LEVEL II MUSCLE CHART NB: Needle length varies with tissue depth, this chart acts as a guide only. Side lye or prone.25 x 30-50mm Inferior to ilium

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1 LUMBAR SPINE LEVEL II MUSCLE CHART NB: Needle length varies with tissue depth, this chart acts as a guide only Muscle/ Innervation Comments Position Quadratus Lumborum T12-L3/4 segmentally PSIS Comments. Threading Safest to crest of ilium, care with rib/kidney Site for attachment of: multifidus, lat dorsi, Thoraco-lumbar fascia, long dorsal sacro-iliac ligament Side lye or prone.25 x 30-50mm Inferior to ilium Side lye or prone.30 x 30-50mm Directly onto PSIS then approach like a compass Signed Off: UPPER EXTREMITY Pectoralis Minor C6,7,8 Medial Pectoral N Subclavius C5,6 N to Subclavius 1. Off coracoid 2. Lift muscle off chest wall 3. Directly off ribs x 30-50mm 1. Towards CP 2. A-P, M-L 3. Perp Directly off clavicle x 30mm Superior onto clavicle Subscapularis C5,6,7 Upper and lower subscapular N s Anterior and posterior approaches with HBB. Side lye or prone..25 x 30-60mm in Towards costal surface of scapula Coracobrachialis C6,7 Musculocutaneous Caution for median N, brachial A and N inferiorly with arm abducted & ER.25 x 30-40mm Perp Biceps-Short Head C5,6 Musculocutaneous Supraspinatus (Suprascapular C4,C5,C6) Sits just superior to previous, consider hammerlock with arm abducted & ER mm 20-50mm.25 x 30-40mm Perp Angle inferior and posterior towards the spine of the scapulae Needle medial 1/3 Avoid lateral aspect. Look to bump scap spine before rolling into fossa

2 Epicondylar part of the common extensor tendon (Rad, C5,C6,C7,C8) Extensor carpi ulnaris (Rad/PI,C6,C7,C8) Extensor digitorum (Rad/PI,C6,C7,C8) Flexor carpi radialis (Median C6,C7,C8) Flexor digitorum superficialis (Median C7,C8,T1) Flexor carpi ulnaris (Ulnar C6,C7) Important for tennis elbow. NB: ulna nerve passes between its two heads Comments: Signed Off: THORACIC SPINE Multifidus Spinalis Longissimus Iliocostalis Locate landmarks of SP, articular pillars, rib angles Insertion point: ½ -1 Fgr breadth from SP.25 x 30-50mm Most medial Erector Spinae.25 x 30-40mm Intermediate mass.25 x 30-40mm Lateral mass.25 x 30-40mm Caudal & Medial Serratus Posterior Superior 2nd-5 th I/Costal N s Only needle if confident Ribs 2-5 have been identified. Can needle at C/T Side lye or prone.25 x 30mm only Perp

3 Middle Trapezius Spinal accessory (XI), sensory C3/4 Lower Trapezius Spinal accessory (XI), sensory C3/4 Rhomboids C4/5 Dorsal Scap N Serratus Anterior C5-7 Long Thoracic chest wall chest wall chest wall. Alternatively needle onto medial scapula border in side lye Along and ONTO rib-only if 100% confident Safest at LTJ. Over rib if confident. support ant Sh support ant Sh support ant Sh. Side lye Side lye or supine.25 x 30mm only Medial approach onto winged scap, or laterally over ribs.25 x at LTJ Perp 30mm over rib Serratus Posterior Inferior T9-12 Ventral rami Comments: Signed Off: HIP Piriformis sacral plexus,l5 S1,S2 Superior Gemelli L5, S1-2 N to Obt Int Obturator Internus L5, S1-2 N to Obt Int Inferior Gemelli L5, S1-2 N to Quad fem Obturator Externus L2-4 Obt N Quadratus Femoris L5, S1-2 N to Quad fem Pectineus L2,3. Fem N & Obt N Adductor Brevis L2-4. Obt N Iliacus (ant hip) L2,3 Fem N Sciatic nerve runs 1/3-1/2 way between the ischial tuberosity and the Needle medial aspect of muscle Needle more deeply posterior to Needle in lateral 1/3 to avoid sciatic N Entry point medial to Femoral A. Medial to Pectineus and lateral to Longus. Entry point lateral to Femoral A. / side lying x mm Perpendicular /side x 40-60mm Perp/lat /side x 40-60mm Perp/lat /side x 40-60mm Perp/lat /side x 40-60mm Perp/lat /side x 30-50mm Perp/lat / side x 30-50mm Perp/med lying with x 30-50mm Perp/lat hip abd/er/fl /Crook x 30-50mm Perp/lat. Medial to ASIS and Sartorius

