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KINESIOLOGY
MUSCULOSKELETAL
SYSTEM
Foundations for Physical Rehabilitation
Donald A. Neumann, PT, PhD
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A n A ffilia te of E lse v ie r
www.elsevierhealth.com
R e c o m m e n d e d S h e lv in g C la s s ific a tio n
P h ysical Therapy
O ccu p a tio n a l Therapy
P h ysical R eh ab ilita tio n
9 780815
163497
C e te .V e
M 4 -1 2 K
KINESIOLOGY
of th
MUSCULOSKELETAL
SYSTEM
Foundations
fo r Physical Rehabili
Artwork by
E l is a b e t h
E.
Ro w a n ,
BSc , BMC
M Mosby
A fi
Affiliate of Elsevier
A B O U T
T H E
A U T H O R
Donald A. Neumann
Donald Neumann began his career in 1972 as a licensed, physical therapy assistant in
Miami, Florida. In 1976, he received a Bachelor of Science degree in physical iherapy
from th University of Florida. By 1986, he received both Master of Science and PhD
degrees from th University of Iowa. His areas of graduate study included Science
education, exercise Science, and kinesiology. While a graduate student at th University
ot Iowa, Donald received th Mary' McMillan Scholarship Award from th American
Physical Therapy Association (APTA).
Donald accepted his tirsi job as a staff physical therapist in 1976, at Woodrow
Wilson Rehabilitation Center in Virginia, vvhere he specialized in th treatment of
persons with spinai cord injuries. Because of his interest in teaching, he became th
Coordinator of Clinical Education within th Physical Therapy Department at this
facility. To this day, Dr. Neumann remains involved in th rehabilitation of persons
with spinai cord injuries. In 2002, he produced a series of educational videos funded
by th Paralyzed Veterans Association. The videos describe many of th kinesiologic
principles used to enhance th movement potential in persons with quadriplegia.
Since finishing graduate school in 1986, Donald has been on faculty at th Depart
ment of Physical Therapy at Marquette University in Milwaukee. His primary areas of
teaching are kinesiology, anatomy, and spinai cord injury rehabilitation. In 1994, Dr.
Neumann received Marquette Universitys Teacher of th Year Award. In 1997, th
APTA awarded Dr. Neumann th Dorothy E. Baethke Eleanor J. Carlin Award for
Excellence in Academic Teaching. He has also presented numerous seminars on th
clinical relevance of kinesiology to a wide range of health care professionals. In 2002,
Dr. Neumann was awarded a Fulbright Scholarship to teach Kinesiology in Lithuama
and Hungary.
Dr. Neumann has received funding by th National Arthritis Foundation to conduct
research that focused on th biomechanics of th hip joint. He studied methods of
protecting an unsiable or a painful hip from potentially large and damaging forces. In
1989, he was th frst recipient of th Steven J. Rose Endowment Award for Excellence
in Orthopedic Physical Therapy Research. In 1991, he received th Eugene Michels
New lnvestigator Award from th APTA. In 2000, Dr. Neumann received th APTAs
Jack Walker Award for th best article on clinical research published in Physical
Therapy in 1999. Dr. Neumann is currently an Associate Editor of th Journal o f
Orthopaedic & Sports Physical Therapy.
viii
About th Author
About th Illustrations
Most of ihe more than 650 illustrations that appear within this volume are originai,
produced by th combined efforts of Donald Neumann and Elisabeth Rowan. The
illustrations were first conceptualized by Dr. Neumann and then rendered by Ms.
Rowan with meticulous attention to detatl. As a team, Don and Elisabeth met weekly
for 6V2 years to complete this project. Dr. Neumann States that The artwork really
drove th direction of much of my writing. I really needed to understand a particular
kinesiologic concept at its most essential level in order to effectively explain lo Elisa
beth what needed to be illustrated. In this way, th artwork kepi me honest; I wrote
only what 1 truly understood.
Neumann and Rowan produced two primary forms of artwork for this text (see th
following samples). Elisabeth depicted th anatomy of bones, joints, and muscles by
hand, creating very detailed pen-and-ink drawings (Fig. 1). These drawings starled
Fibrous
digitai
sheaths
Collateral ligaments
(cord and
accessory parts)
Palmar plates
digita!
sheath
Flexor
digitorum
protundus
tendon
Deep transverse
metacarpal
Flexor
digitorum
superficialis
tendon
FIGURE 1
FIGURE 2
IX
A. J
o sep h
h r e lk e ld
, PT, Ph D
a v id
A. B
r o w n
, PT, P
eb o r a h
A. N
a w o c zen sk t
, PT, P
Xll
Aboul th Contributo
G
uy
G. Sim
o n ea u
, PT, Ph D, A T C
e v i e w e r s
Ann M. Brophy, PT
NovaCare Outpatient Rehabilitation
Milwaukee, WI
Am a Carlisle, MPT
Physical Therapy Department
Zablocki VA Medicai Center
Milwaukee, W1
Leah Cartwright, PT
Physical Therapy Department
Zablocki VA Medicai Center
Milwaukee, WI
Jerem y Karman, PT
Physical Therapy Department
Sports Medicine Institute
Aurora Sinai Medicai Center
Milwaukee, WI
Michelle Lanouette, PT, MS
Physical Therapy Department
Zablocki VA Medicai Center
Milwaukee, WI
Paula M. Ludewig, PT, PhD
Program in Physical Therapy
University of Minnesota
Minneapolis, MN
Jo n D. Marion, OTR, CHT
Marshfield Clinic
Marshfield, WI
Brenda L. Neumann, OTR, BC1AC
Clinic for Neurophysiologic Leaming
Milwaukee, WI
Jan et Palmatier, PT, MHS, CHT
Work Injury Care Center
Gtendale, WI
Randolph E. Perkins, PhD
Physical Therapy and Celi and
Molecular Biology
Northwestern University Medicai
School
Chicago, IL
Christopher M. Powers, PT, PhD
Department of Biokinesiology and
Physical Therapy
University of Southern California
Los Angeles, CA
Kathryn E. Roach, PT, PhD
Division of Physical Therapy
University of Miami School of
Medicine
Coral Gables, FL
M ichelle G. Schuh, PT, MS
Department of Physical Therapy and
Program in Exercise Science
Marquette University
Milwaukee, WI
xiii
XIV
Revicwers
o r e w o r d
R E F A C E
Kinesiology is th study of human movement, typically pursued within th context of sport, art, or medicine. To varytng degrees, Kinesiology o f th Musculoskeletal System: Foundations fo r Physical Rehabilitation, relates to all three areas. It is
intended, however, primarily as a foundation for th practice
of physical rehabilitation. The phrase physical rehabilitation"
is used in a broad sense, referring to therapeutic efforts that
restore optimal physical function. Although kinesiology can
be presented from many different angles, I and my contributing authors have focused primarily on th mechanical interactions between th muscles and joints of th body. These
interactions are described for normal movement and, in th
case of disease, trauma, or otherwise altered tissue, for abnormal movement. I hope that this textbook provides a
valuable educational resource for a wide range of health- and
medical-related professions, both for students and clinicians.
This textbook places a large emphasis on th anatomie
detail of th musculoskeletal System. By applying surprisingly few principles of physics and physiology, th reader
should be able to mentally transform a static anatomie image
into a dynamic, three-dimensional, and relatively predictable
movement. The illustrations created for Kinesiology of th
Musculoskeletal System are designed to encourage this mental
transformation. This approach to kinesiology reduces th
need for rote memorization and favors reasoning based on
mechanical analysis. This type of reasoning can assist th
clinician in developing proper evaluation, diagnosis, and
treatment related to dysfunction of th musculoskeletal Sys
tem.
The completion of this textbook represents th synthesis
of more than 25 years of experience as a physical therapist.
This experience includes a rich blend of clinical, research,
and teaching activities that are related, in one form or another, to kinesiology. Although I was unaware of it at th
time, my work on this textbook began th day 1 prepared
my first kinesiology lecture as a college professor at Marquette University in 1986. Since then, 1 have had th good
fortune of being exposed to intelligent and motivated stu
dents. Their desire to learn has continuali)' fueled my ambidon to teach. As a way to encourage my students to listen
actively rather than to transcribe my lectures passively, 1
developed an extensive set of kinesiology lecture notes. Year
after year, my notes evolved, forming th blueprints of this
text. Now complete, this text embodies my knowledge of
kinesiology' as well as my experiences while teaching th
subject. The book contains many clear and exciting illustra
tions, as well as a compelling list of references that support
my teaching.
The organization of this textbook reflects th overall pian
of study used in my two-semester kinesiology course sequence. The textbook contains 15 chapters, divided into four
major sections. Section l provides th essential topics of kine
siology, including an introduction to terminology and basic
ncepts, a review of basic structure and function of th
musculoskeletal System, and an introduction to biomechanical and quantitative aspeets of kinesiology-. Sections II
through IV present th specific anatomie details and kinesi
ology of th three major regions of th body. Section II
focuses entirely on th upper extremity, from th shoulder
to th hand. Section III covers th kinesiology' of th axial
skeleton, which includes th head, trunk, and spine. A spe
cial chapter is included within this section on th kinesiol
ogy of mastication and ventilation. Section IV presents th
kinesiology of th lower extremity, from th hip to th ankle
and foot. The final chapter in this section, th Kinesiology of
Walking, functionally integraies and reinforces much of th
kinesiology of th lower extremity.
This textbook is specifically designed for th purpose of
teaching. To that end, concepts are presented in layers, starting with Section 1. which lays much of th scientific founda
tion for chapters contained in Sections li through IV. The
material covered in these chapters is also presented layer by
layer, building both clarity and depth of knowledge." Most
chapters begin with osteology th study of th morphology
and subsequent function of bones. This is followed by arthrology th study of th anatomy and th function of th
joint, including th associated periarticular connective tissues. Included in this study is a thorough description of th
regional kmematics, both from an arthrokinematic and osteokinematic perspective.
The most extensive component of most chapters within
Sections II through IV highlights th muscle and joint interac
tions. This topic begins by describing th skeletal attachments of muscles within a region, including a summary of
th innervation to both th muscles and th joint structures.
Once th shape and physical orientation of th muscles are
established, th mechanical interplay between th muscles
and th joints is presented. Topics presented include
strength and movement potential of muscles, muscular-produced forces imposed on joints, intermuscular and interjoint
synergies, important functional roles of muscles, and functional relationships that exist between th muscles and underlying joints.
Clinical examples and corollaries are used extensively
throughout to help narrow th gap between what is often
taught in th classroom and what is experienced in clinical
practice. Clinical examples pertain lo a wide range of issues,
typically relating to how pathology, trauma, and other conditions contribute to functional impairments or limitations.
Discussions are frequenti)' related to issues involving prolonged immobilization of limbs; instability or malalignment
of joints; abnormal posture or limited range of motion; paralysis and muscular force imbalances; and trauma and inflammation of th muscles, joints, and periarticular connec
tive tissues.
Severa] special educational features are included Tore
most are th high quality anatomie and kinesiologic illustra
tions. This artwork is intended to excite and simplify, withXVII
xviii
Fruiate
c k n o w l e d g m e n t s
activities, including proofreading, verifying references or concepts, posing for or supplying photographs, taking x-rays,
and providing elencai assistance. 1 am grateful to Santana
Deacon, Monica Diamond, Gregg Fuhrman, Barbara Haines,
Douglas Heckenkamp, Lisa Hribar, Erika Jacobson, Davin
Kimura, Stephanie Lamon, John Levene, Lorna Loughran,
Christopher Melkovitz, Melissa Merriman, Alexander Ng, Mi
chael OBrien, Ellen Perkins, Gregory Rajala, Elizabeth Shanahan, Pamela Swiderski, Donald Taylor, Michelle Tremi,
Stacy Weineke, Sidney White, and David Williams.
1 am very fortunate to have this forum to acknowledge
those who have made a sigmficant, positive impact on my
professional life. In a sense, th spirit of these persons is
interwoven within this text. I acknowledge Shep Barish for
first inspiring me to teach kinesiology; Martha Wroe for
serving as an enduring role model for my praedee of physi
cal therapy; Claudette Finley for providing me with a rich
foundation in human anatomy; Patty Altland for emphasizing
to Darrell Bennett and myself th importance of noi limiting
th functional potential of our patients; Gary Soderberg for
his overall mentorship and finn dedication to principle;
Thomas Cook for showing me that all this can be fun; and
Mary Pat Murray for setting such high standards for kinesiol
ogy education at Marquette University.
I wish to acknowledge several special people who have
influenced this project in ways that are difficult to describe.
These people include family, old and new friends, profes
sional colleagues, and, in many cases, a combination thereof.
I thank th following people for their sense of humor or
adventure, their loyalty, and their intense dedication to their
own goals and beliefs, and for their tolerance and under
standing of mine. For this 1 thank my four siblings, Chip,
Suzan, Nancy, and Barbara; Brenda Neumann, Tad Hardee,
David Eastwold, Darrell Bennett, Tony Homung, Joseph Berman, Robert Morecraft, Bob Myers, Debbie Neumann, Guy
Simoneau, and th Mehlos family, especially Harvey, for al
ways asking Hows th book coming?
Finally, 1 want to thank all of my students, both past and
present, for making my job so rewarding.
DAN
CO N T E N T S
S E C T 1O N I
Getting Started
h a p t e r
D o n a l d A. N e u m a n n , PT, P h D
C
h a p t e r
25
A. J o s e p h T h r e l k e l d , PT, P h D
C
h a p t e r
41
D a v id A. B r o w n , PT, P h D
C
i i a p t f. r
Biomechanical Principles
56
D e b o r a h A. N a w o c z e n s k i , PT, P h D
D o n a l d A. N e u m a n n , P T , P h D
Ap
86
p e n d ix
11
E C T 1O N
Upper Extremity
C hapter
89
Shoulder Complex
91
D o n a l d A. N e u m a n n , PT, P h D
C i i ap
tfr 6
133
D o n a l d A. N e u m a n n . PT, P h D
C hart e r
Wrist
172
D o n a l d A, N e u m a n n , PT, P h D
C 11AP 1 l r
Hand
194
D o n a l d A. N e u m a n n , PT, P h D
A
S EC T IO N
III
Axial Skeleton
C
iiap
i i
249
Axial Skeleton: Osteology and Arthrology
251
D o n a l d A. N e u m a n n , P T , P h D
C
i i a p t f r
IO
311
D o n a l d A. N e u m a n n , PT, P h D
C
h a p t e r
11
352
D o n a l d A. N e u m a n n , PT, P h D
A P P L NDI X 1 I 1 381
XXI
XXI1
Conienti
S f. c
IV
t i o n
Lower Extremity
c: h a p u r
12 Hip
385
387
D o n a l d A. N e u m a n n , PT, Ph D
ha pt
13 Knee
434
D o n a l d A. N e u m a n n , PT, Ph D
C hapter
477
D o n a l d A. N e u m a n n , PT, P h D
C ha pi Lr
13
Kinesioogy o f Walking
523
G u y G. S im o n e a u , PT, Ph D, ATC
A P P E ND I X I V 5 7 0
Index
577
ll:sJ
1 /
:/
E C T I O N
Essential Topics of
Kinesiology
\ /
MF
Axis of
rotatimi O
S E C T 1 O N
Essential Topics of
Kinesiology
C hapter 1 Getting Started
C hapter 2: Basic Structure and Function of th Joints
C l lAiTKR 3: Muscle: Ultimate Force Generator in th Body
C h a p t e r 4 Biomechanical Principles
Section I is divided into four chapters, each describing a different topic related to
kinesiology. This section provides th background for th more spedire kinesiologic
discussions of th various regions of th body (Sections 11 to IV). Chapter 1 provides
introductory terminology and biomechanical concepts related to kinesiology. Chapter 2
presents th basic anatomie and functional aspeets of joints th pivot points for
movement of th body. Chapter 3 reviews th basic anatomie and functional aspeets of
skeletal muscle th source that produces active movement and stabilization of th
joints. More detailed discussion and quantitative analysis of many of th biomechanical
principles introduced in Chapter 1 are provided in Chapter 4.
l.W
h a p t e r
Getting Started
Donald A. Neum an n , PT, Ph D
TOPICS
What Is Kinesiology?, 3
KINEMATICS, 3
Translation Compared with Rotation, 4
Osteokinematics, 5
Planes of Motion, 5
Axis of Rotation, 5
Degrees of Freedom, 6
Osteokinematics: A Matter of
Perspective, 7
Arthrokinematics, 8
AT
GLANCE
Spin, 10
Motions That Combine Roll-and-Slide
and Spin Arthrokinematics, 10
Predicting an Arthrokinematic Pattern
Based on Joint Morphology, 10
Close-Packed and Loose-Packed
Positions at a Joint, 11
KINETICS, 11
Musculoskeletal Forces, 12
Musculoskeletal Torques, 15
INTRODUCTION_____________________________
What Is Kinesiology?
The origins of th word kinesiology are from th Greek kinesis, to move, and ology, to study. Kinesiology o f th Musculo
skeletal System: Foundations /o r Physical Rehabilitation serves as
a guide to kinesiology by focusing on th anatomie and
biomechanical interactions within th musculoskeletal S y s
tem. The beauty and complexity of these interactions have
tnspired th work of two great artists: Michelangelo Buonar
roti ( 1 4 7 5 -1 5 6 4 ) and Leonardo da Vinci (1 4 5 2 -1 5 1 9 ).
Their work likely inspired th creation of th classic text
Tabulae Sceleti et Musculorum Corporis Fiumani published in
1747 by th anatomist Bernhard Siegfried Albinus ( 1 6 9 7 1770). A sample of this work is presented in Figure 1 - 1 .
The primary intent of this book is to provide students
and clinicians with a foundation fo r th practice of physical
rehabilitation. A detailed review of th anatomy of th mus
culoskeletal system, including tts innervation, is presented as
a background to th structural and functional aspeets of
movement and their clinical applications. Discussions are
presented on both normal conditions and abnormal conditions that result from disease and trauma. A sound understanding of kinesiology allows for th development of a rational evaluation, a precise diagnosis, and an effective
treatment of musculoskeletal disorders. These abilities represent th hallmark of high quality for any health professional
engaged in th practice of physical rehabilitation.
KINEMATICS
Kinematics is a branch of mechanics that describes th motion
of a body, without regard to th forces or torques that may
produce th motion. In biomechanics, th term body is
used rather loosely to describe th entire body, or any of its
parts or segments, such as individuai bones or regions. In
generai, there are two types of motions: translation and rota
tion.
3
Secticm I
B S ALBINI
FIGURE 1 -1 . An illustration from th anatomy text Tabulae Sceleti et Musculorum Corpons Humani (1747) by
Bernhard Siegfried Albinus.
Chapter 1
Getting Started
1
1
:
1
1
1
ft = .305 m
.0254 m
in
in = 2 .54 cm
yd = .91 m
mi = 1.61 km
rad == 57.3 degrees
Osteokinematics
PLANES OF MOTION
Osteokinematics describes th motion o j bones relative to th
three Cardinal (principal) planes of th body: sagittal, frontal,
and horizontal. These planes of motion are depicted in th
context of a person standing in th anatomie position as in
Figure 1 - 4 . The sagittal piane runs parallel to th sagittal
suture of th skull, dividing th body into right and left
sections; th frontal piane runs parallel to th coronai suture
of th skull, dividing th body into front and back sections.
The horizontal (or transverse) piane courses parallel to th
horizon and divides th body into upper and lower sections.
A sample of th terms used io describe th dilferent osteoki
nematics is shown in Table 1 - 2 . More specific terms are
defned in th chapters that describe th various regions of
th body.
AXIS OF ROTATION
Section I
DEGREES OF FREEDOM
Degrees o f freedom
ments allowed at
degrees of angular
mensions of space.
Frontal Piane
Horizontal Piane
Many of th terms are specific to a particular region of th body. The thumb, for example, uses differem terminology.
Knee flexion
A Tibial-on-femoral perspective
S ection J
Arthrokinematics
TVPICAL JOINT M0RPH0L0GY
Arthrokinematics describes th motion that occurs between th
articular surfaces of joints. As described further in Chapter 2,
th shapes of th articular surfaces of joints range from fiat
io curved. Most joint surfaces, however, are curved, with
one surface being relatively convex and one relatively con
cave (Fig. 1 - 7 ) . The convex-concave relationship of most
articulations improves their congruency, inereases th surface
area for dissipating contact forces, and helps guide th mo
tion between th bones.
Roll-and-Slide Movements
One primary way that a bone rotates through space is by a
rolling of its articular surface against another bones articular
sui face. The motion is shown for a convex-on-concave sur
face movement at th glenohumeral joint in Figure 1 -9A .
The contracting supraspinatus muscle rolls th convex humeral head against th slight concavity of th glenoid fossa.
Iti essence, th roll directs th osteokinematic path of th
abducting shaft of humerus.
A rolling convex surface typically involves a concurrent,
oppositely directed slide. As shown in Figure 1 -9A , th
inferior-directed slide of th humeral head offsets most of th
potential superior migration of th rolling humeral head. The
offsetting roll-and-slide kinematics is analogous to a tire on a
car that is spinning on a sheet of ice. The potential for th
Defnition
Roll*
Slidet
Spin
Analogy
A tire rotating across a stretch of pavemenl.
A stationary tire skiddmg across a stretch of icy
pavement.
A rotating toy top on one spot on th floor.
Chapter 1
Cetting Started
Convex-on-concave arthrokinematics
Concave-on-convex arthrokinematics
B
FIGURE 1 -8 . Three fundamental movements between joint surfaces: roll, slide, and spin. A, Convex-on-concave
arthrokinematics; B, concave-on-convex arthrokinematics.
changing th leverage of th muscles that cross th glenohumeral joint. As shown in Figure 1 -9 A , th concurrent roll
and slide maximizes th angular displacement of th abducting humerus, and minimizes th net translation between
joint surfaces. This mechanism is particularly important in
joints in which th articular surface area on th convex
member exceeds that of th concave member.
10
Seniori l
FIGURE 1-9. Arthrokinematics ai ihe glenohumeral joint during abduction. The glenoid fossa is concave, and ihe humeral head is
convex. A, Roll-and-slide anhrokinematics lypical of a convex articular surface moving on a relatively siationary concave articular
surface. B, Consequences of a roll occurring without a sufficieni off-setting slide.
Spin
Another primary way that a bone rotates is by a spinning of
its articular surface against th articular surface of another
bone. This occurs as th radius of th forearm spins against
th capitulum of th humerus during pronation of th fore
arm (Fig. 1 - 1 0 ). Other examples include internai and external rotation of th 90-degree abducted glenohumeral joint
and llexion and extension of th hip. Spinning is th pri
mary mechanism for joint rotation when th longitudinal
Mediai
epicondyle
Chapter 1
Getting Storteci
11
FIGURE 1-11. Extension of th knee demonstrates a combinaiion of roll-and-slide with spin arthrokinematics. The
femoral condyle is convex, and th tibial plateau is slightly concave. A, Femoral-on-tibial (knee) extension. B, Tibial-onfemoral (knee) extension.
KINETICS
Kinetcs is a branch of mechanics that describes th effect of
forces on th body. The topic of kinetics is introduced here
as it applies to th musculoskeletal System. A broader and
more detailed explanation of this subject matter is provided
in Chapter 4.
From a kinesiologic perspective, a force can be considered
as a push or pul that can produce, arrest, or modify
movemenl. Forces therefore provide th ultimate impetus for
movement and stabilization of th body. As described by
Newtons second law, th quantity of a force (F) can be
measured by th product of th mass (m) that received th
push or pul, multiplied by th acceleration (a) of th mass.
The formula F = ma shows that, given a Constant mass, a
force is directly proportional to th acceleration of th
12
Section I
S P E C I A L
F O C U S
U N LO AD ED
T E N S IO N
Musculoskeletal Forces
IMPACT OF FORCES ON THE MUSCULOSKELETAL
TISSUES: INTRODUCTORY CONCEPTS AND
TERMINOLOGY
The same forces that move and stabilize th body also have
th potential to deform and injure th body. The manner by
which forces or loads are most frequently applied to th
musculoskeletal System is illustrated in Figure 1 - 1 2 . (See
th glossary at th end of this chapter for definitions.)
Healthy tissues are able to resist changes in their shape. The
tension force that stretches a healthy ligament, for example,
is met by an intrinsic tension generated within th elongated
tissue. Any tissue weakened by disease or trauma may not
be able to adequately resist th application of th loads
depicted in Figure 1 - 1 2 . The proximal femur weakened by
osteoporosis, for example, may fracture from th impact of a
tali owing to compression or torsion (twisting), shearing or
bending of th neck of th femur.
The inherent ability of connective tissues to tolerate loads
.a n be observed experimentally by plotting th amount of
torce required to deform an excised tissue.6 Figure 1 - 1 3
3hnw s th tension generated by an excised ligament that has
beer. s tic tc h e d to a point of mechanical failure. The vertical
axis ot th graph is labeled stress, a term that denotes th
internai resistance generated as a tissue resists its deforma-
SHEAR
T O R S IO N
C-hapter I
Cetting Starteli
13
FIGURE 1-13. The stress-strain curve of an excised ligament is shown that has been stretched io a
poini of mechanical failure (disruption). The ligament is considered an elastic tissue. Zone A shows
th nonlinear region. Zone B (elastic zone) shows th linear relationship between stress and strain,
demonstrating th stiffness of th tissue. Zone C indicates th mechanical property of plasticity.
Zones D and E demonstrate th points of progressive mechanical failure of th tissue. (Modifted
with permission from Neumann DA: Arthrokinesiologic considerations for th aged aduli. In
Guccione AA (ed): Geriatrie Physical Therapy, 2nd ed. Chicago, Mosby-Year Book, 2000.)
14
Sechoti I
S P E C I A L
F O C U S
1 - 2
Chapter 1
Getting Started
15
Magnitude
Direction (line-of-force or line-of-gravity)
Sense
Point of application
Musculoskeletal Torques
Forces exerted on th body can have two outcomes. First, as
depicted in Figure 1- 16A, forces can potemially translate a
body segment. Second, th forces, if acting at a distance from
'r
Externalforce
External force
16
Chapter 1
Getting Staned
Isometric
Concentric
17
Eccentric
FIGURE 1-18. Three types of muscle activation are shown as th pectoralis major actively attempts to intemally rotate th shoulder
(glenohumeral) joint. In each of th three illustrations, th internai torque is th product of th muscle force (red) and its moment
arm; th external torque is th product of th force in th cable (gray) and its moment arm. Note that th external moment arm and,
therelore, th external torque is different in each illustration. A, Isometric activation is shown as th internai torque matches th
external torque. B, Concentric activation is shown as th internai torque exceeds th external torque. C, Eccentric activation is shown
as th external torque exceeds th internai torque. (Vectors are not drawn to scale.)
18
Section I
Frontal Piane
Horizontal Piane
Sagittal Piane
Superior view
Lateral view
B
Posterior view
FIGURE 1-19. The multiple actions of th posterior deltoid are shown at th glenohumeral joint. A, Adduction in th
frontal piane. B, External rotation in th horizontal piane. C, Extension in th sagittal piane. The internai moment arm
is shown extending from th axis of rotation (small cirele through humeral head) io a perpendicular intersection with
th muscles hne-of-force.
b ib l io t e c a
CASA DE ESTUDIOS
PROVIDENCIA
Chapter I
Musculoskeletal Levers
THREE CLASSES OF LEVERS
A lever is a simple machine consisting of a rod suspended
across a pivot point. The seesaw is a classic example of a
iever. One function of a lever is to convert a force into a
torque. As shown in th seesaw' in Figure 1 - 2 1 , a 672-N
(about 150-lb) man sitting 0.91 m (about 3 fi) from th
pivot point produces a torque that balances a boy weighing
Getting Started
19
First-Class Lever. As depicted in Figure 1 - 2 1 , th firstclass lever has its axis of rotation positioned between th
opposing forces. An example of a frst-class lever in th body
is th head-and-neck extensor muscles that control th pos
ture of th head in sagittal piane (Fig. 1 -2 2 A ). As in th
seesaw' example, th head is held in equilibrium when th
product of th muscle force (MF) multiplied by th internai
moment arm (IMA) equals th product of head weight (F1W)
multiplied by its extemal moment arm (EMA). In first-class
levers, th internai and extemal forces typically act in similar
FIGURE 1-21. A seesaw is shown as a typical first-class lever. The body weight of th man (BWm) is 672 N (about 150 lb). He is
sitting .91 m (about 3 ft) from th pivot point (D). The body weight of th boy (BWb) is only .336 N (about 75 lb). He is sitting
1.82 m (about 6 ft) from th pivot point (D,). The seesaw is balanced since th clockwise torque produced by th man is equal
in magnitude to th counterclockwise torque produced by th boy: 672 N X .91 m = 336 N X 1.82 m.
First-class Iever
Sccond-class Iever
Third-class Iever
Data for third-class Iever:
Muscle force (MF) = unknown
External weight (EW) = 66.7 N (15 Ibs)
Internai moment arm (IMA) = 5.0 cm
External moment arm (EMA) = 35.0 cm
FIGURE 1-22. Anatomie examples are shown of frst- (A), second- (B), and third- (C) class levers. (The
vectors are not drawn to scale.) The data contained in th boxes to th right show how io calcitiate th
muscle force required lo maintain static rotary equilibrium. Note ihai th mechanical advantage is
indicated in each box. The muscle activation is isometric in each case, with no movement occurring at
th joint.
20
Chapter 1
Cetting Storteci
21
22
Section 1
S P E C I A L
F O C U S
A surgeon may perform a muscle-tendon transfer operation as a means to partially restore th loss of internai
torque at a joint. Consider, for example, complete paralysis of th elbow flexor muscles following poliomyelitis.
Such a paralysis can have profound functional consequences, especially if it occurs bilaterally. One approach
to restoring elbow flexion is to surgically reroute th fully
innervated triceps tendon to th anterior side of th el
bow (Fig. 1-23). The triceps, now passing anteriorly to th
medial-lateral axis of rotation at th elbow, becomes a
flexor instead of an extensor. The length of th internai
moment arm for th flexion action can be exaggerated, if
desired, by increasing th perpendicular distance between
th transferred tendon and th axis of rotation. By in
creasing th muscle's mechanical advantage, th activated muscle produces a greater torque per leve! o f elus
ele force. This may be a beneficiai outeome, depending
on th specific circumstances of th patient.
An important mechanical trade-off exists whenever a
muscle's mechanical advantage is increased. Although a
greater torque is produced per level muscle force, a given
amount of muscle shortening results in a reduced angular
displacement o f th joint. As a result, a full muscle contraction may produce an ampie torque, however, th joint
may not complete its full range of motion. In essence, th
active range of motion "Iags" behind th muscle contraction. The reduced angular displacement and velocity of
th joint may have negative functional consequences. This
mechanical trade-off needs to be considered before th
muscles internai moment arm is surgically exaggerated.
Often, th greater torque potential gained by increasing
GLOSSARY
Acceleration: change in velocity of a body over time, expressed in linear (m/s2) and angular (/s2) terms.
Accessory movements: slight, passive, nonvolitional movements allowed in most joints (also called joint play).
Chapter 1
Getting Storteci
23
24
Section 1
Stress: force generateci as a tissue resists deformation, divided by its cross-sectional area falso called pressure).
Synergists: two muscles that cooperate to execute a particular movement.
Tensioni application of one or more forces that pulls apart
or separates a material. (Also called a distraction force.)
Used to denote th internai stress within a tissue as it
resists being stretched.
Torque: a force multiplied by its moment arm; tends io
rotate a body or segment about an axis of rotation.
Torsioni application of a force that twists a material about
its longitudinal axis.
Translation: linear motion in which all parts of a rigid body
move parallel to and in th same direction as every other
point in th body.
Vector: quantity, such as velocity or force, that is completely
specified by its magnitude and direction.
Velocity: change in position of a body over rime, expressed
in linear (m/s) and angular (degrees/s) terms.
Viscoelasticity: property of a material expressed by a changing stress-strain relationship over time.
Weight: gravitational force acting on a mass.
SUMMARY
Many of th basic biomechanical principles and essentia
terms and concepts used to communicate th subject matter
REFERENCES
1 Brand PW: Clinica! Biomechanics of thc Hand. Si Louis, CV Mosby
1985
2. Bynum EB, Barrack RL, Alexander AH: Open versus closed chain ktnetic exercises after anierior cruciale iigament reconstruction. Am J
Sports Med 23:401-406, 1995.
3. Fitzgerald GK: Open versus closed kineiic chan exercises: Afler anteiior
cruciale ligament reconstructive surgery Phys Ther 77:1747-1754
1997.
4. Gowitzke BA, Milner M: Scienufic Bases of Human Movement, 3rd ed.
Baltimore, Williams & Wilkins, 1988.
5. Hardee EB 111: Personal commumcation. Afton, VA, 2002.
6. Neumann DA: Arthrokinesiologic considerations for th aged adult. In
Gucaone AA: Geriatrie Physical Therapy, 2nd ed. Chicago, Mosby-Year
Book, 2000
7. Nordin M, Frankel VH: Basic Biomechanics of th Musculoskeletai Sys
tem, 2nd ed. Philadelphia, Lea & Febiger, 1989.
8. Panjabi MM, Whtte AA: Biomechanics in th Musculoskeletai System
New York, Churchill Livingstone, 2001.
9. Rodgers MM, Cavanagh PR: Glossary of biomechanical terms, concepts,
and units. Phys Ther 64:1886-1902, 1984.
10. Steindler A: Kinesiology' of th Human Body: Under Normal and Pathologtcal Conditions. Springfield, Charles C Thomas, 1955.
11. Williams PL, Bannister LH, Berry M, et al: Gray's Anatomy, 38th ed.
New York, Churchill Livingstone, 1995.
h a p t e r
TOPICS
CLASSIFICATION AND DESCRIPTION OF
JOINTS, 25
Classification Based on Anatomie
Structure and Movement Potential, 25
Synarthrosis, 25
Amphiarthrosis, 25
Diarthrosis: The Synovial Joint, 26
Classification of Synovial Joints Based on
Mechanical Analogy, 27
Simplifying th Classification of Synovial
Joints: Ovoid and Saddle Joints, 30
AT
GLANCE
AXIS OF ROTATION, 31
BI0L0GIC MATERIALS THAT FORM
CONNECTIVE TISSUES WITHIN
JOINTS, 31
Fibers, 31
Ground Substance, 32
Cells, 32
TYPES OF CONNECTIVE TISSUES THAT
FORM THE STRUCTURE OF JOINTS, 32
INTRODUCTION
A joint is th junction or pivot point between two or more
bones. Movement of th body as a vvhole occurs primarily
through rotation of bones about individuai joints. Joints also
transfer and dissipate forces owing to gravity and muscle
activation throughout th body.
Arthrology th study of th classification, structure, and
function of joints is an important foundation for th overall study of kinesiology. Aging, long-term immobilization,
trauma, and disease all affect th structure and ultimate
lunction of joints. These factors also significantly influence
th quality and quantity of human movement.
This chapter focuses on th generai anatomie structure
and function of joints. The chapters contained in Sections II
io IV review th specific anatomy and detailed function of
th individuai joints throughout th body. This detailed information is a prerequisite for th effective rehabilitation of
persons with joint dysfunction.
SYNARTHROSIS
A synarthrosis is a junction between bones that is held together by dense irregular connective tissue. This relatively
rigid junction allows little or no movement. Examples of
synarthrodial joints include th sutures of th skull, th teeth
embedded in th mandible and maxillae, th distai tibiofibular joint, and th interosseous membranes of th forearm
and leg. The epiphysial piate of a growing bone is also
classified as a synarthrodial joint by some.27 Because th
function of an epiphysis is skeletal growth rather than motion, this classification is not used here.
The function of a synarthrosis is to bind bones together
and io transmit force from one bone to th next with mini
mal joint motion. A synarthrodial joint allows forces to be
dispersed across a relatively large area of contaci, thereby
reducing th possibility of injury.
AMPHIARTHROSIS
An amphiarthrosis is a junction between bones that is formed
primarily by fibrocartiiage and/or hyaline cartilage. Perhaps
th most familiar example of an amphiarthrosis is th interbody joint of th spine. This joint uses an intervertebral disc
25
26
Seniori I
TA B L
Available Motion
Primary Funclion
Examples
Synarthrosis
Negligible
Sutures of th skull
Teeth embedded in sockets of
th maxillae and mandible
Interosseous membrane of th
forearm and leg
Distai tibiofibular joint
Amphiarthrosis
Minimal to moderate
Provides a combination of
relatively restrained
movement and shock
absorption
Diarthrosis
(synovial joint)
Extensive
Provides th primary
pivot points for move
ment of th musculoskeletal System
Glenohumeral joint
Tibiofemoral (knee) joint
Interphalangeal joint
Apophyseal (facet) joint of th
spine
and embedded nucleus pulposus to provide a rugged, resilient cushion that absorbs and disperses forces between adjacent vertebrae. Other examples of amphiarthrodial joints are
th pubic symphysis and th manubriosternal joint. These
joints allow relatively restrained movements. They also transmit and disperse forces between bones.
Blood
vessel
Ligament
Nerve
Fibrous
capsule
Synovial
membrane
Fat pad
Muscle
Synovial
fluid
Meniscus
Articular
cartilage
Bursa
Tendon
2-1. Elements
associated
with a typical diarthrodial (synovial)
joint. The synovial plicae are not depicted.
FIGURE
Chapter 2
27
Mechanical Analog
Anatomie Examples
Hinge joint
Door hinge
Humeroulnar joint
Interphalangeal joint
Pivot joint
Door knob
Ellipsoid joint
Radiocarpal joint
Ball-and-socket joint
Glenohumeral joint
Coxofemoral (hip) joint
Piane joint
Intercarpal joints
Iniertarsal joints
Saddle joint
Condyloid joint
Metacarpophalangeal joint
Tibiofemoral (knee) joint
28
Section I
FIGURE 2-2. A hinge joint (A) is illustrateci as analogous to th humeroulnar joint (B). The axis of rotation (i.e., pivot point) is represented by th pin.
Chapter 2
29
Ulna
Radius
Lunate
Scaphoid
30
Section 1
seen in th gentle undulations that characterize th intercarpal and intertarsal joints. These joints produce complex multiplanar movements that are tnconsistent with their simple
planar mechanical classification. To circumvent this difficulty, a simplified classification scheme recognizes only two
arttcular forms: th ovoid joint and th saddle joint (Fig.
2 - 9 ) . Essentially all synovial joints with th notable exception of planar joints can be categorized under this scheme.
An ovoid joint has paired mating surfaces that are imperfectly spherical, or egg-shaped, with adjacent parts possessing a changing surface curvature. In each case, th articular
surface of one bone is convex and th other is concave.
A saddle joint has been previously described. Each member presents paired curved surfaces that are opposite in di
rection and oriented at approximately 90 degrees to each
other. This simplified classification System allows th generalization to th arthrokinematic patterns of movement as a
roll slide, or spin (see Chapter 1). This generalization is
used throughout this text.
Chapter 2
31
AXIS OF ROTATION
Fibers
32
Section I
Ground Substance
Collagen and elastin fibers are embedded within a watersaturated matrix known as ground substance. The ground
substance of joint tissues is made of glycosaminoglycans
(GAGs), water, and solutes. The GAGs are highly branched
and negatively charged amino sugars that are strongly
bonded with water. Structurally, th GAGs resemble long
botile brushes that are strongly hydrophilic due to their
negative charge (Fig. 2 - 1 1 ) . Water provides a fluid medium
for diffusion of nutrients within a tissue. In addition, water
assists with th mechanical properties of tissue. The tendency of GAGs to imbibe and hold water causes th tissue
to swell. Swelling is limited by embedded collagen or elastin
fibers anchored into an adjacent supporting structure, such
as bone or dense bands of fibers. The interaction between
th restraining fibers and th swelling GAGs provides a turgid structure that resists compression, much like a balloon
or a water-filled mattress. An example of such a structurally
dynamic material is articular cartilage. This important tissue
provides an ideal surface covering for joints and is capatile
of dispersing th millions of repetitive forces that have an
impact on joints throughout a lifetime.
Cells
The cells within connective tissues of th joints are responsible for maintenance and repatr. In contrast to skeletal mus
cle cells, these cells do not confer significant mechanical
properties on th tissue. Damaged or aged components are
removed, and new components are manufactured and remodeled. Cells of connective tissues of th joints are gener
ali}- sparse and interspersed between th strands of fibers or
embedded deeply in regions of high GAG coment. This
sparseness of cells in conjunction with limited blood supply
often results in poor or incomplete healing of damaged or
injured joint tissues.
Chapter 2
Anatomie
Location
Fibers
Ground Substance
(GAGs + Water +
Solutes)
Cells
Mechanieal
Specialization
Clinical
Correlate
Dense irregular
connective tis
sue
Ligament: Binds
bones together
and restrains unwanted movement at th
joints; resists tension in several directions
Tendon: attaches
muscle to bone
Rupture of th tar
erai collateral
ligament complex of th ankle can lead to
medial-lateral
instability of
th talocrural
joint.
Articular cartilage
Covers th ends
of articulating
bones in synovial joints
Moderate number of
cells; flattened
near th articular
surface and
rounded in
deeper layers of
th cartilage
Fibrocartilage
Composes th intervertebral
discs and th
disc within th
pubic symphysis
Forms th intraarticular discs
(menisci) of
th tibiofemoral, stemoclavicular, acromioclavicular,
and distai radioulnar joints
Forms th la
brum of th
glenoid fossa
and th acetabulum
Multidirectional
bundles of
type 1 collagen
Moderate number of
cells that are
rounded and
dwell in cellular
lacunae
Tearing of th intervertebral
disc can allow
th centrai nucleus pulposus
to escape (herniate) and press
on a spinai
nerve or nerve
root.
Bone
Forms th inter
nai levers of
th musculoskeletal System
Specialized ar
rangement of
type 1 collagen
to form lamellae and osteons and lo
provide a
framework for
hard minerai
salts (e.g., calcium crystals)
Moderate number of
flattened cells embedded between
th layers of col
lagen; many progenitor cells
found on th fi
brous exiemal
(periosteal) and
internai (endosteal) layers.
Resists deformation;
strongest resis
t a l e is applied
againsl compres
sive forces due to
body weight and
muscle force.
Provides a rigid
lever to trattsmit
muscle force lo
move and stabilize th body
Osteoporosis of
th spine produces a loss of
bony Lrabeculae
and minerai
coment in th
vertebral body
of th spine;
may result in
fractures of th
vertebral body
during walking
or even coughing.
33
34
Section i
Articular Cartilage
Articular cartilage is a specialized type of hyaline carti
lage that forms th load-bearing surface of joints. Artic
ular cartilage covering th ends of th articulating bones
has a thickness that ranges from 1 to 4 mm in th areas of
low compression force and 5 to 7 mm in areas of high
compression.16'25 The tissue is avascular and aneural. Un
like regular hyaline cartilage, articular cartilage lacks a
perichondrium. This allows th opposing surfaces of th
cartilage to form ideal load-bearing surfaces. Similar to
periosteum on bone, perichondrium is a layer of connective
tissue that covers most cartilage. lt contains blood vessels
and a ready supply of primitive cells that maintain and
Parallel bundles
of collagen
Irregularly arranged bundles
of collagen fibers
Fibrocytes
TENDO N
L IG A M E N T
Chapter 2
35
Articular surface
STZ
10 20
( % %)
Middle zone
(40%
60%)
(30%
40%)
n ------------ Calcified zone
Subchondral bone
Chondrocyte
Tidemark
Cancellous bone
FIGURE 2-13. Two schematic diagrams of hyaline articular cartilage. A, The organization of th cells (chondrocytes) is
shown located through th ground substance of th articular cartilage. The flattened chondrocytes near th articular
surface are within th superficial tangential zone (STZ) and are oriented parallel to th joint surface. The STZ comprises
about 10% to 20% of th articular cartilage thickness. The cells in th middle zone are more rounded and become
increasingly arranged in columns in th deep zone. A region of calcified cartilage (calcified zone) joins th deep zone with
th underlying subchondral bone. The edge of th calcified zone that abuts th deep zone is known as th tidemark and
forms a diffusion barrier between th articular cartilage and th underlying bone. Nutrients and gasses must pass from
th synovial fluid through all th layers of articular cartilage to nourish th chondrocytes including th cells at th base
of th deep zone. The diffusion process is assisted by intermittent compression (milking action) of th articular
cartilage. B, The organization of th collagen fibers in articular cartilage is shown in this diagram. In th superficial
tangential zone, th collagen is oriented parallel to th articular surface, forming a fibrous grain that helps resisi
abrasion of th joint surface. The fibers become less tangential and more obliquely oriented in th middle zone, finally
becoming almost perpendicular to th articular surface in th deep zone. The deepest fibers are anchored into th
calcified zone to help lie th cartilage to th underlying subchondral bone.
though articular cartilage is capable of normal mainte:ance and replenishment of its matrix, significant damage io
idult articular cartilage is often repaired very poorly or noi
ai all.
Fibrocartilage
As its name implies, fibrocartilage has a much higher fiber
coment than other types of cartilage. The tissue functionally
shares properties of both dense irregular connective tissue
and articular cartilage. Dense bundles of type I collagen
travel in many directions with a moderate number of GAGs.
As depicted in Figure 2 - 1 4 , round chondrocytes reside
within lacunae that are embedded within a dense collagen
network.
Fibrocartilage forms much of th substance of th inter
vertebral discs, th labrum, and th discs located within th
pubic symphysis and other joints of th extremities (for
example, th menisci of th knee). These structures help
support and stabilize th joints, as well as dissipate compres
sion forces. As depicted in Figure 2 -1 4 A , th menisci of th
- nee dissipate compression forces by spreading out radially.
The dense interwoven collagen fibers also allow th tissue to
resist tensile and shearing forces in multiple planes. Fibro
cartilage is therefore an ideal shock absorber in regions of
th body that are subject to high multidirectional forces.
This function is best realized in th menisci of th knee and
th intervertebral discs of th spinai column.
The perichondrium surrounding fibrocartilage is poorly
36
Section 1
COMPRESSION
of fibrocartilage
FIGURE 2-14. Hstologic organization of fibrocartilage. A, This is a
cut section of a compresseti, wedge-shaped piece of fibrocartilage
(i.e., meniscus) taken from th knee. The meniscus partially dissipates th compression force by spreading out in a radiai direction
indicated by arrows. B, Schematic illustration of a microscopie sec
tion from th middle of th sample of fibrocartilagmous meniscus.
Bone
Bone provides rigid support to th body and equips th
muscles of th body with a System of levers. The outer
cortex of th long bones of th adult skeleton has a shaft
composed of thick, compact cortical bone (Fig. 2 - 1 5 ) . The
ends of long bones, however, are lined with a thin layer of
compact bone that covers an interconnecting network of
cancellous bone. Bones of th adult axial skeleton, such as
th vertebral body, possess an outer shell of cortical bone
that is filled with a supporting core of cancellous bone.
The structural subunit of cortical bone is th osteon or
Haversian System, which organizes th collagen fibers, predominantly type I, into a unique series of concentric spirals
that form lamellae (Fig. 2 - 1 6 ) . The matrix of bone contains
calcium phosphate crystals, which allow bone to accept tremendous compressive loads. The cells of bone are confined
within narrow lacunae (i.e., spaces) positioned between th
lamellae of th osteon. Because bone deforms very little,
blood vessels can pass into its substance from th outer
Chapter 2
37
Outer circumferentiol
lamellae
Interstitiol
lomellae^,
Inner
circumferentiol
lamelloe---------
Haversian systems
(osteons)
Periosteum
Trobeculoe
of cancellous
bone
Blood vessels
Sharpey's
fibers
Endosteum
Hoversion
canals
Volkmanns
canols
EFFECTS OF AGING
Aging is associated with histologic changes in connective
tissue that, in tum, may produce mechanical changes in
joint function. The rate and process by which tissue ages is
highly individuai and can be modified, positively or negatively, by th types and frequency of activities and by a
host of medicai and nutritional factors.2 In th broadest
sense, aging is accompanied by a slowing of th rate of fiber
and GAG replacement and repair.2-11 The effects of microtrauma can accumulate over time to produce subclinical
damage that may progress to a structural failure or a measurable change in mechanical properties. A clinical example
of this phenomenon is th age-related deterioration of th
ligaments and capsule associated with th glenohumeral
joint. Reduced structural support provided by these tissues
may eventually culminate in tendonitis or tears in th rotator
cuff muscles.22
Aging also influences th mechanical resilience of GAGs
within connective tissue. The GAG molecules produced by
aging cells are fewer in number and smaller in size than
those produced by young cells.2'11 This change in th GAGs
results in decreased water-binding capacity that reduces th
hydration of connective tissues. The less hydrated tissue has
38
Secion I
JOINT PATHOLOGY
Trauma to connective tissues of a joint can occur from a
single overwhelming event (acute trauma), or in response lo
an accumulation of lesser injuries over an extended period
(chronic trauma). Acute trauma often produces detectable
pathology. A torn or severely stretched ligament or joint
capsule causes an acute inflammatory reaction. The joint
may also become structurally unstable when damaged con
nective tissues are noi able to restrain th naturai extremes
of motion.
Joints frequently affected by acute traumatic instability are
typically associated with th longest lever arms of th skele
ton and. therefore, are exposed to high external torques. For
this reason, th tibiofemoral, talocrural, and glenohumeral
joints are frequently subjected to acute ligament damage
with resultant instability.
Acute trauma can also result in intraarticular fractures
involving articular cartilage and subchondral bone. Careful
reduction or realignment of th fractured fragments helps to
restore th smooth, low-friction sliding functions of articular
surfaces. This is criticai to maximal recovery of function.
Although th bone adjacent to a joint has excellent ability to
repair, th repair of fractured articular cartilage is often in
complete and produces mechanically inferior areas of th
joint surface that are prone to degeneration. Focal increases
in stress due to poor surface alignment in conjunction with
impaired articular cartilage strength can lead to post-traumatic osteoarthritis.
The repair of damaged fibrocartilaginous joint structures
Chapter 2
39
FIGURE 2-17. A scanning electron micrograph of th articular surface of a femoral condyle of a knee in a 71-year-old embalmed
male cadaver, contrasting levels of degeneration. A, Articular cartilage from an apparently normal-looking region of th lateral fem
oral condyle. The wavy but smooth surface texture represents th
normal aging process in hyaline cartilage (200X). B. Fibrillateci
articular cartilage from a region of th mediai femoral condyle from
th same knee as A (225 X). C, Higher magnifcation of B (600 X)
shows th roughened or frayed region of th cartilage (arrowheads).
The lower case c" indicates an exposed chondrocyte, which is
usually concealed within th matrix. (Micrographs courtesy of Dr.
Robert Morecraft, University of South Dakota School of Medicine,
Sioux Falls, South Dakota.)
SUMMARY
Joints provide th foundation of musculoskeletal rnotion and
permit th stablity and dispersion of internai and external
forces. Several classifcation schemes exist to categorize joints
and to allow discussion of their mechanical and kinematic
characteristics. Motions of anatomie joints are often complex
owing to their asymmetrical shapes and incongruent sur-
40
Section l
26. Swann DA, Silver FH, Slayter HS, et al: The molecular structure and
h a p t e r
Muscle:
TheUltimate Force
Generator in th Body
David A. Br o w n , PT, P h D
TOPICS
.'USCLE AS A SKELETAL STABILIZER:
LENERATING AN APPROPRIATE AMOUNT
OF FORCE AT A GIVEN LENGTH, 41
Muscle Morphology: Shape and Structure,
41
Muscle Architecture, 42
Muscle and Tendon: Generation of Force,
44
Passive Length-Tension Curve, 44
Active Length-Tension Curve, 45
AT
GLANCE
INTRODUCTION
Stable posture results from a balance of competing forces.
Movement, in contrast, occurs when competing forces are
unbalanced. Force generateci by muscles is th primary
means for controlling th intricate balance between posture
and movement. Muscle Controls posture and movement in
two ways: (1) stabilization of bones, and (2) movement of
bones.
This chapter considers th role of muscle and tendon in
generating, modulating, and transmitting force. These functions are necessary to fix and/or move skeletal structures.
How muscle stabilizes bones by generating an appropriate
amount of force at a given length is investigated. Force
generation occurs both passively (i.e., by a muscles resistance to stretch) and, to a much greater extern, actively (i.e.,
by active contraction).
Ways in which muscle modulates or Controls force so that
bones move smoothly and forcefully are investigated next.
Normal movement is highly regulated and refined, regardless
of th infinite environmental constraints imposed on a given
task.
The approach herein enables th student of kinesiology to
understand th multiple roles of muscles in controlling th
postures and movements that are used in daily tasks. In
addition, th clinician also has th information needed to
form clinical hypotheses about muscular impairments that
interfere with functional activities. This understanding can
42
Secdon I
Muscle morphoiogy
Strutturai organization of skeletal muscle
Connettive tissues vvithin muscle
Physiologic cross-sectional area
Pennation angle
Passive length-tension curve
Parallel and series elastic components of muscle and tendon
Elastic and viscous properties of muscle
Attive length-tension curve
Histology of th muscle fber
Total length-tension curve
Isometric force and internai torque-joint angle curve development
Mechanical and physiologic properties affecting internai
torque-joint angle curve
Muscle Architecture
Each muscle and its tendons have different architecture and,
as a consequence, are able to generate different ranges of
force. Understanding muscle architecture allows th prediction of th functional role of a given muscle. Physiologic
cross-sectional area and pennation angle are major determinants of th range and th force produced by th muscle.
The physiologic cross-sectional area of a muscle reflects th
amount of contrattile protein available to generate force.
Generally speaking, th cross-sectional area (cm2) of a fusi
form muscle is determined by dividing th muscles volume
(cm 1) by its length (cm). A fusiform muscle with many thick
fbers has a greater cross-sectional area than a muscle of
similar length and morphoiogy with fewer thinner fbers.
Maximal force potential o f a muscle is, therefore, proportional to
th sum o f th cross-sectional area o f all th fbers. Under
normal conditions, th thicker th muscle, th greater th
force potential. Measuring th cross-sectional area of a fusi
form muscle is relatively simple because all fbers run paral-
Pennate
Fusiform
Chapter 3
A
43
M uscle Belly
Epim ysium
Fasciculus
B M uscle Fiber
Sarcolem m a
Nucleus
Mitochondrion
Endom ysium
FIGURE 3-2. Three seis of connective tissue are identified in muscle. A, The muscle belly is enclosed within th
epimysium and then further subdivided into individuai fasciculi by th perimysium. B, Each muscle fiber contains
myofibrils that are enclosed within th endomysium. (Modified from Williams PL: Grays Anatomy: The Anatomical
Basis of Medicine and Surgery, 38th ed. New York, Churchill Livingstone, 1995.)
44
Section I
within Muscle
1.
2.
3.
4
5.
Bone
Paralel E C
Chapter 3
45
Increasing stretch
FIGURE 3 -5 . A generalized passive length-tension curve is shown.
As a muscle is progressively stretched, th tissue is slack during its
irutial shortened lengths until it reaches a criticai length where it
begins to generate tension. Beyond this criticai length, th tension
builds as an exponential function.
I bands
H band
M lines
Z discs
Region where successive actin filaments mesh together. Z disc helps anchor th thin filaments.
46
Section 1
FIGURE 3-6. Electron micrograph of muscle myofibrils demonstrates th regularly banded organization of
myofilaments actin and myosin. (From Fawcett DW: The Celi. Philadelphia, W.B. Saunders, 1981.)
eie. Each individuai banding unit is called a sarcomere, extending from one Z disc to th next. The sarcomere is
considered th active force generator of th muscle ftber. By
understanding th active contractile events that take place in
H
band
Z
disc
A
band
l
band
FIGURE 3-7. Detail of th regular, banded organization of th myofibril showing th position of th A band, 1 band, H band, and Z
disc. The expanded view of a single sarcomere demonstrates how
th actin and myosin filaments contribute to th banded organiza
tion. (Modified from Guyton AC, Hall JE: Textbook of Medicai
Physiology, lOth ed. Philadelphia, W.B. Saunders, 2000. Modified
in Guyton from Fawcett DW: Bloom and Fawcett: A Textbook of
Histology. Philadelphia, W.B. Saunders, 1986. Originai art by Sylvia
Colarci Keene. Reproduced by permission of Edward Arnold Lim
ited.)
Chapter 3
Troponin
47
/Tropomyosin
Myosin
Myosin head
(cross-bridge)
Actin filament
48
Section 1
Elbow Flexors
HipAbductors
FIGURE 3-12. Internai torque versus joint angle curve of two mus
cle groups under isometric, maximal effort conditions is shown.
The shape of th curves are very different for each muscle group.
A, Internai torque of th elbow flexors is greatest at an angle of
about 75 degrees of flexion, B, Internai torque of th hip abduttore
is greatest at a frontal piane angle of - 1 0 degrees (i.e., 10 degrees
toward adduction).
Chapter 3
49
------------------------------------------------------------------------------>
The torque-angle curve of th hip abductors demonstrated in Figure 3 - 1 2 B depends primarily on muscle
length, as shown by th linear reduction of maximal torque
produced at progressively greater abduction angles of th
hip. Regardless of th muscle group, however, th combination of high total muscle force (based on muscle length) and
great leverage (based on moment arm length) results in th
greatest relative internai torque.
In summary, isometric torque measures differ depending
upon th joint angle, regardless of maximal effort. It is therefore important that clinical measurements of isometric torque
include th joint angle so that future comparisons are. valid.
The testing of isometric strength at different joint angles
enables th characterizing of th functional range of a mus-
TABLE 3 - 4 . Clinical Examples and Consequences of Changes in Mechanical or Physiologic Variables that
Influence th Production of Internai Torque
Changed Variable
Clinical Example
Surgical displacement of
greater trochanter to increase th internai mo
ment arm of hip abduc
tor muscles
Patellectomy following se
vere fracture of th pa
tella
Physiological: Significantly de
creased muscle length at
th lime of neural activa
tion
50
Section I
FIGURE 3-14. Relationship between muscle load (extemal resistance) and maximal shortening velocity. (Velocity is equal to ihe
slope of th dotted line.) At a no load condition, a muscle is
capable of shortening at a high velocity. As a muscle becomes
progressively loaded, th maximal shortening velocity decreases.
Eventually, at some very large load, th muscle is incapable of
shortening and th velocity is 0. (Redrawn from McComas AJ:
Skeletal Muscle: Form & Function. Champaign, IL, Human Kinetics, 1996.)
Chapter 3
angular velocity relationship. This type of data can be denved through isokinetic dynamometry (see Chapter 4).
The inverse relationship between a muscles maximal
force potential and its shortening velocity is related to th
concept of power. Power, or th rate of work, can be expressed as a product of force times contraction velocity, (i.e.,
th area under th curve on th righi hand side of Figure 3 15). A Constant power output of a muscle can be sustained
by increasing th load (resistance) while proportionately decreasing th contraction velocity, or vice versa. This is very
similar in concept to switching gears while riding a bicycle.
51
RECRUITMENT
Recruitment refers to th initial activation of a specific set of
motoneurons resulting in th generation of action potentials
that excite target muscle fibers. The nervous System recruits
a motor unit by altering th voltage potential across th
alpha motoneuron membrane surface. The facilitation process is th summation of competing inhibitory and facilitatory input that ultimately results in a threshold action poten
tial that drives th motoneuron to propagate excitation to
th muscle fibers. Once th muscle fiber is activated, a
muscle twitch occurs and a small amount of force is gener
ated. Table 3 - 5 lists th major sequence of events underly
ing muscle fiber activation. By recruiting more motoneurons,
more muscle fibers are activated, and, therefore, more force
is generated within th whole muscle.
Motoneurons come in different sizes and are connected
with muscle fibers of different contractile characteristics (Fig.
3 - 1 7 ) . The size of th motoneuron influences th order
with which it is recruited by th nervous System (i.e.,
smalier motoneurons will be recruited before larger moto
neurons). This principle is called th Henneman Size Principle. It was first experimentally demonstrated and developed
by Elwood Henneman in th late 1950s.7 The principle accounts for th orderly recruitment of motor units, specified
by size, which allows for smooth and controlled force development.
52
Section l
RATE CODING
After a specific motoneuron is recruited, muscle force is
modulated by an increase in th rate of its excitation, a
Muscle Fatigue
As muscle fibers are repeatedly stimulated, th force generated by a fiber eventually decreases, even though th rate of
activation remains th same (Fig. 3 - 1 9 ) . The decline in
muscle force under conditions of stable activation is termed
muscle fatigue. In theory, muscle fatigue can occur from
metabolic processes, or from failure in physiologic mechanisms involved with th neuromuscular System. Normally,
th nervous System compensates for muscle fatigue by either
increasing th rate of activation (i.e., rate coding) or recruiting assistive motor units (i.e., recruitment), thereby maintaining a stable force evel. When an exercising muscle begins to fatigue and performance begins to degrade, a rest
period allows that muscle to rsum its norma] perfor
mance evel. The rest period that is required depends on
th type and intensity of th fatiguing contraction.1 For example, a muscle that is rapidly fatigued by high intensity
and short duration exercise recovers after a rest of seconds
to minutes. In contrast, a muscle that is slowly fatigued by
low intensity, long duration exercise requires up lo 24 hours
for recovery.
Fatigue involves a variety of elemenis located throughout
th neuromuscular System. It is convenient to think of fa
tigue as occurring primarily within centrai or peripheral
neuromuscular elements. Central fatigue may be affected by
psychological factors, such as sense of effort, and/or neurophysiological factors, such as descending control over interneurons and motoneurons located in th spinai cord. With
centrai fatigue, voluntary efforts at activating th motoneuron
pool become suboptimal when an individuai is asked to
generate a maximum muscle contraction.13 During a maxi
mal effort, th nervous System may initiate inhibitory pathways to prevent th efficient activation of motoneuron pools.
Chapter 3
53
54
Section I
FIGURE 3-19. Muscle fatigue is demonstrated by a reduction in force over a sustained isometric activation. As th
- ___
stonili continue over tinte, th force responses of th
' m muscle lessen.
Stimuli
Time
Chapter 3
The EMG signal requires processing to be useful for kinesiologic interpretation. Raw or raw-filtered signals refer to
th originai biphasic waveform that is picked up by th
electrode. Often, th raw signal is smoothed and/or integrated. Smoothing refers to th flattening of th peaks and
valleys that occurs in a biphasic electrical signal. Smoothing
is performed to allow moment-to-moment quantifcation of
th signal because it eliminates th transient changes in peak
values of th signal. Integration is a mathematica! lerm that
refers to measuring th area under th curve. This process
allows for cumulative EMG quantifcation or averaging EMG
over a fxed period of time. Signals that are smoothed and/or
integrated can be used in biofeedback devices, such as visual
meters or audio signals, and to drive other devices, such as
electrical stimulators, to assist in muscle activation at a pre
set threshold of voluntary activation.
When comparing th intensity of a processed EMG signal
between different muscles, it is often necessary that th sig
nal be normalized to some common reference signal. This is
especially necessary when th magnitude of th EMG is
being compared between persons or between sessions, requiring that th electrodes be reapplied. One common
method of normalization involves referencing th raw EMG
signal from a muscle to th signal produced as a person
performs a maximal voluntary isometric contraction. Meaningful comparisons can then be made on th relative intensity,
expressed as a percent, of th muscles neural drive during
some activity.
The collection of EMG signals during movement, when
supplemented by kinematic and kinetic measures, can pro
vide a comprehensive method for analyzing how muscles
contribute to a movement. EMG can also provide insight
mto th neural control of purposeful movements. A clinician
can use EMG to aid in th understanding of physical impairments underlying dysfunctional movement. This understand
ing can then lead to identification of diagnoses associated
with movement dysfunction and to appropriate intervention
strategies.
REFERENCES
1. Andrews BJ: Reducing FES muscle [angue. In Pedotti A, Ferrarin M
(eds): Restoratton of Walking for Paraplegics. Amsterdam, los Press,
1992, pp 197-202.
2. Asmussen E. Muscle fatigue. Med Sci Sports Exerc 25:412-420, 1993
3. Brouwer B, Wheeldon RK, Stradiotto-Parker N, Alluni J: Reflex excitability and isometric force production in cerebral palsy; The effect of
serial casting. Dev Med Child Neurol 40:168-175, 1998.
4. Burke R, Levine D, Tsairis P, Zajac F: Physiological types and histochemical proflles in motor units of th cat gastrocnemius J Physiol
234:723-748, 1973.
5. Fitts RH, Metzger JM: Mechanisms of muscular fatigue. In PoortmansJR
(ed): Principles of Exercise Biochemtslry, 2nd revised ed. 1993, pp
248-268.
6. Fregly B, Zajac F: A state-space analysis of mechanical energy genera
tion, absorption, and transfer dunng pedaling. J Biomech 29:81-90,
1996.
7. Henneman E, Mendell LM: Functional organization of motoneuron pool
and its tnputs. In Brookhart, JM, Mountcastle, VB, Brooks, VB (eds):
Handbook of Physiology, voi. 2. Bethesda, American Physiological Soci
ety, 1981, pp 423-507'
8. Huxley H, Hanson J: Changes in th cross-striations of muscle during
9.
10.
11
12
13.
14.
15.
16
17.
18.
55
ADDITIONAL READINGS
Biewener A, Roberts T: Muscle and tendon contributions to force, work,
and elastic energy savnngs: A comparative perspective. Exerc Sport Sci
Rev 28:99-107, 2000.
Brown DA, Kautz SA: Increased workload enhances force output during
pedaling exercise in persons with poststroke hemiplegia. Stroke 29:598606, 1998.
Brown DA, Kautz SA: Speed-dependent reductions of force output in people
with poststroke hemiparesis. Phys Ther 79:919-930, 1999.
Enoka R, Fuglevand A: Motor unit physiology: Some unresolved issues.
Muscle Nerve 24:4-17, 2001.
Gordon A, Homsher E, Regnter M: Regulation of muscle contraction in
striated muscle. Physiol Rev 80:853-924, 2000.
Herzog W: Muscle properties and coordination during voluntaiy movement.
J Sports Sci 18:141-152, 2000.
Hill A: The heat of shortening and th dynamic constanls of muscle. Proc R
Soc Lond (Biol) 126:136-195, 1938.
Hof A, Van den BergJ: EMG to force processing 1: An electrical analogue of
th Hill muscle model. J Biomech 14:747-758, 1981.
Hof AL, Pronk CNA, Best JA: Comparison between EMG to force processing
and kinetic analysis for th calf muscle moment in walking and stepping.J Biomech 20:167-178, 1987.
Huijing PA: Muscle, th motor of movement: Properties in function, experiment and modelling. J Electromyogr Kinesiol 8:61-77. 1998.
Kautz S, Brown D: Relationships between timing of muscle excitation and
impaired motor performance during cyclical lower extremity movement
in post-stroke hemiplegia. Brain 121:515-526, 1998.
Komi PV: Stretch-shortening cycle: A powerful model to study normal and
fatigued muscle. J Biomech 33:11971206, 2000.
Lieber R, Friden J: Clinical significance of skeletal muscle architetture Clin
Orthop 383:140-151, 2001
Lippold O: The relationship between integrated action potentials in a hu
man muscle and its isometric tension. J Physiol 117:492-499, 1952
Siegler S, Hillslrom HJ, Freedman W, Moskowitz G: Effect of myoelectric
signal processing on th relationship between muscle force and pro
cessed EMG. Am J Phys Med 64:130-149, 1985.
Woods JJ, Bigland-Riichie B: Linear and nonlinear surface EMG/force rela
tionships in human muscles. Am J Phys Med 62:287-299, 1983.
h a p t e r
Biomechanical Principles
D eborah A. Na w o c z en sk i , PT, Ph D
Donald A. Neum ann , PT, P h D
TOPICS
NEWTON'S LAWS: APPLICATION TO
MOVEMENT ANALYSIS. 56
Newton's Laws of Motion, 57
Newtons First Law: Law of Inertia, 57
Newton's Second Law: Law of
Acceleration, 58
Force (Torque)-Acceleration
Relationship, 58
Impulse-Momentum Relationship, 60
Work-Energy Relationship, 60
Newton's Third Law: Law of ActionReaction, 62
INTRODUCTION TO MOVEMENT
ANALYSIS: SETTING THE BACKGROUND,
63
Anthropometry, 63
Free Body Diagram, 63
Initial Steps for Setting Up th Free
Body Diagram, 64
Reference Frames, 65
Representing Forces, 67
AT
GLANCE
Composition of Forces, 67
Resolution of Forces, 69
Contrasting Internai versus External
Forces and Torques, 69
Influence of Changing th Angle of th
Joint, 69
INTRODUCTION TO MOVEMENT
ANALYSIS: QUANTITATIVE METHODS OF
ANALYSIS, 76
Static Analysis, 77
Guidelines for Problem Solving, 77
INTRODUCTION
It can be overwhelming to consider all th factors that may
have an impact on human movement. And, many treatment
approaches used in physical rehabilitation depnd on an
accurate description of movement and a reliable assessment
of a persons response to intervention. The justification for
and th successful outcome of surgical and nonsurgical interventions are also frequently measured by changes in th
quality and quantity of movement. In response to these
factors, a variety of analysis techniques may be utilized to
assess movement, rangitig from visual observation to
sophisticated motion analyses and imaging techniques.
Most often, th complexity of movement analysis is simplified by starting with a basic evaluation of th forces on a
single rigid body segment. Newtons laws of motion help to
explain th relationship between forces and their impact on
individuai joints, as well as on total body motion. Even at
th basic level of analysis, this informatimi can be used to
understand mechanisms of injury, as well as to guide
56
Problem 1, 77
Solving for Internai Torque and Muscle
Force, 77
Solving for Joint Force, 78
Problem 2, 79
Solving for Internai Torque and Muscle
Force, 80
Solving for Joint Force, 80
Dynamic Analysis, 81
Kinematic and Kinetic Measurement
Systems, 81
treatment approaches. Technologic advances continue to enhance th ability to understand and influence human per
formance.
Chapter 4
Biomechanical Principles
57
Static equilibrium
Dynamic equilibrium
Inertia
Center of mass
Mass moment of inertia
Radius of gyration
Linear Componeni
Rotational Component
58
Section I
2F = m X a
The fact that p is squared in Equation 4.2 has imporiant
biomechanical implications. Consider, for example, that during th swing phase of walking th entire lower limb shortens owing to th combined movements of hip and knee
flexion and ankle dorsiflexion. A functionally shortened limb
reduces th average distance of th mass particles within th
limb relative to th hip joints medial-lateral axis of rotation.
The reduced mass moment of inertia reduces th force required by th hip flexor muscles to accelerate th limb
(Equation 4.3)
Chapter 4
59
Biomechanical Principles
determined using Equation 4.1 and substituting known values (see th box). Next, consider Y2 as th axis of rota
tion. The mass particles are distributed differenti if each
axis is considered separately. As seen in th calculations,
th mass moment of inertia, if considering Y2 as th axis,
is 5.5 times less than that if considering Y, as th axis.
One reason for th reduced moment of inertia is that th
M3 mass particle, which is coincident with th axis Y2,
offers zero resistance to th rotation of th rectangular
object. As a generai principle, therefore, th mass mo
ment of inertia about an axis of rotation that passes
through th center of mass of a body is always smaller
than th moment of inertia about any parallel axis.
Y2 axis
C n^ J
Each segment in th human body is made up of different tissues, such as bone, muscle, fat, and skin, and is
not of uniform density. This makes calculation of th
mass moment of inertia more challenging than th cal
culation of th mass. Values for th mass moment of
inertia for each body segment have been generated
from cadaver studies, mathematica! modeling, and various imaging techniques.2AW5
ST = 1 X a
(Equation 4.4)
60
A Tncreased angular
velocity
B Decreased angular
velocity
Impulse-Momentum Relationship
Additional relationships can be derived from Newtons second law through th broadening and rearranging of Equations 4.3 and 4.4. One such relationship is spectfted as th
impuise-momentum relationship.
Acceleration is th rate of ehange of velocity (Av/t). Substituting this expression for linear acceleration in Equation
4.3 results in Equation 4.5 (see th box). Equation 4.5 can
be further rearranged to Equation 4.6. The product of mass
and velocity on th right side of Equation 4.6 defines th
momentum of a moving body. Momentum describes th
quantity of motion possessed by a body. Momentum is generally represented by th letter p and is in units kgm/s. The
product of force and time on th left side of Equation 4 .6 is
called an impulse, and it measures what is required to ehange
th momentum of a body. The momentum of an object can
be changed by a large force delivered for a brief instant or a
The mass moment of inertia is taken under consideration in prosthetic design for th person with an amputation. The use of lighter components in foot prosthesis,
for example, not only reduces th overall mass of th
prosthesis, but also results in a ehange in th distribution of th mass to a more proximal location in th leg.
As a result, less resistance is imposed upon th remaining limb during th swing phase of gait. The benefit
of these lighter components is realized in terms of lessened energy requirements for th person with an amputation.
T = 1 A&i/t
(Equation 4.7)
Tt = I X
(Equation 4.8)
co
Work-Energy Relationship
To this point, Newtons second law has been described using
(1) th force (torque)-acceleration relationships (Equations
4.3 and 4.4), and (2) th impuise-momentum relationships
(Equations 4.5 through 4.8). Newtons second law can be
restated to provide a work-energy relationship. This third approach can be used to study human movement by analyzing
th extern to which a force or torque can move or rotate an
object over some distance. Work (W) in a linear sense is
equal to th product of th magnitude of th force (F) applied against an object and th distance that th object moves
in th direction of force while th force is being applied
(Equation 4.9 in box). If no movement occurs, no mechanical work is done. The most commonly used units to describe work are equivalent units: th Newton-meter (Nm)
and th joule (J). Similar to th linear case, angular work
can be defined as th product of th magnitude of th
torque (T) applied against th object, and th angular dis
tance in degrees or radians that th object rotates in th
direction of torque, while th torque is being applied (Equa
tion 4.10).
Chapter 4
a s an in d iv id u a i ran a c r o s s a
Biomechamcal Principles
61
t h p o s t e r i o r - d i r e c t e d i m p u ls e d u r in g in itia l f l o o r c o n t a c t
is n e g a t i v e , a n d t h a n t e r i o r - d i r e c t e d i m p u l s e d u r i n g p r o p u l s i o n is p o s i t i v e . If t h t w o i m p u l s e s (i.e., a r e a s u n d e r
th c u r v e s ) a r e e q u a l, t h n e t im p u ls e is ze ro , a n d t h e r e
is n o c h a n g e in t h m o m e n t u m o f t h S y s t e m . In t h i s
e x a m p l e , h o w e v e r , t h p o s t e r i o r - d i r e c t e d i m p u l s e is
g r e a t e r th a n th a n te rio r, in d ic a tin g t h a t th r u n n e r 's fo rw a r d m o m e n t u m is d e c r e a s e d .
f o r c e p i a t e e m b e d d e d in t h f l o o r . T h e c u r v e i s b i p h a s i c :
FIGURE 4-4. Graphic representation of th areas under a force-time curve showing th (A) posterior-directed
and (B) anterior-directed impulses of th horizontal component of th ground reaction force while running.
Work (W)
W (linear) = F X distance
(Equation 4.9)
W (angular) = T X degrees
(Equation 4.10)
62
S P E C I A L
F O C U S
T h e c o n c e p t o f a n g u l a r p o w e r is o f t e n u s e d a s a c l i n i ca l m e a su re of m u s c le p e rfo rm a n ce . The m e c h a n ic a l
p o w e r p r o d u c e d b y t h q u a d r i c e p s , f o r e x a m p l e , is
e q u a l to th n e t in te rn a i t o r q u e p r o d u c e d b y th m u s c le
tim e s th a v e r a g e a n g u la r v e lo c it y of k n e e e x te n s io n .
T h e p o w e r is o f t e n u s e d t o d e s i g n a t e t h n e t t r a n s f e r o f
e n e r g y b e t w e e n a c t iv e m u s c l e s a n d e x t e r n a l lo a d s .
an d d ia g n o s tic to o ls fo r c o m p a r is o n s of n o rm a l an d
p a th o lo g ic fu n c tio n .
Rotational Application
Physical
Measurement
Definition
Distance
Linear displacement
Meter (m)
Angular displacement
Velocity
Degrees ()*
/s
Acceleration
m/s2
/s2
Mass
kilogram (kg)
Not applicable
Mass moment of
inertia
Not applicable
Force
Torque
Not applicable
Units
Definition
Units
kgm2
Not applicable
A force times a moment arm;
mass moment of inertia times
angular acceleration
Impulse
Ns
Nms
Momentum
kgm/s
kgm2/s
Work
Nm (joules)
Nm (joules)
Power
Nm/s or J/s
(watts)
Chapter 4
Biomechanical Principles
63
Anthropometry
iGURE 4-5. The forces between th ground and foot are depicted
-tsring th early part of th walking cycle. The ground reaction
:>rces (red arrows) act superiorly and posteriorly, whereas th foot
nrces (black arrows) act inferiori}' and anteriorly.
odies interact simultaneously, and th consequence is speci:sd by th law of acceleration: XF = ma. That is, each body
-xperiences a different effect and that effect depends on its
mass. For example, a person who falls off th roof of a
second-story building exerts a force on th ground, and th
ground exerts an equal and opposi te force on th person.
Aecause of th discrepancies in mass between th ground
and th person, th effect, or acceleration experienced by th
rerson, is much greater than th effect experienced by th
ground. As a result, th person may sustain signifcant in-
y-
64
Section I
Chapier 4
Biomechanical Principles
65
FIGURE 4 8. Free body diagram isolating th System as a right arm and weight combmation: resultant
shoulder abductor muscle force (MF); glenohumeral joint reaction force (JRF); arm weight (AW); and load
weight (LW). The axis of rotation is shown as an open red circle at th glenohumeral joint. (Modified from
LeVeau BF: Williams & Lissner's Biomechanics of Human Motion, 3rd ed. Philadelphia WB Saunders
1992.)
REFERENCE FRAMES
In order to accurately describe motion or solve for unknown
forces, a reference frame and an associated coordinate System
need to be established. This information allows th position
and movement direction of a body, a segment, or an object
to be defined with respect to some known point, location, or
segments axis of rotation. If a reference frame and coordi
nate System are not identified, it becomes very difficult to
interpret and compare measurements in clinica] and research
settings.
A reference frame is arbitrarily established and may be
placed inside or outside th body. Reference frames used to
describe position or motion may be considered either rela
tive or global. A relative reference frame describes th posi
tion of one limb segment with respect to an adjacent seg
ment, such as th foot relative to th leg, th forearm
relative to th upper arm, or th trunk relative to th thigh,
as shown in Figure 4 -9 A . A measurement is made by comparing motion between an anatomie landmark or coordinates
of one segment with an anatomie landmark or coordinates of
a second segment. Goniometry provides one example of a
relative coordinate System used in clinical practice. Elbow
joint range of motion, for example, describes a measurement
using a relative reference frame defined by th long axes of
th upper arm and forearm segments, with an axis of rota
tion through th elbow.
Relative reference frames, however, lack th information
needed to define motion with respect to a fixed point or
66
A Relative reference
frame
B Global reference
frante
A
X
Chapter 4
Biomedumical Principles
67
FIGURE 4-10. Vector composition of parallel, coplanar forces. A, Two force vectors are acting on th knee: th segment (leg) weight
(SW) and th load weight (LW) applied at th ankle. These forces are added to determine th resultant force (RF). The negative sign
mdcates a downward pul. B, The weight of th head (HW) and traction force (TF) act along th same line but in opposite directions.
The resultant force (RF) is th algebraic sum of these vectors.
Tirection of th torque that is producing a rotation is desigtated by th direction (e.g., counterclockwise, flexion) of th
egment being accelerated. A more mathematically based
.onvention for designating th direction of a torque uses th
nght-hand rule. This convention is described in Appendix
iS.
In closing, 3D analysis is more complicated than 2D analsis, but it does provide a more comprehensive prohle of
ruman movement. There are excellent resources available
:nat describe techniques for conducting 3D analysis, and
some of these references are provided at th end of th
ihapter.1-3-1718 The quantitative analysis discussed in this
.hapter focuses on 2D analysis techniques.
^epresenting Forces
rorce vectors can be represented in different manners, derending on th context of th analysis. Several vectors can
re combined to represent a single vector. This method of
jresentation is called vector composition. Alternatively, a
gle vector may be resolved or decomposed into several
mponents. This technique is termed vector resolution.
The representation of vectors using composition and reso-ttton provides th means of understanding how forces ro
tte or translate body segments and subsequently cause rotaon, compression, shear, or distraction at th joint surfaces.
Composition and resolution of forces can be accomrlished using graphic methods of analysis or right-angle trig.nometry. These techniques are needed to represent and
- absequently calculate muscle and joint forces.
68
Seclion I
Metacarpophalangeal
joint
Stretched collateral
ligaments
Proximal
joint
Distai
interphalangeal
joint
Palmar dislocation of th
metacarpophalangeal
joint
Ruptured
collateral
ligaments
Chapter 4
Biomechanical Principles
69
- GURE 4-13. The muscle force (MF) produced by th brachioradi* is represented as th hypotenuse (diagonal) of th rectangle.
The normal force (MFN) and tangential force (MFT) are also indi:ated. The internai moment arm (IMA) is th perpendicular dis
ance between th axis of rotation (red circle) and (MFN).
Resolution of Forces
The previous section illustrates th composition method of
-epresenting forces, whereby multiple coplanar forces acting
on a body are replaced by a single resultant force. In many
clini cal situations, a knowledge of th effect of th individuai
components that produce th resultant force may be more
relevant to an understanding of th impact of these forces on
joint motion and joint loading, as well as developing specific
treatment strategies. Vector resolution is th process of replacing a single resultant force by two or more forces that, when
combined, are equivalent to th originai resultant force.
One of th most useful applications of th resolution of
forces involves th description and calculation of th rectangular components of a muscle force. As depicted in Figure
4 - 1 3 , th rectangular components of th muscle force are
shown at righi angles to each other and are referred to as
th normal and tangential components (MFN and MFT). The
normal component represents th component of th muscles
resultant force that acts perpendicularly to th long axis of
th body segment. Because of th internai moment arm (see
Chapter 1) associated with this force component, one effect
of th normal force of a muscle is to cause a rotation (i.e.,
produce a torque). The normal force may also cause a translation of th bony segment.
The tangential component represents th component of
th muscles resultant force that is directed parallel to th
long axis of th body segment. The effect of this force is to
compress and stabilize th joint or, in some cases, distract or
sparate th segments forming th joint. The tangential comDonent of a muscle force does not produce a torque when it
The examples presented to this point on methods of resolving forces into normal and tangential components have focused on th forces and torques produced by muscle. As
described in Chapter 1, muscles, by definition, produce in
ternai forces or torques. The resolution of forces into normal
and tangential components can also be applied to external
forces acting on th human body, such as those from gravity,
external load or weight, and manual resistance, as applied by
a clinician. In th presence of an external moment arm,
external forces produce an external torque. Generally, in th
condition of equilibrium, th external torque acts about th
joints axis of rotation in th opposite direction to a given
internai torque.
Figure 4 - 1 4 illustrates th resolution of both internai and
external forces for an individuai who is performing an isometric knee extertsion exercise. Three resultant forces are
depicted in Figure 4 -1 4 A : knee extensor muscle force (MF),
leg segment weight (SW ), and external load weight (LW)
applied at th ankle. The weight of th leg segment and
extemal load acts at th center of th respective masses.
Figure 4 - 1 4 B shows th resultant internai forces and exter
nal forces broken into their normal and tangential compo
nents.
Influence o f Changing th Angle of th Joint
The relative magnitude of th normal and tangential compo
nents of force applied to a bone depends on th position of
th limb segment. Consider firsi how th change in angular
position of a joint alters th angle-of-insertion o j th muscle
(see Chapter 1). Figure 4 - 1 5 shows th biceps muscle force
(MF) at four different elbow joint positions, each with a
different angle-of-insertion (a ) to th forearm. Each angle-of-
Tangential Force
Component
70
Secton 1
Thus far, th composition and resolution of forces are primarily described using a graphic method to determine th
magnitude of forces. A drawback to this method is that it
requires a high degree of precision to accurately represent
th forces analyzed. In th solution of problems involving
rectangular components, right-angle trigonometry provides
a more accurate method of force analysis. The trigonometrie
functions are based on th relationship that exists between
th angles and sides of a right triangle. Refer to Appendix IC
for a review of this material.
I
I
I
I
Chapter 4
Biomechanical Prndples
th elbow joint alters th angle of insertion (a) of th muscle into th forearm. These changes, in turn, alter th
magnimele of th normal (MFN)
and tangential (MFT) components of
th biceps muscle force (MF). The
proportion of MFN and MFT to MF are
listed in each of th four boxes: A,
angle-of-insertion of 20 degrees; B,
angle-of-insertion of 90 degrees; C,
angle-of-insertion of 135 degrees; and
D, angle of insertion of 165 degrees.
The internai moment arm (IMA) is
drawn as a black line, extending from
th axis of rotation to th perpendicular intersection with MFN. The IMA
remains Constant throughout A to D.
(Modified from LeVeau BF: Williams
& Lissners Biomechanics of Human
Motion, 3rd ed. Philadelphia, WB
Saunders, 1992.)
A. 90c of flexion
MF
B. 45 of flexion
FIGURE 4-16. A change in knee joint angle affeets th magnitude of th normal component of th extemal forces generated by th leg
segment weight (SW) and load weight (LW) applied at th ankle. The normal components of LW and SW are indicated as LWNand
SWN, respectively. Different extemal torques are experienced at different knee angles. The largest extemal torques are generated when
th knee is in full extension (C), since SWK and LWN are largest and equal io th full magnitude of SW and LW, respectively. No
external torques are produced when th knee is flexed 90 degrees (A), since SWN and LWN are zero. (EMA, is equal to th extemal
moment arm for SWN; EMA2 is equal to th external moment arm for LWN.)
71
72
Section I
S P E C I A L
F O C U S
4 - 5
Internai Torque
The first method for determining internai torque is illustrated in Figure 4 - 1 8 (black letters). The internai torque is
depicted as th product of MFN (th normal component of
th resultant muscle force (MF) and its internai moment arm
(IMA,)). The second method, depicted in red letters in Fig
ure 4 - 1 8 , does not require th resultant force to be resolved
into rectangular components. In this method, internai torque
is calculated as th product of th resultant force (MF) and
IMA2 (i.e., th internai moment arm that extends between
th axis of rotation and a perpendicular intersection with
MF). Both methods yield th same internai torque because
both satisfy th definition of a torque (i.e., th product of a
Chapter 4
Biomechanical Principes
73
External Torque: R \ x EM A j = R x EM A 2
FIGURE 4-20. A piece of black string is used to mirnic th line-offorce of th resultant force vector of an activated biceps muscle.
The internai moment arm is shown as a red line; th axis of
rotation at th elbow is shown as a solid black circle. Note that th
moment arm is greater when th elbow is in position A compared
with position B. (Modified from LeVeau BF: Williams & Lissner's
Biomechanics of Human Motion, 3rd ed. Philadelphia, WB Saunders, 1992.)
Box con tin u ed on follow in g p a g e
74
Secticm I
S P E C I A L
F O C U S
4 - 6
Continuai
Chapter 4
Biomechanical Principles
75
FIGURE 4-22. A, Hip abductor force (HAF) from th right hip abductor muscles produces a torque necessary for th frontal piane
stability of th pelvis during th right single-limb support phase of walking. Rotary stability is established, assuming static
equilibrium, when th counterclockwise torque equals th clockwise torque. The counterclockwise torque equals HAF times its
moment arm (D), and th clockwise torque equals body weight (BW) times its moment arm (D[). B, This first-class lever seesaw
model simplifes th model shown in A. The joint reaction force (JRF), assuming that all force vectors act vertically, is shown as an
upward directed force at a magnitude equal to th sum of th hip abductor force and body weight. (Reprinted and modifed with
permission from Elsevier Science Publishing Co., Ine., from Neumann DA. Biomechanical analysis of selected principles of hip joint
protection. Arthr Care Res 2:146-155, 1989. Copyright 1989 by ihe Arthritis Health Professions Association.)
76
Sedioli I
Chapter 4
ular approach selected depends on th objective of th analysis. The subsequent sections in this chapter are directed
toward th analysis of forces or torques at one instant in
time, or th force (torque)-acceleration approach.
When considering th effects of a force and th resultant
acceleration at an instant in time, two situations can be
deftned. In th first case, th acceleration has a zero value
because th object is either stationary or moving at a Con
stant velocity. This is th branch of mechanics known as
statics. In th second situation, th acceleration has a non
zero value because th System is subjected to unbalanced
forces or torques. This area of study is known as dynamics.
Static analysis is th simpler approach to problem solving in
biomechanics and is th focus in this chapter.
Static Analysis
Biomechanical studies often induce conditions of static equilibrium in order to simplify th approach to th analysis of
human movement. In static analysis, th System is in equilibrium because it is not experiencing acceleration. As a consequence, th sum of th forces or torques acting on th
System is zero. The forces or torques in one direction equal
th forces or torques in th opposite direction. Because th
linear and angular accelerations are equal, th inertial effect
of th mass and moment of inertia of th bodies is ignored.
The force equilibrium Equations 4.14 A and B are used
for uniplanar translational motion and are listed in th box.
For rotational motion, th forces act together with their mo
ment arms and cause a torque about some axis. In th case
of static rotational equilibrium, th sum of th torques about
an axis of rotation or another point is zero. The torque
equilibrium Equation 4.15 is also included in th box. This
equation implies that th sum of th counterclockwise
torques must equal th sum of th clockwise torques. The
seesaw model of Figure 4 - 2 2 B provides a simplifed example of static rotational equilibrium. The HAF times its mo
ment arm (D) creates a potential counterclockwise (abduction) torque, whereas BW times its moment arm (D t) creates
a potential clockwise (adduction) torque. At any instant, th
opposing torques at th hip are assumed to be equal.
(Equation 4.14 A)
(Equation 4.14 B)
M
H
II
o
77
TABLE
ing an object in th hand. Assuming equilibrium, three unknown variables are to be solved: (1) th internai (muscularproduced) torque, (2) th muscle force, and (3) th joint
reaction force at th elbow. To begin, a free body diagram is
constructed. The axis of rotation and all moment arm distances are indicated (Figure 4 - 2 5 B ). Although at this point
th direction of th joint (reaction) force ( JF) is unknown, il
is assumed to act in a direction opposite to th pul of
muscle. This assumption holds trae in an analysis in which
th mechanical advantage of th System is less than one (i.e.,
when th muscle forces are greater than th external resistance forces) (see Chapter 1). lf after solving th problem
th joint force is positive, then this initial assumption is
correct.
Because all th resultant forces indicated in this problem
act parallel to th Y axis, it is unnecessary to resolve th
resultant forces into their component. vectors. No forces are
acting in th X (horizontal) direction.
Solving for Internai Torque and Muscle Force
The external torques originating from th weight of th forearm-hand segment (SW) and th weight of th load (LW)
generate a clockwise (extension) torque about th elbow. In
order for th System to remain in equilibrium, th elbow
flexor muscle has to generate an opposing internai (flexion)
torque, acting in a counterclockwise direction. This assump
tion of rotational equilibrium allows Equation 4.15 to be
used to solve for th magnitude of th internai torque and
muscle force:
UT = 0 (Internai torque 4 external torque = 0)
Internai torque = external torque
Internai torque = (SW X EMA,) + (LW X EMA2)
Internai torque = (17N X 0.15 m) + (60 N X 0.35 m)
Internai torque = 23.6 Nm
78
Section I
X
Axis of
rotation
0.05 m
MF - SW - LW - JF = 0
MF = 471.0 N
- J F = - M F + SW 4- LW
The magnitude of th muscle force is over six times
greater than th magnitude of th external forces (i.e., forearm-hand segment and load weight). The larger force requirement can be explained by th disparity in moment arm
length used by th elbow flexors when compared with th
moment arms lengths used by th two external forces. The
- J F = - 4 7 1 N + 17 N + 60 N
- J F = - 3 9 4 .0 N
JF = 3 94.0 N
Chapter 4
The positive value of th joint reaction force verifies th
assumption that th joint force acted downward. Because
muscle force is usually th largest force acting about a joint,
th direction of th net joint force must oppose th pul of
th muscle. Without such a force, for example, th muscle
mdicated in Figure 4 - 2 5 would accelerate th forearm upward, resulting in a unstable joint. In short, th joint force
supplied by th humerus against th forearm in this case
provides th missing force needed to maintain linear static
equilibrium at th elbow. As stated earlier, th joint force
does not produce a torque because it is assumed to act
Axis of
rotation
Problem 2
In Problem 1, th forearm is held horizontally, thereby orienting th internai and extemal forces perpendicular to th
forearm. Although this presentation greatly simplifies th calculations, it does not represent a very typical biomechanical
situation. Problem 2 shows a more common situation in
which th forearm is held at a position other than th
horizontal (Fig. 4 -2 6 A ). As a result of th change in fore-
\)
w
1
79
'X
FIGURE 4 - 2 6 . P ro b le m 2. A, An isometric el
Biomcchanical Principles
80
Secticm I
arm position, th angle-of-insertion of th elbow flexor muscles and th angle where th external forces intersect th
forearm are no longer perpendicular. In principle, all other
aspects of ths problem are identical io Problem 1, except
that th resultant vectors need to be resolved into rectangular (X and Y) components. This requires additional steps and
trigonometrie calculations. Assuming equilibrium, three unknown vartables are once again to be determined: (1) th
internai (muscular-produced) torque, (2) th muscle force,
and (3) th joint reaction force at th elbow.
Figure 4 - 2 6 B illustrates th free body diagram of th
forearm held at 30 degrees below th horizontal (0). To
simplify calculations, th X-Y reference frame is established,
such that th X axis is parallel to th forearm segment. All
forces acting on th System are indicated, and each is re
solved into their respective tangential (X) and normal (Y)
components. The angle-of-insertion of th elbow flexors to
th forearm (a ) is 60 degrees. All numeric data and back
ground information are listed in th box associated with
Figure 4 - 2 6 .
Solving for Internai Torque and Muscle Force
2 T = 0 (Internai torque 4- external torque = 0)
MF = 408 N/.866
MF = 471.1 N
The tangential component of th muscle force, MFX, can be
solved by
MFX = MF X cos 60
MFX = 471.1 N X .5
MFX = 235.6 N
Solving for Joint Force
The joint reaction force (JF ) and ts normal and tangential
components (JF Y and JF X) are shown separately in Figure
4 - 2 6 C. (This is done to increase th clarity of th illustration.) In reality, th joint forces are acting concurrently on
th proximal end of th forearm segment along with th
other lorces. The directions of JF V and JF X are assumed lo
act downward (negative) and to th right (positive), respectively. These are directions that oppose th force of th
muscle. The rectangular components (JF Y and JF X) of th
joint force (JF ) can be readily determined by using Equations 4 .14 A and B.
2Fy = 0
MF y - SWY - LWV - JF y = 0
JF y = - M F y 4- SWY 4- l.W Y
-JF y = - 4 0 8 N + (cos 30 X 17 N) + (cos 30 X 60 N)
JF y = 341.3 N
2FX = 0
- M F X + SWX 4- LWX + JF X = 0
.0 5 m
The normal (Y) components (SWV and LWy) of th resultant forces are
used in this calculation because these vectors intersect th external moment
arm lengths (0.15 m and 0.35 m) at tight angles. Using th resultant
external forces (SW and LW) requires moment arm lengths that intersect
these forces at right angles. These adjusted moment arm lengths can be
caiculated with data supplied with this problem. This approach is equally
valid.
