Chapter 1: Introduction

Snell’s Clinical Anatomy Notes

Anatomy – science of structure and function of the body

Clinical Anatomy – study of macroscopic structure and function of the body in relation to the
practice of medicine and other health sciences.

Anatomic terminologies

Anatomical position – a person is standing erect and facing forward, upper limbs are by
the sides, the palms are directed forward, lower limbs together, soles are on the ground, toes
pointing forward.

Planes aligned 90 to one another:

*Median – divides the body into equal R&L portions.
*Structures nearer the median plane is medial, the farther one is lateral

*Coronal (frontal) – divides the body into Anterior & Posterior portions.
Anterior (ventral) vs. Posterior (dorsal) All Virgins Play Dirty
* In describing the hands: Palmar vs. Dorsal
* In describing the foot: Plantar vs. Dorsal

*Horizontal (sometimes Transverse but can differ depending in orientation) – divides the
body into Upper and Lower portions.
Cross-sections of Horizontal and
anatomical parts Transverse Planes
leg same
foot not same

- Superior (cephalic/cranial) vs. Inferior (caudal)

Plane parallel to median plane:

*Sagittal – divides the body into unequal R&L portions.

Terms used to describe positions relative to the core, root, or attached end of a reference
point (such as the limbs):
Proximal (closer to the core) vs. Distal (farther)

Terms used to describe positions relative to the surface of the body or a given structure:
Superficial (near the surface) vs. Deep (farther from the surface)

Terms used to describe locations relative to the center of a structure or space:

Internal (inside the structure) vs. External (outside the structure)
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 Chapter 1: Introduction

Terms used to describe positions relative to a reference side of the body:

Ipsilateral – on the same side from the reference point (e.g., right eye is ipsilateral to the
right ear)
Contralateral – on the opposite side from the reference point (e.g., right eye is
contralateral to the left ear)

Terms used to describe direction of a flow relative to a reference point:

Afferent – flow toward the reference point.
Efferent – flow away from the reference point.
Such as in sensory and motor neurons, having the Brain as a reference point; sensory
neurons are afferent as it fires the action potential toward the brain, while motor neurons are
efferent since it receives the signal sent away from the brain.
SAf vs MEf

Other anatomical terminologies:

Supine (body is lying on the back) vs. Prone (body lying face downward)

Terms related to movement:

In musculoskeletal system, movement takes place at joints.

Joints – site where two or more bones articulate. Some have no movement (e.g., skull
sutures), some are slightly movable (e.g., superior tibiofibular joint), and some are freely
movable (e.g., shoulder joint).

Flexion – joint angle is decreased (closed) occurring in a sagittal plane. Usually an

anterior movement (such as flexing the arms) but can also be directed posteriorly (such as
movement of the knee joint).
Dorsiflexion – equivalent to extension; lifting the top of the foot superiorly,
toward the shin.
Plantar flexion – equivalent to flexion; moving the sole inferiorly, as in standing
in toes by gymnasts.
Extension – joint angle is increased (opened; straightened) occurring in a sagittal plane.

Abduction – movement away from the midline of the body in the coronal plane (e.g.,
spreading apart of finger’s digits).
Adduction – movement toward the midline in the coronal plane (e.g., drawing together
of finger’s digits).

Inversion – turning the sole of the foot so that it faces the medial direction.
Eversion – opposite of inversion.

Rotation – movement of the part of the body around its long axis, with little to no
movement through space.

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 Chapter 1: Introduction
Medial rotation – movement that results in the anterior surface of the part facing
medially.
Lateral rotation – movement that results in the anterior surface of the part facing
laterally.

Circumduction – complex sequence of movements combining flexion, extension,

abduction, adduction, and rotation. Results in transcribing a cone through space; the
cone’s apex is more proximal articular cavity of a joint while the base of the cone being
more distal end of the bone or limb segment (e.g., movement of arm and shoulder).

Pronation – turning the forearm medially in such a manner that the palm is facing
posteriorly.
Supination – opposite of pronation. Both movements are composed of rotation (of the
proximal end of the radius) and circumduction (of the distal end of the radius).
*Pronation and Supination of the foot is entirely different from that of the hands as it is
a combination of plantar flexion, dorsiflexion, eversion, and inversion.

Protraction – moving a body part forward (as when jutting the jaws forward).
Retraction – moving a body part backward (e.g., jutting the jaw in a backward motion).

Eponyms – In scientific context, these are identifying terms formed from the name of a
persons who are believed to be the ones who discovered them. (e.g., foramen of Winslow,
circle of Willis, etc.). But the current official anatomic terminology guidelines discourage
the use of eponyms as it conveys no information about the structure in questions and
often historically misleading as some person honored by the naming did not necessarily
contribute the initial description of the structure.

