Transverse processes C2–C6 erally flexes and rotates head and neck Longissimus cervicis Transverse processes of Superior part of medial bor- (considered part of T1–T5 der of scapula Bilaterally: Extends neck; erector spinae) Unilaterally: Rotates Transverse processes of On and close to inferior head to side Levator scapulae C1–C4 nuchal line Bilaterally: Extends neck, Rectus capitis posterior Spinous process of axis Superior: Occipital bone be- Unilaterally: Rotates (major and minor) (major); posterior arch of tween superior and inferior head to side the atlas (minor) nuchal line; Obliquus capitis (supe- Unilaterally: Elevates and rior and inferior) Superior: Transverse process Inferior: Posterior aspect of adducts scapula; ro- of atlas transverse process of atlas tates scapula (glenoid faces down); Inferior: Spine and lamina Laterally flexes neck to of axis same side and rotates neck to same side; Bi- laterally: Extends neck Extends head; rotates head ipsilaterally Rotates head ipsilaterally; extends head; lateral flexion

250 The Massage Connection: Anatomy and Physiology Table 4.5 Muscles of the Spine Name Origin Insertion Action Nerve Supply Superficial muscles (extensors of spine): made up of the spinalis, longissimus, and iliocostalis groups. Spinalis Group Semispinalis thoracis Transverse processes of Spinous processes of C5–T4 Extends and rotates ver- Thoracic spinal T6–T10 tebral column nerves Spinalis thoracis Spinous processes of Spinous processes of T1–T8 Extends and rotates ver- Lower cervical T11–L2 tebral column and thoracic spinal nerves Longissimus Group Broad sheet of connective Inferior surface of ribs and Extends spine; bends Longissimus thoracis tissue and transverse transverse process of up- spine to same side; de- Lower cervical process of lower thoracic per thoracic vertebrae presses ribs thoracic and (includes longissimus and upper lumbar verte- lumbar spinal capitis and cervicis, brae; with iliocostalis, Angles of upper ribs and Stabilizes thoracic verte- nerves described in Table 4.4) forms sacrospinalis transverse process of last brae during extension; cervical vertebra extends and laterally T7–L2 Iliocostalis Group Medial aspect of the supe- flexes vertebrae Iliocostalis thoracis rior border of lower 7 ribs Inferior surface of angles of T7–L2 lower 7 ribs Extends spine; laterally Iliocostalis lumborum Medial part of iliac crest flexes vertebral col- Dorsal rami of and sacrospinal aponeu- Spinous process of verte- umn, rotates ribs the spinal rosis bra, located about five nerves vertebrae above origin Extends and rotates ver- Deep muscles (extensors of spine) tebrae Dorsal rami of Spinous process of vertebra the spinal Multifidus Sacrum and transverse above origin Extends and rotates ver- nerves process of each vertebra tebrae Dorsal rami of Rotatores Transverse process of each the spinal vertebra nerves Interspinales Spinous processes of each Spinous process of vertebra Extends vertebral column Dorsal and ven- vertebra above origin tral rami of the spinal nerves Intertransversarii Transverse process of each Transverse process of verte- Bends vertebral column vertebra T2, L1–L4 bra above origin laterally Muscles of spine (flexor of spine) 12th rib and transverse Flexes spine; depresses Quadratus lumborum Iliac crest process of L1–L4 ribs; assists in exten- sion; Bilaterally: With the diaphragm fixes the last two ribs during ex- piration; With insertion fixed: Elevates pelvis