JF = V 341.3 N2 4- 197.1 N2
JF = 394.1 N
Another characteristic of th joint reaction force that is of
Chapter 4
Dynamic Analysis
Static analysis is th most basic approach to kinetic analysis
of human movement. This form of analysis is used to evaluate forces on a human when there are little or no significant
linear or angular accelerations. In contrast, when linear or
angular accelerations occur owing to unbalanced forces, a
dynamic analysis must be undertaken. Walking is an example of movement due to unbalanced forces, as th body is in
a continuai state of losing and regaining balance with each
step. Thus, dynamic analysis of gait is a frequently conducted analysis of movement Science.
Dynamic forces that act against th body can be measured
directly by various instruments, such as a force transducer.
Dynamic forces generated from within th body, however,
are usually measured indirectly based on Newtons laws of
motion. (See Special Focus 4 - 7 for one such method.) Solvng for forces and torques under dynamic conditions requires knowledge of mass or mass moment of inertia and
linear or angular acceleration (see Equations 4.1 6 and 4.17
in th box). Anthropometric data provide th inertial characteristics of body segments (mass, mass moment of inertia), as
well as th lengths of body segments and locations of joint
centers. Kinematic data, such as displacement, velocity, and
accelerations of segments, can be measured through laboratory techniques.
Biomechanical Principia
81
SF X = max
(Equation 4.16 A)
2F y = mav
(Equation 4.16 B)
M
H
II
P
Torque Equation
(Equation 4.17)
82
Section l
ter combined with th time data can be mathematically converted to angular velocity and acceleration. Although th
electrogoniometer provides a fairly inexpensive and direct
means of capturing joint angular displacement, it encumbers
th subject and is difficult to fit and secure over fatty and
muscle tissues. A triaxial electrogoniometer measures joint
rotation in three planes; however, this System tends to constrain naturai movement.
Accelerometer
Imaging Techniques
Photography
Cinematography
Videography
Optoelectronics
Unlike th electrogoniometer and accelerometer that measure movement directly from a body, imaging methods typically require additional signal conditioning, processing, and
interpreting prior to obtaining meaningful output.
Photography is one of th oldest techniques for measuring
kinematic data. With th camera shutter held open, light
from a flashing strabe can be used to track th location of
reflective markers wom on th skin of a moving subject (see
Chapter 15 and Fig. 1 5 - 3 ) . By knowing th frequency of
th strabe light, angular displacement data can be converted
lo angular velocity and angular acceleration data. In addition
to using a strabe as an interrupted light source, a 35-mm
camera can use a Constant light source and take multiple
film exposures of a moving event.
Cinematography, th art of movie photography, was once
th most popular method of recording motion. High-speed
cinematography, using 16-mm film, allowed for th measurement of fast movements. By knowing th shutter speed, a
labor-intensive, frame-by-frame digitai analysis on th move
ment in question was performed. Digital analysis was performed on movement of anatomie landmarks or of markers
wom by subjects. Two-dimensional movement analysis was
performed with th aid of one camera; three-dimensional
analysis, however, required two or more cameras.
For th most part, stili photography and cinematography
analysis are rarely used for th study of human motion. The
methods are not practical due to th time required for developing th film and manually analyzing th data. Videography
has replaced these Systems and is one of th most popular
methods for collecting kinematic information in both clinical
and laboratory setungs. The System typically consists of one
or more video cameras, a recorder, a monitor, an image
Electromagnetic tracking devices measure six degrees-of-freedom (three rotational and three translational), providing position and orientation data during both static and dynamic
activities. Small receivers are secured to th skin overlying
FIGURE 4-28. Reflective markers are used to indicate anatomie locations for determination of joint angular displacement of a walking
individuai. Marker location is acquired using a video-based camera
that can operate at variable sampling rates. (Courtesy of Peak Per
formance Technologies, Ine., Englewood, Colorado.)
Chapter 4
83
Biomechanical Prnciples
0.1
0.2
0.3
0.4
0.5
0.6
Time (seconds)
0.7
0.8
0.9
1.0
84
Section I
Transducers
FIGURE 4-31. lsokinetic dynamometry. The subject generates maximal-effort knee flexion torque at a joint angular velocity of 60
degrees/sec. The machine is functioning in its concentric mode,
providing resistance against th contracttng muscles. Note that th
medial-lateral axis of rotation of th tight knee is approximately
aligned with th axis of rotation of th dynamometer. (Courtesy of
Biodex Medicai Systems, Ine., Shirley, New York.)
One of th most popular electromechanical devices for measuring internai torque at a specific joint is th isokinetic dyna
mometer. The device measures th internai torque produced
while maintaining a Constant angular velocity of th joint.
The isokinetic System is adjusted to measure th torque
produced by most major muscle groups of th body. The
machine measures kinetic data produced by muscles during
all three types of activation: concentric, isometric, and eccentric. The angular velocity is determined by th user, varying
between 0 degrees/sec (isometric) and up to 500 degrees/sec
for nonisometric activation. Figure 4 - 3 1 shows a person
who is exerting maximal effort, knee flexion torque through
a concentric contraction of th right knee flexor muscola
ture. Isokinetic dynamometry provides an objective record of
muscular kinetic data, produced during different types of
muscle activation at multiple test velocities. The System also
provides immediate feedback of kinetic data, which may
serve as a source of biofeedback during training or rehabilitation.
Chapter 4
85
Biomechanical Principles
JFX
JF y
- J F X
Thigh (T)
|C
Jh x
JF y
7J)
Leg
Leg (L)
JFy
Foot(F)
JFX
(
-A
Foot
Cf
JF,
GRF
u n r x
t
GRFy
REFERENCES
1. Allard P, Stokes 1AF, Bianchi JP: Three-Dimensional Analysis of Human
Movement. Champaign, Human Kinetics, 1995
2 Clauser CE, McConville JT, Young JW: Weight, volume, and center of
mass segments of th human body. AMRL-TR-69-70, Wright Patterson
Air Force Base, 1969.
3. Craik RL, Oatis CA: Gait Analysis: Theory and Application. St. Louis,
Mosby-Year Book, 1995.
4. Dempster WT: Space requirements for th seated operator. WADC-TR55-159, Wright Patterson Air Force Base, 1955.
5. Enoka RM: Neuromechanical Basis of Kinesiology, 2nd ed. Champaign,
Human Kinetics, 1994.
6. Hamill J, Knutzen KM: Biomechanical Basis of Human Movement. Balti
more, Williams & Wilkins, 1995.
7. Hatze H: A mathematical model for th computational determination of
parameter values of anthropometric segments. J Biomech 13:833-843,
1980.
8. Hindrichs R: Regression equations to predici segmentai moments of
inertia from anthropometric measurements. J Biomech 18:621-624,
1985.
9. Neumann DA: Biomechanical analysis of selected principles of hip joint
protection. Arthritis Care Res 2:146-155, 1989.
10. Neumann DA: Hip abductor muscle activity in persons with a hip
prosthesis while walking and carrying loads in one hand. Phys Ther 76:
1320-1330, 1996.
11 Neumann DA: Hip abductor muscle activity in persons who walk with
a hip prosthesis with different methods of using a cane. Phys Ther 78:
490-501, 1998.
12. Neumann DA: Arthrokinesiological considerations in th aged aduli. In
13.
14.
15.
16.
17.
18.
A D 0ITI0N A L READINGS
Hall SJ: Basic Biomechanics. St. Louis, Mosby, 1998.
Hay JG: The Biomechanics of Sports Techniques. Englewood Cliffs, Prentice
Hall, 1993.
LeVeau BF: Williams & Lissners Biomechanics of Human Motion. Philadelphia, WB Saunders, 1992.
Low J, Reed A: Basic Biomechanics Explained. Oxford, Butterworth-Heinemann, 1996.
Mow VC, Hayes WC: Basic Orthopaedic Biomechanics. New York, Raven
Press, 1991.
Nordin M, Frankel VH: Basic Biomechanics of th Musculoskeletal System.
Philadelphia, Lea and Febiger, 1989.
p p e n d i x
86
Trigonometrie Function
Definition
Sine (sin)
Side opposite/hypotenuse
Cosine (cos)
Side adjacent/hypotenuse
Tangent (tan)
Cotangent (cot)
A p p e n d ix I
87
Segment Weight*
H ea d :
46.2 N (6.9%)
H ea d a n d n ec k :
H ea d :
52.9 N (7.9%)
395.3 N (59.0%)
Upper Limb
18.1 N (2.7%)
A rm :
Fo r e a r m : 10.7 N (1.6%)
4.0 N (0.6%)
32.8 N (4.9%)
F o r e a r m a n d h a n d : 14.7 N (2.2%)
H an d :
U p p er lim b:
Lower Limb
Thigh: 65.0 N (9.7%)
30.2 N (4.5%)
Leg:
9.4 N (1.4%)
104.5 N (15.6%)
a n d f o o t : 40.2 N (6.0%)
F oot:
L o w e r lim b:
Leg
sin 45 = MFX/MF
MF = 141.4 N/sin 45
MF =
200 N
Upper Extremity
E C T I O N
II
C h a p t k r 5; Shoulder Complex
Cl 1AP 1 F.R 6: Elbow and Forearm Complex
C h a r t e r 7 Wrist
C h a rter 8
Hand
Upper Extremity
90
h a p t e r
Shoulder Complex
Donald A. Neum ann , PT, Ph D
TOPICS
0S T E 0L 0G Y , 91
Sternum, 91
Clavicle, 92
Scapula, 92
Proximal-to-Mid Humerus, 95
ARTHROLOGY, 96
Sternoclavicular Joint, 98
G en era l F e atures, 98
P e ria rtic u la r C o n n e c tiv e T is s u e , 99
K in e m a tic s , 99
Movement of th Scapulothoracic
Joint: A Composite of th
AT
GLANCE
Sternoclavicular and
Acromioclavicular Joint
Movements, 103
Elevation and Depression, 103
Protraction and Retraction, 103
Upward and Downward Rotation, 104
J o in t, 119
P ro tra c to rs o f th S c a p u lo th o ra c ic
J o in t, 120
R e tra c to rs o f th S c a p u lo th o ra c ic
J o in t, 120
U p w a rd and D o w n w a rd R o ta to rs o f th
S c a p u lo th o ra c ic J o in t, 120
J o in t, 110
M u s c le s th a t E levate th A rm a t th
G le n o h u m e ra l J o in t, 120
U p w a rd R o ta to rs a t th S c a p u lo th o ra c ic
J o in t, 122
F u n ctio n o f th R o ta to r C uff M u s c le s
D u rin g E levation o f th A rm , 125
INTRODUCTION
Our study of th upper limb begins with th shoulder com
plex, a set of four articulations involving th sternum, clavi
cle, ribs, scapula, and humerus (Fig. 5 - 1 ) . This series of
joints provides extensive range of motion to th upper extremity, thereby increasing th ability to manipulate objects.
Trauma or disease often limits shoulder motion, causing a
signifcant reduction in th effectiveness of th entire upper
limb.
Rarely does a single muscle act in isolation at th shoul
der complex. Muscles work in teams to produce a highly
coordinated action that is expressed over multiple joints. The
very cooperative nature of shoulder muscles increases th
versatility, control, and range of active movements. Because
of th nature of this functional relationship among muscles.
OSTEOLOGY________________________
Sternum
The sternum consists of th manubrium, body, and xiphoid
process (Fig. 5 - 2 ) . The manubrium possesses a pair of ovalshaped clavicular facets, which articulate with th clavicles.
The costai facets, located on th lateral edge of th manu
brium, provide attachment sites for th first two ribs. The
91
92
Section II
Upper Extremity
Scapula
The triangular-shaped scapula has three angles: inferior, supe
rior, and lateral (Fig. 5 - 5 ) . Palpation of th inferior angle
provides a convenient method for following th movement
of th scapula during arm motion. The scapula also has three
borders. With th arm resting by th side, th mediai or
vertebral border runs almost parallel to th spinai column
The lateral or axillary border runs from th inferior angle to
th lateral angle of th scapula. The superior border extends
from th superior angle laterally toward th coracoid process.
Anterior view
Sternocleidomastoid
Clavicle
When looking from above, th shaft of th clavicle is curved
with its anterior surface being generally convex medially and
concave laterally (Fig. 5 - 3 ) . With th arm in th anatomie
position, th long axis of th clavicle is oriented slightly
above th horizontal piane and about 20 degrees posterior to
th frontal piane (Fig. 5 - 4 ; angle A). The rounded and
prominent mediai or stemal end of th clavicle articulates
with th stemum (see Fig. 5 - 3 ) . The costai facet of th
clavicle (see Fig. 5 - 3 ; inferior surface) rests against th first
rib. Lateral and slightly posterior to th costai facet is th
distinct costai tuberosity, an attachment for th costoclavicular
ligament.
Chapter 5
Shoulder Complex
Superior surface
\ \
i ^ ^ K n t e r i o r detto#
Anterior
FIGURE 5 -3 . The superior and infe
rrar surfaces of th right clavicle.
The dashed line around th ends of
th clavicle show attachments of th
ioint capsule. Proximal attachment
of muscles are shown in red, distai
attachments in gray.
93
94
Section II
Upper Extremity
Posterior view
Anterior view
Upper trapezius
lSupraspinatusv
in
supraspinatous
j,
ta s s a i1
Levator
scapulae'
f
Rhomboid
___ minor
Infraspinatus
Sternum
( Subscapularis
infraspinatous fossa
')
Long head triceps on
infraglenoid tubercle
in
Subscapular fossa.
Serratus anterior
^ an#
Latissimus
dorsi
a t r a r h m fi
(B)Lsurfaces of the rlght scapola. Proximal attachment of muscles are shown rn red distai
attachments m gray. The dashed lines show the capsular attachments around the glenohumeral joint.
FIGURE 5 6. Anterior view of the righi scapula showing an approximate 5-degree upward tilt of the glenoid fossa relative to the
mediai border of the scapula.
Chapter 5
Superior view
Shoulder Complex
95
Proximal-to-Mid Humerus
Superior view
96
Section II
Upper Exiremity
Ihe radiai (spirai) groove runs obliquely across th posterior surlace of th humerus. The groove separates th proxi-
ARTHROLOGY
The most proximal articulation within th shoulder complex
is th stemoclavicular joint (see Fig. 5 - 1 ) . The clavicle
through its attachment to th stemum, functions as a mechanical strut, or prop, holding th scapula at a relatively
Constant distance from th trunk. Located ai th lateral end
ot th clavicle is th acromioclavicular joint. This joint and
associated ligaments firmly attach th scapula to th clav
icle. The pomi of contact between th anterior surface of
th scapula and th posterior-lateral surface of th thorax
is called th scapulothoradc joint. In this case, th temi
does not imply a true anatomie joint, rather an interfacing
ol two bones. Movement at th scapulothoradc joint is a
direct result of individuai movements occurring at th sternoclavicular and acromioclavicular jotnts. The position of
th scapula on th thorax provides a base of operation
lor th glenohumeral joint, th most distai link of th com
plex. The term "shoulder movement describes th combined
motions at both th glenohumeral and th scapulothoracic
jomt.
Chapter 5
97
Shoulder Complex
Posterior view
position,
th
scapula
Protraction. The mediai border of th scapula slides anterior-laterally on th thorax away from th midiine.
FIGURE 5-10. Posterior aspect of th tight proximal humerus. Proximal attachments of muscles are in red, distai attachments in gray. The
dashed line shovvs th capsular attachments of th glenohumeral joint.
Sternodavicular
Acromioclavicular
Scapulothoracic
Glenohumeral
Retraction. The mediai border of th scapula slides posterior-medially on th thorax toward th midiine, such as
occurs during th pinching of th shoulder blades together.
Upward Rotation. The inferior angle of th scapula rotates in a superior-lateral direction such that th glenoid
fossa faces upward. This rotation occurs as a naturai component of th arm reaching upward.
Downward Rotation. The inferior angle of th scapula
rotates in an inferior-medial direction such that th glenoid
fossa faces downward. This motion occurs as a naturai com-
FIGURE 5-11. Motions of th right scapula against th posterior-lateral surface of th thorax. A, Elevation and depression. B, Retraction
and protraction. C, Downward and upward rotation.
98
Section II
Upper Extremity
Stemoclavicular Joint
GENERAL FEATURES
The stemoclavicular (SC) joint is a complex articulation,
invohing th mediai end of th clavicle, th clavicular facet
Chapter 5
diameter. The clavicular facet on th stemum typically is
reciprocally shaped, with a slighdy concave longitudinal di
ameter and a slighdy convex transverse diameter.
The large and exposed articular surface of th clavicle
rests against th smaller, sloped, articular surface of th sternum. A prominent articular disc resides within th SC joint,
which tends to increase th congruity of otherwise irregularshaped joint surfaces.
Shoulder Complex
99
KINEMATICS
The osteokinematics of th clavicle are defined for 3 degrees of freedom. Each degree of freedom is associated with
one of th three Cardinal planes: sagittal, frontal, and horizon
tal. The clavicle elevates and depresses, protraets and retraets, and rotates about th bones longitudinal axis (Fig. 5 14). Essentially all functional movement of th shoulder involves at least some movement of th clavicle about th SC
joint.
Osteokinematics at th SC Joint
Elevation and depression
Protraction and retraction
Axial rotation of th clavicle
100
Section II
Upper E xtremity
Acromioclavicular Joint
GENERAL FEATURES
The acromioclavicular (AC) joint is the articulation between
the lateral end of the clavicle and the acromion of the scap
ula (Fig. 5 -1 7 A ). The clavicular facet on the acromion faces
medially and slightly superiorly, providing a fit with th
FIGURE 5 16. Superior view of a tnechanical diagram of the arthroktnematics of roll and slide during retraction of th clavicle about
th right stemoclavicular joint. The vertical axis of rotation is
shown through the stemum. Stretched structures are shown as thin
elongated arrows, slackened structures shown as a wavy arrow.
(Costoclavicular ligament = CCL, anterior capsular ligament =
ACL, posterior capsular ligaments = PCL.)
Chapter 5
101
bhoulaer C omplex
FIGURE 5 - 1 7 . The righi acromioclavicular joint. A, An anterior view showing th sloping nature of ihe articulation. B,
A posterior view of th joint opened up from behind, showing th clavicular facet on th acromion and th disc.
KINEMATICS
Distinct functional differences exist between th SC and AC
joints. The SC joint permits relative extensive motion of th
clavicle, which guides th generai path of th scapula. The
Conoid
ligament
-C oracoclavicular
Trapezoid
ligament _
ligament
102
Section II
Upper Extremity
Osteokincmatics at th AC Joint
Acromioclavicular Joint Dislocation
The AC joint is inherently susceptible to dislocation due
to th sloped nature of th articulation and th high
probability of receiving large shearing forces. Consider
a person fading and striking th tip of th shoulder
abruptly against th ground (Fig. 5-19). The resulting
medially directed ground force may dispiace th acromion medially and under th sloped articular facet of
th well-stabilized clavicle. The coracoclavicular ligaments, particularly th trapezoid ligament, naturally re
sisi such an AC joint displacement.20 On occasion, th
force applied to th scapula exceeds th tensile
strength of th ligaments, resulting in their rupture and
th complete dislocation of th AC joint. Extensive literature exists on th evaluation and treatment of th
injured AC joint, especially in athletes.32
AC joint, in contrast, permits subtle and often slight movements of th scapula. The slight movements at th AC joint
are physiologically important, providing th maximum extern
of mobility at th scapulothoracic joint.63
The motions of th scapula at th AC joint are described
in 3 degrees of freedom (Fig. 5 -2 0 A ). The primary motions
are called upward and downward rotation. Secondary rotational adjustment motions amplify or fine tune th final
position of th scapula against th thorax.63 The range of
motion ai th AC joint is difficult to measure, and this is noi
done in typical clinical situations.
Scapulothoracic Joint
The scapulothoracic joint is noi a true joint per se but rather
a point of contact between th anterior surface of th scap
ula and th posterior-lateral wall of th thorax.67 In th
anatomie position, th scapula is typically positioned be
tween th second and th seventh rib, with th mediai bor-
Chapter 5
Shoulder Complex
103
FIGURE 5-20. A, Posteror view showing th osteokinematics of th tight acromioclavicular joint. The
primari motions of upward and downward rotation are shown in red. Horizontal and sagittal piane
adjustments, considered as secondar) motions, are shown in gray and white, respectively. Note that each
piane of movement is color-coded with a corresponding axis of rotation. B and C show examples of th
horizontal piane adjustment made during scapulothoracic protraction (B) and sagittal piane adjustment
made during scapulothoracic elevation (C).
KINEMATICS
Movement of th Scapulothoracic Joint: A Composite of
th Sternoclavicular and Acromioclavicular Joint
Movements
The movements that occur between th scapula and th
thorax are a result of a cooperation between th SC and th
AC joints.
Elevation and Depresson
Scapular elevation at th scapulothoracic joint occurs as a
composite of SC and AC joint rotations (Fig. 5 -2 1 A ). For
th most part, th motion of shrugging th shoulders occurs
as a direct result of th scapulas following th path of th
elevating clavicle about th SC joint (Fig. 5 -2 1 B ). Down
104
Section II
Upper Extremity
Posterior view
Glenohumeral Joint
GENERAL FEATURES
The glenohumeral (GH) joint is th articulation formed between th large convex head of th humems and th shallow
concavity of th glenoid fossa (Fig. 5 - 2 4 ) . This joint operates in conjunction with th moving scapula to produce an
extensive range of motion of th shoulder. In th anatomie
position, th articular surface of th glenoid fossa is directed
anterior-laterally in th scapular piane. In most people, th 1
glenoid fossa is upwardly rotateci slightly. This position is
dependent on th amount of fixed upward tilt to th fossa
(see Fig. 5 - 6 ) and to th amount of upward rotation of th
scapula in its resting posture.
FIGURE 5 - 2 2 . A Scapulothoracic protraction shown as a summation of B (protraction at th SC joint) and C (slisht horizontal piane
adjustments at th AC joint).
r
Chapter 5
Shoulder Complex
105
FIGURE 5-23. A, Scapulothoracic upward rotation shown as a summation of B (elevation of th SC joint) and C (upward rotation at
th AC joint).
In th anatomie position, th articular surface of th humeral head is directed medially and superiorly, as well as
posteriorly because of its naturai retroversion. This orientation places th head of th humerus directly into th scapular piane and therefore directly against th face of th
glenoid fossa (see Fig. 5 - 4 B and 5 -4 C ).
106
Section II
Upper Extremity
S P E C I A L
F O C U S
5 - 2
Coracoid process
Biceps brachii tendon (long head)
Glenoid labrum
Chapter 5
Shoulder Complex
107
Acromioclavicular
ligament
Coracoacromial
ligament
Subacromial
space
Conoid
ligament
Transverse
ligament
Trapezoid
ligament
glenohumeral ligament attaches as a broad sheet to th anterior-inferior and posterior-inferior margins of th anatomie
neck.
This hammock-like inferior capsular ligament has three
sparate components: an anterior band, a posterior band, and
a sheet of tissue connecting these bands known as an axillary pouch (see Fig. 5 - 2 7 ) . 41 The axillary pouch and th
surrounding inferior capsular ligaments become particularly
uut at about 90 degrees of abduction, providtng an impor
tuni element of anterior-posterior stability to th GH joint in
ras position.62-65 In th abducted position, th anterior and
rosterior bands become taut at th extremes of external and
nternal rotation, respectively.
- Coracoclavicular
ligament
108
Section il
Upper Extremity
Coracoacromial arch
Chapter 5
Shoulder Complex
109
n o
Section 11
Upper Extremity
internai and extema] rotation (gray). Note that each axis of rotation
s color-coded with its corresponding piane of movement: mediallateral axis in white, vertical or longitudinal axis in gray, and
anterior-posterior axis in red.
subacromial bursa, limiting frictional forces between th deltoid and th underlying supraspinatus tendon and humeral
head.
Chapter 5
Shouder Complex
111
head offsets most of th inherent superior translation tendency of th humeral head. In healthy persons, th offsetting
mechanism provtdes suffcient space for th supraspinatus
tendon and th subacromial bursa.
FIGURE 5-32. A, A model of th glenohumeral joint depicting a ball th size of a typical aduli humeral head
rolling across a flattened (glenoid) surface. Based on th assumption that th humeral head is a sphere with a
circumference of 16.3 cm, th head of th humerus would translate upward 1 cm following a superior roll
(abduction) of only 22 degrees. This magnitude of translation would cause th humeral head to impinge against
th coracoacromial arch. B, Anatomie representation of th model used in A. Note that abduction without a
concurrent inferior slide causes th humeral head to impinge against th arch and block further abduction.
112
Section II
Upper Extremity
S P E C I A L
F O C U S
5 - 3
frontal piane and scapular piane abduction should be considered while evaluating and treating patients with shoulder dysfunction, particularly if chronic impingement is suspected.
Flexion and Extension
Flexion and extension al th GH joint is defined as a rotation
of th humerus in th sagittal piane about a medial-lateral
axis of rotation (see Fig. 5 - 3 0 ) . If th motion occurs strictly
in th sagittal piane, th arthrokinematics involve a spinning of
th humeral head about a somewhat fxed point on th face
of th glenoid. No roll or slide is necessary. As shown in
Figure 5 - 3 5 , th spinning action of th humeral head draws
most of th surrounding capsular structures taut. Tension
within th stretched posterior capsule may cause a slight ante
rior translation of th humerus at th extremes of flexion.21
Chapter 5
Shoulder Complex
113
Superior view
Infraspinatus
114
Section II
Upper Extremity
SCAPULOHUMERAL RHYTHM
The most widely cited study on th kinematics of shoulder
abduction was published by Inman and colleagues in 1944 4
This classic work focused on shoulder abduction in th frontal piane. Inman wrote that GH joint abduction or flexiot
occurs simultaneously with scapular upward rotation, an ob
servation referred to as scapulohumeral rhythm.
In th healthy shoulder, a naturai kinematic rhythm or
timing exists between glenohumeral abduction and scapulo
thoracic upward rotation. Inman reported this rhythm io be
remarkably Constant throughout most of abduction, occurring at a ratio of 2:1. For every 3 degrees o f shoulder abdiution, 2 degrees occurs by GH joint abduction and 1 degree occuni
by scapulothoracic joint upward rotation. Based on this rhythmj
a full are of 180 degree of shoulder abduction is th resuii
of a simultaneous 120 degrees of GH joint abduction and 6u
degrees of scapulothoracic upward rotation (Fig. 5 -3 7 A ).
Since th time of Inmans originai work in 1944, addidonai research has examined th kinematics of shoulder ab
duction with an emphasis on motion in th scapular;
piane,2'19-35 -48 and on motion while lifting different loads '
These studies reported a slightly different, and less consisti
ent, scapulohumeral rhythm. For instance, Bagg and Forrest-'
reported a mean glenohumeral-to-scapular rotation ratio
of 3 .2 9 :1 between 21 degrees and 82 degrees of abduction:
.7 1 :1 between 82 degrees and 139 degrees of abduction.;
and 1 .2 5 :1 between 139 degrees and 170 degrees of abduc
tion. Regardless of th differing ratios reported in th literature, Inmans classic 2 : 1 ratio stili remains a valuable axiom
in evaluation of shoulder movement. It is simple to remernber and stili helps to conceptualize th overall relationshsr
between humeral and scapula motion when considering th
full 180 degrees of shoulder abduction.
Arthrokinematics
Abduction/adduction
Intemal/extemal rotation
Chapter 5
Shoulder Complex
115
FIGURE 5-38. Plot showing th relationship of elevation ai th stemoclavicular (SC) joint and upward
rotation at th acromioclavicular (AC) joint during full shoulder abduction. The 180 degrees of abduction is
divided into early and late phases. (Redrawn from data from Inman VT, Saunders M, Abbott LC: Observalions on th function of th shoulder joint. J Bone Joint Surg 26A :l-32, 1944.)
FIGURE 5-39. Plot showing th relationship of posterior rotation of th clavicle at th stemoclavicular (SC)
joint to full shoulder abduction. (Redrawn from data from Inman VT, Saunders M, Abbott LC: Observations on
th function of th shoulder joint. J Bone Joint Surg 26A :l-32, 1944.)
Clavicular
posterior
FIGURE 5-40. The mechanics of posterior rotation of th right clavicle are shown. A, At rest in th anatomie position, th acromioclavic
ular (AC) and stemoclavicular (SC) joints are shown with th coracoclavicular ligament represented by a slackened rope. B, As th
serratus anterior muscle rotates th scapula upward, th coracoclavicular ligament is drawn taut. The tension created within th
stretched ligament rotates th crank-shaped clavicle in a posterior direction, allowing th AC joint io complete full upward rotation.
116
Chapier 5
117
Shoulder Complex
AC Joint
Scapulothoracic Joint
GH Joint
Early phase
0 to 90 degrees
25 degrees of elevation
60 degrees of abduction
Late phase
90 to 180 degrees
25 degrees of upward ro
tation
30 degrees of upward
rotation
60 degrees of abduction
Total
0 to 180 degrees
30 degrees of elevation
and 35 degrees of poste
rior rotation of th clavi
cle
30 degrees of upward ro
tation
60 degrees of upward
rotation
* Data from tnman VT, Saunders M, Abbott LC: Observations on th functton of th shoulder jotnt. J Bone Joint Surg 26A :l-32, 1944. (Some values
bave been rounded slightly for simplicity but are stili dose lo th originai values.)
t Extemal rotation is required if abduction is performed in th fronlal piane.
DIVISIONS
Trunks
D o rsa l s ca p u la r
--- Cords
Posterior
M e d ia i
Lateral pectoral
M usculocutaneous
A x illa r y
R a d ia i
M e d ia n
Long th ora cic
U ln a r
S u p ra s c a p u la r
T h o ra co d o rsa l
M e d ia i
pectoral
M e d ia i cutaneous
nerve to arm
118
Section II
Upper Extremity
S P E C I A L
F O C U S
Paralysis of th upper trapezius may result from damage to th spinai accessory nerve (cranial nerve XI).
Over time, th scapulothoracie joint may become markedly depressed, protracted, and excessively downwardly
rotated owing to th pul of gravity on th arm. A
chronically depressed clavicle may eventually result in
a superior dislocation at th SC joint.7 As th lateral
end of th clavicle is lowered, th mediai end is forced
upward due to th fulcrum action of th underlying first
rib. The depressed shaft of th clavicle may eventually
compress th subclavian vessels and part of th brachial plexus.
Perhaps a more common consequence of long-term
paralysis of th upper trapezius is an inferior subluxation of th GH joint. Recali from earlier discussion that
static stability at th GH joint is partially based on a
humeral head that is held against th inclined piane of
th glenoid fossa. With long-term paralysis of th trape
zius, th glenoid fossa loses its upwardly rotated position, allowing th humerus to slide inferiorly. The downward pul imposed by gravity on an unsupported arm
may strain th GH joint's capsule and eventually lead to
an irreversible subluxation. This complication is often
observed following flaccid hemiplegia.
Chapter 5
Shoulder Complex
119
120
Section II
Upper Extremily
FIGURE 5-44. The lower trapezius and latissimus dorsi are sho.
elevating th ischial tuberosities away from th seat of th whd
chair. The contraction of these muscles lifts th pelvic-and-tr
segment up toward th fixed scapula-and-arm segment.
Chapter 5
Shoulder Complex
Superior view
5-erratus
interior
Sternoclavicular
joint
FIGURE 5-45. The righi serratus anterior muscle. A, This expansive muscle passes anterior io th scapula to attach along th entire
.ength of iis mediai border. The muscles line-of-force is shown protracting th scapula and arm in a forward pushing or reachtng motion. The lbere that attach near th inferior angle may assist with scapulothoracic depression. B, A superior view of th
right shoulder girdle showing th protraction torque produced by th serratus anterior, i.e., th product of th muscle force multiplied by th associated internai moment arm (IMA). The axis of rotation is shown as th red circle running through th sternoclavicu
lar joint.
1. GH joint muscles
Deltoid
Supraspinatus
Coracobrachialis
Biceps (long head)
2. Scapulothoracic joint muscles
Serratus anterior
Trapezius
3. Rotator cuff muscles
S P E C I A L
F O C U S
5 - 6
121
122
Section II
Upper Extremity
FIGURE 5-46. Posterior view of th middle trapezius, lower trapezius, and rhomboids cooperating to retract th scapuothoracic
joint. The dashed line-of-force of both th rhomboid and lower
trapezius combines to yield a single retraction force shown by th
straight arrow.
and long head of th biceps brachii (Fig. 5 - 4 8 ) . The maxi
mal isometric torque generated by th shoulder flexors and
th abductors is shown for two joint positions in Table 5 - 4 .
The line-of-force of th middle deltoid and th supraspinatus are similar during shoulder abduction. Both muscles are
activated at th onset of elevation, reaching a maximum level
near 90 degrees of abduction.30 Both muscles have a significant internai moment arm that remains essentially Constant at
about 25 mm (about 1 in) throughout most of abduction.64
FIGURE 5-48. Lateral view of th anterior deltoid, coracobrachialis, and long head of th biceps flexing th glenohumeral
joint in th pure sagittal piane. The medial-lateral axis of
rotation is shown at th center of th humeral head. An
internai moment arm is shown intersecting th line-of-fon>;
of th anterior deltoid only.
Chapter 5
Test Position
Torque (kg-cm)
Flexors
Extensors
45 of flexion
0 of flexion
566 24
812 40
Abductors
Adductors
45 of abduction
45 of abduction
Internai rotators
Extemal rotators
0 of rotation
0 of rotation
562 23
1051 59
592 27
335 15
* Mean 1 standard error; data are from 20 young males from two test
positions.
Conversion: .098 N-m/kg-cm.
Data from Murray MP, Gore DR, Gardiner GM, et al: Shoulder motton
and musc'le strength of normal men and women in two age groups. Clin
Orthop 182:267-273, 1985.
th up
scapula
provide
as th
Shoulder C om pkx
123
of th
u p w a r d r o t a t io n f o r c e c o u p le a r e
s im ila r to t h m e c h a n i c s
of
th re e
people
w a lk in g
t h r o u g h a r e v o lv in g d o o r . A s s h o w n in F ig u r e 5 - 5 0 ,
t h r e e p e o p le p u s h in g o n t h d o o r r a il in d if f e r e n t lin e a r
d ir e c t io n s p r o d u c e t o r q u e s in t h s a m e r o t a r y d ir e c t io n .
T h is f o r m o f m u s c u la r in t e r a c t io n lik e ly im p r o v e s t h
le v e l o f c o n t r o l o f t h m o v e m e n t a s w e l l a s a m p lif ie s
t h m a x im a l t o r q u e p o t e n t ia l o f t h r o t a t in g s c a p u la .
124
Seaion II
Upper Extremiiy
to contribute upwarcl rotation torque. This muscle stili contributes a needed retraction force on th scapula, which
along with th rhomboid muscles helps to balance th formidable protraction effect of th serratus anterior. The ne:
dominance between th middle trapezius and th serratus
anterior during elevation of th arm determines th final
retraction-protraction position of th upward rotated scapula.
Weakness of th middle trapezius or serratus anterior disrupts th resting position of th scapula. The scapula tendi
to be biased in relative retraction with serratus anteriori
weakness, and in relative protraction with middle trapezius
weakness.
In summary, during elevation of th arm th serratusl
anterior and trapezius control th mechanics of scapular up-1
ward rotation. The serratus anterior has th greater leverage I
for this motion. Both muscles are synergists in upward rota-1
tion, bui are agonists and antagonists as they oppose, and I
thus partially limit, each others strong protraction and re-1
iraction potential.
FIGURE 5-52. The pathomechanics of winging of th scapula A, Winging of th righi scapula due to marked weakness of th righi
serratus antenor. The winging is exaggerated when resistance is applied againsi a shoulder abduction effort. B, Kinesiologic analysis of
th winging scapula. Without an adequate upward rotation force from th serratus anterior (fading arrow), th scapula becomes
unstable and cannot resist th pul of th deltoid. Subsequently, th force of th deltoid (bidirectional arrow) causes th scapula to
downwardly rotaie and th glenohumerai joint io partially abduct.
Chapter 5
Shoulder Complex
125
Anterior view
126
Ac ti ve Controllers of th Arthrokinematics at th
Glenohumeral Joint
In th healthy shoulder, th rotator cuff Controls much of
th active arthrokinematics of th GH jo in t.55 Contraction
anterior direction.
T h e p a t h o m e c h a n ic s o f a n t e r io r
d is lo c a t io n o f te n in v o lv e t h c o m b in e d m o t io n s o f e x
t e r n a l r o t a t io n a n d a b d u c t io n o f t h s h o u ld e r . D u r in g
t h e s e m o t io n s , m u s c le c o n t r a c t io n d r iv e s t h h u m e r a l
h e a d o f f t h a n t e r io r s id e o f t h g le n o id f o s s a . In a d d it io n to t h s t a b iliz in g c o n t r o l a f f o r d e d b y t h r o t a t o r c u f f
m u s c le s , t h h u m e r a l h e a d is n o r m a lly p r e v e n t e d fr o m
d is lo c a t in g a n t e r io r ly b y t h m id d le a n d in f e r io r G H l i g a
m e n t s a n d a n t e r io r - in f e r io r rim o f t h g le n o id la b r u m .
A n t e r io r d is lo c a t io n c a n t e a r p a r t o f t h g le n o id l a
b r u m .42-45 A b n o r m a l s h a p e o r s iz e o f t h h u m e r a l h e a d
o r g le n o id f o s s a m a y p r e d is p o s e t h p e r s o n t o in s t a b ility o f t h G H jo in t . 59
of th horizontally oriented supraspinatus produces a compression force directly imo th glenoid fossa. The compression force stabilizes th humeral head frmly against th
fossa during its supenor roll (Fig. 5 - 5 5 ) . Compression
Deltoid
Supraspinatus
Subscapularis
Infraspinatus
Teres minor
FIGURE 5-55. Anterior view of th right shoulder showing th force couplc between th deltoid and rotator cuff
muscles during active shoulder abduction. The deltoids
superior-directed line-of-force rolls th humeral head upward. The supraspinatus rolls th humeral head into ab
duction, and compresses th joint for added stability. The
remaining rotator cuff muscles (subscapularis, infraspina
tus, and teres minor) exert a downward translational
force on th humeral head io counteract excessive superior translation. Note th internai moment arm used by
both th deltoid and supraspinatus.
Chapter 5
c le o f t h e n t ir e s h o u ld e r c o m p le x . In a d d it io n t o it s r o le
in a s s is t in g t h d e lt o id d u r in g a b d u c t io n , t h m u s c le a ls o
p r o v id e s d y n a m ic a n d , a t t im e s , s t a t ic s t a b ilit y to t h G H
jo in t. B i o m e c h a n ic a lly , t h s u p r a s p in a t u s is s u b j e c t e d to
la r g e in t e r n a i f o r c e s , e v e n d u r in g q u it e r o u t in e a c t iv it ie s .
T h e s u p r a s p in a t u s h a s a n in t e r n a i m o m e n t a r m f o r s h o u l
d e r a b d u c t io n o f a b o u t 2 5 m m ( a b o u t 1 in ). S u p p o r t in g a
lo a d b y t h h a n d 5 0 c m ( a b o u t 20 in ) d is t a i t o t h G H jo in t
c r e a t e s a m e c h a n ic a l a d v a n t a g e o f 1 : 2 0 (i.e ., t h r a t io o f
in t e r n a i m o m e n t a r m o f t h m u s c le to t h e x t e r n a l m o
m e n t a r m o f t h lo a d ) . A 1 : 2 0 m e c h a n ic a l a d v a n t a g e
times greater t h a n
127
s h a r e d b y t h m id d le d e lt o id , b u t n e v e r t h e le s s t h s u p r a
s p in a t u s
T h e s u p r a s p in a t u s m u s c le m a y b e t h m o s t u t iliz e d m u s -
im p lie s t h a t t h s u p r a s p in a t u s m u s t g e n e r a t e a f o r c e
Shoulder Complex
20
t h w e ig h t o f t h lo a d ( s e e C h a p t e r 1).
T h e s e h ig h f o r c e s , g e n e r a t e d o v e r m a n y y e a r s , m a y p a r t ia lly t e a r t h m u s c le t e n d o n a s it in s e r t s o n t h c a p s u le
is
s u b j e c t e d to s u b s t a n t f a f f o r c e . P e r s o n s w it h a
p a r t ia lly t o r n s u p r a s p in a t u s t e n d o n a r e a d v is e d to h o ld
o b j e c t s d o s e t o t h b o d y , t h e r e b y m in im iz in g t h f o r c e
d e m a n d s o n t h m u s c le .
E x c e s s iv e w e a r o n t h s u p r a s p in a t u s m u s c le m a y b e
a s s o c i a t e d w it h e x c e s s i v e w e a r o n o t h e r m u s c le s w it h in
t h r o t a t o r c u f f g r o u p . T h is m o r e g e n e r a i c o n d it io n is
o fte n re fe rre d to a s " r o ta t o r c u ff s y n d ro m e ." T h e c o n d i
t io n in c lu d e s p a r t is i t e a r s o f t h r o t a t o r c u f f t e n d o n s ,
in f la m m a t io n a n d a d h e s io n s o f t h c a p s u le , b u r s it is , p a in ,
a n d a g e n e r a liz e d f e e lin g o f s h o u ld e r w e a k n e s s . T h e s u
p r a s p in a t u s t e n d o n is p a r t ic u la r ly v u ln e r a b le t o d e g e n e r a
t io n if c o u p le d w it h a n a g e - r e la t e d c o m p r o m is e in its
b lo o d s u p p ly . 8 D e p e n d in g o n t h s e v e r it y o f t h r o t a t o r
c u f f s y n d r o m e , t h a r t h r o k in e m a t ic s a t t h G H j o in t m a y
b e c o m p le t e ly d is r u p t e d a n d im m o b ile . T h is v e r y d is a b lin g
c o n d it io n is o f te n r e f e r r e d t o a s a " f r o z e n s h o u ld e r . "
a n d t h h u m e r u s . F o r t u n a t e ly , t h h ig h f o r c e d e m a n d s a r e
128
Section li
Upper Extremily
and th
effort of
and th
assist th
Chapter 5
Shoulder Complex
129
5 -5 8 ).
FIGURE 5-58. The hypertrophied righi posterior deltoid of a Tirio Indian man engaged in bow fishing.
Note th strong synergistic action between th tight lower ttapezius (LT) and righi posterior deltoid (PD).
The lower trapezius must anchor th scapula to th spine and provide a fixed proximal attachment for th
strongly activated posterior deltoid. (Courtesy of Dr. Mark J. Plotkin: Tales of a Shamans Apprenlice. VikingPenguin, New York, 1993.)
130
Section II
Upper Extremity
Superior view
FIGURE 5 60. Superior view of th right shoulder showtng actions of three internai rotators when th distai (humeral) segment is fixed
and th trunk is free to rotate. The line-of-force of th pectoralis major is shown with its internai moment arm originating about th
glenohumeral joint s vertical axis. Inset contains th roll-and-slide arthrokinematics during th concave-on-convex motion.
Chapter 5
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29. Rendali FP, McCreary AK, Provance PG: Muscles: Testing and Function,
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40. Neumann DA, Seeds R: Observations from etneradiography analysis.
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4L OBrien SJ, Neves MC, Amoczky SP, et al: The anatomy and histology
of th inferior glenohumeral ligament complex of th shoulder. Am J
Sports Med 18:449-456, 1990.
42 O Connell PW, Nuber GW, Mileski RA, et al: The contribution of th
glenohumeral ligaments to anterior stability of th shoulder joint. Am J
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43. Paletta GA, Warner JJP, Warren RF, et al: Shoulder kinematics with
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45. Palmer WE, Caslowitz PL: Anterior shoulder instabiiity: Diagnostic criterta determined from prospective analysis of 121 MR arthrograms.
Radiology 197:819-825, 1995.
46. Payne LZ, Deng XH. Craig EV, et al: The combined dynamic and static
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47 Petersson CJ, Redlund-Johnell I: The subacromial space in normal
shoulder radiographs. Acta Orthop Stand 55:57-58, 1984.
48 Poppen NK, Walker PS: Normal and abnormal monon of th shoulder.
J Bonejotnt Surg Am 58A T95-201, 1976.
49. Poppen NK, Walker PS: Forces at th glenohumeral joint in abduction.
Chn Orthop 135:165-170, 1978
50. Reis FP, deCamargo AM, Vitti M, deCarvalho CA: Electromyographic
study of th subclavius. Acta Anat 105:284-290, 1979.
51. Robinson CM: Fractures of th clavicle in th aduli. J Bone Joint Surg
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52 Saha AK: Mechamsm of shoulder movements and a plea for th recognition of zero position" of glenohumeral joint. Clin Orthop 173:3-10,
1983
53. Schwartz E, Warren RF, OBnen SJ, et al: Posterior shoulder instabiiity.
Orthop Clin North Am 18:409-419, 1987.
54. Sharkey NA, Marder RA, Hanson PB: The entire rotator cuff contributes
to elevation of th arm. J Orthop Res 12:699-708, 1994
55. Sharkey NA, Marder RA: The rotator cuff opposes superior translation
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56. Shibuta H, Tamai K, Tabuchi KL Magnetic resonance imaging of th
shoulder in abduction. Clin Orthop 348:107113, 1998
57. Soslowsky LJ, Flatow EI, Bigliani LU, et al: Quaniificaiion of in situ
contact areas at th glenohumeral joint: A biomechamcal study. J Or
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58. Steindler A: Kinesiology of th Human Body, Springfield, 111, Charles C
Thomas, 1955.
132
Seciion II
Upper Exiremity
>9. Stevens KJ, Preston BJ, Wallace WA, et al: CT imaging and threedimensional reconstructions of shoulders with anterior glenohumeral
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passive shoulder restrainis. AmJ Sports Med 19:26-34, 1991.
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62. Ticker JB, Bigliant LU, Soslowsky LJ, et al: Inferior glenohumeral ligament: geometrie and strain-rate dependent properties. J Shoulder Elbow
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in th piane of th scapula. Bull Hosp Joint Dis 38:107-111 1977
65. Warner JJ, Deng XH, Russell WF, et al: Slatic capsuloltgamentous restraints lo superior-infenor translation of th glenohumeral joint Am |
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66. Watson CJ, Sehenkman M: Physical therapy management of tsolated
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ADDITI0NAL REA0INGS
Basmajian JV: Musdes Alive. Their Functions Reveatcd by Electromyography,
4th ed. Baltimore, Williams & Wilkins, 1978.
Bey MJ, Huston LJ, Blasier RB, et al: Ligamentous restraints to extemal
rotatton of th humerus in th late-cocking phase of throwing: A cadaveric biomechantcal investigation AmJ Sports Med 28:200-205, 2000
Codman EA: The Shoulder Boston, Thomas Todd Company, 1934
h a p t e r
TOPICS
OSTEOLOGY, 133
AT
GLANCE
151
P ro n a to r M u s c le s , 169
INTRODUCTION
The elbow and forearm complex consists of three bones and
four joints (Fig. 6 - 1 ) . The humeroulnar and humeroradial
joints form th elbow. The motions of flexion and extension
of th elbow previde a means to adjust th overall functional
length of th upper limb. This function is used for many
important activities, such as feeding, reaching, and throwing,
and personal hygiene.
The radius and ulna articulate with one another within
th forearm at th proximal and distai radioulnar joints. This
set of articulations allows th palm of th hand to be turned
up (supinated) or down (pronated), without requiring motion of th shoulder. Pronation and supination can be performed in conjunction with, or independent from, elbow
flexion and extension. The interaction between th elbow
and forearm joints greatly increases th range of effective
hand placement.
Humeroulnar joint
Humeroradial joint
Proximal radioulnar joint
Distai radioulnar joint
OSTEOLOGY
Mid-to-Distal Humerus
The anterior and posterior surfaces of th mid-to-distal hu
merus provide proximal attachments for th brachialis and
th mediai head of th triceps brachii (Figs. 6 - 2 and 6 - 3 ) .
The distai end of th shaft of th humerus terminates medially as th trochlea and th mediai epicondyle, and laterally
133
134
Seciion II
Upper Extremitv
Anterior view
as th capitulum and lateral epicondyle. The trochlea resembles a rounded, empty spool of thread. On either side of th
trochlea are its mediai and lateral lips. The mediai lip is
prominent and extends iarther distali)' than th adjacent
lateral lip. Midway between th mediai and lateral lips is th
trochlear groove which, when looking from posterior to ante
rior, spirals slightly toward th mediai direction (Fig. 6 - 4 ) .
The coronoid fossa is located just proximal to th anterior
side of th trochlea (see Fig. 6 2).
FIGURE 6 -2 . The antenor aspect of th righi humerus. The muscles proximal attachments are shown in red. The dotted lines show
th capsular attachments of th elbow joint.
Chapter 6
135
Posterior view
Ulna
The ulna has a very thick proximal end with distinct processes (Figs. 6 - 5 and 6 - 6 ) . The olecranon process forms th
large, blunt, proximal tip of th ulna, making up th point
of th elbow (Fig. 6 - 7 ) . The roughened posterior surface of
th olecranon process accepts th attachment of th triceps
brachii. The coronoid process projects sharply from th anterior body of th proximal ulna.
tendon
Trochlea
FIGURE 6-3. The posterior aspect of th righi humerus. The muscle's proximal attachments are shown in red. The dashed lines show
th capsular attachments around th elbow joint.
Trochlear groove
Lateral III
Capitulum
Lateral
epicondyle
Mediai
epicondyle
Posterior
FIGURE 6-4. The distai end of th righi humerus, inferior view.
136
Section 11
Upper Extremity
Radius
A nterior view
Trochlear notch
Coronoid process
Flexor digitorum
superficialis
Brachialis on
tuberosity of
th ulna
Biceps on
bicipital tuberosity
Posterior view
Qlecranon proc,
Triceps
Pronator teres
(Ulnar head)
Anconeus
Flexor digitorum
superficialis
Supinator
Flexor digitorum
superficialis
(on oblique line)
Supinator
(proximal
attachment on
supinator crest)
Flexor digitorum
profundus
Flexor digitorum
profundus
----------Biceps
Pronator teres
Aponeurosis for:
Extensor carpi ulnaris
Flexor carpi ulnaris
Flexor digitorum profundus
Interosseous
membrane
Pronator
teres
Interosseous membrane
Extensor
pollicis
brevis
Ulnar notch
Brachioradialis
Extensor indicis
FIGURE 6-5. The anterior aspect of th right radius and ulna. The
muscles proximal aitachments are shown in red and distai attachments in gray. The dashed lines show th eapsular aitachments
around th elbow and wrist and th proximal and distai radioulnar
joints. The radiai head is depicted from above to show th concavity of th fovea.
%o\d
ProceSS
Sfyltd
Process
FIGURE 6-6. The posterior aspect of th right radius and ulna. The
muscles proximal attachments are shown in red and distai attachments in gray. The dashed lines show th eapsular attachments
around th elbow and wrist and th proximal and distai radioulnar
joints.
Chapter 6
L ateral view
137
ARTHROLOGY_______________________
Pati 1: Joints of th Elbow
GENERAL FEATURES OF THE HUMEROULNAR AND
HUMERORADIAL JOINTS
The elbow joint consists of th humeroulnar and humeroradial articulations. The tight fit between th trochlea and
trochlear notch at th humeroulnar joint provides most of
th elbows structural stability.
Early anatomists classified th elbow as a ginglymus or
hinged joint owing to its predominant uniplanar motion of
flexion and extension. The tema modified funge joint is
actually more appropriate since th ulna experiences a
slight amount of axial rotation (i.e., rotation about its own
longitudinal axis) and side-to-side motion as it flexes and
extends.29 Bioengineers must account for these relatively
small extra-sagittal accessory motions in th design of el
bow joint prostheses. Without attention to this detail, th
prostiaetic implants are more likely to demonstrate prema
ture loosening.2
Norma! "Valgus Angle" of th Elbow
Styloid process
Depression fo r
articular disc
Styloid process
Dorsal tuberete
Ulnar notch
Styloid process
Lateral
The radiai head is a disclike structure located at th extreme proximal end of th radius. Most of th outer rim of
th radiai head is covered with a layer of articular cartilage.
The rim of th radiai head contacts th radiai notch of th
ulna, forming th proximal radioulnar joint.
The superior surface of th radiai head consists of a
shallow, cup-shaped depression known as th fovea. This
cartilage-lined concavity articulates with th capitulum of th
humerus, forming th humeroradial joint. The biceps brachii
muscle attaches to th radius at th bicipital tuberosity, a
roughened region located at th anterior-medial edge of th
proximal radius.
Mediai
FIGURE 6-8. The distai end of th right radius and ulna with
carpai bones removed. The forearm is in full supination. Note th
prominent ulnar head and nearby styloid process of th ulna.
138
Seclion 11
Upper Extremity
FIGURE 6-9. A The elbows axis of rotation (shown as red line) extends slightly obliquely in a medial-lateral
3
* r0U,fh ' he caPitu um a" d lh,e trochiea- Normal cubitus valgus of th elbow ,s shown with th forearm
deviateci laterally frani th longitudinal axis o( th humerus axis about 18 degrees. B, Excessive cubitus vakus
tZZRXSZSXSZ
30
- M - wiih
Chapter 6
139
T AB L E
Valgus
Extension and io a lesser extern
flexion
Valgus
Flexion
Varus
Varus
Flexion
Distraction of th radius
140
Section II
Upper Extremity
M ediai aspect
KINEMATICS
Lateral aspect
Annidar ligament
Radiai
collateral ligament
Lateral
collateral ligament
Lateral (ulnar)
collateral ligament
Ulna
Supinator crest
Chapter 6
141
FIGURE 6-14. A graph showing ihe percent loss in area of forward reach of th arm from th shoulder to finger as a
function of th severity of an elbow flexion contracture in th horizonial axis. Note th sharp increase in th reduction in
reach as th flexion contracture exceeds 30 degrees. The figures across th bottoni of th graph depict th progressive
loss of reach indicateci by th increased semicircle area, as th flexion contracture becomes more severe.
Hyaline cartilage covers about 300 degrees of articular surface on th trochlea compared with only 180 degrees on th
trochlear notch. In order for th humeroulnar joint to he
fully, passively extended, sufficient extensibility is required
in th dermis, flexor muscles, anterior capsule, and anterior
fibers of th mediai collateral ligament (Fig. 6 -1 7 A ). Once
in full extension, th humeroulnar joint is stabilized by th
increased tension in most of th anterior fibers of th mediai
collateral ligament, anterior capsule, and flexor muscles, particularly th broad tendon of th brachialis. The prominent
tip of th olecranon process becomes wedged into th olecranon fossa. Excessive ectopie (from th Greek root ceto;
142
Seclion II
Upper Extremily
FIGURE 6 15. Range ol motion al th elbow. A, Typical healthy elbow showing ihe extern of range of motion from 5 degrees bevond
extension (hyperextenston) through 145 degrees of flexion. The 100-degree functional are" from 30 to 130 degrees of flexton in red
based on th htstogram. B The histogram shows th range of motion at th elbow typically needed to perform th following activities
ol daily hving: open.ng a oor, pouring from a pitcher, nsing from a chair, holding a newspaper, cutting with a knife, bringing a fork to
th rnouth, bnngmg a glass to th mouth, and holding a telephone. (Modifed with permission from Morrey BF, Askew LJ, An KN et al
A btomechanical study of normal functional elbow motion. J Bone Joint Surg 63A:872-876, 1981.)
Chapter 6
143
FIGURE 6-17. A sagittal seciion through th humeroulnar joint. A, The joint is resting tn full
extension. B, The joint is passively flexed through
full flexion. Note that in full flexion, th coronoid
process of th ulna fits imo th coronoid fossa of
th humerus. The medtal-lateral axis of rotation is
shown through th center of th trochlea. The
stretched (taut) structures are shown as thin elongated arrows, and slackened structures are shown
as wavy arrows. AC = anterior capsule, PC =
posterior capsule, MCL-Anterior = anterior fibers
of th mediai collateral ligament, MCL-Posterior =
posterior fibers of th mediai collateral ligament.)
See text for further details.
144
Sedioli II
Upper Extremity
susceptible to injury when th fully extended elbow receivea violent valgus force, often from a fall (Fig. 6 - 2 2 ) . Thd
anterior capsule may be involved with th valgus injury :
th joint is also lorced into hyperexlension. The mediai co
latemi ligament is also susceptible to injury from repeutivq
valgus forces in non-weight-bearing activities, such as pitching a baseball and spiking a volleyball.2,5
In severe elbow injuries, th trochlear notch of th ulni
may dislocate postenor to th trochlea of th humerus (Fig
FIGURE 6 - 2 1 . Holding a load, such as a suitcase, places a distaldirected distrading force predominantly through th radius. This
distraction slackens th interosseous membrane shown by wavy
arrows over th membrane. Other structures, such as th oblique
cord, th annular ligament, and th brachioradialis, must assist with
th support of th load. The stretched (taut) structures are shown
as thin elongated arrows, and th slackened structures are shown as
wavy arrows.
Chapter 6
145
146
Section II
Upper Extremity
Olecranon process
(with cartilage)
Olecranon
process
Fovea
Annular ligament
(with cartilage)-
Radiai
collateral
ligament (cut) -
-A rticu la r su dace on
trochlear notch
Annular ligament -
;ju
i 3 M
w
w U
TO'v i
/ 3
Radiai notch
1
I
,
.
i
B
FIGURE 6-25. The tight proximal radioulnar joint as viewed from above. A, The radius is held against the radiai notch of the ulna
b> th annular ligament. B. The radius is removed, exposing the internai surface of the concave component of the proximal radio1
ulna, jomt. Note the cartilage hning the ennre fibro-osseous ring. The quadrate ligament is cut near its attachment to die neck oflhe
Chapter 6
147
FIGURE 6-26. Three examples of causes of pulled elbow syndrome." (Redrawn wiih permission
from Leus RM: Dislocations of th childs elbow. In Morrey BF (ed): The Elbow and Its Disorders,
3rd ed. Philadelphia, WB Saunders, 2000. By permission of th Mayo Foundation for Medicai
Education and Research.)
KINEMATICS
Stabilizers of th Distai Radioulnar Joint
148
Section II
Upper Extremily
Ulnar collateral
ligament (cut)
Scaphoid facet
Lunate facet
Articular disc
(distai surface)
anftenorrvew of lhf n8hl dislal radioulnarjoint. A, The ulnar head has been pulled away from che concaviiy formed
n t n f^ |
mMSUrr frlhn artlCUf ^ SC and,lhe Ulnar notch of the radius- B The dlslal forearm has been tilted slightly io expose
an ndL Hi, r 1
u
^
and ]t\ c0ecl10
* e palmar capsular ligament of the disiai radioulnar joint. The
articular disc (also called th tnangular fbrocartilage), the capsular hgaments, and the ulnar collateral ligament are collectively referred
hv lnocarpal con,plex- See text for further descriptions. The scaphoid and lunate facets on the distai radius show impressici
made by these carpai bones at the radiocarpal joint of the wrist.
1
0 (Neutral)
80
D
.
Pronation
60
40
20
<n
Neutral a>
o 20
Q
40
Supination
60
80
phone
paper
Chapter 6
torcami rotation from about 50 degrees of pronation
irough 50 degrees of supination .28 Similar lo th elbow
joint, a 100 degree functional are exists an are that does
~ot include ihe terminal ranges of motion. Persons who lack
ie last 30 degrees of complete forearm rotation are stili
eapable of performing many routine activities of daily living.
Supination at th proximal radioulnar joint occurs as a spinning of th radiai head within th fibro-osseous ring formed
by th annular ligament and radiai notch of th ulna (Fig.
- - 2 9 , bottom inset). Supination at th distai radioulnar joint
occurs as th concave ulnar notch of th radius rolls and
sltdes in similar directions on th head of th ulna (Fig.
6 - 2 9 , top inset). During supination, th proximal surface of
th articular disc remains in contact with th ulna head. At
th end range of supination, th palmar capsular ligament is
stretched to its maximal length, creating a stiffness that natu-ally stabilizes th jo in t .42'50
Pronation
The arthrokinematics of pronation at th proximal and distai
radioulnar joints occur by mechanisms similar io those defcribed for supination (Fig. 6 - 3 0 ) . As depicted in th top
inset of Figure 6 - 3 0 , full pronation maximally elongates th
dorsal capsular ligament at th distai radioulnar joint, as th
palmar capsular ligament slackens to about 70% of its origi
nai length .44 Full pronation exposes th articular surface of
S P E C I A L
F O C U S
149
6 - 3
Anterior
Lateral
FIGURE 6-29. Illustration on th left
shows th anterior aspect of a righi
forearm after completing full supinalion. During supination, th radius
and hand (shown in red) rotate
around th fixed humerus and ulna
(shown m gray). The inactive but
siretched pronator teres is also
shown. Viewed as though lookng
down at th right forearm, th two
insets depict th arthrokinematics at
th proximal and distai radioulnar
joints. The stretched (taut) structures
are shown as thin elongated arrows,
and slackened structures are shown
as wavy arrows. See text for further
details.
Lateral
150
Section II
Upper Extremity
Anterior
Styloid process
Mediai
epicondyle
Limit Pronation
Chapter 6
; stationary, or fixed, humerus and ulna (see Figs. 6 - 2 9 and
6 -3 0 ). The rotation of th forearm occurs when th upper
kmb is assumed to be in a non-weight-bearing posinoti. Prona::on and supination are next described when th upper limb
s assumed to be in a weight-bearing position. In this case,
th humerus and ulna rotate relative to a stationary, or fxed,
radius and hand.
Consider a person hearing weight through an upper extremity with elbow and wrist extended (Fig. 6 -3 2 A ). The
oerson's righi glenohumeral joint is held partially internali)'
rotated. The ulna and radius are positioned parallel in full
supination. (The rod" placed through th epicondyles of th
humerus helps with th orientation of this position.) With
die radius and hand held firmly fxed with th ground,
pronation of th forearm occurs by an external rotation of th
humerus and ulna (Fig. 6 -3 2 B ). Because of th tight structural fu of th humeroulnar joint, rotation of th humerus is
transferred, almost degree for degree, to th rotating ulna.
Return to th fully supinated position involves internai rotanon of th humerus and ulna, relative to th fxed radius
and hand.
Figure 6 - 3 2 B depicts an interesting muscle force-couple
used to pronate th forearm from th weight-bearing posiuon. The infraspinatus rotates th humerus relative to a
fixed scapula, while th pronator quadratus rotates th ulna
relative to a fxed radius. Both muscles, acting at either end
of th upper extremity, produce forces that contribute to a
pronation torque at th forearm. From a therapeutic per-
151
Annular
ligament
Proximal Radioulnar
Joint from Above
Anterior
Distai Radioulnar
Joint from Above
A n te rio r
Anterior
FIGURE 6 -3 2 . A, A person is shown supporting his upper body weight through his right forearm, which is in full supination (i.e., th
bones of th forearm are parallel). The radius is held fixed to th ground through th wrist; however, th humerus and ulna are free to
rotate. B, The humerus and ulna have rotated about 8 0 to 90 degrees externally from th initial position shown in A. This rotation
produces pronation at th forearm as th ulna rotates around th fixed radius. Note th activity depicted in th infraspinatus and
pronator quadratus muscles. The two insets each show a superior view of th arthrokinematics at th proximal and distai radioulnar
joints.
152
Seclion II
Upper Extremity
Weight-Bearing
(Radius and Hand Fixed)
Non-weight-bearing
(Radius and Hand
Free to Rotate)
Proximal
Annular ligament and raRadioulnar
diai notch of th ulna
Joint
spin around a fixed ra
diai head.
Distai
Radioulnar
Joint
The anatomie path of these nerves is described as a foundation for this chapter and th following tvvo chapters on th
wrist and th hand.
The musculocutaneous nerve, formed from th C5-7 nerve
roots, innervates th biceps brachii, coracobrachialis, and
brachialis muscles (Fig. 6 -3 3 A ). As its name implies, th
musculocutaneous nerve innervates muscle, then continues
distally as a sensory nerve to th sktn, supplying th lateral
forearm.
The radiai nerve, formed from C5T 1 nerve roots, is a
direct continuation of th posterior cord of th brachial
plexus (Fig. 6 -3 3 B ). This large nerve courses within th
radiai groove of th humerus to innervate th triceps and th
anconeus. The radiai nerve then emerges laterally at th
distai humerus to innervate muscles that attach on or near
th lateral epicondyle. Proximal to th elbow, th radiai
nerve innervates th brachioradialis, a small lateral pari of
th brachialis, and th extensor carpi radialis longus. Distai
to th elbow, th radiai nerve consista of superhcial and
deep branches. The superficial branch is purely sensory, sup
plying th posterior-lateral aspeets of th extrme distai fore
arm and hand, especially concentrated at th dorsal web
space of th thumb. The deep branch contains th remaining
motor fibers of th radiai nerve. This motor branch supplies
th extensor carpi radialis brevis and th supmator muscle.
After piercing through an intramuscular tunnel in th supinator muscle, th final section of th radiai nerve courses
toward th posterior side of th forearm. This terminal
branch, often referred to as th posterior interosseous nerve,
supplies th extensor carpi ulnaris and several muscles of th
forearm, which function in extension of th digits.
The median nerve, formed from C - T 1 nerve roots,
courses toward th elbow to innervate most muscles attaching on or near th mediai epicondyle of th humerus. These
muscles include th wrist flexors and forearm pronators
(pronaior teres, flexor carpi radialis, and palmaris longus),
and th deeper flexor digitorum superficialis (Fig. 6 -3 3 C ). A
deep branch of th median nerve, often referred to as th
IN N E R V A T IO N TO M U S C L E
Chapter 6
153
A MUSCULOCUTANEOUS NERVE ( C ^
Brachial Plexus
Lateral cord
Posterior cord
Mediai cord
Deltoid
Lateral brachial
cutaneous nerve
Biceps brachii-
Axillary nerve
Lateral antebrachial
cutaneous nerve
Musculocutaneous nerve
Sensory Distribution
Iilustration continued
ott
following page
154
Section II
Upper Extremity
B R A D I L N E R V E ( C ^ - I *)
Brachial Plexus
Extensor indicis
FIGURE 6-33 Conti,med. B, The generai path of th tight radiai nerve is shown as il innervates most of th
extensors of th arm forearm, wnst, and digits. See text for more detail on th proxtmal-lo-distal order of
muscle innervai,on. Ihe sensory dtstribunon of th radiai nerve is shown with its area of concentrated supply
at th dorsal web space of th hand.
1 }
Illustration continued on opposite page
Chapter 6
155
Area of concentrated
Brachial Plexus
Lateral cord
Mediai cord
Sensorv Distribution
Flexor-Pronator Group
Pronator teres
Palmaris longus
Opponens pollicis
Lumbricals (lateral-half)
156
Section II
D U L N A R N E R V E (C8-T')
Brachisi Plexus
Lateral cord
Scnsory D istrihution
Median nerve
Ulnar nerve
Mediai epicondyle
Flexor digitorum
profundus (medial-half)
See
median
nerve
Cutaneous branches
Palmaris brevis
Abductor digiti minimi
O D o rs a l interassei (4)
See median nerve
n r iio c c
Chapter 6
TABLE
Muscle
Innervation
157
Elbow flexors
Brachialis
Biceps brachii
Brachioradialis
Pronator teres
Elbow extensors
Triceps brachii
Anconeus
Forearm supinators
Biceps brachii
Supinator
Forearm pronators
Pronator quadratus
Pronator teres
TABLE
ELBOW FLEXORS
The biceps brachii, brachialis, brachioradialis, and pronator
teres are primary elbow flexors. Each of these muscles produces a force that passes anterior to th medial-lateral axis of
rotation at th elbow. Structural and related biomechanical
variables of these muscles are included in Table 6 - 5 .
Individuai Muscle Action of th Elbow Flexors
The biceps brachii attaches proximally on th scapula and
distally on th bicipital tuberosity on th radius (Fig. 6 - 3 4 ) .
Secondar)' distai attachments are made into th deep fascia
of th forearm through an aponeurotic sheet known as th
fibrous acertus.
The biceps produces its maximal electromyography
(EMG) levels when performing both flexion and supination
simultaneously,5 sudi as bringing a spoon to th mouth. The
biceps exhibits relatively low levels of EMG activity when
flexion is performed with th forearm deliberately held in
pronation. This lack of muscle activation can be verified by
self-palpation.
The brachialis muscle lies deep to th biceps, originating
on th anterior humerus and attaching distally on th extreme proximal ulna (Fig. 6 - 3 5 ) . According to Table 6 - 5 ,
th brachialis has an average physiologic cross-section of 7
cm! , th largest of any muscle Crossing th elbow. For comparison, th long head of th biceps has a cross-sectional
area of only 2.5 cm2. Based on its large physiologic crosssection, th brachialis is expected to generate th greatest
force of any muscle Crossing th elbow.
The brachioradialis is th longest of all elbow muscles,
attaching proximally on th lateral supracondylar ridge
Peak Force
Leverage
V o lu m e (cm 3)
L e n g th (cm ) f
P h y sio lo g ic
C r o s s - s e c tio n a l
A r e a (cm 2)
In te r n a i M om en t
A rm ( c m ) )
33.4
13.6
2.5
3.20
30.8
15.0
2.1
3.20
7.0
1.98
Work Capacity
M u scle
Brachialis
59.3
9.0
Brachioradialis
21.9
16.4
1.5
5.19
Pronator teres
18.7
5.6
3.4
2.01
* Structural properties are indicateci by italics. The related biomechanical variables are indicated above in bold
t Internai moment arm measured with elbow flexed to 100 degrees and forearm fully supinated.
(Data from An KN, Hui FC, Morrey BF, et al: Muscles across th elbow joint: A biomechanical analysis. j Biomech 14:659-669, 1981.)
158
Seclion
II
Upper Extremily
The brachioradialis muscle can be readily palpated
th anterior-lateral aspect of th forearm. Resisted el
flexion, from a position of about 90 degrees of flexion
neutral foreann rotation, causes th muscle to stand out
bowstring sharply across th elbow (Fig. 6 - 3 6 ) . .
bowstringing of this muscle mcreases its flexion monr
arm to a length that exceeds all other flexors (see T
6 -5 ).
Biomechanics of th Elbow Flexors
FIGURE 6-34. Anterior view of th righi biceps brachii and brachioradialis muscles. The brachialis is deep to th biceps.
Chapter 6
S P E C I A L
159
F O C U S
Brachioradialis
FIGURE 6 - 3 7 .
The righi brachioradialis muscle is shown bowsringing over th elbow during a maximal effort isometric activanon.
GURE 6 - 3 6 .
Torque (kg-cm)
Torque (kg-cm)
Males
Females
Flexion
725 (154)
336 (80)
Extension
421 (109)
210 (61)
Pronation
73 (18)
36 (8)
Supination
91 (23)
44 (12)
* These are reporied for ihe major movemenis of th elbow and forearm. Standard deviauons are in parentheses. Data are from 104 healthy
subjects; X age male = 41 yrs, X age Iemale = 45.1 yrs. The elbow is
maintamed in 90 degrees of flexion with neuiral forearm rotation. Data are
shown for domnanl limb only.
Conversions: .098 N-m/kg-cm.
(Data from Askew 1.J, An KN, Morrey BF, et al: Isometric elbow strength
in normal individuate. Clin Orthop 222:261-266, 1987.)
160
Secton II
Upper Exiremity
6 - 3 8 A). The predicted maximal lorque for all muscles occurs at about 90 degrees of flexion, which agrees in generai
with actual torque measurements made on healthy persons.40-49
The two primary factors responsible for th overall shape
of th maximal torque-angle curve of th elbow flexors are
(1) th muscles maximal flexion force potential and (2) th
internai moment arm length. The data plotted in Figure
6 - 3 8 B predict that th maximal force of all muscles occurs at a muscle length that corresponds with about 80
degrees of flexion. The data plotted in Figure 6 - 3 8 C predici
that th average maximal internai moment arm of all mus
cles occurs at about 100 degrees of flexion. Ai this joint
angle, insertion of th biceps tendon to th radius is about
90 degrees (see Fig. 6 - 3 7 ) . This mechanical condition maximizes th internai moment arm of a muscle and thereby
maximizes th conversion of a muscle force to a joint
torque. li is interesting that th data presented in Figures 6 38B and C predict peak torques across generally similar joint
angles.
Polyarticular Biceps Brachii: A Physiologic Advantage of
Combining Elbow Flexion with Shoulder Extension
I
A
\i
Chapter 6
161
ELBOW EXTENSORS
Muscular Components
The primary elbow extensors are th triceps brachii and th
anconeus. These muscles converge to a common tendon attaching to th olecranon process of th ulna (Figs. 6 - 4 1 and
6 -4 2 ).
The triceps brachii has three heads: long, lateral, and
mediai. The long head has its proximal attachment on th
infraglenoid tubercle of th scapula, thereby allowing th
muscle to extend and adduct th shoulder. The long head
has an extensive volume, exceeding all other muscles of th
elbow (Table 6 - 7 ) .
The lateral and mediai heads of th triceps muscle have
their proximal attachments on th humerus, on either side
and along th radiai groove. The mediai head has an exten
sive proximal attachment on th posterior side of th hu
merus, occupying a location relatively similar to that of th
brachialis on th bones anterior side.
The anconeus muscle is a small triangular muscle spanning th postenor side of th elbow. The muscle is located between th lateral epicondyle of th humerus and
a strip along th posterior aspect of th proximal ulna
(see Fig. 6 - 4 1 ) . The anconeus appears as a fourth head
of th extensor mechanism, similar to th quadriceps at th
knee.
The triceps brachii produces th majority of th total
extensor torque at th elbow. Compared with th tri
ceps muscle, th anconeus has a relatively small crosssectional area and a small moment arm for extension (see
Table 6 - 7 ) .
Electromyographic Analysis of Elbow Extension
162
Section II
Upper Extremity
S P E C I A L
F O C U S
6 - 5
Contraction of th elbow flexor muscles is typically performed to rotate th forearm to th arm. Contraction of
th same muscles, however, can rotate th arm to th
forearm, provided that th distai aspect of th upper ex
tremity is well fixed. A clinical example of th usefulness
of such a "reverse contraction" of th elbow flexors is
shown for a person with C6 quadriplegia (Fig. 6-40).
The person has complete paralysis of th trunk and lower
extremity muscles, but near normal strength of th shoulder, elbow flexor, and wrist extensor muscles. With th
distai aspect of th upper limb well fixed by action of th
wrist extensor muscles, th elbow flexor muscles can
generate sufficient force to rotate th arm toward th
forearm. This maneuver allows th elbow flexor muscles
to assist th person while moving up to a sitting position.
Interestingly, th arthrokinematics at th humeroulnar joint
during this action involve a roll and slide in opposite
directions.
isometric contraction or very low-velocity eccentric activation. In contrast, these same muscles are required to gen
erate ver)' large and dynamic extensor torques through
high-velocity concentric or eccentric activations. Consider
activities such as throwing a ball, pushing up frotn a low
chair or rapidly pushing open a door. As with many explosive pushing activities, elbow extension is typically combined with some degree of shoulder Uexion (Fig. 6 - 4 3 ) . The
shoulder flexion function of th anterior deltoid is an important synergistic component of th forward push. The an-
Chapter 6
TABLE
163
FIGURE 6-4 2 . A posterior view shows ihe righi mediai head of ihe
triceps brachii The long head and lateral head of th triceps are
partially removed to expose th deeper mediai head,
W ork Capacity
M uscle
V o lu m e (cm J)
C ontraction
E xcursion
Peak Force
Leverage
L e n g th (cm ) t
P h y sio lo g ic
C r o s s -s e c tio n a l
A r e a (c m 2)
In te rn a i M om en t
A rni (cm )!
66.6
10.2
6.7
1.87
38.7
6.3
6.1
1.87
47.3
8.4
6.0
1.87
6.7
2.7
2.5
.72
Anconeus
* Structural properties are indicated by italics. The related biomechanical variables are indicated above in bold.
t Muscle belly length measured at 70 degrees of flexion.
$ Internai moment arm measured with elbow flexed to 100 degrees.
(Data from An KN, Hui FC, Morrey BF, et ai: Muscles across th elbow joint: A biomechanical analysis. J Biomechan 14:659-669, 1981.)
166
Section II
Upper Extremity
Supinators
Pronators
Attive Supination
Low-Power
Supinator
Biceps
Pronator Teres
tor Quadratus
Moderate-Power
High-Power
Supinator
Biceps
Pronator Teres
Pronator Quadratus
Elbow Flexed 90
T30=
T30 =
T30 =
T3o =
By x IMA
(sine 30" x 500 N) x IMA
250 N x 1 cm
250 Ncm
l___________
FIGURE 6-49. The difference in th ability of th biceps to produce a supination torque is illustrated when th elbow is flexed 90
degrees, and th elbow is flexed 30 degrees. Top, lateral view shows th biceps attaching to th radius at a 90-degree angle. The muscle
(B) is contracting to supinate th forearm with a maximal effort force of 500 N. The calculations show that th maximum supination
torque at a 90-degree elbow angle (T90) is 500 Ncm (th product of th maximal force (B) times th 1-cm internai moment arm (IMA)).
Bottom, th angle of th insertion of th biceps to th radius is 30 degrees. The biceps force of 500 N (B) must be trigonometrically
resolved into that which supinates (By) and that whtch runs paraltel to th radius (Bx). The calculations show that th maximum supination
torque with th elbow flexed 30 degrees is reduced to 250 Ncm (sine 30 degrees = .5, and cosine 30 degrees = .86).
167
168
Section II
Upper Exiremity
Chapter 6
169
PRONATOR MUSCLES
The primary muscles for pronation are th pronator quadra
li^ and th pronator teres (Fig. 6 - 5 1 ) . The llexor carpi
radialis and th palmaris longus are secondary pronators,
both attaching to th mediai epicondyle of th humerus (see
Fig. 6 -4 6 B ).
Palmaris longus
S P E C I A L
F O C U S
-URE 6-51, Anterior view of th right pronator teres and prona: quadratus.
When high-power supination torques are needed to vigorly turn a screw, th biceps is used to assist other mus, such as th supinator muscle and extensor pollicis lon(Fig. 6 - 5 0 ) . The elbow is usually held flexed to about
degrees in order to augment th supination torque potenof th biceps. The maintenance of this elbow posture
ring th task requires that th triceps muscle co-contract
chronously with th biceps muscle. The triceps supply
essential force during this activity since it prevents
biceps from actually flexing th elbow and shoulder
ring every supination effort. Unopposed biceps action
~es th screwdriver to be pulled away from th screw
ever}' effort hardly effective. By attaching to th ulna
rsus th radius, th triceps is able to neutralize th elbow
on tendency of th biceps without interfering with th
ination task. This muscular cooperation is an excellent
mple of how two muscles can function as synergists for
activity, while al th same time remain as direct antagos.
170
Seciicm II
Upper Extremity
FIGURE 6-52. A, Anierior view of th distai radioulnar joini shows th line-of-force of th pronator quadratus intersecting th
forcami s axis of rotation (white rod) at a tight angle. 6, The line-of-foree of th pronator quadratus, with its internai moment arm,
is shown with th wrist removed and forearm in full supination. The pronator quadratus produces a pronation torque, which is th
product of pronator muscle's force times th internai moment arm, and a compression force between th joint surfaces (opposing
arrows). C, This dual function of th pronator quadratus is shown as th muscle pronates th forearm to th midposition. The rolland-slide arthrokinematics are also mdicated
The pronator teres has two heads: humeral and ulnar. The
median nerve passes between these two heads. The pronator
teres functions as a primary forearm pronator, in addinoti to
an elbow flexor. This pronator teres produces its greatest
EMG activity during higher power pronation actions,6 such
as attempting to unscrew an overtightened screw with th
right hand or pitching a baseball. The triceps is an important
synergist to th pronator teres, often required to neutralize
th tendency of th pronator teres to flex th elbow.
In cases of median nerve injury proximal to th elbow, all
pronator muscles are paralyzed, and active pronation is essentially lost. The forearm tends to remain chronically supinated owing to th unopposed action of th innervated supinator and biceps muscles.
Chapter 6
17. Goel VK, Singh D, Bijlani V: Contact arcas in human elbow joints. J
Biomech Eng 104:169-175, 1982.
18. Inman VT, Saunders JB: Referred pain from skeletal siructures. J Nerv
Ment Dis 99:660-667, 1944.
19. Kapandji IA: The Physiology of th Joints, voi 1. 5th ed. Edinburgh,
Churchill Livingslone, 1982.
20. Kleinman YVB, Graham TJ: The distai radioulnar joint capsule: Clinical
anatomy and role in post-traumatic limitatton of forearm rotation. J
Hand Surg 23A:588-599, 1998.
21 Le Bozec S, Maton B, Cnockaerl JC: The synergy of elbow extensor
muscles durmg static work in man. Eur J Appi Physiol 43:57-68,
1980.
22. Lehmkuhl LD, Smith LK: Brunnstrom's Clinical Kinesiology, 4th ed
Philadelphia, FA Davis, 1983.
23. Lindau T, Adlercreutz C, Aspendberg P: Periphcral tears of th triangular fibrocartilage complex cause dista) radioulnar joint instability after
distai radiai fractures. j Hand Surg 25A:464-468, 2000.
24. MacConaill MA, Basmajian JV: Muscles and Movements: A Basis for
Human Kinesiology. New York, Robert E. Krieger, 1977.
25. Maloney MD, Mohr KJ, E1 Attrache NS: Elbow injures in th throwing
athlete. Clin Sports Med 18:795-809, 1999.
26. Morrey BF: Post-traumatic contracture of th elbow: Operative treat
ment including dtstraction arthroplasty. ) Bone Joint Surg 72A:601618, 1990.
27 Morrey BF, An KN: Funcnonal anatomy of th ligaments of th elbow.
Clin Onhop 201:84-90, 1985.
28. Morrey BF, Askew LJ, An KN, et al: A biomechanical study of normal
functional elbow motion. J Bone Joint Surg 63A:872-876, 1981.
29. Morrey BF, Chao EY: Passive motion of th elbow joint. J Bone Joint
Surg 58A:501-508, 1976.
30. Morrey BF, An KN, Stormont TJ: Force transmission through th radiai
head. J Bone Joint Surg 70A:250-256, 1988.
31. Morrey BF, Tanaka S, An KN: Valgus stability of th elbow. Clin
Orthop 265:187-195, 1991.
32. Murray WM, Delp SL, Buchanan TS: Variation of muscle moment arms
with elbow and forearm positions. J Biomech 28:513-525, 1995.
33. Nakamura T, Yabe Y, Horiuchi Y: Dynamic changes in th shape of th
triangular fibrocartilage during rotalion demonstrated with high resolu
tion magnetic resonance imaging. J Hand Surg 24B:338-341, 1999.
34. Neumann DA: Use of th diaphragm to assist in rolling in th patient
with quadriplegia. Phys Ther 59:39, 1979.
35. Neumann DA, Soderberg GL, Cook TM. Electromyographic analysis of
hip abductor musculature in healthy right-handed persons. Phys Ther
69:431-440, 1989
36. Olsen BS, Sojbjerg JO, Dalstra M, et al: Kinematics of th lateral ligamentous conslrainls of th elbow joint. J Shoulder Elbow Surg 5:333341, 1996.
37. Palmer AK, Werner FW: Biomechanics of th distai radioulnar joint.
Clin Orthop 187:26-35, 1984.
38. Peirie S, Collins JG, Solomonow M, et al. Mechanoreceptors in th
human elbow ligaments. J Hand Surg 23A:512-518, 1998.
39. Pfaeffle HJ, Fischer KJ, Manson TT, et al: Role of th forearm interosseous ligament: Is it more than just longitudinal load transfer? J Hand
Surg 25A:683-688, 2000.
40 Provins KA, Salters N: Maximum torque exerted about th elbow joint.
J Appi Phys 7:393-398, 1955
41. Regan WD, Korinek SL, Morrey BF, et al: Biomechanical study of
ligaments around th elbow joint. Clin Orthop 271:170-179, 1991.
171
ADDITIONAL READINGS
Bade H, Koebke J, Schluter M: Morphology of th articular surfaces of th
distai radio-ulnar joint. Anat Ree 246:410-414, 1996.
Davidson PA, Pink M, Perry J, et al: Functional anatomy of th flexor
pronator muscle group in relation to th mediai collateral ligament of
th elbow. Am J Sports Med 23:245250, 1995.
Eckstein F, Lohe F, Hillebrand S, et al: Morphomechanics of th humeroulnar joint: 1. Joint space width and contact areas as a function of load
and flexion angle. Anat Ree 243:318-326, 1995.
Fleisig GS, Andrews JR, Dillman CJ, et al: Kinetics of baseball pitching with
implications about injury mechanisms. Am ] Sports Med 23:233-239,
1995.
Kihara H, Short WH, Werner FW, et al: The stabilizing mechanism of th
distai radioulnar joint during pronation and supination. J Hand Surg
20A:930-936, 1995.
London JT: Kinematics of th elbow. J Bone Joint Surg 63A:529-535, 1981.
ODriscoll SW, Horii E, Morrey BF, et al: Anatomy of th ulnar part of th
lateral collateral ligament of th elbow. Clin Anat 5:296-303, 1992.
Palmer AK, Werner FW: The triangular fibrocartilage complex of th wrist:
Anatomy and function. J Hand Surg 6:153-161, 1981.
Pauly JE, Rushing JL, Scheving LE: An electromyographic study of some
muscles Crossing th elbow joint. Anat Ree 159:47-53, 1967.
Sojbjerg JO: The stiff elbow Acta Orthop Scand 67:626-631, 1996.
Totterman SMS, Miller RJ: Triangular fibrocartilage complex: Normal appearance on coronai three-dimensional gradient-recalled-echo MR mages. Radiology 195:521-527, 1995.
h a p t e r
Wrist
Donald A. Neum ann , P hD, PT
TOPICS
OSTEOLOGY, 172
AT
GLANCE
INTRODUCTION
The wrist contains eight small carpai bones, which as a group
act as a flexible spacer between th forearm and hand (Fig.
7 - 1 ) . In addition to several small intercarpal joints, th wrist
or carpus functions as two major aniculations. The radiocarpal
joint is located between th distai end of th radius and th
proximal row of carpai bones. Just distai io this joint is th
midcarpal joint, located between th proximal and distai row
of carpai bones. These two joints allow th wrist to flex and
extend and to move from side to side in a motion called
radiai and ulnar deviation. The distai radioulnar joint is considered part of th forearm complex, rather than th wrist,
due io its role in pronation and supination.
The position of th wrist significanti)' affects th function
of th hand. Many muscles that control th fngers originate
extrinsic lo th hand, with their proximal attachments lo
cated in th forearm. The position of th wrist, therefore, is
criticai in setting th length-tension relationship of th ex
trinsic finger muscles. A fused, painful, or weak wrist often
assumes a posture that interferes with th optimal length of
th extrinsic musculature. The kinesiology of th wrist is
ver)' much linked to th kinesiology of th hand.
Several new terms are introduced here io describe th
relative position, or topography, within th wrist and th
hand. Palmar and volar are synonymous with anteror; dorsal
is synonymous with posterior. These terms are used interchangeably throughout this chapter and th next chapter on
th hand.
172
OSTEOLOGY
Distai Forearm
The dorsal surface of th distai radius has several grooves
and raised areas that help guide many tendons of extrinsic
muscles (Fig. 7 - 2 ) . For example, th palpable dorsal (or
Lister's) tu barle separates th tendons of th extensor carpi
radialis brevis from th extensor pollicis longus.
Chapter 7
Wrist
173
Carpai Bones
From a radiai (lateral) to ulnar direction, th proximal row
of carpai bones includes th scaphoid, lunate, triquetrum,
and pisiform. The distai row includes th trapezium, trapezoid, capitate, and hamate (Figs. 7 - 2 , 7 - 3 , 7 - 5 , and 7 - 6 ) .
Scaphoid
Lunate
Triquetrum
Pisiform
Distai Row of Carpai Bones
Trapezium
Trapezoid
Capitate
Hamate
Dorsal view
174
Section II
Upper Extremity
Pai m ar view
-Trapezoid
Pisiform
Flexor carpi ulnaris
Triquetrurrv
Distai and
proximal poles of scaphoid
Styloid process
Styloid process
Groove for extensor pollicis longus
and abductor pollicis longus
Brachioradialis
Pronator quadratus
bones relattve position and shape is helpful in an understanding of th ligamentous anaiomy and wrist kinematics.
SCAPHOID
The scaphoid, or navicular, is named based on its vague
resemblance to a boat (navicular: from th Latin navicularis;
pertaining to shipping). Mosi of th hull or bottom of th
boat rides on th radius; th cargo area of th boat is filled
with th head of th capitate (see Fig. 7 - 3 ) . The scaphoid
contacts four carpai bones and th radius.
The scaphoid has two convex surfaces called poles. The
proxima pale articulates with th scaphoid facet of th radius
(see Fig. 6 - 2 7 ) . The distai pale of th scaphoid is a slightly
rounded surface, which articulates th trapezium and trape
zoid. The scaphoid has a rather large and blunt tubercle,
which projects palmarly from th distai pole. The scaphoid
Anterior view
Mediai view
Chapter 7
Wrist
175
Triquetrum
Trapezoid
Capitate
Scaphoid
LUNATE
TRIQUETRUM
PISIFORM
The pisiform, meaning shaped like a pea, articulates
loosely with th palmar surface of th triquetrum. The pisi-
Prestyloid recess
collateral ligament
Articular disc
with meniscal extension
Sacciform recess
(within distai radioulnar joint)
176
Secton II
Upper Extremity
CAPITATE
The capitate is th largest of all carpai bones, occupying a
centrai location within th wrist. The word capitate is derived from th Latin root meaning head, which describes th
shape of th bones proximal surface. The large head articulates with th deep concavity provided by th scaphoid and
lunate. The axis of rotation for all wrist motion passes
through th capitate. The capitate is well stabilized between
th hamate and trapezoid by short strong ligaments.
The capitates distai surface is rigidly joined to th base of
th third and, to a lesser extern, th second and fourth
metacarpal bones. This rigid articulation allows th capitate
and th third metacarpal to function as a single column,
providing significant longitudinal slability to th entire wnst
and hand.
TRAPEZIUM
The trapezium, or greater multangular bone, has an asymmetric shape. The proximal surface is slightly concave for
articulation with th scaphoid. O f partcular im portan ce is
th distai saddle-shaped surface, which articulates with th
TRAPEZOID
The trapezoid, or lesser multangular, is a small bone wedged
tightly between th capitate and th trapezium. The trape
zoid, like th trapezium, has a proximal surface that is
slightly concave for articulation with th scaphoid. The bone
makes a relatively frm articulation with th base of th
second metacarpal bone.
HAMATE
The hamate is named after th large hooklike process that
projects from its palmar surface. The hamate has a generai
shape of a pyramid. Its base, or distai surface, articulates
with th bases of th fourth and fifth metacarpals. This
articulation provides mobility to th ulnar aspect of th
hand, most noticeably when cupping th hand.
The apex of th hamate, its proximal surface, projects
toward th concave surfaces of th lunate. The hook of th
hamate and th pisiform bone provides attachment for th
mediai side of th transverse carpai ligament (see Fig. 7 - 5 ) .
Carpai Tunnel
As illustrated in Figure 7 - 5 , th palmar side of th carpai
bones forms a concavity. Arching over this concavity is a
thick fibrous band of connective tissue known as th trans
verse carpai ligament. This ligament is connected to four
raised points on th palmar carpus, namely, th pisiform
and th hook of th hamate on th ulnar side and th
tubercles of th scaphoid and th trapezium on th radiai
side. The transverse carpai ligament serves as a primary
attachment site for many muscles located within th hand
and th palmaris longus, a wrist flexor muscle.
The transverse carpai ligament converts th palmar con
cavity made by th carpai bones into a carpai tunnel. The
tunnel serves as a passageway for th median nerve and th
tendons of extrinsic digitai flexor muscles.
ARTHROLOGY_________
Joint Structure and Ligaments of th Wrist
JOINT STRUCTURE
The primary joints of th wrist are th radiocarpal joint and
th midcarpal joint (see Fig. 7 - 1 ) . Many less significant intercatpa joints exist betw een adjacent carpai bon es (see Fig.
/ - 6 ) . fntercarpal joints contribute to wrist motion through
small gliding motions. Compared with th large range of
motion permitted at th radiocarpal and midcarpal joints,
motion at th intercarpal joints is relatively small. Nevertheless, it is important to th completion of full range of wrist
motion.
Chapter 7
Joints of th Wrist
Radiocarpal joint
Midcarpal joint
Mediai companment
Lacerai compartment
Intercarpal joints
Radiocarpal Joint
The proximal components of th radiocarpal joint are th
concave surfaces of th radius and th adjacent articular disc
(Fig. 1 - 7 A). The distai components of this joint are th
convex proximal surfaces of th scaphoid and th lunate.
The triquetrum is also considered part of th radiocarpal
joint because at full ulnar deviaiion its mediai surface makes
contact with th articular disc (see Fig. 7 - 6 ) .
The thick articular surface of th distai radius and th
articular disc accept and disperse th forces that pass from
th carpus to th forearm. Approximately 20% of th total
compression force that crosses th wrist passes through th
disc. The remaining 80% passes directly through th scaph
oid and lunate to th radius.20 The contact areas at th
radiocarpal joint tend to be greatest when th wrist is extended and ulnarly deviated.1'1 This is a wrist position where
maximal grip strength is obtained.
Midcarpal Joint
The midcarpal joint is th articulation between th proximal
and distai row of carpai bones (see Fig. 7 - 7 ) . The capsule
that surrounds th midcarpal joint is continuous with each
of th intercarpal joints.
Wrist
177
The midcarpal joint can be divided into mediai and lateral joint compartments.38 The larger mediai compartment is
formed by th convex head of th capitate and apex of th
hamate, fitting into th concave recess formed by th distai
surfaces of th scaphoid, lunate, and triquetrum (Fig. 7 -7 B ).
The head of th capitate fts into this concave recess much
like a ball-in-socket joint.
The lateral compartment of th midcarpal joint is formed
by th junction of th slightly convex distai pole of th
scaphoid with th slightly concave proximal surfaces of th
trapezium and th trapezoid. The lateral compartment lacks
th pronounced ovoid shape of th mediai compartment.
Cineradiography of wrist motion shows less movement at
th lateral than th mediai compartment.17 For this reason,
subsequent arthrokinematic analysis of th midcarpal joint
focuses on th mediai compartment.
WRIST LIGAMENTS
Many of th ligaments of th wrist are small and difficult to
isolate. Their inconspicuous nature does not, however, indi
cate their kinesiologic importance. Wrist ligaments are essential to maintaining naturai intercarpal alignment and transferring forces through and across th carpus.2 Muscles supply
th forces for active wrist motion, and ligaments supply th
control and guidance to arthrokinematics. Ligaments that are
damaged through injury and disease leave th wrist vulnerable to deformation and instability.
Wrist ligaments are classified as extrinsic or intrinsic.33
Extrinsic ligaments have their proximal attachments outside
th carpai bones, but attach distally to th carpai bones.