Basic Anatomy – study of minimal amount of anatomy consistent with the understanding
of the overall structure and function of the body.

Skin
 Divided into 2 parts:
Epidermis – stratified epithelium with cells that
flatten as they mature and rise to the surface.
- Extremely thick in the palms
and soles that can withstand
wear and tear. In areas such as
on the anterior surface of the
arm and forearm, it is thin.
Dermis – composed of dense connective tissue
containing many blood vessels, lymphatic
vessels, and nerves.
- Thickness varies depending on
the location and anterior parts

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 Chapter 1: Introduction
tend to be thinner than in posterior ones, also thinner in women than in
men.
Subcutaneous tissue – a.k.a. superficial fascia, found just underneath the dermis.

Skin creases – the skin over joints which always folds in

the same place. Skin is always thinner in these areas than
elsewhere and is firmly supported by strong bands of
connective tissues.

Accessories of the Skin

a. Nails – keratinized plates on the dorsal surfaces of the

tips of fingers and toes.
Root – proximal edge of the nail plate.
Nail folds – skin folds that surround and overlap the
nail.
Nail bed – surface of the skin underneath the nail.

b. Hairs
Hair follicles – invaginations in the epidermis into the
dermis. They lie obliquely to the skin surface.
Hair bulbs – extended extremities of the follicles.
Penetrate to the deeper part of the dermis; concave at its
end which is occupied by a vascular con. tissue called
hair papilla.
Arrector pili – a band of smooth muscle that connects
the undersurface of the follicle to the superficial part of
the dermis.
- Innervated by sympathetic nerve fibers;
makes the hair move into more vertical
position when contracts, it also
compresses the sebaceous gland causing
it to extrude some of its secretion. As this
muscle pulls, it causes dimpling of the
skin surface, a.k.a. gooseflesh / goose
pimples.
Areas where hairs are absent:
Lips, palms, soles, side of fingers and feet, glans
penis, labia majora and minora, and clitoris.
c. Sebaceous glands – secrete sebum (oily material that
helps preserve the flexibility of the emerging hair, thereby preventing brittleness; also
lubricates the surface epidermis around the mouth of the follicle) onto the shaft of the
hairs.
d. Sweat glands – long, spiral, tubular glands distributed over the surface of the body
(except lips, nail beds, glans penis, and clitoris). These are the most deeply
penetrating structures of all the accessories of the epidermis.

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 Chapter 1: Introduction

Clinical notes
Common sites for bacterial infections (e.g., S. aureus infection) are the nail folds, hair follicles, and sebaceous
glands.
Paronychia – infection between nail and the nail fold.
Boil – infection of the hair follicle and sebaceous gland.
Carbuncle – staphylococcal infection of the subcutaneous tissue that commonly occurs in the nape and usually
begins as an infection of a hair follicle or group of follicles.
Sebaceous cyst – caused by the obstruction of the mouth of the sebaceous duct and may be caused by damage of
the comb or by infection. Occurs often on scalp.
Shock – a person in shock is pale and has gooseflesh because of the overactivity of the sympathetic system.
Dermal arterioles are vasoconstricted leading to contraction of arrector pili.
Skin burn – the depth of the burn determines the method and rate of healing. The deeper the burn, the higher the
incidence of contracture (permanent shortening of tissues producing deformity or distortion, such as in scar
formation). Deep burns are often grafted to reduce contracture and speed up healing.
SKIN GRAFT
Split-thickness graft – removing a large part of the epidermis including the tip of dermal papillae from the
donor, leaving epidermal cells on the sides of dermal papillae as well as hair follicle cells and sweat gland cells
for regeneration purposes; then this grafted skin is placed on the recipient site.
Full-thickness graft – includes removal both epidermis and dermis at the donor site to replace the severely
damaged recipient site. The donor site is usually covered with STG.

Fascia
 The connective tissue that encloses the body deep to the skin and compartmentalize
individual muscles and group of muscles as well as deeper organs. It is divided in two
types:
Superficial fascia / Subcutaneous tissue – mixture of loose areolar and adipose tissue
that unites the skin to the underlying tissue.
Areas of SF that are collagen-rich Areas of SF that lacks adipose tissue
Scalp, back of the neck, palms, Eyelids, auricle, penis and scrotum, and
and soles clitoris

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 Chapter 1: Introduction
Deep fascia / Muscular fascia/ Visceral fascia – membranous layer of connective tissue
that envelopes or compartmentalize muscles and deeper structures.
Retinacula – thickened deep fascia that forms restraining bands in some regions
of joints.
Some location of DF Description
Neck Well-defined layers that explain how pathogen can
invade during infection.
Thorax and abdomen Thin film of areolar tissue covering the muscles and
aponeuroses.
Limbs Envelopes muscles and other structure, holding them
in place.

