The 3 Minute Musculoskeletal amp Peripheral Nerve Exam -Alan Miller

Pectoralis Minor 230 MSC ATLAS Pronator Quadratus 230 Pronator Teres 231 Rhomboids 231 Subscapularis 231 Supinator 231 Supraspinatus 231 Teres Major 231 Teres Minor 232 Trapezius 229 Triceps 232 LOWER EXTREMITIES 233 Adductor Brevis 233 Adductor Longus 233 Adductor Magnus 233 Biceps Femoris Long Head 233 Biceps Femoris Short Head 233 Extensor Digitorum Longus 234 Extensor Hallucis Longus 234 Flexor Digitorum Longus 234 Flexor Hallucis Longus 234 Gastrocnemius 235 Gemelli 234 Gluteus Maximus 234 Gluteus Medius 235 Gluteus Minimus 233 Gracilis 235 Iliopsoas 235 Obturator Externus 235 Obturator Internus 233 Pectineus 235 Peroneus Brevis 235 Peroneus Longus 236 Peroneus Tertius 235 Piriformis 236 Plantaris CONTENTS I 223

Popliteus 236 Quadratus Femoris 235 Rectus Femoris 236 Sartorius 236 Semimembranosus 236 Semitendinosus 237 Soleus 237 Tensor Fascia Lata 236 Tibialis Anterior 237 Tibialis Posterior 237 Vastus Intermedius, Lateralis, and Medialis 237 224 I 8 MUSCULOSKELETAL ATLAS

I I I INTRODUCTION MSC ATLAS Visualization of muscles, tendons, origins, and insertions can be helpful in clinical practice. The following collection of images of clinically relevant muscles is provided for your reference. INTRODUCTION I 225

I I I UPPER EXTREMITIES Flexor pollicis brevis Flexor digiti minimi brevis Abductor Abductor digiti pollicis minimi brevis Abductor digiti minimi, abductor Abductor pollicis longus pollicis brevis, abductor pollicis brevis, flexor digiti minimi brevis and flexor pollicis brevis Adductor Pollicis Anconeus Biceps brachii Brachialis 226 I 8 MUSCULOSKELETAL ATLAS

Brachioradialis Coracobrachialis Deltoid Dorsal interossei MSC ATLAS Extensor carpi radialis brevis Extensor carpi radialis longus UPPER EXTREMITIES I 227

Extensor carpi ulnaris Extensor digiti minimi Extensor digitorum Extensor indicis Brevis Flexor carpi radialis Longus Flexor carpi ulnaris Extensor pollicis brevis and longus Flexor carpi radialis and ulnaris 228 I 8 MUSCULOSKELETAL ATLAS

Flexor digitorum profundus Flexor digitorum superficialis Flexor pollicis longus Infraspinatus Trapezius Latissimus MSC ATLAS dorsi Levator scapulae Latissimus dorsi and trapezius UPPER EXTREMITIES I 229

Opponens Opponens digiti pollicis minimi Opponens digiti minimi and pollicis Palmar interossei Palmaris longus Pectoralis major Pectoralis minor Pronator quadratus 230 I 8 MUSCULOSKELETAL ATLAS

Rhomboid minor Rhomboid major Pronator teres Rhomboids Subscapularis Supinator MSC ATLAS Supraspinatus Teres major UPPER EXTREMITIES I 231

Teres minor Triceps 232 I 8 MUSCULOSKELETAL ATLAS

I I I LOWER EXTREMITIES Pectineus Adductor brevis Gracilis Adductor brevis, gracilis and Adductor longus pectineus Adductor magnus Biceps femoris long head MSC ATLAS Biceps femoris short head Extensor digitorum longus LOWER EXTREMITIES I 233

Extensor hallucis longus Flexor digitorum longus Flexor hallucis longus Gastrocnemius Gluteus maximus Gluteus medius 234 I 8 MUSCULOSKELETAL ATLAS

Gluteus minimus Iliopsoas Piriformis Superior gemellus Obturator Quadratus internus femoris Inferior gemellus Obturator externus Obturator internus, piriformis, quadratus femoris, inferior gemellus and superior gemellus MSC ATLAS Peroneus brevis Peroneus longus LOWER EXTREMITIES I 235

Peroneus tertius Plantaris Popliteus Rectus femoris Tensor fascia lata Sartorius Sartorius and tensor fascia lata Semimembranosus 236 I 8 MUSCULOSKELETAL ATLAS

