17 Functional Examination and Treatment of Muscles

Examination and Treatment of Muscles–Overview

4. To determine myofascial tissue changes (e. g. myofascial tissue restrictions; e. g. the ease of displacement of the various fascial and myofascial planes and connections); this may also include the evaluation of such empirical entities as the “tender points” (according to the strain–counterstrain system described by LH Jones, D.O. (1981). See Chapters 4 and 6 of this text for additional information.

5. To determine the presence of one or several myofascial trigger points within the context of the definition of the myofascial pain syndrome (Travell and Simons 1992, 1993)(whether a muscle or several muscles act as pain generator [e. g., myofascial pain]) and to determine any abnormal muscle functioning in form of a muscular imbalance between those muscles that have shortened (e. g., typically those muscles that show a preponderance of the slow-twitch fibers) and those that have become weak (e. g., those that have a preponderance of fast-twitch fibers), for instance.

The myofascial trigger point examination and treatment are presented in a separate chapter (Chapter 18).

For practical purposes it has been found useful to utilize a four-layer system of muscles to assist in the visualization and three-dimensional orientation of the relevant muscles of the back, the neck and the thoracic and lumbar spine (Fig. 17.1 and Tab. 17.1). Like any system, there are advantages and disadvantages, and the interested reader is naturally referred to standard anatomic texts or recent updates (Bogduk, 1997).

The lateral and anterior muscles of the neck, trunk and abdomen as well as a number of extremity muscles can be grouped according to particular categorizations as well and are included in this chapter, following those of the back.

The four-layer system presented here (Table 17.2) applies to both the muscles of the back and neck.

Fig. 17.1 The outermost two layers of muscle of the back and the superficial thoracolumbar fascia that separates them from the deeper two layers (see also Tabs. 17.1 and 17.2). (From Schuenke, Thieme Atlas of Anatomy Vol. I, 2007.)

Muscles of the Posterior Regions of the Neck and Back

Trapezius Muscle

The origin of the trapezius muscleh extends between the occipital bone and the twelfth thoracic vertebra. It is useful to anatomically and spondylogenically divide this muscle into three sections: the descending, horizontal, and ascending portions (Figs. 17.2, 17.3).

• Descending portion: The muscle arises from the superior nuchal line, 2 cm lateral to the external occipital protuberance; the nuchal ligament to the sixth cervical vertebra.

• Horizontal portion: Arises from the spinous processes of C7–T3.

• Ascending portion: Arises from the spinous processes of T4–T12.

Insertion

• Descending portion: Inserts at the superior surface of the spine of the scapula, the acromioclavicular joint, and the posterosuperior margin of the lateral third of the clavicle (Fig. 17.2).

• Horizontal portion: Inserts at the superior surface of the spine of the scapula from the base to the acromioclavicular joint. At the spine of the scapula, this portion overlies the insertion of the descending portion (important for palpation) (Fig. 17.2).

• Ascending portion: The inferior edge of the spine of the scapula, between the tuberosity and the lumbar triangle (Fig. 17.2).

Course and Relations

The muscle bundles arising from the occiput run sharply inferiorly, whereas the fibers continuing below course away from the ligamentum nuchae at a sharp angle. The fibers from the most inferior portion of the cervical spine approximate the transverse direction (Fig. 17.3).

Innervation

The descending portion of the spinal accessory nerve and the rami of C2–C4.

Action

• Descending portion: Elevates the shoulder blade.

• Horizontal portion: Adducts the shoulder blade.

• Ascending portion: Depresses the shoulder blade.

Palpatory Approach

To gain an overview of whether myotendinotic changes are present, the muscle belly of the descending portion is grasped by the thumb and index finger half-way between the shoulder and the neck. The examiner moves up and down perpendicularly in the direction of the muscle fibers (Fig. 17.4). At the spinous processes, the spine of the scapula, and the clavicles, the tendinoses are best palpated in the direction of the incoming fibers (Figs. 17.2 and 17.5).

Comments

It should be noted that the descending and ascending portions of the trapezius muscle are partially covered by fibers of the horizontal portion at the level of the spine of the scapula.

Due to its superficial location, the trapezius is a muscle well suited to learn one’s palpatory skills of muscle and the various muscle fiber directions as well as the palpatory assessment of the various other subcutaneous tissues.

SRS Correlation

The trapezius muscle is extremely important for routine diagnosis of the SRS. Seldom is the trapezius muscle responsible for an isolated segmental dysfunction of an individual vertebrae or vertebrae. The individual myotenones result in painful pathological changes (myotendinosis) in the presence of thoracic or lumbar dysfunction (Fig. 17.2).

Evaluation of Muscle Length

Examination Procedure

The trapezius muscle can be examined with the patient sitting or supine. The examiner stands behind the seated or supine patient. Using the forearm, the examiner stabilizes one of the patient’s shoulders at the level of the acromioclavicular joint. While cradling the patient’s parietal region with the other hand, the examiner introduces side-bending and slight rotation to the opposite side (i. e., in the direction opposite to the location of the stabilized shoulder). The examiner evaluates muscle tension and the contour of the trapezius muscle, as well as the range of motion and end-feel at the barrier (Figs. 17.6 and 17.7).

