Musculoskeletal anatomy by self-examination: A learner-centered method for students and practitioners of musculoskeletal medicine

Journal Pre-proof Musculoskeletal Anatomy by Self-examination: A Learner-centered Method for Students and Practitioners of Musculoskeletal Medicine ´ Juan J. Canoso, Miguel Angel Saavedra, Virginia Pascual-Ramos, ´ Marco Antonio Sanchez-Valencia, Robert A. Kalish

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S0940-9602(19)30161-X

DOI:

https://doi.org/10.1016/j.aanat.2019.151457

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AANAT 151457

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Annals of Anatomy

Received Date:

5 October 2019

Revised Date:

22 November 2019

Accepted Date:

25 November 2019

´ Please cite this article as: Canoso JJ, Saavedra M, Pascual-Ramos V, Sanchez-Valencia MA, Kalish RA, Musculoskeletal Anatomy by Self-examination: A Learner-centered Method for Students and Practitioners of Musculoskeletal Medicine, Annals of Anatomy (2019), doi: https://doi.org/10.1016/j.aanat.2019.151457

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1 Musculoskeletal Anatomy by Self-examination: A Learner-centered Method for Students and Practitioners of Musculoskeletal Medicine

Juan J. Canoso[a,b*], Miguel Ángel Saavedra[c,d], Virginia Pascual-Ramos[d,e], Marco Antonio Sánchez-Valencia[f], Robert A. Kalish[b]

Department of Medicine, ABC Medical Center, Mexico City 01120, Mexico

b

Division of Rheumatology, Tufts University School of Medicine, Boston,

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a

Massachusetts 02111

Department of Medicine, Specialties Hospital “Antonio Fraga Mouret” National

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c

d

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Medical Center La Raza, Mexico City 02990, Mexico

Postgraduate Division, National Autonomous University of Mexico, Mexico City

e

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04510, Mexico

Department of Immunology and Rheumatology, Research Division, National

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Institute of Health Sciences and Nutrition “Salvador Zubirán,” Tlalpan, Mexico City 14000, Mexico f

Department of Anatomy at the National Autonomous University of Mexico (UNAM)

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in Mexico City 04510, Mexico

*Corresponding author: Sur 136 No 116 int 417, Las Américas, Alvaro Obregón 01120, Mexico City, MEXICO. Tel+52-55-54025292, [email protected]

2 Abstract Background: The authors describe a series of learner-centered exercises, highlighting a technique in which the musculoskeletal anatomy is explored and learned through self-examination, with the examiner required to identify designated structures in both the static and dynamic state. Methods: The technique of musculoskeletal anatomy through self-examination

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consists of applying knowledge of the surface anatomy of a region as it exists in

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the static state, to the analysis and understanding of changes that occur with

movement and function of that body part. The sensory input of the examined part

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may contribute to the overall perception of the exercise.

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Results: Three tables provide details that allow the reader to understand and perform the exercises describing the anatomic part explored, the physical

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maneuver required, the expected anatomic finding(s), and their clinical relevance. Conclusions: The authors believe that musculoskeletal self-examination provides

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an engaging learner-centered pedagogy that may complement that which is learned in peer or model examination. The lack of cost, the absence of intimacy barriers, and the opportunity to extend the method to further areas and functions are additional benefits of musculoskeletal self-examination as a learner-centered,

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self-study methodology.

Keywords: Musculoskeletal anatomy, learner-centered method, pre-graduate medical education, postgraduate medical education

3 1. Introduction An accurate diagnosis of regional musculoskeletal (MSK) conditions, such as shoulder pain, requires an anatomically based physical examination. An anatomically based physical examination is also desirable in the evaluation of patients with systemic diseases such as rheumatoid arthritis, albeit with a different emphasis. Because of a shared interest in the care of these patients, generalists,

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neurologists, orthopedic surgeons, physiatrists, physical therapists, and

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rheumatologists should be proficient in a detailed or basic anatomically-based

physical examination. However, a suboptimal knowledge of MSK medicine, both at

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the pre-graduate and post-graduate levels, is currently recognized based on the

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use of standardized questionnaires (Matzkin et al., 2005; Weiss et al., 2015). In Europe, a survey of young rheumatologists revealed that only 52.3% were satisfied

