ANATOMICAL BASIS OF THE

NEUROMUSCULAR DISORDERS
Erial Bahar
2011
 Neuromuscular Disorders
Involving one or more of the followings:
1. Bones
2. Cartilages
3. Joints
4. Skeletal muscles
5. Peripheral nerves
Symptoms and signs in form of:
1. Pain
2. Movement dysfunctions
3. Deformities
 VINDICATE-P
Cause of Any Given Disorders
Vascular,
Inflammatory/infectious,
Neoplastic,
Degenerative,
Intoxication/toxic,
Congenital,
Allergic/autoimmune,
Traumatic,
Endocrine/metabolic,
Psychosomatic
 Skeletal System
Overview of Skeletal System
Bone Growth, Remodeling, and Repair
Bones of the Axial System
Bones of the Appendicular Skeleton
Articulations
 Function of Bones:
Bones perform several important functions:
Support
Protection
Movement
Mineral storage
Blood cell formation
Classification of Bones
Gross
Anatomy
Landmarks
on a typical
long bone
Diaphysis
Epiphysis
Membranes
Membranes
Periosteum
Endosteum
Blood Vessels
Unlike cartilage bone
is well vascularized
Nutrient arteries
serve the diaphysis
The nutrient artery
runs inward to supply
the bone marrow
and the spongy bony
 Compact Bone
Compact bone appears very dense
It actually contains canals and passageways
that provide access for nerves, blood vessels,
and lymphatic ducts
The structural unit of compact bone is the
osteon or Haversian system
Each osteon is an elongated cylinder running
parallel to the long axis of the bone
Structurally each osteon represents a weight
bearing pillar
Compact bone
 An Osteon
Each osteon is a
group of hollow
tubes of bone
matrix
Each matrix tube is
a lamella
Collagen fibers in
each layer run in
opposite directions
Resists torsion
stresses
 Perforating (Volkmanns) Canal
Canals lie at
right angles to
long axis of
bone
Connect the
vascular supply
of the
periosteum to
those of the
central canal
and medullary
cavity
 Spongy Bone
Consisting of
trabeculae
Trabeculae align along
lines of stress
Function as struts of
bone
Trabeculae contain
irregularly arranged
lamallae and osteo-
cytes interconnected
by canaliculi
No osteons present
 The Regulation of Bone and Cartilage
Bone is regulated by
hormones (such as parathyroid hormone,
calcitonin, vitamin D,
vitamin A, estrogens, androgens and growth
hormone.
paracrine and autocrine factors such as proteo
glycans, glyco and phosphoproteins, gama-
carboxyglutamic acid proteins, preteolipids,
growth factors and cytokines such as interleukins.
Growth and Remodeling
 Bone Anatomy and Stress
Wolffs law holds
that a bone grows or
remodels in
response to the
forces which act
upon it
Changes in bone
density in response
to exercise
Tension and
compression forces
must balance
Healing of a Bone Fracture
 Skeletal Cartilages
Initially our skeleton is made up of
cartilages and fibrous membranes
Gradually our skeletal cartilages are
replaced by bone
Upon reaching adulthood the skeleton
becomes almost fully ossified
Only a few cartilages remain in the adult
skeleton
 Basic structure, type & location
A skeletal cartilage is made of some variety
of cartilage tissue
Each type contains a high proportion of
water which makes them resilient
Cartilage has no nerves or blood supply
It is surrounded by a dense tissue
membrane called a perichondrium
 Basic structure, type & location
There are three types of cartilage tissue:
hyaline, elastic, and fibrocartilage
Each contains a matrix of jellylike ground
substance and fibers
Cartilages
 Hyaline cartilages
The most prevalent type of cartilage
Its high proportion of collagen fibers give it
flexibility and resilience while providing
support
Upon examination the tissue appears
white, frosted, and smooth
 Hyaline cartilage locations

