Clinical Anatomy

Tubercle

Tubercle

Small raised eminence

Tuberosity

Large, rounded elevation

Fossa

A shallow depression or hollow

Process

Projecting spine like part

Trochanter

Large Blunt elevation

Condyle

Rounded articular area

Epicondyle

Eminence superior to a condyle

126 bones, Bones of extremites

Upper Extremity (UE): Lower Extremity:

Scapula Pelvic Girdle

Clavicle Femur, Patella

Humerus Tibia, fibula

Ulna Tarsals, Metatarsals

Radius Phalanges

Carpals

Metacarpals

Phalanges

Appendicular

80 Bones

Upright Portion of the body

Head/Cranium

Spinal Column

Sternum

Ribs

Axial Skelton

• Essentially Immobile

• Can be partially mobile depending on the length of the fibers uniting the articular bones

• Ex) Between shafts of radius and ulna, Sutures of cranium

Fibrous

Essentially immobile.  Fibrocartilaginous are partly moveable (intervertebral discs).

Cartilaginous

Mobile Joints

• Space, synovial fluid, articular cartilage, fibrous layer and synovial membrane (joint capsule), ligaments

Synovial

Occurs in same liner path, starting in one place and ending in another

Objects remain in their original orientation

2 points in a segment move at the same speed

Linear/Translatory/Gliding

Occurs in a circular path around a central point

Objects change orientation during movement

2 points in a segment move at different speeds

Close to the center moves slower

Farther form center moves faster

Rotary/Angular

Types of Synovial Joints and examples

• Ball and Socket (hip, shoulder)

• Hinge (Elbpw, IP)

• Plane/Gliding (Intercarpal, Intertarsal, AC)

• Ellipsoidal (condyloid) (Radiocarpal, MCP)

• Saddle (thumb CMC)

• Pivot (atlas-axis, proximal radioulnar joint)

Mechanical principles/laws that relate directly to movement and the effect force has on the human body

Biomechanics

Kinetics Vs Kinematics

Forces causing movement - Kinetics

Time, space, mass, aspects of movement - Kinematics

Types of Forces: Internal vs External

• Internal- within the body (ex. Muscle contraction--agonist pulling \n against antagonist

• External- outside of body (ex. gravity, therapist, therapy bands, \n weights, wind, water-ocean waves, motorized objects; the ground on \n which we step or roll).

Line of Pull

Muscles pulls from its insertion to its origin

Force Couple

two or more forces (three seen in picture) pulling in different directions creating a turning effect or rotation

Moment Arm

perpendicular \n distance b/t the muscle’s line of \n pull and the center of the joint

Where should you MMT & Why

Always MMT at mid- point of movement because that is when the moment arm is strongest

COG vs BOS vs LOG

COG : Center of gravity. Balance point of object, where all three planes intersect Slightly anterior to s2

BOS: Base of support. Part of body in contact with supporting surface

LOG: Line of Gravity. Imaginary vertical line passing COG

Lower the COG

The more stable the object

How to INC stability (4)

Widen the BOS in direction of force

Greater mass = Greater Stability

Greater friction between BOS and underlying surface = INC Stability

When a person visually focuses on stable object

Stability Facilitated by

Low COG

Wide BOS

LOG @ center of support

Hvy Weight/large mass

Mobility Facilated by

High COG

Narrow BOS

LOG away from center of support

Light Weight/Small Mass

Spinal Cord VS spinal/vertebral column

Spinal cord is made of nervous tissue.

\n Spinal column and vertebral column are synonymous terms referring to the bony components housing the spinal cord

Good vs Poor posture

• Good Posture- Good alignment of vertebral column; Good distribution of weight through base of support

• Poor Posture- Any posture deviating from “good”.

