Learning Outcomes: Students will be able to:

1. Describe the musculoskeletal anatomy of the spinal column, trunk, ribcage and associated connective tissues that support these joints.
2. Articulate the functional design of the atlantooccipital and intervertebral joints and the osteokinematic and arthrokinematic movements possible at the joints.
3. Describe the origin, insertion, actions, and nerve innervation of select muscles that act on the lumbar, thoracic, and cervical joints.
4. Identify how to strengthen and stretch each of the muscles or muscle groups that act upon the segments of the spinal column.
5. Articulate the mechanisms that can contribute to pathology of intervertebral joints and discs, and the proper techniques to reduce the risk while enhancing performance.
6. Identify spinal and lower extremity pathologies related to vertebral disc and other spinal pathology using knowledge of myotomes, dermatomes, and cutaneous distribution patterns.
7. Identify the causative factors that contribute to the development of lordosis/lower crossed syndrome and scoliosis, how to assess for their presence and be able to implement interventions to address these conditions

Figure 1

Regions of the Spine

Cervical Spine (neck) contains seven vertebrae (C1-C7) with the convexity of the curve anterior (lordosis).

Thoracic Spine (upper and middle back) contains twelve vertebrae (T1-T12) with the convexity of the curve posterior (kyphosis).

Lumbar Spine (low back) contains five vertebrae (L1-L5) with the convexity of the curve anterior (lordosis).

Sacrococcygeal spine (pelvic) contains the sacrum consisting of five fused vertebrae (S1-S5) and the coccyx consisting of four partially or fully fused vertebrae (Co1-Co4) with the convexity of the curve posterior (kyphosis).

Development of Spinal Curves

Primary Curves (thoracic and sacrococcygeal) are formed before birth.

Secondary Curves (cervical and lumbar) are formed after birth.

Atlantooccipital & Atlantoaxial Joints

Atlantooccipital (condyloidal)

- Occiptial condyles of skull sitting on the articular fossa of the atlas. ≈15° flexion/extension from anatomical.

Atlantoaxial composed of two lateral facet joints (arthrodial) and one median joint named atlanto-odontoid (trochoidal).

Rotation of atlas (C1) around the fingerlike process (odontoid process or dens) of the axis (C2) during rotation of the head.

• 40° rotation (right and left from anatomical).

Figure 2

Joints of the Spine

Cervical facets: oriented in an oblique plane (45º between the transverse and frontal planes) allowing motion in the transverse plane (neck right and left rotation) and frontal plane (neck right and left lateral flexion).

Thoracic facets: generally oriented in a frontal plane facilitating trunk right and left lateral flexion (limited by rib cage).

Lumbar facets: generally oriented in the sagittal plane mostly allowing lumbar flexion and extension.

Figure 3

Spinal Movements & Range of Motion

Cervical Region: Flexion 50-60°, Extension 50-60°, Right and Left Lateral Flexion 45°, Rotation 80°

Thoracic Region: Flexion 35º, Extension 25º, Right and Left Lateral Flexion 25º, Right and Left Rotation 30º

Lumbar Region: Flexion 30°, Extension 20°, Right and Left Lateral Flexion 20°-30º, Right and Left

Rotation 5°

Vertebral Facets & Spinal Motion

Spinal Flexion: Both facets “open”

Spinal Extension: Both facets “close”

Side Bending and Rotation: Concavity side “closes” and convexity side “opens”.

Figure 4

1. Annulus Fibrosus: a tough fibrosus ring shaped fibrocartilaginous material that encircles and encloses the nucleus pulposus. Contains multiple rings in a basket weave configuration (each successive layer with a different fiber orientation) giving it the ability to resist distraction forces, shear forces, and torsion forces.

2. Nucleus Pulposus: a gel type material (at least 80% water) located in the center of the annulus fibrosus providing shock absorption properties to the spine.

3. Vertebral Endplate: composed of hyaline articular cartilage and fibrocartilage, it lines the articulating surfaces of each vertebral body.

Figure 5

How to Keep Intervertebral Discs Healthy

-Exercise Regularly              -Avoid Smoking      

-Drink Plenty of Water         -Avoid Alcohol                                                                                                                    

-Eat a healthy diet                 -Avoid Repetitive

                                                  Flex/Ext Exercises    

Myotome & Dermatome Testing

Myotome Testing

Lower Extremity Myotomes

Nerve Root Level

Patient Position

Joint & Movement Resisted (tested)

L1-L2

Sitting

Hip flexion

L3

Sitting

Knee extension

L4

Long sit

Ankle dorsiflexion

L5

Long sit

Big toe extension

S1

Prone

Ankle plantarflexion, Foot eversion, and Hip extension

S2

Prone

Knee flexion

Dermatome Testing

Dermatomes of the Lower Extremity

Cutaneous Distribution of the Lower Extremity

Figure 6

 Figure 7

Nerve Root

Dermatome Afferent

(Sensory)

Myotome Efferent

(Motor)

Functional Application

L1

Touch: Lower abdomen, groin, lumbar region from 2nd to 4th vertebrae, upper and outer aspect of the buttocks

