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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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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 Palmar plates
accessory parts) digita!
Deep transverse sheath
metacarpal Flexor
digitorum
protundus
tendon

Flexor
digitorum
superficialis
tendon

FIGURE 1
 Atout The Author IX

\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 trans-
formed 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 con-
cepts in a relatively simple manner, while preserving human form and expression.

FIGURE 2
 ABOUT THE CONTRIBUTORS

A. J o sep h T 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 dysfunc-
tions, 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 his-
tology.
Basic Structure and Function o f th Joints (Chapter 2)

D a v id A. B r o w n , PT, P h D
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)

D eb o r a h A. N a w o c zen sk t , PT, P h D
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 walker-
assisted 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
Ann M. Brophy, PT
NovaCare Outpatient Rehabilitation
Milwaukee, WI
Frank L. Buczek, Jr ., PhD
Motion Analysis Laboratory
Shriners Hospital for Children
Erie, PA
Daniel J . Capriani, PT, MEd
Department of Physical Therapy
Medicai College of Ohio
Toledo, OH
Am a Carlisle, MPT
Physical Therapy Department
Zablocki VA Medicai Center
Milwaukee, W1
Leah Cartwright, PT
Physical Therapy Department
Zablocki VA Medicai Center
Milwaukee, WI
R e v i e w e r s
Gary Chleboun, PT, PhD Jerem y Karman, PT
School of Physical Therapy Physical Therapy Department
Ohio University Sports Medicine Institute
Athens, OH Aurora Sinai Medicai Center
Milwaukee, WI
Mary A. Cimrmancic, DDS
Marquette University School of Michelle Lanouette, PT, MS
Dentistry
Physical Therapy Department
Milwaukee, WI Zablocki VA Medicai Center
Milwaukee, WI
Adam M. Davis, PT
Quad Med, LLC
Sussex, WI Paula M. Ludewig, PT, PhD
Program in Physical Therapy
Brian L. Davis, PhD University of Minnesota
Department of Biomedicai Engineering Minneapolis, MN
The Lerner Research Institute
The Cleveland Clinic Foundation Jo n D. Marion, OTR, CHT
Cleveland, OH Marshfield Clinic
Marshfield, WI
Sara M. Dcprey, PT, MS
Department of Allied Health Brenda L. Neumann, OTR, BC1AC
Carroll College Clinic for Neurophysiologic Leaming
Waukesha, WI Milwaukee, WI
Sara Jean Donegan, DDS, MS
Jan et Palmatier, PT, MHS, CHT
Marquette University School of
Work Injury Care Center
Dentistry
Gtendale, WI
Milwaukee, WI
W illiam F. Dostal, PT, PhD Randolph E. Perkins, PhD
Department of Rehabilitation Therapies Physical Therapy and Celi and
University of Iowa Hospitals and Molecular Biology
Clinics Northwestern University Medicai
lowa City, IA School
Chicago, IL
Joan E. Edelstein, PT, MA
Physical Therapy Christopher M. Powers, PT, PhD
Columbia University Department of Biokinesiology and
New York, NY Physical Therapy
University of Southern California
Timothy Fagerson, PT, MS Los Angeles, CA
Orthopaedic Physical Therapy Services,
Ine.
Kathryn E. Roach, PT, PhD
Wellesley Hills, MA
Division of Physical Therapy
Kevin P. Farrell, PT, OCS, PhD University of Miami School of
Physical Therapy Medicine
Saint Ambrose University Coral Gables, FL
Davenport, IA
M ichelle G. Schuh, PT, MS
Esther Haskvitz, PT, PhD Department of Physical Therapy and
Notre Dame College Program in Exercise Science
Physical Therapy Program Marquette University
Manchester, NH 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 Chris L. Zimmermann, PT, PhD
CHT Physical Therapy Program
Department of Rehabilitation Therapies Concordia University, Wisconsin
University of Iowa Hospitals and Mequon, WI
Clinics
Iowa City, IA
David Williams, MPT, ATC, CSCS
Physical Therapy Program
Iowa City, IA
 F 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 signifi-
cant confounding factor is th perpetuai explosion of knowl-
edge for which th author is responsible for inclusion in th
work.
Perhaps in his earlier days, Don Neumann never antici-
pated 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 stu-
dent 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 In-
vestigator Award (1991) and th Jack Walker Award (2000),
which recognizes published clinical research in Physical Ther-
apy.
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 kinesiol-
ogic 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 stu-
dents and professionals alike.
Gara L. Soderberg, PT, PhD, FAPTA
Professor and Director of Research
Department of Physical Therapy
Southwest Missouri State University
Springfield, Missouri
 P R E F A C E
Kinesiology is th study of human movement, typically pur-
sued within th context of sport, art, or medicine. To vary-
tng degrees, Kinesiology o f th Musculoskeletal System: Founda-
tions 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 contrib-
uting authors have focused primarily on th mechanical in-
teractions 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 ab-
normal 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 surpris-
ingly 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 an-
other, 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 Mar-
quette 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 ambi-
don 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 se-
quence. 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 biomechani-
cal 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, start-
ing 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 ar-
thrology th study of th anatomy and th function of th
joint, including th associated periarticular connective tis-
sues. Included in this study is a thorough description of th
regional kmematics, both from an arthrokinematic and os-
teokinematic 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 attach-
ments 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-pro-
duced forces imposed on joints, intermuscular and interjoint
synergies, important functional roles of muscles, and func-
tional relationships that exist between th muscles and un-
derlying 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 condi-
tions contribute to functional impairments or limitations.
Discussions are frequenti)' related to issues involving pro-
longed immobilization of limbs; instability or malalignment
of joints; abnormal posture or limited range of motion; pa-
ralysis and muscular force imbalances; and trauma and in-
flammation 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, with-
XVII
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 teach-
ing tool for instructors who adopt th book for use in their
classes. (Instructors should check with their sales representa-
tive for further information.) Special Focus features are used
to highlight areas of special interest. Topics in a Special
Focus include notable clinical corollaries, distinctive struc-
tural 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 sec-
tions 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-of-
force. 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-dimen-
sional 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
 A 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 comple-
tion of this project. I thank my son, Donnie, and stepdaugh-
ter, 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 through-
out my life.
Four persons signiftcantly influenced th realization of
Kinesiology o f th Musculoskeletal System: Foundations fo r Physi-
cal 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, respec-
tively, 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 contrib-
uted 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 re-
viewed 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 con-
cepts, 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 Shan-
ahan, 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 Ber-
man, 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 1

C h a p t e r 1 Getting Started 3
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 2 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 3 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 4 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 p e n d ix 1 86

S E C T 1O N 11
Upper Extremity 89
C hapter 3 Shoulder Complex 91
D o n a l d A. N e u m a n n , PT, P h D

C i i ap tfr 6 Elbow and Forearm Complex 133

D o n a l d A. N e u m a n n . PT, P h D

C hart e r 7 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 8 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 249

C iiap i i r 9 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 t i o n IV

Lower Extremity 385

c: h a p u r 12 Hip 387
D o n a l d A. N e u m a n n , PT, Ph D

c ha pt i r 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
 S E C T I O N I

Essential Topics of
ll:sJ Kinesiology
1 / \ /
:/
 I

MF

Axis of
rotatimi O

S E C T 1 O N I

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 l.W

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.

2
 C h a p t e r 1

Getting Started
Donald A. Neum an n , PT, Ph D

TOPICS AT A GLANCE

What Is Kinesiology?, 3 Spin, 10 Muscle and Joint Interaction, 16

Motions That Combine Roll-and-Slide Types of Muscle Activation, 16
KINEMATICS, 3
and Spin Arthrokinematics, 10 A Muscle's Action at a Joint, 17
Translation Compared with Rotation, 4
Predicting an Arthrokinematic Pattern Terminology Related to th Actions of
Osteokinematics, 5
Based on Joint Morphology, 10 Muscles, 18
Planes of Motion, 5
Axis of Rotation, 5 Close-Packed and Loose-Packed Musculoskeletal Levers, 19
Positions at a Joint, 11 Three Classes of Levers, 19
Degrees of Freedom, 6
KINETICS, 11 Mechanical Advantage, 21
Osteokinematics: A Matter of
Musculoskeletal Forces, 12
Dictating th Trade-off" between
Perspective, 7
Impact of Forces on th Musculoskeletal Force and Distance, 21
Arthrokinematics, 8
Typical Joint Morphology, 8 Tissues: Introductory Concepts and GLOSSARY, 22
Fundamental Movements Between Joint Terminology, 12 SUMMARY, 24
Surfaces, 8 Internai and External Forces, 13
Roll-and-Slide Movements, 8 Musculoskeletal Torques, 15

INTRODUCTION_____________________________ This text of kinesiology borrows heavily from three bodies

What Is Kinesiology?
The origins of th word kinesiology are from th Greek kine-
sis, 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 condi-
tions that result from disease and trauma. A sound under-
standing of kinesiology allows for th development of a ra-
tional evaluation, a precise diagnosis, and an effective
treatment of musculoskeletal disorders. These abilities repre-
sent th hallmark of high quality for any health professional
engaged in th practice of physical rehabilitation.
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 inter-
act 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 ki-
nesiologic functions of th musculoskeletal system to be rea-
soned 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
4 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 as-
sumed rigid body moves in a circular path aboul some pivot

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 de-
scribed 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
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).
Chapter 1 Getting Started 5
TABLE 1 - 1 . Common Conversions Between Units
of Kinematic Measurements
1 meter (m) = 3 .28 feet (ft) 1 ft = .305 m
1 m = 39.3 7 inches (in) 1 in .0254 m
1 centimeter (cm) = .39 in : in = 2 .54 cm
1 m = 1.09 yards (yd) 1 yd = .91 m
1 kilometer (km) = .62 miles (mi) 1 mi = 1.61 km
1 degree = .0174 radians (rad) 1 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 con-
trast, 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 radi-
ans 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
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


6 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. 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
DEGREES OF FREEDOM about a vertical axis o f rotation. Each axis of rotation is color-coded
with its associated piane of movement. The straight arrows shown
Degrees o f freedom are th number of independent move-
parallel to each axis represent th slight translation potential of th
ments allowed at a joint. A joint can have up to three
humerus relative to th scapula. This illustration shows both angu
degrees of angular freedom, corresponding to th three di- lar and translational degrees of freedom. (See text for further de-
mensions of space. As depicted in Figure 1 - 5 , for example, scription.)

TABLE 1 - 2 . A Samplc of Common Osteokinematic Terms

Sagittal Piane Frontal Piane Horizontal Piane

Flexion and extension Abduction and adduction Internai (mediai) and external (lateral) rotation
Dorsidexion and piantar flexion Lateral flexion Axial rotation
Forward and backward bending Ulnar and radiai deviation
Eversion and inversion

Many of th terms are specific to a particular region of th body. The thumb, for example, uses differem terminology.

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 osteokin-
ematics.
Most routine movements performed by th upper extrem-
:des involve distal-on-proximal segment kinematics. This re-
Qects th need to bring objects held by th hand either
F1GURE 1-6. Sagittal piane os- Proximal segment fixed
teokinematics at th knee show
an example of (A) distal-on-
proximal segment kinematics
and (B) proximal-on-distal seg
ment kinematics. The axis of
rotation is shown as a circle at
th knee.
A Tibial-on-femoral perspective
Chapter 1 Gelting Started 7
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 ex-
amples of distal-on-proximal segment kinematics employed
by th upper extremities. The upper extremities are certainly
capable of performing proximal-on-distal segment kinemai-
ics, such as flexing and extending th elbows while perform-
tng a pull-up.
The lower extremities routinely perform both distal-on-
proximal and proximal-on-distal segment kinematics. These
kinematics reflect, in part, th two primary phases of walk-
ing: 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. Bend-
ing 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 typi-
cally 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
Distai segment free
 8 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 resis-
tance 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 adjust-
ment 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 FIGURE 1 -7 . The humeroulnar joint at th elbow is an example of
open). To avoid confusion, this text uses th terms open and a convex-concave relationship between two articular surfaces The
closed kinematic chains sparingly, and th preference is to trochlea of th humerus is convex, and th trochlear notch of th
ulna is concave.
explicitly state which segment (proximal or distai) is consid-
ered 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.
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 hu-
meral 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
Analogy
Roll*
Multiple points along one rotating articular surface contact multiple
A tire rotating across a stretch of pavemenl.
points on another articular surface.
Slidet
A single poim on one articular surface contacts multiple points on
A stationary tire skiddmg across a stretch of icy
another articular surface.
Spin pavement.
A single pomi on one articular surface rotates on a single point on
A rotating toy top on one spot on th floor.
another articular surface.

TAlso temied gliele

 Chapter 1 Cetting Started 9

Convex-on-concave arthrokinematics

Concave-on-convex arthrokinematics

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 glenohu-
meral joint. As shown in Figure 1 -9 A , th concurrent roll
and slide maximizes th angular displacement of th abduct-
ing 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 exter-
nal 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 combi-
nation 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 auto-
matically 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 mov-
ing, 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 inher-
ent 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

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-on-
femoral (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 circum-
stances, glenohumeral abduction can be facilitateci by apply-
mg an inferior-directed force at th proximal humerus,
stmultaneously with an active-abduction effort. The arthro-
kinematic 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. Acces-
sory 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
Chapter 1 Getting Storteci 11
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).
m
S P E C I A L F O C U S
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-
U N LO AD ED T E N S IO N
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 eom-
bined 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. Phila-
delphia, 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 re-
coverable in its entirety when th deforming force is re-
leased. As elongation continues, th ligament reaches its ini-
tial 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 non-
weight-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 in-
creased 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 ac-
tive or passive. Active forces are generated by stimulated
muscle, generally under volitional control. Passive forces, in
contrast, are typically generated by tension in stretched peri-
articular 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 en-
ergy produced by active contraction of muscle A is trans-
ferred 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 ex-
tend 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 Bio-
mechanics of th Hand. St Louis, CV Mosby
1985.)

URE 1 -1 5 . The branch of th tree ts demonstrating a time-
ndem 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 biomechani-
al 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-of-
force 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-
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 dif-
ferent sense. The two vectors each have a dif-
ferent magnitude and different points of attach-
ment to th forearm. B, Joint reaction force is
added lo prevent th forearm from accelerating
upward. (Vectors are drawn lo relative scale.)
'r
Externalforce
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-of-
insertion 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.
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 differ-
ence 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
External force
 16 Section / Essential Topics of Kinesiology
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
Torque Makes th World Go 'Round
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 im-
portant, 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 ex-
plains 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 chal-
lenge 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 pa-
tient. 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 Getting Staned 17

greater detail in Chapter 3 and briefly summarized subse-
Titly.
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). Dur-
an 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 activa-
on, 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 ec-
centric 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 el-
bow 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.
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 con-
text 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 anterior-
posterior 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 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

B
Posterior view Superior view Lateral 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 Actually, most meaningful movements of th body involve
meral joint. multiple muscles acting as synergists. Consider, for example,
The logie so presented can be used to determine th th flexor carpi ulnaris and flexor carpi radialis muscles
action of any muscle in th body, at any joint. If available, an during flexion of th wrist. The muscles act synergistically
articulated skeleton model and a piece of string that mimics because they cooperate to flex th wrist. Each muscle, how
th line-of-force of a muscle is helpful in applying thts logie. ever, must neutralize th others tendency to move th wrist
This exercise is particularly helpful when analyzing a muscle in a side-to-side (radiai and ulnar deviation) fashion. Paraly-
whose action switches, depending on th position of th sis of one of th muscles signifcanily affeets th overall
joint. One such muscle is th posterior deltoid. From th action of th other.
anatomie position, th posterior deltoid is an adductor of th
glenohumeral joint. If th arm is lifted (abducted) fully over-
head, 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 exam-
ple 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.

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
FIGURE 1-20. Side view ol th force-couple formed between two
considered to have th opposite action of a particular ago
representative hip flexor (rectus femoris and iliopsoas) muscles and
nist. For example, th gastrocnemius and soleus muscles are
back extensor (erector spinae) muscles, as they contract to tilt th
considered th antagonists to th tibialis anterior.
pelvis in an anterior direction. The internai moment arms used by
3. A pair of muscles are considered synergists when they th muscles are indicated by th dark black lines. The axis of
cooperate during th execution of a particular movement. rotation runs through both hip joints.
DEI

b ib l io t e c a
CASA DE ESTUDIOS
PROVIDENCIA
 Chapter I Getting Started 19

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 mus-
des, 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
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 impor-
tant 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 first-
class 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

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, pos-
iisses 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 metatarsopha-
mgeal joints. The internai moment arm used by calf mus-
es 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
Chapter 1 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 com-
pression 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 (muscular-
produced) forces. In th absence of such protection, joints
may partially degenerate and become painful and chroncally
inflamed. This presentation is th hallmark of severe osteoar-
thritis.
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 musculo-
skeletal 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 ear-
lier 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, re-
spectively, 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 envi-
ronment. 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 ath-
leticism, such as dance.
 22 Section 1 Essential Topics o j Kinesiology

M S P E C I A L F O C U S

Surgically Altering a Muscle's Mechanical Advantage:

Dealing with th Trade-off
th moment arm functionally "outweighs" th loss of th
speed and distance of th movement.
A surgeon may perform a muscle-tendon transfer opera-
tion as a means to partially restore th loss of internai
torque at a joint. Consider, for example, complete paraly-
sis of th elbow flexor muscles following poliomyelitis.
Such a paralysis can have profound functional conse-
quences, 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 acti-
vated 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 con-
traction 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 contrac-
tion. The reduced angular displacement and velocity of
th joint may have negative functional consequences. This FIGURE 1-23. An anterior transfer of th triceps following
paralysis of th elbow flexor muscles. The triceps tendon is
mechanical trade-off needs to be considered before th
elongated by a graft of fascia. (From Bunnell S: Restoring
muscles internai moment arm is surgically exaggerated.
flexion to th paralytic elbow. J Bone Joint Sure 33A 566
Often, th greater torque potential gained by increasing 1951.)

GLOSSARY joint about which rotation occurs (also called th pivot

Acceleration: change in velocity of a body over time, ex-
pressed in linear (m/s2) and angular (/s2) terms.
Accessory movements: slight, passive, nonvolitional move-
ments 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 di-
rectly related to th initiation and execution of a particu-
lar 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 oc-
cur between th articular surfaces of joints.
Axis of rotation: an imaginary line extending through a
point or th center of rotation).
Axial rotation: angular motion of an object in a direction
perpendicular to its longitudinal axis, often used to de-
senbe 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 consider-
ing 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.

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 an-
other.
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 exter-
nal 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 partic-
ular force.
Chapter 1 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 periarticu-
lar 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 per-
forms 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, di-
vided by its cross-sectional area falso called pressure).
Synergists: two muscles that cooperate to execute a particu-
lar 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 chang-
ing 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 anatomic-
based chapters, starting with th shoulder complex in Chap-
ter 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 kt-
netic 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 Patho-
logtcal 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.
 C h a p t e r 2

Basic Structure and Function

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

TOPICS AT A GLANCE
CLASSIFICATION AND DESCRIPTION OF AXIS OF ROTATION, 31 Dense Irregular Connective Tissue, 32
JOINTS, 25 Articular Cartilage, 34
BI0L0GIC MATERIALS THAT FORM
Classification Based on Anatomie Fibrocartiiage, 35
CONNECTIVE TISSUES WITHIN
Structure and Movement Potential, 25 JOINTS, 31 Bone, 36
Synarthrosis, 25 Fibers, 31 EFFECTS OF AGING, 37
Amphiarthrosis, 25
Ground Substance, 32 EFFECTS OF IMMOBILIZATION ON THE
Diarthrosis: The Synovial Joint, 26 Cells, 32
Classification of Synovial Joints Based on STRENGTH OF THE CONNECTIVE TISSUES
Mechanical Analogy, 27 TYPES OF CONNECTIVE TISSUES THAT OF A JOINT, 37
Simplifying th Classification of Synovial FORM THE STRUCTURE OF JOINTS, 32 JOINT PATHOLOGY, 38
Joints: Ovoid and Saddle Joints, 30

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

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 over-
all 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 in-
formation 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
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 to-
gether 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 tibiofibu-
lar 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 mo-
tion, 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 inter-
body joint of th spine. This joint uses an intervertebral disc
25
26 Seniori I Essential Topics q f Kinesiology

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

Joint Material Available Motion Primary Funclion Examples

Synarthrosis Dense, irregular connective Negligible Binds bones within a Sutures of th skull
tissue functional unit; dis Teeth embedded in sockets of
perses forces across th th maxillae and mandible
joined bones Interosseous membrane of th
forearm and leg
Distai tibiofibular joint
Amphiarthrosis Hyaline cartilage or fibro- Minimal to moderate Provides a combination of Intervertebral disc (within th
cartilage relatively restrained interbody joints of th
movement and shock spine)
absorption Xiphistemal joint
Pubic symphysis
Manubriosternal joint
Diarthrosis Trae joint space filled Extensive Provides th primary Glenohumeral joint
(synovial joint) with synovial fluid and pivot points for move Tibiofemoral (knee) joint
surrounded by a cap ment of th musculo- Interphalangeal joint
sule skeletal System Apophyseal (facet) joint of th
spine

and embedded nucleus pulposus to provide a rugged, resil-
ient cushion that absorbs and disperses forces between adja-
cent vertebrae. Other examples of amphiarthrodial joints are
th pubic symphysis and th manubriosternal joint. These
joints allow relatively restrained movements. They also trans-
mit 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 fre-
quently 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)
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 glyco-
proteins (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 cap-
sular 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

Elements ALWAYS associateci with Blood

diarthrodial (synovial) joints. vessel
Synovial fluid Ligament
Articular cartilage Nerve
Articular capsule Fibrous
Synovial membrane capsule
Muscle
Capsular ligaments Synovial
Blood vessels membrane Synovial
Sensory nerves FIGURE 2-1. Elements associated
fluid
Elements SOMETIMES associated with Fat pad with a typical diarthrodial (synovial)
Meniscus
diarthrodial (synovial) joints. Articular
joint. The synovial plicae are not de-
Intraarticular discs or menisci cartilage picted.
Peripheral labrum
Fat pads
Synovial plicae Bursa

Tendon
 Chapter 2 Basic Structure and Function o j th Joints 27

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 artic-
ular surfaces of synovial joints. These structures increase
articular congruency and improve force dispersion. Intraar-
ucular 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
Intraarticular Discs (Menisci) Are Found in Several
Synovial Joints of th Body
Tibiofemoral (knee)
Distai radioulnar
Stemoclavicular
Acromioclavicular
Temporomandibular
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
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
Classification of Synovial Joints Based on
Mechanical Analogy
Thus far, joints have been classified into three broad catego-
ries according to th anatomie structure and subsequent
movement potential: synarthrosis, amphiarthrosis, and diar-
throsis. 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 ) .

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

Primary Angular Motions Mechanical Analog Anatomie Examples

Hinge joint Flexion and extension only
Pivot joint Spinning of one member around a sin
gle axis of rotation
Ellipsoid joint Biplanar motion (flexion-and-extension
and abduction-and-adduction)
Ball-and-socket joint Triplanar motion (flexion-and-extension,
abduction-and-adduction, and inter-
nal-and-external rotation)
Piane joint Typical motions include a slide (transla-
tion) or a combined slide and rota
tion.
Saddle joint Biplanar motion; a spin between th
bones is possible bui may be limited
by th interlocking nature of th
joint.
Condyloid joint Biplanar motion; either flexion-and-
extension and abduction-and-
adduction, or flexion-and-extension
and axial rotation (intemal-
and-extemal rotation)
Door hinge Humeroulnar joint
Interphalangeal joint
Door knob Proximal radioulnar joint
Atlantoaxial joint
Flattened convex ellipsoid Radiocarpal joint
paired with a concave
trough.
Spherical convex surface paired Glenohumeral joint
with a concave cup. Coxofemoral (hip) joint
Relatively fiat surfaces apposing Intercarpal joints
one another, like a book on Iniertarsal joints
a table.
Each member has a reciprocaily Carpometacarpal joint of th thumb
curved concave and convex Stemoclavicular joint
surface oriented at right an-
gles to one another, like a
borse rider and a saddle.
Mosily spherical convex surface Metacarpophalangeal joint
that is enlarged in one di- Tibiofemoral (knee) joint
mension like a knuckle;
paired with a shallow con
cave cup.
28 Section I Essential Topics o f Kinesiology
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.
FIGURE 2-2. A hinge joint (A) is illustrateci as analo-
gous to th humeroulnar joint (B). The axis of rota-
tion (i.e., pivot point) 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 pro-
vides 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. Ball-
and-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 visu-
alized 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 lim-
ited spin between th trapezium and th first metacarpal.
A condyloid joint is much like a ball-and-socket joint ex-
cept 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 Lunate
gous to th radiocarpal joint (wrist) (B). The two axes
of rotation are shown by th interseeting ptns.
Scaphoid

FIGURE 2-5. A ball-in-socket articula-

lion (A) is drawn as analogous to th
hip joint (B). The three axes of rota
tion are represented by th three in-
tersecting 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
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.
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 metacar-
pal. The two axes of rotation are shown in B.
seen in th gentle undulations that characterize th intercar-
pal and intertarsal joints. These joints produce complex mul-
tiplanar movements that are tnconsistent with their simple
planar mechanical classification. To circumvent this diffi-
culty, 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 excep-
tion of planar joints can be categorized under this scheme.
An ovoid joint has paired mating surfaces that are imper-
fectly spherical, or egg-shaped, with adjacent parts possess-
ing 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 mem-
ber 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 gener-
alization 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 sur-
face 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 Various types of collagen fibers and elastic fibers occur in
of rotation (i.e., th pin through th hinge) is fixed, because joints. Collagen fibers are made of short subunits (fibrils),
it remains stationary throughout th rotation of th door. which are wound in a helical structure much like short
With th axis of rotation fixed, all points on th door expe- threads. These threads are placed together in a strand, sev-
rience equal arcs of rotation. In anatomie joints, however, eral of which are spirally wound into a rope. Twelve colla
th axis of rotation is rarely, if ever, fixed during bony gen types have been described,27 but two types make up th
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 con-
structing a prosthesis or an orthosis. A series of x-ray mea-
surements 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.

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 funda-
mental 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.
FIGURE 2-10. A simplified method for determining th instanta
neous axis of rotation for 90 degrees of knee flexion (A). With th
Biologie Materials That Form th Connective Tissues use of x-ray, two points (a and b) are identified on th tibial
within Joints plateau. With th position of th femur held stationary, th same
1. Fibers two points are identified following 90 degrees of flexion (a' and
Collagen (types I and li) b')- Next, two perpendicular lines are drawn from a-a' and b-b'.
Elastin The point of intersection of these two perpendicular lines identifies
2. Ground substance th instantaneous axis of rotation for th 90-degree are of motion.
Glycosaminoglycans This same method can be repeated for many smaller arcs of mo
Water tion, producing several slightly different axes of rotation (B). The
Solutes path of th migrating axes is called th evolute. At th knee, th
3. Cells 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 gath-
ered 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 carti-
lage.
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 car-
tilage. 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 de-
formed. 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 water-
saturated 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 ten-
dency 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 tur-
gid 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 responsi-
ble 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 re-
modeled. 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 clini-
cal correlates associated with each tissue.
Dense Irregular Connective Tissue
Dense irregular connective tissue is found in th fibrous exter-
nal 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 33

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

Ground Substance
Anatomie (GAGs + Water + Mechanieal Clinical
Location Fibers Solutes) Cells Specialization Correlate

Dense irregular Composes th ex- High type 1 colla- Low ground substance Sparsely located cells Ligament: Binds Rupture of th tar
connective tis temal fibrous gen fiber con- coment tightly packed be- bones together erai collateral
sue layer of th Lem tween fibers and restrains un- ligament com-
joint capsule Most tissues have wanted move- plex of th an-
Forms ligaments. low elastin fi ment at th kle can lead to
fascia, and ber coment joints; resists ten- medial-lateral
tendons Parallel fibers are sion in several di- instability of
arranged in rections th talocrural
bundles ori- Tendon: attaches joint.
enled in sev muscle to bone
eral directions
Articular cartilage Covers th ends High type il col- High ground sub Moderate number of Resists and distrib- During early stage
of articulating lagen fiber stance coment cells; flattened utes compressive of osteoarthri-
bones in syno- coment; fibers near th articular forces (joint load- tis, GAGs are
vial joints help anchor surface and ing) and shear released from
cartilage to rounded in forces (surface deep in th
subchondral deeper layers of sliding); very low tissue, reducing
bone and re- th cartilage coefficient of fric- th force distri-
strain th tion bulion capabil-
ground sub ity; adjacent
stance. bone thickens
to absorb th
increased force,
often causing
th formation
of osteophytes
(bone spurs).
Fibrocartilage Composes th in- Multidirectional Moderate ground sub Moderate number of Provides some sup- Tearing of th in-
tervertebral bundles of stance coment cells that are pon and stabil- tervertebral
discs and th type 1 collagen rounded and zation lo joints; disc can allow
disc within th dwell in cellular primary function th centrai nu-
pubic symphy- lacunae is to provide cleus pulposus
sis shock absorp- to escape (her-
Forms th intra- tion by resisting niate) and press
articular discs and distributmg on a spinai
(menisci) of compressive and nerve or nerve
th tibiofemo- shear forces root.
ral, stemocla-
vicular, acro-
mioclavicular,
and distai ra-
dioulnar joints
Forms th la
brum of th
glenoid fossa
and th ace-
tabulum
Bone Forms th inter Specialized ar Low GAG coment Moderate number of Resists deformation; Osteoporosis of
nai levers of rangement of flattened cells em- strongest resis th spine pro-
th musculo- type 1 collagen bedded between t a l e is applied duces a loss of
skeletal System to form lamel- th layers of col againsl compres bony Lrabeculae
lae and os- lagen; many pro- sive forces due to and minerai
teons and lo genitor cells body weight and coment in th
provide a found on th fi muscle force. vertebral body
framework for brous exiemal Provides a rigid of th spine;
hard minerai (periosteal) and lever to trattsmit may result in
salts (e.g., cal- internai (endos- muscle force lo fractures of th
cium crystals) teal) layers. move and stabi- vertebral body
lize th body during walking
or even cough-
ing.
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 domi-
nant 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 re-
straining joint movement. Even if muscles surrounding a
ligamentously lax joint are strong, there is loss of joint sta-
bility. Compared with ligaments, muscles are slower to
supply force due to th electromechanical delay neces-
sary to build active force. Muscle forces often have a less
than ideal alignment for restraining undesirable joint move-
ments, and they often cannot provide th most optimal de-
terrent 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
Parallel bundles
of collagen
Irregularly arranged bundles
of collagen fibers
Fibrocytes
TENDO N
L IG A M E N T
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 facili-
tated by th "milking action of articular surface deformation
during intermittent joint loading. The chondrocytes are sur-
rounded by predominantly type II collagen fibers. As de-
picted in Figure 2 - 1 3 B , th fibers are arranged to form a
restraining network or scaffolding that adds structural sta-
bility 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 trans-
versely 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 pro-
vides a unique element of rigidity to articular cartilage. The
rigidity increases th ability of cartilage to adequately with-
stand 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
FIGURE 2-12. Diagrammane represen-
tation 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 hav-
ing 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 orga-
nized parallel to th most common
lines of tension. The fibrocytes of th
ligament are not shown in this draw-
ing 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 depen-
dent 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 fibro-
cartilaginous 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 undifferen-
tiated 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 vascular-
ized 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 sys-
temic 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 dissi-
pates 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, pre-
dominantly type I, into a unique series of concentric spirals
that form lamellae (Fig. 2 - 1 6 ) . The matrix of bone contains FIGURE 215. A cross-section showing th internai architecture of
calcium phosphate crystals, which allow bone to accept tre- th proximal femur. Note th thicker areas of compaci bone around
mendous compressive loads. The cells of bone are confined th shaft and th lattice-like cancellous bone occupying most of th
medullary region. (From Neumann DA: An Arthritis Home Study
within narrow lacunae (i.e., spaces) positioned between th
Course: The Synovial Joint: Anatomy, Function, and Dysfunction.
lamellae of th osteon. Because bone deforms very little,
The Orthopedic Section of th American Physical Therapy Associa-
blood vessels can pass into its substance from th outer tion. La Crosse, WI, 1998.)

Interstitiol
lomellae^,
Inner
circumferentiol
lamelloe---------
Trobeculoe
FIGURE 2-16. Histologic organization of cortical bone. of cancellous
(From Fawcett DW: A Textbook of Flistology, 12th ed. bone
New York, Chapman & Hall. Redrawn after Benninghoff
A: Lehrbuch der Anatomie des Menschen. Berlin, Urban
and Schwarzenberg, 1994.)
Endosteum
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 nega-
tively, 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 micro-
trauma can accumulate over time to produce subclinical
damage that may progress to a structural failure or a mea-
surable 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
Chapter 2 Basic Structure and Function o f th )oints 37
Outer circumferentiol
lamellae
Haversian systems
(osteons)
Periosteum
Blood vessels
Sharpey's
fibers
Hoversion
canals
Volkmanns
canols
lower compressive strength. The dryer connective tissues do
not slide across one another as easily. As a result, th bun-
dles 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, particu-
larly 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 differ-
ent 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 de-
crease in tensile strength of th ligamenis of th knee, for
example, in a period of weeks.19-28 The earliest biochem-
ical 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 post-
immobilization 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 ex-
perimental 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 nec-
essary 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 inter-
vention.
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-trau-
matic 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 cir-
cumference 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, rela-
tively 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 condi-
tions 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 spe-
cific 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.

FIGURE 2-17. A scanning electron micrograph of th articular sur-
face of a femoral condyle of a knee in a 71-year-old embalmed
male cadaver, contrasting levels of degeneration. A, Articular carti-
lage 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-
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 dis-
ease States.
REFERENCES
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 presenta-
tion. 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 ten-
dons 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 long-
lasting 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 Ortho-
paedic Surgeons, 1994.
18. Muller FJ, Setton LA, Manicourt DH, et al: Centrifugai and biochemical
comparison of proteoglycan aggregates from articular cartilage in experi-
mental joint disuse and joint instability. J Orthop Res 12:498-508,
1994.
19 Noyes FR: Functtonal properties of knee ligaments and alterations in-
duced 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 rota-
tor cuff tears. Arthroscopy 12:531-540, 1996.
23. Rubman MH, Noyes FR, Barber-Westin SD: Arthroscopic repair of me-
niscal 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 morpho-
logical 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: Appear-
ance 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.
 C h a p t e r 3

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 A GLANCE
Summation of Active Force and Passive Activating Muscle via th Nervous System,
Tension: Total Length-Tension Curve, 51
47 Recruitment, 51
Isometric Force: Development of th Rate Coding, 52
Internai Torque-Joint Angle Curve, 47 Muscle Fatigue, 52
MUSCLE AS A SKELETAL MOVER: FORCE ELECTROMYOGRAPHY: WINDOW TO THE
MODULATION, 50 NEURAL DRIVE OF MUSCLE. 54
Modulating Force Through Concentric or
Eccentric Activation: Force-Velocity
Relationship, 50

INTRODUCTION lead to th judicious application of interventions to improve

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 func-
tions 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 resis-
tance 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
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 envi-
ronment. 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 amaz-
ingly 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 mysium, is tough and thick and resistive to stretch. The
Stabilizer endomysium surrounds individuai muscle fbers. It is com-
posed of a relatively dense meshwork of collagen ftbrils that
1. Muscle morphoiogy are partly connected to th perimysium. Through lateral
2. Strutturai organization of skeletal muscle connections to th muscle fber, th endomysium conveys
3. Connettive tissues vvithin muscle part of th contrattile force to th tendon.
4. Physiologic cross-sectional area Although th three types of connettive tissues are de-
5. Pennation angle scribed as separate entities, they are interwoven in such a
6. Passive length-tension curve way that they may be considered as a continuous sheet of
7. Parallel and series elastic components of muscle and ten- connettive tissue. All connettive tissue that encases a mus
don cle, directly or indirectly, contributes to th tendons of th
8. Elastic and viscous properties of muscle muscle.
9. Attive length-tension curve
10. Histology of th muscle fber
11. Total length-tension curve Muscle Architecture
12. Isometric force and internai torque-joint angle curve devel-
opment Each muscle and its tendons have different architecture and,
13. Mechanical and physiologic properties affecting internai as a consequence, are able to generate different ranges of
torque-joint angle curve force. Understanding muscle architecture allows th predic-
tion of th functional role of a given muscle. Physiologic
cross-sectional area and pennation angle are major determi-
nants of th range and th force produced by th muscle.
muscle is stimulated by th nervous System. The relationship The physiologic cross-sectional area of a muscle reflects th
between muscle force and length and how it influences th amount of contrattile protein available to generate force.
isometric torque generated about a joint are then examined. Generally speaking, th cross-sectional area (cm2) of a fusi
Table 3 - 1 is a summary of th major concepts addressed in form muscle is determined by dividing th muscles volume
this section. (cm 1) by its length (cm). A fusiform muscle with many thick
fbers has a greater cross-sectional area than a muscle of
Muscle Morphoiogy: Shape and Structure similar length and morphoiogy with fewer thinner fbers.
Maximal force potential o f a muscle is, therefore, proportional to
Muscle morphoiogy describes th basic shape of a vvhole th sum o f th cross-sectional area o f all th fbers. Under
muscle. Muscles have many shapes, reflecting their ultimale normal conditions, th thicker th muscle, th greater th
function. Figure 3 - 1 shows two common shapes of muscle: force potential. Measuring th cross-sectional area of a fusi
fusiform and pennate (from th Latin penna, meaning form muscle is relatively simple because all fbers run paral-
feather). Fusiform muscles, such as th biceps bracini, have
fbers running parallel to each other and to th centrai ten-
don. In pennate muscles, th fbers approach th centrai ten-
don obliquely. Pennate muscles may be further classified as
unipennate, bipennate, or multipennate, depending on th
Pennate Fusiform
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. Simi-
lar to connettive tissue throughout other bodily structures,
th connettive tissue within muscle consists of fbers embed-
ded in an amorphous ground substance. Most fbers are
collagen, and th remaining fbers are elastin. The combina-
tion of these two proteins provides strength, structural sup-
port, 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
FIGURE 3 -1 . Two common shapes of muscle, fusiform and pen
tightly woven bundles of collagen fbers that are highly resis
nate, are shown. Different shapes are formed by different fiber
tive io stretch. The perimysium lies beneath th epimysium, orientation relative to th connecting tendon. (Modifed from Wil
and divides muscle into fascicles that provide a conduit for liams PL: Grays Anatomy: The Anatomical Basis of Medicine and
blood vessels and nerves. This connettive tissue, like epi Surgery, 38th ed. New York, Churchill Livingstone, 1995.)
 Chapter 3 Muscle: The Ultimate Force Generator in th Body 43

A 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 dif-
ferent 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 gener-
ated 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 space-
saving strategy provides pennate muscles with a relatively
large physiologic cross-sectional area and, hence, a relatively
large capability for generating high force. Consider th mul-
tipennate 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 com-
pared with th large force potential furnished by th gain in
 44 Section I Essential Topics o f Kinesiology
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 epimys-
ium, 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 Paralel E C
TABLE 3 - 2 . Functions of Connective Tissue
within Muscle
1. Provides gross structure to muscle
2. Serves as a conduit for blood vessels and nerves
3. Generates passive tension by resisting stretch
4 Assists muscle to regain shape after stretch
5. 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 ex-
tending 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 re-
ferred 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 distrib-
uted 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
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
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 length-
tension curve represents an important component of force-
generating 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, al-
lows 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 suffi-
cient 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 encoun-
tered 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: 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
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 myofi-
brils. 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 myofila-
ments. The primary structures within myofilaments are two
types of proteins: actin and myosin. The regular organization
of myofilaments produces th characteristic banded appear-
ance of th myofibril as seen under th microscope (Fig. 3
6). The actin and myosin physically interact through cross-
bridges (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
Light bands caused by presence of thin actin fila
I bands
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 to-
gether. 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, ex-
tending 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 Z A l
band disc band band
FIGURE 3-7. Detail of th regular, banded organization of th my-
ofibril 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 ap-
proximation 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 fila-
ment 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 length-
tension 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 de-
creases so that lesser amounts of active force are generated,
even under conditions of full activation. The resulting active
 Chapter 3 Muscle: The Ultimate Force Generator in th Body 47

FIGURE 3-8. Further detail of a Troponin /Tropomyosin

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

length-tension curve is described by an inverted U-shape levels of force even as th muscle is stretched to a point
with its peak at th ideal resting length. where active force generation is compromised. As th muscle
The term length-force relationship is more appropriate for fiber is further stretched (c), passive tension dominates th
considering th terminology establshed in this text (see def- curve so that connective tissues are under near maximal
nition of force and tension in Chapter 1). The phrase length- stress. High levels of passive tension are most apparent in
tension is, however, used because of its wide acceptance in two-joint muscles placed in overelongated positions. For ex-
th physiology literature. ample, as th wrist is extended, typically th fingers pas-
sively flex slightly owing to th stretch placed on th finger
flexor muscles as they cross th front of th wrist. The
SUMMATION OF ACTIVE FORCE AND PASSIVE
TENSION: THE TOTAL LENGTH-TENSION CURVE amount of passive tension depends in part on th naturai
stiffness of th muscle.
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
Isometric Force: Development of th Internai
tension allows for a large range of muscle force over a wide Torque-Joint Angle Curve
range of muscle length. Consider th total length-tension As defned in Chapter 1, isometric activation of muscle is a
curve for th muscle shown in Figure 3 - 1 1 . At shortened process by which th muscle produces force without a signif-
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

Actin filament

Length of sarcom ere (micrometers)

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

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.)
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 vari-
able mechanical or physiologic alters th clinical expres-
sion of a muscular-produced internai torque (Table 3 - 4 ) .

A 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 length-
dependent active and passive forces.
B HipAbductors
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 acti-
vated 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 Chap-
ter 4, an extemal torque can be determined by using an
extemal force-sensing device (dynamometer) at a "known dis-
tance from th jo in ts axis of rotation. Because th measure-
ment 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 FIGURE 3-12. Internai torque versus joint angle curve of two mus
shape yields important information about th physiologic cle groups under isometric, maximal effort conditions is shown.
and mechanical factors that determine th torque produced The shape of th curves are very different for each muscle group.
by th muscle group. Consider th following two factors 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
shown in Figure 3 - 1 3 . First, muscle length changes as joint
is greatest at a frontal piane angle of - 1 0 degrees (i.e., 10 degrees
angle changes. As previously described, a muscles force out toward adduction).
 Chapter 3 Muscle: The Ultimate Force Generator in th Body 49

A B

Exploring th Reasons for th Unique "Signature" of a

------------------------------------------------------------------------------>
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. Philadel-
phia, W.B. Saunders, 1992.)
The torque-angle curve of th hip abductors demon-
strated 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
Muscle Group's Isometric Torque-Angle Curve
Consider th functional implications associated with th
shape of a muscle group's torque-angle curve. Undoubt-
edly, th shape is related to th nature of external force
demands on th joint. For th elbow flexors, for exam-
ple, 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 coinci-
dentally, 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 walk-
ing. Large amounts of hip abduction torque are rarely
required in a position of maximal hip abduction.
hip. Regardless of th muscle group, however, th combina-
tion 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 there-
fore 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
Mechanical: Decreased inter
nai moment arm
Physiological: Decreased mus
cle activation
Physiological: Significantly de
creased muscle length at
th lime of neural activa
tion
Surgical displacement of
greater trochanter to in-
crease th internai mo
ment arm of hip abduc
tor muscles
Patellectomy following se
vere fracture of th pa
tella
Damage to th deep portion
of th peroneal nerve
Damage to th radiai nerve
with paralvsis of wrist
extensor muscles
Decrease in th amount of muscle
force required to produce a
given level of hip abduction
torque
Increase in th amount of knee
extensor muscle force required
to produce a given level of
knee extension torque
Decreased strength in th dorsi-
flexor muscles
Decreased strength in wrist exten
sor muscles causes th finger
flexor muscles to flex th wrist
while making a grasp
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
increased force needed to extend
th knee may increase th
wear on tire articular surfaces
of th knee joint
Reduced ability to walk safely
Ineffective grasp due to overcon-
tracted (shortened) finger
flexor muscles
 50 Section I Essential Topcs o j Kinesiology
FIGURE 3-14. Relationship between muscle load (extemal resis-
tance) 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 Kinet-
ics, 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 acti-
vated 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 exam-
ple, 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 fi-
bers. 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 length-
ening. 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-
ography as a tool for understanding muscle activation during
movement is introduced.
Moduiating Force Through Concentric or
Eccentric Activation: Force-Velocity
Relationship
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 exam-
ple, 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 de-
nved 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 ex-
pressed 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 de-
creasing th contraction velocity, or vice versa. This is very
similar in concept to switching gears while riding a bicycle.
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 ac-
tive 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 repre-
sents th three-dimensional relationship between mus
cle force, length, and contraction velocity (Fig. 3-16).
The plot does not, however, include th passive length-
tension component of muscle. The plot shows, for ex-
ample, a muscle contracting at a high velocity over th
shortened range of its overall length producing rela-
tively 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 sub-
stantially 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.
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
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 ex-
tends 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 con-
tractions involving only a few muscle fibers, and large con-
tractions that involve rnost of th fibers. Excitation of alpha
motoneurons may come from many sources, for example,
afferents, spinai interneurons, and cortical descending neu-
rons. 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 re-
cruited 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 pro-
cess is th summation of competing inhibitory and facilita-
tory 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 Princi-
ple. It was first experimentally demonstrated and developed
by Elwood Henneman in th late 1950s.7 The principle ac-
counts for th orderly recruitment of motor units, specified
by size, which allows for smooth and controlled force devel-
opment.
 52 Section l Essential Topici o f Kinesiology
TABLE 3 - 5 . Major Sequence of Events Underlying
Muscle Fiber Activation
1. Action potential initiated and propagated down a motor
axon.
2. Acetylcholine released frorn axon terminals at neuromus-
cular 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 sur-
face.
6. Transverse tubules depolarized leading to release of cal-
cium 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 cross-
bridges.
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 sus-
tained 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 be-
tween slow and fast type motor units (Fig. 3 - 1 7 , middle).
Motor units associated with these fibers are termed FR (fa-
tigue 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 skele-
tal 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 pos-
tures 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 suit-
able lime interval, generates a series of summated mechani-
cal 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 repre-
sents th greatest force evel that is possible for a muscle
fiber. Motor units, therefore, activated at high rates are capa-
ble 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 gener-
ated 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 mecha-
nisms 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 recruit-
ing assistive motor units (i.e., recruitment), thereby main-
taining a stable force evel. When an exercising muscle be-
gins 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 ex-
ample, 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 neuro-
physiological factors, such as descending control over inter-
neurons 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 path-
ways to prevent th efficient activation of motoneuron pools.
 Chapter 3
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 (contrac-
tions) 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.)
Muscie: The Ultimate Force Cenerator in th Body 53
Neural pathway conduction delays or blocks, such as in
multiple sclerosis, may impair th ability to adivate moto-
neuron pools.15 When centrai fatigue is a suspected mecha-
nism contributing to low muscle force output, verbal en-
couragement 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
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 depolariza-
tion 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 ap-
pearance 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 indi-
cating a greater force level in th active contractile compo-
nent 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 dif-
ferent regions of a muscle or even from different muscles.
Because of th length-tension and force-velocity relation-
ships of muscle, th EMG amplitude may vary considerably
as a muscle produces a force via nonisometric activations.
FIGURE 3-19. Muscle fatigue is demonstrated by a reduc-
tion in force over a sustained isometric activation. As th
- ___ stonili continue over tinte, th force responses of th
' m muscle lessen.
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 non-
optimal 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 pro-
duced 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 (inser-
tional) 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 configu-
rations (two pick-up electrodes that are electrically coupled)
are used to subtract th noise signal that is commonly re-
corded by both electrodes. Adequate skin preparation en-
sures 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 kine-
siologic 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 inte-
grated. 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, re-
quiring 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. Meaning-
ful 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 impair-
ments 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 excit-
ability 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 histo-
chemical 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
Muscle: The Ultimate Force Cenerator in th Body 55
contraction and stretch and their structural interpretation. Nature 173:
973-976, 1954.
9. Huxley A, Nedergerke R: Structural changes in muscle dunng contrac
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10. Jaramillo J, Worrell TW, Ingersoll CD: Hip isometric strength following
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Physiol 140, 1958.
12 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.
13. 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.
14. Merletti R, Knaflitz M, Deluca CJ: Electrically evoked myoelectric sig
nals. Crit Rev Biomed Eng 19:293-340, 1992.
15. Sandroni P, Walker C, Starr A: Fatigue in patients with multiple sclero-
sis motor pathway conduction and event-related potentials. Arch Neu
rol 49:517-524, 1992.
16 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
17. Yamaguchi G, Sawa A. Moran D, et al: A survey of human muscuioten-
don actuator parameters. In Winters J, Woo S-Y (eds): Multiple Muscle
Systems: Biomechanics and Movement Organization. New York,
Springer-Verlag, 1990, pp 717-773.
18. 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 29:598-
606, 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 step-
ping.J Biomech 20:167-178, 1987.
Huijing PA: Muscle, th motor of movement: Properties in function, experi-
ment 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.
 C h a p t e r 4

Biomechanical Principles
D eborah A. Na w o c z en sk i , PT, Ph D
Donald A. Neum ann , PT, P h D

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 Action-
Reaction, 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
TOPICS AT A 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
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

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 inter-
ventions 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 simpli-
fied 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
treatment approaches. Technologic advances continue to en-
hance th ability to understand and influence human per
formance.
NEWTON'S LAWS: APPLICATION TO
MOVEMENT ANALYSIS
The outcome of all movement analysis is ultimately deter-
mined 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, re-
ferred 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 Biomechanical Principles 57

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 re-
lated 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 exter-
nal 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 de-
scribes 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.
velocity of a body. The inertia within a body is directly
proportional to its mass (i.e., th amount of matter constitut-
ing 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 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
Newton's first law is also called th law of inertia. Inertia tion. Substituting p, th radius of gyration, for r in th
is related to th amount of energy required to alter 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
Second: Law of Acceleration
Third: Law of Action-Reaction
A body remains at rest or in Constant linear
velocity except when compelled by an external
force to change its state.
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.
For every force there is an equal and opposite
directed force.
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.
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.
For every torque there is an equal and opposite
directed torque.
 58 Section I Essential Topici o j Kinesiology
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).
The fact that p is squared in Equation 4.2 has imporiant
biomechanical implications. Consider, for example, that dur-
ing th swing phase of walking th entire lower limb short-
ens 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 re-
quired by th hip flexor muscles to accelerate th limb
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 suc-
cessfully 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 conserva-
tion 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
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 (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 Biomechanical Principles 59

A Closer Look at Mass Moment of Inedia determined using Equation 4.1 and substituting known val-
ues (see th box). Next, consider Y2 as th axis of rota
Figure 4 -2 illustrates th concept of mass moment of
tion. The mass particles are distributed differenti if each
inertia. A rectangular object is considered to consist of
axis is considered separately. As seen in th calculations,
five point masses (M, M 5), each with a mass of 0.5 kg.
th mass moment of inertia, if considering Y2 as th axis,
The object is free to rotate in th horizontal piane. In this
is 5.5 times less than that if considering Y, as th axis.
example, th rectangular object is able to rotate sepa-
One reason for th reduced moment of inertia is that th
rately about two vertical axes of rotation (Y, and Y2).
M3 mass particle, which is coincident with th axis Y2,
Distances (r, r5) are each 0.1 m long, representing th
offers zero resistance to th rotation of th rectangular
distance between each mass particle (M ,-M 5) and be-
object. As a generai principle, therefore, th mass mo
tween th indicated mass particles and th two axes of
ment of inertia about an axis of rotation that passes
rotation. The axis of rotation Y2 runs through th center of
through th center of mass of a body is always smaller
mass of th entire object (M3). The following calculations
than th moment of inertia about any parallel axis.
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 Y2 axis
C if b C n^ J

Each segment in th human body is made up of differ-

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 momen-
tum 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).
ent 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 vari-
ous imaging techniques.2AW5

that this terni is interchartgeable with moment and moment proportional to th mass moment of inertia of th rotating
of force.) In this equation, 2 T designates th sum of or "net forearm and hand segments.
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 Newton's Second Law of Rotary Motion Quantifying a
net flexion torque at th elbow as th hand is accelerated to Torque
th mouth. The flexion torque is directly proportional to th ST = 1 X a (Equation 4.4)
angular acceleration of th rotating elbow, as well as directly
 60 Section / Essential Topics o f Kinesiology
A Tncreased angular B Decreased angular
velocity 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 sec-
ond law through th broadening and rearranging of Equa-
tions 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). Sub-
stituting 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 gen-
erally 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 considera-
tion in prosthetic design for th person with an amputa-
tion. 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 distribu-
tion of th mass to a more proximal location in th leg.
As a result, less resistance is imposed upon th re-
maining limb during th swing phase of gait. The benefit
of these lighter components is realized in terms of less-
ened energy requirements for th person with an ampu-
tation.
small force delivered over a longer time. Equation 4.6 de
fines th linear impuise-momentum relationship.
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 protec-
tive 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 substi-
tution 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 co (Equation 4.8)
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 ap-
proach 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) ap-
plied 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 mechani-
cal work is done. The most commonly used units to de-
scribe 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).

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
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 consid-
ered as th measure of th fuel available to th System to
perform work. The work-energy relationship has been partic-
ularly 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 ac-
count 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
Chapter 4 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 r-
w a r d m o m e n t u m is d e c r e a s e d .
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 under-
standing 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 re-
stated 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

M S P E C I A L F O C U S

Using Angular Power as a Measure of Muscle

case, using th angular analogs of force and velocity, torque
(T) and angular velocity (co), respectively (Equation 4.13).

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 .
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 con- Table 4 - 2 summarizes th definitions and units needed
centrically active muscles a g a i n s t a n e x t e r n a l l o a d . to describe many of th physical measurements related to
Newton's second law.
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
p a th o lo g ic fu n c tio n . 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

TABLE 4 - 2 Physical Measurements Associated with Newtons Second Law

Linear Application Rotational Application

Physical
Measurement Definition Units Definition Units
Distance Linear displacement Meter (m) Angular displacement Degrees ()*
Velocity Rate of linear displacement Meters per second Rate of angular displacement /s
(m/s)
Acceleration Rate of change in linear veloc- m/s2 Rate of change in angular velocity /s2
ity
Mass Quantity of matter in an ob- kilogram (kg) Not applicable
ject; influences th objects
resistance to a change in lin
ear velocity
Mass moment of Not applicable Quantity and distribution of mat kgm2
inertia
ter in an object; influences an
objects resistance to a change
in angular velocity
Force A push or pul; mass times kgm/s2 (N) Not applicable
linear acceleration
Torque Not applicable A force times a moment arm;
mass moment of inertia times kgm2/s2 (or Nm)
angular acceleration
Impulse Force times lime Ns Torque times lime Nms
Momentum Mass times linear velocity kgm/s Mass moment of inertia times an kgm2/s
gular velocity
Work Force times linear displace Nm (joules) Torque times angular displace Nm (joules)
ment ment
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.

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 superin-
umbent 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
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 exter-
nal forces on th quantity and quality of motion. The follow-
ing 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 exter-
nal forces and torques can have an impact on muscle re-
sponse, joint motion, and joint reaction force.
Anthropometry
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 informa-
tion regarding th mass of individuai segments or th distri-
bution 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 model-
ing 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 solv-
ing 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 act-
ing 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 pre-
sented 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 magni-
tude 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. Alter-
natively, 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
The key elements needed to begin problem solving in hu
FIGURE 4-6. A free body diagram of a sprinter. The external forces man movement are to determine th purpose of th analysis
on th System include th force due to th body weight (BW) of identify th body, and indicate all th forces that act on tha
th runner and contact forces: th ground reaction force (GRF) in
body. The following example presents steps to assist with
vertical (Y) and horizontal directions (X), and th force created by
construction of a free body diagram.
air resistance (AR). (The force vectors are noi drawn to scale.)
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
running. In this example, th System under consideration opposing forces and torques are equal. One goal of
is defined as th lower trunk and lower extremities. The analysis might be to determine how much muscle force
external force vectors include th weight of th combined required by th glenohumeral joint abductor muscles :
body segments, which have been reduced to a single vector keep th arm abducted to 90 degrees; another goal might b.
referred to as body weight (BW), and th contact forces. The to determine th magnitude of th glenohumeral joint ree.
contact forces include th ground reaction forces (GRF), in tion force during this same activity.
both vertical (Y) and horizontal (X) directions, and th air Step l, in setting up th free body diagram, is to iden
resistance (AR).
and isolate th System under consideration. In this exam
The System so described can be specifed differently, de- th System is th entire arm and weight combination.
pending 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 ftgu-
ratively 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
pushes back against th other joint surface. The joint reac FIGURE 4-7. A free body diagram o f th System defined as th fo
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

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 , X-
Y 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 exter-
nal 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 un-
known 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.
Chapier 4 Biomechanical Principles 65
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 com-
paring 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
A Relative reference B Global reference
frame
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 refer-
ence frain e must be defned. The position of th trunk with
respect io a horizontal reference is an example of a measure-
ment 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 snap-
shot 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 lo-
cating 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
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 hor-
izontal piane (X).
frante
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 un-
dergoes 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 produc-
ing 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 seg-
ment is moving, which is perpendicular to th axis of rota-
tion. 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 desig-

tated 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 anal-
sis, 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, de-
rending 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 rota-
on, compression, shear, or distraction at th joint surfaces.
Composition and resolution of forces can be accom-
rlished using graphic methods of analysis or right-angle trig-
.nometry. These techniques are needed to represent and
- absequently calculate muscle and joint forces. 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.
! RAPHIC METHODS OF FORCE ANALYSIS The forces are hip abductor force (HAF), body weight (BW), and
prosthetic hip reaction force (PHRF). B, The polygon (or tip-to-
omposition of Forces tail) method is used to determine th magnitude and direction of
th PHRF, based on th magnitude and direction of FfAF and BW.
ector composition allows several parallel, coplanar forces to (From Neumann DA: Hip abductor muscle activity in persons who
- simply combined graphically as a single resultant force walk with a hip prosthesis while using a cane and carrying a load.
g. 4 - 1 0 ) . In Figure 4 -1 0 A , th weight of th leg segment Phys Ther 79:1163-1176, 1999, with permission of th Physical
''VI and th weight of th load (LW) are added graphically 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 down-
ward 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 abduc-
tor 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
Proximal
joint
Distai
interphalangeal
joint
Palmar dislocation of th
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 profun-
dus, as they pass palmar (anterior) to th metacarpophalan-
geal 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 bow-
stringing 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 seg-
ment 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
FIGURE 4-12. A, Parallelogram
method is used to illustrate th
effect of two force vectors (F,
and F2) produced by contrac-
tion of th flexor digitorum
superficialis and profundus
muscles across th metacarpo
Ruptured
phalangeal (MCP) joint. The re
collateral
sultant force (RF) vector creates
ligaments 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.

- 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 replac-
ing 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 rectan-
gular 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 trans-
lation 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 com-
Donent of a muscle force does not produce a torque when it
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
The examples presented to this point on methods of resolv-
ing forces into normal and tangential components have fo-
cused 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 iso-
metric 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
Tangential Force
Normal Force Component Component
Acts perpendicular to a bony Acts parallel to a bony seg
segment ment
Often indicated as FNbut Often indicated as FT bui
may be indicated as FY, may be indicated as Fx,
depending on th choice of depending on th choice of
th referente frame th reference frame
Can cause rotation and/or A translation may occur as a
translation: compression or distraction
A rotation may occur if th between articulating sur-
moment arm > 0. faces.
A translation may occur as
a compression, distrac-
tion, or shearing be
tween articulating sur-
faces.
 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: mus-
cle 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 compo-
nents: 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.)
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
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 de-
pend 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, activa-
tion type (i.e., isometric, concentric, or eccentric), and speed
of muscle activation.
Changes in joint angle also affect th external or resis-
tance 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 com-
pared 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
Thus far, th composition and resolution of forces are pri-
marily described using a graphic method to determine th
magnitude of forces. A drawback to this method is that it I
requires a high degree of precision to accurately represent I
th forces analyzed. In th solution of problems involving
rectangular components, right-angle trigonometry provides
a more accurate method of force analysis. The trigonometrie I
functions are based on th relationship that exists between I
th angles and sides of a right triangle. Refer to Appendix IC
for a review of this material.
 Chapter 4 Biomechanical Prndples 71

FIGURE 4-15. Changing th angle of

th elbow joint alters th angle of in-
sertion (a) of th muscle into th fore-
arm. 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 MF
th axis of rotation to th perpendicu-
lar 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 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.)
 72 Section I Essential Topics o f Kinesiobgy

0 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 al-
tered in Figure 4-176, th external torque remains maxi
mal; however, th internai torque potential is significantly
reduced. As th elbow approaches extension, th angle-
of-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 Internai 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. Mathemati-
cally, 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).
The first method for determining internai torque is illus-
trated in Figure 4 - 1 8 (black letters). The internai torque is
depicted as th product of MFN (th normal component of
th resultant muscle force (MF) and its internai moment arm
(IMA,)). The second method, depicted in red letters in Fig
ure 4 - 1 8 , does not require th resultant force to be resolved
into rectangular components. In this method, internai torque
is calculated as th product of th resultant force (MF) and
IMA2 (i.e., th internai moment arm that extends between
th axis of rotation and a perpendicular intersection with
MF). Both methods yield th same internai torque because
both satisfy th definition of a torque (i.e., th product of a
 Chapter 4 Biomechanical Principes 73

Internai Torque: MFpjx IM A j = M F x IIVIA2 External Torque: R \ x EM A j = R x EM A 2

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.
orce and its associated moment arm). The associateci force
and moment arm fo r any gtven torque must inlersect one an-
4her 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)
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 result-
ant 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.
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 prac- FIGURE 4-20. A piece of black string is used to mirnic th line-of-
ticed with th aid of a skeletal model and a piece of force of th resultant force vector of an activated biceps muscle.
The internai moment arm is shown as a red line; th axis of
string that represents th resultant muscle's line-of-force
rotation at th elbow is shown as a solid black circle. Note that th
(Fig. 4-20). As apparent in th figure, th moment arm is
moment arm is greater when th elbow is in position A compared
greater in position A than in position B\ not coincidentally, with position B. (Modified from LeVeau BF: Williams & Lissner's
th maximal internai torque of th elbow flexors is also Biomechanics of Human Motion, 3rd ed. Philadelphia, WB Saun-
greater in position A than in position B. In generai, th ders, 1992.)

Box con tin u ed on follow in g p a g e

 74 Secticm I Esseniial Topics o f Kinesiolog)'
u S P E C I A L F O C U S 4 - 6
internai moment arm available to any muscle is greatest
when th angle-of-insertion of th muscle is 90 degrees to
Continuai
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
B. 45 of flexion (partial squat)
A, 90 of flexion (deep squat)
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
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 in-
creases th compressive forces on th joint surfaces.
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 dis-
tance 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.
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 im-
portant for persons with prostheses or artifcial joint replace-
 Chapter 4 Biomechanical Principles 75

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 pros-
thetic 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-
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 equi-
librium. 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

A B

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
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 dif-
ferent 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 neces-
sary if th clinictan chooses to manually challenge a muscle
group as potentially forceful as th quadriceps.
FIGURE 4-23. How th internai
moment arm used by th hip ab-
ductor muscles is altered by dts-
ease 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 tro-
chanter 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 Neu-
mann DA: Biomechanical analysis
of selected principles of hip joint
protection. Arthr Care Res 2:146-
155, 1989. Copyright 1989 by th
Arthritis Health Professtons Associ-
ation.)
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 prob-
lems in biomechanics. These approaches can be employed to
assess (1) th effect of a force at an instant in time (force-
acceleratici! 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-
FIGURE 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-lat-
eral axis of rotation at th knee.
 Chapter 4 Biom echankal Principles 77

ular approach selected depends on th objective of th anal-

TABLE 4 - 4 . Guidelines for Solving for Muscle
ysis. The subsequent sections in this chapter are directed
Force, Torque, and Jo in t Reaction Force
toward th analysis of forces or torques at one instant in
time, or th force (torque)-acceleration approach.
1. Draw th free body diagram and indicale all forces acting
When considering th effects of a force and th resultant
on th body or System under consideration. lt is necessary
acceleration at an instant in time, two situations can be to establish an XY reference frante that specifies th desired
deftned. In th first case, th acceleration has a zero value orentation of th forces. It is often convenirmi to designate
because th object is either stationary or moving at a Con th X axis parallel to th isolated body segment (typically a
stant velocity. This is th branch of mechanics known as long bone), and th Y axis perpendicular to th body seg
statics. In th second situation, th acceleration has a non ment.
zero value because th System is subjected to unbalanced 2. Resolve all forces into their tangential and normal compo-
forces or torques. This area of study is known as dynamics. nents.
Static analysis is th simpler approach to problem solving in 3. ldentify th moment arms associated with each force. The
moment arm associated with a given torque is th distance
biomechanics and is th focus in this chapter.
between th axis of rotation and th 90-degree intersection
with th force. Note that joint reaction force will not have a
Static Analysis moment arm, because it is typically directed through th
center of th joint.
Biomechanical studies often induce conditions of static equi- 4. Use Equations 4 -1 4 and 4 -1 5 as needed to solve th
librium in order to simplify th approach to th analysis of problem.
human movement. In static analysis, th System is in equilib-
rium because it is not experiencing acceleration. As a conse-
quence, 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
ing an object in th hand. Assuming equilibrium, three un-
of th mass and moment of inertia of th bodies is ignored.
known variables are to be solved: (1) th internai (muscular-
The force equilibrium Equations 4.14 A and B are used
produced) torque, (2) th muscle force, and (3) th joint
for uniplanar translational motion and are listed in th box.
reaction force at th elbow. To begin, a free body diagram is
For rotational motion, th forces act together with their mo
constructed. The axis of rotation and all moment arm dis-
ment arms and cause a torque about some axis. In th case
tances are indicated (Figure 4 - 2 5 B ). Although at this point
of static rotational equilibrium, th sum of th torques about
th direction of th joint (reaction) force ( JF) is unknown, il
an axis of rotation or another point is zero. The torque
is assumed to act in a direction opposite to th pul of
equilibrium Equation 4.15 is also included in th box. This
muscle. This assumption holds trae in an analysis in which
equation implies that th sum of th counterclockwise
th mechanical advantage of th System is less than one (i.e.,
torques must equal th sum of th clockwise torques. The
when th muscle forces are greater than th external resis-
seesaw model of Figure 4 - 2 2 B provides a simplifed exam-
tance forces) (see Chapter 1). lf after solving th problem
ple of static rotational equilibrium. The HAF times its mo
th joint force is positive, then this initial assumption is
ment arm (D) creates a potential counterclockwise (abduc-
correct.
tion) torque, whereas BW times its moment arm (D t) creates
Because all th resultant forces indicated in this problem
a potential clockwise (adduction) torque. At any instant, th
act parallel to th Y axis, it is unnecessary to resolve th
opposing torques at th hip are assumed to be equal.
resultant forces into their component. vectors. No forces are
acting in th X (horizontal) direction.

Static Analysis: Forces and Torques are Balanced Solving for Internai Torque and Muscle Force
The external torques originating from th weight of th fore-
Force Equilibrium Equations arm-hand segment (SW) and th weight of th load (LW)
2F X = 0 (Equation 4.14 A) generate a clockwise (extension) torque about th elbow. In
2F y = 0 (Equation 4.14 B) order for th System to remain in equilibrium, th elbow
Torque Equilibrium Equation flexor muscle has to generate an opposing internai (flexion)
M

torque, acting in a counterclockwise direction. This assump

H

(Equation 4.15)
II
o

tion of rotational equilibrium allows Equation 4.15 to be

used to solve for th magnitude of th internai torque and
muscle force:
GUIDELINES FOR PROBLEM SOLVING
The guidelines listed in Table 4 - 4 can help calculate th UT = 0 (Internai torque 4 external torque = 0)
magnitude and direction of muscle force, torque, and joint
reaction force. The following two sample problems illustrate Internai torque = external torque
th use of these guidelines for problem solving in a static
equilibrium situation. Internai torque = (SW X EMA,) + (LW X EMA2)

Problem 1 Internai torque = (17N X 0.15 m) + (60 N X 0.35 m)

Consider th situation in Figure 4 -2 5 A , in which a person
generates an isometric muscle force at th elbow while hold- Internai torque = 23.6 Nm
 78 Section I Essetuial Topics o f Kinesiology

Axis of
rotation

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

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
flexion exercise is performed against a load weight
held in th hand. The forearm is held in th hori-
zontal 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. Philadel-
phia, WB Saunders, 1992.)

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,)
disparity in moment arm length is not unique to th elbow
flexion model, bui it is ubiquitous throughout th muscular-
joint 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.

Muscle torce (MF) - m N X 0.15 m) + (so N X 0.35 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., fore- - J F = - 4 7 1 N + 17 N + 60 N
arm-hand segment and load weight). The larger force re-
quirement can be explained by th disparity in moment arm - J F = - 3 9 4 .0 N
length used by th elbow flexors when compared with th
moment arms lengths used by th two external forces. The JF = 3 94.0 N
 Chapter 4 Biomcchanical Principles 79

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 up-
ward, 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
through th axis of rotation and, therefore, has a zero mo
ment arm.
Problem 2
In Problem 1, th forearm is held horizontally, thereby ori-
enting th internai and extemal forces perpendicular to th
forearm. Although this presentation greatly simplifies th cal-
culations, 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-

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
Axis of SWX = (sin 8) x SW

\)
rotation SWy = (cos 8) X SW
'X Load Weight (LW) = 60N
1 LWX = (sin 8) x LW
LWy = (cos 8) x LW

w
i
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

FIGURE 4 - 2 6 . P ro b le m 2. A, An isometric el
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 dia-
gram is shown including a box with th ab-
breviations and data required to solve th
problem. C, The joint reaction force (JF ) vec-
tors are shown in response to th biomechan-
ics depicted in B. (A modified from LeVeau
BF: Williams & Lissners Biomechanics of Hu
man Motion, 3rd ed. Philadelphia, WB Saun-
ders, 1992.)
 80 Secticm I Essendal Topici of Kinesiology

arm position, th angle-of-insertion of th elbow flexor mus- MF = 408 N/.866

cles 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 rectangu-
lar (X and Y) components. This requires additional steps and
trigonometrie calculations. Assuming equilibrium, three un-
known 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)
Internai torque = external torque
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 illustra-
tion.) 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), respec-
tively. 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 Equa-
tions 4 .14 A and B.
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) JF y = - M F y 4- SWY 4- l.W Y

4- (cos 30 X 60 N X 0.35 m)
-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
JF X = 2 35.6 N - (sin 30 X 17 N) - (sin 30 X 60 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 = 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 theo-
rem:

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
JF = V 341.3 N2 4- 197.1 N2
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 JF = 394.1 N
caiculated with data supplied with this problem. This approach is equally
valid.
Another characteristic of th joint reaction force that is of
 Chapter 4 Biomechanical Principia 81

interest is th direction of th JF with respect to th axis (X) Kinematic Measurement Systems: Electrogoniometer,
of th forearm. This is calculated using th relationship: Accelerometer, Imaging Techniques, and
Electromagnetic Tracking Devices
tan /a = JF y/JFx Detailed analysis of movement requires a careful and objec-
tive evaluation of th motion of th joints and body as a
l i = tan-' (341.3 N/197.1 N) whole. The analysis most frequently includes an assessment
of position, displacement, velocity, and acceleration. Analysis
H = 60 may be used to indirectly measure forces produced by th
body or to assess th quality and quantity of motion without
The resultant joint reaction force has a magnitude of regard to forces and torques. Kinematic analysis is performed
394.1 N and is directed toward th elbow at an angle of 60 in a variety of environments, including sport, ergonomics,
degrees to th forearm segment (i.e., th X axis). The angle and rehabilitation.
is th same as th angle-of-insertion of th muscle, a re-
minder of th dominant role of muscle in determining both Electrogoniometer
th magnitude and direction o f th joint reaction force. An electrogoniometer measures joint angular displacement
during movement. The device typically consists of an electri-
cal potentiometer built into th pivot point (hinge) of two
Dynamic Analysis rigid arms. Rotation of a calibrated potentiometer measures
Static analysis is th most basic approach to kinetic analysis th angular position of th joint. The output can be sent to
a chart recorder or oscilloscope, or more frequently it is
of human movement. This form of analysis is used to evalu-
used as input to a computer program. The arms of th
ate forces on a human when there are little or no significant
electrogoniometer are strapped to th body segments, such
linear or angular accelerations. In contrast, when linear or
that th axis of rotation of th goniometer (potentiometer) is
angular accelerations occur owing to unbalanced forces, a
approximately aligned with th joints axis of rotation (Fig.
dynamic analysis must be undertaken. Walking is an exam-
4 - 2 7 ) . The position data obtained from th electrogoniome-
ple 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 con-
ducted 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.) Solv-
ng for forces and torques under dynamic conditions re-
quires 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 charac-
teristics 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 labora-
tory techniques.

Dynamic Analysis of Force and Torque

Force Equations
SF X = max (Equation 4.16 A)

2F y = mav (Equation 4.16 B)

Torque Equation
M
H

(Equation 4.17)
II
P

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 measure-
ment 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 con- processor or an interface that digitizes th analog signal, a
verted to angular velocity and acceleration. Although th calibration device, and a computer. The procedures involved
electrogoniometer provides a fairly inexpensive and direct in video-based systems typically require markers to be at
means of capturing joint angular displacement, it encumbers tached to a subject at selected anatomie landmarks. Markers
th subject and is difficult to fit and secure over fatty and are considered passive if they are not connected to another
muscle tissues. A triaxial electrogoniometer measures joint electronic device or power source. Passive markers serve as a
rotation in three planes; however, this System tends to con- light source by refiecting th light back to th camera (Fig.
strain naturai movement. 4 - 2 8 ) . Two- and three-dimensional coordinates of markers
Accelerometer are identified in space by a computer and are then used to
An accelerometer is a device that measures acceleration of reconstruct th image (or stick figure) for subsequent kine
th segment to which it is attached. Accelerometers are force matic analysis.
transducers consisting of a strain gauge or piezoresistive Cir Video-based systems are quite versatile and are used to
cuit that measures th reaction forces associated with a given analyze activities from swimming io typing. Some systems
acceleration. Based on Newtons second law, acceleration is allow movement to be captured outdoors and processed at a
determined as th ratio of th measured force divided by a later time. Another desirable feature of th System is that th
known mass. subject is not encumbered by wires or other electronic de-
vices.
Imaging Techniques
Optoelectronics is another popular type of kinematic acqui-
Imagng techniques are th most widely used methods for sition System that uses active markers that are pulsed se-
collecting motion data. Many different types of imaging Sys quentially. The light is detected by special cameras that fo
tems are available. This discussion is limited to th Systems cus it on a semiconductor diode surface. The System enables
listed in th box. 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
Imaging Techniques
feel hampered by th wires that are connected to th active
Photography markers. Telemetry systems enable data to be gathered with-
Cinematography out th subjects being tethered to a power source, but they
Videography
are vulnerable to ambient electrical interference.
Optoelectronics
Electromagnetic Tracking Devices
Electromagnetic tracking devices measure six degrees-of-free-
Unlike th electrogoniometer and accelerometer that mea- dom (three rotational and three translational), providing po-
sure movement directly from a body, imaging methods typi- sition and orientation data during both static and dynamic
cally require additional signal conditioning, processing, and activities. Small receivers are secured to th skin overlying
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 meas-
urement 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 per-
formed 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 devel-
oping th film and manually analyzing th data. Videography
has replaced these Systems and is one of th most popular FIGURE 4-28. Reflective markers are used to indicate anatomie lo-
cations for determination of joint angular displacement of a walking
methods for collecting kinematic information in both clinical
individuai. Marker location is acquired using a video-based camera
and laboratory setungs. The System typically consists of one that can operate at variable sampling rates. (Courtesy of Peak Per
or more video cameras, a recorder, a monitor, an image formance Technologies, Ine., Englewood, Colorado.)

* tems, most operate with wires that connect th receivers to
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) di-
rections during a normal walking trial.
0 0.1
Chapter 4 Biomechanical Prnciples 83
transmitters. Although telemetry is available for these Sys
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 re-
sponse 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.
0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
Time (seconds)
 84 Section I Essentia Topics o f Kinesiology
FIGURE 4-31. lsokinetic dynamometry. The subject generates maxi-
mal-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 indi-
rectly 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 er-
rors in measuring position data magnify errors in velocity
and acceleration.
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 ki-
netic 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-poste-
rior components (Fig. 4 - 3 0 ) . Each component has a charac-
teristic shape and magnitude. The ground reaction force data
can be used as input for subsequent dynamic analysis.
Electromechanical Devices
One of th most popular electromechanical devices for meas-
uring 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 eccen-
tric. 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 rehabili-
tation.
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 equa-
tions 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 Biomechanical Principles 85

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 as-
sumptions made during th use of th inverse dynamic
approach are included in th box.
Assumptions Made During th Inverse Dynamic
Approach
1. Each segment or link has a fixed mass that is con-
centrated at its center of mass.
2. The location of each segments center of mass re-
mains 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 JF y

Thigh (T) - J F X
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 JF y
|C
Jh x
7J)
for th internai forces and torques to be determined, beginning
with th most distai foot segment. The red curved arrows repre- Leg
sents torque about th axes of rotation. (W , segment weight; JF X

Cf
and JF y, joint forces in th horizontal (X) vertical (Y) directions; Leg (L)
GRFX and GRFY, ground reaction forces in th horizontal (X) and
vertical directions (Y).) JFy \

Foot(F) JFX
(
-A GRF
JF,

u n r x

t
Foot W GRFy
B

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-TR-
55-159, 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
Guccione AA (ed): Geriatrie Physical Therapy, 2nd ed. St, Louis,
Mosby, 2000.
13. Ozkaya N, Nordin M: Fundamentals of Biomechanics: Equilibrium, Mo-
tion and Deformation. New York, Springer-Verlag, 1999.
14. Soderberg GL: Kinesiology: Application io Pathological Motion, 2nd ed.
Baltimore, Williams & Wilkins, 1997.
15. Whiting WC, Zemicke RF: Biomechanics of Musculoskeletal Injury.
Champaign, Human Kinetics, 1998.
16. Winter DA: Biomechanics and Motor Control of Human Movement,
2nd ed. New York, John Wiley &r Sons, 1990
17. Zatsiorsky VM: Kinematics of Human Motion. Champaign, Human Ki
netics, 1998.
18. Zatsiorsky VM, Seluyanov V: Esumation of th mass and inertia charac-
teristics 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. Philadel-
phia, WB Saunders, 1992.
Low J, Reed A: Basic Biomechanics Explained. Oxford, Butterworth-Heine-
mann, 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.
 A p p e n d i x I

Appendix IA: Selected Anthropometric Data Figure IC1 illustrates th use of trigonometry io deter
Table 1A1 provides selected anthropometric data on a 670-N mine th force components of th posterior deltoid muscle
man. 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
Appendix IB: The "Right-Hand" Rule muscle force (MF) are labeled MFY (tangential force) and
MFX (normal force). Given a Constant muscle force of 200
As stated in Chapter 1, a torque is detned as a force multi-
N, MFY and MFX can be determined as follows:
plied by its moment arm. Force is a vector quantity that
possesses both magnitude and direction. Moment arm
MFX = MF sin 45 = 200 N X 0 .707 = 141.4 N
length, however, can be treated as a vector or as a scalar
quantity. When considering a moment arm as a vector, MF y = MF cos 45 = 200 N X 0 .707 = 141.4 N
torque is calculated as th product of two vectors. Multiply-
ing two orthogonal vectors (force and its moment arm) Il MFx and MFY are known, MF (hypotenuse) can be deter
through cross-product multiplication yields a third vector mined using th Pythagorean theorem:
(torque) that is directed perpendicularly to th piane that
contains th other two vectors. Using this scheme, th elbow MF2 = MFX2 + MFy2
flexors in Figure 1 - 1 7 , for example, would produce an
internai torque vector that is directed either into th page or MF = V 1 4 1 .4 2 4- 141.42
out ol th page. The right-hand rule is a convention that
can be used to assign a direction to a vector product. The MF s 200 N
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.

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 analy-
sis are found in th following table. Each trigonometrie func-
tion 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
Trigonometrie Function Definition
Sine (sin) Side opposite/hypotenuse FIGURE IC1. Given an angle-of-insertion of th posterior deltoid
Cosine (cos) Side adjacent/hypotenuse (a = 45 degrees) and th resultant posterior deltoid muscle force
(MF), th two rectangular force components of th muscle force
Tangent (tan) Side opposite/side adjacent (MFX and MFV) are detennined using trigonometrie relationships.
Cotangent (cot) Side adjacenbside opposite The axis of rotation at th glenohumeral joint is indicated by th
open circle at th head of th humerus.
86
 A p p e n d ix I 87

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

Segment Weight* Location of Centers of Mass

H ea d : 46.2 N (6.9%) H ea d : In spbenoid sinus, 4 mm beyond anterior inferior margin of sella. (On lateral
surface, over temporal fossa on or near nasion-inion line.)
H ea d a n d n ec k : 52.9 N (7.9%) 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 ead, n eck , a n d tru n k: 395.3 N (59.0%) H ea d , n eck , a n d tru n k: Anterior io eleventh thoracic vertebra.

Upper Limb
U p p er lim b: Just above elbow joint.
A rm : 18.1 N (2.7%) Arm: In mediai head of triceps, adjacent to radiai groove; 5 mm proximal to distai end of
deltoid insertion.
Fo r e a r m : 10.7 N (1.6%) Forearm. 11 mm proximal to most distai pan of pronator teres insertion; 9 mm anterior to
interosseous membrane.
H an d : 4.0 N (0.6%) H a n d (in rest position): On axis of metacarpal III, usually 2 mm deep to volar skin surface;
U p p er lim b: 32.8 N (4.9%) 2 mm proximal to transverse palmar skin crease, in angle between proximal transverse
F o r e a r m a n d h a n d : 14.7 N (2.2%) and radiai longitudinal crease.

Lower Limb

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

Thigh: 65.0 N (9.7%) 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.
Leg: 30.2 N (4.5%) 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: 9.4 N (1.4%) F oot: In piantar ligaments, or just superficial in adjacent deep foot muscles; below proximal
L o w e r lim b: 104.5 N (15.6%) halves of second and third cuneiformi bones. On a line between ankle joint center and
Leg a n d f o o t : 40.2 N (6.0%) 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, sin 45 = MFX/MF

such as those exerted by a wall pulley, body weight, or by
th clinician manually, are determined in a manner similar MF = 141.4 N/sin 45
to that described for th muscle (internai) force.
Trigonometry can also be used to determine th magni- MF = 200 N
tude of th resultant force when one or more components
and th angle-of-insertion are known. Consider th same If only MFY and MFX are known, th angle-of-insertion of
example as given in Figure 1C1, but now consider th goal MF can be determined using th inverse tan 1 a . Note that
of th analysis to be determination of th resultant muscle th components of th force always have a magnitude less
force of th posterior deltoid muscle. The muscle angle-of- than th magnitude of th resultant vector.
nsertion 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:
Upper Extremity
 S 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
 C h a p t e r 5

Shoulder Complex
Donald A. Neum ann , PT, Ph D

TOPICS AT A GLANCE

0S T E 0L 0G Y , 91 Sternoclavicular and Innervation of th Muscles and Joints of

Sternum, 91 Acromioclavicular Joint th Shoulder Complex, 115
Clavicle, 92 Movements, 103 Muscles of th Scapulothoracic
Scapula, 92 Elevation and Depression, 103 Joint, 118
Proximal-to-Mid Humerus, 95 Protraction and Retraction, 103 E le va to rs o f th S c a p u lo th o ra c ic
Upward and Downward Rotation, 104 J o in t, 118
ARTHROLOGY, 96
Sternoclavicular Joint, 98 Glenohumeral Joint, 104 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 J o in t, 119
G en era l F e atures, 98
P e ria rtic u la r C o n n e c tiv e T issu e , 105 P ro tra c to rs o f th S c a p u lo th o ra c ic
P e ria rtic u la r C o n n e c tiv e T is s u e , 99
S ta tic S ta b ility a t th G le n o h u m e ra l J o in t, 120
K in e m a tic s , 99
J o in t, 108 R e tra c to rs o f th S c a p u lo th o ra c ic
Elevation and Depression, 100
C o ra c o a c ro m ia l A rc h and A s s o c ia te d J o in t, 120
Protraction and Retraction, 100
B u rs a , 109 U p w a rd and D o w n w a rd R o ta to rs o f th
Axial (Longitudinal) Rotation of th
K in e m a tic s a t th G le n o h u m e ra l S c a p u lo th o ra c ic J o in t, 120
Clavicle, 100
J o in t, 110 Muscles that Elevate th Arm, 120
Acromioclavicular Joint, 100
G en era l F e a tu re s, 100
Abduction and Adduction, 110 M u s c le s th a t E levate th A rm a t th

P e ria rtic u la r C o n n e c tiv e T is s u e , 101

Flexion and Extension, 112 G le n o h u m e ra l J o in t, 120

K in e m a tic s , 101
Internai and External Rotation, 113 U p w a rd R o ta to rs a t th S c a p u lo th o ra c ic

Upward and Downward Rotation, 102 Summary of Glenohumeral Joint J o in t, 122

Horizontal and Sagittal Piane Arthrokinematics, 114 F u n ctio n o f th R o ta to r C uff M u s c le s

"Rotational Adjustments" at th Overall Shoulder Kinematics During D u rin g E levation o f th A rm , 125

Abduction, 114 Muscles that Adduct and Extend th
Acromioclavicular Joint, 102
S c a p u lo h u m e ra l R hythm , 114 Shoulder. 127
Scapulothoracic Joint, 102
S te rn o c la v ic u la r and A c ro m io c la v ic u la r Muscles that Internally and Externally
K in e m a tic s , 103
J o in t In te ra c tio n , 114 Rotate th Shoulder, 129
Movement of th Scapulothoracic
Joint: A Composite of th MUSCLE A N D J O IN T IN TER AC TIO N , 115

INTRODUCTION paralysis or weakness of any single muscle often disrupts th

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 ex-
tremity, 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.
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 oval-
shaped 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 proc-
ess.

Anterior view
Sternocleidomastoid

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

jugular notch is locateci at th superior aspect of th manu-

brium, 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 FIGURE 5 -2 . An anterior view of th stemum with left clavicle and
Conoid tubercle ribs removed. The dashed line around th clavicular facet shows
Trapezoid line th attachments of th capsule at th sternoclavicular joint. Proxi-
mal attachments of muscle are shown in red.
 Chapter 5 Shoulder Complex 93

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.
 94 Section II Upper Extremity

Posterior view
Anterior view
Upper trapezius Middle and anterior deltoid

Upper trapezius

Short head
biceps and
coracobrachialis
lSupraspinatusv
in Long head biceps
supraspinatous Lower on supraglenoid
j, ta s s a i1 and tubercle
Levator middle Sternum
Pectoralis
scapulae' ^ trapezius m in o r
f Infraspinatus
Rhomboid
w
( Subscapularis
___ minor infraspinatous fossa
') in
Subscapular fossa.
Long head triceps on
infraglenoid tubercle

Serratus anterior

Latissimus
^ an# 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 Socket of joint, + eidos; resembling) (Fig. 5 - 5 B). The
Angles: inferior, superior, and lateral
glenoid fossa is tilted upwardly about 5 degrees relative to
Mediai or vertebral border the scapulas mediai border (Fig. 5 - 6 ) . At resi, the scapula
Lateral or axillary border is normally positioned against the posterior-lateral surface of
Superior border the thorax vvith the glenoid fossa facing about 35 degrees
' 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
FIGURE 5 6. Anterior view of the righi scapula showing an approx-
imate 5-degree upward tilt of the glenoid fossa relative to the
the slightly concave glenoid fossa (from the Greek root glene; mediai border of the scapula.

Superior view
FIGURE 5-7. A close-up view of th righi coracoid process looking
from above. Proximal attachraents of muscle are in red, distai at-
tachments 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
Chapter 5 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 mus-
cles (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
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 medial-
lateral 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 respec-
lively (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 poste-
rior 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 me-
chanical 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 ster-
noclavicular 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 Shoulder Complex 97

Posterior view The joints of th shoulder complex function as a series of

links, all cooperating to maximize th range of motion avail-
able 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 sterno-
clavicular and acromioclavicular joints, th movements at th
scapulothoracic joint must be defined (Fig. 5 - 1 1 ) . The pri-
mary movements of th scapulothoracic joint are elevation
and depression, protraction and retraction, and upward and
downward rotation.

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 position, th scapula
slides inferiorly on th thorax.
Protraction. The mediai border of th scapula slides an-
terior-laterally on th thorax away from th midiine.
FIGURE 5-10. Posterior aspect of th tight proximal humerus. Proxi- Retraction. The mediai border of th scapula slides pos-
mal attachments of muscles are in red, distai attachments in gray. The terior-medially on th thorax toward th midiine, such as
dashed line shovvs th capsular attachments of th glenohumeral joint. occurs during th pinching of th shoulder blades together.
Upward Rotation. The inferior angle of th scapula ro-
tates in a superior-lateral direction such that th glenoid
Four Joints Within th Shoulder Complex fossa faces upward. This rotation occurs as a naturai compo-
1. Sternodavicular nent of th arm reaching upward.
2. Acromioclavicular
3. Scapulothoracic Downward Rotation. The inferior angle of th scapula
4. Glenohumeral rotates in an inferior-medial direction such that th glenoid
fossa faces downward. This motion occurs as a naturai com-

Elevation and Depression 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

on th sternum, and th superior border of th cartilage of
elevated position.
th hrst rib (Fig. 5 - 1 2 ) . The joint is th basilar joint of th
upper extremity, linking th axial skeleton with th appen-
Stemoclavicular Joint dicular skeleton. As such, th SC joint is subjected to unique
GENERAL FEATURES functional demands that are met by a complex saddle-
shaped articular surface (Fig. 5 - 1 3 ) . 68 Although highly vari-
The stemoclavicular (SC) joint is a complex articulation, able, th mediai end of th clavicle is usually convex along
invohing th mediai end of th clavicle, th clavicular facet
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.

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 ster-
num. A prominent articular disc resides within th SC joint,
which tends to increase th congruity of otherwise irregular-
shaped 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 stemothy-
roid 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 depres-
sion 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.
Chapter 5 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 inferi-
orly near th lateral edge of th elavicular facet and superi-
orly 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 ab-
sorber 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 de-
grees 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 re-
traets, and rotates about th bones longitudinal axis (Fig. 5 -
14). Essentially all functional movement of th shoulder in-
volves 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 sternoclavicu-
lar 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 liga-
ment produces a downward force in th di
rection of th slide. (Costoclavicular ligameni
CCL, superior capsule = SC, interclavicu-
lar ligament = 1CL.)

Elevation and Depression

Axial (Longitudinal) Rotation of the Clavicle
Elevation and depression of th clavicle occur approximately
The 3rd degree of freedom ai the SC joint is a rotation of
parallel to th frontal piane about an anterior-posterior axis
th clavicle about the bones longitudinal axis (see Fig
of rotarion (see Fig. 5 - 1 4 ) . A maximum of approximately
5 - 1 4 ) . When the shoulder is abducted or fexed, a point on
45 degrees of elevation and 10 degrees of depression have
the superior aspect of the clavicle rotates posteriorly approxi
been reported.11-38 Elevation and depression of th clavicle
mately 40 to 50 degrees.26-63 As the arm is returned to the
are associated with a similar motion of th scapula.
side, the clavicle rotates back to its originai position.
1 he arthrokinematics for elevation and depression of th
The arthrokinematics of clavicular rotation involve a spin
clavicle occur along th SC joints longitudinal diameter (see
of th head of the clavicle about the lateral surface of the
Fig. 5 - 1 3 ) . Elevation of th clavicle occurs as th convex
articular disc. Full posterior rotation of the clavicle is consid-
sur face of its head rolls superiorly and stmultaneously slides
ered the close-packed position of the SC joint.68
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 Acromioclavicular Joint
its head rolling inferiorly and sliding superiorly (Fig.
GENERAL FEATURES
5 -1 5 B ). A fully depressed clavicle elongates and stretches
th interclavicular ligament and th superior portion of th The acromioclavicular (AC) joint is the articulation between
capsular ligaments.4
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
Protraction and Retraction
medially and slightly superiorly, providing a fit with th
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 particu-
lar movement. At least 15 to 30 degrees of rotation in each
direction have been reported .11-38^ The horizontal piane mo-
tions 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 sur-
face 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 FIGURE 5 16. Superior view of a tnechanical diagram of the arthro-
antenor direction. The extremes of protraction occur during a ktnematics of roll and slide during retraction of th clavicle about
motion involving maximal forward reach. Excessive tightness th right stemoclavicular joint. The vertical axis of rotation is
in the posterior bundle of the costoclavicular ligament, th shown through the stemum. Stretched structures are shown as thin
posterior capsular ligament, and the scapular retractor muscles elongated arrows, slackened structures shown as a wavy arrow.
may limit the extreme of clavicular protraction. (Costoclavicular ligament = CCL, anterior capsular ligament =
ACL, posterior capsular ligaments = PCL.)

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.
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.
Chapter 5 bhoulaer C omplex 101
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.
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
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 acro-
mion medially and under th sloped articular facet of
th well-stabilized clavicle. The coracoclavicular liga-
ments, 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 liter-
ature exists on th evaluation and treatment of th
injured AC joint, especially in athletes.32
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 move-
ments 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 rota-
tional 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.
Osteokincmatics at th AC Joint
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 t-
raised 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 o-
extension. 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
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 pro-
tracting 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 in-
crease 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.
Upward and Downward Rotation
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 sum-
mation 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
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).
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.
Glenohumeral Joint
GENERAL FEATURES
The glenohumeral (GH) joint is th articulation formed be-
tween th large convex head of th humems and th shallow
concavity of th glenoid fossa (Fig. 5 - 2 4 ) . This joint oper-
ates 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.
r

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 hu-
meral head is directed medially and superiorly, as well as
posteriorly because of its naturai retroversion. This orienta-
tion places th head of th humerus directly into th scapu-
lar 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 tis-
sues (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.
Chapter 5 Shoulder Complex 105
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 conjunc-
don 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, in-
fraspinatus, and teres minor) and th capsular ligaments
blend into th fibrous capsule, providing most of th stabil-
ity 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-
Biceps brachii tendon (long head)
Glenoid labrum
Tissues that Stabilize or Deepen th GH Joint
Rotator cuff muscles (subscapularis, supraspinatus, infra-
spinatus, 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 Bigli-
ani.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 re-
pair or injury to th capsule.
posing diameter of th glenoid fossa. By describing th
GH joint as a ball-and-socket joint, th erroneous impres-
sion is given that th head of th humerus fits into th
glenoid fossa. The actual structure of th GH joint articu-
lation 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 tis-
sues and by active forces produced by muscles, not by
bony fit.
Coracoid process
FIGURE 5 - 2 5 . Side view of righi glenohu
meral joint with th joint opened up to ex-
Pose the articular surfaces. Note th extern of
th subacromial space under th coracoacro-
mial arch. The longitudinal diameter is de-
picted 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 be-
comes 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 proxi-
mally 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 Conoid
Transverse
features of th joint capsule: th ligament
ligament - Coracoclavicular
capsular, coracohumeral, and Trapezoid ligament
coracoacromial ligaments. Note ligament
th subacromial space located
between th top of th humeral
head and th underside of th
acromion.

glenohumeral ligament attaches as a broad sheet to th ante-
rior-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 axil-
lary 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.
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
Middle glenohumeral ligament
Inferior glenohumeral ligament
(three parts: anterior band,
posterior band, and connect
ing axillary pouch)
coracohumeral ligament
Anatomie neck, above th tesser tubercle
Along th anterior aspect of th anatomie
neck
As a broad sheet to th anterior-inferior and
posterior-inferior margins of th anatomie
neck
Anterior side of th greater tubercle of th
humerus
Full adduction, and/or inferior and posterior
translation of th humerus
Anterior translation of th humerus and/or
external rotation
All fibers: abduction
Anterior band: abduction and external rotation
Posterior band: abduction and internai rotation
Extremes of external rotation, flexion, and ex
tension; inferior displacement (translation)
of th humeral head
 108 Section il Upper Extremity
Coracoacromial arch
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.
B
FIGURE 5-27. Lacerai aspect of th
right glenohumeral joini showing th
internai surface of th joint. The hu-
merus 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. Sy-
novial membrane is shown in red.
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 liga-
ment, 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 vec-
tors reduces th magnitude of th compres
sion force across th GH joint. As a conse-
quence, th head of th humerus slides
down th now vertically oriented glenoid
fossa. The dashed lines indicate th parallelo-
gram method of adding force vectors.

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 supraspi-
natus, 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 ver-
tically running muscles, such as th biceps, triceps, and
middle deltoid, are generally not actively involved in provid-
tng static stability, even when signifcant downward traction
is applied to th arm.
An important component of th static locking mech-
anism is a scapulothoracic posture that maintains th gle
noid fossa slightly upwardly rotated. The passive tension
within th superior capsular structures is significanti)' re-
duced 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 vec-
tors created by th superior capsular structures and grav-
ity. 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 com-
pletely.
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.
Chapter 5 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 punc-
turing 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 dis-
tance exists between th undersurface of th arch and th
humeral head.47 This important subacromial space con-
tains 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 de-
velop 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 supraspina-
tus 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
internai and extema] rotation (gray). Note that each axis of rotation
s color-coded with its corresponding piane of movement: medial-
lateral axis in white, vertical or longitudinal axis in gray, and
anterior-posterior axis in red.
subacromial bursa, limiting frictional forces between th del-
toid 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.
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 hyper-
extension 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 discus-
ston, 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 arthroki-
nem 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 trans-
ferred 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-
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 Shouder Complex 111

sion within th inferior capsule acts as a hammock or sling,
which supports th head of th humerus.41 Excessive stiff-
ness 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 si-
multaneous 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 ab-
duction 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 supra-
spinatus muscle, its tendon, and th bursa against th rigid
coracoacromial arch. This impingement is painful, blocking
further abduction (Fig. 5 32B). In vivo radiographic meas-
urements in th healthy shouder show that during abduc
tion in th scapular piane, th humeral head remains essen-
tially stationary or may translate superiorly only a negligible
distance.17'43-48 The concurrent inferior slide of th humeral
head offsets most of th inherent superior translation ten-
dency 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 fron-
tal piane and abduction in th scapular piane can be illus-
trated by th following example. Attempt to maximally
abduct your shouder in th pure frontal piane while con-
sciously 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
U 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 condi-
tion typically occurs in athletes and laborers who repeat-
edly 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
frontal piane and scapular piane abduction should be consid-
ered while evaluating and treating patients with shoulder dys-
function, 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
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. So-
derberg.)
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 scapulo-
thoracic 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.

; 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 coraco-
zcromial 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 rota-
don 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.)
Chapter 5 Shoulder Complex 113
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 contrac-
tion 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 gener-
ated 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 rota-
tions 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
TABLE 5 - 2 . A Summary of th Arthrokinematics at th GH Joint
Osteokinematics Piane of Motion/Axis of Rotation
Abduction/adduction Frontal plane/anierior-posterior axis of rotation
Intemal/extemal rotation Horizontal plane/vertical axis of rotation
Flexion/extension and intemal/extemal Sagittal plane/medial-lateral axis of rotation
rotation (in 90 degrees of abduction)
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 ur-
derstanding 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 fron-
tal 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, occur-
ring at a ratio of 2:1. For every 3 degrees o f shoulder abdiu-
tion, 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, addi-
donai 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 litera-
ture, Inmans classic 2 : 1 ratio stili remains a valuable axiom
in evaluation of shoulder movement. It is simple to remern-
ber 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
Arthrokinematics
Roll-and-slide along joints longitudinal
diameter
Roll-and-slide along joints transverse
diameter
Spin between humeral head and
glenoid fossa

FIGURE 5-3 7 . A, Posterior view of th right shoulder complex after
th arm has abducted to 180 degrees. The 60 degrees of scapulo-
thoracic 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 clavi-
cle at th SC joint is represented by th circular arrow around th
middle shaft of th bone.
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 predomi-
nantly 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
Late Phase: Shoulder Abduction from 90 Degrees
to 180 Degrees
Shoulder abduction from 90 degrees to 180 degrees occurs
as a summation of an additional 60 degrees of GH joint
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
Inman and fellow researchers were able to demonstrate
through in vivo techniques that th clavicle rotates posteri-
orly 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 liga-
ment (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 proc-
ess, 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
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 divi-
sions then reorganize into three cords named by their rela-
tionship to th axillary artery. The cords branch into nerves,
which innervate muscles of th upper extremity and lateral
trunk.
SHOULDER MUSCLE INNERVATION
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: Observa-
lions 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 Shoulder Complex 117

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

SC Joint AC Joint Scapulothoracic Joint GH Joint

Early phase 25 degrees of elevation
0 to 90 degrees
Late phase 5 degrees of elevation and
90 to 180 degrees 35 degrees of posterior
rotation of th clavicle
Total 30 degrees of elevation
0 to 180 degrees and 35 degrees of poste
rior rotation of th clavi
cle
5 degrees of upward rota .30 degrees of upward 60 degrees of abduction
tion rotation
25 degrees of upward ro 30 degrees of upward 60 degrees of abduction
tation rotation
30 degrees of upward ro 60 degrees of upward 120 degrees of abduction
tation rotation

* Data from tnman VT, Saunders M, Abbott LC: Observations on th functton of th shoulder jotnt. J Bone Joint Surg 26A :l-32, 1944. (Some values
bave been rounded slightly for simplicity but are stili dose lo th originai values.)
t Extemal rotation is required if abduction is performed in th fronlal piane.

plexus: (1) nerves ihai branch from th posterior cord, such SENSORY INNERVATION OF THE SHOULDER JOINTS
as th axillary, subscapular, and thoracodorsal nerves, and AND SURROUNDING CONNECTIVE TISSUE
(2) nerves that branch from more proximal segments of
The sternoclavicular joint receives sensory (afferent) innerva
th plexus, such as th dorsal scapular, long thoracic, pecto-
tion from th C3 and C4 nerve roots from th cervical
ral, and suprascapular nerves. An exception to this in-
plexus.68 Both th acromioclavicular and glenohumeral joints
nervation scheme is th trapezius muscle, which is inner-
receive sensory innervation via th C5 and C6 nerve roots via
vated primarily by cranial nerve XI, with lesser motor and
th suprascapular and axillary nerves.68
sensory innervation from th ventral roots of upper cervical
nerves.68
Action of th Shoulder Muscles
The primary motor nerve roots that supply th muscles of
th upper extremity are listed in Appendix HA. Appendix 11B Mosi of th muscles of th shoulder complex fall into one of
shows key muscles typically used io test th functional status two categories: proximal stabilizers or distai mobilizers. The
of th C5-T ventral nerve roots. 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 A x illa r y

Jobe MT, Wright PE: Peripheral nerve in- R a d ia i
juries: In Canale ST (ed): Campbells Op
erative Orthopaedies, 9th ed., voi 4. St. M e d ia n
Louis, Mosby, 1998.)
U ln a r Long th ora cic

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
spine, ribs, and cranium, and insert on th scapula and
clavicle. Examples of these muscles are th serratus ante-
rior 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 interdepen-
dence 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 Ap-
pendix 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
FIGURE 5-42. Posterior view showing ihe
upper trapezius, levator scapula, rhomboid
major, and rhomboid minor as elevatore of
th scapulothoracie joint.
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 dam-
age to th spinai accessory nerve (cranial nerve XI).
Over time, th scapulothoracie joint may become mark-
edly 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 bra-
chial plexus.
Perhaps a more common consequence of long-term
paralysis of th upper trapezius is an inferior subluxa-
tion 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 posi-
tion, allowing th humerus to slide inferiorly. The down-
ward 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.

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 sub-
Javius (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 ap-
plied against some object, such as th spring shown in
rigure 5 -43A .
Chapter 5 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 tuberosi-
ties. 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 sub-
clavius during th same activity described in A.
 120 Section II Upper Extremily
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 activi-
ties. 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 ac-
tions. 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
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.
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 potenti-
of 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 121

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 reach-
tng 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 multi-
plied 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 arthrokine-

matics at th GH joint. S P E C I A L F O C U S 5 - 6

Muscles Responsible for Elevation of th Arm Serratus Anterior and th "Push-up" Maneuver
1. GH joint muscles
Another important action of th serratus anterior is to
Deltoid
Supraspinatus
exaggerate th final phase of th standard prone
Coracobrachialis "push-up." The early phase of a push-up is performed
Biceps (long head) primarily by th triceps and pectoral musculature. After
2. Scapulothoracic joint muscles th elbows are completely extended, however, th
Serratus anterior chest can be raised farther from th floor by a deliber
Trapezius ate protraction of both scapulae. This final component
3. Rotator cuff muscles 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
MUSCLES THAT ELEVATE THE ARM AT THE of th serratus anterior may be visualized by rotating
GLENOHUMERAL JOINT Figure 5-45A 90 degrees clockwise and reversing th
The prime muscles that abduct th GH joint are th anterior direction of th arrow overlying th serratus anterior.
deltoid, th middle deltoid, and th supraspinatus muscles Exercises designed to strengthen th serratus anterior
(Fig. 5 - 4 7 ) . Elevation of th arm through flexion is per- incorporate this movement.14
formed primarily by th anterior deltoid, coracobrachialis,
122 Section II Upper Extremity
FIGURE 5-46. Posterior view of th middle trapezius, lower trape-
zius, 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 supraspina-
tus 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 signifi-
cant internai moment arm that remains essentially Constant at
about 25 mm (about 1 in) throughout most of abduction.64
FIGURE 5-47. Anterior view showing th middle deltoid, antenorj
deltoid, and supraspinatus as abductors of th glenohumeral joint.
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, coracobra-
chialis, 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 Shoulder C om pkx 123

TABLE 5 - 4 . Average Maximal Isometric Torques

Trapezius and Serratus Anterior Interaction
Produced by Shoulder Muscle Groups* The axis of rotation for scapular upward rotation is depicted
in Figure 5 - 4 9 as passing in an anterior-poslerior direction
Muscle Group Test Position Torque (kg-cm) through th scapula. This axis allows a convenient way to
analyze th potential for muscles to rotate th scapula. The
Flexors 45 of flexion 566 24 axis of rotation of th upwardly rotating scapula is near th
Extensors 0 of flexion 812 40
root of th spine during th early phase of shoulder abduc-
Abductors 45 of abduction 562 23 tion, and near th acromion during th late phase of abduc-
Adductors 45 of abduction 1051 59 tion.2
Internai rotators 0 of rotation 592 27 The upper and lower fibers of th trapezius and th lower
Extemal rotators 0 of rotation 335 15 fibers of th serratus anterior form a force couple that up
wardly rotates th scapula (see Fig. 5 - 4 9 ) . All three mus-
* Mean 1 standard error; data are from 20 young males from two test cular forces rotaie th scapula in th same direction. The
positions. upper trapezius upwardly rotates th scapula by attach-
Conversion: .098 N-m/kg-cm. ing to th clavicle. The serratus anterior is th most effec-
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 tive upward rotator due to its larger moment arm for this
Orthop 182:267-273, 1985. action.

rior and all parts of th trapezius cooperate during th up

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

FIGURE 5-50. A top view of three people involved in a force
muscular interaction between th scapulothoracic upward rotators
and th glenohumeral abductors. Shoulder abduction requires a couple to rotate a revolving door. The three people are analo-
gous to th three muscles shown in Figure 5 -4 9 upwardly
muscular kinetic are between th humerus and th axial skeleton.
Note two axes of rotation: th scapular axis located near th acro rotating th scapula. (UT = upper trapezius, LT = lower
trapezius, SA = serratus anterior.) Each person, or muscle,
mion, and th glenohumeral joint axis located at th humeral head,
acts with a different internai moment arm (drawn to actual
internai moment arms for all muscles are shown as dark black
scale), which combines to cause a substantial torque in a
hnes. (DEL = deltoid/supraspinatus, UT = upper trapezius, MT =
similar rotary direction.
middle trapezius, LT = lower trapezius, and SA = serratus ante
nne)
 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.)
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 signif-
icant 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
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.
to contribute upwarcl rotation torque. This muscle stili con-
tributes a needed retraction force on th scapula, which
along with th rhomboid muscles helps to balance th for-
midable 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 dis-
rupts 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
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 5-53. 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 pro-
duces a force that rotates th scapula upward. In th ab-
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.
Chapter 5 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 mo-
tion 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 weak-
ness 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, re-
search 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
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 musculo-
skeletal 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
Deltoid
Supraspinatus
Subscapularis
Infraspinatus
Teres minor
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 i-
t 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 il-
ity o f t h G H jo in t . 59
of th horizontally oriented supraspinatus produces a com-
pression force directly imo th glenoid fossa. The compres-
sion force stabilizes th humeral head frmly against th
fossa during its supenor roll (Fig. 5 - 5 5 ) . Compression
FIGURE 5-55. Anterior view of th right shoulder show-
ing 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 up-
ward. 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 supe-
rior translation. Note th internai moment arm used by
both th deltoid and supraspinatus.

The Vulnerability of th Supraspinatus
to Excessive Wear
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 -
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
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
times greater t h a n 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
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 physio-
logic 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 im-
pinge th humeral head superiorly against th coracoacro-
mial arch, thereby blocking complete abduction. This effect
is typically observed following a complete rupture of th
supraspinatus tendon. In addition to th compression pro-
duced 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
Chapter 5 Shoulder Complex 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 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
20
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 . "
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 con-
traction from th shoulders powerful adductor and exten-
sor 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 ster-
nocostal 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 crutch-
and 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 evi-
dent 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 teres major during a strongly resisted adduction The entire rotator cuff group is active during shoulder
effort of th shoulder. The pectoralis minor (Fig. 5 -4 3 B ) adduction and exiension.0 Forces produced by these mus-
and th latissimus dorsi fibers that attach to th scapula cles assist with th action directly or stabilize th head of th
assist th rhomboids in downward rotation. 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 de-
tails.) (TM = teres major, LD = laUssimus dorsi, IF =
infraspinatus and teres minor, PD = posterior deltoid, RB
= rhomboids).
 Chapter 5 Shoulder Complex 129

A Closer Look at th Posterior Deltoid Complete paralysis of th posterior deltoid can occur
owing to an overstretching of th axillary nerve. Persons
The posterior deltoid is a shoulder extensor and adductor.
with this paralysis frequently report difficulty in combining
In addition, this muscle is also th primary horizontal ex
full shoulder extension and horizontal extension, such as
tensor at th shoulder. Vigorous contraction of th poste
that required to place th arm in th sleeve of a coat.
rior deltoid during full horizontal extension requires that
th scapula is firmly stabilized by th lower trapezius (Fig.
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. Viking-
Penguin, 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
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
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.
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 direc-
tions on th convex humeral head (Fig. 5 - 6 0 ; inser).
EXTERNAL ROTATOR MUSCLES
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 rota-
tor cuff syndrome.24
Superior view

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 132 Seciion II Upper Exiremity

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 C h a p t e r 6

Elbow and Forearm Complex

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

TOPICS AT A GLANCE

OSTEOLOGY, 133 J o in t S tru c tu re and P e ria rtic u la r Innervation of Muscles and Joints of th
Mid-to-Distal Humerus, 133 C o n n e c tiv e T issu e , 146 Elbow and Forearm, 152
Ulna, 135 Proximal Radioulnar Joint, 146 Function of th Elbow Muscles, 157
Radius, 136 Distai Radioulnar Joint, 146 E lb o w F le xors, 157

ARTHROLOGY, 137 K in e m a tic s , 147 Individuai Muse le Action of th Elbow

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
Functional Considerations of Pronation Flexors, 157
and Supination, 147 Biomechanics of th Elbow Flexors,
Arthrokinematics at th Proximal and 158
Distai Radioulnar Joints, 149 Maximal Torque Production of th Elbow
Supination, 149 Flexor Muscles, 158
Pronation, 149 Elbow Extensors, 161
Pronation and Supination with th Muscular Components, 161
Radius and Hand Held Fixed, 150 Electromyographic Analysis of Elbow
Extension, 161
M USC LE A N D J O IN T IN TER AC TIO N , 151
Neuroanatomy OverView, 151
Torque Demands on th Elbow
P aths o f th M u s c u lo c u ta n e o u s , R adiai,
Extensors, 162
Function of th Supinator and Pronator
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,
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 Four Articulations Within th Elbow and Forearm

Complex
The elbow and forearm complex consists of three bones and
1. Humeroulnar joint
four joints (Fig. 6 - 1 ) . The humeroulnar and humeroradial
2. Humeroradial joint
joints form th elbow. The motions of flexion and extension 3. Proximal radioulnar joint
of th elbow previde a means to adjust th overall functional 4. Distai radioulnar joint
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
OSTEOLOGY
th forearm at th proximal and distai radioulnar joints. This
set of articulations allows th palm of th hand to be turned
Mid-to-Distal Humerus
up (supinated) or down (pronated), without requiring mo-
tion of th shoulder. Pronation and supination can be per- The anterior and posterior surfaces of th mid-to-distal hu
formed in conjunction with, or independent from, elbow merus provide proximal attachments for th brachialis and
flexion and extension. The interaction between th elbow th mediai head of th triceps brachii (Figs. 6 - 2 and 6 - 3 ) .
and forearm joints greatly increases th range of effective The distai end of th shaft of th humerus terminates medi-
hand placement. ally 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 resem-

bles 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 FIGURE 6 -2 . The antenor aspect of th righi humerus. The mus-
Olecranon fossa cles proximal attachments are shown in red. The dotted lines show
th capsular attachments of th elbow joint.
 Chapter 6 Elbow and Forearm Complex 135

Posterior view 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.

Ulna
The ulna has a very thick proximal end with distinct proc-
esses (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 ante-
rior 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 coro-
notd 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 mus- Trochlear groove
cle's proximal attachments are shown in red. The dashed lines show
th capsular attachments around th elbow joint. Lateral III

Capitulum

Lateral
epicondyle Mediai
ment of th mediai collateral ligament of th elbow as well
epicondyle
as th forearm pronator and wrist flexor muscles.
The lateral epicondyle of th humerus, less prominent than
Sulcus for ulnar nerve
th mediai epicondyle, serves as th proximal attachment for
th lateral collateral ligament of th elbow as well as th Olecranon fossa
forearm supinator and wrist extensor muscles. Immediately
proximal to both epicondyles are th mediai and lateral su- Posterior
pracondylar rdges. FIGURE 6-4. The distai end of th righi humerus, inferior view.
 136 Section 11 Upper Extremity

A nterior view Radius

In th fully supinated position, th radius lies paralld I
and lateral to th ulna (see Figs. 6 - 5 and 6 - 6 ) . The proxi
Trochlear notch mal end of th radius is small and as such constitutes a
Coronoid process relatively small structural component of th elbow. Its distai

Flexor digitorum
superficialis

Brachialis on
Posterior view
tuberosity of
Qlecranon proc,
th ulna
Triceps
Biceps on
bicipital tuberosity Pronator teres
(Ulnar head) Anconeus
Flexor digitorum
superficialis

Supinator

Flexor digitorum
Supinator
superficialis Flexor digitorum (proximal
(on oblique line) profundus attachment on
Flexor digitorum supinator crest)
profundus
----------Biceps
Pronator teres
Aponeurosis for:
Extensor carpi ulnaris
Flexor carpi ulnaris
Flexor digitorum profundus
Flexor pollicis longus

Interosseous
Pronator
membrane
Extensor pollicis longus teres

Pronator quadratus

Interosseous membrane

Extensor
Ulnar notch
pollicis
Extensor indicis
Brachioradialis brevis

FIGURE 6-5. The anterior aspect of th right radius and ulna. The
muscles proximal aitachments are shown in red and distai attach-
ments 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 concav-
ity of th fovea.

%o\d
ProceSS Sfyltd
Process
The ulnar head is located at th distai end of th ulna
FIGURE 6-6. The posterior aspect of th right radius and ulna. The
(Fig. 6 - 8 ) . Most of th rounded ulnar head is lined with
muscles proximal attachments are shown in red and distai attach-
articular cartilage. The pointed styloid (from th Greek root
ments in gray. The dashed lines show th eapsular attachments
stylos; pillar, + eidos; resembling) process projects distally around th elbow and wrist and th proximal and distai radioulnar
from th posterior-medial region of th extreme distai ulna. joints.

L ateral view
FIGURE 6-7. A lateral (radiai) view of th right proximal ulna, with
th radius removed. Note th jawlike shape of th trochlear notch.
end, however, is enlarged, forming a major part of th wrist
joint.
Osteologie Features of th Radius
Radiai head
Fovea
Bicipital tuberosiLy
Ulnar notch
Styloid process
The radiai head is a disclike structure located at th ex-
treme 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.
Chapter 6 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 humerora-
dial 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
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-
Styloid process Depression fo r
articular disc
Styloid process
Dorsal tuberete
Lateral 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 30 c * - M - wiih

longation of th mediai lip of th trochlea. lhe asymmetry

The articular capsule of th elbow is strengthened by an
in th trochlea causes th ulna to deviate laterally relative to
extensive set of collateral ligaments (Table 6 - 1 ) . These liga-
th humerus. The naturai frontal piane angle made by th
ments provide an important source of stability to th elbow
extended elbow is referred to as cubitus valgus. (The term
joint. The mediai collateral ligament consists of anterior, pos-
carrying angle is often used, reflecting th fact that th
terior, and transverse fiber bundles (Fig. 6 - 1 2 ) . The anterior
valgus angle tends to keep carried objects away from th
fibers are th strongest and stiffest of th mediai collateral
side ol th thigh while walking.) In full elbow extension, th
ligament. 1 As such, these fibers provide th most signiftcam
normal carrying angle is about 15 degrees.45
resistance against a valgus (abduction) force at th elbow.
Occasionally, th extended elbow may show an excessive
l he anterior fibers arise from th anterior part of th mediai
cubitus valgus greater than 20 degrees (Fig. 6 -9 B ). In con
epicondyle and msert on th mediai part of th coronoid
tras!, th forearm may less cotnmonly show a cubitus varus
process of th ulna. The majority of th anterior fibers be-
deformity, where th forearm is deviateci toward th midiine
come taut near full extension.13 A few fibers, however, be-
(Fig. 6 -9 C ). Valgus and varus are terrns derived from th
come taut at full flexion. The anterior fiber bundle as a
Latin turned outward (abducted) and tumed inward (ad-
whole, therefore, provides articular stability throughout th
ducted), respectively.
entire range of motion.8
The posterior fibers ol th mediai collateral ligament attach
PERIARTICULAR CONNECTIVE TISSUE on th posterior part of th mediai epicondyle and insert on
th mediai margin of th olecranon process. The posterior
The articular capsule o f th elbow encloses three different
fibers become taut in th extremes of elbow flexion.13-41 A I
articulations: th humeroulnar joint, th humeroradial joint,
third and poorly developed set of transverse fibers of th I
and th proximal radioulnar joint (Fig. 6 - 1 0 ) . The capsule
mediai collateral ligament cross from th olecranon io th ]
is thin and reinforced anteriorly by oblique bands of fibrous
coionoid process of th ulna. Because these fibers originate I
tissue. A synovial membrane lines th internai surface of th
and insert on th same bone, they do not provide significant
capsule (Fig. 6 - 1 1 ) .
articular stability.
 Chapter 6 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
FIGURE 6-10. An anterior view of th right elbow showing th
th proximal radioulnar joint is shown within th elbows capsule.
capsule and collaieral ligaments.
Note th small area on th trochlear notch lacking articular carti-
lage. The synovial membrane lining th internai side of th capsule
is shown in red.

The lederai collateral ligament of th elbow is less delined

and more variable in form than th mediai collateral liga- T AB L E6 - 1. Ligaments of th Elbow and Motions
rnent (Fig. 6 - 1 3 ) .27 The ligament orginates on th lateral that lncreasc Tension
epicondyle and immediately splits into two ftber bundles.
Ligaments M otions that Increase Tension
One fiber bundle, traditionally known as th radiai collateral
ligament, fans out to blend with th annular ligament. A Mediai collateral ligament
second fiber bundle, called th lateral (ulnar) collateral liga (anterior fibers*) Valgus
ment, attaches distally to th supinator crest of th ulna. Extension and io a lesser extern
These fibers become taut at full (lexion.41 flexion
All th fibers of th lateral collateral ligament and th
Mediai collateral ligament
posterior-lateral aspect of th capsule stabilize th elbow (posterior fibers) Valgus
against a varus-directed force.36 By attaching to th ulna, th Flexion
lateral (ulnar) collateral ligament and th anterior fibers of
Lateral collateral ligament
th mediai collateral ligament function as collateral guy-
(radiai collateral com-
wires to th elbow, stabilizing th path of th ulna during
ponent) Varus
sagittal piane motion.
The ligaments around th elbow are endowed with Lateral collateral ligament
mechanoreceptors, consisting of Golgi organs, Ruffini termin- (lateral (ulnar) collat
eral component*) Varus
als, Pacini corpuscles, and free nerve endings.38 These re-
Flexion
ceptors may supply important information to th ner-
vous System for augmenting proprioception and detecting Annular ligament Distraction of th radius
safe limits of passive tension in th structures around th
elbow. * 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 func-
ttons 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 mde-
pendence. Persons with a spinai cord injury above th C5
nerve root have this profound disability due to total paralysis
ol elbow (lexor muscles,
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-
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 mdi-
cates, however, that several common activities of daily liv-
tng 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 im-
pairment.
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

Lateral aspect

Annidar ligament

Radiai FIGURE 6 13. The components of th lateral collateral

collateral ligament ligament ol th right elbow.
Lateral
collateral ligament Radius
Lateral (ulnar)
collateral ligament

Ulna

Supinator crest
 Chapter 6 Elbow and Forearm Complex 141

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
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 immo-
bilization, 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 sur-
face 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, par-
ticularly th broad tendon of th brachialis. The prominent
tip of th olecranon process becomes wedged into th olec-
ranon 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 sur-
face of th trochlear notch rolls and slides on th convex
trochlea (see Fig. 6 17J3). Full passive elbow flexion re-
quires 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 cup-
like 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 tissues at th proximal and distai radioulnar joints also
physical contact exists at th humeroradial jo in t.17 During transfer a portion of th compression force from th radius
attive flexion, however, muscle contraction pulls th radiai to th ulna.
fovea against th capitulum.30 The arthrokinematics of flex Most elbow flexors, and essentially all th major supinato: I
ion and extension consist of th fovea of th radius rolling and pronator muscles, have their distai attachments on th
and sliding across th convexity of th capitulum (Fig. radius. Contraction of these muscles, therefore, pulls th
radius proximally against th humeroradial joint.44 An addi-
Compared with th humeroulnar joint, th humeroradial tional function of th interosseous membrane, therefore, is to I
joint provides minimal structural stability to th elbow. The
humeroradial joint does, however, provide an important
bony resistance against a valgus force.31
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 be-
tween 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
FIGURE 6 - 1 6 . A sagittal seclion through th humeroulnar joint
wrist to cross th elbow via th humeroulnar joint, thereby
showing th well-ftting joint surfaces between th trochlear notch
reducing th amount of force thai must cross th limited and trochlea. The synovial membrane lining th internai side of th
surface area of th humeroradial joint.30 The periarticular capsule is shown in red.
 Chapter 6 Elbow and Forearm Complex 143

FIGURE 6-17. A sagittal seciion through th hu-

meroulnar 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 elon-
gated 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 slack-
ens 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 receive-

a 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 pitch-
ing 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 FIGURE 6 - 2 1 . Holding a load, such as a suitcase, places a distal-
through th forearm. directed 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
TRAUMATIC CAUSES OF ELBOW JOINT INSTABILITY cord, th annular ligament, and th brachioradialis, must assist with
th support of th load. The stretched (taut) structures are shown
Injury to th collateral ligaments of th elbow can result in
as thin elongated arrows, and th slackened structures are shown as
marked elbow instability. The mediai collateral ligament is wavy arrows.

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 capitu-
lum.
A posterior dislocation of th humeroulnar jomt.
FIGURE 6 - 2 3 .
(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 Educa-
tion and Research.)
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 rota-
tion 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 hu-
merus. 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.
Anterior view of th right forearm. A, In full supina
FIGURE 6 - 2 4 .
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.
 146 Section II Upper Extremity

In th anatomie position, th forcami is fully supinated

structural support to th capsule of th proximal radioulr
when th ulna and radius lie parallel to one another (Fig. joint.
6 -2 4 A ). During pronation, th distai segment of th forearm
complex (i.e., th radius and hand) rotates and crosses over Distai Radioulnar Joint
an essentially fixed ulna (Fig. 6 -2 4 B ). The ulna, through its
The distai radioulnar joint consists of th convex head of t
firm attachment to th humerus al th humeroulnar joint,
ulna fittmg imo a shallow concavity formed by th ulr.,
remains essentially stationary during pronation and supina-
notch on th radius and th proximal surface of an articul
tion movements. A stable ulna provides an important rigid
disc (Fig. 6 -2 7 A ). This important joint stabilizes th disi;
link that th radius, wrist, and hand can pivot upon. Only forearm during pronation and supination.
very sltght motion occurs in th ulna during supination and
1 he articular disc at th distai radioulnar joint is alsc 1
pronation .3 The ulna tends to rotate slightly in th frontal
known as th triangular fibrocartilage, indicating its shape I
piane during active pronation and supination; toward abduc-
and predominant tissue type. As depicted in Figure 6 -2 7 A ,
tion (valgus) during pronation, and toward adduction (varus)
the lateral side ol th disc attaches along th entire rim t .
during supination. Other than design of an elbow prosthesis,
th ulnar notch of the radius. The main body of the disi
this slight accessory movement of th ulnar is clinically in
fans out horizontally imo a triangular shape, with its apec
signi ficant.
attaching medially imo the depression on the ulna head anc I
adjacent styloid process. The anterior and posterior edges of
JOINT STRUCTURE AND PERIARTICULAR the disc are continuous with the palm ar (anterior) and dorsci
CONNECTIVE TISSUE (posterior) radioulnar joint capsular ligaments (Fig. 6 - 2 7 A anc
B) The proximal surface of the disc, along with the attachec
Proximal Radioulnar Joint capsular ligaments, holds th head of the ulna snugly against
The proximal radioulnar joint, th humeroulnar joint, and the ulnar notch of the radius.33
th humeroradial joint all share one articular capsule. Within Introduction to the Ulnocarpal Complex
this capsule, th radiai head is held against th proximal
The articular disc is pari of a larger set of connective tissue
ulna by a ftbro-osseous ring. This ring is formed by th
known as the ulnocarpal complex. 3'-42 This complex is ofter i
radiai notch of th ulna and th annular ligament (Fig.
referred to as the triangular fibrocartilage complex. The ulno
6 -2 5 A ). About 75% of th ring is formed by th annular
carpai complex occupies most of the space between tht
ligament and 25% by th radiai notch of th ulna.
distai end ol the ulna and the ulnar side of the carpai bones
Ihe annular (from th Latin annulus; ring) ligament is
Several wrist ligaments, such as the ulnar collateral ligament
a thick circular band of connective tissue, attaching to
are included with this complex (see Fig. 6 - 2 7 B). The ulno
th ulna on either side of th radiai notch (Fig. 6 - 2 5 B).
carpai complex is the primary stabilizer of the distai radioul
The ligament fits snugly around th radiai head, holding
nar joint, particularly important during the dynamics of pro
th proximal radius against th ulna. The internai circum-
nation and supination. Other structures that provide joim
ference ot th annular ligament is lined with cartilage to
stability are the pronator quadratus, joint capsule, tendon of
reduce th friction against th radiai head during prona
the exiensor carpi ulnaris, and interosseous membrane. Tears
tion and supination. The external surface of th ligament re-
or disruptions of the ulnocarpal complex, especially the disc.::
ceives attachments from th elbow capsule, th radiai collat-
may cause complete dislocation or generalized instability ol
eial ligament, and th supinator muscle. The quadrate
the distai radioulnar joint, making pronation and supination
ligament is a short, stout ligament that arises just below th
motions, as well as motions of the wrist, painful and difficuli
radiai notch of th ulna and attaches to th mediai surface of
to perform .11 (The ulnocarpal complex is discussed further
th neck of th radius (Fig. 6 -2 5 B ). This ligament lends in Chapter 7).

Radiai notch
Radiai notch (on ulna) Olecranon process
(with cartilage) Olecranon
Fovea process

Annular ligament
Radiai
(with cartilage)-
collateral
ligament (cut) - -A rticu la r su dace on
trochlear notch
Annular ligament -

w U
w ;ju TO'v i Quadrate ligament (cut)
TO /
i 3 M / 3 i _C /
CD /
r f 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 Elbow and Forearm Complex 147

Dislocations of th Proximal Radioulnar Joint: The this "pulled-elbow" syndrome due to ligamentous laxity
"Pulled-Elbow" Syndrome and increased likelihood of others pulling on their arms
(Fig. 6-26). One of th best ways to prevent this disloca
A strenuous pul on th forearm through th hand can
tion is to explain to parents how a sharp pul on th
cause th radiai head to slip through th distai side of th
child's hand can cause such a dislocation.
annular ligament. Children are particularly susceptible to
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) Functional Considerations of Pronation and Supination
Joint capsule
Forearm supination occurs during many activities that in-
Pronator quadratus
Tendon of th extensor carpi ulnaris volve rotating th palmar surface of th hand toward th
Interosseous membrane 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
Ulnar collateral ligament (cut) Palmar capsular
ligament

Articular disc (proximal surface) Ulnar collateral

Palmar capsular ligament ligament (cut)

Scaphoid facet Lunate facet Articular disc

(distai surface)

anftenorrvew of lhf n8hl dislal radioulnarjoint. A, The ulnar head has been pulled away from che concaviiy formed
n t n f^ | mMSUrr frlhn artlCUf ^ SC and,lhe Ulnar notch of the radius- B The dlslal forearm has been tilted slightly io expose
an ndL Hi, r 1 u ^ and ]t\ c0ecl10 * e palmar capsular ligament of the disiai radioulnar joint. The
articular disc (also called th tnangular fbrocartilage), the capsular hgaments, and the ulnar collateral ligament are collectively referred
hv lnocarpal con,plex- See text for further descriptions. The scaphoid and lunate facets on the distai radius show impressici
made by these carpai bones at the radiocarpal joint of the wrist. 1

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> g

o 20
Q
Supination
40

60

80

B 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 F.Ibow and Forearm Complex 149

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 move-
ment at both proximal and distai radioulnar joints. A restric-
uon at one joint limits motion at th other.
Supination
Supination at th proximal radioulnar joint occurs as a spin-
ning 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 de-
fcribed for supination (Fig. 6 - 3 0 ) . As depicted in th top
inset of Figure 6 - 3 0 , full pronation maximally elongates th
dorsal capsular ligament at th distai radioulnar joint, as th
palmar capsular ligament slackens to about 70% of its origi
nai length .44 Full pronation exposes th articular surface of
S P E C I A L F O C U S 6 - 3
A
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 rota-
tions 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 epicon-
dyle 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 supina-
lion. 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 Lateral
as wavy arrows. See text for further
details.
 150 Section II Upper Extremity

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
Styloid process
tn gray). The inacttve but stretched bieeps mus. J
Distai Kadioulnar Joint from Above is also shown. As viewed in Figure 6 -2 9 , th n ijf
insets show a superior view of th arthrokineraJ
Anterior 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

Pronation and Supination with th Radius and Hand Held
6 - 2.
Fixed
Humeroradial Joint: A "Shared" Joint Between th Elbow
L'p to this point, th kinematics of pronation and su p in a ticJ
and th Forearm
are described as a rotation of th radius and hand relative to
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 capitu-
lum 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 mo-
tion at th humeroradial joint. A limitation of motion at th Mediai
humeroradial joint can therefore disrupt both flexion and epicondyle
extension and pronation and supination.

TABLE 6 - 2 Structures that can Restrict

Supination and Pronation

Limit Supination Limit Pronation

Pronator teres, pronator
quadratus
Palmar capsular ligament at
th distai radioulnar joint20
Oblique cord, interosseous
membrane, and quadrate
ligament719
Ulnocarpal complex
Bieeps or supmator muscles
Dorsal capsular ligament at th
distai radioulnar joint
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:
Ulnocarpal complex
is cotncident with th axis of rotation through th proximal ra-l
dioulnar joint.
 Chapter 6 Elbow and Forearm Complex 151

; 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 ex-
tremity 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 struc-
tural 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 rota-
non 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 posi-
uon. 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-
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 arthrokine-
matics 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 ac-
tive 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
Non-weight-bearing
Weight-Bearing (Radius and Hand
(Radius and Hand Fixed) Free to Rotate)
Proximal Annular ligament and ra- Radiai head spins
Radioulnar
diai notch of th ulna withm a ring
Joint spin around a fixed ra
formed by th
diai head.
annular ligament
and th radiai
notch of th ulna.
Distai Convex ulnar head rolls Concavity of th ul-
Radioulnar and slides in opposite
nar notch of th
Joint direetions on th con radius rolls and
cave ulnar notch of th slides in similar
radius. direetions on th
convex ulna
head.
The anatomie path of these nerves is described as a founda-
tion 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 supi-
nator 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 attach-
ing 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 i-
bers 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 tim-
cian 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 miru-
mizes 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 bre-
chii 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 ac-
tivities 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 el-
dow , wrist, and hand. The fol-
lowing illustrate th path and
cenerai proximal-to-disial order
muscle innervaiion. The loca-
~n of some muscles is altered
htly (or iilustration purposes. Biceps brachii-
primary roots for each nerve
shown in parentheses. (A to
modified with permission from
~root J: Correlative Neuroanat-
21 st ed. Norwalk, Appleton
Lange, 1991. Photograph by
ld A. Neumann.) A, The
of th righi musculo-
neous nerve is shown as il
~rvates th coracobrachialis,
:ps brachii, and brachialis
Axillary nerve
cles. The sensory distribution
shown along th lateral fore- Lateral antebrachial
The motor and sensor)' cutaneous nerve
ponents of th axillary ner\'e
also shown.

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 Elbow and Forearm Compex 155

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) Flexor-Pronator Group
tlexors of th digits (except th
flexor digitorum profundus lo
th ring and little finger), most
mtrinsie muscles io th thumb, Pronator teres
and two lateral lumbricals. The
sensory distribution is shown Flexor carpi radialis
with tts area of concentrated sup-
ply along th distai end of th
Palmaris longus
index and middle fingere. Inset,
The median nerve supplies th
sensation of th skin thal natu Flexor digitorum superficialis
rali) makes contact in a pinching
motion between th thumb and Flexor pollicis longus
fingere.

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
o Area of concentrateti supply
Mediai cord

Scnsory D istrihution

Median nerve
Ulnar nerve

Mediai epicondyle

Flexor carpi ulnaris

See Cutaneous branches

Flexor digitorum
median
profundus (medial-half)
nerve
Palmaris brevis

Abductor digiti minimi

Opponens digiti minimi

Flexor digiti minimi

O D o rs a l interassei (4)
See median nerve Palmar interassei (4)
n r iio c c O Lu m brica ls (medial-half)

SENSORY INNERVATION TO JOINTS

Humeroulnar Joint and Humeroradial Joint
The humeroulnar and humeroradial joints and th surround-
ing 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 Elbow and Forearm Complex 157

TABLE 6 - 4 . Motor Innervation to th Muscles of elbow joint. For this reason, many of th wrist muscles have
th Elbow and Forearm a potential to flex or extend th elbow.3 This potential is
relatively minimal and is not discussed further. The anatomy
Muscle Innervation and nerve supply of th muscles of th elbow and forearm
can be found in Appendix IIC.
Elbow flexors
Brachialis Musculocutaneous nerve (C5-6)
Biceps brachii Musculocutaneous nerve (C5-6) ELBOW FLEXORS
Brachioradialis Radiai nerve (C5-6)
Pronator teres Median nerve (C6J) The biceps brachii, brachialis, brachioradialis, and pronator
teres are primary elbow flexors. Each of these muscles pro-
Elbow extensors duces a force that passes anterior to th medial-lateral axis of
Triceps brachii Radiai nerve (C7-8)
rotation at th elbow. Structural and related biomechanical
Anconeus Radiai nerve (C7-8)
variables of these muscles are included in Table 6 - 5 .
Forearm supinators
Biceps brachii Musculocutaneous nerve (C56) Individuai Muscle Action of th Elbow Flexors
Supinator Radiai nerve (C6)
The biceps brachii attaches proximally on th scapula and
Forearm pronators distally on th bicipital tuberosity on th radius (Fig. 6 - 3 4 ) .
Pronator quadratus Median nerve (C8, Tl) Secondar)' distai attachments are made into th deep fascia
Pronator teres Median nerve (C67)
of th forearm through an aponeurotic sheet known as th
fibrous acertus.
The primary nerve root innervation of th muscles are in parenthescs.
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
th median nerve.51 The distai radioulnar joint receives most flexion is performed with th forearm deliberately held in
of its sensory innervation from th C8 nerve root within th pronation. This lack of muscle activation can be verified by
alnar nerve.18 self-palpation.
The brachialis muscle lies deep to th biceps, originating
Function of th Elbow Muscles on th anterior humerus and attaching distally on th ex-
treme proximal ulna (Fig. 6 - 3 5 ) . According to Table 6 - 5 ,
Muscles that attach distally on th ulna flex or extend th th brachialis has an average physiologic cross-section of 7
elbow, with no ability to pronate or supinate th forearm. In cm! , th largest of any muscle Crossing th elbow. For com-
contrast, muscles that attach distally on th radius may, in parison, th long head of th biceps has a cross-sectional
theory, flex or extend th elbow, but also have a potential to area of only 2.5 cm2. Based on its large physiologic cross-
pronate or supinate th forearm. This basic concept serves as section, th brachialis is expected to generate th greatest
th underlying theme through much of th remainder of this force of any muscle Crossing th elbow.
chapter. The brachioradialis is th longest of all elbow muscles,
Muscles that act primarily on th wrist also cross th attaching proximally on th lateral supracondylar ridge

TABLE 6 - 5 . Structural and Related Biomechanical Variables o f th Primary Elbow Flexor Muscles*

Contraction
Work Capacity Excursion Peak Force Leverage

P h y sio lo g ic
C r o s s - s e c tio n a l In te r n a i M om en t
M u scle V o lu m e (cm 3) L e n g th (cm ) f A r e a (cm 2) 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
Brachialis 59.3 9.0 7.0 1.98
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 brachio-

radialis 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 Elhow and Forearm Complex 159

S P E C I A L 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 meas-
ured 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 FIGURE 6 - 3 7 .A lateral view showing th line-of-force of three
slow, or combined with pronation or supination. Since primary elbow flexors. The internai moment arm (shown as dark
th brachialis attaches distally to th ulna, th motion lines) for each muscle is drawn to approximate scale. Note that th
of pronation or supination has no influence on its elbow has been flexed about 100 degrees, placing th biceps ten-
length, line-of-force, or internai moment arm. don 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.

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 mid-
dle-aged persons. (Table 6 6 ).4 As noted in Table 6 - 6 ,
Brachioradialis
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 dif-
ference 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 pre-
dict 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 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 fore-
arm. 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.
The righi brachioradialis muscle is shown bow-
GURE 6 - 3 6 . Conversions: .098 N-m/kg-cm.
sringing over th elbow during a maximal effort isometric activa- (Data from Askew 1.J, An KN, Morrey BF, et al: Isometric elbow strength
non. 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 oc-
curs at about 90 degrees of flexion, which agrees in generai
with actual torque measurements made on healthy per-
sons.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 oc-
curs 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
Flexor Torque vs Elbow Joint Angle
I k b Y
A Elbow Joint Angle (degrees)
Flexor Moment Arm vs Elbow Joint Angle
90 degrees (see Fig. 6 - 3 7 ) . This mechanical condition maxi-
mizes 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.
k
\-
i i V
B Elbow Joint Angle (degrees)
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-ten-
sion relationship, and internai moment arm. B, The length-ten-
sion relationships of th three muscles are shown as a normal-
ized 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.)

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
I 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 ex-
I ampie in Figure 6 - 3 9 C , combining elbow flexion with
I shoulder extension reduces th average contraction veloc-
I 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
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 con-
traction 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 contrac-
ion of th posterior deltoid, th biceps shortened only 5 cm, at a
contraction velocity of only 5 cm/sec.
Chapter 6 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 at-
taching 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 span-
ning th postenor side of th elbow. The muscle is lo-
cated 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 cross-
sectional area and a small moment arm for extension (see
Table 6 - 7 ) .
Electromyographic Analysis of Elbow Extension
Maximal effort elbow extension generates maximum levels of
EMG from all components of th elbow extensor group.
During submaximal efforts of elbow extension, however, dif-
ferent 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
K 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 per-
formed 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
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 par-
tially flexed. The extensors stabilize th flexed elbow through
extremity muscles, but near normal strength of th shoul-
der, 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 mid-
level (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 move-
ment. The anterior capsule is in a
slackened position, and th posterior
capsule is taut.
isometric contraction or very low-velocity eccentric activa-
tion. 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 ex-
plosive pushing activities, elbow extension is typically com-
bined with some degree of shoulder Uexion (Fig. 6 - 4 3 ) . The
shoulder flexion function of th anterior deltoid is an im-
portant synergistic component of th forward push. The an-
 Chapter 6 Ebow and Forcam i Complex 163

FIGURE 6-4 2 . A posterior view shows ihe righi mediai head of ihe
GURE 6 -4 1 .A posterior view of th right triceps brachit and triceps brachii The long head and lateral head of th triceps are
fico neus muscles. The mediai head of th triceps is deep to th partially removed to expose th deeper mediai head,
mg and lateral heads and therefore not visible.

TABLE 6 - 7 . Strutturai and Related Biomechanical Variables of th Primary Elbow Extensor Muscles*

C ontraction
W ork Capacity E xcursion Peak Force Leverage

P h y sio lo g ic
C r o s s -s e c tio n a l In te rn a i M om en t
M uscle V o lu m e (cm J) L e n g th (cm ) t A r e a (c m 2) 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
Anconeus 6.7 2.7 2.5 .72

* 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.
Supinator versus Biceps Brachii
The supinator muscle has a complex proxtmal muscle attach-
ment (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 elon-
gated 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 ac-
cord with th law of parsimony described earlier in this
chapter.) Only during moderate or high-power supination
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 bicep-
action 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-
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
FIGURE 6-48. The EMG signal from four
Pronator Teres
muscles during three levels of active supi
nation. The minimal EMG activity shown
tor Quadratus
by th pronator muscles during high-
power supination may reflect low level ec-
centric activity from these muscles. (Modi-
Moderate-Power High-Power fied from Basmajian JV: Muscles Alive.
Their Functions Revealed by Electromyog-
Supinator raphy, 4th ed. Baltimore, Williams & Wil-
kins,' 1978.)
Biceps

Pronator Teres

Pronator Quadratus

Elbow Flexed 90

= ^ l___________
T30= By x IMA
T30 = (sine 30" x 500 N) x IMA
T30 = 250 N x 1 cm
T3o = 250 Ncm

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 effective-
ness 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 perpen-
dicular 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.

-URE 6-51, Anterior view of th right pronator teres and prona-
: quadratus.
When high-power supination torques are needed to vigor-
ly 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 poten-
of 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 antago-
s.
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 extrin-
sic fnger flexors. This fiat, quadrilateral muscle attaches be-
tween 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
a S P E C I A L F O C U S
A Return to th Law of Parsimony
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 as-
sistance from th biceps and pronator teres. Each time
th polyarticular muscles are recruited, however, addi-
tional 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 roll-
and-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 es-
sentially lost. The forearm tends to remain chronically supi-
nated owing to th unopposed action of th innervated supi-
nator 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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lar fibrocartilage complex cause dista) radioulnar joint instability after
distai radiai fractures. j Hand Surg 25A:464-468, 2000.
24. MacConaill MA, Basmajian JV: Muscles and Movements: A Basis for
Human Kinesiology. New York, Robert E. Krieger, 1977.
25. Maloney MD, Mohr KJ, E1 Attrache NS: Elbow injures in th throwing
athlete. Clin Sports Med 18:795-809, 1999.
26. Morrey BF: Post-traumatic contracture of th elbow: Operative treat
ment including dtstraction arthroplasty. ) Bone Joint Surg 72A:601-
618, 1990.
27 Morrey BF, An KN: Funcnonal anatomy of th ligaments of th elbow.
Clin Onhop 201:84-90, 1985.
28. Morrey BF, Askew LJ, An KN, et al: A biomechanical study of normal
functional elbow motion. J Bone Joint Surg 63A:872-876, 1981.
29. Morrey BF, Chao EY: Passive motion of th elbow joint. J Bone Joint
Surg 58A:501-508, 1976.
30. Morrey BF, An KN, Stormont TJ: Force transmission through th radiai
head. J Bone Joint Surg 70A:250-256, 1988.
31. Morrey BF, Tanaka S, An KN: Valgus stability of th elbow. Clin
Orthop 265:187-195, 1991.
32. Murray WM, Delp SL, Buchanan TS: Variation of muscle moment arms
with elbow and forearm positions. J Biomech 28:513-525, 1995.
33. Nakamura T, Yabe Y, Horiuchi Y: Dynamic changes in th shape of th
triangular fibrocartilage during rotalion demonstrated with high resolu
tion magnetic resonance imaging. J Hand Surg 24B:338-341, 1999.
34. Neumann DA: Use of th diaphragm to assist in rolling in th patient
with quadriplegia. Phys Ther 59:39, 1979.
35. Neumann DA, Soderberg GL, Cook TM. Electromyographic analysis of
hip abductor musculature in healthy right-handed persons. Phys Ther
69:431-440, 1989
36. Olsen BS, Sojbjerg JO, Dalstra M, et al: Kinematics of th lateral liga-
mentous conslrainls of th elbow joint. J Shoulder Elbow Surg 5:333-
341, 1996.
37. Palmer AK, Werner FW: Biomechanics of th distai radioulnar joint.
Clin Orthop 187:26-35, 1984.
38. Peirie S, Collins JG, Solomonow M, et al. Mechanoreceptors in th
human elbow ligaments. J Hand Surg 23A:512-518, 1998.
39. Pfaeffle HJ, Fischer KJ, Manson TT, et al: Role of th forearm interos-
seous ligament: Is it more than just longitudinal load transfer? J Hand
Surg 25A:683-688, 2000.
40 Provins KA, Salters N: Maximum torque exerted about th elbow joint.
J Appi Phys 7:393-398, 1955
41. Regan WD, Korinek SL, Morrey BF, et al: Biomechanical study of
ligaments around th elbow joint. Clin Orthop 271:170-179, 1991.
Chapter 6 Elbow and Forearm Complex 171
42. Schuind FA, An KN, Berglund L, et al The distai radioulnar joint
ligaments: A biomechanical study. J Hand Surg 16A:1106-1114, 1991,
43. Schuind FA, Linscheid RL. An KN, et al: Changes in wrist and forearm
configuration with grasp and isometric contraction of elbow flexors. J
Hand Surg 17A:698-703, 1992.
44. Schuind FA, Goldschmidt D, Bastin C, et al: A biomechanical study of
th ulnar nerve at th elbow. J Hand Surg 20B:623-627, 1995.
45. Stokdijk M, Meskers CGM, Veeger HEJ, et al: Determination of th
optimal elbow axis for evaluation of placement of prosthesis. Clin Bio
mech 14:177-184, 1999.
46. Stuart PR: Pronator quadratus revisited. J Hand Surg 21B:714-722,
1996.
47. Travili A, Basmajian JV: Electromyography of th supinators of th
forearm Anat Ree 130:557-560, 1961.
48. Travili AA: Electromyographic study of th extensor apparatus. Anat
Ree 144:373-376, 1962.
49. Tsunoda N, OHagan F, MacDougall JD: Elbow (lexion strength curves
in untrained men and women and male bodybuilders. Eur J Appi
Physiol 66:235-239, 1993.
50. Van der Heijden EP, Hillen B: A two-dimensional kinematic analysis of
th distai radioulnar joint. J Hand Surg. 21B:824-829, 1996.
51. Williams PL, Bannister LH, Berry M, et al: Grays Anatomy, 38th ed.
New York, Churchill Livmgstone, 1995.
52. Winters JM, Kleweno DG: Effect of initial upper-limb alignmenl on
muscle contributions to isometric strength curves. J Biomech 26:143-
153, 1993.
53. Youm Y, Dryer RF, Thambyrajah K, et al: Biomechanical analysis of
forearm pronation-supination and elbow flexion-extension. J Biomech
12:245-255, 1979.
ADDITIONAL READINGS
Bade H, Koebke J, Schluter M: Morphology of th articular surfaces of th
distai radio-ulnar joint. Anat Ree 246:410-414, 1996.
Davidson PA, Pink M, Perry J, et al: Functional anatomy of th flexor
pronator muscle group in relation to th mediai collateral ligament of
th elbow. Am J Sports Med 23:245250, 1995.
Eckstein F, Lohe F, Hillebrand S, et al: Morphomechanics of th humero-
ulnar 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 ap-
pearance on coronai three-dimensional gradient-recalled-echo MR m-
ages. Radiology 195:521-527, 1995.
 C h a p t e r 7

Wrist
Donald A. Neum ann , P hD, PT

TOPICS AT A GLANCE
OSTEOLOGY, 172 Kinematics of Wrist Motion, 179 F u n ctio n o f th W r is t E xte n so rs, 187
Distai Forearm, 172 O s te o k in e m a tic s , 179 Muscular Anatomy, 187
Carpai Bones, 173 A rth ro k in e m a tic s , 180 Wrist Extensor Activity While Making
Carpai Tunnel, 176 Wrist Extension and Flexion, 181 a Fist, 188
ARTHROLOGY, 176 Ulnar and Radiai Deviation of th F u n ctio n o f th W r is t F le xors, 189
Joint Structure and Ligaments of th Wrist, 182 Muscular Anatomy, 189
Wrist, 176 Carpai Instability, 184 Functional Considerations of th Wrist
J o in t S tru c tu re , 176 MUSCLE A N D J O IN T IN TER AC TIO N , 186 Flexors, 190
Radiocarpal Joint, 177 Innervation of th Wrist Muscles and F u n ctio n o f th R adiai and U ln a r
Midcarpal Joint, 177 Joints, 186 D e v ia to rs , 191
W r is t Lig a m e n ts, 177 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 con-
sidered 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 inter-
changeably throughout this chapter and th next chapter on
th hand.
172
OSTEOLOGY
Distai Forearm
The dorsal surface of th distai radius has several grooves
and raised areas that help guide many tendons of extrinsic
muscles (Fig. 7 - 2 ) . For example, th palpable dorsal (or
Lister's) tu barle separates th tendons of th extensor carpi
radialis brevis from th extensor pollicis longus.
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

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
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.
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, trape-
zoid, 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
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 de-
scription of each carpai bone. The ability io visualize each
Dorsal view
 174 Section II Upper Extremity
Pai m ar view
Flexor carpi ulnaris
Marnate with hook
Pisiform
Flexor carpi ulnaris
Triquetrurrv
Styloid process
Pronator quadratus
bones relattve position and shape is helpful in an under-
standing 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
A Anterior view
Flexor carpi radialis
-Trapezoid
Abductor pollicis longus
FIGURE 7-3. The palniar aspect of th bones of
Trapezium
th righi carpus. The muscles proximal attach-
Tubercles menis are shown in red and distai atiachments
Distai and in gray. The dashed lines show th proximal
proximal poles of scaphoid aitachment of th palmar capsule of th wrist.
Styloid process
Groove for extensor pollicis longus
and abductor pollicis longus
Brachioradialis
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 Wrist 175

FIGURE 7-5. A view through th

carpai tunnel of th right wrist with
all contenta removed The transverse Hamate with hook
carpai ligament is shown as th roof Trapezium with tubercle
of th tunnel. Pisiform

Groove fo r flexor carpi radialis

Scaphoid tubercle
Triquetrum
Trapezoid
Capitate

Scaphoid

LUNATE
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 appear-
ance (see Fig. 7 - 3 ) . This articular surface accepts two con-
vexities: th mediai half of th head of th capitate and pari
of th apex of th hamate.
TRIQUETRUM
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 Prestyloid recess

right wrist and distai forearm showing th shape of th collateral ligament
bones and connective tissues. 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, signifi-
cantly 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 in-
volve immobilization by casting. In more advanced
cases, th ulna may be surgically lengthened in order
to reduce th compression at th radiocarpal joint. Al-
ternatively, th radius may be surgically shortened to
accomplish th same unloading effect.28 The scaphoid,
trapezium, and trapezoid may also be fused to add sta-
bility 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 de-
rived from th Latin root meaning head, which describes th
shape of th bones proximal surface. The large head articu-
lates 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 asym-
metric 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 ten-
don 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 inter-
catpa 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. Neverthe-
less, it is important to th completion of full range of wrist
motion.
 Chapter 7 Wrist 177

The midcarpal joint can be divided into mediai and lat-

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 ex-
tended 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.
eral 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 essen-
tial to maintaining naturai intercarpal alignment and transfer-
ring 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 vulnera-
ble 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)

Scaphoid
Articular Radiai collateral ligament (cut)
Lunate (proximal pole)
Scapholunate ligament Scaphoid
Dorsal capsular ligament
Lunate
Scaphotrapezial ligament (cut)
Ulnar collateral
ligament (cut) Radiai collateral ligament (cut)

Triquetrum Trapezium

Scaphotrapezial
ligament (cut)

Head of capitate

Mediai compartment
M idcarpal jo in t |
3 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

TA B LE7 - 1. Extrinsic and Intrinsic Ligaments of palmar surface of several carpai bones. The palmar radiocar
th Wrist pal ligaments are much stronger and thicker than th dorsal
radiocarpal ligaments. Significant tension exists in these liga
E xtrinsic Ligaments ments even in th relaxed neutral wrist position.36 In gen
erai, th palmar radiocarpal ligaments become maximally
Dorsal radiocarpal ligament taut al full wrist extension.30
Radiai collateral ligament A complex set of connective tissues exists near th ulnar
border of th wrist known as th ulnocarjral complex. Thts
Palrnar radiocarpal ligam ents
group of connective tissue is often referred to as th triangu-
Radiocapitate
Radiolunate lar fbrocartilage complex (TFCC).20 The ulnocarpal complex
Radioscapholunate includes th articular disc, th ulnar collateral ligament, and
th palmar ulnocarpal ligament (see Fig. 7 - 9 ) . This complex
U lnocarpal com plex
set of tissues fills most of th ulnocarpal space between th
Articular disc
distai ulna and th carpai bones (Fig. 7 10). The ulnocarpal
Ulnar collateral ligament
Palmar ulnocarpal ligament space allows th carpai bones to pronate and supinate with
th radius, without interference from th distai end of th
Intrinsic Ligam ents ulna.
Short ligam ents of th distai row The articular disc, th main leature of th ulnocarpal com
plex, attaches from th ulnar notch of th radius to near th
Interm ediate ligam ents
styloid process of th ulna (see Fig. 6 - 2 7 ) . This disc is an
Lunotriquetral
Scapholunate important structural component of both th distai radioulnar
Scaphotrapezial joint and th radiocarpal joint. Figure 7 - 6 shows a frontal
piane cross-section through th ulnocarpal space, illustrating
Long ligaments
Palmar intercarpal a poorly defined meniscal extension of th articular disc.33
iMtera leg: fibers between th capitale and th scaphoid The meniscal extension of th disc is often called th ulno
Mediai leg: fibers between th capitate and th triquetrum carpal meniscal homologue, indicating its vestigial function
Dorsal intercarpal: fibers between th scaphoid and triquet of once connecting th carpus to th triquetrum. Between
rum 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 pain-
ful with rheumatoid arthritis. Tears in th articular disc may
Extrinsic Ligaments permit synovial fluid to spread from th radiocarpal joint to
th distai radioulnar joint.
A fibrous capsule surrounds th extemal surface of th wrist Ihe ulnar collateral ligament is a thickening of th ulnar
and th distai radioulnar joint. Dorsally, th capsule thickens side of th wrist capsule (Figs. 7 - 6 and 7 - 8 ) . The ligament
slightly io fonti ligamentous bands known as th dorsal originates from th styloid process of th ulna, crosses th
radiocarpal ligaments (Fig. 7 - 8 ) . The ligaments are thin and ulnocarpal space, and attaches distally to th ulnar side of
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 Dorsal view
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-lat-
erally. 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 radio-
capitate 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 FIGURE 7-8. The dorsal ligaments of th righi wrist

Transverse carpai ligament
(cut).
Palmar intercarpal ligament
FIGURE 7 - 9 . The palmar ligaments of th
Lunotriquetral ligament
nght wrist. The transverse carpai ligament
has been cut and rellected to show th Ulnar collateral
underlying ligaments. ligament
Ulnocarpal - P a l r ulnocarpal
complex 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 ex-
tensor 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 exten-
sion 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
FIGURE 7-10. An x-ray of th righi wrist showing th carpai bones
and ulnocarpal space.
Chapter 7 Wrist 179
Palmar view
J 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
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 aforemen-
tioned 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 diar-
throdial 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 continu-
ous 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

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 dy-
namic relationship between these two joints.
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 articula-
tions 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-
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
The arthrokinematics of wrist extension are based on syn-
chronous 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 pro-
duces about 60 degrees of total wrist extension. An advan-
tage 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 com-
bination allows each joint to move within a more restricted
and more stable are of motion.
Full wrist extension elongates th palmar radiocarpal liga-
ments (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 crawl-
tng on th hands and knees, and pushing up when trans-
ferring 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, how-
ever, is that it does not account for all th carpai bones that
participate in th motion. For instance, th model ignores
Carpometacarpal
joint
Midcarpal joint
Radiocarpal joint
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

Radiocarpal
Articolar joint
disc

FIGURE 7-15. X-rays and mechanical depiction of th arthrokinematics of ulnar and radiai deviation for th righi wrist. The roll-
and-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 ments. A doubl VSystem of ligaments illustrates one way in
Radiai and Ulnar Deviation which ligaments help control ulnar and radiai deviation (Fig.
The arthrokinematics of wrist motion are actively driven by 7 - 1 6 ) . 33 in th neutral position, th four ligaments of th
muscle, but controlled by th passive tension action of liga doubl V System appear as two inverted V s. The distai in-

S P E C I A L F O C U S

Additional Arthrokinematics Involving th Proximal Row relative to th radius. The scaphoid appears to "stand up"
of Carpai Bones or to lengthen, which projeets its tubercle distally. At full
radiai deviation, th scaphoid flexes beyond neutral about
Careful observation of ulnar and radiai deviation on cine
20 degrees, taking on a shortened stature with its tubercle
radiography or serial static x-rays reveals more compli-
having approached th radius. A functional shortening of
cated arthrokinematics than previously described. During
th scaphoid allows a few more degrees of radiai devia
motion, th proximal row of carpai bones "rock" slightly
tion before complete blockage against th styloid process
into flexion and extension and, to a much less extent,
of th radius. The exact mechanism responsible for th
"twist." The rocking motion is most noticeable in th
slight flexion and extension of th proximal carpai row
scaphoid and, to a lesser extent, th lunate. During radiai
during ulnar and radiai deviation is not fully understood,
deviation th proximal row flexes slightly; during ulnar
but many explanations have been offered.2637 Most likely,
deviation th proximal row extends slightly." Note that in
th mechanism is driven by forces generated by stretched
Figure 7-15, especially on x-ray, th change in position of
ligaments and compressions that occur between th mov-
th scaphoid tubercle between th extremes of ulnar and
ing carpai bones.
radiai deviation. At full ulnar deviation, th scaphoid is
rotated about 20 degrees into extension,
 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 mech-
anism 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 FIGURE 7-17. A highly diagrammane depiction of a zig-zag col
lapse of th centrai column of th wrist following large compression
pai instability. force.
 Chapter / Wm( 185

COMPRESSION FORCE

FIGURE 7-18. A, Acting through liga-

ments, th scaphoid provides a me-
chanical linkage between th rela-
tively mobile lunate and th rigid
distai row of carpai bones. B, Com-
pression forces through th wrist
Scaphotrapezial
from a fall may fracture th scaphoid
ligament
and tear th scapholunate ligament.
Loss of th mechanical link provided Unstable
by th scaphoid often leads to lunate lunate
instability and/or dislocation. Scapholunate
ligament

cross th wrist are due to muscle activation and contact with ulnar direction. Figure 7 - 2 0 shows that a wrist with an
th surrounding environment. In most healthy persons, th ulnar tilt of 25 degrees has an ulnar translation force of 42%
wrist remains perfectly stable throughout life. Collapse and of th total compression force that crosses th wrist. This
subsequent joint dislocation are prevented by resistance from translational force is naturali)' resisted by passive forces from
ligaments, tendons, and intercarpal articulations. various extrinsic ligaments, such as palmar radiocarpal liga
The lunate is th most frequently dislocated carpai bone.39 ment. A disease like rheumatoid arthritis signifkantly weak-
Because no muscles attach to th lunate, stability must be ens wrist ligaments. Over time, th carpus may migrate ul
provided by ligaments and contact with adjacent bones, narly. An excessive ulnar translocation can significanti)' alter
most notably th scaphoid (Fig. 7 -1 8 A ). The scaphoid func- th biomechanics of th entire wrist and hand.
ttons as a mechanical link between th lunate and th rigid,
distai row of carpai bones. The continuity of this link re-
quires 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 dor-
sally. This condition is referred to clinically as dorsal interca-
lated 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 de-
struction 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 alter-
ing th length-tension relationship and moment arms of th
muscles that cross th wrist.34
Dinar Translocation of th Carpus. As pointed out
earlier, th distai end of th radius is angled from side io FIGURE 7-19. Lateral x-ray showmg th dislocation and subsequent
side so that its articular surface is sloped ulnarly aboul 25 rotational deformity of th lunate in th dorsal direction. Compare
degrees (see Fig. 7 -4 A ). Ulnar tilt of th radius creates a with Figure 7-18B. (Courtesy of Jon Marion, CHT, OTR, and
naturai tendency for th carpus to slide (translate) in an Thomas Hitchcock, MD. Marshfield Clinic, Marshfeld, Wl.)
 186 Seaion II Upper Extremity
FIGURE 7-20. This shows how th ulnar tilt of th distai radius can
predispose an individuai to ulnar translocation of th carpus. Com-
pression 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 magni-
tude 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 po-
tential for th ulnar translation.
MUSCLE AND J OINT INTERACTION ______
Innervation of th Wrist Muscles and Joints
MOTOR INNERVATION TO MUSCLE
The radiai nerve supplies all th muscles that cross th dor-
sal 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 typi-
cally 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
Function of th Muscles at th Wrist
Other than th flexor carpi ulnaris, no tendon of any extrin-
sic 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 pha-
langes. 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, there-
fore, 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
i] TABLE 7 - 2 . Cross-sectional Arca of Most Muscles
i that Cross th Wrist
Potential Wrist Flexor Cross-sectional Area (cm2)
Flexor digitorum profundus 10.8
Flexor digitorum superficialis 10.7
Flexor carpi ulnaris 5.0
Flexor pollicis longus 2.9
Flexor carpi radialis 2.16
Abductor pollicis longus 1.84
Extensor pollicis brevis* .40
All flexor muscles 33.8
Potential Wrist Extensor Cross-sectional Area (cm2)
Extensor carpi ulnaris 5.30
Extensor digitorum communis 4.30
Extensor carpi radialis longus 3.14
Extensor caipi radialis brevis 2.22
Extensor pollicis longus .56
All extensor musclest 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 Wrist 187

Palmar
FIGURE 7-21. 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

Radiai (Lateral)
on th grid is proportional to its cross-
section 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.

torque production, however, each muscle's cross-sectional Posterior view

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.

FUNCTION OF THE WRIST EXTENSORS

Muscular Anatomy
The three primary wrist extensors are th extensor carpi radi-
alis 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 sec-
ondary 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 pollicis brevis
Abductor pollicis longus
Extensor Extensor Extensor
carpi radialis carpi radialis pollicis longus
longus brevis
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 sur-
face 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.
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 par-
ticular 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 7-23. A dorsal oblique view shows a cross-
section of th tendons of th extensor muscles of th
wrist and digits passmg through th extensor retinac-
Extensor carpi ulnaris
ulum 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.
Extensor digiti minimi Synovial lining is indicated by red.
Extensor digitorum communis
and extensor indicis
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 ) .
FIGURE 7-25. The compression forces produced by a maximal ef-
fort 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 Wrist 189

The most active wrist extensor muscle during light clo-
sure 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 epicondy-
litis, or tennis elbow, occurs from stress and resultant in-
flammation 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 produc-
ing 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 mus-
cles 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 con-
ducive 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
transferred to provide wrist extension torque. Often, th pro-
nator teres muscle, innervated by th median nerve, is con-
nected 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 miss-
ing in about 10% of people, however. When present, it is
extremely variable and may have several small tendons. Ten-
dons 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.

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.
 190 Section II Upper Extremity

Anterior view 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 activ-
ity 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 inher-
ently fragile due to its lack of bony reinforcement (see Fig
7 -1 0 ).
The flexor carpi radialis and ulnaris function synergisti-
cally 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 ex-
tend 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
FIGURE 7-27. Anterior view of th tight ibrearm showing th pri-
mary wrist flexors muscles: flexor carpi radialis, palmaris longus,
and flexor carpi ulnaris. The flexor digitorum superficialis is shown
as a wrist flexor because of its large potential to assist with this
action. The pronator teres muscle is shown but does not flex th
wrist. Palmar view

Other secondary muscles capable of flexing th wrist are

th extrinsic flexors of th digits (flexor digitorum profun-
dus, 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) epicon-
dyle 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 FIGURE 7-28. The palmar aspect of th right wrist showing th
th flexor carpi ulnaris courses distally to attach to th pisi- distai attachments of th primary wrist flexors. Note that th ten
don of th flexor carpi radialis courses through a sheath located
form bone and, in a piane superfcial to th transverse carpai
within th superfcial fibers of th transverse carpai ligament. Most
ligament, into th pisohamate and pisometacarpal ligaments of th distai attachment of th palmaris longus has been removed
and th palmar base of th ffth metacarpal bone. with th palmar aponeurosis.

TABLE 7 - 3 . Magnitude and Joint Position of Peak
Isonietric Torque for W rist Movemcnts
Mean Peak Angles of
Wrist Movement Torque (Nm) Peak Torque
Flexion 12.2 (3.7) 40 of flexion
Extension 7.1 (2.1) From 30 of flexion to
70 of extension
Radiai deviation 11 (2) 0 (neutral)
Ulnar deviation 9.5 (2.2) 0 (neutral)
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 radiat-
ulnar 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 pol-
licis 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
FIGURE 7 -2 9 . The muscles that perform ra
diai deviation of th wrist are shown pre-
paring to strike a nal with a hammer. Im-
ages in th background are mirror reflec-
tions 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 -------- ^ l
brevis; APL = abductor pollicis longus;
and EPE and B = extensor pollicis longus
and brevis.)
Lnaptcr / wnst iv i
Table 7 - 3 , th radiai deviator muscles generate about 15%
greater isometric torque than th ulnar deviator muscles.6
Radiai Deviatore of th Wrist
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 contract-
ing 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 associa-
tion 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 \ ^ / |
)r~
 192 Seciion II Upper Extremily
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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Phiadelphia, FA Davis, 1983.
14. Linscheid RL: Kinematic considerations of th wrist Clin Orthop 202'
27 -3 9 , 1986.
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).
15- MacConaill MA, Basmajian JV: Muscles and Movements: A Basis for
Human Kinesiology. New York, Robert E. Krieger, 1977.
16 Mayfield JK, Johnson RP, Kilcoyne RF: The ligaments of th human
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ADDITIONAL READINGS
Berger RA. The anatomy and th basic biomechanics of th wrist joint. J
Hand Surg 9:84-93, 1996.
Chapter 7 Wrist 193
Green DP: Carpai dislocalions and instabilities. In Green DP (ed): Operative
Hand Surgery, voi 1, 3rd ed New York, Churchill Livingstone, 1993.
Jackson WT, Hefzy, Guo H: Determination of wrist kinematics using a
magnetic tracking device. Med Eng Phys 16:123-133, 1994,
Kauer JMG. Functional anatomy of th wrist. Gin Orthop 149:9-20, 1980.
Kobayashi M, Berger RA, Linscheid RL, et al. Intercarpal kinematics during
wrist motion. Hand Clin 1.3:143-149, 1997.
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of scapholunate ligament sectioning, J Hand Surg 20A:986-999, 1995.
Simoneau GG, Marklin RW, Monroe JF: Wrist and forearm postures of
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Donald A. Neumann , PT, P h D
TER M IN O LO G Y, 194
OSTEOLOGY, 195
Metacarpals, 195
Phalanges, 196
Arches of th Hand, 196
ARTHROLOGY, 197
Carpometacarpal Joints, 197
S e co n d th ro u g h Fifth C a rp o m e ta c a rp a l
J o in ts , 198
General Features and Ligamentous
Support, 198
Joint Structure and Kinematics, 198
Carpometacarpal Joint of th Thumb, 200
C apsu le and L ig a m e n ts o f th Th um b
C a rp o m e ta c a rp a l J o in t, 202
S a d d le J o in t S tru c tu re , 202
K in e m a tic s , 203
Abduction and Adduction at th
Thumb Carpometacarpal Joint, 203
Flexion and Extension at th Thumb
Carpometacarpal Joint, 204
Opposition of th Thumb
Carpometacarpal Joint, 205
Metacarpophalangeal Joints, 207
INTRODUCTION
Background
Just as our eyes and skin do, th hand serves as an impor-
tant sensory organ for th perception of our surroundings
(Fig. 8 - 1 ) . The hand is also th primary effector organ for
our most complex motor behaviors. And, th hands help to
express emotions through gesture, touch, craft, and art.
The 19 bones and 19 articulations within th hand are
driven by 29 muscles. Biomechanically, these structures in
ternet with superb proftciency. The hand may be used in a
very primitive fashion, such as a hook or a club. More often,
however, th hand functions as a highly specialized instru-
ment performtng very complex manipulations, requirtng infi
nite levels of force and precision.
Because of its enormous biomechanical complexity, th
function of th hand involves a disproportionately large re-
194
C h a p t e r 8
Hand
TOPICS AT A GLANCE
Fin gers, 207 E x trin s ic E xte n so rs o f th T h u m b , 221
General Features and Ligaments, 207 Anatomie and Functional
Metacarpophalangeal Joint Considerations, 221
Kinematics, 208 In trin s ic M u s c le s o f th H and, 224
T h um b , 211 Muscles of th Thenar Eminence, 224
General Features and Ligaments, 211 Muscles of th Hypothenar Eminence,
Interphalangeal Joints, 211 225
Fin gers, 211 Two Heads of th Adductor Pollicis
General Features and Ligaments, 211 Muscle, 226
Proximal Interphalangeal and Distai Lumbricals and Interossei Muscles,
Interphalangeal Joint Kinematics, 226
212 Interaction of th Extrinsic and Intrinsic
Th um b , 213 Muscles of th Fingers, 230
M USC LE A N D J O IN T IN TE R A C TIO N , 213 O pe ning th H and: F in g e r E xtensio n, 230
Innervation of Muscles, Skin, and Joints of C losing th H and: F in g e r Fle xio n, 233
th Hand, 213 H A N D AS A N EFFECTOR ORGAN, 234
Muscular Function in th Hand, 214
J O IN T DEFORMITIES CAUSED BY
E x trin s ic F le xors o f th D ig its, 214
R H EU M ATO ID AR TH R ITIS , 236
Anatomy and Joint Action of th
Zig-Zag Deformity of th Thumb, 236
Extrinsic Flexors of th Digits, 214
Destruction of th Metacarpophalangeal
E x trin s ic E x te n so rs o f th Fin gers, 219
Joints of th Finger, 236
Muscular Anatomy, 219
Zig-Zag Deformities of th Fingers, 238
Action of th Extrinsic Finger
Extensors, 220
gion of th cortex of th brain (Fig. 8 - 2 ) . Diseases or
injuries affecting th hand often create equally disproportion-
ate disabilities. A hand totally incapacitated by rheumatoid
arthritis or nerve injury, for instance, can dramatically re
duce th functional importance of th remaining joints of
th upper limb. This chapter describes th kinesiologic pnn-
ciples behind many of th musculoskeleial problems encoun-
tered in medicai and rehabilitation settings.
TERMINOLOGY_______________
The wrist, or carpus, has eight carpai bones. The hand has
live metacarpals, often referred to collectively as th meta-
carpus. Each of th live digits contains a set of phalanges.
The digits are designated numerically from one io live, or as
th thumb and th index, middle, ring, and little fingers

FIGURE 8-1. A very strong functional reiationship exists between
th hand and th eyes.
(Fig. 8 -3 A ). A ray describes one metacarpal bone and its
associated phalanges.
Each finger has two interphalangeal joints: a proximal in-
terphalangeal (PIP) and a distai interphalangeal (D1P) joint
(see Fig. 8 - 3 A). The thumb has only two phalanges and,
therefore, only one interphalangeal (IP) joint. The articula-
tions between th metacarpals and th proximal phalanges
are called th metacarpophalangeal (MCP) joints. The articula-
tions between th proximal end of th metacarpals and th
distai row of carpai bones are called th carpometacarpal
(CMC) joints.
Articulations Common to Each Ray of th Hand
Carpometacarpal (CMC) joint
Metacarpophalangeal (MCPI joint
Interphalangeal (IP) joints
Thumb has one IP joint
Fingers have a proximal interphalangeal (PIP) joint and
a distai interphalangeal (DIP) joint
Figure 8 - 3 B shows several features of th external anat
omy of th hand. Observe th palm ar creases, or folds, that
exist in th skin of th palm. They function both as dermal
"hinges, marking where th skin folds upon itself during
movement, and to increase palmar friction to enhance th
Chapter 8 Hand 195
security of grasp. The location of th creases serves as useful
clinical references for th underlying anatomy. The distai
and middle digitai creases are superficial to th D1P and PIF
joints. The proximal digitai creases are located distai to th
actual joint line of th MCP joints. The proximal and distai
palmar creases are enhanced by th folding of th dermis
during flexion of th MCP joints of th fingere. The thenar
crease is formed by th folding of th dermis as th thumb is
moved across th palm. On th palmar (anterior) side of th
wrist are th proximal and distai wrist creases.
0STE0L0GY
Metacarpals
The metacarpals, like th digits, are designated numerically
as one through five, beginning on th radiai daterai) side.
The morphology of each metacarpal is generally similar
(Figs. 8 - 4 and 8 - 5 ) . The firet (thumb) metacarpal is th
shortest and stoutest. Observe that th second metacarpal is
usuaily th longest, and th length of th remaining three
bones decreases from th radiai to ulnar (mediai) direction.
Each metacarpal has an elongated shaft with articular sur-
faces ai each end (Fig. 8 - 6 ) . The palmar surface of th shaft
is slightly concave longitudinally to accommodate many
muscles and tendons in this region. Its proximal end, or
base, articulates with one or more of th carpai bones. The
bases of th second through th fifth metacarpal possess
small facets for articulation with adjacent metacarpal bases.
The distai end of each metacarpal has a large convex head
which, as a group, is evident as th knuckles on th dorsal
side of a clenched fist. A pair of poslerior tubercles marks th
attachment sites for th collateral ligaments ai th MCP
joints.
With th hand ai rest in th anatomie position, th
thumbs metacarpal is oriented in a different piane from th
other digits. The second through th fifth metacarpals are
aligned generally side-by-side, with their palmar surfaces fac-
ing anteriori)'. The position ol th thumbs metacarpal, how-
ever, is rotated almost 90 degrees mediali) (i.e., internali)'),
relative to th other digits (see Fig. 8 -3 A ). Rotalion places
th sensitive palmar surface of th thumb toward th mid
iine of th hand. Optimum prehension depends on flexion
of th thumb occurring in a piane that interseets, versus
parallels, th piane of th flexing fingere. In addition, th
thumbs metacarpal is positioned well anterior, or palmar, io
th other metacarpals (Fig. 8 - 7 ) . This position of th meta
carpal and trapezium is caused by th palmar projection of
th distai pole of th scaphoid.
The location of th first metacarpal allows th entire
thumb to sweep freely across th palm toward th fingers.
Virtuali)' all prehensile motions, from pinch to precision
 196 Seciion 11 Upper Extremily
handling, require th Lhumb to interact with th fingers.
Without a healthy and mobile lhumb, th overall function of
th hand is substantially reduced.
Ihe medially rotateci lhumb requires unique terminology
to describe its movement as well as position. In th ana
tomie position, th dorsal surface of th bones of th thumb
(i.e., th surface where th thumbnail resides) faces laterali)'
(Fig. 8 - 8 ) . The palmar surface, therefore, faces medially, th
radiai surface anieriorly, and th ulnar surface posteriorly.
The terminology io describe th surfaces of th carpai bones
and all other digitai bones is standard: a palmar surface faces
anieriorly, radiai surface faces laterally, and so forth.
Phalanges
lhe hand has 14 phalanges (th Greek root phalanx; a line
of soldiers). The phalanges within each finger are referred to
as proximal, middle, and distai (Fig. 8 -3 A ). The thumb has
only a proximal and a distai phalanx.
FIGURE 8 - 2 . A motor homunculus
Lhe bram showing ihe somatotopic repl
resentation of body parts. The scnscoj
homunculus of th human brain has
similar representation. (After PenfieiJ
and Rosnussen: Cerebral Cortex
Man. The Macmillan Co., 1950.)
Except (or dilferences in sizes, all phalanges within
particular digit have similar morphology (see Figs. 8 - 4 anc
8 - 5 ) . The proximal and middle phalanges of each finger
have a concave base, sbafi, and convex head. Like th metacar-
pals, their palmar surfaces are slightly concave longitudinali-
(see Fig. 8 - 6 ) . The distai phalanx of each digit has a con
cave base. At its distai end is a rounded tuberosity thi.
anchors th fleshy pulp of solt tissue to th terminus of eacfc
digit.
Arches of th Hand
Observe th naturai concavity to th palmar surface of your
relaxed hand. Control of this concavity allows th humar
hand to securely hold and manipulate objects of many anc
varied shapes and sizes. The naturai palmar concavity of th
hand is supported by three integrated arch Systems: two
transverse and one longitudinal (Fig. 8 - 9 ) . The proxim d
transverse arch is formed by th distai row of carpai bones I
This carpai arch is a static, tigid structure that forms th '
carpai tunnel. Like most arches in buildings and bridges, th
arches of th hand are supported by a centrai keystone
structure. The capitate bone is th keystone of th proxima' I
transverse arch, reinforced by strong intercarpal ligaments.
The distai transverse arch passes through th MCP joints
In contrast to th rigidity of th proximal arch, th sides c:
 Lnapter 8 nana IV !

Middie(3) Distai joined together by th rigid tie-beam provided by th sec

interphalangeal ond and third metacarpals.19 In th healthy hand, this me-
joint chanical linkage reinforces th entire arch System. In th
Proximal
hand with joint disease, however, a structural failure at any
Distai
phalanx interphalangeal arch may weaken another. A classic example is th destruc-
joint tion of th MCP joints from severe rheumatoid arthritis.
Middle Metacarpophalangeal
Because this joint is th common keystone for both th
phalanx joint longitudinal and th distai transverse arches, its destruction
has devastating effects on th entire arch System. This par-
Proximal
tially explains why a hand with severe rheumatoid arthritis
phalanx
often appears fiat.
Interphalangeal
joint

ARTHROLOGY
Carpals Carpometacarpal Metacarpophalangeal The terminology that describes th movement of th fngers
joint joint (with sesamoid
bone)
and thumb must be defned. The following descriptions as
sume that a particular movement starts from th anatomie
posilion, with th elbow extended, forearm fully supinated,
and wrist in a neutral position. Movement of th ftngers is
described in th standard fashion using th Cardinal planes
Distai of th body: jlexion and extension occur in th sagittal piane,
Distai digitai crease
and abduction and adduction occur in th frontal piane (Fig.
palmar
crease
Middle 8 - 1 0 A -D ) . The middle fnger is th reference digit for th
digitai crease naming of abduction and adduction. The side-to-side move
Proximal Proximal ment of th middle finger is called radiai and ulnar devia-
palmar digitai crease tion.
crease Because th entire thumb is rotated almost 90 degrees in
relation to th fngers, th terminology used to describe
Web space
Distai
thumb movement is different from that for th fngers. Flex-
wrist Thenar crease
ion is th movement of th palmar surface of th thumb in
crease th frontal piane across th palm. Extension returns th
thumb to its anatomie position. Abduction is th forward
Proximal
w rist
movement of th thumb away from th palm in a near
crease sagittal piane. Adduction returns th thumb to th piane of
th hand. Other terms frequently used to describe th move-
FIGURE 8-3. A palmar view of th basic anatomy of th hand. A, ments of th thumb include ulnar adduction for flexion,
Major bones and joinis. B, Extemal landmarks. radiai abduction for extension, and palmar abduction for
abduction.55 Opposition is a special term describing th
movement of th thumb across th palm, making direct
contact with th tip of any of th fingers. Reposition is a
th distai arch are mobile. To appreciate this mobility, imag- movement from full opposition back to th anatomie posi
ine transforming your completely fiat hand into a cup- tion.
shaped hand that surrounds a baseball. Transverse flexibility
within th hand occurs by action of th peripheral metacar-
pals (first, fourth, and ftfth) collapsing around th more Carpometacarpal Joints
stable centrai (second and third) metacarpals. The keystone O V ER V IEW
of th distai transverse arch is formed by th MCP joints of
these centrai metacarpals. The CMC joints of th hand form th articulation between
The longitudinal arch of th hand follows th generai th distai row of th carpai bones and th bases of th fve
shape of th second and third rays. The metacarpal or proxi metacarpal bones. The CMC joints are located at th very
mal end of this arch is firmly linked to th carpus by th proximal end of th hand.
carpometacarpal (CMC) joints. These rigid articulations pro Figure 8 - 1 1 shows a mechanical illustration of th rela
vide an important element of longitudinal stability to th tive mobility at th CMC joints. The joints of th second
hand. The phalangeal or distai end of th arch is very mo and third digits shown in gray are rigidly joined to th distai
bile. The mobility is exhibited by flexing and extending th carpus, forming a stable centrai pillar throughout th hand.
ftngers. The keystone of th longitudinal arch is provided by In contrast, th more peripheral CMC joints shown in red
th second and third MCP joints. Note that th MCP joints form mobile radiai and ulnar borders, which are capable of
serve as keystones to both th longitudinal and distai trans folding around th hands centrai pillar, thereby altering th
verse arches. shape of th palm. The contrast in mobility at these two sets
As depicted in Figure 8 - 9 , all three arches of th hand of joints accounts for th dynamics described earlier for th
are mechanically interlinked. Both transverse arches are distai transverse arch.
 198 Section 11 Upper Exiremity

Pai mar view

Distai phalanx

Flexor digitorum
Middle phalanx
profundus

Flexor digitorum
superficialis Proximal phalanx

FIGURE 8-4. A palmar view of th

Flexor and Flexor pollicis longus
bones of th right wrist and hand. Prox
abductor digiti minimi imal attachments of muscle are indi-
Adductor pollicis and cated in red and distai attachments in
1st palmar interosseus gray.
Adductor pollicis
(Transverse head)
Flexor pollicis brevis
and abductor pollicis
Opponens digiti minimi
brevis

Palmar interossei
Opponens pollicis
Adductor pollicis (Oblique head)

Opponens digiti minimi 1st palmar interosseus

Flexor carpi ulnaris
Flexor carpi radialis
Flexor digiti minimi
Abductor pollicis longus
Abductor digiti minimi
Flexor pollicis brevis and opponens pollicis
Flexor carpi ulnaris
Abductor
pollicis brevis

The function of th CMC joints allows th concavity of

th paini to ft around many objects. This feature is one of
th most impressive functions of th human hand. Cylindric
objects, for example, can fit snugly into th paini, with th
index and middle digits positioned to retnforce th security
of th grasp (Fig. 8 - 1 2 ) . Without this ability, th dexterity
of th hand is reduced to a primitive hingelike grasping
motion.
SECOND THROUGH FIFTH CARPOMETACARPAL
JOINTS
General Features and Ligamenlous Support
The second CMC joint is fonned through th articulation
between th enlarged base of th second metacarpal and th
distai surface of th trapezoid, and, io a lesser extent, th
capitate and trapezium (see Figs. 8 - 4 and 8 - 5 ) . The third
CMC joint is formed primarily by th articulation between
th base of th third metacarpal and th distai surface of th
capitate. 1 he fourth CMC joint is formed by th articulation
of th base of th fourth metacarpal and th distai surface of
th hamate and, to lesser extent, th capitate. The fifth CMC
joint consists of th articulation between th base of th fifth
metacarpal and th distai surface of th hamate only. The
bases of th second through fifth metacarpals have small
facets for attachments lo one another through intermetacar-
pal joints. These joints help stabilize th bases of th second
through fifth metacarpals, thereby reinforcing th carpometa-
carpal joints.
All CMC joints of th lingers are surrounded by articular
capsules and strengthened by dorsal, palmar, and interos-
seous ligamenis. The dorsal ligaments are particularly well
developed, especially around th middle CMC joint (Fig. 8 -
Joint Structure and Kinematics
The CMC joints of th second and third digits are classified
as complex saddle joints (Fig. 8 - 1 4 ) .55 Their jagged interlock-
ing articular surfaces profide ver)' little movement. As men-
tioned earlier, stability ai these joints allows th second and
third metacarpals io provide th centrai pillar of th hand.
The fiat to slightly convex base of th fourth and fifth
metacarpals articulates with a slightly concave articular sur
face formed by th hamate (see Fig. 8 - 1 4 ) . '7 Two ulnar
 Lhapter ts n an a

Dorsal view

Distai phalanx

Bands of extensor mechanism

Tuberosity

Middle phalanx

Proximal phalanx

FIGURE 8-5. A dorsal view of th bones Extensor pollicis longus

of th tight wrist and hand. Proximal at-
tachments of muscle are tndicated in red Extensor digitorum
communis and Extensor digitorum
and distai attachments in gray. communis and
extensor indicis
extensor digiti minimi
Adductor pollicis

Extensor pollicis brevis

Dorsal interossei

Extensor carpi radialis brevis

Extensor carpi ulnaris
1st dorsal interosseus

Extensor carpi radialis longus

Distai Middle
phalanx phalanx

FIGURE 8-7. A lateral x-ray with an emphasis on th palmar pro-

FIGURE 8-6. A radiai view of th bones of th third ray (metacar- jection of th thumb (first metacarpal), scaphoid, and trapezium.
pal and associated phalanges), including th capitate bone of th Note th contrast in th spatial orientation of th capitale and other
wrist. metacarpal bones.
200 Section l Upper Extremity

Palmar view Faterai view

FIGURE 8-8. Palmar and lateral views of

th hand showing th orientation of th
bony surfaces of th tight thumb. Note
that th bones of th thumb are rotated
90 degrees relative to th other bones of
th wrist and th hand.

