1.

0 Functional Classification of Muscles

Agonist (Prime mover)

The terminology agonist is used to designate a muscle whose role is to produce the desired
motion at a joint. If flexion is the desired action, the flexor muscles are the prime movers. A
movement can always have more than one agonist although a certain agonist may be capable of
producing more torque than its partner. They are also sometimes called protagonists.

Antagonist
An antagonist is a muscle that is capable of opposing the movement of a joint by producing
torque that is opposite to a certain joint action. This is usually a muscle that is located on the
opposite side of the joint from the agonist. In order for an agonist to shorten as it contracts the
antagonist must relax and passively lengthen. This occurs through reciprocal inhibition, which is
necessary for the designated joint movement to occur unimpeded.  

Synergist

Muscle that help the agonist to perform a desired action are called synergists. The anterior
deltoid us the prime mover of shoulder flexion. The much smaller coracobrachialis can also
perform same movement but much weakly. So, coracobrachialis can be referred to as a synergist
for shoulder flexion. Synergist mat assist the agonist indirectly either by bilizing a segment or by
preventing an undesired action. (Muscle Roles: Synergist, Agonist, Antagonist, Stabilizer &
Fixator, 2019)

Stabilizer

It is the group of muscles that stabilize a certain joint to prevent the excessive movement ,for
example, rotator cuff muscles are the important dynamic stabilizer muscles in the glenohumeral
joint. Stabilizer also can be further categorized into fixator and neutralizer for the specific
function to support a certain joint.

Fixator

A fixator is a stabilizer that acts to eliminate the unwanted movement of an agonist’s origin.
Many muscles are attached to more than one bone. When this happens the muscles are said to be
multiarticulate or multijoint muscles. When these muscles contract they tend to move both bones
to which they are attached. For instance, biceps brachii acts to flex the elbow. However, the
biceps is attached at two places. Its distal attachment, the insertion, is to the radial tuberosity of
radius. It’s the radius bone we want to move when we curl a dumbbell. Origin will be in the
supraglenoid tubercle and coracoid process. When the biceps contracts it will tend to draw the
radius and the scapula together. The movement of the scapula must be prevented. This is
accomplished by fixators. Specifically, the trapezius and rhomboids work isometrically to keep
the scapula from moving on the torso.
Neutralizer

This kind of muscle prevents the unwanted movement of a body part by pulling against and
cancelling out an unwanted line of pull from the agonist. Many muscles can produce a pulling
force in more than one direction so that an undesired joint action may occur simultaneously with
the desired one. For example, the biceps brachii can flex the elbow and supinate the forearm. In
order for biceps flex the elbow without the forearm also being supinated, the pronator teres
cancel out the supination torque produced by biceps.
2.0 Muscle Roles of the Joint in Relevant to the Movements
2.1 Shoulder Joint

2.1.1 Shoulder Elevation

Deltoid: Anterior deltoid is the prime mover for flexion and also assists with the abduction of
humerus. Middle deltoid is optimally aligned with the anterior deltoid to produce elevation of the
humerus. Posterior deltoid will extend, abducts, laterally rotates, and horizontally extends the
arm at the shoulder joint. If the scapular upward rotators such as trapezius and serratus anterior
are absent, the middle and posterior deltoid will downwardly rotate lighter scapula. The net
effect of the abduction of the GH joint will be achieved only 45 degree to 60 degree instead of 90
degrees. The action line of all three segments of the deltoid follows the line of pull of the middle
deltoid. The deltoid muscle resultant (FD) resolves into a very large translatory component (Fx)
and a small rotary component (Fy) so that an isolated contraction of the deltoid would cause the
deltoid to produce more superior translation than rotation of the humerus (Figure 1.0).

Figure 1.0

Supraspinatus: It abducts the arm from 0 to 15 degrees when it is the main agonist, it also
assists the deltoid to produce abduction beyond this range up to 90 degrees. When the deltoid is
paralyzed, the supraspinatus alone can bring the arm through most, if not all, of the glenohumeral
range, but the motion will be weaker. Furthermore, it helps to stabilize the shoulder joint by
keeping the head of the humerus firmly pressed medially against the glenoid fossa of the
scapula. 

Infraspinatus: Infraspinatus is the main external rotator of the shoulder joint. It assists in
producing shoulder extension. When the arm is fixed, it abducts the inferior angle of the scapula.
Teres minor: Along with infraspinatus, they produce external rotation of the shoulder joint. It
assists in adduction and extension of the shoulder. When the humerus is stabilized, it abducts the
inferior angle of the scapula. In the initial range of elevation, these muscles (infraspinatus and
teres minor) work to pull the humeral head down, and during the middle range, these muscles act
to externally rotate for clearing greater tubercle under coracoacromial arch.

Subscapularis: Contraction can cause medial rotation and depression of the humerus at the
glenohumeral joint. Subscapularis (one of the rotator cuff muscles) plays an important role in
stabilization of the shoulder, and prevention of dislocation.

The rotator cuff muscles promote the stability of the glenohumeral joint by compression.

Figure 1.1: Actions line of 4 rotator cuff muscles

Serratus Anterior (Scapulothoracic muscle): This allows the forward rotation of the arm and
to pull the scapula forward and around the rib cage. The scapula is able to move laterally due to
the serratus anterior, which is vital for the elevation of the arm. The serratus anterior muscle also
allows the upward rotation of the arm, which allows a person to lift items over their head.

Levator Scapulae: Its functions are to elevate the scapula and tilt the glenoid cavity inferiorly
by rotating the scapula downward.
Trapezius: Upper trapezius produces upward rotation of scapula indirect. It contributes to the
first degrees of clavicle elevation and retraction. Middle trapezius contributes to offset the strong
action of serratus anterior as a protractor and also produces an external rotation of the scapula but
it has a downward moment arm on the scapula larger than its upward moment arm. Lower
trapezius with serratus anterior are primary upward rotators of scapula, it creates an upward
rotation moment arm when the axis reaches the acromioclavicular joint. 

Figure 1.2: Actions line of upward rotators of scapula

Rhomboid Major & Minor: The rhomboid downward rotation action on the scapula helps to
offset the undesired upward rotary torque of the teres major. Acts eccentrically to control change
position of the scapula during arm elevation so it contributes to counter the lateral translation
force of serratus anterior. It has another stabilization role for scapula during adduction or
extension.

Figure 1.3:
For teres major muscle to extend the heavier humerus rather than upwardly rotate the
lighter scapula, the synergy of the rhomboid muscles is necessary to stabilize the scapula.
2.1.2 Shoulder Depression

Teres Major: It adducts and medially rotates the arm and active during extension of the arm
from the flexed position. Teres major activation is high during resisted humeral adduction and
extension, but these functions depend on stability of the muscles’ proximal attachment on the
scapula.

Latissimus Dorsi: It will adduct and depress the scapula and raise the trunk when the arm is
weightbearing or fixed. It is a critical muscle when crutches or walker is needed to assist with
gait.

Pectoralis Major: Sternal portion of the pectoralis major is also an important shoulder complex
depressor. The action of the pectoralis major parallels that of the latissimus dorsi muscle, with
the pectoralis major located anterior to the glenohumeral joint instead of posterior

Pectoralis Minor: It assists the latissimus dorsi and pectoralis major by directly depressing the
scapula through its attachment on the coracoid process. It is oriented to internally rotate,
downwardly rotate, and anteriorly tilt the scapula so the length of this muscle may influence full
scapula movement during arm elevation.

Figure 1.4

Subclavius: The subclavius depresses the shoulder, carrying it downward and forward. It draws
the clavicle inferiorly as well as anteriorly. 

