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UTHSCSA PHYSICAL THERAPY PROGRAM PHYT 5012 KINESIOLOGY SPRING 2004 Instructor: Office hours: Phone: Email: Schedule:

Mike Geelhoed, PT, OCS, MTC TBA 210-567-8756 TBA Monday 10 to 12 and 1 to 3 Wednesday 8 to 10 and 10 to 12

Room 3.108 Room 3.202.2

Course Description: A study of joint structure and function, and the mechanical principles underlying the kinematics and kinetics of human motion. Emphasis is placed on the interaction between biomechanical and physiological factors in skeletomotor function and the implications of kinesiological principles in physical therapy practice. Objectives: By the end of the course, the students will be able to: 1. Evaluate human motion through the application of kinesiological concepts and principles, with specific application to the practice of PT. 2. Specify the kinematics and kinetics for any joint. 3. Analyze concepts and principles of human arthrology. 4. Assess normal and pathological postures and gait patterns. Methods of Instruction: This course will involve class lectures, discussions, and hands-on laboratory sessions. Methods of Evaluation: Exam 1 10% Exam 2 15% Final comprehensive 25% Lab exam 1 Lab exam 2 Lab exam 3 10% 15% 20% Project 5%

Grading: A = 90 100, B = 80 89, C = 75 79, D = 65 74, F =0 64. Readings: Required: Class notes. Levangie P and Norkin C: Joint Structure and Function: A Comprehensive Analysis. 3rd Edition. Philadelphia, PA. FA Davis Co. 2001 Kisner C and Colby LA: Therapeutic Exercise. Foundations and Techniques. 4th Edition. Philadelphia, PA. FA Davis Co. 2002. Recommended: Smith L, Weiss E and Lehmkul D: Brunnstrom's Clinical Kinesiology. 5th Edition. Philadelphia, PA. FA Davis Co, 1996. Kapandji, IA: The Physiology of Joints. Volumes 1 through 3., Edinburgh. Churchill Livingstone, 1982. Nordin M, Frankel V: Basic Biomechanics of the Musculoskeletal System. Philadelphia. Lippincott, Williams and Wilkins, 2001. Petersen C, Foley R: Active and Passive Movement Testing. New York. McGraw-Hill, 2001.

General Course Information: * Please read class notes and Levangie & Norkin before class. This will allow you to stay current & maintain a high standard for the class. * Please review anatomy prior to class as this course assumes you have this knowledge. It will also help you stay current and maintain a high standard for the class. * Please wear appropriate attire for labs. If you have pain and/or dysfunction anywhere notify your classmates and instructor so that no techniques are performed on that area that may cause problems. * To enhance your learning, participation is expected and is based on active, voluntary involvement in questions, answers, discussions and demonstrations. Failure to do so may result in a reduced grade. * Attendance to all classes is required and you are expected to be in class on time. Frequent tardiness may result in diminished grades. Please refer to the attendance policy in the Student Handbook. * Schedule may be subject to change. * Please write a paper on any joint. While it may not count much for your grade, it is intended to facilitate your learning experience. It is graded based depth of the topic covered (content) and structure (context). Deductions are based on omissions, mistakes, repetitiveness and simplicity of the subject, excessive typographical or grammatical errors and unclear statements. You may choose any joint and cover all its salient aspects, and why it may be predisposed to injury. Include a drawing of the joint (by hand). The paper should be no greater than 10 pages in length including references. These should be listed in the body of the work by name, year and page e.g.: Kapandji, 1997 p. 63. They should be recent unless ground-breaking and must be based on peer-reviewed journals and books (excluding your texts and nonpeered reviewed websites). The project must be given to the instructor in class on or before the 28 of April, as late papers will not be graded. Papers are done by 10 -11 groups of 3 students. * Remediation procedures. In order to help you stay in the program to become a competent PT, you may remediate during the semester should your score for an exam = 79 or less. Should this occur, it is your responsibility to seek the instructor for assistance, as this is voluntary. Although your grade for that component may increase, it will not go beyond an 80. This process will assist you in learning and developing the necessary skills to practice competently. Remediation may only occur twice during the semester and consists of identifying areas needing improvement and determining a plan of action to correct them. This plan, your responsibilities and timelines, will be placed in your academic file. Remediation may entail any or all of the following performances, at the instructors discretion, and is not limited to: presenting an oral/practical exam; writing a report on anatomy, kinesiology, etc; performing a literature review; reading selected articles, etc. Remediation terminates on the specified date, during the semester, which is when your performance criteria should be completed. You must pass the remediation (i.e. demonstrate that you know the material and are competent and safe), in order to pass the course. If however, you obtain a grade of 64 or less for you final lab or final written exam, you will fail the course (F) regardless of previous scores unless they all average 90 or above. Dates and times may be offered for review sessions and retake examinations during the original exam week. You have only that week to inform the instructor if you would like remediation as retakes and reviews for the first four exams will occur only once. If you have questions regarding the exams taken, you are welcome to come to the instructor, but have only 2 days after the exam to do this review.

Performance Objectives for Kinesiology Practical Examinations: The course objectives in the syllabus correlate with the following performance objectives during lab exams: 1. Apply learned facts to new situations related to pt. care. 2. Analyze information from pt. examinations. 3. Perform safe and competent joint mobilizations on any joint. 4. Perform other learned procedures safely. Examination Procedures: 1. Two students take part in the exam: 1 is a patient and the other, the tester, and then you switch. 2. You will perform a treatment mobilization or an examination mobilization. 3. The patient will only do as told by the tester and not provide obvious clues regarding the technique. To do so constitutes failure of the exam. 4. The testing students must be prepared to perform the technique, which is blindly selected by 1 of the testers. 6. Each testing student will have up to 7 minutes to perform their part. 7. Appropriate feedback will be provided at completion to both partners to enhance your learning. If you do not want this feedback, you must notify the instructor prior to the exam, otherwise it will automatically be given. 8. Your practical exam may be videotaped. Grading Criteria: Please refer to the lab exam criteria/score sheets. Critical Errors: These are defined as unacceptable errors during the performance of the technique, and constitute termination and failure of the exam (F). Should this occur, you may remediate as stated previously. Critical errors include, but are not limited to: 1. selecting the wrong joint. 2. being unable to describe pertinent basic concepts from previous course work, like anatomy, patient care courses, etc. 3. selecting a contraindicated procedure. 4. performing an unsafe procedure. Safety is judged by the instructor, and constitutes a procedure or statement that would be detrimental to the well-being of a patient/partner, i.e., something that could potentially harm or not benefit someone, performing the technique on the wrong area, placing your partner in an uncomfortable/painful position, etc. Refer also to the Blue MACS for specific safety issues. Criteria for successful completion of labs: Successful completion is considered when the material for that day has been covered and the students have had the opportunity to interact with the instructor regarding the skills being learned. It is your responsibility to seek him out for assistance. At the completion of each lab, students will be able to perform specific joint mobilizations/examinations and/or other procedures pertinent to patient management (listed by region/date in the syllabus and found in handouts and Kisner and Colby book). As part of your commitment to independent learning, it is also your responsibility to practice all labs on your own, as well as reading the appropriate assignments, chapters and notes prior to each class. To further assist you in your learning process, the instructor is available for consultation once other sources have been sought out.

KINESIOLOGY SCHEDULE 2004 Mon 1/12 3.108 3.108 Wed Wed 1/14 1/21 8-12 8-10, 10-12 10-12 8-10, 10-12 10-12, 1-3 8-10, 10-12 10-12 1-3 10-12 7-12 10-12, 1-3 8-10, 10-12 Shoulder Complex Shoulder Lab Elbow complex Lab Wrist & Hand Lab TMJ Lab Written test Lab exams The spine lab CH 9 CH 8 CH 7 Rm 3.108 Rm 3.302 Rm Rm 3.302 Rm 3.108 Rm 3.302 Rm 3.108 Rm 3.302 Rm 3.108 Rm 3.302 Rm 3.108 Rm 10-12 1-3 Kinetics & kinematics Joint structure & function CH 1 CH 2 Rm Rm

Mon 1/26 3.108 Wed 1/28 Mon Wed Mon 2/2 2/4 2/9

CH 6

Wed Wed

2/11 2/18

CH 13

Mon 2/23 Wed 3.302 Mon Wed Mon Mon Wed Mon Wed Mon Wed 3/1 3/3 3/8 3/15 3/17 3/22 3/24 3/29 3/31

CH 4

2/25

10-12, 1-3 8-10, 10-12 SPRING BREAK 10-12, 1-3 8-10, 10-12 10-12, 1-3 8-10, 10-12 10-12 7-12 10-12, 1-3

The neck Lab

CH 4

Rm 3.108 Rm 3.302

The thorax Lab Lumbar spine & SIJ Lab Written test Lab exams The hip

CH 5

Rm 3.108 Rm 3.302 Rm 3.108 Rm 3.302 Rm 3.108 Rm 3.302 CH 10 Rm

CH 4

Mon 4/5 3.108

Wed Mon Wed

4/7 4/12 4/14

8-10, 10-12 10-12, 1-3 8-10, 10-12 10-12, 1-3 8-10, 10-12

Lab The knee Lab Foot & ankle Lab CH 11

Rm 3.302 Rm 3.108 Rm 3.302 Rm 3.108 Rm

Mon 4/19 Wed 4/21 3.302 Mon Wed 4/26 4/28

CH 12

10-12, 1-3 8-10, 10-12 10-12 7-12 10-12

Gait Lab Review Final lab exams Final written test

CH 14

Rm 3.108 Rm 3.302 Rm Rm Rm

Mon 5/3 3.108 Wed 5/5 3.302 Mon 5/10 3.108

KINESIOLOGY
Kinematics and kinetics. Kinesiology is the study of motion. Its purpose is to understand the forces acting on the body and to manipulate these forces in treatment procedures so that human performance may be improved and injury may be prevented. It provides the understanding of how joint structure and muscle function fulfill the needs of the body for mobility and stability. The study of mechanics in the human body is called biomechanics. This is further divided into statics and dynamics, the former relating to bodies at rest or in uniform motion, and the latter is concerned with bodies that are accelerating or decelerating. Kinematics is the science of biomechanics that studies motion without regard to the forces producing the movement (mov't). Kinetics is the area of biomechanics that deals with the forces acting on objects that produce motion or maintain equilibrium. KINEMATICS: Kinematic variables include: *the type of motion: 1. rotatory or angular (mov't on a fixed axis), few are pure. 2. translatory or linear (movt in a straight line). When one flat surface translates along another, it is called gliding. 3. curvilinear, a combination of the above: rotation of a rigid object through space. (A thrown ball moves through space & rotates on its own axis). *the location of motion: transverse, frontal or sagittal planes in the anatomical position. *the direction of motion: flexion, extension, rotation, abduction, etc. *the quantity of the motion: in degrees or degrees per second. Joints that move in one plane have one axis and one degree of freedom (elbow). Joints with 2 axes move in 2 planes and have 2 degrees of freedom (wrist). Joints with 3 degrees are ball in socket joints with 3 degrees of freedom. A degree of freedom is the number of independent coordinates needed to specify the position of an object in space. Kinematic chain: this is a combination of several joints and D of F uniting successive segments. If opened, it means that the distal segment moves in space; if closed, the distal is fixed and the proximal segment is the one that moves. Kinematics is also divided into osteo- and arthrokinematics. The first refers to motion of the bones, and the second refers to motion occurring between joints.

KINETICS:

This describes how or why motion occurs. It analyzes forces. A force is that which changes or tends to change the state of rest or motion in objects. It is also referred to as a push or pull. External forces are pushes and pulls and arise from sources outside the body. Gravity is the most constant force, which is the pull of the earth on the body. Wind and water are others. Internal forces arise from within the body, like muscles (ms), bones, ligaments (ligs). Internal forces counteract the external forces that may jeopardize the integrity of the joints. Friction and pressure are both internal and external forces. Force Vectors. All forces are vector quantities and are defined by a point of application, an action line, direction and a magnitude. Example: elbow flexion: a muscle acting on a bony lever, where the point of application is on the bone, the action line and the direction are in the direction of the pull of the muscle, and the magnitude is any weight. Examples of vectors in the body include muscle fibers, which when taken together, form a concurrent force system resulting in a total muscle force vector. Force of gravity (FOG). Gravity (G) is the attraction of the earth on a body, and has a magnitude of 32 ft/s2 . The FOG gives weight to an object, which is the mass of the object x the acceleration of G (w = m x 32). G acts with its point of application at the center of gravity (COG). This is a hypothetical point at which all mass would appear to be concentrated. It is a single point of a body about which every particle of its mass is equally distributed. In a symmetrical object, the COG is in the center. Otherwise, it is located toward the heavier end, and can lie outside the object (balance point). The action line and direction of the FOG on an object are always vertically downward to the center of the earth regardless of orientation. The gravity vector is the line of gravity. Every segment in the body has its own COG. They can be combined into 1 COG if adjacent and if they are to move as 1 segment with 1 COG (located between and in line with the original 2 COGs). When the segments are not = in weight, the new COG lies closer to the heavier segment. The magnitude of the FOG does not change because the segments do not change their mass, just the location of the vector. STABILITY: In the body in the anatomical position, the COG is just anterior to the 2nd sacral vertebra or at 55% of a persons height, and can change depending on the position of the person. When you lean forward, it goes outside the body in front of the abdomen. With the arms overhead, the COG rises. For an object to be stable, the line of gravity (LOG) or gravity vector, has to be within the base of support; the larger the base, the greater the stability, as in lifting; the closer the COG to the base of support (BOS), the more stable the object. When the

BOS is big, the LOG can move more freely without displacing the LOG from the base. When the COG is low, mov't is less likely to cause the COG to fall outside the base. When you add an object to the body by wearing it or carrying it, the new COG shifts toward the additional weight. Holding a heavy case in the R hand results in a shift of COG up and to the right while leaning to the left to compensate. The main effect is to bring the LOG back to the middle of the BOS. When standing on 1 leg, the COG projects within the weight-bearing foot. To sit up, you need to sit forwards so that the COG projects beneath the feet and not beneath the chair. If the COG is disturbed but then returns to its original balanced position or COG, the body is in stable equilibrium. If it does not return, the body falls and becomes unstable. To prevent this, we place the BOS under the COG via the autonomic neuromuscular system. The degree of stability of the body, i.e., its resistance to being overthrown, depends on: the height of the COG above the base of support, the size of the BOS, the location of the gravity line within the BOS & the weight of the body. This is relevant because it is useful in adjusting exercise loads, applying traction and balancing the patient. For example, to alter the resistive torque (weight x perpendicular distance to the axis of motion), flex the elbow when doing shoulder (shld) flexion to make it easier, or do sit-ups with arms at the side instead of at the chest, or flex the knees instead of having them straight when doing a leg lift. The weight of the leg is the same if bent or straight, but the COG moves so the torque is less, which decreases the force the abs need to exert to lift. NEWTON'S LAWS OF MOTION: THIRD LAW OF REACTION: For every action there is an = and opposite reaction. All forces come from things that touch; all forces come in pairs that are = in magnitude and opposite in direction simultaneously. Whenever 2 objects contact, they exert a force on each other. Example: tug of war, weight lifting, gait. SECOND LAW OF MASS AND ACCELERATION: Acceleration of an object is proportional to the unbalanced forces acting on it and inversely proportional to the mass of that object: a = f/m. This means that a greater force is needed to move or stop a large mass than a small one. For example when doing a sit-up, the iliopsoas which goes to the femur and trunk, will move the part with the least mass when the muscle contract forcefully, so patients (pt) with thin legs have difficulty doing a sit-up because the legs elevate. When the mass is increased as when walking with a cast, greater force is needed to start and stop the leg swing. A large pt. in a wheel chair has more inertia than a small pt., as in order to push, one needs to exert a greater force to obtain the same acceleration. FIRST LAW OF INERTIA OR EQUILIBRIUM:

Objects will remain at rest or in uniform motion in a straight line unless acted on by an unbalanced force. When unbalanced forces are applied to an object, the result is acceleration. Inertia makes an object resist both the initiation of motion and a change in motion. For an object to be in equilibrium, the sum of all the forces applied to that object must = 0. Example: a puck on ice in motion. JOINT DISTRACTION AND COMPRESSION IN A LINEAR FORCE SYSTEM: Knowledge of Newton's laws and of linear force (F) allows us to understand how traction or weights applied to a segment produce joint distraction or compression. Weights can act entirely as distraction forces without a rotatory component, as in Codman or pendulum exercises. In some situations, distraction is not indicated because it may cause further damage to the joint, as in ligamentous injuries of the knee; in this case, instead of applying resistance with free weights, consider manual resistance in order to produce a rotatory component. Most of the tension produced by the quads is directed towards the femur and is causing the tibia to be compressed against it: compression or stabilizing component. If 2 or more forces act along a line, the force is added or subtracted to create a single resultant force. The same applies to over-the-head traction because it is a linear force in opposite directions: 25# of weight cause a resultant upward force of the neck of 15# because the head weighs about 10#. For forces acting on angles, however, simple math won't do. If 2 forces are pulling from the same point, the resultant force can only be found graphically or trigonometrically. As the angle between the F increases, the resultant F decreases. When the angle becomes 0, the forces are on the same line and the resultant F is the sum of 2 F. If a patient in bed with leg traction from 2 angles, moves up in bed, the angle between the ropes decreases and so the traction force increases. The same happens if you move the fixed pulleys on the bed post closer together. When exercising with pulleys, the different angle of application changes in the different parts of the ROM; each change in the angle or direction of the force causes changes in the magnitude of the torque, so the resistance varies at different points of the ROM. For ex: when lifting 30# at the ankle, 30# will be lifted at 90 degrees, 24# will be lifted at 45 and 15# will be lifted at 0 degrees with the same 30# weight. TORQUE: This is a moment of a force and is the product of a force times the perpendicular distance from its line of action to the axis of motion. It is the expression of the effectiveness of a force in turning a lever system, or the measure of the tendency of a force to produce rotation about an axis.

Any force that passes through the center of rotation has a 0 moment as the distance is 0; or forces that act through an axis can't produce torque, so in order to increase the effective moment, increase the F or increase the distance at which the F is applied. t = F x perpendicular distance A moment arm or torque arm is the shortest distance between the action line or vector & the joint axis. As the angle of application changes, so will the length of the moment arm. The moment arm is greatest when the action line is applied at 90 to its lever. The torque generated by a muscle is greatest at the point in which the muscles action lines are furthest from the axis. Examples of torque: opening a door that is stuck; you push or pull at the center of the door as hard as possible, but it won't open, but if that same F is applied as far as possible from the hinges (axis), the F is more effective in opening the door (increased length of the F arm). In testing the strength of the biceps, the PT applies resistance at the wrist instead of at the middle of the forearm. In each case, the torque produced by the patient is the same, but the F exerted by the PT is half less at the wrist because of the longer resistance arm. When lifting a weight, the torque produced increases as the weight is further away from the body, and reaches a max at 90 and then decreases as the weight goes higher, due to the perpendicular distance. Maximum torque is produced when a lever is parallel to the ground.

Torque reduction is thus emphasized in therapy when lifting and carrying in order to prevent injury. When lifting to transfer a patient, have his COG close to yours to reduce the torque. When lifting a weight at the ankle by the quads at an acute angle, the weight will exert less F than what the weight really is; only when the weight acts at 90 degrees to the segment, is the rotary F the same magnitude as the weight. If the goal of the exercise is to give resistance, then the torque should match the torque that the ms is capable of developing.

FORCE COUPLE: Two parallel F = in magnitude but opposite in direction. It is also defined as a synergy where 2 F whose points of application occur on opposite sides of an axis and in opposite directions to produce rotation of a body or segment. Ex: the upper and lower traps and the serratus anterior during arm elevation, which combine forces to produce abduction and upward rotation of the scapula; the

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deltoids and supraspinatus contract together to produce abduction (abd) or flexion (flex) at the glenohumeral joint (GHJ). LAWS OF FRICTION: The force of friction potentially exists when 2 objects come in contact. It is a vector force = in magnitude and opposite in direction whenever there is motion, and it is always parallel. (The maximum potential F of friction for an object that is not moving is the product of the coefficient of friction and the contact F). There is no magnitude unless there is motion. Force increases with the magnitude of contact of the adjacent object. Increasing pressure increases friction while the coefficient remains unchanged because the surfaces remain the same. Ex: rubbing skin on skin. Once an object is moving, friction is a constant value, equal to the product of the reaction F and the coefficient of kinetic friction. The F trying to move the object must be greater than the maximum value of static friction before motion begins. As motion is initiated, friction decreases from its maximum value to its smaller kinetic value. Example: a man trying to push a heavy cart. Friction is the F needed for motion, divided by the compressive F between the 2 bodies. (The coefficient does not have a unit because it is a ratio of 2 forces). PARALLEL FORCE SYSTEMS: They exist whenever 2 or more parallel forces act on the same object but at a distance from each other, which can be seen with levers. LEVERS: A lever is a machine that functions on the principle of a rigid bar being acted on by forces that tend to rotate the bar about its pivot point. Our bones are lever systems that rotate around an axis or joint, and when F are applied to them, they produce equilibrium or movement like rotation or translation. The muscle contraction is the holding or moving force and the resistance is the weight of the segment. A lever arm is the distance from the axis to the point where a force is applied. The 3 F of the mechanical lever are the axis, the weight and the moving F. The perpendendicular distance from the axis to the line of action of the weight is the weight arm, and the perpendicular distance from the F to the axis is the F arm. MECHANICAL ADVANTAGE: This is the measure of the efficiency of the lever (force compared to resistance). It is the ratio between the length of the F arm (FA or effort arm) and the length of the weight arm (WA or resistance arm). The higher the number, the greater the mechanical advantage. An increase in the length of the FA or a decrease in the length of the WA or resistance arm produces a greater mechanical advantage, making the task easier. When the effort arm is larger than the resistance arm, the MA=>1. When this happens, the magnitude of the effort force can be smaller than the magnitude of the

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resistance. That is, a small effort force can produce increased torque and thus overcome a larger resistance. MA = FA length/ WA length First class levers: This system exists whenever 2 forces are applied on either side of an axis at some distance from that axis, creating rotation in opposite directions, such as a seesaw or balance scale. Examples in the body are: the triceps at its attachment. Here it does not matter which F is the effort and which is the resistance since the axis lies in between both. If the forearm extends, it's the triceps; if the external F beats the triceps F, then the external F is the effort. First class levers follow no rules in regards to mechanical advantage; it does not matter which is greater. You gain force or distance, depending on lengths.

Second class lever: This is present when 2 forces are applied so that the resistance lies between the effort F & the axis of rotation. Here the effort arm (the lever arm of the effort F) is always greater than the resistance arm (the lever arm of the resistance F). The benefit of this type of lever is that a very large F can be moved by a smaller F, such as in the use of a wheelbarrow or a crowbar for prying. Examples in the body include: a person standing on both feet on the toes because of the F on the floor, where the calf lifts the body around the axis of the toes. The body weight is the resistance and the ms are the effort. These levers occur only with eccentric contractions against an external moving force, or with the ms acting on its' proximal segment while the distal is fixed.

Third class lever: This is the most common in the body. Here the weight arm is always longer than the force arm with a very low mechanical advantage. This design helps produce speed and move a small weight a long distance. Here the effort F lies closer to the axis than the resistance. The mechanical advantage is always <1. Ex: a small amount of shortening of the brachialis causes a large ROM of the hand. This seems inefficient but in the body the goal is to move, not necessarily to always be mechanically efficient. So, the shorter the lever, the greater the movement. Other examples are the deltoid acting on the GHJ, the extensor carpi radialis at the wrist, the anterior tibialis at the ankle. With all types of levers, what is gained in force is lost in distance & vice versa. PULLEYS: They are used in traction and ex equipment to change the direction of the force or to increase or decrease the magnitude of a force. Anatomic pulleys cannot change the magnitude of a ms force, but the change in direction results in improved ability of the ms to generate torque because the action line is now away from the axis, so the mechanical advantage increases. They deflect the line of pull of a ms. Ex: a tendon that wraps around a bone or is deflected by a

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bony prominence. When the pull of a ms is altered, the bone functions as a pulley. Ex: the pernoneal tendons Single fixed pulleys: Here, the line of action of a F is changed. A F acting in a downward direction is used to move a weight in an upward direction. This does not give any mechanical advantage. Ex: cervical traction. Movable pulley: If a weight is on a movable pulley, half the weight is supported by the rope attached to the hook and half by the rope on the other side of the pulley, so the mechanical advantage is 2. The rope now needs to be moved twice the distance that the pulley is raised, and what is gained in F is lost in distance, like leg traction, but this is not seen in the body. JOINT STRUCTURE AND FUNCTION. All joints, human and otherwise, have the same basic principles. They demonstrate the relationship between structure and function. In human joints, structure usually determines function, but because tissues adapt to stresses, function may determine structure to some extent. If the function of a joint is to provide stability, the design will be different from a design that gives mobility, therefore, the design of a joint is determined by its function and the nature of its components. Once a joint is constructed, the structure determines its function. In terms of design, joints that have only one function are less complex than those having multiple functions. Simple joints usually function for stability purposes, while complex joints function mostly for mobility, although the majority serve a dual purpose. JOINT CATEGORIES: Joints are basically classified into 2 categories: synarthroses (nonsynovial joints) and diarthroses (synovial joints). 1. Synarthroses: What connects these bony components is an interosseus connective tissue that is fibrous and cartilaginous. There are 3 types of fibrous joints: suture, gomphosis and syndesmosis. Suture joints (jnts) consist of the bones being united by a thin layer of dense fibrous tissue, as in the sutures of the head, which in adulthood form a synostosis with little or no motion. Gomphosis joints consist of a peg in a hole, like the teeth. Syndesmosis joints are formed by ligaments or aponeurotic membranes, like the distal tibio-fibular joint. Cartilaginous joints have either fibrocartilage or hyaline growth cartilage to unite bony components. There are 2 types of cartilaginous joints: symphyses and synchondroses. In the former, the fibrocartilage that joins the bones consists of disks or plates, like the symphysis pubis. The synchondrosis, like the first sternocostal joint, has hyaline growth cartilage and functions for stability while allowing a bit of mobility.

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2. Diarthoses: These are the synovial joints, in which the ends of the bony components can move freely as they are only indirectly connected via a capsule that encloses the joint. They are characterized by having a capsule made of fibrous tissue, they have a joint cavity, a synovial membrane to line the inside of the capsule, fluid and hyaline cartilage to cover the joint surfaces. They may also consist of disks, plates, labrums, menisci, fat pads, ligaments and tendons, the first few to prevent excessive compression, and the last 2 keep the surfaces together and assist in guiding motion. Joint separation is limited by passive tension in the ligs, capsule & tendons, & active tension is limited by ms. Subclassification of Synovial joints. There are 3 main categories: uni-, bi- & triaxial joints. 1) uniaxial means that motion occurs only in 1 plane around 1 axis usually located near the center of the joint and have 1 degree of freedom (D of F). There are 2 kinds of uniaxial joints: hinge and pivot or trochoid. Examples of hinge joints: IP joints in fingers, with motion only in the sagittal plane around a coronal axis. A trochoid joint has 1 component shaped like a ring and the other so that it can rotate in the ring. Ex: atlantoaxial joint, where the osteoligamentous ring is formed by the atlas & the transverse lig. with the dens rotating in it. Another example is the proximal radio ulnar joint (PRUJ). 2) biaxial diarthrodial joints move in 2 planes around 2 axes with 2 D of F. There are 2 types: condyloid and saddle. Condyloid joints consist of a concave surface sliding over a convex surface in 2 directions like the MCP, where flexion/extension occur in the sagittal plane around a coronal axis, and abd/adduction occur in the frontal plane around an A-P axis. A saddle joint is a joint in which each joint surface is both convex in 1 plane and concave in the other, like the carpometacarpal joint at the thumb. Here the distal end of the carpal bone attaches to the proximal end of the MCP. 3) triaxial or multiaxial joints can move in 3 planes around 3 axes with 3 D of F. Motions at these joints can happen in an oblique plane. There are 2 types: plane and ball-and-socket. Plane joints have motion between 2 or more bones, like the carpal joints. The adjacent surface can glide or rotate on 1 another in any plane. Ball-and-socket are convex and concave, having flex/ext, abd/add and rotation, like the hip, with flexion in the sagittal plane around a coronal axis, abd/add in the frontal plane around an A-P axis and rotation in the transverse plane around a longitudinal axis. Joint Axes: There are 3 axes: vertical, transverse or horizontal and anteriorposterior (A-P). They move as the joint position changes, usually in a curved path, and are rarely perpendicular to the long axes of bones, but mostly oblique, like the pinky in a fist. As the axes of motion change, they make a series of successive points forming an instantaneous axis of rotation.

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The transverse axis lies in the frontal plane and controls mov't of flex/ext in the sagittal plane. The A-P axis is in the sagittal plane and controls abd/add, which occur in the frontal plane. The vertical axis lies at an intersection between the sagittal and frontal planes and controls rotations. Basic joint shapes: Determine the type of motion that will occur. There are 2 general types of shapes: ovoid, where 1 surface is convex and the other concave; and sellar, where 1 is convex in 1 direction and concave in another, with the opposing surface concave and convex respectively (saddle joint). JOINT COMPONENTS. Joint capsule. It consists of 2 layers: the outer one is the stratum fibrosum and the inner, the stratum synovium. The outer one completely encircles the joint and attaches to the periosteum via Sharpey's fibers and by ligamentous and musculotendinous structures. It is poorly vascularized but highly innervated by joint receptors that detect the rate and direction of motion, compression, tension, vibration and pain. The inner layer of the capsule is highly vascularized and poorly innervated, being insensitive to pain but able to undergo vasodilation and constriction in response to heat or cold. It has specialized cells called synoviocytes that synthesize the hyaluronic acid of synovial fluid. This layer also produces matrix collagen and serves as an entry point for nutrients and exit for waste. The synovial membrane and the fluid of the bursae can be contiguous with the capsule.

Joint receptors The joint receptors transmit information about the joint to the CNS, which responds by coordinating ms activity for mobility and stability, protection, controlled motion and sense of joint position. For example, when the capsule is stretched, it may signal the CNS that normal limits of ROM have been reached, so the response is to inhibit the ms causing the motion and activating the antagonist. Joint receptors (sensory & motor) provide information to: protect the joint, determine balance between prime movers and synergistic and antagonist ms forces, proprioception or postural sensation, kinesthesia, acceleration, deceleration, pain and reflexes. They respond to mechanical tissue deformation and to chemical irritation (histamine release if it is in joint). There are 4 types: 1. Postural mechanoreceptor: contributes to joint position, pressure, postural muscle tone, motion sense, speed and direction of motion.

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2. Dynamic: gives info on acceleration and deceleration, increases muscle tone and relaxation and can inhibit pain. 3. Inhibitive: gives info on direction of motion, inhibits tone and responds to stretch. They are like GTO's. 4. Nociceptive: not active during normal functions, but produces tonic contractions if mechanically or chemically stimulated. Example: in ankle PF, the anterior capsule is stretched, and it responds to mechanical deformation, so types 1 and 2 receptors on the DF side fire to stop excessive motion, and thus inhibit PF to protect the joint from a sprain. This is clinically relevant, as one can selectively stimulate type 1 & 2 with oscillations during joint mobilization (mobs) or inhibit spasm using stretch articulation. Grade I & II oscillations are for type 1 & 2, and Grade III & IV stretch articulations are for type 3 joint receptors. Synovial fluid. It is similar to plasma but it contains hyaluronic acid (HA) and lubricin, which is a glycoprotein. The HA is in charge of the viscosity of the fluid and the lubrication of the synovium. It reduces friction between the synovial folds of the capsule and the joint surfaces. Lubricin is responsible for cartilage lubrication. The coefficient of friction in human joints is one of the lowest known to man. It provides nourishment to the cartilage, and it is clear pale yellow and found in all synovial joints in small quantities (except when there is an injury or disease). This fluid can resist loads that produce shear, and it is thixotropic, which means that its viscosity varies with joint velocity or rate of shear; when a joint moves fast, viscosity decreases, as it does with high temperatures. Lubrication. Human joints are lubricated by at least 2 or more methods, and maybe at the same time, but it is not known for sure. The purpose of the lubrication is primarily to keep the articular surfaces apart and for nutrition. The basic types are boundary and fluid film lubrication. Bursae: They are flat sacs of synovial membrane, located where joint components work very closely, i.e., tendon and bone, bone on skin, ms on bone, and ligs and bone. There function is to protect the joints. Extremity Ligaments and tendons. These structures help control motion at the joints. They are made largely of collagen, whose mechanical stability gives them strength and flexibility. Because their fibers are parallel, they can withstand uniaxial loads well. They are surrounded by connective tissue forming full or partial sheaths. If around a tendon, the sheath is a paratenon, and it protects it, enhancing its mov't. If subjected to high friction, they also have an epitenon, which is a synovial layer located beneath the paratenon and produces synovial fluid to decrease friction. Sheaths in ligs. have no name.

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Cartilage. It functions to distribute joint loads over a wide area to decrease stresses. It is formed by extracellular matrix and by cells (primarily chondrocytes) and type II collagen. Cartilage is divided into 2 types: fibrocartilage and hyaline cartilage. Fibrocartilage can be white or yellow, the latter also called elastic cartilage, which is found in ears and the epiglotis, and contains more elastin. White cartilage permits little motion & forms disks. Hyaline cartilage forms a thin coat on the ends of most bones in the adult (except the TMJ); it is smooth, resilient, having a low friction surface and located on diarthrodial joints that bear and distribute weight. There are several layers of hyaline cartilage based on cellular arrangement: a) the outermost layer or zone 1 is on the surface & functions to lower friction. b) the 2nd layer or zone 2, called the transitional stratum, permits deformation and absorbs the forces placed on the joint. c) the 3rd layer or zone 3 is called the radiate or radial stratum, and has a more vertically oriented fiber arrangement. d) the tidemark zone is the interface between the calcified and uncalcified cartilage, and is important for growth, healing and aging. e) zone 4 is the calcified cartilage, between the tidemark and subchondral bone (after this, there is cancellous bone). When there is motion or compression at a joint, the fluid of the cartilage flows through the pores in the outermost layer, and after the forces stop, the fluid goes back into the cartilage. If, however, the forces are increased and sustained over time, permeability and fluid flow decreases. Because hyaline cartilage is avascular and aneural in adults, its nutrition comes from this flow of fluid, and if decreased, degeneration of the cartilage may be initiated, which can also occur with prolonged immobilization. This degeneration goes through the layers of cartilage with no pain, so if pain is felt from this, it means the damage has reached subchondral bone. Joint wear: There are 2 types of joint wear: 1. Interfacial wear takes place when the surface come in contact with no lubricant, and can happen because of adhesion or abrasion (soft material scraped by a harder one). Once the cartilage surface has defects, fluid can leak, further increasing direct contact between the surfaces. 2. Fatigue wear results from accumulation of microscopic damage due to repetitive stressing: high loads over a short period or low load over an extended time. This occurs also because there is no time for the cartilage (or tendons for that matter), to recover their original shape before they are placed under further loads, so these structures are subjected to repeated loads while they are still deforming.