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with their knowledge of anatomy (Bandinelli et al., 2011). In a one-on-one practical examination of rheumatologists, other MSK-interested specialists and fellows

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performed by the authors in academic centers or rheumatological societies of seven American countries (Navarro-Zarza et al., 2014), a suboptimal knowledge of surface and functional MSK anatomy were found. In this study, 20 MSK items had to be found or demonstrated in the instructors´ or participants´ bodies. As an

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example, the instructor showed his/her foot and asked the participant to passively move the tibiotalar joint and then the subtalar joint. There were 170 examinees, including 84 rheumatology fellows, 61 rheumatologists, and 25 nonrheumatologists. Correct answers averaged 46.6% ± 19.9 and, between countries, ranged from 32.5% to 67.0%. Recently (Hołda et al., 2019), in a comprehensive survey of the recognition of 20 anatomical items pertaining to the head and neck,

4 the thorax, the abdomen and pelvis, and the nervous system among students and graduates from all Polish medical schools an overall mean of 65.6% was achieved. Scores were lower in graduates than in students. From the above data, it may be concluded that anatomical recognition of head, trunk, and nervous system items, as well as MSK limb items, is limited in medical students and graduates in various parts of the world.

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For centuries, cadaver dissection has been the foundation upon which the

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morphological medical sciences are built. In addition to providing an experience that is the closest possible mimic to opening a live body such as in surgery, the

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humanistic impact of cadaver dissection on medical students is well recognized,

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including respect and appreciation for cadaver donors and their families, an opportunity to self-reflect upon emotions, and a coming to terms with death and

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dying (Flack and Nicholson, 2018). However, logistics, societal characteristics, and religious beliefs have diminished the supply of suitable cadavers at a time when

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larger medical school classes have increased demand. Partially as a result of these factors, the traditional teaching of anatomy has been augmented with images (Gross et al., 2017), plastic models, prosected and plastinated specimens, 3-D printed models (McMenamin et al., 2014; Garas et al., 2018), and learning through

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art and humanities, CT and MRI reconstructions. Additional readily available methods for the study of living anatomy include models, consented crossexamination of students (Wearn and Bhoopatkar, 2014), and body painting (Finn and McLachlan,2010). Living anatomy is eminently suited for the study of surface anatomy (Lockhart,1947; Azer, 2013), and when ultrasonography is added (Davis et al., 2018), static and dynamic views of all the intervening structures between

5 bone and skin surface, including nerves, vessels, and blood flow, elucidate the tissues that support, or surround, the surface detail. However, limitations to the use of ultrasound (US) for large groups of students include the need for adequate numbers of US machines and trained instructors. Furthermore, for maximal benefit and realism, i.e., to assess blood flow, US studies should be performed on living models rather than on cadavers, which can also

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prove to be limiting. Looking back historically, scientifically, and according to their

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experience, authorities with different viewpoints have debated whether cadaver

dissection is still essential to the teaching of pre-graduate anatomy (McMenamin et

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al., 2018). As judged by a mixed audience with a vested interest in anatomy, a pre-

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debate poll favored the use of cadavers, while a post-debate poll ended with a tie. In a meta-analysis of pedagogies used in pre-graduate anatomy education (Wilson

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et al., 2018), the conclusion was that the role of cadaver dissection remains unsettled. As could be expected, in Holda´s survey, students that had taken

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cadaver dissection obtained the highest competency marks (Holda et al., 2019). Given today's variety of methods and tools to teach anatomy, why propose yet another learning tool, musculoskeletal self-examination, for the study of surface and functional anatomy? The authors would submit that as a learning

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methodology, MSK self-examination may be considered a learner (in the broad sense)-centered pedagogy that represents an extension of consented peer examination in which the subject being examined is oneself. On the flip side, a drawback of musculoskeletal self-examination, which is inherent to its single-case (N-of-one) methodology, is that it misses anatomical variation which, of course, maybe learned by examining friends, workshop participants, and patients, as well

6 as by carefully observing the human beings seen in one’s daily life. Indeed, the British anatomist Frederick Wood Jones has stated the following: “However, surface anatomy may be studied at all times and in all places” (Wood Jones, 1949). Reachable by musculoskeletal self-examination are the muscles of the hand, forearm, upper arm, shoulder, neck, head, anterolateral chest, abdominal wall,

