Anatomical Relationship of the Axillary Nerve to the Pectoralis Major Tendon Insertion.
The relation of the sciatic nerve and of its subdivisions to the piriformis muscle. Lindsay E. Beaton. Northwestern University Medical School, Chicago. Search for . Orthopedics. May 1;40(3):ee doi: / Epub Feb Anatomical Relationship of the Axillary Nerve to the. Within the gluteal region, anatomical variations have been noted involving divisions of the nerve and the nerves relation to the piriformis muscle. The piriformis.
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Studies demonstrate that there is relationship between muscular facilitation and adverse neural tension in the upper extremity and in the posterior thigh, but few examine a potentially similar interaction in the anterior hip.
The purpose of this study was to determine the relationship between femoral nerve tension and hip flexor muscle tightness. The Prone Knee Bend test and the Thomas test were performed on a group of 20 normal subjects 40 unilateral lower extremities without back pain or dysfunction, and on a group of 12 patients 21 unilateral lower extremities treated with physical therapy for low back pain.
This study indicates a correlation between the Thomas Test and the Prone Knee Bend Test suggesting a relationship between adverse neural tension of the femoral nerve and muscle length of the iliopsoas muscle.
The Relationship between Femoral Nerve Tension and Hip Flexor Muscle Length
Increased femoral nerve tension may influence hip tightness in normal and patient populations. Likewise, adaptive shortening of the hip flexors may lead to adverse femoral nerve tension. ANT has been described in many ways. Controversy still exists regarding the cause of the decrease in range of movement.
Dysfunctions affecting the nerve can occur mechanically or chemically, and can be extra or intra neural. Extra neural dysfunction occurs when the nerve is unable to move dynamically in relation to its interface.
This may lead to decreased ability to glide, slide, translate, or displace, due to either mechanical restrictions or impingement [ 1 ]. Areas that are more vulnerable to extra neural dysfunction include: Tension points, scar tissue, ectopic bone growth, and facilitated, guarded or tight muscles may also create fixed areas that limit neural motion [ 256 ].
Each time a nerve bifurcates, neural tissue glide is sacrificed, predisposing the structure to adverse tension by either neural entrapment or irritation, possibly resulting in muscle guarding and ultimately increasing the chance of injury [ 37 ].
Studies on the brachial plexus have suggested facilitation and muscular guarding in relation to anatomical variations in the upper extremity [ 8, 9 ].
Other investigators studied the relationship between neural mobility and muscular injuries in Australian Rules football players. They suggested that intervention that included a slump stretch for adverse neural tension in the sciatic nerve was more effective in treating players with a grade I hamstring strain when compared to a group of players treated with traditional intervention.
This study presents a possible relationship between ANT of the sciatic nerve and muscular facilitation and strain [ 10 ]. Less studied are the lumbar plexus anomalies and the potential adverse affects on neural mobility. The lumbar plexus supplies the anterior thigh, groin, and pubic region and is composed of six major branches formed by the ventral rami of L1 to L3, the upper portion of L4 and occasionally T The lumbar plexus then pierces the psoas major muscle, but has been known to have variations and anomalies [ 11 ].
Several studies note femoral nerve anomalies occur and may involve piercing by the iliacus or psoas [ 11 - 14 ]. Anloague and Hubijbregts studied anatomical variations of the lumbar plexus and the surrounding musculature in 19 male and female cadavers. Anomalies were noted in the iliohypogastric The femoral nerve was found to vary in In these 12 specimens the femoral nerve was observed to bifurcate into 2 and sometimes 3 separate slips. These slips were separated by the fibers of the psoas major before they rejoined and proceeded to pass beneath the inguinal ligament.
Most of the cadavers demonstrated a bifurcation of the femoral nerve within the midsubstance of the psoas major where the nerve proceeded to rejoin prior to its exit from the pelvic cavity. One cadaver presented with a medial and lateral bifurcation of the nerve with psoas major musculature passing between, an intermediate connection between the two nerve slips, then a rejoining of the nerve segments [ 11 ].
Jacubowicz noted that in 4. In one case it was reported that the nerve split into 3 trunks, 2 anterior and one posterior [ 13 ].
Adverse neural tension has been linked to increased tone in the surrounding musculature [ 1015 ]. The anomalies may lead to tension on the femoral nerve, which could result in muscle guarding, referred pain to the hip and knee joints and to the lumbar dermatomes of L2, 3, and 4 [ 612 ].
The Phrenic Nerve - Anatomical Course - Functions - TeachMeAnatomy
This raises the possibility that anatomical variations of the femoral nerve in the lumbar plexus may indeed affect hip musculature, specifically the psoas musculature. It must also be considered that the relationship between adverse neural tension signs and muscle dysfunction of the psoas musculature may be bidirectional.
While reflexive activity in the psoas may be due to adverse neural tension in the femoral nerve and its roots, adaptive shortening of the psoas may also lead to limitations in neural mobility.
Physical and manual therapists have long appreciated the connection between the musculoskeletal and nervous system. This relationship examined via neurodynamic tests to assess the mobility of neural tissue in the extremities. Historically, Wasserman, inproduced the first documented prone knee bend PKB to reproduce anterior thigh and shin pain in soldiers whose symptoms could not be reproduced with the SLR [ 1617 ]. The tension from this test is attributed to the femoral nerve, and then to the L2, 3, and 4 nerve roots3.
Pain in the anterior thigh experienced during the PKB may indicate tight quadriceps or stretching of the femoral nerve [ 18 ]. Although neural tension has been studied in the upper extremity and regarding the sciatic nerve in the lower extremity, the femoral nerve has gone relatively unnoticed [ 19 ].