Table 4.6 Muscles of the Abdomen Name Origin Insertion Action Nerve Supply Linea alba and anterior part T6–T12 External Lower 8 ribs Bilaterally: Flexes vertebral column; tilts oblique of iliac crest pelvis posteriorly; supports and com- T6–T12, L1 presses the abdominal viscera; de- Internal Thoracolumbar fascia; il- Cartilage of lower 3–4 ribs; presses thorax and assists with respi- T6–T12, L1 oblique iac crest; lateral half of xiphoid process; linea alba ration; T5–T12 inguinal ligament Unilaterally: Depresses ribs; Linea alba and pubis; iliac Laterally flexes the vertebral column Transversus Cartilage of lower 6 ribs; crest approximating the thorax and iliac abdominis thoracolumbar fascia; crest; (along with lateral fibers of in- lateral part of inguinal Xiphoid process; inferior sur- ternal oblique of same side), rotates Rectus ligament face of cartilage of ribs 5–7 the vertebral column (with the inter- abdominis nal oblique on the opposite side); Superior surface of pubis when the pelvis is fixed, the right ex- ternal oblique rotates thorax counter- clockwise, and the left rotates the tho- rax clockwise Bilaterally: Flexes vertebral column; de- presses thorax and assists in respira- tion; compresses and supports the lower abdominal viscera in conjunc- tion with the transversus abdominis; Unilaterally: Rotates thorax backward (in conjunction with the anterior fibers of the external oblique on the opposite side); the right internal oblique rotates the thorax clockwise, and the left rotates the thorax coun- terclockwise on a fixed pelvis; lateral fibers (along with the lateral fibers of the external oblique on the same side) laterally flexes the vertebral column approximating the thorax and pelvis Compresses abdomen Flexes vertebral column by approximat- ing the thorax and pelvis; with the pelvis fixed, moves thorax toward the pelvis; with the thorax fixed, moves pelvis towards the thorax; depresses ribs Table 4.7 Muscles of the Thorax Name Origin Insertion Action Nerve Supply Superior border of lower rib T1–T12 External intercostals Inferior border of each rib Elevates ribs, increasing the volume of the tho- T1–T12 Internal intercostals Superior border of each rib Inferior border of rib above racic cavity—inspira- T7–T12 origin tory muscle phrenic, C3–C5 Transversus thoracis Inner surface of inferior part Cartilage of ribs 2–6 Depresses ribs, reducing Diaphragm of sternum and adjacent thoracic volume—expi- costal cartilages Fibers converge to central ratory muscle tendinous sheet Xiphoid process (sternal); Depresses ribs, reducing cartilages of ribs 4–10 thoracic volume for (costal); body of upper 2–3 forceful expiration lumbar vertebrae (lumbar) Increases volume of tho- racic cavity; decreases volume of abdomino- pelvic cavity—inspira- tory muscle

Table 4.8 252 The Massage Connection: Anatomy and Physiology Muscles That Position and Move the Shoulder Girdle Name Origin Insertion Action Nerve Supply Muscle Diagram Trapezius Posteriorly located muscles XI (accessory nerve) Trapezius Long origin from the V-shaped insertion from (Depends on the fibers contract- occipital bone, liga- the lateral one-third ing) elevates, depresses, mentum nuchae; of clavicle, acromion, adducts, rotates scapula; ele- O spinal processes of and spine of scapula vates clavicle; extends head C7 and all thoracic and neck; acts as accessory vertebrae muscle of respiration O I I O Rhomboideus Spinous processes of Medial border of scapula Adducts, elevates, and rotates C4–C5 (dorsal major T2–T5 vertebrae from spine to inferior the scapula (glenoid cavity scapular) angle faces caudally); helps stabi- lize scapula O I Rhomboideus major

Rhomboideus Spinous processes of Medial border of scapula Adducts, elevates, and rotates C4–C5 (dorsal minor C7 and T1; inferior near spine the scapula (glenoid cavity scapular) part of ligamentum faces caudally); stabilizes nuchae scapula O Rhomboideus minor I Superiorly located muscle Levator Transverse processes Superior part of medial Unilaterally: Elevates and C3–C5 scapulae of C1–C4 border of scapula adducts scapula; rotates scapula (glenoid faces down); lateally flexes neck to same O side; rotates neck to same side; Bilaterally: extends neck Levator I scapulae Continued Chapter 4—Muscular System 253