• Descending portion: Flexion and cervical side-bending to the opposite side.

• Horizontal portion: Side-bending to the opposite side without cervical flexion.

Positive Findings

Motion restriction with significant soft end-feel is an indication of muscle shortening and is usually accompanied by an insertion tendinosis at the spine of the scapula or the clavicle.

Stretching of the Trapezius Muscle (Descending Portion)

NMT 2 (Figs. I17.1a–c)

Latissimus Dorsi Muscle

1. Spine: Arises from the spinous processes and the supraspinous ligaments at T7 or T8–L5, and occasionally from the median sacral crest (Fig. 17.8).

2. Iliac region: Arises from the external lip of the iliac crest, at the junction of the iliac tuberosity and the iliac crest.

3. Ribs: Arises as thin fascicles from the outer surfaces of ribs X–XII; between the origins of the obliquus externus abdominis and the insertions of the serratus posterior inferior muscles (Figs. 17.9, 17.10).

4. Thoracolumbar fascia: The fourth and longest structure from which the latissimus dorsi arises is the thoracodorsal fascia.

Inserts at the proximal end of the crest of the humeral lesser tuberosity, connecting distally to the insertion of the subscapularis muscle. The proximal portion of the insertion belongs to the distal vertebral, iliac, and costal myotenones. The distal portion of the insertion correlates with the proximal vertebral myotenones, which explains the slightly twisted arrangement of the latissimus dorsi muscle (Fig. 17.9).

Course and Relations

The superior bundles run horizontally above the inferior angle of the scapula and cover the teres major muscle at its origin. In the axilla, however, this broad and flat muscles assumes a rather prominent volume.

The lateral edge of the muscle descends almost vertically from the axilla to the ilium (Fig. 17.10).

Innervation

Thoracodorsal nerves C6–C8.

Motor End Plates

The latissimus dorsi muscle is a nonpennate muscle whose fibers converge in the arm. The end plates are arranged in several small units (Fig. 17.11).

The iliac crest, the latissimus dorsi muscle, and the external abdominal oblique muscle form the lumbar triangle (of Petit). Due to the flat origin aponeurosis, a myotendinosis in the lumbar region is almost impossible to palpate. Better information about the muscle is gained in the posterior axillary fold (Fig. 17.12). When investigating the condition of the latissimus dorsi muscle, the approach is similar to that described for the descending portion of the trapezius muscle. The myotendinosis is palpated perpendicular to the muscle fiber orientation in both directions: superiorly to the insertion at the crest of the lesser tuberosity and inferiorly. At the spinous processes, the origin of the latissimus dorsi, which is often painful, must be distinguished from the longissimus thoracis muscle, which lies below. The myotendinosis of this flat muscle can be palpated when pressing it against the underlying rib and following it from one costal/vertebral level to the next.

Levator Scapulae Muscle

The levator scapulae muscle arises by four tendinous slips or fascicles from the transverse processes of the first four cervical vertebrae. The uppermost originating fascicle is the strongest and attaches in a rather broad area along the lateral and inferior portion of the transverse process of the atlas. The tendinous slips from C2 to C4 arise from the posterior tubercles. The first two fascicles are completely fused with the tendons of the splenius cervicis muscle, and the last two are generally fused with the longissimus cervicis muscle (Fig. 17.13).

Insertion

The muscle inserts at the medial border of the scapula between the superior angle and the base of the spine of the scapula. The muscle bundles associated with C1 insert immediately below the superior angle of the scapula. The insertions of the muscle fibers originating from C2 to C4 reach the base of the spine of the scapula at a sharp, nearly vertical angle (Fig. 17.13, Fig. 17.17).

Course and Relations

The levator scapulae muscle is located at the back of the side of the neck between the anterior and posterior muscle mass. From the C5 and C6 level and below, the levator scapulae muscle is covered by fibers of the trapezius muscles.

Innervation

C3, C4, C5, via the dorsal scapular nerve.

Motor End Plates

The motor end plates of the levator scapulae muscle are found in the middle one-third of the muscle, following the double innervation of this muscle (Fig. 17.14).

Action

The origins of the levator scapulae are not accessible to palpation and cannot be differentiated from other muscles that originate in the same area. However, the muscle can be palpated relatively easily at its insertion at the medial border of the scapula, especially when there is increased tone (insertion tendinosis). Due to the steeply angled insertion, the palpatory direction is from a superior direction (Fig. 17.15).

With one hand, the examiner fixates the patient’s superior angle and the upper margin of the patient’s scapula (Figs. 17.15, 17.16). With his other hand, the examiner introduces flexion and rotation of the head in the opposite direction. There are three things the examiner looks for: (1) the presence or appearance of pain associated with this maneuver, (2) any range of motion loss, and (3) palpatory soft-tissue changes proximal to the superior angle including changes in muscle tone with hypertonicity, for instance. If pain or compensatory motions become apparent upon this maneuver, such findings should be followed up with the appropriate examinations accordingly.

