A. Torsal muscle
(1) Thoracolumbar paraspinal muscle
흔히 발생되지만 가장 흔한것은 아니다.
1) Functional Anatomy
- superficial muscle (nealy longitudinal fibers)
more lateral iliocostal
medial longissimus thoracis
---> function : extend spine => are streched by flexion
- deeper group (runs diagonally)
underlying semispinalis, multifidus, rotatores muscle
; more diagonal and shorter
=> stretch-spray ; spinal rotation combined with flexion
2) Referred Pain Pattern
- tend to refer pain caudaly
- intercostalis thoracis
* anterolaterally to the lower chest and abdomen in a roughly
segmental
distribution
* upward through several spinal segments to the scapular region
- intercostalis lumborum, longissimus thoracis
* referred pain ; downward from Trps,
sometimes appearing low in the bottock
- deep muscle
referred pain & tenderness to the midline from either side,
spinous process at the same level as the Trp
3) Diagnosis
- iliocostalis & deep diagonal muscle's strained during combined flexion
and twisting of the torso
- longissimus thoracis : facing forward자세로 무거운 물건을 들 경우
- superficial ; 격렬한 tender trps & strong twitch response
- deep(multifidus, rotator) ; circumscribed deep tenderness adjacent to
a
spinous process that is sensitive to
tapping
or to firm pressure
4) Treatment
* Stretch- spray procedure
- superficial
바닥에 앉아서 고개를 숙이면서 팔은 천천히 양 다리사이에 떨어뜨린다.
- deep
flexion & rotation
시술자가 환자의 어깨를 잡고 반대쪽방향에서 앞쪽으로 회전시킨다.
* Home program
active exercises as described by Cailliet
** In-Bathtub Stretch Exercise
** Pelvis title Exercise
** Sit-back, Abdominal-curl, Sit-up Exercise
(2) Serratus posterior inferior muscle
흔히 나타나는 것은 아니지만 한번 나타나면 고통이 무척 심하지만 잘 치료된
다.
1) Functional Anatomy
- above & laterally ; to the last four ribs
- below & medially ; to the last two thoracic
and first two lumbar vertebrae
- forced expiration시 rib을 depress,
thoracolumbar junction에서 spine을 회전(같은 방향으로 얼굴을 돌리는 것)
시키는 것을 돕는다
2) Referred Pain Pattern
the region of the trp and over the lower ribs posteriorly
3) Diagnosis
- referred pain이 constant over the lower ribs하고
spinal movement와는 독립적으로 나타난다
- chest와 abdomen의 호흡근사이의 부조화를 나타내지만
deep breath시에는 통증이 없다
- associated trps가 adjacent paraspinal and oblique abdominal muscle에서
나타나기도 한다
(3) Rectus abdominis muscle
복부근육의 Trp에서 발생되는 back pain은 주로 rectus abdominis muscle의
cephalad and caudal ends의 terminal fiber에서 나타난다
1) Functional Anatomy
- above : the 5, 6, 7th ribs anteriorly
- below : the pubis
- strongly flex the spine & tense the anterior abdominal wall
help to retrude the abdomen, as in expiration
increase intraabdominal pressure
2) Referred Pain Pattern
- uppermost fibers
xyphoid process부위나 약간 아래에서 rib cage와 midline가 직각이 되는
부위에 trp가 있으며,
referred pain은 lower thoracic level에서
양쪽으로 horizontal하게 나타난다
- lowest fibers
symphysis pubis와 인접한 부위에 trp가 있으며,
referred pain은 horizontal하게
sacrum, iliac crest & upper gluteal region까지 나타난다
3) Diagnosis
- distinctively horizontal pattern of low back pain
& rectus abdominis의 terminal fiber에 특징적인 tenderness
- weakness ; protruded abdomen을 집어 넣지 못한다
4) Treatment
* Stretch-spray procedure
다리는 침상밑으로 하되 support위에 놓고 supine position으로 눞게 되면