254 The Massage Connection: Anatomy and Physiology Table 4.8 Muscles That Position and Move the Shoulder Girdle (Continued) Name Origin Insertion Action Nerve Supply Muscle Diagram Laterally located muscle Serratus Anterior and superior Anterior aspect of the Protracts, abducts, rotates the C5–7 (long Anteriolateral view anterior aspect of ribs 1–9 medial border of inferior angle laterally and thoracic scapula glenoid cavity of scapula cra- nerve) nially; stabilizes scapula by holding medial border firmly I against the rib cage; lower O fibers may depress scapula, upper fibers may elevate it Serratus anterior slightly; starting from a posi- tion with the humerus fixed in flexion and the hands against a wall or floor, acts to displace the thorax posteri- orly (e.g., push-up); with in- sertion fixed, may act in forced inspiration

Anteriorly located muscles Pectoralis Anterior aspect of Coracoid process of Protracts, depresses, lat- C8–T1 minor ribs 3–5 scapula erally rotates scapula; assists in forced inspi- ration by elevating ribs if scapula is held stationary I Pectoralis minor O A Subclavius Junction of 1st rib Middle of clavicle, infe- Depresses and protracts C5–C6 with its costal rior surface shoulder; stabilizes cartilage clavicle during move- ment of shoulder girdle I O Subclavius B Chapter 4—Muscular System 255

Table 4.9 256 The Massage Connection: Anatomy and Physiology Muscles That Move the Arm Name Origin Insertion Action Nerve Supply Muscle Diagram Anteriorly located muscles Greater tubercle of humerus and lateral Pectoralis Body of sternum, car- lip of the bicipital Flexes; adducts; medially ro- C5–C8, T1 major tilage of 2–6 ribs, groove of humerus tates humerus; with insertion aponeurosis of ex- fixed, may assist in elevating ternal oblique (ster- the thorax as in forced inspi- nocostal); medial ration half of clavicle (clavicular) O I Pectoralis major: O Clavicular head Sternocostal head Abdominal head O (Pectoralis minor lies beneath the pectoralis major, but manipulates the scapula.) A Deltoid (delta Lateral third of clavi- Deltoid tuberosity of Flexes arm and medi- C5–C6 (axil- or triangu- cle (anterior); humerus ally rotates shoulder lary nerve) lar muscle acromion process joint (anterior fibers); covering (middle) and spine abducts arm (middle anterior of the scapula (pos- fibers); extends arm and poste- terior) and laterally rotates rior part of shoulder joint (poste- shoulder) rior fibers) Deltoid O I B

Coraco- Coracoid process of Middle third of medial Adducts and flexes arm; C5–C7 Coracobracialis brachialis scapula margin of humerus stabilizes humerus (musculo- cutaneous) O Posteriorly located muscles Subscapularis Subscapular fossa of Lesser tubercle of Medially rotates C5–C6 I (rotator cuff scapula humerus humerus; stabilizes muscle) shoulder joint Anterior view Subscapularis I O Anterior view Chapter 4—Muscular System Continued 257

Table 4.9 258 The Massage Connection: Anatomy and Physiology Muscles That Move the Arm (Continued) Name Origin Insertion Action Nerve Supply Muscle Diagram Anteriorly located muscles Supraspinatus Supraspinous fossa Greater tubercle of Abducts arm (assists at start of C5–C6 (rotator cuff of scapula humerus movements); stabilizes shoul- muscle) der joint Supraspinatus OI Infraspinatus Infraspinous fossa of Greater tubercle of Laterally rotates C5–C6 (rotator cuff scapula humerus humerus; stabilizes muscle) shoulder joint Infraspinatus I O

Teres major Lower third of lateral Medial lip of intertuber- Medially rotates C5–C7 border and inferior cular groove of humerus; adducts angle of scapula humerus arm; extends shoulder Teres minor Upper two-thirds of Greater tubercle of Laterally rotates C5–C6 I (rotator cuff lateral border of humerus humerus; adducts arm (axillary) O Teres major muscle) scapula (weakly); stabilizes shoulder joint I Teres minor Chapter 4—Muscular System O Continued 259