Positive Findings

1. Loss of range of motion with soft end-feel, accompanied by pain between the shoulder blades.

2. Typically, when the levator scapulae is shortened, the muscle attachments can be palpated with relative ease at the superior angle and the upper medial margin of the scapula.

Treatment of the Levator Scapulae Muscle

NMT 2 (Figs. I17.2a–c)

Rhomboid Major and Minor Muscles

Origin (Figs. 17.17–17.19)

• The rhomboid minor muscle arises via a short aponeurosis from the nuchal ligament at the C6 level and from the spinous process of C7. Some authors also describe a spine attachment at T1.

• The rhomboid major muscle arises from the spinous processes of T1 or T2 through T4. There may be a rudimentary origin at T5.

Insertion

Both muscles insert along the medial border of the scapula. The rhomboid minor muscle inserts at the level of the spine of the scapula above the rhomboid major muscle.

The insertion of the rhomboid major muscle starts where the inferiormost portion of the rhomboid minor ends. Its insertion occupies most of the medial border of the spine between the base of the scapular spine and the inferior angle of the scapula (Figs. 17.17–17.19).

Motor End Plates

The rhomboid minor and major muscles are nonpennate muscles. The motor end plate is located in the central portion of the muscle belly and its course is parallel to the muscle fiber direction between the muscle origin at the spinal aponeurosis and the insertion at the scapula (see Fig. 17.56).

Innervation

Nerve of the rhomboids (dorsal scapular nerve, C4 and C5).

Action

Theses two muscles adduct, elevate, and rotate or draw the scapula medially.

Palpatory Approach

The patient is requested to spread the shoulders/scapulae apart against operator resistance (see Fig. 17.21).

SRS Correlation

A regional or segmental dysfunction in the lower cervical and/or upper thoracic spine may be associated with a prominent finding of palpable band or prominent extensive “myospasms” in the incriminated muscle.

Comments

Both of the rhomboid muscles often participate in the spondylogenic event. Clinically, patients localize their pain between the shoulder blades.

Strength Testing of the Medial Shoulder Blade Fixator Muscles

(Serratus posterior muscle, rhomboid muscles and trapezius muscle [horizontal portion].)

Examination Procedure

There are two variations, one with the patient standing and the other with the patient prone.

Variation 1: Standing

The patient stands with his back against the wall and abducts his arms to 90°. Keeping the trunk straight, the patient is then instructed to move both of his feet forward, about two foot lengths. Then the physician requests that the patient lift his trunk and shoulders off and away from the wall (about 2 cm) and to maintain this position as long as possible, for up to 30 seconds. A fit person and persons who exercise regularly should have no difficulty in performing this maneuver (Fig. 17.20).

Variation 2: Prone

Here, the arms of the prone patient are abducted at the shoulder. With his arms crossed, the examiner assesses the muscles at their insertion at the medial margin of the scapula. The patient is then requested to contract the muscles responsible for medial shoulder blade fixation, a maneuver performed by lifting the arms off the examination table (Fig. 17.21).

Positive Findings

Erector Spinae Muscle Group

At the pelvis, the longissimus and iliocostalis muscles cannot be differentiated from each other at their respective origins. Akin to a two-headed muscle, they share a common and rather broad origin. Their origins of the longissimus and iliocostalis muscles stretch from the spinous processes of all five lumbar vertebrae via the median sacral crest and the posterior portion of the sacrum in the S3–S4 region to the lateral sacral crest. They continue further to the medial and superior side of the iliac tuberosity, the short posterior sacroiliac ligaments, and the anterior side of the posterior part of the inner lip of the crest of the ilium (Figs. 17.22, 17.23, and 17.24).

Longissimus Lumborum Muscle

The longissimus lumborum muscle arises from the broad sacrospinous ligament primarily at the superior and anterior portions of the iliac tuberosity (Fig. 17.25).

Insertion

It inserts to all lumbar vertebrae via two rows, a lateral and medial row.

• A lateral row of broad insertions attaches to the entire inferior edge and spans the entire length of the posterior surface of the lumbar transverse processes. The insertion at L5 usually only reaches the iliolumbar ligament (Fig. 17.25).

• The medial row overlies the lateral row and converges toward the ligamentous fascia above the mamillary and accessory processes. The dorsal ramus of the spinal nerves is located beneath this fascia (Fig. 17.25).

Course and Relations

The longissimus lumborum muscle lies deep in relation to the iliocostalis and the longissimus thoracis muscles (see Fig. 17.24). By way of its origin at the iliac tuberosity, it connects to the interosseous sacroiliac ligaments.

Innervation

Dorsal ramus of the respective spinal nerve.