4 Psoas (ant hip) L2,3 Entry point lateral to Femoral A. /Crook x 30-50mm Perp/lat. Postero-lateral Comments: Signed off: CERVICAL SPINE Sternocleidomastoid Spinal accessory (XI), proprio C2/3 Levator Scapulae C3-4 &Dorsal scap N C4-5 Splenius Capitis Post primary rami Inferior Obliquus Capitus C1-post primary rami Rectus Capitus Posterior Major C1-post primary rami Cervical Erector Spinae attachments Rhomboid major/minor (Dorsal scapular, C4,C5) Superior/inferior nuchal lines Grasp and lift muscle off anterior neck Needle onto periosteum of superomedial angle of scapula Caution for depth and VA as it loops above the C2/3 facet jnt. Angle towards root of C2 spinous process. Caution for VA. Aim to needle lamina of C2 jus superior to IOC. Or at Inferior nuchal line. or sitting, head on forearms with hammerlock or sidelying on affected side to wing scapular Major impact on attachments for long Cx extensors and suboccipitals x 30mm Perp or thread Side-lye, prone, seated Seated or or seated or seated.30 x 30-40mm mm 30-40mm or seated and cupped hands mm Angle to medial bone border (not behind scap).25 x 30-40mm Perp/medial.25 x 30-40mm Perp/medial.25 x 30-40mm Medial onto SP, superior to occiput Needle directed superiorly between the sup and inf nuchal lines Angle to the medial bone border of the scapular (NOT behind the scapular) Tap occipital periosteum Care with occipital nerves Common to bump periosteum.30 x 30-40mm 30 degrees along line of skull Comments: Signed Off:

5 Summary of Muscles Supplied By Spinal Segments SEGMENT C4 C5 C6 C7 C8 T1 SEGMENT L2 L3 Cervical Spine (C4-T1) MUSCLES SUPPLIED Supraspinatus, infraspinatus, rhomboids, trapezius, levator scapulae Supraspinatus, infraspinatus, teres minor, teres major, deltoid, pectoralis major, rhomboids, levator scapulae, subclavius, subscapularis, serratus anterior, biceps, wrist extensors Supraspinatus, infraspinatus, teres minor, teres major, latissimus dorsi, deltoid, pectoralis major/minor, subclavius, subscapularis, serratus anterior, coracobrachialis, biceps, triceps, wrist extensors, wrist flexors Teres major, latissimus dorsi, pectoralis major/minor, subscapularis, serratus anterior, coracobrachialis, triceps, wrist extensors, wrist flexors Latissimus dorsi, pectoralis major/minor, triceps, wrist extensors, wrist flexors, Muscles of Hand Muscles of hand Lumbar Spine (L2-S3) MUSCLES SUPPLIED Quads, adductors, Iliacus, psoas, obt externus, pectineus Quadriceps, sartorius, gracilis, pectineus, iliacus, psoas, adductor longus, brevis and magnus, obt externus L4 Gluteus medius and minimus, TFL, quadriceps, sartorius, gracilis, adductor longus, brevis and magnus, semimembranosis, semitendinosis, tibialis anterior/posterior, extensor digitorum longus, obt externus, popliteus, extensor hallucis longus L5 Gluteus maximus, medius and minimus, piriformis, gemelli, obturator Int,TFL, adductor magnus, hamstrings, popliteus, tibialis anterior/posterior, extensor digitorum longus/brevis, peroneals, muscles of foot, ext hallucis and digitorum brevis, quadratus femoris, ext hallucis longus S1 Gluteus maximus, medius and minimus, piriformis, gemelli, obturator Int, quadratus femoris, TFL, hamstrings, popliteus, gastrocnemius, soleus, peroneals, flexor digitorum/hallucis longus, muscles of foot, ext hallucis and digitorum brevis, abd hallucis, flexor digitorum, flexor hallucis brevis, quadratus plantae, abd digiti minimi S2 Piriformis, gemelli, obturators, quadratus femoris, abd/fl Dig minimi, quad plantae, interossei, add and abd hallucis, flexor digitorum brevis, flexor hallucis brevis, quadratus plantae S3 Add hallucis, abd digiti minimi, flexor digiti minimi brevis, quadratus plantae, interossei COMMENTS: