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Chapter 5 Skeletal and Muscular Systems 101
Origins
Tendons
Biceps brachii
Insertion
Scapula
Radius
Ulna
Figure 5-15 Origin and insertion of muscles. (Reprinted
from Cohen BJ. Memmler’s The Human Body in Health and
Disease. 13th ed. Philadelphia, PA: Wolters Kluwer; 2014.)
Humerus
Tendon
More Muscle Movement
There are two ends to the muscle, the origin and the
insertion. The origin is the less moveable, xed end of
the muscle, and the insertion is the moveable end of the
muscle attached to the bone that is moved. Some muscles have more than two points of attachment. At the
point of insertion, the muscle divides, and if there are
two heads, it will usually begin with the prex “bi,” as
in biceps, and if there are three heads of the muscle, the
prex “tri,” as in triceps. See Figure 5-15 that illustrates
the origin of the biceps muscle of the upper arm and the
insertion of the moveable end on the radius bone of the
lower arm.
Muscles work together to efciently move the body.
The main muscle that performs is the prime mover.
Muscles are identied as an agonist or an antagonist.
The agonist performs a specic action, and the antagonist produces an opposite action. When the agonist is
working, the antagonist is relaxing.
C
O
G
The muscles of the body can be grouped together by the
region they are located and other characteristics that are
used to help identify and remember them. These characteristics include the following:
r
r
r
SKELETAL MUSCLES
Size—within their name, a muscle may have terms
such as maximus (large), major (main), minor (lesser),
longus (long), or brevis (short) indicating the size of
the muscle
Shape—muscles appear as various shapes such as circular (orbicularis), trapezoidal (trapezius), or triangular (deltoid)
Location—some muscles are named for the bone that
is close to it and include lateral, medial, external, and
internal to designate where it is in relationship to the
bone
Action—muscles are named for the action they
r
provide such as exor or extensor and adductor or
abductor
Number of heads—a muscle with multiple attach-
r
ment points will be indicated by the prexes bi (two),
tri (three), and quad (four)
Fiber direction—the terms rectus (straight) and
r
oblique (angled) are used to describe the direction the
muscle is situated in the body
The major skeletal muscles of the body will be presented in the separate tables by region they are located.
Look for some of the identifying characteristics as discussed in the previous section. We will start at the top of
the body and work our way down to the feet. Refer to
Figure 5-16, an anterior view, and Figure 5-17, a posterior view of the body muscles.
Muscles of the Head and Neck
Table 5-1 lists the major muscles of the head and neck.
The table also provides the location of each muscle and
the basic function. The muscles of the face primarily
provide the actions of chewing and facial expressions.
Muscles of the Upper Extremities
The muscles of the upper extremities include the shoulder muscles and those that move the upper arm, forearm, and hand. Table 5-2 lists these muscles and their
location and basic function.
Muscles of the Trunk, Abdomen,
and Pelvis
The muscles in this group include those that are involved
in allowing us to breathe. The muscles of the abdomen
and pelvis support internal organs and provide the necessary compression of the abdomen during actions such
as coughing, sneezing, urination, childbirth, and elimination. They also include deep muscles located in the
back that support the spine and support the body during movement. Table 5-3 lists the major muscles of the
trunk, abdomen, and pelvis and their location and basic
function.
Muscles of the Lower Extremities,
Leg and Foot
The body primarily relies on the muscles of the lower
extremities for support, balance, and movement. These
muscles are the longest and strongest muscles in the
body. Table 5-4 lists the major muscles in this region of
the body, their location, and basic function.
102 Section II Anatomy and Physiology
Masseter
Sternocleidomastoid
Deltoid
Pectoralis major
Serratus anterior
Biceps brachii
Brachioradialis
Flexor carpi
Extensor carpi
(Abdominal
aponeurosis)
Adductors
of thigh
Orbicularis
oculi
Temporalis
Orbicularis
oris
Trapezius
External
oblique
Intercostals
Internal oblique
Rectus abdominis
Sartorius
Quadriceps
femoris
C
O
G
Fibularis
longus
Tibialis
anterior
Soleus
Anterior view
MUSCLE DISORDERS
AND INJURIES
Gastrocnemius
The muscular system is subject to problems just like
any other body systems. We explore the more common
disorders and injuries that affect the muscles. The most
common problem would have to be a muscle
spasm.