Intrinsic ligaments, in contrast, have both their proximal and
distai attachments on carpai bones (Table 7 - 1 ) .
Dorsal view
Ulnar collateral
ligament (cut)
Articular
Scapholunate ligament
Lunate
Ulnar collateral
ligament (cut)
Triquetrum
Lunate
Scaphoid
(proximal pole)
Scaphoid
Dorsal capsular ligament
Scaphotrapezial ligament (cut)
Radiai collateral ligament (cut)
Trapezium
Scaphotrapezial
ligament (cut)
Head of capitate
Mediai compartment
M idcarpal jo in t |
Lateral compartment
FIGURE 7-7. A, Dissected right wnst showing a dorsal view of th radiocarpal and midcarpal joints. Refer to text for description of
ligaments and other soft tissues. 8, Red and gray highlight th lateral and mediai compartments of th midcarpal joint.
178
Section II
Upper Extremity
E xtrinsic Ligaments
Dorsal radiocarpal ligament
Radiai collateral ligament
Palrnar radiocarpal ligam ents
Radiocapitate
Radiolunate
Radioscapholunate
U lnocarpal com plex
Articular disc
Ulnar collateral ligament
Palmar ulnocarpal ligament
Intrinsic Ligam ents
Short ligam ents of th distai row
Interm ediate ligam ents
Lunotriquetral
Scapholunate
Scaphotrapezial
Long ligaments
Palmar intercarpal
Extrinsic Ligaments
A fibrous capsule surrounds th extemal surface of th wrist
and th distai radioulnar joint. Dorsally, th capsule thickens
slightly io fonti ligamentous bands known as th dorsal
radiocarpal ligaments (Fig. 7 - 8 ) . The ligaments are thin and
very difficult to distinguish from th capsule itself.
In generai, th dorsal radiocarpal ligaments travel distally
in an ulnarly direction, from th distai radius to th dorsal
surfaces of th scaphoid and th lunate. A larger discrete set
of fibers extends to th triquetrum. The dorsal radiocarpal
ligaments remforce th posterior side of th radiocarpal joint,
becoming taut in full flexion.30
The luterai part of th wrist capsule is strengthened by
fibers called th radiai collateral ligament. These fibers attach
proximally to th styloid process, and distally at th scaph
oid tubercle, trapezium, and adjacent transverse carpai liga
ment (see Figs. 7 - 6 and 7 - 8 ) . This ligament provides only
part ol th lateral stability to th wrist. A major portiott is
lumished by extrinsic muscles, such as th abductor pollicis
longus and th extensor pollicis brevis. The radiai collateral
ligament is more developed palmar-laterally than dorsal-laterally. Ihese fibers, therefore, become maximally taut when
ulnar deviation of th wrist is combined with extension.
Deep and separate from th palmar capsule of th wrist
are several stout and extensive ligaments known collectively
as th palm ar radiocarpal ligaments. These include th radiocapitate ligament, th radiolunate ligament, and, in a deepe r
piane, th radioscapholunate ligament (Fig. 7 - 9 ) . Each liga
ment arises from a roughened area on th distai radius,
travels distally in an ulnar direction, and attaches to th
Dorsal view
Chapter 7
179
Wrist
Palmar view
Lunotriquetral ligament
Ulnar collateral
ligament
Ulnocarpal complex
P a l r ulnocarpal
ligament
------- Articular disc
- Palmar radiocarpal
Radioscapholunate*
li9ament
180
Secfton II
Upper Extremity
FIGURE 7-11. Osteokinematics of th wrist. A, Flexion and exiension. B, Ulnar and radiai deviation. Note thai flexion
exceeds extension and ulnar deviation exceeds radiai deviation.
ARTHROKINFMATICS
S(ud'es ,lave quantified carpa/ bone kinematics using various
technical methods, often as a prerequisite to th design of
wrist joint prostheses.2 These methodologies include th
following:
X-ray
Anatomie dissection
Placement of pins in bones
Three-dimensional computer imaging
Sonic digitizing
Cineradiography
Stereophotography
Optoelectric Systems
Magnetic tracking devices
S P E C I A L
F O C U S
//
ulnar deviation.5-27
C hapler 7
Wrist
181
The arthrokinematics of wrist extension are based on synchronous convex-on-concave rotations at th radiocarpal and
midcarpal joints. Al th radiocarpal joint shown in red in
Figure 7 - 1 4 , extension occurs as th convex surface of th
lunate rolls dorsally on th radius and simultaneously slides
palmarly. Rotation directs th lunates distai surface in an
extended, dorsal direction. At th midcarpal joint shown in
gray in Figure 7 - 1 4 , th head of th capitate rolls dorsally
on th lunate and simultaneously slides in a palmar direc
tion. Combining th arthrokinematics over both joints produces about 60 degrees of total wrist extension. An advantage of two joints contributing to a motion is that a
significant total range of motion is produced by only moder
ate rotations at each individuai joint. Mechanically, this combination allows each joint to move within a more restricted
and more stable are of motion.
Full wrist extension elongates th palmar radiocarpal ligaments (see Fig. 7 - 1 4 ) and th palmar capsule and th wrist
and finger flexor muscles. Tension within these structures
stabilizes th wrist in its close-packed position of extension.13
Stability in wrist extension is useful when weight is borne
through th upper extremity during activities such as crawltng on th hands and knees, and pushing up when transferring from a wheelchair to a bed.
The arthrokinematics of wrist flexion are similar to those
described for extension, but occur in a reverse fashion (see
Fig. 7 - 1 4 ) . The wrist is not very stable in full flexion and is
poorly suited to accept weight-bearing forces through th
upper extremity.
Describing flexion and extension of th wrist using th
centrai column concep allows an excellent conceptualization
of a rather complex event. A limitation of th model, however, is that it does not account for all th carpai bones that
participate in th motion. For instance, th model ignores
Carpometacarpal
joint
Midcarpal joint
Radiocarpal joint
182
Seciion II
Upper Extremity
Daterai view
_ i ______ i___
NEUTRAL
Carpometacarpal
joint
Midcarpal joint
FIGURE 7-14. A model of th centrai column of th righi wrist showing flexion and extension. The wrist in th
center is shown at resi, in a neutral position. The roll-and-slide arthrokinematics are shown in red for th
radiocarpal joint and in light gray for th midcarpal joint. Dtiring wrist extension Qeft), th dorsal radiocarpal
ligaments become slackened and th palmar radiocarpal ligaments taut The reverse arthrokinematics occur durine
wrist flexion (tight).
Chapter 7
Wrisl
183
Palmar view
Carpometacarpal
Midcarpal
joint
Scaphoid
tuberete
Articolar
disc
Radiocarpal
joint
FIGURE 7-15. X-rays and mechanical depiction of th arthrokinematics of ulnar and radiai deviation for th righi wrist. The rolland-slide arthrokinematics are shown in red for th radiocarpal joint and in light gray for th midcarpal joint. (Arthrokinematics
are based on observations made from cineradiography conducted at Marquette University, Milwaukee, Wl, in 1999.)
S P E C I A L
ments. A doubl
System of ligaments illustrates one way in
which ligaments help control ulnar and radiai deviation (Fig.
7 - 1 6 ) . 33 in th neutral position, th four ligaments of th
doubl V System appear as two inverted V s. The distai in-
F O C U S
184
Section 11
Upper Extremity
Palmar v ie w
FIGURE 7 16 rhe tensing and slackening of th doubl V System ligaments of th wrist are illustrated. The collateral ligaments are
also shown. The bones have been blocked together for simplicity. Tarn lines represent ligaments under tncreased tension.
Carpai Instability
The pathomechanics of carpai instability occur in many
forms.32 Esseruially all types o f carpai instability lead to a
loss o f function due to a loss ol normal anatomie alignment.
The following examples describe two common types' of car
pai instability.
Chapter /
Wm(
185
COMPRESSION FORCE
B
FIGURE 7-18. A, Acting through ligaments, th scaphoid provides a mechanical linkage between th relatively mobile lunate and th rigid
distai row of carpai bones. B, Compression forces through th wrist
from a fall may fracture th scaphoid
and tear th scapholunate ligament.
Loss of th mechanical link provided
by th scaphoid often leads to lunate
instability and/or dislocation.
Scaphotrapezial
ligament
Unstable
lunate
Scapholunate
ligament
186
Seaion II
Upper Extremity
FIGURE 7-20. This shows how th ulnar tilt of th distai radius can
predispose an individuai to ulnar translocation of th carpus. Compression forces (Fc) that cross th wrist are resolved into (1) a force
vector acting perpendicularly to th radiocarpal joint (Fy) and (2) a
force vector (F) running parallel to th radiocarpal joint. The Fy
force compresses and stabilizes th radiocarpal joint with a magnitude of about 90% of F( (cosine 25 degrees X Fc). The F force
tends to translate th carpus in an ulnar direction, however, with a
magnitude ol 42% of Fc (sine 25 degrees X Fc). Note that th fiber
direction of th palmar radiocarpal ligaments resists this naturai
ulnar translation of th carpus. The greater th ulnar tilt and/or th
greater th compression force across th wrist, th greater th potential for th ulnar translation.
Other than th flexor carpi ulnaris, no tendon of any extrinsic muscle attaches directly to th carpai bones. Most mus
cles exert their primary action at th wrist through their
distai attachmenis to th base of th metacarpals and phalanges. Extrinsic muscles to th hand, such as th extensor
pollicis longus and th flexor digitorum superficialis, are
considered in detail in Chapter 8. The attachments and
nerve supply of th muscles of th wrist can be found in
Appendix TIC.
As depicted in Figure 7 - 1 2 , th axis of rotation for all
wrist motion is located at th base of th capitate. No wrist
muscle actually crosses th wrist directly antenor-posierior
or medial-lateral to this axis of rotation. All muscles, therefore, have moment arms of varying lengths to produce
torques in both th sagittal and frontal planes. The extensor
carpi radialis brevis, for example, passes dorsally to th
wrists medial-lateral axis of rotation and laterally to th
wrists anterior-posterior axis of rotation. This muscle has a
moment arm for wrist extension as well as radiai deviation.
Table 7 - 2 lists th cross-sectional areas of most muscles
that cross th wrist. This information helps predict a mus
cles relative force potential.13 Some research describes th
position and length of moment arms for most wrist muscles
as they cross th head of th capitate.35 Combining these
data provides a useful method for estimating th action and
relative torque potential of wrist muscles (Fig. 7 - 2 1 ) . Con
sideri for instance, th extensor carpi ulnaris and th flexor
carpi ulnaris. By noting th location of each muscle from th
axis of rotation, it is evident that th extensor carpi ulnaris is
an extensor and ulnar deviatori and th flexor carpi ulnaris
is a flexor and ulnar deviator. Because both muscles have
similar cross-sectional areas, they likely produce comparable
levels of maximal force. In order to estimate th relative
______
* Esumateci.
t Excluding th extensor indicis and extensor digiti mimmi.
(Data Irom Fick R: Lehmkuhl LD, Smith LK: Brunnstroms Clinical
Kinesiology, 4th ed. Philadelphia, FA Davis, 1983.)
Chapter 7
7-21.
187
Palmar
Radiai (Lateral)
A distai perspective
through th righi carpai tunnel similar
io that in Figure 7 -5 . The plot shows
th cross-sectional area and th internai
moment arm for most muscles that cross
th wrist at th level of th head of th
capitate. The area each muscle occupies
on th grid is proportional to its crosssection area and, therefore, is indicative
of relative maximal force production.
The wrists medial-lateral (ML) axis of
rotation (gray) and anterior-posterior
(AP) axis of rotation (red) intersect at
th capitate bone. Each muscles internai
moment arm for a particular action is
equal to th linear distance each muscle
lies from either axis. The length of each
internai moment arm (expressed in cm)
is indicateci by th major tic marks. As
sume that th wrist is held in a neutral
posiiion.
FIGURE
Wrist
Posterior view
Primary
Extensor carpi radialis longus
Extensor carpi radialis brevis
Extensor carpi ulnaris
Secondar)'
Extensor digitorum communis
Extensor indicis
Extensor digiti minimi
Extensor pollicis longus
188
Scction II
Upper Extremity
FIGURE 7-23. A dorsal oblique view shows a crosssection of th tendons of th extensor muscles of th
wrist and digits passmg through th extensor retinaculum of th wrist. All muscles that cross th dorsal
aspect of th wrist travel within one of six fibrous
tunnels embedded within th extensor retinaculum.
Synovial lining is indicated by red.
Extensor
carpi radialis
brevis
Extensor
pollicis longus
FIGURE 7-24. Muscle mechanies are shown that are involved with
FIGURE 7-25. The compression forces produced by a maximal effort grip are shown for different wrist positions. Maximal grip force
occurs at about 30 degrees of extension. (Data are from three
subjects. With permission from lnman VT, Ralston HJ, Todd F,
Human Walking. Baltimore, Williams & Wilkins, 1981.)
Chapter 1
The most active wrist extensor muscle during light closure of th fist is th extensor carpi radialis brevis. As grip
force increases, th extensor carpi ulnaris, followed closely
by th extensor carpi radialis longus, joins th activated
extensor brevis.24 Activities that require repetitive forceful
grasp, such as hammering or playing tennis, may overwork
th wrist extensors, especially th highly active extensor
carpi radialis brevis. A condition known as lateral epicondylitis, or tennis elbow, occurs from stress and resultant inflammation of th proximal attachment of th wrist exten
sors.4
As evident in Figure 7 - 2 5 , grip strength is significanti)'
reduced when th wrist is fully flexed. The decreased grip
strength is caused by a combination of two factors. First,
and likely foremost, th finger flexors cannot generate ade
quate force because they are functioning at an extremely
shortened (slackened) length on their length-tension curve.
Second, th overstretched finger extensors, particularly th
extensor digitorum communis, create a passive extensor
torque at th fingers, which further reduces effective grip
force. This combination of physiologic events explains why a
person with paralyzed wrist extensors has difficulty producing an effective grip even though th finger flexors remain
fully innervated. Attempts at producing a maximal-effort grip
when th wrist extensore are paralyzed results in a posture
of finger flexion with wrist flexion (Fig. 7 - 2 6 A). Stabilizing
th wrist in greater extension enables th finger flexor muscles to nearly triple their grip force (Fig. 7 -2 6 B ). Manually
or orthotically preventing th wrist from flexing maintains
th extrinsic finger flexors at an elongated length more conducive to th higher force production.
Ordinarily, th person depicted in Figure 7 - 2 6 weare a
splint that holds th wrist in 10 to 20 degrees of extension.
When th radiai nerve fails to re-innervate th wrist extensor
muscles, a tendon from another muscle is often surgically
Wrist
189
transferred to provide wrist extension torque. Often, th pronator teres muscle, innervated by th median nerve, is connected lo th tendon of th extensor carpi radialis brevis. Of
th three primary wrist extensors, th extensor carpi radialis
brevis is located most centrally at th wrist and has th
greatest moment arm for extension (see Fig. 7 - 2 1 ) .
Primary
Flexor carpi radialis
Flexor carpi ulnaris
Palmaris longus
Secondar y
Flexor digitorum profundus
Flexor digitonim superficialis
Flexor pollicis longus
190
Section II
Upper Extremity
Anterior view
FIGURE 7-27. Anterior view of th tight ibrearm showing th primary wrist flexors muscles: flexor carpi radialis, palmaris longus,
and flexor carpi ulnaris. The flexor digitorum superficialis is shown
as a wrist flexor because of its large potential to assist with this
action. The pronator teres muscle is shown but does not flex th
wrist.
Palmar view
Lnaptcr
Flexion
Extension
Radiai deviation
Ulnar deviation
Mean Peak
Torque (Nm)
12.2 (3.7)
7.1 (2.1)
11 (2)
9.5 (2.2)
Angles of
Peak Torque
Figure 7 - 2 9 shows th radiai deviator muscles contracting while using a hammer. All these muscles pass laterally to
th wrists anterior-posterior axis of rotation. The action of
th extensor carpi radialis longus and th flexor carpi radi
alis, shown with moment arms, illustrates a fine example of
two muscles cooperating as synergists for one action and
acting as antagonists in another. By opposing each others
flexion and extension potential, these muscles stabilize th
wrist in an extended position necessary to grasp th hammer
effectively.
The primary muscles capable of ulnar deviation of th
wrist are th extensor carpi ulnaris and th flexor carpi
ulnaris. Figure 7 - 3 0 shows both ulnar deviator muscles
contracting to drive a nail with a hammer. Both th flexor
and extensor carpi ulnaris contract synergistically to perform
th ulnar deviation, bui also stabilize th wrist in a slightly
extended position. Because of th strong functional association between th flexor and extensor carpi ulnaris muscles,
injury to either muscle can incapacitate th overall kinetics
of ulnar deviation. For example, rheumatoid arthritis often
causes inflammation and pain in th extensor carpi ulnaris
tendon near its distai attachment. Attempts ai active ulnar
deviation with minimal to no activation in th pain fui exten
sor carpi ulnaris causes th action of th flexor carpi ulnaris
EPB\
ApL \ ^ /
--------
iv i
40 of flexion
From 30 of flexion to
70 of extension
0 (neutral)
0 (neutral)
wnst
Wrist Movement
)r~
192
Seciion II
Upper Extremily
REFERENCES
1. Backdahl M, Carlsoo S: Distribution of activity in muscles acting on th
wrist. Acta Morph. Neerl Scand 4:136-144, 1961.
2. B erger RA: The ligam en ts o f th w rist: A c u rre n t OverView of an ato m y
1997.
3. Berger RA, lmeada T, Berglund L, et al: Constratnt and material properties of th subregions of th scapholunate interosseous ligamem. J Hand
Surg 24:953-962, 1999
4. Blackwell JR, Cole KJ: Wrist kinematics differ in expert and novice
tennis players performing th backhand stroke: Implications for tennis
elbow J Biomech 27:509-516, 1994.
5. Brumfield RH, Champoux JA: A biomechanical study of normal functional wrist motion. Clin Orthop 187:23-25, 1984.
6. Delp SL, Grierson AE, Buchanan TS: Maximum isometric moments
generated by th wrist muscles in flexion-extension and radial-uinar
deviation. J Biomechan 29:1371-1375, 1996.
7. Gray DJ, Gardner E: The innervation of th joints of th wrist and
hand. Anat Ree 151:261-266, 1965.
8. Inman VT, Saunders JB: Referred pain from skeletal structures. J Nerv
Meni Dis 99:660-667, 1944.
9. Kapandji IA: The Physiology of th Joints, voi. 1, 5th ed. Edinburgh.
Churchill Livingstone, 1982.
10. Kauer JMG. The mechamsm of th carpai joint. Clin Orthop 202 1626, 1986.
11. Kobayashi MK, Berger RA, Nagy L, et al Normal kinematics of carpai
bones: A three-dimensional anaiysis of carpai bone motion relative to
th radius.J Biomechan 30:787-793, 1997.
12. Lange A de, Kauer JMG, Huiskes R: The kinematic behavior of th
human wrist joint: A roentgen-stereophotogrammetric anaiysis. Orthop
Res 3:56-64, 1985.
13.
l-t'hmkuh] LD, Sm ith LK: Srunnstrom 's Clinica} Kinesiology, 4th ed.
Phiadelphia, FA Davis, 1983.
15- MacConaill MA, Basmajian JV: Muscles and Movements: A Basis for
Human Kinesiology. New York, Robert E. Krieger, 1977.
16 Mayfield JK, Johnson RP, Kilcoyne RF: The ligaments of th human
wrist and their functional significance. Anat Ree 186:417-428, 1976.
17. Neumann DA: Observations from cineradiography anaiysis. Marquette
University, Milwaukee, WI, 2000.
18. Norkin CC, White DJ: Measurement of Joint Motion: A Guide to Goniometry, 2nd ed. Phiadelphia, FA Davis, 1995.
19. ODriscoll SW, Horii E, Ness R, et al: The relationship between wrist
position, grasp size, and gnp strength. J Hand Surg 17A:169-177
1992.
20. Palmer AK, Werner FW: Biomechanics of th distai radioulnar joint
Clin Orthop 187:26-35. 1984.
21. Palmer AK, Werner FW, Murphy D, et al: Functional wrist motion: A
biomechanical study. J Hand Surg 10A:39-46, 1985
22. Palmer AK, Skahen JR, Werner FW, et al: The extensor retinaculum of
th wrist: An anatomical and biomechanical study. J Hand Surg 10B
11-16, 1985.
23. Patterson RM, Nicodemus CL, Viegas SF, et al: High-speed, threedimensional kinematic anaiysis of th normal wrist. | Hand Surg 23A
446-453, 1998.
24. Radonjic D, Long C: Kinesiology of th wrist. Am J Phys Med 50'5771, 1971
25. Riti MJ, Stuart PR, Berglund LJ, et al: Rotational stability of th carpus
relative to th forearm. J Hand Surg 20A :305-31f, 1995.
26. Ruby LK, Cooney WP, An KN, et al: Relative motion of selected carpai
bones: A kinematic anaiysis of th normal wrist. J Hand Surg 13A 110, 1988.
27 Safaee-Rad R, Shwedyk E, Quanbury AO, et al: Normal functional range
of motion of upper limb joints during performance of three feeding
aerivities. Arch Phys Med Rehabili 71:505-509, 1990.
28. Salmon J, Stanley JK, Trail IA: Kienbocks disease: Conservative man
agement versus radiai shortening. J Bone Joint Surg 82B:820-823
2000
29. Sarrafian SK, Melamed JL, Goshgarian GM: Study of wrist motion in
flexion and extension. Clin Orthop 126:153-159, 1977.
30. Savelberg HHCM, KooloosJGM, Huiskes R, et al: Slrains and forces tn
selected carpai ligaments during in vitro flexion and deviation move
ments of th hand. J Orthop Res 10:901-910, 1992.
31. Shin AY, Battaglia MJ, Bishop AT Lunotriquetral instabilily: Diagnosis
and treatment. J Am Acad Orthop Surg 8:170-179, 2000
32. Stanley JK, Trai! IA: Carpai instabilily. J Bone foint .Surg T6B691-700
1994.
33. Taleisnik J: The ligaments of th wrist. In Taleisnik J (ed): The Wrist.
New York, Churchill Livingstone, 1985.
Chapter 7
34. Tang JB, RyuJ, Han JS, et al: Biomechamcal changes of th wrist flexor
and extensor tendons following loss of scaphoid integrity. J Orthop Res
15:69-75, 1997.
35. Tolbert JR, Blair, WF, Andrews JG, et al: The kinetics of normal and
prosthetic wrists. J Biomech 18:887-897, 1985.
36. Weaver L, Tencer AF, Trumble TE: Tensions in th palmar ligaments of
th wrist. The normal wrist. J Hand Surg 19A:464-474, 1994.
37. Weber HR: Concepts governing th rotational shift of th intercalated
segment of th carpus. Orthop Gin Nonh Am 15:193-207, 1984.
38. Williams PL, Bannister LH, Berry M, et al: Gray's Anatomy, 38th ed,
New York, Churchill Livingstone, 1995.
.39. Wright PE: Wrist. In Crenshaw AH (ed): Campbellss Operative Orthopaedics, voi 5, 8th ed. St. Louis, Mosby, 1992.
40. Youm Y, McMurty RY, Pian AE, et al: Kinemalics of th wrist. 1: An
experimental study of radial-ulnar deviation and flexion-extertsion. J
Bone Joini Surg 60A:423-431, 1978.
41. Youm Y, Flatt AE: Kinematics of th wrist. Clin Orthop 149:21-32,
1980.
ADDITIONAL READINGS
Berger RA. The anatomy and th basic biomechanics of th wrist joint. J
Hand Surg 9:84-93, 1996.
Wrist
193
h a p t e r
Hand
Donald A. Neumann , PT, P h D
TOPICS
TER M IN O LO G Y, 194
OSTEOLOGY, 195
Metacarpals, 195
Phalanges, 196
Arches of th Hand, 196
ARTHROLOGY, 197
AT
GLANCE
212
M USC LE A N D J O IN T IN TE R A C TIO N , 213
Background
Just as our eyes and skin do, th hand serves as an important sensory organ for th perception of our surroundings
(Fig. 8 - 1 ) . The hand is also th primary effector organ for
our most complex motor behaviors. And, th hands help to
express emotions through gesture, touch, craft, and art.
The 19 bones and 19 articulations within th hand are
driven by 29 muscles. Biomechanically, these structures in
ternet with superb proftciency. The hand may be used in a
very primitive fashion, such as a hook or a club. More often,
however, th hand functions as a highly specialized instrument performtng very complex manipulations, requirtng infi
nite levels of force and precision.
Because of its enormous biomechanical complexity, th
function of th hand involves a disproportionately large re-
Th um b , 213
INTRODUCTION
194
TERMINOLOGY_______________
The wrist, or carpus, has eight carpai bones. The hand has
live metacarpals, often referred to collectively as th metacarpus. Each of th live digits contains a set of phalanges.
The digits are designated numerically from one io live, or as
th thumb and th index, middle, ring, and little fingers
Chapter 8
Hand
195
0STE0L0GY
Metacarpals
The metacarpals, like th digits, are designated numerically
as one through five, beginning on th radiai daterai) side.
The morphology of each metacarpal is generally similar
(Figs. 8 - 4 and 8 - 5 ) . The firet (thumb) metacarpal is th
shortest and stoutest. Observe that th second metacarpal is
usuaily th longest, and th length of th remaining three
bones decreases from th radiai to ulnar (mediai) direction.
Each metacarpal has an elongated shaft with articular surfaces ai each end (Fig. 8 - 6 ) . The palmar surface of th shaft
is slightly concave longitudinally to accommodate many
muscles and tendons in this region. Its proximal end, or
base, articulates with one or more of th carpai bones. The
bases of th second through th fifth metacarpal possess
small facets for articulation with adjacent metacarpal bases.
The distai end of each metacarpal has a large convex head
which, as a group, is evident as th knuckles on th dorsal
side of a clenched fist. A pair of poslerior tubercles marks th
attachment sites for th collateral ligaments ai th MCP
joints.
With th hand ai rest in th anatomie position, th
thumbs metacarpal is oriented in a different piane from th
other digits. The second through th fifth metacarpals are
aligned generally side-by-side, with their palmar surfaces facing anteriori)'. The position ol th thumbs metacarpal, however, is rotated almost 90 degrees mediali) (i.e., internali)'),
relative to th other digits (see Fig. 8 -3 A ). Rotalion places
th sensitive palmar surface of th thumb toward th mid
iine of th hand. Optimum prehension depends on flexion
of th thumb occurring in a piane that interseets, versus
parallels, th piane of th flexing fingere. In addition, th
thumbs metacarpal is positioned well anterior, or palmar, io
th other metacarpals (Fig. 8 - 7 ) . This position of th meta
carpal and trapezium is caused by th palmar projection of
th distai pole of th scaphoid.
The location of th first metacarpal allows th entire
thumb to sweep freely across th palm toward th fingers.
Virtuali)' all prehensile motions, from pinch to precision
196
Phalanges
lhe hand has 14 phalanges (th Greek root phalanx; a line
of soldiers). The phalanges within each finger are referred to
as proximal, middle, and distai (Fig. 8 -3 A ). The thumb has
only a proximal and a distai phalanx.
Arches of th Hand
Observe th naturai concavity to th palmar surface of your
relaxed hand. Control of this concavity allows th humar
hand to securely hold and manipulate objects of many anc
varied shapes and sizes. The naturai palmar concavity of th
hand is supported by three integrated arch Systems: two
transverse and one longitudinal (Fig. 8 - 9 ) . The proxim d
transverse arch is formed by th distai row of carpai bones I
This carpai arch is a static, tigid structure that forms th '
carpai tunnel. Like most arches in buildings and bridges, th
arches of th hand are supported by a centrai keystone
structure. The capitate bone is th keystone of th proxima' I
transverse arch, reinforced by strong intercarpal ligaments.
The distai transverse arch passes through th MCP joints
In contrast to th rigidity of th proximal arch, th sides c:
Lnapter 8
Middie(3)
Distai
interphalangeal
joint
Distai
phalanx
Proximal
interphalangeal
joint
Middle
phalanx
Metacarpophalangeal
joint
Proximal
phalanx
nana
IV !
Interphalangeal
joint
ARTHROLOGY
Carpals
Distai
palmar
crease
Proximal
palmar
crease
Carpometacarpal
joint
Metacarpophalangeal
joint (with sesamoid
bone)
Distai
digitai crease
Middle
digitai crease
Proximal
digitai crease
Web space
Distai
wrist
crease
Thenar crease
Proximal
w rist
crease
th distai arch are mobile. To appreciate this mobility, imagine transforming your completely fiat hand into a cupshaped hand that surrounds a baseball. Transverse flexibility
within th hand occurs by action of th peripheral metacarpals (first, fourth, and ftfth) collapsing around th more
stable centrai (second and third) metacarpals. The keystone
of th distai transverse arch is formed by th MCP joints of
these centrai metacarpals.
The longitudinal arch of th hand follows th generai
shape of th second and third rays. The metacarpal or proxi
mal end of this arch is firmly linked to th carpus by th
carpometacarpal (CMC) joints. These rigid articulations pro
vide an important element of longitudinal stability to th
hand. The phalangeal or distai end of th arch is very mo
bile. The mobility is exhibited by flexing and extending th
ftngers. The keystone of th longitudinal arch is provided by
th second and third MCP joints. Note that th MCP joints
serve as keystones to both th longitudinal and distai trans
verse arches.
As depicted in Figure 8 - 9 , all three arches of th hand
are mechanically interlinked. Both transverse arches are
Carpometacarpal Joints
O V ER V IEW
198
Section 11
Upper Exiremity
Distai phalanx
Flexor digitorum
profundus
Middle phalanx
Flexor digitorum
superficialis
Proximal phalanx
Adductor pollicis
(Transverse head)
Opponens pollicis
Lhapter ts
n an a
Dorsal view
Distai phalanx
Tuberosity
Middle phalanx
Proximal phalanx
of th tight wrist and hand. Proximal attachments of muscle are tndicated in red
and distai attachments in gray.
Extensor digitorum
communis and
extensor digiti minimi
Adductor pollicis
Extensor pollicis brevis
Dorsal interossei
Extensor carpi radialis brevis
Extensor carpi ulnaris
1st dorsal
interosseus
Distai
phalanx
Middle
phalanx
FIGURE 8-7. A lateral x-ray with an emphasis on th palmar projection of th thumb (first metacarpal), scaphoid, and trapezium.
Note th contrast in th spatial orientation of th capitale and other
metacarpal bones.
200
Section l
Palmar view
Upper Extremity
Faterai view
FIGURE 8-10. The System for naming th movements within th hand. A to D, Finger moton. to I, Thumb motion. (A, finger extension;
B, finger (lexion; C, finger adduction; D, finger abduction; E, thumb extension; F, thumb flexion; G, thumb adduction; H, thumb
abduction; and i, thumb opposition.)
202
Section 11
Upper llxLremity
Dorsal view
1 TA B LE 8 - 1.
Natne
Anterior oblique
Ulnar collateralt
First intermetacarpal
Posterior oblique
Radiai collaterali
* Ligamem names are based on attachment lo trapezium surfaces noi ihe thumb metacarpal.
t Also called palmar oblique" ligament based on attachment to th metacarpal.
i Also called dorsal-radial" ligament.
Ckapter 8
Hand
203
KINEMATICS
Pai m ar view
FIGURE 8-15. Mobility of th ulnar (fourth and fifth) carpometacarpal joints of th left hand. A, Hand closed but relaxed. B, With a firrn
grip, th finger flexor muscles flex and rotate th ulnar metacarpals.
P a lm a r view
Lateral view
204
Section II
Upper Extremity
P a lm a r vicw
abduction.
Chapter 8
Hand
205
FIGURE 8-19. Abduction of th carpometacarpal joint of th thumb. A, Maximum abduction of 45 degrees opens th web space of
206
Section II
Upper Extremity
N
G roove fo r
fle x o r carpi
ra dialis
f
(\ A
)
D
9a
03
%'
Palmar
FIGURE 8-21. The anhrokinematics of flexion and extension ai th carpomeiacarpal joint of th thumb. A, Flexion is
associated with a slight mediai rotation, causing elongation in th radiai odiatemi ligament. The anterior oblique
ligament is slack. B, Extension is associated with slight lateral rotation, causing elongation of th anterior oblique
ligament. The approximate path of motion of th metacarpal on th trapezium is shown in th insert. Note th analogy
Show,, hccween th anhm kinem atics o f extension and a cow boy fading sidew ays on th horses saddle As th cowbov
faiis sideways (tovvard extension), points on his chesi and rear end boih roli and slide" in th same faterai direction.
TAB LE 8 - 2 Factors Associated with Kinematics of th Primary Motions of th CMC Joint of th Thumb*
Motion
Osteokinematics
Joint Geometry
Arthrokinematics
* P P 0S1U0n and reposition are noi shown because they are dcnved from th two primary planes of motions (see texi for further explanation).
Chapter 8
Hand
207
Metacarpophalangeal Joints
FINGERS
General Features and Ligaments
The MCP joints of th fingers are relatively large, ovoid
articulations between th convex heads of th metacarpals
and th shallow concave proximal surfaces of th proximal
phalanges (Fig. 8 - 2 3 ) . Motion at th MCP joint occurs predominantly in two planes: flexion and extension in th sagittal piane, and abduction and adduction in th frontal piane.
Mechanical stability at th MCP joint is criticai to th
overall biomechanics of th hand. As discussed earlier, th
MCP joints serve as keystones for support of th mobile
arches of th hand. In th healthy hand, stability at th MCP
joints is achieved by an elaborate set of interconnecting connective tissues. Imbedded within th capsule of each MCP
joint is a pair of radiai and ulnar collateral ligam ents and
one palmar ligament or piate (Fig. 8 - 2 4 ) . Each collctterai
ligament has its proximal attachment on th posterior tubercles of th metacarpal head. Crossing th MCP joint in an
oblique palmar direction, th ligament forms two distinct
parts. The cord pari of th ligament is thick and strong,
Distai
interphalangeal joint
Abduction
Proximal
interphalangeal joint
G roove fo r
fle x o r carpi
radialis
cu
aT
Q>
Metacarpophalangeal
joint
Carpometacarpal
joint
FIGURE 8 - 2 3 .
208
Section 11
Upper Extremity
Interphalangeal joint's
collateral ligaments
FIGURE 8-24. A lateral view of th collateral ligaments and associated connective tissues of th metacarpophalangeal, proximal inter
phalangeal, and distai interphalangeal joints of th fnger.
Osteokinematics
In addition to th motions of flexion-and-extension and abduction-and-adduction at th MCP joints, substantial acces
sory motions occur. On th relaxed and nearly extended
MCP joint, it is possible to feel significant passive translation
in an anterior-to-posterior direction, side-to-side direction,
and distraction. Note also th passive axial rotaiion of th
proximal phalanx against th metacarpal head. Although limited, these accessory motions at th MCP joint permit th
fngers to better conform to th shapes of objects, thereby
increasmg security and control of th grasp (Fig. 8 - 2 6 ) . The
range of this passive axial rotation at th MCP joints is
greatest at th ring and little ftngers, with average rotations
of about 30 to 40 degrees.29
Fibrous
digitai sheaths
Collateral ligaments
(cord and accessory parts)
Palmar plates
Fibrous digitai sheath
Flexor digitorum
profundus tendon
Flexor digitorum
superficialis tendon
Chapter 8
-iGURE 8-26. The >assive accessory motions at th metacarpophalangeal joints during th grasp of a cylinder. Axial rotation of th
fcidex finger is most notable.
Hand
209
Arthrokinematics
Each metacarpal head has a slightly different shape, but in
generai each is rounded at th apex and nearly fiat on th
palmar surface (see Fig. 8 - 6 ) . Articular cartilage covers th
entire head and most of th palmar surface. The convexconcave relationship of th joint surfaces is readily apparent
(Fig. 8 - 2 7 ) . The longitudinal diameter of th joint follows
th sagittal piane; th shorter transverse diameter follows th
frontal piane.
210
Seclion II
Upper Extremity
The arthrokinematics of active extension of th metacarpophalangeal joint. A, Active extension starting from a position of
70 degrees of (lexion. The extensor digitorum communis (EDC.) is shown contracting and then starting to drive th roll-and-slide
kinematics. The radiai eollateral Hgament is pulled taut in flexion. B, At 0 degrees of extension, th radiai collateral ligamem is relanvely
slack. C, Hyperextension further slackens th radiai collateral ligament but maximally stretches th palmar piate. Note that th axis of
rotation for this motion is in th medial-lateral direction, through th head of ihe metacarpal.
FIGURE 8 - 2 8 .
Stored passive tension in these ligaments theoretically increases th compression force between th joint surfaces,
thereby reducing active motion. Second, in th position of
about 70 degrees of flexion, th articular surface of th
Chapier 8
S P E C I A L
>
Metacarpophalangeal
joint
Hand
Carpometacarpal
joint
211
Radiocarpal
joint (wrist)
Following surgery or trauma, th hand is often temporarily immobilized to promote healing and relieve pain.
During a prolonged period, connective tissues immobil
ized at a shortened length are likely to become increasingly stiff and resistant to elongation. To reduce th
iikelihood of tightness within th collateral ligaments at
th MCP joints, th hand is often splinted with th MCP
joints flexed to 60 to 70 degrees (Fig. 8-31). This closepacked position of th joints places both th collateral
igaments36 and extrinsic extensor muscles in a relatively elongated and taut position. This position may
prevent subsequent shortening of these tissues.
Proximal
interphalangeal
joint
Distai
interphalangeal
joint
Sesamoid
FIGURE 8-32. A side view showing th shape of many joint surfaces in th wrist and hand. Note th sesamoid bone on th palmar
side of th metacarpophalangeal joint of th thumb.
FIGURE 8-31. Common position used for long-term immobilization of th hand. The flexed position of th metacarpopha
langeal joints elongates th collateral ligaments and th exten
sor digitorum communis muscle. The proximal interphalangeal
and distai interphalangeal joints are immobilized near full extension to prevent flexion contractures at these joints. (See text
for further details.)
THUMB
General Features and Ligaments
The MCP joint of th thumb consists of th articulation
between th convex head of th first metacarpal and th
concave proximal surface of th proximal phalanx of th
Interphalangeal Joints
FINGERS
The proximal and distai interphalangeal joints of th fingere
allow only 1 degree of freedom: flexion and extension. From
both a structural and functional perspective, these joints are
simpler than th MCP joints.
General Features and Ligaments
The p ro x im a l in terp h ala n g ea l (P1P) jo in ts are formed by th
articulation between th heads of th proximal phalanges
212
Section II
Upper Extremity
FIGURE 8-33. The arthrokinematics of active flexion at th meiacarpophalangeal and interphalangeal joints of th thumb. Flexion is
shown powered by th (lexor pollicis longus and ihe llexor pollicis
brevis. The axis of rotation for flexion and extension at th these
joints is in th anierior-poslerior direction, through th convex
member of th joints.
The PIP joints flex to about 100 to 120 degrees. The DI?
joints show less flexion, to about 70 to 90 degrees. Like th
MCP joints, flexion at th IP joints is greater in th more
ulnar digits. Minimal hyperextension is usually available at
th PIP joints. The D1P joints, however, normally allow u:
to 30 degrees of hyperextension.
Flexion range of motion is greater at th PIP joints than
at th D1P joints. Flexion and extension of IP joints of th
ring and little fngers occur in conjunction with slight axi;
rotation. During flexion, this rotation tums th pulp of th
fngertips toward th base of th thumb. Axial rotation al
lows these fingers to contact th opposing thumb more e:
fectively.27
Similarities in joint structure cause similar arthrokinema: 1
ics at th PIP and D1P joints. During active flexion at th PIP
joint, for instance, th concave base of th middle phalam
rolls and slides in a palmar direction by th pul of th
extrinsic finger flexors (see Fig. 8 - 2 9 ) . During flexion, th
passive tension created in th stretched connective tissues or
th dorsal side of th joint help guide and stabilize th rohand-slide arthrokinematics.
In contras! to th MCP joints, passive tension in th
collatera ligaments at th IP joints remains relatively con-
Dorsal view
and th bases of th middle phalanges (see Fig. 8 - 3 4 ) . The
articular surface of a P1P joint appears as a tongue-in-groove
articulation similar to that used in carpentry to join planks
of wood. The head of th proximal phalanx has two
rounded condyles, separated by a shallow centrai groove.
The opposing surface of th middle phalanx has two shallow
concave facets separated by a centrai ridge. Tongue-ingroove articulation helps guide th motion of flexion and
extension and restricts axial rotation.
The P1P joints are surrounded by a capsule that is reinforced by radiai and ulnar collatera ligamenls. The cord pordon of th collatera ligament at th PIP joint significanti
limits abduction and adduction motion. As with th MCP
joint, th accessory portion of th collatera ligament blends
with and reinforces th palmar piate (see Fig. 8 - 3 4 ) . The
anatomie connections between th collatera ligaments and
palmar piate form a secure seat for th head of th proximal
phalanx. Palmar check-rein ligaments at th PIP joint
strengthen th connection between th palmar piate and th
middle phalanx. Similar to th palmar plates, these ligaments
resist hyperextension of th PIP joint.614 Severe hyperextension of th PIP joint is a common athletic injury, with
tearing of both th palmar piate and th check-rein liga
ments.
The distai interphalangeal (D1P) joints are formed through
th articulation between th heads of th middle phalanges
and th bases of th distai phalanges (see Fig. 8 - 3 4 ) . The
structure of th D1P joint and th surrounding connective
Chapter 8
Hand
213
grees. This motion is often employed to apply a force between th pad of th thumb and an object, such as pushing
a tack into a wall. The amount of passive hyperextension
often increases throughout life owing to years of stretch
placed on palmar structures, including th palmar piate.
___
THUMB
Innervation to th muscles and skin of th hand is illustrated in Figure 6 - 3 3 . The radiai nerve innervates th extrin
sic extensor muscles of th digits. These muscles, located on
th dorsal aspect of th forearm, are th extensor digitorum
communis, extensor digiti minimi, extensor indicis, extensor
pollicis longus, extensor pollicis brevis, and abductor pollicis
longus. The radiai nerve is responsible for th sensation on
th dorsal aspect of th wrist and hand, especially around
th dorsal region of th thenar web space.
The median nerve innervates most of th extrinsic flexors
of th digits. In th forearm, th median nerve innervates th
flexor digitorum superficialis. A branch of th median nerve
(anterior interosseous nerve) then innervates th lateral half
of th flexor digitorum profundus, th flexor pollicis longus,
and th pronator quadratus.
The median nerve enters th hand through th carpai
tunnel, deep to th transverse carpai ligament. Once in th
hand, th median nerve innervates th muscles that form th
thenar eminence (flexor pollicis brevis, abductor pollicis
brevis, and opponens pollicis) and th lateral two lumbricals.
The median nerve is responsible for th sensation on th
palmar-lateral aspect of th hand, including th tips and th
palmar aspect of th lateral three and one-half digits.
The ulnar nerve innervates th mediai half of th flexor
digitorum profundus. Distally, th ulnar nerve crosses th
wrist superficial to th carpai tunnel. In th hand, th deep
motor branch of th ulnar nerve innervates th hypothenar
muscles (flexor digiti minimi, abductor digiti minimi, oppo
nens digiti minimi, and palmaris brevis) and th mediai two
lumbricals. The deep motor branch continues laterally, deep
in th hand, to innervate th palmar and dorsal interossei
muscles, and finally th adductor pollicis. The ulnar nerve is
responsible for th sensation on th ulnar border of th
hand, including most of th skin of th ulnar one and onehalf digits.
The motor nerve roots that supply all th muscles of th
upper extremity are listed in Appendix ILA. Appendix 1IB
shows key muscles typically used to test th functional status
of th C -T 1 ventral nerve roots.
214
Section II
Upper Extremity
Intrinsic Muscles
Flexors of th digits
Thenar eminence
heads)
Lumbricals (four)
Interossei
Palmar (four)
Dorsal (four)
follows: C6 supplying th thumb and index finger, C7 supplying th middle finger, and C8 supplying th ring and little
fingere.20'24 The CMC joints are also innervated by sensory
nerves of th C8 nerve root via th deep branch of th ulnar
nerve.20
Palmar
Palmar
v ie w
v ie w
Pronator teres
(cut)
Lateral epicondyle
Pronator teres
(cut)
Chapter 8
Hand
215
Palmar view
FIGURE 8-38. A palmar view illustrates several important structures of th hand Note th little finger showing th fibrous
digitai sheath and ulnar synovial sheath encasing th extrinsic flexor tendons. The ring finger has th digitai sheath removed,
thereby highlighting th digitai synovial sheath (red) and th annular (A, _5) and cruciate (C,_3) pulleys. The middle finger
shows th pulleys removed to expose th distai attachments of th flexor digitorum superficialis and profundus. The index
finger has a portion of flexor digitorum superficialis tendon removed, thereby exposing th deeper tendon of th flexor
digitorum profundus and attached lumbrical. The thumb highlights th oblique and annular pulleys along with th radiai
synovial sheath, surrounding th tendon of th flexor pollicis longus.
216
Section II
Upper Extremity
characterized by pain and/or paresthesia over th sensory distribution of th median nerve. With progression
of th syndrome, muscular weakness and atrophy may
occur in th thenar eminence. Pressures within th car
pai tunnel in persons with carpai tunnel syndrome in
crease significantly during many activities that involve
th hand.46 Pressures increase most significantly during
th extremes of all wrist motions, including th action
of making a fist. Carpai tunnel syndrome may be associ
ateti with prolonged use of a computer keyboard. Alter
native design of th standard computer keyboard may
reduce th extremes of motions used during typing and
thereby reduce th severity of this painful condition.35
FIGURE 8-39. A transverse view through th entrance of th carpai tunnel of th tight wrist. The ulnar synovial sheath
(red) surrounds th tendons of th flexors digitorum superficialis and profundus. The radiai synovial sheath surrounds
th tendon of th flexor pollicis longus.
Chapter 8
S P E C I A L
Hand
217
reduces th friction between th flexor digitorum superficialis and profundus tendons. A lacerated tendon within th
digitai sheath may heal with adhesions lo th digitai sheaths
or adjacent tendons. Splinting and exercise are usually initiated after surgery to facilitate th free gliding of th tendons
within th sheath.
Anatomy and Function of th Flexor Pulleys
Figure 8 - 3 8 shows th flexor pulleys that are embedded
within th fibrous digitai sheath. Five annular pulleys have
been described, designated as Al to A5.15 The major pulleys
(A2 and A4) attach to th shaft of th proximal and middle
phalanges. The minor pulleys (A l, A3, and A5) attach directly to th palmar piate at each of th three joints within a
finger. Three less distinct cruciate pulleys (C to C3) have
also been described. The cruciale pulleys are made of thin,
flexible fibers that crisscross over th tendons at regions
where th digitai sheaths bend during flexion.
F O C U S
Intact pulleys
1.5 cm
MCP
joint
R u p t u r e d p u lle y s
1.5 cm
218
Section II
Upper Extremity
> i
I \
C'~'
Flexor pulleys, palmar aponeurosis, and skin share a similar function of holding th underlying tendons ai a relatively
fixed dislance from th jo in ts.1-7 Without this function, th
force produced by contraction of th extrinsic finger flexor
muscles pulls th tendons away from th axis of rotation at
th joint.
Role of Proximal StabiUzer Muscles during Active
Finger Flexion
The extrinsic- digit#] flex ors #re m echsn icsfly c'spsbJe o f /7ex-
Chapter 8
The naturai tenodesis action of th extrinsic digitai flexors has important clinical implications. One example involves a person with C6 quadriplegia who has paralyzed
finger flexors and extensors, but innervated wrist extensors. Those with this level of spinai injury often employ
a tenodesis action for many functions, such as holding
a cup of water. In order to open th hand to grasp a
Hand
219
Taut flexor
digitorum
profundus
FIGURE 8-43. A person with C6-level quadriplegia using tenodesis action to grasp a cup of water. A, To prepare for
grasp, th hand is opened by gravity flexing th wrist. The stretched (taut) extensor digitorum communis generates
passive force that partially extends th fingers. B, By actively extending th wrist by th innervated extensor carpi
radialis brevis (red), th stretched finger flexors such as th flexor digitorum profundus create a passive force to
assist with grasping th cup.
Muscular Anatomy
The extrinsic extensors of th fingere are th extensor digito
rum communis, th extensor indicis, and th extensor digiti
minimi (see Fig. 7 - 2 2 ) . The extensor digitorum communis
and th extensor digiti minimi originate by a common tendon from th lateral epicondyle of th humerus. The exten
220
Seciion 11
Upper Extremiiy
Dorsal vicw
FIGURE 8-44. A dorsal view of th righi upper extremity highlighting th group of extensors of th digits: th extensor indicis, extensor poilicis longus, extensor pollicis brevis, and abductor pollicis
longus. Note th cut proximal ends of extensor carpi ulnaris and
th extensor digitorum communis.
Chapter 8
Lateral bands
Hand
221
Terminal attachment of
extensor mechanism
Central band
Oblique tibers
Dorsal hood o f extensor mechanism
Transverse fibers
A dorsal view of th
muscles, tendons, and extensor
mechanism of th right hand. The
synovial sheaths are indicated in
darker red, th extensor retinaculum
in lighter red.
FIGURE 8 - 4 5 .
Juncturae tendinae
Extensor indicis
Extensor digitorum communis
Abductor digiti minimi
Dorsal interassei
Extensor pollicis longus
Extensor pollicis brevis
Synovial sheath
Extensor retinaculum
EXTRINSIC E X T E N S O R S OF THE T H U M B
AnatomicaI Considerations
The extrinsic extensors of th thumb are th extensor pollicis
longus, extensor pollicis brevis, and abductor pollicis longus (see
Fig. 8 - 4 7 ) . These radiai innervated muscles have their proximal attachments on th dorsal region of th forearm. The
FIGURE 8 - 4 6 .
- Dorsal
hood
First lumbrical
Insertion of
abductor pollicis brevis
Adductor pollicis
O pponens pollicis
Extensor pollicis brevis
E xtensor pollicis longus
Abductor pollicis longus
FIGURE 8-47. A radiai (lateral) view of th muscles, tendons, and extensor mechanism of th right hand.
Pertinent Anatomy
Functional Significance
Central band*
Lateral bands
Dorsal hood
Chapter 8
Hand
223
FIGURE 8-48. The function of th extrinsic extensor muscles of th hand is demonstrated. Each
muscles action is determined by th orientatton
of th line-of-force relative to th axes of rotations
at each joint (medial-lateral axes are gray; ante-or-posterior axes are red). Isolated contraction of
th extensor digitorum communis (EDC) hyperexends th metacarpophalangeal joints. Full exten
sion of th interphalangeal joints requires assistance from th tntrinsic muscles. The extensor
pollicis longus (EPL), th extensor pollicis brevis
1EPB), and th abductor pollicis longus (API) are
all primary thumb extensors. Attachments of th
abductor pollicis brevis are shown blending into
th distai tendon of th extensor pollicis longus.
Functional Considerations
The multiple actions of th extensor pollicis longus, extensor
pollicis brevis, and abductor pollicis longus can be understood by noting their line-of-force relative to th anteriorposterior and medial-lateral axes of rotation at th joints
they cross (see Fig. 8 - 4 8 ) . The extensor pollicis longus extends th IP, MCP, and CMC joints of th thumb. The
muscle passes to th dorsal side of th medial-lateral axis of
th CMC joint and is therefore also capable of adducting this
joint. The extensor pollicis longus is unique in its ability to
perform all three actions that compose th repositioning of
th thumb: extension, lateral rotation, and adduction of its
metacarpal.
The extensor pollicis brevis is an extensor of th MCP and
CMC joints of th thumb; th abductor pollicis longus is an
extensor of th CMC joint of th thumb. The muscle is also
a prime abductor of th CMC joint since its line-of-force is
anterior to th joints medial-lateral axis of rotation. The dual
action of th long abductor reflects its attachment on th
radial-dorsal corner o f th base o f th thumb metacarpal.
The CMC joint is reinforced by fibers of th abductor longus
that attach into its capsule and adjacent trapezium. The
actions of all th muscles acting on th thumb are summarized in Table 8 - 5 .
The extensor pollicis longus and brevis, and th abductor
pollicis longus, are all potent radiai deviators at th wrist
(see Fig. 7 - 2 1 ) . During extension of th thumb, an ulnar
deviator muscle must be activated to stabilize th wrist
against unwanted radiai deviation. Adivation is apparent by
palpating th raised tendon of th flexor carpi ulnaris, located just proximal to th pisiform, during rapid extension
of th thumb.
224
Section II
Upper Extremity
Flexion
Adductor pollicis
Flexor pollicis brevis
Flexor pollicis longus
Extension
Extensor pollicis brevis
Extensor pollicis longus
Abductor pollicis longus
CMC joint
Abduction
Abductor pollicis brevis
Abductor pollicis longus
Adduction
Adductor pollicis
Extensor pollicis longus
First dorsal interosseus
CMC joint
Opposition
Opponens pollicis
Flexor pollicis brevis
Abductor pollicis brevis
Flexor pollicis longus
Abductor pollicis longus
Reposition
Extensor pollicis longus
MCP joint*
Flexion
Adductor pollicis
Flexor pollicis brevis
Abductor pollicis brevis
Flexor pollicis longus
Extension
Extensor pollicis longus
Extensor pollicis brevis
IP joint
Flexion
Flexor pollicis longus
Extension
Extensor pollicis longus
Abductor pollicis brevis (due to attachment into extensor mechanism)
INTRINSIC M U S C L E S OF THE H A N D
The hand contains 20 intrinsic muscles. Despite their relatively small size, these muscles are essential lo ihe fine con
trol of th digits. Topographically, th intrinsic muscles are
divided into four sets:
A primary responsibility of th muscles of th thenar enunence is to position th thumb in varying amounts of opposition, usually to facilitate grasping. As discussed earlier, opposition combines elements of CMC joint abduction, flexion
and mediai rotation. Each muscle within th thenar emi
nence is a prime mover for at least one component of opposition and an assistant for several others (see Table 8 - 5 ) . 28
The action of each of th thenar muscles is based on their
line-of-force relative to a particular axis of rotation (Fig. 8 51). The abductor pollicis brevis and longus abduct th
metacarpal away from th piane of th palm. The flexor
pollicis brevis, and to a lesser extern th mediai fibers of th
abductor pollicis brevis, flex th thumb at both th MCP
and CMC joints. The opponens pollicis has a line-of-force to
medially rotate th thumb toward th fingers. Because th
opponens pollicis has its distai attachment on th metacar
pal, its entire contractile force is dedicated to controlling th
CMC joint.
Injury to th m edian nerve can disable all com p on en ts o f
opposition. The thenar eminence becomes fiat owing to
musc/e atrophy. The inability to oppose th thumb greatly
reduces th grasping function of th entire hand. About 30%
Chapter 8
Hand
225
P alm ar view
A.
S P E C I A L
F O C U S
Anatomie Considerations
226
Section II
Upper Exiremity
Sp
S P E C I A L
F O C U S
The adductor pollicis has a relatively large cross-sectional area and is therefore capable of generating large
active forces. As a method to compare cross-sectional
areas of this and other muscles, Brand and colleagues9
have assigned each muscle below th elbow a relative
tension fraction. This measurement is determined by
dividing a muscle's physiologic cross-section by th to
tal cross-sectional area of all muscles below th elbow
(Table 8-6). This value, expressed as a percentage,
provides an estimate of each muscle's relative force
capability. The adductor pollicis has a tension fraction
almost twice that of th average of all muscles of th
thenar eminence. Data on tension fraction have been
used by surgeons to help them decide on th most
appropriate muscle for use in reconstructive hand surgery.
TABLE
Muscles
Functional Considerations
Figure 8-52B
Supinator
Extensor carpi radialis brevis
Dorsa! interosseus (index)
Abductor pollicis longus
Adductor pollicis
Pronator quadratus
Flexor digitorum profundus (index)
Flexor pollicis longus
Flexor digitorum superficialis (index)
Opponens digiti minimi
Opponens pollicis
Abductor digiti minimi
Extensor pollicis longus
Flexor pollicis brevis
Palmar interosseus (index)
Abductor pollicis brevis
Extensor digitorum communis (index)
Extensor pollicis brevis
Flexor digiti minimi
Lumbrical (index)
7.1
4.2
3.2
3.1
3.0
3.0
2.8
2.7
2.0
2.0
1.9
1.4
1.3
1.3
1.3
1.1
1.0
.8
.4
.2
Data from Brand PW, Beach RB, Thompson DE: Relative tension
and potential excursion of muscles in the forearm and hand J Hand
Surg 6A :209-219, 1981.
Chapter 8
Hand
111
FIGURE 8 - 5 2 . The biplanar action of th adductor pollicis muscle is illustrated using a pair of scissors for llexion (A) and adduction (B)
at th carpometacarpal joint. In both A and B, th transverse head of th adductor pollicis produces a signilcant torque owing to its
long moment arm about an anterior-posterior axis (red, A) and medial-lateral axis (gray, B). The adductor pollicis is also a potent flexor
of th metacarpophalangeal joint.
Distai interphalangeal
joint
Proximal interphalangeal
joint
Metacarpophalangeal
joint
Extensor digitorum
communis tendon (cut)
228
Section II
Upper Extremity
The four palm ar interossei are slender, single-headed muscles occupying th palmar region of th interosseous spaces.55
The three palmar interossei to th fingers have their proximal attachments on th palmar surfaces and sides of th
second, fourth, and fifth metacarpals (see Fig. 8 - 5 0 ) . These
muscles have their primary distai attachments into th
oblique fibers of th dorsal hood. The palmar interossei
adduci th second, fourth, and fifth MCP joints toward th
midiine of th hand (Fig. 8 - 5 4 ) . The palmar interosseus
muscle to th thumb occupies th first palmar interosseous
space, having a primary distai attachment to th ulnar side
of th proximal phalanx of th thumb, and often into a
sesamoid bone at th MCP joint.55 This muscle flexes th
MCP joint of th thumb, bringing th first metacarpal
toward th middle digit of th hand.
The four dorsal interossei fili th dorsal sides of th inter
osseous spaces (see Fig. 8 - 4 4 ) . In contrast to th palmar
interossei, th dorsal muscles have a bipennate shape. As a
generai rule, th dorsal interossei have distai attachments
into th side of th base of th proximal phalanx and into
th oblique fibers of th dorsal hood. The first dorsal inter
osseus attaches mostly into bone. The dorsal interossei abduct th MCP joints of th index, middle, and ring fingers
Palm ar interossei
Dorsal interossei
FIGURE 8 54 A palmar view o f th franta! piane action of th palmar interossei (PI, to PI4) and dorsal interossei (DI, to DI.,) at th
metacarpophalangea! joints of th hand. The abductor digiti minimi is shown abducting th little finger.
th "strongest" of all thumb movements,28 is driven primarily by th adductor pollicis and flexor pollicis brevis.
The internai moment arm used by th first dorsal inter
osseus for abduction at th MCP joint of th index finger
is about 1 cm. The pinch force applied by th thumb
against th MCP joint of th index finger acts with an
"external" moment arm of about 5 cm. This 5-fold difference in leverage across th MCP joint requires that th
first dorsal interosseus must produce a force 5 times th
pinching force applied by th thumb. Since many functional activities require a pinch force that exceeds 45 N
(10 Ib), th first dorsal interosseus must be able to
produce an abduction force of 225 N (50 Ib)! Skeletal
muscle is capable of producing about 28 N/cm2 (40 Ib/
in2); therefore, an average first dorsal interosseus muscle,
with a cross-section area of about 3.8 cm2, produces only
about 106 N (-24 Ib) of force.15 The additional stabilizing
force required to brace th index finger must be supplied
by other muscles, such as th second, and perhaps th
third, dorsal interosseus.
With an ulnar nerve lesion, th adductor pollicis mus
cle th primary pinching muscle of th thumb and all
interossei muscles are paralyzed. The strength of a key
pinch is significantly reduced following a nerve block to
th ulnar nerve. The region around th dorsal web space
becomes hollow owing to atrophy in th above muscles
(see Fig. 8-56). A person with an ulnar nerve lesion often
relies on th flexor pollicis longus (a median nerve-innervated muscle) to partially compensate for th loss of
thumb pinch. This compensation is evident by th partially
flexed IP joint of th thumb known as th Froment's
sign. Pinch stili remains weak, however, because th dor
sal interossei are not able to stabilize against th flexion
force of th thumb.
230
TABLE
Section II
Upper Extremity
Dorsai Interossei
Palmar Interossei
Innervation
Ulnar nerve
Ulnar nerve
Distai attachments
Contrattile characteristics
Prime action
Comments
Chapter 8
Hand
231
Opening th hand
(FCR)
FIGURE 8-58. A lateral view of th intrinsic and extrinsic muscular interactions at one finger during th opening
of th hand. The dotted outlines depct starting positions. A, Early phase: The extensor digitorum communis is
shown extending primarily th metacarpophalangeal joint. B, Middle phase: The intrinsic muscles (lumbricals and
interossei) assist th extensor digitorum communis with extension of th proximal and distai interphalangeal
joints. The intrinsic muscles also produce a flexion torque at th metacarpophalangeal joint that prevents th
extensor digitorum communis from hyperextending th metacarpophalangeal joint. C, Late phase: Muscle activation continues through full finger extension. Note th activation in th flexor carpi radialis to slightly flex th
wrist. Observe th proximal migration of th dorsal hood between flexion and full extension. (The intensity of
th red indicates th relative intensity of th muscle activity.)
this cooperative relationship is apparent by observing a person with a lesion to th ulnar nerve (Fig. 8 -5 9 A ). Without
active resistance from either th lumbricals or interossei in
th mediai two fingers, activation of th extensor digitorum
communis causes th characteristic clawing of th fingere.
The MCP joints hyperextend, and th IP joints remain partially flexed. This is often called th intrinsic-minus posture
because of th lack of intrinsic-innervated muscle. (This pos
ture is functionally similar to th extrinsic-plus posture
232
Seclion U
Upper Extremity
FIGURE 8-59. Attempts to extend [he fngere with an ulnar nerve lesion and a paralysis of th most intrinsic muscles of th fngere. A,
The mediai fngere show th claw position with metacarpophalangeal joints hyperextended and fngere partially flexed. Note th atrophy
in th hypothenar eminence and interosseous spaces. B, By manually holding th metacarpophalangeal joints into flexion, th extensor
digitorum communis, innervated by th radiai nerve, is able to fully extend th interphalangeal joints.
depicted earlier.) Without th MCP joint flexion torque normally provided by th intrinsic muscles, th extensor digito
rum communis is capable of only hyperextending th MCP
joints. This posture increases th passive tension in th
stretched flexor digitorum profundus, thereby further limiting full IP joint extension. As shown in Figure 8 - 5 9 6 , by
manually providing a flexion torque across th MCP joint
(i.e., a force normally fumished by th intrinsic muscles),
contraction of th extensor digitorum communis fully extends th IP joints. Blocking of th MCP joint from hyperex
tending also slackens th profundus tendon, thereby minimizing passive resistance to IP joint extension.
Function of Wrist Flexors during Finger Extension
Activation of th wrist flexors normally accompanies fnger
extension. Although activity is depicted only in th flexor
carpi radialis in Figure 8 - 5 8 , other wrist flexors are also
active. The wrist flexors offset th potent extension potential
of th extensor digitorum at th wrist. The wrist actually
flexes slightly throughout full fnger extension, especially
when performed rapidly. (Compare Figure 8 - 5 8 A with Fig
ure 8 -5 8 C .) Wrist flexion helps maintain optimal length of
th extensor digitorum during active finger extension.
Chapter 8
Hand
233
does not mean that th lumbrcals are incapable of producing use fui forces. Recali that th lumbrcals attach between
th flexor profundus and th extensor mechanism. During
active finger flexion, th lumbrcals are stretched in a proximal direction owing to th contracting flexor profundus and,
at th same time, stretched in a distai direction owing to th
distai migration of th extensor mechanism (Fig. 8 - 6 1 B ,
bidirectional arrow in lumbrical). Between full fnger extension and full active flexion, a lumbrical must stretch an
extraordinary distance.43 The stretch generates a passive flex
ion torque at th MCP joint, which supplements th active
flexion torque produced by th interassei and extrinsic musculature.
Injury to th ulnar nerve can cause paralysis of most of
th intrinsic muscles, resulting in a noticeably weakened
grasp. When making a fist, th sequencing of flexion across
th joints is altered. Normally, at least in th radiai three
fingers, th P1P and DIP joints flex first, followed closely in
time by flexion at th MCP joints. With paralyzed intrinsic
muscles, especially if overstretched by chronic hyperextension of th MCP joints, th initiation of flexion at th MCP
joints is delayed slightly. The resulting asynchronous flexion
may interfere with th quality of th grasp.
Closing th hand
FIGURE 8-61. A side view of th intrinsic and extrinsic muscular interaction at one fnger during a high-powered
closing of th hand. The dotted outlines depict th starting positions. A, Early phase: The flexor digitorum profundus,
flexor digitorum superficialis, and interassei muscles actively flex th joints of th finger. The lumbrical is shown as
being inactive (white). B, Late phase: Muscle activation continues essentially unchanged through full flexion. The
lumbrical remains inactive, but is stretched across both ends. The extensor carpi radialis brevis is shown extending th
wrist slightly. The extensor digitorum communis helps decelerate flexion of th metacarpophalangeal joint. Note th
distai migration of th dorsal hood between th early and late phases of flexion. (The intensity of th red indicates th
relative intensity of th muscle activity.)
234
Section 11
Upper Extremity
Chapter 8
Hand
235
FIGURE 8-62. A healthy hand is shown performing common types of prehension functions. A, Power grip. B, Precision grip to hold an
egg. C, Precision grip to throw a baseball. D to F, Modifications of th precision grip by altenng th concavity of th distai transverse
arch. G, Power key pinch. H, Tip-to-lip prehension pinch. I, Pulp-to-pulp prehension pinch. J, Hook grip.
236
Section II
Upper Extremity
FIGURE 8 63. Examples of th lerminology to describe th use of three common tools. A, Handling a screwdriver by a predsion pinci of
th tight hand and a combined power grip and power pinch of th left hand. B, A one-handed task of adjusting a wrench requires a power
grip by th mediai ftngers and a manipulation prehension of th index finger and thumb. C, Using pliers requires that th thumb and
index finger produce a power pinch. The upper handle of th pliers is supported by th palm and th lower handle is manipulaied by
action of th finger flexors.
Destruction of th Metacarpophalangeal
Joints of th Finger
A dvanced rheu m atoid arthritis is often associated w ith defotmities at th MCP joint of th fingers. Two common defor
mities are a palmar dislocation and an ulnar drift (Fig
8 -6 5 ).
Chapter 8
Hand
237
.Overstretched palmi
piate at th meta- j
c a rp o p h a la 'ig e a
jo in r
Extensor
pollcis
longus
Ruptured
ligaments
Dislocated
carpometacarpal
joint
U ln a r d rift
238
Section II
Upper Extremity
Metaearpophalangeal
joint
Proximal
joint
Stable Arch
Distai
Palmar dislocation of th
metaearpophalangeal
joint
Ruptured
collateral
ligaments
Collapsed Arch
FIGURE 8-66. Pathomechamcs of progressive palmar dislocation of th metaearpophalangeal joint of th finger. A The bend in th
tendons of th flexor digiiorum superficialis and flexor digitorum profundus across th metaearpophalangeal joint produces a
palmar-directed, bowstringing force against th palmar piate, associated pulley, and collateral ligaments. In th healthy hand th
passive tension in th stretched collateral ligaments adequately resists th palmar pul on th joint structures B In a finger with
rheumatoid arthritis, th bowstringing force can rupture th weakened collateral ligaments. As a result, th proximal phalanx may
eventually dislocate in a palmar direction, causing a loss in strutturai stability of th arch System of th hand.
Splinting and patient education may help decelerate th deforming cycle.44 One surgical correction involves transferring
th extensor digitorum tendon to th radiai side of th MCP
SWAN-NECK DEFORMITY
Swan-neck deformity is characterized by hyperextension of th
PIP join t with flexion at th D IP joint (see Fig. 8 - 6 5 , mid
Chapter 8
Hand
239
FIGURE 8-67. The stages of th development of ulnar drift al th metaearpophalangeal joint of th index finger. A, Ulnar
forces from th thumb produce a naturai bowstringing force on th deflected tendon of th extensor digitorum communis
(EDC). B, In rheumatoid arthritis, rupture of th transverse fibers of th dorsal hood allows th extensor tendon to act with
a moment arm that increases th ulnar deviation torque at th metaearpophalangeal joint. C, Over time, th radiai collateral
ligament (RCL) may rupture, resulting in th ulnar drift deformity.
ened palmar plates at th PIP joint, contracture of th intrinsic muscles may eventually collapse th PIP joints into hyperextension (Fig. 8 -6 8 A ). The hyperextended position
causes th lateral bands of th extensor mechanism to bowstring dorsally, away from th axis of rotation at th PIP
joint. Bowstringing increases th moment arm for th intrinsic muscles to extend th PIP joint, thereby accentuating th
hyperextension deformity. The DIP joint tends to remain
flexed owing to th stretch placed on th tendon of th
flexor digitorum profundus across th PIP joint.
Swan-neck deformity may also occur from trauma to th
ligaments or spasticity of th intrinsic muscles. Regardless of
cause, treatment often involves splinting or surgically limitmg th degree of hyperextension of th PIP joint.
BOUTONNIERE DEFORMITY
The boutonniere deformity is described as flexion of th PIP
joint and hyperextension of th DIP joint (see Fig. 8 - 6 5 ,
index finger). (The term boutonniere a French word
meaning buttonhole describes th appearance of th head
of th proximal phalanx, as it slips through th buttonhole'
created by th slipped lateral bands). The joints collapse in a
reciprocai pattern similar to that described for swan-neck
deformity. The primary cause of th boutonniere deformity
is abnormal displacement of th bands of th extensor mech
anism, typically th result of chronic synovitis of th PIP
joint. Biomechanically, th centrai band ruptures and th
lateral bands slip to th palmar side of th axis of rotation at
th PIP joint (Fig. 8 - 6 8 B ). Consequently, forces transferred
240
Seniori II
Upper Extremity
Overactive
intrinsics
Overstretched
palmar piate
Slipped lateral band
Ruptured
centrai band
B. Boutonniere Deformity
FIGURE 8-68. Two common zig-zag deformities of th finger with severe rheumatoid arthriiis. The
middle finger shows th pathomechanics of th swan-neck deformity (A). The overactive intrinsic
muscles (red) have a chronic hyperextension effect at th proximal interphalangeal joint. Over urne,
th weakened palmar plates become overstretched, allowing th proximal interphalangeal joint lo
deform into severe hyperextension. In this position, th lateral bands produce a bowstring across th
proximal interphalangeal joint, thereby accentuating th hyperextension deformity. The distai inter
phalangeal joint remains partially flexed owing to th increased passive tension in th stretched
flexor digitorum profundus tendon.
The index finger depicts th pathomechanics of th boutonniere deformity (B). As a result of
rheumatoid arthritis, th centrai band ruptures and th lateral bands slip in a palmar direction to th
proximal interphalangeal joint; thus, th proximal interphalangeal joint loses its only means of
extension. Any tension in th lateral bands now produces Jlexion at th proximal interphalangeal
joint. The distai interphalangeal joint remains hyperextended owing to increased passive tension in
th taut lateral bands.
5. Boatright JR, Kiebzak GM: The effeets of low medtan nerve block on
thumb abduction strength. J Hand Surg 22A:849-852, 1997.
6. Bowers WH, Wolf JW, Nehil JL, et al. The proximal interphalangeal
joint volar piate. 1 An anatomical and biomechanical study J Hand
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7. Brand PW: Clinical Biomechanics of th Hand. St Louis CV Mosbv
1985.
8. Brand PW, Cranor KC, Ellis JC: Tendons and pulleys ai th metacarpo
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9. Brand PW, Beach RB, Thompson DE: Relative tension and poteniia!
excursion of muscles in th forearm and hand. J Hand Surg 6A 209219, 1981.
10. Close JR, Kidd CC: The functions of th muscles of th thumb, th
index, and long fingers. J Bone Joint Surg 51A T601-1620, 1969.
11. Cooney WP, P Lucca MJ. Chao EYS, et al: The kinesiology of th
thumb trapeziometacarpal joint. J Bone Joint Surg 63A 1371 1381
1981.
12. Damen A, van der Lei B, Robinson PH: Bilateral osteoarthritis of th
trapeziometacarpal joint treated by bilateral tendon interposition arthroplasty. J Hand Surg 22B:96-99, 1997.
13. Doyle JR, Blythe W: The finger flexor tendon sheath and pulleys
Anatomy and reconstruction. In American Academy of Orthopaedic
Surgeons Symposium on Tendon Surgery' in th Hand. Si Louis, CY
Mosby, 1975
14 Dray GJ, Eaton RG Dislocations and ligament injuries in th digits. In
Green DP (ed): Operative Hand Surgery', 3rd ed. New York, Churchill
Livingstone, 1993
Chapter 8
15. Dvir Z: Biomechanics of muscle. In Dvir Z tedi: Clinical Biomechanics,
Philadelphia, Churchill Livingstone, 2000.
16. Eaton RG, Littler W: Ligament reconslruclion for th painful thumb
carpometacarpal joint. J Bonejoint Surg 55A T655-1666, 1973.
17. El-Bacha A: The carpometacarpal joints (excluding th trapeziometacar
pal). In Tubinia R (ed): The Hand, voi 1. Philadelphia, WB Saunders,
1981
18. Hyler DI-, Markee JE: The anatomy and function of th intrinsic musco
lature of th fingers. J Bonejoint Surg 36A :l-20, 1954.
19. Flatt AE: The Care of th Rheumatoid Hand, 3rd ed Si Louis, CV
Mosby, 1974.
20 Gray DJ, Gardiner E: The innervation of th joints of th wnst and
hand. Anat Ree 151:261-266, 1965.
21 Hahn P, Krimmer H, Hradetzky A, et al: Quantitative analysis of th
linkage between th inlerphalangeal joints of th index fnger. J Hand
Surg 20B:696-699, 1995.
22 Hakstian RW, Tubiana R: Ulnar devialion of th fingers: The role of
joint structure and funaioli. J Bone Joint Surg 49A:299-316, 1967.
23. Imaeda T, Niebur G, Cooney VVP, et al: Kinematics of th norma!
trapeziometacarpal joint. j Orthop Research 12:197-204, 1994.
24 lnman VT, Saunders JB: Referred pam from skeletal structures. J Nerv
Ment Dis 99:660-667, 1944.
25. Jacobson MD, Raab R, Fazcli BM, et al: Architectural design of th
human intrinsic hand muscles. J Hand Surg. 17A:804-809, 1992.
26. Johanson ME, Skinner SR, Lamoreux LW. Phasic relationship of th
intrinsic and extrinsic thumb musculature. Clin Orthop 322:120-130,
1996.
27 Kapandji 1A: The Physiology of th Jomls, voi 1, 5th ed: Edinburgh,
Churchill Livingstone, 1982.
28. Kaufman KR, An KN, Lttchy WJ, et al: In-vivo function of th thumb
muscles. Clin Biomech 14:141-151, 1999.
29 Krishnan J, Chipchase L: Passive rotation of th metacarpophalangeal
joint. J Hand Surg 22B:270-273, 1997.
70 Kuczynski R7 Carpometacarpal joint of th human thumb. J Anat 118:
119-126, 1974
31. Landsmeer JMF: Power grip and precision handling. Ann Rheum Dis
21:164-170, 1962
32. Leijnse JN: Why th lumbrical muscle should not be bigger a force
model of th lumbrical in th unloaded human finger. J Biomechan 30:
1107-1114, 1997.
33. Long C: Intrinstc-extrinsic muscle control of th fingers. J Bone Joint
Surg 50A :973-984, 1968.
34. Long C, Brown ME: Electromyographic kinesiology of th hand: Mus
cles moving th long finger. J Bonejoint Surg 46A: 1683-1706, 1964.
35. Marklin RW, Simoneau GG, Monroe JE: Wrist and forearm posture
from typing on split and vertically inclined computer keyboards. Hu
man Factors 41:559-569, 1999.
36. Minami A, An KN, Cooney WP, et al: Ligamentous structures of th
metacarpophalangeal joint: A quantitative anatomie study. J Orthop Res
1:361-368, 1984.
37. Najima H, Oberlin C, Alnot JY, et al: Anatomical and biomechamcal
sludies of th palhogenesis of trapeziometacarpal degenerative arthrilis.
J Hand Surg 22B: 183-188, 1997
38 Nalebuff EA: Diagnosis, classification, and management of rheumatoid
thumb deformtties. Bull Hosp Joint Dis 24:119-137, 1968
39 Napier JR: The prehensile movements of th human hand J Bone Joint
Surg 38B:902-913, 1956.
40. Neumann DA: Observaltons from cineradiography analysis. Milwaukee,
Wl, Marquelte University, 2000.
41 Pagalidts T, Kuczynski K, lamb DW: Ligamentous stabilty of th base
of th thumb. The Hand 1.3:29-35, 1981.
42. Pieron AP: The first carpometacarpal joint In Tubinia R (ed): The
Hand, voi 1. Philadelphia, WB Saunders, 1981
43. Ranney D, Wells R: Lumbrical muscle function as revealed by a new
and physiological approach. Anat Ree 222:110-114, 1988.
44. Rennie HJ: Evaluation of th effectiveness of a metacarpophalangeal
ulnar devialion orthosis. J Hand Ther 9.371-377, 1996.
45 Rispler D, Greenwald D, Shumway S, et ai: Efficiency of th flexor
tendon pulley System in human cadaver hands. J Hand Surg 21A:444450, 1996.
Hand
241
A D 0 IT I0N A L READING
An KN, Chao EY, Conney WP, et al: Forces in th normal and abnormai
hand. J Ortho Res 3 :2 0 2 -2 1 1, 1985.
Buchholz B, Armstrong TJ, Goldstein SA: Anthropometric data for describing th kinematics of th human hand. Ergonomics 35:261-273, 1992.
Conney WP, Chao EY: Biomechanical analysis of static forces in th thumb
during hand function. J Bonejoint Surg 59A:2736, 1977.
Estes JP, Bochenek C, Fasler P Osteoanhritis of th fingers J Hand Ther
13:108-123, 2000
Forrest WJ, Basmajian JV: Function of human thenar and hypothenar mus
cles: An electromyographic study of twenty-five hands. J Bone Joint Surg
47A: 1585-1594,'1965.
Imaeda T. An KN, Cooney WP, et al: Anatomy of th trapeziometacarpal
ligaments.J Hand Surg 18A:226-231, 1993.
Jarit P: Domtnanl-hand to nondominant-hand grip-strength ratios of college
baseball players. J Hand Ther 4:123-126, 1991.
Johanson ME, Skinner SR, Lamoreux LW Phasic relationships of th intrin
sic and extrinsic thumb musculature. Clin Orthop 322:120-130, 1996
Landsmeer JMF The anatomy ol ihe dorsal aponeurosis of th human fnger
and its functional significante. Anat Ree 104:31-44, 1949.
Long C, Conrad PW, Hall EW, et al: Intrinsic-extrinsie muscle control of
th hand in power grip and precision handling. J Bone Joint Surg 52A:
853-867, 1970.
Najima H. Oberlin C, Alnot JY, et al: Anatomical and biomechanical studies
of ihe palhogenesis of trapeziometacarpal degenerative arthritis. J Hand
Surg 22B :183-188, 1997.
Smith RJ Balano: and kineties of th fingers under normal and pathological
P P E N D I X II
C1
Serratus anterior
Rhomboids, major and minor
Subclavius
C5
c6
c7
c8
X
X
Supraspinatus
lnfraspinatus
(x)
Subscapularis
T1
Latissimus dorsi
Teres major
Pectoralis minor
(x)
Teres minor
Delioid
Coracobrachialis
Biceps
Brachiale
Triceps
Anconeus
Brachioradialis
Supinator
(x)
Extensor digitorum
Extensor indicis
Pronator teres
Flexor carpi radialis
Palmaris longus
Flexor digit, superficialis
Flexor digit, profundus 1
and II
242
(x)
243
A ppenda II
Nerve Root
C1
Muscle
C4
C5
C6
c7
C*
T1
(x)
Pronator quadratus
Abductor pollicis brevis
Opponens pollicis
Lumbricals I and 11
(x)
Palmaris brevis
(x)
(x)
(x)
(x)
Palmar interossei
Dorsal interossei
(x)
(x), minimal literature supporti X, moderate literature supporti X, strong literature support.
Modified from Rendali FP, McCreary AK, Provante PG: Muscles: Testing and Function, 4lh ed. Baltimore, Williams & Wilkins, 1993. Data based on a
compilation from severa! sources in th anatomie literature
Key Muscles
Ventral
Nerve
Roots
Biceps brachii
C5
Middle deltoid
C5
c6
Triceps brachii
Extensor digitorum
c7
C7
Elbow extension
Finger extension (metacarpophalangeal joint)
I 1
Coracobrachialis
Proximal attachment: apex of th coracoid process by a
common tendon with th short head of th biceps
Distai attachment: mediai aspect of middle shaft of th
humerus
Innervation: musculocutaneous nerve
Deltoid
Proximal attachments
Anterior part: anterior surface of th lateral end of th
clavicle
Middle part: superior surface of th lateral edge of th
acromion
Posterior part: posterior border of th spine of th
scapula
Distai attachment: deltoid tuberosity of th humerus
Innervation: axillary nerve
In frasp in atu s
Proximal attachment: infraspinatous fossa
Distai attachment: middle facet of th greater tubercle of
th humerus
innervation: suprascapular nerve
244
Appendix 11
Latissimus Dorsi
Proximal attachments: posterior layer of th thoracolumbar
fascia, spinous processes and supraspinous ligaments of
th lower half of th thoracic vertebrae and all lumbar
vertebrae, median sacrai crest, posterior crest of th
ilium, lower four ribs, small area near th inferior
angle of th scapula, and muscular interdigitations
from th obliquus extemal abdominis
Distai attachment: floor of th intertubercular groove of
th humerus
Innervation: middle subscapular (thoracodorsal) nerve
Levator Scapula
Proximal attachments: transverse processes of C I - 2 and
posterior tubercles of transverse processes of C 3 - 4
Distai attachment: mediai border of th scapula between
th superior angle and root of th spine
Inneiyation: ventral rami of spinai nerves (C3-4) and th
dorsal scapular nerve
Pcctoralis Major
Proximal attachments
Clavicular head: anterior margin of th mediai one half
of th clavicle
Sternocostal head: lateral margin of th manubrium and
body of th stemum and cartilages of th first six or
seven ribs. The costai fibers blend with muscular
slips from th obliquus external abdominis.
Distai attachment: crest of th greater tubercle of th hu
merus.
Innervation
Clavicular head: lateral pectoral nerve
Sternocostal head: lateral and mediai pectoral nerves
Pcctoralis Minor
Proximal attachments: extemal surfaces of th third
through th ffth ribs
Distai attachment: mediai border of th coracoid process
Innervation: mediai pectoral nerve
Serrani Anterior
Proximal attachments: extemal surface of th lateral region
of th first to ninth ribs
Distai attachment: entire mediai border of th scapula,
with a concentration of fibers near th inferior angle
Innervation: long thoracic nerve
Subclavius
Proximal attachment: near th cartilage of th first rib
Distai attachment: inferior surface of th middle aspect of
th clavicle
Inneiyation: branch from th upper trunk of th brachial
plexus (C5-6)
Subscapularis
Proximal attachment: subscapular fossa
Distai attachment: tesser tubercle of th humerus
Innervation: upper and lower subscapular nerves
Supraspinatus
Proximal attachment: supraspinatus fossa
Distai attachment: upper facet of th greater tubercle of
th humerus
Innervation: suprascapular nerve
Teres Major
Proximal attachment: infenor angle of th scapula
Distai attachment: crest of th lesser tubercle of th hu
merus
Innervation: lower subscapular nerve
Teres Minor
Proximal attachment: posterior surface of th lateral border
of th scapula
Distai attachment: lower facet of th greater tubercle of th
humerus
Innervation: axillary nerve
Trapezius
Proximal attachments (all parts): mediai pari of superior
nuchal line and extemal occipital protuberance, ligamentum nuchae, spinous processes and supraspinous
ligaments of th seventh cervical vertebra and all tho
racic vertebrae
Distai attachments
Upper part: posterior-superior edge of th lateral one
third of th clavicle
Middle part: mediai margin of th acromion and upper
lip of th spine of th scapula
Lower pari: Mediai end of th spine of th scapula, just
lateral to th root.
Innervation: primarily by th spinai accessory nerve (cranial nerve XI); secondary innervation directly from
ventral rami of C2~4
Biceps Brachii
Proximal attachments
Long head: supraglenoid tubercle of th scapula
Short head: apex of th coracoid process of th scapula
Distai attachments: bicipital tuberosity of th radius; also
to deep connective tissue within th forearm via th
fibrous lacertus
Innervation: musculocutaneous nerve
Brachiali
Proximal attachment: distai aspect of th anterior surface of I
th humerus
Distai attachments: coronoid process and tuberosity on th
proximal ulna
Innervation: musculocutaneous nerve (small contribution
from th radiai nerve)
Brachioradialis
Proximal attachment: upper two thirds of th lateral supracondylar ridge of th humerus
Distai attachment: near styloid process at th distai radius
Innervation: radiai nerve
Appenaix II
Pronator Teres
Proximal attachments
Humeral head: mediai epicondyle
Ulnar head: mediai to th tuberosity of th ulna
Distai attachment: lateral surface of th middle radius
Innervation: median nerve
Proximal attachments
Humeral head: common flexor-pronator tendon attach
ing io th mediai epicondyle of th humerus
Ulnar head: posterior border of th middle one third of
th ulna
Distai attachments: pisiform bone, pisohamate and pisometacarpal ligaments, and palmar base ol th fifth meta
carpal bone
Innervation: ulnar nerve
Pronator Quadratus
Proximal attachment: anterior surface of th distai ulna
Distai attachment: anterior surface of th distai radius
Innervation: median nerve
Palmaris Longus
Supinator
Proximal attachments: lateral epicondyle of th humerus,
radiai collateral and annular ligaments, and supinator
crest of th ulna
Distai attachment: lateral surface of th proximal radius
Innervation: radiai nerve
Triceps Brachii
Proximal attachments
Long head: infraglenoid tubercle of th scapula
Lateral head: posterior humerus, superior and lateral to
th radiai groove
Mediai head: posterior humerus, inferior and mediai to
th radiai groove
Distai attachment: olecranon process of th ulna
Innervation: radiai nerve
WRIST MUSCOLATURE
Extensor Carpi Radialis Brevis
Proximal attachment: common extensor-supinator tendon
attaching to th lateral epicondyle of th humerus
Distai attachment: radial-posterior surface of th base of
th third metacarpal
Innervation: radiai nerve
Extensor Indicis
Proximal attachments: posterior surface of th middle to
distai part of th ulna and adjacent interosseous mem
brane
Distai attachment: tendon blends with th ulnar side of th
index tendon of th extensor digitorum
Innervation: radiai nerve
246
Appendix l
Dorsal Interossei
Proximal attachments
First: adjacent sides of th first (thumb) and second
metacarpal
Second: adjacent sides of th second and third metacar
pal
Third: adjacent sides of th third and fourth metacarpal
Fourth: adjacent sides of th fourth and fifth metacar
pal
Distai attachments
First: radiai side of th base of th proximal phalanx o:
th index finger and oblique fibers of th dorsal
hood
Second: radiai side of th base of th proximal phalanx
of th middle finger and oblique fibers of th dorsal
hood
Third: ulnar side of th base of th proximal phalanx
ol th middle finger and oblique fibers of th dorsal
hood
Fourth: ulnar side of th base ol th proximal phalanx
of th ring finger and oblique fibers of th dorsal
hood
Innervation: ulnar nerve
Adductor Pollieis
Proximal attachments
Oblique head: capitate bone, base of th second and
third metacarpal, and adjacent capsular ligaments of
th carpometacarpal joints
Transverse head: palmar surface of th third metacarpal
Distai attachments: both heads attach on th ulnar side of
th base of th proximal phalanx of th thumb and to
th m ediai sesam oid b o n e at th m etacarpophalangeal
joint; also attaches into th extensor mechanism of th
thumb
Innervation: ulnar nerve
Lumbricals
Proximal attachments
Mediai two: adjacent sides of th flexor digitorum pro
fundus tendons of th little, ring, and middle fn
gers
Lateral two: lateral sides of th flexor digitorum profun
dus tendons of th middle and index fingers
Distai attachment: lateral margin of th extensor mechanism via th oblique fibers of th dorsal hood
Innervation
Mediai two: ulnar nerve
Lateral two: median nerve
Opponens Pollieis
Proximal attachments: transverse carpai ligament and paimar tubercle o f th trapezium
Appendix II
Distai attachment: radiai surface of th shaft of th thumb
metacarpal
Inneiyation: median nerve
Palmaris Brevis
Proximal allachments: transverse carpai ligament and palmar fascia just distai and lateral to th pisiform bone
Distai attachment: skin on th ulnar border of th hand
Innervation: ulnar nerve
Palmar Interossei
Proximal attachments
First: ulnar side of th thumb metacarpal
Secondi ulnar side of th second metacarpal
247
e c t i o n
III
Axial Skeleton
S e c t i o n
I I I
Axial Skeleton
C h a p t e r 9: Osteology and Anhrology
C h a p t e r 10: Muscle and Joint lnteractions
C
har ter
250
h a p t e r
Axial Skeleton:
Osteology and Arthrology
Donald A. Neum ann , PT, Ph D
TOPICS
Ribs, 253
S te rn u m , 254
V e rte b ra l C olum n, 256
GLANCE
253
OSTEOLOGY, 253
AT
S tru c tu ra l D e fo rm itie s o f th T h o ra c ic
S pine, 287
276
( L I- S I) , 292
K in e m a tic s a t th L u m b a r R egion, 294
Kinematics, 306
Functional Considerations, 307
S tre s s R elief, 307
S ta b ility D u rin g Load T ra n s fe r:
M e c h a n ic s o f G e n e ra tin g a N u ta tio n
T o rq u e a t th S a c ro ilia c J o in t, 307
S tru c tu re s , 284
K in e m a tic s a t th T h o ra c ic R egion, 286
INTRODUCTION
The axial skeleton includes th cranium, vertebral column,
ribs, and sternum (Fig. 9 - 1 ) . This chapter presents th
kinesiologic interactions between th osteology and arthrol
ogy of th axial skeleton. The focus is on th craniocervical
252
Section III
Axal Skeleton
A X IA L S K E L E T O N
Pronaon: Noie:
Straight axis Crossed forearm bones
Originai don ai aspect
of radius and hand
noto fa ce anteriorly
Fentur:
G reaier trochanier
H ead in acetabulum
Neck
Ulna Radius
Metacarpals
Phalanges-
A PPEN D ICU LA R S K E L E T O N
Femoral shaft
Femoral condyles
Patella
M ediai malleolus
Luterai malleolus -
Phalanges
Chapter 9
TABLE
Term
Synonym
Definition
Posterior
Dorsal
Back of th body
Anterior
Ventral
Front of th body
Mediai
None
Midiine of th body
Lateral
None
Superior
Cranial
Inferior
Occipital Bone
External occipital protuberance
Superior nuchal line
Inferior nuchal line
Foramen magnum
Occipital condyles
Basilar pari
OSTEOLOGY
Basic Components of th Axial Skeleton
CRANIUM
The cranium is th bony encasement of th brain, which
protects th brain and sensory organs (eyes, ears, nose, and
vestibular System) and provides a means for ingesting food
and liquid.
Occipital and Temporal Bones
The occipital bone forms much of th posterior base of th
skull (Figs. 9 - 2 and 9 - 3 ) . The external occipital protuberance
is a palpable midiine point, serving as an attachment for th
ligamentum nuchae and th mediai part of th upper trapezius muscle. The superior nuchal line extends laterally from
th external occipital protuberance to th base of th mastoid process of th temporal bone. This thin but distinct line
marks th attachments of several extensor muscles of th
253
Temporal Bone
Mastoid process
RIBS
Twelve pairs of ribs enclose th thoracic cavity, forming a
protective cage for th cardiopulmonary organs. The poste
rior end of a typical rib has a head, a neck, and an articular
tubercle (Fig. 9 - 6 ) . The head and tubercle articulaie with a
thoracic vertebra, forming two synovial joints: costovertebral
and costotransverse, respectively (Fig. 9 - 5 B ) . These joints
anchor th posterior end of a rib to its respective vertebra. A
costovertebral joint connects th head of a rib to a pair of
costai facets that span two adjacent vertebrae and th intervening intervertebral disc. A costotransverse joint connects th
articular tubercle of a rib with a costai facet on th trans
verse process of a corresponding vertebra.
The anterior end of a rib consists of flattened hyaline
cartilage. Ribs 1 to 10 attach to th stemum, thereby completing th thoracic rib cage anteriorly (see Fig. 9 - 1 ) . The
254
Secfion III
Axial Skeleton
Inf'erior vicw
External occipital protuberance
Trapezi us
Superior nuchal line
Semispinalis capitis
Splenius capitis
Lambdoidal suture
Sternocleidomastoid
Mediai nuchal line
Longissimus capitis
Digastric (posterior belly)
Mastoid process
Stylohyoid
Mandibular fossa
Carotid canal
Zygomatic process
FIGURE 9 3. Interior view of th occipital and temperai bones. The lambdoidal sutures separate th occipital bone
mediali)*, troni th temperai bone laterally. Distai muscle attachments are indicated in gray, and proximal attachments are
indicated in red.
STERNUM
The stemum is slightly convex and rough anteriorly, and
slightly concave and smooth posteriorly. The bone has three
parts: th manubrium (from th Latin, handle), th body,
and th xiphoid process (from th Greek, sword) (see Fig.
9 - 7 ) . Developmentally, th manubrium fuses with th body
of th stemum at th manubriostemal joint, a (brocartilaginous articulation that often ossifies later in life.110 Just lateral
to th jugular notch of th manubrium are th clavicular jacets
ot th stemoclavicular joints. Immediately inferior to th sternoclavicular joint is a costai facet that accepts th head c :
th first rib at th first stemocostal joint.
Chapter 9
255
Luterai view
Superior articular process
Transverse
Superior view
Costai facet
p _:------ process
intervertebral foramen
Transverse process
Apophyseal joint
Intervertebral
disc
Spinous
facet
Pedicle
Superior costai facet
Costotransverse joint
Interior
articular
process
Interior
costai
facet
Costovertebral joint
FIGURE 9-5. The essential characteristcs of a vertebra. A, Lateral view of th sixth and seventh vertebrae (T6 and T7). B, Supenor view of
th sixth vertebra with right rib.
Description
Primary Function
Body
Intervertebral disc
Interbody joint
Pedicle
Short, thick dorsal projection of bone from th mid-to-superior part of th vertebral body
Lamina
Vertebral canal
Intervertebral foramen
Transverse process
Rounded impressions formed on th lateral sides of th thoracic vertebral bodies. Most thoracic vertebral bodies have
superior and inferior facets on each side.
Spinous process
256
Section III
Axial Skeleton
Inferior view
Posterior view
Posterior end
Neck
Head'
Articular tubercle for
transverse process
Costai g ro tta
B
FIGURE 9-6. A typical nght rib. A, Inferior view. B, Posterior view.