Quadratus Lumburum

Sensation to low back, over trochanter and groin

L2

Touch: Lowe lumbar region, upper buttock, anterior aspect of thigh

Iliopsoas

Quadriceps

-Hip flexion

-Sensation to back, front of thigh to knee

L3

Touch: Medial aspect of thigh to knee, anterior aspect of lower 1/3 of the thigh to just below the patella

Psoas

Quadriceps

-Knee extension, hip flexion

-Sensation to back, upper buttock, anterior thigh and knee, medial lower let

L4

Touch: Medial aspect of lower leg and foot, inner border of foot, great toe

Tibialis Anterior

Extensor Hallucis Longus

Digitorum Digitorum Longus

Peroneals

-Ankle dorsiflexion, subtalar and transverse tarsal inversion

-Sensation to medial buttock, lateral thigh, medial leg, dorsum of foot, great toe

L5

Touch: Lateral border of leg, anterior surface of lower leg, top of foot to middle three toes

Extensor Hallucis Longus

Extensor Digitorum Longus

Peroneals

Gluteus Maximus and Medius

Dorsiflexors

-Great toe extension, subtalar and transverse tarsal inversion

-Sensation to upper lateral leg, anterior surface of the lower leg, middle three toes

S1

Touch: Posterior aspect of the lower ¼ of the leg, posterior aspect of the foot, including the heel, lateral border of the foot and sole

Gastrocnemius

Soleus

Gluteus Maximus and Medius

Hamstrings

Peroneals

-Ankle plantarflexion, knee flexion, subtalar and transverse tarsal inversion

-Sensation to lateral leg, lateral foot, lateral two toes, plantar aspect of foot

S2

Touch: Posterior central strip of the leg from below the gluteal fold to ¾ of the way down the leg

Gastrocnemius

Soleus

Gluteus Maximus

Hamstrings

-Knee Flexion, Ankle plantarflexion, toe flexion

-Sensation to posterior thigh & upper posterior leg

Spinal Ligaments

1. Ligamentum Nuchae

• Connects spinous processes, runs from external occipital protuberance to C7. Protects against extreme head and neck flexion.

2. Supraspinal

• Connects tips of spinous processes from C7 to sacrum. Protects against extreme of thoracic and lumbar flexion.

3.Ligamentum Flavum

• Connects lamina anteriorly from adjacent vertebrae from axis to sacrum. Provides protection to the neural elements of the spine and provides stability by preventing excess motion between vertebrae

4.Interspinal

• Connects inner surface of spinous processes of adjacent vertebrae. Protects against extreme spinal flexion.

5.Intertransverse

• Connects transverse processes of adjacent vertebrae. Protects against the extreme of lateral spinal flexion.

6.Anterior Longitudinal

• Connects adjacent vertebral bodies, runs from axis to sacrum on “anterior” aspect of vertebral body. Protects against the extreme of spinal extension.

7.Posterior Longitudinal

• Connects adjacent vertebral bodies, runs from axis to sacrum on “posterior” aspect of vertebral body. Protects against the extreme of spinal flexion.

Figure 12

Figure 13

Figure 14

Figure 15

Selected Major Muscles of the Spine (including skull and pelvis)

Sternocleidomastoid

Origin:

Insertion:

Actions:

Nerve Innervation:

Splenius Cervicis & Capitis

Origin:

Insertion:

Actions:

Nerve Innervation:

Suboccipitals

Origin:

Insertion:

Actions:

Nerve Innervation:

Selected Major Muscles of the Spine

Quadratus Lumborum

Origin:

Insertion:

Actions:

Nerve Innervation:

Rotatores

Origin:

Insertion:

Actions:

Nerve Innervation:

Multifidus

Origin:

Insertion:

Actions:

Nerve Innervation:

Selected Major Muscles of the Spine – Erector Spinae Muscle Group

Erector Spinae: Spinalis

Origin:

Insertion:

Actions:

Nerve Innervation:

Erector Spinae: Longissimus

Origin:

Insertion:

Actions:

Nerve Innervation:

Erector Spinae: Iliocostalis

Origin:

Insertion:

Actions:

Nerve Innervation:

Muscles of the Abdominal Wall

Rectus Abdominis

Origin:

Insertion:

Actions:

Nerve Innervation:

Internal Abdominal Oblique

Origin:

Insertion:

Actions:

Nerve Innervation:

External Abdominal Oblique

Origin:

Insertion:

Actions:

Nerve Innervation:

Transverse Abdominis

Origin:

Insertion:

Actions:

Nerve Innervation:

Abdominal Aponeurosis

Abdominal Aponeurosis

A large sheet of fibrous connective tissue located anteriorly in the

abdominal region (right and left sides) providing attachment sites for

the external abdominal oblique, internal abdominal oblique, and the

transverse abominus muscles.

• The linea alba (white line) is where the right and left

abdominal aponeuroses meet in the midline.

• The tendinous intersections divide the rectus abdominus

muscles into segments and are a continuation of the abdominal

Aponeurosis.

