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KINESIOLOGY
MUSCULOSKELETAL
SYSTEM
Foundations for Physical Rehabilitation
Donald A. Neumann, PT, PhD

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A Dynamic and Accessible Guide to Kinesiology!


Introducing th most comprehensive, research-based, and easy-to-use text on
kinesiology ever written! Colorfully and abundantly illustrated, Kinesiology of th
Musculoskeletal System: Foundations for Physical Rehabilitation presents this
complex, scientific subject in a clinically relevant and accessible manner
drawing you into th material.
Written with an engaging style and a thorough appreciation of thetopic, author
Donald A. Neumann helps you clearly understand th fundamental principles of
kinesiology. With this helpful guide, you'll also explore th connection between
anatomy and movement and th link between structure and function of th
musculoskeletal System.

Take a look a t these outstanding features!

A definitive chapter on th kinesiology of walking explains in detail this

complex process that is integrai to physical therapy practice.


Over 650, one- and two-color line drawings illustrate th anatomy,

functional movement, and biomechanical principles underlying movement


making complex kinesiologic concepts easy to grasp.
Three extensive chapters on th axial skeleton provide in-depth coverage

of this important group of structures, often not adequately covered in


sim ilar texts.
Chapters on th fundamental principles of kinesiology with respect to

joints, muscles, and biomechanics impart a clearer understanding of th


why behind th how.
Special Focus elements throughout th text provide abundant clinical
examples as well as more in-depth information if you want to explore
certain topics further.
Topics at a Glance outline chapter content and allow you to quickly locate
needed information.
Special summary boxes synthesize concepts from th text simplifying
review and study.
Useful appendices include muscle attachments and innervations of th
trunk and extremities.

A naturai extension of gross anatomy and physics, Kinesiology of th


Musculoskeletal System: Foundations for Physical Rehabilitation serves as a
complete guide to learning clinical kinesiology.

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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

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KINESIOLOGY

of th

MUSCULOSKELETAL
SYSTEM
Foundations

fo r Physical Rehabili

D onald A. N eumann , PT, Ph D


Professor
Department o f Physical Therapy
Marquette University
Milwaukee, Wisconsin

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.

About th Illustrator: Elisabeth E. Rowan


When she was 8 years old, Elisabeth knew she wanted lo be an illustrator. As a child,
she spent many hours illustrating th books that she had read. Her interest in medicai
illustration grew as she studied th biologie Sciences. She was especially interested in
th form and function of th human body.
Elisabeths formai education in art consists of a Bachelor of Fine Arts in Drawing
and Paintitig from th University of Wisconsin, Milwaukee, and a Bachelor of Science
in Biomedicai Communications (Medicai Illustration) from th University of Toronto.
Elisabeth now works at Kalmbach Publishing Company, Waukesha, Wisconsin, as a
magazine illustrator. Her work is featured regularly in Astronomy and Birders World.
She currently lives in Milwaukee.

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

Atout The Author


\vith a series of pendi sketches, often based on anatomie specimens dissected by Dr.
Neumann. The pen-and-ink medium was chosen to give th material an organic
dassic feeling.
The second form (big. 2) used a layering of artistic media, integrated with th use
ot computer software. Many of th pieces started with a digitai photograph transformed into a simplified outline of a person performing a particular movement. images
of bones, joints, and muscles were then electronically embedded within th human
outline. Overlaying various biomechanical images further embelltshed th resultant
illustration. The final design displayed specific and often complex biomechanical concepts in a relatively simple manner, while preserving human form and expression.

FIGURE 2

IX

ABOUT THE CONTRIBUTORS

A. J

o sep h

h r e lk e ld

, PT, Ph D

Associate Professor, Chair, Department of Physical Therapy; Director, Biody


namics Laboratory, Department of Physical Therapy, Creighton University, Omaha,
Nebraska
A 1976 physical therapy graduate of th University of Kentucky, Lexington, Dr.
Threlkeld has been involved in th clinical management of musculoskeletal dysfunctions, particularly arthritis and related disorders. In 1984, he completed his doctoral
work in anatomy with a focus on th remodeling of articular cartilage. Since then, he
has conducted research on th abnormal kinematics associated with musculoskeletal
and neuromuscular impairments as well as th neuromusculoskeletal responses to
therapeutic intervention. His teaching areas have been kinesiology, anatomy, and histology.
Basic Structure and Function o f th Joints (Chapter 2)

a v id

A. B

r o w n

, PT, P

Assistant Professor, Department of Physical Therapy and Human Movement Sciences


and Department of Physical Medicine and Rehabilitation, Northwestern University
Medicai School, Chicago, Illinois
Dr. David Brown is th son of a physical therapist (Elliott). David graduated with a
masters degree in physical therapy from Duke University, Durham, in 1983 and then
received a PhD in exercise Science from th University of Iowa, Iowa City, in 1989.
His primar)'' area of clinical expertise is neurorehabilitation with a special emphasis on
locomotor impairment follownng stroke. He has published research in journals such as
Journal o f Neurophysiology, Brain, Stroke, and Physical Therapy. Dr. Browm has presented
his research at both national and intemational conferences. His highest ambition is to
contribute to th discovery of innovative intervention strategies for th amelioration of
neuromuscular impairments and for th restoration of locomotor function.
Muscle: The Ultimate Force Generator in th Body (Chapter 3)

eb o r a h

A. N

a w o c zen sk t

, PT, P

Associate Professor, Department of Physical Therapy, Ithaca Colleges Rochester Cam


pus, Rochester, New York
Dr. Nawoczenski received both a Bachelor of Science degree in physical therapy and a
Master of Education degree from Tempie University, Philadelphia. She also received a
PhD in Exercise Science (Biomechanics) from th University of Iowa, low'a City. Dr.
Nawoczenski is co-director of th Movement Analysis Laboratory at Ithaca Colleges
Rochester Campus. She is engaged in research on th biomechanics of th foot and
ankle. Dr. Nawoczenski also holds a position as an Adjunct Assistant Professor of
Orthopaedics in th School of Medicine and Dentistry at th University of Rochester,
Rochester, New York. She has served as an Editorial Board Member for th Journal of
Orthopaedic & Sports Physical Therapy and w?as co-editor of th two-part special issue
on th foot and ankle. Dr. Nawoczenski has co-authored and co-edited two textbooks:
Buchanan LE, Nawoczenski DA (eds): Spinai Cord Injury; Concepts and Management
Approaches, and Nawoczenski DA, Epler ME (eds): Ortholics in Functional Rehabilitation
o f th Lower Lim.
Biomechanical Prnciples (Chapter 4)

Xll

Aboul th Contributo
G

uy

G. Sim

o n ea u

, PT, Ph D, A T C

Professor, Marquetie University, Depanmeni of Physical Therapy, Milwaukee, Wisconsin


Dr. Simoneau received a Bachelor of Science in physiothrapie from ihe Universit de
Montreal, Canada, a Master of Science degree in sports medicine from th University
of Illinois at Urbana-Champaign, Illinois, and a PhD in exercise Science (locomolion
sludies) from The Pennsylvania State University, State College. He teaches orthopaedic
physical therapy and pursues research on gaii and th ergonomie design of computer
keyboards. Dr. Simoneau has been th recipient of several teaching and research
awards from th American Physical Therapy Association, including th 2000 Education
Award of th Orthopaedic Section, th 1998 Education Award of th Sports Section,
th 1997 Eugene Michels New Investigator Award, and th 1996 Margaret L. Moore
New Academic Faculty Award. He has been funded by th National Institutes of
Health and th Foundation t'or Physical Therapy, among others, to study walkerassisted ambulation and by th National Institute of Occupational Safety and Health
(NIOSH) and th Arthritis Foundation to study th design of computer keyboards. Dr.
Simoneau is currently Editor-in-Chief of th Journal o f Orthopaedic & Sports Physical
Therapy.
Kinesiology o f Walking (Chapter 15)

Paul Andrew, PT, PhD


Depariment of Physical Therapy
Ibaraki Prefeciural University of Health
Sciences
Ibaraki-ken, Japan
Susana Arciga, PT
St. Marys Hospital
Outpatient Orthopedic and Sports
Medicine Center
Milwaukee, W1
Cindi Auth, PT
Physical Therapy Department
Zablocki VA Medicai Center
Milwaukee, W1
Marilyn Beck, RDH, MEd
Department of Dentai Hygiene
Marquette University
Milwaukee, WI
Teri Bielefeld, PT, CHT
Physical Therapy Department
Zablocki VA Medicai Center
Milwaukee, WI
Peter Blanpied. PT, PhD
Physical Therapy Program
University of Rhode Island
Kingston, RI

e v i e w e r s

Gary Chleboun, PT, PhD


School of Physical Therapy
Ohio University
Athens, OH
Mary A. Cimrmancic, DDS
Marquette University School of
Dentistry
Milwaukee, WI
Adam M. Davis, PT
Quad Med, LLC
Sussex, WI
Brian L. Davis, PhD
Department of Biomedicai Engineering
The Lerner Research Institute
The Cleveland Clinic Foundation
Cleveland, OH
Sara M. Dcprey, PT, MS
Department of Allied Health
Carroll College
Waukesha, WI
Sara Jean Donegan, DDS, MS
Marquette University School of
Dentistry
Milwaukee, WI

Ann M. Brophy, PT
NovaCare Outpatient Rehabilitation
Milwaukee, WI

W illiam F. Dostal, PT, PhD


Department of Rehabilitation Therapies
University of Iowa Hospitals and
Clinics
lowa City, IA

Frank L. Buczek, Jr ., PhD


Motion Analysis Laboratory
Shriners Hospital for Children
Erie, PA

Joan E. Edelstein, PT, MA


Physical Therapy
Columbia University
New York, NY

Daniel J . Capriani, PT, MEd


Department of Physical Therapy
Medicai College of Ohio
Toledo, OH

Timothy Fagerson, PT, MS


Orthopaedic Physical Therapy Services,
Ine.
Wellesley Hills, MA

Am a Carlisle, MPT
Physical Therapy Department
Zablocki VA Medicai Center
Milwaukee, W1

Kevin P. Farrell, PT, OCS, PhD


Physical Therapy
Saint Ambrose University
Davenport, IA

Leah Cartwright, PT
Physical Therapy Department
Zablocki VA Medicai Center
Milwaukee, WI

Esther Haskvitz, PT, PhD


Notre Dame College
Physical Therapy Program
Manchester, NH

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

Christopher J. Simenz, MS, CSCS


Department of Physical Therapy and
Program in Exercise Science
Marquette University
Milwaukee, WI

Guy G. Simoneau, PT, PhD, ATC


Department of Physical Therapy
Marquette University
Milwaukee, WI

Carolyn Wadsworth, PT, MS, OCS


CHT
Department of Rehabilitation Therapies
University of Iowa Hospitals and
Clinics
Iowa City, IA

David Williams, MPT, ATC, CSCS


Physical Therapy Program
Iowa City, IA

Chris L. Zimmermann, PT, PhD


Physical Therapy Program
Concordia University, Wisconsin
Mequon, WI

o r e w o r d

To be ihe author of a text is a major undertaking and,


possibly, appreciated only by those who have completed
such a venture. The author has a responsibility not only for
providing accurate information but also for delivering th
material in a format conducive to comprehension. A significant confounding factor is th perpetuai explosion of knowledge for which th author is responsible for inclusion in th
work.
Perhaps in his earlier days, Don Neumann never anticipated th creation of this volume on th Kinesiology o f th
Musculoskeletal System, but th work has been intrinsic to
him since his days as a physical therapy assistant in th early
1970s. He received both th Outstanding Clinical Award and
th Outstanding Academic Award as an undergraduate student at th University of Florida under th tutelage of faculty
including Martha Wroe, Fred Rutan, and Claudette Finley.
He then pursued his masters and doctoral degrees. He has
never strayed far from th clinic, however, where he stili
treats patients with spinai cord injuries.
Dr. Neumann excels as a trae teacher. In this capacity, he
has demonstrated his love for teaching others and sharing his
excitement for th subject matter. Don has gone beyond
teaching, however. He has also made a contribution as a
scholar by focusing his attention on th hip joint and th
influence of th arthritic process. His efforts in this domain
have been recognized in terms of awards such as th Ameri
can Physical Therapy Associations Eugene Michels New Investigator Award (1991) and th Jack Walker Award (2000),
which recognizes published clinical research in Physical Therapy.
All of these aspects reveal only part of th picture, how
ever, because you must know th man to appreciate him.

Quiet in manner and complimentary by nature, he gives his


energies to excellence in th projeets that he undertakes. All
his personal qualities would take too long to describe and
would only embarrass this humble author. 1 have had th
distinct privilege of having him as a graduate student and
teaching assistant and as a critic of my work. Although
unsuccessful in attempts to hire him, I recognize that others
have gained from his presence.
Don should be congratulated on th completion of Kinesi
ology o f th Musculoskeletal System: Foundations fo r Physical
Rehabilitation. The osteology, arthrology, and neurology, and
th muscle as a functional unit previde a meaningful
blend for a text on kinesiology, a Science fundamental to th
student and practicing clinician. Of special merit are th
illustrations, which uniquely convey a blending of kinesiologic and anatomie material. Kinesiology of th Musculoskeletal
System is also invaluable for its inclusion of Special Focus
issues and other features that provide clinical relevance to
th presentation.
Don has been successful in developing a useful textbook
not only for physical therapists but also for many in other
disciplines. His work is comprehensive and readable and
contributes greatly to th pool of literature available to students and professionals alike.
Gara L. Soderberg, PT, PhD, FAPTA
Professor and Director of Research
Department of Physical Therapy
Southwest Missouri State University
Springfield, Missouri

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

oui compromising th depth of th material. The textbook is


accompanied by an Evolve website that features an electronic
image coilection, which includes th majority of th figures
in th book. The images, which can be be printed out or
transformed into PowerPoint slides, are available as a teaching tool for instructors who adopt th book for use in their
classes. (Instructors should check with their sales representative for further information.) Special Focus features are used
to highlight areas of special interest. Topics in a Special
Focus include notable clinical corollaries, distinctive structural and functional relationships, and reach-out concepts
designed to stimulate further interest or provide additional
background. Appendices at th end of each of th four sections provide useful reference materials. Appendices 11
through IV, for example, provide a readily accessible refer
ence to th detailed bony attachments of muscles. This infor
mation is useful in laboratory exercises designed to study a
muscles action based on its specific attachments. One very

instructive activity involves having students use a skeleton


model and a piece of string to mimic a muscles line-offorce. Groups of students can discuss a muscles potential
action by observing th line-of-force of th string relative
to an imaginary axis of rotation through a particular joint.
This exercise helps students to understand th three-dimensional nature of muscle actions and how th actions and
strength of a muscle can change with different positions of a
limb. Multiple tables and summary boxes are provided to help
organize th material to facilitate learning.
My originai intention in writing this text was to present
kinesiology in a comprehensive, relevant, logicai, and clear
manner. This textbook will hopefully inspire others to fur
ther pursue a fascinating and important subject matter. 1
intend this first edition to be th beginning of a lifelong
endeavor.
DAN

c k n o w l e d g m e n t s

1 welcome this opportunity to acknowledge a great number


of people who have provided me with kind and thoughtful
assistance throughout this long project. I am sure that 1 have
inadvertently overlooked some people and, for that, I apolo
g ie .
The best place to start with my offering of thanks is with
my immediate family, especially my wife Brenda who, in her
charming and unselfish style, paved th way for th completion of this project. I thank my son, Donnie, and stepdaughter, Megann, for their patience and understanding. I also
thank my caring parents, Betty and Charlie Neumann, for
th many opportunities that they have provided me throughout my life.
Four persons signiftcantly influenced th realization of
Kinesiology o f th Musculoskeletal System: Foundations fo r Physical Rehahilitation. Foremost, I wish to thank Elisabeth E.
Rowan, th primary medicai illustrator of th text, for her
years of dedication and her uncompromisingly high standard
of excellence. 1 also extend my gratitude to Drs. Lawrence
Pan and Richard Jensen, present and past directors, respectively, of th Department of Physical Therapy at Marquette
University. These gentlemen unselfishly provided me with
th opportunity to fulfill a dream. And, finally, 1 wish to
thank Scott Weaver, Managing Editor at Harcourt Health
Sciences, for his patience and guidance through th final,
and most challenging, phases of th project.
1 am also indebted to th following persons who contributed special chapters to this textbook: David A. Brown, Deb
orah A. Nawoczenski, Guy G. Simoneau, and A. Joseph
Threlkeld. 1 am also grateful to th many persons who reviewed chapters, most of whom did so without financial
remuneration. These reviewers are all listed elsewhere in
previous sections.
Several people at Marquette University provided me with
tnvaluable technical and research assistance. I thank Dan
Johnson for much of th digitai photography contained
within this book. 1 appreciate Nick Schroeder, graphic artist,
for always fitting me into his busy schedule. I also wish to
thank Ljudmila (Milly) Mursec and Rebecca Eagleeye for
their important help with library research.
Many persons affiliated directly or indirectly with Mar
quette University provided assistance with a wide range of

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

Essential Topics of Kinesiology


C

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

Basic Structure and Function o f th Joints

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

Muscle: The Ultimate Force Generator in th Body

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

Elbow and Forearm Complex

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

PPF M)IX 11 242

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

Axial Skeleton: Muscle and Joint Interactions

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

Kinesiology o f Mastication and Ventilation

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

14 Ankle and Foot

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

Appendix 1 Reference Material Related to th Essential Topics of Kinesiology

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

Typical Joint Morphology, 8


Fundamental Movements Between Joint
Surfaces, 8
Roll-and-Slide Movements, 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

Impact of Forces on th Musculoskeletal


Tissues: Introductory Concepts and
Terminology, 12
Internai and External Forces, 13

Muscle and Joint Interaction, 16

Types of Muscle Activation, 16


A Muscle's Action at a Joint, 17
Terminology Related to th Actions of
Muscles, 18
Musculoskeletal Levers, 19

Three Classes of Levers, 19


Mechanical Advantage, 21
Dictating th Trade-off" between
Force and Distance, 21
GLOSSARY, 22
SUMMARY, 24

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.

This text of kinesiology borrows heavily from three bodies


of knowledge: anatomy, biomechanics, and physiology. Anat
omy is th Science of th shape and structure of th human
body and its parts. Biomechanics is a discipline that uses
principles of physics to quantitatively study how forces interact within a living body. Physiology is th biologie study of
living organisms. This textbook interweaves an extensive re
view of musculoskeletal anatomy with selected principles of
biomechanics and physiology. This approach allows th kinesiologic functions of th musculoskeletal system to be reasoned rather than purely memorized.
The remainder of this chapter provides fundamental bio
mechanical concepts and terminology related lo kinesiology.
The glossary at th end of th chapter summarizes much of
th essential terminology. A more in-depth and quantitative
approach io th biomechanics applied io kinesiology is pre
sented in Chapter 4.

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

Essential Topics of Kinesology

B S ALBINI

MUSCULORUN TABULA Vili

FIGURE 1 -1 . An illustration from th anatomy text Tabulae Sceleti et Musculorum Corpons Humani (1747) by
Bernhard Siegfried Albinus.

Translation Compared with Rotation


Translation describes a linear motion in which all parts of a
rigid body move parallel to and in th same direction as
every other pari of th body. Translation can occur in either

a straight line (rectilinear) or a curved line (curvilinear). While


walking, for example, a point on th head moves in a gen
erai curvilinear manner (Fig. 1 - 2 ) .
Rotation, in contrast, describes a motion in which an assumed rigid body moves in a circular path aboul some pivot

Chapter 1

Getting Started

TABLE 1 - 1 . Common Conversions Between Units


of Kinematic Measurements
1
1
1
1
1
1

FIGURE 1-2. A point on th top of th head is shown translating


upward and downward in a curvilinear fashion while walking. The
X axis shows th percentage of completion of one entire gait (walk
ing) cycle.

point. As a result, all points in th body simultaneously


rotate in th same angular direction (e.g., clockwise and
counterclockwise) across th same number of degrees.
Movement of th human body, as a whole, is often described as a translation of th bodys center o f mass, located
generally just anterior to th sacrum. Although a persons
center of mass translates through space, il is powered by
muscles that rotate th limbs. The fact that limbs rotate can
be appreciated by watching th path created by a fist while
flexing th elbow (Fig. 1 - 3 ) . (Il is customary in kinesiology
to use th phrases rotation of a joint and rotation of a
bone interchangeably.)
The pivot point for th angular motion is called th axis
of rotation. Tbe axis is at th point where motion of th

meter (m) = 3 .28 feet (ft)


m = 39.3 7 inches (in)
centimeter (cm) = .39 in
m = 1.09 yards (yd)
kilometer (km) = .62 miles (mi)
degree = .0174 radians (rad)

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

rotating body is zero. For most movements of th body, th


axis of rotation is located within or very near th structure
of th joint.
Movement of th body, regardless of translation or rota
tion, can be described as active or passive. Active movements
are caused by stimulated muscle. Passive movements, in contrast, are caused by sources other than muscle, such as a
push from another person, th pul of gravity, and so forth.
The primary variables related to kinematics are position,
velocity, and acceleration. Specific units of measurement are
needed to indicate th quantity of these variables. Units of
meters or feet are used for translation, and degrees or radians are used for rotation. In most situations, Kinesiology oj
th Musculoskeletal System uses th International System oj
Units, adopted in 1960. This System is abbreviateci SI, for
Systme International, th French name. This System of units
is widely accepted in many joumals related to kinesiology
and rehabilitation. The kinematic conversions between th
more common SI units and other measurement units are
listed in Table 1 - 1 .

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

FIGURE 1-3. Using a stroboscopie flash, a camera is able to eapture


th rotation of th forcami. If not for th anatomie constraints of
th elbow, th forearm could, in theory, rotate 360 degrees about
an axis of rotation located at th elbow (red circle).

Bones rotate about a joint in a piane that is perpendicular to


an axis of rotation. The axis is typically located through th
convex member of th joint. The shoulder, for example,
allows movement in all three planes and, therefore, has three
axes of rotation (Fig. 1 - 5 ) . Although th three orthogonal
axes are depicted as stationary, in reality, as in all joints,
each axis shifts throughout th range of motion. The axis of
rotation remains stationary only if th convex member of a

Section I

Essential Topics o f Kinesiology

FIGURE 1-4. The three Cardinal planes of th body are shown as a


person is standing in th anatomie position.

joint were a perfeci sphere, articulating with a perfectly


reciprocally shaped concave member. The convex members
of most joints, like th humeral head at th shoulder, are
imperfect spheres with changing surface curvatures. The
issue of a migrating axis of rotation is discussed further in
Chapter 2.

DEGREES OF FREEDOM
Degrees o f freedom
ments allowed at
degrees of angular
mensions of space.

are th number of independent movea joint. A joint can have up to three


freedom, corresponding to th three diAs depicted in Figure 1 - 5 , for example,

medial-lateral (ML) axis of rotation; abduction and adduction (red


curved arrows) occur about an anterior-posterior (AP) axis of rota
tion; and internai and external rotation (gray curved arrows) occur
about a vertical axis o f rotation. Each axis of rotation is color-coded
with its associated piane of movement. The straight arrows shown
parallel to each axis represent th slight translation potential of th
humerus relative to th scapula. This illustration shows both angu
lar and translational degrees of freedom. (See text for further description.)

TABLE 1 - 2 . A Samplc of Common Osteokinematic Terms


Sagittal Piane

Frontal Piane

Horizontal Piane

Flexion and extension


Dorsidexion and piantar flexion
Forward and backward bending

Abduction and adduction


Lateral flexion
Ulnar and radiai deviation
Eversion and inversion

Internai (mediai) and external (lateral) rotation


Axial rotation

Many of th terms are specific to a particular region of th body. The thumb, for example, uses differem terminology.

Chapter 1 Gelting Started

ie shoulder has three degrees of angular freedom, one l'or


cM:h piane. The wrist allows two degrees of freedom, and
th elbow only one.
Unless specified differently throughout this text, th term
zegrees of freedom indicates th number of permitted planes
: f angular motion at a joint. From a strict engineering per
spective, however, degrees of freedom applies to angular as
'>11 as translational movements. All synovial joints in th
-ody possess at least some translation, driven actively by
riuscle, or passively owing to th naturai laxity within th
sructure of th joint. The slight passive translations that
rceur in most joints are referred to as accessory motions and
ire defined in three linear directions. From th anatomie
rosition, th directions correspond to those of th three axes
:: rotation. In th relaxed glenohumeral joint, for example,
th humerus can be passively translated anterior-posteriorly,
nedial-laterally, and superior-inferiorly (see Fig. 1 - 5 ) . At
nany joints, especially th knee and ankle, th amount of
-anslation is used clinically to test th integrity of ligaments.

OSTEOKINEMATICS: A MATTER OF PERSPECTIVE


in generai, th articulations of two body segments constitute
i joint. Movement at a joint can therefore be considered
from two perspectives. (1) th proximal segment can rotate
igainst th relatively ftxed distai segment, and (2) th distai
segment can rotate against th relatively fixed proximal seg
ment. These two perspectives are shown for knee flexion in
Figure 1 - 6 . A term such as knee flexion, for example, de
scribes only th relative motion between th thigh and leg. It
does not describe which of th two segments is actually
rotating. Often, to be clear, it is necessary to state th bone
that is considered th primary rotating segment. As in Figure
i - 6 , for example, th terms tibial-on-femoral movement or
:emoral-on-tibial movement adequately describe th osteokinematics.
Most routine movements performed by th upper extrem:des involve distal-on-proximal segment kinematics. This reQects th need to bring objects held by th hand either

toward or away from th body. The proximal segment of a


joint in th upper extremity is usually stabilized by muscles
or gravity, whereas th distai, relatively unconstrained, seg
ment rotates.
Feeding oneself or throwing a ball are two common examples of distal-on-proximal segment kinematics employed
by th upper extremities. The upper extremities are certainly
capable of performing proximal-on-distal segment kinemaiics, such as flexing and extending th elbows while performtng a pull-up.
The lower extremities routinely perform both distal-onproximal and proximal-on-distal segment kinematics. These
kinematics reflect, in part, th two primary phases of walking: th slance phase, when th limb is planted on th
ground under th load of body weight, and th swing phase,
when th limb is advancing forward. Many other activities,
in addition to walking, use both kinematic strategies. Bending th knee in preparation to kick a ball, for example, is a
type of distal-on-proximal segment kinematics (Fig. 1 -6 A ).
Descending into a squat position, in contrast, is an example
of proximal-on-distal segment kinematics (Fig. 1 -6 B ). In
this last example, a relatively large demand is placed on th
quadriceps muscle of th knee to control th graduai descent
of th body.
The terms open and closed kinematic chain are frequenti)'
used in th physical rehabilitation literature and clinics to
describe th concep of relative segment kinematics.4-10 A
kinematic chain refers to a series of articulated segmented
links, such as th connected pelvis, thigh, leg, and foot of
th lower extremity. The terms open and closed are typically used to indicate whether th distai end of an extremity
is fixed to th earth or some other immovable object. An
open kinematic chain describes a situation in which th distai
segment of a kinematic chain, such as th foot in th lower
limb, is not fixed to th earth or other immovable object. The
distai segment, therefore, is free to move (see Fig. 1 -6 A ). A
closed kinematic chain describes a situation in which th distai
segment of th kinematic chain is fixed to th earth or
another immovable object. In this case, th proximal seg-

Knee flexion

F1GURE 1-6. Sagittal piane osteokinematics at th knee show


an example of (A) distal-onproximal segment kinematics
and (B) proximal-on-distal seg
ment kinematics. The axis of
rotation is shown as a circle at
th knee.

Proximal segment fixed

Distai segment free

A Tibial-on-femoral perspective

S ection J

Essential Topics o f Kinesiolog)>

ment is iree to move (see Fig. 1 -6 B ). These terms are


employed extensively to describe methods of applying resistance to muscles and ligaments, especially in th knee.2 J
Although very convenient terminology, th terms open
and closed kinematic chains are often ambiguous. From a
strict engineering perspective, th terms open and closed
kinematic chains apply more to th kinematic interdependence
of a series of connected rtgid links, which is not exactly th
same as th previous defnitions given here. From this engi
neering perspective, th chain is closed" if both ends are
fixed to a common object, much like a closed Circuit. In this
case, movement of any one link requires a kinematic adjustment of one or more of th other links within th chain.
Opening" th chain by disconnecting one end from its fixed
attachment interrupts this kinematic interdependence. This
more precise terminology does not apply universally across
all health-related and engineering disciplines. Performing a
one-legged partial squat, for example, is often referred to
clinically as th movement of a closed kinematic chain. li
could be argued, however, that this is a movement of an
open kinematic chain because th contralateral leg is not
fixed to ground (i.e., th Circuit formed by th total body is
open). To avoid confusion, this text uses th terms open and
closed kinematic chains sparingly, and th preference is to
explicitly state which segment (proximal or distai) is considered fixed and which is considered free.

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.

FUNDAMENTAL MOVEMENTS BETWEEN JOINT


SURFACES
Fhree lundamental movements exist between joint surfaces:
roti, slide, and, spiti." These movements occur as a convex
surface moves on a concave surface, and vice versa (Fig.

FIGURE 1 -7 . The humeroulnar joint at th elbow is an example of


a convex-concave relationship between two articular surfaces The
trochlea of th humerus is convex, and th trochlear notch of th
ulna is concave.

1 - 8 ) . Although other terms are used, these are useful for


visualizing th relative movements that occur within a joint.
The terms are formally defined in Table 1 - 3 .

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

TABLE 1 - 3 Three Fundamental Arthrokinematics: Roll, Slide, and Spin


Movement

Defnition

Roll*

Multiple points along one rotating articular surface contact multiple


points on another articular surface.
A single poim on one articular surface contacts multiple points on

Slidet
Spin

another articular surface.


A single pomi on one articular surface rotates on a single point on
another articular surface.

TAlso temied gliele

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.

tire to rotate forward on th icy pavement is offset by a


continuous sliding of th lire in th opposite direction to th
intended rotation. A classic pathologic example of a convex
surface rolling without an off-setting slide is shown in Figure
1 -9 B . The humeral head translates upward and impinges
th delicate tissues in th subacromial space. The migration
alters th relative location of th axis of rotation, thereby

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

Essential Topics o f Kinesiology

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

FIGURE 1-10. Pronation of th forearm shows an example of a

spinning motion between th head of th radius and th capitulum


of th humerus.

axis of th long bone intersects th surface of its articular


mate at right angles.
Motions That Combine Roll-and-Slide and Spin
Arthrokinematics
Severa! joints throughout th body combine roll-and-slide
with spin arthrokinematics. A classic example of this combination occurs during flexion and extension of th knee. As
shown during femoral-on-tibial knee extension (Fig. 1 -1 1 A ),
th femur spins internally slightly, as th femoral condyle
rolls and slides relative to th fixed tibia. These arthrokine
matics are also shown as th tibia extends relative to th
fixed lemur in Figure 1 116. In th knee, th spinning
motion that occurs with flexion and extension occurs automatically and is mechanically linked to th primary motion
of extension. As described in Chapter 13, th obligatory
spinning rotation is based on th shape of th articular
surfaces at th knee. The conjunct rotation helps to securely
lock th knee joint when fully extended.

PREDICTING AN ARTHROKINEMATIC PATTERN


BASED ON JOINT M0RPH0L0GY
As previously stated, most articular surfaces of bones are
either convex or concave. Depending on which bone is moving, a convex surface may rotate on a concave surface or
vice versa (compare Fig. 1 - 1 1 A with l - l 16). Each scenario
presents a different roll-and-slide arthrokinematic pattern. As
depicted in Figure 1 - 11A and 1 -9 A for th shoulder, dur
ing a convex-on-concave movement, th convex surface rolls
and slides in apposite directions. As previously described, th
contradirectional slide offsets th translation tendency inherent to th rolling convex surface. During a concave-on-convex
movement, as depicted in Figure 1 - 1 1 6 , th concave surface
rolls and slides in similar directions. These two principles are
very useful for visualizing th arthrokinematics during a
movement. In addition, th principles serve as a basis for

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.

some marmai therapy techniques. External forces may be


applied by th clinician ihat assist or guide th naturai ar
throkinematics at th joint. For example, in certain circumstances, glenohumeral abduction can be facilitateci by applymg an inferior-directed force at th proximal humerus,
stmultaneously with an active-abduction effort. The arthrokinematic principles do, however, require a knowledge ol
me joint surface morphology.

Arthrokincmatic Principles of Movemenl


1. For a convex-on-concave surface movement, th convex
member rolls and slides in apposite directons.
2. For a concave-on-convex surface movement, th concave
member rolls and slides in smular directons.

ILOSE-PACKED AND LOOSE-PACKED POSITIONS AT


, A JOINT
The pair of articular surfaces within most synovial joints fit
best in only one position, usually in or near th very end
mnge of a motion. This position of maximal congruency is
jeferred to as th joints close-packed position. In this position,
most ligaments and parts of th capsule are pulled taut,
oroviding an element of naturai stability to th joint. Accessory motions are minimal in a joints close-packed position.
For rnany joints in th lower extremity, th close-packed
nosition is associated with a habitual function. At th knee,
:r example, th close-packed position is full extension a
? r*suion that is typically approached while standing. The

combined effect of th maximum joint congruity and


stretched ligaments helps to provide transarticular stability to
th knee.
All positions other than a join ts close-packed position are
referred io as th joints loose-packed positions. In these posi
tions, th ligaments and capsule are relatively slackened,
allowing an increase in accessory movements. The joint is
generally least congruent near its mid range. In th lower
extremity, th loose-packed positions of th major joints are
biased toward flexion. These positions are generally not used
during standing, bui frequently are preferred by th patient
during long periods of immobilization, such as extended bed
rest.

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

Essential Topici o f Kinesiology

mass measuring th force yields th acceleration and vice


versa. A force is zero when th acceleration of th mass is
zero and vice versa.
Based on th SI, th unii of force is a newton (N): 1 N =
1 kg X 1 m/sec2. The English equivalent to th newton is
th pound (lb): 1 lb = 1 slug X 1 ft/sec2 (4.448 N = 1 lb).

S P E C I A L

F O C U S
U N LO AD ED

T E N S IO N

Body Weight Compared with Body Mass

A kilogram (kg) is a unit of mass that indicates th


number of particles within an object. A kilogram is not
a unit of force or weight. Under th influence of gravity,
however, a 1-kg mass weighs 9.8 N. This is th result of
gravity acting to accelerate th 1-kg mass toward th
center of earth at a rate of about 9.8 m/s2. If a person
weighs 150 lb, gravity is pulling th center of mass of
th person toward th center of earth with a force
equal to 150 lb (667 N).
Often, however, th weight of th body is expressed
in kilograms. The assumption is that th acceleration
due to gravity acting on th body is Constant and, for
practical purposes, is ignored. Technically, however, th
weight of a person varies inversely with th square of
th distance between th mass of th person and th
center of th earth. A person on th summit of Mt.
Everest at 29,035 ft (=8,852 m) weighs slightly less than
a person with identical mass at sea level.5 The acceler
ation due to gravity on Mt. Everest is 9.782 m/s2 com
pared with 9.806m/s2 at sea level.4

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

FIGURE 1 -1 2 . The manner by which forces or loads are most fre


quently applied to th musculoskeletal System is shown. The eombined loading of torsion and compression is also illustrated. (With
permission from Nordin M, Frankel VH: Biomechanics of bones.
Basic Biomechanics of th Musculoskeletal System, 2nd ed. Philadelphia, Lea &r Febiger, 1989.)

tion, divided by its cross-sectional area. The horizontal axis


is labeled strain, which is th ratio of th tissues deformed
length to its originai length.8 A similar procedure may be
performed by compressing, rather than by stretching, an ex
cised slice of cartilage or bone, for example, and then plot
ting th amount of stress within th tissue.
Figure 1 - 1 3 shows five zones (A to E). In zone A, th
slightly stretched or elongated ligament produces only a
small amount of tension. This nonlinear region of low ten
sion reflects th fact that th collagen fibers within th liga
ment must first be drawn taut before significant tension is
measured. Zone B shows th linear relationship between
stress and strain in a normal ligament. The ratio of stress to
strain in an elastic material is a measure of its stijjness. All
normal tissues within th musculoskeletal System exhibit
some degree of stiffness. The clinical term tightness usually
implies a pathologic condition of abnormally high stiffness.
Zone B in Figure 1 - 1 3 is often referred to as th elastic
zone of th stress-strain plot. The amount of stretch (strain)
applied to th ligament in this zone is significant and likely
experienced during many naturai movements of th body.
Within this zone, th tissue retums to its originai length or
shape once th deforming force is removed. The area under
th curve (red) represents elastic deformation energy. Most of
th energy utilized to defonn th tissue is released when th
force is removed. Even in a static sense, elastic energy can
do useful work for th body. When stretched even a moder
ate amount within th elastic zone, ligaments and other
connective tissues surrounding muscles perforai important
joint stabilization functions.
Zone C in Figure 1 - 1 3 shows a mechanical property of
stretched connective tissue called plasticity. At this extreme

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.)

and abnormally large stretch, th tissue generates only mar


ginai increases in tension as it continues to elongate. At this
point, th ligament is experiencing microscopie failure and
remains permanently deformed. The area under th curve
(gray) represents plastic deformation energy. Unlike th elastic
deformation energy (region B), th plastic energy is not recoverable in its entirety when th deforming force is released. As elongation continues, th ligament reaches its initial point of failure in zone D and complete failure in zone E.
The graph in Figure 1 - 1 3 does not indicate th variable
of time. Tissues in which th stress-strain curve changes as a
function of time are considered viscoelastic. Most tissues
within th musculoskeletal System demonstrate at least some
degree of viscoelasticity (Fig. 1 - 1 5 ) . One phenomenon of a
viscoelastic material is creep. As demonstrated by th tree
branch in Figure 1 - 1 5 , creep describes a progressive strain
of a material when exposed to a Constant load over time.
The phenomenon of creep explains why a person is taller in
th moming than at night. The Constant compression caused
by body weight on th spine throughout th day literally
squeezes fluid out of th intervertebral discs. The fluid is
reabsorbed at night while th sleeping person is in a nonweight-bearing position.
The stress-strain curve of a viscoelastic material is also
sensitive to th rate of loading of th tissue. In generai, th
slope of a stress-strain relationship when placed under ten
sion or compression increases throughout its elastic range as
th rate of th loading increases.8 The rate-sensitivity nature
of viscoelastic connective tissues may protect surrounding
structures within th musculoskeletal System. Articular carti-

lage in th knee, for example, becomes stiffer as th rate of


compression increases,7 such as during running. The increased stiffness affords greater protecton to th underlying
bone at a time when joint forces are greatest.

INTERNAI. AND EXTERNAL FORCES


The principal forces acting to move and stabilize th muscu
loskeletal System can be conveniently divided into two sets:
internai and external. Internai forces are produced from
structures located within th body. These forces may be active or passive. Active forces are generated by stimulated
muscle, generally under volitional control. Passive forces, in
contrast, are typically generated by tension in stretched periarticular connective tissues, including th intramuscular con
nective tissues, ligaments, and joint capsules. Active forces
produced by muscles are typically th largest of all internai
forces.
External forces are typically produced by forces acting
from outside th body. These forces usually originate from
either gravity pulling on th mass of a body segment or an
external load, such as that of luggage or free weights, or
physical contact, such as that applied by a therapist against
th limb of a patient. Figure 1 -1 6 A shows an opposing pair
of internai and external forces: an internai force (muscle),
pulling th forearm, and an external (graviiaiional) force,
pulling on th center of mass of th forearm. Each force is
depicted by an arrow that represents a vector. By definition,
a vector is a quantity that is completely specified by its
magnitude and its direction. (Quantities such as mass or

14

Sechoti I

Essential Topici o j Kinesiology

S P E C I A L

F O C U S

1 - 2

Productive Antagonismi The Body's Ability to Convert


Passive Tension into Useful Work

As previously described, connective tissue produces ten


sion when stretched. Since tension is a force, it has th
ability to do work. Several examples are presented
throughout this text in which th tension produced by
stretched connective tissues performs useful functions.
This phenomenon is called productive antagonism and is
demonstrated for a pair of muscles in th simplified model
in Figure 1-14. As shown in th middle, part of th energy produced by active contraction of muscle A is transferred and stored as an elastic energy in th stretched
connective tissues within muscle B. The elastic energy is
released as muscle B actively contracts to drive th nail
into th board (lower). Part of th contractile energy pro

duced by muscle B is used to stretch muscle A, and th


cycle is repeated.
This transfer and Storage of energy between opposing
muscles is useful in terms of overall metabolic efficiency.
This phenomenon is often expressed in different ways by
multiarticular muscles (i.e., muscles that cross several
joints). Consider th rectus femoris, a muscle that flexes
th hip and extends th knee. During th upward phase of
jumping, for example, th rectus femoris contracts to extend th knee. At th same time, th extending hip
stretches th active rectus femoris across th front of th
hip. As a consequence, th overall shortening of th rec
tus femoris is minimized, thereby maintaining a low level
of useful passive tension within th muscle.

FIGURE 1-14. A simplified model showing a


pair of opposed muscles surrounding a joint.
Muscles A and B in th top are shown in their
relaxed state. In th middle, muscle A (red) is
contracting to provide th force needed to lift
th hammer in preparation to strike th nail. In
th lower view, muscle B (red) is contracting,
driving th hammer against th nail, while
simultaneously stretching muscle A. (Modified
with permission from Brand PW: Clinical Biomechanics of th Hand. St Louis, CV Mosby
1985.)

Chapter 1

Getting Started

15

serts to th bone. The angle-of-insertion describes th angle


lormed between a tendon of a muscle and th long axis of
th bone to which it inserts. In Figure 1 -1 6 A , th angle-ofinsertion is 90 degrees. The angle-of-insertion changes as th
elbow rotates into flexion or extension. The point of applica
tion of th external force depends on whether th force is
th result of gravity or th result of a resistance applied by
physical contact. Gravity acts on th center o f mass of th
body segmenl (see Fig. 1 -1 6 A , dot at th forearm). The
point of application of a resistance generated from physical
contact can occur anywhere on th body.
URE 1 -1 5 . The branch of th tree ts demonstrating a timendem property of creep associated with a viscoelastic material.
ging a load on th branch at 8 AM creates an immediate
ormation. By 6 p m , th load has caused additional deformation
th branch. (With permission from Panjabi MM, White AA:
mechanics in th Musculoskeletal System. New York, Churchill
ngstone, 2001.)

speed are scalars not vectors. A scalar is a quantity that is


-ompletely spedfied by its magnitude and has no direction.)
In order to completely describe a vector in a biomechanial analysis, its magnitude, direction, sense, and point of
application must be known. The forces depicted in Figure
116A indicate these four factors.
1. The magnitude of each force vector is indicated by th
ength of th shaft of th arrow.
2. The direction of both force vectors is indicated by th
' pattai orientation of th shaft of th arrows. Both forces are
riented vertically, commonly referred to as th Y direction.
The direction of a force can also be described by th angle
rormed between th shaft of th arrow and a reference line.
Throughout this text, th direction of a muscle force and th
direction of gravity are commonly referred to as their line-offorce and line-oj-gravity, respectively.
3. The sense of each force vector is indicated by th
orientation of th arrowhead. In th example depicted in
Mgure 1 -1 6 A , th internai force acts upward in a positive Y
sense; th external force acts downward in a negative Y sense.
4. The point o f application of th vectors is where th base
of th vector arrow contacts th part of th body. The point
of application of th muscle force is where th muscle in-

Factors Required to Completely Describe a Vector in


Most Biomechanical Analyses

Magnitude
Direction (line-of-force or line-of-gravity)
Sense
Point of application

As a push or a pul, all forces acting on th body cause a


potential translation of th segment. The direction of th
translation depends on th net effect of all th applied
forces. Since in Figure 1 - 1 6 A th muscle force is three
times greater than th weight of th forearm, th net effect
of both forces would accelerate th forearm vertically up
ward. In reality, however, th forearm is typically prevented
from accelerating upward by a joint reaction force produced
between th surfaces of th joint. As depicted in Figure 1
16B, th distai end of th humerus is pushing down with a
reaction force against th proximal end of th forearm. The
magnitude of th joint reaction force is equal to th difference between th muscle force and external force. As a
result, th sum of all vertical forces acting on th forearm is
balanced, and net acceleration of th forearm in th vertical
direction is zero. The System is therefore in static linear
equilibiium.

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

RGURE 1 -1 6 . A sagittal piane view of th el


bow joint and associated bones. A, Internai
(muscle) and external (gravitational) forces are
shown both acting vertically, bui each in a different sense. The two vectors each have a different magnitude and different points of attachment to th forearm. B, Joint reaction force is
added lo prevent th forearm from accelerating
upward. (Vectors are drawn lo relative scale.)

'r
Externalforce

External force

16

Section / Essential Topics of Kinesiology

Torque Makes th World Go 'Round

FIGURE 1 -1 7 . The balance of internai and external torques acting


in th sagittal piane about th axis of rotation at th elbow (small
circle) is shown. The internai torque is th product of th internai
force multiplied by th internai moment arm (D). The internai
torque has th potenual to rotate th forearm in a counterclockwise
direction. The external torque is th product of th external force
(gravity) and th external moment arm (D ,). The external torque
has th potential to rotate th forearm in a clockwise direction. The
internai and external torques are equal, demonstrating a condition
of static rotary equilibrium. (Vectors are drawn to relative scale.)

th axis of rotation at th joint, produce a potential rotation


of th joint. The shortest distance between th axis of rota
tion and th force is called a moment arm. The product of a
force and its moment arm is a torque or a moment. Torque
can be considered as a rotatory equivalent to a force. A force
pushes and pulls an object in a linear fashion, whereas a
torque rotates an object about an axis of rotation.
Torques occur in planes about an axis of rotation. Figure
1 - 1 7 shows th torques produced within th sagittal piane
by th internai and external forces introduced in Figure 1 16. The internai torque is defined as th product of th
internai force (muscle) and th internai moment arm. The
internai moment arm (see Fig 1 - 1 7 , D ) is th distance be
tween th axis of rotation and th perpendicular intersection
with th internai force. As depicted in Figure 1 - 1 7 , th
internai torque has th potential to rotate th forearm in a
counterclockwise, or flexion, direction.
The external torque is defined as th product of th exter
nal force (gravity) and th external moment arm. The exter
nal moment arm (see Fig 1 17,D,) is th distance between
th axis of rotation and th perpendicular intersection with
th external force. The external torque has th potential to
rotate th forearm in a clockwise, or extension, direction.
The internai and external torques happen to be equal in
Figure 1 - 1 7 , and therefore no rotation occurs at th joint.
This condition is referred to as static rotary equilibrium.

Muscle and Joint Interaction


The term muscle and joint interaction refers to th overall
effect that a muscle force may have on a joint. This topic is
revisited repeatedly throughout this textbook. A force pro
duced by a muscle that has a moment arm causes a torque,
and a potential to rotate th joint. A force produced by a
muscle that lacks a moment arm (i.e., th muscle force

Torques are experienced by everyone, in one way or


another. Muscles and gravity are constantly competing
for dominance of torque about th axis of rotation at
joints. The direction of rotation of a bone about a joint
can indicate th more dominant torque. Furthermore,
manual contact forces applied against objects in th
environment are frequently converted to torques.
Torques are used to unscrew a cap from a jar, turn a
wrench, swing a baseball bat, and open a door. In th
last example, th door is opened by th product of th
push on th door knob multiplied by th perpendicular
distance between th door knob and th hinge. Trying
to open a door by pushing only a couple of centimeters
from th hinge of th door is very difficult, even when
applying a large pushing force. In contrast, a door can
be opened with a slight push, provided th push is
applied at th door knob, which is purposely located at
a distance far from th hinge. A torque is th product
of a force and its moment arm. Both variables are
equally influential.
Torques are involved in most therapeutic situations
with patients, especially when physical exercise or
strength assessment is involved. A person's "strength"
is th product of their muscle's force, and, equally important, th distance between th muscle's line-of-force
and th axis of rotation. As explained further in Chapter
4, th length of a muscle's moment arm changes con
stantly throughout a range of motion. This partially explains why a person is naturally stronger in certain
parts of a joint's range of motion.
Clinicians frequently apply manual resistance against
their patients as a means to assess, facilitate, and challenge a particular muscle activity. The force applied
against a patient's extremity is usually perceived as an
external torque by th patient's musculoskeletal System.
A clinician can challenge a particular muscle group by
applying an external torque by way of a small manual
force exerted a great distance from th joint or a large
manual force exerted dose to th joint. Either means
can produce th same external torque against th patient. Modifying th force and external moment arm
variables allows different strategies to be employed
based on th strength and skill of th clinician.

passes through th axis of rotation) will not cause a torque or


a rotation. The muscle force is stili important, however,
because it usually provides a source of stability to th joint.

TYPES OF MUSCLE ACTIVATION


A muscle is considered activated when it is stimulated by
th nervous system. A muscle produces a force through
three types of activation: isometric, concentric, and eccentric.
The physiology of th three types of activation is described

Chapter 1

greater detail in Chapter 3 and briefly summarized subseTitly.


Isometrc activation occurs when a muscle is producing a
e while maintaining a Constant length. This type of acti
on is apparent by th origin of th word isometric (from
Greek isos, equal; and metron, measure or length). Duran isometric activation, th internai torque produced at a
t is equal to th external torque; hence, there is no
nuscle shortening or rotaiing at th joint (Fig. 1-1 8 A ).
Concentric activation occurs as a muscle produces a force
rs it contracts (shortens) (Fig. 1 -1 8 B ). Literally, concentric
means coming to th center. During a concentric activaon, th internai torque at th joint exceeds th opposing
lemal torque. This is reflected by th faci that th muscle
- ontracted and accelerated a rotation of th joint in th
direction of th activated muscle.
Eccentric activation, in contrast, occurs as a muscle pro-uces an active force while being elongated. The word eccentric literally means away from th center. During an
eccentric activation, th external torque about th joint ex
ceeds th internai torque. In this case, th joint rotates in
die direction dictated by th relatively larger external torque,
such as that produced by th cable in Figure 1 -1 8 C . Many
common activities employ eccentric activations of muscle.
Slowly lowering a cup of water to a table, for example, is
caused by th pul of gravity on th forearm and water. The
activated biceps slowly elongates in order to control their
descent. The triceps muscle, although considered as an elbow extensor, is most likely inactive during this particular
process.
The term contraction is often used synonymously with
activation, regardless of whether th muscle is actually
shortening, lengthening, or remaining at a Constant length.
The term contract literally means to be drawn together and,
therefore, its use can be confusing when describing either an
isometric or eccentric activation. Technically, a contracting
muscle occurs during a concentric activation only.