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Bone. It is the hardest of all connective tissue. It receives nutrition from blood supplies located within the bone itself. Its cells consist of fibroblasts, fibrocytes, osteoblasts, osteoclasts, osteocytes and osteoprogenitor cells. The first 2 are important for production of collagen; osteoblasts lay down bone and osteoclasts resorb it. The ground substance, in addition to having GAG's, contains HA, calcium and phosphate crystals within the collagen fibrils giving it its solid consistency (inorganic component of bone). The innermost layer of the bone is the cancellous bone, forming thin plates called trabeculae, which are laid down in response to stress, and helps maintain the bones shape. The cancellous bone is covered by cortical bone, which in turn is covered by periosteum, which is composed of osteoblasts for growth and repair. It is well vascularized and innervated. At the ends of the bones, the periosteum is replaced by hyaline cartilage. Bone remodels in response to loads, causing osteoblast activity to increase, with a resultant increase in bone mass. With no external forces, osteoclasts are activated and begin resorbing the bone, so bone mass decreases. If osteoclasts absorb faster than osteoblasts remodel, there is osteoporosis. OSTEOKINEMATICS (OK): This refers to motion of bones, and is a physiologic mov't, which means that they are done voluntarily. The extent of the ROM is determined by the shape of the joint, the joint capsule, ligs, ms bulk and the surrounding musculotendinous and bony structures. MacConaill and Basmajian classify bone mov't into 2: spin, which is rotation around an axis, and is not accompanied by any other motion; and swing, which is any motion other than a spin. O.K. motion is measured in degrees. ARTHROKINEMATICS (AK): This refers to motion of joint surfaces. Usually, 1 of the surfaces is more stable than the other 1 & serves as a base for the motion, while the other surface moves on this relatively fixed base. These motions are called accessory joint motions: roll, slide or glide and spin. For them to occur, there must be adequate joint play. They are necessary for normal ROM but can't be performed voluntarily. Ex: holding a door knob causes rotation at the MCP joints, which does not occur with flexion or abduction, or an inferior glide, which is a joint play mov't at the GHJ. Sliding or gliding is a translatory mov't, with 1 segment gliding on the other. *The surfaces must be congruent, either flat or curved. *The same point on 1 surface is in contact with new points on the opposing surface. *Pure gliding does not occur in joints, since the surfaces are not completely congruent. *The direction depends on whether the moving surface is convex or concave. Roll is 1 bone rolling on another, like a tire on the street. *The surfaces are incongruent *New points on 1 surface come in contact with new points on the other.

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*It results in angular motion of the bone. *It is always in the same direction as the bone motion (convex or concave). *Pure rolling does not occur alone, but in combination with sliding & spinning. Spin is 1 bone spinning on another. The bone moves but the axis stays the same. Examples: shoulder and hip flex/ext. *It has rotation of 1 segment around a fixed axis. *The same point on the moving surf creates an arc as the bone spins. *It rarely occurs alone, but in combination with rolling & sliding. Roll-sliding is a combination and happens at most synovial joints. If not there may be a dislocation or impingement. *The more congruent the surface, the more sliding. *The more incongruent the surface, the more rolling. *For mobs, the gliding component is used to restore joint play, because rolling increases joint compression. Traction is another type of accessory joint motion and is the separation of joint surfaces. If the traction is applied to the long shaft of the bone, like the humerus, it results in gliding. Distraction requires a pull at right angles. CONCAVE-CONVEX RULE: This is the basis for determining the direction of the mobilization force when performing joint mobilization techniques. *Gliding is in the opposite direction of the movement of the bone if the moving surface is convex. *Gliding is in the same direction if the angular movement of the bone of the moving surface is concave. There are 2 ways to figure out the direction in which joint gliding is decreased: direct or indirect method. Direct: perform glide in the direction it is decreased. Indirect: use the concave-convex rule. Ex: a convex humerus gliding down (AK), results in an upward OK motion: an inferior glide will give increased shoulder abduction. Joint mob is a general term applied to any active or passive attempt to in-crease motion. It includes specific passive mobs. to restore component motions. Joint Positions: Close-packed positions (CPP) refer to a point of congruency whereby the maximum area of surface contact occurs, the ligament attachments are the farthest apart and taut, the capsule is taut and the joint is compressed. Loose-packed (LPP) or open packed means that everything in the joint is slack, there is the least amount of congruency, allowing motion to occur. In general, most fractures & dislocations happen in a CPP, while most lig sprains, in the LPP. AK motion must exist for OK motion to take place and vice versa. For ex., if IP joint flex is limited, the normal downward motion of the phalanx into a position of flexion cannot occur. If forced, 1 area of the joint is compressed, and the other overstretched, causing damage. This can occur with passive stretching because the

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use of a lever magnifies the force at the joint, which causes increased compression in the direction of the rolling bone, and a roll without a glide does not replicate normal joint mechanics. For this reason, joint mob techniques are used before passive stretching in PT in order to apply the force close to the joint, control the direction of the force and replicate normal motion with forces selective to the tissues. AK motion or amplitude is graded according to Maitland from grade I to V. From I to IV they are oscillation techniques, which are passive rhythmic oscillations. Gr V is a manipulation that is high velocity, low amplitude passive thrust. Kaltenborn has 3 grades for gliding and for distraction, and these are stretch articulations. End feel: This is the sensation the PT feels in the joint as it reaches the end of ROM of each passive movement. When normal, it can be soft, firm or hard. Manual Traction (or glide) (Kaltenborn): Grade I: unweight. Used for pain. Slowly distract the joint surface & slowly release to starting position. Used with all techniques and tests. Very little motion. Grade II: take up the slack. Used also for pain. Slow, larger amplitude mov't perpendicular to joint surfaces. The joint tightens. Grade III: stretch. Used for pain and extensibility. Slow, even larger amplitude mov't stretching the tissue crossing the joint. Gliding Mobs: It has 2 systems: stretch articulation technique (Kaltenborn) and graded oscillations (Maitland). Gr 1: Used for pain and inflammation. Slow small amplitude oscillation parallel to the joint surface at the beginning of the range. Do 2 to 3 per second. Gr II: For pain also. Slow, large amp. oscill. within free range (no resistance). Gr III: slow, large amp oscill from the middle to the end of the range, through to the 1st tissue stop. Used for maintaining mobility. None go beyond pain. Gr IV: For mobility. Slow, small amp oscill. to the limit of the range. Gr V: fast, sm amp high velocity thrust, non-oscillatory, beyond pathological limit of range. Used in the absence of pain, when resistance limits motion. MOBILIZATION RULES 1. every structure is relaxed and in LPP 2. don't move into or through pain 3. evaluate as you treat 4. one hand stabilizes, the other moves 5. compare to the other side 6. do 1 motion at a time, with Gr1 distraction first INDICATIONS: 1. joint restriction from capsuloligamentous tightness and adherence

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2. pain 3. testing 4. spasm CONTRAINDICATIONS: Absolute: 1. undiagnosed lesions 2. ankylosis block 3. CPP Pagets, In the spine: 4. malignancy / cauda equina lesion 5. prolonged steroid use fx 6. down's syndrome 7. vertebrobasilar insufficiency in neck 8. acute inflamm and infective arthritis

Relative: 1. joint effusion 2. acute DJD or bony 3. metabolic bone dz: osteoporosis, TB, poor coagulation 4. internal derrangement 5. hypermobility/unhealed 6. kids under 2 / elderly weak CT 7. total joint replacements 8. Spine: pregnancy, spinal cord involvement, spondylolisthesis.

MOTION TESTING: 0= ankylosis 1= considerable decrease in motion extensibility 2= slight decrease 3= normal 4= slight increase in motion 5= considerable increase in motion 6= complete instability

EFFECTS: increase nutrition maintain increase proprioception inhibit nociceptors

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THE SHOULDER COMPLEX The shoulder (shld) complex is composed of the scapula, clavicle, humerus and their joints. It is connected to the axial skeleton by a single joint: SCJ. The arrangement of the upper extremity (UE) and the trunk allows increased mobility at the hand, while diminishing stability. This leads to the need for dynamic stability, which occurs when a segment is more dependent on ms than on joint structures to keep its integrity. COMPONENTS OF THE SHLD COMPLEX: There are several joints, some functional and some anatomical. The scapulothoracic joint (STJ) and the suprahumeral joint are functional. The latter is formed by the coracoacromial arch and the head of the humerus. Kapandji considers the subdeltoid area a joint, and consists of the HOH & cuff ms, but this will not be considered here. Anatomical joints are the GHJ, ACJ, & SCJ. GLENOHUMARAL JOINT (GHJ). This is a ball-and-socket synovial joint with 3 D of F formed by the large head of the humerus (HOH) and a small glenoid fossa. It is an incongruent joint as the HOH is convex and not parallel to the concave fossa. It sacrifices stability for mobility and thus is susceptible to degeneration and derangement. Its orientation varies, but in general, it tilts slightly inferiorly. The HOH forms 1/3 to 1/2 a sphere, and faces medially, superiorly and posteriorly. The angle formed between the head and the shaft, or angle of inclination is 135 in the frontal plane in an adult. In the transverse plane, the angle formed between the shaft and the epicondyles is 30 posteriorly and is the angle of torsion. The loose packed position (LPP) of the GHJ is 30 of flexion and 55 of abduction. The CPP is abd and ER. Glenoid labrum: It is a fibrocartilage whose main function is to deepen the fossa to receive the HOH. It surrounds and attaches to the periphery of the fossa and is contiguous to the capsule. The labrum doubles the AP depth of the GHJ; it reduces resistance to translation, it increases the surface contact area for the HOH, and it serves as an attachment to the GH ligs. GHJ Ligs and capsule: The capsule is twice as big as the HOH and can permit up to 1" of distraction. This laxity is needed for there to be increased motion; the ligs and ms enhance stability, especially anteriorly. The 3 GH ligs are superior, inferior and middle. They 3 form a "Z" on the anterior capsule. All portions become taut with external rotation (ER) and anterior glides (AG). The inferior GH lig. has 3 parts, and is termed inferior GH ligamentous complex. The coracohumeral lig blends with the superior capsule and the supraspinatus tendon to insert on the greater turbercle, checking ER and

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supporting the limb against gravity. Its 2 bands form a tunnel through which the LHB travels. Rotator interval capsule: is a connection between the superior GHJ lig, superior capsule and coracohumeral lig. It functions to bridge the gap over the HOH between the subscapularis and supraspinatus tendons & avoid inferior translation & posterior dislocation. It is taut with the arm at the side. It limits flexion, ext., add and ER. Bursae: There are several, but the most important are the subacromial & subdeltoid, collectively known as subacromial. They function to separate the supraspinatus & the HOH from the acromion, coracoid process, deltoid, and coracoacromial lig. They allow a smooth glide between HOH & supraspinatus. Coracoacromial arch (CA arch): The structures overlying the subacromial bursa, the acromion and the coracoacromial lig, constitute the CA arch. This forms an osteoligamentous vault that protects the area from superior dislocations, but at the same time can contribute to impingement problems. Motions: These will be considered as pure GHJ mov'ts with the scapula stabilized. *Rotation occurs in the horizontal plane around a longitudinal axis. It is isolated from elbow supination and pronation by flexion of the elbow to 90. The amount of rotation changes with elevation. About 180 of total rotation are available in abduction and only 90 when the arm is fully elevated due to taut ligs. Arthrokinematically, rotation cannot occur as a pure spin because the joint is incongruent, so there is a combined rolling and gliding opposite to the mov't of the shaft of the humerus: abduction for example causes the HOH to glide inferiorly while it rolls up the fossa. Normally, the HOH does not impact against the acromial arch. With the arm at the side, IR decreases due to the lesser tuberosity impacting on the anterior fossa, and ER decreases due to the greater tuberosity impacting on the acromion. *Flexion in the sagittal plane around a tranverse axis only provides 90, because the inferior GH lig becomes taut and limits further motion. *Hyperextension allows approx 45. *Horizontal abduction and adduction, starts at 90 of abduction. *Abduction happens in the frontal plane around a horizontal axis, and its range depends on the degree of rotation present at the time; if the joint is in full IR, active abduction is limited to 60, because the greater turbercle strikes the acromion and the acromioclavicular lig. With 90 of ER the greater turbercle goes behind and under the acromion and so active abduction increases to 90 and then becomes limited by active insufficiency of the deltoid. Passively, it can go to 120 and then becomes limited by the inferior GH lig. Scapulothoracic rhythm: It has 3 purposes: 1) to distribute the motion between joints to increase ROM with less problems of stability, 2) to keep the glenoid fossa

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in a good position to receive the HOH (to increase joint congruency and decrease shear forces), and 3) to allow the ms that act at the humerus to keep a good length-tension relationship to minimize active insufficiency of GH ms. Its contribution to increased elevation is done by upwardly rotating the fossa 60 from its resting position. The GHJ produces 120 to add to the maximum of 180 of elevation. The ratio is thus 2 degrees of GHJ motion to 1 of ST motion. The ST rhythm not only involves the GH and STJ, but also the AC and especially the SCJ, because the complex is part of a closed kinematic chain. An example of this is the 60 of upward rotation of the scapula, which is due to SC and AC motions caused by the force couple of the traps and serratus anterior. These are the only ms that do upward rotation. So, raising the arm to the horizontal plane involves 60 of GHJ motion and 30 of ST motion, with scapular motion produced at the SCJ by clavicular elevation. Lifting the arm beyond 90 requires an additional 60 of GH motion and 30 of scapular motion produced by clavicular rotation and AC motion. This sequence of mov't is part of the ST rhythm, and takes place regardless of planes of motion. Muscles: They function to move the humerus, for gliding and to keep apposition of the surfaces. In a relaxed, unloaded position, however, the ms are electrically silent, and so the stability of the joint is afforded by the superior joint capsule, the coraco-humeral lig and the tendon of the supraspinatus, which are all taut with the arm at the side. If the arm is loaded, the supraspinatus and the posterior deltoid assist with the stability of the joint. Without the supraspinatus, the capsule and the ligs would creep resulting in GHJ subluxation, which is common in persons who have had a stroke. *Deltoid. Its force causes the HOH to translate superiorly. Its anterior fibers do flexion, the mid fibers abduction and posterior fibers extension. Abduction is assisted by the supraspinatus. The deltoids form part of a force couple. *Rotator cuff. It is comprised of the SITS ms. and form a musculotendinous cuff because they blend in and reinforce the capsule. Their rotatory force causes some rotation and compression of the HOH into the glenoid. The teres minor and infraspinatus contribute to abduction by providing ER to prevent the greater turbercle from impacting the acromion. These 2 ms along with the deltoid and subscapularis form a force couple and create spinning of the HOH. The supraspinatus has a rotatory component that causes strong compressive forces for abduction and stabilization with the help of gravity. Gravity acts as a stabilizing synergist to this ms. causing an IG allowing full articulation and preventing superior displacement. The subscapularis offsets anterior dislocating forces by steering the HOH posteriorly, so it gives anterior stability, while the infraspinatus and teres minor give posterior stability. The function of the supraspinatus in particular, is to abduct, compress, stabilize the dependent arm and vertically steer the HOH. Its force decreases with elevation, but it can still produce full abduction.

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The supraspinatus tendon is poorly vascularized; its location by the HOH is thus called the critical zone, as this is accompanied by pressure from the bursae on top, leading to further degeneration, especially with prolonged overhead positions and due to its role in sustaining the arm in the dependent position. This ms is either almost always contracting or passively tensed in most positions. Cuff lesions usually cause pain with motion between 60 & 120 of elevation, a painful arc. *The teres major acts in most pulling actions. It performs IR, adduction and ext. *The lats do the same with addition of scapular depression, pelvic elevation and trunk side-bending. If acting bilaterally, they can help with trunk ext., and may act as an accessory ms. to respiration. They contribute to actions like rowing, swimming, pushing on parallel bars and climbing. Its shortness prevents full shld flexion along with the teres major. *The pectoralis major adducts and IR the humerus, and in crutch walking, it helps to support the body along with the lats. Its shortness contributes to rounded shlds. The pect minor helps in depressing the scap. and rotating it downward. *The upper fibers of the trapezius perform elevation, upward rotation of the scap & extension, side-bending (SB), and contralateral rotation of the neck. The mid fibers perform scapular adduction, and slight upward rotation, the lower fibers do scapular upward rotation, adduction and depression. *Rhomboids: they act in downward rotation, adduction and scapular elevation. *Serratus anterior abducts the scapula, does upward rotation and holds the medial border of the scapula on the thorax. Its lower fibers can depress the scapula and the upper ones can elevate it. It plays a key role in push-ups. If weak, there is winging. *Levator: performs downward rotation and elevation of the scapula. When fixed, it assists unilaterally in SB and rotation (ipsilateral), and bilaterally it checks neck flexion. *Biceps. Because of its location, it can be considered a reinforcement to the cuff. If the humerus is in ER, it can help with abduction & is also a shld flexor. *Triceps: its long head helps with add and ext of the shld. Upper extremity muscle function. It is difficult to classify the shld complex ms into prime movers except for specific motions, as ms have multiple functions due to the number of joints they cross and because of their large ROM. The majority contract during any motion of the UE. For example, elevating the arm can use up to 11 ms. Also, the traps and the serratus anterior function as synergists with upward rotation, but as antagonists with retraction and protraction. The upper and lower portions of the traps function synchronously in upward rotation but are antagonists in elevation and depression. Reaching overhead which entails flex-abd-upward rot, requires concentric contraction of the anterior delt, pect major, coracobrachialis, biceps, the cuff ms,

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the traps and the serratus anterior. Bringing the arm back down is an antagonistic motion, but not performed by the antagonists, but by eccentric contractions of the same ms to lower the arm. Putting ones hand behind the neck, for example, requires mov't of the elbow flexors, SCJ elevation and upward rotation, scapular elevation, upward rotation, scapular abduction, shld abduction and ER. Pulling oneself up as with a trapeze in bed, pulling down on a pulley or a window entails elbow flexion, SC depression and derotation, scapular adduction, downward rotation, depression, shld adduction, extension and rotation. In pushing on crutches or parallel bars, the muscles used are: triceps, pect major and minor, lats, teres major, posterior delt, lower traps and rhomboids. Dynamic Stability of the GHJ is provided by the forces of the prime movers, gravity, compressors and steerers, passive capsuloligamentous forces, friction and ground reaction forces (GRF) and by the articular configuration. SCAPULOTHORACIC "JOINT". It is not a true anatomic joint because it lacks cartilaginous, fibrous and synovial tissue, but it is considered a functional joint. Its motions are associated with motions of the AC and SC joints because the scapula is attached to the clavicle by the ACJ, and the clavicle is attached to the sternum by the SCJ. So, any motion by 1 results in motion of 1 or both joints, thus, it is part of a closed kinetic chain. Each of these joints contribute to the production of motion in a coordinated and concomitant pattern, or scapulothoracic rhythm. Motions: Movements of the STJ include elevation & depression, abduction and adduction or protraction & retraction, and upward & downward rotations. Elevation and depression and abduction and adduction are translatory mov'ts, while up & downward rotations are rotatory, and tilt the glenoid fossa up or down. The scapula also wings and tips, motions not always evident, but are necessary to keep contact with the thorax. The AC & SC prevent pure motion to take place at the SCJ, so elevation can come with abduction and upward rotation. Stability: The primary force responsible for the stability of the SCJ, is atmospheric pressure. The joints primary function is to orient the glenoid for arm/hand function, to add range of elevation to the arm, and to provide stability for GHJ motion. STERNOCLAVICULAR JOINT. It is the only structural attachment of the scapula to the rest of the body. Motion at the clavicle causes motion at the scapula. It is a plane synovial joint with 3 D of F; it has a capsule, 3 primary ligs and a disk. Its articulating surfaces are sellar; one is at the sternal end of the clavicle and the other is at the notch formed by the manubruim of the sternum and first costal cartilage.

