You are on page 1of 607

U n iv in id K d i i n A m n c is

a i b l l o t i c i P ro v ld n c l


/ ^ jf*/

11||| B|

J f f l H
[Fa m

W m

M S ?* >\<w1 !S iThTi
Foundations for Physical Rehabilitation
Donald A. Neumann, PT, PhD

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.

KA Mosbv IIS
S B N -1
-13 : =
I SBNN - 110
n 71 f7l6- -0
0 --5
f l 1l S5 l1--b 3 M n - 7
0 :: 0 - f l l S l - bb 33 4 c1-S
A n A ffilia te of E lse v ie r

R e c o m m e n d e d S h e lv in g C la s s ific a tio n
P h ysical Therapy
O ccu p a tio n a l Therapy 9 780815 163497
P h ysical R eh ab ilita tio n
C e te .V e
M 4 -1 2 K

of th
Foundations fo r Physical Rehabili

D onald A. N eumann , PT, Ph D

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

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


Collateral ligaments
(cord and Palmar plates
accessory parts) digita!
Deep transverse sheath
metacarpal Flexor


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.


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,
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-
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
Kinesiology o f Walking (Chapter 15)
R e v i e w e r s

Paul Andrew, PT, PhD Gary Chleboun, PT, PhD Jerem y Karman, PT
Depariment of Physical Therapy School of Physical Therapy Physical Therapy Department
Ibaraki Prefeciural University of Health Ohio University Sports Medicine Institute
Sciences Athens, OH Aurora Sinai Medicai Center
Ibaraki-ken, Japan Milwaukee, WI
Mary A. Cimrmancic, DDS
Susana Arciga, PT Marquette University School of Michelle Lanouette, PT, MS
St. Marys Hospital Dentistry
Physical Therapy Department
Outpatient Orthopedic and Sports Milwaukee, WI Zablocki VA Medicai Center
Medicine Center
Milwaukee, WI
Milwaukee, W1 Adam M. Davis, PT
Quad Med, LLC
Cindi Auth, PT Sussex, WI Paula M. Ludewig, PT, PhD
Physical Therapy Department Program in Physical Therapy
Zablocki VA Medicai Center Brian L. Davis, PhD University of Minnesota
Milwaukee, W1 Department of Biomedicai Engineering Minneapolis, MN
The Lerner Research Institute
Marilyn Beck, RDH, MEd The Cleveland Clinic Foundation Jo n D. Marion, OTR, CHT
Department of Dentai Hygiene Cleveland, OH Marshfield Clinic
Marquette University Marshfield, WI
Milwaukee, WI Sara M. Dcprey, PT, MS
Department of Allied Health Brenda L. Neumann, OTR, BC1AC
Teri Bielefeld, PT, CHT Carroll College Clinic for Neurophysiologic Leaming
Physical Therapy Department Waukesha, WI Milwaukee, WI
Zablocki VA Medicai Center
Milwaukee, WI Sara Jean Donegan, DDS, MS
Jan et Palmatier, PT, MHS, CHT
Marquette University School of
Peter Blanpied. PT, PhD Work Injury Care Center
Physical Therapy Program Gtendale, WI
Milwaukee, WI
University of Rhode Island
Kingston, RI W illiam F. Dostal, PT, PhD Randolph E. Perkins, PhD
Department of Rehabilitation Therapies Physical Therapy and Celi and
Ann M. Brophy, PT University of Iowa Hospitals and Molecular Biology
NovaCare Outpatient Rehabilitation Clinics Northwestern University Medicai
Milwaukee, WI lowa City, IA School
Chicago, IL
Frank L. Buczek, Jr ., PhD Joan E. Edelstein, PT, MA
Motion Analysis Laboratory Physical Therapy Christopher M. Powers, PT, PhD
Shriners Hospital for Children Columbia University Department of Biokinesiology and
Erie, PA New York, NY Physical Therapy
University of Southern California
Daniel J . Capriani, PT, MEd Timothy Fagerson, PT, MS Los Angeles, CA
Department of Physical Therapy Orthopaedic Physical Therapy Services,
Medicai College of Ohio Ine.
Kathryn E. Roach, PT, PhD
Toledo, OH Wellesley Hills, MA
Division of Physical Therapy
Am a Carlisle, MPT Kevin P. Farrell, PT, OCS, PhD University of Miami School of
Physical Therapy Department Physical Therapy Medicine
Zablocki VA Medicai Center Saint Ambrose University Coral Gables, FL
Milwaukee, W1 Davenport, IA
M ichelle G. Schuh, PT, MS
Leah Cartwright, PT Esther Haskvitz, PT, PhD Department of Physical Therapy and
Physical Therapy Department Notre Dame College Program in Exercise Science
Zablocki VA Medicai Center Physical Therapy Program Marquette University
Milwaukee, WI Manchester, NH Milwaukee, WI

XIV Revicwers

Christopher J. Simenz, MS, CSCS Carolyn Wadsworth, PT, MS, OCS Chris L. Zimmermann, PT, PhD
Department of Physical Therapy and CHT Physical Therapy Program
Program in Exercise Science Department of Rehabilitation Therapies Concordia University, Wisconsin
Marquette University University of Iowa Hospitals and Mequon, WI
Milwaukee, WI Clinics
Iowa City, IA
Guy G. Simoneau, PT, PhD, ATC
Department of Physical Therapy David Williams, MPT, ATC, CSCS
Marquette University Physical Therapy Program
Milwaukee, WI Iowa City, IA
F o r e w o r d

To be ihe author of a text is a major undertaking and, Quiet in manner and complimentary by nature, he gives his
possibly, appreciated only by those who have completed energies to excellence in th projeets that he undertakes. All
such a venture. The author has a responsibility not only for his personal qualities would take too long to describe and
providing accurate information but also for delivering th would only embarrass this humble author. 1 have had th
material in a format conducive to comprehension. A signifi- distinct privilege of having him as a graduate student and
cant confounding factor is th perpetuai explosion of knowl- teaching assistant and as a critic of my work. Although
edge for which th author is responsible for inclusion in th unsuccessful in attempts to hire him, I recognize that others
work. have gained from his presence.
Perhaps in his earlier days, Don Neumann never antici- Don should be congratulated on th completion of Kinesi
pated th creation of this volume on th Kinesiology o f th ology o f th Musculoskeletal System: Foundations fo r Physical
Musculoskeletal System, but th work has been intrinsic to Rehabilitation. The osteology, arthrology, and neurology, and
him since his days as a physical therapy assistant in th early th muscle as a functional unit previde a meaningful
1970s. He received both th Outstanding Clinical Award and blend for a text on kinesiology, a Science fundamental to th
th Outstanding Academic Award as an undergraduate stu- student and practicing clinician. Of special merit are th
dent at th University of Florida under th tutelage of faculty illustrations, which uniquely convey a blending of kinesiol-
including Martha Wroe, Fred Rutan, and Claudette Finley. ogic and anatomie material. Kinesiology of th Musculoskeletal
He then pursued his masters and doctoral degrees. He has System is also invaluable for its inclusion of Special Focus
never strayed far from th clinic, however, where he stili issues and other features that provide clinical relevance to
treats patients with spinai cord injuries. th presentation.
Dr. Neumann excels as a trae teacher. In this capacity, he Don has been successful in developing a useful textbook
has demonstrated his love for teaching others and sharing his not only for physical therapists but also for many in other
excitement for th subject matter. Don has gone beyond disciplines. His work is comprehensive and readable and
teaching, however. He has also made a contribution as a contributes greatly to th pool of literature available to stu-
scholar by focusing his attention on th hip joint and th dents and professionals alike.
influence of th arthritic process. His efforts in this domain
have been recognized in terms of awards such as th Ameri Gara L. Soderberg, PT, PhD, FAPTA
can Physical Therapy Associations Eugene Michels New In- Professor and Director of Research
vestigator Award (1991) and th Jack Walker Award (2000), Department of Physical Therapy
which recognizes published clinical research in Physical Ther- Southwest Missouri State University
apy. Springfield, Missouri
All of these aspects reveal only part of th picture, how
ever, because you must know th man to appreciate him.

Kinesiology is th study of human movement, typically pur-

musculoskeletal System, and an introduction to biomechani-
sued within th context of sport, art, or medicine. To vary-
cal and quantitative aspeets of kinesiology-. Sections II
tng degrees, Kinesiology o f th Musculoskeletal System: Founda-
through IV present th specific anatomie details and kinesi
tions fo r Physical Rehabilitation, relates to all three areas. It is
ology of th three major regions of th body. Section II
intended, however, primarily as a foundation for th practice focuses entirely on th upper extremity, from th shoulder
of physical rehabilitation. The phrase physical rehabilitation" to th hand. Section III covers th kinesiology' of th axial
is used in a broad sense, referring to therapeutic efforts that skeleton, which includes th head, trunk, and spine. A spe
restore optimal physical function. Although kinesiology can cial chapter is included within this section on th kinesiol
be presented from many different angles, I and my contrib- ogy of mastication and ventilation. Section IV presents th
uting authors have focused primarily on th mechanical in- kinesiology of th lower extremity, from th hip to th ankle
teractions between th muscles and joints of th body. These and foot. The final chapter in this section, th Kinesiology of
interactions are described for normal movement and, in th Walking, functionally integraies and reinforces much of th
case of disease, trauma, or otherwise altered tissue, for ab- kinesiology of th lower extremity.
normal movement. I hope that this textbook provides a This textbook is specifically designed for th purpose of
valuable educational resource for a wide range of health- and teaching. To that end, concepts are presented in layers, start-
medical-related professions, both for students and clinicians. ing with Section 1. which lays much of th scientific founda
This textbook places a large emphasis on th anatomie tion for chapters contained in Sections li through IV. The
detail of th musculoskeletal System. By applying surpris- material covered in these chapters is also presented layer by
ingly few principles of physics and physiology, th reader layer, building both clarity and depth of knowledge." Most
should be able to mentally transform a static anatomie image chapters begin with osteology th study of th morphology
into a dynamic, three-dimensional, and relatively predictable and subsequent function of bones. This is followed by ar-
movement. The illustrations created for Kinesiology of th thrology th study of th anatomy and th function of th
Musculoskeletal System are designed to encourage this mental joint, including th associated periarticular connective tis-
transformation. This approach to kinesiology reduces th sues. Included in this study is a thorough description of th
need for rote memorization and favors reasoning based on regional kmematics, both from an arthrokinematic and os-
mechanical analysis. This type of reasoning can assist th teokinematic perspective.
clinician in developing proper evaluation, diagnosis, and The most extensive component of most chapters within
treatment related to dysfunction of th musculoskeletal Sys Sections II through IV highlights th muscle and joint interac
tions. This topic begins by describing th skeletal attach-
The completion of this textbook represents th synthesis ments of muscles within a region, including a summary of
of more than 25 years of experience as a physical therapist. th innervation to both th muscles and th joint structures.
This experience includes a rich blend of clinical, research, Once th shape and physical orientation of th muscles are
and teaching activities that are related, in one form or an- established, th mechanical interplay between th muscles
other, to kinesiology. Although I was unaware of it at th and th joints is presented. Topics presented include
time, my work on this textbook began th day 1 prepared strength and movement potential of muscles, muscular-pro-
my first kinesiology lecture as a college professor at Mar- duced forces imposed on joints, intermuscular and interjoint
quette University in 1986. Since then, 1 have had th good synergies, important functional roles of muscles, and func-
fortune of being exposed to intelligent and motivated stu tional relationships that exist between th muscles and un-
dents. Their desire to learn has continuali)' fueled my ambi- derlying joints.
don to teach. As a way to encourage my students to listen Clinical examples and corollaries are used extensively
actively rather than to transcribe my lectures passively, 1 throughout to help narrow th gap between what is often
developed an extensive set of kinesiology lecture notes. Year taught in th classroom and what is experienced in clinical
after year, my notes evolved, forming th blueprints of this practice. Clinical examples pertain lo a wide range of issues,
text. Now complete, this text embodies my knowledge of typically relating to how pathology, trauma, and other condi-
kinesiology' as well as my experiences while teaching th tions contribute to functional impairments or limitations.
subject. The book contains many clear and exciting illustra Discussions are frequenti)' related to issues involving pro-
tions, as well as a compelling list of references that support longed immobilization of limbs; instability or malalignment
my teaching.
of joints; abnormal posture or limited range of motion; pa-
The organization of this textbook reflects th overall pian ralysis and muscular force imbalances; and trauma and in-
of study used in my two-semester kinesiology course se- flammation of th muscles, joints, and periarticular connec
quence. The textbook contains 15 chapters, divided into four tive tissues.
major sections. Section l provides th essential topics of kine Severa] special educational features are included Tore
siology, including an introduction to terminology and basic most are th high quality anatomie and kinesiologic illustra
ncepts, a review of basic structure and function of th tions. This artwork is intended to excite and simplify, with-
xviii Fruiate

oui compromising th depth of th material. The textbook is instructive activity involves having students use a skeleton
accompanied by an Evolve website that features an electronic model and a piece of string to mimic a muscles line-of-
image coilection, which includes th majority of th figures force. Groups of students can discuss a muscles potential
in th book. The images, which can be be printed out or action by observing th line-of-force of th string relative
transformed into PowerPoint slides, are available as a teach- to an imaginary axis of rotation through a particular joint.
ing tool for instructors who adopt th book for use in their This exercise helps students to understand th three-dimen-
classes. (Instructors should check with their sales representa- sional nature of muscle actions and how th actions and
tive for further information.) Special Focus features are used strength of a muscle can change with different positions of a
to highlight areas of special interest. Topics in a Special limb. Multiple tables and summary boxes are provided to help
Focus include notable clinical corollaries, distinctive struc- organize th material to facilitate learning.
tural and functional relationships, and reach-out concepts My originai intention in writing this text was to present
designed to stimulate further interest or provide additional kinesiology in a comprehensive, relevant, logicai, and clear
background. Appendices at th end of each of th four sec- manner. This textbook will hopefully inspire others to fur
tions provide useful reference materials. Appendices 11 ther pursue a fascinating and important subject matter. 1
through IV, for example, provide a readily accessible refer intend this first edition to be th beginning of a lifelong
ence to th detailed bony attachments of muscles. This infor endeavor.
mation is useful in laboratory exercises designed to study a
muscles action based on its specific attachments. One very 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 activities, including proofreading, verifying references or con-
of people who have provided me with kind and thoughtful cepts, posing for or supplying photographs, taking x-rays,
assistance throughout this long project. I am sure that 1 have and providing elencai assistance. 1 am grateful to Santana
inadvertently overlooked some people and, for that, I apolo Deacon, Monica Diamond, Gregg Fuhrman, Barbara Haines,
g ie . Douglas Heckenkamp, Lisa Hribar, Erika Jacobson, Davin
The best place to start with my offering of thanks is with Kimura, Stephanie Lamon, John Levene, Lorna Loughran,
my immediate family, especially my wife Brenda who, in her Christopher Melkovitz, Melissa Merriman, Alexander Ng, Mi
charming and unselfish style, paved th way for th comple- chael OBrien, Ellen Perkins, Gregory Rajala, Elizabeth Shan-
tion of this project. I thank my son, Donnie, and stepdaugh- ahan, Pamela Swiderski, Donald Taylor, Michelle Tremi,
ter, Megann, for their patience and understanding. I also Stacy Weineke, Sidney White, and David Williams.
thank my caring parents, Betty and Charlie Neumann, for 1 am very fortunate to have this forum to acknowledge
th many opportunities that they have provided me through- those who have made a sigmficant, positive impact on my
out my life. professional life. In a sense, th spirit of these persons is
Four persons signiftcantly influenced th realization of interwoven within this text. I acknowledge Shep Barish for
Kinesiology o f th Musculoskeletal System: Foundations fo r Physi- first inspiring me to teach kinesiology; Martha Wroe for
cal Rehahilitation. Foremost, I wish to thank Elisabeth E. serving as an enduring role model for my praedee of physi
Rowan, th primary medicai illustrator of th text, for her cal therapy; Claudette Finley for providing me with a rich
years of dedication and her uncompromisingly high standard foundation in human anatomy; Patty Altland for emphasizing
of excellence. 1 also extend my gratitude to Drs. Lawrence to Darrell Bennett and myself th importance of noi limiting
Pan and Richard Jensen, present and past directors, respec- th functional potential of our patients; Gary Soderberg for
tively, of th Department of Physical Therapy at Marquette his overall mentorship and finn dedication to principle;
University. These gentlemen unselfishly provided me with Thomas Cook for showing me that all this can be fun; and
th opportunity to fulfill a dream. And, finally, 1 wish to Mary Pat Murray for setting such high standards for kinesiol
thank Scott Weaver, Managing Editor at Harcourt Health ogy education at Marquette University.
Sciences, for his patience and guidance through th final, I wish to acknowledge several special people who have
and most challenging, phases of th project. influenced this project in ways that are difficult to describe.
1 am also indebted to th following persons who contrib- These people include family, old and new friends, profes
uted special chapters to this textbook: David A. Brown, Deb sional colleagues, and, in many cases, a combination thereof.
orah A. Nawoczenski, Guy G. Simoneau, and A. Joseph I thank th following people for their sense of humor or
Threlkeld. 1 am also grateful to th many persons who re- adventure, their loyalty, and their intense dedication to their
viewed chapters, most of whom did so without financial own goals and beliefs, and for their tolerance and under
remuneration. These reviewers are all listed elsewhere in standing of mine. For this 1 thank my four siblings, Chip,
previous sections. Suzan, Nancy, and Barbara; Brenda Neumann, Tad Hardee,
Several people at Marquette University provided me with David Eastwold, Darrell Bennett, Tony Homung, Joseph Ber-
tnvaluable technical and research assistance. I thank Dan man, Robert Morecraft, Bob Myers, Debbie Neumann, Guy
Johnson for much of th digitai photography contained Simoneau, and th Mehlos family, especially Harvey, for al
within this book. 1 appreciate Nick Schroeder, graphic artist, ways asking Hows th book coming?
for always fitting me into his busy schedule. I also wish to Finally, 1 want to thank all of my students, both past and
thank Ljudmila (Milly) Mursec and Rebecca Eagleeye for present, for making my job so rewarding.
their important help with library research.
Many persons affiliated directly or indirectly with Mar
quette University provided assistance with a wide range of DAN

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


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
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

Essential Topics of
ll:sJ Kinesiology
1 / \ /


Axis of
rotatimi O

S E C T 1 O N I

Essential Topics of

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.

C h a p t e r 1

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


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

Motions That Combine Roll-and-Slide Types of Muscle Activation, 16
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

of knowledge: anatomy, biomechanics, and physiology. Anat
What Is Kinesiology? omy is th Science of th shape and structure of th human
body and its parts. Biomechanics is a discipline that uses
The origins of th word kinesiology are from th Greek kine- principles of physics to quantitatively study how forces inter-
sis, to move, and ology, to study. Kinesiology o f th Musculo act within a living body. Physiology is th biologie study of
skeletal System: Foundations /o r Physical Rehabilitation serves as living organisms. This textbook interweaves an extensive re
a guide to kinesiology by focusing on th anatomie and view of musculoskeletal anatomy with selected principles of
biomechanical interactions within th musculoskeletal S y s biomechanics and physiology. This approach allows th ki-
tem. The beauty and complexity of these interactions have nesiologic functions of th musculoskeletal system to be rea-
tnspired th work of two great artists: Michelangelo Buonar soned rather than purely memorized.
roti ( 1 4 7 5 -1 5 6 4 ) and Leonardo da Vinci (1 4 5 2 -1 5 1 9 ). The remainder of this chapter provides fundamental bio
Their work likely inspired th creation of th classic text mechanical concepts and terminology related lo kinesiology.
Tabulae Sceleti et Musculorum Corporis Fiumani published in The glossary at th end of th chapter summarizes much of
1747 by th anatomist Bernhard Siegfried Albinus ( 1 6 9 7 - th essential terminology. A more in-depth and quantitative
1770). A sample of this work is presented in Figure 1 - 1 . approach io th biomechanics applied io kinesiology is pre
The primary intent of this book is to provide students sented in Chapter 4.
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 KINEMATICS
movement and their clinical applications. Discussions are
presented on both normal conditions and abnormal condi- Kinematics is a branch of mechanics that describes th motion
tions that result from disease and trauma. A sound under- of a body, without regard to th forces or torques that may
standing of kinesiology allows for th development of a ra- produce th motion. In biomechanics, th term body is
tional evaluation, a precise diagnosis, and an effective used rather loosely to describe th entire body, or any of its
treatment of musculoskeletal disorders. These abilities repre- parts or segments, such as individuai bones or regions. In
sent th hallmark of high quality for any health professional generai, there are two types of motions: translation and rota
engaged in th practice of physical rehabilitation. tion.
4 Secticm I Essential Topics of Kinesology


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

Translation Compared with Rotation a straight line (rectilinear) or a curved line (curvilinear). While
walking, for example, a point on th head moves in a gen
Translation describes a linear motion in which all parts of a erai curvilinear manner (Fig. 1 - 2 ) .
rigid body move parallel to and in th same direction as Rotation, in contrast, describes a motion in which an as-
every other pari of th body. Translation can occur in either sumed rigid body moves in a circular path aboul some pivot
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
FIGURE 1-2. A point on th top of th head is shown translating of th joint.
upward and downward in a curvilinear fashion while walking. The Movement of th body, regardless of translation or rota
X axis shows th percentage of completion of one entire gait (walk tion, can be described as active or passive. Active movements
ing) cycle. 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.
point. As a result, all points in th body simultaneously The primary variables related to kinematics are position,
rotate in th same angular direction (e.g., clockwise and velocity, and acceleration. Specific units of measurement are
counterclockwise) across th same number of degrees. needed to indicate th quantity of these variables. Units of
Movement of th human body, as a whole, is often de- meters or feet are used for translation, and degrees or radi-
scribed as a translation of th bodys center o f mass, located ans are used for rotation. In most situations, Kinesiology oj
generally just anterior to th sacrum. Although a persons th Musculoskeletal System uses th International System oj
center of mass translates through space, il is powered by Units, adopted in 1960. This System is abbreviateci SI, for
muscles that rotate th limbs. The fact that limbs rotate can Systme International, th French name. This System of units
be appreciated by watching th path created by a fist while is widely accepted in many joumals related to kinesiology
flexing th elbow (Fig. 1 - 3 ) . (Il is customary in kinesiology and rehabilitation. The kinematic conversions between th
to use th phrases rotation of a joint and rotation of a more common SI units and other measurement units are
bone interchangeably.) listed in Table 1 - 1 .
The pivot point for th angular motion is called th axis
of rotation. Tbe axis is at th point where motion of th
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.

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
FIGURE 1-3. Using a stroboscopie flash, a camera is able to eapture
axes of rotation (Fig. 1 - 5 ) . Although th three orthogonal
th rotation of th forcami. If not for th anatomie constraints of axes are depicted as stationary, in reality, as in all joints,
th elbow, th forearm could, in theory, rotate 360 degrees about each axis shifts throughout th range of motion. The axis of
an axis of rotation located at th elbow (red circle). 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.
Chapter 1 Gelting Started 7

ie shoulder has three degrees of angular freedom, one l'or toward or away from th body. The proximal segment of a
cM:h piane. The wrist allows two degrees of freedom, and joint in th upper extremity is usually stabilized by muscles
th elbow only one. or gravity, whereas th distai, relatively unconstrained, seg
Unless specified differently throughout this text, th term ment rotates.
zegrees of freedom indicates th number of permitted planes Feeding oneself or throwing a ball are two common ex-
: f angular motion at a joint. From a strict engineering per amples of distal-on-proximal segment kinematics employed
spective, however, degrees of freedom applies to angular as by th upper extremities. The upper extremities are certainly
'>11 as translational movements. All synovial joints in th capable of performing proximal-on-distal segment kinemai-
-ody possess at least some translation, driven actively by ics, such as flexing and extending th elbows while perform-
riuscle, or passively owing to th naturai laxity within th tng a pull-up.
sructure of th joint. The slight passive translations that The lower extremities routinely perform both distal-on-
rceur in most joints are referred to as accessory motions and proximal and proximal-on-distal segment kinematics. These
ire defined in three linear directions. From th anatomie kinematics reflect, in part, th two primary phases of walk-
rosition, th directions correspond to those of th three axes ing: th slance phase, when th limb is planted on th
:: rotation. In th relaxed glenohumeral joint, for example, ground under th load of body weight, and th swing phase,
th humerus can be passively translated anterior-posteriorly, when th limb is advancing forward. Many other activities,
nedial-laterally, and superior-inferiorly (see Fig. 1 - 5 ) . At in addition to walking, use both kinematic strategies. Bend-
nany joints, especially th knee and ankle, th amount of ing th knee in preparation to kick a ball, for example, is a
-anslation is used clinically to test th integrity of ligaments. 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
in generai, th articulations of two body segments constitute quadriceps muscle of th knee to control th graduai descent
i joint. Movement at a joint can therefore be considered of th body.
from two perspectives. (1) th proximal segment can rotate The terms open and closed kinematic chain are frequenti)'
igainst th relatively ftxed distai segment, and (2) th distai used in th physical rehabilitation literature and clinics to
segment can rotate against th relatively fixed proximal seg describe th concep of relative segment kinematics.4-10 A
ment. These two perspectives are shown for knee flexion in kinematic chain refers to a series of articulated segmented
Figure 1 - 6 . A term such as knee flexion, for example, de links, such as th connected pelvis, thigh, leg, and foot of
scribes only th relative motion between th thigh and leg. It th lower extremity. The terms open and closed are typi-
does not describe which of th two segments is actually cally used to indicate whether th distai end of an extremity
rotating. Often, to be clear, it is necessary to state th bone is fixed to th earth or some other immovable object. An
that is considered th primary rotating segment. As in Figure open kinematic chain describes a situation in which th distai
i - 6 , for example, th terms tibial-on-femoral movement or segment of a kinematic chain, such as th foot in th lower
:emoral-on-tibial movement adequately describe th osteokin- limb, is not fixed to th earth or other immovable object. The
ematics. distai segment, therefore, is free to move (see Fig. 1 -6 A ). A
Most routine movements performed by th upper extrem- closed kinematic chain describes a situation in which th distai
:des involve distal-on-proximal segment kinematics. This re- segment of th kinematic chain is fixed to th earth or
Qects th need to bring objects held by th hand either another immovable object. In this case, th proximal seg-

Knee flexion

F1GURE 1-6. Sagittal piane os- Proximal segment fixed Distai segment free
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
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.

1 - 8 ) . Although other terms are used, these are useful for
TVPICAL JOINT M0RPH0L0GY visualizing th relative movements that occur within a joint.
The terms are formally defined in Table 1 - 3 .
Arthrokinematics describes th motion that occurs between th
articular surfaces of joints. As described further in Chapter 2, Roll-and-Slide Movements
th shapes of th articular surfaces of joints range from fiat One primary way that a bone rotates through space is by a
io curved. Most joint surfaces, however, are curved, with rolling of its articular surface against another bones articular
one surface being relatively convex and one relatively con
sui face. The motion is shown for a convex-on-concave sur
cave (Fig. 1 - 7 ) . The convex-concave relationship of most face movement at th glenohumeral joint in Figure 1 -9A .
articulations improves their congruency, inereases th surface The contracting supraspinatus muscle rolls th convex hu-
area for dissipating contact forces, and helps guide th mo meral head against th slight concavity of th glenoid fossa.
tion between th bones.
Iti essence, th roll directs th osteokinematic path of th
abducting shaft of humerus.
FUNDAMENTAL MOVEMENTS BETWEEN JOINT A rolling convex surface typically involves a concurrent,
SURFACES oppositely directed slide. As shown in Figure 1 -9A , th
inferior-directed slide of th humeral head offsets most of th
Fhree lundamental movements exist between joint surfaces:
potential superior migration of th rolling humeral head. The
roti, slide, and, spiti." These movements occur as a convex
offsetting roll-and-slide kinematics is analogous to a tire on a
surface moves on a concave surface, and vice versa (Fig.
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
Multiple points along one rotating articular surface contact multiple
A tire rotating across a stretch of pavemenl.
points on another articular surface.
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 changing th leverage of th muscles that cross th glenohu-
continuous sliding of th lire in th opposite direction to th meral joint. As shown in Figure 1 -9 A , th concurrent roll
intended rotation. A classic pathologic example of a convex and slide maximizes th angular displacement of th abduct-
surface rolling without an off-setting slide is shown in Figure ing humerus, and minimizes th net translation between
1 -9 B . The humeral head translates upward and impinges joint surfaces. This mechanism is particularly important in
th delicate tissues in th subacromial space. The migration joints in which th articular surface area on th convex
alters th relative location of th axis of rotation, thereby 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.

axis of th long bone intersects th surface of its articular
Another primary way that a bone rotates is by a spinning of mate at right angles.
its articular surface against th articular surface of another
bone. This occurs as th radius of th forearm spins against Motions That Combine Roll-and-Slide and Spin
th capitulum of th humerus during pronation of th fore Arthrokinematics
arm (Fig. 1 - 1 0 ). Other examples include internai and exter- Severa! joints throughout th body combine roll-and-slide
nal rotation of th 90-degree abducted glenohumeral joint with spin arthrokinematics. A classic example of this combi-
and llexion and extension of th hip. Spinning is th pri nation occurs during flexion and extension of th knee. As
mary mechanism for joint rotation when th longitudinal 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.
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
FIGURE 1-10. Pronation of th forearm shows an example of a rolls and slides in similar directions. These two principles are
spinning motion between th head of th radius and th capitulum very useful for visualizing th arthrokinematics during a
of th humerus.
movement. In addition, th principles serve as a basis for
Chapter 1 Getting Storteci 11

FIGURE 1-11. Extension of th knee demonstrates a combinaiion of roll-and-slide with spin arthrokinematics. The
femoral condyle is convex, and th tibial plateau is slightly concave. A, Femoral-on-tibial (knee) extension. B, Tibial-on-
femoral (knee) extension.

some marmai therapy techniques. External forces may be combined effect of th maximum joint congruity and
applied by th clinician ihat assist or guide th naturai ar stretched ligaments helps to provide transarticular stability to
throkinematics at th joint. For example, in certain circum- th knee.
stances, glenohumeral abduction can be facilitateci by apply- All positions other than a join ts close-packed position are
mg an inferior-directed force at th proximal humerus, referred io as th joints loose-packed positions. In these posi
stmultaneously with an active-abduction effort. The arthro- tions, th ligaments and capsule are relatively slackened,
kinematic principles do, however, require a knowledge ol allowing an increase in accessory movements. The joint is
me joint surface morphology. 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
Arthrokincmatic Principles of Movemenl during standing, bui frequently are preferred by th patient
1. For a convex-on-concave surface movement, th convex during long periods of immobilization, such as extended bed
member rolls and slides in apposite directons. rest.
2. For a concave-on-convex surface movement, th concave
member rolls and slides in smular directons.

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
The pair of articular surfaces within most synovial joints fit more detailed explanation of this subject matter is provided
best in only one position, usually in or near th very end in Chapter 4.
mnge of a motion. This position of maximal congruency is From a kinesiologic perspective, a force can be considered
jeferred to as th joints close-packed position. In this position, as a push or pul that can produce, arrest, or modify
most ligaments and parts of th capsule are pulled taut, movemenl. Forces therefore provide th ultimate impetus for
oroviding an element of naturai stability to th joint. Acces- movement and stabilization of th body. As described by
sory motions are minimal in a joints close-packed position. Newtons second law, th quantity of a force (F) can be
For rnany joints in th lower extremity, th close-packed measured by th product of th mass (m) that received th
nosition is associated with a habitual function. At th knee, push or pul, multiplied by th acceleration (a) of th mass.
:r example, th close-packed position is full extension a The formula F = ma shows that, given a Constant mass, a
? r*suion that is typically approached while standing. The 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).

