대퇴내전근(치골근, 단내전근, 장내전근, 대내전근, 박근)에 대하여

[문형철]

1. 대퇴내전근은 anatomy train상 심부전방선 구조물

2. 대퇴내전근(심부전방선)의 기능부전은 당장 문제를 일으키지 않지만 서서히 허리디스크, 골반, 고관절 통증을 야기함. 

3. 고관절 외전힘 100 : 내전힘 60의 비율 - 항상 내전힘이 약해서 문제

4. 대퇴내전근

1) 치골근 pectineus muscle

2) 장내전근 adductor longus muscle

3) 단내전근 adductor brevis muscle

4) 대내전근 adductor magnus muscle

5) 박근(gracillis muscle)

참고) adductor hiatus로 정맥혈관이 지나감.

panic bird.....

트라벨 정리

obvious problem-makers

주요 내용

장내전근과 단내전근 Tp 연관통은 위로는 서혜부 깊은 곳, 아래로는 슬부와 경골부까지 

대내전근 tp 연관통은 서혜부부터 슬부바로 위까지 대퇴의 전내측에 발생

심부전방선은 거의 모든 곳이 심부전방선의 근육에 의해 수행되는 역할을 중복하는 다른 근육근막에 의해 둘러싸여 있거나 덮혀 있음. 

심부전방선의 근육근막은 심부전방선이 수행하는 안정성제공과 중심구조물에 미세한 위치변화에 좀더 표면구조물과 선들이 골격에 쉽고 효율적으로 작용할 수 있도록 하는 역할을 반영하는 지구력 근섬유인 지근(slow tiwtch) 섬유가 섞여 있음.  그러므로 심부전방선이 적절히 기능을 하지 못한다고 해서 그 즉시 또는 명백하게 기능을 잃는 것은 아님.  기능은 보통 바깥 근육근막선으로 이전될 수 있지만 좀더 부자연스럽고 관절과 관절주변 조직에 좀더 긴장을 주게 되어 시간이 지나면 손상과 퇴행이 발생할 수 있는 조건을 만듬. 그래서 많은 손상은 손상이 발생되기 수년전부터 대개 심부전방선의 기능상실에 의한 것임. 

치골근

The pectineus muscle (from the Latin word pecten, meaning comb^[1]) is a flat, quadrangular muscle, situated at the anterior (front) part of the upper and medial (inner) aspect of the thigh. The pectineus muscle is the most anterior adductor of the hip. The muscle does adduct and medially rotate the thigh but its primary function is hip flexion. It can be classified in the medial compartment of thigh^[2] (when the function is emphasized) or the anterior compartment of thigh (when the nerve is emphasized).^[3]

- 치골근은 대퇴를 내전하고 내측회전시키는 근육. 하지만 주요 기능은 고관절 굴곡기능. 

Structure[edit]

The pectineus muscle arises from the pectineal line of the pubis and to a slight extent from the surface of bone in front of it, between the iliopectineal eminence and pubic tubercle, and from the fascia covering the anterior surface of the muscle; the fibers pass downward, backward, and lateral, to be inserted into the pectineal line of the femurwhich leads from the lesser trochanter to the linea aspera.

Relations[edit]

The pectineus is in relation by its anterior surface with the pubic portion of the fascia lata, which separates it from the femoral artery and vein and internal saphenous vein, and lower down with the profunda artery.

By its posterior surface with the capsule of the hip joint, and with the obturator externus and adductor brevis, theobturator artery and vein being interposed. By its external border with the psoas major, the femoral artery resting upon the line of interval. By its internal border with the outer edge of the adductor longus.

Obturator hernia is situated directly behind this muscle, which forms one of its coverings.^[4]

Innervation[edit]

It is a composite muscle as the innervation is by the femoral nerve (L2 and L3) and occasionally (20% of the population) a branch of the obturator nerve called the accessory obturator nerve.