Long head of Biceps Brachii: If the humerus is laterally abducted, it contributes to the force of
abduction. Long head of biceps is sometimes considered part of the reinforcing cuff of the
glenohumeral joint. Indeed, long head appears to contribute to glenohumeral stabilization by
centring the head in the fossa and by reducing vertical (superior and inferior) and anterior
translations. Long head produce its effect by tightening the relatively loose superior labrum and
transmitting increased tension to the superior and middle glenohumeral ligaments. (Levangie et
al., 2019)
Muscle Action of the Glenohumeral Joint

Sagittal Plane Flexion Extension

Primary Movers Deltoid (anterior) Deltoid (posterior)

Pectoralis Major (clavicular head) Latissimus dorsi

Secondary Movers Biceps Brachii Triceps Brachii (long head)

Coracobrachialis Pectoralis Major (sternal head)
Teres Major

Frontal Plane Abduction Adduction

Primary Movers Supraspinatus Pectoralis Major

Deltoid (middle) Latissimus dorsi
Teres Major

Secondary Movers Coracobrachialis

Transverse Plane Medial Rotation Lateral Rotation

Primary Movers Pectoralis Major Infraspinatus

Teres Major Teres Minor
Subscapularis

Secondary Movers Latissimus dorsi Infraspinatus

Deltoid (anterior) Teres Minor
Deltoid (posterior)
Muscle Action of the Scapulothoracic Joint

Protraction Retraction

Primary Movers Serratus Anterior Trapezius (middle)

Pectoralis Major Rhomboids

Secondary Movers Pectoralis Minor

Elevation Depression

Primary Movers Trapezius (upper) Trapezius (lower)

Secondary Movers Levator Scapulae Latissimus dorsi

Rhomboids Pectoralis Minor

Upward Rotation Downward Rotation

Primary Movers Serratus Anterior Rhomboids

Trapezius (upper) Latissimus dorsi

Secondary Movers Trapezius (lower) Levator Scapulae

Pectoralis Minor
2.2 Elbow Joint

Figure 2.1.0

2.2.1 Elbow Flexion

Elbow flexors are at the back of the elbow and pull it closer to the body by bending the elbow.

Brachialis: The brachialis muscle arises from the anterior surface of the lower portion of the
humeral shaft and attaches by a thick, broad tendon to the ulnar tuberosity and coronoid process.
The brachialis is considered a mobility muscle because its insertion is close to the elbow joint
axis. Also, the muscle has a large strength potential in that it has a large physiological cross-
sectional area (PCSA) and a large work capacity (volume). Its moment arm (MA) is greatest at
slightly more than 100° of elbow flexion at which point its ability to produce torque is greatest.
Due to the brachialis is inserted on the ulna, it is unaffected by changes in the forearm position
brought about by the rotation of the radius. Being a one-joint muscle, it is not affected by the
position of the shoulder. This muscle helps flex the elbow inward toward the body.
   
Biceps brachii: The biceps brachii arises from two heads, one short and the other long. The short
head arises as a thick, flat tendon from the coracoid process of the scapula, and the long head
arises as a long, narrow tendon from the scapula’s supraglenoid tubercle. Muscle fibers from
both heads insert by way of the strongly flattened tendon on the rough posterior area of the
tuberosity of the radius. Other fibers of the biceps brachii insert into the bicipital aponeurosis that
extends medially to blend with the fascia that lies over the forearm flexors. However, when the
magnitude of the resistance increases much beyond limb weight, the biceps are active in all
positions of the forearm. The moment arms of all major supinators exhibit peak values in 40° to
50° of pronation. The biceps brachii and the supinator act as supinators through the entire range
of forearm rotation. The large muscle of the upper arm flexes the arm and powerfully twists the
forearm, turning the palm upward.
   
Brachioradialis: The brachioradialis muscle arises from the lateral supracondylar ridge of the
humerus and inserts into the distal end of the radius just proximal to the radial styloid process.
The brachioradialis is inserted at a distance from the joint axis, and therefore the largest
component of muscle force goes toward compression of the joint surfaces and hence toward
stability. The brachioradialis shows no electrical activity during eccentric flexor activity when
the motion is performed slowly with the forearm supinated. Also, the brachioradialis shows no
activity during slow, unresisted, concentric elbow flexion. When the speed of the motion is
increased, the brachioradialis shows moderate activity if a load is applied and the forearm is
either in a position midway between supination and pronation or in full pronation. A forearm
muscle that flexes the arm at the elbow.

            
2.2.2 Elbow Extension

Elbow extensors are on the inside of the arm and help extend the arm outward.

Triceps brachii: The triceps brachii has three heads: long, medial, and lateral. The long head
crosses both the glenohumeral joint at the shoulder as well as the elbow joint. It arises from the
infraglenoid tubercle of the scapula by a flattened tendon that blends with the glenohumeral joint
capsule. The medial and lateral heads cross only the elbow joint. The three heads insert via a
common tendon into the olecranon process. This muscle at the back of the upper arm extends the
arm and stabilizes the elbow when the hand is used for fine movements. The triceps may be
active during activities requiring stabilization of the elbow. For example, it acts as a synergist to
prevent flexion of the elbow when the biceps is acting as a supinator.

Anconeus: The anconeus is a small triangular muscle that arises from the posterior surface of the
lateral epicondyle of the humerus and extends medially to attach to the lateral aspect of the
olecranon process and the adjacent proximal quarter of the posterior surface of the ulna. This
muscle helps extend the forearm at the elbow. It also acts as a stabilizer during supination and
pronation. (Koo & Mak, 2005)

Synergistic actions of elbow flexor and extensor muscles have been investigated during isometric
contractions in response to a variety of stresses, including varus stress, valgus stress, flexion, and
extension. Some flexor muscle pairs, such as the brachialis and brachioradialis, and the extensor
pairs of the anconeus and medial head of the triceps brachii are coactivated in a similar manner
for all stresses.
2.3 Radioulnar Joint

Figure 3.0

The radio-ulnar joint is located distal part of the elbow joint. It is formed by an articulation
between the head of the radius and the radial notch of the ulna. The radio-ulnar joint can be
differentiated into two parts which are proximal and distal. The proximal radioulnar joint is
located distal to the elbow joint whereas the distal radioulnar joint is located proximal to the
wrist joint. The radial head is held in place by the annular radial ligament.

2.3.1 Radio-Ulnar Pronation

Pronator teres: This muscle extends from the head of the humerus over the elbow to the ulna
bone to help flex the elbow, and also enables pronation of the forearm. The pronator teres has
two heads: a humeral head and an ulnar head. The humeral head comes from the common flexor
tendon on the medial epicondyle of the humerus. The smaller ulnar head arises from the medial
aspect of the coronoid process of the ulna. Both heads attach distally to the surface of the lateral
side of the radius at its greatest convexity. The pronator teres has its major action at the
radioulnar joints, but the long head, as a two-joint muscle, plays a slight role in elbow flexion.
The pronator teres contributes some of its force toward stabilization of the proximal radioulnar
joint, as the muscle’s translatory component helps the radial head maintain contact with the
capitulum.
Pronator quadratus: This muscle is located at the distal end of the forearm, also has two heads
(superficial and deep). Both of these heads arise from the ulna and cross the interosseous
membrane anteriorly to insert on the radius. The fibers of the superficial head pass transversely
across the interosseous membrane, whereas the fibers of the deep head extend obliquely across
the interosseous membrane to insert on the radius. The pronator quadratus, a one-joint muscle, is
unaffected by changing positions at the elbow. The pronator quadratus is active in not resisted
and resisted pronation and in slow and fast pronation. The deep head of the pronator quadratus is
active during both resisted supination and resisted pronation and is thought to act as a dynamic
stabilizer to maintain compression of the distal radioulnar joint

2.3.2 Radio-Ulnar Supination

   
Supinator: The supinator is a short, broad muscle that arises from the lateral epicondyle of the
humerus, the radial collateral ligament, the annular ligament, and the lateral aspect of the ulna.
The muscle crosses the posterior aspect of the interosseous membrane to insert into the radius
just medial and inferior to the bicipital tuberosity. The supinators, like the pronators, act by
pulling the shaft and distal end of the radius over the ulna. The supinator muscle may act alone
during unresisted slow. It can also act alone during unresisted fast supination when the elbow is
extended. However, the activity of the biceps is always evident when supination is performed
against resistance and during fast supination when the elbow is flexed to 90°. As the forearm
moves into pronation, its supination torque increases and reaches a maximum at about 20° of
pronation. Bremer found that the moment arms of all major supinators exhibited peak torque
values in 40° to 50° of pronation.