Semitendinosus Soleus Tibialis anterior Tibialis posterior Vastus Vastus MSC ATLAS lateralis intermedius Vastus medialis Vastus intermedius, lateralis, and medialis LOWER EXTREMITIES I 237

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9CHAPTER I Muscle Tables

I I I CONTENTS 242 248 INTRODUCTION 254 UPPER EXTREMITIES 257 Shoulder and Arm 262 Forearm 266 Hand LOWER EXTREMITIES Abdomen, Hip, and Pelvis Thigh and Leg Foot 240 I 9 MUSCLE TABLES

I I I INTRODUCTION MUSCLES In this chapter, we present a comprehensive list of clinically rele- vant muscles, their actions, nerve supply, and spinal nerve root contributions in alphabetical order grouped by body region. Variation exists in literature as to the major root contributions in the innervation of some muscles. Multiple sources were reviewed1–5 in the composition of this table, and roots shown in bold are those consistently reported to have a relatively greater contribution of innervation than other roots. Muscles without a bold-faced root are supplied in equal contribution by the roots listed . 1. O’Rahilly R, Müller F. Gardner-Gray-O’Rahilly Anatomy: A Regional Study of Human Structure, 5th ed. Philadelphia: W.B. Saunders, 1986. 2. Hollingshead WH, Jenkins DB. Functional Anatomy of the Limbs and Back, 5th ed. Philadelphia: W.B. Saunders, 1981. 3. Kimura J. Electrodiagnosis in Diseases of Nerve and Muscle: Principles and Practice, 3rd ed. New York: Oxford University Press, 2001. 4. Bonsall AP. Flash Anatomy, 2nd ed. Orange, CA: Flash Anatomy, 1988. 5. Davis BA in Feinberg JH, Spielholtz NI, eds. Peripheral Nerve Injuries in the Athlete. Champaign IL: Human Kinetics, 2003:206–237. INTRODUCTION I 241

242 I 9 MUSCLE TABLES I I I UPPER EXTREMITIES Muscle Action, Localization, and Muscle Action Anato Biceps Brachii injecti Coracobrachialis Flexes the elbow and shoulder, supinates the Bulk o Deltoid forearm mid-ar proxim Flexes and adducts the shoulder, brings trunk 4 finge toward arm when arm coraco is fixed axillar Anterior: abducts, flexes, Anteri adducts when arm at side acrom and internally rotates the below shoulder Middle: abducts biceps the shoulder Posterior: 4 finge abducts, extends, adducts distal when arm at side and To the externally rotates the should shoulder tubero

d Innervation—Shoulder and Arm omic Localization EMG/ Nerve Root Supply ion needle placement Musculocutaneous C5, C6 of muscle in anterior Musculocutaneous C5, C6 rm, angle the needle mally er breadths distal to oid process off anterior ry fold ior: Medial edge of Axillary C5, C6 mion, 3 finger breadths w on a line toward the s tendon Middle: 3 to er breadths below the edge of the acromion. e bulk of muscle around der toward the deltoid osity. Posterior: Posterior

UPPER EXTREMITIES I 243 Infraspinatus Externally rotates and edge o Latissimus Dorsi extends shoulder, stabilizes breadt Levator Scapulae humeral head in glenoid toward Extends, adducts and From t internally rotates shoulder; of the depresses the scapula and the inf rotates the glenoid downward Insert in the coronal plane, extends below elbow in closed link chain, on this brings trunk toward arm when arm is fixed One fi inferio Elevates scapula medially Aim th and rotates glenoid poster downward in coronal plane Insert from m to the approx angle MUSCLES

of acromion, 3 finger Suprascapular C5, C6 ths below on a line Thoracodorsal C6, C7, C8 d the olecranon the mid part of the spine scapula, draw a line to ferior angle of the scapula. the needle 11/2 to 2 inches w the spine of the scapula s line. ingerbreadth lateral to the or angle of the scapula. he needle toward the rior axillary fold. needle in a line extending Dorsal Scapular C3, C4 medial angle of the scapula nerves and C5 (dorsal occipital protuberance scapular) ximately 1inch from the of scapula (continued on next page)

244 I 9 MUSCLE TABLES Muscle Action, Localization, and Innervation— Muscle Action Anato Pectoralis Major Adducts and internally injecti rotates the shoulder Pectoralis Minor Clavic Rhomboids Stabilizes scapula to the ribs, needle thorax and depresses the point o Scalenes shoulder needle Elevate and retract the axillar scapula and rotate the the ne glenoid downward in the of the coronal plane Three Rotate the neck to the at the contralateral side, flex the scapul along toward trapez muscl