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The sternal end of the clavicle and the manubrium are incongruent and so the superior part of the clavicle does not touch the manubruim at all, but it attaches to the disk and the interclavicular lig. It's a very stable joint and gives little dysfunction or pain. Motions: They consist of elevation & depression, protraction & retraction, and rotation of the clavicle. Rolling of the entire clavicle occurs with the reference point being the lateral end of the clavicle. *Elevation & depression take place between the convex clavicular surface and a concave surface at the manubruim and first costal cartilage around an AP axis. The convex surface of the clavicle has to glide on the concave manubruim and first costal cartilage. Elevation = 45 Depression = 15. These are associated with scapular elevation and depression and upward and downward rotation. *Protraction & retraction occur around a vertical axis. The joint is sellar, but its configuration changes: the medial end of the clavicle is now concave, and the manubrial side is convex. Protraction comes with anterior glide of the medial clavicle on the manubrium and first costal cartilage, ranging 15 each. *Rotation occurs as a spin between the saddle-shaped surface of the clavicle and the manubriocostal facet in only one direction: it rotates posteriorly from neutral bringing the inferior surface of the clavicle anteriorly, and from here it can rotate anteriorly back to neutral on a longitudinal axis with 30-45. SCJ Disk: This meniscus is found between the articular surface, attached to the superior clavicle and the lower part of the manubriocostal area, dividing the joint in 2 cavities: in elevation and depression, the medial clavicle pivots on the upper part of the disk, and in protraction & retraction, the clavicle and disk pivot around the inferior attachment of the disk, which acts like a hinge. So the disk is part of the manubrium in elevation and part of the clavicle in protraction. It also provides stability by improving joint congruence and by absorbing forces. SCJ ligs: There are 4 main ones: the anterior, posterior SC, costoclavicular and interclavicular ligaments. The first 2 reinforce the capsule and check anterior and posterior motion of the head of the clavicle. The costoclavicular lig checks clavicular elevation and superior glides of the clavicle. The interclavicular lig checks depression and downward glides of the clavicle to protect the brachial plexus and subclavian artery that go by the clavicle and the first rib below it. ACROMIOCLAVICULAR JOINT: It is also a plane synovial joint with 3 of freedom, having a disk, a capsule and 2 major ligs. It functions to keep a good relationship between the clavicle and the scapula, and to allow the scapula additional motion

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on the thorax in the later stages of elevation. This joint has a small convex facet on the lateral end of the clavicle and a small concave facet on the acromion of the scapula. It is usually incongruent and varies a lot, having 3 basic types according to the shape. In general, the more vertically oriented the joint is, the more unstable and prone to degenerative changes. Motions: There is little motion at the ACJ, which comprises scapular rotation, winging and tipping. The total range of clavicular elevation at the ACJ = 20. Some authors refer to ACJ motion as anterior/posterior tipping and medial/lateral rotation, the latter meaning winging *Rotation is the primary motion, which happens around an AP axis; it allows the glenoid to tip up (upward rotation) or down. *Winging occurs around a vertical axis. There is a posterior mov't of the vertebral border of the scapula or an anterior motion at the glenoid fossa that occurs to keep contact of the scapula on the thorax as it goes into abduction and adduction. *Tipping: This happens when the inferior angle of the scapula moves posteriorly while the superior border moves anteriorly around a coronal axis to maintain contact of the scapula with the contour of the thorax. It can be seen in elevation and rotation. ACJ Ligs: Because the capsule is weak, it needs reinforcement from the ligaments. The superior and inferior AC ligs help control horizontal stability; the coracoclavicular ligament unites the clavicle and the scapula and helps stabilize it. This ligament is divided into 2 by a bursa and adipose tissue: trapezoid, which is the lateral part, and conoid, which is the medial part. They are important for the prevention of superior dislocation of the clavicle on the acromion, and they limit rotation of the scapula as they are mostly vertically oriented. Some authors also describe an AC disk, which is fibrocartilaginous, and can be absent in some people.

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THE ELBOW COMPLEX The elbow is a structurally stable joint, which comes from its bony configuration and its ligs. This complex consists of 3 articulations within one capsule: radiohumeral (RHJ), ulnohumeral (UHJ) (which allow flexion and extension), and the proximal radioulnar joint (PRUJ) (which allows pronosupination). Alone they have 1 D of F, and if combined, they provide 2 degrees of freedom. The elbow complex is designed to serve the hand by the apparent shortening and lengthening of the upper extremity, and it also provides stability for skilled mov't like in the use of tools. Many of its ms act also at the shld & wrist. The elbow is a uniaxial hinge or ginglymus type joint with 1 degree of freedom. CARRYING ANGLE: The axis for flexion and extension is not completely perpendicular to the shaft of the humerus as the troclea extends further down than the capitelum, so when the elbow is extended and the forearm supinated, the forearm deviates laterally in relation to the humerus, forming the cubital or carrying angle. It varies and is usually more pronounced in females (10-15). Its postulated purpose is to keep objects we carry away from the body. Normally, this angle disappears when the forearm is pronated with the elbow in extension, and in full flexion. ULNOHUMERAL AND RADIOHUMERAL JOINTS. The articulation between the ulna and humerus allows a gliding motion of the ulna on the troclea. The articulation between the radial head and the capitelum (radiohumeral) involves gliding of the concave radial head over the convex capitelum. In full extension, there is no contact between the articulating surfaces as there is in flexion. (The axis of motion for the UH and RHJ goes through the centers of the troclea and the capitelum). The LPP of the UHJ is 70 of flexion and 10 of supination; for the RUJ it is 70 and 35 and for the RHJ it is full extension and 90 supination. Capsule and ligaments. There is one capsule for all 3 joints: UH, RH and RUJ. It is large, loose and weak anteriorly and posteriorly, but its sides are reinforced by the collaterals, which are found in most hinge joints of the body. They provide medial & lateral (med & lat) stability & keep the joint surfaces in apposition. The anterior part of the capsule gives the majority of resistance to anterior displacement of the humerus. The MCL or medial, ulnar collateral ligament consists of the anterior, posterior and oblique fibers. The anterior portion is the elbows primary stabilizer to valgus

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stress from 20 to 120 of flexion. The carrying angle increases if this lig. is lax. The posterior portion does not stabilize as much as the anterior, but helps limit extension. The oblique fibers assists in stability & keep the joint surfaces together. They are mostly taut in full extension. The MCL is stronger than the LCL, which gives stability against varus, & resistance to distraction. The arcuate ligament, from the olecranon to the medial epicondyle, becomes taut at 90 and makes a fibrous canal for the ulnar nerve. Motion. The elbow has one of the most variable joint ranges as its motion depends on the position of the forearm and shld, and on whether the mov't is active or passive and if the individual is obese or muscular. Active flexion is usually less than passive motion because the bulk of the biceps interferes with the approximation of the forearm to the humerus. Active flexion with supination is ~ 135 to 145 and passively its 150 to 160. When the forearm is in pronation or neutral, range is less than when in supination. Passive insufficiency occurs because of the ms that cross both the shld and elbow. Passive tension in the triceps may limit elbow flexion when the shld is simultaneously moved into full flexion. Passive tension can also be present in the long head of biceps during shld hyperextension and thus limit elbow extension. RADIOULNAR JOINT. The articulation between the radius and the ulna is such that in supination the bones are parallel, and in pronation the radius crosses over the ulna. (The ulna moves little during pronosupination). The proximal & distal RUJs are mechanically linked so motion at 1 comes with motion at the other and they form a uniaxial joint. * The distal RUJ is concave at the radius, so that the radius can pivot around the head of the ulna. It includes the triangular fibrocartilaginous complex (TFCC) that serves as a cushion and stabilizer. This joint is also functionally linked to the wrist, and follows mov't at the radius so that the palm turns up or down, allowing only pronosupination. Stability is given by the pronator teres and quadratus and the ECU tendon, the interosseous membrane, dorsal and palmar radioulnar ligaments and the TFCC. * The proximal RUJ is a pivot joint with a fibrous annular ligament forming a ring around the head of the radius allowing it to rotate within this ring, whose inner wall is covered by cartilage. There are 3 ligs at the proximal RUJ: annular, quadrate and oblique cord. The annular ligament prevents anterior dislocation at 90. The quadrate lig helps to maintain apposition between the radial head and the radial notch, reinforces the inferior aspect of the capsule and limits the spin of the radial head in pronosupination. The oblique cord helps keep the radius and ulna together.

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There is also an interosseous membrane between the 2 bones and it is a collagenous sheet providing stability for both RUJs and transmission of forces from the hand and distal radius to the ulna. Some call it the mid RUJ, as it is like a syndesmosis. These fibers are taut when the forearm is in neutral, and slack in pronosupination. Motion. Pronation and supination are essential for hand control and orientation. They are assessed with the elbow at 90 of flexion so as to stabilize the humerus and avoid shld rotations. When the elbow is fully extended, active pronosupination occurs at the same time as shld rotation. Pronation is limited by bony approximation of the radius and ulna and by the dorsal RU ligament (taut in pronation) and the palmar RU lig, taut in supination. Supination is also limited by passive tension of the ligs. MUSCLES. Their role is determined by the location of the ms, the position of the joints, the magnitude of the load and the speed and type of contraction. There are 3 primary flexors: brachialis, biceps, brachioradialis. *The brachialis or workhorse, is inserted close to the axis and has its greatest moment arm at 100, so its ability to produce torque is best at that position, because its ms pull is perpendicular to the lever arm. The brachialis works in flexion in all positions of the forearm and is active in all types of contractions and speeds, and is not affected by the position of the shld. The brachialis is one of the rare muscles with a single function. *The biceps brachii is considered the eating muscle and is the main flexor. It has its best moment arm at 90 where it develops the greatest torque. Its moment arm decreases if in full flexion or extension. It is active in flexion when the forearm is supinated or in neutral, during a concentric or eccentric contraction but NOT when the forearm is pronated. With increased magnitude, it is active in all positions of the forearm and in quick eccentric extension, and is best suited to use a screwdriver. It is actively insufficient when there is full flexion of elbow and shld. It acts best as a supinator when the elbow is at 90; as extension increases, it is less effective. With its insertion fixed, it flexes the elbow moving the humerus to the forearm, as in a chin-up. *The brachioradialis is inserted at a distance from the axis. When contracting, most of its force is directed toward compression, and thus can serve as a stabilizer. It shows no electrical activity during eccentric flexion when done slowly and in supination or slowly concentrically. But, if the speed increases it shows moderate activity if a load is applied and the forearm is in neutral or full pronation. It is not affected by any shld position. It can supinate in extreme pronation and visa versa.

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There are 2 primary elbow extensors: triceps and anconeus. *Triceps. The long head of the triceps crosses 2 joints and becomes actively insufficient with full elbow extension with the shld in hyperextension as the ms is shortened over the shld and elbow at the same time. The medial and lateral heads are not affected by any position of the shld. The maximum torque the triceps can produce is at 90 of flexion. The ms is active in activities needing stabilization and in flexion and extension during closed kinematic chain actions, such as in a push-up. It can be active with gravity assistance with increased resistance or speed. It acts as a synergist to prevent flexion when the biceps acts as a supinator. *The anconeus assists in extension and stabilizes during pronosupination and varus. * The principal ms that do supination are the biceps and the supinator (unwinds the bone), while the abductor pollicis longus, extensor pollicis brevis and extensor indicis proprius aid in supination as they have poor leverage and are small. *The primary ms that do pronation are the teres and the quadratus, (the flexor carpi radialis, palmaris longus and extensor carpi radialis longus, assist, with the last 3 having also poor leverage and small forces). Function: The pronators and supinators function by pulling the radius causing its shaft and distal end to turn over the ulna resulting in pronation or supination. Flexors and supinators are stronger than extensors and pronators. The number of ms involved in a certain task is determined by the effort needed; if there is a lot of resistance, more ms are recruited. When performing a fist or turning a screwdriver, at first and with light resistance, only the forearm flexors and extensors contract, but if the force increases, then the shld and trunk ms are recruited. The biceps and triceps may be antagonists, but they act as synergists when a forceful grip is needed. This is done to stabilize the elbow from being moved by a strong contraction of the wrist and finger flexor and extensor ms. During closed-chain motion of the elbow, the hand is fixed and the shld is moving. Examples of this are push-ups and pull-ups. During the latter, the elbow flexors raise and lower the body concentrically and eccentrically. In this scenario, the flexors are both flexing and extending, and the opposite happens with pushups, where the triceps extends the elbow concentrically to raise the body, and then, eccentrically, lowers it, thus flexing the elbow. The pectoralis major does not cross the elbow, but it is able to cause elbow extension in closed-chain motion as it adducts the shld. This is seen when the

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hand is on an object with the elbow flexed, and by contracting the pect major, the elbow extends. Functionally, a total of about 100 of elbow flexion and 100 of pronosupination are needed for eating, brushing and dressing. (50 pronation, 50 supination, -30 extension and 130 flexion). Although the elbow is not considered a weight bearing joint, it may be viewed as a load bearing joint; the joint reaction forces (JRF) that act on it increase dramatically when weights are applied, and especially when pushing. Supporting oneself with the arms while rising from a chair can produce 1700N of JRF on the medial aspect of the elbow, and 800N on the lateral aspect. Pulling a table generates 1900N (twice the body weight). The elbow is linked to the wrist due to multijoint muscles and because of the RU joints.

THE WRIST AND HAND The human hand is a delicate and complex system whose function depends on 27 bones, 30 joints, 33 ms, 3 nerves, an intricate vascular system and support structures. It is a sensory and prehensile organ that can grasp with forces exceeding 100# or control the tiniest objects. It is used for tool making, WB, pushing, striking, talking, walking, and touching, a function representing an extension of the brain. Its placement and stabilization depend on mov't of the

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trunk, shld, elbow and wrist; it can be placed on any area of the body except its own arm and forearm. Because the entire upper extremity is at the hands mercy, any loss of motion results in decreased hand function. Lost function at the wrist cannot be compensated by with motion at other joints. THE WRIST: It functions to control the length-tension relationship of the long flexors in the hand for fine adjustments; it transmits loads and serves as a stable base for different hand positions. The wrist is formed by the RCJ and midcarpal joints, having a total of 17 joints. It is biaxial with motions of flex/ext around a coronal axis, and radial and ulnar deviations around an AP axis. Its ROM are 85 of flex, 75 of ext, 20 of RD and 30 of UD. RADIOCARPAL JOINT: It is formed by the radius and the radioulnar disk proximally and by the scaphoid, lunate and triquetrium distally. The TFCC or triangular fibrocartilaginous complex (disk) is part of the RUJ and RCJ. It is like an extension of the radius. It prevents articulation of the lunate or triquetrum with the ulna, which is not considered part of the RCJ. The pisiform is part of the proximal row, but it does not function as part of the RCJ either. It functions as a sesamoid to increase the moment arm of the FCU, which is the only ms that attaches to any of the bones on the proximal row. The RCJ is enclosed by a strong, yet loose, capsule. The distal RCJ surface is somewhat incongruent, and produces more flexion than extension and more UD than RD. MIDCARPAL JOINT: It has 1 degree of freedom and is a hinge joint, but with less of the same motions the RCJ has. (Some consider it a condyloid joint with 2 degrees of freedom). It is formed by the proximal and distal carpal rows, being a functional more than an anatomical unit. It does not have its own capsule, as this is contiguous with each joint. The proximal row is the mobile unit. The distal row moves as a fixed unit. The scaphoid, which articulates with the trapezium, trapezoid and capitate, functions as part of the proximal row in some mov'ts, and as part of the distal in others. It is responsible for half of the motion of RD and for one third of UD, with the remaining motion taking place at the RCJ. The axes for these motions are at the head of the capitate. Of the 85 of flexion at the wrist, 35 occur at the midcarpal joint and 50 at the RCJ. For extension, 50 occur at the midcarpal, and 35 at the RCJ through the capitate. Wrist Ligaments: They give support to the RC and midcarpal joints and contribute to motion by application of passive forces. They provide stability, guidance and checking. Extrinsic ligs connect the radius, ulna or metacarpals to the carpal bones, and intrinsic ligs only run between the carpal bones. (Intrinsics are stronger than the extrinsics, but do not heal as well if injured).

