466 SECTION FOUR Protection of the body and continuation of the species @ SPOT CHECK 7. What isthe difference between rotation and circumduction? 8, The glenoid cavity ofthe scapuia is very shallow. How is the head ofthe humerus held frmiy in such a shallow cup? Skeletal muscle Learning outcomes ‘Atr studying this section, you should be able to: '= identity the main characteristics of skeletal muscle i relate the structure of skeletal muscle fibres to their contractile activity 1= describe the nature of muscle tone and fatigue 1 discuss the factors that affect the performance of skeletal muscle ‘= name the main muscles of the body regions described in this section |= outline the functions of the main muscles described in this section, Muscle cells also called muscle fibres) are specialised contractile cells, The three types of muscle tissue, smooth, cardiac and skeletal, differ in structure, location and physiological function. Smooth muscle and cardiac muscle are not under voluntary control and are discussed elsewhere (pp. 55 and 56). Skeletal ‘muscles, which are under voluntary control, are attached to bones via their tendons (Fig. 1659A) and move the skeleton. Like cardiac but not smooth muscle, skeletal muscle is strated (striped), ancl the stripes are seen in a characteristic banded! pattem when the cells are viewed under the microscope (Fig, 16.598 and Fig, 16.60) Organisation of skeletal muscle A skeletal muscle can contain hundreds of thousands of muscle fibresaswellas blood vesselsand nerves. Throughout the muscle, providing internal structure and scaffolding, an extensive network of connective tissue. The entire muscle is covered in a connective tissue sheath called the epimysium, Within the muscle the fibres are collected into separate bundles called fascicles, and each fascicle is covered in its own connective tissue sheath called the perimysium. Within the fascicles individual muscle fibres are wrapped ve tissue laye in a fine conne alled the enelomysium, Fach of these connective tissue layers runs the length of the muscle. They bind the fibres into ab ly organised structure and blend together at each end of the muscle to form the: tendon, which secures the muscle to bone Often the tendon Faside —Permysun B_ Musce fire (cel) Mtochondria ‘Myofis Sarcomere “Thin aman’ Act c ask band Ugh band Myofb contacted Fig. 16.59 Organisation within a skeletal muscle. (A) A skeet ‘muscle and its connective tissue. (B) A muscle fibre (cel) (C) rnyolibi, relaxed and contracted is ropesiike but sometimes it forms a broad sheet cal aponeurosis, eg the occipitofrontalis musele (see fs, The multiple connective tissue layers throughout the mi are important for transmitting the force of contract each individual muscle fibre to its points of the skel The fleshy part of the muscle is called the belly ache Skeletal muscle cells ( Contraction of a whole skeletal muscle occurs because coordinated contraction ofits ividual fibresfemme ae Zine Zine Fig. 16.60 Coloured transmission electron micrograph of part of ‘skeletal muscle fibre, showing the characteristic banding pattern ‘and multiple mitochonafa, (Steve G Schmeissner/Science Photo brary. Reproduced with permission.) ‘Structure Under the microscope, skeletal muscle fibres are roughly cylindrical in shape, lying parallel to one another, with a distinctive banded appearance of alternate dark and light stripes (Figs 16.598 and 16.60). Muscle fibres run the length of the muscle, from one end to the other, and so individual fibres may be very long, up to 35cm in the longest muscles. Because they are so large, each fibre has multiple nuclei located just under the cell membrane (the sarcolemma). The cytoplasm of muscle cells, also called sarcoplasm, is packed with tiny thread-like filaments called myofibrils running longitudinally along the length of the fibre. They also have many mitochondria (Fig. 1660), essential for roducing, adenosine triphosphate (ATP) from glucose and appt power the contractile mechanism. Abo preset a specialised oxygen-binding substance called myoglobin, which is similar to the haemoglobin of stores oxygen within the muscle. In a : stores of calm, which is reas in the muscle is stimulated by its ae activity of the red blood cells and iddition, there are extensive intracellula which is released into the sarcoplasm w! ‘motor nerve and is essential for the contractile myofilaments, Actin, myosin and sarcomeres The myofibrils inside the muscle fibre of contractile proteins, called actin ( yen Cn aa 1), ing the EE contain two types hin) filaments and lating units called ‘The musculoskeletal system CHAPTER 16 — Myelin sheath — Axon of motor nerve Skeletal muscle ceis Myotioris within muscle fores Synaptic knob < [~synapte ct "ACH receptor ‘Synaptic vesicle containing acetylcholine (ACh) Fig. 16.61 The neuromuscular junction. striped appearance. Because the myosin filaments are thick, they show up as dark bands under the microscope. The light bands contain only thin actin filaments. Sarcomeres are divided from each other by a dense stripe, the Z line, to which the actin fibres are attached, pointing into the middle of the sarcomere. Running up the middle of the sarcomere is the M line, with the myosin filaments projecting out from each side of it. The ends of the myosin filaments overlap with the ends of the actin filaments. This overlap allows them to attach and slide over each other during muscle contraction, The neuromuscular jur The skeletal muscle cell contracts in response to from a motor nerve fibre, which usually synapses muscle cell about halfway along its length between a motor nerve ending anc! its skeletal called the neuromuscular junction and the transit acetylcholine (ACH) (Figs 16.61 and 16.62 ACh receptors at the neuromuscular junction le neuromuscular blockers and are used as adjune esia and surgery, to paralyse the skeletal muscles and facilitate capac emu HE468 SECTION FOUR Protection of the body and continuation of the species Motor terminals t moor and pats ‘Skeletal muscle foxes Motor nene Fig, 16.62 Colour transmission electron micrograph of a motor neurone and two ofits motor end-piates. (Kent Wood/Science Photo Library. Reproduced with permission) access to deeper structures, However, as the diaphragm is also composed of skeletal muscle, patients treated with neuro- ‘muscular blocking drugs must be artificially ventilated When it is very close to the muscle cell, the motor tive fibre splits into a sheaf of very fine synaptic knobs, which come into very close proximity to, but do not actually make direct contact with, the sarcolemma (for a general description ‘of synaptic physiology see p. 163). This area is called the motor cend-plate (Fig, 16.62). Each individual synaptic knob forms a ‘synapse between the motor nerve and the muscle fibre, Skeletal muscle contraction ‘ACh release at the neuromuscular junction generates an action potential that spreads rapidly along the muscle cell ‘membrane. However, in order to activate the contractile machinery inside the muscle fibre, the action potential is also conducted throughout its interior through a specialised network of channels running through the sarcoplasm. This releases calcium from the intracellular stores, which triggers the binding of actin and myosin to each other, forming so- called cross-bridges between them, ATP is split to provide the energy for actin and myosin filaments to slide over each other, pulling the Z lines at each end of the sarcomere closer to one another and shortening it (Fig, 16.59C), This is called the sliding filament theory. If enough fibres in the muscle are simultaneously stimulated, the whole muscle undergoes a degree of contraction. The more individual fibres that are “ctimulated, the greater the degree of contraction. The muscle relaxes when motor nerve stimulation stops. Calcium is pumped back into its intracellular stores, breaking the cross-bridges between the actin and myosin filaments, They slide back into their re ing the muscle to its original length. ng positions, lengthening, the sarcomere and ret Motor units Each muscle cells stimulated at only one motor endplate, but teach motornerve can divide into multiple branches and so can Stimulate several muscle fibres. Figure 16.62shows an electron tricrograph of a motor nerve and two ofits motor endplates, Oncnervefibreandallthe musclecellsitsuppliesconstitute ‘a motor unit, The force of muscle contraction depends on, cular time, The how many motor units are in action at a P: more motor units that are simultaneously stimulated, the sgreater the force of contraction. Some motor units contain large numbers of muscl jie one nerve stimulates many muscle cells. This a is associated with large-scale, powerful movements, such as in the legs or upper arms, Fine, delicate control of muscle movements achieved when one motor unit contains very few muscle fibres, asin the muscles controlling eye movement Action of skeletal muscle When individual muscle cells ina muscle shorten, they pull on the connective tissue framework running through the whole ‘muscle and the muscle develops a degree of tension (tone). Muscle tone Whena muscle fibre contracts, it obeys the all-or-none law, ie. it cither contracts completely or does not contract atl. The degree of contraction achieved by a whole muscle therefore depencls ‘on the number of its fibres that are contracting at any one time, as well as how frequently they are stimulated. This means that in order to increase the strength of a muscle contraction, more ‘motor units must be activated; to lift a heavy weight, more active muscle fibres are required than tolifta lighter one. Muscle tone is a sustained, partial muscle contraction that allows ‘maintenance of posture without tiring the muscles involved. For instance, keeping the head upright requires constant activity of the muscles of the neck and shoulders. Motor units within these muscles take it in tums to contract, s0 that at any one time some muscle cells are contracted and others are resting, This allows the effort required to hold the head upright to be distributed! throughout the muscles involved. Good muscle tone, promotes! by regular exercise, protects joints and gives a muscle firmness and shape, even when relaxed Muscle fatigue To work at sustained levels, muscles need an a¢ supply of oxygen and fuel such as glucose. The fatigues when it works at a level that exceeds these sv and its performance declines. ‘The chemical energy (ATP) that muscles need is generated from the breakdown of carbohydrate protein may be used if supplies of fat and carbohy: exhausted. An adequate oxygen supply is needed release all the energy stored within these fuel m0 without it, the body uses less efficient anaerobic 1 pathways that produce lactate the physiological for acid), Lactate accumulation in strenuously working ©The musculoskeletal syst tomas Aotagonst Treeps Biceps contacts relaxes Antagonist Agora Treeps Fig. 16.63 The action of antagonistic muscle pairs: the bicaps and tnceps (A) Forman extension 8) Forma Hox cases muscle pain and fatigue. Fatigue may also be due ty Skeletal muscles and ot skeletal muscle phvsical muscle injury, which may foto episnes — pertorming the same action generally work in antagonéstic pairs, This ensures that for 2 given movement, there isan opposing muscle group that can perform the opposing Muscle recovery stn. The muscle or muscle performing a moveme ime movers), and the opposing Df strenuous activity, eg are Alter exereise, muscle needs a period of time to recover, called the agonists) « wplenixh its ATP and glycogen stores and to repair any muscles) ate called damage, For some time following exercise, depending on must be tel ‘ertion, the oxygen debt, an extended period — movement to take place and and, remains as the body converts torved stretching, antagonist(s) Antagonist muscle ed during muscle movement, to perimit the the dogo prevent injuring it during Linc teasead oxygen det slate ta pyruvate and replaces its energy’ stores For example, when the elbow is bent during flexion of forearm, the agonist is biceps beach, whic 1 ans Factors affecting skeletal muscle performance — jhe scapula at one end anal on the radius at ¢ Sheletl mute pertorms bother when its 168A), When it contracts pulls or the rad itu improves enaturanee and power. Anaerobic training, forearm up towards the upper arm and bending. the Ibo ehhasmenththiting, creases muscle bulk Fecauseit increases The muscle opposing this movement is the ‘siveps sich ive of anti ida muse fibres (hypertrophy, see must be actively relayed toallow flexion to take place for the opposing movement, extension of the forearin (hig 15658 ones eae the triceps tecomes the ana! the biceps the antagonist dor tr munve-a boaly part, the muscteor its tendon must 'Sometric and isotonic contraction Panne cet one pint Whenat contracts the muscle Contraction of a muscle usually shorter thor patlonns bung toware another The ongin of a muscle for instance to the biceps muscle if the forearm Jeanette prevwnal attachment anal is generally ofthe pick up a cup. The power generate by the muse onetthat teats cait when the muste contracts. proving t0 litt the manageable weight and tension i penn nc nanny pall asunst The insertion ob muscle is femains constant In this situation the contrast aeannnee een Ltatachment site an tssenerally onthe hone Se isotonic (se = same, tonic = t aoe ccna vacie muscle contracts. For example, the frving to fit an Ack man with Fooeeee ace ee uaakler caw Tig. 165) originates on would be unable to perform this ash, t ante ithe sho le and inserts armand shoulder would still work hard ev Henne them i sneracts. the upper arm moves it In Uhis situation, because the resist ao ley snie hs emaine sta weight is too great for him to be move Ht470 ‘Shape Trapezius Fibre direction Oblique musces of abdomen Muscle position Tibia Movement produced Extonsor carpi uinats Number of points of attachment Biceps baci Bones to which muscles attached Carpi radials muscles Aponeurss of ‘captors —__ Orcipttontas (anterior part Later papebrae ‘superiors Ottis ou Orbis os — a Booch Masser SECTION FOUR Protection of the body and continuation of the species ‘Comment. Trapezium-shaped Fibres run oblquely at an angle) Found close tothe tibia inthe leg ‘Attached to the carpal bones athe wrist and the ulna and extn the wrist Bi means two; this muscle has two points of attachment a the shoulder ‘Altached to the carpal bones ofthe wrist andthe racius ofthe forearm (posto par) Fig, 16.64 The main muscles on the let sie ofthe face, head and neck. lifter, the muscles would be unable to shorten, but the work they are doing increases the muscle tension instead. This is isometric contraction (iso = same, metric = length), Principal skeletal muscles Muscles are named according to various characteristics (Table 16.7) and becoming familiar with the main ones makes it much easier to identify unfamiliar muscles, This section ‘considers the main muscles that move the limbs, as well as the major muscles of the face and neck, back, chest floor and abdominal wall. Muscles of the faci e and neck ‘These are shown in Figure 16,64, Muscles of the face Facial muscles change facial expression and move the | Jaw during chewing and speaking. Only the main 1" "ietery are described here. Except where indicated, the muscles are present in pairs, one on each side. Occipitofrontalis (unpaired) ‘This has a posterior muscular part over the occipital bone (occipitalis), an anterior part over the frontal bone (frontalis) and an extensive flat tendon or aponeurosis that stretches ‘over the dome of the skull and joins the two muscular parts Itraises the eyebrows, Levator palpebrae superioris ‘This muscle extends from the posterior part of the orbital cavity to the upper eyelid. It raises the eyelid. Orbicularis oculi ‘This muscle surrounds the eye, eyelid and orbital cavity. It closes the eye and, when strongly contracted, screws up the eyes. Buccinator ‘This flat muscle draws the cheeks in towards the teeth in chewing and in forcible expulsion of air from the mouth (the “trumpeter’s muscle’) Orbicularis oris (unpaired) This muscle surrounds the mouth and blends with the muscles of the cheeks. It closes the lips and, when strongly contracted, shapes the mouth for whistling, Masseter ‘This broad muscle originates from the zygomatic arch and. inserts on the angle of the jaw. In chewing, it draws the ‘mandible up to the maxilla, closing the jaw and exerting, considerable pressure on the food. Temporatis This muscle covers the squamous part of the temporal bone. In passes behind the zygomatic arch and inserts into the coronoid process of the mandible. It closes the mouth and helps with chewing. Prerygoid This musele extends from the sphenoid bone to the mandible. Iteloses the mouth and pulls the lower jaw forwards, Muscles of the neck There are many muscles in the neck but only the two largest are considered here, ‘Stemnocteidomastoi ‘le originates from the manubrium of the sternum and the clavicle and extends upwards to insert on the mastoid process of the temporal bone, It tums the head! from side to idle, ant when the muscle on one side contracts, it draws the head towards that shouilder. ILis an accessory muscle of respiration, and in forced inspiration, pulls the sternum and clavicles upsvards to help expand the ribeag ‘The musculoskeletal system CHAPTER 16 Trapezius This large muscle covers the shoulder and the back of the neck. It has multiple origins on the occipital bone and the transverse processes of the cervical and thoracic vertebrae and it inserts on the clavicle and the spinous processes and acromion of the scapula. It pulls the head backwards, squares the shoulders and controls the movements of the scapula when the shoulder joint is in use, Muscles of the trunk ‘These muscles of the back, abdominal wall and thorax stabilise the association between the appendicular and axial skeletons at the pectoral girdle. They also stabilise and ailow movement of the