Articular - covers the end of bones

Costal - connect ribs to breastbone
Laryngeal - skeleton of larynx
Tracheal & bronchial - reinforce the
respiratory passages
Nasal - support the external nose
 Elastic cartilage
Elastic cartilage is similar to hyaline
cartilage but with more elastic fibers
Its elastic fibers enable it to withstand
repeated bending
Found only in the external ear and the
epiglottis
 Fibrocartilage
The tissue contains parallel rows
chondrocytes alternating with collagen
fibers
Tissue is highly compressible and has great
tensile strength
Found in thick pad-like structures like the
menisci of the knee or the discs of the
vertebral column
 Overview of Joints
Joints or articulations are sites where two
or more bones meet
Joints have two fundamental functions:
provide for skeletal mobility
hold the skeleton together
Weakest parts of the skeleton, yet have a
remarkable ability to resist the forces that
tear them apart
 Classification of Joints
Structural classification
focuses on the material binding the bones
together and whether or not there is a joint
cavity (fibrous, cartilaginous, synovial)
Functional classification
based on the amount of movement allowed at
the joint (synarthroses, amphiarthoroses,
diarthroses)
 Summary of Joint Classes
Fibrous joints
Suture
Syndesmoses
Gomphoses
Cartilaginous joints
Synchondroses
Symphyses
Synovial
Gliding, hinge, pivot, condyloid, saddle, and
ball and socket
 Synovial Joints
In synovial joints articulating bones are
located within a fluid containing joint cavity
Synovial joints permit substantial range of
motion
All synovial joints have similar features
 Structures of Synovial Joint
Articular cartilage
Hyaline cartilage on opposing bone surfaces
Joint (synovial) cavity
Space filled with fluid
Articular capsule
Capsule to confine fluid
Synovial fluid
Fluid to lubricate joints
Reinforcing ligaments
Maintain joint alignment
 Articular Cartilage
Hyaline cartilage
covers the bone
surfaces
Cartilage absorbs
the compression
placed on the
joint
Cartilage keeps
the bone ends
from being
crushed
Joint (synovial)
cavity
Joint spaces are
unique to synovial
joints
Joint spaces are
filled with synovial
fluid
 Articular capsule
The joint cavity is
enclosed by a
double layered
articular capsule
The external layer is
a tough flexible
fibrous capsule
The inner synovial
membrane
 Synovial Fluid
Synovial fluid fills
the entire joint
Slippery fluid
lubricates joint
Weeping
lubrication
squeezes synovial Synovial
fluid into and out Fluid

of the cartilage
nourishing the cells
 Reinforcing ligaments
Extracapsular
Ligaments Ligament
reinforce joints
Intrinsic ligaments
reinforce capsule
Extracapsular are
outside capsule
Intracapsular are
inside capsule

Intracapsular
Ligament
 Features of Select Synovial Joints
Certain synovial joints have additional
structural features
Fatty pads cushion the knee and hip joints
Fibrocartilage articular discs separates articular
surfaces (menisci)
Articular discs improve the fit between the
articulating surfaces (knee, jaw)
 Bursae and Tendon Sheaths
Bursae and tendon sheaths are closely
associated with synovial joints
Essentially sacs of lubricant
Function as ball bearings to reduce
friction between adjacent structures
Reduces friction during joint activity
 Bursae
Bursae are flattened
fibrous sacs lined
with synovial
membrane and
containing a thin film
of synovial fluid
Common at sites
where ligaments,
skin, muscles or
tendons rub against
a bone
 Bursae: Anomolies
A bunion is an enlarged bursae at the base
of the big toe
False bursae may develop at any site where
there is excessive motion
Function similar to a true bursae
 Tendon Sheaths
An elongated bursa Tendon
that wraps completely Sheath
around a tendon
subjected to friction
Tendon slides within
this lubricated sleeve
Common at sites where
the tendon is subject to
friction from other
tendons or bone
features
 Shoulder (Glenohumeral) Joint
The shoulder
joint has
sacrificed
stability for
mobility
 Shoulder (Glenohumeral) Joint
The glenoid
labrum deepens
the cavity
The articular
capsule is thin
and loose to
contribute to
movement
 Shoulder (Glenohumeral) Joint
Ligaments
reinforce
primarily the
anterior aspect
Coracohumeral
Glenohumeral
Transverse
humeral
 Shoulder (Glenohumeral) Joint
Muscles
crossing the
joint provide
most of the
stability
Long head of
the biceps is
the most
important
stabilizer
 Shoulder (Glenohumeral) Joint
Four tendons
of the rotator
cuff encircle
the joint, blend
with the
capsule
Subscapularis
Supraspinatus
Infraspinatus
Teres minor
 Shoulder Joint
The joint lacks structural stability and
shoulder dislocations are quire common
Since the shoulder is weakest anteriorly
and inferiorly, the humerous tends to
dislocate forward and downward
 Hip Joint
This ball and socket
joint has good range of
motion but the motion
is limited by the deep
socket and the joint
ligaments
Deep acetabulum is
enhanced by circular
acetabular labrum
Ligamentum teres
provides internal
support to the joint
 Hip Joint
This ball and socket
joint has good range of
motion but the motion
is limited by the deep
socket and the joint
ligaments
Deep acetabulum is
enhanced by circular
acetabular labrum
Ligamentum teres
provides internal to
the joint
 Hip Joint