lumbar spine이 extend되어 rib cage로부터 pubis를 분리하게 되어
abdominal muscle를 신전시킨다.=> spray =>
마지막으로 deep breath하여 abdomen을 fully protrude하게하여
rectus abdominis muscle을 더욱 신전시킨다
* home exercise
Slow Sit-back Exercise
한번에 1--10내지 15회정도 실시한다
(4) Quadratus lumborum muscle
가장 많이 침범을 당하지만 적절하지 못한 검사로 놓치는 경우가 많다
1) Functional Anatomy
- run nearly vertically, deep under the paraspinal muscle
- above : the 12th rib
- below : the posterior third of the iliac crest
& iliolumbar ligament
- medially : the transeverse processes of the upper four lumbar
verterbrae
- oriented diagonally upward to the 12th rib
downward to the iliac crest
==> forming a series of crisscrossing bundles
- acting unilaterally
* longitudinal fiber ; flex the spine laterally toward the same side
* diagonal fiber ; flex the spine laterally toward opposite side
==> forced expiration & coughing시에 12th rib을 depress
- acting bilaterally
==> extend the spine
2) Referred Pain Pattern
- lateral, more superficial, longitudinal fiber
==> downward,
mainly over the iliac crest and the greater trochanter
and sometimes anteriorly to the lower abdomen and groin
- medial, deeper fiber
===> more posteriorly to the SI joint and deep in the mid buttock
- gluteus minimus에 satellite trp를 activate시킬 경우에 하지방산통유발
3) Diagnosis
- acute strain of this muscle
==> a quick stooping movement(torso가 한쪽 방향으로 twisted되거나
넘어지거나 다른 사고등)로 발생된다
- 걸레질이나 정원을 가꾸는 것과 같이 지속적이고 반복적인 일을 과하게 한
후
활성화 된다. 환자는 걸어다닐 경우에 통증을 호소하며, 침대에서 몸을 돌
릴
경우, 계단오를때, 기침이나 제체기할 경우 혹은 facing foreward하면서 계
단
올라 갈때에도 통증을 호소하게 된다. rest pain이 특히 밤에 심하게 나타나
기도 하여 아침에 환자가 화장실에 가기 위해 거의 무릎과 손으로 엉금엉금
기어서 갈 정도이다.
- 보행시, 침대에 누울 경우, 의자에서 일어 날 때 동작을 주의 깊게 관찰한
다.
즉, 서있을 경우 골반이 한쪽으로 기울지는 않았는가, spine을 flexion시키
거
나 extension시킬 때 통증으로 제한을 받는가, 현저한 tenderness한 spot가
있는 가를 살펴본다
- deep tenderness는 12th rib를 iliac crest로부터 분리시키는 방법으로 관찰
하지 않으면 위치를 정확하게 구별하지 못하므로 놓치는 경우가 많다.
- superficial portion
==> attach to the 12th rib and to the iliac crest
- deep portion
==> palpated with firm downward pressure toward the lumbar transverse
processes just anterior to the paraspinal muscle masss.
4) Treatment
* Stretch-spray procedure
- first position : uppermost leg is lowered behind the other leg
- second position : uppermost leg is lowered in front of the other leg
* correcting a discrepancy in leg length
- short leg, small hemipelvis ==> compensatory scoliosis
==> tilts the axis of the shoulder girdle
- short leg ==> the heel of shoe조절
- small hemipelvis ==> sitting on a "butt lift" on the short side,
placing a wallet in a long back pocket
- short arm ==> armrest에 pad같은 것으로 보상
* Hip hike exercise
* Supine self strech exercise
(5) Iliopsoas muscle
quadratus lumborum만큼 잘 침범당하는 근육으로 지속적으로 치료해야 한다. 흔
히양쪽 근육이 침범을 당하나 편측이 보다 심하게 영향을 받게 된다
1) Functional Anatomy
* cephalad
- psoas ; to the sides of the lumbar vertebral bodies
- iliacus ; to the inner surface of the iliac bone,
thereby lining the lateral wall of the pelvis major.
* distally
- most of the iliacus fibers join the psoas tendon, which attaches to
the lesser trochanter on the medial aspect of the femur.