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thigh, leg, and foot, all of which lend themselves to “palpatory myography,” which is

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a significant component of musculoskeletal self-examination. The authors

introduced this term as “palpatory electromyography” years ago to dramatize in a

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tongue-in-cheek fashion the use of palpation to understand muscle action in

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complex or separate areas (Kalish and Canoso, 2007). Among these regions, thigh palpation during walking and negotiating stairs provides unique demonstrations of

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muscles in action and the events that take place near to, as well as far from, their origins. Additionally, bimanual, encircling palpation of the leg during dorsal and

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plantar flexion and pronation and supination of the foot goes the opposite way: under the deep fascia that integrates the whole, individual structures become less significant than the functions they subserve. Finally, the skin and its gliding properties, fascia, ligaments, tendons around joints, some blood vessels, some

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superficial nerves, and myriad bone landmarks are amenable to self-inspection, palpation, and perception at various positions of the adjacent joint(s). Spatial ability (Nguyen et al., 2014) permeates these exercises and the resulting geometric changes – think of the popliteal fossa in knee extension and flexion or the axilla with the arm hanging on the side or in elevation (Milch, 1949). By continuous

7 surveillance of the moving parts, these startling changes are easy to understand by self-inspection, palpation, and perception. The purpose of the current communication is to list a series of musculoskeletal self-examination exercises that MSK anatomy instructors may wish to teach to all interested in MSK medicine. In turn, participants may extend the method based on their physical prowess, previous knowledge, imagination, and ability to record their

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findings. Ultimately, instructors and participants may build a critical mass of self-

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examination exercises that may convert MSK self-examination into a powerful

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student-centered ancillary method of learning surface and functional anatomy.

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2. Materials and Methods

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2.1. Background

From the outset, the authors want to make clear that none of the described

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exercises are new, as all are part of any human experience, and all may be shown, or their conclusions derived, from any course of clinical MSK anatomy. Indeed, self-examination was mentioned in early textbooks of surface anatomy (i.e., Lockhart, 1947, p 5).

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Any reachable part of the body may be explored, including areas that would be inappropriate to examine in peers and models, and the exercises may be repeated as often as desired. A possible additional benefit of musculoskeletal selfexamination, discussed in greater depth below, is that self-perception by the explored part of the examiner’s body that cannot be perceived when examining another person’s body supplements the sensory input of the examiner’s exploring

8 hand and eye and adds a new dimension to the anatomic learning. Thus, musculoskeletal self-examination may also be viewed as a learner-centered pedagogy in which the examined body parts are Nature-provided 3-D prints that feel and have voluntary movement.

2. 2. The self-examination exercises

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Of the 21 exercises listed in Tables 1 to 3, 13 correspond to the upper limb, and

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eight correspond to the lower limb. Thirteen of the exercises address items

considered important to MSK medical practitioners, based on two international

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Delphi studies conducted by the authors (Villaseñor-Ovies et al., 2016; Hernández-

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Díaz et al., 2017). Eight additional exercises were included by the authors´ agreement based on their diagnostic importance. Four exercises were adapted

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from classical descriptions: Table 2 exercises #4 (Martin, 1932) and #5 and #6 (Kessel and Watson, 1977), and Table 3 exercise #2 (Trendelenburg, 1895). The

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remaining exercises belong to the medical tradition and could not be referenced. The unifying thread in MSK self-examination is that, regardless of their types and sources, all exercises have been adapted for self-examination. Ten of the

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exercises have been filmed and appear in Supplemental Material.

3. Results and Discussion 3.1. Tables

Table 1 lists hand, wrist, forearm and elbow exercises, Table 2 describes upper arm and shoulder exercises, and Table 3 includes selected lower extremity selfexamination exercises. Performance and interpretation of each of the exercises are

9 displayed in four columns: Column 1: Each exercise initiates with a review of the method´s content showing figures or models and, most importantly, a supervised self-identification of these item(s) in the participant's body. Column 2: The target item(s) are self-identified and, in functional exercises, are followed by inspection, palpation, and self-perception during movement of the adjacent joint or joints to determine what has happened. Column 3: The rearrangement of items or other

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enlightening findings is shown. Column 4: The clinical relevance of the exercise is

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mentioned. In functional MSK self-examination exercises, the transition from the

starting position to the end position is a palpable, observable, and self-perceived

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continuum through touch and proprioception (Moscatelli 2019; Proske and Allen,

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2019). The same perceptions, albeit static, underlie the surface anatomy MSK self-

3.2. Discussion

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identification exercises.

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Taken as a system, and limited as the MSK self-examination method as shown may be, the authors suggest that self-examination adds self-perception to the “feeling of life” of consented peer examination. The MSK self-examination anatomist has learned the anatomical structures in the standard positions and

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sections, has identified them on himself or herself, and has imagined what would happen to those structures as neighboring joints are flexed. By watching or by palpating the moving structure, not only has the anatomist learned to identify them in a different arrangement, but also have a better understanding of their function. An example would be to learn the anatomy of the shoulder with the arm by the side, followed by dissection of the axilla with the arm in elevation, and then

10 following in oneself and one’s anatomy partner each contour of the proximal upper limb as the live human arm is raised (Milch,1949). Continuity of structures in motion may lead away from memorizing and rejecting, rather than understanding and loving, anatomy. This simple, observational method has the potential to foster a life-long interest in clinical MSK anatomy. Finally, MSK self-examination may

accuracy in performing joint and soft-tissue procedures.

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provide a deeper understanding of MSK physical examination as well as greater

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In the authors´ view, MSK self-examination as a learner-centered teaching

intervention for MSK anatomy has several advantages. One is that the method was

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designed by rheumatologists, who share conceptual and practical foundations with

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general medicine, neurology, orthopedics, physical medicine and rehabilitation, and physical therapy. Thus, the examples of MSK self-examination shown in the

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Tables bridge clinical applications back to the very bedrock of medical sciences. Another advantage is that any reachable part of the body may be dynamically or

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statically explored, including areas that would be embarrassing or inappropriate to examine in others. Furthermore, muscles may be palpated during complex activities, such as walking, at two sites with one hand, such as distally and proximally in the forearm during pronation, or at a tendon and its muscle belly (for

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example, in the leg); moreover, the coordinated and predictable contraction of muscle groups under the deep fascia may be felt. Additionally, MSK self-examination offers unlimited opportunities to practice the technique at no cost and without the need for special equipment. A possible further advantage is that repetitions of a given exercise under different conditions may lead to novel anatomical and biomechanical hypotheses. Finally, participants may

11 be inspired to design additional exercises, which would add another critical dimension to the knowledge assessment, namely, that of using and applying the imagination, and in the process, they would exercise the type of high-level problem-solving skills so central to excellent clinical practice.

The limitations of MSK self-examination as a learning methodology are several.

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First, there is a lack of demonstration of its utility in enhancing anatomy

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recollection, facilitating training in the MSK system-focused subspecialties, or improving the practice of general medicine. A further limitation of MSK self-

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examination is the lack of exposure to anatomic variation. Several ways to correct

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this deficiency have been mentioned in the introduction. Another possible flaw of this method is the risk of taking as normal some anomaly in the self-examiner or

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applying knowledge learned in an older body (Frontera, 2017) and using it when examining a young person or vice versa. However, the instructor´s experience will

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distinguish typical from atypical anatomy. An additional disadvantage is that the reach of the exploring hand and the field of stereoscopic vision are, of necessity, limited. Thus, data gathering from certain areas, such as the posterior arm, the neck, the back, the buttocks, and the posterior thighs, is limited. A final and

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important limitation is the lack of definitive proof of additional sensory information provided by the examined part. Experimental studies of touch and proprioception have addressed tactile sensations, position, movement, and balance (Moscatelli et al., 2019; Proske and Allen, 2019), all of which might be pertinent to selfexamination. Thus, sensory input of the self-examined part, as proposed in MSK self-examination, appears at least plausible. In support of this channel of

12 information is the third law of Newton, which states that for every action, there is an equal and opposite reaction. According to this law, self-palpation of a bone eminence or a tendon meets an equal force, from the bottom up, that acts on receptors in the periosteum, fascia, subcutaneous tissue, and the contact skin, plus the related joints, tendons, and muscles, all of them variously innervated. Of course, the nature and the ratio of receptors in the “exploring” and the “explored”

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area will vary widely. The best example of reciprocal self-palpation could be the

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pervasive contact of the thumb with any of the fingers. It is not just the thumb perceiving the fingers, but the fingers perceiving the thumb. Reciprocal self-

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palpation would be unbalanced due to the nature and density of receptors, such as

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when the fingers of one hand explore the back of the opposite distal leg. Neuroimaging studies of the empirical method described herein would be of

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4. Conclusions

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interest.