CMC joints contribute a subtle but important element of

mobility to th hand.3 As depicted in Figure 8 - 1 1 , th
articulations at th fourth and fifth CMC joints allow th
ulnar border of th hand to fold slightly toward th center
of th hand, thereby deepening th palmar concavity. Ulnar
mobility, often referred to as a cupping motion, occurs by
forward flexion and slight rotation of th ulnar metacar-
pals toward th middle digit. The fourth metacarpal flexes
about 10 degrees, and th more mobile fifth metacarpal
flexes about 20 to 25 degrees. The irregular and varied
shapes of these joint surfaces prohibit standard arthrokine-
malic description. The mobility at these ulnar CMC joints
can be appreciated by observing th movement of th
fourth and fifth metacarpal heads while clenching a fist (Fig.
8 -1 5 ).

Carpometacarpal Joint of th Thumb

FIGURE 8-9. The naturai concavity of th palm of th hand is
supported by three integrated arch Systems: one longitudinal and
two transverse.
GENERAL FEATURES
The CMC joint of th thumb is located between th base of
th thumb metacarpal and th trapezium (see Fig. 8 4)
This joint is by far th most complex of th CMC joints,
enabling extensive movements of th thumb. The unique
saddle shape of this joint allows th thumb to fully oppose,
thereby easily contacting th tips of th other digits.
Through this action, th thumb is able to encircle objects
placed in th palm. Opposition greatly enhances th security
of grasp, which is especially useful when holding spherical
or cylindrical objects.
The large functional demands placed on th CMC joint of
th thumb often result in a painful condition called basilar
joint arthritis. The terna basilar refers to th CMC joint being
FIGURE 8-10. The System for naming th movements within th hand. A to D, Finger moton. to I, Thumb motion. (A, finger extension;
B, finger (lexion; C, finger adduction; D, finger abduction; E, thumb extension; F, thumb flexion; G, thumb adduction; H, thumb
abduction; and i, thumb opposition.)

FIGURE 8-11. Palmar view of th right hand showtng a highly

mechanical depiction of th mobility across th five carpometacar-
pal joints. The peripheral joints th first, fourth, and fifth (red) FIGURE 8-12. The mobility of th carpometacarpal joints of th hand
are much more mobile than th centrai two joints (gray). enhances th security of grasping objects, such as this cylindric pole.
 202 Section 11 Upper llxLremity

Dorsal view

FIGURE 8 -1 3 . Dorsal side ol th r\g)

hand showing ihe capsule and h a-
ments that stabilize th carpometacarpet
joinis.

th base joint of th entire thumb. Baslar joint arthritis can
be very incapacitaiing, often affecting women in th fifth to
sixth decades of lite.41
CAPSULE AND LIGAMENTS OF THE THUMB
CARPOMETACARPAL JOINT
The capsule at th CMC joint of th thumb is naturally loose
to accommodate to a large range of motion. The capsule is,
however, thickened by ligaments and reinforced by active
muscular contraction.
Many names have been used to describe th ligaments at
th CMC joint of th thumb.416,42 This text incorporates th
scheme of naming ligaments based on their attachments to
th trapezium, not to th thumb metacarpal (see Fig. 8 - 8 ) .
The terminology to describe th ligaments of th CMC joints
is not well established and, therefore, may differ in other
sources.
The CMC joint of th thumb is surrounded by live liga
ments (Fig. 8 - 1 6 ) . 2 Table 8 - 1 summarizes th major at
tachments of these ligaments and th motions that cause
them to become taut. In generai, extension, abduction, and
opposition of th thumb elongate most of th ligaments. All
five ligaments listed in Table 8 - 1 are important stabiliz-
ers at th CMC joint of th thumb.4,16,23,37,41 As a group.
they resisi th tendency for th CMC joint io dislocate.
When th ligaments are weakened by arthritis, th joint
often dislocates laterally relative to th trapezium.
SADDLE JOINT STRUCTURE
The CMC joint of th thumb is th classic saddle joint of th
body (Fig. 8 - 1 7 ) . The characteristic feature of a saddle joint
is that each articular surface is convex in one dimension and
concave in th other.55,58 The longitudinal diameter of th artic-
ular surface of th trapezium (see Fig. 8 - 1 7 ) is generali)-
concave from a palmar-to-dorsal direction. This surface is
analogous to th contour of th front-to-rear diameter of a
horses saddle. The corresponding tramverse diameter on th
articular surface of th trapezium is generally convex along a
medial-to-lateral direction.30 The convexity of th transverse
diameter is analogous to th side-to-side convex contour of a
horses saddle. The contour of th proximal articular surface
of th thumb metacarpal has th reciprocai shape of that
described for th trapezium (see Fig. 8 - 1 7 ) . The longitudinal
diameter along th articular surface of th metacarpal is con
vex from a palmar to dorsal direction. Its transverse diameter
is concave from a mediai to lateral direction.

1 TA B LE 8 - 1. Ligaments of th Carpometacarpal Jo in t of th Thumb*

Natne Proxim al Attachm ent
Anterior oblique Palmar tubercle on trapezium
Ulnar collateralt Transverse carpai ligament
First intermetacarpal Dorsal side of base of second
metacarpal
Posterior oblique Posterior surface of trapezium
Radiai collaterali Radiai surface of trapezium
D istai Attachm ent M ost Taut Positions
Palmar base of thumb meta Abduction, extension, and opposition
carpal
Palmar-ulnar base of thumb Abduction, extension, and opposition
metacarpal
Palmar-ulnar base of thumb Abduction and opposition
metacarpal with ulnar col-
lateral
Palmar-ulnar base of thumb Abduction and opposition
metacarpal
Dorsal surface of thumb meta All movements to varying degrees
carpal except extension

* Ligamem names are based on attachment lo trapezium surfaces noi ihe thumb metacarpal.
t Also called palmar oblique" ligament based on attachment to th metacarpal.
i Also called dorsal-radial" ligament.
 Ckapter 8 Hand 203

Pai m ar view
KINEMATICS
The primary motions at th CMC joint occur in 2 degrees of
freedom. As depicted in Figure 8 - 1 8 , abduction and adduc-
tion occur generally in th sagittal piane, and flexion and
extension occur generally in th fromal piane. Being a saddle
joint, each of th two axes of rotation passes through a
different convex articular surface.23
Opposition and reposition of th thumb are mechanically
derived from th two primary planes of motion ai th CMC
joint. The kinematics of opposition and reposition are dis-
cussed following th description of th two primary motions.

Abduction and Adduction at th Thumb

1GURE 8-14. The palmar side of th rtght hand showing internai
surfaces of th second through th fifth carpometacarpal joints. The
capsule and palmar carpometacarpal ligaments of digits 2 to 5 have
been cut.
Carpometacarpal Joint
In th position of adduction of th CMC joint, th thumb
lies within th piane of th hand. Maximum abduction, in
contrast, positions th thumb metacarpal about 45 degrees

FIGURE 8-15. Mobility of th ulnar (fourth and fifth) carpometacarpal joints of th left hand. A, Hand closed but relaxed. B, With a firrn
grip, th finger flexor muscles flex and rotate th ulnar metacarpals.

P a lm a r view Lateral view

FIGURE 8-16. Palmar and lateral

views of th ligaments of th carpo
metacarpal joint of th right thumb.
Note th distai attachment of th
abductor pollicis longus into th
capsule of th carpometacarpal joint
of th thumb.
 204 Section II Upper Extremity

P a lm a r vicw between full extension and full flexion. This rotation is noi
considered a third degree of freedom because it cannot be
executed independently of th other motions.
In th anatomie position, th thumb metacarpal assumes
a position of nearly full extension. From this position, th
CMC joint can be extended only an additional 10 to 15
degrees.11 From full extension, th thumb metacarpal flexes
across th palm about 45 to 50 degrees.
The arthrokinematics of flexion and extension at th CMC
joint are based on th concave articular surface of th meta
carpal moving across th convex (transverse) diameter on th
trapezium (see Fig. 8 - 1 7 ) . During flexion, th concave sur
face of metacarpal rolls and slides in an ulnar (mediai) direc
tion (Fig. 8 -2 1 A ).23 A shallow groove in th transverse dt-
ameter of th trapezium helps guide th slight mediai
rotation of th metacarpal. Full flexion elongates tissues such
as th radiai collateral ligament.58
During extension of th CMC joint, th concave metacar
pal rolls and slides in a lateral (radiai) direction across th

FIGURE 8-17. The carpometacarpal of th right thumb is opened to

expose th saddle shape of th joint. The longitudinal diameters are
shown in gray and th transverse diameters in red.

anterior to th piane of th palm.11 Full abduction opens th

web space of th thumb. forming a wide concave curvature
useful for grasping large objects (Fig. 8 -1 9 A ). Varying de-
grees of abduction al th CMC joint are also used while
holding and/or manipulating small objects between th index
finger and thumb (Fig. 8 -1 9 B ).
The arthrokinematics of abduction and adduction are
based on th convex articular surface of th thumb metacar-
pal moving on th fixed concave (longitudinal) diameter of
th trapezium (see Fig. 8 17).23-30 During abduction, th
convex articular surface of th metacarpal rolls palmarly
and slides dorsally on th concave surface of th tra
pezium (Fig. 8 - 2 0 ) . Full abduction ai th CMC joint elon-
gates th adductor pollicis muscle and most ligaments at
th CMC joint, especially those imbedded around th poste-
rior aspect ol th joint capsule. The arthrokinematics of
adduction occur in th reverse order from that described for
abduction.
Flexion and Extension at th Thumb
Carpometacarpal Joint
Actively performing flexion and extension of th CMC joint
of th thumb is associated with varying amounts of axial
rotation of th metacarpal. During flexion, th metacarpal FIGURE 8-18. The primary biplanar osteokinematics at th carpo
metacarpal joint of th right thumb. Note that abduction and ad
rotates slightly medially (i.e., toward th third digit); during
duction occur about a medial-lateral axis of rotation (gray); flexion
extension, th metacarpal rotates slightly laterally (i.e., away
and extension occur about an anterior-posterior axis of rotation.
from th third digit). The slight axial rotation is evident by The more complex motion of opposition requires a combination of
watching th change in orientation of th nail of th thumb these two primary motions. (See text for further details.j

FIGURE 8-19. Abduction of th carpometacarpal joint of th thumb. A, Maximum abduction of 45 degrees opens th web space of
th thumb. B, Moderate abduction for fine manipulation with th index finger.
transverse diameter of th joint (Fig. 8 - 2 1B). The groove on
th articular surface of th trapezium guides th metacarpal
imo slight lateral rotation.11'30 Full extension requires elonga-
tion of th anterior oblique ligament. Table 8 - 2 shows a
FIGURE 8-20. The arthrokinematics of abduction of th carpometa
carpal joint of th thumb. Full abduction stretches th anterior
oblique ligament (AOL), th intermetacarpal ligament (1ML), and
th adductor pollicis muscle. A muscle responsibie for th active
roll at th joint is th abductor pollicis longus. Note th analogy
shown between th arthrokinematics of abduction and a cowboy
falling forward on th horses saddle: As th cowboy falls forward
(toward abduction), a point on his chest rolls anteriorly, but a
point on his rear end slides posteriorly.
Chapter 8 Hand 205
summary of th kinematics for flexion-extension and abduc-
tion-adduction at th CMC joint of th thumb.
Opposition of th Thumb Carpometacarpal Joint
For ease of discussion, Fig. 8 -2 2 A shows th full are of
opposition divided into two phases. In phase one, th thumb
metacarpal abduets. In phase two, th abducted metacarpal
flexes and medially rotates across th palm toward th little
finger. Figure 8 - 2 2 B shows th detail of th kinematics of
this complex movement. During abduction, th base of th
thumb metacarpal takes a path in a palmar direction across
th surface of th trapezium. During flexion-medial rotation,
th base of this metacarpal tums slightly medially, led by
th groove on th surface of th trapezium.58 Muscle force,
especially from th opponens pollicis, helps guide th meta
carpal to th extreme mediai side of th transverse articular
surface of th trapezium. The partially abducted CMC joint
increases th passive tension in certain connective tissues.
For example, increased tension in th stretched posterior
oblique ligament promotes th mediai rotation (spin) of th
metacarpal shaft.58
As evident by th change in orientation of th thumbnail,
full opposition incorporates at least 45 to 60 degrees of
mediai rotation of th thumb. The CMC joint of th thumb
cannot account for all of this rotation. Lesser amounts of
axial rotation, in th form of accessory motions, occur at th
MCP and IP joints of th thumb. The body of th trapezium
also medially rotates slightly against th scaphoid and th
trapezoid.40 Trapezial rotation, likely th result of passive
tension in taut ligaments, amplifies th final magnitude ot
th metacarpal rotation. The little finger contributes to oppo
sition through a cupping motion at th fifth CMC joint. This
motion allows th tip of th thumb to make firm contact
with th tip of th little finger.
Full opposition is th close-packed position of th thumb
CMC joint.55 In this position, th CMC joint is usually un
der active control of muscle. Many of th ligaments are
206 Section II Upper Extremity

N
G roove fo r f
fle x o r carpi (\ A
ra dialis )
D
9a
03
%'
Superior View of Trapezium: Path of Metacarpal Movement
\ \
Palmar
FIGURE 8-21. The anhrokinematics of flexion and extension ai th carpomeiacarpal joint of th thumb. A, Flexion is
associated with a slight mediai rotation, causing elongation in th radiai odiatemi ligament. The anterior oblique
ligament is slack. B, Extension is associated with slight lateral rotation, causing elongation of th anterior oblique
ligament. The approximate path of motion of th metacarpal on th trapezium is shown in th insert. Note th analogy
Show,, hccween th anhm kinem atics o f extension and a cow boy fading sidew ays on th horses saddle As th cowbov
faiis sideways (tovvard extension), points on his chesi and rear end boih roli and slide" in th same faterai direction.

TAB LE 8 - 2 Factors Associated with Kinematics of th Primary Motions of th CMC Joint of th Thumb*
Motion
Abduction and adduction
Flexion and extension
Osteokinematics
Sagittal piane movement about a
medial-lateral axis of rotation
through th metacarpal
Frontal piane movement about
an anterior-posterior axis of
rotation through th trape
zium
Joint Geometry
Convex (longitudinal diameter) of
metacarpal moving on a con
cave surface of th trapezium
Concave (transverse) diameter of
th metacarpal moving on a
convex surface of th trape
zium
Arthrokinematics
Abduction: palmar roll and dorsal
slide
Adduction: dorsal roll and pal
mar slide
Flexion: mediai roll and slide
Extension: lateral roll and slide

* P P 0S1U0n and reposition are noi shown because they are dcnved from th two primary planes of motions (see texi for further explanation).
 Chapter 8 Hand 207

twisted taut. Reposition of th CMC joint retums th meta

carpal from full opposition back to th anatomie position.
This motion involves arthrokinemaiics of both adduction
and extension-lateral rotation of th thumb metacarpal.

Metacarpophalangeal Joints
FINGERS
General Features and Ligaments
The MCP joints of th fingers are relatively large, ovoid
articulations between th convex heads of th metacarpals
and th shallow concave proximal surfaces of th proximal
phalanges (Fig. 8 - 2 3 ) . Motion at th MCP joint occurs pre-
dominantly in two planes: flexion and extension in th sagit-
tal piane, and abduction and adduction in th frontal piane.
Mechanical stability at th MCP joint is criticai to th
overall biomechanics of th hand. As discussed earlier, th
MCP joints serve as keystones for support of th mobile
arches of th hand. In th healthy hand, stability at th MCP
joints is achieved by an elaborate set of interconnecting con-
nective tissues. Imbedded within th capsule of each MCP
joint is a pair of radiai and ulnar collateral ligam ents and
one palmar ligament or piate (Fig. 8 - 2 4 ) . Each collctterai
ligament has its proximal attachment on th posterior tuber-
cles of th metacarpal head. Crossing th MCP joint in an
oblique palmar direction, th ligament forms two distinct
parts. The cord pari of th ligament is thick and strong,

Distai
interphalangeal joint

Abduction
Proximal
interphalangeal joint

G roove fo r
fle x o r carpi
radialis

cu
aT Metacarpophalangeal
Q> joint
Superior View of Trapeziuin:
Path of M etacarpal Movement

Palmar
FIGURE 8 - 2 2 . The kinematcs of opposition of ihe carpomeiacarpal
joini of th thumb. A, Two phases of opposition are shown: (1)
abduction and (2) flexion with mediai rotation B, The detailed
kmematics of th two phases of opposition: th posterior oblique Carpometacarpal
ligament is shown taut; th opponens pollicis is shown contracting joint
(red).

FIGURE 8 - 2 3 . The joints of th index finger.

208 Section 11 Upper Extremity
Interphalangeal joint's
collateral ligaments
FIGURE 8-24. A lateral view of th collateral ligaments and associ-
ated connective tissues of th metacarpophalangeal, proximal inter
phalangeal, and distai interphalangeal joints of th fnger.
attaching distally to th palmar aspect of th proximal end
of th phalanx. The accessory part consists of fanshaped
fibers, which attach distally along th edge of each palmar
piate.
Located palmar to each MCP joint are ligamentous-like
structures called palm ar (or volar) plales (see Fig. 8 - 2 4 ) . The
term piate describes a composition of dense, thick discs of
fibrocartilage. The distai end of each piate attaches to th
base of each proximal phalanx. At this region, th plates are
relatively thick and stiff. The thinner and more elastic proxi
Fibrous
digitai sheaths
Collateral ligaments
(cord and accessory parts)
mal ends of th palmar plates attach to th metacarpal bone,
just proximal to th head. Fibrous digitai sheaths, which form
tunnels or pulleys for th extrinsic fnger flexors, are an-
chored immediately anterior to th palmar plates. The pn-
mary function of th palmar plates is to strengthen th MCP
joint and resist hyperextension (i.e., th range of posterior
motion beyond th 0 position).
Figure 8 - 2 5 illustrates anatomie aspeets of th MCP
joints. The concave component of th MCP joint is formed
by th articular surface of th proximal phalanx, th collat
eral ligaments, and th dorsal surface of th palmar piate
These tissues form a three-sided receptacle aptly suited to
accept th heads of th metacarpals. This structure adds
joint stability and increases th area of articular contact
Attaching between th palmar plates are three deep transverse
metacarpal ligaments (see Fig. 8 - 2 5 ) . The wide, fiat structure
helps to interconnect th second through fifth metacarpals.
Metacarpophalangeal Joint Kinematics
Osteokinematics
In addition to th motions of flexion-and-extension and ab-
duction-and-adduction at th MCP joints, substantial acces
sory motions occur. On th relaxed and nearly extended
MCP joint, it is possible to feel significant passive translation
in an anterior-to-posterior direction, side-to-side direction,
and distraction. Note also th passive axial rotaiion of th
proximal phalanx against th metacarpal head. Although lim-
ited, these accessory motions at th MCP joint permit th
fngers to better conform to th shapes of objects, thereby
increasmg security and control of th grasp (Fig. 8 - 2 6 ) . The
range of this passive axial rotation at th MCP joints is
greatest at th ring and little ftngers, with average rotations
of about 30 to 40 degrees.29
Palmar plates
Fibrous digitai sheath
Flexor digitorum
profundus tendon
Flexor digitorum
superficialis tendon
FIGURE 8-25. A dorsal view of th
hand with emphasis on th periarticula:
connective tissues at th metacarpopha
langeal joints. Several metacarpal bones
have been removed to expose various
joint structures.

-iGURE 8-26. The >assive accessory motions at th metacarpopha-
langeal joints during th grasp of a cylinder. Axial rotation of th
fcidex finger is most notable.
The MCP Joint of th Finger Allows Movement Primarily
in 2 Degrees of Frccdom
Flexion and extension occur in th sagittal piane about a
medial-lateral axis of rotation.
Abduction and adduction occur in th frontal piane about
an anterior-posterior axis of rotation.
Both axes of rotation pass through th head of th metacarpal
The overall range of flexion and extension at th MCP
joints increases gradually from th second to th fifth digit.3
About 90 degrees of flexion is available at th second (index)
MCP joint and about 110 to 115 degrees is available at th
6fth. The greater mobility allowed at th more ulnar MCP
joints is similar to that at th CMC joints. The MCP joints
can be passively hyperextended beyond th neutral position
for a considerable range of 30 to 45 degrees.
Abduction and adduction at th MCP joints occurs to
about 20 degrees on either side of th midiine reference
:ormed by th third metacarpal. Mobility is greatest in th
second and fifth digits where adjacent fingere do not limit
motion.3
Arthrokinematics
Each metacarpal head has a slightly different shape, but in
generai each is rounded at th apex and nearly fiat on th
palmar surface (see Fig. 8 - 6 ) . Articular cartilage covers th
entire head and most of th palmar surface. The convex-
concave relationship of th joint surfaces is readily apparent
(Fig. 8 - 2 7 ) . The longitudinal diameter of th joint follows
th sagittal piane; th shorter transverse diameter follows th
frontal piane.
Chapter 8 Hand 209
The arthrokinematics at th MCP joint are based on th
concave articular surface of th phalanx moving on th con-
vex metacarpal head. During active extension, th base of
th proximal phalanx rolls and slides in a dorsal direction
under th power of th extensor digitorum communis mus-
cle (Fig. 8 -2 8 A ). At about 60 to 70 degrees of flexion, th
cord portion of th collateral ligaments is maximally taut.
The eccentric or out-of-round cam-shape of th metacarpal
head is responsible for th stretch in th collateral ligaments.19
At 0 degrees of extension (Fig. 8 - 2 8 B ) , th collateral liga
ments slacken while th palmar piate unfolds and makes
total contact with th head of th metacarpal. Full hyperex-
tension is limited by th stretch placed in th palmar piate
(Fig. 8 -2 8 C ). The arthrokinematics of MCP flexion are simi
lar to those described for extension except that th roll and
slide of th metacarpal occur toward th palmar direction
(see Fig. 8 - 2 9 ) .
The close-packed position at th MCP joint is about 70
degrees of flexion.19 In this position, accessory motion is
minimal. Most fibers of th cord portion of th collateral
ligaments are pulled taut. The flexed position, therefore, of-
fers substantial stability to th base of th fingers. At near
extension, th collateral ligaments slacken, allowing maximal
accessory motions.
The arthrokinematics of abduction and adduction of th
MCP joints are similar to those described for flexion and
extension. During abduction of th index MCP joint, for
instance, th proximal phalanx rolls and slides in a radiai
direction (Fig. 8 - 3 0 ) . The first dorsal interosseus muscle
directs both th roll and th slide arthrokinematics.
The amount of active abduction and adduction at th
MCP joints is significantly less in full flexion compared with
full extension. Two factors can account for this difference.
First, th collateral ligaments are taut near full flexion.
FIGURE 8-27. A dorsal view of th metacarpophalangeal joint
opened io expose th shape of th articular surfaces. The longitudi
nal diameter of th joint is shown in gray; th transverse diameter
in red.
 210 Seclion II Upper Extremity

FIGURE 8 - 2 8 .The arthrokinematics of active extension of th metacarpophalangeal joint. A, Active extension starting from a position of
70 degrees of (lexion. The extensor digitorum communis (EDC.) is shown contracting and then starting to drive th roll-and-slide
kinematics. The radiai eollateral Hgament is pulled taut in flexion. B, At 0 degrees of extension, th radiai collateral ligamem is relanvely
slack. C, Hyperextension further slackens th radiai collateral ligament but maximally stretches th palmar piate. Note that th axis of
rotation for this motion is in th medial-lateral direction, through th head of ihe metacarpal.

Stored passive tension in these ligaments theoretically in-

creases th compression force between th joint surfaces,
thereby reducing active motion. Second, in th position of
about 70 degrees of flexion, th articular surface of th

FIGURE 8 - 2 9 .The arthrokinematics of active (lexion at th metacar

pophalangeal, proximal interphalangeal, and distai interphalangeal
joints of th index finger The radiai collateral ligament at th
metacarpophalangeal joint is pulled taut in flexion. Flexion elon-
gates th dorsal capsule and other associated connective tissues. The
joints are shown flexing under th power of th flexor digitorum
superficialis and th flexor digitorum profundus. The axis of rota
tion for flexion and extension at all three finger joints is in th
medial-lateral direction, through th convex member of th joint.
FIGURE 8 - 3 0 . The arthrokinematics of active abduction at thc
metacarpophalangeal joint. Abduction is shown powered by th frsc
dorsal interosseus muscle (DI,). At full abduction, th ulnar collat
eral ligament is taut and th radiai collateral ligament is slack. Note
that th axis of rotation for this motion is in an anterior-postertor
direction, through th head of th metacarpal.

m / S P E C I A L
> ~
Clinica! Relevance of th Close-Packed Position at th
Metacarpophalangeal Joints
Following surgery or trauma, th hand is often tempo-
rarily immobilized to promote healing and relieve pain.
During a prolonged period, connective tissues immobil
ized at a shortened length are likely to become increas-
ingly stiff and resistant to elongation. To reduce th
iikelihood of tightness within th collateral ligaments at
th MCP joints, th hand is often splinted with th MCP
joints flexed to 60 to 70 degrees (Fig. 8-31). This close-
packed position of th joints places both th collateral
igaments36 and extrinsic extensor muscles in a rela-
tively elongated and taut position. This position may
prevent subsequent shortening of these tissues.
FIGURE 8-31. Common position used for long-term immobili-
zation of th hand. The flexed position of th metacarpopha
langeal joints elongates th collateral ligaments and th exten
sor digitorum communis muscle. The proximal interphalangeal
and distai interphalangeal joints are immobilized near full ex-
tension to prevent flexion contractures at these joints. (See text
for further details.)
proximal phalanges contacts th flattened palmar part of th
metacarpal heads (see Fig. 8 -2 8 A ). This relatively fiat sur-
:ace blocks th naturai arthrokinematics required for maxi
mal abduction and adduction range of motion.
THUMB
General Features and Ligaments
The MCP joint of th thumb consists of th articulation
between th convex head of th first metacarpal and th
concave proximal surface of th proximal phalanx of th
Chapier 8 Hand 211
Metacarpophalangeal Carpometacarpal Radiocarpal
joint joint joint (wrist)
Proximal Distai Sesamoid
interphalangeal interphalangeal
joint joint
FIGURE 8-32. A side view showing th shape of many joint sur-
faces in th wrist and hand. Note th sesamoid bone on th palmar
side of th metacarpophalangeal joint of th thumb.
thumb (Fig. 8 - 3 2 ) . A pair of sesamoid bones is usually
located within th palmar side of th joint capsule.
The basic structure and arthrokinematics of th MCP joint
of th thumb are similar to those of th fngere. Marked
differences exist, however, in osteokinematics. Active and
passive motions at th MCP joint of th thumb are signifi-
cantly less than those at th MCP joints of th fingere. For
all practical purposes, th MCP joint of th thumb allows
only 1 degree of freedom: flexion and extension within th
frontal piane.47 From full extension, th proximal phalanx of
th thumb can actively flex about 60 degrees across th
palm toward th middle digit. Figure 8 - 3 3 depicts th ar
throkinematics at th MCP joint during active flexion under
th power of th intrinsic and extrinsic flexor muscles. Un-
like th MCP joints of th fingere, hyperextension of th
thumb MCP joint is usually limited to just a few degrees.
Active abduction and adduction of th thumb MCP joint
is very limited and, therefore, considered as an accessory
motion. This can be observed on th hand by attempting to
actively abduct or adduct th proximal phalanx while firmly
stabilizing th thumb metacarpal. Collateral ligaments at this
joint markedly restrict this motion. The paucity of this mo
tion lends longitudinal stability throughout th entire ray of
th thumb. Abduction and adduction torques that cross th
MCP joint of th thumb are transferred proximally across
th CMC joint.
Interphalangeal Joints
FINGERS
The proximal and distai interphalangeal joints of th fingere
allow only 1 degree of freedom: flexion and extension. From
both a structural and functional perspective, these joints are
simpler than th MCP joints.
General Features and Ligaments
The p ro x im a l in terp h ala n g ea l (P1P) jo in ts are formed by th
articulation between th heads of th proximal phalanges
212 Section II Upper Extremity

tissue are essentially th same as that of th PIP joint, excep

for th absence of th check-rein ligaments.

Proximal Interphalangeal and Distai Interphalangeal

FIGURE 8-33. The arthrokinematics of active flexion at th meiacar-
pophalangeal and interphalangeal joints of th thumb. Flexion is
shown powered by th (lexor pollicis longus and ihe llexor pollicis
brevis. The axis of rotation for flexion and extension at th these
joints is in th anierior-poslerior direction, through th convex
member of th joints.
Joint Kinematics
The PIP joints flex to about 100 to 120 degrees. The DI?
joints show less flexion, to about 70 to 90 degrees. Like th
MCP joints, flexion at th IP joints is greater in th more
ulnar digits. Minimal hyperextension is usually available at
th PIP joints. The D1P joints, however, normally allow u:
to 30 degrees of hyperextension.
Flexion range of motion is greater at th PIP joints than
at th D1P joints. Flexion and extension of IP joints of th
ring and little fngers occur in conjunction with slight axi;
rotation. During flexion, this rotation tums th pulp of th
fngertips toward th base of th thumb. Axial rotation al
lows these fingers to contact th opposing thumb more e:
fectively.27
Similarities in joint structure cause similar arthrokinema: 1
ics at th PIP and D1P joints. During active flexion at th PIP
joint, for instance, th concave base of th middle phalam
rolls and slides in a palmar direction by th pul of th
extrinsic finger flexors (see Fig. 8 - 2 9 ) . During flexion, th
passive tension created in th stretched connective tissues or
th dorsal side of th joint help guide and stabilize th roh-
and-slide arthrokinematics.
In contras! to th MCP joints, passive tension in th
collatera ligaments at th IP joints remains relatively con-

Dorsal view

and th bases of th middle phalanges (see Fig. 8 - 3 4 ) . The

articular surface of a P1P joint appears as a tongue-in-groove
articulation similar to that used in carpentry to join planks
of wood. The head of th proximal phalanx has two
rounded condyles, separated by a shallow centrai groove.
The opposing surface of th middle phalanx has two shallow
concave facets separated by a centrai ridge. Tongue-in-
groove articulation helps guide th motion of flexion and
extension and restricts axial rotation.
The P1P joints are surrounded by a capsule that is rein-
forced by radiai and ulnar collatera ligamenls. The cord por-
don of th collatera ligament at th PIP joint significanti
limits abduction and adduction motion. As with th MCP
joint, th accessory portion of th collatera ligament blends
with and reinforces th palmar piate (see Fig. 8 - 3 4 ) . The
anatomie connections between th collatera ligaments and
palmar piate form a secure seat for th head of th proximal
phalanx. Palmar check-rein ligaments at th PIP joint
strengthen th connection between th palmar piate and th
middle phalanx. Similar to th palmar plates, these ligaments
resist hyperextension of th PIP joint.614 Severe hyperexten-
sion of th PIP joint is a common athletic injury, with
tearing of both th palmar piate and th check-rein liga
ments.
The distai interphalangeal (D1P) joints are formed through
th articulation between th heads of th middle phalanges FIGURE 8-34. A dorsal view of th proximal interphalangeal an:
and th bases of th distai phalanges (see Fig. 8 - 3 4 ) . The distai interphalangeal joints opened to expose th shape of thr
structure of th D1P joint and th surrounding connective articular surfaces.

stant throughout th range of motion. Perhaps th more
concentric shape of th head of th phalanges prevents a
farge change in length in these collateral ligaments. The
-tose-packed position of th P1P and DIP joints is near full
.xtension,55 most likely caused by th stretch placed on th
palmar plates. During periods of immobilization of th hand,
th IP joints are often splinted in near or full extension (see
Fg- 8 - 3 1 ) . This position places a stretch on th palmar
plates, collateral ligaments, and extrinsic finger flexor mus-
des, reducing th likelihood of flexion contracture of these
joints.
THUMB
The structure and function of th IP joint of th thumb is
similar to those of th IP joints of th fingere (see Fig. 8 -
53). Motion is limited primarily to 1 degree of freedom,
lowing active flexion to about 70 degrees. The IP joint can
re passively hyperextended beyond neuiral to about 20 de-
"Position of Function" of th Wrist and Hand
Some medicai conditions, such as a severe "stroke" or
high-level quadriplegia, often result in a permanent de-
formity of th digits. The deformity is often inevitable,
regardless of th quality or timing of th therapeutic
intervention. Clinicians, therefore, often use spiints that
favor a position of th hand that maximally preserves its
functional potential. This position, often called th posi
tion of function is shown in Figure 8-35. The highlights
of this position are: wrist: 20 to 30 degrees of extension
with slight ulnar deviation; fingers: 45 degrees of MCP
joint flexion and 15 degrees of PIP and DIP joint flexion;
and thumb: 45 degrees of abduction. This position of
function provides a slightly cupped hand, with a wrist in
position to maintain optimal length of th finger flexor
muscles.
FIGURE 8-35. The posiiion of function of th wrist
and hand.
Chapter 8 Hand 213
grees. This motion is often employed to apply a force be-
tween th pad of th thumb and an object, such as pushing
a tack into a wall. The amount of passive hyperextension
often increases throughout life owing to years of stretch
placed on palmar structures, including th palmar piate.
MUSCLE AND JOINT INTERACTION ___
Innervation of Muscles, Skin, and Joints of
th Hand
MUSCLE AND SKIN INNERVATION
Innervation to th muscles and skin of th hand is illus-
trated in Figure 6 - 3 3 . The radiai nerve innervates th extrin
sic extensor muscles of th digits. These muscles, located on
th dorsal aspect of th forearm, are th extensor digitorum
communis, extensor digiti minimi, extensor indicis, extensor
pollicis longus, extensor pollicis brevis, and abductor pollicis
longus. The radiai nerve is responsible for th sensation on
th dorsal aspect of th wrist and hand, especially around
th dorsal region of th thenar web space.
The median nerve innervates most of th extrinsic flexors
of th digits. In th forearm, th median nerve innervates th
flexor digitorum superficialis. A branch of th median nerve
(anterior interosseous nerve) then innervates th lateral half
of th flexor digitorum profundus, th flexor pollicis longus,
and th pronator quadratus.
The median nerve enters th hand through th carpai
tunnel, deep to th transverse carpai ligament. Once in th
hand, th median nerve innervates th muscles that form th
thenar eminence (flexor pollicis brevis, abductor pollicis
brevis, and opponens pollicis) and th lateral two lumbricals.
The median nerve is responsible for th sensation on th
palmar-lateral aspect of th hand, including th tips and th
palmar aspect of th lateral three and one-half digits.
The ulnar nerve innervates th mediai half of th flexor
digitorum profundus. Distally, th ulnar nerve crosses th
wrist superficial to th carpai tunnel. In th hand, th deep
motor branch of th ulnar nerve innervates th hypothenar
muscles (flexor digiti minimi, abductor digiti minimi, oppo
nens digiti minimi, and palmaris brevis) and th mediai two
lumbricals. The deep motor branch continues laterally, deep
in th hand, to innervate th palmar and dorsal interossei
muscles, and finally th adductor pollicis. The ulnar nerve is
responsible for th sensation on th ulnar border of th
hand, including most of th skin of th ulnar one and one-
half digits.
The motor nerve roots that supply all th muscles of th
upper extremity are listed in Appendix ILA. Appendix 1IB
shows key muscles typically used to test th functional status
of th C -T 1 ventral nerve roots.
SENSORY INNERVATION TO THE JOINTS
The periarticular connective tissue of th digits has a rich
sensory nerve supply. Ampie neural feedback is necessary to
control th fine and complex movements. For th most part,
th joints of th hand receive sensation from similar nerve
roots that supply th overlying dermatomes. These nerve
roots are carried in th radiai, median, and ulnar nerves as
 214 Section II Upper Extremity

TABLE 8 - 3 . Extrinsic and Intrinsic Muscles of Muscular Function in th Hand

thc Hand
Extrinsic Muscles
Flexors of th digits
Flexor digitorum superfi-
cialis
Flexor digitorum profun-
dus
Flexor pollicis longus
Extensors of th fngers
Extensor digitorum com-
munis
Extensor indicis
Extensor digiti minimi
Extensors of th thumb
Extensor pollicis longus
Extensor pollicis brevis
Abductor pollicis longus
Muscles that operate th digits are classified as either extrin
sic or intrinsic to th hand (Table 8 - 3 ) . Extrinsic muscles
Intrinsic Muscles
have their proximal attachment in th forearm or, in some
Thenar eminence cases, as far proximal as th epicondyles of th humerus
Abductor pollicis brevis Intrinsic muscles, in contrast, have both their proximal and
Flexor pollicis brevis distai attachments withtn th hand. As a summary and refer-
Opponens pollicis ence, th detailed anatomy and nerve supply of th muscles
of th hand is in Appendix IIC.
Hypothenar eminence
Most active movements of th hand, such as opening and
Abductor digiti minimi
Flexor digiti minimi closing th fingere, require a precise cooperation between th
Opponens digiti minimi extrinsic and th intrinsic muscles of th hand and th
Palmaris brevis muscles of th wrist.
Adductor pollicis (two
heads) EXTRINSIC FLEXORS OF THE DIGITS
Lumbricals (four)
Anatomy and Joint Action of th Extrinsic Flexors of
Interossei
th Digits
Palmar (four)
Dorsal (four) The extrinsic flexor muscles of th digits are th flexor dtgt-
torum superficialis, flexor digitorum profundus, and flexor
pollicis longus (Figs. 8 - 3 6 and 8 37). These muscles have

follows: C6 supplying th thumb and index finger, C7 sup-

plying th middle finger, and C8 supplying th ring and little
fingere.20'24 The CMC joints are also innervated by sensory Palmar v ie w
nerves of th C8 nerve root via th deep branch of th ulnar
nerve.20

Palmar v ie w

Pronator teres
(cut)

Lateral epicondyle Flexor carpi radialis

(cut)
Palmaris longus
(cut)

Flexor carpi ulnaris

(cut)
Pronator teres
Flexor digitorum superficialis
(cut)

Flexor digitorum profundus

FIGURE 8-37. An anterior view of th right forearm highlighting

th flexor digitorum profundus and th flexor pollicis longus mus
FIGURE 8-36. An anterior view of th nght forearm highlighting cles. The lumbrical muscles are shown attaching to th tendons of
th flexor digitorum superficialis muscle. Note th cut proximal th flexor profundus. Note th cut proximal and distai ends of th
ends of th wrist flexors and pronator teres muscles. flexor digitorum superficialis muscle.
 Chapter 8 Hand 215

tensive proximal attachments from th mediai epicondyle
th humerus and from th regions of th forearm.
The muscle belly of th flexor digitorum superficialis is
xated in th anterior forearm, just deep to th three pri-
~ ary wrist flexors and th pronator teres muscle (see Fig.
- 3 6 ) . The four tendons cross th wrist and enter th pal-
r side of th hand. At th level of th proximal phalanx,
h tendon splits to allow passage of th tendon of th
-exor digitorum profundus (Fig. 8 - 3 8 ) . The two split parts
i each tendon partially reunite, cross th PIP joim , and
oach on th sides of th palmar aspect of th middle
halanx.48
The primary action of th flexor digitorum superficialis is
flex th PIP joints. This muscle, however, can flex all
ints it crosses. In generai, with th exception of th little
ger, each tendon of th superficialis can be controlled
latively independently of th other. This independence of
ction is especially evident at th index finger.
The muscle belly of th Jlexor digitorum profundus is lo-
cated in th deepest muscular piane of th forearm, deep to
th flexor digitorum superficialis muscle (see Fig. 8 - 3 7 ) .
Once in th hand, each tendon passes through th split
tendon of th superficialis. Each profundus tendon then con-
tinues distally to attach to th palmar side of th base of th
distai phalanx (see Fig. 8 - 3 8 , index finger). The profundus
is th sole flexor of th DIP joint, but like th superficialis
can assist in flexing every joint it crosses.
The flexor digitorum profundus to th index finger can
be controlled relatively independently of th other profun
dus tendons. The remaining three tendons, however, are
interconnected through various muscular fasciculi, which
usually prohibit isolated DIP joint flexion of a single finger.
To appreciate this interconnection, grasp th middle finger
and maximally extend all of its joints. While holding this
position, attempt to actively flex only th DIP joint of th
ring finger. The inability or difficulty in performing this
motion is due to th excessive elongation placed on th
entire muscle belly of th profundus by th extension of th

Palmar view

FIGURE 8-38. A palmar view illustrates several important structures of th hand Note th little finger showing th fibrous
digitai sheath and ulnar synovial sheath encasing th extrinsic flexor tendons. The ring finger has th digitai sheath removed,
thereby highlighting th digitai synovial sheath (red) and th annular (A, _5) and cruciate (C,_3) pulleys. The middle finger
shows th pulleys removed to expose th distai attachments of th flexor digitorum superficialis and profundus. The index
finger has a portion of flexor digitorum superficialis tendon removed, thereby exposing th deeper tendon of th flexor
digitorum profundus and attached lumbrical. The thumb highlights th oblique and annular pulleys along with th radiai
synovial sheath, surrounding th tendon of th flexor pollicis longus.
216 Section II Upper Extremity
Anatomica! Basis for "Carpai Tunnel Syndrome"
All nine extrinsic flexor tendons of th digits travel with
th median nerve through th carpai tunnel (Fig. 8-39).
The tendons are surrounded by two separate synovial
sheaths that reduce friction between th structures. An
ulnar synovial sheath surrounds th eight tendons of th
flexors digitorum superficialis and profundus, and a sep
arate radiai synovial sheath surrounds th tendon of th
flexor pollicis longus. Hand activities that require pro-
longed and extreme wrist positions can irritate these
tendons. Because of th closed and relatively small
compartment of th carpai tunnel, swelling of th syno
vial membranes may increase th pressure on th me
dian nerve. Carpai tunnel syndrome may result, which is
FIGURE 8-39. A transverse view through th entrance of th carpai tunnel of th tight wrist. The ulnar synovial sheath
(red) surrounds th tendons of th flexors digitorum superficialis and profundus. The radiai synovial sheath surrounds
th tendon of th flexor pollicis longus.
middle finger. This maneuver is ofien used to inhibit pro
fundus action, thereby isolating th P1P joint flexor action of
th superficialis.
The flexor pollicis longus resides in th deepest muscular
piane of th forearm, just lateral to th profundus (see Fig.
8 - 3 7 ) . This muscle crosses th wrist to attach distally to th
characterized by pain and/or paresthesia over th sen-
sory distribution of th median nerve. With progression
of th syndrome, muscular weakness and atrophy may
occur in th thenar eminence. Pressures within th car
pai tunnel in persons with carpai tunnel syndrome in
crease significantly during many activities that involve
th hand.46 Pressures increase most significantly during
th extremes of all wrist motions, including th action
of making a fist. Carpai tunnel syndrome may be associ
ateti with prolonged use of a computer keyboard. Alter
native design of th standard computer keyboard may
reduce th extremes of motions used during typing and
thereby reduce th severity of this painful condition.35
palmar side of th base of th distai phalanx of th thumb.
The flexor pollicis longus is th sole flexor at th IP joint of
th thumb and exerts a fexion torque at th MCP and CMC
joints of th thumb and at th wrist joint.
Distai to th carpai tunnel, th ulnar synovial sheath sur
rounds th flexor digitorum superficialis and profundus ten-

This sheath ends in th proximal paini, except for a
continuation around th tendons of fifth digit (see Fig.
38) The radiai synovial sheath remains in contact with th
on of th flexor pollicis longus to its distai insertion on
ihumb.
The extrinsic flexor tendons of th digits are guided to
distai attachment in protective fibro-osseous tunnels
m as fibrous digitai sheaths (see Fig. 8 - 3 8 , fifth fnger),
ths start proximally as a continuation of th thick apo-
osis just under th skin of th paim. Throughout th
h of each digit, th sheaths are anchored to th pha-
s and th palmar plates (see Fig. 8 - 2 4 ) . Embedded
in each digitai sheath are discrete bands of tissue called
r pulleys (see Fig. 8 - 3 8 , A l - 5 , C I - 3 in ring finger),
p to these pulleys is a digitai synovial sheath, surrounding
flexor tendons from th distai palmar crease to th D1P
t. This sheath serves as a nutritional source for th en-
d tendons. The synovial fluid secreted from th sheath
S P E C I A L F O C U S
Biomechanics of a Ruptured Flexor Pulley
As previously stated, a function of th flexor pulleys is
to maintain a near Constant moment arm length of th
flexor tendons. In a damaged or ruptured pulley, th
force of th contracting muscle causes th tendon to
'pul away" from th joint's axis of rotation, a phenome-
non called "bowstringing" of th tendon. Bowstringing
of a tendon significantly increases th internai moment
arm of th tendon and, in turn, increases th mechani-
cal advantage of th muscle. As described in Chapter 1,
increasing a muscle's mechanical advantage has two
effects on joint mechanics: (1) amplification of th
torque produced per level muscle force, and (2) reduc-
tion of th angular rotation of th joint per linear dis-
tance of muscle shortening. The negative clinical impli-
cations of a ruptured flexor pulley primarily involve th
second factor. To illustrate this effect on grasping, as
Intact pulleys
1.5 cm
MCP
joint
R u p t u r e d p u lle y s
1.5 cm
Chapter 8 Hand 217
reduces th friction between th flexor digitorum superfici-
alis and profundus tendons. A lacerated tendon within th
digitai sheath may heal with adhesions lo th digitai sheaths
or adjacent tendons. Splinting and exercise are usually initi-
ated after surgery to facilitate th free gliding of th tendons
within th sheath.
Anatomy and Function of th Flexor Pulleys
Figure 8 - 3 8 shows th flexor pulleys that are embedded
within th fibrous digitai sheath. Five annular pulleys have
been described, designated as Al to A5.15 The major pulleys
(A2 and A4) attach to th shaft of th proximal and middle
phalanges. The minor pulleys (A l, A3, and A5) attach di-
rectly to th palmar piate at each of th three joints within a
finger. Three less distinct cruciate pulleys (C to C3) have
also been described. The cruciale pulleys are made of thin,
flexible fibers that crisscross over th tendons at regions
where th digitai sheaths bend during flexion.
sume that with intact A2, A3, and A4 pulleys, th mo
ment arm of th flexor digitorum profundus tendon is
about .75 cm at th PIP joint (Fig. 8-40A). A muscle
contraction of 1.5 cm would theoretically produce about
115 degrees of PIP joint flexion.7 A finger with ruptured
pulleys, as shown in Figure 8-406, may cause a two-
fold increase in th moment arm of th flexor digitorum
profundus across th PIP joint. Consequently, a muscle
contraction of 1.5 cm, in theory, produces only about 58
degrees of joint rotation about half th motion pro
duced with intact pulleys. Asssuming that th maximal
shortening range of th flexor digitorum profundus is
about 2.0 cm,1 th finger with a ruptured pulley fails to
flex fully, regardless of effort. This loss in contraction-
to-rotation efficiency tends to be most profound in rup-
ture of th A4 pulley.45 A ruptured pulley often requires
surgical correction.
FIGURE 8-4 0 . The pathomechanics of ruptured flexor pulleys. A, With
intact pulleys, th moment arm of th finger flexors across th proxi
mal interphalangeal (PIP) joint is about .75 cm. With this moment arm
length, a 1.5-cm contraction excursion of th flexor digitorum profun
dus would in theory produce about 115 degrees flexion ai th proxi
mal interphalangeal joint. B, With a rupture of th A-2 and A-3
pulleys, th bowstringing of th tendon across th proximal interphal
angeal joint would doubl th length of th moment arm to 1.5 cm. In
this case, a 1.5-cm contraction excursion of th flexor digitorum pro-
lundus would produce only about 58 degrees of proximal interphalan
geal joint flexion.
 218 Section II Upper Extremity
> i
I \
C'~'
FIGURE 8-41. The muscle aetivation required to produce th sim-
ple motion of proximal interphalangeal joint flexion. A 20 N (4.5
pound) force produced by th flexor digitorum superftcialis creates
a flexion torque across every joint it crosses. Because of th pro
gressive!}' larger moment arms in th more proximal joints, th
flexor torques progressively increase in a proximal direction from
15 to 25 Ncm. To isolate only proximal interphalangeal joint flex
ion, th extensor digitorum communis and th extensor carpi radi-
alis brevis must resisi th flexion effect of th flexor digitorum
superfcialis across th wrist and metacarpophalangeal joints.
Flexor pulleys, palmar aponeurosis, and skin share a simi-
lar function of holding th underlying tendons ai a relatively
fixed dislance from th jo in ts.1-7 Without this function, th
force produced by contraction of th extrinsic finger flexor
muscles pulls th tendons away from th axis of rotation at
th joint.
Role of Proximal StabiUzer Muscles during Active
Finger Flexion
The extrinsic- digit#] flex ors #re m echsn icsfly c'spsbJe o f /7ex-
ing multiple joints, from th DIP joint to, at least theoreti-
cally, th elbow. In order for these muscles to isolate theu
flexion potential across a single joint in th hand requires
additional muscles to act synergistically with th extrinsic
digitai flexors. Consider th flexor digitorum superficiali}
performing isolated PIP joint flexion (Fig. 8 - 4 1 ) . At th
onset of contraction, th extensor digitorum communis must
act as a proximal stabilizer to prevent th flexor digitorum
superfcialis from flexing th MCP joint and th wrist. Be
cause th flexor moment arm length of th flexor digitorum
superfcialis progressively increases at th more proximai
joints, a relatively small force at a distai joint is amplified to
a greater torque at th more proximal joints. Figure 8 -4 1
shows that a 20 N (4.5 lb) force within th superficiali;-j
tendon produces a 15 Ncm torque ai th PIP joint, a 20 j
Ncm torque at th MCP joint, and a 25 Ncm torque at th -
midcarpal joint of th wrist. The greater th force produce.: I
by th flexor digitorum superfcialis, th greater th forc:
demands placed on th proximal stabilizers. The proxims I
stabilizers include th extensor digitorum and, if needed, th
wrist extensors. The amount of muscle force and muscular
interaction required for a simple action of PIP joint flexion ts
actually more than what it frsi appears to be.
Passive Finger Flexion via Tenodesis Action of th
Digital Flexors
The position of th wrist significanti alters th length of th;
extrinsic digitai flexors. One implication of this arrangemer
can be appreciated by actively extending th wrist and ob-
serving th passive jlexion of th fngere and thumb (Fig. 8 -
42). The force responsible for th digitai flexion is generate;
by th stretch placed on th extrinsic digitai flexors, such a;
th flexor digitorum profundus. The stretching of a polyarn-
cular muscle across one joint, which generates a passo:
movement at th other, is referred to as a tenodesis actic-
of a muscle. Figure 8 - 4 2 demonstrates that in th positio;
FIGURE 8-42. Tenodesis action" of th finger flexors in a hi i' J
person. As th wrist is extended, th thumb and fingere au tom aJ
ca//y //c-at due eo che screccfi p/aced on che excrnsic digitai llexors. 1
The flexion occurs passively, without effort from th subject.
 Chapter 8 Hand 219

Clinical Implications of Tenodesis in Persons with cup of water, th person allows gravity to flex th wrist.
Quadriplegia This, in turn, stretches th partially paralyzed extensor
digitorum communis (Fig. 8-43/4). In Figure 8-436, ac-
The naturai tenodesis action of th extrinsic digitai flex-
tive extension of th wrist stretches th paralyzed finger
ors has important clinical implications. One example in-
flexors, such as th flexor digitorum profundus, which
volves a person with C6 quadriplegia who has paralyzed
creates enough passive force in these muscles to grasp
finger flexors and extensors, but innervated wrist exten-
th cup. The amount of passive force in th finger
sors. Those with this level of spinai injury often employ
flexors is controlled by th degree of active wrist exten
a tenodesis action for many functions, such as holding
sion.
a cup of water. In order to open th hand to grasp a

Taut flexor
digitorum
profundus

FIGURE 8-43. A person with C6-level quadriplegia using tenodesis action to grasp a cup of water. A, To prepare for
grasp, th hand is opened by gravity flexing th wrist. The stretched (taut) extensor digitorum communis generates
passive force that partially extends th fingers. B, By actively extending th wrist by th innervated extensor carpi
radialis brevis (red), th stretched finger flexors such as th flexor digitorum profundus create a passive force to
assist with grasping th cup.

of full wrist flexion, th fingere most notably th index
are passively extended owing to a similar tenodesis action
caused by th stretched extrinsic digitai extensors. Tenodesis
occurs to varying degrees in essentially all polyarticular mus
cles in th body.
EXTRINSIC E X T E N S O R S OF T HE FINGERS
Muscular Anatomy
The extrinsic extensors of th fingere are th extensor digito
rum communis, th extensor indicis, and th extensor digiti
minimi (see Fig. 7 - 2 2 ) . The extensor digitorum communis
and th extensor digiti minimi originate by a common ten-
don from th lateral epicondyle of th humerus. The exten
sor indicis has its proximal attachment on th dorsal region
of th forearm. The extensor digitorum communis, in terms of
cross-sectional area, is by far th predominant digitai exten
sor. The name communis refers to th set of usually four
extensor tendons that supply th four fingere. In addition to
functioning as finger extensors, th extensor digitorum has
an excellent moment arm as a wrist extensor (see Fig. 7 -
21 ) .
The extensor digiti minimi is a small fusiform muscle often
interconnected with th extensor digitorum. With th exten
sor digitorum and extensor minimi removed, th deeper
extensor indicis, and th extrinsic extensor muscles of th
thumb become fully exposed (Fig. 8 - 4 4 ) . The extensor indi
cis muscle has only one tendon that serves th index finger.
 220 Seciion 11 Upper Extremiiy
Dorsal vicw
FIGURE 8-44. A dorsal view of th righi upper extremity highlight-
ing th group of extensors of th digits: th extensor indicis, exten-
sor poilicis longus, extensor pollicis brevis, and abductor pollicis
longus. Note th cut proximal ends of extensor carpi ulnaris and
th extensor digitorum communis.
Tendons of th extensor digitorum communis, extensor
indicis, and extensor digiti minimi cross th wrist in syno-
vial-lined tunnels, located within th extensor retinaculum
(see Fig. 7 - 2 3 ) . Distai to th extensor retinaculum, th ten
dons course toward th fingers in a highly variable manner
(Fig. 8 - 4 5 ) . The tendons of extensor digitorum are often
interconnected by several juncturae lendinae (from th Latin
junctura; joining, + tendini; tendon). The strips of connective
tissue stabilize th angle of approach of th tendons to th
base of th MCP joints. The tendons of th extensor indicis
and extensor digitorum communis usually travel in a parallel
fashion, blending with th connective tissue on th dorsum
of th proximal phalanx (Fig. 8 - 4 6 ) .
The anatomie organization of th extensor tendons of th
fingers is very different from that of th finger flexors. The
finger flexor tendons travel in a well-defined digitai sheath
heading toward a single discrete bony attachment. In con-
trast, th distai attachments of th finger extensors lack a
defined digitai sheath or pulley System. The extensor ten
dons eventually become integrated into a fbrous expansion
of connective tissues, located along th entire length of th
dorsum o f each finger (see Fig. 8 - 4 5 ) . The co m plex set o f
connective tissue is called th extensor mechanism. Other
terms are used, including th extensor expansion, extensor
apparatus, and extensor assembly.10-50 The extensor mecha
nism serves as a primary distai attachment for th extensor
digitorum and th majority of th intrinsic muscle of th
fingers. The following section describes th anatomy of th
extensor mechanism. A similar but less organized extensor
mechanism exists for th thumb.
Extensor Mechanism of th Fingers
A small slip of th tendon of th extensor digitorum attaches
lo th base of th dorsal side of th proximal phalanx. The
remaining tendon flattens into a centrai band, or slip, form-
ing th backbone of th extensor mechanism. (see Figs. 8 -
45 and 8 - 4 7 ) . The centrai band courses distally to attach to
th dorsal base of th middle phalanx. Before Crossing th
PIP joint, two lateral bands diverge from th centrai band.
The bands are located dorsal to th axis of rotation at both
th PIP and D1P joints, and they fuse into a terminal tendon
that attaches to th dorsal base of th distai phalanx. The
multiple attachments of th extensor mechanism into th
phalanges allow th extensor digitorum to transfer extensor
force distally throughout th entire finger.
In addition to attaching into th phalanges, th extensor
mechanism attaches mio th palmar surface of th finge:
through two structures: th dorsal hood and th retinacular
ligaments (see Figs. 8 - 4 5 and 8 - 4 7 ) . The dorsal hood is a
wide, nearly triangular sheet of thin aponeurosis located a:
th proximal end of th extensor mechanism. The dorsal
hood contains transverse and oblique fibers. The transverse
fibers, or sagittal" bands, run perpendicular to th long axis
of th tendon of th extensor digitorum. The transverse
fibers from either side of th extensor tendon attach to th
palmar piate, thereby forming a sling around th extreme
proximal end of th proximal phalanx. The transverse fibers.
therefore, transmit forces from th extensor digitorum mus
cle that pul th proximal phalanx into extension. In addt-
tion, th transverse fibers hold th extensor digitorum ten
don over th dorsal side of th MCP joint.
The oblique fibers course distally and tnedially to fuse with
th lateral and centrai bands. The intrinsic muscles of th
hand (th lumbricals and interossei) attach into th extensor
mechanism via th oblique fibers of th dorsal hood. Figure
8 - 4 7 shows this arrangement for th first dorsal interosseus
and lumbrical of th index finger. The intrinsic muscles via
this connection, are able to help th extensor digitorum
communis extend th PIP and DIP joints.
Located at th distai end of th extensor mechanism is a
pair of slender oblique retinacular ligaments (see Fig. 8 - 4 7 ).
The fibers arise proximally from th fibrous digitai sheath,
just proximal to th PIP joint, and course obliquely and
distally to insert into th lateral bands. The ligaments help
coordinate movement between th PIP and DIP joints of th
fingers, a point to be discussed later in this chapter. The
anatomie and functional aspeets of th extensor mechanism i
are summarized in Table 8 - 4 .
Action of th Extrinsic Finger Extensors
Isolated contraction of th extensor digitorum communis pr>
duces hyperextension of th MCP joints (Fig. 8 - 4 8 ) . On>.
in th presence of activated intrinsic muscles can th exten
sor digitorum fully extend th PIP and DIP joints.
 Chapter 8 Hand 221

Terminal attachment of
Lateral bands extensor mechanism

Central band

Oblique tibers
Dorsal hood o f -
extensor mechanism Transverse fibers

FIGURE 8 - 4 5 .A dorsal view of th

muscles, tendons, and extensor
mechanism of th right hand. The Juncturae tendinae Extensor digiti minimi
synovial sheaths are indicated in Extensor indicis
darker red, th extensor retinaculum Extensor digitorum communis
in lighter red. Dorsal interassei Abductor digiti minimi

Extensor pollicis longus

Extensor pollicis brevis Synovial sheath

Extensor carpi radialis longus

Extensor retinaculum
Extensor carpi radialis brevis

Abductor pollicis longus

Extensor carpi ulnaris

EXTRINSIC E X T E N S O R S OF THE T H U M B tendons of these muscles compose th anatomie snuffbox

AnatomicaI Considerations
The extrinsic extensors of th thumb are th extensor pollicis
longus, extensor pollicis brevis, and abductor pollicis longus (see
Fig. 8 - 4 7 ) . These radiai innervated muscles have their prox-
imal attachments on th dorsal region of th forearm. The
located on th radiai side of th wrist (Fig. 8 - 4 9 ) . The
tendons of th abductor pollicis longus and th extensor
pollicis brevis travel together through a fbrous tunnel within
th extensor retinaculum of th wrist (see Fig. 7 - 2 3 ) . Distai
to th extensor retinaculum, th tendon of th abductor
pollicis longus inserts primarily into th radial-dorsal surface

E xtensor indicis tendon

E xtensor digitorum tendon

FIGURE 8 - 4 6 .The two extensor tendons of th right index

finger. The extensor digitorum tendon to th index finger
(indicated by th pointed left finger) lies lateral to th exten
sor indicis tendon.

Distai attachm ent of
extensor pollicis longus
Insertion of
abductor pollicis brevis
Adductor pollicis
O pponens pollicis
Extensor pollicis brevis
Abductor pollicis longus
FIGURE 8-47. A radiai (lateral) view of th muscles, tendons, and extensor mechanism of th right hand.
! T A8 LE 8 - 4 . Anatomical and Functional Components of th Extensor Mechanism
Component Pertinent Anatomy
Central band* Direct continuation of th extensor digitorum
tendon; attaches to th dorsal side of th
base of th middle phalanx.
Lateral bands Formed frorn divistons off th centrai band;
bands fuse forming a single terminal ten
don for attachment into th dorsal side of
th distai phalanx.
Dorsal hood Transverse fiberst connect th extensor ten
don with either side of th palmar piate at
th MCP joint.
Oblique fibers course distally, fusing with th
lateral and centrai bands; serve as primary
or secondar)' attachments for lumbricals
and interossei muscles.
Oblique retinacular ligaments Consist of slender oblique-running fibers
connecting th fibrous digitai sheath to th
lateral bands of th extensor mechanism.
* Also called centrai slip,
t Also called sagittal bands.
Term inal tendon of
extensor m echanism
Fibrous digitai sheath
O blique retinacular ligament
Central band
Lateral band
O blique fib e rs-
- Dorsal
hood
Transverse fibe rs
First lumbrical
E xtensor digitorum com m unis
First dorsal interosseus
E xtensor pollicis longus
Functional Significance
1) Serves as th backbone to th extensor
mechanism.
2) Transmits extensor digitorum, interossei,
and lumbrical extension force to th
middle phalanx.
Transmit extensor digitorum, interossei, and
lumbrical extension forces to th distai
phalanx.
Transverse fibers (1) stabilize th extensor
digitorum tendon to th dorsal aspect of
th MCP joint; (2) form a sling around
th proximal end of th proximal pha
lanx. This sling is used by th extensor
digitorum to extend th MCP joint.
Oblique fibers transfer force from lumbricals
and interossei muscles into th lateral
and centrai bands, and, in this way, th
oblique fibers help extend th PIP and
DIP joints.
Help coordinate movement between th PIP
and DIP joints of th fingere.

FIGURE 8-48. The function of th extrinsic exten-
sor muscles of th hand is demonstrated. Each
muscles action is determined by th orientatton
of th line-of-force relative to th axes of rotations
at each joint (medial-lateral axes are gray; ante-
-or-posterior axes are red). Isolated contraction of
th extensor digitorum communis (EDC) hyperex-
ends th metacarpophalangeal joints. Full exten
sion of th interphalangeal joints requires assist-
ance from th tntrinsic muscles. The extensor
pollicis longus (EPL), th extensor pollicis brevis
1EPB), and th abductor pollicis longus (API) are
all primary thumb extensors. Attachments of th
abductor pollicis brevis are shown blending into
th distai tendon of th extensor pollicis longus.
of th base of th thumb metacarpal.54 The extensor pollicis
brevis attaches distally to th dorsal base of th proximal
phalanx of th thumb. The tendon of th extensor pollicis
longus crosses th wrist in a separate tunnel within th
extensor retinaculum in a groove just mediai to th dorsal
tubercle of th radius (see Fig. 7 - 2 3 ) . The extensor pollicis
longus attaches distally to th dorsal base of th distai pha
lanx of th thumb. Both extrinsic tendons help contribute to
th extensor mechanism of th thumb.
FIGURE 8-49. Muscles of th anatomie snuff box are shown.
Chapter 8 Hand 223
Functional Considerations
The multiple actions of th extensor pollicis longus, extensor
pollicis brevis, and abductor pollicis longus can be under-
stood by noting their line-of-force relative to th anterior-
posterior and medial-lateral axes of rotation at th joints
they cross (see Fig. 8 - 4 8 ) . The extensor pollicis longus ex-
tends th IP, MCP, and CMC joints of th thumb. The
muscle passes to th dorsal side of th medial-lateral axis of
th CMC joint and is therefore also capable of adducting this
joint. The extensor pollicis longus is unique in its ability to
perform all three actions that compose th repositioning of
th thumb: extension, lateral rotation, and adduction of its
metacarpal.
The extensor pollicis brevis is an extensor of th MCP and
CMC joints of th thumb; th abductor pollicis longus is an
extensor of th CMC joint of th thumb. The muscle is also
a prime abductor of th CMC joint since its line-of-force is
anterior to th joints medial-lateral axis of rotation. The dual
action of th long abductor reflects its attachment on th
radial-dorsal corner o f th base o f th thumb metacarpal.
The CMC joint is reinforced by fibers of th abductor longus
that attach into its capsule and adjacent trapezium. The
actions of all th muscles acting on th thumb are summa-
rized in Table 8 - 5 .
The extensor pollicis longus and brevis, and th abductor
pollicis longus, are all potent radiai deviators at th wrist
(see Fig. 7 - 2 1 ) . During extension of th thumb, an ulnar
deviator muscle must be activated to stabilize th wrist
against unwanted radiai deviation. Adivation is apparent by
palpating th raised tendon of th flexor carpi ulnaris, lo-
cated just proximal to th pisiform, during rapid extension
of th thumb.
 224 Section II Upper Extremity

TABLE 8 - 5 . Primary Actions of Muscles that Attach to th Thumb

CMC joint Flexion Extension

Adductor pollicis
Flexor pollicis brevis
Flexor pollicis longus
CMC joint Abduction
Abductor pollicis brevis
Abductor pollicis longus
CMC joint Opposition
Opponens pollicis
Flexor pollicis brevis
Abductor pollicis brevis
Flexor pollicis longus
Abductor pollicis longus
MCP joint* Flexion
Adductor pollicis
Flexor pollicis brevis
Abductor pollicis brevis
Flexor pollicis longus
IP joint Flexion
Flexor pollicis longus
Extensor pollicis brevis
Extensor pollicis longus
Abductor pollicis longus
Adduction
Adductor pollicis
Extensor pollicis longus
First dorsal interosseus
Reposition
Extensor pollicis longus
Extension
Extensor pollicis longus
Extensor pollicis brevis
Extension
Extensor pollicis longus
Abductor pollicis brevis (due to attachment into extensor mechanism)

* Only one degree of frcedom is considered for th MCP joint.

INTRINSIC M U S C L E S OF THE H A N D
The hand contains 20 intrinsic muscles. Despite their rela-
tively small size, these muscles are essential lo ihe fine con
trol of th digits. Topographically, th intrinsic muscles are
divided into four sets:
1. Muscles of th Thenar Eminence
Abductor pollicis brevis
Flexor pollicis brevis
Opponens pollicis
2. Muscles of th Hypothenar Eminence
Flexor digiti minimi
Abductor digiti minimi
Opponens digiti minimi
Palmaris brevis
3. Two Heads of th Adductor Pollicis
4. Lumbricals and Interossei
Muscles of th Thenar Eminence
Anatomie Considerations
The median nerve-innervated abductor pollicis brevis, jlexor
pollicis brevis, and opponens pollicis make up th bulk of th
thenar eminence (see Fig. 8 - 3 8 ) . The flexor pollicis brevis
has two parts: a superficial head, which comprises most of
th muscle, and a deep head, which comprises a small set of
poorly defined fibers, often desenbed as part of th oblique
fibers ol th adductor pollicis. 5:5 This chapter considers only
th superficial h ead w hen discussing th flexor pollicis
brevis. Deep to th abdu ctor pollicis brevis is th opponens
pollicis (Fig. 8 - 5 0 ) . All three muscles have proximal attach-
ments on th transverse carpai ligament, adjacent carpai
bones, and connective tissues. The short abductor and flexor
have similar distai attachmenis to th radiai side of th base
of th proximal phalanx. The abductor pollicis brevis at-
taches to th radiai side of th extensor mechanism of th
thumb; th flexor pollicis brevis frequently attaches to a
sesamoid bone; and th opponens pollicis attaches distally to
th radiai border of th thumb metacarpal.
Functional Considerations
A primary responsibility of th muscles of th thenar enu-
nence is to position th thumb in varying amounts of oppo-
sition, usually to facilitate grasping. As discussed earlier, op-
position combines elements of CMC joint abduction, flexion
and mediai rotation. Each muscle within th thenar emi
nence is a prime mover for at least one component of oppo-
sition and an assistant for several others (see Table 8 - 5 ) . 28
The action of each of th thenar muscles is based on their
line-of-force relative to a particular axis of rotation (Fig. 8 -
51). The abductor pollicis brevis and longus abduct th
metacarpal away from th piane of th palm. The flexor
pollicis brevis, and to a lesser extern th mediai fibers of th
abductor pollicis brevis, flex th thumb at both th MCP
and CMC joints. The opponens pollicis has a line-of-force to
medially rotate th thumb toward th fingers. Because th
opponens pollicis has its distai attachment on th metacar
pal, its entire contractile force is dedicated to controlling th
CMC joint.
Injury to th m edian nerve can disable all com p on en ts o f
opposition. The thenar eminence becomes fiat owing to
musc/e atrophy. The inability to oppose th thumb greatly
reduces th grasping function of th entire hand. About 30%

'1GURE 8-50. A palmar view of th
ceep muscles of th right hand. The
;oductor and flexor musdes of th
nenar and hypothenar eminence
bave been cut away to expose th
underlying opponens pollicis and
opponens digiti minimi.
FIGURE 8-51. The action of th thenar and hypothenar musdes
during opposition of th thumb and cupptng of th little finger.
Muscle function is based on th musdes line-of-force relative to
each joints axes of rotation. (Medial-lateral axes are in gray; ante-
rior-posterior axes are in red.) Other musdes shown in an active
state are th flexor pollicis longus and flexor digitorum profundus
of th little finger. The flexor carpi ulnaris (FCU) stabilizes th
pisiform bone for th abductor digiti minimi. (F = flexor pollicis
brevis and flexor digiti minimi; O = opponens pollicis and oppo
nens digiti mimmi; A = abductor pollicis brevis and abductor digiti
minimi.)
Chapter 8 Hand 225
P alm ar view
of th abduction torque of th thumb is retained, however,
owing to th presence of th radial-nerve innervated abduc
tor pollicis longus.5
A. S P E C I A L F O C U S
Abductor Pollicis Brevis as an Assistant Extensor of
th Interphalangeal Joint of th Thumb
The abductor pollicis brevis has extensive attachments
into th extensor mechanism of th thumb.55 This at-
tachment allows th short abductor to assist with ex-
tension of th IP joint (see Fig. 8-48).5' Persons with
radiai nerve injury often utilize this function as a substi-
tute following paralysis of th extensor pollicis longus.
The clinician must be aware of th potential for this
substitution strategy when testing th integrity of radiai
nerve innervation of th thumb.
Muscles of th Hypothenar Eminence
Anatomie Considerations
The muscles of th hypothenar eminence are th flexor digiti
minimi, abductor digiti minimi, opponens digiti minimi, and pal-
maris brevis (see Fig. 8 - 3 8 ) . The abductor digiti minimi is
th most superficial and mediai of these muscles, occupying
th extreme ulnar border of th hand. The relatively small
flexor digiti minimi is located just lateral to, and often
blended with, th abductor. Deep to these muscles is th
opponens digiti minimi, th largest of th hypothenar mus
cles. The palmaris brevis is a relatively thin and insignificant
 226 Section II Upper Exiremity

muscle aboui ihe thickness of a postage stamp. It attaches

beiween che transverse carpai ligament and an area of skin S P E C I A L F O C U S
jusc distai to th pisiform bone. The palmaris brevis raises
(he height of th hypothenar eminence to assist with th Sp
cupping of th ulnar border of th hand. "Tension Fraction'' of a Muscle
The overall anatomie pian of th hypothenar muscles is The adductor pollicis has a relatively large cross-sec-
similar to that of th muscles of th thenar eminence. The tional area and is therefore capable of generating large
(lexor digiti minimi and opponens digiti minimi sitare proxi- active forces. As a method to compare cross-sectional
mal attachments to th transverse carpai ligament and th areas of this and other muscles, Brand and colleagues9
hook of th hamate. The abductor digiti minimi has exten-
have assigned each muscle below th elbow a relative
sive proximal attachments from th pisohamate ligament, tension fraction. This measurement is determined by
pisiform bone, and Ilexor carpi ulnaris tendon. During re- dividing a muscle's physiologic cross-section by th to
sisted or rapid abduction of th little finger, th flexor carpi tal cross-sectional area of all muscles below th elbow
ulnaris becomes rigid io stabilize th attachment for th (Table 8-6). This value, expressed as a percentage,
abductor digiti minimi. This effect can be verified by palpat- provides an estimate of each muscle's relative force
ing th tendon of th flexor carpi ulnaris just proximal to capability. The adductor pollicis has a tension fraction
th pisiform bone while performing this motion.
almost twice that of th average of all muscles of th
The abductor and flexor digiti minimi both have similar
thenar eminence. Data on tension fraction have been
distai attachments to th mediai border of th base of th used by surgeons to help them decide on th most
proximal phalanx of th little finger. Some fibers from th appropriate muscle for use in reconstructive hand sur-
abductor also extend to th ulnar side of th extensor ntech- gery.
anism. The opponens digiti minimi has its distai attachment
along th ulnar border of th fifth metacarpal, proximal to
th MCP joint. TABLE 8 - 6 . Tension Fractions (% ) of Seleetcd
Muscles
Functional Considerations
A common function of th hypothenar muscles is to cup th Supinator 7.1
ulnar border of th hand and deepen th distai transverse Extensor carpi radialis brevis 4.2
arch (Fig. 8 - 5 1 ) . The flexor digiti minimi flexes th fifth Dorsa! interosseus (index) 3.2
MCP and CMC joints. When needed, th abductor digiti Abductor pollicis longus 3.1
minimi can spread th little finger for greater control of Adductor pollicis 3.0
grasp. The opponens digiti minimi Controls th rotation of Pronator quadratus 3.0
th fifth metacarpal toward th middle digit. Contraction of Flexor digitorum profundus (index) 2.8
Flexor pollicis longus 2.7
th long finger flexors of th little finger, such as flexor
Flexor digitorum superficialis (index) 2.0
digitorum profundus, also contributes to th cupping motion Opponens digiti minimi 2.0
at th fifth CMC joint. Opponens pollicis 1.9
Injury io th ulnar nerve can cause complete paralysis of Abductor digiti minimi 1.4
th hypothenar muscles. The hypothenar eminence becomes Extensor pollicis longus 1.3
fiat owing to muscle atrophy. Cupping of th ulnar border Flexor pollicis brevis 1.3
therefore becomes difficult or impossible. Palmar interosseus (index) 1.3
Abductor pollicis brevis 1.1
Two Heads of th Adductor Pollicis Muscle Extensor digitorum communis (index) 1.0
Extensor pollicis brevis .8
The adductor pollicis is a two-headed muscle lying deep in Flexor digiti minimi .4
th web space of th thumb, palmar to th second and third Lumbrical (index) .2
metacarpals (see Fig. 8 - 5 0 ) . The oblique head has its proxi
mal attachment on th capitate bone, th bases of th sec Data from Brand PW, Beach RB, Thompson DE: Relative tension
ond and third metacarpals, and other adjacent connective and potential excursion of muscles in the forearm and hand J Hand
tissues. The triangular transverse head has its proximal at Surg 6A :209-219, 1981.
tachment on th palmar surface of th third metacarpal
bone. Both heads join before attaching to th ulnar side of
th base of th proximal phalanx of th thumb and often to
a sesamoid bone located near th MCP joint.
Maximal force generation of th adductor pollicis exerts a stabilized, the first dorsal interosseus muscle can assist the
vigorous flexion and adduction torque on th thumb. The adductor pollicis with this function.
force is important when firmly pinching an object between
th thumb and th fingers. Figure 8 -5 2 A illustrates th large Lumbricals and Interossei Muscles
flexion potential ol th adductor pollicis at th CMC joint. The lumbricals (from the Latin root lumbricus; an earthworm
Note th very long moment arm available to th transverse are four very slender muscles originating from the tendons
h ead fo r this action. Based on leverage and Cension fraction, o f the flexor digitorum profundus (see Fig. 8 - 3 8 ) . L ike the
th adductor pollicis is th most potent Ilexor at th CMC flexor digitorum profundus, the lumbricals have a dual
Figure 8-52B
jo in t . illustrates th very large moment arm source of innervation: the two lateral lumbricals are inner-
available to th transverse head of th adductor pollicis for vated by the median nerve, and the two mediai lumbricals
adduction at th CMC joint. With th index finger well are innervated by the ulnar nerve.
 Chapter 8 Hand 111

FIGURE 8 - 5 2 . The biplanar action of th adductor pollicis muscle is illustrated using a pair of scissors for llexion (A) and adduction (B)
at th carpometacarpal joint. In both A and B, th transverse head of th adductor pollicis produces a signilcant torque owing to its
long moment arm about an anterior-posterior axis (red, A) and medial-lateral axis (gray, B). The adductor pollicis is also a potent flexor
of th metacarpophalangeal joint.

All Tour lumbricals show marked anatomie variation in
both size and attachments.55 From their tendinous proximal
attachments, th lumbricals course palmar to th deep inter-
metacarpal ligament, then pass around th radiai side of th
MCP joints. Distally, th lumbricals blend with th oblique
fibers of th dorsal hood (see Fig. 8 - 4 7 , first lumbrical).
The distai attachment enables th lumbricals to exert a pul
through th centrai and lateral bands of th extensor mecha-
nism.
The function of th lumbricals has been a topic of study
for many years (see references 2, 10, 32, 34, 43, and 52).
Muscle contraction produces extension ai both th P1P and
D1P joints and flexion at th MCP joints.2 This seemingly
paradoxical action is possible because th lumbricals pass
palm ar io th MCP joints and dorsal to th PIP and DIP
joints (Fig. 8 - 5 3 ) .
Of all th intrinsic muscles of th hand, th lumbricals
have th longest fiber length, but th smallest tension frac-
tion.g'25 This anatomie design suggests that these muscles are
capable of generating only small amounts of force over a
relatively long distance.
The interassei muscles are named according to their loca-

Distai interphalangeal Proximal interphalangeal Metacarpophalangeal Extensor digitorum

joint joint joint communis tendon (cut)

FIGURE 8 - 5 3 . The combined action of

th lumbricals and interassei are
shown as flexors at th metacarpopha
langeal joint and extensors ai th in-
terphalangeal joints. The lumbrical is
shown with th greatest moment arm
for flexion at th metacarpophalangeal
joint. (Td = trapezoid bone).
228 Section II Upper Extremity
tion in th regions between th shafts of th metacarpal
bones (see Figs. 8 - 4 and 8 - 5 ) . 55 In generai, th interossei
act at th MCP joints to spread th digits apart (abduction)
or bring them together (adductton). The anatomy and pre
cise action of each interosseus muscle is slightly differ-
e n t 18.50,53
The four palm ar interossei are slender, single-headed mus-
cles occupying th palmar region of th interosseous spaces.55
The three palmar interossei to th fingers have their proxi-
mal attachments on th palmar surfaces and sides of th
second, fourth, and fifth metacarpals (see Fig. 8 - 5 0 ) . These
muscles have their primary distai attachments into th
oblique fibers of th dorsal hood. The palmar interossei
adduci th second, fourth, and fifth MCP joints toward th
midiine of th hand (Fig. 8 - 5 4 ) . The palmar interosseus
muscle to th thumb occupies th first palmar interosseous
space, having a primary distai attachment to th ulnar side
of th proximal phalanx of th thumb, and often into a
sesamoid bone at th MCP joint.55 This muscle flexes th
MCP joint of th thumb, bringing th first metacarpal
toward th middle digit of th hand.
The four dorsal interossei fili th dorsal sides of th inter
osseous spaces (see Fig. 8 - 4 4 ) . In contrast to th palmar
interossei, th dorsal muscles have a bipennate shape. As a
generai rule, th dorsal interossei have distai attachments
into th side of th base of th proximal phalanx and into
th oblique fibers of th dorsal hood. The first dorsal inter
osseus attaches mostly into bone. The dorsal interossei ab-
duct th MCP joints of th index, middle, and ring fingers
Palm ar interossei
FIGURE 8 54 A palmar view o f th franta! piane action of th palmar interossei (PI, to PI4) and dorsal interossei (DI, to DI.,) at th
metacarpophalangea! joints of th hand. The abductor digiti minimi is shown abducting th little finger.
away from an imaginary reference line through th middle
digit (see Fig. 8 - 5 4 ) . Abduction of th fifth MCP joint is
performed by th abductor digiti minimi of th hypothenar
group.
In addition to abducting and adducting th fingers, th
interossei and abductor digiti minimi provide an important
source of dynamic stability to th MCP joints. By vtsually
superimposing th two hands shown in Figure 8 - 5 4 , it is
apparent that each MCP joint of th fingers receives a pair of
abducting and adducting muscles. Each pair acts as a set of
dynamic collateral ligaments, providing strength to th MCP
joints and subsequently th arch System of th hand. Acting
in pairs, this intrinsic musculature also Controls th extern of
axial rotation permitted at th MCP joints.
To varying degrees, both palmar and dorsal interossei
have a line-of-force that passes palmar to th MCP joints.
The interossei, via their attachments into th extensor mech-
anism, pass dorsal to th IP joints of th fingers (see Fig. 8 -
53). Like th lumbricals, therefore, contraction of th inter
ossei causes flexion at th MCP joint and extension at th IP
joints. The interossei produce greater flexion torques at th
MCP joints than th lumbricals. Even though th lumbricals
have th larger moment arm for this action, th 20-fold
greater tension fraction of th interossei provides them with
th overpowering flexion torque advantage (Table 8 - 6 ) . In
contrast to th lumbricals, th interossei produce relativelv
larger forces, but over a shorter excursion.25 Table 8 - 7 sum-
marizes some of th differences and similarities between th
lumbricals and interossei.
Dorsal interossei
p
Muscular Bomechanics of a "Key Pinch"
Pinching an object between th thumb and th lateral
side of th index finger is an important function of th
hand. This action is often referred to as a key pinch.
Several muscles interact to produce an effective key
pinch, most notably th first dorsal interosseus and th
adductor pollicis two ulnar nerve innervated muscles.
An especially large force is demanded from th first
dorsal interosseus muscle during th key pinch. This de-
mand can be appreciated by palpating its prominent belly
during th key pinch, about 2.5 cm proximal to th lateral
side of th MCP joint of th index finger. For an effective
pinch, th first dorsal interosseus muscle must provide a
strong counteracting pinch force against th potent pinch
force of th thumb (see PF, vs. PFT in Fig. 8-55). Flexion,
FIGURE 8-55. A dorsal view of th muscle mechamcs of a key
pinch. Illustrated in lighter red, th adductor pollicis and flexor
pollicis brevis are shown producing a pinch force through th
thumb (PFt). In dark red, th first dorsal interosseus is shown
opposing th pinch force through th thumb by producing a
pinch force though th index finger (PF,). The extemal moment
arm (EMA) at th metacarpophalangeal joint equals 5 cm; th
internai moment arm (IMA) at th metacarpophalangeal joint
equals 1 cm.
th "strongest" of all thumb movements,28 is driven pri-
marily by th adductor pollicis and flexor pollicis brevis.
The internai moment arm used by th first dorsal inter
osseus for abduction at th MCP joint of th index finger
is about 1 cm. The pinch force applied by th thumb
against th MCP joint of th index finger acts with an
"external" moment arm of about 5 cm. This 5-fold differ-
ence in leverage across th MCP joint requires that th
first dorsal interosseus must produce a force 5 times th
pinching force applied by th thumb. Since many func-
tional activities require a pinch force that exceeds 45 N
(10 Ib), th first dorsal interosseus must be able to
produce an abduction force of 225 N (50 Ib)! Skeletal
muscle is capable of producing about 28 N/cm2 (40 Ib/
in2); therefore, an average first dorsal interosseus muscle,
with a cross-section area of about 3.8 cm2, produces only
about 106 N (-24 Ib) of force.15 The additional stabilizing
force required to brace th index finger must be supplied
by other muscles, such as th second, and perhaps th
third, dorsal interosseus.
With an ulnar nerve lesion, th adductor pollicis mus
cle th primary pinching muscle of th thumb and all
interossei muscles are paralyzed. The strength of a key
pinch is significantly reduced following a nerve block to
th ulnar nerve. The region around th dorsal web space
becomes hollow owing to atrophy in th above muscles
(see Fig. 8-56). A person with an ulnar nerve lesion often
relies on th flexor pollicis longus (a median nerve-inner-
vated muscle) to partially compensate for th loss of
thumb pinch. This compensation is evident by th partially
flexed IP joint of th thumb known as th Froment's
sign. Pinch stili remains weak, however, because th dor
sal interossei are not able to stabilize against th flexion
force of th thumb.
FIGURE 8-56. A person with an ulnar nerve lesion attempting to
make a key pinch. Note th atrophy over th region of th first
dorsal interosseus muscle. The flexion at th interphalangeal joint
of th thumb is a way lo help compensate for th paralysis of th
adductor pollicis.
 230 Section II Upper Extremity

TABLE 8 - 7 . Anatomical and Functional Comparison Between th Lumbricals and Interossei Muscles

Lumbricals Dorsai Interossei Palmar Interossei

Innervation Lateral: median nerve
Mediai: ulnar nerve
Distai attachments Lateral margin of th dorsai
hood of th extensor mech
anism
Contrattile characteristics Produce a relatively small force
over a long excursion
Prime action MCP joint llexion and IP joint
extension
Comments May have significant anatomie
variation
Ulnar nerve Ulnar nerve
Dorsai hood of extensor mech Dorsai hood of extensor mechanism
anism and proximal phalanx
Produce a relatively large force Produce a relatively large force over
over a short excursion a shon excursion
Abduction; MCP joint flexion Adduction; MCP joint flexion and IP
and IP joint extension joint extension
First dorsai interosseus attaches
almosi exclusively to th
proximal phalanx of th in
dex finger

Interaction of th Extrinsic and Intrinsic scribed subsequently, th extensor mechanism provides th

Muscles of th Fingers
Contraction of th intrinsic muscles of th hand (lumbricals
and interossei) produce MCP joint flexion with IP joint ex-
tension (see Fig. 8 - 5 3 ) . This position is called th intrinsic-
plus position. In contrast, contraction of th extrinsic muscles
(extensor digitorum, (lexor digitorum superficialis, and flexor
digitorum profundus) produces a position of MCP joint hy-
perextension with IP joint flexion: th extrinsic-plus position.
The two contrasting positions are presented in Figure 8 - 5 7 .
Most tneaningful motions of th fingers involve a muscular
interaction of both extrinsic and intrinsic muscles. As de-
mechanical linkage between these sets of muscles. Interac
tion between th extrinsic and intrinsic muscles produces
many combinations of movements at both th finger and th
thumb. The following analysis addresses th muscular inter
action within a typical finger during two fundamental tasks:
opening and closing o f th hand. Much of this material, espe-
cially that involving th actions of th lumbricals and inter
ossei, remains controversial. A complicating factor is that
persons often select different combinations of hand muscles
to perform identical functional tasks.26
OPENING THE HAND: FINGER EXTENSION

Opening th hand is often performed lo prepare for a grasp.

The action occurs through coordinated motions of extension
at th MCP and th IP joints of th fingers. Extension of th
thumb occurs through a coordinated action of all of its
joints.

Primary Muscular Activity

The greatest resistance to complete extension of th fingers is
usually not from external sources, but from th passive resis-
tance generated by th stretching of th extrinsic finger flex-
ors, in particular th flexor digitorum profundus.33 The pas
sive recoil force inherent to this muscle is responsible for th
partially flexed posture of a relaxed hand.
The primary extensors of th fingers are th extensor digi-
torum communis and th intrinsic muscles, specifically th
lumbricals and interossei (Fig. 8 - 5 8 ) . 10'34 The lumbricals
show a greater and more consistent EMG level than th
interossei during finger extension.34
Figure 8 -5 8 A shows th extensor digitorum communis
exerting a force on th extensor mechanism, pulling th
MCP joint toward extension. The intrinsic muscles fumish
both a direct and an indirect effect on th mechanics of
extension of th IP joints (Fig. 8 - 5 8 B and C). The direct
effect is provided by th proximal pul on th bands of th
extensor mechanism; th indirect effect is provided by th
FIGURE 8-57. The extrinsic-plus and intrinsic-plus positions of th production of a flexion torque at th MCP joint. The flexion
hand. torque restrains th extensor digitorum from hyperexiending
 Chapter 8 Hand 231

Opening th hand

(FCR)

FIGURE 8-58. A lateral view of th intrinsic and extrinsic muscular interactions at one finger during th opening
of th hand. The dotted outlines depct starting positions. A, Early phase: The extensor digitorum communis is
shown extending primarily th metacarpophalangeal joint. B, Middle phase: The intrinsic muscles (lumbricals and
interossei) assist th extensor digitorum communis with extension of th proximal and distai interphalangeal
joints. The intrinsic muscles also produce a flexion torque at th metacarpophalangeal joint that prevents th
extensor digitorum communis from hyperextending th metacarpophalangeal joint. C, Late phase: Muscle activa-
tion continues through full finger extension. Note th activation in th flexor carpi radialis to slightly flex th
wrist. Observe th proximal migration of th dorsal hood between flexion and full extension. (The intensity of
th red indicates th relative intensity of th muscle activity.)

th MCP jo in t an action that may prematurely dissipate
most of its contractile force. Only with th MCP joint
blocked from hyperextending can th extensor digitorum
contribute an effettive IP joint extension force throughout
th bands of th extensor mechanism.
The extensor digitorum and th intrinsic muscles must
cooperate to perform complete finger extension. The oppos-
tng actions of these muscles ai th MCP joint permit them to
function synergistically at th IP joints. The importance of
this cooperative relationship is apparent by observing a per-
son with a lesion to th ulnar nerve (Fig. 8 -5 9 A ). Without
active resistance from either th lumbricals or interossei in
th mediai two fingers, activation of th extensor digitorum
communis causes th characteristic clawing of th fingere.
The MCP joints hyperextend, and th IP joints remain par-
tially flexed. This is often called th intrinsic-minus posture
because of th lack of intrinsic-innervated muscle. (This pos
ture is functionally similar to th extrinsic-plus posture
 232 Seclion U Upper Extremity

FIGURE 8-59. Attempts to extend [he fngere with an ulnar nerve lesion and a paralysis of th most intrinsic muscles of th fngere. A,
The mediai fngere show th claw position with metacarpophalangeal joints hyperextended and fngere partially flexed. Note th atrophy
in th hypothenar eminence and interosseous spaces. B, By manually holding th metacarpophalangeal joints into flexion, th extensor
digitorum communis, innervated by th radiai nerve, is able to fully extend th interphalangeal joints.

depicted earlier.) Without th MCP joint flexion torque nor-
mally provided by th intrinsic muscles, th extensor digito
rum communis is capable of only hyperextending th MCP
joints. This posture increases th passive tension in th
stretched flexor digitorum profundus, thereby further limit-
ing full IP joint extension. As shown in Figure 8 - 5 9 6 , by
manually providing a flexion torque across th MCP joint
(i.e., a force normally fumished by th intrinsic muscles),
contraction of th extensor digitorum communis fully ex-
tends th IP joints. Blocking of th MCP joint from hyperex
tending also slackens th profundus tendon, thereby mini-
mizing passive resistance to IP joint extension.
Function of Wrist Flexors during Finger Extension
Activation of th wrist flexors normally accompanies fnger
extension. Although activity is depicted only in th flexor
carpi radialis in Figure 8 - 5 8 , other wrist flexors are also
active. The wrist flexors offset th potent extension potential
of th extensor digitorum at th wrist. The wrist actually
flexes slightly throughout full fnger extension, especially
when performed rapidly. (Compare Figure 8 - 5 8 A with Fig
ure 8 -5 8 C .) Wrist flexion helps maintain optimal length of
th extensor digitorum during active finger extension.
retinacular ligament (Fig. 8 - 6 0 , steps 1 - 3 ) . The passive
force in th elongated oblique ligament is transferred distally,
helping to initiate extension at th DIP joint (Fig. 8 - 6 0 , step
4). The oblique retinacular ligament is sometimes called th
link ligament, suggesting its probable role in synchronizing
extension at both joints.
The oblique retinacular ligament may become tight owing
to arthritis, trauma, or Dupuytrens contracture. Dupuytrens
contracture is a condition of nodular proliferation in th
palmar fascia of th hand, causing a flexed posture of th
fingere, especially on th mediai side of th palm. Tightness
in this structure can cause flexion contracture at th PIP
joint. Attempts at passively extending a PIP joint with a tight
oblique retinacular ligament are often associated with a pas
sive extension of th DIP joint.
Active finger extension
4.

Passive Forces Produced by th Oblique

Retinacular Ligaments
As depicted in Figure 8 - 4 7 , th oblique retinacular liga
ments have proximal attachments on either side of th fi-
brous digitai sheaths surrounding th flexor tendons, just
proximal to th PIP joint. The distai ends of these ligaments
attach to th lateral bands of th extensor mechanism. Each
oblique ligament courses from th palmar side of th PIP
joint to th dorsal side of th DIP joint. Their oblique direc
tion helps coordinate extension between th DIP and PIP
FIGURE 8-60. The transfer of passive force in th stretched oblique
joints.21 The extensor digitorum communis and intrinsic retinacular ligament during active extension of th fnger. The num-
muscles extend th PIP joint, which stretches th oblique bered sequence (1 to 4) indicates th chronologic order of events.
 Chapter 8 Hand 233

iOSING THE HAND: FINGER FLEXION
Ilosing th hand requires a coordinated flexion of th MCP,
IP, and DIP joints of th fingers along with flexion and
pposition of th thumb.
Jtimary Muse le Action
The muscles needed to dose th hand depend in part on th
peciftc joints that need to be flexed and on th force re-
-uirements of th action. Flexing th fingers against a con-
-iderable resistance (i.e., making a high-powered fist) re-
.uires activation from th flexor digitorum profundus, flexor
digitorum superficialis, and interassei muscles (Fig. 8 -6 1 A ).
~orces from th flexor digitorum profundus and superficialis
combine to flex all three joints of th fingers. The flexing
mger pulls th extensor mechanism distally by severa! milli-
meters.
During hand closure against a considerable resistance, th
merossei muscles exhibit a very high level of EMG activity.34
The interassei can produce relatively large flexion torques at
th MCP joint. The lumbrcals, in contrast to th interassei,
show essentially no EMG activity during resisted or nonres-
tsted closing of th hand. The lack of activation, however,
does not mean that th lumbrcals are incapable of produc-
ing use fui forces. Recali that th lumbrcals attach between
th flexor profundus and th extensor mechanism. During
active finger flexion, th lumbrcals are stretched in a proxi-
mal direction owing to th contracting flexor profundus and,
at th same time, stretched in a distai direction owing to th
distai migration of th extensor mechanism (Fig. 8 - 6 1 B ,
bidirectional arrow in lumbrical). Between full fnger exten-
sion and full active flexion, a lumbrical must stretch an
extraordinary distance.43 The stretch generates a passive flex
ion torque at th MCP joint, which supplements th active
flexion torque produced by th interassei and extrinsic mus-
culature.
Injury to th ulnar nerve can cause paralysis of most of
th intrinsic muscles, resulting in a noticeably weakened
grasp. When making a fist, th sequencing of flexion across
th joints is altered. Normally, at least in th radiai three
fingers, th P1P and DIP joints flex first, followed closely in
time by flexion at th MCP joints. With paralyzed intrinsic
muscles, especially if overstretched by chronic hyperexten-
sion of th MCP joints, th initiation of flexion at th MCP
joints is delayed slightly. The resulting asynchronous flexion
may interfere with th quality of th grasp.

Closing th hand

FIGURE 8-61. A side view of th intrinsic and extrinsic muscular interaction at one fnger during a high-powered
closing of th hand. The dotted outlines depict th starting positions. A, Early phase: The flexor digitorum profundus,
flexor digitorum superficialis, and interassei muscles actively flex th joints of th finger. The lumbrical is shown as
being inactive (white). B, Late phase: Muscle activation continues essentially unchanged through full flexion. The
lumbrical remains inactive, but is stretched across both ends. The extensor carpi radialis brevis is shown extending th
wrist slightly. The extensor digitorum communis helps decelerate flexion of th metacarpophalangeal joint. Note th
distai migration of th dorsal hood between th early and late phases of flexion. (The intensity of th red indicates th
relative intensity of th muscle activity.)
234 Section 11 Upper Extremity
In conirast to a high-powered fisi, a light, low-powered
fist produces EMG activiiy almost exclusively frorn th flexor
digitorum profundus. Because this muscle crosses all th
joints of th fingere, its activation alone is minimally ade
quate to lightly dose th fist. The flexor digitorum superfici-
alis functions more as a reserve muscle, becoming active
during a high-powered fist, or when isolated PIP joint flex-
ion is required.
Extensor digitorum shows consistent EMG aciivity while
closing th hand.33 This activity refiecis th musdes role as
an extension brake at th MCP joint. This important stabili-
zation function allows th long finger fiexors to shift their
action distally to th PIP and DIP joints. Without coactiva-
tion of th extensor digitorum, th long finger fiexors ex-
haust most of their flexion potential over th more proximal
MCP joints, reducing their potential for more refined actions
at th more distai joints.
Function of Wrist Extensors During Finger Flexion
Making a strong fisi requires strong synergistic activation
from th wrist extensor muscles (see Fig. 8 - 6 1 , extensor
carpi radialis brevis). Wrist extensor activity can be verified
by palpating th dorsum of th forearm while making a fist.
As explained in Chapter 7, th primary function of th wrist
extensors, including th extensor digitorum, is to neutralize
th strong wrist flexion tendency of th activated extrinsic
finger fiexors (see Fig. 7 - 2 4 ) . Wrist extension, while closing
th hand, also helps to maintain an optimal length of th
extrinsic finger fiexors. (Compare Figure 8 -6 1 A with Figure
8 - 6 1 B .) Il th wrist extensore are paralyzed, attempts at
making a fist result in a posture of wrist flexion and finger
flexion. When combined with th increased passive tension
in th overstretched extensor digitorum, th overshortened,
activated finger fiexors cannot produce an effective grip (see
Fig. 7 - 2 6 ) .
HAND AS AN EFFECTOR ORGAN
The hand functions as an effector organ of th upper ex
tremity for support, manipulation, and prehension. As a sup-
porl, th hand acts in a nonspecific manner to brace or
stabilize an object, often freeing th other hand for a more
specific task. The hand may also be used as a simple plat-
form to transfer or accept forces, such as when supporting
th head when tired or when assisting in standing from a
seated position.
Perhaps th most varied function of th hand is its ability
to dynamically manipulate objects. The number of ways th
digits are used to manipulate objects is essentially infinite. In
a very generai sense, however, th hand manipulates objects
in two fundamentally different ways: digitai motions may be
repetitive and blunt, like typing or scratching; and, in con
tras!, digitai motions may be continuous and fluid, in which
th rate and iniensity of motion are controlled, like writing
or sewing. And, of course, many if not most types of
digitai manipulation combine both of these elements of
movement.
Prehension describes th ability of th fingere and thumb
to grasp or to seize, often for holding, securing, and picking
up objects. Over th years, several terms have evolved to
describe th many forms of prehension.31-39 Most forms of
prehension can be described as a grip (or grasp), in which
all digits are used, or as a pinch, in which primarily th
thumb and index finger are used. Each of these forms of
prehension can be lurther classified based on th need for
power (loosely defined as high force without regard to th
exactness of th task) or precision (i.e., high level of exact-
ness with low force). Basically, most types of prehension
activities fall into one of five types:
1. Power grip is used when stability and large forces are
required from th hand, without th need lor precision. The
shape of th held objects tends to be spherical or cylindrical.
Using a hammer is a good example of a power grip (Fig. 8 -
62A). This aciivity requires strong forces from th finger
fiexors, especially from th fourth and fifth digits; mtrinsic
muscles of th fingere, especially th interassei; and th
thumb adductor and flexor musculature. Wrist extensors are
needed to stabilize th partially extended wrist.
2. Precision grip is used when control and/or some deli
cate action is needed during prehension (Fig 8 - 6 2 B and C).
The thumb is usually held partially abducted, and th fingere
are partially flexed. Precision grip uses th thumb and one
or more of th digits to imprave grip security or to adc j
variable amounts of force. The precision grip is modified t.
fit objects of varied sizes by altering th contour of th disu
transverse arch of th hand (Fig. 8 - 6 2 D to F).
3. Power (key) pinch is used when large forces are neeck-z
to stabilize an object between th thumb and th lat-:'z
border of th index finger (Fig. 8 -6 2 G ). The power pinch *
an extremely useful form of prehension, combining th force
of th adductor pollicis and firet dorsal interosseus with re
dexterity and sensory acuity of th thumb and index finse-
The biomechanics of th power key pinch are illustratec zi
Figure 8 - 5 5 .
4. Precision pinch is used to provide fine control to :r -
jects held between th thumb and index finger, without :h*
need for power. This type of pinch has many forms, such a
th tip-to-tip or pulp-to-pulp method of holding an o b j(4
(Fig. 8 - 6 2 H and I). Tip-to-tip pinch is used especially
tiny objects, w'hen skill and precision are required. Pulp-u
pulp pinch provides greater surface area for contaci
larger objects, thereby increasing prehensile security.
5. Hook grip is a form of prehension that does not o ]
volve th thumb. A hook grip is fonned by th partiair
flexed PIP and DIP joints of th fingere. This grip is .
used in a static nature for prolonged periods of time. s
as holding a luggage strap (Fig. 8 - 6 2 J). The force oi
 Chapter 8 Hand 235

FIGURE 8-62. A healthy hand is shown performing common types of prehension functions. A, Power grip. B, Precision grip to hold an
egg. C, Precision grip to throw a baseball. D to F, Modifications of th precision grip by altenng th concavity of th distai transverse
arch. G, Power key pinch. H, Tip-to-lip prehension pinch. I, Pulp-to-pulp prehension pinch. J, Hook grip.

hook grip is usually produced by relatively low level activity
from th flexor digitorutn profundus.
The categories of prehension now described do not in
clude all of th possible ways that th hand can be used as
an effector organ. These defnitions can, however, establish a
common reference for clinical communication. To illustrate,
consider th terminology to describe methods of using three
common tools. As shown in Figure 8 63A, tightening a
screw involves a precision pinch to hold th screw and a
combinai power grip and power pinch to rotate th screw-
driver. The manipulation or rotation of th screwdriver in
this case is performed by supination of th forearm complex.
As shown in Figure 8 - 6 3 B , a one-handed task of adjusting a
wrench requires a power grip prehension of th mediai fn
gere and a manipulation of th index fnger and thumb. As a
final example, consider th holding of a pliers (Fig. 8 -6 3 C ).
The thumb and index finger are in a modified power (key)
pinch; th one upper handle of th pliers is supportai by th
palm; and th other handle is manipulated by action of th
finger flexors.
 236 Section II Upper Extremity

FIGURE 8 63. Examples of th lerminology to describe th use of three common tools. A, Handling a screwdriver by a predsion pinci of
th tight hand and a combined power grip and power pinch of th left hand. B, A one-handed task of adjusting a wrench requires a power
grip by th mediai ftngers and a manipulation prehension of th index finger and thumb. C, Using pliers requires that th thumb and
index finger produce a power pinch. The upper handle of th pliers is supported by th palm and th lower handle is manipulaied by
action of th finger flexors.

JOINT DEFORMITIES CAUSED BY
RHEUMATOID ARTHRITIS
One of th more destructive aspects of rheumatoid arthritis
is chronic synovitis. Over time, synovitis tends to reduce th
tensile strength of th periarticular connective tissues. With-
out th normal restraint provided by these tissues, forces
from muscle contraction and th extemal environment can
destroy th mechanical integrity of a joint. The joint often
becomes malaligned, unstable, and frequently deformed per-
manently. Knowledge of th pathomechanics of common
hand deformities associated with rheumatoid arthritis is a
prerequisite for effective treatment.
Zig-Zag Deformity of th Thumb
Advanced rheumatoid arthritis often results in a zig-zag de
formity of th thumb. As defined in Chapter 7, zig-zag
deformity describes th collapse of multiple interconnected
joints in altemating directions. A common example of this
deformity involves CMC joint flexion and adduction, MCP
joint hyperextension, and IP joint flexion (Fig. 8 - 6 4 ) . In
this example, th collapse of th thumb starts with instability
at th CMC jo in t.38 Ligaments that normally retnforce th
mediai side of th joint, such as th anterior oblique liga-
ment and th ulnar collateral ligaments, weaken and/or rup-
ture owing to th disease prncess. Subsequem ly, th base o f
th thumb metacarpal disiocates off th Iateral edge of th
trapezium. Once this dislocation occurs, th adductor and
short flexor muscles, which are often in spasm, hold th
thumb metacarpal rigidly against th palm. In time, rheuma
toid disease may cause th muscles to become fibrotic and
permanently shortened, maintaining th deformity at th
CMC joint. In efforts to extend th rigid thumb out of th
palm, a compensatory hyperextension deformity at th MCP
joint often occurs. A weakened palmar piate offers little
resistance to th forces produced by th extensor pollici?
longus and brevis. Eventual bowstringing of these tendoni
across th MCP joint increases their leverage as extensor?
thereby further contributing to th hyperextension deformile
The IP joint tends to remain flexed owing to th passive
tension in th stretched flexor pollicis longus.
Clinical management of a zig-zag deformity of th thumb
depends on th mechanics of th collapse and th severity of I
th underlying disease. Splinting and/or surgery is often ir.-1
dicated to reestablish proper joint alignment, especially at
th CMC joint. Reconstruction of th CMC joint using th I
tendon of th flexor carpi radialis is often performed.12 Be-
cause ol th chronic nature of rheumatoid arthritis and th
complexity of th CMC joint, artifcial joint replacement
often unsuccessful.
Destruction of th Metacarpophalangeal
Joints of th Finger
A dvanced rheu m atoid arthritis is often associated w ith defot-
mities at th MCP joint of th fingers. Two common defor
mities are a palmar dislocation and an ulnar drift (Fig
8 -6 5 ).
 Chapter 8 Hand 237

may or may not be indicateci. Patient education on ways to

Z ig -za g d e fo rm ity o f th tliu m b
protect th joint from further deformity is an important
pari of treatment. Patients are instructed in methods of per-
forming activities that do not place excessive demands on
th finger flexors. Exercises, like squeezing a rubber ball, are
obviously not appropriate for a patient with markedly weak-
ened collateral ligaments.

ULNAR DRIFT
Ulnar drift deformity at th MCP joint consists of an exces
sive ulnar deviation and ulnar translation or slide of th
proximal phalanx. This deformity is common in advanced
rheumatoid arthritis, often seen in conjunction with a palmar
dislocation of th MCP joint (see Fig. 8 - 6 5 ) .
In all hands healthy or otherwise several factors favor
ulnar drift of th fingers. These factors include th pul of
.Overstretched palmi
piate at th meta- j gravity, th asymmetrical structure of th MCP joint, and th
c a rp o p h a la 'ig e a pul of th extrinsic tendons as they pass th MCP
jo in r joints.22'4956 Possibly th most influential factor is th pres-
Extensor
pollcis ence of ulnar-directed forces produced by th thumb toward
longus th fingers. As depicted in Figure 8 - 6 7 A, th contact force
of th thumb causes th MCP joint of th index finger to be
pushed ulnarly. This position of th joint increases th de-
flection or bend of th extensor digitorum communis (EDC)
Ruptured
ligaments

Dislocated
carpometacarpal
joint

FIGURE 8-64. A palmar view showing th pathomechanics of a

common zig-zag deformity of th thumb due to rheumatoid ar
thritis. The thumb metacarpal dislocates laterally at th carpometa
carpal joint, causing hyperextension at th metacarpophalangeal
joint. The interphalangeal joint remains partially flexed owing to
th passive tension in th stretched and taut ilexor pollicis longus.
Note that th bowstringing of th tendon of th extensor pollicis
longus across th metacarpophalangeal joint creates a large extensor
moment arm, thereby magnifying th mechanics of th deformity.

PALMAR DISLOCATION OF THE

METACARPOPHALANGEAL JOINT
When th fingers flex to make a grip, th tendons of th
fiexor digitorum superficialis and profundus are deflecied in
a palmar direction, as they pass th MCP joint (Fig. 8 -6 6 A ).
This naturai bend causes th tendons to generate a bow U ln a r d rift
stringing force in th palmar direction. The greater th de-
gree of flexion, th greater th magnitude of th bowstring
ing force. The bowstringing force is transferred through th
fiexor pulley, th palmar piate, th collateral ligaments, and,
finally, th posterior tubercle of th metacarpal head.
In th hand with severe rheumatoid arthritis, th colat-
eral ligaments may rapture owing to th Constant bowstring
ing force. In time, th proximal phalanx may translate in a
palmar direction, resulting in a completely dislocated MCP
joint (Fig. 8 - 6 6 B ) .49 Palmar dislocation may collapse both FIGURE 8-65. A hand showing th common deformities caused by
th longitudinal and transverse arches of th hand, causing it severe rheumatoid arthritis. Particularly evident are th following:
to appear fiat. palmar dislocation of th metacarpophalangeal joint; ulnar drift;
Clinical management of palmar dislocated MCP joints de- swan-neck deformity; and boutonniere deformity. (See text lor further
pends on th severity of th rheumatoid arthritis and th details) Courtesy of Teri Bielefeld, PT, CHT; Zablocki VA Hospital,
amount of joint destruction. Surgery with joint replacement Milwaukee, W l.)
 238 Section II Upper Extremity

Palmar dislocaUon of th metaearpophalangeal (MCP) joint

Metaearpophalangeal
Metaearpophalangeal
Stretched collateral joint
ligaments
Proximal

joint

Stable Arch
Distai

Palmar dislocation of th Ruptured

metaearpophalangeal collateral
joint ligaments

Collapsed Arch

FIGURE 8-66. Pathomechamcs of progressive palmar dislocation of th metaearpophalangeal joint of th finger. A The bend in th
tendons of th flexor digiiorum superficialis and flexor digitorum profundus across th metaearpophalangeal joint produces a
palmar-directed, bowstringing force against th palmar piate, associated pulley, and collateral ligaments. In th healthy hand th
passive tension in th stretched collateral ligaments adequately resists th palmar pul on th joint structures B In a finger with
rheumatoid arthritis, th bowstringing force can rupture th weakened collateral ligaments. As a result, th proximal phalanx may
eventually dislocate in a palmar direction, causing a loss in strutturai stability of th arch System of th hand.

tendon, as its crosses th MCP joint. Deflection causes a
bowstringing force of th tendon in an ulnar direction. In
th healthy hand, th transverse ftbers of th dorsal hood
keep th tendon centralized over th axis of rotation.
In rheumatoid arthritis, a rupture of th transverse fibers
allows th tendon to slip toward th ulnar side of th join ts
axis of rotation (Fig. 8 - 6 7 6 ) . In this position, forces pro-
duced by th extensor digitorum have a moment arm that
can amplify th ulnar deviation posture. This situation initi-
ates a self-perpetuating action of greater and greater ulnar
deviation. The greater th ulnar deviation, th greater th
moment arm available to produce ulnar deviation torque. In
time, th weakened and overstretched radiai collateral liga-
ment may rupture, allowing th proximal phalanx to rotate
and slide ulnarly, leading to complete joint dislocation (Fig.
8 -6 7 C ).
Treatment of ulnar drift is often aimed at reducing th
m a g n im e le o f i h e u ln a r d e v ia tio n fo r c e s a t t h M C P jo in t.
Splinting and patient education may help decelerate th de-
forming cycle.44 One surgical correction involves transferring
th extensor digitorum tendon to th radiai side of th MCP
joints axis of rotation.37 Surgical realignment of th wrist
may be indicated because a deformity at th wrist can alter
th angle where th extrinsic tendons approach th MCP
joint.
Zig-Zag Deformities of th Fingers
Two zig-zag pattems are often associated with advanced
rheumatoid arthritis: swan-neck deformity and boutonniere
deformity (see Fig. 8 - 6 5 ) . Chronic synovitis and subsequent
malalignment of th PIP joint are th primary causes of these
deformities. Both deformities are often associated with ulnar
drift and palmar dislocation at th MCP joints.
SWAN-NECK DEFORMITY
Swan-neck deformity is characterized by hyperextension of th
PIP join t with flexion at th D IP joint (see Fig. 8 - 6 5 , mid
dle finger). The position of th MCP joint is variable. The
intrinsic muscles in th hand with rheumatoid arthritis often
become contracted and fibrotic. With diseased and weak-
 Chapter 8 Hand 239

The Development of Ulnar Drift

FIGURE 8-67. The stages of th development of ulnar drift al th metaearpophalangeal joint of th index finger. A, Ulnar
forces from th thumb produce a naturai bowstringing force on th deflected tendon of th extensor digitorum communis
(EDC). B, In rheumatoid arthritis, rupture of th transverse fibers of th dorsal hood allows th extensor tendon to act with
a moment arm that increases th ulnar deviation torque at th metaearpophalangeal joint. C, Over time, th radiai collateral
ligament (RCL) may rupture, resulting in th ulnar drift deformity.

ened palmar plates at th PIP joint, contracture of th intrin- BOUTONNIERE DEFORMITY

sic muscles may eventually collapse th PIP joints into hy-
perextension (Fig. 8 -6 8 A ). The hyperextended position
causes th lateral bands of th extensor mechanism to bow-
string dorsally, away from th axis of rotation at th PIP
joint. Bowstringing increases th moment arm for th intrin-
sic muscles to extend th PIP joint, thereby accentuating th
hyperextension deformity. The DIP joint tends to remain
flexed owing to th stretch placed on th tendon of th
flexor digitorum profundus across th PIP joint.
Swan-neck deformity may also occur from trauma to th
ligaments or spasticity of th intrinsic muscles. Regardless of
cause, treatment often involves splinting or surgically limit-
mg th degree of hyperextension of th PIP joint.
The boutonniere deformity is described as flexion of th PIP
joint and hyperextension of th DIP joint (see Fig. 8 - 6 5 ,
index finger). (The term boutonniere a French word
meaning buttonhole describes th appearance of th head
of th proximal phalanx, as it slips through th buttonhole'
created by th slipped lateral bands). The joints collapse in a
reciprocai pattern similar to that described for swan-neck
deformity. The primary cause of th boutonniere deformity
is abnormal displacement of th bands of th extensor mech
anism, typically th result of chronic synovitis of th PIP
joint. Biomechanically, th centrai band ruptures and th
lateral bands slip to th palmar side of th axis of rotation at
th PIP joint (Fig. 8 - 6 8 B ). Consequently, forces transferred
 240 Seniori II Upper Extremity

Zig-Zag Dcformities of th Fingers

A. Swan Neck Deformity

Overactive
intrinsics
Taut flM o cdigitori
profundus

Overstretched
palmar piate
Slipped lateral band
Ruptured
centrai band

B. Boutonniere Deformity

FIGURE 8-68. Two common zig-zag deformities of th finger with severe rheumatoid arthriiis. The
middle finger shows th pathomechanics of th swan-neck deformity (A). The overactive intrinsic
muscles (red) have a chronic hyperextension effect at th proximal interphalangeal joint. Over urne,
th weakened palmar plates become overstretched, allowing th proximal interphalangeal joint lo
deform into severe hyperextension. In this position, th lateral bands produce a bowstring across th
proximal interphalangeal joint, thereby accentuating th hyperextension deformity. The distai inter
phalangeal joint remains partially flexed owing to th increased passive tension in th stretched
flexor digitorum profundus tendon.
The index finger depicts th pathomechanics of th boutonniere deformity (B). As a result of
rheumatoid arthritis, th centrai band ruptures and th lateral bands slip in a palmar direction to th
proximal interphalangeal joint; thus, th proximal interphalangeal joint loses its only means of
extension. Any tension in th lateral bands now produces Jlexion at th proximal interphalangeal
joint. The distai interphalangeal joint remains hyperextended owing to increased passive tension in
th taut lateral bands.

across th slipped lateral bands either from active or passive
sources flex th P1P joint instead of th normal extension.
The DIP joint remains hyperextended owing to th increased
tension in th stretched lateral bands and th shortening of
th oblique retinacular ligaments. Early boutonniere defor
mity may be treated by splinting th P1P joint into exten
sion. Surgery may be required lo repair th centrai band
and/or realign th lateral bands dorsal to th P1P joint. In
cases of severe rheumatoid arthritis, surgery is not always
beneficiai if connective tissues are excessively weak.
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Mosby, 1974.
20 Gray DJ, Gardiner E: The innervation of th joints of th wnst and
hand. Anat Ree 151:261-266, 1965.
21 Hahn P, Krimmer H, Hradetzky A, et al: Quantitative analysis of th
linkage between th inlerphalangeal joints of th index fnger. J Hand
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22 Hakstian RW, Tubiana R: Ulnar devialion of th fingers: The role of
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24 lnman VT, Saunders JB: Referred pam from skeletal structures. J Nerv
Ment Dis 99:660-667, 1944.
25. Jacobson MD, Raab R, Fazcli BM, et al: Architectural design of th
human intrinsic hand muscles. J Hand Surg. 17A:804-809, 1992.
26. Johanson ME, Skinner SR, Lamoreux LW. Phasic relationship of th
intrinsic and extrinsic thumb musculature. Clin Orthop 322:120-130,
1996.
27 Kapandji 1A: The Physiology of th Jomls, voi 1, 5th ed: Edinburgh,
Churchill Livingstone, 1982.
28. Kaufman KR, An KN, Lttchy WJ, et al: In-vivo function of th thumb
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29 Krishnan J, Chipchase L: Passive rotation of th metacarpophalangeal
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70 Kuczynski R7 Carpometacarpal joint of th human thumb. J Anat 118:
119-126, 1974
31. Landsmeer JMF: Power grip and precision handling. Ann Rheum Dis
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32. Leijnse JN: Why th lumbrical muscle should not be bigger a force
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36. Minami A, An KN, Cooney WP, et al: Ligamentous structures of th
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38 Nalebuff EA: Diagnosis, classification, and management of rheumatoid
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39 Napier JR: The prehensile movements of th human hand J Bone Joint
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40. Neumann DA: Observaltons from cineradiography analysis. Milwaukee,
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41 Pagalidts T, Kuczynski K, lamb DW: Ligamentous stabilty of th base
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Chapter 8 Hand 241
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A D 0 IT I0N A L READING
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 A P P E N D I X II

Part A: Nerve Root Innervation of th Upper

Extremity Muscies

Nerve Root
Muscle C1 a a C C5 c6 c7 c8 T1
Serratus anterior X X X X
Rhomboids, major and minor X X
Subclavius X X
Supraspinatus X X X
lnfraspinatus (x) X X
Subscapularis X X X
Latissimus dorsi X X X
Teres major X X X
Pectoralis major (clavicular) X X X
Pecioralis major (sternocosial) X X X X
Pectoralis minor (x) X X X
Teres minor X X
Delioid X X
Coracobrachialis X X
Biceps X X
Brachiale X X
Triceps X X X X
Anconeus
X X
Brachioradialis X X
Extensor carpi radialis longus X X X X
and brevis
Supinator X X (x)
Extensor digitorum X X X
Extensor digiti minimi
X X X
Extensor carpi ulnaris X X X
Abductor pollicis longus X X X
Extensor pollicis brevis X X X
Extensor pollicis longus X X X
Extensor indicis X X X
Pronator teres
X X
Flexor carpi radialis X X X
Palmaris longus
(x) X X X
Flexor digit, superficialis
X X X
Flexor digit, profundus 1
X X X
and II

242
 A ppenda II 243

Nerve Root

Muscle C1 O a C4 C5 C6 c7 C* T1

Flexor pollicis longus (x) X X X

Pronator quadratus X X X

Abductor pollicis brevis X X X X

Opponens pollicis X X X X

Flexor pollicis brevis X X X X

Lumbricals I and 11 (x) X X X

Flexor carpi ulnaris X X X

Flexor digit, profundus 111 X X X

and IV
Palmaris brevis (x) X X

Abductor digiti minimi (x) X X

Opponens digiti minimi (x) X X

Flexor digiti minimi (x) X X

Palmar interossei X X

Dorsal interossei X X

Lumbricals 111 & IV (x) X X

Adductor pollicis X X

(x), minimal literature supporti X, moderate literature supporti X, strong literature support.
Modified from Rendali FP, McCreary AK, Provante PG: Muscles: Testing and Function, 4lh ed. Baltimore, Williams & Wilkins, 1993. Data based on a
compilation from severa! sources in th anatomie literature

Part B: Key Muscles for Testing th Function of Part C: Attachments and Innervations of th
Ventral Nerve Roots (C5-T1) Upper Extremity Muscles
The table shows th key muscles typically used to test SHOULDER COMPLEX MUSCULATURE
th function of individuai ventral nerve roots of th bra-
Coracobrachialis
chial plexus (C5- T ') in th clinic. Reduced strength in a Proximal attachment: apex of th coracoid process by a
key muscle may indicate an injury to th associated nerve common tendon with th short head of th biceps
root. Distai attachment: mediai aspect of middle shaft of th
humerus
Ventral Innervation: musculocutaneous nerve
Nerve
Key Muscles Roots Sample Test Movements Deltoid
Proximal attachments
Biceps brachii C5 Elbow flexion with forearm Anterior part: anterior surface of th lateral end of th
supinated clavicle
Middle deltoid C5 Shoulder abduction Middle part: superior surface of th lateral edge of th
Extensor carpi radialis c6 Wrist extension and radiai acromion
longus deviation Posterior part: posterior border of th spine of th
c7 Elbow extension scapula
Triceps brachii
Extensor digitorum C7 Finger extension (metacar- Distai attachment: deltoid tuberosity of th humerus
pophalangeal joint) Innervation: axillary nerve

Flexor digitomm pro c Finger flexion (distai inter- In frasp in atu s

fundus phalangeal joint) Proximal attachment: infraspinatous fossa
I 1 Finger abduction and ad- Distai attachment: middle facet of th greater tubercle of
Dorsal and palmar in-
lerossei duction th humerus
innervation: suprascapular nerve
244 Appendix 11
Latissimus Dorsi
Proximal attachments: posterior layer of th thoracolumbar
fascia, spinous processes and supraspinous ligaments of
th lower half of th thoracic vertebrae and all lumbar
vertebrae, median sacrai crest, posterior crest of th
ilium, lower four ribs, small area near th inferior
angle of th scapula, and muscular interdigitations
from th obliquus extemal abdominis
Distai attachment: floor of th intertubercular groove of
th humerus
Innervation: middle subscapular (thoracodorsal) nerve
Levator Scapula
Proximal attachments: transverse processes of C I - 2 and
posterior tubercles of transverse processes of C 3 - 4
Distai attachment: mediai border of th scapula between
th superior angle and root of th spine
Inneiyation: ventral rami of spinai nerves (C3-4) and th
dorsal scapular nerve
Pcctoralis Major
Proximal attachments
Clavicular head: anterior margin of th mediai one half
of th clavicle
Sternocostal head: lateral margin of th manubrium and
body of th stemum and cartilages of th first six or
seven ribs. The costai fibers blend with muscular
slips from th obliquus external abdominis.
Distai attachment: crest of th greater tubercle of th hu
merus.
Innervation
Clavicular head: lateral pectoral nerve
Sternocostal head: lateral and mediai pectoral nerves
Pcctoralis Minor
Proximal attachments: extemal surfaces of th third
through th ffth ribs
Distai attachment: mediai border of th coracoid process
Innervation: mediai pectoral nerve
Rhomboid Major and Minor
Proximal attachments: ligamentous nuchae and spinous
processes of C7-T5
Distai attachment: mediai border of scapula, from th root
of th spine to th inferior angle
Innervation: dorsal scapular nerve
Serrani Anterior
Proximal attachments: extemal surface of th lateral region
of th first to ninth ribs
Distai attachment: entire mediai border of th scapula,
with a concentration of fibers near th inferior angle
Innervation: long thoracic nerve
Subclavius
Proximal attachment: near th cartilage of th first rib
Distai attachment: inferior surface of th middle aspect of
th clavicle
Inneiyation: branch from th upper trunk of th brachial
plexus (C5-6)
Subscapularis
Proximal attachment: subscapular fossa
Distai attachment: tesser tubercle of th humerus
Innervation: upper and lower subscapular nerves
Supraspinatus
Proximal attachment: supraspinatus fossa
Distai attachment: upper facet of th greater tubercle of
th humerus
Innervation: suprascapular nerve
Teres Major
Proximal attachment: infenor angle of th scapula
Distai attachment: crest of th lesser tubercle of th hu
merus
Innervation: lower subscapular nerve
Teres Minor
Proximal attachment: posterior surface of th lateral border
of th scapula
Distai attachment: lower facet of th greater tubercle of th
humerus
Innervation: axillary nerve
Trapezius
Proximal attachments (all parts): mediai pari of superior
nuchal line and extemal occipital protuberance, liga-
mentum nuchae, spinous processes and supraspinous
ligaments of th seventh cervical vertebra and all tho
racic vertebrae
Distai attachments
Upper part: posterior-superior edge of th lateral one
third of th clavicle
Middle part: mediai margin of th acromion and upper
lip of th spine of th scapula
Lower pari: Mediai end of th spine of th scapula, just
lateral to th root.
Innervation: primarily by th spinai accessory nerve (cra-
nial nerve XI); secondary innervation directly from
ventral rami of C2~4
ELBOW AND FOREARM MUSCULATURE
Aneoneus
Proximal attachment: posterior side of th lateral epicon-
dyle of th humerus
Distai attachments: between th olecranon process and
proximal surface ol th posterior side of th ulna
Inneiyation: radiai nerve
Biceps Brachii
Proximal attachments
Long head: supraglenoid tubercle of th scapula
Short head: apex of th coracoid process of th scapula
Distai attachments: bicipital tuberosity of th radius; also
to deep connective tissue within th forearm via th
fibrous lacertus
Innervation: musculocutaneous nerve
Brachiali
Proximal attachment: distai aspect of th anterior surface of I
th humerus
Distai attachments: coronoid process and tuberosity on th
proximal ulna
Innervation: musculocutaneous nerve (small contribution
from th radiai nerve)
Brachioradialis
Proximal attachment: upper two thirds of th lateral supra-
condylar ridge of th humerus
Distai attachment: near styloid process at th distai radius
Innervation: radiai nerve
 Appenaix II

Pronator Teres Flexor Carpi Ulnaris

Proximal attachments Proximal attachments
Humeral head: mediai epicondyle Humeral head: common flexor-pronator tendon attach
Ulnar head: mediai to th tuberosity of th ulna ing io th mediai epicondyle of th humerus
Distai attachment: lateral surface of th middle radius Ulnar head: posterior border of th middle one third of
Innervation: median nerve th ulna
Distai attachments: pisiform bone, pisohamate and pisome-
Pronator Quadratus tacarpal ligaments, and palmar base ol th fifth meta
Proximal attachment: anterior surface of th distai ulna carpal bone
Distai attachment: anterior surface of th distai radius Innervation: ulnar nerve
Innervation: median nerve
Palmaris Longus
Supinator Proximal attachment: common flexor-pronator tendon at
Proximal attachments: lateral epicondyle of th humerus, taching to th mediai epicondyle of th humerus
radiai collateral and annular ligaments, and supinator Distai attachment: centrai part of th transverse carpai liga-
crest of th ulna ment and palmar aponeurosis of th hand
Distai attachment: lateral surface of th proximal radius Inneryation: median nerve
Innervation: radiai nerve

Triceps Brachii EXTRINSIC HAND MUSCULATURE

Proximal attachments
Long head: infraglenoid tubercle of th scapula
Lateral head: posterior humerus, superior and lateral to
th radiai groove
Mediai head: posterior humerus, inferior and mediai to
th radiai groove
Distai attachment: olecranon process of th ulna
Innervation: radiai nerve
Abduetor Pollicis Longus
Proximal attachments: posterior surface of th middle part
of th radius and ulna, and adjacent interosseous
membrane
Distai attachments: radial-dorsal surface of th base of th
thumb metacarpal, including th capsule ol th carpo-
metacarpal joint of th thumb
Innervation: radiai nerve

WRIST MUSCOLATURE F.xtensor Digitorum Communis

Extensor Carpi Radialis Brevis
Proximal attachment: common extensor-supinator tendon
attaching to th lateral epicondyle of th humerus
Distai attachment: radial-posterior surface of th base of
th third metacarpal
Innervation: radiai nerve
Extensor Carpi Radialis Longus
Proximal attachments: common extensor-supinator tendon
attaching to th lateral epicondyle of th humerus and
th distai part of th lateral supracondylar ridge of th
humerus
Distai attachment: radial-posterior surface of th base of
th second metacarpal
Innervation: radiai nerve
Extensor Carpi IJlnaris
Proximal attachments: common extensor-supinator tendon
attaching to th lateral epicondyle of th humerus and
th posterior border of th middle one third of th
ulna
Distai attachment: posterior-ulnar surface of th base of
th fifth metacarpal
Innervation: radiai nerve
Flexor Carpi Radialis
Proximal attachment: common flexor-pronator tendon at
taching to th mediai epicondyle of th humerus
Distai attachments: palmar surface of th base of th sec
ond metacarpal and a small slip to th base of th
third metacarpal
Innervation: median nerve
Proximal attachment: common extensor-supinator tendon
attaching to th lateral epicondyle of th humerus
Distai attachments: by four tendons, each to th base of
th extensor mechanism and to th dorsal base of th
proximal phalanx of th fingere
Innervation: radiai nerve
Extensor Digiti Minimi
Proximal attachment: ulnar side of th belly ol th exten
sor digitorum
Distai attachments: tendon usually dividere, joining th ul
nar side of th tendon of th extensor digitorum
Innervation: radiai nerve
Extensor Indicis
Proximal attachments: posterior surface of th middle to
distai part of th ulna and adjacent interosseous mem
brane
Distai attachment: tendon blends with th ulnar side of th
index tendon of th extensor digitorum
Innervation: radiai nerve
Extensor Pollicis Brevis
Proximal attachments: posterior surface of th middle to
distai parts of th radius and adjacent interosseous
membrane
Distai attachment: dorsal base of th proximal phalanx and
extensor mechanism of th thumb
Innervation: radiai nerve
Extensor Pollicis Longus
Proximal attachments: posterior surface of th middle part
of th ulna and adjacent interosseous membrane
246 Appendix l

Distai attachment: dorsal base of th dista] phalanx and Dorsal Interossei

extensor mechanism of th thumb
Innervation: radiai nerve
Flexor Digitoruin Profundus
Proximal attachments: proximal three fourths of th ante-
rior and mediai side of th ulna and adjacent interos-
seous membrane
Distai attachments: by four tendons, each to th palmar
base of th distai phalanges of th fngers
Innervation
Mediai half: ulnar nerve
Lateral half: median nerve
Flexor Digitorum Superficialis
Proximal attachments
Humeroulnar head: common flexor-pronator tendon at-
taching to th mediai epicondyle of th humerus
and th mediai side of th coronoid process of th
ulna
Radiai head: oblique line just distai and lateral to th
bicipital tuberosity
Distai attachments: by four tendons, each to th sides of
th middle phalanges of th fingers Innervation: ulnar nerve
Innervation: median nerve
Flexor Pollieis Longus
Proximal attachments: middle part of th anterior surface
of th radius and adjacent interosseous membrane
Distai attachment: palmar base of th distai phalanx of th
thumb
Innervation: median nerve
INTRINSIC HAND MUSCULATURE
Abductor Digiti Minimi
Proximal attachments: pisohamate ligament, pisiform bone,
and tendon of th flexor carpi ulnaris
Distai attachments: ulnar side of th base of th proximal Innervation: median nerve
phalanx of th little fnger; also attaches into th exten
sor mechanism of th little finger
Innervation: ulnar nerve
Abductor Pollieis Brevis
Proximal attachments: transverse carpai ligament, palmar
tubercles of th trapezium and scaphoid bones
Distai attachments: radiai side of th base of th proximal
phalanx of th thumb; also attaches into th extensor Distai attachment: lateral margin of th extensor mecha-
mechanism of th thumb
Innervation: median nerve
Adductor Pollieis
Proximal attachments
Oblique head: capitate bone, base of th second and
third metacarpal, and adjacent capsular ligaments of
th carpometacarpal joints
Transverse head: palmar surface of th third metacarpal
Distai attachments: both heads attach on th ulnar side of
th base of th proximal phalanx of th thumb and to
th m ediai sesam oid b o n e at th m etacarpophalangeal
joint; also attaches into th extensor mechanism of th Opponens Pollieis
thumb
Innervation: ulnar nerve
Proximal attachments
First: adjacent sides of th first (thumb) and second
metacarpal
Second: adjacent sides of th second and third metacar
pal
Third: adjacent sides of th third and fourth metacarpal
Fourth: adjacent sides of th fourth and fifth metacar
pal
Distai attachments
First: radiai side of th base of th proximal phalanx o:
th index finger and oblique fibers of th dorsal
hood
Second: radiai side of th base of th proximal phalanx
of th middle finger and oblique fibers of th dorsal
hood
Third: ulnar side of th base of th proximal phalanx
ol th middle finger and oblique fibers of th dorsal
hood
Fourth: ulnar side of th base ol th proximal phalanx
of th ring finger and oblique fibers of th dorsal
hood
Flexor Digiti Minimi
Proximal attachments: transverse carpai ligament and hook
of th hamate
Distai attachment: ulnar side of th base of th proximal
phalanx of th little finger
Innervation: ulnar nerve
Flexor Pollieis Brevis
Proximal attachments: transverse carpai ligament and pal
mar tubercle of th trapezium
Distai attachments: radiai side of th base of th proximal
phalanx of th thumb; also to th lateral sesamoid
bone at th metacarpophalangeal joint
Lumbricals
Proximal attachments
Mediai two: adjacent sides of th flexor digitorum pro
fundus tendons of th little, ring, and middle fn
gers
Lateral two: lateral sides of th flexor digitorum profun
dus tendons of th middle and index fingers
nism via th oblique fibers of th dorsal hood
Innervation
Mediai two: ulnar nerve
Lateral two: median nerve
Opponcns Digiti Minimi
Proximal attachments: transverse carpai ligament and hook
of th hamate
Distai attachment: ulnar surface of th shafi of th fiftr.
metacarpal
Innervation: ulnar nerve
Proximal attachments: transverse carpai ligament and pai-
mar tubercle o f th trapezium

Distai attachment: radiai surface of th shaft of th thumb
metacarpal
Inneiyation: median nerve
Palmaris Brevis
Proximal allachments: transverse carpai ligament and pal-
mar fascia just distai and lateral to th pisiform bone
Distai attachment: skin on th ulnar border of th hand
Innervation: ulnar nerve
Palmar Interossei
Proximal attachments
First: ulnar side of th thumb metacarpal
Secondi ulnar side of th second metacarpal
Appendix II 247
Third: radiai side of th fourth metacarpal
Fourth: radiai side of th fifth metacarpal
Distai attachments
First: ulnar side of th proximal phalanx of th thumb,
blending with th adductor pollicis; also attaches to
th mediai sesamoid bone at th metacarpophalan-
geal joint
Second: ulnar side of th extensor mechanism of th
index finger via oblique fbers of dorsal hood
Third: radiai side of th extensor mechanism of th
ring finger via oblique fbers of dorsal hood
Fourth: radiai side of th extensor mechanism of th
little finger via oblique fbers of dorsal hood
Innervation: ulnar nerve
S e c t i o n III

Axial Skeleton
 S e c t i o n I I I

Axial Skeleton

C h a p t e r 9: Osteology and Anhrology

C h a p t e r 10: Muscle and Joint lnteractions

C har ter l i : Kinesiology of Mastication and Veniilation

Ap p e n d i * 111 Reference Material for Attachments and Innervations

of th Muscles of th Axial Skeleton

Section 111 (ocuses on th kinesiology of th axial skeleton: th cranium, vertebrae,

stemum, and ribs. The section is divided into three chapters, each describing a
different kinesiologic aspect of th axial skeleton. Chapter 9 presents osteology and
arthrology, and Chapter 10 presents muscle and joint interactions. Chapter 11 de-
scribes two special topics related to th axial skeleton: th kinesiology of mastication
(chewing) and ventilation.
Section III presents several overlapping functions that involve th axial skeleton.
These functions include providing (1) core stability plus overall mobility to th body;
(2) optimal placement of th senses of Vision, hearing, and smeli; (3) protection to th
spinai cord, brain, and internai organs; and (4) bodily activities such as th mechanics
of ventilation, mastication, childbirth, coughing, and defecation. Musculoskeletal im-
pairments within th axial skeleton can cause limitation in any of these four functions.

250
 C h a p t e r 9

Axial Skeleton:
Osteology and Arthrology
Donald A. Neum ann , PT, Ph D

TOPICS AT A GLANCE
OSTEOLOGY, 253 Interbody Joints, 273 S tru c tu ra l D e fo rm itie s o f th T h o ra c ic
Basic Components of th Axial Skeleton, Structural Considerations of th Lumbar S pine, 287
253 Intervertebral Oisc, 273 Excessive Kyphosis, 288
C ran ium , 253 Intervertebral Disc as a Hydrostatic Scoliosis, 290
Occipital and Temporal Bones, 253 Shock Absorber, 274 Lumbar Region, 292
V e rte b ra e : B u ild in g B lo c k s o f th S pine, R EGIONAL K IN E M A T IC S OF THE SPINE, F u n c tio n a l A n a to m y o f th A r tic u la r
253 276 S tru c tu re s W ith in th L u m b a r R egion
Ribs, 253 Craniocervical Region, 277 ( L I- S I) , 292
S te rn u m , 254 F u n c tio n a l A n a to m y o f th J o in ts W ith in K in e m a tic s a t th L u m b a r R egion, 294
V e rte b ra l C olum n, 256 th C ra n io c e rv ic a l R egion, 277 Sagittal Piane Kinematics, 294
Normal Curvatures Within th Atlanto-occipital Joints, 277 Horizontal Piane Kinematics: Axial
Vertebral Column, 256 Atlanto-axial Joint Complex, 278 Rotation, 303
Line-of-Gravity Passing through th Intracervical Apophyseal Joints IC2-7), Frontal Piane Kinematics: Lateral
Body, 257 279 Flexion, 303
L ig a m e n to u s S u p p o rt o f th V e rte b ra l S a g itta l P iane K in e m a tic s , 279 S U M M A R Y OF THE K IN E M A T IC S W IT H IN
C olum n, 258 Flexion and Extension, 279 THE VERTEBRAL C O LU M N , 303
Regional Osteologie Features, 262 Atlanto-occipital Joint, 281 SAC R OILIAC JO IN T S , 303
Cervical Region, 262 Atlanto-axial Joint Complex, 281 Anatomie Considerations, 303
Typical Cervical Vertebrae (C3-6), 264 Intracervical Articulations (C2-7), 281 J o in t S tru c tu re and L ig a m e n to u s
Atypical Cervical Vertebrae (C1-2 and Protraction and Retraction, 282 S u p p o rt, 304
C7), 264 H o riz o n ta l P iane K in e m a tic s , 282 T h o ra c o lu m b a r Fascia, 306
Thoracic Region, 265 Axial Rotation, 282 Kinematics, 306
Typical Thoracic Vertebrae (T2-T10), Atlanto-axial Joint Complex, 282 Functional Considerations, 307
265 Intracervical Articulations (C2-7), 282 S tre s s R elief, 307
Atypical Thoracic Vertebrae (TI and F ronta l P iane K in e m a tic s , 283 S ta b ility D u rin g Load T ra n s fe r:
T11-12), 267 Lateral Flexion, 283 M e c h a n ic s o f G e n e ra tin g a N u ta tio n
Lumbar Region, 267 Atlanto-occipital Joint, 284 T o rq u e a t th S a c ro ilia c J o in t, 307
Sacrum, 269 Intracervical Articulations (C2-7), 284 Stabilizing Effect of Gravity, 307
Coccyx, 269 Thoracic Region, 284 Stabilizing Effect of Ligaments and
ARTHROLOGY, 269 F u n c tio n a l A n a to m y o f T h o ra c ic A rtic u la r Muscles, 308
Typical Intervertebral Junction, 269 S tru c tu re s , 284
T erm inology that D e scrib e s M ovem ent, K in e m a tic s a t th T h o ra c ic R egion, 286
271 Flexion and Extension, 286
S tru c tu re and F u n c tio n o f th Axial Rotation, 287
A p o p h y s e a l and In te rb o d y J o in ts , 273 Lateral Flexion, 287
Apophyseal Joints, 273

INTRODUCTION
The axial skeleton includes th cranium, vertebral column,
ribs, and sternum (Fig. 9 - 1 ) . This chapter presents th
kinesiologic interactions between th osteology and arthrol
ogy of th axial skeleton. The focus is on th craniocervical
region, vertebral column, and sacroiliac joints, and how th
many articulations provide stability and movement while
transferring loads through th axial skeleton. Muscles play a
large role in th function of th axial skeleton, and they are
th primary focus of Chapter 10.
251
 252 Section III Axal Skeleton

A X IA L S K E L E T O N

5th io 7th cervxcal vertebrae

Ist rib
Stemum:
manubrium
stem al angle
body ( mesostemum j
xiphoid process
A veriebrostemal rib
A venebrochondral rib
Twelfih rib
Isi io 5ih lumbar vertebrae

Suptnation: Note:
Carrying angle
ParaUel forearm bones
in anatomical position
Palmar surface of
hand faces anteriorly
Pronaon: Noie:
Straight axis -
Crossed forearm bones
Originai don ai aspect
of radius and hand
noto fa ce anteriorly
Ulna - Fentur:
FIGURE 9 - 1 . Anterior view of an adult male skeleton-
Radius G reaier trochanier
H ead in acetabulum (From Grays Anatomy: The Anatomical Basis of Medi
Neck
cine and Surgery, 38th ed. New York, Churchill Living-
Metacarpals stone, 1995.)

Phalanges-

A PPEN D ICU LA R S K E L E T O N Femoral shaft

Femoral condyles
Patella

M ediai malleolus

Luterai malleolus -

Phalanges

Disease, trauma, and normal aging can cause a host of
neuromuscular and musculoskeletal problems involving th
axial skeleton. Disorders of th vertebral column are often
associated with pain and impairment, primarily because of
th dose anatomie relationship between neural tissue (spinai
cord and nerve roots) and connective tissue (vertebrae and
associated ligaments, discs, and synovial joints). A slipped
disc," for example, can increase pressure on th adjacent
spinai nerves or spinai cord, causing pain, muscle weakness,
and reduced reflexes. To further complicate matters, certain
movements and habitual postures of th vertebral column
increase th likelihood of connective tissues impinging on
neural tissues. An understanding of th detailed osteology
and arthrology of th axial skeleton is cruciai to an apprecia-
uon of th associated pathomechanics, as well as th ration-
ale for clinical interventions.
The terminology used to describe th relative location or
region within th axial skeleton can differ from that used to
describe th appendicular skeleton. Table 9 - 1 summarizes
this terminology.
 Chapter 9 Osteology and Arthrology 253

TABLE 9 - 1. Terminology Describing Relative head and neck, such as th trapezius and splenius capitus
Location or Region Within th Axial Skeleton muscles. The inferior nuchal line marks th anterior edge of
th attachment of th semispinalis capitis.
Term Synonym Definition

Posterior Dorsal Back of th body

Relevant Osteologie Features
Anterior Ventral Front of th body Occipital Bone
Mediai None Midiine of th body External occipital protuberance
Superior nuchal line
Lateral None Away from th midiine of th Inferior nuchal line
body Foramen magnum
Superior Cranial Head or top of th body Occipital condyles
Basilar pari
Inferior Caudal (th tail) Tail, or th bottoni of th body
Temporal Bone
Mastoid process
The defnitions assume a person is in th anatomie position.

OSTEOLOGY The foram en magnum is a large circular hole located at th

Basic Components of th Axial Skeleton
CRANIUM
The cranium is th bony encasement of th brain, which
protects th brain and sensory organs (eyes, ears, nose, and
vestibular System) and provides a means for ingesting food
and liquid.
Occipital and Temporal Bones
The occipital bone forms much of th posterior base of th
skull (Figs. 9 - 2 and 9 - 3 ) . The external occipital protuberance
is a palpable midiine point, serving as an attachment for th
ligamentum nuchae and th mediai part of th upper trape-
zius muscle. The superior nuchal line extends laterally from
th external occipital protuberance to th base of th mas-
toid process of th temporal bone. This thin but distinct line
marks th attachments of several extensor muscles of th
base of th occipital bone, serving as th passageway for th
spinai cord. A pair of prominent occipital condyles project
from th anterior-lateral margins of th foramen magnum,
forming th convex component of th atlanto-occipital joint.
The basilar part of th occipital bone lies just anterior to th
anterior rim of th foramen magnum.
Each of th two temporal bones forms part of th lateral
external surface of th skull, immediately surrounding and
including th external auditory meatus (see Fig. 9 - 2 ) . The
mastoid process, an easily palpable structure, is just posterior
to th ear. This prominent process serves as an attachment
for many muscles, such as th stemocleidomastoid.
VERTEBRAE: BUILDING BLOCKS OF THE SPINE
In addition to providing an element of stability throughout
th trunk and neck, th vertebral column protects th spinai
cord and exiting spinai nerves. Once outside th vertebral
column, th nerve roots form a ventral ramus and a dorsal
ramus of a spinai nerve (Fig. 9 - 4 ) . The midthoracic verte -
brae demonstrate many of th essential anatomie and func-
tional characteristics of any given vertebra (Fig. 9 - 5 , Table
9 -2 ).

RIBS
Twelve pairs of ribs enclose th thoracic cavity, forming a
protective cage for th cardiopulmonary organs. The poste
rior end of a typical rib has a head, a neck, and an articular
tubercle (Fig. 9 - 6 ) . The head and tubercle articulaie with a
thoracic vertebra, forming two synovial joints: costovertebral
and costotransverse, respectively (Fig. 9 - 5 B ) . These joints
anchor th posterior end of a rib to its respective vertebra. A
costovertebral joint connects th head of a rib to a pair of
costai facets that span two adjacent vertebrae and th inter-
vening intervertebral disc. A costotransverse joint connects th
articular tubercle of a rib with a costai facet on th trans
verse process of a corresponding vertebra.
The anterior end of a rib consists of flattened hyaline
cartilage. Ribs 1 to 10 attach to th stemum, thereby com-
pleting th thoracic rib cage anteriorly (see Fig. 9 - 1 ) . The
 254 Secfion III Axial Skeleton

Inf'erior vicw
External occipital protuberance
Trapezi us
Superior nuchal line

Semispinalis capitis
Interior nuchal line
Splenius capitis
Lambdoidal suture
Sternocleidomastoid
Mediai nuchal line
Longissimus capitis

Digastric (posterior belly)

Mastoid process
Obliquus capitis superior
condyle
Rectus capitis posterior major

Rectus capitis posterior minor

External acoustic meatus
Rectus capitis lateralis
Styloid process
Stylohyoid

Rectus capitis anterior Mandibular fossa

Longus capitis
Carotid canal

Zygomatic process

FIGURE 9 3. Interior view of th occipital and temperai bones. The lambdoidal sutures separate th occipital bone
mediali)*, troni th temperai bone laterally. Distai muscle attachments are indicated in gray, and proximal attachments are
indicated in red.

cartilage of ribs 1 to 7 attaches directly to th lateral border
of th stermini via seven stemocostal joints (Fig. 9 - 7 ) . The
cartilage of ribs 8 to 10 attaches to th stemum by fusing to
th cartilage of th immediately superior rib. Ribs 11 and 12
do not attach to th stemum, but are anchored by lateral
abdominal muscles.
STERNUM
The stemum is slightly convex and rough anteriorly, and
slightly concave and smooth posteriorly. The bone has three
parts: th manubrium (from th Latin, handle), th body,
and th xiphoid process (from th Greek, sword) (see Fig.
9 - 7 ) . Developmentally, th manubrium fuses with th body
of th stemum at th manubriostemal joint, a (brocartilagi-
nous articulation that often ossifies later in life.110 Just lateral
to th jugular notch of th manubrium are th clavicular jacets
ot th stemoclavicular joints. Immediately inferior to th ster-
noclavicular joint is a costai facet that accepts th head c :
th first rib at th first stemocostal joint.

FIGURE 9-4. A cross section of a spinai cord is shown with th

cervical nerve roots forming a typical spinai nerve. Note th rela-
tionship among th neural structures, bony vertebrae, dura mater,
and vertebral artery. (Modified with permission tram Magee DL:
Orthopedic Physical Assessment, 3rd ed. Philadelphia, WB Saun-
ders, 1997.)
 Chapter 9 Osteology and Arthrology 255

Luterai view
Superior a r t i c u l a r ' ' " Superior articular process

Transverse Superior costai facet

Costai facet Superior view

p _:------ process
intervertebral foramen

Apophyseal joint Transverse process

Intervertebral
disc facet
Spinous

Pedicle

Superior costai facet

Costotransverse joint

Interior Interior Superior articular facet

articular costai
process facet B Costovertebral joint

FIGURE 9-5. The essential characteristcs of a vertebra. A, Lateral view of th sixth and seventh vertebrae (T6 and T7). B, Supenor view of
th sixth vertebra with right rib.

1 TABLE9 - 2 . Major Parts of a Midthoracic Vertebra

Pari Description Primary Function

Body barge rounded cylindrical mass of cancellous bone surrounded Primary weight-bearing structure of th
by a thin cortex of bone vertebral column
Intervertebral disc Thick ring of fibrocartilage between vertebral bodies of C2 Shock absorber and spacer throughout
and below th vertebral column
Interbody joint A symphysis joint formed between th superior and inferior Primary bond between vertebrae
surfaces of an intervertebral disc and adjacent vertebral
bodies
Pedicle Short, thick dorsal projection of bone from th mid-to-supe- Connects th vertebral body to th
rior part of th vertebral body posterior parts of a vertebra
Lamina Thin vertical piate of bone connecting th base of th spinous Protects th posteiior aspect of th spi
process to each transverse process. (The term laminae de- nai cord
scribes both right and left lamina.)
Vertebral canal Central canal located just posterior to th vertebral body. The Protects th spinai cord
canal is surrounded by th pedicles and laminae.
Intervertebral foramen Lateral opening between adjacent vertebrae Passageway for nerve roots entenng
and exiting th vertebral canal
Transverse process Horizontal projection of bone from th junction of a lamina Attachments for muscles, ligaments,
and a pedicle and ribs
Costai facet (on body) Rounded impressions formed on th lateral sides of th tho- Attachment sites for th heads of ribs
racic vertebral bodies. Most thoracic vertebral bodies have (costovertebral joints)
superior and inferior facets on each side.
Costai facet (on trans- Ovai facets located at th anterior tips of each thoracic trans Attachment sites for th articular tu
verse process) verse process berete of ribs (costotransverse joints)
Spinous process Dorsal midiine projection of bone from th laminae Midiine attachments for muscles and
ligaments
Superior and inferior Paired vertical articular processes arising from th junction of Superior and inferior articular facets
articular processesi a lamina and pedicle. Each process has smooth cartilage- form paired apophyseal (interverte-
ncluding articular lined articular facets. in generai, superior articular facets bral) joints. Tliese synovial joints
facets and apophy face posteriori)'; inferior articular facets face anteriori)'. guide th direction and magnitude
seal (intervertebral) of intervertebral movement.
joints
256 Section III Axial Skeleton
Inferior view
FIGURE 9-6. A typical nght rib. A, Inferior view. B, Posterior view.
The lateral edge of th body of th stemum is marked by
a series of costai facets that accept th cartilages of ribs 2 to
7. The arthrology of th stemocostal joints is discussed in
greater detail in Chapter 11. The xiphoid process is attached
to th inferior end of th body of th stemum by th
xiphistemal joint. Like th manubriostemal joint, th xiphi-
stemal joint is connected primarily by fibrocartilage. The
xiphistemal joint often ossifies by 40 years of age.110
VERTEBRAL COLUMN
The word trunk describes th body of a person, including
th stemum and ribs, but excluding th head, neck, and
limbs. Vertebral (spinai) column describes th entire set of
vertebrae, excluding th ribs, stemum, and pelvis. The terms
superior and inferior are used interchangeably with th
terms cranial and caudal, respectively.
The vertebral column usually consists of 33 vertebral seg-
ments, divided into live regions. Normally there are seven
cervical, twelve thoracic, five lumbar, five sacrai, and four
coccygeal segments. The sacrai and coccygeal vertebrae are
usually fused in th adult, forming individuai sacrai and
coccygeal bones. individuai vertebrae are abbreviated alpha-
numerically; for example, C2 for th second cervical, T6 for
th sixth thoracic, and LI for th first lumbar. Each region
of th vertebral column (e.g., cervical and lumbar) has a
distinct overall morphology that reflects its specific function.
Vertebrae located at th cervicothoracic, thoracolumbar, and
lumbosacral junctions often share characteristics that reflect
th transition between major regions of th vertebral col
Posterior view
Posterior end Neck
Head'
Articular tubercle for
transverse process
Costai g ro tta
umn. It is not uncommon, for example, for th transverse
processes of C7 to have thoracic-like facets to accept a rib.
or L5 may be sacralized (i.e., fused with th base or top of
th sacrum).
NormaI Curvatures within th Vertebral Column
The human vertebral column consists of a series of recipro
cai curvatures in th sagittal piane. While standing at res:
th curvatures define th neutral posture of th vertebral
column (Fig. 9 -8 A ). The cervical and lumbar regions are
naturally convex anteriorly and concave posteriorly, exhibit-
ing an alignment called lordosis, meaning io bend back-
ward. The degree of lordosis is generally less in th cervical
region than in th lumbar region. The thoracic and sacrococ-
cygeal regions, in contrast, exhibit a naturai kyphosis. Kypho-
sis describes a curve that is concave anteriorly and convex
posteriorly. The anterior concavity provides space for th
organs within th thoracic and pelvic cavities.
The naturai curvatures within th vertebral column are
not fixed, but rather they are dynamic and change shape
during movements and different postures. Extension of th
vertebral column accentuates th cervical and lumbar lordo
sis, but reduces th thoracic kyphosis (Fig. 9 - 8 B ) . In con-
trast, flexion of th vertebral column decreases, or flattens.
th cervical and lumbar lordosis, but accentuates th tho
racic kyphosis (Fig. 9 -8 C ). In contrast, th sacrococcygeal
curvature is fixed, being concave anteriorly, convex posteri
orly. This curvature is essentially fixed by th position of th
pelvis by means of th sacroiliac joints.
The embryonic vertebral column is kyphotic throughout

Sternocleidomastoid
FIGURE 9-7. Anterior view of th sternum, part of th right c ia l
de, and th first seven ribs. The following articulations are seen: (1)
mtrastemal joints (manubriosternal and xiphisternal), (2) sternocos-
tal joints, and (3) sternoclavicular joints. The attachment of th
sternocleidomastoid muscle is indicated in red. The attachments of
th rectus abdominis and linea alba are shown in gray.
its length. Lordosis in th cervical and lumbar regions occurs
after birth, in association with motor maturation and upright
posture. In th cervical spine, extensor muscles pul on th
head and neck as th infant begins to observe th surround-
tngs. In th lumbar spine, developing hip flexor muscles pul
th convexity of th lumbar spine forward in preparation for
walking. Once a child stands, th naturai lordosis of th
lumbar spine helps direct th bodys line-of-gravity througb
th base of support provided by th feet.
The sagittal piane curvatures within th vertebral column
provide strength and resilience to th axial skeleton. A recip-
rocally curved vertebral column acts like an arch. Compres-
sion forces between vertebrae are partially shared by tension
in stretched connective tissues and muscles located along th
convex side of each curve. As is true with long bones such
as th femur, th strength and stability of th vertebral
column reflect its ability to give slightly under a load,
rather than to support large compression forces statically.
A potentially negative consequence of th naturai spinai
curvatures is th presence of shear forces at regions of tran-
Chapter 9 Osteology and Arthrology 257
sition between curves. Shear forces can cause premature
loosening of surgical spinai fusions, especially those per-
formed in th cervicothoracic and thoracolumbar regions.
Line-of-Gravity Passing through th Body
Although highly variable, th line-of-gravity acting on a
standing person with ideal posture passes through th mas-
toid process of th temporal bone, anterior to th second
sacrai vertebra, posterior to th hip, and anterior to th knee
and ankle (Fig. 9 - 9 ) . In th vertebral column, th line-
of-gravity is on th concave side of th apex of each
regions curvature.17 As a consequence, ideal posture allows
gravity to produce a torque that helps maintain th optimal
shape of each spinai curvature. The extemal torque due to
gravity is greatest at th apex of each regioni C 4 - 5 , T6,
and L3.
The image depicted in Figure 9 - 9 is more ideal than reai
because each persons posture is unique and transient. Fac-
tors that alter th spatial relationship between th line-of-
gravity and th spinai curvatures include fai disposition, po-
sition and magnitude of loads supported by th upper body,
shapes of individuai regional spinai curvatures, muscularity,
connective tissue extensibility, and pregnancy. In contrast to
that depicted in Figure 9 - 9 , some describe th line-of-
gravity as fading through49 or just anterior to th lumbar
vertebrae.88 Regardless, th important point is to understand
th biomechanical consequences of each possible relation
ship. Gravity passing posterior to th lumbar region pro-
duces a Constant extension torque on th low back, facilitat-
ng naturai lordosis. Alternatively, gravity passing anterior to
th lumbar region produces a Constant (lexion torque. In
either case, th extemal torque due to gravity, or supported
extemal load, must be neutralized by active forces in
muscles or passive forces in connective tissues. The line-of-
gravity lies anterior to th lumbosacral junction and th
sacroiliac joints.
Structural factors also favor th shape of th naturai
curves, such as wedged intervertebral discs or vertebral bod-
ies, orientation of apophyseal joints, and tension in ligaments
and muscles. The intervertebral discs in th cervical and
lower lumbar regions are thicker anteriorly, for example,
thereby favoring an anterior convexity in these regions.
The normal sagittal piane alignment of th vertebral col
umn may be altered by disease, such as ankylosing spondy-
losis, spondylolisthesis, and muscular dystrophy, or by oste-
oporosis or muscle weakness associated with aging. Often,
minor forms of abnormal or laulty postures occur in healthy
persons (Fig. 9 - 1 0 ) . Excessive cervical or lumbar lordosis
compensates for excessive thoracic kyphosis and vice versa.
The sway back posture shown in Figure 9 -1 0 C , for exam
ple, describes a combined exaggerated lumbar lordosis and
thoracic kyphosis. The pelvis is shifted anteriorly, which
forces th thighs backward. Regardless of th cause or loca
tion, abnormal curvatures alter th relationship between th
line-of-gravity and each spinai region. When severe, abnor
mal vertebral curvatures increase stress on muscles, liga
ments, bones, discs, apophyseal joints, and spinai nerve
roots. Abnormal curves also change th volume of body
cavities. An exaggerated thoracic kyphosis, for example, can
significanti reduce th space for th lungs to expand during
deep breathing (Fig. 9 - 1 1 ) .
258 Seclion III Axial Skeleton

FIGURE 9-8. A side view shows th sagittal piane curvatures of th vertebral column. A, Neutral static position while one is
standing. B, Extension of th vertebral column increases th cervical and lumbar lordosis, but reduces (straightens) th thoracic
kyphosis. C, Flexion of th vertebra! column decreases th cervical and lumbar lordosis, but increases th thoracic kyphosis.

LIGAMENTOUS SUPPORT OF THE

VERTEBRAL COLUMN
The vertebral column is supported by an extensive set of
ligamenis. Spinai ligaments limit motion, maintain naturai
spinai curvature, and indirectly protect th spinai cord. The
major ligaments of th vertebral canal are depicted in Figure
9 - f 2 . The basic strutture and function of each ligament are
summarized in Table 9 - 3 .
The ligamentum Jlavum originates on th anterior surface
of a lamina and inserts on th posterior surface of th lam
ina below. The ligaments are thickest in th lumbar region.
Ligamentum flavum means th yellow ligament, reflecting
its high content of yellow elastic connettive lissue.110 Passive
lension in a series of stretched ligamentum flava limits flex
ion throughout th vertebral column, thereby protecting th
intervertebral disc from excessive compression. Figure 9 - 1 3
shows th increase in tension (stress) in one ligamentum
flavum. Note that between neutral extension and full flexion
th ligament has elongated (strained) 35% of its originai
resting length.73 Flexion beyond physiologic limits can rup-
ture th ligament and pennit compressive damage to th
intervertebral disc.2 The ligamentum flavum lies just poste
rior io th spinai cord. Severe hyperextension of th spine
can buckle th ligamentum flavum inward and pinch th
delicate spinai cord.
The supraspinous and mterspinous ligaments extend between
adjacent spinous processes. As evident by their position.
they limit flexion. In th lumbar region, th supraspinom
and interspinous ligaments are typically th first structures tc
rupture in extreme flexion.4 The intertransverse ligaments ex
tend between adjacent transverse processes, becoming taut ir.
contralateral lateral flexion.
In th cervical region, th supraspinous ligaments thicken
and extend to th cranium as th ligamentum nuchae. Thu
tough membrane consists of a bilaminar strip of fibroelast:
tissue that attaches between th cervical spinous processes
and external occipital protuberance of th occipital bone
Because th center of mass of th head is located antenor t
th cervical spine, gravity naturally flexes th craniocervtca.
region.21 Passive tension in a stretched ligamentum nucha.-.
adds a small bui useful element of support to th head anc
neck. The ligamentum nuchae also provides a nudiine at-
tachment for muscles, such as th trapezius and spleniti;
capitis and cervicis. The ligamentum nuchae accounts for th
difficulty encountered when palpating th spinous process ir.
th mid to upper cervical region (Fig. 9 - 1 4 ) .

lJnc-of-gravitv
HGURE 9-9. The line-of-gravity in a person with an ideal standing
posture. (Modified from Neumann DA: Arthrokinesiologic consider-
auons for th aged aduli. In Guccione AA (ed): Geriatrie Physical
Therapy, 2nd ed. Chicago, Mosby-Year Book, 2000.)
FIGURE 9-10. A diagrammane representation of common
faulty postures in th sagittal piane. (From McMorris RO:
Faulty postures. Pediatr Clin North Am 8:217, 1961.)
Chapter 9 Osteology and Arthrology 259
The anlerior longitudini igament is a long, straplike strut
ture attaching between th basilar part of th occipital bone
and th entre length of th anterior surfaces of all vertebral
bodies, including th sacrum. This strong igament is narrow
at its cranial end and widens caudally. Fibers of th anterior
longitudinal igament blend with and reinforce th adjacent
portion of th intervertebral disc.110 The anterior longitudinal
igament provides stability to th vertebral column, by limit-
ing extension or excessive lordosis in th cervical and lum-
bar regions.
The posteror longitudini igament is a continuous band of
tissue that extends th entire length of th posterior surfaces
of all vertebral bodies, between th axis (C2) and th sa
crum. The posterior longitudinal igament is located within
th vertebral canal, just anterior to th spinai cord. The
posterior and anterior longitudinal ligaments are narned ac-
cording to their relationship to th vertebral body, not th
spinai cord. Throughout its length, th posterior longitudinal
igament blends with and reinforces th intervertebral
discs.110 Cranially, th posterior longitudinal igament is a
broad structure, narrowing as it descends toward th lumbar
region. The slender lumbar portion limils its abilily to re-
strain a posterior bulging (slipped) disc. As with th anterior
longitudinal igament, th posterior longitudinal igament
provides stability to th spine.
A joint capsule surrounds and reinforces each apophyseal
joint (Fig. 9 - 1 5 ) . The capsule is relatively loose, especially
in th cervical region where ampie range of motion is re-
quired. Although relatively loose in a neutral posture, th
capsule of th apophyseal joints is under tension when
stretched. In th lumbar region, th capsule is shown to
accept up to 1000 N ( ~ 225 lb) of tension before failure.20
This tension limits th extremes of all intervertebral motions,
with th exception of extension. The capsule of th apophy
seal joints is reinforced by adjacent muscles (multifdus) and
connective tissue (ligamentum flava), particularly evident in
th lumbar region.96
260 Section ili Axial Skeleton

LIG A M EN T U M FLA V U M

FIGURE 9-12. Primary lgaments that stabilize th vertebral column

(Modified from White AA, Panjabi MM: Clinical Biomechanics of
th Spine, 2nd ed. Philadelphia, JB Lippincott, 1990.)

FIGURE 9-11. Lateral view of a person with ankylosing spondylitis.

Note th severe thoracic kyphosis and flattening of th lumbar
region. (From Polley HF, Hunder GG: Rheumatoogic Inteviewing
and Physical Examination of th Joints. Philadelphia, WB Saunders,
1978.)

TABLE 9 - 3 . Major Ligaments of th Vertebral Column

Name Attachments Function Comment

Ligamentum flavum Between th anterior surface of one
lamina and th posterior surface
of th lamina below
Supraspinous and in- Between th adjacent spinous pro-
terspinous liga cesses from C7 to th sacrum
ments
Intertransverse liga- Between adjacent transverse pro-
menis cesses
Anterior longitudinal Between th basilar part of th oc
ligament cipiti bone and th entire
length of th anterior surfaces of
all vertebral bodies, including
th sacrum
Limits flexion
Limits flexion
Limits contralateral lateral
flexion
Adds stability to th ver
tebral column
Limits extension or ex-
cessive lordosis in th
cervical and lumbar
regions
Contains a high percentage of elastin
Lies posterior to th spinai cord
Thickest in th lumbar region
Ligamentum nuchae is th cervical
and cranial extension of th su
praspinous ligaments, providing a
midiine structure for muscle at
tachments, and passive support for
th head.
Few fbers exist in th cervical re
gion. In th thoracic region, th
ligaments are rounded and inter-
twined with locai muscle. In th
lumbar region, th ligaments are
thin and membranous.
 Chapier 9 Osteology and Arthrology 261

I TABLE 9 - 3 . Major Ligaments of th Vertebra! Column Continued

Name Attachmcnts Function Comment

Posterior longitudinal Throughout th length of th pos Stabihzes th vertebral Lies within th vertebral canal, just
ligament terior surfaces of all vertebra! column anterior to th spinai cord
bodies, between th axis (C2) Limits flexion
and th sacrum Reinforces th posterior
annulus ftbrosus
Capsule of th Margin of each apophyseal joint Strengthens and supports Becomes taut at th extremes of all
apophyseal joints th apophyseal joint intervertebral motions, except for
extension

FIGURE 9 -1 3 . Functional biomechanics of th ligamentum flavum durtng extension and flexion. A, The ligamen-
tum flavum is slackened in extension and stretched in flexion. Excessive flexion can cause trauma. B, The stress-
strain relationship of th ligamentum flavum is shown between full extension to a point of failure (rupture) at
extreme flexion. Note th ligament fails at a point 70% beyond its full slackened length. (Data from Nachemson
A, Evans J: Some mechancal properties of th third lumbar interlaminar ligament. J Biomech 1:211-220, 1968.)

Posterior view
Superior articular
Mamillary process

process

Intertransverse Apophyseal joint

(opened)

Apophyseal
joint capsule
Interspinous ligament

Supraspinous

FIGURE 9 -1 5 . A posterior view of th second and third lumbar

vertebrae. The capsule of th righi apophyseal joint is removed to
show th vertical alignment of th joint surfaces. The top vertebra
FIGURE 9-14. The ligamentum nuchae is shown in a thin young is rotated to th right to maximally expose th articular surfaces of
woman. th right apophyseal joint.
 262 Section III Axial Skeleton

Intra-articuiar Structures Found in Apophyseal Joints c o m p r e s s io n f o r c e s d u r in g t h e x t r e m e s o f m o v e m e n t .66

M o s t a p o p h y s e a l j o in t s c o n t a in intra-articuiar structures S e v e r a l d if f e r e n t f o r m s o f i n t r a - a r t ic u ia r s t r u c t u r e s lo c a t e d

lo c a t e d b e t w e e n t h in t e r n a i s id e o f t h c a p s u le a n d t h w it h in t h lu m b a r a p o p h y s e a l j o in t s a r e illu s t r a t e d in F ig

p e r ip h e r y o f t h a r t ic u la r c a r t ila g e . T h e s t r u c t u r e s c o n t a in u r e 9 - 1 6 . T h e m e n is c o id s m a y b e in v o lv e d in a n a c u t e

s m a ll f a t p a d s m ix e d w it h t h in s h e e t s o f c o n n e c t iv e t is - lo c k e d b a c k " c o n d it io n . D u r in g f le x io n , a m e n is c o id m a y

s u e s t h a t e x t e n d p a r t ia lly in to t h jo in t. T h e s e s t r u c b u c k le o n it s e lf a n d b e c o m e lo d g e d u n d e r t h a d j a c e n t

t u r e s t e r m e d f ib r o a d ip o s e m e n i s c o i d s m a y h e lp p r o - c a p s u le . T h e m e n s ic o id m a y t h e n a c t a s a s p a c e - o c c u p y -

t e c t e x p o s e d c a r t ila g e a n d s y n o v ia l m e m b r a n e f r o m in g le s io n , b lo c k in g f u ll e x t e n s io n . 12

FIGURE 9-16. Intra-articuiar struc- |

tures within th lumbar apophyseal
joints. A, Frontal section shows f-
broadipose meniscoids extending
into th joint cavity from th cap
sule. B, Lateral view of th articular
cartilage of an opened apophyseal
joint shows different forms of an in
tra-articuiar strutture: FM, fbroadi-
pose meniscoid; CT, connective tis-
sue rim; and AP, adipose tissue pad.
(From Bogduk N: Clinical Anatomy
of th Lumbar Spine, 3rd ed. New
York, Churchill Livingstone, 1997.)

Superior view

Atlas (CI) Axis (C2)

REGIONAL 0STE0L0GIC FEATURES Transverse
foramen
The adage that function follows structure is very applicatale
in th study of th vertebral column. Although all vertebrae
have a common morphologic theme, each also has a specific
shape that reflects its unique function. The following section,
along with Table 9 - 4 , highlights specific osteologie features
of each region of th vertebral column.
Pedicle
Cervical Region
The cervical vertebrae are th smallest and most mobile of
all movable vertebrae. The high degree of mobility is essen-
tial to th large range of motion required by th head.
Anterior
Perhaps th most unique anatomie feature of th cervical Vertebra!
and
vertebrae is th presence of transverse foram ina located canal
Posterior
within th transverse processes (Fig. 9 - 1 7 ) . The vertebral
tubercles
artery ascends through these foramina, coursing toward th
foramen magnum to transport blood to th brain and spinai
cord. In th neck, th vertebral artery is located immediately
anterior to th exiting spinai nerve roots (see Fig. 9 - 4 ) . Spinous Transverse
The third through th sixth cervical vertebrae show process
process
nearly identical features and are therefore considered typical
of this region. The upper two cervical vertebrae, th atlas
(C l) and th axis (C2), and th seventh cervical vertebrae
(C7) are atypical for reasons described in a subsequent sec FIGURE 9-17. A superior view of seven cervical vertebrae from
tion. sartie human specimen.
 TABLE 9 - 4 . Osteologie Features o f th Vcrtcbral Column

Superior Inferior Articular

Body Articular Facets Facets

Atlas (Cl) None Concave, face Fiat to slightly con

generally supe cave, face gener
rior ally inferior
Axis (C2) Tali vvith a vertical Fiat to slightly Fiat, face anterior
projecting dens convex, face and inferior
generally supe
rior
C3-6 Wider than deep; Fiat, face posterior As above
have uncinate and superior
processes
CI Wider than deep As above Transition to typical
thoracic vertebrae

T2-T9 Equal width and Fiat, face mostly Fiat, face mostly
depth posterior anterior
Costai facets for at-
tachment of th
heads of ribs 2 to 9
TI and Equal width and As above As above
TI 0-12 depth
TI has a full costai
facet for rib 1 and
a partial facet for
rib 2
T I0-12 each has a
full costai facet.
LI -5 Wider than deep Slightly concave, L I-4 slightly con
L5 is slightly wedged face mediai to vex, face lateral
(i.e., higher height posierior-me- lo anterior-lateral
anteriorly than pos- dial L5: fiat, face ante
teriorly). rior and slightly
lateral
Sacrum Fused Fiat, face posterior None
Body of first sacrai and slightly
vertebra most evi- mediai
dent
Coccyx Fusion of four rudi- Rudimentary Rudimentary
mentary vertebrae

O n
Spinous Processes Vertebra! Canal Transverse Processes Comments

None, replaced by a Triangular, largest Largest of cervical region Two large lateral masses,
small posterior tu of cervical region joined by anterior and
berete posterior arches
Largest of cervical re- Large and triangular Form anterior and pos Contains large spinous
gion, bifid terior tubercles process

Bifd Large and triangular End as anterior and pos Corrsidered typical cervi
terior tubercles cal verLebrae

barge and prominent, Triangular Thick and prominent, Often called vertebral
easily palpable may have a large an prominens due to
terior tuberete form- large spinous process
ing an extra rib."
Long and pointed, Round, smaller than Project horizontally and Constdered typical tho-
slant inferiorly cervical slightly posterior, racic vertebrae
have costai facets for
tubercles of ribs

As above As above T10-12 may lack costai Considered atypical tho-

facets. racic vertebrae pri
mari ly by th manner
of rib attachment

Stout and rectangular Triangular, contains Stender, project laterally Superior articular pro
cauda equina cesses have mammil-
lary bodies

None, replaced by As above None, replaced by mul

multiple spinous tiple transverse tuber-
tubercles cles

Rudimentary Ends at th first Rudimentary

coccyx
264 Section III Axial Skeleton
Typical Cervical Vertebrae (C3-6I
C 3 - 6 have small rectangular-shaped bodies, vvider from side-
to-side than front-to-back (Figs. 9 - 1 7 and 9 - 1 8 ) . The supe-
rior and inferior surfaces of ihe bodies are noi as fiat as
most other vertebrae, but are curved or notched. The supe-
rior surfaces are concave side-to-side, with raised posterior-
lateral hooks called uncinate processes (uncus means hook).
The inferior surfaces, in contrast, are concave anterior-poste-
rior, with elongated anterior and posterior margins. When
articulated, small uncovertebral joints form between th unci
nate process and adjacent part of th superior vertebra be
tween C3 and C7. Uncovertebral joints are often called th
joints of Luschka, named after th person who first de-
scribed them.39 Small fissures extend from th uncovertebral
joints into th adjacent outer rings (annuii) of th interverte-
bral discs. The exact function of uncovertebral joints is un-
clear, although they probably add stability to th cervical
interbody joints.33
The pedides of C 3 - 6 are short and curved posterior-
lateral (see Fig. 9 - 1 7 ) . Very thin laminae extend posterior-
medial from each pedicle (Fig. 9 - 2 0 ) . The triangular-shaped
vertebra/ canal is large in th cervical region in order io
accommodate th thickening of th spinai cord associated
with th formation of th cervical plexus and brachial
plexus.
Anterior view
Intervertebraf
foramen
Uncinate
process
Transverse Posterior
process tubercle
FIGURE 9-18. An anterior view of th cervical vertebral column.
Within th C 3 - 6 region, consecutive superior and infe
rior articular processes form a continuous articular pillar,'
interrupted by apophyseal joints (Fig. 9 - 2 1 ) . The articular
facets within each apophyseal joint are smooth and Dai, with
joint surfaces oriented midway between th vertical and hor-
izontal planes. The superior articular facets face posterior and
superior, whereas th inferior articular facets face anterior and
inferior.
The spinous processes of C 3 - 6 are short, with some pro
cesses being bifid (i.e., doubl) (see Fig. 9 - 1 7 , C3). The
transverse processes are short lateral extensions that terminate
as variably shaped anterior and posterior tubercles. The tuber-
cles are unique to th cervical region, serving as attachments
for muscles, such as th anterior scalene, levator scapulae.
and splenius cervicis.
Atypical Cervical Vertebrae (C1-2 and C7)
Atlas (C l)
As indicated by its name, th primary function of th
atlas is to support th head. Possessing no body, pedicle,
lamina, or spinous process, th atlas is essentially two large
lateral masses joined by anterior and posterior arches (Fig ,
9 - 2 2 ) . The short anterior arch has an anterior tubercle for
attachment of th anterior longitudinal ligament. The muchi
larger posterior arch forms nearly half th circumference of]
th entire atlantal ring. A small posterior tubercle marks th
midiine of th posterior arch. The lateral masses support th
prominent articular processes.
The large and concave superior articular facets face erari -1
ally, in generai, io accept th large, convex occipital cor.-l
dyles. The inferior articular facets are fiat to slightly concave
These facet surfaces generally face mferiorly, with their la I
eral edges sloped downward, approximately 30 degrees frorr I
th horizontal piane (Fig. 9 - 2 2 B ). The alias has large, palpaJ
ble transverse processes, usually th greatest of th cerv cM
vertebrae.
Axis (C2)
The axis has a large, tali body that serves as a base for
upwardy projeetmg d'ens (odontoid process) (Fig. 9 -2 3 A anc
B). Part of th elongated body is formed from remnants &. I
th body of th atlas and th intervening disc. The demi
provides a rigid vertical axis for rotation of th atlas anzi
head (Fig. 9 - 2 4 ) . Projecting laterally from th body is a pai: I
of superior articular processes (Fig. 9 -2 3 A ). These large fla: I
to slightly convex processes have superior facets that ar-: I
generally in a cranial position, exhibiting a 30-degree slope
which matches th slope of th inferior articular facets o: I
th atlas. Projecting from th prominent superior articular
processes of th axis are a pair of stout pedicles and r I
pair of short transverse processes (Fig. 9 - 2 3 B ). A pair 1
inferior articular processes project inferiorly from th I
pedicles, with articular facets facing anteriorly and ir.-1
feriorly (see Fig. 9 - 2 1 ) . The spinous process of th axis 1
bifid and very broad. This palpable spinous process serve.-1
as an attachment for many muscles, such as th sem; - 1
spinalis cervicis.
Vertebral Prominens (C7)
C7 is th most prominent of all cervical vertebrae, havin:
many characteristics of thoracic vertebrae. C7 can have . I
 Chapter 9 Osteology and Arthrology 265

S P E C I A L F O C U S

C e r v ic a l O s te o p h y te s : O n e P o s s ib le C o n s e q u e n c e o f D is c o s t e o p h y t e ( b o n e s p u r ) , d e p ic t e d a t t h C 4 -C 5 in t e r v e r t e
D is e a s e b r a l j o in t in F ig u r e 9 - 1 9 . O s t e o p h y t e s d e v e lo p in a c c o r d -
a n c e w it h t h c e n t u r y - o ld Wolff's / .a w th a t S ta te s " B o n e
O n e im p o r t a n t f u n c t io n o f a h e a lt h y , w e ll- h y d r a t e d in t e r -
is la id d o w n in a r e a s o f h ig h s t r e s s a n d r e a b s o r b e d in
v e r t e b r a l d is c is t o u n lo a d t h u n c o v e r t e b r a l jo in t s . T h is
a r e a s o f l o w - s t r e s s . " A la r g e o s t e o p h y t e m a y e n c r o a c h o n
u n lo a d in g , o r " c u s h i o n i n g " e f f e c t , is illu s t r a t e d a t t h O S
a n e x it in g s p in a i n e r v e ro o t, p r o d u c in g a p in c h e d n e r v e
CA in t e r v e r t e b r a l ju n c t io n in F ig u r e 9 - 1 9 . T h e e f f e c t m a y
s y n d r o m e w it h p a in a n d w e a k n e s s t h r o u g h o u t t h p e r ip h -
b e r e d u c e d in t h c a s e o f a d e g e n e r a t e d o r d e h y d r a t e d
e r a l d is t r ib u t io n .
d is c . O v e r t im e , i n c r e a s e d c o m p r e s s io n f o r c e o n t h u n
c o v e r t e b r a l j o in t m a y s t im u la t e t h f o r m a t io n o f a n

Anterior view

Intervertebral foramen

Uncovertebral joint (C3-C4)

C* spinai nerve
Dorsal root ganglia
Dorsal ramus
Healthy intervertebral disc (C3-C4)

Osteophyte around Ventral ramus

th uncovertebral joint (C4-C5)

Degenerated intervertebral disc

C5 spinai nerve

Anterior tubercle of
transverse process

FIGURE 9-19. A computer-enhanced image depicts th relationship between th health of an interver-

tebral disc and th compression at th adjacent uncovertebral joints. The intervertebral disc between
C3-C4 is shown as a healthy and fully hydrated structure. The height of th disc acts as a spacer,
unloading th uncovertebral joints. In contrast, th disc between C4-C5 is shown as a degenerated,
flattened structure. As a result, th adjacent C4-C5 uncovertebral joint has developed a large osteo
phyte owing to increased compression and resultant stress between its articular surfaces. The osteo
phyte is shown compressing elements of th C5, which may cause radiating pain throughout th
nerves peripheral distribution.

iarge transverse processes, as illustrated in Figure 9 - 1 8 . A
-ypertrophic anterior tubercle on th transverse process may
-prout an extra cervical rib, which may impinge on th
'rachial plexus. This vertebra also has a large, single pointed
.nnous process, characteristic of other thoracic vertebrae (see
Fig. 9 - 2 1 ) .
Thoracic Region
Typical Thoracic Vertebrae IT2-T10)
The second through th tenth thoracic vertebrae demonstrate
similar features (see Fig. 9 - 5 ) . Pedicles are directed posteri-
orly from th body, which reduce th size of th vertebral
canal as compared with th cervical region. The large trans-
verse processes project posterior-laterally, each containing a
costai facet that articulates with th tubercle of th corre-
sponding rib. Short, thick laminae form a broad base for th
downward slanting spinous processes. The articular proc
esses have facets that are oriented nearly vertical, with th
superior Jacets facing generally posterior and th injerior facets
facing generally anterior. The apophyseal joints are aligned
dose to th frontal piane (Fig. 9 - 2 5 ) .
Each head of ribs 2 to 10 forms a costovertebral joint by
articulating at th junction of th T I - 2 through T 9 - 1 0
vertebral bodies. The head of a rib articulates with a pair of
costai facets that span one intervertebral junction. A thoracic
(intercostal) spinai nerve root exits through a corresponding
thoracic intervertebral foramen. The intervertebral foramen is
located just anterior to th apophyseal joints.
266 Secton li Axial Skeleton

Posterior-lateral view Lateral view

Apophyseal joint (C1-2)

Pedicle of axis

Apophyseal joint (C2-3)

Anterior
and
Posterior
tubercles

FIGURE 9-20. A posierior-laieral view of ihe fourth cervical verte

bra.

Pair ol partial
costai facets

FIGURE 9-21. A lateral view of th cervical vertebral column

Superior view
Posterior tubercle
Posterior
arch -

Transverse
process

Transverse
foramen Superior
articolar facet
Anterior - FIGURE 9-22. The atlas. A, Se
tubercle Anterior perior view. B, Anterior view.
arch

Anterior view
 Chapter 9 Osteology and Arthrobgy 267

Superior view

A nterior view
Bifid spinous process
Dens

Anterior tacet articular process

(dorsal side)

Superior Superior
articular facet articular process

Transverse
process

articular facet

FIGURE 9-23. The axis. A, Anterior view. B, Superior view.

Arpicai Thoracic Vertebrae (TI and T11-12)
The first and last two thoracic vertebrae are considered atyp-
cal mainly due to th particular manner of rib attachment.
71 has a full costai facet superiorly that accepts th entire
-jead of th first rib, and a partia facet inferiori) that accepts
nart of th head of th second rib (see Fig. 9 - 2 1 ) . The
spinous process of T I is especially elongated and often as
orominent as th spinous process of C7. The bodies of T l l
and T12 each have a single, full costai facet for articulation
with th heads of th eleventh and twelfth ribs, respectively.
The neck of ribs 11 and 12 typically do not form articula-
tions with corresponding transverse processes.
Lumbar Region
Lumbar vertebrae have massive wide bodies, suitable for sup-
porting th entire superimposed weight of th head, trunk,
and arms (Fig. 9 - 2 6 ) . The total mass of fve lumbar verte
brae is approximately twice that of th seven cervical verte
brae (Fig. 9 - 2 7 ) .

Lateral view
Superior view

FIGURE 9-24. A superior view of th median atlanto-axial articula FIGURE 9-25. A lateral view of th sixth through eighth thoracic
tion. vertebrae.
268 Section III Axial Skeleton
For th most part, th lumbar vertebrae possess similar
characteristics. Laminae and pedicles are short and thick,
forming th posterior and lateral walls of th nearly triangu-
lar-shaped vertebral canal. Thin transverse processa project
almost laterally. Spinous processes are broad and rectangular,
projecting horizontally from th junction of each lamina
(Fig. 9 - 2 8 ) . This shape is strikingly different from that of
th pointed, sloped spinous processes of th thoracic region.
Short mammillary processes project from th posterior sur-
faces of each superior articular process. These structures
serve as attachment sites for th multifidi muscles.
The articular facets of th lumbar vertebrae are oriented
nearly vertical. The superior facets are moderately concave,
facing mediai to posterior-medial. As depicted in Figure
 Chapter 9 Osteology and Arthrology 269

Luterai view th cauda equina. Pedicles are very thick, extending laterally
as th ala (lateral wings) of th sacrum. Stout superior articu
lar processes have articular facets that face generally poste-
rior-medial. These facets articulate with th inferior facets of
L5 to form L5-S1 apophyseal joints (see Fig. 9 - 3 1 ) . The
large auticular surface articulates with th ilium, forming th
sacroiliac joint. The sacrum narrows caudally to form its
apex, a point of articulation with th coccyx.

Coccyx
The coccyx is a small triangular bone consisting of four
fused vertebrae (see Fig. 9 - 3 1 ) . The base of th coccyx joins
th apex of th sacrum at th sacrococcygeal joint. The joint
has a fibrocartilaginous disc and is held together by several
small ligaments. The sacrococcygeal joint usually fuses late
in life. In youths, small intercoccygeal joints persist; however,
these typically are fused in adults.110

FIGURE 9-28. A lateral view of th first lumbar vertebra.