* acting bilaterally
- psoas muscle flex the lower lumbar spine
* acting unilaterally
- psoas and iliacus muscle flex the thigh and
assist external rotation at the hip joint
2) Referred Pain Pattern
- distinctive vertical pattern homolaterally along the lumbosacral spine,
extending downward to the SI region
- the front of the thigh on the same side
3) Diagnosis
- 보행시 external rotation & slight flexion at the hip할 경우
thigh를 사용하게 되므로 정상적인 lodosis가 flatten된다
- stooped posture and psoatic gait(thigh의 extension과 internal rotation
이
제한받고 lumbar spine의 extension제한)==> X-ray로 bony kyphosis를 구별
- physical examination
* immediately above the femoral attachment of the iliopsoas tendon
==> pressure (along the medial wall of the femoral triangle toward
the lesser trochanter)
* in the iliacus muscle
==> pressure (against iliac fossa, just inside the brim of the
pelvis
behind the anterior superior iliac spine)
* in the psoas muscle
==> pressure (lateral to the rectus abdominis muscle, just below
the
level of the umblicus)
4) Treatment
* Stretch-spray procedure
* Slow sit back exercise
* Hip extension exercise
* In-door stretch exercise
* Hip extension stretching exercise
B. Pelvis and lower extremity muscles
- three gluteal muscle
- piriformis muscle
- four pelvis muscle
- soleus muscle
(1) Gluteal muscle
- gluteus maximus and medius --> gluteal and sacral region
- gluteus minimus --> buttock < lower extremity
1) Functional Anatomy
- fibers of gluteus maximus : lie diagonally
and sweep over the ischial tubersity
* above ; the sacrum and adjacent crest of the ilium
below ; the fascia lata of the thigh
===> the prime extensor of the thigh at the hip
and also externally rotates the thigh
- gluteus medius
* above ; the upper part of the ilium,
extend around the pelvis to the ant. sup. iliac spine
below ; greater trochanter of the femur
- gluteus minimus
* above ; the ilium
below ; the greater trochanter
===> ant. fibers of the gluteus medius & minimus
; flex the thigh
post. fiber
; antogonist and extend the thigh at the hip
help to externally rotate the thigh
acting together
; abduct the thigh
2) Referrred Pain Pattern
- gluteus maximus (3) ; any part of the buttock and in the coccyx
* the lowest fiber ; deep in the coccyx
- gluteus medius
* medially -- over the sacrum
laterally-- along the iliac crest,
sometimes downward to the mid buttock,
occasionally to the upper part of the thigh posteriorly
- gluteus minimus
* posterior portion
downward to the lower part of the buttock,
down the thigh posteriorly, into the calf, skipping the knee
* anterior portion
similar low buttock pain but project pain strongly to the lateral
aspect of the thigh and leg, as far as the lateral malleolus
the pain again skips the knee
3) Dignosis
- mapping the patient's pain on a body form
- palpating the muscle to locate spot tenderness at the trp
- reproducing the patient's pain with sustained pressure
on the tender spot
- restricted SLR <=== tightness of the hamstring and gluteus maximus
- gluteus minimus vs SIJ' dysfunction
4) Treatment
* Stretch-spray procedure
- gluteus maximus
- posterior fibers of the gluteus medius and minimus
- anterior fiber of the gluteus medius and minimus
==> hot pack ==> active ROM
* Dudley J. Morton foot
- structural inadequancy of the foot
==> long second and short first metatarsal bone
==> pronation of the ankle, internal rotation of the knee,
and adduction and internal rotation at the hip joint
==> correction
- peroneus longus ; entrap the deep peroneal nerve,
causing sensory deficit and foot-drop
- vastus medialis
- gluteal medius ; sacrum and buttock
- gluteal minimus ; lower extremity below the buttock
(2) Piriformis muscle
- refer pain widely , entrap all or part of the sciatica nerve
1) Functional Anatomy
- medially ; internal surface of the sacrum by three fleshy digitations
- laterally ; external surface of the pelvis , to the greater trochanter
===> powerful external rotators of the thigh
2) Referred Pain Pattern
- to the low back in the SI region, to the buttock over the muscle
to the hip joint, down the back of the thigh and calf,
to the sole of the foot
- relationship of sciatic nerve to piriformis
3) Diagnosis
- dyspareunia, tenderness of the sciatica notch on the involved side,
pain with weakness on the resisted abduction and external rotation of
the
thigh with the patient seated
- increased piriformis tension ==> the leg on the same side appear
shorter,
may cause external rotation of that leg when the supine ia at rest,
internal rotation at the hip is restricted on the involved side
- externally ; direct pressure on its lateral and middle portions through
the overlying gluteal muscle
- rectal or pelvis examination ; medial, intrapelvic portion
(3) Pelvic muscle
- pelvic, coccygeal and sacral pain
<== coccygeus, sphincter ani, levater ani, obturator internus muscle
- digital rectal examination
1) Functional Anatomy
- sphincter ani ; surround and control the anal outlet
- levater ani ; form the pelvis floor on the either side of the sphincter
- coccygeus muscle ; cross the pelvic floor between the laterally placed
sacrotuberous ligaments
- obturator internus ; attach to the inside of the obturator menbrane,
palpated internally on the anterolateral wall of pelvis,
piriformis muscle과 함께 greater trochanter에 부착
-- assist external rotation of the thigh
2) Referred Pain Pattern
- coccygeus, sphincter ani, levater ani ; no clear distinction
on coccyx and rectum
- obturator internus muscle ; rectal area and down the posterior thigh
3) Diagnosis
- rectal or pelvis examination
4) Treatment
* coccygeus, levater ani
---> rectal diathermy, ultrasound, massage
* obturator internus muscle
---> faradic or galvanic stimulation
* ischemic compression
---> effective on the perianal muscle
(4) Soleus muscle
- mid belly of the soleus muscle ===> referrred pain over
the SI joint on the same side
1) Functional Anatomy
- proximally ; to the tibia and fibular posteriorly, just below the knee
- distally ; to the calcaneus bone at the back of the heel
via the Achilles tendon
- soleus and gastrocnemius muscle
===> plantar flexion of the foot at the ankle
2) Referred Pain Pattern
- distally along the Achilles tendon and to the heel
- to a silver-dollar sized area over the SI joint on the same side
3) Diagnosis
- patient complains that walking uphill
==> dorsiflextion of the foot at the ankle ===> pain
- when picking up an object from the floor
==> cannot bend the knee ==> must bend the back
- Calf cramp ===> gastrocnemius, not soleus
* diagnosis
- recognizing the characteristic pattern of heel pain and tenderness
or an isolated spot of pain and tenderness
over the bony promonence of the SIJ
- noting that dorsiflexion of the foot is restricted on the painful side
- locating the palpable band, point tenderness and local twitch response
of the active trp in the distal third of the soleus muscle
* deep in the soleus
- 1-2 cm below the lower border of the gastrocnemius
- occasionally high near its attachment
beneath the lateral head of the gastocnemius
* A/J ; decreased or absent
(5) Gastrocnemius muscle
- Calf cramp muscle(venous stasis and circulatory insufficiency),
- intermittent claudication
- the Pt may complain of pain in the back of the knee on effort
- postlaminectomy syndrome (by residual Trp)
1) Functional Anatomy
- span the knee and ankle joints, the most superficial muscle of the calf
- proximally ; the medial and lateral heads attach seperately to the
distal
femur posterioly(medial head is thicker and farther
distally
than lateral head), V shape
- distally ; the tendon of two muscles attaches to the posterior surface
of
the calcaneus
--- plantar flexion of the foot at the ankle
flexion of the knee joint
standing & walking - "reverse pull"(발을 고정시 하퇴를 후방으로 당긴다)
- cf) soleus ; cross only the ankle and mechanically unaffected by knee
angle.