Despite its limitations, the authors believe that MSK self-examination may be a useful adjunct to standard methods of teaching MSK anatomy. The authors envision the applicability of MSK self-examination as a learner-centered pedagogy

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at the pre-graduate level and in training for several MSK-related specialties. Finally, the authors hope that readers will be eager to try MSK self-examination as the absence of cost, limitless opportunities to practice, and enhanced perception may help solidify the knowledge gained through other living anatomy methods.

13 Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of interest: The authors have no conflict of interest.

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Declaration of interest: Dr. Canoso has received honoraria from Menarini and Pfizer for lectures unrelated to this manuscript

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Ethical statement: Does not apply.

Acknowledgments

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The authors thank Fernando Peña for invaluable help in filming the exercises and

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coupling the audios.

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15 Gross, M.M., Wright, M.C. Anderson, O.S., 2017. Effects of image-based and textbased active learning exercises on student examination performance in a musculoskeletal anatomy course. Anat. Sci. Educ., 10, 444–455. htpps://doi.org/10.1002/ase.1684. Hernández-Díaz, C., Alvarez-Nemegyei, J., Navarro-Zarza, J.E., Villaseñor-Ovies,

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16 Matzkin E., Smith, E.L., Freccero, D., Richardson, A.B., 2005. Adequacy of education in musculoskeletal medicine. J. Bone Joint Surg. Am. 87,310-314. McMenamin, P.G., Quayle, M.R., McHenry, C.R., Adams, J.W., 2014. The production of anatomical teaching resources using three-dimensional (3D) printing technology. Anat. Sci. Educ. 7, 479–486. htpps://doi.org/10.1002/ase.1475.

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18 Wood Jones, F., 1949. The Principles of the Anatomy. As Seen in the Hand.

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London, UK: Baillière, Tindal and Cox Press, p 4.

19 Tables Table 1. Hand, wrist, forearm and elbow self-examination exercises Findings

Clinical relevance

1

The dorsal

Flex and

The firm, linear

Contraction of the dorsal

digital

extend the PIP

tendinous structures

interosseus, palmar inter-

apparatus.

joint of the

are felt to move

The lateral

fingers while

palmarly during PIP

muscles flex the MCP

bands of

palpating the

flexion and dorsally

joints and extend the

the

sides of the

during PIP

PIP and DIP joints.

extensor

proximal

expansion.

phalanges,

osseus, and lumbrical

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anatomy

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se #

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Maneuver

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Relevant

extension. These

In RA contributes to joint

are the lateral bands deformity.

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Exerci

of the extensor

lateral bands

expansion.

Movie1.1

The MCP joint

Same as in Exercise #1

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feeling the

move beneath

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the skin.

2

The 1st

Estimate the

dorsal

transverse axis flexes because the

interosseo

of the 2nd

insertion of the 1st

us muscle.

MCP joint.

dorsal interos-seus

Movie 1.2

Deviate the

tendon is

index radially

approximately 1 cm

to make the

palmar to the

first dorsal

transverse axis of

interosseus

the joint.

muscle

The PIP and DIP

contract and

joints extend

bands connect with

to its insertion.

the dorsal slips.

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of this muscle

Hold a ball.

movement

With the

s.

thumb, press,

follow the ball´s

create forces that

release, and

surface radially =

contribute

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Press = flexion,

Normal hand function.

release = extension,

Disturbed arcs of motion

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Thumb

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3

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follow the edge because the lateral

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20

follow with the

adduction, follow the to deformities in RA and

thumb the

ball´s surface

ball´s surface

ulnarly = abduction.

radially and ulnarly.

OA.