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 FIGURE 1 -1 2 . The manner by which forces or loads are most fre
quently applied to th musculoskeletal System is shown. The eom-
due to gravity acting on th body is Constant and, for
bined loading of torsion and compression is also illustrated. (With
practical purposes, is ignored. Technically, however, th permission from Nordin M, Frankel VH: Biomechanics of bones.
weight of a person varies inversely with th square of Basic Biomechanics of th Musculoskeletal System, 2nd ed. Phila-
th distance between th mass of th person and th delphia, Lea &r Febiger, 1989.)
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 tion, divided by its cross-sectional area. The horizontal axis
pared with 9.806m/s2 at sea level.4 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.
Musculoskeletal Forces Figure 1 - 1 3 shows five zones (A to E). In zone A, th
IMPACT OF FORCES ON THE MUSCULOSKELETAL slightly stretched or elongated ligament produces only a
TISSUES: INTRODUCTORY CONCEPTS AND small amount of tension. This nonlinear region of low ten
TERMINOLOGY sion reflects th fact that th collagen fibers within th liga
ment must first be drawn taut before significant tension is
The same forces that move and stabilize th body also have measured. Zone B shows th linear relationship between
th potential to deform and injure th body. The manner by stress and strain in a normal ligament. The ratio of stress to
which forces or loads are most frequently applied to th strain in an elastic material is a measure of its stijjness. All
musculoskeletal System is illustrated in Figure 1 - 1 2 . (See normal tissues within th musculoskeletal System exhibit
th glossary at th end of this chapter for definitions.) some degree of stiffness. The clinical term tightness usually
Healthy tissues are able to resist changes in their shape. The implies a pathologic condition of abnormally high stiffness.
tension force that stretches a healthy ligament, for example, Zone B in Figure 1 - 1 3 is often referred to as th elastic
is met by an intrinsic tension generated within th elongated zone of th stress-strain plot. The amount of stretch (strain)
tissue. Any tissue weakened by disease or trauma may not applied to th ligament in this zone is significant and likely
be able to adequately resist th application of th loads experienced during many naturai movements of th body.
depicted in Figure 1 - 1 2 . The proximal femur weakened by Within this zone, th tissue retums to its originai length or
osteoporosis, for example, may fracture from th impact of a shape once th deforming force is removed. The area under
tali owing to compression or torsion (twisting), shearing or th curve (red) represents elastic deformation energy. Most of
bending of th neck of th femur. th energy utilized to defonn th tissue is released when th
The inherent ability of connective tissues to tolerate loads force is removed. Even in a static sense, elastic energy can
.a n be observed experimentally by plotting th amount of do useful work for th body. When stretched even a moder
torce required to deform an excised tissue.6 Figure 1 - 1 3 ate amount within th elastic zone, ligaments and other
3hnw s th tension generated by an excised ligament that has connective tissues surrounding muscles perforai important
beer. s tic tc h e d to a point of mechanical failure. The vertical joint stabilization functions.
axis ot th graph is labeled stress, a term that denotes th Zone C in Figure 1 - 1 3 shows a mechanical property of
internai resistance generated as a tissue resists its deforma- 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 lage in th knee, for example, becomes stiffer as th rate of
ginai increases in tension as it continues to elongate. At this compression increases,7 such as during running. The in-
point, th ligament is experiencing microscopie failure and creased stiffness affords greater protecton to th underlying
remains permanently deformed. The area under th curve bone at a time when joint forces are greatest.
(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- The principal forces acting to move and stabilize th muscu
tial point of failure in zone D and complete failure in zone E. loskeletal System can be conveniently divided into two sets:
The graph in Figure 1 - 1 3 does not indicate th variable internai and external. Internai forces are produced from
of time. Tissues in which th stress-strain curve changes as a structures located within th body. These forces may be ac-
function of time are considered viscoelastic. Most tissues tive or passive. Active forces are generated by stimulated
within th musculoskeletal System demonstrate at least some muscle, generally under volitional control. Passive forces, in
degree of viscoelasticity (Fig. 1 - 1 5 ) . One phenomenon of a contrast, are typically generated by tension in stretched peri-
viscoelastic material is creep. As demonstrated by th tree articular connective tissues, including th intramuscular con
branch in Figure 1 - 1 5 , creep describes a progressive strain nective tissues, ligaments, and joint capsules. Active forces
of a material when exposed to a Constant load over time. produced by muscles are typically th largest of all internai
The phenomenon of creep explains why a person is taller in forces.
th moming than at night. The Constant compression caused External forces are typically produced by forces acting
by body weight on th spine throughout th day literally from outside th body. These forces usually originate from
squeezes fluid out of th intervertebral discs. The fluid is either gravity pulling on th mass of a body segment or an
reabsorbed at night while th sleeping person is in a non- external load, such as that of luggage or free weights, or
weight-bearing position. physical contact, such as that applied by a therapist against
The stress-strain curve of a viscoelastic material is also th limb of a patient. Figure 1 -1 6 A shows an opposing pair
sensitive to th rate of loading of th tissue. In generai, th of internai and external forces: an internai force (muscle),
slope of a stress-strain relationship when placed under ten pulling th forearm, and an external (graviiaiional) force,
sion or compression increases throughout its elastic range as pulling on th center of mass of th forearm. Each force is
th rate of th loading increases.8 The rate-sensitivity nature depicted by an arrow that represents a vector. By definition,
of viscoelastic connective tissues may protect surrounding a vector is a quantity that is completely specified by its
structures within th musculoskeletal System. Articular carti- 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 duced by muscle B is used to stretch muscle A, and th
Passive Tension into Useful Work cycle is repeated.
As previously described, connective tissue produces ten This transfer and Storage of energy between opposing
sion when stretched. Since tension is a force, it has th muscles is useful in terms of overall metabolic efficiency.
ability to do work. Several examples are presented This phenomenon is often expressed in different ways by
throughout this text in which th tension produced by multiarticular muscles (i.e., muscles that cross several
stretched connective tissues performs useful functions. joints). Consider th rectus femoris, a muscle that flexes
This phenomenon is called productive antagonism and is th hip and extends th knee. During th upward phase of
demonstrated for a pair of muscles in th simplified model jumping, for example, th rectus femoris contracts to ex-
in Figure 1-14. As shown in th middle, part of th en- tend th knee. At th same time, th extending hip
ergy produced by active contraction of muscle A is trans- stretches th active rectus femoris across th front of th
ferred and stored as an elastic energy in th stretched hip. As a consequence, th overall shortening of th rec
connective tissues within muscle B. The elastic energy is tus femoris is minimized, thereby maintaining a low level
released as muscle B actively contracts to drive th nail of useful passive tension within th muscle.
into th board (lower). Part of th contractile energy pro

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
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.
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 Factors Required to Completely Describe a Vector in
ormation. By 6 p m , th load has caused additional deformation Most Biomechanical Analyses
th branch. (With permission from Panjabi MM, White AA:
mechanics in th Musculoskeletal System. New York, Churchill
Direction (line-of-force or line-of-gravity)
ngstone, 2001.)
Point of application

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

As a push or a pul, all forces acting on th body cause a
-ompletely spedfied by its magnitude and has no direction.)
potential translation of th segment. The direction of th
In order to completely describe a vector in a biomechani-
translation depends on th net effect of all th applied
al analysis, its magnitude, direction, sense, and point of
forces. Since in Figure 1 - 1 6 A th muscle force is three
application must be known. The forces depicted in Figure
times greater than th weight of th forearm, th net effect
116A indicate these four factors.
of both forces would accelerate th forearm vertically up
1. The magnitude of each force vector is indicated by th ward. In reality, however, th forearm is typically prevented
ength of th shaft of th arrow. from accelerating upward by a joint reaction force produced
2. The direction of both force vectors is indicated by th between th surfaces of th joint. As depicted in Figure 1
' pattai orientation of th shaft of th arrows. Both forces are 16B, th distai end of th humerus is pushing down with a
riented vertically, commonly referred to as th Y direction. reaction force against th proximal end of th forearm. The
The direction of a force can also be described by th angle magnitude of th joint reaction force is equal to th differ-
rormed between th shaft of th arrow and a reference line. ence between th muscle force and external force. As a
Throughout this text, th direction of a muscle force and th result, th sum of all vertical forces acting on th forearm is
direction of gravity are commonly referred to as their line-of- balanced, and net acceleration of th forearm in th vertical
force and line-oj-gravity, respectively. direction is zero. The System is therefore in static linear
3. The sense of each force vector is indicated by th equilibiium.
orientation of th arrowhead. In th example depicted in
Mgure 1 -1 6 A , th internai force acts upward in a positive Y
Musculoskeletal Torques
sense; th external force acts downward in a negative Y sense.
4. The point o f application of th vectors is where th base Forces exerted on th body can have two outcomes. First, as
of th vector arrow contacts th part of th body. The point depicted in Figure 1- 16A, forces can potemially translate a
of application of th muscle force is where th muscle in- body segment. Second, th forces, if acting at a distance from

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

bow joint and associated bones. A, Internai
(muscle) and external (gravitational) forces are
shown both acting vertically, bui each in a 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.)

Externalforce External force
16 Section / Essential Topics of Kinesiology

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
FIGURE 1 -1 7 . The balance of internai and external torques acting push on th door knob multiplied by th perpendicular
in th sagittal piane about th axis of rotation at th elbow (small distance between th door knob and th hinge. Trying
circle) is shown. The internai torque is th product of th internai to open a door by pushing only a couple of centimeters
force multiplied by th internai moment arm (D). The internai from th hinge of th door is very difficult, even when
torque has th potenual to rotate th forearm in a counterclockwise applying a large pushing force. In contrast, a door can
direction. The external torque is th product of th external force be opened with a slight push, provided th push is
(gravity) and th external moment arm (D ,). The external torque applied at th door knob, which is purposely located at
has th potential to rotate th forearm in a clockwise direction. The
a distance far from th hinge. A torque is th product
internai and external torques are equal, demonstrating a condition
of a force and its moment arm. Both variables are
of static rotary equilibrium. (Vectors are drawn to relative scale.)
equally influential.
Torques are involved in most therapeutic situations
with patients, especially when physical exercise or
th axis of rotation at th joint, produce a potential rotation strength assessment is involved. A person's "strength"
of th joint. The shortest distance between th axis of rota is th product of their muscle's force, and, equally im-
tion and th force is called a moment arm. The product of a portant, th distance between th muscle's line-of-force
force and its moment arm is a torque or a moment. Torque and th axis of rotation. As explained further in Chapter
can be considered as a rotatory equivalent to a force. A force 4, th length of a muscle's moment arm changes con
pushes and pulls an object in a linear fashion, whereas a stantly throughout a range of motion. This partially ex-
torque rotates an object about an axis of rotation. plains why a person is naturally stronger in certain
Torques occur in planes about an axis of rotation. Figure parts of a joint's range of motion.
1 - 1 7 shows th torques produced within th sagittal piane Clinicians frequently apply manual resistance against
by th internai and external forces introduced in Figure 1 - their patients as a means to assess, facilitate, and chal-
16. The internai torque is defined as th product of th lenge a particular muscle activity. The force applied
internai force (muscle) and th internai moment arm. The against a patient's extremity is usually perceived as an
internai moment arm (see Fig 1 - 1 7 , D ) is th distance be external torque by th patient's musculoskeletal System.
tween th axis of rotation and th perpendicular intersection A clinician can challenge a particular muscle group by
with th internai force. As depicted in Figure 1 - 1 7 , th applying an external torque by way of a small manual
internai torque has th potential to rotate th forearm in a force exerted a great distance from th joint or a large
counterclockwise, or flexion, direction. manual force exerted dose to th joint. Either means
The external torque is defined as th product of th exter can produce th same external torque against th pa-
nal force (gravity) and th external moment arm. The exter tient. Modifying th force and external moment arm
nal moment arm (see Fig 1 17,D,) is th distance between variables allows different strategies to be employed
th axis of rotation and th perpendicular intersection with based on th strength and skill of th clinician.
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. passes through th axis of rotation) will not cause a torque or
a rotation. The muscle force is stili important, however,
Muscle and Joint Interaction because it usually provides a source of stability to th joint.

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 A muscle is considered activated when it is stimulated by
duced by a muscle that has a moment arm causes a torque, th nervous system. A muscle produces a force through
and a potential to rotate th joint. A force produced by a three types of activation: isometric, concentric, and eccentric.
muscle that lacks a moment arm (i.e., th muscle force The physiology of th three types of activation is described
Chapter 1 Getting Staned 17

greater detail in Chapter 3 and briefly summarized subse- A MUSCLES ACTION AT A JOINT
A muscles action at a joint is defined as its potential to cause
Isometrc activation occurs when a muscle is producing a
a torque in a particular rotation direction and piane. The
e while maintaining a Constant length. This type of acti
actual naming of a muscles action is based on an established
on is apparent by th origin of th word isometric (from
nomenclature, such as flexion or extension in th sagittal
Greek isos, equal; and metron, measure or length). Dur-
piane, abduction or adduction in th frontal piane, and so
an isometric activation, th internai torque produced at a
forth. The terms muscle action and joint action are used
t is equal to th external torque; hence, there is no
interchangeably throughout this text, depending on th con-
nuscle shortening or rotaiing at th joint (Fig. 1-1 8 A ).
text of th discussion. If th action is associated with a
Concentric activation occurs as a muscle produces a force
nonisometric muscle activation, th resulting osteokinematics
rs it contracts (shortens) (Fig. 1 -1 8 B ). Literally, concentric
may involve distal-on-proximal segment kinematics, or vice
means coming to th center. During a concentric activa-
versa, depending on th relative stability of th two segments
on, th internai torque at th joint exceeds th opposing
that comprise th joint.
lemal torque. This is reflected by th faci that th muscle
Kinesiology allows one to determine th action of a mus
- ontracted and accelerated a rotation of th joint in th
cle, without relying purely on memory. Suppose th student
direction of th activated muscle.
desires to determine th action of th posterior deltoid at th
Eccentric activation, in contrast, occurs as a muscle pro-
glenohumeral (shoulder) joint. In this particular analysis,
-uces an active force while being elongated. The word ec- two assumptions are made. First, it is assumed that th
centric literally means away from th center. During an humerus is th freest segment of th joint, and that th
eccentric activation, th external torque about th joint ex scapula is ftxed, although th reverse assumption could have
ceeds th internai torque. In this case, th joint rotates in been made. Second, il is assumed that th body is in th
die direction dictated by th relatively larger external torque, anatomie position at th time of th muscle activation.
such as that produced by th cable in Figure 1 -1 8 C . Many The first step in th analysis is to determine th planes of
common activities employ eccentric activations of muscle. rotary motion (degrees of freedom) allowed at th joint. In
Slowly lowering a cup of water to a table, for example, is this case, th glenohumeral joint allows rotation in all three
caused by th pul of gravity on th forearm and water. The planes (see Fig. 1 - 5 ) . Figure 1 -1 9 A shows th potential for
activated biceps slowly elongates in order to control their th posterior deltoid to rotate th humerus in th frontal
descent. The triceps muscle, although considered as an el- piane. The axis of rotation at th joint passes in an anterior-
bow extensor, is most likely inactive during this particular posterior direction through th humeral head. In th ana
process. tomie position, th line-of-force of th posterior deltoid
The term contraction is often used synonymously with passes inferior to th axis of rotation. By assuming that th
activation, regardless of whether th muscle is actually scapula is stable, th posterior deltoid would rotate th hu
shortening, lengthening, or remaining at a Constant length. merus toward adduction, with a strength equal to th prod
The term contract literally means to be drawn together and, uci of th muscle force multiplied by its internai moment
therefore, its use can be confusing when describing either an arm. This same logie is next applied to determine th mus
isometric or eccentric activation. Technically, a contracting cles action in th horizontal and sagittal planes. As depicted
muscle occurs during a concentric activation only. 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

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.

b ib l io t e c a
Chapter I Getting Started 19

Another example of muscle synergy is described as a half his w'eight, who is sitting twice th distance from th
uscular force-couple. A muscular force-couple is formed pivot point. In Figure 1 - 2 1 , th opposing torques are equal:
hen two or more muscles simultaneously produce forces in
cifferent linear directions, although die torques act in th BWm X D = BWb X D,.
siine rotary direction. A familiar analogy of a force couple
occurs between th two hands while tuming a steering As indicated, th boy has th greatest leverage (D,). Leverage
-heel of a car. Rotating th steering w'heet to th right, for describes th relative moment arm length possessed by a
-ixample, occurs by th action of th right hand pulling particular force.
down and th left hand pulling up on th wheel. Although Internai and extemal forces produce torques throughout
th hands are producing forces in different linear directions, th body through a System of bony levers. The most impor-
they cause a torque on th steering wheel in a common tant forces involved with musculoskeletal levers are those
mtary direction. The hip flexor and low back extensor mus- produced by muscle, gravity, and physical contacts within
des, for example, form a force-couple to rotate th pelvis in th environment. Levers are classified as either first, second,
me sagittal piane about both hip joints (Fig. 1 - 2 0 ). or third class.
First-Class Lever. As depicted in Figure 1 - 2 1 , th first-
Musculoskeletal Levers class lever has its axis of rotation positioned between th
THREE CLASSES OF LEVERS opposing forces. An example of a frst-class lever in th body
is th head-and-neck extensor muscles that control th pos
A lever is a simple machine consisting of a rod suspended ture of th head in sagittal piane (Fig. 1 -2 2 A ). As in th
across a pivot point. The seesaw is a classic example of a seesaw' example, th head is held in equilibrium when th
iever. One function of a lever is to convert a force into a product of th muscle force (MF) multiplied by th internai
torque. As shown in th seesaw' in Figure 1 - 2 1 , a 672-N moment arm (IMA) equals th product of head weight (F1W)
(about 150-lb) man sitting 0.91 m (about 3 fi) from th multiplied by its extemal moment arm (EMA). In first-class
pivot point produces a torque that balances a boy weighing 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 = 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 = 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 = 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.

Chapter 1 Cetting Storteci 21

ar directions, although they produce torques in opposing holding an extemal weight of 3 5 .6N (8 lb) in th hand. For
ry directions. th sake of this example, assume that th muscles have an
internai moment arm of 2.5 cm (about 1 in) and that th
Second-Class Lever. A second-class lever has two
center of mass of th extemal weight has an extemal mo
.nique features. First, its axis of rotation is located at one
ment arm of 50 cm (about 20 in). (For simplicity, th
id of a bone. Second, th muscle, or internai force, pos-
weight of th limb is ignored.) The 1/20 MA requires that
iisses greater leverage than th extemal force. As illustrateci
th muscle would have to produce 711.7N (160 lb) of force,
Figure 1 - 2 2 6 , a calf muscle group uses a second-class
or twenty times th weight of th extemal load! As a generai
:ver to produce th torque needed to stand on tiptoes. The
principle, skeletal muscles produce forces several times
i-xis of rotation for this action is through th metatarsopha-
larger than th extemal loads that oppose them. Depending
mgeal joints. The internai moment arm used by calf mus-
on th shape of th muscle and configuration of th joint, a
es greatly exceeds th extemal moment arm used by body
certain percentage of th muscle force produces large com-
eight. Second-class levers are rare in th musculoskeletal
pression or shear forces at th joint surfaces. Periarticular
tissues, such as articular cartilage, fat pads, and bursa, must
Third-Class Lever. As in th second-class lever, th partially absorb or dissipate these large myogenic (muscular-
-fard-class lever has its axis of rotation located at one end of produced) forces. In th absence of such protection, joints
a bone. The elbow flexor muscles use a third-class lever to may partially degenerate and become painful and chroncally
"roduce th flexion torque required to support a barbell inflamed. This presentation is th hallmark of severe osteoar-
rig. 1 -2 2 C ). Unlike th second-class lever, th extemal thritis.
weight supported by a third-class lever always has greater
Dictating th "Trade-off" between Force and Distance
iverage than th muscle force. The third-class lever is th
most common lever used by th musculoskeletal System. 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
VIECHANICAL ADVANTAGE flawed. The design is absolutely necessary, however, when
th large distances and velocities experienced by th more
The mechanical advantage (MA) of a musculoskeletal lever is
distai points of th extremities are considered.
iefined as th ratio of th internai moment arm to th
Work is th product of force times distance (see Chapter
extemal moment arm. Depending on th location of th axis
4). In addition to converting a force to a torque, a musculo-
3i rotation, th first-class lever can have an MA equal to, less
skeletal lever converts th work of a contracting muscle to
than, or greater than one. Second-class levers always have an
th work of a rotating bone. The mechanical advantage of a
MA greater than one. As depicted in th boxes associated
musculoskeletal lever dictates how th work is converted
with Figure 1 -2 2 A and B, lever systems with an MA greater
through either a relatively large force exerted over a short
than one are able to balance th torque equilibrium equation
distance or a small force exerted over a large distance. Con
by an internai (muscle) force that is less than th extemal
sider th small mechanical advantage of 1/20 described ear-
force. Third-class levers always have an MA less than one.
lier for th supraspinatus and deltoid muscles. This mechani
As depicted in Figure 1 -2 2 C , in order to balance th torque
cal advantage implies that th muscle must produce a force
equilibrium equation, th muscle must produce a force
20 times greater than th weight of th extemal load. What
much greater than th opposing extemal force.
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
Mechanical Advantage (MA) is equal to th Internai very short contraction distance of th muscles produces a
Moment Arin/External Moment Arm very large angular displacement of th arm.
Although all points throughout th abducting arm share
First-class levers may have an MA less than 1, equal to 1, th same angular displacement and velocity, th more distai
or more than 1.
points on th arm move at an even greater linear displace
Second-class levers always have an MA more than 1.
ment and velocity. The ability of a short contraction range to
Third-class levers always have an MA less than 1.
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
The majority of muscles throughout th musculoskeletal relatively narrow range of its overall length.
System function with a mechanical advantage of much less In summary, most muscle and joint systems in th body
than one, and, actually, it may be more appropriate to cali function with a mechanical advantage of less than one. The
this a mechanical disadvantage! Consider, for example, th muscles and underlying joints must, therefore, pay th
biceps at th elbow, th quadriceps at th knee, and th price by generating and dispersing relative large forces, re-
supraspinatus and deltoid at th shoulder. Each of these spectively, even for seemingly low-load activities. Obtaining
muscles attaches to bone relatively dose to th join ts axis of a high linear velocity of th distai end of th extremities is a
rotation. The extemal forces that oppose th action of th necessity for generating large contact forces against th envi-
muscles typically exert their influence considerably distally to ronment. These high forces can be used to rapidly accelerate
th joint, such as ai th hand or th foot. Consider th force objects held in th hand, such as a tennis racket, or to
demands placed on th supraspinatus and deltoid muscles accelerate th limbs purely as an expression of art and ath-
to maintain th shoulder abducted to 90 degrees while leticism, such as dance.
22 Section 1 Essential Topics o j Kinesiology


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

point or th center of rotation).
Acceleration: change in velocity of a body over time, ex- Axial rotation: angular motion of an object in a direction
pressed in linear (m/s2) and angular (/s2) terms. perpendicular to its longitudinal axis, often used to de-
Accessory movements: slight, passive, nonvolitional move- senbe a motion in th horizomal piane.
ments allowed in most joints (also called joint play). Bending: effect of a force that deforms a material at righi
Active force: push or pul generated by stimulated muscle. angles to its long axis. A bent tissue is compressed on its
Active movement: motion caused by stimulated muscle. concave side and placed under tension on its convex side.
Agonist muscle: muscle or muscle group that is most di- A bending moment is a quantitative measure of a bend.
rectly related to th initiation and execution of a particu- Similar to a torque, a bending moment is th product of
lar movement. th bending force and th perpendicular distance between
Angle-of-insertion: angle formed between a tendon of a th force and th axis of rotation of th bend.
muscle and th long axis of th bone to which it inserts. Center of mass: point at th exact center of an objects
Antagonist muscle: muscle or muscle group that has th mass (also referred to as center of gravity w'hen consider-
action opposite to a particular agonist muscle. ing th weight of th mass).
Arthrokinematics: motions of roll, slide, and spin that oc- Close-packed position: umque position of most joints of
cur between th articular surfaces of joints. th body where th articular surfaces are most congruent,
Axis of rotation: an imaginary line extending through a and th ligaments are maximally taut.
Chapter 1 Getting Storteci 23

pressioni application of one or more forces that press Line-of-force: direction of a muscles force.
n object or objects together. Compression tends to Line-of-gravity: direction of th gravitational pul on a
morten and widen a material. body.
ttcentric activation: activated muscle that shortens as it Load: generai term that describes th application of a force
produces a force. to a body.
:ep: a progressive strain of a material when exposed to a Longitudinal axis: axis that extends within and parallel to a
Constant load over lime, long bone or body segment.
i- grees of freedom: number of independent movements Loose-packed positions: positions of most joints of th
\ allowed at a joint. A joint can have up to three degrees of body where th articular surfaces are least congment, and
| translation and three degrees of rotation. th ligaments are slackened.
Desplacement: change in th linear or angular position of an Mass: quantity of matter in an object.
f object. Mechanical advantage: ratio of th internai moment arm to
- stal-on-proximal segment kinematics: type of movement th extemal moment arm.
in which th distai segment of a joint rotates relative to a
Muscle action: potential of a muscle to produce an internai
fixed proximal segment falso called an open kinematic
torque within a particular piane of motion and rotar)'
' chain).
direction falso called joint action when referring specifi
Enstraction: movement of two objects away from one an-
cali)' to a muscles potential to rotate a joint). Terms that
describe a muscle action are flexion, extension, pronation,
Eicentric activation: activated muscle that is elongating as it
supination, and so forth.
produces a force.
Elasticity: property of a material demonstrated by its ability Osteokinematics: motion of bones relative to th three Car
to return to its originai length after th removai of a dinal, or principal, planes.
deforming force. Passive force: push or pul generated by sources other than
Esternai force: push or pul produced by sources located stimulated muscle, such as tension in stretched periarticu-
outside th body. These typically include gravity and lar connettive tissues, physical contact, and so forth.
physical contact applied against th body. Passive movement: motion produced by a source other
Esternai moment arm: distance between th axis of ro than activated muscle.
tation and th perpendicular intersection with an extemal Plasticity: property of a material demonstrated by remaining
force. permanently defotmed after th removai of a force.
Extemal torque: product of an extemal force and its exter- Pressure: force divided by a surface area falso called stress).
nal moment arm falso called extemal moment). Produttive antagonismi phenomenon in which relatively
Force: a push or a pul that produces, arrests, or modifies a low-level tension within stretched connettive tissues per-
motion. forms a useful function.
Force-couple: interaction of two or more muscles acting in Proximal-on-distal segment kinematics: type of movement
different linear directions, bui producing a torque in th in which th proximal segment of a joint rotates relative
same rotary direction. to a fixed distai segment falso referred to as a closed
Force of gravity: potential acceleration of a body to th kinematic chain).
center of th earth due to gravity. Rolli multiple points along one rotating articular surface
Friction: resistance to movement between two contacting contact multiple points on another articular surface. (Also
surfaces. called rock.)
Internai force: push or pul produced by a strutture located Rotation: angular motion in which a rigid body moves in a
within th body. Most often internai force refers to that circular path about a pivot point or an axis of rotation.
produced by an attive muscle.
Scalar: quantity, such as speed and temperature, that is
Internai moment arm: distance between th axis of rotation
completely specified by its magnitude and has no direc
and th perpendicular intersection with a muscle (inter
nai) force.
Segment: any pari of a body or limb.
Internai torque: product of an internai force and its internai
Shear: forces on a material that act in opposite but parallel
moment arm.
directions (like th action of a pair of scissors).
Isometric activation: activated muscle that maintains a Con
stant length as it produces a force. Shock absorption: ability to dissipate forces.
Joint reaction force: push or pul produced by one joint Slide: single point on one articular surface contacts multiple
surface against another. points on another articular surface. (Also called glide.)
Kinematics: branch of mechanics that describes th motion Spini single point on one articular surface rotates on a single
of a body, without regard to th forces or torques that point on another articular surface flike a toy top).
may produce th motion. Static linear equilibrium: state of a body at rest in which
Kinematic chain: series of articulated segmented links, such th sum of all forces is equal to zero.
as th connected pelvis, thigh, leg, and foot of th lower Static rotary equilibrium: state of a body at rest in which
extremity. th sum of all torques is equal to zero.
Kinetics: branch of mechanics that describes th effect of Stiffness: ratio of stress (force) to strain (elongation) within
forces on th body. an elastic material.
Leverage: relative moment arm length possessed by a partic- Strain: ratio of a tissues deformed length to its originai
ular force. length.
24 Section 1 Essentia Topics o f Kinesiology

Stress: force generateci as a tissue resists deformation, di- of kinesiology are provided. Chapters 2 to 4 give additional
vided by its cross-sectional area falso called pressure). background on th essentia topics of kinesiology. This
Synergists: two muscles that cooperate to execute a particu- material then sets th foundation for th more anatomic-
lar movement. based chapters, starting with th shoulder complex in Chap-
Tensioni application of one or more forces that pulls apart ter 5.
or separates a material. (Also called a distraction force.)
Used to denote th internai stress within a tissue as it
resists being stretched. REFERENCES
Torque: a force multiplied by its moment arm; tends io 1 Brand PW: Clinica! Biomechanics of thc Hand. Si Louis, CV Mosby
rotate a body or segment about an axis of rotation. 1985
Torsioni application of a force that twists a material about 2. Bynum EB, Barrack RL, Alexander AH: Open versus closed chain kt-
its longitudinal axis. netic exercises after anierior cruciale iigament reconstruction. Am J
Sports Med 23:401-406, 1995.
Translation: linear motion in which all parts of a rigid body
3. Fitzgerald GK: Open versus closed kineiic chan exercises: Afler anteiior
move parallel to and in th same direction as every other cruciale ligament reconstructive surgery Phys Ther 77:1747-1754
point in th body. 1997.
Vector: quantity, such as velocity or force, that is completely 4. Gowitzke BA, Milner M: Scienufic Bases of Human Movement, 3rd ed.
specified by its magnitude and direction. Baltimore, Williams & Wilkins, 1988.
5. Hardee EB 111: Personal commumcation. Afton, VA, 2002.
Velocity: change in position of a body over rime, expressed 6. Neumann DA: Arthrokinesiologic considerations for th aged adult. In
in linear (m/s) and angular (degrees/s) terms. Gucaone AA: Geriatrie Physical Therapy, 2nd ed. Chicago, Mosby-Year
Viscoelasticity: property of a material expressed by a chang- Book, 2000
ing stress-strain relationship over time. 7. Nordin M, Frankel VH: Basic Biomechanics of th Musculoskeletai Sys
tem, 2nd ed. Philadelphia, Lea & Febiger, 1989.
Weight: gravitational force acting on a mass.
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,
SUMMARY 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.
Many of th basic biomechanical principles and essentia 11. Williams PL, Bannister LH, Berry M, et al: Gray's Anatomy, 38th ed.
terms and concepts used to communicate th subject matter 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

JOINTS, 25 Articular Cartilage, 34
Classification Based on Anatomie Fibrocartiiage, 35
Structure and Movement Potential, 25 JOINTS, 31 Bone, 36
Synarthrosis, 25 Fibers, 31 EFFECTS OF AGING, 37
Amphiarthrosis, 25
Diarthrosis: The Synovial Joint, 26 Cells, 32
Classification of Synovial Joints Based on STRENGTH OF THE CONNECTIVE TISSUES
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

exist in th body and are defined as synarthrosis, am phiar
A joint is th junction or pivot point between two or more throsis, and diarthrosis.
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. A synarthrosis is a junction between bones that is held to-
Arthrology th study of th classification, structure, and gether by dense irregular connective tissue. This relatively
function of joints is an important foundation for th over- rigid junction allows little or no movement. Examples of
all study of kinesiology. Aging, long-term immobilization, synarthrodial joints include th sutures of th skull, th teeth
trauma, and disease all affect th structure and ultimate embedded in th mandible and maxillae, th distai tibiofibu-
lunction of joints. These factors also significantly influence lar joint, and th interosseous membranes of th forearm
th quality and quantity of human movement. and leg. The epiphysial piate of a growing bone is also
This chapter focuses on th generai anatomie structure classified as a synarthrodial joint by some.27 Because th
and function of joints. The chapters contained in Sections II function of an epiphysis is skeletal growth rather than mo-
io IV review th specific anatomy and detailed function of tion, this classification is not used here.
th individuai joints throughout th body. This detailed in- The function of a synarthrosis is to bind bones together
formation is a prerequisite for th effective rehabilitation of and io transmit force from one bone to th next with mini
persons with joint dysfunction. mal joint motion. A synarthrodial joint allows forces to be
dispersed across a relatively large area of contaci, thereby
reducing th possibility of injury.
JOINTS______________ ____________________
Classification Based on Anatomie Structure
and Movement Potential An amphiarthrosis is a junction between bones that is formed
primarily by fibrocartiiage and/or hyaline cartilage. Perhaps
One common method to classify joints focuses primarily on th most familiar example of an amphiarthrosis is th inter-
anatomie structure and their subsequent movement potential body joint of th spine. This joint uses an intervertebral disc
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

and embedded nucleus pulposus to provide a rugged, resil- articular capsule. The articular capsule is composed of two
ient cushion that absorbs and disperses forces between adja- histologically distinct layers. The internai layer consists of a
cent vertebrae. Other examples of amphiarthrodial joints are thin (4) synovial membrane, which averages three to ten celi
th pubic symphysis and th manubriosternal joint. These layers thick. The membrane acts as a barrier to adjacent
joints allow relatively restrained movements. They also trans- capillaries, permitting only th fluid and solutes of blood
mit and disperse forces between bones. 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-
A diarthrosis is an articulation that contains a fluid-filled proteins (i.e., lubricin) to th joint fluid.26
joint cavity between bony partners. Because of th presence The external, or fibrous, layer of th articular capsule of
of a synovial membrane, diarthrodial joints are more fre- th synovial joint is composed of dense irregular connective
quently referred to as synovial joints. Synovial joints are th tissue. The articular capsule provides support between th
majority of th joints of th upper and lower extremities. bones and containment of th joint contents. Certain regions
Diarthrodial, or synovial, joints are specialized for move of th fibrous capsule are thicker in order to resist or control
ment and always exhibit seven elements (Fig. 2 - 1 ) . The specific motions. The thickened regions of connective tissue
joint cavity is filled with (1) synovial fluid. This provides represent (5) capsular ligaments. Examples of prominent cap-
nutrition and lubrication for th (2) articular cartilage that sular ligaments are th anterior glenohumeral ligaments and
covers th ends of th bones. The joint is enclosed by a th mediai collateral ligament of th knee. The joint capsule
peripheral curtain of connective tissue that forms th (3) 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
Capsular ligaments Synovial
Blood vessels membrane Synovial
Sensory nerves FIGURE 2-1. Elements associated
Elements SOMETIMES associated with Fat pad with a typical diarthrodial (synovial)
diarthrodial (synovial) joints. Articular
joint. The synovial plicae are not de-
Intraarticular discs or menisci cartilage picted.
Peripheral labrum
Fat pads
Synovial plicae Bursa

Chapter 2 Basic Structure and Function o j th Joints 27

that penetrate as far as th junction of th fbrous capsule size and positioned within th substance of th joint capsule,
and synovial membrane. The (7) sensory nerves also supply interposed between th fbrous capsule and th synovial
th fbrous capsule with appropriate receptors for pain and membrane. Fat pads are most prominent in th elbow and
proprioception. th knee joints. They thicken th joint capsule, causing th
To accommodate th wide spectrum of joint shapes and inner surface of th capsule to fili nonarticulating synovial
iunctional demands, other elements may sometimes appear spaces (i.e., recesses) formed by incongruent bony contours.
in synovial joints (see Fig. 2 - 1 ) . Inttaarticular discs, or In this sense, fat pads reduce th volume of synovial fluid
nenisci, are pads of fibrocartilage imposed between th artic- necessary for proper joint function. If these pads become
ular surfaces of synovial joints. These structures increase enlarged or inflamed, they may alter th mechanics of th
articular congruency and improve force dispersion. Intraar- joint.
ucular discs and menisci are found in several joints of th Synovial plicae (i.e., synovial folds, synovial redundancies,
:ody (see Box). Menisci are occasionally found in th or synovial fringes) are slack, overlapped pleats of tissue
apophyseal joints of th spine, but their function, constancy, composed of th innermost layers of th joint capsule. They
and frequency remain controversial.1-8-29-30 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
Intraarticular Discs (Menisci) Are Found in Several th synovial lining. If these folds are too extensive or be
Synovial Joints of th Body come thickened or adherent due to inflammation, they can
Tibiofemoral (knee) produce pain and altered joint mechanics.3-415
Distai radioulnar
Acromioclavicular Classification of Synovial Joints Based on
Mechanical Analogy
Thus far, joints have been classified into three broad catego-
Two large synovial joints of th body possess a peripheral ries according to th anatomie structure and subsequent
labrum of fibrocartilage. The labrum extends from th bony movement potential: synarthrosis, amphiarthrosis, and diar-
nms of both th glenoid cavity of th shoulder and th throsis. Because an in-depth understanding of synovial joints
acetabulum of th hip. These specialized structures deepen is so cruciai to an understanding of th mechanics of move
th concave member of these joints and supporr and thicken ment, they are here further classified using an analogy to
th attachment of th joint capsule. Fat pads are variable in 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 Door hinge Humeroulnar joint
Interphalangeal joint
Pivot joint Spinning of one member around a sin Door knob Proximal radioulnar joint
gle axis of rotation Atlantoaxial joint
Ellipsoid joint Biplanar motion (flexion-and-extension Flattened convex ellipsoid Radiocarpal joint
and abduction-and-adduction) paired with a concave
Ball-and-socket joint Triplanar motion (flexion-and-extension, Spherical convex surface paired Glenohumeral joint
abduction-and-adduction, and inter- with a concave cup. Coxofemoral (hip) joint
nal-and-external rotation)
Piane joint Typical motions include a slide (transla- Relatively fiat surfaces apposing Intercarpal joints
tion) or a combined slide and rota one another, like a book on Iniertarsal joints
tion. a table.
Saddle joint Biplanar motion; a spin between th Each member has a reciprocaily Carpometacarpal joint of th thumb
bones is possible bui may be limited curved concave and convex Stemoclavicular joint
by th interlocking nature of th surface oriented at right an-
joint. gles to one another, like a
borse rider and a saddle.
Condyloid joint Biplanar motion; either flexion-and- Mosily spherical convex surface Metacarpophalangeal joint
extension and abduction-and- that is enlarged in one di- Tibiofemoral (knee) joint
adduction, or flexion-and-extension mension like a knuckle;
and axial rotation (intemal- paired with a shallow con
and-extemal rotation) cave cup.
28 Section I Essential Topics o f Kinesiology

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.

