Skeletal Muscle - Structure and Histology

This article describes the structure, histologic features, and ultrastructural features of normal adult human skeletal muscle and addresses the results of improper specimen handling during muscle biopsy. Many of the images show the normal microscopic appearance of muscle biopsy specimens, with some of the histological stains that are routinely used in the evaluation of muscle biopsies. Some of the captions mention abnormalities that can be seen with those stains to provide some insight into their practical applications in biopsy diagnosis of neuromuscular disease. This article provides introductory background information that should assist the reader in understanding pathologic findings in muscle the various disorders that are presented in a separate article.

The intended audience is any physician who deals with patients with primary neuromuscular disease or neuromuscular complications of systemic disease and who considers obtaining or performing a muscle biopsy for diagnosis. This includes primary care physicians, pediatricians, rheumatologists, neurologists, dermatologists, oncologists, radiologists, and surgeons. These physicians should use this article as the foundation for comparing normal muscle to what is found in the setting of disease and to learn about appropriate care and handling of skeletal muscle biopsy tissue. This article can assist physicians who read muscle biopsy reports written by others to comprehend the significance of pathological findings described in muscle biopsies by seeing how pathological findings differ from normal skeletal muscle. This article should be useful to those beginning their training in interpretation of muscle biopsies and can serve as a resource for medical students who are learning about muscle structure and function and are being introduced to neuromuscular disorders.

For a detailed discussion of muscle biopsy procedure and an overview of the clinical and laboratory features of neuromuscular disease, see Muscle Biopsy and Clinical and Laboratory Features of Neuromuscular Disease. ^[1] For details on the pathological findings in muscle biopsy in several major categories of neuromuscular disease, see Skeletal Muscle Pathology. ^[2]

Basic structure and terminology

A layer of dense connective tissue, which is known as epimysium, surrounds each muscle (see the image below).  The epimysium is continuous with the tendon of a muscle.  A muscle is composed of numerous bundles of muscle fibers, termed fascicles, which are separated from each other by a connective tissue layer termed perimysium. Endomysium is the connective tissue that separates individual muscle fibers from each other. Mature muscle cells are termed muscle fibers or myofibers and they are often simply referred to as fibers. Each myofiber is a multinucleate syncytium formed by fusion of precursor skeletal muscle cells termed myoblasts.

Basic architectural elements of skeletal muscle.

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Sarcoplasm, the cytoplasm of each myofiber, is occupied largely by the contractile apparatus of the cell. This is composed of myofibrils arranged in sarcomeres, which are the contractile units of the cell. The sarcomeres contain a number of proteins, among them are alpha actinin, which is the major constituent of the Z-band, and actin and myosin, which are the major components of the thin and thick filaments, respectively.

The remainder of the sarcoplasm, located between the myofibrils, is termed the intermyofibrillar network and contains mitochondria, lipid, glycogen, T-tubules, and sarcoplasmic reticulum. T-tubules are responsible for conduction of electrical signals from the cell surface to the internal areas of myofibers.  The sarcoplasmic reticulum provides the intracellular storage and release of calcium required for contraction to occur. The electrical signals conducted by the T-tubules stimulate the sarcoplasmic reticulum to release calcium. This calcium then binds to troponin, one of the proteins associated with the thin actin filaments; through a series of a few steps, this results in the binding of the thick filaments to the thin filaments. The binding of the myosin head to the actin filaments, together with the concomitant hydrolysis of ATP for energy, results in the contraction of the sarcomeres that in turn causes contraction of the entire muscle, resulting in movement (or the development of isometric tension that permits us to hold objects or resist being pulled). The connective tissue of the muscle plays an important role in the transmission of the forces generated by contraction of the sarcomeres to produce movement or isometric tension.

The two basic myofiber types are type 1 and type 2. The designation of these types is based on their physiologic properties, which are correlated with their cellular structural specializations and are reflected in their histochemical properties (see the following image).

Comparison of the histologic features of type 1 and type 2 myofibers. SO represents "slow oxidative," and FG represents "fast glycolytic," which are physiologic characteristics of type 1 and type 2 fibers, respectively.

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Type 1 myofibers are the slow-twitch fibers. Physiologists refer to them as slow-oxidative (SO) fibers. They have a slow contraction time following electrical stimulation, and they generate less force than type 2 myofibers. If the response of a muscle to the application of gradually increasing loads is measured, the slow myofibers are recruited first. They are used for sustained, low-level activity. To accomplish this, they are equipped with numerous large mitochondria and relatively abundant intracellular lipid for oxidative metabolism.

Type 2 myofibers are the fast-twitch fibers. Physiologists call these the fast-glycolytic (FG) fibers. They have a rapid contraction time following stimulation. If the response of a muscle to the application of gradually increasing loads is measured, the fast fibers are recruited late. They are used for brief-duration intense activity and for carrying heavy loads and are specialized for anaerobic metabolism. These myofibers contain smaller, less numerous mitochondria, less lipid, and have larger glycogen stores than type 1 fibers. The subgroups of type 2 myofibers are not discussed here.

Each muscle has a characteristic ratio of type 1 to type 2 myofibers. For example, in the vastus lateralis, the most commonly biopsied muscle, more than 50% of the fibers (as many as two thirds) are expected to be type 2 myofibers. In the deltoid muscle, another commonly biopsied muscle, the balance typically favors type 1 myofibers. In normal human muscle, the two myofiber types are interspersed in a random interdigitating pattern. The type 1 myofibers are normally similar in size to the type 2 fibers.

Different pathologic processes alter the ratio of the myofiber types and their distributions in the muscle and may selectively affect the size of one type or the other or of both equally. Therefore, a change in the arrangement and/or sizes of the myofiber types in a muscle biopsy often provides a significant diagnostic clue about the underlying disorder.

The innervation of a particular muscle fiber determines whether it is type 1 or type 2. Therefore, if the type of motor neuron innervating a myofiber is changed, the myofiber acquires a new phenotype from its new innervation. Pathologists use this fact to evaluate for evidence of neurogenic disease in a muscle biopsy specimen. In a muscle in which denervation has been followed by reinnervation due to sprouting of residual viable motor neuron terminals, groups of myofibers of a single type are present instead of the random interdigitation of myofiber types that is found in normal human skeletal muscles.

This section presents the normal histology of skeletal muscle as seen with some of the tissue stains that are commonly used for the evaluation of muscle biopsy specimens. Some abnormalities that can be seen with these stains and some of the diagnostic utility of some of the preparations are mentioned in the discussion below. Please see Skeletal Muscle Pathology for more extensive and detailed information about the pathologic features of skeletal muscle in a variety of disorders and to see additional stains used in the processing of muscle biopsy specimens.

Cryostat (Frozen) Sections

Hematoxylin and eosin stain

On a cryostat (frozen) hematoxylin and eosin (H&E) section, a cross-section of a frozen sample of normal skeletal muscle stained with H&E (see the image below) exhibits fascicles surrounded by and separated from each other by a thin layer of perimysium. The muscle fibers are of relatively uniform size and shape, with nuclei located at the periphery of the individual muscle cells (myofibers). In normal muscle, fewer than 3% of myofibers should have internal nuclei, which are nuclei that are located in the center of the myofiber. The myofibers fit together in a mosaic pattern.

Normal Muscle. Medium-low power image of a hematoxylin and eosin (H&E) frozen section of skeletal muscle in cross-section shows parts of five fascicles of muscle. Each fascicle is surrounded by thin, delicate perimysium. The myofibers are of relatively uniform size and shape and fit together in a mosaic pattern. The fibers, which appear to be in almost direct contact with one another, are separated by thin, almost invisible endomysium. In contrast, in cases in which fibrosis is present, the muscle fibers appear separated. The myofiber nuclei are normally located at the periphery of the cells, and the cytoplasm is fairly uniformly distributed.

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The following image provides another view of normal muscle with myofibers that are of uniform size and shape, with nuclei located at their peripheries, that are arranged in a mosaic pattern with little to no visible space between contiguous myofibers.

Normal muscle. The center of this area of a cryostat H&E cross-section of muscle is largely occupied by the majority of a single fascicle. The myofibers are of uniform size and shape, they are fit together in a mosaic pattern with no visible space between them. Nuclei are located at the periphery of the myofibers.

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At high power (see the following image), the endomysium separating the myofibers can be observed as normally so thin and delicate it is almost invisible, and the contiguous myofibers appear to have almost no space between them. The sarcoplasm appears relatively uniform throughout the cell.

Normal muscle. High power hematoxylin and eosin (H&E) cross-section of a cryostat section of muscle reveals the normal appearance of the sarcoplasm and the peripherally placed nuclei. Myofibers are separated by thin, delicate endomysial connective tissue. Capillaries, normally indistinct, are found at the corners between myofibers. The terms, cryostat section and frozen section, are used interchangeably. A cryostat is the microtome that is used to produce sections of frozen tissue.

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NADH stain

On the frozen section stained with the nicotinamide adenine dinucleotide tetrazolium reductase stain (NADH or NADH-tr) (see the first image below), which stains predominantly, but not exclusively, mitochondria in the intermyofibrillar network, the type 1 myofibers are darker than the type 2 myofibers. In normal muscle, the stain appears to be distributed fairly uniformly throughout the sarcoplasm. High power (see the second image below) allows one to observe that much of this stain is actually distributed in a punctate pattern, due to its mitochondrial localization in the intermyofibrillar network. The intermyofibrilllar network is discussed further below. The NADH stain also exhibits a trabecular pattern that differs between type 1 and type 2 myofibers, probably due to staining of endoplasmic reticulum.

Normal muscle. Nicotinamide adenine dinucleotide tetrazolium reductase (NADH or NADH-tr) stain demonstrates two populations of myofibers. NADH is an oxidative enzyme. Type 1 myofibers stain more darkly than type 2 myofibers because of the greater use of aerobic metabolism by type 1 fibers. In normal muscle at low power, the sarcoplasm appears to stain fairly uniformly across the cell.

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Normal muscle. High-power view of the nicotinamide adenine dinucleotide tetrazolium reductase (NADH) stain in normal muscle in this case reveals a punctate distribution of the stain throughout the cell because of its predominant colocalization with mitochondria in the intermyofibrillar network. There are also trabecular patterns of staining of the intermyofibrillar network with this stain that differ between type 1 and type 2 myofibers that are not obvious in this case. The darker fibers are type 1 myofibers.

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Myosin ATPase stain

On the cryostat section for fiber-typing in the image below, which is treated with the stain for myosin ATPase at pH 10.5 (the actual pH used varies among laboratories), type 2 myofibers are stained brown, and type 1 myofibers are stained pink with an eosin counterstain to make them visible. This section demonstrates the normal, random, almost checkerboard distribution of the two types of myofibers. The same stain, performed at a pH of 4.3, would demonstrate brown staining of the type 1 myofibers, such that the section would show exactly the reverse or complementary pattern of that seen in the image here. Many laboratories no longer perform this stain because it is labor-intensive and they rely on the less time-consuming myosin heavy chain immunohistochemical fiber-typing stains, which are presented below.

Normal muscle. Myosin adenosine triphosphatase (ATPase) at pH 10.5 stains type 2 myofibers brown. Type 1 fibers are stained with an eosin counterstain so that they are visible. Normal muscle contains a random checkerboard-like interdigitation of the 2 myofiber types. The two types of myofibers are similar in size. In the field shown, more type 1 myofibers than type 2 are present. This is a characteristic feature of the deltoid muscle.

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Myosin heavy chain immunohistochemical stain

An alternative to the relatively technically demanding myosin ATPase stain is the immunohistochemical stain for myosin heavy chain. The first image below shows the stain for myosin heavy chain slow type, which stains the type 1 myofibers. In the second image below, a serial section from the same biopsy is stained for myosin heavy chain fast type, which stains the type 2 myofibers. The positive staining is brown.  The pink in the sections is an eosin counterstain; without a counterstain, the negative myofibers would be invisible.  Currently, hematoxylin, which is a blue stain, is more commonly used as a counterstain than eosin.

Normal muscle. Immunohistochemical fiber-typing stain for myosin heavy chain, slow type, in which type 1 myofibers are brown. The eosin counterstain makes the type 2 myofibers visible with a pink color. The three arrows indicate three type 1 myofibers, which are also seen in the following image. If a laboratory is equipped to perform immunohistochemical studies, this is a technically easier stain to perform than myosin adenosine triphosphatase (ATPase) stains. Another advantage of the immunohistochemical stain is its relative permanence, whereas myosin ATPase stains fade in a few months.

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Normal muscle. Immunohistochemical stain for myosin heavy chain, fast type. In this image, type 2 myofibers are brown, and the type 1 myofibers are pink due to the eosin counterstain. Compare this image with the previous image, which shows the same field. The identical three fibers indicated by arrows in the previous image are also indicated by arrows here. In the present image, the areas indicated by the arrows are pink, confirming their identity as type 1 myofibers.

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Periodic acid-Schiff stain

On the frozen periodic acid-Schiff (PAS) section, PAS-positive material, most of which is glycogen, is distributed fairly uniformly across the normal myofibers (see the following image). It is located mostly in the intermyofibrillar network, which contains much of the intracellular glycogen. Normally, the type 2 myofibers stain darker with this stain than type 1 fibers, because the type 2 fibers use glycolysis more than type 1 fibers. (Glycolysis relies largely on glucose phosphate derived from glycogen as a substrate.) The exact staining in a given case is dependent upon recent carbohydrate ingestion and exercise, so this stain cannot be used to reliably identify myofiber types.

Normal muscle. High-power view of the periodic acid-Schiff (PAS) stain shows the normal color and pattern of this stain, which stains carbohydrate moieties so that glycogen, mucopolysaccharides, and glycoproteins are highlighted. This method is most useful for evaluating glycogen storage disease. It also shows the basal lamina of blood vessels such that the PAS stain also provides information about vascular structure. It can also highlight fibers that are degenerating or necrotic and demonstrate some inclusions.

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Modified Gomori trichrome stain

With the modified Gomori trichrome stain performed on a frozen section (see the image below), the myofibers and connective tissue stain slightly different shades of blue-green. Nuclei are normally red-purple. The intermyofibrillar network exhibits punctate staining of mitochondria, which stain red, which is normally inconspicuous.

Normal muscle. The modified Gomori trichrome stain is valuable in evaluating mitochondrial myopathies, inclusion body myositis, nemaline myopathy, and some other disorders with intracellular inclusions. The nuclei and mitochondria stain red, the cytoplasm is mostly blue-green, and the connective tissue is green.

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Sudan Black stain

With the Sudan Black stain for lipid, performed on a frozen section (see the image below), intracellular lipid appears blue-black and is distributed throughout the intermyofibrillar network. Type 1 myofibers stain darker than the others because of their high reliance on oxidative metabolism, which can use lipid as a substrate. For this reason, type 1 myofibers have a greater lipid content than the type 2 myofibers, because type 2 myofibers rely more on anaerobic than oxidative metabolism. Oil-Red-O is another stain for lipid that many laboratories use as their routine stain for lipid.

Normal muscle. Sudan Black stain for lipid demonstrates slightly more staining of type 1 myofibers because of their higher lipid content due to their greater dependence on aerobic metabolism compared with type 2 myofibers. Some hereditary and acquired disorders of lipid metabolism show excessive staining of myofibers with this stain. Some of the mitochondrial myopathies are associated with increased intracellular lipid content. Intrasarcoplasmic lipid is also increased in starvation.

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Immunohistochemistry for Major Histocompatibility Complex Class I or Human Leucocyte Antigen Class ABC (or type I)= HLA Class I

The image below shows HLA Class I immunohistochemistry study as it appears in normal muscle or in a muscle that does not have an immune-mediated disorder. The capillaries exhibit strong labeling, indicated by the brown staining, and the myofibers are unstained, or negative. This study is most helpful in the diagnosis of some autoimmune disorders that have little to no inflammation, in which a strongly positive HLA Class I immunohistochemistry study provides evidence of an immune-mediated process, despite the lack of inflammation. As with every procedure, this stain must be interpreted with caution because nonspecific myofiber labeling can occur in the setting of myofiber necrosis or myofiber atrophy and because some disorders that are not classic inflammatory myopathies, such as certain muscular dystrophies, can be positive. No individual stain or histological finding is specifically diagnostic by itself, but must be interpreted within the clinical context and in view of the composite of histopathological findings in an individual case.

Normal muscle. Immunohistochemistry for Human Leucocyte Antigen Class ABC or Class I (HLA Class I), also known as Major Histocompatibility Class I, shows strong labeling of capillaries (indicated by the brown color), and the myofibers are unstained, or negative. This is what is seen in normal muscle or in disorders that are not immune-mediated. In autoimmune disorders, there is upregulation of HLA Class I expression on the myofiber surfaces and their surface membranes stain brown. There is often also sarcoplasmic staining. There are some autoimmune disorders in which there is little to no inflammation; it is the positive HLA Class I immunohistochemistry study that permits the histopathologic diagnosis of these disorders. Notice the distribution of capillaries in normal muscle.

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Paraffin Sections

Hematoxylin and eosin stain

The paraffin section is always stained with H&E. Many other stains can be performed on paraffin sections, as indicated in individual cases. In a low-power view of the paraffin section (see the first image below), the myofibers are seen in longitudinal section, forming an array of fibers lined up in parallel. At high power (see the second image below) in normal myofibers, the striations, which are formed by the sarcomeres, are readily demonstrated. One of the earliest changes in myofiber necrosis is loss of the striations. On occasion, this subtle but important finding may be the only pathologic change in a sample.

Normal muscle. Hematoxylin and eosin (H&E) paraffin section shows the fibers aligned parallel to each other in longitudinal section. Most of the nuclei are myofiber nuclei, but some are also capillary endothelial cell nuclei. A paraffin section provides better preservation of cytologic detail than frozen material, so it improves identification of cells involved in inflammatory disorders. Detailed structure of vascular walls can be seen in paraffin sections. This section is usually larger than a frozen section and therefore offers more material for examination.

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Normal muscle. High power hematoxylin and eosin (H&E) paraffin section shows myofibers in longitudinal section. Striations produced by the sarcomeres are clearly visible. One of the earliest signs of myofiber necrosis is the loss of these striations.

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At the ultrastructural level, as seen by electron microscopy (EM), normal muscle in longitudinal section (see the following image) exhibits a remarkable architectural order. The myofibrils are the contractile machinery of the cell and are arranged in units, the sarcomeres. The boundary of each is a thin dark line, the Z-disk or Z-band. This is the anchor for the thin filaments, of which actin is the major constituent.

The thin filaments are best seen in the pale gray zones of the sarcomere, known as the I band, adjacent to each Z-disk. The broad darker gray central region of each sarcomere is the A-band, formed mostly by the overlap of the thick myosin filaments and the thin filaments. In the center of each sarcomere is a thin dark band termed the M-band, flanked by thin pale H-zones, where the thick and thin filaments do not overlap.

Normal muscle. Electron photomicrograph of skeletal muscle in longitudinal section shows the pleasing ultrastructural organization of internal cytoplasmic contents of the cell. Sarcomeres are seen as units bounded by thin, dark lines (Z-bands). Broad, pale gray zones are I-bands, which are formed by predominantly thin actin filaments. Broad, dark gray areas are A-bands formed by the overlap of thick myosin and thin filaments. Thin, pale lines are in the central region of sarcomeres, where only thick filaments are present. Between myofibrils in the intermyofibrillar network, the cell contains glycogen, lipid, mitochondria, and triads. Mitochondria are dark, ovoid structures found mostly next to the I bands. Triads, located at A-I junctions, are better seen on the next image than in the present image.

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Between the myofibrils, the sarcoplasm contains the intermyofibrillar network. Mitochondria are the moderately dense oval structures located adjacent to the I-bands (pale gray zones). At high power (see the image below), glycogen in the intermyofibrillar network can be seen as dark granular material distributed diffusely through this area. The triads are also visible. Each triad is formed by a segment of the T-tubule flanked on either side by the lateral sacs of the sarcoplasmic reticulum.

The T-tubule is continuous with the sarcolemma, which is the plasma membrane of the myofiber, from which it rapidly transmits the muscle cell action potential throughout the cell. When the muscle cell is at rest, calcium is sequestered from the myofibrils by the sarcoplasmic reticulum. Excitation transmitted from the myofiber surface by the T-tubule to the sarcoplasmic reticulum is responsible for the intracellular release of calcium required for contraction.

Normal muscle. High-power electron photomicrograph shows two triads in the middle third of the picture. They are composed of two lateral sacs, which are expanded regions of sarcoplasmic reticulum, located on either side of a thin T-tubule. The T-tubule is continuous with the sarcolemma at the surface of the muscle cell. Triads are seen at the junction of the pale gray I-bands and the dark gray A-bands. Several ovoid mitochondria are noted. Pinpoint granular material is glycogen.

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Distinguishing type 1 and type 2 myofibers is often possible based on their ultrastructural appearances. The ultrastructural specializations are correlated with their functional roles. Type 1 myofibers (see the first image below), the highly oxidative myofibers, contain abundant, fairly large, prominent mitochondria and abundant lipid. The mitochondria are the ovoid structures, and the fat is contained in pale gray homogeneous round structures. Type 2 myofibers (see the second image below), which rely heavily on anaerobic metabolism, contain smaller, less abundant and less prominent mitochondria. Glycogen is abundant, and lipid is more difficult to find in type 2 myofibers than in type 1 myofibers.  These two images are from two adjacent myofibers in one muscle biopsy.

Normal muscle. Electron micrograph of a type 1 myofiber shows abundant and fairly large mitochondria. Round, pale gray fairly homogeneous bodies adjacent to the mitochondria are lipid droplets, which are abundant in type 1 myofibers compared with type 2 myofibers shown in the following image.

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Normal muscle. Electron photomicrograph of a normal type 2 myofiber shows the small, less conspicuous mitochondria and low lipid content of type 2 fibers compared with the type 1 myofiber shown in the previous image. The myofiber in this image is from the same muscle biopsy as the myofiber in the preceding image.

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The preceding presentation of the histologic and ultrastructural features of normal skeletal muscle has been illustrated by images taken of muscle biopsies that are technically excellent. The biopsies were performed properly and the performance of the laboratory technologists was excellent in all of these cases. If either the biopsy or processing procedure is technically deficient, the histologic and ultrastructural features of the sample might not be maintained, which could potentially interfere with diagnosis.

A muscle biopsy should be performed carefully to avoid excessive mechanical trauma to the muscle. The orientation of the myofibers should be maintained. Contraction of the muscle should not be permitted. Electrocautery should be avoided. Please refer to the companion article, Muscle Biopsy and Clinical and Laboratory Features of Neuromuscular Disease, to view two images of electrocautery-induced artifactual changes in a muscle biopsy.

For those planning a muscle biopsy, there are two very important points: (1) A muscle biopsy should be performed by an individual who has knowledge of what is required and (2) the specimen should be sent to a pathology laboratory specialized for the processing of muscle biopsy specimens.