Table 4.9 260 The Massage Connection: Anatomy and Physiology Muscles That Move the Arm (Continued) Name Origin Insertion Action Nerve Supply Muscle Diagram C6–C8 Posteriorly located muscles Unilaterally: Extends; adducts; IO medially rotates arm; de- Latissimus Spinous processes of Floor or bicipital groove presses the shoulder girdle; dorsi lower six thoracic Bilaterally: Assists in hyperex- vertebrae and lum- tending spine and anteriorly bar vertebrae; tho- tilting the pelvis, or in flexing racolumbar fascia; the spine, depending on its re- 8–12 ribs; inferior lation to the axes of motion; angle of scapula With insertion fixed: Assists in lateral flexion of the trunk, assists in tilting the pelvis an- O teriorly and laterally; may act as an accessory muscle of respiration Latissimus O dorsi Triceps Infraglenoid tuberos- Olecranon process of Extends arm; assists in C6–C8 (radial) brachii ity of scapula ulna adduction and exten- (long head) sion of the shoulder OO joint Triceps: Long head Lateral head Medial head I

Table 4.10 Muscles That Move the Forearm and Wrist Name Origin Insertion Action Nerve Supply Muscle Diagram Anteriorly located muscles (with action in the elbow) Flexes, supinates forearm; long head may assist with abduc- Biceps brachii Short head: coracoid Tuberosity of radius; tion if the humerus is later- C5–C6 O process of scapula; (bicipital aponeurosis ally rotated; (musculo- long head: supragle- into deep fascia of me- With the insertion fixed: cutaneous) noid tuberosity dial part of forearm) Flexes the elbow joint, mov- ing the humerus toward the forearm Long head Biceps Short head Brachialis Anterior, lower half Tuberosity and coronoid Flexes forearm; C5–C7 (mus- I of humerus process of ulna With the insertion culocuta- O fixed: Flexes the el- neous, ra- bow joint, moving the dial) Brachialis humerus toward the forearm I Chapter 4—Muscular System Continued 261

Table 4.10 262 The Massage Connection: Anatomy and Physiology Muscles That Move the Forearm and Wrist (Continued) Name Origin Insertion Action Nerve Supply Muscle Diagram C5–C6 (radial) Brachio- Upper two-thirds Lateral aspect of styloid Flexes forearm and assists in O radialis of lateral supra- process of radius pronating and supinating the condylar ridge of forearm Brachioradialis humerus I Anterior view Supinator Lateral epicondyle of Anterolateral surface of Supinates forearm C6–C7 (radial) humerus and ulna upper third of radius Supinator O I Posterior view

Pronator teres Medial supracondylar Middle of lateral sur- Pronates forearm; as- C6–C7 ridge and medial face of radius sists in flexing elbow (median) epicondyle of joint humerus; coronoid process of ulna Pronator O teres I Anterior view Pronator Medial surface of dis- Anterolateral surface of Pronates forearm C7–C8 quadratus tal end of ulna distal end of radius (median) IO Chapter 4—Muscular System Pronator quadratus Anterior view Continued 263

Table 4.10 264 The Massage Connection: Anatomy and Physiology Muscles That Move the Forearm and Wrist (Continued) Name Origin Insertion Action Nerve Supply Muscle Diagram Posteriorly located muscles (with action at the forearm) Anconeus Lateral epicondyle of Olecranon process of Extends arm C7–C8 (radial) humerus, posterior ulna surface Anconeus O I Posterior view Triceps Upper half of supe- Olecranon process of Extends arm C6–C8 (radial) brachii (See rior, lateral margin ulna Chapter of humerus (lateral Appendix head); infraglenoid Table 4.9 tuberosity of for long scapula (long head) head); posterior margin of lower half of humerus (short head)

Anteriorly placed muscles (with action at the wrist) Flexor carpi Medial epicondyle of Base of 2nd and 3rd Flexes and abducts C6–C7 radialis humerus metacarpals wrist; may assist in (median) (superficial pronation of the fore- group of arm and flexion of Flexor carpi O muscles) the elbow radialis Flexor carpi Medial epicondyle of Base of 3rd and 4th Flexes and adducts C7–C8, T1 I ulnaris (su- humerus and me- metacarpals; pisiform wrist; may assist in (ulnar) perficial dial margin of ole- and hamate flexion of the elbow O group of cranon process and muscles) posterior aspects of Flexor carpi ulna ulnaris I Chapter 4—Muscular System Continued 265

Table 4.10 266 The Massage Connection: Anatomy and Physiology Muscles That Move the Forearm and Wrist (Continued) Name Origin Insertion Action Nerve Supply Muscle Diagram Anteriorly located muscles (with action at the forearm) Palmaris Medial epicondyle of Palmar aponeurosis Tense palmar fascia, flexes the C6–C7 longus humerus wrist and may assist in flex- (median) (superficial ion of elbow O group of muscles) (Note that all the flexors of palm arise from the medial epicondyle.) Palmaris longus I Anterior view Posteriorly placed muscles (with action at the wrist) Extensor Lower third of lateral Base of 2nd metacarpal Extends and abducts C6–C7 (radial) carpi radi- supracondylar wrist; assists in flex- alis longus ridge of humerus ion of the elbow O Extensor carpi radialis longus I Posterior view

Extensor Lateral epicondyle of Base of 3rd metacarpal Extends and abducts C7–C8 (radial) carpi radi- humerus wrist alis brevis O Extensor carpi radialis brevis I Extensor Lateral epicondyle of Base of 5th metacarpal Extends and adducts C7–C8 (radial) Posterior view carpi humerus; adjacent wrist ulnaris aspect of ulna O (Note that all the extensors arise from the lateral aspect of humerus.) Extensor carpi ulnaris I Posterior view Chapter 4—Muscular System 267

Table 4.11 268 The Massage Connection: Anatomy and Physiology Muscles That Move the Palm and Fingers (Continued) Name Origin Insertion Action Nerve Supply Muscle Diagram Anteriorly located muscles (deep to the muscles moving the wrist) Flexor digito- Medial epicondyle of Four tendons split into Flexes wrist; flexes fingers, es- C8, T1 rum super- humerus; proximal two slips and at- pecially 2nd phalanx; assists (median) ficialis anterior surface of tached into 2nd pha- in flexion of the metacar- ulna and radius lanx of fingers (except pophalangeal joints O thumb); Flexor digitorum O superficialis I Anterior view Flexor Proximal three- Base of distal phalanges Flexes wrist; flexes fin- C8, T1 (lateral digitorum fourths of antero- of fingers gers; flexes distal in- portion: profundus medial aspect of terphalangeal joints median; ulna; coronoid of index, middle, medial por- process and ring, and little fin- tion: ulnar) Flexor digitorum O interosseous gers, and assists in profundus membrane flexion of proximal interphalangeal and metacarpophalangeal joint I Anterior view

Flexor polli- Medial epicondyle of Distal phalanx of thumb Flexes the interpha- C7–C8 cis longus humerus, middle of langeal joint of (median) anterior shaft of ra- thumb, assists in flex- dius; interosseous ion of the metacar- O membrane pophalangeal and carpometacarpal O joints, and may assist in flexion of the wrist Flexor pollicis longus I Anterior view Posteriorly located muscles Extensor Lateral epicondyle of Dorsal surface of pha- Extends fingers; extends C7–C8 (radial) digitorum humerus langes of all fingers the metacarpopha- langeal joints and, in conjunction with the O lumbricals and in- terossei, extends the Extensor digitorum interphalangeal joints of the 2nd through Chapter 4—Muscular System 5th digits; assists in abduction of the in- dex, ring, and little fingers; assists in ex- tension and abduc- tion of the wrist I Continued 269