Getting Staned

A MUSCLES ACTION AT A JOINT


A muscles action at a joint is defined as its potential to cause
a torque in a particular rotation direction and piane. The
actual naming of a muscles action is based on an established
nomenclature, such as flexion or extension in th sagittal
piane, abduction or adduction in th frontal piane, and so
forth. The terms muscle action and joint action are used
interchangeably throughout this text, depending on th context of th discussion. If th action is associated with a
nonisometric muscle activation, th resulting osteokinematics
may involve distal-on-proximal segment kinematics, or vice
versa, depending on th relative stability of th two segments
that comprise th joint.
Kinesiology allows one to determine th action of a mus
cle, without relying purely on memory. Suppose th student
desires to determine th action of th posterior deltoid at th
glenohumeral (shoulder) joint. In this particular analysis,
two assumptions are made. First, it is assumed that th
humerus is th freest segment of th joint, and that th
scapula is ftxed, although th reverse assumption could have
been made. Second, il is assumed that th body is in th
anatomie position at th time of th muscle activation.
The first step in th analysis is to determine th planes of
rotary motion (degrees of freedom) allowed at th joint. In
this case, th glenohumeral joint allows rotation in all three
planes (see Fig. 1 - 5 ) . Figure 1 -1 9 A shows th potential for
th posterior deltoid to rotate th humerus in th frontal
piane. The axis of rotation at th joint passes in an anteriorposterior direction through th humeral head. In th ana
tomie position, th line-of-force of th posterior deltoid
passes inferior to th axis of rotation. By assuming that th
scapula is stable, th posterior deltoid would rotate th hu
merus toward adduction, with a strength equal to th prod
uci of th muscle force multiplied by its internai moment
arm. This same logie is next applied to determine th mus
cles action in th horizontal and sagittal planes. As depicted
in Figure 1 - 1 9B and C, it is apparent that th muscle is also

Three types of muscle activation

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

Essential Topics o f Kinesiology

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.

an external (lateral) rotator and an extensor of th glenohu


meral joint.
The logie so presented can be used to determine th
action of any muscle in th body, at any joint. If available, an
articulated skeleton model and a piece of string that mimics
th line-of-force of a muscle is helpful in applying thts logie.
This exercise is particularly helpful when analyzing a muscle
whose action switches, depending on th position of th
joint. One such muscle is th posterior deltoid. From th
anatomie position, th posterior deltoid is an adductor of th
glenohumeral joint. If th arm is lifted (abducted) fully overhead, however, th line-of-force of th muscle shifts just to
th superior side of th axis of rotation. As a consequence,
th posterior deltoid actively abduets th shoulder. This shift
can be visualized with th aid of Figure 1-19A . The example shows how one muscle can have opposite actions, de
pending on th position of th joint at th Lime of muscle
activation. lt is importane therefore, to establish a reference
position for th joint when analyzing th actions of a mus
cle. One common reference position is th anatomie position
(see Fig. 1 - 4 ) . Unless otherwise specified, th actions of
muscles described throughout Sections II to IV are based on
th assumption that th joint is in th anatomie position.

Actually, most meaningful movements of th body involve


multiple muscles acting as synergists. Consider, for example,
th flexor carpi ulnaris and flexor carpi radialis muscles
during flexion of th wrist. The muscles act synergistically
because they cooperate to flex th wrist. Each muscle, how
ever, must neutralize th others tendency to move th wrist
in a side-to-side (radiai and ulnar deviation) fashion. Paralysis of one of th muscles signifcanily affeets th overall
action of th other.

Terminology Retateci to th Actions of Muscles


The following terms are often used when describing th
actions of muscles:
1. The agonist is th muscle or muscle group that is most
directly related to th imtiation and execution of a particular
movement. For example, th tibialis anterior is th agonist
for th motion of dorsiflexion of th ankle.
2. The antagonist is th muscle or muscle group that is
considered to have th opposite action of a particular ago
nist. For example, th gastrocnemius and soleus muscles are
considered th antagonists to th tibialis anterior.
3. A pair of muscles are considered synergists when they
cooperate during th execution of a particular movement.
DEI

b ib l io t e c a
CASA DE ESTUDIOS
PROVIDENCIA

FIGURE 1-20. Side view ol th force-couple formed between two


representative hip flexor (rectus femoris and iliopsoas) muscles and
back extensor (erector spinae) muscles, as they contract to tilt th
pelvis in an anterior direction. The internai moment arms used by
th muscles are indicated by th dark black lines. The axis of
rotation runs through both hip joints.

Chapter I

Another example of muscle synergy is described as a


uscular force-couple. A muscular force-couple is formed
hen two or more muscles simultaneously produce forces in
cifferent linear directions, although die torques act in th
siine rotary direction. A familiar analogy of a force couple
occurs between th two hands while tuming a steering
-heel of a car. Rotating th steering w'heet to th right, for
-ixample, occurs by th action of th right hand pulling
down and th left hand pulling up on th wheel. Although
th hands are producing forces in different linear directions,
they cause a torque on th steering wheel in a common
mtary direction. The hip flexor and low back extensor musdes, for example, form a force-couple to rotate th pelvis in
me sagittal piane about both hip joints (Fig. 1 - 2 0 ).

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

half his w'eight, who is sitting twice th distance from th


pivot point. In Figure 1 - 2 1 , th opposing torques are equal:
BWm X D = BWb X D,.
As indicated, th boy has th greatest leverage (D,). Leverage
describes th relative moment arm length possessed by a
particular force.
Internai and extemal forces produce torques throughout
th body through a System of bony levers. The most important forces involved with musculoskeletal levers are those
produced by muscle, gravity, and physical contacts within
th environment. Levers are classified as either first, second,
or third class.

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

Data tor first-class Iever:


Muscle force (MF) = unknown
Head weight (HW) = 467 N (10.5 Ibs)
Internai moment arm (IMA) = 4.0 cm
External moment arm (EMA) = 3.2 cm

Mechanical advantage = 1.25


MF x IMA = HW x EMA
MF = HW x EMA
IMA
MF = 46.7 N x 3.2 cm
4.0 cm
MF = 37.4 N (8.4 Ibs)

Sccond-class Iever

Data for second-class Iever:


Muscle force (MF) = unknown
Body weight (BW) - 667 N (150 Ibs)
Internai moment arm (IMA) = 12.0 cm
External moment arm (EMA) = 3.0 cm

Mechanical advantage = 4.0


M F x IMA = BW x EMA
MF = BW x EMA
IMA
MF = 667 N x 3.0 cm
12.0 cm
MF = 166.8 N (37.5 Ibs)

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

Mechanical advantage - .143


MF x IMA = EW x EMA
MF = EW x EMA
IMA
MF = 66.7 N x 35.0 cm
5.0 cm
MF = 467.0 N (105.0 Ibs)

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

ar directions, although they produce torques in opposing


ry directions.

Second-Class Lever. A second-class lever has two


.nique features. First, its axis of rotation is located at one
id of a bone. Second, th muscle, or internai force, posiisses greater leverage than th extemal force. As illustrateci
Figure 1 - 2 2 6 , a calf muscle group uses a second-class
:ver to produce th torque needed to stand on tiptoes. The
i-xis of rotation for this action is through th metatarsophamgeal joints. The internai moment arm used by calf muses greatly exceeds th extemal moment arm used by body
eight. Second-class levers are rare in th musculoskeletal
system.
Third-Class Lever. As in th second-class lever, th
-fard-class lever has its axis of rotation located at one end of
a bone. The elbow flexor muscles use a third-class lever to
"roduce th flexion torque required to support a barbell
rig. 1 -2 2 C ). Unlike th second-class lever, th extemal
weight supported by a third-class lever always has greater
iverage than th muscle force. The third-class lever is th
most common lever used by th musculoskeletal System.
VIECHANICAL ADVANTAGE
The mechanical advantage (MA) of a musculoskeletal lever is
iefined as th ratio of th internai moment arm to th
extemal moment arm. Depending on th location of th axis
3i rotation, th first-class lever can have an MA equal to, less
than, or greater than one. Second-class levers always have an
MA greater than one. As depicted in th boxes associated
with Figure 1 -2 2 A and B, lever systems with an MA greater
than one are able to balance th torque equilibrium equation
by an internai (muscle) force that is less than th extemal
force. Third-class levers always have an MA less than one.
As depicted in Figure 1 -2 2 C , in order to balance th torque
equilibrium equation, th muscle must produce a force
much greater than th opposing extemal force.

Mechanical Advantage (MA) is equal to th Internai


Moment Arin/External Moment Arm
First-class levers may have an MA less than 1, equal to 1,
or more than 1.
Second-class levers always have an MA more than 1.
Third-class levers always have an MA less than 1.

The majority of muscles throughout th musculoskeletal


System function with a mechanical advantage of much less
than one, and, actually, it may be more appropriate to cali
this a mechanical disadvantage! Consider, for example, th
biceps at th elbow, th quadriceps at th knee, and th
supraspinatus and deltoid at th shoulder. Each of these
muscles attaches to bone relatively dose to th join ts axis of
rotation. The extemal forces that oppose th action of th
muscles typically exert their influence considerably distally to
th joint, such as ai th hand or th foot. Consider th force
demands placed on th supraspinatus and deltoid muscles
to maintain th shoulder abducted to 90 degrees while

Cetting Storteci

21

holding an extemal weight of 3 5 .6N (8 lb) in th hand. For


th sake of this example, assume that th muscles have an
internai moment arm of 2.5 cm (about 1 in) and that th
center of mass of th extemal weight has an extemal mo
ment arm of 50 cm (about 20 in). (For simplicity, th
weight of th limb is ignored.) The 1/20 MA requires that
th muscle would have to produce 711.7N (160 lb) of force,
or twenty times th weight of th extemal load! As a generai
principle, skeletal muscles produce forces several times
larger than th extemal loads that oppose them. Depending
on th shape of th muscle and configuration of th joint, a
certain percentage of th muscle force produces large compression or shear forces at th joint surfaces. Periarticular
tissues, such as articular cartilage, fat pads, and bursa, must
partially absorb or dissipate these large myogenic (muscularproduced) forces. In th absence of such protection, joints
may partially degenerate and become painful and chroncally
inflamed. This presentation is th hallmark of severe osteoarthritis.
Dictating th "Trade-off" between Force and Distance
As previously described, most muscles are obligated to pro
duce a force much greater than th resistance applied by th
extemal load. At first thought, this design may appear
flawed. The design is absolutely necessary, however, when
th large distances and velocities experienced by th more
distai points of th extremities are considered.
Work is th product of force times distance (see Chapter
4). In addition to converting a force to a torque, a musculoskeletal lever converts th work of a contracting muscle to
th work of a rotating bone. The mechanical advantage of a
musculoskeletal lever dictates how th work is converted
through either a relatively large force exerted over a short
distance or a small force exerted over a large distance. Con
sider th small mechanical advantage of 1/20 described earlier for th supraspinatus and deltoid muscles. This mechani
cal advantage implies that th muscle must produce a force
20 times greater than th weight of th extemal load. What
must also be considered, however, is that th muscles need
to contract only 5% (1/20) th distance that th center of
mass of th load would be raised by th abduction action. A
very short contraction distance of th muscles produces a
very large angular displacement of th arm.
Although all points throughout th abducting arm share
th same angular displacement and velocity, th more distai
points on th arm move at an even greater linear displace
ment and velocity. The ability of a short contraction range to
generate large velocities of th limb may have an important
physiologic advantage for th muscle. As explained in Chap
ter 3, a muscle produces its maximal force within only a
relatively narrow range of its overall length.
In summary, most muscle and joint systems in th body
function with a mechanical advantage of less than one. The
muscles and underlying joints must, therefore, pay th
price by generating and dispersing relative large forces, respectively, even for seemingly low-load activities. Obtaining
a high linear velocity of th distai end of th extremities is a
necessity for generating large contact forces against th environment. These high forces can be used to rapidly accelerate
objects held in th hand, such as a tennis racket, or to
accelerate th limbs purely as an expression of art and athleticism, such as dance.

22

Section 1

Essential Topics o j Kinesiology

S P E C I A L

F O C U S

Surgically Altering a Muscle's Mechanical Advantage:


Dealing with th Trade-off

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).

Active force: push or pul generated by stimulated muscle.


Active movement: motion caused by stimulated muscle.
Agonist muscle: muscle or muscle group that is most directly related to th initiation and execution of a particular movement.
Angle-of-insertion: angle formed between a tendon of a
muscle and th long axis of th bone to which it inserts.
Antagonist muscle: muscle or muscle group that has th
action opposite to a particular agonist muscle.
Arthrokinematics: motions of roll, slide, and spin that occur between th articular surfaces of joints.
Axis of rotation: an imaginary line extending through a

th moment arm functionally "outweighs" th loss of th


speed and distance of th movement.

FIGURE 1-23. An anterior transfer of th triceps following

paralysis of th elbow flexor muscles. The triceps tendon is


elongated by a graft of fascia. (From Bunnell S: Restoring
flexion to th paralytic elbow. J Bone Joint Sure 33A 566
1951.)

joint about which rotation occurs (also called th pivot


point or th center of rotation).
Axial rotation: angular motion of an object in a direction
perpendicular to its longitudinal axis, often used to desenbe a motion in th horizomal piane.
Bending: effect of a force that deforms a material at righi
angles to its long axis. A bent tissue is compressed on its
concave side and placed under tension on its convex side.
A bending moment is a quantitative measure of a bend.
Similar to a torque, a bending moment is th product of
th bending force and th perpendicular distance between
th force and th axis of rotation of th bend.
Center of mass: point at th exact center of an objects
mass (also referred to as center of gravity w'hen considering th weight of th mass).
Close-packed position: umque position of most joints of
th body where th articular surfaces are most congruent,
and th ligaments are maximally taut.

Chapter 1

pressioni application of one or more forces that press


n object or objects together. Compression tends to
morten and widen a material.
ttcentric activation: activated muscle that shortens as it
produces a force.
:ep: a progressive strain of a material when exposed to a
Constant load over lime,
i- grees of freedom: number of independent movements
\ allowed at a joint. A joint can have up to three degrees of
| translation and three degrees of rotation.
Desplacement: change in th linear or angular position of an
f object.
- stal-on-proximal segment kinematics: type of movement
in which th distai segment of a joint rotates relative to a
fixed proximal segment falso called an open kinematic
' chain).
Enstraction: movement of two objects away from one another.
Eicentric activation: activated muscle that is elongating as it
produces a force.
Elasticity: property of a material demonstrated by its ability
to return to its originai length after th removai of a
deforming force.
Esternai force: push or pul produced by sources located
outside th body. These typically include gravity and
physical contact applied against th body.
Esternai moment arm: distance between th axis of ro
tation and th perpendicular intersection with an extemal
force.
Extemal torque: product of an extemal force and its external moment arm falso called extemal moment).
Force: a push or a pul that produces, arrests, or modifies a
motion.
Force-couple: interaction of two or more muscles acting in
different linear directions, bui producing a torque in th
same rotary direction.
Force of gravity: potential acceleration of a body to th
center of th earth due to gravity.
Friction: resistance to movement between two contacting
surfaces.
Internai force: push or pul produced by a strutture located
within th body. Most often internai force refers to that
produced by an attive muscle.
Internai moment arm: distance between th axis of rotation
and th perpendicular intersection with a muscle (inter
nai) force.
Internai torque: product of an internai force and its internai
moment arm.
Isometric activation: activated muscle that maintains a Con
stant length as it produces a force.
Joint reaction force: push or pul produced by one joint
surface against another.
Kinematics: branch of mechanics that describes th motion
of a body, without regard to th forces or torques that
may produce th motion.
Kinematic chain: series of articulated segmented links, such
as th connected pelvis, thigh, leg, and foot of th lower
extremity.
Kinetics: branch of mechanics that describes th effect of
forces on th body.
Leverage: relative moment arm length possessed by a particular force.

Getting Storteci

23

Line-of-force: direction of a muscles force.


Line-of-gravity: direction of th gravitational pul on a
body.

Load: generai term that describes th application of a force


to a body.

Longitudinal axis: axis that extends within and parallel to a


long bone or body segment.

Loose-packed positions: positions of most joints of th


body where th articular surfaces are least congment, and
th ligaments are slackened.
Mass: quantity of matter in an object.
Mechanical advantage: ratio of th internai moment arm to
th extemal moment arm.
Muscle action: potential of a muscle to produce an internai
torque within a particular piane of motion and rotar)'
direction falso called joint action when referring specifi
cali)' to a muscles potential to rotate a joint). Terms that
describe a muscle action are flexion, extension, pronation,
supination, and so forth.
Osteokinematics: motion of bones relative to th three Car
dinal, or principal, planes.
Passive force: push or pul generated by sources other than
stimulated muscle, such as tension in stretched periarticular connettive tissues, physical contact, and so forth.
Passive movement: motion produced by a source other
than activated muscle.
Plasticity: property of a material demonstrated by remaining
permanently defotmed after th removai of a force.
Pressure: force divided by a surface area falso called stress).
Produttive antagonismi phenomenon in which relatively
low-level tension within stretched connettive tissues performs a useful function.
Proximal-on-distal segment kinematics: type of movement
in which th proximal segment of a joint rotates relative
to a fixed distai segment falso referred to as a closed
kinematic chain).
Rolli multiple points along one rotating articular surface
contact multiple points on another articular surface. (Also
called rock.)
Rotation: angular motion in which a rigid body moves in a
circular path about a pivot point or an axis of rotation.
Scalar: quantity, such as speed and temperature, that is
completely specified by its magnitude and has no direc
tion.
Segment: any pari of a body or limb.
Shear: forces on a material that act in opposite but parallel
directions (like th action of a pair of scissors).
Shock absorption: ability to dissipate forces.
Slide: single point on one articular surface contacts multiple
points on another articular surface. (Also called glide.)
Spini single point on one articular surface rotates on a single
point on another articular surface flike a toy top).
Static linear equilibrium: state of a body at rest in which
th sum of all forces is equal to zero.
Static rotary equilibrium: state of a body at rest in which
th sum of all torques is equal to zero.
Stiffness: ratio of stress (force) to strain (elongation) within
an elastic material.
Strain: ratio of a tissues deformed length to its originai
length.

24

Section 1

Essentia Topics o f Kinesiology

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

of kinesiology are provided. Chapters 2 to 4 give additional


background on th essentia topics of kinesiology. This
material then sets th foundation for th more anatomicbased chapters, starting with th shoulder complex in Chapter 5.

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

Basic Structure and Function


of th Joints
A. J oseph T h r elk eld , PT, P h D

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.

CLASSIFICATION AND DESCRIPTION OF


JOINTS______________ ____________________
Classification Based on Anatomie Structure
and Movement Potential
One common method to classify joints focuses primarily on
anatomie structure and their subsequent movement potential

Dense Irregular Connective Tissue, 32


Articular Cartilage, 34
Fibrocartiiage, 35
Bone, 36
EFFECTS OF AGING, 37
EFFECTS OF IMMOBILIZATION ON THE
STRENGTH OF THE CONNECTIVE TISSUES
OF A JOINT, 37
JOINT PATHOLOGY, 38

(Table 2 - 1 ) . 27 Based on this scheme, three types of joints


exist in th body and are defined as synarthrosis, am phiar
throsis, and diarthrosis.

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

Essential Topics q f Kinesiology

E 2 - 1. Classifieation of Joints Basiti on Anatomie Structure and Movement Potential


Joint Material

Available Motion

Primary Funclion

Examples

Synarthrosis

Dense, irregular connective


tissue

Negligible

Binds bones within a


functional unit; dis
perses forces across th
joined bones

Sutures of th skull
Teeth embedded in sockets of
th maxillae and mandible
Interosseous membrane of th
forearm and leg
Distai tibiofibular joint

Amphiarthrosis

Hyaline cartilage or fibrocartilage

Minimal to moderate

Provides a combination of
relatively restrained
movement and shock
absorption

Intervertebral disc (within th


interbody joints of th
spine)
Xiphistemal joint
Pubic symphysis
Manubriosternal joint

Diarthrosis
(synovial joint)

Trae joint space filled


with synovial fluid and
surrounded by a cap
sule

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.

DiARTHROSIS: THE SVNOVIAL JOINT


A diarthrosis is an articulation that contains a fluid-filled
joint cavity between bony partners. Because of th presence
of a synovial membrane, diarthrodial joints are more frequently referred to as synovial joints. Synovial joints are th
majority of th joints of th upper and lower extremities.
Diarthrodial, or synovial, joints are specialized for move
ment and always exhibit seven elements (Fig. 2 - 1 ) . The
joint cavity is filled with (1) synovial fluid. This provides
nutrition and lubrication for th (2) articular cartilage that
covers th ends of th bones. The joint is enclosed by a
peripheral curtain of connective tissue that forms th (3)

Elements ALWAYS associateci with


diarthrodial (synovial) joints.
Synovial fluid
Articular cartilage
Articular capsule
Synovial membrane
Capsular ligaments
Blood vessels
Sensory nerves
Elements SOMETIMES associated with
diarthrodial (synovial) joints.
Intraarticular discs or menisci
Peripheral labrum
Fat pads
Synovial plicae

articular capsule. The articular capsule is composed of two


histologically distinct layers. The internai layer consists of a
thin (4) synovial membrane, which averages three to ten celi
layers thick. The membrane acts as a barrier to adjacent
capillaries, permitting only th fluid and solutes of blood
plasma into th synovial fluid of a normal joint. Blood cells
and large proteins, such as antibodies, are normally excluded
from th synovial space. The cells of th synovial membrane
also manufacture and add hyaluronate and lubricating glycoproteins (i.e., lubricin) to th joint fluid.26
The external, or fibrous, layer of th articular capsule of
th synovial joint is composed of dense irregular connective
tissue. The articular capsule provides support between th
bones and containment of th joint contents. Certain regions
of th fibrous capsule are thicker in order to resist or control
specific motions. The thickened regions of connective tissue
represent (5) capsular ligaments. Examples of prominent capsular ligaments are th anterior glenohumeral ligaments and
th mediai collateral ligament of th knee. The joint capsule
is supplied with small (6) blood vessels with capillary beds

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

that penetrate as far as th junction of th fbrous capsule


and synovial membrane. The (7) sensory nerves also supply
th fbrous capsule with appropriate receptors for pain and
proprioception.
To accommodate th wide spectrum of joint shapes and
iunctional demands, other elements may sometimes appear
in synovial joints (see Fig. 2 - 1 ) . Inttaarticular discs, or
nenisci, are pads of fibrocartilage imposed between th articular surfaces of synovial joints. These structures increase
articular congruency and improve force dispersion. Intraarucular discs and menisci are found in several joints of th
:ody (see Box). Menisci are occasionally found in th
apophyseal joints of th spine, but their function, constancy,
and frequency remain controversial.1-8-29-30

27

size and positioned within th substance of th joint capsule,


interposed between th fbrous capsule and th synovial
membrane. Fat pads are most prominent in th elbow and
th knee joints. They thicken th joint capsule, causing th
inner surface of th capsule to fili nonarticulating synovial
spaces (i.e., recesses) formed by incongruent bony contours.
In this sense, fat pads reduce th volume of synovial fluid
necessary for proper joint function. If these pads become
enlarged or inflamed, they may alter th mechanics of th
joint.
Synovial plicae (i.e., synovial folds, synovial redundancies,
or synovial fringes) are slack, overlapped pleats of tissue
composed of th innermost layers of th joint capsule. They
occur normally in joints with large capsular surface areas
such as th knee and elbow. Plicae increase synovial surface
area and allow full joint motion without undue tension on
th synovial lining. If these folds are too extensive or be
come thickened or adherent due to inflammation, they can
produce pain and altered joint mechanics.3-415

Intraarticular Discs (Menisci) Are Found in Several


Synovial Joints of th Body
Tibiofemoral (knee)
Distai radioulnar
Stemoclavicular
Acromioclavicular
Temporomandibular

Classification of Synovial Joints Based on


Mechanical Analogy
Thus far, joints have been classified into three broad categories according to th anatomie structure and subsequent
movement potential: synarthrosis, amphiarthrosis, and diarthrosis. Because an in-depth understanding of synovial joints
is so cruciai to an understanding of th mechanics of move
ment, they are here further classified using an analogy to
familiar mechanical objects or shapes (Table 2 - 2 ) .

Two large synovial joints of th body possess a peripheral


labrum of fibrocartilage. The labrum extends from th bony
nms of both th glenoid cavity of th shoulder and th
acetabulum of th hip. These specialized structures deepen
th concave member of these joints and supporr and thicken
th attachment of th joint capsule. Fat pads are variable in

Basic Structure and Function o j th Joints

TAB LE 2 - 2 . Classification of Synovial Joints by Analogy


Primary Angular Motions

Mechanical Analog

Anatomie Examples

Hinge joint

Flexion and extension only

Door hinge

Humeroulnar joint
Interphalangeal joint

Pivot joint

Spinning of one member around a sin


gle axis of rotation

Door knob

Proximal radioulnar joint


Atlantoaxial joint

Ellipsoid joint

Biplanar motion (flexion-and-extension


and abduction-and-adduction)

Flattened convex ellipsoid


paired with a concave
trough.

Radiocarpal joint

Ball-and-socket joint

Triplanar motion (flexion-and-extension,


abduction-and-adduction, and internal-and-external rotation)

Spherical convex surface paired


with a concave cup.

Glenohumeral joint
Coxofemoral (hip) joint

Piane joint

Typical motions include a slide (translation) or a combined slide and rota


tion.

Relatively fiat surfaces apposing


one another, like a book on
a table.

Intercarpal joints
Iniertarsal joints

Saddle joint

Biplanar motion; a spin between th


bones is possible bui may be limited
by th interlocking nature of th
joint.

Each member has a reciprocaily


curved concave and convex
surface oriented at right angles to one another, like a
borse rider and a saddle.

Carpometacarpal joint of th thumb


Stemoclavicular joint

Condyloid joint

Biplanar motion; either flexion-andextension and abduction-andadduction, or flexion-and-extension


and axial rotation (intemaland-extemal rotation)

Mosily spherical convex surface


that is enlarged in one dimension like a knuckle;
paired with a shallow con
cave cup.

Metacarpophalangeal joint
Tibiofemoral (knee) joint

28

Section I

Essential Topics o f Kinesiology

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.

A hinge joint is analogous to th hinge of a door, formed


by a centrai pin surrounded by a larger hollow cylinder (Fig.
2 -2 A ). Angular motion at hinge joints occurs primarily in a
piane located at right angles to th hinge, or axis of rotation.
The humeroulnar joint is a clear example of a hinge joint
(Fig. 2 - 2 B). As in all synovial joints, slight translation (i.e.,
sliding) is allowed in addition to th rotation. Although th
mechanical similarity is less complete, th interphalangeal
joints of th digits are also classified as hinge joints.
A pivot joint is formed by a centrai pin surrounded by a
larger cylinder. Unlike a hinge, th mobile member of a
pivot joint is oriented parallel to th axis of rotation. This
mechanical orientation produces th primary angular motion
of spin, similar to a doorknobs spin around a centrai axis
(Fig. 2 -3 A ). Two excellent examples of pivot joints are th
proximal radioulnar joint, shown in Figure 2 - 3 B, and th
atlantoaxial joint between th dens of th second cervical
vertebra and th anterior arch of th first cervical vertebra.
An ellipsoid joint has one partner with a convex elongated
surface in one dimension that is mated with a similarly
elongated concave surface on th second partner (Fig.
2 -4 A ). The elliptic mating surfaces severely restrict th spin
between th two surfaces but allow biplanar motions, usually
deftned as flexion-extension and abduciion-adduction. The

FIGURE 2-3. A pivot joint (A) is shown as analogous to th proxi


mal radioulnar joint (B). The axis of rotation is represented by th
pin.

radiocarpal joint is an example of an ellipsoid joint (Fig.


2 -4 B ). The flattened ball of th convex member of th
joint (i.e., carpai bones) cannot spin within th elongated
trough (i.e., distai radius) withoul dislocating.
A ball-and-socket joint has a spherical convex surface that
is paired with a cuplike socket (Fig. 2 -5 A ). This joint provides motion in three planes. Unlike th ellipsoid joint, th
symmetry of th curves of th two mating surfaces of th
ball-and-socket joint allows spin without dislocation. Balland-socket joints within th body include th glenohumeral
joint and th hip joint.
A piane joint is th pairing of two fiat or relatively fiat
surfaces. Movements combine sliding and some rotation of
one partner with respect to th other much like a book
can be slid over a tabletop (Fig. 2 -6 A ). As depicted in
Figure 2 - 6 B, most of th intercarpal joints are considered to
be piane joints. The internai forces that cause or restrict
movement between carpai bones are supplied by tension in
muscles or ligaments.
Each partner of a saddle joint has two surfaces: one sur
face is concave, and th other is convex. These surfaces are
oriented at approximate right angles to one another and are
reciprocali)' curved. The shape of a saddle joint is best visualized using th analogy of a horses saddle and rider (Fig.
2 -7 A ). From front to back, th saddle presents a concave
surface reaching from th saddle horn to th back of th
saddle. From side to side, th saddle is convex stretching
from one stirrup across th back of th horse to th other
stirrup. The rider is also doubly curved, presenting convex
and concave curves to complement th shape of th saddle.
The carpometacarpal joint of th thumb is th clearest exam
ple of a saddle joint (Fig. 2 - 7 B). The reciprocai, interlocking
nature of this joint allows ampie biplanar motion, but limited spin between th trapezium and th first metacarpal.
A condyloid joint is much like a ball-and-socket joint except that th concave member of th joint is very shallow
(Fig. 2 -8 A ). Condyloid joints usually allow 2 degrees of
freedom. Ligaments or bony incongruity restrains th third
degree. Condyloid joints often occur in pairs, such as th
knee (Fig. 2 - 8 B ) , th temporomandibular joints, and th
atlantooccipital joints (i.e., occipital condyles with th first
cervical vertebra). The metacarpophalangeal joint of th fin
ger is also an example of a condyloid joint. The root word
of th term condyle actually means knuckle.

Chapter 2

Basic Stmcture and Function o f th Joints

29

Ulna

Radius

FIGURE 2-4. An ellipsoid joint (A) is shown as analo


gous to th radiocarpal joint (wrist) (B). The two axes
of rotation are shown by th interseeting ptns.

Lunate

Scaphoid

FIGURE 2-5. A ball-in-socket articulalion (A) is drawn as analogous to th


hip joint (B). The three axes of rota
tion are represented by th three intersecting pins.

FIGURE 2-6. A piane joint is formed


by opposition of two fiat surfaces (A).
The hook moving on th table top is
depieted as analogous to th combined
slide and spin at th fourth and fifth
carpometacarpal joints (B).

30

Section 1

Essential Topics o j Kinesiology

FIGURE 2-7. A saddle joint (A) is illustrated as analogous

to th carpometacarpal joint of th thumb (B). The saddle


in A represents th trapezium bone. The "rider, if
present, would represent th base of th thumb's metacarpal. The two axes of rotation are shown in B.

The kinematics at condyloid joints vary based on joint


structure. At th knee, for example, th femoral condyles fu
wtthin th slight concavity provtded by th ttbial plateau.
This articulation allows flexion-extension and axial rotation
(i.e., spin). Abduction and adduction, however, are restricted
primarily by ligaments.

Simplifying th Classification of Synovial


Joints: Ovoid and Saddle Joints
lt is often difficult to classify synovial joints based on an
analogy to mechanics alone. The metacarpophaiangeal joint
(condyloid) and th glenohumeral joint (ball-and-socket), for
example, have similar shapes but differ considerably in th
relative magnitudo of movement and overall function. Joints
always display subtle variations that make simple mechanical
descriptions less applicable. A good example of th differ
ente between mechanical classification and true function is

FIGURE 2 8. A condyloid joint is shown (A) representing an anal


ogy to th tibiofemoral (knee) joint (B). The two axes of rotation
are shown by th pins. The frontal piane motion at th knee is
blocked by tension in th collateral ligament.

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.

FIGURE 2-9. Two basic shapes of joint surfaces. A, The egg-shaped


ovoid surface represents a characteristic of most synovial joints of
th body (for example, hip joint, radiocarpal joint, knee joint,
metacarpophaiangeal joint). The diagram shows only th convex
member of th joint. A reciprocally shaped concave member would
complete th pam of ovoid articulating surfaces. B, The saddle surface is th second basic type of joint surface, having one convex
surlace and one concave surface. The paired articulating surface of
th other half of th joint would be turned so that a cncave
surface is mated to a convex surface of th partner.

Chapter 2

Basic Structure and Functicm o j th Joints

31

AXIS OF ROTATION

Fibers

In th analogy using a door hinge (see Fig. 2 -2 A ), th axis


of rotation (i.e., th pin through th hinge) is fixed, because
it remains stationary throughout th rotation of th door.
With th axis of rotation fixed, all points on th door experience equal arcs of rotation. In anatomie joints, however,
th axis of rotation is rarely, if ever, fixed during bony
rotation. Finding th exact position of th axis of rotation in
anatomie joints is therefore not as obvious. A simplified
method of estimating th position of th axis of rotation in
anatomie joints is shown in Figure 2 -1 0 A . The intersection
of th two perpendicular lines drawn from a-a' and b-b'
defines th instantaneous axis o f rotation for th 90-degree are
of knee flexion. The term instantaneous indicates that th
location of th axis holds true only for th particular are of
motion. The smaller th angular range used to calculate th
instantaneous axis, th more accurate th estimate. If a series
of line drawings are made for a sequence of small angular
arcs of motion, th location of th instantaneous axes can
be plotted for each portion within th are of motion (Fig.
2 -1 0 B ). The path of th serial locations of th instantaneous
axes of rotation is called th evolute. The path of th evolute
is longer and more complex when th mating joint surfaces
are less congruent or have greater changes in their radii of
curvature, such as th knee. The smaller th individuai arcs
used for calculation, th more accurate is th resulting evo
lute.
In many practical clinical situations it is necessary to
make simple estimates of th location of th axis of rotation
of a joint. These estimates are necessary when performing
goniometry, measuring torque about a joint, or when constructing a prosthesis or an orthosis. A series of x-ray measurements are required to precisely identify th instanta
neous axis of rotation at a joint. This method is not practical
in ordinar)' clinical situations. Instead, an average axis of
rotation is assumed to occur throughout th entire are of
motion. This axis is located by an anatomie landmark that
coincides with th convex member of th joint.

Various types of collagen fibers and elastic fibers occur in


joints. Collagen fibers are made of short subunits (fibrils),
which are wound in a helical structure much like short
threads. These threads are placed together in a strand, several of which are spirally wound into a rope. Twelve colla
gen types have been described,27 but two types make up th

BIOLOGIC MATERIALS THAT FORM


CONNECTIVE TISSUES WITHIN JOINTS
The composition, proportion, and arrangement of biologie
materials that compose th connective tissue within joints
strongly influence their mechanical performance. The fundamental materials that make up th connective tissues of a
joint are fibers, ground substance, and cells. These biologie
materials are blended in various proportions based on th
mechanical demands of th joint.

Biologie Materials That Form th Connective Tissues


within Joints
1. Fibers
Collagen (types I and li)
Elastin
2. Ground substance
Glycosaminoglycans
Water
Solutes
3. Cells

FIGURE 2-10. A simplified method for determining th instanta


neous axis of rotation for 90 degrees of knee flexion (A). With th
use of x-ray, two points (a and b) are identified on th tibial
plateau. With th position of th femur held stationary, th same
two points are identified following 90 degrees of flexion (a' and
b')- Next, two perpendicular lines are drawn from a-a' and b-b'.
The point of intersection of these two perpendicular lines identifies
th instantaneous axis of rotation for th 90-degree are of motion.
This same method can be repeated for many smaller arcs of mo
tion, producing several slightly different axes of rotation (B). The
path of th migrating axes is called th evolute. At th knee, th
average axis of rotation is oriented in th medial-lateral direction,
piercing th lateral epicondyle of th femur.

32

Section I

Essentia Topics o f Kinesiology

majority of collagen in normal joints type 1 and type II.


Type I collagen fibers are thick, rugged fibers that are gathered into bundles and elongate very little when placed under
tension. Being relatively stiff, type 1 collagen fibers are ideal
for binding and supporting th articulations between bones.
Type 1 collagen is therefore th primary protein found in
ligaments, fascia and fibrous joint capsules. This type of
collagen also makes up th parallel fibrous bundles that
compose tendons th structures that transmit th force of
muscle to bone.

Two Predominant Types of Collagen Fibers in Normal


Joints

Type I: thick, rugged fibers that elongate very little when


stretched; compose ligaments, tendons, fascia, and fibrous
capsules.
Type II: thinner and less stiff than type I fibers; provide a
flexible woven framework for maintaining th generai
shape and consistency of structures such as hyaline cartilage.

Type II collagen fibers are thinner than type 1 and possess


slightly less tensile strength. These fibers provide a flexible
woven framework for maintaining th generai shape and
consistency of more complex structures, such as hyaline cartilage. Type II collagen stili provides internai strength to th
tissue in which it resides.
in addition to collagen, th connective tissues within
joints have varying amounts of elastin fibers. These fibers are
composed of a netlike interweaving of small elastin fibrils
that resist tensile (stretching) forces, bui they have more
give when elongated. Tissues with a high proportion of
elastin readily return to their originai shape after being deformed. This property is useful in structures that undergo
significant deformation, such as th cartilage of th ear, or in
certain spinai ligaments that help return a bone to its origi
nai posinoti after movement.

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.

AGGREGATE IN COLLAGEN MESHWORK


FIGURE 2-11. Schematic drawing of th molecular organization of
cartilage. A glycosaminoglycan (GAG) molecule is formed by a
hyaluronic acid center thread to which proteoglycan monomers are
attached, forming a botile brush configuration. The GAG molecule
is shown interlacing between collagen fibrils. Water fills much of
th space within th matrix. (From Nordin M, Frankel VH: Basic
Biomechanics of th Musculoskeletal System, 2nd ed. Philadelphia,
Williams & Wilkins, 1989.)

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.

TYPES OF CONNECTIVE TISSUES THAT


FORM THE STRUCTURE OF JOINTS
Four types of connective tissues predominale in joints; dense
ir regalar connective tissue, articular cartilage, Jbrocartilage, and
bone. Anatomie and functional details of th four connective
tissues are listed in Table 2 - 3 . The table also includes clinical correlates associated with each tissue.

Dense Irregular Connective Tissue


Dense irregular connective tissue is found in th fibrous external layer of th articular capsule, ligaments, fascia, and ten
dons. Structurally, this connective tissue has a high propor
tion of type I collagen fibers that are arranged in bundles
and aligned to resist th naturai stresses placed on th tissue.
The connective tissue bundles function most effectively when
they are stretched parallel to their long axis. After th initial

Chapter 2

Basic Structure and Functon o f th Joints

TABLE 2 - 3 . Types of Connective Tissues that Form th Structure of Join ts

Anatomie
Location

Fibers

Ground Substance
(GAGs + Water +
Solutes)

Cells

Mechanieal
Specialization

Clinical
Correlate

Dense irregular
connective tis
sue

Composes th extemal fibrous


layer of th
joint capsule
Forms ligaments.
fascia, and
tendons

High type 1 collagen fiber conLem


Most tissues have
low elastin fi
ber coment
Parallel fibers are
arranged in
bundles orienled in sev
eral directions

Low ground substance


coment

Sparsely located cells


tightly packed between fibers

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

High type il collagen fiber


coment; fibers
help anchor
cartilage to
subchondral
bone and restrain th
ground sub
stance.

High ground sub


stance coment

Moderate number of
cells; flattened
near th articular
surface and
rounded in
deeper layers of
th cartilage

Resists and distributes compressive


forces (joint loading) and shear
forces (surface
sliding); very low
coefficient of friction

During early stage


of osteoarthritis, GAGs are
released from
deep in th
tissue, reducing
th force distribulion capability; adjacent
bone thickens
to absorb th
increased force,
often causing
th formation
of osteophytes
(bone spurs).

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 ground sub


stance coment

Moderate number of
cells that are
rounded and
dwell in cellular
lacunae

Provides some suppon and stabilzation lo joints;


primary function
is to provide
shock absorption by resisting
and distributmg
compressive and
shear forces

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)

Low GAG coment

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

Essential Topici o j Kinesiology

slack is pulled tight, th ligaments and joint capsule provide


immediate tension that restrains undesirable motion between
bony partners.
The ftbrous joint capsule and ligaments resist forces from
severa! directions. To accomplish this, th fiber bundles
within th connective tissues are arranged in several dominant directions, unlike th parallel alignment of collagen
bundles found in a tendon (Fig. 2 12).6 20 The GAGs and
elastin fiber content are usually low in dense irregular con
nective tissue.
When trauma or disease produces laxity in th ligament
or capsules, muscles take on a more dominant role in restraining joint movement. Even if muscles surrounding a
ligamentously lax joint are strong, there is loss of joint stability. Compared with ligaments, muscles are slower to
supply force due to th electromechanical delay necessary to build active force. Muscle forces often have a less
than ideal alignment for restraining undesirable joint movements, and they often cannot provide th most optimal deterrent force.

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

repair underlying tissue. This is an advantage not available


to articular cartilage.
Chondrocytes of various shapes are located within th
ground substance of different layers or zones of articular
cartilage (Fig. 2 -1 3 A ). These cells are bathed and nourished
by nutrients within th synovial fluid. Nourishment is facilitated by th "milking action of articular surface deformation
during intermittent joint loading. The chondrocytes are surrounded by predominantly type II collagen fibers. As depicted in Figure 2 - 1 3 B , th fibers are arranged to form a
restraining network or scaffolding that adds structural stability to th tissue. The deepest fibers in th calcified zone
are firmly anchored to th subchondral bone. These fibers
are linked to th vertically oriented fibers in th adjacent
deep zone which, in tum, are linked to th obliquely ori
ented fibers of th middle zone, and finally to th transversely oriented fibers of th superficial tangential zone. The
series of chemically interlinked fibers form a netlike fibrous
structure that entraps th large GAG molecules beneath th
articular surface. The GAGs in tum attract water that provides a unique element of rigidity to articular cartilage. The
rigidity increases th ability of cartilage to adequately withstand loads.
Articular cartilage distributes and disperses compressive
torces to th subchondral bone. It also reduces friction be
tween joint surfaces. The coefficient of friction between two
surfaces covered by articular cartilage and wet with synovial
fluid is extremely low, ranging from 0.005 to 0.02 in th
human knee for example. This is 5 to 20 times lower and
more slippery than ice on ice, which has a coefficient of 0 .1 .17
The impaci of normal weight-bearing activities, therefore, is
reduced to a stress that typically can be absorbed without
damaging th skeletal System.
The absence of a perichondrium on articular cartilage has
th negative consequence of eliminating a ready source of
primitive perichondrial fibroblastic cells used for repair. Even

Parallel bundles
of collagen
Irregularly arranged bundles
of collagen fibers

Fibrocytes

TENDO N
L IG A M E N T

FIGURE 2-12. Diagrammane representation of th fibrous organization of


tendons and ligaments. A, The bun
dles of collagen in a tendon are lightly
packed and arranged parallel to one
another. The arrangement allows Lhe
tendon to iransmit unidirectional ten
sile forces from a muscle without having to take up slack in th bundles.
The cells that maintain this connective
tissue (fibrocytes) are few in number
and flattened between th collagen
bundles. B, A ligament has collagen
bundles that are less parallel to one
another. This allows th ligament to
accept tensile forces from several dif
ferent directions while holding two
bones together. Bundles may be organized parallel to th most common
lines of tension. The fibrocytes of th
ligament are not shown in this drawing but are few in number and flat
tened.

Chapter 2

Basic Structure and Functon o j th Joints

35

Articular surface
STZ

10 20

( % %)
Middle zone

(40%
60%)

-------------- Deep zone -

(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

organized and contains small blood vessels located only near


th peripheral rim of th tissue. Fibrocartilage is largely
aneural and thus does noi produce pain or participate in
proprioception, although a few neural receptors may be
found at th periphery where fibrocartilage abuts a ligament
or joint capsule.
The nourishmenl of adult fibrocartilage is largely dependent on diffusion of nutrients through th synovial fluid in
synovial joints. In amphiarthrodial joints, such as th adult
intervertebral disc, nutrients are diffused across th fluid
contained in th adjacent trabecular bone. The diffusion of
nutrients and removai of metabolic wastes in th fibrocarti
lage of amphiarthrodial joints is assisted by th milking"
action of intermittent weight hearing.13 This principle is
readily apparent in adult intervertebral discs that are insuffi
cienti)' nourished when th spine is held in fixed postures
for extended periods. Without proper nutrition, th discs
may partially degenerate and lose part of their protective
function.
A direct blood supply penetrates th outer rim of fibrocartilaginous structures where they attach to ligaments (e.g.,
th spine) or to joint capsules (e.g., th knee). In adult
joints, some repair of damaged fibrocartilage can occur near
th vascularized periphery', such as th outer one third of
menisci of th knee and th outermost lamellae of interverte
bral discs. The innermost regions of fibrocartilage structures,
much like articular cartilage, demonstrate poor or negligible
healing owing to th lack of a ready source of undifferentiated fibroblastic cells.13-2123

36

Section 1

Essentia Topics o j Kinesiology

COMPRESSION

periosteal and th inner endosteal surfaces. The vessels can


then tum to travel along th long axis of th bone in a
tunnel at th center of th haversian canals. The connective
tissue of th periosteum and endosteum are richly vascularized and are innervated with sensory receptors for pressure
and pain.
Bone is a very dynamic tissue. Remodeling constantly
occurs in response to forces applied through physical activity
and in response to hormonal influences that regulate systemic calcium balance. The large scale removai of bone is
carried out by osteoclasts specialized cells that originate
from th bone marrow. Primitive fbroblasts for bone repair
originate trom th periosteum and endosteum and from th
perivascular tissues that are woven throughout th vascular
canals of bone. Of th tissues involved with joints, bone has
by far th best capacity for remodeling, repair, and regenera
tion.
Bone demonstrates its greatest strength when compressed
along th long axis of its shaft, which is comparable to
loading a straw along its long axis. The ends of long bones
receive multidirectional compressive forces through th
weight-bearing surfaces of articular cartilage. Stresses are
spread to th subjacent subchondral bone and then into th

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

FIGURE 215. A cross-section showing th internai architecture of


th proximal femur. Note th thicker areas of compaci bone around
th shaft and th lattice-like cancellous bone occupying most of th
medullary region. (From Neumann DA: An Arthritis Home Study
Course: The Synovial Joint: Anatomy, Function, and Dysfunction.
The Orthopedic Section of th American Physical Therapy Association. La Crosse, WI, 1998.)

Chapter 2

37

Basic Structure and Function o f th )oints

Outer circumferentiol
lamellae
Interstitiol
lomellae^,

Inner
circumferentiol
lamelloe---------

Haversian systems
(osteons)
Periosteum

FIGURE 2-16. Histologic organization of cortical bone.


(From Fawcett DW: A Textbook of Flistology, 12th ed.
New York, Chapman & Hall. Redrawn after Benninghoff
A: Lehrbuch der Anatomie des Menschen. Berlin, Urban
and Schwarzenberg, 1994.)

Trobeculoe
of cancellous
bone

Blood vessels

Sharpey's
fibers

Endosteum
Hoversion
canals

Volkmanns
canols

network of cancellous bone, which in tum acts as a series of


struts to redirect th forces into th long axis of th cortical
bone of th shaft. This structural arrangement redirects
forces for absorption and transmission by taking advantage
of bones unique architectural design.

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

lower compressive strength. The dryer connective tissues do


not slide across one another as easily. As a result, th bundles of fibers in ligaments do not align themselves with th
imposed forces as readily, hampering th ability of th tissue
to maximally resist a rapidly applied force. The likelihood of
adhesions forming between previously mobile tissue planes is
increased; thus, aging joints may lose range of motion more
quickly than younger joints. Aged articular cartilage contains
less water and is less able to attenuate and distribute im
posed forces to th adjacent bone.
The age-related alteration of connective tissue metabolism
in bone contributes to th slower healing of fractures. The
altered metabolism also contributes io osteoporosis, particularly type II or senile osteoporosis a type that thins both
trabecular and cortical bone in both genders.9

EFFECTS OF IMMOBILIZATION ON THE


STRENGTH OF THE CONNECTIVE TISSUES
OF A JOINT
The amount and arrangement of fibers and GAGs in connec
tive tissues are influenced by physical activity. At a normal
level of physical activity, th connective tissues are able to
adequately resist th naturai range of forces imposed on th
musculoskeletal System. A joint immobilized for an extended
period demonstrates marked changes in th structure and
function of its associated connective tissues. The mechanical
strength o f th tissue is reduced in accord with th de
creased forces of th immobilized condition. This is a nor
mal response to an abnormal condition. Placing a body part

38

Secion I

Essential Topics o j Kinesiology

in a cast and confining a person to a bed are examples in


which immobilization dramatically reduces th level of force
imposed on th musculoskeletal System. Although for different reasons, muscular paralysis or weakness also reduces th
force on th musculoskeletal System.
The rate of decline in th strength of connective tissue is
somewhat dependent on th normal metabolic activity of
th specifc tissue. Immobilization produces a marked decrease in tensile strength of th ligamenis of th knee, for
example, in a period of weeks.19-28 The earliest biochemical markers of this remodeling can be detected within days
after immobilization.12-18 Even after th cessation of th im
mobilization and after th completion of an extended postimmobilization exercise program, th ligaments continue to
have lower tensile strength than ligaments that were never
subjected to immobilization.12-28 Other tissues such as
bone and cartilage also show a loss of mass, volume, and
strength following immobilization.14-24 The results from experimental studies imply that tissues rapidly lose strength in
response to reduced loading. Full recovery of strength fol
lowing restoration of loading is much slower and often in
complete.
Immobilizing a joint for an extended period is often necessary to promote healing following an injury such as a
fractured bone. Clinical judgment is required to balance th
potential negative effects of th immobilization with th need
to promote healing. The maintenance of maximal tissue
strength around joints requires judicious use of immobiliza
tion, a quick return to loading, and early rehabilitative intervention.

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

depends on th proximity and adequacy of a blood supply.