Figure 22

Functions of the Abdominal Wall

Abdominal Considerations

Protection ____________________________

Support of Viscera _____________________

Elimination ___________________________

Forced Expiration ______________________

Stabilization of Trunk and Pelvis __________

Trunk Movement ______________________

Parturation ___________________________

Kinesiology of the Abdominal Muscles: List in order

the importance or degree of involvement of the

abdominals in the following activities.

_____ Straight leg raises (unilateral)   _____ Pull-ups        

_____ Straight leg raises (bilateral)           _____ Curl-ups

_____ Sit-ups                           _____ Ambulation

_____ Push-ups

Causes for weakness of the abdominal wall

• Developmental
• Pathological

Abdominal Ptosis: Sagging abdomen

Beevor’s Sign: Looking for umbilicus displacement

Figure 24

Thoracolumbar Fascia

A large sheet of fibrous connective tissue located posteriorly in the

thoracic and lumbar trunk regions (right and left sides) providing

attachment sites for the muscles and to add stability to the trunk.

• The quadratus lumborum and erector spinae muscle groups are

encased withing the thoracolumbar fascia.

• The latissimus dorsi attaches into the spinous processes via its

attachment into the thoracolumbar fascia.

• The thoracolumbar fascia attaches to the transverse and spinous

processes in the lumbar region.

• Posterolaterally the internal abdominal oblique and transverse

abdominus muscles attach to it.

• Inferiorly the thoracolumbar fascia attaches to the sacrum and

iliac crest, providing attachment for the gluteus maximus.

  Lower Crossed Syndrome

• Excessive lordosis of lumbar spine
• Excessive anterior pelvic tilt

Note: Not always but a lower crossed syndrome will

often be associated with an upper crossed syndrome.

Causes

• Congenital deformity
• Poor body mechanics
• Muscle imbalance (disuse or disease)
• Overtraining in certain sports
• Compensatory deformity to a kyphosis

or other deformities of foot, knee, or hip

Considerations

• More common in tall ectomorphs
• More common in children and adolescents
• Asymptomatic unless due to trauma
• Relationship to low back pain
• Changes in intervertebral body distance
• Bony changes uncommon

                                                             Therapeutic Interventions for Lower Crossed Syndrome

In the spaces below identify the muscles that are “weak” and those that are “tight” with respect to Lower Crossed  

Syndrome and then identify therapeutic interventions to help correct the problem.

Therapeutic Intervention – How would you isolate to

strengthen the weak muscles?

Therapeutic Intervention – How would you isolate to

stretch the tight muscles?

Scoliosis – Lateral deviation(s)/curve(s) of the spine with coupled vertebral rotation to the opposite side: Spinous processes rotate                           toward concavity of curve and the vertebral bodies rotate toward the convexity of the curve. The convexity of the curve is the                              reference side of the curve for nomenclature (right convexity = right curve).

Causes

1. Known: (20%) Hemivertebrae,

Congenital spinal deformities, neuron-

muscular problems, leg length difference

cerebral palsy, muscular dystrophy

2. Unknown: Idiopathic (80%)

Considerations

1. Most common in adolescence 10-18
2. Onset, typically during puberty
3. Affects 2% women, .5% men
4. Usually asymptomatic

Idiopathic scoliosis is broken down into four categories based on age:

1) Infantile: children ages 3 and under

2) Juvenile: ages 3 to 9

3) Adolescent: ages 10-18

4) Adult: after skeletal maturity.

The most common form of Scoliosis, representing 80% of idiopathic scoliosis cases, is Adolescent Idiopathic Scoliosis, which                           develops around the onset of puberty. People with a family history of spinal deformity are at greater risk for developing scoliosis.

Early detection is essential.

Signs of Scoliosis – common characteristics:

1. Shoulder asymmetry
2. Unilateral scapular prominence and asymmetry
3. Rotation of trunk (one shoulder forward)
4. Contour of trunk (waistline), skin folds
5. Distance from arm to thorax
6. Deviations of spinous processes
7. Chest flatness on side of convexity

Figures 27, 28

Adam’s Forward Bend Test: with their feet together

have the patient bend forward, bending 90º at the waist.

• Rotation of vertebrae with rib prominence

(angulation = Razor back sign) in thoracic

area

and paraspinal muscle prominence in the

 lumbar

area.

Figure 29

Types/Classifications of Curves

Figure 30

Figure 31

Nomenclature

• Left lumbar
• Right lumbar
• Left Thoracic
• Right Thoracic

Simple “C”

Compound “S” (double

major curve)

                                                                       Degree Curvature and Therapeutic Interventions

If curvature of curve is:

• <20º = Therapeutic exercise and monitor
• 20º to 30º = bracing and therapeutic exercise
• >40º = usually requires surgery
• >50º = pulmonary limitations

         = significant

         = back bain

         = arthritis

         = degenerative disc disease

Cobb Method for Measuring Degree of Scoliosis

Choose the most tilted vertebrae above and below the

apex of the curve. The angle between intersceting lines

drawn perpendicular to the top of the vertebrae and the

bottom of the vertebrae is the Cobb Angle.

Figure 32

Figure 33

Sample of Review Questions