Movie 1.3

21

Palpate the

The first three

A conflict of space

insertions

tubercle of the

structures are

beneath

of the

scaphoid, the

regularly palpable,

the transverse carpal

transverse

crest of the

and the hook of

ligam-

carpal

trapezium, the

hamate is palpable,

ent leads to median

ligament.

pisiform, and

and often tender, in

nerve

the hook of the

approximately 40%

hamate.

of people.

of

Bone

ro

dysfunction and carpal tunnel

syndrome.

Movie 1.4

5

ur na

lP

re

-p

4

The

(a) Place your

In (a), the starting

Limited pronation and

hand palm

and end positions

supination, such as in

axis of

upward on a

do not match.

RA,

pronation

surface and

In (b), the starting

interferes with hand

and

then, rolling on

and end positions

functions

supination:

almost match.

such as feeding and self-

(a) ulna vs.

Therefore, (b)

care

Jo

Movies functional

22 (b)

the ulna, place

applies best to this

capitulum

it palm down.

and most everyday

of the humerus to the 2nd

fine functions of the

(b) Pour milk

activities.

Movie 1.5

hand.

into a cup of tea.

of

finger.

Movement

Flex and

Flexion and

In RA and other

s at the

extend your

extension occur at

inflammatory

the humeroulnar

conditions, flexion,

and supinate

trochlea, and

extension,

your hand,

pronation and

pronation, and supination

extend your

supination occur at

tend

elbow at your

the radio-capitellar

to be concurrently

side in the

and proximal

limited, as

anatomical

radioulnar joints.The the three joints share a

position (palm

carrying angle at the single

ur na

6

lP

re

-p

ro

Movie 1.6

Jo

elbow joint. elbow, pronate

23 facing front),

elbow allows the the

and then fully

hand to separate

flex it until it

from the body, so

gets to your

that any carried

mouth.

object is less likely

synovial cavity.

With your arm

nerve in

extended,

the ulnar

palpate the

groove.

ulnar nerve in

groove. Wrist flexion for

the groove

shows that beyond

1 minute) is used to

between the

the osseous groove,

diagnose

olecranon

the nerve path

ulnar nerve compression

process and

continues beneath

at

the medial

the humeral head of

the elbow.

epicondyle.

the FCU.

Jo

With elbow flexion,

re

Ulnar

Next, palpate it with your elbow flexed.

The elbow flexion

the ulnar nerve may

maneuver

or not remain in the

(keeping the elbow flexed

lP

ur na

7

-p

ro

of

to hit the knee

24 DIP: Distal interphalangeal; FCU: Flexor carpi ulnaris; MCP: Metacarpophalangeal;

Jo

ur na

lP

re

-p

ro

of

OA: Osteoarthritis; PIP: Proximal interphalangeal; RA: Rheumatoid arthritis

25 Table 2. Upper arm and shoulder self-examination exercises

Exercise Relevant

Maneuver

Findings

Clinical relevance

anatomy

1

The radial Find the radial

Plucking the

This is the site of

nerve in

nerve at your

nerve causes an

radial nerve

the radial

outer mid-upper unpleasant shock

compression in

groove.

arm and pluck

or even a tingling

“Saturday night palsy”

it. The nerve

sensation in the

and in fractures of the

lies

radial nerve

ro

-p

re

approximately 1 territory. As the triceps muscle

the lowest

tenses up with

lP

cm posterior to

extension the

deltoid. Next,

radial nerve can

place your

no longer be felt

finger over the

beneath the

nerve and exert

lateral head of the

a slightly

triceps.

Jo

ur na

insertion of the

resisted extension of the elbow.

of

#

humeral shaft. Movie 2.1

26

Sitting in a chair In (a), resisted

This exercise

brachii

in front of a

supination causes

distinguishes the

and

table and with

the biceps brachii

action of a pure flexor,

brachialis

the elbow at 90- to contract. In (b),

the brachialis, from a

action.

degree flexion:

resisted flexion

predominant

(a) place the

causes the biceps

supinator, the biceps

fingers on top,

brachii, the

brachii.

and the thumb

underlying

below the

brachialis, and the

table´s edge,

more laterally

supinate while

brachioradialis, to

you feel the

contract.

ur na muscles

proximal to the elbow. (b)

Jo

ro

-p

placed

lP

and attempt to

anterior arm

Place your hand palm up under the table. Attempt to flex the elbow while

of

Biceps

re

2

27 you feel the anterior arm muscles.