The lateral portion is stronger than the medial, and is palpated from a lateral and inferior direction (Fig. 17.26). The examiner must attempt palpatory differentiation between this muscle and the lateral lumbar intertransverse muscles, whereby it should be noted that these two muscles can develop myotendinoses (e. g., hard, palpable band) simultaneously (Fig. 17.27).

SRS Correlation

At first, the patient is sitting. The muscle contours are evaluated for symmetry and presence of any prominence. The patient is examined in the lateral recumbent (sidelying) position, both thighs flexed passively in order to introduce flexion to the lower spine. In this way, the range of motion can also be evaluated. Equally important is the evaluation of the end-feel (Fig. 17.28). Clinical evaluation of the longissimus lumborum muscle is difficult, however, and has proved to be of only limited value, especially when the procedure elicits pain.

If it is difficult to examine the patient in the side-lying position, then the patient can be evaluated in the seated position (Fig. 17.29).

Positive Findings

1. Prominent erector spinae muscle contours in the lumbar region with readily apparent increased tension in the standing patient may be an indication that the erector spinae muscle group is shortened.

2. Significant loss of flexion motion in the lumbar spine with a soft end-feel. The likelihood that the lumbar erector spinae muscle group is shortened increases proportionally with the degree of flexion motion loss in the lumbar area, especially when side-bending and extension motion are relatively preserved.

Longissimus Thoracis Muscle

The longissimus thoracis arises from the broad sacrospinous ligament primarily at the superior and anterior portions of the iliac tuberosity. Together with the longissimus lumborum it arises via a rather large sacrospinalis tendon (Figs. 17.30 and 17.31).

Insertion

The insertions are divided into a medial and a lateral row.

• The medial row of insertions is narrow and reaches the tips of the transverse processes of the thoracic vertebrae between T1 and T12 (Figs. 17.30 and 17.32).

• The lateral row of insertions is rather broad and reaches the ribs, in particular their inferior edge between the tubercle and costal angle (Fig. 17.30). Some of its superior portions are reinforced through other muscle segments originating from the mamillary processes of L1–L2.

Course and Relations

Muscle fibers originating at the iliac crest are destined for inferior insertions. Those arriving from the lumbar spinous processes and the median sacral crest are directed toward the middle and upper thoracic spine. The longissimus thoracis muscle lies lateral to the spinalis muscle and medial to the iliocostalis muscle, thus being on the midline over the thoracic transverse processes and lying lateral to the levatores costarum muscles and the ribs, reaching the line of the costal angle (Figs. 17.32 and 17.33).

The lumbar and thoracic portions of the longissimus dorsi muscles are representative of a nonpennate muscle that has a number of motor end plates (Fig. 17.34).

Action

Bilateral contraction results in extension of the vertebral column. Unilateral contraction results in side-bending of the vertebral column to the side of the contracted muscle.

Palpatory Approach

4. Sectors III and V: The origins of these two sectors are located at the spinous processes of L1–L3 (at the median sacral crest). The palpatory direction is in accordance with the muscle fiber direction when performed at the correct palpatory level and with the proper pressure. At L1 and L2, the superior reinforcement (see above) of the mamillary processes must be considered. Palpatory technique is modified accordingly (Fig. 17.35a).

Insertion

The palpatory approach is the same for all sectors: slightly lateroinferiorly from posterior in the direction of the inferior lateral margin of the transverse process (Fig. 17.35b).

The insertion tendinosis of the longissimus thoracis muscle is almost always accompanied by an irritation zone of the corresponding thoracic vertebra (result of myotendinosis).

At the ribs, the insertions are palpated inferiorly, i. e., between the tubercle and the costal angle at the inferior margin of the rib (comparison with the adjoining ribs is very important).

It is highly unlikely that the SRS correlation of these lateral lines of insertion is identical to that of the medial insertions. Since they have not been definitely categorized, they will not be discussed here. The muscle overlying the hard surface of the ribs and the spinous processes can easily be palpated perpendicular to the fiber direction. This allows for the differential diagnosis of the adjoining muscle layers.

SRS Correlation

See the sector diagrams (Fig. 17.35a). The longissimus thoracis muscle is one of the most important muscles for the SRS. It responds rapidly to a segmental or regional dysfunction and thus can often be clinically found to undergo myotendinotic changes (e. g., hard, palpable band). It should not be difficult for the novice with little palpatory experience to detect the myotendinosis of the longissimus thoracis muscle and to correlate it correctly with the level of dysfunction.

Muscle Endurance Test (Mathiass Test)

Examination Procedure

The standing patient is requested to raise the arms 90° in front and subsequently supinate the forearms so that the palms face horizontally upward. The patient should be as relaxed as possible and breathe slowly without forcing the respiratory movements (Fig. 17.36).

Positive Findings

1. If the patient has difficulty maintaining this position (e. g., the patient is unable to remain in one place), his postural muscles may be weak.

2. If the patient drops the arms without being able to maintain a maximally erect posture, it is most likely the result of postural insufficiency (Fig. 17.37).