This is a sudden and involuntary contraction that causes
various levels of pain from minor to intense. A spasm
can occur in any muscle, not just skeletal muscles. For
example, the smooth muscle of the intestinal tract might
spasm causing abdominal pain. A seizure can also create
Figure 5-16 Anterior view of muscles.
(Reprinted from Cohen BJ. Memmler’s
The Human Body in Health and
Disease. 13th ed. Philadelphia, PA:
Wolters Kluwer; 2014.)
a series of skeletal muscle spasms. Muscle
cramps are
more intense contractions usually following exercise or
strenuous activity. Muscle cramps can also occur when
the body is at rest. We refer to these as a “charley horse,”
and they usually affect the legs. Atrophy is a term used
to describe a decrease in size or lack of development.
When a muscle begins to atrophy, it will become weak
and shrink. A person who is bedridden and not exercising their muscles will begin to experience muscle
atrophy. Even the muscles of a limb that has been in a
cast for a length of time will experience some level of
atrophy. More signicant atrophy occurs when there is
nerve involvement causing paralysis.
Chapter 5 Skeletal and Muscular Systems 103
(Epicranial
aponeurosis)
Ster
nocleidomastoid
Teres minor
Teres major
Latissimus
dorsi
(Lumbodorsal
fascia)
Gluteus maximus
(Iliotibial tract)
Hamstring group
Gastrocnemius
Trapezius
Deltoid
Triceps brachii
(Olecranon
of ulna)
Gluteus
medius
Fibularis
(Achilles tendon)
longus
Figure 5-17 Posterior view of muscles.
(Reprinted from Cohen BJ. Memmler’s The
Human Body in Health and Disease. 13th ed.
Table 5-1
Posterior view
Muscles of the Head and Neck
Philadelphia, PA: Wolters Kluwer; 2014.)
Muscle Location Function
Orbicularis oculi Surrounds the eye Closing the eye
Orbicularis oris Surrounds the mouth Puckering the lips
Buccinator Fleshy part of the cheek Chewing and keeping food between
the teeth
Temporalis Above the ear Close the lower jaw
Masseter At the angle of the jaw Aids in chewing
Sternocleidomastoid Extends from the sternum and clavicle
to the mastoid process behind the ear
Turn the head; ex the neck and
extend the head
104 Section II Anatomy and Physiology
Table 5-2
Muscle Location Function
Trapezius Covers the posterior neck and extends across the posterior
Latissimus dorsi Originates from the spine in the middle and lower back;
Pectoralis major Arises from the sternum, upper ribs, and clavicle on either
Serratus anterior Below the axilla (underarm) on the side of the chest;
Deltoid Covers the shoulder joint at the top of the arm Abduction, exion, extension,
Biceps brachii Anterior arm along the humerus; brachii means arm Flexes the elbow and supinates
Brachialis Deep to the biceps brachii and extends anteriorly over
Brachioradialis Originates at the distal humerus and inserts on the distal
Triceps brachii Originates in the posterior upper arm at the head of the
Extensor carpi
radialis longus and
extensor carpi radialis brevis
Flexor carpi radialis
and exor carpi
ulnaris
Flexor digitorum and
extensor digitorum
Muscles of the Upper Extremities, Forearm, and Hand
shoulder inserting on the clavicle and scapula
covers lower half of the thoracic region forming a portion
of the armpit
side of the upper chest; inserts into the upper arm bone,
humerus
inserts posteriorly on the scapula
the elbow joint
radius (length of the forearm)
scapula and extends to the lower arm
Both extend posteriorly from the lower humerus to
metacarpal bones; longus to the second metacarpal,
brevis to the third metacarpal
Both extend anteriorly from the lower humerus to metacarpal bones; radialis (radial bone side) inserts at the second
metacarpal; ulnaris (ulnar bone side) inserts at the pisiform
(wrist bone) and the fth metacarpal
Both originate at the distal end of the humerus and extend
to the phalanges
Elevates and depresses the
scapula
Adducts the arm and rotates it
medially, and extends it
Adducts and rotates the arm
Rotates the scapula and pulls it
forward, elevates the ribs