ARTHROLOGY

Typical Intervertebral Junction

The typical intervertebral junction has three parts that are
9 - 2 6 , th superior facet surfaces in th upper lumbar region
associated with movement and stability: th transverse and
tend io be oriented dose to th sagittal piane, and th
spinous processes, th apophyseal joints, and th interbody
superior facet surfaces in th mid-to-lower lumbar region
tene/ to b e orien ted m idw ay betw een th sagittal an d frontal joim (Fig. 9-33). All three parts share common functions,
planes. The inferior articular faceti are reciprocally matched allhough each has a predominant function (Table 9 5). The
s p in o u s a n d t r a n s v e r s e p r o c e s s e s fu n ctio n as o u tn ggers, o r lev-
to th shape and orientation of th superior articular facets.
ers, increasing th mechamcal advantage of muscles and liga
In generai, th inferior articular facets are slightly convex,
ments that move and stabilize th vertebral column.
facing generally lateral to anterior-lateral (see Fig. 9 - 2 8 ) .
The apophyseal joints are primarily responsible for guiding
The inferior facets of L5 articulate with th superior facets
intervertebral motion, much like railroad tracks guide th
of th sacrum. The resulting L5-S1 apophyseal joints are
direction of a tram. The geometry, size, and spatial orienta
typically oriented much closer to th frontal piane than are
tion of th articular facets within each apophyseal joint
other lumbar articulations. The L5-S1 apophyseal joints pro
greally influence th direction of intervertebral motion.
vide an important source of anterior-posterior stability to th
The interbody joint functions primarily for shock absorp-
lumbosacral junction.
tion and load distribution. In addition, th interbody joint
Sacrum
The sacrum is a triangular bone with its base facing superi
ori)' and apex inferiori)' (Fig. 9 - 3 0 ) . An important function
of th sacrum is io transmit th weight of th vertebral TABLE 9 - 5 . Predominant Functions of th Three
column to th pelvis. In childhood, each of ftve separate Parts of a Typical Intervertebral Junction
sacrai vertebrae are joined by a cartilaginous membrane. By
adulthood, however, th sacrum has fused into a single Pari Function
bone, whch stili retains th typical anatomie features of a Provide levers for muscles and lig
Spinous process and
generic vertebra. transverse processes aments for th purposes of
The anterior (pelvic) surface of th sacrum is smooth and causing or restricting move
concave, forming pari of th posterior wall of th pelvic ment, and stabilizing th verte-
cavity (see Fig. 9 - 3 0 ) . Four paired ventral (pelvic) sacrai bral column
fem m in a transmit th ventral rami of spinai nerves that form Guides intervertebral motion
Apophyseal joint
much of th sacrai plexus. The clorsal surface of th sacrum
is convex and rough due to th attachments of muscle and Interbody joint Absorbs shock and distributes load
ligaments (Fig. 9 - 3 1 ) . Several spinai and lateral tubercles throughout th vertebral col
umn
mark th remnants of fused spinous and transverse proc-
Provides intervertebral stability
esses, respectively. Four paired dorsal sacrai foram ina trans Serves as th approximate site of
mit th dorsal rami of sacrai nerves. th axes of rotation for move
The superior surface of th sacrum shows a clear repre- ment
sentation of th body of th first sacrai vertebra (Fig. 9 - 3 2 ) . Functions as a deformable inter
The sharp anterior edge of th body of SI is called th sacrai vertebral spacer
promontory. The triangular sacrai canal houses and proteets
270 Secton III Axial Skeleton

S P E C I A L F O C U S

Cauda Equina b a t h e d w it h in c e r e b r o s p in a l f lu id a n d lo c a t e d w it h in t h
lu m b o s a c r a l v e r t e b r a l c a n a l.
T h e s p in a i c o r d a n d v e r t e b r a l c o lu m n h a v e d if f e r e n t
S e v e r e f r a c t u r e o r t r a u m a in t h lu m b o s a c r a l r e g io n
g ro w th ra te s . A s a c o n s e q u e n c e , th c a u d a l e n d o f th
m a y d a m a g e t h c a u d a e q u in a , b u t s p a r e t h s p in a i c o r d .
a d u lt s p in a i c o r d u s u a lly t e r m in a t e s a d j a c e n t t o t h L 1 -2
D a m a g e t o t h c a u d a e q u in a m a y r e s u lt in m u s c le p a r a ly -
in t e r v e r t e b r a l f o r a m e n (F ig . 9 - 2 9 ) . T h e l u m b o s a c r a l n e r v e s
s is a n d a t r o p h y , a lt e r e d s e n s a t io n , a n d r e d u c e d r e f le x e s .
m u s t t r a v e l a g r e a t d is t a n c e b e f o r e r e a c h in g t h e ir c o r r e -
S p a s t ic it y w it h e x a g g e r a t e d r e f le x e s t y p i c a l l y o c c u r s w it h
s p o n d in g in t e r v e r t e b r a l f o r a m in a . A s a g r o u p , t h e lo n -
d a m a g e t o t h s p in a i c o r d .
g a t e d n e r v e s r e s e m b le a h o r s e 's t a il, h e n c e cauda equina.
T h e c a u d a e q u in a is a s e t o f p e r ip h e r a l n e r v e s t h a t a r e

FIGURE 9 -2 9 . Relation of th spinai cord and nerve roots to th vertebral column

The nerve roots of th spinai cord shown in black are numbered C1-S5. The
intervertebral foramina through which th nerve roots pass are indicated by th
numbers in th right column. In th adult, th spinai cord is shorter than th
vertebral column. The spinai cord terminates adjacent lo th Ll-2 intervertebral
foramen. (From Haymaker W, Woodhall B: Peripheral Nerve lnjuries, 2nd ed. Phtla-
delphia, WB Saunders, 1995.)

C a u d a equina
 Chapter 9 Osteology and Arthrology 271

A n t e r i o r v ie w Posterior-lateral view

M ultifdi

articularis

Spinous process (L5)

Apophyseal
jo in t (L5-S1)

Spinai tubercles
Auricular

Lateral tubercles

Erector spinae
and m u ltifid i
Gluteus maxim us

FIGURE 9-31. A posterior-lateral view of th lumbosacral region.

Attachments of th multifdi, erector spinae, and gluteus maximus
are indicated in red.

T E R M IN O L O G Y THAT D E S C R IB E S M OVEM ENT

Movement within one intervertebral junction is small. W hen

added across entire vertebral regions, however, these small
Sacrai Ventral Coccyx Piriform is Auricular surface
movements yield considerable angular rotation. The osteokin-
promontory sacrai (articulates ematics at th vertebral column, including th head, describe
foramina w lth ilium)

FIGURE 9-30. An anterior view of th lumbosacral region. Attaeh-

ments of th piriformis, iliacus, and psoas major are indicated in
red. Attachments of th quadratus lumborum are indicated in gray. Superior view

adds stability between vertebrae, serves as th approximate

site of th axes of rotation, and functions as a deformable
intervertebral spacer. As spacers, th intervertebral discs con-
stitute about 25% of th total height of th vertebral column.
The larger th ratio between th height of th body and th
height of th disc, th greater th relative movement be
tween consecutive bodies. The greatest space between verte
brae occurs in cervical and lumbar regions.
Interaction of all three functional parts of th vertebrae is
required for normal vertebral movement. Mechanical dys-
function in any part can cause articular derangement and/or
impingement of neural tissues. Understanding th spatial and
physical relationships between th neurology, osteology, and
arthrology of th vertebral column is an essential element in
understanding th cause and treatment of spinai pain and FIGURE 9-32. A superior view of th sacrum. Attachments ot th
dysfunction, regardless of etiology. iliacus muscles are indicated in red.
 272 Section III Axial Skeleton

FIGURE 9-33. A model shows

th three functional parts of a
typical intervertebral junction:
Transverse process transverse and spinous proc-
esses, apophyseal joints, and in
Interior articular facet Vertebral body terbody joint, including th in
Apophyseal joint
tervertebral disc. The Ll-2
Intervertebral foramen
junction is shown flexing and
Stretched interspinous ligament sliding between th articular
Superior articular process Intervertebral disc facet surfaces of th apophyseal
(interbody joint) joints. The interspinous liga
ment is shown stretched. Note
th compression of th front of
Splnous process th intervertebral disc.

th piane and direction of rotation for a given region. Mo-
tions are typically defined by their planes, with an associated
axis of rotation located approximately through th body of
th interbody joint (Table 9 - 6 ) . By convention, movement
throughout th vertebral column, including th head on th
cervical spine, occurs in a cranial-to-caudal fashion, with th
direction of movement referenced by a point on th anterior
side of th more cranial (superior) vertebral segment. During
C 4 - 5 axial rotation to th left, for example, a point on th
anterior body of C4 rotates to th left, although th spinous
process rotates to th right.
Arthrokinematic terminology describes th relative move
ment between articular facet surfaces within a given apophy
seal joint. Most joint surfaces are fiat or nearly fiat, and
terms such as approximation, separation, and sliding de-
scribe th arthrokinematics (Table 9 - 7 ) .

TABLE 9 - 6 . Terminology Describing th Osteokinematics of th Axial Skeleton

Common Terminology Piane of Movement Axis of Rotation Other Terminology

Flexion and extension Sagittal Medial-lateral Forward and backward bending
Lateral flexion to th right or left Frontal Anterior-posterior Side bending to th right or left
Axial rotation to th right or left* Horizontal Vertical Rotation, torsion

* Axial rotation of th spine is defined by th direction of movement of a point on th anterior side of Lhe vertebral body.

! TA B LE 9 - 7 . Terminology Describing th Arthrokinematics at th Apophyseal Joints

Terminology Definition Functional Example

Approximation of joint surfaces An articular facet surface tends to move closer Extension or increased lordosis of th lumbar
to its partner facet. Joint approximation is spine
usually caused by a compression force.
S ep a r a tio n (gapping) between joint An articular facet surface tends to move away Therapeutic traction
surfaces lrom its partner facet. Joint separation is
usually caused by a distraelion force.
S lid in g (.gliding) between joint surfaces An articular facet translates in a linear or cur- Flexion-extension of th mid to lower cervi
vilinear direction within th piane of th cal spine
joint. Sliding between joint surfaces is
caused by a force directed tangential to th
joint surfaces. Sliding between joint sur
faces is resisted by a shear force.
 Chapier 9 Osteology and Arthrology 273

Spinai Coupling
M o v e m e n t o f t h v e r t e b r a l c o lu m n in o n e p ia n e is u s u -
a lly a s s o c ia t e c i w it h a n a u t o m a t ic a n d , a t t i mes , nearly
im p e r c e p t ib le m o v e m e n t in a n o t h e r p ia n e . T h is k in e -
m a t ic phenomenon is called spinai coup/ing. Although
m a n y c o u p lin g p a t t e r n s a r e d e s c r ib e d , t h m o s t c o n s is -
t e n t p a t t e r n in v o lv e s a n a s s o c ia t io n b e t w e e n a x ia l r o t a -
t io n a n d la t e r a l f le x io n .
T h e m e c h a n ic a l r e a s o n f o r s p in a i c o u p lin g v a r ie s b e
t w e e n r e g io n s , a n d it o f t e n is n o t c le a r . E x p la n a t io n s
in c lu d e m u s c le a c t io n , a r t ic u la r f a c e t a lig n m e n t , a n d
g e o m e t r y o f t h p h y s io lo g ic c u r v e it s e lf . 18 T h e la t t e r
e x p la n a t io n m a y b e d e m o n s t r a t e d b y u s in g a f le x ib le
ro d a s a m o d e l o f t h s p in e . B e n d t h ro d a b o u t 3 0 to
40 d e g r e e s in o n e p ia n e t o m im ic t h n a t u r a i lo r d o s is o r
k y p h o s is o f a p a r t ic u la r r e g io n . W h i l e m a in t a in in g t h is
c u r v e , " l a t e r a l l y f le x " t h r o d a n d n o t e a s lig h t a u t o
m a t ic a x ia l r o t a t io n . T h e b ip la n a r b e n d p la c e d o n a
f le x ib le r o d a p p a r e n t ly c r e a t e s u n e q u a l s t r a in s t h a t a r e FIGURE 9-34. Typical spatial orientations for selected superior artic-
d is s ip a t e d a s t o r s io n . T h is d e m o n s t r a t io n d o e s n o t e x - ular facet surfaces of cervical, thoracic, and lumbar vertebrae. The
p la in a ll c o u p lin g p a t t e r n s o b s e r v e d c l i n i c a l l y t h r o u g h o u t red line indicates th piane of th superior articular facet, measured
t h v e r t e b r a l c o lu m n , h o w e v e r . against a vertical or horizontal reference line.

STRUCTURE A N D F U N C T IO N O F T H E A P O P H Y S E A L
AND IN T E R B O D Y JO IN T S
Apophyseal Joints
The vertebral column contains twenty-four pairs of apophy
seal joints. Each apophyseal joint is formed by th articula-
tion between opposing facet surfaces (see Fig. 9 - 1 5 ) . Me-
chanically, apophyseal joints are classified as piane joints.
Although exceptions and naturai variations are common, th
articular surfaces of most apophyseal joints are essentially
fiat. Slightly curved joint surfaces are present primarily in
th upper cervical and throughout th lumbar regions.
The word apophysis means bony outgrowth, illustrating
th protruding nature of th articular processes. Acting as
mechanical barricades, th articular processes permit certain
movements and block others. The orientation of th piane of
th facet surfaces within each joint influences th kinematics
at different regions of th vertebral column. As a generai
rule, horizontal facet surfaces favor axial rotation, whereas ver
tical facet surfaces (in either sagittal or frontal planes) block
axial rotation. Most apophyseal joint surfaces, however, are
oriented somewhere between th horizontal and vertical. Fig
ure 9 - 3 4 shows th typical joint orientation for articular
facets in th cervical, thoracic, and lumbar regions. The
piane of th facet surfaces explains, in part, why axial rota
tion is far greater in th cervical region than in th lumbar
region. Additional factors that influence th predominant
motion at each spinai region include th sizes of th inter-
vertebral discs, shapes of th vertebrae, locai muscle actions,
and attachments of th ribs or ligaments.
Interbody Joints
The interbody joint is formed by th connections between
intervertebral discs, vertebral endplates, and adjacent verte
bral bodies. Anatomically, this joint complex is classified as
an amphiarthrosis.
Structural Considerations of th Lumbar Intervertebral Disc
Most of what is known about th intervertebral disc is based
on data from th lumbar region. This region-specifc interest
reflects th greater incidence of disc herniation (rupture).
Discs in other spinai regions possess slightly different struc
tural characteristics.67
Nucleus Pulposus and Annulus Fibrosus
The intervertebral disc consists of a centrai nucleus pul
posus surrounded by an annulus fibrosus (Fig. 9 - 3 5 ) . The
nucleus pulposus is a pulplike gel located in th mid-to-
posterior part of th disc. Consisting of 70 lo 90% water,
th nucleus functions as a modified hydraulic shock ab-
sorber that dissipates and transfers loads between consecu
tive vertebrae. The nucleus pulposus is thtckened by rela-
tively large branching proteoglycans. Each proteoglycan is an
aggregate of many water-binding glycosaminoglycans linked
to core proteins.12 The nucleus also contains type 11 collagen
fbers, elastic fibers, and other noncollagenous proteins. In
th very young, th nucleus pulposus contains a few chon-
drocytes that are remnants of th primitive notochord.110
The annulus fibrosus in th lumbar discs consists of 10 to 20
concentric layers, or rings, of collagen fibers. Like dough
surrounding jelly in a doughnut, th collagen rings encase
and physically entrap th liquid-based centrai nucleus. Com-
pression force increases th hydrostatic pressure within th
entrapped and water-logged nucleus pulposus. The increase
 274 Section III Axial Skeleton
FIGURE 9-35. The intervertebral disc is shown lifted away from th
underlying vertebral endplate. (Modified from Kapandji IA: The
Physiology of Joints, voi. 3. New York, Churchill Livingstone,
1974.)
in pressure absorbs shock across th interbody joint. The
annulus fibrosus contains material similar to that found in
th nucleus pulposus, differing only in proportion. In th
annulus, collagen makes up about 50 to 60% of th dry
weight, as compared with only 15 to 20% in th nucleus
pulposus.'2
The intervertebral discs add considerable stabilii)' to th
vertebral column, as well as being shock absorbers. The
stabilizing function of th disc is due primarily to th struc-
tural configuration of th collagen fibers within th annulus
fibrosus. As shown in Figure 9 - 3 6 , th fibers are oriented in
a precise geometrie pattem. In th lumbar region, collagen
rings lie about 65 degrees from th vertical, with fibers of
adjacent layers traveling in opposite directions.12-61 This
structural arrangement resists distraction (vertical separation),
shear (sliding), and torsion (twisting).12 If th imbedded col
lagen fibers ran nearly vertical, th dsc would resist distrac-
FIGURE 9-36. The detailed organization of th annulus fibrosus
shown with th nucleus pulposus removed. Collagen fibers are
arranged in multiple concentric layers, with fibers in every other
layer running in identical directions. The orientation of each colla
gen fiber (depicted as 0) is about 65 degrees from th vertical.
(From Bogduk N: Clinical Anatomy of th Lumbar Spine, 3rd ed.
New York, Churchill Livingstone, 1997.)
tion forces, bui not sliding or torsion. In contrast, if all
fibers ran parallel to th top of th vertebral body, th disc
would resist shear and torsion, but not distraction forces.
The 65-degree angle likely represents a geometrie compro
mise that allows tensile resistance against th usuai move-
ments at th lumbar spine. Distraction forces are an inherent
component of flexion, extension, and lateral flexion, occur-
ring as one vertebral body tips slightly and, therefore, sepa-
rates relative to its neighbor. Shear and torsion forces are
produced dunng virtuali) all movements of th vertebral
column. Because of th alternating pattem of layering of th
annulus, only th collagen fibers oriented in th direction of
th slide or twist become taut. Fibers in every other layer
slacken.
Vertebral Endplates
The vertebral endplates are thin caps of hyaline and fibro-
cartilage located on th superior and inferior surfaces of each
vertebral body. The collagen fibers within th annulus fibro
sus blend with th endplates of two consecutive vertebrae
(Fig. 9 - 3 7 ) . The anatomie bond between th endplates and
annulus forms th primary adhesion between th vertebrae.
The vertebral endplates, being semipermeable, also allow nu-
trients to pass from blood vessels in th vertebral body to
deeper regions of th disc.
Intervertebral Disc as a Hydrostatic Shock Absorber
The vertebral column is th primary' support structure for
th trunk and neck. Although highly dependent on th posi-
tion of th spine, approximately 80% of th load across two
lumbar vertebrae is carried through th interbody joint. The
remaining 20% is carried by posterior structures, such as
apophyseal joints and laminaeri
The intervertebral discs are uniquely designed as shock
absorbers, protecting th bone from th compression forces
produced by body weight and muscle contraction. Compres
sion forces push th endplates inward and toward th nu
cleus pulposus (Fig. 9 - 3 8 ) . Being filled rnostly with water
and therefore essentially incompressible, th nucleus re-
sponds by deforming radially and outwardly against th an
nulus fibrosus (Fig. 9 -3 8 A ). Radiai deformalion is resisted
by th tension created within th stretched rings of collagen
and elastic fibers. Internai resistance reinforces th walls of
th annulus fibrosus (Fig. 9 - 3 8 B ). As a result, back pressure
FIGURE 9-37. A vertical slice through th interbody joint shows th
structure of th vertebral endplates. The inner two thirds of th
annulus fibrosus blends with th endplate, forming its fibrocartilagi-
nous component. The outer one third of th annulus fibrosus
blends directly with bone (i.e., ring apophysis). (From Bogduk N
Clinical Anatomy of th Lumbar Spine, 3rd ed. New York, Church
ill Livingstone, 1997.)
 Chapter 9 Osteology and Arthrology 275

return to their originai preload length and prepare for an-

other cycle of shock absorption. According to White and
Panjabi,106 two pioneers in th study of th biomechanics of
th spine, th disc provides little resistance to small com
pressive loads, but more resistance to large ones. The disc
thereby allows flexibility at low loads and provides stability
at high loads.106
The shock absorption mechanism protects th disc in two
ways (see Fig. 9 - 3 8 ) . First, compressive forces are diverted
from th nucleus, toward th annulus, and back to th
nucleus and endplates. Such diversion takes lime, thereby
reducing th rate of loading, although noi necessarily th
magnitude. Second, th mechanism allows compressive
forces to be shared by multiple structures, thereby limiting
pressure on any single tissue.

In Vivo Pressure Measurements from th

Nucleus Pulposus
In vivo pressure measurements taken from th nucleus
pulposus in th lumbar region have generally confirmed that
resting in a supine position produces relatively low disc
pressure.8'9-71-72-74 108 Larger discal pressures occur from activ-
ities that combine forward bending and th need for vigor-
ous trunk muscle contraction. These measurements have
helped to increase th understanding of ways to reduce in
jury to th disc. Data produced by two separate studies are
compared in Figure 9 - 3 9 . 71108 Both studies reinlorce three
points: (1) disc pressures are large when one holds a load in
front of th body, especially when bending forward; (2)
lifting a load with knees flexed places less pressure on th
lumbar disc than does lifting a load with th knees straight,
which uses more vigorous back muscle activity; and (3)
sitting in a forward slouched position produces greater discal
pressures than sitting erect. These points serve as th theo-
retical basis for many educational programs designed to pre-
vent lumbar disc hemiation.

FIGURE 9-38. The mechanism of force transmission through an

intervertebral disc. A, Compressimi force from body weight and
muscle coniraction (large arrow) raises th hydrostatic pressure in
th nucleus pulposus. In turn, th increased pressure elevates th
tension in th annular fbrosus (small arrows). B, The increased
tension in th annulus inhibits radiai expansion of th nucleus. The
rising nuclear pressure is also exerted upward and downward
against th endplates. C, The pressure wilhtn th nucleus reinforces
th peripheral annulus fbrosus, converting it imo a stable weight-
bearing structure. The pressure is ultimately transmitted across th
endplates to th next vertebra. (From Bogduk N: Clinica! Anatomy
of th Lumbar Spine, 3rd ed. New York, Churchill Livingstone,
1997.)
FIGURE 9-39. A comparison between data from two intradiscal
pressure studies (see text). Each study measured in vivo pressures
from a lumbar nucleus pulposus in a 70-kg subject during common
is created against th nucleus pulposus and endplates, rein- postures and activities. The pressures are normalized to standing.
forcing th entire disc and passing th load to th next (Modified from Wilke H-J, Neef P, Caimi M, et al: New' in vivo
vertebra (Fig. 9 -3 8 C ). When compressive force is removed measurements of pressures in th intervertebral disc in daily life.
from th endplates, th stretched elastic. and collagen fibers Spine 24:755-762, 1999.)
 276 Section III Axial Skeleton

Water Content within th Intervertebral Disc: Influence

of Diurnal and Age-Related Changes in Overall Height
When a healthy spine is unloaded, such as during bed
rest, th pressure within th nucleus pulposus is rela-
tively low.71 The low pressure, combined with th hydro-
philic nature of th disc, attracts water into th annulus
fibrosus and nucleus pulposus. As a result, th disc
swells slightly when one is sleeping. While awake and
upright, however, weight hearing through th vertebral
column forces water out of th disc. The cycle of swell-
ing and contracting of th disc produces an average
1.1% daily variation in overall height.'00 One is actually
taller in th morning. About 56% of th total loss in
height during th day is recovered after only 2 hours of
bed rest.53
The structure of th intervertebral disc changes with
age." An older disc has less proteoglycan content
and, therefore, less ability to attract and retain water.
The water content of th nucleus pulposus at birth is
88%, but decreases to 65 to 72% by th age of 75
years. The aged disc contains more collagen and less
elastin, rendering it more fibrous and less resilient. A
drier, less elastic nucleus pulposus is less able to cush-
ion th vertebral body against excessive compression
forces. As a consequence, th vertebral bodies and
endplates may experience microfracture and bony reab-
sorption, ultimately leading to progressive and perma- FIGURE 9-40. The normal sagitta piane curvatures across th
nent age-related loss in height. The amount of loss in regions of th vertebral column. The curvatures represent th nor
height is greater in persons with severe osteoporosis of mal resting postures of th region.
th vertebral column and those with osteoporotic frac-
tures, leading to an exaggerated kyphosis known as
"widow's hump."

may vary from data presented in other sources. The variabil-

REGIONAL KINEMATICS OF THE SPINE
This section provides both th range and predominant direc
tion oi movements at th various regions of th vertebral
column. The zero or reference point used to describe th
motion is th resting posture of th region while standing
(Fig. 9 - 4 0 ) . 38'52 The ranges of motion cited in this chapter
ity reflects th differences in measurement techniques and
th flexibility of th subjects. As elsewhere in th body,
range of motion varies based on gender, underlying disease.
activity level, and age.
The connective tissues that surround th vertebral column
limit th extremes of motion (Table 9 - 8 ) . By restricting
motion, connective tissues including those within mus-
cle help protect th delicate spinai cord and maintain opti-
mal posture. In cases of trauma or overuse, biologie tissues

; T A B L E 9 - 8. Connective Tissues That May Limit Motions of th Vertebral Column

Flexion Extension Axial Rotation Lateral Flexion

Ligamentum nuchae Cervical viscera (esophagus Annulus fibrosus Intertransverse ligaments
Interspinous and suprasptnous and trachea) Capsule of th apophyseal joints Contralateral annulus fibrosus
ligamenis Anterior annulus fibrosus Alar ligaments Capsule of th apophyseal joints
Ligamentum flava Anterior longitudinal ligament
Capsule of th apophyseal
joints
Posterior annulus fibrosus
Posterior longitudinal ligament

The lisi docs not include limiutions of motion caused by stretched muscles or by compression force created within th apophyseal and interbody joints
 Chapter 9 Osteology and Arthrology 277

discussion begins with an overview of th functional anat

omy followed by a discussion of th kinematics, organized
by piane of movement.
Measuring Motion of th Vertebral Column: The craniocervical region is th most mobile area within
An OverView th entire vertebral column. Highly specialized joints facili
tate positioning of th head, involving vision, hearing, smeli,
Motion of th vertebral column has been measured
and equilibrium. As in th multiple links of th shoulder
manually and radiographically and through th use of
complex, th individuai joints within th craniocervical re
external tracking systems. Manual in vivo measurements
gion interact in a highly coordinated manner. Table 9 - 1 0
use simple noninvasive tools, such as goniometers, in-
summarizes th average range of motions contributed by
clinometers, and flexible rulers. Although these tools are each region of th craniocervical region.14-31^4-77'78-83-106
simple and inexpensive, they lack high precision for
measuring motion across various regions of th verte
bral column. Invasive in vivo techniques are utilized to F U N C T IO N A L A N A T O M Y OF T H E J O IN T S W IT H IN T H E
C R A N I O C E R V IC A L R E G IO N
measure th rotation of pins implanted directly into th
vertebral column. Although more precise, this form of Atlanto-occipital Joints
measurement has its obvious practical limitations.
Perhaps th most precise in vivo kinematic measure The atlanto-occipital joints provide independent movement
ments of th vertebral column use radiography. Planar of th cranium relative to th atlas. The joints are formed by
th protruding convex condyles of th occipital bone fitting
x-rays of several individuai sequences of a movement
into th reciprocally concave superior articular facets of th
can be reconstructed with th use of a computer to
atlas (Fig. 9 - 4 1 ) . The congruent convex-concave relation-
measure rotation and translation of th vertebral col
ship provides inherent strutturai stability to th articulation.
umn. Biplanar radiography has th advantage of record-
lntra-articular fai pads are commonly found between th
ing movements in three dimensions. The main draw-
joint capsule and th margins of th articular cartilage.66
backs of these techniques are th exposure of subjects
Anteriorly, th capsule of each atlanto-occipital joint blends
to low doses of radiation and th time and cost of th
with th anterior atlanto-occipital membrane and th anterior
procedure.
longitudinal ligament (Fig. 9 - 4 2 ) . Posteriori)', th capsule is
More complicated kinematic measurements involve
covered by a thin, broad posterior atlanto-occipital membrane
computer-based external tracking systems that record
(Fig. 9 - 4 3 ) . As depicted on th right side of Figure 9 - 4 3 ,
and digitize movement. The relative or absolute position
of targets placed on or near th trunk is recorded by
specialized cameras. A more sophisticated tool has a
computerized electromagnetic tracking System that can
record movement in 6 degrees of freedom (three trans- TABLE 9 - 9 . Organization of th Join t Anatomy
lational and three rotational). Electromagnetic fields and Regional Kinematics at th Craniocervical
emitted by a fixed external source are detected by Region
remote sensors attached to th body. A computer pro
gram then calculates th near real-time position and Functional Anatomy of th Joints within th Craniocervical
orientation of th sensors relative to th source. Region

Atlanto-occipital joints
Atlanto-axial joint complex
Intracervical apophyseal joints (C2-7)

may generate excessive tension as a means to protect an Sagittal Piane Kinematics at th Craniocervical Region
injured vertebral segment. Spasm in locai muscles following Osteokinematics of flexion and extension
acceleration-deceleration (whiplash) injury of th neck is a Arthrokinematics of flexion and extension
common expression of this protective guarding. In cases of Atlanto-occipital joint
disease, such as severe rheumatoid arthritis, limited spinai Atlanto-axial joint complex
mobility has no protective function, but is instead an intrin- Intracervical apophyseal joints (C2-7)
sic part of th pathologic process. Understanding th specific Osteokinematics of protraction and retraction
role of connective tissues in limiting motion is useful in Horizontal Piane Kinematics at the Craniocervical Region
devising therapeutic activities for persons with spinal-related
pain or dysfunction. Osteokinematics of axial rotation
Arthrokinematics of axial rotation
Atlanto-axial joint complex
Craniocervical Region Intracervical articulations (C2-7)
The terms craniocervical region and neck are used inter- Frontal Piane Kinematics at the Craniocervical Region
changeably. Both terms refer to th combined set of three
Osteokinematics of lateral flexion
articulations: atlanto-occipital joint, atlanto-axial joint complex,
Arthrokinematics of lateral flexion
and intracervical apophyseal joints (C 2 -7 ). The overall organi-
Atlanto-occipital joint
zation used to present th regional anatomy and kinematics Intracervical articulations (C2-7)
of th craniocervical region is outlined in Table 9 - 9 . The
 278 Section III Axial Skeleton

TABLE 9 - 1 0 . Approximate Range o f Motion for th Three Planes of Movement for th Joints
of th Craniocervical Region

Flexion and Extension Axial Rotation Lateral Flexion

Joint or Region (Sagittal Piane, Degrees) (Horizontal Piane, Degrees) (Frontal Piane, Degrees)
Atlanto-occipital joint Flexion: 5 Negligible About 5
Extension: 10
Total: 15
Atlanto-axial joint complex Flexion: 5 40 -4 5 Negligible
Extension: 10
Total: 15
lniracervical region (C2-7) Flexion: 35 45 35
Extension: 70
Total: 105
Total across craniocervical region Flexion: 4 5 -5 0 90 About 40
Extension: 85
Total: 130-135

The horizontal and frontal piane moiions are to one side only. Data are compiled from multiple sources (see text) and subject io large intersubjea
variatiorts.

th vertebral artery pierces th posterior atlanto-occipital apophyseal joints. The median joint is formed by th dens of
membrane to enter th foramen magnum. This artery sup- C2 projecting through a ring created by th transverse liga-
plies blood to th brain. The concave-convex structure of th ment and th anterior arch of th atlas (Fig. 9 - 4 4 ) . The
atlanto-occipital joints permits angular rotation in two de- joint complex has two synovial cavities. The smaller anterior
grees of freedom. The primary motions are flexion and ex- cavity consists of a synovial membrane that surrounds th
tension. Lateral flexion is slight. Axial rotation is severely articulation between th anterior side of th dens and th
restricted and not considered as a degree of freedom. posterior border of th anterior arch of th atlas. A small
Atlanto-axial Joint Complex anterior facet on th antenor side of th dens marks this
articulation (see Fig. 9 -2 3 A ). The much larger posterior
The atlanto-axial joint complex consists of two joint struc- cavity has a synovial membrane that separates th posterior
tures: a median joint and a pair of laterali)' positioned side of th dens and a cartilage-lined section of th transverse

Anterior view
Posterior view
A n t e r io r lo n g itu d in a l lig a m e n t (cut)

P o s t e r io r a tla n t o - o c c ip it a l O c c ip ita l b o n e
A t la n t o - o c c ip it a l
m e m b ra n e (cu t) O c c ip ita l c o n d y le A n t e r io r a tla n to -o c c ip ita l
jo in t c a p s u le
m e m b ra n e
F o ra m e n
m agnum Exposed pro cess
a tla n to -a x ia l
A tla n t o - a x ia l (a p o p h y s e a l i
S u p e r io r a r tic u la r (a p o p h y s e a l jo in t)
A t la n t o - o c c ip it a l jo in t c a p s u le
fa c e t
jo in t c a p s u le (cu t) P o s t e r io r A p o p h y s e a l jo in t c a p su le
lo n g itu d in a l
A n te r io r
T ra n s v e rs e lig a m e n t (cu t)
- Alias T e c to ria l tu b e rc le
pro cess
T ra n s v e rs e
m e m b ra n e
P o s t e r io r p ro ce ss
A tla n t o -a x ia l A n t e r io r
T ra n s v e rs e tu b e rc le
(a p o p h y s e a l) lo n g itu d in a l
jo in t c a p s u le fo r a m e n lig a m e n t (cu t)

FIGURE 9-42. An anterior view illustrates th connective tissut -

S p in o u s p r o c e s s
FIGURE 9-41. A posterior view of exposed atlanto-occipital joints.
The cranium is rotated forward to expose th articular surfaces of
th joints. Note th tectorial membrane as it crosses between th
atlas and th cranium.
associated with th atlanto-occipital joint and th atlanto-axial joint
complex. The righi side of th atlanto-occipital membrane is re-
moved to show th capsule of th atlanto-occipital joint. The cap
sule of th right atlanto-axial (apophyseal) joint is also removed ! :
expose its articular surfaces. The spinai cord and th bodies of C3
and C4 are removed to show th orientation of th posterior long,
tudinal ligament.

O c c ip ita l c o n d y le
A t la n t o - o c c ip it a l
Dens
A tla n to -a x ia l (a p o p h y s e a l)
jo in t c a p s u le
V e rte b ra l a rte ry
A p o p h y s e a l jo in t c a p s u le
L a m in a
L ig a m e n tu m fla v u m
S p in o u s p r o c e s s
FIGURE 9-43. A postenor view illustrates th connective tissues
associateci with th atlanto-occipital joint and atlanto-axial joint
complex. The left side of th posterior atlanto-occipital membrane
and th underlytng capsule of th atlanto-occipital joint are re-
moved. The laminae and spinous processes of C2 and C3, th
spina] cord, and th posterior longiludinal ligament and tectorial
membrane are also removed io expose th posterior sides of th
vertebral bodies and th dens.
ligament o f th atlas. Because th dens acts as a vertical axis,
th atlanto-axial joint is often described as a pivot joint.
The two apophyseal joints of th atlanto-axial joint are
tormed by articulation of th inferior articular facets of th
alias with th superior facets of th axis (see Fig. 9 - 4 2 ) .
The surfaces of these apophyseal joints are nearly fiat and
oriented dose to th horizontal piane, a design that maxi-
mizes th freedom of axial rotation.
The atlanto-axial joint complex allows two degrees of
freedom. About half th total horizontal piane (axial) rota
tion within th craniocervical region occurs ai th atlanto-
axial joint complex. The second degree of freedom is flexion
and extension. Lateral flexion is ver)' limited and not consid-
ered a degree of freedom.
FIGURE 9-44. A superior view of th dens and its
structural relationship to th median atlanto-axial
joint. The spinai cord is removed and th tectorial
membrane is cut. Synovial membranes are in red.
Chapter 9 Osteology and Arthrology 279
Tectorial Membrane and th Alar Ligaments
A review of th functional anatomy of th atlanto-axial joint
complex must include a description of th tectorial mem
brane and th alar ligaments, connective tissues that help
connect th axis with th cranium. As discussed, th trans
a t la n t o - o c c ip it a l verse ligament of th atlas makes firm contact with th
m e m b ra n e posterior side of th dens (see Fig. 9 - 4 4 ) . Just posterior to
th transverse ligament is a broad, firm sheet of connective
pro cess
tissue called th tectorial membrane. As a continuation of th
posterior longitudinal ligament, th tectorial membrane at-
taches to th basilar part of th occipital bone, just anterior
to th rim of th foramen magnum (see Fig. 9 - 4 1 ) . The
tectorial membrane strengthens th attachment between th
cranium and th cervical column by limiting th extremes of
flexion and extension.
The alar ligaments are tough fibrous cords that pass
obliquely upward and laterally from th apex of th dens to
th mediai sides of th occipital condyles (Fig. 9 - 4 5 ) . Clini-
cally referred to as check ligaments, th alar ligaments limit
axial rotation of th head and alias relative to th axis.79
Evident by their posilion, th alar ligaments also limit lateral
flexion.
Intracervical Apophyseal Joints IC2-7)
The facet surfaces within apophyseal joints of C 2 - 7 are
orientated like shtngles on a 45-degree sloped roof, approxi-
mately halfway between th frontal and horizontal planes
(see Fig. 9 - 2 1 , C 2 - 3 articulation). This orientation provides
great freedom of movement in all three planes, a hallmark of
cervical arthrology.
S A G IT T A L P L A N E K IN E M A T IC S A T TH E
C R A N I O C E R V IC A L R E G IO N
Osteokinematics of Flexion and Extension
Although highly variable, about 130 to 135 degrees of flex
ion and extension occur at th craniocervical region. The
neutral resting posture of th craniocervical region is about
30 to 35 degrees of extension (see Fig. 9 - 4 0 ) . From th
extended position, th craniocervical region extends an addi-
S u p e r io r v ie w
A n t e r io r lo n g itu d in a l lig a m e n t (cu t) A n t e r io r tu b e rc le
A n t e r io r a rc h
A la r lig a m e n t D e n s(C 2 )
S y n o v ia l c a v itie s p ro ce ss
S u p e r io r a r tic u la r fo r a m e n
T ra n s v e rs e lig a m e n t
T e c to ria l m e m b ra n e (cu t)
V e rte b ra l c a n a l P o s t e r io r a rc h
P o s t e r io r tu b e rc le
S p in o u s p r o c e s s
280 Secfion HI Axial Skeleton

P o s t e r io r v ie w tional 85 degrees and flexes 45 to 50 degrees (Figs. 9 - 4 6

and 9 - 4 7 ) . In generai, flexion and extension occur sequen-
T e c to ria l lig a m e n t
tially from a cranial to caudal direction.'3 An abnormal se-
quence in this movement pattern may indicate intervertebral
O c c ip ita l c o n d y le
A t la n t o - o c c ip it a l instabili ty.
About 20 to 25% of th total sagittal piane motion at th
A tla n t o -a x ia l T ra n s v e rs e
craniocervical region occurs over th atlanto-occipital joint
(a p o p h y s e a l) p ro ce ss and atlanto-axial joint complex, and th remainder over th
jo in t apophyseal joints of C 2 - 7 .78 The axis of rotation for flexion
T ra n s v e rs e and extension extends approximately in a medial-lateral di
L ig a m e n tu m lig a m e n t (cu t)
rection through each of th three joint regions: th occipital
fla v u m (cu t)
condyles at th atlanto-occipital joint, th dens at th at
T e c to ria l
lanto-axial joint complex, and th bodies of C 2 -C 7 .23 The
m e m b ra n e (cu t)
S p in o u s p r o c e s s extremes of flexion and extension are limted primarily bv
tension in tissues located either posteriorly or anteriori) to
th various axes of rotation (see Table 9 - 8 ) . Flexion is also
FIGURE 9-45. A posterior view of th atlanto-axial joint complex.
The posterior arch of th atlas, tectorial membrane, and transverse limited by th compression forces from th anterior margin
ligament of th atlas are cut to expose th posterior side of th of th annulus fibrosus, whereas extension is limited by th
dens and th alar ligaments. The dashed lines indicate th removed compression forces from th posterior margin of annulus
segment of th transverse ligament of th atlas. fibrosus.

Craniocerv ical extension

EXTENSION

O c c ip ita l b o n e .,.

M a s t o id p r o c e s s

Atlanto-occipital joint Atlanto-axial joint complex Intracervical region (C2-C7)

FIGURE 9-46. Ktnemaucs of craniocervical extension. A, Atlanto-occipital joint. B, Atlanto-axial joint complex. C, Intracervical
region (C2-7). Elongated and taut tissues are indicated by thin black arrows.
 Chapter 9 Osteology and Arthrology 281

C r a n i o c c r v i c a l f le x io n

FLEXION

Occipital bone Compresseti

a n n u lu s fib r o s u s
P o s t e r io r a tla n te -'
C a p s u le o f
o c c ip ita l m e m b ra n e
a p o p h y s e a l jo in t
a n d jo in t c a p s u le

Atlanto-occipital joint Atlanto-axial joint complex Intracervical region (C2-C7)

FIGURE 9 -4 7 .Kinemattcs of craniocemcal flexion. A, Atlanto-occipital joint. B, Atlanto-axial joint complex. C, Intracervical region (C2-7).
Note in C that flexion slackerts th anterior longitudinal ligament and increases th space between th adjacent laminae and spinous
processes. Elongated and taut tissues are indicated by thin black arrows; slackened tissue is indicated by a wavy black arrow.

The volume of th cervical vertebral canal ts greatest in Atlanto-axial Joint Complex

full flexion and least in full extension.'M For this reason, a
person with stenosis (narrowing) of th vertebral canal may
be more prone to spinai cord injury during hyperextension
activities. Repeated episodes of hyperextension-related inju-
ries may lead to cervical myelopathy (from th Greek root
myelo, denoting spinai cord, and pathos, suffering) and re-
lated neurologie deficits.
Arthrokinematics of Flexion and Exlension
Atlanto-occipital Joint
Like th rockers on a rocking chair, th convex occipital
condyles roll backward in extension and forward in flexion
within th concave superior articular facets of th atlas.
Based on traditional convex-on-concave arthrokinematics, th
condyles simultaneously slide slightly in th direction oppo-
site to th roll (Fig. 9 -4 6 A and Fig. 9 -4 7 A ). Tension in th
tectorial membrane, articular capsules, and atlanto-occipital
membranes limits th extern of th roll of th condyles.
Although th primary motion at th atlanto-axial joint com
plex is axtal rotation, th joint structure does allow about 15
degrees of flexion and extension. As a spacer between th
cranium and axis, th ring-shaped atlas pivots forward dur
ing flexion and backward during extension (Fig. 9 - 4 6 B and
Fig. 9 -4 7 B ). The extent of th pivot motion is limited in
part by th dens that contacts th median joint of th at
lanto-axial articulation.
Intracervical Articulations (C2-7)
Flexion and extension throughout th C 2 - 7 occur about an
are of motion that follows th oblique piane set by th
articular facets of th apophyseal joints. During extension,
which is initiated at th lower cervical spine ( C 4 - 7 ), th
inferior articular facets of superior vertebrae slide inferiorly
and posteriorly, relative io th superior articular facets of th
inferior vertebrae (Fig. 9 -4 6 C ). These movements produce
approximately 70 degrees of extension. Full extension is
 282 Seaion III Axial Skeleton
considered th close-packed position at th cervical apophy-
seal joints, as well as th other regions throughout th verte
bra! column. This position results in maxima! jomt contact
and load-bearing. The inferior sliding of th articular facets
of superior vertebrae tends to slacken th joint capsule. The
close-packed position of most synovial joints increases th
tension in th surrounding capsule and associated ligaments.
The apophyseal joints are one of th few exceptions to this
generai rule.
Flexion is also initiated at th lower cervical spine
( C 4 - 7 ) .H The movements are th reverse of those described
for extension. The inferior articular facets of th superior
vertebrae slide superiorly and anteriorly, relative to th supe
rior articular facets of th inferior vertebrae. As depicted in
Figure 9 - 4 7 C , th sliding between th articular facets pro-
duces approximately 35 degrees of (lexion. Flexion stretches
th capsule of th apophyseal joints and reduces th area for
joint contact.
Overall, approximately 105 degrees of cervical flexion and
extension occur as a result of th sliding between apophyseal
joint surfaces. This extensive range of motion is due in part
to th relatively long and unobstructed are of motion pro-
vided by th oblique piane of th facet surfaces. On average,
about 20 degrees of sagittal piane motion occur at each
intervertebral junction between C 2 - 3 and C 6 - 7 . This is a
considerably greater angular motion than at th adjacent
upper thoracic region. The largest angular displacement
tends to occur between C5 and C6,H possibly accounting for
th relatively high incidence of spondylosis68 and hyperflex-
ion-related fractures at this level (Fig. 9 - 4 8 ) .
Osteokinematics of Protraction and Retraction
In addition to flexion and extension in th craniocervical
region, th head can also translate forward (protraction) and
FIGURE 9-48. In viiro cervical fkxion and extension motions aver-
aged over ten specimens. Daia are expressed as a percent of th
total range of sagittal piane motion in th cervical region. (Data
from Holmes A, Han ZH, Dang GT, et al: Changes in cervical canal
spinai volume during in vitro flexion-extension. Spine 2 1 1 3 1 3 -
1319, 1996.)
backward (retraction) within th sagittal piane.78 Protraction
of th head flexes th lower-to-mid cervical spine and ex-
tends th upper craniocervical region (Fig. 9 -5 0 A ). Retrac
tion of th head, in centrasi, extends or straightens th
lower-to-mid cervical spine and flexes th upper craniocervi
cal region (Fig. 9 - 5 0 B ). In both movements, th lower-to-
mid cervical spine follows th translation of th head. Al-
though protraction and retraction of th head are
physiologically norma! useful motions, they may be associ
ated with faulty posture. Prolonged periods of protraction
may leacl to a chronic forward head posture, causing in-
creased strain on th craniocervical extensor muscles.
HORIZONTAL PLANE KINEMATICS AT THE
CRANIOCERVICAL REGION
Osteokinematics of Axial Rotation
Axial rotation of th head and neck is a very important
function, intimately related to Vision and hearing. As shown
in Figure 9 - 5 1 , th craniocervical region rotates about 90
degrees to each side, for a total range of nearly 180 degrees
With an additional 150 io 160 degrees of total horizontal
piane movemeni of th eyes, th visual field approaches 360
degrees, with little or no movement of th trunk! This wide
visual field depends, of course, on factors such as range of
motion and sight.
About half th axial rotation of th craniocervical region
occurs at th atlanto-axial joint complex, with th remaining
throughout C 2 - 7 . 106 Rotation at th atlanto-occipital joint is
restricted due to th deep-seated placement of th occipital
condyles within th superior articular facets of th atlas.
Arthrokinematics of Axial Rotation
Atlanto-axial Joint Complex
The atlanto-axial joint complex is designed for maximal rota
tion within th horizontal piane. The design is most evident
by th structure of th axis (C2), with its vertical dens and
nearly horizontal superior articular facets (see Fig. 9 - 3 4 )
The ring-shaped atlas twists about th dens, producing
about 40 to 45 degrees of axial rotation in each direction
(Fig. 9 -5 1 A ). The fiat to slightly concave inferior articular
facets of th atlas slide in a circular path across th broad
"shoulders ol th superior articular facets of th axis. These
surfaces have also been described as slightly convex when
considering th thickness of th articular cartilage. Because
of th limited axial rotation permitted at th atlanto-occipital
joint, th cranium follows th rotation of th atlas, essen-
tially degree for degree. The axis of rotation for th head and
atlas is through th vertically projected dens. Horizontal
piane rotation of th atlas is coupled with slight lateral flex
ion to th opposite side.79
Tension in th alar ligaments increases with rotation at
th atlanto-axial joint complex, especially in th ligament
located opposite to th direction of th rotation.79 Tension in
th alar ligaments and capsules of th lateral apophyseal
joints, plus th many muscles about th neck, limit axial
rotation.
Intra cervical Articulations (C2-7)
Rotation throughout C 2 - 7 is guided primarily by th spanai
orientation ot th facet surfaces within th apophyseal joints.
 Chapler 9 Osteology and Arthwlogy 283

Flexion and Extension and Its Effect on th Diameter of compressing against a nerve root causes radiculopathy.
th Intervertebral Foramen Symptoms include radiating pain down th ipsilateral arm,
usually th path of th cervical dermatome. Patients with
Flexion increases th diameter of a cervical intervertebral
this problem often describe shooting pain down th arm.
foramen; extension, in contrast, decreases it.113 The me-
This is in conjunction with craniocervical hyperextension
chanics of this relationship are shown for flexion at C3-4
and/or lateral flexion toward th side of th stenosis. This
in Figure 9-494 and 6. As shown in Figure 9 - 496, an
movement is common in men while shaving under th
upward and forward slide of th inferior articular facet of
chin. Cervical traction performed with th neck partially
C3 significantly increases th diameter of th C3-4 inter
flexed widens th stenosed intervertebral foramen. Thera-
vertebral foramen. Flexion, therefore, allows greater room
peutic traction can decompress an irritated spinai nerve
for passage of a spinai nerve. This principle has clinical
root and often reduces painful symptoms.
relevance in cases of stenosed (narrowed) intervertebral
foramen due to osteophyte formation. A large osteophyte

Neutral position Fully flexed

FIGURE 9 -4 9 . How flexion between C3 and C4 affecis ihe size of th intervertebral foramen is shown. A, in th neutral position, th
facet surfaces within th apophyseal joint are in maximal contact. The size of th intervertebral foramen relative to th circumference of
th exiting nerve is indicated in red. B, Full flexion reduces th contact area within th apophyseal joint; however, it increases th
opening for passage of th nerve.

The facet surfaces are oriented about 45 degrees between th
horizontal and frontal planes (see Fig. 9 - 3 4 ) . The inferior
facets slide posteriorly and somewhat inferiorly on th same
side as th rotation, and anteriorly and somewhat superiorly
on th side opposite th rotation (Fig. 9 - 5 1 B ). Approxi-
mately 45 degrees of axial rotation occur to each side over
th C 2 - 7 region, nearly equal to that permitted at th at-
lanto-axial joint complex. Rotation is greatest in th more
cranial vertebral segments.
FRONTAL PLANE KINEMATICS AT THE
CRANIOCERVICAL REGION
Osteokinematics of Lateral Flexion
Approximately 40 degrees of lateral flexion is available io
each side throughout th craniocervical region (Fig. 9 - 5 2 ) .
The extremes of this movement can be demonstrated by
attempting to touch th ear to th tip of th shoulder. Most
of this movement occurs at th C 2 - 7 region; however,
 284 Section III Axial Skeleton
Protraction
FIGURE 9 -5 0 . Protraction and retraction of th cranium. A, During protraction of th cranium, th lower-to-mid
cervical spine flexes as th upper craniocervical region extends. B, During retraction of th cranium, in contrast, th
lower-to-mid cervical spine extends as th upper craniocervical region flexes. Note th change in distance between
th C l- 2 spinous processes during th two movements.
about 5 degrees may occur at th atlanto-occipital joint.
Luterai flexion at th atlanto-axial joint complex is negligible.
Arthrokinematics of Lateral Flexion
Atlanto-occipital Joint
A small amount of side-to-side rolling of th occipital con-
dyles occurs over th superior articular facets of th atlas. It
is likely that at th extremes of lateral flexion there is a
slight unilateral joint approxitnation on th side of th lateral
flexion, and a slight joint separation on th side opposite th
lateral flexion (Fig. 9 -5 2 A ).
Intracervical Articulations (C2-7)
The arthrokinematics of lateral flexion at th C 2 -C 7 verte
bra! segments are illustrated in Figure 9 - 5 2 B . The inferior
articular facets on th side of th lateral flexion slide inferi-
orly and slightly posteriori)', and th inferior articular facets
on th side opposite th lateral flexion slide superiorly and
slightly anteriorly.
The approximate 45-degree inclination of th articular
facets of C 2 - 7 dictates a mechanical coupling between
movements in th frontal and horizontal planes. Because an
upper vertebra follows th piane of th articular facet of a
lower vertebra, a component of lateral flexion and axial rota-
tion must occur simultaneously. For this reason, lateral flex
ion and axial rotation in th mid-and-low cervical region are
mechanically coupled in an ipsilateral fashion; for example,
lateral flexion to th righi occurs with slight axial rotation to
th right, and vice versa. The overali expression of th cou
Retraction
pling, however, can be altered by muscular action at th
atlanto-occipital joint.
Thoracic Region
The thorax consists of a relatively rigid rib cage, formed by
th ribs, thoracic vertebrae, and stemum. The rigidity of th
region provides three functions: (1) a stable base for muscles
to control th craniocervical region, (2) protection for
th intrathoracic organs, and (3) mechanical bellows for
breathing (see Chapter 11).
FUNCTIONAL ANATOMY OF THORACIC ARTICULAR
STRUCTURES
The thoracic spine has 24 apophyseal joints, 12 on each
side. Each joint consists of a pair of articular facets that art
generaliy in th frontal piane, with a mild slope that varies
between 0 and 30 degrees from th vertical (see Fig. 9 - 3 4
Although th apophyseal joints provide th primary mecha-
nism for thoracic mobility, their potential for movemeni is
restricted by th adjacent costovertebral and cosiotransverse
joints. These joints mechanically tie most of th thoracic I
region anteriorly to th stemum. The costovertebral and cos
totransverse joints function during ventilation, a topic dis-
cussed in Chapter 11.
Most costovertebral joints connect th head of a rib with a
pair of costai facets and th adjacent margin of an interven-
ing intervertebral disc (Fig. 9 -5 3 A and B). The articular
 Chapter 9 Osteology and Arthrology 285

Craniocervical axial rotaton

90" rotaton

A la r lig a m e n t
(taut)

S u p e r io r fa c e t
C a p s u le o f o f a x is
a p o p h y s e a l jo in t

V e rte b ra l c a n a l

In fe rio r fa c e t
o f a tla s

Superior view
Atlanto-axial joint complex (C1-C2) Fntracervical region (C2-C7)
FIGURE 9-51. Kinematics of craniocervical axial rotaton. A, Atlanto-axial joint complex. B, Intracervical region (C2-7).

surfaces of th costovertebral joints are slightly ovoid, 10 held

Key Anatomie Aspccts of th Costovertebral and
together primarily by capsular and radiate ligaments.
Costotransverse Joints
Costotransverse joints connect th articular tubercle of a
E a c h C o s t o v e r t e b r a l J o in t
typical rib io th costai facet on th transverse process of a
connects th head of a typical rib with a pair of cosmi
corresponding thoracic vertebra. An articular capsule sur-
facets and th adjacent margin of an intervemng interver-
rounds this synovial joint (Fig. 9 -5 3 A and B). The extensive
tebral disc.
(nearly 2 cm long) costotransverse ligament frmly anchors th is stabilized by radiate and capsular ligaments.
neck of a rib to th entire length of a corresponding trans
E a c h C o s t o tr a n s v e r s e Jo in t
verse process. In addition, each costotransverse joint is stabi- connects th articular tubercle of a typical rib to th costai
lized by a superior costotransverse ligament. This strong liga facet on th transverse process of a corresponding thoracic
ment attaches between th superior margin of th neck of vertebra.
one rib and th inferior margin of th transverse process of is stabilized by a capsular (costotransverse) ligament and
th vertebra located above (Fig. 9 -5 3 A ). Ribs 11 and 12 th superior costotransverse ligament.
usually lack costotransverse joints.
 286 Section III Axial Skeleton

Cranioccrvical lateral flexion

C a p s u le o f

O c c ip ita l b o n e apophyseal
jo in t.

M a s to ic i p r o c e s s
LATERAL
FLEXION
R e c t u s c a p itis
la t e ra lis

Atlanto-occipital joint Intracervical region (C2-C7)

FIGURE 9-52. Kinematics of craniocervical lateral flexion. A, Atlanto-occipital joint. The primary function of th rectus capitis
lateralis is to laterali)- flex this joint. Note th slight compression and distraction of th joint surfaces. B, Intracervical region
(C2-7). Note th ipsilateral coupling pattern between axial rotation and lateral flexion (see text for further details). Elongated
and taut tissue is indicated by thin black arrows.

The thoracic vertebrae are well stabilized by th ribs and
associated costovertebral and costotransverse joints. Stability
protects th spinai cord from trauma. During a fall, for
example, th impact to th thoracic spine is partially ab-
sorbed and dissipated by th ribs and th associated muscles
and connective tissues.
The arthrokinematics at th apophyseal joints in th tho
racic spine are generally similar to those described for th
C 2 - 7 . Subtle differences are related primarily to different
shapes of th vertebrae and different spadai orientadons of
th articular facets. Flexion between T 5 - 6 , for example.

KINEMATICS AT THE THORACIC REGION

Kinematics of Flexion and Extension
TABLE 9 - 1 1 . Approximate Range of Motion for
Although th range of motion at each thoracic intervertebral th Threc Planes of Movement for th
junction is relatively small, cumulative motion is consider- Thoracic Region
able over th entire thoracic spine (Table 9 - 1 1 ) . Approxi-
mately 30 to 40 degrees of fle x io n and 20 to 25 degrees of Flexion and Extension Axial Rotation Lateral Flexion
extension are available throughoui th thoracic region. These (Sagittal Piane, (Horizontal Piane, (Frontal Piane.
kinematics are shown in context with flexion and extension Degrees) Degrees) Degrees)
over th entire thoracolumbar region in Figures 9 - 5 4 and
Flexion: 30 -4 0 30 25
9 - 5 5 . The extremes of extension are limited owing to th
Extension: 2 0 -2 5
porenriaJ im pingem ent betw een adjacent d o w n ua r-soping Total: 5070
spinous proccsses, especially ol th midthoracic vertebrae. Iti
generai, th magnimele of flexion and extension increases in
a cranial-to-cauda direction. Horizontal and frontal piane moiions are to one side
only. Data are
based on estimates by unpublished x-ray observations and goniometry.

FIGURE 9-53. The costotransverse and costovertebral joints
of th midthoracic region. A, Superior-lateral view highlights
th structure and connective tissues of th costotransverse
and costovertebral joints associated with th sixth through
th eighth thoracic vertebrae. The eighth rib is removed to
expose th costai facets of th associated costovertebral and
costotransverse joints. B, Superior view shows th capsule of
th left costovertebral and costotransverse joints cut to ex
pose joint surfaces. Note th spatial relationships between
th nucleus pulposus, annulus fibrosus, and spinai cord.
occurs by a superior and slighily anterior sliding of th
interior facet surfaces o f T5 on th su p erior facet surfaces o f
T6 (Fig. 9 - 54A). Extension occurs by a reverse process (Fig.
9 -5 5 A ).
Kinematics of Axial Rotation
Approximately 30 degrees of horizontal piane (axial) rotation
occurs to each side throughout th thoracic region. This
motion is depicted in conjunction with axial rotation across
th entire thoracolumbar region in Figure 9 - 5 6 . Rotation
between T6 and T7, for instance, occurs as th near frontal
piane-aligned inferior articular facets of T6 slide for a short
distance against th similarly aligned superior articular facets
of T7 (Fig. 9 -5 6 A ). In generai, th freedom of axial rotation
decreases in th thoracic spine in a cranial-to-caudal direc
tion. In th mid to lower thoracic spine, th greater verti-
cally oriented apophyseal joints tend to block horizontal
piane motion.
Kinematics of Lateral Flexion
The predominant frontal piane orientation of th thoracic
facet surfaces suggests a relative freedom of lateral flexion.
This potential for movement is never fully expressed, how-
ever, because of th stabilization provided by th attach-
ments to th ribs. Lateral flexion in th thoracic region is
illustrated in context with lateral flexion over th entire thor
acolumbar region in Figure 9 - 5 7 . Approximately 25 degrees
Chapter 9 Osteology and Arthrology 287
Superior lateral view
P o s t e r io r lo n g itu d in a l
lig a m e n t
C o s t o t r a n s v e r s e lig a m e n ts
A n t e r io r lo n g itu d in a l
lig a m e n t
S u p e r io r c o s to t r a n s v e r s e
lig a m e n t R a d ia te a n d c a p s u la r
lig a m e n ts o f th
S p in o u s
c o s to v e r te b r a l jo in t
P a ir o f c o s t a i fa c e ts
T ra n s v e rs e p r o c e s s
o f th c o s to v e r te b ra l
jo in t
C o s ta i fa c e t o f th
c o s t o t r a n s v e r s e jo in t
S u p e r io r c o s t o t r a n s v e r s e
A lig a m e n t (cu t)
Superior view
T ra n s v e rs e p r o c e s s
Exposed
jo in t
C o s to tr a n s v e r s e
S u p e r io r a r tic u la r
lig a m e n ts
fa c e t
ra d ia te lig a m e n ts c o s to v e r te b ra l jo in t
A n n u lu s f ib r o s u s
B N u c le u s p u lp o s u s
of lateral flexion occurs to each side in th thoracic region.
The magnitude o f ibis inten'eriebra moiion remains rea-
tively Constant throughout th entire thoracic region. As de
picted in Figure 9 57A, lateral llexion of T 6 on T7 occurs
as th inferior facet surface of T 6 slides superiorly on th
side contralateral to th lateral flexion and inferiorly on th
side ipsilateral to th lateral flexion. Note that th ribs drop
slightly on th side of th lateral flexion, and rise slightly on
th side opposite th lateral flexion.
As in th cervical spine, lateral flexion and axial rotation
are mechanically coupled in an ipsilateral manner.107 Cou-
phng is most evident in th upper thoracic spine where th
articular facets possess a closer orientation to those in th
lower cervical region. The influence of th coupling de
creases and is inconsistent in th middle and lower thoracic
regions.
STRUCTURAL DEFORMITIES OF THE THORACIC SPINE
Maintaining th spine in normal alignment throughout life
requires a delicate balance between intrinsic forces, govemed
by muscles and osseous-ligamentous structures, and extrinsic
forces govemed by gravity. When th balance fails, deformity
occurs. Hemiated discs and nerve root impingements are
relatively uncommon in th thoracic spine. This finding
may be due, in part, to th relatively low intervertebral mo-
bility and high stability provided by th rib cage. Thoracic
 288 Seclton III Axial Skeleton
Thoracolumbar flexion
In te rs p in o u s
lig a m e n t
S u p r a s p in o u s
lig a m e n t
Thoracic region
FIGURE 9-54. The kinemaiics of thoracolumbar flexion is shown through an 85-degree are th sum of 35
degrees of thoracic flexion and 50 degrees of lumbar flexion. A, Kinematics at th thoracic region B Kinematics
at th lumbar region. Elongated and taut tissues are indicated by thin black arrows.
postural abnormalities, however, occur relatively frequently.
The thoracic spine, constituting about half th entire length
of th vertebral column, is particularly vulnerable to th
effeets of gravity and torsion. The two most common exam-
ples of postural abnormalities of th thoracic spine are exces-
sive kyphosis and scoliosis. 1he following sections revrew
th biomechanics of these conditions. More detailed informa-
tion on th biomechanics, medicai management, and physi-
cal therapy can be found in other sources (see references 25
32, and 36).
Excessive Kyphosis
On average, about 42 degrees of naturai kyphosis is present
while standing (see Fig. 9 - 4 0 ) . 52 In some persons, however,
excessive kyphosis occurs and can cause functional limita-
tions. The acquired forni of excessive kyphosis may occur as
a consequence of trauma and related spinai instability, dis-
ease, or connective tissue changes that may be associated
with age. In generai, age-related thoracic kyphosis is usually
slight and not debilitating.
^ C o m p re sse c i
a n n u lu s
f ib r o s u s
Lumbar region
The two most common conditions associated with kypho
sis are Scheuermann disease and osteoporosis. Scheuermann
disease, or juvenile kyphosis, is a hereditary condition that
starts in adolescence. Although th cause of th disease is
unknown, il is characterized by wedging of th atiterior side
of th vertebral bodies, ultimately causing and perpetuating
excessive kyphosis. Up to 10% of th adolescent population
shows signs of this disorder.111
Osteoporosis ol th spine is often associated with excessive
thoracic kyphosis, most often observed in th elderly. Com-
pression tractures in osteoporotic thoracic vertebrae eventu
a l i lead to reduced height in th vertebral bodies. Shorten-
ing of th midthoracic vertebrae can initiate a biomechanical
cycle that accelerates th flexion deformity. Figure 9 58
demonstrates one mechanical scenario associated with th
progression of a severe kyphosis.76 In th ideal spinai pos
ture, th line-of-force due to body weight falls slightly to th
concave side of th apex of th normal cervical and thoracic
curvatures (Fig. 9 - 5 8 A). Gravity acts with an external mo
ment arm that can maintain th normal thoracic and cervical
 Chapter 9 O steobgy and Arthrology 289

FIGURE 9-55. The kinematics of thoracolumbar extension is shown through an are of 35 io 40 degrees: ihe sum of 20 to
25 degrees of thoracic extension and 15 degrees of lumbar extension. A, Kinematics at th thoracic region. B, Kinematics at
th lumbar region. Elongated and taut tissue is indicated by thin black arrows; slackened tissue is indicated by a wavy black
line.

curvatures. Assume that th posture shown in Figure 9 -5 8 A
creates a small cervical extension torque and small thoracic
flexion torque. In th thoracic spine, th naturai kyphosis is
limited by compression forces on th anterior side of th
interbody joints. Vertebrae weakened from osteoporosis and
dehydrated intervertebral discs may be unable to resist th
anterior compression forces. Over time, th compression
forces reduce th height of th anterior side of th interbody
joint, thereby accentuating th kyphosis (Fig. 9 -5 8 B ). At
this point, a pathologic deforming process is initiated. The
increased flexed posture shifts th line-of-force due to body-
weight farther anteriorly, thus increasing th length of th
extemal moment arm (EMA') and magnitude of th flexed
kyphotic posture. As a result, both thoracic and cervical
spine regions may be subjected to a moderate flexion torque
(see Fig. 9 - 5 8 B ). increased extensor rnuscle and ligamen-
tous force is needed to hold th trunk, neck, and head
upright. The increased force passes through th interbody
joints, possibly creating small compression fractures in th
vertebral bodies. At this point th vicious circle is well estab-
lished.
The thoracic posture shown in Figure 9 - 5 8 B may pro
gress, in extreme cases, to that shown in Figure 9 -5 8 C .
While standing, th line-of-force due to body weight has
produced a small upper cervical extension torque and a large
thoracic flexion torque. Note that despite th large thoracic
kyphosis, th person can extend her upper craniocervical
region enough to maintain a horizontal visual gaze. The
main point of Figure 9 -5 8 C , however, is to appreciate th
biomechanical and physiologic impact that a large extemal
 290 Sceltoti III Axial Skeleton

Thoracolumbar axial rotation

S te rn u m
Thoracic region
9 0 c r a n io c e r v ic a l ro ta tio n

3 5 t h o r a c o lu m b a r
a x ia l ro ta tio n

125

S u p e r io r fa c e t o f T 7

I n te rio r fa c e t o f T 6

Lumbar region
Superior view

J o in t
a p p r o x im a tio n

J o in t
s e p a ra tio n
S u p e r io r fa c e t o f L 2

I n te rio r fa c e t o f L1

Superior view
FIGURE 9-56. The kinematics of thoracolumbar axial rotation is depicted as th subject rotates her face 125
degrees to th right. The thoracolumbar axial rotation is shown through a 35-degree are: th sum of 30 degrees
of thoracic rotation and 5 degrees of lumbar rotation. ,4, Kinematics at th thoracic region. B, Knematics at th
lumbar region.

flexion torque can have in predisposing a person to an
exaggerated thoracic kyphosis. Compression fractures from
osteoporosis further accelerate th kyphotic process.
Scoliosis
Scoliosis (from th Greek, meaning curvature) is a deformity
of th vertebra! column characterized by abnormal curva-
tures in all three planes, most notably in th frontal and
horizontal (Fig. 9 - 5 9 ) . The deformity most often involves
th thoracic spine; however, other regions of th spine are
often affected. Scoliosis is typically defned as either func-
tional or structural. Functional scoliosis can be corrected by
an active shift in posture, whereas structural scoliosis is a
fixed deformity that cannot be corrected fully by an active
shift in posture.
Approximately 80 to 90% of all cases of structural scolio
sis are termed idiopathic, meaning th condition has no ap-
parent biologie or mechanical cause.106 Idiopathic scoliosis
most commonly affeets adolescent girls. Most of th remain-
ing 10 to 20% of cases are caused by neuromuscular or
musculoskeletal conditions or by congenital abnormalities. In
these cases, th imbalanced forces that produce th scoliosis
are due most frequently to poliomyelitis, muscular dystro-
phy, spinai cord injury, trauma, or cerebral palsy.25
Typically, scoliosis is described by th location, direction,
and number of fixed frontal piane curvatures daterai bends)
within th vertebral column. The most common pattern of
scoliosis consists of a single lateral curve, with an apex m
th T 7 - 9 region.19 Many other patterns involve a secondari
or compensatory curve, most often in th lumbar spine. The |
direction of th primary lateral curve is defned by th side
of th convexity of th lateral deformity. Because th tho
racic vertebrae are most often involved with scoliosis, asyir
metry of th rib cage is often present. The ribs on th side
 Chapter 9 Osteology and Arthrology 291

T h o ra c ic region
LATERAL
T h o ra c o lu m b a r lateral flexion FLEXION S u p e r io r fa c e ts o f T 6

S u p e r io r fa c e t o f T 7

L u m b a r region
LATERAL r . . . . . .
FLEXION S u p e r io r fa c e ts o f L1

V ____
intertransverse
lig a m e n t

In te rio r fa c e t o f L1

S u p e r io r fa c e t o f L 2

FIGURE 9-57. The kinematics of thoracolumbar lateral flexion is shown through an approximate 45-degree are: th sum of 25 degrees of
thoracic lateral flexion and 20 degrees of lumbar lateral flexion. A, Kinematics at th thoracic region. B, Kinematics at th lumbar region.
Note th slight contralateral coupling pattern between axial rotation and lateral flexion in th lumbar region. Elongated and taut tissue is
indicated by a thin black arrow.

FIGURE 9-58. Lateral views show th biomechanical relationships between th line-of-force due to body weight (BW) and
varying degrees of thoracic kyphosis. In each of th three models, th axes of rotation are depicted as th midpoint of th
thoracic and cervical regions (dark circles). The extemal moment arms used by body weight are shown as dashed lines. A, In a
person with ideal standing posture and normal thoracic kyphosis, body weight created a small cervical extcnsion torque and a
small thoracic flexion torque. B, In a person with moderate thoracic kyphosis, body weight created a moderate cervical and
thoracic flexion torque (EMA', extemal moment arm at midthoracic spine; EMA, extemal moment arm at midcervical spine;
IMA, internai moment arm for trunk extensor muscle force). C, In a person with severe thoracic kyphosis, body weight caused
a small cervical extension torque and a large thoracic flexion torque. All three models are based on x-rays of patients. (From
Neumann DA: Arthrokinesiologic considerations for th aged adult. In Guccione AA (ed): Geriatrie Physical Therapy. Chicago,
Mosby-Year Book, 2000.)
292 Section III Axial Skeleton
S P E C I A L F O C U S 9 - 8
Method for Estimating Interbody Joint Compression
Force Caused by Moderate Thoracic Kyphosis
The compression force exerted on a midthoracic inter
body joint while standing is equal to th sum of th
forces created by body weight, any lifted load, and
muscle force. The amount of intervertebral compression
force required to maintain th posture depicted in Fig
ure 9 - 586 can be estimated by assuming a condition of
static equilibrium: th product of body weight (BW)
force and th external moment arm (EMA') equals th
product of th muscle force times th internai moment
arm (IMA). Assuming that th EMA is about twice th
length of th IMA, rotary equilibrium in th sagittal
piane requires a muscle force of twice BW. Assume
that a 180-lb (1 pound = 4.448 Newtons) person has
about 60% of BW (108 Ib) located above th midtho
racic region. An extensor muscle force of approximately
216 Ib (2 x 108 Ib) is needed to hold th flexed posture.
When considering th effect of BW, a total of about 324
Ib of compression force (216 Ib of muscle force plus 108
Ib of BW) is exerted on a midthoracic interbody joint.
Applying this same biomechanical solution to th ideal
posture shown in Figure 9-58A yields a 67% reduction
in interbody joint force. This reduction is based on th
ideal posture having approximately equal external and
internai moment arm lengths. Although this simple math
ematica! model is not absolutely accurate, it emphasizes
how posture can have a profound effect on th forces
produced across an interbody joint.
of ihe thoracic concavity are pulled together, and th ribs on
th side of th convexity are spread apart. The degree of
torsion, or horizontal piane deformity, can be measured on
standard x-ray by noting th rotated position of th vertebral
pedicles.
The deformity in structural scoliosis typically has a fixed
contralateral spinai coupling pattern involving lateral flexion
and axial rotation. The spinous processes of th involved
vertebrae are typically rotated in th horizontal piane
toward th side of th concavity of th fixed thoracic curva
ture. This explains why th rib hump" is typically on th
convex side of th frontal piane curvature. The ribs are
lorced to follow th rotation of th thoracic vertebrae. The
mechanism for th fixed coupling pattern is not completely
understood.
Lumbar Region
F U N C T I O N A L A N A T O M Y OF T HE A R T IC U L A R
S T R U C T U R E S W IT HIN THE L U M B A R REGION ( L I - S I )
L1-L4 Region
The facet surfaces of lumbar apophyseal joints are oriented
nearly vertical, with a moderate-to-strong sagittal piane bias.
The orientation of th superior articular facet of L2, for
example, is about 25 degrees from th sagittal piane (see Fig.
9 - 3 4 ) . This orientation favors sagittal piane motion at th
expense of axial rotation. This trend is evident even in th
mid-to-lower thoracic regions.
The facet surfaces change their orientation rather abruptlv
at or near th thoracolumbar junction (Fig. 9 - 6 0 ) . The
sharp frontal-to-sagittal piane transition may help to explain
th relatively high incidence of traumatic paraplegia at this
junction. The thorax, held relatively rigid by th rib cage, is
free to flex as a unii over th upper lumbar region. A large
flexion torque delivered to th thorax may concentrate an
excessive hyperflexion stress at th extreme upper lumbar
region. If severe enough, th stress may fracture or dislocate
th bony elements and possibly injure th caudal end of th
spinai cord or th cauda equina. Surgical fixation devices
implanted to immobilize an unstable thoracolumbar junction
are particularly susceptible to stress failure compared with
other regions of th vertebral column.
L5-S1 Junction
As any typical intervertebral junction, th L 5 -S 1 junction
has an interbody joint anteriorly and a pair of apophyseal
FIGURE 9-59. A, Posterior view shows excessive righi
thoracic and left lumbar curvatures in th fronta/
piane. B, Postura! asymmetry is demonstmed in th
horizontal piane. Note th abnormal rib hump" on
th right, and hollow" on th left. (From GartlandJJ:
Fundamentals of Orthopedics. Philadelphia, WB Saun-
ders, L979.)

T10-T11
apophyseal
jo in t
T h o ra c o lu m b a r
ju n c tio n
T12-L1
apophyseal
jo in t
L5-S1
apophyseal
jo in t
FIGURE 9-60. A posterior view of th thoracolumbar and lumbo-
sacral junctions. Note th transition in th orientation of th facet
surfaces within th apophyseal joints between th two junctions.
The bony specimen demonstrates a frontal piane bias at both L4-L5
and L5-S1 apophyseal joints. This lype of variation is common.
joints posteriorly. The facet surfaces of th L 5 -S 1 apophy
seal joints are usually oriented in a more frontal piane than
those of other lumbar regions (Fig. 9 - 6 0 ) .
The base (top) of th sacrum is naturally inclined anteri-
orly and inferiorly, forming an approximate 40-degree sacro-
horizontal angle (a ) while standing (Fig. 9 - 6 1 A )7 : Given
this angle, th resultanl force due to body weight (BW)
creates an anterior shear (BWS), and a compressive force
(BWN) acling normal (perpendicular) to th superior surface
of th sacrum. The magnitude of th anterior shear is equal
to th product of BW times th sine of th sacrohorizontal
angle. A typical sacrohorizontal angle of 40 degrees produces
an anterior shear force at th L 5 -S 1 junction equal to 64%
of superimposed BW. Increasing th degree of lumbar lordo-
sis enlarges th sacrohorizontal angle. Il th sacrohorizontal
angle were increased to 55 degrees, for example, th anterior
shear force would increase to 82% of superimposed BW.
While standing or sitting, lumbar lordosis can be increased
by this amount by antenor tilting of th pelvis (see Fig. 9 -
68A). (Tilting th pelvis is defined as a short-are sagittal
piane rotation of th pelvis relative to th head of th fe-
murs. The direction of th tilt is indicated by th direction
of rotation of th iliac crests of th pelvis.)
Several structures stabilize th anterior-posterior align-
ment of th L 5 -S 1 junction, especially th anterior longitu-
dinal ligament and th iliolumbar ligament. The anterior
longitudinal ligament crosses anterior to th L 5 -S 1 junction.
The iliolumbar ligament arises from th inferior aspect of th
transverse process of L5 and adjacent fibers of th quadratus
lumborum muscle. The ligament attaches inferiorly to th
ilium, just anterior to th sacroiliac joint, and to th upper-
Chapter 9 Osteology and Arthrology 293
lateral aspect of th sacrum (see Fig. 9 - 7 4 ) . As a bilateral
pair, th iliolumbar ligaments provide a frm anchor between
th lower lumbar vertebrae and th underlying ilium and
sacrum.112
in addition to connective tissues, th wide, sturdy articu-
lar facets of th L 5 -S 1 apophyseal joints provide bony stabi-
lization to th L 5 -S 1 junction. The near frontal piane incli-
nation of th facet surfaces can resist pari of th anterior
shear at this region. This blockage creates a force within th
apophyseal joint (see Fig. 9 -6 1 A , arrow labeled JF). With-
ES/34fj
L3-4 C
interbody Erector spinae
joint across L3-4
ES/5
Erector spinae
across L5-S1
A L5-S1
J S
y n -s f
Sacrohorizontal
p O p h y se a
angle ( a ) =40
BWS sm B
BWS iVv
FIGURE 9-61. Lateral view shows th biomechamcs responsible for
th shear forces at th interbody joints of L5-S1 and th middle
lumbar region (L3-4). The sacrohorizontal angle (ai at L5-S1 is
th angle between th honzontal piane and th superior surface of
th sacrum (A). BW (body weight) is th weight of th body
located above th sacrum. BWN is th normal force of body weight
directed perpendicular lo th superior surface of th sacrum. BWS
is th shear force of body weight directed parallel to th superior
surface of th sacrum. The joint force (JF) al th L5-S1 apophyseal
joint is shown as a short gray arrow. The force vector of th active
erector spinae is shown as il crosses L5SI (ES/5-1) (B). ES/5-lNis
th normal force of th muscle directed perpendicular to th supe
rior surface of th sacrum. ES/5-ls is th shear force of th muscle
directed parallel to th superior surface of th sacrum. The torce
vector of th erector spinae is shown as it crosses L 3-4 (ES/3-4)
(C). ES/3-4n is th normal force of th muscle directed parallel to
th superior surface of L4. ES/3-4s is th shear force ol th muscle
directed parallel to th superior surface of L4. See text for further
details. (Created with th assistance of Guy Simoneau.)
294 Section III Aria! Skeleton
Anterior Spondylolisthesis at L5-S1
Anterior spondylolisthesis is a generai term that de-
scribes an anterior slipping or displacement of one verte
bra relative to another. This condition usually occurs at
th L5-S1 junction. The term spondylolisthesis is derived
from th Greek "spondylo" meaning vertebra, and "lis-
thesis" meaning to slip. The amount of anterior slippage
is often graded in severity between I and IV. Figure 9-62
shows a grade 2 spondylolisthesis. Associated with ante
rior spondylolisthesis is a bilateral fracture through th
pars articularis, a section of a lumbar vertebra midway
between th superior and inferior articular processes
(see Fig. 9-31). Severe cases of anterior spondylolisthe
sis may damage th cauda equina, as this bundle of
nerves passes through th L5-S1 junction.
As described for Figure 9-61A, increased lumbar lor-
dosis widens th normal sacrohorizontal angle, thereby
increasing th anterior shear force between L5 and S1.
Exercises or other actions that create a forceful hyper-
extension of th lumbar spine are typically contraindi-
cated in anterior spondylolisthesis. As shown in Figure
9-616, th force vector of th erector spinae that
crosses L5-S1 (ES/5-1) creates an anterior shear force
(ES/5-1s) parallel to th superior body of th sacrum.
The direction of this shear is a function of th orienta-
tion of th adjacent erector spinae fibers and th 40-
degree sacrohorizontal angle. In theory, a greater mus-
cular force increases th anterior and inferior shear at
th L5-S1 junction, especially if th muscle activation
also exaggerates th regional lordosis.
The anterior-directed shear forces produced by th
lumbar erector spinae occur primarily at th L5-S1 junc
tion and not, as a rule, throughout th entire lumbar
region. As indicated in Figure 9-61C, in normal posture,
th superior surfaces of th bodies of th middle lumbar
vertebrae are typically positioned in a more horizontal
orientation. The erector spinae that cross these regions
produce a posterior shear across th lumbar interbody
joints (see Fig. 9-61C, ES/34S).63 This muscle-produced
shear can offset much of th naturai anterior force that
occurs while lifting large loads in front of th body.
FIGURE 9-62. Grade 2 spondylolisthesis. (Modified from Magee
DL: Orthopedic Physical Assessment, 3rd ed. Philadelphia, WB
Saunders, 1997.)
out adequate stabilization, th lower end of th lumbar re-
gton can slip forward relative to th sacrum. This abnormal.
potentially serious condition is known as spondylolisthesis.
KINEMATICS AT THE LUMBAR REGION
Table 9 - 1 2 lists th average range of motion ai th lumbar
region. While standing, th lumbar region in th healthv
adult typically exhibits about 40 to 45 degrees of lordosis ' -
Lumbar lordosis is greater in women than in men, with th
greatest differences appearing after th ffth decade (Fig. 9 -
6 3 ).7 Compared with standing, sitting reduces th lumbar
lordosis by about 20 to 35 degrees.
Sagittal Piane Kinematics at th Lumbar Region
Although data vary across studies and populations, about 50
degrees of flexion and 15 degrees of extension occur at th
heathy lumbar spine.8082 This is a substantial range of mo
tion considering it occurs across only five inlervertebrai
junctions. This predominance of sagittal piane motion is
largely due to th prevailing sagittal piane bias of th face:
surfaces in th lumbar apophyseal joints. As a generai prmci-
ple, th amount of lumbar intervertebral flexion and exten
sion gradually increases in a cranial-to-caudal direction. The
following kinematic discussions include th lumbar kinemat
ics and th strong kinematic relationships between th lum
bar region, th trunk as a whole, and th lower extremities
(Table 9 - 1 3 ) .
Flexion of th Lumbar Region
Figure 9 - 5 4 shows th kinematics of flexion of th lumbar
region in context with flexion of th trunk and hips. Pelvic-
on-femoral (hip) flexion increases th passive tension in th
stretched hamstring muscles. With th lower end of th
vertebral column fixed by th sacroiliac joints, continued
flexion of th middle and upper lumbar region reverses th
naturai lordosis in th low back.
During flexion between L 2 -3 , for example, th inferior ;
articular facets of L2 slide superiorly and anteriorly, relative
to th superior facets of L3 (see Fig. 9 - 5 4 B ). As a conse-
quence, muscular and gravitational forces are transferred .
away from th apophyseal joints, which generally supporr I
about 20% of th total spinai load in erect standing,8 and
toward th discs and posterior spinai ligaments. Discs are
compressed while th posterior ligaments are lensed. In ex-
treme flexion, th fully stretched articular capsule of th 1
9 - 1 2 . Approximate Range of Motion for
T A B L E
thc Three Planes of MoVement for th Lumbar
Region
Flexion and Extension Axial Rotalion Lateral Flexion
(Sagittal Piane, (Horizontal Piane, (Frontal Piane.
Degrees) Degrees) Degrees)
Flexion: 50 5 20
Extension: 15
Total: 65
Horizontal and frontal piane motions are to one side only. Data frorr
Pearcy, et al, 1984; Pearcy and Tibrewal. 1984.
 Chapter 9 Osteology and Arthroogy 295

-GURE 9-63. A plot shows th changes in

hmibar lordosis with aging. (Data from
Amonoo-Kuofi HS: Changes in th lumbo-
sacral angle, sacrai inclinatton and th cur
vature of th lurnbar spine during aging.
Acta Anat 145:373-377, 1992.)

apophyseal joints restrains additional forward migration of a apophyseal joints may become overstretched from a chronic,
superior vertebra.96 The extreme flexed position signifcantly slumped sitting posture.
reduces th contact area within th facet surfaces of th Lumbar Flexion: Its Effect on th Diameter o f th
apophyseal joints. Paradoxically, although a fully flexed lum- Intervertebral Foramen and Migration o f th
bar spine reduces th total force on a given apophyseal joint,
Nucleus Pulposus
th pressure (force per unit area) increases on th decreased Relative to a neutral position, full flexion of th lumbar
surface area under contact. High pressure may damage joints spine increases th diameter of th intervertebral foramina by
that have abnormally developed articular surfaces. 19% and increases th volume of th vertebral canal by
As a way of comparison, Figure 9 - 6 4 shows th relative 11%.45 Therapeutically, flexion of th lumbar region is often
resistance provided by locai connective tissues to extreme used to temporarily reduce th pressure on a lumbar nerve
flexion in th lumbar region.4 Of clinical interest is th root that is impinged by an obstructed foramen. In certain
relatively large resistance provided by th stretched articular
capsule that surrounds th flexed apophyseal joints. In th
healthy lower back, th passive tension within th capsule of
flexed apophyseal joints reduces th compression load on
th intervertebral discs. A weakened or overstretched articu
lar capsule, however, may not be able to generate sufficient
tension to protect th discs from injury. The capsules of th

9 - 1 3 . Organization of th Discussion
T A B L E

Sagittal Piane Kinematies at th Lumbar Region

Flexion of th Lumbar Region

Effect on th diameter of th intervertebral foramen and migra

tion of th annulus pulposus
Extension of th Lumbar Region

Effect on th diameter of th intervertebral foramen and migra

tion of th annulus pulposus
Lumbopelvie Rhythm During Trunk Flexion and Extension

joint capsu le and flavum

Effect of Pelvic Tilt on th Lumbar Spine
Therapeutic and kinesiologic correlations between anterior pel-
vie tilt and increased lumbar lordosis
Therapeutic and kinesiologic correlations between posterior pel
vic tilt and decreased lumbar lordosis
Sitting Posture and Its Effect on Alignment of th Lumbar
and Craniocervical Regions
interspinous
ligam ents
FIGURE 9-64. Results from cadaver experiments show th relative
resistance provided by nonmuscular tissues against a flexion torque
at th lumbar spine. Measurements were recorded at th extremes
of lumbar flexion ai th lime of tissue failure. (Data from Adams
MA, Hutton WC, Stou JRR: The resistance to flexion of th lumbar
intervertebral joint. Spine 5:245-253, 1980.)
296 Secton III Axial Skeleton
circumstances, however, ihis potential therapeutic advantage
may be associaied with a potential therapeutic disadvantage.
For example, fexion of th lumbar region generates com-
pression forces on th anterior side of th disc, which tend
to migrate th nucleus pulposus posteriorly.30 The magni-
tude of th migration is small in th healihy spine. In a
S P E C I A L F O C U S 9 - 1 0
j9
Herniated Nucleus Pulposus
The formai name for a ruptured or slipped disc is herni
ated nucleus pulposus. Most herniations involve a signifi
c a i posterior-lateral or posterior migration of th nucleus
pulposus toward th spinai cord or spinai nerve roots
(Table 9-14 and Fig. 9-65). Nuclear protrusion, th mild-
est form of herniation, may cause locai back pain owing
to pressure exerted against th posterior annulus and/or
posterior longitudinal ligament. Herniations that result in
prolapse, extrusion, or sequestration, however, can place
pressure directly on neural elements. As a consequence,
pain often radiates away from th back and toward th
associated dermatomes in th lower extremities. Muscle
weakness and altered deep tendon reflexes in th legs
may also result from impingement on th neural tissues.
Although a herniated disc typically causes low-back
pain, not everyone with low-back pain has disc involve-
ment. Low-back pain may be caused by a number of
factors besides, or in addition to, disc prolapse. Factors
include muscle-ligament sprains, inflamed apophyseal or
sacroiliac joints, and irritated or impinged nerve roots.
Often th reason for pain is unknown, and occasionally
th pain spontaneously subsides. Pain, in generai, is a
relatively common occurrence, even in otherwise healthy
persons.
The percentage of persons with low-back pain due to
a disc herniation is uncertain, but likely significant. The
subject of disc herniation has generated extensive re-
FIGURE 9 65. Types of disc herniations. (From Magee DL: Orthopedic Physical Assessment, 3rd ed Philadelphia, WB Saunders,
i yy /.)
person with a weakened posterior annulus, however, poste-
rior migration of th nuceus pulposus increases pressure on
th spinai cord or nerve roots. These contrasting therapeutic
effects of fexion in th lumbar region are to be considered
when planning an exercise program for a person with gener-
alized low back pain.
search on methods of diagnosis,40 mechanisms of hernia
tion,69 associated epidemiology,70'01 physical rehabilitation,51
and efficacy of surgery.85
Two mechanisms are typically involved with disc herni
ation.23 The first mechanism involves a very large, sudden
compression force delivered over a lumbar spine that is
flexed or, most likely, flexed and axially rotated (twisted).
TABLE 9 - 1 4 . Types of Herniated
Nucleus Pulposus
N uclear Type Defnition
Protrusion Displaced nucleus pulposus remains within
th annulus tbrosus, but may create a
pressure bulge on th spinai cord.
Prolapse Displaced nucleus pulposus reaches th
posterior edge of th disc, but remains
essentially confned within th outer lay-
ers of th annulus fbrosus.
Extrusion Annulus fbrosus ruptures, allowing th nu
cleus pulposus to completely escape from
th disc into th epidural space.
Sequestration Parts of th nucleus pulposus and fragments
of annulus fbrosus become lodged
within th epidural space.
The lypes are presented in increasing magnitudes of severity.
From Magee DL: Orthopedic Physical Assessment, 3rd ed. Philadel-
phia, WB Saunders, 1997.
Annular fibers disrupted
Free nuclear
material

This mechanism of injury is often associateci with a single
event such as a fall or th lifting of a large load. The
second mechanism involves a series of multiple, low mag-
nitude compression forces, often imposed over a flexed
lumbar spine. This mechanism of prolapse generally oc-
curs gradually from cumulative microtrauma, such as that
which may occur from many years of repetitive lifting or
bending with an excessively flexed back.
A flexed and/or twisted lumbar spine renders th disc
mechanically vulnerable to protrusion. A flexed spine
stretches and thins th posterior side of th annulus as
th nuclear gel is forced posteriorly, often under large
hydrostatic pressure.71 The amount of hydrostatic pressure
increases with greater trunk muscle activation, usually in
response to large external torques. With sufficiently high
hydrostatic pressure, th nuclear gel creates or finds a
Factors that Favor Disc Herniation in th
Lumbar Spine
1. Propensity for fissures or tears in th posterior annulus
that aliows a path for th flow of nuclear material
2. Sufficiently hydrated nucleus structurally capable of ex-
erting high pressure
3. inability of th posterior annulus to resist radiai pres
sure from th nucleus
4. Axial loading applied over a bent (flexed) and twisted
spine
Extension of th Lumbar Region
Extension of ihe lumbar region is essentially th reverse of
flexion (Fig. 9 - 5 5 B ), and it. increases th naturai lordosis.
When lumbar extension is combined with full hip extension,
passive tension in th stretched hip flexor muscles helps
maintain lordosis by anteriori) tilting th pelvis. Extension
between L2 and L3, for example, occurs as th inferior
articular facets of L2 slide inferiorly and slightly posteriorly
relative to th superior facets of th L3. Full extension in
creases both th amount of load and area of contact at th
apophyseal joints.87
In th neutral standing posture, th healthy disc is th
primary load-bearing structure in th lumbar region. As
such, healthy discs reduce th load imposed on apophyseal
ioints and thereby protect them from excessive wear. In
diseased or severely dehydrated discs, however, a greater
proportion of th total load is shifted to th apophyseal
joints. It is not uncommon, therefore, for a person with
severe disc disease to develop osteoarthritis in th lumbar
apophyseal joints.
Extension of th Lumbar Spine and Its Effect on th
Diameter of th Inlervertebral Forameli and
Migration of th Nucleus Pulposus
Relative to th neutral position, full lumbar extension
reduces th diameter of th intervertebral foramina by 11%
and reduces th volume within th vertebral canal by 15%.45
For this reason, clinicians often suggest that a person with
nerve root impingement, from a stenosed intervertebral fora-
Chapter 9 Osteology and Arthrology 297
preexisting fissure in th posterior annulus. A partially
rotated spine renders only half th posterior fibers of th
annulus taut, thereby reducing th potential resistance
that can be applied against approaching nuclear gel.
Despite th abundance of literature and anecdotal evi-
dence, a single unifying cause-and-effect explanation for
all forms of disc herniation is lacking. The four factors
listed in th box, however, appear to be particularly im-
portant.2 Disc prolapse can occur even in th absence of
trauma or mechanical overload. A habitual, chronic sitting
posture involving a rounded and flexed lumbar spine cer-
tainly may predispose a person to posterior migration of
th nucleus pulposus. A chronically flexed lumbar posture
may, in time, overstretch th posterior annulus to a point
where it is unable to resist a potent hyperflexion-induced
posterior migration of th nucleus. This explanation, how
ever, is subject to scrutiny because th incidence of disc
prolapse in th lumbar region is very low in cultures
whose people habitually squat with near maximal flexed
lumbar spines.28
The healthy lumbar disc with an intact annulus fibrosus
is remarkably resistant to disc herniation, even from a
large flexion force. The reason for th relatively high inci
dence of disc prolapse in Western cultures is stili not
fully understood. Several factors involving different and
perhaps interrelated variables must be considered. These
factors include mechanical overload, pathology, poor nu-
trition, age, lifestyle, earlier injury, work habits, socioeco-
nomics, and genetics.
men, limit acttvities that involve hyperextension. Extension,
however, tends to migrate th nucleus pulposus anteriorly.30
Persons with a nuclear protrusion or prolapse may find,
therefore, that extension reduces th pain associated with
pressure on th spinai cord or nerve roots. The normal
lumbar lordotic posture may restrict th migration of th
nucleus pulposus within a weakened disc from approaching
th neural elements. It is uncertain whether th nucleus
pulposus migrates in a similar manner in both healthy and
degenerated discs.10
Lumbopelvic Rhythm During Trunk Flexion
and Extension
In conjunction with th hip joints, th lumbar region pro-
vides th major flexion and extension pivot point for th
trunk, especially during activities such as forward bending,
climbing, and lifting. The kinematic relationship between th
lumbar spine and hip joints during sagittal piane movemenls
is called lumbopelvic rhythm. An understanding of th normal
lumbopelvic rhythm during flexion and extension of th
trunk can help distinguisi! pathology affecting th spine and
that affecting th hips.
Lumbopelvic Rhythm During Trunk Flexion
Consider th common action of bending forward and
toward th ground while keeping th knees straight. This
motion is measured as a combination of about 40 degrees of
lumbar flexion and 70 degrees of hip (pelvic-on-femoral)
flexion (Fig. 9 -6 6 A ).27 Although many strategies are possi-
 298 Section III Axial Skeleton

Three lumbopelvic rhythms used during trunk flexion

Norinal lunibar and hip ilexion I Jniitcd hip flexion with Limited luinbar flexion
execssive lumhar flexion with excessive hip flexion
FIGURE 9-66. Three different lumbopelvic rhythms used to flex th trunk forward and toward th floor with knees held straight.
A, Typical lumbopelvic rhythm consists of about 40 degrees of flexion of th lumbar spine and 70 degrees of flexion ai th hips
(pelvis on femurs). B, With limited flexion in th hips (for example, from tight hamstrings), greater flexion s required of th
lumbar and lower thoracic spine, C, With limited lumbar mobility, greater flexion is required of th hip joints. Red arrows
indicate limited or restricted mobility.

ble, th hips and lumbar spine typically flex simultaneously
throughout th are of trunk flexion, with motion usually
initiated al th lumbar spine.75 Figure 9 - 6 6 B and C shows
obvious abnormal lumbopelvic rhythms associated with
marked restriction in mobility at th hip joints (B) or lumbar
region (C). In both B and C, th amount of overall trunk
flexion is reduced. lf greater trunk flexion is required, th
hip joints or lumbar region may mutually compensate for
th others limited mobility. This situation may increase th
stress on th compensating region. As depicted in Figure
9 -6 6 B , with limited hip flexion due to restricted ham-
string extensibility, for example, bending th trunk toward
th floor requires greater flexion in th lumbar and lower
thoracic spine. Eventually, exaggerated flexion may over-
stretch posterior connective tissues, such as th inter-
spinous ligaments, posterior annular fibrosus, posterior
longitudinal ligarnem, apophyseal joint capsule, and thora-
columbar fascia, or increase stress on th discs and apophy
seal joints.
In contrast, as depicted in Figure 9 -6 6 C , limited mobility
in th lumbar spine may require greater flexion of th hip
joints. Greater forces may be required from th hip extensor
m uscles w hich, as a consequenee, increase th compression
force at th hips. In persons with healthy hips, this relatively
low-level increase in compression force is usually tolerated
without cartilage degeneration or discomfort. In a person
with a preexisting hip condition (e.g., osteoarthritis and
gross joint asymmeiry), however, th increased compression
force may accelerate degenerative changes.
Lumbopelvic Rhythm During Trunk Extension
The typical lumbopelvic rhythm used to extend th trunk
from a forward bent position is depicted in a series of
consecutive phases in Figure 9 -6 7 A to C. Extension of th
trunk with knees extended is normally initiated by extension
of th hips (Fig. 9 -6 7 A ). This is followed by extension of
th lumbar spine (Fig. 9 - 6 7 B to C).75 This normal lumbo
pelvic rhythm reduces th demands on th lumbar extensor
muscles and underlying apophyseal joints and discs, thereby
protecting th region against high stress. Delay in lumbar
extension shifts th extensor torque demand to th powerful
hip extensors (hamstrings and gluteus maximus), at th tinte
when th external flexion torque on th lumbar region is
greatest (external moment arm depicted as dark black line:
see Fig. 9 -6 7 A ). In this scenario, th demand on th lumbar
extensor muscles increases only after th trunk is sufficienti)-
 Chapter 9 Osteology and Arthrology 299

FIGURE 9-67. A typical lumbopelvic rhythm shown in ihree phases and used to extend ihe trunk from a forward bent
position. The moiion is arbitrarily divided into ihree chronologic phases (A lo C). In each phase, ihe axis of rotation (or th
trunk exlension is assumed io pierce ihe body of L3. A, In th early phase, trunk extension occurs to a greater extern ihrough
extension of th hips (pelvis on femurs), under strong actvation of hip extensor muscles (gluteus maximus and hamstrings).
B, In th middle phase, trunk extension occurs to a greater degree by extension of th lumbar spine. The middle phase
requires increased activation from lumbar extensor muscles. C. At th completion of th event, muscle activity typically ceases
once th line-of-force from body weight falls posterior to th hips. The external moment arm used by body weight is depicted
as a solid black line. The greater intensily of red indicates relative greater intensity of muscle activation.

raised and th extemal moment arm, relative to body
weight, is minimized (Fig. 9 - 6 7 B). Persons with severe low-
back pain may purposely delay active contraction of th
lumbar extensor muscles until th trunk is nearly vertical.
After standing completely upright, hip and back muscles are
typically inactive, as long as th force vector due to body
weight falls posterior to th hip joints (Fig. 9 - 6 7 C).
Effect of Pelvic Tilt on th Lumbar Spine
Flexion and extension of th lumbar spine can occur by two
fundamentally different movement strategies. The first strat-
egy is typically used io maximally dispiace th upper trunk
and upper extremities relative to th thighs, such as when
lifting or reaching. As depicted in Figures 9 - 6 6 and 9 - 6 7 ,
this strategy combines maximal flexion and extension of th
lumbar spine with a wide are of pelvic-on-femoral (hip) and
trunk motion. A second movement strategy involves a rela-
tively short-are tilt of th pelvis, with th trunk remaining
nearly stationary. As depicted in Figure 9 -6 8 A to D, an
anterior or a posterior pelvic tilt accentuates or reduces th
lumbar lordosis. Measured whtle standing, an approximate
one-to-one relationship exists between th change in pelvic
tilt and th associated change in lumbar lordosis., '5 The
change in lordosis alters th position of th nucleus pulpo-
sus within th disc and alters th diameter of th interverte-
bral foramina.
The axis of rotation for pelvic ttlting is through both hip
joints. This mechanical association strongly links th move
ment (pelvic-on-femoral) of th hip joints with that of th
lumbar spine. This relationship is discussed further in th
next section and again in Chapter 12.
 300 Section III Axial Skeleton

Anterior pelvic tilt with lumbar extension Posterior pelvic tilt with lumbar flexion

L u m b a r e x te n s o r s
H ip f le x o r s

Intcrverlebral lumbar extension Intervertebral lumbar flexion

V e rte b ra l c a n a l

In te rv e rte b ra l Apophyseal
d is c jo in t

N u c le u s I n te rs p in o u s
In te rs p in o u s p u lp o s u s lig a m e n t
lig a m e n t

In te rv e rte b ra l S p in a i n e rv e
fo r a m e n
D
FIGURE 9-68. Anterior and posterior tilt of th pelvis and its effect on th ktnematics of th lumbar spine. A and C, A n t e n o r p elv ic tilt
extends th lumbar spine and increases lordosis. This action tends to shift th nucleus pulposus anteriori). and reduces th diameter of th
intervertebral foramtna B and D, P o s te r io r p elv ic tilt flexes th lumbar spine and decreases lordosis This action tends to shift th nucleus
pulposus posteriorly and increases th diameter of th intervertebral foramina. Muscle activity is shown in red

Therapeutic and Kinesiologic C.orrelations betwcen The lumbar region may demonstrate greatly exaggeratec
Anterior Pelvic Tilt and Increascd Lumbar Lordosis lordosis that is undesirable from a medicai perspective. The
Active anterior tilt of th pelvis is caused by th hip paihomechanics of severe lordosis often involves a hip flex-
flexor and back extensor muscles (Fig. 9 -6 8 A ). Strengthen-
ion contracture with greatly increased passive tension in th
ing and increasing th control of these muscles, in theory, hip flexor muscles (Fig. 9 -6 9 A and B). Possible negative
favors a more lordotic posture of th lumbar spine. Although
consequences of exaggerated lordosis include increased com- I
this idea is intriguing, whether a person can subconsciously
pression force on th apophyseal joints and increased ante- I
adopt and maintain a newly leamed pelvic posture is uncer-
rior shear force at th lumbosacral junction, possibly leadinc
tain. Nevertheless, maintaining th naturai lordotic posture
to spondylolisthesis.
in th lumbar spine is a fundamental principle espoused by
McRenzie*'5 for persons with a hemiated disc. Increased lum Therapeutic and Kinesiologic Correlations betwcen
bar extension reduces th pressure within th disc71 and, in Posterior Pelvic Tilt and Decreased Lumbar Lordosis
some cases, reduces th contact pressure between th dis- Active posterior tilting of th pelvis is produced by hip I
placed nuclear material and th neural elements.59 Evidence extensor and abdominal muscles (see Fig. 9 - 6 8 B ). Strength- I
of th latter is often described dinically as centralization of ening and increasing th patients conscious control ove: I
low-back pain, meaning that discogenic pain (form erly in th these muscles theoretically favors a redu ced lum bar lordosis I
iowej e.xircmties due io nerve to o l im pm gem en t) migrates
This con cep t was th trademark o f th Williams flexion 1
toward [he low b ack .22 Centralization, therefore, suggests re- exercise, a therapeutic approach that stressed stretching th I
duced disc pressure on th nerve root. hip flexor and back extensor muscles and strengthening th

FIGURE 9-69. The relationship between taut hip flexor muscles,
excessive anterior pelvic tilt, and exaggerated lumbar lordosis. The
medial-lateral axis of rotation of th hip is shown as an open white
cirele. A, A right hip flexion contracture is shown by th angle (a)
formed between th femur (red line) and a white line representing
pelvic position (i.e., a line connecting th anterior and posterior-
superior iliac spines). The left normal hip is held flexed to keep th
pelvis as posteriorly tilted (neutral) as possible. B, With both legs
allowed to lie against th mat, tension created in th taut and
shortened right hip flexors tilts th pelvis anteriorly, exaggerating
th lumbar lordosis evident by th hollow in th low-back region.
The hip flexion contracture is stili present, but masked by th
anteriorly tilted position of th pelvis.
abdominal and hip extensor muscles.109 In principle, these
exercises are most appropriate for persons with back pain
related to excessive lumbar lordosis and significantly in-
creased sacrohorizontal angle (see Fig. 9 - 6 1 ) . This posture,
according to Williams, was associated with degenerative disc
disease, stenosis of th lumbar intervertebral foramen, osteo-
phyte formation with nerve root irritation, and anterior
spondylolisthesis of th lower lumbar region.
Sitting Posture and Its Effect on Alignment of th Lumbar
and Craniocervical Regions
For many persons, a lot of time is spent sitting, either ai
work, school, or home, or in a vehicle. The posture of th
pelvis and lumbar spine has a large influence on th posture
in other areas of th vertebral column. The topic of sitting
Chapter 9 Osteology and Arthrology 301
posture, therefore, has therapeutic implications on treatment
and prevention of spinai problems. Although th posture of
th pelvis can deviate in three planes about th hip joints,
th following discussion highlights th effects of sagittal
piane posturing of th pelvis on th lumbar and craniocervi
cal regions.
Consider th classic contrast made between poor and
ideal sitting postures (Fig. 9 -7 0 A and B). In th poor or
slouched posture depicted in Figure 9 - 7 0 A, th pelvis is
posteriorly tilted with a slightly flexed (flattened) lumbar
spine. Eventually, this posture may lead to adaptative short-
ening in tissues that maintain this posture (see th box). A
habitually slouched sitting posture may, in time, overstretch
and weaken th posterior annular fibrosus, reducing its abil-
ity to block a protruding nucleus pulposus.
Tissues that, if Shortened, Predispose a Person to
Slouched Sitting Posture with a Posterior Tilted Pelvis
1. Hamstring muscles
2. Anterior longitudinal ligament
3. Anterior ftbers of th annulus fibrosus
A slouched sitting posture typically increases th external
moment arm between th line-of-force of th upper body
weight and lumbar vertebrae. As a consequence, th greater
flexor torque increases th compression force on th anterior
margin of th lumbar discs. In vivo pressure measurements
typically demonstrate larger pressures within th lumbar
discs in slouched sitting compared with erect sitting.108
The sitting posture of th pelvis and lumbar spine
strongly influences th posture of th entire axial skeleton,
including th craniocervical region. Consider th contrast in
sitting postures depicted in Figure 9 - 7 0 . On average, th
fiat posture of th low back (see Fig. 9 -7 0 A ) is associated
with a more protracted head (i.e., a forward head) posture."
Sitting with th lumbar spine flexed tips th thoracic and
lower cervical regions forward into excessive flexion. In or-
der to maintain a horizontal visual gaze such as that typi
cally requi red to view a computer monitor th upper cran
iocervical region must compensate by extending slightly.
Over time, this posture may result in adaptive shortening in
th small posterior suboccipital muscles. As depicted in Fig
ure 9 - 7 0 B, th ideal sitting posture with naturai lordosis
and increased anterior pelvic tilt extends th lumbar spine.
The change in posture at th base (inferior aspect) of th
spine has an optimizing influence on th posture of th
entire axial skeleton. The more upright and extended tho
racic spine facilitates a more retracted (extended) base of th
cervical spine, yielding a more desirable chin-in position.
Because th base of th cervical spine is more extended, th
upper craniocervical region tends to flex slightly to a more
neutral posture.
The ideal sitting posture depicted in Figure 9 - 7 0 B is
diffcult for many persons to maintain, especially for several
hours at a time. Fatigue often develops in th lumbar exten
sor muscles. A prolonged, slouched sitting posture may be
an occupational hazard. In addition to th possible negative
effects of a chronically flexed lumbar region, th slouched
sitting posture may also increase th muscular stress at th
302 Section III Axial Skeleton
B o d y w e ig h t
FIGURE 9-70. Sitting posture and effects on th alignment of th lumbar and craniocervical regions. A, With a slouehed sitting
posture, th lumbar spine flexes, which reduces its norma] lordosis. As a consequence, th head tends to assume a forward
posture (see text). B, With an ideal sitting posture aided with a cushion, th lumbar spine assumes a normal lordosis, which
facilitates a more desirable chin-in position of th head.
base of th cervical spine. The forward-head posture in-
creases th extemal flexion torque on th cervical column as
a whole, requiring greater force production from th exten-
sor muscles and locai connective tissues. Sitting posture may
S P E C I A L F O C U S 9 - 1 1
U
Flexion and Extension Exercises for Treatment of Low-
Back Pain Understanding th "Trade-Offs"
As described, flexion and extension of th low back have
marked and usually contrasting biomechanical conse-
quences on intervertebral joints from disc migration to
th relative loading of th apophyseal joints (Table 9-15).
Considerable controversy exists on th effectiveness of
different exercise approaches for th treatment of low-
back pain. An exercise approach that stresses flexion, for
example, may be th most appropriate biomechanical in-
tervention for one patient but not for another. Complicat-
ing matters is often th lack of understanding of th exact
mechanical dysfunction underlying a person's low-back
pain. Although th mechanics and treatment for low-back
pain are sometimes obvious, th exact medicai diagnosis
is not in many cases.
A thorough discussion of th various physical therapy
Services for chronic low-back pain is not in th scope of
this chapter. As a generai principle, however, physical
therapy is used to devise th exercises that strengthen
and stabilize th low back, to educate patients on ways to
reduce th load or stress on th low back during activi-
ties of daily living, and to encourage a pain-free, more
normal range of movement. Regardless of th specific
therapeutic approach, th therapist and physician must
understand th underlying biomechanical contraindications
relevant to th diagnosis. Developing this understanding
requires a sound knowledge of th anatomy and kinesiol-
ogy of th lumbar region and years of clinical practice.
B o d y w e ig h t
be improved by a combination of awareness; strengthening
and stretching th appropriate muscles; eyeglasses; and er-
gonomically designed seating, which includes adequate lum
bar support.
9 - 1 5 . Biomechanical Conscquences of
T A B L E
Lumbar Flexion and Extension
Movement Biom echanical Consequences
Flexion 1. Tends to migrate th nucleus pulposus pos-
leriorly, toward neural tissue.
2. Increases th size of th opening of th inter-
vertebral foramina.
3. Transfers load from th apophyseal joints to
th intervertebral discs.
4 Increases tension in th posterior connective
tissues (ligamentum flava, apophyseal joint
capsules, interspinous and supraspinous lig-
aments, posterior longitudinal ligament) and
posterior margin of th annulus fibrosus.
5. Compresses th anterior side of th annulus
fibrosus.
Extension 1. Tends to migrate th nucleus pulposus cinte-
riorly, away from neural tissue.
2. Decreases th size of th opening of th in
tervertebral foramina.
3. Transfers load from th intervertebral disc to
th apophyseal joints.
4. Decreases tension in th posterior connective
tissues (see above) and posterior margin of
th annulus fibrosus.
5. Stretches th anterior side of th annulus
fibrosus.

Horizontal Piane Kinematics at th Lumbar Regina:
Axial Rotation
Only 5 degrees of horizontal piane rotation occurs to each
side throughout th lumbar region. This motion is shown in
context with th rotation of th thoracolumbar region in
Figure 9 - 5 6 6 . Axial rotation to th tight, between LI and
L2 for instante, occurs as th left inferior articular facet of
LI approximates or compresses against th left superior ar-
ticular facet of L2. Simultaneously, th right inferior articular
Acet of LI separates (distracts) from th right superior artic
ular facet of L2.
The amount of actual intervertebral motion during axial
rotation is ver)-' limited in th lumbar region. Only 1.1 de
grees of unilateral axial rotation is measured at th L 3 - 4
intervertebral junction.93 The near sagittal piane orentaton
of th apophyseal joints physically blocks axial rotation. As
indicateci in Figure 9 - 5 6 6 , th apophyseal joints located
contralateral to th side of th rotation compress, thereby
blocking further movement. Axial rotation is also restricted
by tension created in th stretched capsules of th apophy
seal joints35 and stretched fibers within th annulus fibrosus.54
Axial rotation, as little as 1 to .3 degrees per intervertebral
unction, has been shown to damage th articular facet sur-
taces and annulus fibrosus.12
The naturai resistance to axial rotation provides vertical
stability throughout th lower end of th vertebral column.
The well-developed lumbar multifidi muscles and relatively
ngid sacroiliac joints reinforce this stability.
Frontal Piane Kinematics at th Lumbar Region:
Lateral Flexion
About 15 to 20 degrees of lateral flexion occurs to each side
in th lumbar region.81 Except for differences in orientation
and strutture of th apophyseal joints, th arthrokinematics
of lateral flexion are essentially th same in th lumbar
region as in th thoracic region. Soft tissues on th side
opposite th lateral (lexion limit th motion (Fig. 9 - 5 7 6 ) .
The nucleus pulposus migrates slightly toward th convex
side of th bend.
As with th cervical and thoracic regions, lateral flexion in
th lumbar region is coupled with relatively small amounts
of axial rotation, and vice versa.1842,82 Although th precise
magnitude and direction of th coupling varies between sub-
jects and within th lumbar region, research does suggest an
overall contralateral pattern. Active lateral flexion to th
nght, for example, is typically accompanied with slight axial
rotation to th left.93 Mechanisms to explain th coupling
pattern in th lumbar spine are not clear.
SUMMARY OF THE KINEMATICS WITHIN
THE VERTEBRAL COLUMN
The following points summarize th main kinematic themes
of th vertebral column:
1. The cervical spine permits relatively large amounts of
motion in all three planes. Most notable is th high degree
of axial rotation permitted at th atlanto-axial joint complex.
Ampie range of motion is necessary for spadai orientation of
th neck and head th site of hearing, sight, smeli, and considered in context with th entire pelvic ring. The compo-
equilibrium.
Chapter 9 Osteolog y and Arthrology 303
2. The thoracic spine permits a relatively Constant amount
of lateral flexion. This kinematic feature reflects th generai
frontal piane orientation of th apophyseal joints combined
with th stabilizing function of th ribs.
3. The thoracic spine supports and protects th thorax
and its enclosed organs. As described in Chapter 11, an
importam function of th thorax is io provide a mechanical
bellows for ventilation.
4. The thoracolumbar spine, from a cranial-to-caudal direc
tion, permits increasing amounts of flexion and extension, at
th expense of axial rotation. This feature reflects, among
other things, th progressive transformation of th orienta
tion of th apophyseal joints, from th horizontal/frontal
planes in th cervical-thoracic junction to th near sagittal
piane in th lumbar region. The prevailing near sagittal piane
and vertical orientation of th lumbar region naturally favors
flexion and extension, but restricts axial rotation.
5. The lumbar spine, in combination with flexion and
extension of th hips, forms th primary pivot point for
sagittal piane motion of th entire superimposed trunk.
SACROILIAC JOINTS
The sacroiliac joints mark th transition between th caudal
end of th axial skeleton and th lower appendicular skele
ton. The analogous articulations at th cranial end of th
axial skeleton are th sternoclavicular joints within th
shoulder complex. Both th sternoclavicular and sacroiliac
joints possess unique structural characterisdcs needed to sat-
isfy equally unique functional demands. The saddle-shaped
sternoclavicular joint is designed primarily for mobility. In
contrast, th large, tight-ftting sacroiliac joint is designed
primarily for stability, with mobility being a secondary, al
though nonetheless importam, function.
The structural differences in th sternoclavicular and
sacroiliac joints generally reflect th differences in overall
functions of th upper and lower extremities. The stemocla-
vicular joints enjoy three degrees of freedom, a definite ne-
cessity for providing wide placement of th hands in space.
The sacroiliac joints, in contrast, are stable and relatively
rigid, ensuring effettive load transfer among th vertebral
column, lower extremities, and earth.
The exact relationship between structure and function of
th sacroiliac joint is controversial.6,37,87,97 The location of th
sacroiliac joints seems to make it susceptible to abnormally
large stresses due to asymmetry in leg length and abnormal
posture of th lower spine or pelvis. A mechanism that
describes th deterioratimi or malalignment of th sacroiliac
joint as a common cause of low-back pain, however, is not
universally agreed upon. Mixed conclusions are reached re-
garding th efficacy of diagnostic clinical testing and clinical
intervention.6098105 Adding to th clinical ambiguity of th
sacroiliac joint is th lack of standard terminology to de-
scribe th related anatomy and kinesiology. As a result, th
biomechanical and clinical importance of th sacroiliac joint
is often either understated or exaggerated.
Anatomia Considerations
The structural demands placed on th sacroiliac joints are
nents of th pelvic ring are th sacrum, th pair of sacroiliac
 304 Section III Axial Skeleton

FIGURE 9-71. The pelvic ring. The arrows show th direction of

body weight force between th trunk and th femurs (downward
and lateral arrows), and between th femurs and th trunk (upward
and mediai arrows). The keystone of th pelvic ring is th sacrum
wedged between th two ilia. (From Kapandji 1A: The Physiology of FIGURE 9-72. The exposed auricular surfaces of th sacroiliac joint
Joints, voi. 3. New York, Churchill Livingstone, 1974.) are shown. A, lliac surface. B, Sacrai surface. (From Kapandji IA
The Physiology of Joints, voi. 3. New York, Churchill Livingstone
1974.)

joints, th three bones of each hemipelvis (ilium, pubis, and
ischium), and th pubic symphysis joint (Fig. 9 - 7 1 ) . The
pelvic ring transfers body weight bidirectionally between th
trunk and femurs. The strength of th pelvic ring depends
on th fit and stability of th sacrum, wedged between th
two halves of th pelvis. The sacrum, anchored by th two
sacroiliac joints, is th keystone of th pelvic ring.
JOINT STRUCTURE AND LIGAMENTOUS SUPPORT
th sacroiliac joint as a reliable method to determine th
approximate age of a specimen.
The rather dramatic changes in th articular structure of
th sacroiliac joints between young and old age are in som;
ways similar to those of joints that develop osteoarthritis. '
For unexplained reasons, degenerative-like changes o c c h i
more frequently on th cartilage on th side of th ilium.471:
is likely that th degenerative changes are not pathologic. ir
th strict sense of th word, but rather a naturai response t

The sacroiliac joint is located just anterior to th posterior-

superior iliac-spine of th ilium. Structurally, th joint con-
sists of a relatively rigid articulation between th auricular
surface (from Latin aurcle, meaning little ear) of th sacrum
and th matching auricular surface of th iliac bone. The
articular surface of th joint has a semicircular, boomerang
shape, with th open angle of th boomerang facing posteri-
orly (Fig. 9 - 7 2 ) . Although articular cartilage covers both
bony auricular surfaces of th joint, it is thicker on th side
of th sacrum.86
In childhood, th sacroiliac joint has all th characteristics
of a synovial joint, being mobile and surrounded by a pli-
able capsule. Between puberty and young adulthood, how-
ever, th sacroiliac joint gradually changes from a diarthro-
dial (synovial) joint to a modifed amphiarthrodial jo in t.15
Most notable is th transition from a smooth to a rough
joint surface. A mature sacroiliac joint possesses numerous,
reciprocally contoured elevations and depressions, deeply
etched within th bone and articular cartilage (Fig. 9 - 7 3 ) . 104
With aging, th joint capsule becomes increasingly fibrosed,
less pliable, and less mobile.87 The presence of osteophytes
and defects in and around th joint are relatively common, FIGURE 9-73. A horizontal cross-section of a computed tomogra-
even in th young adult. Fibrous adhesions occur in both phy (CT) scan at th level of th sacroiliac joints. Note th irregular
articular surfaces. (From Weir J, Abrahams PH: An Imaging Atlas of
genders earlier in men and following menopause in
Human Anatomy. St. Louis, Mosby-Year Book, 1992.) KEY: #1.
women.94 By th eighth decade, th hyaline cartilage thins
rectus abdominis; #2, psoas major; #3, iliacus; #4, gluteus mini-
and deteriorates and, in some cases, th joint may com- mus; #5, gluteus medius; #6, gluteus maximus; #7, sacrum; #8,
pletely ossify. Anthropologists routinely use th condition of ilium; #9, sacroiliac joint.
 C hapter 9 O sceology an d A rchioogy 305

Anterior view of th sacrum and other locai ligaments. The interosseous

A n t e r io r lo n g itu d in a l ligament forms th most substantial bond between th sa
llio lu m b a r
lig a m e n t crum and th ilium.110
lig a m e n t The posterior side of th sacroiliac joint is reinforced by
llio lu m b a r lig a m e n t short and long posterior sacroiliac ligaments (Fig. 9 - 7 5 ) . The
(d e e p p a rt)
extensive but relatively thin set of short posterior sacroiliac
A n te rio r s a c r o ilia c In te ro s s e o u s ligaments originates along th posterior-lateral side of th
lig a m e n t lig a m e n t sacrum. The ligaments run superiorly and laterally to insert
on th ilium, near th iliac tuberosity and th posterior-
G re a te r s c ia t ic
superior iliac spine. Many of these fibers blend with th
fo r a m e n
deeper interosseous ligament. Fibers of th well-developed
S a c r o s p in o u s s a c ro c o c c y g e a l
lig a m e n t
long posterior sacroiliac ligament originate from th regions of
lig a m e n t
th third and fourth sacrai segments, then course toward an
attachment on th posterior-superior iliac spine of th ilium.
S a c ro tu b e ro u s
lig a m e n t
Many fibers of th posterior sacroiliac ligament blend with
th sacrotuberous ligament.
Although th sacrotuberous and sacrospinous ligaments
do not actually cross th sacroiliac joint, they do assist with
indirect stabilization (Fig. 9 - 7 5 ) . The sacrotuberous ligament
P u b ic s y m p h y s is
is large, arising from th posterior-superior iliac spine, lateral
FIGURE 9-74. An anterior view of th lumbosacral region and pel- sacrum, and coccyx, attaching distally to th ischial tuberos
s shows th major ligaments in th region, especially those of th ity. The distai attachment blends with th tendon of th
sacroiliac joint. On th left, pari of th sacrum, th superftcial parts biceps femoris (lateral hamstring) muscle. The sacrospinous
of th iliolumbar ligament, and th anterior sacroiliac ligaments are ligament is located deep io th sacrotuberous ligament, aris
removed to expose th auricular surface of th ilium and deeper ing from th lateral margin of th caudal end of th sacrum
interosseous ligament. and coccyx, attaching distally to th ischial spine.

th increased loading associated with walking and increased

body-weight associated with growing. The naturally rough
and irregular surfaces in th subchondral bone and articular Posterior view
cartilage resist movement between th sacrum and ilium.104
In te rtr a n s v e rs e lig a m e n t
The sacroiliac joint, however, is not exempt from degenera- S u p r a s p in o u s lig a m e n t
uve osteoarthritis. llio lu m b a r lig a m e n t
The sacroiliac joint is reinforced by three primary liga
ments: th anterior sacroiliac, interosseous, and posterior
sacroiliac.37110 The sacrotuberous and sacrospinous ligaments
offer a secondary source of stability. P o s t e r io r - s u p e r io r
ilia c s p in e

S h o r t p o s te r io r
s a c r o ilia c lig a m e n ts
Ligaments that Stabilize th Sacroiliac Joint
P rim a ry L o n g p o s t e r io r

1. Anterior sacroiliac ligament s a c r o ilia c lig a m e n ts

2. Interosseous ligament G re a te r s c ia t ic fo r a m e n
3. Short and long posterior sacroiliac ligaments
S a c r o s p in o u s lig a m e n t
S econ dary
4. Sacrotuberous ligament S a c r o t u b e r o u s lig a m e n t

5. Sacrospinous ligament
L e s s e r s c ia t ic fo r a m e n

The anterior sacroiliac ligament is a thickening of th ante

rior and inferior parts of th capsule (Fig. 9 - 7 4 ) . 46 This
aspect of th joint may be strengthened by th parts of th
piriformis and iliacus muscles that cross th joint.
The interosseous ligament is a very strong and massive set u u g tty i u i/ ia i i
s a c r o c o c c y g e a l lig a m e n ts
of short multiple fibers that fili most of th open space along
th posterior and superior margin of th joint. This ligament FIGURE 9-75. A posterior view of th right lumbosacral region and
is exposed on th left side in Figure 9 - 7 4 , by removing part pelvis shows th major ligaments that reinforce th sacroiliac joint.
 306 Seciicm III Axial Skeleton

Superior view

T r a n s v e r s u s a b d o m in is

P s o a s m a jo r O b liq u u s in te r n u s a b d o m in is FIGURE 9-76. A superior view

Q u a d ra tu s O b liq u u s e x te rn u s a b d o m in is
of a horizontal cross-section
through th back at th level of
A n t e r io r la y e r th third lumbar vertebra. The
L a t is s im u s
anterior, middle, and posterior
d o rsi M id d le la y e r - T h o r a c o lu m b a r layers of th thoracolumbar fas
fa s c ia cia are shown surrounding van-
L a te ra l ra p he
P o s t e r io r la y e r-
ous muscle groups.

E r e c t o r s p in a e
M u lt if id u s

THORACOLUMBAR FASCIA
The thoracolumbar fascia is believed to have an important
functional role in th mechanical stability of th low back,
including th sacroiliac jo in t.103 Thts tissue is most extensive
in th lumbar region, where it is organized into anterior,
middle, and posterior layers. Three layers of th thoracolum
bar fascia partially surround and compartmentalize th pos
terior muscles of th lower back (Fig. 9 - 7 6 ) .
The anterior and middle layers of th thoracolumbar fascia
are named according to their position relative to th quadra
tus lumborum muscle. Both layers are anchored medially to
th transverse processes of th lumbar vertebrae, and inferi-
orly to th iliac crests. The posterior layer of th thoracolum
bar fascia lies over th posterior surface of th erector spinae
and, more superfcially, th latissimus dorsi muscle. Thts
layer of th thoracolumbar fascia attaches to th spinous
processes of all lumbar vertebrae and th sacrum, and to th
ilium near th posterior superior-iliac spines. These extensive
skeletal attachments provide mechanical stability to th
sacroiliac joint. Stability is enhanced by attachments made
by th gluteus maximus and latissimus dorsi.
The posterior and middle layers of th thoracolumbar
fascia fuse at their lateral margins, forming a lateral raphe.
This tissue serves as an attachment for th internai obliquus
abdominus and transversus abdominus muscles. The func
tional signifcance of these muscular attachments is clarified
in th discussion on lifting mechanics in Chapter 10.
less, are lypically used for this purpose: nutation and coun-
temutation. They describe movements limited to th sagittal
piane, about a mediai-lateral axis of rotation that traverses
th interosseous ligament (Fig. 9 - 7 7 ) . Nutation (meaning to
nod) is defned as th relative anterior tilt of th base (top
of th sacrum relative to th iltum. Counternutation is a
reverse motion defined as th relative posterior tilt of th bas-
of th sacrum relative to th ilium. (Note th term relatri e
used in th above definitions.) As depicted in Figure 9 - 7 7
nutation and counternutation can occur by sacral-on-iliaa
rotation (as previously defined), by ilium-on-sacral rotation,
or by both motions performed simultaneously.
Motions at th Sacroiliac Joint
1. Nutation occurs by anterior sacral-on-iliac rotation, poste
rior ilium-on-sacral rotation, or by both motions per
formed simultaneously.
2. Counternutation occurs by posterior sacral-on-iliac rota
tion, anterior ilium-on-sacral rotation, or by both mo
tions performed simultaneously.

Kinematics
Relatively small rotational and translational movements occur
at th sacroiliac joint, primarily in th sagittal piane.26'50'89-95
Data from th studies that measured th movements vary
considerably. Typical mean values fall within th 0.2- to
2-degree range for rotation, and 1- to 2-mm range for trans-
lation.26-30-95 Passive range of motion of 7 to 8 degrees has
been measured during th extremes of bilateral hip motions.89
Movements at th sacroiliac joint likely occur as a combina-
f e l l i Anterior sacrai tilt 0 Posterior sacrai tilt
tion of compression force on th articular cartilage and ac-
1___ | Posterior iliac tilt 1 1Anterior iliac tilt
tual slight movement between joint surfaces.
Several terms and axes of rotation have been proposed to
FIGURE 9-77. The kinematics at th sacroiliac joint: A, Nutation 7
describe th motion at th sacroiliac joints.6'48 Although no
Counternutation. (See text for definitions.) Sacrai rotations are ind -
terminology completely describes th complex multiplanar cated in gray, and iliac rotations in white. The axis of rotation fot
rotational and translational movements, two terms, neverthe- sagittal piane movement is indicated by th small circle.
 Chapter 9 Osteology and Arthrology 307

Functional Considerations infant. The articular surfaces of th sacroiliac joints are

The sacroiliac joint provides two functions: (1) a stress reiief
rithin th pelvic ring and (2) a stable means for load trans-
r between th axial skeleton and lower limbs.
STRESS RELIEF
The tnovements at th sacroiliac joint, although slight, per-
mit an element of stress reiief within th pelvic ring. This
stress reiief is especially important during walking and, in
women, during childbirth.
While walking, th reciprocai flexion and extension pat
tern of th lower limbs causes each side of th pelvis to
rotate slightly out of phase with th other. At normal speed
of walking, th heel of th advancing lower limb strikes th
ground as th toes of th opposite limb are stili in contact
with th ground. At this instant, tension in th hip muscles
and ligaments generate oppositely directed torsions on th
nght and left iliac crests.6 The torsions are most notable in
th sagittal piane, as nutation and counternutation, and in
th horizontal planes. Intrapelvic torsions are amplifed with
increased walking speed. Although slight, movements at each
sacroiliac joint during walking help dissipate otherwise po-
tentially damaging stresses that would otherwise develop
throughout th pelvic ring. The pubic symphysis joint likely
has a similar role in this process.
Movements at th sacroiliac joint increase during labor
and delivery.16 A significant increase in joint laxity occurs
during th tasi trimester of pregnancy and is especially nota
ble in women during th second pregnancy as compared
with th first. Increased nutation during childbirth rotates
th lower part of th sacrum posteriorly, thereby increasing
th size of th pelvic outlet and favoring th passage of th
smoother in women, presenting less resistance lo illese slight
physiologic motions.
STABILITA DURING LOAD TRANSFER: MECHANICS OF
GENERATING A NUTATION TORQUE AT THE
SACROILIAC JOINT
The piane of th articular surfaces of th sacroiliac joint is
nearly vertical. This orientation renders th joint vulnerable
to slipping, especially when subjected to large forces. Nuta
tion at th sacroiliac joint elevates th compression and
shear (friction) forces between joint surfaces, thereby increas
ing stability.104 The close-packed position of th sacroiliac
joint is full nutation. Forces that create a nutation torque
therefore stabilize th sacroiliac joint. Torques are created by
gravity, stretched ligaments, and muscle activation.
Nutation Torque Increases th Stability at th Sacroiliac
Joint. This Torque Is Produccd by Three Forces
1. Gravity
2. Passive tension from stretched ligaments
3. Muscle activation
Stabilizing Effect of Gravity
The downward force of gravity due to body weight passes
through th lumbar vertebrae, usually anterior to th mid-
point of th sacroiliac joints. At th same time, gravity pro-
duces an upward hip compressive force that is transmitted
from th femoral heads through th acetabula.48 Each force
acts with a moment arm that creates oppositely directed
nutation torques about th sacroiliac joint (Fig. 9 -7 8 A ). The

The stabilizing effeets of nutation torque

E re c to r
s p in a e

S a c ro tu b e ro u s
lig a m e n t

B ic e p s

Gravity Stretched ligaments Active muscle force

FIGURE 9-78. Nutation torque increases th stability at th sacroiliac joint. A, Two forces originating primarily by
gravity body weight and hip joint compression generate a nutation torque at th sacroiliac joint. Each force has a
moment arm (black lines) that acts from th axis of rotation (circle ai joint). B, The nutation torque stretches th
interosseous and sacrotuberous ligaments that ultimately compresses and stabilizes th sacroiliac joint. C, Muscle
contraction (red) creates an active nutation torque across th sacroiliac joint. Note th biceps femoris transmitting tension
through th sacrotuberous ligament.
 308 Section III Axial Skeleton
torque due to body weight (shown in gray) rotates th sa-
crum anteriorly relative to th ilium, whereas th torque due
to hip compression force (shown in white) rotates th ilium
posterior relative to th sacrum. The nutation torque Iocks
th joint by increasing th friction between th rough and
reciprocally contoured articular surfaces.90104 This mecha-
nism relies primarily on gravity and th congruity of th
joint surfaces, rather than extra-articular structures such as
ligaments and muscles.
Stabilizing Effect of Ligaments and Muscles
Gravity and weight hearing through th pelvis produce th
first line of stability at th sacroiliac joints. Stability is ade
quate for activities that involve relatively low, static loading
between th pelvis and th vertebral column, such as sitting
and standing. For larger and more dynamic loading, how-
ever, th sacroiliac joints are reinforced by ligaments and
muscles. As described in Figure 9 - 7 8 B, nutation torque
stretches many of th connective tissues at th sacroiliac
joint, such as th sacrotuberous and interosseous ligaments.
Increased tension in these ligaments compresses th surfaces
of th sacroiliac joint.
In addition to ligaments, several trunk and hip muscles
reinforce and stabilize th sacroiliac joint (Table 9 - 1 6 ) .84
Additional stability is required during activities such as lift
ing, load carrying, or running. The stabilizing action of many
of these muscles is based on their attachments to th thora-
columbar fascia and to th sacrospinous and sacrotuberous
ligaments.92 Comraciile forces from muscles listed in Table
9 - 1 6 can stabilize th sacroiliac joint by (1) generating ac-
tive compression forces against th articular surfaces, (2)
increasing magnitudo of nutation torque and subsequently
engag ati active locking mechanism, (3) pulling on connec
tive tissues that are able to reinforce th joint,84 102 and (4)
any combination of these effects. As one example, consider
th muscular interaction depicted in Figure 9 -7 8 C . Contrac-
tion of th erector spinae muscle tilts th sacrum anteriorly,
whereas contraction of th rectus abdominis and biceps fem-
oris muscles can tilt th ilium posteriorly, two elements that
produce nutation torque. Through direct attachment, th bi
ceps femoris increases tension into th sacrotuberous liga-
ment. The muscular interaction explains, in part, why
strengthening and hypertrophy of many of th muscles listed
in Table 9 - 1 6 is recommended for treatment of an unstable
sacroiliac joint. In addition, increased strength of th gluteus
maximus, latissimus dorsi, erector spinae, internai oblique
muscles and transverus abdominis increases th stability of
th sacroiliac joint via their connections into th thoracolum-
bar fascia.
TABLE 9 - 1 6 . Muscles that Reinforce and Stabilize
th Sacroiliac Joint
1. Erector spinae
2. Lumbar multifidi
3. Abdominal muscle group
a. Extema! and internai obliques
b. Rectus abdominis
c. Transverus abdominis
4. Hamstrings (such as biceps femoris)
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 C h a p t e r 10

Axial Skeleton:
Muscle and Joint Interactions
Donald A. Neumann, PT, PhD

IN N ERVATIO N TO THE M USCLES A N D
JOINTS W IT H IN THE TR U N K A N D
: r a n io c e r v i c a l r e g i o n s , 312
entrai Ramus Innervation, 312
P lexus, 312
S e g m e n ta i In n e rv a tio n , 313
borsai Ramus Innervation, 314
S e g m e n ta i In n e rv a tio n , 314
TRUNK A N D CRANIO CERVICAL REGIONS,
314
Action of th Muscles of th Trunk and
Craniocervical Region, 315
P ro d u c tio n o f In te rn a i T o rq u e , 315
S p e c ia l C o n s id e ra tio n s fo r th S tu d y o f
M u s c le A c tio n w ith in th A x ia l
S ke le to n , 315
Muscles of th Trunk Section I: Anatomy
and Individuai Muscle Action, 316
S et 1: M u s c le s o f th P o s te rio r T ru n k
( " B a c k " M u s c le s ), 316
Muscles in th Superficial and
Intermediate Layers of th Back,
317
Muscles in th Deep Layer of th
Back, 317
Erector Spinae, 318
Transversospinal M uscles, 321
Short Segmentai Group of Muscles, 323
S et 2: M u s c le s o f th A n te rio r-L a te ra l
T ru n k (" A b d o m in a l" M u s c le s ), 323
Formation of th Rectus Sheaths and
Linea Alba, 323
TOPICS AT A GLANCE
Anatomy and Actions of th
Abdominal Muscles, 325
S e t 3: A d d itio n a l M u s c le (llio p s o a s and
Q u a d ra tu s L u m borum ), 327
Muscles of th Trunk Section II:
Functional Interactions Among Muscles,
328
P ro v id in g C ore S ta b ility to th T ru n k , 329
Intrinsic Muscular Stabilizers of th
Trunk, 329
Extrinsic Muscular Stabilizers of th
Trunk, 330
C o n tro llin g th S it-u p M o v e m e n t, 331
Muscles of th Craniocervical Region
Section I: Anatomy and Individuai
Muscle Action, 333
C e rv ic a l F ascia, 334
S et 1: A n te rio r-L a te ra l M u s c le s o f th
C ra n io c e rv ic a l R egion, 334
Sternocleidomastoid, 334
Scalenes, 336
Longus Colli and Longus Capitis, 336
Rectus Capitis Anterior and Rectus
Capitis Lateralis, 336
S et 2: P o s te rio r M u s c le s o f th
C ra n io c e rv ic a l R egion, 337
Splenius Cervicis and Capitis, 337
Suboccipital Muscles, 338
Muscles of th Craniocervical Region
Section II: Functional Interactions
Among Muscles that Cross th
Craniocervical Region, 338
S ta b iliz in g th C ra n io c e rv ic a l R egion, 339
P ro d u c in g E xtensive and W e ll-
C o o rd in a te d M o v e m e n ts o f th H ead
and N e ck: O p tim izin g th P la c e m e n t
o f th Eyes, Ears, and N ose, 340
SELECTED B IO M E C H A N IC A L ISSUES OF
LIFTING: A FOCUS ON REDUCING BACK
IN JU R Y , 342
Muscular Mechanics of Extension of th
Low-Back While Lifting, 342
E stim a tin g th M a g n itu d e o f Force
Im p o se d on th L o w B a c k W h ile
L iftin g , 342
W a y s to R edu ce th F o rce D em a nds on
th B a c k M u s c le s W h ile L iftin g , 344
Rote o f In c re a s in g In tra -A b d o m in a l
P re s s u re W h ile Liftin g , 345
A d d itio n a l S o u rc e s o f E xtensio n T o rq u e
U sed fo r L iftin g , 346
Passive Tension Generation from
Stretching th Posterior
Ligamentous System, 346
Muscular-Generated Tension
Transferred Through th
Thoracolumbar Fascia, 347
A Closer Look at Lifting Technique, 347
T w o C o n tra s tin g Liftin g T e c h n iq u e s : The
S to o p v e rs u s th S q u a t Lift, 347
Summary: Factors that Contribute to Safe
Lifting, 348

INTRODUCTION The anatomie structure of th muscles within th axial

I Osteologie and arthrologic components of th axial skeleton
I are presented in Chapter 9. This chapter focuses on th
muscle and joint interactions within th axial skeleton. Mus-
' cles of th axial skeleton control posture, stabilize th trunk
and pelvis, produce torque about th trunk for movement,
md fumish fine mobility and stability to th head and neck
or optimal placement of th eyes, ears, and nose.
skeleton varies considerably in length, shape, fber direction,
cross-sectional area, and leverage across th underlying
joints. Such variability reflects th diverse demands placed
on th musculature, from manually lifting and transporting
heavy objects, to producing subtle motions of th head for
accenting a hvely conversation.
In addition to th variability within muscles of th axial
skeleton, they cross multiple regions of th body. The trape-
311
312 Section III Axial Skeleton
zius muscle, for example, attaches to th clavicle and th
scapula within th appendicular skeleton, and to th verte-
bral column and th cranium within th axial skeleton, Pro-
tective guarding due to an itiflamed upper trapezius can
affect th quality of motion throughout th upper extremity
and craniocervical region.
Consider th many neurologie reflexes that exist within
th craniocervical region that help coordinate sight, hearing,
and equilibrium. Muscular dysfunction in this region is
therefore often associated with severe headache, vertigo,
emotional tension, and hypersensitivity to light and sound.
The primary aim of this chapter is to elucidate th struc-
ture and function of th muscles within th axial skeleton.
This information is essential to th evaluation and treatment
of a wide range of musculoskeletal disorders, such as pos
tumi malalignment, muscle and soft tissue strain, and disc
herniation.
INNERVATION TO THE MUSCLES AND
JOINTS WITHIN THE TRUNK AND
CRANIOCERVICAL REGIONS
An understanding of th organization of th peripheral in-
nervation of th craniocervical and trunk muscles begins
with an appreciation of a typical spinai nervo (Fig. 1 0 - 1 ).
Each spinai nerve is formed by th union of a ventral and a
dorsal nerve root: th ventral nerve mot contains primarily
outgoing (elferent) axons that supply motor drive to mus
cles and other effector organs associated with th autonomie
System. The dorsal nerve root contains primarily incoming
(afferenti dendrites with th celi body of th neuron located
in an adjacent dorsal root ganglion. Sensory neurons trans-
mit information to th spinai cord from th muscles, joints,
skin, and other organs associated with th autonomie ner-
vous System.
Protected within th vertebral canal, th ventral and dor
sal nerve roots join to form a mixed spinai nerve. (The
adjective mixed" indicates that th spinai nerve contains
D ura
S u b d u ra i sp a ce
A ra c h n o id
S u b a ra c h n o id sp a ce
Pia
D orsa l root
both sensory and motor fbers.) Once within th interverte-
bral foramen, th spinai nerve thickens owing to th merg-
ing of th motor and sensory neurons and th presence of
th dorsal root ganglion.
The vertebral column contains 31 pairs of spinai nerves:
8 cervical, 12 thoracic, 5 lumbar, 5 sacrai, and 1 coccygeal.
The abbreviations C, T, L, and 5 with th appropriate super-
script number designate each spinai nerve, or nerve root
for example, C5 and T6. The cervical region has seven verte-
brae bui eight cervical nerves. The suboccipital nerve (C:
leaves th spinai cord between th occipital bone and posie-
rior arch of th atlas (C l). The C8 spinai nerve leaves th
spinai cord between th seventh cervical vertebra (C7) and
th first thoracic vertebra (T l). Spinai nerves T l and below
leave th spinai cord below their respective vertebral bodies
Once a spinai nerve exits its intervertebral foramen, it
immediately divides into a ventral and dorsal ramus (from th
Latin ramus, meaning path). The ventral ramus forms
nerves that innervate th muscles, joints, and skin ol th
anterior-lateral trunk and neck and all th extremities. The
dorsal ramus, in contrast, forms nerves that innervate th
muscles, joints, and skin of th posterior trunk and neck.
Ventral Ramus Innervation
Each ventral ramus of a spinai nerve forms a plexus or
continues as a single nerve that innervates tissue in a highly
segmentai fashion.
PLEXUS
A plexus is an intermingling of ventral rami that form pt
ripheral nerves. The four major plexus, excluding th smal
coccygeal plexus, are formed by ventral rami: cervical (C1
brachial ( G - T 1), lumbar (T l2-L4), and sacrai (L4-S4). With
th exception of th cervical plexus, most of th nerves tha:
exit th brachial, lumbar, and sacrai plexus innervate struc-
tures associated with th appendicular skeleton. Only a few
nerves from th brachial, lumbar, and sacrai plexus innerva-.
structures associated with th axial skeleton (Fig. 1 0 -2 A )
D orsa l root FIGURE 10-1. A cross-section of th spinai cord
ga n g lio n shows th dorsal (sensory) and ventral (moloc
S pinai ne rve roots forming a spinai nerve. The spinai nerve d
vides into a relatively small dorsal ramus and a
D orsa l ram us much larger ventral ramus. (Modified with permi;-
sion from Jenkins DB: Hollingsheads F u n a io li.
V entral ro ot
Anatomy of th Limbs and Back, 7th ed. Philade.-
phia, W B Saunders, 1998.)
V entral ra m us
R am i co m m u n i-
ca n te s
 f

Chapter 10 Axial Skeleton: Musde and Jont Interactions 313

VENTRAL RAMI INNERVATION

(A) Plexus (B) Segmentai innervation

Cervical (C1-4) : :r ~
Intercostal nerves (T1-12)
M u scle : 1. lo n g u s co lli and
lo n g u s c a p itis M u scle : 1. in te rco sta l m u scle s (T 2-T 12)
2. d ia p h ra g m 2. "a b d o m in a r m u scle s (T 7- L 1)
S kin: to p o f th c h e s t and S kin: a n te rio r-la te ra l tru n k (T 1' 12)
s h o u ld e rs (s u p ra c la v ic u la r (a n te rio r cu ta n e o u s ne rves)
n e rves) Jo in t: s te rn o c o s ta l jo in t
J o in t: s te rn o c la v ic u la r jo in t
YMi
m zz.
F ~ Recurrent meningeal
Brachial (C5- ! -1)
nerves (C 1- S 4)
M u scle : rh o m b o id s
M u scle : no ne
S kin: none
S kin: none
Jo in t: none
FIGURE 1 0 -2 . Examples of tissues associated Jo in t: in te rb o d y jo in t
vitti th axial skeleton that are innervated by
entrai rami of spinai nerves, via plexus (A) or
segmentai innervation (B).

Lumbar (L1-4)
M u scle : p so a s m a jo r
S kin: no ne
Jo in t: s a c ro ilia c jo in t (L3-4)

1 ... ......
Sacrai (L4-S 4)
M u scle : 1. g lu te u s m a x im u s (by
a ctio n o f ch a n g in g
th d e g re e o f lu m b a r
lord osis)
2. p irifo rm is (as a s ta b iliz e r
o f th s a c ro ilia c jo in t)
S kin: no ne
J o in t: s a c ro ilia c jo in t (L4- S 2)

SEGMENTAI. INNERVATION costai) nerve and pari of th L1 ventral ramus of th lumbar

Ventral rami and associated branches that remain as single
nerves form either intercostal or recurrent meningeal nerves.
These innervate tissues throughout multiple segments or lev-
els within th axial skeleton. This form of innervation is
referred lo as segmentai innervation (Fig. 1 0 -2 6 ).
Intercostal Nerves (T-T2)
Each of th 12 ventral rami of th thoracic spinai nerves
forms an intercostal nerve, innervating an intercostal derma
tome and a set of intercostal muscles that share th same
intercostal space. The T 1 ventral ramus forms th first inter
costal nerve and part of th lower trunk of th brachial
plexus. The ventral rami of T7-T 12 also innervate th muscles
of th anterior-lateral trunk (i.e., th abdominal" muscles).
The T 12 ventral ramus forms th last intercostal (sub
plexus.
Recurrent Meningeal Nerves
Small nerves branch from th extreme proximal aspect of th
ventral ramus at each spinai level. These nerves, such as th
recurrent meningeal (sinuvertebral) nerve, previde mixed
sensory and sympathetic nerve supply to connective tissues
that surround th spinai cord or to those that reinforce each
interbody jo in t.10 As depicted in Figure 1 0 - 1 , each recur
rent meningeal nerve courses back into th intervertebral
foramen, hence th name recurrent, to supply dura mater,
periosteum, blood vessels, posterior longitudinal ligament,
and adjacent areas of th superficial part of th annulus
fibrosus. The anterior longitudinal ligament receives sensory
innervation from small branches from th ventral ramus and
adjacent sympathetic connections.10
 314 Section ili Axial Skeleton

The nucleus pulposus and deeper parts of ihe annulus

fibrosus do not receive sensory innen'ation. Localized pain
from a herniated nucleus pulposis is likely due to pressure
againsi th superficial part of th posterior annulus fibrosus
or posterior longitudinal ligament. As described in Chapter
9, a herniated disc that causes pain or numbness to radiate
down th lower extremity is likely due to pressure from a
disc against a spinai nerve, as it exits th intervertebral
foratnen.

Dorsal Ramus Innervation

SEGMENTAI. INNERVATION
A dorsal ramus branches from every spinai nerve, innervat-
ing structures in th back in a segmentai fashion (Fig. 1 0 -
3). With th exception of th C 1 and C2 dorsal rami, which
are discussed separately, all dorsal rami are smaller than
their ventral rami counterparts. In generai, dorsal rami
course a relatively short distance posteriorly, providing (1)
segmentai innervation to th deep layer of posterior muscles
of th back, (2) dermatome sensation to th posterior back,
and (3) sensation to th ligaments of th posterior aspect of
each vertebrae and capsule of th apophyseal joints (Table
10 - 1).
The dorsal ramus of C 1 (suboccipital nerve) is primarily
a motor nerve, innervating th suboccipital muscles. The
dorsal ramus of C2 is th largest cervical dorsal ramus. It D onai
innervates locai muscles and contributes to th formation of Perforatili# ram i .V.
th greater occipital nerve (C2~3). This large nerve provides cutaneous
nerve
sensory innervation to th posterior scalp as far forward as
th top of th head. D orsal
ram i S . 4. 5
G lutcal a n d Co. 1
ram i o f
posterior
TRUNK AND CRANIOCERVICAL REGIONS cutaneous
nerve

Introduction
The muscles of th axial skeleton can be organized into two
categories. (1) th trunk and (2) th craniocervical region
TABLE 1 0 - 1 . Examples of Tissues Innervateci by
Dorsal Rami of Spinai Nerves
FIGURE 10-3. The cutaneous distribution is shown for th dorsi
rami of spinai nerves. The nerves are numbered on th righi side re
2C for th C2 nerve, IT for th T1, and so forth. The spinoci
processes of various vertebral levels are numbered on th left sidf
(7C for C7, IL for LI, and so forth). The dotted line on th lev
mdicates th lateral limit of skin that is innervated by th dorsal
rami. (From Williams PL, Bannister LH, Berty M, et al: Gray^
Anatomy, 38th ed. New York, Churchill Livingstone, 1995.)

C-S5 Spinai Levels

Muscle
1. Muscles in th deep layer of th back, such as th erector (Table 1 0 - 2 ) . The muscles within each caiegory are furthe:
spinae and transversospinal muscles (C2-S3) organized into sets, based on generai location.
2. Splenius capitis (C3-7)
The material within each category is presented in twc
3. Suboccipital muscles (C1)
Skin sections, th ftrst covering anatomy and individuai muscle
Posterior trunk (C2-S5)* actions, and th second covering examples of th func-
Joint tional interactions among th related muscles or muscle
1. Capsule of apophyseal joints groups. Throughout this chapter, th reader is encouraged to
2. Ligaments to th posLerior aspect of a vertebrae consult Chapter 9 for a review of th pertinent osteology
3. Sacroiliac joints and associated ligaments (L-S2) related to th attachments of muscles. Appendix 111, Parts A
to C, should be consulted for a summary of more detailed
* Dorsal rami of lower sacrai nerves fuse with dorsal rami of coccygeal muscular anatomy and innen'ation to th muscles of th
nerves (sensory only). axial skeleton.
 Chapter 10 Axial Skeleton: Muscle and Joint Interactions 315

TABLE 1 0 - 2 . Anatomie Organization of th

Organization of th Presentation of th Muscles of th
Muscles o f th Axial Skeleton* Trunk and Craniocervical Region
M u s c le s o f t h T r u n k
Muscles of th Trunk
Section I: Anatomy and individuai muscle action
Set 1: M u s c le s o f t h P o s t e r io r T r u n k ( B a c k M u s c le s )
Section 11: Functional interactions among muscles
M u s c le s o f t h C r a n io c e r v ic a l R e g io n
Supetficial layer Section 1: Anatomy and individuai muscle action
Trapezius, latissimus dorsi, rhomboids, levator scapula, and Section 11: Functional interactions among muscles
serratus anterior
Intermediate layert
Serratus posterior superior
Serratus posterior inferior Action of th Muscles of th Trunk and
Deep layer Craniocervical Region
Three groups
1. Erector spinae group (spinalis, longissimus, iliocostalis) PRODUCTION OF INTERNAL TORQUE
2. Transversospinal group
Semispinalis muscles By convention, th strength of a muscle action within th
Multifidi axial skeleton is expressed as an internai torque, defined for
Rotatores th sagittal, frontal, and horizontal planes. Within each
3. Short segmentai group piane, th maximal internai torque potential is equal to th
Interspinalis muscles product of (1) th muscle force generated parai lei to a piane,
Intertransversarus muscles and (2) th length of th internai moment arm available to
th muscle (Fig. 1 0 - 4 ).
S e t 2 : M u s c l e s o f t h A n t e r i o r - L a t e r a l T r u n k ( A b d o m i n a l The spatial orientation of a muscles line-of-force deter-
M u s c le s )
mines its effectiveness for producing a particular action.
Consider, for example, th obliquus externus abdominis
Rectus abdominis muscle producing a force across th lateral thorax, with a
Obliquus intemus abdominis
line-of-force oriented about 30 degrees from th vertical (Fig.
Obliquus externus abdominis
1 0 - 5 ). The muscles resultant force vector can be trigono-
Transversus abdominis
metrically partitioned into unequal vertical and horizontal
S e t 3 : A d d it io n a l M u s c le s force components. The vertical force component about
86% of th muscles maximal force is available for produc
Uiopsoas ing lateral flexion or flexion torques. The horizontal force
Quadratus lumborum component about 50% of th muscles maximal force is
available for producing an axial rotation torque. (This esti-
Muscles of th Craniocervical Region mation is based on cosine of 30 degrees equaling .86, and
th sine of 30 equaling .5.) For a muscle to contribute all its
S e t 1: Muscles o f t h A n t e r io r - L a t e r a l C r a n io c e r v ic a l R e g io n force potential toward axial rotation, its overall line-of-force
must be directed solely in th horizontal direction. For a
Stemocleidomastoid muscle to contribute all its force potential toward either
Scalenes lateral flexion or flexion, its overall line-of-force must be
Scalenus anterior directed vertically. The lines-of-force of muscles that control
Scalenus medius movement of th axial skeleton have a spatial orientation
Scalenus posterior
that varies over a wide spectrum, from nearly vertical to
Longus colli
nearly horizontal.
Longus capitis
Rectus capitis anterior More of th total muscle mass of th trunk is biased
Rectus capitis laterahs vertically than horizontally. This explains, in pari, why maxi
mal effort torques are generally greater for frontal and sagit
S e t 2 : M u s c le s o f t h P o s t e r io r C r a n io c e r v ic a l R e g io n tal piane movements than for horizontal piane move-
ments.8'64
Supetficial group
Splenius cervicis
Splenius capitis SPECIAL C0NSIDERATI0NS FOR THE STUDY 0F
Deep group (suboccipital muscles) MUSCLE ACTION WITHIN THE AXIAL SKELETON
Rectus capitis posterior major
To understand muscle action in th axial skeleton it is nec-
Rectus capitis posterior minor
Obliquus capitis superior essary to frst consider th muscle during both unilateral and
Obliquus capitis inferior bilateral activations. Bilateral activation usually produces pure
flexion or extension of th axial skeleton. Any potential for
lateral flexion or axial rotation is neutralized by opposing
* A muscle is classified as betonging to th trunk or craniocervical
region based on th location of th most of its attachments. forces in contralateral muscles. Unilateral activation, in con-
t These muscles are discussed in Chapter 11. trast, tends to produce flexion or extension of th axial
 316 Section Ili Axial Skeleton

Frontal piane
LATERAL
FLEXION

FIGURE 10-4. Selected muscles

of th trunk are shown produc-
ing an internai torque within
each of th three Cardinal planes.
The internai torque is equal to
th produci of th muscle force
L o n g is s im u s R e c tu s within a given piane and its in
t h o r a c is a b d o m in is
ternai moment arm, shown as
dark bold lines. T6 is chosen as
O b liq u u s e x te rn u s th representative axis of rotation
t h o r a c is
a b d o m in is (small open circle). In each case,
th strength of a muscle action is
determined by th distance and
Horizontal piane
spatial orientation of th mus-
AXIAL ROTATION cles line-of-force relative to th
axis of rotation.

O b liq u u s e x te rn u s
a b d o m in is

skeleton, with some combination of lateral flexion and con- vis. With th pclvis stabilized, th muscle can extend th
tralateral or ipsilateral axial rotation. The term lateral flexion thorax; with th thorax stabilized, th muscle can rotate (tilt)
of th axial skeleton implies ipsilateral lateral flexion. th pelvis. If th thorax and pelvis are both free to move,
The action of a muscle within th axial skeleton depends, th muscle can simultaneously extend th thorax and anteri-
in pari, on th relative degree of fixation, or stabilization, of orly tilt th pelvis. Unless otherwise stated, it is assumed
th attachments of th muscle. As an example, consider th that th superior (cranial) end of a muscle is less constrained
effect of a contraction of a member of th erector spinae and, therefore, freer to move than its inferior or caudal end.
group a muscle that attaches to both th thorax and pel- Depending on body position, gravity routinely assists or
resists movements of th axial skeleton. Slowly flexing th
head from th anatomie position, for example, is normally
controlled by eccentrie activation of th neck extensor mus
cles. Gravity, in this case, is th prime flexor of th head,
whereas th extensor muscles control th speed and extern
of th action. Rapidly flexing th head, however, requires a
burst of concentric activation from th neck flexor muscles,
because th desired speed of th motion may be greater than
that produced by action of gravity alone. Unless otherwise
stated, it is assumed that th action of a muscle is performed
via a concentric contraction, rotating a body segment against
gravity or against some other forni of extemal resistance.

Muscles of th Trunk Section I: Anatomy

and Individuai Muscle Action
The following section describes th relationships between th
anatomy and th actions of th muscles of th trunk.

FIGURE 10-5. The line-of-force of th obliquus externus abdominis

muscle is shown directed in th sagittal piane, with a spatial orien-
SET 1: MUSCLES OF THE P0STERI0R TRUNK
taiion about 30 degrees from th vertical. The resultant muscle
("BACK" MUSCLES)
force vector (red) is trigonometrically partitioned into a vertical
force for th production of lateral (lexion and flexion torques and a The muscles of th posterior trunk are organized into three
horizontal force for th production of axial rotation torque layers: superficial, intermediate, and deep (see Table 1 0 -2 ).
 Chapter 10 Axial Skeleton: Muscle and Joint Interactions 317

Muscles in th Superficial and Intermediate Layers of
th Back
The muscles in th superficial layer of th back are pre-
sented in th study of th shoulder (see Chapter 5). They
include th trapezius, latissimus dorsi, rhomboids, levator
scapula, and serratus anterior. The trapezius and latissimus
dorsi are mesi superficial, followed by th deeper rhomboids
and levator scapula. The serratus anterior muscle ts located
more laterally on th thorax.
In generai, bilateral activation of th muscles of th super
ficial layer extends th adjacent region of th axial skeleton.
Unilateral activation, however, laterally flexes and, in most
cases, axially rotates th region.
The muscles included in th intennediate layer of th
back are th serratus posterior superior and th serratus
posterior inferior. They are located just deep to th rhom
boids and latissimus dorsi. The serratus posterior superior
and inferior are thin muscles that likely contribute little to
th movement or stability of th trunk. Their function is
more likely related to th mechanics of ventilation and, as
such, are described in Chapter 11.
Muscles within th superficial and intennediate layers of
th back are often referred to as extrinsic muscles because,
from an embryologic perspective, they were originally associ-
ated with th front limb buds and only later migrated
dorsally to their final position on th back, lnterestingly,
muscles such as th levator scapula, rhomboids, and serratus
anterior, although located within th back, are actually up
per limb muscles. All extrinsic muscles of th back are,
therefore, innervated by ventral rami of spinai nerves (i.e.,
brachial plexus or intercostal nerves).
Muscles in th Deep Layer of th Back
Muscles in th deep layer of th back are th (1) erector
spinae group, (2) transversospinal group, and (3) short seg
mentai group (Table 1 0 - 3 ). The anatomie organization of
th erector spinae and transversospinal groups is illustrated
in Figure 1 0 - 7 .
In generai, from superficial to deep, th fiber lengths of
th muscles in th deep layer become progressive!)' shorter.
A muscle within th more superficial erector spinae group
may extend virtually th entire length of th vertebral col-
umn. In contrast, muscles within th deeper short segmentai
group each cross only one intervertebral junction.
Although exceptions prevail, muscles in th deep layer of
th back are innervated segmentali)' through th dorsal rami

Muscles of th Superficial Layer of th Back: An

Example of Muscles "Sharing" Actions Between th
Axial and Appendicular Skeletons

Chapter 5 describes th actions of th muscles of th

superficial layer of th back, based on their ability to
rotate th appendicular skeleton (i.e., humerus, scapula,
or clavicle) toward a fixed axial skeleton (i.e., head,
vertebral column, or ribs). The same muscles, however,
are equally capable of performing th "reverse" action
(i.e., rotating segments of th axial skeleton toward th
fixed appendicular skeleton). This muscular action is
demonstrated by highlighting th functions of th trape
zius and rhomboids while using a bow and arrow. As
indicated in Figure 10-6, several muscles produce a
force needed to stabilize th position of th scapula
and abducted arm. Forces produced in th upper trape
zius, middle trapezius, and rhomboids simultaneously ro
tate th cervical and upper thoracic spine to th left,
indicated by th bidirectional arrows. This "contralat-
eral" axial rotation effect is shown for C6 in th inset
within Figure 10-6. As th muscle pulls th spinous
process of C6 to th right, th anterior side of th
vertebra is rotated to th left. The trapezius and rhom
boids also stabilize th scapula against th pul of th shoulder and upper trunk are shown as an archer uses a bow
posterior deltoid, long head of th triceps, and ser and arrow. The upper trapezius, middle trapezius, and rhom
boids demonstrate th dual action of (1) rotating th cervical
ratus anterior. These shared actions of th muscles of
and upper thoracic spine to th left (see inset) and (2) stabiliz-
th superficial layer of th back demonstrate th ing th position of th right scapula relative lo th thorax. The
inherent efficiency of th muscular System. In this bidirectional arrows indicate th muscles simultaneously rotat
example, a few muscles accomplish multiple actions ing th spinous process toward th scapula and stabilizing th
that are shared across th axial and appendicular skel scapula against th pul of th long head of th triceps, poste
etons. rior deltoid, and serratus anterior.
318 Section III Axial Skeleton

TABLE 1 0 - 3 . Muscles in th Deep Layer of th Back

General Fiber
Group (and Relative Depth) Individuai Muscles Direction Comments

E r e c to r S p in a e (S u p e r fic ia l) Iliocostalis lumborum Cranial and lateral Most effettive leverage for lateral flexion
Iliocostalis thoracis Vertical
Iliocostalis cervicis Cranial and mediai
Longissimus thoracis Vertical Most developed of erector spinae group
Longissimus cervicis Cranial and mediai
Longissimus capitis Cranial and lateral
Spinalis thoracis Vertical Poorly defned, fuses with semispinalis muscles
Spinalis cervicis Vertical
Spinalis capitis Vertical
T r a n s v e r s o s p in a l (In te r m e d ia te ) Semispinalis
Semispinalis thoracis Cranial and mediai Cross six to eight intervertebral junctions
Semispinalis cervicis Cranial and mediai
Semispinalis capitis Vertical
Multifidi Cranial and mediai Cross two to four intervertebral junctions
Rotatores
Rotator brevis Cranial and mediai Rotator longus crosses two intervertebral junc-
Rotator longus Horizontal tions; th rotator brevis crosses one inter
vertebral junction. The rotatores are most
developed in thoracic region.
S h ort S eg m en ta i (D eep ) lnlerspinalis Vertical Both muscles cross one intervertebral junction.
Intertransversarus Vertical Most developed in th cervical region.
Interspinalis muscles are mixed with th inter-
spinous ligaments.

of spinai nerves.84 A particularly long muscle within th erec- Erector Spinae

tor spinae group, for instance, is innervateci by multiple levels
throughout th spinai cord. Embryologically, and unlike th
muscles in th extremities and anterior-lateral trunk, th mus
cles in th deep layer of th back have retained their originai
location dorsal to th neuraxis. For this reason, these muscles
are often called intrinsic muscles of th back.
As a generai rule, most intrinsic muscles of th back are
innervated by th dorsal rami of adjacent spinai nerves. in
contrast, most extrinsic muscles of th back, such as th
lastissimus dorsi and serratus posterior superior, are inner
vated by th ventral rami of spinai nerves, via th brachial
plexus or intercostal nerves.
The erector spinae are a large and rather poorly defned
group of muscles that run on either side of th vertebral
column, roughly within one hands width from th spinous
processes (Fig. 1 0 -8 ). Most are located deep to th poster
ior layer of thoracolumbar fascia and th muscles in th
intermediate and superficial layers of th back. The erector
spinae consist of th spinalis, longissimus, and iliocostalis
muscles. Each muscle is further subdivided topographically
into three regions, producing a total of nine named muscles
(see Table 1 0 - 3 ) . Individuai muscles overlap and vary
greatly in size and length.
The bulk of th erector spinae muscles has a common

Superior view

FIGURE 1 0 -7 . Cross-sectional
view through T9 highlighting
th topographic organization of
th erector spinae and th trans-
versospinal group of muscles.
The short segmentai group of
muscles is not shown.
 Chapter 10 Axial Skeleton: Muscle and Joint Interactions 319

Posterior view TABLE 1 0 - 4 . Attachments Made by th Common

Tendon of th Erector Spinae

1. Median sacrai crests

2. Spinous processes and supraspinous lgaments in th lower
ihoracic and entire lumbar region
3. lliac crests
4. Sacrotuberous and sacroiliac lgaments
5. Gluteus maximus
6. Multifidi

from th common tendon, attaching between th posterior

end of th ribs and th transverse and articular processes of
locai vertebrae. In th neck, th longissimus cervicis angles
slightly medially to attach to th posterior tubercles of th
transverse processes of th cervical vertebrae (Fig. 1 0 - 8 ).
The longissimus capitis, in contrast, angles slightly laterally
to attach to th posterior margin of th mastoid process of
th temporal bone. The more oblique angulation of th su
perior portion of th longissimus capitis and cervicis sug-
gests that these muscles assist with ipsilateral axial rotation
of th craniocervical region.

Iliocostalis Muscles
The iliocostalis muscles include th iliocostalis lumborum,
iliocostalis thoracis, and iliocostalis cervicis. They occupy th
most lateral column of th erector spinae group. The iliocos-

FIGURE 1 0 -8 . The muscles of th erector spinae group. For clarity,

th left iliocostalis, left spnalis, and right longissimus muscles are
cut just superior to th common tendon. (From Luttgens K, Hamil
ton N: Kinesiology: Scientific Basis of Human Motion, 9th ed.
Madison, WI, Brown and Benchmark, 1997. The McGraw-Hill
Companies.)

attachment on a broad, thick tendon located superfcial to th

Transversospinal muscles Gluteus
sacrum (see Fig. 1 0 -8 ). This common tendon anchors th
(m ultifidi) maximus
erector spinae to many locations (Table 1 0 -4 ). From this com
mon tendon arises three poorly organized vertical columns of
muscle: th spinalis, longissimus, and iliocostalis.6-49'84
Spnalis Muscles
Spinalis muscles include th spinalis thoracis, spinalis cer-
vicis, and spinalis capitis. In generai, they insert superiorly
on lateral aspects of th spinous processes or ligamentum
nuchae in th cervical region. Spinalis muscles are usually
indistinct from surrounding muscles or missing entirely. The
spinalis capitis, if present, often blends with th semispinalis
capitis.84
Longissimus Muscles FIGURE 1 0 -9 . Muscle activation pattems of a healthy person while
The longissimus muscles include th longissimus thoracis, extending th trunk and head. The upper and lower extremities are
longissimus cervicis, and longissimus capitis. As a set, they also being lifted away from th supporting surface. A, Side view. B,
are th largest and most developed of th erector spinae Top view. Note in A that th stretched iliacus muscle contributes to
group. The fibers of th longissimus muscles fan cranially th anterior tilted position of th pelvis.
 320 Section 111 Axial Skeleton
talis muscies run cranialiy from th common tendon. The
iliocostalis lumborum and thoracis insert generally lateral to
th angle o f th ribs. The iliocostalis cervicis attaches to th
posterior tubercles of th transverse processes of th mid
cervical vertebrae, along with th longissimus cervicis.
Sumniary of th Erector Spinae Group
The erector spinae muscies cross a considerable distance
along th axial skeleton. This anatomie feature suggests a
0 S P E C I A L F O C U S 1 0 -
Forces Generateci by th Lumbar Extensor Muscies
While Carrying External Loads
Because of th ventral positioning of th eyes and
arms, external loads are frequently manipulated, passed,
or carried anterior to th body. The lumbar extensor
muscies such as th erector spinae are consist
e n ti required to produce large internai forces in re-
sponse to these ventrali placed external loads. The
force demands on th entire set of lumbar extensor
muscies are typically large due to th muscle groups'
overall poor mechanical advantage (i.e., th ratio of
internal-to-external moment arm; see Chapter 1). A typi-
cal erector spinae muscle in th lumbar region, for
instance, may have an internai moment arm of 5 cm,
whereas th external moment arm of a hand-held load
could be as great as 70 cm th horizontal distance
between th lumbar vertebral body and th outstretched
hand. Given a mechanical advantage of .07 (5/70), th
extensor muscies must produce a force 14 times larger
than th weight of th load (i.e., th reciprocai of th
mechanical advantage). For example, holding a gallon of
water weighing about 35.6 N (about 8 Ib) at a distance
70 cm in front of th chest requires at least 498 N
(about 112 Ib) of force from th lumbar extensor mus
cies. If th additional external torque created by both
outstretched arms is considered, th total force re
quired by th lumbar extensor muscies is more than
doubled! Although this muscular force is only about
25% of th total maximal force potential of th lumbar
extensor muscies,10 this example does partially explain
why th lumbar spine and associated extensor muscies
are inherently vulnerable to injury when one handles
relatively light materials.
For persons vulnerable to disabling low-back pain,
carrying loads should be limited, especially when held
in front of th body. If loads must be carried, they
should be as lig h t as possible, and carried as d o s e to
th body as possible. Carrying a load directly over th
head reduces th demands on all muscies of th trunk.
Although carrying loads in this method is popular in
some regions of th world, it does have th disadvan-
tage of increased compression forces on th cranio-
cervical region which, generally speaking, is not de-
signed to support large loads. Carrying loads in a
backpack is an alternative. As shown by th electromy-
ographic (EMG) study associated with Figure 10-10,
design more suited for control o f gross movements o f th
entire axial skeleton than for control of finer movements at
individuai intervertebral junctions. As a group, hilateral con-
traction of th erector spinae extends th trunk, neck, or
head (Fig. 1 0 - 9 ).
By attaching to th sacrum and to th pelvis, th erector
spinae can anteriorly tilt th pelvis, thereby accentuating th
lumbar lordosis. (Pelvic tilt describes a sagittal piane rotation
of th pelvis about th hips. The direction of th tilt is
carrying loads in a standard backpack generated, on
average, about th same magnitude from th lumbar
erector spinae as that produced when not carrying a
load.15 This is in sharp contrast to th large EMG re-
sponse from th same muscies when carrying th same
load anterior to th trunk.
Note in Figure 10-10 th large disparity in erector
spinae EMG when hand-held loads are carried either
ipsilateral or contralateral to th side of th lumbar
extensor muscle. The contralateral load requires a large
lateral flexion torque produced unilaterali by th lum
bar erector spinae, as well as th other lumbar exten
sor muscies. This information is helpful when advising
persons about safe methods of carrying hand-held
loads, especially when unilateral muscle, joint, or con-
nective tissue injury is suspected.
1 6 -i
10% B ody weight
C 3 20% B ody weight
12-
o
>
o'
o
UH
Ipsilateral Posterior Contralateral Anterior
Carrying Position
FIGURE Mean electromyographic (EMG) values ex-
1 0 -1 0 .
pressed as a percent of maximal voluntary isometric contraction
(MV1C) from th lumbar erector spinae muscies while walking
and carrying loads of two sizes and lour carrying positions. The
carrying position noted on th X axis is based on th position of
th load relative to th erector spinae muscies. The bold horizon
tal line marks th EMG response while subjects walked without
carrying a load. (Data from Cook TM, Neumann DA: The effeets
of load placement on th EMG activity of th low back muscies
during load carry by men and women. Ergonomics 30 1413-
1423, 1987.)
 Chapter IO Axial Skeleton: Muscle and Joint Interactions 321

indicateci by th rotation direction of th iliac crests.) As

Posterior view
depicted in Figure 1 0 -9 A , th anterior pelvic tilt is accentu-
ated by th increased tension in stretched hip flexor mus-
cles, such as th iliacus.
Contracting unilaterally, th laterally located iliocostalis
muscles are th most effective lateral flexors of th erector
spinae group. The cranial or cervical components of th
longissimus and iliocostalis muscles assist with ipsilateral ax
ial rotation, especially when th head and neck are fully and
contralaterally rotated. The iliocostalis lumborum assists
slightly with ipsilateral axial rotation.
Transversospinal Muscles
Located immediately deep to th erector spinae muscles is
th transversospinal muscle group: th semispinalis, multi-
ftdi, and rotatores (Figs. 1 0 - 1 1 and 1 0 - 1 2 ). Semispinalis
muscles are located superficially; th multifdi, intermedi-
ately; and th rotatores, deeply.
The name transversospinal refers to th generai attach-
ments of most of th muscles, (i.e., from th transverse
processes of one vertebra to th spinous processes of a more
superiorly located vertebra). With a few exceptions, these
attachments align most muscle fibers in a cranial and mediai

Posterior view

FIGURE 10-12. A posterior view shows th deeper muscles within

th transversospinal group (multifdi and rotatores) and th muscles
within th short segmentai group (interspinalis and intertransversa-
rus). The intertransversarus muscles are shown for th right side of
th lumbar region only. The levator costae muscles are involved
with force inspiration and are discussed in Chapter 11. (From
Luttgens K, Hamilton N: Kinesiology: Scientific Basis of Human
Motion, 9lh ed. Madison, Wl, Brown and Benchmark, 1997. The
McGraw-Hill Companies.)

direction. Many of th muscles within th transversospinal

group are morphologically very similar, varying primarily in
length and in th number of intervertebral junctions that
each muscle crosses (Table 1 0 - 5 ).

T A B L E 1 0 - 5 . Basic Morphologic Characteristics of

th Muscles within th Transversospinal Group

Average Number of
Intervertebral
FIGURE 10-11. A posterior view shows th more superficial semi Muscle Relative Length Junctions Crossed
spinalis muscles within th transversospinal group. For clarity, only
th left semispinalis cervicis, left semispinalis thoracis, and right Semispinalis Long 6 -8
semispinalis capitis are included. (From Luttgens K, Hamilton N: Multifdi Intermediate 2 -4
Ktnesiology: Scientific Basis of Human Motion, 9th ed. Madison, Rotatores Short 1 -2
WI, Brown and Benchmark, 1997. The McGraw-Hill Companies.)
 322 Section 111 Axial Skeleton
Semispinalis Muscles
The semispinalis muscles consist of th semispinalis thor-
acis, semispinalis cervicis, and semispinalis capitis (Fig. 1 0 -
11). In generai, each muscle, or main set of fibers within
each muscle, crosses six io eight intervertebral junctions. The
semispinalis thoracis consists of many thin muscle fasciculi,
interconnected by long tendons. Muscle fibers attach from
transverse processes of T 6-10 to spinous processes of C6-T4.
The semispinalis cervicis, much thicker and more devel-
oped than th semispinalis thoracis, attaches from upper
thoracic transverse processes to spinous processes of C2-5.
Muscle fibers that attach to th prominent spinous process
of th axis (C2) are particularly well developed, serving as
important stabilizers for th suboccipital muscles.
The semispinalis capitis lies deep to th splenius and trape-
zius muscles. The muscle arises primarily from upper tho
racic transverse processes. The muscle thickens superiorly as
it attaches to a relatively large region on th occipital bone,
filling much of th area between th superior and inferior
nuchal lines (see Fig. 9 - 3 ) .
The semispinalis cervicis and capitis are th largest mus
cles that cross th posterior side of th neck. Their large size
and near-vertical fiber direction provide significant exlension
torque to th craniocervical region. Right and left semispin
alis capitis muscles are readily palpable as thick and round
cords on either side of th midiine of th upper neck,
especially evident in infants and in thin, muscular adults
(Fig. 1 0 -1 3 ).
FIGURE 10-13. A thin, healthy 22-year-old female demonstrates th
contours of th activated right and left semispinalis capitis muscles.
Manual resistance is applied against an extension effort of th head.
The red dot indicates th spinous process of th C7 vertebra.
TABLE 1 0 - 6 . Multiple Attachments of th
Multifidi Throughout th Lumbosacral Region
Inferior Attachments
1. Mammillary processes of lumbar vertebrae
2. Lumbosacral ligaments
3. Deeper pari of th common tendon of th erector spinae
4. Posterior surface of th sacrum
5. Posterior-superior iliac spine of pelvis
6. Capsule of apophyseal joints
Superior Attachments
1. Lumbar spinous processes
Multifidi
Multifidi lie under th semispinalis muscles. The plural
multifidi indicates a collection of multiple fibers, rather
than a set of individuai muscles. All multifidi share a similar
fiber direction and length, extending between th posterior
sacrum and C2. In generai, th multifidi originate from th
transverse process of one vertebra and insert on th spinous
process of a vertebra located two to four segments above
(see Fig. 1 0 -1 2 ).
Multifidi are thickest and most developed in th lumbo
sacral region (Table 1 0 - 6 ) .51 Muscle fibers within th lum
bar region fili much of th concave space forrned between
th spinous and transverse processes. Throughout th lum
bar region, th multifidi approach th spinous processes at
essentially right angles to th long axis of each correspond-
ing spinous process.48 This angle is only apparent from a
lateral view. This line-of-force maximally converts a force
into a torque. The multifidi, therefore, provide an essential
source of extension torque and stability to th base of th
spine. Excessive force in th lumbar multifidi due either to
attive contraction or protective spasm maybe expressed
clinically as an exaggerated lordosis.
Rotatores
The rotatores are th deepest of th transversospinal
group of muscles. Like th multifidi, th rotatores consist of
a large set of individuai muscle fibers. Although th rotatores
exist throughout th entire vertebral column, they are best
developed in th thoracic region (see Fig. 1 0 - 1 2 ). Each
fiber attaches between th transverse process of one vertebra
and th lamina and base of th spinous process of a vertebra
located one or two segments above. By definition, th rotator
brevis muscle spans one intervertebral junction, and th rota
tor longus muscle spans two intervertebral junctions.
Summary of th Transversospinal Muscle Group
The transversospinal muscles consist of those that, on
average, cross fewer intervertebral junctions than th erector
spinae group. This feature suggests that, in generai, th mus
cles are designed to produce relatively fine controlled move-
ments across th axial skeleton, at least when compared with
th erector spinae.
Contracting bilaterally, th transversospinal muscles ex-
tend th axial skeleton (Fig. 1 0 -9 B ). lncreased extension
torque exaggerates th lumbar and cervical lordosis and de-

creases th thoracic kyphosis. The size and thickness of th
transversospinal muscles are greatest ai either end of th
axial skeleton. Craniali)', th semispinalis cervicis and capitis
are very well-developed extensors of th craniocervical re-
gion; caudally, th lumbar multifidi are very well-developed
extensors of th lumbar region.
Contracting unilaterally, th transversospinal muscles lat
erali)' flex ihe spine; however, their leverage for this action is
limited due to their dose proximity to th vertebral column.
The more obliquely oriented transversospinal muscles assist
with contralateral axial rotation. From a relatively fixed
transverse process, contraction of a single righi multihdus or
rotator longus, for example, can rotate a superiori) located
spinous process toward th tight and, as a result, rotate th
anterior side of th vertebra to th left. Compared with all
th trunk muscles, however, th transversospinal muscles are
secondary axial rotators. The leverage for axial rotation is
relatively poor due to th muscles proximity to th vertebral
column. Compare th multifidi to th obliquus abdominis
externus, for example, in Figure 1 0 -4 C . Furthermore, th
prevailing line-of-force typical of transversospinal muscle fi-
ber is directed more vertically than horizontally, thereby
providing a greater force potential for extension than for
axial rotation.
Short Segmentai Group of Muscles
The short segmentai group of muscles consists of th inter-
spinalis and th intertransversarus muscles (see Fig. 1 0 -1 2 ).
The plural interspinales and intertransversales is often
used to describe all th members within th entire set of
these muscles.) They lie deep to th transversospinal group
o f muscles. The nam e short segm entai" refers to th ex-
remely short length and highly segmented organization of
he muscles. Each individuai interspinalis or intertransversa
rus muscle crosses just one intervertebral junction. The short
segmentai group of muscles exists throughout th vertebral
column except for th thoracic region. These muscles are
most developed in th cervical region, where fine control of
:he head and neck is so criticai.
Each pair of interspinalis muscles is located on either side
of, and often blends with, th corresponding interspinous
ligament. The interspinales have a relatively favorable lever
age and optimal fiber direction for producing extension
torque. The magnitude of this torque is relatively small,
however, considering th small size of th muscles.
Each righi and left pair o f intertransversarus m uscles is
located between adjacent transverse processes. As a group,
th anatomy of th intertransversales is more complex than
that of th interspinales.84 In th cervical region, for exam
TABLE 1 0 - 7 . Physiologic And Kinesiologic Functions of th Abdominal Muscles
Physiologic Functions
1. Suppons and proteets th abdominal viscera
2. Increases intra-abdominal pressure for forced expiration of
air from th lungs, vomiting, micturition, defecation, and
parturition
3. Increases intrathoracic pressure for forced expiration of air
from th lungs
Chapter 10 Axial Skeleton: Muscle and Joint lnteractions 323
ple, each intertransversarus muscle is divided imo small an
terior and posterior muscles, between which pass th ventral
rami of spinai nerves.
As a group, unilateral contraction of th intertransversales
laterally flexes th vertebral column. Although th magnitude
of th lateral tlexion torque is relatively small compared with
other muscle groups, th torque likely provides an important
source of intervertebral stability.
Summary of th Short Segmentai Group of Muscles
The interspinalis and intertransversarus muscles consist of
multiple short pairs of fibers, each of which crosses only one
intervertebral junction. The highly segmented nature of these
muscles contributes io fine control of th axial skeleton.
These muscles also provide a rich source of segmentai sen-
sory feedback, especially in th craniocervical region.10 Feed
back helps coordinate th position of th head and neck
with th position of th visual and auditory systems.
SET 2: M U S C L E S OF THE A N T E R I O R - L A T E R A L T R U N K
("A B D O M IN A L" M USCLES)
The muscles of th anterior-lateral trunk include th rectus
abdominis, obliquus externus abdominis, obliquus intemus
abdominis, and transversus abdominis (Fig. 1 0 -1 4 A to D).
As a group, they are often re ferrod to as th abdominal
muscles. The rectus abdominis is a long straplike muscle,
located on either side of th midiine of th body. The obli
quus externus abdominis, obliquus intemus abdominis, and
transversus abdominis th lateral abdominals are wide
and fiat, layered superficial to deep, across th lateral aspect
o f th abdom en .
The abdominal muscles have several physiologic and ki-
nesiologic functions (Table 1 0 - 7 ). This chapter emphasizes
th muscles kinesiologic functions.
Formation of th Rectus Sheaths and Linea Alba
The obliquus externus abdominis, obliquus internus abdomi
nis, and transversus abdominis muscles from th tight and
left sides of th body fuse at th midiine of th abdomen
through a blending of connective tissues. Each muscle con
tributes a thin bilaminar sheet of connective tissue that ulti-
mately forms th anterior and posterior rectus sheaths. As
depicted in Figure 1015, th anterior rectus sheath is
formed from connective tissues from th obliquus externus
abdominis and th obliquus intemus abdom in is muscles.
The posterior rectus sheath is formed from connective tis
sues from th obliquus internus abdominis and transversus
abdominis. Both sheaths surround th vertically oriented ree-
Kinesiologic Functions
1. Moves and stabilizes th trunk
2. Supports th lumbar spine and sacroiliac joint during forceful
conditions such as lifting heavy loads
3. Stabilizes th proximal bony attachments of hip and knee
muscles
 324 Section III Asciai Skeleton

FIGURE 10-14. The four abdominal muscies of th anterior-lateral trunk. A, Rectus abdominis with th anterior rectus sheath removed. B,
Obliquus extemus abdominis. C, Obliquus internus abdominis, deep to th obliquus extemus abdominis. D, Transversus abdominis, deep io
other abdominal muscies. (Frani Luttgens K, Hamilton N: Kinesiology: Scientific Basis of Human Motion, 9th ed. Madison W1 Brown and
Benchmark, 1997. The McGraw-Hill Companies.)

Rectus
abdominis
FIGURE 10-15. Honzontal cross-
sectional view of th anterior ab-
dominal wall shown at th ap-
proximate level of th third
iumbar vertebra.
Obliquus Obliquus Transversus
externus internus abdominis
abdominis abdominis
tus abdominis muscle and continue medially to fuse with
identical connective tissues from th other side of th abdo-
men.7' (This generai anatomie arrangement pertains to th
abdominal wall located above th level of th iliac crests.
Below this level both anterior and posterior rectus sheaths
course anterior to th rectus abdominis.) The connective
tissues thicken and crisscross as they traverse th midiine,
forming th linea alba (from th Latin linea, line, and albus,
white). Anatomically, th linea alba is described as a tendi-
nous raphe," running longitudinally between th xiphoid
process and pubic symphysis and pubic crest.84
The crisscross arrangement of th fibers within th linea
alba adds considerable strength to th abdominal wall, much
like th laminated structure of plywood. The linea alba also
mechanically links th right and left lateral abdominal mus
cles, providing an effective way to transfer muscular force
across th midiine of th body.
Anatomy of th Abdominal Muscles
The rectus abdominis muscle consists of right and left halves,
separated by th linea alba. Each half of th muscle runs
longitudinally, widening as it ascends within an open sleeve
formed between th anterior and posterior rectus sheaths.
The muscle is intersected and reinforced by three fbrous
bands, known as tendinous intersections. These bands blend
TABLE 1 0 - 8 . Attachments and Individuai Actions of th Lateral Abdominal Muscles
Muscle Lateral Attachm ents
Obliquus externus Lateral side of ribs 4 -1 2
abdominis
Obliquus internus Iliac crest, inguinal ligament, and
abdominis thoracolumbar fascia
Transversus Iliac crest, thoracolumbar fascia, inner
abdominis suri'ace of th cartilages of ribs 6 -
12, and th inguinal ligament
Chapler 10 Axial Skeleton: Muscle and Joint Interactions 325
Superior vievv
Linea alba Anterior rectus
sheath
Posterior rectus
sheath
Connective tissues from
lateral abdominal muscles
with th anterior rectus sheath. The rectus abdominis arises
from th region on and surrounding th crest of th pubis,
and it attaches superiorly on th xiphoid process and carti-
lages of th fifth through seventh ribs.
The anatomie organization of th obliquus externus ab
dominis, obliquus internus abdominis, and transversus ab
dominis muscles is different from that of th rectus abdomi
nis. As a group, th lateral muscles originate laterally or
posterior-laterally on th trunk and run in a different direc
tion toward th midiine, eventually blending with th linea
alba and contralateral rectus sheaths (Table 1 0 - 8 ).
The obliquus externus abdominis is th largest and most
superficial of th lateral abdominal muscles. The extemal
oblique muscles travel in an inferior-and-medial direction, as
if th hands were placed in pockets. The obliquus internus
abdominis is located immediately deep to extemal oblique
muscle, forming th second layer of th lateral abdominals.
Most of its fibers originate on th iliac crest and adjacent
thoracolumbar fascia. From this lateral attachment point, th
fibers course in a cranial-and-medial direction toward th
linea alba and lower ribs. As evident in Figure 1 0 -1 4 C , th
mferior attachments of th internai oblique muscle extend to
th inguinal ligament. The mean fiber direction of th inter
nai oblique muscle is nearly perpendicular to th mean fiber
direction of th overlying extemal oblique muscle.
Midiine A ttachm ents Actions on th Trunk
Iliac crest, linea alba, and Bilaterally: flexion of th trunk and poste
contralateral rectus rior tilt of th pelvis
sheaths Unilaterali)/: lateral flexion and contralat
eral rotation of th trunk.
Ribs 9 -1 2 , linea alba, and Bilaterali)/: as above, plus increases tension
contralateral rectus in th thoracolumbar fascia
sheaths Unilaterali)/: lateral flexion and ipsilateral
rotation of th trunk
Linea alba and contralateral Bilaterali)/: compression of th abdominal
rectus sheaths cavty, plus increases tension in th
thoracolumbar fascia
 326 Section III Axial Skeleton

ments to th thoracolumbar fascia. The transversus abdomi-

nis and th internai oblique muscles share many attach-
ments, including th thoracolumbar fascia.