Function[edit]

It is one of the muscles primarily responsible for hip flexion. It also adducts the thigh.

치골근 TrP탐구

- TrP 연관통은 서혜인대 바로 아래에서 고관절 깊숙한 곳에서 나타남

- 주된증상은 다른 세개의 내전근과 장요근의 통증 유발점이 비활성화된 후에 명확하게 나타나는 지속적인 통증임. 

- 계단에서 넘어지거나 걸려 넘어질때, 대퇴골 경부골절시 또는 전체 고관절 치환술 시, 성관계시 지속적이고 강력한 대퇴부 내전시 통증유발점이 활성화됨. 

- 고관절의 지속적인 또는 반복적인 굴곡-내전운동이나 다른 전체적 신체요소에 의해 통증유발점이 지속화 될 수 있음. 

- 피부아래 바로 위치하기 때문에 통증유발점 검사는 쉽고 정확하게 시행할 수 있음. 근육을 가로지르며 딱하고 소리내는 촉진은 매우 강력한 국소연축반응을 유발하고 연관통을 일으킴. 

-치골근의 통증 유발점은 3개의 내전근과 장요근 통증유발점을 비활성화시킨 후 검사해야 함. 

감별진단

- 폐쇄신경 포착의 경우 치골근 통증유발점의 연관통과 유사한 통증을 나타냄. 폐쇄신경 포착의 경우 감각의 장애가 있고, TrP의 경우 통증이 심함. 

- 고관절 질환과 감별해야

- 스트레스성 치골결합염은 치골결합부위 통증을 유발함. - 장거리 달리기 선수나 아이스하키처럼 몸을 부딪히는 선수에게 흔함. 

- 치골근 통증유발점은 치골결합염이 있을때 악화됨. 

- 치골근 통증유발점은 촉진으로 검사, 치골근 통증 유발점을 비활성화 시킨 후 통증이 완화되면 치골결합염은 쉽게 진단함. 

- 교정동작은 오랫동안 앉아있는 것을 피해야 함. 일정길이 이상으로 갑자기 신장되도록하는 과도한 움직임을 피함. 

- 치골근의 촉진은 Femoral artery안쪽에서 시행

- 치골근은 다양한 변이가 존재함. 표재성 근육과 심부 근육으로 나뉨. 

- 대퇴신경 지배, 내측근육이 존재하면 폐쇄신경의 지배

- 치골근  대퇴내전 기능의 주된 길항근은 중둔근, 소둔근, 대퇴근막장근임. 

단내전근(adductor brevis)과 장내전근(adductor longus)

- 장내전근과 단내전근의 TrP에 의한 통증의 양상에 관해 구분하지 않음.

- 연관통은 서혜부 깊숙히, 원위부쪽으로는 무릎내측상부, 전경골근까지 퍼져나가는 양상. 

- 장내전근은 발떼기 시기에 활성화

- 대내전근은 접지기(Heel strike)시기에 활성화, 계단 올라갈때 활성화, 내려올때는 비활성화. 스키타며 회전할때 승마시 무릎으로 말 옆구리를 죌때 활성화 됨. 

보행시 역할

- 초기 유각기 동안 대내전근은 다리를 중심점으로 끌어옴. 후기 유각기 동안에는 내전근과 박근은 하지 앞으로 뻗을 수 있도록 고관절을 굴곡을 증가시키고 유지시키는 역할

- 입각기의 첫부분에서 박근은 다른 거위발 근육과 내측관근을 도와 체중이 실릴때 무릎이 외반되는 것을 막는 기능. 

- 초기 입각기 동안 대내전근의 좌골결절 부분이 슬굴곡근과 대둔근과 함께 체중에 의해 굴곡되려는 고관절의 굴곡을 막음. 

- 후기 입각기에 체중이 앞쪽으로 그리고 중심을 가로질러 반대쪽 발로 이동될때 장내전근 및 대내전근이 외전을 제한하여 체중이동을 조절하고 안정성을 더함. 