Clinical notes
Fasciae and infections
Its arrangement can help explain how microbes take path in an infection when it spreads from its primary
site. (e.g., spreading of infection from the region of the floor of the mouth to the larynx; from the base of
the skull into the thoracic cavity)

Bone
 It is a living tissue capable of changing its
structure when subjected to stresses (e.g.,
fracture). It has cells, fibers, and matrix. It has
protective function such as the skull and spine
protect the brain and spinal cord from injury
while sternum and ribs protect the thoracic and
upper abdominal viscera. Can be a lever for
movement and storage for calcium salts.
Another important function of bones are storage
and protection of complex blood-forming
marrow.
Calcification – deposition of calcium salts to
the pre-bone making its ECM hard; however, it
still possesses a degree of elasticity because of
the presence of organic fibers.
Periosteum – thick layer of fibrous tissue that
covers all the bone surfaces except articulating
surfaces. It is highly vascularized and innervated
and deeper surface cells are osteogenic; it is
sensitive to trauma. It is particularly united to
bone at sites where muscles, tendons, and
ligaments are attached to bone. Collagen fibers
known as perforating fibers (Sharpey’s fibers)
extend from the periosteum into the underlying
bone.
Vascularized – has networks of blood supply.

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 Chapter 1: Introduction
Osteogenic – cells that are producing bone.
Two forms of bones:
Compact bone – appears as solid mass.
Cancellous / Spongy bone – consists of a branching network called trabeculae (irregular
pattern of thin columns like a sponge providing resistance to mechanical stresses and
strains).

Classification of bones

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 Chapter 1: Introduction
 Long Bones – found in limbs, their length is greater than their width.
Diaphysis – main shaft of the bone; has medullary / marrow cavity that stores the
yellow marrow and various blood vessels in adults.
Epiphysis – prox. and dist. ends of long bone; stores the red marrow.
Metaphysis – a part of the diaphysis that is adjacent to epiphyseal plate.
Endosteum – a thin membrane than lines the medullary cavity. It contains a
single layer of osteoclasts (bone-for
ming cells).

Types of bone cells Description and Function

OsteoGENIC Unspecialized and derived from mesenchyme; the only
bone cells that undergo cell division. They are
progenitors of osteoblasts.
OsteoBLAST Bone-building cells; create fibers and organic
compounds to build the bone’s ECM; initiate
calcification. They turn into osteocytes, eventually.
OsteoCYTE Mature bone cells. main cells in bone tissue and
maintain and monitor the tissue.
OsteoCLAST Huge cells from fusion of monocytes. Has ruffled
border. Breaks down ECM for repair, called resorption.
Regulate blood Ca+ levels.
 Short bones – found in hands and foot. Roughly cuboidal in shape and are spongy inside
surrounded by periosteum; also has articular surfaces covered by hyaline cartilage.
 Flat bones – found in the vault of the skull. Composed of thin parallel compact bones
(tables) sandwiching a spongy bone tissue (diploe).
 Irregular bones – have complex shapes (e.g., vertebrae, hip bones, some facial bones,
and calcaneus: heel bone).
 Sesamoid bones – formed within a tendon where the tendon passes over a joint (e.g.,
tendon in knee joint). Largest sesamoid bone is patella (kneecap).

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Bone surface markings

Bones typically show surface markings or irregular features. Most of these are not
present at birth and appears later in life. Surfaces is raised or roughened where bands of fascia,
ligaments, tendons, and aponeuroses are attached to. The pull of these attachments causes the
periosteum to elevate allowing new bone to be deposited beneath.

Bone Marrow – occupies the marrow cavity in both long and short bones and the interstices of
spongy bone in flat and irregular bones. At birth, all marrows are primarily red and
hematopoietic (blood-forming). As an individual grows, some red marrows turn into yellow
marrow. Appearance of yellow marrow begins distally, moving proximally leaving red marrows
restricted in skull bones, vertebral column, thoracic cage, girdle bones, and heads of humerus and
femur.