shoulders and upper arms. Muscles of the back ‘There are six pairs of large muscles inthe back, in addition to those forming the posterior abdominal wal. The arrangement of these muscles is symmetrical on each side of the vertebral column. They include the trapezius (see above) and the psoas {sce later) and the remaining four are described beiow Latissimus dorsi This muscle (Figs 16.63 and 16.67) originates on the posterior part ofthe iliac crest and the spinous processes of the lumbar and lower thoracic vertebrae. It passes upwards across the back, under the arm and inserts into the bicipital groove of the humerus, It adducts, medially rotates and extends the Teres major ‘This muscle (Fig, 16.65) originates from the inferior angle of the scapula and inserts into the humerus just below the shoulder joint. t extends, adducts and medially rotates the Quadratus lumborum This muscle originates from the il and_ passes upwards, parallel and close to the vertebral column, and inserts into the 12th rib (Figs 16,66 and 16.67). Together the two muscles fix the lower rib during respiration and extend the spine (bending backwards). If one muscle contracts, it causes lateral flexion of the lumbar region of the spine ‘Sacrospinalis (erector spinae) These muscles lie between the spinous and transver Processes of the vertebrae (Figs 16.65 and 16.57). T originate from the sacrum and insert inte the occipi They extend the vertebral column. Muscles of the anterior abdominal wall Five pairs of muscles form the strong. muscu! abdominal wall (Figs 16.67 and 16.68). They in . quadratus lumborum (see above) and the rematning described below. When the muscles contract togeth472 SECTION FOUR Protection of the body and continuation of the species eres major Fig. 16:65 The main muscles of the back. Right side. compress the abdominal organs and flex the lumbar spine Contraction of the muscles on one side bends the trunk towards that side, Contraction of the oblique muscles on one side rotates the trunk. The anterior abdominal wall is divided longitudinally by a strong midline tendinous cord, the linea alba (meaning “white cord’), which extend from the xiphoid process of the sternum to the pubic symphysis, Rectus abdominis ‘This is the most superficial muscle. It is broad and flat, originating from the transverse part of the pubic bone anc passing, upwards (o inset into the lower ribs and the xiphoid process of the sternum, There are fo, separated down the External oblique This muscle lies deep to the rectus abdominis. It extends from the lower ribs downwards and forwards to insert into theiliacerest and, by an aponeurosis, to the inea alba Internal oblique ‘This muscle lies deep to the external oblique. It originates from the iliac erest and a broad band of fascia from the spinous processes of the lumbar vertebrae. Its fibres pass upwards towards the midline to insert into the lower ribs land, by an aponeurosis, into the linea alba. The fibres are at right angles to those of the external oblique. Transversus abdominis “This is the deepest muscle of the abdominal wall. It originates from the iliac crest and the lumbar vertebrae and passes across theabdominal wall oinsertinto the linea alba by an aponeurosis, Its fibres are at right angles to those of rectus abdlominis. Inguinal canal canal is 25-dcm long and passes obliquely through the abdominal wall Itruns parallel toand immediately in front ofthe transversalis fascia and part of the inguinal ligament (Fig, 1666) In the male it contains the spermatic cord, and in the female the round ligament, It constitutes a weak point in the otherwise strong abdominal wall through which herniation may occu, Muscles of the thorax These muscles are concerned with respiration and are discussed in Chapter 10. Muscles of the pelvic floor The pelvic floor (Fig. 16.69), formed from muscle and fascia, i divided into two identical halves that unite along the midline It forms a hammock-ype support for the pelvic organs al ‘maintains continence. The weight of the developing boby and aken associated structures during pregnancy can stretch the pelvic floor muscles, and childbirth can tear them! cause stress incontinence after delivery (p. 397). The ' forming the pelvic floor are the levator ani and coeeyss Levator ani ‘This group of broad, flat muscles forms the ante of the pelvic floor. They originate from the inner su: the true pelvis and unite in the midline. Coccygeus This is a paired triangular sheet of muscle anc fibres situated behind levator ani, They origina medial surface of the ischium and insert into and coceyx. They complete the formation of the jara Fig, 16.68 The muscles of the anterior abdominal wal, Fig. 16.69 The muscles of the female pelvi floor. thra and anus, and by the arethra, vagina and anus, selhich is pettoratestin the mate by the a iy the ten Muscles of the shoulder and upper limb Few muses (Fig 1670) stabilise the association between the apperuticular ant ssial skeletons at the pectoral girdle, Ear ene (Gh) eterak oe (ot) Trarwvernas acorn ects stdomens Ingunaligamert Prac symone and they stabilise and allow movement of the shoulier upper arms. Dettoic This muscle originates from the clavicle, acromion and spine of scapula and passes over the shoulder j insert into the deltoid tuberosity of the humerus. ItThe musculoskeletal system CHAPTER 16 Fig. 10.70 “ve ma ick hay it « the coraroid pre sa cf me nght snouider and uoper lb. (Ay Anterior view. (B) Posterior view, + of the shoulder and its main arm The antenor part causes abduction, and the shoulder joint to the arm. The long head! originates from the tien of the glenoid cavity and its tendon passes through the joint cavity and the bicipttal groove of the humerus (see Fig. 1637) to the arm. The distal tendon crosses the elbow joint and inserts into the radial tuberosity. It helps to stabilise anct the shoulder joint, and at the elbows joint it assists with on and supination Brachialis This muscle fies on the anterior aspect of the upper arm dees to the biceps