A tear of th outermost region of th meniscus of th knee
adjacent to blood vessels embedded with th capsule may
compleiely heal.21-23 In contrast, tears of th innermost circumference of a meniscus do not typically heal completely.
This is also th case in th inner lamellae of th adult
intervertebral disc that does not have th capacity to heal
following significant damage.13
Chronic trauma is often classified as a type of overuse
syndrome and reflects an accumulation of unrepaired, relatively minor damage. Chronically damaged joint capsules
and ligaments gradually lose their restraining functions, al
though th instability of th joint may be masked by a
muscular restraint substitute. In this case, joint forces may
be increased owing io an exaggerated muscular guarding of
th joint. Only when th joint is challenged suddenly or
forced by an extreme movement does th instability become
readily apparent.
Recurring instability may cause abnormal loading conditions on th joint tissues, which can lead to their mechanical
failure. The surfaces of articular cartilage and fibrocartilage
may become fragmented with a concurrent loss of GAGs and
subsequent lowered resistance to compressive and shear
forces. Early stages of degeneration often demonstrate a
roughened or fibrillated surface of th articular cartilage
(Fig. 2 - 1 7 ) . A fibrillated region of articular cartilage may
later develop cracks, or clefts, that extend from th surface
into th middle or deepest layers of th tissue. These
changes may reduce th shock absorption quality of th
tissue.
Two disease States that commonly cause joint dysfunction
are osteoarthritis (OA) and rheumatoid arthritis (RA). Osteo
arthritis is characterized by a graduai erosion of articular
cartilage with a low inflammatory component.7 Some refer to
OA as "osteoarthrosis to emphasize th lack of a distinctive
inflammatory component. As erosion of articular cartilage
progresses, th underlying subchondral bone becomes more
mineralized and, in severe cases, becomes th weight-bearing
surface when th articular cartilage pad is completely wom.
The fibrous joint capsule and synovium become distended
and thickened. The severely involved joint may be com
pletely unstable and dislocate or may fuse allowing no mo
tion.
The frequency of OA increases with age and has several
manilestations. Idiopathic OA occurs in th absence of a specific cause; it affects only one or a few joints, particularly
those that are subjected to th highest weight-bearing loads:
hip, knee, and lumbar spine. Familial OA or generalized OA
affects joints of th hand and is more frequent in women.
Post-traumatic OA may affect any synovial joint that has been
exposed to a trauma of sufficient severity.
Rheumatoid arthritis differs markedly from OA, as it is a
systemic, autoimmune connective tissue disorder with a
strong inflammatory component.10 The destruction of multi
ple joints is a prominent manifestation of RA. The joint
dysfunction is manifested by significant inflammation of th
capsule, synovium, and synovial fluid. The articular cartilage
is exposed io an enzymatic process that can rapidly erode
th articular surface. The joint capsule is distended by th
recurrent swelling and inflammation, often causing marked
joint instability and pain.

Chapter 2

Basic Strutture and Function o j th Joints

39

faces. The axis of rotation is often estimated for purposes of


clinical measurement.
The function and resilience of joints are determined by
th architecture and th types of tissues that make up th
joints. The ability to repair damaged joint tissues is strongly
related to th presence of a direct blood supply and th
availability of progenitor cells. The health and longevity of
joints are affected by age, loading, trauma, and certain disease States.
REFERENCES

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-

1. Bogduk N, Engel R: The menisci of th lumbar zygapophyseal joints. A


review of their anatomy and clinical significance. Spine 9:454-460,
1984.
2 Buckwalter JA, Woo SL, Goldberg VM, et al: Sofl-tissue aging and
musculoskeletal function. J Bone Joint Surg Am 75:1533-1548, 1993.
3 Clarke RP: Symptomatic, lateral synovial frrnge (plica) of th elbow
joint. Arthroscopy 4:112116, 1988.
4. Dandy DJ: Anatomy of th mediai suprapatellar plica and mediai syno
vial shelf. Arthroscopy 6:7 9 -8 5 , 1990.
5. Dupont JY: Synovial plicae of th knee. Controversies and review. Clin
Sports Med 16:87-122, 1997.
6. Fawcelt DW: Conneciive lissue. In Bloom W, Fawcett DW (eds): A
Textbook of Histology, 12th ed. New York: Chapman & Hall, 1994.
7. Fife RS, Hochberg MC: Osteoarthritis. In Khppel JH (ed): Primer on th
Rheumatic Diseases, llth ed. Atlanta, Arthritis Foundation, 1997.
8. Giles LG: Human lumbar zygapophyseal joint mferior recess synovial
folds: A light microscope examination. Anat Ree 220:117124, 1988.
9. Glaser DL, Kaplan FS: Osteoporosis. Definition and clinical presentation. Spine 22 (SuppI): 12S16S, 1997.
10. Goronzy JJ, Weyand CM, Anderson RJ: Rheumatoid arthritis. In Klippel
JH (ed): Primer on th Rheumatic Diseases, llth ed. Atlanta, Arthritis
Foundation, 1997.
11. Hamerman D: Aging and th musculoskeletal System. Ann Rheum Dis
56:578-585, 1997.
12. Hayashi K: Biomechanical studies of th. remodeling of knee joint tendons and ligaments. J Biomech 29:707-716, 1996.
13. Humzah MD, Soames RW: Human intervertebral disc: Structure and
function. Anat Ree 220:337-356, 1988.
14 Jortikka MO, Inkinen RI, Tammi MI, et al: Immobihsation causes longlasting matrix changes both in th immobilised and contralateral joint
cartilage. Ann Rheum Dis 56:255-261, 1997.
15. Kim SJ, Choe WS: Arthroscopic findings of th synovial plicae of th
knee. Arthroscopy 13:33-41, 1997.
16. Kurrat HJ, Oberlander W: The thickness of th cartilage in th hip
joint. J Anat 126:145-155, 1978
17. Mow VC, Flatow EL, Foster RJ, et al: Biomechanics. In Simon SR (ed).
Orthopaedic Basic Science. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994.
18. Muller FJ, Setton LA, Manicourt DH, et al: Centrifugai and biochemical
comparison of proteoglycan aggregates from articular cartilage in experimental joint disuse and joint instability. J Orthop Res 12:498-508,
1994.
19 Noyes FR: Functtonal properties of knee ligaments and alterations induced by immobilization. Clin Orthop Rei Res 123:210-242, 1977.
20. OBrien SJ, Neves MC, Amoczky SP, et al: The anatomy and histology
of th infertor glenohumera! ligament complex of th shoulder. Am J
Sports Med 18:449-456, 1990.
21. O'Meara PM: The basic Science of m en iscu s rep air. Orthop Rev 22:
681-686, 1993.
22. Panni AS, Milano G, Lucania L, et al: Histological analysis of th
coracoacromial arch: Correlation belween age-related changes and rotator cuff tears. Arthroscopy 12:531-540, 1996.
23. Rubman MH, Noyes FR, Barber-Westin SD: Arthroscopic repair of meniscal tears that exlend mio th avascular zone. A review of 198 single
and complex tears. Am J Sports Med 26:87-95, 1998.
24. Sato Y. Fujitnatsu Y, Kikuyama M. et al: Inlluence of immobilization on
bone mass and bone metabolism in hemiplegic elderly patients with a
long-standing stroke. J Neurol Sci 156:205-210, 1998.
25. Stockwell RA The interrelationship of celi density and cartilage thick
ness in mammalian articular cartilage. J Anat 109:411-421, 1971.

40

Section l

Essential Topics o f Kinesiology

26. Swann DA, Silver FH, Slayter HS, et al: The molecular structure and

lubricating activity of lubricin isolated from bovine and human synovial


fluids. BiochemJ 225:195-201, 1985.
27. Williams PL, Bannister LH, Berry MM, et al (eds): The skeletal System.
In Grays Anatomy, 38th ed. New York, Churchill Livingstone, 1995.
28. Woo SL-Y, Gomez MA, Sites TJ, et al: The biomechanical and morphological changes in th mediai collateral ligament of th rabbit after

immobilization and remobilization. J Bone Joint Surg 69A: 1200-1211


1987.
29. Xu GL, Haughton VM, Carrera GF: Lumbar facet joint capsule: Appearance at MR imaging and CT. Radiology 177:415-420, 1990.
30. Yu SW, Sether L, Haughton VM: Facet joint menisci of th cervical
spine: Correlative MR imaging and cryomicrotomy study. Radiology
164:79-82, 1987.

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

Summation of Active Force and Passive


Tension: Total Length-Tension Curve,
47
Isometric Force: Development of th
Internai Torque-Joint Angle Curve, 47

Activating Muscle via th Nervous System,


51
Recruitment, 51
Rate Coding, 52
Muscle Fatigue, 52

MUSCLE AS A SKELETAL MOVER: FORCE


MODULATION, 50
Modulating Force Through Concentric or
Eccentric Activation: Force-Velocity
Relationship, 50

ELECTROMYOGRAPHY: WINDOW TO THE


NEURAL DRIVE OF MUSCLE. 54

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

lead to th judicious application of interventions to improve


a persons abilities.

MUSCLE AS A SKELETAL STABILIZER:


GENERATING AN APPROPRIATE AMOUNT
OF FORCE AT A GIVEN LENGTH
Bones support th human body as it interacts with its environment. Although many tissues that attach to th skeleton
support th body, only muscle can adapt to both immediate
and long-term extemal forces that can destabilize th body.
Muscle tissue is ideally suited for this function because il is
coupled both to th extemal environment and to th internai
control mechanisms offered by th nervous System. Under
th fine control of th nervous System, muscle generates th
force needed to stabilize skeletal structures under an amazingly wide array of conditions. For example, muscle exerts
fine control to stabilize fingers wielding a tiny scalpel during
eye surgery. Il can also generate large forces during th final
seconds of a dead-lift weightlifting task.
Understanding th special role of muscle in generating
stabilizing forces begins with an appreciation of how muscle
morphology and muscle-tendon architecture affect th range
of force available to a given muscle. The components of
muscle are explored that produce passive tension when a
muscle is elongated (or stretched), or active force when a
41

42

Secdon I

Essential Topics o f Kinesiology

T A B LE 3 - 1. Major Concepts: Muscle as a Skeletal


Stabilizer
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.

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 is stimulated by th nervous System. The relationship


between muscle force and length and how it influences th
isometric torque generated about a joint are then examined.
Table 3 - 1 is a summary of th major concepts addressed in
this section.

Muscle Morphoiogy: Shape and Structure


Muscle morphoiogy describes th basic shape of a vvhole
muscle. Muscles have many shapes, reflecting their ultimale
function. Figure 3 - 1 shows two common shapes of muscle:
fusiform and pennate (from th Latin penna, meaning
feather). Fusiform muscles, such as th biceps bracini, have
fbers running parallel to each other and to th centrai tendon. In pennate muscles, th fbers approach th centrai tendon obliquely. Pennate muscles may be further classified as
unipennate, bipennate, or multipennate, depending on th
number of similarly angled sets of fbers that attach into th
centrai tendon.
The muscle fib er is th structural unii of muscle, ranging
in thickness from about 10 to 100 micrometers, and length
from about 1 to 50 cm .17 Each muscle fber is actually an
individuai celi with multiple nuclei. The connettive tissue
that surrounds and supports muscle serves many roles. Similar to connettive tissue throughout other bodily structures,
th connettive tissue within muscle consists of fbers embedded in an amorphous ground substance. Most fbers are
collagen, and th remaining fbers are elastin. The combination of these two proteins provides strength, structural support, and elasticity io muscle.
Three different, although structurally related, sets of con
nettive tissue occur in muscle: epimysium, perimysium, and
endomysium (Fig. 3 - 2 ) . The epimysium is a tough strutture
that surrounds th entire surface of th muscle belly and
separates it from other muscles. In essence, th epimysium
gives form to th muscle belly. The epimysium contains
tightly woven bundles of collagen fbers that are highly resis
tive io stretch. The perimysium lies beneath th epimysium,
and divides muscle into fascicles that provide a conduit for
blood vessels and nerves. This connettive tissue, like epi

mysium, is tough and thick and resistive to stretch. The


endomysium surrounds individuai muscle fbers. It is composed of a relatively dense meshwork of collagen ftbrils that
are partly connected to th perimysium. Through lateral
connections to th muscle fber, th endomysium conveys
part of th contrattile force to th tendon.
Although th three types of connettive tissues are described as separate entities, they are interwoven in such a
way that they may be considered as a continuous sheet of
connettive tissue. All connettive tissue that encases a mus
cle, directly or indirectly, contributes to th tendons of th
muscle.

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

FIGURE 3 -1 . Two common shapes of muscle, fusiform and pen


nate, are shown. Different shapes are formed by different fiber
orientation relative to th connecting tendon. (Modifed from Wil
liams PL: Grays Anatomy: The Anatomical Basis of Medicine and
Surgery, 38th ed. New York, Churchill Livingstone, 1995.)

Chapter 3
A

Muscle: The Ultimate Force Generator in th Body

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.)

lei. Caution needs to be used, however, when measunng th


cross-section of pennate muscles, because fibers run at different angles to each other.
Pennation angle refers to th angle of orientation between
th muscle fibers and tendon (Fig. 3 - 3 ) . If muscle fibers
attach parallel to th tendon, th pennation angle is defined
as 0 degrees. In this case, essentially all of th force generated by muscle fibers is transmitted to th tendon and across
a joint. If, however, th pennation angle is greater than 0
degrees (i.e., oblique to th tendon), then less of th force
produced by th muscle fiber is transmitted to th tendon.
Theoretically, a muscle with a pennation angle dose to 0
degrees transmits full force to th tendon, whereas th same
muscle with a pennation angle dose to 30 degrees transmits

86% of its force to th tendon. (The cosine of 30 degrees is


0.86.)
In generai, pennate muscles produce greater maximal
force than fusiform muscles of similar size. By orienting
fibers obliquely to th centrai tendon, a pennate muscle can
fit more fibers into a given length of muscle. This spacesaving strategy provides pennate muscles with a relatively
large physiologic cross-sectional area and, hence, a relatively
large capability for generating high force. Consider th multipennate gastrocnemius muscle that must generate very
large forces during jumping, for example. Interestingly, th
reduced transfer of force from th pennate fiber to th ten
don, due io th greater pennation angle, is small compared with th large force potential furnished by th gain in

44

Section I

Essential Topics o f Kinesiology

TABLE 3 - 2 . Functions of Connective Tissue

within Muscle

1.
2.
3.
4
5.

FIGURE 3-3. Unipennate muscle is shown with th muscle ftbers


oriented at a 30-degree angle of pennation (0),

physiologic cross-sectional area. As shown in Figure 3 - 3 , a


pennation angle of 30 degrees stili enables th fibers to
transfer 86% of their force through th long axis of th
tendon.

Muscle and Tendon: Generation of Force


PASSIVE LENGTH-TENSION CURVE
Muscle contains contractile proteins that are embedded
within a network of connective tissues, namely, th epimysium, perimysium, and endomysium. Table 3 - 2 lists th
functions of these tissues. Connective tissues are slightly
elastic and, like a rubber band, generate resistive force (i.e.,
tension) when elongated.
For functional rather than anatomie purposes, th con
nective tissues within th muscle and tendon have been
described as th paralel elastic component and th series elas
tic component. Elongation or stretch of th whole muscle
lengthens th connective tissue elements (Fig. 3 - 4 ) . The
paralel elastic component refers to th connective tissues

Bone

Provides gross structure to muscle


Serves as a conduit for blood vessels and nerves
Generates passive tension by resisting stretch
Assists muscle to regain shape after stretch
Conveys contractile force to th tendon and across th joint

that surround or lie paralel to th proteins that cause th


muscle to contract. The series elastic component, in contrast,
refers to th connective tissues within th tendon. Because
th tendon lies in series with th contractile proteins, active
forces produced by these proteins are transferred directly to
th bone and across th joint. Stretching a muscle by extending a joint elongates both th paralel elastic component
and th series elastic component, generating a springlike
resistance, or stiffness, in th muscle. The resistance is referred to as a passive tension because it is does not depend
on active or volitional contraction. The concept of paralel
and serial elastic components is a simplifed description of
th anatomy; however, it is useful to explain th levels of
resistance generated by a stretched muscle.
The tendon has several unique mechanical properties. Be
cause of th longitudinal orientation and thickness of its
collagen fibers, th tendon can resist large forces that might
otherwise damage th muscle tissue. Muscle fibers decrease
in diameter by as much as 90% as they blend with th
tendon tissue.12 As a result, th force through a muscle fiber
per cross-sectional area (i.e., stress) increases significantly. At
each end of a muscle fiber is an extensive folding of th
plasmalemma (i.e., th membrane surrounding th muscle
fiber), which interdigitates with th connective tissue of th
tendon. This folding ensures that high forces can be distributed over a large area, thus reducing th stress on th
muscle.
When th paralel and series elastic components are
stretched within a muscle, a generalized passive length-tension
curve is generated (Fig. 3 - 5 ) . The curve is similar to that
obtained by stretching a rubber band. Approximating th
shape of an exponential mathematica! function, th passive

Paralel E C

FIGURE 3-4. Contractile components


and elastic components (EC) that
generate force in muscle tissue are
shown. The contractile component
represents th actin and myosin
crossbridge structures. The paralel
elastic component (paralel to th
contractile component) represents
muscle connective tissue. The series
elastic component (in series with th
whole muscle) represents th connec
tive tissues within th tendon. The
paralel and series connective tissues
act in a manner similar to a spring.

Chapter 3

Muscle: The Ultimate Force Generator in th Body

45

helps protect a muscle from being damaged by a quick and


forceful stretch. The viscous properties of muscle prolong
th application of force to allow a more graduai elongation,
reducing th risk of tissue rupture. In summary, both elastic
ity and viscosity serve as damping mechanisms that protect
th stracanai components of th muscle and tendon.

ACTIVE LENGTH-TENSION CURVE

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.

elements within th muscle begin generating passive tension


after th criticai length where all of th relaxed (i.e., slack)
tissue has been brought to an initial level of tension. After
this criticai length has been reached, tension progressively
increases until it reaches levels of extremely high stiffness. At
higher tension, th tissue fails. The simple passive lengthtension curve represents an important component of forcegenerating capability in muscle and tendon tissue. This capa
bility is especially important ai very long lengths where
muscle fibers begin to lose their active force-generating capa
bility. Passive tension stabilizes skeletal structures against
gravity and responds to perturbations and other imposed
loads. Passive elongation of th Achilles tendon of th ankle
during th downstroke of bicycle pedaling, for example, allows for transmittal of hip and muscular forces to th bicycle
crank.6 This capability, however, is limited because of th
slow adaptability of th tissue to rapidly changing extemal
forces and because of th significant amount of initial
lengthening that must occur before tissue can generate sufficient passive tension.
Stretched muscle tissue exhibits th properties of elasticity
and viscosity. Both properties influence th amount and rate
of passive tension developed within a stretched muscle. A
stretched muscle exhibits elasticity because it can temporarily
store pari of th energy that created th stretch. Stored
energy, ahhough relatively slight when compared with th
full force potential of th muscle, helps prevent a muscle
from being damaged during maximal elongation. Viscosity, in
this context, describes th rate-dependent resistance encountered between th surfaces of adjacent fluid-like tissues. Vis
cosity is rate dependent; thus, a muscles internai resistance
to elongation increases with th rate of stretch. Viscosity

Muscle tissue is uniquely designed to generate force actively


in response to a stimulus from th nervous System. This
section describes th means for generating active force. Ac
tive force is produced by th muscle fiber. Ultimately, active
force and passive tension must be transmitted io th skeletal
structures. The interaction between active and passive forces
is explored in th next section.
As explained earlier, muscle fibers constitute th basic
functional element of muscle. Furthermore, each muscle fi
ber, or celi, is composed of many tiny strands called myofibrils. Myofibrils are th contractile elements of th muscle
fiber and have a distinctive structure. Each myofibril is 1 io
2 micrometers in diameter and consists of many myofilaments. The primary structures within myofilaments are two
types of proteins: actin and myosin. The regular organization
of myofilaments produces th characteristic banded appearance of th myofibril as seen under th microscope (Fig. 3
6). The actin and myosin physically interact through crossbridges (i.e., projections from th myosin filamenti and
other connective structures. By way of th endomysium,
myofibrils ultimately connect with th tendon. This elegant
connective web, formed between myofilaments and connec
tive tissues, allows force to be evenly distributed throughout
muscle and efficiently transmitted to skeletal structures.
Upon inspection of th muscle fiber, a distinctive light
and dark banding is apparent (Fig. 3 - 7 ) . The dark bands,
th A-bands, correspond to th presence of myosin th
thick filaments. Myosin also contains projections, called
cross-bridges, which are arranged in pairs (Fig. 3 - 8 ) . The
light bands, th I-bands, contain actin th thin filaments
(see Fig. 3 - 7 ) . In a resting muscle fiber, actin filaments
partially overlap myosin filaments. Under an electron micro
scope, th bands reveal a more complex pattern that consists
of H bands, M lines, and Z discs (Table 3 - 3 ) .
The banding pattern repeats along th length of th mus-

TABLE 3 - 3 . Regions Within a Sarcomere


A bands

Dark bands caused by presence of thick myosin


filament

I bands

Light bands caused by presence of thin actin fila


ment

H band

Region within A band where actin and myosin do


not overlap.

M lines

Mid region thickening of thick myosin filament in


th center of H band

Z discs

Region where successive actin filaments mesh together. Z disc helps anchor th thin filaments.

46

Section 1

Essemial Topics o f Kinesiology

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.)

th sarcomere, it is possible to understand th mechanics of


muscle contraction since this process is repeated from one
sarcomere to th next.
The currently accepted model for describing active force
generation is called th sliding filament hypothesis and was
developed independently by Hugh Huxley8 and Andrew
Huxley (no relation).9 In this model, active force is generated
as actin filaments slide past myosin filaments, causing approximation of th Z discs and narrowing of th H band.
This action results in progressive overlap of actin and myo
sin filaments so that sarcomere length is effectively shortened
even though th filaments themselves do not shorten (Fig.
3 - 9 ) . Each cross-bridge attaches to its adjacent actin filament so that th force generated depends on th number of
simultaneous cross-bridge/actin attachments. The greater th
number of cross-bridge attachments, th greater th amount
of active force generated within th sarcomere.
As a consequence of th arrangement between th actin
and myosin within a sarcomere, th amount of active force
depends, in part, on th instantaneous length of th muscle
fiber. A change in fiber length either by active contraction
or by passive elongation alters th amount of overlap be
tween cross-bridges and actin filaments. The active lengthtension curve for a sarcomere is presented in Figure 3 - 1 0 .
The ideal resting length of a muscle fiber or sarcomere is th
length that allows th greatest number of cross-bridge at
tachments and, therefore, th greatest potential active force.
As th sarcomere is lengthened or shortened from its resting
length, th number of potential cross-bridge attachments decreases so that lesser amounts of active force are generated,
even under conditions of full activation. The resulting active

Chapter 3

FIGURE 3-8. Further detail of a


sarcomere showing th crossbridge strutture created by th
myosin heads and their attachment to th actin filaments. Note
thai th actin filament also contains th proteins troponin and
tropomyosin. Troponin is respon
sive for exposing th actin filament to th myosin head, thereby
allowing crossbridge formation.
Modified from Berne RM, Levy
MN; Principles of Physiology,
2nd ed. St. Louis, Mosby, 1996.)

Troponin

length-tension curve is described by an inverted U-shape


with its peak at th ideal resting length.
The term length-force relationship is more appropriate for
considering th terminology establshed in this text (see defnition of force and tension in Chapter 1). The phrase lengthtension is, however, used because of its wide acceptance in
th physiology literature.

SUMMATION OF ACTIVE FORCE AND PASSIVE


TENSION: THE TOTAL LENGTH-TENSION CURVE
The active length-tension curve, when combined with th
passive length-tension curve, yields th total length-tension
curve of muscle. The combination of active force and passive
tension allows for a large range of muscle force over a wide
range of muscle length. Consider th total length-tension
curve for th muscle shown in Figure 3 - 1 1 . At shortened
lengths (a), below active resting length, and below th length
that generates passive tension,' active force dominates th
force generating capability of th muscle. Thus, force rises
rapidly as th muscle is lengthened (stretched) toward its
resting length. As th muscle fiber is stretched beyond its
resting length (b), passive tension begins to contribute so
that th decrement in active force is offset by increased
passive tension, effectively flattening this pari of th total
length-tension curve. This characteristic portion of th pas
sive length-tension curve allows muscle to maintain high

Muscle: The Ultimate Force Generator in th Body

47

/Tropomyosin

Myosin
Myosin head
(cross-bridge)

levels of force even as th muscle is stretched to a point


where active force generation is compromised. As th muscle
fiber is further stretched (c), passive tension dominates th
curve so that connective tissues are under near maximal
stress. High levels of passive tension are most apparent in
two-joint muscles placed in overelongated positions. For example, as th wrist is extended, typically th fingers passively flex slightly owing to th stretch placed on th finger
flexor muscles as they cross th front of th wrist. The
amount of passive tension depends in part on th naturai
stiffness of th muscle.

Isometric Force: Development of th Internai


Torque-Joint Angle Curve
As defned in Chapter 1, isometric activation of muscle is a
process by which th muscle produces force without a signif-

Actin filament

Length of sarcom ere (micrometers)

FIGURE 3-9. The sliding filament action that occurs as myosin


heads attach and then release from th actin filament is illustrated.
Contrattile force is generated during th power stroke of th cycle.
(From Guyton AC, Fiali JE: Textbook of Medicai Physiology, lOth
ed. Philadelphia, W.B. Saunders, 2000.)

FIGURE 3-10. Active length-tension curve of a sacromere for four


specified sarcomere lengths (upper right, A through D). Actin fila
ments (A) overlap so that th number of crossbridge attachments is
reduced. In B and C, actin and myosin filaments are positioned to
allow an optimal number of crossbridge attachments. In D, actin
filaments are positioned out of th range from th myosin heads so
that no crossbridge attachments are possible. (From Guyton AC,
Fiali JE: Textbook of Medicai Physiology, lOth ed. Philadelphia,
W.B. Saunders, 2000.)

48

Section 1

Essential Topics o j Kinesiology

put in both active and passive terms is highly dependent


on muscle length. Second, th changing joint angle alters th
length of th moment arm, or leverage, that is avatlable to
th muscle. Because both length and leverage are altered
simultaneously by joint rotation, it is not always posstble lo
know which is more influential in determining th final
shape of th torque-angle curve. A change in either variable
mechanical or physiologic alters th clinical expression of a muscular-produced internai torque (Table 3 - 4 ) .

Elbow Flexors

FIGURE 3-11. Total length-tension curve for a typical muscle. At


shortened lengths (a), all force is generated actively. As th muscle
fi ber is stretched beyond its resting length (b), passive tension
begins to contribute to th total force, in c, th muscle is further
stretched and passive tension accounts for most of th total force.

icant change in length. This occurs naturally when th joint


over which a stimulated muscle crosses is constratned from
movement. Constraint often occurs from a force produced
by an antagonistic muscle. Isometrically produced forces
provi de th necessary stability to th joints and body as a
whole. The amplitude of an isometrically produced force
Irom a given muscle rellects th summaiion of both lengthdependent active and passive forces.
Maximal isometric force of a muscle is often used as a
generai indicator of a muscle's peak strength and can indi
cate motor recovery.310-16 ln clinical settings, it is not possi
l e to directly measure length or force of maximally activated muscle. However, a muscles internai torque generation
can be measured isometrically about several different joint
angles. Figure 3 - 1 2 shows th internai torque versus th
joint angle curve (torque-angle curve) of two muscle
groups under isometric, maximal effort conditions. The
torque-angle curve is th rotational equivalent to th total
length-tension curve of a muscle group. The internai torque
produced isometrically by a muscle group can be determined
by asking an individuai to produce a maximal effort contrae tion against a known extemal torque. As described in Chapter 4, an extemal torque can be determined by using an
extemal force-sensing device (dynamometer) at a "known distance from th jo in ts axis of rotation. Because th measurement is done in th muscles isometric state, th internai
torque is assumed to be equal to th extemal torque.
The shape of a maximal effort torque angle curve is very
specific to each muscle group (see Fig. 3 -1 2 A and B). Its
shape yields important information about th physiologic
and mechanical factors that determine th torque produced
by th muscle group. Consider th following two factors
shown in Figure 3 - 1 3 . First, muscle length changes as joint
angle changes. As previously described, a muscles force out

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

Muscle: The Ultimate Force Generator in th Body

49

Exploring th Reasons for th Unique "Signature" of a


Muscle Group's Isometric Torque-Angle Curve

Consider th functional implications associated with th


shape of a muscle group's torque-angle curve. Undoubtedly, th shape is related to th nature of external force
demands on th joint. For th elbow flexors, for example, th maximal internai torque potential is greatest in
th mid ranges of elbow motion, and least near full
extension and full flexion (see Fig. 3-12A). Not coincidentally, th external torque-effect due to gravity on
hand-held objects is also typically greatest in th mid
ranges of elbow motion, and least in th extremes of
this motion.
For th hip abductor muscles, th internai torque
potential is greatest near neutral (0 degrees of abduc
tion) (see Fig. 3-126). This joint angle coincides with
th approximate angle where th hip abductor muscles
are most needed for frontal piane stability while walking. Large amounts of hip abduction torque are rarely
required in a position of maximal hip abduction.

------------------------------------------------------------------------------>

Dccrcasing muscle length


Increasing illusele moment arili
FIGURE 3-13. Muscle length and moment arm have an impact on
th maximal effort torque for a given muscle. A, Muscle is al its
near greatest length, and muscle moment arm (red line) is at its
near shortest length. B, Muscle length is shortened, and muscle
moment arm length is greatest. (Modified from LeVeau BF: Wil
liams & Lissners Biomechanics of Human Motion, 3rd ed. Philadelphia, W.B. Saunders, 1992.)

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

Effect of Internai Torque

Possible Clinical Consequence

Mechanical: Increased internai


moment arm

Surgical displacement of
greater trochanter to increase th internai mo
ment arm of hip abduc
tor muscles

Decrease in th amount of muscle


force required to produce a
given level of hip abduction
torque

Decreased hip abductor force can


reduce th force generated
across an unstable or a painful
hip joint; considered a means
of protecting a joint from
damaging forces

Mechanical: Decreased inter


nai moment arm

Patellectomy following se
vere fracture of th pa
tella

Increase in th amount of knee


extensor muscle force required
to produce a given level of
knee extension torque

increased force needed to extend


th knee may increase th
wear on tire articular surfaces
of th knee joint

Physiological: Decreased mus


cle activation

Damage to th deep portion


of th peroneal nerve

Decreased strength in th dorsiflexor muscles

Reduced ability to walk safely

Physiological: Significantly de
creased muscle length at
th lime of neural activa
tion

Damage to th radiai nerve


with paralvsis of wrist
extensor muscles

Decreased strength in wrist exten


sor muscles causes th finger
flexor muscles to flex th wrist
while making a grasp

Ineffective grasp due to overcontracted (shortened) finger


flexor muscles

50

Section I

Essential Topcs o j Kinesiology

ography as a tool for understanding muscle activation during


movement is introduced.

Moduiating Force Through Concentric or


Eccentric Activation: Force-Velocity
Relationship

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.)

cles strength. This information may be required to deter


mine th suitability of a person for a certain task at th
workplace, especially if th task requires a criticai internai
torque to be produced at certain joint angles.

MUSCLE AS A SKELETAL MOVER: FORCE


M0DULATI0N
The previous section considers how an isometrically activated muscle can stabilize th skeletal System; this next sec
tion considers how muscles actively grade forces while
changing lengths, which is necessary to move th skeletal
System. Active grading of muscle force requires a mechanism
to control excitation of muscle tissue. The nervous system
acts as a controller that can vary th activation of muscle
according to th particular demands of th task. For example, if th task is to point accurately at a small target, th
controller must be able to make split-second adjustments in
activation levels io a relatively small number of muscle fibers. With this control strategy, th pointing finger does not
veer off course when extemal perturbations or resistance are
imposed. If th task is to produce a forceful motion, th
controller must then rapidly and efficiently adivate large
numbers of muscle fibers.
Understanding th role of muscle activation in generating
movement begins with an appreciation of how muscle force
is modulated while th muscle is either shortening or lengthening. The ways in which force is graded by neural activa
tion are explored. The reduction in force that occurs with
muscular fatigue is examined. Finally, th use of electromy-

The nervous System stimulates a muscle to generate or resisi


a force by concentric, eccentric, or isometric activation. Dur
ing concentric activation, th muscle shortens (contracts);
during eccentric activation, th muscle elongates; and during
isometric activation, th length of th muscle remains Con
stant. During concentric and eccentric activation, th rate o j
change of length is significanti related to th muscles maxi
mal force potential. During concentric activation, for example, th muscle contracts at a maximum velocity when th
load is negligible (Fig. 3 - 1 4 ) . As th load increases, th
maximal contraction velocity of th muscle decreases. At
some point, a very large load results in a contraction velocity
of zero (i.e., th isometric state).
Eccentric activation needs to be considered separately
from concentric activation. With eccentric activation, a load
that barely exceeds th isometric force level causes th mus
cle to lengthen slowly. Speed of lengthening increases as a
greater load is applied. There is a maximal load that th
muscle cannot resist, and beyond this load level th muscle
uncontrollably lengthens.
The theoretical force-velocity curve for muscle across con
centric, isometric, and eccentric activations is often shown
with th force on th Y (vertical) axis and shortening and
lengthening velocity on th X (horizontal) axis (Fig. 3 - 1 5 ) .
In generai, during a maximal effort concentric activation, th
amount of muscle force is inversely proportional to th veloc
ity of muscle shortening. During a maximal effort eccentric
activation, th muscle force is, to a point, directly proportional
to th velocity of muscle lengthening. The clinical expression
of a force-velocity relationship of muscle is a torque-joint

FIGURE 3-15. Theoretic force-velocity curve of an activated muscle


is shown. Concentric activation is shown on th righi and eccentric
activation on th left. Isometric activation occurs at th zero veloc
ity point on th graph.

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.

Muscle: The Ultimale Force Generator in th Body

51

A muscle undergoing a concentric contraction against a


load is doing positive work on th load. In contrast, a muscle
undergoing eccentric activation against an overbearing load
is doing negative work. In th latter case, th muscle is
storing energy that is supplied by th load. A muscle, there
fore, can act as either an active accelerator of movement
against a load while contracting (i.e., through concentric
activation), or it can act as a brake or decelerator when a
load is applied and th activated muscle is lengthening (i.e.,
through eccentric activation).

Activating Muscle via th Nervous System

Combinine] th Length-Tension and Force-Velocity


Relationships

Although a muscle's length-tension and force-velocity


relationships are described separately, in reality both
are in effect simultaneously. At any given tinte, an active muscle is functioning at a specific length and at a
specific contraction velocity, including isometric. It is
useful, therefore, to generate a surface plot that represents th three-dimensional relationship between mus
cle force, length, and contraction velocity (Fig. 3-16).
The plot does not, however, include th passive lengthtension component of muscle. The plot shows, for example, a muscle contracting at a high velocity over th
shortened range of its overall length producing relatively low levels of force, even with maximal effort. In
contrast, a muscle contracting at a low, near isometric,
velocity within th middle range of its overall length
(i.e., near its optimal muscle length) produces a substantially greater active force.

FIGURE 3-16. Surface plot represents th three-dimensional re


lationship among muscle force, length, and contraction velocity
during maximal effort. Positive work indicates concentric mus
cle activation, and negative work indicates eccentric muscle
activation. (From Winter DA: Biomechanics and Motor Control
of Human Movement, 2nd ed. New York, John Wiley & Sons,
Ine., 1990.) This material is used by permission of John Wiley
& Sons, Ine.

Several important mechanical mechanisms underlying muscle


force generation have been examined. Of utmost importance,
however, is th fact that muscle is excited by impulses that
are generated within th nervous System, specifically by al
pha motoneurons that are located in th ventral hom of th
spinai cord. Each alpha motoneuron has an axon that extends out of th spinai cord and connects with multiple
muscle fibers located throughout a whole muscle. The alpha
motoneuron and all muscle fibers that are innervated by it
are called a motor unit. Because of this arrangement, th
nervous System can produce a muscle force from small contractions involving only a few muscle fibers, and large contractions that involve rnost of th fibers. Excitation of alpha
motoneurons may come from many sources, for example,
afferents, spinai interneurons, and cortical descending neurons. Each source can adivate an alpha motoneuron by first
recruiting th motoneuron and then by driving it to higher
rates of sequential activation. The sequence of driving moto
neurons to higher rates, known as rate coding, allows recruited muscle to generate greater amounts of force. Both of
these issues of driving motoneurons are discussed further.

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

Essential Topici o f Kinesiology

3 - 5 . Major Sequence of Events Underlying


Muscle Fiber Activation
TABLE

1. Action potential initiated and propagated down a motor


axon.
2. Acetylcholine released frorn axon terminals at neuromuscular junction.
3. Acetylcholine bound to receptor sites on motor endplate.
4. Sodiurn and potassium ions enter and depolarize muscle
membrane.
5. Muscle action potential propagated over membrane surface.
6. Transverse tubules depolarized leading to release of calcium ions surrounding th myofibrils.
7. Calcium ions bind to troponin, which leads to th release
of inhibition over actin and myosin binding.
8. Actin combines with myosin adenosine triphosphate
(ATP), an energy-providing molecule.
9. Energy released to produce movement of myosin crossbridges.
10. Thick and thin filaments slide relative to each other.
11. Actin and myosin bond is broken and re-established if
calcium concentration remains sufficiently high.

Muscle fibers that are connected with small motoneurons


bave twitch responses, that are relatively long in duration
and small in amplitude (see Fig. 3 - 1 7 , righi). Motor units
associated with these fibers are classified as S (slow) because
th fibers are slow to respond to a stimuli, or SO (slow,
oxidative). The 0 reflects th histochemical profile. SO fibers
show relatively little latigue (i.e., loss of force during sustained activation).
Muscle fibers that are connected with large motoneurons
have twitch responses that are relatively brief in duration
and high in amplitude (Fig. 3 - 1 7 , left). Motor units associ
ated with these fibers are classified as FF (fast and easily
fatigued), or FG (fast and glycolytic), refiecting th histo
chemical profile. FG fibers fatigue relative easily.
An entire spectrum of intermediate motor units exists that
shows physiologic and histochemical profiles somewhere between slow and fast type motor units (Fig. 3 - 1 7 , middle).
Motor units associated with these fibers are termed FR (fatigue resistant). The fibers are termed FOG io represent th
combined utilization of oxidative and glycolytic energy
sources.
The motor umt types depicted in Figure 3 - 1 7 allow for a
wide range of physiologic responses from fibers within skeletal muscles. The earlier (smaller) recruited motoneurons pro
duce longer duration, small force contractions. Later re
cruited (larger) motoneurons add successively greater forces
of shorter duration. Through this spectrum, th nervous Sys
tem is able to adivate muscle fibers that sustain stable postures over a long period of rime, and, when needed, produce
high, short duration bursts of force for more impulsive
movements.

RATE CODING
After a specific motoneuron is recruited, muscle force is
modulated by an increase in th rate of its excitation, a

concep called rate coding. Although a single action potential


in a skeletal muscle fiber lasts 1 to 2 milliseconds (ms), a
muscle fiber contraction (commonly called a twitch) may last
for as long as 130 ms in an S fiber. Because of th long
twitch duration, il is possible for a number of subsequent
action potentials to begin during th initial twitch.4 If a fiber
is allowed to relax completely before th subsequent action
potential, th second fiber twitch generates equivalent force
to th first twitch (Fig. 3 - 1 8 ) . If th next action potential
arrives before th preceding twitch has relaxed, however, th
muscle twitches summate and generate an even greater evel
of peak force. Altematively, if th next action potential ar
rives closer to th peak force evel of th initial twitch, th
force is even greater.
A set of repeating action potentials, separated by a suitable lime interval, generates a series of summated mechanical twitches, termed unfused tetanus. As th time interval
shortens, th unfused tetanus generates greater force until
th successive peaks and valleys of mechanical twitches fuse
into a single, stable evel of muscle force, termed fused teta
nus (or tetanization) (see Fig. 3 18). Fused tetanus represents th greatest force evel that is possible for a muscle
fiber. Motor units, therefore, activated at high rates are capable of generating greater overall force than th sanie number
of motor units activated at lower rates. Because motor units
are distributed across an entire muscle, fiber contractile
forces summate across th entire muscle and ultimately are
transmitted to th tendon and across th joint.

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

Muscie: The Ultimate Force Cenerator in th Body

53

FIGURE 3 -1 7 . Classifcation of motor


unit types from a traisele based on
histochemical profile, size, and
twitch (contrattile) characteristics.
Modified from Berne RM, Levy MN:
Pnnciples of Physiology, 3rd ed. St.
Louis, Mosby, 1996.)

Rate of stimulation (times per second)


FIGURE 3 -1 8 . Summadon of individuai muscle twitches (contractions) are recorded over a wide range of stimulation frequencies.
Note that at low frequencies of stimulation (5 -1 0 per seeond), th
minai twitch is relaxed before th next twitch can summate. Ai
progressively higher frequencies, th twitches summate to generate
higher force levels until a fused twitch (tetanization) occurs. (From
Guyton AC, Hall JE: Textbook of Medicai Physiology, lOth ed.
Phiadelphia, W.B. Saunders, 2000.)

Neural pathway conduction delays or blocks, such as in


multiple sclerosis, may impair th ability to adivate motoneuron pools.15 When centrai fatigue is a suspected mechanism contributing to low muscle force output, verbal encouragement or loud commands can momentarily enhance
output.
Peripheral fatigue may result from neurophysiologic factors
related to action potential propagation in motor nerves and
transmission of activation to muscle fbers. The motor nerve
terminal, where th motor nerve innervates th muscle f
bers, may exhibit transmission failure so that th action
potential is not propagated across to th plasmalemma.11
Repetitive activation of motor units can result in a graduai
reduction of acetylcholine release.2 Since acetylcholine is th
essenttal transmitter responsible for activating plasmalemma,
a graduai reduction in its release lessens th size of th
resultant twitch for a given muscle. Biochemical factors may
be involved in peripheral fatigue. The Chemical composition
of muscle fiber cytoplasm may undergo a variety of changes
that reduce force output over rime.5

54

Section I

Essential Topics o f Kinesiology

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

ELECTROMYOGRAPHY: WINDOW TO THE


NEURAL DRIVE OF MUSCLE
When a muscle is activated via th nervous System, electrical
potentials are generated. The recording of these amplified
action potentials through special electrodes is referred to as
electromyography (EMG). The EMG signals can indicate th
relative timing and relative level of th neural drive to a
muscle, and thus they are useful in understanding th role
of a particular muscle in controlling a given movement.
Under certain conditions, th magnitude of th EMG signal
can also indicate th relative levels of muscle force.
When a motor unit is activated, th electrical impulse
travels along th axon until it arrives at th motor endplates
of th muscle fibers. Because th tissue around th muscle
fbers is electrically conductive, th subsequent depolarization of th activated muscle fibers tnduces a measurable
electrical signal, which can be sensed by an electrode that is
placed near th muscle fibers. The signal is termed th motor
unit action potential (MUAP) and can be sensed by both
indwelling electrodes (i.e., electrode inserted into th muscle
fibers) and surface electrodes (i.e., electrode placed on th
skin overlying th muscle).
Depending on th characteristics of th motor unit, maxi
mum force is achieved 20 to 150 ms after depolarization. An
electromechanical delay, therefore, exists between th appearance of muscle electrical activity and th mechanical
force generation.1418 As described, two mechanisms exist to
modulate muscle force: recruitment and rate coding. As th
number of active motor umts in th muscle is increased via
recruitment, greater numbers of MUAPs occur. The sum of
these signals generates an overall greater amplitude EMG
signal. As th finng rate of active motor umts is increased,
greater numbers of MUAPs occur within a given time period.
A greater amplitude EMG signal also results, typically indicating a greater force level in th active contractile component ol muscle.
Caution is advised when interpreting changes in EMG
amplitude under conditions other than isometric activation.
When an activated muscle is lengthening or shortening, th
source for th electrical signal changes its orientation in
relation to th electrode that picks up th signal. The signal,
therefore, may represent a compilation of MUAPs from different regions of a muscle or even from different muscles.
Because of th length-tension and force-velocity relationships of muscle, th EMG amplitude may vary considerably
as a muscle produces a force via nonisometric activations.

Consider th following two extreme examples. Muscle A


produces a given submaximal force via an eccentric activa
tion across its optimal force-generating length, at a relatively
high lengthening velocity. Muscle B produces an equivalem
submaximal force via a concentric activation across its nonoptimal force-generating length, at a relatively high shorten
ing velocity. Based on th length-tension and force-velocityI
relationships, Muscle A is operating at a relative physiologic
advantage for producing force. Muscle A, therefore, requires
fewer motoneurons io be recruited, and at slower rates, than
Muscle B. EMG levels would therefore be less for th move
ment performed by Muscle A, although both muscles produced equivalent submaximal forces. Using EMG magnitude
is not a valid tool for comparing th internai force produced
by these two muscles. EMG is a useful tool for this purpose.
however, if th two muscles are operating under similar
activation, length, and velocity conditions.
EMG can be performed with surface or fine wire (insertional) electrodes. Surface electrodes are easy to apply and
noninvasive, and they can detect signals from a large area
overlying muscle. Fine wire electrodes, mserted into th
muscle belly, allow greater speciftcity in terms of th muscle
region and allow th choice of deeper muscles that are not
accessible when using surface electrodes. Nevertheless, fine
wire electrodes require a high level of technical skill and
training before safe implementation; therefore, surface elec
trodes are more commonly used in clinical practice.
Because EMG signals originate as very small signals, there
is a high risk for extraneous electrical noise. Noise signal can
be controlled in several ways. Differential electrode configurations (two pick-up electrodes that are electrically coupled)
are used to subtract th noise signal that is commonly recorded by both electrodes. Adequate skin preparation ensures that th tiny EMG signals are recorded efficienti)'
rather than being overly impeded by unprepared skin. The
recording environment can be electrically isolated so that
extraneous noise is kepi far from th equipment. Electrical
signals can be preamplified at th electrode source, rather
than amplified after th signal is conducted to a distant
amplifier, so that intervening noise from movement of th
electrode cable is minimized. Signal filtering (i.e., eliminating
specific frequencies of electrical signals) can be used to re
duce known sources of interfering electrical signals. Low J
frequency noise, for example, may be present from power
sources coupled to th wall outlet. A filler that is designed
lo eliminate most of th electrical signal at and under 60 Hz

significanily reduces th noise from these sources.

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.
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16

17.

18.

Muscle: The Ultimate Force Cenerator in th Body

55

contraction and stretch and their structural interpretation. Nature 173:


973-976, 1954.
Huxley A, Nedergerke R: Structural changes in muscle dunng contrac
tion. Interference microscopy of living muscle fibres. Nature 173:971
973, 1954.
Jaramillo J, Worrell TW, Ingersoll CD: Hip isometric strength following
knee surgery. J Orthop Sports Phys Ther 20:160-165, 1994.
Kmjevic K, Miledi R: Failure of neuromuscular propogation in rats. J
Physiol 140, 1958.
Loeb G, Prati C, Chanaud C, Richmond F: Distribution and innervation
of short, tnterdigitated muscle fibers in parallel-fibered muscles of th
cat htndlimb. J Morph 191:1-15, 1987.
McKenzie DK, Biglandritchie B, Gorman RB, Gandevia SC: Central and
peripheral fatigue of human diaphragm and limb muscles assessed by
twitch interpolation. J Physiol 454:643-656, 1992.
Merletti R, Knaflitz M, Deluca CJ: Electrically evoked myoelectric sig
nals. Crit Rev Biomed Eng 19:293-340, 1992.
Sandroni P, Walker C, Starr A: Fatigue in patients with multiple sclerosis motor pathway conduction and event-related potentials. Arch Neu
rol 49:517-524, 1992.
Wessel J, Kaup C, Fan J, et al: Isometric strength measurements in
children with arthrins: Reliability and relation to function. Arthr Care
Res 12:238-246, 1999
Yamaguchi G, Sawa A. Moran D, et al: A survey of human muscuiotendon actuator parameters. In Winters J, Woo S-Y (eds): Multiple Muscle
Systems: Biomechanics and Movement Organization. New York,
Springer-Verlag, 1990, pp 717-773.
Zhou S, Lawson DL, Morrison WE, Fairweather I: Electromechanical
delay in isometric muscle contractions evoked by voluntary, reflex and
electrical stimulation. Eur J Appi Physiol 70:138-145, 1995.

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

Graphic Methods of Force Analysis, 67

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

Analytic Methods of Force Analysis, 70

Comparing Two Methods for


Determining Torque About a Joint,
72
Clinica! Issues Related to Joint Force
and Torque, 74
Joint "Protection," 74
Manually Applying External Torques
During Exercise, 75

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

Kinematic Measurement Systems:


Electrogoniometer, Accelerometer,
Imaging Techniques, and
Electromagnetic Tracking Devices,
81
Kinetic Measurement Systems:
Mechanical Devices, Transducers,
and Electromechanical Devices, 83

treatment approaches. Technologic advances continue to enhance th ability to understand and influence human per
formance.

NEWTON'S LAWS: APPLICATION TO


MOVEMENT ANALYSIS
The outcome of all movement analysis is ultimately determined by th forces applied to th body being moved. In
th 17th century, Sir Isaac Newton observed that forces were
related to mass and motion in a predictable fashion. His
Philosophiae Naturalis Principia Mathematica (1687) provided
th basic laws and principles of mechanics that form th
comerstone of human movement analysis. These laws, referred io as th law of inertia, th law of acceleration, and
th law of action and reaction, are collectively known as th
laws o f motion and form th framework from which advanced
motion analysis techniques are derived.

Chapter 4

Newton's Laws of Motion


This chapter uses Newtons laws of motion to introduce
techniques of analysis for describing th relationship between
th forces applied to th body and th consequences of
those forces on human motion. (Throughout th chapter, th
term body is used when elaborating on th concepts related to th laws of motion and th methods of quantitative
analysis. The reader should be aware that this term could
also be used interchangeably with th entire human body; a
segment or part of th body, such as th forearm segment;
an object, such as a weight that is being lifted; or th System
under consideration, such as th foot-floor interface. In most
cases, th simpler term, body, is used when describing th
main concepts.) Newtons laws are described for both linear
and rotational (angular) motion (Table 4 - 1 ) .

NEWTON'S FIRST LAW: LAW OF INERTIA


Newtons first law States that a body remains at rest or in
Constant linear velocity except when compelled by an external force to change its state. A force is required to start,
stop, or alter linear motion. The application of Newtons first
law to rotational motion States that a body remains at rest or
in Constant angular velocity about an axis of rotation unless
compelled by an external torque to change its state. Whether
th motion be linear or rotational, Newtons first law describes th case in which a body is in equilibrium. A body is
in static equilibrium when its velocity is zero, or in dynamic
equilibrium when its velocity is not zero, but Constant. In
either case, th acceleration of th body is zero.