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 Chapter 1: Introduction
Hematopoiesis – process of blood formation in the connective tissue called red bone
marrow.
Yellow bone marrow – consists of adipose cells for triglycerides storage.
Bone development (Ossification / Osteogenesis)
All bones are derived from mesenchyme (undifferentiated cells giving rise to
connective tissues). Bone formation can occur during the following: a. embryonic development;
b. infancy to adulthood; c. bone remodeling (replacement of old to new bones); and d. repair of
fractures.
 Intramembranous ossification – bone from directly from the mesenchyme, w/c is
arranged in sheetlike layers that resemble membranes. (e.g., cranial bones)
 Development of the ossification center – through chemical signals, mesenchyme
forms cluster and differentiate –from osteogenic cells to osteoblasts. This site is
called ossification center. Osteoblasts secrete ECM of the bone until they are
surrounded by it.
 Calcification – secretion of ECM stops, and cells are called osteocytes. Former
osteoblasts deposited Ca+ and other mineral salts w/c hardens the ECM in a few
days trapping the osteocytes in it.
 Formation of trabeculae – Hardened ECM develops into trabeculae that fuse
with one another forming spongy bone.
 Development of periosteum – after formation of trabeculae, periosteum starts to
develop. Mesenchyme condenses at the periphery of the bone and forms the
periosteum. Soon, a thin layer of compact bone replaces the surface layers of the
spongy bone.

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 Endochondral ossification – replacement of cartilage by bone. A cartilaginous model is

first laid down (e.g., long bones).
 Development of the cartilage model – mesenchymal cells develop into
chondroblasts, which form the cartilage model (hyaline cartilage).
 Growth of the cartilage model – Interstitial growth (growth in length) occurs by
cell division of chondrocytes w/c developed from chondroblasts. Chondroblasts in
the perichondrium (outer surface of the cartilage model) also grows in girth.
Chondrocytes in the midregion increase in size (hypertrophy) and the surrounding
cartilage ECM begins to calcify. Some of these cells within the calcifying
cartilage die because of inefficient diffusion of nutrients. Spaces are left behind as
these cells die which merge into small cavities called lacunae.
 Development of the primary ossification center – in this region of the
diaphysis, bone tissue has replaced most of the cartilage. The process proceeds
inward from the external surface. An artery that provides nutrients penetrates the
developing bone which then stimulates the differentiation of osteogenic cells in
the perichondrium into osteoblasts. These osteoblasts builds the compact bone in
the diaphysis called periosteum. At the midregion, periosteal capillaries grow into
the disintegrating calcified cartilage, inducing growth of primary ossification
center. Osteoblast will then begin to deposit bone ECM to form spongy

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 Chapter 1: Introduction
trabeculae. Primary ossification spreads from central region toward both ends of
the cartilage model.
 Development of the medullary cavity – bone breakdown by osteoclasts forms
the medullary cavity as the primary ossification spreads to both ends of the bone.
Soon, most of the wall of the diaphysis (shaft of the long bone) is replaced by
compact bone.
 Development of secondary ossification center - these occur in the epiphyses of
the bone. Epiphyseal artery enters the epiphyses, which initiates secondary
ossification. This occurs usually around the time of birth. The development is
slightly similar to that of primary ossification. However, spongy bones in the
secondary ossification remain in the interior of the epiphyses; thus, no medullary
cavity are formed here. Unlike PO, SO proceeds outward from the center toward
the outer surface of the bone.
 Formation of articular cartilage and the epiphyseal plate – both structures
consist of hyaline cartilage. Hyaline cartilage in between the diaphysis and
epiphyses remains, and it is called the epiphyseal plate w/c is responsible for the
lengthwise growth of long bones.

Clinical notes
Bone fractures
Patient suffers severe local pain after a fracture. The degree of deformity may be influenced not only
by the mechanism of injury by pull of muscles and ligaments attached to the bone. Fracture of the
bone is accompanied by hemorrhage between the bone ends and into the surrounding soft tissue.
Osteoclasts play a vital role in bone repair such in fractures, alongside with blood vessels and
fibroblasts from the periosteum and endosteum.

Rickets
A.k.a. Osteomalacia in adults, is caused by deficiency in Vitamin D. This results in defective
calcification of cartilage matrix in growing bones such as in epiphyseal plates. These growing bones
become soft or rubbery and are easily deformed. Due to failure in ossification of bones in epiphyseal
plate, bowed legs and deformities of the skull, rib cage, and pelvis are common. Administration of
adequate vit. D and exposure to moderate amount of sunlight can prevent and treat this condition.

Epiphyseal plate disorders

This affects children and adolescents only. Epiphyseal plate is responsible for growth in length. Some
conditions that lead to deformity and loss of function of epiphyseal plate are trauma, infection, diet,
exercise, and endocrine disorders.