Place your

The pectoralis

A competent

walls of

hand behind

major and

examination of the

the axilla.

your head while

sometimes the

axilla searching for

the opposite

pectoralis minor is

enlarged lymph nodes

hand palpates

felt at the anterior

and other

the walls of

wall; the

abnormalities is

your axilla.

latissimus dorsi,

dependent upon

ro

-p

subscapularis,

knowing the normal

and teres major,

anatomy. In the Milch

at the posterior

maneuver for anterior-

wall; the serratus

inferior subluxation,

anterior. medially

(Milch, 1949), the

on the chest wall;

humeral head is

the biceps brachii,

pushed back into

coracobrachialis,

place.

lP ur na Jo

of

The four

re

3

triceps, and neurovascular structures, at the superolateral wall;

28 and the head of the humerus, at the vertex.

Abduct your

External rotation

This exercise

abduction

arms first with

of the humerus

demonstrates a

(Martin

at the

your elbows in

(forearms resting

prerequisite for full

1932)

scapular

90-degree

on the head) is

arm abduction,

plane

flexion as high

required for full

namely, external

(30-

as you can,

elevation of the

rotation of the

degree

then

arm.

humerus.

angle

superimpose

anterior

your forearms

to the

on top of your

scapular

head and

plane).

observe the

height to which

Jo

ro

-p

re

lP

additional

your elbows have reached.

of

Arm

ur na

4

29 5

The arc

Fully abduct

Lateral shoulder

This maneuver helps

(Kessel

of

your

pain in mid-range

to diagnose rotator

and

abduction

outstretched

abduction (60 to

cuff tendinopathy.

Watson

maneuver arms.

120-degree)

1977

at the

suggests rotator

scapular

cuff disease.

Jo

ur na

lP

re

-p

ro

of

plane.

Movie 2.5

30

Relevant

Findings

Clinical relevance

e#

anatomy

1

Ischial

Sit on a lightly

In the sitting

Consequences of

tuberosity

cushioned chair

position, the

nonshifting sitting:

and

placing one hand

ischial

pressure sores in

gluteus

beneath the

tuberosity

quadriplegics and

maximus

ischial tuberosity.

appears bare,

paraplegics; ischial

Slowly lift your

only covered

tuberosity pain

by

syndrome; and

re

weight off the

ro

Exercis

of

Maneuver

-p

Table 3. Lower extremity self-examination exercises

subcutaneous ischial bursitis.

second time, this

fat. There is

time grasping

also a

lP

chair. Repeat a

Jo

ur na

your thigh with the nonpalpable thumb over the

ischial bursa

quadriceps and

laid on the

the other fingers

bone. As you

under the

lift your

hamstrings.

weight, you should feel the gluteus maximus

Movie 3.1

31 contracting between your hand and your ischial tuberosity. In

attempt,

ro

quadriceps

of

the second

contracts to

-p

extend the

re

knee and

hamstrigs

extend the hip.

Muscles

Stand on one leg

On the

In abductor

that

and then on the

standing leg

weakness, the

balance

other as if

side, abductor unsupported side

the pelvis

marching in place. muscles are

of the pelvis tilts

Grasp your sides

felt to

down

by placing your

contract.

(Trendelenburg

open hands

From anterior

sign).

Jo

2

ur na

lP

contract to

32

crests and the

beneath your

greater

index finger is

trochanters,

the tensor

indexes to the

fasciae latae,

front, edge of the

beneath your

first web spaces

web space is

in the middle and

the gluteus

thumbs in the

medius

back.

underlined by

Movie 3.2

of

to posterior :

-p

ro

between the iliac

re

the gluteus

minimus, and

thumb is the gluteus maximus.

Hamstring Feel the

The

Deceleration of the

muscles

hamstring

hamstrings

swing phase of

muscles at mid-

contract from

gait.

thigh as you walk

mid-swing

on flat ground.

onward to

Jo

3

ur na

lP

beneath your

decelerate the leg, at

33 heel strike, and in the early stance

Feel the thigh

Thigh

Thigh abductors

abductors

abductors, as in

abductors

balance the pelvis

exercise #2

contract in the and allow the

above, as you

stance phase

swing leg to clear

walk on level

and relax in

the ground.

the swing

In Trendelenburg

phase.

gait (weak

re

ground. Feel the gluteus maximus,

lP

gluteus medius,

abductors gait), weight shifts onto

late throughout

the standing leg at

ur na

and tensor fasciae

their surfaces.

each step.