Benefits of Good Posture

Reduction of Injury by Dec amount of stress on ligaments, tendons, and muscles

↑’d function

↓’d energy expenditure \n ↓’d 2° complications

Poor Posture results

2° medical complications... \n  -pressure ulcers \n  -↓’d respiratory functions \n  -↓’d functional abilities – horizontal gaze, UE function, etc

Kyphosis

↓’d pressure on facets; \n ↑’d pressure on disks \n  tight flexors, stretched extensors

Lordosis

DEC pressure on disks;

INC pressure on facets \n  tight extensors, stretched flexor

Primary Curves

Flexed Curves, Thoracic and Sacral

Secondary Curves

Lumbar and Cervical

Posture Development

Prenatal

1-4 Months

4-6 mo

6-8 mo

10-12 mo

2-3 y

6-7 y

10 y

Adolescent

Old age

Pre-natal – movement in 1st trimester \n  1-4 mos. - primarily flexed – C-curves \n  4-6 mos. - 2° curves – prone \n  6-8 mos. - 2° curves – sitting \n  10-12 mos. – standing \n  2-3 yrs - ↓ lordosis \n  6-7 yrs – longitudinal arch in foot develops \n  10 yrs - ↓ protruding abdomen \n  Adolescence – faulty postural habits begin to emerge – possibly 2° growth in certain \n areas \n  Old age – elders – “forward pitch” – ant. to plumb line, wide BOS, flexed hips/knees, \n flattened L-spine, ↑’d thoracic kyphosis, forward head posture 2° ↓’d vision, \n osteoporosis, habitual Δ’s throughout life

Flatback

↓’d lumbar (lordotic) curve

Sway back

↑’d lumbar (lordotic) curves

Plumb Lines

lateral, anterior/posterior – gravity line from ceiling to floor; used to assess posture; can also use postural grid

Postural Sway

ANT-Post Motion

Antigravity Muscles

muscles that keep our body upright in static and dynamic positions – \n primarily neck/trunk and hip/knee extensors

Advantages of Bipedal (upright Position)

• ↑’d mobility of upper extremities/hands for activities

• ↓’d effort required – as long as we maintain correct posture

• ↑’d mobility of body 2° higher COG

• Frequent body position changes aid in circulation – prevent DVTs

Disadvantages of Bipedal (upright Position)

DEC stability

INC stress on Vertebral Column

Head – through earlobe \n  Shoulder – through acromion process \n  Thoracic spine – ant. to vert. bodies \n  Lumbar spine – through vert. bodies \n  Pelvis – through greater trochanter \n  Hip – through greater trochanter \n  Knee – post. to patella \n  Ankle – ant. to lateral malleolus

Lateral Plumb Line

Head – straight ahead, not tilted \n  Shoulders/scapula – level, not elevated or depressed \n  Sternum vs. spinous processes – centered \n  Pelvis – ASIS vs. PSIS – level \n  Legs – slightly abducted \n  Knees – level, not bowlegged or knock-kneed \n  Ankles/Feet – neutral, slight outward toeing; \n calcaneus straight

Anterior and Posterior Plumb Lines

BODY POSITION: Least Recommended secondary position of neck and need to breathe: may be needed for hip contractures

Prone

BODY POSITION: Least amount of Disk pressure

Good = balance b/t support of curves and conformity to curves

Supine

Trunk – should maintain same plumb line \n  Head/neck – mid-line \n  UEs – supported with pillow b/t for alignment (various positions for those with neurological impairments) \n  LEs – supported with pillow b/t for alignment \n  bottom leg – knee naturally extended \n  top leg – knee slightly flexed

Proper Side Lying

O, I, A, N

Origin,

Insertion, \n Action,

Nerve Innervation

Parrell vs Oblique Muscles

• Parallel- tend to be longer; greater potential for shortening and thus produces more ROM

• Oblique- tend to be shorter (feather arrangement); denser: strong but smaller ROM produced.