VERTEBRAL COLUMN
The word trunk describes th body of a person, including
th stemum and ribs, but excluding th head, neck, and
limbs. Vertebral (spinai) column describes th entire set of
vertebrae, excluding th ribs, stemum, and pelvis. The terms
superior and inferior are used interchangeably with th
terms cranial and caudal, respectively.
The vertebral column usually consists of 33 vertebral segments, divided into live regions. Normally there are seven
cervical, twelve thoracic, five lumbar, five sacrai, and four
coccygeal segments. The sacrai and coccygeal vertebrae are
usually fused in th adult, forming individuai sacrai and
coccygeal bones. individuai vertebrae are abbreviated alphanumerically; for example, C2 for th second cervical, T6 for
th sixth thoracic, and LI for th first lumbar. Each region
of th vertebral column (e.g., cervical and lumbar) has a
distinct overall morphology that reflects its specific function.
Vertebrae located at th cervicothoracic, thoracolumbar, and
lumbosacral junctions often share characteristics that reflect
th transition between major regions of th vertebral col
Chapter 9
Sternocleidomastoid
257
258
Seclion III
Axial Skeleton
FIGURE 9-8. A side view shows th sagittal piane curvatures of th vertebral column. A, Neutral static position while one is
standing. B, Extension of th vertebral column increases th cervical and lumbar lordosis, but reduces (straightens) th thoracic
kyphosis. C, Flexion of th vertebra! column decreases th cervical and lumbar lordosis, but increases th thoracic kyphosis.
Chapter 9
lJnc-of-gravitv
HGURE 9-9. The line-of-gravity in a person with an ideal standing
posture. (Modified from Neumann DA: Arthrokinesiologic considerauons for th aged aduli. In Guccione AA (ed): Geriatrie Physical
Therapy, 2nd ed. Chicago, Mosby-Year Book, 2000.)
259
260
Section ili
Axial Skeleton
LIG A M EN T U M FLA V U M
TABLE
Name
Attachments
Function
Comment
Ligamentum flavum
Limits flexion
Limits flexion
Intertransverse ligamenis
Anterior longitudinal
ligament
Chapier 9
261
Attachmcnts
Function
Comment
Posterior longitudinal
ligament
Stabihzes th vertebral
column
Limits flexion
Reinforces th posterior
annulus ftbrosus
Capsule of th
apophyseal joints
Functional biomechanics of th ligamentum flavum durtng extension and flexion. A, The ligamentum flavum is slackened in extension and stretched in flexion. Excessive flexion can cause trauma. B, The stressstrain relationship of th ligamentum flavum is shown between full extension to a point of failure (rupture) at
extreme flexion. Note th ligament fails at a point 70% beyond its full slackened length. (Data from Nachemson
A, Evans J: Some mechancal properties of th third lumbar interlaminar ligament. J Biomech 1:211-220, 1968.)
FIGURE 9 -1 3 .
Posterior view
Superior articular
Mamillary process
process
Intertransverse
Apophyseal joint
(opened)
Apophyseal
joint capsule
Interspinous ligament
Supraspinous
FIGURE 9 -1 5 .
262
Section III
Axial Skeleton
intra-articuiar structures
c o m p r e s s io n f o r c e s d u r in g t h e x t r e m e s o f m o v e m e n t .66
S e v e r a l d if f e r e n t f o r m s o f i n t r a - a r t ic u ia r s t r u c t u r e s lo c a t e d
lo c a t e d b e t w e e n t h in t e r n a i s id e o f t h c a p s u le a n d t h
w it h in t h lu m b a r a p o p h y s e a l j o in t s a r e illu s t r a t e d in F ig
p e r ip h e r y o f t h a r t ic u la r c a r t ila g e . T h e s t r u c t u r e s c o n t a in
u r e 9 - 1 6 . T h e m e n is c o id s m a y b e in v o lv e d in a n a c u t e
s m a ll f a t p a d s m ix e d w it h t h in s h e e t s o f c o n n e c t iv e t is -
lo c k e d b a c k " c o n d it io n . D u r in g f le x io n , a m e n is c o id m a y
s u e s t h a t e x t e n d p a r t ia lly in to t h jo in t. T h e s e s t r u c
b u c k le o n it s e lf a n d b e c o m e lo d g e d u n d e r t h a d j a c e n t
t u r e s t e r m e d f ib r o a d ip o s e m e n i s c o i d s m a y h e lp p r o -
c a p s u le . T h e m e n s ic o id m a y t h e n a c t a s a s p a c e - o c c u p y -
t e c t e x p o s e d c a r t ila g e a n d s y n o v ia l m e m b r a n e f r o m
in g le s io n , b lo c k in g f u ll e x t e n s io n . 12
Superior view
REGIONAL 0STE0L0GIC FEATURES
The adage that function follows structure is very applicatale
in th study of th vertebral column. Although all vertebrae
have a common morphologic theme, each also has a specific
shape that reflects its unique function. The following section,
along with Table 9 - 4 , highlights specific osteologie features
of each region of th vertebral column.
Cervical Region
The cervical vertebrae are th smallest and most mobile of
all movable vertebrae. The high degree of mobility is essential to th large range of motion required by th head.
Perhaps th most unique anatomie feature of th cervical
vertebrae is th presence of transverse foram ina located
within th transverse processes (Fig. 9 - 1 7 ) . The vertebral
artery ascends through these foramina, coursing toward th
foramen magnum to transport blood to th brain and spinai
cord. In th neck, th vertebral artery is located immediately
anterior to th exiting spinai nerve roots (see Fig. 9 - 4 ) .
The third through th sixth cervical vertebrae show
nearly identical features and are therefore considered typical
of this region. The upper two cervical vertebrae, th atlas
(C l) and th axis (C2), and th seventh cervical vertebrae
(C7) are atypical for reasons described in a subsequent sec
tion.
Atlas (CI)
Axis (C2)
Transverse
foramen
Pedicle
Anterior
and
Posterior
tubercles
Vertebra!
canal
Spinous
process
Transverse
process
Body
O n
Superior
Articular Facets
Inferior Articular
Facets
Atlas (Cl)
None
Concave, face
generally supe
rior
Axis (C2)
Fiat to slightly
convex, face
generally supe
rior
C3-6
As above
CI
As above
Transition to typical
thoracic vertebrae
T2-T9
TI and
TI 0-12
As above
As above
LI -5
Slightly concave,
face mediai to
posierior-medial
Sacrum
Fused
Body of first sacrai
vertebra most evident
None
Coccyx
Rudimentary
Rudimentary
Spinous Processes
Vertebra! Canal
Transverse Processes
Comments
None, replaced by a
small posterior tu
berete
Triangular, largest
of cervical region
Bifd
Triangular
As above
As above
Triangular, contains
cauda equina
None, replaced by
multiple spinous
tubercles
As above
Rudimentary
Ends at th first
coccyx
Rudimentary
264
Section III
Axial Skeleton
Anterior view
Atlas (C l)
As indicated by its name, th primary function of th
atlas is to support th head. Possessing no body, pedicle,
lamina, or spinous process, th atlas is essentially two large
lateral masses joined by anterior and posterior arches (Fig ,
9 - 2 2 ) . The short anterior arch has an anterior tubercle for
attachment of th anterior longitudinal ligament. The muchi
larger posterior arch forms nearly half th circumference of]
th entire atlantal ring. A small posterior tubercle marks th
midiine of th posterior arch. The lateral masses support th
prominent articular processes.
The large and concave superior articular facets face erari -1
ally, in generai, io accept th large, convex occipital cor.-l
dyles. The inferior articular facets are fiat to slightly concave
These facet surfaces generally face mferiorly, with their la I
eral edges sloped downward, approximately 30 degrees frorr I
th horizontal piane (Fig. 9 - 2 2 B ). The alias has large, palpaJ
ble transverse processes, usually th greatest of th cerv cM
vertebrae.
Axis (C2)
Intervertebraf
foramen
Uncinate
process
Transverse
process
Posterior
tubercle
The axis has a large, tali body that serves as a base for
upwardy projeetmg d'ens (odontoid process) (Fig. 9 -2 3 A anc
B). Part of th elongated body is formed from remnants &. I
th body of th atlas and th intervening disc. The demi
provides a rigid vertical axis for rotation of th atlas anzi
head (Fig. 9 - 2 4 ) . Projecting laterally from th body is a pai: I
of superior articular processes (Fig. 9 -2 3 A ). These large fla: I
to slightly convex processes have superior facets that ar-: I
generally in a cranial position, exhibiting a 30-degree slope
which matches th slope of th inferior articular facets o: I
th atlas. Projecting from th prominent superior articular
processes of th axis are a pair of stout pedicles and r I
pair of short transverse processes (Fig. 9 - 2 3 B ). A pair
1
inferior articular processes project inferiorly from th I
pedicles, with articular facets facing anteriorly and ir.-1
feriorly (see Fig. 9 - 2 1 ) . The spinous process of th axis
1
bifid and very broad. This palpable spinous process serve.-1
as an attachment for many muscles, such as th sem; - 1
spinalis cervicis.
Chapter 9
S P E C I A L
265
F O C U S
C e r v ic a l O s te o p h y te s : O n e P o s s ib le C o n s e q u e n c e o f D is c
D is e a s e
o s t e o p h y t e ( b o n e s p u r ) , d e p ic t e d a t t h C 4 -C 5 in t e r v e r t e
b r a l j o in t in F ig u r e 9 - 1 9 . O s t e o p h y t e s d e v e lo p in a c c o r d -
O n e im p o r t a n t f u n c t io n o f a h e a lt h y , w e ll- h y d r a t e d in t e r v e r t e b r a l d is c is t o u n lo a d t h u n c o v e r t e b r a l jo in t s . T h is
u n lo a d in g , o r " c u s h i o n i n g " e f f e c t , is illu s t r a t e d a t t h O S
CA in t e r v e r t e b r a l ju n c t io n in F ig u r e 9 - 1 9 . T h e e f f e c t m a y
a n c e w it h t h c e n t u r y - o ld
Wolff's
/ .a w th a t S ta te s " B o n e
is la id d o w n in a r e a s o f h ig h s t r e s s a n d r e a b s o r b e d in
a r e a s o f l o w - s t r e s s . " A la r g e o s t e o p h y t e m a y e n c r o a c h o n
a n e x it in g s p in a i n e r v e ro o t, p r o d u c in g a p in c h e d n e r v e
s y n d r o m e w it h p a in a n d w e a k n e s s t h r o u g h o u t t h p e r ip h -
b e r e d u c e d in t h c a s e o f a d e g e n e r a t e d o r d e h y d r a t e d
d is c . O v e r t im e , i n c r e a s e d c o m p r e s s io n f o r c e o n t h u n
e r a l d is t r ib u t io n .
c o v e r t e b r a l j o in t m a y s t im u la t e t h f o r m a t io n o f a n
Anterior view
Intervertebral foramen
Osteophyte around
th uncovertebral joint (C4-C5)
Ventral ramus
C5 spinai nerve
Anterior tubercle of
transverse process
FIGURE 9-19. A computer-enhanced image depicts th relationship between th health of an intervertebral disc and th compression at th adjacent uncovertebral joints. The intervertebral disc between
C3-C4 is shown as a healthy and fully hydrated structure. The height of th disc acts as a spacer,
unloading th uncovertebral joints. In contrast, th disc between C4-C5 is shown as a degenerated,
flattened structure. As a result, th adjacent C4-C5 uncovertebral joint has developed a large osteo
phyte owing to increased compression and resultant stress between its articular surfaces. The osteo
phyte is shown compressing elements of th C5, which may cause radiating pain throughout th
nerves peripheral distribution.
costai facet that articulates with th tubercle of th corresponding rib. Short, thick laminae form a broad base for th
downward slanting spinous processes. The articular proc
esses have facets that are oriented nearly vertical, with th
superior Jacets facing generally posterior and th injerior facets
facing generally anterior. The apophyseal joints are aligned
dose to th frontal piane (Fig. 9 - 2 5 ) .
Each head of ribs 2 to 10 forms a costovertebral joint by
articulating at th junction of th T I - 2 through T 9 - 1 0
vertebral bodies. The head of a rib articulates with a pair of
costai facets that span one intervertebral junction. A thoracic
(intercostal) spinai nerve root exits through a corresponding
thoracic intervertebral foramen. The intervertebral foramen is
located just anterior to th apophyseal joints.
266
Secton li
Axial Skeleton
Posterior-lateral view
Lateral view
Anterior
and
Posterior
tubercles
Superior view
Posterior tubercle
Posterior
arch -
Transverse
process
Transverse
foramen
Anterior tubercle
Anterior view
Superior
articolar facet
Anterior
arch
Chapter 9
267
Superior view
A nterior view
Dens
articular process
(dorsal side)
Anterior tacet
Superior
articular facet
Superior
articular process
Transverse
process
articular facet
The neck of ribs 11 and 12 typically do not form articulations with corresponding transverse processes.
Lumbar Region
Lumbar vertebrae have massive wide bodies, suitable for supporting th entire superimposed weight of th head, trunk,
and arms (Fig. 9 - 2 6 ) . The total mass of fve lumbar verte
brae is approximately twice that of th seven cervical verte
brae (Fig. 9 - 2 7 ) .
Lateral view
Superior view
tion.
vertebrae.
268
Section III
Axial Skeleton
Chapter 9
Luterai view
269
Coccyx
The coccyx is a small triangular bone consisting of four
fused vertebrae (see Fig. 9 - 3 1 ) . The base of th coccyx joins
th apex of th sacrum at th sacrococcygeal joint. The joint
has a fibrocartilaginous disc and is held together by several
small ligaments. The sacrococcygeal joint usually fuses late
in life. In youths, small intercoccygeal joints persist; however,
these typically are fused in adults.110
ARTHROLOGY
Typical Intervertebral Junction
Sacrum
The sacrum is a triangular bone with its base facing superi
ori)' and apex inferiori)' (Fig. 9 - 3 0 ) . An important function
of th sacrum is io transmit th weight of th vertebral
column to th pelvis. In childhood, each of ftve separate
sacrai vertebrae are joined by a cartilaginous membrane. By
adulthood, however, th sacrum has fused into a single
bone, whch stili retains th typical anatomie features of a
generic vertebra.
The anterior (pelvic) surface of th sacrum is smooth and
concave, forming pari of th posterior wall of th pelvic
cavity (see Fig. 9 - 3 0 ) . Four paired ventral (pelvic) sacrai
fem m in a transmit th ventral rami of spinai nerves that form
much of th sacrai plexus. The clorsal surface of th sacrum
is convex and rough due to th attachments of muscle and
ligaments (Fig. 9 - 3 1 ) . Several spinai and lateral tubercles
mark th remnants of fused spinous and transverse processes, respectively. Four paired dorsal sacrai foram ina trans
mit th dorsal rami of sacrai nerves.
The superior surface of th sacrum shows a clear representation of th body of th first sacrai vertebra (Fig. 9 - 3 2 ) .
The sharp anterior edge of th body of SI is called th sacrai
promontory. The triangular sacrai canal houses and proteets
Function
Apophyseal joint
Interbody joint
270
Secton III
Axial Skeleton
S P E C I A L
F O C U S
Cauda Equina
b a t h e d w it h in c e r e b r o s p in a l f lu id a n d lo c a t e d w it h in t h
T h e s p in a i c o r d a n d v e r t e b r a l c o lu m n h a v e d if f e r e n t
g ro w th ra te s . A s a c o n s e q u e n c e , th c a u d a l e n d o f th
a d u lt s p in a i c o r d u s u a lly t e r m in a t e s a d j a c e n t t o t h L 1 -2
in t e r v e r t e b r a l f o r a m e n (F ig . 9 - 2 9 ) . T h e l u m b o s a c r a l n e r v e s
m u s t t r a v e l a g r e a t d is t a n c e b e f o r e r e a c h in g t h e ir c o r r e s p o n d in g in t e r v e r t e b r a l f o r a m in a . A s a g r o u p , t h e lo n g a t e d n e r v e s r e s e m b le a h o r s e 's t a il, h e n c e
cauda equina.
lu m b o s a c r a l v e r t e b r a l c a n a l.
S e v e r e f r a c t u r e o r t r a u m a in t h lu m b o s a c r a l r e g io n
m a y d a m a g e t h c a u d a e q u in a , b u t s p a r e t h s p in a i c o r d .
D a m a g e t o t h c a u d a e q u in a m a y r e s u lt in m u s c le p a r a ly s is a n d a t r o p h y , a lt e r e d s e n s a t io n , a n d r e d u c e d r e f le x e s .
S p a s t ic it y w it h e x a g g e r a t e d r e f le x e s t y p i c a l l y o c c u r s w it h
d a m a g e t o t h s p in a i c o r d .
T h e c a u d a e q u in a is a s e t o f p e r ip h e r a l n e r v e s t h a t a r e
C a u d a equina
Chapter 9
271
Posterior-lateral view
A n t e r i o r v ie w
M ultifdi
articularis
Spinous process (L5)
Apophyseal
jo in t (L5-S1)
Spinai tubercles
Auricular
Lateral tubercles
Erector spinae
and m u ltifid i
Gluteus maxim us
T E R M IN O L O G Y
Sacrai
promontory
Ventral
sacrai
foramina
Coccyx
Piriform is
Auricular surface
(articulates
w lth ilium)
THAT
D E S C R IB E S
M OVEM ENT
FIGURE 9-30. An anterior view of th lumbosacral region. Attaehments of th piriformis, iliacus, and psoas major are indicated in
red. Attachments of th quadratus lumborum are indicated in gray.
Superior view
272
Section III
Axial Skeleton
Transverse process
Interior articular facet
Vertebral body
Apophyseal joint
Intervertebral foramen
Splnous process
th piane and direction of rotation for a given region. Motions are typically defined by their planes, with an associated
axis of rotation located approximately through th body of
th interbody joint (Table 9 - 6 ) . By convention, movement
throughout th vertebral column, including th head on th
cervical spine, occurs in a cranial-to-caudal fashion, with th
direction of movement referenced by a point on th anterior
side of th more cranial (superior) vertebral segment. During
Piane of Movement
Axis of Rotation
Other Terminology
Sagittal
Medial-lateral
Frontal
Anterior-posterior
Horizontal
Vertical
Rotation, torsion
Definition
Functional Example
Therapeutic traction
S ep a r a tio n
surfaces
S lid in g
Chapier 9
273
Spinai Coupling
M o v e m e n t o f t h v e r t e b r a l c o lu m n in o n e p ia n e is u s u a lly a s s o c ia t e c i w it h a n a u t o m a t ic a n d , a t t i mes ,
nearly
im p e r c e p t ib le m o v e m e n t in a n o t h e r p ia n e . T h is k in e m a t ic
m a n y c o u p lin g p a t t e r n s a r e d e s c r ib e d , t h m o s t c o n s is t e n t p a t t e r n in v o lv e s a n a s s o c ia t io n b e t w e e n a x ia l r o t a t io n a n d la t e r a l f le x io n .
T h e m e c h a n ic a l r e a s o n f o r s p in a i c o u p lin g v a r ie s b e
t w e e n r e g io n s , a n d it o f t e n is n o t c le a r . E x p la n a t io n s
in c lu d e m u s c le a c t io n , a r t ic u la r f a c e t a lig n m e n t , a n d
g e o m e t r y o f t h p h y s io lo g ic c u r v e it s e lf . 18 T h e la t t e r
e x p la n a t io n m a y b e d e m o n s t r a t e d b y u s in g a f le x ib le
ro d a s a m o d e l o f t h s p in e . B e n d t h ro d a b o u t 3 0 to
40 d e g r e e s in o n e p ia n e t o m im ic t h n a t u r a i lo r d o s is o r
k y p h o s is o f a p a r t ic u la r r e g io n . W h i l e m a in t a in in g t h is
c u r v e , " l a t e r a l l y f le x " t h r o d a n d n o t e a s lig h t a u t o
m a t ic a x ia l r o t a t io n . T h e b ip la n a r b e n d p la c e d o n a
f le x ib le r o d a p p a r e n t ly c r e a t e s u n e q u a l s t r a in s t h a t a r e
d is s ip a t e d a s t o r s io n . T h is d e m o n s t r a t io n d o e s n o t e x p la in a ll c o u p lin g p a t t e r n s o b s e r v e d c l i n i c a l l y t h r o u g h o u t
t h v e r t e b r a l c o lu m n , h o w e v e r .
FIGURE 9-34. Typical spatial orientations for selected superior articular facet surfaces of cervical, thoracic, and lumbar vertebrae. The
red line indicates th piane of th superior articular facet, measured
against a vertical or horizontal reference line.
Interbody Joints
STRUCTURE A N D
AND
F U N C T IO N O F T H E A P O P H Y S E A L
IN T E R B O D Y JO IN T S
Apophyseal Joints
The vertebral column contains twenty-four pairs of apophy
seal joints. Each apophyseal joint is formed by th articulation between opposing facet surfaces (see Fig. 9 - 1 5 ) . Mechanically, apophyseal joints are classified as piane joints.
Although exceptions and naturai variations are common, th
articular surfaces of most apophyseal joints are essentially
fiat. Slightly curved joint surfaces are present primarily in
th upper cervical and throughout th lumbar regions.
The word apophysis means bony outgrowth, illustrating
th protruding nature of th articular processes. Acting as
mechanical barricades, th articular processes permit certain
movements and block others. The orientation of th piane of
th facet surfaces within each joint influences th kinematics
at different regions of th vertebral column. As a generai
rule, horizontal facet surfaces favor axial rotation, whereas ver
tical facet surfaces (in either sagittal or frontal planes) block
axial rotation. Most apophyseal joint surfaces, however, are
oriented somewhere between th horizontal and vertical. Fig
ure 9 - 3 4 shows th typical joint orientation for articular
facets in th cervical, thoracic, and lumbar regions. The
piane of th facet surfaces explains, in part, why axial rota
tion is far greater in th cervical region than in th lumbar
region. Additional factors that influence th predominant
motion at each spinai region include th sizes of th intervertebral discs, shapes of th vertebrae, locai muscle actions,
and attachments of th ribs or ligaments.
274
Section III
Axial Skeleton
Vertebral Endplates
The vertebral endplates are thin caps of hyaline and fibrocartilage located on th superior and inferior surfaces of each
vertebral body. The collagen fibers within th annulus fibro
sus blend with th endplates of two consecutive vertebrae
(Fig. 9 - 3 7 ) . The anatomie bond between th endplates and
annulus forms th primary adhesion between th vertebrae.
The vertebral endplates, being semipermeable, also allow nutrients to pass from blood vessels in th vertebral body to
deeper regions of th disc.
Intervertebral Disc as a Hydrostatic Shock Absorber
Chapter 9
275
return to their originai preload length and prepare for another cycle of shock absorption. According to White and
Panjabi,106 two pioneers in th study of th biomechanics of
th spine, th disc provides little resistance to small com
pressive loads, but more resistance to large ones. The disc
thereby allows flexibility at low loads and provides stability
at high loads.106
The shock absorption mechanism protects th disc in two
ways (see Fig. 9 - 3 8 ) . First, compressive forces are diverted
from th nucleus, toward th annulus, and back to th
nucleus and endplates. Such diversion takes lime, thereby
reducing th rate of loading, although noi necessarily th
magnitude. Second, th mechanism allows compressive
forces to be shared by multiple structures, thereby limiting
pressure on any single tissue.
is created against th nucleus pulposus and endplates, reinforcing th entire disc and passing th load to th next
vertebra (Fig. 9 -3 8 C ). When compressive force is removed
from th endplates, th stretched elastic. and collagen fibers
276
Section III
Axial Skeleton
T A B L
may vary from data presented in other sources. The variability reflects th differences in measurement techniques and
th flexibility of th subjects. As elsewhere in th body,
range of motion varies based on gender, underlying disease.
activity level, and age.
The connective tissues that surround th vertebral column
limit th extremes of motion (Table 9 - 8 ) . By restricting
motion, connective tissues including those within muscle help protect th delicate spinai cord and maintain optimal posture. In cases of trauma or overuse, biologie tissues
Flexion
Extension
Axial Rotation
Lateral Flexion
Ligamentum nuchae
Interspinous and suprasptnous
ligamenis
Ligamentum flava
Capsule of th apophyseal
joints
Posterior annulus fibrosus
Posterior longitudinal ligament
Annulus fibrosus
Capsule of th apophyseal joints
Alar ligaments
Intertransverse ligaments
Contralateral annulus fibrosus
Capsule of th apophyseal joints
The lisi docs not include limiutions of motion caused by stretched muscles or by compression force created within th apophyseal and interbody joints
Chapter 9
Atlanto-occipital Joints
The atlanto-occipital joints provide independent movement
of th cranium relative to th atlas. The joints are formed by
th protruding convex condyles of th occipital bone fitting
into th reciprocally concave superior articular facets of th
atlas (Fig. 9 - 4 1 ) . The congruent convex-concave relationship provides inherent strutturai stability to th articulation.
lntra-articular fai pads are commonly found between th
joint capsule and th margins of th articular cartilage.66
Anteriorly, th capsule of each atlanto-occipital joint blends
with th anterior atlanto-occipital membrane and th anterior
longitudinal ligament (Fig. 9 - 4 2 ) . Posteriori)', th capsule is
covered by a thin, broad posterior atlanto-occipital membrane
(Fig. 9 - 4 3 ) . As depicted on th right side of Figure 9 - 4 3 ,
Craniocervical Region
The terms craniocervical region and neck are used interchangeably. Both terms refer to th combined set of three
articulations: atlanto-occipital joint, atlanto-axial joint complex,
and intracervical apophyseal joints (C 2 -7 ). The overall organization used to present th regional anatomy and kinematics
of th craniocervical region is outlined in Table 9 - 9 . The
277
278
Section III
Axial Skeleton
TABLE 9 - 1 0 . Approximate Range o f Motion for th Three Planes of Movement for th Joints
of th Craniocervical Region
Flexion and Extension
(Sagittal Piane, Degrees)
Axial Rotation
(Horizontal Piane, Degrees)
Lateral Flexion
(Frontal Piane, Degrees)
Atlanto-occipital joint
Flexion: 5
Extension: 10
Total: 15
Negligible
About 5
Flexion: 5
Extension: 10
Total: 15
40 -4 5
Negligible
Flexion: 35
Extension: 70
Total: 105
45
35
Flexion: 4 5 -5 0
Extension: 85
Total: 130-135
90
About 40
Joint or Region
The horizontal and frontal piane moiions are to one side only. Data are compiled from multiple sources (see text) and subject io large intersubjea
variatiorts.
Anterior view
Posterior view
m e m b ra n e (cu t)
A t la n t o - o c c ip it a l
jo in t c a p s u le
O c c ip ita l b o n e
A n t e r io r a tla n to -o c c ip ita l
m e m b ra n e
F o ra m e n
pro cess
Exposed
m agnum
a tla n to -a x ia l
S u p e r io r a r tic u la r
A t la n t o - o c c ip it a l
(a p o p h y s e a l jo in t)
A tla n t o - a x ia l (a p o p h y s e a l i
jo in t c a p s u le
fa c e t
jo in t c a p s u le (cu t)
P o s t e r io r
A p o p h y s e a l jo in t c a p su le
lo n g itu d in a l
lig a m e n t (cu t)
T ra n s v e rs e
pro cess
- Alias
m e m b ra n e
A tla n t o -a x ia l
A n t e r io r
(a p o p h y s e a l)
T ra n s v e rs e
jo in t c a p s u le
fo r a m e n
S p in o u s p r o c e s s
A n te r io r
tu b e rc le
T e c to ria l
P o s t e r io r
T ra n s v e rs e
p ro ce ss
tu b e rc le
lo n g itu d in a l
lig a m e n t (cu t)
FIGURE 9-42. An anterior view illustrates th connective tissut associated with th atlanto-occipital joint and th atlanto-axial joint
complex. The righi side of th atlanto-occipital membrane is removed to show th capsule of th atlanto-occipital joint. The cap
sule of th right atlanto-axial (apophyseal) joint is also removed ! :
expose its articular surfaces. The spinai cord and th bodies of C3
and C4 are removed to show th orientation of th posterior long,
tudinal ligament.
Chapter 9
279
O c c ip ita l c o n d y le
a t la n t o - o c c ip it a l
m e m b ra n e
A t la n t o - o c c ip it a l
Dens
pro cess
A tla n to -a x ia l (a p o p h y s e a l)
jo in t c a p s u le
V e rte b ra l a rte ry
A p o p h y s e a l jo in t c a p s u le
L a m in a
L ig a m e n tu m fla v u m
S p in o u s p r o c e s s
S A G IT T A L P L A N E
K IN E M A T IC S A T TH E
C R A N I O C E R V IC A L R E G IO N
S u p e r io r v ie w
A n t e r io r lo n g itu d in a l lig a m e n t (cu t)
A n t e r io r tu b e rc le
A n t e r io r a rc h
A la r lig a m e n t
D e n s(C 2 )
p ro ce ss
S y n o v ia l c a v itie s
S u p e r io r a r tic u la r
fo r a m e n
T ra n s v e rs e lig a m e n t
T e c to ria l m e m b ra n e (cu t)
P o s t e r io r a rc h
V e rte b ra l c a n a l
P o s t e r io r tu b e rc le
S p in o u s p r o c e s s
280
Secfion HI
Axial Skeleton
P o s t e r io r v ie w
T e c to ria l
lig a m e n t
A t la n t o - o c c ip it a l
O c c ip ita l c o n d y le
A tla n t o -a x ia l
T ra n s v e rs e
(a p o p h y s e a l)
p ro ce ss
jo in t
T ra n s v e rs e
lig a m e n t (cu t)
L ig a m e n tu m
fla v u m (cu t)
T e c to ria l
m e m b ra n e (cu t)
S p in o u s p r o c e s s
EXTENSION
O c c ip ita l b o n e .,.
M a s t o id p r o c e s s
Atlanto-occipital joint
FIGURE 9-46. Ktnemaucs of craniocervical extension. A, Atlanto-occipital joint. B, Atlanto-axial joint complex. C, Intracervical
region (C2-7). Elongated and taut tissues are indicated by thin black arrows.
Chapter 9
281
C r a n i o c c r v i c a l f le x io n
FLEXION
Occipital bone
Compresseti
a n n u lu s fib r o s u s
P o s t e r io r a tla n te -'
C a p s u le o f
o c c ip ita l m e m b ra n e
a p o p h y s e a l jo in t
a n d jo in t c a p s u le
Atlanto-occipital joint
Kinemattcs of craniocemcal flexion. A, Atlanto-occipital joint. B, Atlanto-axial joint complex. C, Intracervical region (C2-7).
Note in C that flexion slackerts th anterior longitudinal ligament and increases th space between th adjacent laminae and spinous
processes. Elongated and taut tissues are indicated by thin black arrows; slackened tissue is indicated by a wavy black arrow.
FIGURE 9 -4 7 .
Atlanto-occipital Joint
282
Seaion III
Axial Skeleton
considered th close-packed position at th cervical apophyseal joints, as well as th other regions throughout th verte
bra! column. This position results in maxima! jomt contact
and load-bearing. The inferior sliding of th articular facets
of superior vertebrae tends to slacken th joint capsule. The
close-packed position of most synovial joints increases th
tension in th surrounding capsule and associated ligaments.
The apophyseal joints are one of th few exceptions to this
generai rule.
Flexion is also initiated at th lower cervical spine
( C 4 - 7 ) .H The movements are th reverse of those described
for extension. The inferior articular facets of th superior
vertebrae slide superiorly and anteriorly, relative to th supe
rior articular facets of th inferior vertebrae. As depicted in
Figure 9 - 4 7 C , th sliding between th articular facets produces approximately 35 degrees of (lexion. Flexion stretches
th capsule of th apophyseal joints and reduces th area for
joint contact.
Overall, approximately 105 degrees of cervical flexion and
extension occur as a result of th sliding between apophyseal
joint surfaces. This extensive range of motion is due in part
to th relatively long and unobstructed are of motion provided by th oblique piane of th facet surfaces. On average,
about 20 degrees of sagittal piane motion occur at each
intervertebral junction between C 2 - 3 and C 6 - 7 . This is a
considerably greater angular motion than at th adjacent
upper thoracic region. The largest angular displacement
tends to occur between C5 and C6,H possibly accounting for
th relatively high incidence of spondylosis68 and hyperflexion-related fractures at this level (Fig. 9 - 4 8 ) .
Osteokinematics of Protraction and Retraction
In addition to flexion and extension in th craniocervical
region, th head can also translate forward (protraction) and
FIGURE 9-48. In viiro cervical fkxion and extension motions averaged over ten specimens. Daia are expressed as a percent of th
total range of sagittal piane motion in th cervical region. (Data
from Holmes A, Han ZH, Dang GT, et al: Changes in cervical canal
spinai volume during in vitro flexion-extension. Spine 2 1 1 3 1 3 1319, 1996.)
Chapler 9
Neutral position
283
Fully flexed
FIGURE 9 -4 9 . How flexion between C3 and C4 affecis ihe size of th intervertebral foramen is shown. A, in th neutral position, th
facet surfaces within th apophyseal joint are in maximal contact. The size of th intervertebral foramen relative to th circumference of
th exiting nerve is indicated in red. B, Full flexion reduces th contact area within th apophyseal joint; however, it increases th
opening for passage of th nerve.
284
Section III
Axial Skeleton
Protraction
Retraction
Thoracic Region
The thorax consists of a relatively rigid rib cage, formed by
th ribs, thoracic vertebrae, and stemum. The rigidity of th
region provides three functions: (1) a stable base for muscles
to control th craniocervical region, (2) protection for
th intrathoracic organs, and (3) mechanical bellows for
breathing (see Chapter 11).
Chapter 9
285
90" rotaton
A la r lig a m e n t
(taut)
S u p e r io r fa c e t
o f a x is
C a p s u le o f
a p o p h y s e a l jo in t
V e rte b ra l c a n a l
In fe rio r fa c e t
o f a tla s
Superior view
Atlanto-axial joint complex (C1-C2)
FIGURE 9-51. Kinematics of craniocervical axial rotaton. A, Atlanto-axial joint complex. B, Intracervical region (C2-7).
286
Section III
Axial Skeleton
C a p s u le o f
apophyseal
O c c ip ita l b o n e
jo in t.
LATERAL
FLEXION
M a s to ic i p r o c e s s
R e c t u s c a p itis
la t e ra lis
Atlanto-occipital joint
FIGURE 9-52. Kinematics of craniocervical lateral flexion. A, Atlanto-occipital joint. The primary function of th rectus capitis
lateralis is to laterali)- flex this joint. Note th slight compression and distraction of th joint surfaces. B, Intracervical region
(C2-7). Note th ipsilateral coupling pattern between axial rotation and lateral flexion (see text for further details). Elongated
and taut tissue is indicated by thin black arrows.
a cranial-to-cauda direction.
Flexion: 30 -4 0
Extension: 2 0 -2 5
Axial Rotation
(Horizontal Piane,
Degrees)
Lateral Flexion
(Frontal Piane.
Degrees)
30
25
Total: 5070
one side
Chapter 9
287
P o s t e r io r lo n g itu d in a l
lig a m e n t
C o s t o t r a n s v e r s e lig a m e n ts
A n t e r io r lo n g itu d in a l
lig a m e n t
S u p e r io r c o s to t r a n s v e r s e
R a d ia te a n d c a p s u la r
lig a m e n t
lig a m e n ts o f th
S p in o u s
c o s to v e r te b r a l jo in t
P a ir o f c o s t a i fa c e ts
T ra n s v e rs e p r o c e s s
o f th c o s to v e r te b ra l
jo in t
C o s ta i fa c e t o f th
c o s t o t r a n s v e r s e jo in t
S u p e r io r c o s t o t r a n s v e r s e
lig a m e n t (cu t)
Superior view
T ra n s v e rs e p r o c e s s
Exposed
jo in t
C o s to tr a n s v e r s e
S u p e r io r a r tic u la r
lig a m e n ts
fa c e t
c o s to v e r te b ra l jo in t
ra d ia te lig a m e n ts
A n n u lu s f ib r o s u s
N u c le u s p u lp o s u s
The magnitude o f ibis inten'eriebra moiion remains reatively Constant throughout th entire thoracic region. As de
picted in Figure 9 57A, lateral llexion of T 6 on T7 occurs
as th inferior facet surface of T 6 slides superiorly on th
side contralateral to th lateral flexion and inferiorly on th
side ipsilateral to th lateral flexion. Note that th ribs drop
slightly on th side of th lateral flexion, and rise slightly on
th side opposite th lateral flexion.
As in th cervical spine, lateral flexion and axial rotation
are mechanically coupled in an ipsilateral manner.107 Couphng is most evident in th upper thoracic spine where th
articular facets possess a closer orientation to those in th
lower cervical region. The influence of th coupling de
creases and is inconsistent in th middle and lower thoracic
regions.
288
Seclton III
Axial Skeleton
Thoracolumbar flexion
^ C o m p re sse c i
a n n u lu s
In te rs p in o u s
f ib r o s u s
lig a m e n t
S u p r a s p in o u s
lig a m e n t
Thoracic region
Lumbar region
FIGURE 9-54. The kinemaiics of thoracolumbar flexion is shown through an 85-degree are th sum of 35
degrees of thoracic flexion and 50 degrees of lumbar flexion. A, Kinematics at th thoracic region B Kinematics
at th lumbar region. Elongated and taut tissues are indicated by thin black arrows.
Excessive Kyphosis
On average, about 42 degrees of naturai kyphosis is present
while standing (see Fig. 9 - 4 0 ) . 52 In some persons, however,
excessive kyphosis occurs and can cause functional limitations. The acquired forni of excessive kyphosis may occur as
a consequence of trauma and related spinai instability, disease, or connective tissue changes that may be associated
with age. In generai, age-related thoracic kyphosis is usually
slight and not debilitating.
Chapter 9
289
FIGURE 9-55. The kinematics of thoracolumbar extension is shown through an are of 35 io 40 degrees: ihe sum of 20 to
25 degrees of thoracic extension and 15 degrees of lumbar extension. A, Kinematics at th thoracic region. B, Kinematics at
th lumbar region. Elongated and taut tissue is indicated by thin black arrows; slackened tissue is indicated by a wavy black
line.
(see Fig. 9 - 5 8 B ). increased extensor rnuscle and ligamentous force is needed to hold th trunk, neck, and head
upright. The increased force passes through th interbody
joints, possibly creating small compression fractures in th
vertebral bodies. At this point th vicious circle is well established.
The thoracic posture shown in Figure 9 - 5 8 B may pro
gress, in extreme cases, to that shown in Figure 9 -5 8 C .
While standing, th line-of-force due to body weight has
produced a small upper cervical extension torque and a large
thoracic flexion torque. Note that despite th large thoracic
kyphosis, th person can extend her upper craniocervical
region enough to maintain a horizontal visual gaze. The
main point of Figure 9 -5 8 C , however, is to appreciate th
biomechanical and physiologic impact that a large extemal
290
Sceltoti III
Axial Skeleton
S te rn u m
Thoracic region
9 0 c r a n io c e r v ic a l ro ta tio n
3 5 t h o r a c o lu m b a r
a x ia l ro ta tio n
125
S u p e r io r fa c e t o f T 7
I n te rio r fa c e t o f T 6
Lumbar region
Superior view
J o in t
a p p r o x im a tio n
J o in t
s e p a ra tio n
S u p e r io r fa c e t o f L 2
I n te rio r fa c e t o f L1
Superior view
FIGURE 9-56. The kinematics of thoracolumbar axial rotation is depicted as th subject rotates her face 125
degrees to th right. The thoracolumbar axial rotation is shown through a 35-degree are: th sum of 30 degrees
of thoracic rotation and 5 degrees of lumbar rotation. ,4, Kinematics at th thoracic region. B, Knematics at th
lumbar region.
Chapter 9
291
T h o ra c ic region
LATERAL
FLEXION
T h o ra c o lu m b a r lateral flexion
S u p e r io r fa c e ts o f T 6
S u p e r io r fa c e t o f T 7
L u m b a r region
LATERAL
FLEXION
r
. . . . . .
S u p e r io r fa c e ts o f L1
V ____
intertransverse
lig a m e n t
In te rio r fa c e t o f L1
S u p e r io r fa c e t o f L 2
FIGURE 9-57. The kinematics of thoracolumbar lateral flexion is shown through an approximate 45-degree are: th sum of 25 degrees of
thoracic lateral flexion and 20 degrees of lumbar lateral flexion. A, Kinematics at th thoracic region. B, Kinematics at th lumbar region.
Note th slight contralateral coupling pattern between axial rotation and lateral flexion in th lumbar region. Elongated and taut tissue is
indicated by a thin black arrow.
FIGURE 9-58. Lateral views show th biomechanical relationships between th line-of-force due to body weight (BW) and
varying degrees of thoracic kyphosis. In each of th three models, th axes of rotation are depicted as th midpoint of th
thoracic and cervical regions (dark circles). The extemal moment arms used by body weight are shown as dashed lines. A, In a
person with ideal standing posture and normal thoracic kyphosis, body weight created a small cervical extcnsion torque and a
small thoracic flexion torque. B, In a person with moderate thoracic kyphosis, body weight created a moderate cervical and
thoracic flexion torque (EMA', extemal moment arm at midthoracic spine; EMA, extemal moment arm at midcervical spine;
IMA, internai moment arm for trunk extensor muscle force). C, In a person with severe thoracic kyphosis, body weight caused
a small cervical extension torque and a large thoracic flexion torque. All three models are based on x-rays of patients. (From
Neumann DA: Arthrokinesiologic considerations for th aged adult. In Guccione AA (ed): Geriatrie Physical Therapy. Chicago,
Mosby-Year Book, 2000.)
292
Section III
Axial Skeleton
S P E C I A L
F O C U S
9 - 8
Lumbar Region
F U N C T I O N A L A N A T O M Y OF T HE A R T IC U L A R
S T R U C T U R E S W IT HIN THE L U M B A R REGION ( L I - S I )
L1-L4 Region
The facet surfaces of lumbar apophyseal joints are oriented
nearly vertical, with a moderate-to-strong sagittal piane bias.
The orientation of th superior articular facet of L2, for
example, is about 25 degrees from th sagittal piane (see Fig.
9 - 3 4 ) . This orientation favors sagittal piane motion at th
expense of axial rotation. This trend is evident even in th
mid-to-lower thoracic regions.
The facet surfaces change their orientation rather abruptlv
at or near th thoracolumbar junction (Fig. 9 - 6 0 ) . The
sharp frontal-to-sagittal piane transition may help to explain
th relatively high incidence of traumatic paraplegia at this
junction. The thorax, held relatively rigid by th rib cage, is
free to flex as a unii over th upper lumbar region. A large
flexion torque delivered to th thorax may concentrate an
excessive hyperflexion stress at th extreme upper lumbar
region. If severe enough, th stress may fracture or dislocate
th bony elements and possibly injure th caudal end of th
spinai cord or th cauda equina. Surgical fixation devices
implanted to immobilize an unstable thoracolumbar junction
are particularly susceptible to stress failure compared with
other regions of th vertebral column.
L5-S1 Junction
As any typical intervertebral junction, th L 5 -S 1 junction
has an interbody joint anteriorly and a pair of apophyseal
Chapter 9
T10-T11
apophyseal
jo in t
T h o ra c o lu m b a r
ju n c tio n
T12-L1
293
apophyseal
jo in t
ES/34fj
L5-S1
L3-4
interbody
joint
Erector spinae
across L3-4
apophyseal
jo in t
ES/5
Erector spinae
across L5-S1
L5-S1
J S
Sacrohorizontal
angle ( a ) =40
y n -s f
p O p h y se a
BWS sm B
iVv
BWS
FIGURE 9-61. Lateral view shows th biomechamcs responsible for
294
Section III
Aria! Skeleton
out adequate stabilization, th lower end of th lumbar regton can slip forward relative to th sacrum. This abnormal.
potentially serious condition is known as spondylolisthesis.
Flexion: 50
Extension: 15
Total: 65
Axial Rotalion
(Horizontal Piane,
Degrees)
Lateral Flexion
(Frontal Piane.
Degrees)
20
Horizontal and frontal piane motions are to one side only. Data frorr
Pearcy, et al, 1984; Pearcy and Tibrewal. 1984.
.
I
Chapter 9
295
9 - 1 3 . Organization of th Discussion
Sagittal Piane Kinematies at th Lumbar Region
T A B L E
joint capsu le
and
interspinous
ligam ents
flavum
296
Secton III
Axial Skeleton
j9
S P E C I A L
F O C U S
person with a weakened posterior annulus, however, posterior migration of th nuceus pulposus increases pressure on
th spinai cord or nerve roots. These contrasting therapeutic
effects of fexion in th lumbar region are to be considered
when planning an exercise program for a person with generalized low back pain.
9 - 1 0
Protrusion
Prolapse
Extrusion
Sequestration
FIGURE 9 65. Types of disc herniations. (From Magee DL: Orthopedic Physical Assessment, 3rd ed Philadelphia, WB Saunders,
i yy /.)
Chapter 9
297
In conjunction with th hip joints, th lumbar region provides th major flexion and extension pivot point for th
trunk, especially during activities such as forward bending,
climbing, and lifting. The kinematic relationship between th
lumbar spine and hip joints during sagittal piane movemenls
is called lumbopelvic rhythm. An understanding of th normal
lumbopelvic rhythm during flexion and extension of th
trunk can help distinguisi! pathology affecting th spine and
that affecting th hips.
298
Section III
Axial Skeleton
FIGURE 9-66. Three different lumbopelvic rhythms used to flex th trunk forward and toward th floor with knees held straight.
A, Typical lumbopelvic rhythm consists of about 40 degrees of flexion of th lumbar spine and 70 degrees of flexion ai th hips
(pelvis on femurs). B, With limited flexion in th hips (for example, from tight hamstrings), greater flexion s required of th
lumbar and lower thoracic spine, C, With limited lumbar mobility, greater flexion is required of th hip joints. Red arrows
indicate limited or restricted mobility.
Chapter 9
299
FIGURE 9-67. A typical lumbopelvic rhythm shown in ihree phases and used to extend ihe trunk from a forward bent
position. The moiion is arbitrarily divided into ihree chronologic phases (A lo C). In each phase, ihe axis of rotation (or th
trunk exlension is assumed io pierce ihe body of L3. A, In th early phase, trunk extension occurs to a greater extern ihrough
extension of th hips (pelvis on femurs), under strong actvation of hip extensor muscles (gluteus maximus and hamstrings).
B, In th middle phase, trunk extension occurs to a greater degree by extension of th lumbar spine. The middle phase
requires increased activation from lumbar extensor muscles. C. At th completion of th event, muscle activity typically ceases
once th line-of-force from body weight falls posterior to th hips. The external moment arm used by body weight is depicted
as a solid black line. The greater intensily of red indicates relative greater intensity of muscle activation.
trunk motion. A second movement strategy involves a relatively short-are tilt of th pelvis, with th trunk remaining
nearly stationary. As depicted in Figure 9 -6 8 A to D, an
anterior or a posterior pelvic tilt accentuates or reduces th
lumbar lordosis. Measured whtle standing, an approximate
one-to-one relationship exists between th change in pelvic
tilt and th associated change in lumbar lordosis., '5 The
change in lordosis alters th position of th nucleus pulposus within th disc and alters th diameter of th intervertebral foramina.
The axis of rotation for pelvic ttlting is through both hip
joints. This mechanical association strongly links th move
ment (pelvic-on-femoral) of th hip joints with that of th
lumbar spine. This relationship is discussed further in th
next section and again in Chapter 12.
300
Section III
Axial Skeleton
L u m b a r e x te n s o r s
H ip f le x o r s
V e rte b ra l c a n a l
In te rv e rte b ra l
Apophyseal
d is c
jo in t
I n te rs p in o u s
N u c le u s
In te rs p in o u s
lig a m e n t
p u lp o s u s
lig a m e n t
In te rv e rte b ra l
S p in a i n e rv e
fo r a m e n
D
FIGURE 9-68. Anterior and posterior tilt of th pelvis and its effect on th ktnematics of th lumbar spine. A and C, A n t e n o r p elv ic tilt
extends th lumbar spine and increases lordosis. This action tends to shift th nucleus pulposus anteriori). and reduces th diameter of th
intervertebral foramtna B and D, P o s te r io r p elv ic tilt flexes th lumbar spine and decreases lordosis This action tends to shift th nucleus
pulposus posteriorly and increases th diameter of th intervertebral foramina. Muscle activity is shown in red
toward [he low b ack .22 Centralization, therefore, suggests reduced disc pressure on th nerve root.
I
I
I
I
1
I
Chapter 9
301
302
Section III
Axial Skeleton
B o d y w e ig h t
B o d y w e ig h t
FIGURE 9-70. Sitting posture and effects on th alignment of th lumbar and craniocervical regions. A, With a slouehed sitting
posture, th lumbar spine flexes, which reduces its norma] lordosis. As a consequence, th head tends to assume a forward
posture (see text). B, With an ideal sitting posture aided with a cushion, th lumbar spine assumes a normal lordosis, which
facilitates a more desirable chin-in position of th head.
base of th cervical spine. The forward-head posture increases th extemal flexion torque on th cervical column as
a whole, requiring greater force production from th extensor muscles and locai connective tissues. Sitting posture may
S P E C I A L
F O C U S
9 - 1 1
Flexion and Extension Exercises for Treatment of LowBack Pain Understanding th "Trade-Offs"
9 - 1 5 . Biomechanical Conscquences of
Lumbar Flexion and Extension
T A B L E
Flexion
Extension
Chapter 9
303
SACROILIAC JOINTS
The sacroiliac joints mark th transition between th caudal
end of th axial skeleton and th lower appendicular skele
ton. The analogous articulations at th cranial end of th
axial skeleton are th sternoclavicular joints within th
shoulder complex. Both th sternoclavicular and sacroiliac
joints possess unique structural characterisdcs needed to satisfy equally unique functional demands. The saddle-shaped
sternoclavicular joint is designed primarily for mobility. In
contrast, th large, tight-ftting sacroiliac joint is designed
primarily for stability, with mobility being a secondary, al
though nonetheless importam, function.
The structural differences in th sternoclavicular and
sacroiliac joints generally reflect th differences in overall
functions of th upper and lower extremities. The stemoclavicular joints enjoy three degrees of freedom, a definite necessity for providing wide placement of th hands in space.
The sacroiliac joints, in contrast, are stable and relatively
rigid, ensuring effettive load transfer among th vertebral
column, lower extremities, and earth.
The exact relationship between structure and function of
th sacroiliac joint is controversial.6,37,87,97 The location of th
sacroiliac joints seems to make it susceptible to abnormally
large stresses due to asymmetry in leg length and abnormal
posture of th lower spine or pelvis. A mechanism that
describes th deterioratimi or malalignment of th sacroiliac
joint as a common cause of low-back pain, however, is not
universally agreed upon. Mixed conclusions are reached regarding th efficacy of diagnostic clinical testing and clinical
intervention.6098105 Adding to th clinical ambiguity of th
sacroiliac joint is th lack of standard terminology to describe th related anatomy and kinesiology. As a result, th
biomechanical and clinical importance of th sacroiliac joint
is often either understated or exaggerated.
1.
The cervical spine permits relatively large amounts of
motion in all three planes. Most notable is th high degree
Anatomia Considerations
of axial rotation permitted at th atlanto-axial joint complex.
Ampie range of motion is necessary for spadai orientation of
The structural demands placed on th sacroiliac joints are
th neck and head th site of hearing, sight, smeli, and
considered in context with th entire pelvic ring. The compoequilibrium.
nents of th pelvic ring are th sacrum, th pair of sacroiliac
304
Section III
Axial Skeleton
FIGURE 9-73. A horizontal cross-section of a computed tomography (CT) scan at th level of th sacroiliac joints. Note th irregular
articular surfaces. (From Weir J, Abrahams PH: An Imaging Atlas of
Human Anatomy. St. Louis, Mosby-Year Book, 1992.) KEY: #1.
rectus abdominis; #2, psoas major; #3, iliacus; #4, gluteus minimus; #5, gluteus medius; #6, gluteus maximus; #7, sacrum; #8,
ilium; #9, sacroiliac joint.
C hapter 9
Anterior view
A n t e r io r lo n g itu d in a l
lig a m e n t
llio lu m b a r
lig a m e n t
llio lu m b a r lig a m e n t
(d e e p p a rt)
A n te rio r s a c r o ilia c
In te ro s s e o u s
lig a m e n t
lig a m e n t
G re a te r s c ia t ic
fo r a m e n
s a c ro c o c c y g e a l
S a c r o s p in o u s
lig a m e n t
lig a m e n t
S a c ro tu b e ro u s
lig a m e n t
P u b ic s y m p h y s is
O sceology an d A rchioogy
305
Posterior view
In te rtr a n s v e rs e lig a m e n t
S u p r a s p in o u s lig a m e n t
llio lu m b a r lig a m e n t
P o s t e r io r - s u p e r io r
ilia c s p in e
S h o r t p o s te r io r
s a c r o ilia c lig a m e n ts
P rim a ry
L o n g p o s t e r io r
s a c r o ilia c lig a m e n ts
G re a te r s c ia t ic fo r a m e n
S a c r o s p in o u s lig a m e n t
S econ dary
S a c r o t u b e r o u s lig a m e n t
4. Sacrotuberous ligament
5. Sacrospinous ligament
L e s s e r s c ia t ic fo r a m e n
u u g tty i u i/ ia i i
s a c r o c o c c y g e a l lig a m e n ts
306
Seciicm III
Axial Skeleton
Superior view
T r a n s v e r s u s a b d o m in is
P s o a s m a jo r
O b liq u u s in te r n u s a b d o m in is
O b liq u u s e x te rn u s a b d o m in is
Q u a d ra tu s
A n t e r io r la y e r
L a t is s im u s
M id d le la y e r - T h o r a c o lu m b a r
d o rsi
fa s c ia
L a te ra l ra p he
P o s t e r io r la y e r-
E r e c t o r s p in a e
M u lt if id u s
THORACOLUMBAR FASCIA
The thoracolumbar fascia is believed to have an important
functional role in th mechanical stability of th low back,
including th sacroiliac jo in t.103 Thts tissue is most extensive
in th lumbar region, where it is organized into anterior,
middle, and posterior layers. Three layers of th thoracolum
bar fascia partially surround and compartmentalize th pos
terior muscles of th lower back (Fig. 9 - 7 6 ) .
The anterior and middle layers of th thoracolumbar fascia
are named according to their position relative to th quadra
tus lumborum muscle. Both layers are anchored medially to
th transverse processes of th lumbar vertebrae, and inferiorly to th iliac crests. The posterior layer of th thoracolum
bar fascia lies over th posterior surface of th erector spinae
and, more superfcially, th latissimus dorsi muscle. Thts
layer of th thoracolumbar fascia attaches to th spinous
processes of all lumbar vertebrae and th sacrum, and to th
ilium near th posterior superior-iliac spines. These extensive
skeletal attachments provide mechanical stability to th
sacroiliac joint. Stability is enhanced by attachments made
by th gluteus maximus and latissimus dorsi.
The posterior and middle layers of th thoracolumbar
fascia fuse at their lateral margins, forming a lateral raphe.
This tissue serves as an attachment for th internai obliquus
abdominus and transversus abdominus muscles. The func
tional signifcance of these muscular attachments is clarified
in th discussion on lifting mechanics in Chapter 10.
less, are lypically used for this purpose: nutation and countemutation. They describe movements limited to th sagittal
piane, about a mediai-lateral axis of rotation that traverses
th interosseous ligament (Fig. 9 - 7 7 ) . Nutation (meaning to
nod) is defned as th relative anterior tilt of th base (top
of th sacrum relative to th iltum. Counternutation is a
reverse motion defined as th relative posterior tilt of th basof th sacrum relative to th ilium. (Note th term relatri e
used in th above definitions.) As depicted in Figure 9 - 7 7
nutation and counternutation can occur by sacral-on-iliaa
rotation (as previously defined), by ilium-on-sacral rotation,
or by both motions performed simultaneously.
Kinematics
Relatively small rotational and translational movements occur
at th sacroiliac joint, primarily in th sagittal piane.26'50'89-95
Data from th studies that measured th movements vary
considerably. Typical mean values fall within th 0.2- to
2-degree range for rotation, and 1- to 2-mm range for translation.26-30-95 Passive range of motion of 7 to 8 degrees has
been measured during th extremes of bilateral hip motions.89
Movements at th sacroiliac joint likely occur as a combination of compression force on th articular cartilage and actual slight movement between joint surfaces.
Several terms and axes of rotation have been proposed to
describe th motion at th sacroiliac joints.6'48 Although no
terminology completely describes th complex multiplanar
rotational and translational movements, two terms, neverthe-
0
1
Chapter 9
Functional Considerations
307
STRESS RELIEF
The tnovements at th sacroiliac joint, although slight, permit an element of stress reiief within th pelvic ring. This
stress reiief is especially important during walking and, in
women, during childbirth.
While walking, th reciprocai flexion and extension pat
tern of th lower limbs causes each side of th pelvis to
rotate slightly out of phase with th other. At normal speed
of walking, th heel of th advancing lower limb strikes th
ground as th toes of th opposite limb are stili in contact
with th ground. At this instant, tension in th hip muscles
and ligaments generate oppositely directed torsions on th
nght and left iliac crests.6 The torsions are most notable in
th sagittal piane, as nutation and counternutation, and in
th horizontal planes. Intrapelvic torsions are amplifed with
increased walking speed. Although slight, movements at each
sacroiliac joint during walking help dissipate otherwise potentially damaging stresses that would otherwise develop
throughout th pelvic ring. The pubic symphysis joint likely
has a similar role in this process.
Movements at th sacroiliac joint increase during labor
and delivery.16 A significant increase in joint laxity occurs
during th tasi trimester of pregnancy and is especially nota
ble in women during th second pregnancy as compared
with th first. Increased nutation during childbirth rotates
th lower part of th sacrum posteriorly, thereby increasing
th size of th pelvic outlet and favoring th passage of th
lo
illese slight
E re c to r
s p in a e
S a c ro tu b e ro u s
lig a m e n t
B ic e p s
Gravity
Stretched ligaments
FIGURE 9-78. Nutation torque increases th stability at th sacroiliac joint. A, Two forces originating primarily by
gravity body weight and hip joint compression generate a nutation torque at th sacroiliac joint. Each force has a
moment arm (black lines) that acts from th axis of rotation (circle ai joint). B, The nutation torque stretches th
interosseous and sacrotuberous ligaments that ultimately compresses and stabilizes th sacroiliac joint. C, Muscle
contraction (red) creates an active nutation torque across th sacroiliac joint. Note th biceps femoris transmitting tension
through th sacrotuberous ligament.
308
torque due to body weight (shown in gray) rotates th sacrum anteriorly relative to th ilium, whereas th torque due
to hip compression force (shown in white) rotates th ilium
posterior relative to th sacrum. The nutation torque Iocks
th joint by increasing th friction between th rough and
reciprocally contoured articular surfaces.90104 This mechanism relies primarily on gravity and th congruity of th
joint surfaces, rather than extra-articular structures such as
ligaments and muscles.
Stabilizing Effect of Ligaments and Muscles
Gravity and weight hearing through th pelvis produce th
first line of stability at th sacroiliac joints. Stability is ade
quate for activities that involve relatively low, static loading
between th pelvis and th vertebral column, such as sitting
and standing. For larger and more dynamic loading, however, th sacroiliac joints are reinforced by ligaments and
muscles. As described in Figure 9 - 7 8 B, nutation torque
stretches many of th connective tissues at th sacroiliac
joint, such as th sacrotuberous and interosseous ligaments.
Increased tension in these ligaments compresses th surfaces
of th sacroiliac joint.
In addition to ligaments, several trunk and hip muscles
reinforce and stabilize th sacroiliac joint (Table 9 - 1 6 ) .84
Additional stability is required during activities such as lift
ing, load carrying, or running. The stabilizing action of many
of these muscles is based on their attachments to th thoracolumbar fascia and to th sacrospinous and sacrotuberous
ligaments.92 Comraciile forces from muscles listed in Table
9 - 1 6 can stabilize th sacroiliac joint by (1) generating active compression forces against th articular surfaces, (2)
increasing magnitudo of nutation torque and subsequently
engag ati active locking mechanism, (3) pulling on connec
tive tissues that are able to reinforce th joint,84 102 and (4)
any combination of these effects. As one example, consider
th muscular interaction depicted in Figure 9 -7 8 C . Contraction of th erector spinae muscle tilts th sacrum anteriorly,
whereas contraction of th rectus abdominis and biceps femoris muscles can tilt th ilium posteriorly, two elements that
produce nutation torque. Through direct attachment, th bi
ceps femoris increases tension into th sacrotuberous ligament. The muscular interaction explains, in part, why
strengthening and hypertrophy of many of th muscles listed
in Table 9 - 1 6 is recommended for treatment of an unstable
sacroiliac joint. In addition, increased strength of th gluteus
maximus, latissimus dorsi, erector spinae, internai oblique
muscles and transverus abdominis increases th stability of
th sacroiliac joint via their connections into th thoracolumbar fascia.
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and function in th sacroiliac joint. Part 1: Clinical anatomical aspects.
Spine 15:130-1.32, 1990.
Walker JM: The sacroiliac joint. A criticai review. Phys Ther 72:903916, 1992
White AA, Panjabi MM: The clinical biomechanics of scoliosis. Clin
Orthop 118:100-112, 1976.
ADDITIONAL READINGS
Andersson GBJ, Ortengren R, Nachemson A: Quantitative studies of th loz_.
on th back in different working postures. Scand J Rehabil Med 6:173178, 1978.
Dunlop RB, Adams MA, Hutton WC: Disc space narrowing and th lumbar
facet joints. J Bone Joint Surg 66B:706-710, 1984.
Galante JO: Tensile properties of th human lumbar annulus fibrosus. Aczs
Orthop Scand Supp 100:1-91, 1967.
Lonstein JE: Congenital spine deformities. Orthop Clin North Am 30:387405, 1999.
McGorry RW, Hsiang SM: A method for dynamic measurement of lumbar
lordosis. J Spinai Disord 13:118-123, 2000.
Potvin JR, Norman RW, McGill SM: Reduction in anterior shear forces oc
th L4/L5 disc by th lumbar musculature. Clin Biomech 6:88-94
1991
Schultz A, Andersson G, Ortengren R, et al: Loads on th lumbar spine
Bone Joint Surg 64A:713-720, 1982.
Sullivan MS, Shoaf LD, Riddle DL: The relationship of lumbar flexion \
disability in patients wilh low back pam. Phys Ther 80:240-250, 2000.
Youdas JW, Garrett TR, Egan KS, et al: Lumbar lordosis and pelvis inclicztion in adults with chronic low back pain. Phys Ther 80:261-27-'
2000.
10
h a p t e r
Axial Skeleton:
Muscle and Joint Interactions
Donald A. Neumann, PT, PhD
TOPICS
IN N ERVATIO N TO THE M USCLES A N D
JOINTS W IT H IN THE TR U N K A N D
: r a n io c e r v i c a l r e g i o n s ,
312
AT
GLANCE
Sternocleidomastoid, 334
Scalenes, 336
Longus Colli and Longus Capitis, 336
Rectus Capitis Anterior and Rectus
Capitis Lateralis, 336
S et 2: P o s te rio r M u s c le s o f th
C ra n io c e rv ic a l R egion, 337
S et 1: A n te rio r-L a te ra l M u s c le s o f th
INTRODUCTION
A d d itio n a l S o u rc e s o f E xtensio n T o rq u e
U sed fo r L iftin g , 346
312
Section III
Axial Skeleton
both sensory and motor fbers.) Once within th intervertebral foramen, th spinai nerve thickens owing to th merging of th motor and sensory neurons and th presence of
th dorsal root ganglion.
The vertebral column contains 31 pairs of spinai nerves:
8 cervical, 12 thoracic, 5 lumbar, 5 sacrai, and 1 coccygeal.
The abbreviations C, T, L, and 5 with th appropriate superscript number designate each spinai nerve, or nerve root
for example, C5 and T6. The cervical region has seven vertebrae bui eight cervical nerves. The suboccipital nerve (C:
leaves th spinai cord between th occipital bone and posierior arch of th atlas (C l). The C8 spinai nerve leaves th
spinai cord between th seventh cervical vertebra (C7) and
th first thoracic vertebra (T l). Spinai nerves T l and below
leave th spinai cord below their respective vertebral bodies
Once a spinai nerve exits its intervertebral foramen, it
immediately divides into a ventral and dorsal ramus (from th
Latin ramus, meaning path). The ventral ramus forms
nerves that innervate th muscles, joints, and skin ol th
anterior-lateral trunk and neck and all th extremities. The
dorsal ramus, in contrast, forms nerves that innervate th
muscles, joints, and skin of th posterior trunk and neck.
PLEXUS
A plexus is an intermingling of ventral rami that form pt
ripheral nerves. The four major plexus, excluding th smal
coccygeal plexus, are formed by ventral rami: cervical (C1
brachial ( G - T 1), lumbar (T l2-L4), and sacrai (L4-S4). With
th exception of th cervical plexus, most of th nerves tha:
exit th brachial, lumbar, and sacrai plexus innervate structures associated with th appendicular skeleton. Only a few
nerves from th brachial, lumbar, and sacrai plexus innerva-.
structures associated with th axial skeleton (Fig. 1 0 -2 A )
D ura
S u b d u ra i sp a ce
A ra c h n o id
S u b a ra c h n o id sp a ce
Pia
D orsa l root
D orsa l root
ga n g lio n
S pinai ne rve
D orsa l ram us
V entral ro ot
V entral ra m us
R am i co m m u n ica n te s
f
Chapter 10
313
Cervical (C1-4)
M u scle : 1. lo n g u s co lli and
lo n g u s c a p itis
2. d ia p h ra g m
S kin: to p o f th c h e s t and
s h o u ld e rs (s u p ra c la v ic u la r
n e rves)
J o in t: s te rn o c la v ic u la r jo in t
:r ~
YMi
F ~
m zz.
Recurrent meningeal
nerves (C 1- S 4)
M u scle : rh o m b o id s
S kin: none
Jo in t: none
M u scle : no ne
S kin: none
Jo in t: in te rb o d y jo in t
Lumbar (L1-4)
M u scle : p so a s m a jo r
S kin: no ne
Jo in t: s a c ro ilia c jo in t (L3-4)
Sacrai (L4-S 4)
... ......
M u scle : 1. g lu te u s m a x im u s (by
a ctio n o f ch a n g in g
th d e g re e o f lu m b a r
lord osis)
2. p irifo rm is (as a s ta b iliz e r
o f th s a c ro ilia c jo in t)
S kin: no ne
J o in t: s a c ro ilia c jo in t (L4- S 2)
SEGMENTAI. INNERVATION
Ventral rami and associated branches that remain as single
nerves form either intercostal or recurrent meningeal nerves.
These innervate tissues throughout multiple segments or levels within th axial skeleton. This form of innervation is
referred lo as segmentai innervation (Fig. 1 0 -2 6 ).
Intercostal Nerves (T-T2)
Each of th 12 ventral rami of th thoracic spinai nerves
forms an intercostal nerve, innervating an intercostal derma
tome and a set of intercostal muscles that share th same
intercostal space. The T 1 ventral ramus forms th first inter
costal nerve and part of th lower trunk of th brachial
plexus. The ventral rami of T7-T 12 also innervate th muscles
of th anterior-lateral trunk (i.e., th abdominal" muscles).
The T 12 ventral ramus forms th last intercostal (sub
314
Section ili
Axial Skeleton
10 - 1).
Perforatili#
cutaneous
nerve
G lutcal
ram i o f
posterior
cutaneous
nerve
D onai
ram i .V.
D orsal
ram i S . 4. 5
a n d Co. 1
Introduction
The muscles of th axial skeleton can be organized into two
categories. (1) th trunk and (2) th craniocervical region
Chapter 10
1 0 - 2 . Anatomie Organization of th
Muscles o f th Axial Skeleton*
TABLE
Muscles of th Trunk
Set
1: M u s c le s o f t h P o s t e r io r T r u n k ( B a c k M u s c le s )
315
Supetficial layer
Trapezius, latissimus dorsi, rhomboids, levator scapula, and
serratus anterior
Intermediate layert
Serratus posterior superior
Serratus posterior inferior
Deep layer
Three groups
1. Erector spinae group (spinalis, longissimus, iliocostalis)
2. Transversospinal group
Semispinalis muscles
Multifidi
Rotatores
3. Short segmentai group
Interspinalis muscles
Intertransversarus muscles
S e t 2 : M u s c l e s o f t h A n t e r i o r - L a t e r a l T r u n k ( A b d o m i n a l
M u s c le s )
Rectus abdominis
Obliquus intemus abdominis
Obliquus externus abdominis
Transversus abdominis
S e t 3 : A d d it io n a l M u s c le s
Uiopsoas
Quadratus lumborum
Muscles of th Craniocervical Region
S e t 1:
Muscles
o f t h A n t e r io r - L a t e r a l C r a n io c e r v ic a l R e g io n
Stemocleidomastoid
Scalenes
Scalenus anterior
Scalenus medius
Scalenus posterior
Longus colli
Longus capitis
Rectus capitis anterior
Rectus capitis laterahs
S e t 2 : M u s c le s o f t h P o s t e r io r C r a n io c e r v ic a l R e g io n
Supetficial group
Splenius cervicis
Splenius capitis
Deep group (suboccipital muscles)
Rectus capitis posterior major
Rectus capitis posterior minor
Obliquus capitis superior
Obliquus capitis inferior
* A muscle is classified as betonging to th trunk or craniocervical
region based on th location of th most of its attachments.
t These muscles are discussed in Chapter 11.
316
Section Ili
Axial Skeleton
Frontal piane
LATERAL
FLEXION
L o n g is s im u s
R e c tu s
t h o r a c is
a b d o m in is
O b liq u u s e x te rn u s
a b d o m in is
Horizontal piane
AXIAL ROTATION
t h o r a c is
O b liq u u s e x te rn u s
a b d o m in is
skeleton, with some combination of lateral flexion and contralateral or ipsilateral axial rotation. The term lateral flexion
of th axial skeleton implies ipsilateral lateral flexion.
The action of a muscle within th axial skeleton depends,
in pari, on th relative degree of fixation, or stabilization, of
th attachments of th muscle. As an example, consider th
effect of a contraction of a member of th erector spinae
group a muscle that attaches to both th thorax and pel-
from an embryologic perspective, they were originally associated with th front limb buds and only later migrated
dorsally to their final position on th back, lnterestingly,
muscles such as th levator scapula, rhomboids, and serratus
anterior, although located within th back, are actually up
per limb muscles. All extrinsic muscles of th back are,
therefore, innervated by ventral rami of spinai nerves (i.e.,
brachial plexus or intercostal nerves).
317
318
TABLE
Section III
Axial Skeleton
Individuai Muscles
General Fiber
Direction
E r e c to r S p in a e (S u p e r fic ia l)
Iliocostalis lumborum
Iliocostalis thoracis
Iliocostalis cervicis
Longissimus thoracis
Longissimus cervicis
Longissimus capitis
Vertical
Cranial and mediai
Cranial and lateral
Spinalis thoracis
Spinalis cervicis
Spinalis capitis
Vertical
Vertical
Vertical
Semispinalis
Semispinalis thoracis
Semispinalis cervicis
Semispinalis capitis
Multifidi
Rotatores
Rotator brevis
Rotator longus
Rotator longus crosses two intervertebral junctions; th rotator brevis crosses one inter
vertebral junction. The rotatores are most
developed in thoracic region.
lnlerspinalis
Vertical
Intertransversarus
Vertical
T r a n s v e r s o s p in a l (In te r m e d ia te )
S h ort S eg m en ta i (D eep )
of spinai nerves.84 A particularly long muscle within th erector spinae group, for instance, is innervateci by multiple levels
throughout th spinai cord. Embryologically, and unlike th
muscles in th extremities and anterior-lateral trunk, th mus
cles in th deep layer of th back have retained their originai
location dorsal to th neuraxis. For this reason, these muscles
are often called intrinsic muscles of th back.
As a generai rule, most intrinsic muscles of th back are
innervated by th dorsal rami of adjacent spinai nerves. in
contrast, most extrinsic muscles of th back, such as th
lastissimus dorsi and serratus posterior superior, are inner
vated by th ventral rami of spinai nerves, via th brachial
plexus or intercostal nerves.
Comments
Erector Spinae
Superior view
FIGURE
1 0 -7 . Cross-sectional
view through T9 highlighting
th topographic organization of
th erector spinae and th transversospinal group of muscles.
The short segmentai group of
muscles is not shown.
Posterior view
319
Iliocostalis Muscles
The iliocostalis muscles include th iliocostalis lumborum,
iliocostalis thoracis, and iliocostalis cervicis. They occupy th
most lateral column of th erector spinae group. The iliocos-
Transversospinal muscles
(m ultifidi)
Gluteus
maximus
Spnalis Muscles
Spinalis muscles include th spinalis thoracis, spinalis cervicis, and spinalis capitis. In generai, they insert superiorly
on lateral aspects of th spinous processes or ligamentum
nuchae in th cervical region. Spinalis muscles are usually
indistinct from surrounding muscles or missing entirely. The
spinalis capitis, if present, often blends with th semispinalis
capitis.84
Longissimus Muscles
The longissimus muscles include th longissimus thoracis,
longissimus cervicis, and longissimus capitis. As a set, they
are th largest and most developed of th erector spinae
group. The fibers of th longissimus muscles fan cranially
320
S P E C I A L
F O C U S
1 0 -
o
>
o'
12-
o
UH
Ipsilateral
Posterior
Contralateral
Anterior
Carrying Position
Mean electromyographic (EMG) values expressed as a percent of maximal voluntary isometric contraction
(MV1C) from th lumbar erector spinae muscies while walking
and carrying loads of two sizes and lour carrying positions. The
carrying position noted on th X axis is based on th position of
th load relative to th erector spinae muscies. The bold horizon
tal line marks th EMG response while subjects walked without
carrying a load. (Data from Cook TM, Neumann DA: The effeets
of load placement on th EMG activity of th low back muscies
during load carry by men and women. Ergonomics 30 14131423, 1987.)
FIGURE
1 0 -1 0 .
321
Posterior view
Transversospinal Muscles
Posterior view
Muscle
Relative Length
Semispinalis
Multifdi
Rotatores
Long
Intermediate
Short
Average Number of
Intervertebral
Junctions Crossed
6 -8
2 -4
1 -2
322
Semispinalis Muscles
The semispinalis muscles consist of th semispinalis thoracis, semispinalis cervicis, and semispinalis capitis (Fig. 1 0 11). In generai, each muscle, or main set of fibers within
each muscle, crosses six io eight intervertebral junctions. The
semispinalis thoracis consists of many thin muscle fasciculi,
interconnected by long tendons. Muscle fibers attach from
transverse processes of T 6-10 to spinous processes of C6-T4.
The semispinalis cervicis, much thicker and more developed than th semispinalis thoracis, attaches from upper
thoracic transverse processes to spinous processes of C2-5.
Muscle fibers that attach to th prominent spinous process
of th axis (C2) are particularly well developed, serving as
important stabilizers for th suboccipital muscles.
The semispinalis capitis lies deep to th splenius and trapezius muscles. The muscle arises primarily from upper tho
racic transverse processes. The muscle thickens superiorly as
it attaches to a relatively large region on th occipital bone,
filling much of th area between th superior and inferior
nuchal lines (see Fig. 9 - 3 ) .
The semispinalis cervicis and capitis are th largest mus
cles that cross th posterior side of th neck. Their large size
and near-vertical fiber direction provide significant exlension
torque to th craniocervical region. Right and left semispin
alis capitis muscles are readily palpable as thick and round
cords on either side of th midiine of th upper neck,
especially evident in infants and in thin, muscular adults
(Fig. 1 0 -1 3 ).
Superior Attachments
1. Lumbar spinous processes
Multifidi
Multifidi lie under th semispinalis muscles. The plural
multifidi indicates a collection of multiple fibers, rather
than a set of individuai muscles. All multifidi share a similar
fiber direction and length, extending between th posterior
sacrum and C2. In generai, th multifidi originate from th
transverse process of one vertebra and insert on th spinous
process of a vertebra located two to four segments above
(see Fig. 1 0 -1 2 ).
Multifidi are thickest and most developed in th lumbo
sacral region (Table 1 0 - 6 ) .51 Muscle fibers within th lum
bar region fili much of th concave space forrned between
th spinous and transverse processes. Throughout th lum
bar region, th multifidi approach th spinous processes at
essentially right angles to th long axis of each corresponding spinous process.48 This angle is only apparent from a
lateral view. This line-of-force maximally converts a force
into a torque. The multifidi, therefore, provide an essential
source of extension torque and stability to th base of th
spine. Excessive force in th lumbar multifidi due either to
attive contraction or protective spasm maybe expressed
clinically as an exaggerated lordosis.
Rotatores
The rotatores are th deepest of th transversospinal
group of muscles. Like th multifidi, th rotatores consist of
a large set of individuai muscle fibers. Although th rotatores
exist throughout th entire vertebral column, they are best
developed in th thoracic region (see Fig. 1 0 - 1 2 ). Each
fiber attaches between th transverse process of one vertebra
and th lamina and base of th spinous process of a vertebra
located one or two segments above. By definition, th rotator
brevis muscle spans one intervertebral junction, and th rota
tor longus muscle spans two intervertebral junctions.
The short segmentai group of muscles consists of th interspinalis and th intertransversarus muscles (see Fig. 1 0 -1 2 ).
The plural interspinales and intertransversales is often
used to describe all th members within th entire set of
these muscles.) They lie deep to th transversospinal group
o f muscles. The nam e short segm entai" refers to th exremely short length and highly segmented organization of
he muscles. Each individuai interspinalis or intertransversa
rus muscle crosses just one intervertebral junction. The short
segmentai group of muscles exists throughout th vertebral
column except for th thoracic region. These muscles are
most developed in th cervical region, where fine control of
:he head and neck is so criticai.
Each pair of interspinalis muscles is located on either side
of, and often blends with, th corresponding interspinous
ligament. The interspinales have a relatively favorable lever
age and optimal fiber direction for producing extension
torque. The magnitude of this torque is relatively small,
however, considering th small size of th muscles.
Each righi and left pair o f intertransversarus m uscles is
located between adjacent transverse processes. As a group,
th anatomy of th intertransversales is more complex than
that of th interspinales.84 In th cervical region, for exam
323
Kinesiologic Functions
324
FIGURE 10-14. The four abdominal muscies of th anterior-lateral trunk. A, Rectus abdominis with th anterior rectus sheath removed. B,
Obliquus extemus abdominis. C, Obliquus internus abdominis, deep to th obliquus extemus abdominis. D, Transversus abdominis, deep io
other abdominal muscies. (Frani Luttgens K, Hamilton N: Kinesiology: Scientific Basis of Human Motion, 9th ed. Madison W1 Brown and
Benchmark, 1997. The McGraw-Hill Companies.)
325
Superior vievv
Rectus
abdominis
Linea alba
Anterior rectus
sheath
Posterior rectus
sheath
FIGURE 10-15. Honzontal crosssectional view of th anterior abdominal wall shown at th approximate level of th third
iumbar vertebra.
Obliquus
externus
abdominis
Obliquus
Transversus
internus
abdominis
abdominis
TABLE
Muscle
Actions on th Trunk
Obliquus externus
abdominis
Obliquus internus
abdominis
Transversus
abdominis
Section III
326
Axial Skeleton
ments to th thoracolumbar fascia. The transversus abdominis and th internai oblique muscles share many attachments, including th thoracolumbar fascia.
Actions of th Abdorninal Muscles
Bilateral action of th abdorninal muscles reduces th distance between th xiphotd process and th pubic symphysis.
Depending on which body segment is more stable, contraction of th abdorninal muscles can flex th thorax and upper
lumbar spine, posteriorly tilt th pelvis, or both. Figure 1 0 16 depicts a diagonally performed sit-up maneuver that
places a relatively large demand on th oblique abdorninal
muscles. During a sagittal piane sit-up, th opposing axial
rotation and lateral flexion tendencies of th various abdominal muscles are neutralized by opposing righi and left mus
cles.
The axes of rotation for all motions of th vertebral column are biased posteriorly in th trunk, through th verte
bral bodies. As a consequence, th abdorninal muscles, most
notably th rectus abdominis, possess very favorable leverage
for generating trunk flexion torque (Fig. 1 0 - 1 7 ). Note in
Figure 1 0 17 that, with th exception of th psoas major,
all muscles have a moment arm to produce torques in both
sagittal and frontal planes.
Contracting unilaterally, th abdorninal muscles laterali)flex th trunk. The extemal and internai obliques are particularly effective in this action owing to their relatively favor
able leverage (i.e., long moment arms) (Fig. 1 0 - 1 7 ) and, as
a pair, relatively large cross-sectional area. The combined
cross-sectional area of th extemal and internai obliques at
L4-L5 is almost twice that of th rectus abdominis muscle.,s
Lateral flexion of th trunk often tnvolves both trunk
flexor and extensor muscles. For example, lateral flexion
against resistance to th right demands a contraction from
th right extemal and internai oblique, right erector spinae.
and righi transversospinal muscles. Coactivation amplifies
th total frontal torque and simultaneously stabilizes th
Superior view
Linea alba
&
Rectus
abdominis
<&
%' K
Left lateral
Obliquus externus
abdominis
Obliquus internus
abdominis
ML axis
Transversus abdominis
Psoas major
iS
Quadratus lumborum
Latissimus dorsi
Erector ...
spinae T llocos,ahs'
LLongissimus
&
S S
P o s t e r io r
<n
327
Although th external and internai obliques are considered th primary axial rotators of th trunk, they rarely
act alone during this activity. Secondary axial rotators
of th trunk include th ipsilateral latissimus dorsi, th
more oblique components of th ipsilateral longissimus
and iliocostalis muscles, and th contralateral transversospinal muscles. In addition to contributing, at least
minimally, to axial rotation torque, th secondary axial
rotators perform th more important function of counteracting th trunk flexion potential of th oblique abdomi
nal muscles.39 Axial rotation of th trunk to th left, for
example, requires strong activation from both right and
left transversospinal muscles in th thoracic region.22
Bilateral activation resists th bilateral flexion tendency
of th oblique abdominal muscles.
The multifidi muscles provide extension stability to
th lumbar region during axial rotation.4883 Pathology
involving th apophyseal joints or discs in th lumbar
region may be associated with weakness, fatigue, or
reflexive inhibition of these muscles. Without adequate
activation from th multifidi during axial rotation, th
partially unopposed oblique muscles would, in theory,
create a subtle flexion bias to th base of th spine.
Such a bias may partially explain th rounded (flexed)
posture of th low back typically seen in a person with
spondYlosis or disc disease of th lumbar spine.
328
Section III
Axial Skeleton
Contracting unilateraliy, th quadratus lumborum has relatively favorable leverage as a lacerai flexor of th lumbar
region.59 The axial rotation potential of th quadratus lum
borum, however, is minimal.
Clinically, th quadratus lumborum is often called a "hip
hiker when describing its role in walking, especially for
persons with paraplegia at or below th L1 neurologie level.
By elevating (hiking) one side of th pelvis, th quadratus
lumborum raises th lower limb to clear th foot from th
ground during th swing phase of brace-assisted ambulation.
Actions of th Iliopsoas
lliacus
Acting Bilaterally
1. Extension of th lumbar region
2. Vertical stabilization of th lumbar spine, including th
lumbosacral junction
Acting Unilaterali)/
1. Lateral flexion of th lumbar region
2. Elevation of one side of th pelvis (hip hiking")
Psoas Major
Posterior view
Quadratus Lumborum
Anatomically, th quadratus lumborum is considered a muscle of th posterior abdominal wall. The muscle attaches
inferiorly to th iliolumbar ligament and iliac crest, and
superiorly to th 12th rib and th tips of th transverse
processes of L l-4 (Fig. 1 0 -1 9 ). The relative thickness of th
muscle is evident by viewing Figure 1 0 - 1 7 . The quadratus
lumborum is innervated by th ventral rami of spinai nerves
T i2-L3.
Contracting bilaterali)/, th quadratus lumborum is an ex
tensor of th lumbar region. Its action is based on th lineof-force passing about 3.5 cm posterior to th medial-lateral
axis of rotation at L3.i9
329
Flexion
Extension
Lateral Flexion
Axial Rotation*
Trapezius
XX
XX
XX
Longissimus thoracis
Longissimus cervicis
Longissimus capitis
XXX
XXX
XXX
XX
XX
XX
XXX
XXX
XXX
XXX
XXX
XXX
X (IL)
XXX
XXX
XXX
X
X
X
X (CL)
X (CL)
XXX
XX
X
X
XX (CL)
XX (CL)
XX
X
XX
Iliocostalis lumborum
Iliocostalis thoracis
Iliocostalis cervicis
Semispinalis thoracis
Semispinalis cervicis
Semispinalis capitis
Multifidi
Rotatores
Interspinalis muscles
lntertransversarus muscles
Rectus abdominis
Obliquus extemus abdominis
Obliquus intemus abdominis
Transversus abdominist
XXX
XXX
XXX
Psoas major
Quadratus lumborum
XX
XXX
XXX
X
XX
XX
XX
XX (CL)
_
XX (IL)
XX (IL)
XX (IL)
XXX (CL)
XXX (IL)
330
A)
Intrinsic muscular
stabilizers
B) Spatial orientation
(a) of musclc's
line-of-force
Percent of force
directed:
Horizontal (FH)
Vertical (Fv)
a = 0
Fh = 0%
Fv = 100%
Semspnais cervicis
(crosses 6 -8 segments)
Multifidus
(crosses 2 -4 segments)
Rotator longus
(crosses 2 segments)
Rotator brevis
(crosses 1 segment)
a =15
Fh = 26%
Fv = 96%
out such control, th vertebral column is vulnerable to exaggerated spinai curvature and instability.
In trin sic
1. Transversospinal group
Semispinalis muscles
Multifidi
Rotatores
2. Short segmentai group
Interspinalis muscles
Intertransversarus muscles
a = 20
Fh = 34%
Fy = 94%
a = 45
Fh = 71 %
Fy= 71%
Obliquus externus
a -80
Fh = 98%
Fv = 17%
Erector spinae
Transversus abdominis
FIGURE 10-20. Diagrammane representation of th spatial orientation of th lines-of-force of th intrinsic muscular stabilizers. A, The
lines-of-force of muscles are shown within th frontal piane. The
number of intervertebral junctions that eaeh muscle crosses is noted
in th parenthesis. B, The spatial orientation of th lines-of-force of
each muscle is indicated by th angle (a) formed relative to th
vertical position. The percentage of muscle force directed vertically
is equal lo th cosine of a; th percentage of muscle force directed
horizontally is equal to th sine of a Assuming adequate leverage,
th vertically directed muscle forces produce extension and lateral
flexion and th more horizontally directed muscle forces produce
axial rotation.
(Fig. 1 0 -2 0 A ) allow them to exert fine control of core stability in all planes. As indicated in Figure 1 0 -2 0 B , th
spatial orientation of each muscles line-of-force (a ) produces
a unique stabilization effect on th vertebral column. Vertically running interspinalis and intertransversarus muscles
produce 100% of their force in th vertical direction (Fv). In
contrast, th near horizontally oriented rotator brevis muscle
produces dose to 100% of its force in th horizontal direc
tion (Fh). All of th remaining muscles produce forces that
are directed diagonally. Muscle forces directed across th
entire spectrum of th frontal piane optimize th triplanar
control of core stability within th vertebral column. With-
Quadratus lumborurr
Rectus abdominis
Psoas
Giuteus maximus
Hamstrings
331
#1 Isometrics
#3 Rotating th Trunk
and Pelvis Toward (he
Stationary Legs
#4 Rotating th
Pelvis (and/or Legs)
Toward th
Stationary Trunk
Exam ples:
1- Balancing th trunk
upright while seated on
a very large ball.
2- Holding a rigid trunk
and low back while
m aintaining a militarystyle push-up.
3- Keeping th trunk and
low b a c k rigid w hile
m aintaining all-fours
position, then progress
to raising one arm and
th contralateral leg.
Exam ples:
1 - Partial sit-ups
(crunches).*
2- A s above, but incorporate
diagonal piane m ovem ents
of th trunk.
3- Lateral trunk curls.
Exam ples:
1 - Standard full sit-up.*
2- A s above, but incorporate
diagonal piane movement
of th trunk and pelvis.
Exam ples:
1- Posterior pelvic tilt
while lying supine.
2- Antigravity or
otherwlse resisted hip
flexion.*
3- Straight leg raises.
4- A s above, but
incorporate diagonal
p ia n e m o v e m e n ts of
th leg s.
FIGURE 10-22. Categones of abdominal strengthening exercises, with selected examples. The examples marked by th
asterisk are pictured below.
332
Seniori
III
Axial Skeleton
Obliquus externus
abdominis
Obliquus internus
abdominis
Transversus
abdominis
FIGURE 10 23. A typical activation pattern is shown of a sample of muscles, as a healthy person performs a traditional sit-up maneuver. The
intensity of th red color is related to th assumed intensity of th muscle activation. A, The trunk flexion phase of th sit-up involves strong
activation of th abdominal muscles, especially th rectus abdominis. B, The hip flexion phase of th sit-up involves strong activation of th
abdominal and hip flexor muscles. Note in B th farge pelvic-on-femoral kinematic contribution to die sit-up maneuver.
333
Inferior view
Posterior
Extensor and left
lateral flexor
Trapeline
Semispinalis
Splenius capitis
Sternocleiomastoid
Longissimus capitis
Digastric (posterior belly)
(O
i
a>
co'
ML axis
tu
IC
CU
co
t
Q
>
Anterior
FIGURE 10-24. The potential action of muscles that attach to th inferior surface of th occipital and temperai bones is highlighted. The
actions of th muscles across th atlanto-occipital joints are based on their location relative to th medial-lateral (ML) (black) and
anterior-posterior (red) axis of rotation at th level of th occipital condyles. Note that th actions of most muscles fu into one o( four
quadrants.
334
Sternothyroid
Omohyoid
Thyroid gland
Platysma
Trachea
Sternocleidomastoid
Esophagus
Longus colli
Internai juguiar vein
Scalenus anterior
Scalenus medius
and posterior
Carotid artery
Carotid sheath
Longissimus capitis
Brachial plexus
Longissimus cervicis
Vertebral artery
Multifidus and
rotator longus and brevis
Deep (prevertebral)
fascia
Semispinalis cervicis
Semispinalis capitis
Splenius capitis and cervicis
Trapezius
Superficial (investing)
fascia
Superior view
CERVICAL FASCIA
Cervical fascia surrounds and compartmentalizes many structures within th neck, including muscles and neurovascular
structures. The cervical fascia is subdivided into three com-
Middle (Visceral)
Fascia
Deep (Prevertebral)
Fascia
335
Torticollis
An anterior view of th stemocleidomastoid muscles. (From Luttgens K, Hamilton N: Kinesiology: Scientific Basis of
Human Motion, 9th ed. Madison, WI, Brown and Benchmark,
1997. The McGraw-Hill Compames.)
FIGURE 1 0 -2 7 .
FIGURE 1 0 -2 8 .
336
Section III
Axial Skeleton
A nterior view
Scalenes
As a group, th scalene muscles attach between th tubercles
of th transverse processes of th middle to lower cervical
vertebrae and th first two ribs (Fig. 1 0 -2 9 ). The specific
attachments of these muscles are lisied in Appendix 111 (Pari
B, Set 1). The brachial plexus courses between th scalene
anterior and scalene medius (see Fig. 1 0 -2 5 ). Excessive hypertrophy or spasm of these muscles or their associated
lascia can compress th brachial plexus and can cause motor
and sensory disturbances in th upper extremity.
The function of th scalene muscles depends on whtch
skeletal attachments are more fxed. Assuming that th cervi
cal spine is well stabilized, th scalene muscles raise th ribs
to assist with inspiration during breathing; assuming that th
scalene muscles are contracting from a fxed inferior base
afforded by th first two ribs, their potential actions become
evident by using a skeleton and string io mimic th line-offorce. Contracting unilaterally, th scalene muscles laterally
flex th cervical spine. Axial rotation is limited in th sca
lenus medius and posterior due to th muscles' nearly vertical orientation. The more oblique scalenus anterior, however,
has a potential for contralateral axial rotation of th cervical
spine.
Contracting bilaterally, th scalenus anterior and medius
bave a limited moment arm to flex th cervical spine, particularly in th lower regions. The cervical attachments of all
three scalene muscles split into several individuai fasciculi
(see Fig. 1 0 -2 9 ). Like a System of guy wires that stabilize a
large antenna, th scalene muscles provide excellent bilateral
and vertical stability to th middle and lower cervical spine.
Fine control of th upper craniocervical region is more likely
The rectus capitis anterior and rectus capitis lateralis are two
short muscles that arise on th elongated transverse pro
cesses of th atlas (C l) and insert on th inferior surface o
occipital bone (see Fig. 1 0 - 3 0 ). The rectus capitis laterale
Anterior view
S P E C I A L
F O C U S
337
1 0 - 5
The cervical spine is vulnerable to acceleration (whiplash) injury, especially as a result of an automobile
accident. Vulnerability is due, in part, to th large mass
moment of inertia of th relatively heavy head. An im
pact that creates a large angular velocity of th head
generates a proportionally large angular momentum
throughout th entire craniocervical region. If directed
in th sagittal piane, th momentum of th flexing or
extending head can damage tissues that are excessively strained or compressed. Momentum directed in
th frontal piane can create lateral flexion whiplash,
which also damages tissue.
Whiplash associated with cervical hyperextension
generally creates greater strain on muscles and soft
tissues than does whiplash associated with cervical
flexion.68 The greater range of hyperextension can severely strain th flexor muscles and cervical viscera,
and it can excessively compress th apophyseal joints
and posterior aspects of th cervical spine (Fig. 1031/4). The maximum extent of flexion is partially blocked
by th chin striking th chest (Fig. 10-316).
Research on replicas of th human head, neck, and
FIGURE 10-31. During acceleration (whiplash) injuries, cervical extension (A) typically exceeds cervical flexion
(B). As a result, th anterior structures of th cervical region are more vulnerable to strain injury. (From
Porterfield JA, DeRosa C: Mechanical Neck Pain: Perspectives in Functional Anatomy. Philadelphia, WB Saunders,
1995.)