Biceps brachii: The biceps brachii has been discussed previously. The biceps brachii has been
found to exert four times as much supination torque with the forearm in the pronated position
than with other forearm positions. A supination torque for the neutral forearm position with the
elbow at 45° of flexion.

  
Anconeus: The anconeus muscle is active in supination and pronation, and an elbow
stabilization role has been suggested to explain this activity. As determined by isometric testing,
the supinators are stronger than the pronators. Non-muscular support of the distal radioulnar joint
is provided by the dorsal and palmar radioulnar ligaments, the interosseous membrane and its
tract, and the articular disc. The dorsal radioulnar ligament becomes taut in pronation, whereas
the palmar radioulnar ligament becomes taut in supination. (Levangie & Norkin, 2011)

Muscle Action of the Elbow Joint

Sagittal Plane Flexion Extension
(Humeroulnar & Humeroradial Joint)
Primary Movers Biceps Brachii Triceps Brachii
Brachialis Anconeus

Secondary Movers Pronator teres

Brachioradialis

Transverse Plane (Radioulnar Joint) Supination Pronation

Primary Movers Biceps Brachii Pronator teres

Supinator Pronator Quadratus
2.4 Wrist (Radiocarpal) Joint

Figure 4.0

The wrist joint is an ellipsoidal synovial joint, located on the distal end of the upper limb.
Movement able to occur at the wrist joint are flexion and extension, ulnar deviation and radial
deviation.    
    
There are two groups of muscles that can be divided depending on their function. The first group
of the forearm muscles is to control the wrist movement and the second group is aimed to
produce the movement of phalanges. The anterior part of the forearm’s objective is to cause the
flexion of the wrist or phalanges. In contrast, the posterior forearm muscles extend the wrist and
fingers.

2.4.1 Wrist Flexion/ Palmar Flexion

These are the palmaris longus (PL), the flexor carpi radialis (FCR), the flexor carpi ulnaris, the
flexor digitorum superficialis (FDS), the flexor digitorum profundus (FDP), and the flexor
pollicis longus (FPL) muscles. The first three of these muscles are primary wrist muscles. 
  
The flexor digitorum superficialis and flexor digitorum profundus muscles are
predominantly flexors of the fingers, and the flexor pollicis longus muscle is predominantly the
flexor of the thumb. As multijoint muscles, their capacity to produce an effective wrist flexion
force depends on synergistic stabilization by the extensor muscles of the more distal joints that
these muscles cross to prevent excessive shortening of the muscles over multiple joints.  The
palmaris longus muscle is a wrist flexor without producing either radial or ulnar deviation.
   
2.4.2 Wrist Extension/ Dorsi Flexion

Three of the nine muscles are primary wrist muscles: the extensor carpi radialis longus, the
extensor carpi radialis brevis (ECRB), and the extensor carpi ulnaris. The other six are finger and
thumb muscles that may act secondarily on the wrist: the extensor digitorum communis (EDC),
the extensor indicis proprius (EIP), the extensor digiti minimi (EDM), the extensor pollicis
longus (EPL), the extensor pollicis brevis (EPB), and the abductor pollicis longus (APL).
    
The extensor digitorum communis and the extensor indicis proprius muscles are more
simply, as the extensor digitorum and the extensor indicis, respectively. The tendons of all nine
muscles pass under the extensor retinaculum, which is divided into six distinct tunnels by septa.
As the tendons pass deep to the retinaculum, each tendon is encased within its own tendon sheath
to prevent friction between the tendons and the retinaculum. The septa of the retinaculum
through which the tendons pass are attached to the dorsal carpal ligaments and help maintain the
stability of the extensor tendons on the dorsum, as well as allowing those muscles to contribute
to wrist extension and preventing bowstringing of the tendons with active contraction.

The extensor digiti minimi and the extensor indicis proprius muscles insert into the tendons of
the extensor digitorum communis muscle and, therefore, have a common function with the
extensor digitorum communis muscle.
     
2.4.3 Radial Abduction/ Radial Deviation/ Wrist Abduction

The extensor carpi radialis longus and extensor carpi radialis brevis muscles together make
up the predominant part of the wrist extensor mass. The extensor carpi radialis brevis muscle is
somewhat smaller than the extensor carpi radialis longus muscle but has a more central location,
inserting into the third metacarpal, and generally shows more activity during wrist extension
activities. One study found the extensor carpi radialis brevis muscle to be active during all grasp-
and-release hand activities, except those performed in supination. The extensor carpi radialis
longus muscle inserts into the more radial second metacarpal and, therefore, has a smaller
moment arm for wrist extension than does the extensor carpi radialis brevis muscle.
The extensor carpi radialis longus muscle shows increased activity when either radial deviation
or support against ulnar deviation is required or when forceful finger flexion motions are
performed. 

Three extrinsic thumb muscles cross the wrist. Both the abductor pollicis longus and the extensor
pollicis brevis muscles are capable of radially deviate the wrist and may serve a minor role in
that function. However, radial deviation of the wrist may detract from their prime action on the
thumb. A synergistic contraction of the extensor carpi ulnaris muscle may be required to offset
the unwanted wrist motion when the abductor pollicis longus and extensor pollicis brevis
muscles act on the thumb.

When muscles producing ulnar deviation are absent, the thumb extrinsic muscles may produce a
significant radial deviation deformity at the wrist. Little evidence has been found to indicate that
the more centrally located extensor pollicis longus muscle has any notable effect on the wrist.
2.4.4 Ulnar Abduction/ Ulnar Deviation/ Wrist Adduction

The extensor carpi ulnaris muscle extends and ulnarly deviates the wrist. It is active not only
in wrist extension but frequently in wrist flexion as well.

The flexor carpi ulnaris muscle envelops the pisiform, a sesamoid bone that increases the
moment arm of the flexor carpi ulnaris muscle for flexion. The flexor carpi ulnaris tendon
crosses the wrist at a greater distance from the axis for wrist radial/ulnar deviation than does the
flexor carpi radialis muscle, so the flexor carpi ulnaris muscle is more effective in its ulnar
deviation function than is the flexor carpi radialis muscle is in its radial deviation function.