For information on the proper performance of a muscle biopsy, please see Muscle Biopsy and Clinical and Laboratory Features of Neuromuscular Disease.

Examples of Suboptimal Handling

The following biopsies were performed by individuals who did not follow the optimal procedures. Compare the appearances of improperly handled specimens with those of properly handled specimens shown in the preceding sections.

The specimen shown in the following image arrived at the laboratory stuck to dry ice. This improper handling caused uneven freezing of the specimen and freeze artifact, resulting in disruption of the sarcoplasmic features and a loss of information about the state of the myofibers.

Improper handling of a muscle biopsy sample. This hematoxylin and eosin (H&E) section is from a muscle sample that arrived in the laboratory stuck to dry ice; this improper handling caused uneven freezing of the sample. Compare this with the normal structure of muscle in H&E–stained sections of muscle that were properly handled. This error can interfere with diagnosis.

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The image below is from a case in which the muscle specimen was immersed in very cold fixative without prior immobilization by a clamp. This allowed the muscle to hypercontract, producing contraction bands. Contraction band artifact can make it difficult or even impossible to detect relatively mild or subtle pathological features in myofibers that may be of diagnostic importance. Contraction bands can sometimes be associated with myofiber necrosis, although this occurrence is probably more common in cardiac muscle than skeletal muscle, where contraction bands are not often found as a sign of myofiber necrosis. In the case shown below, the finding of contraction bands is an artifact and has no bearing on the diagnosis. 

Improperly handled muscle biopsy sample; hematoxylin and eosin (H&E) paraffin section. This specimen was dropped into cold fixative in the operating room without first immobilizing it at rest length. The result was artifactual hypercontraction of the myofibers, that disrupts the architectural pattern of myofibers, which could interfere with the visibility of potentially diagnostically significant findings in myofibers. It might potentially raise concern for acute infarction of muscle.

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The following image is an electron micrograph of a specimen of muscle in which the surgeon was instructed to mince the muscle sample before submitting it in glutaraldehyde. The photograph demonstrates the serious disruption of the normally orderly ultrastructural architecture of the myofiber caused by this procedure.

Improperly handled muscle biopsy sample; electron micrograph. The surgeon was instructed to mince the muscle and then place it in glutaraldehyde in the operating room, rather than immobilizing it at rest length prior to fixation. Compare the internal architectural disarray of this image with the ultrastructural appearance of muscle that has been properly handled in the section above, Ultrastructure of Normal Skeletal Muscle.

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In the 3 examples above, improper handling of the muscle specimen at the time of biopsy in the operating room could have made diagnosis impossible. Fortunately, in each of these examples, arriving at a diagnosis was still possible.

This article has presented the normal structure, histology and ultrastructure of skeletal muscle, as seen in biopsies that have been performed to evaluate for possible neuromuscular disease. The photomicrographs provide excellent examples of biopsies that have been obtained and processed optimally. This article also includes some examples of biopsies that have not been optimally obtained (but nonetheless were diagnostically useful) to contrast with the ideal appearance of skeletal muscle.  This also helps to emphasize the importance of proper handling and technique and its relationship to the quality of a muscle biopsy, which is directed at those physicians who will be involved in planning or performing muscle biopsies.

In addition, this article provides a limited introduction to the correlation of muscle structure with function to assist with comprehension of basic muscle physiology needed for assessment of the various stains and preparations used in neuromuscular pathology and for understanding the clinical manifestations of some neuromuscular disorders. Finally, the article serves as a foundation to facilitate learning about the clinical presentation of neuromuscular disease and the pathology of skeletal muscle in neuromuscular diseases, as well as serves to demonstrate the need for proper performance of muscle biopsies.

To read further on these topics, please see Muscle Biopsy and Clinical and Laboratory Features of Neuromuscular Disease and Skeletal Muscle Pathology.