A hinge joint is analogous to th hinge of a door, formed radiocarpal joint is an example of an ellipsoid joint (Fig.
by a centrai pin surrounded by a larger hollow cylinder (Fig. 2 -4 B ). The flattened ball of th convex member of th
2 -2 A ). Angular motion at hinge joints occurs primarily in a joint (i.e., carpai bones) cannot spin within th elongated
piane located at right angles to th hinge, or axis of rotation. trough (i.e., distai radius) withoul dislocating.
The humeroulnar joint is a clear example of a hinge joint A ball-and-socket joint has a spherical convex surface that
(Fig. 2 - 2 B). As in all synovial joints, slight translation (i.e., is paired with a cuplike socket (Fig. 2 -5 A ). This joint pro-
sliding) is allowed in addition to th rotation. Although th vides motion in three planes. Unlike th ellipsoid joint, th
mechanical similarity is less complete, th interphalangeal symmetry of th curves of th two mating surfaces of th
joints of th digits are also classified as hinge joints. ball-and-socket joint allows spin without dislocation. Ball-
A pivot joint is formed by a centrai pin surrounded by a and-socket joints within th body include th glenohumeral
larger cylinder. Unlike a hinge, th mobile member of a joint and th hip joint.
pivot joint is oriented parallel to th axis of rotation. This A piane joint is th pairing of two fiat or relatively fiat
mechanical orientation produces th primary angular motion surfaces. Movements combine sliding and some rotation of
of spin, similar to a doorknobs spin around a centrai axis one partner with respect to th other much like a book
(Fig. 2 -3 A ). Two excellent examples of pivot joints are th can be slid over a tabletop (Fig. 2 -6 A ). As depicted in
proximal radioulnar joint, shown in Figure 2 - 3 B, and th Figure 2 - 6 B, most of th intercarpal joints are considered to
atlantoaxial joint between th dens of th second cervical be piane joints. The internai forces that cause or restrict
vertebra and th anterior arch of th first cervical vertebra. movement between carpai bones are supplied by tension in
An ellipsoid joint has one partner with a convex elongated muscles or ligaments.
surface in one dimension that is mated with a similarly Each partner of a saddle joint has two surfaces: one sur
elongated concave surface on th second partner (Fig. face is concave, and th other is convex. These surfaces are
2 -4 A ). The elliptic mating surfaces severely restrict th spin oriented at approximate right angles to one another and are
between th two surfaces but allow biplanar motions, usually reciprocali)' curved. The shape of a saddle joint is best visu-
deftned as flexion-extension and abduciion-adduction. The 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
FIGURE 2-3. A pivot joint (A) is shown as analogous to th proxi cervical vertebra). The metacarpophalangeal joint of th fin
mal radioulnar joint (B). The axis of rotation is represented by th ger is also an example of a condyloid joint. The root word
pin. of th term condyle actually means knuckle.
Chapter 2 Basic Stmcture and Function o f th Joints 29


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.

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

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.

The kinematics at condyloid joints vary based on joint

seen in th gentle undulations that characterize th intercar-
structure. At th knee, for example, th femoral condyles fu
pal and intertarsal joints. These joints produce complex mul-
wtthin th slight concavity provtded by th ttbial plateau.
tiplanar movements that are tnconsistent with their simple
This articulation allows flexion-extension and axial rotation
planar mechanical classification. To circumvent this diffi-
(i.e., spin). Abduction and adduction, however, are restricted
primarily by ligaments. 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.
Simplifying th Classification of Synovial An ovoid joint has paired mating surfaces that are imper-
Joints: Ovoid and Saddle Joints fectly spherical, or egg-shaped, with adjacent parts possess-
ing a changing surface curvature. In each case, th articular
lt is often difficult to classify synovial joints based on an
surface of one bone is convex and th other is concave.
analogy to mechanics alone. The metacarpophaiangeal joint
A saddle joint has been previously described. Each mem-
(condyloid) and th glenohumeral joint (ball-and-socket), for
ber presents paired curved surfaces that are opposite in di
example, have similar shapes but differ considerably in th
rection and oriented at approximately 90 degrees to each
relative magnitudo of movement and overall function. Joints
other. This simplified classification System allows th gener-
always display subtle variations that make simple mechanical
alization to th arthrokinematic patterns of movement as a
descriptions less applicable. A good example of th differ
roll slide, or spin (see Chapter 1). This generalization is
ente between mechanical classification and true function 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-
FIGURE 2 8. A condyloid joint is shown (A) representing an anal
face is th second basic type of joint surface, having one convex
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 surlace and one concave surface. The paired articulating surface of
blocked by tension in th collateral ligament. 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


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
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.


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

Type I: thick, rugged fibers that elongate very little when
stretched; compose ligaments, tendons, fascia, and fibrous
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. 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
Type II collagen fibers are thinner than type 1 and possess attached, forming a botile brush configuration. The GAG molecule
is shown interlacing between collagen fibrils. Water fills much of
slightly less tensile strength. These fibers provide a flexible
th space within th matrix. (From Nordin M, Frankel VH: Basic
woven framework for maintaining th generai shape and
Biomechanics of th Musculoskeletal System, 2nd ed. Philadelphia,
consistency of more complex structures, such as hyaline car- Williams & Wilkins, 1989.)
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 Cells
composed of a netlike interweaving of small elastin fibrils
The cells within connective tissues of th joints are responsi-
that resist tensile (stretching) forces, bui they have more
ble for maintenance and repatr. In contrast to skeletal mus
give when elongated. Tissues with a high proportion of
cle cells, these cells do not confer significant mechanical
elastin readily return to their originai shape after being de-
properties on th tissue. Damaged or aged components are
formed. This property is useful in structures that undergo
significant deformation, such as th cartilage of th ear, or in removed, and new components are manufactured and re-
certain spinai ligaments that help return a bone to its origi modeled. Cells of connective tissues of th joints are gener
nai posinoti after movement. 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
Ground Substance often results in poor or incomplete healing of damaged or
Collagen and elastin fibers are embedded within a water- injured joint tissues.
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 TYPES OF CONNECTIVE TISSUES THAT
and negatively charged amino sugars that are strongly FORM THE STRUCTURE OF JOINTS
bonded with water. Structurally, th GAGs resemble long
botile brushes that are strongly hydrophilic due to their Four types of connective tissues predominale in joints; dense
negative charge (Fig. 2 - 1 1 ) . Water provides a fluid medium ir regalar connective tissue, articular cartilage, Jbrocartilage, and
for diffusion of nutrients within a tissue. In addition, water bone. Anatomie and functional details of th four connective
assists with th mechanical properties of tissue. The ten- tissues are listed in Table 2 - 3 . The table also includes clini-
dency of GAGs to imbibe and hold water causes th tissue cal correlates associated with each 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
Dense Irregular Connective Tissue
th restraining fibers and th swelling GAGs provides a tur- Dense irregular connective tissue is found in th fibrous exter-
gid structure that resists compression, much like a balloon nal layer of th articular capsule, ligaments, fascia, and ten
or a water-filled mattress. An example of such a structurally dons. Structurally, this connective tissue has a high propor
dynamic material is articular cartilage. This important tissue tion of type I collagen fibers that are arranged in bundles
provides an ideal surface covering for joints and is capatile and aligned to resist th naturai stresses placed on th tissue.
of dispersing th millions of repetitive forces that have an The connective tissue bundles function most effectively when
impact on joints throughout a lifetime. 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-
and distai ra-
dioulnar joints
Forms th la
brum of th
glenoid fossa
and th ace-
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-
34 Section i Essential Topici o j Kinesiology

slack is pulled tight, th ligaments and joint capsule provide repair underlying tissue. This is an advantage not available
immediate tension that restrains undesirable motion between to articular cartilage.
bony partners. Chondrocytes of various shapes are located within th
The ftbrous joint capsule and ligaments resist forces from ground substance of different layers or zones of articular
severa! directions. To accomplish this, th fiber bundles cartilage (Fig. 2 -1 3 A ). These cells are bathed and nourished
within th connective tissues are arranged in several domi- by nutrients within th synovial fluid. Nourishment is facili-
nant directions, unlike th parallel alignment of collagen tated by th "milking action of articular surface deformation
bundles found in a tendon (Fig. 2 12).6 20 The GAGs and during intermittent joint loading. The chondrocytes are sur-
elastin fiber content are usually low in dense irregular con rounded by predominantly type II collagen fibers. As de-
nective tissue. picted in Figure 2 - 1 3 B , th fibers are arranged to form a
When trauma or disease produces laxity in th ligament restraining network or scaffolding that adds structural sta-
or capsules, muscles take on a more dominant role in re- bility to th tissue. The deepest fibers in th calcified zone
straining joint movement. Even if muscles surrounding a are firmly anchored to th subchondral bone. These fibers
ligamentously lax joint are strong, there is loss of joint sta- are linked to th vertically oriented fibers in th adjacent
bility. Compared with ligaments, muscles are slower to deep zone which, in tum, are linked to th obliquely ori
supply force due to th electromechanical delay neces- ented fibers of th middle zone, and finally to th trans-
sary to build active force. Muscle forces often have a less versely oriented fibers of th superficial tangential zone. The
than ideal alignment for restraining undesirable joint move- series of chemically interlinked fibers form a netlike fibrous
ments, and they often cannot provide th most optimal de- structure that entraps th large GAG molecules beneath th
terrent force. 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-
Articular Cartilage stand loads.
Articular cartilage distributes and disperses compressive
Articular cartilage is a specialized type of hyaline carti torces to th subchondral bone. It also reduces friction be
lage that forms th load-bearing surface of joints. Artic tween joint surfaces. The coefficient of friction between two
ular cartilage covering th ends of th articulating bones surfaces covered by articular cartilage and wet with synovial
has a thickness that ranges from 1 to 4 mm in th areas of fluid is extremely low, ranging from 0.005 to 0.02 in th
low compression force and 5 to 7 mm in areas of high human knee for example. This is 5 to 20 times lower and
compression.16'25 The tissue is avascular and aneural. Un more slippery than ice on ice, which has a coefficient of 0 .1 .17
like regular hyaline cartilage, articular cartilage lacks a The impaci of normal weight-bearing activities, therefore, is
perichondrium. This allows th opposing surfaces of th reduced to a stress that typically can be absorbed without
cartilage to form ideal load-bearing surfaces. Similar to damaging th skeletal System.
periosteum on bone, perichondrium is a layer of connective The absence of a perichondrium on articular cartilage has
tissue that covers most cartilage. lt contains blood vessels th negative consequence of eliminating a ready source of
and a ready supply of primitive cells that maintain and 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
Parallel bundles
of collagen
packed and arranged parallel to one
another. The arrangement allows Lhe
Irregularly arranged bundles tendon to iransmit unidirectional ten
of collagen fibers 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
Fibrocytes bundles that are less parallel to one
another. This allows th ligament to
TENDO N accept tensile forces from several dif
ferent directions while holding two
L IG A M E N T 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
Chapter 2 Basic Structure and Functon o j th Joints 35

Articular surface

10 20
( % %)

Middle zone

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

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- organized and contains small blood vessels located only near
:ance and replenishment of its matrix, significant damage io th peripheral rim of th tissue. Fibrocartilage is largely
idult articular cartilage is often repaired very poorly or noi aneural and thus does noi produce pain or participate in
ai all. 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-
As its name implies, fibrocartilage has a much higher fiber dent on diffusion of nutrients through th synovial fluid in
coment than other types of cartilage. The tissue functionally synovial joints. In amphiarthrodial joints, such as th adult
shares properties of both dense irregular connective tissue intervertebral disc, nutrients are diffused across th fluid
and articular cartilage. Dense bundles of type I collagen contained in th adjacent trabecular bone. The diffusion of
travel in many directions with a moderate number of GAGs. nutrients and removai of metabolic wastes in th fibrocarti
As depicted in Figure 2 - 1 4 , round chondrocytes reside lage of amphiarthrodial joints is assisted by th milking"
within lacunae that are embedded within a dense collagen action of intermittent weight hearing.13 This principle is
network. readily apparent in adult intervertebral discs that are insuffi
Fibrocartilage forms much of th substance of th inter cienti)' nourished when th spine is held in fixed postures
vertebral discs, th labrum, and th discs located within th for extended periods. Without proper nutrition, th discs
pubic symphysis and other joints of th extremities (for may partially degenerate and lose part of their protective
example, th menisci of th knee). These structures help function.
support and stabilize th joints, as well as dissipate compres A direct blood supply penetrates th outer rim of fibro-
sion forces. As depicted in Figure 2 -1 4 A , th menisci of th cartilaginous structures where they attach to ligaments (e.g.,
- nee dissipate compression forces by spreading out radially. th spine) or to joint capsules (e.g., th knee). In adult
The dense interwoven collagen fibers also allow th tissue to joints, some repair of damaged fibrocartilage can occur near
resist tensile and shearing forces in multiple planes. Fibro th vascularized periphery', such as th outer one third of
cartilage is therefore an ideal shock absorber in regions of menisci of th knee and th outermost lamellae of interverte
th body that are subject to high multidirectional forces. bral discs. The innermost regions of fibrocartilage structures,
This function is best realized in th menisci of th knee and much like articular cartilage, demonstrate poor or negligible
th intervertebral discs of th spinai column. healing owing to th lack of a ready source of undifferen-
The perichondrium surrounding fibrocartilage is poorly 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
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 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.)
Chapter 2 Basic Structure and Function o f th )oints 37

Outer circumferentiol


circumferentiol Haversian systems
lamelloe--------- (osteons)


FIGURE 2-16. Histologic organization of cortical bone. of cancellous Blood vessels
(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.) Sharpey's



network of cancellous bone, which in tum acts as a series of lower compressive strength. The dryer connective tissues do
struts to redirect th forces into th long axis of th cortical not slide across one another as easily. As a result, th bun-
bone of th shaft. This structural arrangement redirects dles of fibers in ligaments do not align themselves with th
forces for absorption and transmission by taking advantage imposed forces as readily, hampering th ability of th tissue
of bones unique architectural design. 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
EFFECTS OF AGING quickly than younger joints. Aged articular cartilage contains
less water and is less able to attenuate and distribute im
Aging is associated with histologic changes in connective posed forces to th adjacent bone.
tissue that, in tum, may produce mechanical changes in The age-related alteration of connective tissue metabolism
joint function. The rate and process by which tissue ages is in bone contributes to th slower healing of fractures. The
highly individuai and can be modified, positively or nega- altered metabolism also contributes io osteoporosis, particu-
tively, by th types and frequency of activities and by a larly type II or senile osteoporosis a type that thins both
host of medicai and nutritional factors.2 In th broadest trabecular and cortical bone in both genders.9
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 EFFECTS OF IMMOBILIZATION ON THE
damage that may progress to a structural failure or a mea- STRENGTH OF THE CONNECTIVE TISSUES
surable change in mechanical properties. A clinical example OF A JOINT
of this phenomenon is th age-related deterioration of th
ligaments and capsule associated with th glenohumeral The amount and arrangement of fibers and GAGs in connec
joint. Reduced structural support provided by these tissues tive tissues are influenced by physical activity. At a normal
may eventually culminate in tendonitis or tears in th rotator level of physical activity, th connective tissues are able to
cuff muscles.22 adequately resist th naturai range of forces imposed on th
Aging also influences th mechanical resilience of GAGs musculoskeletal System. A joint immobilized for an extended
within connective tissue. The GAG molecules produced by period demonstrates marked changes in th structure and
aging cells are fewer in number and smaller in size than function of its associated connective tissues. The mechanical
those produced by young cells.2'11 This change in th GAGs strength o f th tissue is reduced in accord with th de
results in decreased water-binding capacity that reduces th creased forces of th immobilized condition. This is a nor
hydration of connective tissues. The less hydrated tissue has 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 depends on th proximity and adequacy of a blood supply.
which immobilization dramatically reduces th level of force A tear of th outermost region of th meniscus of th knee
imposed on th musculoskeletal System. Although for differ- adjacent to blood vessels embedded with th capsule may
ent reasons, muscular paralysis or weakness also reduces th compleiely heal.21-23 In contrast, tears of th innermost cir-
force on th musculoskeletal System. cumference of a meniscus do not typically heal completely.
The rate of decline in th strength of connective tissue is This is also th case in th inner lamellae of th adult
somewhat dependent on th normal metabolic activity of intervertebral disc that does not have th capacity to heal
th specifc tissue. Immobilization produces a marked de- following significant damage.13
crease in tensile strength of th ligamenis of th knee, for Chronic trauma is often classified as a type of overuse
example, in a period of weeks.19-28 The earliest biochem- syndrome and reflects an accumulation of unrepaired, rela-
ical markers of this remodeling can be detected within days tively minor damage. Chronically damaged joint capsules
after immobilization.12-18 Even after th cessation of th im and ligaments gradually lose their restraining functions, al
mobilization and after th completion of an extended post- though th instability of th joint may be masked by a
immobilization exercise program, th ligaments continue to
muscular restraint substitute. In this case, joint forces may
have lower tensile strength than ligaments that were never
be increased owing io an exaggerated muscular guarding of
subjected to immobilization.12-28 Other tissues such as
th joint. Only when th joint is challenged suddenly or
bone and cartilage also show a loss of mass, volume, and
forced by an extreme movement does th instability become
strength following immobilization.14-24 The results from ex- readily apparent.
perimental studies imply that tissues rapidly lose strength in
Recurring instability may cause abnormal loading condi-
response to reduced loading. Full recovery of strength fol
tions on th joint tissues, which can lead to their mechanical
lowing restoration of loading is much slower and often in
complete. failure. The surfaces of articular cartilage and fibrocartilage
may become fragmented with a concurrent loss of GAGs and
Immobilizing a joint for an extended period is often nec-
subsequent lowered resistance to compressive and shear
essary to promote healing following an injury such as a
forces. Early stages of degeneration often demonstrate a
fractured bone. Clinical judgment is required to balance th
roughened or fibrillated surface of th articular cartilage
potential negative effects of th immobilization with th need
to promote healing. The maintenance of maximal tissue (Fig. 2 - 1 7 ) . A fibrillated region of articular cartilage may
strength around joints requires judicious use of immobiliza later develop cracks, or clefts, that extend from th surface
tion, a quick return to loading, and early rehabilitative inter- into th middle or deepest layers of th tissue. These
vention. changes may reduce th shock absorption quality of th
Two disease States that commonly cause joint dysfunction
JOINT PATHOLOGY are osteoarthritis (OA) and rheumatoid arthritis (RA). Osteo
arthritis is characterized by a graduai erosion of articular
Trauma to connective tissues of a joint can occur from a cartilage with a low inflammatory component.7 Some refer to
single overwhelming event (acute trauma), or in response lo OA as "osteoarthrosis to emphasize th lack of a distinctive
an accumulation of lesser injuries over an extended period inflammatory component. As erosion of articular cartilage
(chronic trauma). Acute trauma often produces detectable progresses, th underlying subchondral bone becomes more
pathology. A torn or severely stretched ligament or joint mineralized and, in severe cases, becomes th weight-bearing
capsule causes an acute inflammatory reaction. The joint surface when th articular cartilage pad is completely wom.
may also become structurally unstable when damaged con The fibrous joint capsule and synovium become distended
nective tissues are noi able to restrain th naturai extremes and thickened. The severely involved joint may be com
of motion. pletely unstable and dislocate or may fuse allowing no mo
Joints frequently affected by acute traumatic instability are tion.
typically associated with th longest lever arms of th skele The frequency of OA increases with age and has several
ton and. therefore, are exposed to high external torques. For manilestations. Idiopathic OA occurs in th absence of a spe-
this reason, th tibiofemoral, talocrural, and glenohumeral cific cause; it affects only one or a few joints, particularly
joints are frequently subjected to acute ligament damage those that are subjected to th highest weight-bearing loads:
with resultant instability. hip, knee, and lumbar spine. Familial OA or generalized OA
Acute trauma can also result in intraarticular fractures affects joints of th hand and is more frequent in women.
involving articular cartilage and subchondral bone. Careful Post-traumatic OA may affect any synovial joint that has been
reduction or realignment of th fractured fragments helps to exposed to a trauma of sufficient severity.
restore th smooth, low-friction sliding functions of articular Rheumatoid arthritis differs markedly from OA, as it is a
surfaces. This is criticai to maximal recovery of function. systemic, autoimmune connective tissue disorder with a
Although th bone adjacent to a joint has excellent ability to strong inflammatory component.10 The destruction of multi
repair, th repair of fractured articular cartilage is often in ple joints is a prominent manifestation of RA. The joint
complete and produces mechanically inferior areas of th dysfunction is manifested by significant inflammation of th
joint surface that are prone to degeneration. Focal increases capsule, synovium, and synovial fluid. The articular cartilage
in stress due to poor surface alignment in conjunction with is exposed io an enzymatic process that can rapidly erode
impaired articular cartilage strength can lead to post-trau- th articular surface. The joint capsule is distended by th
matic osteoarthritis. recurrent swelling and inflammation, often causing marked
The repair of damaged fibrocartilaginous joint structures joint instability and pain.
Chapter 2 Basic Strutture and Function o j th Joints 39

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

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

1. Bogduk N, Engel R: The menisci of th lumbar zygapophyseal joints. A
review of their anatomy and clinical significance. Spine 9:454-460,
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
FIGURE 2-17. A scanning electron micrograph of th articular sur-
knee. Arthroscopy 13:33-41, 1997.
face of a femoral condyle of a knee in a 71-year-old embalmed 16. Kurrat HJ, Oberlander W: The thickness of th cartilage in th hip
male cadaver, contrasting levels of degeneration. A, Articular carti- joint. J Anat 126:145-155, 1978
lage from an apparently normal-looking region of th lateral fem 17. Mow VC, Flatow EL, Foster RJ, et al: Biomechanics. In Simon SR (ed).
oral condyle. The wavy but smooth surface texture represents th Orthopaedic Basic Science. Rosemont, IL, American Academy of Ortho-
normal aging process in hyaline cartilage (200X). B. Fibrillateci paedic Surgeons, 1994.
articular cartilage from a region of th mediai femoral condyle from 18. Muller FJ, Setton LA, Manicourt DH, et al: Centrifugai and biochemical
th same knee as A (225 X). C, Higher magnifcation of B (600 X) comparison of proteoglycan aggregates from articular cartilage in experi-
shows th roughened or frayed region of th cartilage (arrowheads). mental joint disuse and joint instability. J Orthop Res 12:498-508,
The lower case c" indicates an exposed chondrocyte, which is
19 Noyes FR: Functtonal properties of knee ligaments and alterations in-
usually concealed within th matrix. (Micrographs courtesy of Dr.
duced by immobilization. Clin Orthop Rei Res 123:210-242, 1977.
Robert Morecraft, University of South Dakota School of Medicine, 20. OBrien SJ, Neves MC, Amoczky SP, et al: The anatomy and histology
Sioux Falls, South Dakota.) 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
SUMMARY 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-
Joints provide th foundation of musculoskeletal rnotion and niscal tears that exlend mio th avascular zone. A review of 198 single
permit th stablity and dispersion of internai and external and complex tears. Am J Sports Med 26:87-95, 1998.
forces. Several classifcation schemes exist to categorize joints 24. Sato Y. Fujitnatsu Y, Kikuyama M. et al: Inlluence of immobilization on
bone mass and bone metabolism in hemiplegic elderly patients with a
and to allow discussion of their mechanical and kinematic
long-standing stroke. J Neurol Sci 156:205-210, 1998.
characteristics. Motions of anatomie joints are often complex 25. Stockwell RA The interrelationship of celi density and cartilage thick
owing to their asymmetrical shapes and incongruent sur- 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 immobilization and remobilization. J Bone Joint Surg 69A: 1200-1211
lubricating activity of lubricin isolated from bovine and human synovial 1987.
fluids. BiochemJ 225:195-201, 1985. 29. Xu GL, Haughton VM, Carrera GF: Lumbar facet joint capsule: Appear-
27. Williams PL, Bannister LH, Berry MM, et al (eds): The skeletal System. ance at MR imaging and CT. Radiology 177:415-420, 1990.
In Grays Anatomy, 38th ed. New York, Churchill Livingstone, 1995. 30. Yu SW, Sether L, Haughton VM: Facet joint menisci of th cervical
28. Woo SL-Y, Gomez MA, Sites TJ, et al: The biomechanical and morpho- spine: Correlative MR imaging and cryomicrotomy study. Radiology
logical changes in th mediai collateral ligament of th rabbit after 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

.'USCLE AS A SKELETAL STABILIZER: Summation of Active Force and Passive Activating Muscle via th Nervous System,
LENERATING AN APPROPRIATE AMOUNT Tension: Total Length-Tension Curve, 51
OF FORCE AT A GIVEN LENGTH, 41 47 Recruitment, 51
Muscle Morphology: Shape and Structure, Isometric Force: Development of th Rate Coding, 52
41 Internai Torque-Joint Angle Curve, 47 Muscle Fatigue, 52
Muscle and Tendon: Generation of Force, MODULATION, 50 NEURAL DRIVE OF MUSCLE. 54
44 Modulating Force Through Concentric or
Passive Length-Tension Curve, 44 Eccentric Activation: Force-Velocity
Active Length-Tension Curve, 45 Relationship, 50

INTRODUCTION lead to th judicious application of interventions to improve

a persons abilities.
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 MUSCLE AS A SKELETAL STABILIZER:
and movement. Muscle Controls posture and movement in GENERATING AN APPROPRIATE AMOUNT
two ways: (1) stabilization of bones, and (2) movement of OF FORCE AT A GIVEN LENGTH
This chapter considers th role of muscle and tendon in Bones support th human body as it interacts with its envi-
generating, modulating, and transmitting force. These func- ronment. Although many tissues that attach to th skeleton
tions are necessary to fix and/or move skeletal structures. support th body, only muscle can adapt to both immediate
How muscle stabilizes bones by generating an appropriate and long-term extemal forces that can destabilize th body.
amount of force at a given length is investigated. Force Muscle tissue is ideally suited for this function because il is
generation occurs both passively (i.e., by a muscles resis- coupled both to th extemal environment and to th internai
tance to stretch) and, to a much greater extern, actively (i.e., control mechanisms offered by th nervous System. Under
by active contraction). th fine control of th nervous System, muscle generates th
Ways in which muscle modulates or Controls force so that force needed to stabilize skeletal structures under an amaz-
bones move smoothly and forcefully are investigated next. ingly wide array of conditions. For example, muscle exerts
Normal movement is highly regulated and refined, regardless fine control to stabilize fingers wielding a tiny scalpel during
of th infinite environmental constraints imposed on a given eye surgery. Il can also generate large forces during th final
task. seconds of a dead-lift weightlifting task.
The approach herein enables th student of kinesiology to Understanding th special role of muscle in generating
understand th multiple roles of muscles in controlling th stabilizing forces begins with an appreciation of how muscle
postures and movements that are used in daily tasks. In morphology and muscle-tendon architecture affect th range
addition, th clinician also has th information needed to of force available to a given muscle. The components of
form clinical hypotheses about muscular impairments that muscle are explored that produce passive tension when a
interfere with functional activities. This understanding can muscle is elongated (or stretched), or active force when a
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


B M uscle Fiber

Sarcolem m a /



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 86% of its force to th tendon. (The cosine of 30 degrees is
cross-section of pennate muscles, because fibers run at dif- 0.86.)
ferent angles to each other. In generai, pennate muscles produce greater maximal
Pennation angle refers to th angle of orientation between force than fusiform muscles of similar size. By orienting
th muscle fibers and tendon (Fig. 3 - 3 ) . If muscle fibers fibers obliquely to th centrai tendon, a pennate muscle can
attach parallel to th tendon, th pennation angle is defined fit more fibers into a given length of muscle. This space-
as 0 degrees. In this case, essentially all of th force gener- saving strategy provides pennate muscles with a relatively
ated by muscle fibers is transmitted to th tendon and across large physiologic cross-sectional area and, hence, a relatively
a joint. If, however, th pennation angle is greater than 0 large capability for generating high force. Consider th mul-
degrees (i.e., oblique to th tendon), then less of th force tipennate gastrocnemius muscle that must generate very
produced by th muscle fiber is transmitted to th tendon. large forces during jumping, for example. Interestingly, th
Theoretically, a muscle with a pennation angle dose to 0 reduced transfer of force from th pennate fiber to th ten
degrees transmits full force to th tendon, whereas th same don, due io th greater pennation angle, is small com-
muscle with a pennation angle dose to 30 degrees transmits pared with th large force potential furnished by th gain in
44 Section I Essential Topics o f Kinesiology

TABLE 3 - 2 . Functions of Connective Tissue

within Muscle
1. 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
FIGURE 3-3. Unipennate muscle is shown with th muscle ftbers and th series elastic component, generating a springlike
oriented at a 30-degree angle of pennation (0), 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
physiologic cross-sectional area. As shown in Figure 3 - 3 , a and serial elastic components is a simplifed description of
pennation angle of 30 degrees stili enables th fibers to th anatomy; however, it is useful to explain th levels of
transfer 86% of their force through th long axis of th resistance generated by a stretched muscle.
tendon. 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
Muscle and Tendon: Generation of Force otherwise damage th muscle tissue. Muscle fibers decrease
PASSIVE LENGTH-TENSION CURVE in diameter by as much as 90% as they blend with th
tendon tissue.12 As a result, th force through a muscle fiber
Muscle contains contractile proteins that are embedded per cross-sectional area (i.e., stress) increases significantly. At
within a network of connective tissues, namely, th epimys- each end of a muscle fiber is an extensive folding of th
ium, perimysium, and endomysium. Table 3 - 2 lists th plasmalemma (i.e., th membrane surrounding th muscle
functions of these tissues. Connective tissues are slightly fiber), which interdigitates with th connective tissue of th
elastic and, like a rubber band, generate resistive force (i.e., tendon. This folding ensures that high forces can be distrib-
tension) when elongated. uted over a large area, thus reducing th stress on th
For functional rather than anatomie purposes, th con muscle.
nective tissues within th muscle and tendon have been When th paralel and series elastic components are
described as th paralel elastic component and th series elas stretched within a muscle, a generalized passive length-tension
tic component. Elongation or stretch of th whole muscle curve is generated (Fig. 3 - 5 ) . The curve is similar to that
lengthens th connective tissue elements (Fig. 3 - 4 ) . The obtained by stretching a rubber band. Approximating th
paralel elastic component refers to th connective tissues shape of an exponential mathematica! function, th passive

Bone Paralel E C
FIGURE 3-4. Contractile components
and elastic components (EC) that
generate force in muscle tissue are
shown. The contractile component
represents th actin and myosin
crossbridge structures. The paralel
elastic component (paralel to th
contractile component) represents
muscle connective tissue. The series
elastic component (in series with th
whole muscle) represents th connec
tive tissues within th tendon. The
paralel and series connective tissues
act in a manner similar to a spring.
Chapter 3 Muscle: The Ultimate Force Generator in th Body 45

helps protect a muscle from being damaged by a quick and

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


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-
Increasing stretch brils. Myofibrils are th contractile elements of th muscle
fiber and have a distinctive structure. Each myofibril is 1 io
FIGURE 3 -5 . A generalized passive length-tension curve is shown. 2 micrometers in diameter and consists of many myofila-
As a muscle is progressively stretched, th tissue is slack during its ments. The primary structures within myofilaments are two
irutial shortened lengths until it reaches a criticai length where it
types of proteins: actin and myosin. The regular organization
begins to generate tension. Beyond this criticai length, th tension
builds as an exponential function. 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
elements within th muscle begin generating passive tension connective web, formed between myofilaments and connec
after th criticai length where all of th relaxed (i.e., slack) tive tissues, allows force to be evenly distributed throughout
tissue has been brought to an initial level of tension. After muscle and efficiently transmitted to skeletal structures.
this criticai length has been reached, tension progressively Upon inspection of th muscle fiber, a distinctive light
increases until it reaches levels of extremely high stiffness. At and dark banding is apparent (Fig. 3 - 7 ) . The dark bands,
higher tension, th tissue fails. The simple passive length- th A-bands, correspond to th presence of myosin th
tension curve represents an important component of force- thick filaments. Myosin also contains projections, called
generating capability in muscle and tendon tissue. This capa cross-bridges, which are arranged in pairs (Fig. 3 - 8 ) . The
bility is especially important ai very long lengths where light bands, th I-bands, contain actin th thin filaments
muscle fibers begin to lose their active force-generating capa (see Fig. 3 - 7 ) . In a resting muscle fiber, actin filaments
bility. Passive tension stabilizes skeletal structures against partially overlap myosin filaments. Under an electron micro
gravity and responds to perturbations and other imposed scope, th bands reveal a more complex pattern that consists
loads. Passive elongation of th Achilles tendon of th ankle of H bands, M lines, and Z discs (Table 3 - 3 ) .
during th downstroke of bicycle pedaling, for example, al- The banding pattern repeats along th length of th mus-
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- TABLE 3 - 3 . Regions Within a Sarcomere
cient passive tension.
Stretched muscle tissue exhibits th properties of elasticity A bands Dark bands caused by presence of thick myosin
and viscosity. Both properties influence th amount and rate filament
of passive tension developed within a stretched muscle. A Light bands caused by presence of thin actin fila
I bands
stretched muscle exhibits elasticity because it can temporarily ment
store pari of th energy that created th stretch. Stored
energy, ahhough relatively slight when compared with th H band Region within A band where actin and myosin do
not overlap.
full force potential of th muscle, helps prevent a muscle
from being damaged during maximal elongation. Viscosity, in M lines Mid region thickening of thick myosin filament in
this context, describes th rate-dependent resistance encoun- th center of H band
tered between th surfaces of adjacent fluid-like tissues. Vis Z discs Region where successive actin filaments mesh to-
cosity is rate dependent; thus, a muscles internai resistance gether. Z disc helps anchor th thin filaments.
to elongation increases with th rate of stretch. Viscosity
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- th sarcomere, it is possible to understand th mechanics of
tending from one Z disc to th next. The sarcomere is muscle contraction since this process is repeated from one
considered th active force generator of th muscle ftber. By sarcomere to th next.
understanding th active contractile events that take place in The currently accepted model for describing active force
generation is called th sliding filament hypothesis and was
developed independently by Hugh Huxley8 and Andrew
H Z A l Huxley (no relation).9 In this model, active force is generated
band disc band band
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
FIGURE 3-7. Detail of th regular, banded organization of th my-
tween cross-bridges and actin filaments. The active length-
ofibril showing th position of th A band, 1 band, H band, and Z
disc. The expanded view of a single sarcomere demonstrates how tension curve for a sarcomere is presented in Figure 3 - 1 0 .
th actin and myosin filaments contribute to th banded organiza The ideal resting length of a muscle fiber or sarcomere is th
tion. (Modified from Guyton AC, Hall JE: Textbook of Medicai length that allows th greatest number of cross-bridge at
Physiology, lOth ed. Philadelphia, W.B. Saunders, 2000. Modified tachments and, therefore, th greatest potential active force.
in Guyton from Fawcett DW: Bloom and Fawcett: A Textbook of As th sarcomere is lengthened or shortened from its resting
Histology. Philadelphia, W.B. Saunders, 1986. Originai art by Sylvia length, th number of potential cross-bridge attachments de-
Colarci Keene. Reproduced by permission of Edward Arnold Lim 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
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

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
FIGURE 3-9. The sliding filament action that occurs as myosin allow an optimal number of crossbridge attachments. In D, actin
heads attach and then release from th actin filament is illustrated. filaments are positioned out of th range from th myosin heads so
Contrattile force is generated during th power stroke of th cycle. that no crossbridge attachments are possible. (From Guyton AC,
(From Guyton AC, Fiali JE: Textbook of Medicai Physiology, lOth Fiali JE: Textbook of Medicai Physiology, lOth ed. Philadelphia,
ed. Philadelphia, W.B. Saunders, 2000.) 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


Exploring th Reasons for th Unique "Signature" of a

Muscle Group's Isometric Torque-Angle Curve
Consider th functional implications associated with th
shape of a muscle group's torque-angle curve. 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-
Dccrcasing muscle length ing. Large amounts of hip abduction torque are rarely
required in a position of maximal hip abduction.
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 hip. Regardless of th muscle group, however, th combina-
moment arm length is greatest. (Modified from LeVeau BF: Wil tion of high total muscle force (based on muscle length) and
liams & Lissners Biomechanics of Human Motion, 3rd ed. Philadel- great leverage (based on moment arm length) results in th
phia, W.B. Saunders, 1992.) greatest relative internai torque.
In summary, isometric torque measures differ depending
upon th joint angle, regardless of maximal effort. It is there-
The torque-angle curve of th hip abductors demon- fore important that clinical measurements of isometric torque
strated in Figure 3 - 1 2 B depends primarily on muscle include th joint angle so that future comparisons are. valid.
length, as shown by th linear reduction of maximal torque The testing of isometric strength at different joint angles
produced at progressively greater abduction angles of th 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 Surgical displacement of Decrease in th amount of muscle Decreased hip abductor force can
moment arm greater trochanter to in- force required to produce a reduce th force generated
crease th internai mo given level of hip abduction across an unstable or a painful
ment arm of hip abduc torque hip joint; considered a means
tor muscles of protecting a joint from
damaging forces
Mechanical: Decreased inter Patellectomy following se Increase in th amount of knee increased force needed to extend
nai moment arm vere fracture of th pa extensor muscle force required th knee may increase th
tella to produce a given level of wear on tire articular surfaces
knee extension torque of th knee joint
Physiological: Decreased mus Damage to th deep portion Decreased strength in th dorsi- Reduced ability to walk safely
cle activation of th peroneal nerve flexor muscles
Physiological: Significantly de Damage to th radiai nerve Decreased strength in wrist exten Ineffective grasp due to overcon-
creased muscle length at with paralvsis of wrist sor muscles causes th finger tracted (shortened) finger
th lime of neural activa extensor muscles flexor muscles to flex th wrist flexor muscles
tion while making a grasp
50 Section I Essential Topcs o j Kinesiology

ography as a tool for understanding muscle activation during

movement is introduced.