338
Suboccipital Muscles
The suboccipital muscles consist of four paired muscles located very deep in th neck, immediately superficial to th
Posterior view
Obliquus
capitis superior
Obliquus
capitis inferior
Rectus capitis
posterior minor
Rectus capitis
posterior major
S P E C I A L
F O C U S
339
1 0 - 6
P
Specialized Muscles that Control th Atlanto-Axial and
Atlanto-Occipital Joints: An Example of Fine-Tuning of
th Cervical Coupling Pattern
F ig . 9 - 5 2 6 ) . In o r d e r t o m a in t a in a le v e l h o r iz o n t a l v i
s u a l g a z e t h r o u g h o u t a x ia l r o t a t io n , t h le ft r e c t u s c a p it is la t e r a lis , f o r in s t a n c e , p r o d u c e s a s lig h t le f t la t e r a l
T h e s p e c ia liz e d m u s c le s t h a t c o n t r o l t h a t la n t o - a x ia l
flexion
a n d a t la n t o - o c c ip it a l j o in t s e x e r t f in e c o n t r o l o v e r t h
m o v e m e n t o f t h u p p e r c r a n i o c e r v i c a l r e g io n . O n e b e n
e f it o f t h is f in e le v e l o f c o n t r o l is r e la t e d t o t h c o u p lin g
p a t t e r n o f t h c e r v i c a l r e g io n . A s d e s c r ib e d in C h a p t e r
to rq u e to th
head
v ia t h a t la n t o - o c c ip it a l
jo in t s . T h is m u s c u la r a c t io n o f f s e t s t h t e n d e n c y f o r t h
h e a d t o b e n d t o t h r ig h t w it h t h r e s t o f t h c e r v i c a l
r e g io n d u r in g t h r ig h t a x ia l r o t a t io n . S im ila r ly , r ig h t
la t e r a l f le x io n o f t h C 2 -7 r e g io n , w h i c h a ls o r e s u lt s in
9, a n i p s ila t e r a l c o u p lin g p a t t e r n e x is t s in t h C 2 -C 7
r e g io n b e t w e e n t h m o t io n s o f a x ia l r o t a t io n a n d la t e r a l
f le x io n . A x ia l r o t a t io n , d u e p r im a r ily t o t h o r ie n t a t io n o f
t h a p o p h y s e a l jo in t s , is a s s o c i a t e d w it h s lig h t ip s i l a t
r ig h t a x ia l r o t a t io n o f t h is c e r v i c a l r e g io n , m a y b e a c c o m p a n ie d b y a s lig h t , o f f s e t t in g le f t a x ia l r o t a t io n
t o r q u e t o t h h e a d b y t h le f t o b liq u u s c a p it is in f e r io r
m u s c le . In b o th e x a m p le s , m o v e m e n t o f t h h e a d a n d
e r a l la t e r a l f le x io n a n d v ic e v e r s a . T h e e x p r e s s io n o f
t h is c o u p lin g p a t t e r n c a n b e o b s c u r e d , h o w e v e r , b y t h
s p e c ia liz e d m u s c le s t h a t c o n t r o l t h a t la n t o - o c c ip it a l a n d
a t la n t o - a x ia l jo in ts . C o n s id e r , f o r e x a m p le , t h c o u p lin g
S T A B IL IZ IN G T H E C R A N I O C E R V IC A L R E G IO N
T A B L E
b e t w e e n r ig h t a x ia l r o t a t io n a n d r ig h t la t e r a l f le x io n ( s e e
e y e s c a n b e m o r e p r e c i s e l y m a in t a in e d w it h in t h h o r i
z o n t a l p ia n e , t h e r e b y f a c ilit a t in g t h v is u a l t r a c k in g o f a
m o v in g o b j e c t w h ile r o t a t in g t h h e a d .
joints, and neural tissues. Resistive exercises are often performed by athletes involved in contact sports as a means to
hypertrophy this musculature. Hypertrophy alone, however,
may not necessarily prevent neck injury. Data on th biomechanics of whiplash injury, for example, suggest that th
time required to react to an impending injury and generate a
substantial stabilizing force may exceed th time of th
Muscle
Flexion
Extension
Lateral Flexion
Axial R otation*
Stemocleidomastoid
XXX
X*
XXX
XXX (CL)
Scalenus anterior
XX
XXX
X (CL)
Scalenus medius
XXX
Scalenus posterior
XX
Longus colli
XX
XX
Longus capitis
XX
XX
XX (AOJ only)
X (AOJ only)
XX (AOJ only)
Splenius capitis
XXX
XX
XXX (IL)
Splenius cervicis
XXX
XX
XXX (IL)
XX (AOJ only)
XX (AOJ only)
X (AOJ only)
XX (AAJ only)
* Upper parts of stemocleidomastoid extend th upper cervical region, atlanto-axial joint, and atlanto-occipital joint.
A muscles relative potential to move or stabilize a region is scored X, minimal, XX, moderate, and XXX, maximum;
action. AOJ, atlanto-occipital joint; AAJ, atlanto-axial joint; CL, contralateral rotation; IL, ipsilateral rotation.
340
Section III
Axial Skeleton
Obliquus
capitis
superior
Rectus capitis
lateralis
Rectus capitis
anterior
Obliquus capitis
interior
Rectus capitis
posterior minor
Rectus capitis
posterior major
Semispinalis cervicis
Posterior view
A
T
E
R
A
LF
A
X
IT
A
F
L
E
X
IO
NE
X
T
E
N
S
IO
NL
F
L
X
IO
N
L
E
X
IO
NE
X
T
E
N
S
IO
NR
O
T
A
IL
O
N
ATLANTO-AXIAL J0INT
XX
XX
Rectus capitis
posterior major
XXX
XX
Rectus capitis
posterior minor
XX
Obliquus capitis
inferior
Obliquus capitis
superior
XXX
XX(IL)
XX
XXX
XXX
XXX(IL)
Chapter 10
Ideal posture
FIGURE 10-35. A, Four muscles
acting as guy wires to maintain
an ideal posture within th
craniocervical region. B, Mechanics associated with a
chronic forward head posture as
discussed in Special Focus 107. The protracted position of
th craniocervical region places
greater stress on th levator
scapula and semispinalis capitis
muscles. The rectus capitis posterior major one of th suboccipital muscles is shown
actively extending th upper
craniocervical region. The highly
attive and stressed muscles are
depicted in brighter red.
Rectus capitis
posterior major
Semispinalis
c a p it is
Sternocleidomastoid
Levator scapula
;alenus anterior
M u s c u la r Im b a la n c e A s s o c ia te d
341
Head Posture
clinical sign often associated with forward head posturing is a realignment of sternocleidomastoid muscle
within th sagittal piane. The cranial end of th muscle,
normally a/igned posterior to th sternoclavicular joint,
shifts anterorly to a position d irectly above th sterno
cla vicular jo in t (compare Fig. 0 - 3 5 A w ith ff/.
th scalp. The key to most treatment for chronic forw ar head p osture is to restore optim al craniocervical
342
Section HI
Axial Skeleton
Scalenus anterior
Splenius capitis
and cervicis
Sternocleidomastoid
Longissimus
capitis
Jfansversospinal
muscles
(m ultifidi)
Latissimus dorsi
Obliquus
externus
abdominis
- Erector spinae
Gluteus maximus
Biceps femoris
Chapter 10
LIFT
343
body weight. The axis of rotation for th sagittal piane motion is oriented in th medial-lateral direction in th region
of L2 (see Fig. 1 0 - 3 8 , open circle). Estimating th compression force is a three-step process.
Step 1 establishes an equation that demonstrates static
rotary equilibrium about th axis of rotation. The equation
specifies that th sum of th internai and extemal torques
within th sagittal piane is equal to zero. This assumption
allows th internai (muscular) torque to be estimated by
344
Section III
Axial Skeleton
Data
In te rn a i m o m e n t a rm ( D i) =
5 cm.
Parte/ body
o r - 520 N.
E x te rn a l m o m e n t a rm tr a m B W (D 2) =
13 cm.
E x te rn a l Io a d (E L ) = 2 5 % o f tota) b o d y w e ig h t = 200 N ( - 4 5
Ibs).
E x te rn a l m o m e n t a rm fr o m E L (D 3 ) = 2 9 cm .
N + 200 N
Chapter 10
345
Load distance
0 =.
^ $
-20 cm
------------ 30 cm
-
- - - - 40 cm
------------ 50 cm
Oq
gj
(D*9
Q. m
| ~Z
o W
Therapeutic and educational efforts directed toward reoff th floor, for example, tends to flex th lumbar spine,
iuction of th likelihood of back injury are often directed
thereby decreasing th lordosis. Even if lifting while maintoward reduction of th muscle force demands by four
taining an exaggerated lumbar lordosis, th associated in
"Tiethods. First, reduce th rate of lifting. As previously
creased compression force on th apophyseal joints may not
uated, reducing th lifting velocity proportionately decreases
be well tolerated.
die amount of back extensor muscle force.
Second, reduce th weight of th extemal load. This point
is obvious, but not always possible.
Third, reduce th length o f th external moment arm of
Four Ways to Reduce th Amount of Force Required of
th Back Extensor Muscles While L iftin g
die external load. This is likely th most effective and practi1. Reduce th speed of lifting
:al method of decreasing compression forces on th low
2. Reduce th magnitude of th extemal load
back. As demonstrated in Figure 1 0 - 3 8 , a load should be
3. Reduce th length of th external moment arm
jfted from between th legs, thereby minimizing th distance
4. Increase th length o f th internai moment arm
between th lo ad and th lum bar region. As estimated, lift
ing a heavy load using ideal technique produced a compres
sion force on th lumbar region that remained dose to th
ip p er lim its o f safety p r o p o s e d b y NIOSH. Lifting th sante
R0LE 0F INCREASING INTRA-ABDOMINAL PRESSURE
ioad with a longer extemal moment arm creates very large
WHILE LIFTING
and potentially dangerous compression forces on th low
rack. Figure 1 0 - 3 9 sh ow s a p lo t o f p red icted com pression
In 1957, B artelink7 in trodu ced th notion that th Valsalva
'orces on che L5-S1 disc as a function o f dodi io a d size an d
maneuver (named after th Italian anatomist, 1 6 6 6 -1 7 2 3 ),
distance between th load and th front of th chest.12 Altypically used while lifting loads, may help unload and
though an extreme example, th plot predicts that holding
thereby protect th lumbar spine. The Vaisalva maneuver
in extemal load that wetghs 200 N (45 Ib) 50 cm in from
describes th action of voluntarily increasing intra-abdominal
f th body creates about 4500 N of compression force,
pressure by vigorous contraction of th abdominal muscles
greatly exceeding th upper safe limit of 3400 N. In everyagainst a closed glottis. The Valsalva maneuver creates a
day life, lifting an object from between th legs is not always
rigid, vertical column of high pressure within th abdomen
practical. Consider th act of sliding an obese patient toward
that pushes upward against th diaphragm and dow nw ard
die head of a hospital bed. Inability to reduce th distance
against th pelvic floor. Acting as an inflated intra-abdomi
between th patient's center of mass (located anterior to S2)
nal balloon, Bartelink proposed that activating this rnechaand th lifter can dramatically compromise th safety of th
nism while lifting may partially reduce th demands on th
lifter.
lumbar extensor muscles and, therefore, lower th compres
Fourth, increase th internai moment arm available to th
sion force on th lu m bar spine.
!ow-back extensor muscles. A larger internai moment arm
Although th notion of increasing intra-abdominal pres
for extension allows a given extension torque to be genersure as a way to reduce compression forces on th spine is
ated with less muscle force. As stated, less muscle force
intriguing, studies have refuted th biomechanical validity of
typically equates to less force on th vertebral elements.
th concept.5-34-57-61 Contraction of th abdominal muscles
Increased lumbar lordosis does indeed raise th internai mo
p rod u ces forces that increase th vertical com pression on th
ment arm available to th lumbar erector spinae muscles.77
lumbar spine. Because th abdominal muscles flex th lum
Lifting with an accentuated lumbar lordosis, however, is not
bar spine, their strong activation requires increased counteralways practical or even desirable. Lifting a very heavy load
balancing torques from th extensor muscles, thereby adding
346
Section III
Axial Skeleton
1 0 - 3 8 would have exceeded his theoretical 200 Nm threshold if th extemal load were increased to about 80% of his
body weight. Although this is a considerable weight, it is not
unusual for a person to successfully lift much greater loads,
such as those regularly encountered by heavy labor workers
and by competitive power lifters. In attempts to explain
this apparent dilemma, two secondary sources of extension
torque are p ro p osed : (1) passive tension gen erated from
stretching th posterior ligamentous System, and (2) muscular-generated tension transferred through th thoracolumbar
fascia.
P a ssive T e nsion G e n e ra tio n fro m S tre tc h in g th P o s te rio r
L ig a m e n to u s S yste m
90
.02
1.8
Ligamentum flava
244
.03
7.3
680
.04
27.2
Inierspinous ligament
107
.05
5.4
500
.06
Ligament
Posterior longitudinal ligament
Total
30
71.7
o-
.............
-..w vn **..1*1*1
-Extensor moment arm is th perpendicular distance between th attaehment sites of th ligaments and th medial-lateral axis of rotation wuhm a
Chapter 10
*t
S P E C I A L
F O C U S
1 0 - 8
347
348
Section III
Axial Skeleton
LIFT
Chapter 10
TABLE
349
Consideration
Rationale
Comment
many settings.
Those persons with a history of or propensity for lowback injury should heed th following three common sense
considerations: (1) know your physical limits, (2) think th
lift through before th event, and (3) within practical and
health limits, stay in optim al physical and cardiovascular
condition.
REFERENCES
1. Adams MA, Dolan P: A technique for quanlifying th bending moment
acting on th lumbar spine in vivo. J Biomech 24:117-126, 1991.
350
Section 111
Axial Skeleton
Chapter 10
breathing technique on trunk and pelvic coordination during a liftino
lask. Spine 24:1124-1130, 1999.
61. Nachemson AL, Andersson GBJ, Schullz AB: Vaisalva maneuver biomechanics: Hlfects on lumbar trunk loads of elevated intraabdominal pressures. Spine 11:476-479, 1986.
62. National nsiilute for Occupational Safety and Health (NIOSH): The
National Occupational Exposure Survey (Publication No 89-103) Cin
cinnati, OH, NIOSH, 1989.
63. National Institute for Occupational Safety and Health (NIOSH): Work
Practices Guide for Manual Lifting (Reper No. 81-122). Cincinnati
OH, NIOSH, 1992.
64. Newton M, I how M, Somerville D, et al: Trunk strength testing with
iso-machines. Part 2: Experiraental evaluation of th Cybex li back
testing System in normal subjects and patients with chronic low back
pain. Spine 18:812-824, 1993.
65. Nordin M, Kahanovhz N, Verderame R, et al: Normal trunk muscle
strength and endurance in women and th effect of exercises and
electrical stimulation. Part 1: Normal endurance and trunk muscle
strength in 100 women. Spine 12:105-111, 1987.
66. Panjabi MM, Cholewtcki J. Nibu K, et al: Criticai load of th human
cervical spine: An in litro experimental study. Clin Biomech 1 3 1 1 - 1 7
1998.
/ Patwardhan AG, Havey RM, Ghanayem AJ, et al: Load-carrying capacity
of th human cervical spine in compression is increased under a follower load. Spine 25:1548-1554, 2000.
68. Porterfield JA, DeRosa C: Mechanical Neck Pain: Perspectives in Functional Anatomy. Philadelphia, WB Saunders, 1995.
69. Potvin JR, McGill SM, Norman RW. Trunk muscle and lumbar ligament
contributions to dynamic lifts with varying degrees of trunk flexion
Spine 16:1099-1107, 1991
70. Potvin JR, Norman RW, McGill SM: Reduction in anterior shear forces
on th L4/L5 disc by th lumbar musculaiure. Clin Biomech 6:88-96
1991.
Rizk NN.: A new description o ( th anterior abdom m al waII in man and
mammals. J Anai 131:373-385, 1980.
*2. Santaguida PL, McGill SM: The psoas major muscle: A three-dimensional geometrie study. J Biomech 28:339-345, 1995.
~3- Schipplem OD, Reinsel TE, Andersson GBJ, et al: The in/iuence of
inma/ horizontal weight placement on th loads at th lumbar spine
while lifting. Spine 20:1.895-1898, 1995.
' Schipplein OD, Trafimow JH, Andersson GBJ, et al: Relaiionship between moments at th L5/S1 level, hip and knee joint when lifting, J
Biomech 23:907-912, 1990.
*5. Shirazi-Adl A, Pam ianpour M : Elfecl o f changes in lordosis on mechanics of th lum bar spine-lumbar curvature in lifting. J Spinai Dis 5:43644 r, 1999.
351
ADDITIONAL READINGS
Adattai MA, M cN ally DS, C hinn H, et al: Posture and th compressive
11
h a p t e r
Kinesiology
Mastication and Ventilation
Donald A. Neum ann , PT, Ph D
TOPICS
PART 1: M A S T IC A T IO N , 352
AT
GLANCE
Arthrokinematics, 360
Thorax, 369
0 S T E 0 L 0 G Y A N D TEETH, 352
M a n u b rio s te rn a l J o in t, 370
S te rn o c o s ta l J o in ts , 370
In te rc h o n d ra l J o in ts , 370
M a n d ib le , 352
M a x illa e , 353
S p h e n o id B one, 355
Masseter, 363
Temporalis, 363
Mediai Pterygoid, 364
Lateral Pterygoid, 364
S e c o n d a ry M u s c le s of M a s tic a tio n ,
Teeth, 355
ARTHROLOGY, 356
D ia p h ra g m , 372
365
In te rc o s ta le s M u s c le s , 372
C h ro n ic O b s tru c tiv e P u lm o n a ry D isease
A lte re d M u s c le M e c h a n ic s , 373
TE M P O R O M A N D IB U LA R DISORDERS, 367
PART 2: V EN T ILA TIO N , 368
ARTHROLOGY. 369
S c a le n e M u s c le s , 372
o f th M o u th , 366
352
Ventilation, 371
365
J o in ts , 370
S u m m a ry o f In d iv id u a i M u s c le A c tio n ,
PART 1: MASTICATION
Individuai Bones
The mandible, maxillae, temporal, zygomatic, sphenoid, and
hyoid bones are all related to th structure or function of th
TMJ.
M ANDIBLE
The mandible is th largest of th facial bones (see Fig. 1 1 1). It is a very mobile bone, suspended from th cranium bv
Chapter 11
353
L a t e r a l view
Coronoid process
(attachment for
temporalis muscle)
Pterygoid fossa
(attachment for
lateral pterygoid
Temporalis
Temporalis
muscle
M a ndibu lar
notch
-ygomaT/S
Occipital
bone
Mediai
pterygoid
muscle
M andib ular
con dyle
yjonsg.
External acoustic
meatus
'Wax.ijiaT.
Masseter
muscle-
Mastoid process
Styloid process-
Condyle of
te m p o ro m a n d ib u la r jo in t
Mental foramen
Angle
Masseter
muscle
Z yg om a tic
arch
muscles, ligaments, and capsule of th TMJ. Muscles of masti-ation attach either directly or indirectly to th mandtble.
Muscle contraction brings th teeth embedded within th
mandible against th teeth embedded within th fixed maxilbe.
The two main parts of the mandible are the body and the
:wo rami (Fig. 1 1 - 2 ). The body, the horizontal portion of
the bone, accepts the lower 16 adult teeth (see Fig. 1 1 -3 ).
The rami of the mandible project verticali)' from the poste
rior aspect of the b od y (see Fig. 1 1 -2 ). Faeh ramus has an
external and internai surface, four borders, and two processes at its superior aspect the coronoid process and the
condylar process. Extending betw een the coron oid an d condylar process is the mandibular notch. The posterior and
tnferior borders of th ramus join ai the readily palpable
angle o f the mandible. The masseter and mediai pterygoid
muscles two powerful muscles of mastication share similar attachments in the region of the angle of the mandible.
The coronoid process is a triangular projection of thin bone
that extends upward from the anterior border of the ramus.
This process is the primary inferior attachment of the tem-
Molars
Tip of
coronoid
process
Lateral
pole
Mediai
pole
M a n d ib u la r
condyle
Section III
354
Axial Skeleton
M a n d ib u la r
foramen
Mediai
pterygoid
muscle
Symphysis menti
(attachment for
th geniohyoid
muscle)
Digastric fossa
(attachment for
anterior belly of th
digastric muscle)
Mylohyoid line
(attachment for th
mylohyoid muscle)
Angle
TEMPORAL BONE
Two temporal bones exist one on each side of th cranium. The mandibular fossa forms th bony concavity of th
TMJ (Fig. 1 1 - 5 ) . The fossa is bound anteriorly by th ernie -
Inferior view
Postglenoid
Zygomatic process,
Zygomatic
Temporal process
FIGURE 11-5. Inferior view of th skull highlighting th righi mandibular fossa, lateral pterygoid
piate, and zygomatic arch. The proximal attachments of th masseter, mediai pterygoid, and lat
eral pterygoid (superior head) muscles are shown
in red.
Mandibular
fossa
Foramen
ovale
Anterior
Mediai
Chaptcr 11
355
Mediai
pterygoid
muscle
Mediai
pterygoid
piate
Lateral
pterygoid
piate
Foramen
rotundum
ZYGOMATIC BONE
The right and left zygomatic bones constitute th major part
h e c h eek s and th lateral orbits o f th eyes (see Fig.
1 1 -1 ). The temporal process of a zygomatic bone contributes
-he anterior half of th zygomatic arch (see Fig. 1 1 - 5 ). A
arge part of th masseter muscle attaches to th zygomatic
bone and th adjacent zygomatic arch.
HYOID BONE
The hyoid is a U-shaped bone located at th base of th
throat, just anterior to th body of th third cervical verte
bra. The body o f th hyoid is convex anteriorly. The bilateral
greater horns form its slightly curved sides. The hyoid is
suspended primarily by its bilateral stylohyoid ligaments.
Several muscles involved wilh moving o f th tongue, svvallowing, and speaking attach to th hyoid bone (see Fig. 1 1 20 ) .
Teeth
The maxillae and mandible each contain 16 permanent teeth
(see Fig. 1 1 - 3 , for names of lower teeth). The structure of
each tooth refleets its function in mastication (Table 1 1 -1 ).
Each tooth has two basic parts: crown and root (Fig.
1 1 - 8 ). Normally th crown is covered with enamel and is
located above th gingiva (gum). The root of each tooth is
embedded in alveolar bone. The peridontal ligaments help
attach th roots of th teeth within their sockets.
Cusps are conical elevations that arise on th surface of a
tooth. Maximal intercuspation describes th position of th
mandible when th cusps of th opposing teeth are in maxi
mal contact. The term is frequently used interchangeably
with centric relation, especially in describing th relative posi
tion of th articular surfaces within th TMJ. The relaxed
postura! position of th mandible allows a slight freeway
Lateral view
Partial attachment of
lateral pterygoid musclesuperior
1empo/-5/
Cut edge of
zygomatic
arch
SPHENOID BONE
Although th sphenoid bone does not contribute to th
structure o f th TMJ, it d o es provide proxim al an achm em s
or th mediai and lateral pterygoid muscles. When articulated within th cranium, th sphenoid bone lies transversely
356
Section III
T A B LE 1 1 - 1
Axial Skeleton
. Permancnt Teeth
Names
Functions
Numbers
Structural C haracteristics
Incisors
Cut food
Maxillary, 4
Mandibular, 4
Sharp edges
Canines
Tear food
Maxillary, 2
Mandibular, 2
Premolare
Maxillary, 4
Mandibular, 4
Molare
Maxillary, 6
Mandibular, 6
ARTHROLOGY
The TMJ is formed by th condyle of th mandible that hts
loosely within th mandibular fossa of th temporal bone
(see Fig. 1 1 - 1 ) . It is a synovial joint that permits a wide
range of rotation as well as translation. An articular disc
cushions th potentially large and repetitive muscle forces
inherent io mastication. The disc separates che joinc imo cwo
synovial joint cavities (Fig. 1 1 - 9 ) . The inferior joint cavity is
between th inferior aspect of th disc and th mandibular
condyle. The larger superior joint cavity is between th superior surface of th disc and th bone formed by th mandib
ular fossa and th articular eminence.
Although both right and left TMJs function together, each
retains its ability to function relatively independently. Masti
cation is typically performed asymmetrically, with one side
of th mandible exerting a greater biting force than th
other. The dominant side is often referred to as th work
ing side, whereas th nondominant side is referred to as th
balancing side.20 Different demands are placed on th muscles and joints of th working and balancing sides.
Osseous Structure
MANDIBULAR CONDYLE
The mandibular condyle is flattened from front to back, witr
its medial-lateral length twice as long as its anterior-postenc ? '
length (see Fig. 1 1 - 3 ) .46 The condyle is generally convex.1
possessing short projections of bone known as mediai and
lateral poles. The mediai pole is more prominent than th
lateral. When opening and closing th mouth, th outsic-.
edge of th lateral pole can be palpated as a point under thel
skin just anterior to th external auditory meatus.
The articular surface of th mandibular condyle is lined
with a thin but dense layer of fibrous connective tissue. This
tissue absorbs loads associated with mastication better than
hyaline cartilage, and it has a superior reparative process.- I
Both of these functions are important when considering th
extraordinary demands placed on th joint surfaces.48
MANDIBULAR FOSSA
The mandibular fossa of th temporal bone is dvided inte j
two surfaces: articular and nonarticular. The articular surface
of th fossa is formed by th articular eminence, occupying
th sloped anterior wall of th fossa (see Figs. 1 1 - 5 and
1 1 - 9 ) . This thick and smooth loadbearing surface is lined
with a dense layer of fbrocartilage. Full opening of th
mouth requires that each condyle slides forward across th
articular eminence. The slope of th articular eminence varies considerably among persons but typically is oriented
about 70 degrees from th horizontal piane.29 The slope I
affeets th path taken by th condyles during th openir:
and closing of th mouth.
The nonarticular surface of th fossa consists of a very rhiI
layer of bone and fbrocartilage that occupies much of tre I
superior (dome) and posterior walls of th fossa (see Fu I
1 1 - 5 ) . The thin region is not an adequate loadbearing s u r i
face. A large force applied to th chin can fracture t h J
region of th fossa, possibly even sending bone fragmensl
into th cranium.
Articular Disc
Chapter 11
357
Lateral view
Superior joint cavity
r Superior
Interior
Lateral pterygoid
Interior head-
FIGURE 11 9. A lateral v iew o f a sagittal piane cross-section through a normal right temporomandibular joint. The mandible is in
a posiuon ot maxima! intercuspation, with th disc in iis ideal position relative to th condyle and th temporal bone.
tfexible but firm owing to its high collagen coment. The
tire periphery of th disc anaches to th surrounding cap
ale of th joint.
The disc is divided into three regions: posterior, intermete, and anterior (see Fig. 1 1 - 9 ). The shape of each region
ows th disc to accommodate th contour of th condyle
d th fossa. The posterior region of th disc is convex
periorly and concave inferiorly. The concavity accepts
most of th condyle much like a ball-and-socket joint. The
estreme posterior region atlaches to a loosely organized ret
iseli laminae, containing collagen and elastin fibers. Contions made by th laminae anchor th disc posteriorly to
ne (see th box). A meshwork of fat, blood vessels, and
ory nerves flls th space between th superior and infe~r laminae.
358
Collateral ligaments
Lateral TMJ ligament
Sphenomandibular ligament
Stylomandibular ligament
Osteokinematics
LATERAL LIGAMENT
The primary ligament reinforcing th TMJ is th lateral (tem
poromandibular) ligament (Fig. 11-1 0 A ). The lateral ligament
is typically described as a combination of horizontal and
oblique fibers (Fig. 1 1 -1 0 B ).59 The more superficial oblique
fibers course in an anterior-superior direction, from th posterior neck of th mandible to th lateral margins of th
articular eminence and zygomatic arch. The deeper, horizon
tal fibers share similar temporal attachments. They course
horizontally and posteriorly to attach into th lateral pole of
th mandibular condyle.
The primary function of th lateral ligament is to stabilize
th lateral side of th capsule. Tears or excessive elongation
of th lateral ligament may cause th disc to be moved
medially by an unopposed pul of th superior head of th
lateral pterygoid muscle. As described in Arthrokinematics,
th oblique fibers have a special function in guiding th
movement of th condyle during opening of th mouth.47
LATERAL EXCURSION
Lateral excursion of th mandible occurs primarily as a sideto-side translation (Fig. 1 1 -1 3 A ). The direction (right <:c]
left) of active lateral excursion can be described as eith:
contralateral or ipsilateral to th side of th primary me
action. In th adult, an average of 11 mm of maximal unLr-l
eral excursion is considered norm al60 Lateral excursion i
th mandible is usually combined with other relatively si
ivieaiai view
Capsule of
of th sphenoid bone
ligamr!
Lateral pterygoid p ia
Mediai pterygoid pbrs
Styloid process
ACCESSORY LIGAMENTS
Stylomandibular
ligament
Chapter 11
Protrusion
359
Retrusion
I .alerai excursion
360
Section
III
Axia Skeleton
Elevatimi
Depressimi
B
FIGURE 11-14. Depression (A) and elevation (B) of th mandible.
edges of th upper and lower incisors is considered abnormal. Elevation of th mandible doses th mouth an
action used to grind food during mastication (Fig.
1 1 -1 4 B ).
Arthrokinematics
Opening th mouth
Chapter 11
Mechanical problems within th TMJ can cause impairments in mastication. A common cause of impairment is
internai derangement of th disc-condyle complex.*1 The
condition is defined as an abnormal position of th disc
relative to th condyle and fossa. The derangement can
be caused by abnormal disc shape, overstretched collateral ligaments, chronic inflammation, loss of elasticity
within th superior retrodiscal lamina, or abnormal forces
from th lateral pterygoid muscle.34
361
362
Section III
Axial Skeleton
LATERAL EXCURSION
Lateral excursion involves primarily a side-to-side translation
of th condyle and disc within th fossa. Slight multiplanar
rotations are typically combined with lateral excursion.47 Fig
ure 1 1 -1 3 B shows an example of lateral excursion com
bined with slight horizontal piane rotation. The left condyle
forms a pivot point within th fossa as th right condyle
rotates slightly anteriorly and medially. Slight rotations also
occur in sagittal and frontal planes, owing primarily to th
effect of th condyle and disc sliding across th sloped articular eminence.
Innervation
Masseter
Temporalis
Mediai Pterygoid
Lateral Pterygoid
Secondary Muscles
Innervation
Suprahyoid Croup
Digastric (posterior belly)
Geniohyoid
Mylohyoid
Slylohyoid
Infrahyoid Group
Omohyoid
Stemohyoid
Stemothyroid
Thyrohyoid
Chapter 11
363
FIGURE 1 1 -1 7 . The masseter (A) and temporalis (B) muscles. (Modified from Okeson JP: Management of Temporomandibular Disorders and Occlusion, 4th ed. Chicago, Mosby, 1998.)
The synovial membrane and th centrai pan of th articular disc within th TMJ lack sensory innervation. The periphery of th disc, capsule, lateral ligament, and retrodiscal
tissues, however, possess pain fibers and mechanorecepI tors.'H-66 Mechanoreceptors and sensory nerves, from orai
mucosa, periodontal ligaments, and muscles, provide th
nervous System with a rich source of proprioception. This
source of information helps to protect th tissues through
neuromuscular reflex actions and allows coordination between th muscles and joint. The sensory innervation to th
TMJ is carried through two bran ches o f th mandibular
nerve: auriculotemporal and masseteric.
364
Seciion 111
Axial Skeleton
The mediai pterygoid and masseter have a very similar lineof-force and size (compare Fig. 1 1 -1 7 A with Fig. 1 1-19A ).
The mediai pterygoid arises from th mediai surface of th
lateral pterygoid piate of th sphenoid bone (see Figs. 1 1 - 5
and 1 1 - 6 ). From this attachment, it courses parallel to th
superficial fibers of th masseter to attach on th internai
surface of th ramus near th angle of th mandible (see
Figs. 1 1 - 2 and 1 1 - 4 ). Acting bilaterally, contraction of th
mediai pterygoid muscles elevates and, to a limited extern,
protrudes th mandible. Because of th oblique line-of-force
of th muscle relative to th fromal piane, a unilateral con
traction produces a very effective contralateral excursion of
th mandible (see Fig. 1118).
L a te ra l P te ry g o id
Lateral pterygoid
superior head
Lateral pterygoid
inferior h e a d
FIGURE 11-19. A, The mediai view of th righi mediai pterygoid. B, The lateral view of th two heads of th lateral pterygoid.
(A with permission from Okeson JP; Management of Temporomandibular Disorders and Occlusion, 4th ed. Chicago, Mosby,
1998. B modified from Kaplan AS and Assael LA: Temporomandibular Disorders: Diagnosis and Treatment Philadelphia WB
Saunders, 1991.)
Chapter 11
365
th right lateral and mediai pterygoid and by th left masseter and temporalis.
Bilateral contraction of th lateral pterygoids produces
strong protrusion of th mandible.34 As described in Muscular
Control of Opening and Closing of th Mouth, th two
heads of th lateral pterygoid muscles have antagonistic roles
during opening and closing of th mouth. Most data suggest
that th inferior head is th primary depressor of th mandible, especially during resisted opening of th mouth.313742
The superior head helps control th position of th disc and
joint during elevation of th mandible.31'37 This function is
especially important during resisted, unilateral closure of th
jaw, such as when biting down on a hard object between
th molars.
The suprahyoid and infrahyoid muscles are considered secondary muscles of mastication (see Table 1 1 - 2 ). Forces produced by these muscles are transferred either directly or
indirectly to th mandible (Fig. 1 1 - 2 0 ). The suprahyoid mus
cles attach between th base of th cranium, th hyoid, and
th mandible; th infrahyoid muscles attach superiorly to th
hyoid and inferiorly to th thyroid cartilage, sternum, and
scapula. The mandibular attachments of three of th supra
hyoid muscles anterior belly of th digastric, geniohyoid,
and mylohyoid are shown in Figure 1 1 4. Appendix III,
Parts E and F, includes th attachments and innervations of
th suprahyoid and infrahyoid muscles.
With th hyoid bone stabilized by activation of th in
frahyoid muscles, th suprahyoid muscles assist with depression of th mandible.6 The suprahyoid and infrahyoid mus
cles are also involved in speech, tongue movement, and
swallowing, and in controlling of boluses of food prior to
swallowing.
Muscle
Elevation
(closing of
th mouth)
Masseter
XXX
Mediai pterygoid
XXX
Depression
(opening
of th
mouth)
Lateral Excursion*
Protrusion
X
XXX (CL)
XXX (CL)
XXX
XXX
XXX (CL)
XXX
XXX
XXX
(posterior ftbers)
XXX
X (IL)
Retrusion
X (IL)
Xf
366
Section III
Axial Skeleton
S P E C I A L
F O C U S
Opening of th mouth is performed primarily through contraction of th inferior head o f th lateral pterygoid and th
suprahyoid group o f muscles. This action is depicted in Figure
1 1 -2 2 A as th mouth opens in preparation to bite on a
grape. The inferior head of th lateral pterygoid is primarily
responsible for th forward translation (protrusion) of th
mandibular condyle.34 This muscle is also involved in a forcecouple with th contracting suprahyoid muscles. The forcecouple rotates th mandible about its axis of rotation, shown
as a white circle below th neck of th mandible. Although
mandibular rotation is minimal during th later phase of
opening th mouth, it does facilitate th extremes of this
action. Gravity also assists with opening of th mouth.
As described previously, th disc and condyle slide for
ward as a unit during th late phase of opening of th
mouth. The disc is stretched and pulled anteriorly by (1)
collateral ltgaments attaching th disc to th translating'con
dyle, and (2) increased intra-articular pressure created by
activation of th inferior head of th lateral pterygoid. Al
disc-condyle complex. Although th data suggest an association between abnormal craniocervical posture and disorders of th TMJ, th literature does not unequivocally
support a cause-and-effect relationship between these
variables.69
Forw ard Head Posture
Suprahyoids
Sternohyoid
Omohyoid
Chapter 11
Opening th mouth
367
Closing th mouth
TeinporaliS;
Lateral pterygoid
superior head
Lateral
pterygoid
Superior N
etr.odfscal
Lateral
pterygoid
piate
lamina
W Lateral
pterygoid
k interior
s u ftM rh e a d
H F L a te r a l
pterygoid
interior head ^
;Whead-
Masseter
Suprahyoids
Mediai pterygoid
\ /
'
'
Hyoid bone
Infrahyoids
TEMPOROMANDIBULAR DISORDERS
The Special Role of th Superior Head of th Lateral
Pterygoid in Adjusting Disc Position
368
Section III
Axial Skeleton
Intercostales
externi
Intercostales
interni
Diaphragm
PART 2: VENTILATION
Ventilation is th mechanical process by which air is inhaled
and exhaled through th lungs and airways. This rhythmic
process persists 12 to 20 times per minute at rest and is
essential to th maintenance of fife. This chapter now focuses on th kinesiology of ventilation.
Ventilation allows for th exchange of oxygen and carbon
dioxide between th alveoli of th lungs and th blood. This
exchange is essential to oxidative metabolism within muscle
fibers. The process converts Chemical energy stored in ATP
into th mechanical energy needed to move and stabilize th
joints of th body.
The relative intensity of ventilation can be described as
quiet or forced. In th healthy population, quiet venllalion occurs during relatively sedentary activities that have
low metabolic demands. In contrast, forced ventilation occurs
during strenuous activities that require rapid and voluminous exchange of air, such as exercising, or in th presence
of some respiratory diseases. A wide and continuous range
of ventilation intensity exists between quiet and forced venti
lation.
Figure 1 1 - 2 3 shows th lung volumes and capacities in
p re ss u re
exerted by a gas
Chapter 1 1
369
S P E C I A L
F O C U S
4
Factors that Can Oppose Expansion of th Thorax
The work performed by th muscles of inspiration must
overcome th naturai elastic recoil of th lung tissue
and th joints that compose th thorax. Additional work
is performed to overcome th resistance of th inspired
air as it passes through th extensive airways. The
amount of air that reaches th alveoli depends on th
reduced alveolar pressure, which is determined in part
by th net effect of muscle contraction and th mechanical properties that oppose thoracic expansion.
Several factors can oppose expansion of th thorax.
Advanced age, for example, is associated with in
creased stiffness of th joints and connective tissues
that make up th thorax.18 The lung parenchyma, however, loses elastic recoil and becomes more compliant
with aging. Compliance, in this context, is a measure of
th distensibility of th lungs produced for a given drop
in transpulmonary pressure or th slope of th volumepressure curve. When combined, th total System (tho
rax and lungs) shows a net decrease in compliance
with aging.68 A greater reduction in pressure is required
to inspire a given volume of air. In effect, muscles have
to work harder during inspiration. This partially explains
why aging is typically associated with a slight decrease
in tidal volume and slight increase in respiratory frequency.
Diseases or abnormal postures can also oppose tho
racic expansion. Rheumatoid arthritis, for example, can
increase th stiffness of th cartilage of th sternocostal joints, thereby resisting an increase in intrathoracic
volume. Severe scoliosis or kyphosis may physically
limit th expansion of th thorax.
ARTHROLOGY
Thorax
The rib cage, or thorax, is a closed System that functions as
th mechanical bellows of ventilation (Fig. 1 1 -2 5 ). The in
ternai aspect of th thorax is sealed from th outside by
several structures (Table 1 1 - 4 ) . Although this chapter fo-
Posterior-laterally
thoracic vertebrae
ribs
intercostal muscles and membrane
Anteriorly
Expiration s th process of expiring (exhaling) air from
th lungs into th environment. In accord with th analogy
to th piston previously described, decreasing th volume
within th chamber of a piston increases th pressure on th
contained air, forcing it outward. Expiration in th human
occurs by a similar process. Reducing th intrathoracic vol
ume increases th alveolar pressure, thereby driving air from
th alveoli to th atmosphere.
Quiet expiration is primarily a passive process that does
not depend on muscle activation. When th muscles of in
spiration relax after contraction, th intrathoracic volume is
costai cartilages
sternum
intercostal muscles and membranes
Superiorly
upper ribs and clavicles
cervical fascia that surrounds th esophagus and trachea
cervical muscles
Inferiorly
diaphragm muscle
370
Section
S te rn o co sta l jo in t
C o s to c h o n d ra l
ju n c tio n
C h o n d ro s te rn a l
ju n c tio n (u n d e r ra diate
and c a p s u la r lig a m e n ts)
C la v ic u la r fa c e t
1 st rib
2 nd
M a n u b rio s te m a l
lig a m e n t o v e r
m a n u b rio s te m a l jo in t
C o sta i fa c e t of th
4 th ch o n d ro ste rn a l
ju n c tio n
(S te rn o co sta l joint)
MANUBRIOSTERNAL JOINT
The manubrium fuses with th body of th stemum at th
manubriostemal joint (Fig. 1 1 -2 6 ). This fibrocartilaginous articulation is an amphiarthrosis, similar to th strutture of th
pubic symphysis. A partial disc fills th cavity of th manubriosternal joint, completely ossifying late in life. Before ossification, th joint may contribute modestly to expansion of
th thorax.
STERNOCOSTAL JOINTS
Bilaterally, th anterior cartilaginous ends of th first seven
ribs articulate with th lateral sides of th stemum. In a
broad sense, these articulations may be called sternocostal
joints (see Fig. 1 1 -2 6 ). Because of th intervening cartilage
between th bone of th ribs and th stemum, however,
each sternocostal joint is structurally divided into a costo
chondral and chondrosternal junction.
The costochondral junctions represent th transition be
tween th bone and cartilage of th anterior ends of each
rib. No capsule or ligament reinforces these junctions. The
periosteum of th ribs gradually transforms into th perichondriutn ol th cartilage. Costochondral junctions permit
very little movement.
The chondrosternal junctions are formed between th me
diai ends of th cartilage of th ribs and th small concave
costai facets on th stemum. The first chondrosternal jun c
tion is a synarthrosis, providtng a relatively stiff connection
with th stemum.64 The second through th seventh joints,
however, are synovial in nature, permitting slight gliding
motions. Fibrocartilaginous discs are sometimes present, especially in th lower joints where cavities are frequently
absent. Each synovial joint is surrounded by a capsule thai is
strengthened by radiate ligaments. An intra-articular ligament
is frequently encountered in th second chondrosternal jun c
tion.64
X ip h o id p ro ce ss
ln te rc h o n d ra l lig a m e n ts
in te rch o n d ra l jo in t
INTERCHONDRAL JOINTS
The opposed borders of th cartilages of ribs 6 lo 10 form
small, synovial-lined interchondral joints, strengthened by in
terchondral ligaments (see Fig. 1 1 -2 6 ). Ribs 11 and 12 do
not attach anteriorly to th stemum.
Chapter 11
I
I
I
I
I
CHANGES
5th rib
Superior view
371
372
Section III
Axial Skeleton
DIAPHRAGM
Ihe diaphragm is a dome-shaped, thin, musculotendinous
sheet of tissue that separates th thoracic cavity from th
abdominal cavity (Fig. 1 1 - 2 8 ). Its convex upper surface is
th floor of th thoracic cavity, and its concave lower surface
is th roof of th abdominal cavity.
The diaphragm has three parts based on bony attachments: th costai part arises from th upper margins of th
lower six ribs; th relatively small and variable sterna! pan
arises from th posterior side of th xiphoid process; and th
thicker crural part is anchored to th bodies of th upper
three lumbar vertebrae through two distinct tendinous at-
Muscle
Mode of Action
Innervation
Location of Illustrations
Diaphragm
Chapter 11
Scalenes
Chapter 10
Intercostales
Chapter 11
Chapter 11
SCALENE MUSCLES
The scalenus anterior, medius, and posterior muscles attach between th cervical spine and th upper two ribs (see Chapter
373
INTERCOSTALES MUSCLES
Anatomy of th Intercostales Muscles
The intercostales are a thin, three-layer set of muscles that
occupy th intercostal spaces. Each set of intercostal muscles
within a given intercostal space is innervated by an adjacent
intercostal nerve.
The intercostales extem i are most superficial, analogous in
depth and fiber direction to th obliquus abdominis extemus
muscles (see Chapter 10). There are eleven per side, and
each intercostalis extemi arises from th lower border of a
rib and inserts on th upper border of th rib below (see
Fig. 1 1 - 2 5 , see right side). Fibers travel obliquely between
ribs in an interior and m ediai direction. The intercostales
ex tem i are most d ev elop ed laterally. Near th sternum, th
intercostales exterm are very thin and terminate as th ante
rior intercostal membrane.
The intercostales interni are deep to th extemi and are
analogous in depth and fiber direction to th obliquus ab
dominis intemus. There are also eleven per side, and each
intercostalis interni occupies one intercostal space, in a manner similar to th intercostalis externi. A major difference,
however, is that th fibers of th intercostales interni travel
perpendicular to th fibers of th intercostales externi (Fig.
1 1 - 2 5 , see right side). The intercostales interni are most
developed in th parasternal region; posteriorly, they termi
nate as th posterior intercostal membrane.
The intercostales intimi muscles are th deepest and least
developed o f th intercostales. T hey run para Ilei and d eep to
th intercostales interni. Fibers of th intercostales intimi
near th angle of th ribs, often called th subcostales, may
cross one or two intercostal spaces. The intercostales intimi
are most developed in th lower thorax.
Function of th Intercostales Muscles
By spanning each intercostal space, an intercostalis muscle
has th potential to alter th volume within th thorax by
elevating a lower rib, depressing an upper rib, or performing
both actions. The spedite strategy used by th different in
tercostales muscles during th different phases of ventilation
is an uncertain and a controversial topic.24 The conventionai
teaching is that th intercostales externi are more associated
with inspiration, and th interni are more associated with
expiration .63-64 Although this association has been shown in
EMG studies, simple functional distinction is not clear.12'35-55
For instance, both th intercostales extemi and interni have
been shown to be active during inspiration.16 Research also
suggests that th parasternal intercostales interni are consistently more active during inspiration than th more lateral set
of intercostales muscles.24 The lateral set of intercostales (in
terni and extemi) show considerable activation during axial
rotation of th trunk. In a similar manner as th oblique
abdominals (see Chapter 10), th more lateral intercostales
externi are most active during contralateral trunk rotation.
374
Sedioli III
Axial Skeleton
?I
S P E C I A L
FOCUS
1 1 -
In th healthy person, ventilation typically involves a characteristic pattern of movement between th thorax and
abdomen. During inspiration, th thorax expands outwardly owing to th elevation of th ribs and sternum.
The abdomen may protrude slightly because of th anterior displacement of th abdominal viscera, compresseti
by th descending diaphragm.
A complete cervical spinai cord injury below th C4
vertebra does not paralyze th diaphragm because its
innervation is primarily from th C4 nerve root. The inter
costales and abdominal muscles, however, are typically
totally paralyzed. The patient with this level of spinai cord
injury often displays a "paradoxical breathing" pattern.45
The pathomechanics of this breathing pattern provide insight into th normal interaction of th diaphragm, inter
costales, and abdominal muscles during inspiration.
Without th splinting action of th intercostales across
th intercostal spaces, th lowering of th dome of th
diaphragm creates an internai suction within th chest
that constricts th upper thorax, especially in its anteriorposterior diameter. The term paradoxical breathing describes th constriction, rather than th normal expansion,
of th rib cage during inspiration.45 The constriction of th
thorax can reduce th vital capacity of a person with an
acute cervical spinai cord injury. In th healthy adult, vital
capacity is about 4000 mL. About 3000 mL of this capa
Chapter 11
375
Mode of Action
Innervano
Location of Illustrations
Chapter 11
Chapter 11
Chapter 10
Stemocleidomastoid
Chapter 10
Latissimus dorsi
Chapter 5
Chapter 10
Pectoralis minor
Chapter 5
Chapter 5
Serratus anterior
Chapter 5
Quadratus lumborum
Chapter 10
complication is caled hyperinflation o f th ungs, 10-54 In advanced cases, th thorax remains in a chronic state of near
full inflation, regardless of th actual phase of ventilation.
The thorax of a person with COPD, therefore, typically develops a barrel-shaped appearance.
The excessive air in th ungs at th end of expiration
alters th geometry of th muscles of inspiration, especially
;he diaphragm. Throughout th ventilation cycle, th dia
phragm flattens and remains abnormally low in th thorax.
rhe change in position and shape of th diaphragm alters its
i-esting length and line-of-force.41 These two factors reduce th
dfectiveness of th diaphragm during inspiration. Operating
H a shortened length on its length-tension curve compronises force production. Furthermore, functioning in a low:red position redireets th line-of-force of th costai fibers of
he diaphragm more horizontally. This robs th muscles
iffectiveness at elevating th ribs. At a low enough position,
-p-1 2 )
376
Section ili
Axial Skeleton
transversus abdominis (see Chapter 10). Contraction of these
muscles has a direct and indirect effect on forced expiration
(Fig. 1 1 - 3 0 ). By acting directly, contraction of th abdomi
nal muscles flexes th thorax and depresses th ribs and
stemum. These actions can rapidly and forcefully reduce
intrathoracic volume, such as when coughing, sneezing, or
vigorously exhaling to th limits of th expiratory reserve
volume (see Fig. 1 1 - 2 3 ). When acting indirectly, contrac
tion of th abdominal muscles especially th transversus
ab d om in is increases th intra-abdom inal pressure and
compresses th abdominal viscera. The increased pressure
can forcefully push th relaxed diaphragm upward, well into
th thoracic cavity. In this manner, active contraction of th
abdominal muscles takes advantage of th parachute-shaped
diaphragm to help expel air from th thorax. As described in
Chapter 10, th increased intra-abdominal pressure is also
used during activities involving th Valsalva maneuver, including defecation, childbirth, and lifting of heavy loads.
A lthough che abdom in al musdes are described here as
muscles of forced expiration, their contraction also enhances
inspiration. As th diaphragm is forced upward at maximal
expiration, it is stretched to an optimal point on its lengthtension curve. As a consequence, th muscle is more pre-
FIGURE 11-29. A posterior view shows th serratus posterior superior and serratus posterior inferior muscles. These are cortsidered as
th intermediate muscles of th back, located deep to th rhomboids and th latissimus dorsi. (Modifted with permission from
Luttgens K and Hamilton N: Kinesiology: Scientifc Basis of Human
Motion, 9th ed. New York, McGraw-Hill, 1997. With permission of
th McGraw-Hill Companies.)
and walking, often starting a vicious circle of increased fatigue and dyspnea.
Transversus
thoracis
Intercostales
interni
externus
Transversus
abdominis
Rectus
abdominis
ABDOMINAL MUSCLES
The abdominal muscles include th rectus abdominis, obliquus externus abdominis, obliquus intemus abdominis, and
Chapter 11
377
Stem um
T ransversus
thoracis
Diaphragm
Intercostales
interni
T ransversus
abdom inis
Muscle
Mode of Action
Innervation
Abdominal muscles
rectus abdominis
obliquus extemus abdominis
obliquus internus abdominis
transversus abdominis
Chapter 10
Transversus thoracis
Chapter 11
ven erai r a m i)
Intercostales
The intercostales, especially th interni fibers, decrease intrathoracic volume by depressing th ribs.
Chapter 11
378
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ADDITIONAL READINGS
Campbell EJM: The role of th scalene and stemomastoid muscles in
breathing in a normal subject: An eleciromyographic study J Anat 89
378-386, 1955.
Di Fabio RP: Physical therapy for patients with TMD: A descriptive study of
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1998.
Goldman MD, Loh L, Sears TA: The respiratory activity of human levatoicostae muscles and its modification by posture. J Physiol .362:189-204
1985
Goodheart G: Applied kinesiology in dysfunction of th temporomandibular
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Clin Geriatrie Med 1:143-175, 1985.
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McKay GS, Ycmm R, Cadden SW: The strutture and function of th lemporomandibular joint, Br DentJ 173:127-132, 1992.
Passero PL, Wyman BS, Bell JW, et al: Temporomandibular joint dysfuncuon syndrome. Phys Ther 65:1203-1207, 1985
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p p e n d i x
III
S e t I: M u s c le s o f th P o s te rio r T ru n k
S et II: M u s c le s o f th A n te rio r-la te ra l
T ru n k
S e t I: M u s c le s o f th A n te rio r-la te ra l
C ra n io c e rv ic a l R egion
S e t II: M u s c le s o f th P o s te rio r
C ra n io c e rv ic a l R egion
Iliocostalis Lumborum
Injeror attachments: common tendon*
Superior attachments: inferior surface of th angle of ribs 6
to 12
Iliocostalis Thoracis
Inferior attachments: upper surface o f th angle of ribs 6 to
'
12
Iliocostalis Cervieis
Inferior attachments: angle of ribs 3 to 7
Superior attachments: posterior tubercles of th transverse
processes of C 4 - 6
Longissimus Thoracis
Inferior attachments: common tendon
Superior attachments: transverse processes of T I - 1 2 and
areas between th tubercle and angle of ribs 3 lo 12
Longissimus Cervieis
Inferior attachments: transverse processes of T I - 4
Superior attachments: posterior tubercles of th transverse
processes o f C 2 - f
Longissimus Capitis
Inferior attachments: transverse processes of T 1 - 5 and articular processes of C 4 - 7
Superior attachments: posterior margin of th mastoid process of th temporal bone
Spinalis Thoracis
Inferior attachments: common tendon
Superior attachments: spinous processes of T I - 6
Spinalis Cervieis
Inferior attachments: ligamentum nuchae and spinous proc
esses of C 7 -T 1
Superior attachments: spinous process of C2
Spinalis Capitis
Blends with semispinalis capitis
Innervation to th erector spinae: dorsal rami of adjacent
spinai nerves (C3- L 3)
Transversospinal Group
Multifidi, Rotatores, and Semispinalis Muscles
Multifidi
Inferior attachments (lumbar): mammillary processes of
lumbar vertebrae, lumbosacral ligaments, deep part of
th common tendon of th erector spinae, posterior
surface of th sacrum, posterior-superior iliac spine of
th pelvis, and th capsule of th lumbar and lumbo
sacral apophyseal joints
Inferior attachments (thoracic): transverse processes of
' TI 12
Inferior attachments (cervica!): articular processes of C 3 - 7
Superior attachments: spinous processes of vertebrae lo
cateci 2 - 4 intervertebral segments superior
Innervation: dorsal rami of adjacent spinai nerves ( O - S 3)
Semispinalis Thoracis
Inferior attachments: transverse processes of T 6 - 1 0
Superior attachments: spinous processes of C 6 -T 4
Semispinalis Cervieis
Inferior attachments: transverse processes of T I - 6
Superior attachments: spinous processes of C 2 - 5 , primar
ily C2
Semispinalis Capitis
This broad tendon connects th inferior end of most of th erector
spinse to th base of th axial skeleton. The specifc attachments of th cen
trai tendon include median sacrai crests, spinous processes and supraspinous
ligaments in th lower thoracic and entire lumbar region, iliac crests, sacroluberous and sacroiltac ligaments, gluteus maximus, and multifidi muscles.
381
382
Appendix III
Interspinalis Muscles
These paired muscles attach regularly between adjacent
spinous processes within th cervical vertebrae, except C I
and C2, and th lumbar vertebrae. In th thoracic spine, th
interspinalis muscles exist only at th extreme upper and
lower regions.
Longus Colli
Intertransversarus Muscles
S u p e r i o r O b l i q u e P o r t io n
Rectus Abdominis
Superior attachments: xiphoid process and cartilages of ribs
5 to 7
Inferior attachments: crest of pubis and adjacent ligaments
supporting th pubic symphysis joint
Innervation: intercostal nerves (T7- T 12)
Transversus Abdominis
Lateral attachments: anterior two thirds of th inner lip of
th iliac crest, thoracolumbar fascia, inner surface of
th cartilages of ribs 6 to 12, and inguinal ligament
Mediai attachments: linea alba and contralateral rectus
sheaths
Innervation: intercostal (T T 12), iliohypogastric (L1), and
ilioinguinal (L1) nerves
Scalenes
Scalenus Anterior
Superior attachments: anterior tubercles of th transverse
processes of C 3 - 6
Inferior attachment: inner border of first rib
Scalenus Medius
Superior attachments: posterior tubercles of th transverse
processes of 0 1 - 1
Inferior attachment: upper border of th first rib, posterior
to th attachment ol th scalenus anterior
Scalenus Posterior
Superior attachments: posterior tubercles of th transverse
processes of C 5 - 7
Inferior attachment: extemal surface of th second rib
Innervation to th scalene muscles: ventral rami of spinai
nerves (C3- C 7)
Appendix III
Sternocleidomastoid
Injerior attachments: stemal head, anterior surface of th
upper aspect of th manubrium of th sternum; clavicular head; posterior-superior surface of th mediai one
third of th clavicle
Superior attachments: lateral surface of th mastoid process
of th temporal bone and lateral one half of th supe
rior nuchal line of th occipital bone
Innervation: spinai accessory nerve (cranial nerve XI). A
secondary source of innervation is through th ventral
rami of th mid and upper cervical plexus, which may
carry sensory (proprioceptive) information.
Splenius Cervicis
Injerior attachments: spinous process of T 3 - 6
Superior attachments: posterior tubercles of th transverse
processes of C I - 3
Innervation: dorsal rami of spinai nerves (C2- C 8)
Temporalis
Proximal attachments: temporal fossa and deep surfaces of
temporal fascia
Distai attachments: apex and mediai surfaces of th coro
noid process of th mandible and th entire anterior
edge of th ramus of th mandible
Innervation: branch of th mandibular nerve, a division of
cranial nerve V
Mediai Pterygoid
Proximal attachment: mediai surface of th lateral ptery
goid piate
Distai attachment: internai surface of th mandible be
tween th angle and mandibular foramen
Innervation: branch of th mandibular nerve, a division of
cranial nerve V
Lateral Pterygoid
S u p e r io r H e a d
Suboccipital Muscles
383
Superior
In fe r io r H ea d
Geniohyoid
Proximal attachment: small region at th midiine of th
anterior aspect of th mandibles internai surface (symphysis menti)
Distai attachment: body of th hyoid bone
384
Appendix III
Slylohyoid
Proximal attachment: base o f th styloid process o f th
temporal bone
Distai attachment: anterior edge of th greater hom of th
hyoid bone
Innervation: facial nerve (cranial nerve VII)
lntercostales Externi
A tta ch m en ts
lntercostales Interni
A tta ch m en ts
Omohyoid
Intercostales Intimi
A tta ch m en ts
Stcmohyoid
Inferior attachments: posterior surface of th mediai end of
th clavicle, superior-posterior part of th manubrium
stemum, and posterior stemoclavicular ligament
Superior attachment: body of th hyoid bone
Innervation: ventral rami of C ~3
Sternothyroid
Inferior attachments: posterior part of th manubrium of
th stemum and th cartilage of th first rib
Superior attachment: thyroid cartilage
Innervation: ventral rami of C'~3
Thyrohyoid
Inferior attachment: thyroid cartilage
Superior attachment: junction of th body and greater hom
of th hyoid bone
nnenation: ventral rami of C 1 via cranial nerve VII
I.evatores Costarum
Superior attachments: ends of th transverse processes of
C 7 -T 1 1
Inferior attachments: external surfaces of ribs, betw'een th
tubercle and angle. Each of th twelve muscles attach
to th rib immediately inferior to its vertebral attach
ment.
Innervation: Branches of dorsi rami of adjacent thoracic
spinai nerves
I n fe r io r a tta c h m e n ts
Superior attachments: spinous processes of C 6 -T 3 , including supraspinous ligaments and ligamentum nuchae
Inferior attachmenls: posterior surfaces of ribs 2 - 5 , near
their angles
Innervation: intercostal nerves (ventral rami T2" 3)
S u p e r io r a tta c h m e n t
Transversus Thoracis
Inferior attachments: inner surfaces of th lower third of
th body of th stemum and adjacent surfaces of th
xiphoid process
Superior attachments: internai surfaces of th cartilages of
ribs 2 to 6
Innervation: intercostal nerves (adjacent ventral rami)
e c t i o n
IV
Lower Extremity
Giunrtriceps
contractinn
E C T
! O
I V
Lower Extremity
C h a r t e r 12: Hip
C h a r t e r 13: Knee
C h a r t e r 14: Ankle and Foot
C h a r t e r 15: Kinesiology of Walking
A e f e n d ix IV: Reference material on innervation and attachments of th muscles of th
lower extremity
386
12
h a p t e r
TOPICS
0 S T E 0 L 0 G Y , 388
Innominate, 388
AT
GLANCE
lliu m , 388
S a g it t a l P ia n e : T h e A n t e r io r a n d
P ubis, 390
P o s t e r io r P e lv ic T ilt, 404
Is c h iu m , 391
A c e ta b u lu m , 391
Femur, 391
"A n g le o f In c lin a tio n ," 392
P e lv ic - o n - F e m o r a l R o ta tio n in th F ro n ta l
P ia n e , 406
P e lv ic - o n - F e m o r a l R o ta tio n in th
H o riz o n ta l P ia n e , 406
Arthrokinematics, 406
ARTHROLOGY, 394
A d d u c t o r s , 413
Hip In te rn a i R o ta to r M u s c le s , 415
INTRODUCTION
V a ra a n d C o x a V a lg a , 429
388
OSTEOLOGY
Iliac crest
Innominate
Eaeh innominate (from th Latin innominatum, meaning
nameless) is th uron of three bones: th ilium, pubis, and
ischium (Figs. 1 2 - 1 and 1 2 - 2 ). The right and left innominates connect with each other anteriorly at th pubic symphysis and posteriorly at th sacrum. The innominate bones
and th sacrum form th bony pelvis (from th Latin, mean
ing basiti or bowl). While a person stands, th pelvis is
normally oriented so that when viewed laterally, a vertical
line passes between th anterior-superior iliac spine and th
pubic tubercle (see Fig. 1 2 - 1 ).
The extemal surface of th innominate has three conspicuous features. The large fan-shaped wing (or ala) of th ilium
forms th superior half of th innominate. Just below th
wing is th deep, cup-shaped acetabulum. Just inferior and
slightly mediai to th acetabulum is th large obturator jo ra men. This foramen is covered by an obturator membrane (see
Fig. 1 2 -2 ).
Iliac fossa
Auricular surface
Iliac tuberosity
ILIUM
The extemal surface of th ilium is marked by rather fairn
posterior, anterior, and inferior gluteal lines (see Fig. 1 2 -1 ).
These lines help to identify attachment sites of th gluteal
muscles to th pelvis. At th most anterior extern of th
ilium is th easily palpable anterior-superior iliac spine (see
Figs. 1 2 - 1 and 1 2 - 2 ) . Below this spine is th anteriorinferior iliac spine. The promi nent iliac crest, th most supe-
Lateral view
Latissimus dorsi
^Vuteus m in imus
Gluteus maximus
Sartorius
W
'J
Ischia! spine
Acetabulum
Rectus femoris
Greater
sciatic notety
fbturator J f
Semimembranosus
Adductor longus
Gracilis
Adductor brevis
Obturator externus
Ischial tuberosity
Adductor
magnus
Quadratus
femoris
Chapter 12
Hip
389
A n t e r io r view
390
P o s te rio r view
Posterior-inferior
iliac spine
Lesser
sciatic notch
Adductor brevis -
f!Il
U hm
FIGURE 12-3. The posterior aspect of th pelvis, sacrum, and righe proximal femur. Proximal attachments ,
Chapter 12
The two pubic bones articulate in th midiine by way of
th fibrocartilaginous pubic symphysis joint. This jo in t typically classified as an amphiarthrosis is lined with hyaline
cartilage and held together by a fibrocartilaginous, interpubic
disc and supportive ligaments. Up to 2 mm of translation
and 3 degrees of rotation occur at th pubic symphysis
jo in t.8385 Structurally, th p u bic sym physis co m p letes th
anterior pelvic ring. As described in Chapter 9, other components that form th pelvic ring are th sacrum, th pair of
sacroiliac joints, and th innominate. The pubic symphysis
provides stress relief throughout th pelvic ring during walking and, in women, during childbirth. The inferior pubic
ramus extends from th body of th pubis posteriorly to th
junction of th ischium (see Fig. 1 2 - 2 ).
ISCHIUM
Hip
391
Femur
The femur is th longest and strongest bone of th human
body (Fig. 1 2 - 4 ). Its shape and robust stature reflect th
powerful action of muscles and contribute to th long stride
length during walking. At its proximal end, th femoral head,
projects m edialy [or an articuation with th acetabulum .
The femoral neck connects th femoral head to th shaft. The
neck serves to dispiace th proximal shaft of th femur
laterally away from th joint, thereby reducing th likelihood
of bony impingement against th pelvis. Distai to th neck,
th femoral shaft courses slightly mediai, thereby placing th
knees and feet closer to th midiine of th body.
A n te r io r view
Obturator internus
and gemelli
ACETABULUM
Located just above th obturator foramen is th large cupshaped acetabulum (see Fig. 1 2 - 1 ) . The acetabulum forms
th socket of th hip. All three bones of th pelvis form part
of th acetabulum: th ilium and ischium contributing 80%
and th pubis th remaining 20%. The speciftc features of
th acetabulum are discussed in th section, Arthrology.
392
M ediai vievv
yPirformis
Fovea-Gluteus medius
'O btu rato r internus
and gemelli
'O bturator externus in
trochanterc tossa
lliopsoas on
lesser trochanter
l/astus m e diate- Pectineus
Adductor brevis
Vastus intermedius -
- Linea aspera
Adductor longus
Adductor magnus
"ANGLE OF INCLINATION"
Articularis genu-
-A dd uctor magnus on
supracondylar line and
-a dductor tuberete
Gastrocnemius
(mediai head)
gazasi
FIGURE 12-5. The mediai aspect of th nghr femur. Proxima! attachments of muscles are indicated in red, distai attachments in
gray. The femoral attachments of th hip joint capsule and th knee
joint capsule are indicated by dashed lines.
The shaft of th femur displays a slight anterior convexity (Fig. 1 2 - 5 ). As a long, eccentrically loaded column,
th lemur bows slightly when subjected to body weight.
As a consequence, stress along th bone is dissipated
through compression along its posterior shaft and through
tension along its anterior shaft. This bowing allows th fe
mur to bear a greater load than if th femur were perfectly
straight.
1
Anteriorly, th intertrochanteric line marks th distai attachment of th capsular ligaments (see Fig. 1 2 - 4 ). The
greater trochanter extends laterali)' and posteriorly from th
junction ol th femoral neck and shaft (Fig. 1 2 - 6 ). This
prominent and easily palpable strutture serves as th distai
"TORSION ANGLE"
The torsion angle of th femur describes th relative rotation (twist) that exists between th shaft and neck of th
femur. Normally, as viewed from above, th femoral neck
projeets on average 10 to 15 degrees anterior to a mediallateral axis through th femoral condyles. This degree of
torsion is called normal anteversion (Fig. 1 2 -9 A ). In conjunction with th normal angle of inclination, a 15-degree
angle ol anteversion affords optimal alignment and joint congruence (see alignment of red dots in Figs. 1 2 -8 A and 1 2 9A).
A torsion angle that is markedly different from 15 degrees
Chapter 12
Hip
393
Posterior view
Superior view
is generally considered abnormal. A torsion angle significantly greater than 15 degrees is calfed excessive anteversion
(Fig. 1 2 -9 B ). In contrast, a torsion angle significantly less
than 15 degrees (i.e., approaching 0 degrees) is in retroversion (Fig. 1 2 -9 C ).
Typically, an infant is bom with about 30 degrees of
tem erai anteversion. 18 With b on e grow th and increased muscle activity, this angle usually decreases to 15 degrees by 6
years of ag.7187 Excessive anteversion is often associated
with congenital dislocation, marked joint incongruence, and
increased wear on articular cartilage. Excessive anteversion in
children may also be associated with an abnormal gait pat
tern called in-toeing.70 In-toeing" is a walking pattern with
exaggerated posturing of hip internai rotation. This gait pat
tern apparently is a compensatory mechanism used to guide
th excessively anteverted femoral head more directly into
394
Angle of inclination
C Coxa Valga
ARTHR0L0GY
Functional Anatomy of th Hip Joint
I he hip is th classic ball-in-socket joint of th body. Extensive Iigaments and large muscles maintain th femoral head
securely in th acetabulum. Thick layers of articular cartilage, muscle, and cancellous bone in th proximal femur
help dampen th large forces that routinely cross th
hip. Failure of any of these protective mechanisms due to
disease or injury often leads io deterioration of th joir.structure.
FEMORAL HEAD
fhe femoral head is located just inferior to th middle
third of th tnguinal ligament. On average, th centers of
th two adult femoral heads are 17.5 cm (6.9 in) apart from
each other. '* The head of th femur forms about twe
thirds of a nearly perfect sphere (Fig. 1 2 - 1 3 ) . Located
slightly posterior to th center of th head is a prommen;
pit, or fovea (see Fig. 1 2 - 5 ) . The entire surface of th
femoral head is covered by articular cartilage, except for
th region of th fovea. The cartilage tends to be thickest
in a broad region above and anterior to th fovea (Fte
1 2 - 1 4 ) .42
Femoral Head
Fovea and ligamentum teres
Acetabulum
Acetabular notch
Transverse acetabular ligament
Acetabular labrum
Lunate surface
Acetabular fossa
Chapter 12
femoral head, th major supply provided by arteries that
course through th joint capsule.
ACETABULUM
The acetabulum is a deep, hemispheric cup-like socket that
accepts th femoral head. The bony rim of th acetabulum is
Hip
395
ACETABULAR ALIGNMENT
B Excessive anteversion
396
Section /V
During prenatal development, th upper and lower extremities both undergo significant axial rotation (Fig. 12-11).
By about 54 days after conception, th lower limbs have
rotated internally (medially) about 90 degrees. This rota
tion turns th knee cap region to its final anterior position.
In essence, th lower limbs have become permanently
"pronated." This helps to explain why th "extensor" muscles such as th quadriceps and tibialis anterior face
anteriorly, and th "flexor" muscles such as th hamstrings and gastrocnemius face posteriorly after birth.
Chapter 12
Hip
397
FIGURE 12-13. The tight hip joint is opened to expose its internai
components.
FIGURE 12-12. A frontal piane cross-section showing ihe internai
Femoral head
Acetabulum
A n te rio r
>2.5 mm
<2.5> 2.0 mm
< 2 .0 > 1 .5 mm
]~]~| <1.5>0 5 mm
<0 5 mm
<1.5>1.0 mm
<1.0 mm
398
3 ~
EVENTS
Initial
heel
contact
8
Foot
fiat
30
40
60
Mid
stance
Heel
off
Toe off
75
85
100
Heel
contact
Center-edge angle
Acetabular anteversion angle
Chapler 12
Hip
399
Anterior view
"Developmental Dysplasia of th Hip": A Case of
Acetabular Malalignment
Posterior view
The iliofemoral ligament is one of th thickest and thus
one of th strongest ligaments of th body. When a person
stands with th hip fully extended, th anterior surface of
th femoral head rests against th iliofemoral ligament. Pas
sive tension in this ligament forms an important stabilizing
force that resists further extension of th pelvis on th fe
mur. Persons with paraplegia often use th passive tension o f
an elongated (or taut) iliofemoral ligament to assist with
standing (Fig. 1 2 -1 9 ).
Although thinner and more circular than th fibers of th
iliofemoral ligament, th pubofemoral and ischtofemoral ligaments blend with and strengthen th inferior and posterior
aspects of th capsule. The pubofemoral ligament attaches
along th anterior and inferior rim of th acetabulum and
adjacent parts of th superior pubic ramus and obturator
membrane (see Fig. 1 2 -1 7 ). The fibers blend with th me
diai fasciculus of th iliofemoral ligament, becoming taut in
hip abduction and extreme extension.
The ischiofemoral ligament attaches from th posterior and
inferior aspects of th acetabulum, primarily from th adja
cent ischium (see Fig. 1 2 -1 8 ). Fibers from this ligament
join circular fibers located deeper within th capsule. Other
hip.
400
Extension
20 of extension (with
knee extended)*
0 (with knee fully flexed)
Abduction
40
Adduction
25
Superior fbers of ischiofemoral ligament, iliotibial band, and abductor muscles such as th tensor fasciae Iatae
Internai Rotation
35
Extemal Rotation
45
Osteokinematics
This section describes th range of motion allowed at th
hip, including th factors that permit and restrict this motion. Reduced hip motion may be an early indicator of hip
disease or trauma, lt is often associated with pain, musei;
Chapter 12
Anterior vicw
lliofemoral
ligament
401
Posterior
Lateral
Ischiofemoral
ligament
Hip
Supcrior vie
Mediai
Anterior
Taut iliofemoral
ligament from
extension
FIGURE 12-20. A, The hip is shown in a neutral position, with all three capsular ligamenis identified. 6, Superior view of th
hip in its close-packed position, i.e., fully extended with slight abduction and internai rotation. This position elongates ai least
some component of all three capsular ligaments.
S P E C I A L
F OCUS
402
scribed from th anatomie posttion. The names of th movements are as folows: flexion and extension in th sagittaJ
piane, abduction and adducton in th frontal piane, and inter
nai and external rotation in th horizontal piane. The term
horizontal ts used with th assumption that a subject is
standing in th anatomie position.
Reporting th range of motion at th hip uses th ana
tomie position as th 0-degree or neutral reference point. In
th sagittal piane, for examp/e, fem oral-on -pelvic flexion is
described by th rotation of th femur anterior to th 0degree position. Extension, th reverse movement, is de
scribed as th rotation o f th femur posterior to th 0-degree
position. The term hyperextension is not used to describe
normal range of motion at th hip.
As dep icted in Figure 1 2 - 2 2 , each pian e o f m otion is
associated with a unique axis of rotation. The axis of rotation for internai and external rotation is often referred to as
th longitudinal axis of rotation. The longitudinal axis of
rotation is also referred to as a vertical axis. The latter description, however, assumes th subject is standing with th
hip in th anatomie position. This axis extends as a line
between th center of th femoral head and th center of th
knee joint. Because of th angle of inclination of th proximal femur and th antenor bowing of th femoral shafl.
FEMORAL-ON-PELVIC OSTEOKINEMATICS
Rotation of th Femur in th Sagittal Piane
On average, with th knee fully flexed, th hip flexes to 120
degrees (Fig. 1 2 -2 3 ).72 Tasks such as squatting and tying a
shoelace typically require near full hip flexion.35 With th
knee extended, hip flexion is limited to about 80 degrees
because of th passive tension within th stretched hamstring and gracilis muscles.10 Full hip flexion slackens most
ligaments, but stretches th inferior capsule.
Posterior..
pelvic tilt ^
T'Anterior
pelvic tilt
ABDUCTION
FLEXION
EXTENSION
ADDUCTON
EXTERNAL
ROTATION
o n -p e iii'^
FIGURE 12-22. The osteokinematics of th righi hip joint Femoral-on-pelvic and pelvic-on-femoral rotations occur in three planes,
depicted as red arrows. The axis of rotation for each piane of movement is shown as a red dot, located at th center of th femoral
head. A, Side view shows sagittal piane rotations about a medial-lateral axis of rotation. B, Front view shows frontal piane rotations about
an anterior-posterior axis of rotation. C, lop view shows horizontal piane rotations about a longitudinal, or vertical, axis of rotation.
Chapter 12
Hip
403
Psoas major
lliofemoral
ligament
lliofemoral ligament
fiaterai fasciculus)
FIGURE 12-23. The approximate maximal range of passive femoral-on-pelvic (hip) motion is depicied in th sagittal piane (A), frontal
piane (B), and horizontal piane (C). Ligaments and muscles, elongated and pulled taut, are indicated by straight black (or dashed)
arrovvs. Slackened tissue is indicated by a wavy black arrow.
404
Contra-directional"
lumbopelvic
rhythm
PELVIC-ON-FEMORAL OSTEOKINEMATICS
Lumbopelvic Rhythm
The lower, caudal end of th axial skeleton is firmly attached
to th pelvis by way of th sacroiliac joints. As a consequence, rotation of th pelvis over th femoral heads typically changes th configuraton o f th lu m bar spine. This
important kinematic relationship is known as lumbopelvic
rhythm, introduced in Chapter 9. This concept is revisited in
this chapter with a focus on th kinesiology at th hip.
Figure 1 2 - 2 4 shows two contrasting types of lumbopel
vic rhythms frequently used during pelvic-on-femoral hip
flexion. Although th kinematics depicted are limited to th
sagittal piane, th concepts apply to pelvic rotations in all
planes.
Figure 1 2 - 2 4 shows an example of an ipsi-directional lum
bopelvic rhythm, where th pelvis and lumbar spine rotate in
th same direction. This movement maximizes th angular
displacement of th entire trunk relative to th lower extremities, and it is useful for activities such as extending th
reaching capacity of th upper extremities. The kinematics of
th ipsi-directional lumbopelvic rhythm are discussed in detail in Chapter 9. In contrast, during contra-directional lumbo
pelvic rhythm, th pelvis rotates in one direction while th
lumbar spine simultaneously rotates in th opposite direction
(Fig. 1 2 -2 4 B ). The important consequence of this move
ment is that th supralumbar trunk (i.e., that part of th
body located above th First lumbar vertebra) can remain
Chapter 12
Hip
EXTENSION
(posterior pelvic tilt)
Slack iliofemorai
FIGURE 12-25. The maximal range of passive pelvic-on-femoral hip motion in ihe sagittal piane (A), frontal piane (Et), and horizonial
piane (C), The motion assumes that th supralumhar trunk remains essentially stationary during th hip motion Ligaments and
muscles elongated and pulled taut are indicated by straight black arrows; tissues slackened are indicated by wavy black arrows.
405
406
desired forward moiion of th supralumbar trunk. The anterior tilt of th pelvis occurs about a medial-lateral axis of
rotation through both femoral heads. While sitting upright
with 90 degrees of hip flexion, th normal adult can achieve
about 30 degrees of additional pelvic-on-femoral hip flexion
before betng restncted by a completely extended lumbar
spine. Full anterior tilt of th pelvis slackens th iliofemoral
ligament and elongates th inferior capsule.
As depicted in Figure 1 2 -2 5 A , th hips can be extended
about 10 to 20 degrees from th 90-degree sitting posture
via a posterior tilt of th pelvis. The lumbar spine flexes or
flailens as th pelvis is tilted. The iliofemoral ligament and
iliopsoas muscle are slightly elongated.
support hip.
Abduction of th support hip occurs by raising or hiking
th iliac crest on th side of th nonsupport hip (Fig.
1 2 -2 5 B ). Assuming that th supralumbar trunk remains stationary, th lumbar spine must bend in th direction opposite th rotating pelvis. A faterai convexity occurs within th
lumbar region toward th side of th abducting hip.
Pelvic-on-femoral hip abduction is restricted to about 30
degrees, pnmarily due to th naturai limits of lateral bending
in th lumbar spine. Severe tightness in th adductor muscles and/or restriction in th pubofemoral ligament limits
pelvic-on-femoral hip abduction. In th event of marked
adductor contracture, th iliac crest on th side of th non
support hip remains lower than th iliac crest of th support
hip, markedly interfering with walking.
Hip adduction of th support hip occurs by a lowering of
th iliac crest on th side of th nonsupport hip. This rnotion causes a slight lateral concavity within th lumbar re
Arthrokinematics
During hip moiion, th nearly spherical femoral head re-1
mains snugly seated within th confnes of th acetabulum. |
The steep walls of th acetabulum, in conjunction with th I
tightly futing acetabular labrum, limit significani translatior1
between th joint surfaces. Hip arthrokinematics are base; I
on th traditional convex-on-concave or concave-on-convex 1
principles (see Chapter 1).
Figure 1 2 - 2 6 shows a highly mechanically based illustra-1
don of a hip opened to enable visualization of th paths of I
articular motion. Abduction and adduction occur across th |
ongitudinal diameter of th joint surfaces (red). With thr I
hip extended, internai and extem al rotation occur across th 1
Femoral head
Lunate surface
o
O
fo r internai and
extemal rotation
CO
for abduction
and adduction
Chapter 12
Hip
407
FIGURE 12-27. The path and generai proximal-to-distal order of muscle innervaiion for th femoral nerve and obturator
nerve (A) and th sciatte nerve (B). The locaiions of certain muscles relative to th joint are altered slightly for clarity.
The roots for each nerve are shown in parenthesis. (Modifed from deGroot J: Correlative Neuroanatomy, 2 lst ed.
Norwalk, Appleton & Lange, 1991.)
Illustratimi continued on following page
408
^Gluteus medius
Superior
gluteal nerve
^ * x ^ T e n s o r fasciae latae
Gluteus mlnimus
'4
. SC IA T IC N ER V E
(L 4~S4)
gemellus interior
Common
peroneal nerve
(L4S2)
B
FIGURE 12-27.
!
Continued
riceps muscle group. The femoral nerve has an extensive sensory distribution covering much of th skin of th
anterior-medial aspect of th thigh. The sensory branches
of th femoral nerve innervate th skin of th anteriormedial aspect of th lower leg, via th saphenous cuianeous
nerve.
/
Chapter 12
Like th femoral nerve, th obturator nerve is formed from
th ventral rami of L2- L 4 nerve roots. Motor branches inner
vate th hip adductor muscles. The obturator nerve divides
into anterior and posterior branches as it passes through th
obturator foramen. The posterior branch innervates th obtu
rator externus and anterior head of th adductor magnus.
The anterior branch innervates part of th pectineus, th
adductor brevis, th adductor longus, and th gracilis. The
obturator nerve has a sensory distribution to th skin of th
mediai thigh.
S a c ra i P le x u s
409
Hip
Superior
410
Adductors
Internai Rotators
Extensors
Abductors
External Rotators
Primary
Primary
Secondary
Primary
Iliopsoas
Tensor fasciae latae
Sartorius
Rectus femoris
Adductor longus
Pectineus
Primary
Adductor longus
Adductor brevis
Pectineus
Gracilis
Adductor magnus
(both heads)
Primary
Secondary
Adductor brevis
Gracilis
Gluteus minimus
(anterior fibers)
Gluteus maximus
Biceps femoris
(long head)
Semitendinosus
Semimembranosus
Adductor magnus
(posterior head)
Gluteus medius
Gluteus minimus
Tensor fasciae latae
Secondary
Biceps femoris
Gong head)
Quadratus femoris
Gluteus maximus
(lower fibers)
Gluteus minimus
(anterior fibers)
Gluteus medius
(anterior fibers)
Tensor fasciae latae
Adductor longus
Adductor brevis
Pectineus
Semitendinosus
Semimembranosus
Gluteus maximus
Piriformis
Obturator intemus
Gemellus superior
Gemellus inferior
Quadratus femoris
Sartorius
Secondary
Piriformis
Sartorius
Secondary
Secondary
Gluteus medius
(posterior fibers)
Gluteus medius
(posterior fibers)
Gluteus minimus
(posterior fibers)
Obturator externus
Biceps femoris
(long head)
Each action assumes a muscle contraction originating from th anatomie position. Many of these muscles will have different actions if they contract from
a position other than th anatomie position.
Chapter 12
411
Hip
Psoas minor
Psoas major
Psoas major
Sartorius (cut)
lliacus
lliacus
Piriformis
lliofemoral ligament
Tensorfasciae latae
Pectineus (cut)
Pectineus
externus
Gracilis
Adductor longus
Gracilis (cut)
Sartorius
Adductor brevis
lliotibial tract
Adductor magnus
Vastus lateralis
Rectus temoris
Vastus medialis
traci (cut)
Rectus femoris (cut)
Vastus medialis (cut)
Sartorius (cut)
412
Femoral-on-pelvic hip flexion is performed through a synergy between th hip flexors and abdominal muscles. This
cooperation is most apparent during activities that require
large amounts of hip flexor force. Consider, for example, th
straight-leg-raise exercise often used to strengthen th ab
dominal muscles. This action requires that th rectus abdominis generate a potent posteror pelvic tilt in order to
neutralize th strong anterior pelvic tilt potential of th hip
flexor muscles (Fig. L 2 -3 1 A ). Without sufficient stabilization
from th rectus abdominis, contraction of th hip flexor
muscles is ineffcienily spent tilting th pelvis anteriorly (Fig.
1 2 -3 1 B ). The excessive anterior tilt of th pelvis accentuates
th lumbar lordosis.
The pathomechanics depicted in Figure 1 2 - 3 1 B are most
severe in situations in which th abdominal muscles are
weak, but th hip flexors remain relatively strong. With th
exception of poliomyelitis or muscular dystrophy, this pat
tern of weakness is relatively rare. More commonly, th
FIGURE 12-30. The force-couple is shown between two representative hip flexor muscles and th erector spinae to anteriorly tilt th
pelvis. The moment arms for th erector spinae and rectus femoris
are indicated by th dark black lines. Note th increased lordosis at
th lumbar spine.
Functional Anatomy
The adductor muscle group occupies th mediai quadrant of
th thigh. Topographically, th adductor muscles are organized into three layers (Fig. 1 2 - 3 4 ). The pectineus, adduc
tor longus, and gracilis occupy th superficial layer. Proximally, these muscles attach along th superior and inferior
pubic ramus and adjacent body of th pubis. Distally, th
pectineus and th adductor longus attach to th posterior
surface of th femur near and along varying regions of th
linea aspera. The long and slender gracilis attaches distally to
th mediai side of th proximal tibia (see Fig. 1 3 - 7 ).
The middle layer of th adductor group is occupied by th
triangular-shaped adductor brevis. The adductor brevis at
taches to th pelvis on th inferior pubic ramus, and to th
fem ur along th proxim al one third o f th linea aspera.
The deep layer of th adductor group is occupied by th
massive, triangular-shaped adductor magnus (see Fig. 1 2 - 2 9
left side, and Fig. 1 2 - 4 0 , right side). This large muscle
attaches prtmarily from th entire ischial ramus and part o:
th ischial tuberosity. From its proxim al attachment, th
adductor magnus forms anterior and posterior heads.
The anterior head o f th adductor magnus has two sets of
fbers: horizontal and oblique. The relatively small set of
horizontally directed fbers crosses from th inferior pubi:
ramus to th extreme proximal end of th linea aspera, often
called th adductor minimus. The Iarger obliquely directed
fbers run from th ischial ramus to nearly th entire length
of th linea aspera, as far distally as th mediai supracondvlar line. Both parts of th anterior head are innervated by th
obturator nerve, which is typical of th adductor muscles
The posterior head o j th adductor magnus consista o f a
thick mass of th fbers arising from th region of th pelvis
adjacent to th ischial tuberosity. From this posterior attach
ment, th fbers run vertically and attach as a tendon on th
adductor tubercle on th mediai side of th distai femur.
The posterior head of th adductor magnus is innervated bv
th tibial branch of th sciatte nerve, as are th hamstring
muscles. Because of a similar location, innervation, and ac
tion as th hamstring muscles, th posterior head is often
referred io as th extensor head of th adductor magnus.
Chapter 12
Hip
413
FIGURE 12 31. The stabilizing role of th abdominal muscles is shown dunng a umlateral straight-leg raise. A, VVith normal
activation of th rectus abdominis, th pelvis is stabilized and prevented from anterior tilting by th pul of th hip flexor
muscles. B, With teduced activation of th rectus abdominis, contraction of th hip flexor muscles causes a marked anterior tilt
of th pelvis. Note th increase in lumbar lordosis that accompanies th anterior tilt of th pelvis. The reduced activation in th
abdominal muscle is indicated by th lghter red.
414
Chapter 12
Superior
Hip
415
FIGURE 12-33. A posterior view depicts th frontal piane line-offorce of several musdes that cross th right hip. The axis of rotation (red) is directed in th anterior-posterior direction through th
femoral head. The abductors are indicated by solid lines and th
adductors by dashed lines.
are mechanically prepared to augment th extensors. In contrast, when th hip is near full extension, they are mechani
cally prepared to augment th flexors. This utilitarian function of th adductors may partially explain their relatively
high susceptibility to strain injury while running.
416
Middle layer
PROXIMAL. ATTACHMENTS
Superficial layer
FIGURE 12-34. The anatomie organization and proximal attachments of th righi adductor muscle gvoup, as seen from a lateral view
through a transparent femur.
The guteus maximus has numerous proximal attachments
from th posterior side of th iliurn, sacrum, coccyx, sacrotuberous and posterior sacroiliac ligaments, and adjacent fas
cia. The muscle attaches into th iliotibial band of th fascia
lata, along with th tensor fasciae latae, and th gluteal
tuberosity on th lemur. The gluteus maximus is a primary
extensor and extemal rotator of th hip.
Chapier 12
Hip
Rectus
femoris
Adductor magnus
Adductor longus
Adductor longus
FIGURE 12-37. A superior view depicts th horizontal piane line-offorce of severa 1 muscles that cross th hip. The longitudinal axis of
rotation is in th superior-inferior direction through th femoral
head. For clarity, th tensor fasciae latae, sartortus, and hamstring
muscles are noi shown. The extemal rotators are indicated by solid
lines and th internai rotators by dashed lines.
417
E x te n s o rs
P e rfo rm in g
P o s te r io r
P e lv ic T ilt .
418
15%
30%
50%
50%
Pattem ,of several muscles of the nghl hip is depicted during various parts of th gaii cycle The hip
heT p lL r i h
T fafCT alae 8 Uler s m
5' anlenor Parts of th giuteus medtus, and adductor longus) are shown rotatine
he pelvis in th honzontal piane over a relatively fixed righi femur. (Compare the bottom and top views.) The tensor fasciae latae and
he glutea muscles function as hip abductors by controlling the frontal piane stability of the pelvis. (The images were prepared from
J T phS f af SK
UbjeCt Wf lk.lng at a relatively fast sPeed of about 1.9 m/s. This relatively fast walking spted has exaggerated the
normal amount of honzontal piane rotation used during walking )
s K
cxaggcraiea ine
H ip E x te n s o rs C o n t r o llin g a F o r w a rd L e a n o f the
B o d y. Leaning forward while standing is a very common
Chapter 12
Hip
419
Gluteus medius
Gluteus medius
Gluteus maximus (cut)
Gluteus maximus
Piriformis
Gemellus superior
internus
Gemellus inferior
femoris
Adductor
maximus (cut)
femoris
1
Semitendinosus
lliotibial tract
Biceps femoris
(long head)
Semitendinosus
Wcut)
SemimembranosusJ
Adductor magnus
Biceps femoris
(short head)
Biceps femoris
(long head) (cut)
Gracilis (cut)
Semitendinosus (cut)
Semimembranosus (cut)
FIGURE 12-41. The force-coupie between representative hip extensors (gluteus maximus and hamstrings) and abdominal muscles
(rectus abdominis and obliquus extemus abdominis) that posteri
ori)' tilt th pelvis. The moment arms for each muscle group are
indicated by th dark black line. Note th decreased lordosis at th
lumbar spine. The extension at th hip stretches th iliofemoral
ligament.
420
S ig n ific a n t fo rw a rd lean
A
A
A
a
o
O
_L
_L
15
30
45
o
J __
60
75
f- fA
Adductor magnus
O Semitendinosus
Body weight
O Gluteus maximus
FIGURE 12-42. The hip extensor muscles are shown controlling a forward lean of th pelvis over th thighs. A, Slight forward
lean of th upper body displaces th body-weight force slightly anterior to th mediai-/alerai axis of rotation at th hip B A
more significaci forward lean displaces th body-wetght force even fanher anteriorly. The greater flexion of th hips rotates
th tschial tuberostes postenorly, thereby mcteasmg th hip extension moment arm of th hamstrings. The tatti Ime (wifh
arrow head within th stretched hamstring muscles) indicates th increased passive tension. In both A and B th relative
demands placed on th muscles are shown by relative shades o f red. At tight is a graph showing th length of hip extension
moment arms of selected hip extensors as a function of forward lean. (Data from Pohtilla JF: Kinesiology of hip extension at
selected angles of pelvilemoral extension. Arch Phys Med Rehabil 50:241-250, 1969.)
Chapter 12
421
Hip
Sacrospinous ligament
superior
medius (cut)
Sacrotuberous ligament
Gemellus inferior
Obturator externus (deep)
Obturator internus
Quadratus femoris
422
HAF
FIGURE 12-45. A frontal piane diagram shows th function of th righi hip abductor muscles dunng single-limb support on th
right hip. On th left, th pelvis-and-trunk are in stane equilibriti about th righi hip. The sum o f th torques in th frontal piane
equal zero. Ihe counterclockwise torque (solid circle) is th product of Lhe hip abductor force (HAF) times moment arm (D)- th
doekwise torque (dashed circle) is th product of body weight (BW) times moment arm (D,). Static stability occurs when HAF X
BVV. X D|; , e see-saw model (righi) simplifies th major kinetic events during single-limb support. A joint reaction force
(JRF) is directed through th fulcrum of th see-saw (hip joint). The sample data in th box are used in th torque and force
equilibnum equations These equattons determine th magnitude of th hip abductor force and joint reaction force needed during
smgle-hmb support. (See text.) Note that for simplicity, th calculations assume static equilibrium and that all force vectors are
acting in a vemcal direction. (From Neumann DA: Biomechamcal analysis of selected principles of hip joint protection Arthntis
Care Res 2:146-155, 1989. Reprirued with permission from Anhritis Care and Research. American College of Rheumatology.)
Chapter 12
Hip
423
424
Standing at rest
FIGURE 12-46. Superior view depicts th oremation and action o f th obturacor intemus muscie. A, While standing at
rest, th obturator intemus muscie makes a 130-degree deflection as it courses through th pulley frmed by th tesser
sciatic notch. B, With th femur fxed dunng standing, contraction of this muscie causes pelvic-on-femoral extemal
rotation. Note that th compression force generated imo th joint is th result of th muscie contraction.
As described for th internai rotators of th hip, th functional potential of th extemal rotators is most evident dur
ing pelvic-on-fem oral rotation. C onsider, for ex am p le, che
right extemal rotator muscles contracting to rotate th pelvis
over th femur (Fig. 1 2 - 4 7 ). With th right lower extremity
firmly in contact with th ground, concentric contraction of
th right extemal rotators accelerates th anterior side of th
pelvis and attached trunk away from th fxed femur. This
horizontal piane action of planting a foot and cutting to th
opposite side is a naturai way to abruptly change direction
while running. If needed, eccentric activation of th internai
rotators may decelerate this action. Extremely rapid coactivation of th adductor muscles to help decelerate extemal
rotation of th pelvis may cause strain injury to these
muscles. The mechanism of injury may further explatn th
relatively high incidence of adductor muscie pulls during
many sporting activities, which involve rapid rotation of th
pelvis-and-irunk while running.
Chapter 12
Hip
425
Transversospinal
muscle
Gluteus medius
(posterior fibers)
Piriform is
Obturator
internus
Quadratus
femoris
Gluteus
maximus
1 TABLE
12-3.
Muscle Group
Extensors
Older Men
(X = 54 yrs)
Younger Women
(X = 27 yrs)
Older Women
(X
53 yrs)
177 (42)
157 (22)
110 (37)
101 (27)
Flexors
152 (50)
113 (21)
91 (24)
67 (21)
Adductors
121 (26)
99 (18)
82 (26)
63 (17)
Abductors
103 (26)
75 (18)
66 (19)
48 (14)
Internai rotators
72 (17)
61 (21)
47 (13)
34 (9)
External rotators
65 (24)
50 (15)
43 (13)
32 (11)
^Standard deviauons in parenthesis. Torques were measured isokineticaffy at 30/sec and then averaged over th fu ll range o f motion. The torques are
presented in order from greatest to least values. Data are based on 72 healthy subjects between 20 and 81 years of age. (Modified from Cahalan TD, Johnson
ME, Liu 5, ef ai: Quantitative measurements o f h ip strength in different age groups C lin O rthop 246: 1 3 6 -1 4 5 , 1989.)
Conversion: 1 36 N m = l ft-lb
426
100
UJ
RIGHT HIP
80 T- -
o
o
70
--
50
--
LEFT HIP
- -
40
30
10
10
20
30
Loss o f Balance
I
Failure of Protective Reflexes
(e.g., slowed reaction time, sedation, dementia, muscle weakness)
I
Fall
1
Potential Energy Dissipated Primarily over Hip Region
i
Failure of Locai Shock Absorption
(e.g., reduced fat around hip, weakness/atrophy of hip mus
cles, hard impact surface)
l
Diminished Strength of Bone
(e.g., osteoporosis, thinned bone cortex, loss of major trabecufae)
!