and rotation of the humerus at
the shoulder joint
the forearm
Flexes the elbow
Flexes the elbow
Extends the elbow
Extend and adduct the hand at
the wrist joint
Flex and abduct the wrist
Flex and extend the ngers but
not the thumb
Table 5-3
Muscle Location Function
Diaphragm Dome-shaped muscle that separates the
Intercostal Attached to and lling the spaces between
External and internal oblique Extend from the back (dorsal) around the
Rectus abdominis Extends from the xiphoid process of the
Levator ani Floor of the pelvis, extends from the pubis to
Erector spinae Group of muscles extending the length of the
Muscles of the Trunk, Abdomen, and Pelvis
abdomen from the thorax
the ribs
sides (lateral) to the front (anterior)
sternum to the pubis symphysis
the sides of the lower part of the sacrum and
coccyx
spine
Contracts to allow inhalation, and
relaxes during exhalation
Assist to expand the thoracic cavity
during respiration
Compress the abdominal wall supporting internal structures
Flexes the lumbar spine
Aids in defecation, bowel elimination
Flexes and extends the spine
Chapter 5 Skeletal and Muscular Systems 105
Table 5-4
Muscle Location Function
Gluteus maximus Extends from the posterior ilium, sacrum,
Gluteus medius Extends from the lateral ilium to greater
Iliopsoas Extends from the T12–L5 spine to the
Adductor longus Extends from pubis symphysis to the inner
Adductor magnus Extends from the ischium to the inner
Gracilis Extends from the pubis to the upper,
Sartorius Extends from the anterior iliac spine to
Quadriceps femoris includes
4 heads:
1) Rectus femoris
2) Vastus lateralis
3) Vastus medialis
4) Vastus intermedius
Hamstring muscles include
1) Biceps femoris
2) Semimembranosus
3) Semitendinosus
Gastrocnemius Major muscle of the calf (posterior lower
Soleus Extends from the distal femur to the cal-
Tibialis anterior Anterior to the tibia Dorsiexion, lifting foot off the ground
Flexor digitorum longus and
extensor digitorum longus
Muscles of the Lower Extremities, Leg and Foot
and coccyx to the femur (thigh bone)
trochanter of the femur
lesser trochanter of the femur
aspect of the femur
aspect of the femur
medial tibia (crosses over the knee)
the medial tibia
Extends from the length of the anterior
thigh to the tibia
Posterior thigh extending from the
ischium and femur to the tibia and bula
leg), extends from the distal end of the
femur to the calcaneus ankle bone
(Achilles tendon attaches the muscle to
the heel bone)
caneus (ankle bone)
Flexor is in the posterior lower leg, and
extensor is in the anterior lower leg
Extends, abducts, and laterally rotates
the thigh
Abducts and medially rotates the
thigh
Flexes the thigh and vertebral column
Adducts, exes, and medially rotates
the thigh
Adducts, exes, and laterally rotates
the thigh
Adducts the thigh, exes the leg at the
knee, and medially rotates the leg
Flexes the thigh at the hip and exes
the leg at the knee
As a group, these muscles ex the
thigh, extend the leg at the knee, and
stabilize the patella and knee
As a group, these muscles ex the leg
and extend and rotate the thigh
Plantar exion of the foot (standing on
tiptoes)
Plantar exion of the foot at the ankle
Flex and extend the foot and phalanges (toes)
Muscle injuries due to overstretching muscles will
cause a strain of the muscle. The muscle tissue will actually tear between the muscle and the attached tendon.
Straining a muscle can occur when lifting heavy objects
incorrectly or from prolonged poor posture.
Case Question
A
F
F
Let’s go back to Hunter’s problem with
the fractured radius. When the physi-
cian was talking with his mother, he
mentioned that Hunter will probably need to be
in a cast for 6 to 8 weeks but should not have any
muscle atrophy. Why do you think the physician
made this determination?
Muscle Diseases
Diseases that affect the muscles leave the muscles very
weak and unable to function to provide the body with
support and movement. Among these muscle diseases
are muscular dystrophy, myasthenia gravis, and myalgia.