—Shoulder and Arm (continued) omic Localization EMG/ Nerve Root Supply ion needle placement Clavicular head: Clavicular Lateral Pectoral head: C5, cular head: Insert the Sternal head: C6, C7 e 1 inch below the mid Medial Pectoral Sternal head: of clavicle aiming the C8, T1 e toward the anterior Medial Pectoral ry fold. Sternal head: insert C8, T1 eedle to the inferior edge C5 anterior axillary fold Anterior: C5, fourths of the way down Dorsal Scapular C6, C7, C8 medial edge of the la with the needle angled Cervical the course of the rhomboid Ventral Rami d the spine (only place zius does not cover the le)

UPPER EXTREMITIES I 245 Serratus Anterior neck, raise the first rib, may In late assist with inspiration mid ax Sternocleido- below mastoid Protracts the scapula and directl Subclavius rotates the glenoid upward fingers in the sagittal plane on eith inserti Unilateral action: interco Contralateral rotation and ipsilateral bending of the Insert neck Bilateral action: the ste flexes the neck and th Depresses the shoulder, the ma draws the clavicle anteriorly and inferiorly and stabilizes the sternoclavicular joint MUSCLES

eral decubitus position, Long Thoracic Middle: C3, xillary line, 4 fingerbreadths C4 Posterior: w the axilla, insert needle Spinal Accessory C6, C7, C8 ly over the rib. Keep the (CN XI) C5, C6, C7 s in the intercostal spaces Nerve to her side of the rib to avoid Subclavius Anterior rami ion of the needle to the of C2, C3 ostal space (mainly sensory) needle at midpoint between C5, C6 ernal end of the clavicle he mastoid process, toward astoid process (continued on next page)

246 I 9 MUSCLE TABLES Muscle Action, Localization, and Innervation— Muscle Action Anato Subscapularis Internally rotates and adducts injecti shoulder, stabilizes humeral Supraspinatus head in glenoid Latera the sid Teres Major Externally rotates and abducts exami shoulder, stabilizes humeral rotatio head in glenoid and depresses needle the humeral head during media abduction scapul anterio Adducts and internally rotates shoulder Patien point b lateral spine to the next to toward hit bon a milli Arm o 90° ab 1/3 dis at the

—Shoulder and Arm (continued) omic Localization EMG/ Nerve Root Supply ion needle placement Upper C5, C6 Subscapular al decubitus position on Lower C5, C6 de of the muscle to be Subscapular ined. Shoulder in external C5, C6 on and abduction. Insert Suprascapular e in the midpoint of the al edge and deep to the Lower Subscapular la, aiming to hug the or surface of the scapula nt sitting, at the half-way between the medial and l border of the scapular at the superior edge close spine, insert the needle o the spine and aim it d the supraspinous fossa, ne and pull back about imeter over table, with shoulder at bduction and elbow bent, stance from lower angle lateral margin of scapula.

UPPER EXTREMITIES I 247 Teres Minor Externally rotates shoulder, Patien Trapezius stabilizes humeral head over ta Triceps in glenoid abduc one-th Upper: elevates and retracts acrom scapula Middle: retracts scapul scapula Lower: depresses and of scap retracts scapula All: rotate glenoid upward in coronal Upper plane and an Middl Extends elbow; Long head media assists shoulder extension and th and adduction Lower or T7 s Latera way p in the to the flexed table w pronat to the MUSCLES

nt prone with the forearm Axillary C5, C6 able, with shoulder at 90° ction and elbow bent, Spinal C3, C4 hird of the distance from Accessory (mainly (CN XI) sensory) mion to lower angle of la along lateral margin Radial C6, C7, C8 pula r: Halfway between C7 nterior edge acromion. le: Halfway between the al angle of the scapula he T4 spinous process. r: 1 inch lateral to the T6 spinous process. al head: One third of the proximally from the elbow lateral arm just posterior humerus with elbow d and rested on the exam with hand on the body in tion, insert perpendicular arm