3. The patient is either unable to maintain this position at all or only for a few seconds along with obvious asymmetry. This is probably due to significant postural de-compensation (Fig. 17.37).

Longissimus Cervicis Muscle

Arises from upper six thoracic transverse processes, near to the center of the superior surface of the tip. On occasion the muscle may arise as inferiorly as T8 (Fig. 17.38).

Insertion

It inserts to the posterior surface and the root of posterior tubercles of the second to sixth cervical transverse processes, occasionally the atlas. It inserts practically together with the iliocostalis cervicis, splenius cervicis, levator scapulae, posterior scalene, and the longissimus capitis muscles.

Course and Relations

This is a flat and rather weak muscle with its main surface in the sagittal plane. At the T4–T5 level, it is often connected to the belly of the longissimus thoracis muscle via a tendon. In its lower half, it runs medially to the longissimus thoracis muscle. The muscle belly in the lower cervical region runs deeply and laterally to the longissimus capitis muscle, which in turn is lateral to the semispinalis capitis muscle. The muscle fiber direction is nearly perfectly longitudinal. The longissimus group and the semispinalis capitis muscle have their own muscular fasciae and can therefore easily be distinguished from each other by palpation (Fig. 17.39).

Innervation

Dorsal rami of the spinal nerve, the cervical nerves, and the thoracic nerves C3–T2.

Action

Bilateral contraction results in extension of the cervical spine. Unilateral contraction results in side-bending of the cervical spine to the side of the contracted muscle.

Palpatory Approach

The muscle belly is, as already described, easily palpable in the region of the lower cervical spine (perpendicular to the fiber direction).

The origins are palpated at the tip of the thoracic transverse processes from superior to inferior. It is very difficult to differentiate these origins from the semispinalis capitis and cervicis muscles. The insertion at the posterior tubercle of the costal transverse processes is palpated from inferior to superior.

SRS Correlation

Each origin to insertion unit represents one myotenone (i. e., always the most superior insertion together with the most superior origin).

Longissimus Capitis Muscle

Origin

The longissimus capitis muscle arises from the upper six thoracic transverse processes (T1–T6), together with the longissimus cervicis muscle, and from the articular processes of the lower four to five cervical vertebrae (C3 or C4 to C7). In the cervical spine the origins are medial to the insertions of the longissimus cervicis muscle and in the thoracic spine they arise medial to the origins of the longissimus cervicis muscle.

Insertion

The posterior margin of the mastoid process to its tip with a length of 1.5 cm (Fig. 17.41).

Course and Relations

The longissimus capitis muscle is a slender muscle oriented in the sagittal plane. The longitudinal muscle bundles arise most inferiorly at the anterior edge of the muscle belly. In the cervical spine, the deep layer of the muscle can be relatively easily palpated between the semispinalis capitis and the longissimus cervicis muscles. At its insertion, the longissimus cervicis muscle is covered by the splenius capitis muscle and the sternocleidomastoid muscle (Figs. 17.39 and 17.40).

Innervation

Dorsal rami of the corresponding cervical nerves C1–C3, possibly C4.

The insertion at the mastoid is palpated beneath the splenius capitis muscle and the sternocleidomastoid muscle from an initial posterior and inferior position following the muscle in a superior direction (Fig. 17.41). The origins are palpated from superior to inferior approaching the roots of the corresponding transverse processes.

SRS Correlation

Similar to the longissimus cervicis muscle, each origin to insertion unit of the longissimus capitis muscle represents one myotenone. The various muscles are differentiated from each other at their origins and the respective irritation zones.

Iliocostalis Muscle

Arises from the broad sacrospinous ligament and the ante-rolateral surface of the iliac tuberosity (Fig. 17.42).

Insertion

Inserts at the costal angle of the lower ribs, about IV–XII (Fig. 17.43).

Iliocostalis Thoracis Muscle

Origin

Arises medially at the costal angle of the lower ribs, about IV–XII (Figs. 17.42 and 17.44).

Inserts laterally at the costal angle of the upper ribs, VII–I (Fig. 17.44)

Iliocostalis Cervicis Muscle

Origin

Arises directly medial to the costal angle of the upper ribs, III (IV)–VII (Fig. 17.45).

Insertion

Inserts at the posterior tubercles of the transverse processes of C3 and C4 to C6 (refer to the insertion of the longissimus cervicis muscle) (Fig. 17.45)

Course and Relations

The iliocostalis muscle (Fig. 17.42) shows a roof-tile arrangement. The iliocostalis lumborum muscle ascends from inferior, traverses the posterior surfaces of the ribs going superiorly, and runs lateral to the longissimus thoracis muscle. In the neck, the iliocostalis cervicis muscle also lies lateral to the longissimus cervicis and capitis muscles, and medial to the posterior and medial scalene muscles, as well as the levator scapulae muscle. Its main course is in the sagittal plane. The iliocostalis cervicis muscle can be isolated anatomically but should be viewed as the direct continuation of the iliocostalis lumborum muscle (Figs. 17.43–17.45).