Muscular Dystrophy
The term dystrophy means bad development, or in this
case, a wasting or deterioration of the muscle. Muscular
dystrophy is a general term for a variety of hereditary,
progressive degenerative disorders affecting the skeletal muscles. Duchenne muscular dystrophy is a specic
type that frequently affects male children. This form of
dystrophy results from a protein defect that affects the
structure of the muscle ber. The muscles eventually
106 Section II Anatomy and Physiology
weaken and paralysis sets in. The cardiac and respiratory muscles are also affected as the disease progresses,
leading to death.
Myasthenia Gravis
This muscular condition affects adults and is characterized by muscular fatigue with only minimal exertion.
Early symptoms include drooping eyelids. The neurons
that supply the muscles are not triggered to contract due
to a loss of acetylcholine receptors.
Myalgia
Myalgia is a general term meaning pain in the muscle
(myo—muscle, algia—pain). Myositis results when
there is inammation of the muscle tissue. When there
is involvement of the connective tissues and the muscles,
the term brositis is combined with myositis resulting
in the diagnosis bromyositis. This condition causes
severe pain, which may be acute or chronic. To relieve
the symptoms, anti-inammatory medications are indicated as well as rest, heat, and massage. Another term
associated with these conditions is bromyalgia. This
condition causes diffuse muscle aches, tenderness, and
stiffness throughout the body. Although it is difcult to
diagnose this condition, it may be associated with an
autoimmune disease where the body reacts to its own
tissues.
the size of the muscle. Routine exercise is important
to delay the aging process that affects the muscles.
Something as simple as light weight lifting, resistance
exercise, increases muscle strength and function.
C
O
G
Patients with musculoskeletal injuries and disorders
seek medical care with their primary care physician or
may be referred to a specialist in the practice of orthopedics. The eld of orthopedics is a very fascinating practice. There is no age limit to the clients who are treated
for muscle and bone conditions. Some orthopedic specialists further specialize in the treatment of pediatric
patients and others may focus on the aging client. Most
orthopedic physicians also perform surgery of the bones
and muscles.
of the bones, especially fractures, patients will nd the
need to use crutches to assist in ambulating. The medical assistant will teach the patient how to properly use
the crutches to avoid further injury. Figure 5-18 shows a
medical assistant tting a crutch for a patient. Crutches
are adjustable, and there should be a two-nger space
ORTHOPEDICS
As a result of some of the conditions and diseases
Associated Disorders
Other structures associated with the musculoskeletal
system may become injured or diseased. These structures become injured causing pain and inammation.
These conditions include the following:
Tendonitis—inammation of the tendon, the struc-
r
ture that attaches the muscle to the bone. Typically
occurs when there is overuse of the tendon. The
tiny bers of the muscle tear away from the tendon, and with repeated use of the muscle, tendonitis occurs. For example, tennis elbow from the
repeated overuse of the elbow joint; the tendons
become inamed.
Plantar fasciitis—inammation of the connective tis-
r
sue on the bottom of the foot; may be caused from
improper posture and obesity
Shin splints—pain in the anterior area of the tibia
r
(shin bone); may be caused from running on hard
surfaces without adequate footwear
Torticollis—also called wryneck; caused by injury or
r
spasm of muscles of the neck making it painful and
difcult to turn the head
In addition to the disorders mentioned above, aging
takes its toll on the muscles too. As we age, there is a
gradual loss of muscle cells that leads to a decrease in
Figure 5-18 Medical assistant tting crutch. (Reprinted
from Kronenberger J, Ledbetter J. Lippincott Williams
& Wilkins’ Comprehensive Medical Assisting. 5th ed.
Philadelphia, PA: Wolters Kluwer; 2016.)
Chapter 5 Skeletal and Muscular Systems 107
between the top of the crutch and the patient’s underarm. The hand rest should be adjusted to allow the
elbow to slightly ex.
In addition to adjusting the crutches, the medical
assistant will instruct the patient how to walk with the
crutches so there is weight bearing or non–weight bearing. The physician will determine whether the patient
should put any weight on the affected side. Figure 5-19
4 POINT GAIT
s Partial weight
bearing both feet
s Maximal support
provided
s Requires constant
shift of weight
4. Advance right foot
2 POINT GAIT
s Partial weight
bearing both feet
s Provides less
support than
4 point gait
s Faster than a
4 point gait
4. Advance right foot
and left crutch
3 POINT GAIT
s Non weight bearing
s Requires good
balance
s Requires arm
strength
s Faster gait
s Can use with walker
4. Advance right foot
is a chart showing the correct foot and crutch placement
used to achieve the desired gait.