Table 4.11 270 The Massage Connection: Anatomy and Physiology Muscles That Move the Palm and Fingers (Continued) Name Origin Insertion Action Nerve Supply Muscle Diagram C7–C8 (radial) O Anteriorly located muscles (deep to the muscles moving the wrist) Abductor pol- Proximal, posterior Lateral margin of 1st Abducts and extends the car- licis longus surface of ulna and metacarpal pometacarpal joint of the radius thumb; abducts (radial devia- tion) and assists in flexion of the wrist Abductor pollicis longus I Extensor dig- Common extensor Dorsal surface of proxi- Extends the metacarpopha- Nerve root: Posterior view iti minimi origin on the lat- mal phalanx of fifth langeal joint and, in conjunc- C7–C8 eral epicondyle of digit tion with the lumbricalis and (radial) O the humerus interosseus, extends the inter- phalangeal joints of the little Extensor digiti minimi finger; assists in abduction of the little finger I Posterior view

Intrinsic muscles of the hand (muscles that originate and insert in the hand) Dorsal inter- Adjacent sides of All insert into the dorsal Abducts 2nd to 4th fingers from C8, T1 (ulnar) ossei (first– metacarpal bones digital expansions (in the axial line through the 3rd fourth) the base of the proxi- digit; assists in flexion of mal phalanx) of either metacarpophalangeal joints the index, middle, or and extension of inter- I Dorsal ring fingers phalangeal joints of the same fingers; the first assists in ad- interossei duction of the thumb O Palmar inter- Side of the shaft of All insert into the dorsal Adducts the thumb, index, ring, C8, T1 (ulnar) Posterior view ossei (first– all metacarpal digital expansions at and little finger toward the fourth) bones (ulnar side, the sides of bases of axial line through the 3rd I 1st and 2nd; radial proximal phalanges of digit; assists in flexion of side, 3rd and 4th) all digits (except the metacarpophalangeal joints except middle middle) metacarpal Palmer O interossei Anterior view Continued Chapter 4—Muscular System 271

Table 4.11 272 The Massage Connection: Anatomy and Physiology Muscles That Move the Palm and Fingers (Continued) Name Origin Insertion Action Nerve Supply Muscle Diagram Anteriorly located muscles (deep to the muscles moving the wrist) Lumbricalis Tendons of flexor dig- Radial aspects of the Extends the interphalangeal Medial two itorum profundus dorsal expansion of joints and simultaneously lumbri- of each finger the corresponding in- flexes the metacarpopha- calis—C8, dex, middle, ring, and langeal joints of the 2nd T1 (ulnar), little fingers through 5th digits; extends lateral two Lumbrical I the interphalangeal joints lumbri- muscles O when the metacarpopha- calis—C8, langeal joints are extended T1 (median) Abductor dig- Pisiform bone; Ulnar aspect of the base Abducts, assists in opposition, C8, T1 (ulnar) Anterior view iti minimi tendon of flexor of the proximal pha- and may assist in flexion of carpi ulnaris lanx of the little fin- the metacarpophalangeal I ger; dorsal digital ex- joint of the little finger; may pansion of the little assist in extension of inter- finger phalangeal joints O Abductor digiti minimi muscle Anterior view

Opponens Hook of hamate; Ulnar and adjacent pal- Opposes little finger with C8, T1 (ulnar) digiti flexor retinaculum mar surface of the 5th thumb; helps to cup the palm minimi metacarpal bone of the hand I Opponens O digiti minimi Flexor digiti Hook of hamate; Ulnar aspect of the base Flexes the metacarpophalangeal C8, T1 (ulnar) Anterior view minimi flexor retinaculum of the proximal pha- joint of the little finger and lanx of the little finger assists in opposition of the lit- I tle finger toward the thumb Flexor digiti O minimi Anterior view Continued Chapter 4—Muscular System 273