Moduiating Force Through Concentric or

Eccentric Activation: Force-Velocity
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
FIGURE 3-14. Relationship between muscle load (extemal resis- some point, a very large load results in a contraction velocity
tance) and maximal shortening velocity. (Velocity is equal to ihe of zero (i.e., th isometric state).
slope of th dotted line.) At a no load condition, a muscle is Eccentric activation needs to be considered separately
capable of shortening at a high velocity. As a muscle becomes from concentric activation. With eccentric activation, a load
progressively loaded, th maximal shortening velocity decreases.
that barely exceeds th isometric force level causes th mus
Eventually, at some very large load, th muscle is incapable of
cle to lengthen slowly. Speed of lengthening increases as a
shortening and th velocity is 0. (Redrawn from McComas AJ:
Skeletal Muscle: Form & Function. Champaign, IL, Human Kinet- greater load is applied. There is a maximal load that th
ics, 1996.) 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
cles strength. This information may be required to deter lengthening velocity on th X (horizontal) axis (Fig. 3 - 1 5 ) .
mine th suitability of a person for a certain task at th In generai, during a maximal effort concentric activation, th
workplace, especially if th task requires a criticai internai amount of muscle force is inversely proportional to th veloc
torque to be produced at certain joint angles. 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
MUSCLE AS A SKELETAL MOVER: FORCE of a force-velocity relationship of muscle is a torque-joint

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-
FIGURE 3-15. Theoretic force-velocity curve of an activated muscle
ening. The ways in which force is graded by neural activa
is shown. Concentric activation is shown on th righi and eccentric
tion are explored. The reduction in force that occurs with activation on th left. Isometric activation occurs at th zero veloc
muscular fatigue is examined. Finally, th use of electromy- ity point on th graph.
Chapter 3 Muscle: The Ultimale Force Generator in th Body 51

angular velocity relationship. This type of data can be de- A muscle undergoing a concentric contraction against a
nved through isokinetic dynamometry (see Chapter 4). load is doing positive work on th load. In contrast, a muscle
The inverse relationship between a muscles maximal undergoing eccentric activation against an overbearing load
force potential and its shortening velocity is related to th is doing negative work. In th latter case, th muscle is
concept of power. Power, or th rate of work, can be ex- storing energy that is supplied by th load. A muscle, there
pressed as a product of force times contraction velocity, (i.e., fore, can act as either an active accelerator of movement
th area under th curve on th righi hand side of Figure 3 - against a load while contracting (i.e., through concentric
15). A Constant power output of a muscle can be sustained activation), or it can act as a brake or decelerator when a
by increasing th load (resistance) while proportionately de- load is applied and th activated muscle is lengthening (i.e.,
creasing th contraction velocity, or vice versa. This is very through eccentric activation).
similar in concept to switching gears while riding a bicycle.
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
Combinine] th Length-Tension and Force-Velocity pha motoneurons that are located in th ventral hom of th
Relationships spinai cord. Each alpha motoneuron has an axon that ex-
tends out of th spinai cord and connects with multiple
Although a muscle's length-tension and force-velocity
muscle fibers located throughout a whole muscle. The alpha
relationships are described separately, in reality both
motoneuron and all muscle fibers that are innervated by it
are in effect simultaneously. At any given tinte, an ac-
are called a motor unit. Because of this arrangement, th
tive muscle is functioning at a specific length and at a
nervous System can produce a muscle force from small con-
specific contraction velocity, including isometric. It is
useful, therefore, to generate a surface plot that repre- tractions involving only a few muscle fibers, and large con-
tractions that involve rnost of th fibers. Excitation of alpha
sents th three-dimensional relationship between mus
motoneurons may come from many sources, for example,
cle force, length, and contraction velocity (Fig. 3-16).
afferents, spinai interneurons, and cortical descending neu-
The plot does not, however, include th passive length-
rons. Each source can adivate an alpha motoneuron by first
tension component of muscle. The plot shows, for ex-
recruiting th motoneuron and then by driving it to higher
ample, a muscle contracting at a high velocity over th
rates of sequential activation. The sequence of driving moto
shortened range of its overall length producing rela-
neurons to higher rates, known as rate coding, allows re-
tively low levels of force, even with maximal effort. In
cruited muscle to generate greater amounts of force. Both of
contrast, a muscle contracting at a low, near isometric,
these issues of driving motoneurons are discussed further.
velocity within th middle range of its overall length
(i.e., near its optimal muscle length) produces a sub-
stantially greater active force. 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
FIGURE 3-16. Surface plot represents th three-dimensional re
lationship among muscle force, length, and contraction velocity with which it is recruited by th nervous System (i.e.,
during maximal effort. Positive work indicates concentric mus smalier motoneurons will be recruited before larger moto
cle activation, and negative work indicates eccentric muscle neurons). This principle is called th Henneman Size Princi-
activation. (From Winter DA: Biomechanics and Motor Control ple. It was first experimentally demonstrated and developed
of Human Movement, 2nd ed. New York, John Wiley & Sons, by Elwood Henneman in th late 1950s.7 The principle ac-
Ine., 1990.) This material is used by permission of John Wiley counts for th orderly recruitment of motor units, specified
& Sons, Ine. by size, which allows for smooth and controlled force devel-
52 Section l Essential Topici o f Kinesiology

concep called rate coding. Although a single action potential

TABLE 3 - 5 . Major Sequence of Events Underlying
in a skeletal muscle fiber lasts 1 to 2 milliseconds (ms), a
Muscle Fiber Activation
muscle fiber contraction (commonly called a twitch) may last
for as long as 130 ms in an S fiber. Because of th long
1. Action potential initiated and propagated down a motor
axon. twitch duration, il is possible for a number of subsequent
2. Acetylcholine released frorn axon terminals at neuromus- action potentials to begin during th initial twitch.4 If a fiber
cular junction. is allowed to relax completely before th subsequent action
3. Acetylcholine bound to receptor sites on motor endplate. potential, th second fiber twitch generates equivalent force
4. Sodiurn and potassium ions enter and depolarize muscle to th first twitch (Fig. 3 - 1 8 ) . If th next action potential
membrane. arrives before th preceding twitch has relaxed, however, th
5. Muscle action potential propagated over membrane sur- muscle twitches summate and generate an even greater evel
face. of peak force. Altematively, if th next action potential ar
6. Transverse tubules depolarized leading to release of cal- rives closer to th peak force evel of th initial twitch, th
cium ions surrounding th myofibrils. force is even greater.
7. Calcium ions bind to troponin, which leads to th release
of inhibition over actin and myosin binding. A set of repeating action potentials, separated by a suit-
8. Actin combines with myosin adenosine triphosphate able lime interval, generates a series of summated mechani-
(ATP), an energy-providing molecule. cal twitches, termed unfused tetanus. As th time interval
9. Energy released to produce movement of myosin cross- shortens, th unfused tetanus generates greater force until
bridges. th successive peaks and valleys of mechanical twitches fuse
10. Thick and thin filaments slide relative to each other. into a single, stable evel of muscle force, termed fused teta
11. Actin and myosin bond is broken and re-established if nus (or tetanization) (see Fig. 3 18). Fused tetanus repre-
calcium concentration remains sufficiently high. 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
Muscle fibers that are connected with small motoneurons transmitted to th tendon and across th joint.
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 Muscle Fatigue
th fibers are slow to respond to a stimuli, or SO (slow,
As muscle fibers are repeatedly stimulated, th force gener-
oxidative). The 0 reflects th histochemical profile. SO fibers ated by a fiber eventually decreases, even though th rate of
show relatively little latigue (i.e., loss of force during sus- activation remains th same (Fig. 3 - 1 9 ) . The decline in
tained activation).
muscle force under conditions of stable activation is termed
Muscle fibers that are connected with large motoneurons muscle fatigue. In theory, muscle fatigue can occur from
have twitch responses that are relatively brief in duration
metabolic processes, or from failure in physiologic mecha-
and high in amplitude (Fig. 3 - 1 7 , left). Motor units associ nisms involved with th neuromuscular System. Normally,
ated with these fibers are classified as FF (fast and easily th nervous System compensates for muscle fatigue by either
fatigued), or FG (fast and glycolytic), refiecting th histo increasing th rate of activation (i.e., rate coding) or recruit-
chemical profile. FG fibers fatigue relative easily.
ing assistive motor units (i.e., recruitment), thereby main-
An entire spectrum of intermediate motor units exists that taining a stable force evel. When an exercising muscle be-
shows physiologic and histochemical profiles somewhere be- gins to fatigue and performance begins to degrade, a rest
tween slow and fast type motor units (Fig. 3 - 1 7 , middle).
period allows that muscle to rsum its norma] perfor
Motor units associated with these fibers are termed FR (fa- mance evel. The rest period that is required depends on
tigue resistant). The fibers are termed FOG io represent th th type and intensity of th fatiguing contraction.1 For ex-
combined utilization of oxidative and glycolytic energy ample, a muscle that is rapidly fatigued by high intensity
and short duration exercise recovers after a rest of seconds
The motor umt types depicted in Figure 3 - 1 7 allow for a to minutes. In contrast, a muscle that is slowly fatigued by
wide range of physiologic responses from fibers within skele- low intensity, long duration exercise requires up lo 24 hours
tal muscles. The earlier (smaller) recruited motoneurons pro for recovery.
duce longer duration, small force contractions. Later re
Fatigue involves a variety of elemenis located throughout
cruited (larger) motoneurons add successively greater forces
th neuromuscular System. It is convenient to think of fa
of shorter duration. Through this spectrum, th nervous Sys
tigue as occurring primarily within centrai or peripheral
tem is able to adivate muscle fibers that sustain stable pos-
neuromuscular elements. Central fatigue may be affected by
tures over a long period of rime, and, when needed, produce
psychological factors, such as sense of effort, and/or neuro-
high, short duration bursts of force for more impulsive
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
RATE CODING pool become suboptimal when an individuai is asked to
generate a maximum muscle contraction.13 During a maxi
After a specific motoneuron is recruited, muscle force is mal effort, th nervous System may initiate inhibitory path-
modulated by an increase in th rate of its excitation, a ways to prevent th efficient activation of motoneuron pools.
Chapter 3 Muscie: The Ultimate Force Cenerator in th Body 53

FIGURE 3 -1 7 . Classifcation of motor

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

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
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
Rate of stimulation (times per second) potential is not propagated across to th plasmalemma.11
Repetitive activation of motor units can result in a graduai
FIGURE 3 -1 8 . Summadon of individuai muscle twitches (contrac-
reduction of acetylcholine release.2 Since acetylcholine is th
tions) are recorded over a wide range of stimulation frequencies.
essenttal transmitter responsible for activating plasmalemma,
Note that at low frequencies of stimulation (5 -1 0 per seeond), th
minai twitch is relaxed before th next twitch can summate. Ai a graduai reduction in its release lessens th size of th
progressively higher frequencies, th twitches summate to generate resultant twitch for a given muscle. Biochemical factors may
higher force levels until a fused twitch (tetanization) occurs. (From be involved in peripheral fatigue. The Chemical composition
Guyton AC, Hall JE: Textbook of Medicai Physiology, lOth ed. of muscle fiber cytoplasm may undergo a variety of changes
Phiadelphia, W.B. Saunders, 2000.) that reduce force output over rime.5
54 Section I Essential Topics o f Kinesiology

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.


ELECTROMYOGRAPHY: WINDOW TO THE Consider th following two extreme examples. Muscle A

NEURAL DRIVE OF MUSCLE produces a given submaximal force via an eccentric activa
tion across its optimal force-generating length, at a relatively
When a muscle is activated via th nervous System, electrical high lengthening velocity. Muscle B produces an equivalem
potentials are generated. The recording of these amplified submaximal force via a concentric activation across its non-
action potentials through special electrodes is referred to as optimal force-generating length, at a relatively high shorten
electromyography (EMG). The EMG signals can indicate th ing velocity. Based on th length-tension and force-velocityI
relative timing and relative level of th neural drive to a relationships, Muscle A is operating at a relative physiologic
muscle, and thus they are useful in understanding th role advantage for producing force. Muscle A, therefore, requires
of a particular muscle in controlling a given movement. fewer motoneurons io be recruited, and at slower rates, than
Under certain conditions, th magnitude of th EMG signal Muscle B. EMG levels would therefore be less for th move
can also indicate th relative levels of muscle force. ment performed by Muscle A, although both muscles pro-
When a motor unit is activated, th electrical impulse duced equivalent submaximal forces. Using EMG magnitude
travels along th axon until it arrives at th motor endplates is not a valid tool for comparing th internai force produced
of th muscle fibers. Because th tissue around th muscle by these two muscles. EMG is a useful tool for this purpose.
fbers is electrically conductive, th subsequent depolariza- however, if th two muscles are operating under similar
tion of th activated muscle fibers tnduces a measurable activation, length, and velocity conditions.
electrical signal, which can be sensed by an electrode that is EMG can be performed with surface or fine wire (inser-
placed near th muscle fibers. The signal is termed th motor tional) electrodes. Surface electrodes are easy to apply and
unit action potential (MUAP) and can be sensed by both noninvasive, and they can detect signals from a large area
indwelling electrodes (i.e., electrode inserted into th muscle overlying muscle. Fine wire electrodes, mserted into th
fibers) and surface electrodes (i.e., electrode placed on th muscle belly, allow greater speciftcity in terms of th muscle
skin overlying th muscle). region and allow th choice of deeper muscles that are not
Depending on th characteristics of th motor unit, maxi accessible when using surface electrodes. Nevertheless, fine
mum force is achieved 20 to 150 ms after depolarization. An wire electrodes require a high level of technical skill and
electromechanical delay, therefore, exists between th ap- training before safe implementation; therefore, surface elec
pearance of muscle electrical activity and th mechanical trodes are more commonly used in clinical practice.
force generation.1418 As described, two mechanisms exist to Because EMG signals originate as very small signals, there
modulate muscle force: recruitment and rate coding. As th is a high risk for extraneous electrical noise. Noise signal can
number of active motor umts in th muscle is increased via be controlled in several ways. Differential electrode configu-
recruitment, greater numbers of MUAPs occur. The sum of rations (two pick-up electrodes that are electrically coupled)
these signals generates an overall greater amplitude EMG are used to subtract th noise signal that is commonly re-
signal. As th finng rate of active motor umts is increased, corded by both electrodes. Adequate skin preparation en-
greater numbers of MUAPs occur within a given time period. sures that th tiny EMG signals are recorded efficienti)'
A greater amplitude EMG signal also results, typically indi- rather than being overly impeded by unprepared skin. The
cating a greater force level in th active contractile compo- recording environment can be electrically isolated so that
nent ol muscle. extraneous noise is kepi far from th equipment. Electrical
Caution is advised when interpreting changes in EMG signals can be preamplified at th electrode source, rather
amplitude under conditions other than isometric activation. than amplified after th signal is conducted to a distant
When an activated muscle is lengthening or shortening, th amplifier, so that intervening noise from movement of th
source for th electrical signal changes its orientation in electrode cable is minimized. Signal filtering (i.e., eliminating
relation to th electrode that picks up th signal. The signal, specific frequencies of electrical signals) can be used to re
therefore, may represent a compilation of MUAPs from dif- duce known sources of interfering electrical signals. Low J
ferent regions of a muscle or even from different muscles. frequency noise, for example, may be present from power
Because of th length-tension and force-velocity relation- sources coupled to th wall outlet. A filler that is designed
ships of muscle, th EMG amplitude may vary considerably lo eliminate most of th electrical signal at and under 60 Hz
as a muscle produces a force via nonisometric activations.
significanily reduces th noise from these sources.
Chapter 3 Muscle: The Ultimate Force Cenerator in th Body 55

The EMG signal requires processing to be useful for kine- contraction and stretch and their structural interpretation. Nature 173:
973-976, 1954.
siologic interpretation. Raw or raw-filtered signals refer to
9. Huxley A, Nedergerke R: Structural changes in muscle dunng contrac
th originai biphasic waveform that is picked up by th tion. Interference microscopy of living muscle fibres. Nature 173:971
electrode. Often, th raw signal is smoothed and/or inte- 973, 1954.
grated. Smoothing refers to th flattening of th peaks and 10. Jaramillo J, Worrell TW, Ingersoll CD: Hip isometric strength following
valleys that occurs in a biphasic electrical signal. Smoothing knee surgery. J Orthop Sports Phys Ther 20:160-165, 1994.
11 Kmjevic K, Miledi R: Failure of neuromuscular propogation in rats. J
is performed to allow moment-to-moment quantifcation of Physiol 140, 1958.
th signal because it eliminates th transient changes in peak 12 Loeb G, Prati C, Chanaud C, Richmond F: Distribution and innervation
values of th signal. Integration is a mathematica! lerm that of short, tnterdigitated muscle fibers in parallel-fibered muscles of th
refers to measuring th area under th curve. This process cat htndlimb. J Morph 191:1-15, 1987.
13. McKenzie DK, Biglandritchie B, Gorman RB, Gandevia SC: Central and
allows for cumulative EMG quantifcation or averaging EMG
peripheral fatigue of human diaphragm and limb muscles assessed by
over a fxed period of time. Signals that are smoothed and/or twitch interpolation. J Physiol 454:643-656, 1992.
integrated can be used in biofeedback devices, such as visual 14. Merletti R, Knaflitz M, Deluca CJ: Electrically evoked myoelectric sig
meters or audio signals, and to drive other devices, such as nals. Crit Rev Biomed Eng 19:293-340, 1992.
electrical stimulators, to assist in muscle activation at a pre 15. Sandroni P, Walker C, Starr A: Fatigue in patients with multiple sclero-
sis motor pathway conduction and event-related potentials. Arch Neu
set threshold of voluntary activation. rol 49:517-524, 1992.
When comparing th intensity of a processed EMG signal 16 Wessel J, Kaup C, Fan J, et al: Isometric strength measurements in
between different muscles, it is often necessary that th sig children with arthrins: Reliability and relation to function. Arthr Care
nal be normalized to some common reference signal. This is Res 12:238-246, 1999
17. Yamaguchi G, Sawa A. Moran D, et al: A survey of human muscuioten-
especially necessary when th magnitude of th EMG is
don actuator parameters. In Winters J, Woo S-Y (eds): Multiple Muscle
being compared between persons or between sessions, re- Systems: Biomechanics and Movement Organization. New York,
quiring that th electrodes be reapplied. One common Springer-Verlag, 1990, pp 717-773.
method of normalization involves referencing th raw EMG 18. Zhou S, Lawson DL, Morrison WE, Fairweather I: Electromechanical
signal from a muscle to th signal produced as a person delay in isometric muscle contractions evoked by voluntary, reflex and
electrical stimulation. Eur J Appi Physiol 70:138-145, 1995.
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
The collection of EMG signals during movement, when Biewener A, Roberts T: Muscle and tendon contributions to force, work,
supplemented by kinematic and kinetic measures, can pro and elastic energy savnngs: A comparative perspective. Exerc Sport Sci
vide a comprehensive method for analyzing how muscles Rev 28:99-107, 2000.
Brown DA, Kautz SA: Increased workload enhances force output during
contribute to a movement. EMG can also provide insight pedaling exercise in persons with poststroke hemiplegia. Stroke 29:598-
mto th neural control of purposeful movements. A clinician 606, 1998.
can use EMG to aid in th understanding of physical impair- Brown DA, Kautz SA: Speed-dependent reductions of force output in people
ments underlying dysfunctional movement. This understand with poststroke hemiparesis. Phys Ther 79:919-930, 1999.
Enoka R, Fuglevand A: Motor unit physiology: Some unresolved issues.
ing can then lead to identification of diagnoses associated
Muscle Nerve 24:4-17, 2001.
with movement dysfunction and to appropriate intervention Gordon A, Homsher E, Regnter M: Regulation of muscle contraction in
strategies. 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.
1. Andrews BJ: Reducing FES muscle [angue. In Pedotti A, Ferrarin M Hof A, Van den BergJ: EMG to force processing 1: An electrical analogue of
(eds): Restoratton of Walking for Paraplegics. Amsterdam, los Press, th Hill muscle model. J Biomech 14:747-758, 1981.
1992, pp 197-202. Hof AL, Pronk CNA, Best JA: Comparison between EMG to force processing
2. Asmussen E. Muscle fatigue. Med Sci Sports Exerc 25:412-420, 1993 and kinetic analysis for th calf muscle moment in walking and step-
3. Brouwer B, Wheeldon RK, Stradiotto-Parker N, Alluni J: Reflex excit- ping.J Biomech 20:167-178, 1987.
ability and isometric force production in cerebral palsy; The effect of Huijing PA: Muscle, th motor of movement: Properties in function, experi-
serial casting. Dev Med Child Neurol 40:168-175, 1998. ment and modelling. J Electromyogr Kinesiol 8:61-77. 1998.
4. Burke R, Levine D, Tsairis P, Zajac F: Physiological types and histo- Kautz S, Brown D: Relationships between timing of muscle excitation and
chemical proflles in motor units of th cat gastrocnemius J Physiol impaired motor performance during cyclical lower extremity movement
234:723-748, 1973. in post-stroke hemiplegia. Brain 121:515-526, 1998.
5. Fitts RH, Metzger JM: Mechanisms of muscular fatigue. In PoortmansJR Komi PV: Stretch-shortening cycle: A powerful model to study normal and
(ed): Principles of Exercise Biochemtslry, 2nd revised ed. 1993, pp fatigued muscle. J Biomech 33:11971206, 2000.
248-268. Lieber R, Friden J: Clinical significance of skeletal muscle architetture Clin
6. Fregly B, Zajac F: A state-space analysis of mechanical energy genera Orthop 383:140-151, 2001
tion, absorption, and transfer dunng pedaling. J Biomech 29:81-90, Lippold O: The relationship between integrated action potentials in a hu
1996. man muscle and its isometric tension. J Physiol 117:492-499, 1952
7. Henneman E, Mendell LM: Functional organization of motoneuron pool Siegler S, Hillslrom HJ, Freedman W, Moskowitz G: Effect of myoelectric
and its tnputs. In Brookhart, JM, Mountcastle, VB, Brooks, VB (eds): signal processing on th relationship between muscle force and pro
Handbook of Physiology, voi. 2. Bethesda, American Physiological Soci cessed EMG. Am J Phys Med 64:130-149, 1985.
ety, 1981, pp 423-507' Woods JJ, Bigland-Riichie B: Linear and nonlinear surface EMG/force rela
8. Huxley H, Hanson J: Changes in th cross-striations of muscle during 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 Graphic Methods of Force Analysis, 67 Problem 1, 77
MOVEMENT ANALYSIS. 56 Composition of Forces, 67 Solving for Internai Torque and Muscle
Newton's Laws of Motion, 57 Resolution of Forces, 69 Force, 77
Newtons First Law: Law of Inertia, 57 Contrasting Internai versus External Solving for Joint Force, 78
Newton's Second Law: Law of Forces and Torques, 69 Problem 2, 79
Acceleration, 58 Influence of Changing th Angle of th Solving for Internai Torque and Muscle
Force (Torque)-Acceleration Joint, 69 Force, 80
Relationship, 58 Analytic Methods of Force Analysis, 70 Solving for Joint Force, 80
Impulse-Momentum Relationship, 60 Comparing Two Methods for Dynamic Analysis, 81
Work-Energy Relationship, 60 Determining Torque About a Joint, Kinematic and Kinetic Measurement
Newton's Third Law: Law of Action- 72 Systems, 81
Reaction, 62 Clinica! Issues Related to Joint Force Kinematic Measurement Systems:
INTRODUCTION TO MOVEMENT and Torque, 74 Electrogoniometer, Accelerometer,
ANALYSIS: SETTING THE BACKGROUND, Joint "Protection," 74 Imaging Techniques, and
63 Manually Applying External Torques Electromagnetic Tracking Devices,
Anthropometry, 63 During Exercise, 75 81
Free Body Diagram, 63 INTRODUCTION TO MOVEMENT Kinetic Measurement Systems:
Initial Steps for Setting Up th Free ANALYSIS: QUANTITATIVE METHODS OF Mechanical Devices, Transducers,
Body Diagram, 64 ANALYSIS, 76 and Electromechanical Devices, 83
Reference Frames, 65 Static Analysis, 77
Representing Forces, 67 Guidelines for Problem Solving, 77

treatment approaches. Technologic advances continue to en-
hance th ability to understand and influence human per
It can be overwhelming to consider all th factors that may formance.
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 NEWTON'S LAWS: APPLICATION TO
and th successful outcome of surgical and nonsurgical inter- MOVEMENT ANALYSIS
ventions are also frequently measured by changes in th
quality and quantity of movement. In response to these The outcome of all movement analysis is ultimately deter-
factors, a variety of analysis techniques may be utilized to mined by th forces applied to th body being moved. In
assess movement, rangitig from visual observation to th 17th century, Sir Isaac Newton observed that forces were
sophisticated motion analyses and imaging techniques. related to mass and motion in a predictable fashion. His
Most often, th complexity of movement analysis is simpli- Philosophiae Naturalis Principia Mathematica (1687) provided
fied by starting with a basic evaluation of th forces on a th basic laws and principles of mechanics that form th
single rigid body segment. Newtons laws of motion help to comerstone of human movement analysis. These laws, re-
explain th relationship between forces and their impact on ferred io as th law of inertia, th law of acceleration, and
individuai joints, as well as on total body motion. Even at th law of action and reaction, are collectively known as th
th basic level of analysis, this informatimi can be used to laws o f motion and form th framework from which advanced
understand mechanisms of injury, as well as to guide motion analysis techniques are derived.
Chapter 4 Biomechanical Principles 57

Newton's Laws of Motion velocity of a body. The inertia within a body is directly
proportional to its mass (i.e., th amount of matter constitut-
This chapter uses Newtons laws of motion to introduce ing th body). For example, if two bodies have different
techniques of analysis for describing th relationship between masses but are moving at similar linear velocities, a greater
th forces applied to th body and th consequences of force is required to alter th motion of th more massive
those forces on human motion. (Throughout th chapter, th body.
term body is used when elaborating on th concepts re- Each body has a point about which its mass is evenly
lated to th laws of motion and th methods of quantitative distributed. The point, called th center o f mass, can be
analysis. The reader should be aware that this term could considered where th acceleration of gravity acts on th
also be used interchangeably with th entire human body; a body. When subjected to gravity, th center of mass of a
segment or part of th body, such as th forearm segment; body is often described as its center o f gravity. For th entire
an object, such as a weight that is being lifted; or th System upright human body, th center of mass lies just anterior to
under consideration, such as th foot-floor interface. In most th second sacrai vertebra (Fig. 4 - 1 A). The center of mass
cases, th simpler term, body, is used when describing th for an individuali thigh and leg segments is shown in Figure
main concepts.) Newtons laws are described for both linear 4 - 1 B and C, respectively. During movement, th center of
and rotational (angular) motion (Table 4 - 1 ) . mass is continually changing its location being a function
of th location and size of th individuai body segments.
NEWTON'S FIRST LAW: LAW OF INERTIA Additional information regarding th center of mass of body
segments is discussed later in this chapter under th topic of
Newtons first law States that a body remains at rest or in Anthropometry.
Constant linear velocity except when compelled by an exter- The mass moment o f inertia of a body is a quantity that
nal force to change its state. A force is required to start, indicates its resistance to a change in angular velocity. Unlike
stop, or alter linear motion. The application of Newtons first mass, its linear counterpart, th mass moment of inertia
law to rotational motion States that a body remains at rest or depends not only on th mass of th body, bui also on th
in Constant angular velocity about an axis of rotation unless distribution of its mass with respect to an axis of rotation.6
compelled by an external torque to change its state. Whether Because most human motion is angular, rather than linear, it
th motion be linear or rotational, Newtons first law de- is important to understand th concept of mass moment of
scribes th case in which a body is in equilibrium. A body is inertia. The mass moment of inertia (i) is defined in th box,
in static equilibrium when its velocity is zero, or in dynamic where n indicates th number of particles in a body, m,
equilibrium when its velocity is not zero, but Constant. In indicates th mass of each particle in th body, and r, is th
either case, th acceleration of th body is zero. distribution or distance of each particle from th axis of

Kcy Terms Associated >vilh Newtons First Law

Static equilibrium
Dynamic equilibrium
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 A body remains at rest or in Constant linear A body remains at rest or in Constant angular
velocity except when compelled by an external velocity about an axis of rotation unless when
force to change its state. compelled by an external torque to change its
Second: Law of Acceleration The linear acceleration of a body is directly pro The angular acceleration of a body is directly pro
portional to th force causing it, takes place in portional to th torque causing it, takes place in
th same direction in which th force acts, and th same rotary direction in which th torque
is inversely proportional to th mass of th acts, and is inversely proportional to th mass
body. moment of inertia of th body.
Third: Law of Action-Reaction For every force there is an equal and opposite For every torque there is an equal and opposite
directed force. directed torque.
58 Section I Essential Topici o j Kinesiology

forward. Alternatively, a given muscle force can advance th

lower limb more quickly while walking when th lower
extremity is flexed as compared W'ith straightened. The
change in joint position (i.e., increased hip and knee flexion
and ankle dorsiflexion) used io decrease th resistance to
angular motion becomes even more apparent as a person
changes from walking to running.
Athletes often attempt to control th mass moment of
inertia of their entire body by altering th position of their
individuai body segments. This concept is well illustrated by
divers who reduce their moment of inertia in order to 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


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
FIGURE 4 -1 . The center of mass of th whole body (A) is shown tion 4.3 defines a force-acceleration relationship. Considered a
with respect to th frontal piane. The center of mass is also shown cause-and-effect relationship, th left side of th equation,
for th thigh segment (B) and th leg segment (C). 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
pler Equation 4.2 shown in th box. The units of I are net forces acting on a body. If th sum of th forces acting
kilograms-meters squared (kgm2). The equation describes on a body is zero, acceleration also is zero and th body is
that a bodys resistance to a change in angular velocity is in linear equilibrium. As previously discussed, this case is
proportional to th mass of th object (m) and th squared described by Newtons first law. lf, however, th net force
distance between th center of mass of th object and th produces an acceleration, th body travels in th direction of
axis of rotation (p2). th resultant force.

Newtons Second Law of Linear Motion Quantifying a

2F = m X a (Equation 4.3)

The fact that p is squared in Equation 4.2 has imporiant 1 Newton (N) = 1 kgm/s2
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 The angular counterpart to Newtons second law States that
flexion and ankle dorsiflexion. A functionally shortened limb a torque (T) produces an angular acceleration (a ) of th body
reduces th average distance of th mass particles within th that is proportional to, and in th rotary direction of th
limb relative to th hip joints medial-lateral axis of rotation. torque, and is inversely proportional to th mass moment of
The reduced mass moment of inertia reduces th force re- inertia of th body (I) (see Equation 4.4 in th box). (This
quired by th hip flexor muscles to accelerate th limb 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 ent tissues, such as bone, muscle, fat, and skin, and is
rotate about two separate axes of rotation (Yt, Y2). The two sets not of uniform density. This makes calculation of th
of calculations associated with each axis of rotation show how
mass moment of inertia more challenging than th cal
th distribution of mass within a body affects th mass momen-
tum of inertia. The object is assumed to consist of five equal culation of th mass. Values for th mass moment of
mass points (M,-M 5), located at set distances (r ,-r 5) from each inertia for each body segment have been generated
other and from th axes of rotation. The center of mass of th from cadaver studies, mathematica! modeling, and vari-
entire object is located at M, (red circle). 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

small force delivered over a longer time. Equation 4.6 de

fines th linear impuise-momentum relationship.