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Cartilage
A connective tissue in w/c cells and fibers are embedded in a gel-like matrix w/in the fibers make
it firm and resilient.
Perichondrium – a fibrous membrane that covers the cartilage except on the exposed surfaces in
joints.
Cartilage type Description Calcification /
Ossification
Hyaline Has amorphous (glass-like) matrix. Plays vital role in in Present
Cartilage growth in length of long bones. Can resist wear and
covers articular surfaces most synovial joints. Incapable
of repair when fractured; defect is filled with fibrous
tissue.
Fibrocartilage Abundant in collagen fibers embedded in a small Present
amount of matrix; found in disc within joints (e.g., knee
joint) and on articular surfaces of clavicle and mandible.
It lacks perichondrium. If damage, can repair itself but
slowly. Joint disc is poorly vascularized therefore it is
incapable of repair when damaged.
Elastic cartilage Abundant in elastic fibers lending it flexible. Found in Absent
auricle, external auditory meatus, auditory tube, and
epiglottis. Capable of repair with fibrous tissue when
damaged.

Joints
Site where two or more bones come together, whether movement occurs between them or not, is
termed a joint.

Classification of joints
 Fibrous joints – the articulating surfaces of the bones are tightly linked by dense
irregular connective tissue rich in collagen fiber that fills the joint space (e.g., coronal
sutures of the skull). There is no synovial cavity, thus, minimal movement at these joints
(amphiarthrosis).
 Cartilage joints – the articulating surfaces of the bones is filled with a cartilaginous pad
(e.g., joint between two vertebral bodies). Also has no synovial cavity. It has two types:
 Synchondrosis – a cartilaginous joint in w/c the articulating bones are united by a
plate of hyaline cartilage [e.g., epiphyseal plate (temporary), 1 st sternocostal joint
between the first rib and the manubrium sterni (permanent)]. No movement in this
type (synarthrosis).
 Symphysis – bones are united primarily by a pad or plate of fibrocartilage.
Symphyses are located along the midline of the body (e.g., intervertebral disc).
Slight movement is possible (amphiarthrosis).
 Synovial joints – articular surfaces are covered by a thin layer of hyaline cartilage and
are separated by a fluid-filled joint cavity. It is freely movable (diarthrosis).
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Synovial membrane – lines the cavity of synovial joints w/c extends from the
margins of one articular surface to those of the other. It is composed of areolar
connective tissue with elastic fibers.
Capsule – tough fibrous membrane that protects the synovial membrane.
Synovial fluid – a viscous fluid produced by synovial membrane that lubricates the
articular surfaces.
Articular discs – discs or wedges of fibrocartilage interposed between articular
surfaces of synovial joints.
Articular fat pads – accumulation of adipose tissue that lies between the synovial
membrane and the fibrous capsule of some synovial joints.
Ligaments – consist of fibers that are arranged as parallel bundles of dense regular
connective tissue highly adapted for resisting strains.
Extracapsular ligaments – ligaments that lie outside the joint capsule.
Intracapsular ligaments – ligaments that lie inside the capsule.

Factors affecting the degree of movement in a synovial joint:

 Shape of bones participating in the joint.
 Approximation of adjacent anatomic parts.
 Presence of fibrous ligaments uniting the bone.ß

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Types of Synovial joints according to shape of articular surfaces a

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 Chapter 1: Introduction
Joint Stability depends on 3 factors:
 Morphology of bony articular surfaces – shape of the bones and their articular surfaces
form tight-fitting framework that imparts joint stability. However, in some joints, the
bone’s shape contributes little or nothing to joint stability.
 Ligaments – fibrous ligaments prevent excessive movement in a joint. But if stress is
continued for an excessively long period, then fibrous ligaments stretch (such as in pes
planus). Elastic ligaments, conversely, return to their original length after stretching.
 Tone of muscles around the joint – e.g., muscle tone of the short muscles around the
shoulder joint keeps the hemispherical head of the humerus in the shallow glenoid cavity
of the scapula. Without it, very little force will dislocate this joint.

Joint Nerve Supply – joint capsule and ligaments are innervated by sensory neurons. Sensory
neurons supplying a joint also supplies the muscles moving the joint and the skin overlying
insertions of these muscles (as per Hilton’s law).

Clinical notes
Joint Examination
Assessment of normal range of movements of all joints. Dislocation refers to a condition in
which bones of a joint are no longer in their normal anatomic relationship with one another.
This can occur if the joint stability is compromised (factors are listed above).
*In sports, injury can occur when cartilaginous disc within joints, especially weight-bearing ones (e.g.,
knee), loses its normal relationship to the bones and become crushed between the weight-bearing
surfaces.
Syringomyelia – loss of pain sensation in joints which may result in destruction of joint since
warning sensations of pain are not experienced.
One or more joints can be supplied by the same nerve. In some cases, if a patient suffering a
disease limited to one of these joints may experience pain in both.