Biomechanical Principles

57

velocity of a body. The inertia within a body is directly


proportional to its mass (i.e., th amount of matter constituting th body). For example, if two bodies have different
masses but are moving at similar linear velocities, a greater
force is required to alter th motion of th more massive
body.
Each body has a point about which its mass is evenly
distributed. The point, called th center o f mass, can be
considered where th acceleration of gravity acts on th
body. When subjected to gravity, th center of mass of a
body is often described as its center o f gravity. For th entire
upright human body, th center of mass lies just anterior to
th second sacrai vertebra (Fig. 4 - 1 A). The center of mass
for an individuali thigh and leg segments is shown in Figure
4 - 1 B and C, respectively. During movement, th center of
mass is continually changing its location being a function
of th location and size of th individuai body segments.
Additional information regarding th center of mass of body
segments is discussed later in this chapter under th topic of
Anthropometry.
The mass moment o f inertia of a body is a quantity that
indicates its resistance to a change in angular velocity. Unlike
mass, its linear counterpart, th mass moment of inertia
depends not only on th mass of th body, bui also on th
distribution of its mass with respect to an axis of rotation.6
Because most human motion is angular, rather than linear, it
is important to understand th concept of mass moment of
inertia. The mass moment of inertia (i) is defined in th box,
where n indicates th number of particles in a body, m,
indicates th mass of each particle in th body, and r, is th
distribution or distance of each particle from th axis of
rotation.

Kcy Terms Associated >vilh Newtons First Law

Static equilibrium
Dynamic equilibrium
Inertia
Center of mass
Mass moment of inertia
Radius of gyration

Newton's first law is also called th law of inertia. Inertia


is related to th amount of energy required to alter th

The average distance between th axis of rotation and th


center of mass of a body is called th radius o f gyration. The
Greek letter rho (p) is used to indicate th radius of gyra
tion. Substituting p, th radius of gyration, for r in th
moment of inertia equation (Equation 4.1), yields th sim-

TABLE 4 - 1. Newtons Laws: Linear and Rotational Components


Law

Linear Componeni

Rotational Component

First: Law of Inertia

A body remains at rest or in Constant linear


velocity except when compelled by an external
force to change its state.

A body remains at rest or in Constant angular


velocity about an axis of rotation unless when
compelled by an external torque to change its
state.

Second: Law of Acceleration

The linear acceleration of a body is directly pro


portional to th force causing it, takes place in
th same direction in which th force acts, and
is inversely proportional to th mass of th
body.

The angular acceleration of a body is directly pro


portional to th torque causing it, takes place in
th same rotary direction in which th torque
acts, and is inversely proportional to th mass
moment of inertia of th body.

Third: Law of Action-Reaction

For every force there is an equal and opposite


directed force.

For every torque there is an equal and opposite


directed torque.

58

Section I

Essential Topici o j Kinesiology

forward. Alternatively, a given muscle force can advance th


lower limb more quickly while walking when th lower
extremity is flexed as compared W'ith straightened. The
change in joint position (i.e., increased hip and knee flexion
and ankle dorsiflexion) used io decrease th resistance to
angular motion becomes even more apparent as a person
changes from walking to running.
Athletes often attempt to control th mass moment of
inertia of their entire body by altering th position of their
individuai body segments. This concept is well illustrated by
divers who reduce their moment of inertia in order to successfully complete multiple somersaults while in th air (Fig.
4 -3 A ). The athlete can assume an extreme tuck position
by placing th head near th knees, holding th arms and
legs tightly together, thereby bringing more body mass closer
to th axis of rotation. Based on th principle of conservation of angular momentum," reducing th resistance to th
angular motion increases th angular velocity. Conversely,
th athlete could slow or stop th rotation by assuming a
pike position, or by straightening th extremities (Fig.
4 - 3 B ) . The mass of th extremities is positioned farther
from th medial-lateral axis of rotation, thereby increasing
th resistance to angular motion and decreasing th rate of
spin.

NEWTON'S SECOND LAW: LAW OF ACCELERATION


Force (Torque)-Acceleration Relationship

FIGURE 4 -1 . The center of mass of th whole body (A) is shown


with respect to th frontal piane. The center of mass is also shown
for th thigh segment (B) and th leg segment (C).

pler Equation 4.2 shown in th box. The units of I are


kilograms-meters squared (kgm2). The equation describes
that a bodys resistance to a change in angular velocity is
proportional to th mass of th object (m) and th squared
distance between th center of mass of th object and th
axis of rotation (p2).

Newtons second law States that th acceleration of a body is


directly proportional to th force causing it, takes place in
th same direction in which th force acts, and is inversely
proportional to th mass of th body. Newtons second law
generates an equation that relates th force (F), mass (m),
and acceleration (a) (see Equation 4.3). Conceptually, Equa
tion 4.3 defines a force-acceleration relationship. Considered a
cause-and-effect relationship, th left side of th equation,
force (F), can be regarded as a cause because it represents
th interaction between a body and its environment. The
right side, m X a, represents th effect of th interaction on
th System. In this equation, XF designates th sum of or
net forces acting on a body. If th sum of th forces acting
on a body is zero, acceleration also is zero and th body is
in linear equilibrium. As previously discussed, this case is
described by Newtons first law. lf, however, th net force
produces an acceleration, th body travels in th direction of
th resultant force.

Newtons Second Law of Linear Motion Quantifying a


Force

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)

1 Newton (N) = 1 kgm/s2

The angular counterpart to Newtons second law States that


a torque (T) produces an angular acceleration (a ) of th body
that is proportional to, and in th rotary direction of th
torque, and is inversely proportional to th mass moment of
inertia of th body (I) (see Equation 4.4 in th box). (This
chapter uses th terni torque. The reader should be aware

Chapter 4

A Closer Look at Mass Moment of Inedia

Figure 4 -2 illustrates th concept of mass moment of


inertia. A rectangular object is considered to consist of
five point masses (M, M 5), each with a mass of 0.5 kg.
The object is free to rotate in th horizontal piane. In this
example, th rectangular object is able to rotate separately about two vertical axes of rotation (Y, and Y2).
Distances (r, r5) are each 0.1 m long, representing th
distance between each mass particle (M ,-M 5) and between th indicated mass particles and th two axes of
rotation. The axis of rotation Y2 runs through th center of
mass of th entire object (M3). The following calculations
demonstrate how th distribution of th mass particles,
relative to a given axis of rotation, dramatically affects th
mass moment of inertia of th rotating object. Consider Y,
as th axis of rotation. The mass moment of inertia is
Yi axis
C if b

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

FIGURE 4-2. A rectangular object is shown with a potemial to


rotate about two separate axes of rotation (Yt, Y2). The two sets
of calculations associated with each axis of rotation show how
th distribution of mass within a body affects th mass momentum of inertia. The object is assumed to consist of five equal
mass points (M,-M 5), located at set distances (r ,-r 5) from each
other and from th axes of rotation. The center of mass of th
entire object is located at M, (red circle).

that this terni is interchartgeable with moment and moment


of force.) In this equation, 2 T designates th sum of or "net
torques acting to rotate a body. Conceptually, Equation 4.4
defines a torque-angular acceleration relationship. Within th
musculoskeletal System, th primary torque producer is mus
cle. The contracting biceps muscle, for example, produces a
net flexion torque at th elbow as th hand is accelerated to
th mouth. The flexion torque is directly proportional to th
angular acceleration of th rotating elbow, as well as directly

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

proportional to th mass moment of inertia of th rotating


forearm and hand segments.

Newton's Second Law of Rotary Motion Quantifying a


Torque

ST = 1 X a

(Equation 4.4)

60

Section / Essential Topics o f Kinesiology

small force delivered over a longer time. Equation 4.6 de


fines th linear impuise-momentum relationship.

A Tncreased angular
velocity

B Decreased angular
velocity

FIGURE 4 -3 . A diver illustrates an example of how th mass mo


ment of merda about a medial-laieral axis (black dot) can be altered
through changes in th position of th trunk and extremities. In
position A, th diver decreases th mass moment of inertia, which
increases th angular velocity of th spin. in position B, a ehange in
th position of th extremities causes a greater mass moment of
inertia and decreases th angular velocity of th spin.

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

Mass Moment of Inertia and Prosthetic Design

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.

The impuise-momentum relationship provides another


perspective from which to study human performance, as
well as to gain msight into injury mechanisms. The concept
of an impuise-momentum relationship is often utilized in th
design features of sports and recreation equipment for th
purpose of protecting users from injury. Running footwear
with shock-absorbing outsoles and bike helmets with protective padding are examples of designs intended io reduce
injuries by increasing th lime, or duration, of impact in
order to minimize th peak force of th impact.
Newtons second law involving torque can apply to th
rotary case of th impuise-momentum relationship. Similar
to th substitutions and rearrangements for th linear rela
tionship, th angular relationship can be expressed by substitution and rearrangement of Equation 4.4. Substituting Aw/t
(ehange in angular velocity) for a (angular acceleration) re
sults in Equation 4.7 (see th box). Equation 4.7 can be
rearranged to Equation 4.8 th angular equivalent of th
impuise-momentum relationship.

T = 1 A&i/t

(Equation 4.7)

Tt = I X

(Equation 4.8)

co

Angular Momentum = I X Angular Velocity


Angular Impulse = Torque x Time

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 Closer Look at th Impulse-Momentum Relationship


N u m e ric a lly , an im p u ls e c a n be c a lc u la t e d a s th p r o d u c t
o t t h a v e r a g e f o r c e ( N ) a n d i t s t i m e o f a p p l i c a t i o n . Im
p u ls e c a n a ls o be r e p r e s e n t e d g r a p h ic a lly a s th a re a
u n d e r a f o r c e - t im e c u rv e . F ig u re 4 - 4 d is p la y s a fo r c e - tim e
c u rv e of th h o rizo n ta l c o m p o n e n t of th a n te rio r-p o s te rio r s h e a r f o r c e a p p lie d by t h g r o u n d a g a in s t t h f o o t

(ground reaction force)

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)

The work-energy relationship describes mechanical work


in tenns of th expenditure of energy. Energy can be considered as th measure of th fuel available to th System to
perform work. The work-energy relationship has been particularly helpful to th study of walking in humans. The me
chanical work of walking is often th global indicator of th
metabolic demands on th body, without th detailed account of th intricacies of th movement.
The work-energy relationships previously described in
Equations 4.9 and 4.10 do not take into account th time

over which th forces or torques are applied. Yet, in most


daily activities, it is often th rate at which a force does
work that is important. The rate of work is defined as
power. The ability for muscles to generate adequate power
may be criticai to th success of movement or to th understanding of th impact of a treatment intervention. On th
basketball court, for example, il is often th speed at which
a player can jump for a rebound that determines success.
Another example of th importance of th rate of work can
be appreciated in an elderly person with Parkinsons disease
who must cross a busy Street in th time determined by a
pedestrian traffic signal.
Power (P) is work (W) divided by time (see Equation 4.11
in box on th following page). Because work is th product
of force (F) and distance (d), th rate of work can be restated in Equation 4.12 as th product of force and velocity
(d/t). Angular power may also be defined as in th linear

62

Section 1 Essential Topics o j Kinesiology

S P E C I A L

case, using th angular analogs of force and velocity, torque


(T) and angular velocity (co), respectively (Equation 4.13).

F O C U S

Using Angular Power as a Measure of Muscle


Performance

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 .

Table 4 - 2 summarizes th definitions and units needed


to describe many of th physical measurements related to
Newton's second law.

Positive power r e f l e c t s t h r a t e o f w o r k d o n e b y concentrically active muscles a g a i n s t a n e x t e r n a l l o a d .


Negative power, in c o n t r a s t , r e f l e c t s t h r a t e o f w o r k
d o n e b y t h e x t e r n a l l o a d a g a i n s t eccentrically active
muscles. T h i s I n f o r m a t i o n c a n b e u t i l i z e d a s r e s e a r c h

NEWTON'S THIRD LAW: LAW OF ACTION-REACTION

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

Newton s third law of motion States that for every action


there is an equal and opposite reaction. This law implies that
every effect one body exerts on another is counteracted by
an effect that th second body exerts on th first. The two

p a th o lo g ic fu n c tio n .

TABLE 4 - 2 Physical Measurements Associated with Newtons Second Law


Linear Application

Rotational Application

Physical
Measurement

Definition

Distance

Linear displacement

Meter (m)

Angular displacement

Velocity

Degrees ()*

Rate of linear displacement

Meters per second


(m/s)

Rate of angular displacement

/s

Acceleration

Rate of change in linear velocity

m/s2

Rate of change in angular velocity

/s2

Mass

Quantity of matter in an object; influences th objects


resistance to a change in lin
ear velocity

kilogram (kg)

Not applicable

Mass moment of
inertia

Not applicable

Force

A push or pul; mass times


linear acceleration

Torque

Not applicable

Units

Definition

Quantity and distribution of mat


ter in an object; influences an
objects resistance to a change
in angular velocity
kgm/s2 (N)

Units

kgm2

Not applicable
A force times a moment arm;
mass moment of inertia times
angular acceleration

kgm2/s2 (or Nm)

Impulse

Force times lime

Ns

Torque times lime

Nms

Momentum

Mass times linear velocity

kgm/s

Mass moment of inertia times an


gular velocity

kgm2/s

Work

Force times linear displace


ment

Nm (joules)

Torque times angular displace


ment

Nm (joules)

Power

Rate of linear work

Nm/s or J/s (watts)

Rate of angular work

Nm/s or J/s
(watts)

Radians, which are unitless, may be used insiead of degrees.

Chapter 4

Biomechanical Principles

63

cep ualize th role of muscles in human movement, it is also


important to understand th added impact of gravity and
other extemal forces. The observation and analysis of move
ment must take into consideration th net effect of muscle
activity, th resulting internai forces, as well as all th external forces on th quantity and quality of motion. The following section illustrates methods for basic analysis of move
ment, beginning with an introduction to anthropometry
th measurement of th design characteristics of th human
body. This section also demonstrates how changes in external forces and torques can have an impact on muscle response, joint motion, and joint reaction force.

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-

Perhaps th most direct application of Newtons law of


iClion-reaction is th reaction force provided by th surface
.pon which one is walking. The foot produces a force
against th ground owing to th accelerations of all superinumbent body segments. In accord with Newtons third law,
ne ground generates a ground reaction force in th opposite
arection but of equal magnitude (Fig. 4 - 5 ) . The ground
reaction force changes in magnitude, direction, and point of
-oplication on th foot/shoe throughout th period of gait.
Ground reaction forces can be measured via force platforms
see section on Kinematic and Kinetic Measurement Systems
ater in this chapter), and th forces are commonly used as
nput data for th quantitative analysis of human motion.

NTRODUCTION TO MOVEMENT ANALYSIS:


SETTING THE BACKGROUND
~; previous section describes th nature of th cause and
et relationship between force and motion as outlined by
'nvtons laws. Although it may be relatively simple to con

Anthropometry is derived from th Greek root anthropos


(man) and metron (measure). In th context of human move
ment analysis, anthropometry may be broadly defned as th
measurement of certain physical design features of th hu
man body, such as length, mass, volume, density, center of
mass, radius of gyration, and mass moment of inerlia. These
body segment parameters are essential lo conduction of kin
ematic and kinetic analyses for boih normal and pathologic
motion. Analysis of movement frequently requires information regarding th mass of individuai segments or th distribution of mass within a given segment. These factors deter
mine th inertial properties that muscles must overcome to
generate movement. Anthropometric information is also
valuabte in th design of th work environment, furniture,
tools, and sports equipment.
Much of th information regarding th body segments
center of mass and mass moment of inerba has been derived
from cadaver studies.4 Refer to Table l in Appendix 1A for
anthropometric data on weights of different body segments
and locations of th centers of mass. Other methods for
deriving this information have included mathematical modeling and imaging techniques, such as computed tomography
and magnetic resonance imaging.

Free Body Diagram


The analysis of movement requires that all forces that act on
th body be taken into account. Prior to any analysis, a free
body diagram is constructed to facilitate th process of solving biomechanical problems. The free body diagram is a
snapshot or simplifed sketch that represents th interac
tion between a System and its environment. The System
under consideration may be a single rigid segment, such as
th foot, or il may be several segments, such as th head,
arms, and trunk. These can be regarded together as a single
rigid System.
A free body diagram requires that all relevant forces acting upon th System are carefully drawn. These forces may
be produced by muscle; gravity, as reflected in th weight of
th segment; fluid; air resistance; friction; and ground reac
tion forces. Arrows are used to indicate force vectors.
How a free body diagram is defned depends on th
intended purpose of th analysis. Consider th example presented in Figure 4 - 6 . In this example, th free body dia
gram represents th extem al forces acting on th body of an
individuai during th push off, or th propulsive, phase of

64

Section I

Essential Topics o f Kinesiology

forces are caused prim arily by activation o f m uscle and Ir.


passive tension in stretched ligaments and gravity (bodv
weight). Passive forces from stretched soft tissues are rela-:
tively small in magnitude and are often excluded from th '
analysis.
Clinically, reducing joint reaction force is a major focus in
treatment programs designed to lessen patn and preven:
joint degeneration. Frequently, treatments are directed
toward reducing joint forces through changes in th magnitude of muscle activity and their activation pattems or
through a reduction in th weight transmitted through a
joint. Consider th patient with osteoarthritis of th hip joim
as an example. The magnitude of joint reaction force may be
decreased by having th person reduce walking velocitv.
thereby lessening th magnitude of muscle activation. Alternatively, a cane may be used to reduce forces through th
hip jo in t." If obesity is a factor, a weight-reduction program
could be recommended.

IMI MAL STEPS FOR SETTING UP THE FREE BODY


DIAGRAM
GRFy

FIGURE 4-6. A free body diagram of a sprinter. The external forces


on th System include th force due to th body weight (BW) of
th runner and contact forces: th ground reaction force (GRF) in
vertical (Y) and horizontal directions (X), and th force created by
air resistance (AR). (The force vectors are noi drawn to scale.)

The key elements needed to begin problem solving in hu


man movement are to determine th purpose of th analysis
identify th body, and indicate all th forces that act on tha
body. The following example presents steps to assist with
construction of a free body diagram.
Consider th situation in which an individuai is holding
weight out to th side, as shown in Figure 4 - 8 . This systei
is assumed to be in static equilibrium, and th sum of
opposing forces and torques are equal. One goal of
analysis might be to determine how much muscle force
required by th glenohumeral joint abductor muscles :
keep th arm abducted to 90 degrees; another goal might b.
to determine th magnitude of th glenohumeral joint ree.
tion force during this same activity.
Step l, in setting up th free body diagram, is to iden
and isolate th System under consideration. In this exam
th System is th entire arm and weight combination.

running. In this example, th System under consideration


is defined as th lower trunk and lower extremities. The
external force vectors include th weight of th combined
body segments, which have been reduced to a single vector
referred to as body weight (BW), and th contact forces. The
contact forces include th ground reaction forces (GRF), in
both vertical (Y) and horizontal (X) directions, and th air
resistance (AR).
The System so described can be specifed differently, depending on th analysis. Assume that it is of interest to
exami ne th major vertical forces acting on th foot and
ankle region while standing on tiptoes (Fig. 4 - 7 ) . The Sys
tem of interest is redefned as th foot, and it is represented
as a simplified single rigid link that is isolated from th
remainder of th body. The free body diagram involves ftguratively cutting through th desired joint. The effects of
muscle force are usually distinguished from th effects of
other soft tissues, such as th joint capsule and ligaments.
Although th contribution of th individuai muscles acting
across a joint may be determined, a single resultant muscle
force (MF) vector is often used to represent th sum total of
all muscle forces. In order to complete th free body dia
gram, th ground reaction force (GRF) and weight of th
foot (FW) are indicated in a manner similar to that de
scribed for th analysis in Figure 4 - 6 .
As shown in th free body diagram of Figure 4 - 7 , an
additional contact force is identified: th joint reaction force
(JRF). The term reaction implies that one joint surface
FIGURE 4-7. A free body diagram o f th System defined as th fo
pushes back against th other joint surface. The joint reac
The following vertical forces are shown: resultant piantar fle
tion force represents th net or cumulative effect of forces
muscle force (MF); joint reaction force (JRF); weight of foot (F
transmitted from on e segm ent to an oth er.5 J o in t reaction
and ground reaction force (GRF), Vectors are noe drawn to scale

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.)

Step II involves setting up a reference frame that allows


th position and movement of a body to be defined with
respect to a known point, location, or axis (see Fig. 4 - 8 , XY reference). More detail on establishing a reference frame is
discussed in th next section.
Step III illustrates th internai and extemal forces that act
on th System. Internai forces are those produced by muscle
MF). Extemal forces include th gravitational pul of both
th weight of th load (LW), as well as th weight of th
arm (AW). The extemal forces are drawn on th figure at
th approximate point of application of these forces. The
location of th vector (AW) acts at th center of mass of th
upper extremity and is determined using anthropometric
data, such as those presented in Appendix 1A.
The direction of th internai MF is drawn in a direction
that opposes th potential motion produced by th extemal
forces. In this example, th rotation produced by th external forces, AW and LW together with their moment arms,
tends to move th arm in a clockwise or adduction direc
tion. Thus, th line-of-force of MF, in combination with its
moment arm, tends to rotate th arm in a counterclockwise
or abduction direction.
Step IV of th procedure is to show th contact forces that
act on th System. Because this System is assumed to be in
static equilibrium, contact forces such as air resistance are
ignored. Another contact force to consider is a push or pul
applied to th extemal aspect of th body, such as th
manual resistance delivered by a therapist or by an opposing
player in a sporting event. In this example, th only relevant
contact force is th joint reaction force (JR F) created across
th glenohumeral articulation. Initially, th direction of th
joint force may not be known but, as explained later, is
typically drawn in a direction opposite to th pul of th
dominant muscle force. The precise direction of th JRF can
be determined after static analysis is carried out and unknown variables are calculated. This method of analysis is
discussed in detail in th following section of this chapter.
The box summarizes th key steps in setting up th free
body diagram.

Initial Steps in Setting Up th Free Body Diagram


Step I: Identify and isolate th System under consideration.
Step II: Establish a reference frame.
Step III: Illustrate th internai (muscular) and extemal (gravita
tional) forces that act on th System.

Step IV: Illustrate th contact forces that act on th System,


typically including th joint reaction force.

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

Seclion / Essential Topici o j Kinesiology

FIGURE 4-9. Two types of reference frames. A


depicis a relative reference frame showing th
trunk roiated 100 degrees relative to th thigh; B
depicts a global reference frame showing th
trunk rotated 65 degrees with respect to th horizontal piane (X).

A Relative reference
frame

B Global reference
frante

A
X

location in space. To analyze tnotion with respect io th


ground, direction of gravity, or another type of externally
defned reference frame in space, a global or laboratory reference frain e must be defned. The position of th trunk with
respect io a horizontal reference is an example of a measurement made with respect io a global reference frame (Fig.
4 -9 B ).
Use of one type of reference frame over another may
result in different outcome measures. Figure 4 - 9 illustrates
how a relative and global reference frame can be used to
describe th position of th trunk during th sit-to-stand
activity, but th outcome measures are different. The use of
two distinct reference frames for describing th same snapshot of an activity, bui having different results, emphasizes
th importance of identifying th reference frame when de
scribing human movement.
Whether motion is measured via a relative or global refer
ence frame, th location of a point or segment in space can
be specified using a coordinale System. In human movement
analysis, th Cartesian coordinate System is most frequently
employed. The Cartesian System utilizes coordinates for locating a point on a piane by identifying th distance of th
point from each of two intersecting lines or, in space, by th
distance from each of three planes intersecting at a point.
This System, therefore, is either two-dimensional (2D) or
three-dimensional (3D). A 2D System is defned by two
imaginary axes arranged perpendicular to each other. The
two axes (X, Y) are usually positioned such that one is

horizontal (X) and th other vertical (Y), although they may


be oriented in any manner that facilitates quantitative Solu
tions. A 2D System is frequently utilized when th motion
being described is predominantly planar (i.e., in one piane),
such as knee flexion and extension during gait.
In most cases, human motion occurs in more than one
piane. Even th knee, whose motion is considered to occur
predominantly in th sagittal piane while walking, also undergoes small rotations in both horizontal and frontal planes.
In order to adequately describe th motions that occur in
more than one piane, a 3D reference System is necessary. A
3D System has three axes, each perpendicular or orthogonal
to each other. In contrast to th planar description of th 2D
System, th coordinates in a 3D System can designate any
point or vector in space relative to th X, Y, and Z axes.
A coordinate System needs to indicate direction of motion
as well as position in both a linear and a rotational sense.
By convention, most coordinate Systems are constructed
such that linear movements to th righi, up, and forward are
defned as positive, whereas movements to th left, down,
and backward are negative. The direction of a force producing a motion can be defned by th direction that th object
is being accelerated. Rotary or angular movements are de
scribed in th piane (sagittal, frontal, horizontal) that a segment is moving, which is perpendicular to th axis of rotation. A segments rotation direction may be described as
clockwise or counterclockwise or as flexion or extension (see
Chapter 1), depending on th situation. In this text, th

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.

! RAPHIC METHODS OF FORCE ANALYSIS


omposition of Forces
ector composition allows several parallel, coplanar forces to
- simply combined graphically as a single resultant force
g. 4 - 1 0 ) . In Figure 4 -1 0 A , th weight of th leg segment
''VI and th weight of th load (LW) are added graphically

FIGURE 4-11. A, Three forces are shown acting on a pelvis that is


involved in single-limb standing over a right prosthetic hip joint.
The forces are hip abductor force (HAF), body weight (BW), and
prosthetic hip reaction force (PHRF). B, The polygon (or tip-totail) method is used to determine th magnitude and direction of
th PHRF, based on th magnitude and direction of FfAF and BW.
(From Neumann DA: Hip abductor muscle activity in persons who
walk with a hip prosthesis while using a cane and carrying a load.
Phys Ther 79:1163-1176, 1999, with permission of th Physical
Therapy Association.)

68

Seclion I

Essential Topics o f Kinesiology

by means of a ruler and a scale factor determined for th


vectors. In this example, th resultant force (RF) acts downward and has th tendency to distract (pul apart) th knee
joint, if unopposed by other forces. Figure 4 - 1 0 B illustrates
a cervical traction device that employs a weighted pulley
System, acting in th direction opposite to th force createci
by th weight of th head. Simple addition yields th value
of th resultant force. The positive sign of RF indicates a
slight net upward distraction force on th head and neck.
Force vectors acting on a body may be coplanar, but they
may not always act parallel. In this case, th individuai
vectors may be composed using th polygon method. Figure
4 - 1 1 illustrates how th polygon method can be applted to
a frontal piane model to estimate th reaction force on a
prosthetic hip while standing on one limb. With th arrows
drawn in proportion to their magnitude and in th correct
orientation, th vectors of body weight (BW) and hip abductor force (HAF) are added in a tip-to-tail fashion (Fig. 4
11B). The combined effect of th BW and HAF vectors is
determined by placing th tail of th HAF vector to th tip
of th BW vector. Completing th polygon yields th result
ant prosthetic hip reaction force (PHRF), showtng its magni
tude and direction (see Fig. 4 - 1 1 B , dotted line). In this
case, th resultant vector represents a reaction force and,
therefore, is directed in a sense that opposes th sum of th
other two vectors.
A parallelogram can also be constructed to determine th
resultant of two coplanar but nonparallel forces. Instead of
placing th force vectors tip-to-tail, as discussed in th previ -

Metacarpophalangeal
joint

ous example, th resultant vector can be found by drawing


parallelogram based on th magnitude and direction of th
two component force vectors. Figure 4 -1 2 A provides ar.
illustration of th parallelogram method to combine severa]
component vectors into one resultant vector. The component
force vectors, Fj and F2 (black solid arrows), are generated
by th pul of th flexor digitorum superficialis and profundus, as they pass palmar (anterior) to th metacarpophalangeal joint. The diagonal, originating at th intersection of F
and F2, represents th resultant force (RF) (see Fig. 4 -1 2 A ,
thick red arrow). Because of th angle between F, and F2.
th resultant force tends to raise th tendons away from th
joint. Clinically, this phenomenon is described as a bowstringing force due to th tendons resemblance to a pulled
cord connected to th two ends of a bow. In rheumatoid
arthritis, th bowstringing force may rupture th ligaments
and dislocate th metacarpophalangeal joints (Fig. 4 12B).
In many cases, especially when analyzing muscle forces.
th parallelogram method can be described as a reclangle,
such that th components of th resultant force are oriented
at right angles to each other. As shown in Figure 4 - 1 3 , th
two right-angle forces are referred to as normaI and tangential
components (MFN and MFT). The hypotenuse of th right
triangle is th resultant muscle force (MF).
In summary, when two or more forces applied to a segment are combined into a single resultant force, th magni
tude of th resultant force is considered equal to th sum of
th component vectors. The resultant force can be deter
mined graphically as summarized in th box.

Stretched collateral
ligaments

Proximal
joint

Distai
interphalangeal
joint

Palmar dislocation of th
metacarpophalangeal
joint

Ruptured
collateral
ligaments

FIGURE 4-12. A, Parallelogram


method is used to illustrate th
effect of two force vectors (F,
and F2) produced by contraction of th flexor digitorum
superficialis
and
profundus
muscles across th metacarpo
phalangeal (MCP) joint. The re
sultant force (RF) vector creates
a bowstringing force on th
connective lissues at th MCP
joint. B, In a digit with rheuma
toid arthritis, th resultant force
can, over time, rupture liga
ments and cause palmar disloca
tion of th metacarpophalangeal
joint.

Chapter 4

Biomechanical Principles

69

passes through th axis of rotation because it has no mo


ment arm (see Fig. 4 - 1 3 , MFT). Table 4 - 3 summarizes th
characteristics of th tangential and normal force compo
nents of a muscle, as in Figure 4 - 1 3 .
Contrasting Internai versus External Forces and Torques

- 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).

Summary of How to Graphically Compose Force Vcctors


ParaLlel forces vectors can be combined by using simple
vector addition (Fig. 4-10).
Nonparallel, coplanar force vectors can be composed by
using th polygon (tip-to-tail) method (Fig. 4 -1 1 ), or
th parallelogram method (Figs. 4 -1 2 and 4-13).

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-

TABLE 4 - 3 . Normal versus Tangential Force


Components of a Muscle Force
Normal Force Component

Tangential Force
Component

Acts perpendicular to a bony


segment

Acts parallel to a bony seg


ment

Often indicated as FNbut


may be indicated as FY,
depending on th choice of
th referente frame

Often indicated as FT bui


may be indicated as Fx,
depending on th choice of
th reference frame

Can cause rotation and/or


translation:
A rotation may occur if th
moment arm > 0.
A translation may occur as
a compression, distraction, or shearing be
tween articulating surfaces.

A translation may occur as a


compression or distraction
between articulating surfaces.

70

Secton 1

Essential Topici o j Kinesiology


MF

Free body diagram


FIGURE 4-14. Resoluiion of internai forces (red) and external forces
(black) for an individuai performing an isometric knee extension
exercise. A, The following resultant force vectors are depicted: muscle force (MF) of th knee extensors; leg segment weight (SW); and
load weight (LW) applied ai th ankle. B, A free body diagram
shows th resultant vectors resolved into their rectangular components: normal component of th muscle force (MFN); tangential
component of th muscle force (MFT); norma! component of th
segment weight (SWN); tangential component of th segment weight
(SWT); normal component of th load weight (LWN); and tangential
component of th load weight (LWT). In both A and B, th open
red circles mark th medial-lateral axis of rotation at th knee. Note
that th XY reference frame is rotated so that tangential forces are
oriented in th X direction and normal forces are oriented in th Y
direction. (Vectors are not drawn to scale.)

force to compress th joint surfaces of th elbow. Becaust.


th angle-of-insertion is less than 45 degrees, th tangentu
force exceeds th normal force. At an angle-of-insertion o
45 degrees, th tangential and normal forces are equal, with
each about 71% of th resultant. When th angle-of-inser
tion of th muscle reaches 90 degrees (Fig. 4 - 1 5 B ) , 100%
of th total force is available to rotate th joint and produce
a torque.
As shown in Figure 4 - 1 5 C , th magnitude of th force
components continues to change as elbow flexion continues
The 135-degree angle-of-insertion produces equal tangentia
and normal force components, each about 71% of th result
ant. Because th tangential force is now directed away from
th joint, it produces a distracting or separating force on th
joint. As th angle-of-insertion exceeds 135 degrees (Fig
4 -1 5 D ), th tangential force component exceeds th norma
force component.
In Figure 4 -1 5 A through D, th internai torque is th
product of MFN and th internai moment arm (IMA). Be
cause MF n changes with angle-of-insertion, th magnitude or
an internai torque naturally changes throughout th range ot
motion. This concept helps explain why people have greater
strength at certain locations throughout th joints range ol
motion. The torque-generating capabilities of th muscle depend not only on th angle-of-insertion, and subsequeni
magnitude of MFN, but also on other physiologic factors. '
discussed in Chapter 3. These include muscle length, activation type (i.e., isometric, concentric, or eccentric), and speed
of muscle activation.
Changes in joint angle also affect th external or resistance end of th musculoskeletal System. Retuming to th
example of th isometric knee extension exercise, Figure
4 - 1 6 shows how a change in knee joint angle affects th
normal component of th external forces. The external I
torque experienced by th exercising person is equal to th
product of th external moment arm (EMA) and th normal I
component of th external forces (LWN or SW N). In Figure
4 -1 6 A , no external torque exists in th sagittal piane be
cause th SW and LW force vectors pass through th axis of
rotation and, therefore, have no moment arm. Figure 4 -1 6 B
through C shows how a greater external torque is placed
against th individuai with th knee fully extended compared with th knee flexed 45 degrees. Although th exter
nal forces, SW and LW, are th same in all three cases, th I
external torque is greatest when th knee is in full extension
As a generai principle, th external torque applied against a
joint is greatest when th resultant external force vector I
intersects th bone or body segment at a right angle.

ANALYTIC METHODS OF FORCE ANALYSIS

insertion results in a different combination of tangential


(MFt ) and normal (MFN) force components. The tangential
forces create compression or distraction forces at th elbow.
By acting with an internai moment arm (IMA), th normal
forces also generate an internai torque (i.e., potential rota
tion) at a joint. As shown in Figure 4 -1 5 A , a relatively
small angle-of-insertion favors a relatively larger tangential
force, which directs a larger percentage of th total muscle

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

FIGURE 4-15. Changing th angle of

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

C. 0 of flexion (full extension)

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

Essential Topics o f Kinesiobgy

S P E C I A L

F O C U S

4 - 5

Designing Resistive Exercises So That th External and


Internai Torque Potentials Are Optimally Matched

The concept of altering th angle of a joint is frequently


utilized in exercise programs to adjust th magnitude of
resistance experienced by th patient or Client. It is often
desirable to design an exercise program so that th exter
nal torque matches th internai torque potential of th
muscle or muscle group. Consider a person performing a
"biceps curi" exercise shown in Figure 417/4. With th
elbow flexed to 90 degrees, both th internai and external
torque potentials are greatest, because th product of
each resultant force (MF and LW) and their moment arms

(IMA and EMA) are maximal. At this unique elbow position


th internai and external torque potentials are maximal as
well as optimally matched. As th elbow position is altered in Figure 4-176, th external torque remains maxi
mal; however, th internai torque potential is significantly
reduced. As th elbow approaches extension, th angleof-insertion of th muscle and th normal muscle force
(M FJ are reduced, thereby decreasing th potential for
generating internai torque. A person with significant
weakness of th elbow flexor muscle may have difficulty
holding an object in position B, but may have no difficulty
holding th same object in position A.

FIGURE 4-17. Changing th angle of elbow flexion altere both th

internai and external torque potential. A, The 90-degree position of


th elbow maximizes th potential for both th internai and external
torque. B, With th elbow doser to extension, th external torque
remains maximal, but th internai torque potential (i.e., th product
of MFN and IMA) is reduced. (MF is equal to muscle force; MFN,
normai component of muscle force; IMA, internai moment arm; l.W,
load weight; EMA, external moment arm.) (Modified from LeVeau
BF: Williams <Sr Lissners Biomechanics of Human Motion, 3rd ed.
Philadelphia, WB Saunders, 1992.)

Comparing Two Methods for Determining Torque


about a Joint
In th context of kinesiobgy, a torque is th effect of a force
tending to move a body segment about a joints axis of
rotation. Torque is th rotary equivalent of a force. Mathematically, torque is th produci of a force and its moment arm
and has units of Nm. Torque is a vector quantity, having
both magnitude and direction.
Two methods for determining torque yield identical
mathematica! Solutions. The methods apply to both internai
and external torque, assuming that th System in question is
in rotational equilibrium (i.e., th angular acceleration about
th joint is zero).

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

Internai Torque: MFpjx IM A j = M F x IIVIA2

FIGURE 4-18. The internai (muscle-produced) flexion torque at th


elbow can be determined using two different methods. The first
method (shown in black lettere) is expressed as th produci of th
norma! force of th muscle (MFN) times its internai moment arm
'.IMA,). The second method (shown in red lettere) s expressed as
th produci of th resultant force of th muscle (MF) times its
internai moment arm (IMA;,). Both expressions yield equivalent in
ternai torques. The axis of rotation is depicted as th open black
circle at th elbow.

Biomechanical Principes

73

External Torque: R \ x EM A j = R x EM A 2

FIGURE 4-19. An external torque is applied to th elbow through a


resistance generated by tension in a cable (R). The weight of th
body segment is ignored. The external torque can be determined
using two different methods. The firei method (shown in black
lettere) is expressed as th product of th normal force of th
resistance (RN) times its external moment arm (EMA,). The second
method, shown in red lettere, is expressed as th product of resultant force of th resistance (R) times its external moment arm
(EMA2). Both expressions yield equivalent external torques. The axis
of rotation is depicted as th open black circle through th elbow.

orce and its associated moment arm). The associateci force


and moment arm fo r any gtven torque must inlersect one an4her at a 90-degree angle.
External Torque

Figure 4 - 1 9 shows an external torque applied to th elbow


through a resistance produced by a cable (depicted as R).
The weight of th body segmeni is ignored in this example.
The first method for determining external torque is shown in
black letters. External torque is depicted as th product of
Rn (th norma! component of th cables resistive force)

times its external moment arm (EMA,). The second method,


shown in red letters, uses th product of th cables resultant
resistive force (R) and its external moment arm (EMA2). As
with internai torque, both methods yield th same external
torque because both satisfy th definition a torque (i.e., th
produci of a resistance (external) force and its associated
external moment arm).

A "Shortcut" Method of Estimating Relative Torque


Potential

The second method used to measure internai and external


torques, depicted in red letters in Figures 4-18 and 4-19,
respectively, is considered a "shortcut" because it is not
necessary to resolve th resultant forces into their com
ponent forces. Consider first internai torque (see Fig. 4 18). The relative internai moment arm (depicted as
IMA2) or leverage of most muscles in th body can
be qualitatively assessed by simply visualizing th shortest
distance between a given whole muscle and th associ
ated joints axis of rotation. This experience can be practiced with th aid of a skeletal model and a piece of
string that represents th resultant muscle's line-of-force
(Fig. 4-20). As apparent in th figure, th moment arm is
greater in position A than in position B\ not coincidentally,
th maximal internai torque of th elbow flexors is also
greater in position A than in position B. In generai, th

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

Esseniial Topics o f Kinesiolog)'

S P E C I A L

F O C U S

4 - 6

Continuai

internai moment arm available to any muscle is greatest


when th angle-of-insertion of th muscle is 90 degrees to
th bone.
Next consider external torque. Clinically, it is often
necessary to quickly compare th relative external torque
generated by gravity or other external forces applied
against a joint. The leverage of an external force, such as
EMA2 in Figure 4-19, may need to be adjusted in order to
match th internai torque potential of th musculature
most effectively. Consider, for example, th external
torque at th knee during two squat postures (Fig. 4-21).
By visualizing th external moment arm between th knee

and th line-of-force from body weight, it can be readily


concluded that th external torque is greater in a deep
squat (A) compared with a partial squat (6). The ability to
judge th relative demand placed on th muscles due to
th external torque is useful in terms of protecting a joint
that is painful or otherwise abnormal. For instance, a
person with arthritic pain between th patella and femur
is often advised to limit activities that involve lowering
and rising from a deep squat position. This activity places
large demands on th quadriceps muscle, which increases th compressive forces on th joint surfaces.

B. 45 of flexion (partial squat)

A, 90 of flexion (deep squat)

FIGURE 4-21. The depth of a squai

significanily affeets th magnimele of


th external torque produced by body
weight at th knee. The relative exter
nal torque, within th sagittal piane,
can be estimated by comparmg th distance that th body weight force vector
falls posteriorly to th medial-lateral
axis of rotation at th knee. The exter
nal moment arm (EMA) and, thus,
th external torque created by body
weight is greater in A than in B.

Clinica! Issues Related to Joint Force and Torque


Joint Protection"

Some treatments in rehabilitation medicine are directed


toward reducing th magnitude of force on joint surfaces
during th performance of a physical activity. The purpose
of such treatment is to protect a weakened or painful joint

from large and potentially damaging forces. This result can


be achieved by reducing th rate of movement (power),
providing shock absorption (e.g., cushioned footwear), or
limiting th mechanical force demands on th muscle.
Minimizing large muscular-based joint forces may be important for persons with prostheses or artifcial joint replace-

Chapter 4

menis. A person with a hip replacemeni, for example, is


often advised on ways to minimize unnecessarily large forces
produced by th hip abductor muscles.9'10J 2 Figure 4 - 2 2
depicts a simple schematic representation of th pelvis and
femur while standing on a tight lower limb that has a prosthetic hip. The snapshot during th single-limb support
phase of gait assumes a condition of static equilibrium (i.e.,
no acceleration is experienced by th pelvis relative to th
femur). In order for equilibrium io be maintained within th
frontal piane, th internai (counterclockwise) and external
(clockwise) torques about th stance hip must be balanced:
th produci of hip abductor force (HAF) times its moment
arm D must equal body weight (BW) times its moment arm
D,, or HAF X D = BW X D,. The external moment arm
about th hip is almost twice th length of th internai
moment arm. The disparity in moment arm lengths requires
that th muscle force be almost twice th force of body
weight in order to maintain equilibrium. In theory, reducing
excessive body weight, carrying lighter loads, or carrying
loads in certain fashions can decrease th external moment
arm and external torque about th hip.9 Reduction of unnec
essarily large external torques can decrease unnecessarily
large force demands on hip abductors and on underlying
prosthetic hip joints.
Certain orthopedic procedures illustrate how concepts of
joint protection are utilized in rehabilitation practice. Con-

Biomechanical Principles

75

sider th case of severe hip osteoarthritis that results in


destruction of th femoral head and an associated decrease
in th size of th femoral neck and head (Fig. 4 -2 3 A ). The
bony loss shortens th internai moment arm length (D)
available to th hip abductor muscles; thus, greater muscle
and joint forces are produced to maintain frontal piane equilibrium. A surgical procedure that is an attempi to reduce
joint forces on th hip entails th relocation of th greater
trochanter to a more lateral position (Fig. 4 - 2 3 B ). This
procedure increases th length of th internai moment arm
of th hip abductor muscles. An increase in th internai
moment arm reduces th force required by th abductor
muscles to generate a given torque during single-limb sup
port of gait.
Manually Applying External Torques During Exercise

External or resistance torques are often applied manually


during an exercise program. For example, if a patient is
beginning a knee rehabilitation program to strengthen th
quadriceps muscle, th clinician may initially apply manual
resistance to th knee extensors at th midtibial region. As
th patients knee strength increases, th clinician can exert a
greater force at th midtibial region or th same force near
th ankle.
Because external torque is th product of a force (resis
tance) and an associated external moment arm, an equivalent

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

Essential Topics o f Kinesiology

FIGURE 4-23. How th internai


moment arm used by th hip abductor muscles is altered by dtsease or surgery. A, The right hip s
shown with partial degeneration of
th femoral head, which decreases
th length of th internai moment
arm (D) to th hip abductor force
(HAF). B, A surgical approach is
shown in which th greater trochanter is relocated to a more fat
erai position, thereby increasing
th length of th internai moment
arm (D) to th hip abductor force.
(Adapted and modified from Neumann DA: Biomechanical analysis
of selected principles of hip joint
protection. Arthr Care Res 2:146155, 1989. Copyright 1989 by th
Arthritis Health Professtons Association.)

external torque can be applied by a relatively short extemal


moment arm and a large external force or a long extemal
moment arm and a smaller extemal force. As depicted in
Figure 4 - 2 4 , th same extemal torque (15 Nm) applied
against th quadriceps muscle can be generated by two different combinations of extemal forces and moment arms.
Note that th resistance force applied io th leg is greater in
Figure 4 -2 4 A than in Figure 4 -2 4 B . The higher contact
force may be uncomfortable for th patient and needs to be
considered during th application of resistance. A larger ex
ternal moment arm, shown in Figure 4 - 2 4 B , may be necessary if th clinictan chooses to manually challenge a muscle
group as potentially forceful as th quadriceps.

INTRODUCTION TO MOVEMENT ANALYSIS:


QUANTITATIVE METHODS OF ANALYSIS
In th previous section, concepts are introduced that provtde
th tramework for performance of quantitative methods of
analysis. Many approaches are applied when solving problems in biomechanics. These approaches can be employed to
assess (1) th effect of a force at an instant in time (forceacceleratici! relationship)', (2) th effect of a force applied over
an in tern i of time (impulse-momentum relationship); and (3)
th application of a force that causes an object to move
through some distance (work-energy relationship). The partic-

4-24. The same extemal


torque (15 Nm) is applied against th
quadriceps muscle by ustng a rela
tively large resistance and small exter
nal moment arm (A), or a relatively
small resistance and large external
moment arm (B). The external mo
ment arms are indicated by th red
lines that extend from th medial-lateral axis of rotation at th knee.
FIGURE

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.

Static Analysis: Forces and Torques are Balanced


Force Equilibrium Equations
2F X = 0
2F y = 0

(Equation 4.14 A)
(Equation 4.14 B)

M
H
II
o

Torque Equilibrium Equation


(Equation 4.15)

GUIDELINES FOR PROBLEM SOLVING


The guidelines listed in Table 4 - 4 can help calculate th
magnitude and direction of muscle force, torque, and joint
reaction force. The following two sample problems illustrate
th use of these guidelines for problem solving in a static
equilibrium situation.
Problem 1
Consider th situation in Figure 4 -2 5 A , in which a person
generates an isometric muscle force at th elbow while hold-

Biom echankal Principles

77

4 - 4 . Guidelines for Solving for Muscle


Force, Torque, and Jo in t Reaction Force

TABLE

1. Draw th free body diagram and indicale all forces acting


on th body or System under consideration. lt is necessary
to establish an XY reference frante that specifies th desired
orentation of th forces. It is often convenirmi to designate
th X axis parallel to th isolated body segment (typically a
long bone), and th Y axis perpendicular to th body seg
ment.
2. Resolve all forces into their tangential and normal components.
3. ldentify th moment arms associated with each force. The
moment arm associated with a given torque is th distance
between th axis of rotation and th 90-degree intersection
with th force. Note that joint reaction force will not have a
moment arm, because it is typically directed through th
center of th joint.
4. Use Equations 4 -1 4 and 4 -1 5 as needed to solve th
problem.

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

Essetuial Topics o f Kinesiology

X
Axis of
rotation

Muscle Force (MF) = unknown


Segment Weight (SW) = 17N
Load Weight (LW) = 60N
Joint Force (JF) at th elbow = unknown
Internai Moment Arm (IMA) to MF = ,05m
External Moment Arm to SW (EMA,) = ,15m
External Moment Arm to LW (EMA2) = ,35m

The resultant muscle (internai) torque is th net sum of


all th muscles that llex th elbow. This type of analysis
does not, however, provide information about how th
torque is distributed among th various elbow fexor mus
cles. This requires more sophisticated procedures, such as
muscle modeling and optimization techniques, which are
beyond th scope of this text.
The muscle force required to maintain th forearm in a
static position at a given instant in time is calculated by
dividing th external torque by th internai moment arm:
MF X IMA = (SW X EMA,) + (LW X EMA,)

Muscle torce (MF) - m

N X 0.15 m) + (so N X 0.35

FIGURE 4-25. Problem 1. A, An isometric elbow


flexion exercise is performed against a load weight
held in th hand. The forearm is held in th horizontal position, parallel to th X axis. B, A free
body diagram is shown of th exercise, including a
box with th abbreviations and data required to
solve th problem. The medial-lateral axis of rota
tion at th elbow is shown as an open red circle.
(A modified from LeVeau BF: Williams & Lissner's
Biomechanics of Human Motion, 3rd ed. Philadelphia, WB Saunders, 1992.)

disparity in moment arm length is not unique to th elbow


flexion model, bui it is ubiquitous throughout th muscularjoint systems in th body. For this reason, most muscles of
th body routinely generate a force many times greater than
th weight of th external load. This principle requires that
th bone and articular cartilage absorb large joint forces that
result from seemingly nonstressful activities.
Solving for Joint Force

Because th joint reaction force (JF ) is th only remaining


unknown variable depicted in Figure 4 - 2 5 B , this variable is
determined by Equation 4.14 B, where downward forces are
negative.
XFy = 0

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

bow flexion exercise is performed against an


identical load weight as that depicted in Figure
4 - 2 5 . The forearm is held 3 0 degrees below
th horizontal position. B, A free body diagram is shown including a box with th abbreviations and data required to solve th
problem. C, The joint reaction force (JF ) vectors are shown in response to th biomechanics depicted in B. (A modified from LeVeau
BF: Williams & Lissners Biomechanics of Hu
man Motion, 3rd ed. Philadelphia, WB Saunders, 1992.)

79

through th axis of rotation and, therefore, has a zero mo


ment arm.

'X

FIGURE 4 - 2 6 . P ro b le m 2. A, An isometric el

Biomcchanical Principles

Angle of forearm segment relative to horizontal (8) = 30


Muscle Force (MF) = unknown
Angle of insertion of MF to forearm (a) = 60
MF* and MFy = unknown
Segment Weight (SW) = 17N
SWX = (sin 8) x SW
SWy = (cos 8) X SW
Load Weight (LW) = 60N
LWX = (sin 8) x LW
LWy = (cos 8) x LW
Joint Force (JF) at th elbow = unknown
Angle of approach of JF to X axis (py) = unknown
JFy and JFX = unknown
Internai Moment Arm (IMA) to MFy= ,05m
External Moment Arm to SWy = (EMA,) = .15m
Extemal Moment Arm to LWy= (EMA2) = ,35m

80

Secticm I

Essendal Topici of Kinesiology

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.