It originates from the shaft of the humer extends across the elbow joint and inserts into the ul Jistal to the yoint capsule. Wes the main Triceps This muscle fies F nthe posterior aspect of the he tent arises tron three heads, one trom the scapula ol vo from the posterior surface of the humerus, IE inscrls by a single tendon on the olecranon of the vo stabilise the for joint, assists in adduction of the arm and extends the elbow jon 475476 SECTION Brachioradialis ‘The brachioradialis spans the elb elbow joint, originating on the distal end of the humerus, and inverts the sl epicondyle of the radius. Contraction flexes the elbow joint. Pronator quadratus This square-shaped muscle is the main muscle causing Pronation of the hand and inserts on the lower sections of both the radius and the ulna, Pronator teres This muscle lies obliquely across the upper third of the front of the forearm. Itarises from the medial epicondyle of the humerus and the coronoid process of the ulna and passes obliquely ‘across the forearm to insert into the lateral surface of the shaft Of the radius. Itrotates the radioulnar joints, changing the hand from the anatomical to the writing position, ie. pronation, Supinator This muscle lies obliquely across the posterior and lateral aspects of the forearm. It originates from the lateral epicondyle ‘of the humerus and the upper part of the ulna and inserts into the lateral surface of the upper third of the radius. Itrotates the radioulnar joints, often with help from the biceps, changing the hand from the writing to the anatomical position, ie supination, It lies deep to the muscles shown in Figure 16.70 Flexor carpi radialis, ‘This muscle lies on the anterior surface of the forearm. It originates from the medial epicondyle of the humerus and inserts into the second and third metacarpal bones. It flexes the wrist joint and, when acting with the extensor carpi radi- alis, abducts the joint. Flexor carpi ulnaris ‘This muscle lies on the medial aspect of the forearm. It originates from the medial epicondyle of the humerus and the upper parts of the ulna, and inserts into the pisiform, the hamate and the fifth metacarpal bones. It flexes the wrist and, when acting with the extensor carpi ulnaris, adducts the joint. Extensor carpi radialis longus and brevis These muscles lie on the posterior aspect of the forearm. The fibres originate from the lateral epicondyle of the humerus, and are inserted by a long tendon into the second and third metacarpal bones. They extend and abduct the wrist. Extensor carpi ulnaris, ‘This muscle lies on the posterior surface of the forearm, It originates from the lateral epicondyle of the humerus and inserts into the fifth metacarpal bone. It extends and adducts the wrist, Palmaris longus = ‘This muscle resists shearing forces that might pull the skin and fascia of the palm a ay from the underlying structures FOUR Protection of the body and continuation of the species and flexes the wrist. It originates on the medial epicondy of the humerus, and it inserts on tendons on the palm ofthe hand. Extensor digitorum This muscle originates on the lateral epicondyle of the hum cerus and spans both the elbow and wrist joints; in the wrist it divides into four tendons, one for each finger. Contraction of this muscle can extend any of the joints across which i passes, ie. the elbow, wrist or finger joints. ‘Muscles that control finger movements Large muscles in the forearm that extend to the hand give power to the hand and fingers, but not the delicate movements needed for fine and dexterous finger control. Smaller muscles, which originate on the carpal and metacarpal bones, control tiny and precise finger movements via tendinous attachments ‘on the phalanges; muscle fibres do not extend into the fingers Muscles of the hip and lower limb Most of these are shown in Figure 16.71. The biggest muscles of the body are found here, since their function is largely in weight bearing, The lower parts of the body are designed to transmit the force of body weight evenly through weight- bearing structures when walking or running and to act as shock absorbers, Psoas This muscle originates from the transverse processes and bodies of the lumbar vertebrae (Fig. 16.66). It passes across the flat part ofthe ilium and behind the inguinal ligament to insert into the femur. Together with iliacus, it flexes the hip joint. us This muscle lies in the iliac fossa of the innominate bone. It originates from the iliac crest, passes over the iliac fossa and joins the tendon of the psoas muscle to insert into the lesser trochanter of the femur. The combined action of iliacus and psoas flexes the hip joint Quairiceps femoris This group of four muscles lies on the front and 5) the thigh. They are rectus femoris and three vast: la medialis and intermedius (this last muscle is not shi Figure 16.71 because it lies deep to the other tw: femoris originates from the ilium and the three ¥ the upper end of the femur. Together they pass over of the knee joint to insert into the tibia by the patellar ‘Only rectus femoris flexes the hip joint. Together, ( isa powerful extensor of the knee joint Obturators The obturators, deep muscles of the buttock, oF! the rim of the obturator foramen of the pelvis ary the proximal femur. They laterally rotate the hipRect femoris Vast laterals (Quadiceps femoris tendon Pair igarent Fars longus ‘ero as ‘The musculoskeletal system | Bows eros — | Hamsiengs Somtandeasus Serine | Fig. 16.71 The main muscles of the right lower limb, (A) Anterior view. (B) Posterior view. Gluteal muscles ‘These are the gluteus maximus, medius and minimus, which together form the fleshy part of the buttock. They originate from the ilium and sacrum and insert into the femur. They extend, abduct and medially rotate the hip joint. Sartorius This is the longest muscle in the body and crosses both the hip and knee joints. It originates from the anterior superior iliac spine and passes obliquely across the hip joint, thigh and knee