248 I 9 MUSCLE TABLES Muscle Action, Localization, and Muscle Action Anato injecti Abductor Abducts the thumb, assists Pollicis Longus with thumb extension 4 finge radial Anconeus Assists elbow extension and Halfw Brachialis forearm pronation and and th Brachioradialis supination Elbow flexion 3 finge inserti Flexes elbow, supinates the the rad forearm when pronated, to bice pronates the forearm when supinated One th betwe and la forearm finger crease lateral 2 finge cubita

d Innervation—Forearm omic Localization EMG/ Nerve Root Supply ion needle placement C7, C8 er breadths above the Posterior C7, C8 styloid on the radius Interosseous C5, C6, C7 of Radial way between the olecranon C5, C6 he lateral epicondyle Radial er breadths proximal to Musculocutaneous ion of biceps brachii on Radial dial tuberosity, just lateral eps brachii Radial hird of the distance een biceps brachii tendon ateral epicondyle with m semipronated and 3 breadths distal to elbow e or 1 finger breadth l to biceps tendon and er breadths distal to the al crease

Extensor Carpi Extends and radially 4 finge Radialis Brevis deviates wrist line jo lateral Extensor Carpi Extends and radially brachi Radialis Longus deviates wrist styloid semip Extensor Carpi Extends and ulnarly Pronat Ulnaris deviates wrist subcu ulna a UPPER EXTREMITIES I 249 Extensor Digiti Extends the MCP and Minimi (via extensor hood mechanism) Pronat the PIP and DIP joints of the at wris Extensor Digitorum little finger, assists in wrist at junc Communis extension mid th up wit Extends the MCP and (via extensor hood mechanism) the PIP and DIP joints of the index, middle, ring, and little fingers, assists in wrist extension MUSCLES

er breadths distal along Radial C6, C7, C8 oining midpoint between Radial C6, C7 l epicondyle and biceps ii tendon to the radial Posterior C7, C8 d at wrist (forearm Interosseous C7, C8 pronated) of Radial te hand, lateral to C7, C8 utaneous edge of shaft of Posterior at mid forearm Interosseous of Radial te hand, grasp forearm st, drop index finger Posterior ction of proximal and Interosseous hird of forearm, line of Radial th lateral epicondyle (continued on next page)

250 I 9 MUSCLE TABLES Muscle Action, Localization, and Innervation— Muscle Action Anato Extensor Indicis Extends the MCP and (via injecti extensor hood mechanism) Extensor Pollicis the PIP and DIP joints of the 2 finge Brevis index finger, assists in wrist ulnar s Extensor Pollicis extension breadt Longus extens Extends the thumb MCP joint pronat point) Extends the thumb MCP and IP joints 4 finge radial the ed Distal radial Flexor Carpi Flexes and radially Midwa Radialis deviates the wrist epicon at the breadt that jo the rad

—Forearm (continued) Nerve Root Supply Posterior C7, C8 omic Localization EMG/ Interosseous ion needle placement of Radial C7, C8 C7, C8 er breadths proximal to Posterior C6, C7 styloid and 1 finger Interosseous th radial to ulna in of Radial sor forearm (same as Posterior tor quadratus insertion Interosseous aim proximally of Radial Median er breadths above the styloid 1cm ulnar to dge of the posterior radius extensor forearm, along border of ulna ay point between medial ndyle and biceps tendon cubital crease, 4 finger ths distal along the line oins the midpoint and dial styloid

Flexor Carpi Flexes and ulnarly One th Ulnaris deviates the wrist, stabilizes from o pisiform during movement breadt Flexor Digitorum edge o Profundus Flexes the MCP, PIP, and DIP joints, assists in wrist Flex w and elbow flexion portio olecra Flexor Digitorum Flexes the MCP and PIP flexor Superficialis joints, assists in wrist portio and elbow flexion olecra UPPER EXTREMITIES I 251 midpo Grasp finger needle the mi junctio slip of insert get to perpen MUSCLES

hird of the distance of ulna Ulnar C7*, C8 olecranon, 2 finger ths volar to subcutaneous Index and C7, C8, T1 of the shaft of the ulna middle: Anterior C7*, C8, T1 Interosseous wrist and elbow Ulnar Ring and little: C7, C8, T1 on: 4 finger breadths from Ulnar anon, off ulna deep to Median carpi ulnaris Median on: 4 finger breadths from anon, deep toward oint of arm p wrist, point the index to biceps tendon, place e ulnar to tip of finger at iddle and upper third on of the forearm to get f muscle to middle finger, 3/4 to 1 inch deep to the muscle while ndicular to the skin (continued on next page)

252 I 9 MUSCLE TABLES Muscle Action, Localization, and Innervation— Muscle Action Anato injecti Flexor Pollicis Flexes the MCP and CMC Brevis joints of the thumb One th ulnar a Flexor Pollicis Flexes the thumb IP joint, metac Longus the first MCP and the pisifor CMC joints or one Palmaris Longus betwe Flexes the wrist, tenses trapez Pronator palmar aponeurosis middle Quadratus Pronates the forearm At the shaft o Supina 2 finge midpo proces dorsal and ve interos