Innervation

Dorsal rami of the corresponding spinal nerves.

Action

Bilateral contraction results in extension of the spine. Unilateral contraction results in side-bending of the spine toward the side of the contracted muscle.

Palpatory Approach

At its origin, the iliocostalis lumborum muscle (Fig. 17.46) cannot be distinguished from the tendon of the longissimus dorsi muscle. In its course, the iliocostalis muscle is found lateral to the longissimus dorsi muscle. Inferiorly, it is possible to palpate the insertion tendinoses at the inferior edge and the posterior surface of the costal angle (Fig. 17.47). To avoid contact with the levator costae muscle, the direction must be perfectly inferior.

The iliocostalis cervicis muscle is relatively accessible to palpation. Following the costal angle of the ribs, the origins are approached by starting medially and superiorly and moving laterally and inferiorly. The insertions are palpated from inferior to superior at the posterior tubercles of the cervical transverse processes.

Spinalis Muscle

Spinous processes between T11 and L2 or L3 (Fig. 17.48).

Insertion

Tips of the spinous processes between C7, and T1 through T9 (Fig. 17.49).

Course

The longest fascicles run from L3 to C7 and T1. The shortest fascicles run from T11 to T8 or T9. This arrangement results in the largest muscle profile in the lower thoracic region. The fibers can be palpated above the tips of the transverse processes (when myotendinosis [e. g., hard palpable band] is present) (Figs. 17.50 and 17.51).

Innervation

Dorsal rami of the thoracic nerves T6–T8.

Action

Bilateral contraction results in extension of the vertebral column. Unilateral contraction results in side-bending (lateral flexion) of the vertebral column.

Palpatory Approach

The origin tendinosis of the spinalis thoracis muscle is palpated from a superior direction in order to reach the proximal pole of the spinous process. It must be differentiated from the adjoining origin tendinoses, for instance, that of the latissimus dorsi muscle in the lumbar region and the serratus posterior inferior muscle in the upper thoracic and cervical region (Fig. 17.52).

SRS Correlation

The spinalis muscle is spondylogenically and reflexogenically correlated with the lumbar spine.

Comments

As already noted, the spinalis cervicis and capitis muscles are nonuniform and, for all purposes, spondylogenically and reflexogenically insignificant.

Treatment of Erector Spinae Muscles in the Lumbar Region

NMT 2 (Figs. I17.3a–c)

Splenius Muscles

Arises from the lower half of the nuchal ligament, and from the spinous processes of C7 and T1–T3 (Fig. 17.54).

Insertion

Inserts at the lateral surface of the mastoid process, including its tip, and the occipital bone of the skull. This insertion forms a posterior arch that reaches the lateral half of the superior nuchal line (Figs. 17.53, 17.54).

Splenius Cervicis Muscle

Origin

Arises from the spinous processes and the supraspinous ligaments of T3–T10. The length of the tendons increases inferiorly. The parallel muscle bundles form a long, slender belly that is more vertical than that of the splenius capitis muscle and swings around the neck superolaterally (Fig. 17.54).

Insertion

Inserts via three tendons of disproportionate size at the first three cervical vertebrae. The largest fascicle inserts at the posteroinferior portion of the tip of the transverse process of the atlas. The second largest inserts at the tip of the transverse process of the axis, and the third inserts at the posterior surface of the transverse process of C3 (Fig. 17.54).

Course and Relations

The trapezius, the rhomboid, and the serratus posterior superior muscles cover a broad section of the inferior and medial portions of the splenius muscle. The sternocleidomastoid and the levator scapulae muscles cover the splenius muscle superiorly and laterally. The splenius muscle overlies the semispinalis capitis muscle. Many parts of the inserting tendons of the splenius cervicis muscles are fused with the tendons of the levator scapulae and the longissimus cervicis muscle. The free medial border of the splenius capitis muscle forms together with the nuchal ligament and the medial end of the superior nuchal line, a triangular space through which the occipital vessels and the greater occipital nerve emerge (Fig. 17.55).

Innervation

Dorsal rami of the cervical nerves C1–C5.

Action

Bilateral contraction results in extension of the head and the cervical spine. Unilateral contraction results in side-bending and rotation of the head toward the side of the contracted muscle.

Palpatory Approach

Due to its rather flat shape, the splenius muscle is not easily accessible to direct palpation. Palpation starts by identifying the spinous process of C3 superolaterally. While staying relatively superficial, the examiner follows inferiorly along C4–C5 to T5–T6. In the more inferior segments, the palpatory direction is primarily vertical. The inserting portion of the splenius capitis muscle is palpated inferiorly at the lateral surface of the mastoid process and is then followed along a curve that reaches the superior nuchal line. The largest tendon insertion of the splenius cervicis muscle is palpated posteroinferiorly, by approaching the tip of the transverse process of the atlas. The tendon insertions leading to C2 and C3 are substantially weaker and are palpated from a posteroinferior direction as well.