Figure 4.1

Figure 4.2
Actions of the wrist and fingers

Table Key : Primary Movers Secondary Movers

Sagittal Plane Flexion Extension

Radiocarpal Joint Flexor carpi radialis Extensor carpi radialis longus

Midcarpal Joint Flexor carpi ulnaris Extensor carpi radialis brevis
Carpometacarpal Joint Palmaris longus Extensor carpi ulnaris
Flexor digitorum superficialis Extensor digitorum communis
Flexor digitorum profundus Extensor indicis
Flexor pollicis longus Extensor digiti minimi
Abductor pollicis longus Extensor pollicis longus

Metacarpophalangeal Joint Interossei (palmar and dorsal) Extensor digitorum communis

Lumbricals Extensor indicis
Flexor digitorum superficialis Extensor digiti minimi
Flexor digitorum profundus
Flexor digiti minimi
Opponens digiti minimi

Proximal Interphalangeal Joint Flexor digitorum superficialis Extensor digitorum communis

Flexor digitorum profundus Extensor indicis
Extensor digiti minimi
Lumbricals

Distal Interphalangeal Joint Flexor digitorum profundus Extensor digitorum communis

Extensor indicis
Extensor digiti minimi
Lumbricals

Frontal Plane Radial Deviation/ Abduction Ulnar Deviation/Abduction

Radiocarpal Joint Extensor carpi radialis longus Extensor carpi ulnaris

Midcarpal Joint Extensor carpi radialis brevis Flexor carpi ulnaris
Carpometacarpal Joint Extensor indicis Abductor pollicis longus
Flexor carpi radialis Extensor pollicis brevis
Flexor pollicis longus Extensor pollicis longus

Metacarpophalangeal Joint Dorsal interossei Palmar interossei

Abductor Digiti Minimi
2.5 Metacarpophalangeal Joint & Interphalangeal Joint

                                

The metacarpophalangeal joint (MCP) is located from the thumb to the other four fingers. The
metacarpophalangeal joint of the thumb is the hinge joint which is different from others. It
allows flexion movement (80-90 degree) and sometimes extension. On top of that, the
metacarpophalangeal joint from second to fifth fingers is a ball and socket joint with a slack joint
capsule. It is reinforced by strong palmar ligaments and the collateral ligaments.

The metacarpophalangeal joint is a synovial, ellipsoid-shaped joint that serves as the articulation
between the base of the proximal phalanges and the head of its metacarpal (Steven D. Waldman
MD, 2009). The movements which occur in these joints are flexion, extension, adduction,
abduction, and circumduction; the movements of abduction and adduction are very limited, and
cannot be performed when the fingers are flexed.

2.5.1 Flexion
   
The lumbrical muscles actually have a greater moment arm for metacarpophalangeal joint
flexion than do the interossei muscles because the lumbrical muscles lie volar to the interossei
muscles. However, metacarpophalangeal flexion is weaker in the lumbrical muscles than in the
interossei muscles. This relative weakness may be attributed to the small cross-section of the
lumbrical muscles in comparison with the interossei muscles. 

The distal migration of the flexor digitorum profundus tendon and lumbrical muscle has the
effect both of releasing passive tension in the inactive flexor digitorum profundus tendon that
might contribute to metacarpophalangeal joint flexion and of minimizing the active force of the
lumbrical muscle at the metacarpophalangeal joint. The unusually large contractile range of the
lumbrical muscles seems to prevent the lumbrical muscles from becoming actively insufficient
when shortening both over the metacarpophalangeal joints and at the interphalangeal joints.
To sum up, flexion of MCP joint is done primarily by the lumbricals, assisted by its synergists
interosseous muscles. Antagonistic muscles to this action are the extensor digitorum. Stabilizer
and fixator of the joint during the movement are the flexor and extensor carpi muscles.

2.5.2 Extension

The arm (and rotary component) of all the interossei muscles for metacarpophalangeal joint
flexion is so small that little flexion torque is produced. In spite of their poor flexor torque with
the metacarpophalangeal joint extended, the interossei muscles can be effective stabilizers (joint
compressors) and appear to be important in helping to prevent clawing (metacarpophalangeal
joint hyperextension) of the fingers.

Overall, extension of MCP joint is done primarily by extensor digitorum, assisted by its synergist
extensor digiti minimi, and extensor indicis. Antagonistic muscles to this action are the
lumbricals and interosseous muscles. Stabilizer and fixator of the joint during the movement are
the flexor and extensor carpi muscles.

Extension of Interphalangeal joint is done primarily by extensor digitorum, assisted by its

synergists, the lumbricals and interosseous muscles. Antagonist muscles to this action are flexor
digitorum profundus and flexor digitorum superficialis. Stabilizer and fixator of the joint during
the movement are the flexor and extensor carpi muscles.

2.5.3 Adduction

Adduction is done by palmar interossei. Antagonistic muscles to this action are the dorsal
interosseus and abductor digiti minimi. Stabilizer and fixator of the joint during the movement
are the flexor and extensor carpi muscles.

2.5.4 Abduction

The abductor pollicis longus and abductor pollicis brevis abducts the metacarpal phalangeal
joints. The interossei muscles also abduct the fingers at the metacarpal joint.
The abductor digiti minimi abducts the little finger

Reference 

Steven D. Waldman MD, J. (2009). Intra-articular Injection of the Metacarpophalangeal Joints

2.6 Thumb joint

Figure 6.0

The muscles of the thumb have been compared to guy wires supporting a flagpole, in which
there must be a continuous effective pull in every direction to maintain stability. The metacarpal
joint and the proximal and distal phalanges form an articulated shaft that sits on the trapezium.
The thumbs actions are flexion, extension, abduction (palmar and radial), adduction and
opposition.

2.6.1 Flexion

The flexor pollicis longus (FPL), inserts on the distal phalanx and is the correlate of the flexor
digitorum profundus muscles of the fingers. The flexor pollicis longus muscle is unique in that it
functions independently of other muscles and is the only muscle responsible for flexion of the
thumb interphalangeal joint. The flexor pollicis longus tendon sits between the sesamoid bones
and appears to derive some protection from those bones.

2.6.2 Extension

The extensor pollicis brevis and abductor pollicis longus muscles run a common course from
the dorsal forearm, traversing through the first dorsal compartment and crossing the wrist on its
radial aspect to their insertion.

The extensor pollicis longus muscle originates in the forearm by the abductor pollicis longus
and extensor pollicis brevis muscle but crosses the wrist closer to the dorsal midline before using
the dorsal radial (Lister’s) tubercle as an anatomical pulley to turn toward the thumb; the
extensor pollicis longus muscle inserts on the base of the distal phalanx. At the level of the
proximal phalanx, the extensor pollicis longus tendon is joined by expansions from the abductor
pollicis brevis (APB) muscle, the first volar interossei muscle, and the adductor pollicis (ADP)
muscle.
The extensor pollicis longus muscle can also extend and adduct the carpometacarpal joint of the
thumb. The maximal glide of the extensor pollicis longus tendon is achieved with the wrist in an
extended position. In contrast to the fingers, there is a separate extensor tendon for each joint of
the thumb. The abductor pollicis longus muscle attaches to the base of the metacarpal, the
extensor pollicis brevis muscle to the base of the proximal phalanx, and the extensor pollicis
longus muscle to the base of the distal phalanx.

Because the extrinsic thumb muscles span multiple joints, they must coordinate together to
influence the positioning and functioning of the thumb as a whole. As is true for other extrinsic
hand muscles, wrist positioning is an essential factor in providing an optimal length-tension
relationship for the extrinsic muscles of the thumb. The flexor pollicis longus muscle is less
effective as an interphalangeal flexion in wrist flexion. The abductor pollicis longus and extensor
pollicis brevis muscles require the synergy of an ulnar deviator of the wrist to prevent the
muscles from creating wrist radial deviation, which thus affects their ability to generate tension
over the joints of the thumb.

2.6.4 Abduction

The abductor pollicis longus and abductor pollicis brevis abducts the metacarpal phalangeal
joints. The interossei muscles also abduct the fingers at the metacarpal joint. The abductor digiti
minimi abducts the little finger.

2.6.5 Adduction

Adduction is done by palmar interossei.