joint to insert into the medial surface of the upper part of the tibia. It assists with flexion and abduction at the hip joint and knee flexion Adductor group ‘These muscies, on the medial aspect of the thigh, originate from the pubic bone and insert into the linea aspera ot the femur. They adduct and medially rotate the thigh Hamstrings ‘Thehamstringscomprisethebicepsfemoris,semimembranosus and semitenclinosus muscles and lie on the posterior aspe:t of the thigh. They originate from the ischium and insert inte the upper end of the tibia, They flex the knce joint. Gastrocnemius, ‘This muscle forms the bulk of the calf of the leg. It arises by two heads, one from each condyle of the fermur, 3 arrSECTION FOUR Protection of the body and continuation of the species down behind the tibia to insert into the calcaneus by the calcanean tendon (Achilles tendon). It crosses both knee and. ankle joints, flexes the knee and plantarflexes (rising on to the ball of the foot) the ankle. Anterior tibialis This muscle originates from the upper end of the tibia, lies on the anterior surface of the leg and inserts into the middle cuneiform bone by a long tendon. It assists with dorsiflexion of the foot Soleus This is one of the main muscles of the calf ofthe leg, lying immediately deep to gastrocnemius. It originates from the hheads and upper parts ofthe fibula and the tibia. Its tendon joins that of gastrocnemius so that they have a common insertion into the calcaneus by the calcanean (Actilles) tendon. It plantarflexes the ankle and helps to stabilise the joint when standing @ SPOT CHECK 8. Define the term ‘motor unit. 40. What isthe difference between the origin and the insertion of a skeletal muscle? ——————— Effects of ageing on the musculoskeletal system eed ‘Atter studying this section, you should be able to: | | 1m describe the effects of ageing on the structure and function of the musculoskeletal system. chat dheebteiaiibepiamlatene eee ees Bone tissue in old age becomes lighter and less dense, «9 fractures are more likely. This natural process is called csteopenia and begins between the ages of 30 and 40. tis Gue to a shift of the osteoblast-osteoclast balance towarcs Cteoclast activity, meaning that bone is reabsorbed faster than new bone is laid down to replace it. Osteopenia does rot cause symptoms but can progress to osteoporosis (se below) Oestrogen maintains bone mass, So pre-menopaussl women have a degree of protection against osteopenc changes compared to age-matched men. ‘Compaction of the intervertebral discs reduces the length of the spinal column and lead to loss of height Cartilage and other connective tissues stiffen and may degenerate with age, reducing joint flexibility and mobility land predisposing to osteoarthritis (p. 482). Skeletal muscle ‘ells become smaller and less elastic and take longer to repar following injury. Damaged muscle may be replaced with fibrous tissue, which is inelastic and reduces the strength of contraction. Exercise tolerance reduces because each muscle cell stores less glucose and myoglobin, and as cardiovasculer function declines, regulation of blood supply to muscle becomes less efficient, In addition, older adults cannot lose the heat generated by working muscle as effectively as younger people, reducing exercise tolerance. Regular exercise throughout life can significantly slow these age-related changes._ Diseases of bone ed After studying this section, you should be able to: 1 explain the pathological features of osteoporosis, Paget's disease. rickets and osteomalacia 1 describe abnormalities of bone development 12 expiain the effects of bone tumours. | 1 outline the causes and effects of osteomyelitis Osteoporosis In this condition, bone density (the amount of bone tisste) sd because its deposition does not keep pace with see osteopenia above) and the risk of fracture is osis may not be made until a fracture he bone is adequately mineralised, itis al, with loss of le porous and microscopically abnorn Fig. 16.72). A range of environmental ses increase the risk of osteoporosis (Box Some can be influenced by changes in lifestyle icium intake during childhood and a nce are thought to be important in determining, porosis in later life. Reduced mobility r coporosis, the extent of which corresponds gree. For instance, during prolonged osteoporati it immobilisation of a particular and therefore the risk | osteop og electron marograph of spongy Gen, University ‘La Sapienza wth pereision ) Fig. 16.72 Osteoporosss Sos prot. P Motta, Dept of Ar Library, Peproduce Rome/Science Phot The musculoskeletal system CHAPTER 16 Common features of osteoporosis include + skeletal deformity coatseal by vertebral comp gradual loss of height with age + fractures ist (Celle fracture) and vertebrae especially of the neck of femur,» Paget's disease Paget’s disease is a disorder of bone remodelling, whee the normal balance between bone buildings ard bone breakdown becomes «is osteoclasts become abnormally act eralises! and structurally abnormal. This anise and both o ited i The bone dep ‘undlermi to deformities (Fig. 16.73) and fracture pelvis, femur, tibia and skull, The cause is unknown and the disease often goes undetected untsl com Age is a risk factor; the avera at diagnosis is 70 year Both genetic and environmental factors are \" also important. The disease increases the risk o! rthritis(p 482) and development of benign or malignant bone t Rickets and osteomalacia In both conditions, bone is inadequately minerals usually because of vitamin D deficiency, or sometimes because 0 defective vitamin D metabolism, Rickets occurs in children, Box 16.1 Causes of decreased bone mass Risk factors Female sex, especially post-menopa Drugs Diseases Cushing's syndrome Iyperparattyrantise Type T aiabetes mellt seumatoid arthritis ‘Clune renal failure Chronic liver dis Anoresia nervosa480 SECTION FOUR Protection of the body and continuation of the species Fig. 16.73 Severe log deformity in Paget's disease. ‘Aacociaten/Scionce Photo