A Tncreased angular B Decreased angular The impuise-momentum relationship provides another

velocity velocity perspective from which to study human performance, as
FIGURE 4 -3 . A diver illustrates an example of how th mass mo well as to gain msight into injury mechanisms. The concept
ment of merda about a medial-laieral axis (black dot) can be altered of an impuise-momentum relationship is often utilized in th
through changes in th position of th trunk and extremities. In design features of sports and recreation equipment for th
position A, th diver decreases th mass moment of inertia, which purpose of protecting users from injury. Running footwear
increases th angular velocity of th spin. in position B, a ehange in
with shock-absorbing outsoles and bike helmets with protec-
th position of th extremities causes a greater mass moment of
inertia and decreases th angular velocity of th spin. 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
Impulse-Momentum Relationship
to th substitutions and rearrangements for th linear rela
Additional relationships can be derived from Newtons sec- tionship, th angular relationship can be expressed by substi-
ond law through th broadening and rearranging of Equa- tution and rearrangement of Equation 4.4. Substituting Aw/t
tions 4.3 and 4.4. One such relationship is spectfted as th (ehange in angular velocity) for a (angular acceleration) re
impuise-momentum relationship. sults in Equation 4.7 (see th box). Equation 4.7 can be
Acceleration is th rate of ehange of velocity (Av/t). Sub- rearranged to Equation 4.8 th angular equivalent of th
stituting this expression for linear acceleration in Equation impuise-momentum relationship.
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 T = 1 A&i/t (Equation 4.7)
momentum of a moving body. Momentum describes th
quantity of motion possessed by a body. Momentum is gen- Tt = I X co (Equation 4.8)
erally represented by th letter p and is in units kgm/s. The Angular Momentum = I X Angular Velocity
product of force and time on th left side of Equation 4 .6 is Angular Impulse = Torque x Time
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 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
Mass Moment of Inertia and Prosthetic Design th extern to which a force or torque can move or rotate an
object over some distance. Work (W) in a linear sense is
The mass moment of inertia is taken under considera-
equal to th product of th magnitude of th force (F) ap-
tion in prosthetic design for th person with an amputa-
plied against an object and th distance that th object moves
tion. The use of lighter components in foot prosthesis,
in th direction of force while th force is being applied
for example, not only reduces th overall mass of th
(Equation 4.9 in box). If no movement occurs, no mechani-
prosthesis, but also results in a ehange in th distribu-
cal work is done. The most commonly used units to de-
tion of th mass to a more proximal location in th leg.
scribe work are equivalent units: th Newton-meter (Nm)
As a result, less resistance is imposed upon th re-
and th joule (J). Similar to th linear case, angular work
maining limb during th swing phase of gait. The benefit
can be defined as th product of th magnitude of th
of these lighter components is realized in terms of less-
torque (T) applied against th object, and th angular dis
ened energy requirements for th person with an ampu-
tation. tance in degrees or radians that th object rotates in th
direction of torque, while th torque is being applied (Equa
tion 4.10).
Chapter 4 Biomechamcal Principles 61

A Closer Look at th Impulse-Momentum Relationship 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 -
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
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
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
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
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
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
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
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
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 -
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-
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
w a r d m o m e n t u m is d e c r e a s e d .
(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.

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

Work (W) daily activities, it is often th rate at which a force does
W (linear) = F X distance (Equation 4.9) work that is important. The rate of work is defined as
power. The ability for muscles to generate adequate power
W (angular) = T X degrees (Equation 4.10) 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
The work-energy relationship describes mechanical work a player can jump for a rebound that determines success.
in tenns of th expenditure of energy. Energy can be consid- Another example of th importance of th rate of work can
ered as th measure of th fuel available to th System to be appreciated in an elderly person with Parkinsons disease
perform work. The work-energy relationship has been partic- who must cross a busy Street in th time determined by a
ularly helpful to th study of walking in humans. The me pedestrian traffic signal.
chanical work of walking is often th global indicator of th Power (P) is work (W) divided by time (see Equation 4.11
metabolic demands on th body, without th detailed ac- in box on th following page). Because work is th product
count of th intricacies of th movement. of force (F) and distance (d), th rate of work can be re-
The work-energy relationships previously described in stated in Equation 4.12 as th product of force and velocity
Equations 4.9 and 4.10 do not take into account th time (d/t). Angular power may also be defined as in th linear
62 Section 1 Essential Topics o j Kinesiology


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).

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

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
Acceleration Rate of change in linear veloc- m/s2 Rate of change in angular velocity /s2
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
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
Radians, which are unitless, may be used insiead of degrees.
Chapter 4 Biomechanical Principles 63

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

important to understand th added impact of gravity and
other extemal forces. The observation and analysis of move
ment must take into consideration th net effect of muscle
activity, th resulting internai forces, as well as all th 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 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
iGURE 4-5. The forces between th ground and foot are depicted motion. Analysis of movement frequently requires informa-
-tsring th early part of th walking cycle. The ground reaction
tion regarding th mass of individuai segments or th distri-
:>rces (red arrows) act superiorly and posteriorly, whereas th foot
bution of mass within a given segment. These factors deter
nrces (black arrows) act inferiori}' and anteriorly.
mine th inertial properties that muscles must overcome to
generate movement. Anthropometric information is also
valuabte in th design of th work environment, furniture,
odies interact simultaneously, and th consequence is speci- tools, and sports equipment.
:sd by th law of acceleration: XF = ma. That is, each body Much of th information regarding th body segments
-xperiences a different effect and that effect depends on its center of mass and mass moment of inerba has been derived
mass. For example, a person who falls off th roof of a from cadaver studies.4 Refer to Table l in Appendix 1A for
second-story building exerts a force on th ground, and th anthropometric data on weights of different body segments
ground exerts an equal and opposi te force on th person. and locations of th centers of mass. Other methods for
Aecause of th discrepancies in mass between th ground deriving this information have included mathematical model-
and th person, th effect, or acceleration experienced by th ing and imaging techniques, such as computed tomography
rerson, is much greater than th effect experienced by th and magnetic resonance imaging.
ground. As a result, th person may sustain signifcant in-
y- Free Body Diagram
Perhaps th most direct application of Newtons law of
iClion-reaction is th reaction force provided by th surface The analysis of movement requires that all forces that act on
.pon which one is walking. The foot produces a force th body be taken into account. Prior to any analysis, a free
against th ground owing to th accelerations of all superin- body diagram is constructed to facilitate th process of solv-
umbent body segments. In accord with Newtons third law, ing biomechanical problems. The free body diagram is a
ne ground generates a ground reaction force in th opposite snapshot or simplifed sketch that represents th interac
arection but of equal magnitude (Fig. 4 - 5 ) . The ground tion between a System and its environment. The System
reaction force changes in magnitude, direction, and point of under consideration may be a single rigid segment, such as
-oplication on th foot/shoe throughout th period of gait. th foot, or il may be several segments, such as th head,
Ground reaction forces can be measured via force platforms arms, and trunk. These can be regarded together as a single
see section on Kinematic and Kinetic Measurement Systems rigid System.
ater in this chapter), and th forces are commonly used as A free body diagram requires that all relevant forces act-
nput data for th quantitative analysis of human motion. 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
NTRODUCTION TO MOVEMENT ANALYSIS: tion forces. Arrows are used to indicate force vectors.
SETTING THE BACKGROUND How a free body diagram is defned depends on th
intended purpose of th analysis. Consider th example pre-
~; previous section describes th nature of th cause and sented in Figure 4 - 6 . In this example, th free body dia
et relationship between force and motion as outlined by gram represents th extem al forces acting on th body of an
'nvtons laws. Although it may be relatively simple to con 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 '
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.


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
Chapier 4 Biomechanical Principles 65

FIGURE 4 8. Free body diagram isolating th System as a right arm and weight combmation: resultant
shoulder abductor muscle force (MF); glenohumeral joint reaction force (JRF); arm weight (AW); and load
weight (LW). The axis of rotation is shown as an open red circle at th glenohumeral joint. (Modified from
LeVeau BF: Williams & Lissner's Biomechanics of Human Motion, 3rd ed. Philadelphia WB Saunders

Step II involves setting up a reference frame that allows

th position and movement of a body to be defined with Initial Steps in Setting Up th Free Body Diagram
respect to a known point, location, or axis (see Fig. 4 - 8 , X- Step I: Identify and isolate th System under consideration.
Y reference). More detail on establishing a reference frame is Step II: Establish a reference frame.
discussed in th next section.
Step III: Illustrate th internai (muscular) and extemal (gravita
Step III illustrates th internai and extemal forces that act tional) forces that act on th System.
on th System. Internai forces are those produced by muscle
Step IV: Illustrate th contact forces that act on th System,
MF). Extemal forces include th gravitational pul of both
typically including th joint reaction force.
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 In order to accurately describe motion or solve for unknown
data, such as those presented in Appendix 1A. forces, a reference frame and an associated coordinate System
The direction of th internai MF is drawn in a direction need to be established. This information allows th position
that opposes th potential motion produced by th extemal and movement direction of a body, a segment, or an object
forces. In this example, th rotation produced by th exter- to be defined with respect to some known point, location, or
nal forces, AW and LW together with their moment arms, segments axis of rotation. If a reference frame and coordi
tends to move th arm in a clockwise or adduction direc nate System are not identified, it becomes very difficult to
tion. Thus, th line-of-force of MF, in combination with its interpret and compare measurements in clinica] and research
moment arm, tends to rotate th arm in a counterclockwise settings.
or abduction direction. A reference frame is arbitrarily established and may be
Step IV of th procedure is to show th contact forces that placed inside or outside th body. Reference frames used to
act on th System. Because this System is assumed to be in describe position or motion may be considered either rela
static equilibrium, contact forces such as air resistance are tive or global. A relative reference frame describes th posi
ignored. Another contact force to consider is a push or pul tion of one limb segment with respect to an adjacent seg
applied to th extemal aspect of th body, such as th ment, such as th foot relative to th leg, th forearm
manual resistance delivered by a therapist or by an opposing relative to th upper arm, or th trunk relative to th thigh,
player in a sporting event. In this example, th only relevant as shown in Figure 4 -9 A . A measurement is made by com-
contact force is th joint reaction force (JR F) created across paring motion between an anatomie landmark or coordinates
th glenohumeral articulation. Initially, th direction of th of one segment with an anatomie landmark or coordinates of
joint force may not be known but, as explained later, is a second segment. Goniometry provides one example of a
typically drawn in a direction opposite to th pul of th relative coordinate System used in clinical practice. Elbow
dominant muscle force. The precise direction of th JRF can joint range of motion, for example, describes a measurement
be determined after static analysis is carried out and un- using a relative reference frame defined by th long axes of
known variables are calculated. This method of analysis is th upper arm and forearm segments, with an axis of rota
discussed in detail in th following section of this chapter. tion through th elbow.
The box summarizes th key steps in setting up th free Relative reference frames, however, lack th information
body diagram. needed to define motion with respect to a fixed point or
66 Seclion / Essential Topici o j Kinesiology

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

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

A Relative reference B Global reference

frame frante

location in space. To analyze tnotion with respect io th horizontal (X) and th other vertical (Y), although they may
ground, direction of gravity, or another type of externally be oriented in any manner that facilitates quantitative Solu
defned reference frame in space, a global or laboratory refer- tions. A 2D System is frequently utilized when th motion
ence frain e must be defned. The position of th trunk with being described is predominantly planar (i.e., in one piane),
respect io a horizontal reference is an example of a measure- such as knee flexion and extension during gait.
ment made with respect io a global reference frame (Fig. In most cases, human motion occurs in more than one
4 -9 B ). piane. Even th knee, whose motion is considered to occur
Use of one type of reference frame over another may predominantly in th sagittal piane while walking, also un-
result in different outcome measures. Figure 4 - 9 illustrates dergoes small rotations in both horizontal and frontal planes.
how a relative and global reference frame can be used to In order to adequately describe th motions that occur in
describe th position of th trunk during th sit-to-stand more than one piane, a 3D reference System is necessary. A
activity, but th outcome measures are different. The use of 3D System has three axes, each perpendicular or orthogonal
two distinct reference frames for describing th same snap- to each other. In contrast to th planar description of th 2D
shot of an activity, bui having different results, emphasizes System, th coordinates in a 3D System can designate any
th importance of identifying th reference frame when de point or vector in space relative to th X, Y, and Z axes.
scribing human movement. A coordinate System needs to indicate direction of motion
Whether motion is measured via a relative or global refer as well as position in both a linear and a rotational sense.
ence frame, th location of a point or segment in space can By convention, most coordinate Systems are constructed
be specified using a coordinale System. In human movement such that linear movements to th righi, up, and forward are
analysis, th Cartesian coordinate System is most frequently defned as positive, whereas movements to th left, down,
employed. The Cartesian System utilizes coordinates for lo- and backward are negative. The direction of a force produc-
cating a point on a piane by identifying th distance of th ing a motion can be defned by th direction that th object
point from each of two intersecting lines or, in space, by th is being accelerated. Rotary or angular movements are de
distance from each of three planes intersecting at a point. scribed in th piane (sagittal, frontal, horizontal) that a seg-
This System, therefore, is either two-dimensional (2D) or ment is moving, which is perpendicular to th axis of rota-
three-dimensional (3D). A 2D System is defned by two tion. A segments rotation direction may be described as
imaginary axes arranged perpendicular to each other. The clockwise or counterclockwise or as flexion or extension (see
two axes (X, Y) are usually positioned such that one is 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
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 ous example, th resultant vector can be found by drawing
vectors. In this example, th resultant force (RF) acts down- parallelogram based on th magnitude and direction of th
ward and has th tendency to distract (pul apart) th knee two component force vectors. Figure 4 -1 2 A provides ar.
joint, if unopposed by other forces. Figure 4 - 1 0 B illustrates illustration of th parallelogram method to combine severa]
a cervical traction device that employs a weighted pulley component vectors into one resultant vector. The component
System, acting in th direction opposite to th force createci force vectors, Fj and F2 (black solid arrows), are generated
by th weight of th head. Simple addition yields th value by th pul of th flexor digitorum superficialis and profun-
of th resultant force. The positive sign of RF indicates a dus, as they pass palmar (anterior) to th metacarpophalan-
slight net upward distraction force on th head and neck. geal joint. The diagonal, originating at th intersection of F
Force vectors acting on a body may be coplanar, but they and F2, represents th resultant force (RF) (see Fig. 4 -1 2 A ,
may not always act parallel. In this case, th individuai thick red arrow). Because of th angle between F, and F2.
vectors may be composed using th polygon method. Figure th resultant force tends to raise th tendons away from th
4 - 1 1 illustrates how th polygon method can be applted to joint. Clinically, this phenomenon is described as a bow-
a frontal piane model to estimate th reaction force on a stringing force due to th tendons resemblance to a pulled
prosthetic hip while standing on one limb. With th arrows cord connected to th two ends of a bow. In rheumatoid
drawn in proportion to their magnitude and in th correct arthritis, th bowstringing force may rupture th ligaments
orientation, th vectors of body weight (BW) and hip abduc- and dislocate th metacarpophalangeal joints (Fig. 4 12B).
tor force (HAF) are added in a tip-to-tail fashion (Fig. 4 In many cases, especially when analyzing muscle forces.
11B). The combined effect of th BW and HAF vectors is th parallelogram method can be described as a reclangle,
determined by placing th tail of th HAF vector to th tip such that th components of th resultant force are oriented
of th BW vector. Completing th polygon yields th result at right angles to each other. As shown in Figure 4 - 1 3 , th
ant prosthetic hip reaction force (PHRF), showtng its magni two right-angle forces are referred to as normaI and tangential
tude and direction (see Fig. 4 - 1 1 B , dotted line). In this components (MFN and MFT). The hypotenuse of th right
case, th resultant vector represents a reaction force and, triangle is th resultant muscle force (MF).
therefore, is directed in a sense that opposes th sum of th In summary, when two or more forces applied to a seg-
other two vectors. ment are combined into a single resultant force, th magni
A parallelogram can also be constructed to determine th tude of th resultant force is considered equal to th sum of
resultant of two coplanar but nonparallel forces. Instead of th component vectors. The resultant force can be deter
placing th force vectors tip-to-tail, as discussed in th previ - mined graphically as summarized in th box.

Stretched collateral


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
phalangeal (MCP) joint. The re
Palmar dislocation of th
metacarpophalangeal collateral
sultant force (RF) vector creates
joint 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
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
- GURE 4-13. The muscle force (MF) produced by th brachioradi- a clinician. In th presence of an external moment arm,
* is represented as th hypotenuse (diagonal) of th rectangle. external forces produce an external torque. Generally, in th
The normal force (MFN) and tangential force (MFT) are also indi- condition of equilibrium, th external torque acts about th
:ated. The internai moment arm (IMA) is th perpendicular dis joints axis of rotation in th opposite direction to a given
ance between th axis of rotation (red circle) and (MFN). 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),
Summary of How to Graphically Compose Force Vcctors leg segment weight (SW ), and external load weight (LW)
ParaLlel forces vectors can be combined by using simple applied at th ankle. The weight of th leg segment and
vector addition (Fig. 4-10). extemal load acts at th center of th respective masses.
Nonparallel, coplanar force vectors can be composed by Figure 4 - 1 4 B shows th resultant internai forces and exter
using th polygon (tip-to-tail) method (Fig. 4 -1 1 ), or
nal forces broken into their normal and tangential compo
th parallelogram method (Figs. 4 -1 2 and 4-13).
Influence o f Changing th Angle of th Joint
The relative magnitude of th normal and tangential compo
Resolution of Forces
nents of force applied to a bone depends on th position of
The previous section illustrates th composition method of th limb segment. Consider firsi how th change in angular
-epresenting forces, whereby multiple coplanar forces acting position of a joint alters th angle-of-insertion o j th muscle
on a body are replaced by a single resultant force. In many (see Chapter 1). Figure 4 - 1 5 shows th biceps muscle force
clini cal situations, a knowledge of th effect of th individuai (MF) at four different elbow joint positions, each with a
components that produce th resultant force may be more different angle-of-insertion (a ) to th forearm. Each angle-of-
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 TABLE 4 - 3 . Normal versus Tangential Force
combined, are equivalent to th originai resultant force. Components of a Muscle Force
One of th most useful applications of th resolution of
forces involves th description and calculation of th rectan- Tangential Force
gular components of a muscle force. As depicted in Figure Normal Force Component Component
4 - 1 3 , th rectangular components of th muscle force are
Acts perpendicular to a bony Acts parallel to a bony seg
shown at righi angles to each other and are referred to as
segment ment
th normal and tangential components (MFN and MFT). The
normal component represents th component of th muscles Often indicated as FNbut Often indicated as FT bui
resultant force that acts perpendicularly to th long axis of may be indicated as FY, may be indicated as Fx,
th body segment. Because of th internai moment arm (see depending on th choice of depending on th choice of
th referente frame th reference frame
Chapter 1) associated with this force component, one effect
of th normal force of a muscle is to cause a rotation (i.e., Can cause rotation and/or A translation may occur as a
produce a torque). The normal force may also cause a trans- translation: compression or distraction
lation of th bony segment. A rotation may occur if th between articulating sur-
The tangential component represents th component of moment arm > 0. faces.
A translation may occur as
th muscles resultant force that is directed parallel to th
a compression, distrac-
long axis of th body segment. The effect of this force is to
tion, or shearing be
compress and stabilize th joint or, in some cases, distract or tween articulating sur-
sparate th segments forming th joint. The tangential com- faces.
Donent of a muscle force does not produce a torque when it
70 Secton 1 Essential Topici o j Kinesiology

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
Free body diagram torque experienced by th exercising person is equal to th
product of th external moment arm (EMA) and th normal I
FIGURE 4-14. Resoluiion of internai forces (red) and external forces component of th external forces (LWN or SW N). In Figure
(black) for an individuai performing an isometric knee extension 4 -1 6 A , no external torque exists in th sagittal piane be
exercise. A, The following resultant force vectors are depicted: mus-
cause th SW and LW force vectors pass through th axis of
cle force (MF) of th knee extensors; leg segment weight (SW); and
rotation and, therefore, have no moment arm. Figure 4 -1 6 B
load weight (LW) applied ai th ankle. B, A free body diagram
shows th resultant vectors resolved into their rectangular compo- through C shows how a greater external torque is placed
nents: normal component of th muscle force (MFN); tangential against th individuai with th knee fully extended com-
component of th muscle force (MFT); norma! component of th pared with th knee flexed 45 degrees. Although th exter
segment weight (SWN); tangential component of th segment weight nal forces, SW and LW, are th same in all three cases, th I
(SWT); normal component of th load weight (LWN); and tangential external torque is greatest when th knee is in full extension
component of th load weight (LWT). In both A and B, th open As a generai principle, th external torque applied against a
red circles mark th medial-lateral axis of rotation at th knee. Note joint is greatest when th resultant external force vector I
that th XY reference frame is rotated so that tangential forces are intersects th bone or body segment at a right angle.
oriented in th X direction and normal forces are oriented in th Y
direction. (Vectors are not drawn to scale.)
Thus far, th composition and resolution of forces are pri-
marily described using a graphic method to determine th
insertion results in a different combination of tangential magnitude of forces. A drawback to this method is that it I
(MFt ) and normal (MFN) force components. The tangential requires a high degree of precision to accurately represent I
forces create compression or distraction forces at th elbow. th forces analyzed. In th solution of problems involving
By acting with an internai moment arm (IMA), th normal rectangular components, right-angle trigonometry provides
forces also generate an internai torque (i.e., potential rota a more accurate method of force analysis. The trigonometrie I
tion) at a joint. As shown in Figure 4 -1 5 A , a relatively functions are based on th relationship that exists between I
small angle-of-insertion favors a relatively larger tangential th angles and sides of a right triangle. Refer to Appendix IC
force, which directs a larger percentage of th total muscle 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
(IMA and EMA) are maximal. At this unique elbow position
th internai and external torque potentials are maximal as
The concept of altering th angle of a joint is frequently well as optimally matched. As th elbow position is al-
utilized in exercise programs to adjust th magnitude of tered in Figure 4-176, th external torque remains maxi
resistance experienced by th patient or Client. It is often mal; however, th internai torque potential is significantly
desirable to design an exercise program so that th exter reduced. As th elbow approaches extension, th angle-
nal torque matches th internai torque potential of th of-insertion of th muscle and th normal muscle force
muscle or muscle group. Consider a person performing a (M FJ are reduced, thereby decreasing th potential for
"biceps curi" exercise shown in Figure 417/4. With th generating internai torque. A person with significant
elbow flexed to 90 degrees, both th internai and external weakness of th elbow flexor muscle may have difficulty
torque potentials are greatest, because th product of holding an object in position B, but may have no difficulty
each resultant force (MF and LW) and their moment arms 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 The first method for determining internai torque is illus-
In th context of kinesiobgy, a torque is th effect of a force trated in Figure 4 - 1 8 (black letters). The internai torque is
tending to move a body segment about a joints axis of depicted as th product of MFN (th normal component of
rotation. Torque is th rotary equivalent of a force. Mathemati- th resultant muscle force (MF) and its internai moment arm
cally, torque is th produci of a force and its moment arm (IMA,)). The second method, depicted in red letters in Fig
and has units of Nm. Torque is a vector quantity, having ure 4 - 1 8 , does not require th resultant force to be resolved
both magnitude and direction. into rectangular components. In this method, internai torque
Two methods for determining torque yield identical is calculated as th product of th resultant force (MF) and
mathematica! Solutions. The methods apply to both internai IMA2 (i.e., th internai moment arm that extends between
and external torque, assuming that th System in question is th axis of rotation and a perpendicular intersection with
in rotational equilibrium (i.e., th angular acceleration about MF). Both methods yield th same internai torque because
th joint is zero). 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 FIGURE 4-19. An external torque is applied to th elbow through a
th produci of th resultant force of th muscle (MF) times its resistance generated by tension in a cable (R). The weight of th
internai moment arm (IMA;,). Both expressions yield equivalent in body segment is ignored. The external torque can be determined
ternai torques. The axis of rotation is depicted as th open black using two different methods. The firei method (shown in black
circle at th elbow. 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.
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
times its external moment arm (EMA,). The second method,
Figure 4 - 1 9 shows an external torque applied to th elbow shown in red letters, uses th product of th cables resultant
through a resistance produced by a cable (depicted as R). resistive force (R) and its external moment arm (EMA2). As
The weight of th body segmeni is ignored in this example. with internai torque, both methods yield th same external
The first method for determining external torque is shown in torque because both satisfy th definition a torque (i.e., th
black letters. External torque is depicted as th product of produci of a resistance (external) force and its associated
Rn (th norma! component of th cables resistive force) external moment arm).

A "Shortcut" Method of Estimating Relative Torque


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

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

concluded that th external torque is greater in a deep
th bone. squat (A) compared with a partial squat (6). The ability to
Next consider external torque. Clinically, it is often judge th relative demand placed on th muscles due to
necessary to quickly compare th relative external torque th external torque is useful in terms of protecting a joint
generated by gravity or other external forces applied that is painful or otherwise abnormal. For instance, a
against a joint. The leverage of an external force, such as person with arthritic pain between th patella and femur
EMA2 in Figure 4-19, may need to be adjusted in order to is often advised to limit activities that involve lowering
match th internai torque potential of th musculature and rising from a deep squat position. This activity places
most effectively. Consider, for example, th external large demands on th quadriceps muscle, which in-
torque at th knee during two squat postures (Fig. 4-21). creases th compressive forces on th joint surfaces.
By visualizing th external moment arm between th knee

B. 45 of flexion (partial squat)

A, 90 of flexion (deep squat)

FIGURE 4-21. The depth of a squai

significanily affeets th magnimele of
th external torque produced by body
weight at th knee. The relative exter
nal torque, within th sagittal piane,
can be estimated by comparmg th 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.

Clinica! Issues Related to Joint Force and Torque from large and potentially damaging forces. This result can
Joint Protection" be achieved by reducing th rate of movement (power),
Some treatments in rehabilitation medicine are directed providing shock absorption (e.g., cushioned footwear), or
toward reducing th magnitude of force on joint surfaces limiting th mechanical force demands on th muscle.
during th performance of a physical activity. The purpose Minimizing large muscular-based joint forces may be im-
of such treatment is to protect a weakened or painful joint portant for persons with prostheses or artifcial joint replace-
Chapter 4 Biomechanical Principles 75

menis. A person with a hip replacemeni, for example, is sider th case of severe hip osteoarthritis that results in
often advised on ways to minimize unnecessarily large forces destruction of th femoral head and an associated decrease
produced by th hip abductor muscles.9'10J 2 Figure 4 - 2 2 in th size of th femoral neck and head (Fig. 4 -2 3 A ). The
depicts a simple schematic representation of th pelvis and bony loss shortens th internai moment arm length (D)
femur while standing on a tight lower limb that has a pros- available to th hip abductor muscles; thus, greater muscle
thetic hip. The snapshot during th single-limb support and joint forces are produced to maintain frontal piane equi-
phase of gait assumes a condition of static equilibrium (i.e., librium. A surgical procedure that is an attempi to reduce
no acceleration is experienced by th pelvis relative to th joint forces on th hip entails th relocation of th greater
femur). In order for equilibrium io be maintained within th trochanter to a more lateral position (Fig. 4 - 2 3 B ). This
frontal piane, th internai (counterclockwise) and external procedure increases th length of th internai moment arm
(clockwise) torques about th stance hip must be balanced: of th hip abductor muscles. An increase in th internai
th produci of hip abductor force (HAF) times its moment moment arm reduces th force required by th abductor
arm D must equal body weight (BW) times its moment arm muscles to generate a given torque during single-limb sup
D,, or HAF X D = BW X D,. The external moment arm port of gait.
about th hip is almost twice th length of th internai
moment arm. The disparity in moment arm lengths requires Manually Applying External Torques During Exercise
that th muscle force be almost twice th force of body External or resistance torques are often applied manually
weight in order to maintain equilibrium. In theory, reducing during an exercise program. For example, if a patient is
excessive body weight, carrying lighter loads, or carrying beginning a knee rehabilitation program to strengthen th
loads in certain fashions can decrease th external moment quadriceps muscle, th clinician may initially apply manual
arm and external torque about th hip.9 Reduction of unnec resistance to th knee extensors at th midtibial region. As
essarily large external torques can decrease unnecessarily th patients knee strength increases, th clinician can exert a
large force demands on hip abductors and on underlying greater force at th midtibial region or th same force near
prosthetic hip joints. th ankle.
Certain orthopedic procedures illustrate how concepts of Because external torque is th product of a force (resis
joint protection are utilized in rehabilitation practice. Con- tance) and an associated external moment arm, an equivalent


FIGURE 4-22. A, Hip abductor force (HAF) from th right hip abductor muscles produces a torque necessary for th frontal piane
stability of th pelvis during th right single-limb support phase of walking. Rotary stability is established, assuming static
equilibrium, when th counterclockwise torque equals th clockwise torque. The counterclockwise torque equals HAF times its
moment arm (D), and th clockwise torque equals body weight (BW) times its moment arm (D[). B, This first-class lever seesaw
model simplifes th model shown in A. The joint reaction force (JRF), assuming that all force vectors act vertically, is shown as an
upward directed force at a magnitude equal to th sum of th hip abductor force and body weight. (Reprinted and modifed with
permission from Elsevier Science Publishing Co., Ine., from Neumann DA. Biomechanical analysis of selected principles of hip joint
protection. Arthr Care Res 2:146-155, 1989. Copyright 1989 by ihe Arthritis Health Professions Association.)
76 Sedioli I Essential Topics o f Kinesiology

FIGURE 4-23. How th internai

moment arm used by th hip 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-

external torque can be applied by a relatively short extemal INTRODUCTION TO MOVEMENT ANALYSIS:
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- In th previous section, concepts are introduced that provtde
ferent combinations of extemal forces and moment arms. th tramework for performance of quantitative methods of
Note that th resistance force applied io th leg is greater in analysis. Many approaches are applied when solving prob-
Figure 4 -2 4 A than in Figure 4 -2 4 B . The higher contact lems in biomechanics. These approaches can be employed to
force may be uncomfortable for th patient and needs to be assess (1) th effect of a force at an instant in time (force-
considered during th application of resistance. A larger ex acceleratici! relationship)', (2) th effect of a force applied over
ternal moment arm, shown in Figure 4 - 2 4 B , may be neces- an in tern i of time (impulse-momentum relationship); and (3)
sary if th clinictan chooses to manually challenge a muscle th application of a force that causes an object to move
group as potentially forceful as th quadriceps. 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-
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)

torque, acting in a counterclockwise direction. This assump


(Equation 4.15)

tion of rotational equilibrium allows Equation 4.15 to be

used to solve for th magnitude of th internai torque and
muscle force:
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

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

flexion exercise is performed against a load weight
Muscle Force (MF) = unknown
held in th hand. The forearm is held in th hori-
Segment Weight (SW) = 17N
Load Weight (LW) = 60N
zontal position, parallel to th X axis. B, A free
Joint Force (JF) at th elbow = unknown body diagram is shown of th exercise, including a
Internai Moment Arm (IMA) to MF = ,05m box with th abbreviations and data required to
External Moment Arm to SW (EMA,) = ,15m solve th problem. The medial-lateral axis of rota
External Moment Arm to LW (EMA2) = ,35m 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 disparity in moment arm length is not unique to th elbow
all th muscles that llex th elbow. This type of analysis flexion model, bui it is ubiquitous throughout th muscular-
does not, however, provide information about how th joint systems in th body. For this reason, most muscles of
torque is distributed among th various elbow fexor mus th body routinely generate a force many times greater than
cles. This requires more sophisticated procedures, such as th weight of th external load. This principle requires that
muscle modeling and optimization techniques, which are th bone and articular cartilage absorb large joint forces that
beyond th scope of this text. result from seemingly nonstressful activities.
The muscle force required to maintain th forearm in a
static position at a given instant in time is calculated by Solving for Joint Force
dividing th external torque by th internai moment arm: 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
MF X IMA = (SW X EMA,) + (LW X EMA,)

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 through th axis of rotation and, therefore, has a zero mo
assumption that th joint force acted downward. Because ment arm.
muscle force is usually th largest force acting about a joint,
th direction of th net joint force must oppose th pul of Problem 2
th muscle. Without such a force, for example, th muscle In Problem 1, th forearm is held horizontally, thereby ori-
mdicated in Figure 4 - 2 5 would accelerate th forearm up- enting th internai and extemal forces perpendicular to th
ward, resulting in a unstable joint. In short, th joint force forearm. Although this presentation greatly simplifies th cal-
supplied by th humerus against th forearm in this case culations, it does not represent a very typical biomechanical
provides th missing force needed to maintain linear static situation. Problem 2 shows a more common situation in
equilibrium at th elbow. As stated earlier, th joint force which th forearm is held at a position other than th
does not produce a torque because it is assumed to act 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

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 MF = 471.1 N
aspects of ths problem are identical io Problem 1, except
that th resultant vectors need to be resolved into rectangu- The tangential component of th muscle force, MFX, can be
lar (X and Y) components. This requires additional steps and solved by
trigonometrie calculations. Assuming equilibrium, three un-
known vartables are once again to be determined: (1) th MFX = MF X cos 60
internai (muscular-produced) torque, (2) th muscle force,
and (3) th joint reaction force at th elbow.
MFX = 471.1 N X .5
Figure 4 - 2 6 B illustrates th free body diagram of th
forearm held at 30 degrees below th horizontal (0). To
MFX = 235.6 N
simplify calculations, th X-Y reference frame is established,
such that th X axis is parallel to th forearm segment. All Solving for Joint Force
forces acting on th System are indicated, and each is re The joint reaction force (JF ) and ts normal and tangential
solved into their respective tangential (X) and normal (Y) components (JF Y and JF X) are shown separately in Figure
components. The angle-of-insertion of th elbow flexors to 4 - 2 6 C. (This is done to increase th clarity of th illustra-
th forearm (a ) is 60 degrees. All numeric data and back tion.) In reality, th joint forces are acting concurrently on
ground information are listed in th box associated with th proximal end of th forearm segment along with th
Figure 4 - 2 6 . other lorces. The directions of JF V and JF X are assumed lo
act downward (negative) and to th right (positive), respec-
Solving for Internai Torque and Muscle Force tively. These are directions that oppose th force of th
muscle. The rectangular components (JF Y and JF X) of th
2 T = 0 (Internai torque 4- external torque = 0) joint force (JF ) can be readily determined by using Equa-
tions 4 .14 A and B.
Internai torque = external torque
2Fy = 0

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

MF y - SWY - LWV - JF y = 0

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


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
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,

JF X = 197.1 N
th last calculation yielded th magnitude of its associateci
perpendicular vector, MFY, not MF. The resultant muscle
As depicted in Figure 4 26C, JF V and JF X act downward
force, or MF, can be determined by
and lo th right, respectively, in a direction that opposes th
force of th muscle. The magnitude of th resultant joint
MF = MFY/sin 60 force (JF ) can be determined using th Pythagorean theo-

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
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

(Equation 4.17)


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 FIGURE 4-27. An electrogoniometer is shown strapped to th thigh
Readings at th end of this chapter for further elaboration of and leg. The axis of th goniometer contains th potentiometer and
th uses, advantages, and disadvantages of these measure- is aligned over th medial-lateral axis of rotation at th knee joint.
ment techniques. 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-
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
are vulnerable to ambient electrical interference.
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.)
Chapter 4 Biomechanical Prnciples 83

transmitters. Although telemetry is available for these Sys

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

Kinetic Measurement Systems: Mechanical Devices,

Transducers, and Electromechanical Devices
Mechanical Devices
Mechanical devices measure an applied force by th amount
of strain or th compression of deformable material.
FIGURE 4-29. A hand-held dynamometer is used to measure th Through purely mechanical means, th strain in th material
isometric elbow extension torque produced by th triceps musele. causes th movement of a dial. The numeric values associ
The product of th resistive force (RF) times its external moment
ated with th diai are calibrated to a known force. Some of
arm (EMA), assuming static equilibrium, is equal io th product of
th most common mechanical devices for measuring force
th triceps force (TF) times its internai moment arm (IMA).
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
anatomie landmarks. Position and orientation data from th torque produced by a patient (Fig. 4 - 2 9 ) . In th example,
receivers located within a specified operating range of th th dynamometer measures a resistance force (RF) in re-
transmitter are sent to th data capture System. sponse to a maximal effort, isometrically produced elbow
One disadvantage of this System is that th transmitters extension torque. The triceps force (TF) is determined by
and receivers are sensitive to metal in their vicinity. The dividing th external torque (RF X EMA) by an estimate of
metal distorts th electromagnetic field generated by th th internai moment arm.