2.6.6 Opposition

Opposition is done primarily by opponens pollicis, supported by its synergist abductor pollicis
longus and flexor pollicis longus. Antagonistic muscles to opposition are the extensor pollicis
longus and adductor pollicis. The joint is stabilized and fixated during the movement by flexor
and extensor carpi muscles, and all muscles of the forearm.
2.7 Hip Joint

                              
The hip joint is a ball and socket synovial joint, formed by an articulation between the pelvic
acetabulum and the head of the femur. The acetabulum is a cup-like depression located on the
inferolateral aspect of the pelvis. Its cavity is deepened by the presence of a fibrocartilaginous
collar – the acetabular labrum. The head of femur is hemispherical, and fits completely into the
concavity of the acetabulum. Both the acetabulum and head of femur are covered in articular
cartilage, which is thicker at the places of weight bearing. The capsule of the hip joint attaches to
the edge of the acetabulum proximally. Distally, it attaches to the intertrochanteric line anteriorly
and the femoral neck posteriorly.

2.7.1 Hip Flexion

The flexors of the hip joint function primarily as mobility muscles in open-chain function; that is,
they function primarily to bring the swinging limb forward during ambulation or in various
sports-specific movements. The flexors may function secondarily to resist strong hip extension
forces that occur as the body passes over the weight-bearing foot. Nine muscles have action lines
crossing the anterior aspect of the hip joint.

The rectus femoris muscle is the only portion of the quadriceps muscle that crosses both the hip
joint and knee joint. It originates on the anterior inferior iliac spine and inserts by way of a
common tendon into the tibial tuberosity. The rectus femoris muscle flexes the hip joint and
extends the knee joint. Because it is a two-joint hip flexor, the position of the knee during hip
flexion will affect its ability to generate force at the hip. Simultaneous hip flexion and knee
extension considerably shorten this muscle and increase the likelihood of active insufficiency.
Consequently, the rectus femoris muscle makes its best contribution to hip flexion when the knee
is maintained in flexion.
 
The sartorius muscle is a strap-like muscle originating on the anterior superior iliac spines. It
crosses the anterior aspect of the femur to insert into the upper portion of the medial aspect of the
tibia. The sartorius muscle is considered to be a flexor, abductor, and lateral rotator of the hip, as
well as a flexor and medial rotator of the knee. The sartorius muscle, although a two-joint
muscle, should be relatively unaffected by the position of the knee, given the relatively small
proportional change in length with increased knee flexion. Its function is probably most
important when the knee and hip need to be flexed simultaneously (as in climbing stairs), but its
small cross-section argues against a unique or critical role at the hip joint.

The tensor fascia latae muscle originates more laterally than the sartorius muscle, on the
anterolateral lip of the iliac crest. The muscle fibers insert into the iliotibial band about one-
fourth of the way down the lateral aspect of the thigh. The iliotibial band or iliotibial tract is the
thickened lateral portion of the fascia latae of the hip and thigh. The iliotibial band attaches
proximally to the iliac crest lateral to the tensor fascia latae and gluteus maximus muscle. The
iliotibial band continues distally on the lateral thigh to insert into the lateral condyle of the tibia.
The tensor fascia latae muscle is considered to flex, abduct, and medially rotate the femur at the
hip, although the tensor fascia latae contribution to hip abduction may be dependent on
simultaneous hip flexion. The most important contribution of the tensor fascia latae muscle may
be in maintaining tension in the iliotibial band, in combination with the gluteus maximus. The
iliotibial band assists in relieving the femur of some of the tensile stresses imposed on the shaft
by weight-bearing forces. Because bone more effectively resists compressive than tensile
stresses, the reduction of tensile stresses is important in maintaining the integrity of the bone.
   
The secondary hip flexors are the pectineus, adductor longus, adductor magnus, and the
gracilis muscles. These muscles are described in the next section because they are predominantly
adductors of the hip. Each, however, is capable of contributing to hip joint flexion, but that
contribution is dependent on hip joint position. these muscles contribute to flexion only up to 40°
to 50° of hip flexion.  Once the femur is superior to the point of origin of a muscle, the muscle
will become an extensor of the hip joint. The gracilis, a two-joint muscle, is active as a hip flexor
when the knee is extended but not when the knee is flexed.
2.7.2 Hip Extension

The one-joint gluteus maximus muscle and the two-joint hamstrings muscle group are the
primary hip joint extensors. These muscles may receive assistance from the posterior fibers of
the gluteus medius, from the posterior adductor magnus muscle, and from the piriformis muscle.
The gluteus maximus is a large, quadrangular muscle that originates from the posterior sacrum,
dorsal sacroiliac ligaments, sacrotuberous ligament, and a small portion of the ilium. The gluteus
maximus crosses the sacroiliac joint before its most superior fibers insert into the iliotibial band
(as do the fibers of the tensor fascia latae muscle) and its inferior fibers insert into the gluteal
tuberosity.

The three two-joint extensors are the long head of the biceps femoris, the semitendinosus, and
the semimembranosus muscles, known collectively as the hamstrings. Each of these three
muscles originates on the ischial tuberosity. The biceps femoris crosses the posterior femur to
insert into the head of the fibula and lateral aspect of the lateral tibial condyle. The other two
hamstrings insert on the medial aspect of the tibia. All three muscles extend the hip with or
without resistance, as well as serving as important knee flexors.

2.7.3 Hip Abduction

 The abductors have been likened to the “rotator cuff of the hip,” with the gluteus medius and
gluteus minimus being analogous to the supraspinatus and subscapularis muscles, respectively.
The medius tendon inserts on the lateral and posterior superior portion of the greater trochanter,
resulting in a moment arm similar in direction and force to the supraspinatus. Active abduction
of the hip is brought about predominantly by the gluteus medius and the gluteus minimus
muscles. The superior fibers of the gluteus maximus and the sartorius muscles may assist when
the hip is abducted against strong resistance.
  
The tensor fascia lata muscle is given variable credit for its contribution and may be effective
as an abductor only during simultaneous hip flexion.

The gluteus medius has anterior, middle, and posterior parts that function asynchronously
during movement at the hip.

The gluteus minimus muscle lies deep to the gluteus medius, arising from the outer surface of
the ilium with its fibers converging on an aponeurosis that ends in a tendon on the greater
trochanter. The minimus is consistently an abductor and flexor of the hip, with its rotator
function dependent on hip position. However, the minimus is a medial rotator in hip flexion.
 
The gluteus minimus and medius muscles function together either to abduct the femur or, more
important, to stabilize the pelvis  in a unilateral stance against the effects of gravity. As will be
presented later, the gluteus medius and minimus muscles will offset the gravitation adduction
torque on the pelvis (pelvis drop) around the weight-bearing hip in unilateral stance.
The abductors are physiologically designed to work most effectively in a neutral or slightly
adducted hip. Isometric abduction torque in the neutral hip position is 82% greater than
abduction torque when the hip is at 25° of abduction (shortened abductors). Because the gluteus
medius is an important pelvic stabilizer, its weakness has been implicated in lower extremity
overuse injuries such as bursitis and hip osteoarthritis, as well as disorders at the knee.

2.7.4 Hip Adductors

The adductors are located anteromedially. The adductors longus, brevis, and magnus muscles
arise in a group from the body and inferior ramus of the pubis to insert along the linea aspera of
the femur. The gracilis muscle is the only two-joint adductor. It originates on the symphysis
pubis and pubic arch and inserts on the medial surface of the shaft of the tibia.