Actions of th Abdorninal Muscles

Bilateral action of th abdorninal muscles reduces th dis-
tance between th xiphotd process and th pubic symphysis.
Depending on which body segment is more stable, contrac-
tion of th abdorninal muscles can flex th thorax and upper
lumbar spine, posteriorly tilt th pelvis, or both. Figure 1 0 -
16 depicts a diagonally performed sit-up maneuver that
places a relatively large demand on th oblique abdorninal
muscles. During a sagittal piane sit-up, th opposing axial
rotation and lateral flexion tendencies of th various abdomi-
nal muscles are neutralized by opposing righi and left mus
cles.
The axes of rotation for all motions of th vertebral col-
umn are biased posteriorly in th trunk, through th verte
bral bodies. As a consequence, th abdorninal muscles, most
notably th rectus abdominis, possess very favorable leverage
for generating trunk flexion torque (Fig. 1 0 - 1 7 ). Note in
Figure 1 0 17 that, with th exception of th psoas major,
all muscles have a moment arm to produce torques in both
sagittal and frontal planes.
Contracting unilaterally, th abdorninal muscles laterali)-
flex th trunk. The extemal and internai obliques are partic-
ularly effective in this action owing to their relatively favor
able leverage (i.e., long moment arms) (Fig. 1 0 - 1 7 ) and, as
a pair, relatively large cross-sectional area. The combined
cross-sectional area of th extemal and internai obliques at
L4-L5 is almost twice that of th rectus abdominis muscle.,s
Lateral flexion of th trunk often tnvolves both trunk
flexor and extensor muscles. For example, lateral flexion
The transversus abdominis is th deepest of th abdorninal
against resistance to th right demands a contraction from
muscles. lh e muscle is also known as th corset muscle,"
th right extemal and internai oblique, right erector spinae.
reflecting its primary functions of increasing intra-abdominl
and righi transversospinal muscles. Coactivation amplifies
pressure and in stabilizing th lumbar region through attach-
th total frontal torque and simultaneously stabilizes th

Superior view

Linea alba
& FIGURE 10-17. Horizontal cross-sec
Rectus tional view through several muscles
V abdominis <&
4 ? %' K .
of th trunk at th approximate
level of th third lumbar vertebra.
The potemial of muscles to pro
Obliquus externus duce a torque in both sagittal and
abdominis frontal planes is shown. The an-
Obliquus internus terior-posterior (AP) axis of rota
Left lateral

abdominis tion (red) and medial-lateral (ML)

ML axis <n axis of rotation (black) intersect in
Transversus abdominis
th center of th third lumbar ver
Psoas major Quadratus lumborum ?
tebra. Muscles located anterior and
posterior to th medial-lateral axis

iS
have th potential to flex and ex-
tend th trunk, respectively; mus
Latissimus dorsi
Erector ... cles located right and left to th
spinae T llocos,ahs' anterior-posterior axis have th po-
LLongissimus &
lential to laterally flex th trunk to
S S right and left, respectively.

P o s t e r io r

trunk within th sagittal piane. Various muscle actions can
be verified by studying th position of th muscles relative
to th axes of rotation (see Fig. 1 0 -1 7 ).
The internai and external oblique muscles are th most
effective axial rotators of th trunk. Strong axial rotation
potential is due to their relatively large combined cross-
sectional area and favorable leverage (see Fig. 1 0 -4 C , ex-
tended moment arm length of th obliquus externus abdom-
inis). During axial rotation, th external oblique muscle
functions synergistically with th contralateral intentai
oblique muscle (see Fig. 1 0 -1 6 ). As a pair, th external and
internai oblique muscles from opposite sides of th body
produce a diagonal line-of-force that crosses th midiine
through their mutuai attachments into th linea alba. When
contracting together, th two muscles reduce th distance
between one shoulder and th contralateral iliac crest. By
considering each muscle separately, th external oblique
muscle is a contralateral rotator of th trunk, and th inter
nai oblique muscle is an ipsilateral rotator of th trunk.
Although anatomically thought of as two separate muscles,
during active rotation of th trunk th extemal and internai
oblique muscles from opposite sides function as one muscle,
joined in th midiine by th linea alba.
The torque demands placed on th axial rotators of th
trunk vary considerably based on th nature of th given
activity. Torque demands are relatively large during high-
Role of Trunk Extensors as "Rotational Synergists" to
th Oblique Abdominal Muscles
Although th external and internai obliques are consid-
ered th primary axial rotators of th trunk, they rarely
act alone during this activity. Secondary axial rotators
of th trunk include th ipsilateral latissimus dorsi, th
more oblique components of th ipsilateral longissimus
and iliocostalis muscles, and th contralateral transver-
sospinal muscles. In addition to contributing, at least
minimally, to axial rotation torque, th secondary axial
rotators perform th more important function of counter-
acting th trunk flexion potential of th oblique abdomi
nal muscles.39 Axial rotation of th trunk to th left, for
example, requires strong activation from both right and
left transversospinal muscles in th thoracic region.22
Bilateral activation resists th bilateral flexion tendency
of th oblique abdominal muscles.
The multifidi muscles provide extension stability to
th lumbar region during axial rotation.4883 Pathology
involving th apophyseal joints or discs in th lumbar
region may be associated with weakness, fatigue, or
reflexive inhibition of these muscles. Without adequate
activation from th multifidi during axial rotation, th
partially unopposed oblique muscles would, in theory,
create a subtle flexion bias to th base of th spine.
Such a bias may partially explain th rounded (flexed)
posture of th low back typically seen in a person with
spondYlosis or disc disease of th lumbar spine.
Chapter 10 Axial Skeleton: Muscle and Joint Interactions 327
power axial rotations, such as sprinting, wrestling, and
throwing a discus or javelin. The demands are very low,
however, during activities that involve slow twisting of th
trunk in an upright position, such as walking. Because axial
rotation occurs in th horizontal piane, th muscles do not
have to overcome th extemal torque generated by gravity.46
Their primary resistance is that caused by th inertia of th
upper body and th passive tension created by th stretching
antagonist muscles.
Trunk Flexor versus Trunk Extensor Peak Internai Torque
In th healthy adult, th magnitude of maximal effort trunk
flexion torque is typically less than maximal effort trunk
extension torque. Although data vary owing to gender, age,
health, and angular velocity of th testing device, th flexor-
to-extensor ratios determined isometrically are generally be
tween .51 and .77.H-65 Although th trunk flexor muscles
possess greater leverage for sagittal piane torque, th trunk
extensor muscles possess greater mass and, equally impor
tant, greater overall vertical orientation of muscle fibers.2458
The relatively greater torque potential of th back extensor
muscles, at least isometrically, reflects th muscles predomi-
nant role in counteracting gravity, either for th maintenance
of upright posture or for carrying loads in front of th chest.
SET 3: ADDITIONAL MUSCLES (ILI0PS0AS AND
QUADRATUS LUMBORUM)
Although th iliopsoas and quadratus lumborum are not
anatomically considered as muscles of th trunk, they are
strongly associated with th movement of this region.
Iliopsoas
The iliopsoas is a large muscle consisting of two parts: th
iliacus and th psoas major (see Fig. 1 2 - 2 9 ). As are most
hip fexors, th iliopsoas is innervated by th femoral nerve,
a large branch from th lumbar plexus. The iliacus has a
proximal attachment on th iliac fossa and lateral sacrum,
just anterior and superior to th sacroiliac joint. The psoas
major attaches proximally to th transverse processes of th
T I 2 to L5, including th intervertebral discs. The two mus
cles fuse distai to th inguinal ligament and attach as a
single tendon to th lesser trochanter of th femur.
The iliopsoas is a long muscle, exerting a potent kinetic
influence across th lumbar spine, lumbosacral junction, and
hip joint. Crossing anterior to th hip, it is a dominant
flexor, drawing th femur toward th pelvis or th pelvis
toward th femur. In th last movement, th iliopsoas can
anteriorly tilt th pelvis, a motion that increases th lordosis
of th lumbar region (see Fig. 9 -6 8 A ).
Function of th Psoas Major at th Lumbosacral Region
In th anatomie position, th psoas major demonstrates ef
fective leverage for lateral flexion of th lumbar spine.45
Little, if any, leverage exists for axial rotation. The flexor and
extensor capacity of th psoas major differs throughout th
lumbosacral region (Fig. 1 0 - 1 8 ). Across th L5-S1 junction,
th psoas major has an approximate 2-cm moment arm for
flexion.59 The psoas major is, therefore, an effective flexor of
th lower end of th lumbar spine relative to th sacrum.
Progressing superiorly toward L I, th line-of-force of th
psoas major gradually shifts slightly posterior, fal/ing either
through or just posterior to th multiple medial-lateral axes
 328 Section III Axial Skeleton

Contracting unilateraliy, th quadratus lumborum has rel-

atively favorable leverage as a lacerai flexor of th lumbar
region.59 The axial rotation potential of th quadratus lum
borum, however, is minimal.
Clinically, th quadratus lumborum is often called a "hip
hiker when describing its role in walking, especially for
persons with paraplegia at or below th L1 neurologie level.
By elevating (hiking) one side of th pelvis, th quadratus
lumborum raises th lower limb to clear th foot from th
ground during th swing phase of brace-assisted ambulation.

Actions of th Quadratus Lumborum

FIGURE 1 0 -1 8 . A lacerai view of th psoas major highlights its Acting Bilaterally
multiple lines-of-force relative to th medial-lateral axis of rotation 1. Extension of th lumbar region
within th T12-L5 and L5-S1 intervertebral junctions. Note that th 2. Vertical stabilization of th lumbar spine, including th
lines-of-force pass near or through th axes, with th exception of lumbosacral junction
L5-S1. The flexion moment arm of th psoas major at L5-S1 is
shown as th short black line.
Acting Unilaterali)/
1. Lateral flexion of th lumbar region
2. Elevation of one side of th pelvis (hip hiking")

of rotation. This reduces or eliminates its flexor or extensor Both th psoas major and th quadratus lumborum pro
capacity. Psoas major is neither a dominant flexor nor exten vide substantial muscular stability to th lumbar spine. Both
sor of th lumbar region, but rather a dominant vertical muscles run nearly vertical on either side of th lumbar
stabilizer.72 The term vertical stabilizer describes a muscu- vertebrae (see Fig. 1 0 -1 7 ). A strong bilateral contraction of
lar funaion o f stabilizing a region o f th axial skeleton in a both m uscles affords excellent vertical stability throughout
near vertical position while maintaining its naturai physio- th entire base of th spine, including th L5-S1 junction.
logic curve. Because of th lack of effective leverage in th
lumbar region, th psoas major has a minimal role in di-
rectly infiuencing th degree of lordosis.72 The iliopsoas, as Muscles of th Trunk Section II: Functional
most hip flexors, can indirectly increase th lordotic posture Interactions Among Muscles
of th lumbar spine by tilting th pelvis anteriorly.
Section I describes th individuai actions of th muscles of
Through attachments on th lumbar spine, th psoas ma
th trunk. These actions are summarized in Table 1 0 - 9 .
jo r affords excellent control of th sagittal piane positions of
Section II highlights th functional interactions among th
th trunk relative to th thighs, especially when sitting.40
muscles of th trunk during two activities: (1) generating
core stability to th trunk, and (2) controlling th sit-up
movement. The second interaction exemplifies a classic kine-
Actions of th Iliopsoas
siologic relationship between th trunk and hip muscles.
lliacus
1. Predominant hip flexor, both femur-on-pelvis and pelvis-
on-femur
Psoas Major
1. Lateral flexor of th lumbar region Posterior view
2. Flexor of th lower lumbar spine (L5) relative to th
sacrum (S I)
3. Venical stabilizer of th lumbar spine

Quadratus Lumborum
Anatomically, th quadratus lumborum is considered a mus-
cle of th posterior abdominal wall. The muscle attaches
inferiorly to th iliolumbar ligament and iliac crest, and
superiorly to th 12th rib and th tips of th transverse
processes of L l-4 (Fig. 1 0 -1 9 ). The relative thickness of th
muscle is evident by viewing Figure 1 0 - 1 7 . The quadratus
lumborum is innervated by th ventral rami of spinai nerves
T i2-L3.
Contracting bilaterali)/, th quadratus lumborum is an ex
FIGURE 10 19. A posterior view of th quadratus lumborum mus
tensor of th lumbar region. Its action is based on th line-
cle. (From Luttgens K, Hamilton N: Kinesiology: Scientifc Basis of
of-force passing about 3.5 cm posterior to th medial-lateral Human Motion, 9th ed. Madison, W l, Brown and Benchmark,
axis of rotation at L3.i9 1997. The McGraw-Hill Companies.)
 Chapter 10 Axial Skeleton: Muscle and Joint Interactions 329

TABLE 1 0 - 9 . Actions of Most Muscles of th Trunk

Muscle Flexion Extension Lateral Flexion Axial Rotation*

Trapezius XX XX XX (CL)
Spinalis muscles (as a group) XX X _
Longissimus thoracis _ XXX XX
Longissimus cervicis XXX XX XX (IL)
Longissimus capitis XXX XX XX (IL)
Iliocostalis lumborum _ XXX XXX X (IL)
Iliocostalis thoracis XXX XXX
Iliocostalis cervicis XXX XXX XX (IL)
Semispinalis thoracis _ XXX X X (CL)
Semispinalis cervicis XXX X X (CL)
Semispinalis capitis XXX X
Multifidi _ XXX X XX (CL)
Rotatores XX X XX (CL)
Interspinalis muscles _ XX
lntertransversarus muscles X XX

Rectus abdominis XXX XX

Obliquus extemus abdominis XXX XXX XXX (CL)
Obliquus intemus abdominis XXX XXX XXX (IL)
Transversus abdominist

Psoas major X X XX
Quadratus lumborum XX XX _

* CL = contralateral rotation, IL = ipsilateral rotation.

i Acts primarily to increase intra-abdomina! pressure and, via attachments to ihe thoracoiumbar fascia, to siabilize th lumbar region.
Unless otherwise stated, th actions describe movement of th muscles superior or lateral aspect relative to its fixed inferior or mediai aspect. The actions
are assumed to occur from th anatomie position, against an extemal resistance. A muscles relative potential to move or stabilize a region is assigned X,
minimal, XX, moderate, and XXX, maximum, based on moment arm (leverage), cross-sectional area, and fiber direction; indicates no effective muscular
action.

for th same movement, persons with low-back pain history

Functional Interactions Antong th Muscles of th Trunk
1. Providing core stability to th trunk
2. Controlling th traditional sit-up movement
PROVIDING CORE STABILITY TO THE TRUNK
Active muscle force provides th primary form of stability to
th vertebral column. Although ligaments and other connec-
tive tissues provide a secondary source of stability, only
muscles can adjust both th magnitude and timing of their
forces.
Muscles of th trunk provide core stability to th trunk
and, therefore, to th body as a whole. Stability allows th
trunk to hold a static posture even under th influence of
destabilizing extemal torques. The wave of muscular activa-
tion throughout th trunk muscles is experienced when at-
tempting to stand or sit upright in an accelerating bus or
train.
Core stability of th trunk establishes a base for muscles
to move th limbs. During shoulder flexion, for instance, th
transversus abdominis muscle is shown to become active
38.9 msec before th anterior deltoid muscle.36 Interestingly,
have a threefold delay in th onset of EMG activity in th
transversus abdominis. Whether th delay in muscle activa-
tion is associated with th actual cause of th back pain is
an intriguing question.
Muscular stabilizers of th trunk can be partitioned into
two sets based primarily on anatomie organization: intrinsic
and extrinsic. Intrinsic muscular stabilizers include th rela-
tively short and segmented muscles that attach primarily
within th region of th vertebral column. These muscles are
involved with fine tuning of th stability within th multiple
segments of th vertebral column. Extrinsic muscular stabiliz
ers, in contrast, include relatively long muscles that attach,
either partially or totally, to structures outside th region of
th vertebral column, such as th cranium, pelvis, ribs, and
lower extremities. These muscles contribute generai stability
to th trunk and provide a semiri gid link between th verte
bral column and th lower extremities.
Intrinsic Muscular Stabilizers of th Trunk
The intrinsic muscular stabilizers of th tmnk include th
transversospinal and short segmentai groups of muscles.
Most of these muscles are organized in a relatively seg
mented fashion, Crossing a few intervertebral junctions. The
varying lines-of-force of th intrinsic muscular stabilizers
 330 Section III Axial Skeleton

A) Intrinsic muscular B) Spatial orientation out such control, th vertebral column is vulnerable to exag-
stabilizers (a) of musclc's gerated spinai curvature and instability.
line-of-force
Percent of force
directed: In trin sic Muscular Stabilizers of th Trunk Include
Horizontal (FH) 1. Transversospinal group
Vertical (Fv) Semispinalis muscles
a = 0 Multifidi
Fh = 0% Rotatores
Fv = 100% 2. Short segmentai group
Interspinalis muscles
Intertransversarus muscles

Semspnais cervicis a =15 Extrinsic Muscular Stabilizers of th Trunk

(crosses 6 -8 segments) Fh = 26%
Fv = 96%
The extrinsic muscular stabilizers of th trunk include th
abdominal muscles, th erector spinae, th quadratus lum-
borum, th psoas major, and th hip muscles that conneci

Multifidus a = 20
(crosses 2 -4 segments) Fh = 34%
Fy = 94%

Rotator longus a = 45
(crosses 2 segments) Fh = 71 % Obliquus externus
Fy= 71%

Rotator brevis a -80

(crosses 1 segment) Fh = 98%
Fv = 17% Erector spinae

Quadratus lumborurr
Transversus abdominis

FIGURE 10-20. Diagrammane representation of th spatial orienta- Rectus abdominis

tion of th lines-of-force of th intrinsic muscular stabilizers. A, The Psoas
lines-of-force of muscles are shown within th frontal piane. The Giuteus maximus
number of intervertebral junctions that eaeh muscle crosses is noted
in th parenthesis. B, The spatial orientation of th lines-of-force of
each muscle is indicated by th angle (a) formed relative to th
vertical position. The percentage of muscle force directed vertically
is equal lo th cosine of a; th percentage of muscle force directed Hamstrings

horizontally is equal to th sine of a Assuming adequate leverage,

th vertically directed muscle forces produce extension and lateral
flexion and th more horizontally directed muscle forces produce
axial rotation.

(Fig. 1 0 -2 0 A ) allow them to exert fine control of core sta-

bility in all planes. As indicated in Figure 1 0 -2 0 B , th
spatial orientation of each muscles line-of-force (a ) produces
a unique stabilization effect on th vertebral column. Verti-
cally running interspinalis and intertransversarus muscles
produce 100% of their force in th vertical direction (Fv). In
contrast, th near horizontally oriented rotator brevis muscle
produces dose to 100% of its force in th horizontal direc FIGURE 10-21. A typical activation pattern is shown of a sample of
external muscular stabilizers. The healthy person activates muscles
tion (Fh). All of th remaining muscles produce forces that
to stabilize th body against an external force. The activation pro-
are directed diagonally. Muscle forces directed across th
vides core stability to th trunk and th lumbosacral regions and
entire spectrum of th frontal piane optimize th triplanar increases th rigidity between th trunk, lower extremities, and
control of core stability within th vertebral column. With- floor.
 Chapter 10 Axial Skeleton: Muscle and Joint lnteractions 331

th pelvis with th lower extremities. External siabilizers
provide core stabilily lo ihe trunk by regulating rigidity
within th trunk, and between th trunk and lower extremi
ties. Core stability is particularly important in th lumbar
and lumbosacral regions, where external forces applied
against th upper body can develop substantial destabilizing
leverage against th more caudal or inferior regions of th
axial skeleton. Instability at th base of th spine can lead to
postural malalignment throughout th entire vertebral col-
umn, as well as predispose a person to impairments related
to (1) spondylolisthesis or spondylosis, (2) abnormal lordo-
sis, and (3) damaging forces on th apophyseal, interbody,
and sacroiliac joints.
Primary Extrinsic Muscular Stabilizers of th Trunk
Include
1. Muscles of th anterior-lateral trunk
Abdominals
rectus abdominis
obliquus extemus abdominis
obliquus intemus abdominis
transversus abdominis
2. Erector spinae
3. Quadratus lumborum
4. Psoas major
5. Muscles that connect th pelvis with th lower extrem-
ity th hip muscles.
Figure 1 0 - 2 1 shows a person activating his external mus
cular stabilizers in response to an external force. Note th
concentration of muscular activity in th lower region of th
spine. (Although th intrinsic muscular stabilizers are also
active for th purposes described, they are omitted from th
illustration for clarity.) Activation of th psoas major, quad
ratus lumborum, and erector spinae muscles provides sub
stantial vertical stability to th lumbar and lumbosacral
regions, in both th frontal and sagittal planes. Co-contrac-
tion of th abdominal muscles in particular th transversus
abdominis reinforces th stability of th lumbar region by
increasing th tension within th thoracolumbar fascia,
thereby creating a corset effect across th low back.
Activation of th abdominal muscles is essential to stabili-
zation of th pelvis against th pul of trunk extensor mus
cles, especially th erector spinae, quadratus lumborum, and
hip muscles (see Fig. 1 0 - 2 1 ). With th pelvis well stabi-
lized, forces that have an impact on th trunk are effectively
transferred across th sacroiliac joints, through th hips, and
ultimately through th lower extremities. Strengthening exer-
cises, designed to increase th stability of th low back and
lower trunk regions, ideally include those that challenge
both th trunk and th hip muscles in all planes.
CONTROLLINO THE SIT-UP MOVEMENT
The muscles of th trunk interact with each other and with
th muscles of th hip joint during many activities. Con-
sider, for instance, th combined movements of th trunk
and hips while swinging a baseball bat, figure skating, or
shoveling snow. To underscore this important synergistic
relationship, th following discussions focus on th muscular
actions of th sit-up movement.
Several strategies are used to strengthen th abdominal
muscles. The common goal of th exercises is to increase th
strength and control of these muscles, often as a way to
improve core stability within th trunk. In a very broad
sense, abdominal exercises fall into one of four categories. In
column 1 of Figure 1 0 - 2 2 , th abdominal muscles produce
an isometric force to maintain a Constant distance between
th xiphoid process and th anterior pelvis. In columns 2 to

#1 Isometrics i t i Rotating (he Trunk #3 Rotating th Trunk #4 Rotating th

Toward (he Stationary and Pelvis Toward (he Pelvis (and/or Legs)
Pelvis Stationary Legs Toward th
Stationary Trunk

Exam ples: Exam ples: Exam ples: Exam ples:

1- Balancing th trunk 1 - Partial sit-ups 1 - Standard full sit-up.* 1- Posterior pelvic tilt
upright while seated on (crunches).* 2- A s above, but incorporate while lying supine.
a very large ball. 2- A s above, but incorporate diagonal piane movement 2- Antigravity or
2- Holding a rigid trunk diagonal piane m ovem ents of th trunk and pelvis. otherwlse resisted hip
and low back while of th trunk. flexion.*
m aintaining a military- 3- Lateral trunk curls. 3- Straight leg raises.
style push-up. 4- A s above, but
3- Keeping th trunk and incorporate diagonal
low b a c k rigid w hile p ia n e m o v e m e n ts of
m aintaining all-fours th leg s.
position, then progress
to raising one arm and
th contralateral leg.

3 ^
FIGURE 10-22. Categones of abdominal strengthening exercises, with selected examples. The examples marked by th
asterisk are pictured below.
 332 Seniori III Axial Skeleton

4, th abdominal muscles contract to reduce th distance (Fig. 1 0 -2 3 B ). As depicted in Figure 1 0 -2 3 A , th trunk

between th xiphoid process and th anterior pelvis. Of
these examples, perhaps th most well-recognized exercise is
th standard sit-up, depicted in column 3.
A sit-up performed in a hook-lying position (i.e., hips
and knees are flexed) is divided into two phases. The early
trunk flexion phase terminates when both scapulae are
raised off th mat (Fig. 10-23A ). The later hip flexion phase
involves 70 to 90 degrees of pelvic-on-femoral hip flexion
flexion phase is driven primarily by contraction of th ab
dominal muscles, especially th rectus abdominis.2 The up
per and lower parts of th rectus abdominis respond with
equal intensity during this motion.47 The latissimus dorsi,
passing anterior to th upper thoracic spine, may assist in
flexing this region; th stemal head of th pectoralis major
may assist in advancing th upper extremities and head
toward th pelvis.

Obliquus externus Obliquus internus Transversus

abdominis abdominis abdominis

FIGURE 10 23. A typical activation pattern is shown of a sample of muscles, as a healthy person performs a traditional sit-up maneuver. The
intensity of th red color is related to th assumed intensity of th muscle activation. A, The trunk flexion phase of th sit-up involves strong
activation of th abdominal muscles, especially th rectus abdominis. B, The hip flexion phase of th sit-up involves strong activation of th
abdominal and hip flexor muscles. Note in B th farge pelvic-on-femoral kinematic contribution to die sit-up maneuver.
 Chapter 10 Axial Skeleton: Muscle and Joint Interactions 333

During th trunk jlexon phase of th full sit-up, th thora-
columbar spine flexes, and th pelvis is tilted posteriorly,
flattening th lumbar spine. The EMG level of th hip flexor
muscles is relatively low, regardless of th position of th
hips and knees.2 Partially flexing th hips prior to th exer-
cise increases th passive tension in th gluteus maximus,
assisting with th posteriov tilting posture of th pelvis.
During th hip jlexon phase of th sit-up, th pelvis and
trunk rotate toward th femurs. The hip flexion phase is
driven by active contraction of th hip flexor muscles. Al-
though any hip flexor muscle can assist with this action,
Figure 10-2315 shows th iliacus and rectus femoris as th
active participants. Relative levels of EMG from th iliacus,
sartorius, and rectus femoris are signifcantly greater when
th legs are held fixed to th supporting surface.2 The axis of
rotation during th hip flexion phase of th full sit-up shifts
toward th hip joints. The abdominal muscles remain iso-
metrically active, holding th flexed thoracolumbar region
against th rotating pelvis.
The full sit-up places different mechanical workloads on
th abdominal muscles as compared with th hip flexor
muscles. (Work, in this context, is th product of muscle
force times th distance il contracts.) In th trunk flexion
phase of th sit-up, th abdominal muscles produce work by
rotating th trunk toward th pelvis; in th hip flexion
phase, th hip flexor muscles produce work by contracting
and rotating th pelvis and trunk toward th femurs.
Persons with moderately weakened abdominal muscles
typically display a characteristic posture when attempting to
perform a full sit-up. Throughout th attempt, th hip flexor
muscles dominate th activity. As a result, there is minimal
thoracolumbar flexion and excessive and early pelvic-on-
femoral (hip) flexion. The dominating contraction of th hip
flexor muscles exaggerates th lumbar lordosis, especially
during th initiation of th maneuver.42
Muscles of th Craniocervical Region
Section I: Anatomy and Individuai Muscle
Action
The following sections describe th anatomy and individuai
actions of th muscles that act exclusively within th cranio
cervical region. Musculature is di vi ded into two sets: th
muscles of th anterior-lateral region and th muscles of th
posterior region (see Table 1 0 - 2 ).
Figure 1024 depicts many of th muscles of craniocervi
cal region as flexors or extensors, or tight or left lateral
flexors, depending on their attachment relative to th axes of
rotation through th atlanto-occipital joints. Although Figure
1 0 - 2 4 describes th muscle actions at th atlanto-occipital
joint only, th relative position of th muscles provides a
useful guide for an understanding of th actions at other
joints within th craniocervical region.

Inferior view
Posterior

Extensor and left Extensor and right

Trapeline
lateral flexor lateral flexor

Semispinalis

Splenius capitis
Sternocleiomastoid
Longissimus capitis

Digastric (posterior belly)

(O
i co'
a> ML axis
tu
IC Obliquus capitis superior co
CU t
Q>
Rectus capitis posterior
Rectus capitis posterior minor
Rectus capitis lateralis
Stylohyoid
Rectus capitis anterior
Longus capitis
Flexor and left Flexor and right
lateral flexor lateral flexor

Anterior
FIGURE 10-24. The potential action of muscles that attach to th inferior surface of th occipital and temperai bones is highlighted. The
actions of th muscles across th atlanto-occipital joints are based on their location relative to th medial-lateral (ML) (black) and
anterior-posterior (red) axis of rotation at th level of th occipital condyles. Note that th actions of most muscles fu into one o( four
quadrants.
334 Section III Axial Skeleton

Sternohyoid Anterior juguiar vein

Sternothyroid
Middle (visceral) fascia
Omohyoid
Thyroid gland
Platysma
Trachea
Sternocleidomastoid
Esophagus
Longus colli
Internai juguiar vein
Scalenus anterior
External juguiar vein
Scalenus medius FIGURE 10-25. A horizontal cross-
and posterior Carotid artery sectional view through th neck at
Carotid sheath
th level of th sixth cervical verte
Longissimus capitis
bra. Note th three components of
Longissimus cervicis Brachial plexus th cervical fascia.
Vertebral artery
Multifidus and
rotator longus and brevis
Deep (prevertebral)
Semispinalis cervicis fascia
Semispinalis capitis Superficial (investing)
Splenius capitis and cervicis fascia
Trapezius

Superior view

CERVICAL FASCIA ponents: superficial (investing), middle (visceral), and deep

Cervical fascia surrounds and compartmentalizes many struc- (prevertebral) (Fig. 1 0 - 2 5 ) and (Table 1 0 - 1 0 ). These com
tures within th neck, including muscles and neurovascular ponents exclude th subcutaneous fascia that is imbedded
structures. The cervical fascia is subdivided into three com- within th platysma muscle. Important functions of th cer
vical fascia are to protect muscle, to provide structural sup-
port and protection to th cervical viscera and important
TABLE 1 0 - 1 0 . Components of th Cervical Fascia neurovascular structures, and to help transfer forces between
muscles.
Superficial (Investing) Covers th entire neck region. Tissue
Fascia also surrounds and interconnects
th trapezius and th stemocleido- SET 1: MUSCLES 0F THE ANTERIOR-LATERAL
mastoid muscles. CRANIOCERVICAL REGION
Superficial fascia anaches or is con-
tinuous with many structures in The muscles of th anterior-lateral craniocervical region are
th area: listed in Table 1 0 - 1 1 . With th exception of th sternoclei-
Superioriy domastoid, which is innervated primarily by th spinai ac-
Hyoid bone and surrounding cessory nerve, th other muscles in th group are innervated
muscular fascia by small unnamed nerves that branch from th cervical
Mandible plexus.
Mastoid process
Superior nuchal line Sternocleidomastoid
Temporalis muscle
Inferiori}' The sternocleidomastoid is a ver} prominent muscle located
Pectoral and deltoid fascia superficially on th anterior aspect of th neck (Fig. 1 0 - 2 6 )
Acromion Inferiorly, th muscle attaches by two heads: th mediai
Clavicle (stemal) and lateral (clavicular) (Fig. 1 0 - 2 7 ). From this at-
Manubrium
Posterioriy
Ligamentum nuchae
Spinous processes of cervical TABLE 1 0 - 1 1 . Muscles of th Anterior-Lateral
vertebrae Craniocervical Region
Middle (Visceral) Surrounds and protects th cervical
Fascia viscera: trachea, esophagus, and Sternocleidomastoid
thyroid gland Scalenes
Scalenus anterior
Deep (Prevertebral) Surrounds th large set of muscles Scalenus medius
Fascia of th craniocervical region lo- Scalenus posterior
cated posterior to th cervical vis Longus colli
cera and antenor to th trapezius. Longus capitis
The fascia is continuous with th Rectus capitis anterior
thoracolumbar fascia. Rectus capitis lateralis

FIGURE 1 0 -2 6 .The lefi stemocleidomasioid muscle durng active
rotation of th head and neck to th righi. The muscle is evident as
a thick cord between th left mastoid process, just inferior to th
ear, and th left stemoclavicular joint. Both stemal and clavicular
heads of th muscle are visible.
tachment, th muscle ascends obliquely across th neck to
attach along a thin line, extending across much of th mas
toid process of th temporal bone and th lateral half of th
superior nuchae line.
Acting unilaterally, th stemocleidomastoid is a lateral
flexor and contralateral axial rotator of th craniocervical
region. The axial rotation action is demonstrated in Figure
1 0 - 2 6 . Bilaterally, th sagittal piane action of th stemoclei
domastoid depends on th level of th craniocervical region.
An anterior view of th stemocleidomastoid mus-
FIGURE 1 0 -2 7 .
cles. (From Luttgens K, Hamilton N: Kinesiology: Scientific Basis of
Human Motion, 9th ed. Madison, WI, Brown and Benchmark,
1997. The McGraw-Hill Compames.)
Chapter 10 Axial Skeleton: Muscle and Joint Interactions 335
From a lateral view of a person with normal posture, it can
be seen that th stemocleidomastoid crosses th neck in an
oblique fashion. Below approximately th C3 region, th
stemocleidomastoid crosses anterior to th medial-lateral
axes of rotation; above C3, however, th stemocleidomastoid
crosses posterior to th medial-lateral axes of rotation. Acting
together, th stemocleidomastoids have th potential to Jlex
th mid to lower cervical spine and to extend th upper
cervical spine and th atlanto-axial and atlanto-occipital
joints. This muscular action varies depending on th initial
posture of th craniocervical region.
Torticollis
Torticollis (from th Latin tortus, twisted; collum, neck)
or "wryneck" describes a condition of chronic contrac-
tion of at least one of th cervical muscles, most com-
monly th stemocleidomastoid. The condition may be
congenital or acquired. Shortening of th muscle may
be due to a fibrous mass or may indicate neuromuscu-
lar disease. Often th cause of torticollis is unknown.
A person with unilateral torticollis involving a right or
left stemocleidomastoid typically has an asymmetrical
craniocervical posture that reflects components of th
muscle's action (Fig. 10-28). Parents of a child with
torticollis are often taught how to stretch th tight mus
cle and how to position and handle th child to pro
mote elongation of th involved muscle. In severe cases
of contracture, th muscle may be surgically released,
most commonly at th sternal and clavicular heads.85
Postsurgical treatment typically involves physical ther-
apy to maintain th overcorrected position of th neck
and reduce scar formation.
Congenital torticollis affects th right stemo
FIGURE 1 0 -2 8 .
cleidomastoid of a 10-year-otd boy. (From Tachdjian MO: Pe
diatrie Orthopedics. Philadelphia, WB Saunders, 1972.)
 336 Section III Axial Skeleton

A nterior view th responsibility of smaller more specialized muscles, such

as th rectus capitis anterior and th suboccipital muscles.

Longus Colli and Longus Capitis

FIGURE 1 0 -2 9 . An anterior view of th scalene muscles. The sca-
lenus posterior and anterior are shown on th right; th scalenus
medius is shown on th left. (From Luttgens K, Hamilton N:
Kinesiology: Scientifie Basis of Human Motion, 9th ed. Madison
W I, Brown and Benchmark, 1997. The McGraw-Hill Companies.)
The longus colli and longus capitis are located deep to th
cervical viscera (trachea and esophagus), on either side of
th cervical column (Fig. 1 0 -3 0 ). These muscles function as
dynamic anterior longitudinal ligaments, providing an impor-
tant element of vertical stability to th region.
The longus colli consists o f m ultiple fascicles that closely
adhere to th anterior surfaces of th upper three thoracic
and all cervical vertebrae. The muscle ascends th cervical
region through multiple attachments between th vertebral
bodies, anterior tubercles o f transverse processes, and ante
rior arch of th atlas. The longus colli is th only muscle
that attaches in its entirety to th anterior surface of th
vertebral column. Compared with th scalene and stemoclei-
domastoid muscles, th longus colli is a relarively thin m us
cle (see Fig. 1 0 - 2 5 ). The m ore anterior fibers o f th longus
colli flex th cervical region. The more lateral fibers act in
conjunction with th scalene muscles to vertically stabilize
th region.
The longus capitis arises from th anterior tubercles of th
transverse processes of th mid to lower cervical vertebrae
and inserts into th basilar part of th occipital bone (see
Fig. 1 0 - 2 4 ). The primary action of th longus capitis is to
llex and stabilize th upper craniocervical region. Lateral
flexion is a secondary action.

Rectus Capitis Anterior and Rectus Capitis Lateralis

Scalenes The rectus capitis anterior and rectus capitis lateralis are two
short muscles that arise on th elongated transverse pro
As a group, th scalene muscles attach between th tubercles
cesses of th atlas (C l) and insert on th inferior surface o
of th transverse processes of th middle to lower cervical
occipital bone (see Fig. 1 0 - 3 0 ). The rectus capitis laterale
vertebrae and th first two ribs (Fig. 1 0 -2 9 ). The specific
attachments of these muscles are lisied in Appendix 111 (Pari
B, Set 1). The brachial plexus courses between th scalene
anterior and scalene medius (see Fig. 1 0 -2 5 ). Excessive hy-
pertrophy or spasm of these muscles or their associated Anterior view
lascia can compress th brachial plexus and can cause motor
and sensory disturbances in th upper extremity.
The function of th scalene muscles depends on whtch
skeletal attachments are more fxed. Assuming that th cervi
cal spine is well stabilized, th scalene muscles raise th ribs
to assist with inspiration during breathing; assuming that th
scalene muscles are contracting from a fxed inferior base
afforded by th first two ribs, their potential actions become
evident by using a skeleton and string io mimic th line-of-
force. Contracting unilaterally, th scalene muscles laterally
flex th cervical spine. Axial rotation is limited in th sca
lenus medius and posterior due to th muscles' nearly verti-
cal orientation. The more oblique scalenus anterior, however,
has a potential for contralateral axial rotation of th cervical
spine.
Contracting bilaterally, th scalenus anterior and medius
bave a limited moment arm to flex th cervical spine, partic-
ularly in th lower regions. The cervical attachments of all
three scalene muscles split into several individuai fasciculi FIGURE 1 0 -3 0 . An antenor view of th deep muscles in th neck
(see Fig. 1 0 -2 9 ). Like a System of guy wires that stabilize a The iollowing muscles are shown: right longus capitis, righi rectus
capitis anterior, right rectus capitis lateralis, and left longus colli.
large antenna, th scalene muscles provide excellent bilateral
(From Luttgens K, Hamilton N: Kinesiology: Scientifie Basis of Hu
and vertical stability to th middle and lower cervical spine.
man Motion, 9th ed. Madison, W I, Brown and Benchmark, 1997.
Fine control of th upper craniocervical region is more likely The McGraw-Hill Companies.)

S P E C I A L F O C U S 1 0 - 5
M
Vulnerability of th Longus Colli and Longus Capitis to
Acceleration Injury
The cervical spine is vulnerable to acceleration (whip-
lash) injury, especially as a result of an automobile
accident. Vulnerability is due, in part, to th large mass
moment of inertia of th relatively heavy head. An im
pact that creates a large angular velocity of th head
generates a proportionally large angular momentum
throughout th entire craniocervical region. If directed
in th sagittal piane, th momentum of th flexing or
extending head can damage tissues that are exces-
sively strained or compressed. Momentum directed in
th frontal piane can create lateral flexion whiplash,
which also damages tissue.
Whiplash associated with cervical hyperextension
generally creates greater strain on muscles and soft
tissues than does whiplash associated with cervical
flexion.68 The greater range of hyperextension can se-
verely strain th flexor muscles and cervical viscera,
and it can excessively compress th apophyseal joints
and posterior aspects of th cervical spine (Fig. 10-
31/4). The maximum extent of flexion is partially blocked
by th chin striking th chest (Fig. 10-316).
Research on replicas of th human head, neck, and
FIGURE 10-31. During acceleration (whiplash) injuries, cervical extension (A) typically exceeds cervical flexion
(B). As a result, th anterior structures of th cervical region are more vulnerable to strain injury. (From
Porterfield JA, DeRosa C: Mechanical Neck Pain: Perspectives in Functional Anatomy. Philadelphia, WB Saunders,
1995.)
attaches laterally to th occipital condyle; th rectus capitis
anterior, th smaller of th recti, attaches immediately ante-
rior to th occipital condyle (see Fig. 1 0 -2 4 ).
The actions of th rectus capitis anterior and lateralis
muscles are limited to th atlanto-occipital joint, where each
muscle Controls one of th joints two degrees of freedom
(see Chapter 9). The rectus capitis anterior is primarily a
flexor, and th rectus capitis lateralis is primarily a lateral
(lexor.
Chapter 10 Axial Skeleton: Muscle and Joint lnteracdons 337
torso has shown that th longus colli and longus
capitis are particularly vulnerable to strain injury from
hyperextension-associated whiplash. Whiplash from ex-
cessive hyperextension produced a 56% strain (elonga-
tion) in th longus colli, and whiplash from excessive
lateral flexion produced a 57% strain in th longus capi
tis.18 Both these levels of strain can cause tissue dam
age.
Clinically, a person with a hyperextension injury often
shows marked tenderness and protective spasm in th
region of th longus colli. Tenderness may also be as
sociated with excessive strain in other flexor muscles,
such as th sternocleidomastoid and scalenus anterior,
and th cervical viscera. Spasm in th longus colli
tends to produce a straight cervical spine, lacking th
normal lordosis. Persons with a strained and painful
longus colli often have difficulty shrugging their shoul-
ders. Without th adequate stabilization provided by th
longus colli and other flexors, th upper trapezius mus
cle loses stable cranial attachment and, therefore, be-
comes an ineffective elevator of th shoulder girdle.68
This clinical scenario is an excellent example of th
interdependence of muscle function, in which one mus-
cle's action depends on th stabilization force of an-
other.
SET 2: MUSCLES OF THE POSTERIOR
CRANIOCERVICAL REGION
The muscles of th posterior craniocervical region are listed
in Table 1 0 - 1 2 . They are innervated by dorsi rami of cervi
cal spinai nerves.
Splenius Cervicis and Capitis
The splenius cervicis and capitis muscles are a long and thin
pair o f m uscles, n am ed by their resem blan ce to a bandage
 338 Section III Axial Skeleton
TABLE 1 0 - 1 2 . Muscles of th Posterior
Craniocervical Region
Splenius muscles
Splenius cervicis
Splenius capitis
Suboccipital muscles
Rectus capitis posterior major
Rectus capitis posterior minor
Obliquus capitis superior
Obliquus capitis inferior
(from th Greek splenion, bandage) (Fig. 1 0 - 3 2 ). As a pair,
th splenius muscles arise from th inferior half of th liga-
m em u m n u chae and spin ou s p ro cesses o f C7-T6, ju st d eep
to th trapezius muscle. The splenius capitis attaches cranially
just deep to th sternocleidomastoid, along a thin line that
extends across th mastoid process and th lateral one third
of th superior nuchae line (see Fig. 1 0 - 2 4 ). The splenius
cervicis attaches to th posterior tubercles of th transverse
processes of C l-3 . Much of this cervical attachment is
shared by th levator scapula muscle.
Contracting unilaterally, th splenius muscles perform lat
eral flexion and ipsilateral axial rotation of th head and
cervical spine. Contracting bilaterally, th splenius muscles
extend th upper craniocervical region.
Suboccipital Muscles
The suboccipital muscles consist of four paired muscles lo-
cated very deep in th neck, immediately superficial to th
FIGURE 10-32. A posterior view of th left splenius cervicis, right
splenius capitis, and right levator scapula. Although not visible, th
levator scapula has similar cervical attachments as th splenius cer
vicis. (From I.uttgens K, Hamilton N: Kinesiology: Scientific Basis of
llum an Moilon, 9ih ed. Madison, \V1, Brown and Benchmark
1997. The McGraw-Hill Companies.)
atlanto-occipital and atlanto-axial joints (Fig. 1 0 - 3 3 ). These
relatively short, thick muscles attach between th atlas, axis,
and occipital bone. Their specific muscular attachments are
listed in Appendix III (Part B, Set II). The suboccipital mus
cles are not easily palpable. They lie deep to th upper
trapezius, splenius group, and semispinalis capitis muscles
(see Fig. 1 0 -2 4 ).
The primary function of th suboccipital muscles is to
provide fine control of movement at th atlanto-occipital and
atlanto-axial joints. In conjuncton with th rectus capitis
anteri or and lateralis, these specialized join ts increase th
number of movements possible within th upper craniocervi
cal region to orient th eyes, ears, and nose. As indicated in
Figure 1 0 - 3 4 , no two muscles have identical actions at both
joints.
M u scles o f th Craniocervical Region
Section II: Functional Interactions
Among Muscles that Cross th
Craniocervical Region
Nearly 30 muscles cross th craniocervical region. They in
clude th muscles that act exclusively within th craniocervi
cal region (Table 1 0 - 1 3 ), plus those classified as muscles of
th posterior trunk that cross th craniocervical region (e.g..
trapezius and longissimus capitis).
This section highlights th functional interactions among
th muscles that cross th craniocervical regions during two
activities: (1) stabilizing th craniocervical region and (2)
producing th movements of th head and neck that opti-
mize th function of visual, auditory, and olfactory systems.
Although other functional interactions exist for these mus
cles, th two activities provide a format for describmg key
kinesiologic principles involved in this important region of
th body.
Functional Interactions Among Muscles that Cross th
Craniocervical Region
1. Stabilization of th head and neck
2. Production of th movements of th head and neck that
optimize Vision and hearing
Posterior view
Obliquus Rectus capitis
capitis superior posterior minor
Obliquus
Rectus capitis
capitis inferior
posterior major
FIGURE 10-33. A posterior view of th suboccipital muscles. The
left obliquus capitis superior, left obliquus capitis inferior, left rec
tus capitis posterior minor, and right rectus capitis posterior major
are shown. (From Luttgens K, Hamilton N: Kinesiology: Scientific
Basis of Human Motion, 9th ed. Madison, WI, Brown and Bench
mark, 1997. The McGraw-Hill Companies.)
 Chapter 10 Axial Skeleton: Muscle and Joint Interactions 339

S P E C I A L F O C U S 1 0 - 6
P
Specialized Muscles that Control th Atlanto-Axial and b e t w e e n r ig h t a x ia l r o t a t io n a n d r ig h t la t e r a l f le x io n ( s e e
Atlanto-Occipital Joints: An Example of Fine-Tuning of F ig . 9 - 5 2 6 ) . In o r d e r t o m a in t a in a le v e l h o r iz o n t a l v i
th Cervical Coupling Pattern s u a l g a z e t h r o u g h o u t a x ia l r o t a t io n , t h le ft r e c t u s c a p i-
t is la t e r a lis , f o r in s t a n c e , p r o d u c e s a s lig h t le f t la t e r a l
T h e s p e c ia liz e d m u s c le s t h a t c o n t r o l t h a t la n t o - a x ia l
flexion to rq u e to th head v ia t h a t la n t o - o c c ip it a l
a n d a t la n t o - o c c ip it a l j o in t s e x e r t f in e c o n t r o l o v e r t h
jo in t s . T h is m u s c u la r a c t io n o f f s e t s t h t e n d e n c y f o r t h
m o v e m e n t o f t h u p p e r c r a n i o c e r v i c a l r e g io n . O n e b e n
h e a d t o b e n d t o t h r ig h t w it h t h r e s t o f t h c e r v i c a l
e f it o f t h is f in e le v e l o f c o n t r o l is r e la t e d t o t h c o u p lin g
r e g io n d u r in g t h r ig h t a x ia l r o t a t io n . S im ila r ly , r ig h t
p a t t e r n o f t h c e r v i c a l r e g io n . A s d e s c r ib e d in C h a p t e r
la t e r a l f le x io n o f t h C 2 -7 r e g io n , w h i c h a ls o r e s u lt s in
9, a n i p s ila t e r a l c o u p lin g p a t t e r n e x is t s in t h C 2 -C 7
r ig h t a x ia l r o t a t io n o f t h is c e r v i c a l r e g io n , m a y b e a c -
r e g io n b e t w e e n t h m o t io n s o f a x ia l r o t a t io n a n d la t e r a l
c o m p a n ie d b y a s lig h t , o f f s e t t in g le f t a x ia l r o t a t io n
f le x io n . A x ia l r o t a t io n , d u e p r im a r ily t o t h o r ie n t a t io n o f
t o r q u e t o t h h e a d b y t h le f t o b liq u u s c a p it is in f e r io r
t h a p o p h y s e a l jo in t s , is a s s o c i a t e d w it h s lig h t ip s i l a t
m u s c le . In b o th e x a m p le s , m o v e m e n t o f t h h e a d a n d
e r a l la t e r a l f le x io n a n d v ic e v e r s a . T h e e x p r e s s io n o f
e y e s c a n b e m o r e p r e c i s e l y m a in t a in e d w it h in t h h o r i
t h is c o u p lin g p a t t e r n c a n b e o b s c u r e d , h o w e v e r , b y t h
z o n t a l p ia n e , t h e r e b y f a c ilit a t in g t h v is u a l t r a c k in g o f a
s p e c ia liz e d m u s c le s t h a t c o n t r o l t h a t la n t o - o c c ip it a l a n d
m o v in g o b j e c t w h ile r o t a t in g t h h e a d .
a t la n t o - a x ia l jo in ts . C o n s id e r , f o r e x a m p le , t h c o u p lin g

S T A B IL IZ IN G T H E C R A N I O C E R V IC A L R E G IO N joints, and neural tissues. Resistive exercises are often per-

The muscles that cross th craniocervical region compose
much of th bulk of th neck, especially in th regions
lateral and posterior to th cervical vertebrae (see Fig. 1 0 -
25). When strongly activated, this mass of muscle can pro-
tect th cervical viscera, intervertebral discs, apophyseal
formed by athletes involved in contact sports as a means to
hypertrophy this musculature. Hypertrophy alone, however,
may not necessarily prevent neck injury. Data on th biome-
chanics of whiplash injury, for example, suggest that th
time required to react to an impending injury and generate a
substantial stabilizing force may exceed th time of th

T A B L E 1 0 - 1 3 . Aetions of Muscles Located Exclusively within th Craniocervical Region

Muscle Flexion Extension Lateral Flexion Axial R otation*

Stemocleidomastoid XXX X* XXX XXX (CL)

Scalenus anterior XX XXX X (CL)

Scalenus medius X XXX

Scalenus posterior XX

Longus colli XX XX

Longus capitis XX XX

Rectus capitis anterior XX (AOJ only) X (AOJ only)

Rectus capitis lateralis XX (AOJ only)

Splenius capitis XXX XX XXX (IL)

Splenius cervicis XXX XX XXX (IL)

Rectus capitis posterior major XXX (AOJ and AAJ) XX (AOJ only) XX (IL) (AAJ only)

Rectus capitis posterior minor XX (AOJ only) X (AOJ only)

Obliquus capitis inferior XX (AAJ only) XXX (IL) (AAJ only)

Obliquus capitis superior XXX (AOJ only) XXX (AOJ only)

* Upper parts of stemocleidomastoid extend th upper cervical region, atlanto-axial joint, and atlanto-occipital joint.
A muscles relative potential to move or stabilize a region is scored X, minimal, XX, moderate, and XXX, maximum; indicates no effective muscular
action. AOJ, atlanto-occipital joint; AAJ, atlanto-axial joint; CL, contralateral rotation; IL, ipsilateral rotation.
 340 Section III Axial Skeleton

than th actual weight of th head!66-67 A coordinated inter

action of muscles generates forces that are, on average, di-
Obliquus
capitis rected through th axis of rotation at each intervertebral junc-
superior tion. By passing through these multiple axes, th forces
compress th intervertebral segments together, thereby stabi-
Rectus capitis
lateralis
lizing them without buckling.
The muscular interaction associated with th stabilization
Rectus capitis
of th craniocervical region likely involves th more precise
anterior
control afforded by relatively short, segmented muscles such
Obliquus capitis
as th multifidi, rotatores, and interspinalis muscles. The
interior
stability in th region is augmented by other longer muscles,
Rectus capitis including th scalenes, stemocleidomastoid, levator scapula,
posterior minor semispinalis capitis and cervicis, and trapezius. As a group.
Rectus capitis they form an extensive guy wire System that ensures vertical
posterior major stability, mosi notably in frontal and sagittal planes. Figure
Semispinalis cervicis 1 0 -3 5 A highlights a sample of muscles that act as guy vvires
Posterior view to maintain ideal anterior-posterior alignment throughout th
craniocervical region. Ideally, th co-contraction of flexor

F
L
E
XIO
NE
X
T
EN
SNL
IOA
T
E
F
LR
XA
LF
IO
N A
XIT
A
IL
ATLANT0-0C CIP1TAL J0INT

L
EX
IO
NE
X
T
EN
S
IO
NR
O
T
A O
N
ATLANTO-AXIAL J0INT and extensor muscles counterbalance each other and, as ,
consequence, vertically stabilize th region. Note that th
MUSCLES * muscles depicted in Figure 1 0 -3 5 A are anchored inferiori*-
Rectus capitis
anterior XX - X
to several different structures: th stemum, clavicle, ribs j
- - -
scapula, and vertebral column. These bony structures must
Rectus capitis be stabilized by other muscles, such as th lower trapezius j
lateralis - - XX -
and subclavius muscles for securing th scapula and cavick
Rectus capitis respectively.
posterior major XXX XX XXX XX(IL)

Rectus capitis
posterior minor XX X -
Obliquus capitis
inferior - XX
Obliquus capitis
superior XXX XXX
-
CL = contralateral rotation, IL = ipsilateral rotation
FIGURE 1 0 -3 4 . A posterior view depicts th lines-of-force of mus-
cles that exert exclusive control of th atlanto-occipital and atlanto-
axial joints. The joints each allow two primary degrees of freedom.
Note that th attachment of th semispinalis cervicis muscle pro-
vides a stable base for th rectus capitis posterior major and th
obliquus capitis inferior, two of th larger and more dominant
suboccipital muscles. The chart summarizes th actions of th mus-
cles at th atlanto-occipital and atlanto-axial joints. A muscle's rela
tive potential to perform a movement is assigned one of three
scores: X, minima!; XX, moderate; and XXX, maximum. The
dash indicates no effective torque production.
whiplash event.18 For this reason, aihletes need to anticipate
a potentially harmful situation and contract th neck musco
lature before impact. The timing of muscle contraction ap-
pears as imporiant in protecting th neck as does th magni-
tude of muscle force.
In addition to protecting th neck, forces produced by
muscles provide th primary source of vertical stability to
th craniocervical region. The criticai load of th cervical
spine (i.e., maximum compressive load that th neck, un-
supported by muscle, can sustain before buckling) is be-
tween 10.5 and 40 N (between ~ 2 .4 and 9 Ib). This is less
rHUDUCING EXTENSIVE AND WELL-COORDINATED
MOVEMENTS OF THE HEAD AND NECK: OPTIMIZING
XXX(IL) THE PLACEMENT OF THE EYES, EARS, AND NOSE
The craniocervical region allows th greatest triplanar mobil-
ity of any region of th axial skeleton. Ampie movement is
essential to optimal spatial orientation of th eyes, ears, arte
nose. Although all planes of motion are important in this
regard, th following section highlights movement within th
horizontal piane.
Figure 1 0 - 3 6 illustrates a total body movement that ex-
hibits a sample of th muscular interactions used to maxi-
mize th extent of axial rotation of th craniocervical region.
Note that lui! axial rotation of th craniocervical region pro-
vides th eyes with at least 180 degrees of visual scanning
As depicted, rotation to th right is driven by simultaneous
activation of th left stemocleidomastoid and scalenus ante-
nor (Fig. 1 0 -3 6 A ); right splenius capitis and cervicis; right
upper erector spinae, such as th longissimus capitis; and
left transversospinal muscles, such as th multifidi (Fig. 1 0 -
36B). Activation of these muscles provides th required rota-
tional power to th head and neck, as well as simultaneously
stabilizing th craniocervical region in bolh th frontal and
sagittal planes. For example, th extension potential provjded
by th splenius capitis and cervicis and th upper erector
spinae is offset by th flexion potential of th sternocleido-
mastoid and scalenus anterior. Furthermore, th left lateral
flexion potential of th left stemocleidomastoid is offset by
th right lateral flexion potential of th right splenius capitus
and cervicis.
Full axial rotation of th craniocervical region requires
muscular interactions that extend into th trunk and lower
extremities. Consider, for example, th activation of th right
and left oblique abdominal muscles (see Fig. 1 0 -3 6 A ). They

FIGURE 10-35. A, Four muscles
acting as guy wires to maintain
an ideal posture within th
craniocervical region. B, Me-
chanics associated with a
chronic forward head posture as
discussed in Special Focus 10-
7. The protracted position of
th craniocervical region places
greater stress on th levator
scapula and semispinalis capitis
muscles. The rectus capitis pos-
terior major one of th sub-
Semispinalis
occipital muscles is shown
actively extending th upper
craniocervical region. The highly Levator scapula
attive and stressed muscles are
depicted in brighter red.
provide much of th torque needed to rotate th base of
th craniocervical region. As shown in Figure 1 0 -3 6 B ,
th erector spinae and transversospinal muscles throughout
th entire posterior trunk are active to offset th potent
trunk flexion tendency of th oblique abdominal muscles.
M u s c u la r Im b a la n c e A s s o c ia te d with Chronic Forward
Head Posture
The ideal posture shown in Figure 1035/4 depicts an
optim ally balanced craniocervical guy w ire System. Ex-
cessive muscular tension in any of th muscles, how-
ever, can disrupt th vertical stability of th region. One
such disruption is a chronic forw ard head posture, in-
volv/ng excessive protraction of th craniocervical re
gion (Fig. 10-356). Habitual forward head posture can
occur for two different reasons. First, a hyperextension
(whiplash) to th neck can injure anterior muscles, such
as th sternocleidomastoid, longus colli, and scalenus
anterior. As a result, chronic spasm in th strained
muscles translates th head forward, resulting in exces
si ve flexion, especially at th cervicothoracic junction. A
clinical sign often associated with forward head postur-
ing is a realignment of sternocleidomastoid muscle
within th sagittal piane. The cranial end of th muscle,
normally a/igned posterior to th sternoclavicular joint,
shifts anterorly to a position d irectly above th sterno
cla vicular jo in t (compare Fig. 0 - 3 5 A w ith ff/.
A second cause of a chronic forward head posture
may be related to a progressive shortening of several
anterior neck musc/es. One sucri scenario involves pur-
Chapter 10 Axiai Skeleton: Muscle and Joint Interactions 341
Ideal posture Chronic forward head posture
Rectus capitis
posterior major
c a p it is
Sternocleidomastoid
;alenus anterior
The latissimus dorsi is an ipsilateral rotator of th trunk
when th glenohumeral joint is well stabilized by other mus
cles. Selecied left hip muscles actively rotate th pel vis and
attached lumbosacral region to th right, relative to th lxed
left femur.
posely protracting th craniocervical region to improve
visual contact with objects manipulated in front of th
body. This activity is typical when viewing a computer
screen. This position, if heid for an extended period,
may alter th functional resting length of th muscles,
eventually transforming th forward posture into a "nat
urai" posture.
Regardless o f th factors friat predispose a person to
a chronic forward head posture, th posture itself
stresses extensor muscles, such as th levator scapula
and semispinalis capitis (see Fig. 10-356). The suboc-
cipital muscle, such as th rectus capitis posterior ma
jor, may be fatigued as a result of its prolonged exten-
sion activity required to "level" th head and eyes. Over
time, (nere ased muscular stress throughout th entire
craniocervical region can lead to localized and painful
muscle spasms, or "trigger points," common in th leva
tor scapula and suboccipital muscles. This condition is
often associated w ith headaches and radiating pain into
th scalp. The key to most treatment for chronic for-
w ar head p osture is to restore optim al craniocervical
posture, accomplished through improved postural
awareness, ergonomie workplace design, and therapeu-
tic exercise.
 342 Section HI Axial Skeleton
Scalenus anterior
Splenius capitis
and cervicis
Sternocleidomastoid
Jfansversospinal
muscles
(m ultifidi)
Obliquus
externus
Obliquus internus abdominis
abdominis
Gluteus maximus
Biceps femoris
SELECTED BIOMECHANICAL ISSUES
OF LIFTING: A FOCUS ON REDUCING
BACK INJURY
Lifting heavy objects places considerable demands on many
muscles throughout th body (Fig. 1 0 - 3 7 ). Lifting can gen
erate large compression, tension, and shear forces through
out th body, most notably at th base of th spine. At some
criticai level, forces that have an impact on th low-back
region may exceed th structural tolerance of th locai mus
cles, ligaments, and apophyseal and interbody joints. Lifting
is a leading risk factor associated with low-back pain in th
United States and is especially related to occupation.25-41-43'53
Disability associated with low-back pain is a signihcant prob-
lem, both in terms of cost and suffering. An estimated 30%
of th workforce in th United States regularly handles mate-
rials in a potentially harmful manner, including lifting.63
This topic of th biomechanics of lifting describes (1)
why th low-back region is vulnerable to lifting-related in
jury and (2) how th forces in th low-back region can be
minimized in order to reduce th chance of injury.
Muscular Mechanics of Extension of th
Low Back While Lifting
The amount of force produced by th extensor muscles of
th posterior trunk is strongly correlated with th amount of
force placed on th connective tissues (tendons, ligaments,
fascia, discs) within th low back. The following sections,
therefore, focus on th role of th muscles during lifting,
and how forces produced by muscles can be modified to
reduce th stress on th structures in th low-back region.
Longissimus
capitis
FIGURE 10-36. A typical activa-
tion pattern of selected mus-
Latissimus dorsi
cles of th cranioeervical region,
trunk, and hip is shown, as a
- Erector spinae healthy person rotates th entire
body to th righi within th
horizontal piane. A, Anterior
view. B, Posterior view.
ESTIMATING THE MAGNITUDE OF FORCE IMPOSED
ON THE LOW BACK WHILE LIFTING
Considerable research has been undertaken to quantify th
relative forces and torques imposed on th various structures
in th low back while lifting.1-3-31-56-70 This research helps
clinicians and members of govemmental agencies develop
safety guidelines and limits for lifting, especially in th work-
place.12-13-23-2935-37-44 Of particular interest during lifting are
th variables of peak force, or torque, produced by muscles;
tension developed within stretched ligaments; and compres
sion and shear forces developed against th intervertebral
discs and apophyseal joints. Measurement of these variables
is typically not made directly, but rather through relatively
sophisticated equipment that permits indirect estimates or
model-based estimates of a desired variable. Such equipment
is usually not available in most clinical settings. A more
simple but less accurate method of estimating forces im
posed on th low back uses calculations based on th as-
sumption of static equilibrium (see Chapter 4).
The following section presents th steps used in making
these calculations in order to estimate th compression force
on th L2 vertebra while lifting a load in th sagiual piane
Although this hypothetic example provides a limited amount
of information on a rather complex biomechanical event, it
does yield valuable insight into th mathematical relationship
between th force produced by th muscle and th compres
sion force imposed on a representative structure within th
low back.
Figure 1 0 - 3 8 shows th data required to make a generai
estimale of th compression force against th L2 vertebra
while lifting. The subject is depicted midway through a ver-
tical lift of a moderately heavy load, weighing 25% of his

LIFT
FIGURE 10-37. The typical activaton pattern of selected muscles is
shown as a healthy person lifts a load.
body weight. The axis of rotation for th sagittal piane mo-
tion is oriented in th medial-lateral direction in th region
of L2 (see Fig. 1 0 - 3 8 , open circle). Estimating th compres-
sion force is a three-step process.
Step 1 establishes an equation that demonstrates static
rotary equilibrium about th axis of rotation. The equation
specifies that th sum of th internai and extemal torques
within th sagittal piane is equal to zero. This assumption
allows th internai (muscular) torque to be estimated by
Chapter 10 Axial Skeleton: Muscle and Joint Interactions 343
calculating th extemal torque imposed by th extemal
forces. Note that two extemal torques are described: one due
to th extemal load (EL) and one due to th subjects body
weight (BW) located above L2. The extensor muscle force
(MF) is defined as th MF generated on th posterior (exten
sor) side of th axis of rotation. As shown in Step 1, th
back extensor muscles produce an internai torque of 125.6
Nm to support th combined extemal torque of th load
and body weight.
Static Equilibrium Mcthod for Estimating th
Compression Force on th L2 Vertebra Requires
Three Steps
Step 1 Formulate a static equilibrium equation in which th
sum of th internai and extemal torques in th sagittal
piane is equal to zero. This step allows th determination
of th internai torque produced by th back extensor mus
cles.
Step 2 Determine th extensor muscle force required to gener
ate th internai extensor torque.
Step 3 Determine th compression (reaction) force (RF) on th
superior surface of L2 as th sum of th vectors produced
by (1) th back extensor muscle force, (2) extemal load,
and (3) body weight. L2 must produce an upward reac
tion force (labeled RF) that opposes EL, BW, and MF.
Step 2 estimates th amount of extensor muscle force
needed to sustain th internai torque. By assuming that th
back extensor muscles have an average internai moment arm
of 5 cm, th extensor muscles must p rod u ce at least 2512 N
(565.1 lb) of force to lift th load.
Step 3 estimates th total compression reaction force im
posed on th L2 vertebra while lifting. (The term reaction
implies that th L2 vertebra must push back against th
other downward acting forces.) A rough estimate of this
force can be made by assuming static equilibrium (E forces =
0). It is assumed that th muscle, body weight, and extemal
load forces are parallel to each other and are directed per-
pen dicu ar to th su perior surface o f 12. (This assum ption
creates a small error in th estimation of th compression
force. A more valid approach requires th use of trigonome-
try to determine th components of body weight and exter-
nal load that truly act perpendicular to L2.) The compres
sion reaction force (see Fig. 1 0 - 3 8 , RF vector) is equal in
magnitude but opposue in direction to th sum o f MF, BW,
and EL.
The solution to this hypothetic example suggests that a
compression force of 3232 N (over 725 lb) is exerted on L2
while lifting an extemal load weighing 200 N (about 45 lb).
To put this m agnitude o f force in to clinical perspective,
consider th following two points. First, th National Insti-
tute of Occupational Safety and Health (NIOSH) has set
guidelines to protect workers from excessive loads on th
lumbar region caused by lifting and handling materials.
NIOSH has recommended an upper safe limit of 3 4 0 0 N
(764 lb) of compression force on L5-S1.63-81 Second, th
maximal load-carrying capacity of th lumbar spine is esti
mated to be 6400 N (1439 lb),38 almost twice th maximal
safe force recommended by NIOSH. The limit of 6400 N of
force applies to a 40-year-old man. This is a maximal limit
 344 Section III Axial Skeleton

Data

In te rn a i m o m e n t a rm ( D i) = 5 cm.
T o tal b o d y w e ig h t = 800 N (-1 8 0 Ibs).

Parte/ body weight (BW) above L2= 65% ot total body weight,
o r - 520 N.

E x te rn a l m o m e n t a rm tr a m B W (D 2) = 13 cm.
E x te rn a l Io a d (E L ) = 2 5 % o f tota) b o d y w e ig h t = 200 N ( - 4 5 Ibs).
E x te rn a l m o m e n t a rm fr o m E L (D 3 ) = 2 9 cm .

FIGURE 10-38. The steps usec

Step 1 Establish Sagittal Piane Equilibrium
to estimale th compression re
Internai Torque = External Torque (BW x D2 + EL x D3) action force (RF) on th L2 ver
tebra while lifting a load are
Internai Torque = (520 N x .13 m) + (200 N x ,29m) shown. The biomechanics are
limited to th sagittal piane
Internai Torque = 125.6 Nm
about an axis of rotation at LI
(open circle). The calculatioL-
are shown in three steps: (1) es
Step 2 Estimate th Extensor Muscle Force (MF) tablish sagittal piane equilit-
rium, (2) estimale th extensc-
Internai Torque (MF x D,) = External Torque (BW x D2 + EL x D3) muscle force, and (3) estima!-:
th compression reaction force
MF = (520 N x .13 m) + (200 N x .29 m)
acting on L2. The mathematica!
.05 m Solutions assume a condition a:
static equilibrium. (All abbrevia-
MF = 2512 N (-565.1 Ibs) tions are defined in th boxes. ) I

Step 3 Estimate th Compression Reaction Force (RF) on L2

I Forces = 0

-MF + -EL + -BW + RF = 0

RF = 2512 l\l + 520 N + 200 N

CF = 3232 N (726.6 Ibs)

that decreases by 1000 N each subsequent decade. These
force values are generai estimates that do not apply equally
to all persons in all lifting situations.
The static model ver)' likely underestimates th actual
compressive force on th L2 vertebra for th following two
reasons. First, th model accounts for muscle force produced
by th back extensors only. Other muscles, especially those
with near-vertical fiber orientation such as th rectus abdom-
inis and th psoas major, certainly add to th muscular-
based compression on th lumbar spine. Second, th model
contains an assumption of a condition of static equilibrium,
thereby ignoring th additional forces needed to accelerate
th body and load upward. A rapid lift requires greater
muscle force and imposes greater compression and shear on
th joints and connective tissues in th low back. For this
reason, it is usually recommended that a person lift loads
slowly and smoothly, a condition not always practical in
occupational settings.
WAYS T0 REDUCE THE FORCE DEMANDS 0N THE
BACK MUSCLES WHILE LIFTING
An essential point to recognize, from th calculations per-
formed in Step 3 of Figure 1 0 - 3 8 , is that th MF vector is
by far th most influential variable for determining th mag
nitudo of th compression force. Proportional reductions in
muscle force have th greatest effect on reducing th overall
compression force on th structures in th low back.
The primary factor responsible for th large force required
by th low-back muscles while lifting is th disparity in th
length of th internai and external moment arms. The inter
nai moment arm (D ,) depicted in Figure 1 0 - 3 8 is assumed
to be 5 cm. The extensor muscles are therefore at a sizable
mechanical disadvantage and must produce a force manv
times larger than th weight of th load being lifted. As
previously demonstrated, lifting an external load weighing
25% of ones body weight produces a compression force on
L2 of four times body weight!

FIGURE 10-39. Graph shows ihe predicted corri- O
pression force at th L5-S1 disc as a function of 0 =.
load size and th dislance th loads are held in ^ $
front of th body (1 Ib = 4.448 N.). The two red Oq
horizontal lines indicate (1) th maximal load-carry- gj
ing capacity of th lumbar region before structural (D*9
failure, and (2) th upper safe limits of compresson Q. m
force on th lumbar spine as determined by th | ~Z
National lnstitute of Occupational Safety and o W
Health. (Plot modified from Chaffin DB, Andersson
GBJ: Occupational Biomechanics, 2nd ed. New
York, John Wiley and Sons, 1991.
Therapeutic and educational efforts directed toward re-
iuction of th likelihood of back injury are often directed
toward reduction of th muscle force demands by four
"Tiethods. First, reduce th rate of lifting. As previously
uated, reducing th lifting velocity proportionately decreases
die amount of back extensor muscle force.
Second, reduce th weight of th extemal load. This point
is obvious, but not always possible.
Third, reduce th length o f th external moment arm of
die external load. This is likely th most effective and practi-
:al method of decreasing compression forces on th low
back. As demonstrated in Figure 1 0 - 3 8 , a load should be
jfted from between th legs, thereby minimizing th distance
between th lo ad and th lum bar region. As estimated, lift
ing a heavy load using ideal technique produced a compres
sion force on th lumbar region that remained dose to th
ip p er lim its o f safety p r o p o s e d b y NIOSH. Lifting th sante
ioad with a longer extemal moment arm creates very large
and potentially dangerous compression forces on th low
rack. Figure 1 0 - 3 9 sh ow s a p lo t o f p red icted com pression
'orces on che L5-S1 disc as a function o f dodi io a d size an d
distance between th load and th front of th chest.12 Al-
though an extreme example, th plot predicts that holding
in extemal load that wetghs 200 N (45 Ib) 50 cm in from
f th body creates about 4500 N of compression force,
greatly exceeding th upper safe limit of 3400 N. In every-
day life, lifting an object from between th legs is not always
practical. Consider th act of sliding an obese patient toward
die head of a hospital bed. Inability to reduce th distance
between th patient's center of mass (located anterior to S2)
and th lifter can dramatically compromise th safety of th
lifter.
Fourth, increase th internai moment arm available to th
!ow-back extensor muscles. A larger internai moment arm
for extension allows a given extension torque to be gener-
ated with less muscle force. As stated, less muscle force
typically equates to less force on th vertebral elements.
Increased lumbar lordosis does indeed raise th internai mo
ment arm available to th lumbar erector spinae muscles.77
Lifting with an accentuated lumbar lordosis, however, is not
always practical or even desirable. Lifting a very heavy load
Chapter 10 Axial Skeleton: Muscle and Joint lnteractions 345
Load distance
-20 cm
------------ 30 cm
- - - - - 40 cm
------------ 50 cm
off th floor, for example, tends to flex th lumbar spine,
thereby decreasing th lordosis. Even if lifting while main-
taining an exaggerated lumbar lordosis, th associated in
creased compression force on th apophyseal joints may not
be well tolerated.
Four Ways to Reduce th Amount of Force Required of
th Back Extensor Muscles While L iftin g
1. Reduce th speed of lifting
2. Reduce th magnitude of th extemal load
3. Reduce th length of th external moment arm
4. Increase th length o f th internai moment arm
R0LE 0F INCREASING INTRA-ABDOMINAL PRESSURE
WHILE LIFTING
In 1957, B artelink7 in trodu ced th notion that th Valsalva
maneuver (named after th Italian anatomist, 1 6 6 6 -1 7 2 3 ),
typically used while lifting loads, may help unload and
thereby protect th lumbar spine. The Vaisalva maneuver
describes th action of voluntarily increasing intra-abdominal
pressure by vigorous contraction of th abdominal muscles
against a closed glottis. The Valsalva maneuver creates a
rigid, vertical column of high pressure within th abdomen
that pushes upward against th diaphragm and dow nw ard
against th pelvic floor. Acting as an inflated intra-abdomi
nal balloon, Bartelink proposed that activating this rnecha-
nism while lifting may partially reduce th demands on th
lumbar extensor muscles and, therefore, lower th compres
sion force on th lu m bar spine.
Although th notion of increasing intra-abdominal pres
sure as a way to reduce compression forces on th spine is
intriguing, studies have refuted th biomechanical validity of
th concept.5-34-57-61 Contraction of th abdominal muscles
p rod u ces forces that increase th vertical com pression on th
lumbar spine. Because th abdominal muscles flex th lum
bar spine, their strong activation requires increased counter-
balancing torques from th extensor muscles, thereby adding
 346 Section III Axial Skeleton
to th overall myogenic compression on th lumbar spine.
Most persons, however, likely do benefit from th Vaisalva
maneuver while lifting. In a healthy person, increased com
pression on th lumbar spine, especially when produced
through co-contraction of th surrounding muscles, provides
an effective source of vertical stability to th region. Muscles
such as th transversus abdominis and obliquus intemus
abdominis are very active w hile lifting,l6J7 providing an ad-
ditional corset effect across th posterior lumbar region.
Strong contraction of these muscles also resists unwanted
torsions created by th asymmetrical lifting of an extemal
load.
In summary, th Vaisalva maneuver, typically performed
while lifting, is likely a beneficiai action that provides an
important element o f stability to th lumbar spine. The in
creased stability is th result of th increased myogenic lum
bar compression and direct splinting action on th low back.
The increased intra-abdominal pressure while lifting is more
a consequence of strong contraction of th abdominal mus
cles and not a method, in itself, to unload th lumbar spine.
ADDITIOJMAL SOURCES OF EXTENSION TORQUE USED
FOR LIFTING
The maximal force-generating capacity of th low-back ex-
tensor muscles in a typical young adult in estimated to be
approximately 4000 N (900 lb).10 By assuming an average
internai moment arm of 5 cm, this muscle group is expected
to produce about 200 Nm of trunk extension torque. Al-
though this estimation varies for any given person, it serves
as a useful reference for th following discussion. Given a
hypothetic maximal voluntary trunk extensor torque of
about 200 Nm, how is th faci explained that lifting typi
cally requires extensor torques that greatly exceed 200 Nm?
For instance, th person dep icted lifting th load in Figure
TABLE 1 0 - 1 4 . Maxima! Passive Extensor Torque Produced by Stretched Lumbar Ligaments
Average Maximum Tension
Ligament (N)
Posterior longitudinal ligament 90
Ligamentum flava 244
Capsule of apophyseal joints 680
Inierspinous ligament 107
Posterior layer of thoracolumbar 500
fascia, including supraspi-
nous ligaments and th apo-
neurosis covering th erector
spinae muscles
Total
o- ............. -..w vn **..1*1*1 autiLutu iisiuc ai me pumi oi rupiure.
-Extensor moment arm is th perpendicular distance between th attaehment sites of th ligaments and th medial-lateral axis of rotation wuhm a
representative lumbar vertebra.
5Maximal passive extensor torque is estimated by th produci of 1 and 2 above.
Data from Bogduk N, Twomey L: Clinical Anatomy of th Lumbar Spine, 2nd ed. New York, Churchill Livingstone, 1991
1 0 - 3 8 would have exceeded his theoretical 200 Nm thresh-
old if th extemal load were increased to about 80% of his
body weight. Although this is a considerable weight, it is not
unusual for a person to successfully lift much greater loads,
such as those regularly encountered by heavy labor workers
and by competitive power lifters. In attempts to explain
this apparent dilemma, two secondary sources of extension
torque are p ro p osed : (1) passive tension gen erated from
stretching th posterior ligamentous System, and (2) muscu-
lar-generated tension transferred through th thoracolumbar
fascia.
P a ssive T e nsion G e n e ra tio n fro m S tre tc h in g th P o s te rio r
L ig a m e n to u s S yste m
When stretched, healthy ligaments and fascia exhibit some
degree of naturai elasticity. This quality allows connective
tissue to temporarily store a small part of th force that
initially causes th elongation. Bending forward in prepara-
tion for lifting progressively elongates several connective tis-
sues in th lumbar region and, presumably, th passive ten
sion developed in these tissues can assist with an extension j
torque.21 These connective tissues, collectively known as th
posterior ligamentous System, include th posterior longitudine '
ligament, ligamentum fiavum, apophyseal joint capsule, in-
terspinous ligament, and th posterior layer of th thoraco
lumbar fascia.30
In theory, about 72 Nm of total passive extensor torque is
produced by maximally stretching th posterior ligamentous
System (Table 1 0 - 1 4 ) .10 Adding this passive torque to th
hypothetic 200 Nm of active torque yields a total of 272 Nm
of extension torque available for lifting. A fully engaged
(stretched) posterior ligamentous System can, therefore, gen
erate about 25% of th total extension torque for lifting
Note, however, that this 25% passive torque reserve is only
available after th lumbar spine is maximally fiexed, which
Extensor Moment Arm Maximal Passive Extension Torque
(m)2 (Nm)3
.02 1.8
.03 7.3
.04 27.2
.05 5.4
.06 30
71.7

in reality is rare while lifting. Even some competitive power
lifters, who appear to lift with a fully rounded low back,
avoid th extremes of flexion.14 It is generally believed that
maximum flexion of th lumbar spine should be avoided
while lifting.54155 The lumbar region should be held in a near
neutral lordotic position neither hyperlordotic or hypolor-
dotic.55 The neutral position of th lumbar spine apparently
aligns th locai extensor muscles to more effectively resist
anterior shear produced at th lumbar spine while lifting.54
Although th neutral position of th lumbar spine may re
duce th chance of injury to th low back, it engages only a
small portion of th total passive torque reserve available to
assist with extension. Most of th extension torque must be
generated by active muscle contraction.69 Muscle tissue can
be significanti)' strengthened through resistive exercise in or-
der to meet th large demands imposed by lifting.
*t S P E C I A L F O C U S 1 0 - 8
Period of "Electrical Silence" of th Erector
Spinse Muscles
As described, flexing th lumbar spine engages th
posterior ligamentous System to produce a passive ex
tension torque, thereby potentially relieving some of th
force demands placed on th extensor muscles. The full
expression of this unloading phenomenon can be dem-
onstrated by placing surface EMG electrodes over th
lumbar erector spinae muscle group. The subject then
slowly bends th trunk forward while keeping th hips
and knees as extended as possible. Throughout this
motion a variable amount of EMG activity from th
erector spinae is observed, reflecting this muscle's ec-
centric activity while lowering th trunk. Once in full
lumbar flexion, however, th EMG signal from th erec
tor spinae group typically ceases.26 The weight of th
flexed trunk is supported totally by th passive torque
generateci by th fully stretched posterior ligamentous
System, as well as th stretched connective tissues
within th electrically silent erector spinae. From th
flexed position, th subject actively and swiftly returns
th trunk to an erect position. As th lumbar spine
progressively extends, th passive torque reserve of th
posterior ligamentous System progressively falls. The ex
tension torque is then generated actively by contracting
th erector spinae muscles, as evident by th large
increase in th EMG signal.
Muscular-Generated Tension Transferred Through th
Thoracolumbar Fascia
The thoracolumbar fascia is thickest and most extensively
developed in th lumbar region (see Fig. 9 - 7 6 ) . Much of
th tissue attaches to th lumbar spine, sacrum, and pelvis
in a position well posterior to th axis of rotation at th
lumbar region. Theoretically, therefore, passive tension
within stretched thoracolumbar fascia can produce an exten
Chapter 10 Axial Skeleton: Muscle and Jont Interactions 347
sion torque in th lumbar region and, as such, may augment
th torque created by th low-back musculature.
In order for th thoracolumbar fascia to generate useful
tension, it must be stretched and rendered taut. This can
occur in two ways. First, th fascia is stretched simply by
bending forward and flexing th lumbar spine in preparation
for lifting. Second, th fascia is stretched by active contrac
tion of muscles that attach imo th thoracolumbar fascia,
such as th obliquus intemus abdominis, transversus abdom-
inis, latissimus dorsi, and gluteus maximus. These muscles
are active during lifting.
Vigorous contraction of th abdominal muscles naturally
occurs as a person lifts. This phenomenon is associated with
an increase in intra-abdominal pressure. In theory, a contrac
tion force generated by th obliquus intemus abdominis and
transversus abdominis can be transferred posteriori) to th
thoracolumbar fascia to generate an extension torque in th
lumbar region. The prevailing horizontal fiber direction of
most of th thoracolumbar fascia limits th amount of exten
sion torque that can be produced.9 The force generated by
th abdominal muscles may indirectly produce 6 Nm of
extensor torque across th lumbar spine50 compared with th
approximately 200 Nm of active torque generated by th
low-back extensor muscles. Although th actual extension
torque may be small, th tension transferred through th
thoracolumbar fascia may provide important static bracing to
th lumbar region, much like a corset.
The latissimus dorsi and gluteus maximus may also indi
rectly contribute to lumbar extension torque via attachments
to th thoracolumbar fascia. The two muscles attach exten
sively into th thoracolumbar fascia. Both are active during
lifting, bui for different reasons (Fig. 1 0 -4 0 ). The gluteus
maximus stabilizes and Controls th hips. The latissimus
dorsi heps transfer th ex tem a/ lo ad bein g lifted from th
arms to th trunk. In addition to attaching into th thoraco
lumbar fascia, th latissimus dorsi attaches into th posterior
aspect of th pelvis, sacrum, and spine. Basecl on these
attachments and its relative moment arm for producing lum
bar extension (see Fig. 1 0 - 1 7 ), th latissimus dorsi has all
th attrbutes o f an extensor o f th low back. The ob liqu e
fiber direction o f th muscle as it ascends th trunk can also
provide torsional stability to th axial skeleton, especially
when bilaterally active. This stability may be especially useful
when handling large loads in an asymmetrical fashion.
A Closer Look at Lifting Technique
Extensive research has been conducted in th attempt to
define th safest technique for lifting, especially with regard
to th posture of th lumbar spine. 19202833-60-757R No tech
nique is considered th safest for all persons across th wide
spectrum of lifting situations.
TWO C0NTRASTING LIFTING TECHNIQUES: THE
ST00P VERSUS THE SQUAT LIFT
The stoop lift and th squat lift represent th biomechanical
extremes of a broad continuum of possible lifting strategies
(Fig. 1 0 - 4 1 ). The stoop lift is performed primarily by ex-
tending th hips and lumbar region, while th knees remain
 348 Section III Axial Skeleton

LIFT consequence, dimnish th extensor torque demands on th

muscles of th back.
The squat lift is most often advocated as th safer of th
two techniques in terms of preventing back injuries. No
overwhelming scientifc evidence, however, supports this
strongly held clinical belief.79 As with many espoused clinical
principles, th advantage of one particular concept or tech-
nique is often at least partially offset by a disadvantage. This
holds true for th apparent advantage of th squat lift over
th stoop lift. Although th squat lift may reduce th de
mands on th extensor muscles in th low back, it usually
creates greater demands on th knees.32-74 The extreme de-
gree of initial knee flexion associated with th full squat
places high force demands on th quadriceps muscle to
extend th knees. The forces impose very large pressures
across th tibiofemoral and patellofemoral joints. Healthy
persons may tolerate high pressures at these joints without
negative consequences; however, someone with patnful or
arthritic knees may noi. The adage that lifting with th legs
spares th back and spoils th knees does, therefore, have
some validity.
Another factor to consider when evaluating th benefts of
th squat lift over th stoop lift is th total work required to
lift th load. The mechantcal work performed while lifting is
equal to th product of th weight of th body and extemal
load multiplied by th vertical displacement of th body and
load. The stoop lift is 23% to 34% more metabolically eff-
cient than th squat lift in terms of work performed per
level of oxygen consumption.82 The squat lift requires greater
work because a greater proportion of th total body mass
must be moved through space.

Summary: Factors that Contribute to Safe

Lifting
Rather than a squat lift or stoop lift, people usually choose
an individualized (freestyle) technique. A freestyle technique

The Stoop Lift The Squat Lift

slightly flexed. This lifting strategy is associateci with greater

flexion of th low back, especially at th initiation of th lift.
Furthermore, th stoop lift creates long extemal moment
arms between th trunk and th low back, and between th
load and th low back. The greater extemal torque requires
greater extension torque from th trunk extensor muscles. In
combination with a maximally flexed lumbar spine, th
stoop lift can create large and possibly damaging compres-
sion and shear forces on th discs.
The squat lift, in contrast, typically begins with maximally
flexed knees. The knees are extended during th lift, pow-
ered by th quadriceps muscles (Fig. 1 0 -4 1 B ). Depending
on th physical characteristics of th load and th initial
depth of th squat, th lumbar region may remain nearly
hyperextended, neutral (normal lordosis), or flexed through-
out th lift. Perhaps th greatest advantage of th squat lift is
that it typically allows th load io be raised more naturally
FIGURE 10-41. Two contrasting styles of lifting. A, The initiation of
from between th knees. The squat lift can, in theory, re th stoop lift. B, The initiation of th squat lift. The axes of rotation
duce th moment arm of th load and trunk and, as a are shown at th hip and knee joints.
 Chapter 10 Axial Skeleton: Muscle and Joint Interactions 349

TABLE 1 0 - 1 5 . Factors Considered lo Contribuie to Safe Lifting Techniques

Consideration Rationale Comment

Maintain th extemal load as dose to
th body as possible.
Lift with th lumbar spine held as
dose to a neutral lordotic posture
as possible. Avoid th extremes of
flexion and extension. Exact posi-
tion of th spine can vary based
on comfort and practicality.
When lifting, fully utilize th hip
and knee extensor muscles to
minimize th force demands on
th low-back muscles.
Minimize th vertical and horizontal
distance that a load must be lifted.
Avoid twisting when lifting.
Lift as slowly and smoothly as con-
ditions allow.
Lift with a moderately wide and
slightly staggered base o f support
provided by th legs.
When possible, use th assistance of
a mechanical device or additional
people while lifting.
Minimizes th extemal moment arm of th
load, thereby reduces torque and force de
mands on back muscle.
Concentrating on holding th lumbar spine in
a neutral lordotic position may help pre-
vent th spine from extremes of flexion
and extension. Vigorous contraction of th
back extensor muscles, with th lumbar
spine maximally jlexed, may produce dam-
aging forces on th intervertebral discs. In
contrast, vigorous contraction of th back
extensor muscles with th lumbar spine
maximally extended may damage th
apophyseal joints.
Very large forces produced by low-back ex
tensor muscles can injure th muscles
themselves, intervertebral discs, vertebral
endplates, or apophyseal joints.
Minimizing th distance that th load is
moved reduces th total work of th lift,
thereby reducing fatigue; minimizing th
distance that th load is moved reduces th
extremes of movement in th low back and
lower extremities.
Torsional forces applied to vertebrae can pre
dispose th person to intervertebral disc
injury.
A slow and smooth lift reduces th large peak
force generated in muscles and connective
tissues.
A relatively wide base of support affords
greater overall stabilicy o f th body,
thereby reducing th chance of a fall or
slip.
Using assistance while lifting can reduce th
demand on th back of th pnmary lifter.
Holding th load between th knees while
lifting is ideal but not always possible.
Lifting with minimal-to-moderaie flexion or
extension in th lumbar spine may be
acceptable for some persons, depending
on th health and experience of th lifter
and th situation. Minimal-to-moderate
flexion or extension both have a biome-
chanical advantage:
Minimal-to-moderate flexion increases
th passive tension generated by th
posterior ligamentous System, possi-
bly reducing th force demands on
extensor muscles.
Minimal-to-moderate extension places
th apophyseal joints nearer to their
close-packed position, thereby pro-
viding greater stability io th re-
gion.
Persons with hip or knee arthritis may be
unable to effectively use th muscles in
th legs to assist th back muscles.
The squat lift may encourage th use of
th leg muscles but also increases th
overall work demands on th body.
Using handles or an adjustable-height plat-
form may be helpful.
Properly designed work environment can
reduce th need for twisting while lift
ing.
Using a mechanical hoist (Hoyer lift) or a
two-man transfer may be prudent in
many settings.

allows th lifter to combine some of th benefits of th squat
lift with th more metabolically efficient stoop lift. Workers
have reported a higher, self-perceived, maximal safe limit
when allowed to lift in a freestyle technique rather than in
a set tech n iqu e.76 A lthough not ideal for everyone and
every lifting task, th technique depicted in Figure 1 0 - 3 8
llustrates two safety features: (1) th lumbar spine is held in
a near-neutral lordotic position, and (2) th load is lifted
from between th legs. These and additional consider-
ations for safe lifting techniques are also listed in Table
1 0 -1 5 .
Those persons with a history of or propensity for low-
back injury should heed th following three common sense
considerations: (1) know your physical limits, (2) think th
lift through before th event, and (3) within practical and
health limits, stay in optim al physical and cardiovascular
condition.
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 C h a p t e r 11

Kinesiology
Mastication and Ventilation
Donald A. Neum ann , PT, Ph D

PART 1: M A S T IC A T IO N , 352
0 S T E 0 L 0 G Y A N D TEETH, 352
Regional Surface Anatomy, 352
Individuai Bones, 352
M a n d ib le , 352
M a x illa e , 353
Temporal Bone, 354
Z y g o m a tic B one, 355
S p h e n o id B one, 355
H yoid B one, 355
Teeth, 355
ARTHROLOGY, 356
Osseous Structure, 356
M a n d ib u la r C ondyle, 356
M a n d ib u la r Fossa, 356
Articular Disc, 356
Capsular and Ligamentous Structures, 357
Osteokinematics, 358
P ro tru s io n and R etrusion, 358
L a te ra l E x c u rs io n , 358
D e p re s s io n an d E levation , 359
TOPICS AT A GLANCE
Arthrokinematics, 360 Thorax, 369
P ro tru s io n and R e tru sio n , 360 M a n u b rio s te rn a l J o in t, 370
L a te ra l E xcu rsio n , 362 S te rn o c o s ta l J o in ts , 370
D e p re ssio n and E le va tio n , 362 In te rc h o n d ra l J o in ts , 370
M USC LE A N D J O IN T IN TER AC TIO N , 362 C o s to tra n s v e rs e and C o s to v e rte b ra l
Innervation to th Muscles and Joints, 362 J o in ts , 370
Changes in Intrathoracic Volume During
Moscular Anatomy and Function, 363
P rim a ry M u s c le s o f M a s tic a tio n , 363 Ventilation, 371
Masseter, 363 M U S C U LA R AC TIO N S DURING
Temporalis, 363 V E N T ILA TIO N , 372
Mediai Pterygoid, 364 Muscles of Quiet Inspiration, 372
Lateral Pterygoid, 364 D ia p h ra g m , 372
S e c o n d a ry M u s c le s of M a s tic a tio n , 365 S c a le n e M u s c le s , 372
S u m m a ry o f In d iv id u a i M u s c le A c tio n , In te rc o s ta le s M u s c le s , 372
365 Muscles of Forced Inspiration, 373
M u s c u la r C o n tro l o f O pening and C losing C h ro n ic O b s tru c tiv e P u lm o n a ry D isease
o f th M o u th , 366 A lte re d M u s c le M e c h a n ic s , 373
TE M P O R O M A N D IB U LA R DISORDERS, 367 Muscles of Forced Expiration, 376
A b d o m in a l M u s c le s , 376
PART 2: V EN T ILA TIO N , 368
T ra n s v e rs u s T h o ra c is and In te rc o s ta le s
ARTHROLOGY. 369 377

PART 1: MASTICATION anterior to th extem al auditoiy meatus (i.e., th opening intc

th ear). The cranial attachment of th temporalis muscle is
Mastication is th process of chewing, tearing, and grinding
within a broad, slightly concave region of th skull known as
food with th teeth. This process involves an interaction of
th temporal fossa. The temporal, parietal, frontal, sphenoid
th muscles of mastication, th teeth, and th pair of tempo-
and zygomatic bones all contribute to th temporal fossa.
romandibular joints (TMJs). The joints form th pivot point
Additional surface anatomy associated with th TMJ is th
between th lower jaw (mandible) and th base of th cra-
mastoid process of th temporal bone, th angle o f th mandt-
nium, The TMJs are one of th most continuously used pairs
ble, and th zygomatic arch. The zygomatic arch is formed b\
of joints in th body, not only during mastication, but also
th union of th zygomatic process of th temporal bone
during swallowing and speaking. The first part of this chap
and th temporal process of th zygomatic bone.
ter focuses on th kinesiologic role of th TMJ during masti
cation.
Individuai Bones
The mandible, maxillae, temporal, zygomatic, sphenoid, and
OSTEOLOGY AND TEETH hyoid bones are all related to th structure or function of th
TMJ.
Regional Surface Anatomy
M ANDIBLE
Figure 1 1 - 1 highlights th surface anatomy associated with
th TMJ. The mandibular condyle fits within th mandibular The mandible is th largest of th facial bones (see Fig. 1 1 -
fossa of th temporal bone. The condyle can be palpated just 1). It is a very mobile bone, suspended from th cranium bv
352
 Chapter 11 Kinesiology o f Mastication and Ventilation 353

L a t e r a l view

Coronoid process Pterygoid fossa

(attachment for (attachment for
temporalis muscle) lateral pterygoid Temporalis
Temporalis
muscle

M a ndibu lar
notch
Mediai
pterygoid
M andib ular muscle
Occipital -ygomaT/S con dyle
bone yjonsg.
External acoustic
meatus
'Wax.ijiaT.
Mastoid process Masseter
muscle-
Styloid process-

Condyle of
te m p o ro m a n d ib u la r jo in t
Angle Masseter
muscle
FIGURE 11-1. Lateral view o f th skull with emphasis on bony
andmarks associateci with th temporomandibular joint. The proxi-
mal attachments of th temporalis and masseter muscles are indi
cateci in red.
muscles, ligaments, and capsule of th TMJ. Muscles of masti-
-ation attach either directly or indirectly to th mandtble.
Muscle contraction brings th teeth embedded within th
mandible against th teeth embedded within th fixed maxil-
be.
Mental foramen
Z yg om a tic
arch
FIGURE 1 1 -2 . Lateral view of th mandible. Muscle attachments are
shown.
poralis muscle. The condyle of th mandible extends upward
from th posterior border of th ramus. The condyle forms
th convex bon y com pon en t o f th TMJ. The mandibular
neck is a siightly constricted region located immediately be-
low th condyle. The lateral pterygoid muscle attaches to th
anterior-medial surface of th mandibular neck, wdthin a
small depression called th pterygoid fossa (Figs. 1 1 - 2 and
1 1 -4 ).

MAXILLAE
Relevant Osteologie Features of the Mandible
Body The right and left maxillae fuse to form a single maxilla, or
Ramus upper jaw. The maxilla is fixed within the skull through
Angle
Coronoid process
Condyle
Neck
Mandibular notch
Pterygoid fossa

Molars
The two main parts of the mandible are the body and the
:wo rami (Fig. 1 1 - 2 ). The body, the horizontal portion of
the bone, accepts the lower 16 adult teeth (see Fig. 1 1 -3 ).
The rami of the mandible project verticali)' from the poste Tip of
rior aspect of the b od y (see Fig. 1 1 -2 ). Faeh ramus has an coronoid
process
external and internai surface, four borders, and two pro-
cesses at its superior aspect the coronoid process and the
condylar process. Extending betw een the coron oid an d con-
dylar process is the mandibular notch. The posterior and Lateral
pole
tnferior borders of th ramus join ai the readily palpable
angle o f the mandible. The masseter and mediai pterygoid Mediai M a n d ib u la r
muscles two powerful muscles of mastication share simi- pole condyle
lar attachments in the region of the angle of the mandible. FIGURE 1 1 -3 . The mandible as viewed from above. The names of
The coronoid process is a triangular projection of thin bone the permanent teeth are indicated. The long (side-to-side) axis
that extends upward from the anterior border of the ramus. through each mandibular condyle interseets at an approximate 160-
This process is the primary inferior attachment of the tem- degree angle.
354 Section III Axial Skeleton

Internai (mediai) view

M a n d ib u la r
condyle

Pterygoid
fossa

Coronoid
process FIGURE 11-4. Lniernal view of
th righi side of th mandible
The bone is bisected in th mie
M a n d ib u la r sagittal piane. The attachmemr:
foramen
of th mylohyoid and gemohyoiTi
muscles are indicated in red: th
attachment of th anterior beB 1
Symphysis menti Mediai
of th digastric and mediai pter-j
(attachment for pterygoid
th geniohyoid muscle ygoid muscles are indicated c j
muscle)
gray. Note th one missing wis-j
dom tooth (third molar).

Digastric fossa Mylohyoid line Angle

(attachment for (attachment for th
anterior belly of th mylohyoid muscle)
digastric muscle)

rigid articulations to adjacent bones (see Fig. 1 1 - 1 ). The TEMPORAL BONE

maxillae extend superiorly forming th floor of th nasal Two temporal bones exist one on each side of th cra-
cavity and th orbit of th eyes. The lower horizontal por- nium. The mandibular fossa forms th bony concavity of th
tions of th maxillae accept th upper teeth. TMJ (Fig. 1 1 - 5 ) . The fossa is bound anteriorly by th ernie -

Inferior view
Postglenoid Zygomatic process, Zygomatic Temporal process

FIGURE 11-5. Inferior view of th skull highlight-

ing th righi mandibular fossa, lateral pterygoid
piate, and zygomatic arch. The proximal attach-
ments of th masseter, mediai pterygoid, and lat
eral pterygoid (superior head) muscles are shown
in red.

Mandibular Foramen Lateral pterygoid piate Lateral pterygoid muscle

fossa ovale (attachment for th (superior head)
mediai pterygoid muscle)
Lateral

Posterior Anterior

Mediai

Mediai Mediai Lateral Foramen
pterygoid pterygoid pterygoid rotundum
muscle piate piate
FIGURE 11 -6 . Posteror view of a sphenoid bone removed from th
cranium. The proximal attachment of th mediai pterygoid muscle
is indicated in red.
ular eminence, and posteriorly by th postglenoid tuberete and
th lympanic part of th temperai bone. On full opening of
th mouth, th condyles of th mandtble slide anteriorly and
inferiorly across th pair of sloped articular eminences.
Rclevant Osteologie Features of th Tcmporal Bone
Mandibular fossa
Articular eminence
Postglenoid tubercle
Styloid process
Zygomatic process
The styloid process is a long slender extension of bone that
protrudes from th inferior aspect of th temperai bone (see
Fig. 11 - 1 ) . The pointed process serves as an attachment for
ine stylomandibular ligament (to be discussed further) and
three small muscles (styloglossus, stylohyoid, and stylophar-
ymgeus). The zygomatic process of th temporal bone forms
he posteror half of th zygomatic arch (see Fig. 1 1 -5 ).
ZYGOMATIC BONE
The right and left zygomatic bones constitute th major part
h e c h eek s and th lateral orbits o f th eyes (see Fig.
1 1 -1 ). The temporal process of a zygomatic bone contributes
-he anterior half of th zygomatic arch (see Fig. 1 1 - 5 ). A
arge part of th masseter muscle attaches to th zygomatic
bone and th adjacent zygomatic arch.
SPHENOID BONE
Although th sphenoid bone does not contribute to th
structure o f th TMJ, it d o es provide proxim al an achm em s
or th mediai and lateral pterygoid muscles. When articu-
lated within th cranium, th sphenoid bone lies transversely
Chaptcr 11 Kinesiology o f Mastication and Ventlation 355
across th base of th skull. The relevant osteologie features
of th sphenoid bone are its greater wing, mediai pterygoid
piate, and lateral pterygoid piate (Fig. 1 1 - 6 ). By removing a
section of th zygomatic arch, th lateral surfaces of th
greater wing and lateral pterygoid piate are revealed (Fig.
Relevant Osteologie Features of th Sphenoid Bone
* Greater wing
* Mediai pterygoid piate
* Lateral pterygoid piate
HYOID BONE
The hyoid is a U-shaped bone located at th base of th
throat, just anterior to th body of th third cervical verte
bra. The body o f th hyoid is convex anteriorly. The bilateral
greater horns form its slightly curved sides. The hyoid is
suspended primarily by its bilateral stylohyoid ligaments.
Several muscles involved wilh moving o f th tongue, svval-
lowing, and speaking attach to th hyoid bone (see Fig. 1 1 -
20 ) .
Teeth
The maxillae and mandible each contain 16 permanent teeth
(see Fig. 1 1 - 3 , for names of lower teeth). The structure of
each tooth refleets its function in mastication (Table 1 1 -1 ).
Each tooth has two basic parts: crown and root (Fig.
1 1 - 8 ). Normally th crown is covered with enamel and is
located above th gingiva (gum). The root of each tooth is
embedded in alveolar bone. The peridontal ligaments help
attach th roots of th teeth within their sockets.
Cusps are conical elevations that arise on th surface of a
tooth. Maximal intercuspation describes th position of th
mandible when th cusps of th opposing teeth are in maxi
mal contact. The term is frequently used interchangeably
with centric relation, especially in describing th relative posi
tion of th articular surfaces within th TMJ. The relaxed
postura! position of th mandible allows a slight freeway
Lateral view
Partial attachment of
lateral pterygoid muscle- 1empo/-5/
superior
Lateral pterygoid piate
(attachment fo r lateral
pterygoid muscle-
inferior head) Cut edge of
zygomatic
arch
FIGURE 1 1 -7 , Lateral view of th righi side o f th cra n iu m w ith a
section o f th zygomatic arch removed. The greater wing and lateral
side of th lateral pterygoid piate are visible. Note th attachments
in red of th two heads of th lateral pterygoid muscle.
356 Section III Axial Skeleton
T A B LE 1 1 - 1 . Permancnt Teeth
Names Functions
Incisors Cut food
Canines Tear food
Premolare Crush food into smaller particles
Molare Grind food into small panicles
for swallowing
space' (interocclusal dearance) between th upper and lower
teeth. Normally, th teeth make contact (occlude) only dur-
ing chewing and swallowing.
ARTHROLOGY
The TMJ is formed by th condyle of th mandible that hts
loosely within th mandibular fossa of th temporal bone
(see Fig. 1 1 - 1 ) . It is a synovial joint that permits a wide
range of rotation as well as translation. An articular disc
cushions th potentially large and repetitive muscle forces
inherent io mastication. The disc separates che joinc imo cwo
synovial joint cavities (Fig. 1 1 - 9 ) . The inferior joint cavity is
between th inferior aspect of th disc and th mandibular
condyle. The larger superior joint cavity is between th supe-
rior surface of th disc and th bone formed by th mandib
ular fossa and th articular eminence.
Although both right and left TMJs function together, each
retains its ability to function relatively independently. Masti
cation is typically performed asymmetrically, with one side
of th mandible exerting a greater biting force than th
other. The dominant side is often referred to as th work
ing side, whereas th nondominant side is referred to as th
balancing side.20 Different demands are placed on th mus-
cles and joints of th working and balancing sides.
FIGURE 11-8. The tooth and its periodontal supportive structures.
The width of th periodontal ligaments is greatly exaggerated for
illustrative purposes. (From Okeson JP: Management of Temporo-
mandibular Disorders and Occulsion, 4th ed. Chicago, Mosby,
1998.)
Numbers Structural C haracteristics
Maxillary, 4 Sharp edges
Mandibular, 4
Maxillary, 2 Longest permanent teeth; crown has a single cusp.
Mandibular, 2
Maxillary, 4 Crown has two cusps (bicuspidi; lower second
Mandibular, 4 premolare may have three cusps.
Maxillary, 6 Crown has four or fve cusps.
Mandibular, 6
Osseous Structure
MANDIBULAR CONDYLE
The mandibular condyle is flattened from front to back, witr
its medial-lateral length twice as long as its anterior-postenc ? '
length (see Fig. 1 1 - 3 ) .46 The condyle is generally convex.1
possessing short projections of bone known as mediai and
lateral poles. The mediai pole is more prominent than th
lateral. When opening and closing th mouth, th outsic-.
edge of th lateral pole can be palpated as a point under thel
skin just anterior to th external auditory meatus.
The articular surface of th mandibular condyle is lined
with a thin but dense layer of fibrous connective tissue. This
tissue absorbs loads associated with mastication better than
hyaline cartilage, and it has a superior reparative process.- I
Both of these functions are important when considering th
extraordinary demands placed on th joint surfaces.48
MANDIBULAR FOSSA
The mandibular fossa of th temporal bone is dvided inte j
two surfaces: articular and nonarticular. The articular surface
of th fossa is formed by th articular eminence, occupying
th sloped anterior wall of th fossa (see Figs. 1 1 - 5 and
1 1 - 9 ) . This thick and smooth loadbearing surface is lined
with a dense layer of fbrocartilage. Full opening of th
mouth requires that each condyle slides forward across th
articular eminence. The slope of th articular eminence var-
ies considerably among persons but typically is oriented
about 70 degrees from th horizontal piane.29 The slope I
affeets th path taken by th condyles during th openir:
and closing of th mouth.
The nonarticular surface of th fossa consists of a very rhiI
layer of bone and fbrocartilage that occupies much of tre I
superior (dome) and posterior walls of th fossa (see Fu I
1 1 - 5 ) . The thin region is not an adequate loadbearing s u r i
face. A large force applied to th chin can fracture t h J
region of th fossa, possibly even sending bone fragmensl
into th cranium.
Articular Disc
The articular disc within th TMJ consists primarily of dense I
fibrous connective tissue that, with th exception of its pe-
riphery, lacks a blood supply (see Fig. 1 1 - 9 ). The tissue i=

Lateral view
Superior joint cavity
External acoustic meatus
r Superior
Retrodiscal lam inae-j
Interior
Temporomandibular joint capsule
FIGURE 11 9. A lateral v iew o f a sagittal piane cross-section through a normal right temporomandibular joint. The mandible is in
a posiuon ot maxima! intercuspation, with th disc in iis ideal position relative to th condyle and th temporal bone.
tfexible but firm owing to its high collagen coment. The
tire periphery of th disc anaches to th surrounding cap
ale of th joint.
The disc is divided into three regions: posterior, interme-
te, and anterior (see Fig. 1 1 - 9 ). The shape of each region
ows th disc to accommodate th contour of th condyle
d th fossa. The posterior region of th disc is convex
periorly and concave inferiorly. The concavity accepts
most of th condyle much like a ball-and-socket joint. The
estreme posterior region atlaches to a loosely organized ret
iseli laminae, containing collagen and elastin fibers. Con-
tions made by th laminae anchor th disc posteriorly to
ne (see th box). A meshwork of fat, blood vessels, and
ory nerves flls th space between th superior and infe-
~r laminae.
The P o ste rio r Region of th Articular Disc Attachcs to th
1. Collagen-rich in jerior retrodiscal lam in a which, in lum,
attaches to th periphery of th superior neck of th
mandible along with th capsule of th TMJ.
2. Elastin-rich su p erior retrodiscal lam in a which. in tum. at
taches to th lympanic piate of th temporal bone just
posterior to th fossa.
The intermediate region of th disc is concave inferiorly
and generally fiat superiori). The anterior region is nearly fiat
inferiorly and slightly con cave superiori}' to accom m od ate
th maximal convexity of th articular eminence. The ante
rior region of th disc attaches to several tissues (see th
box).
The thickness of th disc varies between its anterior and
posterior regions. The thinnest intermediate region is only 1
mm thick.25 The anterior and posterior regions, however, are
about two to three times thicker. The disc is constricted at
Chapter 11 Kinesiobgy o j Masticaton and Ventilation 357
Articular disc regions
i
Superior head-
Lateral pterygoid
Interior head-
its intermediate region.47 The constriction, flanked by th
adjacent thicker anterior and posterior regions, forms a dim-
ple on th discs mferior surface. In maximal intercuspation,
th dimpled region of th intermediate region of th disc fits
between th anterior-superior edge of th condyle and th
articular eminence of th fossa.33 The disc position proteets
th condyle as it slides forward across th articular eminence
during th later phase of opening th mouth widely.
The A n terio r Region of th Articular Disc Attaches to th
1. Periphery of th superior neck of th mandible along
with th anterior capsule of th TMJ.
2. Tendon of th superior head of th lateral pterygoid
muscle.
3. Temporal bone ju st anterior to th articular eminence.
The articular disc maximizes th congruency within th
TMJ to reduce contact pressure. The disc adds stability to
th joint and helps guide th condyle of th mandible dur
ing movement. In th healthy TMJ, th disc slides with th
translating condyle. Movement is govemed by intra-articular
pressure, by muscle forces, and by collateral ligaments that
attach th condyle to th periphery of th disc.
Capsular and Ligamentous Structures
FIBROUS CAPSULE
The TMJ and disc are surrounded by a loose fibrous capsule.
The internai surfaces of th capsule are lined with a synovial
membrane. Superiorly, th capsule attaches to th rim of th
mandibular fossa, as far anterior as th articular eminence.
Inferiorly, th capsule forms collateral ligaments that attach to
th periphery of th articular disc. Anteriorly, th capsule,
358 Section III Axial Skeleton
FIGURE 11-10. A, The lateral ligament of th temporomandibular
joint. B, The lateral ligaments mairi fibers: oblique and horizontal.
and part of th anterior edge of disc, attaches to th tendon
of th superior head of th lateral pterygoid muscle (see Fig.
1 1 - 9 ).
The capsule supports th joint, produces synovial fluid,
and contains sensory nerve endings. Medially and laterally
th capsule is hrm, providing stability to th joint during
lateral movements such as those produced during chewing.
Anteriorly and posteriorly, however, th capsule is lax, al-
lowing th condyle and disc to translate forward when th
mouth is opened.
LATERAL LIGAMENT
The primary ligament reinforcing th TMJ is th lateral (tem
poromandibular) ligament (Fig. 11-1 0 A ). The lateral ligament
is typically described as a combination of horizontal and
oblique fibers (Fig. 1 1 -1 0 B ).59 The more superficial oblique
fibers course in an anterior-superior direction, from th pos-
terior neck of th mandible to th lateral margins of th
articular eminence and zygomatic arch. The deeper, horizon
tal fibers share similar temporal attachments. They course
horizontally and posteriorly to attach into th lateral pole of
th mandibular condyle.
The primary function of th lateral ligament is to stabilize
th lateral side of th capsule. Tears or excessive elongation
of th lateral ligament may cause th disc to be moved
medially by an unopposed pul of th superior head of th
lateral pterygoid muscle. As described in Arthrokinematics,
th oblique fibers have a special function in guiding th
movement of th condyle during opening of th mouth.47
ACCESSORY LIGAMENTS
The stylomandibular and sphenomandibular ligaments are th
accessory ligaments of th TMJ. Both are located mediai to
th joint capsule (Fig. 1 1 - 1 1 ). The ligaments help suspend
th mandible from th cranium. The base of th sphenoman-
dibular ligament attaches to th mediai side of th disc.
Although this ligament may have some stabilizing effect on
th disc, most likely both th stylomandibular and spheno-
mandibular ligaments have a very limited role in TMJ func-
tion.
Supporting Conncctive Tissues within th TMJ
Articular disc
Fibrous capsule
Collateral ligaments
Lateral TMJ ligament
Sphenomandibular ligament
Stylomandibular ligament
Osteokinematics
The osteokinematics descriptors of mandibular motion are
protrasion and retrusion, lateral excursion, and depressior
and elevation (Figs. 1 1 - 1 2 to 1 1 - 1 4 ). All of these move-
ments are used during mastication. For a more detailed
analysis of mandibular movements, th reader is encouraged
to consult th classic work by Posselt,51 thoroughly summz
rized by Okeson.47
PROTRUSION AND RETRUSION
Prolrusion of th mandible occurs as it translates anteriori.
without signifcant rotation (Fig. 1 1 -1 2 A ). Protrusion is ar
important component of th mouths opening maximali
Retrusion of th mandible occurs in th reverse directio*
(Fig. 1 1 -1 2 B ). Retrusion provides an important componer:
of closing th widely opened and protruded mouth.
LATERAL EXCURSION
Lateral excursion of th mandible occurs primarily as a side-
to-side translation (Fig. 1 1 -1 3 A ). The direction (right <:c]
left) of active lateral excursion can be described as eith:
contralateral or ipsilateral to th side of th primary me
action. In th adult, an average of 11 mm of maximal unLr-l
eral excursion is considered norm al60 Lateral excursion i
th mandible is usually combined with other relatively si
ivieaiai view
Capsule of of th sphenoid bone
ligamr!
Lateral pterygoid p ia
Mediai pterygoid pbrs
Styloid process
Stylomandibular
ligament
FIGURE 11-11. A mediai view of th temporomandibular joint cap
sule shows th stylomandibular and sphenomandibular ligaments
 Chapter 11 Kinesiology 0} Mastication and Ventilation 359

Protrusion
Retrusion

FIGURE 11-12. Protrusion (A) and retrusion (B) of th mandible.

ranslations and rotations. Normally, th speciftc path of

movement is guided by th contact made between th op-
posed teeth and th shape of th mandibular fossa.
DEPRESSION AND ELEVATION
Depression of th mandible opens th mouth, a fundamental
com ponenc o f eacing (Fig. 1 1 - MA). Maxima/ opening o f th
mouth typically occurs during actions such as yawning and
singing. In th adult, th mouth can be opened an average
of 50 mm as measured between th incisa! edges of th
upper and lower front teeth.60 The tnterincisal opening is
typically large enough to fit three adult ''knuckles (proximal
inteqohalangeai joints). Typical mastication, however, re-
quires an average maximal openin g o f 18 m m or aboul 36%
of maximum. Being unable to fit two knuckles between th

I .alerai excursion

FIGURE 11-13. Lateral excur-

aon of th mandible (A) shown
combined with horizontal piane
rotation (B).
 360 Section III Axia Skeleton

Depressimi Elevatimi

B
FIGURE 11-14. Depression (A) and elevation (B) of th mandible.

edges of th upper and lower incisors is considered ab- translational movemenl, th mandibular condyle and disc slide
normal. Elevation of th mandible doses th mouth an essentially together. This is referred to as condyle-disc complex
action used to grind food during mastication (Fig. translation. The disc is stretched in th direction of th trans-
1 1 -1 4 B ). lating condyle.

Arthrokinematics PROTRUSION AND RETRUSION

Movement of th mandible typically tnvolves bilateral action
of th TMJs. Abnormal function in one joint interferes with
th function of th other. The following principles are help-
ful in an understanding of th arthrokinematics at th TMJ:
(1) durmg rotational movement, th mandibular condyle rolls
relative to th inferior surface of th disc, and (2) during
During protrusion and retrusion, th mandibular condyle
and disc complex translates anteriorly and posteriorly, re-
spectively, relative io th fossa (Fig. 1 1 -1 2 A and B). The
condyle and disc follow th downward slope of th articular
eminence. The mandible slides slightly downward during
protrusion and slightly upwarcl during retrusion. The path of

Opening th mouth

FIGURE 11-15. Arthrokinemat

ics of opening th mouth: early
phase (A) and late phase (B).

Internai Derangement of th Disc-Condyle Complex
Mechanical problems within th TMJ can cause impair-
ments in mastication. A common cause of impairment is
internai derangement of th disc-condyle complex.*1 The
condition is defined as an abnormal position of th disc
relative to th condyle and fossa. The derangement can
be caused by abnormal disc shape, overstretched collat-
eral ligaments, chronic inflammation, loss of elasticity
within th superior retrodiscal lamina, or abnormal forces
from th lateral pterygoid muscle.34
Internai Derangement of th Disc-Condylc Complex
Disc displacement
Pain, clicking sounds, and timited range in opening
th mouih
Chiome disc dislocation
Pain, very limited range in opening th mouth, in
flammation possibly leading to osteoarthritis
Regardless of th cause of th derangement, th disc
and condyle translate out of phase with each other. This
condition is referred to as disc displacement. Even at rest,
th intermediate region of th disc is displaced anterior
and mediai to th anterior margin of th condyle. At-
tempts at fully opening th mouth may abruptly relocate
FIGURE 1 1 -1 6 . Stages of internai derangement of
l i th temporomandibular joint. Normal joint (A), dis-
l i placement of th disc (B), dislocation of th disc
I (C), impingement of th retrodiscal tissues (D), re-
' trodiscits and tissue breakdown (E), and osteoar-
|thritis (F). (Modified from Farrar WB, McCarty WL:
| A Clinical Outline of Temporomandibular Joint Di-
. agnosis and Treatment, 7th ed. Montgomery, AL,
Normandic Publications, 1983.)
Chapter 11 Kinesiology o f Mastication and Ventilation 361
th disc to its ideal position. The abrupt movement may
create a single or a reciprocai clicking sound, depending
on th degree of th disc displacement.4752
A displaced disc can deteriorate to chronic dislocation.
The disc remains abnormally anterior and mediai to th
condyle both at rest ("closed-lock position") and through-
out th entire opening and closing cycle. A TMJ with a
chronically dislocated disc typically does not emit clicking
sounds because th disc usually does not relocate or
"reduce" to its ideal position during movement. The ab
normal position of th disc blocks forward translation of
th condyle. Mouth opening is limited, often associated
with a deviation of th mandible toward th affected side.
A joint with chronic disc dislocation or malalignment often
becomes inflamed and painful. In severe cases, th joint
tissues may degenerate and eventually become arthritic
(Fig. 11-16). As in other synovial joints, an arthritic TMJ
may demonstrate crepitus during movement and, in ex-
treme cases, may ankylose or fuse.
The clinical course of a patient with internai derange
ment of th disc-condyle complex is highly variable. Often
th patient offers an extended history of nonpainful move-
ments that emit clicking sounds. The condition may gradu
a l i or suddenly worsen, with recurring periods of in-
creased pain, cessation of clicking, and episodes of
locking or severely limited motion.26 The condition is often
exacerbated by a forced yawn, a minor trauma to th jaw,
or a dentai procedure that requires prolonged opening of
th mouth.
 362 Section III Axial Skeleton

movement varies depending on th degree of opening of th The arthrokinematics of closing th mouth occur in th
mouth. reverse order of that described for opening. When th
mouth is fully opened and prepared to dose, tension in th
superior retrodiscal lamina starts to retract th disc, initiating
LATERAL EXCURSION
th early phase of closing. The later phase is dominated by
Lateral excursion involves primarily a side-to-side translation rotation of th condyle within th concavity of th disc.
of th condyle and disc within th fossa. Slight multiplanar terminated when contact is made between th upper and
rotations are typically combined with lateral excursion.47 Fig lower teeth.
ure 1 1 -1 3 B shows an example of lateral excursion com
bined with slight horizontal piane rotation. The left condyle
forms a pivot point within th fossa as th right condyle MUSCLE AND JOINT INTERACTION
rotates slightly anteriorly and medially. Slight rotations also
occur in sagittal and frontal planes, owing primarily to th Innervation to th Muscles and Joints
effect of th condyle and disc sliding across th sloped artic-
The muscles of mastication and their innervation are listec
ular eminence.
in Table 1 1 - 2 . Based primarily on size, th muscles of
mastication are divided into two groups: primary and se:
DEPRESSION AND ELEVATION ondary. The primary muscles are th masseter, temporalr-
Opening and closing of th mouth occur by depression and medial pterygoid, and lateral pterygoid. The secondary mu:-
elevation of th mandible, respectively. During these move- cles are much smaller. The primary muscles of masticaticr.
ments, each TMJ experiences a combination of rotation and are innervated by th mandibular nerve, a diVision of th
translation between th mandibular condyle, articular disc, trigeminal nerve (cranial nerve V). This nerve exits th sk cl
and fossa. Because rotation and translation occur simulta- via th foramen ovale (see Fig. 1 1 -5 ).
neously, th axis of rotation is constantly moving. In th
ideal case, th movements within both joints result in a
maximal range of mouth opening with a minimal stress
placed on th articular surfaces. TABLE 1 1 - 2 . Primary and Secondary Muscles of
The arthrokinematics of opening th mouth are depicted
j Mastication and Their Innervation
for an early and a late phase in Figure 1 1 - 1 5 . The early
Primary Muscles Innervation
phase, constituting th frst 35 to 50% of th range of mo-
tion, involves primarily rotation of th mandible relative to Masseter Branch of th mandibular nerve.
th cranium.57-67 As depicted in Figure 1 1 -1 5 A , th condyle a division of cranial nerve V
rolls posteriorly within th concave inferior surface of th
Temporalis Branch of th mandibular nerve,
disc. The direction of th roll is in relation to th rotation of
a division of cranial nerve V
a point on th ramus of th mandible. The rolling motion
swings th body of th mandible inferiorly and posteriorly. Mediai Pterygoid Branch of th mandibular nerve,
The axis of rotation is not fxed but migrates within th a division of cranial nerve V
vicinity of th condyles.20' 50 Lateral Pterygoid Branch of th mandibular nerve.
The rolling motion of th condyle stretches th oblique a division of cranial nerve V
portion of th lateral ligament. The increased tension in th
Secondary Muscles Innervation
ligament helps to initiate th late phase of th mouths open
ing.49' 59 Suprahyoid Croup
The late phase of opening th mouth comprises th final
50 to 65% of th total range of motion. This phase is Digastric (posterior belly) Facial nerve (cranial nerve VII)
marked by a graduai transition from primary rotation to Digastric (anterior belly) Inferior alveolar nerve (branch of
primary translation. The transition can be readily appreciated th mandibular nerve, a divi
by palpaling th condyle of th mandible during th full sion of cranial nerve V)
opening of th mouth. During th translation, th condyle
Geniohyoid C1 via th hypoglossal nerve
and disc slide together in a forward and inferior direction
(cranial nerve XII)
against th slope of th articular eminence (Fig. 1 1 -1 5 B ). At
th end of opening, th axis of rotation shifts inferiorly. The Mylohyoid Inferior alveolar nerve (branch of
exact point of th axis is difficult to define because it de- th mandibular nerve, a divi
sion of cranial nerve V)
pends on th persons unique rotation-to-translation ratio.30
At th later phase of opening, th axis is usually below th Slylohyoid Facial nerve (cranial nerve VII)
neck of th mandible.20
Infrahyoid Group
Full opening of th mouth maximally stretches and pulls
th disc anteriorly. The extent of th forward translation Omohyoid Ventral rami of C1' 3
(protrusion) is limited, in part, by tension in th stretched,
Stemohyoid Ventral rami of C1-3
elastic superior retrodiscal lamina. The intermediate region of
th disc translates forward while remaining between th su Stemothyroid Ventral rami of CU3
perior aspect of th condyle and th articular eminence. This Thyrohyoid Ventral rami of C1 (via cranial
placement of th disc maximizes joint congruency and re- nerve XII)
duces large variation in intra-articular stress.
 Chapter 11 Kinesiology o f Mastication and Ventiation 363

A B
FIGURE 1 1 -1 7 . The masseter (A) and temporalis (B) muscles. (Modified from Okeson JP: Management of Tempo-
romandibular Disorders and Occlusion, 4th ed. Chicago, Mosby, 1998.)

The synovial membrane and th centrai pan of th articu-
lar disc within th TMJ lack sensory innervation. The pe-
riphery of th disc, capsule, lateral ligament, and retrodiscal
tissues, however, possess pain fibers and mechanorecep-
I tors.'H-66 Mechanoreceptors and sensory nerves, from orai
mucosa, periodontal ligaments, and muscles, provide th
nervous System with a rich source of proprioception. This
source of information helps to protect th tissues through
neuromuscular reflex actions and allows coordination be-
tween th muscles and joint. The sensory innervation to th
TMJ is carried through two bran ches o f th mandibular
nerve: auriculotemporal and masseteric.
slightly. Unilateral contraction of th masseter, however,
causes slight ipsilateral excursion of th mandible. Such an
action may occur during a lateral grinding motion while
chewing (Fig. 1 1 - 1 8 ). The multiple actions of th masseter
are useful for effective mastication.
T e m p o ra lis
The temporalis is a fiat, fan-shaped muscle that fills much of
th concavity of th temporal fossa of th skull (Fig. 1 1 -
Active lateral excursion

Muscular Anatomy and Function

PRIMARY MUSCLES OF MASTICATION

The primary muscles of mastication are th masseter, tempo

ralis, mediai pterygoid, and lateral pterygoid. Refer to Ap
pendi* 111, Pan D, [or a sum m ary o f m u scle attachm em s.

M a s s e te r

The masseter is a thick, powerful muscle, easily palpable just

above th angle of th mandible (Fig. 11-1 7 A ). It originates
from th zygomatic arch and zygomatic bone (see Figs. 1 1 -
1 and 1 1 - 5 ) and inserts inferiorly on th extemal surface of
th ramus of th mandible (see Fig. 1 1 - 2 ).
The m asseter has tw o sets o f fibers: superfcial and deep.
The iarger, more superfcial fibers travel inferiorly and poste-
riorly, attaching near th angle of th mandible. The deeper
fibers travel more vertically, attaching to th upper regions
of th ramus of th mandible.
Bilateral contraction of th masseters elevates th mandi
ble to bring th teeth into contact during mastication. The
line-of-force of th superfcial fibers is nearly perpendicular
to th biting surface of th molars. The primary function of FIGURE 1 1 -1 8 . Frontal piane view shows th muscular interaction
th masseter, therefore, is to develop large forces between during left active lacerai excursion of th mandible. This action may
th molars for effective grinding and crushing of food. Bilat occur during a side-to-side grinding motion while chewing. The
eral action of th masseters also protrudes th mandible muscles producing th movement are indicated in red.
364 Seciion 111 Axial Skeleton
17B). From its cranial auachment, th muscle forms a broad
tendon that narrows distally through a space formed be-
tween th zygomatic arch and th lateral side of th skull
(see Fig. 1 1 - 5 ). The muscle attaches distally to th coronoid
process and to th anterior edge and mediai surface of th
ramus of th mandible (see Fig. 1 1 - 2 ). Bilateral contractions
of th temporalis muscles elevate th mandible. The oblique
posterior fibers elevate and retrude th mandible.
Similar to th masseter, th temporalis courses slightly
medially as its approaches its distai attachment. Unilateral
contraction of th temporalis, as when chewing in a side-to-
side manner, causes slight ipsilateral excursion o f th mandible
(Fig. 1 1 -1 8 ).
M e d ia i P te ry g o id
The mediai pterygoid and masseter have a very similar line-
of-force and size (compare Fig. 1 1 -1 7 A with Fig. 1 1-19A ).
The mediai pterygoid arises from th mediai surface of th
lateral pterygoid piate of th sphenoid bone (see Figs. 1 1 - 5
and 1 1 - 6 ). From this attachment, it courses parallel to th
superficial fibers of th masseter to attach on th internai
surface of th ramus near th angle of th mandible (see
Figs. 1 1 - 2 and 1 1 - 4 ). Acting bilaterally, contraction of th
mediai pterygoid muscles elevates and, to a limited extern,
protrudes th mandible. Because of th oblique line-of-force
of th muscle relative to th fromal piane, a unilateral con
traction produces a very effective contralateral excursion of
th mandible (see Fig. 1118).
L a te ra l P te ry g o id
The lateral pterygoid has a superior and an inferior head
(Fig. 1 1 -1 9 B ). The superior head arises from th greater
wing of th sphenoid bone. The considerably larger inferior
head arises from th lateral surface of th lateral pterygoid
piate. As a whole, th muscle traverses nearly horizontally io
insert into (1) th neck of th mandible at th pterygoid
fossa, (2) th articular disc, and (3) th capsule of th TMJ
FIGURE 11-19. A, The mediai view of th righi mediai pterygoid. B, The lateral view of th two heads of th lateral pterygoid.
(A with permission from Okeson JP; Management of Temporomandibular Disorders and Occlusion, 4th ed. Chicago, Mosby,
1998. B modified from Kaplan AS and Assael LA: Temporomandibular Disorders: Diagnosis and Treatment Philadelphia WB
Saunders, 1991.)
Functional Interactions Between th Masseter and
Mediai Pterygoid Muscles
The mediai pterygoid and masseter muscles form a
sling around th angle of th mandible. Simultaneous
bilateral contractions of these muscles exert a very
powerful biting force between th molars. These forces
average 419 N (94.2 Ib) in th adult.34 The bite force
measured between th molars is approximately doubl
th bite force measured between th incisors.
Acting on opposite sides of th mandible, th masse-
ter and mediai pterygoid also coproduce a laterally di-
rected force on th mandible. As shown in Figure 11-
18, simultaneous contraction of th right mediai ptery
goid and left masseter produces left lateral deviation.
Contraction of these muscles in this synergistic fashion
can produce a potent shear force between th molars
and food on both sides of th mouth. The combined
muscular action is very effective at grinding and crush-
ing food prior to swallowing.
(Fig. 11 9 )., 56S The precise distai attachments are stili :
subject of debate.27 About 65% of th fibers of th superior
head attach into th pterygoid fossa (see Fig. 1 1 - 2 ) ; th
remaining attach into th mediai wall of th capsule, and a
relatively small portion into th mediai side of th ariicuk-
disc. Activation of th superior head exerts an anterior-me-
dial force on th capsule and disc. This muscular action mav
be involved in th pathomechanics of excessive anterior-
Lateral pterygoid
superior head
Lateral pterygoid
inferior h e a d
 Chapter 11 Kinesiology o f Mastication and Ventilation 365

th right lateral and mediai pterygoid and by th left masse-

ter and temporalis.
Bilateral contraction of th lateral pterygoids produces
strong protrusion of th mandible.34 As described in Muscular
Control of Opening and Closing of th Mouth, th two
heads of th lateral pterygoid muscles have antagonistic roles
during opening and closing of th mouth. Most data suggest
that th inferior head is th primary depressor of th mandi-
ble, especially during resisted opening of th mouth.313742
The superior head helps control th position of th disc and
joint during elevation of th mandible.31'37 This function is
especially important during resisted, unilateral closure of th
jaw, such as when biting down on a hard object between
th molars.

SECONDARY MUSCLES OF MASTICATION

FIGURE 1 1 -2 0 . The suprahyoid (red) and infrahyoid muscles are
shown, attaching io th hyoid bone. The stemothyroid and thyro-
hyoid muscles are deep to th stemohyoid and are not visible.
Modified with pennission from Kaplan AS and Assael LA: Tempo-
romandibular Disorders: Diagnosis and Treatment. Philadelphia,
WB Saunders, 1991.)
mediai disc displacement.34 The entire inferior head attaches
within th pterygoid fossa.
Unilateral contraction of both heads of th lateral ptery
goid produces effective contralateral excursion of th mand-
ble (see Fig. 1 1 -1 8 ). Unilateral muscle contraction rotates
th ipsilateral condyle anterior-medially within th horizontal
piane. Usually a given right or left lateral pterygoid muscle
contracts synergistically with other muscles during mastica
tion. For example, as depicted in Figure 11 18, a chewing
motion that involves left lateral excursion is controlled by
The suprahyoid and infrahyoid muscles are considered sec-
ondary muscles of mastication (see Table 1 1 - 2 ). Forces pro-
duced by these muscles are transferred either directly or
indirectly to th mandible (Fig. 1 1 - 2 0 ). The suprahyoid mus
cles attach between th base of th cranium, th hyoid, and
th mandible; th infrahyoid muscles attach superiorly to th
hyoid and inferiorly to th thyroid cartilage, sternum, and
scapula. The mandibular attachments of three of th supra
hyoid muscles anterior belly of th digastric, geniohyoid,
and mylohyoid are shown in Figure 1 1 4. Appendix III,
Parts E and F, includes th attachments and innervations of
th suprahyoid and infrahyoid muscles.
With th hyoid bone stabilized by activation of th in
frahyoid muscles, th suprahyoid muscles assist with depres-
sion of th mandible.6 The suprahyoid and infrahyoid mus
cles are also involved in speech, tongue movement, and
swallowing, and in controlling of boluses of food prior to
swallowing.
SUMMARY OF INDIVIDUAI MUSCLE ACTION
Table 1 1 - 3 provides a summary of th individuai actions of
th muscles of mastication.

TABLE 1 1 - 3 . Actions of th Muscles of Mastication on th Mandible

Depression
Elevation (opening
(closing of of th
Muscle th mouth) mouth) Lateral Excursion* Protrusion Retrusion
Masseter XXX X (IL) X

Mediai pterygoid XXX XXX (CL) X

Lateral pterygoid (superior head) t XXX (CL) XXX

Lateral pterygoid (inferior head) XXX XXX (CL) XXX
Temporalis XXX X (IL) XXX
(posterior ftbers)
Suprahyoid muscle group XXX Xf

* CL = contralateral excursion, IL = ipsilateral excursion

t Stabilizes or adjusts th position of th disc.
t By direct action of th geniohyod, mylohyoid, and digastric (anterior belly) only.
A muscle's relative potential to move th mandible is assigned one of three scores: X = minimal, XX = moderate, and XXX = maximum. A dash
tndicates no effective muscular action.
 366 Section III Axial Skeleton

S P E C I A L F O C U S

Passive Muscular Tension and its Possible Influence on disc-condyle complex. Although th data suggest an asso-
th Posture of th Mandible ciation between abnormal craniocervical posture and dis-
Based on muscular anatomy, it is logicai to assume that orders of th TMJ, th literature does not unequivocally
th posture of th head can influence th resting posture support a cause-and-effect relationship between these
of th mandible.8-22-39 Consider, for example, th chronic variables.69
forward head posture described previously in Chapters 9
and 10. The person depicted in Figure 11-21 shows a
Forw ard Head Posture
variant of this posture. Observe that th protracted (for
ward) head is combined with a flexed upper thoracic and
lower cervical spine and with an extended upper cervical
and craniocervical region. This posture stretches infra-
hyoid muscles, such as th sternohyoid and omohyoid,
which can create an inferior and posterior traction on th
hyoid. The traction is transferred to th mandible through
suprahyoid muscles such as th anterior belly of th di-
gastric. As a result, th mandible is pulled in a direction
of retrusion and depression. Because of th attachment of
th omohyoid to th scapula, poor posture of th shoulder
girdle could indirectly place additional tension against th
mandible.
Altering th resting posture of th mandible changes
th position of its condyle within th fossa. A posteriorly
Suprahyoids
displaced condyle could, in theory, compress th delicate
retrodiscal tissues, creating inflammation and muscle Sternohyoid
spasm. Spasm in th lateral pterygoid muscle may be a
naturai protective mechanism to protrude th mandible Omohyoid
away from th compressed retrodiscal tissues. Chronic
spasm within this muscle may, however, abnormally posi FIGURE 11-21. A forward head posture shows one mechanism by
tion th disc anterior and mediai to th condyle. As de which passive tension in selected suprahyoid and infrahyoid mus
cles altere th resting posture of th mandible. The mandible is
scribed in Special Focus 11-1, this situation may predis
pulled inleriorly and posteriorly, changing th position of th con
pose a person to a condition of derangement of th dyle within th temporomandibular joint.

MUSCULAR CONTROL OF OPENING AND CLOSING OF

THE MOUTH though th superior head of th lateral pterygoid attaches
directly to th disc, it is relatively inactive while th mouth
O p e n in g o f th M o u th is opening.
Opening of th mouth is performed primarily through con-
traction of th inferior head o f th lateral pterygoid and th C lo s in g o f th M o u th
suprahyoid group o f muscles. This action is depicted in Figure
Closing of th mouth against resistance is performed primar
1 1 -2 2 A as th mouth opens in preparation to bite on a
ily by contraction of th masseter, mediai pterygoid, and th
grape. The inferior head of th lateral pterygoid is primarily
temporalis muscles (Fig. 1 1 -2 2 B ). They all have a very favor-
responsible for th forward translation (protrusion) of th
able moment arm (leverage) for this action. The more
mandibular condyle.34 This muscle is also involved in a force-
oblique posterior fbers of th temporalis muscles also re-
couple with th contracting suprahyoid muscles. The force-
trude th mandible. This action translates th mandible in a
couple rotates th mandible about its axis of rotation, shown
posterior-superior direction, helping to reseat th condyle
as a white circle below th neck of th mandible. Although deep within th fossa.
mandibular rotation is minimal during th later phase of
The superior head o f th lateral pterygoid is active eccentri-
opening th mouth, it does facilitate th extremes of this
cally while closing th mouth. The activation tends to be
action. Gravity also assists with opening of th mouth.
greatest on th working side of th mandible (i.e., that side
As described previously, th disc and condyle slide for
most involved with chewing).47 Eccentric activation exerts a
ward as a unit during th late phase of opening of th
forward tension on th disc and neck of th mandible. The
mouth. The disc is stretched and pulled anteriorly by (1)
tension stabilizes and optimally positions th disc between
collateral ltgaments attaching th disc to th translating'con
th condyle and articular eminence. The muscle activation
dyle, and (2) increased intra-articular pressure created by
also helps balance th retrusion force generated by th pos
activation of th inferior head of th lateral pterygoid. Al terior fbers of th temporalis.
 Chapter 11 Kinesiology o f Mastication and Ventilation 367

Opening th mouth Closing th mouth

TeinporaliS;

Lateral pterygoid
superior head

Superior N Lateral
FIGURE 1 1 -2 2 .The muscle and etr.odfscal pterygoid
lamina Lateral s u ftM rh e a d
joint interaction while opening pterygoid
(A) and closing (B) th mouth. piate
The relative degree of muscle W Lateral H F L a te r a l
pterygoid pterygoid
activation is indicated by th k interior interior head ^
different intensity of red. In B ;Whead-
th superior head of th lateral
pterygoid muscle is shown ec-
centrically active. (These loca-
tions of th axes of rotation in Masseter \ / / '
A and B are estimates only.)
Suprahyoids
Mediai pterygoid '

Hyoid bone

Infrahyoids

TEMPOROMANDIBULAR DISORDERS

Temporomandibular iso rd a (TMD) is a broad and often

The Special Role of th Superior Head of th Lateral vague term that defnes a number of clinical problems that
Pterygoid in Adjusting Disc Position involve th masticatory System. '40 TMDs are typically asso-
ciated with a primary dysfunction involving either th mus-
The specific position of th disc relative to th condyle
cles or th joint structure.43-61 Muscular dysfunctions typi
while biting depends on th type of resistance created
cally respond more favorably to conservative treatment.53 In
by th objects being chewed. While closing of th
addition to pain in th muscles and joint during movement,
mouth against a relatively low bite resistance, such as
th signs and symptoms include joint sounds, reduced molar
on a soft grape as depicted in Figure 11-22S, th thin
bite forces, limited ranges in opening of th mouth, tension
intermediate region of th disc is typically in its ideal
headaches, joint locking, referred pain to th face and scalp,
position between th condyle and articular eminence.
and nocturnal bruxism (i.e., excessive grinding of th teeth
During th application of a large, asymmetrical bite
while sleeping).
force, however, th position of th disc may need to be
No single mechanical or physiologic explanation can ac-
adjusted. Unilaterally biting on a hard piece of candy
count for th myriad of symptoms associated with TMD.62
between th molars, for example, momentarily reduces
The pathomechanics involved with a particular disorder may
th intra-articular pressure within th ipsilateral TMJ.
stem from an isolated traumatic event, such as a fall, blow to
Until th candy is crushed, it acts as a spacer between
th face, or severe cervical hyperextension/hyperflexion
th upper and lower jaw, which reduces joint contact.
(whiplash). Often, however, th exact pathomechanics are
During this event, a forceful concentric contraction of
unknown. Little scientific evidence supports a direct cause-
th superior head of th lateral pterygoid muscle can
and-effect relationship between poor occlusion of th teeth
protrude th disc forward, thereby sliding its thicker,
and TMD.9'58
posterior region between th condyle and articular emi
The treatment for TMD is mixed and depends primarily
nence. The thicker surface increases th congruency
on th nature of th underlying problem.17'23'2838 Dentists,
within th joint, helping to stabilize it against th un-
physical therapists, and counselors occasionally collaborate
even forces applied to th mandible as a whole. Fibers
in th treatment of TMD. Surgical intervention is rare and
of th lateral pterygoid that attach to th neck of th
usually performed only when th pain is so great or motion
mandible can brace, if necessary, th condyle against
so limited that th quality of life is significanti reduced. The
th articular eminence.
more common conservative, nonsurgical treatments for TMD
are listed in th box on th following page.
 368 Section III Axial Skeleton

Mechanics of inspira tion

Common Nonsurgical Treatment for Temporomandibular
Disordcrs Include
Exercise and postural correction
Biofeedback/relaxation procedures
Use of cold or heat
Patent education
Joint mobilization
Ultrasound
Behavioral modification
Pharmacotherapy Intercostales
Occlusal therapy (altering tooth structure or jaw positon) externi
Intraoral appltances (splints)
Intercostales
interni

Diaphragm
PART 2: VENTILATION

Ventilation is th mechanical process by which air is inhaled

and exhaled through th lungs and airways. This rhythmic
process persists 12 to 20 times per minute at rest and is
essential to th maintenance of fife. This chapter now fo-
cuses on th kinesiology of ventilation.
Ventilation allows for th exchange of oxygen and carbon
dioxide between th alveoli of th lungs and th blood. This
exchange is essential to oxidative metabolism within muscle
fibers. The process converts Chemical energy stored in ATP
into th mechanical energy needed to move and stabilize th
joints of th body.
The relative intensity of ventilation can be described as FIGURE 11-24. The muscular mechanics of inspiration. A, Ths
quiet or forced. In th healthy population, quiet venlla- analogy shows Boyles law. increasing th volume within a piston
lion occurs during relatively sedentary activities that have reduces th air pressure within th chanrber of th piston. The
low metabolic demands. In contrast, forced ventilation occurs negative air pressure creates suction that draws th outside, higher
during strenuous activities that require rapid and volumi- pressure air into th piston through an aperture at th top of th
nous exchange of air, such as exercising, or in th presence piston. B, A healthy adult shows how contraction of th primary
of some respiratory diseases. A wide and continuous range muscles (diaphragm, scalenes, intercostales) of inspiration inereases
intrathoracic volume, which in turn expands th lungs and reduces
of ventilation intensity exists between quiet and forced venti
alveolar pressure. The negative alveolar pressure draws atmosphenc
lation.
air into th lungs. The descent of th diaphragm is indicated by th
Figure 1 1 - 2 3 shows th lung volumes and capacities in pair of thick, black, vertical arrows.

th normal aduli. As depicted, th total lung capacity is about

5 Vi liters of air. Tidal volume is defned as th volume of air
moved in and out of th lungs during each ventilation cycle.
At rest, tidal volume is about Vi liter, increasing to about
60% of vital capacity during exercise.
Ventilation is driven by a combination of active and pas
sive forces that alters th volume within (he expandable
thorax. In accordance with Boyles law, th volume occupied
by a gas, such as air, is inversely proportional to (he pressure
exerted by th gas. Increasing th volume within th cham-
ber of a piston, for example, lowers th pressure of th
contained air (Fig. 1 1 -2 4 A ). Because air flows spontane-
ously from high to low pressure, th relatively high air
pressure outside th piston forces air into an opening at th
top of th piston. In other words, th negative pressure in
th piston sucks air into th piston.

FIGURE 11-23. The lung volumes and capacities in th normal

aduli are shown. Lung capacity is th sum of two or more volumes. Boyles law States that th volume and p re ss u re exerted by a gas
(With permission from Guyton AC and Hall JE: Textbook of Medi are inversely proportional.
cai Physiology, lOth ed. Philadelphia, WB Saunders, 2000.)
 Chapter 1 1 Kinesiology o f Mastication and Ventilation 369

Much of th physics of human ventilation is based on th

inverse relationship between volume and pressure of a gas.
During inspiration, th imrathoracic volume is increased by
contraction of th muscles that attach to th ribs and ster
mini (Fig. 1124B). As th thorax expands, th pressure
within th interpleural space, which is already negative, is
further reduced, creating a suction that expands th lungs.
The resulting expansion of th lungs reduces alveolar pres
sure below atmospheric pressure, ultimately drawing air
from th atmosphere to th lungs.

m S P E C I A L F O C U S
4
Factors that Can Oppose Expansion of th Thorax
The work performed by th muscles of inspiration must FIGURE 11-25. The bony housing of th thorax is shown along
overcome th naturai elastic recoil of th lung tissue with th enclosed lungs, parietal and visceral pleural, and intercos-
and th joints that compose th thorax. Additional work tal and diaphragmatic muscles. (Modified with permisston from
is performed to overcome th resistance of th inspired McNaught AB and Callander R: Illustrated Physiology. New York,
air as it passes through th extensive airways. The Churchill Livingstone, 1975.)
amount of air that reaches th alveoli depends on th
reduced alveolar pressure, which is determined in part
by th net effect of muscle contraction and th me-
naturally decreased by th elastic recoil of lungs, thorax, and
chanical properties that oppose thoracic expansion.
connective tissues of stretched inspiratory muscles. Forced
Several factors can oppose expansion of th thorax.
expiration, such as that required to cough or blow out a
Advanced age, for example, is associated with in
candle, requires th active force produced by expiratory
creased stiffness of th joints and connective tissues
muscles, such as th abdominals.
that make up th thorax.18 The lung parenchyma, how-
ever, loses elastic recoil and becomes more compliant
with aging. Compliance, in this context, is a measure of ARTHROLOGY
th distensibility of th lungs produced for a given drop
in transpulmonary pressure or th slope of th volume- Thorax
pressure curve. When combined, th total System (tho
rax and lungs) shows a net decrease in compliance The rib cage, or thorax, is a closed System that functions as
with aging.68 A greater reduction in pressure is required th mechanical bellows of ventilation (Fig. 1 1 -2 5 ). The in
to inspire a given volume of air. In effect, muscles have ternai aspect of th thorax is sealed from th outside by
to work harder during inspiration. This partially explains several structures (Table 1 1 - 4 ) . Although this chapter fo-
why aging is typically associated with a slight decrease
in tidal volume and slight increase in respiratory fre-
quency.
Diseases or abnormal postures can also oppose tho TABLE 1 1 - 4 . Tissues that Seal th Thorax
racic expansion. Rheumatoid arthritis, for example, can
increase th stiffness of th cartilage of th sternocos- Posterior-laterally
tal joints, thereby resisting an increase in intrathoracic
volume. Severe scoliosis or kyphosis may physically thoracic vertebrae
limit th expansion of th thorax. ribs
intercostal muscles and membrane
Anteriorly
costai cartilages
Expiration s th process of expiring (exhaling) air from sternum
th lungs into th environment. In accord with th analogy intercostal muscles and membranes
to th piston previously described, decreasing th volume
within th chamber of a piston increases th pressure on th
Superiorly
contained air, forcing it outward. Expiration in th human upper ribs and clavicles
occurs by a similar process. Reducing th intrathoracic vol cervical fascia that surrounds th esophagus and trachea
ume increases th alveolar pressure, thereby driving air from cervical muscles
th alveoli to th atmosphere.
Inferiorly
Quiet expiration is primarily a passive process that does
not depend on muscle activation. When th muscles of in diaphragm muscle
spiration relax after contraction, th intrathoracic volume is


370 Section III Axial Skeleton

cuses on th thorax as a mechanical bellows, th thorax also S te rn o co sta l jo in t

(1) protects cardiopulmonary organs and large vessels; (2)
serves as a structural base for th cervical spine; and (3)
C o s to c h o n d ra l C h o n d ro s te rn a l
provides a site for attachment of muscles thai move and
ju n c tio n ju n c tio n (u n d e r ra diate
stabilize th head, neck, and upper extremities. and c a p s u la r lig a m e n ts)

Articulations within th Thorax C la v ic u la r fa c e t

1 st rib
The thorax changes shape during ventilation by movement
at five articulations: manubriostemal, sternocostal, interchon-
dral, costotransverse, and costovertebral joints. 2 nd

M a n u b rio s te m a l
lig a m e n t o v e r
Articulations within th Thorax
m a n u b rio s te m a l jo in t
Manubriostemal joint
Sternocostal joints (including th costochondral and chon-
drosternal junctions)
lnterchondral joints
Costotransverse joints
C o sta i fa c e t of th
Costovertebral joints
4 th ch o n d ro ste rn a l
ju n c tio n
(S te rn o co sta l joint)

MANUBRIOSTERNAL JOINT
The manubrium fuses with th body of th stemum at th
manubriostemal joint (Fig. 1 1 -2 6 ). This fibrocartilaginous ar-
X ip h o id p ro ce ss
ticulation is an amphiarthrosis, similar to th strutture of th
pubic symphysis. A partial disc fills th cavity of th manu-
briosternal joint, completely ossifying late in life. Before ossi- ln te rc h o n d ra l lig a m e n ts
fication, th joint may contribute modestly to expansion of in te rch o n d ra l jo in t
th thorax.

FIGURE 11-26. Anterior view of pari of th thoracic wall highlights

STERNOCOSTAL JOINTS
Bilaterally, th anterior cartilaginous ends of th first seven
ribs articulate with th lateral sides of th stemum. In a
broad sense, these articulations may be called sternocostal
joints (see Fig. 1 1 -2 6 ). Because of th intervening cartilage
between th bone of th ribs and th stemum, however,
each sternocostal joint is structurally divided into a costo
chondral and chondrosternal junction.
The costochondral junctions represent th transition be
tween th bone and cartilage of th anterior ends of each
rib. No capsule or ligament reinforces these junctions. The
periosteum of th ribs gradually transforms into th peri-
chondriutn ol th cartilage. Costochondral junctions permit
very little movement.
The chondrosternal junctions are formed between th me
diai ends of th cartilage of th ribs and th small concave
costai facets on th stemum. The first chondrosternal jun c
tion is a synarthrosis, providtng a relatively stiff connection
with th stemum.64 The second through th seventh joints,
however, are synovial in nature, permitting slight gliding
motions. Fibrocartilaginous discs are sometimes present, es-
pecially in th lower joints where cavities are frequently
absent. Each synovial joint is surrounded by a capsule thai is
strengthened by radiate ligaments. An intra-articular ligament
is frequently encountered in th second chondrosternal jun c
tion.64
th manubriostemal joint, sternocostal joints with costochondral
and chondrosternal junctions, and interchondral joints. The ribs are
removed on th left side to expose th costai facets.
INTERCHONDRAL JOINTS
The opposed borders of th cartilages of ribs 6 lo 10 form
small, synovial-lined interchondral joints, strengthened by in
terchondral ligaments (see Fig. 1 1 -2 6 ). Ribs 11 and 12 do
not attach anteriorly to th stemum.
COSTOTRANSVERSE AND COSTOVERTEBRAL JOINTS
The posterior end of th ribs attaches to th vertebral col-
umn via th costotransverse and costovertebral joints. The
costovertebral joints connect th heads of each of th twelve
ribs to th corresponding sides of th bodies of th thoracic
vertebrae. The costotransverse joints connect th articular tu-
bercles of ribs 1 to 10 to th transverse processes of th
corresponding thoracic vertebrae. Ribs 11 and 12 usually
lack costotransverse joints. The anatomy and ligament struc-
tures of these joints are described and illustrated in Chapter
9 (see Fig. 9 - 5 3 ) .
 Chapter 11 Kinesiology of Maslicalion and Ventilation 371

Changes in Intrathoracic Volume During of th axis of rotation that runs through th costotransverse

I
Ventilation
VERTICAL CHANGES
I During inspiration, th vertical diameter of th thorax is
I tncreased primarily by contraction and subsequent lowering
I o f th dome o f th diaphragm musc/e (see Fig. 1 1 -2 4 B ).
I During quiet expiration, th diaphragm relaxes, allowing th
dome to recoil upward to its resting position.
ANTERIOR-POSTERIOR AND MEDIAL-LATERAL
CHANGES
Elevation and depression of th ribs and sternum produce
Icnanges in th anterior-posterior and medial-lateral diameters
of th thorax. To varying degrees, all five articulations within
th thorax contribute to these changes in diameter.
During inspiration, th shaft of th ribs elevates in a path
I generally perpendicular to th axis of rotation that courses
between th costotransverse and costovertebral joints (Fig.
1 1 -2 7 ). The downward sloped shaft of th ribs rotates up
ward and outward, increasing th intrathoracic volume in
both anterior-posterior and medial-lateral diameters. Only a
slight rotation at th posterior joints produces a relatively
large displacement of th shaft of th ribs. This mechanism
is somewhat similar to th rotation of a bucket handle.
The specific path of movement of a given rib clepends
partially on its unique shape, and on th spadai orientation
and costovertebral joints. In th upper six ribs, th axis
makes an approximate 25- to 35-degree angle with th fron-
tal piane; in th lower six tibs, th axis makes an approxi
mate 35- to 45-degree angle with th frontal piane. The
anatomie specimen used to illustrate Figure 1 1 -2 7 A shows
an approxim ate 3 5 -d eg ree angle. This slight d ifferen ce in
angulation causes th upper ribs to elevate slightly more in
th anterior direction, thereby facilitating th forward and
upward movement of th stemum.
The e/evating ribs and stemum create s/ight bending and
twisting movements within th pliable cartilages associated
with th joints of th thorax. As depicted in Figure 1 1 -2 7 6 ,
torsion created in th twisted cartilage within a sternocostal
joint Stores a component of th energy used to elevate th
ribs. The energy is partially recaptured during expiration, as
th rib cage recoils to its relatively constricted state.
Because of th contrast in length of th first seven ribs
and th differences in stiffness between th first and th
remainder of th sternocostal joints, elevation of th ribs
places dissimilar stresses on th lateral edge of th stemum.
Part of th stress may be dissipated by slight movement ai
th manubriosternal joint.
During expiration, th muscles of inspiration relax, allow-
ing th ribs and th stemum to return to their preinspiration
position. The lowering of th body of th ribs combined
with th inferior and posterior movements of th stemum
decreases th anterior-posterior and medial-lateral diameters
of th thorax.

FIGURE 11-27. A top view of

th 5th rib shows th bucket-
handle mechanism of elevation
of th ribs during inspiration.
The ghosted outline of th rib
mdicates its position prior to in
spiration. Elevation of th rib
increases both th anterior-pos
terior (AP) and tnedial-lateral
(ML) diameters of th thorax.
The rib connects to th verte-
bral column via costotransverse
and costovertebral joints (A)
and to th stemum via th ster
nocostal joint (B). During eleva
tion, th neck of th rib moves
about an axis of rotation that
courses between eacb costo
transverse and costovertebral
joint. The elevating rib creates a 5th rib
torsion in th cartilage associ
ated with th sternocostal joint.

Superior view
372 Section III Axial Skeleton

MUSCULAR ACT10NS DURING VENTILATION____

An extraordinarily large number of muscles and joints inter-

act during ventilation. The actions of many differem muscles
can produce similar effecis on changirtg intrathoracic vol
ume. The redundancy provides for a very adaptable and
responsive sysiem, a necessity considering th complexity
and simultaneous demands placet! on th muscles that at-
tach to th thorax. With th exception of th diaphragm, th
muscles of ventilation may be concurrently used for other
functions, such as control of movements of th trunk, neck,
and upper extremities.
A great deal s stili to be learned about th function of
th muscles of ventilation. Much of what is known is as-
sumed through irtdirect analysis of muscle actwation. The
indirect analysis includes measurement of fiber type and
cross-sectional data,44 ventilato!ry pressures,7 hum an an d ani
mai EMC,16'155 optical45 and ultrasonic imaging,4 and deter-
mtning th effects of nerve sumulaon.3 Clirtical observations
of th effects of muscle paralysis follow ing spinai cord injury
bave h elp ed in th understanding of th norma! function of FIGURE 1 1 -2 8 . T h e action o f th diaphragm during th tnitiation ci
th muscles.45 inspiration. Key: 1, centrai tendon; 2, muscle fibers (costai part); 3
Any muscle that attaches to th thorax can potentially left crus; 4, righi crus; 5, opening for th aorta; 6, opening for tre
e s o p h a g u s ; 7, part o f th p s o a s m uscle-, a n d 8 , part o f th quadre-
assist with th mechanics of ventilation. A muscle that in-
tus lumborum muscle. (Modified from Kapandji LA: The Physiolop.
creases intrathoracic volume is considered a muse le o f inspira-
of Joints, voi. 3. New York, Churchill Livingstone, 1974).
tion. A muscle that decreases intrathoracic volume is consid
ered a muscle o f expiration. The detailed anatomy and
innervation of th muscles of ventilation are found through-
out Appendix III, Part G in particular DIAPHRAGM
Ihe diaphragm is a dome-shaped, thin, musculotendinous
Muscles of Quiet Inspiration sheet of tissue that separates th thoracic cavity from th
abdominal cavity (Fig. 1 1 - 2 8 ). Its convex upper surface is
The muscles of quiet inspiration are th diaphragm, scalenes, th floor of th thoracic cavity, and its concave lower surface
and intercostales. These muscles are considered primary be- is th roof of th abdominal cavity.
cause they are active during all work intensities. Active con-
The diaphragm has three parts based on bony attach-
traction of th diaphragm muscle is dedicateci totally toward ments: th costai part arises from th upper margins of th
th mechanics of inspiration. The intercostales and scalene lower six ribs; th relatively small and variable sterna! pan
muscles, however, also stabilize and rotate parts of th axial arises from th posterior side of th xiphoid process; and th
skeleton. The mode of action and innervation of th primary
thicker crural part is anchored to th bodies of th upper
muscles of inspiration are summarized in Table 1 1 - 5 .
three lumbar vertebrae through two distinct tendinous at-

TABLE 11 - 5. Primary Muscles of Inspiration

Muscle Mode of Action Innervation Location of Illustrations
Diaphragm 1. The diaphragm increases th vertical diameter Phrenic nerve (ventral ramus C3-5) Chapter 11
of th thorax by lowering and flattening its
dome.
2. Ihe increasing intra-abdominal pressure caused
by th lowering of th diaphragm expands th
lower ribs laterally.
3. Once stabilized by increased intra-abdominal
pressure, continued contraction of th costai
fibers of diaphragm elevates th middle and
lower ribs.
Scalenes The scalene anterior, medius, and posterior elevate Ventral rami of spinai nerves (C3* 7) Chapter 10
th upper ribs and th sternum.
Intercostales The intercostales, especially th parasternal interni, Intercostal nerves (ventral rami T2-12) Chapter 11
elevate th ribs. The intercostales stabilize th
intercostal spaces and prevent an inward col-
lapse of th upper thoracic wall.

The Variable Positions of th Diaphragm
Because of th position of th liver within th abdomen,
th right side of th diaphragm lies slightly higher than
th left. In quiet inspiration, th dome of th diaphragm
drops about 1.5 cm. During forced inspiration, th dia
phragm flattens and may drop 6 to 10 cm.64 At maximum
inspiration, th right sides descend to th level of th
body of T11; th left side descends to th level of th
body of T12.
In th upright position, gravity lowers th position of
th abdominal contents. For this reason, th dome of
th diaphragm rests lower while standing or sitting
compared with being supine. Persons with dyspnea, or
"shortness of breath" associated with respiratory dis-
ease, often feel that they can breathe more easily while
sitting. The diaphragm can contract a greater distance
before encountering resistance from th abdominal con
tents in th sitting position.
tachments known as th right and left crus. Two aponeurotic
arches attach th diaphragm to th external surfaces of th
quadratus lumborum and psoas major muscles. The crural
part of th diaphragm contains th longest and most verti-
cally oriented fibers.
The three sets of peripheral attachments of th diaphragm
converge to form a centrai tendon at th upper dome of th
muscle. Each half of th diaphragm receives its innervation
via th phrenic nerve, with nerve roots originating from
ventral roots C3~5, but primarily C4.
The diaphragm is th most important and efficient muscle
of inspiration, performing 70 io 80% of th work of inspira
tion.36 This function is due in part to th muscle's ability to
increase intrathoracic volume in three diameters; vertical,
mediai-iateraf, and anterior-posterior.
With th lower ribs stabilized, th initial contraction of
th diaphragm lowers and flattens its dome. This piston
action increascs th vertical diameter of th thorax as it
simultaneously decreases th vertical diameter of th abdo
men. The descent of th diaphragm is resisted by an increase
in intra-abdominal pressure; by compressed abdominal con
tents; and by passive tension in stretched abdominal mus
cles, such as th transversus abdominis. The increased intra-
abdominal pressure causes th lower ribs to expand laterally.
The naturai resistance provided by th abdomen stabilizes
th dome of th diaphragm, allowing continued contraction
of th costai part of th muscle to elevate th ribs. The
elevation can be visualized by reversing th direction of th
arrowheads in Figure 1 1 - 2 8 . The action of th diaphragm
on th ribs expands th middle and lower thorax in both
anterior-posterior and medial-lateral diameters.
SCALENE MUSCLES
The scalenus anterior, medius, and posterior muscles attach be-
tween th cervical spine and th upper two ribs (see Chapter
Chapter 11 Kinesiology of Mastication and Ventilation 373
10). By assuming that th cervical spine is well stabilized,
bilateral contraction of th muscles increases intrathoracic
volume by elevating th upper ribs and attached sternum.
The scalene muscles are active along with th diaphragm
during every inspiration cycle.12
INTERCOSTALES MUSCLES
Anatomy of th Intercostales Muscles
The intercostales are a thin, three-layer set of muscles that
occupy th intercostal spaces. Each set of intercostal muscles
within a given intercostal space is innervated by an adjacent
intercostal nerve.
The intercostales extem i are most superficial, analogous in
depth and fiber direction to th obliquus abdominis extemus
muscles (see Chapter 10). There are eleven per side, and
each intercostalis extemi arises from th lower border of a
rib and inserts on th upper border of th rib below (see
Fig. 1 1 - 2 5 , see right side). Fibers travel obliquely between
ribs in an interior and m ediai direction. The intercostales
ex tem i are most d ev elop ed laterally. Near th sternum, th
intercostales exterm are very thin and terminate as th ante
rior intercostal membrane.
The intercostales interni are deep to th extemi and are
analogous in depth and fiber direction to th obliquus ab
dominis intemus. There are also eleven per side, and each
intercostalis interni occupies one intercostal space, in a man-
ner similar to th intercostalis externi. A major difference,
however, is that th fibers of th intercostales interni travel
perpendicular to th fibers of th intercostales externi (Fig.
1 1 - 2 5 , see right side). The intercostales interni are most
developed in th parasternal region; posteriorly, they termi
nate as th posterior intercostal membrane.
The intercostales intimi muscles are th deepest and least
developed o f th intercostales. T hey run para Ilei and d eep to
th intercostales interni. Fibers of th intercostales intimi
near th angle of th ribs, often called th subcostales, may
cross one or two intercostal spaces. The intercostales intimi
are most developed in th lower thorax.
Function of th Intercostales Muscles
By spanning each intercostal space, an intercostalis muscle
has th potential to alter th volume within th thorax by
elevating a lower rib, depressing an upper rib, or performing
both actions. The spedite strategy used by th different in
tercostales muscles during th different phases of ventilation
is an uncertain and a controversial topic.24 The conventionai
teaching is that th intercostales externi are more associated
with inspiration, and th interni are more associated with
expiration .63-64 Although this association has been shown in
EMG studies, simple functional distinction is not clear.12'35-55
For instance, both th intercostales extemi and interni have
been shown to be active during inspiration.16 Research also
suggests that th parasternal intercostales interni are consist-
ently more active during inspiration than th more lateral set
of intercostales muscles.24 The lateral set of intercostales (in
terni and extemi) show considerable activation during axial
rotation of th trunk. In a similar manner as th oblique
abdominals (see Chapter 10), th more lateral intercostales
externi are most active during contralateral trunk rotation.
374 Sedioli III Axial Skeleton

and th more lateral intercostales interni are most active
during ipsilateral trunk rotation.55
In summary, th human body apparently has several
strategies available for activating th intercostales. Both sets
of muscles may elevate or depress th ribs, depending on
th workload placed on th ventilatory System and th
torque demands placed on th trunk as a whole, and which
of th two adjacent ribs is freest to move.14
One function of th intercostales that is clear is their
ability to stabilize th intercostal spaces. During inspiration,
th intercostales muscles contract to stiffen th rib cage.4
With th assistance of th scalene muscles, th splinting
action prevents th thoracic wall from being partially sucked
tnward by th reduced intrathoracic pressure caused by con-
traction of th diaphragm.11
Muscles of Forced Inspiration
Forced inspiration requires additional muscles to assist th
primary muscles of inspiration. As a group, th additional
muscles are referred to as muscles o f fo rced inspiration, or
accessory muscles o f inspiration. Tabie 1 1 - 6 shows a sample
of th mode of action of several muscles of forced inspira
tion. Each muscle has a line-of-action that can directly or
indirectly mcrease intrathoracic volume. The muscles listed
in Table 1 1 - 6 are illustrated elsewhere in this textbook. The
serratus posterior superior and serratus posterior inferior,
however, are illustrated in Figure 1 1 - 2 9 ; th levator costae
muscles are illustrated in Figure 1 0 -1 2 .
The muscles of forced inspiration are typically used in
healthy persons to increase both th rate and volume of
inspired air. These muscles may also compensate for th
dysfunction of one or more of th primary muscles of inspi
ration, such as th diaphragm. This compensation is fre-
quently employed in persons with severe chronic obstructive
pulmonary disease.
Chronic Obstructive Pulmonary Disease: Altercd
Muscle Mechanics
Chronic obstructive pulmonary disease (COPD) is a disordei
that typically incorporates three components: (1) chronic
bronchitis, (2) emphysema, and (3) asthma. Symptoms in
clude chronic inflammation and narrowing of th bronchi-
oles, chronic cough, and mucus-filled airways, with overdis-
tension and destruction of th alveolar walls. A significarti
complication of COPD is elastic recoil loss within th lungs
and collapsed bronchioles. As a result, air remams trapped
in th lungs at th end of quiet or forced expiration. This

S P E C I A L FOCUS 1 1 -
?I
"Paradoxical Breathing" Following Cervical Spinai Cord
Injury
In th healthy person, ventilation typically involves a char-
acteristic pattern of movement between th thorax and
abdomen. During inspiration, th thorax expands out-
wardly owing to th elevation of th ribs and sternum.
The abdomen may protrude slightly because of th ante-
rior displacement of th abdominal viscera, compresseti
by th descending diaphragm.
A complete cervical spinai cord injury below th C4
vertebra does not paralyze th diaphragm because its
innervation is primarily from th C4 nerve root. The inter
costales and abdominal muscles, however, are typically
totally paralyzed. The patient with this level of spinai cord
injury often displays a "paradoxical breathing" pattern.45
The pathomechanics of this breathing pattern provide in-
sight into th normal interaction of th diaphragm, inter
costales, and abdominal muscles during inspiration.
Without th splinting action of th intercostales across
th intercostal spaces, th lowering of th dome of th
diaphragm creates an internai suction within th chest
that constricts th upper thorax, especially in its anterior-
posterior diameter. The term paradoxical breathing de-
scribes th constriction, rather than th normal expansion,
of th rib cage during inspiration.45 The constriction of th
thorax can reduce th vital capacity of a person with an
acute cervical spinai cord injury. In th healthy adult, vital
capacity is about 4000 mL. About 3000 mL of this capa
city is accounted for by contraction and full descent of
th diaphragm. The vital capacity of a person immediately
following a C4 spinai cord injury may fall as low as
300 mL.64 Although th diaphragm may be operating at
near normal capacity, th constricting, rather than th
normally expanding, thorax limits th inhalation of 2700 mL
of air. Several weeks following a spinai injury, however,
th atonie (flaccidi intercostales typically become hyper-
tonic. The increased muscle tone can act as a spfint to
th thoracic wall, as evident by th fact that vital capacity
in an average size adult with a C4 or below injury often
returns to near 3000 mL.
In addition to th constriction of th upper thorax dur
ing inspiration, a person with an acute cervical injury
often displays marked forward protrusion of th abdomen
during inspiration. The atonie and paralyzed abdominal
muscles offer little resistance to th forward migration of
th abdominal contents. Without this resistance, th con-
tracting diaphragm has little leverage to expand th mid
dle and lower ribs. These pathomechanics also contribute
to th loss of vital capacity following a cervical injury.
While seated, th person with an acute cervical spinai
cord injury may benefit from an elastic abdominal binder.
In th seated position, th dome of th diaphragm rests
lower than in th supine position. An abdominal binder
can offer beneficiai resistance to th descent of th dia
phragm until th anticipated return of firmness in th
muscles that support th anterior abdominal wall.2'
 Chapter 11 Kinesiology of Masticatori and Ventilatori 375

TABLE 1 1 - 6 . Muscles o f Forced Inspiration

Muscle Mode of Action Innervano Location of Illustrations

Serratus postenor su- Increases intrathoracic volume by elevating lntercostal nerves (ventral rami T2-5) Chapter 11
perior th upper ribs

Serratus postenor infe- Stabilizes th lower ribs for contraction of lntercostal nerves (ventral rami Chapter 11
rior th diaphragm -p-1 2 )
Levator costae (longus Increases intrathoracic volume by elevating Branches of dorsi rami of adjacent Chapter 10
and brevis) th upper ribs thoracic spinai nerves
Stemocleidomastoid Increases intrathoracic volume by elevating Primary source: spinai accessory Chapter 10
th sternum and upper ribs nerve (cranial nerve XI)
Latissimus dorsi Increases intrathoracic volume by elevating Thoracodorsal nerve (C6-8) Chapter 5
ribs; this function requires th arms to
be ftxed.

lltocostalis thoracts and Increases intrathoracic volume by extend- Adjacent dorsal rami of spinai Chapter 10
cervicis (erector spi- ing th trunk; stabilizes th neck for nerves
nae) contraction of th stemocleidomastoid
and scalenes.
Pectoralis minor Increases intrathoracic volume by elevating Mediai pectoral nerve (C7-*) Chapter 5
th upper ribs; requires activation from
muscles such as trapezius and levator
scapulae to stabilize th scapula.
Pectoralis major (ster Increases intrathoracic volume by elevating Lateral and mediai pectoral nerves Chapter 5
na! head) th middle ribs and sternum; this fune- (C-T 1)
don requires th arms to be fixed.
Greater flexion or abduction of th shoul-
ders increases th vertical line-of-force
of th muscle fibers relative to its tho
racic attachments: this strategy increases
th effectiveness o f this muscle in ex-
panding intrathoracic volume.
Serratus anterior Increases intrathoracic volume by elevating Long thoracic nerve (C5-7) Chapter 5
th ribs.

Quadratus lumborum Stabilizes th lower ribs for contraction o f Ventral rami o f T'--L Chapter 10
th diaphragm during early forced in
spiration.

complication is caled hyperinflation o f th ungs, 10-54 In ad-
vanced cases, th thorax remains in a chronic state of near
full inflation, regardless of th actual phase of ventilation.
The thorax of a person with COPD, therefore, typically de-
velops a barrel-shaped appearance.
The excessive air in th ungs at th end of expiration
alters th geometry of th muscles of inspiration, especially
;he diaphragm. Throughout th ventilation cycle, th dia
phragm flattens and remains abnormally low in th thorax.
rhe change in position and shape of th diaphragm alters its
i-esting length and line-of-force.41 These two factors reduce th
dfectiveness of th diaphragm during inspiration. Operating
H a shortened length on its length-tension curve compro-
nises force production. Furthermore, functioning in a low-
:red position redireets th line-of-force of th costai fibers of
he diaphragm more horizontally. This robs th muscles
iffectiveness at elevating th ribs. At a low enough position,
th lin e-of-force o f th m u scle can paradoxically draw th
lower ribs inward, thereby inhibiting inspiration.
Because of th compromised function of th diaphragm,
persons with advanced COPD often depend on muscles of
forced inspiration in addition to other primary muscles of
inspiration. Even at rest, ventilation appears labored. Muscles
such as th scalenes, stemocleidomastoid, erector spinae,
and pectoralis major can be observed contracting. Often, a
person with COPD may stand or walk with th body par-
tially bent over while placing one or both arms on a stable
object, such as th back of a chair, grocery cart, or walker.2
This strategy stabilizes th distai attachments of arm muscles,
such as th sternal head of th pectoralis major and latissi
mus dorsi. As a consequence, these muscles can assist with
inspiration by elevating th sternum and ribs. Although this
method increases th number of muscles available to assist
with inspiration, it also increases th workload of standing
 376 Section ili Axial Skeleton

transversus abdominis (see Chapter 10). Contraction of these

muscles has a direct and indirect effect on forced expiration
(Fig. 1 1 - 3 0 ). By acting directly, contraction of th abdomi
nal muscles flexes th thorax and depresses th ribs and
stemum. These actions can rapidly and forcefully reduce
intrathoracic volume, such as when coughing, sneezing, or
vigorously exhaling to th limits of th expiratory reserve
volume (see Fig. 1 1 - 2 3 ). When acting indirectly, contrac
tion of th abdominal muscles especially th transversus
ab d om in is increases th intra-abdom inal pressure and
compresses th abdominal viscera. The increased pressure
can forcefully push th relaxed diaphragm upward, well into
th thoracic cavity. In this manner, active contraction of th
abdominal muscles takes advantage of th parachute-shaped
diaphragm to help expel air from th thorax. As described in
Chapter 10, th increased intra-abdominal pressure is also
used during activities involving th Valsalva maneuver, in-
cluding defecation, childbirth, and lifting of heavy loads.
A lthough che abdom in al musdes are described here as
muscles of forced expiration, their contraction also enhances
inspiration. As th diaphragm is forced upward at maximal
expiration, it is stretched to an optimal point on its length-
tension curve. As a consequence, th muscle is more pre-

Mechanics of forced expiration

FIGURE 11-29. A posterior view shows th serratus posterior supe-

rior and serratus posterior inferior muscles. These are cortsidered as
th intermediate muscles of th back, located deep to th rhom-
boids and th latissimus dorsi. (Modifted with permission from Intercostales
Luttgens K and Hamilton N: Kinesiology: Scientifc Basis of Human Transversus interni
Motion, 9th ed. New York, McGraw-Hill, 1997. With permission of thoracis
th McGraw-Hill Companies.) externus
Transversus
and walking, often starting a vicious circle of increased fa- abdominis
tigue and dyspnea. Rectus
abdominis

Muscles of Forced Expiration

Quiet expiration is normally a passive process, driven pri-
marily by th elastic recoil of th thorax, lungs, and relaxing
diaphragm. In th healthy lungs, th increased alveolar pres
sure associated with th passive process is sufficient to ex-
hale th approximately 500 mL of air normally associated
with quiet expiration.
During forced expiration, active muscle contraction is re-
quired to rapidly reduce intrathoracic volume. Muscles of
forced expiration include th four abdominal muscles, trans
versus thoracis, and intercostales. The modes of action of th
muscles of forced expiration are summarized in Table 1 1 -7 .
FIGURE 11-30. Muscle activation during forced expiration. Contrac
tion of abdominal muscles, transversus thoracis, and intercostales
ABDOMINAL MUSCLES interni are shown increasing both intrathoracic and intra-abdominal
pressures. The passive recoil of th diaphragm is indicated by th
The abdominal muscles include th rectus abdominis, obli- pair of thick, black, venical arrows. The intercostales extemi may
quus externus abdominis, obliquus intemus abdominis, and be active in varying degrees; however, that is not shown.
 Chapter 11 Kinesiology of Mastication and Ventilation 377

Stem um

T ransversus Intercostales
thoracis interni Important Physiologic Functions of th Abdominal
Muscles
Forceful expiration is driven primarily by th abdominal
muscles. These muscles are included in several physio
logic functions, including singing, laughing, coughing,
and adequately responding to a "gag" reflex when
choking. The latter two functions are particularly vital to
health and safety. Coughing or vigorously "clearing th
throat" is a naturai way to remove secretions from th
bronchial tree, thereby reducing th likelihood of lung
infection. A sfrong contraction of th abdominal mus
cles is also used to dislodge objects lodged in th
trachea.
Persons with weakened or completely paralyzed ab
dominal muscles must learn alternative methods of
coughing or have others "manually" assist with this
function. Consider, for example, a person with a com
Diaphragm T ransversus
plete spinai cord lesion at th T4 level. Because of th
abdom inis
innervation of th abdominal muscles (ventral rami of
FIGURE 11-31. An internai view of th anterior thoracic wall shows
T7-L'), that person would likely have completely para
th transversus thoracis (red), intercostales interni, diaphragm, and
lyzed abdominal muscles. Persons with paralyzed or
transversus abdominis. (Modified with permission from Luttgens K
very weakened abdominal muscles must exercise extra
and Hamilton N: Kinesiology: Scientific Basis of Human Motion,
9th ed. New York, McGraw-Hill, 1997 With pennission of th caution to prevent choking.
McGraw-Hill Companies.)

pared to initiate a more forceful contraction at th next
inspiration cycle.
TRANSVERSUS THORACIS AND INTERCOSTALES
The transversus thoracis muscle, also known as th triangu-
laris stemi or sternocostalis, is a muscle of forced expiration.
The muscle is located on th internai side of th thorax,
fanning in an oblique and inferior direction between th
upper ftve ribs and th stemum (Fig. 1 1 -3 1 ). The muscles
neural activation is coupled with that of th abdominal mus
cles during forced expiration.15
The intercostales, especially th interni fibers, depress th
ribs during forced expiration.12

TABLE 1 1 - 7 . Muscles of Forced Expiration

Location of
Muscle Mode of Action Innervation lllustrations

Abdominal muscles
rectus abdominis
obliquus extemus abdominis
obliquus internus abdominis
transversus abdominis
Transversus thoracis
1. Decreases intrathoracic volume by flexing th Intercostal nerves; ventral Chapter 10
trunk and depressing th ribs. rami T7-Ll.
2. Compresses th abdominal wall and contents,
which increases intra-abdominal pressure; as a re-
sult, th relaxed diaphragm is pushed upward, de-
creasing intrathoracic volume.
Decreases intrathoracic volume by depressing th ribs. Intercostal nerves (adjacent Chapter 11
ven erai r a m i)

Intercostales The intercostales, especially th interni fibers, de- Intercostal nerves; ventral Chapter 11
crease intrathoracic volume by depressing th ribs. rami T2-T 12
 378 Section III Axia! Skeleton
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 A p p e n d i x III
MUSCLES OF THE A X IA L SKELETON Part B: M u scle s of th Craniocervical Part C: M iscellaneous: The Quadratus
Part A: M u scle s of th Trunk Region Lumborum
S e t I: M u s c le s o f th P o s te rio r T ru n k S e t I: M u s c le s o f th A n te rio r-la te ra l Part D: M uscles of M astication
S et II: M u s c le s o f th A n te rio r-la te ra l C ra n io c e rv ic a l R egion Part E: Suprahyoid M uscles
T ru n k S e t II: M u s c le s o f th P o s te rio r Part F: Infrahyoid M uscles
C ra n io c e rv ic a l R egion Part G: M u scle s Related Prim arily to
Ventilation

Part A: Muscles of th Trunk Spinalis Cervieis

Inferior attachments: ligamentum nuchae and spinous proc
SET 1: MUSCLES OF THE POSTERIOR TRUNK
esses of C 7 -T 1
Superior attachments: spinous process of C2
See Appendix li for attachments and innervations of th
Spinalis Capitis
muscles in th superficial layer of th posterior trunk (trape-
Blends with semispinalis capitis
zius, latissimus dorsi, serratus anterior, and so forth).
Innervation to th erector spinae: dorsal rami of adjacent
Erector Spinse Group spinai nerves (C3- L 3)
Iliocostalis, Longissimus, and Spinalis Muscles
Transversospinal Group
Iliocostalis Lumborum Multifidi, Rotatores, and Semispinalis Muscles
Injeror attachments: common tendon*
Superior attachments: inferior surface of th angle of ribs 6 Multifidi
to 12 Inferior attachments (lumbar): mammillary processes of
lumbar vertebrae, lumbosacral ligaments, deep part of
Iliocostalis Thoracis th common tendon of th erector spinae, posterior
Inferior attachments: upper surface o f th angle of ribs 6 to surface of th sacrum, posterior-superior iliac spine of
' 12 th pelvis, and th capsule of th lumbar and lumbo
Superior attachments: angle of ribs 1 io 6 sacral apophyseal joints
Iliocostalis Cervieis Inferior attachments (thoracic): transverse processes of
Inferior attachments: angle of ribs 3 to 7 ' TI 12
Superior attachments: posterior tubercles of th transverse Inferior attachments (cervica!): articular processes of C 3 - 7
processes of C 4 - 6 Superior attachments: spinous processes of vertebrae lo
cateci 2 - 4 intervertebral segments superior
Longissimus Thoracis Innervation: dorsal rami of adjacent spinai nerves ( O - S 3)
Inferior attachments: common tendon
Superior attachments: transverse processes of T I - 1 2 and Rotatores: Longus and Brevis
areas between th tubercle and angle of ribs 3 lo 12 Inferior attachments: transverse processes of all vertebrae
Superior attachments: spinous processes o f vertebrae lo
Longissimus Cervieis cateci 1 to 2 intervertebral segments superior
Inferior attachments: transverse processes of T I - 4 Note: th rotator longus crosses two intervertebral junc-
Superior attachments: posterior tubercles of th transverse tions; th more horizontal rotator brevis crosses only
processes o f C 2 - f one intervertebral junction.
Longissimus Capitis Innervation: dorsal rami of adjacent spinai nerves ( 0 - 0
Inferior attachments: transverse processes of T 1 - 5 and ar- Semispinalis Thoracis
ticular processes of C 4 - 7 Inferior attachments: transverse processes of T 6 - 1 0
Superior attachments: posterior margin of th mastoid proc- Superior attachments: spinous processes of C 6 -T 4
ess of th temporal bone
Semispinalis Cervieis
Spinalis Thoracis Inferior attachments: transverse processes of T I - 6
Inferior attachments: common tendon Superior attachments: spinous processes of C 2 - 5 , primar
Superior attachments: spinous processes of T I - 6 ily C2
Semispinalis Capitis
This broad tendon connects th inferior end of most of th erector Inferior attachments: transverse processes of C 7 -T 7 and
spinse to th base of th axial skeleton. The specifc attachments of th cen articular processes of C 4 - 6
trai tendon include median sacrai crests, spinous processes and supraspinous
ligaments in th lower thoracic and entire lumbar region, iliac crests, sacrolu-
Superior attachments: between th superior and inferior
berous and sacroiltac ligaments, gluteus maximus, and multifidi muscles. nuchal lines of th occipital bone
381
 382 Appendix III
Innervation to th semispinalis muscles: dorsal rami of adja-
cent spinai nerves ( G - T 6)
Short Segmentai Group
Interspinalis and Intertransversarus Muscles
Interspinalis Muscles
These paired muscles attach regularly between adjacent
spinous processes within th cervical vertebrae, except C I
and C2, and th lumbar vertebrae. In th thoracic spine, th
interspinalis muscles exist only at th extreme upper and
lower regions.
Innervation: dorsal rami of adjacent spinai nerves (C3- L 5)
Intertransversarus Muscles
These paired right and left muscles attach between adja
cent transverse processes of all cem cal, lower thoracic, and
lumbar vertebrae. In th cem cal region, th intertransversa
rus muscles are subdivided imo small anterior and posterior
muscles, indicating their position relative to th anterior and
posterior tubercles of th transverse processes, respectively.
In th lumbar region, th intertransversarus muscles are sub
divided into small lateral and mediai muscles, indicating
their relative position between th transverse processes.
Innervation: th anterior, posterior, and lateral intertrans
versarus muscles are innervated by ventral rami of ad
jacent spinai nerves (C3- L 5); th mediai intertrans
versarus muscles, within th lumbar region, are
innervated by th dorsal rami of adjacent spinai nerves
( L '- L 5).
SET 2: MUSCLES OF THE ANTERIOR-LATERAL TRUNK:
"ABDOMINAL" MUSCLES
Obliquus Externus Abdominis
Lateral attachments: lateral side of ribs 4 to 12
Mediai attachments: anterior half of th outer lip of th
iliac cresi, linea alba, and contralateral rectus sheaths
Innervation: intercostal nerves (T8- T 12), iliohypogastric
(L1), and ilioinguinal (L1) nerves
Obliquus Internus Abdominis
Lateral attachments: anterior two thirds of th middle lip
of th iliac cresi, inguinal ligament, and thoracolumbar
fascia
Mediai attachments: ribs 9 to 12, linea alba, and contralat
eral rectus sheaths
Innervation: intercostal (T8- T 12), iliohypogastric (L1), and
ilioinguinal (L 1) nerves
Rectus Abdominis
Superior attachments: xiphoid process and cartilages of ribs
5 to 7
Inferior attachments: crest of pubis and adjacent ligaments
supporting th pubic symphysis joint
Innervation: intercostal nerves (T7- T 12)
Transversus Abdominis
Lateral attachments: anterior two thirds of th inner lip of
th iliac crest, thoracolumbar fascia, inner surface of
th cartilages of ribs 6 to 12, and inguinal ligament
Mediai attachments: linea alba and contralateral rectus
sheaths
Innervation: intercostal (T T 12), iliohypogastric (L1), and
ilioinguinal (L1) nerves
Part B: Muscles of th Craniocervical Region
SET 1: MUSCLES OF THE AIMTERIOR-LATERAL
CRANIOCERVICAL REGION
Longus Capitis
Inferior attachments: anterior tubercles of transverse proc
esses of C 3 - 6
Superior altachment: inferior surface of th basilar part of
th occipital bone, immediately anterior to th attach-
ment o f th rectus capitis anterior
Innervation: ventral rami of spinai nerves ( O - C 5)
Longus Colli
S u p e r i o r O b l i q u e P o r t io n
Inferior attachments: anterior tubercles of transverse proc
esses o f C 3 - 5
Superior attachment: tubercle on anterior arch of CI
V e r t i c a l P o r t io n
Inferior attachments: anterior surface of th bodies of
C 5 -T 3
Superior attachments: anterior surface of th bodies of
C 2 -4
I n fe r io r O b liq u e P o r tio n
Inferior attachments: anterior surface of th bodies of
T l-3
Superior attachments: anterior tubercles of transverse proc
esses of C 5 - 6
Innervation: ventral rami of spinai nerves (C2- C 8)
Rectus Capitis Anterior
Inferior attachment: anterior surface of th transverse proc
ess of CI
Superior attachment: inferior surface of th basilar pari of
th occipital bone immediately anterior to th occipital
condyle
Innervation: ventral rami of spinai nerves (C l- C 2)
Rectus Capitis Lateralis
Inferior attachment: superior surface of th transverse proc
ess of C I
Superior attachment: inferior surface of th occipital bone
immediately lateral to th middle section of th occipi-
tal condyle
Innervation: ventral rami of spinai nerves (C * -C 2)
Scalenes
Scalenus Anterior
Superior attachments: anterior tubercles of th transverse
processes of C 3 - 6
Inferior attachment: inner border of first rib
Scalenus Medius
Superior attachments: posterior tubercles of th transverse
processes of 0 1 - 1
Inferior attachment: upper border of th first rib, posterior
to th attachment ol th scalenus anterior
Scalenus Posterior
Superior attachments: posterior tubercles of th transverse
processes of C 5 - 7
Inferior attachment: extemal surface of th second rib
Innervation to th scalene muscles: ventral rami of spinai
nerves (C3- C 7)

Sternocleidomastoid
Injerior attachments: stemal head, anterior surface of th
upper aspect of th manubrium of th sternum; clavic-
ular head; posterior-superior surface of th mediai one
third of th clavicle
Superior attachments: lateral surface of th mastoid process
of th temporal bone and lateral one half of th supe
rior nuchal line of th occipital bone
Innervation: spinai accessory nerve (cranial nerve XI). A
secondary source of innervation is through th ventral
rami of th mid and upper cervical plexus, which may
carry sensory (proprioceptive) information.
SET 2: MUSCLES OF THE POSTERIOR
CRANIOCERVICAL REGION
Splenius Capitis
Injerior attachments: inferior half of th ligamentum nu-
chae and spinous process of C 7 -T 4
Superior attachments: mastoid process of th temporal
bone and th lateral one third of th superior nuchal
line of th occipital bone. These attachments are im-
mediately mediai to th attachments of th sternoclei
domastoid.
Innervation: dorsal rami o ( spinai nerves (C 2- C g)
Splenius Cervicis
Injerior attachments: spinous process of T 3 - 6
Superior attachments: posterior tubercles of th transverse
processes of C I - 3
Innervation: dorsal rami of spinai nerves (C2- C 8)
Suboccipital Muscles
Obliquus Capitis Inferior
Injerior attachment: apex of th spinous process of C2
Superior attachment: inferior margin of th transverse proc
ess of C I
O b liq u u s C a p itis Superior
Injerior attachment: superior margin of th transverse proc
ess of C I
Superior attachments: between th lateral end of th infe
rior and superior nuchal lines; lateral to th attach
ment of th semispinalis capitis
Reetus Capitis Posterior Major
Inferior attachment: spinous process o f C2
Superior attachment: immediately mediai to th lateral end
of th inferior nuchal line
Reetus Capitis Posterior Minor
Injerior attachment: tubercle on th posterior arch of CI
Superior attachment: immediately anterior to th mediai
end of th inferior nuchal line, just posterior io th
foramen magnum
Inneixation to suboccipital muscles; suboccipital nerve (dor
sal ramus C 1)
Part C: Miscellaneous: Quadratus Lumborum
Quadralus Lumborum
Injerior attachment: iliolumbar ligament and crest of th
ilium
Appendix III 383
Superor attachments: rib 12 and tips of th transverse
processes of th L I - 4
Innervation: T 12' L3 (ventral rami)
Part D: Muscles of Mastication
Massetcr: Comhined Superfcial and Deep Fibers
Proximal attachments: lateral-inferior surfaces of th zygo-
matic bone and mferior surfaces of th zygomatic arch
Distai attachment: external surface of th mandible, be-
tween th angle and just below th coronoid process
Innervation: branch of th mandibular nerve, a division of
cranial nerve V
Temporalis
Proximal attachments: temporal fossa and deep surfaces of
temporal fascia
Distai attachments: apex and mediai surfaces of th coro
noid process of th mandible and th entire anterior
edge of th ramus of th mandible
Innervation: branch of th mandibular nerve, a division of
cranial nerve V
Mediai Pterygoid
Proximal attachment: mediai surface of th lateral ptery
goid piate
Distai attachment: internai surface of th mandible be
tween th angle and mandibular foramen
Innervation: branch of th mandibular nerve, a division of
cranial nerve V
Lateral Pterygoid
S u p e r io r H e a d
Proximal attachment: greater wing of th sphenoid bone
In fe r io r H ea d
Proximal attachment: lateral surface of th lateral pterygoid
piate
Distai attachments: pterygoid fossa on th mandible and
th articular disc an d capsule o f th tem porom andibu -
lar joint
Innervation; branch of th mandibular nerve, a division of
cranial nerve V
Part E: Suprahyoid Muscles
Digastric: Posterior Belly
Proximal attachment: mastoid notch o f th temporal bone
Distai attachment: facial sling attached to th lateral aspect
of th hyoid bone
Innervation: facial nerve (cranial nerve VII)
Digastric: Anterior Belly
Proximal attachment: fasciai sling attached to th lateral
aspect of th hyoid bone
Distai attachment: base of th mandible near its midiine
(digastric fossa)
Innervation: inferior alveolar nerve (branch of th mandib
ular nerve, a division of cranial nerve V)
Geniohyoid
Proximal attachment: small region at th midiine of th
anterior aspect of th mandibles internai surface (sym-
physis menti)
Distai attachment: body of th hyoid bone
 384 Appendix III
Innervation: O via th hypoglossal nerve (cranial nerve
XII)
M y lo h y o id
Proximal attachment: th internai surface of th mandible,
bilaterally on th mylohyoid line
Distai attachment: body of th hyoid bone
Innervation: inferior alveolar nerve (branch o f th mandib-
ular nerve, a di Vision of cranial nerve V)
Slylohyoid
Proximal attachment: base o f th styloid process o f th
temporal bone
Distai attachment: anterior edge of th greater hom of th
hyoid bone
Innervation: facial nerve (cranial nerve VII)
Part F: Infrahyoid Muscles
Omohyoid
Inferior attachment: upper border of th scapula near th
scapular notch
Superior attachment: body of th hyoid bone
Innervation: ventral rami of C ~3
Stcmohyoid
Inferior attachments: posterior surface of th mediai end of
th clavicle, superior-posterior part of th manubrium
stemum, and posterior stemoclavicular ligament
Superior attachment: body of th hyoid bone
Innervation: ventral rami of C ~3
Sternothyroid
Inferior attachments: posterior part of th manubrium of
th stemum and th cartilage of th first rib
Superior attachment: thyroid cartilage
Innervation: ventral rami of C'~3
Thyrohyoid
Inferior attachment: thyroid cartilage
Superior attachment: junction of th body and greater hom
of th hyoid bone
nnenation: ventral rami of C 1 via cranial nerve VII
Part G: Muscles Related Primarily to
Ventilation
Diaphragni
I n fe r io r a tta c h m e n ts
Costai part: inner surfaces of th cartilages and adjacent
bony regions of ribs 6 - 1 2
Stornai part: posterior side of th xiphoid process
Crural (lumbar) part: (1) two aponeurotic arches covering
th external surfaces of th quadratus lumborum and
psoas major muscles; (2) tight and left crus, originat-
ing from th bodies of L I - 3 and their intervertebral
discs
S u p e r io r a tta c h m e n t
Central tendon near th center of th dome of th muscle
Innervation: phrenic nerve (C3-5)
lntercostales Externi
A tta ch m en ts
Eleven per side, each muscle arises from th low er border
of a rib and inserts on th upper border of th rib below
Fibers are th most superficial of th intercostales muscles,
running in an inlerior and mediai direction. Fibers are most
developed laterali/.
lntercostales Interni
A tta ch m en ts
Eleven per side, each muscle arises from th lower border
of a rib and inserts on th upper border of th rib below.
Fibers run in a piane immediately deep to th intercostales
externi. Fibers of th intercostales interni run in an inferior
and slightly lateral direction, nearly perpendicular to th
direction of th intercostales extemi. Fibers of th intercos-
tales interni are most developed adjacent to th stemum,
parastemally.
Intercostales Intimi
A tta ch m en ts
Each muscle arises from th lower border of a rib near iis
angle and inserts on th upper border of th second or ihirc
rib below. Fibers run parallel and deep to th intercostales
interni. Fibers of th intercostales intimi located near th
angle of th ribs, often called subcostales, may cross tw.
intercostal spaces. The intercostales intimi are most deve;-
oped in th lower thorax.
Innervation to th intercostales: intercostal nerves (venirsi
rami T2-12)
I.evatores Costarum
Superior attachments: ends of th transverse processes of
C 7 -T 1 1
Inferior attachments: external surfaces of ribs, betw'een th
tubercle and angle. Each of th twelve muscles attach
to th rib immediately inferior to its vertebral attach
ment.
Innervation: Branches of dorsi rami of adjacent thoracic
spinai nerves
Serratus Posterior Inferior
Superior attachments: posterior surfaces of ribs 9 - 1 2 , neai
their angles
Inferior attachments: spinous processes and supraspinous
ligaments of T 1 1 -L 3
Innervation: intercostal nerves (ventral rami T - 12)
Serratus Posterior Superior
Superior attachments: spinous processes of C 6 -T 3 , includ-
ing supraspinous ligaments and ligamentum nuchae
Inferior attachmenls: posterior surfaces of ribs 2 - 5 , near
their angles
Innervation: intercostal nerves (ventral rami T2" 3)
Transversus Thoracis
Inferior attachments: inner surfaces of th lower third of
th body of th stemum and adjacent surfaces of th
xiphoid process
Superior attachments: internai surfaces of th cartilages of
ribs 2 to 6
Innervation: intercostal nerves (adjacent ventral rami)
 S e c t i o n IV

Lower Extremity
Giunrtriceps
contractinn
S E C T ! O N I V

Lower Extremity
C h a r t e r 12: Hip

C h a r t e r 13: Knee

C h a r t e r 14: Ankle and Foot

C h a r t e r 15: Kinesiology of Walking

A e f e n d ix IV: Reference material on innervation and attachments of th muscles of th

lower extremity

S e c t i o n IV is divided into four chapters. Chapters 12 to 14 describe th kinesiology

of th major articular region within th lower extremity; Chapter 15 describes th
kinesiology of walking, an ultimate functional expression of th kinesiology of th
lower extremity. For either limb, about 60% of th walking cycle is involved in th
stance phase in which th distai end of th extremity is fixed to th ground. During
th swing phase th remaining 40% of th walking cycle th distai end of th
extremity is unconstrained and free to move. Chapters 12 to 14 describe th function
of th muscles and joints from two perspectives: when th distai end of th extremity
is fixed, and when it is free. An understanding of both types of actions greatly
increases th ability to appreciate th beauty and complexity of human movement, as
well as to diagnose, treat, and prevent any related mpairments of th musculoskeletal
System.