- 장내전근, 단내전근, 대내전근을 완전히 제거하면 70%의 내전근 근력의 손실을 보이지만, 걷거나 계단오르기, 점프에서는 단지 경미한 장애만 보임. 

- 일반적으로 박근과 3개 내전근이 주요 역할은 고관절 내전

- 장내전근 단내전근 그리고 대 내전근의 앞, 위 부분은 대퇴의 굴곡과 내회전을 도움. 

- 대내전근의 뒷부분은 고관절 신전근으로 작용.

- 4개의 내전근중 박근만 고관절과 슬관절을 가로지름. 박근은 기본적으로 고관절 내전근이며, 슬관절이 신전되어 있을때에는 슬관절의 굴곡을 도우며, 슬관절이 굴곡되어 있을때는 경골의 내회전을 도움. 

고관절 내전의 길항근

- 중둔근, 소둔근, 대퇴근막장근에 의해 길항작용

통증유발점의 활성화와 지속화

- 박근을 포함한 내전근의 통증유발점은 얼음위에서 미끄러지거나 균형을 찾으려고 다리가 벌어지지 않게 하려고 할때와 같이 갑작스러운 과부하에 의해서 활성화됨. 

- 장내전근은 격렬한 승마에 의해서 활성화

- 대내전근은 스키를 타거나 익숙하지 못한 오랜 시간의 자전거 타기에 의해서 활성화

- 거위발 점액낭염이 있을때 살펴야 함. 

- 내전근 관 hunter's canal

The adductor brevis is a muscle in the thigh situated immediately behind the pectineus and adductor longus. It belongs to the adductor muscle group. The main function of the adductor brevis is to pull the thigh medially.^[1] The adductor brevis and the rest of the adductor muscle group is also used to stabilize left to right movements of the trunk, when standing on both feet, or to balance when standing on a moving surface. The adductor muscle group is used pressing the thighs together to ride a horse, and kicking with the inside of the foot in soccer or swimming. Last, they contribute to flexion of the thigh when running or against resistance (squats, jumping, etc).^[2]

Origin and insertion[edit]

It is somewhat triangular in form, and arises by a narrow origin from the outer surfaces of the superior and inferior rami of the pubis, between the gracilis and obturator externus.

Its fibers, passing backward, lateralward, and downward, are inserted, by an aponeurosis, into the line leading from the lesser trochanter to the linea aspera and into the upper part of the linea aspera, immediately behind the pectineus and upper part of the adductor longus.

Actions[edit]

The muscle is primarily known as a hip adductor. It also functions as a hip flexor. Whether it acts to rotate the femur laterally or medially is dependent on position.

Relations[edit]

By its anterior surface, the adductor brevis is in relation with the pectineus, adductor longus, and anterior branches of the obturator artery, the obturator vein, and the obturator nerve.

By its posterior surface with the adductor magnus and the posterior branches of the obturator artery, the obturator vein, and the obturator nerve.

By its outer border with the obturator externus, and the iliopsoas. By its inner border with the gracilis and adductor magnus.

It is pierced near its insertion by the middle perforating artery.^[3]

Innervation[edit]

The adductor brevis is innervated dually by the anterior and posterior branches of the obturator nerve.^[4]

장내전근(adductor longus)

In the human body, the adductor longus is a skeletal muscle located in the thigh. One of the adductor muscles of the hip, its main function is to adduct the thigh and it is innervated by the obturator nerve. It forms the medial wall of the femoral triangle.

Origin and insertion[edit]

The adductor longus arises from the superior ramus of the pubis. ^[1] It lies ventrally on the adductor magnus, and near the femur, the adductor brevis is interposed between these two muscles. Distally, the fibers of the adductor longus extend into the adductor canal.^[1] It is inserted into the middle third of the medial lip of the linea aspera.^[1]

Relations[edit]

The adductor longus is in relation by its anterior surface with the pubic portion of the fascia lata, and near its insertion with the femoral artery and vein. By its posterior surface with the adductor brevis and magnus, the anterior branches of the obturator artery, vein, and nerves, and near its insertion with the profunda artery and vein. By its outer border with the pectineus, and by the inner border with the gracilis.