Fractured Hip
HIP ANGLE
FIGURE 12-48. This plot shows che ctteci o f /roncai piane range o f
hip motion on ihe maximal effori, isometric hip abductor torque in
30 healthy persona. The 10-degree hip angle represems a fully
adducted position where che muscles are at a relaiively long length
(Data from Neumann DA, Soderberg GL, Cook TM: Comparison of
maxima! isometric hip abductor muscle torques between hip sides.
Phys Ther 68:496-502, 1988.)
From C um m ings SR, N evai MC: A hypothesis: The causes of hip frac
Pain
Synovitis
Loss of joint space
Muscle atrophy
Hypcrtrophic bone formadon
Reduced range of motion
Abnormal gait
Chapter 12
Hip osteoarthritis may be classified as either a primary
or secondary disease. Primary or idiopathic hip osteoarthritis
refers to an arthritic condition without a known cause. Sec
ondary hip osteoarthritis, in contrast, refers to an arthritic
condition resulting from a known mechanical disruption
of th joint. This may occur from trauma, structural failure
such as slipped capitai femoral epiphysis, anatomie asymmetry such as excessive acetabular anteversion, leg length
discrepancy, avascular necrosis of th femoral head (i.e.,
Legg-Calv-Perthes disease), or congenital dislocation. Persons who perform heavy physical work are more likely to
require hospitalization because of osteoarthritis of th
hip.82
T h e ra p e u tic In te rv e n tio n fo r a P a in fu l o r S tru c tu ra lly
U n s ta b le H ip
Hip
Counterclockwise
torque
Clockwise
torque
FIGURE 12-49. A frontal piane diagram shows how a cane force (CF) applied by th left hand produces a frontal piane torque
about th right hip in single-limb supporr. This cane-produced torque can minimize th torque demands on th right hip abductor
muscles. Note that th clockwise torque (dashed circle) due to body weight (BW X D,) is balanced by th counterclockwise torques
(solid circles) due to th hip abductor force (HAF X D) and th cane force (CF X D2). The data shown in th box are used in th
torque and force equilibrium equations to solve for hip abductor force and joint reaction force (JRF). The moment arm used by
cane force is represented by D2. (See Fig. 1 2 - 4 5 for additional abbreviations and background.) For simplicity, th calculations in
th inset assume static equilibrium and that all force vectors are acting in a vertical direction. (From Neumann DA: Hip abductor
muscle activity in persons with a hip prosthesis while carrying loads in one hand. Phys Ther 7 6 :1 3 2 0 -1 3 3 0 , 1996. With
permission of th APTA.)
427
428
Clockwise torque
FIGURE 12-50. A frontal piane diagram shows how a load held in th left hand significantly increases th
amount of righi hip abductor force (HAF) dunng single-limb support. Two clockwise torques (dashed circles)
are produced about th righi hip due to body weight (BW X D.) and th contralaterally held load (CL X DA
For equ.libnum about th nght hip, th clockwise torques must be balanced by a counterdockwise torque (sofid
frre ePr S C
>'
P
T
(HAF X D)' The data shown in lhe box
used in th torque and
orce equilibrami equations lo solve for hip abductor force and joint reaction force (JRF). D, is equal to the
moment arm used by th contralateral-held load (CL). Refer to Figure 1 2 - 4 5 for background and other
abbreviauons. For simplicity, the calculations assume stane equilibrium and that all force vectors are aciine in
vertica! direct,ons. (From Neumann DA: Hip abductor muscle ac.ivity m persons with a hip p r o s t L is whik
carrying loads in one hand. Phys Ther 7 6 :1 3 2 0 -1 3 3 0 , 1996. With permission of the APTA.)
Chapter 12
Hip
429
FIGURE 12-51. X-rays show two common forms of internai fixation for treatment of a fratture of th proximal
femur. A, A compression screw s used to repair an intertrochanteric fratture. The screw is designed like a piston,
compressing slightly when under th load of body weight. The compression increases bone-to-bone contact across
th fratture site. B, Three pins are used to stabilize a fratture through th femoral neck. (Courtesy of Michael
Anderson, M.D., Blount Orthopedic Clinic, Milwaukee, Wl.)
materiali (Fig. 12-52). A prosthetic hip is secured by cement or through biologie fixation, provided by bone growth
into th surface of th implanted components. Although th
total hip arthroplasty is typically a successful procedure, pre
mature loosening of th femoral and/or acetabular compo
rne/ can be a postoperative problem.28 farge torsional
loads between th prosthetic implant and th bony interface
may contribute to th loss of fixation.5 Until sufficient longterm data emerge from clinical trials, debate regarding th
most durable materials and effettive methods of fixation continue.
Biomechanical Consequences of Coxa Vara and Coxa Valga
The average angle of inclination of th femoral neck is 125
degrees. The angle may be changed as a result of a surgical
repair o f a fractured hip o r an angle o f inclination designed
into a prosthesis. Additionally, an operation known as a coxa
vara (or valga) osteotomy intentionally alters a preexisting
angle of inclination. This operation involves cutting a wedge
of
healing.
A total hip arthroplasty is often indicated when a person
with hip disease, most often osteoarthritis, has Constant pain
lim it e d
u n ti1 t h
fr a c tu r e s it e
s h o w s a m p ie
e v id e n c e
430
Chapter 12
Hip
431
A : POSITIVE
C:
1. Increased moment
arm (D ) fo r hip
abductor force.
1. Decreased bending
moment arm (T)
decreases bending
moment (ACF x I");
decreases shear force
across femoral neck.
2.
B : NEGATIVE
1. Increased
bending
moment arm (I')
increases bending
moment (ACFx I');
increases shear force
across femoral neck.
POSITIVE
Increased functional
length of hip abductor
muscle.
D : NEGATIVE
1. Decreased moment
arm (D ) fo r hip
abductor force.
2. Alignment may favor
joint dislocation.
2. Decreased functional
length of hip abductor
muscle.
FIGURE 12-54. The negative and positive biomechanical effects of coxa vara and coxa valga are contrasted. As a reference, a hip with a
normal angle of inclination ( a = 125 degrees) is shown in th center of th display. D is th internai moment arm used by hip
abductor force; 1 is th bending moment arm across th femoral neck.
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Chapter 12
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Knee
Donald A. Neumann, PT, P h D
TOPICS
0STE0L0GY, 435
Distai Femur, 435
Proximal Tibia and Fibula, 435
Patella, 437
ARTHROLOGY, 438
General Anatomie and Alignment
Considerations, 438
Capsule and Related Structures, 438
AT
G LANCE
A n a t o m ie C o n s id e r a t io n s , 455
Q u a d r ic e p s A c t io n a t th K n e e :
U n d e r s t a n d in g th B io m e c h a n ic a l
I n t e r a c t io n s B e t w e e n E x te rn a l a n d
I n te rn a i T o r q u e s , 456
P a t e llo f e m o r a l J o in t K in e t ic s , 457
F u n c t io n a l C o n s id e r a t io n s , 454
INTRODUCTION_______________________
The knee consists of th lateral and mediai tibiofemoral
joints and th patellofemoral joint (Fig. 1 3 - 1 ). Motion at
th knee occurs in two planes, allowing flexion and exten
sion in th sagittal piane, and internai and external rotation
in th horizontal piane. Functionally, however, these movements rarely occur independent of movement at other joints
of th lower limb. Consider, for example, th interaction
among th hip, knee, and ankle during running or climbing
or standing from a seated position. The strong functional
association within th joints of th lower limb is reflected by
th fact that most muscles that cross th knee also cross
either th hip or ankle.
The knee has important biomechanical functions, many of
which are expressed during walking and running. During
434
Chapter 13
Knee
435
0STE0L0GY
Distai Femur
At th distai end of th femur are th large lateral and mediai
condyles (from th Greek kondylos, knuckle) (Figs. 1 3 - 2 to
1 3 -4 ). Lateral and mediai epicondyles project from each condyle, providing elevated attachment sites for th collateral
ligaments. A large intercondylar notch separates th lateral and
mediai condyles, forming a passageway for th cruciate liga
ments (Fig. 1 3 - 4 ). Interestingly, a narrower than average
notch may increase th likelihood of injury to th anterior
cruciate ligament.106
Articular cartilage covers much of th surface of th femoral condyle. The articular surface for th tibia follows a curve
that is a flat-to-convex path from front to back (Fig. 1 3 - 5 ).
The most distai end of each femoral condyle is nearly fiat,
thereby increasing th area for weight hearing.
Lateral and mediai grooves are etched faintly in th carti
lage of th femoral condyles (see Fig. 1 3 - 4 ). When th knee
is fully extended, th anterior edge of th tibia is aligned
with these grooves. The position of th grooves highlights
th asymmetry in th shape of th mediai and lateral articu
lar surfaces of th femur. The mediai surface curves slightly
laterally from back to front, and extends farther anteriorly
than th lateral articular surface. As explained later in this
chapter, th asymmetry in shape of th condyles affects th
sagittal piane kinematics.
436
Anterior view
Intercondylar groove
Lateral epicondyle
lliotibial tract on
lateral condyle
Adductor tubercle
Mediai epicondyle
Styloid process
Mediai condyle
Biceps femoris
Proximal
tibiofibular joint
Peroneus longus
Extensor
digitorum longus
Attachment of
patellar ligament
G racilis-
Posterior view
Sartorius
-P e s
anserinus
SemitendinosusJ
tendons
yemu/Plantaris
Adductor tubercle
Extensor hallucis
longus
Tibialis anterior
Gastrocnemius
(mediai head)
Gastrocnemius
(lateral head)
Lateral epicondyle
Mediai epicondyle
Popliteus
Semimembranosus
Styloid process
Intercondylar notch
Proximal
tibiofibular joint
Peroneus brevis
Interosseous membrane
Soleus
Peroneus tertius
Soleal line
Distai
tibiofibular joint
Lateral malleolus
Flexor hallucis
longus
Mediai malleolus
Peroneus brevis
Tibia
Fibula
Proximal Fibula
Head
Proximal Tibia
Mediai and lateral condyles
Intercondylar eminence
Anterior intercondylar fossa
Posterior intercondylar fossa
Tibia! tuberosity
Soleal (popliteal) line
Chapter 13
fa c e t
L a te ra l fa c e t
M e d ia i g r o o v e
In te rc o n d y la r g r o o v e
(in c a rtila g e )
Knee
4.37
L a te ra l g r o o v e
(in
M e d ia i e p ic o n d y le
Patella
L a te ra l e p ic o n d y le
c o n d y le
L a te ra l c o n d y le
P o s t e r io r
In te rc o n d y la r
in te r c o n d y la r f o s s a
e m in e n c e
(w ith
c o n d y le
L a te ra l c o n d y le
A n te r io r
in te r c o n d y la r f o s s a
The patella (from th Latin, small piate) is a nearly triangular-shaped bone embedded within th quadriceps tendon. lt
is th largest sesamoid bone in th body. The patella has a
curved b a s e superiorly and a pointed a p e x inferiorly (Figs.
1 3 - 6 and 1 3 - 7 ) . In a relaxed standing position, th apex of
th patella lies just proximal to th knee joint line. The
subcutaneous a n t e r io r s u r fa c e of th patella is convex in all
directions. The base of th patella is rough due to th at
tachment of th quadriceps tendon. The patellar ligament
attaches between th apex of th patella and th tibial tuber
osity.
Base
Apex
Anterior surface
Posterior articular surface
Vertical ridge
Lateral, mediai, and odd facets
L a te r a l view
G a s tr o c n e m ii/ s
(la te ra l h e a d )
L a te ra l c o lla te ra l
lig a m e n t
P o p lit e u s
llio t ib ia l
traci
B ic e p s fe m o r is
P r o x im a l t ib io f ib u la r
L a te ra l c o lla te ra l lig a m e n t
jo in t
P o s te rio r
A n t e r io r
Patellar ligament
P e r o n e u s lo n g u s
V e rtic a l rid g e
T ib ia lis a n te r io r
L a te ra l fa c e t
p a te lla r lig a m e n t
438
Section IV
Lower Extremity
L a te ra l p a te lla r r e t in a c u la r fib e r s
/wLir
L a te ra l c o lla te ra l lig a m e n t
tP1'
jj---------- M e d ia i
T e n d o n o f b ic e p s fe m o r is (c u t) ------- l
c o lla te ra l lig a m e n t
M e d ia i p a te lla r
retinacular fib e rs
S e m it e n d in o s u s - i
G r a c ilis
S a r t o r iu s
P e s a n s e r in u s
te n d o n s (cu t)
A n t e r io r t lb io f ib u la r lig a m e n t
P a te lla r lig a m e n t
ARTHROLOGY
General Anatomie and Alignment
Considerations
NORMAL ALIGNMENT OF THE KNEE
The shaft of th femur angles slightly medially as it descends
toward th knee. This oblique orientation is due to th
naturai 125-degree angle of inclination of th proximal fe
mur (Fig. 1 3-8A ). Because th articular surface of th proxi
mal tibia is oriented nearly horizontal, th knee forms an
angle on its lateral side of about 170 to 175 degrees. This
normal alignment of th knee within th frontal piane is
referred to as genu vagum.
Variation in normal frontal piane alignment ai th knee is
not uncommon. A lateral angle less than 170 degrees is
called excessive genu valgum, or "knock-knee" (Fig. 138B).
In contrast, a lateral angle that exceeds about 180 degrees is
called genu varum, or bow-leg (Fig. 1 3 -8 C ).
The longitudinal or vertical axis of rotation at th hip is
defned in Chapter 12 as a line connecting th femoral head
with th center of th knee joint. As depicted in Figure 1 3 -
Chapter 13
N o r m a l g e n u v a lg u m
G e n u varu m
g e n u v a lg u m
( b o w - le g )
(kn o ck -kn e e )
Knee
439
440
Section IV
TABLE
13-1.
Lower Extremity
L ig a m e n ts ,
Region of th
C a p s u le
Anterior
Muscular-Tendinous Reitiforcement
Quadriceps
Lateral
Biceps femoris
Tendon of th popliteus
Lateral head of th gastrocnemius
Posterior
Popliteus
Gastrocnemius
Hamstrings
Posterior-lateral
Tendon of th popliteus
Mediai
Tibiofemoral Joint
ARTICULAR STRUCTURE
Bony Fit
The mediai and lateral tibiofemoral joint consists of th articulations between th large, convex femoral condyles and
th nearly fiat and smaller tibial condyles. The large surface
area of th femoral condyles permits extensive knee motion
in th sagittal piane for activities such as running, squatting,
and climbing. Joint stability ts provided not by a tight congruous bony' fit, but by forces and physical containment
provided by muscles, ligaments, capsule, menisci, and body
weight.
L a te r a l view
Menisci
Anatomie Considerations
The mediai and lateral menisci are crescent-shaped, hbrocartilaginous discs located within th knee joint (Fig. 1 3 -1 2 ,4
and B). The menisci transform nearly fiat articular surfaces of
th tibia into shallow seats for th femoral condyles.
The menisci are anchored to th intercondylar region of
th tibia by their anterior and posterior homs. The extemal
edge of each meniscus is attached to th tibia and th adjacent capsule by coronary (or meniscotibial) ligaments (see Fig.
1 3 -1 2 A ). The coronary ligaments are relatively loose
thereby allowing th menisci, especially th lateral, io pivot
freely during movement. A slender transverse ligament conneets th two menisci anteriorly.
Severa 1 muscles have secondary attachments mto th
menisci. The quadriceps and semimembranosus attach to
both menisci.67 The popliteus attaches io th lateral menis
cus. Through these attachments, th muscles help stabilize
th position of th menisci during active knee movement.
Blood supply to th menisci is greatest near th peripheral (extemal) border. Blood comes from capillaries located
within th adjacent synovial membrane and capsule.18 The
internai border of th menisci, in contrast, is essentially
avascular. The menisci are essentially aneural, except near
their homs.
Ihe two menisci have different shapes and methods of
Q u a d ric e p s
G a s t r o c n e m iu s -
te n d o n
la te ra l h e a d (cu t)
L a te ra l c o lla te ra l
lig a m e n t
L a te ra l m e n is c u s
T e n d o n o f p o p lite u s
B ic e p s fe m o r is (cu t)
L a te ra l p a te lla r
re t in a c u la r fib e rs
T ib ia lis a n te r io r
niijn E x te n s o r d ig ito ru m
lo n g u s
Chapter 13
Knee
441
Posterior view
S e m im e m b r a n o s u s
G a s t r o c n e m iu s - m e d ia l h e a d
(cu t)
P la n t a r is (cu t)
G a s t r o c n e m iu s - la t e r a l h e a d
(cu t)
G r a c ilis
S a r t o r iu s
M e d ia i c o lla te ra l lig a m e n t
(a tta c h in g to m e d ia i m e n is c u s )
L a te ra l c o lla te r a l lig a m e n t
S e m im e m b r a n o s u s
A rc u a t e p o p lite a l lig a m e n t
O b liq u e p o p lite a l lig a m e n t
P o s t e r io r t ib io f ib u la r lig a m e n t
F a s c ia i e x te n s io n o f
s e m im e m b r a n o s u s
M ediai view
Q u a d r ic e p s te n d o n
S e m im e m b r a n o s u s
M e d ia i p a te lla r
P o s t e r io r i
I M e d ia i
A n t e r io r
C 0 ||ate ra l
re t in a c u la r fib e r s
lig a m e n t
P a te lla r lig a m e n t
P es
a n s e r in u s
| S a r t o r iu s ( c u t )
|
V
te n d o n sH
G r a c ilis (cu t)
- S e m it e n d in o s u s
442
Section IV
Dnver Extremity
T A B L E
JlL
S P E C I A L
F O C U S
1 3 -
Intertissue Ju n ctio n
Exam ples
D u r in g e m b r y o n ic d e v e lo p m e n t , t h k n e e e x p e r ie n c e s
S e m im e m b r a n o su s b u r s a between
th tendon of th semimembra
nosus and mediai condyle of th
tibia
Bone and muscle
S u p r a p a t e lla r b u rs a between th fe
p o s t e r io r m e n is c o fe m o r a l lig a m en t
Functonal Considerations
s ig n if ic a n t p h y s ic a l t r a n s f o r m a t io n . M e s e n c h y m a l t is s u e s t h ic k e n a n d t h e n r e a b s o r b , f o r m in g p r im it iv e c o m p a r t m e n t s , lig a m e n t s , a n d m e n is c i. I n c o m p le t e r e s o r p t io n o f m e s e n c h y m a l t is s u e d u r in g d e v e lo p m e n t f o r m s
t is s u e s k n o w n a s
plicae.23 P lic a e ,
o r s y n o v ia l p le a t s ,
a p p e a r a s f o ld s in t h s y n o v ia l m e m b r a n e s . P l i c a e m a y
b e v e r y s m a ll a n d u n r e c o g n iz a b le , o r s o la r g e t h a t t h e y
n e a r ly s e p a r a t e t h k n e e in to m e d ia i a n d la t e r a l c o m p a r t m e n t s . P l i c a e r e in f o r c e t h s y n o v ia l m e m b r a n e o f
th k n ee .
T h r e e p lic a e in t h k n e e a r e t h (1) s u p e r io r o r
s u p r a p a t e lla r p lic a , (2) in t e r io r p lic a ( f ir s t c a lle d lig a m e n t u m m u c o s u m b y V e s a l i u s in 15 15 ),23 a n d (3) m e d ia i
p lic a . T h e m o s t p r o m in e n t m e d ia i p lic a is k n o w n b y
a b o u t 20 n a m e s , in c lu d in g a la r lig a m e n t , s y n o v ia lis p a t e lla r is , a n d in t r a a r t ic u la r m e d ia i b a n d . P li c a e e x is t in
a p p r o x im a t e ly 25 to 50% o f k n e e s .
P li c a e t h a t a r e u n u s u a lly la r g e , o r a r e t h ic k e n e d o w in g to ir r it a t io n o r t r a u m a , c a u s e k n e e p a in . T h e m e d ia i
p lic a is m o s t c o m m o n ly in v o lv e d w it h a p a in f u l p lic a
s y n d r o m e . T r e a t m e n t in c lu d e s r e s t, a n t i- in f la m m a t o r y
m e d ic a t io n , is o m e t r ic e x e r c is e , a n d a r t h r o s c o p y r e s e c tio n .
M enisci as Shock Absorbcrs. While walking, compression forces at th knee joint routinely reach approximately 2
to 3 times body weight. Forces as high as nine times body
weight may occur during maximal-effort isokinetic knee extension.88 By nearly tripling th area of joint contact, th
menisci significanti reduce pressure (i.e., force per una
area) on th articular cartilage.103 A complete lateral meniscectomy increases th peak contact pressures by 230% ,91
which likely increases th risk of developing stress-related
arthritis. Surgically repairing a meniscus instead of removing
it is clearly th treatment of choice.102
The menisci supporr about half th total load across th
knee.68 At every step, th menisci deform peripherally as
they are compressed.108 This mechanism allows part of th
compression force at th knee to be absorbed as a circumferential tension throughout each meniscus. A torn meniscus
therefore loses its capacity to absorb loads.
Chapter 13
Knee
443
Superior view
.G a s tro c n e m iu s ( m e d ia i he a d )
G a s t r o c n e m iu s fia te ra i he a d )
P la n ta riS '
S e m it e n d in o s u s
S e m im e m b r a n o s u s
B ic e p s fe m o r is
G r a c llis
P o p lit e u s te n d o n
S a r to r iu s
L a te ra l c o lla te ra l lig a m e n t
P o s t e r io r m e n is c o fe m o r a l
M e d ia i c o lla te r a l lig a m e n t
lig a m e n t
P o s t e r io r c r u c ia te lig a m e n t
L a te ra l m e n is c u s
llio t ib ia l tra c t
M e d ia i m e n is c u s
A n t e r io r c r u c ia te lig a m e n t
T r a n s v e r s e lig a m e n t
C o r o n a r y lig a m e n t
P o s t e r io r c r u c ia te lig a m e n t
In fra p a te lla r fat
P a te lla r lig a m e n t
h o r n s o t m e d ia i m e n is c u s
h o r n s o f la te ra l m e n is c u s
A n t e r io r c r u c ia te lig a m e n t
444
Section IV
Lower Extremity
Posterior vievv
S P E C I A L
F O C U S
1 3 - 2
A n t e r o r c r u c ia te
lig a m e n t
T e a r s o f t h m e n is c u s o f te n o c c u r b y f o r c e f u l, h o r iz o n t a l p ia n e r o t a t io n o f t h f e m o r a l c o n d y le s o v e r a p a r t ia lly f le x e d a n d w e ig h t - b e a r in g k n e e . T h e t o r s io n w it h in
t h c o m p r e s s e d k n e e c a n p in c h a n d d is lo d g e t h m e
n is c u s . A d is lo d g e d o r f o ld e d f la p o f m e n is c u s c a n
M e d ia i c o lla te ra l
lig a m e n t
L a te ra l c o lla te ra l
b lo c k k n e e m o v e m e n t , c a u s in g t h " lo c k e d - k n e e " s y n -
lig a m e n t
d ro m e .
P o p lit e u s te n d o n
M e d ia i m e n is c u s
(cu t)
L a te ra l m e n is c u s
P o s t e r io r
T h e m e d ia i m e n is c u s is in j u r e d m o r e f r e q u e n t ly t h a n
t h la t e r a l m e n is c u s . T h e m e c h a n is m o f in j u r y o fte n
in v o lv e s a n e x t e r n a l f o r c e a p p lie d t o t h la t e r a l a s p e c t
" v a lg u s
m e n is c o fe m o r a l
f o r c e " c a u s e s a n e x c e s s i v e v a lg u s p o s it io n o f t h
lig a m e n t
k n e e a n d s u b s e q u e n t ly s t r a in s t h m e d ia i c o lla t e r a l lig a
P o s t e r io r c r u c ia te
lig a m e n t
m e n t. T h e m e d ia i m e n is c u s m a y t e a r a s it is s t r e t c h e d
b e t w e e n t h c o m p r e s s e d j o in t s u r f a c e s a n d it s c o n n e c
t io n t o t h t a u t m e d ia i c o lla t e r a l lig a m e n t .
A Tibial-on-femoral perspective
B Femoral-on-tibial perspective
FIGURE 13-14. Sagittal piane motion at th knee. A, Tibial-on-femoral perspective. B, Femoral-on-tibial perspeclive.
Chapter 13
Knee
445
Tibial-on-femoral rotation
Femoral-on-tibial rotation
Knee
external
rotation
Knee
internai
rotation
K nee flexed 30
Anterior
Mediai
ial H
Superior view
Lateral
Posterior
FIGURE 13-15. Horizontal piane (axial) rotation at th knee. A, Tibial-on-femoral rotation. B, Femoral-on-tibial rotation.
OF TH E KN EE
FIGURE 13-16. The flexing knee generates a migrating medial-lateral axis of rotation. This migration is described as th evolute.
446
Section IV
Lower Extremitv
A C T IV E FLE X IO N
OF THE KN EE
The arthrokinematics of active knee flexion occur by a reverse fashion depicted in Figure 1 3 -1 7 A and B. To unlock a
knee that is fully extended, th joint must first internali)'
rotate. This action is driven primarily by th popliteus mus
cle. The muscle can rotate th femur extemally to initiate
temoral-on-iibial flexion, or rotate th tibia internally to initi
ate tibial-on-femoral flexion.
A. Tibial-on-femoral extension
IN T E R N A L A N D
THE KNEE
E X T E R N A L (A X IA L ) R O T A T IO N
OF
Patellofemoral Joint
The patellofemoral joint is th interface between th articular
side of th patella and th intercondylar groove on th fe
mur. The quadriceps muscle, th articular joint surfaces, and
th retinacular fibers stabilize th joint (see Fig. 1 3 -7 ). As
th knee flexes and extends, th articular surface of th
patella slides over th intercondylar groove of th femur.
During tibial-on-femoral flexion, th patella slides against th
femur; during femoral-on-tibial flexion, th femur slides
against th patella.
P A T E L L O F E M O R A L JO IN T K IN E M A T IC S
K. Femoral-on-tibial extension
FIGURE 13-17. The active arthrokinematics of knee extension. A, Tibial-on-femoral perspective. B, Femoral-on-tibial perspective.
In both A and B, th meniscus is pulled toward th contracting quadriceps.
C h a p t e r 13
1. S h a p e o f m e d ia i
fe m o r a l c o n d y le
2. T e n s io n in a n te r io r
c r u c ia te lig a m e n t
3 . L a te ra l p u l
o f q u a d r ic e p s
E x te rn a l ro ta tio n
K n ee
447
E x te n s io n
Collateral Ligaments
A N A T 0 M IC
C 0 N S ID E R A T I0 N S
F U N C T I0 N A L C O N S ID E R A T IO N S
448
Section IV
Lower Extremity
B. Knee flexed 90
C. Knee flexed 20
V a stu s
m e d ia lis
V a s tu s
la te ra lis
L a t e r a lf a c e t
O dd
M e d ia i
P a te lla r lig a m e n t
FIGURE 13-19. The kinematics ai th patellofemoral joint during active tibial-on-femoral extension. The circle depicted in A - C
indicates th point of maximal contact between th patella and th femur. As th knee is extended, th contact point on th patella
migrates from its superior pole to its inferior pole. Note th suprapatellar fat pad deep to th quadriceps. D and E show th path
and contact areas of th palella on th intercondylar groove of th femur. The values 135, 90, 60, and 20 degrees indicate flexed
positions of th knee.
Chapter 13
Knee
449
Varus Force
Primary restraint
Secondary restraint
Mediai capsule
Posterior-medial capsule (includes semimembranosus tendon)
Anterior and posterior cruciate ligaments
Bony contact laterally
Compression of th lateral meniscus
Mediai retmacular fibers
Pes anserinus (i.e., tendons of th sartorius, gracilis,
and semitendinosus)
Gastrocnemius (mediai head)
Mediai view
450
Seclion IV
Lower Extremity
Fu nction (s)
Mediai collateral
ligament
Lateral collateral
ligament
Posterior capsule
Anterior cruciate
ligament
1. Hyperextension of th knee
2. Large valgus force with foot planted
3. Either of th above combined with large internai
axial rotation torque (e.g., th fernur forcefully
extemally rotates over a fixed tibia)
Posterior cruciate
ligament
1. Hyperflexion of th knee
2. Dashboard injuries with excessive posterior
translation of th tibia relative to th fernur
3. Severe hyperextension of th knee with a gapping
of th posterior side of th joint
4. Large valgus or varus force with foot planted
5. Any of th above combined with large axial rota
tion torque
A. Lateral vievv
B. Anterior view
I n te rc o n d y la r g r o o v e
(to r p a te lla )
A n te r io r c r u c ia te lig a m e n t
P o s t e r io r c r u c ia te
lig a m e n t
FIGURE 13 21. The anterior and posterior cruciate [igaments. A, Lateral view. B, Anterior view. The two fiber bundles within th
antenor cruciate ligament are evident in A.
Chapter 13
A N T E R IO R C R U C IA T E L IG A M E N T
Functional Anatomy
The anterior cruciate ligament (AGL) attaches along an
approximate 30-mm impression on th anterior intercondylar area of th tibia] plateau.36 From this attachment, th
ligament runs obliquely in a posterior, slightly superior,
and lateral direction to attach on th mediai side of th
lateral femoral condyle (see Fig. 1 3 -2 1 A and B). The collagen fibers within th AGL twist upon one another, thereby
forming spiraling fascicles, or bundles. The bundles are
often referred to as posterior-lateral and anterior-medial,
named according io their relative attachment on th tibia.36
The posterior-lateral bundle is th main component of th
ACL.
The length and orientation of th twisting ACL change
as th knee joint rotates. Although some fibers of th
ACL remain taut throughout th full range of motion, most
fibers, especially within th posterior-lateral bundle, become
more taut as th knee approaches full extension (Fig. 1 3 22A).'W Along with th posterior capsule, collateral ligaments, and hamstring muscles, th ACL produces useful
tension that helps stabilize th extended or near-extended
knee.
o f th ACL provides a wide range o f stabifity, il also predisposes th person to ligament injury. As listed in Table 1 3 - 4 ,
th ACL is pulled taut as a result of many tibial-on-femoral
or femoral-on-tibial movements. One finding common to
many ACL injuries is a high-velocity stretch while th liga
ment is under tension. This may occur, for example, when
th foot is firmly planted and th femur is vigorously externally rotated and/or translated posteriorly. As noted by observing a skeletal model or Figure 1 3 - 2 1 , this movement in
conjunction with a valgus force can elongate and potentially
tear th ACL.
Another common mechanism for injuring th ACL in
volves excessive hvperextension of th knee while th foot
:s planted on th ground. Very large forces produced by
Knee
451
Functional Anatomy
The posterior cruciate ligament (PCL) provides another important source of resistance to th anterior-posterior shear
forces at th knee. Slightly thicker than th ACL, th PCL
attaches from th posterior intercondylar area of th tibia to
th lateral side of th mediai femoral condyle (see Figs. 1 3 12A and B, 1 3 - 1 3 , and 1 3 -2 1 A and B). The course of this
ligament is more vertical and slightly less oblique than that
of th ACL.
The specific anatomy of th PCL is variable. It has two
bundles: a larger anterior set (anterior-lateral), forming th
bulk of th ligament, and a smaller posterior set (posteriormedial).15-4284
Two accessory components of th PCL are often present.
In about 70% of knees, either an anterior menisco femoral
ligament or a posterior meniscofemoral ligament is present.45
These ligaments have a mass of only 20% of th PCL and,
therefore, play a minor role in stability. Figures 1 3 -1 2 A and
1 3 - 1 3 show a segment of th more common posterior men
iscofemoral ligament, originating from th lateral meniscus
and blending into th posterior fibers of th PCL.
Like th ACL, some fibers within th PCL remain taut
throughout th entire range of motion. The majority of th
ligament (i.e., th larger anterior fibers), however, becomes
taut at th extremes of flexion.36 As depicted in Figure 1 3 2 2 C, th PCL is pulled taut by th hamstring muscle contraction and subsequent posterior slide of th tibia. Adding a
forceful quadriceps contraction to an existing hamstring contraction reduces th tension and stretch on th PCL.48
One of th most common exams of th integrity of th
PCL is th posterior drawer test. This test involves pushing
th leg posteriorly with th knee flexed to 90 degrees (Fig.
1 3 -2 2 D ). Normally, th PCL provides about 95% of th
total passive resistance to th posterior translation of th
tibia.11 Ollen, following a PCL injury, th tibia sags posteri
orly against th femur. This observation, in conjunction with
a positive posterior drawer sign, suggests a ruptured PCL.
Another important function o f th PCL is to limit th
extern of anterior translation of th femur over th fxed
tibia. Activities, such as rapidly descending into a squat
and landing from a jump with knee partially flexed, create
a large anterior shear force on th femur against th tibia.
The femur is held from sliding off th anterior edge of
th tibia by forces in th PCL, joint capsule, and muscle.
The popliteus muscle, by Crossing th posterior side of th
knee, may share a portion of th force naturally placed on
th PCL.42
452
Section IV
Lower Extremity
Taut ACL
FIGURE 13-22. The interaciion between muscle comracuon and tension changes in th cruciate ligaments is shown. A, Contraction of th quadriceps muscle extends th knee and slides th tibia anterior relative to th femur. Knee extension als elongates most of th anterior cruciate ligament (ACL), posterior capsule, hamstring muscles, and collateral ligaments (not shown).
Note that th quadriceps and ACL have an antagonistic relationship throughout most of th terminal range of extension. B, The
antenor drawer test can help evaluate th integrity of th ACL. C, Contraction of th hamstring muscles flexes th knee and slides
th tibia posterior relative to th femur. Knee flexion elongates th quadriceps muscle and most of th fibers within th posterior
cruciate ligament (PCL). D, The posterior drawer test checks th integrity of th PCL. Tissues pulled taut are tndicated by thin
black arrows.
Chapter 13
Knee
453
c a u s e s a p o s t e r io r t r a n s la t io n o f t h tib ia t h a t s la c k e n s
m o s t f ib e r s o f t h A C L . 79 F o llo w in g a n A C L in ju ry , t h
h a m s t r in g s o fte n e x p e r ie n c e s p a s m . T h e r e s u lt in g f le x e d
k n e e m a y b e a m e c h a n is m t h a t is e m p lo y e d to lim it th
s t r e t c h o n a r e c o n s t r u c t e d o r d a m a g e d A C L . 1 S t im u la t io n
fr o m s t r e t c h r e c e p t o r s in a n in ju r e d b u t in t a c t A C L m a y
t r ig g e r s p a s m in th h a m s tr in g m u s c le s . T h is , in tu rn ,
m a y r e f le x iv e ly in h ib it t h q u a d r ic e p s m u s c le . 69 T h is m u s c u la r - b a s e d " f le x io n b ia s " o f t h k n e e p la c e s th tib ia
r e la t iv e ly p o s t e r io r to t h f e m o r a l c o n d y le s , t h e r e b y u n -
lo a d in g m o s t f ib e r s o f t h A C L .
F o llo w in g a n A C L in ju r y o r r e c o n s t r u c t io n , a p a t t e r n
o f m u s c le a c t iv a t io n w h ile w a lk in g m a y d e v e lo p t h a t
f a v o r s g r e a t e r a c t iv a t io n o f t h h a m s t r in g s a n d in h ib itio n o f t h q u a d r i c e p s . " 9 In t h e o r y , i n c r e a s e d a c t iv a t io n
o f t h h a m s t r in g s in a n A C L - d e f i c i e n t k n e e m a y p a r t ia lly
c o m p e n s a t e f o r a n e x c e s s iv e a n t e r io r d i s p la c e m e n t o f
t h t ib ia r e la t iv e t o t h f e m u r . 77
I N N E R V A T IO N TO M U S C L E S
t h a n 70 d e g r e e s o f fu ll e x t e n s io n . '2-25-6'-88-126 A s t h k n e e
V o lu m e s o f m a t e r ia l h a v e b e e n w r it t e n o n t h A C L , e s p e -
a p p r o a c h e s f u ll e x t e n s io n , t h a c t iv e q u a d r ic e p s p r o d u c e s
r e h a b ilit a t io n . M a n y r e p o r t s h a v e w a r n e d a g a in s t r e s is t e d
( t ib ia l- o n - f e m o r a l) k n e e e x t e n s io n a t a n g le s t h a t a r e le s s
c i a l l y r e la t e d t o t h t o p i c s o f b io m e c h a n i c s 66-73-92 s u r g ic a l
a n a n t e r io r s h e a r o n t h t ib ia , w h ic h c a n s t r a in t h A C L
r e c o n s t r u c t io n a n d h e a lin g 22'29'43-12'-122 lo n g - t e r m r e s u lt s f o l
( s e e F ig . 1 3 - 2 2 A a n d
q u a d r ic e p s , t h g r e a t e r t h a n t e r io r s h e a r a n d s u b s e q u e n t
n o n s u r g ic a l r e h a b ilit a t io n . 28 M u c h o f t h d e b a t e a n d c o n -
lo a d p l a c e d o n t h A C L . 47 A s a r e s p o n s e to t h e s e r e p o r t s ,
B).
T h e la r g e r t h f o r c e in t h
t r o v e r s y a s s o c ia t e d w it h t h is lit e r a t u r e a b o u t t h A C L is
c l i n i c i a n s r o u t in e ly a d v o c a t e e x e r c i s e s t h a t c o n c e n t r a t e
b e y o n d t h s c o p e o f t h is te x t. O n e t o p ic , h o w e v e r , t h a t is
o n lo a d in g t h
h ig h lig h t e d h e r e is t h is s u e o f s t r e n g t h e n in g t h q u a d r i
g re e s of
c e p s a s a p a r t o f A C L r e h a b ilit a t io n .
a r e o f te n r e f e r r e d t o a s " c l o s e d k in e t ic c h a i n " e x e r c is e s .
S o m e p e r s o n s f o llo w in g A C L r e c o n s t r u c t iv e s u r g e r y
lim it q u a d r ic e p s a c t iv it y w h ile w a lk in g . P e r s is t e n t w e a k -
quadriceps muscle d u r in g th Ia s t 45 d e
femoral-on-tibial extension .l2-46 T h e s e e x e r c i s e s
E x e r c is e s s u c h a s " m in i s q u a t s , " s q u a t s a g a in s t e la s t ic
r e s is t a n c e , s in g le - le g h a lf s q u a t s , a n d le g p r e s s e s p r o
n e s s o f t h m u s c le m a y e n s u e , d e s p it e im p r o v e m e n t in
d u c e e q u a l, 4 o r le s s , s t r a in o n t h A C L t h a n t ib ia l- o n -
m a n y f u n c t io n a l m e a s u r e s . 64 R e d u c e d f u n c t io n a l s t r e n g t h
f e m o r a l r e s is t a n c e e x e r c is e s , s u c h a s lif t in g a n k le
in t h q u a d r ic e p s m a y c a u s e a lo s s o f a c t iv e t e r m in a l
e x t e n s io n , p o o r g a it, a n d e x c e s s iv e w e a r o n t h k n e e 's
c o a c t iv a t io n o f t h k n e e e x t e n s o r a n d f le x o r m u s c le s ,
a r t ic u la r c a r t ila g e . S t r e n g t h e n in g a n d g e n e r a i a c t iv a t io n o f
t h e r e b y in c r e a s in g s t a b ilit y o f t h k n e e a n d lim it in g a n te -
t h q u a d r ic e p s a r e t h e r e f o r e im p o r t a n t g o a ls in a n y A C L
r io r - p o s t e r io r s h e a r f o r c e s . T h is m e t h o d o f e x e r c i s e m a y
r e p a ir r e h a b ilit a t io n p r o g r a m .
lim it t e n s io n p l a c e d o n t h A C L a n d , a t t h s a m e t im e ,
D e p e n d in g o n t h p a t ie n t 's a g e , t im e s i n c e s u r g e r y ,
a n d in j u r y s e v e r it y , it m a y b e p r u d e n t t o lim it t h a m o u n t
o f t e n s io n p l a c e d o n a h e a lin g A C L g r a ft. C e r t a in m e t h o d s
f o r s t r e n g t h e n in g t h q u a d r ic e p s a r e c o n t r a in d ic a t e d o r a t
le a s t q u e s t i o n a l e , e s p e c i a l l y d u r in g t h e a r ly c o u r s e o f
p r o v id e a d e q u a t e r e s is t a n c e a g a in s t t h q u a d r ic e p s . A t
s o m e p o in t in t h r e h a b ilit a t io n p r o c e s s , h o w e v e r , t e n s io n
in t h A C L m a y a c t u a lly f a c ilit a t e h e a lin g a n d c a n b e
c o n s id e r e d t h e r a p e u t i c . " 5
454
IN N E R V A T IO N TO T H E JO IN T
F L E X O R -R O T A T O R M U S C L E S
Action
Innervation
Piexus
Sartorius
Femoral nerve
Lumbar
Obturator nerve
Lumbar
Femoral nerve
Lumbar
Popliteus
Tibial nerve
Sacrai
Semimembranosus
Hip extension
Sacrai
Sacrai
Hip extension
Sacrai
Biceps femoris
(long head)
Hip extension
Sacrai
Tibial nerve
Sacrai
Tibial nerve
Sacrai
Gastrocnemius
Plantaris
Knee flexion
Ankle piantar flexion
* The actions involving th knee are shown in bold. Muscles are listed in descending order of nerve root innervation.
Chapter 13
VI
FIGURE 13-23. A cross-section through ihe right quadriceps muscle. The arrows d ep ia th approximate line-of-force of each of part
of th quadriceps: vastus lateralis (VL), vastus ntermedius (VI),
rectus femoris (RF), vastus medialis longus (VML), and vastus medialis obliquus (VMO).
250-i
K nee extensors
225
z
455
Anatomie Considerations
RF
Knee
Zi
Oo
1-
iK n e e flexors
200175150125-
co 100-
E
X
cc
2
75 5025o -l
Vasti
Rectus femoris
Hamstrings
Gastrocnemius
Other
456
Section IV
Lower Extremity
FIGURE 13-25. An analogy is triade between a crane (A) and th human knee (B). In th crane, th moment arm is th distance
between th axis and th tip of th piece of metal that functions like a patella.
Chapter 13
S P E C I A L
F O C U S
following
p r o d u c e a n e q u iv a le n t p r e - p a t e lle c t o m iz e d e x t e n s o r
A c c o r d i n g t o o n e s t u d y , a n a p p r o x im a t e 20 % lo s s o f in t e r
a p a t e lle c t o m y . 63 A v e r -
a g e d o v e r f u ll r a n g e o f m o tio n , t h in t e r n a i m o m e n t a r m
o f a p a t e lle c t o m iz e d k n e e w a s r e d u c e d f r o m 4.7 c m to
3.8 c m . T h e s e d a t a s u g g e s t th a t , in t h e o r y , a k n e e
t o r q u e . T h e i n c r e a s e d m u s c le f o r c e is n e e d e d t o c o m p e n
s a t e f o r t h p r o p o r t io n a l lo s s in le v e r a g e . A s a c o n s e q u e n c e , t h g r e a t e r m u s c le f o r c e i n c r e a s e s t h c o m p r e s
s io n f o r c e o n t h t ib io f e m o r a l jo in t, c r e a t in g a d d it io n a l
w e a r o n t h a r t ic u la r c a r t ila g e (F ig . 1 3 - 2 6 ) .
w it h o u t a p a t e lla n e e d s t o g e n e r a t e 25% m o r e f o r c e t o
A. With patella
457
1 3 - 5
Consequences of a Patellectomy
n a i m o m e n t arm o c c u r s
Knee
B. Without patella
458
Section IV
Lower Extremity
B. 45 of flexion
C. 0 (full extension)
FIGURE 13-27. The extemal (flexion) torques are shown imposed on th knee between flexion (90 degrees) and full
extension (0 degrees). Tibial-on-femoral extension is shown in A C, and femoral-on-tibial extension is shown in DF. The
extemal torques are equal to th product of body or leg weight times th extemal moment arm (EMA). The graph shows
th relationship between th extemal toique normalized to a maximum (100% ) torque fot each method of extending th
knee
for selected knee joint angles. (Tibial-on-femoral extension shown in black; femoral-on-tibial extension shown in
gray.) Extemal torques above 70% for each method of extension are shaded in light red. The increasing red color of th
quadriceps muscle denotes th increasing demand on th muscle and underlying joint. in response to th increasing
extemal torque.
Chapter 13
5.5 r-
I 60
- 55
- 50
- 45
- 40
O
co
3
o
3.0
35
75
60
45
30
Knee Angle (degrees)
15
30
459
Knee
460
Excessive resistance
from connective
tissues
Faulty arthrokinematics
Tracking Within th Patellofemoral join t. During active knee extension, several structures guide, or track, th
patella through th intercondylar groove of th femur (see
th next box). Acting alone, each structure exerts a mediai
or lateral pul on th patella as it slides in th groove (Fig.
1 3 - 3 1 ). When these forces balance each other, they
cooperate to track th patella through th groove with as
little stress to th articular surfaces as possible.44 If th
forces do not balance one another, th patella may not track
optimally and may even dislocate. Increased stress due to
abnormal tracking may lead io arthritis, chondromalacia, recurrent patellar dislocation, or patellofemoral joint pain syndrome.
illustrate these factors, consider th force on th patellofemoral joint while in a partial squat position (Fig. 1 3-29 A ). The
force withtn th extensor mechanism is transmitted proxiinally and distallv through th quadriceps tendon (QT) and
patellar ligament (PL), much like a cable Crossing a ftxed
pulley. The resultant, or combined effect, of these forces is
directed toward th intercondylar groove of th femur as a
joint force QF). Increasing knee flexion by descending into a
deeper squat significanti)' raises th force demands throughout th extensor mechanism. ultimately on th patellofemoral joint (Fig. 1 3 -2 9 B ). The increased knee flexion associated with th deeper squat also reduces th angle formed by
th intersection of force vectors QT and PL. As shown by
th vector addttion, reducing th angle of these force increases th magnitude of th JF directed between th patella
and th femur.
t e n s h o w c o n s id e r a b le d if f ic u lt y c o m p le t in g t h fu ll
r a n g e o f t ib ia l- o n - f e m o r a l e x t e n s io n o f t h k n e e , c o m m o n ly d is p la y e d w h ile s it t in g . T h is d if f ic u lt y p e r s is t s
e v e n w h e n t h e x t e r n a l lo a d is lim it e d to ju s t t h
w e ig h t o f t h lo w e r le g . A lt h o u g h t h k n e e c a n b e f u lly
e x t e n d e d p a s s iv e ly , e f f o r t s a t a c t iv e e x t e n s io n t y p ic a lly
f a il to p r o d u c e t h la s t 15 t o 20 d e g r e e s o f e x t e n s io n .
C lin ic a lly , t h is c h a r a c t e r i s t i c d e m o n s t r a t io n o f q u a d r i
c e p s w e a k n e s s is o f t e n r e f e r r e d to a s a n " e x t e n s o r
la g ."
E x t e n s o r la g a t t h k n e e is o f te n a p e r s is t e n t a n d
p e r p le x in g p r o b le m d u r in g r e h a b ilit a t io n o f t h p o s t s u r g ic a l k n e e . T h e m e c h a n ic s t h a t c r e a t e t h is c o n d it io n d u r in g t h s e a t e d p o s it io n a r e a s f o llo w s : A s th
k n e e a p p r o a c h e s t e r m in a l e x t e n s io n , t h m a x im a l
in t e r n a i t o r q u e p o t e n t ia l o f t h q u a d r ic e p s is le a s t w h ile
t h o p p o s in g e x t e r n a l ( fle x o r ) t o r q u e is g r e a t e s t . T h is
n a t u r a i d is p a r it y is h a r d ly e v id e n t in p e r s o n s w it h n o r -
m a l q u a d r ic e p s s t r e n g t h . W it h m o d e r a t e m u s c ie w e a k
n e s s , h o w e v e r , t h d is p a r it y o f te n r e s u lt s in e x t e n s o r
la g .
S w e llin g o r e f f u s io n o f t h k n e e i n c r e a s e s t h lik e lih o o d o f a n e x t e n s o r la g . S w e llin g i n c r e a s e s in t r a a r t ic u la r p r e s s u r e , w h i c h c a n p h y s ic a lly im p e d e fu ll k n e e e x
t e n s io n . 123 I n c r e a s e d in t r a a r t ic u la r p r e s s u r e c a n
r e f le x iv e ly in h ib it t h n e u r a l a c t iv a t io n o f t h q u a d r ic e p s
m u s c i e . '983 M e t h o d s t h a t r e d u c e s w e llin g o f t h k n e e ,
t h e r e f o r e , h a v e a n im p o r t a n t r o le in a t h e r a p e u t ic e x e r c is e p r o g r a m o f t h k n e e .
Chapter 13
Knee
461
FIGURE 13-29. The relationship berween th depth o f a squat position and th compression fo r c e within th patellofemoral joint is shown. A, Maintaining a partial squat requires that th quadriceps transmit a force through th quadriceps
tendon (QT) and th patellar ligament (PL). The vector addition of QT and PL provides an estimation of th
patellofemoral jo in t force (JF). B, A deeper squat requires greater force from th quadriceps owing to th greater extemal
(flexion) torque on th knee. Furthermore, th greater knee flexion (B) decreases th angle between QT and PL and,
consequently, produces a greater joint fo r c e between th patella and femur.
462
a d v is e d a g a in s t p e r f o r m in g s q u a t t in g a c t iv it ie s , e s p e c i a l l y
w h ile c a r r y in g lo a d s .
P a te llo fe m o ra l jo in t p a in syndrom e is a c o m m o n c o n d it io n
in p e r s o n s in v o lv e d in s p o r t s , r a n k in g f ir s t in t r a c k a n d
s e c o n d in A m e r i c a n f o o t b a ll a n d s o c c e r . 20 J o i n t p a in a ls o
o c c u r s in p e r s o n s n o t in v o lv e d in s p o r t s . T h o s e w h o h a v e
n o h is t o r y o f t r a u m a c a n a ls o e x p e r ie n c e jo in t p a in . C a s e s
m a y b e m ild , in v o lv in g o n ly a g e n e r a liz e d a c h in g a b o u t
t h a n t e r io r k n e e , o r t h e y m a y b e s e v e r e a n d in v o lv e
r e c u r r e n t d is lo c a t io n o r s u b lu x a t io n o f t h p a t e lla f r o m t h
in t e r c o n d y la r g r o o v e .
O v e r t im e , s o m e o f t h o s e w it h p a t e llo f e m o r a l j o in t p a in
s y n d r o m e d e v e lo p d e g e n e r a t iv e c h a n g e s in t h jo in t s u r f a c e s , a c o n d it io n k n o w n a s c h o n d r o m a la c ia p a t e lla e .
Posterior
Chapter 13
Knee
463
The h a m s t n n g m u s c le s (i.e., semimembranosus, semitendinosus, and long head of th biceps femoris) have their proximal attachment on th ischial tuberosity. The short head of
th biceps has its proximal attachment on th lateral lip of
th linea aspera of th femur. Distally, th three hamstrings
cross th knee joint and attach to th tibia and fibula (see
Figs. 1 3 - 9 to 1 3 -1 1 ).
The semimembranosus attaches distally to th posterior
side of th mediai condyle of th tibia. Additional distai
attachments of this muscle include th mediai collateral ligament, both menisci, oblique popliteal ligament, and poplit
eus muscle. For most of its course, th sinewy s e m it e n d in o s u s
tendon lies immediately posterior to th semimembranosus
muscle. Just proximal to th knee, however, th tendon of
th semitendinosus courses anteriorly toward th distai at
tachment on th anterior-medial aspect of tibia. Both heads
of th b i c e p s f e m o r i s attach on th head of th fibula, beside
th fibular collateral ligament.
464
Secton IV
Lower Extremity
TABLE
Structural or
Functional
Abnomiality
Specific Exampies
Excessive tightness
in lateral soft tis
sues
Excessive laxity in
mediai soft tis
sues
Bony dysplasia
Abnormal patellar
position
Knee malalignment
Increased
Increased
Excessive
Excessive
Muscle weakness
Q-angle
genu valgum
anteversion of th hip
extemal tibial torsion
TABLE
Dislocation
M en
Shoulder (recurrent)
38.1
Shoulder (acute)
22.1
Patella (recurrent)
14.0
Patella (acute)
W o m en
W om en
1.9
1.9
0.1
3.8
1.1
0.3
58.4
0.7
4.6
11.0
34.0
0.5
2.7
Finger
5.1
0.3
Elbow
5.1
0.3
0.1
1.9
* Data collected on athletic injuries over a 7-year period at University of Rochester, Section of Sporta Medicine. Note in bold th high percentage of
recurrent patellar dislocation for women.
t The dislocation is expressed as a percentage of th total injuries by gender.
Data from DeHaven KE, Lintner DM: Athletic injuries: Comparison by age, sport, and gender Am J Sports Med 14:218-224, 1986.
Chapter 13
M
1
S P E C I A L
F O C U S
1 3 - 8
p
Kinesiologic Basis for Treatment of Abnormal
Patellofemoral Joint Tracking
M u c h o f t h o r t h o p e d ic t r e a t m e n t a n d p h y s ic a l t h e r a p y
fo r
of
abnormal
t r a c k in g o f
th
p a t e lla
involves th altering
t h t ib io f e m o r a l a n d p a t e llo f e m o r a l j o in t a lig n m e n t .
S u r g e r y is o f te n p e r f o r m e d t o le s s e n t h e f f e c t o f e x a g g e r a t e d la t e r a l f o r c e s o n t h p a t e lla . E x a m p le s in c lu d e
f a t e r a i r e t in a c u la r r e le a s e a n d r e a lig n m e n t o f t h e x t e n s o r m e c h a n is m , in p a r t ic u la r t h o b liq u e f ib e r s o f t h
v a s t u s m e d ia lis . 31
P h y s ic a l t h e r a p y f o r c h r o n ic p a t e lla r d is lo c a t io n in c lu d e s t r a in in g f o r s e le c t iv e c o n t r o l o f t h o b liq u e f ib e r s
o f t h v a s t u s m e d ia lis , s t r e t c h in g o f t h s o f t t is s u e , a n d
w e a r in g o f f o o t o r t h o t ic s t o r e d u c e e x c e s s i v e p r o n a t io n
o f t h f e e t . T a p in g o f t h s k in h a s b e e n s u g g e s t e d a s a
w a y t o h e lp g u id e t h p a t e lla a n d / o r a lt e r t h m u s c le
a c t iv a t io n p a t t e r n o f t h v a s t u s m u s c le s . 34 A lt h o u g h
b a s e d o n s o u n d b io m e c h a n ic a l p r in c ip le s , t h e f f i c a c y
o f u s in g p h y s ic a l t h e r a p y t o s e le c t i v e l y a d i v a t e t h
o b liq u e f ib e r s o f t h v a s t u s m e d ia lis to c o r r e c t a b n o r
m a l t r a c k in g o r r e c u r r e n t d is lo c a t io n o f t h p a t e lla r e m a in s a s u b j e c t o f d e b a t e . 70'93' 96' 27
actions during walking and running. Examples of these actions are considered separately for tibial-on-femoral and femoral-on-tibial movements of th knee.
465
Knee
S P E C I A L
F O C U S
0
Popliteus Muscle: The "Key to th Knee"
T h e p o p lit e u s is a n im p o r t a n t in t e r n a i r o t a t o r a n d f le x o r
o f t h k n e e jo in t. A s a n in t e r n a i r o t a t o r , t h p o p lit e u s is
c o n s id e r e d t h " k e y " t o t h k n e e . A s t h e x t e n d e d a n d
lo c k e d k n e e p r e p a r e s t o f le x (e .g ., w h e n b e g in n in g to
d e s c e n d in t o a s q u a t p o s it io n ) , t h p o p lit e u s p r o v id e s
a n in t e r n a i r o t a t io n t o r q u e t h a t h e lp s m e c h a n i c a l l y u n l o c k t h k n e e .3 R e c a li t h a t t h k n e e is m e c h a n ic a lly
lo c k e d b y a c o m b in a t io n o f e x t e n s io n a n d s lig h t e x t e r n a l r o t a t io n . U n lo c k in g t h k n e e t o f le x in t o a s q u a t
p o s it io n r e q u ir e s t h a t t h f e m u r
externally rotate
on th
t ib ia . T h is a c t io n o n t h f e m u r is r e a d ily a p p a r e n t b y
o b s e r v in g t h m u s c l e 's o b liq u e lin e - o f - f o r c e b e h in d t h
k n e e ( s e e F ig . 1 3 - 1 0 ) . B y a t t a c h in g t o t h p o s t e r io r
h o r n o f t h la t e r a l m e n is c u s , t h p o p lit e u s c a n s t a b iliz e
t h la t e r a l m e n is c u s d u r in g t h is f le x io n - r o t a t io n m o v e m e n t.
466
Section IV
Lower Extremity
Left obliquus
internus abdominis
(on anterior side)
R ig h t s t e r n o c le id o m a s t o id
(o n a n te rio r s id e )
R ig h t o b liq u u s e x te rn u s a b d o m in is
(o n a n t e r io r s id e )
R ig h t tr a n s v e r s o s p in a l m u s c le
Pes
anserinus pSartorius
group -i-Gracilis
L-Semitendinosus
P ir if o r m is
B ic e p s f e m o r is
(sh o rt head)
Oecelerators:
P e s g ro u p
Accelerator:
B ic e p s f e m o r is ( s h o r t h e a d )
From above
Chapter 13
65
467
Knee
r~
60 E
ai
3
o-
55 -
50 -
45
o
'S
V
C
15
40
(O
35
30
J ___________!___________ 1
___________ !___________ !___________ !___________
15
30
45
60
Knee Angle (degrees)
75
90
468
Section IV
Lower Extremity
f o u n d t o v a r y c o n s id e r a b ly , t h e r e f o r e lim it in g c l i n i c a l
u s e f u ln e s s . G r a c e a n d c o l l e a g u e s 39 r e p o r t e d a n e x t e n
s o r - t o - f le x o r t o r q u e r a t io o f 1.67:1 (i.e ., e x t e n s o r s p r o
d u c e d 67% g r e a t e r p e a k t o r q u e t h a n f le x o r s ) in 172 h ig h
s c h o o l - a g e m a le s . In a n o t h e r s t u d y , t h p e a k k n e e
e x t e n s o r - t o - f le x o r t o r q u e r a t io s w e r e m e a s u r e d a t t h r e e
d if f e r e n t is o k in e t ic t e s t s p e e d s in 100 h e a lt h y s u b j e c t s . 124 R e s u lt s w e r e 1.39:1 a t 60 d e g r e e s / s e c , 1.27:1 a t
180 d e g r e e s / s e c , a n d 1.19:1 a t 3 0 0 d e g r e e s / s e c . T h e
d if f e r e n c e in p e a k t o r q u e s b e t w e e n t h e x t e n s o r a n d
f le x o r m u s c le s d e c r e a s e d a s t h s p e e d o f c o n t r a c t io n
in c r e a s e d .
FIGURE 13-36. The action of several monoarticular and biarticular muscles are depicted during th
hip-and-knee extension phase of running. Observe
that th vasti extend th knee, which then
stretches th distai end of th semitendinosus. The
gluteus maximus extends th hip, which then
stretches th proximal end of th rectus femors.
The stretched biarticular muscles are depicted by
thin black arrows. The stretch placed on th active
biarticular muscles reduces th rate and amount of
their overall contraction. (See text for further details.)
Chapter 13
Knee
469
Monoarticular Muscles
Action
Biarticular
Transducers
Action
Augmented
Vasti
Gluteus maximus
Knee extension
Hip extension
Two-joint hamstrings
Rectus femoris
Hip extension
Knee extension
lliopsoas
Biceps femoris (short
head), popliteus
Hip flex io n
Knee flexion
Two-joint hamstrings
Rectus femoris
Knee flex io n
Hip flex ion
After Leiber RL: Skeletal Muscle Strutture and Function. Baltimore, Williams & Wilkins, 1992.
A. Hip flcxion
and knce extension
FIGURE 13-37. The motions of (A) hip flexion and knee extension
and (B) hip extension and knee flexion. For both movements, th
near-maximal contraction of th btarttcular muscles (red) causes a
near-maximal stretch in th biarticular antagonist muscles (thin
black arrows).
between th vasti and semitendinosus. In essence, th powerful monoarticular gluteus maximus augments knee exten
sion force by extending th hip. This, in tum, stretches th
activated rectus femoris. In this example, th rectus femoris
is th biarticular transducer, transferring force from th glu
teus maximus to knee extension. A summary of these and
other muscular interactions used during hip-and-knee flex
ion are listed in Table 1 3 - 9 .
The interdependence between th hip and knee extensor
muscles allows for th most efficient force development. This
interdependence is considered when evaluating functional
activities that require combined hip-and-knee extension,
such as standing from a chair. Weakness of th vasti could
cause difficulty in extending th hip, whereas weakness of
th gluteus maximus could cause difficulty in extending th
knee.
Atypical Movement Combinations: Hip Flexion-and-Knee
Extension or Hip Extension-and-Knee Flexion
Consider movement pattems of th hip and knee that are
out of phase with th more lypical movement pattems described here. Hip flexion can occur with knee extension
(Fig. 1 3 -3 7 A ), or hip extension can occur with knee flexion
(Fig. 1 3 -3 7 B ). The physiologic consequences of these move
ments are very different from those described in Figure 1 3 36. In Figure 1 3 -3 7 A , th biarticular rectus femoris must
shorten a great distance, and with relatively higher velocity,
in order to flex th hip and extend th knee. Even with
maximal effort, active knee extension is usually limited dur
ing this action. Based on th length-tension and force-velocity relationships of muscle, th rectus femoris is not able to
develop maximal knee extensor force. The hamstrings are
overstretched across both th hip and knee, thereby passively resisting knee extension.
The situation described in Figure 1 3 -3 7 A applies to th
movement described in Figure 1 3 -3 7 B . The biarticular ham
strings must contract to a very short length a movement
that is often accompanied by cramping. Furthermore, th
biarticular rectus femoris is overstretched across both th hip
and knee, thereby passively resisting knee flexion. For both
reasons, knee flexion force and range of motion are usually
limited by th out-of-phase movement.
The atypical movements depicted in Figure 1 3 -3 7 A and
B may have a useful purpose. Consider th movement of
kicking a football. Elastic energy is stored in th stretched
rectus femoris by th preparatory movement of combined
470
Seclion IV
Lowcr Extremity
Chapter 13
Knee
471
SAGITTAL PLANE
Genu Recurvatum
Full extension with slight external rotation is th knees
close-packed, stable position. While standing in this locked
position, th knee is typically hyperextended about 5 to IO
degrees owing in pari to th posterior slope of th tibial
plateau. Hyperextension directs th line-of-gravity from body
weight slightly anterior lo th medial-lateral axis of rotation
at th knee. Gravity, therefore, produces a slight knee exten
sion torque that can naturally assist with locking of th
knee, allowing th quadriceps to relax while standing. Nor
mally, this gravity-assisted extension torque is adequately
resisted by passive tension in th stretched posterior capsule
and stretched flexor muscles of th knee.
Hyperextension beyond 10 degrees is called genu recurva
tum (from th Latin genu, knee; 4- recurvare, to bend backward). The primary cause of genu recurvatum is a chronic,
overpowering knee extensor torque that eventually overstretches th posterior structures in th knee. The overpow
ering knee extension torque may stem from poor postural
control or from neuromuscular disease that causes spasticity
of th quadriceps muscles and/or paralysis of th knee llexors.
472
Section IV
Lower Extremily
S P E C I A L
F O C U S
1 3 -
Genu Recurvatum
B. Corrected
A. llncorrected
Body weight
Body weight
FIGURE 13-42. Subject showing marked genu recurvatum of th left knee secondary to polio. In addition to sporadic muscle
weakness ihroughoul th left lower exiremily, th left ankle was surgically fused in 25 degrees of piantar flexion. A, When
standing barefoot, th subjects body weight acts with an abnormally large external moment arm (EMA) at th knee. The
resulting large extensor torque amplifies th magniiude of th knee hyperextension deformity. B, Subject is able to reduce th
severity of th recurvatum deformity by wearing a tennis shoe with a built-up heel. The shoe tilted her tibia and knee forward,
thereby reducing th length of th deforming external moment arm at th knee.
Several interrelated factors are responsible for th development of th deformity depicted in Figure 13-42A
Because of th fixed piantar flexion position of th ankle,
th tibia must be tilted posteriorly so that th bottom of
th foot makes full contact with th ground. Over th
years, this tilted position of th tibia hyperextended th
knee and overstretched th posterior structures of th
knee. Of particular importance is th fact that total paralysis of th knee's flexor muscles provided no direct muscular resistance against th knee's hyperextension deformity.
Furthermore, th greater th hyperextension deformity, th
longer th external moment arm available to body weight
to perpetuate th deformity. Without bracing of th knee,
th hyperextension deformity produced a vicious circle,
allowing continuous stretching of th posterior structures
of th knee and continuous progression of th deformity.
474
Section IV
Lower Extremity
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Lnwer Extremily
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14
h a p t e r
TOPICS
OSTEOLOGY, 478
AT
G LANCE
Kinematics, 493
Mediai Longitudinal Arch of th Foot,
496
Anatomie Considerations, 496
Functional Considerations, 496
Abnormal Shape of th Mediai
Longitudinal Arch, 497
C om b ined A c tio n o f th S u b ta la r and
T ra n s v e rs e T a rs a l J o in ts , 498
INTRODUCTION
The primary function of th ankle and foot is to absorb
shock and impari thrust to th body during walking. While
walking and running, th foot must be pliable enough to
absorb th impact of millions of contacts throughout a lifetime. Pliability also allows th foot to conform to countless
spadai configurations between it and th ground. Walking
and running also require that th foot be relatively rigid
to be able io withstand large propulsive thrusts. The
healthy foot satisfies th seemingly paradoxical requirements
of both shock absorption and thrust through an interaction
M e ta ta rs o p h a la n g e a l J o in ts , 504
of interrelated joints, connective tissues, and muscles. Although not emphasized in this chapter, th sensory functions
of th healthy foot also offer important measures of protecdon and guidance to th lower extremity. This chapter sets
forth a firm basis for an understanding of th evaluation and
treatment of a multitude of disorders that affect th ankle
and foot, many of which are kinesiologically related to th
movement of th entire lower extremity.
Many of th kinesiologic issues addressed in this chapter
are related specifically to th process of walking, or gait, a
topic covered in greater detail in Chapter 15. Figure 1 5 - 1 2
should be consulted as a reference to th terminology used
477
478
Section TV
Lower Extremity
0STE0 L0GY
________
________
Foot
Rearfoot
Bones
Tibia, fibula, and talus
Joints
Talocrural
Proximal and distai
tibiofbular
Bones
Calcaneus and talus*
Joint
Subtalar (talocalcaneal)
Midfoot
Bones
Navicular, cuboid, and cuneiforms
Joints
Transverse tarsal
Talonavicular
Calcaneocuboid
Distai intertarsal
Cuneonavicular
Cuboideonavicular
lntercuneiform and cuneocuboid complex
Forefoot
Bones
Metatarsals and phalanges
Joints
Tarsometatarsal
lntermetatarsal
Metatarsophalangeal
Interphalangeal
* The talus is included as a bone of th ankle and a bone of th foot.
Superior
individuai Bones
FIBULA
Chapter 14
479
TARSAL BONES
The seven tarsal bones are shown in four different perspectives in Figures 1 4 - 4 through 1 4 - 7 .
Anterior view
Interosseous ligament
DISTAL TIBIA
The distai end of th tibia expands in size to accommodate
loads transferred across th ankle. On th mediai side of th
distai shaft of th tibia is th prominent mediai malleolus. On
th lateral side is th fibular notch, a triangular concavity that
accepts th distai end of th fibula at th distai tibiofibular
joint (see Fig. 1 4 -1 0 ).
Talocrural joint
Anterior tibiofibular
malleolus
Lateral malleolus
Deltoid ligament
T o rs io n A n g le o f th T ib ia
480
Section IV
Lower Extremity
Superior view
Interphalangeal
joint
I n fe r io r view
Flexor digitorum longus
Extensor digitorum
longus and brevis
Flexor digitorum brevis
Extensor
hallucis longus
Dorsal interossei
Extensor
digitorum brevis
Distai phalanx
Piantar interossei
i i ^ A b d u c t o r and flexor
hallucis brevis
Middle phalanx
Proximal phalanx
Abductor and
flexor digiti minimi
Dorsal interossei
Adductor hallucis
(oblique head)
Metatarsal
Mediai cuneiform
Peroneus tertius
Peroneus brevis
Intermediate cuneiform
Peroneus longus
Piantar interossei
Abductor and
flexor digiti minimi
Tibialis anterior
Groove for
peroneus longus
Navicular
TuberosityLateral cuneiform
I Head
TalusH ------ Neck
L-Trochlea
Cuboid
WavicuS*
Talus
Extensor digitorum
brevis
Articulation with
mediai malleolus
Articulation with
lateral malleolus
Tibialis posterior
^neiforms)
Sustentaculum talus
Groove fo r flexor
hallucis longus
Abductor
digiti minimi
Lateral p r o c e s s - ^ H R i l v /
Mediai process
Calcaneal
tuberosity
Achilles tendon
attaching to
tuberosity
Mediai view
Neck
Facet for
mediai malleolus
Mediai tubercle
Middle
phalanx
Proximal
phalanx
tuberoto'-
Chapter 14
481
Lateral view
Facet for articulation
with lateral malleolus
Navicular
Cuneiforms
Subtalar joint
(posterior
1st metatarsal
tarsus
process
Proximal
phalanx
Distai
phalanges
phalanx
Superior view
Tibialis anterior
tendon
Socket for
head of talus
Deltoid ligament
Spring ligament
facet
Middle facet
ligament
within
talar sulcus
Tibialis posterior
Flexor digitorum longus
Anterior facet
Middle
Interosseous
within calcaneal sulcus
Flexor hallucis
Deltoid
ligament (cut)
Posterior facets
ligament
Calcaneal (Achilles)
tendon
482
ABDUCTION/
ADDUCTION
(vertical axis)
PRONATION:
EVERSION
ABDUCTION
DORSIFLEXION
(AP axis)
(ML axis)
EVERSION/
INVERSIONE
DORSIFLEXION/
PLANTAR
FLEXION
ARTHROLOGY
Oblique axis
SUPINATION:
INVERSION
ADDUCTION
PLANTAR FLEXION
483
TABLE 1 4 - 2 . Terms that Describc Movements and Deformities of th Ankle and Foot
Motion
Axis of Rotation
Piane of Motion
Medial-lateral
Sagittal
Piantar flexion
Pes equinus
Dorsiflexion
Pes calcaneus
Inversion
Varus
Anterior-posterior
Frontal
Eversion
Valgus
Abduction
Abductus
Vertical
Horizontal
Adduction
Adductus
Supination
Oblique (varies by joint)
Pronation
Axes of Rotation
Movements at th ankle and foot are assumed to occur
about axes of rotation that remain nearly stationary throughout th range of motion. Although this assumption does not
hold for all joints, it does allow a rather complicated System
to be explained in a relatively simple fashion. More compli
cated, and likely more accurate, axes of rotation and kinematic models of th ankle and foot are described elsewhere.
(See references 1 , 1 0 , 45, and 48.)
Ligaments
The interosseous ligament provides th strongest bond be
tween th distai ends of th tibia and fibula.55 This ligament
484
TALOCRURAL JOINT
Articular Structure
The talocrural joint is formed by th articulation of th
trochlear surface and th sides of th talus, with th rectangular cavity formed by th distai end of th tibia and both
malleoli (see Fig. 1 4 - 3 ). The talocrural joint is often referred to as th "mortise, owing its resemblance to th
wood joint used by carpenters (Fig. 1 4 - 1 2 ). The concave
shape of th proximal side of th ankle mortise is maintained by connective tissues that bind th tibia with th
fibula. Interestingly, th total contact area within th talo
crural joint is about 350 mm2, which is relatively small
compared with 1,120 mm2 and 1,100 mm2 for th knee and
hip, respectively.4
FIGURE 14-10. An anterior-Iateral view of th right distai tibiofibular joint with th fbula reflected to show th articular surfaces.
Ligaments
A thin capsule surrounds th talocrural joint. Extemally, th
capsule is reinforced by collateral ligaments that limit excessive inversion and eversion tilting of th talus within th
rectangular concavity.
The mediai collateral ligament of th talocrural joint is
also referred to as th deltoid ligament. lt is strong and expansive (Fig. 1 4 - 1 3 ). The apex of th triangular ligament is
anchored to th mediai malleolus, with its base fanning into
three sets of superficial fibers. The distai attachments of
these fibers are listed in th box. The deeper tibiotalar fibers
blend with and strengthen th mediai capsule of th talo
crural joint.
Interosseous ligament
Anterior tibiofibular ligament
Posterior tibiofibular ligament
Postcrior view
Interosseous
ligament
Groove fortendons
of tibialis posterior and
flexor digitorum longus
The shape of th
talocrural joint
Posterior talofibular
ligament
Calcaneofibular
ligament
A carpenters
mortise joint
Chapter 14
485
M ediai view
posterior
tendon (cut)
calcaneonavicular
(spring) ligament
ligament
joints. Sprains to th deltoid ligament are relatively uncommon due, in part, to th ligaments strength and to th fact
that th lateral malleolus serves as a bony block against
excessive eversion.
The lateral collateral ligamenls of th ankle include th
anterior and posterior talofbular and th calcaneofibular lig
amenls. Because of th relative inability of th mediai mal
leolus to adequately block th mediai side of th mortise, th
majority of ankle sprains involve excessive inversion and
subsequent injury to th lateral collateral ligaments.12
The anterior talofbular ligament attaches to th anterior
aspect of th lateral malleolus and courses anteriorly and
medially to th neck of ihe talus (Fig. 1 4 - 1 4 ). This ligament
The posterior talofbular ligament originates on th posterior-medial side of th lateral malleolus and attaches to th
lateral tubercle of th talus (Figs. 1 4 - 1 1 and 1 4 - 1 4 ). Its
fbers run horizontally across th posterior side of th talo
crural joint, in an oblique anterior-lateral to posterior-medial
direction (Fig. 1 4 - 1 5 ). The primary function of th poste
rior talofbular ligament is to stabilize th talus within th
mortise. In particular, it limits excessive abduction of th
talus, especially when th ankle is fully dorsiflexed.7
The inferior transverse ligament is a small thick strand of
fibers considered part of th posterior talofbular ligament
(see Fig. 1 4 -1 1 ). The fibers continue medially to th poste
rior aspect of th mediai malleolus, forming part of th
posterior wall of th talocrural joint.
In summary, th mediai and lateral collateral ligaments of
th ankle limit excessive inversion and eversion at every
joint that th fbers cross. Because most ligaments course
from anterior-to-posterior, they also limit anterior-to-posterior translation of th talus within th mortise. As described
in th section on arthrokinematics, th movements of piantar
Lateral view
Posterior tibiofibular
ligament
Posterior talofbular
ligament
Cervical ligament
Bifurcated ligament
Dorsal tarsometatarsal
ligaments
Achilles tendon
(cu t)Calcaneofibular
ligam ent'
Lateral talocalcaneal
ligam ent'
Interior peroneal
retinaculum '
Peroneus
longus tendon
(cut)
Peroneus
brevis tendon
(cut)
Dorsal
calcaneocuboid
ligament
486
Superior view
Extensor
hallucis longus
Tibialis anterior
Peroneus tertius
Extensor digitorum longus
Deltoid ligament
Interior extensor
retinaculum
Mediai malleolus
of th tibia
Tibialis posterior
Flexor digitorum
Flexor hallucis longus
Peroneus longus
talofibular ligament
Calcaneal (Achilles) tendon
righi talocrural joint. The talus remains, but th lateral and mediai
malleolus and all th tendons are cut.
Osteokinematics
The talocrural jom t possesses one degree of freedom. Motion
at this joint occurs about an axis of rotation that passes
through th body of th talus and through th tips of both
malleoli. Because th lateral malleolus is inferior and poste
rior to th mediai malleolus, which can be verified by palpation, th axis of rotation departs slightly from a pure medial-
Arthrokinematics
The following discussion assumes that th foot is unloaded
and free to rotate, in a manner listed in Table 1 4 - 3 . During
dorsiflexion, th superior surface of th talus rolls forward
relative to th leg as it simultaneously slides posteriorly (Fig.
1 4 -1 7 A ). The simultaneous posterior slide allows th talus
to rotate forward without much anterior translation. Figure
1 4 -1 7 A shows th calcaneofibular ligament becoming taut
in response io th posterior sliding tendency of th talocalcaneal segment. As a generai rule, any collateral ligament that
becomes increasingly taut upon posterior translation of th
talus also becomes increasingly taut at full dorsiflexion. Max-
Primary Joints
Talocrural joint
Talocrural joint
Talonavicular joint
Deltoid ligament (tibiocalcaneal fibers)
Eversion
Talocrural joint
Calcaneofibular ligament
Talocrural joint
Talocrural joint
Subtalar joint
Chapter 14
487
Talocrural joint
FIGURE 14-16. The axis of rotation and osteokinematics at ihe lalocairal joint. The slightly oblique axis of rotation at th talocrural
joint (red) is shown from behind (A) and above (B). C to E show th primary active movement components of dorsiflexion and
piantar flexion. Note that dorsiflexion (D) is combined with slight abduction and eversion, which are th other components of
pronation; piantar flexion (E) is combined with slight adduction and inversion, which are th other components of supination.
imal dorsiflexion elongates th posteror capsule and all tissue capable of transmitting piantar flexion torque, such as
th Achilles tendon.
During piantar flexion, th superior surface of th talus
rolls backward as th bone simultaneously slides anteriorly,
Talocrural joint
DORSIFLEXION
PLANTAR FLEXION
488
Sect\on V
L o w e r E x trem ity
Path of
th tibia
Superior view
Achilles tendon
Calcaneofibular
ligament
FULL DORSIFLEXION
Peroneus longus -
0
o
-JS
e
o
o
o5
a)
X
10
20
30
40
CO
3=
o
o
<13
X
LL_
50
60
70
5=
O
CD
O
1
Percent of G ait C y c le
80
90
Swing phase
100
I
I
I
|
I
Chapter 14
jS
S P E C I A L
F O C U S
1 4 - 1
489
Ligaments
The posterior articulation within th subtalar joint is reinforced by a set of three slender ligaments, named by location
as th mediai, posterior, and lateral talocalcaneal ligaments (see
Figs. 1 4 - 1 1 , 1 4 - 1 3 , and 1 4 - 1 4 ). These ligaments provide
only secondar)' stability to th subtalar joint. Other larger
ligaments provide th primary source of stability. The calcaneofibular ligament and th deltoid ligament are both discussed previously in reference to th talocrural joint. The
most substantial ligaments to cross only th subtalar joint
are th interosseous (talocalcaneal) and cervical ligaments.
Broad and fiat, these ligaments cross obliquely within th
sinus tarsi and, therefore, are difficult to view unless th
joint is opened, as in Figure 1 4 - 8 . The interosseous (talocal
caneal) ligament has two distinct, flattened, anterior and posterior bands. These bands arise from th calcaneal sulcus
and atiach superiorly and medially on th talar sulcus and
adjacent regions. The larger cervical ligament has an oblique
fiber arrangement similar to th preceding ligament, but is
located more laterally within th sinus tarsi. Distally, th
cervical ligament courses superiorly and medially to attach
primarily to th inferior-lateral surface of th neck of th
talus (hence, th name cervical) (see Fig. 1 4 - 1 4 ). As a
group, th interosseous (talocalcaneal) and cervical ligaments
provide th strongest connettive tissue bond between th
talus and calcaneus.55
The ligaments of th subtalar joint control th extremes of
eversion and inversion (see th boxes).
490
Section IV
Lower Extremity
Kinematics
Osteokinematics and Arthrokinematics
Subtalar joint
ABDUCTION/ADDUCTION
(Vertical axis)
DORSIFL EXION/
PLANTAR FLEXION
(M L axis)
EVERSION/
INVERSION
EVERSION/
INVERSION
(AP axis)
(AP axis)
Mediai view
Superior view
axim f T ati0n ? d osteokine dcs 31 th subtalar joint are shown. The axis of rotation (red) is shown fror
th side (A) and above (B); th axis of rotation is shown again in C. D, The movement of pronation, with th main components c
shown"1 and abdUClIOn 1$ demonstrated- E, The movement of supination, with main components of inversion and adduction i
Chapter 14
491
As described earlier, th talocrural (ankie) joint permits motion primarily in th sagittal piane. The subtalar joint, however, permits a more oblique path of motion consisting of
two primary components: inversion and eversion, and abduction and adduction. This section describes how th trans
verse tarsal joint allows even a more oblique path of motion,
passing almost equally through all three Cardinal planes.
While weight hearing, th pronation and supination of th
midfoot region allows th foot to adapt to a variety of surface contours (Fig. 1 4 -2 1 ).
The transverse tarsal joint has a strong functional relationship to th subtalar joint. As subsequently described, these
two major joints function cooperatively to control most of
th pronation and supination posturing of th entire foot.
1 4 - 4 . The Mean and Standard Error* for Active Range of Motion in Degrees for Inversion and Eversion
and Abduction and Adduction at th Ankie Jo in t Complext
TABLE
Age (yr)
Inversion
Eversion
Abduction
Adduction
9-13
26.7 (.7)
10.5 (.4)
41.6 (1.0)
42.2 (1.7)
14-16
28.8 (1.4)
12.6 (.8)
46.8 (1.5)
42.4 (2.6)
17-20
27.1 (1.3)
11.9 (.7)
45.0 (1.3)
31.0 (13.6)
21-39
20.5 (1.3)
15.2 (.9)
38.2 (1.9)
34.5 (9.6)
40-59
20.7 (1.5)
13.8 (.9)
33.2 (1.4)
29.9 (1.7)
60-69
17.1 (1.1)
12.3 (.6)
31.7 (1.0)
27.9 (1.6)
70-79
17.1 (1.0)
11.4 (.6)
31.3 (1.5)
27.1 (1.3)
Average
22.6
12.5
38.3
33.6
* in parentheses.
t The subtalar and talocrural joint make up th ankie joint complex. The data were collected from healthy persons across different age groups, and th
Liala
492
Sectkm IV
S P E C I A L
Lower Extremiy
F O C U S
1 4 - 3
th precise details of foot and ankle kinesiology. For reasons such as those just described, pronation and supination at th subtalar joint are often referred to simply as
"eversion and inversion" of th calcaneus, respectively.
Eversion, for example, is only a component of, rather than
a synonym for, pronation. Comparisons of range of motion
data between studies are often made difficult, unless th
motions are explicitly defined.
Clinically, th expression "subtalar joint neutral" is of
ten used to establish a "baseline" or reference for evaluating a foot for an orthotic device.9'30 The neutral, or 0
degree, position of th subtalar joint is attained by placing
th subject's calcaneus in a position that allows both
lateral and mediai sides of th talus to be equally exposed for palpation within th mortise. In this position, th
joint is typically one-third th distance from full eversion
and two-thirds th distance from full inversion.
Chapter 14
Achilles
tendon
493
^lyTL'M
joint
Intermetatarsal joints
Calcaneocuboid joint
.Tarsometatarsal joints
r
o
o
Dista!
intertarsal
joints-
Talonavicular joint
Cuboideonavicular joint
Intercuneiform and
cuneocuboid joint
complex
Cuneonavicular joints
Cuneonavicular joints
Intercuneiform and
cuneocuboid joint
complex
Peroneus
brevis
_ Cuboideonavicular jointj
Transverse r- Talonavicular joint
tarsal i in t" | j ; a|Cane0Cup0j(j j 0jnt
Tarsometatarsal joints
Igalcaneusj
A
^ fa t a r s a ls
Achilles
tendon
FIGURE 14-22. A, Th e bones and disarticulated joinis o f th right foot are show n from tw o perspectives: superior-postenor (A) and
superior-anterior (B). A highlights th overall organization of th joints o f th foot.
longitudinal axis is nearly coincident with th straight anterior-posterior axis (Fig. 1 4 - 2 5 A to C), with th primary
component motions of eversion and inversion (Fig. 1 4 -2 5 D
and E). The oblique axis, in contrast, has a strong vertical
and medial-lateral pitch (Fig. 1 4 - 2 5 F to H). Motion about
this axis, therefore, occurs freely as a combination of abduction and dorsiflexion (Fig. 1 4 -2 5 1 ) and adduction and piantarJex-
Plantar view
Peroneus brevis
Osteokinematics
Peroneuslongus
Piantar
calcaneocuboid ligament
(short piantar ligament)
Long piantar ligament
Navicular tuberosity
Piantar calcaneonavicular
ligament (spring ligament)
Flexor digitorum longus
(cut)
Flexor hallucis longus
(cut)
FIGURE 14-23. Ligaments and tendons deep w ithin th piantar aspect o f th right foot. Note th course o f th tendons of th
peroneus longus and tibialis posterior.
494
Section IV
Lower Extremity
yi
? = >
j
Tibialis posterior
x Subtalar joint
FIGURE 1 4 -2 4 . Pronation and supination o f th unloaded tight foot demonstrates th interplay o f th subtalar and transverse tarsal
joints. W ith th calcaneus held fixed, pronation and supination occur prim arily at th m idfoot {A and C). W hen th calcaneus is
free, pronation and supination occur as a sum matton across both th rearfoot and m idfoot (B and D). Rearfoot m ovem ent is
indicated by gray arrows; m idfoot m ovem ent is indicated by red arrows. T h e tibialis posterior is show n in D as it directs attive
supination o ver both th rearfoot and midfoot.
Chapter 14
DORSIFLEXION/PLANTAR FLEXION
(Vertical axis)
(ML axis)
EVERSION/
INVERSION
EVERSION/
INVERSION
(AP axis)
j (APaxis)
Mediai view
Superior view
ABDUCTION/ADDUCTION
DORSIFLEXION/PLANTAR FLEXION
(Vertical axis)
(ML axis)
Mediai view
EVERSION/
INVERSION
EVERSION/
INVERSION
(AP axis)
(AP axis)
Superior view
FIGURE 14 25. T h e axes of rotation and osteokinemadcs al th transverse larsal joint. Th e longitudinal axis o f rotation is show n in
red from th side (A and C) and from above (B). M ovem ents that occur about this axis (D) are pronation (w ith th main
com ponent of eversion) and (E) supination (w ith th m ain com ponent o f in v e rs io n i T h e oblique axis o f rotation is show n in red
from th side (F and H ) and from above (C). M ovem ents that occur about this axis are (I) pronation (w ith main components o f
abduction and dorsiflexion) and ( J ) supination (w ith m ain components o f adducton and piantar flexion).
495
496
transverse arch exists (see Fig. 1 4 - 2 6 ). This arch is discussed in a later section covering th distai intertarsal joints.
Anatomie Considerations
Chapter 14
497
Pes Cavus Abnormally Raised Mediai Longiludinal Arch. In its least complicated form, pes cavus describes
an abnormally high mediai longitudinal arch.41 The condi-
Normal arch
Dropped arch
498
Section IV
Lower Exiremity
FIGURE 14-28. A case o f a m ild pes cavus deform ity o f unknow n etiology is show n in A. B to E show signs o r other deform i ties thai
m ay be associated w ith pes cavus: (B) callus form ation under th metatarsal heads; (C) equinus (piantar flexion) deform ity o f th forefoot,
(D) pronated forefoot relative to th rearfoot durin g weight hearing; (E) shortening o f th mediai colum n of th foot. (From Richardson
EG: N eurogenic disorders. In Canale S T (ed): Cam pbells Operative Orthopaedics, voi 4, 9th ed. St. Louis, M osby-Year Book, 1998.)
Severe cases ol pes cavus may develop secondary to neuromuscular disorders, such as Charcot-Marie-Tooth disease,
poliomyelitis, and cerebral palsy.41 In these cases, pes cavus
is often associated with other progressive problems, like
clawing of th toes, tight piantar fascia, and compensatory
overpronation of th forefoot. Treatment involves surgery
and orthotic management.
Chapter 14
499
Kinematic Mechanisms of Pronation. Immediately following th heel contact phase of gait, th dorsiflexed talocrural joint and slightly supinated subtalar joint rapidly pian
tar flex and pronate, respectively. The pronation at th
subtalar joint during stance is controlled by two mecha
nisms. First, th calcaneus tips into eversion as a result of
th ground reaction force passing just lateral to th anterior-
posterior axis of rotation through th calcaneus. The simultaneous impact of heel contaci also pushes th head of th
talus medially in th horizontal piane and inferiorly in th
sagittal piane. Relative to th calcaneus, this motion of th
talus abducts and dorsiflexes th subtalar joint. These motions are consistent with th defnition of pronation. A
loosely articulated skeletal model aids in th visualization of
this motion. Second, during th early stance phase, th tibia
and fibula, and io a lesser extern th femur, internally rotate
after initial heel contact.I7't0 Because of th embracing configuration of th talocrural joint, th internally rotating lower
leg steers th subtalar joint into further pronation. The argument is often raised that with th calcaneus in contact with
th ground, pronation at th subtalar joint causes, rather
than follows, internai rotation of th leg, and either perspective is valid.
The amplitude of pronation at th subtalar joint during
early stance is relatively small about 2 to 3 degrees on
average and lasts only about 1/4 of a second during average speed walking. The amount and th speed of th prona
tion influences th kinematics of th more proximal joints of
500
Seciion IV
Lower Exlremity
Action
Hip
Knee
Valgus strain
Subtalar joint
(rearfoot)
Transverse tarsal
joint (midfoot)
Inversion (supination)
Chapter 14
are th basis for many of th exercises and orthotics employed to reduce painful conditions related to excessive pronation.
50 1
w h i c h a r e r e c e iv in g fir m u p w a r d c o u n t e r f o r c e f r o m t h
f lo o r , t o t w is t in to r e la t iv e s u p in a t io n ( s e e Fig . 1 4 - 3 0 ) .
T h is r e c i p r o c a i k in e m a t ic r e la t io n s h ip b e t w e e n t h r e a r
f o o t a n d m o r e a n t e r io r r e g io n s o f t h f o o t d e m o n s t r a t e s
t h v e r s a t ilit y o f t h fo o t, a m p lif y in g t h o t h e r 's a c t io n
w h e n t h f o o t is u n lo a d e d ( s e e F ig . 14 - 2 4 6 ) , o r c o u n t e r a c t in g e a c h o t h e r s a c t io n w h e n t h f o o t is lo a d e d
( s e e F ig . 1 4 - 3 0 ) .
Foot Orthoses
C l i n ic ia n s g e n e r a lly a g r e e t h a t s o m e fo r m o f f o o t o r t h o s i s o r s p e c ia liz e d f o o t w e a r C o n t r o ls e x c e s s i v e p r o n a t io n
a t t h s u b t a la r jo in t .3202934 In g e n e r a i, a f o o t o r t h o s is is
a d e v ic e in s e r t e d in t o t h s h o e in o r d e r t o m o d if y t h
f o o t 's m e c h a n ic s . M o s t o fte n , a w e d g e is p l a c e d o n t h
m e d ia i a s p e c t o f t h o r t h o s is , w h i c h in t h e o r y C o n t r o ls
t h r a t e , a m o u n t , a n d t e m p o r a l s e q u e n c in g o f p r o n a t io n
a t t h s u b t a la r jo in t. A s a n a d j u n c t t o o r t h o s e s , s o m e
c l i n i c i a n s a ls o s t r e s s t h n e e d t o im p r o v e t h " e c c e n
t r ic c o n t r o l" o f t h m u s c le s t h a t d e c e le r a t e p r o n a t io n
a n d o t h e r a s s o c i a t e d m o t io n s m e c h a n i c a l l y lin k e d to
p r o n a t io n ( s e e T a b le 1 4 - 5 ) . T h e s e m u s c le g r o u p s in
c lu d e t h s u p in a t o r s o f t h f o o t a n d t h m o r e p r o x im a l
e x t e r n a l r o t a t o r s a n d a b d u c t o r s o f t h h ip . T h is t h e r a p e u t ic a p p r o a c h s t r iv e s to r e d u c e t h r a t e o f p r o n a t io n
a s w e l l a s t h r a t e o f lo a d in g o n t h fo o t.
The underlying pathomechanics of an excessively pronated foot are complex and not fully understood. The patho
mechanics can involve many kinematic relationships, both
within th joints of th foot or between th foot and th rest
of th lower limb. Even if th pathomechanics are obviously
located within th foot, abnormal motion in th forefoot can
be compensated by abnormal motion in th rearfoot and
vice, versa. Furthermore, extrinsic factors, such as footwear,
orthotics, terrain, and speed of walking or running, alter th
kinematic relationships within th foot and lower extremity.
An understanding of th complex kinesiology of th entire
lower extremity is a definite prerequisite for th effective
treatment of th painful or malaligned foot.
Mid to Late Stance Phase: Supination at th Subtalar Joint
502
FIGURE 14-31. With ihe foot fixed, full external rotation of th lower limb causes th following associateci movements: rearfoot supination (inversion) and raising of th mediai
longitudinal arch. Note that as th rearfoot
supinates, th forefoot and midfoot pronate to
maintain contact with th ground.
Cuneonavicular joints
Cuboideonavicular joint
lntercuneiform and cuneocuboid joint complex
Chapter 14
503
TARSOMETATARSAL JOINTS
INVERSION
Anatomie Considerations
Five tarsometatarsal joints are formed by th articulation
between th bases of th metatarsals and th distai surfaces
of th three cuneiforms and cuboid (see Fig. 1 4 - 2 2 ). Specifically, th first metatarsal articulates with th mediai cunei
form, th second with th intermediate cuneiform, and th
third with th lateral cuneiform. The bases of th fourth and
ffth metatarsal both articulate with th distai surface of th
cuboid.
The articular surfaces of th tarsometatarsal joints are
essentially fiat. Dorsal, piantar, and interosseous ligaments
add stability to these articulations. Of th five tarsometatarsal
joints, only th first has a well-developed capsule.55
Kinematic Considerations
The tarsometatarsal joints serve as base joints for each of th
rays of th foot. Mobility is least at th second tarsometatar
sal joint due, in part, to th wedged position of its base
between th mediai and lateral cuneiforms. Consequently,
he second ray forms a stable centrai pillar through th foot,
504
IN T E R M E T A T A R S A L JO IN T S
o u pc i i n i v ie
Interphalangeal
joint
Extensor hallucis
longus (cut)
Extensor digitorum
brevis (cut)
Distai interphalangeal
joint
Proximal interphalangeal
joint
Dorsal digitai expansion
Piantar piate
Sesamoid bones
Dorsal interassei
Extensor
digitorum brevis
Extensor
igitorum longus
M E T A T A R S O P H A L A N G E A L JO IN T S
Anatomie Considerations
Five metatarsophalangeal joints are formed between th convex head of each metatarsal and th shallow concavity of th
proximal end of each proximal phalanx (see Fig. 1 4 -2 2 ).
These joints can be palpated at about 2.5 cm proximal to
th web of th toes.
A r t ic u la r c a r t ila g e covers th distai end of each metatarsal
head (Fig. 1 4 -3 4 ). A pair of c o lla t e r a l lig a m en ts spans each
metatarsophalangeal joint, blending with and reinforcing th
capsule. As in th hand, each collateral ligament courses
obliquely from a dorsal-proximal to plantar-distal direction,
forming a thick cord portion and a fanlike accessory portion.