Library. Reproduced with po whose bonesarestill growing, causingcharacter deformity ofthe lower limbs. Adults need vitamin D for normal bone tumover, and d iciency causes osteomalacia, which is associated with increased risk of fractureand bone pain, Deficiency may be due to poor diet, malabsorption or limited exposure to sunlight (needed for normal vitamin D metabolism), Osteomyelitis This is bacterial infection of bone and may follow an open fracture or surgical procedures, which allow microbial contamination through broken skin, It may also result from slooxl-borne infection from infection elsewhere, eg, the ear, throat or skin; this is most com nin children. If promptly and adequately treated, theinfection can resolve without permanent damage, but if not, it may become chronic, with fever, pain and sinus formation draining pus to the skin (see Fig. 14.10) Developmental abnormalities of bone Achondroplasia hat prevents normal 16.7), stich as the long, bones of the limbs, producing short Osteogenesis imperfecta (‘brittle bone syndrome’) Tumours of bone and cartilage Benign tumours These may cause pa res oF pressure dam to soft issues, eg. a benign vertebral tumour may dma, tend to become malignant, Malignant tumours Metastatic tumours (Gecondary growths) of primary carcinomas of the b thyroid, kidneys and prostate gland, The usual sites ane those with the best blood supply, ie bone, especially th bodies ofthe lumbar vertebrae and the epiphyses of the humeru usually painful and ¢ nr eatuse path Primary tumours Primary malignant bone tumoursare-relatively rare: Osteosarcoma is rapidly growing and often highly’ malignant. It is most comm imadolescence and usually develops in the medullary canal of lon bones, especially the ermur. It occasionally occursin elderly people sgenerally in asscxiation with Paget's disease, and involving the vertebrae skull and pelvis @ SPOT CHECK 11. Which vitamin is deficiant in rickets in chi why does this deficiency lead to differen in adults’ 12, What is osteosarcoma? _—_— Disorders of joints dy | ter = compare and contraThe musculoskeletal system CHAPTER 16 Inflammatory joint disease (arthritis) Rheumatoid arthritis (rheumatoid disease) Rheumatoid arthritis (RA) isa chronic progressive nflammatory autoimmune disease. Its a systemic disorder in which inflammatory changes affect not only joints but also iny other sites, including the heart, blood vessels and skin. nin females than males; premenopausal ‘omen are affected three times more often than men. It can ffect all ages, including children (Stills disease), although risk increases with age and it usually develops between 35 and 55 years of age. The cause is not clearly understood but there is sometimes a clear familial link, and autoimmunity may be initiated by microbial infection, possibly by viruses, netically susceptible people. ave rheumatoid factor ids, High levels of RF Up to 90% of affected individuals [RF-autoantibodies) in their body i especially early in the disease, are strongly associated with accelerated and more severe disease Acute exacerbations of RA are usually accompanied fever and are interspersed with periods of remission ‘ptoms include joint pain and stiffness, particularly in ter rest. Affected joints can be visibly nd tender. The joints most commonly a re those of the hands (Fig. 1674) and fect, but in severe cases most synovial joints may be involved. With eack flare up these is additional and cumulative joint damage, leading, ) increasing deformity, pain and los of function. The eats which may be reversible, include hypertrophy and cells and inflammatory effusion into sgression ustially causes permanent tissue lammatory granulation tissue, called h of intl joint and destroys articu 1g further dam mobility. Pain, stitfne ar cartilage, below and vsis of the pannus reduces joi ‘ tia abnormalities, pleurisy and vasculitis. Other types of polyarthritis Fig, 16.74 Severe detormty of the hands permission.) te. Alain Pol, ISM/Science Photo Library. Reproduced with Type of disease Dego Tissue affected Aricular carta Age at ot factor is absent, The causes are not kni features may be involv Ankylosing spondylitis, Thistends to oecurin young spine, including the sacroiliac joint (F of the intervertebral joints and laying dow jedce spinal flexibility mane Psoriatic arthritis $%-10%% of people with psoriasis (p arthritis, more likely ifthe re inv toe joints are most commonly afte Rheumatic fever and ankles. Unlike the cardia hich Fheumatic heart disease, p. 159), arthritis spontaneously without complications istics similar to those of RA but a0_ EE LLLhltltwwww SECTION FOUR Protection of the body and continuation of the species 482 infective arthritis Joint nfection (septic arthritis) usually results tram a blood: sh th by preexsting dseae making inflamed. Complete resolution is possible f treatment prompt but permanent ont damage us borne bacterial infection, usually staphylococcal, alth nt has been dan ly occurs early in the disease Osteoarthritis (osteoarthrosis) (OA) nad nmatory lisease that causes pain and restricted movement of affected joints. In its early stages, OA is often asymptomatic. tis very common, and most people over 65 show some degree of osteoarthritie changes. Articular cartilage gradually becomes thinner because its renewal no longer keeps pace with its breakdown. Eventually, the bony articular surfaces coms in contact and the bones begin to degenerate. Bone repair is abnormal and the articular surfaces become misshapen, reducing joint mobility. Chronic inflammation develops with cffusion (collection of fluid) in the joint. Sometimes there is abnormal outgrowth of cartilage at the edges of bones which ossifies, forming osteophytes In most cases, the cause is unknown (primary OA), butrisk factors include excessive repetitive use of the affected joints, female sex, increasing age, obesity and heredity. Secondary (OA occurs when the joint is already affected by disease or abnormality, e.g. trauma or gout. OA usually