Thick articular capsule encloses the joint

Several strong ligaments support the joint
Iliofemoral, Pubofemoral, Ischiofemoral
Ligaments are arranged in such a manner that
they screw the head of the femur into the
acetabulum when standing erect
 Elbow Joint

The ulna and humerus provide a stable hinge joint

that allow flexion and extension
The Annular ligament anchors the head of the
radius
Supported laterally and medially by ligaments
 Knee Joint
Largest and most
complex joint
Allows for flexion
extension and
some rotation
C-shaped menisci
deepen the tibial
articular surface
Menisci prevent
side to side
rocking and act a
shock absorbers
 Knee Joint
The intracapsular
ligaments of the knee
cruciates are located
within the
intercondylar notch
Ligaments restrict
anterior / posterior
displacement
Ligaments are named
for their tibial
attachment sites
 Knee Joint
Posteriorly the joint
is reinforced by the
oblique popliteal
ligament
Gastrocnemius has
two head that cross
the joint posteriorly
and provide
dynamic stability
 Analysis of Knee Movements
Weight bearing begins with
the femur sliding posteriorly
on the posterior aspect of
the condyles
During extension the
femoral condyles travel
forward until restricted by
the anterior cruciate
ligament
Finally the lateral condyle
stops before the medial
spinning the joint into a
locked position
 Analysis of Knee Movements
When extending the
knee as in kicking the
same movements
occur but in this case
the tibia does the
moving
 Analysis of Knee Injuries
Knee is vulnerable to
horizontal forces or
high tension twisting
movements
These factors lead to
Isolated meniscus
tears
Isolated medial
collateral ligament
tears
Isolated cruciate tears
Triad of ODonahue
 Orthopedic Injuries to Joints
Sprains - Ligament supporting a joint are
stretched or torn
Strains - Tendons or muscle fibers are
stretched or torn
Cartilage - Tear or fragmentation of the
cartilaginous tissue
Dislocation - Bones are forced out of their
normal alignments at a joint
Bursitis/Tendonitis - Inflammation caused
by trauma or more frequently overuse
 Degenerative Conditions of Joints
Arthritis
A general reference to over 100 different types
of inflammatory or degenerative diseases of
the joints
Osteoarthritis
A degenerative disease related to the aging
process (wear-and-tear arthritis)
Rheumatoid Arthritis
A chronic inflammatory disorder alters the
synovival membrane
Can lead to changes in articular cartilage and
bone tissue of the joints
 Degenerative Conditions of Joints
Gouty Arthritis
Abnormal amount of Uric acid contribute to
the deposition of urate crystals in the soft
tissues of joints
Lead to agonizingly painful joints
If untreated can lead to fusion and
immobilization of the joint
 Retinaculum