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There are also MCL and LCL's, which articulate the 2 rows to each other and the radius and disk. The MCL is actually part of the TFCC. There are also numerous dorsal and volar ligs as well as retinacula to further afford support to the joint structures. The intercarpal ligs are important because they prevent diastesis or separation of the carpals, to which they attach. Wrist motion: *Wrist extension from a fully flexed position requires the distal carpal row to glide on the relatively fixed proximal row in the same direction as motion of the hand. When the wrist is in neutral, the ligs spanning the capitate and scaphoid draw together and as movement continues, they operate as one unit on a relatively fixed lunate and triquetrium. At 45 the scaphoid and lunate are closepacked uniting all the carpals to function as a single entity. Full extension then is completed in a close-packed position. *Flexion occurs in the reverse direction. Both motions depend on the varied ligamentous checks & locking of the joints. 60% of flexion is at the midcarpal row. *In RD the distal row moves radially on the proximal row until the rows are locked. The proximal row glides ulnarly. *UD occurs at the RCJ and midcarpal joint, with RCJ motion being more evident. UD and RD are greatest with the wrist in neutral. Muscles: Almost all the wrists ms are multiarticular, some crossing as many as 7 joints. The hand has several neurophysiologic synergies that are so strongly linked, that they cannot willfully be separated. For ex, when making a fist, the wrist extensors contract forcefully and cannot be inhibited. In flexion and extension of the wrist, the FCU & ECU are antagonists, but in UD they are synergists. When making a fist, wrist flexion is prevented by the stabilizing action of the extensors, and so the harder the fist grip, the stronger the extensor contraction, otherwise, the fist would be very weak. The same occurs when preventing the finger extensors from moving the wrist: the wrist flexors contract synergistically, keeping the wrist in neutral or flexing it. Wrist flexion accompanies finger extension, and wrist extension with finger flexion. Volar aspect: There are 6 flexors crossing this area. The FCR, FCU and FDS do mostly wrist flexion, while the FDP, FPL and PL flex the digits. The FCU also does UD and the FCR also does RD, but not as strongly because it is more centrally located on the wrist. Because the FCU passes over the pisiform, it increases the moment arm for the FCU for flexion and extension. The FDS, FDP and FPL are multijoint ms acting mostly as finger flexors. They can however, act at the wrist, but if they attempt to act over both at the same time, there will be active insufficient. They can all contribute to RD and UD.

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Dorsal aspect: The ECRL & ECRB are the main extensors. They oppose and stabilize wrist flexion with a fist. The ECRB is slightly more active. It is also active in grasping. The ECU extends and UD the wrist, and can be active in wrist flex & provides additional stability. Muscle stability is not needed so much on the radial side due to ligamentous & bony control. The ECU is less effective as a wrist extensor in pronation because the radius crossing on the ulna decreases its moment arm. The EDM and EI function with the ED, and can extend the wrist, although most of extension is done by the ED. The 3 extrinsic thumb ms that cross the wrist do not do much for wrist function; the APL & EPB can help with RD, but this detracts from its prime function at the thumb. THE HAND: It consists of the fingers, the CMC joints and the MCP joints (19 bones and joints). The closed-packed position of the CMCJs is in full flexion. CMC JOINTS: they are formed between the distal carpal row and the bases of the second though fifth metacarpals. They are plane synovial joints with 1 of freedom for flex/ext. The 5th CMC joint is a saddle joint with 2 of freedom for flex/ext and abd/adduction. The CMCJs are supported by the transverse and the longitudinal ligaments. The 2nd and 3rd CMCJ hardly move; the 4th moves little and the 5th is the most mobile, and it can flex and adduct at the same time. Function: The function of the CMCJ is to contribute to the hallow shape of the palm during ADLs. The palmar arch permits the hand to conform to different objects, enhancing stability and providing sensory feedback. The ligs. that maintain this arch are the flexor retinaculum and the intercarpal ligs. The consistent concavity of the palm, even when extended, is the carpal arch. This together with the retinaculum forms the carpal tunnel. This tunnel is a pathway and an area of protection for the long finger flexors and the median nerve. The concavity of the arch increases with the help of the FCU and the intrinsic hand ms. MCP JOINTS: These 4 joints are condyloid with 2 of freedom for flex/ext and abd/adduction. Their capsule is lax in extension, and they have a volar and 2 collateral ligs for stability. Volar plate: This is the volar lig. at the MCP joint that reinforces the capsule. It is a fibrocartilage that attaches to the base of the proximal phalanx and blends with the transverse metacarpal lig. It restricts hyperextension and prevents pinching of the long flexor tendons during flexion. Collateral ligs: These are slack in extension, although they provide stability throughout the MCP ROM.

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Motion: Flexion and extension ranges increase from a radial to an ulnar direction, with the index having 90 and the pinky 110. These 2 fingers have generally more motion than the ring or middle fingers. IPJOINTS: They are synovial joints with 1 of freedom for flex/ext. They have a volar plate, a capsule and 2 collaterals, which remain taut in all positions. The DIP has some passive hyperextension, while the PIP has almost none. The range for each IPJ increases ulnarly, with the index having more motion at the PIP than at the DIP. Their ranges are geared or angled toward the thumb to facilitate opposition. Finger muscles: There are 2 extrinsic flexor ms: FDS and FDP. Their function depends on the position of the wrist. If there is no counterbalancing extensor force (usually the ECRB), they will cause wrist flexion, which decreases the efficiency of the finger flexors. The FDS and FDP can loss tension ulnarly due to the increased MCP and IP ranges in the last 2 fingers. This is why heavy tools have a wide grip at the bottom. There are 5 annular ligaments and 3 cruciates providing a pulley system to prevent bowstringing. Function: The FDS & FDP function depends also on their gliding mechanism, which consists of a retinaculae, ligs, bursae and tendon sheaths that tether the tendons to the hand allowing their frictionless motion. The tendons would bowstring if it were not for the retinaculae and ligamentous support. The long flexor tendons of each digit also go through 3 fiberosseous tunnels or annular pulleys, further protecting the tendons. The FDS is more active than the FDP. The FDS can perform finger flexion independently, but only when flexion of the DIP is not needed. If simultaneous DIP & PIP flexion are required, the FDS acts as a reserve. The extrinsic finger extensors are the ED, EI, & EDM, which go under the extensor retinaculum, and are encased in their own tendon sheath, to prevent friction. Unlike the flexors, the extensors have no bursae or annular pulleys protecting them. The ED is the only ms able to extend the MCPJ of the fingers, and it is also a wrist extensor. The extensor mechanism consists of the extensor hood (extensor expansion), the ED, lumbricals and dorsal and volar interossei. The hood splits into 3 parts just proximal to the head of the proximal phalanx. It functions to prevent bowstringing and contributes to the proper function of the fingers. Coupled actions of the IPJ: 1. active extension of the PIP is normally accompanied by extension of the DIP.

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2. active or passive flexion of the DIP is normally accompanied by flexion of the PIP. 3. full flexion of the PIP prevents the DIP from being actively extended. Intrinsic finger ms: These are the dorsal and volar or palmar interossei and the lumbricals. The first 2 produce MCP abd and adduction and flexion, which vary with MCPJ position. The MCP needs to be extended for abduction and adduction. When the MCP is flexed, the tight collaterals restrict the motion. In addition, the shape of the condyles of the MCP heads and the inability of the interossei to shorten enough, make abduction and adduction difficult. The lumbricals are the only ms that attach entirely to tendons of other ms: FDP to the extensor mechanism. Like the interossei, they cross the MCPJ volarly and the IPJ dorsally. They are strong IP extensors and weak MCP flexors.

THUMB: CARPOMETACARPAL JOINT (CMCJ) of the thumb and trapezium is a saddle joint with 2 of freedom (flex/ext & abd/adduction) with some axial rotation at the same time. It can circumduct and cause opposition and reposition, which is its primary function. Its capsule is lax, but it is reinforced by the intercarpal, ulnar, radial, volar and dorsal ligs. Its CPP is in extremes of abduction and adduction. METACARPOPHALAGEAL JOINT (MCPJ) of the thumb is condyloid with 2of freedom, and helps provide additional range to the thumb pad in opposition and grasping. It is reinforced by 2 sesamoids on the volar aspect. These bones appear around the age of 12.

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The IPJ of the thumb is the same as the other fingers. Extrinsic thumb ms: There are 4, 3 on the dorsolateral side and 1 on the palmar side: EPB, APL and EPL, and the FPL respectively. They all depend on wrist position for function. For ex: the FPL is a poor IP flexor in wrist flexion; the EPL cannot complete IP extension when extended. Main function: returning the thumb to extension. Intrinsic thumb ms: There are 4: the OP, APB, FPB and ADP, and are active to varying degrees in most grasping activities. When opposing firmly to the index or middle fingers, the FPB activity exceed that of the OP, but with firm opposition to the last 2 fingers, OP activity increases due to increased need for abduction and metacarpal rotation. Prehension: This is grasping an object between any 2 surfaces of the hand, and is divided into 2: power grip and precision handling. Power grip is flexion of all the finger joints. When the thumb is used, it functions as a stabilizer. Precision handling is the skillful placement of an object between the fingers, and the palm is not involved. Grip types: cylindrical, spherical, hook grip (FDS & FDP) and lateral prehension. Precision types: pad-to-pad (80%), tip-to-tip and pad-toside prehension (least precise). Functionally, the heavier an object, the more likely it is that the wrist will ulnarly deviate. The last 2 fingers generate only 70% of the flexor force of the index and middle, but are more mobile. Writing causes loads 4 times the grip of a pen, that is, 1# of grip = 4# of force. To diminish this, it is recommended to increase the grip width. The functional position of the wrist is 20 of extension and 10 ulnar deviation, 45 MCPJ flexion, 30 PIP flexion and slight DIP flexion. This is when all the wrist ms are under equal tension.

THE TEMPOROMANDIBULAR JOINT The TMJ is probably the most moved of all joints, requiring fine control and little force for function. It forms 2 separate but solidly connected joints with a disk that divides it in 2. The condyle and the inferior surface of the disk is a hinge joint,

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while the articular eminence and the superior surface of the disk is a condylar joint, and is larger. The capsule is thin and loose. The entire joint is synovial, although there is no hyaline cartilage covering the surfaces, but dense collagenous tissue or fibrocartilage. This is important because fibrocartilage can be repaired and remodeled but hyaline cartilage cannot. Most of the fibrocartilage is located on the articular eminence and the anterior superior aspect of the condyle, which are primary areas of contact. Fibrocartilage is present in areas that undergo high stresses. Its' nutrition and that of the mid portion of the disk is provided by synovial fluid. There are 2 CPP: full opening and full closing. The LPP is lips together and teeth apart. Normal resting position of the jaw is 1.5 - 5 mm. The Disk: allows 2 convex surfaces to be congruent (articular eminence & condyle) as it is biconcave. Only the middle part of the disk is avascular and aneural, which is consistent with the area of stress acceptance. The disk is also very flexible and conforms easily to the articular surface. Its thick-thin-thick appearance gives it a self-centering mechanism, where, as pressure increases, the disk rotates on the condyle so that the thinnest portion lies between the articulating areas. Its control is via the ligs & superior part of the lateral pterigoid attaching to it. The lower joint: It is formed by the anterior surface of the condyle of the mandible and the inferior surface of the disk, where the condyle rotates forward and the disc rotates backward, during opening. The opposite is true for elevation. The upper joint: Gliding occurs at this joint whereby the disk glides on the articular eminence of the temporal bone. The middle portion of the disk is its articulating surface and it translates forward with the condyle during mouth opening (to keep in contact with the articular eminence). Recent research shows, however that at no time during mandibular depression or elevation is there a pure rotation around the intercondylar hinge axis. Ligaments: The primary ligs are the capsular ligament, the TM lig, pintos lig, styloidmandibular lig, and sphenomandibular lig. The capsule is weak anteriorly and thus there is a predisposition for anterior dislocation of the condyle. Motions: These consist of opening or mandibular depression, closing or mandibular elevation, protrusion and retrusion and lateral deviations, created by a combination of rotation and gliding in the upper and lower joints. These allow the functions of chewing, talking and swallowing. * Elevation & depression: these motions are relatively symmetrical and take place in a coronal axis passing through both condyles. During opening, the 1st portion

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of the motion is done by anterior rotation of the condyle on the disk and ranges from 11-35 mm. The 2nd portion of mouth opening entails gliding of the disk-condyle complex anteriorly and inferiorly along the articular eminence in the upper joint, with a total mouth opening of 40-50 mm or the width of 3 PIP joints. Mouth closing is the reverse, and consists of gliding posteriorly and superiorly followed by rotation of the condyle posteriorly on the disk.

* Protrusion & retrusion: Protrusion takes place when all points of the mandible
move forward the same amount, without rotation, but only with translation in the upper joint. It results in the teeth being separated. The condyle and the disk glide anterior and inferiorly along the articular eminence causing the posterior attachments of the disk to stretch from 6-9 mm. Retrusion allows only 3 mm of translation and is limited by the TM lig. * Lateral deviation: The mandible can move asymmetrically, either around a vertical or A-P axis. When moving on a vertical axis, 1 condyle spins in the horizontal plane and the other moves forward, i.e.: R deviation = R condyle spinning and L condyle gliding forwards, resulting in the chin going to the R ~ 8 mm. The functional measurement of lateral motion is when the inferior frenulum moves at least the width of 1 full upper central incisor to either side. * Rotation (around an A-P axis entails 1 condyle spinning but in the frontal plane; as 1 condyle spins, the other depresses). Rotation results in the center of the mandible moving down and deviating from the midline towards the other condyle that is spinning. Rotation & lateral deviation combine to chew and grind food. Muscles: The ms responsible for opening are the digastric and the lower portion of the lateral pterigoids. Gravity also assists. The ms for closing the mouth are the temporalis, masseter, medial pterigoid ms and the superior portion of the lateral pterigoid. This ms rotates the disk anteriorly on the condyle. Protrusion is done by the masseter, & medial and lateral pterigoid. Retrusion is done by the posterior fibers of the temporalis, the digastric and suprahyoid ms. Lateral deviation by unilateral action of: medial and lateral pterigoids and temporalis, (the latter to the same side and the former one to the opposite side). Other muscles important to function are the new sphenomandibularis, the tensor timpani, tensor veli, palatini, hyoids, suboccipitals, SCM & upper traps.

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Relationship with the C-Spine and teeth: These 2 areas are intimately connected: ms attach the mandible to the cranium, the hyoid and clavicle. Ms in this area as well as the position of the head can affect the position of the mandible. Symptoms in 1 area may cause symptoms in the other. Tooth position also affects the TMJ; contact of the upper and lower teeth limit motion and the presence and position of the teeth determine function. Poor posture can also predispose to TMJ problems due to altered alignment.

POSTURE It is the position or attitude of the body. It is static (sitting) or dynamic (walking). The goal of any posture is to decrease energy expenditure & stress. Standing: The maintenance of erect bipedal stance is unique to humans and allows us to use the UEs. However, we pay the price by increasing the stresses placed on the spine and LEs and by loosing some stability, as compared to a quadruped position. In stance, the BOS is between the tips of the heels and the tips of the toes, thus the COG is far from the ground. Keeping this position requires little ms energy expenditure. The ability to change postures frequently is important (due to mechanoreceptors), to avoid tissue damage, mo-tion restrictions, venous stasis (adequate return of blood to the heart through ms pumping; if not, there is decreased cardiac output & fainting), deformities, fatigue & discomfort from vascular insufficiency in compressed joints. Postural control entails responding to forces placed on the body to alter its equilibrium (gravity & ground reaction forces) with adequate speed and force. This helps maintain stability, and is due to the CNS, the eyes (stability decreases 30% with eyes closed and decreases to 50% in people over 60), the vestibular system, musculoskeletal system and joint receptors. If the input received is altered, the response is distorted. A postural sway is one such response, and is the constant correction of the position of the COG within the BOS. A normal sway standing with the feet 4" apart averages 14 as the LOG falls outside the BOS. Younger and older people have slower reaction times (of ms contractions) to disturbances of posture. This is important due to its correlation with falls. In infants, postural control develops progressively during the childs first year, from control of the head, to control of the body while sitting and then standing. Stability is achieved prior to the child being able to move within a posture. He or she learns to maintain a certain posture via cocontractions of agonists and antagonists, and then is capable of moving within that posture. After stability is acquired, mobility and skill proceed. By the time the child is 10 or 11, postural alignment is similar as it is as an adult.