2) Referred Pain Pattern
- from the instep of the ipsilateral foot, over the calf and back of the
knee to the lower posterior thigh
- the most common Trp ; Trp 1 ; the most extensive pattern
- the other Trps ; locally around the Trp
3) Diagnosis
- primarily inability to extend the knee fully with the ankle in
dorsiflexion
- difficalty walking fast and walking on uneven ground
- activated by chilling of the muscle and by mechanical overload
- perpetuating factors ; sustained contraction, shorting, immorbility and
compromised circulation
- A/J ; normal but soleus Trp decreased or absent
- 어린이 성장통
- calf cramps and trps are prone to occor in fatigue( or chilled) muscsles
and are relieved by passive stretch
* differential diagnosis
- S1 radiculopathy (그러나 radiculopathy의 합병증으로도 많이 발생됨)
- spinal stenosis
4) Treatment
* Stretch-spray procedure
* Check list of gastrocnemius corrective actions
* Home therapeutic program
- prevent prolonged immorbility of the calf muscles
and increase the blood flow
- Pedal exercise
- Standing passive self-strtch exercise
- Seated self-strtch exercise
* Noctural Calf Cramps
- Stretching of the muscle
- warmth
- positioning of the feet
- electrolyte replacement
- vitamins E, B2(pregnancy)
- membrane-stabilizing drugs
- circulatory drugs
- electrical stimulation (TENS)
1) Functional anatomy
- proximally ; to the ischial tuberosity
- distally
medial hamstrings ; to the medial side of the tibia just below the knee
lateral ; to the lateral and posterior aspects of the
fibular
below the knee, short head
----- hip extensors & knee flexor
essential for running, jumping, dancing and bending forward
2) Referred Pain Pattern
- semitendinosus and semimembranosus ; project upward to the gluteal fold,
downward to the medial region of the posterior thigh and back of the
knee and sometimes to the calf medially
(upward pattern ; biceps brachii muscle)
more sharper than the deep aching pain from the biceps femoris
- biceps femoris ; distalward to the back of the knee, more laterally
3) Diagnosis
- pain is increased by sitting and walking and that often disturbs sleep
- caused by Trps in 8 other muscles ;
(obturator internus, piriformis, gluteus minimus, gluteus medius,
vastus lateralis, popliteus, plantaris, gastrocnemius)
- 어린이 성장통
- sciatica
- osteoarthritis of the knee
- muscle tears
- acute or repetitive overload or from the chronic trauma of underthigh
pressure by the high front edge of a chair seat
- prolonged bed rest with the knee flexed can aggravate hamstrings muscle
- SLR ; markedly limit motion
- Lasegue's sign ; absent
4) Treatment
* Stretch-spray procedure
* Home Exercise program
- long seated reach exercise
- In-bathtub stretch
- seated self-stretch exrecise
* caution ; avoid the sciatic nerve
(7) Adductor longus
1) Functional anatomy
- above; a narrow flat tendon to a relatively small spot on the outer
surface of the pubis between the symphysis pubis and the obturator foramen.
--> downward, laterally and posterioly
- below: medial third of the femur.
2) Referred Pain Pattern
- proximal pattern(more proximal Trp): deep in, and proximal to, the groin
and the anteromedial portion of the upper thigh
- distal pattern(more distal Trp): upper medial part of the knee with a
spillover pattern(downward over the tibia)
- 소아: inguinal ligament, anteromedial thigh, medial knee, upper 2/3 of
medial lig.
3) Diagnosis
- 휴식시보다는 강력한 운동을 할 때, 서혜부, 대퇴부 내측 통증
- 통증은 힘을 주거나 고관절은 틀 때 증가된다.