2.7.5 Lateral rotation/ External rotation

Six short muscles have lateral rotation as a primary function. These muscles are the obturator
internus and externus, the gemellus superior and inferior, the quadratus femoris, and the
piriformis muscles. Other muscles that have fibers posterior to the axis of motion at the hip (the
posterior fibers of the gluteus medius and minimus and the gluteus maximus) may produce
lateral rotation combined with the primary action of the muscle (although it has already been
noted that the lateral rotary function of these muscles decreases or becomes medial with
increased hip flexion). Of the primary lateral rotators, each insert either on or in the vicinity of
the greater trochanter. The obturator internus muscle originates from the inside (posterior aspect)
of the obturator foramen and emerges through the lesser sciatic foramen to insert on the medial
aspect (inside) of the greater trochanter. The gemellus superior and gemellus inferior muscles
arise from the ischium of the pelvis, just above and just below the point at which the obturator
internus passes through the lesser sciatic notch. Both gemelli follow and blend with the obturator
internus tendon to insert with the internus tendon into the greater trochanter.

The obturator externus muscle is sometimes considered to be an anteromedial muscle of the

thigh because it originates on the external (anterior) surface of the obturator foramen. However,
it crosses the posterior aspect of the hip joint and inserts on the medial aspect of the greater
trochanter in the trochanteric fossa.

The quadratus femoris muscle is a small quadrangular muscle that originates on the ischial
tuberosity and inserts on the posterior femur between the greater and lesser trochanters. The
piriformis muscle originates largely on the anterior surface of the sacrum, passes through the
greater sciatic notch, and follows the inferior border of the posterior gluteus medius to insert
above the other lateral rotators into the medial aspect of the greater trochanter.
The piriformis and gluteus maximus are the only two muscles that cross the sacroiliac joint.
The sciatic nerve, the largest nerve in the body, enters the gluteal region just inferior to the
piriformis muscle as both structures pass through the greater sciatic notch.

The lateral rotator muscles are positioned to perform their rotary function effectively, given the
nearly perpendicular orientation to the shaft of the femur.
The obturator externus and quadratus femoris were the only lateral rotators that did not
diminish their moment arm for lateral rotation with increased hip joint flexion.

2.7.6 Medial rotation/ Internal rotation

There are no muscles with a primary function of producing medial rotation of the hip joint. The
more consistent medial rotators are the anterior portion of the gluteus medius, gluteus minimus,
and the tensor fascia lata muscles. Although the role of the adductors in hip joint rotation is
controversial, the weight of evidence appears to support the adductor muscles as medial rotators
of the joint, with the possible exception of the gracilis muscle. The ability of hip joint muscles to
shift function with changing position of the hip joint is evident when medial rotation of the hip is
examined. There is a trend toward increased medial rotation torques (or decreased lateral rotation
torques) with increased hip flexion among many of the hip joint muscles, with three times more
medial rotation torque in the flexed hip than in the extended hip.

Muscle Action of the Hip Joint (Femoralacetabular Joint)

Sagittal Plane Flexion Extension

Primary Movers Iliopsoas Gluteus Maximus

Secondary Movers Rectus Femoris Semitendinosus
Tensor fascia Latae Semimembranosus
Sartorius Biceps Femoris (long head)

Dependent on hip Pectineus Gluteus Medius (posterior fibers)

position Adductor Longus Adductor Magnus (posterior fibers)
Adductor Magnus Piriformis
Gracilis
Gluteus Minimus (anterior fibers)
Frontal Plane Abduction Adduction

Primary Movers Gluteus Medius Adductor Magnus

Secondary Movers Gluteus Minimus Coracobrachialis
Tensor Fascia Latae Pectineus
Adductor Longus
Adductor Brevis
Gracilis
Obturator Externus

Dependent on hip Piriformis

position Sartorius
Rectus Femoris
Transverse Plane Medial Rotation Lateral Rotation

Primary Movers Gluteus Maximus

Piriformis
Secondary Movers Tensor Fascia Latae Quadratus Femoris
Gluteus Minimus Obturator Internus & Externus
Gluteus Medius (anterior fibers) Gemellus Superior & Inferior
Sartorius

Dependent on hip Pectineus Gluteus Medius (posterior fibers)

position Adductor Longus & Brevis Biceps Femoris (Long head)
Adductor Magnus (posterior
fibers)
Semimembranosus
Semitendinosus

2.8 Knee Joint

2.8.1 Knee Extension 

For the knee, the extension is acted by the quadriceps femoris muscle group crosses the knee via
the patella

Quadriceps femoris consists of four parts:

Rectus femoris:  Rectus femoris arises from two tendons that originate from the anterior
inferior iliac spine and the acetabular ridge. The end of the muscle inserts into the base of patella
forming the patella tendon with the rest of quadriceps muscles. Rectus femoris extends the lower
leg at the knee alongside its quadriceps muscle counterparts (Bruno, 2018). In terminal swing
phase rectus femoris acts as an extensor of the knee and also generate force needed for loading in
stance phase (Physiopedia,n.d.).

Vastus lateralis: located on the side of the thigh. This muscle is the largest of the quadriceps.
The specific task of the vastus lateralis muscle is to extend the lower leg and allow the body to
rise up from a squatting position (Healthline Medical Network, 2015)

Vastus medialis: attack from anatomical neck of the femur and medial lip of the linea aspera and
inserted in the aponeurosis of the vastus intermedius. Vastus medialis acts indirectly as a patella
stabilizer. During its contraction, it placing contractile force on the median axis of the femur and
pulling the aponeurosis of the vastus intermedius, counteracting the lateral forces on the patella
of the vastus lateralis.

Vastus intermedius : originates from the proximal three-fourths of the anterior and the lateral
faces of the femoral body and from the lateral lip of the linea aspera. Insertion via the quadriceps
femoris tendon to form the deep part of the tendon and then inserts into the lateral margin of the
patella. It facilitates knee extension together with other quadriceps muscles.
 Figure 8.0

2.8.2 Knee Flexion

Knee flexion is responsible by the posterior muscles of the thigh, the hamstring muscles.

Hamstring muscles consist of；

Biceps femoris: It arises proximally by long head and the short head. Actions of both long and
short head are flex the knee and laterally rotates lower leg when knee slightly flexed.

Semitendinosus: It acts as a prime mover, it extends and internally rotates the thigh, flexes and
internally rotates the leg. It also maintain the pousture by stabilizing the pelvic girdle (Kenhub)

Semimembranosus: It works in conjunction with other hamstring muscles causes flexion of the
knee and internal rotation of the leg on the thigh (Kenhub) 

Popliteus muscle is located behind the knee joint and acts to “unlock” the knee by rotating the
femur on the tibia allowing for the lower leg to be flexed.

Muscle Action of the Knee Joint

Sagittal Plane Flexion Extension

Primary Movers Semimembranosus Vastus lateralis

Semitendinosus Vastus medialis
Biceps femoris (long and short head) Vastus intermedius
Rectus femoris
 Secondary Movers Sartorius
Gracilis
Popliteus
Gastrocnemius

Transverse Plane Medial Rotation Lateral Rotation

Primary Movers Popliteus Biceps femoris

Semimembranosus
Semitendinosus
Sartorius
Gracilis

2.9 Ankle Joint

This joint is important during ambulation because it adapts to the surface on which one walks.
The movements that occur at the ankle joint are plantarflexion, dorsiflexion, inversion, eversion
abduction and adduction. Dorsiflexion and plantarflexion that occurs in plane around a coronal
axis. Inversion and eversion occur in the frontal plane around longitudinal axis. Abduction and
adduction occur in transverse plane around vertical axis. 