Table 4.11 274 The Massage Connection: Anatomy and Physiology Muscles That Move the Palm and Fingers (Continued) Name Origin Insertion Action Nerve Supply Muscle Diagram Anteriorly located muscles (deep to the muscles moving the wrist) Superficial I head: C8, T1 Flexor pollicis Superficial head: Radial side of the base Flexes the metacarpophalangeal (median) brevis Flexor retinaculum of the proximal pha- and carpometacarpal joints Deep head: and the tubercle of lanx of the thumb of the thumb; assists in oppo- C8, T1 the trapezium bone sition of the thumb toward (ulnar) Deep head: Capitate the little finger; may extend and trapezoid the interphalangeal joint bones and the pal- mar ligaments of the distal row of carpal bones O Flexor pollicis brevis Extensor pol- Posterior aspect of Dorsal aspect of the Extends the metacarpopha- C7–C8 (radial) Anterior view licis brevis the radius below base of the proximal langeal joint of the thumb, the abductor polli- phalanx of the thumb extends and abducts the car- O cis longus; poste- pometacarpal joint, and as- rior surface of the sists in abduction of the wrist Extensor interosseous mem- pollicus brevis brane I Posterior view

Abductor pol- Flexor retinaculum; Radial aspect of the Abducts the carpometacarpal C8, T1 licis brevis tubercles of the base of the proximal and metacarpophalangeal (median) scaphoid and phalanx of the thumb; joints of the thumb in a ven- trapezium bones; dorsal digital expan- tral direction perpendicular tendon of abductor sion of the thumb to the plane of the palm; by pollicis longus virtue of its attachment into the dorsal extensor expan- sion, extends the interpha- I langeal joint of the thumb; assists in opposition, may as- O sist in flexion and medial ro- tation of the metacarpopha- Abductor pollicis langeal joint brevis Anterior view Adductor pol- Oblique head: Capi- Ulnar aspect of the base Adducts the carpometacarpal C8, T1 (ulnar) licis tate bone and pal- of the proximal pha- joint, and adducts and assists Adductor mar surfaces of the lanx of the thumb; in flexion of the metacar- pollicis bases of the 2nd dorsal digital expan- pophalangeal joint, so that and 3rd metacarpal sion of the thumb the thumb moves toward the I bones plane of the palm; aids in op- O position of the thumb toward Transverse head: Dis- the little finger; by virtue of tal two-thirds of the attachment of the oblique the palmar surface fibers into the extensor ex- of the shaft of the pansion, may assist in ex- 3rd metacarpal tending the interphalangeal bone joint Opponens Flexor retinaculum; Lateral surface and as- Opposes (i.e., flexes and C8, T1 Anterior view pollicis tubercle of the pect of the palmar abducts with slight medial ro- (median) trapezium bone surface of the first tation) the carpometacarpal I metacarpal bone joint of the thumb, placing O Chapter 4—Muscular System the thumb in a position so that, by flexion of the Opponens pollicis metacarpophalangeal joint, it Anterior view can oppose the fingers 275

276 The Massage Connection: Anatomy and Physiology Table 4.12 An Overview of Innervation of the Upper Limb (also see page 325) Name Muscle Innervated Disability Caused by Damage Axillary Main abductor of shoulder (deltoid) Weakness in abduction of shoulder Musculocutaneous Flexors of elbow (except brachioradialis) Median Flexors of wrist and fingers; pronators of forearm; Weakness in flexing elbow Ulnar nerve thenar muscles Difficulty in opposing thumb; (if nerve affected in carpal tunnel); weakness in flexion of wrist and fingers and Radial nerve Intrinsic muscles of hand pronation seen as well, if the nerve is affected more proximally Triceps; extensors of elbow, wrist Difficulty adducting and abducting fingers; hands ap- pear like claws (claw hands) due to the unopposed ac- tion of unaffected muscles “Wrist drop.” Wrist flexed; cannot extend fingers and abduct thumb, as in hitchhiking; can be caused by compression of the nerve against bone when using crutches or draping arm over a chair