386

Donald A. Neum ann , PT, Ph D
0 S T E 0 L 0 G Y , 388
Innominate, 388
lliu m , 388
P ubis, 390
Is c h iu m , 391
A c e ta b u lu m , 391
Femur, 391
"A n g le o f In c lin a tio n ," 392
"T o rs io n A n g le ," 392
In te rn a i S tru c tu re o f th P ro x im a l Fem ur,
394
ARTHROLOGY, 394
Functional Anatomy of th Hip Joint, 394
F em oral H ead, 394
A c e ta b u lu m , 395
A c e ta b u la r A lig n m e n t, 395
C apsule and L ig a m e n ts o f th Hip, 397
Close-packed Position, 400
Osteokinematics, 400
F e m o ra l-o n -P e lv ic O s te o k in e m a tic s , 402
Rotation of th Femur in th Sagittal
Piane, 402
Rotation of th Femur in th Frontal
Piane, 404
Rotation of th Femur in th Horizontal
Piane, 404
P e lv ic -o n -F e m o ra l O s te o k in e m a tic s , 404
INTRODUCTION
The hip is th articu/ation between th farge sphericaf
head of th femur and th deep socket provided by th
acetabulum of th pelvis. This major joint provides simul-
taneous movement between th lower extremity and th
pelvis. Because of its location within th body, a patho-
logic or traumatized hip typically causes a wide range of
functional limilations, including difficulty in walking, dress-
ing, driving a car, lifting and carrying loads, and climbing
stairs.
The hip has many anatomie features that are well suited
for stability during standing, walking, and running. The
femoral head is stabilized by a deep socket that is sur-
C h a p t e r 12
TOPICS AT A GLANCE
Lumbopelvic Rhythm, 404 Overall Function of th Hip Internai
P e lv ic - o n - F e m o r a l R o ta tio n in th Rotators, 415
S a g it t a l P ia n e : T h e A n t e r io r a n d Hip E xte n so r M u s c le s , 415
P o s t e r io r P e lv ic T ilt, 404 Anatomy and Individuai Action, 415
P e lv ic - o n - F e m o r a l R o ta tio n in th F ro n ta l Overall Function of th Hip Extensors,
P ia n e , 406 417
P e lv ic - o n - F e m o r a l R o ta tio n in th Hip A b d u c to r M u s c le s , 420
H o riz o n ta l P ia n e , 406 Anatomy and Individuai Action, 420
Arthrokinematics, 406 Hip Abductor Mechanism, 421
Hip E xte rn a l R o ta to r M u s c le s , 423
M USC LE A N D J O IN T IN TER AC TIO N , 407
Innervation to th M u scle s and Joint, Functional Anatomy of th "Short
407 External Rotators, " 423
S e n s o ry In n e rv a tio n to th H ip, 409 Overall Function of th External
M uscu lar Function at th Hip, 409 Rotators, 424
Hip F le xor M u s c le s , 410 M a x im a l T o rq u e P ro d u c e d by th Hip
Anatomy and Individuai Action, 410 M u s c le s , 424
Overall Function of th Hip Fiexors, Examples of Hip Disease, 425
411 R a tio n a le fo r S e le c te d T h e ra p e u tic and
Hip A d d u c to r M u s c le s , 412 S u rg ic a l In te rv e n tio n , 425
Functional Anatomy, 412 Fracture of th Hip, 426
Overall Function of th Hip Adductors, Hip Osteoarthritis, 426
412 Therapeutic Intervention for a Painful
F ro n ta l P ia n e F u n c tio n o f t h A d d u c t o r s , or Structurally Unstable Hip, 427
413 Surgical Intervention Following
S a g it t a l P ia n e F u n c t io n o f th Fracture or Osteoarthritis, 429
A d d u c t o r s , 413 B io m e c h a n ic a l C o n s e q u e n c e s o f C o x a
Hip In te rn a i R o ta to r M u s c le s , 415 V a ra a n d C o x a V a lg a , 429
rounded by an extensive set of capsular ligaments. Many
large forceful muscles provide th necessary torques needed
to p ro p el th b o d y upw ard an d forward. W eakness in these
muscles has profound impact on th mobility of th body as
a whole.
Hip disease and injury are relatively common, particularly
in th very young and in th elderly. The abnormally formed
hip in an infant is prone to dislocation. The hip in th aged
is vulnerable to degenerative joint disease. Increased osteo-
porosis coupled with increased risk of fading predispose th
elderly to a higher incidence of hip fracture.
This chapter describes th structure of th hip, its associ-
ated capsule and ligaments, and th actions of th surround-
ing musculature. This information is th basis for treatment
387
 388 Section IV Lower Extremity

and diagnosis of musculoskeletal problems in this region of

th body. Osteologie Features of th Ilium
E x t e m a l S u r fa c e
Posterior, anterior, and inferior gluteal lines
Anterior-superior iliac spine
OSTEOLOGY Anterior-inferior iliac spine
Iliac crest
Innominate Posterior-superior iliac spine
Posterior-inferior iliac spine
Eaeh innominate (from th Latin innominatum, meaning Greater sciatic notch
nameless) is th uron of three bones: th ilium, pubis, and Greater sciatic foramen
ischium (Figs. 1 2 - 1 and 1 2 - 2 ). The right and left innomi- Sacrotuberous and sacrospinous ligaments
nates connect with each other anteriorly at th pubic sym- In te r n a i S u r fa c e
physis and posteriorly at th sacrum. The innominate bones Iliac fossa
and th sacrum form th bony pelvis (from th Latin, mean Auricular surface
ing basiti or bowl). While a person stands, th pelvis is Iliac tuberosity
normally oriented so that when viewed laterally, a vertical
line passes between th anterior-superior iliac spine and th
pubic tubercle (see Fig. 1 2 - 1 ). ILIUM
The extemal surface of th innominate has three conspic-
The extemal surface of th ilium is marked by rather fairn
uous features. The large fan-shaped wing (or ala) of th ilium
posterior, anterior, and inferior gluteal lines (see Fig. 1 2 -1 ).
forms th superior half of th innominate. Just below th
These lines help to identify attachment sites of th gluteal
wing is th deep, cup-shaped acetabulum. Just inferior and
muscles to th pelvis. At th most anterior extern of th
slightly mediai to th acetabulum is th large obturator jo ra -
ilium is th easily palpable anterior-superior iliac spine (see
men. This foramen is covered by an obturator membrane (see Figs. 1 2 - 1 and 1 2 - 2 ) . Below this spine is th anterior-
Fig. 1 2 -2 ).
inferior iliac spine. The promi nent iliac crest, th most supe-

Lateral view

Anterior gluteal line

Latissimus dorsi Obliquus internus abdominis

Obliquus externus abdominis

^Vuteus m in imus
Tensor fasciae latae
Gluteus maximus
FIGURE 1 2 -1 . A view from th side
Posterior-superior iliac spine
1 Anterior-superior iliac spine
ot th righi innominate bone. Proxi-
Sartorius rnal attachments of muscle are indi-
Posterior gluteal line
Inferior gluteal line cated in red, distai attachments in
Posterior-inferior iliac spine gray.

W
Anterior-inferior iliac spine

'J Greater
sciatic notety

Ischia! spine
Rectus femoris

Acetabulum

Superior and inferior gemelli

Pectineus
Pubic tubercle
Lesser sciatic notch
fbturator J f Adductor longus
Semimembranosus
Gracilis
Biceps fem oris (long head) Adductor brevis
and semitendinosus Obturator externus
Ischial tuberosity
Adductor Quadratus
magnus femoris
 Chapter 12 Hip 389

A n t e r io r view

rior rim of th ilium, continues posteriorly and ends at th
posteror-superior iliac spine (Fig. 123). The soft tissue su-
perficial to th posterior-superior iliac spine is often marked
by a dimple in th skin. The less prominent posterior-inferior
iliac spine marks th superior rim of th greater sciatic noti.
The opening of this notch is bridged by th sacrotuberous
and sacrospinous ligaments to form th greater sciatic forameli.
The internai aspect of th ilium has two surfaces (see Fig.
1 2 - 2 ). Anteriorly, th smooth concave iliac fossa is filled by
th iliacus muscle. Posteriorly, th aurcular surface articu-
lates with th sacrum at th sacroiliac joint, shown on th
right side in Figure 1 2 - 2 . Just posterior to th auricular
surface is th large, rough iliac tuberosity formed by attach-
ments of sacroiliac ligaments.
390 Section IV Lower Extremity

PUBIS
The superor pubic ramus extends anteriorly from th anterior
wall of th acetabulum to th large flattened body of th
pubis (see Fig. 1 2 - 2 ). On th upper surface of th superior
ramus is th pectineal line, marking th attachment of th
pectineus muscle. The pubic tubero le projects anteriorly from
th superior pubic ramus, serving as an attachment for th
mguinal ligament.

P o s te rio r view

Posterior-inferior
iliac spine

Lesser
sciatic notch

f!Il
U hm
Adductor brevis -

FIGURE 12-3. The posterior aspect of th pelvis, sacrum, and righe proximal femur. Proximal attachments ,
rea, distai attachmenis in gray.
 Chapter 12 Hip 391

The two pubic bones articulate in th midiine by way of Femur

th fibrocartilaginous pubic symphysis joint. This jo in t typi-
cally classified as an amphiarthrosis is lined with hyaline
cartilage and held together by a fibrocartilaginous, interpubic
disc and supportive ligaments. Up to 2 mm of translation
and 3 degrees of rotation occur at th pubic symphysis
jo in t.8385 Structurally, th p u bic sym physis co m p letes th
anterior pelvic ring. As described in Chapter 9, other com-
ponents that form th pelvic ring are th sacrum, th pair of
sacroiliac joints, and th innominate. The pubic symphysis
provides stress relief throughout th pelvic ring during walk-
ing and, in women, during childbirth. The inferior pubic
ramus extends from th body of th pubis posteriorly to th
junction of th ischium (see Fig. 1 2 - 2 ).
The femur is th longest and strongest bone of th human
body (Fig. 1 2 - 4 ). Its shape and robust stature reflect th
powerful action of muscles and contribute to th long stride
length during walking. At its proximal end, th femoral head,
projects m edialy [or an articuation with th acetabulum .
The femoral neck connects th femoral head to th shaft. The
neck serves to dispiace th proximal shaft of th femur
laterally away from th joint, thereby reducing th likelihood
of bony impingement against th pelvis. Distai to th neck,
th femoral shaft courses slightly mediai, thereby placing th
knees and feet closer to th midiine of th body.

ISCHIUM A n te r io r view
Obturator internus
The sharp ischial spine projects from th posterior side of th
and gemelli
ischium, just inferior to th greater sciatic notch (see Fig.
1 2 - 3 ). The tesser sciatic notch is located just inferior to th
spine. The sacrotuberous and sacrospinous ligaments convert
th lesser sciatic notch into a tesser sciatic foram en.

Osteologie Features of th Ischium

Ischial spine
Lesser sciatic notch
Lesser sciatic foramen
Ischial tuberosity
Ischial ramus

Projecting posteriorly and inferiorly from th acetabulum

is th large, stout ischial tuberosity (see Fig. 1 2 - 3 ). This
palpable structure serves as th proximal attachment for
many muscles of th lower extremity, most notably th ham-
strings. The ischial ramus extends anteriorly from th ischial
tuberosity, ending at th junction with th inferior pubic
ramus (see Fig. 1 2 2).

ACETABULUM
Located just above th obturator foramen is th large cup-
shaped acetabulum (see Fig. 1 2 - 1 ) . The acetabulum forms
th socket of th hip. All three bones of th pelvis form part
of th acetabulum: th ilium and ischium contributing 80%
and th pubis th remaining 20%. The speciftc features of
th acetabulum are discussed in th section, Arthrology.

Osteologie Features of th Fcmur

Femoral head
Femoral neck
Intenrochanteric line
Greater trochanter
Trochanteric fossa
Intertrochanteric cresi
Quadrate tubercle
Lesser trochanter
Linea aspera
Pectineal (spirai) line
Gluteal tuberosity FIGURE 12-4. The anterior aspect of th right femur. Proximal
Lateral and mediai supracondylar lines aitachments of muscles are indicated in red, distai attachments in
Adductor tubercle gray. The femoral attachments of th hip joint capsule and th knee
joint capsule are indicated by dashed lines.
 392 Section IV Lower Extremity

M ediai vievv attachment for many muscles. On th mediai surface of th

greater trochanter is a small pit called th trochanterc fossa
yPirformis (Figs. 1 2 - 5 and 1 2 - 7 ) . This fossa accepts th distai attach
Fovea- ment of th obturator extemus muscle.
-Gluteus medius Posteriorly, th femoral neck joins th femoral shaft at
'O btu rato r internus th raised intertrochanteric crest (see Fig. 1 2 -6 ). The quad
and gemelli rate tuhercle, th distai attachment of th quadratus fem-
'O bturator externus in oris muscle, is a slightly raised area on th crest just inferior
trochanterc tossa to che trochanterc fossa. The lesser trochanter projeets
lliopsoas on sharply from th inferior end of th cresi in a posterior-
lesser trochanter mediai direction. The lesser trochanter serves as th major
l/astus m e diate- distai attachment for th iliopsoas muscle, an important hip
flexor.
- Pectineus Ih e middle third of th posterior side of th femoral
shaft is clearly marked by a vertical ridge called th linea
aspera (from th Latin linea, line 4- aspera, rough). This
raised line serves as an attachment site for th vasti mus
Adductor brevis
cles ol th quadriceps group, many of th adductor muscles.
and th intermuscular fascia of th thigh. Proximally, th
Vastus intermedius - linea aspera splits into th pectineal (spirai) line medially and
th gluteal tuberosty laterally (see Fig. 1 2 - 6 ). At th distai
- Linea aspera end of th femur, th linea aspera divides into th lateral
Adductor longus and mediai supracondylar lines. The adductor tuberce is lo- )
cated at th extreme distai end o f th mediai supracondylar
line.

Adductor magnus
"ANGLE OF INCLINATION"

Articularis genu-
-A dd uctor magnus on
supracondylar line and
-a dductor tuberete
Gastrocnemius
(mediai head)
gazasi
FIGURE 12-5. The mediai aspect of th nghr femur. Proxima! at-
tachments of muscles are indicated in red, distai attachments in
gray. The femoral attachments of th hip joint capsule and th knee
joint capsule are indicated by dashed lines.
The angle o f inclination of th femur describes th angle
within th frontal piane between th fem oral n eck and th
mediai side of th femoral shaft (Fig. 1 2 - 8 ). Al birth, this
angle measures about 140 to 150 degrees. Because of th
loadmg across th femoral neck during walking, this angle
usually reduces to its normal adulthood value of about 125
degrees.6; As depicted in Figure 1 2 - 8 , this angle provides
optimal alignment of th joint surfaces.
A change in th angle of inclination can occur owing to
acquiied or congenital factors. In generai, coxa vara (Latin
coxa, hip, 4- vara, to bend inward) desenbes an angle of
inclination markedly less than 125 degrees. Coxa valga (Latin
valga, to bend outward) describes an angle of inclination
markedly greater than 125 degrees (Fig. 1 2 - 8 B and O.
These abnormal angles alter th alignment between th fem
oral head and th acetabulum, thereby altering hip biome-
chanics. In a severe case, malalignment may lead io abnor
mal joint wear or hip dislocation.

The shaft of th femur displays a slight anterior convex-

ity (Fig. 1 2 - 5 ). As a long, eccentrically loaded column, "TORSION ANGLE"
th lemur bows slightly when subjected to body weight.
The torsion angle of th femur describes th relative rota-
As a consequence, stress along th bone is dissipated
tion (twist) that exists between th shaft and neck of th
through compression along its posterior shaft and through
femur. Normally, as viewed from above, th femoral neck
tension along its anterior shaft. This bowing allows th fe
projeets on average 10 to 15 degrees anterior to a medial-
mur to bear a greater load than if th femur were perfectly
straight. 1 lateral axis through th femoral condyles. This degree of
torsion is called normal anteversion (Fig. 1 2 -9 A ). In con-
Anteriorly, th intertrochanteric line marks th distai at-
junction with th normal angle of inclination, a 15-degree
tachment of th capsular ligaments (see Fig. 1 2 - 4 ). The
angle ol anteversion affords optimal alignment and joint con-
greater trochanter extends laterali)' and posteriorly from th
gruence (see alignment of red dots in Figs. 1 2 -8 A and 1 2 -
junction ol th femoral neck and shaft (Fig. 1 2 - 6 ). This 9A).
prominent and easily palpable strutture serves as th distai
A torsion angle that is markedly different from 15 degrees
 Chapter 12 Hip 393

Posterior view

FIGURE 12-6. The posterior aspect of th tight femur. Proximal

attachments of muscles are indicateci in red, distai attachments
in gray. The femoral attachments of th hip joint capsule and
th knee joint capsule are indicated by dashed lines.

Superior view
is generally considered abnormal. A torsion angle signifi-

(cantly greater than 15 degrees is calfed excessive anteversion

(Fig. 1 2 -9 B ). In contrast, a torsion angle significantly less
than 15 degrees (i.e., approaching 0 degrees) is in retrover-
sion (Fig. 1 2 -9 C ).
Typically, an infant is bom with about 30 degrees of
tem erai anteversion. 18 With b on e grow th and increased mus-
cle activity, this angle usually decreases to 15 degrees by 6
years of ag.7187 Excessive anteversion is often associated
with congenital dislocation, marked joint incongruence, and
increased wear on articular cartilage. Excessive anteversion in
children may also be associated with an abnormal gait pat
tern called in-toeing.70 In-toeing" is a walking pattern with
exaggerated posturing of hip internai rotation. This gait pat
tern apparently is a compensatory mechanism used to guide FIGURE 12-7. The superior aspect of th right femur. Distai attach
th excessively anteverted femoral head more directly into ments of muscles are shown in gray.
 394 Section IV Lower Extremity
Angle of inclination
th aceiabulum (Fig. 1 2 -1 0 A and B). Over time, children
may develop contracture of th internai rotator muscles and
various Iigaments, thereby reducing external rotation range
of motion.23 Approximately 50% of th children with in-
toeing eventually walk normally.18 The gatt pattern im-
proves primarily because of strnctural compensation in other
pans of th lower extremity, mosi commonly th tibia.
INTERNAI. STRUCTURE OF THE PROXIMAL FEMUR
Compact and Cancellous Bone
Walking produces tension, compression, bending, shear, and
torsion on th proximal femur (see Chapter 1). Each type of
lerce produces a different kind of stress on th proximal
femur. (Stress is a resistance produced by tissue in response
to an external load.) In order to tolerate repetitive stresses
throughout a lifetime, th proximal femur must resist and
absorb mechanical energy. These two functions are accom-
plished by two strikingly different compositions of bone.
Compaci bone is very dense and unyielding, with an ability to
withstand large external loads. This type of bone is particu-
larly thick in th cortex, th outer shell, of th lower femoral
neck and entire shaft (Fig. 1212). These regions are sub-
jected to large shear and torsion forces. Cancellous bone, in
contrast, consists of a three-dimensional lattice of branching
trabeculae. The relative spongy consistency of cancellous
bone absorbs external forces. Cancellous bone tends to con
centrate along lines of stress, forming trabecular networks A
mediai trabecular and an arcuate trabecular network are visible
within th femur shown in Figure 1 2 - 12.65 The overall
pattern ol th trabecular network changes when th proxi
mal femur is subjected to abnormal forces over an extended
lime.
ARTHR0L0GY
Functional Anatomy of th Hip Joint
I he hip is th classic ball-in-socket joint of th body. Exten-
sive Iigaments and large muscles maintain th femoral head
FIGURE 12-8. The proximal femur is
shown: A, normal angle of inclination;
B, coxa vara; and C, coxa valga. The
pair of red dots in each figure mdi-
cates th different alignments of th
hip joint surfaces. Optimal alignmeni
is shown in A.
C Coxa Valga
securely in th acetabulum. Thick layers of articular carti-
lage, muscle, and cancellous bone in th proximal femur
help dampen th large forces that routinely cross th
hip. Failure of any of these protective mechanisms due to
disease or injury often leads io deterioration of th joir.-
structure.
FEMORAL HEAD
fhe femoral head is located just inferior to th middle
third of th tnguinal ligament. On average, th centers of
th two adult femoral heads are 17.5 cm (6.9 in) apart from
each other. '* The head of th femur forms about twe
thirds of a nearly perfect sphere (Fig. 1 2 - 1 3 ) . Located
slightly posterior to th center of th head is a prommen;
pit, or fovea (see Fig. 1 2 - 5 ) . The entire surface of th
femoral head is covered by articular cartilage, except for
th region of th fovea. The cartilage tends to be thickest
in a broad region above and anterior to th fovea (Fte
1 2 - 1 4 ) .42
Osteologie Features of th Femoral Head and Acetabulum
Femoral Head
Fovea and ligamentum teres
Acetabulum
Acetabular notch
Transverse acetabular ligament
Acetabular labrum
Lunate surface
Acetabular fossa
The ligamentum teres (ligament to th head of th femur)
runs between th transverse acetabular ligament and th fo
vea of th femoral head (see Fig. 1 2 - 1 3 ). The ligamentum
teres is a tubular sheath of synovial-lined connective tissue.
which adds little stabilily to th joint. Within th teres liga
ment is a small brandi of th obturator artery. This small
and inconstant vessel provides only minimal blood to th

femoral head, th major supply provided by arteries that
course through th joint capsule.
ACETABULUM
The acetabulum is a deep, hemispheric cup-like socket that
accepts th femoral head. The bony rim of th acetabulum is
B Excessive anteversion
FIGURE 12-9. The angle of lorsion is shown between th neck and
shaft of th femur: A, normal anteversion; B, excessive anteversion;
and C, retroversion. The pair of red dots in each figure indicates
th different alignments of th hip joint surfaces. Optimal alignment
is shown in A.
Chapter 12 Hip 395
incomplete near its inferior pole, creating th acetabular noteh
(see Fig. 1 2 - 1 ) . The transverse acetabular ligament spans th
acetabular notch.
The acetabular labrum is a ring of fibrocartilage that sur-
rounds th circumference of th acetabulum (see Fig. 1 2 -
13). The labrum is triangular in cross-section, with its base
attaching along th rim of th acetabulum. Adjacent io th
acetabular notch, th labrum blends with th transverse ace
tabular ligament. The labrum deepens th concavity of th
socket and securely grips th periphery of th femoral head.
The acetabular labrum, therefore, adds significantly to th
stability of th articulation. Traumatic dislocation of th hip
usually tears th labrum.
The femoral head contacts th acetabulum only along its
horseshoe-shaped lunate surface (see Fig. 1 2 -1 3 ). This sur-
face is covered with articular cartilage, thickest along th
superior-anterior region of its dome (see Fig. 1 2 - 1 4 ) .42 The
regions of thickest cartilage correspond to roughly th
regions of highest joint pressures when walking.13 During
walking, hip forces lluctuate between 13% of body-weight
during mid swing phase to over 300% body-weight during
stance phase (Fig. 1 2 - 1 5 ) .13 During stance phase, th lunate
surface flattens slightly as th acetabular notch widens,
thereby increasing contact area and reducing peak pressure.47
Forces on th acetabulum during walking are also trans-
ferred to th sacroiliac joint and pubic symphysis jo in t.13
Hypomobility at these joints may increase stress at th hip,
possibly causing excessive wear.
The acetabular /ossa is a depression located deep within
th floor of th acetabulum. Because th fossa does not
normally make contact with th femoral head, it is devoid of
cartilage. Instead, th fossa contains th teres ligament, fat,
synovial membrane, and blood vessels.
ACETABULAR ALIGNMENT
In th anatomie position, th aceLabulum projeets laterally
from th pelvis with a varying amount ol inferior and ante-
rior tilt. Acetabular dysplasia describes a congenital or an
acquired condition in which th acetabulum is abnormally
shaped and poorly aligned. A malaligned acetabulum does
not adequately cover th femoral head, often causing chronic
dislocation and osteoarthritis.50 Two angles describe th ex
tern to which th shape of th acetabulum naturally covers
th femoral head; th center-edge angle and th acetabular
anteversion angle.
Center-Edge Angle
The center-edge angle (also called th angle of Wiberg) de
scribes th extern to which th acetabulum covers th femo
ral head within th frontal piane (Fig. 1 2 -16A ). The center-
edge angle is highly variable but, on average, measures about
35 to 40 degrees in th x-rays of adults.1 The normal center-
edge angle provides a protective shelf over th temoral head.
A more vertical alignment (i.e., a smaller angle) offers less
containment of th femoral head and is associated with an
increased risk of dislocation.*
Acetabular Anteversion Angle
The acetabular anteversion angle describes th extern to
which th acetabulum surrounds th femoral head within
 396 Section /V Low er E x tre m ity
A Excessive anteversion B Excessive anteversion with 'in-toeing
th hcirizontal piane.' A normal acetabular anteversion
angle of about 20 degrees exposes pan of th anterior side
ol th femoral head (Fig. 1 2 -1 6 B ). The ihick anterior cap-
sular iigament of th hip and th iliopsoas tendon cover
Naturai Anteversion of th Femur: A Reflection of th
General Prenatal Development of th Lower Limb
During prenatal development, th upper and lower extrem-
ities both undergo significant axial rotation (Fig. 12-11).
By about 54 days after conception, th lower limbs have
rotated internally (medially) about 90 degrees. This rota
tion turns th knee cap region to its final anterior position.
In essence, th lower limbs have become permanently
"pronated." This helps to explain why th "extensor" mus-
cles such as th quadriceps and tibialis anterior face
anteriorly, and th "flexor" muscles such as th ham-
strings and gastrocnemius face posteriorly after birth.
FIGURE 12-10. Two situations show th
sanie individuai with excessive anteversion
of th proximal femiir. A, Offset red dots
indicate malalignment of th hip while
standing in th anatomie position. B, As evi-
dent by th alignment of th red dots.
standing with th hip intemally rotated (in-
toeing") improves th joint congruity.
this side of th hip. Persons with excessive anteversion of
both th femur and th acetabulum are susceptible to ante
rior joint dislocation, especially at th extremes of extemal
rotation.
The final torsion angle between th shaft and th neck of
th femur reflects th degree of this mediai rotation.
The funzionai consequence of th mediai rotation of
th lower limbs is that th piantar surfaces of th feet
assume a plantigrade and pronated position suitable for
walking. This pronated position is evident by th mediai
position of th great toe on th lower limb, similar to th
thumb when th forearm is fully pronated. Other anatomie
features, such as th oblique nature of th lower extrem
ity dermatomes and th twisted ligaments of th hip (see
Figs. 1217 and 12-18), reflect th developmental mediai
rotation of th lower extremity.
 Chapter 12 Hip 397

FIGURE 12-13. The tight hip joint is opened to expose its internai
components.

FIGURE 12-12. A frontal piane cross-section showing ihe internai

architecture of th proximal femur. Note th thicker areas of com
pact bone around th shaft, and th eancellous bone occupying
most of th medullary (internai) region. Two trabecular networks
within th eancellous bone are also indicated. (From Neumann DA:
An Arthritis Home Study Course: The Synovial Joint: Anatomy,
Function, and Dysfunction. The Orthopedic Section of th Ameri
can Physical Therapy Association, 1998.)
CAPSULE AND LIGAMENTS OF THE HIP
A synovial membrane lines th internai surface of th hip
capsule. The external surface of th capsule is reinforced by
th iliofemoral, pubofemoral, and ischiofemoral ligaments
(Figs. 1 2 - 1 7 and 1 2 -1 8 ). Passive tension in these ligaments
and in surrounding muscles limits th extremes of all move-

Femoral head Acetabulum

FIGURE 12-14. The average thick-

A n te rio r
ness of anicular cartilage is shown,
as distributed over th right fem-
oral head and th right acetabu-
lum. The key defines th varying
thicknesses. The small dots repre-
sent sampled sites. For proper
orientation, compare this drawing
with Figure 12-13. (From Kurrat
HJ, Oberlander W: The thickness
of th cartilage in th hip joint. J >2.5 mm
Anat 126:145-155, 1978.)
<2.5> 2.0 mm

< 2 .0 > 1 .5 mm

]~]~| <1.5>0 5 mm <1.5>1.0 mm

<0 5 mm <1.0 mm
 398 Section IV Lower Extremity

3 .5 - |

3 ~

FIGURE 12-15. Graph shows a corn-J

puter models estimate of th hip jo t a !
force during various times in th gain
cycle. Stance phase is between O lJ
and 60% of th gait cycle, and th-
swing phase is between 60% anc
100% of th gait cycle. (Data froi:
Dalstra M, Huiskes R: Load transfer
across th pelvic bone. J Biomechar
2 8 :7 1 5 -7 2 4 , 1995.)

0 8 30 40 60 75 85 100
EVENTS Initial Foot Mid Heel Toe off Heel
heel fiat stance off contact
contact

Percent of Gait Cycle

menis of th hip (Table 1 2 l ) .21 All three ligaments are ai
least partially taut in full hip extension.
The iliofemoral ligament (or Y-ligameni) is a very thick and
strong sheet of connective tissue, resembling an inverted Y.
Proximally, th iliofemoral ligament attaches near th ante-
rior-inferior iliac spine and along th adjacent margin of th
acetabulum. Fibers forni distinct mediai and lateral fastidili
each attaching to either end of th mtertrochanteric line o?
th femur. lhe motion of full hip extension stretches th
iliofemoral ligament and anterior capsule.85 Full extemal ro-
tation elongates th lateral fasciculus of th iliofemoral liga-
ment.21

Center-edge angle FIGURE 12-16. Two angles describe th extern to which

Acetabular anteversion angle
th shape of th acetabulum naturally covers th femora.
head. A, The center-edge angle indicates th relative cover
age provided by th acetabulum over th femoral head
within th Irontal piane. This angle is formed by th
intersection ol a vertical reference line (stippled) and a
line that connects th upper edge of th acetabulum to
th center of th femoral head. The normal 125-degree
angle of inclination of th proximal femur is also indi-
cated. B, The acetabular anteversion angle describes th
extern to which th acetabulum surrounds th femoral
head within th horizontal piane. Measured from above,
this angle is normally about 2 0 degrees. As shown, th
angle is formed by th intersection of an anterior-poste-
rior reference line (stippled) and a line across th rim of
th acetabulum. The 15 degrees of normal anteversion of
th proximal femur is also indicated.
 Chapler 12 Hip 399

Anterior view

"Developmental Dysplasia of th Hip": A Case of

Acetabular Malalignment
Developmental dysplasia of th hip (DDH) is a childhood
condition usually involving abnormal formation (i.e., dys
plasia) of th hip.3 The cause of DDH is not completely
clear, but abnormal physical stress on th hip in
utero or in early childhood may interfere with joint
formation and alignment.
DDH is often associated with a shallow and abnor-
mally aligned acetabulum (i.e., a small center-edge an
gle). The femoral head, therefore, is allowed to "drift,"
usually superiorly and posteriorly from th acetabulum.
The loss of a stable fulcrum for hip motion can change
th moment arms and operational lengths of hip mus-
cles, thereby causing functional weakness of th joint.
A child born with cerebral palsy has a particularly
high likelihood of DDH. Hip dysplasia is often th result
of muscle "imbalance," retained primitive reflexes, and
absence of weight-bearing stimulation to th bones. Hip
deformities, such as coxa valga and excessive femoral
or acetabular anteversion, are often associated with
DDH.75
Treatment of DDH depends on th age of th child
and th underlying etiology. In th newborn, splinting or
casting th hip in abduction is often performed in an
attempt to "seat" th femoral head directly into th
acetabulum. Over time, this position may stimulate th FIGURE 12-17. The anterior capsule and ligaments of th right hip.
formation of a more normal joint shape. In th older The iliopsoas is cut to expose th anterior side of th joint. Note
that part o f th femoral head protrudes just mediai to th iliofe
child, surgery is often indicated. Osteotomy with realign-
moral ligament. This region is normally covered by a bursa.
ment of th pelvis and/or th proximal femur is per
formed to improve stability and increase surface area
for weight bearing.14-30-64

Posterior view
The iliofemoral ligament is one of th thickest and thus
one of th strongest ligaments of th body. When a person
stands with th hip fully extended, th anterior surface of
th femoral head rests against th iliofemoral ligament. Pas
sive tension in this ligament forms an important stabilizing
force that resists further extension of th pelvis on th fe
mur. Persons with paraplegia often use th passive tension o f
an elongated (or taut) iliofemoral ligament to assist with
standing (Fig. 1 2 -1 9 ).
Although thinner and more circular than th fibers of th
iliofemoral ligament, th pubofemoral and ischtofemoral liga-
ments blend with and strengthen th inferior and posterior
aspects of th capsule. The pubofemoral ligament attaches
along th anterior and inferior rim of th acetabulum and
adjacent parts of th superior pubic ramus and obturator
membrane (see Fig. 1 2 -1 7 ). The fibers blend with th me
diai fasciculus of th iliofemoral ligament, becoming taut in
hip abduction and extreme extension.
The ischiofemoral ligament attaches from th posterior and
inferior aspects of th acetabulum, primarily from th adja
cent ischium (see Fig. 1 2 -1 8 ). Fibers from this ligament FIGURE 12-18. The posterior capsule and ligaments of th righi
join circular fibers located deeper within th capsule. Other hip.
 400 Section IV Lower Extremity

T A B L E 1 2 - 1 . Ligamentous and Muscular Tissues that Limit th Extremes of Hip Motion

Hip Motion Magnitudo of Hip Motion Exam ples o f Tissue that may Limit th Extrem es o f M otion

Flexion 80 (with knee extended) Hamstrings and gracilis muscles

120 (with knee futly flexed) Inferior fbers of ischiofemoral ligament

Inferior capsule

Extension 20 of extension (with Predominanti)' iliofemoral ligament and anterior capsule; some
knee extended)* components of th pubofemoral and ischiofemoral ligaments
0 (with knee fully flexed) Rectus femoris muscle
Abduction 40 Pubofemoral ligament, inferior capsule, adductor and hamstring
muscles
Adduction 25 Superior fbers of ischiofemoral ligament, iliotibial band, and ab-
ductor muscles such as th tensor fasciae Iatae
Internai Rotation 35 Ischiofemoral ligament, extemal rotator muscles (e.g., piriformis)
Extemal Rotation 45 Lateral fasciculus of iliofemoral ligament, iliotibial band, and inter
nai rotator muscles (e.g., gluteus minimus, tensor fasciae Iatae)

* Implies 20 degrees ol extension beyond th neutral zero degree position.

m ore superficial fibers spirai superorly and Zateraiiy across

Osteokinematics
ihe posterior neck of th femur to attach near th apex of
th greater trochanter (see Fig. 1 2 - 1 7 ). These superficial This section describes th range of motion allowed at th
fbers become taut in full internai rotation and extension; hip, including th factors that permit and restrict this mo-
superior fbers of th ischiofemoral ligament become taut in tion. Reduced hip motion may be an early indicator of hip
full adduction; and inferior fbers and a portion of th disease or trauma, lt is often associated with pain, musei;
nearby inferior capsule become taut in flexion.
In addition to th three primary ligaments, th capsule
consists of dense longitudinal and circular fbers. These fi-
bers are covered by more superficial ligaments. Longitudinal
fbers are most extensive withtn th anterior capsule, deep
to and partially imbedded within th iliofemoral ligament.
Circular fb ers known as th zona orbiculans of th cap
sule are located more extensively on th inner layer of
th capsule, forming a ring around th base of th fmoral
neck.85

Close-packed Position of th Hip

Full extension (i.e., about 20 degrees beyond th neutral
position) of th hip twists or spirais much of th capsular
ligaments to their most taut position. Adding slight interna!
rotation and abduction to full extension elongates some
component of all th capsular ligaments (Fig. 1 2 -2 0 ). This
faci is useful when attempting to provide a maximum stretch
to th hips capsular ligaments.
Because th position of full extension, slight internai rota
tion, and abduction of th hip elongates most of th capsu
lar ligaments, it is considered th close-packed position at th
hip. The increased passive tension generated by th stretched
capsular ligaments lends stability to th joint and reduces
passive accessory movemeni or joint play. Interestingly, th
hip is unique in that its close-packed position is not associ-
ated with its position of maximal joint congruency.85 The FIGURE 12 19. A person with paraplegia is shown standing with
joint surfaces fu most congruently in 90 degrees of flexion th aid ol braces ai th knees and ankles. Leaning of th pelvis and
with moderate abduction and extemal rotation. In this posi trunk posteriorly, relative to th hip joints, stretches th iliofemoral
tion, much of th capsule and associated ligaments have ligaments. This stretch provides a passive flexor lorque at th hip.
which helps to stabilize th pelvis and trunk while standing. (From
"unraveled to a more slackened state, adding only little
passive tension to th joint. Somers MF. Spinai Cord Injury: Functional Rehabilitation Norwalk
Appleton & lange, 1992.)
 Chapter 12 Hip 401

Anterior vicw Posterior

Lateral Mediai
Ischiofemoral
ligament
Supcrior vie Anterior

Taut ischiofemoral ligament from

extension and internai rotation
lliofemoral
ligament
Pubofemoral
ligament

Taut pubofemoral ligament from

extension and abduction

Taut iliofemoral
ligament from
extension

FIGURE 12-20. A, The hip is shown in a neutral position, with all three capsular ligamenis identified. 6, Superior view of th
hip in its close-packed position, i.e., fully extended with slight abduction and internai rotation. This position elongates ai least
some component of all three capsular ligaments.

weakness, or trauma to bone and joint. Limited hip motion
can impose significam functional limitations when walking
or tying shoelaces.
Two terms describe th range of motion of th hip. Femo-
ral-on-pelvic hip osteokinematics describes th rotation of th
femur about a relatively fxed pelvis. Pelvic-on-femoral hip
osteokinematics, in contrast, describes th rotation of th pel
vis, and often th superimposed trunk, over relatively fxed
Temurs. Regardless o f whether th femur or th pelvis is
considered th moving segment, th osteokinematics are de-

0 S P E C I A L F OCUS

Intracapsular Pressure Within th Hip

The intracapsular pressure in th healthy hip is normally
less than atmospheric pressure. This relatively low pres
sure creates a partial suction that resists distraction of
th articular surfaces, providing an additional element of
stability to th hip.
Wingstrand and colleagues86 studied th effect of joint
position and capsular swelling on th intracapsular pres
sure within cadaveric hips. Except in th extremes of mo
tion, pressures remained relatively low throughout most of
flexion and extension. When fluid was injected into th
joint to simulate capsular swelling, pressures rose dramati-
cally throughout a greater portion of th range of motion
(Fig. 12-21). Regardless of th amount of injected fluid,
however, pressures always remained lowest in th mid
range of motion. These data help to explain why persons
FIGURE 12-21. The intracapsular pressure in th hip joint of
with capsulitis and swelling within th hip tend to feel most
cadavere as a function of hip flexion angle. The four curved
comfortable holding th hip in partial flexion. Reduced in
lines indicate th pressure-angle relationships after th injection
tracapsular pressure decreases distension of th inflamed of different volumes of fluid into th capsule. (Data from W ing
capsule. Unfortunately, over time, th flexed position may strand H, Wingstrand A, Krantz P: Intracapsular and atmo
lead to contracture caused by th adaptive shortening of spheric pressure in th dynamics and stability of th hip. Acta
th hip flexor muscles and capsular ligaments. Orthop Scand 6 1 :2 3 1 -2 3 5 , 1990.)
 402 Section IV Lower Extremity

scribed from th anatomie posttion. The names of th move-
ments are as folows: flexion and extension in th sagittaJ
piane, abduction and adducton in th frontal piane, and inter
nai and external rotation in th horizontal piane. The term
horizontal ts used with th assumption that a subject is
standing in th anatomie position.
Reporting th range of motion at th hip uses th ana
tomie position as th 0-degree or neutral reference point. In
th sagittal piane, for examp/e, fem oral-on -pelvic flexion is
described by th rotation of th femur anterior to th 0-
degree position. Extension, th reverse movement, is de
scribed as th rotation o f th femur posterior to th 0-degree
position. The term hyperextension is not used to describe
normal range of motion at th hip.
As dep icted in Figure 1 2 - 2 2 , each pian e o f m otion is
associated with a unique axis of rotation. The axis of rota-
tion for internai and external rotation is often referred to as
th longitudinal axis of rotation. The longitudinal axis of
rotation is also referred to as a vertical axis. The latter de-
scription, however, assumes th subject is standing with th
hip in th anatomie position. This axis extends as a line
between th center of th femoral head and th center of th
knee joint. Because of th angle of inclination of th proxi-
mal femur and th antenor bowing of th femoral shafl.
most of th longitudinal axis of rotation lies outside th
femur itself (see Fig. 1222^4 and fi). The extramedullary
location of th axis has implications in th understanding of
some of th actions of muscles, a point discussed later in
this chapter,
Unless otherwise specified, th following discussions on
osteokinematics include average passive ranges of motion at
th hip. The connective tssues and muscles that limit mo
tion are also d escrib ed (see Table 1 2 -1 ). The m uscles used
to produce and control th hip motion are discussed later in
this chapter. Although femoral-on-pelvic and pelvic-on-femo-
ral movements often occur simultaneousiy, they are pre-
sented here separately.
FEMORAL-ON-PELVIC OSTEOKINEMATICS
Rotation of th Femur in th Sagittal Piane
On average, with th knee fully flexed, th hip flexes to 120
degrees (Fig. 1 2 -2 3 ).72 Tasks such as squatting and tying a
shoelace typically require near full hip flexion.35 With th
knee extended, hip flexion is limited to about 80 degrees
because of th passive tension within th stretched ham-
string and gracilis muscles.10 Full hip flexion slackens most
ligaments, but stretches th inferior capsule.

Sagittal piane rotation Frontal piane rotation

* T'Anterior
Posterior..
pelvic tilt
pelvic tilt ^

ABDUCTION ADDUCTON
FLEXION
EXTENSION

Horizontal piane rotation

EXTERNAL
ROTATION

c o n -p e iii'^

FIGURE 12-22. The osteokinematics of th righi hip joint Femoral-on-pelvic and pelvic-on-femoral rotations occur in three planes,
depicted as red arrows. The axis of rotation for each piane of movement is shown as a red dot, located at th center of th femoral
head. A, Side view shows sagittal piane rotations about a medial-lateral axis of rotation. B, Front view shows frontal piane rotations about
an anterior-posterior axis of rotation. C, lop view shows horizontal piane rotations about a longitudinal, or vertical, axis of rotation.
 Chapter 12 Hip 403

Femoral-On-Pelvic Hip kotation

Psoas major
lliofemoral
ligament

lliofemoral ligament
fiaterai fasciculus)

FIGURE 12-23. The approximate maximal range of passive femoral-on-pelvic (hip) motion is depicied in th sagittal piane (A), frontal
piane (B), and horizontal piane (C). Ligaments and muscles, elongated and pulled taut, are indicated by straight black (or dashed)
arrovvs. Slackened tissue is indicated by a wavy black arrow.
 404 Section IV Lower Extremity

The hip normally extends about 20 degrees beyond th essentially stationary as th pelvis rotates over th femurs.
neutral position.73 When th knee is fully flexed during th This type of rhythm is used during walking and dancing and
hip extension, passive tension in th stretched rectus fe- other activities in which th position of th supralumbar
moris, which crosses both th hip and knee, reduces hip trunk, mcluding th head and eyes, needs to be held fixed in
extension to about th neutral position. Full hip extension space, independent of th rotation of th pelvis. In this man-
increases th passive tension in most capsular connective ner, th lumbar spine functions as a mechanical de-coupler,"
tissues, especially th iliofemoral ligament, and th hip flexor allowing th pelvis and th supralumbar trunk to move inde-
muscles. pendently. A person with a fused lumbar spine, therefore, is
unable to rotate th pelvis about th hips without a similar
Rotation of th Femur in th Frontal Piane rotation of parts of th supralumbar trunk. This abnormal
On average, th hip abducts 40 degrees (Fig. 1 2 -2 3 B ).72 This situation is readily apparent when th individuai walks.
motion is limited primarily by th pubofemoral ligament and Figure 1 2 - 2 5 shows pelvic-on-femoral osteokinematics at
by th adductor and hamstring muscles. The hip adducts 25 th hip, organized by piane of motion. These kinematics are
degrees beyond th neutral position.7 In addition to interfer- all based on th contra-directional lumbopelvic rhythm. The
ence with th contralateral limb, passive tension in stretched range of motions depicted in each figure have been esti-
hip abductor muscles, iliotibial band, and superior fibers of mated using photographs of healthy young adults. In most
th ischiofemoral ligament all limit full adduction. cases, th amount of pelvic-on-femoral rotation is restricted
by th naturai limitations of movement at th lumbar spine
Rotation of th Femur in th Horizontal Piane
Pelvic-on-Femoral Rotation in th Sagittal Piane:
Like most movements, internai and external rotation of th The Anterior and Posterior Pelvic Tilt
hip shows large intersubject variability. On average, th hip Hip flexion can occur through a limited are via an untene
inlemally rolates about 35 degrees from th neutral position tilt (Fig. 1 2 -2 5 A ) of th pelvis over stationary femori.
(Fig. 1 2 - 2 3 C ) .72-77 With th h ip fully extended, maximal heads. As d efin ed in C hapter 9, pelvic tilt is a sagitu.
internai rotation elongates external rotator muscles, such as piane rotation of th pelvis relative to th femur. The direc
th piriformis, and parts of th ischiofemoral ligament. In tion of th tilt either anterior or posterior is based or J
healthy young adults, th amount of internai rotation re- th direction of rotation of a poini on th iliac cresi. The \
mains essentially unchanged with th hip flexed or extended.72 associated increased lumbar lordosis offsets most of th un-
The extended hip extemally rotates on average about 45
degrees. Excessive tension in th tensor fasciae latae, iliotibial
band, and lateral fasciculus of th iliofemoral ligament may
limit full extemal rotation. The position of hip flexion de- Contra-directional"
creases active extemal rotation motion to 30 to 35 degrees. lumbopelvic
rhythm
PELVIC-ON-FEMORAL OSTEOKINEMATICS
Lumbopelvic Rhythm
The lower, caudal end of th axial skeleton is firmly attached
to th pelvis by way of th sacroiliac joints. As a conse-
quence, rotation of th pelvis over th femoral heads typi-
cally changes th configuraton o f th lu m bar spine. This
important kinematic relationship is known as lumbopelvic
rhythm, introduced in Chapter 9. This concept is revisited in
this chapter with a focus on th kinesiology at th hip.
Figure 1 2 - 2 4 shows two contrasting types of lumbopel
vic rhythms frequently used during pelvic-on-femoral hip
flexion. Although th kinematics depicted are limited to th
sagittal piane, th concepts apply to pelvic rotations in all
planes.
Figure 1 2 - 2 4 shows an example of an ipsi-directional lum
bopelvic rhythm, where th pelvis and lumbar spine rotate in
th same direction. This movement maximizes th angular
displacement of th entire trunk relative to th lower ex-
tremities, and it is useful for activities such as extending th
reaching capacity of th upper extremities. The kinematics of
th ipsi-directional lumbopelvic rhythm are discussed in de-
tail in Chapter 9. In contrast, during contra-directional lumbo FIGURE 12-24. Two contrasting types of lumbopelvic rhythms used
pelvic rhythm, th pelvis rotates in one direction while th to rotate th pelvis over fixed femurs. A, An ipsi-directional'
rhythm describes a movement in which th lumbar spine and
lumbar spine simultaneously rotates in th opposite direction
pelvis rotate in th same direction, thus amplifying overall trunk
(Fig. 1 2 -2 4 B ). The important consequence of this move
motion. B, A contra-directional rhythm describes a movement in
ment is that th supralumbar trunk (i.e., that part of th which th lumbar spine and pelvis rotate in opposite directions. See
body located above th First lumbar vertebra) can remain text for further explanation.
 Chapter 12 Hip 405

Pelvic-On-Femoral Hip Rotatimi

(VVith Supralumhar Trunk Stationary)

FLEXION EXTENSION
(anterior pel vie tilt) (posterior pelvic tilt)

Slack iliofemorai

FIGURE 12-25. The maximal range of passive pelvic-on-femoral hip motion in ihe sagittal piane (A), frontal piane (Et), and horizonial
piane (C), The motion assumes that th supralumhar trunk remains essentially stationary during th hip motion Ligaments and
muscles elongated and pulled taut are indicated by straight black arrows; tissues slackened are indicated by wavy black arrows.
 406 Secfion IV Lower Extremity
desired forward moiion of th supralumbar trunk. The ante-
rior tilt of th pelvis occurs about a medial-lateral axis of
rotation through both femoral heads. While sitting upright
with 90 degrees of hip flexion, th normal adult can achieve
about 30 degrees of additional pelvic-on-femoral hip flexion
before betng restncted by a completely extended lumbar
spine. Full anterior tilt of th pelvis slackens th iliofemoral
ligament and elongates th inferior capsule.
As depicted in Figure 1 2 -2 5 A , th hips can be extended
about 10 to 20 degrees from th 90-degree sitting posture
via a posterior tilt of th pelvis. The lumbar spine flexes or
flailens as th pelvis is tilted. The iliofemoral ligament and
iliopsoas muscle are slightly elongated.
Pelvic-on-Femoral Rotation in th Frontal Piane
Pelvic-on-femoral rotations in th frontal and horizontal
planes are best described assuming a person is standing on
one limb. The weight-bearing extremity is referred to as th
support hip.
Abduction of th support hip occurs by raising or hiking
th iliac crest on th side of th nonsupport hip (Fig.
1 2 -2 5 B ). Assuming that th supralumbar trunk remains sta-
tionary, th lumbar spine must bend in th direction oppo-
site th rotating pelvis. A faterai convexity occurs within th
lumbar region toward th side of th abducting hip.
Pelvic-on-femoral hip abduction is restricted to about 30
degrees, pnmarily due to th naturai limits of lateral bending
in th lumbar spine. Severe tightness in th adductor mus-
cles and/or restriction in th pubofemoral ligament limits
pelvic-on-femoral hip abduction. In th event of marked
adductor contracture, th iliac crest on th side of th non
support hip remains lower than th iliac crest of th support
hip, markedly interfering with walking.
Hip adduction of th support hip occurs by a lowering of
th iliac crest on th side of th nonsupport hip. This rno-
tion causes a slight lateral concavity within th lumbar re
A rticu lar Paths of H ip Motion
Acetabulum
Femoral head
Axis of rotation for flexion
and extension
for abduction
and adduction
CO
gion on th side of th adducted hip. A hypomobile lumbar
spine and/or marked decreased length within th iliotibial
band or hip abductor muscles, such as th gluteus medius.
piriformis, or tensor fasciae latae, may restrict th extremes
of this motion.
Pelvic-on-Femoral Rotation in th Horizontal Piane
Pelvic-on-femoral rotation occurs in th horizontal piane
about a ongitudinal axis of rotation (Fig. 1 2 -2 5 C ). Interna,
rotation of th support hip occurs as th iliac cresi on th
side of th nonsupport hip rotates forw ard in th horizontal
piane. During extem al rotation, in contrast, this same iliac
crest rotates backward in th horizontal piane. If th pelvis is
rotating beneath a relatively stationary trunk, th lumbar
spine must rotate or twist in th opposite direction as th
rotating pelvis. The modest amount of axial rotation nor-
mally permitted in th lumbar spine limits th full rotation
potential of th support hip. In th healthy person, there-
fore, th ligaments and capsule at th hip are not signifi-!
j
cantly stretched during horizontal piane pelvic-on-femoral I
rotation.
Arthrokinematics
During hip moiion, th nearly spherical femoral head re-1
mains snugly seated within th confnes of th acetabulum. |
The steep walls of th acetabulum, in conjunction with th I
tightly futing acetabular labrum, limit significani translatior1
between th joint surfaces. Hip arthrokinematics are base; I
on th traditional convex-on-concave or concave-on-convex 1
principles (see Chapter 1).
Figure 1 2 - 2 6 shows a highly mechanically based illustra-1
don of a hip opened to enable visualization of th paths of I
articular motion. Abduction and adduction occur across th |
ongitudinal diameter of th joint surfaces (red). With thr I
hip extended, internai and extem al rotation occur across th 1
Lunate surface
o
fo r internai and
FIGURE 12-26. A mechanical" drawing
O extemal rotation of th right hip. The joint surfaces are
exposed by swinging th femur oper.
like a door on a funge. The articular
paths of hip frontal and horizontal
piane motion occur along th ongitu
dinal (red) and transverse (gray) diame-
ters, respectively.
 Chapter 12 Hip 407

FIGURE 12-27. The path and generai proximal-to-distal order of muscle innervaiion for th femoral nerve and obturator
nerve (A) and th sciatte nerve (B). The locaiions of certain muscles relative to th joint are altered slightly for clarity.
The roots for each nerve are shown in parenthesis. (Modifed from deGroot J: Correlative Neuroanatomy, 2 lst ed.
Norwalk, Appleton & Lange, 1991.)
Illustratimi continued on following page

transverse diameter of th joint surfaces (gray). Flexion and
extension occur as a spin between th femoral head and th
lunate surfaces of th acetabulum. The axis of rotation for
this spin passes through th femoral head.
cluding th quadriceps femoris. Nerves from th sacrai
plexus innervate th muscles of th posterior and lateral hip,
posterior thigh, and entire lower leg.
L u m b a r P le x u s

The lumbar plexus is formed from th ventral rami of T12

MUSCLE AND JOINT INTERACTION_________
Innervation to th Muscles and Joint
INNERVATION TO MUSCLES
The lumbar plexus and th sacrai plexus arise from nerve
roots of T 12 through S4. Nerves from th lumbar plexus
innervate th muscles of th anterior and mediai thigh, in-
L4. This plexus gives rise to th femoral and obturator
nerves (Fig. 1 2 -2 7 A ). The femoral nerve, th largest branch
of th lumbar plexus, is formed by L2- L 4 nerve roots. Motor
branches innervate most hip flexors and all knee extensors.
Within th pelvis, proximal to th inguinal ligament, th
femoral nerve innervates th psoas major, psoas minor, and
iliacus. Distai to th inguinal ligament, th femoral nerve
innervates th sartorius, p a n o f th pectineus, and th quad-
 408 Sedioli IV Lower Extremity

Superior ^Gluteus medius

gluteal nerve

^ * x ^ T e n s o r fasciae latae

Gluteus mlnimus

. SC IA T IC N ER V E
'4 / (L 4~S4)
Interior gluteal nerve to
gluteus maximus ^

Nerve to obturator internus &

gemellus superior

Nerve to quadratus femoris &

gemellus interior

SACRAL PLEXUS EXITING Common

PELVIS VIA GREATER peroneal nerve
SCIATIC FORAMEN (L4S2)

B !
FIGURE 12-27. Continued

riceps muscle group. The femoral nerve has an exten-

sive sensory distribution covering much of th skin of th Primary Sources of Nluscular Innervation from th
anterior-medial aspect of th thigh. The sensory branches Lumbar Plexus
of th femoral nerve innervate th skin of th anterior- Femoral nerve (L2-L 4)
medial aspect of th lower leg, via th saphenous cuianeous * Obturator nerve ( I J - L 4)
nerve.
 /

Chapter 12 Hip 409

Like th femoral nerve, th obturator nerve is formed from
th ventral rami of L2- L 4 nerve roots. Motor branches inner
vate th hip adductor muscles. The obturator nerve divides
into anterior and posterior branches as it passes through th
obturator foramen. The posterior branch innervates th obtu
rator externus and anterior head of th adductor magnus.
The anterior branch innervates part of th pectineus, th
adductor brevis, th adductor longus, and th gracilis. The
obturator nerve has a sensory distribution to th skin of th
mediai thigh.
S a c ra i P le x u s
The sacrai plexus, located on th posterior wall of th pelvis,
is formed from th ventral rami of (L4- S 4).85 Most nerves
from th sacrai plexus exit th pelvis via th greater sciatic
foramen to innervate th posterior hip muscles (Fig. 12-27B ).
Primary Sources of Lower Limb Muscular Innervaiion
from th Sacrai Plexus
Nerve io th piriformis (S1-2)
Nerve to th obturator intemus and gemellus superior
(L5- S 2)
Nerve to th quadratus femoris and gemellus inferior (L4- S l)
Superior gluteal nerve (L4- S )
Inferior gluteal nerve (L5- S 2)
Sciatic nerve (L4- S 3) with tibial and common peroneal
portions
shows key muscles typically used to test th functional status
of th L2- S ventral nerve roots.
SENSORY INNERVATION TO THE HIP
As a generai rule, th hip capsule receives sensory innerva
tion by th same nerve roots that supply th overlying mus-
cle. The femoral nerve sends nerve flaments into th ante
rior aspect of th hip capsule. Nerve branches enter th
posterior joint capsule from all roots of th sacrai plexus.32-85
The obturator nerve sends flaments into th mediai aspect
of th hip and of th knee joint. This explains why inflam-
mation of th hip may be perceived as pain in th mediai
knee region.
Muscular Function at th Hip
Throughout this chapter, th line-of-force of several muscles
is illustrated relative to th axes of rotation at th hip. Fig
ure 1 2 - 2 8 , for example, shows a sagittal piane representa-
tion of th signifcant flexor and extensor muscles of th
Superior

Three small nerves in ne iva te five of th six short extemal

rotators of th hip. The nerves are named simply by th
muscles that they innervate. The nerve to th piriformis (S1- 2) in
nervates th piriformis within th pelvis. Extemal to th pelvis,
th nerve to th obturator intemus and gemellus superior (L5- S 2)
and th nerve to th quadratus femoris and gemellus inferior (L4-
S1) travel to and innervate their respective muscles.
The superior and inferior gluteal nerves are named accord-
tng to their position as they exit th greater sciatic notch.
The superior gluteal nerve (L4- S ') innervates th gluteus
medius, gluteus minimus, and tensor fasciae latae. The infe
rior gluteal nerve (L5- S 2) is th sole innervation to th glu
teus maximus.
The sciatic nerve (L4- S 3), th widest and longest nerve in
th body, exits th pelvis through th greater sciatic fora
men, usually inferior to th piriformis. The sciatic nerve
actually consists of two nerves: th tibial and th common
peroneal, both enveloped in one connective tissue sheath. In
th posterior thigh, th tibial portion of th sciatic nerve
innervates all th biarticular muscles within th hamstring
group and th posterior (extensor) head of th adductor
magnus. The common peroneal portion of th sciatic nerve
innervates th short head of th biceps femoris.
The sciatic nerve branches into separate tibial and com
mon peroneal components usually just proximal to th knee.
FIGURE 12-28. A view from th side that depiets th sagittal piane
It is noi uncommon, however, that th division occurs more
line-of-force of several muscles that cross th hip. The axis of
proximally near th pelvis. A division proximal to th greater rotation (red) is directed in th medial-lateral direction through th
sciatic foramen usually results in th common peroneal femoral head. The flexors are indicated by sold lines and th
nerve piercing th piriform is as th nerve exits th pelvis.83 exiensors by dasbed lines. The internai moment arm, used by th
The m o to r nerve roots that su pp/y che m uscles o f th rectus femoris, is represented by th thick black line. (For c/arity,
lower extremity are listed in Appendix IVA. Appendix IVB th gracilis is not shown.)
410 Section IV Lower Extremity

hip.1617 Although Figure 1 2 - 2 8 provides useful insight imo
th potential function of several muscles of th hip, two
limitations are considered. First, th line-of-force of each
muscle does not represent a force vector, only th overall
direction of th muscles force. The figure does not provi de
th information needed to compare th strength or
torque potential of each muscle. This comparison requires
additional data, especially th muscles cross-sectional area.
Second, th lines-of-force and subsequent lengths of th mo
ment arms depicted in Figure 1 2 - 2 8 apply only to th
anatomie position. Once th hip moves out of this position,
th potential action and torque potential of each muscle
change. This partially explains why th maximal-effort, inter
nai torque of a muscle group varies throughout th range of
motion.
Throughout this chapter, a muscles action is considered
either primary or secondary (Table 1 2 - 2 ). The designation
of muscle action is based on data such as moment arm,
muscle size, and, when available, reports from EMG-based
and anatomie studies. Unless otherwise specified, muscle ac-
tions are based on a concentric contraction, originating from
th anatomie position. A muscle with a relatively insignifi-
cant action, or an action that is more substantial outside th
anatomie position, is not included in Table 1 2 - 2 . Consult
Appendix IVC for a listing of detailed attachments of
muscles of th hip.
HIP FLEXOR M U S C L E S
The primary hip flexors are th iliopsoas, sartorius, tensor
fasciae latae, rectus femoris, pectineus, and adductor longus
(Fig. 1 2 - 2 9 ) .17 Figure 1 2 - 2 8 shows th excellent flexion
leverage of many of these muscles. Secondary hip flexors are
th adductor brevis, gracilis, and anterior fibers of th glu-
teus minimus.
A n a to m y a n d In d iv id u a i A c tio n
The iliopsoas is large and long, spanning between th last
thoracic vertebra and th proximal femur (see Fig. 1 2 -2 9 ).
Anatomically, th iliopsoas consists of two muscles: th ilia-
cus and th psoas major. The iliacus attaches on th iliac
fossa and extreme lateral edge of sacrum, just over th sacro-
iliac joint. The psoas major attaches along th transverse
processes of th last thoracic and all lumbar vertebrae, in-
cluding th intervertebral discs. The fibers of th iliacus and
th psoas major fuse just anterior to th femoral head (see
Fig. 1 2 - 2 9 , right side). A tendon forms that anchors th
muscle to th femur, near and on th lesser trochanter. In
route to its distai insertion, th broad tendon of th iliopsoas
is deflected posteriorly about 35 to 45 degrees, immediately
after it crosses th rim of th pubis. With th hip in full
extension, this deflection raises th lendons angle-of-inser-
tion to th femur, thereby increasing th muscles leverage
for hip flexion.
The iliopsoas is a potent hip flexor, from both a femoral-
on-pelvic and pelvic-on-femoral perspective. From th ana
tomie position, th iliopsoas is not an effective rotator. In th
hip abducted position, th iliopsoas can assist in extema!
rotation.99
The iliopsoas muscle produces forces that cross th lumbar
and lumbosacral regions as well as th hip.2'37J6 The iliacus,
by anterior tilting of th pelvis, can accentuate th lumbar
lordosis if th pelvis is not well stabi lized by a muscle such as
th rectus abdominis. The psoas major provides excellent ver-
tical stability to th lumbar spine (see Chapter 10).
The psoas minor lies anterior to th muscle belly of th
psoas major. This slender muscle attaches proximally be
tween th twelfth thoracic and first lumbar vertebra, anc
distally to th pelvis near th pectineal line. Unlike th psoas
major, th psoas minor has little, if any, functional signifi-
cance in hip motion. The psoas minor is absent in abou:
40% of people.85
The sartorius, th longest muscle in th body, originates ai
th anterior-superior iliac spine (see Fig. 1 2 - 2 9 ). This thm.
fusiform muscle courses inferiori)' and medially across th
thigh to attach distally on th mediai surface of th proximal
tibia (see Fig. 1 3 - 7 ) . The name sartorius is based on th
Latin root sartor, referring to a tailors position of crossed-
legged sitting. This name describes th muscles combined
action of hip flexion, external rotation, and abduction.

TABLE 1 2 - 2 . Muscles of th Hip Organized According to Their Action*

Flexors Adductors Internai Rotators Extensors Abductors External Rotators

Primary Primary Secondary Primary Primary Primary
Iliopsoas Adductor longus Gluteus minimus Gluteus maximus Gluteus medius Gluteus maximus
Tensor fasciae latae Adductor brevis (anterior fibers) Biceps femoris Gluteus minimus Piriformis
Sartorius Pectineus Gluteus medius (long head) Tensor fasciae latae Obturator intemus
Rectus femoris Gracilis (anterior fibers) Semitendinosus Secondary Gemellus superior
Adductor longus Adductor magnus Tensor fasciae latae Semimembranosus Piriformis Gemellus inferior
Pectineus (both heads) Adductor longus Adductor magnus Sartorius Quadratus femoris
Secondary Secondary Adductor brevis (posterior head) Sartorius
Adductor brevis Biceps femoris Pectineus Secondary Secondary
Gracilis Gong head) Semitendinosus Gluteus medius Gluteus medius
Gluteus minimus Quadratus femoris Semimembranosus (posterior fibers) (posterior fibers)
(anterior fibers) Gluteus maximus Gluteus minimus
(lower fibers) (posterior fibers)
Obturator externus
Biceps femoris
(long head)

Each action assumes a muscle contraction originating from th anatomie position. Many of these muscles will have different actions if they contract from
a position other than th anatomie position.

Psoas minor
Psoas major
lliacus
Piriformis
Tensorfasciae latae
FIGURE 12-29. Muscles of th anterior
hip region. The right side shows th Pectineus
primary flexors and adductor muscles Gracilis
of th hip. Many muscles on th left Adductor longus
side are cut to expose th adductor
Sartorius
brevis and adductor magnus.
lliotibial tract
Vastus lateralis
Rectus temoris
Vastus medialis
The tensorfasciae latae attaches to th ilium just lateral to
th sartorius (see Fig. 1 2 - 2 9 ). This relatively short muscle
attaches distally to th proximal part of th iliotibial band or
tract.85 The band extends distai to th knee to th lateral
tubercle of th tibia.
The iliotibial tract is a component of a more extensive
connective tissue known as th fascia lata o f th thigh,36
Laterally, th fascia lata is thickened by attachments from th
tensor fasciae latae and th gluteus maximus. At multiple
locations, th fascia lata tums inward between muscles,
forming distinct fasciai sheets known as intermuscular septa.
These septa partition each of th main muscle groups of th
thigh according to innervation. The septa, along with most
attachments of th adductor muscles, are anchored to th
femur along th linea aspera.
From th anatomie position, th tensor fasciae latae is a
primary flexor and abductor of th hip. The muscle is also a
secondar)' internai rotator of th hip.66 As indicated by its
name, th tensor fasciae latae increases tension throughout
th fascia lata. Tension passed inferiori)' through th iliotibial
tract may help stabilize th lateral aspect of th extended
knee. Repetitive tension within th iliotibial band may cause
inflammation at its insertion site near th lateral tubercle of
th tibia. Stretching an excessively tight iliotibial band with
Chapter 12 Hip 411
Psoas major
Sartorius (cut)
lliacus
lliofemoral ligament
Pectineus (cut)
externus
Adductor longus (cut)
Gracilis (cut)
Adductor brevis
Adductor magnus
Vastus lateralis (cut)
traci (cut)
Rectus femoris (cut)
Vastus medialis (cut)
Sartorius (cut)
th knee extended often incorporates various combinations
of hip adduction and extension.
The proximal part of th rectus fem oris emerges between
an inverted V, formed by th sartorius and tensor fasciae
latae (see Fig. 1 2 - 2 9 ). This large bipennate-shaped muscle
has its proximal attachment at th anterior-inferior iliac
spine and along th superior rim of th acetabulum and into
th joint capsule. Along with th other members of th
quadriceps, th rectus femoris attaches to th tibia via th
ligamentum patelae. The rectus femoris is responsible for
about one third of th total isometric, flexor torque at th
hip.48 In addition, th rectus femoris is a primary knee
extensor. The combined two-joint actions of this important
muscle are considered in Chapter 13. The anatomy and
function of th pectineus and adductor longus are described
in th section on th adductors of th hip.
Overall Function of th Hip Flexors
Pelvic-on-Femoral Hip Flexion: Anterior Pelvic Tilt
The anterior pelvic tilt is performed by a force-couple be
tween th hip flexors and low-back extensor muscles (Fig.
1 2 -3 0 ). With fxed femurs, contraction of th hip flexors
rotates th pclvis about th medial-lateral axis through both
hips. Although Figure 1 2 - 3 0 illustrates th iliopsoas and
 412 Section IV Lower Extremity
rectus femoris, any muscle capable o f femoral-on-pelvic flexion
is equally capable of tilting th pelvis anteriorly. Clinically, th
most important aspect of th anterior tilt is related to th
increase in lordosis at th lumbar spine. Greater lordosis
increases th compressive loads on th lumbar apophyseal
joints.
A lumbopelvic posture with norma! lumbar lordosis opti-
mizes th alignment of th entire spine (see Chapter 9).
Some persons have difficulty maintaining lumbar lordosis
while standing. Increased stiffness in connective tissue
around th lumbar spine and/or increased passive resistance
from hamstring muscles favors a relatively fiat (i.e., slightly
flexed) lumbar spine. The quantitative relationship between
th degree of hamstring tightness and posture of th pelvis
and lumbar spine remains controversial.'
Femoral-on-Pelvic Hip Flexion
Femoral-on-pelvic hip flexion is performed through a syn-
ergy between th hip flexors and abdominal muscles. This
cooperation is most apparent during activities that require
large amounts of hip flexor force. Consider, for example, th
straight-leg-raise exercise often used to strengthen th ab
dominal muscles. This action requires that th rectus ab-
dominis generate a potent posteror pelvic tilt in order to
neutralize th strong anterior pelvic tilt potential of th hip
flexor muscles (Fig. L 2 -3 1 A ). Without sufficient stabilization
from th rectus abdominis, contraction of th hip flexor
muscles is ineffcienily spent tilting th pelvis anteriorly (Fig.
1 2 -3 1 B ). The excessive anterior tilt of th pelvis accentuates
th lumbar lordosis.
The pathomechanics depicted in Figure 1 2 - 3 1 B are most
severe in situations in which th abdominal muscles are
weak, but th hip flexors remain relatively strong. With th
exception of poliomyelitis or muscular dystrophy, this pat
tern of weakness is relatively rare. More commonly, th
FIGURE 12-30. The force-couple is shown between two representa-
tive hip flexor muscles and th erector spinae to anteriorly tilt th
pelvis. The moment arms for th erector spinae and rectus femoris
are indicated by th dark black lines. Note th increased lordosis at
th lumbar spine.
abdominal muscles are only moderately weak, secondar)' io
disuse atrophy or abdominal surgery. In this case, persons
may develop low-back pain due to th increased compres-
sion force on th apophyseal joints of th chronically, fully
extended lumbar vertebrae.
HIP ADDUCTOR MUSCLES
The primary adductors of th hip are th pectineus, adduc-
tor longus, gracilis, adductor brevis, and adductor magnus
(see Fig. 1 2 - 2 9 ). Secondary adductors are th biceps fe
moris (long head), th gluteus maximus, especially th infe-
rior fbers, and th quadratus femoris. The line-of-force of
these muscles is shown in Figure 1 2 - 3 3 .
Functional Anatomy
The adductor muscle group occupies th mediai quadrant of
th thigh. Topographically, th adductor muscles are orga-
nized into three layers (Fig. 1 2 - 3 4 ). The pectineus, adduc
tor longus, and gracilis occupy th superficial layer. Proxi-
mally, these muscles attach along th superior and inferior
pubic ramus and adjacent body of th pubis. Distally, th
pectineus and th adductor longus attach to th posterior
surface of th femur near and along varying regions of th
linea aspera. The long and slender gracilis attaches distally to
th mediai side of th proximal tibia (see Fig. 1 3 - 7 ).
The middle layer of th adductor group is occupied by th
triangular-shaped adductor brevis. The adductor brevis at
taches to th pelvis on th inferior pubic ramus, and to th
fem ur along th proxim al one third o f th linea aspera.
The deep layer of th adductor group is occupied by th
massive, triangular-shaped adductor magnus (see Fig. 1 2 - 2 9
left side, and Fig. 1 2 - 4 0 , right side). This large muscle
attaches prtmarily from th entire ischial ramus and part o:
th ischial tuberosity. From its proxim al attachment, th
adductor magnus forms anterior and posterior heads.
The anterior head o f th adductor magnus has two sets of
fbers: horizontal and oblique. The relatively small set of
horizontally directed fbers crosses from th inferior pubi:
ramus to th extreme proximal end of th linea aspera, often
called th adductor minimus. The Iarger obliquely directed
fbers run from th ischial ramus to nearly th entire length
of th linea aspera, as far distally as th mediai supracondv-
lar line. Both parts of th anterior head are innervated by th
obturator nerve, which is typical of th adductor muscles
The posterior head o j th adductor magnus consista o f a
thick mass of th fbers arising from th region of th pelvis
adjacent to th ischial tuberosity. From this posterior attach
ment, th fbers run vertically and attach as a tendon on th
adductor tubercle on th mediai side of th distai femur.
The posterior head of th adductor magnus is innervated bv
th tibial branch of th sciatte nerve, as are th hamstring
muscles. Because of a similar location, innervation, and ac
tion as th hamstring muscles, th posterior head is often
referred io as th extensor head of th adductor magnus.
Overall Function of th Hip Adductors
The line-of-force of th adductors approaches th hip from
many different orientations. Functionally, therefore, th ad
ductor muscles produce torques in all planes at th hip.17-61
The following section considera th primary' actions of th
 Chapter 12 Hip 413

Reduced activation of abdominal muscles

FIGURE 12 31. The stabilizing role of th abdominal muscles is shown dunng a umlateral straight-leg raise. A, VVith normal
activation of th rectus abdominis, th pelvis is stabilized and prevented from anterior tilting by th pul of th hip flexor
muscles. B, With teduced activation of th rectus abdominis, contraction of th hip flexor muscles causes a marked anterior tilt
of th pelvis. Note th increase in lumbar lordosis that accompanies th anterior tilt of th pelvis. The reduced activation in th
abdominal muscle is indicated by th lghter red.

adductors in th frontal and sagittal planes. The secondary
action o f these m uscles as internai rotators is discusseci later
in this chapter.
Frontal Piane Function of th Adductors
The most obvtous function of th adductor muscles is pro
duction of adduction torque. The torque Controls th kine-
matics of both femoral-on-pelvic as well as peivic-on-femoral
hip adduction. Figure 1 2 - 3 5 shows an example of th ad-
ductor muscles contracting bilaterali)' to control both forms
of motion. On th tight side, several adductors are shown
accelerating th femur toward th ball. Adding to th force-
fulness of this action is th downward rotation or lowering
of th righi iliac crest a motion controlled through pelvic-
on-femoral hip adduction at th left hip. Although only th
adductor magnus is shown on th left side, other adductor
muscles assist in this action.
Sagittal Piane Function o f th Adductors
Regardless of hip position, th posterior fibers of th adduc
tor magnus are powerful extensors of th hip, similar to th
hamstring muscles. In generai, th remaining adductor mus
cles, h ow ev er, are flexors or extensors, dep en d in g on h ip
position.1769 Consider, for example, th adductor longus as
a representative adductor muscle during a fast sprint (Fig.
1 2 -3 6 A ). From a position of at least about 50 to 60 degrees
of hip flexion, th line-of-force of th adductor longus is
posterior to th medial-lateral axis of th joint. At this posi
tion, th adductor longus has an extensor moment arm and
is capable of generating an extension torque similar to th
posterior head of th adductor magnus. From a hip position
less than 60 degrees of hip flexion, however, th line-of-force
of th adductor longus shifts anteriori)/ to th medial-lateral
axis of rotation (Fig. 1 2 -3 6 B ). The adductor longus now has
a flexor moment arm and generates a flexor torque similar to
th rectus femoris, for example.
The adductors provide a useful source of flexor and ex
tensor torque at th hip. The bidirectional torques are useful
during high pow er, cyclic m otions such as sprinting, cycling,
running up a steep hill, and descending and rising from a
deep squat. When th hip is near full flexion, th adductors
414 Secrton IV Lower Extremity

Effect of Hip Flexor Contracture on Standing

Hips that remain flexed for a prolonged time often develop
flexion contracture. This situation is often associated with
spasticity of th hip flexors, weakness of th hip exten-
sors, arthritis or dysplasia of th hip, or confinement to a
wheelchair. In time, adaptive shortening in th flexor mus-
cles and capsular ligaments limits full extension of th hip.
One consequence of a hip flexion contracture is a
disruption in th normal biomechanics of standing. Nor-
mally, standing requires very little muscular energy. While
standing, th hip is stabilized through an interaction of
two opposing torques: body weight and passive tension
from taut anterior capsular ligaments of th hip. As shown
in Figure 12-32A, standing with th hips near full exten
sion directs th force of body weight slightly posterior to
th medial-lateral axis of rotation at th hip. The force of
body weight, therefore, is converted to a small, but never-
theless useful, hip extensor torque. The hip is prevented
from further extension by passive flexor torque created by
th stretched capsular ligaments. The static equilibrium
formed between th forces of gravity and stretched con-
nective tissues minimizes th need for metabolically "ex-
pensive" muscle activation.
With a hip flexion contracture, th hip remains partially
flexed while th person attempts to stand. This posture
redirects th force of body weight anterior to th hip,
creating a flexion torque (Fig. 12-32B). Whereas gravity
normally extends th hip while standing, gravity now acts
as a hip flexor. In order to prevent flexing into a full
squat, active extensor torques are required from muscles
such as th gluteus maximus. In turn, th metabolic cost
of standing increases and, over time, increases th desire
to sit. Often, prolonged sitting perpetuates th circum-
stances that initiated th flexion contracture.
Standing with a hip flexion contracture interferes with
th joint's ability to optimally dissipate compression loads. FIGURE 12-32. The effect of a hip flexion contracture on th
Normally, standing with hips near full extension places th biomechanics of standing. A, When standing with hips fully
extended, th force of body weight falls slightly posterior to
highest regions of joint pressure over th regions of thick-
th axis of rotation at th hip. Body weight, therefore, causes
est articular cartilage. Standing, or walking, with a par
an extension torque at th hip. The anterior capsule and
tially flexed hip, however, causes th higher regions of ligaments at th hip are pulled taut, which prevents further
joint pressure to pass through th thinner regions of carti hip extension. B, An attempt to stand upright with a hip
lage. This arrangement cannot optimally dissipate com flexion contracture redirects th force of body weight anterior
pression loads, which cross th joint (see Fig. 2-32A to th hip joints, causing a hip flexor torque. The gluteus
and B, compare red dots at joint interface). As a result, maximus (red) is active to prevent th hip joints from further
th articular cartilage is not able to protect th underlying flexion. The very tight iliofemoral ligament and psoas major
bone from large forces that are usually produced by acti- muscle are indicated by th black arrows. In A and B, th
vated muscles. red circle at th center of th femoral head represents th
axis of rotation. The pair of red dots denote th relative
Clinically, persons with painful arthritis or bursitis of
overlap of articular cartilage. (See text for further descrip-
th hip are susceptible to flexion contracture. It is impor- tion.) (From Neumann DA: An Arthritis Home Study Course:
tant to reduce th inflammation through medicine and The Synovial Joint: Anatomy, Function, and Dysfunction.
physical therapy so that activities that favor th extended The Orthopedic Section of th Amencan Physical Therapy
position can be tolerated. Hip extension exercises can Association, 1998.)
strengthen th extensor muscles, while stretching th hip
flexors and anterior capsular structures.

Superior
FIGURE 12-33. A posterior view depicts th frontal piane line-of-
force of several musdes that cross th right hip. The axis of rota-
tion (red) is directed in th anterior-posterior direction through th
femoral head. The abductors are indicated by solid lines and th
adductors by dashed lines.
are mechanically prepared to augment th extensors. In con-
trast, when th hip is near full extension, they are mechani
cally prepared to augment th flexors. This utilitarian func-
tion of th adductors may partially explain their relatively
high susceptibility to strain injury while running.
HIP INTERNAI. ROTATOR MUSCLES
From th anatomie position, there are no primary internai
rotators of th hip because no muscle is optimally positioned
in th horizontal piane to produce internai rotation torque.
Many secondary internai rotators exist, including th anterior
fibers of th gluteus minimus and th gluteus medius, tensor
fasciae latae, adductor longus, adductor brevis, and pectineus
(Fig. 1 2 -3 7 ). The tensor fascia latae and th mediai ham-
strings (i.e., semitendinosus and semimembranosus)45 also
function as secondary internai rotators of th hip.
With th hip flexed toward 90 degrees, th internai rota
tion torque potential of th internai rotator muscles dramati-
cally increases. This becomes clear with th help of a skele
ton model and piece of string to mimic th line-of-force of
muscles, such as th gluteus minimus and anterior fibers of
th gluteus medius. Flexing th hip dose to 90 degrees
orients th line-of-force of these muscles nearly perpendicu-
Chapter 12 Hip 415
lar to th longitudini axis of rotation. The internai rotation
moment arm of th anterior part of th gluteus medius, for
example, increases 8 fold between 0 and 90 degrees of
flexion.15 Interestingly, even several extemal rotator muscles,
such as th piriformis, switch leverage to become internai
rotators at 90 degrees of flexion. These changes in leverage
explain why internai rotation torque in healthy persons is
about 50% greater with th hip flexed rather than extended.45
This phenomena may partially explain th excessively inter-
nally rotated gait pattern typically observed in a person with
cerebral palsy. With poor control of hip extensor muscles,
th resulting flexed posture of th hip enhances th torque
potential of th internai rotator muscles. This gait pattern
may be better controlled by enhanced activation of th glu
teus maximus, a potent extensor and extemal rotator.15 The
anatomy of each of th internai rotators is described under
other sections (see Figs. 1 2 - 2 9 and 1 2 -4 4 ).
Overall Function of th Hip Internai Rotators
Biomechanics o f th Adductor Muscles as Internai Rotators
of th Hip
Many of th adductor muscles are capable of producing at
least modest internai rotation torque at th hip when th
body is in th anatomie position.17-8485 This action, however,
may be difficult to reconcile considering that most adductors
attach to th posterior side of th femur along th linea
aspera. A shortening of these muscles appears to rotate th
femur extemally instead of intemally. What must be consid-
ered, however, is th effect that th naturai bowing of th
femoral shaft has on th line-of-force of th muscles. Bowing
places much of th linea aspera anterior to th longitudinal
axis of rotation at th hip (Fig. 1 2 -3 8 A ). As depicted in
Figure 1 2 -3 8 6 , th horizontal force component of an ad
ductor muscle, such as th adductor longus, lies anterior to
th axis of rotation. Force from this muscle, therefore, acts
with a moment arm necessary to produce internai rotation,
although torque is minimal.
Functional Potential of th Internai Rotator Muscles
While Walking
From a pelvic-on-femoral perspective, th internai rotators
perform a subtle but nevertheless important function during
gait. During th stance phase, th internai rotators move th
pelvis in th horizontal piane over a relatively fixed femur
(Fig. 1 2 - 3 9 ) .33-66 The pelvic rotation about th right hip is
evident by th forward rotation of th lefi iliac crest. The
right internai rotator muscles, therefore, can provide some of
th drive to th contralateral (left) swinging limb. During
relatively fast walking speed, a greater demand is placed on
th internai rotator muscles to increase th stride length of
th contralateral lower limb.
HIP EXTENSOR MUSCLES
Anatomy and Individuai Action
The primary hip extensors are th gluteus maximus, th
hamstrings (i.e., th long head of th biceps femoris, th
semitendinosus, and th semimembranosus), and th poste
rior head of th adductor magnus (Fig. 1 2 - 4 0 ) .1725 The
posterior fibers of th gluteus medius are secondary exten
sors. As described earlier, th adductor muscles can extend
th hip provided that it is flexed beyond about 50 degrees.17
416 Section IV Lower Extremity

Adductor Muscle Group

ORGANIZATION PROXIMAL. ATTACHMENTS

Deep layer Middle layer Superficial layer

FIGURE 12-34. The anatomie organization and proximal attachments of th righi adductor muscle gvoup, as seen from a lateral view
through a transparent femur.

The guteus maximus has numerous proximal attachments
from th posterior side of th iliurn, sacrum, coccyx, sacro-
tuberous and posterior sacroiliac ligaments, and adjacent fas
cia. The muscle attaches into th iliotibial band of th fascia
lata, along with th tensor fasciae latae, and th gluteal
tuberosity on th lemur. The gluteus maximus is a primary
extensor and extemal rotator of th hip.
The hamslring muscles have their proximal attachment
on th posterior side of th ischial tuberosity, and attach
distally io th tibia and fibula. Based on these attachments,
th hamstrings extend th hip and flex th knee. The anat-
omy and function of th posterior head of th adductor
magnus is described under th section on adductors of th
hip.

FIGURE 12-35. The bilateral coopera

tive action of th adductor muscles
while kicking a soccer ball. The lek
adductor magnus is shown actively
producing pelvic-on -Jem oral adduction
Severa] righi adductor muscles are
shown actively producing fem oral-on -
pelvic adduction torque, needed lo ac
celerale th ball.
 Chapier 12 Hip 417

Adductor longus as a hip extensor Adductor longus as a hip flexor

FIGURE 12-36. The dual sagiual
piane action of th adductor longus
muscle is demonstrated while
sprinting. A, With th hip flexed,
Rectus
th adductor longus is in position
femoris
to extend th hip, along with th Adductor magnus
adductor magnus. B, With hip ex- Adductor longus
tended, th adductor longus is in Adductor longus
position to flex th hip, along with
th rectus femoris. These contrast-
tng actions are based on th change
in line-of-action of th adductor
longus, relative to th medial-lateral
axis of rotation at th hip.

Figure 1 2 - 2 8 depicts th line-of-force of th primary Overall Function of th Hip Extensors

hip extensors. In th extended position, th posterior head
Pelvic-on-Femoral Hip Extension
of th adductor magnus has th greatest moment arm for
The following sections describe two different situations in
extension, followed closely by th biceps femoris and th
which th hip extensor muscles control pelvic-on-femoral
semitendinosus. The semimembranosus and th gluteus
extension.
maximus have th greatest cross-sectional areas of all th
extensors.69 H ip E x te n s o rs P e rfo rm in g a P o s te r io r P e lv ic T ilt .
From a position of 75 degrees of flexion, th hamstrings With th supralumbar trunk held relatively stationary, th
and adductor magnus produce about equal magnitudes of hip extensor and abdominal muscles act as a force-couple to
extension torque, or about 90% o f th total extensor torque
potential at th hip.69 Most of th remaining torque is gener-
ated by th gluteus maximus.

FIGURE 12-38. The function of th adductor muscles as internai

FIGURE 12-37. A superior view depicts th horizontal piane line-of-
force of severa 1 muscles that cross th hip. The longitudinal axis of
rotation is in th superior-inferior direction through th femoral
head. For clarity, th tensor fasciae latae, sartortus, and hamstring
muscles are noi shown. The extemal rotators are indicated by solid
lines and th internai rotators by dashed lines.
rotators of th hip: A, Because of th antenor bowing of th femo
ral shaft, a large segment of th linea aspera (red) runs anterior to
th longitudinal axis of rotation. B, A superior view of th righi hip
shows th horizontal line-of-force of th adductor longus. The mus
cle causes an internai rotation torque by producing a force that
passes anterior to th axis of rotation (white dot at femoral head).
The moment arm used by th adductor longus is indicated by th
thick dark line. The dashed circle represents th outline of th
midshaft of th femur at th region of th distai attachment of th
adductor longus.
 418 Section IV Lower Extremity

S u p e r io r vievv

15% 30% 50%

50%
Percent of gait cycle

Pattem ,of several muscles of the nghl hip is depicted during various parts of th gaii cycle The hip
heT p lL r i h T fafCT alae 8 Uler s m 5' anlenor Parts of th giuteus medtus, and adductor longus) are shown rotatine
he pelvis in th honzontal piane over a relatively fixed righi femur. (Compare the bottom and top views.) The tensor fasciae latae and
he glutea muscles function as hip abductors by controlling the frontal piane stability of the pelvis. (The images were prepared from
J T phS f af SK UbjeCt Wf lk.lng at a relatively fast sPeed of about 1.9 m/s. This relatively fast walking spted has exaggerated the
normal amount of honzontal piane rotation used during walking ) s K cxaggcraiea ine

posteriorly tilt the pelvis (Fig. 1 2 -4 1 ). The posterior tilt

extends the hips and reduces the lutnbar lordosis.
The muscular mechanics involved with posterior tilting of
the pelvis are similar to those described for the anterior
tilting o f the pel vis (com pare Figs. 1 2 - 3 0 and 1 2 -4 1 ). In
both tilting actions, a force-couple exists between the hip
and trunk muscles. As a consequence, the pelvis rotates
through a relatively short are, using the femoral heads as a
pivot point.
H ip E x te n s o rs C o n t r o llin g a F o r w a rd L e a n o f the
B o d y. Leaning forward while standing is a very common
activity. Consider, for example, the forward lean used to
wash the face over a sink. The muscular support of this near
static posture at the hips is primarily the responsibility of
th hamstring muscles. Consider the two phases of a for
ward lean shown in Fig. 1 2 - 4 2 . During a slight forward
lean (Fig. 1 2 -4 2 A ), body weight force is displaced just ante-
rtor to the medial-lateral axis of rotation at the hip. This
 Chapter 12 Hip 419

Gluteus medius
Gluteus medius
Gluteus maximus (cut)
Gluteus maximus Piriformis
Gemellus superior
internus
FIGURE 12-40. The posterior muscles
Gemellus inferior
of th hip. The left side highlights th
gluteus maximus and hamstring mus femoris
Adductor
cles (long head of th biceps femoris, maximus (cut)
semitendinosus, and semimembrano- femoris 1
sus). The nghi side shows th ham Semitendinosus Wcut)
string muscles cut io expose th adduc- lliotibial tract SemimembranosusJ
tor magnus and short head of th
Biceps femoris Adductor magnus
biceps fetnoris. The righi side shows
(long head)
th gluteus medius and five of th six Biceps femoris
short external rotators, i.e., piriformis, Semitendinosus
(short head)
gemellus superior and inferior, obtura-
Biceps femoris
tor intemus, and quadratus femoris.
(long head) (cut)

Gracilis (cut)
Semitendinosus (cut)
Semimembranosus (cut)

I slightly flexed posture of th hips is restrained by minirrial

activation from th gluteus maximus and hamstring muscles.
During a m ore signiRcant forw ard lean, h ow ev er, b od y
1 tveighi force is displaced farther in from of th medial-Iateral
1 axis of rotation at th hips (Fig. 1 2 42B). Supporting this
markedly flexed posture requi res greater muscle activation
I from th hamstring muscles. The gluteus maximus, however,
rematns relatively inactive in this position a point verifia-
| ble b y palpation an d inferred from EMG data.20 This appar-
ent increased responsibility of th hamstrings, in contras! to
th gluteus maximus, can be explained biomechanically and
physiologicaly. A significant forward lean increases th hip
extension moment arm of th hamstring muscles, while it
decreases th hip extensor moment arm of th gluteus maxi
mus.0' (Compare th 15-degree and 30-degree points in th
graph in Fig. 1 2 - 4 2 .) Leaning forward mechanically opti-
mizes th extensor torque potential of hamstrings. A signifi
cant forward lean elongates th hamstring muscles across both
th hip and knee joints. Elongation significanti)- increases th
passive force in these muscles which, in turn, helps support
th partially flexed position of th hips. For these reasons. th FIGURE 12-41. The force-coupie between representative hip exten-
hamstrings appear uniquely equipped to support th hip pos sors (gluteus maximus and hamstrings) and abdominal muscles
ture associateci with forward lean. Apparently, th nervous (rectus abdominis and obliquus extemus abdominis) that posteri
ori)' tilt th pelvis. The moment arms for each muscle group are
System recruits th large gluteus maximus for activities that
indicated by th dark black line. Note th decreased lordosis at th
require more substantial hip extension torque, such as those lumbar spine. The extension at th hip stretches th iliofemoral
needed for climbing a steep flight of stairs. ligament.
 420 Section IV Lower Extremity

S lig h t fo rw a rd lea n S ig n ific a n t fo rw a rd lean

A
A A
m
a

O
o o
_L _L J __
15 30 45 60 75

PELVIC-ON-FEMORAL FLEXION (DEG.)

t f- f-
A Adductor magnus
O Semitendinosus
Body weight O Gluteus maximus
FIGURE 12-42. The hip extensor muscles are shown controlling a forward lean of th pelvis over th thighs. A, Slight forward
lean of th upper body displaces th body-weight force slightly anterior to th mediai-/alerai axis of rotation at th hip B A
more significaci forward lean displaces th body-wetght force even fanher anteriorly. The greater flexion of th hips rotates
th tschial tuberostes postenorly, thereby mcteasmg th hip extension moment arm of th hamstrings. The tatti Ime (wifh
arrow head within th stretched hamstring muscles) indicates th increased passive tension. In both A and B th relative
demands placed on th muscles are shown by relative shades o f red. At tight is a graph showing th length of hip extension
moment arms of selected hip extensors as a function of forward lean. (Data from Pohtilla JF: Kinesiology of hip extension at
selected angles of pelvilemoral extension. Arch Phys Med Rehabil 50:241-250, 1969.)

Femoral-on-Pelvic Hip Extension HIP ABDUCT0R MUSCLES

As a group, th hip extensor muscles are frequently required
to produce large femoral-on-pelvic hip extensor torque to
accelerate th body forward and upward. Consider, for ex-
ample, th demands placed on th right hip extensors while
climbing a steep mountain (Fig. 1243). The flexed position
of th right hip while th climber is carrying a heavy pack
imposes a large extemal (flexion) torque at th hip. The
flexed position, however, favors greater extensor torque gen
eration from th hip extensor muscles.69 Furthermore, with
th hip markedly flexed, many of th adductor muscles can
produce an extensor torque, thereby assistmg th primary
hip extensors.
Anatomy and Individuai Action
The primary hip abductor muscles are th gluteus medius.
gluteus mintmus, and tensor fasciae latae.9'17 The piriformis
and sartorius are considered secondari' hip abductors (see
Figs. 1 2 - 2 9 , 1 2 - 4 0 , and 1 2 -4 4 ).
The gluteus medius attaches on th extemal surface of th
ilium above th anterior gluteal line. The muscle attaches
distally on th lateral aspect of th greater trochanter. The
distai attachment provides th gluteus medius with th great-
est abductor moment arm of all th abductor muscles (see
Fig. 1 2 - 3 3 ). The gluteus medius is also th largest of th
 Chapter 12 Hip 421

hip abductor muscles, occupying about 60% of th total

abductor cross-sectional area.9
Based on anatomie and EMG-based studies, th gluteus
medius is classified into three independent anatomie and
functional sets of fibers: anterior, middle, and posterior.980
Although all fibers contribute to abduction, from th ana
tomie position th anterior fibers intemally rotate th hip
and th posterior fibers extend and externally rotate il. These
actions change considerably when motion is performed out
of th anatomie position.16
The gluteus minimus lies deep and slightly anterior to th
gluteus medius. This muscle attaches proximally on th il-
ium between th anterior and inferior gluteal lines and
distally on th anterior aspect of th greater trochanter. The
gluteus minimus is smaller than th gluteus medius, occupy
ing about 20% of th total abductor cross-sectional area.9
The actions of th gluteus minimus are similar lo those of
th gluteus medius,9 especially in regard to abduction.41 One
notable exception, however, is th flexion potential of th
anterior fibers of th gluteus minimus (see Fig. 1 2 - 2 8 ).
The tensor fasciae latae is th smallest of th three primary
hip abductors, occupying about 11% of th total abductor
cross-sectional area.9 The anatomy of th tensor fasciae latae
is discussed elsewhere in this text.

H ip A b d u c to r M e c h a n is m

FIGURE 12-43. Relaiively high demands are placed on hip extensor Control of Frontal Piane Stability of th Pelvis during Walkmg
muscles while climbing a mountain and supporting an external The abduction torque produced by th hip abductor muscles
load. is essential to th control of frontal piane, pelvic-on-femoral

Gluteus maximus (cut)

FIGURE 12-44. Deep muscles of th poste Sacrospinous ligament superior

rior and lateral hip region. The gluteus medius (cut)
medius and th gluteus maximus are cut to
expose deeper muscles.
Sacrotuberous ligament
Gemellus inferior

Obturator externus (deep)

Obturator internus Quadratus femoris

422 Section IV Lower Extremity

kinematics during walking. During most of th stance phase,
th hip abductors stabilize th pelvis over th relatively fixed
femur (see Fig. 1 2 - 3 9 ) .3J-51 During th stance phase, there-
fore, th hip abductors have a role in controlling th pelvis
in th frontal piane and, as discussed earlier, in th horizon-
tal piane.
The abduction torque produced by th hip abductor
muscles is particularly important during th single-limb
support phase of gait. During this lime, th opposite leg is
off th ground and swinging forward. Without adequate ab
duction torque on th stance limb, th pelvis and trunk may
drop uncontrollably toward th side of th swinging limb.
The activation of th hip abductor muscle is verified by
palpating th gluteus medius just superior to th greater
trochanter. The right muscle, for example, becomes frm as
th left leg lifts off th ground. The bursa located at th
point of distai attachment of th hip abductor muscles may
become inflamed. Trochanteric bursitis can be very painful,
especially during activation of th abductor muscles during
single-limb support.
The frontal piane stabilizing function of hip abductor
muscles is an extremely important component of walking.
The force produced by th abductors during stance accounls
for most of th compressive forces generated at th hip.
Role of th Hip Abductors in th Production of Hip Force
Figure 1 2 - 4 5 shows th major factors involved with frontal
piane stability of th right hip during single-limb support

HAF

FIGURE 12-45. A frontal piane diagram shows th function of th righi hip abductor muscles dunng single-limb support on th
right hip. On th left, th pelvis-and-trunk are in stane equilibriti about th righi hip. The sum o f th torques in th frontal piane
equal zero. Ihe counterclockwise torque (solid circle) is th product of Lhe hip abductor force (HAF) times moment arm (D)- th
doekwise torque (dashed circle) is th product of body weight (BW) times moment arm (D,). Static stability occurs when HAF X
BVV. X D|; , e see-saw model (righi) simplifies th major kinetic events during single-limb support. A joint reaction force
(JRF) is directed through th fulcrum of th see-saw (hip joint). The sample data in th box are used in th torque and force
equilibnum equations These equattons determine th magnitude of th hip abductor force and joint reaction force needed during
smgle-hmb support. (See text.) Note that for simplicity, th calculations assume static equilibrium and that all force vectors are
acting in a vemcal direction. (From Neumann DA: Biomechamcal analysis of selected principles of hip joint protection Arthntis
Care Res 2:146-155, 1989. Reprirued with permission from Anhritis Care and Research. American College of Rheumatology.)

in walking. The hip abductor and body weight forces act
as two opposing forces that balance th pelvis over th
stance femoral head. The pelvis is comparable to a see-saw,
with its fulcrum represented by th femoral head. When th
see-saw is balanced, th counterclockwise (internai) torque
produced by th hip abductor force (HAF) equals th clock-
wise (external) torque caused by body weight (BW). Balance
of opposing torques is called static rotary equilibrium (see
Chapter 4).
During single-limb supporr, th hip abductor muscles
in particular th gluteus medius produce mosi of th
forces ai th hip.13 This important point is demonstrated by
th model in Figure 1 2 45. Note that th internai moment
arm (D) used by th hip abductor muscles is about half
th length of th external moment arm (D,) used by body
weight.5363 Given this length disparity, th hip abductor
m uscles must produ ce a force twice that o f b od y weight
in order to achieve stability during single-limb support.
On every step, therefore, th pelvis is forced against th
femoral head by th combined force created by th hip
abductor muscles and th pul of body weight, To achieve
static linear equilibrium, th downward force is counter-
acted by a joint reaction force of equal magnitude, but ori-
ented in nearly th opposite direction (see Fig. 1 2 - 4 5 , JR F).60
Inman calculated that th joint reaction force is directed 10
to 15 degrees from vertical, an angle that is strongly influ-
enced by th orientation of th hip abductor muscle force
vector.31
The sample data supplied in Figure 1 2 - 4 5 allow th
magnitude of th hip abductor force and joint reaction force
to be estimated. The torque and force equilibrium equations
assume that th sum of frontal piane torques about th righi
hip and vertical forces are both equal to zero. As shown, a
hip joint reaction force of 1873.8 N (421.3 Ib) occurs when
a 760.6 N (171 lb)-person is in single stance over th right
limb during gait. About 66% of th joint reaction force
Comes from th hip abductor muscles. These calculations
demonstrate that a joint reaction force of about 2.4 times
body weight is generated through th hip during single-limb
support. While th person is w'alking, this force is greater
due to accelerations of th pelvis over th femoral head.
Research using strain gauges implanted into a hip prosthesis
show that joint compression forces reach 2.5 to 3 times
body weight in walking. These forces increase to 5.5 times
body weight in running.4-74 Even ordinary daily functional
activities cari generate very high jo in t forces. H odge and
colleagues29 reported pressures (forces per unii area) of
18 MPa (1 MPa equals 145 lb/in2) on th acetabulum
while th healthy adult is rising from a chair. To appre-
ciate th magnitude of this pressure, consider that th air
pressure within a car tire is about 29 lb/in2 (0.2 MPa).
During sit-to-stand, therefore, pressures on th acetabulum
reach 90 times th pressure in a full tire.19 Joint forces have
important physiologic functions, such as stabilizing th fem
oral head within th acetabulum, assisting in th nutrition
of th articular cartilage, and providtng th stimulus for
normal development and shape o f joint structure in child-
hood. The articular cartilage and trabecular bone must,
however, protect th joint by dispersing these large forces. A
hip with arthritis may no longer be able to provide this
protection.
Chapter 12 Hip 423
Hip Abductor Muscle Weakness
Several medicai conditions are associated with weak
ness of th hip abductor muscles. These conditions
include muscular dystrophy, Guillain-Barr syndrome,
and poliomyelitis. The abductors may also be weakened
owing to hip arthritis, hip instability, or hip surgery. The
classic indicator of hip abductor weakness is th posi
tive Trendelenburg signP The patient is asked to stand
in single-limb support over th weak hip. A positive sign
occurs if th pelvis drops to th side of th unsup-
ported limb; in other words, th weak hip "falls" into
pelvic-on-femoral adduction (see Fig. 12-256). The clini-
cian needs to be cautious in interpreting and document- ,
ing th results of this test. The patient with a weak
right hip abductor, for example, may drop th pelvis to
th left. Weakness is often masked, however, by a com-
pensatory lean of th trunk to th right. Leaning th
trunk to th side of th weakness reduces th external
torque demand on th abductor muscles by reducing
th length of th external moment arm (see Fig. 12-45,
D,). When seen in gait, this compensatory lean to th
side of weakness is referred to as a "gluteus medius
limp" or "compensated Trendelenburg gait." Using a
cane in th hand opposite th weakened hip abductors
corrects this abnormal gait pattern.6
HIP EXTERNAL R0TAT0R MUSCLES
The primary external rotator muscles of th hip are fve of
th six "short external rotators, th gluteus maximus, and
th sartorius. In th anatomie position, muscles considered
as secondary external rotators are th posterior hbers of th
gluteus medius and th gluteus minimus, th long h ead o f
th biceps femoris, and th obturator extemus. The last
muscle is a secondar)' rotator because in th anatomie posi
tion its line-of-force lies only a few millimeters posterior to
th longitudinal axis of rotation (see Fig. 1 2 - 3 7 ).
F u n c tio n a l A n a to m y o f th "S h o rt E x te rn a l R o ta to rs "
The six short external rotators of th hip are th piriformis,
obturator intemus, gemei/us superior, gemeffus inferior,
quadratus femoris, and obturator extemus (see Figs. 1 2 - 1 7 ,
1 2 - 4 0 , and 1 2 -4 4 ). The line-of-force of these muscles is
oriented primarily in th horizontal piane. This orientation is
optimal for th production of external rotation torque. In a
manner similar to th infraspinatus and teres minor at th
shoulder, th short external rotators also provide stability to
th posterior side of th joint.
The piriformis attaches proximally on th anterior surface
of th sacram, among th exiting ventral rami of sacrai
spinai nerves (see Fig. 1 2 - 2 9 ). Exiting th pelvis through
th greater sciatic foramen, th piriformis attaches on th
superior aspect of th greater trochanter (see Fig. 1 2 -4 4 ).
In addition to th action of external rotation, th piri
formis also has a secondary action as a hip abductor. Both
actions are apparent by th muscles line-of-force rela-
 424 Section IV Lower Extremity
Standing at rest
FIGURE 12-46. Superior view depicts th oremation and action o f th obturacor intemus muscie. A, While standing at
rest, th obturator intemus muscie makes a 130-degree deflection as it courses through th pulley frmed by th tesser
sciatic notch. B, With th femur fxed dunng standing, contraction of this muscie causes pelvic-on-femoral extemal
rotation. Note that th compression force generated imo th joint is th result of th muscie contraction.
live to th axis of rotation at th hip (see Figs. 1 2 - 3 3 and
1 2 -3 7 ).
The sciatic nerve usually exits th pelvis below th piri-
formis. As described earlier in this chapter, th sciatic nerve
tnay pass through th belly of th piriformis. A shortened
piriformis may, for example, compress and irritate th sciatic
nerve. This condition, known as piriformis syndrome,85 is
often treated by stretching th muscie through a combina-
tion of adduction and internai rotation, from a position near
full hip extension.
The obturator intemus muscie arises from th internai side
of th obturator membrane and from th adjacent ilium (see
Fig. 1 2 -4 4 ). From this origin, th fibers converge to a
tendon and exit th pelvis through th lesser sciatic foramen.
The fxed pulley provided by th lesser sciatic notch deflects
th tendon about 130 degrees on its approach to th tro-
chanteric fossa of th femur (Fig. 1 2-46A ). Contraction of
this muscie with th femur held fxed, causes th pelvis to
rotate on th femur (Fig. 1 2 -4 6 B ). Force produced by th
obturator intemus compresses th joint surface. This com
pression force may help stabilize th joint during active
pel vie rotation.
The gemellus superior and gemellus inferior muscles are
located on either side of th centrai tendon of th obturator
intemus (see Fig. 1 2 - 4 4 ). The gemelli (from th Latin root
geminus, meaning twins) are two small muscles with proxi-
mal attachments on either side of th lesser sciatic notch.
Each muscie blends in with th centrai tendon of th obtu
rator intemus for a common attachment to th femur. Im-
mediately below th gemellus inferior is th quadratus fem oris
muscie. This fiat muscie arises from th extemal side of th
ischial tuberosity and inserts on th posterior side of th
proximal femur.
The obturator extemus muscie anses from th extemal side
of th obturator membrane and adjacent ilium (see Fig. 1 2 -
Active pelvic-on-femora external rotation
17). The belly of this muscie is visible from th anterior side
after removai of th adductor longus and pectineus muscles
(Fig. 1 2 - 2 9 ). The muscie attaches posteriorly on th femur
at th introchanteric fossa (see Figs. 1 2 - 5 and 1 2 - 7 ).
O v e ra ll F u n c tio n o f th E x te rn a l R o ta to rs
As described for th internai rotators of th hip, th func-
tional potential of th extemal rotators is most evident dur
ing pelvic-on-fem oral rotation. C onsider, for ex am p le, che
right extemal rotator muscles contracting to rotate th pelvis
over th femur (Fig. 1 2 - 4 7 ). With th right lower extremity
firmly in contact with th ground, concentric contraction of
th right extemal rotators accelerates th anterior side of th
pelvis and attached trunk away from th fxed femur. This
horizontal piane action of planting a foot and cutting to th
opposite side is a naturai way to abruptly change direction
while running. If needed, eccentric activation of th internai
rotators may decelerate this action. Extremely rapid coactiva-
tion of th adductor muscles to help decelerate extemal
rotation of th pelvis may cause strain injury to these
muscles. The mechanism of injury may further explatn th
relatively high incidence of adductor muscie pulls during
many sporting activities, which involve rapid rotation of th
pelvis-and-irunk while running.
MAXIMAL TORQUE PRODUCED BY THE HIP MUSCLES
Several studies have measured th maximal-effort torque
production of hip muscles.34'45 Table 1 2 - 3 summarizes th
average maximal (isokinetic) torques produced by healthy
men and women of different age groups.8 These normative
data are useful when assessing progress and setting goals for
persons involved in strength training programs of th hip
muscles.
 Chapter 12 Hip 425

Transversospinal
muscle
FIGURE 12-47. Action of th external Gluteus medius
rotator muscles during pelvic-on- (posterior fibers)
femoral external rotation of th right Piriform is
hip. Back extensor muscles are also
shown rotating th trunk. Obturator
internus

Quadratus
femoris

Gluteus
maximus

M a x im a l Torque Versus H ip J o in t A n g le R e la tio n s h ip
In contrast to th isokinetic data presented in Table 1 2 - 3 ,
maximal-effort torque produced by hip muscles is often
measured isometrically, across several different joint angles.
The unique shape of a muscle groups torque-joint angle
curve can identify th points in th range of motion where
functional dem an ds are g reaiesi on th muscle. Consider, fo r
example, th isometric torque-angle curve of th hip abduc-
tor muscles in healthy young adults (Fig. 1 2 - 4 8 ) . The hip
abductor muscles produce their greatest torque at full adduc-
tion (i.e., near th position associated with single-limb sup-
port). In contrast, abductor torque potential is least at th
fully shortened muscle length that corresponds to 40 degrees
of abduction. Ironically, th near maximally abducted hip is
th position suggested for manually testing th strength of
th hip abductors.39
Examples of Hip Disease
RATIONALE FOR SELECTED THERAPEUTIC AND
SURGICAL IN TER V EN TI
Two of th most common causes of hip impairment occur
from fracture of th proximal femur and osteoarthritis. This

1 TABLE 12-3. Average Maximal-Effort Torque (N m) for th Six Major Muscle Groups at th Hip*

Younger Men Older Men Younger Women Older Women

Muscle Group (X = 28 yrs) (X = 54 yrs) (X = 27 yrs) (X 53 yrs)
Extensors 177 (42) 157 (22) 110 (37) 101 (27)
Flexors 152 (50) 113 (21) 91 (24) 67 (21)
Adductors 121 (26) 99 (18) 82 (26) 63 (17)
Abductors 103 (26) 75 (18) 66 (19) 48 (14)
Internai rotators 72 (17) 61 (21) 47 (13) 34 (9)
External rotators 65 (24) 50 (15) 43 (13) 32 (11)

^Standard deviauons in parenthesis. Torques were measured isokineticaffy at 30/sec and then averaged over th fu ll range o f motion. The torques are
presented in order from greatest to least values. Data are based on 72 healthy subjects between 20 and 81 years of age. (Modified from Cahalan TD, Johnson
ME, Liu 5, ef ai: Quantitative measurements o f h ip strength in different age groups C lin O rthop 246: 1 3 6 -1 4 5 , 1989.)
Conversion: 1 36 N m = l ft-lb
 426 Section TV Lower Extremity

Sustaining a Fracture of th Hip Following a Fall

110 Loss o f Balance

RIGHT HIP
LEFT HIP I
100 - -

w Failure of Protective Reflexes

(e.g., slowed reaction time, sedation, dementia, muscle weak-
ness)

\
I
80 T- -
Fall
UJ
3 1
o Potential Energy Dissipated Primarily over Hip Region
70 --
o i
Failure of Locai Shock Absorption

\
(e.g., reduced fat around hip, weakness/atrophy of hip mus
cles, hard impact surface)
50 --
l
Diminished Strength of Bone
40 (e.g., osteoporosis, thinned bone cortex, loss of major tra-
becufae)
30 !
10 10 20 30
Fractured Hip
HIP ANGLE
FIGURE 12-48. This plot shows che ctteci o f /roncai piane range o f From C um m ings SR, N evai MC: A hypothesis: The causes of hip frac
hip motion on ihe maximal effori, isometric hip abductor torque in tures. J Gerontol Med Sci 44: M 107-M111, 1989.
30 healthy persona. The 10-degree hip angle represems a fully
adducted position where che muscles are at a relaiively long length
(Data from Neumann DA, Soderberg GL, Cook TM: Comparison of
maxima! isometric hip abductor muscle torques between hip sides.
Phys Ther 68:496-502, 1988.)

Clinical Signs of Hip Osteoarthritis Include

section describes each of these conditions, followed by a
discussion on clinica! biomechanics associated with selected
therapeutic and surgical interventions.
Fracture o f th Hip
Fracture of th hip (i.e., proximal femur) is a major health
and economie problem in th United States.11 About 20%
of persons with hip fractures die within a year owing to
factors directly related to these fractures.43 Nearly 80% of
persons over 65 years of age who sustain hip fractures are
female.38
The risk of hip fracture doubles each decade after th age
of 50 years.22 Two primary factors most often associated
with th higher incidence of hip fracture in th elderly are
age-related osteoporosis and th higher incidence of fading.
Additional factors proposed by Cummings and Nevitt12 are
included in Table 1 2 - 4 .
Hip Osteoarthritis
Hip osteoarthritis is a disease manifested primarily by th
deterioration of th joint's articular cartilage. Without an
adequate mechanism to dissipate loads, th joint surfaces
may rapidly degenerate an d change shape.
Clinical signs of hip osteoarthritis are listed in th box.
Hip osteoarthritis is often referred to as degenerative ar-
thritis of th hip. The term arthrosis is often used io de-
scribe a condition in which a joint is degenerated but not
infam ed.
Pain
Synovitis
Loss of joint space
Muscle atrophy
Hypcrtrophic bone formadon
Reduced range of motion
Abnormal gait
What Causes Primary Osteoarthritis of th Hip?
The exact cause of primary hip osteoarthritis remains
unclear. Although th frequency of osteoarthritis at
any joint increases with age, th disease is not trig-
gered solely by th aging process.46 If this were true,
then all elderly persons would develop this disease. The
causes of osteoarthritis are complicated and not exclu-
sively based on a simple wear-and-tear phenomenon.
Although physical stress may increase th rate and
amount of wear at a joint,68 this does not always lead
to osteoarthritis. Other mechanisms related to osteoar
thritis are metabolism of th ground matrix of th carti
lage, genetics, immune System factors, neuromuscular
dysfunctions,78 and biochemical factors.46
 Chapter 12 Hip 427

Hip osteoarthritis may be classified as either a primary
or secondary disease. Primary or idiopathic hip osteoarthritis
refers to an arthritic condition without a known cause. Sec
ondary hip osteoarthritis, in contrast, refers to an arthritic
condition resulting from a known mechanical disruption
of th joint. This may occur from trauma, structural failure
such as slipped capitai femoral epiphysis, anatomie asym-
metry such as excessive acetabular anteversion, leg length
discrepancy, avascular necrosis of th femoral head (i.e.,
Legg-Calv-Perthes disease), or congenital dislocation. Per-
sons who perform heavy physical work are more likely to
require hospitalization because of osteoarthritis of th
hip.82
T h e ra p e u tic In te rv e n tio n fo r a P a in fu l o r S tru c tu ra lly
U n s ta b le H ip
Using a Cane and Proper Methods for Carrying
External Loads
Physical rehabilitation of a painful or structurally unstable
hip often includes instructions in assisted gait40 and func-
tional activities, exercise,24-81 modalities for relieving pain,
and aerobic conditioning. In addition, clinicians frequently
give advice on how to protect th hip from large forces
while a person is walking.54 One method of protecting th
hip is to use a cane in th hand opposite to th affected hip.
Use of th cane reduces joint forces that are caused by th
activation of th hip abductor muscles.59-60 Figure 1 2 - 4 9
shows that applying a cane force in th left hand results in a
joint reaction force at th right hip of 1195.4 N (268.8 lb).
This correlates with a 36% reduction in joint reaction force
compared with that producd when not using a cane (see
Fig. 1 2 - 4 5 , for comparison).
Methods of carrying external loads influence th demands
placed on th hip abductor muscles and therefore on th
underlying hip joint.52-56-57 Persons with painful, unstable, or
surgically replaced hips are to be cautioned about th conse-
qu en ces o f carrying a hand-held baci opposite, or con trast
erai, to th affected hip.4'49-58 As shown in Figure 1 2 - 5 0 ,
th contralateral load has a very large external moment arm
(D2), creating a substantial clockwise torque about th right
hip. For frontal piane stability, th right hip abductors must

Counterclockwise Clockwise
torque torque

FIGURE 12-49. A frontal piane diagram shows how a cane force (CF) applied by th left hand produces a frontal piane torque
about th right hip in single-limb supporr. This cane-produced torque can minimize th torque demands on th right hip abductor
muscles. Note that th clockwise torque (dashed circle) due to body weight (BW X D,) is balanced by th counterclockwise torques
(solid circles) due to th hip abductor force (HAF X D) and th cane force (CF X D2). The data shown in th box are used in th
torque and force equilibrium equations to solve for hip abductor force and joint reaction force (JRF). The moment arm used by
cane force is represented by D2. (See Fig. 1 2 - 4 5 for additional abbreviations and background.) For simplicity, th calculations in
th inset assume static equilibrium and that all force vectors are acting in a vertical direction. (From Neumann DA: Hip abductor
muscle activity in persons with a hip prosthesis while carrying loads in one hand. Phys Ther 7 6 :1 3 2 0 -1 3 3 0 , 1996. With
permission of th APTA.)
 428 Section IV Luwer Extremity

Counterdockwise torque Clockwise torque

FIGURE 12-50. A frontal piane diagram shows how a load held in th left hand significantly increases th
amount of righi hip abductor force (HAF) dunng single-limb support. Two clockwise torques (dashed circles)
are produced about th righi hip due to body weight (BW X D.) and th contralaterally held load (CL X DA
For equ.libnum about th nght hip, th clockwise torques must be balanced by a counterdockwise torque (sofid
frre ePr S C >' P T (HAF X D)' The data shown in lhe box used in th torque and
orce equilibrami equations lo solve for hip abductor force and joint reaction force (JRF). D, is equal to the
moment arm used by th contralateral-held load (CL). Refer to Figure 1 2 - 4 5 for background and other
abbreviauons. For simplicity, the calculations assume stane equilibrium and that all force vectors are aciine in
vertica! direct,ons. (From Neumann DA: Hip abductor muscle ac.ivity m persons with a hip p r o s t L is whik
carrying loads in one hand. Phys Ther 7 6 :1 3 2 0 -1 3 3 0 , 1996. With permission of the APTA.)

create a counterdockwise torque large enough to balance the

2897.5 N (651.4 lb). A healthy hip can usually tolerate this
clockwise torques because of the load (CL X D2) and body
amount of force without difficulty. Caution must be exer-
weight (BW X D,). As a result of the relatively small mo
cised, however, if structural stability of the hip is compro-
ment arm available to the hip abductor muscles (D), the mised.
amount of hip abductor force during single-limb support is
The previous discussion focuses on methods that reduce
very large. As shown by the calculations in Figure 1 2 - 5 0 a
the iorce demands on the hip abductor muscles as a means
contralaterally held load of only 15% of body weight (i.e.,
to reduce the force on a painful or an unstable hip. Al-
114.1 N or 25.7 lb) results in a joint reaction force of
though these methods may have their desired effect, the
 Chapter 12 Hip 429

FIGURE 12-51. X-rays show two common forms of internai fixation for treatment of a fratture of th proximal
femur. A, A compression screw s used to repair an intertrochanteric fratture. The screw is designed like a piston,
compressing slightly when under th load of body weight. The compression increases bone-to-bone contact across
th fratture site. B, Three pins are used to stabilize a fratture through th femoral neck. (Courtesy of Michael
Anderson, M.D., Blount Orthopedic Clinic, Milwaukee, Wl.)

reduced functional demand placed on th hip may also per
petuate prolonged weakness in th hip abductor muscles
which, in tum , causes deviations in gait.67 Clinicians must
meet th dual challenge of protecting a vulnerable hip from
excessive and potentially damaging abductor forces, while
sim ultaneously increasing th functional strength and endur
ance of th abductors. This requires knowledge of th nor
ma/ and abn orm al frontal p ia n e m echan ics o f th hip, th
pathology specific to th patients condition, and th symp-
toms that suggest th hip is being subjected to potentially
damaging forces. The signs and symptoms include excessive
pain, marked gait deviaiion, generalized hip instability, and
abn orm al p osition in g o f th lo w er limb.
that signifcantly limits function and quality of life. This
operation replaces th diseased joint with biologically inert
materiali (Fig. 12-52). A prosthetic hip is secured by ce-
ment or through biologie fixation, provided by bone growth
into th surface of th implanted components. Although th
total hip arthroplasty is typically a successful procedure, pre
mature loosening of th femoral and/or acetabular compo
rne/ can be a postoperative problem.28 farge torsional
loads between th prosthetic implant and th bony interface
may contribute to th loss of fixation.5 Until sufficient long-
term data emerge from clinical trials, debate regarding th
most durable materials and effettive methods of fixation con-
tinue.

S u r g ic a l In te rv e n tio n F o llo w in g F ra c tu re o r O s te o a rth ritis

Surgery is often indicated to repair a fractured hip. The
type of surgical repair depends on th location and severity
o( th fracture. 3 Figure 1 2 - 5 1 shows two common types of
internai fixation used for a fractured proximal femur. The
amount of weight placed on th hip after surgery is usually
lim it e d u n ti1 t h fr a c tu r e s it e s h o w s a m p ie
healing.
A total hip arthroplasty is often indicated when a person
with hip disease, most often osteoarthritis, has Constant pain
Biomechanical Consequences of Coxa Vara and Coxa Valga
The average angle of inclination of th femoral neck is 125
degrees. The angle may be changed as a result of a surgical
repair o f a fractured hip o r an angle o f inclination designed
into a prosthesis. Additionally, an operation known as a coxa
vara (or valga) osteotomy intentionally alters a preexisting
angle of inclination. This operation involves cutting a wedge
e v id e n c e of o f bone from th proxim al fem ur, thereby changing th
orientation of th femoral head to th acetabulum.64 A goal
o f this operation is often to improve th congruency o f th
weight-bearing surfaces of th hip (Fig. 1 2 -5 3 ).
 430 Section IV Lower Extremity

Regardless of th type and rationale of th hip surgery,

changing th angle of inclination of th proximal femur
alters th stability, stress, and function of th muscles. These
alterations can have positive and negative biomechanical
effects. Figure 1 2 -5 4 A shows two positive biomechani
cal effects of coxa vara. The varus position increases th
moment arm of th hip abductor force (compare th dashed
lines indicated by D, and D). The greater leverage in
creases th abduction torque produced per unit of hip
abductor muscle force. This situation is useful for persons
with hip abductor weakness. Reducing th force demands
on th hip abductors while walking also helps to protect an
arthritic or a prosthetic hip from excessive wear. A varus
osteotomy is performed to improve th stability of th joint
by aligning th femoral head more directly into th acetab-
ulum.
A potentially negative effect of coxa vara is an increased
bending moment generated across th femoral neck (Fig.
1 2 -5 4 B ). The bending moment arm (dashed line indicated
by T) increases as th angle of inclination approaches 90
degrees. Increasing th bending moment raises th tension
across th superior aspect of th femoral neck. This situation
may cause a fracture of th femoral neck or a structural
failure of th prosthesis. Marked coxa vara increases th

FIGURE 12-53. A varus osteotomy was performed on a hip with

avascular necrosis of th femoral head. The removed wedge of bone
is apparent at th extreme proximal femoral shaft. The increased
varus position in this particular patient improved th congruency of
th weight-bearing surface of th hip. The osteotomy site was stabi-
lized with a biade piate. (Courtesy of Michael Anderson, M.D.,
Blount Orthopedic Clinic, Milwaukee, WI.)

vertical shear between th femoral head and th adjacent

FIGURE 12-52. An x-ray shows a total hip arthroplasty. The femo
ral component is made of a high-strength Steel alloy that is ce-
mented into th medullary canal. The socket is porous coated,
allowing th pelvic bone to grow into th device and provide
biologie fixation. (Courtesy of Michael Anderson, M.D., Blount Or-
thopedic Clinic, Milwaukee, Wl.)
epiphysis. In children, this situation may lead to a condition
known as a slipped capitai femoral epiphysis. Coxa vara may
decrease th functional length of th hip abductor muscles,
thereby reducing th force generating capability of these
muscles and increasing th likelihood of a gluteus medius
limp." The loss in muscle force may offset th increased
abductor torque potential gained by th increased hip ab
ductor moment arm.
Coxa valga may result from a surgical intervention or
from pathology such as hip dysplasia. A potentially positive
elteci of th valgus position is a decreased bending moment
arm across th femoral neck (see Fig. 1 2 -5 4 C , compare 1"
with I'). This situation decreased th vertical shear across
th femoral neck. The valgus position, however, may in-
crease th functional length of th hip abductor muscles,
thus their force generating capability may increase. In con
tras!, a potentially negative effect of coxa valga is th de
creased moment arm available to th hip abductor force (see
Fig. 1 2 -5 4 D , compare D" with D). In extreme coxa valga,
th femoral head is positioned more lateral to th acetabu-
lum, possibly favoring dislocation.
 Chapter 12 Hip 431

A : POSITIVE C: POSITIVE
1. Increased moment 1. Decreased bending
arm (D ) fo r hip moment arm (T)
abductor force. decreases bending
moment (ACF x I");
2. Alignment may improve
decreases shear force
joint stability.
across femoral neck.

2. Increased functional
length of hip abductor
muscle.

B : NEGATIVE D : NEGATIVE
1. Increasedbending 1. Decreased moment
moment arm (I') arm (D ) fo r hip
increases bending abductor force.
moment (ACFx I');
increases shear force 2. Alignment may favor
across femoral neck. joint dislocation.

2. Decreased functional
length of hip abductor
muscle.

FIGURE 12-54. The negative and positive biomechanical effects of coxa vara and coxa valga are contrasted. As a reference, a hip with a
normal angle of inclination ( a = 125 degrees) is shown in th center of th display. D is th internai moment arm used by hip
abductor force; 1 is th bending moment arm across th femoral neck.

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ADDITIONAL REAOING
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Bone Joint Surg 71B:47-50, 1989.

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Botja F, Latta LL, Stinchfield FH, et al: Abductor muscle performance in
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Evans BG, Salvati EA, Huo MH, Huk OL: The Tallonale for cemented total
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Bone Joint Surg 54B:157-163, 1972,
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 Knee
Donald A. Neumann, PT, P h D

TOPICS AT A G LANCE
0STE0L0GY, 435 Patellofemoral Joint, 446 A n a t o m ie C o n s id e r a t io n s , 455
Distai Femur, 435 Patellofemoral Joint Kinematics, 446 Q u a d r ic e p s A c t io n a t th K n e e :
Proximal Tibia and Fibula, 435 Path and Area of Patellar Contact on U n d e r s t a n d in g th B io m e c h a n ic a l
Patella, 437 th Femur, 446 I n t e r a c t io n s B e t w e e n E x te rn a l a n d
Collateral Ligaments, 447
ARTHROLOGY, 438 I n te rn a i T o r q u e s , 456

General Anatomie and Alignment

Anatomie Considerations, 447 P a t e llo f e m o r a l J o in t K in e t ic s , 457

Considerations, 438
Functional Considerations, 447 Knee Flexor-Rotator Muscles, 463
Anterior and Posterior Cruciate Ligaments, F u n c t io n a l A n a to m y , 463
Capsule and Related Structures, 438
449
Synovial Membrane and Associated G r o u p A c t io n o f F le x o r - R o t a t o r M u s c le s ,

Structures, 439 General Considerations, 449 465

Tibiofemoral Joint, 440

Anterior Cruciate Ligament, 451 M a x im a l T o r q u e P r o d u c t io n o f th K n e e

Articular Structure, 440 Functional Anatomy, 451 F le x o r - R o t a t o r M u s c le s , 465

Menisci, 440 Mechanism of Injury to th Anterior Maximal Torque Production at th

Cruciate Ligament, 451 Knee: Effects of Type and Speed of
A n a t o m ie C o n s id e r a t io n s , 440
Posterior Cruciate Ligament, 451 Muscle Activation, 466
F u n c t io n a l C o n s id e r a t io n s , 442
Functional Anatomy, 451 Synergy Among Monoarticular and
Osteokinematics at th Tibiofemoral Joint,
442 Mechanism of Injury to th Posterior Biarticular Muscles of th Hip and
Flexion and Extension, 443 Cruciate Ligament, 451 Knee, 466
Internai and External Rotation, 443 MUSCLE AND JOINT INTERACTION, 453 Abnormal Alignment of th Knee, 470
Arthrokinematics at th Tibiofemoral Joint, Innervation to th Muscles and Joints, 453 Frontal Piane, 470
445 Muscular Function at th Knee, 454 Genu Varum with Unicompartmental
Active Extension of th Knee, 445 Extensor and Flexor-Rotator Muscles, Osteoarthritis of th Knee, 470
Screw-Home" Rotation of th Knee, 454 Excessive Genu Valgum, 471
445 Quadriceps: Knee Extensor Sagittal Piane, 471
Active Flexion of th Knee, 446 Mechanism, 454 Genu Recurvatum, 471
Internai and External (Axial) Rotation of F u n c t io n a l C o n s id e r a t io n s , 454
th Knee, 446

INTRODUCTION_______________________ th swing phase of walking, th knee flexes to shorten th

The knee consists of th lateral and mediai tibiofemoral
joints and th patellofemoral joint (Fig. 1 3 - 1 ). Motion at
th knee occurs in two planes, allowing flexion and exten
sion in th sagittal piane, and internai and external rotation
in th horizontal piane. Functionally, however, these move-
ments rarely occur independent of movement at other joints
of th lower limb. Consider, for example, th interaction
among th hip, knee, and ankle during running or climbing
or standing from a seated position. The strong functional
association within th joints of th lower limb is reflected by
th fact that most muscles that cross th knee also cross
either th hip or ankle.
The knee has important biomechanical functions, many of
which are expressed during walking and running. During
434
functional length of th lower limb; otherwise, th foot
would noi easily clear th ground. During th stance phase,
th knee remains slightly flexed, allowing shock absorption,
conservation of energy, and transmission of forces through
th lower limb. Running requires that th knee moves
through a large range of motion, especially in th sagittal
piane. Rapidly changing directions while running (i.e., cut
ting) requires additional freedom of movement in th hori
zontal piane.
Stability of th knee is based primarily on its soft tissue
constraints rather than on its bony configuration. The mas
sive femoral condyles articulate with th nearly fiat surfaces
of th tibia, held in place by an extensive ligamentous cap
sule and large muscles. With th foot firmly in contaci with
th ground, these soft tissues are often subjected to large

FIGURE 13-1. X-ray shows th bones and
associated articulations of th knee.
forces, from both muscles and extemal sources. Injury to
ligaments and to cartilage are two common consequences of
th large functional demands placed on th knee. Knowledge
of th anatomy and kinesiology of th knee is an essential
prerequisite to th understanding of th mechanism of injury
and th most effective therapeutic intervention.
0STE0L0GY
Distai Femur
At th distai end of th femur are th large lateral and mediai
condyles (from th Greek kondylos, knuckle) (Figs. 1 3 - 2 to
1 3 -4 ). Lateral and mediai epicondyles project from each con-
dyle, providing elevated attachment sites for th collateral
ligaments. A large intercondylar notch separates th lateral and
mediai condyles, forming a passageway for th cruciate liga
ments (Fig. 1 3 - 4 ). Interestingly, a narrower than average
notch may increase th likelihood of injury to th anterior
cruciate ligament.106
Articular cartilage covers much of th surface of th femo-
ral condyle. The articular surface for th tibia follows a curve
that is a flat-to-convex path from front to back (Fig. 1 3 - 5 ).
The most distai end of each femoral condyle is nearly fiat,
thereby increasing th area for weight hearing.
Lateral and mediai grooves are etched faintly in th carti
lage of th femoral condyles (see Fig. 1 3 - 4 ). When th knee
is fully extended, th anterior edge of th tibia is aligned
with these grooves. The position of th grooves highlights
th asymmetry in th shape of th mediai and lateral articu
lar surfaces of th femur. The mediai surface curves slightly
laterally from back to front, and extends farther anteriorly
than th lateral articular surface. As explained later in this
chapter, th asymmetry in shape of th condyles affects th
sagittal piane kinematics.
Chapter 13 Knee 435
Osteologie Features of th Distai Femur
Lateral and mediai condyles
Lateral and mediai epicondyles
Intercondylar notch
Lateral and mediai grooves (etched in th cartilage of th
femoral condyles)
Intercondylar or trochlear groove
Lateral and mediai facets for th patella
The femoral condyles fuse anteriorly to form th inter
condylar (or trochlear) groove (see Fig. 1 3 - 4 ). This pulley-
shaped structure articulates with th posterior side of th
patella, forming th patellofemoral joint. The intercon
dylar groove is concave from side to side and slightly convex
from front to back. The sloping sides of th groove form
lateral and mediai jacets. The more pronounced lateral facet
extends more proximally and projects farther anteriorly than
th mediai facet. The shape of th lateral facet helps to
stabilize th patella within th groove during knee move-
ment.
Proximal Tibia and Fibula
The fibula is essentially a non-weight-bearing bone. Although
it has no direct function at th knee, th slender bone
splints th lateral side of th tibia and helps maintain its
alignment.
The head o f th fibula serves as an attachment for th
biceps femoris and th lateral collateral ligament. The
fibula is attached to th lateral side of th tibia by prox
imal and distai tibiofibular joints (see Fig. 1 3 - 2 ) . The
structure and function of these joints are discussed in Chap
ter 14.
 436 Section IV Lower Extremity

Anterior view The primary functiort of th tibia is to transfer weight

across th knee to th ankle. Its proximal end llares into
mediai and lateral condyles, which form articular surfaces with
th distai femur (see Fig. 1 3 - 2 ) . The superior surfaces of
Intercondylar groove th condyles form a fiat, broad region, often referred to as
Lateral epicondyle Adductor tubercle th tibial plateau. The plateau supports two smooth articular
Mediai epicondyle surfaces that accept th large femoral condyles, forming th
lliotibial tract on
lateral condyle tibiofemoral joints of th knee (see Fig. 1 3 - 4 ). The larger.
mediai articular surface is fiat to slightly concave, whereas
Styloid process
th lateral articular surface is fiat to slightly convex. The
Mediai condyle
Biceps femoris articular surfaces are separated down th midiine by an in-
Attachment of
Proximal
patellar ligament
tibiofibular joint

Peroneus longus G racilis-

Extensor Sartorius -P e s Posterior view

digitorum longus anserinus
SemitendinosusJ
tendons yemu/-
Plantaris

Adductor tubercle Gastrocnemius

Extensor hallucis Tibialis anterior (lateral head)
Gastrocnemius
longus
(mediai head)
Lateral epicondyle
Mediai epicondyle Popliteus

Intercondylar notch

Semimembranosus Styloid process

Proximal
tibiofibular joint

Peroneus brevis Interosseous membrane

Soleus
Peroneus tertius
Soleal line

Distai
tibiofibular joint Flexor hallucis
longus
Mediai malleolus
Lateral malleolus

FIGURE 13 -2 . Anterior view of th righi distai femur, th tibia, anc

th fbula. Proximal attachments of muscles are shown in red, dista
attachments in gray. The dashed lines show th attachments of th Peroneus brevis
capsule of th knee jotnt.

Tibia

Osteologie Features of th Proximal Tibia and Fibula Fibula

Proximal Fibula
Head
Distai tibiofibular joint
Proximal Tibia
Mediai and lateral condyles Mediai malleolus
Lateral malleolus
Intercondylar eminence
Anterior intercondylar fossa
Posterior intercondylar fossa
FIGURE 13 -3 . Posterior view of th righi distai femur, th tibia, and
Tibia! tuberosity
th fbula. Proximal attachments of muscles are shown in red, distai
Soleal (popliteal) line
attaehments in gray. The dashed lines show th attachment of th
joint capsule of th knee.
 Chapter 13 Knee 4.37

ity serves as th distai attachment for th quadriceps femoris

L a te ra l fa c e t
fa c e t muscle. On th posterior side of th proximal tibia is a
roughened s o le a l ( p o p lite a l) lin e, coursing diagonally in a dis-
In te rc o n d y la r g r o o v e M e d ia i g r o o v e
(in c a rtila g e ) tal-to-medial direction (see Fig. 1 3 - 3 ).
L a te ra l g r o o v e
(in
M e d ia i e p ic o n d y le
Patella
L a te ra l e p ic o n d y le

The patella (from th Latin, small piate) is a nearly triangu-

L a te ra l c o n d y le c o n d y le
lar-shaped bone embedded within th quadriceps tendon. lt
is th largest sesamoid bone in th body. The patella has a
In te rc o n d y la r P o s t e r io r
in te r c o n d y la r f o s s a
curved b a s e superiorly and a pointed a p e x inferiorly (Figs.
e m in e n c e
(w ith 1 3 - 6 and 1 3 - 7 ) . In a relaxed standing position, th apex of
c o n d y le th patella lies just proximal to th knee joint line. The
L a te ra l c o n d y le
subcutaneous a n t e r io r s u r fa c e of th patella is convex in all
directions. The base of th patella is rough due to th at
A n te r io r tachment of th quadriceps tendon. The patellar ligament
in te r c o n d y la r f o s s a
attaches between th apex of th patella and th tibial tuber
osity.

FIGURE 1 3 -4 . Osteology of th tight patella, articular surface of th

distai femur and of th proxtmal tibia.
Osteologie Features of th Patella
Base
Apex
t e r c o n d y la r e m in e n c e formed by mediai and lateral tubercles. Anterior surface
A shallow anterior and a posterior in t e r c o n d y la r f o s s a flank Posterior articular surface
either side of th eminence. The cruciate ligaments and Vertical ridge
menisci attach along th intercondylar regions. Lateral, mediai, and odd facets
The prominent tib ia tu b er o s ity is located on th anterior
surface of th proximal shaft of th tibia. The tibial tuberos-

The p o s t e r io r a r t ic u la r s u r fa c e of th patella is covered

with articular cartilage up to 4 to 5 mm thick.32 This surface
L a te r a l view contacts th intercondylar groove of th femur, forming th
patellofemoral joint. The thick cartilage helps to disperse th
large compression forces that cross th joint. A rounded
v e r tic a l rid g e runs longitudinally from top to bottom across
th posterior surface of th patella. On either side of this
G a s tr o c n e m ii/ s ridge are lateral and mediai facets. The larger and slightly
(la te ra l h e a d )
concave la t e r a l f a c e t matches th generai contour of th lat
L a te ra l c o lla te ra l eral facet of th intercondylar groove of th femur (see Fig.
lig a m e n t
1 3 - 4 ). The m e d i a i f a c e t shows signifcant anatomie variation.
P o p lit e u s A third o d d f a c e t exists along th extreme mediai border of
th mediai facet.
llio t ib ia l traci
B ic e p s fe m o r is
P r o x im a l t ib io f ib u la r
L a te ra l c o lla te ra l lig a m e n t jo in t
A n t e r io r P o s te rio r
Extensor digitorum longus Patellar ligament

P e r o n e u s lo n g u s
V e rtic a l rid g e

T ib ia lis a n te r io r
L a te ra l fa c e t

p a te lla r lig a m e n t

FIGURE 1 3 -6 . Anterior and posterior surfaces of th right patella.

FIGURE 1 3 -5 . Lateral view of th righi knee. Proximal attachments The attachment o f th tendon of th quadriceps muscles is in gray;
of muscles and ligaments are shown in red, distai attachments in th proximal attachment of th patellar ligament is in red. Note th
gray. Note th curved shape of th articular surface of th femoral smooih articular cartilage covering th posterior articular surlace of
condyles. th patella.
 438 Section IV Lower Extremity

L a te ra l p a te lla r r e t in a c u la r fib e r s

/wLir FIGURE 1 3 -7 . Anterior view of th

L a te ra l c o lla te ra l lig a m e n t tP1' jj---------- M e d ia i c o lla te ra l lig a m e n t right knee, highlighting many muscles
M e d ia i p a te lla r retinacular fib e rs and connective tissues. The pes anseri
T e n d o n o f b ic e p s fe m o r is (c u t) ------- l
nus tendons are cut to expose th me
S e m it e n d in o s u s - i
diai patellar retinaculum.
G r a c ilis P e s a n s e r in u s
S a r t o r iu s te n d o n s (cu t)
A n t e r io r t lb io f ib u la r lig a m e n t

P a te lla r lig a m e n t

ARTHROLOGY 8A, this longitudinal axis can be extended inferiori)' through

th knee to th ankle and foot. The axis mechanically links
General Anatomie and Alignment th horizontal piane movements of th major joints of th
Considerations entire lower limb. Horizontal piane rotations that occur in
NORMAL ALIGNMENT OF THE KNEE th hip, for example, affect th posture of th joints as far
distai as those in th foot. This topic is developed further in
The shaft of th femur angles slightly medially as it descends Chapter 14.
toward th knee. This oblique orientation is due to th
naturai 125-degree angle of inclination of th proximal fe
mur (Fig. 1 3-8A ). Because th articular surface of th proxi Capsule and Related Structures
mal tibia is oriented nearly horizontal, th knee forms an
The fibrous capsule of th knee encloses th mediai and
angle on its lateral side of about 170 to 175 degrees. This
lateral tibiofemoral joints and th patellofemoral joint. The
normal alignment of th knee within th frontal piane is
proximal and distai attachments of th capsule to bone are
referred to as genu vagum.
indicated by th dotted lines in Figures 1 3 - 2 and 1 3 -3 .
Variation in normal frontal piane alignment ai th knee is
The capsule of th knee receives significant reinforcement
not uncommon. A lateral angle less than 170 degrees is
fiom muscles, ligaments, and fascia. Five reinforced regions
called excessive genu valgum, or "knock-knee" (Fig. 138B).
of th capsule are described next and summarized in Table
In contrast, a lateral angle that exceeds about 180 degrees is
called genu varum, or bow-leg (Fig. 1 3 -8 C ).
The anterior capsule of th knee attaches to th margins of
The longitudinal or vertical axis of rotation at th hip is
th patella and th patellar ligament, being reinforced by th
defned in Chapter 12 as a line connecting th femoral head
quadriceps muscle and patellar retinacular fibers. The retinac
with th center of th knee joint. As depicted in Figure 1 3 -
ular fibers are extensions of th connective tissue covering

th vastus lateralis, vastus medialis, and iliotibial tract (see
Fig. 1 3 - 7 ) . This extensive set of netlike fibers connects th
femur, tibia, patella, patellar ligament, collateral ligaments,
and menisci.
The lateral capsule of th knee is reinforced by th lateral
(fibular) collateral ligament, lateral patellar retinacular fibers,
N o r m a l g e n u v a lg u m
Excessive frontal piane deviation
E x c e s s iv e G e n u varu m
g e n u v a lg u m ( b o w - le g )
(kn o ck -kn e e )
FIGURE 13-8. Frontal piane deviations of th knee. A, Norma) genu
valgum. The normal 125-degree angle of inclination of th proximal
femur and th longitudinal axis of rotation throughout th entire
lower extremity are also shown. B and C illustrate excessive frontal
piane deviations.
Chapter 13 Knee 439
and iliotibial tract (Fig. 1 3 - 9 ). Muscular stability is provided
by th biceps femoris, th tendon of th popliteus, and th
lateral head of th gastrocnemius.
The posteror capsule is reinforced by th oblique popliteal
ligament and th arcuate popliteal ligament (Fig. 1 3 -1 0 ).
The oblique popliteal ligament spans between th semimem-
branosus tendon from which much of th ligament origi-
nates and th lateral femoral condyle. This ligament is
pulled taut in full knee extension, when th tibia is rotated
externally relative to th femur. The arcuate popliteal ligament
originates from th fibular head, then divides into two limbs.
The larger and more prominent limb arches across th ten
don of th popliteus muscle to attach to th posterior inter-
condylar area of th tibia. An inconsistent and smaller limb
attaches to th posterior side of th lateral femoral condyle,
and often to a sesamoid bone (or (labella, meaning bean)
imbedded within th lateral head of th gastrocnemius.
The posterior capsule is further reinforced by th popliteus,
gastrocnemius, and hamstring muscles, especially by th fi-
brous extensions of th semimembranosus tendon. Unlike
th elbow, th knee has no bony block against hyperexten-
sion. The muscles and posterior capsule limit hyperexten-
sion.
The posterior-lateral capsule of th knee is reinforced by
th arcuate popliteal ligament, lateral collateral ligament, and
popliteus muscle and tendon. This set of tissues is often
referred to as th arcuate complex.
The mediai capsule of th knee is very extensive, covering
th entire posterior-medial to anterior-medial region of th
knee.109 The capsule is reinforced by th mediai collateral
ligament and mediai patellar retinacular fibers, and by th
expansions from th tendon ol th semimembranosus (Fig.
1 3 -1 1 ). The mediai capsule is further reinforced by th fiat
tendons of th sartorius, gracilis, and semitendinosus col-
lectively referred to as th pes anserinus (from th Latin,
gooses foot) tendons. The mediai capsule and associated
structures provide stabilization to th knee.
SYNOVIAL MEMBRANE AND ASSOCIATED
STRUCTURES
Bursae, Fat Pads, and Plicae
The internai surface of th capsule of th knee is lined with
a synovial membrane. The anatomie organization of this
membrane is th most complex and extensive in th body.120
The complexity is due in part to th convoluted embryonic
development of th knee.71
The knee has as many as 14 bursae, which form at
intertissue junctions that encounter high friction during
movement.120 These intertissue junctions involve tendon, lig
ament, skm, bone, capsule, and muscle (Tab)e 1 3 -2 ). Al-
though some bursae are simply extensions of th synovial
membrane, others are formed extemal to th capsule. Activi-
ties that involve excessive and repetitive forces at these inter
tissue junctions frequently lead to bursitis, an inflammation
of th bursa.
Fat pads are often associated with bursae around th
knee. Fat and synovial fluid reduce friction between moving
parts. At th knee, th most extensive fat pads are associated
with th suprapatellar and deep infrapatellar bursae.
 440 Section IV Lower Extremity

TABLE 13-1. L ig a m e n ts , Fascia, and Muscles That Reinforce th Capsule o f th Knee

Region of th Connective Tissue

C a p s u le Reinforcement Muscular-Tendinous Reitiforcement
Anterior Patellar ligament Quadriceps
Patellar retinacular fibers
Lateral Lateral collateral ligament Biceps femoris
Lateral patellar retinacular hbers Tendon of th popliteus
lliotibial tract Lateral head of th gastrocnemius
Posterior Oblique popliteal ligament Popliteus
Arcuate popliteal ligament Gastrocnemius
Hamstrings
Posterior-lateral Arcuate popliteal ligament Tendon of th popliteus
Lateral collateral ligament
Mediai Mediai collateral ligament Expansions from th tendon of th semimembranosus
Mediai patellar retinacular fibers Tendons of th sartorius, gracilis, and semitendinosus

Tibiofemoral Joint attaching to th tibia. The mediai meniscus has an ovai or C

ARTICULAR STRUCTURE shape, with its extemal border attaching io th deep surface
of th mediai collateral ligament and adjacent capsule; th
Bony Fit lateral meniscus has a circular or 0 shape, with its extemai
The mediai and lateral tibiofemoral joint consists of th ar-
ticulations between th large, convex femoral condyles and
th nearly fiat and smaller tibial condyles. The large surface
L a te r a l view
area of th femoral condyles permits extensive knee motion
in th sagittal piane for activities such as running, squatting,
and climbing. Joint stability ts provided not by a tight con-
gruous bony' fit, but by forces and physical containment
provided by muscles, ligaments, capsule, menisci, and body
weight.

Menisci
Anatomie Considerations
The mediai and lateral menisci are crescent-shaped, hbrocar-
Q u a d ric e p s
tilaginous discs located within th knee joint (Fig. 1 3 -1 2 ,4 G a s t r o c n e m iu s - te n d o n
and B). The menisci transform nearly fiat articular surfaces of la te ra l h e a d (cu t)

th tibia into shallow seats for th femoral condyles.

The menisci are anchored to th intercondylar region of L a te ra l c o lla te ra l
lig a m e n t
th tibia by their anterior and posterior homs. The extemal
edge of each meniscus is attached to th tibia and th adja- T e n d o n o f p o p lite u s
L a te ra l m e n is c u s

cent capsule by coronary (or meniscotibial) ligaments (see Fig. llio t ib ia l tra c t (cut)

1 3 -1 2 A ). The coronary ligaments are relatively loose P a te lla r lig a m e n t

B ic e p s fe m o r is (cu t)
thereby allowing th menisci, especially th lateral, io pivot
freely during movement. A slender transverse ligament con- L a te ra l p a te lla r
neets th two menisci anteriorly. re t in a c u la r fib e rs

Severa 1 muscles have secondary attachments mto th

menisci. The quadriceps and semimembranosus attach to
both menisci.67 The popliteus attaches io th lateral menis T ib ia lis a n te r io r

cus. Through these attachments, th muscles help stabilize

niijn E x te n s o r d ig ito ru m
th position of th menisci during active knee movement.
lo n g u s
Blood supply to th menisci is greatest near th periph-
eral (extemal) border. Blood comes from capillaries located
within th adjacent synovial membrane and capsule.18 The
internai border of th menisci, in contrast, is essentially
avascular. The menisci are essentially aneural, except near FIGURE 13-9. Lateral view of th righi knee shows many muscles
their homs. and connective tissues. The iliotibial tract, lateral head of th gas
Ihe two menisci have different shapes and methods of trocnemius. and biceps femoris are cut to better expose th lateral
collateral ligament, popliteus tendon, and lateral meniscus
 Chapter 13 Knee 441

Posterior view

S e m im e m b r a n o s u s G a s t r o c n e m iu s - m e d ia l h e a d
(cu t)

P la n t a r is (cu t)

G a s t r o c n e m iu s - la t e r a l h e a d
G r a c ilis (cu t)

FIGURE 13-10. Posterior view of th right

knee that emphasizes th major parts of
th posterior capsule: th oblique popliteal S a r t o r iu s

and arcuale popliteal ligaments. The lateral

and mediai heads of th gastrocnemius and
plantaris muscles are cut to expose th pos
terior capsule. Observe th popliteus muscle
deep in th popliteal fossa, lying partially
covered by th fasciai extension of th semi-
membranosus.
M e d ia i c o lla te ra l lig a m e n t
(a tta c h in g to m e d ia i m e n is c u s )
L a te ra l c o lla te r a l lig a m e n t
S e m im e m b r a n o s u s
A rc u a t e p o p lite a l lig a m e n t
O b liq u e p o p lite a l lig a m e n t

P o s t e r io r t ib io f ib u la r lig a m e n t

F a s c ia i e x te n s io n o f
s e m im e m b r a n o s u s

M ediai view

Q u a d r ic e p s te n d o n
S e m im e m b r a n o s u s FIGURE 13-11. Mediai view of th right knee shows many
muscles and connective tissues. The tendons of th sarto
rius and gracilis are cut to better expose th anterior and
P o s t e r io r i posterior parts of th mediai collateral ligament.
I M e d ia i
M e d ia i p a te lla r A n t e r io r C 0 ||ate ra l

re t in a c u la r fib e r s lig a m e n t

P a te lla r lig a m e n t

P es | S a r t o r iu s ( c u t )

C
a n s e r in u s | V
te n d o n sH G r a c ilis (cu t)

- S e m it e n d in o s u s
 442 Section IV Dnver Extremity

T A B L E1 3 - 2 . Examples of Bursae at Various

Intertissue Junctions
JlL S P E C I A L F O C U S 1 3 -

Intertissue Ju n ctio n Exam ples Development and Function of Plicae

Ligament and tendon Bursa between th lateral collateral D u r in g e m b r y o n ic d e v e lo p m e n t , t h k n e e e x p e r ie n c e s
ligament and tendon of th bi- s ig n if ic a n t p h y s ic a l t r a n s f o r m a t io n . M e s e n c h y m a l t is -
ceps femoris
s u e s t h ic k e n a n d t h e n r e a b s o r b , f o r m in g p r im it iv e c o m -
Bursa between th mediai collateral p a r t m e n t s , lig a m e n t s , a n d m e n is c i. I n c o m p le t e r e s o r p -
ligament and tendons of th pes t io n o f m e s e n c h y m a l t is s u e d u r in g d e v e lo p m e n t f o r m s
anserinus (i.e., gracilis, semiten- t is s u e s k n o w n a s plicae.23 P lic a e , o r s y n o v ia l p le a t s ,
dinosus, and sartorius)
a p p e a r a s f o ld s in t h s y n o v ia l m e m b r a n e s . P l i c a e m a y
Muscle and capsule Unnamed bursa between th me b e v e r y s m a ll a n d u n r e c o g n iz a b le , o r s o la r g e t h a t t h e y
diai head of th gastrocnemius n e a r ly s e p a r a t e t h k n e e in to m e d ia i a n d la t e r a l c o m -
and th mediai side of th cap p a r t m e n t s . P l i c a e r e in f o r c e t h s y n o v ia l m e m b r a n e o f
sule th k n ee .
Bone and skin S u b cu ta n eo u s p r e p a t e lla r b u rs a be- T h r e e p lic a e in t h k n e e a r e t h (1) s u p e r io r o r
tween th inferior border of th s u p r a p a t e lla r p lic a , (2) in t e r io r p lic a ( f ir s t c a lle d lig a -
patella and th skin m e n t u m m u c o s u m b y V e s a l i u s in 15 15 ),23 a n d (3) m e d ia i
Tendon and bone S e m im e m b r a n o su s b u r s a between p lic a . T h e m o s t p r o m in e n t m e d ia i p lic a is k n o w n b y
th tendon of th semimembra a b o u t 20 n a m e s , in c lu d in g a la r lig a m e n t , s y n o v ia lis p a -
nosus and mediai condyle of th t e lla r is , a n d in t r a a r t ic u la r m e d ia i b a n d . P li c a e e x is t in
tibia a p p r o x im a t e ly 25 to 50% o f k n e e s .
Bone and muscle S u p r a p a t e lla r b u rs a between th fe P li c a e t h a t a r e u n u s u a lly la r g e , o r a r e t h ic k e n e d o w -
mur and th quadriceps femoris in g to ir r it a t io n o r t r a u m a , c a u s e k n e e p a in . T h e m e d ia i
(largest of th knee) p lic a is m o s t c o m m o n ly in v o lv e d w it h a p a in f u l p lic a
Bone and ligament D eep in fr a p a t e lla r b u r s a between s y n d r o m e . T r e a t m e n t in c lu d e s r e s t, a n t i- in f la m m a t o r y
th tibia and patellar liga m e d ic a t io n , is o m e t r ic e x e r c is e , a n d a r t h r o s c o p y r e s e c -
ment tio n .

border attaching only to th lateral capsule (Fig. 1 3 - 1 3 ).
The tendon of th popliteus passes between th lateral col-
latera! ligament and th extemal border of th lateral menis-
cus.
Ligaments Associated with th Menisci
Coronar)' (meniscotibial) ligaments
Transverse ligament
Posterior meniscofemoral ligament
The lateral meniscus also attaches to th femur via th
(see Figs. 1 3 -1 2 A and 1 3 -
p o s t e r io r m e n is c o fe m o r a l lig a m en t
13). The ligament arises from th posterior hom of th
lateral meniscus and attaches to th femur along with th
posterior cruciale ligament. This and other meniscofemoral
ligaments are sometimes th only bony attachment made by
th posterior hom of th lateral meniscus.120
describes th role of th menisci in transferring loads across
th knee.
M enisci as Shock Absorbcrs. While walking, compres-
sion forces at th knee joint routinely reach approximately 2
to 3 times body weight. Forces as high as nine times body
weight may occur during maximal-effort isokinetic knee ex-
tension.88 By nearly tripling th area of joint contact, th
menisci significanti reduce pressure (i.e., force per una
area) on th articular cartilage.103 A complete lateral menis-
cectomy increases th peak contact pressures by 230% ,91
which likely increases th risk of developing stress-related
arthritis. Surgically repairing a meniscus instead of removing
it is clearly th treatment of choice.102
The menisci supporr about half th total load across th
knee.68 At every step, th menisci deform peripherally as
they are compressed.108 This mechanism allows part of th
compression force at th knee to be absorbed as a circumfer-
ential tension throughout each meniscus. A torn meniscus
therefore loses its capacity to absorb loads.

Functonal Considerations
The primary function of th menisci is to reduce th
compressive stress at th tibiofemoral joint. Other func-
tions include stabilizing th joint during motion, lubricat-
ng th articular cartilage, reducing th fricuon, and guid-
ing th knees arthrokinematics. The following section
Osteokinematics at th Tibiofemoral Joint
The tibiofemoral joint possesses two degrees of freedom:
flexion and extension in th sagittal piane and, provided th
knee is slightly flexed, internai and extemal rotation in th
horizontal piane. These motions are shown for both t ib ia l-o n -

Superior view
.G a s tro c n e m iu s ( m e d ia i he a d )
G a s t r o c n e m iu s fia te ra i he a d )
P la n ta riS '
B ic e p s fe m o r is
P o p lit e u s te n d o n
L a te ra l c o lla te ra l lig a m e n t
P o s t e r io r m e n is c o fe m o r a l
lig a m e n t
P o s t e r io r c r u c ia te lig a m e n t
L a te ra l m e n is c u s
llio t ib ia l tra c t
C o r o n a r y lig a m e n t
In fra p a te lla r fat
A P a te lla r lig a m e n t
FIGURE 13-12. A, The superior surface of th tibia shows th menisci and
cut collateral ligaments, cruciate ligaments, muscles, and tendons. B, The
superior view of th right tibia marks th relative attachment points of th
menisci (gray) and cruciate ligaments (black) within th intercondylar region.
Jemoral and femoral-on-tibial situations in Figures 1 3 - 1 4 and
1 3 - 1 5 . Frontal piane motion at th knee occurs passively
only, limited to about 6 to 7 degrees.81
FLEXION AND EXTENSION
Flexion and extension at th knee occur about a medial-
lateral axis of rotation. Range of motion varies with age and
gender, but in generai th healthy knee rotates from 130 to
140 degrees of flexion to about 5 to 10 degrees of hyperex-
tension.7-101
The medial-lateral axis of rotation for flexion and exten
sion is not fixed, but migrates within th femoral condyles.
The curved path of th axis is known as an evolute, or
instant center of rotation (Fig. 1 3 - 1 6 ) .111 The path of th
axis is influenced by th eccentric curvature of th femoral
condyles.3030110
The migrating axis of rotation has biomechanical and
clinical implications. First, th migrating axis alters th
length of th internai moment arm of th flexor and exten-
sor muscles. This fact explams, in part, why maximal-effort
internai torque varies across th range of motion. Second,
many extemal devices that attach to th knee, such as a
goniometer or a hinged knee orthosis, rotate about a fixed
Chapter 13 Knee 443
S e m it e n d in o s u s
S e m im e m b r a n o s u s
G r a c llis
S a r to r iu s
M e d ia i c o lla te r a l lig a m e n t
M e d ia i m e n is c u s
A n t e r io r c r u c ia te lig a m e n t
T r a n s v e r s e lig a m e n t
P o s t e r io r c r u c ia te lig a m e n t
A n t e r io r a n d p o s t e r io r
A n t e r io r a n d p o s t e r io r
h o r n s o t m e d ia i m e n is c u s
h o r n s o f la te ra l m e n is c u s
B A n t e r io r c r u c ia te lig a m e n t
axis of rotation. During knee motion, therefore, th extemal
devices may rotate in a dissimilar piane as th leg. As a
consequence, a hinged orthosis, for example, may act as a
piston relative to th leg, causing rubbing against and abra-
sion io th skin.
INTERNAL AND EXTERNAL ROTATION
Internai and extemal rotation of th knee occurs in a hori-
zontal piane about a vertical or longitudinal axis of rota-
tion. This motion is also called axial rotation. In generai,
horizontal piane rotation increases with greater knee flexion.
A knee flexed to 90 degrees permits about 40 io 50 degrees
of total rotation.86-89 External rotation range of motion gener-
ally exceeds internai rotation by a ratio of 2:1.86 In full
extension, however, horizontal piane rotation is essentially
absent. Rotation is blocked by passive tension in th
stretched ligaments and by increased bony congruity within
th joint.
As depicted in Figure 1 3 - 1 5 , horizontal piane rota
tion at th knee occurs by either tibial-on-femoral or
femoral-on-iibial rotation. Both forms of rotation prolde
a functional and very important element of mobility to
movement of th lower extremily as a whofe. Consider, for
444 Section IV Lower Extremity

Posterior vievv
S P E C I A L F O C U S 1 3 - 2
m
Common Mechanism of Injury of th Menisci of
th Knee
A n t e r o r c r u c ia te
T e a r s o f t h m e n is c u s o f te n o c c u r b y f o r c e f u l, h o r iz o n -
lig a m e n t
t a l p ia n e r o t a t io n o f t h f e m o r a l c o n d y le s o v e r a p a r -
t ia lly f le x e d a n d w e ig h t - b e a r in g k n e e . T h e t o r s io n w it h in
t h c o m p r e s s e d k n e e c a n p in c h a n d d is lo d g e t h m e

M e d ia i c o lla te ra l
lig a m e n t L a te ra l c o lla te ra l
lig a m e n t
P o p lit e u s te n d o n
M e d ia i m e n is c u s (cu t)
L a te ra l m e n is c u s
n is c u s . A d is lo d g e d o r f o ld e d f la p o f m e n is c u s c a n
b lo c k k n e e m o v e m e n t , c a u s in g t h " lo c k e d - k n e e " s y n -
d ro m e .
T h e m e d ia i m e n is c u s is in j u r e d m o r e f r e q u e n t ly t h a n
t h la t e r a l m e n is c u s . T h e m e c h a n is m o f in j u r y o fte n
in v o lv e s a n e x t e r n a l f o r c e a p p lie d t o t h la t e r a l a s p e c t

P o s t e r io r
of th knee. This force often described as a " v a lg u s

m e n is c o fe m o r a l
lig a m e n t
P o s t e r io r c r u c ia te
lig a m e n t
f o r c e " c a u s e s a n e x c e s s i v e v a lg u s p o s it io n o f t h
k n e e a n d s u b s e q u e n t ly s t r a in s t h m e d ia i c o lla t e r a l lig a
m e n t. T h e m e d ia i m e n is c u s m a y t e a r a s it is s t r e t c h e d
b e t w e e n t h c o m p r e s s e d j o in t s u r f a c e s a n d it s c o n n e c
t io n t o t h t a u t m e d ia i c o lla t e r a l lig a m e n t .

FIGURE 13-13. Posterior view o f th deep structures of th tight
knee after all muscles and th posterior capsule are removed. Ob-
serve th menisci, collateral ligaments, and cruciate ligaments. Note
th popliteus tendon that courses between th lateral meniscus and
lateral collateral ligament.
example, a sharp 90-degree cutting maneuver used to
change directions while running. The trunk and pelvis rotate
over th femur, as th femur rotates over th tibia. Chapter
14 describes how th tibia rotates over th relatively fixed
foot.

Flexion and extension in thc sagittal piane

A Tibial-on-femoral perspective B Femoral-on-tibial perspective

FIGURE 13-14. Sagittal piane motion at th knee. A, Tibial-on-femoral perspective. B, Femoral-on-tibial perspec-
live.
 Chapter 13 Knee 445

Horizontal piane rotation

Tibial-on-femoral rotation Femoral-on-tibial rotation

Knee
Knee
external internai
rotation rotation

K nee flexed 30 Anterior

Mediai
ial H h Lateral

Superior view Posterior

FIGURE 13-15. Horizontal piane (axial) rotation at th knee. A, Tibial-on-femoral rotation. B, Femoral-on-tibial rotation.

Arthrokinematics at th Tibiofemoral Joint similar but less obvious locking mechanism also takes place
during femoral-on-tibial extension (compare Fig. 1 3 -1 7 A
A C T IV E E X T E N S IO N OF TH E KN EE
with B). Rising up from a squat position, for example, th
Figure 1 3 - 1 7 depicts th arthrokinematics of th last 90 knee locks into extension as th femur intemally rotates
degrees of active knee extension. During tibial-on-femoral ex-
tension, th articular surface of th tibia rolls and slides
anteriorly on th femoral condyles (Fig. 13-17A ). The
menisci are shown pulled anteriorly by th contracting quad-
riceps muscle.
During femoral-on-tibial extension, as in standing up
| from a deep squat position, th femoral condyles simulta-
neously roll anteriorly and slide posteriorly on th articular
surface of th tibia (Fig. 1 3 -1 7 B ). These off-setting arthro-
kinematics may help limit th magnitude of anterior transla-
tion of th femur on th tibia. The quadriceps direct th roll
of th femoral condyles. The quadriceps also stabilize th
menisci against th posterior shear caused by th sliding
femur.

"Screw-Home" Rotation of th Knee

Locking th knee in full extension requires about 10 de
grees of external rotation.59 The rotary locking action is
called screw-home rotation, based on th observable twist-
ing of th knee during th last 30 degrees of extension.
External rotation is different from th axial rotation l-
lustrated in Figure 1 3 - 1 5 . Screw-home rotation has
been kinematically described as a conjunct rotation.120 This
type of rotation is mechanically linked to th flexion and
extension kinematics and cannot be performed indepen-
dently.
To observe th screw-home rotation at th knee, have a
partner sit with th knee flexed to about 90 degrees. Draw a
line on th skin between th tibial tuberosity and th apex
of th patella. After completing full tibial-on-femoral exten
sion, redraw this line between th same landmarks and note FIGURE 13-16. The flexing knee generates a migrating medial-lat-
th change in position of th extemally rotated tibia. A eral axis of rotation. This migration is described as th evolute.
446 Section IV Lower Extremitv

relative to th fxed tibia. Regardless of whether th thigh or IN T E R N A L A N D E X T E R N A L (A X IA L ) R O T A T IO N OF

leg is th moving segment, both knee extension movemerus THE KNEE
depicted in Figure 1 3 -1 7 A and B show a knee joint that is
As described earlier, th knee must be partially flexed to
extemally rotated when fully extended.
allow independent horizontal piane rotation between th
The screw-home rotation mechantcs are driven by ai
tibia and femur. Once flexed, th arthrokinematics of inter
least three factors: th shape o f th mediai fmora! con-
nai and extemal rotation involve a spin between th menisci
dyle, th passive tension in th amerior cruciate ligamem,
and th articular surfaces of th tibia and femur. Horizontal
and th lateral pul of th quadriceps muscle (Fig. I S
piane rotation of th femur over th tibia causes th menisci
IS ).33^ most important factor is th shape of th me
to deform slightly, as they are compressed between th spin-
diai femoral condyle. As depicted in Figure 1 3 -1 8 B , th
ning femoral condyles. The menisci are stabilized by connec-
articular surface of th mediai femoral condyle curves about
tions from active musculature such as th popliteus and
30 degrees laterally, as it approaches th intercondylar semimembranosus.
groove. Because th articular surface on th mediai condyle
extends farther anteriorly than on th lateral condyle, th
tibia follows this laterally curved path during full tibial-on-
Patellofemoral Joint
femoral extension. During femoral-on-tibial extension, th The patellofemoral joint is th interface between th articular
femur follows a medially curved path on th tibia. In either side of th patella and th intercondylar groove on th fe
case, th result is extemal rotation of th knee at full exten mur. The quadriceps muscle, th articular joint surfaces, and
sion. th retinacular fibers stabilize th joint (see Fig. 1 3 -7 ). As
th knee flexes and extends, th articular surface of th
patella slides over th intercondylar groove of th femur.
A C T IV E FLE X IO N OF THE KN EE
During tibial-on-femoral flexion, th patella slides against th
The arthrokinematics of active knee flexion occur by a re- femur; during femoral-on-tibial flexion, th femur slides
against th patella.
verse fashion depicted in Figure 1 3 -1 7 A and B. To unlock a
knee that is fully extended, th joint must first internali)'
rotate. This action is driven primarily by th popliteus mus P A T E L L O F E M O R A L JO IN T K IN E M A T IC S

cle. The muscle can rotate th femur extemally to initiate
temoral-on-iibial flexion, or rotate th tibia internally to initi
ate tibial-on-femoral flexion.
Path and Area of Patellar Contact on th Femur
Studies on cadavere have provided detailed descriptions of
th regions of joint contact and pressure in th patellofemo-

A. Tibial-on-femoral extension K. Femoral-on-tibial extension

FIGURE 13-17. The active arthrokinematics of knee extension. A, Tibial-on-femoral perspective. B, Femoral-on-tibial perspective.
In both A and B, th meniscus is pulled toward th contracting quadriceps.
 C h a p t e r 13 K n ee 447

A. Factors guiding screw-homc rotatimi ral joint.3756'82 Data from these studies and cineradiographic
observations were used to construct th model illustrateci in
Figure 1 3 - 1 9 . At 135 degrees of flexion, th patella contacts
th femur near its superior pole (Fig. 1 3 -1 9 A ). At this
flexed position, th patella rests below th intercondylar
groove, bridging th intercondylar notch of th femur (Fig.
1 3 -1 9 D ). At this position, th lateral edge of th lateral
1. S h a p e o f m e d ia i
facet and th odd facci of th patella share articular contact
fe m o r a l c o n d y le
with th femur (Fig. 1 3 -1 9 E ). As th knee extends toward
90 degrees of flexion, th contact region on th patella starts
io migrate inferiorly (Fig. 1 3 -1 9 B ). Between 90 and 60
degrees of flexion, th patellofemoral joint occupies its great-
2. T e n s io n in a n te r io r est contact area with th femur (Fig. 1 3 -1 9 D , ).82 At its
c r u c ia te lig a m e n t maximum, this contact area is only about 30% of th total
surface area of th patella. Joint pressure (i.e., compression
force per unit area), therefore, can rise to significant levels
3 . L a te ra l p u l within th patellofemoral joint.
o f q u a d r ic e p s As th knee extends through th last 20 degrees of llex-
ion, th primary contact point on th patella migrates to th
inferior pole (Fig. 1 3 -1 9 C ). In full extension th patella
rests completely above th intercondylar groove, against th
suprapatellar fat pad. In this position with quadriceps re-
E x te rn a l ro ta tio n
laxed, th patella can be moved freely within th intercondy
lar groove. Flexing th knee to about 20 or 30 degrees,
however, reduces this mobility. The patella becomes seated
in th intercondylar groove and stabilized by tension in th
stretched quadriceps and locai connettive tissues.
E x te n s io n

B. Patii of th tibia on th femoral condyles
FIGURE 13-18. The screw-home locking mechanism of th knee.
A, During terminal tibial-on-femoral extension, three factors con-
tribuie to th locking mechanism of th knee. Each factor comrib-
utes bias to external rotation of th tibia, relative to th femur. B,
The two red arrows depict th path of th tibia across th femoral
condyles during th last 90 degrees of extension. Note that th
eurved mediai femoral condyle helps to direct th tibia to its exter-
nally rotated and locked position.
Collateral Ligaments
A N A T 0 M IC C 0 N S ID E R A T I0 N S
The mediai collateral ligament (MCL) is a fiat, broad structure
that spans th mediai side of th joint (see Fig. 1 3 -1 1 ).
Several structures blend with and reinforce th MCL, most
notably th mediai patellar retinacular fibers and mediai cap
sule.
The MCL consists of anterior and posterior parts. The
larger anterior part consists of a relatively well-defined set of
superficial fibers about 10 cm long. Distally these fibers blend
with mediai patellar retinacular fibers before attaching to th
medial-proximal aspect of th tibia. The fibers attachments
are just posterior to th attachments of th pes anserinus
group. From proximal to distai, th anterior part of th MCL
runs in a slightly oblique posterior-to-anterior direction.
The posterior part of th MCL consists of a short set of
fibers, deep to th anterior fibers. These fibers have extensive
distai attachments to th posterior-medial joint capsule, me
diai meniscus, and thick tendon of th semimembranosus
muscle.
The lateral (fibular) collateral ligament consists of a round,
strong cord that runs nearly vertical between th lateral
epicondyle of th femur to th head of th fibula (see Fig.
1 3 - 9 ). Distally, th lateral collateral ligament blends with
th tendon of th biceps femoris muscle. Unlike its mediai
counterpart, th MCL, th lateral collateral ligament does not
attach to th adjacent meniscus (see Fig. 1 3 -1 3 ).
F U N C T I0 N A L C O N S ID E R A T IO N S

The primary function of th collateral ligaments is to limit

excessive motion in th frontal piane. With th knee ex-
448 Section IV Lower Extremity

A. Knee ncxcd 135 B. Knee flexed 90 C. Knee flexed 20

D. Palli of sliding patella on th femur E. Posterior articular surface of patella

V a s tu s V a s tu s
in te rm e d iu s la te ra lis
V a stu s
m e d ia lis
\

L a t e r a lf a c e t
O dd

M e d ia i

P a te lla r lig a m e n t

FIGURE 13-19. The kinematics ai th patellofemoral joint during active tibial-on-femoral extension. The circle depicted in A - C
indicates th point of maximal contact between th patella and th femur. As th knee is extended, th contact point on th patella
migrates from its superior pole to its inferior pole. Note th suprapatellar fat pad deep to th quadriceps. D and E show th path
and contact areas of th palella on th intercondylar groove of th femur. The values 135, 90, 60, and 20 degrees indicate flexed
positions of th knee.

tended, th anterior pari of th MCL provides th primary
resistance against a valgus, or an abduction, stress. The lat
eral collateral ligament, in comparison, provides th primary
resistance against a varus, or an adduction, stress.104 Many
other tissues provide varying amounts of restraint to valgus
and varus forces applied to th knee (Table 1 3 - 3 ) .104118
A secondary function of th collateral ligaments is to limit
th extremes of knee extension. This function is shared,
however, by th posterior capsule, oblique popliteal liga
ment, knee flexor muscles, and anterior cruciate ligament.
Figure 1 3 -2 0 A and B demonstrates th increase in passive
tension in both MCL and posterior capsule, as th knee
assumes th locked position of full femoral-on-tibial exten
sion. In flexion, th capsule and ligaments are relatively
slack (see Fig. 1 3 -2 0 A ). Full extension which includes th
screw-home rotation elongates th collateral ligaments
roughly 20% beyond their length at full flexion."8 Although
a valuable stabilizer, a taut MCL is especially vulnerable to
injury from a valgus (i.e., an abduction) stress delivered over
a planted foot. This mechanism of injury is part of th
classic clip in American football.
The collateral ligaments also provide limited resistance to
th extremes of internai and extemal rotation while th knee
is partially flexed.118 Table 1 3 - 4 provides a summary of th
functions and common mechanisms of injury for th major
ligaments of th knee, including th posterior capsule.
 Chapter 13 Knee 449

J TABLE 1 3 - 3 . Tissues That Provide Primary and Secondary Restraint to th Knee*

Valgus Force Varus Force

Primary restraint
Secondary restraint
Mediai collateral ligament, especially th anterior fi- Lateral collateral ligament
bers
Mediai capsule Arcuate complex (includes lateral collateral liga
Posterior-medial capsule (includes semimembrano- ment, posterior-lateral capsule, popliteus ten
sus tendon) don, and arcuate popliteal ligament)
Anterior and posterior cruciate ligaments lliotibial tract
Bony contact laterally Biceps femoris tendon
Compression of th lateral meniscus Bony contact medially
Mediai retmacular fibers Compression of th mediai meniscus
Pes anserinus (i.e., tendons of th sartorius, gracilis, Anterior and posterior cruciate ligaments
and semitendinosus) Gastrocnemius Oateral head)
Gastrocnemius (mediai head)

* Assume a fully extended knee.