Figure 9.0

2.9.1 Ankle plantar flexion

It is opposite motion of the head and body of talus that occurs as your foot and toes point down
which increases the angle between the leg and the dorsum of the foot (20 to 50 degree) :

Gastrocnemius: It has medial and lateral heads. Medial head of gastrocnemius originates on the
posterior surface of the femur superior to the medial condyle. The lateral head originates in the
lateral epicondyle of the femur. Both insert into a long common muscle aponeurosis which form
the Achilles tendon with the aponeurosis of the soleus. Gastrocnemius muscles contribute to
plantar flexion of the foot through their pull on Achilles tendon (Corey, 2017) 

Soleus: It is located beneath gastrocnemius muscle. It connects to the Achilles tendon and works
with other calf muscles to accomplish plantar flexion (Brett, 2020) 

Plantaris: This muscle works with the Achilles tendon to flex the ankle, allowing a person to
stand on tiptoes in plantar flexion (William, 2017) 

Flexor hallucis longus: If flexes all the joints of the great toe and stabilizes the first metatarsal
head when on tip-toe. It aids in plantar flexion at the ankle joint.

Tibialis posterior: Contraction of tibialis posterior approximates the tibia and fibula brings the
malleoli together during plantar flexion, improving their grip on the talus and supporting the
ankle. This muscle also elevates, tense and reinforce the medial longitudinal arch of the foot
helps to distribute the body weight when the foot is planted on the ground (Niamh, 2020) 

Peroneus Longus: It works with tibialis posterior muscle to keep ankle joint stable when stand
on tiptoe. (William, 2017)

2.9.2    Ankle Dorsiflexion

It occurs when the foot raises upwards towards the shin which decreases the angle between the
leg and the dorsum of the foot (10 to 20 degree). Dorsiflexion is more limited typically with the
knee in extension than with the knee in flexion.

Tibialis anterior: It situated on the lateral side of the tibia. The fibers run vertically downward
and end in a tendon insert at the inferomedial aspect of medial cuneiform and base of the first
metatarsal. It involves in dorsiflexion with synergistic action of the extensor hallucis longus,
extensor digitorum longus and peroneus tertius.
 Figure 9.1: Location of muscle insertions in relation to ankle(talocrural) and subtalar joint axes.

Muscles that insert anterior to the ankle joint axis will cause dorsiflexion torques at the ankle
joint, whereas those that insert posterior to the axis will cause plantarflexion torques. Muscles
that insert medial to subtalar joint axis will cause supination torques, whereas those that insert
laterally will cause pronation torques.

2.10 Subtalar Joint (Talocalcaneal joint)

It is a composite joint formed by the talus superiorly and the calcaneus inferiorly. Subtalar joint
provides a triplanar movement around a single joint axis. The subtalar joint is formed in an
oblique axis and is therefore the chief site within the foot for generation of eversion and
inversion. The subtalar axis inclined 42 degree upward and anteriorly from the transverse plane
and inclined medially 16 degree from the sagittal plane.  The subtalar axis is inclined only very
slightly toward being a coronal axis, 16 degree and therefore has only a small component of
dorsiflexion and plantarflexion.

2.10.1 Inversion
It is tilting the sore of the foot which occurs when the plantar surface of the body segment is
brought towards the midline of the body.

Tibialis posterior along with the tibialis anterior is a primary inverter of the foot. This inversion
happens at two synovial joints of the foot which are midtarsal joints and the subtalar joint
(Nicholas,2019) 

2.10.2 Eversion

It is the movement that ankle joint is tilting of the sole of the foot away from the midline.

Peroneus Longus: This muscle attaches around lateral foot and on the bottom of foot. It everts
the foot when contracts. (Brett, 2020)

Peroneus Brevis: Muscle fibers of this muscle traverse downwards and form into a tendon just
posterior to the lateral malleolus, crossing the ankle and inserting on the fifth metatarsal bone.
Thus, it assists with eversion of foot (Hajira, Benjamin & Marco, 2019).

In non-weight bearing supination and pronation is described by motion of its distal segment on
the stationary talus and lower leg. Non-weightbearing supination is the coupled calcaneal
motions of adduction, inversion and plantarflexion. Non-weight bearing pronation is the coupled
motions of abduction, eversion and dorsiflexion.

2.11 Metatarsophalangeal Joints

It is the joints between the heads of metatarsals and corresponding bases of the proximal
phalanges of the foot. The MTP joints have 2 degrees of freedom. Flexion or extension motion is
much greater than abduction and adduction motion and extension exceeds flexion. Limited
extension at the first MTP joint will interfered with the metatarsal break and is known as Hallux
rigidus.

Interphalangeal joints are between the phalanges of the foot. The great toe has only one
interphalangeal joint, while the other four toes has a proximal and a distal interphalangeal joint.
The toes function to smooth the weight shifts to the opposite foot in gait and help maintain
stability by pressing against the ground in standing. The foot muscles are divided into plantar and
dorsal groups. There are only two muscles in the dorsal group, while the plantar muscles are
further subdivided into three groups which are lateral, central and medial. The dorsal foot
muscles are in the dorsum of foot and they extend the toes (Jana Vaskovic, 2020) Moreover, The
extensor hallucis longus muscle also prevents the toes from dragging by extending (or preventing
flexion) of the metatarsophalangeal joints of the hallux. The extensor digitorum longus muscle
also extends the metatarsophalangeal joints of the lesser toes, working with the extensor hallucis
longus muscle to hold the toes up when the foot is off the ground.

Extensor digitorum brevis: Originate from superolateral surface of calcaneus bone and inserted
to middle phalanges of toes 2-4. It extends the toes at the distal interphalangeal joints 2-4
Extensor hallucis brevis: Originate from superolateral surface of calcaneus bone and inserted
into proximal phalanx of great toe for great toe extension at metatarsophalangeal joint.

Figure 11

2.11.1 Plantar Foot Muscles

The plantar foot muslces are divided into lateral, central and medial. Lateral plantar muscles act
upon the fifth toe.

Abductor digiti minimi: Orginate from calcaneal tuberosity and inserted to base of proximal
phalanx of digit 5. It can abduct the little toe, flexion and supports longitudinal arch of foot.

Flexor digiti minimi: Originate from base of metatarsal bone 5, perform the toe flexion.
 Opponens digiti minimi: Originate from long plantar ligament and in charge o little toe
abduction and flexion.

2.11.2 Central Plantar Muscles

Central plantar muscles act upon the lateral four toes.

Flexor digitorium brevis and quadratus plantae are responsible for lateral four toes flexion.

Lumbricals Plantar interossei and Dorsal interossei are in charge of lateral four toes flexion
and abduction at metatarsophalangeal joints. Besides, it is also contracting for toe extension. In
the meanwhile, they also flex metatarsophalangeal joints, this helps to stabilize the
metatarsophalangeal joints during walking to allow the toes to remain weight-bearing and reduce
loading on the metatarsal heads.

Medial plantar muscle act upon great toe. 

Abductor and adductor hallucis muscles are responsible for great toe flexion, abduction and
support of longitudinal arch of foot.

Flexor halluces brevis muscle contracts to flex the great toe and support longitudinal arch of
foot at metatarsophalangeal joint.