Retinaculum

Retinaculum function to confine tendons to a specific line

of pull
Muscle exerts a force around a skeletal feature
Similar to a pulley or gear changing the angle of force
exerted by a machine
 Factors Influencing Synovial Joint
Stability
The stability of a synovial joint depends on
three factors . . .
The nature of the articular surfaces
The number and positioning of the ligaments
The tone and strength of the muscles acting
upon the joint
 Articular Surfaces
The surfaces determine what movements
are possible at a joint, but play a minimal
role in joint stability
Many joints have shallow, misfit surfaces
Larger surfaces or deeper sockets vastly
improve stability
Ball and socket joints are very stable
because of their articular surfaces
 Articular Surfaces
The knee is a hinge joint
by classification
The knee is an example of
a joint that allows for
extra movements
The joint surfaces allow
for some anterior -
posterior sliding, sliding,
as well as a slight amount
of rotation at full
extension
 Ligaments
Ligaments unite the bones of a joint
Ligaments help to direct bone movement
and prevent excessive or undesirable
motion
As a rule, the more ligaments a joint has
the stronger it is
Ligaments can stretch due to undue tension
or trauma
Ligaments can stretch only 6% of its length
before it snaps
 Supporting Ligaments
The supporting
ligaments of the
elbow allow
flexion / extension
and restrict
movement in any
other plane
The Annular
ligament allows for
rotation of the
head of the radius
but restricts other
movements
 Muscle Tone
In most joints the muscles that act upon a joint
are the most important stabilizing factor
The tendons of the muscles keep the joint taunt
and provide dynamic support
Muscle tone is extremely important in
reinforcing the shoulder and knee joint as well
as the arches of the foot
The articular capsule and the ligament have
extensive sensory nerve endings providing
reflexive contraction of supporting muscles
Muscle Tone
The knee is a joint
that features
movement over
stability
The knee is very
dependent upon
the muscles to
provide dynamic
stability to the
joint while it
moves
Note: Rehab
 Introduction
The CNS would be useless without a means of
sensing our own internal as well as the
external environments
In addition, we need a means by which we can
effect our external environment
The peripheral nervous system provides these
links to the CNS
 Introduction
The peripheral nervous system includes all the
neural structures outside the brain and spinal
cord
Sensory receptors
Peripheral nerves and their ganglia
Efferent motor endings
 Introduction
Basic components of
the PNS
Sensory components
provide the
information
interpreted by the
CNS
Motor components
stimulate the effectors
of the CNS
The CNS commands;
the PNS acts
 Nerves and Associated Ganglia
A nerve is a cordlike organ that
is part of the peripheral nervous
system
Every nerve consists of parallel
bundles of peripheral axons
enclosed by successive
wrappings of connective tissue
 Sensory Receptors
Sensory receptors are structures that are
specialized to respond to changes in their
environment
Such environmental changes are called stimuli
Typically activation of a sensory receptor by
an adequate stimulus results in depolarization
or graded potentials that trigger nerve
impulses along the afferent fibers coursing to
the CNS
 Peripheral Sensory Receptors

Dendritic endings of sensory neurons monitor

most types of general sensory information (touch,
pain, pressure, temperature, and proprioception)
Proprioceptors
 Proprioceptors
Virtually all proprioceptors are encapsulated
dendritic endings that monitor stretch in the
locomotor organs
Proprioceptors include
Muscle spindles
Golgi tendon organs
Joint kinesthetic receptors
 Proprioceptors
Muscle spindles
measure the changing
length of a muscle as
that muscle contracts
and as it is stretched
back to its original
length
Muscle spindles are
found throughout
skeletal muscle
 Muscle Spindles
Structurally each muscle
spindle consists of a bundle
of modified skeletal muscle
fibers called intrafusal
fibers enclosed in a
connective tissue capsule
Infrafusal fibers have fewer
striations than do the
ordinary muscle cells
 Proprioceptors

The intrafusal fibers are innervated by the dendrites of

several sensory neurons
 Golgi Tendon Organs
Relaxation reflex is important in motor
activities that involve the rapid alternation
between flexion and extension such as in
sprinting
 Joint Kinesthetic Receptors
These proprioceptors monitor stretch in the
synovial joints
Specifically, they are sensory dendritic
endings within the joint capsules
Four types of receptors are present within
each joint capsule
Pacinian corpuscles
Ruffini corpuscles
Free dendritic endings
Golgi tendon organs (kinda?)
 Joint Kinesthetic Receptors
Pacinian corpuscles are rapidly adapting
stretch receptors that are ideal for measuring
acceleration and rapid movement of the joints
Ruffini corpuscles are slowly adapting stretch
receptors that are ideal for measuring the
positions of non-moving joints and the stretch
of joints that undergo slow, sustained
movements
 Joint Kinesthetic Receptors
Free dendritic endings in joint may serve as
pain receptors
Receptors resembling Golgi tendon organs
have been identified in joints but their
function is not yet known
 Joint Kinesthetic Receptors
Joint receptors, like the other two classes of
proprioceptors, send information on body
movements to the cerebellum and cerebrum,
as well as to spinal reflex arcs
 Innervation of Skeletal Muscle