Internai torque = external torque

2Fy = 0

Internai torque = (SWY X EMA,) 4- (LWY X EMA2)*

MF y - SWY - LWV - JF y = 0

Internai torque = (cos 30 X 17 N X 0.15 m)


4- (cos 30 X 60 N X 0.35 m)

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)

Internai torque = 20.4 Nm


- J F Y = - 3 4 1 .3 N
The muscle force required to generate th internai flexor
torque at th elbow is determined by

JF y = 341.3 N

MFY X IMA = (SWY X EMA,) + (LWY X EMA2)

2FX = 0

. (co s 3 0 X 17 N X Q .15 m ) 4- (co s 3 0 X 6 0 N X 0 .3 5 m )

- M F X + SWX 4- LWX + JF X = 0

.0 5 m

JF X = MFX - SWX - LWX


MFy = 4 08.0 N
Because an internai moment arm length of .05 m was used,
th last calculation yielded th magnitude of its associateci
perpendicular vector, MFY, not MF. The resultant muscle
force, or MF, can be determined by
MF = MFY/sin 60

JF X = 2 35.6 N - (sin 30 X 17 N) - (sin 30 X 60 N)


JF X = 197.1 N
As depicted in Figure 4 26C, JF V and JF X act downward
and lo th right, respectively, in a direction that opposes th
force of th muscle. The magnitude of th resultant joint
force (JF ) can be determined using th Pythagorean theorem:
JF = V (J F Y2) + (JF X2)

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

interest is th direction of th JF with respect to th axis (X)


of th forearm. This is calculated using th relationship:
tan /a = JF y/JFx
l i = tan-' (341.3 N/197.1 N)
H = 60
The resultant joint reaction force has a magnitude of
394.1 N and is directed toward th elbow at an angle of 60
degrees to th forearm segment (i.e., th X axis). The angle
is th same as th angle-of-insertion of th muscle, a reminder of th dominant role of muscle in determining both
th magnitude and direction o f th joint reaction force.

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

Kinematic Measurement Systems: Electrogoniometer,


Accelerometer, Imaging Techniques, and
Electromagnetic Tracking Devices
Detailed analysis of movement requires a careful and objective evaluation of th motion of th joints and body as a
whole. The analysis most frequently includes an assessment
of position, displacement, velocity, and acceleration. Analysis
may be used to indirectly measure forces produced by th
body or to assess th quality and quantity of motion without
regard to forces and torques. Kinematic analysis is performed
in a variety of environments, including sport, ergonomics,
and rehabilitation.
Electrogoniometer

An electrogoniometer measures joint angular displacement


during movement. The device typically consists of an electrical potentiometer built into th pivot point (hinge) of two
rigid arms. Rotation of a calibrated potentiometer measures
th angular position of th joint. The output can be sent to
a chart recorder or oscilloscope, or more frequently it is
used as input to a computer program. The arms of th
electrogoniometer are strapped to th body segments, such
that th axis of rotation of th goniometer (potentiometer) is
approximately aligned with th joints axis of rotation (Fig.
4 - 2 7 ) . The position data obtained from th electrogoniome-

Dynamic Analysis of Force and Torque


Force Equations

SF X = max

(Equation 4.16 A)

2F y = mav

(Equation 4.16 B)

M
H
II
P

Torque Equation

(Equation 4.17)

KINEMATIC AND KINETIC MEASUREMENT SYSTEMS


This section introduces common methods and systems used
to collect kinematic and kinetic data in th study of human
movement.11314-16 The reader is referred to th Additional
Readings at th end of this chapter for further elaboration of
th uses, advantages, and disadvantages of these measurement techniques.

FIGURE 4-27. An electrogoniometer is shown strapped to th thigh


and leg. The axis of th goniometer contains th potentiometer and
is aligned over th medial-lateral axis of rotation at th knee joint.
This particular instrument records a single piane of motion only.

82

Section l

Essential Topici o j Kinesiology

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

An accelerometer is a device that measures acceleration of


th segment to which it is attached. Accelerometers are force
transducers consisting of a strain gauge or piezoresistive Cir
cuit that measures th reaction forces associated with a given
acceleration. Based on Newtons second law, acceleration is
determined as th ratio of th measured force divided by a
known mass.
Imaging Techniques

Imagng techniques are th most widely used methods for


collecting motion data. Many different types of imaging Sys
tems are available. This discussion is limited to th Systems
listed in th box.

Imaging Techniques

Photography
Cinematography
Videography
Optoelectronics

processor or an interface that digitizes th analog signal, a


calibration device, and a computer. The procedures involved
in video-based systems typically require markers to be at
tached to a subject at selected anatomie landmarks. Markers
are considered passive if they are not connected to another
electronic device or power source. Passive markers serve as a
light source by refiecting th light back to th camera (Fig.
4 - 2 8 ) . Two- and three-dimensional coordinates of markers
are identified in space by a computer and are then used to
reconstruct th image (or stick figure) for subsequent kine
matic analysis.
Video-based systems are quite versatile and are used to
analyze activities from swimming io typing. Some systems
allow movement to be captured outdoors and processed at a
later time. Another desirable feature of th System is that th
subject is not encumbered by wires or other electronic devices.
Optoelectronics is another popular type of kinematic acquisition System that uses active markers that are pulsed sequentially. The light is detected by special cameras that fo
cus it on a semiconductor diode surface. The System enables
collection of data at high sampling rates and" can acquire
real-time 3D data. The System is limited in its ability to
acquire data outside a controlled environment. Subjects may
feel hampered by th wires that are connected to th active
markers. Telemetry systems enable data to be gathered without th subjects being tethered to a power source, but they
are vulnerable to ambient electrical interference.
Electromagnetic Tracking Devices

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

transmitters. Although telemetry is available for these Sys


tems, most operate with wires that connect th receivers to
th data capture System. The wires limit th volume of space
from which motion can be recorded.
In any motion analysis System that uses skin sensors to
record underlying bony movement, there is th potential for
error associated with th extraneous movement of skin and
soft tissue.

Kinetic Measurement Systems: Mechanical Devices,


Transducers, and Electromechanical Devices
Mechanical Devices

Mechanical devices measure an applied force by th amount


of strain or th compression of deformable material.
Through purely mechanical means, th strain in th material
causes th movement of a dial. The numeric values associ
ated with th diai are calibrated to a known force. Some of
th most common mechanical devices for measuring force
include a bathroom scale, a grip strength dynamometer, and
a hand-held dynamometer. The hand-held dynamometer, for
example, provides useful clinical measurement of th internai
torque produced by a patient (Fig. 4 - 2 9 ) . In th example,
th dynamometer measures a resistance force (RF) in response to a maximal effort, isometrically produced elbow
extension torque. The triceps force (TF) is determined by
dividing th external torque (RF X EMA) by an estimate of
th internai moment arm.

FIGURE 4-29. A hand-held dynamometer is used to measure th


isometric elbow extension torque produced by th triceps musele.
The product of th resistive force (RF) times its external moment
arm (EMA), assuming static equilibrium, is equal io th product of
th triceps force (TF) times its internai moment arm (IMA).

anatomie landmarks. Position and orientation data from th


receivers located within a specified operating range of th
transmitter are sent to th data capture System.
One disadvantage of this System is that th transmitters
and receivers are sensitive to metal in their vicinity. The
metal distorts th electromagnetic field generated by th

FIGURE 4-30. Output from a force


piate indicates ground reaction forces
(GRF) in th vertical (V), medial-lateral
(ML), and anterior-posterior (AP) directions during a normal walking trial.

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

Essentia Topics o f Kinesiology

Transducers

Vartous types of transducers have been developed and


widely used to measure force. Among these are strain gauges
and piezoelectric, piezoresistive, and capacitance transducers
Essentially, these transducers operate on th principle that
an applied force deforms th transducer, resulting in a
change in voltage in a known manner. Output from th
transducer is converted to meaningful measures through a
calibration process.
One of th most common transducers for collecting kinetic data while a subject is walking, stepping, or running is
th force piate. Force plates utilize piezoelectric quartz or
strain gauge transducers that are sensitive to load in three
orthogonal directions. The force piate measures th ground
reaction forces in vertical, medial-lateral, and anterior-posterior components (Fig. 4 - 3 0 ) . Each component has a characteristic shape and magnitude. The ground reaction force data
can be used as input for subsequent dynamic analysis.
Electromechanical Devices

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.)

introduction to th "Inverse Dynamic Approach" for


Solving for Internai Forces and Torques

Measuring joint reaction forces and muscle-produced net


torques during dynamic conditions is often performed indirectly utilizing a technique called th inverse dynamic
approach.'6 This approach uses data on anthropometry,
kinematics, and external forces, such as gravity and con
tact forces. Accelerations are determined employing th
first and second derivatives of position-time data to yield
velocity-time and acceleration-time data, respectively. The
importance of acquiring accurate position data is a pre
requisite to th soundness of this approach, because errors in measuring position data magnify errors in velocity
and acceleration.

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.

In th inverse dynamics approach, th System under


consideration is often defined as a series of links. Figure
4-32A illustrates th relationship between th anatomie
link segment models of th lower limb. In Figure 4-326,
th segments are disarticulated and th individuai forces
and torques are identified at each segment end point. The
center of mass is located for each segment. The analysis
on th series of links usually begins with th analysis of
th most distai segment, in this case th foot. Information
gathered through motion analysis techniques, typically
camera-based, serves as input data for th dynamic equations of motion. This information includes th position and
orientation of th segment in space, th acceleration of
th segment and segment center of mass, and th reac
tion force acting on th distai end of th segment. From

Chapter 4

these data, th reaction force and th net muscle torque


at th ankle joint are determined. This information is then
utilized as input for continued analysis of th next most
proximai segment, th leg. Analysis takes place until all
segments or links in th model are studied. Several assumptions made during th use of th inverse dynamic
approach are included in th box.

85

Biomechanical Principles

Assumptions Made During th Inverse Dynamic


Approach
1. Each segment or link has a fixed mass that is concentrated at its center of mass.
2. The location of each segments center of mass remains fixed during th movement.
3. The joints in this model are considered frictionless
hinge joints.
4. The mass moment of inertia of each segment is
Constant during th movement.
5. The length of each segment remains Constant.

JFX

FIGURE 4-32. A link model of th lower limb consisting of three


segments: thigh (T), leg (L), and foot (F). In A, th center of mass
(CM) of each segment is represented as a fixed point (red circle):
CMt , CMl , and CMF. in B, th segments are disarticulated in order
for th internai forces and torques to be determined, beginning
with th most distai foot segment. The red curved arrows represents torque about th axes of rotation. (W , segment weight; JF X
and JF y, joint forces in th horizontal (X) vertical (Y) directions;
GRFX and GRFY, ground reaction forces in th horizontal (X) and
vertical directions (Y).)

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.

Guccione AA (ed): Geriatrie Physical Therapy, 2nd ed. St, Louis,


Mosby, 2000.
Ozkaya N, Nordin M: Fundamentals of Biomechanics: Equilibrium, Motion and Deformation. New York, Springer-Verlag, 1999.
Soderberg GL: Kinesiology: Application io Pathological Motion, 2nd ed.
Baltimore, Williams & Wilkins, 1997.
Whiting WC, Zemicke RF: Biomechanics of Musculoskeletal Injury.
Champaign, Human Kinetics, 1998.
Winter DA: Biomechanics and Motor Control of Human Movement,
2nd ed. New York, John Wiley &r Sons, 1990
Zatsiorsky VM: Kinematics of Human Motion. Champaign, Human Ki
netics, 1998.
Zatsiorsky VM, Seluyanov V: Esumation of th mass and inertia characteristics of th human body by means of ihe best predictive regression
equations. In DA Winter, RW Norman, RP Wells, et al (eds): Biome
chanics. Champaign, Human Kinetics, 1985.

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

Appendix IA: Selected Anthropometric Data


Table 1A1 provides selected anthropometric data on a 670-N
man.

Appendix IB: The "Right-Hand" Rule


As stated in Chapter 1, a torque is detned as a force multiplied by its moment arm. Force is a vector quantity that
possesses both magnitude and direction. Moment arm
length, however, can be treated as a vector or as a scalar
quantity. When considering a moment arm as a vector,
torque is calculated as th product of two vectors. Multiplying two orthogonal vectors (force and its moment arm)
through cross-product multiplication yields a third vector
(torque) that is directed perpendicularly to th piane that
contains th other two vectors. Using this scheme, th elbow
flexors in Figure 1 - 1 7 , for example, would produce an
internai torque vector that is directed either into th page or
out ol th page. The right-hand rule is a convention that
can be used to assign a direction to a vector product. The
fingers of th righi hand are curled in th direction of th
rotating segment. The positive direction of th torque is
defined by th direction of th extended thumb. In Figure
1 - 1 7 , th direction of th internai torque is out of' th
page, or in a positive Z direction.

Figure IC1 illustrates th use of trigonometry io deter


mine th force components of th posterior deltoid muscle
during active isometric activation. The angle-of-insertion (a
of th muscle with th bone is 45 degrees. Based on th
particular reference frame, th rectangular components of th
muscle force (MF) are labeled MFY (tangential force) and
MFX (normal force). Given a Constant muscle force of 200
N, MFY and MFX can be determined as follows:
MFX = MF sin 45 = 200 N X 0 .707 = 141.4 N
MF y = MF cos 45 = 200 N X 0 .707 = 141.4 N
Il MFx and MFY are known, MF (hypotenuse) can be deter
mined using th Pythagorean theorem:
MF2 = MFX2 + MFy2
MF = V 1 4 1 .4 2 4- 141.42
MF s 200 N

Appendix IC: Basic Review of Trigonometry


Trigonometrie functions are based on th relationship that
exists between th angles and sides of a right triangle. The
sides of th triangle can represent distances, force magni
tude, velocity, and other physical properties. Four of th
common trigonometrie functions used in quantitative analysis are found in th following table. Each trigonometrie function has a speciftc value for a given angle. If th vectors
representng two sides of a right triangle are known, th
remaining side of th triangle can be determined by using
th Pythagorean theorem: a2 = b2 + c2, where a is th
hypotenuse of th triangle. If one side and one angle other
than th right angle are known, th remaining parts of th
triangle can be determined by using one of th four trigono
metrie functions listed in th table.

Right-Angle Trigonometrie Functions Commonly Used in


Biomechanical Analysis

86

Trigonometrie Function

Definition

Sine (sin)

Side opposite/hypotenuse

FIGURE IC1. Given an angle-of-insertion of th posterior deltoid

Cosine (cos)

Side adjacent/hypotenuse

Tangent (tan)

Side opposite/side adjacent

Cotangent (cot)

Side adjacenbside opposite

(a = 45 degrees) and th resultant posterior deltoid muscle force


(MF), th two rectangular force components of th muscle force
(MFX and MFV) are detennined using trigonometrie relationships.
The axis of rotation at th glenohumeral joint is indicated by th
open circle at th head of th humerus.

A p p e n d ix I

87

TABLEI A- 1 . Selected Anthropometric Data on a 670-N (64.4 kg) Man


Location of Centers of Mass

Segment Weight*
H ea d :

46.2 N (6.9%)

H ea d a n d n ec k :

In spbenoid sinus, 4 mm beyond anterior inferior margin of sella. (On lateral


surface, over temporal fossa on or near nasion-inion line.)
H e a d a n d n ec k : On inferior surface of basioccipital bone or within bone 23 5 mm from
crest of dorsum sellae. (On lateral surface, 10 mm anterior to supratragal notch above
head of mandible.)
H ea d , n eck , a n d tru n k: Anterior io eleventh thoracic vertebra.

H ea d :

52.9 N (7.9%)

H ead, n eck , a n d tru n k:

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:

U p p er lim b: Just above elbow joint.


Arm: In mediai head of triceps, adjacent to radiai groove; 5 mm proximal to distai end of
deltoid insertion.
Forearm. 11 mm proximal to most distai pan of pronator teres insertion; 9 mm anterior to
interosseous membrane.
H a n d (in rest position): On axis of metacarpal III, usually 2 mm deep to volar skin surface;
2 mm proximal to transverse palmar skin crease, in angle between proximal transverse
and radiai longitudinal crease.

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

L o w e r lim b: Just above knee joint.


T high: In adductor brevis muscle (or

magnus or vastus medialis) 13 mm mediai to linea


aspera, deep to adductor canal; 29 mm below apex of femoral triangle and 18 mm
proximal to most distai fibers of adductor brevis.
L eg: 35 mm below popliteus, at posterior part of posterior tibialis; 16 mm above proximal
end of Achilles tendon; 8 mm posterior to interosseous membrane.
F oot: In piantar ligaments, or just superficial in adjacent deep foot muscles; below proximal
halves of second and third cuneiformi bones. On a line between ankle joint center and
ball of foot in piane of metatarsal 11.
E n tire b o d y .

Anterior to second sacrai vertebra.

Expressed in newtons (N) and percentage of total body weight.


Based on Dempster WT: 1955: Space requiremems for ihe seated operator WADC-TR-55-159, Wright Patterson Air Force Base. Value for head weighl
was compuied from Braune and Fischer, 1889. Centers of mass loci are from Dempsier except those for entire limbs and body.

The norma] and tangential components of external forces,


such as those exerted by a wall pulley, body weight, or by
th clinician manually, are determined in a manner similar
to that described for th muscle (internai) force.
Trigonometry can also be used to determine th magnitude of th resultant force when one or more components
and th angle-of-insertion are known. Consider th same
example as given in Figure 1C1, but now consider th goal
of th analysis to be determination of th resultant muscle
force of th posterior deltoid muscle. The muscle angle-ofnsertion is 45 degrees and MFX is 141.4 N. The resultant
muscle force (hypotenuse of th triangle) can be derived
using th relationship of th rectangular components:

sin 45 = MFX/MF
MF = 141.4 N/sin 45
MF =

200 N

If only MFY and MFX are known, th angle-of-insertion of


MF can be determined using th inverse tan 1 a . Note that
th components of th force always have a magnitude less
than th magnitude of th resultant vector.

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

Ap p e n d ix 11: Reference Material on Innervation and Attachments of th Muscles of th

Upper Extremity

Section II is made up of four chapters, each describing th kinesiology of a major


arncular region within th upper extremity. Although presented as separate anatomie
entities, th four regions cooperate functionally to place th hand in a position to most
optimally interact with th environment. Disruption in th function of th muscles or
jotnts of any region can greatly interfere with th capacity of th upper extremity as a
whole. As described through Section II, impairments nvolving th muscles and joints
of th upper extremity can significanti reduce th quality or th ease of performin^
many important activities related to personal care, livelihood, and recreation.

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

Elevation and Depression, 100


Protraction and Retraction, 100
Axial (Longitudinal) Rotation of th
Clavicle, 100
Acromioclavicular Joint, 100
G en era l F e a tu re s, 100
P e ria rtic u la r C o n n e c tiv e T is s u e , 101
K in e m a tic s , 101

Upward and Downward Rotation, 102


Horizontal and Sagittal Piane
"Rotational Adjustments" at th
Acromioclavicular Joint, 102
Scapulothoracic Joint, 102
K in e m a tic s , 103

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

Glenohumeral Joint, 104

Innervation of th Muscles and Joints of


th Shoulder Complex, 115
Muscles of th Scapulothoracic
Joint, 118
E le va to rs o f th S c a p u lo th o ra c ic
J o in t, 118
D e p re s s o rs o f th S c a p u lo th o ra c ic

G en era l F e atures, 104


P e ria rtic u la r C o n n e c tiv e T issu e , 105
S ta tic S ta b ility a t th G le n o h u m e ra l
J o in t, 108
C o ra c o a c ro m ia l A rc h and A s s o c ia te d
B u rs a , 109
K in e m a tic s a t th G le n o h u m e ra l

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

Muscles that Elevate th Arm, 120

J o in t, 110

Abduction and Adduction, 110


Flexion and Extension, 112
Internai and External Rotation, 113
Summary of Glenohumeral Joint
Arthrokinematics, 114
Overall Shoulder Kinematics During
Abduction, 114
S c a p u lo h u m e ra l R hythm , 114
S te rn o c la v ic u la r and A c ro m io c la v ic u la r
J o in t In te ra c tio n , 114

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

Muscles that Adduct and Extend th


Shoulder. 127
Muscles that Internally and Externally
Rotate th Shoulder, 129

MUSCLE A N D J O IN T IN TER AC TIO N , 115

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.

paralysis or weakness of any single muscle often disrupts th


naturai kinematic sequencing of th entire shoulder. This
chapter describes several of th important muscular synergies
that exist at th shoulder complex and how weakness in one
muscle can affect th force generation potential in others.

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

The lateral or acromial end of th clavicle articulates with


th scapula at th oval-shaped acromial facet (see Fig. 5 - 3 :
inferior surface). The inferior surface of th lateral end of th
clavicle is well marked by th conoid tubercle and th trape
zoid line.

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

FIGURE 5 -1 . The joints of th righi shoulder complex.

jugular notch is locateci at th superior aspect of th manubrium, between th clavicular facets.

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.

Osteologie Features of th Clavicle


Shaft
Costai facet
Costai tuberosity
Acromial facet
Conoid tubercle
Trapezoid line

FIGURE 5 -2 . An anterior view of th stemum with left clavicle and


ribs removed. The dashed line around th clavicular facet shows
th attachments of th capsule at th sternoclavicular joint. Proximal attachments of muscle are shown in red.

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.

FIGURE 5 -4 . Superior view of both shoulders in th anatomie position. Angle A: th orientation of th


clavicle deviated about 20 degrees posterior io th frontal piane. Angle B: th orientation of th scapula
(scapular piane) deviated about 35 degrees anterior to th frontal piane. Angle C: retroversion of th humeral
head about 30 degrees posterior to th medial-lateral axis at th elbow. The right clavicle and acromion have
been removed to expose th top of th right glenohumeral joint.

93

94

Section II

Upper Extremity

Posterior view

Anterior view

Upper trapezius

Middle and anterior deltoid


Upper trapezius
Short head
biceps and
coracobrachialis

lSupraspinatusv
in
supraspinatous

j,

ta s s a i1

Levator
scapulae'

f
Rhomboid
___ minor

Long head biceps


on supraglenoid
Lower
tubercle
and
middle
Pectoralis
trapezius
m in o r

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.

Osteologie Features of the Scapula


Angles: inferior, superior, and lateral
Mediai or vertebral border
Lateral or axillary border
Superior border
' Supraspinatous fossa
Infraspinatous fossa
Spine
Root of the spine
Acromion
Clavicular facet
Glenoid fossa
Supraglenoid and infraglenoid tubercles
Coracoid process
Subscapular fossa

The posterior surface of the scapula is separated into a


supraspinatous fossa and infraspinatous fossa by the prominent
spine. The depth of the supraspinatous fossa is filled by the
supraspinatus muscle. The mediai end of the spine diminishes
in height at the root o f the spine. In contrast, the lateral end of
the spine gains considerable height and flattens into the broad
and prominent acromion. The acromion extends in a lateral
and anterior direction, forming a horizontal shelf over the
glenoid fossa. The clavicular facet on the acromion marks the
surface of the acromioclavicular joint (see Fig. 5 -1 7 B ).
The scapula articulates vvith the head of the humerus at
the slightly concave glenoid fossa (from the Greek root glene;

Socket of joint, + eidos; resembling) (Fig. 5 - 5 B). The


glenoid fossa is tilted upwardly about 5 degrees relative to
the scapulas mediai border (Fig. 5 - 6 ) . At resi, the scapula
is normally positioned against the posterior-lateral surface of
the thorax vvith the glenoid fossa facing about 35 degrees

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

fossa are th supraglenoid and in/raglenoid tubercles. These


tubercles serve as th proximal attachment for th long head
of th biceps and triceps brachii, respectively (see Fig.
5 - 5 B). Near th superior rim of th glenoid fossa is th
prominent coracoid process, meaning th shape ol a crows
beak. The coracoid process projects sharply from th scap
ula, providing multiple attachments for ligaments and muscles (Fig. 5 - 7 ) . The subscapular fossa is located on th ante
rior surface of th scapula. The concavity within th fossa is
filled with th thick subscapularis muscle (see Fig. 5 -5 B ).

Proximal-to-Mid Humerus

FIGURE 5-7. A close-up view of th righi coracoid process looking


from above. Proximal attachraents of muscle are in red, distai attachments in gray. Ligamentous attachment is indicated by light
gray area outlined by dashed line.

anterior to th frontal piane (see Fig. 5 - 4 ; angle B). This


orientation of th scapula is called th scapular piane. The
scapula and humeras tend to follow this piane when th
arm is raised over th head.
Located at th superior and inferior rim of th glenoid

The head o f th humerus, nearly one half of a full sphere,


forms th convex component of th glenohumeral joint (Fig.
5 - 8 ) . The head faces medially and superiorly, forming an
approximate 135-degree angle of inclination with th long
axis of th humeral shaft (Fig. 5 -9 A ). Relative to a mediallateral axis through th elbow, th humeral head is rotated
posteriori)' about 30 degrees within th horizontal piane
(Fig. 5 -9 B ). This rotation, known as retroversion (from th
Latin root retro; backward, + verto; to turn), orients th
humeral head in th scapular piane for articulation with th
glenoid fossa (Fig. 5 - 4 ; angle C).
The anatomie neck of th humerus separates th smooth
articular surface of th head from th proximal shaft (Fig.
5 -8 A ). The prominent lesser and greater tubercles surround
th anterior and lateral circumference of th extreme proxi
mal end of th humerus (Fig. 5 -8 B ). The lesser tubercle

Superior view

FIGURE 5-8. Anterior (A) and superior (B) aspeets of th nght


humerus. The dashed line in A shows th capsular attachments
around th glenohumeral joint. Distai attachment of muscles is
shown in gray.

96

Section II

Upper Exiremity

projects rather sharply and anteriorly for attachment of th


subscapularis. The large and rounded greater tuberete has an
upper, middle, and lower Jacet, marking th distai attachment
of th supraspinatus, infraspinatus, and teres minor respeclively (Figs. 5 - 8 B and 5 - 1 0 ) .
Sharp crests extend distally trom th anierior side of th
greater and lesser tubercles. lhese crests receive th distai
attachments of th pectoralis major and teres major (see Fig.
5 -8 A ). Between these crests is th intertubercular fridpital)
groove, which houses th long head of th tendon of th
biceps brachii. The latissimus dorsi muscle attaches to th
floor of th intertubercular groove, mediai to th biceps
tendon. Distai and lateral to th termination of th intertu
bercular groove is th deltoid tuberosity.

Osteologie Features of th Proximal-to-Mid Humerus


Head of th humerus
Anatomie neck
Lesser tubercle and cresi
Greater tubercle and erest
Upper, middle, and lower facets on th greater tubercle
Intertubercular (bicipital) groove
Deltoid tuberosity
Radiai (spirai) groove

Ihe radiai (spirai) groove runs obliquely across th posterior surlace of th humerus. The groove separates th proxi-

mal attachments of th lateral and mediai head of th triceps


(see Fig. 5 - 1 0 ) . Traveling distally, th radiai nerve spirals
around th posterior side of th humerus in th radiai
groove, heading toward th distal-latera! side of th hu
merus.

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

The joints of th shoulder complex function as a series of


links, all cooperating to maximize th range of motion available to th upper lim. A weakened, painful, or unstable
link anywhere along th chain significantly decreases th
effectiveness of th entire complex.
Before discussion of th kinematic analysis of th sternoclavicular and acromioclavicular joints, th movements at th
scapulothoracic joint must be defined (Fig. 5 - 1 1 ) . The primary movements of th scapulothoracic joint are elevation
and depression, protraction and retraction, and upward and
downward rotation.

Posterior view

Movements at th Scapulothoracic Joint


Elevation and depression
Protraction and retraction
Upward and downward rotation

Elevation. The scapula slides superiorly on th thorax,


such as in th shrugging of th shoulders.

Depression. From an elevateci


slides inferiorly on th thorax.

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.

Four Joints Within th Shoulder Complex


1.
2.
3.
4.

Sternodavicular
Acromioclavicular
Scapulothoracic
Glenohumeral

Elevation and Depression

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-

Retraction and Protraction

Downward and Upward Rotation

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

FIGURE 5-12. The stemoclavicular


joints. The capsule and lateral sec
tion of th anterior bundle of th
eostoclavicular ligament have been
removed on th left side.

ponent of th lowering of th arra to th side from th


elevated position.

Stemoclavicular Joint
GENERAL FEATURES
The stemoclavicular (SC) joint is a complex articulation,
invohing th mediai end of th clavicle, th clavicular facet

on th sternum, and th superior border of th cartilage of


th hrst rib (Fig. 5 - 1 2 ) . The joint is th basilar joint of th
upper extremity, linking th axial skeleton with th appendicular skeleton. As such, th SC joint is subjected to unique
functional demands that are met by a complex saddleshaped articular surface (Fig. 5 - 1 3 ) . 68 Although highly variable, th mediai end of th clavicle is usually convex along
its longitudinal diameter and concave along its transverse

FIGURE 5-13. An anterior-lateral view of th ar


ticular surfaces of th right stemoclavicular joint
The joint has been opened up to expose its artic
ular surfaces. The longitudinal diameters (red)
extend roughly in th frontal piane between su
perior and inferior points of th articular sur
faces. The transverse diameters (gray) extend
roughly in th horizontal piane between anterior
and posterior points of th articular surfaces.

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.

PERIARTICULAR CONNECTIVE TISSUE


The SC joint is enclosed by a capsule reinforced by anteror
and posterior stemocavicular ligaments (Fig. 5 - 1 2 ) . The inner
surface of th capsule is lined with synovial membrane. In
addition, th joint is stabilized anteriorly by th sternal head
of th stemocleidomastoid and posteriorly by th stemothyroid and stemohyoid muscles. The interclavicular ligament
spans th jugular notch, connecting th mediai end of th
right and left clavicles.

Tissues That Stabilize th SC Joint


Anterior and postenor stemocavicular ligaments
Interclavicular ligament
Costoclavicular ligament
Articular disc
Stemocleidomastoid, stemothyroid, and stemohyoid mus
cles

The costoclavicular ligament is a strong structure extending


from th cartilage of th first rib to th costai tuberosity on
th inferior surface of th clavicle. The ligament has two
distinct fiber bundles running perpendicular to each other.68
The anterior bundle runs obliquely in a superior and lateral
direction, and th more posterior bundle runs obliquely in a
superior and mediai direction (see Fig. 5 - 1 2 ) . The costo
clavicular ligament firmly stabilizes th SC joint and limits

FIGURE 5-14. The righi stemocavicular joint


showing th osteokinematic motions of th
clavicle. The motions are elevation and depression in a near frontal piane (red), protraction
and retraction in a near horizontal piane
(gray), and posterior elavicular rotation in a
near sagittal piane (white). The vertical axis
(gray) and anterior-posterior axis (red) are
color-coded with th corresponding planes of
movement. Longitudinal axis is indicated by
th dashed line.

Shoulder Complex

99

th extremes of all elavicular motion, except for a downward


movement of th clavicle (i.e., depressioni.
The articular disc at th SC joint separates th joint into
distinct mediai and lateral joint cavities (see Fig. 5 - 1 2 ) . The
disc is a flattened piece of fbrocartilage that attaches inferiorly near th lateral edge of th elavicular facet and superiorly at th head of th clavicle and interclavicular ligament.
The remaining outer edge of th disc attaches to th internai
surface of th capsule. The disc functions as a shock absorber within th joint by increasing th surface area of joint
contact. This absorption mechanism apparently works well
since significant age-related degenerative arthritis is relatively
rare at this jo in t.16
The tremendous stability at th SC joint is due to th
arrangement of th surrounding periarticular connective tis
sues.12 Large medially directed forces through th clavicle
often cause fracture of th bones shaft instead of a SC joint
dislocation. Clavicular fractures are most common in males
under 30 years old. Most often these fractures are th result
of contact-sport or road-traffic accidents.51

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

FIGURE 5 - 1 5 . Anterior view of a medianica!


diagram of ihe anhrokinematics of roll and
slide during elevation (A) and depression (B,
of ihe clavicle about th right sternoclavicular joint. The axes of rotation are shown in
th anterior-posterior direction near th head
of th clavicle. Stretched structures are
shown as thin elongated arrows, slackened
structures are shown as wavy arrows. Note
in A that th stretched costoclavicular ligament produces a downward force in th di
rection of th slide. (Costoclavicular ligameni
CCL, superior capsule = SC, interclavicular ligament = 1CL.)

Elevation and Depression


Elevation and depression of th clavicle occur approximately
parallel to th frontal piane about an anterior-posterior axis
of rotarion (see Fig. 5 - 1 4 ) . A maximum of approximately
45 degrees of elevation and 10 degrees of depression have
been reported.11-38 Elevation and depression of th clavicle
are associated with a similar motion of th scapula.
1 he arthrokinematics for elevation and depression of th
clavicle occur along th SC joints longitudinal diameter (see
Fig. 5 - 1 3 ) . Elevation of th clavicle occurs as th convex
sur face of its head rolls superiorly and stmultaneously slides
inferiorly on th concavity of th stemum (Fig. 5 -1 5 A ). The
stretched costoclavicular ligament helps stabilize th position
of th clavicle. Depression of th clavicle occurs by action of
its head rolling inferiorly and sliding superiorly (Fig.
5 -1 5 B ). A fully depressed clavicle elongates and stretches
th interclavicular ligament and th superior portion of th
capsular ligaments.4
Protraction and Retraction
Protraction and retraction of th clavicle occur nearly parallel
to th horizontal piane about a vertical axis of rotation (see
Fig. 5 - 1 4 ) . The axis is shown in Figure 5 - 1 4 intersecting
th stemum because, by convention, an axis of rotation
always intersects th convex member of a joint for a particular movement. At least 15 to 30 degrees of rotation in each
direction have been reported .11-38^ The horizontal piane motions of the clavicle are associated with a similar protraction
and retraction motion of the scapula.
Ih e arthrokinematics for protraction and retraction of the
clavicle occur along the SC joints transverse diameter (see
F*S- 5 13). Retraction occurs as the concave articular surface of the clavicle rolls and slides posteriorly on the convex
surface of the stemum (Fig. 5 - 1 6 ) . The end ranges of re
traction elongate the anterior bundles of the costoclavicular
ligament and the anterior capsular ligaments.
The anhrokinematics of protraction about the SC joint are
similar to those of retraction, except that they occur in an
antenor direction. The extremes of protraction occur during a
motion involving maximal forward reach. Excessive tightness
in the posterior bundle of the costoclavicular ligament, th
posterior capsular ligament, and the scapular retractor muscles
may limit the extreme of clavicular protraction.

Axial (Longitudinal) Rotation of the Clavicle


The 3rd degree of freedom ai the SC joint is a rotation of
th clavicle about the bones longitudinal axis (see Fig
5 - 1 4 ) . When the shoulder is abducted or fexed, a point on
the superior aspect of the clavicle rotates posteriorly approxi
mately 40 to 50 degrees.26-63 As the arm is returned to the
side, the clavicle rotates back to its originai position.
The arthrokinematics of clavicular rotation involve a spin
of th head of the clavicle about the lateral surface of the
articular disc. Full posterior rotation of the clavicle is considered the close-packed position of the SC joint.68

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.

corresponding acromial facet on th clavicle. An articular


disc of varying form is present in most AC joints.
The AC joint is most often described as a gliding or piane
joint, reflecting th predominantly fiat contour of th joint
surfaces. Joint surfaces vary, however, from fiat to slightly
convex or concave (Fig. 5 - 1 7 B ). Because of th predomi
nantly fiat joint surfaces, roll-and-slide arthrokinematics are
noi here described.

PERIARTICULAR CONNECTIVE TISSUE


The AC joint is surrounded by a capsule that is reinforced
by superior and inferior ligaments (Fig. 5 - 1 8 ) . The superior
capsular ligament is remforced through attachments from th
deltoid and trapezius.

The coracoclavicular ligament provides additional stability


to th AC joint (see Fig. 5 - 1 8 ) . This extensive ligament
consists of th trapezoid and conoid ligaments. The irapezoid
ligament extends in a superior-lateral direction from th su
perior surface of th coracoid process to th trapezoid line
on th clavicle. The conoid ligament extends almost vertically
from th proximal base of th coracoid process to th co
noid tubercle on th clavicle.
The articular surfaces at th AC joint are lined with a
layer of fbrocartilage and often separated by a complete or
incomplete articular disc. An extensive dissection of 223 sets
of AC joints revealed complete discs in only about 10% of
th joints.16 The majority of joints possessed incomplete
discs, which appeared fragmented and worn. According to
DePalma,16 th incomplete discs are not structural anomalies,
but rather indications of th degeneration that often affects
this joint.

Tissues that Stabilire th AC Joint


Superior and inferior AC joint capsular ligaments
Deltoid and upper trapezius
Coracoclavicular ligament
Articular disc

FIGURE 5 - 1 8 . An anterior view of th


nght acromioclavicular joint including
many surrounding ligaments.

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

Upward and downward rotation


Horizontal piane rotational adjustments
Sagitial piane rotational adjustments

Upward and Downward Rotation


Upward rotation of th scapula at th AC joint occurs as th-.
scapula swings upwardly and outwardly" in relation to th;
lateral edge of th clavicle (Fig. 5 -2 0 A ). Reports vary, but
up to 30 degrees of upward rotation can occur as th arm traised over th head.2638-63 The motion contributes an exten
sive component of overall upward rotation at th scapulo-J
thoracic joint (Fig. 5 -1 1 C ). Downward rotation at th AC1
joint returns th scapula back to its anatomie position, ^
motion mechanically associated with shoulder adduction oextension. Although Figure 5 -2 0 A depiets th upward and
downward rotation of th scapula as a pure frontal piane
motion, most naturai motions occur within th scapularl
piane.
Complete upward rotation of th scapula at th AC joint
is considered th close-packed position.68 This motion place;
significant stretch on th inferior AC joint capsule and thel
coracoclavicular ligament.
Horizontal and Sagittal Piane "Rotational Adjustments"
at th Acromioclavicular Joint

FIGURE 5-19. An anterior view of th shoulder striking th


ground with th force of th impact directed at th acromion.
Note th increased tension and partial tear withm th coraco
clavicular ligament (CCL).

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.

Cineradiographic observations of th AC joint during shoul-1


der movement reveal small pivoting or twisting motions ol
th scapula about th lateral end of th clavicle (see Fig I
o -2 0 A ).4J These so-called rotational adjustment motions fine I
lune th position of th scapula or add to th total amount I
of its motion permitted on th thorax.
Horizontal piane adjustments at th AC joint occur about I
a vertical axis that causes th mediai border of th scapula I
to pivot away and toward th outer surface of th thorax. I
Sagittal piane adjustments at th AC joint occur about a I
medial-lateral axis. which causes th inferior angle to tilt or I
pivot away or toward th outer surface of th thorax. Rota- I
tional adjustments between 10 and 30 degrees have been !
reported.6-11'63
The horizontal and sagittal piane adjustments at th AC
joint enhance both th quality and quantity of movement at I
th scapulothoracic joint. For instance, during protraction of I
th scapula, small horizontal piane adjustments at th AC I
joint allow th anterior surface of th scapula to change its I
position as it follows th curved contour of th thorax (Fig I
5 -2 0 B ). A similar adjustment occurs in th sagittal piane I
during elevation of th scapula (Fig. 5 -2 0 C ). Without these I
rotational adjustments th scapula is obligated to follow th I
exact path of th moving clavicle, without any ability to fine I
tune its position relative to th thorax.

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).

der located about 6 cm (2 Vi in) faterai to th spine. This


resting posture of th scapula varies considerably from one
person to another.
Movements at th scapulothoracic joint are a very impor
t a i element of shoulder kinesiology. The wide range of
motion available to th shoulder is due, in pari, to th large
movement available to th scapulothoracic joint.

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

ward rotation of th scapula at th AC joint allows th


scapula to remain nearly vertical throughout th elevation
(Fig. 5 -2 1 C ). Additional adjustments at th AC joint help to
keep th scapula flush with th thorax. Depression of th
scapula at th scapulothoracic joint occurs as th reverse
action described for elevation.
Protraction and Retraction
Protraction of th scapula occurs through a summation of
horizontal piane rotations at both th SC and AC joints (Fig.
5 - 2 2 A). The scapula follows th generai path of th protracting clavicle about th SC joint (Fig. 5 -2 2 B ). The AC
joint can amplify or adjust th total amount of scapulotho
racic protraction by contributing varying amounts of adjust
ments within th horizontal piane (Fig. 5 -2 2 C ). Scapulotho
racic protraction increases th extern of forward reach.
Because scapulothoracic protraction occurs as a summa
tion of both th SC and AC joint, a decrease in motion at
one joint can be at least partially compensated by an increase at th other. Consider, for example, a case of severe
degenerative arthritis and decreased motion at th AC joint.
The SC joint may compensate by contributing a greater de-

104

Section II

Upper Extremity

Posterior view

gree of protraction, thereby limiting th extent of loss in th


forward reach of th upper limb.
Retraction of th scapula occurs in a similar but reverse
fashion as protraction. Retraction of th scapula is often
performed in th context of pulling an object toward th
body, such as pulling on a wall pulley, climbing a rope, or
putting th arm in a coat sleeve.

retumed to th side from a raised position. The motion is I


described as similar to upward rotation, except that th I
clavicle depresses at th SC joint and th scapula down- I
wardly rotates at th AC joint. The motion of downward I
rotation usually ends when th scapula has retumed to th
anatomie position.

Upward and Downward Rotation

Glenohumeral Joint

Upward rotation of th scapulothoracic joint is an integrai


part of raising th arm over th head (Fig. 5 -2 3 A ). This
motion places th glenoid fossa in a position to support and
stabilize th head of th abducted (i.e., raised) humerus.
Complete upward rotation of th scapula occurs as a summation of clavicular elevation at th SC joint (Fig. 5 - 2 3 B)
and scapular upward rotation at th AC joint (Fig. 5 -2 3 C ).
These dual frontal piane rotattons occur about parallel SC
and AC joint axes, allowing a total of 60 degrees of scapular
rotation. The scapula may rotate upwardly and strictly in th
frontal piane as in true abduction, but it usually follows a
path closer to its own piane.
Downward rotation of th scapula occurs as th arm is

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 ).

PERIARTICULAR CONNECTIVE TISSUE


The GH joint is surrounded by a fibrous capsule, which
isolates th internai joint cavity from most surrounding tissues (see Fig. 5 - 2 4 ) . The capsule attaches along th rim of
th glenoid fossa and extends to th anatomie neck of th
humerus. A synovial membrane lines th inner wall of th
joint capsule. An extension of this synovial membrane lines
th intracapsular portion of th tendon of th long head of
th biceps brachii. This synovial membrane continues to

FIGURE 5-24. Anterior view of a frontal section


through th right glenohumeral joint. Note th
fibrous capsule, synovial membrane (red), th long
head of th biceps tendon. The axillary pouch is
shown as a recess in th inferior capsule.

surround th biceps tendon as it exits th joint capsule and


descends into th intertubercular (i.e., bicipitali groove.
The potential volume of space within th GH joint cap
sule is about twice th size of th humeral head. In conjuncdon with a loose fitting and expandable capsule, th GH
joint allows extensive mobility. This mobility is evident by
th amount of passive translation available at th GH joint.
The humeral head can be pulled away from th fossa a
significant distance without causing pain or trauma to th
joint. In th anatomie or adducted position, th inferior
portion of th capsule appears as a slackened recess called
th axillary pouch.
The rotator cuff muscles (subscapularis, supraspinatus, infraspinatus, and teres minor) and th capsular ligaments
blend into th fibrous capsule, providing most of th stability to this articulation. The long head of th biceps also
contributes stability to th join t.34

106

Section II

Upper Extremity

S P E C I A L

F O C U S

5 - 2

The "Loose-Fit" of th Glenohumeral Joint


The articular surface of th glenoid fossa covers only
about one third of th articular surface of th humeral
head. This size difference allows only a small part of th
humeral head to make contact with th glenoid fossa. In
a typical adult, th longitudinal diameter of th humeral
head is about 1.9 times larger than th same diameter of
th glenoid fossa (Fig. 5-25). The transverse diameter of
th humeral head is about 2.3 times larger than th op-

posing diameter of th glenoid fossa. By describing th


GH joint as a ball-and-socket joint, th erroneous impression is given that th head of th humerus fits into th
glenoid fossa. The actual structure of th GH joint articulation resembles more that of a golf ball pressed against
a coin th size of a quarter. Joint stability is achieved by
passive tension produced by periarticular connective tissues and by active forces produced by muscles, not by
bony fit.

Coracoid process
Biceps brachii tendon (long head)

Glenoid labrum

Tissues that Stabilize or Deepen th GH Joint


Rotator cuff muscles (subscapularis, supraspinatus, infraspinatus, and teres minor)
GH joint capsular ligaments
Coracohumeral ligament
Long head of th biceps
Glenoid labrum

The extemal layers of th anterior and inferior walls of th


joint capsule are thickened and strengthened by fibrous con
nective tissue known simply as th glenohumeral (capsular) liga
ments (Fig. 5 - 2 6 ) . Passive tension in th capsular ligaments
limits th extremes of GH joint rotation and translation.
The following discussion provides th essential anatomy
and function of th GH joint capsular ligaments. For more
detail, refer to additional literature, such as Curi13 and Bigliani.5 Table 5 - 1 lists th distai attachments of th ligaments
and th motions that render each capsular ligament taut.
This information is useful for th understanding of th cause
of th limitations in movement that may follow surgery repair or injury to th capsule.

FIGURE 5 - 2 5 . Side view of righi glenohu


meral joint with th joint opened up to exPose the articular surfaces. Note th extern of
th subacromial space under th coracoacromial arch. The longitudinal diameter is depicted in th frontal piane and th transverse
diameter is depicted in th horizontal piane.

The GH joints capsular ligaments consist of complex


bands of interlacing collagen fibers, divided into superior,
middle, and inferior bands. The ligaments are best visualized
from an internai view of th GH joint (Fig. 5 - 2 7 ) . The
superior glenohumeral ligament has its proximal attachment
near th supraglenoid tubercle, just anterior to th attach
ment of th long head of th biceps. The ligament, with
associated capsule, attaches distally near th anatomie neck
of th humerus above th lesser tubercle. The ligament becomes particularly taut in full adduction or during inferior
and posterior translations of th humerus.5365
The middle glenohumeral ligament has a wide proximal
attachment to th superior and middle aspeets of th ante
rior rim of th glenoid fossa. The ligament blends with th
anterior capsule and tendon of th subscapularis muscle,
then attaches along th anterior aspect of th anatomie neck.
This ligament provides substantial anterior restraint to th
GH joint, resisting anterior translation of th humerus and
th extremes of extemal rotation.51
The extensive inferior glenohumeral ligament attaches proximally along th anterior-inferior rim of th glenoid fossa,
including th adjacent glenoid labrum. Distally th inferior

Chapter 5

Shoulder Complex

107

Acromioclavicular
ligament
Coracoacromial
ligament

Subacromial
space

FIGURE 5-26. Anterior view of


th right glenohumeral joint
showing th following external
features of th joint capsule: th
capsular, coracohumeral, and
coracoacromial ligaments. Note
th subacromial space located
between th top of th humeral
head and th underside of th
acromion.

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

The GH joint capsule receives additional reinforcement


from th coracohumeral ligament (see Figs. 5 - 2 6 and 5 - 2 7 ) .
This ligament extends from th lateral border of th coracoid
process to th anterior side of th greater tubercle of th
humerus. The coracohumeral ligament blends in with th
capsule and supraspinatus tendon, becoming taut at th ex
tremes of external rotation, flexion, and extension. The liga
ment also resists inferior displacement (i.e., translation) of
th humeral head.60
The GH joint capsule receives significant structural rein
forcement through th attachments of th four rotator cujf
muscles (see Fig. 5 - 2 7 ) . The subscapularis lies just anterior
to th capsule, and th supraspinatus, infraspinatus, and

TAB LE 5 - 1. Anatomy and Tissue Mechanics of th Glenohumeral Joint Capsule


Ligament

D istai A ttachm ents

M otions Drawing Stru cture Taut

Superior glenohumeral ligament

Anatomie neck, above th tesser tubercle

Full adduction, and/or inferior and posterior


translation of th humerus

Middle glenohumeral ligament

Along th anterior aspect of th anatomie


neck

Anterior translation of th humerus and/or


external rotation

Inferior glenohumeral ligament

As a broad sheet to th anterior-inferior and


posterior-inferior margins of th anatomie
neck

All fibers: abduction


Anterior band: abduction and external rotation
Posterior band: abduction and internai rotation

Anterior side of th greater tubercle of th


humerus

Extremes of external rotation, flexion, and ex


tension; inferior displacement (translation)
of th humeral head

(three parts: anterior band,


posterior band, and connect
ing axillary pouch)
coracohumeral ligament

108

Section il

Upper Extremity

Coracoacromial arch

FIGURE 5-27. Lacerai aspect of th


right glenohumeral joini showing th
internai surface of th joint. The humerus has been removed to expose
th capsular ligaments and th
glenoid fossa. Note th prominent
coracoacromial arch and underlying
subacromial bursa. The four rotator
cuff muscles are shown in pink. Synovial membrane is shown in red.

teres minor lie superior and posterior to th capsule. These


muscles previde th majority of th stability to th joint
during active motion.
The head of th humerus and th glenoid fossa are both
lined with hyaline canilage. The rim of th glenoid fossa is
encircled by a fibrocartilage ring, or lip, known as th
glenoid labrum (see Fig. 5 - 2 7 ) . The long head of th biceps
originates as a partial extension of th glenoid labrum. About
50% of th overall depth of th glenoid fossa is attributed to
th glenoid labrum.23 The labrum deepens th concavity of
th fossa, providing additional stability to th joint.

STATIC STABILITY AT THE GLENOHUMERAL JOINT


Normally, when standing at rest with arms at th side, th
head of th humerus remains stable against th glenoid
fossa. This stability is referred to as stalle since it exists ai
rest. One mechanism for controlling th static stability at th
GH joint is based on th analogy of a ball compressed
against an inclined surface (Fig. 5 -2 8 A ).3 At rest, th supe
rior capsular structures, including th coracohumeral ligament, previde th primary stabilizing forces between th
humeral head and th glenoid fossa. Combining this capsu
lar force vector with th force vector due to gravity yields a

FIGURE 5-28. Static docking mechanism ai


th glenohumeral (GH) joint A, The rope
indicates a muscular force that holds th
glenoid fossa in a slightly upward rotated
position. In this position, th passive tension
in th taut superior capsular strutture (SCS)
is added to th force produced by gravity
(G), yielding th compression force (CF).
The compression force applied against th
slight incline of th glenoid locks" th joint
B, With a loss of upward rotation posture of
th scapula (indicated by th cut rope), th
change in angle between th SCS and G vectors reduces th magnitude of th compres
sion force across th GH joint. As a consequence, th head of th humerus slides
down th now vertically oriented glenoid
fossa. The dashed lines indicate th parallelogram method of adding force vectors.