Anterior and Posterior Cruciate Ligaments
G E N E R A L C O N S ID E R A T IO N S
Cruciate, meaning cross-shaped, describes th spatial relation
of th ligaments as they cross within th intercondylar notch
of th femur (Fig. 1 3 -2 1 A and B). The cruciate ligaments
are intracapsular structures that are covered by an extensive
synovial lining. Since most of th surface of th ligaments
lies between th synovial membrane and th capsule, th
cruciates are considered extrasynovial. The ligaments are
supplied with blood from small vessels in th synovial mem
brane and nearby soft tissue.
The cruciate ligaments are named according to their at-
tachment to th tibia (see Fig. 1 3 -1 2 A and B). Both liga
ments are thick and strong, reflecting their important role in
providing stability to th knee. Acting together, th antenor
and posterior cruciate ligaments resist th extremes of all
knee motions (see Table 1 3 - 4 ). The cruciate ligaments,
however, provide most of th resistance to anterior-posterior
shear forces between th tibia and femur. These forces arise
primarily from th sagittal piane progression intrinsic to
walking, squatting, running, and jumping.17 The ligaments
help to guide th arthrokinematics at th knee.
Injury to th cruciate ligaments can lead to marked insta -
bility of th knee. Because th cruciates do not spontane-
ously heal on their own, surgical reconstruction often re-
quires autograft (patellar tendon or hamstring/adductor
tendon), and less frequently, an allograft (artificial ligament).
Although these reconstructions are reasonably successful at
restoring basic stability, th naturai kinematics at th re-
paired knee are never completely normal. A retrospective
review of th literature suggests that th likelihood of gonar-
throsis (or arthrosis) of th knee increases signifcantly fol-
lowing injury to th anterior cruciate ligament.35

A. Ligaments slack in flexion B. Ligaments pulled taut in extension

FIGURE 13-20. Media) view of th

knee shows th elongation of th me
diai collateral ligament and th poste
rior capsule and oblique popliteal liga
ment during active femoral-on-tibial
extension. A, In knee flexion, th me
diai collateral ligament, oblique poplit
eal ligament, and posterior capsule are
relatively slackened. B, The structures
are pulled taut as th knee actively
extends by contraction of th quadri-
ceps. Note th screw-home rotation
of th knee during end-range exten
sion.

Mediai view
450 Seclion IV Lower Extremity

TABLE 1 3 - 4 . Function of Ligaments at th Knee and Common Mechanisms of Injury

Structure Fu nction (s) Com m on M echanism s o f Injury

Mediai collateral I. Resists valgus (abduction) 1. Valgus force with foot planted (e.g., "clip in
ligament 2. Resists excesstve knee extension football)
3. Resists axial rotation 2. Severe hyperextension of th knee

Lateral collateral 1. Resists varus (adduction) 1. Varus force with foot planted
ligament 2. Resists knee extension 2. Severe hyperextension of th knee
3. Resists axial rotation

Posterior capsule 1. Resists full knee extension 1. Hyperextension or combined hyperextension with
2. Oblique popliteal ligament resists extemal extemal rotation of th knee
rotation
3. Posterior-lateral capsule resists varus

Anterior cruciate 1. Most fibers resist excessive anterior trans-
ligament lation of th tibia or excessive posterior
translation of th femur
2. Most fibers limit full knee extension
3. Resists extremes of varus, valgus, and axial
rotation
Posterior cruciate 1. Most fibers resist excessive posterior trans
ligament lation of th tibia or excessive anterior
translation of th fernur
2. Most fibers become taut at full flexion
3. Some fibers become taut ai maximal hy-
perextension and th extremes of varus,
valgus, and axial rotation
1. Hyperextension of th knee
2. Large valgus force with foot planted
3. Either of th above combined with large internai
axial rotation torque (e.g., th fernur forcefully
extemally rotates over a fixed tibia)
1. Hyperflexion of th knee
2. Dashboard injuries with excessive posterior
translation of th tibia relative to th fernur
3. Severe hyperextension of th knee with a gapping
of th posterior side of th joint
4. Large valgus or varus force with foot planted
5. Any of th above combined with large axial rota
tion torque

A. Lateral vievv B. Anterior view

I n te rc o n d y la r g r o o v e
(to r p a te lla )

P o s t e r io r c r u c ia te
A n te r io r c r u c ia te lig a m e n t
lig a m e n t

FIGURE 13 21. The anterior and posterior cruciate [igaments. A, Lateral view. B, Anterior view. The two fiber bundles within th
antenor cruciate ligament are evident in A.

A N T E R IO R C R U C IA T E L IG A M E N T
Functional Anatomy
The anterior cruciate ligament (AGL) attaches along an
approximate 30-mm impression on th anterior intercondy-
lar area of th tibia] plateau.36 From this attachment, th
ligament runs obliquely in a posterior, slightly superior,
and lateral direction to attach on th mediai side of th
lateral femoral condyle (see Fig. 1 3 -2 1 A and B). The colla-
gen fibers within th AGL twist upon one another, thereby
forming spiraling fascicles, or bundles. The bundles are
often referred to as posterior-lateral and anterior-medial,
named according io their relative attachment on th tibia.36
The posterior-lateral bundle is th main component of th
ACL.
The length and orientation of th twisting ACL change
as th knee joint rotates. Although some fibers of th
ACL remain taut throughout th full range of motion, most
fibers, especially within th posterior-lateral bundle, become
more taut as th knee approaches full extension (Fig. 1 3 -
22A).'W Along with th posterior capsule, collateral liga-
ments, and hamstring muscles, th ACL produces useful
tension that helps stabilize th extended or near-extended
knee.
Mechanism of Injury to th Anterior Cruciate Ligament
The ACL is th most frequently injured ligament of th
knee, occurring often during sports activities such as foot
ball, downhill skiing, basketball, and soccer. An ACL injury
may occur in conjunction with injury to other structures,
such as th mediai collateral ligament and mediai meniscus.
One of th most common and relatively simple manual ex-
ams for ACL integrity is called th anterior drawer test. The
basic component of this test involves pulling th leg forward
with th knee flexed lo about 90 degrees (see Fig. 13-2 2 A
and B). In th normal knee, th ACL provides about 85% of
th total passive resistance to th anterior translation of th
tibia.11 An anterior laxity of 8 mm (1/3 in) greater than th
contralateral knee is indicative of an ACL tear. With th
knee flexed and unlocked, secondary restraint structures
such as th posterior capsule, collateral Hgaments, and flexor
muscles offer less resistance to an anteriorly translating tibia.
Spasm in th hamstring muscles may limit anterior transla
tion of th tibia, thereby masking a tom ACL.
The oblique manner in which th ACL courses through
th knee allows at least a pari o f this structure io resist th
extremes of all movements. Although th spatial orientation
o f th ACL provides a wide range o f stabifity, il also predis-
poses th person to ligament injury. As listed in Table 1 3 - 4 ,
th ACL is pulled taut as a result of many tibial-on-femoral
or femoral-on-tibial movements. One finding common to
many ACL injuries is a high-velocity stretch while th liga
ment is under tension. This may occur, for example, when
th foot is firmly planted and th femur is vigorously exter-
nally rotated and/or translated posteriorly. As noted by ob-
serving a skeletal model or Figure 1 3 - 2 1 , this movement in
conjunction with a valgus force can elongate and potentially
tear th ACL.
Another common mechanism for injuring th ACL in
volves excessive hvperextension of th knee while th foot
:s planted on th ground. Very large forces produced by
Chapter 13 Knee 451
th quadriceps muscle during this event may add to th
severity of th injury. Marked hyperextension frequently in
volves trauma to th collateral ligaments and th posterior
capsule.
P O S T E R IO R C R U C IA T E L IG A M E N T
Functional Anatomy
The posterior cruciate ligament (PCL) provides another im-
portant source of resistance to th anterior-posterior shear
forces at th knee. Slightly thicker than th ACL, th PCL
attaches from th posterior intercondylar area of th tibia to
th lateral side of th mediai femoral condyle (see Figs. 1 3 -
12A and B, 1 3 - 1 3 , and 1 3 -2 1 A and B). The course of this
ligament is more vertical and slightly less oblique than that
of th ACL.
The specific anatomy of th PCL is variable. It has two
bundles: a larger anterior set (anterior-lateral), forming th
bulk of th ligament, and a smaller posterior set (posterior-
medial).15-4284
Two accessory components of th PCL are often present.
In about 70% of knees, either an anterior menisco femoral
ligament or a posterior meniscofemoral ligament is present.45
These ligaments have a mass of only 20% of th PCL and,
therefore, play a minor role in stability. Figures 1 3 -1 2 A and
1 3 - 1 3 show a segment of th more common posterior men
iscofemoral ligament, originating from th lateral meniscus
and blending into th posterior fibers of th PCL.
Like th ACL, some fibers within th PCL remain taut
throughout th entire range of motion. The majority of th
ligament (i.e., th larger anterior fibers), however, becomes
taut at th extremes of flexion.36 As depicted in Figure 1 3 -
2 2 C, th PCL is pulled taut by th hamstring muscle con-
traction and subsequent posterior slide of th tibia. Adding a
forceful quadriceps contraction to an existing hamstring con-
traction reduces th tension and stretch on th PCL.48
One of th most common exams of th integrity of th
PCL is th posterior drawer test. This test involves pushing
th leg posteriorly with th knee flexed to 90 degrees (Fig.
1 3 -2 2 D ). Normally, th PCL provides about 95% of th
total passive resistance to th posterior translation of th
tibia.11 Ollen, following a PCL injury, th tibia sags posteri
orly against th femur. This observation, in conjunction with
a positive posterior drawer sign, suggests a ruptured PCL.
Another important function o f th PCL is to limit th
extern of anterior translation of th femur over th fxed
tibia. Activities, such as rapidly descending into a squat
and landing from a jump with knee partially flexed, create
a large anterior shear force on th femur against th tibia.
The femur is held from sliding off th anterior edge of
th tibia by forces in th PCL, joint capsule, and muscle.
The popliteus muscle, by Crossing th posterior side of th
knee, may share a portion of th force naturally placed on
th PCL.42
Mechanism of Injury to th Posterior Cruciate Ligament
Injury to th PCL accounts for only 5% io 20% of all such
injuries to th knee.14 Half of PCL injuries occur with inju
ries to other knee structures, most often th ACL and poste
rior-lateral capsule. Three mechanisms are proposed for rup-
452 Section IV Lower Extremity

Taut ACL

A. Attive knee extension

FIGURE 13-22. The interaciion between muscle comracuon and tension changes in th cruciate ligaments is shown. A, Con-
traction of th quadriceps muscle extends th knee and slides th tibia anterior relative to th femur. Knee extension als elon-
gates most of th anterior cruciate ligament (ACL), posterior capsule, hamstring muscles, and collateral ligaments (not shown).
Note that th quadriceps and ACL have an antagonistic relationship throughout most of th terminal range of extension. B, The
antenor drawer test can help evaluate th integrity of th ACL. C, Contraction of th hamstring muscles flexes th knee and slides
th tibia posterior relative to th femur. Knee flexion elongates th quadriceps muscle and most of th fibers within th posterior
cruciate ligament (PCL). D, The posterior drawer test checks th integrity of th PCL. Tissues pulled taut are tndicated by thin
black arrows.
 Chapter 13 Knee 453

ture of th PCL (see box).60 Falling over a hyperflexed knee

is th most common mechanism of injury. The most com
mon high-energy injury to th PCL is th dashboard in
Altered Muscle Activation Pattern Following Anterior jury, in which a passengers knee strikes an automobiles
Cruciate Ligament Injury dashboard, driving th tibia posteriorly relative to th femur.
Severe hyperextension with an associateci gapping of th
C o n t r a c t io n o f t h q u a d r ic e p s m u s c le c a u s e s a n a n t e
posterior side of th joint can cause combined injury to th
r io r t r a n s la t io n o f t h t ib ia r e la t iv e to t h fe m u r . T h is
ACL, PCL, and posterior capsule. Additional mechanisms of
t r a n s la t io n c a n in c r e a s e t h t e n s io n in m o s t f ib e r s o f th
injury to th PCL are included in Table 1 3 - 4 .
A C L . '05 C o n t r a c t io n o f t h h a m s tr in g m u s c le s , in c o n t r a s t ,
c a u s e s a p o s t e r io r t r a n s la t io n o f t h tib ia t h a t s la c k e n s
m o s t f ib e r s o f t h A C L . 79 F o llo w in g a n A C L in ju ry , t h
h a m s t r in g s o fte n e x p e r ie n c e s p a s m . T h e r e s u lt in g f le x e d Three Common Mechanisms of Injury to th PCL
k n e e m a y b e a m e c h a n is m t h a t is e m p lo y e d to lim it th 1. Hyperflexion
s t r e t c h o n a r e c o n s t r u c t e d o r d a m a g e d A C L . 1 S t im u la t io n 2. Pretibial trauma (dashboard' injury)
fr o m s t r e t c h r e c e p t o r s in a n in ju r e d b u t in t a c t A C L m a y 3. Hyperextension
t r ig g e r s p a s m in th h a m s tr in g m u s c le s . T h is , in tu rn ,
m a y r e f le x iv e ly in h ib it t h q u a d r ic e p s m u s c le . 69 T h is m u s -
c u la r - b a s e d " f le x io n b ia s " o f t h k n e e p la c e s th tib ia
r e la t iv e ly p o s t e r io r to t h f e m o r a l c o n d y le s , t h e r e b y u n - M USCLE AND JOINT INTERACTION
lo a d in g m o s t f ib e r s o f t h A C L .
F o llo w in g a n A C L in ju r y o r r e c o n s t r u c t io n , a p a t t e r n Innervation to th Muscles and Joints
o f m u s c le a c t iv a t io n w h ile w a lk in g m a y d e v e lo p t h a t
f a v o r s g r e a t e r a c t iv a t io n o f t h h a m s t r in g s a n d in h ib i- I N N E R V A T IO N TO M U S C L E S
tio n o f t h q u a d r i c e p s . " 9 In t h e o r y , i n c r e a s e d a c t iv a t io n
The quadriceps femoris is innervated by th femoral nerve
o f t h h a m s t r in g s in a n A C L - d e f i c i e n t k n e e m a y p a r t ia lly
(see Fig. 1 2 -2 7 A ). Like th triceps at th elbow, th knees
c o m p e n s a t e f o r a n e x c e s s iv e a n t e r io r d i s p la c e m e n t o f
sole extensor group is innervated by just one peripheral
t h t ib ia r e la t iv e t o t h f e m u r . 77
nerve. A complete femoral nerve lesion, therefore, can cause
total paralysis of th knee extensors. The flexors and rotators

Considerations Regarding Resistive Exercises r e h a b ilit a t io n . M a n y r e p o r t s h a v e w a r n e d a g a in s t r e s is t e d

During Postsurgical Rehabilitation of ( t ib ia l- o n - f e m o r a l) k n e e e x t e n s io n a t a n g le s t h a t a r e le s s
th Anterior Cruciate Ligament t h a n 70 d e g r e e s o f fu ll e x t e n s io n . '2-25-6'-88-126 A s t h k n e e

V o lu m e s o f m a t e r ia l h a v e b e e n w r it t e n o n t h A C L , e s p e - a p p r o a c h e s f u ll e x t e n s io n , t h a c t iv e q u a d r ic e p s p r o d u c e s

c i a l l y r e la t e d t o t h t o p i c s o f b io m e c h a n i c s 66-73-92 s u r g ic a l a n a n t e r io r s h e a r o n t h t ib ia , w h ic h c a n s t r a in t h A C L

r e c o n s t r u c t io n a n d h e a lin g 22'29'43-12'-122 lo n g - t e r m r e s u lt s f o l ( s e e F ig . 1 3 - 2 2 A a n d B). T h e la r g e r t h f o r c e in t h

lo w in g s u r g ic a l r e p a ir , 80 a n d p o s t s u r g i c a l 2-4-5'24 " 4- " 6 a n d q u a d r ic e p s , t h g r e a t e r t h a n t e r io r s h e a r a n d s u b s e q u e n t

n o n s u r g ic a l r e h a b ilit a t io n . 28 M u c h o f t h d e b a t e a n d c o n - lo a d p l a c e d o n t h A C L . 47 A s a r e s p o n s e to t h e s e r e p o r t s ,

t r o v e r s y a s s o c ia t e d w it h t h is lit e r a t u r e a b o u t t h A C L is c l i n i c i a n s r o u t in e ly a d v o c a t e e x e r c i s e s t h a t c o n c e n t r a t e

b e y o n d t h s c o p e o f t h is te x t. O n e t o p ic , h o w e v e r , t h a t is o n lo a d in g t h quadriceps muscle d u r in g th Ia s t 45 d e
h ig h lig h t e d h e r e is t h is s u e o f s t r e n g t h e n in g t h q u a d r i g re e s of femoral-on-tibial extension .l2-46 T h e s e e x e r c i s e s
c e p s a s a p a r t o f A C L r e h a b ilit a t io n . a r e o f te n r e f e r r e d t o a s " c l o s e d k in e t ic c h a i n " e x e r c is e s .

S o m e p e r s o n s f o llo w in g A C L r e c o n s t r u c t iv e s u r g e r y E x e r c is e s s u c h a s " m in i s q u a t s , " s q u a t s a g a in s t e la s t ic

lim it q u a d r ic e p s a c t iv it y w h ile w a lk in g . P e r s is t e n t w e a k - r e s is t a n c e , s in g le - le g h a lf s q u a t s , a n d le g p r e s s e s p r o

n e s s o f t h m u s c le m a y e n s u e , d e s p it e im p r o v e m e n t in d u c e e q u a l, 4 o r le s s , s t r a in o n t h A C L t h a n t ib ia l- o n -

m a n y f u n c t io n a l m e a s u r e s . 64 R e d u c e d f u n c t io n a l s t r e n g t h f e m o r a l r e s is t a n c e e x e r c is e s , s u c h a s lif t in g a n k le

in t h q u a d r ic e p s m a y c a u s e a lo s s o f a c t iv e t e r m in a l w e ig h t s . 46- " 3-'25 F e m o r a l- o n - t ib ia l e x t e n s io n m a y d e m a n d a

e x t e n s io n , p o o r g a it, a n d e x c e s s iv e w e a r o n t h k n e e 's c o a c t iv a t io n o f t h k n e e e x t e n s o r a n d f le x o r m u s c le s ,

a r t ic u la r c a r t ila g e . S t r e n g t h e n in g a n d g e n e r a i a c t iv a t io n o f t h e r e b y in c r e a s in g s t a b ilit y o f t h k n e e a n d lim it in g a n te -

t h q u a d r ic e p s a r e t h e r e f o r e im p o r t a n t g o a ls in a n y A C L r io r - p o s t e r io r s h e a r f o r c e s . T h is m e t h o d o f e x e r c i s e m a y

r e p a ir r e h a b ilit a t io n p r o g r a m . lim it t e n s io n p l a c e d o n t h A C L a n d , a t t h s a m e t im e ,
p r o v id e a d e q u a t e r e s is t a n c e a g a in s t t h q u a d r ic e p s . A t
D e p e n d in g o n t h p a t ie n t 's a g e , t im e s i n c e s u r g e r y ,
s o m e p o in t in t h r e h a b ilit a t io n p r o c e s s , h o w e v e r , t e n s io n
a n d in j u r y s e v e r it y , it m a y b e p r u d e n t t o lim it t h a m o u n t
in t h A C L m a y a c t u a lly f a c ilit a t e h e a lin g a n d c a n b e
o f t e n s io n p l a c e d o n a h e a lin g A C L g r a ft. C e r t a in m e t h o d s
c o n s id e r e d t h e r a p e u t i c . " 5
f o r s t r e n g t h e n in g t h q u a d r ic e p s a r e c o n t r a in d ic a t e d o r a t
le a s t q u e s t i o n a l e , e s p e c i a l l y d u r in g t h e a r ly c o u r s e o f
454 Section IV Lower Extremity

of th knee are innervateci by severa! nerves from both th
lumbar and sacrai piexus, bui primarily by th tibial portion
of th sciatic nerve (see Fig. 1 2 -2 7 B ). Table 1 3 - 5 summa-
rizes th motor innervation to th knee.
The motor nerve roots that supply all th muscles of th
lower extremity are listed in Appendix IVA. Appendix IVB
shows key muscles typically used to test th functional status
of th L2- S 3 ventral nerve roots.
SENSO RY IN N E R V A T IO N TO T H E JO IN T
Sensory inner\'ation to th knee is supplied primarily from
th L3 through L5 nerve roots, carried by anterior and
posterior sets of nerves.58,65 The posterior set is derived from
th posterior tibial and obturator nerves. The posterior tibial
nerve (a branch from th tibial portion of th sciatic) is
th largest afferent supply to th knee joint. It supplies
sensation to th posterior capsule and associated ligaments,
and most of th internai structures of th knee as far ante-
rior as th infrapatellar fat pad. The afferent ftbers within th
obturator nerve are th reason why inflammation of th hip
joint is often perceived as referred pain in th mediai knee
region.
The anterior set of sensory nerves to th knee consists
primarily of sensory branches from th femoral nerve. Artic-
ular branches of th femoral nerve supply most of th ante-
rior-medial and anterior-lateral capsule and th associated
ligaments. The anterior set also contains sensory branches
from th common peroneal nerve and th saphenous nerve
(L 3-4).
Muscular Function at th Knee
EXTENSOR AN D F L E X O R -R O T A T O R M U S C L E S
Muscles of th knee are described here as two groups:
th knee extensors (i.e., quadriceps) and th knee flexor-
rotators. The anatomy of many of these muscles is pre-
sented in Chapter 12. Consult Appendix IV, Part C, for a
summary of th attachments and nerve supply to th mus
cles of th knee.
Quadriceps: Knee Extensor Mechanism
Functional Considerations
By isometric, eccentric, and concentric activations, th quad
riceps femoris muscle is able to perform multiple functions
at th knee. Through isometric activation, th quadriceps sta-
bilizes and helps to protect th knee; through eccentric act:
vation, th quadriceps Controls th rate of descent of th
bodys center of mass, such as in sitting or stooping. Eccen
tric activation provides shock absorption to th knee. At th
heel contact phase of walking, th knee flexes slightly in
response to th posteriorly located ground reaction forct
Eccentrically active quadriceps Controls flexion. Acting as ;
spring, th muscle helps dampen th impact of loading oc
th joint. This protection is especially useful during high
impact loading, such as landing from a jump, running, cr
descending from a high step. A person whose knee is brace;
or fused in full extension lacks this naturai shock absorption
mechanism.
In th previous examples, eccentric activation of th.

TABLE 1 3 - 5 . Actions and Innervation of Muscles That Cross th Knee*

Muscle Action Innervation Piexus

Sartorius Hip flexion, extemal rotation, and abduction Femoral nerve Lumbar
Knee flexion and internai rotation
Gracilis Hip flexion and adduction Obturator nerve Lumbar
Knee flexion and internai rotation
Quadriceps femoris
Rectus femoris Knee extension and hip flexion Femoral nerve Lumbar
Vastus group Knee extension
Popliteus Knee flexion and internai rotation Tibial nerve Sacrai
Semimembranosus Hip extension Sciatic nerve (tibial portion) Sacrai
Knee flexion and internai rotation
Semitendinosus Hip extension Sciatic nerve (tibial portion) Sacrai
Knee flexion and internai rotation
Biceps femoris Knee flexion and external rotation Sciatic nerve (common per Sacrai
(short head) oneal portion)
Biceps femoris Hip extension Sciatic nerve (tibial portion) Sacrai
(long head) Knee flexion and external rotation
Gastrocnemius Knee flexion Tibial nerve Sacrai
Ankle piantar flexion
Plantaris Knee flexion Tibial nerve Sacrai
Ankle piantar flexion

* The actions involving th knee are shown in bold. Muscles are listed in descending order of nerve root innervation.
 Chapter 13 Knee 455

VI RF
FIGURE 13-23. A cross-section through ihe right quadriceps mus-
cle. The arrows d ep ia th approximate line-of-force of each of part
of th quadriceps: vastus lateralis (VL), vastus ntermedius (VI),
rectus femoris (RF), vastus medialis longus (VML), and vastus me-
dialis obliquus (VMO).
quadriceps is employed to decelerate knee flexion. Concertine
contraction of this muscle, in contrast, accelerates th tibia or
femur into knee extension. This action is often used to raise
th bodys center of mass, such as running uphill, jumping,
or standing from a seated position.
Anatomie Considerations
The quadriceps femoris is a large and powerful extensor mus
cle, consisting of th rectus femoris, vastus lateralis, vastus
medialis, and deeper vastus ntermedius (Figs. 1 3 - 7 and
1 3 -2 3 ). The large vastus group produces about 80% of th
total extension torque at th knee, and th rectus femoris
produces about 20% (Fig. 1 3 - 2 4 ) .54 Contraction of th vasti
extends th knee only. Contraction of th rectus femoris,
however, causes hip flexion and knee extension.
All heads of th quadriceps unite to form a strong tendon
that attaches to th base of th patella. The quadriceps ten
don continues distally as th patellar ligament, joining th
apex of th patella to th tibial tuberosity. The vastus latera
lis and vastus medialis attach into th capsule and menisci
via patellar retinacular fbers (see Fig. 1 3 - 7 ). The quadriceps
muscle and tendon, patella, and patellar ligament are often
described as th knee extensor mechanism.
The rectus femoris attaches to th pelvis near th anterior-
inferior iliac spine. The vastus muscles, however, attach to
an extensive part of th femur, particularly th anterior-
lateral shaft and th linea aspera (see Figs. 1 2 - 4 to 1 2 - 6 ).
Although th vastus lateralis is th largest of th quadriceps
muscles, th vastus medialis extends farther distally toward
th knee.
The vastus medialis consists of fbers that form two dis-
tinct fiber directions. The more distai oblique fbers (th
vastus medialis obliquus) approach th patella at 50 to 55
degrees, mediai to th quadriceps tendon; th remaining
more longitudinal fbers (th vastus medialis longus) ap
proach th patella at 15 to 18 degrees, mediai to th quadri
ceps tendon (see Fig. 1 3 - 2 3 ) .74 These two sets of fbers are
a subset of one anatomically distinct muscle: th vastus me
dialis.35 The two sets of fbers, however, have different lines-
of-force on th patella. Although th oblique fbers account
for only 30% of th cross-sectional area of th entire vastus
medialis muscle,97 th oblique pul on th patella has impor-
tant implications for th stabilization and orientation of th
patella as it tracks or slides through th intercondylar groove
of th femur.
The deepest quadriceps muscle, th vastus ntermedius, is
located under th rectus femoris. Deep to th vastus nter
medius is th articularis genu. This muscle contains a few
slips of muscle fbers that attach proximally to th anterior
side of th distai femur, and distally into th anterior cap
sule. This muscle pulls th capsule and synovial membrane

250-i
K nee extensors
225-
iK n e e flexors
200-
z
175-
FIGURE 13-24. The maximal knee torque
produced by muscles that cross th knee is Zi 150-
O-
displayed. Note th relatively large torque o 125-
potential of th vastus group. (Data from 1-
Hoy MG, Zajac FE, Gordon ME: Musculo- co 100-
skeletal model of th human lower extrem- E 75 -
X
ity. j Biomechan 2 3 :1 5 7 -1 6 9 , 1990.) cc
50-
2
25-
o -l
Vasti Rectus femoris Hamstrings Gastrocnemius Other
456 Section IV Lower Extremity
FIGURE 13-25. An analogy is triade between a crane (A) and th human knee (B). In th crane, th moment arm is th distance
between th axis and th tip of th piece of metal that functions like a patella.
proximally during active knee extension.120 The articularis
genu is analogous to th articularis cubiti at th elbow.
Patella: Augmentation of Knee Extension Lever-
age. Functionally, th patella displaces th tendon of th
quadriceps anteriorly, thereby increasing th internai mo
ment arm of th knee extensor mechanism. In this way, th
patella augments th torque potential of th quadriceps. Fig
ure 1 3 - 2 5 shows an analogy between a mechanical crane
and th human knee. Both use a spacer to increase th
distance between th axis of rotation and th internai lift
ing force. The larger th internai moment arm, th greater
th internai torque produced per level of force generated by
th quadriceps of th human knee (or transferred by th
cable in th crane).
Quadriceps Action at th Knee: Understanding th Biomechanical
Interactions Between External and Internai Torques
In many upright activities, th external (flexor) torque at th
knee is th produci of th external load being moved multi-
plied by its external moment arm. The internai (extensor)
torque, in contrast, is th product of quadriceps force multi-
plied by its internai moment arm. An understanding of how
these opposing torques are produced and how they interact
is an important consideration in knee rehabilitation.
External Torque Demands Against th Quadriceps:
Contrasting Tibial-on-Fem oral with Feinoral-on-Ttb-
ial Methods of Knee Extension. Strengthening exercises
for th quadriceps muscle typically are reliant on resistive,
external torques generated by gravity acting on th body.
The magnilude of external torques varies depending on how
th knee is being extended. During tibial-on-femoral knee
extension, th external moment arm of th weight of th
lower leg increases from 90 to 0 degrees of knee flexion
(Fig. 1 3 - 2 7 A to C). In contrast, during femoral-on-tibial
knee extension, th external moment arm of th upper body
weight decreases from 90 to 0 degrees of knee flexion (Fig
1 3 - 2 7 D to F). Figure 1 3 - 2 7 shows th relationships be
tween th relative external torque for th two methods of
extending th knee over a selected range of motion.
Information from th graph in Figure 1 3 - 2 7 is useful
when designing quadriceps strengthening exercises, espe-
cially for persons with knee pathology. By necessity, exer
cises that significantly challenge th quadriceps also stress
th knee joint and its associated connective tissues. Clini-
cally, this stress is considered either therapeutic or damag-
ing, depending on th type and severity of th pathology o:
injury. A person with marked patellofemoral joint pain or
painful arthritis, for example, is typically advised lo avoid
large forces created by th quadriceps.112 Muscle forces
are typically large when responding to large external torques.
As depicted by th red shading in th graph in Figure
1 3 - 2 7 , external torques are relatively large from 90 to 45
degrees of flexion via femoral-on-tibial extension, and from
45 to 0 degrees of flexion via tibial-on-femoral extension.
Reducing relatively large external torques can be accom-
plished by modifying th manner of applying resistance
against th knee extensor muscles. An external load, for
example, can be applied al th ankle during tibial-on-femo-
ral knee extension between 90 and 45 degrees of flexion.
This exercise can be followed by an exercise that involves
rising from a partial squat position, a motion that incorpo-
rates femoral-on-tibial extension between 45 and 0 degrees
of flexion. Combining both exercises in th manner de-
scribed provides moderate to minimal external torques
against th quadriceps, throughout a continuous range of
motion.
Internai Torque-Joint Angle Relationship of th
Quadriceps Muscle. Maximal knee extension torque typi
cally occurs between 45 and 60 degrees of flexion (Fig.
 Chapter 13 Knee 457

13-28).54,98,no a s depicted by th dashed red line in Figure
1 3 -28 A , th maximal-effort knee extension torque remains
at least 90% of maximum between 80 and 30 degrees of
flexion. This 50-degree, high-torque potential of th quadri-
ceps is used during many activities that incorporate femoral-
on-tibial kinematics, such as ascending a high step72 or
holding a partial squat position while participating in sports,
such as basketball and football. Note th rapid decline in
internai torque potential as th knee angle approaches full
extension. Interestingly, th extemal torque applied against
th knee during femoral-on-tibial extension also declines
rapidly during th same range of motion (see Fig. 1 3 - 2 7 ,
graph). There appears to be a biomechanical match in th
internai torque potential of th quadriceps and th extemal
torques applied against th quadriceps during th last 45
to 60 degrees of femoral-on-tibial knee extension. This
match accounts, in part, for th popularity of closed-kinetic
chain exercises that focus on applying resistance to th
quadriceps while th person is standing upright and moving
through th last 45 to 60 degrees of femoral-on-tibial knee
extension.
The variables of internai moment arm and muscle length
strongly influence th shape of th knee extension torque-
angle curve (Fig. 1 3 -2 8 B ). Moment arm influences torque,
and muscle length influences muscle force potential (see
Chapter 3). It is not possible to determine with certainty
which variable leverage or muscle length has th greater
influence on th maximal torque production of th quadri
ceps. Knee extensor torque potential (see Fig. 1 3 -2 8 A ) and
internai moment ann length of th quadriceps (see Fig. 1 3 -
28B) both peak at about 45 degrees of flexion.
Loss o f Full Knee Extension. The inability to extend
th knee fully is a relatively common clinica! phenomenon.
Factors that often prevent full knee extension can be broadly
classified into three categories: (1) reduced force production
from th quadriceps, (2) excessive resistance front th con-
nective tissues, and (3) faulty arthrokinematics. Table 1 3 - 6
presents clinical examples for each of these categories.
P a te llo fe m o r a l J o in t K in etics
Patellofemoral joint compression forces may reach 3.3 times
body weight while climbing stairs and may rise to 7.8 times
body weight in performing deep knee bends.100 Such large
joint forces reflect th magnitude of th forces produced
within th quadriceps muscle. An additional factor is th
angle of th knee joint at th time of muscle activation. To

S P E C I A L F O C U S 1 3 - 5

Consequences of a Patellectomy p r o d u c e a n e q u iv a le n t p r e - p a t e lle c t o m iz e d e x t e n s o r

t o r q u e . T h e i n c r e a s e d m u s c le f o r c e is n e e d e d t o c o m p e n
A c c o r d i n g t o o n e s t u d y , a n a p p r o x im a t e 20 % lo s s o f in t e r
s a t e f o r t h p r o p o r t io n a l lo s s in le v e r a g e . A s a c o n s e -
n a i m o m e n t arm o c c u r s following a p a t e lle c t o m y . 63 A v e r -
q u e n c e , t h g r e a t e r m u s c le f o r c e i n c r e a s e s t h c o m p r e s
a g e d o v e r f u ll r a n g e o f m o tio n , t h in t e r n a i m o m e n t a r m
s io n f o r c e o n t h t ib io f e m o r a l jo in t, c r e a t in g a d d it io n a l
o f a p a t e lle c t o m iz e d k n e e w a s r e d u c e d f r o m 4.7 c m to
w e a r o n t h a r t ic u la r c a r t ila g e (F ig . 1 3 - 2 6 ) .
3.8 c m . T h e s e d a t a s u g g e s t th a t , in t h e o r y , a k n e e
w it h o u t a p a t e lla n e e d s t o g e n e r a t e 25% m o r e f o r c e t o

A. With patella B. Without patella

FIGURE 13-26. The quadriceps is

shown contracting wiih a patella
(A) and without a patella (B). In
each case, th quadriceps maintains
equilibrium at th knee by re-
sponding to two equal magnitudes
of extemal resistance. The moment
arm (black line) is reduced in B
owing to th patellectomy. As a
consequence, th quadriceps must
produce a greater force to extend
th knee. This greater joint force is
transferred across th tibiofemoral
joint.
458 Section IV Lower Extremity

Tibial-on-FemoraJ Extension (A-C)

A. 90 of flcxion B. 45 of flexion C. 0 (full extension)

FIGURE 13-27. The extemal (flexion) torques are shown imposed on th knee between flexion (90 degrees) and full
extension (0 degrees). Tibial-on-femoral extension is shown in A C, and femoral-on-tibial extension is shown in DF. The
extemal torques are equal to th product of body or leg weight times th extemal moment arm (EMA). The graph shows
th relationship between th extemal toique normalized to a maximum (100% ) torque fot each method of extending th
knee for selected knee joint angles. (Tibial-on-femoral extension shown in black; femoral-on-tibial extension shown in
gray.) Extemal torques above 70% for each method of extension are shaded in light red. The increasing red color of th
quadriceps muscle denotes th increasing demand on th muscle and underlying joint. in response to th increasing
extemal torque.
 Chapter 13 Knee 459

FIGURE 13-28. Biomechanical varia-

bles related to maximal-effori knee
extension torque. A, The plot depicts
knee extension torque between
90 degrees and near 0 degrees of
knee flexion. Knee extensor torques
are produced isometrically, with th
hip extended. B, The plot shows th
relationship between th internai mo
ment arm of th quadriceps (left y
axis, in red) and rectus femoris
length (tight y axis, in black) be B 5.5 r- I 60
tween 9 0 degrees and near 0 degrees
of knee flexion. Data on muscle
length were estimated using a human
skeleton. Data on torque and moment - 55
arm are based on a healthy male pop-
ulation. (Data from Smidt GL: Bio

Rectus femoris length (cm)

mechanical analysis of knee flexion
and extension. J Biomechan 6 :7 9 -9 2 , - 50
1973.)

- 45

- 40

O
co
3
o 3.0 35

J _______ I_______ I_______ I_______ I_______ I_______ L 30

90 75 60 45 30 15 5
Knee Angle (degrees)
 460 Seciion /V Lower Extremity
TABLE 1 3 - 6 . Selected Factors that Contribute to
th Inability to Completely Extend th Knee
Factor C linical Exam ples
Reduced force pro Disuse atrophy of quadriceps following
duction from th trauma and/or prolonged immobili-
quadriceps zation
Lacerated femoral nerve
Herniated disc compressing L3 or L4
nerve roots
Severe pain
Excessive swelling in th knee
Excessive resistance Excessive lightness in hamstring or
from connective other knee flexor muscles
tissues Excessive stiffness in th anterior cruci
ate ligament, posterior capsule, or
collateral ligaments
Scarring of th skin in th popliteal
fossa
Faulty arthrokine- Lack of screw-home rotation mechan-
matics ics
Lack of anterior slide of th tibia*
Meniscal block or other derangement
Lack of superior slide of th patella*
* Assume Libial-on-femoral knee extension
illustrate these factors, consider th force on th patellofemo-
ral joint while in a partial squat position (Fig. 1 3-29 A ). The
force withtn th extensor mechanism is transmitted proxi-
inally and distallv through th quadriceps tendon (QT) and
patellar ligament (PL), much like a cable Crossing a ftxed
pulley. The resultant, or combined effect, of these forces is
directed toward th intercondylar groove of th femur as a
joint force QF). Increasing knee flexion by descending into a
deeper squat significanti)' raises th force demands through-
out th extensor mechanism. ultimately on th patellofemo-
ral joint (Fig. 1 3 -2 9 B ). The increased knee flexion associ-
ated with th deeper squat also reduces th angle formed by
th intersection of force vectors QT and PL. As shown by
th vector addttion, reducing th angle of these force in-
creases th magnitude of th JF directed between th patella
and th femur.
Two Inlerrelated Factors That Incrcasc th Compression
Force in th Patellofemoral Joint
1. Increased force demands on th quadriceps muscie
2. Increased knee flexion
While performing a squat maneuver, th pressure (force/
area) within th patellofemoral joint is greatest at 60 to 90
degrees of knee flexion. The contact area within th patello
femoral joint is also greatest at 60 to 90 degrees of knee
flexion (Fig. 1 3 - 19E).10-50-82 Without this large area to dis
perse th forces, th pressure at th patellofemoral joint cari
rise to an intolerable leve!. Flaving th contaci area within
th joint greatest at th positions that receive th largest
compression forces protects th joint against degeneration.
This mechanism allows a healthy patellofemoral joint to tol-
erate large compression forces over a lifetime, often with
little or no appreciable wear or discomfort.
Tracking Within th Patellofemoral join t. During ac-
tive knee extension, several structures guide, or track, th
patella through th intercondylar groove of th femur (see
th next box). Acting alone, each structure exerts a mediai
or lateral pul on th patella as it slides in th groove (Fig.
1 3 - 3 1 ). When these forces balance each other, they
cooperate to track th patella through th groove with as
little stress to th articular surfaces as possible.44 If th
forces do not balance one another, th patella may not track
optimally and may even dislocate. Increased stress due to
abnormal tracking may lead io arthritis, chondromalacia, re-
current patellar dislocation, or patellofemoral joint pain syn-
drome.
Quadriceps Weakness: Pathomechanics of "Extensor
Lag"
P e r s o n s w it h m o d e r a t e w e a k n e s s in t h q u a d r ic e p s o f
t e n s h o w c o n s id e r a b le d if f ic u lt y c o m p le t in g t h fu ll
r a n g e o f t ib ia l- o n - f e m o r a l e x t e n s io n o f t h k n e e , c o m -
m o n ly d is p la y e d w h ile s it t in g . T h is d if f ic u lt y p e r s is t s
e v e n w h e n t h e x t e r n a l lo a d is lim it e d to ju s t t h
w e ig h t o f t h lo w e r le g . A lt h o u g h t h k n e e c a n b e f u lly
e x t e n d e d p a s s iv e ly , e f f o r t s a t a c t iv e e x t e n s io n t y p ic a lly
f a il to p r o d u c e t h la s t 15 t o 20 d e g r e e s o f e x t e n s io n .
C lin ic a lly , t h is c h a r a c t e r i s t i c d e m o n s t r a t io n o f q u a d r i
c e p s w e a k n e s s is o f t e n r e f e r r e d to a s a n " e x t e n s o r
la g ."
E x t e n s o r la g a t t h k n e e is o f te n a p e r s is t e n t a n d
p e r p le x in g p r o b le m d u r in g r e h a b ilit a t io n o f t h p o s t -
s u r g ic a l k n e e . T h e m e c h a n ic s t h a t c r e a t e t h is c o n -
d it io n d u r in g t h s e a t e d p o s it io n a r e a s f o llo w s : A s th
k n e e a p p r o a c h e s t e r m in a l e x t e n s io n , t h m a x im a l
in t e r n a i t o r q u e p o t e n t ia l o f t h q u a d r ic e p s is le a s t w h ile
t h o p p o s in g e x t e r n a l ( fle x o r ) t o r q u e is g r e a t e s t . T h is
n a t u r a i d is p a r it y is h a r d ly e v id e n t in p e r s o n s w it h n o r -
m a l q u a d r ic e p s s t r e n g t h . W it h m o d e r a t e m u s c ie w e a k
n e s s , h o w e v e r , t h d is p a r it y o f te n r e s u lt s in e x t e n s o r
la g .
S w e llin g o r e f f u s io n o f t h k n e e i n c r e a s e s t h lik e li-
h o o d o f a n e x t e n s o r la g . S w e llin g i n c r e a s e s in t r a a r t ic u -
la r p r e s s u r e , w h i c h c a n p h y s ic a lly im p e d e fu ll k n e e e x
t e n s io n . 123 I n c r e a s e d in t r a a r t ic u la r p r e s s u r e c a n
r e f le x iv e ly in h ib it t h n e u r a l a c t iv a t io n o f t h q u a d r ic e p s
m u s c i e . '983 M e t h o d s t h a t r e d u c e s w e llin g o f t h k n e e ,
t h e r e f o r e , h a v e a n im p o r t a n t r o le in a t h e r a p e u t ic e x e r -
c is e p r o g r a m o f t h k n e e .
 Chapter 13 Knee 461

FIGURE 13-29. The relationship berween th depth o f a squat position and th compression fo r c e within th patellofem-
oral joint is shown. A, Maintaining a partial squat requires that th quadriceps transmit a force through th quadriceps
tendon (QT) and th patellar ligament (PL). The vector addition of QT and PL provides an estimation of th
patellofemoral jo in t force (JF). B, A deeper squat requires greater force from th quadriceps owing to th greater extemal
(flexion) torque on th knee. Furthermore, th greater knee flexion (B) decreases th angle between QT and PL and,
consequently, produces a greater joint fo r c e between th patella and femur.

The overall line-of-force of th quadriceps tends to pul

S tru ctu res th at Guide th P atella through th th patella superiorly and laterally relative to its ligament.
Intercondylar Groove o f th Femur The degree o f faterai pul exerted by th quadriceps is often
Quadriceps muscle
referred to as th Q-angle (Fig. 1 3 - 3 2 ) .52 This angle is
Quadriceps tendon
formed between (1) a line representing th resultant pul of
Patellar ligament
Iliotibial traci
th quadriceps, made by connecting a point near th ante-
Patellar retinacular fibers rior-superior iliac spine to th midpoint o f th patella, and
Shape of th articular surfaces (2) a line connecting th tibial tuberosity with th midpoint
o f t h p a t e l l a . D if f e r e n l Q - a n g le s e x i s i b e t w e e n t h g e n c l e r s :
462 Section IV Lower Extremity

15.8 degrees in women, and 11.2 degrees in men.53 A Cl
angle greater than 15 degrees is often thought to contribute
io paiellofemoral joint pain, chondromalacia, and patellar
dislocation. Little scientific evidence, however, supports this
assumption.78
The lateral bias in pul of th quadriceps produces a
naturai bowstringing force against th patella (see Fig. I S
S I). An important function of th oblique fibers of th
vastus medialis is to counteract th tendency of th quadri
ceps muscle as a whole to dislocate th patella laterally.74
The mediai paiellofemoral (retinacular) fibers21 and th nor-
mally raised lateral facet within th intercondylar groove of
th femur resist th laterally encroaching patella.
A combination of several structural and functional factors
can lead to excessive lateral tracking of th patella (Table
1 3 - 7 ) . Abnormal tracking is often associated with an abnor-
mal tilting of th patella as it rides in th groove. A shallow
intercondylar groove of th femur is a reliable predictor of
excessive lateral tilt of th patella in women, especially near
full knee extension.96 Over time, an abnormal tilt can lead to
increased stress on th articular cartilage and recurrent lat-
eral dislocation.38
Increased Q-angle due to bony malalignment is a possible
factor contributmg to excessive lateral tracking of th patella.78
The greater th Q-angle, th greater th lateral bowstringing
effect on th patella. Factors that increase th Q-angle also
tend to increase genu valgum. These factors include an over-
stretched mediai collateral ligament, internai rotation/adduc-
tion hip posturing, excessive foot pronation, and gender.
Data collected ai a large sports medicine clinic showed that
recurrent dislocation of th patella accounted for 58.4% of
all dislocations in women, compared with only 14% in men.20

Two Common Painful Conditions Involving th a d v is e d a g a in s t p e r f o r m in g s q u a t t in g a c t iv it ie s , e s p e c i a l l y

Patellofemora! Joint w h ile c a r r y in g lo a d s .

P a te llo fe m o ra l jo in t p a in syndrom e is a c o m m o n c o n d it io n
in p e r s o n s in v o lv e d in s p o r t s , r a n k in g f ir s t in t r a c k a n d
s e c o n d in A m e r i c a n f o o t b a ll a n d s o c c e r . 20 J o i n t p a in a ls o
o c c u r s in p e r s o n s n o t in v o lv e d in s p o r t s . T h o s e w h o h a v e
n o h is t o r y o f t r a u m a c a n a ls o e x p e r ie n c e jo in t p a in . C a s e s
m a y b e m ild , in v o lv in g o n ly a g e n e r a liz e d a c h in g a b o u t
t h a n t e r io r k n e e , o r t h e y m a y b e s e v e r e a n d in v o lv e
r e c u r r e n t d is lo c a t io n o r s u b lu x a t io n o f t h p a t e lla f r o m t h
in t e r c o n d y la r g r o o v e .
O v e r t im e , s o m e o f t h o s e w it h p a t e llo f e m o r a l j o in t p a in
s y n d r o m e d e v e lo p d e g e n e r a t iv e c h a n g e s in t h jo in t s u r -
f a c e s , a c o n d it io n k n o w n a s c h o n d r o m a la c ia p a t e lla e .
C h ondrom alacia p a te lla e ( fr o m t h G r e e k chondros, c a r t i
la g e , 4- m alakia, s o f t n e s s ) is a g e n e r a i t e r m t h a t d e -
s c r i b e s e x c e s s i v e c a r t ila g e d e g e n e r a t io n o n t h p o s t e r io r
s id e o f t h p a t e lla . 90' 09 T h o s e w it h t h is c o n d it io n o fte n
e x p e r ie n c e r e t r o p a t e lla r p a in a n d c r e p it u s , e s p e c i a l l y
w h ile s q u a t t in g o r c lim b in g s t e e p s t a ir s o r a f t e r s it t in g f o r
a p r o lo n g e d p e r io d . T h e c a r t ila g e b e c o m e s s o ft, p itte d ,
a n d f r a g m e n t e d . D e p e n d in g o n t h a m o u n t o f c a r t ila g e
w e a r a n d a s s o c ia t e d in f la m m a t io n , c h o n d r o m a la c ia c a n
b e v e r y p a in fu l.
T h e e x a c t c a u s e s o f ch o n d ro m a la cia are u n k n o w n . T h e
c o n d it io n o c c u r s f r e q u e n t ly in th young and old and in
t h a c t iv e a n d s e d e n t a r y , a n d it d o e s n o t a lw a y s d e v e lo p
in t o a m o r e g e n e r a liz e d o s t e o a r t h r it is o f t h k n e e . In s o m e
c a s e s , h o w e v e r , c h o n d r o m a la c ia m a y b e a s s o c ia t e d w it h Posterior
o s t e o a r t h r it is o f t h e n t ir e k n e e . F ig u r e 1 3 - 3 0 s h o w s a n
FIGURE 13-30. The distai surface of th left femur and th pa
e x t r e m e c a s e o f o s t e o a r t h r it is o f a c a d a v e r i c k n e e w it h
tella is shown in th knee of a cadaver. This specimen is from an
d e g e n e r a t io n t h r o u g h o u t its e n t ir e t y . B a s e d o n t h b io m e -
individuai who had chondromalacia patellae and generalized os-
c h a n i c s d e s c r ib e d , p e r s o n s w it h c h o n d r o m a la c ia , a c t iv e
teoarthritis of th knee. Note th irregular surfaces and marked
a r t h r it is , o r g e n e r a liz e d p a t e llo f e m o r a l jo in t p a in a r e o fte n degeneration on th cartilage of th femur and patella.

M a jo r Guiding Forces Acting on th Patella
FIGURE 13-31. The major guiding forces
acting on th patella are shown as it moves
through th mtercondylar groove of th fe-
mur. Each structure has a naturai tendenq
to pul th patella laterally or medially. In
most cases, th opposing forces counteract
one another so that th patella moves opti-
mally during flexion and extension.
(See Table 1 3 - 8 for a partial summary of these data.) The
greater Q-angle reported in women may partially account for
this large disparity.
Knee Flexor-Rotator Muscles
With th exception of th gastrocnemius, all muscles that
cross posterior to th knee have th ability to flex and to
internally or externally rotate th knee. The so-called flexor-
rotator group of th knee includes th hamstrings, sartorius,
gracilis, and popliteus. Unlike th knee extensor group,
which are all innervated by th femoral nerve, th flexor-
rotator muscles have three sources of innervation: femoral,
obturator, and sciatic.
Functional Anatomy
The h a m s t n n g m u s c le s (i.e., semimembranosus, semitendi-
nosus, and long head of th biceps femoris) have their prox-
imal attachment on th ischial tuberosity. The short head of
th biceps has its proximal attachment on th lateral lip of
th linea aspera of th femur. Distally, th three hamstrings
cross th knee joint and attach to th tibia and fibula (see
Figs. 1 3 - 9 to 1 3 -1 1 ).
The semimembranosus attaches distally to th posterior
side of th mediai condyle of th tibia. Additional distai
attachments of this muscle include th mediai collateral liga-
ment, both menisci, oblique popliteal ligament, and poplit
eus muscle. For most of its course, th sinewy s e m it e n d in o s u s
tendon lies immediately posterior to th semimembranosus
muscle. Just proximal to th knee, however, th tendon of
th semitendinosus courses anteriorly toward th distai at
tachment on th anterior-medial aspect of tibia. Both heads
of th b i c e p s f e m o r i s attach on th head of th fibula, beside
th fibular collateral ligament.
Chapter 13 Knee 463
All hamstring muscles, except th short head of th bi
ceps femoris, cross th hip and knee. As described in Chap
ter 12, th three biarticular hamstrings are very effective hip
extensors, especially in th control of th position of th
pelvis and trunk over th femur.
In addition to flexing th knee, th mediai hamstrings
(i.e., semimembranosus and semitendinosus) internally rotate
th knee. The biceps femoris externally rotates th knee.
Horizontal rotation occurs when th knee is flexed. This
horizontal piane action of th hamstrings can be appreciated
by palpating th tendons of semitendinosus and biceps fe
moris behind th knee as th leg is internally and externally
rotated repeatedly. This is performed while th subject is
sitting with th knee flexed 70 to 90 degrees. As th knee is
gradually extended, th pivot point for th rotating lower leg
shifts from th knee to th hip. At full extension, rotation
at th knee ceases because th knee becomes mechani-
cally locked and most ligaments are pulled taut. Further-
more, th moment arm of th hamstrings for internai and
extemal rotation of th knee is reduced significantly at full
extension.
The s a r t o r i u s and g r a c i li s have their proximal attachments
on different parts of th pelvis (see Chapter 12). At th hip,
both muscles are hip flexors, but they have opposite actions
in th frontal and horizontal planes. Distally, th tendons of
th sartorius and gracilis travel side by side across th me
diai side of th knee to attach to th proximal shaft of th
tibia, near th semitendinosus (see Fig. 1 3 - 1 1 ). The three
juxtaposed tendons of th sartorius, gracilis, and semitendi
nosus attach to th tibia using a common, broad sheet of
connective tissue known as th p e s a n s e r in u s . As a group, th
pes muscles are effective internai rotators of th knee.
Connective tissues hold th tendons of th pes group just
464 Secton IV Lower Extremity

TABLE 1 3 - 7 . Possible Causes and Exampies of

Excessive Lateral Tracking of th Patella

Structural or
Functional
Abnomiality Specific Exampies

Excessive tightness Tight iliotibial tract and/or lateral patel-

in lateral soft tis lar retinacular fibers
sues

Excessive laxity in Laxity of mediai collateral ligament

mediai soft tis and/or mediai patellar retinacular
sues fibers
Bony dysplasia Hypoplastic lateral facet on th inter-
condylar groove of th femur (i.e.,
a shallow intercondylar groove)
Small or dysplastic patella
Abnormal patellar Patella alta (high-riding patella)
position

Knee malalignment Increased Q-angle

Increased genu valgum
Excessive anteversion of th hip
Excessive extemal tibial torsion
Muscle weakness Weakness and atrophy of th oblique
fibers of th vastus medialis

posterior to th medial-lateral axis of rotation. Although these

FIGURE 13-32. The overall line-of-force of th quadriceps is showii
as well as th separate line-of-force of th muscles within th
quadriceps. The vastus medialis is divided into its two predominant
fber groups: th obliquus and th longus. The net lateral pul
exerted on th patella by th quadriceps is indicated by th Cl
angle. (See text for further details.)
muscle do noi attach to th femur, their indirect attachment
via connective tissues allows them to flex and internally
rotate th knee.
The pes anserinus group adds significant dynamic stability
to th mediai side of th knee. Along with th mediai collat-
eral ligament, active tension in th pes muscles resists knee
extemal rotation and valgus stress at th knee. Surgical re-
positioning of th pes tendons is recommended to reinforce
th mediai side of th knee in persons with chronic laxity in
th mediai collateral ligament.109
The poplUeus is a triangular muscle located deep to th
gastrocnemius within th popliteal fossa (see Fig. 1 3 -1 0 ).

TABLE 1 3 - 8 . Frequency of Jo in t Dislocation by Gender**

% of Dislocation by Gender % of Total Injuries by Gender

Dislocation M en W o m en M en W om en

Shoulder (recurrent) 38.1 1.9 1.9 0.1

Shoulder (acute) 22.1 3.8 1.1 0.3
Patella (recurrent) 14.0 58.4 0.7 4.6
Patella (acute) 11.0 34.0 0.5 2.7
Finger 5.1 0.3 _
Elbow 5.1 1.9 0.3 0.1

* Data collected on athletic injuries over a 7-year period at University of Rochester, Section of Sporta Medicine. Note in bold th high percentage of
recurrent patellar dislocation for women.
t The dislocation is expressed as a percentage of th total injuries by gender.
Data from DeHaven KE, Lintner DM: Athletic injuries: Comparison by age, sport, and gender Am J Sports Med 14:218-224, 1986.
 Chapter 13 Knee 465

M S P E C I A L F O C U S 1 3 - 8
Control of Femoral-on-Tibial Osteokinematics. The
muscular demand needed to control femoral-on-tibial mo-
1 p tions is generali)1 larger and more complex than that needed
Kinesiologic Basis for Treatment of Abnormal to control most ordinary tibial-on-femoral knee motions. A
Patellofemoral Joint Tracking muscle like th sartorius, for example, may have to simulta-
neously control up to five degrees of freedom (i.e., two at
M u c h o f t h o r t h o p e d ic t r e a t m e n t a n d p h y s ic a l t h e r a p y th knee and three at th hip). To illustrate, consider th
fo r abnormal t r a c k in g o f th p a t e lla involves th altering
action of severa! knee flexor-rotator muscles vvhile running
of t h t ib io f e m o r a l a n d p a t e llo f e m o r a l j o in t a lig n m e n t .
lo catch a ball (Fig. 1 3 -3 3 A ). While th tight foot is frmly
S u r g e r y is o f te n p e r f o r m e d t o le s s e n t h e f f e c t o f e x a g -
ftxed to th ground, th right femur, pelvis, trunk, neck,
g e r a t e d la t e r a l f o r c e s o n t h p a t e lla . E x a m p le s in c lu d e
head, and eyes all rotate to th left. Note th diagonal flow
f a t e r a i r e t in a c u la r r e le a s e a n d r e a lig n m e n t o f t h e x t e n -
of contracting muscles between th right fibula and left side
s o r m e c h a n is m , in p a r t ic u la r t h o b liq u e f ib e r s o f t h
of th neck. The muscle action epitomizes intermuscular
v a s t u s m e d ia lis . 31
synergy. In this case, th short head of th biceps femoris
P h y s ic a l t h e r a p y f o r c h r o n ic p a t e lla r d is lo c a t io n in -
anchors th diagonal kinetic chain to th fbula. The fibula,
c lu d e s t r a in in g f o r s e le c t iv e c o n t r o l o f t h o b liq u e f ib e r s
in tum, is anchored to th tibia via th interosseous mem
o f t h v a s t u s m e d ia lis , s t r e t c h in g o f t h s o f t t is s u e , a n d
brane and other muscles.
w e a r in g o f f o o t o r t h o t ic s t o r e d u c e e x c e s s i v e p r o n a t io n
Stability and control at th knee requi re interaction of
o f t h f e e t . T a p in g o f t h s k in h a s b e e n s u g g e s t e d a s a
forces produced by muscles and ligaments.9 Interaction is
w a y t o h e lp g u id e t h p a t e lla a n d / o r a lt e r t h m u s c le
espeeially important for control of movements in th hori-
a c t iv a t io n p a t t e r n o f t h v a s t u s m u s c le s . 34 A lt h o u g h
zontal and frontal planes. To illustrate, refer to Figure 1 3 -
b a s e d o n s o u n d b io m e c h a n ic a l p r in c ip le s , t h e f f i c a c y
33B. With th right foot planted, th short head of th
o f u s in g p h y s ic a l t h e r a p y t o s e le c t i v e l y a d i v a t e t h
biceps femoris accelerates th femur intemally. By way of
o b liq u e f ib e r s o f t h v a s t u s m e d ia lis to c o r r e c t a b n o r
eccentric activation, th pes anserinus muscles help deceler
m a l t r a c k in g o r r e c u r r e n t d is lo c a t io n o f t h p a t e lla r e -
ate th internai rotation of th femur and pelvis over th
m a in s a s u b j e c t o f d e b a t e . 70'93' 96' 27
tibia. The pes anserinus group of muscles functions as a
dynamic mediai collateral ligament by resisting th extema/
rotation and valgus torques produced at th knee. Muscle
action may help compensate for a weak or lax mediai collat
eral ligament.

By a strong intracapsular tendon, die popliteus attaches Maximal Torque Production o f th Knee Fiexor-Rotator
proximally to th lateral condyle of th femur, between th Muscles
lateral collateral ligament and th lateral meniscus (see Fig. Maximal effort knee flexion torque is generally greatest near
1 3 - 9 ) . The popliteus is th only muscle ol th knee that full extension, then declines steadily as th knee is progres-
attaches within th capsule. Alter exiting th posterior cap sively flexed (Fig. 1 3 - 3 4 A ) ." 0 Although th hamstrings have
sule, th popliteus has an extensive attachment to th poste
rior side of th tibia. Fibers from th popliteus attach to th
lateral meniscus and blend with th arcuate popliteal liga
ment.
The anatomy and action of th gastrocnemius and plan-
taris are considered in Chapter 14. S P E C I A L F O C U S
0
Group Action o f Fiexor-Rotator Muscles
Popliteus Muscle: The "Key to th Knee"
The flexor-rotator muscles o f th knee best perform their
actions during walking and running. Examples of these ac- T h e p o p lit e u s is a n im p o r t a n t in t e r n a i r o t a t o r a n d f le x o r

tions are considered separately for tibial-on-femoral and fem- o f t h k n e e jo in t. A s a n in t e r n a i r o t a t o r , t h p o p lit e u s is

oral-on-tibial movements of th knee. c o n s id e r e d t h " k e y " t o t h k n e e . A s t h e x t e n d e d a n d

lo c k e d k n e e p r e p a r e s t o f le x (e .g ., w h e n b e g in n in g to

Control o f Tibial-on-Fem oral Osteokinematics. An d e s c e n d in t o a s q u a t p o s it io n ) , t h p o p lit e u s p r o v id e s

a n in t e r n a i r o t a t io n t o r q u e t h a t h e lp s m e c h a n i c a l l y u n -
important action of th flexor-rotator muscles is to accelerate
l o c k t h k n e e .3 R e c a li t h a t t h k n e e is m e c h a n ic a lly
or decelerate th tibia during walking or running. Typically,
lo c k e d b y a c o m b in a t io n o f e x t e n s io n a n d s lig h t e x t e r -
these muscles produce relatively low-to-moderate forces bui
n a l r o t a t io n . U n lo c k in g t h k n e e t o f le x in t o a s q u a t
at relatively high shortening or lengthening velocities. One of
th more important functions of th hamstring muscles, for p o s it io n r e q u ir e s t h a t t h f e m u r externally rotate on th
t ib ia . T h is a c t io n o n t h f e m u r is r e a d ily a p p a r e n t b y
example, is to decelerate th advancing tibia at th late
o b s e r v in g t h m u s c l e 's o b liq u e lin e - o f - f o r c e b e h in d t h
swing phase of walking. Through eccentric action, th mus
k n e e ( s e e F ig . 1 3 - 1 0 ) . B y a t t a c h in g t o t h p o s t e r io r
cle helps dampen th impact of full knee extension. Con-
h o r n o f t h la t e r a l m e n is c u s , t h p o p lit e u s c a n s t a b iliz e
sider also sprinting or rapidly walking uphill. These same
t h la t e r a l m e n is c u s d u r in g t h is f le x io n - r o t a t io n m o v e -
muscles rapidly contract to accelerate knee flexion in order
m e n t.
to shorten th functional length of th lower limb during th
swing phase.
 466 Section IV Lower Extremity

R ig h t s t e r n o c le id o m a s t o id
Left splenius capitis
(o n a n te rio r s id e )
and cervicis
FIGURE 13-33. A, Several muscles
are shown controlling th rotation of
th head, neck, trunk, pelvis, and
Left obliquus R ig h t o b liq u u s e x te rn u s a b d o m in is femur toward th approaching ball.
internus abdominis (o n a n t e r io r s id e ) Since th right foot is fixed to th
(on anterior side) ground, th right knee functions as
R ig h t tr a n s v e r s o s p in a l m u s c le an important pivot point. B, Control
of th movement of th right knee
within th horizontal piane is illus
trateci from above. The short head of
Pes P ir if o r m is th biceps femoris contracts to accel
anserinus pSartorius erate th femur intemally (i.e., th
group -i-Gracilis knee joint moves into external rota
L-Semitendinosus tion). Active force from th pes an
B ic e p s f e m o r is serinus muscles in conjunction with
(sh o rt head) Oecelerators: a passive force from th stretched
P e s g ro u p mediai collatera! ligament (MCL)
helps to decelerate, or limit, th ex-
temal rotation at th knee.

Accelerator:
B ic e p s f e m o r is ( s h o r t h e a d )

From above

their greatest internai moment arm at about 45 degrees of
knee flexion (Fig. 1 3 -3 4 B ), th muscles produce their great
est knee flexor torque when fully elongated. Flexing th hip
to elongate th hamstrings promotes even greater knee flex-
ion torque.6 Length-tension relationship appears to be a very
influential factor in determining th flexion torque potential
of th hamstrings.
Few data are available on th maximal torque potential of
th internai and external rotator muscles of th knee. With
th hip and knee each flexed to 90 degrees, th internai and
external rotators at th knee produce peak torques of about
30 Nm,107 With hips- and knees flexed to only about 20
degrees, th peak internai rotation torque exceeds external
rotation torque by about 40%.
Maximal Torque Production at th Knee: Effects of Type
and Speed of Muscle Activation
Clinically, internai torque at th knee is typically measured
using isokinetic. dynamometry (see Chapter 4). In this type
of measurement, th joint is typically rotating so that both
th length and moment arm of th muscles are constantly
changing across a range of motion. Isokinetic dynamometry
allows internai torques to be measured during concentric,
isometric, and eccentric muscle activations. In generai, inter
nai torques produced through eccentric or isometric activa
tions are greater than those produced through concentric
contraction. Based on th force-velocity curve of muscle (see
Chapter 2), concentrically produced muscle torques decline
as th contraction speed increases.6-8'40 2 Figure 1 3 - 3 5
shows a plot of th peak torque produced by th knee
extensors and flexors during nonisometric (isokinetic) activa
tions.'2 The decline in peak torque occurs during concentric
contractions for both knee extensors and knee flexors. In
contrast, th peak torques remain essentially Constant during
increasing eccentric activated velocities.
Synergy Among Monoarticular and Biarticular Muscles
of th Hip and Knee
Typical Movement Combinations: Hip-and-Knee Extension or
Hip-and-Knee Flexion
Many movements performed by th lower extremities involve
th cyclic actions of hip-and-knee extension or hip-and-knee
flexion. These patterns of movement are fundamental com-
ponents of walking, running, jumping, and climbing. Hip-
and-knee extension propels th body forward or upward.
whereas hip-and-knee flexion advances or swings th lower
limb. These movements are controlled, in part, through a
synergy among monoarticular and polyarticular muscles.
many of which cross th hip and knee.
Figure 1 3 - 3 6 shows an interaction of muscles during th
hip-and-knee extension phase of running. The vastius and
gluteus maximus two monoarticular muscles are shown
contracting synergistically with th biarticular semitendinosus
and rectus femoris. The vastus group of th quadriceps and
th semitendinosus are both electrically active, yet their net
torque at th knee favors extension. The active shortening of
 Chapter 13 Knee 467

A 65 r~

60 -

E
z
ai 55 -
3
o-

c 50 -
o
'S
V

g 45
C
15
E 40
X
(O

35
FIGURE 13 -3 4 . Biomechanical varia-
bles relaied io maximal-effort knee
flexion torque. A, The plot depicts
knee flexion torque between near 0 30 J ___________!___________ 1
___________ !___________ !___________ !___________ L
degrees and 9 0 degrees of knee flex 5 15 30 45 60 75 90
ion. Knee flexor torques are pro- Knee Angle (degrees)
duced isometrieally, with th hip ex-
tended. B, This plot shows th
relationships between th internai
moment arm o f th hamstrings (left y
axis, in red) and hamstring length
(righi y axis, in blaek) between near
0 degrees and 9 0 degrees of knee
flexion. Data on muscle length were
estimated ustng a human skeleton.
Data on torque and moment arm are
based on a healthy male population.
(Data from Srnidt GL: Biomechanical

Hamstring length (cm)

analysis of knee flexion and exten-
sion. J Biomechan 6 :7 9 - 9 2 , 1973.)
468 Section IV Lower Extremity
FIGURE 13-35. Peak torque generateci by th knee extensor muscles
(top, solid line) and knee flexor muscles (bottoni, dashed line).
Positive velocities denoie concentric (muscle shortening) activity
and negative velocities denote eccentric (muscle lengthening) activ-
ity. Data are from 6 4 untrained, healthy males. (From Horstmann
T, Maschmann J, Mayer F, et al: The influence of age on isokinetic
torque of th upper and lower leg musculature in sedentary men.
Ini J Sports Med 2 0 :3 6 2 -3 6 7 , 1999. Georg Thieme Verlag.)
th overpowering vastus not only extends th knee, but
lengthens or stretches th active semitendinosus. Because th
semitendinosus is lengthened across th knee as it simulta-
neously produces hip extension, little overall change occurs
in th muscles length. The semitendinosus, therefore, ex
tends th hip but actually contracts or shortens a relatively
short distance.
The action of th semitendinosus muscle favors relatively
high force output per level of neural drive or effort. The
physiologic basis for this phenomenon rests on th force-
velocity and length-tension relationships of muscle. Consider
primarily th effect of muscle velocity on muscle force pro
duction. Muscle force per level of effort increases sharply as
th contraction velocity is reduced (see Chapter 3). As an
Extensor-to-Flexor Peak Torque Ratios
In g e n e r a i, t h k n e e e x t e n s o r m u s c le s p r o d u c e a t o r q u e
a b o u t t w o - t h ir d s g r e a t e r t h a n t h k n e e f le x o r m u s c l e s . 13
A m a jo r f a c t o r a c c o u n t in g f o r t h is d if f e r e n c e is t h
r e la t iv e ly la r g e t o r q u e p r o d u c e d b y t h v a s t u s m u s c le s
( s e e F ig . 1 3 - 2 4 ) . 54 T h e p a t e lla s ig n if ic a n t ly i n c r e a s e s t h
m o m e n t a r m a v a ila b le to t h q u a d r ic e p s .
R e s e a r c h h a s b e e n p e r f o r m e d t o d e f in e a n o r m a t iv e
e x t e n s o r - t o - f le x o r p e a k t o r q u e r a t io a t t h k n e e to h e lp
c l i n i c i a n s s e t a p p r o p r ia t e g o a ls f o r is o k in e t ic s t r e n g t h
t r a in in g . 1351 U n f o r t u n a t e ly , t h t o r q u e r a t io s h a v e b e e n
f o u n d t o v a r y c o n s id e r a b ly , t h e r e f o r e lim it in g c l i n i c a l
u s e f u ln e s s . G r a c e a n d c o l l e a g u e s 39 r e p o r t e d a n e x t e n
s o r - t o - f le x o r t o r q u e r a t io o f 1.67:1 (i.e ., e x t e n s o r s p r o
d u c e d 67% g r e a t e r p e a k t o r q u e t h a n f le x o r s ) in 172 h ig h
s c h o o l - a g e m a le s . In a n o t h e r s t u d y , t h p e a k k n e e
e x t e n s o r - t o - f le x o r t o r q u e r a t io s w e r e m e a s u r e d a t t h r e e
d if f e r e n t is o k in e t ic t e s t s p e e d s in 100 h e a lt h y s u b -
j e c t s . 124 R e s u lt s w e r e 1.39:1 a t 60 d e g r e e s / s e c , 1.27:1 a t
180 d e g r e e s / s e c , a n d 1.19:1 a t 3 0 0 d e g r e e s / s e c . T h e
d if f e r e n c e in p e a k t o r q u e s b e t w e e n t h e x t e n s o r a n d
f le x o r m u s c le s d e c r e a s e d a s t h s p e e d o f c o n t r a c t io n
in c r e a s e d .
example, a muscle contracting at 6.3% of its maximum
shortening velocity produces a force of about 75% of its
maximum. Slowing th contraction velocity to only 2.2% of
maximal (i.e., very near isometric) raises force output to
90% of maximum.75 In th movement of hip-and-knee ex
tension, th vastus muscles, by extending th knee, indi-
rectly augment hip extension force by reducing th contrac-
tion velocity of th semitendinosus.
FIGURE 13-36. The action of several monoarticu-
lar and biarticular muscles are depicted during th
hip-and-knee extension phase of running. Observe
that th vasti extend th knee, which then
stretches th distai end of th semitendinosus. The
gluteus maximus extends th hip, which then
stretches th proximal end of th rectus femors.
The stretched biarticular muscles are depicted by
thin black arrows. The stretch placed on th active
biarticular muscles reduces th rate and amount of
their overall contraction. (See text for further de-
tails.)

TABLE 13- 9. Examples of Muscle Synergies at th Hip and Knee
Monoarticular Muscles
Active hip an d knee exlension Vasti
Gluteus maximus
Active hip an d knee flex io n lliopsoas
Biceps femoris (short
head), popliteus
After Leiber RL: Skeletal Muscle Strutture and Function. Baltimore, Williams & Wilkins, 1992.
Consider next ihe effect of muscle length on th passive
force produced by a muscle. Based on a muscles passive
length-tension relationship, th internai resistance or force
within a muscle, such as th semitendinosus, increases as
it is stretched. The semitendinosus as well as all biartic-
ular hamstrings functions as a transducer by transferring
force from th contracting vastus muscles to th extending
hip.
During active hip-and-knee extension, th gluteus maxi-
mus and rectus femoris have a relationship similar to that
A. Hip flcxion
and knce extension
FIGURE 13-37. The motions of (A) hip flexion and knee extension
and (B) hip extension and knee flexion. For both movements, th
near-maximal contraction of th btarttcular muscles (red) causes a
near-maximal stretch in th biarticular antagonist muscles (thin
black arrows).
Chapter 13 Knee 469
|
Biarticular Action
Action Transducers Augmented
Knee extension Two-joint hamstrings Hip extension
Hip extension Rectus femoris Knee extension
Hip flex io n Two-joint hamstrings Knee flex io n
Knee flexion Rectus femoris Hip flex ion
between th vasti and semitendinosus. In essence, th pow-
erful monoarticular gluteus maximus augments knee exten
sion force by extending th hip. This, in tum, stretches th
activated rectus femoris. In this example, th rectus femoris
is th biarticular transducer, transferring force from th glu
teus maximus to knee extension. A summary of these and
other muscular interactions used during hip-and-knee flex
ion are listed in Table 1 3 - 9 .
The interdependence between th hip and knee extensor
muscles allows for th most efficient force development. This
interdependence is considered when evaluating functional
activities that require combined hip-and-knee extension,
such as standing from a chair. Weakness of th vasti could
cause difficulty in extending th hip, whereas weakness of
th gluteus maximus could cause difficulty in extending th
knee.
Atypical Movement Combinations: Hip Flexion-and-Knee
Extension or Hip Extension-and-Knee Flexion
Consider movement pattems of th hip and knee that are
out of phase with th more lypical movement pattems de-
scribed here. Hip flexion can occur with knee extension
(Fig. 1 3 -3 7 A ), or hip extension can occur with knee flexion
(Fig. 1 3 -3 7 B ). The physiologic consequences of these move
ments are very different from those described in Figure 1 3 -
36. In Figure 1 3 -3 7 A , th biarticular rectus femoris must
shorten a great distance, and with relatively higher velocity,
in order to flex th hip and extend th knee. Even with
maximal effort, active knee extension is usually limited dur
ing this action. Based on th length-tension and force-veloc-
ity relationships of muscle, th rectus femoris is not able to
develop maximal knee extensor force. The hamstrings are
overstretched across both th hip and knee, thereby pas-
sively resisting knee extension.
The situation described in Figure 1 3 -3 7 A applies to th
movement described in Figure 1 3 -3 7 B . The biarticular ham
strings must contract to a very short length a movement
that is often accompanied by cramping. Furthermore, th
biarticular rectus femoris is overstretched across both th hip
and knee, thereby passively resisting knee flexion. For both
reasons, knee flexion force and range of motion are usually
limited by th out-of-phase movement.
The atypical movements depicted in Figure 1 3 -3 7 A and
B may have a useful purpose. Consider th movement of
kicking a football. Elastic energy is stored in th stretched
rectus femoris by th preparatory movement of combined
470 Seclion IV Lowcr Extremity

Reaction Forces through th Normal Knee hip extension and knee flexion. The action of kicking th
A. Standing B. Walking ball involves a rapid and full contraction of th rectus fe-
moris to simultaneously flex th hip and exlend th knee.
The goal of this action is to dissipate all force in th rectus
femoris as quickly as possible. In contrast, activities such
as walking or jogging use biarticular muscles so that forces
are developed more slowly and in a repetitive or cyclic
fashion. The rectus femoris and semitendinosus, for instance,
tend to remain at a relatively fxed length throughout much
of th activation cycle. In this way, muscles avoid repetitive
cycles of storing and immediately releasing relatively large
amounts of energy. More moderate levels of active and pas
sive torces are cooperatively shared between muscles,
thereby optimizing th metabolic effciency of th move-
ment.

Abnormal Alignment of th Knee

FROIMTAL PLANE

In th frontal piane, th knee is normally aligned in about 5

FIGURE 13-38. A, While standing, a force equal to about 44% of
body weight (BW) passes dose io th center of each knee joint.
The lateral and mediai articular surfaces of th tibia respond with
forces equal to about 22% of body weight. B, While walking, a
force equal to about three times body weight passes mediai to th
knee joint, creating a varus torque at every step. The direction of
this force causes th mediai articular surface of th tibia to respond
with a greater reaction force than th lateral articular surface. (Force
vectors are not drawn to scale.)
to 10 degrees of valgus. Deviation from this alignment is
referred to as excessive genu valgum or genu varum.
Genu Varum with Unicompartmental Osteoarthritis of th
Knee
In th normally aligned knee, joint reaction forces during
standing pass almost equally through th lateral and mediai
knee compartments (Fig. 1 3 -3 8 A ). Assuming that 44% of

FIGURE 13-39. Bilateral genu varum

with osteoarthritis in th mediai
compartment of th right knee. A,
The varus deformity of th right
knee is shown with associated in-
creased joint reaction force on th
mediai compartment. The area in
red indicates arthritic changes. B, An
anterior x-ray view with subject (a
43-year-old man) standing, showing
bilateral genu varum and mediai
joint osteoarthritis. Both knees have
a loss of mediai joint space and hy-
pertrophic bone around th mediai
compartment. To correct th defor
mity on th right (R) knee, a wedge
of bone will be surgically removed
by a procedure known as a high
tibial osteotomy. C, The x-ray shows
th right knee after th removai of
th wedge of bone. Note th change
in joint alignment compared with
th same knee in B. (Courtesy of
Joseph Davies, M.D., Milwaukee Or-
thopedic Group, Sinai Samariur
Medicai Center, Milwaukee.)

Excessive genu valgum
(knock-knee)
FIGURE 13-40. Excessive genu valgum of ihe righi knee. In ihis
example, ihe valgus deformity is th result of abnormal align-
ment at both proximal and distai ends of th lower limb (red).
Coxa vara and/or excessive pronation of th foot can increase th
valgus stress at th knee. Over lime, greater valgus stress at th
knee can increase th strain in th mediai collateral ligament
(MCL), and can increase th compression force on th lateral com-
partment of th knee. Note that th excessive pronation of th foot,
from a dropped mediai arch, causes th tibia to rotate internali)'
while standing.
body weight is located above th knees, each compartment
theoretically receives joint reaction forces equal to about
22% of body weight. (See th two small arrows in Fig. 1 3 -
38A.) While walking, however, total knee reaction forces
increase to about three times body weight. The increase
is due to th combined effect of muscle activation and re-
action forces produced by th ground at heel contact. Be-
cause th heel normally strikes th ground just lateral io its
midiine, th resulting ground reaction force passes just me
diai to th knee (Fig. 1 3 -3 8 B ). A net varus torque, there-
fore, is created with every step. For this reason, joint reac
tion forces while walking are typically greater on th mediai
compartment.
Most persons tolerate th asymmetrical dynamic loading
of th knee with little or no difficulty. In some persons,
however, th mediai compartment experiences excessive
wear, ultimately leading to umcompartmental osteoarthritis.76
Thinning of th articular cartilage on th mediai side can tilt
Chapter 13 Knee 471
th knee into genu varum, or bow-legged deformity (Fig.
1 3 -3 9 A ). A vicious circle may erupt: th varus deformity
increases mediai compartment loading, resulting in greater
loss of mediai joint space, causing greater varus deformity,
and so on. Figure 1 3 -3 9 B is an anterior view of an x-ray
showing bilateral genu varum. Both knees illustrate signs of
mediai joint osteoarthritis (i.e., loss of mediai joint space and
hypertrophic reactive bone around th mediai compartment).
Management of genu varum often involves surgery, such as a
high tibial (wedge) osteotomy. The goal of this surgery is to
correct th varus deformity and reduce th stress over th
mediai compartment (Fig. 1 3 -3 9 C ).117 In addition to sur
gery, foot orthoses are wom to reduce stress on knees with
mediai joint arthritis. Laterally wedged insoles decrease th
varus torque on th knee, and thereby decrease th load on
th mediai compartment.16
Excessive Genu Valgum
Several biomechanical factors can lead to excessive genu val
gum, or knock-knee (Fig. 1 3 - 4 0 ). Genu valgum is often
th result of abnormal alignment at either end of th lower
extremity. As indicated in Figure 1 3 - 4 0 , coxa vara (i.e., a
femoral neck-shaft angle less than 125 degrees) or exces-
sively pronated feet may increase th valgus stress on th
knee. Over lime, this stress may strain and subsequently
weaken th mediai collateral ligament. Standing with a val
gus deformity of approximately 10 degrees greater than nor-
mal directs most of th joint force to th lateral compart
ment.62 Knee replacement surgery may be indicateci to
correct a valgus deformity, especially if it is painful or causes
loss of function or lessens quality of life. Figure 1 3 - 4 1
shows severe bilateral osteoarthritis of th knee, with severe
genu valgum on th right and genu varum on th left. This
wind-swept deformity was corrected surgically with bilat
eral knee replacements (Fig. 1 3 - 4 1 0 .
SAGITTAL PLANE
Genu Recurvatum
Full extension with slight external rotation is th knees
close-packed, stable position. While standing in this locked
position, th knee is typically hyperextended about 5 to IO
degrees owing in pari to th posterior slope of th tibial
plateau. Hyperextension directs th line-of-gravity from body
weight slightly anterior lo th medial-lateral axis of rotation
at th knee. Gravity, therefore, produces a slight knee exten
sion torque that can naturally assist with locking of th
knee, allowing th quadriceps to relax while standing. Nor
mally, this gravity-assisted extension torque is adequately
resisted by passive tension in th stretched posterior capsule
and stretched flexor muscles of th knee.
Hyperextension beyond 10 degrees is called genu recurva
tum (from th Latin genu, knee; 4- recurvare, to bend back-
ward). The primary cause of genu recurvatum is a chronic,
overpowering knee extensor torque that eventually over-
stretches th posterior structures in th knee. The overpow
ering knee extension torque may stem from poor postural
control or from neuromuscular disease that causes spasticity
of th quadriceps muscles and/or paralysis of th knee llex-
ors.
472 Section IV Lower Extremily

FIGURE 13-41. Bilaieral frontal piane malalign-

meni in th knees of an 83-year-old female. A,
The classic "wind-swept deformity, with ex-
cessive genu valgum on right and genu varum
on th left. B and C are th x-rays of th
patient in A, before and after knee replace-
ment. Note in B, th hypertrophic bone forma-
tion in areas of increased stress. With exces-
sive genu valgum, th stress is greater on th
lateral compartment; with genu varum, th
stress is greater on th mediai compartment.
(Courtesy of Joseph Davies, M.D., Milwaukee
Orthopedic Group, Sinai Samaritan Medicai
Center, Milwaukee.)

S P E C I A L F O C U S 1 3 -

Case Report: Pathomechanics and Treatment of Severe
Genu Recurvatum
Figure 13-42A shows a case of severe genu recurvatum
of th left knee, caused by a flaccid muscle paralysis
from polio, contracted 30 years earlier. The deformity has
progressed slowly over th last 20 years as th individuai
continued to walk without a knee brace. She has partial
paralysis of th left quadriceps and hip flexors, but com
plete paralysis of th left knee flexors. Her completely
paralyzed left ankle joint was surgically fused in about 25
degrees of piantar flexion.
 Genu Recurvatum
A. llncorrected B. Corrected

Body weight Body weight

FIGURE 13-42. Subject showing marked genu recurvatum of th left knee secondary to polio. In addition to sporadic muscle
weakness ihroughoul th left lower exiremily, th left ankle was surgically fused in 25 degrees of piantar flexion. A, When
standing barefoot, th subjects body weight acts with an abnormally large external moment arm (EMA) at th knee. The
resulting large extensor torque amplifies th magniiude of th knee hyperextension deformity. B, Subject is able to reduce th
severity of th recurvatum deformity by wearing a tennis shoe with a built-up heel. The shoe tilted her tibia and knee forward,
thereby reducing th length of th deforming external moment arm at th knee.

Several interrelated factors are responsible for th de-
velopment of th deformity depicted in Figure 13-42A
Because of th fixed piantar flexion position of th ankle,
th tibia must be tilted posteriorly so that th bottom of
th foot makes full contact with th ground. Over th
years, this tilted position of th tibia hyperextended th
knee and overstretched th posterior structures of th
knee. Of particular importance is th fact that total paraly-
sis of th knee's flexor muscles provided no direct muscu-
lar resistance against th knee's hyperextension deformity.
Furthermore, th greater th hyperextension deformity, th
longer th external moment arm available to body weight
to perpetuate th deformity. Without bracing of th knee,
th hyperextension deformity produced a vicious circle,
allowing continuous stretching of th posterior structures
of th knee and continuous progression of th deformity.
The knee functions as th middle link of th lower
limb. Consequently, th knee joint is vulnerable to deform
ing stresses from musculoskeletal pathology at either end
of th lower extremity. This case report demonstrates how
an excessive and fixed piantar flexed ankle can predis
pose a person to genu recurvatum. As depicted in Figure
13 - 426, a relatively simple modification of footware was
used to treat th hyperextension deformity. Wearing a
tennis shoe with a "built-up" heel provided excellent re-
duction in th severity of th genu recurvatum. The raised
heel tilted th tibia and knee anteriorly, thereby signifi-
cantly reducing th length of th deforming external mo
ment arm at th knee. Body weight now produced a
relatively small hyperextension torque at th knee, held in
check by th anteriorly tilted tibia and by th rigidity
provided by th fused ankle joint.

473
474 Section IV Lower Extremity
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 C h a p t e r 14

Ankle and Foot

Donald A. Neumann , PT, Ph D

TOPICS AT A G LANCE

OSTEOLOGY, 478 Talonavicular Joint, 491 M e ta ta rs o p h a la n g e a l J o in ts , 504

Basic Terms and Concepts, 478 Calcaneocuboid Joint, 492 Anatomie and Kinematic
Individuai Bones, 478 Kinematics, 493 Considerations, 504
Fibula, 478 Mediai Longitudinal Arch of th Foot, Deformities Involving th First Toe,
D ista i T ib ia , 479 496 504
T a rs a l B one s, 479 Anatomie Considerations, 496 In te rp h a la n g e a l J o in ts , 505
Rays o f th Foot, 480 Functional Considerations, 496 A c tio n o f th J o in ts W ith in th F o re fo o t

ARTHROLOGY, 482 Abnormal Shape of th Mediai D u rin g th Late S ta n c e Phase o f G ait,

Terminology for Motions and Positions, 482 Longitudinal Arch, 497 506

Axes of Rotation, 483 C om b ined A c tio n o f th S u b ta la r and MUSCLE A N D J O IN T IN TE R A C TIO N , 506

Structure and Function of Joints
Associated with th Ankle, 483
T ib io fib u la r J o in ts , 483
Proximal Tibiofibular Joint, 483
Distai Tibiofibular Joint, 483
A rticular Structure, 483
Ligaments, 483
T a lo c ru ra l J o in t, 484
Articular Structure, 484
Ligaments, 484
Kinematics, 486
Structure and Function of th Joints
Associated with th Foot, 489
S u b ta la r J o in t, 489
Articular Structure, 489
Kinematics, 490
T ra n s v e rs e T a rs a l J o in t, 491
Articular and Ligamentous Structure,
491
T ra n s v e rs e T a rs a l J o in ts , 498
Joint Interactions During th Stance
Phase of Gait, 498
Early Stance Phase: Pronation at th
Subtalar Joint, 499
Mid to Late Stance Phase: Supination at
th Subtalar Joint, 501
D istai Intertarsal Join ts, 502
Basic Structure and Function, 502
Cuneonavicular Joints, 502
Cuboideonavicular Joint, 502
Intercuneiform and Cuneocuboid Joint
Complex, 502
T a rs o m e ta ta rs a l J o in ts , 503
Anatomie and Kinematic
Considerations, 503
In te rm e ta ta rs a l J o in ts , 504
Structure and Function, 504
Innervation of Muscles and Joints, 506
Anatomy and Function of th Muscles, 507
E xtrin sic M u s c le s , 507
Anterior Compartment Muscles, 508
Muscular Anatomy, 508
Joint Action, 510
Lateral Compartment Muscles, 510
Muscular Anatomy, 510
Joint Action, 511
Posterior Compartment Muscles, 512
Anatomy, 512
Joint Action: Piantar Flexion and
Supination, 514
M u s c u la r P a ra ly s is From In ju ry to th
P e ro n e a l o r T ib ia l N e rv e s , 516
In trin s ic M u s c le s , 518
Anatomie and Functional
Considerations, 518

INTRODUCTION of interrelated joints, connective tissues, and muscles. Al-

The primary function of th ankle and foot is to absorb
shock and impari thrust to th body during walking. While
walking and running, th foot must be pliable enough to
absorb th impact of millions of contacts throughout a life-
time. Pliability also allows th foot to conform to countless
spadai configurations between it and th ground. Walking
and running also require that th foot be relatively rigid
to be able io withstand large propulsive thrusts. The
healthy foot satisfies th seemingly paradoxical requirements
of both shock absorption and thrust through an interaction
though not emphasized in this chapter, th sensory functions
of th healthy foot also offer important measures of protec-
don and guidance to th lower extremity. This chapter sets
forth a firm basis for an understanding of th evaluation and
treatment of a multitude of disorders that affect th ankle
and foot, many of which are kinesiologically related to th
movement of th entire lower extremity.
Many of th kinesiologic issues addressed in this chapter
are related specifically to th process of walking, or gait, a
topic covered in greater detail in Chapter 15. Figure 1 5 - 1 2
should be consulted as a reference to th terminology used
477
 478 Section TV Lower Extremity

in this chapter to describe th different phases of th gait

cycle. TABLE 1 4 - 1 . Structural Organization of th Bones
and Join ts of th Foot and Ankle

Ankle Foot
0STE0 L0GY ________ ________
Rearfoot
Basic Terms and Concepts Bones Bones
NAMING THE JOINTS AND REGIONS Tibia, fibula, and talus Calcaneus and talus*
Joints Joint
The term ankle refers primarily to th talocrural joint, but Talocrural Subtalar (talocalcaneal)
also includes two related articulations: th proximal and dis Proximal and distai
tai tibiofbular joints. The term foot refers to all th struc- tibiofbular
tures distai lo th tibia and fibula. Note that this classifica- Midfoot
tion scheme includes th talus as part of both th ankle and
Bones
th foot. The talus is an extremely important bone, having
Navicular, cuboid, and cunei-
an essential role in both th locai kinesiology of th ankle forms
and foot and th kinesiology of th entire lower extremity. Joints
Figure 1 4 - 1 depicts an ovemew of th terminology that Transverse tarsal
describes th regions of th ankle and foot. The terms ante- Talonavicular
rior and posterior have their conventional meanings when Calcaneocuboid
referring to th tibia and fibula (i.e., th leg). In reference to Distai intertarsal
th ankle and foot, these terms are often used interchange- Cuneonavicular
ably with distai and proximal, respectiveiy. The terms dorsal Cuboideonavicular
and piantar describe th superior (top) and inferior aspects lntercuneiform and cuneo-
of th foot, respectiveiy. cuboid complex
Within th foot are three regions, each consisting of a set Forefoot
of bones and one or more joints. The rearfoot (hindfoot) Bones
consists of th talus, calcaneus, and subtalar joint; th mid- Metatarsals and phalanges
foot consists of th remaining tarsal bones, including th Joints
transverse tarsal joint and th smaller distai intertarsal joints; Tarsometatarsal
and th forefoot consists of th metatarsals and phalanges, lntermetatarsal
including all joints distai to and including th tarsometatar- Metatarsophalangeal
Interphalangeal
sal joints. Table 1 4 - 1 provides a summary of th organiza-
tion of th bones and joints of th ankle and foot.
* The talus is included as a bone of th ankle and a bone of th foot.

SIMILARITIES BETWEEN THE JOINTS OF THE DISTAL

LEG AND DISTAL ARM
The ankle and foot have several features that are structurally
similar to th wrist and hand. The radius in th forearm and
th tibia in th leg each articulates with a set of small bones,
Superior
th carpus and tarsus, respectiveiy. When considering th
pisiform of th wrist as a sesamoid, th carpus and tarsus
each have seven bones. The generai pian of th metatarsus
and nretacarpus, as well as th more distai phalanges, is
nearly identical. A notable exception is that th frst toe in
th foot is noi as functtonally developed as th thumb in th
hand.
As described in Chapter 12, th entire lower extremity
intemally or medially rotates during embryologic develop-
ment. As a result, th first toe is positioned on th mediai
side of th foot, and th top of th foot is actually its dorsal
surface. This orientation is snudar to that of th hand when
th forearm is fully pronated (Fig. 1 4 2). This plantigrade
position of th foot is used for walking and standing.

individuai Bones
FIBULA

The long and thin fibula is located luterai and parallel to th

FIGURE 14-1. The essential terminology used to describe th
regions of th foot and ankle.
tibia (Figs. 1 3 - 2 and 1 3 - 3 ). The fibular head can be pal-
pated just lateral to th lateral condyle of th tibia. The
stender shaft of th fibula transfers a small fraction of th
load through th leg, most of it being transferred through
th thicker tibia. The shaft of th fibula continues distally to

FIGURE 14-2. Topographic similarities between th pronated forc
ami and th foot. Note th thumb and great toe are both on th
mediai side of th respective extremity.
form th sharp and easily palpable lateral malleolus (from th
Latin root malleus; a hammer). The lateral malleolus func-
tions as a pulley for th tendons of th peroneus longus and
brevis. The lateral malleolus also forms th lateral wall of th
ankle or talocrural joint (Fig. 1 4 - 3 ).
DISTAL TIBIA
The distai end of th tibia expands in size to accommodate
loads transferred across th ankle. On th mediai side of th
distai shaft of th tibia is th prominent mediai malleolus. On
th lateral side is th fibular notch, a triangular concavity that
accepts th distai end of th fibula at th distai tibiofibular
joint (see Fig. 1 4 -1 0 ).
T o rs io n A n g le o f th T ib ia
In adults, th distai end of th tibia is twisted about its long
axis about 20 to 30 degrees relative to its proximal end.57
Naturai torsion is evident by th slight externally rotated
position of th foot while standing. This twist of th leg is
Chapter 14 Ankle and Foot 479
referred to as lateral tibial torsion, based on th orientation
of th bones distai end relative to its proximal end.
TARSAL BONES
The seven tarsal bones are shown in four different perspec-
tives in Figures 1 4 - 4 through 1 4 - 7 .
T alu s
The talus is th most proximal tarsal bone. Its dorsal or
trochlear surface is a rounded dome, convex anterior-posteri-
orly and slightly concave tnedial-laterally (Fig. 1 4 - 6 ) . Carti-
lage covers th trochlear surface and its adjacent sides, pro-
viding smooth articular surfaces for th talocrural joint. The
prominent head of th talus projects forward and slightly
mediai toward th navicular. In th adult, th long axis of
Anterior view
Interosseous ligament
Talocrural joint
Anterior tibiofibular
malleolus
Lateral malleolus
Deltoid ligament
FIGURE 14-3. An anterior view of th distai end of th tight tibia,
fibula, and talus. The articulation of th three bones forms th
talocrural (ankle) joint. The dashed line shows th attachment of
th capsule of th ankle joint.
480 Section IV Lower Extremity

Superior view I n fe r io r view

Interphalangeal Extensor digitorum Flexor digitorum longus
joint longus and brevis
Flexor digitorum brevis
Flexor hallucis longus
Extensor Distai and proximal
hallucis longus interphalangeal joints
Adductor hallucis and
Dorsal interossei flexor hallucis brevis
Extensor Distai phalanx Piantar interossei
digitorum brevis i i ^ A b d u c t o r and flexor
Middle phalanx
Abductor and hallucis brevis
Proximal phalanx
flexor digiti minimi
Dorsal interossei Lateral and mediai
sesamoid bones
Adductor hallucis
(oblique head)
Metatarsal
Mediai cuneiform Piantar interossei Peroneus longus
Peroneus tertius
Abductor and
Peroneus brevis Tibialis anterior
flexor digiti minimi
Intermediate cuneiform
Groove for ^neiforms) Tibialis posterior
Navicular peroneus longus
Tuberosity- WavicuS*
Flexor hallucis brevis
I Head Lateral cuneiform
TalusH ------ Neck Cuboid Quadratus plantae Talus
L-Trochlea
Extensor digitorum
Articulation with brevis Sustentaculum talus
mediai malleolus Articulation with Groove fo r flexor
lateral malleolus hallucis longus
Mediai and lateral Abductor
tubercles of talus digiti minimi Flexor digitorum brevis
and abductor hallucis
Calcaneus Lateral p r o c e s s - ^ H R i l v / Mediai process

Calcaneal
Achilles tendon
tuberosity
attaching to
tuberosity FIGURE 14-5. An inferior (piantar) view of th bones of th righi
FIGURE 14-4. A superior (dorsal) view of th bones of th righi ankle and foot. Proximal attachments of muscles are indicateci in
red, distai attachments in gray.
ankle and foot. Proximal attachments of muscles are indicated in
red, distai attachments in gray.

th neck of th talus positions th head about 30 degrees
mediai to th sagittal piane. In striali children, th head is
projected medially about 40 to 50 degrees, partially account-
itig for th often inverted appearance of their feet.
Figure 1 4 - 8 shows three articular facets on th piantar
(inferior) surface of th talus. The anterior and middle facets
are slighily curved and often continuous with each other.
Note that th articular cartilage that covers these facets also
covers th adjacent head of th talus. The ovai, concave
posterior facci is th largest facet. As a functional set, th
three facets articulate with th three facets on th dorsal (su
perior) surlace of th calcaneus, forming th subtalar joint.
The lalar sulcus is an obliquely running groove located be-
tween th anterior-middle and posterior facets.
Lateral and mediai tubercles are located on th posterior-
medial surface ol th talus (see Fig. 1 4 -4 ). A groove formed

Mediai view
Neck Facet for
mediai malleolus

Mediai tubercle

FIGURE 14-6. A mediai view of th bones

of th tight ankle and foot

Middle Proximal
tuberoto'-
phalanx phalanx
 Chapter 14 Ankle and Foot 481

Lateral view
Facet for articulation Navicular
with lateral malleolus Cuneiforms

Subtalar joint
(posterior 1st metatarsal

FIGURE 14-7. A lateral view of th bones of

th tight ankle and foot.

tarsus process
Proximal Distai
phalanx phalanx phalanges

between these tubercles serves as a pulley for th tendon of The cuneiforms contribute to th Lransverse arch of th foot,
th flexor hallucis longus (see Fig. 1 4 -1 1 ). accounting in part for th dorsal convexity to th middle
region of th foot. The lateral cuneiform has a facet for
C a lc a n e u s articulation with a portion of th mediai surface of th cu
The calcaneus, th largest of th tarsal bones, is well suited boid.
to accept th impact of heel contact during walking. The
C u b o id
large and rough calcaneal tuberosity receives th attachment
of th Achilles (calcaneal) tendon. The piantar surface of th As its name indicates, th cuboid has six surfaces, three of
tuberosity has lateral and mediai processes that serve as ai- which articulate with adjacent tarsal bones (see Figs. 1 4 - 4 ,
tachments for many of th intrinsic muscles and th deep 1 4 - 5 , and 1 4 - 7 ) . The distai surface articulates with th
piantar fascia of th foot (see Fig. 1 4 - 5 ). bases of both th fourth and frfth metatarsals. The cuboid is
The calcaneus articulates with other tarsal bones on its therefore homologous to th hamate bone of th wrist.
dorsal and anterior surfaces. The dorsal surface contains three The entire proximal surface of th cuboid articulates with
facets that join th matching facets on th talus (see Fig. th calcaneus. This surface is fiat to slightly curved. The
1 4 -8 ). The anterior and middle facets are relatively small and mediai surface has an ovai facet for articulation with th
nearly fiat. The posterior facet is large and convex, conforming lateral cuneiform and, occasionally, a very small facet for
io th concave shape of th equally large posterior facet on articulation with th navicular. A distinct groove runs across
th talus. Between th posterior and mediai facet is a wide th piantar surface of th cuboid, occupied by th tendon of
oblique groove called th calcaneal sulcus. This sulcus is filled th peroneus longus muscle.
with th attachments of several ligaments that bind th subta
lar joint. With th subtalar joint articulated, th sulci of th
calcaneus and talus form a tunnel within th subtalar joint,
known as th sinus tarsi (see Fig. 1 4 -7 ). Superior view
The relatively small anterior surface of th calcaneus joins
th cuboid at th calcaneocuboid joint. The sustentaculum
talus projects medially as a horizontal shelf from th dorsal
surface of th calcaneus. (Sustentaculum talus literally means
a shelf for th talus.) The sustentaculum talus lies under
and supports th middle facets of th subtalar joint (see Fig. Tibialis anterior
tendon
1 4 - 6 ). facet
Socket for Middle facet
Ala v i c u la r head of talus
The navicular bone is named for its resemblance to a ship Deltoid ligament ligament
within
(Le., referring to navy). Its concave proximal surface (th Spring ligament
talar sulcus
hull) accepts th head of th talus at th talonavicular joint Tibialis posterior
Deltoid
(see Fig. 1 4 - 4 ). The distai surface of th navicular bone Flexor digitorum longus
ligament (cut)
contains three relatively fiat facets that articulate with th Anterior facet
Posterior facets
three cuneiform bones. Middle
The mediai surface of th navicular has a prominent (u- Interosseous ligament
berosity, easily palpable about 1 inch (2.5 cm) inferior and within calcaneal sulcus
Calcaneal (Achilles)
distai (anterior) to th tip of th mediai malleolus. This Flexor hallucis
tendon
tuberosity serves as one of several distai attachments of th
tibialis posterior muscle. FIGURE 14-8. A superior view of th talus (lipped laterally to reveal
its piantar side as well as th dorsal side of th calcaneus. Observe
M e d ia i, In te rm e d ia te , a n d L a te ra l C u n e ifo rm s
th three articular facets located on th talus and on th calcaneus.
As a set, th cuneiform bones act as a spacer between th (The interosseous and cervical ligaments and multiple tendons have
navicular and three mediai metatarsal bones (see Fig. 1 4 - 4 ). been cut.)
 482 Section TV Lower Extremity
RAYS OF THE FOOT
A ray of th forefoot is defined as one metatarsal and its
associated set of phalanges.
Metatarsals
The five metatarsal bones link th distai row of tarsal bones
with th proximal phalanges (see Fig. 1 4 - 4 ). Metatarsals are
numbered 1 through 5, starting on th mediai side. The first
metatarsal is th shortest and thickest, and th second is
usually th longest and th most rigidly attached to th
distai row of tarsal bones. These morphologic characteristics
reflect th larger forces that pass through th mediai side of
th forefoot during th push-off phase of gait. Each metatar
sal has a base at its proximal end, a shaft, and a convex head
at its distai end (see Fig. 1 4 - 4 , first metatarsal). The bases
of th metatarsals have small articular Jacets that mark th
site of articulation with th bases of th adjacent metatarsals.
The articular facet on th first metatarsal is occasionally
lacking. Longitudinally, th shafts of th metatarsals are
slightly concave on their piantar side. This arched shape
enhances th load-supporting ability of th metatarsals (see
Fig. 1 4 - 6 ). The piantar surface of th first metatarsal head
has two small facets for articulation with two sesamoid
bones that are imbedded within th tendon of th flexor
hallucis brevis. The fifth metatarsal has a prominent stvloid
process just lateral to its base, marking th attachment of th
peroneus brevis muscle (see Fig. 1 4 - 7 ).
Osteologie Features of a Metatarsal
Base (with articular facets for articulation with th bases of
adjacent metatarsals)
Shaft
Head
Styloid process (on th fifth metatarsal only)
Phalanges
As in th hand, th foot has 14 phalanges, named proximal,
middle, and distai (see Fig. 1 4 - 4 ). The first toe com-
monly called th great toe or hallux has two phalanges,
designated as proximal and distai. In generai, each phalanx
has a concave base at its proximal end, a shaft, and a convex
head at its distai end.
A. Fundamental movement definitions B. Applied movement definitions
ABDUCTION/
ADDUCTION
(vertical axis)
EVERSION/
INVERSIONE
(AP axis)
Oblique axis
DORSIFLEXION/
PLANTAR
FLEXION
(ML axis)
ARTHROLOGY
The major joints of th ankle and foot are th talocrural,
subtalar, and transverse tarsal joints. The talus is mechanically
involved with all three of these joints. The multiple articula-
tions made by th talus help to explain th bones complex
shape, with nearly 70% of its surface covered with articular
cartilage. An understanding of th shape of th talus is
cruciai to an understanding of th arthrology of th ankle
and foot.
Terminology for Motions and Positions
The terminology used to describe th movements of th
ankle and foot incorporates two sets of definitions: a funda-
mental set and an applied set. The fundamental terminology
describes movement of th foot or ankle that occurs at right
angles to th three standard axes of rotation (Fig. 1 4-9A ).
Dorsiflexion (exlension) and piantar flexion describe th mo-
tion that is parallel to th sagittal piane, around a medial-
lateral axis of rotation. Eversion and inversion describe th
motion parallel to th frontal piane, around an anterior-
posterior axis of rotation. Abduction and adduction describe
motion in th horizontal (transverse) piane, around a vertical
(superior-inferior) axis of rotation. At th major joints of th
ankle and foot, however, th fundamental definitions are
inadequate because most movements of th ankle and foot
occur about an oblique axis rather than th three standard,
orthogonal axes of rotation depicted in Figure 1 4-9A .
A second and more applied terminology or set of defini
tions is used to describe movements that occur perpendicu-
lar to an oblique axis of rotation (Fig. 1 4 -9 B ). Pronation
describes a motion that has elements of eversion, abduction,
and dorsiflexion. Supination, in contrast, describes a motion
that has elements of inversion, adduction, and piantar flex
ion. The orientation of th oblique axis of rotation depicted
PRONATION: SUPINATION: FIGURE 14-9. A, Fundamental move
EVERSION INVERSION ment definitions are based on th
ABDUCTION ADDUCTION movement of any pari of th ankle
DORSIFLEXION PLANTAR FLEXION or foot in a piane perpendicular to
th three standard axes of rotation:
vertical, anterior-posterior (AP), and
medial-lateral (ML). B, Applied
movement definitions are based on
th movements that occur at right
angles to one of severa] oblique axes
of rotation in th foot and ankle.

TABLE 1 4 - 2 . Terms that Describc Movements and Deformities of th Ankle and Foot
Motion Axis of Rotation Piane of Motion
Piantar flexion
Medial-lateral Sagittal
Dorsiflexion
Inversion
Anterior-posterior Frontal
Eversion
Abduction
Vertical Horizontal
Adduction
Supination Varyng ekmems of inversion.
adduction, and piantar
Oblique (varies by joint) flexion
Pronation Varying elements of eversion,
abduction, and dorsflexion
in Figure 1 4 -9 B varies by major joint but, in generai, has a
pitch that is similar to that illustrateci. The exact pitch of
each major joints axis of rotation is described in subsequent
sections.
Pronation and supination are often called "triplanar mo-
tions. Unfortunately, this description is confusing. The temi
triplane implies that th movement cuts through all three
Cardinal planes, not that th joint exhibiting this motion
possesses three degrees of freedom. Pronation and supination
occur in only one piane, about one (oblique) axis of rota-
tion. Table 1 4 - 2 summarizes th terminology used to de-
scribe th movements of th ankle and foot, including th
terminology that describes abnormal posture or deformity.
Axes of Rotation
Movements at th ankle and foot are assumed to occur
about axes of rotation that remain nearly stationary through-
out th range of motion. Although this assumption does not
hold for all joints, it does allow a rather complicated System
to be explained in a relatively simple fashion. More compli
cated, and likely more accurate, axes of rotation and kine-
matic models of th ankle and foot are described elsewhere.
(See references 1 , 1 0 , 45, and 48.)
Structure and Function of Joints Associated
with th Ankle
From an anatomie perspective, th ankle includes one articu-
lation: th talocrural joint. Movement at th talocrural joint
results in slight movement at th proximal and distai tibiofi-
bular joints. Because of this functional association, all three
joints are included under th topic of ankle.
TIBIO FIB U L AR J O I N T S
The fibula is bound to th lateral side of th tibia by two
aniculations: th proximal tibiofibular joint and th distai
tibiofibular joint (see Fig. 1 3 - 2 ). The interosseous mem
brane a sheet of connective tissue that runs between th
Chapter 14 Ankle and Foot 483
Example of Fixed Deformity or Abnormal Posture
Pes equinus
Pes calcaneus
Varus
Valgus
Abductus
Adductus
Inconsistent terminology usuali'/ implies one or more
of th components of supination
Inconsistent terminology usually implies one or more
of th components of pronation
tibia and fibula also helps to bind th bones together. The
interosseous membrane provides an attachment for many
muscles that affect th foot and ankle.
Proximal Tibiofibular Joint
The proximal tibiofibular joint is a synovial joint located just
lateral to and below th knee. The joint is formed by th
head of th fibula and th posterior-lateral aspect of th
lateral condyle of th tibia (see Fig. 1 3 - 5 ). The joint sur-
faces are generally fiat or slightly ovai, covered by articular
cartilage.
The proximal tibiofibular joint is enclosed by a capsule
that is strengthened by anterior and posterior ligaments (see
Figs. 1 3 - 7 and 1310). The tendon of th popliteus muscle
provides additional stabilization as it crosses just posterior to
th joint. Firm stabilization is needed ai th proximal tibiofi
bular joint so that forces within th biceps femoris and
lateral collateral ligament of th knee can be transferred
effectively from th fibula to th tibia.
Connective Tissues that Stabilize th Proximal
Tibiofibular Joint
Capsular ligaments
Popliteus tendon
Distai Tibiofibular Joint
Articular Structure
The distai tibiofibular joint is formed by th articulation of
th convex mediai surface of th distai fibula, with th con
cave fibular notch of th tibia (Fig. 1 4 -1 0 ). Anatomists
typically classify this joint as a s y n a r th r o s is because it allows
very slight movement and is filled with dense irregular con
nective tissue. The synovial membrane lining this joint is
often continuous with th synovial membrane lining th talo
crural joint.
Ligaments
The interosseous ligament provides th strongest bond be
tween th distai ends of th tibia and fibula.55 This ligament
 484 Section IV Lower Extremty

TALOCRURAL JOINT
Articular Structure
The talocrural joint is formed by th articulation of th
trochlear surface and th sides of th talus, with th rectan-
gular cavity formed by th distai end of th tibia and both
malleoli (see Fig. 1 4 - 3 ). The talocrural joint is often re-
ferred to as th "mortise, owing its resemblance to th
wood joint used by carpenters (Fig. 1 4 - 1 2 ). The concave
shape of th proximal side of th ankle mortise is main-
tained by connective tissues that bind th tibia with th
fibula. Interestingly, th total contact area within th talo
crural joint is about 350 mm2, which is relatively small
compared with 1,120 mm2 and 1,100 mm2 for th knee and
hip, respectively.4

FIGURE 14-10. An anterior-Iateral view of th right distai tibiofibu-

lar joint with th fbula reflected to show th articular surfaces.
is a distai extension of th interosseous membrane. The
anterior and posterior (distai) tibiofibular ligaments also rein-
force th distai tibiofibular joint (Figs. 1 4 - 1 0 and 1 4 -1 1 ).
A stable union between th distai tibia and distai fibula is
essential lo th stability and function of th talocrural joint.
Ligaments of th Distai Tibiofibular Joint
Interosseous ligament
Anterior tibiofibular ligament
Posterior tibiofibular ligament
Postcrior view
Ligaments
A thin capsule surrounds th talocrural joint. Extemally, th
capsule is reinforced by collateral ligaments that limit exces-
sive inversion and eversion tilting of th talus within th
rectangular concavity.
The mediai collateral ligament of th talocrural joint is
also referred to as th deltoid ligament. lt is strong and ex-
pansive (Fig. 1 4 - 1 3 ). The apex of th triangular ligament is
anchored to th mediai malleolus, with its base fanning into
three sets of superficial fibers. The distai attachments of
these fibers are listed in th box. The deeper tibiotalar fibers
blend with and strengthen th mediai capsule of th talo
crural joint.
Distai Attachments of th Three Components of th
Deltoid Ligament
Tibionavicular fibers attach to th navicular tuberosity.
Tibiocalcaneal fibers attach to th sustentaculum talus.
Tibiotalar fibers attach to th mediai tubercle and adjacent
side of th talus.

Interosseous
ligament
The primary function of th deltoid ligament is to limit
Groove fortendons
Groove for tendons eversion across th talocrural, subtalar, and talonavicular
of tibialis posterior and
of peroneuslongus
flexor digitorum longus
and brevis

Posterior tibiofibular
ligament The shape of th
Inferior transverse talocrural joint
ligament
Deltoid Tibiotalar fibers
ligament- Tibiocalcaneal
fibers
Posterior talofibular
Groove for tendon
ligament
A carpenters
of flexor hallucis longus mortise joint
Calcaneofibular
Mediai talocalcaneal ligament
ligament
Posterior talocalcaneal ligament

Achilles tendon
(cut)

FIGURE 14-11. Posterior view of th right ankle region shows th

major ligaments of th distai tibiofibular, talocrural, and subtalar
joints. The dashed line indicates th attachments of th capsule of FIGURE 14-12. The similanty in shape of th talocrural joint (A)
th talocrural (ankle) joint. and a carpenters mortise joint (B) is demonstrated.

M ediai view
posterior calcaneonavicular ligament
tendon (cut) (spring) ligament
FIGURE 14-13. Mediai view of th tight ankle region highlights th
mediai collateral ligament.
joints. Sprains to th deltoid ligament are relatively uncom-
mon due, in part, to th ligaments strength and to th fact
that th lateral malleolus serves as a bony block against
excessive eversion.
The lateral collateral ligamenls of th ankle include th
anterior and posterior talofbular and th calcaneofibular lig
amenls. Because of th relative inability of th mediai mal
leolus to adequately block th mediai side of th mortise, th
majority of ankle sprains involve excessive inversion and
subsequent injury to th lateral collateral ligaments.12
The anterior talofbular ligament attaches to th anterior
aspect of th lateral malleolus and courses anteriorly and
medially to th neck of ihe talus (Fig. 1 4 - 1 4 ). This ligament
Posterior tibiofibular
Posterior talofbular
FIGURE 14-14. Lateral view of th right ankle
region highlights th lateral collateral liga
ment.
Achilles tendon
(cu t)-
Calcaneofibular
ligam ent'
Lateral talocalcaneal
ligam ent'
Interior peroneal
retinaculum '
Chapter 14 Ankle and Foot 485
is th most frequently injured of th lateral ligaments. Injury
is often due to excessive inversion or adduction of th ankle,
especially when combined with piantar flexion, for example,
when inadvertently stepping into a Itole.7'46 The calcaneofibu
lar ligament courses mferiorly and posteriorly from th apex
of th lateral malleolus to th lateral surface of th calcaneus
(see Fig. 1 4 - 1 4 ). This ligament resists inversion across th
talocrural and subtalar joints. The calcaneofibular and ante-
rior talofbular ligaments together limit inversion throughout
most of th range of dorsiflexion and piantar flexion.7
Thrcc Major Components of th Lateral Collateral
Ligaments of th Ankle
Anterior talofbular ligament
Calcaneofibular ligament
Posterior talofbular ligament
The posterior talofbular ligament originates on th poste-
rior-medial side of th lateral malleolus and attaches to th
lateral tubercle of th talus (Figs. 1 4 - 1 1 and 1 4 - 1 4 ). Its
fbers run horizontally across th posterior side of th talo
crural joint, in an oblique anterior-lateral to posterior-medial
direction (Fig. 1 4 - 1 5 ). The primary function of th poste
rior talofbular ligament is to stabilize th talus within th
mortise. In particular, it limits excessive abduction of th
talus, especially when th ankle is fully dorsiflexed.7
The inferior transverse ligament is a small thick strand of
fibers considered part of th posterior talofbular ligament
(see Fig. 1 4 -1 1 ). The fibers continue medially to th poste
rior aspect of th mediai malleolus, forming part of th
posterior wall of th talocrural joint.
In summary, th mediai and lateral collateral ligaments of
th ankle limit excessive inversion and eversion at every
joint that th fbers cross. Because most ligaments course
from anterior-to-posterior, they also limit anterior-to-poste-
rior translation of th talus within th mortise. As described
in th section on arthrokinematics, th movements of piantar
Lateral view
Anterior tibiofibular ligament
ligament
Anterior talofbular ligament
Cervical ligament
ligament
Bifurcated ligament
Dorsal tarsometatarsal
ligaments
Peroneus Peroneus Dorsal
longus tendon brevis tendon calcaneocuboid
(cut) (cut) ligament
 486 Section IV Lower Extremily

Superior view lateral axis. As depicted in Figure 1 4 -1 6 A and B, th axis of

rotation (red) is inclined slightly superior and anterior, as il
crosses from th lateral to th mediai side of th talus
through both malleoli.27 The axis deviates from a pure me-
Extensor dial-lateral axis about 10 degrees in th frontal piane (see
hallucis longus Fig. 1 4 -1 6 A ), and 6 degrees in th horizontal piane (see
Peroneus tertius
Tibialis anterior Fig. 1 4 -1 6 B ). Because of th pitch of th axis of rotation,
Extensor digitorum longus
dorsiflexion is associated with slight abduction and eversion,
Deltoid ligament Extensor digitorum brevis
and piantar flexion with slight adduction and inversion.
muscle (cut)
Interior extensor (These small secondary components are depicted in Fig. 1 4 -
retinaculum Interior extensor retinaculum
16A and B.) The talocrural joint by definition, therefore,
Talus
Mediai malleolus produces a movement of pronation and suptnation. As a
of th tibia Lateral malleolus of th fibula result of relaiively small differences in th orientation of th
Peroneus brevis
Tibialis posterior axis from th pure medial-lateral, th main components of
Peroneus longus
pronation and supination at th talocrural joint are, by far,
Flexor digitorum talofibular ligament
dorsiflexion and piantar flexion (Fig. 1 4 -1 6 D and E).48
Flexor hallucis longus Calcaneal (Achilles) tendon
An average of 26 degrees of dorsiflexion and 48 degrees
of piantar flexion have been measured at th talocrural jo in t.14
Associated movement at th subtalar joint may contribute to
FIGURE 14-15. A superior view displays a cross-seciion through th about 20% ol this total motion. The 0-degree (neutrali posi
righi talocrural joint. The talus remains, but th lateral and mediai
ti on at th talocrural joint is defned by th foot held at 90
malleolus and all th tendons are cut.
degrees to th leg. Dorsiflexion and piantar flexion at th
talocrural joint need to be visualized when th foot is un-
loaded (i.e., off th ground and free to rotate) and when th
flexion and dorsiflexion are kinematically linked to anterior foot is loaded during th stance phase of gait.
and posterior translation oF th talus, respectively. Table 1 4 -
3 summarizes movements that significantly stretch th major Arthrokinematics
ligaments of th ankle. This Information helps to explain th The following discussion assumes that th foot is unloaded
rationale behtnd several manual stress tests performed to and free to rotate, in a manner listed in Table 1 4 - 3 . During
evaluate th integrity of ligaments following ankle injury. dorsiflexion, th superior surface of th talus rolls forward

Osteokinematics relative to th leg as it simultaneously slides posteriorly (Fig.

The talocrural jom t possesses one degree of freedom. Motion
at this joint occurs about an axis of rotation that passes
through th body of th talus and through th tips of both
malleoli. Because th lateral malleolus is inferior and poste
rior to th mediai malleolus, which can be verified by palpa-
tion, th axis of rotation departs slightly from a pure medial-
1 4 -1 7 A ). The simultaneous posterior slide allows th talus
to rotate forward without much anterior translation. Figure
1 4 -1 7 A shows th calcaneofibular ligament becoming taut
in response io th posterior sliding tendency of th talocalca-
neal segment. As a generai rule, any collateral ligament that
becomes increasingly taut upon posterior translation of th
talus also becomes increasingly taut at full dorsiflexion. Max-

j| TABLE 1 4 - 3 . Movements that Stretch and Elongate th Major Ligaments o f th Ankle*

Ligaments Primary Joints Movements that Stretch or Elongate Ligaments

Deltoid ligament (tibiotalar fibers) Talocrural joint
Deltoid ligament (tibionavicular fibers) Talocrural joint
Talonavicular joint
Deltoid ligament (tibiocalcaneal fibers) Talocrural joint and subtalar
joint
Anterior talofibular ligament Talocrural joint
Calcaneofibular ligament Talocrural joint
Subtalar joint
Posterior talofibular ligament Talocrural joint
Eversion, dorsiflexion with associated posterior slide of talus
within th mortise
Eversion, piantar flexion with associated antenor slide of talus
within th mortise
Eversion, abduction
Eversion
Piantar flexion with associated anterior slide of talus within
th mortise, inversion, adduction
Dorsiflexion with associated posterior slide of talus within th
mortise, inversion
Inversion
Dorsiflexion with associated posterior slide of talus within th
mortise, abduction, inversion

* The informaiion is based on movements of th unloaded fooi relative lo a stationary leg.

 Chapter 14 Ankle and Foot 487

Talocrural joint

FIGURE 14-16. The axis of rotation and osteokinematics at ihe lalocairal joint. The slightly oblique axis of rotation at th talocrural
joint (red) is shown from behind (A) and above (B). C to E show th primary active movement components of dorsiflexion and
piantar flexion. Note that dorsiflexion (D) is combined with slight abduction and eversion, which are th other components of
pronation; piantar flexion (E) is combined with slight adduction and inversion, which are th other components of supination.

imal dorsiflexion elongates th posteror capsule and all tis-
sue capable of transmitting piantar flexion torque, such as
th Achilles tendon.
During piantar flexion, th superior surface of th talus
rolls backward as th bone simultaneously slides anteriorly,
stretching th anterior talofibular ligament (Fig. 1 4 -1 7 B ). As
a generai rule, any collateral ligament that becomes increas-
ingly taut upon anterior translation of th talus also becomes
increasingly taut at full piantar flexion. Although not shown
in Figure 1 4 -1 7 B , th tibionavicular fbers of th deltoid liga-

Talocrural joint
DORSIFLEXION PLANTAR FLEXION

FIGURE 14-17. A lateral view depicts

th arthroktnematics at th talocrural
joint during passive dorsiflexion (A)
and piantar flexion (B). Stretched
(taut) structures are shown as thin
elongated arrows; slackened struc
tures are shown as wavy arrows.
488 Sect\on V L o w e r E x trem ity

FIGURE 14-18. Factors that increase

th mechanieal stability of th fully
dorsiflexed talocrural joint are
shown. A, The increased passive ten-
sion in severa] connective tissues and
muscles is demonstraied. B, The
Path of trochlear surface of th talus is wider
Superior view
th tibia
anteriorly than posteriorly (red line).
Achilles tendon The path of dorsiflexion places th
concave tibiofibular segment of th
Calcaneofibular FULL DORSIFLEXION
ligament
mortise in contact with th wider
anterior dimension of th talus,
Peroneus longus -
thereby causing a wedging effect
within th joint.

ment become taut at full piantar llexion (see Table 1 4 - 3 ).
Piantar llexion also stretches th dorsillexor muscles and th
anterior capsule.
Progressive Stabilization of th Talocrural Joint
Throughout th Stance Phase of Gait
At initial heel contact, th ankle rapidly piantar flexes io
lower th foot to th ground (see Fig. 1 5 -1 5 D ). As soon as
th foot fiat phase of gait is reached, th leg starts to rotate
forward (dorsiflex) over th foot. Dorsiflexion continues until
just after heel off phase. At this point in th gait cycle, th
ankle becomes increasing stable owing to th greater tension
in many stretched collateral ligaments and piantar flexor
muscles (Fig. 1 4 -1 8 A ). The dorsiflexed ankle becomes fur-
ther stabilized as th wider anterior part of th talus wedges
into th tibiofibular component of th mortise (Fig. 1 4 -
18B). The wedging effect causes th distai tibia and fibula to
spread apart slightly. This action is resisted by tension in th
distai tibiofibular ligaments and interosseous membrane. At
th initiation of th push-off phase of walking, th talocrural

FIGURE 14-19. The compression force on th talocrural joint is

plotted as a normal subject progresses through th stance phase
of walking (0 to 60% of th gait cycle). The area shaded in red
represents th push-off phase of walking. (Data from Stauffer
RN, Chao EYS, Brewster RC: Force and motion analysis of th
normal, diseased, and prosthetic ankle joint. Clin Orthop Rei Res
127:189-196, 1977.)

0 10 20 30 40 50 60 70 80 90 100
o CO 3=
o 5= Swing phase
-JS O
e CD
o o <13 O
o o
LL_ X 1
o5
a)
X

Percent of G ait C y c le

joint is well stabilized and prepared to accept compression
forces that may reach over 4 times body weight (Fig. 14
I
I 19).49
The slight spreading of th concavity of th mortise at
maximal dorsiflexion causes slight movement of th fibula.
| The line-of-force of th stretched anterior and posterior (dis-
I tal) tibiofbular ligaments and interosseous membrane pro-
I duces a slight superior translation of th fibula that is trans-
ferred superiorly to th proximal tibiofbular joint. For this
reason, th proximal tibiofbular joint is more functionally
related to th ankle (talocrural joint) than to th adjacent
knee.
jS
S P E C I A L F O C U S 1 4 - 1
i
Ankle Injury Resulting from th Extremes of
Dorsiflexion or Piantar Flexion
The proximal and distai tibiofbular joints and interos
seous membrane are functionally and structurally re
lated to th talocrural joint. This relationship becomes
readily apparent following an injury related to extreme
dorsiflexion; for example, landing from a fall. An ex
treme and violent dorsiflexion of th leg over th talus
can cause th mortise to "explode" outward, rupturing
many of th collateral ligaments. The explosive widen-
ing of th mortise can also injure th distai tibiofbular
joint and interosseous membrane, th so-called high
ankle sprain.
Full piantar flexion th loose-packed position of th
talocrural joint slackens most collateral ligaments of
th ankle and all piantar flexor muscles. Full piantar
flexion also causes th distai tibia and fibula to "loosen
its grip" on th talus. Piantar flexion places th nar-
rower width of th talus between th malleoli, thereby
releasing th tension within th mortise. Bearing all
body weight over a fully piantar flexed ankle, therefore,
places th talocrural joint at a relatively unstable posi
tion. Wearing high heels or landing from a jump in a
piantar flexed, and usually inverted, position increases
th likelihood of injuring th mortise.
Structure and Function of th Joints
Associated with th Foot
SUBTALAR JOINT
The subtalar joint is th set of articulations formed by th
posterior, middle, and anterior facets of th calcaneus and
th talus (see Fig. 1 4 - 8 ). (Anatomy texts often limit th
description of th subtalar joint to th prominent posterior
facets only, referring to it as th talocalcaneal joint.55)
To appreciate th extern of subtalar joint motion, one can
hrmly grasp th unloaded calcaneus and twist it in a side-to-
side and rotary fashion. During this motion, th talus re-
mains nearly fixed within th talocrural joint. Pronation and
supination during non-weight-bearing activities occur as th
calcaneus moves relative to th fixed talus. Mosi activities,
Chapter 14 Ankle and Fool 489
however, occur as th calcaneus is relatively fixed under th
load of body weight. This situation requires more complex
kinematics involving th leg and talus rotating over a more
stable calcaneus. Mobility at th subtalar joint allows th foot
io assume positions that are independent of th orientation
of th superimposed ankle and leg. This function is essential
to activities such as walking across a steep hill, standing
with feet held wide apart, and keeping ones balance on a
rocking boat.
Articular Structure
The prominent posterior articulation of th subtalar joint oc-
cupies about 70% of th total articular surface area (see Fig.
1 4 - 8 ). The concave posterior facet of th talus rests upon
th convex posterior facet of th calcaneus. The articulation
is normally held tightly opposed by its interlocking shape,
body weight, interosseous ligaments, and activated muscle.
The anterior and middle articulations consist of small, nearly
fiat joint surfaces.
Ligaments
The posterior articulation within th subtalar joint is rein-
forced by a set of three slender ligaments, named by location
as th mediai, posterior, and lateral talocalcaneal ligaments (see
Figs. 1 4 - 1 1 , 1 4 - 1 3 , and 1 4 - 1 4 ). These ligaments provide
only secondar)' stability to th subtalar joint. Other larger
ligaments provide th primary source of stability. The calca-
neofibular ligament and th deltoid ligament are both dis-
cussed previously in reference to th talocrural joint. The
most substantial ligaments to cross only th subtalar joint
are th interosseous (talocalcaneal) and cervical ligaments.
Broad and fiat, these ligaments cross obliquely within th
sinus tarsi and, therefore, are difficult to view unless th
joint is opened, as in Figure 1 4 - 8 . The interosseous (talocal
caneal) ligament has two distinct, flattened, anterior and pos-
terior bands. These bands arise from th calcaneal sulcus
and atiach superiorly and medially on th talar sulcus and
adjacent regions. The larger cervical ligament has an oblique
fiber arrangement similar to th preceding ligament, but is
located more laterally within th sinus tarsi. Distally, th
cervical ligament courses superiorly and medially to attach
primarily to th inferior-lateral surface of th neck of th
talus (hence, th name cervical) (see Fig. 1 4 - 1 4 ). As a
group, th interosseous (talocalcaneal) and cervical ligaments
provide th strongest connettive tissue bond between th
talus and calcaneus.55
The ligaments of th subtalar joint control th extremes of
eversion and inversion (see th boxes).
Ligaments that Limit th Extremes of E version at th
Subtalar Joint
Mediai fbers of th interosseous (talocalcaneal) ligament
Tibiocalcaneal fbers within th deltoid ligament
Ligaments that Limit th Extremes of In v ersion at th
Subtalar Joint
Cervical ligament
CalcaneofiSular ligaments
 490 Section IV Lower Extremity

Kinematics
Osteokinematics and Arthrokinematics
The arthrokinematics at th subtalar joint involve a sliding
between th three sets of facets, yielding a curvilinear are of
movement between th calcaneus and th talus. The axis of
rotation for this rnotion is described by several investigators.
(See references 17, 19, 28, 44, and 56.) Although consider
a l e variation exists from one subject to another, th axis of
rotation is typically described as a line that pierces th lat-
eral-posterior heel and courses through th subtalar joint in
anterior, mediai, and superior directions (Fig. 1 4 - 2 0 A to C,
red). According to Manter,2S th axis of rotation is typically
positioned 42 degrees from th horizontal piane (see Fig.
1 4 -2 0 A ) and 16 degrees from th sagittal piane (see Fig
1 4 -2 0 B ).
The calcaneus pronates and supinates about th talus (or
vice versa when th foot is planted) in a path perpendicular
to th axis of rotation (see th red circular arrows in Fig.
1 4 - 2 0 A to C). Given th generai pitch to th axis, only two
ol th three main components of pronation and supination
are readily evident at th subtalar joint: inversion and ever-
sion, and abduction and adduction (see Fig. 1 4 -2 0 A and B).
Pronation, therefore, has main components of eversion and
abduction (Fig. 1 4 -2 0 D ); supination has main components of
inversion and adduction (Fig. 1 4 -2 0 E ). The calcaneus can
dorsiflex and piantar flex slightly relative to th talus; how-
ever, this rnotion is small.
For simplicity, th osteokinematics of th subtalar joint
are demonstrated by rotating th calcaneus against a fixed
and immobile talus. During walking, however, when th
calcaneus is relatively immobile due to th load of body
weight, pronation and supination at th subtalar joint occur
primarily by rotation of th talus and leg.
Range o f Motion
Grimston and colleagues14 reported active range of motion
across th ankle complex (combined talocrural joint and
subtalar joint) in 120 subjects across multiple age groups.
The range of motion for inversion and eversion and for
abduction and adduction are listed in Table 1 4 - 4 . Averaged
across all age groups, total inversion exceeds eversion by
nearly doubl: inversion, 22.6 degrees; eversion, 12.5 de
grees. Although these data include slight motion from th
talocrural joint, th ratio of inversion-to-eversion movement
is consistent with data reported for th subtalar joint alone.21
Eversion range of motion is naturally limited by th distai,
projecting, lateral malleolus and th thick deltoid ligament.
As shown in Fable 1 4 - 4 , th maximal range of abduction
and adduction is nearly equivalent.

Subtalar joint
ABDUCTION/ADDUCTION
(Vertical axis)

DORSIFL EXION/
PLANTAR FLEXION
(M L axis)

- EVERSION/
INVERSION EVERSION/
(AP axis) INVERSION
(AP axis)

A Mediai view
Superior view

axim f T ati0n ? d osteokine dcs 31 th subtalar joint are shown. The axis of rotation (red) is shown fror
th side (A) and above (B); th axis of rotation is shown again in C. D, The movement of pronation, with th main components c
shown"1 and abdUClIOn 1$ demonstrated- E, The movement of supination, with main components of inversion and adduction i
 Chapter 14 Ankie and Foot 491

Close-Packed and Loose-Packed Position of th Subtalar
Joint
In addition to controlling th position of th rearfoot, th
subtalar joint also indirectly Controls th stability of th
more distai joints, especially th transverse tarsal joint.
Although th relevance of this concept is discussed later
in this chapter, full supination at th subtalar joint re-
stricts th overall flexibility of th midfoot. A loosely artic-
ulated skeletal model helps to demonstrate this principle.
With one hand stabilizing th forefoot, maximally "swing"
th calcaneus into full inversion and note that th lateral
aspect of th midfoot "drops" relative to th mediai as-
pect. As a result, th talonavicular and calcaneocuboid
joints become twisted longitudinally, thereby increasing
th rigidity of th midfoot. For this reason, maximal supi
nation at th subtalar joint is considered th close-packed
position. The description does not imply maximal congruity
at th joint, rather a position that increases th stability
through th midfoot.
Full pronation of th subtalar joint, in contrast, in
creases th overall flexibility of th midfoot. Again, re-
turning to a loosely articulated skeleton model, maximal
eversion of th calcaneus untwists th mediai and
lateral aspects of th midfoot, placing them in a more or
less parallel position. As a result, th talonavicular and
calcaneocuboid joints untwist longitudinally, thereby in
creasing th flexibility of th midfoot. The loose-packed
position of th subtalar joint is often described as maximal
pronation, implying a reduced stability over th midfoot.
Make th effort to "feel," on a partner, th increased
flexibility of th midfoot as th calcaneus is gradually
l a k e n riu n i i ia x im a l i i i v e i s i u n lu m a x im a l e v e i s l u n . A s
described in subsequent sections, th ability of th mid
foot to change from greater to lesser flexibility has impor-
tant mechanical implications during th stance phase of
gait.

TRANSVERSE TARSAL JOINT Articular and Ligamentous Structure

As described earlier, th talocrural (ankie) joint permits mo-
tion primarily in th sagittal piane. The subtalar joint, how-
ever, permits a more oblique path of motion consisting of
two primary components: inversion and eversion, and ab-
duction and adduction. This section describes how th trans
verse tarsal joint allows even a more oblique path of motion,
passing almost equally through all three Cardinal planes.
While weight hearing, th pronation and supination of th
midfoot region allows th foot to adapt to a variety of sur-
face contours (Fig. 1 4 -2 1 ).
The transverse tarsal joint has a strong functional relation-
ship to th subtalar joint. As subsequently described, these
two major joints function cooperatively to control most of
th pronation and supination posturing of th entire foot.
The transverse tarsal joint, also known as th mid-tarsal or
Chopart's joint, consists of two articulations: th talonavicular
joint and th calcaneocuboid joint. Although functionally re-
lated, each joint is anatomically distinct. As a composite
joint, th transverse tarsal joint is stabilized by th mediai
longitudinal arch, specialized ligaments, joint capsule, and, if
needed, muscle.55 The articular and ligamentous structure of
th talonavicular and calcaneocuboid joints are described
separately.
Talonavicular Joint
The talonavicular joint is th articulation between th convex
head of th talus and th continuous concavity formed by
th proximal side of th navicular bone and th dorsal sur-

TABLE 1 4 - 4 . The Mean and Standard Error* for Active Range of Motion in Degrees for Inversion and Eversion
and Abduction and Adduction at th Ankie Jo in t Complext

Age (yr) Inversion Eversion Abduction Adduction

9-13 26.7 (.7) 10.5 (.4) 41.6 (1.0) 42.2 (1.7)
14-16 28.8 (1.4) 12.6 (.8) 46.8 (1.5) 42.4 (2.6)
17-20 27.1 (1.3) 11.9 (.7) 45.0 (1.3) 31.0 (13.6)
21-39 20.5 (1.3) 15.2 (.9) 38.2 (1.9) 34.5 (9.6)
40-59 20.7 (1.5) 13.8 (.9) 33.2 (1.4) 29.9 (1.7)
60-69 17.1 (1.1) 12.3 (.6) 31.7 (1.0) 27.9 (1.6)
70-79 17.1 (1.0) 11.4 (.6) 31.3 (1.5) 27.1 (1.3)
Average 22.6 12.5 38.3 33.6

* in parentheses.
t The subtalar and talocrural joint make up th ankie joint complex. The data were collected from healthy persons across different age groups, and th
Liala were averaged across gender.14
 492 Sectkm IV Lower Extremiy
S P E C I A L F O C U S 1 4 - 3
Standard Clinical Measurements of Subtalar Joint Range
of Motion
The range of motion at th subtalar joint is typically mea-
sured clinically by th use of a standard goniometer. To
obtain a reliable and valid measurement through this
means is difficult and, perhaps, impossible.36 Causes of
measurement error are due to th inability of a standard,
rigid goniometer to follow th are of pronation and supi-
nation, compounded by th movement in adjacent soft
tissues and surrounding joints. As a method of improving
th validly of this measurement, clinicians often report
subtalar joint motion as a more simple motion of inversion
and eversion of th rearfoot (calcaneus).
The rather strict terminology described for subtalar mo
tion is not always adhered to in clinical and research
settings. "Short-cuts" in terminology have evolved that,
unfortunately, limit th ability to effectively communicate
face of th piantar calcaneonavicular (spring) ligameni
(Figs. 1 4 - 8 and 1 4 -2 2 ). The spring ligament is thick and
wide, spanning th gap between th sustentaculum talus of
th calcaneus and th piantar surface of th navicular (Fig.
1 4 - 2 3 ). Functioning as th floor of th talonavicular joint,
th spring ligament supports th head of th talus, ihereby
helping to explain th terminology spring. Support is im-
portant during standing because body weight depresses th
head of th talus toward th floor. The surface of th spring
ligament that directly contacts th head of th talus is lined
with smooth fibrocartilage.55
The talonavicular joint is enclosed by a thin, irregularly
shaped capsule. Posteriori)', th capsule is thickened by th
interosseous ligament of th subtalar joint (see Fig. 1 4 - 8 ).
The capsule is strengthened dorsally by th dorsal talonavicu
lar ligament and laterally by th calcaneonavicular fibers of
th bijurcated ligament (see Figs. 1 4 - 1 3 and 1 4 - 1 4 ). Medi-
FIGURE 14-21. Th e transverse tarsal joints allow for pronation and
supination durin g standing on uneven surfaces.
th precise details of foot and ankle kinesiology. For rea-
sons such as those just described, pronation and supina-
tion at th subtalar joint are often referred to simply as
"eversion and inversion" of th calcaneus, respectively.
Eversion, for example, is only a component of, rather than
a synonym for, pronation. Comparisons of range of motion
data between studies are often made difficult, unless th
motions are explicitly defined.
Clinically, th expression "subtalar joint neutral" is of
ten used to establish a "baseline" or reference for evalu-
ating a foot for an orthotic device.9'30 The neutral, or 0
degree, position of th subtalar joint is attained by placing
th subject's calcaneus in a position that allows both
lateral and mediai sides of th talus to be equally ex-
posed for palpation within th mortise. In this position, th
joint is typically one-third th distance from full eversion
and two-thirds th distance from full inversion.
ally, th capsule of th talonavicular joint blends with th
anterior edge of th deltoid ligament.
The ball-and-socket-like articulation of th talonavicular
joint provides significant rotation to th mediai side of th
midfoot. The extern ol this mobility becomes readily appar-
ent by twisting th midfoot relative to th rearfoot.
Calcaneocuboid Joint
The calcaneocuboid joint is th lateral component of th
transverse tarsal joint, formed by th junction of th anterior
(distai) surface of th calcaneus and th proximal surface of
th cuboid (see Fig. 1 4 - 2 2 ). Each articular surface has a
slight concave and convex curvature that, when articulated,
forms an interlocking wedge that resists sliding. The joint is
therefore relatively inflexible, providing an element of rigid-
ity to th lateral column of th foot. The limited mobility at
th calcaneocuboid joint is in contrast to th ampie move
ment permitted at th talonavicular joint.
The dorsal surface of th capsule of th calcaneocuboid
joint is thickened by th dorsal calcaneocuboid ligament (see
Fig. 1 4 -1 4 ). The joint is further stabilized by three addi-
tional ligaments. The bijurcated ligament is a Y-shaped band
ol tissue with its stem attached to th calcaneus, just dorsal
and lateral to th margin of calcaneocuboid joint. The stem
of th ligament flares into lateral and mediai fiber bundles.
The mediai (calcaneonavicular) fibers reinforce th dorsal-
lateral side of th talonavicular joint. The lateral (calcaneocu
boid) fibers cross dorsal to th calcaneocuboid joint, forming
th primary bond between th two bones. The long and
short piantar ligaments reinforce th piantar side of th cal
caneocuboid joint (see Fig. 1 4 -2 3 ). The long piantar liga
ment, th longest ligament in th foot, arises from th piantar
surface of th calcaneus, just anterior to th calcaneal tuber-
osity. The ligament inserts on th piantar surface of th
bases of th lateral three or four metatarsal bones. The short
piantar ligament, also called th piantar calcaneocuboid liga
ment, arises just anterior and deep to th long piantar liga-
 Chapter 14 Ankle and Foot 493

Achilles
Interphalangeal jo in ts -
tendon

Metatarsophalangeal joints
^lyTL'M
joint
Intermetatarsal joints Calcaneocuboid joint Talonavicular joint

.Tarsometatarsal joints
Cuboideonavicular joint

r Intercuneiform and Cuneonavicular joints

Dista! cuneocuboid joint
intertarsal complex
o joints-
o Cuneonavicular joints Intercuneiform and
Peroneus cuneocuboid joint
_ Cuboideonavicular jointj
brevis complex
Transverse r- Talonavicular joint
tarsal i in t" | j ; a|Cane0Cup0j(j j 0jnt Tarsometatarsal joints

tc -{S iibtalar joint

Igalcaneusj ^ fa t a r s a ls

Achilles
A tendon
B

FIGURE 14-22. A, Th e bones and disarticulated joinis o f th right foot are show n from tw o perspectives: superior-postenor (A) and
superior-anterior (B). A highlights th overall organization of th joints o f th foot.

ment and inserts on th piantar surface of th cuboid bone. longitudinal axis is nearly coincident with th straight ante-
By passing perpendicularly to th calcaneocuboid joint, th rior-posterior axis (Fig. 1 4 - 2 5 A to C), with th primary
piantar ligaments provide excellent structural stability to th component motions of eversion and inversion (Fig. 1 4 -2 5 D
lateral side of th foot. and E). The oblique axis, in contrast, has a strong vertical
and medial-lateral pitch (Fig. 1 4 - 2 5 F to H). Motion about
Kinematics
this axis, therefore, occurs freely as a combination of abduc-
The transverse tarsal joint rarely functions without an associ tion and dorsiflexion (Fig. 1 4 -2 5 1 ) and adduction and piantarJex-
ateci movement ai nearby joints, especially th subtalar joint.
To appreciate th component of pronation and supination
that occurs primarily at th transverse tarsal joint, hold th
Plantar view
calcaneus firmly while maximally pronating and supinating
th midfoot (Fig. 1 4 -2 4 A and C). During this motion, th
navicular spins within th talonavicular joint. The combina-
tion of rotations at both subtalar and transverse tarsal joint
accounts for most of th pronation and supination through-
out th foot (Fig. 1 4 -2 4 B and D). As evident in th Figures, First tarsometatarsal joint

mobility of th forefoot also contributes to th pronation and

Tibialis anterior (cut)
supination postures of th foot. Peroneus brevis
Tibialis posterior
Osteokinematics Peroneuslongus
Navicular tuberosity
The description of th function of th transverse tarsal joint Piantar Piantar calcaneonavicular
is complicated by three factors. First, two separate axes of calcaneocuboid ligament ligament (spring ligament)
rotation exist. Second, th amplitude and direction of move (short piantar ligament)
Flexor digitorum longus
ment at th transverse tarsal joint may be different during
Long piantar ligament (cut)
weight-bearing versus non-weight-bearing activities. Third,
Flexor hallucis longus
th stabilizing function of th transverse tarsal joint at th
(cut)
midfoot is influenced by th position of th subtalar joint.
Each of these factors is considered in th upcoming sections.
Axes oF Rotation. Manter28 described two axes of rota
tion for movement ai th transverse tarsal joint: longitudinal FIGURE 14-23. Ligaments and tendons deep w ithin th piantar as-
and oblique. Motion about th transverse tarsal joint occurs pect o f th right foot. Note th course o f th tendons of th
in a piane that is perpendicular to each of these axes. The peroneus longus and tibialis posterior.
494 Section IV Lower Extremity

Pronation of th foot (Dorsal-medial view)

Supination of th foot (Plantar-medial view)

yi Transverse tarsal joint

? = >
J j Tibialis posterior

x Subtalar joint

FIGURE 1 4 -2 4 . Pronation and supination o f th unloaded tight foot demonstrates th interplay o f th subtalar and transverse tarsal
joints. W ith th calcaneus held fixed, pronation and supination occur prim arily at th m idfoot {A and C). W hen th calcaneus is
free, pronation and supination occur as a sum matton across both th rearfoot and m idfoot (B and D). Rearfoot m ovem ent is
indicated by gray arrows; m idfoot m ovem ent is indicated by red arrows. T h e tibialis posterior is show n in D as it directs attive
supination o ver both th rearfoot and midfoot.

ion (Fig. 14-25/ ). Combining th movements produced transverse tarsal join t makes th midfoot ver)' adaptable in
about both axes produces th true Form of pronation and shape.
supination (i.e., movement that maximally expresses compo- Range of motion at th transverse tarsal joint is diffcult
nents of all three Cardinal planes). Movement at th to measure and isolate from adjacem joints. By visual and
 Chapter 14 Ankle and Foot 495

Transverse larsal joint: Longitudinal axis

ABDUCTION/ADDUCTION
DORSIFLEXION/PLANTAR FLEXION
(Vertical axis)
(ML axis)

EVERSION/ EVERSION/
INVERSION INVERSION
(AP axis) j (APaxis)
Mediai view Superior view

Transverse tarsal joint: Oblique axis

ABDUCTION/ADDUCTION DORSIFLEXION/PLANTAR FLEXION
(Vertical axis) (ML axis)

EVERSION/ EVERSION/
INVERSION INVERSION
(AP axis) (AP axis)

F Mediai view Superior view

FIGURE 14 25. T h e axes of rotation and osteokinemadcs al th transverse larsal joint. Th e longitudinal axis o f rotation is show n in
red from th side (A and C) and from above (B). M ovem ents that occur about this axis (D) are pronation (w ith th main
com ponent of eversion) and (E) supination (w ith th m ain com ponent o f in v e rs io n i T h e oblique axis o f rotation is show n in red
from th side (F and H ) and from above (C). M ovem ents that occur about this axis are (I) pronation (w ith main components o f
abduction and dorsiflexion) and ( J ) supination (w ith m ain components o f adducton and piantar flexion).
496 Section IV Lower Extremity
manual inspection, however, il is evident that th supinaiion
range of th midfoot region is approximately twice that of
th pronation range. The amount of pure inversion and
eversion of th midfoot occurs in a pattern similar to that
observed ai th subtalar joint: about 20 to 25 degrees of
inversion and 10 to 15 degrees of eversion.
Arthrokinematics
The arthrokinematics at th transverse tarsal joint are best
described in context with motion of both th rearfoot and
midfoot. Consider th movement of active supination of th
unloaded foot (see Fig. 1 4 -2 4 D ). The tibialis posterior mus-
cle, with its multiple attachments, is th prime supinator of
th foot. Because of th relatively rigid calcaneocuboid joint,
an inverting and adducting calcaneus draws th lateral col-
umn of th foot under th mediai column of th forefoot.
An important pivot point for this motion is th talonavicular
joint. The pul of th tibialis posterior contributes to th spin
of th navicular, and to th raising of th mediai arch (in-
step) of th foot. During this motion, th concave proximal
surface of th navicular and spring ligament spin around th
convex head of th talus.
Pronation of th unloaded foot occurs by similar but re
verse kinematics as that described. The pul of th peroneus
longus contributes to a lowering of th mediai side and a
raising of th lateral side of th foot.
M ediai Longitudinal Arch of th Foot
The characteristic concave in-step at th mediai side of th
foot is maintained primarily by th mediai longitudinal arch
(Fig. 1 4 -2 6 ). The keystone of this arch is located near th
talonavicular joint.
The mediai longitudinal arch is th primary load-bearing
and shock-absorbing structure in th foot. The bones that
contribute to th mediai arch are th calcaneus, talus, navic
ular, cuneiforms, and three mediai metatarsals. Without th
arched confguration, th large and rapidly acting forces pro-
duced during running, for example, may exceed th physio-
logic weight-bearing capacity of th bones. Additional struc-
tures that assist with reducing th forces acting on th foot
are piantar fat pads, superfcial piantar fascia, and sesamoid
bones located at th piantar base of th frst (great) toe.
In addition to th mediai longitudinal arch, a secondary
FIGURE 14-26. The mediai side o f a normal foot shows th mediai
longitudinal arch (w hite) and th transverse arch (black).
transverse arch exists (see Fig. 1 4 - 2 6 ). This arch is dis-
cussed in a later section covering th distai intertarsal joints.
Anatomie Considerations
The talonavicular joint and associated connective tissues
forni th keystone of th mediai longitudinal arch. The
height and generai shape of th mediai longitudinal arch are
maintained by th thick piantar fascia, spring ligament, sta-
bility of th mediai tarsometatarsal joints, short piantar liga-
ments, and intrinsic and extrinsic muscles of th foot.
Piantar Fascia. The piantar fascia of th foot provides
th primary support of th mediai longitudinal arch.16 The
fascia consists of an extensive series of thick, very strong
longitudinal and transverse bands of collagen-rich tissue.55
The piantar fascia covers th sole and sides of th foot and
is organized into superfcial and deep layers. The superfcial
fbers are attached primarily to th thick dermis, and they
function to reduce shear forces and provide shock absorp-
tion. The more extensive deep piantar fascia attaches posteri-
orly to th mediai process of th calcaneal tuberosity. From
this origin, lateral, mediai, and centrai sets of fbers course
anteriorly, blending with and covering th frst layer of th
intrinsic muscles of th foot. The mam, larger, centrai set of
fbers extends anteriorly toward th metatarsal heads
where they attach to th piantar plates (ligaments) that cover
th metatarsophalangeal joints and fibrous sheaths of th
adjacent flexor tendons of th digits. Active toe extension,
therefore, stretches th centrai band of deep fascia, adding
tension to th mediai longitudinal arch. The functional signif-
icance of this point is described later in this chapter.
Functional Considerations
The mediai longitudinal arch in th healthy foot is supported
by two primary forces: (1) active muscle force and (2) pas
sive force produced by th combined elasticity and tensile
strength of connective tissues and th shape of th bones.
When standing at ease, passive forces are generally suffcient
to support th arch. Active forces are required, however.
during more dynamic actions, such as standing on tiptoes,
walking, and running. The following discussion is limited to
passive forces that support th arch. The role of muscle
forces are described later in this chapter.
Passive Forces That Support th Mediai Longitudinal
Arch. When standing, body weight crosses th mortise and
is distributed across th mediai longitudinal arch and, ulti-
mately, to fai pads and th thick dermis located primarily at
th heel and ball (metatarsal head region) of th foot. Body
weight forces are distributed therefore, across a wide region
of th foot (see th box).6 The pressure under th forefoot is
usually greatest in th region of th second and third meta
tarsal heads. Substantially greater pressure occurs during
walking and even more so when running and jumping.
Dislribution of Comprcssion Forces (by percent) Across
th Foot whilc Standing
Rearfoot (heel), 60%
Forefoot, 28%
Midfoot, 8%
Body weight tends to depress th talus inferiorly and
flatten th mediai longitudinal arch. This action increases th
distance between th calcaneus and metatarsal heads. Ter.-
 Chapter 14 Ankle and Foot 497

sion in stretched connective tissues, especially th deep pian indicated for flexible pes planus. Treatment is usually in th
tar fascia, acts as a semielastic tie rod that yields slightly form of orthoses, specialized footwear, and exercise.
under load, allowing only a marginai drop in th arch (Fig.
Pes Cavus Abnormally Raised Mediai Longiludi-
14-27A , stretched spring). Acting like a truss, th tie rod
nal Arch. In its least complicated form, pes cavus describes
supports and absorbs body weight. Experiments on cadaveric
an abnormally high mediai longitudinal arch.41 The condi-
specimens indicate that th piantar fascia is th major struc-
ture that maintains th height of th mediai longitudinal arch.16
Sectioning of this fascia decreased arch stiffness by 25%.
While th arch is depressed, th rearfoot tends to pronate
slightly. This is most evident from a posterior view as th
calcaneus everts slightly relative to th tibia. As th foot is
unloaded, such as when shifting body weight to th other Normal arch
leg, th naturally elastic and flexible arch retums to its pre-
loaded raised height. The calcaneus inverts slightly back to
its neutral position, allowing th mechanism to repeat its
shock absorption function once again.
Standing at ease on healthy feet requires little or no
activity of th intrinsic or extrinsic muscles of th foot.2 The
height and shape of th mediai longitudinal arch is con-
trolled primarily by passive restraints from th connective
tissues depicted by th spring in Figure 14-27A . Active
muscle support is required when one stands only as a sec
ondar)' line of support, for example, when holding heavy
loads, or when th arch lacks inherent support because of
overstretched connective tissues.51 Basmajian and Stecko2
showed signifcant EMG responses from th tibialis posterior
and th intrinsic muscles, only after th healthy arch was
loaded in excess of 400 pounds (1780 N).
Abnormal Shape of th Mediai Longitudinal Arch
Pes Planus Dropped' Mediai Longitudinal Arch.
Pes planus or flatfooi" describes a chronically dropped or
abnormally low mediai longitudinal arch.24 The piantar fascia
may be overstretched with th subtalar joint excessively pro-
nated, causing a rearfoot valgus posture, where th calcaneus Dropped arch
is everted away from th midiine. The forefoot is usually
abducted, and th talus and navicular bones are depressed,
often causing a callus to develop on th adjacent skin. A
foot with moderate-to-severe pes planus typically has a com-
promised ability io transfer loads throughout th foot. As
depicted in Figure 1 4 -2 7 B , active forces from intrinsic and
extrinsic muscles, such as th tibialis posterior, may be
needed to compensate for th lack of tension produced in
overstretched connective tissues. Increased muscular activity
during standing may contribute to fatigue and various over-
use symptoms, including pain, shin splints, bone spurs, and
fascia and connective tissue inflammation.
Pes planus is often described as being either a rigid or
flexible deformity.41 The foot with rigid pes planus (see Fig.
1 4 -2 7 B ) demonstrates a dropped arch even in non-weight-
bearing. This deformity is often congenital, secondar)' to
bony or joint malformation, such as tarsal coalition (i.e.,
partial fusion of th calcaneus with th talus fixed in ever-
sion). Pes planus may also occur as a result of spastic paral- FIGURE 14-27. Models of th foot show a mechanism of accepting
ysis. Because of th fixed nature and potential for producing body weight while standing. A, With a normal mediai longitudinal
painful symptoms, rigid pes planus may require surgical cor- arch, body weight is accepted and dissipated through elongation of
rection during childhood. th piantar fascia, depicted as a red spring. The footprint illustrates
th concavity of th normal arch. B, With an abnormally dropped
Flexible pes planus is th more common form of dropped
mediai longitudinal arch, th overstretched and weakened piantar
arch. The mediai longitudinal arch appears normal when
fascia, depicted as an overstretched red spring, cannot adequately
unloaded, but drops excessively upon weight hearing. A flex accept or dissipate body weight. As a consequence, various extrinsic
ible pes planus is often associated with other structural and intrinsic muscles are active as a secondary source of support io
momalies and/or compensatory mechanisms that cause ex- th arch. The footprint illustrates th dropped arch and loss of a
essive pronation of th foot. Surgical intervention is rarely characteristie instep.
498 Section IV Lower Exiremity

FIGURE 14-28. A case o f a m ild pes cavus deform ity o f unknow n etiology is show n in A. B to E show signs o r other deform i ties thai
m ay be associated w ith pes cavus: (B) callus form ation under th metatarsal heads; (C) equinus (piantar flexion) deform ity o f th forefoot,
(D) pronated forefoot relative to th rearfoot durin g weight hearing; (E) shortening o f th mediai colum n of th foot. (From Richardson
EG: N eurogenic disorders. In Canale S T (ed): Cam pbells Operative Orthopaedics, voi 4, 9th ed. St. Louis, M osby-Year Book, 1998.)

tion is usually idiopathic and nonprogressive. As shown in
Figure 1 4 - 2 8 , a high arch tends to place th metatarsal
heads more perpendicular to th ground. Callus formation
under th metatarsal heads and metatarsalgia may result and
is often treated with specialized footwear and orthoses. An
abnormally high mediai longitudinal arch is not as common
as an abnormally low arch.
Severe cases ol pes cavus may develop secondary to neu-
romuscular disorders, such as Charcot-Marie-Tooth disease,
poliomyelitis, and cerebral palsy.41 In these cases, pes cavus
is often associated with other progressive problems, like
clawing of th toes, tight piantar fascia, and compensatory
overpronation of th forefoot. Treatment involves surgery
and orthotic management.

COMBINED ACTION OF THE SUBTALAR AND

A Possible Association Between a High Arch and
Stress Fracture
A study on 449 United States Navy Sea, Air, and Land
(SEAL) candidates showed a higher incidence of stress
fractures in feet with abnormally high arches.2 The
higher arch may involve a more supinated posture of
th rearfoot and an associated increased rigidity
throughout th foot. With a loss of pliability, th foot is
subjected to a greater rate of stress, possibly contribut-
ing to th higher reported frequency of fracture. Inter-
estingly, and probably for different reasons, th study
also showed a higher incidence of stress fractures in
th feet with abnormally low arches. Participants in th
study were subjected to an extraordinarily high level of
physical training, however.
TRANSVERSE TARSAL JOINTS
Joint Interactions During th Stance Phase of Gait
Generally, when th foot is unloaded (i.e., non-weight-bear-
ing), pronation twists th sole of th foot outward, whereas
supination twists th sole of th foot inward. During weight-
bearing, however, pronation and supination of th foot per-
mit th leg and talus to rotate in all three planes relative to a
somewhat fxed calcaneus. This important kinesiologic func-
tion is orchestrated primarily through interaction among th
subtalar joint, transverse tarsal joint, and mediai longitudinal
arch.
in th healthy foot, th mediai longitudinal arch raises
and lowers cyclically throughout th gait cycle. During most
of th stance phase, th arch lowers slightly in response to
th progressive loading of body weight (Fig. 1 4 -2 9 A ).5
Structures that resist th lowering of th arch help to absorb
th stress of body weight and thus protect th foot, particu-
larly its osseous structures. During th first 30 to 35% of th

FIGURE 14-29. A, The percent change in height of th mediai
longitudini arch throughout th stance phase (0 to 60%) of
th gait cycle. On th vertical axis, th 100% value is th
height of th arch when th foot is unloaded during th
swing phase. B, Frontal piane range of motion at th subtalar
joint (i.e., tnversion and eversion of th calcaneus), through
out th stance phase. The area shaded in red represents th
push-off phase of walking.
gait cycle, th subtalar joint pronates or everts, adding an
element of flexibility to th midfoot (Fig. 1 4 -2 9 B ).8 By late
stance, th arch rises as th supinated subtalar joint renders
th midfoot relatively rigid. The foot is now well prepared to
accept a large bending moment, created across th foot at
th push-off phase of gait. The ability of th foot to repeat-
edly transform from a flexible and shock absorbent structure
to a more rigid lever during each gait cycle is one of th
most important and clinically relevant actions of th foot. As
subsequently described, th subtalar joint is th principal
joint that directs th pronation and supination kinematics of
th foot.
Early Stance Phase: Pronation at th Subtalar Joint
Kinematic Mechanisms of Pronation. Immediately fol-
lowing th heel contact phase of gait, th dorsiflexed talo-
crural joint and slightly supinated subtalar joint rapidly pian
tar flex and pronate, respectively. The pronation at th
subtalar joint during stance is controlled by two mecha
nisms. First, th calcaneus tips into eversion as a result of
th ground reaction force passing just lateral to th anterior-
Chapter 14 Ankle and Foot 499
Percent of Gait Cycle
posterior axis of rotation through th calcaneus. The simulta-
neous impact of heel contaci also pushes th head of th
talus medially in th horizontal piane and inferiorly in th
sagittal piane. Relative to th calcaneus, this motion of th
talus abducts and dorsiflexes th subtalar joint. These mo-
tions are consistent with th defnition of pronation. A
loosely articulated skeletal model aids in th visualization of
this motion. Second, during th early stance phase, th tibia
and fibula, and io a lesser extern th femur, internally rotate
after initial heel contact.I7't0 Because of th embracing con-
figuration of th talocrural joint, th internally rotating lower
leg steers th subtalar joint into further pronation. The argu-
ment is often raised that with th calcaneus in contact with
th ground, pronation at th subtalar joint causes, rather
than follows, internai rotation of th leg, and either perspec-
tive is valid.
The amplitude of pronation at th subtalar joint during
early stance is relatively small about 2 to 3 degrees on
average and lasts only about 1/4 of a second during aver-
age speed walking. The amount and th speed of th prona
tion influences th kinematics of th more proximal joints of
500 Seciion IV Lower Exlremity

FIGURE 14-30. With th foot fxed, full internai

rotation of th lower limb causes th following as
sociateci movements: rearfoot pronatioti (eversioni,
lowering of th mediai longitudinal arch, and valgus
stress at th knee. Note that as th rearfoot pro-
nates, th floor pushes th forefoot and midfoot
into a relatively supinated position.

th lower extremity. These effects can be appreciated by not been established conclusively.40 Precise measurements of
exaggerating and dramatically slowing th pronation action these kinematic relationships while a subject is walking are
of th rearfoot during th initial loading phase of gait. Con- technically difficult. The kinematics themselves are highly
sider th demonstration depicted in Figure 1 4 - 3 0 . While variable and poorly defined. Some studies report th kine
standing over a loaded and fixed foot, forcefully but slowly matics as a rotation of a single bone, and others repon
internally rotate th lower leg and note th associated prona relative rotations between bones.40 Additional studies are
tion at th rearfoot (subtalar joint) and simultaneous lower needed in this area before definite cause and effect relation
ing of th mediai longitudinal arch. If forceful enough, this ships are known. These relationships are important for they
action also tends to internally rotate, slightly flex, and ad-
duct th hip and to create a valgus strain on th knee (Table
1 4 - 5 ). These so-called mechanical events are exaggerated
and do not all occur to this degree and precise pattern when TABLE 1 4 - 5 . Associated Movements During an
th limb is loaded and at normal walking speed. Neverthe- Exaggerated Pronation of th Subtalar Join t while
less, because of th linkages throughout th lower limb,
Weight Bearing
excessive or uncontrolled pronation of th rearfoot could
exaggerate one or more of these mechanically related joint Joint Action
actions. Clinically, a person who excessively pronates during Hip Internai rotation, flexion, and adduction
early stance often complains of mediai knee pain, apparently
from a net genu valgus strain and subsequent overstretching Knee Valgus strain
on th mediai collateral ligament. Whether th overpronation Subtalar joint Pronation (and lowering of mediai lon
causes th knee valgus or vice versa is not always obvious. (rearfoot) gitudinal arch)
Although widely accepted, a predictable kinematic rela- Transverse tarsal Inversion (supination)
tionship between th magnitude and timing of excessive pro joint (midfoot)
nation and excessive internai rotation of th lower limb has

are th basis for many of th exercises and orthotics em-
ployed to reduce painful conditions related to excessive pro-
nation.
Example of th Kinematic Versatility of th Foot
E a r lie r in t h is s e c t io n , t h p o in t w a s m a d e t h a t p r o n a -
t io n o f t h u n lo a d e d f o o t o c c u r s p r im a r ily a s a s u m m a -
t io n o f t h p r o n a t io n a t b o th t h s u b t a la r a n d t r a n s v e r s e
t a r s a l j o in t s ( s e e F ig . 1 4 - 2 4 6 ) . T h is s u m m a t io n o f m o -
t io n d o e s n o t, h o w e v e r , n e c e s s a r i l y o c c u r w h e n t h
f o o t is lo a d e d w h ile w e ig h t h e a r in g . W it h t h f o o t
lo a d e d o r o t h e r w is e f ix e d to t h g r o u n d , p r o n a t in g th
r e a r f o o t m a y c a u s e t h m id f o o t a n d f o r e f o o t r e g io n s ,
w h i c h a r e r e c e iv in g fir m u p w a r d c o u n t e r f o r c e f r o m t h
f lo o r , t o t w is t in to r e la t iv e s u p in a t io n ( s e e Fig . 1 4 - 3 0 ) .
T h is r e c i p r o c a i k in e m a t ic r e la t io n s h ip b e t w e e n t h r e a r
f o o t a n d m o r e a n t e r io r r e g io n s o f t h f o o t d e m o n s t r a t e s
t h v e r s a t ilit y o f t h fo o t, a m p lif y in g t h o t h e r 's a c t io n
w h e n t h f o o t is u n lo a d e d ( s e e F ig . 14 - 2 4 6 ) , o r c o u n -
t e r a c t in g e a c h o t h e r s a c t io n w h e n t h f o o t is lo a d e d
( s e e F ig . 1 4 - 3 0 ) .
Kincsiologic Benefits o f Controlling Normal Prona
tion. From a kincsiologic perspective, controlled pronation
of th subtalar joint at early stance has several useful me-
chanical effects. Pronation at th subtalar joint permits inter
nai rotation of th talus, and th entire lower extremity,
against a firmly planted calcaneus. The strong horizontal
orientation of th facets at th subtalar joint certainly sug-
gests this action. Without such a joint mechanism, th pian
tar surface of th calcaneus would otherwise spin like a
childs top against th walking surface, along with th medi-
ally rotating leg. Eccentric activation of supinator muscles,
such as th tibialis posterior, can help to decelerate th
pronation and resisi th lowering of th mediai longitudinal
arch. Controlled pronation of th subtalar joint favors rela
tive flexibility throughout th midfoot, allowtng th foot to
accommodate to th varied shapes and contours of walking
surfaces.
Consequences of Excessive Pronation. Innumerable
examples exist on how malalignment of th foot affects th
kinematics of walking. A common situation results from ex
cessive or poorly controlled pronation al th subtalar joint
during stance phase. This disorder has multiple causes, such
as (1) laxity or weakness in th mechanisms that normally
support and control th mediai longitudinal arch, (2) abnor-
mal shape or mobility of th tarsal bones, (3) excessive
femoral anteversion, and (4) generalized muscle weakness
and/or reduced flexibility. In each case, a structural fault
causes th rearfoot to fall into excessive valgus (eversion)
following heel contact.29 Often, excessive subtalar joint pro
nation is a compensation for either excessive or restricted
motion throughout th lower extremity, particularly in th
untai and horizontal planes. The most common structural
Chapter 14 Ankle and Foot 50 1
deformity of th foot is rearfoot varus. (Varus describes a
segment of th foot that is inverted toward th midiine.) As
a response to this deformity, th subtalar joint often over-
compensates by excessively pronating, in speed and/or mag
nimele, to ensure that th mediai aspect of th forefoot
contacts th ground during stance phase.30'3852
Similar compensations occur as a result of forefoot varus.
The associated excessive internai rotation of th talus and leg
may, in some cases, create a chain reaction of kinematic
disturbances and compensations throughout th entire limb,
such as those depicted in Figure 1 4 - 3 0 . The abnormal kine
matic sequence between th tibia and femur may cause an
tncreased Q angle at th knee and an increased net lateral
pul of th quadriceps or iliotibial band on th patella.38
These situations may predispose th patient to patellofemoral
joint dysfunction. For this reason, clinicians often note th
position of th subtalar joint while th patient stands and
walks in evaluation of th cause of patellofemoral joint pain.
Foot Orthoses
C l i n ic ia n s g e n e r a lly a g r e e t h a t s o m e fo r m o f f o o t o r t h o -
s i s o r s p e c ia liz e d f o o t w e a r C o n t r o ls e x c e s s i v e p r o n a t io n
a t t h s u b t a la r jo in t .3202934 In g e n e r a i, a f o o t o r t h o s is is
a d e v ic e in s e r t e d in t o t h s h o e in o r d e r t o m o d if y t h
f o o t 's m e c h a n ic s . M o s t o fte n , a w e d g e is p l a c e d o n t h
m e d ia i a s p e c t o f t h o r t h o s is , w h i c h in t h e o r y C o n t r o ls
t h r a t e , a m o u n t , a n d t e m p o r a l s e q u e n c in g o f p r o n a t io n
a t t h s u b t a la r jo in t. A s a n a d j u n c t t o o r t h o s e s , s o m e
c l i n i c i a n s a ls o s t r e s s t h n e e d t o im p r o v e t h " e c c e n
t r ic c o n t r o l" o f t h m u s c le s t h a t d e c e le r a t e p r o n a t io n
a n d o t h e r a s s o c i a t e d m o t io n s m e c h a n i c a l l y lin k e d to
p r o n a t io n ( s e e T a b le 1 4 - 5 ) . T h e s e m u s c le g r o u p s in
c lu d e t h s u p in a t o r s o f t h f o o t a n d t h m o r e p r o x im a l
e x t e r n a l r o t a t o r s a n d a b d u c t o r s o f t h h ip . T h is t h e r a -
p e u t ic a p p r o a c h s t r iv e s to r e d u c e t h r a t e o f p r o n a t io n
a s w e l l a s t h r a t e o f lo a d in g o n t h fo o t.
The underlying pathomechanics of an excessively pro-
nated foot are complex and not fully understood. The patho
mechanics can involve many kinematic relationships, both
within th joints of th foot or between th foot and th rest
of th lower limb. Even if th pathomechanics are obviously
located within th foot, abnormal motion in th forefoot can
be compensated by abnormal motion in th rearfoot and
vice, versa. Furthermore, extrinsic factors, such as footwear,
orthotics, terrain, and speed of walking or running, alter th
kinematic relationships within th foot and lower extremity.
An understanding of th complex kinesiology of th entire
lower extremity is a definite prerequisite for th effective
treatment of th painful or malaligned foot.
Mid to Late Stance Phase: Supination at th Subtalar Joint
Kinematic Mechanisms Related to Supination. At
about 15 to 20% into th gait cycle, th entire stance limb
dramatically reverses its horizontal piane motion from inter-
502 Section IV Lower Extremily
nal to extemal rotation.17 Extemal rotation of th leg, while
th foot remains pianteci, coincides roughly with th begin-
ning of th swing phase of th contralateral lower extremity.
With th stance foot securely planted, extemal rotation of
th femur, followed by th tibia, gradually reverses th direc
tion of th lalus from internai to extemal rotation. As a
result, at about 35% into th gait cycle, th pronated
(everted) subtalar joint starts to move toward supination (see
Fig. 1 4 -2 9 B ). As demonstrated in Figure 1 4 - 3 1 , with th
rearfoot supinating, th midfoot and forefoot must simulta-
neously twist into relative pronation in order for th foot to
remain in full contact with th ground. By late stance, th
fully supinated subtalar joint and elevated and tensed mediai
longitudinal arch convert th midfoot into a more rigid
lever. Muscles such as th gastrocnemius and soleus use this
stability to transfer forces from th Achilles tendon, through
th midfoot, to th metatarsal heads during th push-off
phase of walking or running.
A person who, for whatever reason, remains relatively
pronated late into stance phase often has difhculty stabilizing
th midfoot at a time when that is required. As a conse-
quence, excessive activity may be needed from extrinsic and
intrinsic muscles of th foot to reinforce th mediai longitu
dinal arch. Over time, hyperactivty may lead to generalized
muscle fatigue and painful syndromes, such as shin splints.
DISTAL INTERTARSAL JOINTS
The distai intertarsal joints describe a collection of several
joints or joint complexes (see Fig. 1 4 - 2 2 and th box).
These joints are surrounded by a continuous capsule and
synovial membrane. As a group, th distai intertarsal joints
assist th transverse tarsal joint in th production of prona
tion and supination throughout th entire midfoot. Motions
in these joints, however, are small. The primary function of
these joints is to provide stability across th midfoot by
formadon of th transverse arch.
FIGURE 14-31. With ihe foot fixed, full exter-
nal rotation of th lower limb causes th fol-
lowing associateci movements: rearfoot supi-
nation (inversion) and raising of th mediai
longitudinal arch. Note that as th rearfoot
supinates, th forefoot and midfoot pronate to
maintain contact with th ground.
Collection of Articulations within th Distai Intertarsal
Joints Include
Cuneonavicular joints
Cuboideonavicular joint
lntercuneiform and cuneocuboid joint complex
Basic Structure and Function
Cuneonavicular Joints
Three articulations are formed between th anterior side of
th navicular and th posterior surfaces of th three cunei-
form bones. Surrounding these articulations are piantar and
dorsal ligaments. The slightly concave surface of each cunei-
form ftts into one of three slightly convex facets on th
anterior side of th navicular. The large mediai facet of th
navicular accepts th large mediai cuneiform. The major
function of th cuneonavicular joints is to help transfer pro
nation and supination movements distally through th me
diai midfoot to th forefoot.
Cuboideonavicular Joint
A relatively small, fbrous cuboideonavicular joint is located
between th lateral side of th navicular and proximal one-
ffih of th mediai side of th cuboid. This joint links th
lateral and mediai components of th transverse tarsal joint,
thereby assisting in transferring pronation and supination
movements across th more proximal regions of th midfoot
The cuboideonavicular joint is strengthened by dorsal, pian
tar, and interosseous ligaments.
lntercuneiform and Cuneocuboid Joint Complex
Three articulations are formed in this joint complex: two
between th cuneiforms, and one between th lateral cunei
form and mediai surface of th cuboid. Articular surfaces are
essentially fiat and aligned nearly parallel with th long axis
of th metatarsals. The tarsal bones are held together by
dorsal, piantar, and interosseous ligaments.
 Chapter 14 Ankle and Foot 503

similar to th third ray in th hand (Fig. 1 4 -3 2 B ). This

FIGURE 14-32. Strutturai and functional features of th midfoot
and forefoot. A, The transverse arch is formed by th intercunei-
form and cuneocuboid joint complex. B, The stable second ray is
reinforced by th recessed second tarsometatarsal joint. C, Com-
bined piantar flexion and eversion of th left tarsometatarsal joint of
th [irsi ray allow th forefoot lo conform to th surface of th
rock.
stability is useful in late stance as th forefoot prepares for
th dynamics of push off.
Mobility is greatest in th more peripheral tarsometatarsal
joints, consisting primarily of dorsiflexion and piantar flex
ion, combined with inversion and eversion. At th first ray,
dorsiflexion occurs naturally with inversion, and piantar flex
ion with eversion (Fig. 1 4 -3 3 A and 8 ).13 Note that these
movement combinations are atypical in th ankle and foot
because they do not fit th strici defnition of pronation or
supination. Nevertheless, movements at this joint provide
useful functions, such as allowing th mediai side of th foot
to better conform around irregularities in th walking surface
(Fig. 1 4 -3 2 C ). The first tarsometatarsal joint provides an
element of flexibility to th mediai longitudinal arch. During
th loading phase of walking, th first ray yields (dorsiflexes)
slightly under th force of body-weight. Stiffness of th first
ray limits th shock absorption ability of th mediai longitu
dinal arch.13

The intercuneiform and cuneocuboid joint complex forms

th transverse arch of th foot (Fig. 14-3 2 A ). This arch
provides transverse stability to th midfoot. Under th load
of body weight, th transverse arch depresses slightly, allow-
ing body weight to be shared across all fve metatarsal heads.6
The arch receives dynamic support by intrinsic muscles; ex-
trinsic muscles, such as th tibialis posterior and peroneus
longus; connettive tissues; and its keystone th intermedi
ate cuneiform.
INVERSION

TARSOMETATARSAL JOINTS A

Anatomie Considerations
Five tarsometatarsal joints are formed by th articulation
between th bases of th metatarsals and th distai surfaces
of th three cuneiforms and cuboid (see Fig. 1 4 - 2 2 ). Specif-
ically, th first metatarsal articulates with th mediai cunei
form, th second with th intermediate cuneiform, and th
third with th lateral cuneiform. The bases of th fourth and
ffth metatarsal both articulate with th distai surface of th
cuboid.
The articular surfaces of th tarsometatarsal joints are
essentially fiat. Dorsal, piantar, and interosseous ligaments
add stability to these articulations. Of th five tarsometatarsal
joints, only th first has a well-developed capsule.55

Kinematic Considerations
The tarsometatarsal joints serve as base joints for each of th
rays of th foot. Mobility is least at th second tarsometatar
sal joint due, in part, to th wedged position of its base FIGURE 14-33. The osteokinematics of th first tarsometatarsal
between th mediai and lateral cuneiforms. Consequently, joint: Dorsiflexion and inversion (A) and piantar flexion and ever
he second ray forms a stable centrai pillar through th foot, sion (B).
 504 Section IV Lcwer Extremity
IN T E R M E T A T A R S A L JO IN T S
Structure and Function
The bases of th tour lateral metatarsals are interconnected
by piantar, dorsal, and interosseous ligaments. Three small
intermetatarsal synovial joints form at th points of contact
between th bases of these metatarsals. Although intercon
nected by ligaments, a true joint does not typically form
between th bases of th frst and second metatarsals. This
lack of articulation increases th relative movement of th
frst ray, in a manner similar io th hand.55 Unlike th hand,
however, th distai ends of all five metatarsals are intercon
nected by th deep transverse metatarsal ligaments. Slight
motion ai th intermetatarsal joints augments th flexibility
at th tarsometatarsal joints.
M E T A T A R S O P H A L A N G E A L JO IN T S
Anatomie Considerations
Five metatarsophalangeal joints are formed between th con-
vex head of each metatarsal and th shallow concavity of th
proximal end of each proximal phalanx (see Fig. 1 4 -2 2 ).
These joints can be palpated at about 2.5 cm proximal to
th web of th toes.
A r t ic u la r c a r t ila g e covers th distai end of each metatarsal
head (Fig. 1 4 -3 4 ). A pair of c o lla t e r a l lig a m en ts spans each
metatarsophalangeal joint, blending with and reinforcing th
capsule. As in th hand, each collateral ligament courses
obliquely from a dorsal-proximal to plantar-distal direction,
forming a thick cord portion and a fanlike accessory portion.
The accesso^ portion attaches to th thick, dense p ia n t a r
p ia t e , located on th piantar side of th joint. The piate, or
ligament, is grooved for th passage of llexor tendons. Fibers
from th deep piantar fascia connect into th piantar plates
and sheaths of th flexor tendons. Two s e s a m o id b o n e s lo
cated within th tendon of th flexor hallucis brevis rest
against th piantar piate of th frst metatarsophalangeal joint
(Fig. 1 4 -3 5 ). Although not depicted in Figure 1 4 - 3 5 , four
deep t r a n s v e r s e m e t a t a r s a l lig a m en ts blend with and join th
adjacent piantar plates of all five metatarsophalangeal joints.
By interconnecting all five plates, th transverse metatarsal
ligaments help maintain th first ray in a similar piane as th
tesser rays, thereby adapting th foot for propulsion and
weight hearing rather than manipulation. In th hand, th
P ia n ta r p ia te
a n d sesa m oid s
FIGURE 14-34. A mediai view of th first metatarsophalangeal joint
showing th cord and accessory' portion of th mediai (collateral)
capsular ligaments. The accessory portion attaches to th piantar
piate and sesamoid bones. (Redrawn from Haines R, McDougall A:
Anatomy of hallux valgus. J Bone Joint Surg 36-B.-272, 1954.)
o u pc i i n i v ie
Interphalangeal Distai attachment of extensor
joint digitorum longus and brevis (cut)
Extensor hallucis Distai interphalangeal
longus (cut) joint
Proximal interphalangeal
Extensor digitorum
joint
brevis (cut)
Dorsal digitai expansion
Piantar piate
Sesamoid bones Dorsal interassei
Flexor hallucis brevis
Extensor
Abductor hallucis digitorum brevis
Extensor
r
igitorum longus
Peroneus tertius
FIGURE 14-35. Muscles and joints of th dorsal surface of th righi
forefoot. The distai half of th frst metatarsal is removed to expose
th concave surface of th first metatarsophalangeal joint. A pair of
sesamoid bones is located deep within th first metatarsophalangeal
joint. The proximal phalanx of th second toe is removed to expose
th concave side of th proximal interphalangeal joint
deep transverse metacarpal ligament connects only th fin
gere, freeing th thumb for opposition.
A fib r o u s c a p s u le encloses each metatarsophalangeal joint
and biends with th collateral ligaments and piantar plates.
A poorly defined e x t e n s o r m e c h a n is m covere th dorsal side
ol each metatarsophalangeal joint. This structure consists of
a thin layer of connective tissue that is essentially inseparable
from th dorsal capsule and extensor tendons.
Kinematic Considerations
Movement at th metatarsophalangeal joints occurs in two
degrees of freedom. E x ten sio n (dorsiflexion) and j l e x i o n (pian
tar flexion) occur approximately in th sagittal piane about a
medial-lateral axis; a b d u c tio n and a d d u c tio n occur in th hon-
zontal piane about a vertical axis. Both axes of rotation
ntersect at th center of each metatarsal head.
Mosi people demonstrate limited dexterity in movements
at th metatarsophalangeal joints, especially in abduction and
adduction. Passively, th toes can be hyperextended about
65 degrees and flexed about 30 to 40 degrees. The first toe
typically allows greater hyperextension to near 85 degrees.
Deformities Involving th Metatarsophalangeal Joint of
th First Toe
Hallux Rigidus and llallux Valgus. H a llu x rigidu s, or
imitus in its less severe form, is a conditiott charactenzed
by marked limitation of motion and by pain at th metatar
sophalangeal joint of th first toe. Although th cause of th
condition is not clear, degenerative changes frequently follow
locai trauma.54 As th condition progresses, osteophytes
formed on th doreum of th metatarsal head may block
hyperextension. The limitation of motion and th pain at

this joint can have significant impact on walking. Normally,
walking requires about 65 degrees of hyperextension at th
metatarsophalangeal joints as th heel rises at late stance
phase.'5 A person with hallux rigidus typically resorts to
walking on th outer surface of th affected foot to avoid th
necessity of hyperextending th first metatarsophalangeal
joint at late stance. Those affected are advised to wear stiff-
soled shoes for walking and to avoid inclines or declines.
Surgery is often recommended in more severe cases.42
The centrai feature of hallux valgus is a progressive lateral
deviation of th first toe. Although th deformity appears to
involve primarily th metatarsophalangeal joint, th patho-
mechanics of hallux valgus often involve th entire first ray
(Fig. 1 4 -3 6 A and B). As depicted in th x-ray, hallux valgus
is associated with excessive adduction of th first metatarsal
about its tarsometatarsal joint. This is often referred to in th
medicai literature as metatarsus primus varus.11 The ad-
ducted position of th metatarsal bone eventuali)- collapses
th proximal phalanx into excessive abduction, thereby ex-
posing th metatarsal head as a bunion. If th metatarsopha
langeal joint assumes an abducted position in excess of 30
degrees, th proximal phalanx often begins to evert, or to
rotate about its long axis.42 The bunion deformity is also
referred to as hallux abducto-valgus in order to account for
th deviations in both horizontal and frontal planes.
The progressive axial rotation of th abducted proximal
phalanx creates a muscular imbalance in th forces that
normally align th metatarsophalangeal joint. The abductor
hallucis muscle shifts toward th piantar aspect of th first
metatarsophalangeal joint. The unopposed pul of th adduc-
tor hallucis and lateral head of th flexor hallucis brevis
progressively increases th lateral deviation posture of th
proximal phalanx. In time, th overstretched mediai collat-
eral ligament and capsule may weaken or rupture, removing
an important source of reinforcement to th mediai side of
th join t.26 Persons with marked hallux valgus often avoid
FIGURE 14-36. Hallux valgus. A, Multiple features
of hallux valgus and associated deformities. B, X-ray
shows th pathomechanics often associated with
hallux valgus: adduction of th first metatarsal evi-
dent by th increased angle between th first and
second metatarsal bones; abduction of th proximal
phalanx with subluxation of th metatarsophalan
geal joint; displacement of th lateral sesamoid; ro
tation (eversion) of th phalanges; and exposed
metatarsal head. (From Richardson EG: Disorders of
th hallux. In Canale ST (ed): Campbells Operative
Orthopaedics, voi 4, 9th ed. St. Louis, Mosby-Year
Book, 1998.)
Chapter 14 Ankle and Foot 505
hearing weight over th first metatarsophalangeal joint, caus-
ing th lateral metatarsal bones to accept a greater propor-
tion of th load. The pathomechanics of marked hallux val
gus involve a zigzag-like collapse of th first ray, similar to
th ulnar drift of th metacarpophalangeal joint in th rheu-
matoid hand (see Chapter 8).
Although th etiology of hallux valgus is noi totally clear,
genetics, incorrect footwear, pronated feet that cause valgus
strain at th hallux, and asymmetry of th bones and joints
all contribute to th condition. The full spectrum of severe
hallux valgus is often associated with dislocation and osteo-
arthritis of th metatarsophalangeal joint, metatarsus varus
(adductus), valgus of th first toe, bunion formation over th
mediai joint, hammer toe of th second digit, calluses, and
metatarsalgia.42 Surgical intervention is often indicated in
cases of marked deformity and dysfunction.
IN T E R P H A L A N G E A L JO IN T S
As in th fingers, each toe has a proximal interphalangeal and
a disiai interphalangeal joinl. The first toe, being analogous io
th thumb, has only one interphalangeal joint (Fig. 1 4 -2 2 A ).
All interphalangeal joints of th foot possess similar ana
tomie features. The joint consists of th convex head of th
more proximal phalanx articulating with th concave base of
th more distai phalanx. The proximal phalanx of th second
toe is removed in Figure 1 4 - 3 5 to expose th concave side
of th proximal interphalangeal joint. The structure and
function of th connective lissues at th interphalangeal
joints are generally similar to those described for th meta
tarsophalangeal joints. Collateral ligaments, piantar plates,
and capsules are present, but smaller and less defined.
Mobility at th interphalangeal joints is limited primarily
to flexion and extension. The amplitude of flexion generally
exceeds extension, and motion tends to be greater at th
proximal than th distai joints. Extension is limited primarily
506 Sedioli IV Lower Extremity
Normal foot
Foot with pes planus
FIGURE 14-37. The windlass effeet of th piantar fascia is demon-
strated while standing on tiptoes. A windlass is a hauling or lifting
device consisting of a rape wound around a cylinder that is tumed
by a crank. The rope is analogous to th piantar fascia, and th
cylinder is analogous to th metatarsophalangeal joints. A, In th
normal foot, contraction of th extrinsic piantar flexor muscles
raises th calcaneus, thereby transferring body weight forward over
th metatarsal heads. The resulting hyperextension of th metatarso
phalangeal joints (shown collectively as th white disk) stretches (or
winds up) th piantar fascia within th mediai longitudinal arch
(red spring). The increased tension from th stretch strengthens th
midfoot and forefoot. Contraction of th intrinsie muscles provides
additional reinforcement to th arch. B, The foot with pes planus
(fiat foot) typically has a poorly supported mediai longitudinal arch.
While attempting to stand up on tiptoes, th forefoot sags under
th load of body weight. The reduced hyperextension of th meta
tarsophalangeal joints limits th usefulness of th windlass effeet.
Even with strong activation of th intrinsie muscles, th arch re-
mains flattened and th midfoot and forefoot unstable.
by passive tension in th toe flexor muscles and piantar
ligaments.
ACTION OF THE JOINTS WITHIN THE FOREFOOT
DURING THE LATE STANCE PHASE OF GAIT
The joints of th forefoot include all articulations associated
with each ray, from th tarsometatarsal joint to th distai
interphalangeal joints of th toe. Depending on th phase of
gait, these joints provide an element of flexibility or stability
to th forefoot.
During th later part of stance phase, th midfoot and
forefoot must be relatively stable or rigid to accept th
stresses that are associated with push off. In addition to
activation of locai intrinsie and extrinsic muscles, th foot is
further stabilized by increased tension in th mediai longitu
dinal arch. The increased tension occurs through a mecha-
nism known as th windlass effeet, demonstrated by stand
ing on tiptoes shown in Figure 1 4 -3 7 A . Because of th
attachments of th piantar fascia on th proximal phalanges,
hyperextension of th metatarsophalangeal joints increases
th tension throughout th mediai longitudinal arch. As th
heel and most of th foot is raised, body weight shifts
anteriorly toward th mediai metatarsal heads, where fat
pads and sesamoid bones and th rigidity of th second ray
provide a suitable base of support for th action of th
piantar flexor muscles.
In contrast to th healthy foot, consider th pathome-
chanics involved as a person with an unstable flatfoot (pes
planus) attempts to rise up on tiptoes (Fig. 1 4 -3 7 B ). Al-
though th individuai has no neuromuscular deficit, there is
significant loss in th amount of lift of th heel, even upon
maximal muscular effort. Without an effective mediai longi
tudinal arch, th unstable, unlocked midfoot and forefoot
sag under body weight. Consequently, th reduced hyperex
tension of th metatarsophalangeal joints limits th useful
ness of th windlass effeet for stretching th piantar fascia.
Table 1 4 - 6 summarizes th important functions of th
ankle and foot during th stance phase of walking.
MUSCLE AND JOINT INTERACTION
Innervation of Muscles and Joints
INNERVATICI OF MUSCLES
Extrinsic muscles of th ankle and foot have their proximal
attachments in th leg, and a few extend as far proximal as
th distai thigh. Intrinsie muscles, in contrast, have both
proximal and distai attachments within th foot.
The extrinsic muscles are arranged in three compartments
of th leg: anterior, lateral, and posterior. Each compartment
is innervated by a different motor nerve. The anterior com
partment is innervated by th deep branch of th peroneal
nerve, th lateral compartment by th superficial branch of
th peroneal nerve, and th posterior compartment by th
tibia! nerve. Each of these is a branch of th sciatic nerve,
formed from th L4-S3 nerve roots of th sacrai plexus.
Lateral to th head of th fibula, th common peroneal
nerve (L4-S2) divides into a deep and superficial branch (Fig.
1 4 -3 8 ). The deep branch o f th peroneal nerve innervates th
muscles within th anterior compartment: th tibialis ante-
 Chapter 14 Ankle and Foot 507

TABLE 1 4 - 6 . Major Actions at Regions o f th Ankle and Foot During th Stance Phase of Walking*

Early Stance Mid to Late Stance

R eg ion R e p r e s e n t a t iv e Jo in t A ction D e s ir e d F u n ctio n A ctio n D e s ir e d F u n ction

Ankle Talocrural Piantar flexion Allows rapid foot con Dorsiflexion followed Produces a stable joint to
tact by rapid piantar accept body weight,
flexion followed by thrust
needed for push off
Rearfoot Subtalar Pronation and lowering Permits internai rotation Continued pronation Permits extemal rotation
of th mediai longi- of lower limb changing to supi- of lower limb
tudinal arch Allows th foot to func nation, followed Converts th midfoot to
tion as a shock ab- by a raising of th a rigid lever for push
sorber mediai longitudi- off
Produces a pliable mid nal arch
foot
Midfoot Transverse tarsal Relative inversion as a Allows full extent of Relative everson Allows th midfoot and
joint response to counter- subtalar joint prona forefoot to maintain
force from th tion finn contact with th
ground ground
Forefoot Metatarsophalangeal Insignificant Hyperextension Increases tension in th
piantar fascia
Through th windlass ef-
fect, raises th mediai
longitudinal arch and
stabilizes th midfoot
and forefoot for push
off

* Each region of th foot is represented by only one joint.

rior, extensor digtorum longus, extensor hallucis longus,
and peroneus tertius. The deep branch continues distally to
innervate th extensor digitorum brevis (i.e., an intrinsic
muscle located on th dorsum of th foot). It also supplies
sensory innervation to a triangular area of skin in th web
space between th first and second toes. The s u p e r fic ia l
b r a n c h o f th p e r o n e a l n e rv e innervates th peroneus longus
and peroneus brevis within th lateral compartment. It then
continues distally as a sensory nerve io much of th skin on
th dorsal and lateral aspects of th leg and foot.
The tib ia l n e r v e (L4-S 3) and its terminal branches innervate
th remainder of th extrinsic and intrinsic muscle of th
foot and ankle (Fig. 1 4 - 3 9 ). The muscles within th poste-
rior compartment are divided into a superficial and deep set.
The superficial set includes th calf muscles: th gastrocne-
mius and soleus, together known as th triceps surae, and
th small plantaris. The deep set includes th tibialis poste-
rior, flexor hallucis longus, and flexor digitorum longus. As
th tibial nerve approaches th mediai side of th ankle, it
sends a sensory branch to th skin over th heel.
Just posterior to th mediai malleolus, th tibial nerve
bifurcates into th m e d ia i p i a n t a r n e r v e (L4-S2) and la t e r a l
p ia n t a r n e r v e (L4-S3). The piantar nerves supply sensation to
th skin of most of th piantar side on th foot and motor
innervation to all intrinsic muscles, except th extensor digi
torum brevis. The organization of th innervation of th
intrinsic muscles of th foot is similar to that in th hand.
The mediai piantar nerve is analogous to th median nerve,
whereas th lateral piantar nerve is analogous to th ulnar
nerve. Tables 1 4 - 7 and 1 4 - 8 summarize th motor inner
vation of th extrinsic and intrinsic muscles of th ankle and
foot.23-55 As an additional reference, th motor nerve roots
that supply all th muscles of th lower extremity are listed
in Appendix IVA. Appendix IVB shows key muscles typically
used to test th functional status of th L2-S3 ventral nerve
roots.
S E N S O R Y IN N E R V A T IO N TO T H E JO IN T S
The ta lo c r u r a l jo i n t receives sensory innervation from th
deep branch of th peroneal nerve. Detailed information on
th sensory inneivation to th more distai joints of th ankle
however, is limited. In generai, sensory innervation to th
joints of th foot is supplied primarily through nerve
branches that cross th region. Each major joint usually
receives multiple sources of sensory innervation, traveling to
th spinai cord primarily through S 1 and S2 nerve roots.18
Anatomy and Function of th Muscles
E X T R IN S IC M U S C L E S
The primary functions of th muscles of th ankle and foot
are to provide static control, dynamic thrust, and shock
absorption to th distai lower extremity. These functions are
performed by both intrinsic and extrinsic muscles. Addi
tional discussion of th muscular interaction during th gait
process follows in Chapter 15.
 508 Section IV Lower Exiremity
Antcrior view
Because all th extrinsic muscles cross multiple joints,
they possess multiple actions. Many actions can be appreci-
ated by noting th point where th tendons cross th axes of
rotation at th talocrural and subtalar joints (Fig. 1 4 -4 0 ).
Although Figure 1 4 - 4 0 is oversimplifed (by lacking th
transverse tarsal joint as well as other components of prona-
tion and supination at th ankle and foot), it is useful for
helping to understand th actions of th extrinsic muscles.
Anterior Compartment Muscles
Muscular Anatomy
The four muscles of th anterior compartment are listed in
th box. As a group, these pretibial muscles have their prox-
imal attachments on th anterior and lateral aspects of th
proximal half of th tibia, th adjacent fibula, and th inter-
osseous membrane (Fig. 1 4 - 4 1 ). The tendons of these mus
cles cross th dorsal side of th ankle, restrained by a syno-
vial-lined superior and injeror extensor retinaculum. Locateci
most medially is th prominent tendon of th tibialis ante
rior that courses distally to th medial-plantar surface of th
ftrst tarsometatarsal joint. The tendon of th extensor hallu-
cis longus passes just lateral to th tendon of th tibialis
anterior, as it courses toward th dorsal surface of th first
FIGURE 14-38. The path and generai prox-
imal-to-distal order of muscle innervation
for th deep and superficial branches of
th common peroneal nerve are illustrated.
The primary nerve roots are in parenthe-
ses. (Modified with permission front de-
Groot J: Correlative Neuroanatomy, 2 lst
ed. Norwalk, Appleton & Lange, 1991.)
toe. Progressing laterally across th dorsum of th ankle are
th tendons of th extensor digitorum longus and th pero-
neus tertius (or third peronei). The four tendons of th
extensor digitorum longus attach to th dorsal surface of th
middle and distai phalanges via th dorsal digitai expansion.
(This tissue is structurally analogous to th extensor mecha-
nism in th fingers.) The peroneus tertius is part of th
extensor digitorum longus muscle and may be considered as
th toe-extensor s fifth tendon.5 The peroneus tertius at-
taches to th base of th fifth metatarsal bone.
Muscles of th Anterior Compartment of th Leg
(Pretibial Dorsiflexors)
M u scles
Tibialis anterior
Extensor digitorum longus
Extensor hallucis longus
Peroneus tertius
In n er v a tio n
Deep portion of th peroneal nerve
 Chapter 14 Ankle and Foot 509

Posterior vievv

-Sural nerve

Tibial nerve

m Lateral piantar
nerve

M ediai piantar '--V

n e rv e ' s.