Elasticity vs Contractility vs Extensibility

Elasticity: muscle’s ability to recoil or return to normal resting length when the \n stretching or shortening force is \n removed

Contractility: MA to contract and generate force when it receives stimulation

Extensibility: MA to Strech or lengthen when a force is applied

Impacts of gravity

• Movements against Gravity- moving away from the ground surface

• Gravity Reduced (a.k.a. Gravity Eliminated)- typically moving in the \n horizontal plane

• Gravity Assisted- moving toward the ground surface

CNS Disorders and Diagnoses

Cerebrovascular Accidents (CVA/Stroke) \n • Traumatic/Acquired Brain Injury (TBI/ABI) \n • Amyotrophic Lateral Sclerosis \n • Alzheimer’s Disease \n • Huntington's Disease \n • Multiple Sclerosis (MS) \n • Parkinson's Disease

PNS Disorders and Diagnoses

Guillain-Barre’ Syndrome \n • Poliomyelitis and Post polio Syndrome \n • Peripheral Nerve Injuries/Lacerations \n • Myopathic Disorders \n • Muscular Dystrophies \n • Neuromuscular Disorders \n • Myasthenia Gravis

Autonomic Nervous System

“involuntary”

Regulates functions of our internal organs, heart, stomach, lungs, intestines

Somatic Nervous System

“Voluntary”

Part of PNS connects brain to the motor neurons such as those found in the skeletal muscles

consists of both afferent (sensory) and \n efferent (motor) nerves.. \n • It is also responsible for the reflex arc

PNS includes both…

the 12 pairs of cranial nerves and all the nervous tissue outside of the \n vertebral column (for the most part); begins at anterior (ventral) horn of spinal cord sending motor impulses (Efferent) out to muscles and receiving sensory impulses \n (Afferent)

Spinal Cord

main pathway for information connecting the brain and peripheral nervous system

Approx 17 inch long

Spinal Column

the vertebral bodies that house and protect the spinal cord

Parts of Spine

Cervical, Thoracic, Lumbar, Sacral, Coccygeal

Cervical

8 pairs of nerves; \n • 7 vertebral bodies; 1-7 exit above \n vertebral body, but 8 exits below C 7

Thoracic

12 pairs of nerves

12 bodies All nerves exit below vertebral bodies

Lumbar

5 pairs of nerves

5 bodies All nerves exit below vertebral bodies

Sacral

5 pairs of nerves

5 bodies All nerves exit below vertebral bodies

Coccygeal

1 pair

Spinal Nerves

formed by any one of the paired peripheral nerves from each of the spinal cord levels.

spinal nerves that join together and/or branch out to form a “network”

Plexus

Where do Cervical, Brachial and Lumbosacral plexus run

Cervical plexus- C1-C4 (innervates mm of neck) \n • Brachial plexus- C5-T1 (primarily innervates mm of the upper limb) \n • Lumbosacral plexus- L1-S5 (innervates lower limb)

Nerve

A nerve is a bundle of fibers composed of neurons that carry electrical impulses and chemical signals to transmit sensory and motor information from one body part to another.”

Neuron

Information Messengers

They use electrical impulses and chemical \n signals to transmit information between \n different areas of the brain, and between \n the brain and the rest of the nervous \n system

Afferent vs Efferent Nerves

Afferent/Sensory- brings information in. Through dorsal root Efferent/Motor-sends information out/exits. Through ventral root

Basic motor pathway involves

upper motor neurons (UMN) which sends signals down the spinal cord \n to the lower motor neurons (LMN). The UMN travels through the ventral horn of the spinal cord and synapse with the lower motor neurons and send their signals through peripheral axons to the neuromuscular junction (the synapse of the neuron with its muscle fiber) of skeletal muscle.

UMN

Ex of injuries

Upper motor Neron

Motor neuron that travels from the brain or brainstem down the spinal cord and synapse above the anterior horn (just prior to leaving the spinal cord)

SCI, MS, PArkinsons, CVA, Head injuries

LMN (Lower Motor Neuron)

EX of injuries

• Motor neurons that synapse at the anterior horn of the spinal cord \n • Injury to = MD, Polio, Myasthenia Gravis, peripheral nerve injuries

How is spinal cord Injuries (SCI) named

SCI named by last fully innervated level

Causes of Poor Posture

structural/congenital, habit (functional), trauma (acute injuries), neurological conditions – muscle imbalances 2° weakness and tonal imbalances