Chapter 5

compressive locking force, oriented at right angles to th


surface of th glenoid fossa. The compressimi force pinches
th humeral head firmly against th glenoid fossa, thereby
resisting any desceni of th humerus. The inclined piane of
th glenoid also acts as a partial shelf that supports part of
th weight of th arm.
Electromyographic (EMG) data suggest that th supraspinatus, and to a tesser extern th posterior deltoid, provides a
secondary source of static stability by generating active forces
that are directed nearly parallel to th superior capsular force
vector. Interestingly, Basmajian and Bazant3 showed that vertically running muscles, such as th biceps, triceps, and
middle deltoid, are generally not actively involved in providtng static stability, even when signifcant downward traction
is applied to th arm.
An important component of th static locking mechanism is a scapulothoracic posture that maintains th gle
noid fossa slightly upwardly rotated. The passive tension
within th superior capsular structures is significanti)' reduced when th scapula loses this upward rotation position
Fig. 5 - 2 8 B). A chronically, downwardly rotated posture
may be associated with poor posture or may be secondary
to paralysis or weakness of certain muscles, such as th
upper trapezius. Regardless of cause, loss of th upwardly
rotated position increases th angle between th force vectors created by th superior capsular structures and gravity. Vector addition of th forces produced by th su
perior capsular structures and gravity now yields a reduced
compressive force. Gravity can pul th humerus down th
face of th glenoid fossa. The GH joint may eventually be:ome mechanically unstable and eventually subluxed completely.
The normally negative intra-articular pressure within th
GH joint offers a secondary source of static stability. Expert-

FIGURE 5-29. An anterior view of a frontal piane


sross-section of th right glenohumeral joint. Note
th subacromial and subdeltoid bursa within th
subacromial space. The deltoid and supraspinatus
-.uscles are also shown.

Shoulder Complex

109

mental release of th pressure within th GH joint capsule


by piercing th capsule with a needle has been shown to
cause inferior subluxation of th humeral head.31 The puncturing of th capsule equalizes th pressure on both sides,
removing th slight suction force between th head and th
fossa.

C0RAC0ACR0MIAL ARCH AND ASSOCIATED BURSA


The coracoacromial arch is formed by th coracoacromial
ligament and th acromion process of th scapula (see Figs.
5 - 2 5 and 5 - 2 7 ) . The coracoacromial ligament attaches be
tween th anterior margin of th acromion and th lateral
border of th coracoid process.
The coracoacromial arch functions as th roof of th
GH joint. In th healthy adult, only about 1 cm of distance exists between th undersurface of th arch and th
humeral head.47 This important subacromial space contains th supraspinatus muscle and tendon, th subacromial
bursa, th long head of th biceps, and part of th superior
capsule.
Eight separate bursa sacs are located in th shoulder.68
Some of th sacs are direct extensions of th synovial mem
brane of th GH joint, such as th subscapular bursa,
whereas others are considered separate structures. All are
situated in regions where signifcant frictional forces develop between tendons, capsule and bone, muscle and lig
ament, or two muscles. Two important bursa are located
superior to th humeral head (Fig. 5 - 2 9 ) . The subacromial
bursa lies within th subacromial space above th supra
spinatus muscle and below th acromion process. This
bursa protects th relatively soft and vulnerable supraspinatus muscle and tendon from th rigid undersurface of th
acromion. The subdeltoid bursa is a lateral extension of th

n o

Section 11

Upper Extremity

Reporting th range of motion at th GH joint uses th


anatomie position as th 0-degree or neutral reference point
In th sagittal piane, for example, flexion is described as th
rotation of th humerus anterior to th 0-degree position
Extension, in contrast, is described as th rotation of th
humerus posterior to th 0-degree position. The term hyperextension is not used to describe normal range of motion at
th shoulder.
Virtually any purposeful motion of th GH joint involves
motion at th scapulothoracic joint, including th associated
movements at th SC and AC joints. The following discusston, however, focuses on th isolated kinematics of th GH
joint.
Abduction and Adduction
Abduction and adduction are traditionally defined as rotation
ol th humerus in th frontal piane about an axis oriented in
th anterior-posterior direction (see Fig. 5 - 3 0 ) . This axis
remains within 6 mm (about A in) of th humeral head's
geometrie center throughout full abduction.48
The arthrokinematics of abduction involve th convex
head of th humerus rolling superiorly while simultaneously
sliding inferiorly (Fig. 5 - 3 1 ) . These roll-and-slide arthrokinem atics o ccu r along, o r d o s e to, (he longitudinal diameter
of th glenoid fossa. The arthrokinematics of adduction are
similar to abduction but occur in a reverse direction.
Figure 5 - 3 1 shows that pari of th supraspinatus muscle
attaches to th superior capsule of th GH joint. When th
muscle contracts to produce movement, forces are transferred through th capsule, providing dynamic stability to
th joint. (Dynamic stability refers to th stability achieved
while th joint is moving.) As abduction proceeds, th
prominent humeral head unfolds and stretches th axillary
pouch of th inferior capsular ligament. The resulting ten-

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.

KINEMATICS AT THE GLENOHUMERAL JOINT


The GH joint is a universal joint because movement occurs
in all 3 degrees of freedom. The primary motions at th GH
joint are flexion and extension, abduction and adduction,
and internai and extemal rotation (Fig. 5 - 3 0 ) .*
*Ofien, a lourth motion is deftned at th GH joint: horizontal flexion
and extension (also called horizontal adduction and abduction). The motion
occurs from a starting position of 90 degrees of abduction. The humerus
moves anteriorly during horizontal flexion and posteriorly during horizontal
extension.

FIGURE 5-31. The arthrokinematics of th tight glenohumeral joint


during active abduction. The supraspinatus is shown contracting io
direct th superior roll of th humeral head. The taut inferior
capsular ligament (1CL) is shown supporting th head of th hu
merus like a hammock (see text). Note that th superior capsular
ligament (SCL) remains relative!) taut owing to th pul from th
attached contracting supraspinatus. Stretched ttssues are depicted as
long black arrows.

Chapter 5

sion within th inferior capsule acts as a hammock or sling,


which supports th head of th humerus.41 Excessive stiffness in th inferior capsule due lo adhesive capsulitis may
limit th full extern of th abduction motion.
Approximately 120 degrees of abduction are available at
th healthy GH joint. A wide range of values, however, have
been reported.2'19-26-58 Full shouder abduction requires a simultaneous 60 degrees of upward rotation of th scapula and
s discussed further in a subsequent section of this chapter.

Importance of Roll-and-Slide Arthrokinematics at th


Glenohumeral Joint
The roll-and-slide arthrokinematics depicted in Figure 5 - 3 1
are essential to th completion of full range abduction. Recali
that th longitudinal diameter of th articular surface of th
humeral head is almost twice th size as th longitudinal
diameter on th glenoid fossa. The arthrokinematics of abduction demonstrate how a simultaneous roll and slide allow
a larger convex surface to roll over a much smaller concave
surface without running out of articular surface.
Without a suffcient inferior slide during abduction, th
superior roll of th humeral head ultimately leads to a jam
ming or impingement of th head against th coracoacromial
arch. An adult-sized humeral head that is rolling up a
glenoid fossa without a concurrent inferior slide would trans
late through th 10-mm coracoacromial space after only 22
degrees of abduction (Fig. 5 -3 2 A ). This situation causes an
impingement of th head of th humerus against th supraspinatus muscle, its tendon, and th bursa against th rigid
coracoacromial arch. This impingement is painful, blocking
further abduction (Fig. 5 32B). In vivo radiographic measurements in th healthy shouder show that during abduc
tion in th scapular piane, th humeral head remains essentially stationary or may translate superiorly only a negligible
distance.17'43-48 The concurrent inferior slide of th humeral

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.

Abduction in th Frontal Piane Versus th Scapular Piane


Shouder abduction in th frontal piane is often used as a
representative motion to evaluate overall shouder function.
Despite its common usage, however, this motion is not ver)'
naturai. Elevating th humerus in th scapular piane (about
35 degrees anterior to th frontal piane) is generally a more
functional and naturai movement.
The functional differences between abduction in th frontal piane and abduction in th scapular piane can be illustrated by th following example. Attempt to maximally
abduct your shouder in th pure frontal piane while consciously avoiding any accompanying extemal rotation. The
diffculty or inability lo complete th extremes of this motion
is due in part to th greater tubercle of th humerus com
pressing th contents of th subacromial space against th
low point on th coracoacromial arch (Fig. 5 -3 4 A ). In order
to complete full frontal piane abduction, extemal rotation of
th humerus must be combined with th abduction effort.
This ensures that th prominent greater tubercle clears th
posterior edge of th undersurface of th acromion.
Next, fully abduct your arm in th scapular piane. This
abduction movement can usually be performed without th
need to extemally rotate th shouder.52 Impingement is
avoided since scapular piane abduction places th apex of
th greater tubercle under th relatively high point of th
coracoacromial arch (Fig. 5 -3 4 B ). Abduction in th scapular
piane also allows th naturally retroverted humeral head to
fit more directly into th glenoid fossa. The proximal and
distai attachments of th supraspinatus muscle are placed
along a straight line. These mechanical differences between

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

Chronic Impingement Syndrome at th Shoulder

Repeated compression of th humeral head and/or th


greater tubercle against th contents of th subacromial
space often leads to "chronic impingement syndrome."27
The syndrome is characterized by th inability to abduct
th shoulder in a pain free or naturai manner. The condition typically occurs in athletes and laborers who repeatedly abduct their shoulders over 90 degrees, but also
occurs in relatively sedentary persons. The impingement
of th head of th humerus against th coracoacromial
arch can be detected on standard x-ray examination (Fig.
5-33), as well as on magnetic resonance imaging.56
Many factors predispose people to shoulder impinge
ment syndrome. One factor is th inability of muscles
such as th rotator cuff or serratus anterior to optimally
coordinate th GH joint arthrokinematics of abduction.9'7'33
Additional factors include "slouched" thoracic posture,28

degeneration of th rotator cuff muscles, instability of th


GH joint, tightness or adhesions within th GH joint cap
sule, and reduced volume in th subacromial space.46 The
last factor may result from th abnormal shape of th
acromion, presence of osteophytes around th AC joint, or
swelling of structures in and around th subacromial
space. Regardless of cause, each time an impingement
occurs, th delicate supraspinatus tendon and subacro
mial bursa become further traumatized. The long head of
th biceps and th superior capsule of th GH joint may
also be impinged and further traumatized. Therapeutic
goals include decreasing inflammation within th subacro
mial space, conditioning th rotator cuff muscle, improving
kinesthetic awareness of th movement, and attempting to
restore th naturai shoulder arthrokinematics. Ergonomie
education is also a factor in goal setting.

FIGURE 5-33. An x-ray of a


person with chronic impinge
ment syndrome" attempting full
abduction. Note th position of
th humeral head up against th
acromion (compare with Fig. 5 32B). (Courtesy of Gary L. Soderberg.)

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

Direct measurements have shown that flexion at th GH


joint is associated with a slight internai rotation of th hu
merus.44 This subtle motion is difficult to appreciate through
casual observation. As th GH joint is flexed beyond 90
degrees, tension in th stretched coracohumeral ligament may
produce a small internai rotation torque on th humerus.
At least 120 degrees of flexion are available to th GH
joint. The ability io flex th shoulder to nearly 180 degrees
tncludes th accompanying upward rotation of th scapulothoracic joint.
Full extension of th shoulder occurs to a position of
about 45 to 55 degrees behind th frontal piane. The ex
tremes of this motion stretch th anterior capsular ligaments,
causing a slight forward tilting of th scapula. This forward
tilt may enhance th extern of a backward reach.

Chapter 5

Shoulder Complex

113

; GURE 5-34. Side vievv of righi


nenohumeral joint comparing abduc~on of th humerus in A: th trae
^ontal piane (red arrow) and B: th
spu lar piane (gray arrow). In both
Aand B, th glenoid fossa is oriented
31 th scapular piane. The relative
iow and high points of th coracozcromial arch are also depicted. The
hne-of-force of th supraspinatus is
shown in B, coursing through th
subacromial arch.

'nternal and External Rotation


From th anatomie position, internai and external rotation at
th GH joint is defined as an axial rotation of th humerus
m th horizontal piane (see Fig. 5 - 3 0 ) . This rotation occurs
about a vertical or longitudinal axis that runs through th
shaft of th humerus. The arthrokinematics of external rotadon take place over th transverse diameters of th humeral
head and th glenoid fossa (see Fig. 5 - 2 5 ) . The humeral
head simultaneously rolls posteriorly and slides anteriorly on
th glenoid fossa (Fig. 5 - 3 6 ) . The arthrokinematics for in
ternai rotation are similar, except that th direction of th
roll and slide is reversed.
The simultaneous roll and slide of internai and external
rotation allows th much larger transverse diameter of th
humeral head to roll over a much smaller surface area of th

FIGURE 5-35. Side view of flexion in th sagittal piane of th right


glenohumeral joint. A point on th head of th humerus is shown
spinning about a point on th glenoid fossa. Stretched stractures
tre shown as long arrows. (PC = posterior capsule, ICL = inferior
sapsular ligament, and CHL = coracohumeral ligament.)

glenoid fossa. The physiologic importance of these anterior


and posterior slides is evident by retuming to th model of
th humeral head shown in Figure 5 - 3 2 A, but now envision
th humeral head rolling over th glenoid fossas transverse
diameter. If, for example, 75 degrees of external rotation
occurs by a posterior roll without a concurrent anterior slide,
th head displaces posteriorly, roughly 38 mm (about IV2
in). This amount of translation completely disarticulates th
joint because th entire transverse diameter of th glenoid
fossa is only about 25 mm (1 in). Normally, however, full
extemal rotation results in only 1 to 2 mm of posterior
translation of th humeral head,21 demonstrating that an
offsetting anterior slide accompanies th posterior roll.

Superior view

Infraspinatus

FIGURE 5-36. Superior view of th roll-and-slide arthrokinematics


during active external rotation of th right glenohumeral joint. The
infraspinatus is shown contracting (in dark red) causing th poste
rior roll of th humerus. The subscapularis muscle and anterior
capsular ligament (ACL) generate passive tension from being
stretched. The posterior capsule (PC) is held relatively taut due to
th pul of th contracting infraspinatus muscle. The two bold black
arrows represent forces that centralize and thereby stabilize th
humeral head during th extemal rotation. Stretched tissues are
depicted as thin, elongated arrows.

114

Section II

Upper Extremity

Centralization of th Humeral Head: Special Function of


th Rotator Cuff Muscles

During all volitional motions at th GH joint, forces from


activated rotator cuff muscles combine with th passive
forces from stretched capsular ligaments to maintain th
humeral head in proper position on th glenoid fossa. As
an example of this mechanism, consider Figure 5-36 that
shows th infraspinatus muscle contracting to produce
active external rotation at th GH joint. Because part of
th infraspinatus attaches into th capsule, its contraction prevents th posterior capsule from slackening dur
ing th motion. This maintenance of tension in th poste
rior capsule, combined with th naturai rigidity from th
activated muscle, stabilizes th posterior side of th joint
during active external rotation. In th healthy shoulder,
th anterior side of th joint is also well stabilized during
active external rotation. Passive tension in th stretched
subscapularis muscle, anterior capsule, middle GH cap
sular ligament, and coracohumeral ligament all add rigid
ity to th anterior capsule. Forces, therefore, are generated on both sides of th joint during active external
rotation, serving to stabilize and centraline th humeral
head against th glenoid fossa. A similar mechanism
exists during active internai rotation.

From th anatomie position, about 75 to 85 degrees of


internai rotation and 60 to 70 degrees of external rotation
are usually possible, but much variation can be expected
among people. In a position of 90 degrees of abduction, th
external rotation range of motion usually increases to near
90 degrees. Regardless of th position at which these rotations occur, there is usually movement at th scapulothoracic
joint. Maximal internai rotation usually includes scapular
protraction, and maximal external rotation usually includes
scapular retraction.

Summary of Glenohumoral Joint Arthrokinematics


Table 5 - 2 shows a summary of th arthrokinematics and
osteokinematics at th glenohumeral joint.

Overall Shoulder Kinematics During


Abduction
To this point, this study of shoulder arthrology has focused
primarily on th structure and function of th individuai

joints. The next discussions focus on th sequencing


motion that occurs between th joints. This issue is discusse:
for th motion of shoulder abduction. The ability to full
abduct in a pain-free and naturai fashion is indicative of i
healthy shoulder. Knowledge of how th joints of th shou der interact during this movement is a prerequisite for urderstanding of shoulder pathology and effettive therapeutu
intervention.

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.

STERNOCLAVICULAR AND ACR0MI0CLAVICULAR


JOINT INTERACTION
Inmans research was th frst major study to measure th:
SC and AC joint contribution to th full 60 degrees of
scapulothoracic upward rotation.26 The following data are

TABLE 5 - 2 . A Summary of th Arthrokinematics at th GH Joint


Osteokinematics

Piane of Motion/Axis of Rotation

Arthrokinematics

Abduction/adduction

Frontal plane/anierior-posterior axis of rotation

Roll-and-slide along joints longitudinal


diameter

Intemal/extemal rotation

Horizontal plane/vertical axis of rotation

Roll-and-slide along joints transverse


diameter

Flexion/extension and intemal/extemal


rotation (in 90 degrees of abduction)

Sagittal plane/medial-lateral axis of rotation

Spin between humeral head and


glenoid fossa

Chapter 5

Shoulder Complex

115

abduction and an additional 30 degrees of scapulothoracic


upward rotation. During this late phase, th clavicle elevates
only an additional 5 degrees at th SC joint. The scapula, in
contrast, upwardly rotates at th AC joint 20 to 25 degrees
(see Fig. 5 - 3 8 ; late phase). By th end of 180 degrees of
abduction, th 60 degrees of scapulothoracic upward rota
tion can be accounted for by 30 degrees of elevation at th
SC joint and 30 degrees of upward rotation at th AC joint
(Fig. 5 -3 7 B ).
Posterior Rotation of th Clavicle

FIGURE 5-3 7 . A, Posterior view of th right shoulder complex after


th arm has abducted to 180 degrees. The 60 degrees of scapulothoracic joint upward rotation and th 120 degrees of glenohumeral
(GH) joint abduction are shaded in red. B, The scapular upward
rotation is depicted as a summation of 30 degrees of elevation at
th stemoclavicular (SC) joint and 30 degrees of upward rotation at
th acromioclavicular (AC) joint. The posterior rotation of th clavicle at th SC joint is represented by th circular arrow around th
middle shaft of th bone.

Inman and fellow researchers were able to demonstrate


through in vivo techniques that th clavicle rotates posteriorly about 40 degrees during th late phase of shoulder
abduction (Fig. 5 - 3 9 ) . Posterior rotation was described dur
ing th description of th kinematics at th SC joint. The
mechanism that drives this rotation is shown in a highly
diagrammatic fashion in Figure 5 - 4 0 . At th onset of shoul
der abduction, th scapula begins to upwardly rotate at th
AC joint, stretching th relatively stiff coracoclavicular ligament (Fig. 5 -4 0 B ). The inability of this ligament to signifi
c a n t i elongate restricts further upward rotation at this joint.
According to Inman,26 tension within th stretched ligament
is transferred to th conoid tubercle region of th clavicle, a
point posterior to th bones longitudinal axis. The applica
tion of this force rotates th crank-shaped clavicle posteriorly
(Fig. 5 -4 0 B ). This rotation places th clavicular attachment
of th coracoclavicular ligament closer to th coracoid process, unloading th ligament slightly and permitting th scap
ula to continue its final 30 degrees of upward rotation.
Inman26 describes this mechanism as a fundamental feature
of shoulder motion and without this motion, complete
shoulder abduction is not possible.
Table 5 - 3 summarizes th major kinematic events of th
shoulder complex during th late and final phases of shoul
der abduction. The data are based on Inmans research,
which used a limited sample size. The actual values within
th population wrould certainly vary.

MUSCLE AND JOINT INTERACTION___________


Innervation of th Muscles and Joints of th
Shoulder Complex
INTR0DUCTI0N T0 THE BRACHIAL PLEXUS

based on this research. The 180 degrees of abduction has


been divided imo an early and a late phase.
Early Phase: Shoulder Abduction to 90 degrees
Assuming a 2 :1 scapulohumeral rhythm, shoulder abduction
up to about 90 degrees occurs as a summation of 60 degrees
of GH abduction and 30 degrees of scapulothoracic upward
rotation. The 30 degrees of upward rotation occurs predominantly through a synchronous 20 to 25 degrees of clavicular
elevation at th SC joint and 5 to 10 degrees of upward
rotation at th AC joint (Fig. 5 - 3 8 ; early phase). Other subtle
rotational adjustments occur simultaneously at th AC joint.63

The entire upper extremity receives innervation primarily


through th hrachial plexus (Fig. 5 - 4 1 ) The brachial plexus
is formed by a consolidation of th ventral nerve roots
from mixed spinai nerves C5- T 1. Ventral nerve roots C5 and
C6 form th upper tnink, C7 forms th middle trunk, and CB
and T 1 form th lower trunk Trunks course a short dis
tarne before forming anterior or posterior divisioni. The divisions then reorganize into three cords named by their relationship to th axillary artery. The cords branch into nerves,
which innervate muscles of th upper extremity and lateral
trunk.

Late Phase: Shoulder Abduction from 90 Degrees


to 180 Degrees

SHOULDER MUSCLE INNERVATION

Shoulder abduction from 90 degrees to 180 degrees occurs


as a summation of an additional 60 degrees of GH joint

The majority of th muscles in th shoulder complex receive


their motor innervation from two regions of th brachial

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

TABLE 5 - 3 . Summary of th Major Kinematic Events during Shoulder Abduction v


SC Joint

AC Joint

Scapulothoracic Joint

GH Joint

Early phase
0 to 90 degrees

25 degrees of elevation

5 degrees of upward rota


tion

.30 degrees of upward


rotation

60 degrees of abduction

Late phase
90 to 180 degrees

5 degrees of elevation and


35 degrees of posterior
rotation of th clavicle

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

120 degrees of abduction

* 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.

plexus: (1) nerves ihai branch from th posterior cord, such


as th axillary, subscapular, and thoracodorsal nerves, and
(2) nerves that branch from more proximal segments of
th plexus, such as th dorsal scapular, long thoracic, pectoral, and suprascapular nerves. An exception to this innervation scheme is th trapezius muscle, which is innervated primarily by cranial nerve XI, with lesser motor and
sensory innervation from th ventral roots of upper cervical
nerves.68
The primary motor nerve roots that supply th muscles of
th upper extremity are listed in Appendix HA. Appendix 11B
shows key muscles typically used io test th functional status
of th C5-T ventral nerve roots.

SENSORY INNERVATION OF THE SHOULDER JOINTS


AND SURROUNDING CONNECTIVE TISSUE
The sternoclavicular joint receives sensory (afferent) innerva
tion from th C3 and C4 nerve roots from th cervical
plexus.68 Both th acromioclavicular and glenohumeral joints
receive sensory innervation via th C5 and C6 nerve roots via
th suprascapular and axillary nerves.68

Action of th Shoulder Muscles


Mosi of th muscles of th shoulder complex fall into one of
two categories: proximal stabilizers or distai mobilizers. The
proximal stabilizers consist of muscles that originate on th

DIVISIONS
Trunks
D o rsa l s ca p u la r

--- Cords

Posterior
M e d ia i
Lateral pectoral
M usculocutaneous

FIGURE 5-41. -The brachial plexus. From


Jobe MT, Wright PE: Peripheral nerve injuries: In Canale ST (ed): Campbells Op
erative Orthopaedies, 9th ed., voi 4. St.
Louis, Mosby, 1998.)

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

FIGURE 5-42. Posterior view showing ihe


upper trapezius, levator scapula, rhomboid
major, and rhomboid minor as elevatore of
th scapulothoracie joint.

spine, ribs, and cranium, and insert on th scapula and


clavicle. Examples of these muscles are th serratus anterior and th trapezius. The distai mobilizers consist of
muscles that originate on th scapula and clavicle and in
ser on th humerus or forearm. Examples of two distai
mobilizers are th deltoid and biceps bracini muscles. As
described subsequently, optimal function across th entire
shoulder complex is based on a functional interdependence between th proximal stabilizers and th distai mobil
izers. For example, in order for th deltoid to generate an
effective abduction torque at th glenohumeral joint, th
scapula must be ftrmly stabilized against th thorax by th
serratus anterior. In cases of a paralyzed serratus anterior
muscle, th deltoid muscle is unable to express its full ab
duction function. Several examples follow that reinforce this
important point. The spectfic anatomy and nerve supply of
th muscles of th shoulder complex can be found in Appendix IIC.

Muscles of th Scapulothoracie Joint


ELEVATORS OF THE SCAPULOTHORACIC JOINT
The muscles responsible for elevation of th scapula and
clavicle are th upper trapezius, levator scapulae, and to a
lesser extern, th rhomboids (Fig. 5 - 4 2 ) . 15 The upper trape
zius provides postural support to th shoulder girdle (scap
ula and clavicle). Ideal posture of th shoulder girdle is often
defined as a slightly elevated and retracted scapula, with th
glenoid fossa facing slightly upward. The upper trapezius,
attaching to th lateral end of th clavicle, provides excellent

S P E C I A L

F O C U S

Paralysis of th Upper Trapezius: Effects on


Sternoclavicular and Glenohumeral Joint Stability

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

leverage about th SC joint for th maintenance of this


posture.

3EPRESS0RS OF THE SCAPULOTHORACIC JOINT


3epression of th scapulothoracic joint is performed by th
ower trapezius, latissimus dorsi, pectoralis minor, and th subJavius (Fig. 5 - 4 3 ) .29-50 The latissimus dorsi depresses th
shoulder girdle by pulling th humerus and scapula infen.uly. The force generated by th depressor muscles can be
iirected through th scapula and upper extremity and applied against some object, such as th spring shown in
rigure 5 -43A .

Shoulder Complex

119

If th arm is physically blocked from being depressed,


force from th depressor muscles can raise th thorax rela
tive to th fxed scapula and arm. This action can occur only
if th scapula is stabilized to a greater extent than th tho
rax. For example, Figure 5 - 4 4 shows a person sitting in a
wheelchair using th scapulothoracic depressors to relieve
th pressure in th tissues superficial to th ischial tuberosities. With th arm firmly held against th armrest of th
wheelchair, contraction of th lower trapezius and latissimus
dorsi pulls th thorax and pelvis up toward th fxed scap
ula. This is a very useful movement especially for persons
with quadriplegia who lack sufficient triceps strength to lift
body weight through elbow extension.

FIGURE 5-43. A, A posterior view of th lower trapezius and th


latissimus dorsi depressing th scapulothoracic joint. These muscles
are pulling down against th resistance provided by th spring
mechanism. B, An anterior view of th pectoralis minor and subclavius during th same activity described in A.

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.

PROTRACTORS OF THE SCAPULOTHORACIC JOINT


The serratus anterior muscle is th prime protractor at th
scapulothoracic joint (Fig. 5 45A). This extensive muscle
has excellent leverage for protracuon, especially about th SC
join ts vertical axis of rotation (Fig. 5 -4 5 B ). The force of
scapular protraction is usually transferred across th GH
joint and employed for forward pushing and reaching activities. Persotis with serratus anterior weakness have difficulty
in performance of forward pushing motions. No other mus
cle can aclequately provide this protraction effect on th
scapula.

RETRACTORS OF THE SCAPULOTHORACIC JOINT


The middle trapezius muscle has an optimal line-of-force to
retract th scapula (Fig. 5 46). The rhomboids and th lower
trapezius muscles function as secondary retractors. All th
retractors are particularly active while using th arms for
pulling activities, such as climbing and rowing. The muscles
secure th scapula to th axial skeleton.
The secondary retractors show an excellent example of
how muscles function as synergists sharing identical actions. At th same lime, however, they function as direct
antagonists. During a vigorous retraction effort, th elevation
tendency of th rhomboids is neutralized by th depression

tendency of th lower trapezius. A component of each musi


cles overall line-of-force summate, however, producing pi
retraction (see Fig. 5 - 4 6 ) .
Complete paralysis of th trapezius, and to a lesser exte
th rhomboids, signifcantly reduces th retraction potentiof th scapula. The scapula tends to drift slightly in l
protraction owing to th partially unopposed protraction a tion of th serratus anterior muscle.7

UPWARD AND DOWNWARD R0TAT0RS OF THE


SCAPULOTHORACIC JOINT
Muscles that perform upward and downward rotation of
scapulothoracic joint are discussed next in context
movement of th entire shoulder.

Muscles that Elevate th Arm


The term "elevation of th arm describes ihe active m o ti,
ment of bringing th arm overhead without specifying tF
exact piane of th motion. Elevation of th arm is perforine-,
by muscles that fall into three groups: (1) muscles th a l
elevate (i.e., abduct or flex) th humerus at th GH joint; ( 2 J
scapular muscles that control th upward rotation and pr
traction of th scapulothoracic joint; and (3) rotator cu

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.

muscles that control th dynamic stability and arthrokinematics at th GH joint.

Muscles Responsible for Elevation of th Arm

1. GH joint muscles
Deltoid
Supraspinatus
Coracobrachialis
Biceps (long head)
2. Scapulothoracic joint muscles
Serratus anterior
Trapezius
3. Rotator cuff muscles

MUSCLES THAT ELEVATE THE ARM AT THE


GLENOHUMERAL JOINT
The prime muscles that abduct th GH joint are th anterior
deltoid, th middle deltoid, and th supraspinatus muscles
(Fig. 5 - 4 7 ) . Elevation of th arm through flexion is performed primarily by th anterior deltoid, coracobrachialis,

S P E C I A L

F O C U S

5 - 6

Serratus Anterior and th "Push-up" Maneuver


Another important action of th serratus anterior is to
exaggerate th final phase of th standard prone
"push-up." The early phase of a push-up is performed
primarily by th triceps and pectoral musculature. After
th elbows are completely extended, however, th
chest can be raised farther from th floor by a deliber
ate protraction of both scapulae. This final component
of th push-up is performed primarily by contraction of
th serratus anterior. Bilaterally, th muscles raise th
thorax toward th fixed stabilized scapulae. This action
of th serratus anterior may be visualized by rotating
Figure 5-45A 90 degrees clockwise and reversing th
direction of th arrow overlying th serratus anterior.
Exercises designed to strengthen th serratus anterior
incorporate this movement.14

121

122

Section II

Upper Extremity

FIGURE 5-47. Anterior view showing th middle deltoid, antenorj


deltoid, and supraspinatus as abductors of th glenohumeral joint.

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

The deltoid and th supraspinatus muscles contribute


about equal shares of th total abduction torque at th GH
joint.22 With th deltoid paralyzed, th supraspinatus muscle
is generally capable of fully abducting th GH joint. The
torque, however, is reduced. With th supraspinatus para
lyzed or ruptured, full abduction is often difficult or not
possible due to th altered arthrokinematics ai th GH joint.
Full active abduction is not possible with a combined del
toid and supraspinatus paralysis.10

UPWARD R0TAT0RS AT THE SCAPULOTHORACIC


JOINT
Upward rotation of th scapula is an essential component of
elevation of th arm. To varying degrees, th serratus ante-

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

TABLE 5 - 4 . Average Maximal Isometric Torques


Produced by Shoulder Muscle Groups*
Muscle Group

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.

rior and all parts of th trapezius cooperate during


ward rotation (Fig. 5 - 4 9 ) . These muscles drive th
through upward rotation and, equally as important,
stable attachment sites for distai mobilizers, such
deltoid and supraspinatus.

th up
scapula
provide
as th

Shoulder C om pkx

123

Trapezius and Serratus Anterior Interaction


The axis of rotation for scapular upward rotation is depicted
in Figure 5 - 4 9 as passing in an anterior-poslerior direction
through th scapula. This axis allows a convenient way to
analyze th potential for muscles to rotate th scapula. The
axis of rotation of th upwardly rotating scapula is near th
root of th spine during th early phase of shoulder abduction, and near th acromion during th late phase of abduction.2
The upper and lower fibers of th trapezius and th lower
fibers of th serratus anterior form a force couple that up
wardly rotates th scapula (see Fig. 5 - 4 9 ) . All three muscular forces rotaie th scapula in th same direction. The
upper trapezius upwardly rotates th scapula by attaching to th clavicle. The serratus anterior is th most effective upward rotator due to its larger moment arm for this
action.

The Upward Rotation Force Couple: A Familiar Analogy


T h e m e c h a n ic s

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 .

FIGURE 5-49. Posterior view of a healthy shoulder showing th


muscular interaction between th scapulothoracic upward rotators
and th glenohumeral abductors. Shoulder abduction requires a
muscular kinetic are between th humerus and th axial skeleton.
Note two axes of rotation: th scapular axis located near th acro
mion, and th glenohumeral joint axis located at th humeral head,
internai moment arms for all muscles are shown as dark black
hnes. (DEL = deltoid/supraspinatus, UT = upper trapezius, MT =
middle trapezius, LT = lower trapezius, and SA = serratus ante
nne)

FIGURE 5-50. A top view of three people involved in a force


couple to rotate a revolving door. The three people are analogous to th three muscles shown in Figure 5 -4 9 upwardly
rotating th scapula. (UT = upper trapezius, LT = lower
trapezius, SA = serratus anterior.) Each person, or muscle,
acts with a different internai moment arm (drawn to actual
scale), which combines to cause a substantial torque in a
similar rotary direction.

124

Seaion II

Upper Extremiiy

Arm Abduction Angle


(degrees)
FIGURE 5-51. The EMG attivai ion pattern of th upper trapezius
and lower trapezius and th lower lbere of th serratus anterior
during shoulder abduction in th scapular piane. (Data from Bagg
SD, Forrest WJ: Electromyographic study of th scapular rotators
during arm abduction in th scapula piane. Am J Phys Med 65'
111-124, 1986.)

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.

Effects of Paralysis of th Upwarcl Rotators of th


Scapulothoracic Joint
Trapezius Paralysis

The lower trapezius has been shown to be particularly


attive during th later phase of shoulder abduction (Fig.
5 - 5 1 ) . 2 The upper trapezius, by comparison, shows a significant rise in EMG activation level during th initiation of
shoulder abduction, then continues a graduai rise in activa
tion throughout th remainder of th range of motion. The
upper trapezius must elevate th clavicle throughout th
early phase of abduction, while simultaneously balance
th inferior pul of th lower trapezius during th late phase
of abduction. The serratus anterior muscle shows a graduai
increase in amplitude throughout th entire range of shoul
der abduction.
Figure 5 - 4 9 shows th Ime-of-force of th middle trape
zius running through th rotating scapula's axis of rotation.
In this case, th middle trapezius is robbed of its leverage

Complete paralysis of th trapezius usually causes moderate I


to marked difficulty in elevating th arm overhead. The task,!
however, can usually be completed through full range as I
long as th serratus anterior remains totally innervated. Eie-1
vation of th arm in th pure frontal piane is particularly I
difficull because it requires that th middle trapezius gener-l
ate a strong retraction force on th scapula.7
Serratus Anterior Paralysis

Paralysis or weakness of th serratus antenor muscle causes I


signifcant disruption in normal shoulder kinesiology. Dis-1
abilily may be slight with parlial paralysis, or profound with I
complete paralysis. Paralysis of th serratus anterior can o c-1
cur from an overstretching of th long thoracic nerve6*5 o r i
from an injury to th cervical spinai cord or nerve roots.
As a rule, persons with complete or marked paralysis I

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

FIGURE 5-53. Posterior view of th righi shoulder showing th


supraspinatus, infraspinatus, and teres minor muscles. Note that th
distai attachments of these niuscles blend mto and reinforce th
superior and posterior aspects of th joint capsule.

of th serratus anterior cannot elevale their arms above


90 degrees of abduction. This limiiation persists evert wth
completely intact trapezius and glenohumeral abductor mus
cles. Attempts at elevating th arm, especially against resis
t a l e , result in a scapula that excessively rotates downwardly
with its mediai border flaring outwardly. This characteristic
posture is often referred to as "winging of th scapula (Fig.
5 - 5 2 A). Normally, a fully innervated serratus anterior produces a force that rotates th scapula upward. In th ab-

Shoulder Complex

125

sence of adequate upward rotation force on th scapula,


however, th contracting deltoid and supraspinatus have
an overall line-of-force that rotates th scapula downward
and toward th humerus (Fig. 5 -5 2 B ). This abnormal motion is associated with a rapid overshortening of th gleno
humeral abductor muscles. As predicted by th force-velocity
and lengih-tension relationship of muscle (see Chapter 3),
th rapid overshortening of these muscles reduces their
maximal force potential. The reduced force output from
th overshortened glenohumeral abductors, in conjunction
with th downward rotation of th scapula, reduces both
th range of motion and torque potential of th elevating
arm.
An analysis of th pathomechanics associated with weakness of th serratus anterior provides a valuable lesson in th
extreme kinesiologic importance of this muscle. Normally
during elevation of th arm, th serratus anterior produces
an upward rotation torque on th scapula that exceeds th
downward rotation torque produced by th active deltoid
and supraspinatus. lnterestingly, slight weakness in th serra
tus anterior can disrupt th normal arthrokinematics of th
shoulder. Without th normal range of upward rotation of
th scapula, th acromion is more likely to interfere with th
arthrokinematics of th abducting humeral head. Indeed, research has shown that persons with chronic impingement
syndrome have a reduced upward rotation of th scapula
and a reduced relative EMG activity from th serratus ante
rior during abduction.33

FUNCTION OF THE R0TAT0R CUFF MUSCLES DURING


ELEVATION OF THE ARM
The rotator cuff group muscles include th subscapularis,
supraspinatus, infraspinatus, and teres minor (Figs. 5 - 5 3
and 5 - 5 4 ) . All these muscles show signiftcant EMG activity
when th arm is raised overhead.30 The EMG activity reflects

FIGURE 5-54. Anterior view of th right shoul


der showing th subscapularis muscle blendtng
mto th anterior capsule before attaching to th
lesser tubercle of th humerus. The subscapu
laris is shown with diverging arrows, reflecting
two main ftber directions. The supraspinatus,
coracobrachialis, tendon of th long head of th
biceps, and coracohumeral and coracoacromial
hgamenls are also depicted.

Anterior view

126

Section 11 Upper Extremity

th function of these muscles as (1) regulators of th dynamic


joint stability and (2) controllers of th arthrokinematics.

Regulators of Dynamic Stability at th Glenohumeral


Joint
The loose fu between th head of th humerus and glenoid
fossa permits extensive range of motion at th GH joint. The
surrounding joint capsule, therefore, must be free of thick
restraining ligaments that otherwise restrict motion. The ana
tomie design at th glenohumeral joint favors mobility at th
expense of stability. An essential function of th rotator cuff
group is to compensate for th lack of naturai stability at
th GH joint. The distai attachment of th rotator cuff
muscles blends into th GH joint capsule before attaching
to th proximal humerus. The anatomie arrangement forms
a protective cuff around th joint (see Figs. 5 - 5 3 and
5 - 5 4 ) . Nowhere else in th body do so many muscles form
such an intimate structural pari of a joints periarticular
siructure.
Earlier in this chapter th dynamic stabilizing function
of th infraspinatus muscle during external rotation is dis
cusseci (see Fig. 5 - 3 6 ) . This dynamic stabilization is an
essential function of all members of th rotator cuff. Forces
produced by th rotator cuff not only actively move th
humerus, bui also stabilize and centralize its head against
th glenoid fossa. Dynamic stability at th GH joint, there
fore, requires a healthy neuromuscular System and musculoskeletal System.

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

Spontaneous Anterior Dislocation of th


Glenohumeral Joint
T h e d y n a m ic s t a b ilit y o f t h G H jo in t is o f te n r e d u c e d
w h e n t h n e u r o m u s c u la r a n d / o r t h m u s c u lo s k e le t a l
s y s t e m s f a il t o p r o v id e n e c e s s a r y r ig id it y t o t h jo in t
c a p s u le . A m o tio n o f p la c in g t h a r m in a c o a t o r
t h r o w in g a b a ll c a n t h e r e b y c a u s e a s p o n t a n e o u s d i s l o
c a t io n o f t h h u m e r a l h e a d , o c c u r r in g m o s t o f t e n in
an

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

The Vulnerability of th Supraspinatus


to Excessive Wear

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

forces between th joint surfaces increase linearly from


0 io 90 degrees of shoulder abduction, reaching a magnitude
of 90% of body weight.49 The surface area for dissipating
toint forces increases to a maximum between 60 degrees
and 120 degrees of shoulder elevation.57 This increase in
surface area helps to maintain pressure at tolerable physiologic levels.

Functions of thc Rotator Cuff Muscles in th Active


Control of th Arthrokinematics at th GH Joint
Supraspinatus: Compresses th humeral head directly into
th glenoid fossa.
Subscapuaris, infraspinatus, aid teres minor: Produces
an inferior-directed iranslaiion force on th humerus
head.
Infraspinatus and teres minor: Rotates th humeral head
extemally.

Without adequate supraspinatus force, th near vertical


line-of-force of a contracting deltoid tends to jam or impinge th humeral head superiorly against th coracoacromial arch, thereby blocking complete abduction. This effect
is typically observed following a complete rupture of th
supraspinatus tendon. In addition to th compression produced by th supraspinatus, th remaining rotator cuff mus
cles exert an inferior depression force on th humeral head
during abduction (see Fig. 5 - 5 5 ) . The inferiorly directed
force counteracts much of th tendency for th deltoid mus
cle to translate th humerus superiorly during abduction.43
During frontal piane abduction, th infraspinatus and teres

minor muscles can rotate th humerus extemally in order to


increase th clearance between th greater tubercle and th
acromion.

Muscles that Adduct and Extend th


Shoulder
Pulling th arm against resistance offered by climbing a
rope or propelling through water requires a forceful contraction from th shoulders powerful adductor and extensor muscles. These muscles are capable of generating th
largest isometric torque of any muscle group of th shoulder
(Table 5 - 4 ) .
The iatissimus dorsi shown in Figure 5 -4 3 A and th sternocostal head o f th pectoralis major shown in Fig. 5 - 5 6 are
th largest of th adductor and extensor muscles of th
shoulder. With th humerus held stable, contraction of th
latissimus dorsi can raise th pelvis toward th upper body.
Persons with paraplegia often use this action during crutchand brace-assisted ambulation as a substitute for weakened
or paralyzed hip flexors.
The teres major, long head o f th triceps, posteror deltoid,
infraspinatus, and teres minor are also primary muscles for
shoulder adduction and extension. These muscles have their
proximal attachments on th inherently unstable scapula. It
is th primary responsibility of th rhomboid muscles to
stabilize th scapula during active adduction and extension
of th glenohumeral joint. This stabilization function is evident by th dowmward rotation and retraction movements
that naturally occur with shoulder adduction. Figure 5 - 5 7
highlights th synergistic relationship between th rhomboids

128

Section li

Upper Extremily

FIGURE 5-56. Anterior view of th righi pecto-

ralis major showng th adduction/extensior


function ol th sternocostal head. The clavicula:
head ot th pectoralis major is also shown.

and th
effort of
and th
assist th

teres major during a strongly resisted adduction


th shoulder. The pectoralis minor (Fig. 5 -4 3 B )
latissimus dorsi fibers that attach to th scapula
rhomboids in downward rotation.

The entire rotator cuff group is active during shoulder


adduction and exiension.0 Forces produced by these muscles assist with th action directly or stabilize th head of th
humerus against th glenoid fossa.54

FIGURE 5-57. Posterior view of a shoulder showing th

muscular interaction between th scapulothoracic downward


rotators and th glenohumeral adductors (and extensors) ol
th right shoulder. For clarity, th long head of th triceps
is not shown. The teres major is shown with its internai
moment arm (dark line) extendng front th glenohumeral
joint. The rhomboids are shown with th internai moment
extending from th scapulas axis. (See text for further details.) (TM = teres major, LD = laUssimus dorsi, IF =
infraspinatus and teres minor, PD = posterior deltoid, RB
= rhomboids).

Chapter 5

A Closer Look at th Posterior Deltoid

The posterior deltoid is a shoulder extensor and adductor.


In addition, this muscle is also th primary horizontal ex
tensor at th shoulder. Vigorous contraction of th poste
rior deltoid during full horizontal extension requires that
th scapula is firmly stabilized by th lower trapezius (Fig.

Shoulder Complex

129

Complete paralysis of th posterior deltoid can occur


owing to an overstretching of th axillary nerve. Persons
with this paralysis frequently report difficulty in combining
full shoulder extension and horizontal extension, such as
that required to place th arm in th sleeve of a coat.

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.)

Muscles that Internally and Externally Rotate


th Shoulder
INTERNAL ROTATOR MUSCLES
The primary muscles that internally rotate th GH joint are
th subscapularis, anterior deltoid, pectoralis major, latissimus

dorsi, and teres major. Many of these internai rotators are


also powerful extensors and adductors, such as those needed
for swimming.
The total muscle mass of th shoulders internai rotators
is much greater than that of th external rotators. This factor
explains why th shoulder internai rotators produce about

130

Section II

Upper Extremity

described as rotators of th humerus relative to a fixed


scapula (Fig. 5 - 5 9 ) . The arthrokinematics of this motion are
based on th convex humeral head rotating on th fixed
glenoid fossa. Consider, however, th muscle function and
kinemaiics that occur when th humerus is held in a fixed
position and th scapula is free to rotate. As depicted in
Figure 5 - 6 0 , with suffcient muscle force, th scapula and
trunk can rotate around a fixed humerus. Note that th
arthrokinematics of th scapula-on-humerus roiation involse
a concave glenoid fossa rolling and sliding in similar directions on th convex humeral head (Fig. 5 - 6 0 ; inser).

EXTERNAL ROTATOR MUSCLES

humerus is free to rotate. The line-of-force of th pectoralis major


is shown vvith its internai moment ami. Note th roll-and-slide
arthrokinenratics of th convex-on-concave motion. For clarity, th
anterior deltoid is noi shown.

1.75 times greater isometric torque than th external rotators


(see Table 5 - 4 ) . 39 Peak torques of th internai rotators also
exceed th extemal rotators when measured isokinetically,
under both concentric and eccentric conditions.37
The muscles that nternally rotate th GH joint are oflen

The primary muscles that externally rotaie th glenohumeral


joint are th infraspinatus, teres minor, and posterior deltoid.
Ihe supraspinatus can assist with external rotation provided
th glenohumeral joint is between neutra! and full external
rotation.23
The external rotators are a relatively small percentage of
th total muscle mass at th shoulder. Accordingly, maximal
effort extemal rotation produces th smallest isometric
torque of any muscle group ai th shoulder (see Table 5 - 4 ) .
Regardless of th relatively low maximal torque potential, th
extemal rotators stili must generate high-velocity concentnc
contractions, such as when cocking th arm backward to
pitch a ball. Through eccentric activation, these sanie mus
cles must decelerate internai rotation of th shoulder at th
release phase of pitching: a peak velocity measured at dose
to 7000 degrees/sec.18 These large force demands placed on
th relatively small infraspinatus and teres minor may cause
partial tears within th muscle and capsule, leading io rotator cuff syndrome.24

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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Shoulder Complex

131

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30. Kronberg M, Nemeth G, Brostrom LA: Muscle activity and coordination
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31 Rumar VP, Batasubramaniam P: The role of atmospheric pressure in
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32 Lemos ML. The evaluation and treatment of th injured acromioclavicular joint in athletes. Am J Sports Med (S8)26:137-144, 1998.
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35. Mandalidis DG, McGlone BS, Quigley RF, et al: Digital fluoroscopic
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36. McQuade KJ, Smidt GL: Dynamic scapulohumeral rhythm: The effeets
of external resistance during elevation of th arm in th scapular piane.
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37. Mikesky AE, Edwards JE, Wigglesworth JK, et al: Eccentric and concentric strength of th shoulder and arm musculalure in collegiate baseball
pitchers. AmJ Sports Med 23:6.38-642, 1995.
38. Moseley HF: The clavicte: Its anatomy and function. Clin Orthop 58:
17-27, 1968.
39. Murray MP, Gore DR, Gardiner GM, et al: Shoulder motion and muscle
strength of normal men and women in two age gtoups. Clin Orthop
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40. Neumann DA, Seeds R: Observations from etneradiography analysis.
Marquette University, Milwaukee, WI, 1999.
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
Sports Med 18:579-584, 1990.
43. Paletta GA, Warner JJP, Warren RF, et al: Shoulder kinematics with
two-plane x-ray evaluation in patients with anterior instabiiity or rotator
cuff learing. J Should Elbow Surg 6:516-527, 1997.
44. Palmer ML, Blakely RL: Documentation of mediai rotation accompanytng shoulder llexon Phys Ther 66:55-58, 1986
45. Palmer WE, Caslowitz PL: Anterior shoulder instabiiity: Diagnostic criterta determined from prospective analysis of 121 MR arthrograms.
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46. Payne LZ, Deng XH. Craig EV, et al: The combined dynamic and static
contributtons to subacromial impingemenl. A m J Sports Med 25:801808, 1997.
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.
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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
80B:476-484, 1998.
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
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55. Sharkey NA, Marder RA: The rotator cuff opposes superior translation
of th humeral head. Am J Sports Med 23:270-275, 1995
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
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thop Res 10:524-534, 1992.
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
instabilily. Clin Anat 12:326-336, 1999.
60. Terry CC, Haramon D, France P, et al: The stabilizing function of
passive shoulder restrainis. AmJ Sports Med 19:26-34, 1991.
61. Thomas CB, Friedman RJ: Ipstlateral stemoclavicular dislocation and
eiavide fracture J Orthop Trauma 3:355-357, 1989.
62. Ticker JB, Bigliant LU, Soslowsky LJ, et al: Inferior glenohumeral ligament: geometrie and strain-rate dependent properties. J Shoulder Elbow
Surg 5:269-279, 1996.
63. Van Der Helm FCT, Pronk GM: rhree-dimensional recording and descrtptions of motions of th shoulder mechanism. ] Biomech Ene 117
2 7 -4 0 , 1995.
64. Walker PS, Poppen NK: Btomechancs of th shoulder joint abduction
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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68. Williams PL, Bannister LH, Berry M, Collins P, et al: Grays Anatomy,
38lh ed, New York, Churchill Livingstone, 1995.