^[2]

Actions[edit]

Its main actions is to adduct and laterally rotate the femur; it can also produce some degree of flexion/anteversion.^[1]

Innervation[edit]

As part of the medial compartment of the thigh, the adductor longus is innervated by the anterior division (sometimes the posterior division) of the obturator nerve.^[1] The obturator nerve exits via the anterior rami of the spinal cord from L2, L3, and L4.^{[3][not in citation given]}

Development[edit]

Adductor longus is derived from the myotome of spinal roots L2, L3, and L4.^[4]

대내전근(adductor magnus)

- TrP2는 좌골부위, TrP1은 대내전근 중앙

- 연관통은 서혜인대부위, 아래로는 무릎근처 대퇴부까지 통증

- TrP2의 연관통은 골반내 전체적인 통증뿐 아니라 치골, 질, 직장 또는 방광까지 통증이 느껴지기도 함. 

The adductor magnus is a large triangular muscle, situated on the medial side of the thigh.

It consists of two parts. The portion which arises from the ischiopubic ramus (a small part of the inferior ramus of the pubis, and the inferior ramus of the ischium) is called the pubofemoral portion, adductor portion, or adductor minimus, and the portion arising from the tuberosity of the ischium is called the ischiocondylar portion, or "hamstring portion". Due to its common embryonic origin, innervation, and action the ischiocondylar portion (or hamstring portion) is often considered part of the hamstring group of muscles. The ischiocondylar portion of the adductor magnus is considered a muscle of the posterior compartment of the thigh while the pubofemoral portion of the adductor magnus is considered a muscle of the medial compartment.

Origin and insertion[edit]

Pubofemoral (adductor) portion[edit]

Those fibers which arise from the ramus of the pubis are short, horizontal in direction, and are inserted into the rough line of the femur leading from the greater trochanter to thelinea aspera, medial to the gluteus maximus.

Those fibers from the ramus of the ischium are directed downward and laterally with different degrees of obliquity, to be inserted, by means of a broad aponeurosis, into the linea aspera and the upper part of its medial prolongation below.

Ischiocondylar (hamstring) portion[edit]

The medial portion of the muscle, composed principally of the fibers arising from the tuberosity of the ischium, forms a thick fleshy mass consisting of coarse bundles which descend almost vertically, and end about the lower third of the thigh in a rounded tendon which is inserted into the adductor tubercle on the medial condyle of the femur, and is connected by a fibrous expansion to the line leading upward from the tubercle to the linea aspera.

Relations[edit]

By its anterior surface the adductor magnus is in relation with the pectineus, adductor brevis, adductor longus, femoral artery and vein, profunda artery and vein, with their branches, and with the posterior branches of the obturator artery, obturator vein and obturator nerve. By its posterior surface with the semitendinosus, semimembranosus, biceps, and gluteus maximus muscle. By its inner border with the gracilis and sartorius. By its upper border with the obturator externus, and quadratus femoris.^[1]

Innervation[edit]

It is a composite muscle as the adductor and hamstring portions of the muscle are innervated by two different nerves. The adductor portion is innervated by the posterior division of the obturator nerve while the hamstring portion is innervated by the tibial nerve.^[2][3]

Osseoaponeurotic openings[edit]

Further information: Adductor hiatus and Adductor canal

At the insertion of the muscle, there is a series of osseoaponeurotic openings, formed by tendinous arches attached to the bone. The upper four openings are small, and give passage to the perforating branches of theprofunda femoris artery. The lowest (often referred to as the adductor hiatus) is large, and transmits the femoral vessels to the popliteal fossa.