Muscle Action of the Ankle & Foot

Talocrural joint

Sagittal Plane DorsiFlexion Plantarflexion

Primary Movers Tibialis anterior Gastrocnemius

Extensor digitorium longus Soleus
Extensor hallucis longus

Secondary Movers Fibularis Tertius Plantaris

Tibialis Posterior
Flexor Hallucis longus
Flexor digitorium longus
Fibularis longus
Fibularis brevis
Metatarsophalangeal joint

Sagittal Plane Flexion Extension

Primary Movers Flexor hallucis brevis Extensor digitorum longus

Lumbricals Extensor digitorum brevis
Extensor hallucis longus
Secondary Movers Interossei
Flexor digiti minimi brevis
Flexor digitorium longus
Flexor digitorium brevis
Flexor hallucis longus

Proximal interphalangeal joint

Sagittal Plane Flexion Extension

Primary Movers Flexor digitorum longus (digit 2-5) Extensor digitorum longus (digit 2-5)
Flexor digitorum brevis (digit 2-5) Extensor digitorum brevis
Flexor hallucis longus (digit 1) Extensor hallucis longus (digit 1)

Distal interphalangeal joint

Sagittal Plane Flexion Extension

Primary Movers Flexor digitorum longus (digits 2-5) Extensor digitorum longus (digit 2-5)
Extensor digitorum brevis

Frontal Plane Inversion Eversion

Primary Movers Tibialis anterior Fibularis longus

Tibialis posterior Fibularis brevis

Secondary Movers Flexor digitorum longus Fibularis Tertius

Flexor hallucis longus Extensor digitorum longus
 2.12 Cervical spine.
Cervical column is divided into two distinct region which are upper craniovertebral region and
lower cervical spine. 

Craniovertebral contains the atlas (C1) and the axis (C2) .C1 is a ring like structure and does not
have a spinous process. C2 serves as s transitional vertebra between the cervical spine proper and
the craniovertebral region. It has a unique feature named dens is located on its superior aspect.
The dens’ functions as a pivot for the upper cervical joints and as center of rotation for the
atlanto-axial joint. The major motion that occurs at all three of the A-A joint articulations is axial
rotaion, totaling approximately 40-47 degree to each side. During rotation of the head to the
right, right side bending and right rotation occur at A-A joint and at C2-3. Left side bending and
right rotation occur at the atlanto-occipital joint accompanied by a translation to the right.
Flexion is 10 degree and extension is 5 degree. 

The 5 cervical vertebrae that make up the lower cervical spine, C3-C7. These 5 vertebrae are
more classic vertebrae, having a body, pedicles, laminae, spinous processes and facet joints (Sian
& Alicia, 2011).
 Figure 12

2.12.1 Cervical Flexion

Sternocleidomastoid functions bilaterally to create neck flexion and unilaterally to create

ipsilateral flexion and contralateral rotation.

Anterior scalene functions to elevate the first rib and creates ipsilateral lateral flexion and
contralateral rotation.

Longus colli & longus capitus create cranio-cervical flexion and support cervical lordosis
anteriorly. Long capitus is innervated by C1-3 spinal segments and longus colli from C2 to 6.

2.12.2 Cervical Extension

Levator scapulae and upper trapezius which are muslces of the shoulder girdle and form a
superficial layer over the cervical extensor group. It moves the scapula and causes extension,
lateral rotation of the head and neck.
Splenius capitus and cervicis which acts bilaterally as an extensor and ipsilaterally to produce
rotation.

Semispinalis capitus is primarily a cervical extensor and unilaterally to create lateral flexion.

Semispinalis cervicis act as a cervical extender and multifidus acts as a segmental stabilizer.
They provide posterior support of cervical lordosis in synergy with the deep neck flexors and
prevent a forward head position.           
     

2.12.3 Craniocervical Extension                                       

Craniocervical extensors are four muscles form the suboccipital muscle group and assessed
separately to the deep cervical extensors.    

Rectus capitus posterior major & minor function for head extension and ipsilateral
rotation.            

Obliquus capitus superior functions for head extension and side bending.

Obliqus capitus inferior acts as ipsilateral head-on-neck rotation.

2.13 Thoraco-Lumbar spine

Thoracic spine: The 1st and 12th thoracic vertebrae are transitional vertebrae. First thoracic
vertebrae has a typical cervical shaped body with a transverse diameter. 12th thoracic vertebrae
has thoracic-like superior zygapophyseal articular facets that face posterolaterally.

The ratio of discs size to vertebral body size is smallest in the thoracic region, which results in
greater stability and less mobility for this region. The range of flexion and extension is extremely
limited in the upper thoracic region (T1 to T6) because of the rigidity of the ribcage.

In the lower part (T9 to T12) allowing an increased amount of flexion and extension (Stephen,
2017). 

Rhomboids span between the T2-T5 vertebrae and medial border of the scapula. The latter
attaches from the nuchal ligament and C7-T11 vertebrae to the root of the spine of scapular. Both
muscles act upon the scapulothoracic joint where they draw the scapula superomedially, rotate
the glenoid cavity inferiorly and support the position of the scapula.
Serratus posterior consists of superior posterior superior and serratue posterior inferior. It
atteaches between vertebrae C7-T3 and ribs 2-4. It elevates the ribs. The latter soan from
vertebrae T11-L2 and ribs 9-12. It acts to depress the ribs.

Iliocostalis Thoracis originate from angles of ribs 7-12, medial to insertions of iliocostalis
lumborum and inserts to transverse process of C7. Extension of vertebral column is it bilateral
action while the unilateral action is laterally flexes vertebral column.

 Longissimus Thoracis originate from transverse and spinous processes of lumbar vertebrae and
inserted to transverse processes of T1-T12. The bilateral action of this muscle is to extend and
hyperextend vertebral column and laterally flexes vertebral column to the same side is the
unilateral action.

2.14.2 Lumbar spine

The lumbar spine consists of 5 moveable vertebrae numbered L1-L5. It forms an effective load-
bearing system. When a load is applied externally to the vertebral column, it produces stresses to
the stiff vertebral body and the relatively elastic disc, causing strains to be produced more easily
in the disc. Pressure within the nucleus pulposus providing a “preload” mechanism allowing for
greater resistance to applied forces. The vertebral discs are an essential biomechanical feature,
effectively acting as a fibrocartilage ‘cushion’ transmitting force between adjacent vertebrae
during spinal movement (Panjabi, 1980) 
 Figure 13

Iliocostalis lumborum originates from medial and lateral sacral crests and inserted into angles
of ribs 6 or 7 -12. Bilateral actions of the iliocostalis lumborum muscle is to extend lower
vertebral column and the unilateral action is to laterally flexes cervical vertebrae.          

                                  
 Multifidus originates from posterior sacrum, superior iliac spine, mammillary processes of
lumbar vertebrae, transverse processes of thoracic vertebrae and articular processes of C4-C7.
Insetion is the spinous processes of the vertebrae, except C1. Actions of the multifidus muscle is
to extends vertebrae except C1. The unilateral action is laterally flexes and contralaterally rotates
vertebral column(Java, 2020)

Muscle Action of the Vertebral Column (Intervertebral & Craniovertebral Joints)

Sagittal Plane Flexion Extension

Primary Movers Rectus Abdominis Splenius cervisis/capitis
External & Internal Oblique Iliocostalis group
Sternocleidomastoid Longissimus group
Semispinalis group
Multifidus
Rectus Capitis posterior Major/Minor

Secondary Movers Longus Capitis Oblique Capitis Superior/ Inferior

Longus Colli Spinalis
Anterior Scalane Rotatores
Rectus Capitis Anterior Levator Scapulae
Trapezius
Quadratus Lumborum

Transverse Plane Ipsilateral Rotation Contralateral Rotation

Primary Movers Splenius External Oblique

Cervicis/ Capitis Sternocleidomastoid
Internal Oblique

Secondary Movers Longissimus group Trapezius

Iliocostalis group Semispinalis capitis/cervicis
Levator Scapulae Rotators
Multifidus

Frontal Plane Lateral Flexion

Primary Movers Iliocostalis Group Internal Oblique

External Oblique

Secondary Movers Semispinalis Group Trapezius

Longissimus group Multifidi
Quadratus Lumborum Intertransversarli
Splenius Capitis/Cervicis Scalanes
Sternocleidomastoid Levator Scapulae

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