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

Ferrari DA: Capsular iigaments of th shoulder. Anatomica! and functions;


swdy of th anterior superior capsule. Am J Sports Med 18:20-24
Friedman RJ, Blocker ER, Morrow DL Glenohumeral Instabilily J Soutr
Orthop Assoc 4:182-199, 1995.
Guttmann D, Paksima NE. Zuckerman JD: Complications of treatment et
complete acromioclavicular joint dtslocations. lnstr Course Lect 49 4 0 7 413, 2000.
Haider AM, Itoi E, An KN: Anatomy and biomechanics of th shoulder
Orthop Clin N Am 31:159-176, 2000
Johnson G, Bogduk N, Nowitzke A, et al: Anatomy and actions of th
trapezius. Clin Biomech 9:44-50, 1994.
Johnson GR, Spaldtng D, Nowitzke A, et al: Modelltng th musclcs of th
scapula: Morphometric and coordinate data and functional tmplications
J Biomech 29:1039-1051, 1996.
Mayer F, Horstmann T, Rocker K, et al: Normal values of isokinetic maxi
mum strength, th strength/velocity curve, and th angle at peak torque d
all degrees of freedom in th shoulder. Int J Sports Med 15:19-25, 1994
Medvecky MJ, Zuckerman JD: Stemoclavicular joint injuries and disorders
lnstr Course Lect 49:397-406, 2000.
Olis JC, Jiang CC, W'ickiewicz TL, et al: Changes of moment arms in th
rotator cuff and deltoid muscles with abduction and rotatton J Bone
Joint Surg 76A:667-676, 1994.
Placzek JD, Roubal PJ, Freeman DC, et al: Long-term effectiveness of transldTfi13* man'Pu'ation r adhesive capsulitis. Clin Orthop 356:181-191
Saha AK: Dynamtc stability of th glenohumeral joint. Acta Orthop Scand
42:491-505, 1971,
H
Sanders TG, Morrison WB, Miller MD. Imaging techniques for th evaluation of glenohumeral instability. AmJ Sports Med 28:414-434 2000
Wuelker N, Wolfgang P, Roetman B, et al: Function of th supraspinatus
muscle. Acta Orthop Scand 65:442-446, 1994,
Wuelker N, Schmotzer H, Thren K, et al: Translation of th glenohumeral
joint with simulated active elevation. Clin Orthop 309:193-200, 1994

h a p t e r

Elbow and Forearm Complex


D onald A. Neum an n , PT, Ph D

TOPICS
OSTEOLOGY, 133

Mid-to-Distal Humerus, 133


Ulna, 135
Radius, 136
ARTHROLOGY, 137

Part I: Joints o< th Elbow, 137


G en era l F e a tu re s o f th H u m e ro u ln a r
and H u m e ro ra d ia l J o in ts , 137
P e ria rtic u la r C o n n e c tiv e T is s u e , 138
K in e m a tic s , 140

Functional Considerations of Flexion


and Extension, 140
Arthrokinematics at th Humeroulnar
Joint, 140
Arthrokinematics at th Humeroradial
Joint, 141
Part II: Joints of th Forearm, 145
G en era l F e atures o f th P ro x im a l and
D ista i R a d io u ln a r J o in ts , 145

AT

GLANCE

J o in t S tru c tu re and P e ria rtic u la r


C o n n e c tiv e T issu e , 146

Proximal Radioulnar Joint, 146


Distai Radioulnar Joint, 146
K in e m a tic s , 147

Functional Considerations of Pronation


and Supination, 147
Arthrokinematics at th Proximal and
Distai Radioulnar Joints, 149
Supination, 149
Pronation, 149

Pronation and Supination with th


Radius and Hand Held Fixed, 150
M USC LE A N D J O IN T IN TER AC TIO N , 151

Neuroanatomy OverView, 151


P aths o f th M u s c u lo c u ta n e o u s , R adiai,
M e d ia n , and U ln a r N e rv e s T h ro u g h o u t
th E lbow , Forea rm , W ris t, and H and,

Innervation of Muscles and Joints of th


Elbow and Forearm, 152
Function of th Elbow Muscles, 157
E lb o w F le xors, 157

Individuai Muse le Action of th Elbow


Flexors, 157
Biomechanics of th Elbow Flexors,
158
Maximal Torque Production of th Elbow
Flexor Muscles, 158
Elbow Extensors, 161

Muscular Components, 161


Electromyographic Analysis of Elbow
Extension, 161
Torque Demands on th Elbow
Extensors, 162
Function of th Supinator and Pronator
Muscles, 165
S u p in a to r M u s c le s , 165

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.

Four Articulations Within th Elbow and Forearm


Complex
1.
2.
3.
4.

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

Directly lateral to th trochlea is th rounded capitulum


The capitulum forms nearly one half of a sphere. A small
radiai fossa is located just proximal to th anterior side of]
th capitulum.
The mediai epicondyle of th humerus projeets mediali'
from th trochlea (see Figs. 6 - 2 and 6 - 4 ) . This prominent
and easily palpable structure serves as th proximal attach-

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).

Osteologie Features of th Mid-to-Distal Humcrus


Trochlea including groove and mediai and lateral lips
Coronoid fossa
Capitulum
Radiai fossa
Mediai and lateral epicondyles
Mediai and lateral supracondylar ridges
Olecranon fossa

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

Elbow and Forearm Complex

On th posterior side of th humerus, just proximal to


th trochlea, is th very deep and broad olecranon fossa. Only
a thin sheet of bone or membrane separates th olecranon
fossa from th coronoid fossa.

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.

Osteologie Features of th Ulna


Olecranon process
Coronoid process
Trochlear notch and longitudinal crest
Radiai notch
Supinator crest
Tuberosity of th ulna
Ulnar head
Styloid process

The trochlear notch of th ulna is th large jawlike process


located between th anterior tips of th olecranon and coronotd processes. This concave notch articulates firmly with
th reciprocally shaped trochlea of th humerus, forming th
humeroulnar joint. A thin raised longitudinal crest divides th
trochlear notch down its midiine.
The radiai notch of th ulna is an articular depression just
lateral to th inferior aspect of th trochlear notch (see Fig.
6 - 7 ) . Extending distally, and slightly dorsally, from th ra
diai notch is th supinator crest, marking th distai attach
ments for part of th lateral collateral ligament and th
supinator muscle. The tuberosity o f th ulna is a roughened
impression just distai to th coronoid process, formed by th
attachment of th brachialis muscle (see Fig. 6 - 5 ) .

Right humerus: Inferior view


tendon

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

ment of th mediai collateral ligament of th elbow as well


as th forearm pronator and wrist flexor muscles.
The lateral epicondyle of th humerus, less prominent than
th mediai epicondyle, serves as th proximal attachment for
th lateral collateral ligament of th elbow as well as th
forearm supinator and wrist extensor muscles. Immediately
proximal to both epicondyles are th mediai and lateral supracondylar rdges.

Lateral
epicondyle

Mediai
epicondyle

Sulcus for ulnar nerve


Olecranon fossa

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

In th fully supinated position, th radius lies paralld I


and lateral to th ulna (see Figs. 6 - 5 and 6 - 6 ) . The proxi
mal end of th radius is small and as such constitutes a
relatively small structural component of th elbow. Its distai

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

Flexor pollicis longus

Interosseous
membrane

Pronator
teres

Extensor pollicis longus


Pronator quadratus

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

The ulnar head is located at th distai end of th ulna


(Fig. 6 - 8 ) . Most of th rounded ulnar head is lined with
articular cartilage. The pointed styloid (from th Greek root
stylos; pillar, + eidos; resembling) process projects distally
from th posterior-medial region of th extreme distai ulna.

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

F.lbow and Forearm Complex

137

The distai end of th radius articulates with carpai bones


to form th radiocarpal joint at th wrist (see Fig. 6 - 8 ) . The
ulnar notch of th distai radius accepts th ulnar head at th
distai radioulnar joint. The prominent styloid process projects
from th lateral surface of th distai radius.

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

FIGURE 6-7. A lateral (radiai) view of th right proximal ulna, with


th radius removed. Note th jawlike shape of th trochlear notch.

Elbow flexion and extension occur about a medial-lateral


axis of rotation, passing through th vicinity of th lateral
epicondyle (Fig. 6 -9 A ).45 From mediai to lateral, th axis
courses slightly superiorly owing in part to th distai pro-

end, however, is enlarged, forming a major part of th wrist


joint.

Osteologie Features of th Radius


Radiai head
Fovea
Bicipital tuberosiLy

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

Normal cubitus valgus

Excessive cubitus valgus

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

longation of th mediai lip of th trochlea. lhe asymmetry


in th trochlea causes th ulna to deviate laterally relative to
th humerus. The naturai frontal piane angle made by th
extended elbow is referred to as cubitus valgus. (The term
carrying angle is often used, reflecting th fact that th
valgus angle tends to keep carried objects away from th
side ol th thigh while walking.) In full elbow extension, th
normal carrying angle is about 15 degrees.45
Occasionally, th extended elbow may show an excessive
cubitus valgus greater than 20 degrees (Fig. 6 -9 B ). In con
tras!, th forearm may less cotnmonly show a cubitus varus
deformity, where th forearm is deviateci toward th midiine
(Fig. 6 -9 C ). Valgus and varus are terrns derived from th
Latin turned outward (abducted) and tumed inward (adducted), respectively.

PERIARTICULAR CONNECTIVE TISSUE


The articular capsule o f th elbow encloses three different
articulations: th humeroulnar joint, th humeroradial joint,
and th proximal radioulnar joint (Fig. 6 - 1 0 ) . The capsule
is thin and reinforced anteriorly by oblique bands of fibrous
tissue. A synovial membrane lines th internai surface of th
capsule (Fig. 6 - 1 1 ) .

30

- M - wiih

The articular capsule of th elbow is strengthened by an


extensive set of collateral ligaments (Table 6 - 1 ) . These ligaments provide an important source of stability to th elbow
joint. The mediai collateral ligament consists of anterior, posterior, and transverse fiber bundles (Fig. 6 - 1 2 ) . The anterior
fibers are th strongest and stiffest of th mediai collateral
ligament. 1 As such, these fibers provide th most signiftcam
resistance against a valgus (abduction) force at th elbow.
l he anterior fibers arise from th anterior part of th mediai
epicondyle and msert on th mediai part of th coronoid
process of th ulna. The majority of th anterior fibers become taut near full extension.13 A few fibers, however, become taut at full flexion. The anterior fiber bundle as a
whole, therefore, provides articular stability throughout th
entire range of motion.8
The posterior fibers ol th mediai collateral ligament attach
on th posterior part of th mediai epicondyle and insert on
th mediai margin of th olecranon process. The posterior
fibers become taut in th extremes of elbow flexion.13-41 A I
third and poorly developed set of transverse fibers of th I
mediai collateral ligament cross from th olecranon io th ]
coionoid process of th ulna. Because these fibers originate I
and insert on th same bone, they do not provide significant
articular stability.

Chapter 6

FIGURE 6-10. An anterior view of th right elbow showing th


capsule and collaieral ligaments.

The lederai collateral ligament of th elbow is less delined


and more variable in form than th mediai collateral ligarnent (Fig. 6 - 1 3 ) .27 The ligament orginates on th lateral
epicondyle and immediately splits into two ftber bundles.
One fiber bundle, traditionally known as th radiai collateral
ligament, fans out to blend with th annular ligament. A
second fiber bundle, called th lateral (ulnar) collateral liga
ment, attaches distally to th supinator crest of th ulna.
These fibers become taut at full (lexion.41
All th fibers of th lateral collateral ligament and th
posterior-lateral aspect of th capsule stabilize th elbow
against a varus-directed force.36 By attaching to th ulna, th
lateral (ulnar) collateral ligament and th anterior fibers of
th mediai collateral ligament function as collateral guywires to th elbow, stabilizing th path of th ulna during
sagittal piane motion.
The ligaments around th elbow are endowed with
mechanoreceptors, consisting of Golgi organs, Ruffini terminals, Pacini corpuscles, and free nerve endings.38 These receptors may supply important information to th nervous System for augmenting proprioception and detecting
safe limits of passive tension in th structures around th
elbow.

Elbow and t'orearm Complex

139

FIGURE 6-11. Anterior view of th right elbow disarticulated to


expose th humeroulnar and humeroradial joints. The margin of
th proximal radioulnar joint is shown within th elbows capsule.
Note th small area on th trochlear notch lacking articular cartilage. The synovial membrane lining th internai side of th capsule
is shown in red.

T AB L E

6 - 1. Ligaments of th Elbow and Motions


that lncreasc Tension
Ligaments
Mediai collateral ligament
(anterior fibers*)

Mediai collateral ligament


(posterior fibers)
Lateral collateral ligament
(radiai collateral component)
Lateral collateral ligament
(lateral (ulnar) collat
eral component*)
Annular ligament

M otions that Increase Tension

Valgus
Extension and io a lesser extern
flexion
Valgus
Flexion

Varus

Varus
Flexion
Distraction of th radius

* Primary valgus or varus stabilizers.

140

Section II

Upper Extremity

M ediai aspect

FIGURE 6-12. The components of th mediai collateral lioa


ment of th right elbow.
6
Mediai
collateral ligament

As in all joints, th elbow joini has an intracapsular air


pressure. This pressure, which is determined by th ratio of
th volume of air to th volume of space, is lowest when th
capsule is most compliant, or less stiff. The intracapsular air
pressure is lowest at about 80 degrees of flexion.''5 This joint
position is often a position ol comfort for persons with
joint inflammation and swelling.26 Maintaining a swollen el
bow in a flexed position may improve comfort but may also
predispose th person to an elbow flexion contratture (from
th Latin root contractura; to draw together).

KINEMATICS

Functional Considerations of Flexion and Extension


Elbow (lexion provides several important physiologic functtons such as pulling, lifting, feeding, and groomng. The
inability to actively bring th hand to th mouth for feeding
for example, significantly limits th level of functional mdependence. Persons with a spinai cord injury above th C5
nerve root have this profound disability due to total paralysis
ol elbow (lexor muscles,

mally stili after long periods of immobilization in a flexec


and shortened position. Long-term flexion may be th resuli
ol casting (ollowing a fractured bone, an elbow joint inllam
mation, an elbow flexor muscle spasticity, a paralysis of th
tnceps muse e or a scarring of th skin over th antenoi
elbow. In additton to th tightness in th flexor muscles.
tncreased stiffness may occur in th anterior capsule and
anterior parts of th collateral ligaments.
The maximal range of passive motion generally available
to th elbow is from 5 degrees of hyperextension through
145 degrees of flexion (Fig. 6 -1 5 A and B). Research mdicates, however, that several common activities of daily livtng use only a limited are of motion, usually between 30
and 130 degrees of flexion** Unlike lower extremity
joints, such as in th knee, th loss of th extremes o f motion
at th elbow usually results in only mimmal functional impairment.
Arthrokinematics at th Humeroulnar Joint
The humeroulnar joint is th articulation of th concave
trochlear notch of th ulna around th convex trochlea of
th humerus (Fig. 6 - 1 6 ) . From a sagittal section, th hu
meroulnar joint resembles a ball-and-socket joint. The firm
mechanical link between th trochlea and trochlear notch.
however, limits th motion to essentially th sagittal piane

Elbow extension occurs with activittes such as throwing,


pushtng, and reaching. Loss of complete extension due to an
elbow flexion contracture is often caused by marked stiffness
tn th elbow flexor muscles. The muscles become abnor-

Lateral aspect

Annidar ligament
Radiai
collateral ligament
Lateral
collateral ligament

FIGURE 6 13. The components of th lateral collateral


ligament ol th right elbow.
Radius

Lateral (ulnar)
collateral ligament

Ulna

Supinator crest

Chapter 6

Elbow Flexion Contracture and Loss of Forward Reach


One of th most disabling consequences of an elbow
flexion contracture is reduced reaching capacity. The loss
of forward reach varies with th degree of elbow flexion
contracture. As shown in Figure 6-14, a fully extendable
elbow (i.e., with a 0-degree contracture) demonstrates a
0-degree loss in area of forward reach. The area of for
ward reach diminishes only slightly (less than 6%) with

Elbow and Forearm Complex

141

a flexion contracture of less than 30 degrees. A flexion


contracture that exceeds 30 degrees, however, results in
a much greater loss of forward reach. As noted in th
graph, a flexion contracture of 90 degrees reduces total
reach by almost 50%. Minimizing a flexion contracture to
less than 30 degrees is therefore an important functional
goal for patients following elbow trauma, prolonged immobilization, or joint replacement.

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;

outside, + topos; place) bone formation around th olecra


non fossa can limit full passive extension.
During flexion at th humeroulnar joint, th concave surface of th trochlear notch rolls and slides on th convex
trochlea (see Fig. 6 17J3). Full passive elbow flexion requires elongation of th posterior capsule, extensor muscles,
ulnar nerve,44 and certain collateral ligaments, especially th
posterior hbers of th mediai collateral ligament.

Arthrokinematics at th Humeroradial Joint


The humeroradial joint is an articulation between th cuplike fovea of th radiai head and th reciprocally shaped

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.)

rounded capitulum. At resi in full extension, little if any


physical contact exists at th humeroradial jo in t.17 During
attive flexion, however, muscle contraction pulls th radiai
fovea against th capitulum.30 The arthrokinematics of flex
ion and extension consist of th fovea of th radius rolling
and sliding across th convexity of th capitulum (Fig.
Compared with th humeroulnar joint, th humeroradial
joint provides minimal structural stability to th elbow. The
humeroradial joint does, however, provide an important
bony resistance against a valgus force.31

tissues at th proximal and distai radioulnar joints also


transfer a portion of th compression force from th radius
to th ulna.
Most elbow flexors, and essentially all th major supinato: I
and pronator muscles, have their distai attachments on th
radius. Contraction of these muscles, therefore, pulls th
radius proximally against th humeroradial joint.44 An additional function of th interosseous membrane, therefore, is to I

Force Transmission Through th Interosseous Membrane


o f th Forearm

Most of th fibers ol th interosseous membrane of th fore


arm are directed away from th radius in an oblique mediai
and distai direction (Fig. 6 - 1 9 ) . A few separate sparse and
poorly deftned bands flow perpendicular to th membranes
matn ftber direction. One of these bands, th oblique cord,
runs from th lateral side of th tuberosity of th ulna to
just distai to th bicipital tuberosity. Another unnamed band
is located at th extreme distai end of th interosseous mem
brane.
The interosseous membrane has several functions related
to force transmission through th upper limb. As illustrated
in Figure 6 - 2 0 , about 80% of th compression force due to
hearing weight through th forearm crosses th wrist between th lateral side of th carpus and th radius. The
remaining 20% of th compression force passes across th
mediai side of th carpus and th ulna, at th ulnocarpal
space.37 Because of th fiber direction of th interosseous
membrane, pan of th proximal directed force through th
radius is transferred across th membrane to th ulna.39 This
mechanism allows a share of th compression force at th
wrist to cross th elbow via th humeroulnar joint, thereby
reducing th amount of force thai must cross th limited
surface area of th humeroradial joint.30 The periarticular

FIGURE 6 - 1 6 . A sagittal seclion through th humeroulnar joint


showing th well-ftting joint surfaces between th trochlear notch
and trochlea. The synovial membrane lining th internai side of th
capsule is shown in red.

Chapter 6

Elbow and Forearm Complex

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.

transfer a component of th muscle force applied to th


radius to th ulna. This occurs through a mechanism similar
to that during weight hearing through th forearm. A mecha
nism that permits two joints to share these compression
forces reduces each individuai joint's long-term wear and
tear. Failure of th integrity of this mechanism may lead to
joint deterioration and possible osteoarthritis.
The predominant fber direction of th interosseous mem
brane is not aligned to resist distally applied forces on th
radius. For example, holding a heavy suitcase with th elbow
extended causes a distracting force almost entirely through
th radius (Fig. 6 - 2 1 ) . The distai pul on th radius slackens rather than tenses th interosseous membrane, thereby
necessitating other less capable tissues, such as th oblique
cord and annular ligament, to accept th weight of th load.
Contraction of th brachioradialis or other muscles normally

FIGURE 6-18. A sagittal section through th humeroradial joint


dunng flexion. Note th medial-lateral axis of rotation in th center
of th capitulum. The stretched (taut) structures are shown as thin
elongated arrows, and slackened structures are shown as wavy ar
rows. Note th elongation of th lateral (ulnar) collateral ligament
during flexion.

FIGURE 6-19. An anterior view of th interosseous membrane of


th right forearm. Note th contrasting fber direction of th
oblique cord.

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 0 . A compressiti?! force through th hand is transmitted


primarily through th wrist (#1) ai th radiocarpal joint and to th
radius (#2). This force stretches th interosseous membrane (shown
by doubl taut arrows) that transfers a part of th compression
force to th ulna (#3) and across th elbow at th humeroulnar
joint (#4). The compression forces that cross th elbow are finally
directed toward th shoulder (#5). The stretched (taut) structures
are shown as thin elongated arrows.

involved with grasp can assist with holding th radius and


load against th humeroradial joint. Complaints of a deep
aching in th forearm from persons who carry heavy loads
for extended periods may be from fatigue in these muscles.
Supporting loads through th forearm at shoulder level, for
example, like a waiter carrying a tray of food, directs th
weight proximally through th radius where th interosseous
membrane can assist with dispersing these loads more evenly
through th forearm.

TRAUMATIC CAUSES OF ELBOW JOINT INSTABILITY


Injury to th collateral ligaments of th elbow can result in
marked elbow instability. The mediai collateral ligament is

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

Ebow and Forearm Complex

145

Part II: Joints of th Forearm


GENERAL FEATURES OF THE PROXIMAL AND DISTAL
RADIOULNAR JOINTS
The radius and ulna are bound together by th interosseous
membrane and th proximal and distai radioulnar joints.
This set of joints, situated at either end of th forearm,
allows th forearm to rotate into pronation and supination.
Forearm supination places th palm up, or supine, and pro
nation places th palm down, or prone. This forearm rotation occurs about an axis of rotation that extends from th
radiai head through th head of th ulna an axis that
intersects and connects both radioulnar joints (Fig. 6 - 2 4 ) . 55
As is apparent in Figure 6 - 2 4 , pronation and supination
provide a mechanism that allows independent rotation of
th hand without an obligatory rotation of th ulna or humerus. A person with limited pronation or supination range
of motion must rely on greater internai or external rotation
of th shoulder to perform activities such as tightening a
screw and tuming a doorknob.
The kinematics of foreann rotation are more complicated
than those implied by th simple palm-up and palm-down
terminology. The palm does indeed rotate, but only because
th hand and wrist connect to th radius and noi to th ulna.
The space between th distai ulna and th mediai side of th
carpus allows th carpai bones to rotate freely along with
th radius without interference from th distai ulna.

FIGURE 6 - 2 2 . Attempts at catching oneself from a fall may induce a


severe valgus force, overstretching or mpturing th mediai collateral
ligament.

6 - 2 3 ) . This dislocation is frequenti) caused from a fall onto


m outstretched arm and hand and, thus, may be associated
with a fracture of th proximal radius and humeral capitulum.

Anterior view of th right forearm. A, In full supina


tion with th radius and ulna parallel. B, Moving into full pronation
with th radius Crossing over th ulna. The axis of rotation (shown
by dashed line) extends obliquely across th forearm from th
radiai head to th ulnar head. The radius and hand (shown in red)
is th distai segment of th forearm complex. The humerus and
ulna (shown in gray) is th proximal segment of th forearm com
plex. Note that th thumb stays with th radius during pronation.
FIGURE 6 - 2 4 .

A posterior dislocation of th humeroulnar jomt.


(From ODriscoll SW: Elbow dislocations. In Morrey BF (ed): The
Elbow and lts Disorders, 3rd ed. Phladelphia, WB Saunders, 2000,
p 410. By permission of th Mayo Foundation for Medicai Education and Research.)
FIGURE 6 - 2 3 .

146

Section II

Upper Extremity

In th anatomie position, th forcami is fully supinated


when th ulna and radius lie parallel to one another (Fig.
6 -2 4 A ). During pronation, th distai segment of th forearm
complex (i.e., th radius and hand) rotates and crosses over
an essentially fixed ulna (Fig. 6 -2 4 B ). The ulna, through its
firm attachment to th humerus al th humeroulnar joint,
remains essentially stationary during pronation and supination movements. A stable ulna provides an important rigid
link that th radius, wrist, and hand can pivot upon. Only
very sltght motion occurs in th ulna during supination and
pronation .3 The ulna tends to rotate slightly in th frontal
piane during active pronation and supination; toward abduction (valgus) during pronation, and toward adduction (varus)
during supination. Other than design of an elbow prosthesis,
this slight accessory movement of th ulnar is clinically in
signi ficant.

JOINT STRUCTURE AND PERIARTICULAR


CONNECTIVE TISSUE
Proximal Radioulnar Joint
The proximal radioulnar joint, th humeroulnar joint, and
th humeroradial joint all share one articular capsule. Within
this capsule, th radiai head is held against th proximal
ulna by a ftbro-osseous ring. This ring is formed by th
radiai notch of th ulna and th annular ligament (Fig.
6 -2 5 A ). About 75% of th ring is formed by th annular
ligament and 25% by th radiai notch of th ulna.
Ihe annular (from th Latin annulus; ring) ligament is
a thick circular band of connective tissue, attaching to
th ulna on either side of th radiai notch (Fig. 6 - 2 5 B).
The ligament fits snugly around th radiai head, holding
th proximal radius against th ulna. The internai circumference ot th annular ligament is lined with cartilage to
reduce th friction against th radiai head during prona
tion and supination. The external surface of th ligament receives attachments from th elbow capsule, th radiai collateial ligament, and th supinator muscle. The quadrate
ligament is a short, stout ligament that arises just below th
radiai notch of th ulna and attaches to th mediai surface of
th neck of th radius (Fig. 6 -2 5 B ). This ligament lends

structural support to th capsule of th proximal radioulr


joint.
Distai Radioulnar Joint
The distai radioulnar joint consists of th convex head of t
ulna fittmg imo a shallow concavity formed by th ulr.,
notch on th radius and th proximal surface of an articul
disc (Fig. 6 -2 7 A ). This important joint stabilizes th disi;
forearm during pronation and supination.
1 he articular disc at th distai radioulnar joint is alsc
known as th triangular fibrocartilage, indicating its shape
and predominant tissue type. As depicted in Figure 6 -2 7 A
the lateral side ol th disc attaches along th entire rim t
th ulnar notch of the radius. The main body of the disi
fans out horizontally imo a triangular shape, with its apec
attaching medially imo the depression on the ulna head anc
adjacent styloid process. The anterior and posterior edges of
the disc are continuous with the palm ar (anterior) and dorsci
(posterior) radioulnar joint capsular ligaments (Fig. 6 - 2 7 A anc
B) The proximal surface of the disc, along with the attachec
capsular ligaments, holds th head of the ulna snugly against
the ulnar notch of the radius.33

The articular disc is pari of a larger set of connective tissue


known as the ulnocarpal complex. 3'-42 This complex is ofter i
referred to as the triangular fibrocartilage complex. The ulno
carpai complex occupies most of the space between tht
distai end ol the ulna and the ulnar side of the carpai bones
Several wrist ligaments, such as the ulnar collateral ligament
are included with this complex (see Fig. 6 - 2 7 B). The ulno
carpai complex is the primary stabilizer of the distai radioul
nar joint, particularly important during the dynamics of pro
nation and supination. Other structures that provide joim
stability are the pronator quadratus, joint capsule, tendon of
the exiensor carpi ulnaris, and interosseous membrane. Tears
or disruptions of the ulnocarpal complex, especially the disc.::
may cause complete dislocation or generalized instability ol
the distai radioulnar joint, making pronation and supination
motions, as well as motions of the wrist, painful and difficuli
to perform .11 (The ulnocarpal complex is discussed further
in Chapter 7).

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

Introduction to the Ulnocarpal Complex

Radiai notch

Radiai notch (on ulna)

1
I
,
.

Quadrate ligament (cut)


TO /
_C /
CD /

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

Dislocations of th Proximal Radioulnar Joint: The


"Pulled-Elbow" Syndrome

A strenuous pul on th forearm through th hand can


cause th radiai head to slip through th distai side of th
annular ligament. Children are particularly susceptible to

Elbow and Forearm Complex

147

this "pulled-elbow" syndrome due to ligamentous laxity


and increased likelihood of others pulling on their arms
(Fig. 6-26). One of th best ways to prevent this disloca
tion is to explain to parents how a sharp pul on th
child's hand can cause such a dislocation.

Causes of "pulled" elbow

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

Ulnocarpal complex (triangolar fibrocartilage complex)


Joint capsule
Pronator quadratus
Tendon of th extensor carpi ulnaris
Interosseous membrane

Functional Considerations of Pronation and Supination


Forearm supination occurs during many activities that involve rotating th palmar surface of th hand toward th
face, such as feedtng, washing, and shaving. Forearm prona
tion, in contrast, is used to place th palmar surface of th

148

Section II

Upper Extremily

Dorsal capsular ligament


Articular capsule (cut)
Ulnar head
Attachment of articular disc
Palmar capsular
ligament

Ulnar collateral ligament (cut)

Articular disc (proximal surface)

Ulnar collateral
ligament (cut)

Palmar capsular ligament

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

hand down on an object, such as grasping a coin or pushing


up from a chair.
The neutral or zero reference position of forearm rotation
is the thumb-up position, midway between complete pro-

nation and supination. On average, the forearm rotat


through about 75 degrees of pronation and 85 degrees
supination (Fig. 6 -2 8 A ). As shown in Figure 6 -2 8 B , severa!
activities of daily living require only about 100 degrees ol

0 (Neutral)

80

D
.
Pronation

60
40

20

<n

Neutral a>

o 20
Q
40

Supination

60
80

phone

paper

Activities of daily living


FIGURE 6-28 Range of motion at the forearm complex. A, Typical healthy forearm showing range of motion- 0 to 85 degrees of
elbow 7 1 0 0 d t0 f degreeS,f Pnatlon/ h e 0-degree neutral position is shown with the fhumb point.ng straight up. As with th
elbow, a 100-degree functional are ex.sts (shown in red). This are ,s derived from the histogram in B. B Histogram showing th
amoum of forearm rotation usually required for healthy persons to perform the foilowing activities of daily living: bringing a glass to the
mouth, bringing a /orfe to the mouth, nsing from a chair, opening a door, pouring from a pitcher, cutting with a feni/e ^holding a
telephony and teading a newspaper. (Modified with permission from Morrey BF, Askew LJ, An KN, et al: A biomechanical study80f
normal functional elbow motion. J Bone Joint Surg 63A:872-876. 1981.)

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.

Arthrokinematics at th Proximal and Distai Radioulnar


Joints
Pronation and supination require simultaneous joint movement at both proximal and distai radioulnar joints. A restricuon at one joint limits motion at th other.
Supination

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

F.Ibow and Forearm Complex

S P E C I A L

F O C U S

149

6 - 3

Functional Association Between Pronation and


Supination at th Forearm and Shoulder Rotation

Active internai and external rotation at th shoulder is


functionally linked with active pronation and supination.
Shoulder internai rotation often occurs with pronation,
whereas shoulder external rotation often occurs with
supination. Combining these shoulder and forearm rotations allows th hand to rotate nearly 360 degrees in
space, rather than only 170 to 180 degrees by pronation
and supination alone. When clinically testing forearm
muscle strength and range of motion, care must be
taken to eliminate contributing motion or torque that
has originated from th shoulder. To accomplish this,
forearm pronation and supination are tested with th
elbow held flexed to 90 degrees with th mediai epicondyle of th humerus pressed against th side of th
body. In this position, any undesired rotation at th
shoulder is easily detected.

th ulnar head (see th asterisk in Fig. 6 - 3 0 , top inset),


making it readily palpable.

Restrictions in Passive Range of Pronation and


Supination Motions
Restrictions in passive range of pronation and supination
motions can occur from tightness in muscle and/or con-

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

Distai Kadioulnar Joint from Above


Anterior

FIGURE 6-30. Illustration on th left shows li


tight forearm after completing full pronation. Duj
ing pronation, th radius and hand (shown in r e i
rotates around th fixed humerus and ulna (sho- 3
tn gray). The inacttve but stretched bieeps mus. J
is also shown. As viewed in Figure 6 -2 9 , th n ijf
insets show a superior view of th arthrokineraJ
ics at th proximal and distai radioulnar joinwl
1 he stretched (taut) structures are shown as t h J
elongated arrows, and slackened structures as
shown as wavy arrows. The asterisks mark t~cj
exposed point on th anterior aspect of th ufn*j
head, which is apparent once th radius rotaisl
fully around th ulna into complete pronation. &3I
text for further details.

Bieeps on bicipital tuberosity

Proximal Radioulnar Joint from Above

nective tissues. Samples of these tissues are listed in Table


6 - 2.
Humeroradial Joint: A "Shared" Joint Between th Elbow
and th Forearm

During active pronation and supination, th extreme proxi


mal end of th radius articulates with th ulna or humerus
in two locations. First, as described in Figures 6 - 2 9 and 6 30, th circumference ol th radiai head articulates with th
hbro-osseous ring at th proximal radioulnar joint. Second
th fovea of th radiai head makes contact with th capitulum ol th humerus at th humeroradial joint. Dunng pro
nation, for instance, th fovea of th radiai head^spins
against th rounded capitulum of th humerus (Fig. 6 - 3 1 ) .
Any motion ai th elbow-and-forearm complex involves motion at th humeroradial joint. A limitation of motion at th
humeroradial joint can therefore disrupt both flexion and
extension and pronation and supination.

Pronation and Supination with th Radius and Hand Held


Fixed
L'p to this point, th kinematics of pronation and su p in a ticJ
are described as a rotation of th radius and hand relative to

Mediai
epicondyle

TABLE 6 - 2 Structures that can Restrict


Supination and Pronation
Limit Supination

Limit Pronation

Pronator teres, pronator


Bieeps or supmator muscles
quadratus
Palmar capsular ligament at
Dorsal capsular ligament at th
th distai radioulnar joint20
distai radioulnar joint
Oblique cord, interosseous
membrane, and quadrate
ligament719
Ulnocarpal complex
Ulnocarpal complex

FIGURE 6-31. An anterior view of a righi elbow during pronation


ol th forearm. During pronation, th fovea of th radiai head m usj
spin against th capitulum. The rotation occurs about an axis iha:
is cotncident with th axis of rotation through th proximal ra-l
dioulnar joint.

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-

Elbow and Forearm Complex

151

spective, an understanding of th muscular mechanics of


pronation and supination from both a non-weight-bearing
and weight-bearing perspective provides additional exercise
strategies for strengthening or stretching muscles of th fore
arm and shoulder.
The right side of Figure 6 - 3 2 B illustrates th arthrokinematics at th radioulnar joints during pronation while th
radius and hand are stationary. At th proximal radioulnar
joint, th annular ligament and radiai notch of th ulna spin
around th fxed radiai head (see Fig. 6 - 3 2 B , top inset). At
th distai radioulnar joint, th head of th ulna rotates
around th fxed ulnar notch of th radius (see Fig. 6 - 3 2 B,
bottom inset). Table 6 - 3 summarizes and compares th active arthrokinematics at th radioulnar joints for both
weight-bearing and non-weight-bearing conditions of th up
per limb.

MUSCLE AND JOINT INTERACTION


Neuroanatomy OverView
Paths of th Musculocutaneous, Radiai, Median, and
Ulnar Nerves Throughout th Elbow, Forearm, Wrist,
and Hand
The musculocutaneous, radiai, median, and ulnar nerves
previde motor and sensory innervation to th muscles and
connective tissues of th elbow, forearm, wrist, and hand.

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

TABLE 6 - 3 Arthrokinematics of Pronation and


Supination1

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.

Radiai head spins


withm a ring
formed by th
annular ligament
and th radiai
notch of th ulna.

Distai
Radioulnar
Joint

Concavity of th ulnar notch of th


radius rolls and
slides in similar
direetions on th
convex ulna
head.

Convex ulnar head rolls


and slides in opposite
direetions on th con
cave ulnar notch of th
radius.

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

anterior interosseous nerve, innervates th deep muscles


th forearm: th lateral half of th flexor digitorum profa
dus, th flexor pollicis longus, and th pronator quadrane.
The main pari ol th median nerve continues distally :j
cross th wrist through th carpai tunnel, under th cover i
th transverse carpai ligament. The nerve then innerva
several of th intnnsic muscles of th thumb and th late.,
fngers. The median nerve provides a source of sensory ibers to th lateral palm, palmar surface of th thumb, 2
lateral two and one-half fngers (Fig. 6 -3 3 C , see inset
median nerve sensory distribution). This sensory supply
especially rich and concentrated about th distai ends of 1
index and middle fngers.
The ulnar nerve, formed from nerve roots CR- T ',
formed by a direct branch of th mediai cord of th braci
plexus (Fig. 6 - 3 3 D). After passing posteriorly to th mec
epicondyle, th ulnar nerve innervates th flexor carpi _
naris and th mediai half of th flexor digitorum profundi3
The nerve then crosses th wrist external to th carpai tu o i
nel and supplies motor innervation to many of th intrins-I
muscles of th hand. The ulnar nerve supplies sensory strucJ
tures to th skin on th ulnar side of th hand, in c lu d irj
th mediai side of th ring fnger and entire little fnger. T h ij
sensory supply is especially concentrated about th little f i - J
ger and ulnar border of th hand.

Innervation of Muscles and Joints of th


Elbow and Forearm
Knowledge of th innervation to th muscle, skin, and joina
is useful clinical information in th treatment of injury \
th peripheral nerves or nerve roots. The informed timcian can anticipale th extent of th sensory and motcrl
involvement following an acute injury. Therapeutic aclivities, I
such as splinting, selective strengthening, range of motios
exercise, and patient education, can be initiated almost in.- .
mediately following injury. This proactive approach mirumizes th potential for deformity and damage to insensitive
skin and joints, thereby limiting th amount of permaner:
disability.

IN N E R V A T IO N TO M U S C L E

The elbow flexors have three different sources of peripheral


nerve supply: th musculocutaneous nerve to th biceps brechii and brachialis, th radiai nerve to th brachioradiaiisl
and lateral part ol th brachialis, and th median nerve tol
th pronator teres, which is a secondary flexor. In contras!!
th elbow extensors, th triceps brachii and anconeus, have J
single source of nerve supply through th radiai nerve. In-J
jury to this nerve can result in complete paralysis of th I
elbow extensors. In centrasi three different nerves must b;
alfected lo paralyze all elbow flexors. Fortunately, redundan:
innervation to th elbow flexor muscles helps preserve th I
important hand-to-mouth function required for essential activities such as feeding.
Ihe muscles that pronate th forearm (pronator teres, pro
nator quadratus, and other secondary' muscles that originate
from th mediai epicondyle) are innervated through th me
dian nerve. Supination o f th forean n is driven by th bicep-

Chapter 6

Elbow and Forearm Complcx

153

A MUSCULOCUTANEOUS NERVE ( C ^
Brachial Plexus
Lateral cord
Posterior cord
Mediai cord

Deltoid

Lateral brachial
cutaneous nerve

FIGURE 6-33. Paths of th pe


ccherai nerves throughout th eldow , wrist, and hand. The following illustrate th path and
cenerai proximal-to-disial order
muscle innervaiion. The loca~n of some muscles is altered
htly (or iilustration purposes.
primary roots for each nerve
shown in parentheses. (A to
modified with permission from
~root J: Correlative Neuroanat21 st ed. Norwalk, Appleton
Lange, 1991. Photograph by
ld A. Neumann.) A, The
of th righi musculoneous nerve is shown as il
~rvates th coracobrachialis,
:ps brachii, and brachialis
cles. The sensory distribution
shown along th lateral foreThe motor and sensor)'
ponents of th axillary ner\'e
also shown.

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

Elbow and Forearm Compex

Area of concentrated

Brachial Plexus
Lateral cord
Mediai cord

Sensorv Distribution

C MEDIAN NERVE <O T<)


FIGURE 6 - 3 3 Contmued. C, The
path of th righi median nerve is
shown supplying th pronatore,
.'risi flexors, long (extrinsic)
tlexors of th digits (except th
flexor digitorum profundus lo
th ring and little finger), most
mtrinsie muscles io th thumb,
and two lateral lumbricals. The
sensory distribution is shown
with tts area of concentrated supply along th distai end of th
index and middle fingere. Inset,
The median nerve supplies th
sensation of th skin thal natu
rali) makes contact in a pinching
motion between th thumb and
fingere.

Flexor-Pronator Group

Pronator teres

Flexor carpi radialis

Palmaris longus

Flexor digitorum superficialis


Flexor pollicis longus

Abductor pollicis brevis

Opponens pollicis

Flexor pollicis brevis

Lumbricals (lateral-half)

lllustmtion continued on following page

brachii via th musculocutaneous nerve and th supinator


muscle, plus other secondary muscles that arise front th
lateral epicondyle and dorsal forearm, via th radiai nerve.
Table 6 - 4 summarizes th peripheral nerve and primary
nerve root innervation io th muscles of th elbow and

forearm. This table was derived from Appendix HA, which


lists th primary motor nerve roots for all th muscles of th
upper extremity. Appendix I1B shows key muscles typically
used io test th functional status of th C -T 1 ventral nerve
roots.

156

Section II

U pper Extrem ity

D U L N A R N E R V E (C8-T')
Brachisi Plexus
Lateral cord

Area of concentrateti supply


Mediai cord

Scnsory D istrihution
Median nerve
Ulnar nerve
Mediai epicondyle

Flexor carpi ulnaris

Flexor digitorum
profundus (medial-half)

See
median
nerve

Cutaneous branches

Palmaris brevis
Abductor digiti minimi

Opponens digiti minimi


Flexor digiti minimi

O D o rs a l interassei (4)
See median nerve
n r iio c c

Palmar interassei (4)


O Lu m brica ls (medial-half)

SENSORY INNERVATION TO JOINTS


Humeroulnar Joint and Humeroradial Joint
The humeroulnar and humeroradial joints and th surrounding connective tissues receive their sensory innervation l'rom
th C" h nerve roots.18 These afferent nerve roots are carried

primarily by th musculocutaneous and radiai nerves and b\


th ulnar and median nerves.51
Proximal and Distai Radioulnar Joints
The proximal radioulnar joint and surrounding elbow cap
sule receive sensory innervation from C1" 7 nerve roots within

Chapter 6

6 - 4 . Motor Innervation to th Muscles of


th Elbow and Forearm

TABLE

Muscle

Innervation

Elbow and Forearm Complex

157

elbow joint. For this reason, many of th wrist muscles have


a potential to flex or extend th elbow.3 This potential is
relatively minimal and is not discussed further. The anatomy
and nerve supply of th muscles of th elbow and forearm
can be found in Appendix IIC.

Elbow flexors
Brachialis
Biceps brachii
Brachioradialis
Pronator teres

Musculocutaneous nerve (C5-6)


Musculocutaneous nerve (C5-6)
Radiai nerve (C5-6)
Median nerve (C6J)

Elbow extensors
Triceps brachii
Anconeus

Radiai nerve (C7-8)


Radiai nerve (C7-8)

Forearm supinators
Biceps brachii
Supinator

Musculocutaneous nerve (C56)


Radiai nerve (C6)

Forearm pronators
Pronator quadratus
Pronator teres

Median nerve (C8, Tl)


Median nerve (C67)

The primary nerve root innervation of th muscles are in parenthescs.

th median nerve.51 The distai radioulnar joint receives most


of its sensory innervation from th C8 nerve root within th
alnar nerve.18

Function of th Elbow Muscles


Muscles that attach distally on th ulna flex or extend th
elbow, with no ability to pronate or supinate th forearm. In
contrast, muscles that attach distally on th radius may, in
theory, flex or extend th elbow, but also have a potential to
pronate or supinate th forearm. This basic concept serves as
th underlying theme through much of th remainder of this
chapter.
Muscles that act primarily on th wrist also cross th

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

6 - 5 . Structural and Related Biomechanical Variables o f th Primary Elbow Flexor Muscles*


Contraction
Excursion

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 ) )

Biceps brachii (long head)

33.4

13.6

2.5

3.20

Biceps brachii (short head)

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 Muscle belly length measured at 70 degrees of flexion.

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

MaximaI Torque Production of th Elbow Flexor Muscles


Figure 6 - 3 7 shows th line-of-force of three primary elbc
flexors. The strength of th flexion torque varies consic
bly based on age,14 gender, weightlifting experience,
speed of muscle contraction, and position of th jo :
across th upper extremity.52 According to a study repon
by Gallagher and colleagues,14 th dominant side produ

FIGURE 6-34. Anterior view of th righi biceps brachii and brachioradialis muscles. The brachialis is deep to th biceps.

of th humerus and distally near th styloid process of


th radius (see Fig. 6 - 3 4 ) . Maximal shortening of th
brachioradialis causes full elbow flexion and rotation of
th forearm to th near neutral position. EMG studies
suggest that th brachioradialis is a primary elbow flexor,
especially during rapid movements against a high resis
t a l e . 3'1CU2

Chapter 6

S P E C I A L

159

Elhow and Forearm Complex

F O C U S

Brachialis: The "Work-horse" of th Elbow Flexors


In addition to a large cross-sectional area, th brachi
alis muscle also has th iargest volume of all elbow
flexors (see Table 6-5). Muscle volume can be measured by recording th volume of water displaced by th
muscle.3 Large muscle volume suggests that th muscle
has a large work capacity. For this reason, th brachi
alis has been called th "work-horse" of th elbow
flexors.5 This name is due in part to its large work
capacity, but also to its active involvement in all types
of elbow flexion activities, whether performed fast or
slow, or combined with pronation or supination. Since
th brachialis attaches distally to th ulna, th motion
of pronation or supination has no influence on its
length, line-of-force, or internai moment arm.

Brachioradialis

A lateral view showing th line-of-force of three


primary elbow flexors. The internai moment arm (shown as dark
lines) for each muscle is drawn to approximate scale. Note that th
elbow has been flexed about 100 degrees, placing th biceps tendon at 90 degrees of insertion with th radius. See text for further
details. The elbows medial-lateral axis of rotation is shown piercmg
th capitulum.

FIGURE 6 - 3 7 .

significantly higher levels of flexion torque, work, and


power. No significant differences were found across sides,
however, for elbow extension and forearm pronation and
supination.
Maximal effort flexion torques of 725 kg-cm for men and
3 3 6 kg-cm for women have been reporied for healthy middle-aged persons. (Table 6 6 ).4 As noted in Table 6 - 6 ,
flexion torques are about 70% greater than elbow extensor
torques. Furthermore, elbow flexor torques produced with
th forearm supinated are about 20 to 25% greater than
those produced with th forearm fully pronated.40 This difference is due to th increased flexor moment arm of th
biceps32 and th brachioradialis muscles when th forearm is
in or near full supination.
Biomechanical and physiologic data can be used to predict th maximal flexion torque produced by th major el
bow flexor muscles across a full range of motion (Fig.

TABLE 6 - 6. Average Maximal Isometric Internai


Torques*
Movement

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

The biceps is a polyarticular muscle that can produce forces


across multiple joints. As subsequently described, combinine
active elbow flexion with shoulder extension is a naturai and
effective way for producing biceps-generated elbow flexe:
torque.

Flexor Torque vs Elbow Joint Angle

I
A

Elbow Joint Angle (degrees)

\i

Elbow Joint Angle (degrees)

Flexor Moment Arm vs Elbow Joint Angle

FIGURE 6-38. A, Predicted maximal isometric torque-angle


curves for three primary elbow flexors based on a theoretical
model that incorporates each muscles architecture, length-tension relationship, and internai moment arm. B, The length-tension relationships of th three muscles are shown as a normalized flexor force plotted against elbow joint angle. Note that
muscle length decreases as joint angle increases. C, The length
of each muscles internai moment arm is plotted against th
elbow joint angle. The joint angle of each maximal predicted
vartable is hightghted in red. (Data for A and B from An KN,
Kaufman KR, Chao EYS: Physiological considerations of muscle
force through th elbow joint. J Biomechanics 22: 1249-1256,
1989. Data for C from Amis AA, Dowson D, Wright V: Muscle
strengths and musculoskeletal geometry of th upper limb.
Engng Med 8:41-48, 1979.)

Chapter 6

For th sake of discussion, assume that at rest in th


I anatomie position th biceps is about 30 cm long (Fig.
I -39A ). The biceps shortens to about 23 cm after an active
motion that combines 45 degrees of shoulder flexion and
90 degrees of elbow flexion (Fig. 6 -3 9 B ). If th motion
I took 1 second to perform, th muscle experiences an aver
l e contraction velocity of 7cm/sec. In contrast, consider a
more naturai but effective method of biceps activation that
combines elbow flexion with shoulder extcnsion (Fig. 6 -3 9 C ).
During an activity such as pulling a heavy load up toward
I th side, for example, th biceps produces elbow flexion
I while, at th same lime, is elongated across th extending
I snoulder. In effect, th contraction of th posterior deltoid
I neduces th net shortening of th biceps. Based on th exI ampie in Figure 6 - 3 9 C , combining elbow flexion with
I shoulder extension reduces th average contraction velocI cy of th biceps to 5cm/sec. This is 2cm/sec slower than
I combining elbow flexion with shoulder flexion. As described
m Chapter 3, th maximal force output of a muscle is
I greater when its contraction velocity is closer to zero, or
tsometric.
The simple model described here illustrates one of many

Elbow and Forcam i Complex

161

examples in which a one-joint muscle, such as th posterior


deltoid, can enhance th force potential of another muscle.
In th example, th posterior deltoid serves as a powerful
shoulder extensor for a vigorous pulling motion. In addition,
th posterior deltoid assists in controlling th optimal con
traction velocity and operational length of th biceps
throughout th elbow flexion motion. The posterior deltoid,
especially during high power activities, is a ver)' important
synergist to th elbow flexors. Consider th consequences of
perfommng th lift described in Figure 6 - 3 9 C with total
paralysis of th posterior deltoid.

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

RGURE 6-39. A, This model is shovving a person standing in th


anatomie position with a 30-cm long biceps muscle. B, After a 1<ec contraction, th biceps has contracted to a length of 23 cm,
causing a simultaneous motion of 90 degrees of elbow flexion and
45 degrees of shoulder flexion. The biceps has shortened at a contraction velocity of 7 cm/sec. C, The biceps and posterior deltoid
are shown active in a typical pulling motion. The contraction lasts
; sec and causes a simultaneous moiion of 90 degrees of elbow
dexion and 45 degrees of shoulder extension. Because of th contracion of th posterior deltoid, th biceps shortened only 5 cm, at a
contraction velocity of only 5 cm/sec.

Maximal effort elbow extension generates maximum levels of


EMG from all components of th elbow extensor group.
During submaximal efforts of elbow extension, however, different muscles are recruited only at certain levels of effort.48
The anconeus is usually th first muscle to initiate and
maintain low levels of elbow extension force.21 As extensor
effort gradually increases, th mediai head of th triceps is
usually next in line to join th anconeus.48 The mediai head
remains active for most elbow extension movements.12 The
mediai head has been termed th workhorse of th exten
sors, functioning as th extensor counterpart to th brachi
alis.48
Only after extensor demands at th elbow increase to
moderate-to-high levels does th nervous System recruit th
lateral head of th triceps, followed closely by th long head.