A muscles characteristic of responding to stimulus, an impulse from a nerve or external application of electrical current, resulting in contraction

Irritability

Four characteristics of muscle

Irritability, Extensibility, Contractility, Elasticity

ANT tilt vs POST tilt Pelvis

Ant tilt: Pressure on Facets, dec pressure on disk Tight EXT, Lengthened Flexors

POST tilt: Dec pressure on Facets and INC pressure on disk, Tight flexors, Lengthened EXT

Define Dermatome and importance

Dermatome is an area of skin that is mainly supplied by single spinal nerve

When injury involves only one spinal nerve, sensation will be DEC or altered but not lost completely

Anterior Thigh Nerves

Hip Flexors, and Knee Extensors

Femoral Nerve

Exceptions: PSOAS (lumbar)

TFL (superior gluteal nerve)

Posterior Glutes

Hip Extensors/Abductors/Rotators

Glute Max: Inferior Gluteal Nerve

Gluteus Medius and Minimus: Superior Gluteal Nerve

Medial Thigh Nerves

Hip Adductors

Obturator Nerve: Pectineus

Posterior Leg

Knee Flexors (hamstrings) and Ankle Plantar Flexors

Tibial Nerve

Exception: Bicep Femoris Short Head (fibular nerve)

Anterior Lower Leg

Ankle Dorsiflexors, Everters, Inverters) \n • Fibular Nerve (A.K.A. Peroneal Nerve) \n • Tibialis Posterior is an ankle inverter and is located on the \n posterior leg. It is also a plantar flexor and is innervated by the \n Tibial N. \n • Also...Fibularis Longus/Brevis \n • Location is slightly more lateral (vs. truly anterior or posterior) \n • Fibular Nerve

Sciatic Nerve

Two Nerves (Tib and Fib) are loosely bound together in the upper posterior portion of the leg

This bundle is referred to as the “sciatic nerve” - The two nerves separate in the \n inferior 1/3 of the thigh into the tibial (posterior lower leg) and fibular (anterior \n lower leg).

Joint range of motion

Amount of movement that is possible at a joint

Muscle Strength

The maximal force you can apply against a load/resistance

Why do we assess ROM

Decreased ROM can cause limited functionand interfere with performance in areasoccupation.
May affect both speed and strength ofmovement.
People who constantly have to work toovercome the resistance of an inflexiblejoint will probably demonstrate decreasedendurance and fatigue easily during activity.

If recovery or improvement is expected

Plan for intervention designed to remediate or restore (INC and maximize return)

If permant issue

Plan for interventions designed to modify or adapt(use of adaptive equipment and techniques)

Observation: Note how the patient

- Ambulates and moves within the environment- Sits & rises from the chair- Gets on & off the plinth or other surfaces- Changes positions- Performs functionally- dressing, toileting, bathing, etc. .- See if there is symmetry of both sides

Range of motion

Arc of motion that occurs at a joint
Starting position is anatomical position
0-180 degrees (always a range)

Informal measurements and Formal measurements of rom

Informally:◦ Eyeball◦ Degrees◦ Quarters◦ Occupation Based Functional Motion Assessment
Formally:◦ Goniometry

Goniomterty

Measurement of angles created atjoints by the bones
Measures:◦ amount of motion at joint◦ abnormal fixed positionsCan measure:◦ active and passive joint motion

HOW DO WE USE IT (THEMEASUREMENT)? Goniometry

Determine the presence/absence of impairment

Establish diagnosis

Evaluate progress of therapy

Motivate patient

Fabricate adaptive equipment

Competnecy in Goni: Must have knowlegde of

Joint structure & function
Testing positions
◦ Position & stabilize correctly
Anatomical bony landmarks
Instrument alignment
Typical ROM
Normal end-feels and determine end-feel
Reading instrument
Recording data

Precautions

a measure taken beforehand to preventharm or secure good

Contraindications

something (such as a symptom orcondition) that makes a particulartreatment or procedure inadvisable

Contrindications for ROM

Joint dislocation
Myositis ossificans
Recent/unhealed fractures
Immediately following surgery