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An ideal standing posture requires that the body segments be aligned so that the torques and stresses are minimized throughout the kinematic chain; the segments must be vertically aligned and the LOG (plumb line) must pass through all joint axes, but this is almost impossible, so for optimal posture, the LOG must pass close to the axes. If the LOG goes through the joint axis, there is no gravitational torque around that joint. If the LOG is anterior to the joint, the torque tends to cause an anterior motion of the proximal segments to that joint. If it falls posterior, there is a posterior motion of the proximal segments. Examples: the LOG is anterior to the ankle; the gravitational torque rotates the proximal tibia anteriorly, resulting in ankle dorsiflexion. Here, the moment of force is called DF moment. When the LOG is anterior to the knee, there is an anterior proximal femoral rotation called extension moment. Postural analysis: The foot and ankle provide the basis for the position of the remaining joints, where the axis should be equidistant from the malleoli. This observational postural analysis identifies the location of body parts in the LOG. It can be done via a plumb line, video, XR, etc. in all planes. Ankle: it must be in neutral (midway between DF and PF), with the LOG falling slightly anterior to the lateral malleolus. To prevent the body from falling forward, the PFs, especially the soleus (a uniarticular slow twitch ms), must be actively or passively tensed to oppose the DF moment. There is no other ms activity during stance in the foot due to bony and ligamentous support. Knee: it must be in full extension with the LOG going just anterior to the midline of the knee (axis of rotation), posterior to the patella, causing an extension moment, needing little quad activity. The position is achieved mostly with passive tension of inert tissues, but the hamstrings and soleus assist. Hip and pelvis: the hip must be in neutral and the pelvis level without tilting. The symphysis and the ASISs are aligned and the ASIS and PSIS are level. The LOG is just posterior to the axis of the hip, through the greater trochanter to cause an extension moment at the hip that rotates the proximal pelvis posteriorly on the femoral heads. The iliofemoral ligament checks hip hyperextension. In a relaxed standing position, there is no ms activity at the hip so the stresses are taken up by the anterior ligaments. Trunk: the LOG passes through the midline of the trunk, where balance in the curves must be present. An increased lumbar lordosis results in an increased kyphosis and cervical lordosis to balance the vertebra on each other. There is some erector spinae ms. activity, while the rectus abdominis is inactive, and some activity is noted in the internal obliques. In the lumbar spine, tension at the anterior longitudinal ligament balances the gravitational extension moment. Gravity tends to cause the superior part of the sacrum to rotate anteriorly and

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inferiorly but tension at the sacrotuberous, sacroiliac and sacrospinous ligaments counterbalances this torque. Head: its COG is ~ 1" above the transverse axis of the atlanto-occipital joint, so the LOG is anterior to the axis of flexion and extension, so the cervical extensors are usually active to prevent the head form falling forward to counteract the flexion moment. If it is fully flexed, the lig. nuchae is taut and ms activity is minimal. If the head is in extension, the COG is posterior to the transverse axis. The LOG goes through the ear lobe and the dens or odontoid process of C-2. Faulty Posture: Malalignment of one body segment can cause changes in other segments. If stresses are maintained over a long period there is a resultant shortening, ms can lose sarcomeres and perpetuate abnormal posture, preventing full ROM. If ms are kept in a lengthened position too long, sarcomeres can be added changing the length-tension relationship. Shortened ligs. limit ROM, and lengthened ones can cause instability. Prolonged WB stresses the joint surface, deforms cartilage and interferes with its nutrition, making it susceptible to DJD (degeneration). Patterns of faulty mechanics can be related to handedness. Ex: people who stand with the R hip higher than the left have a resulting tight L TFL. There may be a slight deviation of the spine to the opposite side of the higher hip and a low shoulder on the high hip side. Asymmetry causes imbalance due to abnormal forces. A flexed knee posture has its LOG posterior to the axis, creating a flexion moment that has to be balanced by quad activity. At 30 of flexion, this activity increases to 50% of quad force, thus increasing compressive stresses. There is also hip flexion and ankle DF. The LOG falls anterior at the hip, whereby the hip extensors need to function to counter the flexion moment, while the soleus counters the DF moment. An excessive anterior pelvic tilt forces the pelvis forward, and the lumbar vertebrae anteriorly, increasing lordosis and the extension moment, while the thoracic curve increases to attain balance. The lumbar disks are tensed anteriorly and compressed posteriorly, altering the nutritional diffusion. This can result in ms imbalances: tight low back ms, weak abdominals, tight hip flexors and weak hamstrings. With genu valgum, the LOG is lateral to the axis of the knee. The gravitational moment causes lateral femoral mov't and medial tibial mov't, so the lateral aspect is compressed and the medial side is tensed. This causes foot pronation stressing the medial longitudinal arch and abnormal WB on the medial side of the calcaneus. In pes planus, the medial longitudinal arch is absent or reduced. Pes planus can be rigid or flexible. If rigid, the arch is absent in NWB, toe-standing and WB, and if flexible, it's reduced only in WB. The degree is determined by the distance of the

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navicular to the Feiss line, which falls between the malleolus and the head of the 1st MTT (metatarsal). All this results in a hypermobile foot, increased WB on the 2 to 4 MTT heads, callous formation, decreased supination in gait, while the tibia internally rotates affecting then the knee. Pes cavus is the opposite, stretching the lateral ligaments and the peroneus longus muscle. At the toes, hallux valgus is a lateral deviation of the greater toe at the MTP (metatarsophalangeal) joint. Claw toes is hyperextension at the MTP with flexion at the distal and proximal IPJ (interphalangeal joint), usually associated with pes cavus. Hammertoes are hyperextension at the MTP and distal IP with flexion at the proximal IP joints, resulting in calluses under the heads of the MPJs and superior surface of the IP. Scoliosis is defined as a series of vertebra that are laterally deviated from the LOG in one or more regions. It is a lateral spinal curvature accompanied by rotation. There are 2 basic types: structural and functional. Structural can also be idiopathic and is characterized by being non-reversible as the cause of the curve cannot be corrected. They are named according to the direction of the convexity and the location of the curve. If there is more than one, i.e. compensated, the top one is named first. If severe, it can affect breathing & function of other internal organs and look unattractive. In a severe right thoracic and left lumbar scoliosis, a hump can be noted on the right side of the posterior rib cage, which is due to rotation of the vertebra to the side of the convexity, so the ribs form the hump. Treatment approach is geared at combining axial with transverse loads to prevent the curve from increasing, through the principles of creep and relaxation. Ex: Milwaukee brace, Harrington rods, E.S., exercises.

THE VERTEBRAL COLUMN The complex relationship between structure and function is evident in the spine, which is able to provide a base of support for the head and the internal organs, for attachment of ligs, bones and ms of the limbs, rib cage and pelvis, a link between the UEs and LEs, protection of the spinal cord, & trunk mobility. The spine is composed of 33 vertebrae and 23 disks, divided into 5 regions. Viewed from the side, there are 4 curves, which in a baby appear as one convex curve. As the baby develops and starts holding the head upright, the first curve,

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or cx lordosis, becomes concave and constitutes a secondary curve; as the child begins to walk, the other secondary curve also reverses and forms the lumbar lordosis. The other 2 curves are primary as the retain there original shape, and are the kyphotic curves of the thorax and sacrum. The secondary curves continue to develop until the ages of 12-17. These curves allow the spine to behave as part of a closed kinematic chain. A spinal segment, motion segment or functional unit of the spine, consists of 2 adjacent vertebrae with their disk and soft tissues. The anterior portion of the segment is formed by 2 superimposed vertebral bodies, the intervertebral disk and the longitudinal ligaments. The posterior elements correspond to the vertebral arches, the facets, transverse and spinous processes and various ligs. Each segment forms a first class lever system where the facets are the fulcrum. The vertebral bodies are designed to bear mainly compressive loads and are progressively larger from top to bottom. The closed pack position for the entire spine is the military salute. Changes in the position of 1 segment results in changes in position of adjacent superior and inferior segments. JOINTS AND LIGs: There are 2 types of joints in the spine: cartilaginous, between the vertebral bodies (disks), and diarthrodial or synovial, between the superior articular processes and inferior articular processes, also called facets, zygo- and apophyseal joints. Their capsular ligs resist flexion of the intervertebral joints & protect the disk from shear forces, supporting up to 40% of the body weight in the lumbar area. Every facet, except for the first 2 are plane synovial joints. Synovial joints are also present at the attachment of the ribs and skull. The SIJ is part synovial and part fibrous. The type of motion occurring at any level of the spine is determined by the orientation of the facets, which also function as load-bearing structures. There are 2 ligamentous systems: intrasegmental and intersegmental. The first binds individual or adjacent vertebra, and the other, binds a number of vertebra into a unit. These ligs, along with the fascia and ms, are necessary for stability, while the ms also contribute to mobility. There are 6 main ligs: anterior longitudinal ligament (ALL), posterior longitudinal ligament (PLL), supraspinous, (intersegmental), flavum, interspinous, and intertransverse (intra), and the thoracolumbar fascia. * The ALL, which has at least 2 layers, runs from the sacrum to C2 (after that it's called anterior atlanto-axial lig). Its deep fibers blend with the disk reinforcing it. Its tensile strength is highest at the lumbar area. It increase is size from the lower TS to S1. It is the only lig. that resists backward bending (BB) due to bony checks. It is compressed in flexion and stretched in extension and it is twice as strong as the PLL.

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* The PLL, which also has 2 layers, runs the same course on the posterior aspect of the vertebral bodies, and parts attach to the posterior aspect of the disk and end plates. At the occiput, its called the tectorial membrane. It provides little support for the joints in the lumbar area. It is stretched in flexion and slack in extension. * The ligamentum flavum is a thick, elastic lig on the posterior surface of the vertebral canal, also running the same course, and is strongest in the lower thoracic area. It is stretched in flexion and is under constant tension with the spine in neutral. This tension causes the disk pressure to rise, making the disk stiffer and more able to support the spine in neutral. * The interspinal lig is well developed only in the lumbar area and goes from the base of 1 spinous process to another. It is stretched in flexion and slack in extension. It resists separation between the spinous processes, but is very weak. * The supraspinous lig goes from the tips of the spinous processes from C7 to the sacrum, and it merges with the lumbar ms. In the cx area, it becomes the ligamentum nuchae. It also resists separation of spinous processes in flexion (FF). * The intertransverse ligs are also only well developed in the LB. They are paired, and stretch and compress in SB. * The facet capsule is strongest at the CT and TL junctions, where the shape of the vertebra changes from kyphosis to lordosis and vsvs. The capsule resists flexion and rotation, especially at the lumbar spine. THE DISK: Its thickness varies from 3-9 mm, increasing in size from cx to lumbar region. It consists of 2 parts: nucleus pulposus (NP), which carries compressive loads), and annulus fibrosus (AF), which carries tensile loads, and is composed of water, collagen (especially Type I and II) and proteoglycans (PGs). Water and PG concentrations are highest in the nucleus, while collagen is highest in the annulus. The nucleus also contains glycosaminoglycans or GAG's, (chondroitin sulfate, keratin sulfate and hylarunate which link to protein and form PGs) whose biochemical characteristics change with age and injury, decreasing the strength of the water-binding capability of the nucleus; with degeneration, the disk gives up water more easily. Under normal situations, the nucleus has 88% water, making it nearly incompressible, thus being a good force distributor. Because it is nearly incompressible, loads make it bulge laterally, and circumferential tensile stress is sustained by the annular fibers. The fluid content depends on the composition of the disk and the applied load. The NP contributes to nutrition through diffusion by releasing water during WB, and imbibing it from the vertebra while recumbent. The entire disk serves as a cushion to store energy and distribute loads. The NP

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lies directly in the center of all disks except in the lumbar area, where it is slightly posterior. The annulus consists of about 18 layers attaching to vertebral end plates and bodies. These layers contain collagen fibers aligned at 120 to each other with alternate layers going the opposite direction. Thus, half the layers are taut in one direction of rotation while the other half, are slack. The AF absorbs forces & acts as a fulcrum of motion for 3 degrees of freedom at each vertebral level. In the cx and lumbar areas, the outer third of the annulus is innervated by branches of the vertebral and sinuvertebral nerves. No blood vessels or nerves are found in the nucleus. The disk is flexible and allows motion in all directions, and serves to dissipate forces and stresses transmitted to it, especially compressive forces. The vertebral end plate is a thin layer of hyaline cartilage covering the superior and inferior surface of the vertebral bodies separating them from the disks, and is sometimes considered as part of the disk because of its chemical composition. Its collagen fibers are arranged horizontally to withstand pressure of the nucleus that happens with axial compression or when water is imbibed in the nucleus. FUNCTION: Stability, Force and Motion: Stability: The stability of the spine is determined by its stiffness or its ability to resist applied loads as seen in the stress-strain curve. Instability is lack of stiffness denoting disequilibrium and increased -abnormal- ROM. Forces: The spine is subjected to axial compression, tension, bending, torsion and shear stresses during activity and rest. Its ability to resist these depends on: the location, type, duration, frequency, age, posture, position and integrity of the surrounding structures. Axial compression: This is a force acting through the long axis of the spine at right angles to the disk, and occurs due to musculoligamentous forces, gravity forces & loads. It is resisted mostly by the disk and the vertebral bodies, and less so by the posterior elements. It is transmitted from the superior end plate to the inferior end plate. The facets and spinous processes can transmit some forces depending on the position of the spine. The NP deforms with compressive loads. When a weight is applied vertically downward on the spine, the NP loses height, it expands outwardly to the end plates and AF, and its pressure increases. As it tries to distribute the pressure in all directions, stress is created in the AF and compression takes place at the end plates, which cannot deform easily and are the first to fail under high loads. The disk is the last to fail. In the elderly, the amount of creep that occurs is greater than in young people, and the recovery from creep and hysteresis is slower. Their "shrinkage" is due to their NP losing their fluid-imbibing capabilities. Facet loads are greatest when the spine is hyperextended. The pressure in the NP correlates

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with the degree of myoelectric activity in the back muscles, and in the NP, it is greater than the force of the applied load. Bending loads: Bending creates compression and tension on the spine. With FF, the anterior structures compress while the posterior are subject to tension. Resistance to tensile forces in the posterior aspect limits extremes of motion and provides stability in FF. The creep that takes place in the spine when it is subject to prolonged loads in full BB or FF (painting a ceiling or gardening) leads to an increased ROM beyond normal limits. The elongation caused by creep leads to instability and risk of injury. In BB the posterior structures are either unloaded or under compression, while the anterior aspect is under tension. Resistance to BB is given by the anterior aspect and possibly by contact of the spinous processes. In side bending (SB), the ipsilateral side is compressed while the opposite is stretched. In the lumbar spine, sitting and bending cause more intradiscal pressure than standing. Shear: this force acts at the midplane of the disk and causes each vertebra to move in a horizontal plane. The facets resist some of the shear forces, while the disk resists the rest. If the load is sustained, the disks creep & so the facets take the brunt. The vertebral arches also play a role in resisting these forces. The degree of shear depends on the angle of the vertebra & the orientation of the muscle fibers. Ex: the multifidus exerts mostly anterior forces at the upper LS. In general, the net effect of these forces in stance, is that the back muscles exert a posterior shear on upper lumbar segments and an anterior shear force on L5. These forces change with position: posterior shear forces in the upper LS is decreased by flexion. Torsion: Torsion is created during axial rotation as part of coupled motions. The highest torsional stiffness is located at the TL junction. It is provided by the outer layers of the vertebral bodies and disks and by the orientation of the facets. A disk can rupture with combined torsion, heavy axial compression and bending. Torsion increases discal pressure and tends to narrow the disk space. Motion: One vertebra can move on another in 6 different directions. Spinal motion occurs on an axis that is located slightly posteriorly to the center of the disk. This axis moves anteriorly with FF and posteriorly with BB. The facets, which are highly innervated, guide and limit these motions. Their orientation determines the direction and amount of motion or glide between segments, with the nucleus functioning as a swivel, allowing 6 of freedom. The size of the disks also determine the amount of motion. The orientation of the facets varies from region to region. If they lie in the sagittal plane, flexion and extension are facilitated; if in the frontal plane, SB is facilitated. Motion between 2 vertebrae is small and does not happen independently, and cannot be measured clinically.

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Fryette's Laws: There are 3 and they refer to spinal motion or coupled movements or patterns. They are also designated as type I, II or III. The patterns depend on the location of the motion, spinal posture and curves, facet orientation, disk fluidity and elasticity and ligs. and capsules. They are more likely to be pure if facet orientation is equal at 3 adjacent vertebrae. Law I: If the segments are in neutral, without locking of the facets, rotation (ROT) occurs in the opposite side of SB in the lumbar and thoracic regions. Law II: If the segments are in full flexion or extension with the facets engaged, rotation and SB occur to the same side for the lumbar and thoracic areas. This law always applies to the cx area regardless of its position. Law III: If motion is introduced into 1 segment in any plane, motion in all other planes is reduced. Ex: LSB causes RROT. If you do LSB, the left facet glides inferiorly and the R glides up. If the L facet is restricted, loss of motion is in RSB and LROT, which Cyriax calls capsular pattern of motion restriction. * Flexion: Normally, with flexion, the anterior tilting and gliding of the superior vertebra produces widening of the foramen and separation of the spinous processes. This is limited by the supraspinous and interspinous ligs, by passive tension in the joint capsule of the facets, by the lig flavum, the PLL, posterior annulus and back extensors. The anterior portion of the annulus is compressed and bulges anteriorly while the posterior portion is stretched. The opposite is true in extension. * Extension: Here the intervertebral foramen is narrowed & the spinous processes approximate. The amount of motion is also limited by the size of the disks, and by the spinous processes, tension in the capsules, anterior fibers of the annulus, anterior trunk ms & the ALL. More structures limit flexion than extension. * Side Bending: The superior vertebra tilts and rotates over the adjacent vertebra below. The annulus is compressed on the concave side and stretched on the convex side. * Rotation: This also varies from area to area due to the facet orientation. There are structural variations throughout the spine, and are seen in C1 and the thorax, L5, the sacrum and the junctions: CT, TL and LS, where, there must be a transition between 1 vertebral structure and another. During rotation, the back muscles give little if any stability in the LS, which consequently relies on the abdominals.