Ligaments
A cord or band of fibrous connective tissue uniting two or more structures. They typically bind
bones and joints. It has two types:
 Fibrous ligaments – composed of dense bundles of collagen fibers and not stretchable
under normal conditions (e.g., iliofemoral ligament).
 Elastic ligaments – composed largely of elastic tissues and can regain its original length
after stretching (e.g., ligamentum flavum of the vertebral column).

Clinical notes
Ligament damage
Joint ligaments are very prone excessive stretching, tearing, and rupture.
Sprain – caused by excessive or abnormal force at a joint, but w/out dislocation or fracture.

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Bursae and Synovial Sheaths
Bursa is a closed fibrous sac lined internally with synovial membrane. They alleviate friction in
some joints, such as the shoulder and knee joints. They are commonly found close to joints
where the skin rubs against underlying bony structures (e.g., prepatellar bursa). Sometimes,
bursal cavity communicates with the synovial cavity.

Synovial sheath is a tubular bursa that wraps around tendon. The tendon invaginates the bursa
from one side so that the tendon becomes suspended within the bursa by a mesotendon. This
mesotendon enables blood vessels to enter the tendon along its course.
In certain situations, when the range of movement is extensive, the mesotendon disappears or
remains in the form of narrow threads, the vincula (e.g., on the long flexor tendons of the fingers
and toes). These sheaths occur where tendons pass under ligaments and retinacula and through
osseofibrous tunnels to reduce friction between tendon and its surrounding structures.

Clinical notes
Bursae and Synovial Sheath Trauma and Infection
Bursitis – inflammation of bursa (“housemaid’s knee”) occurring because of trauma from
repeated kneeling on hard surface.
Tenosynovitis – inflammation of a tendon and its synovial sheath. Notable tenosynovitis may
lead to contracture of the synovial sheath and obstruct efficient sliding of the tendon.

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 Chapter 1: Introduction

Muscles
Muscle tone – strength, firmness, or tautness of a muscle.
Type Description

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 Chapter 1: Introduction
Skeletal a.k.a. voluntary /
striated muscles.
Produce the
movements of the
skeleton. Consists
of long,
cylindrical,
striated (striped)
muscle fibers.
These fibers are
multinucleated
w/ the nuclei at
the periphery.

Smooth Consists of
involuntary
muscle fibers and
are non-striated.
Cells are long,
spindle-shaped /
fusiform wherein
thickest in
middle, tapering
at each end (e.g.,
in the linings and
walls of hollow
structures, iris of
the eye, etc.).
Cardiac Consists of
branched, striated
fibers but has
centrally located
nucleus (max. of
two). Only found
in heart walls.
Fibers are
attached from
end to end by
transverse
thickenings of
plasma
membrane called
intercalated discs.

Skeletal Muscles

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 Chapter 1: Introduction
It has two or more attachments. The more proximal is called an origin; the more distal is
insertion. When muscle contracts, the insertion is drawn proximally toward the origin.
However, under varying circumstances, the degree of mobility of the attachments may be
reversed; thus, origin and insertion are relative terms. The ends of a muscle are attached to
supporting elements (bines, cartilage, ligaments, or other muscles) through cords of fibrous
tissue called tendons.
Belly – fleshy part of the muscle.
Aponeurosis – tendons that form a thin and strong sheet (e.g., flat, wide abdominal oblique
muscles) attaching muscle-to-muscle or muscle-to-bone.
Raphe – interdigitation of tendinous ends of fibers of flat muscles.

Internal Structure of Skeletal muscles

Epimysium – a deep fascia made of delicate sheaths of
areolar tissue, which are condensed on the surface of the
muscle to form a fibrous envelope.
Muscle fiber shortens 1/3 – 1/2 its resting length
when it contracts. Individual muscle fibers run either
parallel or oblique to the long axis of the muscle. Muscles
whose fibers run parallel to the line of pull have greater
range of motion (sternocleidomastoid, rectus abdominis,
sartorius muscles, etc.) than that of oblique-fibered
muscles.
Pennate muscles – muscles whose fibers run obliquely to
the line of pull; they resemble a feather.
Unipennate muscle –
tendon lies along one side of
the muscle, and the muscle
fibers pass obliquely to it.
Bipennate muscle – tendon
lies in the center of the muscle, and the muscle
fibers pass to it from 2 sides.

Multipennate muscle – may be arranged as a series of

bipennate muscles lying alongside one another or may have
the tendon lying within its center and the muscle fibers
passing to it from all sides, converging as they go.