The accesso^ portion attaches to th thick, dense p ia n t a r
p ia t e , located on th piantar side of th joint. The piate, or
ligament, is grooved for th passage of llexor tendons. Fibers
from th deep piantar fascia connect into th piantar plates
and sheaths of th flexor tendons. Two s e s a m o id b o n e s lo
cated within th tendon of th flexor hallucis brevis rest
against th piantar piate of th frst metatarsophalangeal joint
(Fig. 1 4 -3 5 ). Although not depicted in Figure 1 4 - 3 5 , four
deep t r a n s v e r s e m e t a t a r s a l lig a m en ts blend with and join th
adjacent piantar plates of all five metatarsophalangeal joints.
By interconnecting all five plates, th transverse metatarsal
ligaments help maintain th first ray in a similar piane as th
tesser rays, thereby adapting th foot for propulsion and
weight hearing rather than manipulation. In th hand, th
Peroneus tertius
Kinematic Considerations
Movement at th metatarsophalangeal joints occurs in two
degrees of freedom. E x ten sio n (dorsiflexion) and j l e x i o n (pian
tar flexion) occur approximately in th sagittal piane about a
medial-lateral axis; a b d u c tio n and a d d u c tio n occur in th honzontal piane about a vertical axis. Both axes of rotation
ntersect at th center of each metatarsal head.
Mosi people demonstrate limited dexterity in movements
at th metatarsophalangeal joints, especially in abduction and
adduction. Passively, th toes can be hyperextended about
65 degrees and flexed about 30 to 40 degrees. The first toe
typically allows greater hyperextension to near 85 degrees.
505
hearing weight over th first metatarsophalangeal joint, causing th lateral metatarsal bones to accept a greater proportion of th load. The pathomechanics of marked hallux val
gus involve a zigzag-like collapse of th first ray, similar to
th ulnar drift of th metacarpophalangeal joint in th rheumatoid hand (see Chapter 8).
Although th etiology of hallux valgus is noi totally clear,
genetics, incorrect footwear, pronated feet that cause valgus
strain at th hallux, and asymmetry of th bones and joints
all contribute to th condition. The full spectrum of severe
hallux valgus is often associated with dislocation and osteoarthritis of th metatarsophalangeal joint, metatarsus varus
(adductus), valgus of th first toe, bunion formation over th
mediai joint, hammer toe of th second digit, calluses, and
metatarsalgia.42 Surgical intervention is often indicated in
cases of marked deformity and dysfunction.
IN T E R P H A L A N G E A L JO IN T S
506
Normal foot
INNERVATICI OF MUSCLES
Extrinsic muscles of th ankle and foot have their proximal
attachments in th leg, and a few extend as far proximal as
th distai thigh. Intrinsie muscles, in contrast, have both
proximal and distai attachments within th foot.
The extrinsic muscles are arranged in three compartments
of th leg: anterior, lateral, and posterior. Each compartment
is innervated by a different motor nerve. The anterior com
partment is innervated by th deep branch of th peroneal
nerve, th lateral compartment by th superficial branch of
th peroneal nerve, and th posterior compartment by th
tibia! nerve. Each of these is a branch of th sciatic nerve,
formed from th L4-S3 nerve roots of th sacrai plexus.
Lateral to th head of th fibula, th common peroneal
nerve (L4-S2) divides into a deep and superficial branch (Fig.
1 4 -3 8 ). The deep branch o f th peroneal nerve innervates th
muscles within th anterior compartment: th tibialis ante-
507
TABLE 1 4 - 6 . Major Actions at Regions o f th Ankle and Foot During th Stance Phase of Walking*
Early Stance
R eg ion
R e p r e s e n t a t iv e Jo in t
A ction
D e s ir e d F u n ctio n
A ctio n
D e s ir e d F u n ction
Ankle
Talocrural
Piantar flexion
Dorsiflexion followed
by rapid piantar
flexion
Rearfoot
Subtalar
Continued pronation
changing to supination, followed
by a raising of th
mediai longitudinal arch
Midfoot
Transverse tarsal
joint
Relative inversion as a
response to counterforce from th
ground
Relative everson
Forefoot
Metatarsophalangeal
Insignificant
Hyperextension
Increases tension in th
piantar fascia
Through th windlass effect, raises th mediai
longitudinal arch and
stabilizes th midfoot
and forefoot for push
off
S E N S O R Y IN N E R V A T IO N TO T H E JO IN T S
508
Antcrior view
FIGURE 14-38. The path and generai proximal-to-distal order of muscle innervation
for th deep and superficial branches of
th common peroneal nerve are illustrated.
The primary nerve roots are in parentheses. (Modified with permission front deGroot J: Correlative Neuroanatomy, 2 lst
ed. Norwalk, Appleton & Lange, 1991.)
Tibialis anterior
Extensor digitorum longus
Extensor hallucis longus
Peroneus tertius
In n er v a tio n
509
Posterior vievv
-Sural nerve
Tibial nerve
M ediai piantar
n e rv e '
Lateral piantar
nerve
'--V
s.
SENSORY DISTRIBUTION
Nerve
Muscles
Nerve
Muscles
Tibialis anterior
Extensor digitorum longus
Peroneus tertius
Extensor hallucis longus
Plantaris
Tibialis posterior
Flexor digitorum longus
Flexor hallucis longus
Gastrocnemius and soleus
510
DORSIFLEXION [\
INVERSION
DORSIFLEXION
EVERSION
J h loerin-iii
Peroneus tertius
/"'rixT
\i
Tibialis posterior-
'Peroneus brevis
PLANTAR FLEXION
INVERSION
m
t r \)
A nterior view
PLANTAR FLEXION
EVERSION
FIGURE 14-40. The multiple actions of muscles that cross th taiocrural and subtalar joints, as viewed from above. The actions of
each muscle are based on its position relative to th axes of rotation
at th joints. Note that th muscles have multiple actions.
Joint Action
- Tibialis anterior
Peroneus longus-
Superior extensor
retinaculum -
Interior extensor
retinaculum-
Extensor digitorum
brevis -
Chapter 14
511
Piantar view
Lateral view
The tendon of th peroneus brevis muscle travels posterior to th lateral malleolus alongside th peroneus longus
(see Fig. 1 4 - 1 5 ). Both peroneal tendons occupy th same
synovial sheath as they pass under th peroneal retinaculum.
It holds th tendons posterior to th lateral malleolus. The
512
Chapter 14
513
FIGURE 14-45. The superficial muscles of th postevior compartment of th righi leg are shown: A, th gastrocnemius; B, th soleus and plantaris.
514
Plantaris
(cut)
(cut)
Tibialis posterior
Flexor digitorum
hallucis longus
malleolus
tendon
(cut)
Chapter 14
515
FIGURE 14-47. A mediai view of ihe flexor retinaculum that covers th tendons of th tibialis posterior,
flexor digitorum longus, and posterior tibial neurovascular bundle. (Front Richardson EG: Neurogenic
disorders. In Canale ST (ed): Campbell's Operative Orthopaedics, voi 4, 9th ed. St. Louis, Mosby-Year
Book, 1998.)
Dorsiflexion
producine
knee flexion
Piantar flexion
producine knee
extension
f u n c t io n b e c o m e s e v id e n t w h e n o b s e r v in g t h g a it o f a
p e r s o n w it h w e a k e n e d p ia n t a r f le x o r m u s c le s . W it h o u t t h
m u s c l e 's n e c e s s a r y b r a k in g o r d e c e le r a t in g a c t io n a t t h
a n k le , t h lo w e r le g a d v a n c e s v ia a n k le d o r s if le x io n to o
r a p id ly a n d t o o f a r d u r in g t h m id t o la t e s t a n c e p h a s e o f
g a it. A s s h o w n w it h a w e a k e n e d s o le u s w h ile s t a n d in g
( F ig u r e 1 4 - 4 8 A ) , a f o r w a r d ly r o t a t e d le g s h if t s t h f o r c e o f
b o d y w e ig h t p o s t e r io r t o t h m e d ia l- la t e r a l a x is o f r o t a t io n
a t t h k n e e . T h is s h if t c a n c r e a t e a s u d d e n a n d o fte n
u n e x p e c t e d k n e e f le x io n t o r q u e . T h e d o r s if le x e d a n k le , in
t h is c a s e , b ia s e s f le x io n a t t h k n e e .
Weakened soleus
unable to decelerate
dorsiflexion
A n im p o r t a n t f u n c t io n o f t h s o le u s m u s c le is t o r e s is t
e x c e s s i v e f o r w a r d r o t a t io n o f t h le g , t h e r e b y m a in t a in in g
b o d y w e ig h t o v e r o r ju s t a n t e r io r t o t h k n e e 's m e d ia lla t e r a l a x is o f r o t a t io n . W it h t h f o o t f ix e d t o t h g r o u n d ,
a c t iv e p ia n t a r f le x io n a t t h a n k le c a n e x t e n d t h k n e e
(F ig . 1 4 - 4 8 B ) . 50 T h e s o le u s m u s c le is p a r t ic u la r ly w e ll
s u it e d t o s t a b iliz e t h k n e e in e x t e n s io n . A s a p r e d o m in a t e ly s lo w - t w it c h m u s c le , t h s o le u s c a n p r o d u c e r e la t iv e ly lo w f o r c e s o v e r a r e la t iv e ly lo n g d u r a t io n b e f o r e
f a t ig u in g . M a r k e d s p a s t ic it y in t h s o le u s m u s c le e x e r t s a
p o t e n t a n d c h r o n ic k n e e e x t e n s io n b ia s th a t , o v e r t im e ,
c a n c o n t r ib u t e t o g e n u r e c u r v a t u m d e f o r m it y .
Body weight
Body weight
516
FLEXION
FLEXION
M U S C U L A R P A R A L Y S IS F R O M IN JU R Y TO T H E
P E R O N E A L OR T IB IA L N E R V E S
The common branch of th peroneal nerve is located superfcially as it winds around th lateral neck of th fibula, just
deep to th peroneus longus. This nerve is mjured fre
q u e n ti from lacerations or trauma that involves a fractured
fibula. Injury to th deep branch of th peroneal nerve can
result in paralysis of all th dorsiflexor (pretibial) muscles
(see Fig. 1 4 -3 8 ). With paralysis of th dorsiflexor muscles,
th foot rapidly and uncontrollably piantar flexes following
floor contact. During th swing phase, th hip and knee
must excessively flex to ensure that th toes clear th
ground.
Paralysis of th dorsiflexor muscles dramatically increases
th likelihood of developing a fixed piantar flexion contracture at th talocrural joint. This deformity is called a dropfoot or pes equinus. In a surprisingly short period of time, a
Gastrocnemius
89.7
4.8
430.6
Soleus
78.0
4.8
374.4
Tibialis posterior
22.6
2.3
52.0
Peroneus longus
16.8
2.6
43.7
17.6
2.3
40.5
Peroneus brevis
14.8
2.6
38.5
10.9
2.3
25.1
250.4
1004.8
Total
B i o m e c h a n i c s o f R a is in g u p o n T ip t o e s
517
h e lp s t h in t r in s ic m u s c le s s u p p o r t t h m e d ia i lo n g it u d in a l
T h e f u n c t io n a l s t r e n g t h o f t h p ia n t a r f le x o r m u s c le s is
o f t e n e v a lu a t e d b y r e q u ir in g a s u b j e c t t o r e p e a t e d ly s t a n d
a r c h a n d m a in t a in a r ig id f o r e f o o t , t h e r e b y a llo w in g t h
f o o t t o a c c e p t t h lo a d im p o s e d b y b o d y w e ig h t .
o n t ip t o e s . A s s h o w n in F ig u r e 1 4 - 5 0 , m a x im a lly r a is in g
t h b o d y r e q u ir e s a n in t e r a c t io n o f t w o c o n c u r r e n t
t o r q u e s , o n e a t t h t a lo c r u r a l jo in t a n d o n e a t t h m e t a t a r s o p h a la n g e a l jo in t s . T h e p ia n t a r f le x o r m u s c le s , r e p r e s e n t e d b y t h g a s t r o c n e m iu s , p ia n t a r f le x t h
jo in t
talocrural
b y r o t a t in g t h c a l c a n e u s a n d t a lu s w it h in t h m o r -
t is e . T h e p r im a r y t o r q u e u s e d t o r a is e t h b o d y , h o w e v e r ,
is p r o d u c e d b y e x t e n s io n a c r o s s t h
joints.
metatarsophalangeal
A c t in g a b o u t t h e s e a x e s , t h g a s t r o c n e m iu s h a s a n
in t e r n a i m o m e n t a r m t h a t g r e a t ly e x c e e d s t h e x t e r n a l
m o m e n t a r m o w in g t o b o d y w e ig h t ( c o m p a r e
and
C in
F ig . 1 4 - 5 0 ) . S u c h a la r g e m e c h a n ic a l a d v a n t a g e is r a r e in
t h m u s c u lo s k e le t a l S y s t e m . A c t in g a s a s e c o n d - c l a s s
le v e r w it h t h p iv o t p o in t a t t h m e t a t a r s o p h a la n g e a l
jo in t s , t h g a s t r o c n e m iu s lif t s t h b o d y u s in g m e c h a n ic s
s im ila r t o t h o s e o f a p e r s o n lif tin g a la r g e lo a d w it h a
w h e e lb a r r o w . If, f o r in s t a n c e , t h g a s t r o c n e m iu s f u n c t io n s
w it h a m e c h a n ic a l a d v a n t a g e o f 3:1 (i.e ., t h r a t io o f t h
in t e r n a l- t o - e x t e r n a l m o m e n t a r m , o r
B/C
in t h F ig u r e ) , t h
m u s c le n e e d s t o p r o d u c e a lif t in g f o r c e o f o n ly o n e t h ir d ,
o r 33 % , o f b o d y w e ig h t t o s u p p o r t t h p ia n t a r f le x e d
p o s it io n . R a r e ly in t h b o d y d o e s a m u s c le p r o d u c e a
f o r c e le s s t h a n t h lo a d it is s u p p o r t in g . A s a m e c h a n ic a l
t r a d e - o f f , h o w e v e r , t h g a s t r o c n e m iu s , in t h e o r y , n e e d s to
s h o r t e n a d is t a n c e t h r e e t im e s g r e a t e r t h a n t h v e r t ic a l
d is p la c e m e n t o f t h b o d y 's c e n t e r o f m a s s ( s e e C h a p t e r
1). M a x im a l c o n t r a c t io n o f t h g a s t r o c n e m iu s w o u ld p r o
d u c e a v e r t ic a l d is p la c e m e n t o f t h b o d y o n ly o n e - t h ir d
t h le n g t h o f t h m u s c le c o n t r a c t io n . N e v e r t h e le s s , t h
n a t u r e o f t h is t r a d e - o f f a l l o w s o n e t o s t a n d u p o n t ip t o e s
w it h r e la t iv e e a s e .
F ig u r e 1 4 - 5 0 s h o w s t h im p o r t a n c e o f a m p ie h y p e r e x t e n s io n r a n g e o f m o tio n a t t h m e t a t a r s o p h a la n g e a l
jo in t s . N o t o n ly d o t h p ia n t a r f le x io n m u s c le s u s e t h e s e
jo in t s t o a u g m e n t t h e ir in t e r n a i m o m e n t a r m , b u t, a s d e s c r ib e d e a r lie r , h y p e r e x t e n s io n o f t h e s e j o in t s p u lls t h
p ia n t a r f a s c i a t a u t v ia t h w i n d l a s s e f f e c t . T h is a c t io n
Injury to th tibial nerve may cause varying levels of weakness or paralysis in th muscles of th posterior compartment (see Fig. 1 4 -3 9 ). Paralysis of th gastrocnemius and
soleus results in profound diminution in piantar flexion
torque. Over time, a fixed dorsiflexion posture may result at
518
Section /V
Lower Exlremity
TABLE 1 4 - 1 0 . Common Fixed Deformities or Abnormal Postures of th Ankle and Foot from Muscle
Paralysis*
Fixed Deformity or Abnormal
Posture
Common
Clinical Name
Examples of Subsequent
Musculotendinous Shortening
Drop-foot or pes
equinus
Gastrocnemius, soleus
Inversion (supination) of th
foot
Pes varus
Tibialis posterior
Pes equinovarus
Pes calcaneus
Pretibial muscles
Pes valgus
Peroneal muscles
Dorsiflexion of th talocrural
joint and eversion of th foot
Pes calcaneovalgus
INTRINSIC M U S C L E S
l. a y e r 1
A n a to m ie a n d F u n c tio n a l C o n s id e ra tio n s
519
2nd laver
lst la ver
Flexor digitorum
brevis (cut)
Abductor
hallucis
(cut)
Sesamoids
Abductor digiti
minimi (cut)
Abductor
digiti
minimi
Lumbricals
Flexor
hallucis
longus
Abductor
hallucis
Flexor
digitorum
brevis
Adductor hallucis
(transverse head)
Piantar interassei
Flexor digiti minimi
Flexor
digitorum
longus
Quadratus
plantae
Abductor hallucis
(cut)
Adductor hallucis
(oblique head)
Flexor hallucis
brevis
Peroneus brevis
Peroneus longus
Tibialis posterior
Long piantar
ligament
Piantar fascia
(cut)
P ia n t a r a s p e c t
FIGURE 14-51. The intrinsic muscles of th piantar aspect of th foot are organized into four layers.
attaches dstally to th mediai border of th proximal phalanx of th frst toe, together with th mediai head of th
flexor hallucis brevis (Fig. 1 4 -5 1 C ). The abductor digiti min
imi forms th lateral-plantar margin of th loot, attaching
dstally to th lateral border of th base of th proximal
phalanx of th ffth toe. Each muscle abducts and flexes its
respective digit.
I.ayer 2
The intrinsic muscles in th second layer are th quadra
tus plantae and th lumbricals (Fig. 14-51J3). Both muscles
are functionally related to th tendons of th ilexor digito
rum longus. The quadratus plantae (flexor digitorum accessorius) attaches by two heads to th piantar aspect of th
calcaneus. Both heads attach dstally on th lateral edge of
th common tendon of th flexor digitorum longus. The
quadratus plantae helps to stabilze th tendons of th flexor
digitorum longus, preventng them from migrating medially
when under force. The four lumbricals have their proximal
atiachment from th tendons of th flexor digitorum longus.
These small fleshy muscles pass on th mediai side of th
lesser toes to attach into th extensor digitai expansion. They
can flex th metatarsophalangeal joint and extend th interphalangeal joints.
Quadratus plantae
Lumbricals
Layer 3
The intrinsic muscles in th third layer are th adductor
hallucis, flexor hallucis brevis, and flexor digiti minimi (Fig.
1 4 -5 1 C ). As a whole, these short muscles arise from th
piantar aspect of th cuboid, cuneifonrts, and bases of more
centrai metatarsal bones, and from th locai conneclive tissues. As in th hand, th adductor hallucis arises from two
heads: oblique and transverse. Both heads attach to th lat
eral base of th proximal phalanx of th First toe and adjacent lateral sesamoid bone. The muscle flexes and adducts
th metatarsophalangeal joint of th first toe. The flexor hal
lucis brevis has two heads that attach dstally to th mediai
and lateral sides of th base of th proximal phalanx of th
first toe. Mediai and lateral sesamoid bones are located
within th two tendons of this muscle, providing padding to
th head of th First metatarsal. The flexor digiti minimi at
taches to th lateral base of th proximal phalanx of th ffth
toe, together with th abductor digiti minimi. Both muscles
flex th metatarsophalangeal joint of their respective toes.
Adductor hallucis
Flexor hallucis brevis
Flexor digiti minimi
520
Layer 4
The fourth layer of intrinsic muscles contains three pian
tar and four dorsal interassei muscles. The piantar interassei
are shown in Figure 1 4 -5 1 C , along with th muscles of th
third layer. The dorsal interassei are illustrated in Figure
1 4 - 3 5 . The overall pian of th interassei is nearly identical
to that of th hand, except that th reference digit for
abduction/adduction of th toes is th second, instead of th
third.
REFERENCES
1. Allinger TL, Ensberg JR: A method to determine th range of motion of
th ankle complex: In vivo. J Biomechan 26:69-76, 1993.
2. Basmajian JV, Stecko G: The role of muscles in arch support of th
foot. J Bone Joint Surg 45A 1184-1190, 1963.
3. Brown GP, Donatelli RD, Catlin PA, et al: The effect of two types of
foot orthoses on rearfoot mechanics. J Orthop Sports Phys Ther 21
258-266, 1995.
4 Buckwalter JA, Saltzman CL: Ankle osteoarthrilis: Distinctive characieristics. AAOS Instructional Course Leciures 48:233-241, 1999.
5. Cashmere T, Smith R, Hunt A: Mediai longitudinal arch of th foot:
Stationary versus walking measures. Foot Ankle Ini 20:112-118, 1999.
6. Cavanagh PR, Rodgers MM, liboshi A: Pressure distribution under
symptom-free feet during barefoot standing. Foot Ankle lnt 7 262-276
1987.
7. Colville MR, Marder RA, Boyle JJ, et al: Strain measurement in lateral
ankle ligaments. Am J Sports Med 18:196-200, 1990.
8. Cornali MW, McPoil TG: Three-dimensional movement of th foot
during th stance phase of walking. J Am Podiatr Med Assoc 89:56-66
1999.
Elveru RA, Rothstein JM, Lamb RL, et al: Methods for taking subtaar
joint measurements: A clinical report. Phys Ther 68:678-682, 1988.
10. Engsberg JR: A biomechanical analysis of th talocalcaneal joint in
vitro. J Biomechan 20:429-442, 1987
11 Faber FWM, Kleinrensink GJ, Verhoog MW, et al: Mobility of th (irsi
tarsometatarsal joint in relation to hallux valgus deformity: Anatomical
and biomechanical aspects. Foot Ankle Ini 20:651-656, 1999.
12. Fallai L, Grimm DJ, Saracco JA: Sprained ankle syndrome: Prevalence and
analysis of 639 acute mjures. J Foot Ankle Surg 37:280-285, 1998.
13. Glasoe WM, Yack HJ, Saltzman CL: Anatomy and biomechanics of th
first ray. Phys Ther 79:854-859, 1999.
14. Grimston SK, Nigg BM, Hanley DA, et al: Differences in ankle joint
complex range of motion as a function of age. Foot Ankle Ini 14 215
222, 1993.
15. Hopson MM, McPoil TG, Comwall MW: Motion of th frst metatarso
phalangeal joint: Reliability and validity of four measurement techniques. J Am Podiatr Med Assoc 85:198-204, 1995.
16. Huang CK, Kitaoka HB, An KN, et al: Biomechanical evaluation of
longitudinal arch stability. Foot Ankle lnt 14:353-357, 1993.
17. Inman VT: The Joints of th Ankle. Baltimore, Williams & Wilkins
1976
18. Inman VT, Saunders JB: Referred pain from skeleta! siructures. J Nerv
Meni Dis 99:660-667, 1944.
19. Isman RE, Inman VT: Anthropometric studies of th human foot and
ankle. Bull Prosthet Res 10:97-129, 1969.
20. Johanson MA, Donatelli R, Wooden ML, et al: Effects of three different
posting methods on controlling abnormal subtaar pronation. Phys Ther
79:149-158, 1994.
21 Kaufman KR, Brodine SK, Shaffer RA, et al: The effect of foot structure
and range of motion on musculoskeletal overuse mjuries. Am J Sports
Med 27:585-593, 1999
22. Kapandji 1A: The Physiology of th Joints, voi 2, 5th ed., Edinburgh,
Churchill Livingstone, 1982
23. Rendali FP, McCreary AK, Provance PG: Muscles: Testing and Function,
4th ed. Baltimore, Williams & Wilkins, 1993.
24. Kitaoka HB, Luo ZP, An KN: Three-dimensional analysis of flatfoot
deformity: Cadaver study. Foot Ankle lnt 19:447-451, 1998.
25. Kitaoka HB, Patzer GL: Subtaar arthrodesis for postenor tibia! tendon
dysfunction and pes planus. Clin Orthop Rei Res 345:187-194, 1997.
26. Kura H, Luo ZP, Kitaoka HB, et ai: Role of th mediai capsule and
transverse metatarsal ligament in hallux valgus deformity. Clin Orthop
Rei Res 354:235-240, 1998.
27. Mann RA: Biomechanics of th foot. In American Academy of Orthopedic Surgeons (eds): Atlas of Orthotics: Biomechanical Principles and
Application. St. Louis, Mosby, 1975, pp 257-266.
28. Manter JT: Movements of th subtaar joint and transverse tarsal joint.
Anat Ree 80:397-410, 1941.
29. McCulloch MU, Brunt D, Vander Linden D: The effect of foot orthotics
and gait velocity on lower limb kinematics and temporal events of
stance. J Orthop Sports Phys Ther 17:2-10, 1993.
30. McPoil TG: The Foot and Ankle. In Malone TR, McPoil T, Nttz AJ
(eds): Orthopedic and Sports Physical Therapy, 3rd ed. St. Louis,
Mosby-Year Book, 1997.
31. McPoil TG, Knecht HG, Schuit D: A survey of foot types in norma!
females between ages of 18 and 30 years. J Orthop Sports Phys Ther 9'
406-409, 1988.
32 Murray MP, Guten GN, Baldwin JM, et al: A comparison of plantarflexlon torque with and withoui th triceps surae. Acta Orthop Scand 47
122-124, 1976
33. Murray MP, Guten GN, Sepie SB, et al: Function of th triceps surae
during gait. J Bone Joint Surg 60A:473-476, 1978.
34. Nigg BM, Khan A, Fisher V, et al: Effect of shoe insert construction on
foot and leg movement Med Sci Sports Exerc 30:550-555, 1998.
35. Nistor L, Markhede G, Grimby G: A technique for measurements of
piantar flexion torque with th Cybex dynamometer. Scand J Rehab
Med 14:163-166, 1982.
36. Pearce TJ, Buckley RE: Subialar joint movement: Clinical and computed
tomography scan correlation Foot Ankle lnt 20:428-432, 1999.
37. Pomeroy GC, Pike RH, Beals TC, et al: Acquired flatfoot in adults due
to dysfunction of th posterior tibial tendon. J Bone Joint Surg 81A
1173-1182, 1999.
38. Powers CM, Maffucci R, Hampton S: Rearfoot posture in subjecis with
patellofemoral pain. J Orthop Sports Phys Ther 22:155-160, 1995.
39. Proctor P, PaulJP: Ankle joint biomechanics. J Biomechan 15:627-634
1982
52.
53.
54
55
56.
57.
521
ADDITIONAL READINGS
Basmajian JV, Bentzon JW: An electromyographic study of certain muscles
of th leg and foot in th standing posilion. Surg Gynecol Obstet 98:
662-666. 1954.
Chan CW, Rudins A: Foot Biomechanics dunng walking and running Mayo
Clin Proc 69:448-461, 1994.
Comwall MW, McPoil TG: Relative movement of th navicular bone during
normal walking. Foot Ankle Int 20:507-512, 1999.
Eng JJ, Pierrynowski MR: The effect of soft foot orthotics on th threedimensional lower limb kinematics during walking and running. Phys
Ther 74:836-844, 1994.
Oatis CA: Biomechanics of th foot and ankle under static conditions. Phys
Ther 68:1815-1821, 1988.
C h a p t e r
15
Kinesiology of Walking
Guy G. Sim o n ea u , PT, P h D, ATC
TOPICS
HISTORICAL PERSPECTIVE OF GAIT
ANALYSIS, 524
SPATIAL ANO TEMPORAL DESCRIPTORS,
527
AT
GLANCE
Knee, 550
Ankle and Foot, 550
Trunk, 551
GAIT KINETICS, 551
Hip, 548
INTRODUCTION
Walking (ambulation) serves an individual's basic need to
move from place to place. As such, walking is one of th
most common activities that people do on a daily basis.
Ideally, walking is performed both efficiently, to minimize
fatigue, and safely, to prevent falls and associated injuries.
Years of practice provide a healthy person with th control
needed to ambulate while carrying on a conversation, looking in various directions, and even handling obstacles and
other destabilizing forces with minimal effort.
Although a healthy person gives walking th appearance
of an effortless task, th challenge of ambulation can be
recognized by looking at individuals at both ends of th
lifespan (Fig. 1 5 - 1 ). Early in life, th young child needs
several rnonths to leam how to stand and walk. In fact, it is
only by th age of 7 years that all th refinements of a
mature gait pattern are completed.76 Late in life, walking
often becomes an increasingly greater challenge. Because of
decreased strength, decreased balance, or disease, th elderly
may require a cane or walker to ambulate safely. Patla6'1
eloquently expressed th importance of ambulation in our
lives: Nothing epitomizes a level of independence and our
perception of a good quality of life more than th ability to
travel independently under our own power from one place
to another. We celebrate th development of this ability in
children and try io nurture and sustain it throughout th
lifespan.
M ajo r T o p ics
Spatial and temperai descriptors
Control of th bodys center of mass
Joint kinematics
Strategies to minimize energy expenditure
Energy expenditure
Muscle activity
Gait kinetics
Gait dysfunctions
524
FIGURE 15-2. Mareys instrumented shoes used for th measurement of gait. (From Marey, 1873.)
Chapter 15
individuai walked and provided a permanent record of
movement.
Concurrently, advances in th field of cinematography
created a powerful medium to study and record th kinematic patterns of humans and animals walking. Muybridge
may be th most recognized individuai of his time to use
cinematography to document sequence ol movements. Muy
bridge is most famous for settling an old controversy regarding a trotting horse. In 1872, using sequence photography,
he showed that all four feet of a trotting horse are indeed
simultaneously off th ground for very brief periods of lime.
Muybridge created an impressive collection of photographs
on human and animai gait, which was initially published in
1887 and assembled and reproduced in 1979.60-6'
Initially, th description of gait was limited to planar
analyses; th motion was typically recorded in th sagittal
'
'muti,
525
Kinesiology of Walking
1i
7 ! V. 7
^rrr-
' i
pi
t n
ncww www*////,,
7 tat
\\
j .
526
Section /V
Lower Extremity
ing was greatly enhanced by many scientific advances. Instrumentation to document kinematics evolved from simple
video cameras, with film that required painstaking analysis
with a ruler and protractor, to highly sophisticated infrared
Systems, with real-time coordinate data of limb segments.
Notable researchers who contributed to th description of
th kinematics of gait using a variety of imaging techniques
include Eberhart (1 9 4 7 ),17 Murray (1967),53 54 Inman (1 9 8 1 ),34
Winter (1991),98 and Perry (1992).67 Noteworthy is th
work by Murray, a physical therapist and researcher, who
published several papers in th 1960s, 1970s, and 1980s,
describing th kinematics of many aspects of normal and
abnormal gait (Fig. 1 5 - 3 ) .52'55-56-59 Among other accomplishments, data from her research on th kinematics of walking in individuals with disabilities influenced th design of
artificial joints and lower extremity prosthetic limbs.
Chapter 15
Kinesiology of Walking
527
Left step
Righi step
FIGURE 15-6. The gaie cycle from righi heel contact to th subsequent right heel contact.
Gait Cycle
Walking is th result of a cyclic series of movements. As
such, it can be convenienti) characterized by a detailed description of its most fundamental unii: a gait cycle (Fig.
1 5 - 6 ) . The gait cycle is initiated as soon as th foot contacts
th ground. Because foot contact is normally made with th
heel, th 0% point or beginning of th gait cycle is referred
to as heel contact, or heel strike. The 100% point or comple-
Right
heel
contact
FIGURE 15-7. Spatial descriptors of gait and their normal values for a right gait cycle.
528
A.
NORMAL
G A IT
/V /
|- ------------ 78 c . --- H
RIGHI
UMB
LEfT
UMB
C . H E M IP A R E S IS
B. P A I N F U L
H----- 78 -------- -J
LEFT
LIMB
G A IT
RIGHI
LIMB
H IP
z_u
I- R itaH
SOUND
LIMB
| 31 ca|
I M P A I R E D I M P A I R E D SOUND
UMB
UMB
UMB
D. PARKINSON'S DISEASE
GAIT
R 33c.4
SOUND
UMB
PARETIC
LIMB
f27c4
PARE TIC
UMB
SOUND
UMB
G A IT
|26t|
-24ca
|
RIGHI
LEFT
LEFT
RIGHI
UM B
LIMB
UMB
UMB
Walking speed combines both spatial and temporal measurements by providing information on th distance covered
in a given amount of time. The units of measurements are
FIGURE 15-8. Influence of impairmem and pathology on siep lengih. A illustraies ihe symmetrical siep length expected in a healthy individuai. B
and C are examples of siep length asymmetry
often seen in those wiih an impairment or a pathology thai affects a single lower extremity. Noie
thai th unilaieral paihology in C resulted in bilateral shortening of th normal step length, demonstrating th interdependence of th lower exiremities during gaii. D illusirates a relatively
symmetrical bilateral reduction in step length secondary to Parkinsons disease, a pathology ihat
often affects both lower exiremities. (From Mur
ray MP: Gait as a total pattern of movement. Am
J Phys Med 46:290, 1967.)
Chapter 15
529
Kincsiology of Walking
J T A B L E 1 5 - 1 . Normative Data for W alking Speed, Step Rate, and Step Length
Drillis (1961)
(New York City)
Molen (1973)
(Amsterdam)
Average Over
Gender and City
1.46*
1.39 (males)
1.27 (females)
1.37 (males)
1.24 (females)
1.37
1.9*
1.79 (males)
1.88 (females)
1.84 (males)
1.94 (females)
1.87
0.76*
0.77 (males)
0.67 (females)
0.74 (males)
0.63 (females)
0.72
1 5 - 9 ). Typically, an individuai combines both sirategies until th longest comfortable step length is reached. From that
point on, a further increase in speed is solely related to
increased cadence. All measurements o f gait (spadai, temporal,
kinematic, and kinetic) depend on walking speed. For proper
referente and interpretation, therefore, reports of gait characteristics should include th walking speed at which th data
were collected.
FREE
SPEED
W A L K IN G
FIGURE 15-9. Methods to increase walking speed. A illustrates th longer step length used to increase walking speed;
B illustrates th walking cadence used at a faster walking speed. The duration of th gait cycle is reduced from 1.08
seconds to 0.91 second. B also illustrates that at th faster walking speed, a smaller percemage of th gait cycle is
spent in double-limb support (i.e., 16% at fast speed compared with 24% at free speed walking). (A from Murray MP,
Kory RC, Clarkson BH, Sepie SB: Comparison of free and fast speed walking patterns of normal men. Am J Phys Med
45:8, 1966; B Modified from Murray MP, Gore DR, Clarkson BH: Walking patterns of patients with unilateral hip
pain due to osteoarthritis and avascular necrosis. J Bone Joint Surg 53A:259, 1971.)
530
Chapter 15
Kinesiology of Walking
531
Events
Heel contact
Foot fiat
Stance
Mid stance
Heel off
Toe off
Swing
Early swing
Mid swing
Late swing
Heel contact
% o f Cycle
0
8
10
30
40
50
60
6 0 -7 5
7 5 -8 5
8 5 -1 0 0
90
100
Toe off
Mid swing (2 5 -3 5 % )
Heel contact
532
FIGURE 15 12. Terminology lo describe th events of th gait cycle. Inaiai contact corresponds to th beginning of stante when th
loot first contacts th ground ai 0% of gait cycle. Opposite toc off occurs when th contrasterai foot leaves th ground ai 10% of
gait cycle. Heel rise corresponds to th heel lifting from th ground and occurs at approximately 30% of gait cycle Opposite initial
contact corresponds to th foot contact of th opposite limb, typically at 50% of gait cycle. Toe off occurs when th foot leaves th
ground at 60% of gait cycle. Feet adjacent takes place when th foot of th swing leg is next to th foot of th stance lee at 73% of
gait cycle. Tibia vertical corresponds to th tibia of th swing leg being oriented in th vertical direction at 87% of gait cycle The
linai event is, again, initial contact, which in fact is th start of th next gait cycle.
Ihese eight events divide ihe gait cycle into seven periods. Loading response, between initial contact and opposite toe off
corresponds to th urne when th weight is accepted by th lower extremity, initiating contact with th ground. Mid stance is from
opposite toe off to heel rise (10 to 30% of gait cycle). Terminal stance begins when th heel rises and ends when th contrasterai
ower extremity touches th ground, from 30 to 50% of gait cycle. Pre swing takes place from foot contact of th contrasterai limb
nt e r
, 1Ps'later?1 lootl wt,ch 1S lhe llme corresponding lo th second double-limb supporr period of th gau cycle (50 to
60% of gau cycle). Inaiai swing is from toe off lo feet adjacent, when th foot of th swing leg is next to th foot of th stance leg
(60 to 73% ol gau cycle). Mici swing is from leet adjacent to when th tibia of th swing leg is vertical (73 to 87% of gait cycle)
i acT r l mng 'S fr m 3 vemcal Posltlon of the tibia to immediately prior to heel contaci (87 to 100% of th gait cycle) The first
10% of th gait cycle corresponds to a task of weight acceptance-when body mass is tra n sfe rt from one lower extremity to th
other. Single-hmb supporr, from 10 to 50% of th gait cycle. serves to support th weight of th body as th opposite limb swings
lorward. The Sst 10% of stance phase and th entire swing phase serve to advance th limb forward to a new location.
contact, opposite toe off, heel rise, opposite initial contact, toe off,
feet adjacent, tibia vertical, and initial contact for th next
stride. The four time periods durmg stance are loading re
sponse, mid stance, terminal stance, and pre swing. Swing
phase has three lime periods: initial swing, mid swing, and
terminal swing. With a few exceptions, this terminology is in
generai agreement with th more traditional description of
gait.
The existence of two dtfferent terminologies can be confusing, especially w'hen many use them interchangeably. In
this chapter, we predominantly use th terminology proposed by Perry in 1992.67 And to eliminate any confusion,
we describe th timing of th events during gait as a percentage of th gait cycle.
Chapter 15
S P E C I A L
F O C U S
1 5 - 2
Kinesiology oj Walking
533
534
Section IV
Lower Extremity
15-1
1 5 -2
Chapier 15
Kinesiology o f Walking
535
Potential Energy
FIGURE 15-14. Transfer between potential and kinettc energy during gait. The minimum potential energy exists
when th center of mass (CoM) is at its lowest points (5% and 55% of th gait cycle). The maximum potential
energy occurs when th CoM is at its highest points (30% and 80% of th gait cycle). The reverse occurs for
kinetic energy. For example, a bicycle that gains speed while going down a hill and loses speed while it climbs
up th next hill illustrates th transfer between potential and kinetic energy.
JOINT KINEMATICS
During gait, th bodys CoM is displaced linearly as a result
of th summation of th angular rotation of th joints of th
lower extremities, which is not unlike a car moving forward
owing to th rotation of its tires. Movements at th joints of
th lower extremities, therefore, are described as a function
of angular rotation. Although joint angular rotation occurs
primarily in th sagittal piane, important motion, although of
smaller magnitude, occurs in th frontal and horizontal
planes.
536
Section IV
Lower Extremity
Chapter 15
Kinesiology o j Walking
537
100%
0%
B
Gait Cycle
100%
0%
Gait Cycle
538
Sectioti IV
Lower Extremity
Ankle (Talocrural Jo in t). At th ankle, heel contact occurs with th talocrural joint in a slightly piantar fiexed
position (between 0 and 5 degrees) (Fig. 1 5 -1 5 D ). Shortly
after heel contact (th Arsi 8% of th gait cycle), th foot is
positioned fiat on th ground by th movement of piantar
flexion controlled eccentrically by th ankle dorsiflexors.
Then, up to 10 degrees of ankle dorsillexion occurs as th
tibia moves forward over th planted foot (from 8 to 45% of
th gait cycle). Shortly after heel off (40% of th gait cycle),
th ankle starts to piantar flex, reaching a maximum of 15 to
20 degrees of piantar flexion just after toe off. During th
swing phase, th ankle is again dorsiflexed to a neutra]
position to allow th toes to clear th ground.
Average speed of ambulation requires approximately 10
degrees of dorsiflexion and 20 degrees of piantar flexion.
interestingly, greater dorsiflexion is needed during th stance
phase than during th swing phase ol gait. Similar to th
knee and th hip, limitation of motion at th ankle leads to
an abnormal gait pattern. For example, limited ankle piantar
flexion may result in a decreased push off, possibly leading
to a shorter step length.
Chapter 15
Kinesiology o f Walkmg
539
Conversely, a lack of adequate dorsiflexion mobility during stance, due to a tight heel cord, for example, may cause
a premature heel off, resulting in a bouncing-type gait.
Interestingly, limited dorsiflexion may also lead to a shorter
step length because th body is bouncing excessively up
and down instead of moving forward. A toeing-out gait
pattern can somewhat compensate for limited ankle dorsiflexion. With excessive toeing-out of th foot, th individuai
rolls off th mediai aspect of th foot in th second half of
stance phase. Although toeing-out reduces th need for ankle
dorsiflexion, it increases th stress applied to th mediai
structures of th foot and th knee.
In extreme cases where there is a pes equinus deformity
(i.e., fixed piantar flexion of th ankle), th individuai may
walk on hyperextended toes and th heel never Comes in
contact with th ground. This condition is most often observed in individuals with cerebral palsy.
Limited ankle dorsiflexion also intereferes with clearing
th toes during swing phase. To compensate, increased knee
and/or hip flexion may be needed. Limited dorsiflexion in
swing may be due to piantar flexor tightness, calf spasticity,
or ankle dorsiflexor weakness.
First Metatarsophalangcal Joint. The metatarsophalangeal (MTP) joint of th hallux (great toe) is cruciai to normal
gait. At heel contact, th MTP joint is slightly hyperex
FIGURE 15-17. Frontal piane pelvis and hip motion for a full
gait cycle starting with righi heel contact. A illustrates that
during right stance phase, th left iliac crest initially drops
before progressively moving upward in late stance. The rela
tively higher left iliac crest during right swing phase rellects
th drop of th right iliac crest when th right foot is off th
ground. B illustrates frontal piane hip motion, accounting for
th frontal piane motion of th pelvis and th femur. (Data
from Ounpuu S: Clinical gait analysis. In Spivack BS (ed):
Evaluation and Management of Gait Disorders. New York,
Marcel Dekker, 1995.)
540
Section IV
Lower Extremity
Chapter 15
Kinesiology o j Walking
541
10
20
30
40
50
60
70
80
90
100
W5
8 = Frontal Piane
Subtalar Joint Angle
FIGURE 15-20. Method to measure rear foot (subtalar joint) mo
tion. The inversion/everston angle, made by th lines bisecting th
lower leg and th calcaneus, is measured as a simpliled indicator of
th amount of foot pronation/supination. This measurement can be
made using a video System. (Modified from McClay IS: The use of
gait analysis to enhance th understanding of running injuries. In
Craik RL, Oatis CA (eds): Gait Analysis: Theory and Application. Si.
Louis, Mosby, 1995.)
542
Seciion IV
Lower Extremity
Chapter 15
Tibia.
The pattern of movement of th tibia is very similar to th movement described for th femur (see Fig. 1 5 22). The magnitude of th rotation is about 8 to 9 degrees
in each direction.
Kinesiology o f Walking
543
Hip.
Horizontal piane rotation of th talocrural joint is slight and is not considered here. The primary
movement of th subtalar joint (inversion and eversion) is in
th frontal piane and is described earlier.
544
Section IV
Lower Extremity
S P E C I A L
F O C U S
1 5 - 7
S u m m a r y o f H o r iz o n t a l P i a n e K i n e m a t i c s
a n d s u b t a la r j o in t d u r in g w a lk in g , u s in g d if f e r e n t s e t s o f
d a t a . 14'30-46 T h e p e lv is , fe m u r , a n d t ib ia r o t a t e in t e r n a lly ,
T h is s t a b ilit y e n a b le s t h m id f o o t to s e r v e a s a r ig id
w e l l a f t e r h e e l c o n t a c t (i.e ., t h r o u g h a b o u t 15 t o 20% o f
le v e r in t e r m in a l s t a n c e a n d p r e s w in g , a llo w in g t h
F ig u r e 1 5 - 2 5 s u m m a r iz e s t h d ir e c t io n o f h o r iz o n t a l
p ia n e r o t a t io n o f t h m a j o r b o n e s o f t h lo w e r e x t r e m it y
t h g a it c y c le ) . T h is m a s s in t e r n a i r o t a t io n is a c c o m p a -
p ia n t a r f le x o r s to lif t t h c a l c a n e u s w it h o u t t h m id f o o t
n ie d b y s u b t a la r jo in t e v e r s io n . A s d e s c r ib e d in C h a p t e r
c o lla p s in g u n d e r t h b o d y 's w e ig h t . F u r t h e r in v e s t ig a -
14, a n e v e r t in g s u b t a la r jo in t t e n d s t o i n c r e a s e t h p lia -
t io n , s u c h a s t h a t p e r f o r m e d b y R e is c h l a n d c o ll e a g u e s , 70
b ilit y o f t h m id f o o t r e g io n , in c lu d in g t h t r a n s v e r s e
is n e e d e d to c l e a r l y e lu c id a t e t h e x a c t r e la t io n s h ip
t a r s a l jo in t. A p lia b le m id f o o t s e r v e s t o c u s h io n t h
t h a t e x is t s b e t w e e n t h t im in g a n d m a g n it u d e o f p r o n a -
im p a c t o f lim b lo a d in g . A f t e r a b o u t 15 t o 20 % o f t h g a it
t io n o f t h f o o t a n d r o t a t io n o f t h f e m u r a n d t ib ia .
FIGURE 15 25. Honzonial piane rotation of th major bones of th lower extremity and subtalar joint during walking. The graph
shows th direction of rotation, which is not necessarily th same as th absolute joint position.
Chapter 15
Elbow. The elbow is in approximately 20 degrees of flexion at heel contact. As th shoulder moves into flexion in
th first 50% of th gait cycle, th elbow flexes to a maxi
mum of approximately 45 degrees. In th second half of th
gait cycle, as th shoulder extends, th elbow extends to
return to 20 degrees of flexion.54
M I N I M I Z I N G V E R T I C A L D I S P L A C E M E N T OF THE
C EN T ER OF M A S S
Kinesiology o f Walking
545
While a person walks, his or her CoM shifts side to side and
remains within th dynamic base of support provided by th
feet (see Fig. 1 5 - 1 3 ). A person strives to minimize th
amplitude of this medial-lateral displacement by reducing
step width, which is a function of frontal piane hip motion
(i.e., hip abduction/adduction).
Although reduced step width minimizes side-to-side dis
placement and therefore energy expenditure, it also decreases
th size of th dynamic base of support. The average step
width of 7 to 9 cm represents a mechanical compromise of
being narrow enough to reduce side-to-side shifts of th
CoM, but wide enough to provide an adequate base of
support. A greater or lesser step width is associated with a
trade-off in either energy expenditure or stability. Persons
with balance disorders, for example, may choose a wider
Name of Strategy
Action
Vertical
Vertical
Vertical
Vertical
Medial-lateral
546
A. VV'alking vvithout
reduction of
CoM displacement
B. Addin horizontal
piane pelvic rotation
C. Adding sagittal
piane ankle rotation
E. Adding l'rontal
piane pelvic rotation
F GURE 5 a . TIls series illustrates th individuai and additive effects ol tour kinematic strategies to reduce vertical CoM excursion. A illustrates th large vertical oscillation
S
e, W nln8 wtthout th strategies B illustrates that rotation of th petvis in th horizontal piane functionally lengthens th lower extremities and reduces th
|Hf h iP fex- n-
on angle required for a given step length, thereby reducing th downward displacement of th CoM. C illustrates that further reduction of
, 4, .
dlSp aC,e?lentu * * . 'C M 15 achieved b>' rolalion of lhe ankle ln lhc sagittal piane. D illustrates that th small amount of knee flexion present during stance
reduces th funzionai ength of th lower extremity and, therefore, th upward displacement of th CoM. shows that th contrasterai pelvic drop during stance also
minimizes th net overall elevation of th CoM. The angle values in A and fi are for illustrative purposes only and do not represent th actual hip angles during walking.
Chapter 15
Kinesiology o j Walking
547
FIGURE 15-27. Combined action of th four kinematic strategies to reduce vertical CoM excursion. Without these strategies, a large
vertical displacement of th bodys CoM (red) would occur when walking (A). B illustrates th combined action of horizontal piane
pel vie rotation (HPPR) and sagittal piane ankle rotation (SPAR) to minimize th downward displacement of th CoM dunng doubllimb support. It also shows th action of stance phase knee llexion (SPKF) and frontal piane pelvic rotation (FPPR) to minimize th
upward displacement of th CoM at mid stance.
ENERGY EXPENDITURE
Energy expenditure during gait is measured by th amount
of energy used in kilocalories per meter walked per kilogram
of body weight (kcal/m/kg). Typically, energy expenditure is
measured indirectly by quantifying oxygen consumption.72
When walking, th body strives to minimize energy cost.
Conservation of energy is achieved by minimizing th excur
sion of th CoM, controlling th body momentum, and taking advantage of th intersegmental transfers of energy.
The gait speed at which optimal energy conservation occurs is approximately 1.33 m/s, or 80 mAnin or 3 mph.72
MUSCLE ACTIVITY
548
Section IV
Lower Extremity
3 -6
2 3 -3 3
37
32
2 0 -3 8
2 0 -6 0
55
Authors
Hip
Three muscle groups at th hip play a criticai role during
normal ambulation: th hip extensors, such as th gluteus
maximus and th hamstrings; th hip flexors, such as th
iliacus and th psoas; and th hip abductors, such as th
gluteus medius and minimus. Less well documented is th
role of th hip adductors and rotators.
Hip Extensors. Activation of th gluteus maximus starts
in an eccentric manner at terminal swing. This mild muscu
lar activation serves two purposes decelerating hip flexion
and preparing th muscolature for weight acceptance at th
beginning of stance. At heel contact, th gluteus maximus is
strongly activated in order to extend th hip and prevent
forward jackknifng, or uncontrolled trunk flexion over th
femur. This abnormal jackknifng occurs if pelvic motion
were slowed following heel contact while th trunk continues its forward displacement. The gluteus maximus remains
active from heel contact to mid stance (i.e., first 30% of th
gait cycle) to support th weight of th body and produce
hip extension. Strong activation of th gluteus maximus
when th foot is frmly planted on th ground also assists
indirectly with knee extension.
The hamstrings assist th gluteus maximus durtng th
first 10% ol th gait cycle. Similar to th gluteus maximus,
th hamstrings serve to generate hip extension and to sup
port th weight of th body to prevent th collapse of th
lower extremity during early stance.
Chapter 15
Kinesiology o f Walking
549
Percent of G a it C y cle
550
Section IV
Lower Extremity
Knee
Two rnuscle groups play a criticai role at th knee during
ambulation: th knee extensors and knee flexors.
Chapter 15
Tibialis Posterior. The tibialis posterior, a potent supinator muscle of th foot, is active between 5 and 55% of th
gait cycle. Tibialis posterior decelerates pronation of th foot
between 5 and about 35% of th cycle and supinates th
foot between 35% and 55% (mid stance to toe off) of th
cycle.37
The tibialis posterior receives special attention in th
treatment of people with cerebral palsy. The often hyperactive tibialis posterior along with th soleus muscle may cause
an equinovarus deformity of th foot and ankle, resulting in
th individuals walking on a foot that is piantar flexed and
supinated.
Active individuate with fiat, overly pronated feet may develop a syndrome known as shin splints. This syndrome is
due to overuse and subsequent strain of th tibialis posterior
and/or anterior ankle muscles. The overuse is secondary to
th increased work demands placed on th supinator mus
cles as they attempt to control th excessive pronation bias
of th foot during early stance.
Peronei. The peroneus brevis and longus are active from
about 20 to 30% of th gait cycle to just after heel off. In
addition to their function as piantar flexors, these pronator
(everter) muscles help counteract th inversion of th foot
caused by activation of th tibialis anterior and posterior leg
muscles. The peronei help with th alignment and stabilization of th subtalar joint. The peroneus longus assists in th
overall kinematics of th foot by placing th first ray rigidly
on th ground, which provides a frm base of support for
th action of th foot as a rigid lever during th terminal
stance and pre swing phases of gait.
In trinsic Muscles o f th Foot. The intrinsic muscles of
th foot are typically active from mid stance to toe off (30 to
60% of th gait cycle), particularly if th foot is not supported by well-fitting shoes. These muscles stabilize th forefoot and raise th mediai longitudinal arch, thereby providing a rigid lever for ankle piantar flexion in terminal stance
and pre swing.
Trunk
Only th actions of th erector spinae and th rectus abdominis are discussed here.
Kinesiology o f Walking
551
GAIT KINETICS
Understanding th forces that are responsible for movement
during gait plays a criticai role in understanding normal and
pathologic movement. Although th kinetics (study of forces)
of walking are not visually observable, they are responsible
for th observed kinematics.
552
Seclion IV
Lower Extremity
FIGURE 15-30.
Ground reaction
forces (GRFs) during gait. A illustrates th vertical and anterior-posterior GRF (black and
white arrows, respectively) and
foot forces (filled arrows) at
10% of gait cycle B illustrates
th medial-laieral forces at 10%
of gait cycle. C, D, and E show
th GRF for a gait cycle. Dashed
lines are data for left foot con
tact. (Data front Whittle M: Gait
Analysis: An Introduction, 2nd
ed. Oxford, Buiterworth-Heinemann Ltd., 1996.)
GROUND
REACTION
FORCES
FOOT
FORCES
*Toe Off is at 57%
Chapter 15
Kinesiology o f Walking
553
from one lower extremity to th other at th time of doublelimb support. Slowing down requires a greater braking force
than propulsive force, and speeding up requires th oppo
site.
HEEL
CONTACT
TOE
OFF
554
Secfion IV
Lower Extremity
TOE OFF
FIGURE 15-32.
GRF
FIGURE 15-33.
FIGURE 15-34.
Chapter 15
Kinesiology o f Walking
555
Joint Torques
Internai joint torques: produced by th body
Extemal joint torques: applied to th body
FIGURE 15-35.
556
Seniori IV
Lower Extremiiy
Chapter 15
To complete th description of sagittal piane hip movement during gail, Figure 1 5 -3 5 D illustrates th relative intensity of activity of two primary antagonistic muscles of th
hip. The areas of th EMG curve that are shaded indicate an
eccentric muscle activation. The hatched areas indicate a
concentric muscle activation. In generai, th muscular activations correlate with power absorption and power generation.
In th frontal piane, a large abduction torque occurs dur
ing stance to support th mass of th body that is located
mediai to th hip joint (Fig. 1 5 -3 6 A and 6). Power absorp
tion during th initial lowering of th opposite side of th
pelvis (Fig. 1 5 -3 6 C ) reflects th eccentric activation of th
hip abductors (Fig. 1 5 -3 6 D ). Power generation is seen at 20
and 60% of th gait cycle, as th contralateral pelvis is raised
(Fig. 1 5 -3 6 C ).
In th horizontal piane, an extemal rotation torque is used
to decelerate th internai rotation of th femur in th frst
20% of th gait cycle (Fig. 15-3 7 A ). This torque is followed
by an internai rotation torque that advances th contralateral
side of th pelvis forward during th remainder of stance.
Notice th small magnitude of these torques, approximately
15% of those in th sagittal and frontal planes. The eccentric
activation of th hip external rotators in th initial 20% of
th gait cycle accounts for th power absorption noted at
that time (Fig. 1 5 -3 7 6 ).
Kinesiology o f Walking
557
10
20
30
40
50
60
70
80
90 100
Knee.
558
Sec'tion (V
Lcnver Extremity
Ankle and Foot. In th sagittal piane, a small dorsiflexion torque is generated at th ankle immediately after heel
contaci (Fig. 1 5 -4 2 A and B). This torque serves to eccentrically control th movement of piantar flexion generated by
th application of body weight on th calcaneus (see Fig.
1 5 - 3 3 ). A piantar flexion torque prevails throughout th
rest of stance, initially to eccentrically control th tibia advancing over th foot, then to piantar flex th ankle at push
off. A very small dorsiflexion torque is present during swing
to keep th ankle dorsiflexed in order to clear th toes.
FIGURE 15-39.
FIGURE 15-40.
Chapter 15
Kinesiology o f Walking
559
2.00 - 1
5.0-1
10
20
30
40
50
60
70
80
90 100
560
Section IV
Lower Extremity
GAIT DYSFUNCTIONS____________________
Most of us take for granted our ability to walk. The fact is,
unless we have personally experienced an injury or a physical impairment, we do not think of walking as a difficult
task. The information provided thus far in this chapter, however, reminds us of th complexity of ambulation. Many
actions must occur simultaneously at each pari of th gait
cycle for ambulation to take place with maximum efficiency.
Normal ambulation requires sufficient range of motion
and strength at each participating joint. Walking also re
quires sophisticated control of movement through th centrai
nervous System. The complexity of walking creates many
opportunities for th normal gait pattern to be affected by
impairment. The adaptability of th System, however, does
create many opportunities to modify th gait pattern in order to walk despite even severe impairments. In these
cases, a normal gait pattern is sacrifced for th ability to
move from one location to another independently. We have
all used this ability to adapt gait, even if for only a painful
blister under th foot or for walking on hot sand at th
beach. In essence, an abnormal or a pathologic gait pattern
reflecis an effort lo preserve ambulation through adaptation.
The cost of gait deviation is, typically, increased energy expenditure and application of abnormal stresses to th body.
Ihree common causes of pathologic gait patterns are
listed in th box. Each includes many spedire and generai
pathologies. The observed deviations may be th direct response to a specifc impairment or may in fact be a compensation. Ihe features of pathologic gait, therefore, depend on
th nature of th impairment as well as th ability of th
individuai to compensate for that impairment.
Chapter 15
T A 8 L E
561
Kinesiology o f Walking
Speed
Authors
Magnitude (BW)
Ankle
Talocrural joint (peak compression)
Talocrural joint (peak compression)
Talocrural joint (peak compression)
Talocrural joint (peak anterior shear*)
Talocrural joint (peak posterior shear*)
Achilles tendon (peak tension)
Achilles tendon (peak tension)
Achilles tendon (peak tension)
Ankle dorsiflexors (peak tension)
Piantar fascia (peak tension)
1.4 m/s
114 s/min
4.2 m/s (r)
116 s/min
116 s/min
1.5 m/s
1.7 m/s
4.2 m/s (r)
114 s/min
4.2 m/s (r)
4.2
4.8
12.0
0.6
0.3
2.0
4.0
7.0
1.4 m/s
114 s/min
1.0 m/s
1.5 m/s
1.0 m/s
4.2 m/s (r)
114 s/min
114 s/min
1.7 m/s
4.2 m/s (r)
114 s/min
4.6
5.0
0.3
1.5
0.8
9.0
1.5
0.4
3.0
5.8
1.1
1.4 m/s
0.9 m/s
114 s/min
0.9 m/s
0.9 m/s
6.4
3.1
3.8
0.3
0.5
K
nee
1.0
2.1
Hip
Hip (peak compression)
Hip (peak compression)
Hip (peak compression)
Adductor magnus (peak tension)
Gluteus medius (peak tension)
BW, units in number of body weights; s/min, steps per minute; m/s, meters per second; * direction of shear of tibia on talus; (r), runntng speed.
ing gait. Apraxia, defined as a disorder of voluntary movement, occurs in some disease processes affecting th elderly.
Gait apraxia may result in an ambulation pattern characterized by a wide base of support, short stride, and shuffling.
Individuai with impaired sensory function and balance may
show an unstable gait pattern.76 With neurologie disorders,
th primary cause of gait dysfunction is an inability to gener
ate and control an appropriate level of muscle force. Eventually, muscle weakness and joint contracture may compound
th primary neuromotor deficit.
Deficits in th musculoskeletal System also result in a
wide variety of gait deviations. Abnormal (excessive or limited) joint range of motion and/or limited muscle strength
562
Sedioli IV
Lowcr Extremily
Selected Pathologic
Precursors
Marked weakness of
ankle dorsiflexors
Severe weakness of an
kle dorsiflexors
Heel pain
Premature elevation of th
heel in mid stance
Weakness or flaccid
paralysis of piantar
flexors with or without a fixed dorsiflexed position of
th ankle (pes calcaneus deformity)
Congenital or acquired
muscular tightness of
ankle piantar flexors
Peripheral or centrai
nervous System disorders
Excessive surgical
lengthening of th
Achilles tendon
Congenital structural
deformity
Congenital or acquired
structural deformity
Weakness (paralysis) of
ankle invertors
Congenital structural
deformity
Likely Impairment
Pes equinovarus deformity due to spasticity of th piantar
flexors and invertors
Weakness of dorsiflexors and/or pes
equinus deformity
Selected Pathologic
Precursore
TABLE 15-7. Gait Deviations Seen at th Ankle/Foot as a Compensation for an Impairment of th Ipsilateral
Knee, Ipsilateral Hip, or Contralateral Lower Extremity
Observed Gait Deviation at th
Ankle/Foot
Likely Impairment
Mechanical Rationale
The terms in bold indicate th time in th gait cycle when th gait deviation is expressed.
564
Section IV
Lower Extremity
Likely Tmpairment
Selected Pathologic
Precursors
Spasticity of th quadriceps
Weak quadriceps
Knee pain
Arthritis
Poliomyelitis
Trauma or arthritis
Immobilization (cast,
brace) or surgical fusion
The lerms in bold indicate th time in th gait cycle when th gait deviation is expressed
Chapter 15
Kmesiology o f Walking
565
15-9. Gait Deviations Seen at th Knee as a Compensation for an lmpairment of th Ipsilateral Anklc,
Ipsilateral Hip, or Contralateral Lower Extremity
TABLE
Likely lmpairment
Mechanical Rationale
Antalgic gait
The terms in bold indicate th time in th gait cycle when th gait deviation ts expressed.
Normal
FIGURE 15-47. Vaulting on unaffected side to compensate for limited functional shortening of th swing leg. (From Whittle M: Gait
Analysis: An lntroduction, 2nd ed. Oxford, Butterworth-Heinemann
Ltd., 1996.)
Anterior trunk
bending
566
Likely Impairment
Selected Pathologic
Precursore
Paralysis or poliomyelitis
Marked weakness of
th hip abductors
Guillain-Barr or poliomyelitis
Hip pain
Arthritis
Mild weakness of th
gluteus medius of
th stance leg
Guillain-Barr or poliomyelitis
Hip osteoarthritis
Hip pain
Hip osteoarthritis
Arthritis
* The terms in bold indicate th tinte in th gatt cycle when th gait deviation is expressed.
Chapter 15
Kinesiology of Walking
567
TABLE
Likely Impairment
M echanical Rationale
Weak quadriceps
Ankle piantar flexor weakness leads to prolonged heel contact and lack of push off. An
increased pelvic horizontal rotation is used
to lengthen th limb and maintain adequate
step length.
* The terms in bold indicate th lime in th gait cycle when th gait deviation is expressed.
568
REFERENCES
1. Adams JM, Perry j: Gait analysis: clinical application. In RoseJ, Gam
ble JG (eds): Human Walking, 2nd ed. Philadelphia, Williams &
Wilkins, 1994.
2. Allard P, Cappozzo A, Lundberg A, Vaughan CL: Three-Dimensional
Analysis of Human Locomotion. New York, John Wiley & Sons, 1997.
3. Amar J: Trattori dynamographique. Comptes rendus hebdomadaires
des sances de lAcadmie des Sciences 163:130, 1916.
4. Andrews JG: Euler's and Lagrange's equations for linked rigid-body
models of three-dimensional human motion. In Allard P, Slokes IAF,
Bianchi JP (eds): Three-Dimensional Analysis of Human Movement
Champaign, IL. Human Kinetics, 1995.
5. Bechtol CO: Normal human gait In Bowker JH, Hall CB (eds): Alias
of Onhotics: American Academy of Orthopaedic Surgeons. St. Louis
Mosby, 1975.
6. Braune W, Fisher O: Der Gang des Menschen [The human gait].
Leipzig, Germany, B.G. Teubner, 1895-1904.
7. Braune W, Fisher O: The Human Gait (translation by Maquet P,
Furlong R). Berlin, Springer-Verlag, 1987. (Originai work published
1895-1904.)
8. Bresler B, Frankel JP: Forces and moments in th leg during walkin.
Am Soc Mech Engrs Trans 72:27, 1950.
9 Calve J, Galland M, De Cagny R: Pathogenesis of ihe hmp due lo
coxalgia: The antalgtc gait. J Bone Joint Surg 21:12, 1939.
10. Carlsoo S: How man moves: Kinesiological methods and studies. New
York, Crane, Russak & Company, 1972.
1 I Chan CW, Rudins A: Foot biomechanics during walking and running.
Mayo Clin Proc 69:448, 1994.
t2. Collins JJ: The redundant nature of locomotor optimization laws j
Biomech 28:251, 1995.
13. Corcoran PJ, Jebsen RH, Brengelmann GL, Simons BC: Effects of
plastic and metal leg braces on speed and energy cosi of hemiparetic
ambulation. Arch Phys Med Rehabil 51:69, 1970,
14. Comwall MW, McPoil TG: Three-dimensional movement of th foot
during th stance phase of walking. J Am Podiatr Med Assoc 89 56
1999.
'
15. Craik RL, Dutterer L: Spatial and temporal characteristics of foot fall
patlems. In Craik RL, Oatis CA (eds): Gait Analysis: Theory and
Application. St. Louis, Mosby-Year Book, Ine, 1995.
16. Drillis R: The influence of aging on th kinematics of gait. In Geriatrie
Amputee (NAS-NRC pub. No. 919). Washington, DC, NAS-NRC,
1961.
17. Eberhart H: Fundamental studies of human locomotion and other
information relating to design of artificial limbs. Report to US Veterans' Association. Berkeley, C, University of California, 1947.
Chapter 15
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
67.
68
69.
70.
71.
72.
73.
74.
75.
Kinesiology of Walking
569
p p e n d i x
IV
Nerve Root
Lumbar
Muscle
L1
L2
Psoas minor
Psoas major
Hiatus
00
Sacrai
L4
Sartorius
(x)
Quadriceps
Adductor brevis
Adductor longus
Gracilis
Pectineus
Obturator externus
Adductor magnus
S*
(x)
(x)
(x)
Gluteus medius
Gluteus minimus
Tensor fascia lata
Gluteus maximus
Piriformis
Gemellus superior
Obturator intemus
Gemellus inferior
Quadratus femoris
Biceps (long head)
Semitendinosus
Semimembranosus
Gastrocnemius
Popliteus
570
s2
L5
(x)
S3
Appendix IV
571
Nerve Root
Sacrai
Lumbar
L5
S>
s2
(x)
Muscle
L2
L3
L4
Soleus
(x)
Tibialis posterior
Abductor hallucis
Lumbrical 1
Quadratus plantae
Adductor hallucis
Piantar interossei
Dorsal interossei
(x)
(x)
S3
(x), mirumal literature support; X, moderate literature support; X, strong literature support.
Modified from Rendali FP, McCreary AK, and Provante PG: Muscles: Testing and Function, ed. 4. Baltimore, Williams & Wilkins, 1993. Data based on a
compilation from several anatomical sources.
T h e ta b le s h o w s th k e y m u s c le s t y p ic a lly u s e d to test th
H IP A N D
f u n c t io n o f in d iv id u a i v e n tr a l n e rv e r o o t s o f th lu m b o s a c r a l
p le x u s ( L 2-S 3) i n th c lin ic . R e d u c e d s tr e n g th in a k e y tn u s c le m a y in d ic a te a n in j u r y to th a s s o c ia te d n e rv e ro o t.
KNEE M USCULATURE
Adductor Brevis
P r o x im a l a t ta c h m e n t : a n te r io r s u rfa c e o f th in f e r io r p u b ic
ra m u s
D istai a t ta c h m e n t : p r o x im a l o n e t h ir d o f th lin e a a sp e ra
Key Muscles
Ventral
Nerve
Root
Iliopsoas
Adductor longus
L2
L2
Hip flexion
Hip adduction
Adductor Longus
Quadriceps femoris
L3
Knee extension
Tibialis anterior
L4
Ankle dorsiflexion
p u b is
D istai a t ta c h m e n t : m id d le o n e t h ir d o f th lin e a a s p e ra o f
Extensor digitorum
longus
Gluteus medius
L5
Toe extension
L5
Hip abduction
Gluteus maximus
S>
Semitendinosus
S1
Gastrocnemius/soleus
Flexor hallucis longus
S2
S3
s2
o f th fe m u r
In n e r v a tio n : o b t u r a t o r n e rv e
P r o x im a l a t ta c h m e n t : a n te r io r s u rfa c e o f th b o d y o f th
th fe m u r
In n e r v a tio n : o b t u r a t o r n e rv e
Adductor Magnus
A n te r io r (A d d u cto r H e a d )
P r o x im a l a t ta c h m e n t : is c h ia l ra m u s
D istai a t ta c h m e n t : e n tire lin e a a s p e ra o f th fe m u r
In n e r v a tio n : o b t u r a t o r n e rv e
P o s te r io r (E x te n s o r H ea d )
P r o x im a l a t ta c h m e n t : is c h ia l tu b e ro s ity
D istai a t ta c h m e n t : a d d u c t o r tu b e re te o n fe m u r
In n e r v a tio n : t ib ia l p o r t io n o f s c ia tic n e rv e
572
Appendix IV
Articularis Genu
P r o x im a l a t ta c h m e n t : a n te r io r s u rfa c e o f th d is ta i fe m o ra l
sh a ft
D istai a t ta c h m e n t : p r o x im a l c a p s u le o f th k n e e
ie s o f th la st t h o r a c ic a n d a ll lu m b a r v e rte b ra e in c lu d in g th in t e r v e r t e b r a l d is c s
D istai a t ta c h m e n t : le s s e r t ro c h a n te r o f th fe m u r
In n e r v a tio n : fe m o ra l n e rv e
llia c u s
Biceps Femoris
P r o x im a l a t ta c h m e n t s : s u p e r io r tw o t h ir d s o f th ilia c fossa,
L on g H ead
P r o x im a l a tta c h m e n ts :
fro m
a com m on
te n d o n
w it h
th
s e m ite n d in o s u s ; o r ig in a t in g fro m a m e d ia i im p r e s s io n
o n th p o s t e r io r s u rfa c e o f th is c h ia l t u b e ro s it y a n d
p a rt o f th s a c ro tu b e ro u s lig a m e n t.
in n e r lip o f th ilia c c re s i, a n d s m a ll
s a c ru m a c ro s s th s a c r o ilia c jo in t
D is ta i a t ta c h m e n t : le ss e r t ro c h a n te r o f th fe m u r v ia th
la te ra l s id e o f p s o a s m a jo r te n d o n
in n e r v a t io n : fe m o ra l n e rv e
D istai a t ta c h m e n t : h e a d o f th fib u la
Obturator Externus
In n e r v a tio n : t ib ia l p o r t io n o f th s c ia tic n e rv e
P r o x im a l
S hort H ead
P r o x im a l a t ta c h m e n t : la te ra l lip o f th lin e a a sp e ra b e lo w
th g lu te a l tu b e ro s ity
D is ta i a t ta c h m e n t : h e a d o f th f ib u la
In n e r v a tio n : c o m m o n p e r o n e a l p o r t io n o f th s c ia tic n e rv e
a t ta c h m e n t s :
e x te rn a l
of
th
o b tu ra to r
D istai a t ta c h m e n t : m e d ia i s u rfa c e o f th g re a te r t ro c h a n te r
at th t r o c h a n te r ic fossa
In n e r v a tio n : o b t u r a t o r n e rv e
P r o x im a l a tta c h m e n ts : in t e r n a i s id e o f th o b t u r a t o r m e m
P r o x im a l a tta c h m e n t: tu b e ro s ity o f th is c h iu m
b ra n e a n d im m e d ia t e ly s u r r o u n d in g su rfa c e s o f th i n
D istai a t ta c h m e n t : b le n d s w it h th te n d o n o f th o b t u r a t o r
in t e m u s
f e r io r
In n e r v a tio n : n e rv e to th q u a d r a tu s fe m o ris
m e n ts e x te n d s u p e r io r ly
g re a te r s c ia tic n o tc h .
Gemellus Superior
p u b ic
ra m u s
and
is c h ia l ra m u s ;
w it h in
th
bony
p e lv is
a tta c h
to
th
P r o x im a l a t ta c h m e n t : d o r s a l s u rfa c e o f th is c h ia l s p in e
D is ta i a t ta c h m e n t : b le n d s w it h th te n d o n o f th o b t u r a t o r
in t e m u s
In n e r v a tio n : n e rv e to th o b t u r a t o r in t e m u s
In n e r v a tio n : n e rv e io th o b t u r a t o r in t e m u s
Pectineus
P io x im a l a t ta c h m e n t : p e c tin e a l lin e o n s u p e r io r p u b ic r a
m us
Gluteus Maxiinus
P r o x im a l a tta c h m e n ts : o u te r iliu m , p o s t e r io r g lu te a l lin e ,
a p o n e u r o s is o f th e re c to r s p in a e a n d g lu te u s m e d iu s
m u s c le s , p o s t e r io r s id e o f s a c ru m a n d c o c c y x , a n d p a rt
o f s a c ro tu b e ro u s a n d p o s t e r io r s a c ro - ila c lig a m e n ts
D is ta i a tta c h m e n ts : g lu te a l t u b e ro s it y a n d ilio t ib ia l b a n d
In n e r v a tio n : in f e r io r g lu te a l n e rv e
Piriformis
P io x im a l a t ta c h m e n t : a n te r io r s id e o f th s a c ru m b e tw e e n
Gluteus Medius
P r o x im a l a tta c h m e n t: o u te r s u rfa c e o f th iliu m , a b o v e th
a n t e r io r g lu te a l lin e
D is ta i a t ta c h m e n t : la te ra l s u rfa c e o f th g re a te r tro c h a n te r
In n e r v a tio n : s u p e r io r g lu te a l n e rv e
th s a c ra i fo ra m in a ; b le n d s p a r t ia lly w it h th c a p s u le o f
th s a c r o ilia c j o in t
D istai a t ta c h m e n t : a p e x o f th g re a te r t ro c h a n te r
In n e r v a tio n : n e rv e to th p ir if o r m is
Popliteus
Gluteus Minimus
b e tw e e n
th a n te r io r a n d in f e r io r g lu te a l lin e s , as far p o s t e r io r
as th g re a te r s c ia tic n o tc h
D istai a t ta c h m e n t : a n te r io r a s p e c t o f th g re a te r tro c h a n te r
I n n e r v a tio n : s u p e r io r g lu te a l n e rv e
Graeilis
P r o x im a l a t ta c h m e n t s :
s u rfa c e
m e m b ra n e a n d s u r r o u n d in g e x te rn a l s u rfa c e s o f th
in f e r io r p u b ic ra m u s a n d is c h ia l ra m u s
Obturator Internus
Gemellus Inferior
P t o x im a l a tta c h m e n t.
re g io n o f th
ta c h e s to th la te ra l a s p e c t o f th la te ra l fe m o ra l c o n d y le
D istai a t ta c h m e n t : p o s t e r io r s u rfa c e o f th p r o x im a l tib ia ,
a b o v e th s o le a l lin e
Innervation: t ib ia l n e rv e
Psoas Minor
a n te r io r a s p e c t
o f lo w e r
body
of
p u b is a n d in le r io r ra m u s o f p u b is
D is ta i a t ta c h m e n t : p r o x im a l m e d ia i s u rfa c e o f th t ib ia ju st
p o s t e r io r to th u p p e r e n d o f th a tta c h m e n t o f th
s a r t o r iu s
In n e r v a tio n : o b t u r a t o r n e rv e
Iliopsoas
P s o a s M a jo r
P r o x im a l a tta c h m e n ts : tra n sv e rs e p ro c e s se s a n d la te ra l b o d -
Quadratus Femoris
P r o x im a l a t ta c h m e n t : la te ra l s u rfa c e o f th is c h ia l tu b e ro s
it y ju s t a n te r io r io th a tta c h m e n ts o f th s e m im e m b ra nosus
Appenclix IV
573
Rectus Femoris
P r o x im a l a t ta c h m e n t : straight tend on: an terio r-in ferio r iliac
sp in e, and reflected ten d o n : groove arou nd th superior rim o f th acetabu lu m and into th cap su le o f th
hip
Distai a t ta c h m e n t : base o f th patella and, via ligam entum
patella, to th tibial tu berosity
ln n e r v a tio n : fem oral nerve
ANKLE AND
FOOT M U S C U L A T U R E
Sartorius
proxim al m ediai
P r o x im a l
surface o f th tibia
ln n e r v a tio n : fem oral nerve
Semimembranosus
Semitendin osus
from a co m m o n tend o n w ith th
lo n g head o f th b ice p s fem oris originai ing from a
m ediai im p ressio n on th p o sterio r surface o f th is
ch ial tuberosity and part o f th sacro tu b ero u s ligam ent
Distai a t ta c h m e n t : proxim al m ediai surface o f th tibia ju s t
p o sterio r to th low er end o f th attach m en t o f th
P r o x im a l a tta c h m e n ts :
sartorius
Gastrocnemius
d on
o f th fascia lata
ln n e r v a tio n : su p erio r gluteal nerve
Vastus Intermedius
Vastus Lateralis
a tta c h m e n ts : u p p er region o f in tertro ch an teric
lin e, an terio r and in ferio r b o rd e r o f th greater troch an te r, lateral region o f th gluteal tubero sity, lateral
P r o x im a l
Pcroneus Brevis
o f th fibula
D is ta i a t ta c h m e n t : styloid p ro cess o f th fifth m etatarsal
ln n e r v a tio n : superficial b ran ch o f th p eroneal nerve
Pcroneus Longus
P r o x im a l a tta c h m e n ts : head and proxim al two third s o f th
Pcroneus Tertius
Vastus Medialis
a tta c h m e n ts : lo w er region o f in tertro ch an teric
lin e, m ediai lip o f linea aspera, p roxim al m ediai supracon d y lar lin e, fibers from ad d u cto r m agnus
P r o x im a l
Plantaris
P r o x im a l a tta c h m e n ts : m ost m ferio r part o f lateral supra-
574
Appenda IV
con d y lar line o f th fem u r and o bliqu e popliteal ligam e n t o f th knee
Soleus
P r o x im a l a t ta c h m e n t s : p o sterio r surface o f th fibula head
d on
th
sid es o f th piantar aspect o f th base o f th m iddle
p h alan x o f th lesser toes.
In n e r v a tio n : m ediai p iantar nerve
LAYER 2
Lumbrieals
P r o x im a l a tta c h m e n ts : from th ten d o n s o f th flexo r d igi
Tibialis Anlerior
lateral con d y le and proxim al two
thirds o f th lateral surface o f th tibia and th intero sseou s m em brane
P t o x im a l
a tta c h m e n ts :
Quadralus Plantae
P r o x im a l a tta c h m e n ts : by tw o head s from th m ediai and
Tibialis Posterior
P r o x im a l a tta c h m e n ts : p roxim al tw o thirds o f p o sterio r su r
LAYER 3
Adductor Hallucis
P r o x im a l A tta c h m e n t
OF THE FOOT
ju s t proxim al to th calcan eo cu b o id jo in t
D is ta i a tta c h m e n ts : by three ten d o n s that blen d w ith th
tend ons o f th exte n so r d igitoru m longu s o f th s e c
ond throu gh fifth toes. A fourth tend o n inserts on th
dorsal base o f th p roxim al p h alan x o f th great toe.
in n e r v a tio n : deep b ran ch o f th peroneal nerve
su p p o rt th m etatarsophalangeal jo in ts
th ro u g h fifth toes
o f th
third
LAYER 1
th flexor
Abductor Hallucis
P r o x im a l a tta c h m e n ts : flexor retinacu lu m , m ediai p ro cess
P r o x im a l
in w hich th lateral
tend o n attach es to th lateral base o f th proxim al
p halanx o f th great toe w ith th ad d u cto r h allu cis; th
m ediai tend o n attach es to th m ediai base o f th p ro x
im al p h alan x o f th great toe w ith th a b d u cto r h allu
cis. A pair o f sesam oid b o n es is located w ithin th
ten d o n s o f this m uscle.
In n er v a tio n : m ediai piantar nerve
Append'ix IV
LAYER 4
Dorsal Interossei
P r o x im a l A tta c h m e n ts
F irs t: a d ja c e n t s id e s o f th firs t a n d s e c o n d m e ta ta rs a l
S e c o n d i a d ja c e n t s id e s o f th s e c o n d a n d t h ir d m e ta ta rs a l
T h ir d : a d ja c e n t s id e s o f th t h ir d a n d fo u rth m e ta ta rs a l
F o u r th : a d ja c e n t s id e s o f th fo u rth a n d fift h m e ta ta rs a l
D istai A t t a c h m e n t s *
F irs t: m e d ia i s id e o f th b a se o f th p r o x im a l p h a la n x o f
th s e c o n d toe
S e c o n d : la te ra l s id e o f th ba se o f th p r o x im a l p h a la n x
Piantar Interossei
P r o x im a l A tta c h m en ts
F irs t: m e d ia i s id e o f th t h ir d m e ta ta rs a l
S e c o n d : m e d ia i s id e o f th fo u rth m e ta ta rs a l
T h ir d : m e d ia i s id e o f th fifth m e ta ta rsa l
D is ta i A t t a c h m e n t s *
F irs t: m e d ia i s id e o f th p r o x im a l p h a la n x o f th t h ir d toe
S e c o n d : m e d ia i s id e o f th p r o x im a l p h a la n x o f th fo u r t h
toe
T h ir d : m e d ia i s id e o f th p r o x im a l p h a la n x o f th fift h to e
In n e r v a tio n : la te ra l p ia n t a r n e rv e
o f th s e c o n d toe
T h ir d : la te ra l s id e o f th ba se o f th p r o x im a l p h a la n x o f
th t h ir d toe
F o u r th : la te ra l s id e o f th base o f th p r o x im a l p h a la n x o f
th fo u rth toe
Inner\'ation: la te ra l p ia n t a r n e rv e
575
n d e x
Note: Page numbers followed by th letter f refer to figures; those followed by th letter t refer to
lables, and those followed by th letter b refer to boxed material.
A
A bands, of myoftlaments, 45, 46f
Abdominal muscles
anatomy and action of, 315t, 323-327, 324f326f, 325t, 327b
as extrinsic trunk stabilizers, 330f, 330-331,
331b
attachmetits and innervations of, 382t
in forced expiration, 376f, 376-377, 377t
in posterior pelvic tilt, 414, 42 lf
in straight-leg raise, 415f
lacerai, attachments and individuai actions of,
325t
paralysis of in spinai cord mjury, 374b
physiologic and ktnesiologic funclions of,
323t, 377b
rectus sheaths and linea alba of, 323, 325,
325f
strengthening exercises for, 331f, 331-333,
332f.
Sit-up exercise.
trunk flexion torque generated by, 326f, 3 26327
Abduction
of fngere, 197, 201 f
of foot and ankle, definition of, 482, 482f,
483t
of glenohumeral joint, 112f113f, 112-113,
115f, 116t
arm elevation in, 123-124, 124f, 125t
in chronic impingement syndrome, 114b,
114f
in frontal piane vs. scapular piane, 113,
115f, 116, 117f
interaction with scapulothoractc upward rotators, 116-117, 117f, 1 18f, 119t, 125f
scapulohumeral rhythm in, 116, 117f
of hip, 405f, 406, 407 1, 408f, 408-409
of metacarpophalangeal joints, 209, 2 lOf
of sublalar joint, 490, 490f, 491 1
of talocrural joint, 4 9 11
of ihumb, 197, 201f, 203-204, 204f, 205f,
206t
of transverse tarsal joint, 493, 495f
Abductor digiti minimi
of foot
anatomy and function of, 518-519, 519f
attachments and innervation of. 574t
of hand, 225f, 225226
attachments and innervation of, 246t
Abductor hallucis
anatomy and function of, 518-519, 519f
allachments and innervation of, 574t
Abductor pollicis brevis, 224, 225f
as assistant extensor of interphalangeal joint of
thumb, 223f, 225b
attachments and innervation of, 246t
Abductor pollicis longus, 221, 223, 223f
attachments and innervation of, 245t
in abduction of thumb, 205f
radiai deviation of wrist by, 191, 1911
See also
Acceleration, 60
Accelerometer, 82
Acetabular fossa, 397
Acetabular labrum, 397, 399f
Acetabular notch, 397
Acetabulum, 390, 390f-391f, 393
malalignment of, in hip dysplasia, 40 Ib
lunate surface of, 396b, 397, 399f
osteologie features of, 396b, 397, 399f
Acetylcholine, in muscle fatigue, 53
Achilles tendon, forces applied to, in gait,
5611
Acromioclavicular joint, 98
connective tissue of, 103, 103f
dislocation of, 104, 104f
generai features of, 102-104, 103f-105f
in scapulothoracic joint movement, 105
106
in shoulder motion during abduction, 116
117, 118f, 119t
kinematics of, 103-104, 104b, 105f
sensory innervation of, 119
Actin
in attive force generation, 46
of myofilaments, 45, 46f, 47f
Action potential, 51, 54
Activittes of daily living
elbow function and, 140, 142f
forearm activity in, 148f, 148149
Adduction
of fingere, 2 0 lf
of foot and ankle, definition oi. 482, 482f,
483t
of glenohumeral joint, 112f113f, 112-113,
116t
of hip, 407f, 408f, 408-409
of metacarpophalangeal joints, 209
of shoulder, muscles active in, 129130,
130f, 131 b
of subtalar joint, 490, 490f, 4 9 lt
of talocrural joint, 49 lt
of thumb, 107, 2 0 lf, 203-204, 204f, 205f,
206t
of transverse tarsal joint, 493, 495f
Adductor brevts
anatomy and action of, 414-415, 418f
attachments and innervation of, 571 1
Adductor hallucis
anatomy and action of, 519, 519f
attachments and innervation of, 574t
Adductor longus
anatomy and action of, 414415, 418f, 419f,
420f
attachments and innervation of, 571 1
in gait, 549f, 550
Adductor magnus
anatomy and action of, 413f, 414-415, 421 f
attachments and innervation of, 571t
in gait, 549f, 550, 561t
Adductor pollicis
heads of, 226, 227f
in key pinch action, 229, 229f
tension fraction of, 226, 226t
Aging, effeets of on joints, 37
Alar ligaments, 279, 280f, 442b
in axial rotation, 282
Amphiarthrosis, definition and function of, 2 5 26
Anatomie position, 5, 6f
Anatomy, definition of, 3
Anconeus, 161, 163f
attachments and innervation of, 244t
structural and biomechanical variables of,
163t
Angle of inclination, of femur, 394, 396f
Angle-of-insertion, 15
Angle of Wiberg, 397
Angular power, in work-energy relaiionship, 6162, 62b
Angular velocity, 57 -5 8 , 60f
Ankle. See also Subtalar joint ; Talocrural joint.
abnormalities of, 516-518, 518l
gait deviations with, 562t
at hip/pelvis/trunk, 567t
at knee, 565t
bones of, 478t, 478-479, 479b, 479f, 484f
function of, 477-478
in gait
forces applied to, 561t
in stance phase, 507t
joint torques and powere of, 558, 5591560f
motion of
in frontal piane, 540-541
in horizontal piane, 543
in sagittal piane, 535-539, 536f, 537f,
538b
muscles of, 549f, 550-551
injury of, extreme doreiflexion or piantar flex
ion and, 472b-473b, 489b
ligaments of, 483-486, 486t
stretch of, 486, 486t
muscles of. See Muscle(s), ankle and foot.
extrinsic, attachments and innervation of,
573t-574t
osteologie features of, 478-482
range of motion at, 491t
sensory innervation of, 507, 509f
structure and function of joints of, 478l, 483489
terminology of, 478, 478f, 482f, 482-483,
483t
Annuius fibrosus, 273-275, 274f, 275f, 276b
Annulus pulposus, migratton of
in lumbar extension, 297
in lumbar flexion, 295-296
Anterior drawer test, for anterior cruciate ligameni injury, 451, 452f
Anthropometiic data, 87t
577
578
Index
Apophyseal joint(s)
arthrokinematics of, lerminology for, 272t
intra-articular stractures of, 262b, 262f
imracervical, 279
axial rotation at, 282-283, 285f
flexion and extension at, 279-282, 280f282f
faterai flexion at, 284, 286f
joint capsule of, 259, 260f, 261 f
resistance of to extreme lumbar flexion,
295, 295f
of atlantoaxial joint, 278f, 279
of intervertebral junction, 269, 272f
of lumbar spine, anatomy of, 292-294, 293f
of thoracic spine, flexion and extension of,
286, 286t, 288f, 289f
structure and function of, 273, 273f
Arch(es)
coracoacromial, 108f, HOf, 111-112
impingement of humeral head at. 113,
114b, 114f
longitudinal, of hand, 197, 200f
mediai longitudinal
of foot, 496f-498f, 496-498
abnormal, 497f-498f, 497-498
in stance phase of gait, 4 9 8-499, 499f
passive forces supporting, 496b, 4 9 6 497, 497f
on tiptoes, 512, 512f
windlass effect and, 506, 506f, 507t
of atlas, anterior and posterior, 264, 266f
transverse
of foot, 503, 503f
of hand, 196-197, 200f
zygomatic, 352, 353f
Arm, elevation of
muscles active in, 122-129, 123b
at glenohumeral joint, 123-124, 124f,
1251
rotator cuff muscles in, 127f-128f, 127-129,
128b, 129b
upward rotators al scapulothoracic joint in,
124-127, 125b, 125f-126f
Arthrokinematics
definition of, 8
fundamental movements between joint surfaces in, 8t, 8 -1 0 , 9f, lOf
typical joint morphology in, 8, 8f
Arthrology, definition of, 25
Articular capsule, 26, 26f
fibrous, 32, 34, 34f
of glenohumeral joint, 107f, 107-110, 109f
of metatarsophalangeal joints, 504
of temporomandtbular joint, 357f, 3 57358
of apophyseal joints, 259, 260f, 261 f
in lifting heavy Ioads, 346t
resistance of to extreme flexion, 295, 2951
ol carpometacarpal joint
of thumb, 202
second through fifth, 198, 202f
of costotransverse joint, 285
of elbow, 138, 139f, 139t, HOf
of hip
anterior and posterior, 399, 401f, 402
imracapsular pressure in, 403b, 403f
of knee, 438-439, 440f, 440t, 441f
anterior, 438f, 438-439, 440f, 440t, 441f
lateral, 438f, 438-439, 4401', 440t
mediai, 439, 440t, 4411
posterior, 439, 440t, 441f, 448, 449f, 450t
posterior-lateral, 439, 440t, 441f
of radioulnar joints, 146
of talocrural joint, 484
of talonavtcular joint, 492
Articular disc
of acromioclavicular joint, 103
of mandibular disc-condyle complex, 359f,
360-362
displaced or dislocated, 361, 361f
lateral pterygoid action and, 367b, 367f
of stemoclavicular joint, lOOf, 101
of synovial joints, 26f, 27, 27b
of temporomandibular joint, 356-357, 357b,
357f
of ulnocarpal complex, 148, 178, 179f
Articular eminence, of temporal bone, 354f,
354-355
Articular processes, sacrai, 269, 271 f
Articularis genu, 455-456
attachments and innervation of, 572t
Atlantoaxial joint complex, 267f
anatomy of, 278f-279f, 278-279
as pivot joint, 28
axial rotation at, 282, 285f
connecttve tissues of, 278f-280f, 279
flexion and extension at, 279-282, 280f-282f
muscles at, 340f
range of molion of, 278t
Atlanto-occipital joint
anatomy of, 277-278, 278f-279f
connective tissues of, 278f-279f, 279
flexion and extension at, 279-282, 280f-282f
lateral flexion at, 284, 286f
muscles at, 333f, 340f
range of motion of, 278t
Atlas, 264, 266f
in axial rotation, 282, 285f
transverse ligament of, 279, 280f
Auditory meatus, extemal, 352, 353f
Axial rotation
apophyseal joint facet surfaces and, 273, 273f
of atlas, 282, 285f
of axis (C2 vertebra), 282. 285f
of craniocervical spine, 282-283, 285f
coupling pattern vvith lateral flexion in, 339b
muscles active in, 340-341, 342f
of thoracic spine, 287, 290f
of trunk
abdominal muscle action in, 327, 327b
secondary muscle action in, 327b
Axial skeleton
components of, 251, 252f, 253-269
in cranium, 253, 253f
in ribs, 253-254, 256f, 257f
in sternum, 254, 256, 257f
in vertebrae, 253-254, 254f-255f, 255t
in vertebral column, 256-269, 258f-260f.
Vertebral column.
disorders of, 252
osteologie features of, 252-269, 253b
posture of, sitting posture and, 301-302
302f
terminology relating to, 252, 253t, 272l
tissues of
innervated by dorsal rami, 314t
innervated by ventral rami, 313f, 313-314
Axillary pouch
of glenohumeral joint, 107, 107f
of interior glenohumeral ligament, 109, 1lOf
Axis (C2 vertebra), 264, 267f
in axial rotation, 282, 285f
Axis of rotation, 5f, 5 -6 , 6f, 17, 18f
average and estimates of, 31, 31f
of ankle and foot, 482f, 482-483
of hip, 404, 404f
of knee, 443, 445f
of fielvic tilt, 299
of subtalar joint, 490, 490f
of talocrural joint, 486, 487f
See also
(Continued)
Axis of rotation
of transverse tarsal joint, 493, 495f, 496
of wrist, 180-181, 181 f
See also
Back,
Lumbar spine; Vertebral column
muscles of.
Muscle(s), back,
vertebrae of
anatomy and kinematics of, 292-303
osteologie features of, 263t, 267-269,
268f-269f
Balance, in gali, 533, 534f
role of trunk and upper extremity in, 543545
Bandfs)
of digitai extertsor mechanism, 220, 22 l f 223f, 222t
of myofilaments, 45, 45f
Bending, as musculoskeletal force, 12f
Biceps brachii
as supinator muscle of forcami, 165-169,
166f, 167f
attachments and innervation of, 244t
biomechanical and structural variables of, 157l
function of, 157, 158f
in combined elbow flexion and shoulder ex
tension, 160-161, 161f
Ime of force of. 159f
long head of, in arm elevation at glenohu
meral joint, 124, 124f, 125t
Biceps curi exercise, 72b, 72f
Biceps femoris
attachments and innervation of, 572t
functional anatomy of, 440f-441f, 463
long head of, action and innervation of at
knee, 454t
short head of
action and innervation of al knee, 454t
in gait, 549f, 550
Biomechanics
definition of, 3
principles of, 5 6 -85
problems in, guidelines for solvtng, 77t
Biomechanics laboratones, used in gait analysis,
526, 526f
Blood vessels, of synovial joints, 26f, 2 6 -2 7
Body weight, vs. mass, 12b
Bone.
e.g.,Tibia,
cancellous, in proximal femur, 396, 399f
compaci, in proximal femur, 396, 399f
organization and structure of, 36f-37f, 3 6 -37
remodeling of, 36
stresses on, 36 -3 7
Bone spurs, cervical, 265b, 265f
Boutonniere deformity, of fingers, 239, 240f
Bow-legs, 438, 439f
Bowstringing
force of, 68, 68f
in (lexor pulley rupture, 217, 217f
in palmar dislocation of metacarpophalangeal
joint, 237, 238f
in ulnar drift at metacarpophalangeal joint,
238, 239f
in zig-zag deformity of thumb, 236, 237C
of quadriceps agatnst knee, 462, 463f
Boyles law, 368, 368b. 368f
Brachial plexus
in innervation of shoulder, 117, 119f
ventral nerve roots of, muscles used for testing
function of, 243t
Brachiale
attachments and innervation of, 244t
biomechanical and structural variables of, 157t
function of, 157, 158f
See
Index
(Continued)
Brachialis
line of force of, 159f
work capacity of, 157t, 159b, 159f
Brachioradialis
as secondary supinator muscle of forearm, 165
attachmems and innervation of, 244i
biomechanical and structural variables of, 157t
function of, 157-158, 159f
line of force of, 159f
Breathing
lungs in, 368f, 369
muscles used in, 374t, 375t
paradoxical, after spinai cord injury, 374b
rib movement during, 371, 37 lf
Bunion, 505, 505f
Bursa, of knee, 439, 442t
Bursa sacs, of shoulder, 11 lf, 111-112
C
Calcaneal tuberosity, 480f481 f, 481
Calcaneocuboid joint.