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 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

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-
FIGURE 4-31. lsokinetic dynamometry. The subject generates maxi- tric. The angular velocity is determined by th user, varying
mal-effort knee flexion torque at a joint angular velocity of 60 between 0 degrees/sec (isometric) and up to 500 degrees/sec
degrees/sec. The machine is functioning in its concentric mode, for nonisometric activation. Figure 4 - 3 1 shows a person
providing resistance against th contracttng muscles. Note that th who is exerting maximal effort, knee flexion torque through
medial-lateral axis of rotation of th tight knee is approximately
a concentric contraction of th right knee flexor muscola
aligned with th axis of rotation of th dynamometer. (Courtesy of
ture. Isokinetic dynamometry provides an objective record of
Biodex Medicai Systems, Ine., Shirley, New York.)
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-

introduction to th "Inverse Dynamic Approach" for In th inverse dynamics approach, th System under
Solving for Internai Forces and Torques consideration is often defined as a series of links. Figure
4-32A illustrates th relationship between th anatomie
Measuring joint reaction forces and muscle-produced net link segment models of th lower limb. In Figure 4-326,
torques during dynamic conditions is often performed indi- th segments are disarticulated and th individuai forces
rectly utilizing a technique called th inverse dynamic and torques are identified at each segment end point. The
approach.'6 This approach uses data on anthropometry, center of mass is located for each segment. The analysis
kinematics, and external forces, such as gravity and con on th series of links usually begins with th analysis of
tact forces. Accelerations are determined employing th th most distai segment, in this case th foot. Information
first and second derivatives of position-time data to yield gathered through motion analysis techniques, typically
velocity-time and acceleration-time data, respectively. The camera-based, serves as input data for th dynamic equa-
importance of acquiring accurate position data is a pre tions of motion. This information includes th position and
requisite to th soundness of this approach, because er- orientation of th segment in space, th acceleration of
rors in measuring position data magnify errors in velocity th segment and segment center of mass, and th reac
and acceleration.
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 Assumptions Made During th Inverse Dynamic
utilized as input for continued analysis of th next most
proximai segment, th leg. Analysis takes place until all 1. Each segment or link has a fixed mass that is con-
centrated at its center of mass.
segments or links in th model are studied. Several as-
2. The location of each segments center of mass re-
sumptions made during th use of th inverse dynamic mains fixed during th movement.
approach are included in th box. 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.


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
Jh x
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

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

u n r x

Foot W GRFy

REFERENCES Guccione AA (ed): Geriatrie Physical Therapy, 2nd ed. St, Louis,
Mosby, 2000.
1. Allard P, Stokes 1AF, Bianchi JP: Three-Dimensional Analysis of Human 13. Ozkaya N, Nordin M: Fundamentals of Biomechanics: Equilibrium, Mo-
Movement. Champaign, Human Kinetics, 1995 tion and Deformation. New York, Springer-Verlag, 1999.
2 Clauser CE, McConville JT, Young JW: Weight, volume, and center of 14. Soderberg GL: Kinesiology: Application io Pathological Motion, 2nd ed.
mass segments of th human body. AMRL-TR-69-70, Wright Patterson Baltimore, Williams & Wilkins, 1997.
Air Force Base, 1969. 15. Whiting WC, Zemicke RF: Biomechanics of Musculoskeletal Injury.
3. Craik RL, Oatis CA: Gait Analysis: Theory and Application. St. Louis, Champaign, Human Kinetics, 1998.
Mosby-Year Book, 1995. 16. Winter DA: Biomechanics and Motor Control of Human Movement,
4. Dempster WT: Space requirements for th seated operator. WADC-TR- 2nd ed. New York, John Wiley &r Sons, 1990
55-159, Wright Patterson Air Force Base, 1955. 17. Zatsiorsky VM: Kinematics of Human Motion. Champaign, Human Ki
5. Enoka RM: Neuromechanical Basis of Kinesiology, 2nd ed. Champaign, netics, 1998.
Human Kinetics, 1994. 18. Zatsiorsky VM, Seluyanov V: Esumation of th mass and inertia charac-
6. Hamill J, Knutzen KM: Biomechanical Basis of Human Movement. Balti teristics of th human body by means of ihe best predictive regression
more, Williams & Wilkins, 1995. equations. In DA Winter, RW Norman, RP Wells, et al (eds): Biome
7. Hatze H: A mathematical model for th computational determination of chanics. Champaign, Human Kinetics, 1985.
parameter values of anthropometric segments. J Biomech 13:833-843,
8. Hindrichs R: Regression equations to predici segmentai moments of A D 0ITI0N A L READINGS
inertia from anthropometric measurements. J Biomech 18:621-624, Hall SJ: Basic Biomechanics. St. Louis, Mosby, 1998.
1985. Hay JG: The Biomechanics of Sports Techniques. Englewood Cliffs, Prentice
9. Neumann DA: Biomechanical analysis of selected principles of hip joint Hall, 1993.
protection. Arthritis Care Res 2:146-155, 1989. LeVeau BF: Williams & Lissners Biomechanics of Human Motion. Philadel-
10. Neumann DA: Hip abductor muscle activity in persons with a hip phia, WB Saunders, 1992.
prosthesis while walking and carrying loads in one hand. Phys Ther 76: Low J, Reed A: Basic Biomechanics Explained. Oxford, Butterworth-Heine-
1320-1330, 1996. mann, 1996.
11 Neumann DA: Hip abductor muscle activity in persons who walk with Mow VC, Hayes WC: Basic Orthopaedic Biomechanics. New York, Raven
a hip prosthesis with different methods of using a cane. Phys Ther 78: Press, 1991.
490-501, 1998. Nordin M, Frankel VH: Basic Biomechanics of th Musculoskeletal System.
12. Neumann DA: Arthrokinesiological considerations in th aged aduli. In 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.
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

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.

C h a p t e r 5

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


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
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

naturai kinematic sequencing of th entire shoulder. This
Our study of th upper limb begins with th shoulder com chapter describes several of th important muscular synergies
plex, a set of four articulations involving th sternum, clavi that exist at th shoulder complex and how weakness in one
cle, ribs, scapula, and humerus (Fig. 5 - 1 ) . This series of muscle can affect th force generation potential in others.
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 OSTEOLOGY________________________
signifcant reduction in th effectiveness of th entire upper
limb. Sternum
Rarely does a single muscle act in isolation at th shoul
der complex. Muscles work in teams to produce a highly The sternum consists of th manubrium, body, and xiphoid
coordinated action that is expressed over multiple joints. The process (Fig. 5 - 2 ) . The manubrium possesses a pair of oval-
very cooperative nature of shoulder muscles increases th shaped clavicular facets, which articulate with th clavicles.
versatility, control, and range of active movements. Because The costai facets, located on th lateral edge of th manu
of th nature of this functional relationship among muscles. brium, provide attachment sites for th first two ribs. The
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.

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-

Anterior view

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.

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

Osteologie Features of th Clavicle

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#

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

Serratus anterior

^ 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
Root of the spine
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.
Chapter 5 Shoulder Complex 95

Superior view 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-
FIGURE 5-7. A close-up view of th righi coracoid process looking lateral axis through th elbow, th humeral head is rotated
from above. Proximal attachraents of muscle are in red, distai at- posteriori)' about 30 degrees within th horizontal piane
tachments in gray. Ligamentous attachment is indicated by light
(Fig. 5 -9 B ). This rotation, known as retroversion (from th
gray area outlined by dashed line.
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).
anterior to th frontal piane (see Fig. 5 - 4 ; angle B). This The anatomie neck of th humerus separates th smooth
orientation of th scapula is called th scapular piane. The articular surface of th head from th proximal shaft (Fig.
scapula and humeras tend to follow this piane when th 5 -8 A ). The prominent lesser and greater tubercles surround
arm is raised over th head. th anterior and lateral circumference of th extreme proxi
Located at th superior and inferior rim of th glenoid 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

mal attachments of th lateral and mediai head of th triceps
subscapularis. The large and rounded greater tuberete has an
(see Fig. 5 - 1 0 ) . Traveling distally, th radiai nerve spirals
upper, middle, and lower Jacet, marking th distai attachment
around th posterior side of th humerus in th radiai
of th supraspinatus, infraspinatus, and teres minor respec-
lively (Figs. 5 - 8 B and 5 - 1 0 ) . groove, heading toward th distal-latera! side of th hu
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) ARTHROLOGY
groove, which houses th long head of th tendon of th
biceps brachii. The latissimus dorsi muscle attaches to th The most proximal articulation within th shoulder complex
floor of th intertubercular groove, mediai to th biceps is th stemoclavicular joint (see Fig. 5 - 1 ) . The clavicle
tendon. Distai and lateral to th termination of th intertu through its attachment to th stemum, functions as a me-
bercular groove is th deltoid tuberosity. 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
Osteologie Features of th Proximal-to-Mid Humerus associated ligaments firmly attach th scapula to th clav
Head of th humerus icle. The pomi of contact between th anterior surface of
Anatomie neck th scapula and th posterior-lateral surface of th thorax
Lesser tubercle and cresi is called th scapulothoradc joint. In this case, th temi
Greater tubercle and erest does not imply a true anatomie joint, rather an interfacing
Upper, middle, and lower facets on th greater tubercle ol two bones. Movement at th scapulothoradc joint is a
Intertubercular (bicipital) groove
Deltoid tuberosity direct result of individuai movements occurring at th ster-
Radiai (spirai) groove 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
Ihe radiai (spirai) groove runs obliquely across th poste-
motions at both th glenohumeral and th scapulothoracic
rior surlace of th humerus. The groove separates th proxi- 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.
Chapter 5 Shoulder Complex 99

diameter. The clavicular facet on th stemum typically is th extremes of all elavicular motion, except for a downward
reciprocally shaped, with a slighdy concave longitudinal di movement of th clavicle (i.e., depressioni.
ameter and a slighdy convex transverse diameter. The articular disc at th SC joint separates th joint into
The large and exposed articular surface of th clavicle distinct mediai and lateral joint cavities (see Fig. 5 - 1 2 ) . The
rests against th smaller, sloped, articular surface of th ster- disc is a flattened piece of fbrocartilage that attaches inferi-
num. A prominent articular disc resides within th SC joint, orly near th lateral edge of th elavicular facet and superi-
which tends to increase th congruity of otherwise irregular- orly at th head of th clavicle and interclavicular ligament.
shaped joint surfaces. 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
The SC joint is enclosed by a capsule reinforced by anteror since significant age-related degenerative arthritis is relatively
and posterior stemocavicular ligaments (Fig. 5 - 1 2 ) . The inner rare at this jo in t.16
surface of th capsule is lined with synovial membrane. In The tremendous stability at th SC joint is due to th
addition, th joint is stabilized anteriorly by th sternal head arrangement of th surrounding periarticular connective tis
of th stemocleidomastoid and posteriorly by th stemothy- sues.12 Large medially directed forces through th clavicle
roid and stemohyoid muscles. The interclavicular ligament often cause fracture of th bones shaft instead of a SC joint
spans th jugular notch, connecting th mediai end of th dislocation. Clavicular fractures are most common in males
right and left clavicles. under 30 years old. Most often these fractures are th result
of contact-sport or road-traffic accidents.51

Tissues That Stabilize th SC Joint KINEMATICS

Anterior and postenor stemocavicular ligaments
Interclavicular ligament The osteokinematics of th clavicle are defined for 3 de-
Costoclavicular ligament grees of freedom. Each degree of freedom is associated with
Articular disc one of th three Cardinal planes: sagittal, frontal, and horizon
Stemocleidomastoid, stemothyroid, and stemohyoid mus tal. The clavicle elevates and depresses, protraets and re-
cles 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
The costoclavicular ligament is a strong structure extending joint.
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 Osteokinematics at th SC Joint
The anterior bundle runs obliquely in a superior and lateral Elevation and depression
direction, and th more posterior bundle runs obliquely in a Protraction and retraction
superior and mediai direction (see Fig. 5 - 1 2 ) . The costo Axial rotation of th clavicle
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.
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.
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.)
Chapter 5 bhoulaer C omplex 101

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 The coracoclavicular ligament provides additional stability
disc of varying form is present in most AC joints. to th AC joint (see Fig. 5 - 1 8 ) . This extensive ligament
The AC joint is most often described as a gliding or piane consists of th trapezoid and conoid ligaments. The irapezoid
joint, reflecting th predominantly fiat contour of th joint ligament extends in a superior-lateral direction from th su
surfaces. Joint surfaces vary, however, from fiat to slightly perior surface of th coracoid process to th trapezoid line
convex or concave (Fig. 5 - 1 7 B ). Because of th predomi on th clavicle. The conoid ligament extends almost vertically
nantly fiat joint surfaces, roll-and-slide arthrokinematics are from th proximal base of th coracoid process to th co
noi here described. 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
PERIARTICULAR CONNECTIVE TISSUE incomplete articular disc. An extensive dissection of 223 sets
The AC joint is surrounded by a capsule that is reinforced of AC joints revealed complete discs in only about 10% of
by superior and inferior ligaments (Fig. 5 - 1 8 ) . The superior th joints.16 The majority of joints possessed incomplete
capsular ligament is remforced through attachments from th discs, which appeared fragmented and worn. According to
deltoid and trapezius. DePalma,16 th incomplete discs are not structural anomalies,
but rather indications of th degeneration that often affects
this joint.
Tissues that Stabilire th AC Joint
Superior and inferior AC joint capsular ligaments KINEMATICS
Deltoid and upper trapezius
Coracoclavicular ligament Distinct functional differences exist between th SC and AC
Articular disc joints. The SC joint permits relative extensive motion of th
clavicle, which guides th generai path of th scapula. The

FIGURE 5 - 1 8 . An anterior view of th

nght acromioclavicular joint including
many surrounding ligaments.
-C oracoclavicular
Trapezoid ligament
ligament _
102 Section II Upper Extremity

Osteokincmatics at th AC Joint
Upward and downward rotation
Acromioclavicular Joint Dislocation Horizontal piane rotational adjustments
Sagitial piane rotational adjustments
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 Upward and Downward Rotation
a person fading and striking th tip of th shoulder
abruptly against th ground (Fig. 5-19). The resulting Upward rotation of th scapula at th AC joint occurs as th-.
medially directed ground force may dispiace th acro- scapula swings upwardly and outwardly" in relation to th;
mion medially and under th sloped articular facet of lateral edge of th clavicle (Fig. 5 -2 0 A ). Reports vary, but
th well-stabilized clavicle. The coracoclavicular liga- up to 30 degrees of upward rotation can occur as th arm t-
ments, particularly th trapezoid ligament, naturally re raised over th head.2638-63 The motion contributes an exten
sisi such an AC joint displacement.20 On occasion, th sive component of overall upward rotation at th scapulo-J
force applied to th scapula exceeds th tensile thoracic joint (Fig. 5 -1 1 C ). Downward rotation at th AC1
strength of th ligaments, resulting in their rupture and joint returns th scapula back to its anatomie position, ^
th complete dislocation of th AC joint. Extensive liter- motion mechanically associated with shoulder adduction o-
ature exists on th evaluation and treatment of th extension. Although Figure 5 -2 0 A depiets th upward and
injured AC joint, especially in athletes.32 downward rotation of th scapula as a pure frontal piane
motion, most naturai motions occur within th scapularl
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 !
FIGURE 5-19. An anterior view of th shoulder striking th reported.6-11'63
ground with th force of th impact directed at th acromion.
Note th increased tension and partial tear withm th coraco The horizontal and sagittal piane adjustments at th AC
clavicular ligament (CCL). 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
AC joint, in contrast, permits subtle and often slight move- rotational adjustments th scapula is obligated to follow th I
ments of th scapula. The slight movements at th AC joint exact path of th moving clavicle, without any ability to fine I
are physiologically important, providing th maximum extern tune its position relative to th thorax.
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 Scapulothoracic Joint
are called upward and downward rotation. Secondary rota-
tional adjustment motions amplify or fine tune th final The scapulothoracic joint is noi a true joint per se but rather
position of th scapula against th thorax.63 The range of a point of contact between th anterior surface of th scap
motion ai th AC joint is difficult to measure, and this is noi ula and th posterior-lateral wall of th thorax.67 In th
done in typical clinical situations. 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 ward rotation of th scapula at th AC joint allows th
resting posture of th scapula varies considerably from one scapula to remain nearly vertical throughout th elevation
person to another. (Fig. 5 -2 1 C ). Additional adjustments at th AC joint help to
Movements at th scapulothoracic joint are a very impor keep th scapula flush with th thorax. Depression of th
t a i element of shoulder kinesiology. The wide range of scapula at th scapulothoracic joint occurs as th reverse
motion available to th shoulder is due, in pari, to th large action described for elevation.
movement available to th scapulothoracic joint.
Protraction and Retraction
KINEMATICS Protraction of th scapula occurs through a summation of
horizontal piane rotations at both th SC and AC joints (Fig.
Movement of th Scapulothoracic Joint: A Composite of
5 - 2 2 A). The scapula follows th generai path of th pro-
th Sternoclavicular and Acromioclavicular Joint
tracting clavicle about th SC joint (Fig. 5 -2 2 B ). The AC
joint can amplify or adjust th total amount of scapulotho
The movements that occur between th scapula and th racic protraction by contributing varying amounts of adjust
thorax are a result of a cooperation between th SC and th ments within th horizontal piane (Fig. 5 -2 2 C ). Scapulotho
AC joints. racic protraction increases th extern of forward reach.
Elevation and Depresson Because scapulothoracic protraction occurs as a summa
Scapular elevation at th scapulothoracic joint occurs as a tion of both th SC and AC joint, a decrease in motion at
composite of SC and AC joint rotations (Fig. 5 -2 1 A ). For one joint can be at least partially compensated by an in-
th most part, th motion of shrugging th shoulders occurs crease at th other. Consider, for example, a case of severe
as a direct result of th scapulas following th path of th degenerative arthritis and decreased motion at th AC joint.
elevating clavicle about th SC joint (Fig. 5 -2 1 B ). Down 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 retumed to th side from a raised position. The motion is I
forward reach of th upper limb. described as similar to upward rotation, except that th I
Retraction of th scapula occurs in a similar but reverse clavicle depresses at th SC joint and th scapula down- I
fashion as protraction. Retraction of th scapula is often wardly rotates at th AC joint. The motion of downward I
performed in th context of pulling an object toward th rotation usually ends when th scapula has retumed to th
body, such as pulling on a wall pulley, climbing a rope, or anatomie position.
putting th arm in a coat sleeve.
Upward and Downward Rotation Glenohumeral Joint
Upward rotation of th scapulothoracic joint is an integrai
part of raising th arm over th head (Fig. 5 -2 3 A ). This
motion places th glenoid fossa in a position to support and The glenohumeral (GH) joint is th articulation formed be-
stabilize th head of th abducted (i.e., raised) humerus. tween th large convex head of th humems and th shallow
Complete upward rotation of th scapula occurs as a sum- concavity of th glenoid fossa (Fig. 5 - 2 4 ) . This joint oper-
mation of clavicular elevation at th SC joint (Fig. 5 - 2 3 B) ates in conjunction with th moving scapula to produce an
and scapular upward rotation at th AC joint (Fig. 5 -2 3 C ). extensive range of motion of th shoulder. In th anatomie
These dual frontal piane rotattons occur about parallel SC position, th articular surface of th glenoid fossa is directed
and AC joint axes, allowing a total of 60 degrees of scapular anterior-laterally in th scapular piane. In most people, th 1
rotation. The scapula may rotate upwardly and strictly in th glenoid fossa is upwardly rotateci slightly. This position is
frontal piane as in true abduction, but it usually follows a dependent on th amount of fixed upward tilt to th fossa
path closer to its own piane. (see Fig. 5 - 6 ) and to th amount of upward rotation of th
Downward rotation of th scapula occurs as th arm is scapula in its resting posture.

FIGURE 5 - 2 2 . A Scapulothoracic protraction shown as a summation of B (protraction at th SC joint) and C (slisht horizontal piane
adjustments at th AC joint). r
Chapter 5 Shoulder Complex 105

FIGURE 5-23. A, Scapulothoracic upward rotation shown as a summation of B (elevation of th SC joint) and C (upward rotation at
th AC joint).

In th anatomie position, th articular surface of th hu- surround th biceps tendon as it exits th joint capsule and
meral head is directed medially and superiorly, as well as descends into th intertubercular (i.e., bicipitali groove.
posteriorly because of its naturai retroversion. This orienta- The potential volume of space within th GH joint cap
tion places th head of th humerus directly into th scapu- sule is about twice th size of th humeral head. In conjunc-
lar piane and therefore directly against th face of th don with a loose fitting and expandable capsule, th GH
glenoid fossa (see Fig. 5 - 4 B and 5 -4 C ). 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
The GH joint is surrounded by a fibrous capsule, which joint. In th anatomie or adducted position, th inferior
isolates th internai joint cavity from most surrounding tis- portion of th capsule appears as a slackened recess called
sues (see Fig. 5 - 2 4 ) . The capsule attaches along th rim of th axillary pouch.
th glenoid fossa and extends to th anatomie neck of th The rotator cuff muscles (subscapularis, supraspinatus, in-
humerus. A synovial membrane lines th inner wall of th fraspinatus, and teres minor) and th capsular ligaments
joint capsule. An extension of this synovial membrane lines blend into th fibrous capsule, providing most of th stabil-
th intracapsular portion of th tendon of th long head of ity to this articulation. The long head of th biceps also
th biceps brachii. This synovial membrane continues to contributes stability to th join t.34

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.
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

posing diameter of th glenoid fossa. By describing th
The articular surface of th glenoid fossa covers only GH joint as a ball-and-socket joint, th erroneous impres-
about one third of th articular surface of th humeral sion is given that th head of th humerus fits into th
head. This size difference allows only a small part of th glenoid fossa. The actual structure of th GH joint articu-
humeral head to make contact with th glenoid fossa. In lation resembles more that of a golf ball pressed against
a typical adult, th longitudinal diameter of th humeral a coin th size of a quarter. Joint stability is achieved by
head is about 1.9 times larger than th same diameter of passive tension produced by periarticular connective tis-
th glenoid fossa (Fig. 5-25). The transverse diameter of sues and by active forces produced by muscles, not by
th humeral head is about 2.3 times larger than th op- bony fit.

Coracoid process

Biceps brachii tendon (long head)

FIGURE 5 - 2 5 . Side view of righi glenohu
meral joint with th joint opened up to ex-
Glenoid labrum 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.

Tissues that Stabilize or Deepen th GH Joint The GH joints capsular ligaments consist of complex
bands of interlacing collagen fibers, divided into superior,
Rotator cuff muscles (subscapularis, supraspinatus, infra-
spinatus, and teres minor) middle, and inferior bands. The ligaments are best visualized
GH joint capsular ligaments from an internai view of th GH joint (Fig. 5 - 2 7 ) . The
Coracohumeral ligament superior glenohumeral ligament has its proximal attachment
Long head of th biceps near th supraglenoid tubercle, just anterior to th attach
Glenoid labrum 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-
The extemal layers of th anterior and inferior walls of th comes particularly taut in full adduction or during inferior
joint capsule are thickened and strengthened by fibrous con and posterior translations of th humerus.5365
nective tissue known simply as th glenohumeral (capsular) liga The middle glenohumeral ligament has a wide proximal
ments (Fig. 5 - 2 6 ) . Passive tension in th capsular ligaments attachment to th superior and middle aspeets of th ante
limits th extremes of GH joint rotation and translation. rior rim of th glenoid fossa. The ligament blends with th
The following discussion provides th essential anatomy anterior capsule and tendon of th subscapularis muscle,
and function of th GH joint capsular ligaments. For more then attaches along th anterior aspect of th anatomie neck.
detail, refer to additional literature, such as Curi13 and Bigli- This ligament provides substantial anterior restraint to th
ani.5 Table 5 - 1 lists th distai attachments of th ligaments GH joint, resisting anterior translation of th humerus and
and th motions that render each capsular ligament taut. th extremes of extemal rotation.51
This information is useful for th understanding of th cause The extensive inferior glenohumeral ligament attaches proxi-
of th limitations in movement that may follow surgery re-
mally along th anterior-inferior rim of th glenoid fossa,
pair or injury to th capsule.
including th adjacent glenoid labrum. Distally th inferior
Chapter 5 Shoulder Complex 107




FIGURE 5-26. Anterior view of

th right glenohumeral joint
showing th following external Conoid
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

glenohumeral ligament attaches as a broad sheet to th ante- The GH joint capsule receives additional reinforcement
rior-inferior and posterior-inferior margins of th anatomie from th coracohumeral ligament (see Figs. 5 - 2 6 and 5 - 2 7 ) .
neck. This ligament extends from th lateral border of th coracoid
This hammock-like inferior capsular ligament has three process to th anterior side of th greater tubercle of th
sparate components: an anterior band, a posterior band, and humerus. The coracohumeral ligament blends in with th
a sheet of tissue connecting these bands known as an axil- capsule and supraspinatus tendon, becoming taut at th ex
lary pouch (see Fig. 5 - 2 7 ) . 41 The axillary pouch and th tremes of external rotation, flexion, and extension. The liga
surrounding inferior capsular ligaments become particularly ment also resists inferior displacement (i.e., translation) of
uut at about 90 degrees of abduction, providtng an impor th humeral head.60
tuni element of anterior-posterior stability to th GH joint in The GH joint capsule receives significant structural rein
ras position.62-65 In th abducted position, th anterior and forcement through th attachments of th four rotator cujf
rosterior bands become taut at th extremes of external and muscles (see Fig. 5 - 2 7 ) . The subscapularis lies just anterior
nternal rotation, respectively. to th capsule, and th supraspinatus, infraspinatus, and

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

Ligament D istai A ttachm ents M otions Drawing Stru cture Taut

Superior glenohumeral ligament Anatomie neck, above th tesser tubercle Full adduction, and/or inferior and posterior
translation of th humerus
Middle glenohumeral ligament Along th anterior aspect of th anatomie Anterior translation of th humerus and/or
neck external rotation
Inferior glenohumeral ligament As a broad sheet to th anterior-inferior and All fibers: abduction
(three parts: anterior band, posterior-inferior margins of th anatomie Anterior band: abduction and external rotation
posterior band, and connect neck Posterior band: abduction and internai rotation
ing axillary pouch)
coracohumeral ligament Anterior side of th greater tubercle of th Extremes of external rotation, flexion, and ex
humerus tension; inferior displacement (translation)
of th humeral head
108 Section il Upper Extremity

Coracoacromial arch

FIGURE 5-27. Lacerai aspect of th

right glenohumeral joini showing th
internai surface of th joint. The 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.

teres minor lie superior and posterior to th capsule. These STATIC STABILITY AT THE GLENOHUMERAL JOINT
muscles previde th majority of th stability to th joint
during active motion. Normally, when standing at rest with arms at th side, th
head of th humerus remains stable against th glenoid
The head of th humerus and th glenoid fossa are both
fossa. This stability is referred to as stalle since it exists ai
lined with hyaline canilage. The rim of th glenoid fossa is
rest. One mechanism for controlling th static stability at th
encircled by a fibrocartilage ring, or lip, known as th
GH joint is based on th analogy of a ball compressed
glenoid labrum (see Fig. 5 - 2 7 ) . The long head of th biceps
against an inclined surface (Fig. 5 -2 8 A ).3 At rest, th supe
originates as a partial extension of th glenoid labrum. About
rior capsular structures, including th coracohumeral liga-
50% of th overall depth of th glenoid fossa is attributed to
ment, previde th primary stabilizing forces between th
th glenoid labrum.23 The labrum deepens th concavity of humeral head and th glenoid fossa. Combining this capsu
th fossa, providing additional stability to th joint. 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.