—Forearm (continued) Nerve Root Supply Median C8, T1 omic Localization EMG/ ion needle placement Anterior C8, T1 Interosseous C7, C8 hird of distance from Median C7, C8 aspect of the first Anterior carpophalangeal joint to Interosseous rm bone, 1/2 inch deep e third the distance een the tubercle of the zium and base of the e finger. e mid forearm, below of radius, ulnar side ate hand with elbow bent, er breadths proximal to oint from inter styloid ss line, approach from the l surface to avoid nerves essels, penetrate sseous membrane.

Pronator Teres Pronates the forearm Midwa epicon 2 finge crease radial Supinator Supinates the forearm Latera brachi tubero *C7 contribution to the ulnar nerve is believed to be provided by a separate UPPER EXTREMITIES I 253 MUSCLES

ay point between medial Median C6, C7 ndyle and biceps tendon, C5, C6 er breadths distal to cubital Posterior e on a line toward the Interosseous styloid of Radial al to insertion of biceps ii tendon on the radial osity branch from the lateral cord.

254 I 9 MUSCLE TABLES Muscle Action, Localization, and Muscle Action Anato Abductor Digiti injecti Minimi Abducts little finger away from the long finger, weakly Midwa Abductor Pollicis flexes the MCP crease Brevis on the Abducts the thumb from the palmar surface Midwa just la Adductor Pollicis Adducts the thumb attach Dorsal Interossei radial Abduct the index and ring joint, i fingers away from the long junctio finger, flex the MCP and dorsal weakly extend the PIP and bulk o DIP joints Hand of the First D 1 finge angle metac betwe

d Innervation—Hand omic Localization EMG/ Nerve Root Supply ion needle placement Deep Branch C8, T1 of Ulnar C8, T1 ay between distal wrist Median e and distal palmar crease C8, T1 e ulnar edge of the hand Deep Branch C8, T1 of Ulnar ay between trapezium Deep Branch ateral to flexor carpi radialis of Ulnar hment at the wrist and the metacarpophalangeal insert just lateral to the on of the palmar and l surface, aim toward the of the muscle pronated, at medial edge first web space Dorsal Interosseous: er breadth distal from the between first and second carpal bones midway een first and second

metac the sec joint in Flexor Digiti Flexes the MCP of the Minimi Brevis little finger Flexor Pollicis Flexes the MCP of the thumb Brevis UPPER EXTREMITIES I 255 Lumbricals Extend PIP, DIP (with weak Midwa flexion of MCP) through fifth m Opponens Digiti extensor hood, pulls Minimi profundus distally Midwa Opponens Pollicis of first Brings the little finger into and fir opposition, weak MCP joint. S flexion the bo Brings the thumb into opposition by abduction and rotation at the CMC joint MUSCLES

carpal, aim toward the head of cond metacarpophalangeal n a 30o angle Deep Branch C8, T1 of Ulnar Superficial head: C8, T1 Median C8, T1 Deep head: Deep Branch of Ulnar Index and middle: C8, T1 Median C8, T1 Ring and little: Ulnar ay between pisiform and Deep Branch C8, T1 metacarpophalangeal joint of Ulnar ay between radial aspect Median C8, T1 t carpometacarpal joint rst metacarpophalangeal Straight in right next to one (continued on next page)

256 I 9 MUSCLE TABLES Muscle Action, Localization, and Innervation— Muscle Action Anato Palmar Interossei injecti Adduct the index, ring and Palmaris Brevis little fingers toward the long finger Contracts skin of palm, deepens palm, increases grip strength

—Hand (continued) Nerve Root Supply Deep Branch C8, T1 omic Localization EMG/ of Ulnar ion needle placement C8, T1 Superficial Branch of Ulnar

I I I LOWER EXTREMITIES Muscle Action, Localization, and In Muscle Action Anato Adductor Brevis Adducts hip injecti Adductor Longus Adducts hip 4 finge Adductor Magnus Adducts hip, anterior portion tuberc assists in hip flexion, femora LOWER EXTREMITIES I 257 posterior portion assists in hip extension One th adduc condy poster External Oblique Flexes, rotates and laterally bends the thoracolumbar spine, supports the abdominal organs, assists in forced respiration MUSCLES