Force of muscle increases as total physiological cross-sectional area

increases. For instance:
Pennate muscle’s force > Parallel-fibered muscle’s force

Skeletal Muscle Action

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 Chapter 1: Introduction
Agonist (prime mover) – A chief muscle or member of a chief group of muscles responsible for
producing a particular movement (e.g., quadriceps femoris is the agonist for extension of knee
joint).
Antagonist – Any muscle that opposes the action of agonist (e.g., biceps femoris is an antagonist
for quadriceps femoris during knee extension as it opposes the latter’s action). As the agonist /
prime mover contracts, antagonist must be equally relaxed through nervous reflex inhibition.
Note: Agonist and Antagonist are relative terms in a sense that muscles can act paradoxically (contradictory).
In the given example, biceps femoris can be an agonist during knee flexion, while quadriceps femoris is the
antagonist during this action.
Fixator – contracts isometrically that is
contraction increases the tone but does not in
itself produce movement to stabilize the origin
of the prime mover so that it can act efficiently
(e.g., muscles attaching the shoulder girdle to the
trunk contract as fixators to allow the deltoid to
on the shoulder joint).
Synergist – Some agonist muscle crosses
multiple joints before it reaches the joint at w/c
its main action takes place. Synergists contract
and stabilize the intermediate joints (e.g., flexor
and extensor carpus contract to acts as synergists to fix the wrist joint giving way for the long
flexor and extensor finger muscles to work efficiently).

Skeletal Muscle Nerve Supply

Nerve trunk to a muscle is a mixed nerve. Approx. 60% are Motor neurons while 40% are
sensory. Also, nerve contains some sympathetic autonomic fibers (for sympathetic response).
The nerve enters the muscle at about the midpoint on its deep surface, often near the margin.
Motor point – point of entrance of nerve to muscle.
Individual motor neurons innervate the muscle at a variable number of muscle fibers
arranged in variable spatial distribution rather than clustered together.
Motor unit – single motor neuron + all the muscle fibers innervated by that neuron.

Size of Motor Unit depends to the size and function of the muscle.
Muscle Number of Muscle fibers per Neuron (motor unit)

Biceps brachii, Gastrocnemius, etc. 2000-3000 motor units

(moving in unison)
Muscles of larynx, extraocular muscles, 10-20 motor units
etc. (for precision movement)

Skeletal Muscle Naming

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 Chapter 1: Introduction
Naming is based on their shape, size, number of heads or bellies, position, depth,
attachments, or actions.

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 Chapter 1: Introduction
Smooth Muscle
Peristalsis – contraction of longitudinal fibers of smooth muscle to pull the wall of hollow
organs of the body proximally such as in the gut.
In most tubes of the body, it provides the motive power for propelling the contents
through the lumen. In storage organs (e.g., urinary bladder, and the uterus), fibers are arranged
irregularly and are interlaced w/ one another. Their contraction is slow and sustained to expel
organ contents. In blood vessels, they either contract during vasoconstriction or relax during
vasodilation. Contraction of these fibers may be stimulated by autonomic nerve impulse or
hormones, depending on the organ from where they are found.

Cardiac Muscle
Forms the myocardium of the heart. Its fibers tend to be arranged in whorls and spirals,
which contracts spontaneously and rhythmically. Specialized cardiac muscle fibers form the
conducting system of the heart. These fibers are innervated by autonomic nerve fibers.

Clinical notes
Muscle tone
If the muscle is flaccid (stiff or not firm), then the
afferent, the efferent, or both neurons involved in the
reflex arc necessary to produce muscle tone is
interrupted.
Poliomyelitis – caused by polio virus marked by fever,
severe headache, stiff neck and back, deep muscle pain
and weakness, and loss of certain somatic reflexes;
obviously, affecting muscle tone. It may produce
paralysis by destroying cell bodies of motor neurons,
specifically those in the anterior horns of the spinal cord
and in the nuclei of cranial nerves.
Hypertonia – too much muscle tone due to a possibility
of lesion involving higher motor neurons in the spinal

Muscle Attachments
It is important to know the attachments and actions of muscles or group of muscles to analyze, for
example, a patient’s normal or abnormal gait.

Muscle Shape and Form

Muscle atrophy – decrease in size and wasting of muscle tissue due to lose of nerve supply
resulting to immobility.
Cardiac muscle Necrosis – a blockage in large branches coronary arteries (blood supply to
cardiac muscle) will lead to necrosis (death of tissue due to insufficient blood flow) and even death

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 Chapter 1: Introduction
Nervous System
Together with the endocrine system, controls
and integrates the activities of the different parts of the
body. It has two main parts: the CNS, w/c consists of
the brain and spinal cord, and the PNS, w/c consists of
a paired series of cranial and spinal nerves and their
associated ganglia.
Functionally, it is further divided into somatic
NS and autonomic NS. SNS acts upon the body’s
external environment, mostly voluntary responses to
consciously perceived sensory signals. The ANS acts
upon the body’s internal environment, mostly
involuntary responses to sensory signals that are not
consciously perceived.