Thus, the purpose of this study was to examine hip flexor guarding, facilitation, or tightness using the Thomas test in conjunction with the PKB test to assess femoral nerve tension.
A strong correlation may indicate a potential cause-and-effect relationship between ANT and hip flexor tightness. Methods Subjects A convenience sample of 20 healthy subjects 7 males and 13 females selected from the physical therapy program at Andrews University and a sample of 12 patients receiving physical therapy for back pain at Orion Physical Therapy 5 males and 7 females participated in this study.
All subjects provided signed written informed consent in accordance with the policies of the Institutional Review Board of Andrews University.Sural Nerve Anatomy - Everything You Need To Know - Dr. Nabil Ebraheim
Subjects were eligible for the study if they were between ages 18 and 60 and had low back pain for less than 6 months. Procedure The Thomas test and the Prone Knee Bend test were performed on each subject by a single qualified physical therapist certified in manual therapy and who is a board certified orthopaedic specialists.
Subjects were assigned to patient and non-patient groups. The test order was alternately varied to prevent a testing effect. The Thomas test Figure 1 was performed with the patient lying supine with a pressurized biofeedback bladder The Stabilizer from Chattanooga under the lumbar spine inflated to 40 mmHg to ensure accuracy in determining the outcome.
The test was positive if the pressure in the bladder deviated less than 40 mmHg before the leg reached the table due to an anterior tilt of the pelvis. Hip range of motion deficit Hip ROM Deficit was recorded via measurement with a universal goniometer.
While a positive Thomas test is indicative of tightness in the hip flexors, false positives may be related to weakness in the abdominal musculature, lumbosacral joint instability, or immobility of the hip joint. The test was repeated on the opposite leg and the results were compared. While inter rater reliability was not established, utilization of this device was intended to assist in monitoring anterior tilt of the pelvis positive sign in an objective manner.
There is little research related to the reliability and validity of the utilization of this device with the Thomas Test at this time. The PKB test, also known as the femoral nerve stretch test, has received little attention in clinical research. One study published by Kreitz researched the crossed femoral stretching test that was first described by Cyriax in [ 17 ].
For this reason, we believe that the PKB test should be performed in conjunction with the Thomas test to assess tightness or facilitation in the hip flexor musculature.
Once parotid tissue was encountered, blunt dissection was carried out to the facial nerve branches. Because of the ease of palpation and fixed location during ORIF of the subcondylar region, the posterior apex of the tragus and the lateral pole of the condyle were used as reference points for measurements.
Measurements were made as follows Figure 1 a: All dissections were performed by one of two authors H. Measurements were made by one of the authors and verified independently by the other. Illustrated in photo are the relationships of the temporozygomatic upper division of the facial nerve FN to the tragus Tlateral pole of condyle Cand pes anserinus P. Results The temporozygomatic upper division of the facial nerve was encountered during each of our dissections to the subcondylar region.
This division of the facial nerve consistently emerged from posterior and medial to the condylar neck and traveled in an oblique plane. In all cases, this division crossed the mandible at the condylar neck.
The Facial Nerve (CN VII)
The mean depth from facial nerve to underlying condylar neck was 5. The mean distance from tragus posterior apex to condyle lateral pole was 2. Discussion An open approach to the treatment of condylar fractures has become increasingly common, and several surgical incisions including preauricular, rhytidectomy, retromandibular, submandibular, and postauricular incision have been described. A potential and devastating complication of ORIF in this region is facial paralysis or palsy. Our findings support those of authors prior in suggesting that the temporozygomatic division of the facial nerve has an intimate anatomic relationship to the condylar process.
We attempt to expand on this work by highlighting the depth of tissue separating the nerve from the underlying condylar process. When approaching the condylar region from a retromandibular approach or preauricular approach, visualization of the facial nerve-condyle relationship is limited, and moderately strong retraction is frequently required to obtain an adequate visual field and working space for osteosynthesis.
Although the temporozygomatic upper division of the facial nerve should not be encountered during the submandibular or high submandibular approaches, the nerve is retracted laterally and easily stretched when attempting to achieve an ample working space and optical field. On average, only 5. The surgeon must appreciate that blind and aggressive lateral or superior retraction of overlying soft tissue in this region can easily result in stretch injury and neuropraxis.
Understanding this close relationship should help reduce the incidence of facial nerve injury during ORIF of the condylar region. Reported rate of facial nerve injury. Additionally, on average, the pes anserinus of the facial nerve was located approximately 2. The measurements and relationship of the facial nerve from this study should allow for nerve position to be estimated using the tragus and palpated posterior border of the mandible.
It is our opinion that the use of a palpable landmark is of greatest utility to the novice surgeon, less experienced in this region. Techniques and measurements to predict nerve location are only estimates and cannot replace the need for precise anatomic understanding and cautious dissection in the condylar region. Further, they must be interpreted understanding the inherent, well documented anatomic variation of the facial nerve.
Several studies have demonstrated efficacy of techniques for locating the facial nerve, with the work of de Ru et al.
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These findings were confirmed by Pather and Osman. However, Pather and Osman noted that the TMF was not an ideal landmark because it often lay behind the sturdy tendon of the sternocleidomastoid muscle, thus requiring a complex dissection [ 7 ].
These techniques are excellent in localizing the nerve during dissection but do not help provide a preoperative estimate of nerve location in the condylar region.
Limitations to this study include those that are common to any cadaveric anatomic study.