SRS Correlation

Both the splenius capitis and the splenius cervicis muscles are correlated with C7 as a single myotenone.

Motor End Plates

The splenius capitis muscle is a nonpennate muscle with a number of motor end plate zones, that correlate with their respective segmental innervation (Fig. 17.56).

Posterior Serratus Muscles

The muscle arises from the nuchal ligament close to the spinous process of C6 and from the tips of the spinous processes of C7, T1, and T2 (Figs. 17.57, 17.58).

Insertion

The muscle inserts via four fascicles at ribs II–V, lateral to the costal angles.

Course and Relations

This is a deep muscle that extends from the spinous processes to the ribs at an angle of about 30° and is primarily covered by the rhomboid and the trapezius muscles (Figs. 17.57, 17.58).

Innervation

Intercostal nerves of T1–T4.

Action

Rib elevation.

Palpatory Approach

Using an anterior and inferior approach, this deep muscle can only be palpated at the spinous processes, which requires that one localizes any insertion tendinoses. The latter must be differentiated from the spondylogenic correlation with the rhomboid muscle.

Arises from the spinous processes and the supraspinous ligament at T11–L2, occasionally L3. The tendon of the origin of the serratus posterior inferior muscle is virtually identical with the superficial layer of the thoracolumbar fascia and the lumbar aponeurosis of the latissimus dorsi muscle (origin) (Fig. 17.57, 17.58).

Insertion

The serratus posterior inferior muscle inserts by four fascicles at the inferior margin of ribs IX–XII between the origins of the latissimus dorsi and the iliocostalis muscles. The most lateral fibers travel to the ninth rib almost horizontally.

Course and Relations

This muscle, which shows a near-perfect horizontal course, is only covered by the latissimus dorsi muscle. The tendon and muscle junction is located at the lateral edge of the iliocostalis muscle, where a painful myotendinosis can often be found.

Innervation

Suboccipital Muscles (Overview)

Rectus Capitis Posterior Major Muscle

The rectus capitis posterior major arises from the spinous process of the axis (its lateral and superior half), and has a pointed tendinous origin. The thick muscle belly takes on a triangular shape, with its muscle bundles spreading toward the skull. In this arrangement, the muscle fibers are twisted so that those bundles originating most anteriorly have their insertion medially (Fig. 17.88).

Insertion

On the occiput, the lateral half of the inferior nuchal line (Fig. 17.61).

Course and Relationships

The rectus capitis posterior major muscle courses from its origin obliquely and superolaterally to the occiput and is primarily superimposed by the trapezius muscle (descending portion) and the semispinalis capitis muscle (Fig. 17.63).

Innervation

Dorsal rami of the spinal nerves C1 and C2.

Arises from the posterior tubercle of the atlas (Fig. 17.64).

Insertion

Inserts on the occipital bone, between the medial third of the lower nuchal line and the external margin of the occiput (Fig. 17.62).

Course and Relations

Covered mainly by the trapezius and splenius muscles (descending portion) as well as the semispinalis capitis muscle (medial portions) (Fig. 17.63).

Innervation

Dorsal rami of the spinal nerves C1 and C2.

Action

The main action of this short-lever muscle is that of posture and stabilization of the atlanto-occipital joint. Bilateral contraction results in extension of the head, and unilateral contraction results in lateral bending to the side of the contracted muscle.

Palpatory Approach

About 2 cm below the external occipital protuberance the palpating finger presses deeply, but very carefully, between the two semispinalis capitis muscles. The palpatory direction is such that one starts inferiorly, then goes from medial to lateral. Palpation of the origin at the posterior tubercle of the atlas is done at its usual anatomic location (Fig. 17.64).

SRS Correlation

This occipital muscle also represents a single myotenone.

Comments

Myotendinotic changes (i. e., palpable bands) in the rectus capitis posterior minor muscle can influence the normal physiologic motion in the atlanto-occipital joints.

Clinical Pearl

From this position one can use NMT2, where the patient’s head is resting in the examiner’s hand. The patient is asked to push downward into the hand against equal resistance and, during the relaxation phase, the head is carried more anteriorly in a stepwise fashion with each repetition of this step. It is surmised that with this procedure one is also able to potentially “induce” stretching of the nuchal ligament.

Obliquus Capitis Superior Muscle

This muscle originates from the transverse process of the atlas, in thick tendinous fibers from the posterior corner and the lateral segment of the C1 transverse process (Figs. 17.67).

Insertion

Inserts into the occipital bone at the superior to the lateral third of the inferior nuchal line (Fig. 17.65).

Innervation

Dorsal rami of C1.

Action

Bilateral contraction results in extension of the head. Unilateral contraction results in side-bending of the head toward the side of the contracted muscle.

Palpatory Approach

The origin is palpated inferiorly, below the most lateral insertion of the semispinalis capitis muscle (about 3 cm lateral to the external occipital protuberance). The origin is palpated superoposteriorly in the direction of the tip of the transverse process of the atlas (Fig. 17.66).