Brain
Central nervous
System
Spinal Cord
Nervous
system
Sensory Neurons
Peripheral Somatic nervous
nervous system system
Sympathetic
Motor neurons
division
Autonomic nervous
sytem
Parasympathetic
division

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 Chapter 1: Introduction

Central Nervous System

It consists of the brain and spinal cord w/c is composed of large numbers of nerve cells and their
processes, supported by tissue called neuroglia consists of specialized cells. The brain has
approx. 85 billion neurons, while spinal cord has about 100 million neurons. Thought, emotions,
and memories are integrated and stored here.
Neuron – individual nerve cell including all its processes (fibers).
Cell body / Perikaryon – contains the nucleus and other maintenance organelles.
Dendrites – short processes that conduct nerve impulses TOWARD the cell body.
Axon – long processes that conduct impulses AWAY from the cell body.
Nuclei – part of CNS where cell bodies are mostly clustered.
Gray matter – consists largely of nerve
cell bodies embedded in neuroglia. In
contrast to white matter, cell bodies are
unmyelinated, presenting a dull, grayish
color. In spinal cord, these are arranged
in H-shaped or butterfly-shaped pattern.
Paired posterior and anterior horns
extend along the length of the cord.
Paired lateral gray horns bulge out in the
thoracic and upper lumbar portions of
the cord.
White matter – consists largely of nerve
processes (axons) and blood vessels also
embedded in neuroglia. Both gray and
white matter are named because of their
relative color tones in fresh tissue. Since
axons are myelinated (surrounded by
myelin sheath), it appears as white,
glistening color.
Central canal – found at the internal
length of CNS containing cerebrospinal
fluid (CSF).
CSF – produced by the choroid plexus in the brain ventricles. It occupies the
subarachnoid space in between arachnoid and pia matter.
Meninges – membrane consists of connective tissue surrounding the CNS. It protects,
anchor, and stabilize the CNS.
Dura matter – most external meningeal layer.
Arachnoid matter – middle membrane
Pia matter – innermost layer.

Peripheral Nervous System

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 Chapter 1: Introduction
It consists of the cranial and spinal nerves and their associated ganglia, enteric plexuses, and
sensory receptors. When dissected, cranial and spinal nerves appear as grayish white cords. They
are made up of neuron processes (axons) supported by delicate areolar tissue.
Ganglion – cluster of neuron cell bodies located outside the CNS.
Neuron vs Nerve
Neuron is individual nerve cell.
Nerve is a bundle of hundreds to thousands of axons plus assoc. connective tissue and blood vessels
that lies outside the brain and spinal cord.

Cranial nerves
12 pairs of cranial nerves branch off the brain and upper spinal cord passing through openings
(foramina) in the skull. All these nerves are distributed in head and neck exc. CN X (vagus
nerve) that supplies structures in the thorax and abdomen. Study cranial nerves deeper in Ch. 12.

Spinal Nerves
31 pairs of spinal nerves leave the spinal cord
and pass through intervertebral foramina in the
vertebral column. These are named according to
the region of the vertebral column with w/c they
are assoc. C8-T12-L5-S5-C1

Each spinal nerve originates w/ a paired bundle of anterior and posterior rootlets
extending to the spinal cord along the lines of posterior and anterior gray horns, respectively.
These rootlets join forming a single posterior and anterior root w/in the vertebral canal; the
roots merge w/in the intervertebral foramen (IVF) and forms the single spinal nerve. Each
posterior root possesses a posterior root ganglion, located in IVF. Spinal nerve passes through
the IVF and immediately divides into posterior ramus (smaller) and anterior ramus (larger).
Anterior rootlets and roots consist of bundles of efferent (motor; MEf) nerve fibers
carrying nerve impulses away from the CNS.
Innervated organ Type of nerve supply Location of cell bodies of the nerve
supply

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 Chapter 1: Introduction
Skeletal muscle Somatic motor neuron Anterior gray horn
Smooth muscle, cardiac Autonomic (visceral) Lateral gray horn
muscle, and glands motor neuron

Posterior rootlets and roots consist of bundles of afferent (sensory; SAf) nerve fibers
that carry impulses to the CNS. These fibers convey information about touch, pain, temperature,
and other sensations from the periphery. The cell bodies of sensory neurons lie in the posterior
root ganglion.
Spinal nerve and rami (singular: ramus) are mixed nerve components in that they convey
both motor and sensory neuron processes to and from the periphery. Therefore, lesions/injury of
rootlets and roots versus spinal nerves and rami result in different combinations of sensory and
motor deficit. Thus, lesion of anterior roots affect MEf fibers only while lesion of anterior rami
affects both SAf and MEf fibers.

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