- DDX
1) MPS
2) mechanical overload
3) articular dysfunction
4) nerve entrapment
4) Treatment
* Stretch-spray procedure: 간헐적인 신전분부보다는 injection이 효과적
* 구조적인 인자보다는 비타민, 빈혈, 만성 감영, 갑상선기능저하, 당뇨와 관련
* Corrective posture
- 앉아 있을 때: 장시간 운전, 다리 꼬고 앉지 말 것
- 누울 때, 잘 때: shortened posture, hyperhipflexion을 피하라
* Home Exercise program: 똑바로 서서 손으로 table을 잡고 다리를 swing
(8) Quadriceps femoris
1) Functional anatomy
* rectus femoris
-above: 1) ant inf iliac spine 2) a groove above the post brim of the
acetabulum
-below: proximal border of the patella
* Vastus medialis
-above: posteromedial aspect of the shaft of the femur
-below: medial border of patella
* Vastus intermedius
-above: ant and lat surface of the upper 2/3 of the shaft of femur
-below: patella
* Vastus lateralis
-above: lat side of post aspect of the upper 3/4 of femur
-below: lat border of patella
2) Referred Pain Pattern
* thigh and knee pain
* rectus femoris & vatus medialis --> ant knee pain, knee extension의 weakness
* vatus lateralis --> posterolateral knee pain
* rectus femoris(buckling hip syndrome)
- trp: hip level(ant inf iliac spine 아래)
- patella주위, knee pain, 야간에 severe deep pain(vastus medialis or lateralis
보다 deep pain)
- 계단 내려갈 때 불편함, 야간에 자다가 무릎과 ant thigh가 아퍼서 깰 때 의심
(vatus intermedius: 계단 올라갈 때 불편함)
* Vastus medialis(buckling knee syndrome)
- trp1: the front of knee, trp2: linear distribution over the anteromedial
aspect of knee and lower thigh
-trp가 knee의 ROM을 약간 제한할 뿐 통증이 없을 수 있다.
* Vastus intermedius(buckling hip syndrome)
- trp: restus femoris내에 multiple에게 존재
- front of the thigh nearly to knee, mid thigh에 가장 강력한 통증
* Vastus lateralis(locked patella syndrome)
-trp: 대퇴외측을 따라 multiple하게 나타남(5개의 trp)
-전체 대퇴의 외측과 슬관절 외측으로 통증, 병변이 있는 쪽으로 누워자기 어렵다.
(9) Tibialis anterior Muscle(foot-drop muscle)
1) Functional anatomy
- above; lat condyle of the tibia
- below: medial and platar surface of the medial cuneiform bone anf to the
base of the first metatasal
2) Referred Pain Pattern
- Trp: upper third of muscle
- pain: anteromedial aspect of the ankle and in the big toe,
야간에는 통증을 호소하지 않음(잠 잘 때 다리 자세 때문).
- other symptoms: foot drop, general weakness of the ankle
- 소아에게서 흔히 발생되는 통증(장시간 서 있고 난 후 발과 무릎에 심한 통증)
3) Diagnosis
- extensor hallucis longus and brevis
- extensor digitorum longus and brevis
- peroneus tertius
- DDx
1) MPS: taut band, trp
2) joint: tenderness + ROM장애
3) ligament: tenderness
4) L5 radiculopathy
5) Ant compartment syndrome
(Trp는 nerve entrapment를 안해도 nerve entrapment의 후유증으로 발생
됨)
4) Treatment
* Stretch-spray procedure: release the calf muscle tightness
* Morton's foot교정
* Corrective posture
- exessive dorsiflexion을 피하라(예, 운전)
- 울퉁불퉁한 길 보다는 평지를 걸어라
* Home Exercise program: 하루에 3번 정도, pedal exercise(tibialis ant and
soleus)
(10) Peroneus longus, brevis, tertius(weak ankle muscle)
1) Functional anatomy
- above; fibula and adjacent intermuscular septa
(longus and brevis: lat compartment, tertius: ant compartment)
- below:
* longus: passes behind the lat malleus, runs obliquely across the sole
of the foot from lat to medial, and ends on the first
metatasal and medial cuneiform bones.
* brevis: curves behind the lat malleus but ends on the tuberosity of
the fifth
metatasal
* tertius: passes in front of the lat malleus and ends on the proximal
portion of
the fifth metatasal
2) Referred Pain Pattern
- peroneus longus and brevis: region over the lat malleolus of the
ankle,above, behind, and below it. a short distance along
the lat aspect of the foot.
spilllover pattern: middle third of the leg
- peroneus tertius: anterolateral aspect of the ankle with a spillover
pattern projecting downward behind the lat malleus to the
lat aspect of the heel
- weak ankle, frequently sprain, ankle unbalance