Other health care professionals are involved in the
treatment of orthopedic conditions. X-ray technicians are
responsible for taking x-rays that will assist the physician
in making an accurate diagnosis. Physical therapists are
involved in the rehabilitation process assisting patients in
strengthening muscles and increasing mobility of joints.
SWING TO
s Weight bearing
both feet
s Provides stability
s Requires arm
strength
s Can use with walker
4. Lift both feet/swing
forward/land feet
next to crutches
SWING THROUGH
s Weight bearing
s Requires arm
strength
s Requires
coordination/balance
s Most advanced gait
4. Lift both feet/swing
forward/land feet
in front of crutches
3. Advance left crutch
2. Advance left foot
1. Advance right
crutch
Beginning stance
3. Advance left foot
and right crutch
2. Advance right foot
and left crutch
1. Advance left foot
and right crutch
Beginning stance Beginning stance Beginning stance
3. Advance left foot
and both crutches
2. Advance right foot
1. Advance left foot
and both crutches
3. Advance both
crutches
2. Lift both feet/swing
forward/land feet
next to crutches
1. Advance both
crutches
3. Advance both
crutches
2. Lift both feet/swing
forward/land feet
in front of crutches
1. Advance both
crutches
Beginning stance
Figure 5-19 Chart of foot and crutch placement. (Reprinted from Kronenberger J,
Ledbetter J. Lippincott Williams & Wilkins’ Comprehensive Medical Assisting. 5th ed.
Philadelphia, PA: Wolters Kluwer; 2016.)
108 Section II Anatomy and Physiology
Cultural Connection
Acupuncture predates recorded history possibly as
far back as 8,000 years. It has been used as a useful tool for pain management that has been practiced
and documented in oriental medicine for over 2,000.
Chinese physicians developed the philosophy behind
acupuncture. It involves the application of needles to
specic meridian points in the body. These meridians
are the pathways of energy ow through the body.
This energy or life force is known as qi or chi (chee).
Preparing for Externship
You may have heard that your attitude determines
your altitude. This is a saying that means you can
soar higher in your career if you maintain a positive
attitude. As you start preparing for your externship,
keep in mind that the site might be looking for a new
employee and what a great chance for you to audition for that position. It would be great to get your
rst medical assisting position at your externship.
If the site is not hiring, you may want to ask for a
letter of recommendation you can use to start your
Acupuncture is a treatment that is becoming more
and more popular with Westerners and conventional
medical practitioners. It has been found to improve
health outcomes and is recommended for the treatment of lower back pain, sports injuries, neck and
facial pain, osteoarthritis, and tennis elbow. A benet
of treating with acupuncture is that it is cost-effective
and a great alternative to the use of prescribed pain
medications.
job search. Most medical facilities are eager to assist
new graduates with their search for the rst job.
They may actually have knowledge of other facilities
in the area that are hiring. The externship supervisor
may be able to introduce you to the facilities that
are hiring. In order to secure a position with your
externship site or receive a letter of recommendation
or introduction to another facility, a positive attitude
is critical. This could be one of your most valuable
assets and qualities.
Chapter Recap
● There are approximately 206 bones and 600 muscles
in the human body that work together to provide
support and mobility to the body.
● Bone is made up of living tissue that needs to repair
and rebuild itself throughout our life.
● The skeleton is divided into the axial and appendicular
skeleton. The axial is the head and trunk bones, and
the appendicular is composed of the extremities.
● Bone disorders include those that are caused by
metabolic conditions, tumor growth, infection,
structural defects, and fractures.
Online Resources for Students
Resources for students available on thepoint.
lww.com include the following:
● Audio Glossary
● Animations
● Competency Evaluation Forms
● The joints are critical junctions between bones that
allow for movement of the body.
● There are three types of muscle including cardiac,
smooth, and skeletal.
● Various types of muscle disorders include muscular
dystrophy, myasthenia gravis, and myalgia.
● Exercise is necessary to keep the body’s muscle toned
and able to support the skeleton.