SRS Correlation

The posterior cervical intertransverse muscles and the obliquus capitis superior muscle play an important role in the spondylogenic event.

Even though the obliquus capitis superior muscle belongs anatomically to the posterior cervical intertransverse muscle group, it has been reported that it is spondylogenically and reflexogenically correlated with the sacroiliac joint.

Obliquus Capitis Inferior Muscle

Origin

The spinous process of the axis.

Insertion

The transverse process of the atlas, along the inferior and posterior surface.

Course and Relations

Refer to Figures 17.63 and 17.67.

Fig. 17.65 Muscle attachments at the occiput (see Fig. 17.62 for specific muscles).

Innervation

The patient is in the supine position. The examiner cradles the patient’s head by placing one palm over the patient’s occiput while the other embraces the forehead. The examiner then carefully introduces flexion to the upper cervical spine, specifically inclination to the upper cervical spinal segments, while at the same time applying traction. The axis of rotation is hypothetically placed through both mastoid processes (Fig. 17.68).

Positive Findings

1. Loss of inclination motion with soft end-feel indicates shortening of the suboccipital muscles.

2. Loss of inclination motion with hard end-feel indicates degenerative joint changes.

Transversospinalis Muscle Group (Semispinalis, Multifidus, Rotatores)

Semispinalis Muscle – Overview

Spanning from the sacrum to the upper cervical spine, the semispinalis muscle is a long and rather flat muscle that is made up of many divergent fascicles. From superior to inferior, the muscular units overlap each other in a roof-tile manner. Starting at the axis and going inferior, the characteristic feature of the transversospinal muscle system is determined by the muscle’s shape and varying length: the muscle fibers originate from an individual transverse process but then the various muscle slips fan out to attach at several spinous processes. which explains the different lengths. The superficial portions are the longer muscle sections with the fibers running nearly vertically. The deeper muscle portions are the shorter components of the muscle with the fibers extending in a transverse direction (Figs. 17.69, 17.70).

Semispinalis Lumborum Muscle

Origin

The muscle arises by a strong fascia from the mamillary processes of S1, L5, and L2.

At L1 and T12, the muscles originate directly from the vertebra’s mamillary processes.

• Cervical portion: the superior margin of the transverse processes of upper thoracic vertebrae, T2 through T5 (Fig. 17.71).

Insertion

The structure of the myotenone remains the same as described previously. The insertions are found at the spinous processes, which are six to seven segmental levels higher than the vertebra from which the myotenone originates. The insertion tendinosis is most prominent at the medial and posterior margin of the muscle (Figs. 17.69, 17.71).

Course and Relations

All three semispinalis muscles are positioned at the same level. The superior surface is covered by the longissimus muscle and the spinalis muscle, and partially by the semi-spinalis capitis muscle (Fig. 17.70). A thin connective-tissue layer demarcates this muscle from the multifidus muscle below, which is important for palpation. Differentiation from the multifidus muscle is facilitated by recalling that the longest portions of the multifidus muscle skip two fewer vertebrae than the semispinalis muscle.

Innervation

Dorsal rami of the spinal nerves.

Action

Bilateral contraction results in extension of the vertebral column. Unilateral contraction results in contralateral rotation of the vertebral column.

Palpatory Approach

Due to its frequent spondylogenic participation, exact palpation of the transversospinal system is extremely important. As a result of the close anatomical arrangement at the mamillary or transverse processes, it is difficult to distinguish between a tendinosis at the origin of the semispinalis muscle, and other muscles including the multifidus muscle and the rotator muscles. Only when the attachment tendinoses are present at both poles of the muscle is differentiation possible.

The rotator muscles pass from one vertebra to the first or second above (be aware of the difference between the anatomical and spondylogenic units). The multifidus muscle passes from one vertebra to the third above and inserts via three fascicles. The semispinalis muscle extends from one vertebra to the sixth above and inserts via two fascicles. When a painful superior margin of the mamillary bodies is located, all seven spinous processes must be palpated from their lateral aspect to the root in order to eliminate the rotatores muscles and the multifidus muscle as the source of the dysfunction and pain.

The origin tendinosis is determined to belong to the semispinalis muscle when the insertion is on opposite poles and lies six to seven segmental levels above the roots of the spinous process. The myotendinosis of the individual muscle fibers can normally be palpated as a thin matchlike band.

SRS Correlation

The spondylogenic unit, the myotenone, is represented in Fig. 17.72. The 17 myotenones of the semispinalis muscle are correlated with the spinal segments C0 through T9.

Related posts:

Evidence Base in Manual Medicine for the Treatment of Back Pain Syndromes: Background, Status, and Practice The Pharmacologic and Psychologic Treatment of Chronic Pain Nonradicular Pain: Spondylogenic and Myofascial Pain Syndromes Myofascial Trigger Point Treatment Imaging Studies of the Spine Structural and Functional Diagnosis and Treatment of the Spine, Ribs, Pelvis, and Sacroiliac Joint

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