Chapter 5 Shoulder Complex 109

compressive locking force, oriented at right angles to th mental release of th pressure within th GH joint capsule
surface of th glenoid fossa. The compressimi force pinches by piercing th capsule with a needle has been shown to
th humeral head firmly against th glenoid fossa, thereby cause inferior subluxation of th humeral head.31 The punc-
resisting any desceni of th humerus. The inclined piane of turing of th capsule equalizes th pressure on both sides,
th glenoid also acts as a partial shelf that supports part of removing th slight suction force between th head and th
th weight of th arm. fossa.
Electromyographic (EMG) data suggest that th supraspi-
natus, and to a tesser extern th posterior deltoid, provides a C0RAC0ACR0MIAL ARCH AND ASSOCIATED BURSA
secondary source of static stability by generating active forces
that are directed nearly parallel to th superior capsular force The coracoacromial arch is formed by th coracoacromial
vector. Interestingly, Basmajian and Bazant3 showed that ver- ligament and th acromion process of th scapula (see Figs.
tically running muscles, such as th biceps, triceps, and 5 - 2 5 and 5 - 2 7 ) . The coracoacromial ligament attaches be
middle deltoid, are generally not actively involved in provid- tween th anterior margin of th acromion and th lateral
tng static stability, even when signifcant downward traction border of th coracoid process.
is applied to th arm. The coracoacromial arch functions as th roof of th
An important component of th static locking mech- GH joint. In th healthy adult, only about 1 cm of dis-
anism is a scapulothoracic posture that maintains th gle tance exists between th undersurface of th arch and th
noid fossa slightly upwardly rotated. The passive tension humeral head.47 This important subacromial space con-
within th superior capsular structures is significanti)' re- tains th supraspinatus muscle and tendon, th subacromial
duced when th scapula loses this upward rotation position bursa, th long head of th biceps, and part of th superior
Fig. 5 - 2 8 B). A chronically, downwardly rotated posture capsule.
may be associated with poor posture or may be secondary Eight separate bursa sacs are located in th shoulder.68
to paralysis or weakness of certain muscles, such as th Some of th sacs are direct extensions of th synovial mem
upper trapezius. Regardless of cause, loss of th upwardly brane of th GH joint, such as th subscapular bursa,
rotated position increases th angle between th force vec- whereas others are considered separate structures. All are
tors created by th superior capsular structures and grav- situated in regions where signifcant frictional forces de-
ity. Vector addition of th forces produced by th su velop between tendons, capsule and bone, muscle and lig
perior capsular structures and gravity now yields a reduced ament, or two muscles. Two important bursa are located
compressive force. Gravity can pul th humerus down th superior to th humeral head (Fig. 5 - 2 9 ) . The subacromial
face of th glenoid fossa. The GH joint may eventually be- bursa lies within th subacromial space above th supra
:ome mechanically unstable and eventually subluxed com- spinatus muscle and below th acromion process. This
pletely. bursa protects th relatively soft and vulnerable supraspina-
The normally negative intra-articular pressure within th tus muscle and tendon from th rigid undersurface of th
GH joint offers a secondary source of static stability. Expert- acromion. The subdeltoid bursa is a lateral extension of th

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.
n o Section 11 Upper Extremity

Reporting th range of motion at th GH joint uses th

anatomie position as th 0-degree or neutral reference point
In th sagittal piane, for example, flexion is described as th
rotation of th humerus anterior to th 0-degree position
Extension, in contrast, is described as th rotation of th
humerus posterior to th 0-degree position. The term 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

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-

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


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 ) .* 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
*Ofien, a lourth motion is deftned at th GH joint: horizontal flexion capsular ligament (1CL) is shown supporting th head of th hu
and extension (also called horizontal adduction and abduction). The motion merus like a hammock (see text). Note that th superior capsular
occurs from a starting position of 90 degrees of abduction. The humerus ligament (SCL) remains relative!) taut owing to th pul from th
moves anteriorly during horizontal flexion and posteriorly during horizontal attached contracting supraspinatus. Stretched ttssues are depicted as
extension. long black arrows.
Chapter 5 Shouder Complex 111

sion within th inferior capsule acts as a hammock or sling, head offsets most of th inherent superior translation ten-
which supports th head of th humerus.41 Excessive stiff- dency of th humeral head. In healthy persons, th offsetting
ness in th inferior capsule due lo adhesive capsulitis may mechanism provtdes suffcient space for th supraspinatus
limit th full extern of th abduction motion. tendon and th subacromial bursa.
Approximately 120 degrees of abduction are available at
Abduction in th Frontal Piane Versus th Scapular Piane
th healthy GH joint. A wide range of values, however, have
Shouder abduction in th frontal piane is often used as a
been reported.2'19-26-58 Full shouder abduction requires a si-
representative motion to evaluate overall shouder function.
multaneous 60 degrees of upward rotation of th scapula and
Despite its common usage, however, this motion is not ver)'
s discussed further in a subsequent section of this chapter.
naturai. Elevating th humerus in th scapular piane (about
Importance of Roll-and-Slide Arthrokinematics at th 35 degrees anterior to th frontal piane) is generally a more
Glenohumeral Joint functional and naturai movement.
The roll-and-slide arthrokinematics depicted in Figure 5 - 3 1 The functional differences between abduction in th fron-
are essential to th completion of full range abduction. Recali tal piane and abduction in th scapular piane can be illus-
that th longitudinal diameter of th articular surface of th trated by th following example. Attempt to maximally
humeral head is almost twice th size as th longitudinal abduct your shouder in th pure frontal piane while con-
diameter on th glenoid fossa. The arthrokinematics of ab- sciously avoiding any accompanying extemal rotation. The
duction demonstrate how a simultaneous roll and slide allow diffculty or inability lo complete th extremes of this motion
a larger convex surface to roll over a much smaller concave is due in part to th greater tubercle of th humerus com
surface without running out of articular surface. pressing th contents of th subacromial space against th
Without a suffcient inferior slide during abduction, th low point on th coracoacromial arch (Fig. 5 -3 4 A ). In order
superior roll of th humeral head ultimately leads to a jam to complete full frontal piane abduction, extemal rotation of
ming or impingement of th head against th coracoacromial th humerus must be combined with th abduction effort.
arch. An adult-sized humeral head that is rolling up a This ensures that th prominent greater tubercle clears th
glenoid fossa without a concurrent inferior slide would trans posterior edge of th undersurface of th acromion.
late through th 10-mm coracoacromial space after only 22 Next, fully abduct your arm in th scapular piane. This
degrees of abduction (Fig. 5 -3 2 A ). This situation causes an abduction movement can usually be performed without th
impingement of th head of th humerus against th supra- need to extemally rotate th shouder.52 Impingement is
spinatus muscle, its tendon, and th bursa against th rigid avoided since scapular piane abduction places th apex of
coracoacromial arch. This impingement is painful, blocking th greater tubercle under th relatively high point of th
further abduction (Fig. 5 32B). In vivo radiographic meas- coracoacromial arch (Fig. 5 -3 4 B ). Abduction in th scapular
urements in th healthy shouder show that during abduc piane also allows th naturally retroverted humeral head to
tion in th scapular piane, th humeral head remains essen- fit more directly into th glenoid fossa. The proximal and
tially stationary or may translate superiorly only a negligible distai attachments of th supraspinatus muscle are placed
distance.17'43-48 The concurrent inferior slide of th humeral 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 degeneration of th rotator cuff muscles, instability of th
Repeated compression of th humeral head and/or th GH joint, tightness or adhesions within th GH joint cap
greater tubercle against th contents of th subacromial sule, and reduced volume in th subacromial space.46 The
space often leads to "chronic impingement syndrome."27 last factor may result from th abnormal shape of th
The syndrome is characterized by th inability to abduct acromion, presence of osteophytes around th AC joint, or
th shoulder in a pain free or naturai manner. The condi- swelling of structures in and around th subacromial
tion typically occurs in athletes and laborers who repeat- space. Regardless of cause, each time an impingement
edly abduct their shoulders over 90 degrees, but also occurs, th delicate supraspinatus tendon and subacro
occurs in relatively sedentary persons. The impingement mial bursa become further traumatized. The long head of
of th head of th humerus against th coracoacromial th biceps and th superior capsule of th GH joint may
arch can be detected on standard x-ray examination (Fig. also be impinged and further traumatized. Therapeutic
5-33), as well as on magnetic resonance imaging.56 goals include decreasing inflammation within th subacro
Many factors predispose people to shoulder impinge mial space, conditioning th rotator cuff muscle, improving
ment syndrome. One factor is th inability of muscles kinesthetic awareness of th movement, and attempting to
such as th rotator cuff or serratus anterior to optimally restore th naturai shoulder arthrokinematics. Ergonomie
coordinate th GH joint arthrokinematics of abduction.9'7'33 education is also a factor in goal setting.
Additional factors include "slouched" thoracic posture,28

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-

frontal piane and scapular piane abduction should be consid- Direct measurements have shown that flexion at th GH
ered while evaluating and treating patients with shoulder dys- joint is associated with a slight internai rotation of th hu
function, particularly if chronic impingement is suspected. merus.44 This subtle motion is difficult to appreciate through
casual observation. As th GH joint is flexed beyond 90
Flexion and Extension
degrees, tension in th stretched coracohumeral ligament may
Flexion and extension al th GH joint is defined as a rotation produce a small internai rotation torque on th humerus.
of th humerus in th sagittal piane about a medial-lateral At least 120 degrees of flexion are available to th GH
axis of rotation (see Fig. 5 - 3 0 ) . If th motion occurs strictly joint. The ability io flex th shoulder to nearly 180 degrees
in th sagittal piane, th arthrokinematics involve a spinning of tncludes th accompanying upward rotation of th scapulo-
th humeral head about a somewhat fxed point on th face thoracic joint.
of th glenoid. No roll or slide is necessary. As shown in Full extension of th shoulder occurs to a position of
Figure 5 - 3 5 , th spinning action of th humeral head draws about 45 to 55 degrees behind th frontal piane. The ex
most of th surrounding capsular structures taut. Tension tremes of this motion stretch th anterior capsular ligaments,
within th stretched posterior capsule may cause a slight ante causing a slight forward tilting of th scapula. This forward
rior translation of th humerus at th extremes of flexion.21 tilt may enhance th extern of a backward reach.
Chapter 5 Shoulder Complex 113

; GURE 5-34. Side vievv of righi

nenohumeral joint comparing abduc-
~on of th humerus in A: th trae
^ontal piane (red arrow) and B: th
spu lar piane (gray arrow). In both
Aand B, th glenoid fossa is oriented
31 th scapular piane. The relative
iow and high points of th 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 glenoid fossa. The physiologic importance of these anterior
From th anatomie position, internai and external rotation at and posterior slides is evident by retuming to th model of
th GH joint is defined as an axial rotation of th humerus th humeral head shown in Figure 5 - 3 2 A, but now envision
m th horizontal piane (see Fig. 5 - 3 0 ) . This rotation occurs th humeral head rolling over th glenoid fossas transverse
about a vertical or longitudinal axis that runs through th diameter. If, for example, 75 degrees of external rotation
shaft of th humerus. The arthrokinematics of external rota- occurs by a posterior roll without a concurrent anterior slide,
don take place over th transverse diameters of th humeral th head displaces posteriorly, roughly 38 mm (about IV2
head and th glenoid fossa (see Fig. 5 - 2 5 ) . The humeral in). This amount of translation completely disarticulates th
head simultaneously rolls posteriorly and slides anteriorly on joint because th entire transverse diameter of th glenoid
th glenoid fossa (Fig. 5 - 3 6 ) . The arthrokinematics for in fossa is only about 25 mm (1 in). Normally, however, full
ternai rotation are similar, except that th direction of th extemal rotation results in only 1 to 2 mm of posterior
roll and slide is reversed. translation of th humeral head,21 demonstrating that an
The simultaneous roll and slide of internai and external offsetting anterior slide accompanies th posterior roll.
rotation allows th much larger transverse diameter of th
humeral head to roll over a much smaller surface area of th
Superior view

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
FIGURE 5-35. Side view of flexion in th sagittal piane of th right stretched. The posterior capsule (PC) is held relatively taut due to
glenohumeral joint. A point on th head of th humerus is shown th pul of th contracting infraspinatus muscle. The two bold black
spinning about a point on th glenoid fossa. Stretched stractures arrows represent forces that centralize and thereby stabilize th
tre shown as long arrows. (PC = posterior capsule, ICL = inferior humeral head during th extemal rotation. Stretched tissues are
sapsular ligament, and CHL = coracohumeral ligament.) depicted as thin, elongated arrows.
114 Section II Upper Extremity

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
Centralization of th Humeral Head: Special Function of abduct in a pain-free and naturai fashion is indicative of i
th Rotator Cuff Muscles healthy shoulder. Knowledge of how th joints of th shou -
der interact during this movement is a prerequisite for ur-
During all volitional motions at th GH joint, forces from
derstanding of shoulder pathology and effettive therapeutu
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 SCAPULOHUMERAL RHYTHM
shows th infraspinatus muscle contracting to produce
active external rotation at th GH joint. Because part of The most widely cited study on th kinematics of shoulder
th infraspinatus attaches into th capsule, its contrac- abduction was published by Inman and colleagues in 1944 4
tion prevents th posterior capsule from slackening dur This classic work focused on shoulder abduction in th fron-
ing th motion. This maintenance of tension in th poste tal piane. Inman wrote that GH joint abduction or flexiot
rior capsule, combined with th naturai rigidity from th occurs simultaneously with scapular upward rotation, an ob
activated muscle, stabilizes th posterior side of th joint servation referred to as scapulohumeral rhythm.
during active external rotation. In th healthy shoulder, In th healthy shoulder, a naturai kinematic rhythm or
th anterior side of th joint is also well stabilized during timing exists between glenohumeral abduction and scapulo
active external rotation. Passive tension in th stretched thoracic upward rotation. Inman reported this rhythm io be
subscapularis muscle, anterior capsule, middle GH cap remarkably Constant throughout most of abduction, occur-
sular ligament, and coracohumeral ligament all add rigid ring at a ratio of 2:1. For every 3 degrees o f shoulder abdiu-
ity to th anterior capsule. Forces, therefore, are gener- tion, 2 degrees occurs by GH joint abduction and 1 degree occuni
ated on both sides of th joint during active external by scapulothoracic joint upward rotation. Based on this rhythmj
rotation, serving to stabilize and centraline th humeral a full are of 180 degree of shoulder abduction is th resuii
head against th glenoid fossa. A similar mechanism of a simultaneous 120 degrees of GH joint abduction and 6u
exists during active internai rotation. 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;
From th anatomie position, about 75 to 85 degrees of piane,2'19-35 -48 and on motion while lifting different loads '
internai rotation and 60 to 70 degrees of external rotation
These studies reported a slightly different, and less consisti
are usually possible, but much variation can be expected
ent, scapulohumeral rhythm. For instance, Bagg and Forrest-'
among people. In a position of 90 degrees of abduction, th
reported a mean glenohumeral-to-scapular rotation ratio
external rotation range of motion usually increases to near
of 3 .2 9 :1 between 21 degrees and 82 degrees of abduction:
90 degrees. Regardless of th position at which these rota-
.7 1 :1 between 82 degrees and 139 degrees of abduction.;
tions occur, there is usually movement at th scapulothoracic
and 1 .2 5 :1 between 139 degrees and 170 degrees of abduc
joint. Maximal internai rotation usually includes scapular
tion. Regardless of th differing ratios reported in th litera-
protraction, and maximal external rotation usually includes
ture, Inmans classic 2 : 1 ratio stili remains a valuable axiom
scapular retraction.
in evaluation of shoulder movement. It is simple to remern-
Summary of Glenohumoral Joint Arthrokinematics ber and stili helps to conceptualize th overall relationshsr
between humeral and scapula motion when considering th
Table 5 - 2 shows a summary of th arthrokinematics and full 180 degrees of shoulder abduction.
osteokinematics at th glenohumeral joint.


Inmans research was th frst major study to measure th:
To this point, this study of shoulder arthrology has focused SC and AC joint contribution to th full 60 degrees of
primarily on th structure and function of th individuai scapulothoracic upward rotation.26 The following data are

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

Osteokinematics Piane of Motion/Axis of Rotation Arthrokinematics

Abduction/adduction Frontal plane/anierior-posterior axis of rotation Roll-and-slide along joints longitudinal
Intemal/extemal rotation Horizontal plane/vertical axis of rotation Roll-and-slide along joints transverse
Flexion/extension and intemal/extemal Sagittal plane/medial-lateral axis of rotation Spin between humeral head and
rotation (in 90 degrees of abduction)
glenoid fossa
Chapter 5 Shoulder Complex 115

abduction and an additional 30 degrees of scapulothoracic

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

Posterior Rotation of th Clavicle

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
FIGURE 5-3 7 . A, Posterior view of th right shoulder complex after
th population wrould certainly vary.
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 MUSCLE AND JOINT INTERACTION___________
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
Innervation of th Muscles and Joints of th
middle shaft of th bone. Shoulder Complex
based on this research. The 180 degrees of abduction has
The entire upper extremity receives innervation primarily
been divided imo an early and a late phase.
through th hrachial plexus (Fig. 5 - 4 1 ) The brachial plexus
Early Phase: Shoulder Abduction to 90 degrees is formed by a consolidation of th ventral nerve roots
from mixed spinai nerves C5- T 1. Ventral nerve roots C5 and
Assuming a 2 :1 scapulohumeral rhythm, shoulder abduction
C6 form th upper tnink, C7 forms th middle trunk, and CB
up to about 90 degrees occurs as a summation of 60 degrees
and T 1 form th lower trunk Trunks course a short dis
of GH abduction and 30 degrees of scapulothoracic upward
tarne before forming anterior or posterior divisioni. The divi-
rotation. The 30 degrees of upward rotation occurs predomi-
sions then reorganize into three cords named by their rela-
nantly through a synchronous 20 to 25 degrees of clavicular
tionship to th axillary artery. The cords branch into nerves,
elevation at th SC joint and 5 to 10 degrees of upward
which innervate muscles of th upper extremity and lateral
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

Shoulder abduction from 90 degrees to 180 degrees occurs The majority of th muscles in th shoulder complex receive
as a summation of an additional 60 degrees of GH joint 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.)


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

* 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
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

D o rsa l s ca p u la r
--- Cords


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
M e d ia i cutaneous
nerve to arm
118 Section II Upper Extremity

FIGURE 5-42. Posterior view showing ihe

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

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

clavicle. Examples of these muscles are th serratus ante- S P E C I A L F O C U S
rior and th trapezius. The distai mobilizers consist of
muscles that originate on th scapula and clavicle and in
Paralysis of th Upper Trapezius: Effects on
ser on th humerus or forearm. Examples of two distai
Sternoclavicular and Glenohumeral Joint Stability
mobilizers are th deltoid and biceps bracini muscles. As
described subsequently, optimal function across th entire Paralysis of th upper trapezius may result from dam-
shoulder complex is based on a functional interdepen- age to th spinai accessory nerve (cranial nerve XI).
dence between th proximal stabilizers and th distai mobil Over time, th scapulothoracie joint may become mark-
izers. For example, in order for th deltoid to generate an edly depressed, protracted, and excessively downwardly
effective abduction torque at th glenohumeral joint, th rotated owing to th pul of gravity on th arm. A
scapula must be ftrmly stabilized against th thorax by th chronically depressed clavicle may eventually result in
serratus anterior. In cases of a paralyzed serratus anterior a superior dislocation at th SC joint.7 As th lateral
muscle, th deltoid muscle is unable to express its full ab end of th clavicle is lowered, th mediai end is forced
duction function. Several examples follow that reinforce this upward due to th fulcrum action of th underlying first
important point. The spectfic anatomy and nerve supply of rib. The depressed shaft of th clavicle may eventually
th muscles of th shoulder complex can be found in Ap- compress th subclavian vessels and part of th bra-
pendix IIC. chial plexus.
Perhaps a more common consequence of long-term
paralysis of th upper trapezius is an inferior subluxa-
Muscles of th Scapulothoracie Joint tion of th GH joint. Recali from earlier discussion that
ELEVATORS OF THE SCAPULOTHORACIC JOINT static stability at th GH joint is partially based on a
humeral head that is held against th inclined piane of
The muscles responsible for elevation of th scapula and th glenoid fossa. With long-term paralysis of th trape
clavicle are th upper trapezius, levator scapulae, and to a zius, th glenoid fossa loses its upwardly rotated posi-
lesser extern, th rhomboids (Fig. 5 - 4 2 ) . 15 The upper trape tion, allowing th humerus to slide inferiorly. The down-
zius provides postural support to th shoulder girdle (scap ward pul imposed by gravity on an unsupported arm
ula and clavicle). Ideal posture of th shoulder girdle is often may strain th GH joint's capsule and eventually lead to
defined as a slightly elevated and retracted scapula, with th an irreversible subluxation. This complication is often
glenoid fossa facing slightly upward. The upper trapezius, observed following flaccid hemiplegia.
attaching to th lateral end of th clavicle, provides excellent
Chapter 5 Shoulder Complex 119

leverage about th SC joint for th maintenance of this If th arm is physically blocked from being depressed,
posture. 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
3epression of th scapulothoracic joint is performed by th wheelchair using th scapulothoracic depressors to relieve
ower trapezius, latissimus dorsi, pectoralis minor, and th sub- th pressure in th tissues superficial to th ischial tuberosi-
Javius (Fig. 5 - 4 3 ) .29-50 The latissimus dorsi depresses th ties. With th arm firmly held against th armrest of th
shoulder girdle by pulling th humerus and scapula infen- wheelchair, contraction of th lower trapezius and latissimus
.uly. The force generated by th depressor muscles can be dorsi pulls th thorax and pelvis up toward th fxed scap
iirected through th scapula and upper extremity and ap- ula. This is a very useful movement especially for persons
plied against some object, such as th spring shown in with quadriplegia who lack sufficient triceps strength to lift
rigure 5 -43A . 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

FIGURE 5-44. The lower trapezius and latissimus dorsi are sho.
elevating th ischial tuberosities away from th seat of th whd
chair. The contraction of these muscles lifts th pelvic-and-tr
segment up toward th fixed scapula-and-arm segment.

PROTRACTORS OF THE SCAPULOTHORACIC JOINT tendency of th lower trapezius. A component of each musi
The serratus anterior muscle is th prime protractor at th cles overall line-of-force summate, however, producing pi
scapulothoracic joint (Fig. 5 45A). This extensive muscle retraction (see Fig. 5 - 4 6 ) .
has excellent leverage for protracuon, especially about th SC Complete paralysis of th trapezius, and to a lesser exte
join ts vertical axis of rotation (Fig. 5 -4 5 B ). The force of th rhomboids, signifcantly reduces th retraction potenti-
scapular protraction is usually transferred across th GH of th scapula. The scapula tends to drift slightly in l
joint and employed for forward pushing and reaching activi- protraction owing to th partially unopposed protraction a -
ties. Persotis with serratus anterior weakness have difficulty tion of th serratus anterior muscle.7
in performance of forward pushing motions. No other mus
cle can aclequately provide this protraction effect on th
Muscles that perform upward and downward rotation of
scapulothoracic joint are discussed next in context
The middle trapezius muscle has an optimal line-of-force to movement of th entire shoulder.
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 Muscles that Elevate th Arm
pulling activities, such as climbing and rowing. The muscles The term "elevation of th arm describes ihe active m o ti,
secure th scapula to th axial skeleton. ment of bringing th arm overhead without specifying tF
The secondary retractors show an excellent example of exact piane of th motion. Elevation of th arm is perforine-,
how muscles function as synergists sharing identical ac- by muscles that fall into three groups: (1) muscles th a l
tions. At th same lime, however, they function as direct elevate (i.e., abduct or flex) th humerus at th GH joint; ( 2 J
antagonists. During a vigorous retraction effort, th elevation scapular muscles that control th upward rotation and pr
tendency of th rhomboids is neutralized by th depression traction of th scapulothoracic joint; and (3) rotator cu
Chapter 5 Shoulder Complex 121

Superior view



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

deltoid, and supraspinatus as abductors of th glenohumeral joint.

FIGURE 5-46. Posterior view of th middle trapezius, lower trape- The deltoid and th supraspinatus muscles contribute
zius, and rhomboids cooperating to retract th scapuothoracic about equal shares of th total abduction torque at th GH
joint. The dashed line-of-force of both th rhomboid and lower joint.22 With th deltoid paralyzed, th supraspinatus muscle
trapezius combines to yield a single retraction force shown by th
is generally capable of fully abducting th GH joint. The
straight arrow.
torque, however, is reduced. With th supraspinatus para
lyzed or ruptured, full abduction is often difficult or not
and long head of th biceps brachii (Fig. 5 - 4 8 ) . The maxi possible due to th altered arthrokinematics ai th GH joint.
mal isometric torque generated by th shoulder flexors and Full active abduction is not possible with a combined del
th abductors is shown for two joint positions in Table 5 - 4 . toid and supraspinatus paralysis.10
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 JOINT
near 90 degrees of abduction.30 Both muscles have a signifi-
cant internai moment arm that remains essentially Constant at Upward rotation of th scapula is an essential component of
about 25 mm (about 1 in) throughout most of abduction.64 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, provide
stable attachment sites for distai mobilizers, such as th The Upward Rotation Force Couple: A Familiar Analogy
deltoid and supraspinatus. 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
124 Seaion II Upper Extremiiy

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
In summary, during elevation of th arm th serratusl
Arm Abduction Angle anterior and trapezius control th mechanics of scapular up-1
(degrees) ward rotation. The serratus anterior has th greater leverage I
for this motion. Both muscles are synergists in upward rota-1
FIGURE 5-51. The EMG attivai ion pattern of th upper trapezius
tion, bui are agonists and antagonists as they oppose, and I
and lower trapezius and th lower lbere of th serratus anterior
thus partially limit, each others strong protraction and re-1
during shoulder abduction in th scapular piane. (Data from Bagg
iraction potential.
SD, Forrest WJ: Electromyographic study of th scapular rotators
during arm abduction in th scapula piane. Am J Phys Med 65'
111-124, 1986.) Effects of Paralysis of th Upwarcl Rotators of th
Scapulothoracic Joint
Trapezius Paralysis
Complete paralysis of th trapezius usually causes moderate I
The lower trapezius has been shown to be particularly
to marked difficulty in elevating th arm overhead. The task,!
attive during th later phase of shoulder abduction (Fig.
however, can usually be completed through full range as I
5 - 5 1 ) . 2 The upper trapezius, by comparison, shows a signif-
long as th serratus anterior remains totally innervated. Eie-1
icant rise in EMG activation level during th initiation of
vation of th arm in th pure frontal piane is particularly I
shoulder abduction, then continues a graduai rise in activa
difficull because it requires that th middle trapezius gener-l
tion throughout th remainder of th range of motion. The
ate a strong retraction force on th scapula.7
upper trapezius must elevate th clavicle throughout th
early phase of abduction, while simultaneously balance Serratus Anterior Paralysis
th inferior pul of th lower trapezius during th late phase Paralysis or weakness of th serratus antenor muscle causes I
of abduction. The serratus anterior muscle shows a graduai signifcant disruption in normal shoulder kinesiology. Dis-1
increase in amplitude throughout th entire range of shoul abilily may be slight with parlial paralysis, or profound with I
der abduction. complete paralysis. Paralysis of th serratus anterior can o c-1
Figure 5 - 4 9 shows th Ime-of-force of th middle trape cur from an overstretching of th long thoracic nerve6*5 o r i
zius running through th rotating scapula's axis of rotation. from an injury to th cervical spinai cord or nerve roots.
In this case, th middle trapezius is robbed of its leverage As a rule, persons with complete or marked paralysis I

FIGURE 5-52. The pathomechanics of winging of th scapula A, Winging of th righi scapula due to marked weakness of th righi
serratus antenor. The winging is exaggerated when resistance is applied againsi a shoulder abduction effort. B, Kinesiologic analysis of
th winging scapula. Without an adequate upward rotation force from th serratus anterior (fading arrow), th scapula becomes
unstable and cannot resist th pul of th deltoid. Subsequently, th force of th deltoid (bidirectional arrow) causes th scapula to
downwardly rotaie and th glenohumerai joint io partially abduct.
Chapter 5 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
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
FIGURE 5-53. Posterior view of th righi shoulder showing th th scapula, th acromion is more likely to interfere with th
supraspinatus, infraspinatus, and teres minor muscles. Note that th arthrokinematics of th abducting humeral head. Indeed, re-
distai attachments of these niuscles blend mto and reinforce th
search has shown that persons with chronic impingement
superior and posterior aspects of th joint capsule.
syndrome have a reduced upward rotation of th scapula
and a reduced relative EMG activity from th serratus ante
of th serratus anterior cannot elevale their arms above rior during abduction.33
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 ELEVATION OF THE ARM
t a l e , result in a scapula that excessively rotates downwardly
with its mediai border flaring outwardly. This characteristic The rotator cuff group muscles include th subscapularis,
posture is often referred to as "winging of th scapula (Fig. supraspinatus, infraspinatus, and teres minor (Figs. 5 - 5 3
5 - 5 2 A). Normally, a fully innervated serratus anterior pro- and 5 - 5 4 ) . All these muscles show signiftcant EMG activity
duces a force that rotates th scapula upward. In th ab- when th arm is raised overhead.30 The EMG activity reflects

FIGURE 5-54. Anterior view of th right shoul

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

Anterior view
126 Section 11 Upper Extremity

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

joint stability and (2) controllers of th arthrokinematics.

Regulators of Dynamic Stability at th Glenohumeral

Joint Spontaneous Anterior Dislocation of 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 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
surrounding joint capsule, therefore, must be free of thick 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
restraining ligaments that otherwise restrict motion. The ana 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
tomie design at th glenohumeral joint favors mobility at th 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
expense of stability. An essential function of th rotator cuff 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
group is to compensate for th lack of naturai stability at 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
th GH joint. The distai attachment of th rotator cuff 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
muscles blends into th GH joint capsule before attaching 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
to th proximal humerus. The anatomie arrangement forms 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
a protective cuff around th joint (see Figs. 5 - 5 3 and 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
5 - 5 4 ) . Nowhere else in th body do so many muscles form 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-
such an intimate structural pari of a joints periarticular 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
siructure. 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
Earlier in this chapter th dynamic stabilizing function 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
of th infraspinatus muscle during external rotation is dis 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 .
cusseci (see Fig. 5 - 3 6 ) . This dynamic stabilization is an 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
essential function of all members of th rotator cuff. Forces 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
produced by th rotator cuff not only actively move th 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-
humerus, bui also stabilize and centralize its head against ity o f t h G H jo in t . 59
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 of th horizontally oriented supraspinatus produces a com-
pression force directly imo th glenoid fossa. The compres-
In th healthy shoulder, th rotator cuff Controls much of sion force stabilizes th humeral head frmly against th
th active arthrokinematics of th GH jo in t.55 Contraction 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
Subscapularis force on th humeral head io counteract excessive supe-
Infraspinatus rior translation. Note th internai moment arm used by
Teres minor both th deltoid and supraspinatus.
Chapter 5 Shoulder Complex 127

The Vulnerability of th Supraspinatus 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

to Excessive Wear 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
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 -
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
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
d e m a n d s o n t h m u s c 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
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
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
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
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
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
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 .
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 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
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 ,
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
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 ,
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
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
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
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
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
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
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
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
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 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
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).
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
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 -
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 . "
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 minor muscles can rotate th humerus extemally in order to
0 io 90 degrees of shoulder abduction, reaching a magnitude increase th clearance between th greater tubercle and th
of 90% of body weight.49 The surface area for dissipating acromion.
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- Muscles that Adduct and Extend th
logic levels. Shoulder
Pulling th arm against resistance offered by climbing a
rope or propelling through water requires a forceful con-
Functions of thc Rotator Cuff Muscles in th Active
traction from th shoulders powerful adductor and exten-
Control of th Arthrokinematics at th GH Joint
sor muscles. These muscles are capable of generating th
Supraspinatus: Compresses th humeral head directly into
largest isometric torque of any muscle group of th shoulder
th glenoid fossa.
Subscapuaris, infraspinatus, aid teres minor: Produces (Table 5 - 4 ) .
an inferior-directed iranslaiion force on th humerus The iatissimus dorsi shown in Figure 5 -4 3 A and th ster-
head. nocostal head o f th pectoralis major shown in Fig. 5 - 5 6 are
Infraspinatus and teres minor: Rotates th humeral head th largest of th adductor and extensor muscles of th
extemally. 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-
Without adequate supraspinatus force, th near vertical and brace-assisted ambulation as a substitute for weakened
line-of-force of a contracting deltoid tends to jam or im- or paralyzed hip flexors.
pinge th humeral head superiorly against th coracoacro- The teres major, long head o f th triceps, posteror deltoid,
mial arch, thereby blocking complete abduction. This effect infraspinatus, and teres minor are also primary muscles for
is typically observed following a complete rupture of th shoulder adduction and extension. These muscles have their
supraspinatus tendon. In addition to th compression pro- proximal attachments on th inherently unstable scapula. It
duced by th supraspinatus, th remaining rotator cuff mus is th primary responsibility of th rhomboid muscles to
cles exert an inferior depression force on th humeral head stabilize th scapula during active adduction and extension
during abduction (see Fig. 5 - 5 5 ) . The inferiorly directed of th glenohumeral joint. This stabilization function is evi-
force counteracts much of th tendency for th deltoid mus dent by th dowmward rotation and retraction movements
cle to translate th humerus superiorly during abduction.43 that naturally occur with shoulder adduction. Figure 5 - 5 7
During frontal piane abduction, th infraspinatus and teres 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 dorsi, and teres major. Many of these internai rotators are
th Shoulder also powerful extensors and adductors, such as those needed
for swimming.
INTERNAL ROTATOR MUSCLES The total muscle mass of th shoulders internai rotators
The primary muscles that internally rotate th GH joint are is much greater than that of th external rotators. This factor
th subscapularis, anterior deltoid, pectoralis major, latissimus explains why th shoulder internai rotators produce about
130 Section II Upper Extremity

described as rotators of th humerus relative to a fixed

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


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
The external rotators are a relatively small percentage of
th total muscle mass at th shoulder. Accordingly, maximal
humerus is free to rotate. The line-of-force of th pectoralis major effort extemal rotation produces th smallest isometric
is shown vvith its internai moment ami. Note th roll-and-slide torque of any muscle group ai th shoulder (see Table 5 - 4 ) .
arthrokinenratics of th convex-on-concave motion. For clarity, th Regardless of th relatively low maximal torque potential, th
anterior deltoid is noi shown.
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
1.75 times greater isometric torque than th external rotators release phase of pitching: a peak velocity measured at dose
(see Table 5 - 4 ) . 39 Peak torques of th internai rotators also to 7000 degrees/sec.18 These large force demands placed on
exceed th extemal rotators when measured isokinetically, th relatively small infraspinatus and teres minor may cause
under both concentric and eccentric conditions.37 partial tears within th muscle and capsule, leading io rota-
The muscles that nternally rotate th GH joint are oflen tor cuff syndrome.24

Superior view

FIGURE 5 60. Superior view of th right shoulder showtng actions of three internai rotators when th distai (humeral) segment is fixed
and th trunk is free to rotate. The line-of-force of th pectoralis major is shown with its internai moment arm originating about th
glenohumeral joint s vertical axis. Inset contains th roll-and-slide arthrokinematics during th concave-on-convex motion.
Chapter 5 Shoulder Complex 131