SENSORY DISTRIBUTION

FIGURE 14-39. The path and generai

proximal-to-distal order of muscle in-
nervaiion for th tibial nerve and its
branches are shown. The primary
nerve roots are in paremheses. (Mod-
ified with permisston from deGroot J:
Correlative Neuroanatomy, 21st ed.
Norwalk, Appleton <Sr Lange, 1991.)

TABLE 1 4 - 8 . Motor Innervation to th In trin sic

Muscles of th Foot*
TABLE 1 4 - 7 . Motor Innervation to th E xtrinsic
Muscles of th Ankle and Foot* Nerve Muscles

Deep branch of th peroneal Extensor digitorum brevis

Nerve Muscles
Deep branch peroneal nerve Tibialis anterior
Extensor digitorum longus
Peroneus tertius
Extensor hallucis longus
Superficial branch peroneal Peroneus longus and brevis
nerve
Tibial nerve Plantaris
Tibialis posterior
Flexor digitorum longus
Flexor hallucis longus
Gastrocnemius and soleus
nerve
Mediai piantar nerve
Lateral piantar nerve
Flexor digitorum brevis
Abductor hallucis
Flexor hallucis brevis
Lutnbrical (second toe)
Abductor digiti minimi
Quadratus plantae
Flexor digiti minimi
Adductor hallucis
Piantar interossei
Dorsal interossei
Lumbricals (third to ffth toes)

* The muscles are listed in a generai descending order of nerve root * The muscles are listed in generai descending order of nerve root
innervation. innervation.
510 Section IV Lower Extremity

tibialis anterior muscle, although rare, th ankle can stili be

DORSIFLEXION [\
INVERSION
Extensor hallucis longus N
Tibialis anteriore.
J h loerin-iii
/"'rixT
Tibialis posterior-
Flexor digitorum longus'
Flexor hallucis lo n g u s'
DORSIFLEXION
EVERSION
- Extensor digitorum longus
Peroneus tertius
w piantar side of th foot through a groove in th cuboid
\i
'Peroneus brevis
'P eroneus longus
dorsiflexed, but th motion of th foot has a slight eversion-
and-abduction bias.
Lateral Compartment Muscles
Muscular Anatomy
The peroneus longus and th peroneus brevis muscles, often
referred to as th evertors of th foot, occupy th lateral
compartment of th leg muscles (Fig. 1 4 - 4 2 ). Both muscles
attach proximally along th lateral fibula. The tendon of th
peroneus longus, th more superficial of th two, courses
distally a remarkable distance. After wrapping around th
posterior side of th lateral malleolus, th tendon enters th
bone. The tendon then travels between th long and short
piantar ligaments to its final distai attachment on th plan-
tar-lateral aspect of th first tarsometatarsal joint (Fig.
1 4 -4 3 ).

Achilles tendon'
m
PLANTAR FLEXION PLANTAR FLEXION A nterior view
INVERSION t r \) EVERSION
FIGURE 14-40. The multiple actions of muscles that cross th taio-
crural and subtalar joints, as viewed from above. The actions of
each muscle are based on its position relative to th axes of rotation
at th joints. Note that th muscles have multiple actions.

Joint Action
All four pretibial muscles are dorsiflexors because they cross - Tibialis anterior
anterior to th axis of rotation at th talocrural joint. The
Peroneus longus-
tibialis anterior also inverts th subtalar joint by passing just
mediai to th axis of rotation (see Fig. 1 4 - 4 0 ). The tibialis
anterior inverts and adducts th talonavicular joint, as well
as supports th mediai longitudinal arch.
The primary actions of th extensor hallucis longus are
dorsiflexion at th talocrural joint and extension of th first
toe. Inversion ai th subtalar joint is negligible due its small
moment arm, at least when analyzed from th anatomie Extensor digitorum longus
position. In addition to dorsiflexion of th ankle, th extensor and peroneus tertius-
digitorum longus and peroneus tertius evert th foot.
The pretibial muscles are most active during th early
-Extensor hallucis longus
stance phase and again throughout th swing phase of gait Superior extensor
(see Fig. 1 5 - 2 9 , tibialis anterior). During early stance, th retinaculum -
muscles are eccentrically active to control th rate of piantar
flexion (i.e., th period between heel contact and foot-flat). Interior extensor
Controlled piantar flexion is necessary for a soft landing of retinaculum-
th foot. Through similar eccentric activation, th tibialis
anterior decelerates th lowering of th mediai longitudinal
Extensor digitorum
arch, including th pronation of th rearfoot. During th brevis -
swing phase, th pretibial muscles actively dorsiflex th an
kle and extend th toes to ensure that th entire foot clears
th ground. m
The ability to actively dorsiflex th entire foot in th near
sagittal piane requires a rather exacting balance of forces
from th pretibial muscles. The eversion and/or abduction
influence of th extensor digitorum longus and peroneus
FIGURE 14-41. The pretibial muscles of th leg: tibialis anterior,
tertius must counterbalance th inversion and adduction in extensor digitorum longus, extensor hallucis longus, and peroneus
fluence of th tibialis anterior. With isolated paralysis of th tertius. All four muscles dorsiflex th ankle.

Lateral view
FIGURE 14-42. A lateral view of th muscles of th leg is shown.
Note how both th peroneus longus and peroneus brevis (primary
evertors) use th lateral malleolus as a pulley to change direction.
The tendon of th peroneus brevis muscle travels poste-
rior to th lateral malleolus alongside th peroneus longus
(see Fig. 1 4 - 1 5 ). Both peroneal tendons occupy th same
synovial sheath as they pass under th peroneal retinaculum.
It holds th tendons posterior to th lateral malleolus. The
Chapter 14 Ankle and Foot 511
Piantar view
FIGURE 14-43. A piantar view of th right foot shows th distai
course of th tendons of th peroneus longus, peroneus brevis, and
tibialis posterior. The tendons of th flexor digitorum longus and
flexor hallucis longus are cut.
tendon of th peroneus brevis separates from th peroneus
longus tendon and courses toward its distai attachment on
th styloid process of th fifth metatarsal.
Joint Action
The peroneus longus and peroneus brevis are th primary ever
tors of th joints of th foot (Fig. 1 4 -4 0 ). Both muscles also
piantar flex th talocrural joint. The lateral malleolus, serving
as a fixed pulley, routes th peroneal tendons posterior to
th axis of rotation at th talocrural joint. Although not
evident in Figure 1 4 - 4 0 , th peroneus longus and brevis
also abduct th subtalar and transverse tarsal joints. The
muscles provide stability to th lateral side of th talocrural
joint. Strengthening exercises of th peroneal muscles are
often advised for persons with histories of recurring inver-
sion ankle sprains and injured lateral ligaments.
The distai attachment of th peroneus longus provides an
ideal line-of-force for pronation of th forefoot. This is evi
dent by th slight depression (piantar llexion) of th first ray
during maximal-effort pronation of th unloaded foot. The
peroneus longus also stabilizes th first tarsometatarsal joint
against th mediai pul of th tibialis anterior. Without this
stability, th first ray would migrate medially, predisposing a
person to a hallux valgus deformity.
The peroneus longus and brevis are most active through-
out th mid to late stance phase,50 when th subtalar joint is
supinating and th dorsiflexed ankle joint is preparing to
piantar flex. Activation of th peroneal muscles decelerates
th rate and extern of supination at th subtalar joint. With
th first ray fixed to th ground, th supinating rearfoot
creates a relative pronated position at th midfoot and fore
foot (see Fig. 1 4 - 3 1 ). W ith paralysis of th peroneus lon
gus, th potent supination pul of th tibialis posterior is
unopposed. As a result, th forefoot follows th rearfoot into
 512 Section IV Lower Extremity
supination, causing th persoti to walk on th lateral border
of th foot.22
At th push-off phase of walking, th peroneal muscles
assist other muscles with piantar flexion at th talocrural
joint. The lateral position of th peroneal muscles helps
neulralize th strong inversion (supination) bias of th re-
maining piantar flexors, including th tibialis posterior, th
extrinsic toe flexors, and, to a limited degree, th gastrocne-
mius. Furthermore, as th heel is raised, contraction of th
peroneal muscles, especially th peroneus longus, helps
transfer body weight from th lateral to th mediai side of
th forefoot. This shifts th bodys center-of-mass toward th
opposite foot, which is entering th early stance phase of
gail.
The eversion force of th peroneus longus stabilizes th
foot by counteracting th potent mediai pul of th many
invertor-plantar flexor muscles. This is especially evident as
th heel rises when standing on tiptoes (Figure 1 4 - 4 4 ). The
strongly activated peroneus longus and tibialis posterior
muscles neutralize one another as they form a functional
sling that supports th transverse and mediai longitudinal
FIGURE 14-44. The line-of-force of several piantar flexor muscles
while rising on tiptoes. Note that th peroneus longus (black) and
tibialis posterior (red) form a sling that supports th transverse and
mediai longitudinal arches. The pul of th gastrocnemius and tibi
alis posterior muscles causes a slight supination of th rearfoot,
which adds further stability to th foot.
arches. The net effect of this muscle action slightly supinates
th unloaded rearfoot, which provides further stability to th
foot. This stability is necessary so that th piantar flexion
torque required to stand on tiptoes can be effectively trans-
ferred forward over th metatarsal heads.
Posterior Compartment Muscles
Anatomy
The muscles of th posterior compartment are divided into
two groups. The superftcial calf group includes th gas
trocnemius, soleus (together known as triceps surae), and
plantaris (Fig. 1 4 -4 5 A and B). The deep group includes th
tibialis posterior, flexor digitorum longus, and flexor hallucis
longus (Fig. 1 4 -4 6 ).
Muscles of th Posterior Compartment of th Leg
Superficial group (piantar flexors")
Gastrocnemius
Soleus
Plantaris
Deep group (invenors)
Tibialis posterior
Flexor digitorum longus
Flexor hallucis longus
Innervation
Tibial nerve
Superficial Group. The gastrocnemius muscle forms th
prominent belly of th calf. This two-headed muscle attaches
by separate heads from th posterior side of th mediai and
lateral femoral condyles. The larger mediai head joins th
lateral head midway down th leg to form a tendinous ex-
pansion that, after insertion of th tendon from th soleus
muscle, forms th Achilles tendon. The broad fiat soleus
muscle lies deep to th gastrocnemius, arising primarily from
th posterior side of th proximal fibula and middle tibia.
The soleus blends with th Achilles tendon for its distai
attachmeni to th calcaneal tuberosity. The gastrocnemius
crosses th knee but th soleus does not. The functional
significance of this anatomie arrangement is discussed later
in th section. The plantaris muscle arises from th lateral
supracondylar line of th femur. The fusiform muscle belly
is only 7 to 10 cm long,55 unusually small especially when
compared with th surrounding muscles. The plantaris has a
very long, slender tendon that courses between th gas
trocnemius and soleus, eventually fusing with th mediai
margin of th Achilles tendon.
Deep Group. The tibialis posterior, flexor hallucis lon
gus, and flexor digitorum longus muscles are located be-
neath th soleus muscle (see Fig. 1 4 - 4 6 ). As a group, these
muscles arise from th posterior side of th tibia, fibula, and
interosseous membrane. The more centrally located tibialis
posterior muscle is framed and partially covered by th
flexor hallucis longus laterally and th flexor digitorum lon
gus medially. At their musculotendinous junctions, all three
muscles with th juxtaposed tibial nerve and artery enter th
piantar aspect of th foot from its mediai side (see Fig. 1 4 -
43). The position of th tendons as they cross th ankle and
foot explains th strong supination (inversion) component of

FIGURE 14-45. The superficial muscles of th postevior compartment of th righi leg are shown: A, th gastrocne-
mius; B, th soleus and plantaris.
these muscles (see Fig. 1 4 - 4 0 ). The libialis posterior, flexor
digitorum longus, and aforementioned neurovascular bundle
course through th tarsal tunnel, located just deep to th
flexor retinaculum (Fig. 1 4 -4 7 ). The tarsal tunnel is analo-
gous to th carpai tunnel in th wrist. Tarsal tunnel syn-
drome (analogous to carpai tunnel syndrome) is character-
ized by entrapment of th tibial nerve beneath th flexor
retinaculum and subsequent paresthesia over th piantar as-
pect of th foot.43
The tendon of th flexor hallucis longus courses distally
through th ankle in a groove formed between th tubercles
of th talus and th inferior edge of th sustentaculum talus
(see Fig. 1 4 - 1 1 ). Fibrous bands convert this groove into a
synovial-lined canal, anchoring th position of th tendon.55
The somewhat deep fiaterai) position of th tendon relative
to th tibialis posterior and flexor digitorum longus explains
why th flexor hallucis longus is not considered as a struc-
ture within th tarsal tunnel. Once in th piantar aspect of
th foot, th tendon of th flexor hallucis longus courses
between th two sesamoid bones of th first metatarsopha-
Chapter 14 Ankle and Foot 513
langeal joint, fnally attaching to th piantar side of th base
of th distai phalanx of th first toe (see Fig. 1 4 - 4 3 ).
The tendon of th flex or digitorum longus courses distally
across th ankle posterior to th mediai malleolus. At about
th level of th base of th metatarsals, th main tendon of
th flexor digitorum longus divides into four smaller ten-
dons, each attaching to th base of th distai phalanx of th
lesser toes (see Fig. 1 4 -4 3 ).
The tendon of th tibialis posterior muscle lies just anterior
to th tendon of th flexor digitorum longus in a shared
groove on th posterior side of th mediai malleolus (see
Fig. 1 4 -4 7 ). Once in th piantar aspect of th foot, th
tendon of th tibialis posterior passes deep to th flexor
retinaculum and superficial to th deltoid ligament. At this
point, th tendon divides into superficial and deep parts,
establishing attachments to every tarsal bone, except th ta
lus, and to th bases of several of th more centrai metatar
sals (see Fig. 1 4 - 4 3 ). The extensive attachments support th
mediai longitudinal arch. A ruptured tendon may cause a
collapse of th mediai longitudinal arch and a drop in th
 514 Section IV Lower Extremily
Plantaris
(cut)
Tibia
(cut)
Tibialis posterior
Flexor digitorum
hallucis longus
malleolus
tendon
(cut)
FIGURE 14-46. The deep muscles of ihe posterior compartment of
'he righi leg: th tibialis posterior, flexor digitorum longus, and
flexor hallucis longus.
height of th talus.2x37 The most prominent, and readily
palpatile, distai attachment of th tibialis posterior is to th
navicular tuberosity.
The tendons of both th tibialis posterior and th flexor
digitorum longus use th mediai malleolus as a fixed pulley
to direct their force posterior to th axis of rotation at th
talocrural joint. An analogous pulley is described for th
peroneal tendons, as they pass posterior lo th lateral mal
leolus (see Fig. 1 4 -4 2 ). Tendons of th tibialis posterior and
flexor digitorum longus are held posterior to th mediai
malleolus by th flexor reiinaculum. lnterestingly, th flexor
hallucis longus uses a different piantar flexion pulley, formed
by th mediai and lateral tubercles of th talus and th
sustentaculum talus.
Joint Action: Piantar Flexion and Supination
With th exception of th peroneus longus and brevis, all
muscles that piantar flex th talocrural joint also supinate
th subtalar or transverse tarsal joints. This strong tnversion
bias can be appreciated by noting th position of th poste-
rior compartment muscles relative lo th subtalar joint in
Figure 1 4 - 4 0 . The flexor digitorum longus and flexor hallu
cis longus have additional actions at th more distai joints of
th foot, especially ai th metatarsophalangeal and interpha-
langeal joints.
Active Piantar Flexion Used to Decelerate or Control
Ankle Dorsi flexion. The piantar flexor muscles are active
throughout most of th stance phase of gait, particularly
between foot-flat and toe-off phases (Fig. 1 5 - 2 9 , gastrocne-
mius and soleus muscles). Normally, these muscles become
active immediately after th dorsillexor muscles relax. From
foot-flat lo just prior to about heel off, th piantar flexors act
eccentrically to decelerate th forward rotation (dorsiflexion)
of th leg over th fixed talus. Between th heel-off and toe-
off phase, however, th muscle switches to a concentric
activation to provide th thrust needed for push off.
Active Piantar Flexion Used to Accelerate Ankle
Piantar Flexion. In healthy persons, maximal isometric
piantar flexion torque exceeds th maximal torque of all
other movements about th ankle and foot combined (Fig.
1 4 - 4 9 ) .47 A large piantar flexion torque reserve is needed to
accelerate th body up and forward during brisk walking,
running, jumping, and climbing. Piantar flexion torque is
greatest with th ankle fully dorsiflexed (i.e., piantar flexor
muscles elongated), and least with th ankle fully piantar
flexed.35 The fully dorsiflexed ankle is typically assumed as
one prepares io sprint or jump. lnterestingly, as th ankle
vigorously piantar flexes at th take off' of a sprint or jump,
th contracting gastrocnemius is simultaneously elongated by
th action of th extending knee. This biarticular arrange
ment prevents th gastrocnemius from overshortening, allow-
ing greater torques throughout a larger range of ankle mo-
tion.1, Because th soleus muscle does not cross th knee, its
length-tension relationship is unaffected by th position of
th knee. On th one hand, th slow-twitch soleus is more
suited to control th relatively slow-changing postural move
ments of th leg over th talus during standing. The fast-
twitch gastrocnemius, on th other hand, is apparently better
suited for providing a propulsive piantar flexion torque for
activities that also involve dynamic knee extension, such as
jumping and sprinting.
Of all th piantar flexor muscles, th gastrocnemius and
soleus are by far th most powerful, theoretically capable of
producing about 80% of th total piantar flexion torque ai
th ankle.3- The large torque potential of th triceps surae is
due, in part, to th muscles large cross-sectional area and
relatively long moment arm (Table 1 4 9). The protruding
calcaneal tuberosity provides th triceps surae with a mo
ment arm of about 4.8 cm from th talocrural joint, roughly
twice th average moment arm of th other piantar flexor
muscles.
Supination Potential o( th Piantar Flexor Muscles.
The tibialis posterior, flexor hallucis longus, and flexor
digitorum longus are th primary supinatore o f th foot.
The tibialis posterior likely produces th greatest .supina
tion torque across th subtalar joint. The exlensive distai
attachments o f th muscle, especially to th navicular
bone, provide an effective supination twist o f th mid-
foot (see Fig. 1 4 -2 4 D ). As depicted in Figure 1 4 -4 0 , th
triceps surae passes slightly mediai to th subtalar joints
 Chapter 14 Artide and Foot 515

FIGURE 14-47. A mediai view of ihe flexor retinaculum that covers th tendons of th tibialis posterior,
flexor digitorum longus, and posterior tibial neurovascular bundle. (Front Richardson EG: Neurogenic
disorders. In Canale ST (ed): Campbell's Operative Orthopaedics, voi 4, 9th ed. St. Louis, Mosby-Year
Book, 1998.)

Piantar Flexor Muscles Acting as Extensors of th Knee Dorsiflexion Piantar flexion

A n im p o r t a r e f u n c t io n o f t h p ia n t a r f le x o r m u s c le s is to
producine producine knee
s t a b iliz e t h k n e e in e x t e n s io n . 33 T h e im p o r t a n c e o f t h is
knee flexion extension
f u n c t io n b e c o m e s e v id e n t w h e n o b s e r v in g t h g a it o f a
p e r s o n w it h w e a k e n e d p ia n t a r f le x o r m u s c le s . W it h o u t t h
m u s c l e 's n e c e s s a r y b r a k in g o r d e c e le r a t in g a c t io n a t t h
a n k le , t h lo w e r le g a d v a n c e s v ia a n k le d o r s if le x io n to o
r a p id ly a n d t o o f a r d u r in g t h m id t o la t e s t a n c e p h a s e o f
g a it. A s s h o w n w it h a w e a k e n e d s o le u s w h ile s t a n d in g
( F ig u r e 1 4 - 4 8 A ) , a f o r w a r d ly r o t a t e d le g s h if t s t h f o r c e o f
b o d y w e ig h t p o s t e r io r t o t h m e d ia l- la t e r a l a x is o f r o t a t io n
a t t h k n e e . T h is s h if t c a n c r e a t e a s u d d e n a n d o fte n
u n e x p e c t e d k n e e f le x io n t o r q u e . T h e d o r s if le x e d a n k le , in
t h is c a s e , b ia s e s f le x io n a t t h k n e e . Weakened soleus
A n im p o r t a n t f u n c t io n o f t h s o le u s m u s c le is t o r e s is t unable to decelerate
e x c e s s i v e f o r w a r d r o t a t io n o f t h le g , t h e r e b y m a in t a in in g dorsiflexion

b o d y w e ig h t o v e r o r ju s t a n t e r io r t o t h k n e e 's m e d ia l-
la t e r a l a x is o f r o t a t io n . W it h t h f o o t f ix e d t o t h g r o u n d ,
a c t iv e p ia n t a r f le x io n a t t h a n k le c a n e x t e n d t h k n e e
(F ig . 1 4 - 4 8 B ) . 50 T h e s o le u s m u s c le is p a r t ic u la r ly w e ll
s u it e d t o s t a b iliz e t h k n e e in e x t e n s io n . A s a p r e d o m i-
n a t e ly s lo w - t w it c h m u s c le , t h s o le u s c a n p r o d u c e r e la -
Body weight Body weight
t iv e ly lo w f o r c e s o v e r a r e la t iv e ly lo n g d u r a t io n b e f o r e
f a t ig u in g . M a r k e d s p a s t ic it y in t h s o le u s m u s c le e x e r t s a FIGURE 14-48. Two examples of how th ankle affects th position
p o t e n t a n d c h r o n ic k n e e e x t e n s io n b ia s th a t , o v e r t im e , and stability of th knee while standing. A, Weakened soleus mus
c a n c o n t r ib u t e t o g e n u r e c u r v a t u m d e f o r m it y . cle is unable to decelerale ankle dorsiflexion (DF). With th foot
fixed to th ground, ankle dorsiflexion occurs as a forward rotation
of th leg over th talus. The forward position of th leg shifts th
force of body weight posterior to th knee, causing tt to buckle
into flexion. B, A normal strength soleus muscle causes th ankle to
piantar flex (PF). With th foot fixed to th ground, piantar flexion
rotates th leg posteriorly, bringing th knee toward extension.
516 Section IV Lower Extremity

The tibialis posterior, flexor hallucis longus, and flexor

FLEXION FLEXION
Ankle and Foot Action
FIGURE 14-49. The magnitude of maximal-effort isometric torque is
shown for four actions of th ankle and foot. (N = 86 healthy men
and women.) (Data from Sepie SB, Murray MP, Mollinger LA, et al:
Strength and range of motion in th ankle in two age groups of
men and women. Am J Phys Med 65: 75-84, 1986.)
digitorum longus muscles also exert control of pronation and
supination movements while walking. The tibialis posterior
muse le is active during th stance phase longer than any
other supinator muscle, from just before foot-fiat to heel-off
phase.50 As th entire foot contacts th ground, th tibialis
posterior decelerates th pronating rearfoot and, if needed,
assists in a controlled lowering of th mediai longitudinal
arch. Through this eccentric action, th tibialis posterior ab-
sorbs some of th impact of loading. Persons who exces-
sively and/or rapidly pronate during th stance phase may
place excessive braking demands on th tibialis posterior,
possibly explaining their complaints of muscle soreness in
th lower mediai leg.53
Throughout th mid to late stance, th tibialis posterior,
flexor hallucis longus, and flexor digitorum longus help
guide th rearfoot toward supination as th lower leg exter-
nally rotates. During this time, th tibialis posterior, in par-
ticular, continues to support th mediai longitudinal arch.
M U S C U L A R P A R A L Y S IS F R O M IN JU R Y TO T H E
P E R O N E A L OR T IB IA L N E R V E S

Injury to th Common Peroneal Nerve and Its Branches

axis o f rotation, thereby providing this inuscle wich a
potential to invert th rearfoot.
Function of th Tibialis Posterior, Flexor Hallucis
Longus, and Flexor Digitorum Longus. The tibialis poste
rior, flexor hallucis longus, and flexor digitorum longus as
sist with th piantar fexion mechanics at th ankle during
th late stance phase of walking. The flexor hallucis longus
and flexor digitorum longus muscles are also flexors of th
distai joints of th toes. During mid and especially late
stance phase, active force in these muscles and in th lum-
bricals and interossei pulls th piantar surface of th hyper-
extendng toes frmly against th ground. This action ex-
pands th weight-bearing surfaces of th toes, thereby
minimizing contact pressures.55
The common branch of th peroneal nerve is located superf-
cially as it winds around th lateral neck of th fibula, just
deep to th peroneus longus. This nerve is mjured fre
q u e n ti from lacerations or trauma that involves a fractured
fibula. Injury to th deep branch of th peroneal nerve can
result in paralysis of all th dorsiflexor (pretibial) muscles
(see Fig. 1 4 -3 8 ). With paralysis of th dorsiflexor muscles,
th foot rapidly and uncontrollably piantar flexes following
floor contact. During th swing phase, th hip and knee
must excessively flex to ensure that th toes clear th
ground.
Paralysis of th dorsiflexor muscles dramatically increases
th likelihood of developing a fixed piantar flexion contrac-
ture at th talocrural joint. This deformity is called a drop-
foot or pes equinus. In a surprisingly short period of time, a

TABLE 1 4 - 9 . A Comparison of th Maximal Piantar Flexion Torque Potential of Muscles at th Talocrural

Jo in t

Muscle Estimated Maximal Force Potential (kg) Internai Moment Arm (cm) Torque Potential* (kg-cm)
Gastrocnemius 89.7 4.8 430.6
Soleus 78.0 4.8 374.4
Tibialis posterior 22.6 2.3 52.0
Peroneus longus 16.8 2.6 43.7
Flexor hallucis longus 17.6 2.3 40.5
Peroneus brevis 14.8 2.6 38.5
Flexor digitorum longus 10.9 2.3 25.1
Total 250.4 1004.8

Conversion: .098 N-m/kg-cm

* Torque potential is based on th muscles estimateci maxima! force potential (physiologic cross-sectionai area) and moment arm length.
 Chapter 14 Ankle and Foot 517

B i o m e c h a n i c s o f R a is in g u p o n T ip t o e s h e lp s t h in t r in s ic m u s c le s s u p p o r t t h m e d ia i lo n g it u d in a l
a r c h a n d m a in t a in a r ig id f o r e f o o t , t h e r e b y a llo w in g t h
T h e f u n c t io n a l s t r e n g t h o f t h p ia n t a r f le x o r m u s c le s is
f o o t t o a c c e p t t h lo a d im p o s e d b y b o d y w e ig h t .
o f t e n e v a lu a t e d b y r e q u ir in g a s u b j e c t t o r e p e a t e d ly s t a n d
o n t ip t o e s . A s s h o w n in F ig u r e 1 4 - 5 0 , m a x im a lly r a is in g
t h b o d y r e q u ir e s a n in t e r a c t io n o f t w o c o n c u r r e n t
t o r q u e s , o n e a t t h t a lo c r u r a l jo in t a n d o n e a t t h m e t a -
t a r s o p h a la n g e a l jo in t s . T h e p ia n t a r f le x o r m u s c le s , r e p r e -
s e n t e d b y t h g a s t r o c n e m iu s , p ia n t a r f le x t h talocrural
jo in t b y r o t a t in g t h c a l c a n e u s a n d t a lu s w it h in t h m o r -
t is e . T h e p r im a r y t o r q u e u s e d t o r a is e t h b o d y , h o w e v e r ,
is p r o d u c e d b y e x t e n s io n a c r o s s t h metatarsophalangeal
joints. A c t in g a b o u t t h e s e a x e s , t h g a s t r o c n e m iu s h a s a n
in t e r n a i m o m e n t a r m t h a t g r e a t ly e x c e e d s t h e x t e r n a l
m o m e n t a r m o w in g t o b o d y w e ig h t ( c o m p a r e B and C in
F ig . 1 4 - 5 0 ) . S u c h a la r g e m e c h a n ic a l a d v a n t a g e is r a r e in
t h m u s c u lo s k e le t a l S y s t e m . A c t in g a s a s e c o n d - c l a s s
le v e r w it h t h p iv o t p o in t a t t h m e t a t a r s o p h a la n g e a l
jo in t s , t h g a s t r o c n e m iu s lif t s t h b o d y u s in g m e c h a n ic s
s im ila r t o t h o s e o f a p e r s o n lif tin g a la r g e lo a d w it h a
w h e e lb a r r o w . If, f o r in s t a n c e , t h g a s t r o c n e m iu s f u n c t io n s
w it h a m e c h a n ic a l a d v a n t a g e o f 3:1 (i.e ., t h r a t io o f t h
in t e r n a l- t o - e x t e r n a l m o m e n t a r m , o r B/C in t h F ig u r e ) , t h
m u s c le n e e d s t o p r o d u c e a lif t in g f o r c e o f o n ly o n e t h ir d ,
o r 33 % , o f b o d y w e ig h t t o s u p p o r t t h p ia n t a r f le x e d
p o s it io n . R a r e ly in t h b o d y d o e s a m u s c le p r o d u c e a
f o r c e le s s t h a n t h lo a d it is s u p p o r t in g . A s a m e c h a n ic a l
t r a d e - o f f , h o w e v e r , t h g a s t r o c n e m iu s , in t h e o r y , n e e d s to
s h o r t e n a d is t a n c e t h r e e t im e s g r e a t e r t h a n t h v e r t ic a l
d is p la c e m e n t o f t h b o d y 's c e n t e r o f m a s s ( s e e C h a p t e r
1). M a x im a l c o n t r a c t io n o f t h g a s t r o c n e m iu s w o u ld p r o
d u c e a v e r t ic a l d is p la c e m e n t o f t h b o d y o n ly o n e - t h ir d
t h le n g t h o f t h m u s c le c o n t r a c t io n . N e v e r t h e le s s , t h
FIGURE 14-50. A mechanical model shows th biomechanics of
n a t u r e o f t h is t r a d e - o f f a l l o w s o n e t o s t a n d u p o n t ip t o e s
standing on tiptoes. The force of a contracting gastrocnemius mus
w it h r e la t iv e e a s e .
cle acts with a relatively short internai moment arm from th
F ig u r e 1 4 - 5 0 s h o w s t h im p o r t a n c e o f a m p ie h y p e r e x -
talocrural joint (A), and a relatively long internai moment ann from
t e n s io n r a n g e o f m o tio n a t t h m e t a t a r s o p h a la n g e a l th metatarsophalangeal joints (B). Once on tiptoes, th line-of-
jo in t s . N o t o n ly d o t h p ia n t a r f le x io n m u s c le s u s e t h e s e gravity due to body weight falls just posterior to th axis of rotation
jo in t s t o a u g m e n t t h e ir in t e r n a i m o m e n t a r m , b u t, a s d e - at th metatarsophalangeal joints. As a result, body weight acts with
s c r ib e d e a r lie r , h y p e r e x t e n s io n o f t h e s e j o in t s p u lls t h a relatively small external moment arm (C) from th metatarsopha
p ia n t a r f a s c i a t a u t v ia t h w i n d l a s s e f f e c t . T h is a c t io n langeal joints.

piantar flexed posture may lead lo an adaptive shortening
and tightening of th Achilles tendon. The relentless pul of
gravity often contributes to a plantar-flexed posture, often
requiring an orthosis to maintain adequate dorsiflexion while
walking.
An injury to th supcrficial branch of th peroneal nerve
resulting paralysis of th dorsiflexor and peroneal muscles
predisposes a person to a fixed deformity of combined pian
tar flexion of th talocrural joint and supination of th foot,
a condition referred to as pes equinovarus.
In ju ry to th T ib ia l N e rve

may result in paralysis of th peroneus longus and peroneus
brevis (see Fig. 1 4 -3 8 ). Over time, paralysis may lead to a
fixed supinated or inverted posture of th foot, a condition
called pes vams. An injury to th common peroneal nerve
may involve both deep and superficial nerve branches. The
Injury to th tibial nerve may cause varying levels of weak-
ness or paralysis in th muscles of th posterior compart-
ment (see Fig. 1 4 -3 9 ). Paralysis of th gastrocnemius and
soleus results in profound diminution in piantar flexion
torque. Over time, a fixed dorsiflexion posture may result at
 518 Section /V Lower Exlremity

TABLE 1 4 - 1 0 . Common Fixed Deformities or Abnormal Postures of th Ankle and Foot from Muscle
Paralysis*

Fixed Deformity or Abnormal Common Muscle Paralysis and Associated Examples of Subsequent
Posture Clinical Name Nerve Injury Musculotendinous Shortening
Piantar llexion of th talocrural Drop-foot or pes Paralysis of pretibial muscles from in Gastrocnemius, soleus
joint equinus jury to th deep branch of peroneal
nerve
Inversion (supination) of th Pes varus Paralysis of th peroneus longus and Tibialis posterior
foot brevis from injury io th superficial
branch of th peroneal nerve
Piantar flexion of th talocrural Pes equinovarus Paralysis of th dorsiflexor and pero Gastrocnemius, soleus and tibi
joint and supination of th neal muscles from injury to th alis posterior
foot common peroneal nerve
Dorsi flexion of th talocrural Pes calcaneus Paralysis of th piantar flexor muscles Pretibial muscles
joint from injury to th tibial nerve
Eversion (pronation) of th foot Pes valgus Paralysis of th supinator muscles from Peroneal muscles
injury to th tibial nerve
Dorsiflexion of th talocrural Pes calcaneovalgus Paralysis of all th muscles in th pos Pretibial and peroneal muscles
joint and eversion of th foot terior compartment of th leg from
a severance of th tibial nerve just
proximal to th popliteal fossa

* The foot refers to ihe subtalar and transverse tarsal joints.

th talocrural joint, a condition krtown as pes calcaneus. The
name calcaneus reflects th prominent heel pad that forms
as a response to th heel of th dorsiflexed foot repeatedly
striking th ground.
Paralysis involving primarily th supinator muscles may
result in a fixed pronated deformity of th foot, primarily th
result of th unopposed pul of th peroneus longus and
brevis. The terni pes valgus describes both eversion and ab-
duction components of th pronation deformity. Paralysis
involving all th muscles of th posterior compartment in-
creases th potential for a fixed deformity called pes calcaneo-
valgus.
The common fixed deformities or abnormal postures of
th ankle and foot are summarized in Table 1 4 -1 0 .
INTRINSIC M U S C L E S
A n a to m ie a n d F u n c tio n a l C o n s id e ra tio n s
Intrinsic muscles are those that originate and insen within
th foot. The following discussion highlights th primary
attachments and actions of th intrinsic muscles. More de-
tailed material is presented in Appendix IVC.
1 he dorsum of th (oot has one intrinsic muscle, th
extensor digitorum brevis, which is innervated by th deep
branch of th peroneal nerve (see Figs. 1 4 - 3 5 and 1 4 -4 1 ).
The extensor digitorum brevis originates on th dorsal-lateral
surface of th calcaneus, just proximal to th caicaneocuboid
articulation. l'he muscle belly sends four tendons: one to th
dorsal surface of th first toe, often designated as th exten
sor hallucis brevis, and three that join th tendons of th
extensor digitorum longus of th second through th fourth
toes.5'5 The extensor digitorum brevis assists th extensor
hallucis longus and extensor digitorum longus muscles in
extension of th toes.
The remaining intrinsic muscles of th foot originate and
insert within th piantar aspect of th foot. Anatomically
these muscles are organized in a fashion similar to th in
trinsic muscles of th hand. One major difference, however,
is that th foot does not contain muscles that oppose th
first and fifth digits. The intrinsic muscles of th piantar
aspect of th foot can be organized into four layers (Fig. 1 4 -
51A to C). The piantar fascia is located just superficial to th
first layer of muscles.
l. a y e r 1
The intrinsic muscles in th first layer are th (lexor
digitorum brevis, abductor hallucis, and abductor digiti min
imi (Fig. 145 1A). As a group, they originate on th lateral
and mediai processes ol th calcaneal tuberosity and nearby
connective tissues. The flexor digitorum brevis attaches distally
to both sides of th middle phalanges of th four lesser toes.
Proximal lo this distai attachment, each tendon divides to
allow passage of th tendons of th flexor digitorum longus.
Note th similar relationship between th flexor digitorum
superficialis and profundus of th hand. The flexor digito
rum brevis assists th flexor digitorum longus in flexing th
toes. The abductor hallucis forms th mediai border of th
foot, providmg a covered passage for th piantar nerves that
enter th piantar aspect of th foot. The abductor muscle
 Chapter 14 Ankle and Foot 519

Intrinsic muscles of th foot

lst la ver 2nd laver 3rd and 4th lavers

Flexor digitorum
Abductor
brevis (cut)
hallucis Adductor hallucis
(cut) (transverse head) Abductor hallucis
Sesamoids
(cut)
Abductor digiti Lumbricals
minimi (cut) Piantar interassei Adductor hallucis
Flexor (oblique head)
Abductor hallucis
Abductor Flexor digiti minimi Flexor hallucis
hallucis longus
digiti brevis
minimi Flexor Flexor Peroneus brevis
digitorum Quadratus digitorum
brevis plantae longus Tibialis posterior
Peroneus longus

Long piantar
Piantar fascia ligament
(cut)

P ia n t a r a s p e c t

FIGURE 14-51. The intrinsic muscles of th piantar aspect of th foot are organized into four layers.

attaches dstally to th mediai border of th proximal pha-

lanx of th frst toe, together with th mediai head of th
flexor hallucis brevis (Fig. 1 4 -5 1 C ). The abductor digiti min
imi forms th lateral-plantar margin of th loot, attaching
dstally to th lateral border of th base of th proximal
phalanx of th ffth toe. Each muscle abducts and flexes its
respective digit.
Intrinsic Muscles of th Foot, Laycr 1
Flexor digitorum brevis
Abductor hallucis
Abductor digiti minimi
I.ayer 2
The intrinsic muscles in th second layer are th quadra
tus plantae and th lumbricals (Fig. 14-51J3). Both muscles
are functionally related to th tendons of th ilexor digito
rum longus. The quadratus plantae (flexor digitorum accesso-
rius) attaches by two heads to th piantar aspect of th
calcaneus. Both heads attach dstally on th lateral edge of
th common tendon of th flexor digitorum longus. The
quadratus plantae helps to stabilze th tendons of th flexor
digitorum longus, preventng them from migrating medially
when under force. The four lumbricals have their proximal
atiachment from th tendons of th flexor digitorum longus.
These small fleshy muscles pass on th mediai side of th
lesser toes to attach into th extensor digitai expansion. They
can flex th metatarsophalangeal joint and extend th inter-
phalangeal joints.
Intrinsic Muscles of th Foot, I.ayer 2
Quadratus plantae
Lumbricals
Layer 3
The intrinsic muscles in th third layer are th adductor
hallucis, flexor hallucis brevis, and flexor digiti minimi (Fig.
1 4 -5 1 C ). As a whole, these short muscles arise from th
piantar aspect of th cuboid, cuneifonrts, and bases of more
centrai metatarsal bones, and from th locai conneclive tis-
sues. As in th hand, th adductor hallucis arises from two
heads: oblique and transverse. Both heads attach to th lat
eral base of th proximal phalanx of th First toe and adja-
cent lateral sesamoid bone. The muscle flexes and adducts
th metatarsophalangeal joint of th first toe. The flexor hal
lucis brevis has two heads that attach dstally to th mediai
and lateral sides of th base of th proximal phalanx of th
first toe. Mediai and lateral sesamoid bones are located
within th two tendons of this muscle, providing padding to
th head of th First metatarsal. The flexor digiti minimi at
taches to th lateral base of th proximal phalanx of th ffth
toe, together with th abductor digiti minimi. Both muscles
flex th metatarsophalangeal joint of their respective toes.
Intrinsic Muscles of the Foot, Layer 3
Adductor hallucis
Flexor hallucis brevis
Flexor digiti minimi
 520 Section IV Lower Extremity
Layer 4
The fourth layer of intrinsic muscles contains three pian
tar and four dorsal interassei muscles. The piantar interassei
are shown in Figure 1 4 -5 1 C , along with th muscles of th
third layer. The dorsal interassei are illustrated in Figure
1 4 - 3 5 . The overall pian of th interassei is nearly identical
to that of th hand, except that th reference digit for
abduction/adduction of th toes is th second, instead of th
third.
Intrinsic Muscles of th Foot, l.ayer 4
Piantar interassei (3)
Dorsal interassei (4)
The dorsal interassei are two-headed, bipennate muscles.
The second digit contains two dorsal interassei, whereas th
third and fourth digit each contain one. All dorsal interassei
insert on th base of th proximal phalanges; th frst and
second interassei insert on th mediai and lateral side of th
second digit, respectively, and th third and fourth dorsal
interossei insert on th lateral side of th third and fourth
digit (see Fig. 1 4 - 4 ). Each dorsal interosseus muscle ab-
ducts th metatarsophalangeal joint. The third, fourth, and
fifth digit each contain a piantar interosseus muscle. Each
muscle consists of one head and inserts on th mediai side
of th base of th corresponding proximal phalanx (see Fig.
1 4 - 5 ). These muscles adduct their respective metatarsopha
langeal joint.
The actions assigned to each of th intrinsic muscles in
th previous section are based on th assumption that th
foot is unloaded and th toes are free to move. Although
these unique actions allow th clinician to test th strength
and dexterity of these muscles, th actions are not very
relevant functionally. The intrinsic muscles of th foot are
used less for manual dexterity, such as in th hand, and
more for providing balance and, most notably, adding rigid-
ity to th foot and stabilizing th mediai longitudinal arch
during push-off phase. This latter function explains why th
intrinsic muscles are maximally active during late stance, just
as th heel is rising off th floor (see Fig. 1 5 -2 9 ).
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9 Elveru RA, Rothstein JM, Lamb RL, et al: Methods for taking subtaar
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18. Inman VT, Saunders JB: Referred pain from skeleta! siructures. J Nerv
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29. McCulloch MU, Brunt D, Vander Linden D: The effect of foot orthotics
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lon torque with and withoui th triceps surae. Acta Orthop Scand 47
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33. Murray MP, Guten GN, Sepie SB, et al: Function of th triceps surae
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36. Pearce TJ, Buckley RE: Subialar joint movement: Clinical and computed
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38. Powers CM, Maffucci R, Hampton S: Rearfoot posture in subjecis with
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 Chapter 14 Ankle and Fool 521

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ADDITIONAL READINGS
Basmajian JV, Bentzon JW: An electromyographic study of certain muscles
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662-666. 1954.
Chan CW, Rudins A: Foot Biomechanics dunng walking and running Mayo
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Oatis CA: Biomechanics of th foot and ankle under static conditions. Phys
Ther 68:1815-1821, 1988.
 C h a p t e r 15

Kinesiology of Walking
Guy G. Sim o n ea u , PT, P h D, ATC

TOPICS AT A GLANCE

HISTORICAL PERSPECTIVE OF GAIT JOINT KINEMATICS, 535 Knee, 550

ANALYSIS, 524
SPATIAL ANO TEMPORAL DESCRIPTORS,
527
Gait Cycle, 527
Stance and Swing Phase, 529
DISPLACEMENT AND CONTROL OF THE
BODY'S CENTER OF MASS, 533
Displacement of th Center of Mass, 533
Kinetic and Potential Energy
Considerations, 534
Sagittal Piane Kinematics, 535 Ankle and Foot, 550
Frontal Piane Kinematics, 539 Trunk, 551
Horizontal Piane Kinematics, 542 GAIT KINETICS, 551
Trunk and Upper Extremity Kinematics, 543 Ground Reaction Forces, 551
Kinematic Strategies to Minimize Energy Path of th Center of Pressure, 553
Expenditure, 545 Joint Torques and Powers, 553
ENERGY EXPENDITURE, 547 Joint/Tendon Forces, 560
MUSCLE ACTIVITY, 547 GAIT DYSFUNCTIONS, 560
Hip, 548

INTRODUCTION This chapter provides a description of th fundamental

Walking (ambulation) serves an individual's basic need to
move from place to place. As such, walking is one of th
most common activities that people do on a daily basis.
Ideally, walking is performed both efficiently, to minimize
fatigue, and safely, to prevent falls and associated injuries.
Years of practice provide a healthy person with th control
needed to ambulate while carrying on a conversation, look-
ing in various directions, and even handling obstacles and
other destabilizing forces with minimal effort.
Although a healthy person gives walking th appearance
of an effortless task, th challenge of ambulation can be
recognized by looking at individuals at both ends of th
lifespan (Fig. 1 5 - 1 ). Early in life, th young child needs
several rnonths to leam how to stand and walk. In fact, it is
only by th age of 7 years that all th refinements of a
mature gait pattern are completed.76 Late in life, walking
often becomes an increasingly greater challenge. Because of
decreased strength, decreased balance, or disease, th elderly
may require a cane or walker to ambulate safely. Patla6'1
eloquently expressed th importance of ambulation in our
lives: Nothing epitomizes a level of independence and our
perception of a good quality of life more than th ability to
travel independently under our own power from one place
to another. We celebrate th development of this ability in
children and try io nurture and sustain it throughout th
lifespan.
kinesiologic characteristics of gait (see th box). Unless tndi-
cated otherwise, th information provided refers to individu
als with a normal and mature (age greater than 7 years) gait
pattern, walking on level surfaces at a steady average speed.
The chapter also provides enough details to be read inde
pendently of th rest of this book. The reading of chapters
12, 13, and 14, however, will facilitate a more thorough
understanding of walking.
M ajo r T o p ics
Spatial and temperai descriptors
Control of th bodys center of mass
Joint kinematics
Strategies to minimize energy expenditure
Energy expenditure
Muscle activity
Gait kinetics
Gait dysfunctions
The observation of gait, which is th focus of this chap
ter, provides information on th outcome of a complex set
of behind th scenes interactions between sensory and mo-
tor functions. For a person to walk, th centrai nervous
System must generate appropriate motor actions from th
integration of visual, proprioceptive, and vestibular sensory
523
 524 Section IV Lower ExtremUy

FIGURE 15-1. Walking at various stages in life.

inputs. Although this chapter covers th intricacy of lim
and muscular actions performed during walking, it does noi
cover th concept of motor control. To gain a greater under-
standing of th complexity of th motor control of gait, th
reader is advised to examine other sources on th topic,
such as Shumway-Cook and Woollacott, 1995,76 and Mas-
deu et a l, 1997.49
novel methods of measurements are shoes that had air
chambers attached to a recorder to indicate th swing and
stance phase of gait (Fig. 15 2).47-48 Another clever idea was
th use of ink in small spray nozzles attached to th shoes
and limbs.87 The ink sprayed on th floor and wall as th
b

HISTORICAL PERSPECTIVE OF GAIT

ANALYSIS

The Weber brothers (Wilhelm, a physicist/electrician, and

Eduard, an anatomist/physiologist)94 published th frst sci-
entifc work on gait in 1836. Using instruments, such as a
chronometer and a telescope with a scale, they described
and measured elements of gait, such as step length, cadence,
foot-to-ground clearance, and vertical excursion of th body.
They also defined basic elements of th gait cycle, such as
swing phase, stance phase, and double-limb support periods.
Many of th terms they introduced remain in use today. The
Webers hypothesized that th basic principle of walking is
one of least muscular effort a concept known to be true
today, although th exact methods by which th body mini-
mizes energy expendtture are stili not fully understood. An
extensive account of their work was published in 1894 and
later translated in 1992.9596
In th 19th century, other researchers, such as Marey and
Vierordt, made use of ingenious technology to expand our FIGURE 15-2. Mareys instrumented shoes used for th measure-
knowledge of gait. Most often cited among Mareys many ment of gait. (From Marey, 1873.)
 Chapter 15 Kinesiology of Walking 525

individuai walked and provided a permanent record of
movement.
Concurrently, advances in th field of cinematography
created a powerful medium to study and record th kine-
matic patterns of humans and animals walking. Muybridge
may be th most recognized individuai of his time to use
cinematography to document sequence ol movements. Muy
bridge is most famous for settling an old controversy regard-
ing a trotting horse. In 1872, using sequence photography,
he showed that all four feet of a trotting horse are indeed
simultaneously off th ground for very brief periods of lime.
Muybridge created an impressive collection of photographs
on human and animai gait, which was initially published in
1887 and assembled and reproduced in 1979.60-6'
Initially, th description of gait was limited to planar
analyses; th motion was typically recorded in th sagittal
piane and less frequently in th frontal piane. Braune and
Fisher67 are credited as being th first researchers, from
1895 to 1904, to perform a comprehensive three-dimen-
sional analysis of a walking individuai. By using four cam-
eras (two pairs of cameras recording motion for each side of
th body) and a number of light tubes attached to various
body segments, they documented joint kinematics in three
dimensions. They were also th first to use th principles of
mechanics to measure dynamic quantities such as segmentai
acceleration, segmentai inertial properties, and intersegmental
loads (e.g., joint torques and forces). Their analysis of joint
torques, limited to th swing phase of gait, dispelled th
earlier concept, suggested by Weber and Weber in 1836,
that lower extremity motion during th swing phase of gait
was explained by a passive pendulum theory.
Throughout th 20th century, th understanding of walk-

FIGURE 15-3. A sample of th technology

used by Murray to record th basic kine
matics of gait. An older man (A) and a
' ^rrr- ' i pi t n

1i \ ncww www*////,,
young boy (B) wear reflective targets while
walking in a semidark hallway. Using a
camera with th shutter opened, light was 'muti, 1
flashed 20 times per second to track th
location of th markers. An additional
.................. ' ' 7 ! V. 7 7 tat
brighter flash of light was used to photo- \\ j .
graph th man or boy while they were
walking. This early technique allowed th v :
visualization of an entire gait cycle with a
single photograph. A ceiling-mounted mir
rar was also employed to observe horizon-
tal piane motion. (A, From Murray MP,
Gore DR: Gait of patients with hip pain or
loss of hip joint motion. In Black J , Dum-
bleton JH (eds): Clinical Biomechanics: A
Case llistory Approach. New York,
Churchill Livingstone, 1981; B, from Stra-
tham L, Murray MP. Early walking pat
terns of normal children. Clin Orthop 79:
8, 1971.)
 526 Section /V Lower Extremity
The G ait Laboratory
FIGURE 15-4. Instrumentation used in a typical laboratory to study
gait.
ing was greatly enhanced by many scientific advances. In-
strumentation to document kinematics evolved from simple
video cameras, with film that required painstaking analysis
with a ruler and protractor, to highly sophisticated infrared
Systems, with real-time coordinate data of limb segments.
Notable researchers who contributed to th description of
th kinematics of gait using a variety of imaging techniques
include Eberhart (1 9 4 7 ),17 Murray (1967),53 54 Inman (1 9 8 1 ),34
Winter (1991),98 and Perry (1992).67 Noteworthy is th
work by Murray, a physical therapist and researcher, who
published several papers in th 1960s, 1970s, and 1980s,
describing th kinematics of many aspects of normal and
abnormal gait (Fig. 1 5 - 3 ) .52'55-56-59 Among other accomplish-
ments, data from her research on th kinematics of walk-
ing in individuals with disabilities influenced th design of
artificial joints and lower extremity prosthetic limbs.
Similarly, a more extensive understanding of th kinetics
of gait was made possible through th development of de-
vices to measure th forces taking place at th foot-ground
interface. Amar (1916),3 Elftman (1 9 3 8 ),18 and Bresler and
Frankel (1950)8 all made significant contributions in this
field. With th ability to measure th forces between th foot
and th ground carne computational methods to calculate
th forces and torques taking place at th joints during
ambulaton.65-77'100
Surface and intramuscular electrodes can also be used to
record th electrical activity pattern of muscles during gait.
When this information is integrated with th kinematics of
walking, th role that each muscle plays during gait is de-
scribed. Many researchers, including Sutherland, Perry', In-
man, and Winter, have made notable contributions to th
study of electromyography (EMG) during walking. Knutson
and Soderberg41 provide a summary of th application of
EMG in th study of gait.
Today, gait analysis is routinely performed in specialized
biomechanics laboratories (Fig. 1 5 - 4 ). Three-dimensional
kinematic data are obtained by using two or more synchro-
nized high-speed cameras. Ground reaction forces are mea-
sured utilizing force platforms embedded in th floor. Mus
cle activity pattems are recorded by multichannel EMG
systems. Ultimately, lower extremity joint forces, torques,
and powers are calculated with a combination of kinematic
data, ground reaction forces, and anthropometric characteris-
tics of th individuai (Fig. 155). These data are then used
to describe normal and abnormal gait.
Patients with a variety of pathologies can benefit from
instrumented gait analyses. The primary beneficiaries of this
technology, however, are children with cerebral palsy. In this
population, instrumented gait analysis is often used prior to
surgery to help determine th proper intervention. It is em-
ployed again after surgery to objectively evaluate th out-
come.27 Comprehensive descriptions of th tools and meth
ods used for gait analysis can be found in several other
sources, such as Vaughan et al., 1992;86 Whittle, 1996;97
Harris and Smith, 1996;33 and Allard et al., 1997.2
Sophisticated technology, such as that described here,
provides detailed information that can enhance th ability io
describe and understand gait. Such technology is rarely
available in th typical clinical setting, however. Clinicians
must routinely rely on direct visual observation to evaluate
th gait characteristics of their patients. Such observational
analysis requires a thorough knowledge and understanding
of normal gait. Learning about gait, as presented here, is a
FIGURE 15-5. Typical approach used
for th analysis of human motion.
Variables in th shaded ovals can be
precisely measured. Computational
methods, in th rectangles, are used
to calculate th variables in th non-
shaded ovals.
 Chapter 15 Kinesiology of Walking 527

The G ait C yde

Stride (gait cycle)

Left step 1 Righi step

FIGURE 15-6. The gaie cycle from righi heel contact to th subsequent right heel contact.

more dynamic experience if th reading and studying of this
chapter are combined with th observing of th gait pattems
of relatives, friends, and neighbors.
SPAT1AL AND TEMPORAL DESCRIPTORS ______
This section describes measurements of distance and Urne as
related to walking.
Gait Cycle
Walking is th result of a cyclic series of movements. As
such, it can be convenienti) characterized by a detailed de-
scription of its most fundamental unii: a gait cycle (Fig.
1 5 - 6 ) . The gait cycle is initiated as soon as th foot contacts
th ground. Because foot contact is normally made with th
heel, th 0% point or beginning of th gait cycle is referred
to as heel contact, or heel strike. The 100% point or comple-
tion of th gait cycle occurs as soon as th same foot once
again makes contact with th ground. A stride (synonymous
with a gait cycle) is th sequence of events taking place
between successive heel contacts of th same foot. In com-
parison, a step is th sequence of events that occurs within
successive heel contacts of opposite feet, for example, be
tween right and left heel contacts. A gait cycle, therefore, has
two steps a left step and a right step.
The most basic spatial descriptors of gait include th
length of a stride and th length of a step (Fig. 1 5 - 7 ). Stride
length is th distance between two successive heel contacts of
th same foot. Step length, in contrast, is th distance be
tween successive heel contacts of th two different feet.
Comparing righi with left step lengths can help to evaluate
th symmetry of gait between th lower extremities (Fig.
1 5 - 8 ). Step width is th lateral distance between th heel
centers of two consecutive foot contacts and normally ranges
from 7 to 9 cm (Fig. 1 5 - 7 ) . Foot angle, th degree of toe-
out, is th angle between th line of progression of th

Spatial Descriptors of G ait

Right
heel
contact

Step width = 7-9 cm

FIGURE 15-7. Spatial descriptors of gait and their normal values for a right gait cycle.
 528 Section /V Lower Exlremity

A. NORMAL G A IT B. P A I N F U L H IP G A IT

A A FIGURE 15-8. Influence of impairmem and pa-

/V /
|- ------------ 78 c . --- H
RIGHI LEfT
t
H----- 78 -------- -J
LEFT RIGHI
z_u
I- R itaH | 31 ca|
thology on siep lengih. A illustraies ihe symmetri-
cal siep length expected in a healthy individuai. B
and C are examples of siep length asymmetry
often seen in those wiih an impairment or a pa-
SOUND I M P A I R E D I M P A I R E D SOUND
UMB UMB LIMB LIMB LIMB UMB UMB UMB thology thai affects a single lower extremity. Noie
thai th unilaieral paihology in C resulted in bi-
lateral shortening of th normal step length, dem-
C . H E M IP A R E S IS G A IT
D. PARKINSON'S DISEASE onstrating th interdependence of th lower ex-
GAIT iremities during gaii. D illusirates a relatively
symmetrical bilateral reduction in step length sec-
ondary to Parkinsons disease, a pathology ihat
often affects both lower exiremities. (From Mur
ray MP: Gait as a total pattern of movement. Am
J Phys Med 46:290, 1967.)

R 33c.4 f27c4 |26t| |

-24ca
|
SOUND PARETIC PARE TIC SOUND
RIGHI LEFT LEFT RIGHI
UMB LIMB UMB UMB
UM B LIMB UMB UMB

body and th long axis of th foot. About 7 degrees is
considered normal.53
The most basic lemporal descriptor of gait is cadence, th
number of steps per minute, which is also called step rate.
Other temporal descriptors of gait are strde lime (th lime
for a full gait cycle) and step lime (th time for th comple-
tion of a right or a left step). Note thai in normal symmetri
cal gait, step time can be derived from cadence (i.e., step
time is th reciprocai of cadence).
typically meters per second (m/s) or miles per hour (mph).
Speed can be calculated by measuring th time it takes to
cover a given distance, or th distance covered in a given
amount of time, or by multiplying th step rate by th step
length. Walking speed varies considerably between persons
based on factors such as age and physical characteristics,
such as height and weight.15 Of all spatial and temporal
measurements of gait, speed may be th best and most
lunctional measure of an individuala walking ability.
Among normal adults, a gait cycle (i.e., two consecutive
steps) takes slightly more than 1 second and covers approxi-
mately 1.44 meters (4.5 feet), representing a speed of 1.37
m/s. Data in Table 1 5 - 1 indicate that, at a freely chosen
walking speed, women exhibit a slower walking speed,
shorter step length, and faster cadence than men. These
differences are likely in part reflective of anthropometric dis-
parities between genders. Interestingly, even when anthropo-
metrically matched with men, women demonstrate a htgher
cadence and shorter step length than men when walking at a
standard speed.2l 5fi

Walking speed combines both spatial and temporal mea-

surements by providing information on th distance covered 1here are two strategies to raise walking speed: increasing
in a given amount of time. The units of measurements are th stride, or step length, and increasing th cadence (Fig
 Chapter 15 Kincsiology of Walking 529

J T A B L E 1 5 - 1 . Normative Data for W alking Speed, Step Rate, and Step Length f

Drillis (1961) Molen (1973) Finley and Cody (1970) Average Over
(New York City) (Amsterdam) (Philadelphia) Gender and City

Walking speed (m/s) 1.46* 1.39 (males) 1.37 (males) 1.37

1.27 (females) 1.24 (females)
Step rate (steps/s) 1.9* 1.79 (males) 1.84 (males) 1.87
1.88 (females) 1.94 (females)
Step length (m) 0.76* 0.77 (males) 0.74 (males) 0.72
0.67 (females) 0.63 (females)

* M ales a n d fem ales are avcraged to g e th e r for th ese data.

D ata o b ta in e d fro m 2 3 0 0 p e d estria n s im aw are of b e in g o b se rv ed a s ihey w alked

1 5 - 9 ). Typically, an individuai combines both sirategies un- using th right lower extremity as a reference. A full gait
til th longest comfortable step length is reached. From that cycle for th right lower extremity can be divided into two
point on, a further increase in speed is solely related to major phases stance and swing (Fig. 1 5 - 1 0 ). Stance phase
increased cadence. All measurements o f gait (spadai, temporal, (from right heel contact to righi toe off) occurs as th righi
kinematic, and kinetic) depend on walking speed. For proper foot is on th ground, supporting th bodys weight. Swing
referente and interpretation, therefore, reports of gait charac- phase (from right toe off to th next right heel contact)
teristics should include th walking speed at which th data occurs as th right foot is in th air, being advanced forward
were collected. for th next contact with th ground. At normal walking
speed, th stance phase occupies approximately 60% of th
gait cycle, and th swing phase occupies th remaining 40%.
Stance and Swing Phase
To help describe events taking place during th gait cycle, it
is customary to subdivide th gait cycle from 0 to 100%. As
stated earlier, heel or foot contact with th ground is consid-
ered th start of th gait cycle (0% ) and th next ground
contaci made by th same foot is considered th end of th
gait cycle (100% ). Throughout this chapter, gait is described

FREE SPEED W A L K IN G

FIGURE 15-9. Methods to increase walking speed. A illustrates th longer step length used to increase walking speed;
B illustrates th walking cadence used at a faster walking speed. The duration of th gait cycle is reduced from 1.08
seconds to 0.91 second. B also illustrates that at th faster walking speed, a smaller percemage of th gait cycle is
spent in double-limb support (i.e., 16% at fast speed compared with 24% at free speed walking). (A from Murray MP,
Kory RC, Clarkson BH, Sepie SB: Comparison of free and fast speed walking patterns of normal men. Am J Phys Med
45:8, 1966; B Modified from Murray MP, Gore DR, Clarkson BH: Walking patterns of patients with unilateral hip
pain due to osteoarthritis and avascular necrosis. J Bone Joint Surg 53A:259, 1971.)
530 Section IV Lower Extremity
Simple Clinica) Measurements of Gait
S o p h is t ic a t e d in s t r u m e n t a t io n , s u c h a s w a l k w a y s a n d
f o o t s w it c h e s , e x is t s t o m a k e s p a t ia l a n d t e m p o r a l m e a
s u r e m e n t s o f f o o t p la c e m e n t d u r in g g a it .88 F o r m o s t c l i n
ic a ! a p p lic a t io n s , t h is in f o r m a t io n c a n , h o w e v e r , b e
m e a s u r e d w it h r e a d ily a v a ila b le t o o ls a n d a lit t le im a g i-
n a tio n . A v e r a g e w a lk in g s p e e d c a n b e m e a s u r e d u s in g
a s t o p w a t c h a n d a k n o w n d is t a n c e . S t e p le n g t h a n d
s t e p w id t h c a n b e m e a s u r e d b y t h u s e o f in k m a r k s
m a d e b y s h o e s o r f e e t o n a r o ll o f p a p e r c o v e r in g th
f lo o r . T h is t e c h n iq u e w o r k s e s p e c i a l l y w e ll t o d o c u m e n t
a b n o r m a l g a it p a t t e r n s , in c lu d in g a s y m m e t r y in s t e p
le n g t h .
C lin ic a lly , s im p le m e a s u r e m e n t s o f w a lk in g s p e e d
a n d d is t a n c e c a n b e h e lp f u l in m o n it o r in g f u n c t io n a l
p r o g r e s s o r d o c u m e n t in g f u n c t io n a l lim it a t io n s . R e s u lt s
o b t a in e d f r o m a p a t ie n t c a n b e c o m p a r e d w it h n o r m a l
v a lu e s p r o v id e d in T a b le 1 5 - 1 , o r w it h m in im u m s t a n -
d a r d s r e q u ir e d t o p e r f o r m a s p e c i f i c t a s k , s u c h a s
C r o s s in g a S t r e e t w it h in t h t im e a llo w e d b y t h s t o p -
lig h t s . 22-23-45-71-90 91 T h e f o llo w in g a r e t w o p r o p o s e d m in i
m u m s t a n d a r d s , b a s e d o n c o m m u n it y - liv in g a c t iv it ie s :
t h a b ilit y t o w a lk 3 0 0 m (100 0 f e e t ) in le s s t h a n 11.5
m in u t e s ( w a lk in g s p e e d o f 0 .45 m /s o r 1 m p h ); t h a b ilit y
t o w a l k a t a s p e e d o f 1.3 m /s (3 m p h ) f o r 13 t o 27 m (42
t o 85 f e e t ) in o r d e r t o c r o s s a S t r e e t s a f e ly .
Within a gait cycle, th body experiences two periods ol
double-limb support (when both feet are in contact with th
ground simultaneously) and two periods of single-limb sup
puri (when only one foot is on th ground) (see Fig. 1 5 -
10). We observe th first period of double-limb support
between 0 and 10% of th gait cycle. During that time
period, th bodys weight is being transferred from th left
to th right lower extremity. The right lower extremity is
then in single-limb support until 50% of th gait cycle.
During that time, th left lower extremity is in its swing
phase, being advanced forward. The second period of dou
ble-limb support takes place between 50% and 60% of th
gait cycle and serves th purpose of transferring th weight
of th body from th right to th left lower extremity. Fi-
nally, from 60 to 100% of th gait cycle, th body is again
m single-limb support, this time on th left lower extremity.
This period of left single-limb support corresponds to th
swing phase of th right lower extremity.
As gait speed increases, th percentage of th gait cycle
spent in periods of double-limb support becomes shorter
(see Fig. 1 5 - 9 ). Race walkers aim to walk as fast as possible
while always keeping one foot in contact with th ground.
For these alhletes, greater speed is achieved by increasing
cadence and stride length and by minimizing periods of
double-limb support to th point where stance and swing
phase times are about equal. Walking speed during race
walking can be in excess of 3.3 m/s (7.5 mph).58-80
In running, th periods of double-limb support disappear
altogether to be replaced by periods when both feet are off
th ground simultaneously. The transition from walking to
running normally takes place at a step rate of approximately
 Chapter 15 Kinesiology of Walking 531

180 steps/minute or at a speed of approximately 2.0 m/s
(4.5 mph). Above 2.0 m/s it is more energy effcieru to run
than walk.
Conversely, at a slow walking speed, th periods of dou-
ble-limb support occupy an increasingly greater percentage
of th gait cycle. A slower gait provides greater stability
because both feet are on th ground simultaneously for a
greater percentage of th cycle. In fact, th reduced speed,
shorter step length, and slower cadence commonly seen in
th elderly serve to improve gait stability and prevent falls.
Subdivisions o f stance and swing phases: Traditionally, five
events are defined to occur during stance phase: heel con
tact, foot fiat, mid stance, heel off (or heel rise), and toe off
(Fig. 1 5 - 1 1 and Table 1 5 - 2 ). Heel contact is defined as th
instant th heel comes in contact with th ground, at 0% of
th gait cycle. Foot fiat corresponds to th instant th entire
piantar surface of th foot comes in contaci with th ground.
This event occurs at approximately 8% of th gait cycle. Mid
stance is most often defined as th point where th bodys
weight passes directly over th supporting lower extremity. It
is also defined as th time when th foot of th lower
extremity in th swing phase passes th lower extremity in
th stance phase (i.e., th feet are side by side). A third
definition of mid stance is th lime when th greater tro-
chanter of th femur is vertically above th midpoint of th
supporting foot in th sagittal piane. In reality, these three
definitions all correspond to about 30% of th gait cycle or
50% of th stance phase. Heel off, which occurs at approxi
mately 40% of th gait cycle, is th instant th heel comes
off th ground. Toe o ff occurs at 60% of th gait cycle. It is
defined as th instant th toes come off th ground.
A period referred to as push o ff is also often used. This
period roughly corresponds to th movement of ankle pian
tar flexion from 40 to 60% of th gait cycle.

TABLE 1 5 - 2 . Common Terminology Defining th Subdivisions of th Gait Cycle

Phases Events % o f Cycle Events o f O pposite Limb

Heel contact 0
Foot fiat 8
10 Toe off
Stance Mid stance 30 Mid swing (2 5 -3 5 % )
Heel off 40
50 Heel contact
Toe off 60

Early swing 6 0 -7 5
Swing Mid swing 7 5 -8 5 Mid stance (80% )
Late swing 8 5 -1 0 0
90 Heel off
Heel contact 100
 532 Section IV Lower Exlremity

FIGURE 15 12. Terminology lo describe th events of th gait cycle. Inaiai contact corresponds to th beginning of stante when th
loot first contacts th ground ai 0% of gait cycle. Opposite toc off occurs when th contrasterai foot leaves th ground ai 10% of
gait cycle. Heel rise corresponds to th heel lifting from th ground and occurs at approximately 30% of gait cycle Opposite initial
contact corresponds to th foot contact of th opposite limb, typically at 50% of gait cycle. Toe off occurs when th foot leaves th
ground at 60% of gait cycle. Feet adjacent takes place when th foot of th swing leg is next to th foot of th stance lee at 73% of
gait cycle. Tibia vertical corresponds to th tibia of th swing leg being oriented in th vertical direction at 87% of gait cycle The
linai event is, again, initial contact, which in fact is th start of th next gait cycle.
Ihese eight events divide ihe gait cycle into seven periods. Loading response, between initial contact and opposite toe off
corresponds to th urne when th weight is accepted by th lower extremity, initiating contact with th ground. Mid stance is from
opposite toe off to heel rise (10 to 30% of gait cycle). Terminal stance begins when th heel rises and ends when th contrasterai
ower extremity touches th ground, from 30 to 50% of gait cycle. Pre swing takes place from foot contact of th contrasterai limb
nt e r , 1Ps'later?1 lootl wt,ch 1S lhe llme corresponding lo th second double-limb supporr period of th gau cycle (50 to
60% of gau cycle). Inaiai swing is from toe off lo feet adjacent, when th foot of th swing leg is next to th foot of th stance leg
(60 to 73% ol gau cycle). Mici swing is from leet adjacent to when th tibia of th swing leg is vertical (73 to 87% of gait cycle)
i acT r l mng 'S fr m 3 vemcal Posltlon of the tibia to immediately prior to heel contaci (87 to 100% of th gait cycle) The first
10% of th gait cycle corresponds to a task of weight acceptance-when body mass is tra n sfe rt from one lower extremity to th
other. Single-hmb supporr, from 10 to 50% of th gait cycle. serves to support th weight of th body as th opposite limb swings
lorward. The Sst 10% of stance phase and th entire swing phase serve to advance th limb forward to a new location.

Although there is a significant amount of variation in th
descnption of th swing phase of gait, this phase is iradi-
tionally subdivided into three sections: early, mid, and late
swing (see Fig. 1 5 -1 1 ). Early swing is th period from th
tinte of toe off to mid swang (60 to 75% of th gait cycle).
Mid swing corresponds to th mid stance event of th
opposite lower extremity when th foot of th swing
leg passes next lo th foot of th stance leg (75 to 85% of
th gait cycle). Late swing is th period from mid swing
to foot contact with th ground (85 io 100% of th gait
cycle).
An alternate and relatively more recent terminology, pro-
posed by Perry,67 consists of eight events to divide th gait
cycle into seven periods (Fig. 1 5 - 1 2 ). The events are initial
contact, opposite toe off, heel rise, opposite initial contact, toe off,
feet adjacent, tibia vertical, and initial contact for th next
stride. The four time periods durmg stance are loading re
sponse, mid stance, terminal stance, and pre swing. Swing
phase has three lime periods: initial swing, mid swing, and
terminal swing. With a few exceptions, this terminology is in
generai agreement with th more traditional description of
gait.
The existence of two dtfferent terminologies can be con-
fusing, especially w'hen many use them interchangeably. In
this chapter, we predominantly use th terminology pro-
posed by Perry in 1992.67 And to eliminate any confusion,
we describe th timing of th events during gait as a per-
centage of th gait cycle.

S P E C I A L F O C U S 1 5 - 2
Take Time to Develop Your Observation Skills
T h e e v e n t s o f g a it c y c l e d e s c r ib e d in t h is s e c t io n c a n
b e o b s e r v e d b y w a t c h in g p e o p le w a lk in g in n o r m a l s u r -
r o u n d in g s ( s t r e e t s , m a lls , a ir p o r t s ) . L ik e a n y c l i n i c a l s k ill,
o b s e r v a t io n a l g a it a n a ly s is im p r o v e s w it h p r a c t ic e . R e -
p e a t e d o b s e r v a t io n o f in d iv id u a ls w it h n o r m a l g a it p a t-
t e m s s h a r p e n s t h a b ilit y t o r e c o g n iz e n o r m a l g a it v a r i-
a t io n s a n d id e n t if y a b n o r m a l g a it d e v ia t io n s .
O p p o r t u n it ie s t o p r a c t ic e t h is s k ill w it h a p e r s o n a lr e a d y
t r a in e d in o b s e r v a t io n a l g a it a n a ly s is f u r t h e r s h a r p e n
t h e s e s k ills .
DISPLACEMENT AND CONTROL OF THE
BODY'S CENTER OF MASS
Walking can be defined as a series of losses and recoveries
of balance. Ambulation is initiated by allowing th body to
lean forward. To prevent a fall, momentary recovery of bai-
ance is achieved by moving either foot forward to a new
location. Once gait is initiated, th bodys forward momen-
tum carries th center of mass (CoM) of th body beyond
th foots new location, necessitating a step forward with th
other foot. Forward progression is then achieved by th
successive and alternate relocations of th feet. The smooth,
controlled transition between loss and recovery of balance
continues as long as forward displacement of th body is
desired. Ambulation stops when foot placement stops th
forward momentum of th body and balance is regained
over th static base of support. Although this description
provides a useful and relatively accurate explanation of gait,
il must be pointed out that walking also requires active
participation of th musculature of th lower extremities.
Displacement of th Center of Mass
The bodys CoM is located just anterior to th second sacrai
vertebra, bui th best visualization of th movement of th
CoM is by tracking th displacement of th head or torso.
Clearly, th most notable displacement of th body during
gait is in th forward direction (Fig. 1 5 - 1 3 ). Superimposed
on this forward displacement, however, are two sinusoidal
pattems of movement that correspond to th movement of
th CoM in th vertical and medial-lateral directions.
In th vertical direction, th CoM describes two full sine
waves per gait cycle (Fig. 15-1 3 A ). This movement of th
CoM is best understood by looking at th individuai from
th side. Minimum height of th CoM occurs at th mid-
point of both periods of double-limb support (5% and 55%
of th gait cycle). Maximum height of th CoM occurs at th
midpoint of both periods of single-limb support (30% and
80% of th gait cycle). A total vertical displacement of ap-
proximately 5 cm is noted at th average walking speed in
th aduli male.
Chapter 15 Kinesiology oj Walking 533
Displaccmenl of th Center of Mass
Total vertical displacement: 5 cm
Total medial-lateral displacement: 4 cm
Side-to-side (medial-lateral) movement of th CoM also
occurs during ambulation, creating a single sinusoidal pat
tern in th horizontal piane. This movement can be viewed
from above th individuai but is typically viewed from th
rear or front (Fig. 1 5 -1 3 B ). In this piane of movement, th
CoM is alternately shifted from th right lo th left lower
extremity. Maximum position of th CoM to th right occurs
at th midpoint of th stance phase on th right lower
extremity (30% of th gait cycle), and maximum position of
th CoM to th left occurs at th midpoint of th stance
phase on th left lower extremity (80% of th gait cycle). A
total medial-lateral displacement of approximately 4 cm oc
curs during normal ambulation.34 The amount of displace
ment increases when th individuai has a wider base of
suppon during gait (i.e., walking with th feet wider apart)
and decreases with a narrower base of support (i.e., walking
with th feet closer together).
To summarize, consider th total pattern of motion of th
CoM during a full gait cycle (see Fig. 1 5 - 1 3 ). Starting
shortly after right heel contact, th CoM is moving forward,
upward, and toward th right foot. This generai direction of
movement continues for th first 30% of th gait cycle th
body is essentially climbing and shifting its mass over th
supporting lower extremity. At right mid stance, th CoM
reaches its highest and most lateral position toward th
right. Just after right mid stance, th CoM continues forward
but starts moving in a downward direction and toward th
left side of th body th body is essentially falling away
from th supporting lower extremity. This is a criticai mo
ment in th gait cycle. With th left limb in its swing phase,
th body depends on th left lower extremity to make
proper contact with th ground in order to accept th
weight transfer and to prevent a fall. Shortly after left heel
contact, during th double-limb support phase, th CoM is
located midway between th feet and reaches its lowest posi
tion as it continues to move forward and toward th left
lower extremity. From right toe off to mid stance on th left
lower extremity (80% of th gait cycle), th CoM moves
forward, upward, and toward th left lower extremity, which
is now providing support. At 80% of th gait cycle, th CoM
is again at its highest point, but in its most lateral position
to th left. Shortly after left mid stance, th movement of th
CoM shifts downward and toward th right side of th body.
The gait cycle is completed when th right heel contacts th
ground.
The bodys CoM never direcily falls over th bodys base
of support during single-limb support (Fig. 15 13B). This
fact speaks to th relative imbalance of th body during gait.
In th frontal piane, to avoid a loss of balance, th foot must
be positioned just slightly lateral to th path of th bodys
CoM to control its medial-lateral movement. Proper location
of th foot by hip frontal piane motion (i.e., hip abduction/
adduction) is cruciai considering th view of th limited
ability of th subtalar joint musculature to generate a stabi-
lizing torque in th frontal plane.gg
 534 Section IV Lower Extremity
A. Vertical Displaeement of CoM
Kinetic and Potential Energy Considerations
Although ambulaiion appears to take place at a steady for-
ward speed, th body actually speeds up and slows down
slightly with each step. When th supporting lower extrem
ity is in front of th bodys CoM, th body slows down.
Conversely, when th supporting lower extremity is behind
th bodys CoM, th body speeds up. The body reaches its
lowest velocity, therefore, at mid stance, once it has
climbed on th supporting lower extremity, and its highest
velocity during double-limb support, once it has fallen
away from th supporting lower extremity and before
climbing on th oppostte limb. Because kinetic energy of
th body during ambulation is a direct function of its veoc-
ity (equation 1 5 - 1 ) , minimum kinetic energy is reached at
mid stance (30% and 80% of th gait cycle) and maximum
kinetic energy is reached at double-limb support (5% and
55% of th gait cycle) (big. 1 5 -1 4 ).
Kinetic energy = 0.5 mv2 15-1
Where m is th mass of th body, and v th velocity of th
CoM of th body.
Kinetic energy is complemented by potential energy (see
Fig. 1 5 - 1 4 ). Potential energy is a function of th mass of
th body, th gravitational field acting on th body, and th
height of th bodys CoM (equation 15 2). During gait,
maximum potential energy is achieved when th CoM
reaches its highest points (30% and 80% of th gait cycle).
Minimum potential energy of th body occurs at double-
limb support (5% and 55% of th gait cycle), when th
bodys CoM is at its lowest points.
Potential energy = mgh 1 5 -2
Where m is th mass of th body, g is th acceleration of
th body due io th gravitational field, and h is th height of
th bodys CoM.
In a graphic representation of th changes in kinetic and
potential energy during gait, a relationship between th
curves is readily observed (see Fig. 1 5 -1 4 ). The times of
maximum potential energy correspond to th times of mini
mum kinetic energy and vice versa. As potential energy is
lost from mid stance to double-limb support (th CoM o(
th body going from its highest to its lowest location), ki
netic energy is gained (th CoM of th body going from its
minimum to maximum speed). Conversely, as kinetic energy
 Chapier 15 Kinesiology o f Walking 535

Transfer of Energy During Gait

Potential Energy

FIGURE 15-14. Transfer between potential and kinettc energy during gait. The minimum potential energy exists
when th center of mass (CoM) is at its lowest points (5% and 55% of th gait cycle). The maximum potential
energy occurs when th CoM is at its highest points (30% and 80% of th gait cycle). The reverse occurs for
kinetic energy. For example, a bicycle that gains speed while going down a hill and loses speed while it climbs
up th next hill illustrates th transfer between potential and kinetic energy.

is lost from double-limb support to mid stance, potential
energy is gained. This cyclic transfer between kinetic and
potential energy minimizes th metabolic cost of walking.
Despite th ability of th body to efficiently transfer and
thereby conserve energy while walking, a net energy cost
stili occurs. This cost is proportional to th amount of me-
dial-lateral and vertical displacement of th CoM.
Most often, th angular rotation that takes place at th
joint itself is described (i.e., th relative motion of one bone
compared with another). In some instances (e.g., for th
sagittal piane motion of th pelvis), th movement of th
bones in space is described without regard to th other
bones that make up th adjacent joints. The reader must
therefore be careful to recognize when a discussion pertains
to joint kinematics and when it pertains to bone kinematics.

JOINT KINEMATICS
During gait, th bodys CoM is displaced linearly as a result
of th summation of th angular rotation of th joints of th
lower extremities, which is not unlike a car moving forward
owing to th rotation of its tires. Movements at th joints of
th lower extremities, therefore, are described as a function
of angular rotation. Although joint angular rotation occurs
primarily in th sagittal piane, important motion, although of
smaller magnitude, occurs in th frontal and horizontal
planes.
Gait Kinemalics are Described for th
Sagittal piane
Frontal piane
Horizontal piane
Sagittal Piane Kinematics
Sagittal piane movement of th pelvis is small and is de
scribed here as movement of th bony structure itself. Con-
versely, th sagittal piane kinematics of th hip, knee, ankle,
and first metatarsophalangeal joints are of larger magnitude
and are described as joint motion. In this section, as in th
entire chapter, th gait cycle is described from right heel
contact to th subsequent right heel contact.
Pelvis. Movement of th pelvis in th sagittal piane is
described in terms of anterior and posterior pelvic tilt about
a medial-lateral axis (see Chapter 12). Neutral pelvis position
is used as a reference. This neutral position (0 degrees) is
defined as th orientation of th pelvis in relaxed stance.
Because th pelvis is a relatively rigid structure, both iliac
crests are considered as moving together. During gait at
normal speed, th amount of anterior and posterior pelvic
536 Section IV Lower Extremity
tilt is small (i.e., a total of approximately 2 to 4 degrees).
Although th movement of th pelvis is described as an
independent detached structure, this small movement takes
place both at th hips (pelvic-on-femoral flexion/extension)
and at th lumbosacral joint (pelvic-on-lumbar flexion/exten
sion).
The pattern of motion of th pelvis over th full gait cycle
resembles a sine wave with two full cycles (Fig. 15-1 5 A ). At
Lower Extremity Kinematics (Sagittal Piane)
right heel contact, th pelvis is near neutral. From 0 to 10%
of th gait cycle, a period of double-limb support, a small
amount of posterior pelvic rotation (tilt) occurs. Then th
pelvis starts tilting anteriorly during th period of single-limb
support, reaching a slight anterior pelvic tilted position just
after mid stance (30% of th gait cycle). In th second half
of th stance phase, th pelvis tilts posteriorly until just after
toe off. During initial and mid swing (60 to 87% of gait),
FIGURE 15-15. Sagittal piane angular rotation of th pelvis (A),
hip (B), knee (C), and ankle (D) during a gait cycle.

th pelvis agairt tilts anteriorly before starting to tilt in th
posterior direction in terminal swing.
In generai, pelvic motion increases when speed of ambu-
lation increases.34 Variability in th amount, timing, and di
rection of tilt, however, has been noted across walking
speed. The greater magnitude of pelvic tilt with faster walk
ing speed serves to increase functional leg length, which in
tum serves to increase step length.
The sagittal piane tilt of th pelvis while walking is
caused by th sum of th passive and active forces produced
by th hip joint capsule and th hip flexor and extensor
muscles. In pathologic situations, persons with marked hip
flexion contractures show an exaggerated anterior tilt of th
pelvis in th second half of th stance phase (i.e., between
30 and 60% of th gait cycle). The large passive tension in
th shortened anterior hip structures creates a potent ante
rior tilting tendency often associated with an increased lum-
bar lordosis.
H ip . At a typical walking speed, th hip is flexed approx-
imately 30 degrees at heel contact (Fig. 1 5 -1 5 B ). As th
body moves forward over th fixed foot, th hip extends.
Maximum hip extension of approximately 10 degrees is
achieved prior to toe off. Flexion of th hip is initiated
FIGURE 15-16. Body diagram (A) and average
sagittal piane kinematic pattems (B) of men with
unilateral hip fusion (red lines) compared with
men with normal hip motion. The lack of mo
bility of one hip drastically affeets motion of th
pelvis, th ipsilateral knee, and th contralateral
hip. Less significant effeets are noted at th con
tralateral knee and at both ankles. This figure
illustrates how impairment (i.e., reduced mobil-
ity of th hip) that affeets a single joint will
affect motion of th other joints. (Modified from
Gore DR, Murray MP, Sepie SB, Gardner GM:
Walking pattems of men with unilateral surgical
hip fusion. J Bone Joint Surg 57A .759, 1975.)
B Gait Cycle
Chapter 15 Kinesiology o j Walking 537
during pre swing, and th hip is at about 0 degrees of
flexion/extension by toe off (60% of gait). During th swing
phase, th hip further flexes to bring th lower extremity
forward for th next foot placement. Maximum flexion
(slightly more than 30 degrees) is achieved just prior to heel
contact. Note that at heel contact, th hip has already started
to extend in preparation for weight acceptance. Overall, ap
proximately 30 degrees of flexion and 10 degrees of exten
sion, from anatomie neutral position, are needed at th hip
for normal walking. As for all of th joints of th lower
extremities, th magnitude of hip movement is proportional
to walking speed.
Individuai with limited hip mobility may appear to walk
without gait deviations. The movement of th pelvis and
lumbar spine, compensating for reduced hip motion, may
remain unnoticed. Apparent hip extension can be achieved
through an anterior pelvic tilt and associated increase in
lumbar lordosis. Conversely, a posterior pelvic tilt accompa-
nied by a flattening of th lumbar spine provides apparent
hip flexion. To ambulate, individuai with a fused (i.e., an-
kylosed) hip use an exaggerated posterior and anterior pelvic
tilt io compensate for th absence of hip mobility (Fig. 15
16). Because th pelvis and lumbar spine motions are me-
chanically linked at th sacroiliac joint, exaggerated pelvic
0% 100% 0% 100%
Gait Cycle
 538 Sectioti IV Lower Extremity
Abnormal Pelvic Motion as an Indicator of Hip
Pathology
Although a completely fused hip is a relatively rare
occurrence, limited hip range of movement due to or-
thopedic and neurologie disorders is not uncommon.
Tight hip flexors, which limit hip extension, may be
present in th elderly with a hip flexion contracture as
well as in individuals with cerebral palsy and hip flexor
spasticity. Limited hip motion may also be present in
those with advanced hip osteoarthritis. Clinically, pelvic
motion is evaluated during observational gait analysis
because excessive pelvic tilt is a due to a possible
pathology that limits hip motion.
tilting may increase th stress at th lumbar spine. These
stresses could eventually irritate th structures within this
region, resulting in low back pain.
Kiiee. The kinematic pattern of th knee is a little more
complex than that of th hip (Fig. 1 5 -1 5 C ). At heel contact,
th knee is fiexed approximately 5 degrees and it continues
to flex an addittonal 10 to 15 degrees, during th initial 15%
of th gait cycle. This slight knee flexion, controlled by
eccentric action of th quadriceps, serves th purpose of
shock absorption and weight acceptance as body weight is
progressively transferred to this lower extremity. Following
initial flexion, th knee extends to nearly full extension until
about heel off (40% of th gait cycle). At this point th knee
starts flexing, reaching approximately 35 degrees of flexion
by th time of toe off (60% of gait). Maximum knee flexion
of approximately 60 degrees is assumed by th beginning of
mid swing (73% ol gait). Knee flexion during initial swing
serves to shorten th length of th lower limb, facilitating toe
clearance. In mid and terminal swing, th knee extends to
just short of full extension in preparation for heel contact.
Normal function of th knee during gait on a leve] sur-
face requires range of motion from nearly full extension to
approximately 60 degrees of flexion. A limitation of knee
extension (i.e., knee flexion contracture) results in a func-
tionally shorter leg, affecting th kinematics of both th
stance leg and th swing leg. The stance leg, lacking full
knee extension, must assume a crouched position, involv-
ing th hip, knee, and ankle, and th normal swing leg
needs greater knee and, possibly, hip flexion to clear th
toes. The uneven functional leg length also leads to excessive
trunk and CoM movement, increasing th metabolic de-
mands of walking. A fiexed knee posture during gait also
increases th muscular demand on th knee extensors, re
sulting in further metabolic costs.
A lack of suffcient knee flexion during th swing phase
of gait interferes with toe clearance as th foot moves for-
ward. To compensate, th hip must flex excessively. If th
knee is immobilized in full extension with an orthosis or a
cast, more noticeable compensations, such as hip hiking
and hip circumduction, are required.
Ankle (Talocrural Jo in t). At th ankle, heel contact oc-
curs with th talocrural joint in a slightly piantar fiexed
position (between 0 and 5 degrees) (Fig. 1 5 -1 5 D ). Shortly
after heel contact (th Arsi 8% of th gait cycle), th foot is
positioned fiat on th ground by th movement of piantar
flexion controlled eccentrically by th ankle dorsiflexors.
Then, up to 10 degrees of ankle dorsillexion occurs as th
tibia moves forward over th planted foot (from 8 to 45% of
th gait cycle). Shortly after heel off (40% of th gait cycle),
th ankle starts to piantar flex, reaching a maximum of 15 to
20 degrees of piantar flexion just after toe off. During th
swing phase, th ankle is again dorsiflexed to a neutra]
position to allow th toes to clear th ground.
Average speed of ambulation requires approximately 10
degrees of dorsiflexion and 20 degrees of piantar flexion.
interestingly, greater dorsiflexion is needed during th stance
phase than during th swing phase ol gait. Similar to th
knee and th hip, limitation of motion at th ankle leads to
an abnormal gait pattern. For example, limited ankle piantar
flexion may result in a decreased push off, possibly leading
to a shorter step length.
Summary of Sagittal Piane Kinematics
Several underlying principles govern sagittal piane mo
tion of th joints of th lower extremities. At heel con
tact, th joints of th lower extremity are aligned to
reach forward," or to elongate th lower extremity, in
order to position th foot on th ground. Shortly after
heel contact, controlled knee flexion and ankle piantar
flexion cushion loading for a smooth weight accept
ance. All th joints of th supporting lower extremity
then extend in order to support th weight of th body
at th necessary height so that th foot of th contra
sterai swing leg can clear th ground. During swing, all
th joints of th swing leg participate in shortening th
lower extremity to bring th foot forward without trip-
ping on th ground. In terminal swing, th lower ex
tremity again "reaches forward" for th next heel con
tact.
The level of control of th lower limbs during ambu
lation is remarkable.98 During swing, typical toe clear
ance (th minimum distance between th toes and th
floor) is only 0.8 to 0.9 cm. This minimum clearance
occurs at mid swing, when th foot actually has its
greatest linear horizontal speed (4.5 m/s). The transition
from th swing to th stance phase is also amazingly
well controlled. To provide smooth contact with th
ground, vertical heel speed slows just prior to heel
contact to only 0.05 m/s. This level of control is th
basis of th argument against using th term heel
"strike" to describe th typically well-controlled heel
contact with th ground. Further evidence of th fine
control taking place during walking is expressed by th
small clearance observed between th edge of th
steps and th foot during stair descent.78

Conversely, a lack of adequate dorsiflexion mobility dur-
ing stance, due to a tight heel cord, for example, may cause
a premature heel off, resulting in a bouncing-type gait.
Interestingly, limited dorsiflexion may also lead to a shorter
step length because th body is bouncing excessively up
and down instead of moving forward. A toeing-out gait
pattern can somewhat compensate for limited ankle dorsi-
flexion. With excessive toeing-out of th foot, th individuai
rolls off th mediai aspect of th foot in th second half of
stance phase. Although toeing-out reduces th need for ankle
dorsiflexion, it increases th stress applied to th mediai
structures of th foot and th knee.
In extreme cases where there is a pes equinus deformity
(i.e., fixed piantar flexion of th ankle), th individuai may
walk on hyperextended toes and th heel never Comes in
contact with th ground. This condition is most often ob-
served in individuals with cerebral palsy.
Limited ankle dorsiflexion also intereferes with clearing
th toes during swing phase. To compensate, increased knee
and/or hip flexion may be needed. Limited dorsiflexion in
swing may be due to piantar flexor tightness, calf spasticity,
or ankle dorsiflexor weakness.
First Tarsom etatarsal Joint. The frst tarsometatarsal
joint, th function of which is described in Chapter 14, has
a slight amount of piantar and dorsiflexion that contributes
to th overall flexibility of th foots mediai longitudinal arch
during gait.28
First Metatarsophalangcal Joint. The metatarsophalan-
geal (MTP) joint of th hallux (great toe) is cruciai to normal
gait. At heel contact, th MTP joint is slightly hyperex
FIGURE 15-17. Frontal piane pelvis and hip motion for a full
gait cycle starting with righi heel contact. A illustrates that
during right stance phase, th left iliac crest initially drops
before progressively moving upward in late stance. The rela
tively higher left iliac crest during right swing phase rellects
th drop of th right iliac crest when th right foot is off th
ground. B illustrates frontal piane hip motion, accounting for
th frontal piane motion of th pelvis and th femur. (Data
from Ounpuu S: Clinical gait analysis. In Spivack BS (ed):
Evaluation and Management of Gait Disorders. New York,
Marcel Dekker, 1995.)
Chapter 15 Kinesiology o f Walkmg 539
tended. From shortly after heel contact to heel off, th MTP
joint is in a relatively neutral position. Between heel off to
just prior to toe off, th MTP joint hyperextends approxi-
mately 45 to 55 degrees. (This is th angle measured be
tween th long axis of th first metatarsal and th proximal
phalanx of th hallux.14) During th late part of stance phase
and initial swing, th joint flexes and retums to th neutral
position.
Limited MTP joint hyperextension due to a soft tissue
injury, such as a joint sprain (turf-toe) or degeneration of
th joint (hallux rigidus), typically results in an exaggerated
toeing-out gait. One consequence of this abnormal gait pat
tern is a less effcient push off. Toeing-out also creates in
creased stress to th mediai structures of th knee and foot,
including th hallux, as mentioned earlier.
Frontal Piane Kinematics
Joint rotations within th frontal piane are of smaller ampli-
tude compared with those in th sagittal piane. Yet, these
rotations are important, especially at th hip and subtalar
joints.
Pelvis. Frontal piane motion of th pelvis during walking
is best observed from in front of or behind th individuai,
watching th iliac crests rise and fall. The pelvis rotates
through a total excursion of about 10 to 15 degrees as a
result of pelvic-on-femoral (hip) adduction and abduction on
th stance limb. During weight acceptance on th right lower
extremity (i.e., th first 15 to 20% of th gait cycle), th
pelvis drops on th swing (left) side owing to pelvic-on-
femoral adduction of th right stance hip (Fig. 1 5 -1 7 A ).
Pelvic and H ip Kinematics (Frontal Piane)
Percent of Gait Cycle
 540 Section IV Lower Extremity

Possible Causes For Excessive Hip Frontal Piane Motion borum of th swing leg, and possibly th abdominals and
Excessive frontal piane movement of th stance hip is back extensors on th side of th swing leg.
quite common, causing exaggerated medial-lateral shifts A significant leg length difference also affects move
in th CoM. There are at least three reasons why exces ment of th pelvis in th frontal piane. Leg length discrep
sive movement of th pelvis and hip in th frontal piane ancy can be severe, secondary to a fracture of th femur
may be observed: weakness of th hip abductors, reduced or a unilateral coxa valga, or it can be slight (<0.5 cm)
shortening" of th swing leg, and a discrepancy in leg owing to naturai variability. During periods of double-limb
length. support, th iliac crest of th longer leg is positioned
The drop of th contralateral iliac crest (i.e., hip adduc- higher than th iliac crest of th shorter leg. This pelvic
tion) during early to mid stance is normally controlled by obliquity, which is occurring for every gait cycle, results
an eccentric activation of th hip abductor muscles of th in increased side bending of th lumbar spine.
stance leg. Inadequate abduction torque from these mus
cles often leads to excessive frontal piane motion during
stance.62 While standing on one limb, a person with mod
erate hip abductor weakness demonstrates an excessive
drop of th pelvis to th side of th lifted leg (Fig. 15-18).
This action is referred to as a positive Trendelenburg sign.
Typically, however, a person with weakened hip abduc
tors, especially if severe, compensates by leaning th
trunk to th side of th weakened muscle during any
single-limb support activities, whether standing or walking.
While walking, this is called a "compensated" Trendelen
burg gait or gluteus medius limp. Leaning of th trunk to
th side of weakness minimizes th external torque de-
mands, due to body weight, on th abductor muscles of
th stance leg.
Another deviation that is observed by looking at th
movement of th pelvis in th frontal piane is called hip
hiking. Hip hiking on th side of th swing leg compen
sates for th inability of th knee and/or ankle of th
lower extremity to sufficienti shorten th limb for clear-
ance of th foot. The classic example is walking with a
knee orthosis, keeping th knee in full extension. Hip hik
ing is more accurately described as th excessive eleva-
tion of th iliac crest on th side of th swing leg. Eleva- FIGURE 15-18. Excessive drop of th nght iliac crest and lean of
tion results from pelvic-on-femoral abduction of th th trunk toward th left stance leg are characteristic of weakness
of th left gluteus medius. (From Calve J, Galland M, De Cagny
stance leg. Muscles involved in this movement include th
R: Pathogenesis of th limp due to coxalgia: The antalgic gait. J
primary abductors of th stance leg, th quadratus lum- Bone Joint Surg 21A :12, 1939.)

Between 20 and 60% of th gait cycle, th tight stance hip

progressively abducts, thereby elevating th left (swing leg)
iliac crest. Throughout most of th right swing phase, th
tight iliac crest progressively drops as a consequence of th
pelvic-on-femoral hip adduction of th left stance hip.
H ip. The pattern ol elevation and depression of th iliac
crests reflects frontal piane hip motion (Fig. 1 5 -1 7 B ). Dur
ing th stance phase, hip frontal piane motion results almost
entirely from pelvic-on-femoral movement (see Chapter 12,
pelvis movtng on femur). During swing, motion of th pelvis
as well as th freely moving femur contributes to th hip
joint returning to its neutral frontal piane position.
clifficult to quantify. Pins inserted in th cortices of th
femur and th tibia demonstrate that at a walking speed of
1.2 m/sec, an average of 1.2 degrees of knee abduction
(valgus) is present at th time of heel contact (Fig. 1 5 - 1 9 ) .H
This alignment remains unchanged throughout th stance
phase. The knee usually abducts an additional 5 degrees
during initial swing. This maximum abduction occurs when
th knee is near its maximum flexion angle in th sagittal
piane. The knee retums to its slightly abducted position
prior to th next heel contact. Advanced osteoarthritic
changes and abnormal lower extremity alignments (e.g
genu valgum) may affect frontal piane motion of th knee.

Knee. Because of th articular geometry and strong col-

Ankle (Talocrural Join t). The primary motion of th
lateral ligaments, th knee is stable in th frontal piane.
talocrural joint is dorsiflexion/plantar flexion. Although as
Small amounts of angular movement occur but are very
described in Chapter 14, th ankle everts and abducts

Knee Kinematics (Frontal Piane)
0 10 20 30 40 50 60 70 80 90
Percent of Gait Cycle
FIGURE 15-19. Frontal piane angular motion of th knee is illus
trateci. The red line is th average of four of th five subjects. The
gray lines are each subjects individuai data. (Data from Lafortune
MA, Cavanagh PR, Sommer 111 HJ, Kalenak A: Three-dimensional
kinematics of th human knee during walking. J Biomech 2 5:347,
1992.)
slightly with dorsiflexion and inverts and adducts slightly
with piantar flexion, these secondary frontal and horizontal
piane motions are very small and are ignored here.
Fool/Subtalar Joint. The triplanar motions of pronation
and supination occur through interaction of th subtalar and
transverse tarsal joints. Pronation combines components of
eversion, abduction, and dorsiflexion; supination combines
inversion, adduction, and piantar flexion. This chapter con-
siders th frontal piane motions of subtalar joint eversion
and inversion io represent th more global motions of foot
pronation and supination, respectively. Subtalar motions are
typically measured as th angle made between th posterior
aspect of th calcaneus and th posterior aspect of th lower
leg (Fig. 1 5 -2 0 ).
The subtalar joint is inverted approximately 2 to 3 de-
grees at th time of heel contact (Fig. 1 5 - 2 1 ). Immediately
after heel contact, rapid eversion of th calcaneus begins and
continues until mid stance (30 to 35% of th gait cycle),
where a maximally everted position of approximately 2 de-
grees is reached. Al that time, th subtalar joint reverses its
direction of movement and starts toward inversion. Nor-
mally, a relatively neutral position of th calcaneus is
reached at about 40 to 45% of th gait cycle, at approxi
mately heel off. Between heel off and toe off, calcaneal inver
sion continues until it reaches a value of approximately 6
degrees of inversion.14 During swing, th calcaneus retums
to a slightly inverted position in preparation for th next
heel contact. This pattern of motion is generally agreed upon
in th literature; however, th reported amount of foot pro
nation during gait varies based on th techniques and prefer-
ences for measurement. Reischl and coworkers,70 using a
Chapter 15 Kinesiology o j Walking 541
100
W5
8 = Frontal Piane
Subtalar Joint Angle
FIGURE 15-20. Method to measure rear foot (subtalar joint) mo
tion. The inversion/everston angle, made by th lines bisecting th
lower leg and th calcaneus, is measured as a simpliled indicator of
th amount of foot pronation/supination. This measurement can be
made using a video System. (Modified from McClay IS: The use of
gait analysis to enhance th understanding of running injuries. In
Craik RL, Oatis CA (eds): Gait Analysis: Theory and Application. Si.
Louis, Mosby, 1995.)
three-dimensional model of th foot, report a mean peak
pronation of 10.5 3.4 degrees, occurring at 26.8 8.7%
of th gait cycle, on their sample of 30 subjects.
The movement of foot pronation/supination during walk
ing is accompanied by changes in height of th foots mediai
longitudinal arch. A detailed review of foot kinesiology and
function, including th fall and rise of th mediai longitudi
nal arch during gait, is provided in Chapter 14.
Summary of Frontal Piane Kinematics
The best location to observe frontal piane kinematics of
th joints of th lower extremities is from behind th
individuai. Hip motion plays an important role in minimiz-
ing th vertical displacement of th body's CoM. The
rapid pronation (eversion) of th foot after heel contact
participates in th process of weight acceptance and
provides a flexible and adaptable structure for making
contact with th ground. Later in th stance phase,
between heel off and toe off, th inversion of th calca
neus associated with supination of th foot provides a
more rigid foot structure, which helps propel th body
forward.
 542 Seciion IV Lower Extremity
Subtalar Joint Kineniatics (Frontal Piane)
Horizontal Piane Kinematics
Information currently available about lower extremity kine
matics in th horizontal piane is provided by a limtted num-
ber ol studies. To improve th accuracy of measurements, inves
tigatore have on some occasions fixed rigid metal pins in th
pelvis, lemur, and tibia of their subjects. Attached to these
metal pins were markers that allowed video cameras to track
bone movement. In some studies only th movement of th
bony structures in space was observed; other researchere
its e lf^ lhC relatVe motion thal took P^ce at th joint
In th following sectton, rotation of th pelvis, femur, and
tibia describes horizontal piane movement of th bone itself
Convereely, movement of th hip and knee refers to th
rotation taking place at these articulations. Most of th stud
ies that describe horizontal piane kinematics include a small
number of typically healthy young individuals. Generaliza-
tion to a larger population and a population with gait devia-
uons, therefore, must be done with some degree of reserva-
tion.
Pelvis. During walking, th pelvis rotates in th horizon
tal piane about a vertical axis of rotation through th hip
joint of th stance leg. The following description of pelvic
rotation is based on a top view for a righi gait cycle. At righi
ned contact, th righi anterior-superior iliac spine (AS1S) is
forward compared with th left ASIS. For th initial 15 io
2U/o ot gait, counterclockwise rotation of th pelvis takes
place (Fig. 1 5 -2 2 ). Throughout th rest of stance on th
righi lower extremity, a clockwise rotation of th pelvis oc-
cure as th left ASIS progressively moves forward along with
th advancing left swing leg. At tight toe off, th right ASIS
is now behind th left. During swing of th right lower
extremity, th right ASIS progressively moves forward
Throughout th gait cycle, th pelvis rotates 3 to 4 degrees
in each direction. A greater amount of rotation of th pelvis
occurs with increasing walking speed to increase step length.
Femur. After heel contact, th femur rotates intemallv
for th first lo to 20% of th gait cycle (see Fig. 1 5 -2 2 ). At
about 20% of th gait cycle, it reverses its direction and
rotates extemally unti! shonly after toe off. Internai rotation
ol th femur takes place throughout most of th swing
phase. Overall, th femur rotates approximately 6 to 7 de
grees in each direction during gait.11
FIGURE 15-22. Pattern of horizontal piane mo
tion of th pelvis, femur, and tibia. The pattern
of motion is similar for th three bony struc-
tures, with progressively larger amplitude of
movement for th more distai structures. For
th right lower extremity, th clockwise motion
corresponds to exiemal rotation. (From Mann
RA: Biomechanics of th fooi. In American
Academy of Orthopedic Surgeons (ed): Atlas of
Orthotics: Bomechanical Principles and Applica
tion. St. Louis, Mosby, 1975.)
 Chapter 15 Kinesiology o f Walking 543

Tibia. The pattern of movement of th tibia is very simi- Knee Kinematics (Horizontal Piane)
lar to th movement described for th femur (see Fig. 1 5 -
22). The magnitude of th rotation is about 8 to 9 degrees
in each direction.

Hip. Both th femur and th pelvis rotate simulianeously.

At right heel contact, th right hip is in slight extemal
rotation based on th relative posterior position of th con-
tralateral (left) ASIS (Fig. 1 5 -2 3 ). A net internai rotation
movement of th right hip occurs during most of stance on
th right lower extremity as th contralateral (left) ASIS is
brought forward. A maximum intemally rotated position is
achieved by 50% of gait. Extemal rotation of th right hip
occurs from 50% o f gait unti! mid swing, as th right leg is
picked up and brought forward. From mid swing to right
heel contact, a slight amount of right hip internai rotation
takes place.84
Knee. At th time of heel contact, th knee is in a posi
tion of 2 to 3 degrees of relative extemal rotation (i.e., th
tibia is extemally rotated relative to th femur). Throughout
stance, th knee progressively intemally rotates by virtue of
th greater internai rotation of th tibia as compared with
th femur. By toe off, th knee approaches about 5 degrees
of relative internai rotation. Again, th tibia being relative to FIGURE 15-24. Horizontal piane angular motion of th knee. The
th femur. During swing, th joint extemally rotates in prep- red line is th average of th five subjects. The gray lines are each
aration for th next heel contact (Fig. 1524).44 subjects individuai data. (Data from Lafortune MA, Cavanagh PR,
Disruption of synchrony of movement between th tibia Sommer III HJ, Kalenak A: Three-dimensional kinematics of th
and femur (e.g., as a result of excessive pronation of th human knee during walking. J Biomech 25:347, 1992.)
foot) may cause knee pain with walking and running. Vali-
dation of this concept is impeded by th difficulty of accu-
rately measuring th knees horizontal piane rotation during
gait. Ankle and Foot. Horizontal piane rotation of th talo-
crural joint is slight and is not considered here. The primary
movement of th subtalar joint (inversion and eversion) is in
Hip Kinematics (Horizontal Piane) th frontal piane and is described earlier.

Trunk and Upper Extremity Kinematics

FIGURE 15-23. Horizontal piane angular motion of th hip. (Data
from Sutherland DH, Kaufman KR, Moitoza JR: Kinematics of nor-
mal human walking. In Rose J, Gamble JG (eds): Human Walking,
2nd ed. Pliiladelphia, Williams & Wilkins, 1994.)
The role of th trunk and upper extremities in maintaining
balance and minimizing energy expenditure during gait must
be recognized.
Trunk. During ambulation, translation of th CoM fol-
lows th generai pattern of translation of th trunk (see Fig.
1 5 - 1 3 ). In addition to its translational movement, th trunk
rotates in th horizontal piane, about a vertical axis. The
shoulder girdle rotates in th opposite direction of th pel
vis. The average total rotational excursion of th shoulder
girdle is approximately 7 degrees.54 This pattern of move
ment of th trunk is believed to be important to th overall
efficiency of gait. Restriction of trunk motion increases en
ergy expenditure during walking by as much as 10%.68
Shoulder. In th sagittal piane, th shoulder exhibits a
sinusoidal pattern of movement that is out of phase with hip
flexion/extension. As th hip (femur) moves toward exten-
sion, th ipsilateral shoulder (humerus) moves toward flex-
ion and vice versa. At heel contact, th shoulder is in its
maximally extended position of approximately 25 degrees
from th anatomically neutral position. The shoulder then
progressively rotates forward to reach a maximum of 10
degrees of flexion by 50% of th gait cycle. In th second
half of th gait cycle, as th ipsilateral hip moves forward
 544 Section IV Lower Extremity

S P E C I A L F O C U S 1 5 - 7
w
S u m m a r y o f H o r iz o n t a l P i a n e K i n e m a t i c s
F ig u r e 1 5 - 2 5 s u m m a r iz e s t h d ir e c t io n o f h o r iz o n t a l
p ia n e r o t a t io n o f t h m a j o r b o n e s o f t h lo w e r e x t r e m it y
a n d s u b t a la r j o in t d u r in g w a lk in g , u s in g d if f e r e n t s e t s o f
d a t a . 14'30-46 T h e p e lv is , fe m u r , a n d t ib ia r o t a t e in t e r n a lly ,
cycle, th pelvis, femur, and tibia all begin to externally
rotate until toe off. Simultaneously, after a slight delay,
th subtalar joint starts moving toward inversion, which
tends to increase th stability of th midfoot region.
T h is s t a b ilit y e n a b le s t h m id f o o t to s e r v e a s a r ig id

w e l l a f t e r h e e l c o n t a c t (i.e ., t h r o u g h a b o u t 15 t o 20% o f le v e r in t e r m in a l s t a n c e a n d p r e s w in g , a llo w in g t h

t h g a it c y c le ) . T h is m a s s in t e r n a i r o t a t io n is a c c o m p a - p ia n t a r f le x o r s to lif t t h c a l c a n e u s w it h o u t t h m id f o o t

n ie d b y s u b t a la r jo in t e v e r s io n . A s d e s c r ib e d in C h a p t e r c o lla p s in g u n d e r t h b o d y 's w e ig h t . F u r t h e r in v e s t ig a -

14, a n e v e r t in g s u b t a la r jo in t t e n d s t o i n c r e a s e t h p lia - t io n , s u c h a s t h a t p e r f o r m e d b y R e is c h l a n d c o ll e a g u e s , 70

b ilit y o f t h m id f o o t r e g io n , in c lu d in g t h t r a n s v e r s e is n e e d e d to c l e a r l y e lu c id a t e t h e x a c t r e la t io n s h ip

t a r s a l jo in t. A p lia b le m id f o o t s e r v e s t o c u s h io n t h t h a t e x is t s b e t w e e n t h t im in g a n d m a g n it u d e o f p r o n a -

im p a c t o f lim b lo a d in g . A f t e r a b o u t 15 t o 20 % o f t h g a it t io n o f t h f o o t a n d r o t a t io n o f t h f e m u r a n d t ib ia .

Lower Extremity Kinematics (Horizontal Piane)

FIGURE 15 25. Honzonial piane rotation of th major bones of th lower extremity and subtalar joint during walking. The graph
shows th direction of rotation, which is not necessarily th same as th absolute joint position.

toward flexion, th shoulder extends to return to 25 degrees
of extension by th next heel contact.
The pattern of movement of th shoulder is consistent
across individuals, although th magnitude of movement var-
ies greatly. In generai, th amplitude of shoulder movement
increases with greater speed. Arm swing is partly active,
rather than fully passive, especially for th movement of
extension that requires activation of th posterior deltoid
muscle 9- The major function of arm swing is io balance th
rotational forces in th trunk.19 Restriction of arm motion
has not been shown to have a significant effect on th
energy cost of ambulation.68

Elbow. The elbow is in approximately 20 degrees of flex-
ion at heel contact. As th shoulder moves into flexion in
th first 50% of th gait cycle, th elbow flexes to a maxi
mum of approximately 45 degrees. In th second half of th
gait cycle, as th shoulder extends, th elbow extends to
return to 20 degrees of flexion.54
Kinematic Strategies to Minimize
Energy Expenditure
During gait, five kinematic strategies are used to minimize
th displacement of th CoM. In tum, they optimize energy
efficiency. Vertical displacement of th CoM is reduced by
th combined actions of th first four strategies. The fifth
strategy serves to minimize th medial-lateral displacement
of th CoM (Table 1 5 - 3 ). The strategies detailed in this
chapter are based on th six determinants of gait originally
described by Saunders and colleagues in 1953.73 A detailed
account of th determinants is found in Inman and col
leagues.34'35
To appreciate th usefulness of these five strategies, envi-
sion gait without such mechanisms. This can be duplicated
by using two pencils connected at th eraser ends (Fig. 1 5 -
26A). When walking, a large vertical oscillation of th eraser
end of th pencils (th bodys CoM) is readily observed. The
eraser end is highest when th pencils are side by side in a
vertically oriented position (i.e., mid stance). Conversely, th
eraser end is lowest when th pencils are maximally angled
(i.e., double-limb support). This gait pattern results in a
large displacement of th CoM.
M I N I M I Z I N G V E R T I C A L D I S P L A C E M E N T OF THE
C EN T ER OF M A S S
Limiting th downward displacement of th CoMs is
achieved by horizontal piane pelvic rotation and sagittal
piane ankle rotation. Horizontal piane rotation of th pelvis
advances th entire swing leg forward, thereby minimizing
th amount of hip flexion and extension needed for a given
step length (compare Fig. 1 5 -2 6 A with Fig. 1 5 -2 6 B ). As a
consequence of th lower extremities remaining closer to a
vertical orientation throughout th gait cycle, th lowest
points of th CoM trajectory are raised, which reduces th
downward displacement of th CoM. Sagittal piane ankle
rotation makes use of th inverted T-shaped configuration of
th ankle/foot complex (Fig. 1 5 -2 6 C ). At heel contact, th
TABLE 15-3. Kinematic Strategies to Minimize Energy Expenditure During Gait
Direction of Action Name of Strategy
Vertical Horizontal piane pelvic rotation
Vertical Sagittal piane ankle rotation
Vertical Stance phase knee flexion
Vertical Frontal piane pelvic rotation
Medial-lateral Frontal piane hip rotation (step width)
Chapter 15 Kinesiology o f Walking 545
alignment of th ankle places th large protruding calcaneus
in contact with th ground, functionally elongating th lower
extremity. Near th end of stance, as th hip extends and
th knee starts to flex, th lower extremity is elongated by
piantar flexion of th ankle (i.e., heel rise). This functional
elongation of th lower extremity at both ends of stance
phase further reduces th downward displacement of th
CoM (compare Fig. 1 5 -2 6 B with Fig. 1 5 -2 6 C ).39
Limiting th upward displacement of th CoM is partially
achieved by stance phase knee flexion, when th lower ex
tremity is in its most vertical orientation (Fig. 1 5 -2 6 D ).
Frontal piane pelvic rotation further assists in minimizing
upward displacement of th CoM (Fig. 1 5 -2 6 E ). During
stance phase, th contralateral iliac crest falls as th ipsilat-
eral iliac crest rises. Throughout a complete gait cycle, there-
fore, th iliac crests altemately rise and fall like th ends of a
see saw, but th point just anterior to S2 (i.e., th point
representing th bodys CoM) remains relatively stationary,
as would th pivot point of a seesaw. This frontal piane
seesaw action of th iliac crests minimizes th vertical oscil
lation of th bodys CoM.
As shown in Figure 1 5 - 2 7 , th combination of th four
strategies minimizes th total net vertical displacement of th
CoM. The downward displacement of th CoM is reduced
by horizontal piane pelvic rotation and sagittal piane ankle
rotation. The upward displacement of th CoM is reduced
by stance phase knee flexion and frontal piane pelvic rota
tion.
M I N I M I Z I N G M E D I A L - L A T E R A L D I S P L A C E M E N T OF
THE C EN T ER OF M A S S
While a person walks, his or her CoM shifts side to side and
remains within th dynamic base of support provided by th
feet (see Fig. 1 5 - 1 3 ). A person strives to minimize th
amplitude of this medial-lateral displacement by reducing
step width, which is a function of frontal piane hip motion
(i.e., hip abduction/adduction).
Although reduced step width minimizes side-to-side dis
placement and therefore energy expenditure, it also decreases
th size of th dynamic base of support. The average step
width of 7 to 9 cm represents a mechanical compromise of
being narrow enough to reduce side-to-side shifts of th
CoM, but wide enough to provide an adequate base of
support. A greater or lesser step width is associated with a
trade-off in either energy expenditure or stability. Persons
with balance disorders, for example, may choose a wider
Action
Minimizes th downward displacement of th center of
mass (CoM)
Minimizes th downward displacement of th CoM
Minimizes th upward displacement of th CoM
Minimizes th upward displacement of th CoM
Minimizes th side-to-side excursion of th CoM
546

A. VV'alking vvithout
reduction of B. Addin horizontal C. Adding sagittal I). Adding stance E. Adding l'rontal
CoM displacement piane pelvic rotation piane ankle rotation phase knee flexioii piane pelvic rotation

F GURE 5 a . TIls series illustrates th individuai and additive effects ol tour kinematic strategies to reduce vertical CoM excursion. A illustrates th large vertical oscillation
S e, W nln8 wtthout th strategies B illustrates that rotation of th petvis in th horizontal piane functionally lengthens th lower extremities and reduces th
|Hf h iP fex- n- on angle required for a given step length, thereby reducing th downward displacement of th CoM. C illustrates that further reduction of
, 4, . dlSp aC,e?lentu * * . 'C M 15 achieved b>' rolalion of lhe ankle ln lhc sagittal piane. D illustrates that th small amount of knee flexion present during stance
reduces th funzionai ength of th lower extremity and, therefore, th upward displacement of th CoM. shows that th contrasterai pelvic drop during stance also
minimizes th net overall elevation of th CoM. The angle values in A and fi are for illustrative purposes only and do not represent th actual hip angles during walking.

A. Walking without reduction
of CoM displacement
FIGURE 15-27. Combined action of th four kinematic strategies to reduce vertical CoM excursion. Without these strategies, a large
vertical displacement of th bodys CoM (red) would occur when walking (A). B illustrates th combined action of horizontal piane
pel vie rotation (HPPR) and sagittal piane ankle rotation (SPAR) to minimize th downward displacement of th CoM dunng doubl-
limb support. It also shows th action of stance phase knee llexion (SPKF) and frontal piane pelvic rotation (FPPR) to minimize th
upward displacement of th CoM at mid stance.
base of support. They must pay for this benefit, however, by
th associateci increased energy cost of walking.
ENERGY EXPENDITURE
Energy expenditure during gait is measured by th amount
of energy used in kilocalories per meter walked per kilogram
of body weight (kcal/m/kg). Typically, energy expenditure is
measured indirectly by quantifying oxygen consumption.72
When walking, th body strives to minimize energy cost.
Conservation of energy is achieved by minimizing th excur
sion of th CoM, controlling th body momentum, and tak-
ing advantage of th intersegmental transfers of energy.
The gait speed at which optimal energy conservation oc-
curs is approximately 1.33 m/s, or 80 mAnin or 3 mph.72
Energy Expenditure During Walking
FIGURE 15-28. Energy expenditure as a function of walking speed.
The lowest energy expenditure per meter walked is at a speed of
approximately 1.33 m/s (80 rn/rnin). (Data from Ralston HJ: Effects
of immobilization of various body segments on energy cost of
human locomotion. Ergonomics $uppl:53, 1965.)
Chapter 15 Kinesiology o j Walking 547
B. Walking with reduction of
CoM displacement
SPKFand FPPR
Not surprisingly, th speed at which th body is most en
ergy' efficient roughly corresponds to th walking speed
freely adopted by individuals ambulating on th Street (see
Table 1 5 - 1 ). Walking faster or slower than that optimal
speed increases th energy cost of ambulaiion (Fig. 1 5 -2 8 ).
Walking speed is equal to th product of step length and
cadence (step rate). Maximum energy efficiency at th opti
mal walking speed is achieved by th bodys innate ability to
adopt th ultimate combination of step length and step rate.
Amazingly, this ability is demonstrated across all walking
speeds. While th energy cost of ambulaiion changes across
walking speeds, a standard and optimal ratio of step length
to step rate of 0.0072 m/sieps/min for men and 0.0 0 6 4
m/steps/min for women is maintained.102 At any given walk
ing speed, imposilion of a different step length or step rate
increases energy expenditure.
With abnormal gait th energy cost of ambulation in
creases (Table 1 5 - 4 ) . As a consequence of increased energy
cost per distance walked, individuals whth disability tend to
walk slower so as to keep th rate of energy consumption
per minute at a comfortable aerobic level. They naturally
adopt a walking speed that is most efficient and comfortable
for them. Further discussion of th energetics of walking in
individuals with pathologic gaits can be found in Perrys
textbook67 and revtews of th literature by Gonzalez and
Corcoran29 and Waters and Mulroy.92
MUSCLE ACTIVITY
During a gait cycle, most muscles of th lower extremities
have one or two short bursts of electrical activity lasting
from 100 io 400 msec (10 to 40% of th gait cycle). Like all
other elements of gait, phasic muscular activation is repeated
at each stride. Knowledge of when muscles are active during
th gait cycle provides insight into their specific roles. Gait
deviations can be more easily understood and treated when
th clinician has a thorough knowledge of specific muscle
function during ambulation.
Activity of th lower extrenuty musculature has been
studied extensively using eleciromyography (EMG). Most of-
ten, muscular activity is expressed on a temporal basis; th
 548 Section IV Lower Extremity
TABLE 1 5 - 4 . Increased Energy Cost o f W alking Associated with Specific Conditions
Conditions
Immoblization of one ankle
Immobilization of one knee in full extension
Immoblization of one knee at 45 degrees of flexion
Immobilization of one hip, arthrodesis
Unilateral transtibial amputation, walking with
prosthesis
Unilateral transfemoral amputation, walking with
prosthesis
Postcerebrovascular accident, moderate-to-severe re
siduai deficits
Percentage increase based on energy cost of normal gait.
muscle is simply considered ON or O FF. The muscle is
said to be ON when its EMG activity level reaches a prede-
termined value above th resting level. Otherwise, th mus
cle is considered to be OFF. The red horizontal bars used in
Figure 1 5 - 2 9 illustrate when selected muscles are ON dur-
ing th gait cycle. Another method io report muscular activ
ity (th lighter shaded areas in Fig. 1 5 - 2 9 ) is to express th
intensity of th EMG signal during gait as a percentage of
th amount of EMG recorded during maximum voluntary
contraction of th same muscle.98 This type of analysis pro-
vides insight into th relative level of activation of th mus
cle (i.e., an index of muscular effort) throughout th gait
cycle.
Hip
Three muscle groups at th hip play a criticai role during
normal ambulation: th hip extensors, such as th gluteus
maximus and th hamstrings; th hip flexors, such as th
iliacus and th psoas; and th hip abductors, such as th
gluteus medius and minimus. Less well documented is th
role of th hip adductors and rotators.
Hip Extensors. Activation of th gluteus maximus starts
in an eccentric manner at terminal swing. This mild muscu
lar activation serves two purposes decelerating hip flexion
and preparing th muscolature for weight acceptance at th
beginning of stance. At heel contact, th gluteus maximus is
strongly activated in order to extend th hip and prevent
forward jackknifng, or uncontrolled trunk flexion over th
femur. This abnormal jackknifng occurs if pelvic motion
were slowed following heel contact while th trunk contin-
ues its forward displacement. The gluteus maximus remains
active from heel contact to mid stance (i.e., first 30% of th
gait cycle) to support th weight of th body and produce
hip extension. Strong activation of th gluteus maximus
when th foot is frmly planted on th ground also assists
indirectly with knee extension.
The hamstrings assist th gluteus maximus durtng th
first 10% ol th gait cycle. Similar to th gluteus maximus,
th hamstrings serve to generate hip extension and to sup
port th weight of th body to prevent th collapse of th
lower extremity during early stance.
Increased Energy Cost (%) Authors
3 -6 Ralston, 1965; Waters et al., 1988
2 3 -3 3 Kerrigan et al., 1995; Waters et al., 1982
37 Ralston, 1965
32 Waters et al., 1988
2 0 -3 8 Fisher and Gullickson, 1978
2 0 -6 0 Fisher and Gullickson, 1978
55 Corcoran et al., 1970
Hip Flexors. The iliacus and psoas become active prior to
toe off to decelerate hip extension. Eccentric muscle activation
is followed by concentric muscle activation to bring th hip
into flexion just prior to toe off and into initial swing. Despite
th movement of hip flexion continuing into terminal swing,
th hip flexors are considered active only in th first 50% of
swing. Hip flexion in th second half of th swing phase is a
result of th forward momentum that th thigh gains in initial
swing. The rectus femoris also acts as a hip flexor and there-
fore assists with th aforementioned actions. The key roles of
th hip flexors are to advance th leg forward during swing in
preparation for th next step and to lift th leg to allow for
toe clearance during swing. The action of th sartorius is
similar to that of th iliacus and psoas.
Hip A bductors. While hip flexors and extensors have
their primary role in th sagittal piane, th hip abductors
gluteus medius, gluteus minimus, and tensor fascia lata
stabilize th pelvis in th frontal piane. The gluteus medius
is active toward th very end of th swing phase in prepara
tion for heel contact. The gluteus medius and minimus, th
two primary hip abductors, are most active during th first
40% of th gait cycle, especially during single-limb support.
The primary function of th abductors is to control th
slight dropping of th pelvis to th side of th swing leg (see
Fig. 1 5 -1 7 ). Following this eccentric activation, these mus
cles act concentrically to initiate th relative abduction of th
hip that occurs in later stance. As described earlier in this
chapter, adequate frontal piane torque from th hip abductor
muscles is cruciai for frontal piane stability during gait (see
Fig. 1 5 -1 8 ). A cane used in th hand contralateral to th
weak hip abductors is an effective way to reduce th de-
mands placed on th weakened abductors, thereby reducing
frontal piane instability of th pelvis due to body weight (see
Chapter 12).
The hip abductors also control th alignment of th fe
mur in th frontal piane. Inadequate muscular activation
may result in excessive adduction of th femur, producing
an excessive valgus torque at th knee during th stance
phase. Other accessory roles of th gluteus medius include
assisting with hip flexion and internai rotation, using ante-
rior fibers, and assisting with hip extension and extema:
rotation, using posterior fibers.
 Chapter 15 Kinesiology o f Walking 549

Timing and Relative Intensity of EMG During Gait

FIGURE 15-29. Timing (dark red

bars) and relative intensity of muscle
activation (light red shading) during
gait. (Muscle timing data from Knut-
son and Soderberg, 1995; relative in
tensity of muscle activation data
from Winter, 1991; Bechtol,* 1975;
Carlsoo.t 1972.)

Percent of G a it C y cle
 550 Section IV Lower Extremity
H ip Adduclors and H ip Rolalors. The hip adductors
show two bursts of activity during gait.98 The first burst
occurs at heel contact and th second just after toe off. The
initial burst of activity serves to stabilize th hip through co-
activation with th hip extensors and hip abductors. It is
also likely that th adductor magnus and other adductors
assist with hip extension at that time. The second burst of
activity, after toe off, assists th hip flexors with initiating
hip flexion. As illustrated in Figure 1 2 - 3 6 , th adductors
have a moment arm to extend th hip when it is flexed (i.e.,
th hip position at heel contact) and a moment arm to flex
th hip when it is in extension (i.e., th hip position at toe
off).
The hip internai rotators (tensor fascia lata, gluteus mini-
mus, and anterior fibers of th gluteus medius) are active
throughout much of th stance phase. During this time,
these internai rotators move th contralateral side of th
pelvis forward, thereby assisting with advancement of th
swing leg (see Fig. 1 2 -3 9 ).
The hip external rotators, consisting of th six short ex-
ternal rotators, th posterior fibers of th gluteus medius,
and th gluteus maximus, are most active during early
stance. These muscles, in conjunction with th hip internai
rotators, control th alignment of th hip in th horizontal
piane. In particular, they control pelvic rotation while th
lower limb is fixed to th ground. Consider th important
action of these rotators in th rapid change of direction
while walking or running.
Eccentric activation of th external rotators may be espe-
cially important to th control of th internai rotation of th
lower limb in early stance (see Fig. 1 5 -2 5 ). Inadequate
strength or control of th external rotators may result in
excessive internai rotation of th femur, especially in individ-
uals with excessive foot pronation.
Knee
Two rnuscle groups play a criticai role at th knee during
ambulation: th knee extensors and knee flexors.
Knee Extensors. As a group, th quadriceps become ac
tive in th very late stage of swing in preparation for heel
contact. The major burst of activity, however, occurs shortly
after heel contact. The function of th quadriceps at this
time is to control th knee flexion that takes place in th
first 10% of th gait cycle. Eccentric activation serves to
cushion th rate of weight acceptance on th lower extremity
(i.e., shock absorption) and to prevent excessive knee flex
ion. The quadriceps then act concentrically to extend th
knee and support th weight of th body during mid stance.
Some individuals show increased activity of th rectus fem-
oris immediately following toe off. This action reflects th
role of this biarticular muscle as a hip flexor.
Knee Flexors. The hamstnngs are most active from a
period just before to just after heel contact. Before heel
contact, th hamstrings decelerate knee extension in prepara
tion for th placement of th foot on th ground. During th
initial 10% of stance, th hamstrings are active in order to
assist with hip extension and to provide stability to th knee
through co-activation. The short head of th biceps femoris
may also assist with knee flexion during th swing phase.
Most of th knee flexion during pre swing and th swing
phase of gait results from passive intersegmental dynamics of
th limb and a small gastrocnemius activation.75'98
Ankle and Foot
At th ankle, several muscles play a cruciai role in normal
gait: th tibialis anterior, extensor digitorum, extensor hallu-
cis longus, gastrocnemius, soleus, tibialis posterior, and per-
oneals.
T ib ia lis Anterior. The tibialis anterior has two periods
of activity. At heel contact, a strong eccentric activation is
present to decelerate th passive piantar flexion of th ankle
caused by th weight of th body being applied on th most
posterior section of th calcaneus. Unopposed by th eccen
tric activation of th tibialis anterior and other ankle dorsi-
flexors, this large, passive piantar flexion torque results in
th gait deviation referred to as foot slap. This term is
derived from th characteristic sound made by th foot slap-
ping th ground just after heel contact. From heel contact to
foot fiat, th tibialis anterior may also assist with decelerating
foot pronation, also an eccentric muscle activation. The poor
mechanical advantage of th muscle to inveri th foot, how
ever, raises some doubt with regard io th effectiveness of
th tibialis anterior in strongly controlling foot pronation.
The second action of th tibialis anterior is th dorsiflex-
ion of th ankle dunng swing. The purpose of this muscle
action is to clear th toes from th ground. Extreme weak-
ness of th tibialis anterior and th other ankle dorsiflexors
is expressed by th inability to dorsiflex th ankle during
swing. This problem, known as drop foot, causes an indi
viduai to excessively flex th knee and hip during swing.
Other compensatory maneuvers, such as vaulting, hip cir-
cumduction, and hip hiking, may also be adopted to clear
th toes. A drop foot causes th forefoot to contact th
ground first. A common remedy for a drop foot is a poste
rior ankle-foot orthosis that passively maintains ankle dorsi-
flexion during swing.
Extensor Digitorum and Extensor H allu cis Lon
gus. Similar to th tibialis anterior, th extensor digitorum
longus and extensor hallucis longus decelerate piantar flex
ion of th ankle at heel contact. These muscles, however,
lack th line-of-force to decelerate foot pronation during
loading response and mid stance. During th swing phase.
th toe extensors assist with dorsiflexion of th ankle and
extend th toes to ensure that th toes clear th ground.
Minor activity of th extensor digitorum longus and extensor
hallucis longus during push off may provide stability to th
ankle through co-activation with th ankle piantar flexors.98
.Ankle Piantar Flexors. The soleus and gastrocnemius
are active throughout most of th stance phase. From about
10 through 40% of th gait cycle (i.e., opposite toe off to
heel off), th ankle piantar flexors eccentrically control th
forward movement of th tibia on th foot (i.e., ankle dorsi
flexion). Excessive or uncontrolled forward movement of th
tibia results in exaggerated ankle dorsiflexion and possibly
uncontrolled knee flexion. The major burst of activity of th
ankle piantar flexors occurs near heel off and decreases rap-
idly to near zero at toe off. During that brief period, short-
ening of th muscles creates an ankle piantar flexion torque

that participaies in ihe forward propulsion of th body. This
action is referred to as push off.
The gastrocnemius also generates low-level muscular ac-
tivity in initial swing, presumably to help with knee flexion.
Note that since th rectus femoris is also active during initial
swing, a small amount of co-activation of th knee flexors
and extensors is taking place.98
The other piantar flexors of th ankle (tibialis postenor,
flexor hallucis longus, flexor digitorum longus, and pero-
neals) assist th gastrocnemius-soleus group in th previ-
ously described actions. Some additional actions of these
muscles are noteworthy.
Tibialis Posterior. The tibialis posterior, a potent supi-
nator muscle of th foot, is active between 5 and 55% of th
gait cycle. Tibialis posterior decelerates pronation of th foot
between 5 and about 35% of th cycle and supinates th
foot between 35% and 55% (mid stance to toe off) of th
cycle.37
The tibialis posterior receives special attention in th
treatment of people with cerebral palsy. The often hyperac-
tive tibialis posterior along with th soleus muscle may cause
an equinovarus deformity of th foot and ankle, resulting in
th individuals walking on a foot that is piantar flexed and
supinated.
Active individuate with fiat, overly pronated feet may de-
velop a syndrome known as shin splints. This syndrome is
due to overuse and subsequent strain of th tibialis posterior
and/or anterior ankle muscles. The overuse is secondary to
th increased work demands placed on th supinator mus
cles as they attempt to control th excessive pronation bias
of th foot during early stance.
Peronei. The peroneus brevis and longus are active from
about 20 to 30% of th gait cycle to just after heel off. In
addition to their function as piantar flexors, these pronator
(everter) muscles help counteract th inversion of th foot
caused by activation of th tibialis anterior and posterior leg
muscles. The peronei help with th alignment and stabiliza-
tion of th subtalar joint. The peroneus longus assists in th
overall kinematics of th foot by placing th first ray rigidly
on th ground, which provides a frm base of support for
th action of th foot as a rigid lever during th terminal
stance and pre swing phases of gait.
In trinsic Muscles o f th Foot. The intrinsic muscles of
th foot are typically active from mid stance to toe off (30 to
60% of th gait cycle), particularly if th foot is not sup-
ported by well-fitting shoes. These muscles stabilize th fore-
foot and raise th mediai longitudinal arch, thereby provid-
ing a rigid lever for ankle piantar flexion in terminal stance
and pre swing.
Trunk
Only th actions of th erector spinae and th rectus abdom-
inis are discussed here.
Erector Spinae. The erector spinae at th level of th
mid-lumbar region (L3-L4) show two periods of activity. The
first period is from slightly before heel contact to about 20%
of th gait cycle. The second period is from 45 to 70% of
th gait cycle, which corresponds to opposite heel contact.
Chapter 15 Kinesiology o f Walking 551
These two bursts of activity control th forward momentum
of th trunk shortly after heel contact for each step.
Rectus Abdominis. This muscle has very low activity
throughout th gait cycle. Nevertheless, increased activity
occurs at 20% and again at 70% of th gait cycle. This
activity may reflect a period of co-activation with th erector
spinae for th purpose of trunk stability in th sagittal piane.
The activity of th trunk flexors ateo coincides with th time
when th hip flexors actively flex th hip. Increased activity
of th rectus abdominis, therefore, may be used to stabilize
th pelvis and lumbar spine and to provide a stable fxation
for th hip flexor muscles, principally th iliopsoas and rec
tus femoris.
The role of th trunk musculature during gait may in fact
be underestimated. Based on th evolution of th vertebrate
spine, Gracovetsky31-32 proposed his theory of th spinai
engine, in which walking was first achieved by motion of
th spine. The hypothesis that th lumbar spine actually
plays an important role to move th pelvis during walking
may deserve consideration in future research.
GAIT KINETICS
Understanding th forces that are responsible for movement
during gait plays a criticai role in understanding normal and
pathologic movement. Although th kinetics (study of forces)
of walking are not visually observable, they are responsible
for th observed kinematics.
Ground Reaction Forces
During ambulation, forces are applied under th surface of
th foot every lime a person takes a step (Fig. 1 5 -3 0 A and
B). The forces applied to th ground by th foot are called
foot forces. The forces applied to th foot by th ground are
called ground (or floor) reaction forces. These forces are of
equal magnitude but opposite direction. (Newtons Third
Law th law of action and reaction States that forces are
always present in pairs that are equal in magnitude and
opposite in direction.) In this chapter, ground reaction forces
are consistently referred to because in most instances th
interest is in th forces applied to th body, as opposed to
those applied to th ground.
The description of th ground reaction forces follows a
Cartesian coordinate System, with th forces being expressed
along three orthogonal axes: vertical, anterior-posterior, and
medial-lateral. The vector summation of th three forces
gives a single resultant force vector between th foot and th
ground. Such vector summation performed for th vertical
and anterior-posterior components of th ground reaction
forces leads to th classic butterfly representation of th
ground reaction forces for a single step (Fig. 1 5 -3 1 ).
Ground Reaction Forces
Vertical: peak value = 120% body weight (BW)
Anterior-posterior: peak value = 20% BW
Medial-lateral: peak value = 5% BW
552 Seclion IV Lower Extremity
Ground Reaction Forces During Gait
B
GROUND
REACTION
FORCES
FOOT
FORCES
*Toe Off is at 57%
V ertical Forces. The vertical forces are those directed
perpendicular to th supporting surface. In th vertical direc
tion, th ground reaction forces peak twice in a given gait
cycle. Forces are slightly greater than body weight ai th
time of th loading response and again at th tinte of termi
nal stance (Fig. 1 5 - 3 0 0 . During mid stance, th ground
reaction forces are slightly lower than body weight. This
slight fluctuation in force is due to th vertical acceleration
of th bodys CoM. (Force is a function of mass as well as
acceleration: F = ma.) Al th time of loading response, th
bodys CoM is moving downward (see Fig. 1 5 -1 3 ). A verti
cal ground reaction force greater than ones body weight,
therefore, is needed to initially decelerate th downward
movement of th body and then accelerate it upward. This is
similar to jumping on a bathroom scale and briefly readtng a
weight that is higher than static body weight. At mid stance,
th vertical ground reaction forces are less than body weight
as a result of a relative unweighting, caused by th upward
momentum of th body gained during th early pari of
stance. The higher ground reaction force ai terminal slance
reflects th combined push provided by th piantar flexors
FIGURE 15-30. Ground reaction
forces (GRFs) during gait. A il-
lustrates th vertical and ante-
rior-posterior GRF (black and
white arrows, respectively) and
foot forces (filled arrows) at
10% of gait cycle B illustrates
th medial-laieral forces at 10%
of gait cycle. C, D, and E show
th GRF for a gait cycle. Dashed
lines are data for left foot con
tact. (Data front Whittle M: Gait
Analysis: An Introduction, 2nd
ed. Oxford, Buiterworth-Heine-
mann Ltd., 1996.)
and th need to reverse th downward movement of th
body that occurs in terminal stance through pre swing.
Anterior-Posterior Forces. In th anterior-posterior di
rection, shear forces are applied parallel to th supporting
surface. Al heel contact, th ground reaction force is in th
postenor direction (i.e., th foot applies an anteriorly di
rected force to th ground) (Fig. 1 5 -3 0 D ). At that time.
sufficient friction is required between th foot and th
ground to prevent th foot front slipping forward (picture
th classic cartoon of a person fading to th ground after
slipping on a banana peel). The magnitudo of th ground
reaction lorces increases with longer steps. This is th reason
people often take shorter steps when walking on an icv
surface they are decreasing th demand for friction.
During terminal stance and pre swing, th ground reac
tion force is directed anteriorly, with th foot applying a
posteriorly directed force to th ground in order to prope.
th body forward. The magnitude of th propulsive force
depends on walking speed and, especially, attempts to accel
erate. Inadequate friction between th foot and th ground a:

HEEL TOE
CONTACT OFF
FIGURE 15-31. Classc butterfly representation of th ground reac
tion forces for a step. Each line represents th resultant force from
th vector addition of th vertical and anterior-posterior forces at
regular time intervals (i.e., every 10 ms in this case). Progression
from heel contaci to toe off takes place from left to righi. (Data
from Whittle M: Gait Analysis: An Introduction, 2nd ed. Oxford,
Butterworth-Heinemann Ltd., 1996.)
this time often causes th foot to slide backward without
propelling th body forward. This explains th difficuhy ex-
perienced when accelerating quickly while walking on a slip-
pery surface.
The peak anterior-posterior ground reaction force is typi-
cally equal to about 20% of body weight. These shear forces
are in large part th result of th CoM of th body being
either posterior (at heel contact) or anterior (at terminal
stance and pre swing) to th foot. The larger th step length,
th greater th shear forces because of th greater angle
between th lower extremity and th floor. Inertial properties
of th body, such as momentum, also contribute to anterior-
posterior ground reaction forces.
The posteriorly directed ground reaction force at heel
contact momentarily slows th forward progression of th
body. Conversely, th body is momentarily accelerated for
ward at toe off as a result of an anteriorly directed ground
reaction force. Note that th propulsive force of one limb is
applied simultaneously to th braking force of th opposite
limb during th times of double-limb support (see Fig. 1 5 -
30D). When walking at a Constant velocity, th propulsive
force occurring late in stance balances th braking force
occurring early in stance. Because these forces are of rela-
tively equal magnitude but of opposite direction, they pro
vide balance to th body when th weight is transferred
Chapter 15 Kinesiology o f Walking 553
from one lower extremity to th other at th time of double-
limb support. Slowing down requires a greater braking force
than propulsive force, and speeding up requires th oppo
site.
M edial-Lateral Forces. The magnitude of th ground
reaction force in th medial-lateral direction is relatively
small (i.e., less than 5% of body weight) and more variable
across individuals (Fig. 1 5 -3 0 E ). As with anterior-posterior
shear force, th magnitude and direction of this shear force
depends mostly on th relationship between th position of
th bodys CoM and th location of th foot. During th
initial 5 to 10% of th gait cycle, a small, laterally directed
ground reaction shear force is produced to stop th smali
lateral-to-medial velocity of th foot that is typically present
at th time of heel contact. During th resi of stance phase,
however, th CoM of th body is mediai to th foot (see Fig.
1 5 - 1 3 ), causing a laterally directed force to be applied to
th ground by th foot and, therefore, a medially directed
ground reaction force. These medially directed ground reac
tion forces throughout stance initially decelerate th lateral
movement of th CoM. Then, these ground reaction forces
accelerate CoM medially toward th contralateral lower ex
tremity, which is swinging forward and preparing to make
th next foot contact with th ground.
Although th action ol th medial-lateral ground reaction
forces may not be easily feli during normal gait, they can be
readily felt when walking while using very large steps or
when jumping from side to side. In fact, greater peak values
in medial-lateral ground reaction forces are often seen in
individuals with wider step widths. The need for friction can
again be appreciated by observing someone walking on ice.
Individuals walking on icy surfaces reduce their step widths
almost as if they were walking on a tightrope. This leamed
adaptation is intended to keep th bodys CoM directly over
th feet to minimize th medial-lateral ground reaction forces
and, therefore, th need for friction. Ice skaters make use of
these medial-lateral ground reaction forces to propel their
bodies forward. This is achieved by using a biade that digs
into th ice, providing an adequate resistance for propul-
sion.
Path of th Center of Pressure
The path of th center of pressure (CoP) under th foot
throughout stance follows a relatively reproducible pattern
(Fig. 1 5 - 3 2 ). At heel contact, th CoP is located just lateral
to th midpoint of th heel. It then moves progressively to
th lateral midfoot region at mid stance, and io th mediai
forefoot region (under th first/second metatarsal head) dur
ing heel off to toe off. The location of th CoP, acting as th
point of application of th ground reaction forces at heel
contact, helps to explain th tendency for th ankle and foot
to piantar flex and evert, respectively (Fig. 1 5 - 3 3 ). Both
tendencies are partially controlled by eccentric activation of
ankle muscles, namely th ankle dorsiflexors and th tibialis
posterior.
Joint Torques and Powers
During gait, th ground reaction forces applied under th
foot generate an extemal torque on th joints of th lower
554 Secfion IV Lower Extremity
Path of th Center of Pressure
on th Piantar Surface o f th Foot
' TOE OFF
FIGURE 15-32. Path of th center of pressure (CoP) under th foot
from heel contact to toe off. The shaded area is representative of
individuai variability of th CoP path. (Data from Katoh Y, Chao
EYS, Laughman RK, et al: Biomechanical analysis of foot function
during gait and clinical applications. Gin Orthop 177:23, 1983.)
Torques Generateci by Ground Reaetion
Forces at Heel Contact
B GRF
FIGURE 15-33. At heel contact, th point and direction of applica
tion of th ground reaction forces on th calcaneus behind th
center of rotation of th ankle (black circle) create a piantar flexion
torque at th ankle (A). This external torque requires th generation
of an oppostng dorsiflexion internai torque by th ankle dorsiflex-
ors. In B, th lateral location of th ground reaction force on th
calcaneus produces subtalar joint eversion and, therefore, foot pro-
nation. This tendency is controlled by action of th tibialis poste-
rior. (From Adams JM, Perry J: Gait analysis: Clinical application.
In Rose J, Gamble JG: Human Walking, 2nd ed. Philadelphia,
Williams & Wilkins, 1994.)
extremities. This fact is illustrateci in Figure 1 5 - 3 4 . During
th loading response on th righi lim, th line of action of
th ground reaction force is located behind th ankle and
knee but anterior to th hip. As a consequence, th ground
reaction forces ai heel contact produce ankle piantar flexion,
knee flexion, and hip flexion. To prevent collapse of th
lower extremity, these external torques are resisted by inter
nai joint torques created by th ankle dorsiflexors, th knee
extensors, and th hip extensors.
Knowledge of ground reaction force and length of th
external moment arms (see Fig. 1 5 - 3 4 ) allows for an esti
mate of th torques imposed on th joints of th lower
extremity during stance phase. This simplified analysis as-
sumes a condition of static equilibrium. Accurate calculation
of joint torques during gait requires th use of th inverse
dynamic approach, which takes into account th dynamic
nature of th action.4 This approach requires th knowledge
of th anthropometric characteristics of th individuali seg-
ment masses, location of th segments' center of mass, and
segments mass center inertia matrix, and precise measure-
ments of body motion (each segm enti linear and angular
velocity) and ground reaction forces throughout th gait cy-
cle (see Fig. 1 5 - 5 ).
In th following description, internai joint torques refer to
those created by th body. Most often these torques can be
related to th activity of th surrounding musculature. Mus-
cles do generate most of th internai torques necessary to
keep th body upright and move th body forward. Descrip
tion of joint torque, therefore, should match th description
of muscular activation provided earlier in this chapter. In
some cases, especially with pathologic conditions, joint
torques can be th result of passive forces generated by th
deformation of soft tissues, such as th capsule and liga-
ments. Joint torques can be generated, therefore, even in th
absence of EMG activity of th surrounding musculature. In
fact, many patients without normal muscular function leam
to use passive forces to generate th joint torques necessary
to ambulate.
FIGURE 15-34. During th loading response, th line of action of
th ground reaction forces (posterior io th ankle, posterior to th
knee, and anterior to th hip) promotes ankle piantar flexion, knee
flexion, and hip flexion. (From Whittle M: Gait Analysis: An Intro-
duction, 2nd ed. Oxford, Butterworth-Heinemann Ltd., 1996.)
 Chapter 15 Kinesiology o f Walking 555

Joint Torques
Hip Kinetics (Sagittal Piane)
Internai joint torques: produced by th body
Extemal joint torques: applied to th body

The term net joint torques reflects th fact that th in

verse dynamic approach used to calculate internai joint
torques does not take imo account co-activation of agonist-
antagonist muscle groups. Note, too, that th net torque
produced by muscles does not necessarily reflect th direc
tion of movement of that joint. As illustrated in Figure 15
34, during th loading response, a net internai dorsiflexion
torque exists while th ankle is moving in piantar flexion.
This combination of dorsiflexion torque and piantar flexion
movement indicates an eccentric activation of th ankle dor-
siflexors.
The concept of net internai torque provides valuable in-
sight into th role of particular muscles in controlling a joint
during walking. Internai net torque does not, however, pro
vide th answer to th rate of muscle activation. Understand-
ing th rate of work performed by th controlling muscles
requires knowledge of power. Joint power is th product of
th net joint torque and th joint angular velocity. Joint
power reflects th net rate of generating or absorbing energy
by all muscles and other connective tissues Crossing a joint.
A positive value indicates power generation, which reflects a
concentric muscle activation, whereas a negative value indi
cates power absorption, which reflects an eccentric muscle
activation. The concept of power generation and absorption
may be understood with th example of performing a jump.
During th initial squatting movement preceding a jump,
most muscles of th lower extremities work eccentrically,
absorbing energy. This energy is then released by a concen
tric muscle activation during th upward movement of th
body. Application of this concept in th feld of athletic
strength building is known as plyometric training.

Joint Power is th Product of th Net Joint Torque and

th Joint Angular Velocity
Power is generated by concentric muscle activation
Power is absorbed by eccentric muscle activation

Analysis of joint torques and powers gives a more com

plete picture of th biomechanics of gait. These variables
help establish th relative contribution of various joints and
muscle groups to tasks such as generation of forward veloc
ity, support of body weight, and control of balance during
gait. In th healthy adult, for example, th ankle piantar Percent of Gait Cycle
flexors are suggested as th primary source of forward veloc
ity of th body.38 The understanding and treatment of patho-
FIGURE 15-35. Sagittal piane hip motion (A), net internai torques
(B), powers (C), and electromyographic (EMG) activity (D) for a gait
logic gait benefit from this type of information. cycle. The EMG curves represent th relative intensity of th muscle
The following sections highlight th primary' torques and activation during th gait cycle, with th shaded and hatched areas
powers generated during walking. These sections also pro indicating eccentric and concentric muscle activation, respectively.
vide th figures that summarize th kinematics and kinetics (Torque and power data normalized to body mass from Winter et
of th hip, knee, and ankle in th sagittal piane and th hip al, 1996, and EMG data from Winter, 1991, and Bechtol, 1975.)
in th frontal piane. Careful study of these figures should
provide an increased understanding of th relationships
556 Seniori IV Lower Extremiiy

Hip Kinetics (Frontal Piane) among joint motion, torque, power, and muscle activation
during gait.

Hip. In th early stance, in th sagittal piane, th hip

musculature generates a hip extension torque that serves to
accept th weight of th body, control th trunk, and extend
th hip (Fig. 1 5 -3 5 A and B). In th second half of stance, a
flexion torque is generated to decelerate hip extension. This
hip flexion torque is th result of passive forces from th
anterior capsule and activity of th hip flexors. In initial
swing, a small hip flexion torque, corresponding to th con
centric activation of th flexors, initiates hip flexion. In ter
minal swing, an extensor torque is needed to decelerate th
movement of hip flexion.
Figure 1 5 -3 5 C shows th power curve for th hip in th
sagittal piane. Power is generated to support th body, raise
th CoM, control th trunk, and propel th body forward in
th first 35% of th gait cycle. Power is then absorbed until
50 to 55% of th gait cycle is reached, reflecting th deceler-
ation of hip extension secondary to resistance provided by
th anterior capsule of th hip and th eccentric activation of
th hip flexors. In pre swing and initial swing, power is
generated to flex th hip.

Hip Kinetics (Horizontal Piane)

Percent of Gait Cycle

FIGURE 15-36. Frontal piane hip motion (A), net internai torques
(B), powers (C), and electromyographic (EMG) activity (D) for a gait
cycle. The EMG curves represent th relative intensity of th muscle
activation during th gait cycle, with th shaded and hatched areas
indicating eccentric and concentric muscle activation, respectively.
(Torque and power data normalized to body mass from Winter et
al, 1996, and EMG data from Winter, 1991.)
Percent of Gait Cycle
FIGURE 15-37. Horizontal piane net internai torques (A) and
powers (B). (Data normalized to body mass from Winter et al
1996.)
 Chapter 15 Kinesiology o f Walking 557

To complete th description of sagittal piane hip move- Knee Kinetics (Sagittal Piane)
ment during gail, Figure 1 5 -3 5 D illustrates th relative in-
tensity of activity of two primary antagonistic muscles of th
hip. The areas of th EMG curve that are shaded indicate an
eccentric muscle activation. The hatched areas indicate a
concentric muscle activation. In generai, th muscular activa-
tions correlate with power absorption and power generation.
In th frontal piane, a large abduction torque occurs dur 0 10 20 30 40 50 60 70 80 90 100
ing stance to support th mass of th body that is located
mediai to th hip joint (Fig. 1 5 -3 6 A and 6). Power absorp
tion during th initial lowering of th opposite side of th
pelvis (Fig. 1 5 -3 6 C ) reflects th eccentric activation of th
hip abductors (Fig. 1 5 -3 6 D ). Power generation is seen at 20
and 60% of th gait cycle, as th contralateral pelvis is raised
(Fig. 1 5 -3 6 C ).
In th horizontal piane, an extemal rotation torque is used
to decelerate th internai rotation of th femur in th frst
20% of th gait cycle (Fig. 15-3 7 A ). This torque is followed
by an internai rotation torque that advances th contralateral
side of th pelvis forward during th remainder of stance.
Notice th small magnitude of these torques, approximately
15% of those in th sagittal and frontal planes. The eccentric
activation of th hip external rotators in th initial 20% of
th gait cycle accounts for th power absorption noted at
that time (Fig. 1 5 -3 7 6 ).

Knee. In th sagittal piane, at heel contact, a very brief

(frst 4% of th gait cycle) initial flexion torque presumably
ensures that th knee is flexed to provide an adequate knee
alignment for shock absorption (Fig. 1 5 -3 8 A and B). A
large extensor torque needed for th loading response
quickly follows this flexion torque. This extensor torque con-
tinues until 20% of gait, initially to eccentrically control
knee flexion, then to extend th knee. Between 20 and 50%
of th gait cycle, a net flexor torque is present as th knee
flexes before toe off. Because little activity of th hamstrings
is present at that time, th net flexor torque likely results
from passive tension in th posterior capsule of th knee.
Just before toe off, however, a small extensor torque occurs
to control knee flexion. In terminal swing, a flexion torque is
generated to decelerate knee extension.
The power curve for th sagittal piane reflects th action
of th musculature surrounding th knee (Fig. 1 5 - 3 8 C and
D). The short duration power generation at early stance
shows that th net knee flexion torque creates flexion of th
knee. Then, power absorption momentarily takes place, re-
flecting th eccentric action of th quadriceps. This is fol
lowed by another brief moment of power generation, indi-
cating th start of knee extension. Just prior to toe off,
power is absorbed by th knee extensors that control th
flexion of th knee. In terminal swing, th hamstrings are
absorbing energy as th swing leg is decelerated. Percent of Gait Cycle
In th frontal piane (Fig. 1 5 -3 9 A ), an internai abductor FIGURE 15-38. Sagittal piane knee motion (A), net internai torques
torque ai th knee counters th extemal adductor (varus) (B), powers (C), and electromyographic (EMG) activity (D) for a gait
torque created by th resultant ground reaction force passing cycle. The EMG curves represent th relative intensity of th muscle
mediai to th stance knee (Fig. 1 5 -4 0 ). The internai abduc activation dunng th gait cycle, with th shaded and hatched areas
tor torque is created by a combination of active and passive indicating eccentric and concentric muscle activation, respectively.
structures, including th iliotibial tract, th tensor fascia la- (Torque and power data normalized to body mass from Winter et
tae, and th lateral ligaments of th knee. Power values in al, 1996, and EMG data from Winter, 1991.)
this piane are very low because of th low knee angular
velocities in th frontal piane (Fig. 15396).
 558 Sec'tion (V Lcnver Extremity
Knee Kinetics (Frontal Piane)
Percent of Gait Cycle
FIGURE 15-39. Frontal piane net internai torques (A) and powers
(B) for th knee. (Data normalized to bodv mass from Winter et al,
1996.)
FIGURE 15-40. Weight application on th foot during gait creates a
varus torque at th knee. Greater loading of th mediai femoral
condyle and tibial plateau explains th greater incidence of joint
deterioration of th mediai aspect of th knee. This varus torque
also tends to open th lateral aspect of th knee. This tendency is ers (B) for th knee. (Data normalized to body mass from Winter e:
resisted by th lateral structures of th knee.
In th horizontal piane that describes tibial on femoral
motion, th joint torques are similar to those at th hip,
with an extemal rotation torque in th frst hall' of
stance and an internai rotation torque in th second half
(Fig. 1 5 -4 1 A ). These torques are generated by knee liga-
ments in response to th attive hip torques in th horizontal
piane.20 During loading response, a small amount of power
is absorbed as th knees capsular and ligamentous struc
tures resist th internai rotation motion of th tibia (Fig. 1 5 -
4 1 B).
Ankle and Foot. In th sagittal piane, a small dorsiflex-
ion torque is generated at th ankle immediately after heel
contaci (Fig. 1 5 -4 2 A and B). This torque serves to eccentri-
cally control th movement of piantar flexion generated by
th application of body weight on th calcaneus (see Fig.
1 5 - 3 3 ). A piantar flexion torque prevails throughout th
rest of stance, initially to eccentrically control th tibia ad-
vancing over th foot, then to piantar flex th ankle at push
off. A very small dorsiflexion torque is present during swing
to keep th ankle dorsiflexed in order to clear th toes.
Knee Kinetics (Horizontal Piane)
Percent of Gait Cycle
FIGURE 15-41. Horizontal piane net internai torques (A) and pow
al, 1996.)
 Chapter 15 Kinesiology o f Walking 559

Ankle Kinctics (Sagittal Piane) In th sagittal piane, power is absorbed prior to push off
(Fig. 1 5 -4 2 C ), reflecting th eccentric nature of th action
of th piantar flexors (Fig. 1 5 -4 2 D ). This is followed by a
large generation of energy from th piantar flexors at push
off. This power generation is responsible for a large portion
of th propulsive forces pushing th body forward during
gait.38
The torques and especially th power values in th jrontal
and horizontal planes are very smal] and exhibit large varia-
don among people (Figs. 1 5 - 4 3 and 1 5 -4 4 ). In th frontal
piane, stance phase is characterized by a small initial ever-
sion torque (from 0 to 20% of gait) followed by an inversion
torque (from 20 to 45% of gait) and a smaller eversion
torque just prior to toe off.101 In th horizontal piane, an
extemal rotation torque is present during th stance phase.
This extemal rotation torque should in fact be called an
abduction torque based on th description of ankle move-
ment provided in Chapter 14.

Ankle Kinetics (Frontal Piane)

- 2.00 - 1
C 5.0-1

0 10 20 30 40 50 60 70 80 90 100
Percent of Gait Cycle
FIGURE 15-42. Sagittal piane ankle motion (A), net internai torques
(B), powers (C), and electromyographic (EMG) activity (D) for a gait
cycle. The EMG curves represent th relative intensity of th muscle
activation during th gait cycle, with th shaded and hatched areas
indicating eccentric and concentric muscle activation, respectively. Percent of Gait Cycle
(Torque and power data normalized to body mass from Winter et
al, 1996, and EMG data from Winter, 1991.) FIGURE 15-43. Frontal piane net internai torques (A) and powers
(B) for th ankle. (Data normalized to body mass from Winter et al,
1996.)
 560 Section IV Lower Extremity
Ankle Kinetics (Horizontal Piane)
Percent of Gait Cycle
FIGURE 15-44. Horizontal piane net internai torques (A) and pow-
ers (B) for th ankle. (Data normalized to body mass from Winter
et al, 1996.)
Joint and Tendon Forces
Joint surfaces, ligaments, and tendons are all subjeeted to
large tensile, compressive, or shear forces durtng walking.
Knowledge of th magnitude of these forces is of interest,
especially to th clinician, orthopedic surgeon, and bioengi-
neer. The design of surgical joint implants, in particular,
requires these types of data. Direct measurements in men
and women are obviously not readily oblainable; therefore,
these forces are typically calculated indirectly through bio-
mechanical analysis including modeling and optnnizaiion
techniques.
Forces applied to various structures of th lower extremi-
ties during ambulation are presented in Table 1 5 - 5 . These
forces can be surprisingly large. Consider, for example, that
th compressive bone-on-bone force at th hip during ambu
lation at 1.4 m/s is equal to 6.4 times body weight.79
GAIT DYSFUNCTIONS____________________
Most of us take for granted our ability to walk. The fact is,
unless we have personally experienced an injury or a physi-
cal impairment, we do not think of walking as a difficult
task. The information provided thus far in this chapter, how-
ever, reminds us of th complexity of ambulation. Many
actions must occur simultaneously at each pari of th gait
cycle for ambulation to take place with maximum efficiency.
Normal ambulation requires sufficient range of motion
and strength at each participating joint. Walking also re
quires sophisticated control of movement through th centrai
nervous System. The complexity of walking creates many
opportunities for th normal gait pattern to be affected by
impairment. The adaptability of th System, however, does
create many opportunities to modify th gait pattern in or-
der to walk despite even severe impairments. In these
cases, a normal gait pattern is sacrifced for th ability to
move from one location to another independently. We have
all used this ability to adapt gait, even if for only a painful
blister under th foot or for walking on hot sand at th
beach. In essence, an abnormal or a pathologic gait pattern
reflecis an effort lo preserve ambulation through adaptation.
The cost of gait deviation is, typically, increased energy ex-
penditure and application of abnormal stresses to th body.
Ihree common causes of pathologic gait patterns are
listed in th box. Each includes many spedire and generai
pathologies. The observed deviations may be th direct re-
sponse to a specifc impairment or may in fact be a compen-
sation. Ihe features of pathologic gait, therefore, depend on
th nature of th impairment as well as th ability of th
individuai to compensate for that impairment.
Causes of Pathologic Gait Patterns
Pain
Central nervous System disorders
Musculoskeletal System impairments
Pain can cause an abnormal gait pattern that is often
referred to as an antalgic gait. The pattern of weight avoid-
ance on th painful limb often leads to characteristic fea
tures. The primary fndings are a shorter step length, slance
time on th painful side, and swing time on th uninvolved
side. 11 th pain is related to hip joint compression from
muscle activation, lateral displacement of th head and trunk
loward th painful weight-bearing lower extremity occurs
(see Chapter 12). If th source of pain is other than th hip.
th trunk may lean slightly toward th swing leg in an
attempt to alleviate weight hearing on th injured stance leg
Many neurologie disorders, such as cerebrovascular acci-
dents (CVA), Parkinsons disease, and cerebral palsy, can
cause abnormal gait patterns.83 Spasticity of muscles, defned
as increased ione and resistance to stretch, often affeets th
extensor musculature of individuals with cerebral palsy and
CVA. As a result, th gait pattern appears stiff-legged and is
often accompamed by a tendency to circumduct and scuff
th feet. A scissoring gait panem due to hyperactive hip
adductors may also be noted. Parkinsons disease often
causes a hurried small-step gait pattem, also called festinat-
 Chapter 15 Kinesiology o f Walking 561

T A 8 L E 15-5. Forces Applied to th Lower Extremity Structures During Ambulation

Structures (Types of Force) Speed Authors Magnitude (BW)

Ankle

Talocrural joint (peak compression) 1.4 m/s Simonsen et al. (1995) 4.2
Talocrural joint (peak compression) 114 s/min Collins (1995) 4.8
Talocrural joint (peak compression) 4.2 m/s (r) Scott and Winter (1990) 12.0
Talocrural joint (peak anterior shear*) 116 s/min Stauffer et al. (1977) 0.6
Talocrural joint (peak posterior shear*) 116 s/min Stauffer et al. (1977) 0.3
Achilles tendon (peak tension) 1.5 m/s Finni et al. (1998) 2.0
Achilles tendon (peak tension) 1.7 m/s Finni et al. (1999) 4.0
Achilles tendon (peak tension) 4.2 m/s (r) Scott and Winter (1990) 7.0
Ankle dorsiflexors (peak tension) 114 s/min Collins (1995) 1.0

K
nee
Piantar fascia (peak tension) 4.2 m/s (r) Scott and Winter (1990) 2.1

Tibiofemoral joint (peak compression) 1.4 m/s Simonsen et al. (1995) 4.6
Tibiofemoral joint (peak compression) 114 s/min Collins (1995) 5.0
Patellofemoral joint (peak compression) 1.0 m/s Komistek et al. (1998) 0.3
Patellofemoral joint (peak compression) 1.5 m/s Kuster et al. (1993) 1.5
Patellofemoral joint (peak compression) 1.0 m/s Taylor et al. (1998) 0.8
Patellofemoral joint (peak compression) 4.2 m/s (r) Scott and Winter (1990) 9.0
Anterior cruciate ligament (peak tension) 114 s/min Collins (1995) 1.5
Posterior cruciate ligament (peak tension) 114 s/min Collins (1995) 0.4
Patellar tendon (peak tension) 1.7 m/s Finni et al. (1999) 3.0
Patellar tendon (peak tension) 4.2 m/s (r) Scott and Winter (1990) 5.8
Hamstrings (peak tension) 114 s/min Collins (1995) 1.1

Hip

Hip (peak compression) 1.4 m/s Simonsen et al. (1995) 6.4

Hip (peak compression) 0.9 m/s Pedersen et al. (1997) 3.1
Hip (peak compression) 114 s/min Collins (1995) 3.8
Adductor magnus (peak tension) 0.9 m/s Pedersen et al. (1997) 0.3
Gluteus medius (peak tension) 0.9 m/s Pedersen et al. (1997) 0.5

BW, units in number of body weights; s/min, steps per minute; m/s, meters per second; * direction of shear of tibia on talus; (r), runntng speed.

ing gait. Apraxia, defined as a disorder of voluntary move-
ment, occurs in some disease processes affecting th elderly.
Gait apraxia may result in an ambulation pattern character-
ized by a wide base of support, short stride, and shuffling.
Individuai with impaired sensory function and balance may
show an unstable gait pattern.76 With neurologie disorders,
th primary cause of gait dysfunction is an inability to gener
ate and control an appropriate level of muscle force. Eventu-
ally, muscle weakness and joint contracture may compound
th primary neuromotor deficit.
Deficits in th musculoskeletal System also result in a
wide variety of gait deviations. Abnormal (excessive or lim-
ited) joint range of motion and/or limited muscle strength
can cause gait deviations. Abnormal joint range of motion
may occur secondary to injuries, tightness or contracture of
connective tissues and muscles, abnormal joint structure,
joint instability, or congenital connective tissue laxity. In
most cases, abnormal range of motion in one joint leads to
some form of compensation in one or more surrounding
joints. Muscular weakness may be due to disuse atrophy
following an injury or a limited neural drive secondary to a
peripheral neural injury. Whatever th cause, weakness ulti-
mately leads to modification of th gait pattern. Tables 1 5 - 6
through 1 5 - 1 1 and Figures 1 5 - 4 5 through 1 5 - 5 1 present
some of th most common gait deviations observed in th
generai population.
562 Sedioli IV Lowcr Extremily
TABLE 1 5 - 6 . Gait Deviations at th Ankle/Foot Secondary to Specific Anklc/Foot Impairments*
Observed Gail Deviation at
th Ankle/Foot __________ Likely Impairment
Foot slap: rapid ankle pian
tar flexion occurs following
heel contact.t The name
foot slap is derived from
th characteristic noise
made by th forefoot hitting
th ground.
Entire piantar aspect of th
foot touches th ground at
initial contact,f followed
by normal, passive ankle
dorsiflexion during th rest
of stance.
Initial contact with th
ground is made by th
forefoot followed by th
heel region. Normal passive
ankle dorsiflexion occurs
during stance.
Initial contact is made with
th forefoot, but th heel
never makes contact with
th ground during stance.
Initial contact is made with
th forefoot, and th heel is
brought io th ground by a
posterior displacement of
th tibia (Fig. 15-45)
Premature elevation of th
heel in mid stance
Heel remains in contact with
th ground late in terminal
stance
Supinated foot position and
weight hearing on th lat-
eral aspect of th foot dur
ing stance
Excessive foot pronation oc
curs during stance with
failure of th foot to supi-
nate in mid stance. Normal
mediai longitudinal arch
noied during swing.
Excessive foot pronation with
weight hearing on th me
diai portion of th foot dur
ing stance. The mediai lon
gitudinal arch remains
absent during swing.
Selected Pathologic Mechanical Rationale and/or
Precursors Associated Compensations
Mild weakness of ankle Common peroneal nerve Ankle dorsiflexors have sufficient
dorsiflexors palsy and distai pe- strength to dorsiflex th ankle dur
ripheral neuropathy ing swing but noi enough to control
ankle piantar flexion after heel con
tact.
Marked weakness of Common peroneal nerve Sufficient strength of th dorsiflexors
ankle dorsiflexors palsy and distai pe- to partially, but not completely, dor
ripheral neuropathy siflex th ankle during swing. Nor
mal dorsiflexion occurs during
stance as long as th ankle has nor
mal range of motion.
Severe weakness of an Common peroneal nerve No active ankle dorsiflexion is possible
kle dorsiflexors palsy and distai pe- during swing. Normal dorsiflexion
ripheral neuropathy occurs during stance as long as th
ankle has normal range of motion.
Heel pain Calcaneal fracture, pian Purposeful strategy to avoid weight
tar fasciitis hearing on th heel
Piantar flexion contrac- Upper motor neuron le- To maintain th weight over th foot,
ture (pes equinus sion/cerebral palsy, th knee and hip are. kepi in flexion
deformity) or spas- cerebrovascular acci- throughout stance, leading to a
ticity of ankle pian dent (CVA) crouched gait.
tar flexors
Piantar flexion contrae - Upper motor neuron le- Knee hyperextension occurs during
ture (pes equinus sion (cerebral palsy, stance owing to th inability of th
deformity) or spas- CVA) tibia to move forward over th foot.
ticity of ankle pian Ankle fusion in a pian Hip flexion and excessive forward
tar flexors tar flexed position trunk lean during terminal stance
occur to shift th weight of th body
over th foot.
Lack of ankle dorsi Congenital or acquired Characteristic bouncing gait pattern
flexion muscular tightness of
ankle piantar flexors
Weakness or flaccid Peripheral or centrai Excessive ankle dorsiflexion results in
paralysis of piantar nervous System disor- prolonged heel contact, reduced
flexors with or with- ders push off, and a shorter step length.
out a fixed dorsi- Excessive surgical
flexed position of lengthening of th
th ankle (pes calca- Achilles tendon
neus deformity)
Pes cavus deformity Congenital structural A high mediai longitudinal arch is
deformity noied with reduced midfoot mobility
throughout swing and stance.
Rearfoot varus and/or Congenital or acquired Excessive foot pronation and associated
forefoot varus structural deformity flattening of th mediai longitudinal
arch may be accompanied by a gen
erai internai rotation of th lower
extremity during stance.
Weakness (paralysis) of Upper motor neuron le- An overall excessive internai rotation of
ankle invertors sion th lower extremity during stance is
possible.
Pes planus deformity Congenital structural
deformity
 TABLE 1 5 - 6 . Gait Deviations at th Ankle/Foot Secondary to Specific Ankle/Foot Impairments* C o n tin u ed

Observed Gait Deviation at Selected Pathologic Mechanical Rationale and/or

th Ankle/Foot Likely Impairment Precursore Associated Compensations

Excessive inversion and pian
tar flexion of th foot and
ankle occur during swing
and at initial contact.
Ankle remains piantar flexed
during swing and can be
associated with dragging of
th toes, typically called
drop foot (Fig. 15-46).
Pes equinovarus defor-
mity due to spastic-
ity of th piantar
flexors and invertors
Weakness of dorsiflex-
ors and/or pes
equinus deformity
Upper motor neuron le-
sion (cerebral palsy,
CVA)
Common peroneal nerve
palsy
Contact with th ground is made with
th lateral border of th forefoot.
Weight hearing on th laterai border
of th foot during stanee.
Flip htking, hip circumduction, or ex
cessive hip and knee flexion of th
swing leg or vauliing of th stanee
leg may be noted to lift th toes off
th ground and prevent th toes
from dragging during swing.

* An impairmeni is a loss or an abnormalily in physiologc, psychoiogic, or anatomie structure or function.

tThe terms in bold indicate th time in th gait cycle when th gait deviation is expressed.
t Initial contact is often used instead of heel contact to rellect th faci that with many gait deviations th heel is not th section of th foot that makes
initial contact with th ground.

TABLE 15-7. Gait Deviations Seen at th Ankle/Foot as a Compensation for an Impairment of th Ipsilateral
Knee, Ipsilateral Hip, or Contralateral Lower Extremity
Observed Gait Deviation at th
Ankle/Foot Likely Impairment Mechanical Rationale

Vaulting: compensatory mechanism
demonstrated by exaggerated ankle
piantar flexion during mid stanee;
leads to excessive vertical movement
of th body (Fig. 15-47).
Excessive foot angle during stanee that
is called toeing-out.
Reduction of th normal foot angle
during stanee that is called toeing-
in.
Any impairment of th contralateral
lower extremity that reduces hip llex-
ion, knee flexion, or ankle dorsiflex-
ion during swing.
Retroversion of th neck of th femur
or tight hip extemal rotators
Excessive femoral anteversion or spastic-
ity of th hip adductors and/or hip
internai rotators
Strategy used to allow th foot of a
functionally long, contralateral lower
extremity to clear th ground during
swing.
Foot is in excessive toeing-out due to
excessive extemal rotation of th
lower extremity.
General internai rotation of th lower
extremity

The terms in bold indicate th time in th gait cycle when th gait deviation is expressed.

FIGURE 15-45. Knee hyperextension and forward trunk lean with FIGURE 15-46. Drop foot during swing phase, reflective of weak
an ankle piantar flexion contracture. (From Perry J. Contractures: A dorsillexors. (From Shumway-Cook A: Motor Control: Theory and
historical perspective. Clin Orthop 219:8, 1987.) Practical Applications. Baltimore, Williams & Wilkins, 1995.)
563
564 Section IV Lower Extremity
TABLE 15-8. Gait Deviations at th Knec Secondary to Specific Knce Impairments
Observed Gait Deviation
at th Knee
Rapid extension of th knee
(knee extensor thrust)
immediately after initial
contact
Knee remams extended
during th loading re-
sponse, but there is no
extensor thrust.
Genu recurvatum (hyperex-
tension) during stance
Varus thrust during stance
Flexed position of th knee
during stance and lack
of knee extension in ter
minal swing (Fig. 15-
49)
Reduced or absent knee
flexion during swing
The lerms in bold indicate th time in th gait cycle when th gait deviation is expressed
Likely Tmpairment
Spasticity of th quadriceps
Weak quadriceps
Knee pain
Knee extensor weakness
(see th two previously
described gait deviations
in this table)
Laxity of th posterior and
lateral ligamentous joint
structures of th knee
Knee flexion contracture
> 10 (genu flexum)
Hamstring overactivity
(spasticity)
Knee pain and joint effu-
sion
Spasticity of knee exten-
sors
Knee extension contracture
Selected Pathologic
Precursors
Upper motor neuron lesion Depending on th status of th poste
Femoral nerve palsy, L3-L 1
compression neuropathy
Arthritis
Poliomyelitis
Traumatic injury or pro Rapid varus deviation of th knee
gressive laxity
Upper motor neuron lesion
Trauma or arthritis
Upper motor neuron lesion
Immobilization (cast,
brace) or surgical fusion
Mechanical Rationale and/or
Associated Compensatiotts
rior structures of th knee, may oc-
cur with or without knee hyperex-
tension.
Knee remains fully extended through-
out stance. An associated anterior
trunk lean in th early part of
stance moves th line of gravity of
th trunk, slightly anterior to th
axis of rotation of th knee. (Fig.
15-48). This keeps th knee ex
tended without action of th knee
extensors. This gait deviation may
lead to an excessive stretching of
th posterior capsule of th knee
and eventual knee hyperextension
(genu recurvatum) during stance.
Knee is kept in extension to reduce
th need for quadriceps activity
and associated compressive forces.
It may be accompanied by an ant-
algic gait pattern characterized by a
reduced stance time and shorter
step length.
Secondary to progressive stretching of
th posterior capsule of th knee
during mid stance, typically accom
panied by knee hyperextension
Associated increase in hip flexion and
ankle dorsiflexion during stance
Knee is kept in flexion since this is
th position of lowest intraarticular
pressure.
Compensatory hip hiking and/or hip
circumduction could be noted.
 Chapter 15 Kmesiology o f Walking 565

TABLE 15-9. Gait Deviations Seen at th Knee as a Compensation for an lmpairment of th Ipsilateral Anklc,
Ipsilateral Hip, or Contralateral Lower Extremity
Observed Gait Deviation at th Knee Likely lmpairment Mechanical Rationale

Knee is kept in flexion during stance
despile th knee having normal range
of motion on examination.
Hyperextension of th knee (genu recur-
vatum) from initial contact to pre
swing
Antalgic gait
Excessive knee Qexion in swing
Impairments at th ankle or th hip
including a pes calcaneus deformity,
piantar flexor weakness, and hip
flexion contracture.
Ankle piantar flexion contracture (pes
equinus deformity) or spasticity of
ankle piantar flexors
Painful stance leg
Lack of ankle dorsiflexion of th swing
leg or a short stance leg
Exaggerated ankle dorsiflexion or hip flexion
during stance forces th knee in a flexed
position. The contralateral (healthy) swing
leg shows exaggerated hip and knee flex
ion to clear th toes owing to th func-
tionally shorter stance leg.
Knee must hyperextend to compensate for
th lack of forward displacement of th
tibia during stance (see Fig. 15-45).
This is characterized by a shorter step length
and stance time on th side of th painful
lower extremity; it may be accompanied
by ipsilateral trunk lean, if hip pain, con
tralateral trunk lean occurs wth knee and
foot pain.
Strategy to increase toe clearance of th
swing leg and is typically accompanied by
increased hip flexion.