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Common Muscles: the erector spinae or sacrospinalis from sacrum to occiput have 3 divisions: iliocostalis, longissimus and spinalis. They extend the trunk and function as a strong lever for lifting. The interspinalis and intertransversarii function more for sensory purposes than as prime movers. The multifidi are more prominent in the LS, and function mostly for rotation. They counter anterior shear forces and help with extension. See appendix in book, page 164. Function of the Back Muscles: According to Bogduk, each back muscle can perform several actions, and no muscle has a single action. Their function is considered in terms of observed motion. There are 3 types of spinal motions: minor active movement, postural movement and major motion. For minor motion, muscles usually initiate the movement, but gravity completes it. Ex: during extension in stance, back muscles contribute to the initial tilt but are not needed for further BB as the LOG is now posterior. To maintain posture, the back muscles correct any displacement to prevent imbalance. This ms activity fluctuates from nil to intermittent or continuous activity (mostly by slow-twitch fibers), depending on the position of the body (and thus the LOG). Major active movements, like FF & BB, increase in proportion to the angle of motion and the load that is carried. For ex: flexion is produced by gravity, but controlled by the back muscles. Half of the extensor moment on the LSp is exerted via the erector spinae, and other half by the multifidi, longissimus thoracis and iliocostalis lumborum. AGING: Begins in the 2nd decade for men and in the 3rd decade for women. * fluid content of the disk decreases * disk height decreases * vertebrae get closer * altered facet alignment * posterior lig systems gets slack * more motion is possible * decreased stability CERVICAL SPINE The cervical (cx) spine (CS) is the most mobile area of the spine, more so in children than in adults. It supports the head and protects the spinal cord and vertebral arteries. The first 2 cx vertebrae are atypical and have no disks, while the 7th is transitional, having characteristics of 2 areas. C3-C7 are typical vertebrae. The occiput (CO), atlas (C1) and axis (C2), from the craneovertebral area, where the facets provide 2 to 3 degrees of freedom. The O-A joint (CO-C1) is a plane synovial joint formed by 2 concave superior facets of the atlas that articulate with the 2 convex occipital condyles of the skull.

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The O-A joint has 2 degrees of freedom consisting of 10-15 of flexion (nodding) and extension, and 8 of SB. The joint configuration does not allow much rotation, but if there is ROT, it will occur to the opposite of SB. Flexion at this level is limited by the tectorial membrane and the anterior ring of the foramen magnum. The O-A joint provides motion between the head and the vertebral column. The atlas can be considered like a washer facilitating motion between C0 and C2. It can move independently from the rest of the CS. The A-A joint (C1-C2) is a plane joint. It is composed of 3 separate joints: the median atlantoaxial or atlanto-odontoid joint between the dens and the atlas, and 2 lateral joints between the superior convex facets of the axis and the inferior convex facets of the atlas. The median joint is a trocoid or pivot joint in which the dens of the axis rotates in a osteoligamentous ring formed by the anterior arch of the atlas and the cruciform ligament. The 2 lateral joints are plane synovial joints, where rotation occurs without SB. Most of the rotation of the CS takes place at C1-2. SB below this level comes with coupled rotation to the same side. Fifty % of the entire spinal rotation occurs at the dens and it happens before rotation at the rest of the CS. The atlas pivots 45 to either side, and is limited by the alar ligs. There is minimal flexion due to the anterior ring of the foramen magnum on the dens and the tectorial membrane, which also checks extension. SB is minimal. C0-C2 as a whole produce rotation opposite to SB. From C3 to C7 the facet orientation changes from horizontal to a 45 angle between the horizontal and frontal planes. This orientation along with loose and elastic capsules permits motion in all directions. The facets separate in flexion, approximate in extension and move asymmetrically in SB and rotation. With RSB, the L superior (sup) facet goes up and forward and the R sup facet goes down and backward with rotation of the vertebra to the R and the spinous process to the L. SB is restricted due to the presence of the uncovertebral joints. During rotation, the size of the canal is decreased because of the oval shape of the central foramen of C1, which does not coincide with that of C2. This also stretches the vertebral artery. The facets also share in weight bearing of the head due to their orientation to the frontal plane and because there are no disks at C0, 1 and 2. This is important because the head can be supported by the long lever arm of the CS for long periods of time. Loads are less with retraction and are carried by the facets, disks and vertebral bodies. Maximum flexion and extension is at C4-C6. During normal ext. C6 should "disappear". Flexion causes the maximum load and chin tucking, the minimum load.

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The uncovertebral joints, which are developed mostly from C2-C5, are cartilaginous and encapsulated, sliding on each other in flexion and extension. With SB and ROT, the contralateral joint opens and the ipsilateral closes. The uncovertebral joints give additional stability guiding translation & reinforcing the posteriorlateral disk. They limit SB and prevent a posterior translation of the vertebral bodies. They play a roll in coupling patterns. Ligaments: Some ligaments change name in the cervical region: The posterior A-A is a continuation of the ligamentum flavum, the anterior A-A, is the ALL, the tectorial membrane the PLL and the ligamentum nuchae is the supraspinous lig. Specific ligs. to this area include: The cruciform atlantal lig holds the dens and the atlas and plays a vital role in stability and in preventing anterior displacement of C1 on C2. The transverse band of this lig. has a thin layer of cartilage on the anterior aspect for the dens to rotate on. The alar ligs provide stability and are relaxed in extension and taut in flexion and rotation. The R one limits L ROT and they both prevent C1-2 distraction. The apical ligament from the tip of the dens to the bastion (anterior aspect of foramen magnum), is small, and its contribution to stability is unclear, but it would appear to guide the rotator motion of the dens. Muscles: The head, neck and trunk ms are paired with a ms on each side of the midline. When both contract and cause motion, the result is FF or BB in the sagittal plane. If only 1 ms causes motion, then there is SB or ROT. The ms that flex the head on the neck are the rectus capitis anterior and rectus capitis laterals. The SCM flexes head and neck if acting bilaterally. Flexion at the lower CS is done by the longus colli, longus capitis, rectus capitis anterior and lateralis. Both scalenes flex the neck or elevate the upper ribs. SB is done by unilateral contractions of the scalenes, and splenius capitis. The upper traps extend and rotate the head to the opposite side of shld elevation. Unilateral SCM action causes combined SB and contralateral rotation. There are several extensors and most of them can produce rotation. The ones that produce it to the opposite side are the multifidus, rotators and semispinalis; the ipsilateral rotators are the oblique capitis and erector spinae. The levator scapulae functions to limit anterior shear forces and some flexion, and can produce SB and rotation when the scapula is fixed. There are 4 ms that move the head on the neck called suboccipials and they are: rectus major and minor, & obliquus superior and inferior and are important in small neck motion like reading. They are frequently affected in patients who have headaches and PT plays an important role in treating these muscles. (Other

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anterior neck ms are the supra- and infrahyoids). The muscles that stabilize are the multifidi, interspinalis, semispinalis capitis and cervicis.

THORACIC SPINE & CHEST WALL This area is not as flexible and is more stable than the neck due to structures such as the rib cage, the longer spinous processes, the facet capsules and the size of the vertebral bodies. The thoracic spine (TS) supports and allows motion at the head and trunk, it protects the heart, lung and great vessels, & helps with breathing & ms attachments. The 1st and 12th vertebrae are transitional. C7 to T3 are transitional zones between curves, (the facets become more vertically oriented into the frontal plane), with all ranges limited in this area. T3 to T10 are more typical thoracic vertebra, having narrow disc spaces and longer spinous processes (sp. proc.), which become nearly vertical in the frontal plane and thus limit extension. SB and ROT are limited by the thorax. T11 to L1 is also a transitional zone between curves, (where the facets begin to change from the frontal to sagittal plane). T12 has its superior facets in the frontal and the inferior in the sagittal. The disks here start to increase in height and in motion. The ligs are the same as in the initial general vertebral column description except for the lig flavum and ALL, which are thicker, & the facets are tighter; (the superior facet faces superiorly and laterally, and the inferior, anteriorly and medially.) MOTION: All motions are possible in the TS but FF & BB are limited in the upper TS from T1 to T6, where the facets lie in the frontal plane. From T9 to T12, the facets lie more in the sagittal plane, thus allowing more FF and BB. The opposite is true for ROT, where there is more in the upper area and less in the lower TS. SB is permitted throughout, but increases in the lower part. Flexion is limited due to tension in the PLL, lig flavum, interspinous lig and facet capsules. BB is limited due to contact of the sp. proc., facets, size of the disks and

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tension of the ALL, capsules and abdominal ms. SB is restricted by contact of the facets on the concavity and by the rib cage. This also limits ROT. When the thoracic vertebra rotates it comes along with distortion of the associated rib pair (convex anteriorly on L and convex posteriorly on R). The amount of ROT depends on the ribs ability to distort and on the motion available at the costovertebral & costotransverse joints, which decreases caudally and with age. Elevation and depression of the ribs takes place due to a pivoting motion through an axis crossing the costovertebral and costotransverse joints. The Thorax and Chest wall. The chest wall has 3 parts: rib cage, diaphragm & abdomen. The joints of the thorax or chest wall are the: manubiosternal (MS), xiphisternal (XS), costovertebral (CV), costotransverse (CT), costochondral (CC), costosternal (CS) and interchondral joints (IC). The MS joint is a synchondrosis with a fibrocartilaginous disk between its surfaces, similar to the symphysis. It ossifies in about 10% of older adults. The XS is also a synchondrosis and usually ossifies at the age of 45. The CS joints of ribs 2 to 7 are synovial joints divided by an intraarticular lig. Support for these joints include a thin capsule reinforced by 2 ligs. The IC or interchondral joints are synovial-like and are supported by a capsular lig and IC ligs, and also tend to become fibrous and fuse with age. The 8th to the 10th or 11th costal cartilages articulate with the cartilage immediately above them, attaching to the sternum by a fused costal cartilage. The CC joints are synchondrosis surrounded by periosteum and have no ligamentous support. The 1st through 7th ribs articulate with the costal cartilages and the cartilages articulate with the manubriosternum (CSJs). The CV joint is a plane synovial joint between the head of the rib and 2 demifacets on the adjacent thoracic vertebra. The CV also includes articulation with the disks. The 1st, 11th and 12th ribs articulate only with 1 vertebra and are more mobile. The CVJ are joined by ligs and capsule, tethering the rib to the annulus and the vertebra, providing stability. Motion includes rotation and gliding. The CT joint is a plane synovial joint formed by the costal tubercle of the rib with a costal facet on the transverse process of the 1st through 10th thoracic vertebra. The last 2-3 ribs don't have these joints. They allow some rotation and gliding. The CT joint capsule is strengthened by 3 major ligs that give stability.

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Ribs 1 to 10 articulate with the spine by 2 synovial joints, CV and CT, and with the manubriosternum, forming a closed kinematic chain (CKC), where motion is more restricted. The 11th and 12th ribs are open (OKC) & thus less restricted. KINEMATICS: The 1st costal cartilage and CS joints are stiffer than the rest. The 1st rib articulates at the CV joint with 1 facet, increasing its motion. During inspiration, the first rib elevates, moves superiorly and posteriorly at the CVJ and pushes the manubrium up. The CV and CTJ have a common axis of motion. Motion at the CSJ is limited to slight vertical motion without rotation. Motion at the ICJ consists of superior-inferior gliding. There is and upward and forward motion characteristic of the upper ribs called "pump-handle " motion, as their orientation is more horizontal. This elevation increases the anterior diameter of the rib cage. The lower ribs move up and laterally in a "bucket-handle" motion as they have a more oblique downward orientation, increasing the transverse diameter of the rib cage. All ribs, however have a combination of both motions. The intermediate ribs move minimally forward and laterally. Ribs 11 & 12 can move freely in any direction, as they have no anterior joint and articulate only with 1 vertebral facet. Inspiration and expiration depend on musculoskeletal and kinesiological interrelationships of the chest wall, and involves ~88 joints and 46 ms. The ribs move in a cephalad direction more easily at low lung volumes and caudally more easily at high lung volumes. This "compliance" is determined by the stabilizing of the upper ribs during inspiration and the lower ribs during expiration, as well as lung elasticity. MUSCLES OF THE RIB CAGE: The respiratory or ventilatory ms that function during normal quiet breathing differ from other skeletal ms because: a) b) c) d) e) they they they they they contract rhythmically and intermittently through life, can be controlled voluntarily and involuntarily and work against elastic and airway resistive loads, not against gravity. have increased resistance to fatigue & more oxidative capacity are life sustaining

Primary inspiratory muscles: The diaphragm, external intercostals and the scalenes are used in quiet ventilation (at rest). The intercostals connect adjacent ribs and are internal or external. The parasternal portion of the internal intercostals, however are considered primary ms of ventilation (attaching anteriorly from the chondrosternal junction to the CC joints). There are no primary ms for expiration because this is passive at rest. The external intercostals are mostly inspiratory. The scalenes contribute to quiet inspiration and expand

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the upper rib cage in an A-P dimension (pump-handle). The respiratory ms. also help with speech, defecation and posture. Diaphragm: This muscle accounts for about 75% of inspiration during quiet breathing. It separates the thorax and the abdomen. When it contracts during inspiration the shortening of the ms. fibers decreases the length with the descent of the dome, increasing abdominal pressure which acts as a stabilizer for the central tendon. There is an upward pull of the lower ribs resulting in an upward and outward motion of the lower rib cage due to the bucket-handle principle. The interchondral part of the parasternals ms are inspiratory. The parasternals, scalenes & levatores costarum rotate upper ribs & elevate the sternum as a whole. The upper chest moves out (anteriorly). Expiration is a passive with recoil of the elastic components of the lungs and the chest. Accessory ms: They assist with inspiration or expiration but not during quiet breathing under normal circumstances. They increase thoracic diameters by moving the rib cage up and out when the shld girdle is fixed. They are the SCM, pect major & minor, the traps, subclavius, transverses abdominis, external & internal oblique, rectus abdominis and quadratus, levatores costarum and infraand suprahyoids. The quadratus lumborum, which acts as an expiratory muscle, depresses and fixes the last 2 ribs to allow diaphragmatic muscle tension. Abdomen: There are 4 ms of the abdominal wall: transverse abdominis, internal and external abdominal obliques and the rectus abdominis. They used to be considered expiratory ms as well as trunk flexors and rotators, but it is now recognized that they function also as inspiratory ms. They function by passively increasing intraabdominal pressure, which pushes the lower rib cage out, and forces the diaphragm up, thus pulling the lower ribs up. During exercise, the activity of the abdominals to enhance ventilation increases.

Development. Shape, compliance and motion of the chest wall changes from infancy to old age. A newborn has a compliant chest wall due to cartilage, which allows distortion for the thorax to go through the birth canal, so the ms are basically stabilizers counteracting the tendency of the diaphragm to pull the lower ribs in during inspiration. The horizontal alignment of the ribs in the infant, as opposed to the oval shape in the adult, changes the diaphragm angle of insertion allowing this tendency.

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With age, the costal cartilage ossifies, which interferes with trunk rotation; there may be osteoporosis of the ribs and vertebrae, and increased kyphosis; the CC, CS, MS and XS joints can become fibrotic and fuse; synovial joints may feel the effect of wear and tear; there is decreased abdominal strength resulting in a less domed diaphragm and thus altered the kinematics of respiration. During pregnancy, there is an alteration of every organ and tissue, especially during the last trimester. Progressive uterine distension repositions the diaphragm upward resulting in increased chest girth & decreased functional residual capacity; tidal volumes increase but vital capacity stays the same. Diaphragm contraction is improved due to a better length-tension relationship where a lengthened diaphragm increases tension. With scoliosis, a structural curve alters the chest wall biomechanics and respiration, depending on the severity of the curve. On the concave side, the transverse processes rotate anteriorly, taking the ribs with them, decreasing the intercostal spaces. On the convex side, the opposite occurs, so rib cage compliance is reduced, resulting in a restrictive lung problem that reduces lung capacity. With COPD there is airway trapping with hyperinflation of the lungs affecting the chest wall. This results in an inflated resting position of the rib cage or barrel chest, and shortening the inspiratory ms. This along with a flattened diaphragm, makes breathing less efficient.