Action[edit]

The adductor magnus is a powerful adductor of the thigh, made especially active when the legs are moved from a wide spread position to one in which the legs parallel each other. The part attached to the linea aspera acts as a lateral rotator. The part which reaches the medial epicondyle acts as a medial rotator when the leg is rotated outwards and flexed, and also acts to extend the hip joint.^[4]

Variation[edit]

The upper, lateral part of the adductor magnus is an incompletely separated division often considered a separate muscle — the adductor minimus.^[4] These two muscles are frequently separated by a branch of the superiorperforating branch of the profunda femoris artery.^[5]

Ontogeny and phylogeny[edit]

In other tetrapods, the adductor magnus crosses the knee joint and inserts into the tibia. In humans, the distal part of the tendon detaches and becomes the medial collateral ligament of the knee. Because of this, the medial collateral ligament of the knee in humans may contain a few muscle fibres as an atavistic variation.^[6]

박근(gracillis muscle)

- 박근의 TrP는 국소적이로 뜨겹게 느껴지거나 벌에 쏘인 듯한 표재성 통증, 대퇴내측을 따라 위아래로 연관통

Structure[edit]

It arises by a thin aponeurosis from the anterior margins of the lower half of the symphysis pubis and the upper half of the pubic arch.

The muscle's fibers run vertically downward, ending in a rounded tendon. This tendon passes behind the medial condyle of the femur, curves around the medial condyle of the tibia where it becomes flattened, and inserts into the upper part of the medial surface of the body of the tibia, below the condyle. For this reason, the muscle is a lower limbadductor. At its insertion the tendon is situated immediately above that of the semitendinosus muscle, and its upper edge is overlapped by the tendon of the sartorius muscle, which it joins to form the pes anserinus. The pes anserinus is separated from the medial collateral ligament of the knee-joint by a bursa.

A few of the fibers of the lower part of the tendon are prolonged into the deep fascia of the leg.

Relations[edit]

By its inner or superficial surface gracilis is in relation with the fascia lata, and below with the sartorius and internal saphenous nerve; the internal saphenous vein crosses it lying superficially to the fascia lata.

By its outer or deep surface with the adductor longus, brevis, and magnus, and the internal lateral ligament of the knee-joint, from which it is separated by a synovial bursa common to the tendons of the gracilis and semitendinosus.^[1]

Function
[edit]

The muscle adducts, medially rotates, and flexes the hip as above, and also aids in flexion of the knee.^[2]

Clinical relevance[edit]

The gracilis muscle is commonly used as a flap in microsurgery. According to the classification of Mathes and Nahai, it presents a type II blood supply, allowing it to be transferred on its artery derived from the medial circumflex femoral artery. This artery enters the muscle about 10 cm from the pubic symphysis. At this point (or 1 cm proximal) the nerve also enters.

Gracilis muscle is widely used in reconstructive surgery, either as a pedicled flap or as a free microsurgical flap. Both pedicled and free flaps can be muscular or musculocutaneos (the so- called "composite flaps"). As a pedicled flap, gracilis muscle can be used in perineal and vaginal reconstruction, after oncological surgery, in the treatment of recurrent anovaginal and rectovaginal fistulas as well in the coverage of the neurovascular bundle after vascular surgery.^[3]

As a functioning pedicled flap, the gracilis muscle can be transferred for the treatment of anal incontinence. This technique called graciloplasty was described in the 1950s by Pickrell and was revolutionized in the late 1980s by the introduction of chronic muscle electro-stimulation. The gracilis microsurgical free flap is commonly used in the reconstruction of upper and lower limbs, in breast reconstruction and – as a free functioning flap – to restore forearm function or in dynamic reconstruction of facial paralysis.Gracilis Muscles Clinical Role

Transplantation sites[edit]

The muscle may be split to reduce bulk for facial reanimation, as well as to repair hand muscles. It can be used to fashion an external anal sphincter.^[4]

단내전근, 장내전근, 대내전근, 박근 Trp 탐구

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