Quadricep Grasp the

The

Quadriceps

s femoris

quadriceps

quadriceps

femoris contraction

femoris in the

femoris

during gait

front of your thigh

contracts at

provides shock

heel strike, at

absorption and

Jo

5

of

Thigh

ro

4

-p

phase.

34 the beginning

enhances oknee

level ground.

of the stance

stability.

Your thumb is

phase, and

over vastus

again at the

medialis, the

beginning of

index over vastus

the swing

lateralis, and the

phase.

of

as you walk on

ro

web space over

Understanding

in the

extension, several

identify the

medial knee

medial

structures

tibial plateau;

anatomic

knee

including the pes

the rim of the

relationships in

anserinus

femoral

extension vs

tendons, the

condyle; the

flexion enhances

anserinus bursa,

tibial (medial)

understanding and

the tibial collateral

collateral

detection of pes

ligament, and the

ligament; the

anserinus

tibial insertion of

medial

syndrome;

semimembranops

meniscus; the

meniscal tears

us overlap. Now

tendonds of

(focal tenderness);

bend your knee

gracilis and

and

Jo

You may now

lP

re

Structures With your knee in

ur na

6

-p

rectus femoris

35 semitendinos

osteonecrosis

observe what

us (the tape-

(bone tenderness)

happens to the

like sartorius

.

previously

is not

overlapping

palpable but

structures

on occasion may be

ro

seen); and

of

90 degrees and

the tibial

-p

semimembra

re

nosus

insertion. The

bursa is not palpable in the normal state

Leg

Sit in a low chair

In

This simple

muscles

with the knee

dorsiflexion,

exercise provides

flexed at 90

lateral to the

a panoramic

degrees and, in

medial

functional view of

sequence,

malleolus, the

muscle bellies and

Jo

7

ur na

lP

anserine

36 tendons of

tendons, as well as

plantarflex,

the tibialis

their intricate

supinate (invert),

anterior, the

relationships

and pronate

extensor

beneath the deep

(evert) one foot

hallucis

fascia.

while you explore

longus, and

the leg,

farther

embracing it with

laterally the

both hands, from

extensor

the knee to the

digitorum

ro

-p longus tense

re

ankle. To

up over the

exercise, place

ankle joint.

lP

complement the

one hand on the

In plantar

contracting

flexion

ur na Jo

of

dorsiflex,

muscles, and with

performed

the other, explore

keeping the

the corresponding

metatarsal

tendons around

heads planted

the ankle.

on the floor, the wide soleus may be felt from

37 near the knee to near the ankle. Invert the ankle, and the tibialis

emerges

ro

beneath the

of

posterior

distal soleus.

-p

Evert the

re

ankle and feel the peroneus

Jo

ur na

lP

longus and

8

peroneus brevis contract from the fibular head downward.

Tendons

Imagine your foot

Tendons

A simple linear

that cross

moving along two

anterior to T

coordinate system

the ankle

axes. One is the

dorsiflex the

helps to

38 foot, and

understand the

bimalleolar axis

those

functional axis of

(T) of the ankle

posterior to T

the ankle and the

joint. The other is

plantar flex

subtalar joint as

the axis of the

the foot.

well as the function

subtalar joint, an

Tendons

of the individual

oblique axis (O)

medial to O

tendons as they

that extends from

supinate the

cross the ankle.

the postero-lateral

foot, and

corner of the

tendons

ro

-p lateral to O

re

calcaneus to the superomedial

pronate the

lP

aspect of the neck foot. Thus, anterior

dorsum of the

tibialis is

ur na

of talus in the

Jo

foot.

of

transverse

dorsiflexor and supinator, flexor hallucis longus and flexor digitorum longus are

39 plantar flexors and supinators, extensor digitorum

dorsifllexor

and the

ro

and pronator,

-p

peroneal

re

muscles are

plantar flexors

ur na

lP

and

Jo

of

longus is

pronators.