162

Section II

Upper Extremity

S P E C I A L

F O C U S

6 - 5

"Reverse Action" of th Elbow Flexor Muscles: A Clinical


Example

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.

FIGURE 6-40. A person with midlevel (cervical) quadriplegia using his


muscles to flex th elbow and bring
his trunk off th mai. Note that th
distai forearm is held fixed by th ac
tion of th wrist extensors. Inset, The
arthrokinematics at th humeroulnar
joint are shown during this movement. The anterior capsule is in a
slackened position, and th posterior
capsule is taut.

The iong head functions as a reserve elbow extensor,


equipped with a large volume suited for tasks that require
high work performance.
Torque Demands on th Elbow Extensors
The elbow extensor muscles provide static stability to th
elbow, similar to th way th quadriceps are often used to
stabilize th knee. Consider th common posture of hear
ing weight through th upper limb with elbows held partially flexed. The extensors stabilize th flexed elbow through

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

A posterior view of th right triceps brachit and


fico neus muscles. The mediai head of th triceps is deep to th
mg and lateral heads and therefore not visible.
GURE 6 -4 1 .

TABLE

163

Ebow and Forcam i Complex

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,

6 - 7 . Strutturai and Related Biomechanical Variables of th Primary Elbow Extensor Muscles*

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 )!

Triceps brachii (long head)

66.6

10.2

6.7

1.87

Triceps brachii (mediai head)

38.7

6.3

6.1

1.87

Triceps brachii (lateral head)

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

FIGURE 6-46. The line-of-force of th supinators (A) and th pro


nators (B) of th forearm during an active motion. Note th degree
to which all muscles intersect th forearms axis of rotation (shown
as dashed line). For clarily, not all th secondary supinators and
pronators are depicted.

mottons does th biceps show significant EMG activity (Fie


6 - 4 8 ) . Using th large polyarticular biceps to perform a
simple, low-power supination task is not an efficient moto*
response. Additional muscles, such as th triceps and poste
rior deltoid, are required to neutralize any undesired bicepaction at th shoulder and elbow. A simple movement ther.
becomes increasingly more complicated and more energj
consuming than absolutely necessary.
The biceps brachii is a powerful supinator muscle of th
forearm. The biceps has about three times th physiologit
cross-section area as th supinator muscle.22 The dominan.
role of th biceps as a supinator can be verified by palpatine
th biceps during a series of rapid and forceful pronation-to- 1
supination motions, especially with th elbow flexed to 9C
degrees. As th forearm is pronated, th biceps tendon
wraps around th proximal radius. From a fully pronate:
position, active contraction of th biceps can spin th ra
dius sharply into supination.
The effectiveness of th biceps as a supinator is greates
when th elbow is flexed to about 90 degrees. Supination
torque perform ed with th elbow flexed to 90 degrees may
produce twice th torque than with th elbow held near fuD
extension. At a 90-degree elbow angle, th tendon of th
biceps approaches a 90-degree angle-of-insertion into th
radius (Fig. 6 - 4 9 , top). This biomechanical situation allow s
th entire magnitude of a maximal effort biceps force, show-

Supinator versus Biceps Brachii


The supinator muscle has a complex proxtmal muscle attachment (Fig. 6 - 4 7 ) . A superficial set of fibers arises from th
lateral epicondyle of th humerus and th radiai collateral
and annular ligaments. A deeper set of fibers arises from th
ulna near and along th supinator crest. Both sets of muscle
fibers attach along th proximal one third of th radius.
From a pronated view (Fig. 6 - 4 7 ) , th supinator is elongated and in excellent position io rotate th radius into
supination. The supinator has only minimal attachments to
th humerus and passes too dose to th medial-lateral axis
of rotation at th elbow to produce significant torque.
The supinator muscle is a relentless forearm supinator,
similar io th brachialis during elbow flexion. The supinator
muscle generates significant EMG activity during forearm
supination, regardless of th elbow angle or th speed or
power of th action.^ The biceps muscle, also a primary
supinator, is normally recruited during higher power supina
tion activities, especially those associated with elbow flexion.
The nervous System usually recruits th supinator muscle
for low-power tasks that require a supination motion only,
while th biceps remains relatively inactive. (This is in accord with th law of parsimony described earlier in this
chapter.) Only during moderate or high-power supination

Radiai collateral ligament


Annular ligament

Deep branch of radiai nerve

FIGURE 6-47. A lateral view of th tight supinator muscle. Th I


deep branch of th radiai nerve is shown exiting between thel
superficial and deep fibers of th muscle. The radiai nerve is court I
ing distally, as th dorsal interosseous nerve, to innervate th fnger
and thumb extensors.

Attive Supination
Low-Power
Supinator
Biceps
Pronator Teres
tor Quadratus

Moderate-Power

High-Power

Supinator

FIGURE 6-48. The EMG signal from four


muscles during three levels of active supi
nation. The minimal EMG activity shown
by th pronator muscles during highpower supination may reflect low level eccentric activity from these muscles. (Modified from Basmajian JV: Muscles Alive.
Their Functions Revealed by Electromyography, 4th ed. Baltimore, Williams & Wilkins,' 1978.)

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___________

Proximal Radioulnar Joint from Behind

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

Supination vs. Pronation Torque Potential


As a group, th supinators produce about 25% greater
isometric torque than th pronators (see Table 6-6).
This difference may be partially explained by th fact
that th supinator muscles possess about twice th
physiologic cross-sectional area than th pronator mus
cles.22 Many functional activities rely on th greater
strength of supination. Consider th activity of using a
screwdriver to tighten a screw. When performed by th
right hand, a clockwise tightening motion is driven by a
concentric contraction of th supinator muscles. The
direction of th threads on a standard screw reflects
th dominance in strength of th supinator muscles.
Unfortunately for th left-hand dominant, a clockwise
rotation of th left forearm must be performed by th
pronators. A left-handed person often uses th right
hand for this activity, explaining why so many are
somewhat ambidextrous.

as 500 N in Figure 6 - 4 9 , top, to be generated at near righ:


angles to th axis of rotation of th forearm. Subsequently,
all of th biceps force is multiplied by th estimated 1-cm
interna! moment ami available for supination, producing 50C
Ncm of torque. As a contrast, consider th reduced effectiveness of th biceps as a supinator when th elbow is flexed to
30 degrees (Fig. 6 - 4 9 , bottom). This elbow angle changes
th angle that th biceps tendon inserts onto th radius tc
about 30 degrees. This insertion angle reduces th force that
th biceps can use to supinate (i.e., that generated perpendicular to th radius) to 250 N (By). An even larger force
component of th biceps, labeled Bx, is directed proximalh
through th radius in a direction parallel with th forearm s
axis of rotation. This force component has no moment arra
to supinate. As shown by th calculations in Figure 6 - 4 9 .
bottom, th effective supination torque from a maximal effor.
muscle contraction yields 250 Ncm.
The aforementioned sample problem shows that with an
equivalent maximal effort muscle force, th supination
torque is reduced by 50% owing to th change in elbow
angle. Clinically, this difference is important when evaluatinr
th torque output from a strength-testing apparatus, or when
providing advice about ergonomics.

FIGURE 6-50. Vigorous contraction show of th right biceps, supinator


and extensor pollicis longus muscles tc
lighten a screw using a clockwise rota
tion with a screwdriver. The triceps
muscle is activated isometrically to
neutralize th strong elbow ilexion
tendency of th biceps.

Chapter 6

Elbow and Forearm Complex

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 ).

Primary Pronator Muscles


Pronator teres
Pronator quadratus

Secondary Pronator Muscles


Flexor carpi radialis

Palmaris longus

Pronator Quadratus vs. Pronator Teres


The pronator quadratus is located at th extreme distai end of
th anterior forearm, deep to all th wrist flexors and extrinsic fnger flexors. This fiat, quadrilateral muscle attaches between th anterior surfaces of th distai one quarter of th
ulna and th radius. Overall, from proximal to distai, th
pronator quadratus has a slight obliquity in fber direction,
similar to, but not quite as angled as, th pronator teres.
The pronator quadratus is th most active and consist
enti} used pronator muscle, involved during all pronation
movements, regardless of th power demands or th amount
of associated elbow flexion.6

S P E C I A L

F O C U S

A Return to th Law of Parsimony

-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.

Low-power activities that involve isolated pronation are


generally initiated and controlled by th pronator quad
ratus. Throughout this chapter, a theme has developed
between th function of a usually smaller one-joint
muscle and an associated larger polyarticular muscle.
In all cases, th hierarchical recruitment of th muscles
followed th law of parsimony. At th elbow, low-power
flexion or extension activities tend to be controlled or
initiated by th brachialis, th anconeus, or th mediai
head of th triceps. Only when relatively high-power
actions are required does th nervous System recruit
th larger polyarticular biceps and long head of th
triceps. At th forearm, low-power supination and pro
nation activities are controlled by th small supinator or
th pronator quadratus; high-power actions require assistance from th biceps and pronator teres. Each time
th polyarticular muscles are recruited, however, additional muscles are needed to stabilize their undesired
actions. Increasing th power of any action at th el
bow and forearm creates a sharp disproportionate rise
in overall muscle activity. Not only do th one-joint
muscles increase their activity, but so do th polyarticu
lar "reserve" muscles and a host of other neutralizer
muscles.

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.

Pronator Quadratus: Dual Rote as Torque Producer and


Stabilizer of Distai Radioulnar Joint
The pronator quadratus is well designed biomechanically as
an effective torque producer and a stabilizer al th distai
radioulnar joint.46 The pronator quadratus has a line-of-force
oriented almost perpendicular to th forearms axis of rota
tion (Fig. 6 -5 2 A ). This design maximizes th potential of
th muscle to produce a torque. The force produced by th
pronator quadratus causes a pronation torque. At th same
time, it compresses th ulnar notch of th radius directly
against th ulna head (Fig. 6 - 5 2 B). This compression force
provides an important element of stabilization to th distai
radioulnar joint, which continues throughout pronation (Fig.
6 -5 2 C ). The force of th pronator quadratus also guides th
joint through its naturai arthrokinematics.
In th healthy joint, th compression force from th pro
nator quadratus and other muscles is absorbed by th joint
without diffculty. In cases of severe rheumatoid arthritis, th
articular cartilage, bone, and periarticular connective tissue
lose their ability to adequately absorb joint forces. These myo-

genic (from th Greek root myo; muscle + genesis; generation


compressive forces can become detrimental to joint stabiliti I
The same forces that help stabilize th joint in th healthvB
state may cause joint destruction in th diseased state.
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ADDITIONAL READINGS
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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

Distai Forearm, 172


Carpai Bones, 173
Carpai Tunnel, 176
ARTHROLOGY, 176

Joint Structure and Ligaments of th


Wrist, 176
J o in t S tru c tu re , 176

Radiocarpal Joint, 177


Midcarpal Joint, 177
W r is t Lig a m e n ts, 177

AT

GLANCE

Kinematics of Wrist Motion, 179


O s te o k in e m a tic s , 179
A rth ro k in e m a tic s , 180

Wrist Extension and Flexion, 181


Ulnar and Radiai Deviation of th
Wrist, 182
Carpai Instability, 184
MUSCLE A N D J O IN T IN TER AC TIO N , 186

Innervation of th Wrist Muscles and


Joints, 186
Function of th Muscles at th Wrist, 186

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

F u n ctio n o f th W r is t E xte n so rs, 187

Muscular Anatomy, 187


Wrist Extensor Activity While Making
a Fist, 188
F u n ctio n o f th W r is t F le xors, 189

Muscular Anatomy, 189


Functional Considerations of th Wrist
Flexors, 190
F u n ctio n o f th R adiai and U ln a r
D e v ia to rs , 191

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.

Osteologie Fcatures of th Distai Forearm


Dorsal or Listers tubercle of th radius
Styloid proeess of th radius
Styloid proeess of th ulna
Distai articular surface of th radius

The palmar surface of th distai radius is th location of


th proximal attachments of th wrist capsule and th thick
palmar radiocarpal ligaments (Fig. 7 - 3 ) . The styloid proeess
oj th radius projeets distally from th lateral side of th
radius. The styloid proeess o f th ulna, much sharper than its
radiai counterpart, extends distally from th posterior-medial
surface of th ulna.
The distai articular surface o f th radius is concave in both
medial-lateral and anterior-posterior directions (see Fig.
6 - 2 7 8 ) . Facets are formed in th articular cartilage from

Chapter 7

Wrist

173

angles about 25 degrees toward th ulnar (mediai) direction


(Fig. 7 -4 A ). This ulnar tilt allows th wrist and hand to
rotate farther into ulnar deviation than into radiai deviation.
As a result of this tilt, radiai deviation of th wrist is limiled
by impingement of th lateral side of th carpus against th
styloid process of th radius. Second, th distai articular
surface of th radius is angled about IO degrees in th
palmar direction (Fig. 7 -4 B ). This palmar tilt accounts, in
part, for th greater amounts of flexion than extension at th
wrist.

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 ) .

Proximal Row of Carpai Bones

Scaphoid
Lunate
Triquetrum
Pisiform
Distai Row of Carpai Bones

Trapezium
Trapezoid
Capitate
Hamate

Tidentations triade by th scaphoid and lunate bones of th


wrist.
The distai end of th radius has two configurations of
biomechanical importance. First, th distai end of th radius

The proximal row of carpai bones is joined in a relatively


loose fashion. In contrast, th distai row of carpai bones is
bound tightly by strong ligaments, providing a rigid and
stable base for articulation with th metacarpal bones.
The following section presents a generai anatomie description of each carpai bone. The ability io visualize each

Dorsal view

FIGURE 7-2. The dorsal aspect of th bones of th rtght


carpus. The muscles distai attachments are shown in
gray. The dashed lines show th proximal attachmetu of
th dorsal capsule of th wrist.

174

Section II

Upper Extremity

Pai m ar view

Flexor carpi ulnaris


Flexor carpi radialis
Marnate with hook

-Trapezoid

Pisiform
Flexor carpi ulnaris

Abductor pollicis longus


Trapezium
Tubercles

Triquetrurrv

Distai and
proximal poles of scaphoid

Styloid process

FIGURE 7-3. The palniar aspect of th bones of


th righi carpus. The muscles proximal attachmenis are shown in red and distai atiachments
in gray. The dashed lines show th proximal
aitachment of th palmar capsule of th wrist.

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

tubercle can be palpated at th radiai side of th base of th


palm.
The distal-medial surface is deeply concave to accept th
lateral half of th prominent head of th capitate bone (see
Fig. 7 - 3 ) . A small facet on th mediai side contacts th
lunate. The scaphoid and radius are located in th direct
path ol most of th force transmission through th wrist.
Injury from fading on an extended and radially deviated
wrist often results in fracture to th scaphoid. Fracture of
th scaphoid occurs more frequenti)' than any other fracture
of th carpai bones. Healing is often hindered if th fracture
is at th scaphoids proximal pole because blood supply is
often absent or minimal in this region. Seventeen percent of
all scaphoid fractures are associated with other injuries along
th weight-bearing path of th wrist and hand.39 Associated
injuries often involve fracture and/or dislocation of th lu
nate and lracture of th trapezium and distai radius.

Mediai view

FIGURE 7-4. A, Anterior view of th distai


radius showing an ulnar tilt of about 25
degrees. B, A mediai view of th distai ra
dius showing a palmar tilt of about 10 de
grees.

Chapter 7

FIGURE 7-5. A view through th


carpai tunnel of th right wrist with
all contenta removed The transverse
carpai ligament is shown as th roof
of th tunnel.

Wrist

175

Hamate with hook


Trapezium with tubercle
Pisiform
Groove fo r flexor carpi radialis
Scaphoid tubercle

Triquetrum

Trapezoid
Capitate
Scaphoid

LUNATE

TRIQUETRUM

The lunate (from th Latin luna, moon) bone is th centrai


bone of th proximal row, wedged between th scaphoid
and triquetrum. Like th scaphoid, th lunates proximal
surface is convex to fu into th concave facet on th radius
Fig. 6 - 2 7 B ). The distai surface of th lunate is deeply
concave, giving th bone its crescent m oon-shaped appearance (see Fig. 7 - 3 ) . This articular surface accepts two convexities: th mediai half of th head of th capitate and pari
of th apex of th hamate.

The triquetrum, or triangular bone, occupies th most ulnar


position in th wrist, just mediai to th lunate. The lateral
surface of th triquetrum is long and fiat for articulation
with a similarly shaped surface on th hamate.

PISIFORM
The pisiform, meaning shaped like a pea, articulates
loosely with th palmar surface of th triquetrum. The pisi-

Ulnar collateral ligament

FIGURE 7-6. A frontal piane cross-section through th


right wrist and distai forearm showing th shape of th
bones and connective tissues.

Prestyloid recess
collateral ligament
Articular disc
with meniscal extension
Sacciform recess
(within distai radioulnar joint)

176

Secton II

Upper Extremity

Kienbock's Disease: Avascular Necrosis of th Lunate


Kienbock's disease is a painful orthopedic disorder of
unknown etiology, characterized by avascular necrosis
of th lunate.39 Without adequate blood supply, th lu
nate may become fragmented and shortened, significantly altering th relative position of th other carpai
bones. In severe cases, th lunate may totally collapse,
disrupting th normal kinematics of th entire wrist. This
tends to occur more often in those involved in manual
labor.
Treatment of Kienbock's disease may be conserva
tive or radicai, depending on th severity. In relatively
mild or early forms of th disease before th lunate
fragments and becomes sclerotic treatment may involve immobilization by casting. In more advanced
cases, th ulna may be surgically lengthened in order
to reduce th compression at th radiocarpal joint. Alternatively, th radius may be surgically shortened to
accomplish th same unloading effect.28 The scaphoid,
trapezium, and trapezoid may also be fused to add stability to th radiai side of th wrist.

forni bone rests upon th triquetrums palmar surface This


easily mobile and palpable bone is th attachment site for
several muscles and ligaments. Otherwise, th pisiform has
little functional signifcance in th kinematics of th wrist.

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

base of th first metacarpal. The carpometacarpal joint is a


highly specialized articulation allowing a wide range of mo
tion to th human thumb.
A slender and sharp tubercle projects from th palmar

surface of th trapezium. This tubercle and palmar tubercle


of th scaphoid provide attachment for th lateral side of th
transverse carpai ltgament (see Fig. 7 - 5 ) . Immediaiely me
diai to th palmar tubercle is a distinct groove for th tendon of th flexor carpi radialis.

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

Radiai collateral ligament (cut)

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

7 - 1. Extrinsic and Intrinsic Ligaments of


th Wrist
TA B LE

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

iMtera leg: fibers between th capitale and th scaphoid


Mediai leg: fibers between th capitate and th triquetrum
Dorsal intercarpal: fibers between th scaphoid and triquet
rum

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

palmar surface of several carpai bones. The palmar radiocar


pal ligaments are much stronger and thicker than th dorsal
radiocarpal ligaments. Significant tension exists in these liga
ments even in th relaxed neutral wrist position.36 In gen
erai, th palmar radiocarpal ligaments become maximally
taut al full wrist extension.30
A complex set of connective tissues exists near th ulnar
border of th wrist known as th ulnocarjral complex. Thts
group of connective tissue is often referred to as th triangular fbrocartilage complex (TFCC).20 The ulnocarpal complex
includes th articular disc, th ulnar collateral ligament, and
th palmar ulnocarpal ligament (see Fig. 7 - 9 ) . This complex
set of tissues fills most of th ulnocarpal space between th
distai ulna and th carpai bones (Fig. 7 10). The ulnocarpal
space allows th carpai bones to pronate and supinate with
th radius, without interference from th distai end of th
ulna.
The articular disc, th main leature of th ulnocarpal com
plex, attaches from th ulnar notch of th radius to near th
styloid process of th ulna (see Fig. 6 - 2 7 ) . This disc is an
important structural component of both th distai radioulnar
joint and th radiocarpal joint. Figure 7 - 6 shows a frontal
piane cross-section through th ulnocarpal space, illustrating
a poorly defined meniscal extension of th articular disc.33
The meniscal extension of th disc is often called th ulno
carpal meniscal homologue, indicating its vestigial function
of once connecting th carpus to th triquetrum. Between
th meniscal extension of th disc and th ulnar collateral
ligament is th small prestyloid recess, a space filled with
synovial fluid. This space often becomes distended and painful with rheumatoid arthritis. Tears in th articular disc may
permit synovial fluid to spread from th radiocarpal joint to
th distai radioulnar joint.
Ihe ulnar collateral ligament is a thickening of th ulnar
side of th wrist capsule (Figs. 7 - 6 and 7 - 8 ) . The ligament
originates from th styloid process of th ulna, crosses th
ulnocarpal space, and attaches distally to th ulnar side of

Dorsal view

FIGURE 7-8. The dorsal ligaments of th righi wrist

Chapter 7

179

Wrist

Palmar view

Transverse carpai ligament


(cut).
Palmar intercarpal ligament
FIGURE 7 - 9 . The palmar ligaments of th

nght wrist. The transverse carpai ligament


has been cut and rellected to show th
underlying ligaments.

Lunotriquetral ligament
Ulnar collateral
ligament
Ulnocarpal complex

P a l r ulnocarpal
ligament
------- Articular disc

th triquetrum and as far distai as th base of th fifth


metacarpal. Full radiai deviation of th wrist elongates th
ulnar collateral ligament and surrounding capsule. The extensor carpi ulnaris assists th ulnar collateral ligament in
remforcing th ulnar margin of th wrist.1
The palmar ulnocarpal ligament is a thickened band of
contiective tissue that originates from th anterior margin of
th articular disc (see Fig. 7 - 9 ) . The ligament attaches dis
tali)' to th palmar surfaces of th lunate and, to a lesser
degree, th triquetrum.16 It becomes taut in full wrist extension and full ulnar deviation.36
Intrinsic Ligaments
The intrinsic ligaments of th wrist are classified as short,
intermediate, or long (see Table 7 - 1 ) . 33 Short ligaments
within th wrist connect th bones of th distai row by their

Short palmar ligaments


of distai row

Transverse carpai ligament (cut)

Radiai collateral ligament


Radiocapitate--------Radiolunate

- Palmar radiocarpal

Radioscapholunate*

li9ament

palmar, dorsal, or interosseous surfaces (Figs. 7 - 8 and


7 - 9 ) . The short ligaments firmly stabilize and unite th row
of bones, permitting thern to function as a single mechanical
unit. Three intermediate ligaments exist within th wrist. The
lunotriquetral ligament is a ftbrous continuation of th palmar
radiolunate ligament (see Fig. 7 - 9 ) . The scapholunate liga
ment is a broad colleciion of fibers that links th scaphoid
with th lunate (see Fig. 1 - 1 A). Several scaphotrapezial liga
ments reinforce th articulation between th scaphoid and
th trapezium (see Figs. 1 - 1 A and 7 - 8 ) .
Two relatively long ligaments are present. within th wrist.
The palm ar intercarpal ligament is firmly attached to th pal
mar surface of th capitate bone (see Fig. 7 - 9 ) . The liga
ment bifurcates proximally into two fber groups that form
an inverted V shape. The lateral leg of th inverted V is
formed by fibers from th capitate to th scaphoid; th
mediai leg is formed by fibers between th capitate and
triquetrum. A thin ligament, th dorsal intercarpal ligament,
provides transverse stability io th wrist by binding th
scaphoid to th triquetrum (see Fig. 7 - 8 ) .

Kinematics of Wrist Motion


OSTEOKINEMATICS

FIGURE 7-10. An x-ray of th righi wrist showing th carpai bones


and ulnocarpal space.

The osteokinematics of th wrist are limited to 2 degrees of


freedom: flexion-and-extension and ulnar-and-radial devia
tion (Fig. 7 - 1 1 ) . Wrist circumduction a full circular mo
tion made by th wrist is a combination of th aforementioned movements, not a third degree of freedom.
Except for minimal passive accessory motions, th wrist
does not rotate about an axis running longitudinally through
th radius. This motion is blocked by th bony fit of th
radiocarpal joint and th ftber direction of many radiocarpal
ligaments.25 The apparent axial rotation of th palm called
pronation and supination occurs at th proximal and distai

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.

radioulnar joints of th forearm. Forcami motions require


that th hand moves with th radius, not separately from it.
The lack of this third degree of freedom at th radiocarpal
.joint allows th pronator and supinator muscles to transfer
torques across th wrist io th working hand.
The wrist rotates in th sagittal piane about 130 to 140
degrees (Fig. 7 - 1 1A). On average, th wrist flexes from 0
degrees to about 65 to 80 degrees and extends from 0
degrees to about 55 to 70 degrees.18-22 29 As with any diarthrodial joint, wrist range of motion varies with age and
state of health and whether th motion is performed actively
or passively. Total flexion normally exceeds extension by
about 10 to 15 degrees. End-range extension can be limited
by stiffness in th thick palmar radiocarpal ligaments. In
some persons, a greater than average palmar tilt of th distai
radius may limit th extension range (see Fig. 7 -4 B ).
The wrist rotates in th frontal piane approximately 45 to
55 degrees (Fig. 7 - 1 1B).18-22-41 Radiai and ulnar deviation is
measured as th angle between th radius and th shaft of
th third metacarpal. Ulnar deviation of th wrist occurs
from 0 degrees to about 30 degrees. Radiai deviation occurs
from 0 degrees to about 15 degrees. Because of th ulnar tilt
of th distai radius (see Fig. 7 -4 A ), maximum ulnar devia
tion normally is doubl that of radiai deviation.
Most naturai movements of th wrist use a combination
of frontal and sagittal piane motions. The greatest continuous are of motion at th wrist exists between full extension/
radiai deviation and full flexion/ulnar 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

Despite many studies, several explanations exist on th pre


cise detail of these kinematics.
The axis of rotation for wrist movement is assumed to
pass through th head of th capitate.40 The axis runs in a
medial-lateral direction for flexion and extension, and in an
anterior-posterior direction for radiai and ulnar deviation

S P E C I A L

F O C U S

Position of Function" of th Wrist

Many daily activities require 45 degrees of sagittal


piane motion: from 5 to 10 degrees of flexion to 30 to 35
degrees of extension. In addition, many daily activities
require 25 degrees of frontal piane motion: from 15
degrees of ulnar deviation to 10 degrees of radiai devia
tion.5-21 Medicai management of a severely painful or an
unstable wrist sometimes requires surgical fusion. To

//

minimize th functional im pairm ent o f this procedure, a

wrist may be fused in an "average" position of function:


about 10 to 15 degrees of extension and 10 degrees of

ulnar deviation.5-27

C hapler 7

Wrist

181

thrology, it does show many of th paramount features of


sagittal piane wrist arthrokinematics.
Dynamic Interaction Within th Joints of th Central Column
of th Wrist

FIGURE 7 - 1 2 . The medial-lateral (gray) and anterior-posterior (red)


axes of rotation for wrist movement are shown piercing th head of
th capitate bone.

>.Fig. 7 - 1 2 ) . Although th axes are depicted as stationary, in


reality they migrate slightly throughout th full range of
motion.23 The firm articulation between th capitate and th
base of th third metacarpal bone causes th rotation of th
capitate to direct th osteokinematic path of th entire hand.
The wrist is a double-joint System with motion occurring
simultaneously at both th radiocarpal and midcarpal joints.
The next discussion on arthrokinematics focuses on th dynamic relationship between these two joints.

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

Wrist Extensian and Flexion


Several models have been created to attempt to define th
individuai angular contributions of th radiocarpal and mid
carpal joints to th total sagittal piane motion of th
wrist.1012'2326-29 41 The essential kinematics of th sagittal
piane involve movements that occur within th centrai col
lima of th wrist (i.e., that formed by th series of articulations among th radius, lunate, capitate, and third metacar
pal bone) (Fig. 7 - 1 3 ) . Within this column, th radiocarpal
joint is represented by th articulation between th radius
and lunate, and th mediai compartment of th midcarpal
joint is represented by th articulation between th lunate
and th capitate. The carpometacarpal joint is assumed to be
a rigid articulation between th capitate and th base of th
third metacarpal. Although this mechanical depiction of th
wrist represents an oversimplification of ver)' complex ar-

Carpometacarpal
joint

Midcarpal joint
Radiocarpal joint

FIGURE 7-13. A lateral view of th centrai column through th


wrist. The axis of rotation for flexion and extension is shown as a
small circle through th capitate.

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).

th kinematics of th scaphoid bone at th radiocarpal joint.


In brief, th arthrokinematics of th scaphoid on th radius
are similar to those of th lunate during flexion and exten
sion, except for one feature. Based on th different size and
curvature of th two bones, th scaphoid rolls on th radius
at a different speed than th lunate.26 This difference causes
a slight displacement between th scaphoid and lunate by
th end of full motion. Normally, in th healihy wrist, th
amount of displacement is minimized by th action of liga
ments, especially th scapholunate ligament (see Fig. 7 - 7 A).
Damage to this ligament can occur through traumatic
scapholunate dislocation, chronic synovitis from rheumatoid
arthritis, and even trom surgical removai of a ganglion cyst.
A torn scapholunate ligament may predispose a person to
scapholunate joint instability, which interferes with th natu
rai kinematics at th wrist 7
Ulnar and Radiai Deviation o f th Wrist
Dynamic Interaction Between th Radiocarpal Joint and th
Midcarpal Joint

Like flexion and extension, ulnar and radiai deviation oc


cur through synchronous convex-on-concave rotations at
both th radiocarpal joint and th midcarpal joint. The
arthrokinematics of ulnar and radiai deviation, however, are

slightly more complicated than those of flexion and exten


sion.
During ulnar deviation, th radiocarpal and midcarpal
joints contribute fatrly equally to overall wrist motion (Fig
7 - 1 5 ) . At th radiocarpal joint shown in red in Figure
7 - 1 5 , th scaphoid, lunate, and iriquetrum roll ulnarly and
slide a significant distance radially. The extent of this radiai
slide is evident by noting th final position of th lunate
relative to th radius at full ulnar deviation.
Ulnar deviation ai th midcarpal joint occurs primarih
from th capitate rolling ulnarly and sliding slightly radially.
Full range of ulnar deviation causes th triquetrum to con
tact th articular disc. Compression of th hamate against
th triquetrum pushes th proximal row of carpai bones
radially against th styloid process of th radius. This com
pression helps stabilize th wrist for activities that require
large gripping forces.
Radiai deviation at th wrist occurs through similar ar
throkinematics as described for ulnar deviation (see Fig
7 - 1 5 ) . The amount ol radiai deviation at th radiocarpal
joint is limited as th radiai side of th carpus impinges
against th styloid process of th radius. Most radiai devia
tion of th wrist, therefore, occurs at th midcarpal joint
The hamate and triquetrum separate by th end of full radiai
deviation.

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.)

Tension in th "Doubl I/" System of Ligaments During


Radiai and Ulnar Deviation

The arthrokinematics of wrist motion are actively driven by


muscle, but controlled by th passive tension action of liga

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

Additional Arthrokinematics Involving th Proximal Row


of Carpai Bones

Careful observation of ulnar and radiai deviation on cine


radiography or serial static x-rays reveals more complicated arthrokinematics than previously described. During
motion, th proximal row of carpai bones "rock" slightly
into flexion and extension and, to a much less extent,
"twist." The rocking motion is most noticeable in th
scaphoid and, to a lesser extent, th lunate. During radiai
deviation th proximal row flexes slightly; during ulnar
deviation th proximal row extends slightly." Note that in
Figure 7-15, especially on x-ray, th change in position of
th scaphoid tubercle between th extremes of ulnar and
radiai deviation. At full ulnar deviation, th scaphoid is
rotated about 20 degrees into extension,

relative to th radius. The scaphoid appears to "stand up"


or to lengthen, which projeets its tubercle distally. At full
radiai deviation, th scaphoid flexes beyond neutral about
20 degrees, taking on a shortened stature with its tubercle
having approached th radius. A functional shortening of
th scaphoid allows a few more degrees of radiai devia
tion before complete blockage against th styloid process
of th radius. The exact mechanism responsible for th
slight flexion and extension of th proximal carpai row
during ulnar and radiai deviation is not fully understood,
but many explanations have been offered.2637 Most likely,
th mechanism is driven by forces generated by stretched
ligaments and compressions that occur between th moving carpai bones.

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.

veneti V represents th mediai and lateral legs of th palmar


intercarpal ligament (see Fig. 7 - 9 ) . The proximal inverted V
is formed by fibers of th palmar ulnocarpal and palmar
radiocarpal ligaments. All four legs of th ligamentous mechanism are under slight tension even in th neutral position.
During ulnar deviation, passive tension rises diagonally
across th wrist by th stretch placed in th lateral leg of th
palmar intercarpal ligament and fibers of th palmar ulnocar
pal ligament.36 During radiai deviation, tension is created in
th opposite diagonal by a stretch in th mediai leg of th
palmar intercarpal ligament and fibers of th palmar radi
ocarpal ligament. A graduai increase in tension within these
ligaments provides an important source of control to th
movement, as well as dynamic stability to th carpai bones.

Two Common Types of Carpai Instability


1. Rotational collapse of wrist: The zig-zag deformity
Volar intercalateci segment instability (VISI)
Dorsal intercalated segment instability (DISI)
2. Translocation of th corpus

Rotational Collapse of Wrist. Mechanically, th wrist


consists of a mobile proximal row of carpai bones interca
lated or interposed between two rigid structures: th forearm
and th distai row of carpai bones.14 Like derailed cars of a
freight train, th proximal row of carpai bones is prone to a
rotational collapse in a zig-zag fashion when compressed
from both ends (Fig. 7 - 1 7 ) . The compression forces that

Tensions Created within th "Doubl V System of


Ligaments during Frontal Piane Movement
During ulnar deviation, tension rises in th
Lateral leg of th palmar intercarpal ligament
Palmar ulnocarpal ligament.
During radiai deviation, tension rises in th
Mediai leg of th palmar intercarpal ligament
Palmar radiocarpal ligament.

Tension in stretched collateral ligaments of th doubl V


System helps determine th end range of motion of radiai
and ulnar deviation. Passive ulnar deviation is limited by
tension in th stretched radiai collateral and palmar ulnocar
pal ligaments. Radiai deviation, in contrast, is limited by
tension in th stretched ulnar collateral and palmar radiocar
pal ligaments.

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.

FIGURE 7-17. A highly diagrammane depiction of a zig-zag col


lapse of th centrai column of th wrist following large compression
force.

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

cross th wrist are due to muscle activation and contact with


th surrounding environment. In most healthy persons, th
wrist remains perfectly stable throughout life. Collapse and
subsequent joint dislocation are prevented by resistance from
ligaments, tendons, and intercarpal articulations.
The lunate is th most frequently dislocated carpai bone.39
Because no muscles attach to th lunate, stability must be
provided by ligaments and contact with adjacent bones,
most notably th scaphoid (Fig. 7 -1 8 A ). The scaphoid functtons as a mechanical link between th lunate and th rigid,
distai row of carpai bones. The continuity of this link requires that th scaphoid is well stabilized by intrinsic liga
ments. Consider, for example, a fall over an outstretched
hand with a resulting fracture of th scaphoid and tearing of
th scapholunate ligament (Fig. 7 1813). Disruption of th
mechanical link provided by th scaphoid often leads to
lunate dislocation. As shown in Figure 7 - 1 8 B , th lunate
most often dislocates so its distai articular surface faces dorsally. This condition is referred to clinically as dorsal intercalated segment instability (DISI) (Fig. 7 - 1 9 ) . Injury to other
ligaments, such as th lunotriquetral ligament, may cause a
lunate dissociation with its distai articular surfaces, facing
volarly (palmarly). This condition is referred to as volar (pal
mari intercalateli segment instability (VISI).31 Regardless of th
type of rotational collapse, th consequences can be painful
and disabling. Changes in th naturai arthrokinematics may
create regions of high stress, eventually leading to joint destruction and carpai morphology changes. A painful and
arthritic wrist may fail to provide a stable platform for th
hand. A collapsed wrist may shorten its length, thereby altering th length-tension relationship and moment arms of th
muscles that cross th wrist.34

ulnar direction. Figure 7 - 2 0 shows that a wrist with an


ulnar tilt of 25 degrees has an ulnar translation force of 42%
of th total compression force that crosses th wrist. This
translational force is naturali)' resisted by passive forces from
various extrinsic ligaments, such as palmar radiocarpal liga
ment. A disease like rheumatoid arthritis signifkantly weakens wrist ligaments. Over time, th carpus may migrate ul
narly. An excessive ulnar translocation can significanti)' alter
th biomechanics of th entire wrist and hand.

Dinar Translocation of th Carpus. As pointed out


earlier,
side so
degrees
naturai

th distai end of th radius is angled from side io


that its articular surface is sloped ulnarly aboul 25
(see Fig. 7 -4 A ). Ulnar tilt of th radius creates a
tendency for th carpus to slide (translate) in an

FIGURE 7-19. Lateral x-ray showmg th dislocation and subsequent


rotational deformity of th lunate in th dorsal direction. Compare
with Figure 7-18B. (Courtesy of Jon Marion, CHT, OTR, and
Thomas Hitchcock, MD. Marshfield Clinic, Marshfeld, Wl.)

186

Seaion II

Upper Extremity

Function of th Muscles at th Wrist

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.

MUSCLE AND J OINT INTERACTION

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

______

Innervation of th Wrist Muscles and Joints


MOTOR INNERVATION TO MUSCLE
The radiai nerve supplies all th muscles that cross th dorsal side of th wrist (see Fig. 6 - 3 3 B). Muscles with prime
action at th wrist are th extensor carpi radialis longus,
extensor carpi radialis brevis, and extensor carpi ulnaris. The
median and ulnar nerves innervale all muscles that cross th
palmar side of th wrist, including th primary wrist flexors
(Fig. 6 - 3 3 C and D). The flexor carpi radialis and palmaris
longus are innervated by th median nerve; th flexor carpi
ulnaris is innervated by th ulnar nerve. The motor nerve
roots that supplv all th muscles of th upper limb are listed
in Appendix HA. Appendix I1B shows th key muscles typically used to test th functional status of th C5-T' ventral
nerve roots.

SENSORY INNERVATION TO THE JOINTS


The radiocarpal and midcarpal joints receive sensory fibers
from th O 7 nerve roots carried in th median and radiai
nerves.7-8 The midcarpal joint is also innervated by sensory
nerves traveling to th C8 nerve root via th deep branch of
th ulnar nerve.7

i] TABLE 7 - 2 . Cross-sectional Arca of Most Muscles


i that Cross th Wrist
Potential Wrist Flexor
Flexor digitorum profundus
Flexor digitorum superficialis
Flexor carpi ulnaris
Flexor pollicis longus
Flexor carpi radialis
Abductor pollicis longus
Extensor pollicis brevis*
All flexor muscles
Potential Wrist Extensor
Extensor carpi ulnaris
Extensor digitorum communis
Extensor carpi radialis longus
Extensor caipi radialis brevis
Extensor pollicis longus
All extensor musclest

Cross-sectional Area (cm2)


10.8
10.7
5.0
2.9
2.16
1.84
.40
33.8
Cross-sectional Area (cm2)
5.30
4.30
3.14
2.22
.56
15.5

* 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.

torque production, however, each muscle's cross-sectional


area must be multiplied by th appropriate internai moment
arm. The extensor carpi ulnaris, therefore, is considered a
more potent ulnar deviatoi' than an extensor; th flexor carpi
ulnaris is considered both a potent flexor and a potent ulnar
deviator.

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

FUNCTION OF THE WRIST EXTENSORS


Muscular Anatomy
The three primary wrist extensors are th extensor carpi radialis longus, th extensor carpi radialis brevis, and th extensor
carpi ulnaris (Fig. 7 - 2 2 ) . The extensor digitorum communis
is capable of generating significant wrist extension torque,
but is primarily involved with finger extension. Other secondary wrist extensors are th extensor indicis, extensor dig
iti minimi, and extensor pollicis longus. The function of
these muscles is studied in greater detail in Chapter 8.

Wrist Extensor Muscles

Primary
Extensor carpi radialis longus
Extensor carpi radialis brevis
Extensor carpi ulnaris
Secondar)'
Extensor digitorum communis
Extensor indicis
Extensor digiti minimi
Extensor pollicis longus

The proximal attachments of th primary wrist extensors


are located on and near th lateral (extensor-supinator)
epicondyle of th humerus and dorsal border of th ulna
(see Figs. 6 - 2 and 6 - 6 ) . Distally, th extensor carpi radialis
longus and brevis attach side by side to th dorsal bases of
th second and third metacarpals; th extensor carpi ulnaris
attaches to th dorsal base of th fifth metacarpal.

FIGURE 7-22. A posterior view of th right forearm showing th

primary wrist extensor muscles: extensor carpi radialis longus, ex


tensor carpi radialis brevis, and extensor carpi ulnaris. The extensor
digitorum communis is depicted as a wrist extensor because of its
large potential to assist with this action. Many of th secondary
wrist extensors are also shown,

188

Scction II

Upper Extremity

Extensor carpi ulnaris

Extensor pollicis brevis

Extensor digiti minimi


Extensor digitorum communis
and extensor indicis

Abductor pollicis longus


Extensor
carpi radialis
longus

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

The tendons of th muscles that cross th dorsal and


dorsal-radial side of th wrist are secured in place across th
wrist by th extensor retinaculum (Fig. 7 - 2 3 ) . The extensor
retinaculum wraps around th styloid process of th ulna to
attach palmarly to th llexor carpi ulnaris, pisiform, and
pisometacarpal ligament. The retinaculum attaches to th
styloid process of th radius and th radiai collateral liga
ment. Between th extensor retinaculum and th dorsal surface of th wrist are six fibro-osseus tunnels that house th
tendons along with their synovial sheaths. The extensor reti
naculum prevents th tendons from bowstringing up and
away from th radiocarpal joint during active extension. The
retinaculum and associated tendons also assist th dorsal
capsular ligaments in stabilizing th dorsal side of th wrist.

in making a fist. To demonstrate this, rapidly tighten and


release th fisi and note th strong synchronous activity from
th wrist extensors. The extrinsic finger flexor muscles.
namely th flexor digitorum profundus and flexor digitorum
superficialis, pass a signi ficant distance palmar to th wrists
medial-lateral axis of rotation (see Fig. 7 - 2 1 ) . Their contrac
tion as primary finger flexors generates a significant flexion
torque at th wrist that must be counterbalanced by th
extensor muscles (Fig. 7 - 2 4 ) . As a strong grip is applied to
an object, th wrist extensors hold th wrist in about 35
degrees of extension and about 5 degrees of ulnar deviation.19
This position optimizes th length-tension relationship of th
extrinsic finger flexors, thereby facilitating maximal grip
strength (Fig. 7 - 2 5 ) .

Wrist Extensor Activity While Making a Fist


The main function of th wrist extensors is to position and
stabilize th wrist for activities involving th fingers. Of particular importance is th role of th wrist extensor muscles

FIGURE 7-24. Muscle mechanies are shown that are involved with

th application of a strong grip. Contraction of th long finger


flexors flex th fingers but also cause a simultaneous wrist Jlexion
torque. Activation of th wrist extensors, such as th extensor carpi
radialis brevis, is necessary lo block th wrist flexion tendency
caused by activated finger flexors. In this manner, th wrist exten
sors are able to maintain th optimal length of th finger flexors to
effectively flex th fingers. The internai moment arms for th exten
sor carpi radialis brevis and finger flexors are shown in dark bold
lines.

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

FIGURE 7-26. A person with paralysis of


th right wrist extensor muscles, following
a radiai nerve injury, is performing a max
ima! effort grip using a dynamometer.
A, Despite normally innervated finger
(lexor muscles, maximal grip strength
measures only about 10 pounds. B, The
same person is shown stabilizing her wrist
m order to prevent it from flexing during
th grip effort. Note that th grip force
has nearly tripled.

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 ) .

W rist Flexor Muscles

Primary
Flexor carpi radialis
Flexor carpi ulnaris
Palmaris longus
Secondar y
Flexor digitorum profundus
Flexor digitonim superficialis
Flexor pollicis longus

FUNCTION OF THE WRIST FLEXORS


Muscular Anatomy
The three primary wrist flexors are th flex or carpi radialis,
th flex or carpi ulnaris, and, when present and fully fortned,
th palmaris longus (Fig. 7 - 2 7 ) . The palmaris longus is missing in about 10% of people, however. When present, it is
extremely variable and may have several small tendons. Tendons of these muscles are easily identified on th anterior
distai wrist, especially during strong isometric activation. The
palmar carpai ligament, not easily identified by palpation, is
located proximal to th transverse carpai ligament. This
structure, analogous to th extensor retinaculum, stabilizes
th tendons of th wrist flexors and prevents excessive
bowstringing during flexion.

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.

Other secondary muscles capable of flexing th wrist are


th extrinsic flexors of th digits (flexor digitorum profundus, flexor digitorum superficialis, and flexor pollicis lon
gus). With th wrist in a neuiral position, th abductor
pollicis longus and extensor pollicis brevis have a small mo
ment ama for wrist flexion (see Fig. 7 21). These secondar)'
wrist muscles are studied in greater detail in Chapter 8.
The proximal attachments of th primary wrist flexors are
located on and near th mediai (flexor-pronator) epicondyle of th humerus and dorsal border of th ulna (see Figs.
6 - 2 , 6 - 3 , and 6 - 6 ) . Technically, th tendon of th flexor
carpi radialis does not cross th wrist in th carpai tunnel;
rather, th tendon passes in a separate tunnel formed by a
groove in th trapezium and fascia from th adjacent trans
verse carpai ligament (Fig. 7 - 2 8 ) . The tendon of th flexor
carpi radialis attaches distally to th palmar base of th
second and, sometimes, th third metacarpal. The palmaris
longus has an extensive distai attachment primarily into th
thick aponeurosis of th palm of th hand. The tendon of
th flexor carpi ulnaris courses distally to attach to th pisiform bone and, in a piane superfcial to th transverse carpai
ligament, into th pisohamate and pisometacarpal ligaments
and th palmar base of th ffth metacarpal bone.

Functional Considerations of th Wrist Flexors


Based on internai moment arm and cross-sectional area (see
Fig. 7 - 2 1 and Table 7 - 2 ) , th flexor carpi ulnaris produces
th greatest flexor torque of th three primary wrist flexor
muscles.
In addition to th primary wrist flexors, th extensor
carpi ulnaris demonstrates significant electromyographic
(EMG) activity during active wrist flexion.1 This EMG activity reflects eccentric activity from th muscle, as it produces
a force to assist th ulnar collateral ligament with stability of
th ulnar side of th wrist. The ulnocarpal space is inherently fragile due to its lack of bony reinforcement (see Fig
7 -1 0 ).
The flexor carpi radialis and ulnaris function synergistically lo flex th wrist; however, they oppose each others
radiai and ulnar deviation ability (see Fig. 7 - 2 1 ) . Depending
on th relative activation level of th two muscles, a posture
of wrist flexion is combined with varying degrees of radiai or
ulnar deviation.
Table 7 - 2 shows that muscles that flex th wrist have a
total cross-sectional area twice that of th muscles that extend th wrist. A similar disparity is observed in th strength
dominance of th flexors over th extensors (Table 7 - 3 ) . Of
particular interest are th extrinsic finger flexors (flexors dig
itorum superficialis and profundus) that account for about
two thirds of th total cross-sectional area of th wrist flex
ors. Many activities that require a powerful grip, such as
lifting and pulling heavy objects, also require large isometric
wrist flexor torques. Co-activation of th wrist extensors is
usually required to position th wrist toward extension in

Palmar view

FIGURE 7-28. The palmar aspect of th right wrist showing th


distai attachments of th primary wrist flexors. Note that th ten
don of th flexor carpi radialis courses through a sheath located
within th superfcial fibers of th transverse carpai ligament. Most
of th distai attachment of th palmaris longus has been removed
with th palmar aponeurosis.

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

Standard deviattons in parenthesis. Results from study of ten healihy


aduli males.
Conversions: 1.36 N-m/ft-lb.
(Data from Delp SL, Grierson AE, Buchanan TS: Maximum isometne
moments generateci by th wrist muscles in flexion-extension and radiatulnar deviation. J Biomechan 29:1371-1375, 1996.)

order io maintain favorable activation length of ihe finger


flexors.

FUNCTION OF THE RADIAI. AND ULNAR DEVIATORS


Muscles capable of producing radiai deviation of ihe wrist
are th extensor carpi radialis brevis and longus, extensor
pollicis longus and brevis, flexor carpi radialis, abductor pollicis longus, and flexor pollicis longus (see Fig. 7 - 2 1 ) . In
th neutral wrist position, th extensor carpi radialis longus
possesses th largest product of cross-sectional area and th
moment arm for radiai deviation torque, followed by th
abductor pollicis longus and th extensor carpi radialis
brevis. The extensor pollicis brevis has th greatest moment
arm of all radiai deviatore; however, because of a ver)' small
cross-sectional area, this muscles torque production is likely
small. The abductor pollicis longus and extensor pollicis
brevis provide important stability to th radiai side ol th
wrist along with th radiai collateral ligament. As shown in

Extensor carpi radialis longus


Extensor caipi radialis brevis
Extensor pollicis longus
Extensor pollicis brevis
Flexor carpi radialis
Abductor pollicis longus
Flexor pollicis longus

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

Radiai Deviatore of th Wrist

40 of flexion
From 30 of flexion to
70 of extension
0 (neutral)
0 (neutral)

FIGURE 7 -2 9 . The muscles that perform ra


diai deviation of th wrist are shown preparing to strike a nal with a hammer. Images in th background are mirror reflections of objects tn th foreground. The axis
of rotation is through th capitate with th
internai moment arms shown for th exten
sor carpi radialis brevis (ECRB) and th
flexor carpi radialis (FCR) only. The flexor
pollicis longus is noi shown. (ECRL and
B = extensor carpi radialis longus and
brevis; APL = abductor pollicis longus;
and EPE and B = extensor pollicis longus
and brevis.)

wnst

Table 7 - 3 , th radiai deviator muscles generate about 15%


greater isometric torque than th ulnar deviator muscles.6

TABLE 7 - 3 . Magnitude and Joint Position of Peak


Isonietric Torque for W rist Movemcnts

Wrist Movement

)r~

192

Seciion II

Upper Extremily

FIGURE 7-3 0 . The muscles that perform


ulnar deviation are shown striking a nail
with a hammer. The images in th
background are a mirror refiection of
th objects in th foreground. The axis
of rotation is shown through th capi
tate with internai moment arms shown
for th flexor carpi ulnaris (FCU) and
th extensor carpi ulnaris (ECU).

to remain unopposed. The resulting flexed posture of th


wrist is thereby not suitable for an effective grasp.

Ulnar Deviators of th Wrist


Extensor carpi ulnaris
Flexor carpi ulnaris

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