● Harris CareTracker Case Studies
● Interactive Games & Activities
● Certication Preparation Question Bank
● Videos
Chapter 5 Skeletal and Muscular Systems 109
Exercises and Activities
Certication Preparation Questions
1. What is the term for a decrease in muscle size, as
from disuse?
a. Strain
b. Sprain
c. Atrophy
d. Dislocation
e. Hypertrophy
2. Which condition involves the area on the anterior
tibia and frequently occurs in runners?
a. Shin-splints
b. Fibromyalgia
c. Myositis
d. Tendonitis
e. Torticollis
3. What is an abnormal exaggerated lumbar spinal
curve called?
a. Kyphosis
b. Lordosis
c. Osteomyelitis
d. Scoliosis
e. Herniation
4. Which type of bone fracture involves one broken
side and one bent side?
a. Open
b. Impacted
c. Greenstick
d. Comminuted
e. Transverse
5. The main shaft of a bone is called the:
a. epiphysis.
b. meatus.
c. spine.
d. diaphysis.
e. fossa.
6. The part of the muscle that is the xed,
immoveable end is the:
a. tendon.
b. myobril.
c. insertion.
d. maximus.
e. origin.
7. What type of fracture involves a break in the bone
and the bone protruding through the skin?
a. Simple
b. Compound
c. Impacted
d. Comminuted
e. Oblique
8. What condition is associated with fragile, porous
bones due to a loss of bone mass?
a. Myalgia
b. Osteitis
c. Osteogenesis
d. Osteoporosis
e. Ossication
9. Which of these is a general term for a variety of
hereditary, progressive degenerative disorders
affecting the skeletal muscles?
a. Myalgia
b. Myasthenia gravis
c. Muscular dystrophy
d. Fibromyositis
e. Atrophy
10. Which of these is the group of muscles found in
the anterior thigh?
a. Quadriceps
b. Hamstrings
c. Gluteals
d. Adductors
e. Abductors
P
S
Y
CareTracker Connection
Documenting Clinical Data and
Entering a Referral Related to the
Musculoskeletal System
CareTracker Activities Related to
This Chapter
Case Study 9: Urgent Care Practicum
r
Musculoskeletal conditions range from common
acute injuries, such as fractures and strains, to complex chronic diseases, such as muscular dystrophy and
rheumatoid arthritis. As a medical assistant, you will
document patients’ complaints, signs and symptoms,
and health history; assist with physical examinations,
tests, and procedures; enter medication and test orders;
and process referrals pertaining to a wide range of
110 Section II Anatomy and Physiology
musculoskeletal conditions. All of these tasks can be
efciently performed in CareTracker.
Tasks discussed in this chapter that can be performed
in CareTracker include the following:
Documenting the following patient’s clinical informa-
r
tion related to musculoskeletal conditions:
Health history
Diseases and conditions
Hospitalizations
Surgeries and procedures
Preventive care
Family history
Review of systems
Physical examination ndings
Tests and procedures completed during the visit
X-rays
Computed tomography scans
Magnetic resonance imaging scans
Electromyograms
Bone scans
Diagnoses
Treatment plan
Ordering the following related to musculoskeletal
r
conditions:
Medications
Laboratory tests
Diagnostic tests
Many of these tasks are discussed in CareTracker
Connection features in other chapters. A task we’ll consider here is entering a patient referral to an orthopedic
surgeon.
When a condition or disease requires expertise that
goes beyond the scope of practice of a primary care physician, the patient may be referred to a specialist, such as
an orthopedic surgeon. In CareTracker, you may enter a
referral by clicking on the
near the top of the screen in the Medical Record (either
from the main screen or from within the Progress Note).
icon in the Clinical Toolbar
Alternatively, you may click on the icon at the
bottom of the PLAN tab in the Progress Note.
Within the Referral window, you select the referral
type (outgoing or incoming), the name of the referring
provider, the name of the provider the patient is being
referred to, the group and specialty of the referred provider, from and to dates that the referral is good for,
the authorization type (visits, amount, or hours), the
authorization number (if needed), and the number
of visits authorized (if needed). Below is an example
of a referral, in which the primary care physician Jim
Schroeder is referring a patient to the orthopedic surgeon James O’Brien for a single visit that must occur
within 2 months from the date authorized.