Motor axons innervate skeletal muscle fibers at

junctions called neuromuscular junctions, or motor
end plates
 Innervation of Skeletal Muscle

A single neuromuscular is associated with each muscle

fiber
These junctions are similar to the synapses between
neurons
 Innervation of Skeletal Muscle
As in typical synapses, the axon terminals
contain synaptic vesicles that release a
neurotransmitter when a nerve impulse
reaches the terminals
The neurotransmitter (acetylcholine) diffuses
across the synaptic cleft and binds to receptor
molecules on the sarcolemma, where it
induces an impulse that signals the muscle cell
to contract
 Innervation of Skeletal Muscle

Although neuromuscular junctions resemble synapses they

have several unique features
 Innervation of Skeletal Muscle

The invaginations and the synaptic cleft contain a basal

lamina that does not appear in synapses between
neurons
 Innervation of Skeletal Muscle
Each motor axon branches
to innervate a number of
muscle fibers within a
skeletal muscle
A motor neuron and all
the muscle fibers it
innervates is called a
motor unit
When a motor unit fires,
all the skeletal muscle cells
in the motor unit contract
together
 Cranial Nerves
Twelve pair of cranial nerves are associated
with the brain and pass through various
foramina of the skull
The first two attach to the forebrain, while
the rest originate from the brain stem
Cranial nerves serve only the head and neck
structures with the exception of the vagus
nerves
In most cases, the nerve are named for the
structures they serve or their primary
functions
 Location of Cranial Nerves

The cranial nerves as they emerge from the brain

and spinal cord
 Cranial Nerves
The cranial nerves
are numbered from
the most rostal to the
most caudal
Some cranial nerves
are exclusively
sensory and others
are exclusively motor
and still others are
mixed
The differences are
due to the functions
the nerves serve
 Distribution of Spinal Nerves
There are 31 pairs of
spinal nerves each
containing thousands of
nerve fibers
All arise from the spinal
cord and supply all parts
of the body except the
head and neck
All are mixed nerves
Spinal nerves are named
according to where they
exit the spinal cord
 Brachial Plexus and Upper Limb
The main nerves that
Roots
emerge from the
brachial plexus are

Axillary
Musculotaneous
Median
Ulnar
Radial
 Lumbar Plexus and Lower Limb
The lumbar plexus
arises from the first
four spinal nerves and
lies within the psoas
major muscle
Its proximal branches
innervate parts of the
abdominal wall and
iliopsoas
Major branches of the
plexus descend to
innervate the medial
and anterior thigh
 Sacral Plexus and Lower Limb

The sacral plexus arises from spinal nerves L4-S4 and lies
immediately caudal to the lumbar plexus
Half the nerves serve muscles of the buttocks and lower limb
while others innervate pelvic structures and the perineum
 Sciatic Nerve
The sciatic nerve is the
thickest and longest nerve
in the body
The sciatic nerve leaves
the pelvis via the greater
sciatic notch
Actually the tibial and
common peroneal nerves
It courses deep to the
gluteus maximus muscle
It gives off branches to
the hamstrings and
adductor magnus
 Innervation of the Joints
Hiltons law . . . any nerve serving a muscle
producing movement at a joint also innervates
the joint itself and the skin over the joint
 Reflex Activity
Many of the bodys control systems belong to
the general category of stimulus response
consequences known as reflexes
A reflex is a rapid, predictable motor response
to a stimulus
It is unlearned, unpremeditated, and
involuntary
Basic reflexes may be considered to be built
into our neural anatomy
 Reflex Activity
In addition to these basic, inborn types of
reflexes, there are many learned, or acquired
reflexes that result from practice of repetition
There is no clear cut distinction between basic
and learned reflexes
 Components of a Reflex Arc

All reflex arcs have five essential components

The receptor
The sensory neuron, afferent impulses to CNS
Integration center
Monosynaptic (one neuron)
Polysynaptic (more than one chain of neurons)
The motor neuron, efferent impulses to effector organ
The effector, the muscle spindle or gland
 The Stretch Reflex
Whatever the
stimulus, when the
spindles are activated
their associated
sensory neurons
transmit impulses at
a higher frequency to
the spinal cord