REFERENCES 29. Rendali FP, McCreary AK, Provance PG: Muscles: Testing and Function,
4th ed. Baltimore, Williams & Wilkins, 1993.
1 Bagg SD, Forrest WJ: Eleciromyographic study of ihe scapular rotators 30. Kronberg M, Nemeth G, Brostrom LA: Muscle activity and coordination
during arm abduciion in th scapula piane. Am J Phys Med 65:111- in th normal shoulder. Clin Orthop Res 257:76-85, 1990.
124, 1986. 31 Rumar VP, Batasubramaniam P: The role of atmospheric pressure in
2 Bagg SD, Forrest WJ: A biomechamcal analysis of scapula relation stabilising th shoulder: An experimental study. J Bone Joint Surg 67B:
during arm abduciion in th scapula piane. Am J Phys Rehabil 7:238- 719-721, 1985.
245, 1988. 32 Lemos ML. The evaluation and treatment of th injured acromioclavicu-
3. Basmajian JV, Bazant FJ: Factors preventing downward dislocation of lar joint in athletes. Am J Sports Med (S8)26:137-144, 1998.
th adducted shoulder joini. J Bone Joint Surg 41A: 1182-1186, 1959 33. Ludewig PM, Cook TM: Alterattons in shoulder kinematics and associ-
4. Beam JG: Direct observanons on th functioti of th capsule of th ated muscle activity in people with symptoms of shoulder tmpingement.
stemoclavicular joint tn clavicular supporr J Anat 101:159-170, 1967. Phys Ther 80(S12B):276-291, 2000.
5. Btgliani LU, Kelkar R, Flatow FI-, et al: Glenohumeral stabilii)': Biome- 34. Malicky DM. Soslowsky LJ, Blasier RP, et al: Anterior glenohumeral
chanical properties of passive and aciive stabilizers. Clin Orthop stabilization factors: Progressive effeets in a biomechanical model. J
(SI 5)330:13-30, 1996. Orthop Res (S15)14:282-288, 1996.
6 Branch TP, Burdette HL, Shahriari AS, et al: The rolc of che acromiocla- 35. Mandalidis DG, McGlone BS, Quigley RF, et al: Digital fluoroscopic
vicular ligaments and th effect of distai davicle reseclion. Am J Sports assessment of th scapulohumeral rhythm. Surg Radiol Anat (S10)21 :
Med (S8)24:293-297, 1996. 241-246, 1999.
7. Brunnstrom S: Muscle testing around th shoulder girdle. J Bone Joint 36. McQuade KJ, Smidt GL: Dynamic scapulohumeral rhythm: The effeets
Surg 23A:263-272, 1941. of external resistance during elevation of th arm in th scapular piane.
8. Chansky HA, lannotti ]P: The vascularity of th rotator cuff. Clin Sports J Orthop Sports Phys Ther (S10)27:125-133, 1998.
Med 10:807-822, 1991. 37. Mikesky AE, Edwards JE, Wigglesworth JK, et al: Eccentric and concen-
9. C.hen SK, Simonian PT, Wickiewicz TL, et al: Radiographic evaluation tric strength of th shoulder and arm musculalure in collegiate baseball
of glenohumeral kinematics: A muscle fatigue model. J Shoulder Elbow pitchers. AmJ Sports Med 23:6.38-642, 1995.
Surg ($2)8:49-52, 1999. 38. Moseley HF: The clavicte: Its anatomy and function. Clin Orthop 58:
10. Colachis SC, Strohm BR: Effect of suprascapular and axillary nerve 17-27, 1968.
blocks on muscle force in upper extremity. Arch Phys Med Rehabil 52: 39. Murray MP, Gore DR, Gardiner GM, et al: Shoulder motion and muscle
22-29, 1971. strength of normal men and women in two age gtoups. Clin Orthop
11. Conway AM: Movements al th stemoclavicular and acromioclavicular 182:267-273, 1985.
joints. Phys Ther 41:421-432, 1961, 40. Neumann DA, Seeds R: Observations from etneradiography analysis.
12. Cope R: Dislocations of th stemoclavicular joint. Skeletal Radio! 22: Marquette University, Milwaukee, WI, 1999.
233-238, 1993. 4L OBrien SJ, Neves MC, Amoczky SP, et al: The anatomy and histology
13. Curi LA, Warren RF: Glenohumeral joint stability: Selective cutting stud- of th inferior glenohumeral ligament complex of th shoulder. Am J
ies on th static capsular restraints. Clin Orthop (SI5)330:54-65, 1996. Sports Med 18:449-456, 1990.
14 Decker MJ, Hintermeister RA, Faber KL, et al: Serratus anterior muscle 42 O Connell PW, Nuber GW, Mileski RA, et al: The contribution of th
activity during selected rehabilitation exercises Am J Sports Med glenohumeral ligaments to anterior stability of th shoulder joint. Am J
(S26)27:784-791, 1999. Sports Med 18:579-584, 1990.
15. DeFreitas V, Vitti M, Furlani J: Electromyographic analysis of th leva- 43. Paletta GA, Warner JJP, Warren RF, et al: Shoulder kinematics with
tor scapulae and rhomboideus major muscle in movements of th two-plane x-ray evaluation in patients with anterior instabiiity or rotator
shoulder. Electromyogr Clin Neurophysiol 19:335-342, 1979. cuff learing. J Should Elbow Surg 6:516-527, 1997.
16. DePalma AF: Degenerative changes in stemoclavicular and acromiocla 44. Palmer ML, Blakely RL: Documentation of mediai rotation accompany-
vicular joints in various decades. Spnngfield, 111, Charles C Thomas, tng shoulder llexon Phys Ther 66:55-58, 1986
1957. 45. Palmer WE, Caslowitz PL: Anterior shoulder instabiiity: Diagnostic cri-
17. Deutsch A, Altchek DW, Schwartz E, et al: Radiologie measuremenl of terta determined from prospective analysis of 121 MR arthrograms.
supenor displacement of th humeral head in th impingement syn- Radiology 197:819-825, 1995.
drome. J Shoulder F.lbow Surg 5:186-193, 1996. 46. Payne LZ, Deng XH. Craig EV, et al: The combined dynamic and static
18. Dillman CJ, Fleisig GS, Andrews JR: Biomechanics of pitebing with contributtons to subacromial impingemenl. A m J Sports Med 25:801-
emphasis upon shoulder kinematics. J Orthop Sports Phys Ther 18: 808, 1997.
402-408, 1993. 47 Petersson CJ, Redlund-Johnell I: The subacromial space in normal
19. Freedman L, Munroe RR: Abduciion of th arm in th scapular piane: shoulder radiographs. Acta Orthop Stand 55:57-58, 1984.
Scapular and glenohumeral movements. J Bone Joint Surg 48.4:1503- 48 Poppen NK, Walker PS: Normal and abnormal monon of th shoulder.
1510, 1966. J Bonejotnt Surg Am 58A T95-201, 1976.
20. Fukuda K, Craig EV, An KN, et al: Biomechamcal study of th ligamen- 49. Poppen NK, Walker PS: Forces at th glenohumeral joint in abduction.
tous System of th acromioclavicular joint. 1 Bone )oint Surg 68A:434-
Chn Orthop 135:165-170, 1978
440, 1986. 50. Reis FP, deCamargo AM, Vitti M, deCarvalho CA: Electromyographic
21. Harryman DT, Sidles JA, Clark JM, et al: Translalion of th humeral study of th subclavius. Acta Anat 105:284-290, 1979.
head on th glenoid with passive glenohumeral motton. J Bone. Joint 51. Robinson CM: Fractures of th clavicle in th aduli. J Bone Joint Surg
Surg 72A: 1334-1343, 1990.
80B:476-484, 1998.
22. Howell SM, Imobersteg AM, Seger DH, et al: Clariftcation of th role of
52 Saha AK: Mechamsm of shoulder movements and a plea for th recog-
th supraspinatus muscle in shoulder funciion. J Bone Joint Surg 68A:
nition of zero position" of glenohumeral joint. Clin Orthop 173:3-10,
398-404, 1986.
23. Howell SM, Galinat BJ: The glenoid-labral Socket. Clin Orthop 243:
53. Schwartz E, Warren RF, OBnen SJ, et al: Posterior shoulder instabiiity.
122-125, 1989.
Orthop Clin North Am 18:409-419, 1987.
24. Hughes RE, An KN: Force analysis of rotator cuff muscles. Clin Orthop
54. Sharkey NA, Marder RA, Hanson PB: The entire rotator cuff contributes
(515)330:75-83, 1996.
25. Ihashi K, Matsushtla N, Yagt R, et al: Rotattonal action of th supraspi- to elevation of th arm. J Orthop Res 12:699-708, 1994
natus muscle on th shoulder joint. J Electromyogr Kinesiol 8:337-346, 55. Sharkey NA, Marder RA: The rotator cuff opposes superior translation
1998. of th humeral head. Am J Sports Med 23:270-275, 1995
26. lnman VT, Saunders M, Abbott LC: Observations on th function of th 56. Shibuta H, Tamai K, Tabuchi KL Magnetic resonance imaging of th
shoulder joint. J Bone Joint Surg 26A :l-32, 1944. shoulder in abduction. Clin Orthop 348:107113, 1998
27 Jobe CM: Superior glenoid tmpingement: Current concepts. Clin Or 57. Soslowsky LJ, Flatow EI, Bigliani LU, et al: Quaniificaiion of in situ
thop 330:98-107, 1996. contact areas at th glenohumeral joint: A biomechamcal study. J Or
28. Kebaetse M, McClure P, Pratt NA: Thoracic position effect on shoulder thop Res 10:524-534, 1992.
range of moiion, strength, and three-dtmensional scapular kinematics. 58. Steindler A: Kinesiology of th Human Body, Springfield, 111, Charles C
Arch Phys Med Rehab 80(S10):945-950, 1999. Thomas, 1955.
132 Seciion II Upper Exiremity

>9. Stevens KJ, Preston BJ, Wallace WA, et al: CT imaging and three-
Ferrari DA: Capsular iigaments of th shoulder. Anatomica! and functions;
dimensional reconstructions of shoulders with anterior glenohumeral
instabilily. Clin Anat 12:326-336, 1999. swdy of th anterior superior capsule. Am J Sports Med 18:20-24
60. Terry CC, Haramon D, France P, et al: The stabilizing function of
Friedman RJ, Blocker ER, Morrow DL Glenohumeral Instabilily J Soutr
passive shoulder restrainis. AmJ Sports Med 19:26-34, 1991.
Orthop Assoc 4:182-199, 1995.
61. Thomas CB, Friedman RJ: Ipstlateral stemoclavicular dislocation and
Guttmann D, Paksima NE. Zuckerman JD: Complications of treatment et
eiavide fracture J Orthop Trauma 3:355-357, 1989.
complete acromioclavicular joint dtslocations. lnstr Course Lect 49 4 0 7 -
62. Ticker JB, Bigliant LU, Soslowsky LJ, et al: Inferior glenohumeral liga- 413, 2000.
ment: geometrie and strain-rate dependent properties. J Shoulder Elbow
Surg 5:269-279, 1996. Haider AM, Itoi E, An KN: Anatomy and biomechanics of th shoulder
Orthop Clin N Am 31:159-176, 2000
63. Van Der Helm FCT, Pronk GM: rhree-dimensional recording and de-
Johnson G, Bogduk N, Nowitzke A, et al: Anatomy and actions of th
scrtptions of motions of th shoulder mechanism. ] Biomech Ene 117
trapezius. Clin Biomech 9:44-50, 1994.
2 7 -4 0 , 1995.
Johnson GR, Spaldtng D, Nowitzke A, et al: Modelltng th musclcs of th
64. Walker PS, Poppen NK: Btomechancs of th shoulder joint abduction
scapula: Morphometric and coordinate data and functional tmplications
in th piane of th scapula. Bull Hosp Joint Dis 38:107-111 1977
J Biomech 29:1039-1051, 1996.
65. Warner JJ, Deng XH, Russell WF, et al: Slatic capsuloltgamentous re-
Mayer F, Horstmann T, Rocker K, et al: Normal values of isokinetic maxi
straints lo superior-infenor translation of th glenohumeral joint Am |
Sports Med 20:675-685, 1992. mum strength, th strength/velocity curve, and th angle at peak torque d
all degrees of freedom in th shoulder. Int J Sports Med 15:19-25, 1994
66. Watson CJ, Sehenkman M: Physical therapy management of tsolated
Medvecky MJ, Zuckerman JD: Stemoclavicular joint injuries and disorders
serratus anterior muscle paralysis. Phys Ther 75:194-202, 1995.
lnstr Course Lect 49:397-406, 2000.
67. Williams GR, Shaki! M, Khmkiewicz J, et al: Anatomy of th scapulo-
Olis JC, Jiang CC, W'ickiewicz TL, et al: Changes of moment arms in th
thoracic articulation. Clin Orthop 359:237-246, 1999
rotator cuff and deltoid muscles with abduction and rotatton J Bone
68. Williams PL, Bannister LH, Berry M, Collins P, et al: Grays Anatomy,
Joint Surg 76A:667-676, 1994.
38lh ed, New York, Churchill Livingstone, 1995.
Placzek JD, Roubal PJ, Freeman DC, et al: Long-term effectiveness of trans-
ldTfi13* man'Pu'ation r adhesive capsulitis. Clin Orthop 356:181-191
ADDITI0NAL REA0INGS Saha AK: Dynamtc stability of th glenohumeral joint. Acta Orthop Scand
42:491-505, 1971, H
Basmajian JV: Musdes Alive. Their Functions Reveatcd by Electromyography,
4th ed. Baltimore, Williams & Wilkins, 1978. Sanders TG, Morrison WB, Miller MD. Imaging techniques for th evalua-
tion of glenohumeral instability. AmJ Sports Med 28:414-434 2000
Bey MJ, Huston LJ, Blasier RB, et al: Ligamentous restraints to extemal
Wuelker N, Wolfgang P, Roetman B, et al: Function of th supraspinatus
rotatton of th humerus in th late-cocking phase of throwing: A cadav-
muscle. Acta Orthop Scand 65:442-446, 1994,
eric biomechantcal investigation AmJ Sports Med 28:200-205, 2000
Codman EA: The Shoulder Boston, Thomas Todd Company, 1934 Wuelker N, Schmotzer H, Thren K, et al: Translation of th glenohumeral
joint with simulated active elevation. Clin Orthop 309:193-200, 1994
C h a p t e r 6

Elbow and Forearm Complex

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


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 Functional Considerations of Pronation Flexors, 157
and Supination, 147 Biomechanics of th Elbow Flexors,
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
Arthrokinematics at th Proximal and 158
Distai Radioulnar Joints, 149 Maximal Torque Production of th Elbow
P e ria rtic u la r C o n n e c tiv e T is s u e , 138
Supination, 149 Flexor Muscles, 158
K in e m a tic s , 140
Pronation, 149 Elbow Extensors, 161
Functional Considerations of Flexion
and Extension, 140 Pronation and Supination with th Muscular Components, 161
Radius and Hand Held Fixed, 150 Electromyographic Analysis of Elbow
Arthrokinematics at th Humeroulnar
Extension, 161
Joint, 140 M USC LE A N D J O IN T IN TER AC TIO N , 151
Neuroanatomy OverView, 151
Torque Demands on th Elbow
Arthrokinematics at th Humeroradial
Joint, 141 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
Part II: Joints of th Forearm, 145 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
G en era l F e atures o f th P ro x im a l and
S u p in a to r M u s c le s , 165
D ista i R a d io u ln a r J o in ts , 145 151
P ro n a to r M u s c le s , 169

INTRODUCTION Four Articulations Within th Elbow and Forearm

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
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

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
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.

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
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


epicondyle Mediai
ment of th mediai collateral ligament of th elbow as well
as th forearm pronator and wrist flexor muscles.
The lateral epicondyle of th humerus, less prominent than
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

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


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

Extensor pollicis longus teres

Pronator quadratus

Interosseous membrane

Ulnar notch
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.

ProceSS Sfyltd
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.
Chapter 6 F.lbow and Forearm Complex 137

L ateral view 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.


Pati 1: Joints of th Elbow

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
FIGURE 6-7. A lateral (radiai) view of th right proximal ulna, with courses slightly superiorly owing in part to th distai pro-
th radius removed. Note th jawlike shape of th trochlear notch.

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


Styloid process Depression fo r

Osteologie Features of th Radius
articular disc
Radiai head
Fovea Styloid process
Dorsal tuberete
Bicipital tuberosiLy
Ulnar notch
Styloid process

Lateral Mediai

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 FIGURE 6-8. The distai end of th right radius and ulna with
roughened region located at th anterior-medial edge of th carpai bones removed. The forearm is in full supination. Note th
proximal radius. 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-
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

collateral ligament

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

mally stili after long periods of immobilization in a flexec
pressure. This pressure, which is determined by th ratio of
th volume of air to th volume of space, is lowest when th and shortened position. Long-term flexion may be th resuli
ol casting (ollowing a fractured bone, an elbow joint inllam
capsule is most compliant, or less stiff. The intracapsular air
pressure is lowest at about 80 degrees of flexion.''5 This joint mation, an elbow flexor muscle spasticity, a paralysis of th
position is often a position ol comfort for persons with tnceps muse e or a scarring of th skin over th antenoi
elbow. In additton to th tightness in th flexor muscles.
joint inflammation and swelling.26 Maintaining a swollen el
bow in a flexed position may improve comfort but may also tncreased stiffness may occur in th anterior capsule and
anterior parts of th collateral ligaments.
predispose th person to an elbow flexion contratture (from
th Latin root contractura; to draw together). 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-
Functional Considerations of Flexion and Extension tng use only a limited are of motion, usually between 30
and 130 degrees of flexion** Unlike lower extremity
Elbow (lexion provides several important physiologic func- joints, such as in th knee, th loss of th extremes o f motion
ttons such as pulling, lifting, feeding, and groomng. The
at th elbow usually results in only mimmal functional im-
inability to actively bring th hand to th mouth for feeding pairment.
for example, significantly limits th level of functional mde-
pendence. Persons with a spinai cord injury above th C5 Arthrokinematics at th Humeroulnar Joint
nerve root have this profound disability due to total paralysis
ol elbow (lexor muscles, The humeroulnar joint is th articulation of th concave
Elbow extension occurs with activittes such as throwing, trochlear notch of th ulna around th convex trochlea of
pushtng, and reaching. Loss of complete extension due to an th humerus (Fig. 6 - 1 6 ) . From a sagittal section, th hu
elbow flexion contracture is often caused by marked stiffness meroulnar joint resembles a ball-and-socket joint. The firm
tn th elbow flexor muscles. The muscles become abnor- 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.
collateral ligament Radius
Lateral (ulnar)
collateral ligament


Supinator crest
Chapter 6 Elbow and Forearm Complex 141

Elbow Flexion Contracture and Loss of Forward Reach a flexion contracture of less than 30 degrees. A flexion
contracture that exceeds 30 degrees, however, results in
One of th most disabling consequences of an elbow
a much greater loss of forward reach. As noted in th
flexion contracture is reduced reaching capacity. The loss graph, a flexion contracture of 90 degrees reduces total
of forward reach varies with th degree of elbow flexion
reach by almost 50%. Minimizing a flexion contracture to
contracture. As shown in Figure 6-14, a fully extendable less than 30 degrees is therefore an important functional
elbow (i.e., with a 0-degree contracture) demonstrates a goal for patients following elbow trauma, prolonged immo-
0-degree loss in area of forward reach. The area of for
bilization, or joint replacement.
ward reach diminishes only slightly (less than 6%) with

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- outside, + topos; place) bone formation around th olecra
face on th trochlea compared with only 180 degrees on th non fossa can limit full passive extension.
trochlear notch. In order for th humeroulnar joint to he During flexion at th humeroulnar joint, th concave sur-
fully, passively extended, sufficient extensibility is required face of th trochlear notch rolls and slides on th convex
in th dermis, flexor muscles, anterior capsule, and anterior trochlea (see Fig. 6 17J3). Full passive elbow flexion re-
fibers of th mediai collateral ligament (Fig. 6 -1 7 A ). Once quires elongation of th posterior capsule, extensor muscles,
in full extension, th humeroulnar joint is stabilized by th ulnar nerve,44 and certain collateral ligaments, especially th
increased tension in most of th anterior fibers of th mediai posterior hbers of th mediai collateral ligament.
collateral ligament, anterior capsule, and flexor muscles, par-
ticularly th broad tendon of th brachialis. The prominent
Arthrokinematics at th Humeroradial Joint
tip of th olecranon process becomes wedged into th olec- The humeroradial joint is an articulation between th cup-
ranon fossa. Excessive ectopie (from th Greek root ceto; 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: 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
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 FIGURE 6-19. An anterior view of th interosseous membrane of
rows. Note th elongation of th lateral (ulnar) collateral ligament th right forearm. Note th contrasting fber direction of th
during flexion. 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.
Chapter 6 Ebow and Forearm Complex 145

Part II: Joints of th Forearm

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.

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

severe valgus force, overstretching or mpturing th mediai collateral

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-

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
A posterior dislocation of th humeroulnar jomt.
FIGURE 6 - 2 3 . by dashed line) extends obliquely across th forearm from th
(From ODriscoll SW: Elbow dislocations. In Morrey BF (ed): The radiai head to th ulnar head. The radius and hand (shown in red)
Elbow and lts Disorders, 3rd ed. Phladelphia, WB Saunders, 2000, is th distai segment of th forearm complex. The humerus and
p 410. By permission of th Mayo Foundation for Medicai Educa- ulna (shown in gray) is th proximal segment of th forearm com
tion and Research.) 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
(with cartilage)-
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.)

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

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 nation and supination. On average, the forearm rotat
up from a chair.
through about 75 degrees of pronation and 85 degrees
The neutral or zero reference position of forearm rotation supination (Fig. 6 -2 8 A ). As shown in Figure 6 -2 8 B , severa!
is the thumb-up position, midway between complete pro- activities of daily living require only about 100 degrees ol

0 (Neutral)


D .


Neutral a> g

o 20



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 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

S P E C I A L F O C U S 6 - 3
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 Functional Association Between Pronation and
ie last 30 degrees of complete forearm rotation are stili Supination at th Forearm and Shoulder Rotation
eapable of performing many routine activities of daily living.
Active internai and external rotation at th shoulder is
Arthrokinematics at th Proximal and Distai Radioulnar functionally linked with active pronation and supination.
Joints Shoulder internai rotation often occurs with pronation,
Pronation and supination require simultaneous joint move- whereas shoulder external rotation often occurs with
ment at both proximal and distai radioulnar joints. A restric- supination. Combining these shoulder and forearm rota-
uon at one joint limits motion at th other. tions allows th hand to rotate nearly 360 degrees in
space, rather than only 170 to 180 degrees by pronation
Supination and supination alone. When clinically testing forearm
Supination at th proximal radioulnar joint occurs as a spin- muscle strength and range of motion, care must be
ning of th radiai head within th fibro-osseous ring formed
taken to eliminate contributing motion or torque that
by th annular ligament and radiai notch of th ulna (Fig. has originated from th shoulder. To accomplish this,
- - 2 9 , bottom inset). Supination at th distai radioulnar joint forearm pronation and supination are tested with th
occurs as th concave ulnar notch of th radius rolls and elbow held flexed to 90 degrees with th mediai epicon-
sltdes in similar directions on th head of th ulna (Fig. dyle of th humerus pressed against th side of th
6 - 2 9 , top inset). During supination, th proximal surface of
body. In this position, any undesired rotation at th
th articular disc remains in contact with th ulna head. At
shoulder is easily detected.
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 th ulnar head (see th asterisk in Fig. 6 - 3 0 , top inset),
The arthrokinematics of pronation at th proximal and distai
making it readily palpable.
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 Restrictions in Passive Range of Pronation and
dorsal capsular ligament at th distai radioulnar joint, as th Supination Motions
palmar capsular ligament slackens to about 70% of its origi Restrictions in passive range of pronation and supination
nai length .44 Full pronation exposes th articular surface of motions can occur from tightness in muscle and/or con-


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
150 Section II Upper Extremity


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.
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 Bieeps or supmator muscles
Palmar capsular ligament at Dorsal capsular ligament at th
th distai radioulnar joint20 distai radioulnar joint
Oblique cord, interosseous
membrane, and quadrate FIGURE 6-31. An anterior view of a righi elbow during pronation
ligament719 ol th forearm. During pronation, th fovea of th radiai head m usj
Ulnocarpal complex 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 spective, an understanding of th muscular mechanics of
6 -3 0 ). The rotation of th forearm occurs when th upper pronation and supination from both a non-weight-bearing
kmb is assumed to be in a non-weight-bearing posinoti. Prona- and weight-bearing perspective provides additional exercise
::on and supination are next described when th upper limb strategies for strengthening or stretching muscles of th fore
s assumed to be in a weight-bearing position. In this case, arm and shoulder.
th humerus and ulna rotate relative to a stationary, or fxed, The right side of Figure 6 - 3 2 B illustrates th arthrokine-
radius and hand. matics at th radioulnar joints during pronation while th
Consider a person hearing weight through an upper ex- radius and hand are stationary. At th proximal radioulnar
tremity with elbow and wrist extended (Fig. 6 -3 2 A ). The joint, th annular ligament and radiai notch of th ulna spin
oerson's righi glenohumeral joint is held partially internali)' around th fxed radiai head (see Fig. 6 - 3 2 B , top inset). At
rotated. The ulna and radius are positioned parallel in full th distai radioulnar joint, th head of th ulna rotates
supination. (The rod" placed through th epicondyles of th around th fxed ulnar notch of th radius (see Fig. 6 - 3 2 B,
humerus helps with th orientation of this position.) With bottom inset). Table 6 - 3 summarizes and compares th ac-
die radius and hand held firmly fxed with th ground, tive arthrokinematics at th radioulnar joints for both
pronation of th forearm occurs by an external rotation of th weight-bearing and non-weight-bearing conditions of th up
humerus and ulna (Fig. 6 -3 2 B ). Because of th tight struc- per limb.
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- MUSCLE AND JOINT INTERACTION
non of th humerus and ulna, relative to th fxed radius
and hand. Neuroanatomy OverView
Figure 6 - 3 2 B depicts an interesting muscle force-couple
Paths of th Musculocutaneous, Radiai, Median, and
used to pronate th forearm from th weight-bearing posi-
Ulnar Nerves Throughout th Elbow, Forearm, Wrist,
uon. The infraspinatus rotates th humerus relative to a and Hand
fixed scapula, while th pronator quadratus rotates th ulna
relative to a fxed radius. Both muscles, acting at either end The musculocutaneous, radiai, median, and ulnar nerves
of th upper extremity, produce forces that contribute to a previde motor and sensory innervation to th muscles and
pronation torque at th forearm. From a therapeutic per- connective tissues of th elbow, forearm, wrist, and hand.


Proximal Radioulnar
Joint from Above

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
152 Seclion II Upper Extremity

TABLE 6 - 3 Arthrokinematics of Pronation and anterior interosseous nerve, innervates th deep muscles
Supination1 th forearm: th lateral half of th flexor digitorum profa
dus, th flexor pollicis longus, and th pronator quadrane.
Non-weight-bearing The main pari ol th median nerve continues distally :j
Weight-Bearing (Radius and Hand cross th wrist through th carpai tunnel, under th cover i
(Radius and Hand Fixed) Free to Rotate) th transverse carpai ligament. The nerve then innerva
several of th intnnsic muscles of th thumb and th late.,
Proximal Annular ligament and ra- Radiai head spins
Radioulnar fngers. The median nerve provides a source of sensory i-
diai notch of th ulna withm a ring
Joint spin around a fixed ra bers to th lateral palm, palmar surface of th thumb, 2
formed by th
diai head. lateral two and one-half fngers (Fig. 6 -3 3 C , see inset
annular ligament
and th radiai median nerve sensory distribution). This sensory supply
notch of th ulna. especially rich and concentrated about th distai ends of 1
index and middle fngers.
Distai Convex ulnar head rolls Concavity of th ul-
Radioulnar and slides in opposite The ulnar nerve, formed from nerve roots CR- T ',
nar notch of th
Joint direetions on th con radius rolls and formed by a direct branch of th mediai cord of th braci
cave ulnar notch of th slides in similar plexus (Fig. 6 - 3 3 D). After passing posteriorly to th mec
radius. direetions on th epicondyle, th ulnar nerve innervates th flexor carpi _
convex ulna naris and th mediai half of th flexor digitorum profundi3
head. 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
The anatomie path of these nerves is described as a founda-
sensory supply is especially concentrated about th little f i - J
tion for this chapter and th following tvvo chapters on th ger and ulnar border of th hand.
wrist and th hand.
The musculocutaneous nerve, formed from th C5-7 nerve
roots, innervates th biceps brachii, coracobrachialis, and Innervation of Muscles and Joints of th
brachialis muscles (Fig. 6 -3 3 A ). As its name implies, th Elbow and Forearm
musculocutaneous nerve innervates muscle, then continues
distally as a sensory nerve to th sktn, supplying th lateral Knowledge of th innervation to th muscle, skin, and joina
forearm. is useful clinical information in th treatment of injury \
The radiai nerve, formed from C5T 1 nerve roots, is a th peripheral nerves or nerve roots. The informed tim-
direct continuation of th posterior cord of th brachial cian can anticipale th extent of th sensory and motcrl
plexus (Fig. 6 -3 3 B ). This large nerve courses within th involvement following an acute injury. Therapeutic aclivities, I
radiai groove of th humerus to innervate th triceps and th such as splinting, selective strengthening, range of motios
anconeus. The radiai nerve then emerges laterally at th exercise, and patient education, can be initiated almost in.- .
distai humerus to innervate muscles that attach on or near mediately following injury. This proactive approach miru-
th lateral epicondyle. Proximal to th elbow, th radiai mizes th potential for deformity and damage to insensitive
nerve innervates th brachioradialis, a small lateral pari of skin and joints, thereby limiting th amount of permaner:
th brachialis, and th extensor carpi radialis longus. Distai disability.
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 The elbow flexors have three different sources of peripheral
space of th thumb. The deep branch contains th remaining nerve supply: th musculocutaneous nerve to th biceps bre-
motor fibers of th radiai nerve. This motor branch supplies chii and brachialis, th radiai nerve to th brachioradiaiisl
th extensor carpi radialis brevis and th supmator muscle. and lateral part ol th brachialis, and th median nerve tol
After piercing through an intramuscular tunnel in th supi- th pronator teres, which is a secondary flexor. In contras!!
nator muscle, th final section of th radiai nerve courses th elbow extensors, th triceps brachii and anconeus, have J
toward th posterior side of th forearm. This terminal single source of nerve supply through th radiai nerve. In-J
branch, often referred to as th posterior interosseous nerve, jury to this nerve can result in complete paralysis of th I
supplies th extensor carpi ulnaris and several muscles of th elbow extensors. In centrasi three different nerves must b;
forearm, which function in extension of th digits. alfected lo paralyze all elbow flexors. Fortunately, redundan:
The median nerve, formed from C - T 1 nerve roots, innervation to th elbow flexor muscles helps preserve th I
courses toward th elbow to innervate most muscles attach- important hand-to-mouth function required for essential ac-
ing on or near th mediai epicondyle of th humerus. These tivities such as feeding.
muscles include th wrist flexors and forearm pronators Ihe muscles that pronate th forearm (pronator teres, pro
(pronaior teres, flexor carpi radialis, and palmaris longus), nator quadratus, and other secondary' muscles that originate
and th deeper flexor digitorum superficialis (Fig. 6 -3 3 C ). A
from th mediai epicondyle) are innervated through th me
deep branch of th median nerve, often referred to as th dian nerve. Supination o f th forean n is driven by th bicep-
Chapter 6 Elbow and Forearm Complcx 153

Brachial Plexus
Lateral cord

Posterior cord

Mediai cord


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


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

Abductor pollicis brevis

Opponens pollicis

Flexor pollicis brevis

Lumbricals (lateral-half)

lllustmtion continued on following page

brachii via th musculocutaneous nerve and th supinator forearm. This table was derived from Appendix HA, which
muscle, plus other secondary muscles that arise front th lists th primary motor nerve roots for all th muscles of th
lateral epicondyle and dorsal forearm, via th radiai nerve. upper extremity. Appendix I1B shows key muscles typically
Table 6 - 4 summarizes th peripheral nerve and primary used io test th functional status of th C -T 1 ventral nerve
nerve root innervation io th muscles of th elbow and 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
profundus (medial-half)
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)


primarily by th musculocutaneous and radiai nerves and b\
Humeroulnar Joint and Humeroradial Joint th ulnar and median nerves.51
The humeroulnar and humeroradial joints and th surround- Proximal and Distai Radioulnar Joints
ing connective tissues receive their sensory innervation l'rom
The proximal radioulnar joint and surrounding elbow cap
th C" h nerve roots.18 These afferent nerve roots are carried
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*

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


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
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 ,
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


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- 90 degrees (see Fig. 6 - 3 7 ) . This mechanical condition maxi-
curs at about 90 degrees of flexion, which agrees in generai mizes th internai moment arm of a muscle and thereby
with actual torque measurements made on healthy per- maximizes th conversion of a muscle force to a joint
sons.40-49 torque. li is interesting that th data presented in Figures 6 -
The two primary factors responsible for th overall shape 38B and C predict peak torques across generally similar joint
of th maximal torque-angle curve of th elbow flexors are angles.
(1) th muscles maximal flexion force potential and (2) th
internai moment arm length. The data plotted in Figure Polyarticular Biceps Brachii: A Physiologic Advantage of
6 - 3 8 B predict that th maximal force of all muscles oc- Combining Elbow Flexion with Shoulder Extension
curs at a muscle length that corresponds with about 80 The biceps is a polyarticular muscle that can produce forces
degrees of flexion. The data plotted in Figure 6 - 3 8 C predici across multiple joints. As subsequently described, combinine
that th average maximal internai moment arm of all mus active elbow flexion with shoulder extension is a naturai and
cles occurs at about 100 degrees of flexion. Ai this joint effective way for producing biceps-generated elbow flexe:
angle, insertion of th biceps tendon to th radius is about torque.

Flexor Torque vs Elbow Joint Angle

I k b Y k
i i V
A Elbow Joint Angle (degrees) B Elbow Joint Angle (degrees)

Flexor Moment Arm vs Elbow Joint Angle

FIGURE 6-38. A, Predicted maximal isometric torque-angle

curves for three primary elbow flexors based on a theoretical
model that incorporates each muscles architecture, length-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.)
Chapter 6 Elbow and Forcam i Complex 161

For th sake of discussion, assume that at rest in th examples in which a one-joint muscle, such as th posterior
I anatomie position th biceps is about 30 cm long (Fig. deltoid, can enhance th force potential of another muscle.
I -39A ). The biceps shortens to about 23 cm after an active In th example, th posterior deltoid serves as a powerful
motion that combines 45 degrees of shoulder flexion and shoulder extensor for a vigorous pulling motion. In addition,
90 degrees of elbow flexion (Fig. 6 -3 9 B ). If th motion th posterior deltoid assists in controlling th optimal con
I took 1 second to perform, th muscle experiences an aver traction velocity and operational length of th biceps
l e contraction velocity of 7cm/sec. In contrast, consider a throughout th elbow flexion motion. The posterior deltoid,
more naturai but effective method of biceps activation that especially during high power activities, is a ver)' important

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
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.

I snoulder. In effect, th contraction of th posterior deltoid

I neduces th net shortening of th biceps. Based on th ex- ELBOW EXTENSORS
I ampie in Figure 6 - 3 9 C , combining elbow flexion with
Muscular Components
I shoulder extension reduces th average contraction veloc-
I cy of th biceps to 5cm/sec. This is 2cm/sec slower than The primary elbow extensors are th triceps brachii and th
I combining elbow flexion with shoulder flexion. As described anconeus. These muscles converge to a common tendon at-
m Chapter 3, th maximal force output of a muscle is taching to th olecranon process of th ulna (Figs. 6 - 4 1 and
I greater when its contraction velocity is closer to zero, or 6 -4 2 ).
tsometric. The triceps brachii has three heads: long, lateral, and
The simple model described here illustrates one of many 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
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
RGURE 6-39. A, This model is shovving a person standing in th maintain low levels of elbow extension force.21 As extensor
anatomie position with a 30-cm long biceps muscle. B, After a 1- effort gradually increases, th mediai head of th triceps is
<ec contraction, th biceps has contracted to a length of 23 cm,
usually next in line to join th anconeus.48 The mediai head
causing a simultaneous motion of 90 degrees of elbow flexion and
remains active for most elbow extension movements.12 The
45 degrees of shoulder flexion. The biceps has shortened at a con-
traction velocity of 7 cm/sec. C, The biceps and posterior deltoid mediai head has been termed th workhorse of th exten
are shown active in a typical pulling motion. The contraction lasts sors, functioning as th extensor counterpart to th brachi
; sec and causes a simultaneous moiion of 90 degrees of elbow alis.48
dexion and 45 degrees of shoulder extension. Because of th contrac- Only after extensor demands at th elbow increase to
ion of th posterior deltoid, th biceps shortened only 5 cm, at a moderate-to-high levels does th nervous System recruit th
contraction velocity of only 5 cm/sec. 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 extremity muscles, but near normal strength of th shoul-
Example der, elbow flexor, and wrist extensor muscles. With th
Contraction of th elbow flexor muscles is typically per- distai aspect of th upper limb well fixed by action of th
formed to rotate th forearm to th arm. Contraction of wrist extensor muscles, th elbow flexor muscles can
th same muscles, however, can rotate th arm to th generate sufficient force to rotate th arm toward th
forearm, provided that th distai aspect of th upper ex forearm. This maneuver allows th elbow flexor muscles
tremity is well fixed. A clinical example of th usefulness to assist th person while moving up to a sitting position.
of such a "reverse contraction" of th elbow flexors is Interestingly, th arthrokinematics at th humeroulnar joint
shown for a person with C6 quadriplegia (Fig. 6-40). during this action involve a roll and slide in opposite
The person has complete paralysis of th trunk and lower 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.

The iong head functions as a reserve elbow extensor, isometric contraction or very low-velocity eccentric activa-
equipped with a large volume suited for tasks that require tion. In contrast, these same muscles are required to gen
high work performance. erate ver)' large and dynamic extensor torques through
high-velocity concentric or eccentric activations. Consider
Torque Demands on th Elbow Extensors
activities such as throwing a ball, pushing up frotn a low
The elbow extensor muscles provide static stability to th chair or rapidly pushing open a door. As with many ex-
elbow, similar to th way th quadriceps are often used to plosive pushing activities, elbow extension is typically com-
stabilize th knee. Consider th common posture of hear bined with some degree of shoulder Uexion (Fig. 6 - 4 3 ) . The
ing weight through th upper limb with elbows held par- shoulder flexion function of th anterior deltoid is an im-
tially flexed. The extensors stabilize th flexed elbow through 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 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
FIGURE 6-46. The line-of-force of th supinators (A) and th pro torque perform ed with th elbow flexed to 90 degrees may
nators (B) of th forearm during an active motion. Note th degree
produce twice th torque than with th elbow held near fuD
to which all muscles intersect th forearms axis of rotation (shown
as dashed line). For clarily, not all th secondary supinators and extension. At a 90-degree elbow angle, th tendon of th
pronators are depicted. biceps approaches a 90-degree angle-of-insertion into th
radius (Fig. 6 - 4 9 , top). This biomechanical situation allow s
th entire magnitude of a maximal effort biceps force, show-

Supinator versus Biceps Brachii

The supinator muscle has a complex proxtmal muscle attach-