develops in late middle age and affects large weight-bearing joints, ic the hips, knees and joints of the cervical and lower lumbar spine. In many cases only one joint is involved. Traumatic injury to joints Sprains, strains and dislocations these damage the soft tissues, tendons and ligaments round the joint without penetrating the joint capsule. in dislocations there may be additional damage to intracapsular structures by stretching, eg. to the long head of biceps muscle in the shoulder joint, the cruciate ligaments in the knee joint or {head of femur in the hip joint. f repair is there may be some loss of stability, which njury the Tigament incomplete ses the tisk of repeated Penetrating injuries Thew: may be caused by a compound fracture of one of the articulating bones or by trauma, Healing may be uneventful or Jayeal by the presence of fragments of damaged or torn joint .e or ligaments), Which cannot be removed smal boxly mechanisms and prevent full joint another risk, Chronic inflammation can tissue (leone cart ee rative changes in the joint. Gout —_ ; with reduced ur Secondary gout is usually kidney failure, both of which rv In many cases only one joint i which is typically red, hot and extremely painful, The site most commonly: affected are the metatarsephalangeal Of the big toe and the ankle, knee, wrist and etbow jc isodes of arthritis lasting days or weeks ate intersperse remission, Repeated acute attacks Can cause y and loss of function of the affected nyolved (monoarthnts with periods of permanent deformit joints, Gout is sometimes complicated by the development of renal calculi Connective tissue diseases This group of chronic autoimmune disorders has common features. They affect many body tissues, especially the joints skin and subcutaneous tissues and tend to occur in early adult life, affecting more women than men, They include the following; + Systemic lupus erythematosus (SLE) ~ the affected joints are usually the hands, knees and ankles, A characteristic red “butterfly’ rash may occur on the face. Kidney involvement is common and can result in glomerulonephritis that may be complicated by chronic kidney disease + Systemic sclerosis (scleroderma) ~ in this group of disorders there is progressive thickening of connective tissue. There is increased collagen production within many organs. In the skin there is dermal fibrosis and tightness that impairs joint function, especially o! the hands. It also affects the walls of blood vessels, the intestinal tract and other organs, + Rheumatoid arthritis (p. 481) + Ankylosing spondylitis (p. 481) + Reiter's syndrome. Signs and symptoms include polyarthritis, urethritis and conjunctivitis); it m.! precipitated by Chlamydia trachomatis infection. Th! et Jimb joints are the most commonly affected Carpal tunnel syndrome This occurs when the median nerve is comp’ asit passes through the carpal tunnel (see Fig, 16.55 ‘common in women aged between 30 and 50 ve numbness in the hand and wrist affects the thum! middle fingers, and half of the ring, finger, the ar inl by the median nerve. Many cases arv idiopathic y to other conditions, eg, RA, diabetes mellitus, ahypothyroidism. Repetitive flexion and extension of the wrist joint also cause the condition, eg. prolonged keyboard tse, @ SPOT CHECK 18. Why does gout affect the joints? 14. Which nerve is compressed in carpal tunnel syndrome, and by what? TS Diseases of muscle eed ‘After studying this section, you should be able to: 1 list the causes of the diseases in this section ‘= compare and contrast the characteristics of itferent types of muscular dystrophy. Myasthenia gravis This autoimmune condition of unknown origin affects more women than men, usually between 20 and 40 years of age. Circulating autoantibodies bind to and block the acetylcholine receptors of the neuromuscular junction (Fig, 1661). The transmission of nerve impulses to skeletal muscle is therefore blocked, causing progressive and extensive muscle weakness, although the muscles themselves are normal. Muscles moving the eyeballs and the eyelids are usually affected first, causing ptosis (drooping, of the eyelid) or diplopia (double vision), followed by those of the neck, possibly affecting chewing, swallowing and speech, and limb muscles. There are periods of remission, relapses being precipitated by, for example, strenuous exercise, infections or pregnancy. The musculoskeletal system CHAPTER 16 Muscular dystrophies In this group of inherited diseases there is progressive degeneration of groups of muscles. The main differences in the types are age of onset, rate of progression and muscles involved Duchenne muscular dystrophy Inheritance of this condition is sex-linked (p. 495). Signs and symptoms may not appear until about 5 years of age. Wasting and weakness begin in lower limb muscles, then spread to the upper limbs, progressing rapidly without remission. Death usually occurs in adolescence, often from respiratory failure, cardiac arrhythmias or cardiomyopathy Facioscapulohumeral dystrophy This disease affects both sexes. Itusually beginsin adolescence, land the younger the age of onset, the more rapidly it progresses, Muscles of the face and shoulders are affected first It is a chronic condition which usually progresses slowly and 1use complete disabi may not Life expectancy is normal Myotonic dystrophy This inherited disease usually begins in adult life and affects both sexes, Muscle contraction is prolonged and relaxation can be slow, so that sufferers have difficulty in releasing an object held in the hand, Muscles of the tongue and the face are affected first, then limb muscles, Other effects of this condition include cataract (p. 235), abnormalities of cardiac conduction and inereased risk of diabetes mellitus (p. 261) The disease progresses without remission and with increasing disability. Death usually occurs in middle age from respiratory oF cardiac failure @ SPOT CHECK 15, In myasthenia gravis, against which structure are the autoantibodies directed?