Tarsal joint, trans
verse.
articular and ligamentous structure of, 49 2 493, 493f
Calcaneocuboid ligament, dorsal, 485f. 492
Calcaneus, osteologie features of, 479b, 480f4 8 lf, 481
Callus formation, and high mediai longnudinal
arch, 498
Cane, proper use of, 429, 429f
Capitate bone, 174f-175f, 176, 199f
Capitulum, 134, 134f, 135f
Capsular ligaments, 260f
of radioulnar joint, 146, 148f
of synovial joints, 26, 26f
of thoracic spine, 285
Capsule, articular. See Articular capsule.
Carpai bones
in ulnar and radiai deviation of wrist motion,
183b, 183f
osteology of, 173b, 173f-175f, 173-176
Carpai instabihty, of wrist, 184b, 184f-186f,
184-185
Carpai tunnel, 175f, 176
Carpai tunnel syndrome, 216, 216f
Carpometacarpal joint(s), 195, 197f, 197-200,
201f-203f.
Hand.
as saddle joint, 28, 30f, 202
movement and function of, 197-198, 200,
2 0 lf, 203f
of thumb, 200-207, 202f-207f
adduction and abduction of, 203-204, 205f
capsule and ligaments of, 202, 202t, 203f204f
flexion and extension of, 204-205, 206f,
206t
generai features of, 200, 202
in zig-zag deformity of thumb, 236, 237f
muscles attached to, 224t
opposition of, 205, 207, 207f
saddle joint structure of, 202
second through ftfth
generai features of, 198
ligaments of, 198, 202f
structure and ktnematics of, 198, 200, 203f
Carpus, ulnar translocation of, 185, 186f
Cartesian coordinate System, 66
Cartilage
articular, 26, 26f
chronic trauma to, 38, 39f
composition and function of, 32, 32f, 33t,
34 -3 5 , 35f
of distai femur, 435
of palella, 437
See also
See also
(Continued)
Cartilage
hyaline, 3435, 35f
of femoral condyle, grooves on, 435, 437f
of femoral head, 396, 399f
Cauda equina, 270b, 270f
Cells, in connective tissues in joints, 32
Center of gravity, 57
Center of mass. 5, 57, 58f
displacement of, in gait, 533, 533b, 534f,
540b, 540f
methods of minimizing, 535-537, 545t,
546f-547f
Center of pressure, path of, in gait, 553, 554f
Cerebral palsy
gait analysis and, 526
gait pattern in, 417, 539, 5491, 551, 560, 563
hip dysplasia and, 401b
pes cavus and, 498
Cerebrovascular accident, abnormal gait pattern
with, 560, 563
Charcot-Marie-Tooth syndrome, pes cavus and,
498
Choking, abdomtnal muscle function in, 377b
Chondrocytes, in articular cartilage, 34, 35f
Chondromalacia patellae, 462b, 462f
Chondrosternal junctions, 370
Chopart's joint, 491.
Tarsal joint, trans
verse.
Chronic impingement syndrome at shoulder,
114b, 114f
Chronic obstructive pulmonary disease, 373,
375-376
Cinematography
for collection of kinemattc data, 83
in gait analysis, 525
Clavide
movement of, in shoulder function, 101 f
102f, 101-102, 117, 118f, 119t
osteologie features of, 94, 95f
Clavicular facets
of manubrium, 93, 94f
of sternum, 254, 257f
Coccyx, vertebrae of, 263t, 269, 271 f
Collagen fibers
in articular cartilage, 34, 35f
in dense connective tissues, 32, 34, _34f
in nucleus pulposus and annulus ftbrosus,
273, 276b
types of, 31-32, 32b, 34, 34f
Compartments
of leg, 506
of midcarpal joint, 177, 177f
Compression force, 12f
on apophyseal joints, 272t
on foot, in standing position, 496b
on interbody joints, in thoracic kyphosis,
292b
on intervertebral disc, 274-275, 275f
on knee, 74b, 74f, 460, 461 f
menisci function and, 442
on L2 vertebra during lifting, 342-345, 343b,
344f-345f
Valsalva maneuver and, 345-346
on mediai longitudinal arch, 496b
on patellofemoral joint, 457, 460, 460b, 461 f
on talocrural joint, in stance phase of gait,
488f, 488-489
Computer-based Systems, for measurement of
vertebral column motion, 277b
Condyle(s)
of distai femur, 435, 436f, 437f
of mandible, 353, 353f, 354f, 356
in disc-condyle complex
derangement of, 361b, 36lf
lateral pterygoid action and, 367b, 367f
See also
(Continued)
579
Condyle(s)
translalional movement of, 359f, 360,
362
Connective tissue(s)
aging and, 37
dense irregular, 32, 33t, 34
immobilization and, 3 7 -3 8
in acromioclavicular joint, 103, 103f
in atlanto-occipital and atlantoaxial joints,
278f, 279, 279f, 280f
in elbow, 138-140, 139f, 139t, 140f
in glenohumeral joint, 107-110, 109f, llOf
in joints
biologie materials forming, 31b, 3 1 -32
biomechanical function of, 12, 13f, 14, 14f
types of, 32, 33t, 34-37
in knee capsule, 440t
in mandibular condyle, 356
in mediai longitudinal arch, 496-498
in muscle, 42, 43f, 44, 44f, 44t
in proximal ubiofibular joint, 483b
in radioulnar joints, 146, 146f
in rectus sheaths and linea alba, 323, 325,
325f
in sternoclavicular joint, lOOf, 101
in temporomandibular joint, 358b
in vertebral column
limitalion of motion by, 276t, 276-277
lumbar region of, 293, 295, 295f
periarticular, of metacarpophalangeal joints,
208, 208f, 213, 214
Contracture
Dupuytrens, 232
flexion
of elbow, 140, 141b, 141f
of hip, 300, 301 f, 416, 416f
piantar flexor, at ankle, 516-517
Coordinale System, in free body diagram, 66
Coracoacromtal arch, 108f, llOf, 111-112
impingement of humeral head al, 113, 114b,
114f
Coracoacromial ligament, 111
Coracobrachialis
attachments and innervation of, 243t
in arm elevation at glenohumeral joint, 123
124, 124f, 125t
Coracoid process, 97, 97f
Coronoid fossa, 134, 134f
Coronoid process, 135, 1361, 137f, 353, 353f
Costai facets, 256, 257f
of manubrium, 93, 94f
Costochondral junctions, 370
Cosioiransverse joints, 253, 285, 285b, 287f, 370
Costovertebral joints, 253, 284-285, 285b,
287f, 370
Coughing, abdominal muscle function in, 377b
Counter-nutation, 306, 306b
Coxa valga, 394, 396f
biomechanical consequences of, 431-432,
433f
Coxa vara, 394, 396f
biomechanical consequences of, 431-432,
4331
with excessive genu valgum, 471, 47lf
Craniocervical region
analomy and kinematics of, 277, 277i, 277
284
muscles of, 315t, 333-338
actions of, 339t
in axial roialion, 282-283, 285f, 34 0 341, 342f
in stabilization, 339-340, 3 4 lf
anterior-lateral, 315t, 334t, 334-337
attachments of, 382l
functional mteractions among, 338-341
080
Index
(Commue.d)
Craniocervical region
innervation of, 312-314, 382l-383l
posterior, 315i, 337-338, 338t
attachmems of, 383l
protraction of, muscuiar imbalance wiih
341b. 3411'
Cranium. See also Head
osteologie features of, 253, 253f
Creep, in ttssues, 13, 15f
Cross-bridges
in active force generation, 46
of myofilaments, 45, 46f, 47f
Crown, of teeth, 355, 356f
Crus, of diaphragm, 372
Cubitus valgus, of elbow, 138, 138f
Cubitus varus, of elbow, 138, 138f
Cuboid bone, 4801-48 lf, 481
Cuboideonavicular joint, 4931, 502b, 502-503
5031
Cuneiform bones, 479b, 4801-4811, 481
Cuneocuboid joint complex, 4931, 502b, 50 2 503, 503f
Cuneonavicular joint, 4931, 502b, 502-503
503f
Cusp, of teeth, 355, 356f
See aho
E
D
See also
See also
See also
See
See also
(Conlinued)
Energy
potential and kinetic, 534-535, 535f
walktng speed and, 547, 547f
in work-energy relationship, 600-602
Epicondyle(s)
lateral
of distai femur, 435, 436f, 437f
of humcrus, 135, 135f
mediai
of distai femur, 435, 436f, 437f
of humerus, 134, 134f, 135f
Epicondylitis, lateral, 189
Epimysium, in muscle, 42, 43f
Equilibrium, static and dynamic, in Newtons
law of inerita, 57
Erector sptnae
actions of, 319f, 320-321
as extrinsic trunk stabilizers, 316, 330f 330331, 33 Ib
attachmems and innervation of, 381t
common lendon of, attachmems of, 319t
eross-seclional anatomy of, 318f
in gait, 549f, 551
lumbar, in lifting heavy loads, 320, 320f 347
3481
of deep layer of back, 318f-320f, 318t-319t
318-321, 320b
Eversion
definition of, 482, 4821, 483t
of subtalar joini, 49 lt, 492b
of talocrural joint, 4 9 lt
of transverse tarsal joint, 493, 4951'
Evolute, 31
of knee, 443, 445f
Exercise(s)
closed kinetic chatn, 453b
extemal torque in. manual application of 7576, 76f
fiexion and extension, for treatment of lowback pain, 302b
isometric, at elbow, biomechanical problem
solving with, 77 -8 1 , 78f, 791
resistive, design of, 72b, 72f, 74b, 74f
sit-up
abdominal muscle action in, 331-333,
332f, 3331
diagonal, 326f
hip flexor muscles in, 332f, 333
Expiration
forced, iniercostales in, 3761, 377, 3771, 377t
lowering of ribs during, 371, 37 lf
of lungs, 369
Extension
of craniocervical spine, 279-282, 280f-282f
of elbow, 140-144, 161-162, 163f, 163t
164, 164f
of fingers, 201f
of glenohumeral joint, 112f, 114, 116t
of head, 3191 320
of hip, 405f, 406, 407f, 408f, 408-409, 466,
468f-469f, 468-470, 469t
of knee. See Knee, extension of.
of lumbar spine, for low back pain, consequences of, 302b
of metacarpophalangeal joints, 209, 2101
of shoulder, 129-130, 130f, 131 b
of thoracic spine, 286t, 286-287, 2881 289f
of thumb, 201f, 204f, 204-205, 206f, 206l
ofwrist, 179-180, 180f, 181f-182f, 181182, 187, 187f
Extensor carpi radialis brevis
attachmems and innervation of, 245t
function of, 187f1891 187-189
in making a fisi, 189
radiai deviation by, 191, 1911
Index
Extensor carpi radialis longus
attachmenis and innervation of, 245t
function of, 187f-189f, 187-189
radiai deviation by, 191
Extensor carpi ulnaris
attachments and innervation of, 245t
function of, 187f-189f, 187-189
in wrist flexion, 190
ulnar deviation by, 191-192, 192f
Extensor digiti minimi, 219-220, 220f-221f
attachments and innervation of, 245t
Extensor digitorum brevis
anatomy and function of, 504f, 510f, 518,
519f
attachmenis of, 574t
innervation of, 507, 508f, 574t
Extensor digitorum communis, 187f, 2 lOf, 21 9 220, 220f22lf
action of, 220, 223f
attachmenis and innervation of, 245t
in openinghand, 230-232, 231f-232f
wrist extension with, 187, 187f
Extensor digitorum longus
anatomy and function of, 508, 510, 510f
attachments and innervation of, 573i
in gait, 549f, 550
innervation of, 507, 508f
Extensor digitorum muscles, in finger flexion,
234
Extensor hallucis longus
anatomy and function of, 508, 510, 510f
attachments of, 573t
in gau, 549f, 550
innervation of, 507, 508f, 573t
Extensor indicis, 219-220, 220f221f
attachments and innervation of, 245t
Extensor lag," at knee, 460b
Extensor pollici? brevis, 221, 223, 223f
attachments and innervation of, 246t
radiai deviation of wrist by, 191, 191 f
Extensor pollicis longus, 221, 223, 223f
attachmenis and innervation of, 246t
radiai deviation of wrist by, 191, 191f
Extensor retinaculum
of ankle and foot, 508, 510f
of wrist, 188, 188f
Eyes, in axial rotation in craniocervical region,
340
F
Facet(s)
articular
of atlas, 264, 266f
of lumbar vertebrae, 268f, 268-269, 269f
clavicular
of manubrium, 93, 94f
of sternum, 254, 257f
costai, 256, 257f
of manubrium, 93, 94f
of ihoracic vertebrae, 265, 267f
of calcaneus, 480f-481f, 481
of femoral condyie. 435, 437f
of patella, 437, 437f, 447, 448f
of talus, 480, 4 8 lf
Facet surfaces, of apophyseal joints, 273, 273f.
292, 293f
Falls, hip fracture following, 428t
Fascia
cervical, components of, 334, 334f, 334t
piantar
forces applied to in gait, 561t
of mediai longitudinal arch, 496, 497
windlass effect on, 506, 506f
thoracolumbar, in lifting heavy loads, 346t,
347
also
also
581
Finger(s) (Commutiti)
rote of proximal stabihzer muscles in, 218,
218f
interphalangeal joints of, 211-213
movements of, terminolog)' of, 197, 201f
muscles of
extensors, 219-220, 221f-223f, 222t,
230-232, 231f-232f
extrinstc and intrinsic, interaction of, 2 30234
flexors, 214-219, 233f, 233-234
in makmg a fisi, 188f-189f, 188-189
position of function of, 213, 213f
ulnar drift of, in rheumatoid arthritis, 2 37238, 239f
Fist, muscle mechanics of, 188f-189f, 188-189,
233f, 233-234
Flabella, 439
Flatfoot, 497, 497f
decreased windlass effect in, 506, 506f
Flexion
lateral
of craniocervical spine. 283-284, 286f
in coupling with axial rotation, 339b
of thoracic spine, 287, 291 f
of craniocervical spine, 279-282, 280f-282f
of elbow. 157t, 157-161, 158f-162f, 159t,
162b
of fingers, 201 f
of glenohumeral joint, 112f, 114, 115f, 116l
of hip, 406, 407f, 408f, 408-409
of knee.
Knee, flexion of.
of lumbar spine, for low back pain, consequences of, 302b
of metacarpophalangeal joints, 209, 210f
of thoracic spine, 286t, 286-287, 288f, 289f
of thumb, 201 f, 204f, 204-205, 206f, 206t
of wrist, 179-180, 180f, 181f-182f, 181182, 190-191, 191t
Flexion contracture
elbow, loss of forsvard reach with, 140, 141b,
141 f
hip
effect on standing, 416, 416f
lumbar lordosis with, 300, 301f
Flexor carpi radialis
anatomy and function of, 189-190, 190f
attachments and innervation of, 245t
radiai deviation by, 191, 191 f
Flexor carpi ulnaris
anatomy and function of, 189-190, 190f
attachments and innervation of, 245t
ulnar deviation by, 191-192, 192f
Flexor digiti mimmi
of foot
anatomy and function of, 519, 519f
attachments and innervation of, 574t
of hand, 225h 225-226
attachments and innervation of, 246t
Flexor digitorum brevis, attachments and nnervation of, 574t
Flexor digitorum longus
anatomy and function of, 512-514, 514f, 516
attachments and innervation of, 5731
maximal torque potential of at ankle, 514,
516t
supinatton potential of, 514, 516
Flexor digitorum profundus, 2 14f215f, 215
216
attachments and innervation of, 246t
in finger flexion. 233f, 233-234
in wrist flexion, 190-191
Flexor digitorum superficialis, 190, 190f, 214f
2151, 214-215, 218, 218f
attachments and innervation of, 246l
See
Index
582
(Conlinued)
See also
See also
also
See also
See also
See also
See
See
See also
See
G
Gagging, abdominal muscle function in, 377b
Gait, 523-568.
Walking.
analysis of, histoncal aspeets of, 524-527
525f-526f
antalgic, 560
at different ages, 523, 524f
bodys center of mass in, 533-535, 534f, 535f
cadence of, 528
clinical measurements of, 530b
compensated Trendelenburg, 425b
energy used in, kinetic and potential, 5 34535, 535f, 547, 547f, 548t
kinematic methods of minimizing, 545t,
545-547, 546f-547f
festinating, 563
hip abductor use in, 424f, 424-425
hip internai rotator muscle use in, 417, 420f
impaired, 559-560. 561t-567t, 563, 563f
565f, 567f, 568f
adaptation to, 560
anterior cruciate ligament injur>' and, 453b
causes of, 560, 560b
in cerebral palsy, 417
"in-toeing" as sign of, 395-396, 398f
secondar)^ to ankle/foot impairment, 561t
562t
step length in, 528f
with hemiparesis, 528f
with painful hip, 528f
with Parkinsons disease, 528f
joint kinematics in
in frontal piane, 539f-542f, 539-541
541b
in horizontal piane, 542f-543f, 542-543
544b, 544f
in sagittal piane, 535-539, 536f-537f,
538b
to minimize energy expenditure, 545t 545547, 5461-547f
kinetics of, 551-559
See also
Index
Gait
(Continued)
(Continued)
Genu varum
management of, 471
with unicompartmental osteoarthrilis, 470f,
471
Ginglymus, elbow as, 137
Glenohumeral joint, 98, 106-116
abduction of, 116-117, 118f, 119t
arm elevation in, 123-124, 124f, 125t
in chronic impingement syndrome at shoulder, 114b, 114f
in frontal piane vs. scapular piane, 113,
115f, 116, 117f
interaction with scapulothoracic upward rotators, 125f
scapulohumeral rhythm in, 116, 117f
arthrokinematics ai, 116t
roll and slide, lOf
rotator cuff muscles in, 128-129, 129b
dynamic stability of, rotator cuff muscles and,
128
generai features of, 106-107, 107f
kinematics at, 112f115f, 112-116, 116t
during abduction, 116-117, 117f, 118f,
119t
loose fit of, 108b, 108f
periarticular connective tissue of, 107-110,
109f, HOf
sensory innervation of, 119
spontaneous anterior dislocation at, 128b
stability of, 107-110, 108b, 109f-110f, 109t
static, 110-111
locking mechanism of, llOf
upper trapezius paralysis and, 120b
Glenoid fossa, 96, 96f.
Glenohu
meral joint.
Glenoid labrum, 110, llOf
Gluteal lines, 390, 390f-391f
Gluteal nerve, inferior and superior, 410f, 411
Gluteal tuberosity, 394, 395f
Gluteus maximus
anatomy and action of, 418, 4 2 lf
attachments and innervation of, 572t
in forward lean of body, 420-421, 4 2 lf, 422f
in gait, 548, 5491
in hip and knee extension, 469. 469t
in lifting heavy loads, 347, 348f
in lumbojielvic rhythms in trunk llexion and
extension, 298-299, 299f
Gluteus medius, 420f
anatomy and action of, 42lf, 422-423, 423f
attachments and innervation of, 572t
in gait. 548, 549f, 561l
weakness of, 540, 540f
Gluteus medius limp, 425b, 432, 540
Gluteus minimus, 420f
anatomy and action of, 423, 423f
attachments and innert'ation of, 572t
in gait, 548, 549f
Glycosaminoglycans
aging effeets on, 37
in ground substance, 32, 32f
Goniometry, 31
for measuremeni of motion at subtalar joint,
492b
Gracilis
anatomy and action of, 414, 418f, 441 f, 463
at knee, 454l
attachments and innervation of, 572t
Grasp (grip)
at carpometacarpal joints, 201 f
at metacarpophalangeal joints, 208-209, 209f,
210f
metacarpophalangeal joint of thurnb and, 211,
212f
muscle mechanics of, 188f-189f, 188-189
583
584
Index
(Continued)
Hand
muscles of, 214, 214t
extrinsic, 214f-222f, 214-223
attachments of, 245i-246t
innervation of, 152-156, 155f-156f,
213, 245t-246t
intrinsic, 224-228, 225i, 227f-228f
anachmenis of, 246t-247t
m grasp action, 233. Set
Grasp
(gnp).
innervation of, 152-156, 155f-156f,
213, 246t-247t
opcning of, muscles and joints used in, 2 30232, 231 f232f
palm of
arches of, 200f
creases of, 196, 1971
position of
extrinsic-plus, 230, 230f
for funccion, 213, 213f
intrinsic-minus, 231-232, 232f
intrinsic-plus, 230, 230f
Haversian System , 36, 37f
Head.
Craniocervical region
extension of, erector spinae muscle action in,
319f, 320
in axial rotation of craniocervical spine, 3 4 0 341, 342f
motion of, 279-284
osteologie features of, 253, 253f
posture of
chronic forward, muscular imbalance with,
341b, 341f
muscles active in, 340, 341f
temporomandibular joint disorders and,
366b, 366f
protraction and retraction of, 282, 284f
Heel contact, 527, 527f, 531, 531f, 531t
ground reaction forces at, 554f
Heel off, 531, 531f, 531t
abnormal, 539
Heel pain, gait deviations with, 562t
Heel strike, 527, 527f
Hemiparesis, gait step length with, 528f
Henneman size principle, 51
Hip, 389-433
abduction of, 405f, 406, 407f, 408f, 4 0 8 409.
Muscle(s), hip, abductor
adduction of, 405f, 406, 407f, 408, 408f
in gait, 549f, 550
arthrokinematics of, 408f, 408-409
in gait, 536f, 537f, 537-538
in frontal piane, 539f, 540, 540b, 540f
arthrology of, 396-409
acetabular alignment and, 397-398, 399f,
400f, 40 lb
capsule and ligamenis of, 399-402, 40 lf,
402f, 402t
femoral head and, 396-397, 399f
artificial, minimization of hip abductor forces
on, 75, 75f
axis ol rotation at, longitudinal (vertical), 404
extended through knee, 438, 439f
close-packed position of, 402, 403f
definition of, 389
developmental dysplasia of, acetabular malalignment and, 40lb
extension of, 405f, 406, 407f, 408, 408f
with knee extension, 466, 468f, 468-469
469t
with knee (lexion, 469f, 469-470
flexion of, 404, 405f, 406, 407f, 408, 408f
with knee extension, 469f. 469-470
with knee (lexion, 469t
fratture of, 428, 428t
internai fixauon for, 431, 431 f
also
See also
See also
(Continued)
Hip
functional anatomy of, 389, 396-402
impatrment of
gait deviations with ai ankle-fooi, 563t
gait deviations with ai hip/pelvis/trunk,
566t, 567f, 568f
gait deviations with at knee, 565t
in gait
adduction of, 549f, 550
arthrokinetics of, 536f, 537f, 537-538
forces applied to, 561 1
in frontal piane, 539f, 540, 540b, 540f
in horizontal piane, 543, 543f
in sagittal piane, 536f, 537f, 537-538
joint torques and powers in, 555f-556f,
556-557
linutation of movement in, 537, 5371',
538b
muscle action in, 548, 549f, 550
in trunk extension, lumbopelvic rhythms in
298-299, 299f
in trunk flexion, lumbopelvic rhythms in,
297-298, 298f
intracapsular pressure in, 403b, 40.3f
muscles of.
Musclefs), hip.
attachmenis and innervations of, 571t-573t
osteoarthritis of, 428b, 428-429
causes of, 428b
clinica! signs of, 428b
osteokinematics of, 402-408
femoral-on-pelvic rotation in, 404f-405f,
4 04-406
pelvic-on-femoral rotation in, 404f, 406f,
406-408, 407f
planes and axes of rotation of, 404, 404f
osteology of, 390-396
painful.
Hip disease.
gait deviations with, 563t, 565t, 566t, 567f,
568f
gait step length with, 528f
range of motion of, 402-404
rotation of, internai and external, 405f, 406
407f, 408, 408f
Hip disease
causes of, 427-428
gait deviations with, 563t, 565t, 566t 567f
568f
gait step length with, 528f
thcrapeutic intervention for, 429-431
methods of carrving loads with, 429-431
430f
surgical intervention for, 431f433f 4 3 1 432
use of cane with, 429, 429f
Hip flexion contracture
in standing, effect of, 416, 416f
mcreased lumbar lordosts with, 300, 301 f
Hip hiking, 540
Hook grip, 234-235
Hortzontal piane, 5, 6f, 6t
Humeroradial joint, 133-134, 134f
arthrokinematics of, 141-144, 143f, 144f
as shared joint between elbow and forearm
150, 150f
force transmission through forearm interosseous membrane and, 142-144, 143f
144f
generai features of, 137-138, 138f
sensory innervation of, 156
Humeroulnar joint, 133-134, 134f
arthrokinematics of, 140-141, I42f, 143f
as hinge joint, 28, 28f
generai features of, 137-138, 138f
joint surface relationships in, 8f
posterior dislocation of, 145, 145f
sensory innervation of, 156
See
See also
Humerus
angle of inclination and retroversion of, 98f
head of, 97, 97f-98f. See also Glenohumeral
joint
centralization and stabilization of by rotator
cuff muscles, 115f, 116b
impingement of, 113, 114b, 114f
in chronic impingement syndrome at shoulder, 1 14b, 114f
in kinematics of glenohumeral joint, 112f115f, 112-116
mid-to-distal, osteologie features of, 133-135
134b, 134f, 135f
neck of, 97f, 9 7 -9 8
proximal to mtd, osteologie features of, 9 7 f99f, 9 7 -9 8 , 98b
Hyoid bone, 355
Hyperextension, craniocervical
chronic forward head posture with, 341b
341f
injury with (whiplash), 277, 281, 337b, 337f
osteophyte lormation and, 283f, 283b
Hypothenar eminence, muscles of, 225f 2 25226
I
1 bands, of myofilaments, 45, 46f
Iliac cresi, 390-391, 391f
elcvaton of in gait, 540, 540f
Iliac fossa, 391, 39 lf
Iliac spine, 390f-392f, 390-391
Iliac tuberosity, 391, 391f
Iliacus
anatomy and action of, 412, 413f
attachments and innervation of, 572t
in gait, 548, 549f
in iliac fossa, 391, 391f
in trunk movement, 327, 328b
Uiocostalis
anatomy and actions of, 318t, 319f, 3 19-32!
as secondary axial rotators, 327b
in trunk movement, 329t
Uiocostalis cervicis
action of, 375t
attachments of, 38 lt
innervation of, 375t, 381t
Uiocostalis lumborum, attachments and mnervation of, 381 1
Uiocostalis thoracis
action of, 375t
attachments of, 381 1
innervation of, 375t, 3 8 11
Iliopsoas
anatomy and action of, 412, 413f
attachmenis and innervation of, 572t
in gait, 548, 549f
in trunk movement, 327-328, 328b, 328f
Iliotibial tract, anatomy and action of, 413, 413f
Ilium, osteologie features of, 390b, 390f-391f
390-391
Imaging techniques, for collection of kinematir
data, 83, 83f
Immobilization, effeets on connective tissue 3 7 38
Impulse, 60
Impulse-momentum relationship, 60, 60b, 61b
61f
Infrahyoid
attachments and innervation of, 384t
in mastication, 365, 365f
lnfraspinatus, 109-110, llOf
attachments and innervation of, 244t
in elevation of arm, 127f-128f, 127-128
129b
in external rotation of shoulder, 132
Index
(Continued)
lnfraspinaius
in shoulder adduction and exiension, 1 2 9 130, 130f
in stabilization of humeral head, 115f, 116b
Innominate bone, 390b, 390f-392f, 390-393,
392b, 393b
extemal surface of, 390
Inspiration
elevation of ribs dunng, 371, 37 If
muscles of, action and innervation of, 372t,
375t
of lungs, 3681, 369
Instruments, used in gait analysis, 526, 526f
Interbody joint
compression force on, in thoracic kyphosis,
292b
lumbar, shear forces on, 293, 293f
of intervertebral junction, 269, 272f
structure and function of, 273-274, 274(
Intercarpal joint
as piane joint, 28, 29f
of wrist, 173f, 175f, 176
intercarpal ligament, dorsal, of wrist, 179
lnterchondral joint, 370, 370f
lntercoccygeal joint, 269
Intercondylar eminence, of tibia, 436-437
Intercondylar notch, of distai femur, 435, 436f,
437f
intercostal membrane, posterior, 373
Intercostal nerve, axial skeletal tissues innervatcd
by, 313, 313f
Intercostales
action and innervation of, 372t, 384t
anatomy of, 369f, 373
function of, 373-374
in forced expiration, 373, 376f, 377f, 377 1
paralysis of in cervical spinai cord injury,
374b
Intercostales extemi, 369f, 373
attachments and innervation of, 372t, 384t
Intercostales interni, 369f, 373
attachments and innervation of, 372t, 384t
Intercostales intimi, 373
attachments and innervation of, 372t, 384t
Intercuneiform joint, 493f, 502b, 502-503,
503f
Intermetatarsal joint, 504
Intermuscular septa, 413
Interossei
dorsal
of foot
anatomy and function of, 519f, 520
attachments and innervation of, 574i-575i
of hand, 227-228, 228f
attachmenis and innervation of, 246t
in finger flexion, 233, 233f
in key pinch action, 229, 229f
in opening hand, 230-232, 232f
palmar, attachments and innervation of, 247t
piantar
anatomy and function of, 519f, 520
attachments and innervation of, 575t
tension fraction of, 226t
vs. lumbrical muscles, 230t
Interosseous membrane
of ankle, injury of, 489b
of forearm, 145
force transmission through, 142-144, 143f,
144f
Interosseous nerve
anterior, 152, 155f
posterior, 152, 154f
lnterphalangeal jomt(s), 195, 197f, 211-213
distai, 212f, 212-213
of foot, 493f, 504f, 505-506
mobility al, 505-506
(Continued)
lnterphalangeal jointfs)
of thumb
abductor pollicis longus as assistant extensor of, 223f, 225
muscles attached to, 224t
position of function of, 213, 213f
proximal, 211-213, 212f
lnterspinalis, 321, 323
attachmenis and innervation of, 3811
in irunk movement, 329t
lntenarsal joint, distai, 493f, 502b, 502-503,
503f
Intertendinous conneclions, 220
Intertransversarus, 321, 323
attachments and innervation of, 381t-382t
in trunk movement, 329t
Intertrochantertc cresi, 394, 395f
Intertrochanteric line, 393f, 394
Intertubercular groove, of humerus, 98
Intervertebral disc
hemiated (slipped), 265b, 265f, 296b, 296f,
296t
factors favonng, 297b
mechanisms of, 296b-297b, 296f, 296t
lumbar
as hydrostatic shock absorber, 274-275,
275f
structure and function of, 273-274, 274f
water coment of, 276b
trauma lo, 38
Intervertebral joints, consequences of exercises
for low-back pain on, 302b
Intervertebral junction
function of, 269, 269t. 272f
movement of, terminology for, 271-272,
272f, 272l
typical, 269, 271, 272f, 272t
In-toeing, 395-396, 398f
Intra-abdominal pressure, during lifting, 345346, 347
Intra-articular discs, of synoval joints, 26f, 27,
27b
Inverse dynamic approach, to measuring internai
torque and joint reaction force, 81b, 81f
Inversion
definition of, 482, 482f, 483t
of subtalar joint, 4911, 492b
of talocrural joint, 49 lt
of transverse tarsal joint, 493, 495f
Ischial ramus, 39 lf, 393
Ischial spine, 392f, 393
Ischial tuberosily, 390f, 392f, 393
lschium, osteologie features of, 39lf, 392f, 393,
393b
See
oj specific joints.
Joint(s).
nls numes
aging effecls on, 37
angle of displacement of, muscles mechanical
advantage and. 21, 22, 221, 6 9 -7 0 , 71f,
72b, 72f
ball-and-socket, 28, 29f, 396
classification of, 2 5 -3 0
by mechanical analogy, 27l, 27 -2 8 , 28f30f, 30
by structure and movement potential, 2 5 27, 26f, 26i
condyloid, 28, 30f
connective tissues in,
Connective tissuc(s).
biologie materials forming, 3 lb, 31-32
biomechanical function of, 12, 131, 14. 14f
types of, 32, 33t, 3 4 -37
definition of, 25
dislocation of, by gender, 464t
See aho
585
(Continued)
Joint(s)
ellipsoid, 28. 29f
forces applied to.
Force(s).
function of, 25
htnge, 28, 28f, 137
instabilily of, with chronic trauma, 38, 39f
ovoid, classification of, 30, 30f
pivot, 28, 28f
piane, 28, 29f, 273
position of, close-packed and loose-packed, 11
saddle, 28, 30f
classification of, 30, 30f
complex, 198, 200, 203f
of carpometacarpal joint of thumb, 202,
204f
structure and function of, 25 -3 9
surfaces of, 8, 8f
synovial
classification of
based on mechanical analogy, 27t, 2 7 28, 281-30f, 30
of ovoid and saddle joints, 30, 30f
definition and function of, 26f, 2 6 - 27
elements associated with, 26f, 2 6 -2 7
trauma effeets on, 38, 39f
uncovertebral, 264, 264f, 266f
in disc disease, 265b, 265f
Joint capsule.
Articular capsule.
Joint power, definition of, 555, 555b
Joint reaction force, 15, 15f, 64, 64f
guidelines for solving biomechanical problems
in, 77t
in knee, in standing, 470f, 470-471
in walking, 424f, 425
measurements of, inverse dynamic approach
to, 81b, 81f
Joint torques.
Torque.
in gait, 553-558, 555b
in ankle and foot, 558, 559f-560f
in hip, 555f-556f, 556-557
in knee, 557f-559f, 557-558
net, definition of, 555
Joints of Luschka, 264
Jugular notch, 254, 257f
of manubrium, 94, 94f
Juncturae tendinae, of digitai extensor mechamsm, 220, 221f
See
See
See also
K
Key pinch, muscular biomechanics of, 229, 229f
Kienbcks disease, 176b
Kinemaiic chain, open or closed, 7 -8
Kinematics, 3 -1 1
definition of, 3
units of measurement in, 5t
variables in, 5
Kinesiology, definition of, 3
Kinetics, 11-21
definition of, 11
force principle in, 11-12
muscle and joint interaction in, 16-19, 17f,
18f
musculoskeletal forces in, 12f-l5f, 12-15
musculoskeletal levers in, 19f-20f, 19-21,
22f
musculoskeletal torques in, 15-16, 16f
Knee, 438-439, 440f-441f, 440t.
Tibiofemoral joint.
abduction of, litnits on, 448, 449t
alignment of
abnormal
in frontal piane, 470f-472f, 470-471
in sagittal piane, 471, 472b-473b, 47.3f
normal, 438, 4391
arthrology of. 438-453
See aho
586
Index
(Continued)
Knee
biomechanical functions of, 434
bones and joims of, 434, 435f
bursae of, 439, 442i
extension of, 443, 444f, 445f, 445-446. 446f,
447f
hip extension or flexion with, 469f, 4 6 9 470
in gait, 538
limits on, 448, 449f, 457, 460, 460t, 46if
screw-home rotation and, 445-446, 446f
447f
tracking of patellofemoral joint during,
460-463, 463f, 464f, 464t, 465b
with piantar flexion by soleus, 515b, 515f
extensor lag and, 460b
extensor-to-flexor peak torque ratios in, 468b
fat pads of, 439, 442t
femoral-on-tibial movements in.
Femoralon-tibial knee motion.
flexion of, 7f, 443, 444f, 445f, 446
hip extension or llexion with, 469f. 4 6 9 470
in gait, 538
hyperextension of
abnormal gait pattern with, 563f
anterior cruciate ligament injur) with, 451
in genu recurvatum, 471, 472b-473b
473b
impairment of
extensor lag and, 460b
gait deviations ai ankle-foot with, 563t
gait deviations at hip/pelvis/trunk with, 567t
gait deviations at knee with, 564t, 565f
in gait
abnormal pattems in, 563t, 564t, 565f,
567t
extension in, 538
extensor muscles in, 549f, 550
flexion of, 538
flexor muscles in, 549f, 550
forces applied to, 561t
joint kinematics of, 536f, 538
in frontal piane, 540, 54lf
in horizontal piane, 543, 543f
in sagttal piane, 536f, 538
joint torques and powers in, 557f-559f
557-558
internai and extemal rotation of, 443-444
445f
ligaments of, 438f, 438-439, 440f-441f, 440t
muscle and joint interaction at, 434, 453-473
muscles of.
Musclefs), knee
norma!, joint reaction forces in, 470, 470f
osteoarthritis of, chondromalacia patellae with
462b, 462f
osteology of, 435-437
plicae of, 439, 442t
quadriceps strengthening exercises and, 4 5 6 457, 458f, 459f
range of motion of, 443
restraints on, in varus and valgus forces, 448
449l
rotation of. limits on, 448, 450l
screw-home rotation of, 445-446, 446f, 447f
sensory innervation of, 454
stability of, 434-435
synovial membrane of, 439, 442t
tibial-on-femoral movements in. See Tibial-onfemoral knee motion.
tibiofemoral joint of, 440, 442-444, 443f445f, 446.
Tibiofemoral joint
Knock-knee, 438, 439f
excessive, 471, 4 7 lf, 472f
Kyphosts, 256, 257, 258f, 260f, 276b
juvenile, 288
See
See
See also
(Continued)
Kyphosts
thoracic, 260f, 288-290, 291f
compression force on interbody joint in,
292b
L
Labor and delivery, sacrai liac joint movements
during, 307
Labrum, peripheral, of fibrocartilage, 27
Laminae
of cemcal vertebrae, 264, 266f
retrodiscal, of articular disc of temporomandibular joint, 357, 357f
Lateral epicondylitis, 189
Latissimus dorsi
action of, 317, 317f, 375t
as secondary axial rotator, 327b
attachments of, 244t
in depression of scapulothoracic joint, 121
121f, 122f
in internai rotation of shoulder, 131-132
132f
in lifting heavy loads, 347, 348f
in shoulder adduction and extension, 129130, 130f
innervation of, 244t, 317, 317f, 375t
Law of acceleration, 58b, 58 -6 2 , 61f, 62b, 62t
physical measurements associated with, 62t
Law of action-reaction, 62 -6 3 , 63f
in gait, 551
Law of inertia, 57b-60b, 57 -5 8 , 59f, 60f
Law of parsimony
in elbow extensors, 164b
in forearm supination and pronation 166
169b
Laws of motion, 56 -6 3 , 57t.
Newton's
laws.
Leg, compartments of, 506
anterior, muscles of, 506, 510, 510f
lateral, muscles of, 510-512, 511f, 512f
posterior, muscles of, 512b, 512-514 513f515f, 515b, 516
Leg length, difference in, and pelvic motion in
gait, 540
Levator scapula,
action of, 120f, 120-121, 317, 317f
attachments and innervation of, 244t
Levatores costarum
action of, 375t
attachments of, 384t
innervation of, 375t, 384t
Levers, musculoskeletal
classes of, 19, 19f-20f, 21
mechanical advantage of, 20f, 21, 2 lb
surgical alteration of, 22, 22f
Lifting, See
Load(s).
biomechanical issues with, 34 2 - 349
extension torque used in, additional sources
of. 346t, 346-347
intra-abdominal pressure dunng, 345-346
low-back muscle force and, 342-347
estimation of force magnitude in, 320, 320f
342-344, 343b, 344f
ways of reducing, 344-345, 345b, 345f
muscles active in, 343f
techniques of, 347-348, 348f
safety factors in, 348-349, 349i
Ligament(s)
accessory, of temporomandibular joint 358
358f
alar, 279, 280f, 282, 442b
ankle, 483-486, 486t
stretch of, 486, 486t
annular, 146, 146f
See also
also
Ligamentfs) (Continued)
arcuate popliteal. 439, 440t, 4411
btfurcated, 485f, 492
calcaneofbular
at subtalar joint, 4 8 lf, 489
at talocrural joint, 485, 485f, 486t
capsular, 260f
of glenohumeral joint. 108-109, 109f-110f
of hip, 402, 402t, 403f
of knee, 438f, 438-439, 440f-441f, 440t
of radioulnar joint, 146, 148f
of synovial joints, 26, 26f
of thoracic spine, 285
cervtcal, at subtalar joint, 485f, 489
check-rein, of proximal interphalangeal joints
212
collagen fibers in, 32
collateral
lateral (fibular), 438f, 439, 440f-441f, 440t
anatomy and function of, 440f-441f,
444f, 447-448, 449f. 449t-450t
function and common mechanisms of in
jury of, 450l
lateral (ulnar), 139, 139f, 139t, 140f, 148,
175f, 178f, 178-179, 212
lateral, of talocrural joint, 485, 485b, 485f
mediai (elbow), 138, 139f, 139t, 140f
injury of, 144-145, 145f
mediai (knee), 438f, 439, 440f-441f, 440t
anatomy and function of, 440f-441f,
444f, 447-448, 449f, 449t-450t
common mechanisms of injury of, 450t
mediai (deltoid), of talocrural joint, 4 8 4 485, 485f, 486l, 489b
of metacarpophalangeal joints, 207-208
208f
of metatarsophalangeal joints, 504, 504f
of proximal interphalangeal joints, 212
of temporomandibular joint, 357-358
radiai, 139, 139t, 140f. 177f-178f, 178,
212
ulnar, 175f, 178f, 178-179
of ulnocarpal complex, 148, 178, 179f
coracoacromial, 111
coracoclavicular, 103, 103f, 104, 104f
coracohumeral. 109, 109t, llOf
coronary (meniscotibial), 440, 443f
costoclavicular, lOOf, 101
costoiransverse, 285
cruciate, 443f, 444f, 449
anterior
forces applied to, in gait. 56li
funclional anaiomy of, 448, 449f, 450f
450t, 451, 452f
injury of, 449, 450t, 451
anterior drawer test for, 451, 452f
consequences of, 449, 453b
reconstruction of, quadriceps strengthening in, 453b
posterior
accessory components of, 451
forces applied to, in gait, 561t
functional anatomy of, 443f, 444f 450f
451
injury of
mechanisms of, 450t, 451, 453, 453b
posterior drawer test of, 451, 452f
reconstruction of, 449
deltoid, 479f, 485f, 492
of subtalar joint, 481f, 489
of talocrural joint, 484-485, 485f, 486t
dorsal calcaneocuboid, 485f, 492
dorsal intercarpal, of wrist, 179
dorsal talonavicular, 485f, 492
doubl V System of, in wrist, in ulnar and
radiai deviation, 183-184, 184b, 184f
Index
(Continued)
Ligament(s)
fibrous organization of, 34, 341
forces applied to, in gait, 558-559, 561 1
glenohumeral capsular, 108-109, 1091- 110C
interior, 108-109, 109t, 1101
middle, 108, I09t, 1101
superior, 108, 109t, 1101
hip capsular
hip motion limited by, 402t
in close-packed position ol hip, 402, 4031
iliofemoral, 399-401, 401 f, 402t
in paraplegia, 401, 4021
iliolumbar, in lumbar spine, 293
interchondral, 370
inlerdavicular, lOOf, 101
intermediate, ol wrsl, 179
mterosseous, 305, 3051, 4791
of distai tibiofibular joint, 483-484, 4841
sacroiliac joint stability and, 307f, 308
interosseous (talocalcaneal), of subtalar joint,
4841, 485f, 489
interspinous, 258, 2601, 260t
in lifting heavy loads, 346t, 346-347
intertransverse, 258, 2601, 260t
intra-articular, 370
ischiofemoral, 399, 401 f, 401-402
lateral (temporomandibular), of temporomandibular joint, 358, 3581
link, in finger extension, 232, 2321
long (intrinsic), of wrist, 179
long piantar, 485f, 492
longitudinal
anterior, 259, 2601, 260t
in lumbar spine, 293
posterior, 259, 2601, 261t
in lifting heavy loads, 346t, 346-347
lunotriquetral, of wrist, 179
mentscofemoral, 4431, 4441, 451
posterior, 442, 443f, 4441
oblique popliteal, 439, 440t, 441f, 448, 4491
oblique reiinacular, of digitai extensor mechanism, 220, 222t, 232, 2321
of acromioclavicular joint, 103, 1031, 104,
1041
of carpometacarpal joints, 198, 202f
of ihumb, 202, 202t, 2031-2041
of knee capsule, 4381, 438-439, 4401-4411,
440t
of sacroiliac joints, 304-305, 305b, 3051
of temporomandibular joint, 358, 3581
of vertebral column, 258-259, 260f-261f,
260t-261t
of wrist, 176-179, 1 7 7 f-1791, 178l
palmar carpai, 189
palmar tntercarpal, 179
palmar radiocarpal, 172, 1741
palmar ulnocarpal, 148, 178, 179, 1791
patellar, 4381, 438-439, 4401-4411, 440t.
460, 4611
patellar retinacular, 462, 463f
periodontal, of teeth, 355, 3561
piantar calcaneocuboid, 492-493, 4931
popliteal
arcuate, 439, 440t. 4411
oblique, 439, 440t, 441 f, 448, 4491
posterior, stretching of, passive tension generated from. 346t
pubofemoral, 399, 401, 4011
quadrate, 146, 1461
radiate, 370
of thoractc spine, 285
radiocapitale, 178, 1791
radiocarpal, dorsal and palmar, 178, 1781,
179f
radiolunale, 178, 1791
radioscapholunate, 178, 1791
(Continued)
Ugametu(s)
sacroiliac
anterior, 305, 3051
posterior, 305, 3051
sacrospinous, 305, 3051, 391, 392f
sacroluberous, 305, 305f, 391, 3921
sacroiliac joint stability and, 3071, 308
scapholunate, 179, 185, 1851
scaphotrapezial, 179
short (intrinsic), of wrist, 179
short piantar, 492-493, 4931
sphenomandibular, of temporomandibular
joint, 358, 3581
spring, 4851, 492, 4931
stemoclavicular, lOOf, 101
stylomandibular, of temporomandibular joint,
358, 3581
supraspinous, 258, 260f, 260t
in lifting heavy loads, 346t, 346-347
talofibular
anterior, at talocrural joint, 485, 4851, 486t
posterior, at talocrural joint, 485, 4861,
486t
tibiofibular
anterior, 4791
distai, of distai tibiofibular joint, 484, 484b,
4841
stabilizing proximal tibiofibular joint, 483b
transverse, 440, 4431
inferior, at talocrural jomt, 4841, 485
of alias, 279, 280f
transverse acetabular, 397
transverse carpai, 1751, 176, 189, 190f
transverse metacarpal, deep, of metacarpophalangeal joints, 208, 2081
transverse metatarsal, of metatarsophalangeal
joints, 504, 5041
wrist, 177f, 177-179, 178t
extrinsic, 178t, 178-179, 1791
intrinsic, 1781-1791, 178t, 179
Ltgamentum flavum, 258, 2601, 260t, 2611
in exiension and flexion, 2611
in lifting heavy loads, 346t, 346-347
Ligamentum nuchae, 258, 2601, 260t, 2611
Ltgamentum teres, of femoral head, 396, 3991
Linea aspera, 394, 3941
Ltne-of-force, 15, 17, 181
due to body weight, kyphosis development
and, 288-290, 2911
Line-of-gravity, 15
in standing person, and curvature of spine,
257, 259f-260f
Load(s)
lumbar extensor muscles active in, 320, 3201
methods of carrying, 320
intervertebral disc pressure and, 275, 2751
with hip disease, 429-431, 4301
Loadtng, combined, as musculoskeletal force, 121
Longissimus capitis
attachments and tnnervation of, 38 lt
in trunk movement, 329l
Longissimus cervicis
attachments and tnnervation of, 381 1
in trunk movement, 329t
Longissimus muscles, anatomy and acttons of,
'3 1 8 l, 3191, 319-321, 327b, 329t
Longissimus thoracis
attachments and innervation of, 381 1
in trunk movement, 329t
Longitudinal crest, of ulna, 135, 1361, 137f
Longus capitis
anatomy and action of, 336, 3361, 339b
attachmenis and innervation of, 382l
whtplash tnjury and, 337b, 337f
Longus colli
anatomy and action of, 336, 3361, 339b
587
See also
joints, e.g.,
of specijlc
588
Index
M
Malleolus
lateral, 479f
mediai, 479f
and tendons of tlbialis posterior and flexor
digilorum longus, 514
Mamillary processes, of lumbar vertebrae, 268,
269f
Mandible, 352-353, 353f, 354f
angle of, 352, 353, 353f
body and rami of, 353, 353f
condyle of, 353, 353f, 354f, 356
in disc-condyle complex
derangemeni of, 361b, 361 f
lateral pterygold action and, 367b, 367f
translational movement of, 359f, 360,
362
motion of
in contralateral excursion, 363f, 365
in depression and elevaiion, 359-360,
360f, 362
in lateral excursion, 358-359, 359f, 362
in protrusion and retrusion, 358, 359f, 360
362
in rotation, 360, 360f, 362
in translation, 360, 360f, 362
osteokinematics of, 358-360, 359f, 360f
osteologie features of, 353b
positton of, 355-356
and head position, 366b, 366f
Mandibular fossa, 354f, 354-355
articular and nonarticular surfaces of, 354f
354t, 356, 357f
Mandibular nerve, muscles of mastication innervated by, 362t
Mandibular notch, 353, 353f
Manubriosternal joint, 254, 257f, 370, 370f
Manubrium. 93, 94f, 254, 257(
Marey, in gait analysis, 524, 524f
Mass
center of, 5, 57
dsplacement of, in gait, 535-537, 540b,
540f, 545t, 546f-547f
vs. body weight, 12b
Mass moment of inertia
calculation of, 59b, 59f
in Newton's law of inertia, 57b, 57-58, 58b
60f
prosthetic design and, 60b
Masseter
anatomy and function of, 363, 363f, 365t
attachments and innervation of, 383t
in closing of mouth, 366, 367f
mediai pterygoid interaction with, 363f, 364b
Mastication, 352-367
by temporomandibular joint, 356
disc-condyle complex derangement and, 361,
361f
muscles of, 362t
actions of, 365t
attachments and innervation of, 383t
function of, 363(-365f, 363-365, 365t
secondary, 365, 365f, 365t
osteokinematics of. 358-360, 359f, 360f
Mastoid process, 253, 253f
Maxillae, 353f, 353-354
Measurement Systems
for motion of vertebral column, 277b
kinemattc, 82f-85f, 8 2 -8 5
units of, 5l
Mechanoreceptors, of elbow ligaments, 139
Medtan nerve
in thumb opposition, 224-225
of elbow and forearm, 152, 155f
of hand, 213, 216
of wrist, muscles irmervated by, 186
See alsa
See also
See alsa
See also
(Contmued)
Motion
linear or rotational, in Newtons law of inertia
57, 57t
planes of, 5, 6f, 6t, 7
types of, 3
Motoneuron
alpha, 51
classification of, 52, 531
rate coding of, 52, 53f
recruitment of, 51 -5 2 , 52t, 53f
Motor unit(s), of muscle, 51-52, 53f
Motor unit action potential, 51, 54
Mouth
closing of, 362, 365
muscular control of, 366, 367f
opening of, .365
muscular control of, 366, 367f
phases in, 359360, 360f, 362,
also
Mandible, motion of.
Movement(s).
Motion.
active and passive, 5
analysis of
anthropometry in, 63, 87t
concepts in, 6 3 -7 6
dynamic, 82f-85f, 8 2 -8 5
free body diagram in, construction of, 6 3 67, 64f, 65b, 65f
guidelines for solving biomechanics problems in, 77l
quantitative methods of, 76 -8 5
static, 77b, 77-81
arthrokinemalc principles of
concave-on-convex, 10-11, llb , 1 lf
convex-on-concave, 10-11, llb , 1lf
of joints, 8t, 8 -1 0 , 9f, lOf
Multifidi
anatomy and action of, 32lf, 321t, 321-323
as secondary axial rotators, 327b
attachments of, 38 lt
in lumbosacral region, 322t
in trunk movement, 329t
innervation of, 3 8 lt
Murray MP, in gait analysis, 525f, 526
Muscle(s)
abdominal.
Abdominal muscles
actions of
at joints
analysis of, 17-19, 18f
types of, 16-17, 17f
force couple of, 18f, 19
terminology of, 18
activation of
by nervous System, 51-52, 52t, 53f
concentric, 50f, 5 0 -5 1 , 51f
eccentric, 50f, 5 0 -5 1 , 5 lf
nonisometric, 54
See
See also
See
Index
(Contnued)
Musciefs)
paralysis of, 516-518, 518t
piantar flexor, 514, 516
in stabilizing knee in extension. 515b,
5151
in standing on tiptoes, 517b, 517f
maximal torque potential of at ankle,
514, 516l
supination by, 514, 516
pretibial dorsiflexor, 508, 508b, 510, 5 10f
supination by
at subtalar joint, 490, 490f, 491b, 50 1 502, 502f, 514
ai transverse tarsal joint, 491, 492f, 493,
4941', 496
architecture of, 4 2 -4 4 , 44f
as skeletal movers, 5 0 -5 5
as skeletal stabilizers, 4 1 -5 0 , 42t
back, 315t
deep layer of
anatomv and action of, 317-323, 318f321 f, 318l
tnnervation of, 318
short segmentai, 317, 318t, 321f, 323,
329-330, 330b, 330f
attachmems and innervation of, 38 l t 382t
extensor, forces on in lifting heavy loads,
320, 320f, 343b, 343-345, 344f-345f
superficial and intermediate layers of, anatomy and action of, 317, 317f
connective tissue of, 42, 43f, 44, 44f, 44t. See
Connective lissue(s).
cross-sectional area of, 4 2 -4 3
elastici!)' of, 45
elbow and forearm
attachments of, 244t-245t
electromyographic analysis of, 161-162
flexors
biomechamcs of, 27t, 157t, 157-161,
159f-161f
function of, 157t, 157-161, 158f-162f,
162b
mnervation of, 152, 157t, 244t-245t
maximal torque production of, 158-160,
159f-160f, 159t
paralysis of, surgical correction of, 22,
22f
reverse action of, 162b, I62f
torque angle curve of, 48f, 49b, 49t
function of, 161-162, 163f. 163t, 164,
164f
innervation of. 152, 155, I57t, 244t-245t
law of parsimony in, 164b
paralysis of, 22, 22f, 165b, 165f
supinators
function of, 165-169, 166b
law of parsimony in, 169b
line-of-force of, 165, 166f
torque generatcd by, 166, 167f, 168b,
168f, 168-169
torque demanda of, 162, 164, 164b. 164f
force components of, normal vs. tangentiai,
69t
force couple of, 18f, 19
force generation by, 44-47.
Force(s),
musculoskeletal.
force modulation of
by rate coding, 52, 53f
muscle fatigue and, 5 2 -5 3 , 54f
force potential of, 4 2 -4 3
force-velocity and length-tension relationships
of, 51, 51f
fusiform, 42, 42f
hand, 2)4, 214t
extri nsic
also
See also
Muscle(s) (Continuer
attachments of, 245t-246t
extensors of digtts, 219f-222f, 219-220,
222t
extensors of thumb, 221, 223
flexors of digts, 214f-219f, 214-219
(lexors of thumb, 224t
innervation of, 153-156, 213
intrinsic, 224
attachments of, 246t-247t
of hypothenar eminence, 225f, 225-226
of lumbricals and interosset, 225f, 2 2 6 228, 227f-228f, 230t
of thenar eminence, 224-225, 2251
hip
abductor, 412t, 422-425, 423f, 424f
in gail, 423-425, 424f, 540, 540f, 548,
549f
torque-angle curve of, 427, 428f
weakness of, 425b
action of, primary and secondary, 412, 412t
adductor, 412t, 414-415, 417, 417f-419f
as internai rotators of hip, 417, 419f
in gait, 549f, 550
attachments and innervations of, 571 1573t
extensor, 412t, 417-422, 4 2 lf423f
in controlling forward lean, 420-421,
422f
in gail, 548, 549f
in performing posterior pelvic tilt, 4 1 9 420, 421f
in sit-up exercise, 332f, 333
line-of-force of, 41 lf, 419
overall function of, 419-422
extemal rotator, 412t, 425-426, 426f, 427f
function of, 426, 427f
in gait, 549f, 550
primary and secondar), 425
short," 4 0 lf, 42lf, 423f, 425-426
flexor. 412t, 412-414, 413f-415f, 416,
416f
contracture of, in standing, 416, 416f
function of, 413414, 414f-415f
in gait, 548, 549f
in tmnk stabilization, 330f, 330-331, 331b
innervation of, 409f-410f, 409-411
internai rotator, 412l, 417, 419f, 420f
while walking, 417, 420f
limiting motion of, 402t
lines of force of, 41 lf, 411-412, 414, 417f
maximal torque produced bv, 426-427,
427t, 428f
posterior, 4 2 lf
in force generation and transmission, 4 1 -5 5
sometric measurement of, 4 7 -4 8 , 48f, 49f
length-tension curve of
active. 45t, 4 5 -4 7 , 46f, 47f, 48f
passive, 44 -4 5 , 45f, 47, 48f
total, 47, 48f
leverage of. and torque-joint angle curve,
4 8 -4 9 , 49f, 49t
maximal torque-angle curve of, 4 7 -5 0 , 48f.
49b, 49f, 49t
knee
abnormal alignment of, 470-473
attachments and innervations of, 571 1573t
extensor, in gait, 549f, 550
flexor-rotator, 463-470
functional anatomy of, 440f-441f, 46 3 465
group action of, 465, 466f
maximal torque production by, 465-466,
467f, 468f
synergy with hip muscles and, 466, 468f,
468-469, 469t
innervation of, 453-454, 454t, 57lt573t
(Conlinued)
589
Muscle(s)
quadriceps. See also Quadriceps.
anatomy of. 455f, 455-456
function of, 454-455
function of in knee extension, 456f, 4 5 6 457, 458f, 459f
reinforcing knee capsule, 440t
leg
of anterior compartment, 508, 508b, 510,
510f
of lateral compartment, 510-512. 51 lb,
51 lf, 512f
of postenor compartment, 512b, 512-514,
513f515f, 515b, 516
length of
and length-tension curve, 44 -4 7 , 45f-48f,
45t
and torque-joint angle curve, 4 8 -4 9 , 49f,
49t
in force-velocity relationship, 50f, 50-51
nervous System activation of, 51-52, 52t, 53f
nonisometric activation of, electromyographic
tnterpretation of, 54
of lower extremity
attachments and innervations of, 571t-575t
nerve roots of, 570t-571t
ventral, used for testing function, 57lt
of mastication
attachments of, 383t
function of, 363f-365f, 363-365, 365t
innervation of, 362t, 383t
on mandible, 353
of trunk and craniocervical region, 314-315,
315t, 333-338
action of, 315-316, 316f
active in stabilizing attachments of, 316,
339-340, 341 f
anterior-lateral. 323-327, 324f-326f, 325t,
327b, 334l, 334-337
attachments of, 382t-383t
functional interactions among, 328-333,
329b, 338-341
influence of gravity and, 316
innervation of, 312-314, 382t-383t
internai torque of, 315, 316f
lines of force of, 315, 316f
posterior, 316-323, 318f-319f, 318t, 3 37338, 338t
shared actions of axial and appendicular
skeletons, 317, 317f
unilateral and bilateral activation of, 315-316
of upper extremity
attachments and innervations of, 243t-247t
nerve roots of, 242t-243l
ventral, used for testing function, 243t
of ventilation
attachments and innervation of, 384t
in expiration, 372
forced, 376f, 376-377, 377t
in inspiration, 368f, 372
accessory muscles of, 373, 375l
forced, 373, 375, 375t, 376, 376f
primar)' muscles of, 372t
quiet, 372f, 372-373
interactions among, 372-377
pennate, 42, 42f
pennation angle of, 43, 44f
role in restraining joint movement, 34
shape and structure of. 42, 42f, 43f
shoulder, attachments and innervations of,
243t-244t
spastic, 560
tension fraction of, 226, 226t
used in lifting, 343f
additional sources of extension torque used
in, 346t, 346-347
590
Index
(Continued)
Muscle(s)
estimatton of force magnitude in, 342-344,
343b, 344f
mcreasing imra-abdominal pressure during,
345-347
iechniques of, 347-348, 348f
safety factors in, 348-349, 349l
ways of reducing force used in, 344-345,
345b, 345f
viscosty of, 45
work of, 21
wrist, 186-192
action and torque potenttal of, 186-187,
187f
auachments of, 245t
cross-secttonal area of, 186, 186t, 1871'
extensors, 187f-189f, 187-189
in makinga fisi, 188f-189f, 188-189
flexors, 189-191, 190f, 1911
innervation of, 186, 245t
joim interaction with, 186-192
Muscle fattgue, 52-53, 54f
centrai, 52 -5 3 , 54f
peripheral, 53, 54f
Muscle fibers
activation of, 51-52, 52t
components of, 45t, 4 5 -4 6 , 46f
fatigue of, 52 -5 3 , 54f
ideal resting length of, 46
in active force generation, 4 6 -4 7 , 47f
twitch responses of, 52, 53f
Muscle twitch, in force modulation of muscle
52, 53f
Musculocutaneous nerve, of elbow and forearm,
152, 153f
Muybridge, in gai! analysis, 525
Mylohyoid, auachments and innervation of,
383t
Myofbrils, structure of, 45, 46f
Myofilaments, structure of, 45, 46f
N
Navicular bone, 174, 174f. See Iso Scaphoid,
osteologie features of, 479b, 480f-481f, 481
Neck
extension of, erector spinae muscle action in
319f, 320
in axial rotation in craniocervical region, 340341, 342f
vertebrae of, osteologie features of, 262, 262f,
2631, 264, 264f, 266t, 267f
Nerve(s).
Ulnar nerve.
of muscles of ankle and foot, 506-507, 509i
of muscles of elbow and forearm complex,
151-152, 153f-156f
of muscles of hip
lumbar plexus of, 409f-410f, 409-411
sacrai plexus of, 410f, 411
scnsory, 411
of muscles of knee, 453-454, 454t
of muscles of mastication, 362t
of muscles of irunk and craniocervical regions,
312-314
of synovial joints, sensory, 26f, 27
Nerve roots
of lower extremity muscles, 570t-571t
of spinai nerves, 312, 312f
of upper extremity muscles, 242t-243t
ventral
of muscles of lower extremity used for testing function, 57 lt
of muscles of upper extremity used for testing function, 243t
0
Oblique cord, of interosseous membrane of fore
arm, 142, 143, 143f, 144f
Obliquus capitis
inferior, 339b, 340f
supertor, 339b, 340f
Obliquus capitis inferior and superior, auachmenis and innervation of, 383t
Obliquus extemus abdominis, 323, 324f, 325
as extrmsic trunk stabilizer, 330f, 330-331
33 lb
attachments and mnervattons of, 325t, 382t
in trunk movement, 329t
line of force of, and muscle action, 315, 316f
Obliquus internus abdominis, 323, 324f, 325
as extrinsic trunk stabilizer, 330f, 330-331
33 lb
attachments and innervation of, 325t
in trunk movemem, 329i
Ohturator extemus
anaiomy and action of, 401f, 413f, 426
attachments and innervation of, 572t
Ohturator internus
anatomy and action of, 423f, 426, 426f
aiiachmenis of, 572t
innervation of, 410f, 411, 572l
Obturator membrane, 390, 39 lf
Obturaior nerve, muscles mnervated by, al hip,
409f, 409-411
Occipital bones, 253, 253f
Occipital condyles, 253
Occipital proiuberance, extemal, 253, 253f
Odontoid process, of axis, 264, 267f
Olecranon fossa, 135
Olecranon process, 135, 136f, 137f
Omohyoid, auachments of, 384t
Opponens digiti minimi, 225f, 225-226
attachments and innervation of, 246t-247t
Opponens pollicis, 224, 225f
attachments and innervation of, 247i
Opioelectronics, for collection of kinemaiic data
83
Orthoses, foci, for control of excessive pronation, 50lb
Osteoarthritis.
Rheumaioid arthritis.
amcular camlage damage in, 38
manifestations of, 38
of hip, 428b, 428-429
causes of, 428b
coxa vara or coxa valga with, 431-432
432f, 433f
See also
(Continued)
Osteoarthritis
total hip arthroplastv for, 431, 432f
of knee, 462b, 462f
unicompartmental, genu varum with, 470f
471
Osteoclasts, in bone, 36
Osteokinematics, 5 -8 , 6f, 6t, 7f
perspectives in, 7f, 7 - 8
Osteon System, 36
Osteophyte(s)
cervical, 265b, 265f
craniocervical hyperextension and, 283b, 2831
in hallux rigidus, 504
Osteoporosis, of thoraeic spine, kyphosis wilh,
288-290, 291f
Osteoiomy, coxa vara, 431, 432f
P
Pam
abnormal gait pattern with, 560
low-back, 300-301
causes of, 296b
exercises for, 302b
herntated disc and, 296b
with lifting, 342
of heel, 562t
of hip, 528f, 566t, 567f, 568f
of knee, 462b, 462f
Palmar inierossei, auachments and innervation
of, 247t
Palmaris brevis, 225f, 225-226
auachments and innervation of, 247t
Palmaris longus
anatomy and function of, 189-190, 1901"
aitachments and innervation of, 245l
Paraplegia, iliofemoral ligament strength and,
401, 402f
Parkinsons disease, abnormal gait pauern with
528f, 560, 563
Pars articularis, fracture of, anterior spondylolisthesis and, 294b, 294f
Patella
excessive iracking of. 462, 464t, 465b
knee exlension leverage and, 456, 456f
osteologie features of, 437, 437b, 437f-438f
path and contact area on femur, 446-447, 448f
Patelleciomy, 457b, 457f
Patellofemoral joint, 437
compression forces on. 457, 460, 460b, 461 f
forces applied lo, in gait, 561 1
kinemarics of, 446-447, 448f
pain in, causes of, 462b, 462f
tracking of in knee extension, 460-463, 463f
464f, 464t, 465b
Pectineal line, 391f, 392, 394, 395f
Pectineus
anaiomy and action of, 414, 418f
attachmenis and innervation of, 572t
Pectoralis major
action of, 375l
auachments of, 244t
in internai rotation of shoulder, 131-132, 132f
innervation of, 244i, 375t
sternocostal head of, in shoulder adduction
and extension, 129-130, 130f
Pectoralis minor
action of, 375t
auachments of, 244t
in scapulothoracic joint depression, 121, 1211
122f
innervation of, 244t, 375i
Pedicle
of cervical vertebrae, 264, 266f
sacrai, 269, 27tf
Index
Pelvic ring, 303-304, 304f
stress relief at, 307
Pelvic tilt
anterior
hip flexor funclion in, 413-414, 4141
muscular force couple in, 181
axis of rotation for, 299
effect of on lumbar spine, 299-301, 3001, 4151
in gait, 535-537, 5361
vvith limited hip motion, 537, 5371, 538b
in hip rotation, 406, 407f, 408
lumbar extensor muscte action in, 320-321
posterior
hip extensor function in, 419-420, 42 lf
hip flexor function in, 414, 4151
Pelvic-on-femoral hip motion, 403
hip flexor function in, 413-414, 4141
in hip abduction, 424
in hip extension, 419-421, 4211, 4221
in hip rotation. 4041, 406f, 406-408, 4071
hip extemal rotators in, 426, 4271
in frontal piane, on support hip, 4071, 408
in sagittal piane, pelvic tilt in, 406, 4071,
408
Pelvis, 390, 39013921
impairment of, abnormal gali pattern al hip/
pelvis/trunk with, 566t, 567f, 5681
motion of, in gait, 535-537, 5361, 538b
in frontal piane, 5391, 539540
in horizoncal piane, 542, 542f, 544b
591
483, 483l
of forearm, 145f, 145-149
as spin movement, lOf
innervation of, 152, 157t
of subtalar joint, 490, 490f, 49 lb
of transverse tarsal joint, 491, 492f, 493, 4941,
496
Pronator quadratus
attachments and innervation of, 245t
dual role in distai radioulnar joint, 170, 170f
vs. pronator teres, 169-170
Pronator teres
attachments and innervation of, 245t
biomechanical and structural variables of, 157t
vs. pronator quadratus, 169-170
Prosthetic design, mass moment of inertia and,
60b
Proteoglycans, in nucleus pulposus, 273, 276b
Psoas major
anatomy and action of, 412, 413f
as extrinsic trunk stabihzer, 330f, 330-331,
331b
attachments and innervation of, 572t
in gait, 548, 549f
in trunk movement, 327-328, 328b, 3281,
329t
lines of force of, 328, 328f
Psoas minor
anatomy and action of, 412, 413f
attachments and innervation of, 572t
Pterygoid muscles
attachments and innervation of, 383t
lateral
anatomy and function of, 364f, 364-365,
365t
inferior head of, 366, 367f
supenor head of, 366, 367b, 367f
mediai
anatomy and function of, 364, 364b, 364f,
365t, 366, 3671'
interaction with masseter, 363f, 364b
Pterygoid piate, mediai and lateral, of sphenoid
bone, 355, 3551
Pttbic ramus
inferior, 39 lf, 393
superior, 39lf, 392
592
Index
Radiai deviation, of wrist. 179-180, 180f, 182184, 18311841, 184b, 191, 191f, 191t
Radiai fossa, 134, 134f
Radiai nerve
of elbow and forearm, 152. 1541
deep and superlicial branches of, 152, 1541
of hand, 213
of wrist, muscles innervated by, 186
Radiai notch, of ulna, 135, 1361
Radiculopathy, 2381, 283b
Radtocarpal joint, 173f, 176-177, 1771
as ellipsoid joint, 28, 29f
in ulnar translocation of carpus, 185, 1861
movements of
flexion and extension, 1811-1821, 181-182
ulttar and radiai deviation, 182-184, 1831
184f, 184b
See also
Ribs
at costovenebral joints, 265, 2671
in ventilation, 371, 3711
structure of, 253-254, 256f. 2571
Rtght-hand rule, 67, 86
Roll-and-slide movements
of glenohumeral joint, 113, 113f, 115, 1151,
1161
s
Sacrai canal, 269, 271f
Sacrai plexus, innervating muscles of hip and
lower limb, 4101, 411, 41 Ib
Sacrai promontory, 269, 2711
Sacrococcygeal joint, 269
Sacrohorizontal angle, anterior spondylolisthests
and, 294b
Sacroiliac joint, 303-308
anatomy of, 303-306, 3041-306f
funetional considerations with, 3071, 307-308
ligamentous support of, 304-305, 3051
motion of, 306, 306b, 3061
stability of
muscular reinforcement of, 3071, 308, 308t
nutation torque and, 307, 3071
structure of, 3041, 304-305, 305f
Sacrum
anatomy of, 293, 2931
vertebrae of, osteologie features of, 263t, 269
271 f
Saddle jotnt(s), 28, 30, 301
complex, 198, 200, 202, 2031, 2041
Sagittal piane, 5, 61, 6t
Sarcomere
active length-tension curve of, 4 6 -4 7 , 47f
banding pattern of, 45t, 4 5 -4 6
ideal resting length of, 46
Index
Sartorius
anatomy and action of, 412, 413f, 4411, 454t
463
attachments and innervation of, 454t, 573t
in gau, 548, 549f
Scalene muscles, anatomy and action of, 336,
336f, 339b, 372t, 373
Scalenus anterior, attachments and innervation
of, 382t
Scalenus medius, attachments and innervation of,
3821
Scalenus posterior, attachments and innervation
of, 382t
Scaphoid, 174, 174f-175f, 199f
fracture of, 174, 185, 185f
in carpai instability, 174, 185, I85f
in opposition of thurnb, 205
in ulnar and radiai deviation of wrist, 183b
183f
Scapholunate ligament, in carpai instability, 179,
185, 185f
Scapula
osteologie features of, 94, 96b, 96f, 9 6 -9 7 ,
97f
winging of, 126f, 126-127
Scapular piane, 97
Scapulothoracic joint, 98, 104-106, 1061107f
movement at, 99b, 99f, 9 9-100, 105-106,
106f-107f
muscles of, 120f-124f, 120-122
as depressors, 99, 99f, 105, 106f, 121,
121f, 122f
as elevators, 120f, 120-121, 317, 317f
as protractors, 122, 123f
as retractors, 122, 124f
as rotators, 122
upper trapezius paralysis and, 120b
upward rotation ai, 116-117, 117f, 118f,
119t, 124-127, 125b, 125f, 126f
Scheuermann disease, 288
Sciatic foramen, Iesser, 393
Sciatic nerve
branches of, in comparttnents of leg, 506
in piriformis syndrome, 426
muscles innervated by, at hip, 41 Of, 411
tibial portion of, 454, 454t
Sciatic notch
greater, 391, 392f
Iesser, 392f, 393
Scoliosis, of thoractc spine. 290, 292, 292f
Screw-home rotation, of knee. 445-446, 446f,
447f
knee ligaments in, 448, 449f
Semmembranosus
action of at knee, 454t
attachments of, 573t
functional anatomy of, 440f-441f, 463
innervation of, 454t, 573t
Semispinalis capitis, 321f-322f, 322
attachments and innervation of, 381 1
Semispinalis cervicis, 32 lf, 322
attachments and innervation of, 38 lt
Semispinalis muscles
anatomy and action of, 321f-322f, 3 2 lt,
321-323
in trunk movement, 329t
Semispinalis thoracis, 32lf, 322
attachments and innervation of, 38 lt
Semitendinosus
action of at knee, 454t
attachments of, 573t
functional anatomy of, 440f-441f, 463
in hip and knee extension in running, 468,
468f, 469, 469t
innervation of, 454i. 573t
Serratus anterior
action of, 317, 317f, 375t
attachments of, 244t
in push-up maneuver, 123b
in scapulothoracic joint protraction, 122, 123f
in scapulothoracic upward rotation, 125f,
125-126, 126f
innervation of, 244t, 375t
kinesiologic importante of, 127
paralysis of, 126f, 126-127
Serratus posterior
inferior, 3761
action and innervation of, 317, 317f, 375t,
376f, 384t
attachments of, 384t
superior
action and innervation of, 317, 317f, 375t,
376f, 384t
attachments of, 384t
Sesamoid bones, of first metatarsophalangeal
joint, 504, 504f
Shear forces, 12f
anterior-posterior
anterior spondylolislhesis and, 294b
cruciale ligaments and, 449
at apophyseal joints, 272t
on lumbar interbody joints, 293, 293f
Sheath(s)
digitai synovial, 215f, 217
fibrous digitai, 215f, 217
of metacarpophalangeal joints, 208, 208f
Shin splints, in gait, 551
Short segmentai muscles
as intrinsic trunk stabilizers, 329-330, 330b,
330f
attachments of, 381t
innervations of, 382t
of deep layer of back, 317, 318t, 321f, 323
Shoulder complex, 93-132.
Clavicle;
Humerus; Rib; Scapula; Stemum
abduction of
acromioclavicular joint interaction during,
116-117, 118f, 119t
scapulohumeral rhyihm in, 116, 117f
scapulothoracic upward rotation in, 124127, 125b, 125f, 126f
stemoclavicular joint interaction during,
116-117, 118f, 119t
adduction and extension of, 129-130, 130f,
131b
arthology of, 98-1 1 7
chronic impingemem syndrome at, 114b,
114f, 127
definition of, 93, 94f
in anatomie posiiion, 95f
internai and exlemal rotation of, 131-132
See ako
132f
(Cimtinuecl)
593
Sil-up exercise
diagonal, 3261
trunk muscles active in, 331 f, 331-333,
3321
Sliding filament hypothesis, of active force gener
ation, 4 6 -4 7
Slipped capitai femoral epiphysis, 432
Snuflbox, anatomie, of thumb, 221, 223f
Soleus
anatomy and function of, 512, 513f, 514,
5151
attachments and innervation of, 574t
in gait, 5491, 550
in stabilizing knee in extension, 515b, 5151
maximal torque potential of at ankle, 514,
516t
paralysis of, 517-518, 518t
Sphenoid bone, 355, 355b, 3551
Sphenomandibular ligament, of temporomandibular joint, 358, 3581
Spinai accessory nerve, paralysis of upper trape
zius and, 120b
Spinai cord
cross section of, 2541
in cauda equina, 270b, 2701
injury of, paradoxical breathing after, 374b
Spinai coupling, 273b
Spinai nerve(s), 312
cervical nerve roots of, 254f
dorsal rami of. 312
cutaneous distribution of, 3141
segmentai innervation of, 312, 314, 314t
mixed, structure of, 312, 312f
ventral rami of, 312-314, 3131
of lower extremity muscles used for lesting
function, 571t
of upper extremity muscles used for lesting
function, 243t
plexus of, 312, 3131
segmentai nerves of, 3131, 313-314
Spinalis cervicis, attachments and innervation of,
381t
Spinalis muscles
anatomy and actions of, 318t, 3191, 319-321
in trunk movement, 329t
Spinalis thoracis, attachments and innervation of,
3811
Spinous process, 269, 2721
Splenius capitis, 339b
anatomy and action of, 337-338, 3381, 339b
attachments and innervation of, 383t
Splenius cervicis, 339b
anatomy and action of, 337-338, 338f, 339b
atlachments and innervation of, 383t
Spondylolisthesis, anterior, of lumbar spine,
294b, 2941
Sport equipment, impulse-momentum relationship and, 60
Squat lift, 348, 348f
Squat position, extemal torque at knee in, 74b,
741, 460, 4611
Stance phase.
Gait, phases of, stancc.
Standing
compression forces on foot during, 496b
effect of hip flexor contracture on, 416, 4161
mediai longitudinal arch function during,
496-497, 497f
normal joint reaction forces through knee in,
470f, 470-471
Static rotary equilibnum, 16, 161
Step, 527, 5271
Step length, 527, 5271
impaired, 528f
normal, 529t
Step rate, 528
normal, 529t
See
594
Index
See
T
Talocrural joint, 479f
dorsiflexion of, 486-487, 487f
in gait
compression forces on, in stance phase
488f, 488-489
forces applied to, 56lt
joint kinematics at, 491t, 536f, 538-541
(Continued)
Talocrural joint
stabilization of, in stance phase, 488f 4 88489
in standing on tiptoe, 517b, 517f
joint kinematics of, 486-488, 4871
ligaments of, 484-486, 4851', 4861
muscles Crossing, muscle action and, 508,
510f
osteokinematics of, 486, 487f
piantar (lexion of, 486-488, 487f, 514
sensory innervation of, 507, 5081
structure of, 484, 484f
Talonavicuar joint.
Tarsal joint, trans
verse.
articular and ligamentous structure of 4 9 1 492, 493f
Talonavicuar ligament, dorsal, 485f, 492
Talus, osteologie features of, 479b, 479-481
480f-481f
Tarsal bones, osteologie features of, 479b, 4 7 9 481, 480f-481f
Tarsal joint, transverse, 491-498, 4921-4981
articular and ligamentous structure of, 4 9 1 493, 4931
in pronation and supination of foot, 493, 494f
kinematics of, 493-496, 494f, 495f
range of motion at, 494, 496
subtalar joint movement and, 491, 493, 494f
498-502
supination of, 514
Tarsal tunnel, 513, 515f
Tarsal tunnel syndrome, 513
Tarsometatarsal joint
anatomy and kinematic mechamsms of, 503,
503f
first, 503, 503f
in gait, 539
Tectonal membrane, 279, 280f
Teeth, functions and structural characteristics of
353f, 355-356, 356f, 356t
Temporal bones, 253, 253f, 354f, 354-355
355b
Temporal fossa, 352, 353f
Temporal process, of zygomatic bone, 354f, 355
Temporalis
anatomy and function of, 363f, 363-364
365l
attachments and innervation of, 383t
in closing of mouth, 366, 367f
Temporomandibular joint(s)
arthrokinematics of, 359f, 360-362
bones of, 352-356
capsular and ligamentous stmetures of 357360
condyle-disc complex of
internai derangement of, 361, 361f
lateral pterygoid action and, 367b, 367f
translational movement of, 359, 360, 362
disorders of, 367, 368b
and head position, 366b, 366f
nonsurgical treatments for, 368b
innervation of, 362t, 362-363
muscles of, 362t, 362-366, 363f-365f, 365t
osseous structure of, 356-360
osteokinematics of, 358-360, 359f, 360f
regional surface anatomy of, 352, 353f
structure and function of, 356, 357f
Tendon(s)
Achilles, forces applied to in gait, 561i
bowstringing of, with flexor pulley rupture
217, 217f
collagen fibers in, 32
fibrous organization of, 34, 34f
forces applied to, in gait, 558-559, 561t
mechanical properties of, 44, 44f
of diaphragm, 372, 372f
See also
Index
Tendon(s) (Continuo#
of digitai extensor mechanism, 220, 221,
221f-222f, 222t, 223, 223f
of erector spinae muscles, 319, 319f, 319t
of extensor digitorum longus, 508, 51 Of
of extensor hallucis longus, 508, 510f
of extensor muscles
of index finger, 22 lf
of thumb, 221, 223, 223f
of wrist, 188, 188f
of flexor digitorum longus. 51 lf, 513-514,
515f
of flexor hallucis longus, 484f, 513
of flexor muscles of wrist, 189-190, 190f
of hand, 215, 215f
of iliopsoas, 412
of patella, forces applied to in gail, 561t
of peroneus brevis, 511, 51 lf
of peroneus longus, 510, 51 lf
of peroneus lertius, 508, 510f
of piantar flexor muscles, 512-514
of popliteus, 440f, 444f
stabilizing proximal tibiofibular joint, 483b
of quadriceps, 460, 461 f
of tibialis anterior, 508, 510f
of tibialis posterior, 51 lf, 513-514, 515f
Tennis elbow, 189
Tenodesis action, of finger flexors, 218f, 218
219
in quadriplegia, 219, 2I9f
Tension
as musculoskeletal force, 12f
in connective tissue, conversion to useful
work, 14, 14f
Tensor fascia lata
anatomy and action of, 413, 413f, 420f, 423,
423f
attachments and innervation of, 573t
in gait, 548, 549f
Teres major
attachments and innervation of, 244t
in shoulder adduction and extension, 129130, 130f
in shoulder internai rotation, 131-132, 132f
Teres minor, 109-110, llOf
attachments and innervation of, 244t
in elevation of ami, 127f128f, 127-128,
129b
in shoulder adduction and extension, 129
130, 130f
in shoulder external rotation, 132
Tetanization, of musclc fibers, 52, 53f
Thenar crease, of hand, 195, I97f
Thenar eminence.
Thumb.
muscles of, 224-225, 225f
Thoracic spine
anatomy of, 263t, 265, 267, 267f, 284-286,
285b, 287f
axial rotation of, 287, 290f
components of, 284
flexion and extension of, 286t, 286-287,
288f, 289f
lateral flexion of, 287, 29lf
motion of, 286t, 286-287, 288f-291f
range of motion of, 286t
structural deformities of. 287-290, 291f, 292,
292f
Thoracolumbar fascia, 306, 306f
Thoracolumbar spine, movement of, 286-287,
288f, 289f, 290f, 291f, 303
Thorax, 369f
aniculations with, 370, 370b, 370f
constriction of, in cervical spinai cord injury,
374b
expansion of, factors opposing, 369, 369f
functions of, 370
See aho
(Continued)
Thorax
in ventilation, 369b, 369f-370f, 369t, 36 9 370
tissues that seal, 369t, 369-370
vertebrae of, osteologie features of, 263t, 265,
267, 267f
Thumb, 195, 197f
abduction and adduction of, 197, 20lf, 20 3 204, 204f, 205f, 206t
basilar joint arthritis affecting, 200, 202
bones of, 199f-200f
carpometacarpal joint of, 200-207
adduction and abduction of, 203-204, 205f
capsule and ligaments of, 202, 202t, 203f204f
flexion and extension of, 204-205, 206f,
206t
in zig-zag deformity, 236, 237f
muscles of, 224t
opposition of, 205, 207, 207f
saddle joint structure of, 202
close-packed position of, 205
extensors of, extrtnsic, 2 2 1, 223, 223f, 224t
interphalangeal joint of, 213
abductor pollicis longus as assistant exten
sor of, 223f, 225
muscles of, 224t
metacarpal bones of, 195-196, 197f, 199f200f
metacarpophalangeal joint of, 211, 21 lf212f
muscles of, 224i
movement of, 201f, 203-207
terminology of, 197, 201f
opposition of
mediali nerve in, 224-225
muscles of thenar and hypothenar eminence
in, 224-225, 225f
terminology of, 197, 20lf
pinching action of
in power (key) pinch, 234-235, 235f-236f
muscular biomechanics in, 229, 229f
position of function of, 213, 213f
terminology of, 196
zig-zag deformity of, 236, 237f
Thyrohyoid, attachments and innervation of,
384t
Tibia
anatomy and function of, 436f, 436-437,
437f
distai, 479, 479f, 484f
motion of, in gait, 542f, 543, 544b
osteologie features of, 436b
Tibial nerve
injury lo, 517-518. 518l
muscles of foot and ankle innervated by, 507,
509f
posterior, neurovascular bundle of, 513, 515f
Tibiai tuberosity, 437, 437f
Tibialis anterior
action of, on tiptoes, 512, 512f
anatomy and function of, 508, 510, 5 lOf
attachments of, 574l
in gait, 549f. 550
innervation of, 506-507, 574t
weakness of, in gait, 550
Tibialis posterior
anatomy and function of, 512-514, 514f, 516
attachments and innervation of, 574t
in gait, 549f, 551
maximal torque potential of at ankle, 514,
516t
supination potential of, 514, 516
Tibia-on-femoral knee motion, 4441, 445f
flexor-rotalor muscle interaction in, 465
in knee extension, 445, 446f
anterior cruciate ligament strain and, 453b
595
See also
See aho
590
Index
2721
(Continuai)
Trunk
extension of, erector spinae muscle action in,
319f, 320
flexion of, abdominal muscle action in, 326f,
326-327
forward lean of
abnormal gail pattern with, 563f
hip extensors and, 420-421, 421 f, 422f
joints of, innervation of, 312-314
maximal effort torque in, 327
muscles of, 314-315, 315t, 549f, 551
action of
in gau, 543, 5631, 566t, 567f, 568f
in providing core stability, 329-331,
330f, 331b
in sit-up movement, 331 f, 331-333.
332f
actions of, shared across axial and appendicular skeletons, 317, 317f
anterior-lateral
anatomy and action of, 315t, 323-327,
3241-326f, 325t, 327b
attachments and innervations of, 382t
impairment of, gait deviation at hip/pelvis/
trunk with, 566t, 567f, 568f
influence of gravity and, 316
innervation of, 312-314, 381-382t
internai torque of, 315, 316f
lines of force of, 315, 316f
unilateral and bilateral activation of, 315
posterior, muscles of
anatomy and action of, 315t, 316-323,
318f-319f, 318t
attachments and innervation of, 381 1382t
Tubercle(s)
articular, of nbs, 253, 256f
greater, of humerus, 97f, 98
infraglenoid, 97
lesser, of humerus, 97f, 9 7 -9 8
of cervical vertebrae, 264, 264f, 266f
of talus, 480f, 480-481
posterior, of metacarpal joints, 195
postglenoid, of temporal bone, 354f, 355
pubic, 39 lf, 392
quadrate, 394, 395f
spinai and lateral, of sacrum, 269, 271f
supraglenoid, 97
Tuberosity
calcaneal, 480f-481f, 481
delloid, 98
gluteal, 394, 395f
iliac, 391, 391f
ischial, 390f, 3921, 393
navicular, 481
of ulna, 135
libisi, 437, 437f
U
Ulna
head of, 136, 137f
osteologie features of, 135b, 135-136, 136f
137f
styloid process of, 172
Ulnar deviation, of wrist, 179-180, 180f, 182184, 183f-184f, 184b, 191t, 191-192,
192(
Ulnar drift, of fingers, 237-238, 239f
Ulnar nerve
hypothenar muscle function and, 226
in key pinch action, 229, 229f
lesion of
in finger flexion, 233
in opening hand, 231-232, 232f
of elbow and forearm, 152, 156f
(Continuai)
Ulnar nerve
of hand, 213
of wrist, 186
Ulnocarpal complex, 146, 147b, 148f, 178, I79f
Ulnocarpal meniscal homologue, 175f, 178
Ulnocarpal space, 175f, 178, 179f, 190
Uncinate process, 264, 264f, 266f
Uncovertebral joints, 264, 264f, 266f
tn disc disease, 265b, 265f
Unfused tetanus, of muscle fibers, 52, 53f
Upper extremity, 92. See also Arm; Elbow;
Shoulder complex;
Glenehumeral joint.
muscles of
attachments and innervations of, 243t-247t
nerve roots of, 242l-243t
V
Valgus angle, of elbow, 137-138, 138f
Valgus force, on elbow, 144-145, 145f
Vaisalva maneuver, during lifting, 345-346
Varus torque, at knee, in gail, 557, 558f
Vastus
in hip and knee extension, in running, 468,
468f, 469, 469t
torque production by, 468b
Vastus intermedius, 455-456
attachments and innervation of, 573t
Vastus lateralis, 455
attachments and innervation of, 573t
oblique fibers of, 462, 463f
Vastus medialis, 455
attachments and innervation of, 573t
Vector, definilion and descriptors of, 13, 15,
15b, 15f
Ventilation, 368-377
after cervical spinai cord injury, 374b
btomechanics of, 368f, 368-369
changes in intrathoracic volume during, 371,
371f
definition of, 368
lung volumes and capacities in, 368, 368f
muscles of, attachments and innervation of,
384t
muscular actions during, 372-377
thoracic function in, 369b, 369f-370f, 369l,
369-370
thoracic structure and, 369f-370f, 369t, 36 9 370
Ventral ramus(i), of spinai nerves
of lower extremity muscles used for testing
function, 57li
of upper extremity muscles used for testing
function, 243t
plexus of, 312, 313f
segmentai nerves of, 313f, 313-314
Vertebrae
cervical
atypical, 264, 266f, 267f
typical, 262, 262f, 263t, 264, 264f, 266t
L2, compression force on in lifting, estimation
of, 342-344, 343b, 344f
lumbar, 261f, 267-269, 268f-269f
structure and function of, 253-254, 254f255f, 255t, 269, 271, 272f
thoracic
atypical, 267
typical, 265, 267f
Vertebral artery, 262
Vertebral canal, 262f, 264
Vertebral column. See
Apophyseal joint(s);
Interbody joint.
cervical region of, 262, 262f, 263t, 264, 264f,
266t, 267f. See
Cramocervical region;
Neck.
also
also
Index
(Continued)
Vertebral column
motion ai
flexion and extension, 279-282, 280f282f
in fronial piane, 283-285, 2861
in horizontal piane, 282-283, 285f
in sagittal piane, 279-282. 2801-2821
range of motion ai, 278i
coccygeal region of, 263t, 269, 2711
connective tissues limiiing molion of, 276t,
276-277
curvalures of, normal, 256-257, 258f, 276,
276f
tntervertebral junction and, 269, 271, 272f,
272t
ligamentous supporl of, 258-259, 2601-261 f,
260l-261t
line ol gravity and, 257, 259f-260f
lumbar region of, 263t, 267-269, 268f-269f.
See uso Lumbar spine,
anatomy and kinematics of, 292-303
motion of, 276f, 276t. 276-277, 303
in cervical region, 279-285, 280f-286f
in lumbar region, 294-303
in sacroiliac region, 306, 306b, 306f
in thoracic region, 286-287, 288f-291f
in thoracolumbar region, 286-287, 288f291 f, 303
measurements of, 277b
range of motion in, 276, 278t, 286t
spinai coupling and, 273b
terminology for, 271-272, 272f, 272t
osteologie features of, 256-257, 258f-260f,
262-269, 263l
cervical, 262, 262f, 264, 264f, 266f
of atlas, 264, 2661
of axis, 264, 267f
of coccyx, 269, 27 lf
of lumbar region, 267-269, 268f-269f
of sacrum, 269, 2 7 lf
of thoracic region, 265, 267, 267f
of vertebral prommens, 264-265
(Continued)
Vertebral column
sacrai region of, 263l, 269, 271 f
sacroiliac joints in, 303-308. 5ee
Sacro
iliac joint.
spinai nerves of, 312
thoracic region of, 263l, 265, 267, 267f.
Thoracic spine.
Vertebral endplates, 274, 274f
Vertebral prominens, 264-265
Video-based Systems, for collection of kinematic
data, 83, 83f
Viscoelastic tissues. 13, 15f
Vital capacity, 368, 368f
also
See
also
also
Walking. See
Gait.
normal reaction forces through knee in, 470f,
470-471
speed of, 528-529, 529t, 530-531
methods of increasing, 529f
normal, 529l
Water, in ground substance, 32, 32f
Weber brothers, in gali analysis, 524
Whiplash injury, 277, 281, 337b, 337f
chronic forward head posture with, 341b,
34 l f
osteophyte formation and, 283b, 283f
Williams flexion exercise, 300-301
Windlass effect, of forefoot in late stance phase,
506, 506f
Wind-swept deformity, of knee, 471, 472f
Wolffs law, 265b
Work, definition of, 60, 61b
Work-energy relationship, Newton's second law
and, 6 0 -6 2 , 61b, 62b
Wrist, 172-193
bones and joints of, 172, 173f, 176-185,
199f
carpai instability of, 184b, 184f- 186f, 184185
597
(Continued)
Wrist
centrai column of, movement through, 181 f
182f, 181-182
creases of, 195, 197f
deviators of, 191b, 19lf192f, 191t, 191192, 192b
extensors of, in finger flexion, 234
flexion of, 190-191, 191t
flexion torque in, in making a fisi, 188, 188f
flexors of, in finger extension, 231f, 232
joints of, 176-177, 177b
innervation of, 186
muscle interaction with, 1.86-192
ligaments of, 177f, 177-179, 178t
motion at
arthrokinematics of, 180-184
kinematics of, 179184
osteokinematics of, 179-180, 180f
muscles of, attachments and mnervation of,
245t
osteologie features of, 172-173, 173f-175f
position of
and tenodesis action of finger flexors, 2 1 8 219, 219f
for function, 180b, 213, 213f
rotational collapse of, 184b, I84f, 184-185
X
Xiphisternal joint, 256, 257f
Xiphoid process, 256, 257f
z
Zig-zag deformity, of thumb, 236, 237f
Zona orbiculans, of hip capsule, 402
Zones, of articular cartilage, 34, 35(
Zygomatic arch, 352, 353f
Zygomatic bone, 354f, 355
Zygomatic process, of lemporal bone, 354f, 355
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