The terms in bold indicate th time in th gait cycle when th gait deviation ts expressed.

Anterior trunk
Normal
bending

FIGURE 15-47. Vaulting on unaffected side to compensate for lim-

ited functional shortening of th swing leg. (From Whittle M: Gait FIGURE 15-48. Weak quadriceps leading to anterior trunk lean.
Analysis: An lntroduction, 2nd ed. Oxford, Butterworth-Heinemann (From Whittle M: Gait Analysis: An lntroduction, 2nd ed. Oxford,
Ltd., 1996.) Butterworth-Heinemann Ltd., 1996.)
566 Section IV Lower Extremity
TABLE 1 5 - 1 0 . Gait Deviations at th Hip/Pelvis/Trunk Seeondary to Specific Hip/Pelvis/Trunk Impairments
Observed Gait Deviation at th
Hip/Pelvis/Trunk
Backward irunk lean during load-
ing response
Lateral trunk lean toward th
stance leg; since this movement
compensates for a weakness, it is
often called compensated Tren-
delenburg gait and is referred to
as a waddling gait if bilaieral.
Excessive downward drop of th
contralateral pelvis during
stance. (Referred to as positive
Trendelenburg sign if present
during single-limb standing.)
Forward bending of th trunk dur
ing mid and term inal stance, as
th hip is moved over th foot.
Excessive lumbar lordosis in term i
nal stance
Trunk lurches backward and
toward th unaffected stance leg
from heel o ff to mid swing.
Posterior tilt of th pelvis during
initial swing
Hip circumduction: semicircle
movement of th hip during
sw ing combining hip flexion,
hip abduction, and forward rota-
tion of th pelvis (Fig. 1 5 -5 0 ).
* The terms in bold indicate th tinte in th gatt cycle when th gait deviation is expressed.
Likely Impairment
Weak hip extensors
Marked weakness of
th hip abductors
Hip pain
Mild weakness of th
gluteus medius of
th stance leg
Hip flexion contracture
Hip pain
Hip flexion contracture
Hip flexor weakness
Hip flexor weakness
Hip flexor weakness
Selected Pathologic
Precursore
Paralysis or poliomyelitis
Guillain-Barr or poliomyelitis
Arthritis
Guillain-Barr or poliomyelitis
Hip osteoarthritis
Hip osteoarthritis
Arthritis
l.2-L ! nerve compression
L2-L3 nerve compression
L2-L ! nerve compression
M echanical Rationale and/or
Associated Com pensations
This action moves th line of
gravity of th trunk behind
th hip and reduces th need
for hip extension torque.
Shifting th trunk over th sup-
porting limb reduces th de-
mand on th hip abductors.
Shifting th trunk over th sup-
porting lower extremity re
duces compressive joint forces
associated with th action of
hip abductors (see Fig. 1 5 -
18).
While th Trendelenburg sign
may be seen in single-limb
standing, a compensated Tren
delenburg gait is often seen in
severe weakness of th hip ab
ductors.
Forward trunk lean is used to
compensate for lack of hip ex
tension. An alternative adapta-
tion could be excessive lum
bar lordosis.
Keeping th hip at 30 degrees of
flexion mintmizes intraarticu-
lar pressure.
Lack of hip extension in termi
nal stance is compensated for
by increased lordosis.
Hip flexion is passively gener-
ated by a backward movement
of th trunk.
Abdominals are used during ini
tial swing to advance th
swing leg.
Hip abductors are used as flex-
ors.
 Chapter 15 Kinesiology of Walking 567

TABLE 1 5 - 1 1 . Gait Deviations Seen at th Hip/Pelvis/Trunk as a Compensation for an Impairment of th

Ipsilateral Ankle, Ipsilateral Knee, or Contralateral Lower Extremity

Observed G ait Deviation at th

Hip/Pelvis/T runk Likely Impairment M echanical Rationale

Forward bending of th trunk dur
ing th loading response
Forward bending of th trunk dur
ing mid and term inal stance
Excessive hip and knee flexion dur
ing swing (Fig. 1 5 -5 1 )
Hip circumduction during swing
(Fig. 1 5 -5 0 )
Hip hiking (elevation of th ipsilat-
eral pelvis during swing)
Excessive backward horizontal rota-
tion of th pelvis on th side of
th stance leg in terminal stance
Weak quadriceps
Pes equinus deformity
Often due io lack of ankle dorsiflexion
of th swing leg; may also be due to
a functionally or anatomically short
contralateral stance leg.
Lack of shortening of th swing leg
secondary to reduced hip (lexion, re-
duced knee flexion, and/or lack of
ankle dorsiflexion
Lack of shortening of th swing leg
secondary to reduced hip flexion, re
duced knee flexion, and/or lack of
ankle dorsiflexion
Functionally or anatomically short
stance leg
Ankle piantar flexor weakness
Trunk is brought forward to move th line of
gravity anterior to th axis of rotation of th
knee, thereby reducing th need for knee
extensors (see Fig. 1 5 -4 8 ).
Lack of ankle dorsiflexion during stance results
in knee hyperextension and forward trunk
lean io move th weight of th body over
th stance foot (see Fig. 1 5 -4 5 ).
Used to clear th toes of th swing leg
Used to lift th foot of th swing leg off th
ground and provide toe clearance
Used to lift th foot of th swing leg off th
ground and provide toe clearance
Ankle piantar flexor weakness leads to pro-
longed heel contact and lack of push off. An
increased pelvic horizontal rotation is used
to lengthen th limb and maintain adequate
step length.

* The terms in bold indicate th lime in th gait cycle when th gait deviation is expressed.

FIGURE 15-49. Knee (lexion contratture causing a crouched gait of FIGURE 15-50. Hip circumduction during swing. (From Whittle M:
th stance leg. (From Perry J: Contractures: A historical perspective. Gait Analysis: An Introduction, 2nd ed. Oxford, Butterworth-Heine-
Clin Orthop 219:8, 1987.) mann Ltd., 1996.)
 568 Section IV Lower Extremity
FIGURE 15-51. Excessive hip and knee flexion to compensate for
fooi drop. (From Whittle M: Gait Analysis: An Iniroduction, 2nd
ed. Oxford, Butterworih-Heinemann Ltd.i 1996.)
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 A p p e n d i x IV

Pari A: Nerve Root Innervation of th Lower

Extremity Muscles

Nerve Root
Lumbar Sacrai
Muscle L1 L2 V L4 L5 S* s2 S3
Psoas minor X X
Psoas major X X X X
Hiatus 00 X X X
Pectineus X X X
Sartorius X X (x)
Quadriceps X X X
Adductor brevis X X X
Adductor longus X X X
Gracilis X X X
Obturator externus X X
Adductor magnus X X X X X
Gluteus medius
X X X
Gluteus minimus
X X X
Tensor fascia lata
X X X
Gluteus maximus
X X X
Piriformis
(x) X X
Gemellus superior
X X X
Obturator intemus
X X X
Gemellus inferior
X X X (x)
Quadratus femoris
X X X (x)
Biceps (long head)
X X X X
Semitendinosus
X X X X
Semimembranosus
X X X X
Biceps (short head)
X X X
Tibialis anterior
X X X
Extensor hallucis longus
X X X
Extensor digitorum longus
X X X
Peroneus tertius
X X X
Extensor digitorum brevis
X X X
Peroneus longus
X X X
Peroneus brevis
X X X
Plantaris
X X X (x)
Gastrocnemius
X X
Popliteus
1 X x r X
570
 Appendix IV 571

Nerve Root
Lumbar Sacrai

Muscle V L2 L3 L4 L5 S> s2 S3

Soleus X X X

Tibialis posterior (x) X X

Flexor digitorum longus X X (x)

Flexor hallucis longus X X X

Flexor digitorum brevis X X X

Abductor hallucis X X X

Flexor hallucis brevis X X X

Lumbrical 1 X X X

Abductor digiti minimi X X

Quadratus plantae X X

Flexor digiti minimi X X

Abductor digiti minimi X X

Adductor hallucis X X

Piantar interossei X X

Dorsal interossei X X

Lumbricals II, III, IV (x) (x) X X

(x), mirumal literature support; X, moderate literature support; X, strong literature support.
Modified from Rendali FP, McCreary AK, and Provante PG: Muscles: Testing and Function, ed. 4. Baltimore, Williams & Wilkins, 1993. Data based on a
compilation from several anatomical sources.

Part B: Key Muscles for Testing th Function Part C: Attachments and Innervations of th
of Ventral Nerve Roots (L2-S3) Lower Extremity Muscles
T h e ta b le s h o w s th k e y m u s c le s t y p ic a lly u s e d to test th H IP A N D KNEE M USCULATURE
f u n c t io n o f in d iv id u a i v e n tr a l n e rv e r o o t s o f th lu m b o s a c r a l
Adductor Brevis
p le x u s ( L 2-S 3) i n th c lin ic . R e d u c e d s tr e n g th in a k e y tn u s -
P r o x im a l a t ta c h m e n t : a n te r io r s u rfa c e o f th in f e r io r p u b ic
c le m a y in d ic a te a n in j u r y to th a s s o c ia te d n e rv e ro o t.
ra m u s
D istai a t ta c h m e n t : p r o x im a l o n e t h ir d o f th lin e a a sp e ra
Ventral
o f th fe m u r
Nerve
In n e r v a tio n : o b t u r a t o r n e rv e
Key Muscles Root Sample Test Movements
Iliopsoas L2 Hip flexion Adductor Longus
Adductor longus L2 Hip adduction P r o x im a l a t ta c h m e n t : a n te r io r s u rfa c e o f th b o d y o f th
Quadriceps femoris L3 Knee extension p u b is
D istai a t ta c h m e n t : m id d le o n e t h ir d o f th lin e a a s p e ra o f
Tibialis anterior L4 Ankle dorsiflexion
th fe m u r
Extensor digitorum L5 Toe extension In n e r v a tio n : o b t u r a t o r n e rv e
longus
Gluteus medius L5 Hip abduction
Adductor Magnus
Gluteus maximus S> Hip extension with knee A n te r io r (A d d u cto r H e a d )
flexed P r o x im a l a t ta c h m e n t : is c h ia l ra m u s
Semitendinosus S1 Knee flexion and internai D istai a t ta c h m e n t : e n tire lin e a a s p e ra o f th fe m u r
rotation
In n e r v a tio n : o b t u r a t o r n e rv e
Gastrocnemius/soleus S2 Ankle piantar flexion
Flexor hallucis longus s2 Flexion of th hallux P o s te r io r (E x te n s o r H ea d )

S3 Abduction and adduction of P r o x im a l a t ta c h m e n t : is c h ia l tu b e ro s ity

Dorsal and piantar
interossei th toes D istai a t ta c h m e n t : a d d u c t o r tu b e re te o n fe m u r
In n e r v a tio n : t ib ia l p o r t io n o f s c ia tic n e rv e
572 Appendix IV

Articularis Genu
ie s o f th la st t h o r a c ic a n d a ll lu m b a r v e rte b ra e in c lu d -
P r o x im a l a t ta c h m e n t : a n te r io r s u rfa c e o f th d is ta i fe m o ra l
in g th in t e r v e r t e b r a l d is c s
sh a ft
D istai a t ta c h m e n t : le s s e r t ro c h a n te r o f th fe m u r
D istai a t ta c h m e n t : p r o x im a l c a p s u le o f th k n e e
In n e r v a tio n : fe m o ra l n e rv e llia c u s
P r o x im a l a t ta c h m e n t s : s u p e r io r tw o t h ir d s o f th ilia c fossa,
Biceps Femoris
in n e r lip o f th ilia c c re s i, a n d s m a ll re g io n o f th
L on g H ead
s a c ru m a c ro s s th s a c r o ilia c jo in t
P r o x im a l a tta c h m e n ts : fro m a com m on te n d o n w it h th
D is ta i a t ta c h m e n t : le ss e r t ro c h a n te r o f th fe m u r v ia th
s e m ite n d in o s u s ; o r ig in a t in g fro m a m e d ia i im p r e s s io n
la te ra l s id e o f p s o a s m a jo r te n d o n
o n th p o s t e r io r s u rfa c e o f th is c h ia l t u b e ro s it y a n d
in n e r v a t io n : fe m o ra l n e rv e
p a rt o f th s a c ro tu b e ro u s lig a m e n t.
D istai a t ta c h m e n t : h e a d o f th fib u la Obturator Externus
In n e r v a tio n : t ib ia l p o r t io n o f th s c ia tic n e rv e P r o x im a l a t ta c h m e n t s : e x te rn a l s u rfa c e of th o b tu ra to r
S hort H ead m e m b ra n e a n d s u r r o u n d in g e x te rn a l s u rfa c e s o f th
in f e r io r p u b ic ra m u s a n d is c h ia l ra m u s
P r o x im a l a t ta c h m e n t : la te ra l lip o f th lin e a a sp e ra b e lo w
D istai a t ta c h m e n t : m e d ia i s u rfa c e o f th g re a te r t ro c h a n te r
th g lu te a l tu b e ro s ity
at th t r o c h a n te r ic fossa
D is ta i a t ta c h m e n t : h e a d o f th f ib u la
In n e r v a tio n : o b t u r a t o r n e rv e
In n e r v a tio n : c o m m o n p e r o n e a l p o r t io n o f th s c ia tic n e rv e

Gemellus Inferior Obturator Internus

P r o x im a l a tta c h m e n t: tu b e ro s ity o f th is c h iu m P r o x im a l a tta c h m e n ts : in t e r n a i s id e o f th o b t u r a t o r m e m
b ra n e a n d im m e d ia t e ly s u r r o u n d in g su rfa c e s o f th i n
D istai a t ta c h m e n t : b le n d s w it h th te n d o n o f th o b t u r a t o r
in t e m u s f e r io r p u b ic ra m u s and is c h ia l ra m u s ; bony a tta c h
In n e r v a tio n : n e rv e to th q u a d r a tu s fe m o ris m e n ts e x te n d s u p e r io r ly w it h in th p e lv is to th
g re a te r s c ia tic n o tc h .
Gemellus Superior D istai a tta c h m e n t: m e d ia i su rfa c e o f th g re a te r tro c h a n te r
P r o x im a l a t ta c h m e n t : d o r s a l s u rfa c e o f th is c h ia l s p in e ju s t a n te r io r a n d s u p e r io r t o th t r o c h a n te r ic fossa
D is ta i a t ta c h m e n t : b le n d s w it h th te n d o n o f th o b t u r a t o r In n e r v a tio n : n e rv e io th o b t u r a t o r in t e m u s
in t e m u s
In n e r v a tio n : n e rv e to th o b t u r a t o r in t e m u s
Pectineus
P io x im a l a t ta c h m e n t : p e c tin e a l lin e o n s u p e r io r p u b ic r a
Gluteus Maxiinus m us
P r o x im a l a tta c h m e n ts : o u te r iliu m , p o s t e r io r g lu te a l lin e , D istai a tta c h m e n t. p e c tin e a l ( s p ir a i) lin e o n th p o s t e r io r
a p o n e u r o s is o f th e re c to r s p in a e a n d g lu te u s m e d iu s s u rfa c e o f th fe m u r
m u s c le s , p o s t e r io r s id e o f s a c ru m a n d c o c c y x , a n d p a rt In n e r v a tio n : fe m o ra l n e rv e a n d o c c a s io n a lly a b r a n c h fro m
o f s a c ro tu b e ro u s a n d p o s t e r io r s a c ro - ila c lig a m e n ts th o b t u r a t o r n e rv e
D is ta i a tta c h m e n ts : g lu te a l t u b e ro s it y a n d ilio t ib ia l b a n d
In n e r v a tio n : in f e r io r g lu te a l n e rv e Piriformis
P io x im a l a t ta c h m e n t : a n te r io r s id e o f th s a c ru m b e tw e e n
Gluteus Medius th s a c ra i fo ra m in a ; b le n d s p a r t ia lly w it h th c a p s u le o f
P r o x im a l a tta c h m e n t: o u te r s u rfa c e o f th iliu m , a b o v e th th s a c r o ilia c j o in t
a n t e r io r g lu te a l lin e D istai a t ta c h m e n t : a p e x o f th g re a te r t ro c h a n te r
D is ta i a t ta c h m e n t : la te ra l s u rfa c e o f th g re a te r tro c h a n te r In n e r v a tio n : n e rv e to th p ir if o r m is
In n e r v a tio n : s u p e r io r g lu te a l n e rv e
Popliteus
Gluteus Minimus
P r o x im a l a t ta c h m e n t : b y a n in t r a c a p s u la r te n d o n th at at-
P t o x im a l a tta c h m e n t. o u te r s u rfa c e o f th iliu m b e tw e e n ta c h e s to th la te ra l a s p e c t o f th la te ra l fe m o ra l c o n -
th a n te r io r a n d in f e r io r g lu te a l lin e s , as far p o s t e r io r d y le
as th g re a te r s c ia tic n o tc h
D istai a t ta c h m e n t : p o s t e r io r s u rfa c e o f th p r o x im a l tib ia ,
D istai a t ta c h m e n t : a n te r io r a s p e c t o f th g re a te r tro c h a n te r a b o v e th s o le a l lin e
I n n e r v a tio n : s u p e r io r g lu te a l n e rv e Innervation: t ib ia l n e rv e

Graeilis Psoas Minor

P r o x im a l a t ta c h m e n t s : a n te r io r a s p e c t o f lo w e r body of
P r o x im a l a tta c h m e n ts : tra n sv e rs e p ro c e s se s a n d la te ra l b o d -
p u b is a n d in le r io r ra m u s o f p u b is
ie s o f th last t h o r a c ic a n d th firs t lu m b a r v e rte b ra e
D is ta i a t ta c h m e n t : p r o x im a l m e d ia i s u rfa c e o f th t ib ia ju st in c lu d m g th in te rv e r te b ra l d is c
p o s t e r io r to th u p p e r e n d o f th a tta c h m e n t o f th
D istai a t ta c h m e n t : p u b is n e a r th p e c tin e a l lin e
s a r t o r iu s
In n e r v a tio n : fe m o ra l n e rv e
In n e r v a tio n : o b t u r a t o r n e rv e
Quadratus Femoris
Iliopsoas
P s o a s M a jo r P r o x im a l a t ta c h m e n t : la te ra l s u rfa c e o f th is c h ia l tu b e ro s
it y ju s t a n te r io r io th a tta c h m e n ts o f th s e m im e m b ra -
P r o x im a l a tta c h m e n ts : tra n sv e rs e p ro c e s se s a n d la te ra l b o d -
nosus

D istai a t ta c h m e n t : quad rate tu bercle (m id dle o f in tertro -
ch an teric cre si)
ln n e r v a tio n : nerve to th quad ratus fem oris
Rectus Femoris
P r o x im a l a t ta c h m e n t : straight tend on: an terio r-in ferio r iliac
sp in e, and reflected ten d o n : groove arou nd th supe-
rior rim o f th acetabu lu m and into th cap su le o f th
hip
Distai a t ta c h m e n t : base o f th patella and, via ligam entum
patella, to th tibial tu berosity
ln n e r v a tio n : fem oral nerve
Sartorius
P r o x im a l a t ta c h m e n t : an terio r-su p erio r iliac spine
D istai a t ta c h m e n t : alo ng a line o n th proxim al m ediai
surface o f th tibia
ln n e r v a tio n : fem oral nerve
Semimembranosus
P r o x im a l a tta c h m e n t: lateral im p ressio n o n th p osterior
surface o f th ischial tuberosity
D is ta i a tta c h m e n ts : p osterior aspect o f th m ediai condyle
o f th tibia. A dditional attach m en ts in clu d e th m ediai
collateral ligam ent, o bliqu e popliteal ligam ent, and
pop liteu s m u scle.
ln n e r v a tio n : tibial portion o f th sciatic nerve
Semitendin osus
from a co m m o n tend o n w ith th
P r o x im a l a tta c h m e n ts :
lo n g head o f th b ice p s fem oris originai ing from a
m ediai im p ressio n on th p o sterio r surface o f th is
ch ial tuberosity and part o f th sacro tu b ero u s ligam ent
Distai a t ta c h m e n t : proxim al m ediai surface o f th tibia ju s t
p o sterio r to th low er end o f th attach m en t o f th
sartorius
ln n e r v a tio n : tibial p o rtio n o f th sciatic nerve
Tensor Fasciae Lata
P r o x im a l a t ta c h m e n t : o u ter surface o f th iliac crest ju s t
p osterior to th an terio r-su p erio r iliac spine
D istai a t ta c h m e n t : proxim al on e third o f th iliotibial band
o f th fascia lata
ln n e r v a tio n : su p erio r gluteal nerve
Vastus Intermedius
P r o x im a l a tta c h m e n t: anterio r-lateral reg ions o f th u p per
tw o third s o f th fem oral shaft
D istai a tta c h m e n ts : m ediai cap su le, base o f th patella, and
via ligam entum patella, to th tibial tu berosity
ln n e r v a tio n : fem oral nerve
Vastus Lateralis
P r o x im a l a tta c h m e n ts : u p p er region o f in tertro ch an teric
lin e, an terio r and in ferio r b o rd e r o f th greater tro-
ch an te r, lateral region o f th gluteal tubero sity, lateral
lip o f th linea aspera
D is ta i a t ta c h m e n t : lateral cap su le, base o f th patella, and
via ligam entu m patella, to th tibial tuberosity
ln n e r v a tio n : fem oral nerve
Vastus Medialis
P r o x im a la tta c h m e n ts : lo w er region o f in tertro ch an teric
lin e, m ediai lip o f linea aspera, p roxim al m ediai supra-
con d y lar lin e, fibers from ad d u cto r m agnus
Appenclix IV 573
D is ta i a t ta c h m e n t : m ediai cap su le, base o f th patella and
via ligam entu m patella, io th tibial tuberosity
ln n e r v a tio n : fem oral nerve
ANKLE AND FOOT M U S C U L A T U R E
Extensor Digitorum Longus
P r o x im a l a tta c h m e n ts : lateral con dyle o f tibia, p roxim al
tw o third s o f th m ediai surface o f th fibula, and
ad jacen t interosseous m em brane
D istai a tta c h m e n ts : by four ten d o n s th at attach to th
proxim al base o f th dorsal surface o f th m id dle and
distai phalanges via th dorsal digitai expan sion
ln n e r v a tio n : d eep bran ch o f th p eroneal nerve
Extensor Hallucis Longus
P r o x im a l a tta c h m e n ts : m id dle section o f th m ediai surface
o f th fibula and ad jacen t interosseous m em brane
D is ta i a tta c h m e n ts : dorsal base o f th distai p h alan x o f th
great toe
ln n e r v a tio n : deep bran ch o f th peroneal nerve
Flexor Digitorum Longus
P r o x im a l a tta c h m e n ts : p o sterio r surface o f th m id dle one
third o f th tibia ju s t m ediai to th proxim al attach
m en t o f th tibialis p osterior
D istai a tta c h m e n ts : by four separate ten d o n s to th base o f
th distai p h alan x o f th four lesser toes
ln n e r v a tio n : tibial nerve
Flexor HallucLs Longus
P r o x im a l a t ta c h m e n t : distai tw o third s o f m ost o f th p o s
terior surface o f th fibula
D istai a t ta c h m e n t : piantar surface o f th base o f th distai
p halanx o f th great toe
ln n e r v a tio n : tibial nerve
Gastrocnemius
P r o x im a l a t ta c h m e n t s : by tw o separate head s from th pos
terior aspect o f th lateral and m ediai fem oral con dyle
D istai a t ta c h m e n t : calcaneal tu berosity via th A chilles ten
d on
ln n e r v a tio n : tibial nerve
Pcroneus Brevis
P r o x im a l a t ta c h m e n t : distai two third s o f th lateral surface
o f th fibula
D is ta i a t ta c h m e n t : styloid p ro cess o f th fifth m etatarsal
ln n e r v a tio n : superficial b ran ch o f th p eroneal nerve
Pcroneus Longus
P r o x im a l a tta c h m e n ts : head and proxim al two third s o f th
lateral surface o f th fibula
D istai a t ta c h m e n t : lateral surface o f th m ediai cu n eifo rm
and lateral side o f th base o f first m etatarsal bone
ln n e r v a tio n : su perficial b ran ch o f th peroneal nerve
Pcroneus Tertius
P r o x im a l a tta c h m e n ts : distai one third o f th m ediai sur
face o f th fibula and ad jacen t in tero sseo u s m em brane
D istai a t ta c h m e n t : dorsal surface o f th base o f th fifth
m etatarsal
ln n e r v a tio n : deep b ran ch o f th peroneal nerve
Plantaris
P r o x im a l a tta c h m e n ts : m ost m ferio r part o f lateral supra-
 574 Appenda IV
con d y lar line o f th fem u r and o bliqu e popliteal liga-
m e n t o f th knee
D is ta i a t ta c h m e n t : jo in s th m ediai aspect o f A chilles ten-
d on to insert on th calcan eal tuberosity
I n n e n a t i o n : tibial nerve
Soleus
P r o x im a l a t ta c h m e n t s : p o sterio r surface o f th fibula head
and p roxim al one third o f its shaft and from th p o ste
rior side o f th tibia n ear th soleal lin e
D istai a t ta c h m e n t : calcaneal tu bero sity via th A chilles ten-
d on
In n e r v a tio n : tibial nerve
Tibialis Anlerior
P t o x im a l lateral con d y le and proxim al two
a tta c h m e n ts :
thirds o f th lateral surface o f th tibia and th intero s-
seou s m em brane
D is ta i a t ta c h m e n t : m ediai and piantar aspects o f th m ediai
cu n eifo rm and th base o f th first m etatarsal
In n e n 'a tio n : deep b ran ch o f th peroneal nerve
Tibialis Posterior
P r o x im a l a tta c h m e n ts : p roxim al tw o thirds o f p o sterio r su r
face o f th tibia and fibula and ad jacen t interosseous
m em brane
D is ta i a tta c h m e n ts : ten d o n attach es to every tarsal b o n e
b u t th talus plus th bases o f th seco n d throu gh th
fou rth m etatarsal bones. T h e m ain in sertio n is o n th
nav icu lar tu bero sity and th m ed iai cu n eifo rm bone.
In n e r v a tio n : tibial nerve
IN TR IN SIC M U S C L E S OF THE FOOT
Extensor Digitorum Brevis
P r o x im a l a t ta c h m e n t : lateral-d istal asp ect o f th calcaneu s
ju s t proxim al to th calcan eo cu b o id jo in t
D is ta i a tta c h m e n ts : by three ten d o n s that blen d w ith th
tend ons o f th exte n so r d igitoru m longu s o f th s e c
ond throu gh fifth toes. A fourth tend o n inserts on th
dorsal base o f th p roxim al p h alan x o f th great toe.
in n e r v a tio n : deep b ran ch o f th peroneal nerve
LAYER 1
Abductor Digiti Minimi
P r o x im a l a tta c h m e n ts : m ediai and lateral p rocesses o f th
calcaneal tuberosity, p iantar ap o n eu ro sis, and piantar
surface o f th base o f th fifth m etatarsal b o n e with
flex o r digiti m inim i
D istai a t ta c h m e n t : lateral side o f th p roxim al p halanx o f
th fifth toe sharing an attach m en t w ith th flexor
digiti m inim i
In n e r v a tio n : lateral piantar nerve
Abductor Hallucis
P r o x im a l a tta c h m e n ts : flexor retinacu lu m , m ediai p ro cess
o f th calcan eu s and piantar fascia
D is ia i a tta c h m e n ts : m ediai side o f th base o f p roxim al
p halanx o f th hallux sharing an attach m en t w ith th
m ed iai tend on o f th flex o r hallu cis brevis
I n n e r v a tio n : m ediai pian tar nerve
Flexor Digitorum Brevis
P r o x im a l a tta c h m e n ts : m ediai p ro cess o f calcaneal tu b ero s
ity and cen trai part o f th piantar fascia
D is ta i a tta c h m e n ts : e ach o f four ten d o n s inserts on
th
sid es o f th piantar aspect o f th base o f th m iddle
p h alan x o f th lesser toes.
In n e r v a tio n : m ediai p iantar nerve
LAYER 2
Lumbrieals
P r o x im a l a tta c h m e n ts : from th ten d o n s o f th flexo r d igi
toru m longus m u scle
D istai a tta c h m e n ts : each m u scle cro sses th m ediai side o f
each m etatarsophalangeal jo in t to in sert into th dorsal
digitai exp an sio n o f th four lesser toes
In n e r v a tio n : to seco n d to e m ediai piantar nerve; to third
throu gh fifth to e s lateral p iantar nerve
Quadralus Plantae
P r o x im a l a tta c h m e n ts : by tw o head s from th m ediai and
lateral aspect o f th piantar surface o f th calcaneu s,
distai to th calcan eal tuberosity
D istai a t ta c h m e n t :lateral b o rd er o f th flexor d igitorum
longu s co m m o n tend o n
In n e r v a tio n : lateral p iantar nerve
LAYER 3
Adductor Hallucis
P r o x im a l A tta c h m e n t
O blique h ead: piantar asp ect o f th base o f th second
throu gh fourth m etatarsal and th fibrous sheath o f th
p eroneu s longu s tend on
T ran sverse head: piantar aspect o f th ligam ents that
su p p o rt th m etatarsophalangeal jo in ts o f th third
th ro u g h fifth toes
D is ta i a t ta c h m e n t s : bo th heads converge to insert on th
lateral base o f th p roxim al p halanx o f th great toe
along w ith th lateral tend on o f th Ilexor hallucis
brevis
In n e r v a tio n : lateral p iantar nerve
Flexor Digiti Minimi
P r o x im a l a tta c h m e n ts : p ian tar surface o f th base o f th
fifth m etatarsal b o n e and fibrous sheath cov erin g th
tend o n o f th pero n eu s longu s
D is ta i a t ta c h m e n t : lateral surface o f th base o f th p ro x i
m al p halanx o f th fifth toe b len d in g with th tendon
o f th ab d u cto r digiti m inim i
lnner\>ation: lateral piantar nerve
Flexor Hallucis Brevis
a t ta c h m e n t : piantar surface o f th cu b o id and
P r o x im a l
lateral cu n eifo rm bones and from parts o f th tend on
o f th tibialis p o sterio r m u scle
D istai a t ta c h m e n t : by tw o tend onsin w hich th lateral
tend o n attach es to th lateral base o f th proxim al
p halanx o f th great toe w ith th ad d u cto r h allu cis; th
m ediai tend o n attach es to th m ediai base o f th p ro x
im al p h alan x o f th great toe w ith th a b d u cto r h allu
cis. A pair o f sesam oid b o n es is located w ithin th
ten d o n s o f this m uscle.
In n er v a tio n : m ediai piantar nerve
 Append'ix IV 575

LAYER 4 Piantar Interossei

P r o x im a l A tta c h m en ts
Dorsal Interossei
F irs t: m e d ia i s id e o f th t h ir d m e ta ta rs a l
P r o x im a l A tta c h m e n ts
S e c o n d : m e d ia i s id e o f th fo u rth m e ta ta rs a l
F irs t: a d ja c e n t s id e s o f th firs t a n d s e c o n d m e ta ta rs a l
T h ir d : m e d ia i s id e o f th fifth m e ta ta rsa l
S e c o n d i a d ja c e n t s id e s o f th s e c o n d a n d t h ir d m e ta ta rs a l
T h ir d : a d ja c e n t s id e s o f th t h ir d a n d fo u rth m e ta ta rs a l D is ta i A t t a c h m e n t s *
F o u r th : a d ja c e n t s id e s o f th fo u rth a n d fift h m e ta ta rs a l F irs t: m e d ia i s id e o f th p r o x im a l p h a la n x o f th t h ir d toe
S e c o n d : m e d ia i s id e o f th p r o x im a l p h a la n x o f th fo u r t h
D istai A t t a c h m e n t s *
toe
F irs t: m e d ia i s id e o f th b a se o f th p r o x im a l p h a la n x o f
T h ir d : m e d ia i s id e o f th p r o x im a l p h a la n x o f th fift h to e
th s e c o n d toe
In n e r v a tio n : la te ra l p ia n t a r n e rv e
S e c o n d : la te ra l s id e o f th ba se o f th p r o x im a l p h a la n x
o f th s e c o n d toe
T h ir d : la te ra l s id e o f th ba se o f th p r o x im a l p h a la n x o f
th t h ir d toe
F o u r th : la te ra l s id e o f th base o f th p r o x im a l p h a la n x o f
th fo u rth toe
Inner\'ation: la te ra l p ia n t a r n e rv e Auaches mto [he dorsal digitai expansion of th toes.
 I n d e x

Note: Page numbers followed by th letter f refer to figures; those followed by th letter t refer to
lables, and those followed by th letter b refer to boxed material.

A Acceleration, 60 Adductor pollicis

A bands, of myoftlaments, 45, 46f
Abdominal muscles
anatomy and action of, 315t, 323-327, 324f-
326f, 325t, 327b
as extrinsic trunk stabilizers, 330f, 330-331,
331b
attachmetits and innervations of, 382t
in forced expiration, 376f, 376-377, 377t
in posterior pelvic tilt, 414, 42 lf
in straight-leg raise, 415f
lacerai, attachments and individuai actions of,
325t
paralysis of in spinai cord mjury, 374b
physiologic and ktnesiologic funclions of,
323t, 377b
rectus sheaths and linea alba of, 323, 325,
325f
strengthening exercises for, 331f, 331-333,
332f.See also Sit-up exercise.
trunk flexion torque generated by, 326f, 3 26-
327
Abduction
of fngere, 197, 201 f
of foot and ankle, definition of, 482, 482f,
483t
of glenohumeral joint, 112f113f, 112-113,
115f, 116t
arm elevation in, 123-124, 124f, 125t
in chronic impingement syndrome, 114b,
114f
in frontal piane vs. scapular piane, 113,
115f, 116, 117f
interaction with scapulothoractc upward rota-
tors, 116-117, 117f, 1 18f, 119t, 125f
scapulohumeral rhythm in, 116, 117f
of hip, 405f, 406, 407 1, 408f, 408-409
of metacarpophalangeal joints, 209, 2 lOf
of sublalar joint, 490, 490f, 491 1
of talocrural joint, 4 9 11
of ihumb, 197, 201f, 203-204, 204f, 205f,
206t
of transverse tarsal joint, 493, 495f
Abductor digiti minimi
of foot
anatomy and function of, 518-519, 519f
attachments and innervation of. 574t
of hand, 225f, 225226
attachments and innervation of, 246t
Abductor hallucis
anatomy and function of, 518-519, 519f
allachments and innervation of, 574t
Abductor pollicis brevis, 224, 225f
as assistant extensor of interphalangeal joint of
thumb, 223f, 225b
attachments and innervation of, 246t
Abductor pollicis longus, 221, 223, 223f
attachments and innervation of, 245t
in abduction of thumb, 205f
radiai deviation of wrist by, 191, 1911
Accelerometer, 82
Acetabular fossa, 397
Acetabular labrum, 397, 399f
Acetabular notch, 397
Acetabulum, 390, 390f-391f, 393
malalignment of, in hip dysplasia, 40 Ib
lunate surface of, 396b, 397, 399f
osteologie features of, 396b, 397, 399f
Acetylcholine, in muscle fatigue, 53
Achilles tendon, forces applied to, in gait,
5611
Acromioclavicular joint, 98
connective tissue of, 103, 103f
dislocation of, 104, 104f
generai features of, 102-104, 103f-105f
in scapulothoracic joint movement, 105
106
in shoulder motion during abduction, 116
117, 118f, 119t
kinematics of, 103-104, 104b, 105f
sensory innervation of, 119
Actin
in attive force generation, 46
of myofilaments, 45, 46f, 47f
Action potential, 51, 54
Activittes of daily living
elbow function and, 140, 142f
forearm activity in, 148f, 148149
Adduction
of fingere, 2 0 lf
of foot and ankle, definition oi. 482, 482f,
483t
of glenohumeral joint, 112f113f, 112-113,
116t
of hip, 407f, 408f, 408-409
of metacarpophalangeal joints, 209
of shoulder, muscles active in, 129130,
130f, 131 b
of subtalar joint, 490, 490f, 4 9 lt
of talocrural joint, 49 lt
of thumb, 107, 2 0 lf, 203-204, 204f, 205f,
206t
of transverse tarsal joint, 493, 495f
Adductor brevts
anatomy and action of, 414-415, 418f
attachments and innervation of, 571 1
Adductor hallucis
anatomy and action of, 519, 519f
attachments and innervation of, 574t
Adductor longus
anatomy and action of, 414415, 418f, 419f,
420f
attachments and innervation of, 571 1
in gait, 549f, 550
Adductor magnus
anatomy and action of, 413f, 414-415, 421 f
attachments and innervation of, 571t
in gait, 549f, 550, 561t
heads of, 226, 227f
in key pinch action, 229, 229f
tension fraction of, 226, 226t
Aging, effeets of on joints, 37
Alar ligaments, 279, 280f, 442b
in axial rotation, 282
Amphiarthrosis, definition and function of, 2 5 -
26
Anatomie position, 5, 6f
Anatomy, definition of, 3
Anconeus, 161, 163f
attachments and innervation of, 244t
structural and biomechanical variables of,
163t
Angle of inclination, of femur, 394, 396f
Angle-of-insertion, 15
Angle of Wiberg, 397
Angular power, in work-energy relaiionship, 61-
62, 62b
Angular velocity, 57 -5 8 , 60f
Ankle. See also Subtalar joint ; Talocrural joint.
abnormalities of, 516-518, 518l
gait deviations with, 562t
at hip/pelvis/trunk, 567t
at knee, 565t
bones of, 478t, 478-479, 479b, 479f, 484f
function of, 477-478
in gait
forces applied to, 561t
in stance phase, 507t
joint torques and powere of, 558, 5591-
560f
motion of
in frontal piane, 540-541
in horizontal piane, 543
in sagittal piane, 535-539, 536f, 537f,
538b
muscles of, 549f, 550-551
injury of, extreme doreiflexion or piantar flex
ion and, 472b-473b, 489b
ligaments of, 483-486, 486t
stretch of, 486, 486t
muscles of. See Muscle(s), ankle and foot.
extrinsic, attachments and innervation of,
573t-574t
osteologie features of, 478-482
range of motion at, 491t
sensory innervation of, 507, 509f
structure and function of joints of, 478l, 483-
489
terminology of, 478, 478f, 482f, 482-483,
483t
Annuius fibrosus, 273-275, 274f, 275f, 276b
Annulus pulposus, migratton of
in lumbar extension, 297
in lumbar flexion, 295-296
Anterior drawer test, for anterior cruciate liga-
meni injury, 451, 452f
Anthropometiic data, 87t
577
 578 Index

Apophyseal joint(s) Articular disc Axis of rotation (Continued)

arthrokinematics of, lerminology for, 272t
intra-articular stractures of, 262b, 262f
imracervical, 279
axial rotation at, 282-283, 285f
flexion and extension at, 279-282, 280f-
282f
faterai flexion at, 284, 286f
joint capsule of, 259, 260f, 261 f
resistance of to extreme lumbar flexion,
295, 295f
of atlantoaxial joint, 278f, 279
of intervertebral junction, 269, 272f
of lumbar spine, anatomy of, 292-294, 293f
of thoracic spine, flexion and extension of,
286, 286t, 288f, 289f
structure and function of, 273, 273f
Arch(es)
coracoacromial, 108f, HOf, 111-112
impingement of humeral head at. 113,
114b, 114f
longitudinal, of hand, 197, 200f
mediai longitudinal
of foot, 496f-498f, 496-498
abnormal, 497f-498f, 497-498
in stance phase of gait, 4 9 8-499, 499f
passive forces supporting, 496b, 4 9 6 -
497, 497f
on tiptoes, 512, 512f
windlass effect and, 506, 506f, 507t
of atlas, anterior and posterior, 264, 266f
transverse
of foot, 503, 503f
of hand, 196-197, 200f
zygomatic, 352, 353f
Arm, elevation of
muscles active in, 122-129, 123b
at glenohumeral joint, 123-124, 124f,
1251
rotator cuff muscles in, 127f-128f, 127-129,
128b, 129b
upward rotators al scapulothoracic joint in,
124-127, 125b, 125f-126f
Arthrokinematics
definition of, 8
fundamental movements between joint sur-
faces in, 8t, 8 -1 0 , 9f, lOf
typical joint morphology in, 8, 8f
Arthrology, definition of, 25
Articular capsule, 26, 26f
fibrous, 32, 34, 34f
of glenohumeral joint, 107f, 107-110, 109f
of metatarsophalangeal joints, 504
of temporomandtbular joint, 357f, 3 57-
358
of apophyseal joints, 259, 260f, 261 f
in lifting heavy Ioads, 346t
resistance of to extreme flexion, 295, 2951
ol carpometacarpal joint
of thumb, 202
second through fifth, 198, 202f
of costotransverse joint, 285
of elbow, 138, 139f, 139t, HOf
of hip
anterior and posterior, 399, 401f, 402
imracapsular pressure in, 403b, 403f
of knee, 438-439, 440f, 440t, 441f
anterior, 438f, 438-439, 440f, 440t, 441f
lateral, 438f, 438-439, 4401', 440t
mediai, 439, 440t, 4411
posterior, 439, 440t, 441f, 448, 449f, 450t
posterior-lateral, 439, 440t, 441f
of radioulnar joints, 146
of talocrural joint, 484
of talonavtcular joint, 492
of acromioclavicular joint, 103
of mandibular disc-condyle complex, 359f,
360-362
displaced or dislocated, 361, 361f
lateral pterygoid action and, 367b, 367f
of stemoclavicular joint, lOOf, 101
of synovial joints, 26f, 27, 27b
of temporomandibular joint, 356-357, 357b,
357f
of ulnocarpal complex, 148, 178, 179f
Articular eminence, of temporal bone, 354f,
354-355
Articular processes, sacrai, 269, 271 f
Articularis genu, 455-456
attachments and innervation of, 572t
Atlantoaxial joint complex, 267f
anatomy of, 278f-279f, 278-279
as pivot joint, 28
axial rotation at, 282, 285f
connecttve tissues of, 278f-280f, 279
flexion and extension at, 279-282, 280f-282f
muscles at, 340f
range of molion of, 278t
Atlanto-occipital joint
anatomy of, 277-278, 278f-279f
connective tissues of, 278f-279f, 279
flexion and extension at, 279-282, 280f-282f
lateral flexion at, 284, 286f
muscles at, 333f, 340f
range of motion of, 278t
Atlas, 264, 266f
in axial rotation, 282, 285f
transverse ligament of, 279, 280f
Auditory meatus, extemal, 352, 353f
Axial rotation
apophyseal joint facet surfaces and, 273, 273f
of atlas, 282, 285f
of axis (C2 vertebra), 282. 285f
of craniocervical spine, 282-283, 285f
coupling pattern vvith lateral flexion in, 339b
muscles active in, 340-341, 342f
of thoracic spine, 287, 290f
of trunk
abdominal muscle action in, 327, 327b
secondary muscle action in, 327b
Axial skeleton
components of, 251, 252f, 253-269
in cranium, 253, 253f
in ribs, 253-254, 256f, 257f
in sternum, 254, 256, 257f
in vertebrae, 253-254, 254f-255f, 255t
in vertebral column, 256-269, 258f-260f.
See also Vertebral column.
disorders of, 252
osteologie features of, 252-269, 253b
posture of, sitting posture and, 301-302
302f
terminology relating to, 252, 253t, 272l
tissues of
innervated by dorsal rami, 314t
innervated by ventral rami, 313f, 313-314
Axillary pouch
of glenohumeral joint, 107, 107f
of interior glenohumeral ligament, 109, 1lOf
Axis (C2 vertebra), 264, 267f
in axial rotation, 282, 285f
Axis of rotation, 5f, 5 -6 , 6f, 17, 18f
average and estimates of, 31, 31f
of ankle and foot, 482f, 482-483
of hip, 404, 404f
of knee, 443, 445f
of fielvic tilt, 299
of subtalar joint, 490, 490f
of talocrural joint, 486, 487f
of transverse tarsal joint, 493, 495f, 496
of wrist, 180-181, 181 f
B
Back,See also Lumbar spine; Vertebral column
muscles of. See Muscle(s), back,
vertebrae of
anatomy and kinematics of, 292-303
osteologie features of, 263t, 267-269,
268f-269f
Balance, in gali, 533, 534f
role of trunk and upper extremity in, 543-
545
Bandfs)
of digitai extertsor mechanism, 220, 22 l f -
223f, 222t
of myofilaments, 45, 45f
Bending, as musculoskeletal force, 12f
Biceps brachii
as supinator muscle of forcami, 165-169,
166f, 167f
attachments and innervation of, 244t
biomechanical and structural variables of, 157l
function of, 157, 158f
in combined elbow flexion and shoulder ex
tension, 160-161, 161f
Ime of force of. 159f
long head of, in arm elevation at glenohu
meral joint, 124, 124f, 125t
Biceps curi exercise, 72b, 72f
Biceps femoris
attachments and innervation of, 572t
functional anatomy of, 440f-441f, 463
long head of, action and innervation of at
knee, 454t
short head of
action and innervation of al knee, 454t
in gait, 549f, 550
Biomechanics
definition of, 3
principles of, 5 6 -85
problems in, guidelines for solvtng, 77t
Biomechanics laboratones, used in gait analysis,
526, 526f
Blood vessels, of synovial joints, 26f, 2 6 -2 7
Body weight, vs. mass, 12b
Bone. See also names o) specific bones, e.g.,Tibia,
cancellous, in proximal femur, 396, 399f
compaci, in proximal femur, 396, 399f
organization and structure of, 36f-37f, 3 6 -37
remodeling of, 36
stresses on, 36 -3 7
Bone spurs, cervical, 265b, 265f
Boutonniere deformity, of fingers, 239, 240f
Bow-legs, 438, 439f
Bowstringing
force of, 68, 68f
in (lexor pulley rupture, 217, 217f
in palmar dislocation of metacarpophalangeal
joint, 237, 238f
in ulnar drift at metacarpophalangeal joint,
238, 239f
in zig-zag deformity of thumb, 236, 237C
of quadriceps agatnst knee, 462, 463f
Boyles law, 368, 368b. 368f
Brachial plexus
in innervation of shoulder, 117, 119f
ventral nerve roots of, muscles used for testing
function of, 243t
Brachiale
attachments and innervation of, 244t
biomechanical and structural variables of, 157t
function of, 157, 158f

Brachialis(Continued)
line of force of, 159f
work capacity of, 157t, 159b, 159f
Brachioradialis
as secondary supinator muscle of forearm, 165
attachmems and innervation of, 244i
biomechanical and structural variables of, 157t
function of, 157-158, 159f
line of force of, 159f
Breathing
lungs in, 368f, 369
muscles used in, 374t, 375t
paradoxical, after spinai cord injury, 374b
rib movement during, 371, 37 lf
Bunion, 505, 505f
Bursa, of knee, 439, 442t
Bursa sacs, of shoulder, 11 lf, 111-112
C with, 560, 563
Calcaneal tuberosity, 480f481 f, 481
Calcaneocuboid joint. See alsoTarsal joint, trans
verse.
articular and ligamentous structure of, 49 2 -
493, 493f
Calcaneocuboid ligament, dorsal, 485f. 492
Calcaneus, osteologie features of, 479b, 480f-
4 8 lf, 481
Callus formation, and high mediai longnudinal
arch, 498
Cane, proper use of, 429, 429f
Capitate bone, 174f-175f, 176, 199f
Capitulum, 134, 134f, 135f
Capsular ligaments, 260f
of radioulnar joint, 146, 148f
of synovial joints, 26, 26f
of thoracic spine, 285
Capsule, articular. See Articular capsule.
Carpai bones
in ulnar and radiai deviation of wrist motion,
183b, 183f
osteology of, 173b, 173f-175f, 173-176
Carpai instabihty, of wrist, 184b, 184f-186f,
184-185
Carpai tunnel, 175f, 176
Carpai tunnel syndrome, 216, 216f
Carpometacarpal joint(s), 195, 197f, 197-200,
201f-203f. See also Hand.
as saddle joint, 28, 30f, 202
movement and function of, 197-198, 200,
2 0 lf, 203f
of thumb, 200-207, 202f-207f
adduction and abduction of, 203-204, 205f
capsule and ligaments of, 202, 202t, 203f-
204f
flexion and extension of, 204-205, 206f,
206t
generai features of, 200, 202
in zig-zag deformity of thumb, 236, 237f
muscles attached to, 224t
opposition of, 205, 207, 207f
saddle joint structure of, 202
second through ftfth
generai features of, 198
ligaments of, 198, 202f
structure and ktnematics of, 198, 200, 203f
Carpus, ulnar translocation of, 185, 186f
Cartesian coordinate System, 66
Cartilage
articular, 26, 26f
chronic trauma to, 38, 39f
composition and function of, 32, 32f, 33t,
34 -3 5 , 35f
of distai femur, 435
of palella, 437
Cartilage (Continued)
hyaline, 3435, 35f
of femoral condyle, grooves on, 435, 437f
of femoral head, 396, 399f
Cauda equina, 270b, 270f
Cells, in connective tissues in joints, 32
Center of gravity, 57
Center of mass. 5, 57, 58f
displacement of, in gait, 533, 533b, 534f,
540b, 540f
methods of minimizing, 535-537, 545t,
546f-547f
Center of pressure, path of, in gait, 553, 554f
Cerebral palsy
gait analysis and, 526
gait pattern in, 417, 539, 5491, 551, 560, 563
hip dysplasia and, 401b
pes cavus and, 498
Cerebrovascular accident, abnormal gait pattern
Charcot-Marie-Tooth syndrome, pes cavus and,
498
Choking, abdomtnal muscle function in, 377b
Chondrocytes, in articular cartilage, 34, 35f
Chondromalacia patellae, 462b, 462f
Chondrosternal junctions, 370
Chopart's joint, 491. See also Tarsal joint, trans
verse.
Chronic impingement syndrome at shoulder,
114b, 114f
Chronic obstructive pulmonary disease, 373,
375-376
Cinematography
for collection of kinemattc data, 83
in gait analysis, 525
Clavide
movement of, in shoulder function, 101 f
102f, 101-102, 117, 118f, 119t
osteologie features of, 94, 95f
Clavicular facets
of manubrium, 93, 94f
of sternum, 254, 257f
Coccyx, vertebrae of, 263t, 269, 271 f
Collagen fibers
in articular cartilage, 34, 35f
in dense connective tissues, 32, 34, _34f
in nucleus pulposus and annulus ftbrosus,
273, 276b
types of, 31-32, 32b, 34, 34f
Compartments
of leg, 506
of midcarpal joint, 177, 177f
Compression force, 12f
on apophyseal joints, 272t
on foot, in standing position, 496b
on interbody joints, in thoracic kyphosis,
292b
on intervertebral disc, 274-275, 275f
on knee, 74b, 74f, 460, 461 f
menisci function and, 442
on L2 vertebra during lifting, 342-345, 343b,
344f-345f
Valsalva maneuver and, 345-346
on mediai longitudinal arch, 496b
on patellofemoral joint, 457, 460, 460b, 461 f
on talocrural joint, in stance phase of gait,
488f, 488-489
Computer-based Systems, for measurement of
vertebral column motion, 277b
Condyle(s)
of distai femur, 435, 436f, 437f
of mandible, 353, 353f, 354f, 356
in disc-condyle complex
derangement of, 361b, 36lf
lateral pterygoid action and, 367b, 367f
Index 579
Condyle(s) (Continued)
translalional movement of, 359f, 360,
362
Connective tissue(s)
aging and, 37
dense irregular, 32, 33t, 34
immobilization and, 3 7 -3 8
in acromioclavicular joint, 103, 103f
in atlanto-occipital and atlantoaxial joints,
278f, 279, 279f, 280f
in elbow, 138-140, 139f, 139t, 140f
in glenohumeral joint, 107-110, 109f, llOf
in joints
biologie materials forming, 31b, 3 1 -32
biomechanical function of, 12, 13f, 14, 14f
types of, 32, 33t, 34-37
in knee capsule, 440t
in mandibular condyle, 356
in mediai longitudinal arch, 496-498
in muscle, 42, 43f, 44, 44f, 44t
in proximal ubiofibular joint, 483b
in radioulnar joints, 146, 146f
in rectus sheaths and linea alba, 323, 325,
325f
in sternoclavicular joint, lOOf, 101
in temporomandibular joint, 358b
in vertebral column
limitalion of motion by, 276t, 276-277
lumbar region of, 293, 295, 295f
periarticular, of metacarpophalangeal joints,
208, 208f, 213, 214
Contracture
Dupuytrens, 232
flexion
of elbow, 140, 141b, 141f
of hip, 300, 301 f, 416, 416f
piantar flexor, at ankle, 516-517
Coordinale System, in free body diagram, 66
Coracoacromtal arch, 108f, llOf, 111-112
impingement of humeral head al, 113, 114b,
114f
Coracoacromial ligament, 111
Coracobrachialis
attachments and innervation of, 243t
in arm elevation at glenohumeral joint, 123
124, 124f, 125t
Coracoid process, 97, 97f
Coronoid fossa, 134, 134f
Coronoid process, 135, 1361, 137f, 353, 353f
Costai facets, 256, 257f
of manubrium, 93, 94f
Costochondral junctions, 370
Cosioiransverse joints, 253, 285, 285b, 287f, 370
Costovertebral joints, 253, 284-285, 285b,
287f, 370
Coughing, abdominal muscle function in, 377b
Counter-nutation, 306, 306b
Coxa valga, 394, 396f
biomechanical consequences of, 431-432,
433f
Coxa vara, 394, 396f
biomechanical consequences of, 431-432,
4331
with excessive genu valgum, 471, 47lf
Craniocervical region
analomy and kinematics of, 277, 277i, 277
284
muscles of, 315t, 333-338
actions of, 339t
in axial roialion, 282-283, 285f, 34 0 -
341, 342f
in stabilization, 339-340, 3 4 lf
anterior-lateral, 315t, 334t, 334-337
attachments of, 382l
functional mteractions among, 338-341
 080 Index
Craniocervical region (Commue.d)
innervation of, 312-314, 382l-383l
posterior, 315i, 337-338, 338t
attachmems of, 383l
protraction of, muscuiar imbalance wiih
341b. 3411'
Cranium. See also Head
osteologie features of, 253, 253f
Creep, in ttssues, 13, 15f
Cross-bridges
in active force generation, 46
of myofilaments, 45, 46f, 47f
Crown, of teeth, 355, 356f
Crus, of diaphragm, 372
Cubitus valgus, of elbow, 138, 138f
Cubitus varus, of elbow, 138, 138f
Cuboid bone, 4801-48 lf, 481
Cuboideonavicular joint, 4931, 502b, 502-503
5031
Cuneiform bones, 479b, 4801-4811, 481
Cuneocuboid joint complex, 4931, 502b, 50 2 -
503, 503f
Cuneonavicular joint, 4931, 502b, 502-503
503f
Cusp, of teeth, 355, 356f
D Elastic deformation energy, in ligament, 12, 13f
Degrees of freedom, 6f, 6 -7
Deltoid
anlerior
in arm elevation al glenohumeral joint,
123-124, 1241, 125t
in internai rotation of shoulder, 131-132,
1321
attachmems and innervation of, 243t
middle, in arm elevation at glenohumeral
joint, 123-124, 124f, 125t
posterior
actions of at glenohumeral joint, 17-18,
18f, 111, 129-130, 1301, 131 b. 1311
as synergist to elbow flexors, 161
in extemal rotation of shoulder, 132
paralysis of, 131b, 1311
Deltoid luberosity, 98
Dens, 2791
in axial rotation, 282, 2851
of axis, 264, 2671
Developmental dysplasia, of hip, acetabular mal-
alignment and, 401b
Diaphragm
abnormalities of
in cervical spinai cord tnjury, 374b
in chronic obstructive pulmonary disease,
375
action and innervation of, 372t, 373, 384t
attachmems of, 372, 3721, 384t
in inspiration, 372-373, 3721
parts of. 372, 3721
variable position of, 37.3b
Diarthrosis, definitton and function of, 26f, 2 6 -
27
Digastric muscle, attachmems and innervation of,
383t
Digit(s)
of foot, 480f-4811, 482. See also Metatarso-
phalangeal joint(s).
of hand, 194-195, 1991. See also Carpometa-
carpal jointfs); Finger(s).
extensors of, 219f-222f, 219-220, 222t
llexors of, 214219
second and third, as complex saddle joints,
198, 203f
Distraction force, at apophyseal joints, 272t
Dorsal digitai expansion, 508
Dot sai hood, ol digitai extensor mechantsm, 220
2211-2231, 222l
Dorsal interossei. See aho Interassei,
of foot
anaiomy and function of, 519f, 520
attachmems and innervation of, 574t-575t
of hand, attachmems and innervation of
246t
Dorsillexion
ankle injury and, 489b
definition of, 482, 4821, 483t
of talocrural joint, 486-487, 487f
of transverse tarsal joint, 493, 4951
Drop foot
abnormal gail pattern with, 5491, 550, 5631
common peroneal nerve in|ury and, 516-517
518t
Dupuytren's contracture, oblique retinacular liga-
ment in, 232
Dynamometry
for collectioti of kinematic data, 51, 84 841
85, 85f
for measurement of torque angle curve, 48
Dysplasia, developmental. of hip, 401b
E 318-321, 320b
Elastic zone, in ligament, 12, 131
Elastin tiber, 32
Elbow
activities of daily living and. 140, 142f
flexion contracture of, 140, 141b, 141 f
tnjury of, 144-145, 1451
intracapsular air pressure in, 140
isometric exercise at, biomechanical problem
solving with, 77-79, 781
joints of, 137-145. See also Humeroradial
joint; Humeroulnar joint.
generai features of, 137-138
instability of, 144-145, 145f
kinematics of, 140-144, 141b, 1411-1441
motion of, in gait, 545
muscle interaction with, 151-170
periarticular connective tissue of, 138-140
range of motion of, 140, 142f
muscles of. See Musclefs), elbow and forearm.
normal valgus angle of, 137-138, 138f
Elbow and lorearm complex, 133b, 133-171.
See also Humeroradial joint; Humeroulnar
joint; Radioulnar joint
arthrology of, 137-151
composition ol, 133, 1341
innervation of, 152, 153f-156f, 155-157,
157t, 244t-245t
muscles of
attachmems of, 244t-245t
interaction with joints at, 151-170
osteologie features of, 133-137
Electrogoniometer, 82, 82f
Electromagnetic tracking device, for collection of
kinematic data, 83
Electromyography
extraneous electrical noise with, 54
for study of muscle activity in gait, 547-548
549f
normalization of signal of, 55
uses and processing of, 5 4 -5 5 , 526
Endomysium, in muscle, 42, 43f
Energy
elastic deformation, in ligaments, 12, 13f
in gail
disability and, 547, 548t
kinematic methods of minimizing, 545t
545-547, 546f, 547f
Energy (Conlinued)
potential and kinetic, 534-535, 535f
walktng speed and, 547, 547f
in work-energy relationship, 600-602
Epicondyle(s)
lateral
of distai femur, 435, 436f, 437f
of humcrus, 135, 135f
mediai
of distai femur, 435, 436f, 437f
of humerus, 134, 134f, 135f
Epicondylitis, lateral, 189
Epimysium, in muscle, 42, 43f
Equilibrium, static and dynamic, in Newtons
law of inerita, 57
Erector sptnae
actions of, 319f, 320-321
as extrinsic trunk stabilizers, 316, 330f 330-
331, 33 Ib
attachmems and innervation of, 381t
common lendon of, attachmems of, 319t
eross-seclional anatomy of, 318f
in gait, 549f, 551
lumbar, in lifting heavy loads, 320, 320f 347
3481
of deep layer of back, 318f-320f, 318t-319t
Eversion
definition of, 482, 4821, 483t
of subtalar joini, 49 lt, 492b
of talocrural joint, 4 9 lt
of transverse tarsal joint, 493, 4951'
Evolute, 31
of knee, 443, 445f
Exercise(s)
closed kinetic chatn, 453b
extemal torque in. manual application of 75-
76, 76f
fiexion and extension, for treatment of low-
back pain, 302b
isometric, at elbow, biomechanical problem
solving with, 77 -8 1 , 78f, 791
resistive, design of, 72b, 72f, 74b, 74f
sit-up
abdominal muscle action in, 331-333,
332f, 3331
diagonal, 326f
hip flexor muscles in, 332f, 333
Expiration
forced, iniercostales in, 3761, 377, 3771, 377t
lowering of ribs during, 371, 37 lf
of lungs, 369
Extension
of craniocervical spine, 279-282, 280f-282f
of elbow, 140-144, 161-162, 163f, 163t
164, 164f
of fingers, 201f
of glenohumeral joint, 112f, 114, 116t
of head, 3191 320
of hip, 405f, 406, 407f, 408f, 408-409, 466,
468f-469f, 468-470, 469t
of knee. See Knee, extension of.
of lumbar spine, for low back pain, conse-
quences of, 302b
of metacarpophalangeal joints, 209, 2101
of shoulder, 129-130, 130f, 131 b
of thoracic spine, 286t, 286-287, 2881 289f
of thumb, 201f, 204f, 204-205, 206f, 206l
ofwrist, 179-180, 180f, 181f-182f, 181-
182, 187, 187f
Extensor carpi radialis brevis
attachmems and innervation of, 245t
function of, 187f1891 187-189
in making a fisi, 189
radiai deviation by, 191, 1911

Extensor carpi radialis longus Fascia lata of thigh, 413
attachmenis and innervation of, 245t Fat pads
function of, 187f-189f, 187-189 of knee, 439, 442t
radiai deviation by, 191 of synovial joints. 27
Extensor carpi ulnaris Femoral head
attachments and innervation of, 245t acetabular malalignment and, 397-398, 400f
function of, 187f-189f, 187-189 osteologie features of, 396b, 396-397, 399f
in wrist flexion, 190 Femoral neck, angle of inclination of. See Coxa
ulnar deviation by, 191-192, 192f valga; Coxa vara.
Extensor digiti minimi, 219-220, 220f-221f Femoral nerve
attachments and innervation of, 245t muscles innervated by, at hip, 409f, 409-411
Extensor digitorum brevis lo quadriceps, 453-454, 454t
anatomy and function of, 504f, 510f, 518, Femoral-on-pelvic hip motion, 403
519f hip extensor muscles active in, 422, 423f
attachmenis of, 574t hip flexor function in, 414, 415f
innervation of, 507, 508f, 574t in rotation, 404f-405f, 404-406
Extensor digitorum communis, 187f, 2 lOf, 21 9 - Femoral-on-tibial knee motion, 4441, 445f
220, 220f22lf flexor-rotator muscle interaction in, 465,
action of, 220, 223f 466f
attachmenis and innervation of, 245t in knee extension, 445, 446f
in openinghand, 230-232, 231f-232f extemal torque in, 456, 458f
wrist extension with, 187, 187f in anterior cruciale ligamenl reconstruction,
Extensor digitorum longus 45 3b
anatomy and function of, 508, 510, 510f vs. tibial-on-femoral motion, 7f
attachments and innervation of, 573i Femur, 393f-399f, 393-396
in gait, 549f, 550 anatomy of, 393f-394f, 393-394
innervation of, 507, 508f angle of inclination of, 394, 396f. See also
Extensor digitorum muscles, in finger flexion, Coxa valga; Coxa vara,
234 anteversion of
Extensor hallucis longus excessive, 395, 397f-398f
anatomy and function of, 508, 510, 510f naturai, 398, 398f
attachments of, 573t attachments to, 393f-395f
in gau, 549f, 550 distai, osteologie features of, 435, 435b, 436f-
innervation of, 507, 508f, 573t 437f
Extensor indicis, 219-220, 220f221f motion of, in gait. 542, 542f, 544b
attachments and innervation of, 245t patellar contact with, 446-447, 4481
Extensor lag," at knee, 460b proximal, 396
Extensor pollici? brevis, 221, 223, 223f retroversion of, 395, 397f
attachments and innervation of, 246t rotational range of, in hip motion, 404, 405f,
radiai deviation of wrist by, 191, 191 f 406
Extensor pollicis longus, 221, 223, 223f lorsion angle of, 394-396, 397f, 398f
attachmenis and innervation of, 246t Fiberfs)
radiai deviation of wrist by, 191, 191f collagen
Extensor retinaculum in articular carlilage, 34, 35f
of ankle and foot, 508, 510f tn nucleus pulposus and annuiti? fibrosus,
of wrist, 188, 188f 273, 276b
Eyes, in axial rotation in craniocervical region,
types of, 31-32, 32b
340 elastin, 32
in connective tissues, 3 1 -3 2 , 32b, 33t
muscle, 42, 43, 43f
F of digitai exiensor mechanism, 220, 221 f-
Facet(s)
223f, 222t
articular
of hip capsule, 402, 402t
of atlas, 264, 266f
of lateral ligament of temporomandibular
of lumbar vertebrae, 268f, 268-269, 269f
joint, 358, 358f
clavicular
of manubrium, 93, 94f of mediai collateral ligament of elbow, 138,
of sternum, 254, 257f 140f
costai, 256, 257f patellar retinacular, 438, 438f
of manubrium, 93, 94f Fibrocartilage
of ihoracic vertebrae, 265, 267f in connective tissues, 33t
of calcaneus, 480f-481f, 481 nourishment and blood supply of, 35
of femoral condyie. 435, 437f organization and function of, 35, 36f
of patella, 437, 437f, 447, 448f peripheral labrum of, 27
of talus, 480, 4 8 lf triangular, 146, 148f
Facet surfaces, of apophyseal joints, 273, 273f. Fibrous capsule
292, 293f of glenohumeral joint, 107f, 107110, 109f
Falls, hip fracture following, 428t of melalarsophalangeal joints, 504
Fascia of temporomandibular joint, 357f, 357-358
cervical, components of, 334, 334f, 334t Fibula, 435, 436f, 478-479, 479f
piantar Finger(s). Seealso Carpomeiacarpal joint(s);
forces applied to in gait, 561t Metacarpophalangeal joint(s).
of mediai longitudinal arch, 496, 497 clawing of, 231, 232f
windlass effect on, 506, 506f flexion of
thoracolumbar, in lifting heavy loads, 346t, passive, via tenodesis action of digitai flex-
347 ors, 2 18f219f, 218-219
Index 581
Finger(s) (Commutiti)
rote of proximal stabihzer muscles in, 218,
218f
interphalangeal joints of, 211-213
movements of, terminolog)' of, 197, 201f
muscles of
extensors, 219-220, 221f-223f, 222t,
230-232, 231f-232f
extrinstc and intrinsic, interaction of, 2 30-
234
flexors, 214-219, 233f, 233-234
in makmg a fisi, 188f-189f, 188-189
position of function of, 213, 213f
ulnar drift of, in rheumatoid arthritis, 2 37-
238, 239f
Fist, muscle mechanics of, 188f-189f, 188-189,
233f, 233-234
Flabella, 439
Flatfoot, 497, 497f
decreased windlass effect in, 506, 506f
Flexion
lateral
of craniocervical spine. 283-284, 286f
in coupling with axial rotation, 339b
of thoracic spine, 287, 291 f
of craniocervical spine, 279-282, 280f-282f
of elbow. 157t, 157-161, 158f-162f, 159t,
162b
of fingers, 201 f
of glenohumeral joint, 112f, 114, 115f, 116l
of hip, 406, 407f, 408f, 408-409
of knee.See Knee, flexion of.
of lumbar spine, for low back pain, conse-
quences of, 302b
of metacarpophalangeal joints, 209, 210f
of thoracic spine, 286t, 286-287, 288f, 289f
of thumb, 201 f, 204f, 204-205, 206f, 206t
of wrist, 179-180, 180f, 181f-182f, 181-
182, 190-191, 191t
Flexion contracture
elbow, loss of forsvard reach with, 140, 141b,
141 f
hip
effect on standing, 416, 416f
lumbar lordosis with, 300, 301f
Flexor carpi radialis
anatomy and function of, 189-190, 190f
attachments and innervation of, 245t
radiai deviation by, 191, 191 f
Flexor carpi ulnaris
anatomy and function of, 189-190, 190f
attachments and innervation of, 245t
ulnar deviation by, 191-192, 192f
Flexor digiti mimmi
of foot
anatomy and function of, 519, 519f
attachments and innervation of, 574t
of hand, 225h 225-226
attachments and innervation of, 246t
Flexor digitorum brevis, attachments and nner-
vation of, 574t
Flexor digitorum longus
anatomy and function of, 512-514, 514f, 516
attachments and innervation of, 5731
maximal torque potential of at ankle, 514,
516t
supinatton potential of, 514, 516
Flexor digitorum profundus, 2 14f215f, 215
216
attachments and innervation of, 246t
in finger flexion. 233f, 233-234
in wrist flexion, 190-191
Flexor digitorum superficialis, 190, 190f, 214f
2151, 214-215, 218, 218f
attachments and innervation of, 246l
 582 Index
Flexor digitorum superficialis (Conlinued)
in Finger flexion, 233f, 233-234
in wrist flexion, 190-191
Flexor hallucis brevis
anatomy and function of, 519, 519f
attachments and innervaiion of, 574l
Flexor hallucis longus
anatomy and function of, 512-514, 514f, 516
attachments and mnervation of, 573t
maximal torque potenttal of at ankle, 514,
516t
supination potential of, 514, 516
Flexor pollicis brevis, 224, 225f
attachments and mnervation of, 246t
Flexor pollicis longus, 214f-215f, 216-217
attachments and innervation of, 246t
radiai deviation of wrist by, 191, 191f
Flexor pulley, 215f. 217
anatomy and function of, 217-218
ruptured, btomechanics of, 217, 217f
Foot (feet). See also Ankle.
deformities or abnormal postures of, 5 16-
518, 518l
gali deviations with, 501, 562t
function of, 477-478
joints of
distai mtertarsal, 502-503
intermetatarsal, 504
interphalangeal, 505-506. See also
phalangeal joint(s).
kinematic relationshtp with other parts of
foot, 501b
malalignment of, walking and, 501
metatarsophalangeal, 504f-505f, 504-505.
also
5ee Metatarsophalangeal joim(s).
motions of, in gatt, 541, 541f-542f
abnormalities in, 501, 561t-562t
in horizontal piane, 543, 544b, 544f
in late stance phase, 506
in stance phase, 507t
subtalar, 48 lf, 484f-485f, 489-490, 490f,
See also
491t. Subtalar joint.
tarsometatarsal, 503. See also Tarsometatar-
sal joint
See also
transverse tarsal. Tarsal joint, trans
verse.
combined action with subtalar joint,
498-502, 499f-500f, 500t
structure and function of, 491-498,
492f-498f
muscles of. See Muscle(s), ankle and foot.
osteologie features of, 478-482
prenatal development of, 398, 398f
rays of, 480f481 f, 482
sensory innervation of, 507, 509f
structure and function of, 478t, 479f 4 8 9 -
506
terminology of, 478, 478f
for motions and positions, 482f, 482-483
483l
Foot angle, 527
Foot drop, gait abnormality with, 568f
Foot fiat, 531, 53lf, 531t
Foot forces, 63, 63f, 551, 552f
Foot slap, 561t
in gait, 549f. 550
Foramen (foramina)
intervertebral
effeets of flexion and extension on, 283b
283f
in lumbar extension, 297
in lumbar flexion, 295-296
sacrai, 269, 2711
sctatic, greater, 391, 392f
transverse, 262, 262f
Foramen magnum, 253, 253f Forefoot varus, 501
Force(s). See also Torque. gait deviations with, 562t
and dtstancc, 21, 22, 22f Forward lean
compression. See Compression force, abnormal gait pattem with, 563f
distraction, at apophyseal joints, 272t hip extensors conirolling, 420-421 4 2 lf
dynamic analysis of, 82b, 82f85f, 8 2 -8 5 422f
in Newtons laws of motion, 57 Fossa
isometric, development of torque-joint angle acetabular, 397
curve and, 4 7 -5 0 coracoid, 134, 134f
joint reaction. See Joint reaction force, glenoid, 96, 96f
moduauon of iliac, 391, 3911
by rate coding, 52, 53f infraspmatus, 96, 96f
in force-velocity relationship, 50f51 f, 5 0 - mtercondylar, 437
51, 5 lb
mandibular, 354f, 354l, 354-355, 356, 3571
muscle faiigue and, 52-53, 54f olecranon, 135
musculoskeletal radiai, 134, 134f
generation and transmission of, 4 1 -5 5
supraspinatus, 96, 96f
active, 45t, 4 5 -4 7 , 46f, 47f temporal, 352, 353f
guidelines for solving problems in, 77t trochanteric, 393f, 394, 395f
in gait, 558-559, 561t
in skeletal movemeni, 50-55
Fovea
in pronation of forearm, 150, 150f
in skeletal stabilization, 4 1 -5 0 , 42t of femoral head, 394f, 396
sliding filament hypothesis of, 4 6 -4 7 of radius, 137
47f Fracture
in joint protecuon, clinical issues in, 7 4 - ofscaphoid. 174
76, 75f, 76f stress, and high mediai longitudinal arch,
in kinetics, 11-15, 12f-15f 498b
internai and external, 13, 15, 15f
Inter- representation of
Free body diagram, 6 3 -6 4 , 64f
reference frames for, 6 5 -6 7 , 66f
analytic methods of, 70, 7 2 -7 6 steps in setting up, 64 -6 5 , 65b, 65f
graphic methods of, 6 7 -7 0 Fronial piane, 5, 6f, 6t
in contrasting internai vs. external forces, Fused tetanus, of muscle fibers, 52, 53f
69, 69f-70f. 69t
result of changed joint angle in, 6 9 -7 0
71 f, 72b, 72f G
vector composilion in, 67f-68f, 67-68, 69b Gagging, abdominal muscle function in, 377b
parallelogram method of, 68, 68f, 69f Gait, 523-568. See also Walking.
polygon method of, 67f, 68 analysis of, histoncal aspeets of, 524-527
vector resoluuon in, 69f71 f, 69t, 6 9 -7 0
525f-526f
Force piate, for collection of kinematic data, 84f antalgic, 560
8 4 -8 5
Force-accelerauon relationship, 58b, 5 8 -62 61f
at different ages, 523, 524f
62b, 621
bodys center of mass in, 533-535, 534f, 535f
cadence of, 528
Force-couple, of muscles, 18f, 19
Force-time curve, 61b, 61f
clinical measurements of, 530b
compensated Trendelenburg, 425b
Force-velocity relationship, 50f, 50 -5 1 , 51b, 51f energy used in, kinetic and potential, 5 34-
Forearm. See also Elbow and forearm complex. 535, 535f, 547, 547f, 548t
attachments and innervation of, 244t-245t kinematic methods of minimizing, 545t,
distai, bones and joints of, 172b 172-173
545-547, 546f-547f
173f festinating, 563
in activities of daily living, 148, 148f hip abductor use in, 424f, 424-425
interosseous membrane of, force transmission
hip internai rotator muscle use in, 417, 420f
through, 142-144, 143f. 144f impaired, 559-560. 561t-567t, 563, 563f
joints of, 145-151 See also Radiocarpal joini; 565f, 567f, 568f
Radioulnar joint. adaptation to, 560
kinematics of, 147-151
anterior cruciate ligament injur>' and, 453b
pronation of, 145f, 145-149 causes of, 560, 560b
as spin movement, lOf in cerebral palsy, 417
innervation of, 152, 157t
"in-toeing" as sign of, 395-396, 398f
muscles active in, 166f, 169-170 secondar)^ to ankle/foot impairment, 561t
law of parsimony in, 169b 562t
line of force of, 165, 166f, 170f
step length in, 528f
torque generated by, 168b, 168-170 with hemiparesis, 528f
range of motion of, 148, 148f
with painful hip, 528f
supination of, 145f, 145-149 with Parkinsons disease, 528f
at radioulnar joint, 149, 1491
joint kinematics in
restriction of, 149-150, 150f, 150t in frontal piane, 539f-542f, 539-541
with weight-bearing, 150-151, 151f 541b
152t
in horizontal piane, 542f-543f, 542-543
innervation of, 152, 155, 157t 544b, 544f
law of parsimony in, 166
in sagittal piane, 535-539, 536f-537f,
Forefoot 538b
action of, in stance phase of gait, 506, 506f
to minimize energy expenditure, 545t 545-
5071
547, 5461-547f
definition of, 478 kinetics of, 551-559

Gait (Continued)
ground reaction forces in, 551-553, 552f,
553f
joint and lendon forces in, 424f, 425, 5 58-
559
joint reaction force during, 424f, 425
joint torques and powers in, 553-558
path of center of pressure in, 553, 554f
muscle activity in, 547-551
normal values for, 528b, 529t
phases of, 529-532, 530f-532f, 531t
push-off, peroneus longus and brevis action
in, 512, 512f
slance
action of forefoot joints in. 506
action of various foot regions during,
507t
combined subtalar and transverse tarsal
joint action in, 498-502
definition of, 529, 530f
early
pretibial muscle action in. 510
pronation of subtalar joint in, 4 9 9 -
501, 500f, 500t, 501b
late, action of joints in, 506, 506f, 507t
mid to late
action of peroneus longus and brevis
in, 511
supmation of subtalar joint in, 501-
502, 502f
piantar flexion muscle action in, 514
talocrural joint stabilization in, 488f,
488-489
terminology of, 531f, 531t, 531-532
swing
definition of, 529, 530f
pretibial muscle action in, 510
terminology of, 531f, 531t, 531-532
temporal values for, 528-529, 529t
terminology of, 527f-532f, 527-532
spanai descriptors in, 527f, 527-528, 528b
temporal descriptors in, 528, 528b
walking speed and, 528-531, 529f, 529t
Gait apraxia, 563
Gait cycle, 527f-529f, 527-529, 528b, 529t
double-limb and single-limb support in, 529f-
530f, 530-531
events and periods in, 532
stance and swing phases in, 520f-532f, 529b,
529-532, 531t
terminology of, 531 f, 531t, 531-532
Gastrocnemius
anatomy and function of, 512, 512f, 513f, 514
at knee, 454l
attachments and innervation of, 573t
in gait, 549f, 550
in standing on tiptoe, 512, 512f, 517b, 517f
maximal torque potential of at ankle, 514,
516t
paralysis of, 517-518, 518t
Gemellus inferior
anatomy and action of, 423f, 426
attachments and innervation of, 572t
Gemellus superior
anatomy and action of, 423f, 426
attachments and innervation of, 572t
Geniohyoid, attachments and innervation of,
383t
Genu recurvatum, 471, 472b-473b, 473f
Genu valgum
excessive, 471, 47 lf, 472f
factors increasing, 462
normal and excessive, 438, 439f
Genu varum, 438, 439f
in wind-swept deformity, 472f
Genu varum (Continued)
management of, 471
with unicompartmental osteoarthrilis, 470f,
471
Ginglymus, elbow as, 137
Glenohumeral joint, 98, 106-116
abduction of, 116-117, 118f, 119t
arm elevation in, 123-124, 124f, 125t
in chronic impingement syndrome at shoul-
der, 114b, 114f
in frontal piane vs. scapular piane, 113,
115f, 116, 117f
interaction with scapulothoracic upward ro-
tators, 125f
scapulohumeral rhythm in, 116, 117f
arthrokinematics ai, 116t
roll and slide, lOf
rotator cuff muscles in, 128-129, 129b
dynamic stability of, rotator cuff muscles and,
128
generai features of, 106-107, 107f
kinematics at, 112f115f, 112-116, 116t
during abduction, 116-117, 117f, 118f,
119t
loose fit of, 108b, 108f
periarticular connective tissue of, 107-110,
109f, HOf
sensory innervation of, 119
spontaneous anterior dislocation at, 128b
stability of, 107-110, 108b, 109f-110f, 109t
static, 110-111
locking mechanism of, llOf
upper trapezius paralysis and, 120b
Glenoid fossa, 96, 96f. See also underGlenohu
meral joint.
Glenoid labrum, 110, llOf
Gluteal lines, 390, 390f-391f
Gluteal nerve, inferior and superior, 410f, 411
Gluteal tuberosity, 394, 395f
Gluteus maximus
anatomy and action of, 418, 4 2 lf
attachments and innervation of, 572t
in forward lean of body, 420-421, 4 2 lf, 422f
in gait, 548, 5491
in hip and knee extension, 469. 469t
in lifting heavy loads, 347, 348f
in lumbojielvic rhythms in trunk llexion and
extension, 298-299, 299f
Gluteus medius, 420f
anatomy and action of, 42lf, 422-423, 423f
attachments and innervation of, 572t
in gait. 548, 549f, 561l
weakness of, 540, 540f
Gluteus medius limp, 425b, 432, 540
Gluteus minimus, 420f
anatomy and action of, 423, 423f
attachments and innert'ation of, 572t
in gait, 548, 549f
Glycosaminoglycans
aging effeets on, 37
in ground substance, 32, 32f
Goniometry, 31
for measuremeni of motion at subtalar joint,
492b
Gracilis
anatomy and action of, 414, 418f, 441 f, 463
at knee, 454l
attachments and innervation of, 572t
Grasp (grip)
at carpometacarpal joints, 201 f
at metacarpophalangeal joints, 208-209, 209f,
210f
metacarpophalangeal joint of thurnb and, 211,
212f
muscle mechanics of, 188f-189f, 188-189
Index 583
Grasp (grip) (Continued)
types of, 233, 234-235, 235f-236f
ulnar nerve lesion and, 233
Gravity
and naturai curvature of vertebral column,
256, 257, 259f-260f
as extemal force, 13
as hip flexor in hip (lexor contracture, 416
axial skeletal muscle action and, 316
center of, 57
knee extension torque with, 471
line of, 15, 257, 259f-260f
nuiation torque produced by, 307, 307f
Groove(s)
intercondylar (trochlear)
of femoral condyles, 435, 437f
patellar position and, 447, 4481
structures guiding patella through, 460,
46 lb, 463f
luterai and mediai, of femoral condyle carti-
lage, 435, 437f
Ground reaction force, 63, 63f
in force-time curve, 61b, 61f
in gait, 551b, 551-553, 552f, 553f
anterior-posterior, 552f, 552-553
al heel contact, 554f
line of action of, joint torques and, 554.
554f
medial-lateral, 552f, 553
vertical, 552, 552f
Ground substance, composilion of, 32, 32f
H
Hallus rigidus, 504-505, 505f
Hallus valgus, 505, 505f
Hallux abducto-valgus, 505
Hamate, 175f, 176
Hamstring muscles
anatomy and action of, 418, 421f, 440f-441f,
463
cruciate ligament changes and, 451, 452f, 453b
in atypical movement combinations between
hip and knee, 469f, 469-470
in forward lean of body, 420-421, 421f, 422f
in gait, 548, 549f, 550
forces applied to, 561t
in lumbopelvic rhythms in trunk flexion and
extension, 298f, 298-299. 299f
lumbopelvic posture and, 414
maximal effort torque of, at knee, 465-466,
467f
Hand, 194-240. See also Carpometacarpal
joinl(s); Metacarpophalangeal joint(s)
arches of, 196-197, 200f
arthrology of, 197-213
of carpometacarpal joint, 197-200, 201 f
203f
of thurnb, 200-207, 202f-207f
of interphalangeal joint, 211-213
of metacarpophalangeal joint, 207-211,
208f-212f
articulations common to each ray of, 195b
as effector organ, 234-240, 235f-236f
bonesof, 195-197, 198f-200f
terminology of, 194-195, 195b, 197f
closing of, muscles and joints used in, 188f-
189f, 188-189, 233f, 233-234
extemal anatomy of, 195, 197f
function of, 234b
and brain cortex, 194, 1961
and eyes, 194, 195f
immobilization of, 211, 21 lf
movements of, 198, 200, 201 f, 203f
terminology of, 197, 2 0 lf
 584 Index

Hand (Continued) Hip (Continued) Humerus

muscles of, 214, 214t functional anatomy of, 389, 396-402 angle of inclination and retroversion of, 98f
extrinsic, 214f-222f, 214-223 impatrment of head of, 97, 97f-98f. See also Glenohumeral
attachments of, 245i-246t gait deviations with ai ankle-fooi, 563t joint
innervation of, 152-156, 155f-156f, gait deviations with ai hip/pelvis/trunk, centralization and stabilization of by rotator
213, 245t-246t 566t, 567f, 568f cuff muscles, 115f, 116b
intrinsic, 224-228, 225i, 227f-228f gait deviations with at knee, 565t impingement of, 113, 114b, 114f
anachmenis of, 246t-247t in gait
also
m grasp action, 233. Set Grasp adduction of, 549f, 550
in chronic impingement syndrome at shoul-
der, 1 14b, 114f
(gnp). arthrokinetics of, 536f, 537f, 537-538 in kinematics of glenohumeral joint, 112f-
innervation of, 152-156, 155f-156f, forces applied to, 561 1 115f, 112-116
213, 246t-247t in frontal piane, 539f, 540, 540b, 540f mid-to-distal, osteologie features of, 133-135
opcning of, muscles and joints used in, 2 30- in horizontal piane, 543, 543f 134b, 134f, 135f
232, 231 f232f in sagittal piane, 536f, 537f, 537-538 neck of, 97f, 9 7 -9 8
palm of joint torques and powers in, 555f-556f, proximal to mtd, osteologie features of, 9 7 f-
arches of, 200f 556-557 99f, 9 7 -9 8 , 98b
creases of, 196, 1971 linutation of movement in, 537, 5371', Hyoid bone, 355
position of 538b Hyperextension, craniocervical
extrinsic-plus, 230, 230f muscle action in, 548, 549f, 550 chronic forward head posture with, 341b
for funccion, 213, 213f in trunk extension, lumbopelvic rhythms in 341f
intrinsic-minus, 231-232, 232f 298-299, 299f injury with (whiplash), 277, 281, 337b, 337f
intrinsic-plus, 230, 230f in trunk flexion, lumbopelvic rhythms in, osteophyte lormation and, 283f, 283b
Haversian System , 36, 37f 297-298, 298f
Head. See also Craniocervical region intracapsular pressure in, 403b, 40.3f
Hypothenar eminence, muscles of, 225f 2 25-
226
extension of, erector spinae muscle action in, muscles of. See Musclefs), hip.
319f, 320 attachmenis and innervations of, 571t-573t
in axial rotation of craniocervical spine, 3 4 0 - osteoarthritis of, 428b, 428-429 I
341, 342f causes of, 428b 1 bands, of myofilaments, 45, 46f
motion of, 279-284 clinica! signs of, 428b Iliac cresi, 390-391, 391f
osteologie features of, 253, 253f osteokinematics of, 402-408 elcvaton of in gait, 540, 540f
posture of femoral-on-pelvic rotation in, 404f-405f, Iliac fossa, 391, 39 lf
chronic forward, muscular imbalance with, 4 04-406 Iliac spine, 390f-392f, 390-391
341b, 341f pelvic-on-femoral rotation in, 404f, 406f, Iliac tuberosity, 391, 391f
muscles active in, 340, 341f 406-408, 407f Iliacus
temporomandibular joint disorders and, planes and axes of rotation of, 404, 404f anatomy and action of, 412, 413f
366b, 366f osteology of, 390-396 attachments and innervation of, 572t
protraction and retraction of, 282, 284f painful. See also Hip disease. in gait, 548, 549f
Heel contact, 527, 527f, 531, 531f, 531t gait deviations with, 563t, 565t, 566t, 567f, in iliac fossa, 391, 391f
ground reaction forces at, 554f 568f in trunk movement, 327, 328b
Heel off, 531, 531f, 531t gait step length with, 528f Uiocostalis
abnormal, 539 range of motion of, 402-404 anatomy and actions of, 318t, 319f, 3 19-32!
Heel pain, gait deviations with, 562t rotation of, internai and external, 405f, 406 as secondary axial rotators, 327b
Heel strike, 527, 527f 407f, 408, 408f in trunk movement, 329t
Hemiparesis, gait step length with, 528f Hip disease Uiocostalis cervicis
Henneman size principle, 51 causes of, 427-428 action of, 375t
Hip, 389-433 gait deviations with, 563t, 565t, 566t 567f attachments of, 38 lt
abduction of, 405f, 406, 407f, 408f, 4 0 8 - 568f
See also
409. Muscle(s), hip, abductor gait step length with, 528f
innervation of, 375t, 381t
Uiocostalis lumborum, attachments and mnerva-
adduction of, 405f, 406, 407f, 408, 408f thcrapeutic intervention for, 429-431 tion of, 381 1
in gait, 549f, 550 methods of carrving loads with, 429-431 Uiocostalis thoracis
arthrokinematics of, 408f, 408-409 430f action of, 375t
in gait, 536f, 537f, 537-538 surgical intervention for, 431f433f 4 3 1 - attachments of, 381 1
in frontal piane, 539f, 540, 540b, 540f 432 innervation of, 375t, 3 8 11
arthrology of, 396-409 use of cane with, 429, 429f Iliopsoas
acetabular alignment and, 397-398, 399f, Hip flexion contracture anatomy and action of, 412, 413f
400f, 40 lb in standing, effect of, 416, 416f attachmenis and innervation of, 572t
capsule and ligamenis of, 399-402, 40 lf, mcreased lumbar lordosts with, 300, 301 f in gait, 548, 549f
402f, 402t Hip hiking, 540 in trunk movement, 327-328, 328b, 328f
femoral head and, 396-397, 399f Hook grip, 234-235 Iliotibial tract, anatomy and action of, 413, 413f
artificial, minimization of hip abductor forces Hortzontal piane, 5, 6f, 6t
on, 75, 75f Ilium, osteologie features of, 390b, 390f-391f
Humeroradial joint, 133-134, 134f 390-391
axis ol rotation at, longitudinal (vertical), 404 arthrokinematics of, 141-144, 143f, 144f Imaging techniques, for collection of kinematir
extended through knee, 438, 439f as shared joint between elbow and forearm data, 83, 83f
close-packed position of, 402, 403f 150, 150f
definition of, 389 Immobilization, effeets on connective tissue 3 7 -
force transmission through forearm interos- 38
developmental dysplasia of, acetabular mal- seous membrane and, 142-144, 143f Impulse, 60
alignment and, 40lb 144f
extension of, 405f, 406, 407f, 408, 408f Impulse-momentum relationship, 60, 60b, 61b
generai features of, 137-138, 138f 61f
with knee extension, 466, 468f, 468-469 sensory innervation of, 156 Infrahyoid
469t Humeroulnar joint, 133-134, 134f attachments and innervation of, 384t
with knee (lexion, 469f, 469-470 arthrokinematics of, 140-141, I42f, 143f in mastication, 365, 365f
flexion of, 404, 405f, 406, 407f, 408, 408f as hinge joint, 28, 28f lnfraspinatus, 109-110, llOf
with knee extension, 469f. 469-470 generai features of, 137-138, 138f
with knee (lexion, 469t attachments and innervation of, 244t
joint surface relationships in, 8f in elevation of arm, 127f-128f, 127-128
fratture of, 428, 428t posterior dislocation of, 145, 145f 129b
internai fixauon for, 431, 431 f sensory innervation of, 156 in external rotation of shoulder, 132
 Index 585

lnfraspinaius (Continued) lnterphalangeal jointfs) (Continued) Joint(s)(Continued)

in shoulder adduction and exiension, 1 2 9 -
130, 130f
in stabilization of humeral head, 115f, 116b
Innominate bone, 390b, 390f-392f, 390-393,
392b, 393b
extemal surface of, 390
Inspiration
elevation of ribs dunng, 371, 37 If
muscles of, action and innervation of, 372t,
375t
of lungs, 3681, 369
Instruments, used in gait analysis, 526, 526f
Interbody joint
compression force on, in thoracic kyphosis,
292b
lumbar, shear forces on, 293, 293f
of intervertebral junction, 269, 272f
structure and function of, 273-274, 274(
Intercarpal joint
as piane joint, 28, 29f
of wrist, 173f, 175f, 176
intercarpal ligament, dorsal, of wrist, 179
lnterchondral joint, 370, 370f
lntercoccygeal joint, 269
Intercondylar eminence, of tibia, 436-437
Intercondylar notch, of distai femur, 435, 436f,
437f
intercostal membrane, posterior, 373
Intercostal nerve, axial skeletal tissues innervatcd
by, 313, 313f
Intercostales
action and innervation of, 372t, 384t
anatomy of, 369f, 373
function of, 373-374
in forced expiration, 373, 376f, 377f, 377 1
paralysis of in cervical spinai cord injury,
374b
Intercostales extemi, 369f, 373
attachments and innervation of, 372t, 384t
Intercostales interni, 369f, 373
attachments and innervation of, 372t, 384t
Intercostales intimi, 373
attachments and innervation of, 372t, 384t
Intercuneiform joint, 493f, 502b, 502-503,
503f
Intermetatarsal joint, 504
Intermuscular septa, 413
Interossei
dorsal
of foot
anatomy and function of, 519f, 520
attachments and innervation of, 574i-575i
of hand, 227-228, 228f
attachmenis and innervation of, 246t
in finger flexion, 233, 233f
in key pinch action, 229, 229f
in opening hand, 230-232, 232f
palmar, attachments and innervation of, 247t
piantar
anatomy and function of, 519f, 520
attachments and innervation of, 575t
tension fraction of, 226t
vs. lumbrical muscles, 230t
Interosseous membrane
of ankle, injury of, 489b
of forearm, 145
force transmission through, 142-144, 143f,
144f
Interosseous nerve
anterior, 152, 155f
posterior, 152, 154f
lnterphalangeal jomt(s), 195, 197f, 211-213
distai, 212f, 212-213
of foot, 493f, 504f, 505-506
mobility al, 505-506
of thumb ellipsoid, 28. 29f
abductor pollicis longus as assistant exten- forces applied to.See Force(s).
sor of, 223f, 225 function of, 25
muscles attached to, 224t htnge, 28, 28f, 137
position of function of, 213, 213f instabilily of, with chronic trauma, 38, 39f
proximal, 211-213, 212f ovoid, classification of, 30, 30f
lnterspinalis, 321, 323 pivot, 28, 28f
attachmenis and innervation of, 3811 piane, 28, 29f, 273
in irunk movement, 329t position of, close-packed and loose-packed, 11
lntenarsal joint, distai, 493f, 502b, 502-503, saddle, 28, 30f
503f classification of, 30, 30f
Intertendinous conneclions, 220 complex, 198, 200, 203f
Intertransversarus, 321, 323 of carpometacarpal joint of thumb, 202,
attachments and innervation of, 381t-382t 204f
in trunk movement, 329t structure and function of, 25 -3 9
Intertrochantertc cresi, 394, 395f surfaces of, 8, 8f
Intertrochanteric line, 393f, 394 synovial
Intertubercular groove, of humerus, 98 classification of
Intervertebral disc based on mechanical analogy, 27t, 2 7 -
hemiated (slipped), 265b, 265f, 296b, 296f, 28, 281-30f, 30
296t of ovoid and saddle joints, 30, 30f
factors favonng, 297b definition and function of, 26f, 2 6 - 27
mechanisms of, 296b-297b, 296f, 296t elements associated with, 26f, 2 6 -2 7
lumbar trauma effeets on, 38, 39f
as hydrostatic shock absorber, 274-275, uncovertebral, 264, 264f, 266f
275f in disc disease, 265b, 265f
structure and function of, 273-274, 274f Joint capsule.See Articular capsule.
water coment of, 276b Joint power, definition of, 555, 555b
trauma lo, 38 Joint reaction force, 15, 15f, 64, 64f
Intervertebral joints, consequences of exercises guidelines for solving biomechanical problems
for low-back pain on, 302b in, 77t
Intervertebral junction in knee, in standing, 470f, 470-471
function of, 269, 269t. 272f in walking, 424f, 425
movement of, terminology for, 271-272, measurements of, inverse dynamic approach
272f, 272l to, 81b, 81f
typical, 269, 271, 272f, 272t See also
Joint torques. Torque.
In-toeing, 395-396, 398f in gait, 553-558, 555b
Intra-abdominal pressure, during lifting, 345- in ankle and foot, 558, 559f-560f
346, 347 in hip, 555f-556f, 556-557
Intra-articular discs, of synoval joints, 26f, 27, in knee, 557f-559f, 557-558
27b net, definition of, 555
Inverse dynamic approach, to measuring internai Joints of Luschka, 264
torque and joint reaction force, 81b, 81f Jugular notch, 254, 257f
Inversion of manubrium, 94, 94f
definition of, 482, 482f, 483t Juncturae tendinae, of digitai extensor mecha-
of subtalar joint, 4911, 492b msm, 220, 221f
of talocrural joint, 49 lt
of transverse tarsal joint, 493, 495f
Ischial ramus, 39 lf, 393 K
Ischial spine, 392f, 393 Key pinch, muscular biomechanics of, 229, 229f
Ischial tuberosily, 390f, 392f, 393 Kienbcks disease, 176b
lschium, osteologie features of, 39lf, 392f, 393, Kinemaiic chain, open or closed, 7 -8
393b Kinematics, 3 -1 1
definition of, 3
units of measurement in, 5t
J variables in, 5
Joint(s).See nls numesoj specific joints. Kinesiology, definition of, 3
aging effecls on, 37 Kinetics, 11-21
angle of displacement of, muscles mechanical definition of, 11
advantage and. 21, 22, 221, 6 9 -7 0 , 71f, force principle in, 11-12
72b, 72f muscle and joint interaction in, 16-19, 17f,
ball-and-socket, 28, 29f, 396 18f
classification of, 2 5 -3 0 musculoskeletal forces in, 12f-l5f, 12-15
by mechanical analogy, 27l, 27 -2 8 , 28f- musculoskeletal levers in, 19f-20f, 19-21,
30f, 30 22f
by structure and movement potential, 2 5 - musculoskeletal torques in, 15-16, 16f
27, 26f, 26i Knee, 438-439, 440f-441f, 440t. See ahoTib-
condyloid, 28, 30f iofemoral joint.
connective tissues in, See aho Connective tis- abduction of, litnits on, 448, 449t
suc(s). alignment of
biologie materials forming, 3 lb, 31-32 abnormal
biomechanical function of, 12, 131, 14. 14f in frontal piane, 470f-472f, 470-471
types of, 32, 33t, 3 4 -37 in sagittal piane, 471, 472b-473b, 47.3f
definition of, 25 normal, 438, 4391
dislocation of, by gender, 464t arthrology of. 438-453
 586 Index
Knee (Continued)
biomechanical functions of, 434
bones and joims of, 434, 435f
bursae of, 439, 442i
extension of, 443, 444f, 445f, 445-446. 446f,
447f
hip extension or flexion with, 469f, 4 6 9 -
470
in gait, 538
limits on, 448, 449f, 457, 460, 460t, 46if
screw-home rotation and, 445-446, 446f
447f
tracking of patellofemoral joint during,
460-463, 463f, 464f, 464t, 465b
with piantar flexion by soleus, 515b, 515f
extensor lag and, 460b
extensor-to-flexor peak torque ratios in, 468b
fat pads of, 439, 442t
femoral-on-tibial movements in. See Femoral-
on-tibial knee motion.
flexion of, 7f, 443, 444f, 445f, 446
hip extension or llexion with, 469f. 4 6 9 -
470
in gait, 538
hyperextension of
abnormal gait pattern with, 563f
anterior cruciate ligament injur) with, 451
in genu recurvatum, 471, 472b-473b
473b
impairment of
extensor lag and, 460b
gait deviations ai ankle-foot with, 563t
gait deviations at hip/pelvis/trunk with, 567t
gait deviations at knee with, 564t, 565f
in gait
abnormal pattems in, 563t, 564t, 565f,
567t
extension in, 538
extensor muscles in, 549f, 550
flexion of, 538
flexor muscles in, 549f, 550
forces applied to, 561t
joint kinematics of, 536f, 538
in frontal piane, 540, 54lf
in horizontal piane, 543, 543f
in sagttal piane, 536f, 538
joint torques and powers in, 557f-559f
557-558
internai and extemal rotation of, 443-444
445f
ligaments of, 438f, 438-439, 440f-441f, 440t
muscle and joint interaction at, 434, 453-473
muscles of. See Musclefs), knee
norma!, joint reaction forces in, 470, 470f
osteoarthritis of, chondromalacia patellae with
462b, 462f
osteology of, 435-437
plicae of, 439, 442t
quadriceps strengthening exercises and, 4 5 6 -
457, 458f, 459f
range of motion of, 443
restraints on, in varus and valgus forces, 448
449l
rotation of. limits on, 448, 450l
screw-home rotation of, 445-446, 446f, 447f
sensory innervation of, 454
stability of, 434-435
synovial membrane of, 439, 442t
tibial-on-femoral movements in. See Tibial-on-
femoral knee motion.
tibiofemoral joint of, 440, 442-444, 443f-
445f, 446. See also Tibiofemoral joint
Knock-knee, 438, 439f
excessive, 471, 4 7 lf, 472f
Kyphosts, 256, 257, 258f, 260f, 276b
juvenile, 288
Kyphosts (Continued)
thoracic, 260f, 288-290, 291f
compression force on interbody joint in,
292b
L capsular, 260f
Labor and delivery, sacrai liac joint movements
during, 307
Labrum, peripheral, of fibrocartilage, 27
Laminae
of cemcal vertebrae, 264, 266f
retrodiscal, of articular disc of temporoman-
dibular joint, 357, 357f
Lateral epicondylitis, 189
Latissimus dorsi
action of, 317, 317f, 375t
as secondary axial rotator, 327b
attachments of, 244t
in depression of scapulothoracic joint, 121
121f, 122f
in internai rotation of shoulder, 131-132
132f
in lifting heavy loads, 347, 348f
in shoulder adduction and extension, 129-
130, 130f
innervation of, 244t, 317, 317f, 375t
Law of acceleration, 58b, 58 -6 2 , 61f, 62b, 62t
physical measurements associated with, 62t
Law of action-reaction, 62 -6 3 , 63f
in gait, 551
Law of inertia, 57b-60b, 57 -5 8 , 59f, 60f
Law of parsimony
in elbow extensors, 164b
in forearm supination and pronation 166
169b
Laws of motion, 56 -6 3 , 57t. See also Newton's
laws.
Leg, compartments of, 506
anterior, muscles of, 506, 510, 510f
lateral, muscles of, 510-512, 511f, 512f
posterior, muscles of, 512b, 512-514 513f-
515f, 515b, 516
Leg length, difference in, and pelvic motion in
gait, 540
Levator scapula,
action of, 120f, 120-121, 317, 317f
attachments and innervation of, 244t
Levatores costarum
action of, 375t
attachments of, 384t
innervation of, 375t, 384t
Levers, musculoskeletal
classes of, 19, 19f-20f, 21
mechanical advantage of, 20f, 21, 2 lb
surgical alteration of, 22, 22f
Lifting, See also Load(s).
biomechanical issues with, 34 2 - 349
extension torque used in, additional sources
of. 346t, 346-347
intra-abdominal pressure dunng, 345-346
low-back muscle force and, 342-347
estimation of force magnitude in, 320, 320f
342-344, 343b, 344f
ways of reducing, 344-345, 345b, 345f
muscles active in, 343f
techniques of, 347-348, 348f
safety factors in, 348-349, 349i
Ligament(s)
accessory, of temporomandibular joint 358
358f
alar, 279, 280f, 282, 442b
ankle, 483-486, 486t
stretch of, 486, 486t
annular, 146, 146f
Ligamentfs) (Continued)
arcuate popliteal. 439, 440t, 4411
btfurcated, 485f, 492
calcaneofbular
at subtalar joint, 4 8 lf, 489
at talocrural joint, 485, 485f, 486t
of glenohumeral joint. 108-109, 109f-110f
of hip, 402, 402t, 403f
of knee, 438f, 438-439, 440f-441f, 440t
of radioulnar joint, 146, 148f
of synovial joints, 26, 26f
of thoracic spine, 285
cervtcal, at subtalar joint, 485f, 489
check-rein, of proximal interphalangeal joints
212
collagen fibers in, 32
collateral
lateral (fibular), 438f, 439, 440f-441f, 440t
anatomy and function of, 440f-441f,
444f, 447-448, 449f. 449t-450t
function and common mechanisms of in
jury of, 450l
lateral (ulnar), 139, 139f, 139t, 140f, 148,
175f, 178f, 178-179, 212
lateral, of talocrural joint, 485, 485b, 485f
mediai (elbow), 138, 139f, 139t, 140f
injury of, 144-145, 145f
mediai (knee), 438f, 439, 440f-441f, 440t
anatomy and function of, 440f-441f,
444f, 447-448, 449f, 449t-450t
common mechanisms of injury of, 450t
mediai (deltoid), of talocrural joint, 4 8 4 -
485, 485f, 486l, 489b
of metacarpophalangeal joints, 207-208
208f
of metatarsophalangeal joints, 504, 504f
of proximal interphalangeal joints, 212
of temporomandibular joint, 357-358
radiai, 139, 139t, 140f. 177f-178f, 178,
212
ulnar, 175f, 178f, 178-179
of ulnocarpal complex, 148, 178, 179f
coracoacromial, 111
coracoclavicular, 103, 103f, 104, 104f
coracohumeral. 109, 109t, llOf
coronary (meniscotibial), 440, 443f
costoclavicular, lOOf, 101
costoiransverse, 285
cruciate, 443f, 444f, 449
anterior
forces applied to, in gait. 56li
funclional anaiomy of, 448, 449f, 450f
450t, 451, 452f
injury of, 449, 450t, 451
anterior drawer test for, 451, 452f
consequences of, 449, 453b
reconstruction of, quadriceps strengthen-
ing in, 453b
posterior
accessory components of, 451
forces applied to, in gait, 561t
functional anatomy of, 443f, 444f 450f
451
injury of
mechanisms of, 450t, 451, 453, 453b
posterior drawer test of, 451, 452f
reconstruction of, 449
deltoid, 479f, 485f, 492
of subtalar joint, 481f, 489
of talocrural joint, 484-485, 485f, 486t
dorsal calcaneocuboid, 485f, 492
dorsal intercarpal, of wrist, 179
dorsal talonavicular, 485f, 492
doubl V System of, in wrist, in ulnar and
radiai deviation, 183-184, 184b, 184f

Ligament(s) (Continued)
fibrous organization of, 34, 341
forces applied to, in gait, 558-559, 561 1
glenohumeral capsular, 108-109, 1091- 110C
interior, 108-109, 109t, 1101
middle, 108, I09t, 1101
superior, 108, 109t, 1101
hip capsular
hip motion limited by, 402t
in close-packed position ol hip, 402, 4031
iliofemoral, 399-401, 401 f, 402t
in paraplegia, 401, 4021
iliolumbar, in lumbar spine, 293
interchondral, 370
inlerdavicular, lOOf, 101
intermediate, ol wrsl, 179
mterosseous, 305, 3051, 4791
of distai tibiofibular joint, 483-484, 4841
sacroiliac joint stability and, 307f, 308
interosseous (talocalcaneal), of subtalar joint,
4841, 485f, 489
interspinous, 258, 2601, 260t
in lifting heavy loads, 346t, 346-347
intertransverse, 258, 2601, 260t
intra-articular, 370
ischiofemoral, 399, 401 f, 401-402
lateral (temporomandibular), of temporoman-
dibular joint, 358, 3581
link, in finger extension, 232, 2321
long (intrinsic), of wrist, 179
long piantar, 485f, 492
longitudinal
anterior, 259, 2601, 260t
in lumbar spine, 293
posterior, 259, 2601, 261t
in lifting heavy loads, 346t, 346-347
lunotriquetral, of wrist, 179
mentscofemoral, 4431, 4441, 451
posterior, 442, 443f, 4441
oblique popliteal, 439, 440t, 441f, 448, 4491
oblique reiinacular, of digitai extensor mecha-
nism, 220, 222t, 232, 2321
of acromioclavicular joint, 103, 1031, 104,
1041
of carpometacarpal joints, 198, 202f
of ihumb, 202, 202t, 2031-2041
of knee capsule, 4381, 438-439, 4401-4411,
440t
of sacroiliac joints, 304-305, 305b, 3051
of temporomandibular joint, 358, 3581
of vertebral column, 258-259, 260f-261f,
260t-261t
of wrist, 176-179, 1 7 7 f-1791, 178l
palmar carpai, 189
palmar tntercarpal, 179
palmar radiocarpal, 172, 1741
palmar ulnocarpal, 148, 178, 179, 1791
patellar, 4381, 438-439, 4401-4411, 440t.
460, 4611
patellar retinacular, 462, 463f
periodontal, of teeth, 355, 3561
piantar calcaneocuboid, 492-493, 4931
popliteal
arcuate, 439, 440t. 4411
oblique, 439, 440t, 441 f, 448, 4491
posterior, stretching of, passive tension gener-
ated from. 346t
pubofemoral, 399, 401, 4011
quadrate, 146, 1461
radiate, 370
of thoractc spine, 285
radiocapitale, 178, 1791
radiocarpal, dorsal and palmar, 178, 1781,
179f
radiolunale, 178, 1791
radioscapholunate, 178, 1791
Ugametu(s) (Continued)
sacroiliac
anterior, 305, 3051
posterior, 305, 3051
sacrospinous, 305, 3051, 391, 392f
sacroluberous, 305, 305f, 391, 3921
sacroiliac joint stability and, 3071, 308
scapholunate, 179, 185, 1851
scaphotrapezial, 179
short (intrinsic), of wrist, 179
short piantar, 492-493, 4931
sphenomandibular, of temporomandibular
joint, 358, 3581
spring, 4851, 492, 4931
stemoclavicular, lOOf, 101
stylomandibular, of temporomandibular joint,
358, 3581
supraspinous, 258, 260f, 260t
in lifting heavy loads, 346t, 346-347
talofibular
anterior, at talocrural joint, 485, 4851, 486t
posterior, at talocrural joint, 485, 4861,
486t
tibiofibular
anterior, 4791
distai, of distai tibiofibular joint, 484, 484b,
4841
stabilizing proximal tibiofibular joint, 483b
transverse, 440, 4431
inferior, at talocrural jomt, 4841, 485
of alias, 279, 280f
transverse acetabular, 397
transverse carpai, 1751, 176, 189, 190f
transverse metacarpal, deep, of metacarpopha-
langeal joints, 208, 2081
transverse metatarsal, of metatarsophalangeal
joints, 504, 5041
wrist, 177f, 177-179, 178t
extrinsic, 178t, 178-179, 1791
intrinsic, 1781-1791, 178t, 179
Ltgamentum flavum, 258, 2601, 260t, 2611
in exiension and flexion, 2611
in lifting heavy loads, 346t, 346-347
Ligamentum nuchae, 258, 2601, 260t, 2611
Ltgamentum teres, of femoral head, 396, 3991
Linea aspera, 394, 3941
Ltne-of-force, 15, 17, 181
due to body weight, kyphosis development
and, 288-290, 2911
Line-of-gravity, 15
in standing person, and curvature of spine,
257, 259f-260f
Load(s)
lumbar extensor muscles active in, 320, 3201
methods of carrying, 320
intervertebral disc pressure and, 275, 2751
with hip disease, 429-431, 4301
Loadtng, combined, as musculoskeletal force, 121
Longissimus capitis
attachments and tnnervation of, 38 lt
in trunk movement, 329l
Longissimus cervicis
attachments and tnnervation of, 381 1
in trunk movement, 329t
Longissimus muscles, anatomy and acttons of,
'3 1 8 l, 3191, 319-321, 327b, 329t
Longissimus thoracis
attachments and innervation of, 381 1
in trunk movement, 329t
Longitudinal crest, of ulna, 135, 1361, 137f
Longus capitis
anatomy and action of, 336, 3361, 339b
attachmenis and innervation of, 382l
whtplash tnjury and, 337b, 337f
Longus colli
anatomy and action of, 336, 3361, 339b
Index 587
Longus colli (Continued)
attachments and innervation ol, 382t
whiplash injury and, 337b, 3371
Lordosis, 256, 257, 2581
lumbar
anterior and posterior pelvtc tilt and, 3001,
300-301, 3011, 414, 414f, 415f
anterior spondylolisthesis and, 294b
Low-back pain, 300-301
causes of, 296b
centralization of, 300
flexion and extension exercises for, 302b
hemiatcd discs and, 296b
with lifting, 342.See also Lifting; Load(s).
Lower exlremiiy, 388. See also names of specijlc
joints, e.g., Hip.
impairment of
gait deviations at ankle-foot with, 563t
gait deviations al hip/pelvis/trunk with,
567l
gait deviations at knee with, 565t
muscles of
attachmenis and innervations of, 571t-575t
nerve roots of, 570t57lt
prenatal mediai rotation of, 398, 3981
ventral nerve roots of muscles of, used for
testing function of, 57li
Lumbar plexus, innervating muscles of hip,
4091-4101, 409-411, 410b
Lumbar spine, 292-303
anterior spondylolisthesis at, 294b, 2941
articular struclures in, 292-294, 2931
axial rotation of, 290f
extension of, 289f, 297
biomechanical consequences of, 302b, 302t
for low back pam, 302b
lumbopelvic rhythm in, 297-299, 2981,
2991
fiexton of, 2881, 294-296, 295f
biomechanical consequences of, 302b, 302t
for low back pain, 302b
lumbopelvic rhythm in, 297299, 298f,
2991
lateral flexion of, 29 lf
motion at, 294-303
in fronial piane, 2911, 303
in horizontal piane, 2901, 303
in sagittal piane, 294-302, 2951, 295t,
2981-3021
range of motion at, 294t
pclvic tilt and, 299-301, 3001
Lumbopelvic rhythm, 406, 4061, 4071, 408
in anterior and posterior pelvic tilt, 406, 407f,
408
in trunk flexion and extension, 297-299,
2981, 2991
ipsi-dtrectional and contra-directional, 406,
406f, 4071
Lumbosacral plexus, ventral nerve roots ol, mus
cles used for testing function of, 571t
Lumbrical muscles
of foot
anatomy and function of, 519, 5191
attachments and innervation of, 574t
of hand, 2151, 2221, 226-227
anatomy and function of, 227, 227f
attachments and innervation of, 246t
in finger flexion, 233, 2331
in opentng hand, 230-232, 231 f232f
vs. mterosseous muscles, 2.30t
Lunate bone, 1741, 175, 1751
avascular necrosis of (Kienbcks disease),
176b
in carpai instability, 185, 1851
Lungs, hyperinllation of, in chronic obstructtve
pulmonary disease, 375
 588 Index

M
Malleolus
Meningea! nerve, recurrent, axial skeletal ttssues Motion (Contmued)
innervated by, 313, 313f linear or rotational, in Newtons law of inertia
lateral, 479f Mentscoids, 262b, 262f 57, 57t
mediai, 479f Meniscus(i) planes of, 5, 6f, 6t, 7
and tendons of tlbialis posterior and flexor hbrocartilage organization in, 35, 36f types of, 3
digilorum longus, 514 of synovial joints, 26f, 27, 27b Motoneuron
Mamillary processes, of lumbar vertebrae, 268, of tibiofemoral joint (knee), 440, 443f alpha, 51
269f attachment of, 440, 442, 444f classification of, 52, 531
Mandible, 352-353, 353f, 354f blood supply of, 440 rate coding of, 52, 53f
angle of, 352, 353, 353f function of, 442 recruitment of, 51 -5 2 , 52t, 53f
body and rami of, 353, 353f injury of, 38, 444b Motor unit(s), of muscle, 51-52, 53f
condyle of, 353, 353f, 354f, 356 ligaments associated with, 442b Motor unit action potential, 51, 54
in disc-condyle complex mediai, tnjury of, 444b Mouth
derangemeni of, 361b, 361 f Metacarpal bones closing of, 362, 365
lateral pterygold action and, 367b, 367f ftrst, 199f muscular control of, 366, 367f
translational movement of, 359f, 360, morphology of, 195-197, 198f-200f opening of, .365
362 third. 199f
motion of muscular control of, 366, 367f
Metacarpophalangeal joint(s), 195, 197f, 2 0 7 - phases in, 359360, 360f, 362, Seealso
in contralateral excursion, 363f, 365 211, 208f-212f, See alsa Finger(s). Mandible, motion of.
in depression and elevaiion, 359-360,
360f, 362
arthritis of, 236-238, 237f239f Movement(s). See also Motion.
close-packed position of, 209, 211, 211 f active and passive, 5
in lateral excursion, 358-359, 359f, 362 generai features of, 207f, 207-208 analysis of
in protrusion and retrusion, 358, 359f, 360 interossei muscle function and, 228, 230t anthropometry in, 63, 87t
362 kinematics of, 208-211, 209b, 209f2 lOf concepts in, 6 3 -7 6
in rotation, 360, 360f, 362 ligaments of, 207-208, 208f dynamic, 82f-85f, 8 2 -8 5
in translation, 360, 360f, 362 lumbrical muscle function and, 228 free body diagram in, construction of, 6 3 -
osteokinematics of, 358-360, 359f, 360f of thumb 67, 64f, 65b, 65f
osteologie features of, 353b arthrokinematics of, 211, 21 lf212f
positton of, 355-356 guidelines for solving biomechanics prob-
muscles attached to, 224t lems in, 77l
and head position, 366b, 366f palmar dislocation of, 237, 238f quantitative methods of, 76 -8 5
Mandibular fossa, 354f, 354-355 passive accessory motions at, 208, 209 static, 77b, 77-81
articular and nonarticular surfaces of, 354f 209f arthrokinemalc principles of
354t, 356, 357f periarticular connective tissues of, 208 concave-on-convex, 10-11, llb , 1 lf
Mandibular nerve, muscles of mastication inner- 208f
vated by, 362t convex-on-concave, 10-11, llb , 1lf
position of function of, 213, 213f of joints, 8t, 8 -1 0 , 9f, lOf
Mandibular notch, 353, 353f ulnar drift al, 237-238, 239f Multifidi
Manubriosternal joint, 254, 257f, 370, 370f Metatarsal bones, osteologie features of, 480f-
Manubrium. 93, 94f, 254, 257( anatomy and action of, 32lf, 321t, 321-323
4 8 lf, 482 as secondary axial rotators, 327b
Marey, in gait analysis, 524, 524f Metatarsophalangeal joint(s)
Mass attachments of, 38 lt
extensor mechanism of, 504 in lumbosacral region, 322t
center of, 5, 57 tirsi in trunk movement, 329t
dsplacement of, in gait, 535-537, 540b, deformities of, 504-505, 505f innervation of, 3 8 lt
540f, 545t, 546f-547f in gait, 539
vs. body weight, 12b Murray MP, in gait analysis, 525f, 526
structure and function of, 504, 504f Muscle(s)
Mass moment of inertia
calculation of, 59b, 59f
in hallux rigidus and hallux valgus, 504-505
505f
abdominal. See Abdominal muscles
actions of
in Newton's law of inertia, 57b, 57-58, 58b in standing on tiptoe, 517b, 517f at joints
60f structure and function of, 504f, 504-505 analysis of, 17-19, 18f
prosthetic design and, 60b 505f
Masseter types of, 16-17, 17f
windlass effect on, 506, 506f force couple of, 18f, 19
anatomy and function of, 363, 363f, 365t Metatarsus primus varus, 505 terminology of, 18
attachments and innervation of, 383t Mid stance activation of
in closing of mouth, 366, 367f action of muscles and joints in, 501-502 by nervous System, 51-52, 52t, 53f
mediai pterygoid interaction with, 363f, 364b 502f, 511 concentric, 50f, 5 0 -5 1 , 51f
Mastication, 352-367 defimiion of, 531, 531f, 531t eccentric, 50f, 5 0 -5 1 , 5 lf
by temporomandibular joint, 356 Midcarpal joint, 173f, 176-177, 177f nonisometric, 54
disc-condyle complex derangement and, 361, flexion and extension of, 181f-182f, 181-182 ankle and foot
361f ulnar and radiai deviation of, 182-184 183f-
muscles of, 362t dorsiflexor, paralysis of, 516-517, 518t
184f, 184b extrinsic
actions of, 365t Midfoot
attachments and innervation of, 383t anatomy and function of, 507, 5 lOf
actions of during stance phase of gait, 507t 51 lf, 512t, 513f-515f, 516
function of, 363(-365f, 363-365, 365t definition of, 478 attachments of, 573t-574t
secondary, 365, 365f, 365t
osteokinematics of. 358-360, 359f, 360f
Mid-tarsal joint, 491 See also Tarsal joint, trans- motor innervation of, 509t, 573t574t
verse.
Mastoid process, 253, 253f of anterior compartment of leg, 508 510
Moment arm 510f
Maxillae, 353f, 353-354 in lifting heavy loads, 320, 344f-345f 3 4 4 -
Measurement Systems of lateral compartment of leg, 510-512
345 5 1 lb, 51 lf, 512r
for motion of vertebral column, 277b internai and extemal, 16, 16f
kinemattc, 82f-85f, 8 2 -8 5 of posterior compartment of leg, 512
of muscle, and torque-joint angle curve 4 8 - 514, 513f515f, 515b, 516
units of, 5l 49, 49f, 49t in gait, 549f, 550-551
Mechanoreceptors, of elbow ligaments, 139 Moment of force, 59
Medtan nerve innervation of, 506-507, 509t, 573t-575t
Momentum, 60 intrinsic
in thumb opposition, 224-225 Motion. See alsa Movement. anatomy and function of, 518-520 5191
of elbow and forearm, 152, 155f distal-on-proximal and proximal-on-distal kin
of hand, 213, 216 549f, 551
ematics in, 7 attachments of, 574t-575t
of wrist, muscles irmervated by, 186 laws of, 5663, 57t. See also Newton's laws. motor innervation of, 509t, 574t-575t

Musciefs) (Contnued)
paralysis of, 516-518, 518t
piantar flexor, 514, 516
in stabilizing knee in extension. 515b,
5151
in standing on tiptoes, 517b, 517f
maximal torque potential of at ankle,
514, 516l
supination by, 514, 516
pretibial dorsiflexor, 508, 508b, 510, 5 10f
supination by
at subtalar joint, 490, 490f, 491b, 50 1 -
502, 502f, 514
ai transverse tarsal joint, 491, 492f, 493,
4941', 496
architecture of, 4 2 -4 4 , 44f
as skeletal movers, 5 0 -5 5
as skeletal stabilizers, 4 1 -5 0 , 42t
back, 315t
deep layer of
anatomv and action of, 317-323, 318f-
321 f, 318l
tnnervation of, 318
short segmentai, 317, 318t, 321f, 323,
329-330, 330b, 330f
attachmems and innervation of, 38 l t -
382t
extensor, forces on in lifting heavy loads,
320, 320f, 343b, 343-345, 344f-345f
superficial and intermediate layers of, anat-
omy and action of, 317, 317f
connective tissue of, 42, 43f, 44, 44f, 44t. See
also Connective lissue(s).
cross-sectional area of, 4 2 -4 3
elastici!)' of, 45
elbow and forearm
attachments of, 244t-245t
electromyographic analysis of, 161-162
flexors
biomechamcs of, 27t, 157t, 157-161,
159f-161f
function of, 157t, 157-161, 158f-162f,
162b
mnervation of, 152, 157t, 244t-245t
maximal torque production of, 158-160,
159f-160f, 159t
paralysis of, surgical correction of, 22,
22f
reverse action of, 162b, I62f
torque angle curve of, 48f, 49b, 49t
function of, 161-162, 163f. 163t, 164,
164f
innervation of. 152, 155, I57t, 244t-245t
law of parsimony in, 164b
paralysis of, 22, 22f, 165b, 165f
supinators
function of, 165-169, 166b
law of parsimony in, 169b
line-of-force of, 165, 166f
torque generatcd by, 166, 167f, 168b,
168f, 168-169
torque demanda of, 162, 164, 164b. 164f
force components of, normal vs. tangentiai,
69t
force couple of, 18f, 19
force generation by, 44-47. See also Force(s),
musculoskeletal.
force modulation of
by rate coding, 52, 53f
muscle fatigue and, 5 2 -5 3 , 54f
force potential of, 4 2 -4 3
force-velocity and length-tension relationships
of, 51, 51f
fusiform, 42, 42f
hand, 2)4, 214t
extri nsic
Muscle(s) (Continuer
attachments of, 245t-246t
extensors of digtts, 219f-222f, 219-220,
222t
extensors of thumb, 221, 223
flexors of digts, 214f-219f, 214-219
(lexors of thumb, 224t
innervation of, 153-156, 213
intrinsic, 224
attachments of, 246t-247t
of hypothenar eminence, 225f, 225-226
of lumbricals and interosset, 225f, 2 2 6 -
228, 227f-228f, 230t
of thenar eminence, 224-225, 2251
hip
abductor, 412t, 422-425, 423f, 424f
in gail, 423-425, 424f, 540, 540f, 548,
549f
torque-angle curve of, 427, 428f
weakness of, 425b
action of, primary and secondary, 412, 412t
adductor, 412t, 414-415, 417, 417f-419f
as internai rotators of hip, 417, 419f
in gait, 549f, 550
attachments and innervations of, 571 1573t
extensor, 412t, 417-422, 4 2 lf423f
in controlling forward lean, 420-421,
422f
in gail, 548, 549f
in performing posterior pelvic tilt, 4 1 9 -
420, 421f
in sit-up exercise, 332f, 333
line-of-force of, 41 lf, 419
overall function of, 419-422
extemal rotator, 412t, 425-426, 426f, 427f
function of, 426, 427f
in gait, 549f, 550
primary and secondar), 425
short," 4 0 lf, 42lf, 423f, 425-426
flexor. 412t, 412-414, 413f-415f, 416,
416f
contracture of, in standing, 416, 416f
function of, 413414, 414f-415f
in gait, 548, 549f
in tmnk stabilization, 330f, 330-331, 331b
innervation of, 409f-410f, 409-411
internai rotator, 412l, 417, 419f, 420f
while walking, 417, 420f
limiting motion of, 402t
lines of force of, 41 lf, 411-412, 414, 417f
maximal torque produced bv, 426-427,
427t, 428f
posterior, 4 2 lf
in force generation and transmission, 4 1 -5 5
sometric measurement of, 4 7 -4 8 , 48f, 49f
length-tension curve of
active. 45t, 4 5 -4 7 , 46f, 47f, 48f
passive, 44 -4 5 , 45f, 47, 48f
total, 47, 48f
leverage of. and torque-joint angle curve,
4 8 -4 9 , 49f, 49t
maximal torque-angle curve of, 4 7 -5 0 , 48f.
49b, 49f, 49t
knee
abnormal alignment of, 470-473
attachments and innervations of, 571 1573t
extensor, in gait, 549f, 550
flexor-rotator, 463-470
functional anatomy of, 440f-441f, 46 3 -
465
group action of, 465, 466f
maximal torque production by, 465-466,
467f, 468f
synergy with hip muscles and, 466, 468f,
468-469, 469t
innervation of, 453-454, 454t, 57lt573t
Index 589
Muscle(s) (Conlinued)
quadriceps. See also Quadriceps.
anatomy of. 455f, 455-456
function of, 454-455
function of in knee extension, 456f, 4 5 6 -
457, 458f, 459f
reinforcing knee capsule, 440t
leg
of anterior compartment, 508, 508b, 510,
510f
of lateral compartment, 510-512. 51 lb,
51 lf, 512f
of postenor compartment, 512b, 512-514,
513f515f, 515b, 516
length of
and length-tension curve, 44 -4 7 , 45f-48f,
45t
and torque-joint angle curve, 4 8 -4 9 , 49f,
49t
in force-velocity relationship, 50f, 50-51
nervous System activation of, 51-52, 52t, 53f
nonisometric activation of, electromyographic
tnterpretation of, 54
of lower extremity
attachments and innervations of, 571t-575t
nerve roots of, 570t-571t
ventral, used for testing function, 57lt
of mastication
attachments of, 383t
function of, 363f-365f, 363-365, 365t
innervation of, 362t, 383t
on mandible, 353
of trunk and craniocervical region, 314-315,
315t, 333-338
action of, 315-316, 316f
active in stabilizing attachments of, 316,
339-340, 341 f
anterior-lateral. 323-327, 324f-326f, 325t,
327b, 334l, 334-337
attachments of, 382t-383t
functional interactions among, 328-333,
329b, 338-341
influence of gravity and, 316
innervation of, 312-314, 382t-383t
internai torque of, 315, 316f
lines of force of, 315, 316f
posterior, 316-323, 318f-319f, 318t, 3 37-
338, 338t
shared actions of axial and appendicular
skeletons, 317, 317f
unilateral and bilateral activation of, 315-316
of upper extremity
attachments and innervations of, 243t-247t
nerve roots of, 242t-243l
ventral, used for testing function, 243t
of ventilation
attachments and innervation of, 384t
in expiration, 372
forced, 376f, 376-377, 377t
in inspiration, 368f, 372
accessory muscles of, 373, 375l
forced, 373, 375, 375t, 376, 376f
primar)' muscles of, 372t
quiet, 372f, 372-373
interactions among, 372-377
pennate, 42, 42f
pennation angle of, 43, 44f
role in restraining joint movement, 34
shape and structure of. 42, 42f, 43f
shoulder, attachments and innervations of,
243t-244t
spastic, 560
tension fraction of, 226, 226t
used in lifting, 343f
additional sources of extension torque used
in, 346t, 346-347
 590 Index
Muscle(s) (Continued)
estimatton of force magnitude in, 342-344,
343b, 344f
mcreasing imra-abdominal pressure during,
345-347
iechniques of, 347-348, 348f
safety factors in, 348-349, 349l
ways of reducing force used in, 344-345,
345b, 345f
viscosty of, 45
work of, 21
wrist, 186-192
action and torque potenttal of, 186-187,
187f
auachments of, 245t
cross-secttonal area of, 186, 186t, 1871'
extensors, 187f-189f, 187-189
in makinga fisi, 188f-189f, 188-189
flexors, 189-191, 190f, 1911
innervation of, 186, 245t
joim interaction with, 186-192
Muscle fattgue, 52-53, 54f
centrai, 52 -5 3 , 54f
peripheral, 53, 54f
Muscle fibers
activation of, 51-52, 52t
components of, 45t, 4 5 -4 6 , 46f
fatigue of, 52 -5 3 , 54f
ideal resting length of, 46
in active force generation, 4 6 -4 7 , 47f
twitch responses of, 52, 53f
Muscle twitch, in force modulation of muscle
52, 53f
Musculocutaneous nerve, of elbow and forearm,
152, 153f
Muybridge, in gai! analysis, 525
Mylohyoid, auachments and innervation of,
383t
Myofbrils, structure of, 45, 46f
Myofilaments, structure of, 45, 46f
N in trunk movemem, 329i
Navicular bone, 174, 174f. See Iso Scaphoid,
osteologie features of, 479b, 480f-481f, 481
Neck
extension of, erector spinae muscle action in
319f, 320
in axial rotation in craniocervical region, 340-
341, 342f
vertebrae of, osteologie features of, 262, 262f,
2631, 264, 264f, 266t, 267f
Nerve(s). See alno names of specifc nerves, e.g.,
Ulnar nerve.
of muscles of ankle and foot, 506-507, 509i
of muscles of elbow and forearm complex,
151-152, 153f-156f
of muscles of hip
lumbar plexus of, 409f-410f, 409-411
sacrai plexus of, 410f, 411
scnsory, 411
of muscles of knee, 453-454, 454t
of muscles of mastication, 362t
of muscles of irunk and craniocervical regions,
312-314
of synovial joints, sensory, 26f, 27
Nerve roots
of lower extremity muscles, 570t-571t
of spinai nerves, 312, 312f
of upper extremity muscles, 242t-243t
ventral
of muscles of lower extremity used for test-
ing function, 57 lt
of muscles of upper extremity used for test-
ing function, 243t
Nervous System, as controller of muscle force, Osteoarthritis (Continued)
5 0 -5 2 , 52t, 53f total hip arthroplastv for, 431, 432f
Neurologie disease, abnormal gait pauern wilh of knee, 462b, 462f
560, 563 unicompartmental, genu varum with, 470f
Newton's laws 471
first (law of inertta), 57b-60b, 57-58, 59f Osteoclasts, in bone, 36
60f Osteokinematics, 5 -8 , 6f, 6t, 7f
in movemeni analysis, 56-63, 57t perspectives in, 7f, 7 - 8
in solving problems in biomechanics, 7 6 -7 7 Osteon System, 36
linear and rotational components of, 57t Osteophyte(s)
second (law of acclerauon), 11, 58b, 58-62 cervical, 265b, 265f
61 f, 62b. 621 craniocervical hyperextension and, 283b, 2831
physical measuremenis associated with, 62t in hallux rigidus, 504
third (law of action-reaction), 6 2 -6 3 , 63f, 551 Osteoporosis, of thoraeic spine, kyphosis wilh,
Nuchal line, superior and inferior, 253, 254f 288-290, 291f
Nucleus pulposus, 273-275, 274f, 275f, 276b Osteoiomy, coxa vara, 431, 432f
hemiated, 296b-297b, 296f, 296t
factors favoring, 297b
lypes of, 296f, 296t
pressure measurements on, 275, 275f P
Nutation, 306, 306b Pam
Nutation torque, 307, 307f abnormal gait pattern with, 560
low-back, 300-301
causes of, 296b
exercises for, 302b
0 herntated disc and, 296b
Oblique cord, of interosseous membrane of fore with lifting, 342
arm, 142, 143, 143f, 144f of heel, 562t
Obliquus capitis of hip, 528f, 566t, 567f, 568f
inferior, 339b, 340f of knee, 462b, 462f
supertor, 339b, 340f Palmar inierossei, auachments and innervation
Obliquus capitis inferior and superior, auach- of, 247t
menis and innervation of, 383t Palmaris brevis, 225f, 225-226
Obliquus extemus abdominis, 323, 324f, 325 auachments and innervation of, 247t
as extrmsic trunk stabilizer, 330f, 330-331 Palmaris longus
33 lb anatomy and function of, 189-190, 1901"
attachments and mnervattons of, 325t, 382t aitachments and innervation of, 245l
in trunk movement, 329t Paraplegia, iliofemoral ligament strength and,
line of force of, and muscle action, 315, 316f 401, 402f
Obliquus internus abdominis, 323, 324f, 325 Parkinsons disease, abnormal gait pauern with
as extrinsic trunk stabilizer, 330f, 330-331 528f, 560, 563
33 lb Pars articularis, fracture of, anterior spondylolis-
attachments and innervation of, 325t thesis and, 294b, 294f
Patella
Ohturator extemus excessive iracking of. 462, 464t, 465b
anaiomy and action of, 401f, 413f, 426 knee exlension leverage and, 456, 456f
attachments and innervation of, 572t osteologie features of, 437, 437b, 437f-438f
Ohturator internus path and contact area on femur, 446-447, 448f
anatomy and action of, 423f, 426, 426f Patelleciomy, 457b, 457f
aiiachmenis of, 572t Patellofemoral joint, 437
innervation of, 410f, 411, 572l compression forces on. 457, 460, 460b, 461 f
Obturator membrane, 390, 39 lf forces applied lo, in gait, 561 1
Obturaior nerve, muscles mnervated by, al hip,
409f, 409-411
kinemarics of, 446-447, 448f
pain in, causes of, 462b, 462f
Occipital bones, 253, 253f tracking of in knee extension, 460-463, 463f
Occipital condyles, 253 464f, 464t, 465b
Occipital proiuberance, extemal, 253, 253f Pectineal line, 391f, 392, 394, 395f
Odontoid process, of axis, 264, 267f Pectineus
Olecranon fossa, 135 anaiomy and action of, 414, 418f
Olecranon process, 135, 136f, 137f attachmenis and innervation of, 572t
Omohyoid, auachments of, 384t Pectoralis major
Opponens digiti minimi, 225f, 225-226 action of, 375l
attachments and innervation of, 246t-247t auachments of, 244t
Opponens pollicis, 224, 225f in internai rotation of shoulder, 131-132, 132f
attachments and innervation of, 247i innervation of, 244i, 375t
Opioelectronics, for collection of kinemaiic data sternocostal head of, in shoulder adduction
83
and extension, 129-130, 130f
Orthoses, foci, for control of excessive prona- Pectoralis minor
tion, 50lb action of, 375t
Osteoarthritis.See also Rheumaioid arthritis. auachments of, 244t
amcular camlage damage in, 38
in scapulothoracic joint depression, 121, 1211
manifestations of, 38 122f
of hip, 428b, 428-429 innervation of, 244t, 375i
causes of, 428b Pedicle
coxa vara or coxa valga with, 431-432 of cervical vertebrae, 264, 266f
432f, 433f sacrai, 269, 27tf

Pelvic ring, 303-304, 304f
stress relief at, 307
Pelvic tilt
anterior
hip flexor funclion in, 413-414, 4141
muscular force couple in, 181
axis of rotation for, 299
effect of on lumbar spine, 299-301, 3001, 4151
in gait, 535-537, 5361
vvith limited hip motion, 537, 5371, 538b
in hip rotation, 406, 407f, 408
lumbar extensor muscte action in, 320-321
posterior
hip extensor function in, 419-420, 42 lf
hip flexor function in, 414, 4151
Pelvic-on-femoral hip motion, 403
hip flexor function in, 413-414, 4141
in hip abduction, 424
in hip extension, 419-421, 4211, 4221
in hip rotation. 4041, 406f, 406-408, 4071
hip extemal rotators in, 426, 4271
in frontal piane, on support hip, 4071, 408
in sagittal piane, pelvic tilt in, 406, 4071,
408
Pelvis, 390, 39013921
impairment of, abnormal gali pattern al hip/
pelvis/trunk with, 566t, 567f, 5681
motion of, in gait, 535-537, 5361, 538b
in frontal piane, 5391, 539540
in horizoncal piane, 542, 542f, 544b
Perimysium, in muscle, 42, 431
Peroneal nerve, common, 506, 5081
dcep and superfcial branches of, 506-507,
508f
injury to, 516-517, 518t
Peroneus brevis
anatomy and function of, 510-512, 51 11
attachments and innervation of, 573t
in gait, 5491, 551
maximal torque potential of al ankle, 514,
516l
Peroneus longus
action of, on tiptoes, 512, 5121
anatomy and funclion of, 510-512, 5111,
5121
attachments and innervation of, 573t
in gait, 549f, 551
maximal torque potential of at ankle, 514,
516t
paralysis of, 511-512
Peroneus tertius
anatomy and function of, 508, 510, 5101
attachments and innervation of, 573t
innervation of, 507, 5081
Pes anserinus, 439, 440t, 4411
functional anatomy of, 463-464
Pes calcaneus, 518, 518t
gait deviations with, 562t
Pes cavus, 497-498, 4981
gait deviations with, 562t
Pes equinovarus
gait deviations with, 562t
mjury lo common peroneal nerve and, 517,
518t
Pes equinus
gait deviations wilh, 539, 562t
injury to common peroneal nerve and, 516
517, 518l
Pes planus, 497, 4971
decreased windlass effect in, 506, 5061
flexible, 497
gait deviations with, 562t
rigid, 497, 4971
Pes varus, peroneal nerve injury and, 518,
518t
Phalanges. 5ee also Melacarpophalangeal joint(s);
Metatarsophalangeal joint(s).
of foot, osteologie features of, 4801, 4811, 482
of hand
morphology of, 196, 1981- 199f
osteologie features of, 196, 196b, 198f-
1991
Photography, for colleciion of kinematic data, 83
Physiology, defrrition of, 3
Pinch
muscular biomechanics in, 229, 2291
types of, 234-235, 2351-2361
Piriformis
anatomy and action of, 4131, 423f, 425-426
attachments of, 572t
innervation of, 411, 572t
Piriformis syndrome, 426
Pisiform, 1741, 1751. 175-176
Piane joints, 273
Piantar fascia
forces applied to, in gait, 5611
of mediai longitudinal arch, 496, 497
wmdlass effect on, 506, 506f
Piantar flexion
ankle, acceleration of by acttve piantar flexion
of foot, 514, 516f
delnition of. 482, 482f, 483t
extreme, ankle injury from, 489b
knee extension with, 515b, 515f
of lalocrural pini, 186-488, 4871, 514
of transverse tarsal joint, 493, 495f
used to decelerate ankle dorsiflexion, 514
Piantar mierossei, attachments and inneivation
of, 575l
Piantar nerve
lateral, 507, 509f
mediai, 507, 509f
Piantar piate, of metatarsophalangeal joints, 504,
504f
Plantaris
action and innervation of at knee, 454t
anatomy and function of, 512, 513f, 514
attachments of, 573t
innervation of, 454t, 573t
Piate
palmar, of metacarpophalangeal joints, 208,
208f
piantar, of metatarsophalangeal joints, 504,
504f
pterygoid, of sphenotd bone, 355, 355f
Plicae, of knee, 439, 442b
Poliomyelitis, pes cavus and, 498
Popliteus
action of al knee, 454t
attachments of, 572t
functional anatomy of, 4 4 lf, 464-465, 465b
innervation of, 454t, 572t
internai rotator function of, 465b
Posterior dravver test, of posterior cruciate liga-
menl, 451, 452f
Postglenoid tubercle, of temporal bone, 354f,
355
Posture
abnormal
in thoracic spine, 288-292
kyphosis development and, 288-290, 291f
types of, 259f, 260f
in static stability of glenohumeral joint, 111
sitting. See Sitting posture,
vertebra! coiumn curvature and, 256, 2591
260f
Power, in work-energy relationship, 61 -6 2 ,
62b
Power gnp, 234-235, 2351-2361
Power (key) pinch, 234-235, 23.5f-236f
Index 591
Preciston grip, 234235, 235f-236f
Precision pinch, 234-235, 235f-236f
Prestyloid recess, 175f, 178
Process
coracoid, 97, 971
coronoid, 135, 1361', 137f, 353, 353f
mamillary, of lumbar vertebrae, 268, 269f
mastoid, 253, 2531, 352, 3531
odontoid, of axis, 264, 267f
olecranon, 135, 136f, I37f
sacrai articular, 269, 2 7 lf
spinous, 269, 272f
stylotd
ofradius, 136f, 137, 137f
of temporal bone. 354f, 355
of ulna, 136, 136f, 137f
temporal, of zygomatic bone, 354f, 355
transverse, 269, 272f
uncinate, 264, 2641, 266f
zygomatic, of temporal bone, 354f, 355
Productivc antagonism, between opposing mus-
cles, 14, 14f
Pronation
at radioulnar joints, 149, 1501
restriction of, 149-150, 150f, 150t
with weight-bearing, 150-151, 151f, 152t
kinematic mechamsms of, in early stance
phase, 499-501, 500f. 500t, 501b
of foot and ankle, delnition of, 482f, 4 8 2 -
483, 483l
of forearm, 145f, 145-149
as spin movement, lOf
innervation of, 152, 157t
of subtalar joint, 490, 490f, 49 lb
of transverse tarsal joint, 491, 492f, 493, 4941,
496
Pronator quadratus
attachments and innervation of, 245t
dual role in distai radioulnar joint, 170, 170f
vs. pronator teres, 169-170
Pronator teres
attachments and innervation of, 245t
biomechanical and structural variables of, 157t
vs. pronator quadratus, 169-170
Prosthetic design, mass moment of inertia and,
60b
Proteoglycans, in nucleus pulposus, 273, 276b
Psoas major
anatomy and action of, 412, 413f
as extrinsic trunk stabihzer, 330f, 330-331,
331b
attachments and innervation of, 572t
in gait, 548, 549f
in trunk movement, 327-328, 328b, 3281,
329t
lines of force of, 328, 328f
Psoas minor
anatomy and action of, 412, 413f
attachments and innervation of, 572t
Pterygoid muscles
attachments and innervation of, 383t
lateral
anatomy and function of, 364f, 364-365,
365t
inferior head of, 366, 367f
supenor head of, 366, 367b, 367f
mediai
anatomy and function of, 364, 364b, 364f,
365t, 366, 3671'
interaction with masseter, 363f, 364b
Pterygoid piate, mediai and lateral, of sphenoid
bone, 355, 3551
Pttbic ramus
inferior, 39 lf, 393
superior, 39lf, 392
 592 Index
Pubic symphysis joim, 3911. 393
Pubic tubercle, 391f, 392
Pubis, osteologie features of, 391f, 392b. 3 9 2 -
393
Pulled elbow syndrome, 147, 147f
Pulmonary dtsease, chronic obstructive, 373,
375-376
Push-off, 531, 531 f, 531t
Push-up maneuver, serratus anterior action in,
123b
Q 146, 1461
Q angle, 461-462, 4641, 501
Quadrate tubercle, 394, 3951
Quadratus lemoris
attachments ol, 572t
mnervaton ol, 4101, 411, 572t
Quadratus lumborum
action ol, 375l
as extrinsic trunk stabilizer, 3301, 330-331,
331b
attachments of, 383t
in trunk movement, 328, 328b, 3281, 329t
innervation of, 375t, 383l
Quadratus plantae
anatomy and function of, 519, 5191
attachments and innervation of, 574t
Quadriceps
action and innervation of, 453-454, 454t
anatomy of. 4551, 455-456
cruciate ligament changes and, 451, 452f,
453b
forces in, and patellofemoral joint kinetics,
457, 4571, 460, 4611, 462, 463f
function of, 454-455
in gait, 5491, 550, 564t, 5651
in patellectomy, 4571
lines of force of, 455f, 461, 4641
maximal knee torque produced by, 4551
strengthening exercises for, 453b, 456-457,
4581, 459f
torque potenual of
extemal, 456, 458f
internai, 456-457, 4591
patellar augmentation of, 456, 4561
weakness of
abnormal gait pattern ai knee with, 564t,
5651
extensor lag with, 460b
Quadriplegia
elbow extensor paralysis in, 165b, 1651
reverse contraction of elbow flexors in, 162b,
162f
tenodesis action of finger flexors in, 219,
2191
Radiai deviation, of wrist. 179-180, 180f, 182-
184, 18311841, 184b, 191, 191f, 191t
Radiai fossa, 134, 134f
Radiai nerve
of elbow and forearm, 152. 1541
deep and superlicial branches of, 152, 1541
of hand, 213
of wrist, muscles innervated by, 186
Radiai notch, of ulna, 135, 1361
Radiculopathy, 2381, 283b
Radtocarpal joint, 173f, 176-177, 1771
as ellipsoid joint, 28, 29f
in ulnar translocation of carpus, 185, 1861
movements of
flexion and extension, 1811-1821, 181-182
ulttar and radiai deviation, 182-184, 1831
184f, 184b
Radiography, for measurements of vertebral col-
umn motion, 277b
Radioulnar joint
distai, 133-134, 134f, 1451, 145-146, 146,
1481
pronation and supination at, 1491-15H,
149-151, 152t
sensory tnnert'ation of, 157
stabilizers of, 146, 147b
periarticular connective tissue of, 146, 1461,
1481
proximal, 133-134, 1341, 1451, 145-146,
as pivot joint, 28, 281
dislocation of, 147, 1471
pronation and supination at, 1491-15U,
149-151, 152t
pulled elbow syndrome of, 147, 1471
sensory innervation of, 156-157
structure of, 146, 1461
Radtus
distai
articular surface of, 172-173
osteology of, 172-173, 1731, 1741
head of, 1361, 137
osteology of, 1361, 136-137, 137b, 137f
palmar tilt of, 173, 1741
styloid process of, 172
ulnar tilt of, 1741
Rays
of feet, 4801-48 If, 482
of hand, 195, 195b, 1991
Rearfoot.See also Subtalar joint.
actions of during stance phase of gait, 507t
defmition of, 478
Rearfoot varus, 501
gait deviations with, 562t
Rectus abdomints, 323, 3241, 325
as extrinsic trunk stabilizer, 3301, 330-331
331b
attachments and innervations of, 382l
in gait, 5491, 551
in trunk movement, 329t
Rectus capitis
antenor, 3361, 336-337, 339b, 3401
attachments and innervation ol, 382t
lateral, 336f, 336-337, 339b, 3401
attachments and innervation of, 382i
posterior, 339b, 340f
attachments and innervation of, 383t
Rectus femoris, 455
anatomy and action of, 413, 4131
auachments and innervation of, 573t
in atypical movement combinations between
hip and knee, 469f, 469-470
in gait, 548, 5491
in hip and knee extension, 469, 469t
Rectus shealh, formation of, 323, 325, 3251
Recurrent mentngeal nerve, axial skeletal tissues
innervated by, 313, 313f
Rheumatold arthritis, 38
joint deformtties due to, 236-240, 2371-
2391
boutonniere deformity as, 237f 239240
2401
palmar dislocation of metacarpophalangeal
joint as, 237, 2381
swan-neck deformity as, 2371, 238-239
2401
ulnar drift at metacarpophalangeal joint as,
237, 239f
zig-zag deformity of fngere as, 238-240
zig-zag deformity of thumb as, 236, 2371
Rhombotds
action of, 120f, 120-121, 317, 317f
attachments and innervation of, 244i
Ribs
at costovenebral joints, 265, 2671
in ventilation, 371, 3711
structure of, 253-254, 256f. 2571
Rtght-hand rule, 67, 86
Roll-and-slide movements
of glenohumeral joint, 113, 113f, 115, 1151,
1161
of joints, 8t, 8 -1 0 , 9f, 101
with spin, 10, lOf
of wrist, 181-182, 182f-184f
Rotatton
of acromtoclavicular joint, 104, 1051
of clavicle, 1011-1021, 102
of forearm, 145f, 145-146
of glenohumeral joint, 1121, 1151, 115-116,
116t, 131-132, 132f
of hip, internai and extemal, 4071, 4081, 408-
409
of scapulothoracic joint, upward and down-
ward. 99, 991, 106, 1071. 124-127
125b, 1251. 1261
screw-home, of knee, 445-446, 4461, 4471,
448, 4491
vs. translation, 4 -5 , 51, 5t
Rotator culi muscles, 107, 108b, 109-110, 1101
in chronic impingement syndrome at shoul-
der, 114b, 1141
in elevation of arm, 1271-128f, 127-129.
128b, 129b
in shoulder adduction and extension, 129-
130
in stabilizing glenohumeral joint, 128-129,
129b
in stabilizing humeral head, 1151, 116b
Rotator culi syndrome, 129b
Rotatores
anatomy and action of, 3211, 32 lt, 321-323,
329t
attachments and innervation of, 38lt
Running
gait speed in, 530-531
hip-and-knee flexion-extension in, muscle syn-
ergy in, 466, 4681, 468-469
knee flexor-rotator muscle interaction in, 465
4661
s
Sacrai canal, 269, 271f
Sacrai plexus, innervating muscles of hip and
lower limb, 4101, 411, 41 Ib
Sacrai promontory, 269, 2711
Sacrococcygeal joint, 269
Sacrohorizontal angle, anterior spondylolisthests
and, 294b
Sacroiliac joint, 303-308
anatomy of, 303-306, 3041-306f
funetional considerations with, 3071, 307-308
ligamentous support of, 304-305, 3051
motion of, 306, 306b, 3061
stability of
muscular reinforcement of, 3071, 308, 308t
nutation torque and, 307, 3071
structure of, 3041, 304-305, 305f
Sacrum
anatomy of, 293, 2931
vertebrae of, osteologie features of, 263t, 269
271 f
Saddle jotnt(s), 28, 30, 301
complex, 198, 200, 202, 2031, 2041
Sagittal piane, 5, 61, 6t
Sarcomere
active length-tension curve of, 4 6 -4 7 , 47f
banding pattern of, 45t, 4 5 -4 6
ideal resting length of, 46
 Index 593

Sartorius
anatomy and action of, 412, 413f, 4411, 454t
Serratus anterior Sil-up exercise(Cimtinuecl)
action of, 317, 317f, 375t diagonal, 3261
463 attachments of, 244t trunk muscles active in, 331 f, 331-333,
attachments and innervation of, 454t, 573t in push-up maneuver, 123b 3321
in gau, 548, 549f in scapulothoracic joint protraction, 122, 123f Sliding filament hypothesis, of active force gener
Scalene muscles, anatomy and action of, 336, in scapulothoracic upward rotation, 125f, ation, 4 6 -4 7
336f, 339b, 372t, 373 125-126, 126f Slipped capitai femoral epiphysis, 432
Scalenus anterior, attachments and innervation innervation of, 244t, 375t Snuflbox, anatomie, of thumb, 221, 223f
of, 382t kinesiologic importante of, 127 Soleus
Scalenus medius, attachments and innervation of, paralysis of, 126f, 126-127 anatomy and function of, 512, 513f, 514,
3821 Serratus posterior 5151
Scalenus posterior, attachments and innervation inferior, 3761 attachments and innervation of, 574t
of, 382t action and innervation of, 317, 317f, 375t, in gait, 5491, 550
Scaphoid, 174, 174f-175f, 199f 376f, 384t in stabilizing knee in extension, 515b, 5151
fracture of, 174, 185, 185f attachments of, 384t maximal torque potential of at ankle, 514,
in carpai instability, 174, 185, I85f superior 516t
in opposition of thurnb, 205 action and innervation of, 317, 317f, 375t, paralysis of, 517-518, 518t
in ulnar and radiai deviation of wrist, 183b 376f, 384t Sphenoid bone, 355, 355b, 3551
183f attachments of, 384t Sphenomandibular ligament, of temporomandib-
Scapholunate ligament, in carpai instability, 179, Sesamoid bones, of first metatarsophalangeal ular joint, 358, 3581
185, 185f joint, 504, 504f Spinai accessory nerve, paralysis of upper trape
Scapula Shear forces, 12f zius and, 120b
osteologie features of, 94, 96b, 96f, 9 6 -9 7 , anterior-posterior Spinai cord
97f anterior spondylolislhesis and, 294b cross section of, 2541
winging of, 126f, 126-127 cruciale ligaments and, 449 in cauda equina, 270b, 2701
Scapular piane, 97 at apophyseal joints, 272t injury of, paradoxical breathing after, 374b
Scapulothoracic joint, 98, 104-106, 1061- on lumbar interbody joints, 293, 293f Spinai coupling, 273b
107f Sheath(s) Spinai nerve(s), 312
movement at, 99b, 99f, 9 9-100, 105-106, digitai synovial, 215f, 217 cervical nerve roots of, 254f
106f-107f fibrous digitai, 215f, 217 dorsal rami of. 312
muscles of, 120f-124f, 120-122 of metacarpophalangeal joints, 208, 208f cutaneous distribution of, 3141
as depressors, 99, 99f, 105, 106f, 121, Shin splints, in gait, 551 segmentai innervation of, 312, 314, 314t
121f, 122f Short segmentai muscles mixed, structure of, 312, 312f
as elevators, 120f, 120-121, 317, 317f as intrinsic trunk stabilizers, 329-330, 330b, ventral rami of, 312-314, 3131
as protractors, 122, 123f 330f of lower extremity muscles used for lesting
as retractors, 122, 124f attachments of, 381t function, 571t
as rotators, 122 innervations of, 382t of upper extremity muscles used for lesting
upper trapezius paralysis and, 120b of deep layer of back, 317, 318t, 321f, 323 function, 243t
upward rotation ai, 116-117, 117f, 118f, Shoulder complex, 93-132. See ako Clavicle; plexus of, 312, 3131
119t, 124-127, 125b, 125f, 126f Humerus; Rib; Scapula; Stemum segmentai nerves of, 3131, 313-314
Scheuermann disease, 288 abduction of Spinalis cervicis, attachments and innervation of,
Sciatic foramen, Iesser, 393 acromioclavicular joint interaction during, 381t
Sciatic nerve 116-117, 118f, 119t Spinalis muscles
branches of, in comparttnents of leg, 506 scapulohumeral rhyihm in, 116, 117f anatomy and actions of, 318t, 3191, 319-321
in piriformis syndrome, 426 scapulothoracic upward rotation in, 124- in trunk movement, 329t
muscles innervated by, at hip, 41 Of, 411 127, 125b, 125f, 126f Spinalis thoracis, attachments and innervation of,
tibial portion of, 454, 454t stemoclavicular joint interaction during, 3811
Sciatic notch 116-117, 118f, 119t Spinous process, 269, 2721
greater, 391, 392f adduction and extension of, 129-130, 130f, Splenius capitis, 339b
Iesser, 392f, 393 131b anatomy and action of, 337-338, 3381, 339b
Scoliosis, of thoractc spine. 290, 292, 292f arthology of, 98-1 1 7 attachments and innervation of, 383t
Screw-home rotation, of knee. 445-446, 446f, chronic impingemem syndrome at, 114b, Splenius cervicis, 339b
447f 114f, 127 anatomy and action of, 337-338, 338f, 339b
knee ligaments in, 448, 449f definition of, 93, 94f atlachments and innervation of, 383t
Semmembranosus in anatomie posiiion, 95f Spondylolisthesis, anterior, of lumbar spine,
action of at knee, 454t internai and exlemal rotation of, 131-132 294b, 2941
attachments of, 573t 132f Sport equipment, impulse-momentum relation-
functional anatomy of, 440f-441f, 463 isometric torque at, of (lexors and abductors, ship and, 60
innervation of, 454t, 573t 125t Squat lift, 348, 348f
Semispinalis capitis, 321f-322f, 322 joints of, innervation of, 117, 119, 119f Squat position, extemal torque at knee in, 74b,
attachments and innervation of, 381 1 motion of, in gait, 543-544 741, 460, 4611
Semispinalis cervicis, 32 lf, 322
attachments and innervation of, 38 lt
muscles of, 93 Stance phase. See Gait, phases of, stancc.
action of, 119-120 Standing
Semispinalis muscles attachments of, 243t-244t compression forces on foot during, 496b
anatomy and action of, 321f-322f, 3 2 lt, in triceps paralysis, 165, 165f effect of hip flexor contracture on, 416, 4161
321-323 innervation of, 117, 119, 1191, 243t-244t mediai longitudinal arch function during,
in trunk movement, 329t osteology of, 9 3 -9 8 , 94f-99f 496-497, 497f
Semispinalis thoracis, 32lf, 322 sensory innervation of, 119 normal joint reaction forces through knee in,
attachments and innervation of, 38 lt Sitting posture 470f, 470-471
Semitendinosus effect on alignment of lumbar and craniocervi- Static rotary equilibnum, 16, 161
action of at knee, 454t cai regions, 301-302, 3021 Step, 527, 5271
attachments of, 573t hermated disc and, 297b Step length, 527, 5271
functional anatomy of, 440f-441f, 463 poor, 30 lb impaired, 528f
in hip and knee extension in running, 468, Sit-up exercise normal, 529t
468f, 469, 469t abdominal muscle action in, 331-333, 332f Step rate, 528
innervation of, 454i. 573t 3331 normal, 529t
 594 Index
Stop me, 528
btep width, 527, 527f
Sternoclavicular joint, 98, 254, 257f
connective tissue of, 101
generai feaiures of, 1001, 100-101
in movement of scapulothoracic joint, 105-
106
in shoulder motion during abduction, 116-
117, 118f, 119t
kinematics of, 101 b, 101 f102f, 101-102
sensory innervation of, 119
scabilily of, upper trapezius paralvsis and,
120b
Sternocleidomastoid
action of, 375t
anatomy and action of, 334-335, 335f, 339b
375t
attachments of, 382t
in torticollis, 335b, 335f
innervation of, 375t, 382t
Sternocostal joint, 254, 2571, 370, 370f
Stertohyoid, attachments and innervation of
384t
Sternothyroid, attachments and innervation of,
3841
Stemum
elevation and depressioti of, during ventila-
lion, 371, 371 f
osteologie features of, 9 3 -9 4 , 94b, 94f, 254
254b, 256, 257f
Stiffness, in ligament, 12, 13f
Stoop lift, 347-348, 348f
Straight-leg raise, abdominal muscle action in,
415f
Strain, in connective tissue, 12, 13f
Stress, in connective tissue, 12, 13f
Stress fracture, and high mediai longitudinal
arch, 498b
Stride, 527, 527f
Stride length, 527, 527f
Stylohyoid, attachments and innervation of,
383t
Styloid process
of radius, 136f, 137, 137f
of temporal bone, 354f, 355
of ulna, 136, 136f, 137f
Stylomandibular ligament, of lemporomandibular
joint, 358, 358f
Subacromial bursa. 111, 11 lf
Subacrormal space, 111, 11 lf
at glenohumeral joint, 108b, 108f
in chronic impingement syndrome at shoul
der, 114b, 114f
Subclavius, in depression of scapulothoracic
joint, 121, 121f, 122f
Subdeltoid bursa, 111 f, 111-112
Suboccipital muscles, anatomy and action of
338, 338f
Subscapulans, 109-110, llOf
attachments and innervation of, 244t
humeral head stabilization and, 115f, 116b
in elevation of arm, 127f1281 127-128
129b
in interna! rotation of shoulder 131-132
132f
Subtalar joint.See also Rearfoot.
and stability of foot, 491b
close-packed and loose-packed position of
491b
eversion and mversion of, 489b
in pronation and supination of foot, 493
494f, 499-502, 514
kmematics of, 490, 490f, 491 1, 492b
in gait, 541, 541f-542f, 543, 544b, 544f
in early stance phase, 499-501, 500f
500t, 50 lb
Subtalar joint fCotuinued) Talocrural joint (Continued)
in mid to late stance phase, 501-502, stabilization of, in stance phase, 488f 4 88-
502f 489
ligaments of, 481f, 484f-485f, 489-490 in standing on tiptoe, 517b, 517f
muscles Crossing, muscle action and, 508, joint kinematics of, 486-488, 4871
510f ligaments of, 484-486, 4851', 4861
range of motion of, 490, 4 9 lt, 492b muscles Crossing, muscle action and, 508,
relaiion lo transverse tarsal joint, 491, 4 9 8 - 510f
502 osteokinematics of, 486, 487f
structure of, 4 8 lf, 489 piantar (lexion of, 486-488, 487f, 514
Subtalar joint neutral, 492b sensory innervation of, 507, 5081
Sulcus structure of, 484, 484f
of calcaneus, 480f481 f, 481 Talonavicuar joint. See also Tarsal joint, trans
of talus, 480, 4 8 lf verse.
Suptnation, of forearm, 147-149 articular and ligamentous structure of 4 9 1 -
innervation of, 152, 155, I57t 492, 493f
Supinator, aitachments and innervation of, 245l Talonavicuar ligament, dorsal, 485f, 492
Supinalor crest, of ulna, 135, 136f, 137f Talus, osteologie features of, 479b, 479-481
Supinator muscle, as supinator muscle of fore 480f-481f
arm, 165-166, 166f, 167f Tarsal bones, osteologie features of, 479b, 4 7 9 -
Supracondylar line, 394, 394f 481, 480f-481f
Supracondylar ridge, 135 Tarsal joint, transverse, 491-498, 4921-4981
Suprahyoid articular and ligamentous structure of, 4 9 1 -
attachments and innervation of, 383t 493, 4931
in mastication, 365, 365f, 365t in pronation and supination of foot, 493, 494f
in opening of mouth, 366, 367f kinematics of, 493-496, 494f, 495f
Supraspinatus, 109-110, llOf range of motion at, 494, 496
aitachments and inncrvtion of, 244t subtalar joint movement and, 491, 493, 494f
excessive wear of, 129b 498-502
in arm elevation at glenohumeral joint, 123 supination of, 514
124, 124f, 125t, 127f-128f, 127-128 Tarsal tunnel, 513, 515f
129b Tarsal tunnel syndrome, 513
in arthrokinematics of glenohumeral joini, Tarsometatarsal joint
128-129, 129b anatomy and kinematic mechamsms of, 503,
In kinematics of glenohumeral joint, 112, 503f
112 f - 113f first, 503, 503f
>n static stability of glenohumeral joint, 111 in gait, 539
Surgery, for correction of hip disease, 43 I f- Tectonal membrane, 279, 280f
433f, 431-432 Teeth, functions and structural characteristics of
Sustentaculum talus, 481 353f, 355-356, 356f, 356t
Swan-neck deformity, of fingers, 238-239, 240f
Temporal bones, 253, 253f, 354f, 354-355
Synarthrosis, 483 355b
definition of, 25 Temporal fossa, 352, 353f
function of, 25 Temporal process, of zygomatic bone, 354f, 355
Synovial cavity, of temporomandibular joint, 356 Temporalis
Synovial fluid, 26, 26f anatomy and function of, 363f, 363-364
Synovial joint(s) 365l
classifcation of attachments and innervation of, 383t
by mcchanical analogy, 27t, 2 7 -2 8 28f- in closing of mouth, 366, 367f
30f, 30 Temporomandibular joint(s)
of ovoid and saddle joints, 30, 30f arthrokinematics of, 359f, 360-362
definition and function of, 26f, 2 6 -2 7 bones of, 352-356
elementi associated with, 26f, 26-27
capsular and ligamentous stmetures of 357-
Synovial membrane, 26, 26f 360
of anicular capsule of elbow, 138, 139f
condyle-disc complex of
of glenohumeral joint, 107, 107f internai derangement of, 361, 361f
of hip capsule, 399
lateral pterygoid action and, 367b, 367f
of humeroulnar joini, 142f
translational movement of, 359, 360, 362
of knee, 439, 442t
disorders of, 367, 368b
Synovial plicae, definition and function of, 27 and head position, 366b, 366f
Synovial sheath
nonsurgical treatments for, 368b
radiai, 216, 217
innervation of, 362t, 362-363
ulnar, 216f, 216-217
muscles of, 362t, 362-366, 363f-365f, 365t
Synovialis patellaris, 442b
osseous structure of, 356-360
Synovitis, chronic, joint deformities due to 2 3 6 -
240. 237f-239f
osteokinematics of, 358-360, 359f, 360f
regional surface anatomy of, 352, 353f
structure and function of, 356, 357f
Tendon(s)
T
Achilles, forces applied to in gait, 561i
Talocrural joint, 479f
bowstringing of, with flexor pulley rupture
dorsiflexion of, 486-487, 487f 217, 217f
in gait
collagen fibers in, 32
compression forces on, in stance phase fibrous organization of, 34, 34f
488f, 488-489
forces applied to, in gait, 558-559, 561t
forces applied to, 56lt
mechanical properties of, 44, 44f
joint kinematics at, 491t, 536f, 538-541 of diaphragm, 372, 372f

Tendon(s) (Continuo#
of digitai extensor mechanism, 220, 221,
221f-222f, 222t, 223, 223f
of erector spinae muscles, 319, 319f, 319t
of extensor digitorum longus, 508, 51 Of
of extensor hallucis longus, 508, 510f
of extensor muscles
of index finger, 22 lf
of thumb, 221, 223, 223f
of wrist, 188, 188f
of flexor digitorum longus. 51 lf, 513-514,
515f
of flexor hallucis longus, 484f, 513
of flexor muscles of wrist, 189-190, 190f
of hand, 215, 215f
of iliopsoas, 412
of patella, forces applied to in gail, 561t
of peroneus brevis, 511, 51 lf
of peroneus longus, 510, 51 lf
of peroneus lertius, 508, 510f
of piantar flexor muscles, 512-514
of popliteus, 440f, 444f
stabilizing proximal tibiofibular joint, 483b
of quadriceps, 460, 461 f
of tibialis anterior, 508, 510f
of tibialis posterior, 51 lf, 513-514, 515f
Tennis elbow, 189
Tenodesis action, of finger flexors, 218f, 218
219
in quadriplegia, 219, 2I9f
Tension
as musculoskeletal force, 12f
in connective tissue, conversion to useful
work, 14, 14f
Tensor fascia lata
anatomy and action of, 413, 413f, 420f, 423,
423f
attachments and innervation of, 573t
in gait, 548, 549f
Teres major
attachments and innervation of, 244t
in shoulder adduction and extension, 129-
130, 130f
in shoulder internai rotation, 131-132, 132f
Teres minor, 109-110, llOf
attachments and innervation of, 244t
in elevation of ami, 127f128f, 127-128,
129b
in shoulder adduction and extension, 129
130, 130f
in shoulder external rotation, 132
Tetanization, of musclc fibers, 52, 53f
Thenar crease, of hand, 195, I97f
Thenar eminence. See aho Thumb.
muscles of, 224-225, 225f
Thoracic spine
anatomy of, 263t, 265, 267, 267f, 284-286,
285b, 287f
axial rotation of, 287, 290f
components of, 284
flexion and extension of, 286t, 286-287,
288f, 289f
lateral flexion of, 287, 29lf
motion of, 286t, 286-287, 288f-291f
range of motion of, 286t
structural deformities of. 287-290, 291f, 292,
292f
Thoracolumbar fascia, 306, 306f
Thoracolumbar spine, movement of, 286-287,
288f, 289f, 290f, 291f, 303
Thorax, 369f
aniculations with, 370, 370b, 370f
constriction of, in cervical spinai cord injury,
374b
expansion of, factors opposing, 369, 369f
functions of, 370
Thorax (Continued)
in ventilation, 369b, 369f-370f, 369t, 36 9 -
370
tissues that seal, 369t, 369-370
vertebrae of, osteologie features of, 263t, 265,
267, 267f
Thumb, 195, 197f
abduction and adduction of, 197, 20lf, 20 3 -
204, 204f, 205f, 206t
basilar joint arthritis affecting, 200, 202
bones of, 199f-200f
carpometacarpal joint of, 200-207
adduction and abduction of, 203-204, 205f
capsule and ligaments of, 202, 202t, 203f-
204f
flexion and extension of, 204-205, 206f,
206t
in zig-zag deformity, 236, 237f
muscles of, 224t
opposition of, 205, 207, 207f
saddle joint structure of, 202
close-packed position of, 205
extensors of, extrtnsic, 2 2 1, 223, 223f, 224t
interphalangeal joint of, 213
abductor pollicis longus as assistant exten
sor of, 223f, 225
muscles of, 224t
metacarpal bones of, 195-196, 197f, 199f-
200f
metacarpophalangeal joint of, 211, 21 lf212f
muscles of, 224i
movement of, 201f, 203-207
terminology of, 197, 201f
opposition of
mediali nerve in, 224-225
muscles of thenar and hypothenar eminence
in, 224-225, 225f
terminology of, 197, 20lf
pinching action of
in power (key) pinch, 234-235, 235f-236f
muscular biomechanics in, 229, 229f
position of function of, 213, 213f
terminology of, 196
zig-zag deformity of, 236, 237f
Thyrohyoid, attachments and innervation of,
384t
Tibia
anatomy and function of, 436f, 436-437,
437f
distai, 479, 479f, 484f
motion of, in gait, 542f, 543, 544b
osteologie features of, 436b
Tibial nerve
injury lo, 517-518. 518l
muscles of foot and ankle innervated by, 507,
509f
posterior, neurovascular bundle of, 513, 515f
Tibiai tuberosity, 437, 437f
Tibialis anterior
action of, on tiptoes, 512, 512f
anatomy and function of, 508, 510, 5 lOf
attachments of, 574l
in gait, 549f. 550
innervation of, 506-507, 574t
weakness of, in gait, 550
Tibialis posterior
anatomy and function of, 512-514, 514f, 516
attachments and innervation of, 574t
in gait, 549f, 551
maximal torque potential of at ankle, 514,
516t
supination potential of, 514, 516
Tibia-on-femoral knee motion, 4441, 445f
flexor-rotalor muscle interaction in, 465
in knee extension, 445, 446f
anterior cruciate ligament strain and, 453b
Index 595
Tibial-on-femoral knee moiion (Continued)
cxtcmal torque in, 456, 458f
in extensor lag, 460b
paiellar contact in, 447, 448f
Tibial-on-femoral motion, vs. femoral-on-tibial
motion, 7f
Tibiofemoral joint, 440, 442. See also Knee.
articular structure of, 440, 442, 443f, 444f
as condyloid joint, 28, 30f
extension of, 445-446, 446f, 447f
flexion of, 446
forces applied to, in gait, 56 It
internai and extental rotation of, 446
osteokinematics at, 442-444, 444f, 445f
Tibiofibular joint
distai, 483-484, 484f
proximal, 437, 438, 441, 483
relation to talocrural joint, 489
Tidal volume, 368, 368f
Toeing in, gait deviations with, 563t
Toeing out, 539
gait deviations with, 563t
Toe-off, 531 f532f, 531t, 531-532
Toc-out, 527
Torque. See aho Force(s).
climcal issues in, 74 -7 6 , 75f. 76f
determnation of
inverse dynamic approach to, 81b, 81f
methods of, 72-73, 73b-74b, 73f-74f
dynamic analysis of, 82, 82b
methods of. 82f-85f, 8 2 -8 5
extensor-to-flexor peak ratios of, in knee.
468b
external, 16, 16f
determination of, 73, 73f, 74b, 74f
manual application of during exercise, 7 5 -
76, 76f
on joints, in gait, 553-558, 555b
in ankle and foot, 558, 559f-560f
in hip, 555f- 556f, 556-557
in knee, 557f-559f, 557-558
guidelines for solving biomechamcal problems
in, 77t
internai, 16, 16f
determination of, 7 2 -7 3 , 73b, 73f
in knee extension, 456-457, 459f
maxnnal effort
in knee extension, 459f
in trunk, 327
of hip muscles, 426-427, 427t, 428f
of knee flexor-roiator muscles, 465-466,
466, 467f, 468f
musculoskeletal, 15-16, 16f
varus, in walking, 470f, 471
Torque potential
in design of resistive exercises, 72b, 72f
of piantar flexor muscles at ankle, 514, 516t,
517-518
Torque-acccleration relationship, 58b, 58-62,
61f, 62b, 62t
Torque-angular acceleration relationship, 59
Torque-joint angle curve
of hip abductor muscles, 427, 428f
of muscle, 4 7 -5 0 , 48f, 49b, 49f, 49t
unique signature of, 49b
variables affecting, 49t
Torsion, as musculoskeletal force, 12f
Torsion angle, of femur, 394-396, 397f, 398f
Torlicollis, 335b, 335f
Total lung capacity, 368, 368f
Trabecuiar network, in femur, 396, 399f
Transducers, for collection of kmemalic data,
84f, 8 4 -8 5
Translation, vs. rotation. 4 -5 , 5f. 5t
Transversarus abdominis, as extrinsic trunk sia-
bilizer, 330f, 330-331, 33 lb
 590 Index
Transverse process, 269, 2721
Transversospinal muscles
anaiomy and action of, 318t, 321f-322f,
321-323
as intrinsic trunk stabiltzers, 329-330, 330b,
330f
as secondary axial rotators, 327b
attachments and mnervations of, 38 lt
cross-sectional anaiomy of, 318f
in lifting heavy loads, 347, 348f
morphological characteristics of, 3 2 lt
Transversus abdommts, 323, 324f, 326
auachments and innervations of, 325t, 382t
in lifting heavy loads, 347, 348f
in trunk movement, 329t
Transversus thoracis
attachments and innervation of, 384t
in forced expiration, 376f, 377, 377f, 377t
Trapezium, 174f-175f, 176
in flexton and extension of thumb, 206f
in opposition of thumb, 204, 206f, 207f
of wrist, 199f
saddle joint structure of, 202, 204f
Trapezius
action of, 317, 317f
attachments and innervation of, 244t
in trunk movement, 329t
interaction wnh serratus anterior, in scapulo-
thoracic upward rotation, 125f, 125-126,
126f
lower, in scapulothoracic joint movement,
121, 121f, 122f
middle, in scapulothoracic joint movement,
122, 124f
paralysis of, 120b, 126
upper, in scapulothoracic joint movement,
120f, 120-121
Trapezoid, 174f-175f, 176
Trauma
acute and chronic, effeets of on joints, 38
elbow joint instability and, 144-145, 1451
Trendelenburg gatt, compensaled, 425b
Trendelenburg sign, 425b
positive, 540, 540f
Triangular fibrocartilage complex, 146, 147b,
148f, 178
Triceps brachii, 161, 163f
attachments and innervation of, 245t
lateral and mediai heads of, 161, 163f, 163t
long head of, 129-130, 130f
paralysis of, shoulder muscle substitution in,
165b, I65f
structural and biomechanical variables of,
163t, 164, 164f
surgical transfer of, 22, 22f
Triceps surae, in runningand jumping, 514,
5161
Trigonometrie functtons, used in biomechanical
analysis, 86f, 86t, 8 6 -8 7
Triquetrum, 174f, 175, 175f
Trochanter
greater, 393f, 394, 395f
tesser, 393f, 394
Trochanteric fossa, 393f, 394, 395f
Trochlea, 134, 134f, 135f
of humeroulnar joint, 142f
Trochlear groove, 134, 1341, 135f
Trochlear notch
of humeroulnar joint, 142f
of ulna, 135, 136f, 137f
Tropomyosin, of sarcomere, 47f
Troponin, of sarcomere, 47f
Trunk
axial rotation of, abdominal muscle action in,
327, 327b
Trunk (Continuai)
extension of, erector spinae muscle action in,
319f, 320
flexion of, abdominal muscle action in, 326f,
326-327
forward lean of
abnormal gail pattern with, 563f
hip extensors and, 420-421, 421 f, 422f
joints of, innervation of, 312-314
maximal effort torque in, 327
muscles of, 314-315, 315t, 549f, 551
action of
in gau, 543, 5631, 566t, 567f, 568f
in providing core stability, 329-331,
330f, 331b
in sit-up movement, 331 f, 331-333.
332f
actions of, shared across axial and appen-
dicular skeletons, 317, 317f
anterior-lateral
anatomy and action of, 315t, 323-327,
3241-326f, 325t, 327b
attachments and innervations of, 382t
impairment of, gait deviation at hip/pelvis/
trunk with, 566t, 567f, 568f
influence of gravity and, 316
innervation of, 312-314, 381-382t
internai torque of, 315, 316f
lines of force of, 315, 316f
unilateral and bilateral activation of, 315
posterior, muscles of
anatomy and action of, 315t, 316-323,
318f-319f, 318t
attachments and innervation of, 381 1382t
Tubercle(s)
articular, of nbs, 253, 256f
greater, of humerus, 97f, 98
infraglenoid, 97
lesser, of humerus, 97f, 9 7 -9 8
of cervical vertebrae, 264, 264f, 266f
of talus, 480f, 480-481
posterior, of metacarpal joints, 195
postglenoid, of temporal bone, 354f, 355
pubic, 39 lf, 392
quadrate, 394, 395f
spinai and lateral, of sacrum, 269, 271f
supraglenoid, 97
Tuberosity
calcaneal, 480f-481f, 481
delloid, 98
gluteal, 394, 395f
iliac, 391, 391f
ischial, 390f, 3921, 393
navicular, 481
of ulna, 135
libisi, 437, 437f
U atypical, 264, 266f, 267f
Ulna
head of, 136, 137f
osteologie features of, 135b, 135-136, 136f
137f
styloid process of, 172
Ulnar deviation, of wrist, 179-180, 180f, 182-
184, 183f-184f, 184b, 191t, 191-192,
192(
Ulnar drift, of fingers, 237-238, 239f
Ulnar nerve
hypothenar muscle function and, 226
in key pinch action, 229, 229f
lesion of
in finger flexion, 233
in opening hand, 231-232, 232f
of elbow and forearm, 152, 156f
Ulnar nerve (Continuai)
of hand, 213
of wrist, 186
Ulnocarpal complex, 146, 147b, 148f, 178, I79f
Ulnocarpal meniscal homologue, 175f, 178
Ulnocarpal space, 175f, 178, 179f, 190
Uncinate process, 264, 264f, 266f
Uncovertebral joints, 264, 264f, 266f
tn disc disease, 265b, 265f
Unfused tetanus, of muscle fibers, 52, 53f
Upper extremity, 92. See also Arm; Elbow;
Shoulder complex; specific joints, e.g.,
Glene-
humeral joint.
muscles of
attachments and innervations of, 243t-247t
nerve roots of, 242l-243t
V
Valgus angle, of elbow, 137-138, 138f
Valgus force, on elbow, 144-145, 145f
Vaisalva maneuver, during lifting, 345-346
Varus torque, at knee, in gail, 557, 558f
Vastus
in hip and knee extension, in running, 468,
468f, 469, 469t
torque production by, 468b
Vastus intermedius, 455-456
attachments and innervation of, 573t
Vastus lateralis, 455
attachments and innervation of, 573t
oblique fibers of, 462, 463f
Vastus medialis, 455
attachments and innervation of, 573t
Vector, definilion and descriptors of, 13, 15,
15b, 15f
Ventilation, 368-377
after cervical spinai cord injury, 374b
btomechanics of, 368f, 368-369
changes in intrathoracic volume during, 371,
371f
definition of, 368
lung volumes and capacities in, 368, 368f
muscles of, attachments and innervation of,
384t
muscular actions during, 372-377
thoracic function in, 369b, 369f-370f, 369l,
369-370
thoracic structure and, 369f-370f, 369t, 36 9 -
370
Ventral ramus(i), of spinai nerves
of lower extremity muscles used for testing
function, 57li
of upper extremity muscles used for testing
function, 243t
plexus of, 312, 313f
segmentai nerves of, 313f, 313-314
Vertebrae
cervical
typical, 262, 262f, 263t, 264, 264f, 266t
L2, compression force on in lifting, estimation
of, 342-344, 343b, 344f
lumbar, 261f, 267-269, 268f-269f
structure and function of, 253-254, 254f-
255f, 255t, 269, 271, 272f
thoracic
atypical, 267
typical, 265, 267f
Vertebral artery, 262
Vertebral canal, 262f, 264
Vertebral column. See also Apophyseal joint(s);
Interbody joint.
cervical region of, 262, 262f, 263t, 264, 264f,
also
266t, 267f. See Cramocervical region;
Neck.
 Index 597

Vertebral column (Continued) Vertebral column (Continued) Wrist (Continued)

motion ai
flexion and extension, 279-282, 280f-
282f
in fronial piane, 283-285, 2861
in horizontal piane, 282-283, 285f
in sagittal piane, 279-282. 2801-2821
range of motion ai, 278i
coccygeal region of, 263t, 269, 2711
connective tissues limiiing molion of, 276t,
276-277
curvalures of, normal, 256-257, 258f, 276,
276f
tntervertebral junction and, 269, 271, 272f,
272t
ligamentous supporl of, 258-259, 2601-261 f,
260l-261t
line ol gravity and, 257, 259f-260f
lumbar region of, 263t, 267-269, 268f-269f.
See uso Lumbar spine,
anatomy and kinematics of, 292-303
motion of, 276f, 276t. 276-277, 303
in cervical region, 279-285, 280f-286f
in lumbar region, 294-303
in sacroiliac region, 306, 306b, 306f
in thoracic region, 286-287, 288f-291f
in thoracolumbar region, 286-287, 288f-
291 f, 303
measurements of, 277b
range of motion in, 276, 278t, 286t
spinai coupling and, 273b
terminology for, 271-272, 272f, 272t
osteologie features of, 256-257, 258f-260f,
262-269, 263l
cervical, 262, 262f, 264, 264f, 266f
of atlas, 264, 2661
of axis, 264, 267f
of coccyx, 269, 27 lf
of lumbar region, 267-269, 268f-269f
of sacrum, 269, 2 7 lf
of thoracic region, 265, 267, 267f
of vertebral prommens, 264-265
sacrai region of, 263l, 269, 271 f
sacroiliac joints in, 303-308. 5ee alsoSacro
iliac joint.
spinai nerves of, 312
thoracic region of, 263l, 265, 267, 267f. See
also Thoracic spine.
Vertebral endplates, 274, 274f
Vertebral prominens, 264-265
Video-based Systems, for collection of kinematic
data, 83, 83f
Viscoelastic tissues. 13, 15f
Vital capacity, 368, 368f
w arthrokinematics of, 180-184
Walking. See also Gait.
normal reaction forces through knee in, 470f,
470-471
speed of, 528-529, 529t, 530-531
methods of increasing, 529f
normal, 529l
Water, in ground substance, 32, 32f
Weber brothers, in gali analysis, 524
Whiplash injury, 277, 281, 337b, 337f
chronic forward head posture with, 341b,
34 l f
osteophyte formation and, 283b, 283f
Williams flexion exercise, 300-301
Windlass effect, of forefoot in late stance phase,
506, 506f
Wind-swept deformity, of knee, 471, 472f
Wolffs law, 265b
Work, definition of, 60, 61b
Work-energy relationship, Newton's second law
and, 6 0 -6 2 , 61b, 62b
Wrist, 172-193
bones and joints of, 172, 173f, 176-185,
199f
carpai instability of, 184b, 184f- 186f, 184-
185
centrai column of, movement through, 181 f
182f, 181-182
creases of, 195, 197f
deviators of, 191b, 19lf192f, 191t, 191-
192, 192b
extensors of, in finger flexion, 234
flexion of, 190-191, 191t
flexion torque in, in making a fisi, 188, 188f
flexors of, in finger extension, 231f, 232
joints of, 176-177, 177b
innervation of, 186
muscle interaction with, 1.86-192
ligaments of, 177f, 177-179, 178t
motion at
kinematics of, 179184
osteokinematics of, 179-180, 180f
muscles of, attachments and mnervation of,
245t
osteologie features of, 172-173, 173f-175f
position of
and tenodesis action of finger flexors, 2 1 8 -
219, 219f
for function, 180b, 213, 213f
rotational collapse of, 184b, I84f, 184-185
X
Xiphisternal joint, 256, 257f
Xiphoid process, 256, 257f
z
Zig-zag deformity, of thumb, 236, 237f
Zona orbiculans, of hip capsule, 402
Zones, of articular cartilage, 34, 35(
Zygomatic arch, 352, 353f
Zygomatic bone, 354f, 355
Zygomatic process, of lemporal bone, 354f, 355

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