THE LUMBAR SPINE

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The 1st 4 vertebrae of the lumbar spine (LS) are similar to each other, and thicker and wider than in the rest of the spine in order to sustain larger loads. The 5th vertebra has structural adaptations to articulate with the sacrum, being more wedge-shaped and becoming a transitional vertebra. Its superior diskal surface is greater than the other vertebrae and the inferior surface is smaller; its spinous processes are small and the transverse processes are long. The lumbosacral joint is formed by the 5th vertebra and the 1st sacral segment. It is inclined slightly in an anterior and inferior direction, forming the sacral angle with the horizontal, which is normally 30. This angle varies with the position of the pelvis and can affect the lumbar curve. An increase causes hyperlordosis resulting in increased shear stress at the lumbosacral joint in a CKC situation. This can cause damage to facets, spinous processes, and the PLL. The lumbosacral angle is formed by an angle between the body of L5 and the sacrum, with its axis at the L5 disc. Normal value = 140 The facet orientation in the lumbosacral joints is oblique and allows for ROT. FUNCTIONS: The primary function of the LS is to give support for the weight of the upper body, and stability through the AF and the facets. In normal standing posture, the LOG passes through the combined axis for the lumbar bones and therefore no net torque exists. Any deviation of the LOG, however, will produce torque. This along with muscle contractions creates additional compression and a potential for excessive torsional and shear stresses. (For ex: if you stand holding something with the R arm at 90, 2 torques are formed: a forward flexion bending moment and a R lat flex moment. The trunk ms (especially the abs) exert an opposing moment or countertorque to maintain balance of the spine and prevent motion in the direction of the moments, trying to stabilize the area). LUMBO-PELVIC RHYTHM: this is a specific coordinated activity of lumbar flexion and anterior pelvic tilt in the sagittal plane. It is an open chain phenomenon in the hip joint, pelvis and lumbar spine. The 1st part consists of lumbar flexion followed by anterior pelvic tilting at the hips and a backward mov't of the pelvis on the hips so the COG stays over the feet. This integration increases the ROM to the total spine and decreases the amount of flexibilty at the lumbar area, similar to the scapulothoracic rhythm. A restriction in either area can disturb the rhythm, or result in hypermobility of the unrestricted segment, or decreased ability to reach flexion. Returning to stance involves the opposite motions: posterior pelvic tilting followed by lumbar extension. MOBILITY: The facets from L1-L4 are oriented at right angles in the sagittal plane and thus facilitate flex/ext, (less flexion than extension) while limiting SB and ROT. Normally, it is not possible to flex the lumbar spine to form a kyphotic

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curve. Most of the flexion occurs at L4-5-1, where most of the weight is supported. There is hardly any SB at the lumbosacral joint due to orientation. Here the facets go obliquely to the frontal plane. Most of the SB occurs at L3-4 and most of the rotation, at L5-S1 (according to White and Panjabi). The facets of S1 face posteriorly to help prevent anterior shear at L5. Extension: During this motion, the facets approximate and the intervertebral foramen (IVF) narrows. Flexion: The 1st 50-60 occur at the lower segment of the LS. Flexion is initiated by the abdominals and the vertebral portion of the psoas. The weight of the upper body causes more flexion, which is controlled by activity of the paravertebrals (PVs). When the trunk is in full FF, the PVs become inactive and are fully stretched. Flexion is now stopped by the facets and the PLL. SB and ROT: During SB, the transversospinal systems and the abdominals are active. Ipsilateral contractions initiate the motion and contralateral ones modify it. Rotation (5) is associated with SB, especially at L5-S1. STABILITY: The taut facet capsules and the ligs. limit motion and give stability. The intertransverse and iliolumbar ligs. limit SB. The lig flavum and interspinous ligs limit flexion. The ALL limits BB and the PLL, FF, but its width decreases caudally, so that the LS has less than 1/2 a disc covered and is more susceptible to HNPs. The iliolumbar lig. stabilizes L4-5 segments during FF and ROT. In flexion both ligs. get taut and in ROT, the opposite side gets taut. This lig. has 5 strong bands that help resist all motions and stabilize L5. The thoracolumbar fascia is one of the most important noncontractile structures in the lumbar area as a resisting factor against full FF. It also gives us the ability of lifting heavy objects overhead and stabilizing the trunk during activities like throwing & it helps the extensors resist loads. It consists of 3 layers (anterior, middle and posterior) coming from the spinous and transverse processes, blending with other tissues & surrounding the ms of the LS. It has a tensile strength of 2000 psi. MUSCLES: * Extensors: The erector spinae or sacrospinalis ms, which consists 3 parts or groups, (iliocostalis, longissimus & spinalis) represents the largest portion of the posterior trunk ms., extending from the sacrum to the skull. Their role is to hold the trunk erect during certain postures and to produce enough tension for lifting, but in standing, very low ms. activity is evident, (intermittent). These ms also control FF in standing; gravity facilitates FF but it is controlled mostly via eccentric extensor contractions, by the thoracolumbar fascia and the posterior ligs. The extensors are active until about 50 of flexion, and then become inactive. This occurs because the erector ms are elongated, causing a lot of passive tension

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in the elastic elements of the ms. The posterior ligs have a better mechanical advantage than the ms as they have longer moment arms. So, support of the trunk in a fully inclined position is a passive mechanism. It is the hamstrings that secure the pelvis and the trunk over the legs. All the trunk extensors contribute to increasing the lumbar curve. As they contract, they produce a longitudinal compressive load on the LS, increasing thus, disc pressure. * Flexors: These muscles act indirectly on the spine by pulling on adjacent structures. Flexion from standing does not need any flexor ms activity due to gravity, but pushing or pulling will cause immediate isometric contractions of the flexors to stabilize the ribs, pelvis and spine. They are not active during normal erect standing, but they are essential for balancing the pull of the extensors & for maintaining the pelvis aligned. These muscles also support the guts. The primary trunk flexor is the rectus abdominis. The psoas flexes the hip, extends and stabilizes the L-S, especially during lifting. It can tilt the pelvic rim and is thus directly related to the amount of lordosis. If the psoas acts bilaterally in a CKC with femurs fixed, it pulls the L-S anteriorly and increases the lordosis, extending the L-S. Hip flexion, posterior pelvic tilt and lumbar flexion are related in the same way extension, anterior tilting and lumbar extension are related. Posterior pelvic tilt is done in supine by the rectus abd and the external obliques when the ribs are fixed, but in standing, the internal obliques are active. The psoas is a lumbar spine flexor, extensor and stabilizer; if the lumbar spine is flexed, the fibers are anterior to the axis and thus produce flexion; if the LS is extended, the fibers are mostly posterior to the axis and thus cause an extension moment. During lifting, these ms help stabilize the spine. * Rotators and SBs: LROT requires simultaneous contraction of the R external obliques and the left internal obliques. Rot and SB to the same side is done by iliocostalis, longissimus, spinalis, quadratus and serratus posterior superior. Ms that rotate to the opposite side are semispinalis, multifidus, rotators and transverse thoracis. The rotators belong to the transversospinalis group and go from transverse process to the spinous process and are more predominant in the TS. The SB are the quadratus and iliopsoas. If the quadratus works alone, it hikes the hip or tilts the pelvis laterally. LOAD ANALYSIS: Loads on the LS are produced by the bodys' own weight, by external loads, ms activation and pre-stress from the ligs. The loads on the lumbar facets are greatest (30% of a total load) when the spine is hyperextended or when there is combined FF & rotation. The facets otherwise take 20% of the vertebral load.

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Postural ms are constantly active during standing. This is minimized when the body segments are well aligned. While standing, the LOG passes in front of L4, so the motion segment is subject to a FF moment. This is counterbalanced by the ligs and the PVs. If there is disequilibrium, ms activity increases and there is a postural sway. Also involved in maintenance of an erect posture are the abdominals and psoas. Positional loads: The position of the body determines the magnitude of the load on the spine. These are minimal in supine, then in relaxed standing, then supported sitting, standing FF and worse in unsupported sitting. Flexion increases the load by increasing the forward-bending moment on the spine, which affects the disk with compressive and tensile stresses, making it bulge. During slouched sitting, there is posterior pelvic tilting and decreased lordosis, so the LOG shifts forward more, causing a longer lever arm for the trunk. This increases the torque, which increases even more as the trunk flexes. The psoas also contributes to increasing loads during sitting. With erect sitting, the pelvis is anteriorly tilted leading to increased lordosis and reduced lumbar loads. During lifting and carrying, damage to the spine is influenced by: the size, shape, weight of the object, its position and the degree of flexion or ROT of the spine. The larger the object, the greater the torque. The loads to the spine may be decreased by intraabdominal pressure (IAP), which rises as we lift and increases our FF, thus probably stabilizing the trunk. The primary reason for not lifting in FF position is due to increases in intradiskal pressure in the L-S. There is also passive insufficiency and decreased moment arm of the extensors. Consider also the distance of the object to the body and the velocity of lifting; the faster the lift, the more weight can be lifted, but the higher the load on the lumbar disks. The longer the weight is lifted, the more creep there is. These heavy lifts are possible in part due to IAP, with the transversus ms being the one who contributes the most to this action. If sacral inclination angle increases to 40, shear forces increase to 65%.

The lumbopelvic region consists of 7 bones: L4 &5, L&R innominates, sacrum and 2 femurs, 6 synovial joints ( 4 facets and 2 hip joints), 2 SIs and 1 symphysis. 28 ms attaching to the pelvis. The pelvis consists of the 2 iliums or innominates, the sacrum and coccyx. There are 7 joints formed by the pelvic bones: lumbosacral, SI, sacrococcygeal, symphysis and 2 hips. They are all linked in WB and NWB.

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SACROILIAC JOINTS These joints are the buffers between the LEs and the spine, bearing the weight of the body and transmitting it to the LEs. They can be considered as 2: sacroiliac and ilosacral (SI and IS). The sacrum is associated with the spine and the ilium with the hips. The SIJ is an amphiarthrodial or slightly movable joint, but some classify it as diarthrodial. Except for cartilage arrangement, it can be considered synovial. It is lined with hyaline cartilage on the sacral surface, and some authors say with fibrocartilage on the iliac surface. It has a capsule and synovial fluid. The

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irregular surfaces are covered with cartilaginous plates in close contact with each other and bound together by fibrous strands. Its structure and function changes from birth to maturity, between genders and from side to side. In early childhood, the surfaces are smooth, with some motion possible in all directions; after maturity, there is an A-P motion restriction. In women, the joint surfaces are smaller and flatter, the iliac crests are farther apart and the SI is farther from the hips. Due to these differences and hormonal changes, women are more likely to suffer SIJ problems. MOTION: Movt at the SI is slight (1-8 mm) and is only directly influenced by the piriformis; all other motions are indirect, caused by stresses and motion at other joints. Some authors state there are 4 of freedom; Weisl says there are 6 degrees. Kapandji describes nutation & counternutation (flex & ext with the ilia), on a transverse axis posterior to the joint. Other axes include: rot on a vertical axis, rot on oblique axis, SB on a sagittal axis (AP) and 3 transverse axes: superior, inferior and anterior. During nutation, the promontory moves anterior and inferiorly, the ilia approximate and the ischial tuberosities move apart. The opposite is true for extension or counternutation. These motions happen during trunk flex and ext as part on the lumbopelvic rhythm. Increased body weight tends to increase the angle of nutation. Nutation is limited by the anterior SI ligs, the sacrospinalis and sacrotuberous ligs. The change in sacral position during flex and ext alters the diameter of the pelvic brim and outlet. In standing lumbar FF there is an extension moment at the sacrum to counterbalance the forward migration of the COG during FF, due to the glut max and hams. With hip flexion in supine, the pelvis moves posteriorly due to the hamstrings so the sacrum remains nutated, and vice a versa. Other movts may take place but under abnormal conditions: upslips, outflares, etc & are considered to be IS motions. According to Greenman, there is normal sacral torsion during ambulation. Normally, though, the ilia move in AP direction during gait through the symphysis, and during one-legged stance. The symphysis, has 3 supporting ligaments and is linked to the SIJ in a CKC, so motion at one joint will affect the other, especially with one-legged stance. Its articular surface is covered by hyaline and separated by a fibrocartilaginous disk. Its protected by strong ligs. on all sides, while the disk is reinforced by the rectus abd, the pyramidalis and the internal oblique ms. The anterior aspect of the symphysis is reinforced by muscle expansions of the transverse abdominis, internal oblique and the adductor longus. Motion at the symphysis is minimal, and is described as cephalic to caudal translatory motion with prolonged one-legged stance. The other motion is alternating anterior and posterior rotation of each pubis on a transverse axis

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during gait. Pelvic alignment occurs when the ASIS is in line with the symphysis. During pregnancy, the ligs supporting both the symphysis and SIs become lax resulting in more mobility and less stability. If on top of this we add the weight of the uterus, the ilia tend to move on the sacrum, further stretching the capsules. The SIs are also indirectly connected to the hip and spine, so they can affect and be affected by motion of the trunk and legs. Ex: weight shifting in standing causes slight SI motion. With gait, the ilia alternately rotate A-P. LIGAMENTS: These, and not the muscles, support the joints. These are some of the strongest ligaments in the body: the anterior SI and posterior SI, interosseous ligs, iliolumbar, sacrotuberous and sacrospinous ligaments. The iliolumbar lig: can restrict all motions, especially SB. They are strong and help stabilize L5 on the sacrum. The sacrotuberous, sacrospinous and SI ligs limit ROT of the sacrum on the ilium and counteract nutation. The SI ligs keep the ilia and sacrum together and act as shock absorbers. At the symphysis, there are 3 ligs: superior pubic lig, inferior pubic lig and posterior pubic lig. along with a disc in between the joint. The anterior part of the joint is reinforced by muscle expansions: transverse abdominis, internal obliques and adductor longus.

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HIP COMPLEX This ball and socket joint, unlike the shld, promotes stability and limits mobility. It is also called the coxofemoral joint, and has 3 degrees of freedom, which are usually combined for most activities. All its axes of motion pass through the femoral head. The planes of motion are sagittal for flexion and extension, frontal for abd and adduction and transverse for rotations. One of its most important functions is to support the weight of the head, arms and trunk (HAT), to connect the lower and upper parts of the body, and provide a pathway for the transmission of forces between the pelvis and the LEs, and for locomotion. It is studied as part of a CKC. Pelvis: its full ossification (ilium, ischium and pubis) happens between 15 and 25 years of age. Acetabulum: its roundness decreases with age. Only the upper horse-shoe shaped part of its periphery is covered with hyaline cartilage and articulates with the head of the femur (HOF). The lower portion is covered by the transverse acetabular ligament, which forms a tunnel for blood vessels. It is part of the labrum but has no cartilage cells. The center and deepest part of the acetabulum, is the acetabular fossa and does not articulate with the HOF; it contains fatty tissue covered with synovial membrane. The acetabulum does not fully cover the HOF superiorly. The entire periphery of the acetabulum is rimmed by a wedgeshaped ring of fibrocartilage called labrum, which deepens the socket and increases concavity & stability. The acetabulum is oriented laterally, inferiorly & anteriorly. Femoral head: it is 2/3 of a sphere, smaller in women and has a pit almost in the middle called fovea capitis which is not covered with cartilage; it is where the lig. teres attaches, providing nutrition to the HOF. The head faces medially, superiorly & anteriorly. It has 2 angulations, which are independent of the hip joint: The angle of inclination is in the frontal plane between the axis of the femoral neck and the axis of the shaft. The angle of torsion is in the transverse plane between the axis of the femoral neck and the femoral condyles. The magnitude of these angles (or femoral twisting) depend on embrionic growth, fetal position and on the early years of development. These angles are part of the femur only and not of the hip joint, but if abnormal, they can alter its biomechanics. The angle of inclination in early infancy is 150 degrees, decreasing to 125 in adulthood, being smaller in women due to the wider pelvis. If increased it is coxa

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valga, if decreased, coxa vara. The former causes a decrease in stability and the latter, while increasing congruency, increases the bending moment predisposing to fractures of the femoral neck. The angle of torsion or angle of anteversion also decreases with age. In the newborn, its about 40, and decreases a lot in the first 2 years, until it is 15 in the adult. If increased it is anteversion, if decreased, retroversion. Internal femoral torsion occurs when the condyles are turned medially from the frontal plane and is the same as anteversion. If the HOF is twisted anteriorly to where there is an increased amount of anterior articular surface exposed, then the entire femur has to internally rotate to reestablish joint congruity. As a result, the hip joint looks aligned, but the condyles are facing medially (internal femoral torsion). Retroversion can manifest itself distally as external femoral torsion when the HOF is twisted posteriorly so that the entire femur has to rotate laterally to increase congruence. The decreases in these angles are due to normal compressive and tensile loads as the child bears weight. Hip joint: It is very congruent, but the HOF is larger than the acetabulum, so part of the femoral articular surface stays exposed anteriorly and somewhat superiorly decreasing stability. Congruency is improved with combined flexion abduction and ER. This frog leg position is used for immobilization only to improve congruency. Because the HOF does not articulate 100% with the acetabular fossa, there is a vacuum in the joint so that atmospheric pressure is present and helps with stability. This joint is subject to high loads that can reach 5 times body weight when running. For protection, the articular cartilage and subchondral bone are flattened to create more surface contact and thus decrease force per unit area. Total hip joint compression at each hip in bilateral stance is 1/3 body weight. Capsule and ligs: The capsule is strong and dense and contributes to stability. Together with the ligaments, it can support up to 2/3 body weight. It is attached to the entire periphery of the acetabulum and blends with the labrum covering the femoral neck. The anterior portion is reinforced by 2 strong ligs and the posterior part by 1. The iliofemoral lig or Y is the strongest, becoming taut and restricting hip hyperextension. The pubofemoral lig is also anterior and is taut in abduction and extension. They both form a Z similar to the GHJ. The ischiofemoral lig is posterior and tightens in extension while loosening in flexion. All of the ligs are coiled or twisted as they go from the pelvis to the femur, with hyperextension twisting them further, making this the CPP. Extension is the stable position because the ligs draw the surfaces together. The hip is one of the few joints where the position of optimal contact (flexion, abduction and ER) is the LPP, since flexion and ER uncoil the ligs and make them slack. The lig teres provides

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little stability and only in adduction with some flexion, but it provides blood supply and nerves to the HOF. Weight-bearing: The WB lines of the pelvis and femur are seen by looking at the arrangement of the trabeculae. The pelvic trabeculae pass through the acetabulum from 2 major systems within the femur: the medial and lateral trabecular systems (in the shaft) plus 2 minor accessory systems (for the trochanter and the neck). The force of half of the body weight passes through the trabecular systems of each side. The area of increased subchondral bone density in the superior acetabulum is the primary WB surface of the acetabulum. Where the systems cross constitutes the area of greatest resistance to stress and strain. The zone of weakness in the femoral neck is where the trabeculae are thin and do not cross, being thus susceptible to bending forces and fractures. The primary WB surface of the acetabulum is the dome on the superior aspect of the lunate surface. This area is thus subject to degeneration. The primary WB area of the HOF is also the superior part. Arthokinematics: The HOF glides in the acetabulum in a direction opposite to the motion of the distal end of the femur. When the hip is WB, the femur is relatively fixed and motion is produced by mov't of the pelvis on the femur. The HOF spins posteriorly in flexion. Osteokinematics: Flexion has 90 with the knee extended and 120-135 with the knee flexed and passive tension of the two-joint hamstrings is released. Extension has 10-30. When combined with knee flexion, passive tension in the 2-joint rectus femoris may limit motion. Abduction is 30-50 and adduction 10-30. Abduction is limited by the 2-joint gracilis and adduction by the TFL and ITB. Lateral rotation ranges from 45-60 and 30-45 for IR. Gait requires at least 30 flexion, 10 hyperextension, 5 abduction, adduction & ER/IR. ADLs require 120 of flexion, 20 of abduction and ER. Pelvic motions: (tilts). Anterior and posterior pelvic tilt happen in the sagittal plane around a coronal axis. Tilting anterior on a fixed femur causes hip flexion and vice versa. Lateral pelvic tilt is a hike equivalent to abduction, & pelvic drop is equivalent to adduction. Pelvic rotation happens in a transverse plane around a vertical axis. Forward rotation of the pelvis causes IR of the hip and vice versa. If the pelvis is anteriorly tilted during WB (hip flexion), the head and trunk will be displaced forward. To prevent this, anterior tilting must be accompanied by lumbar spine extension to keep the head upright & over the sacrum. Muscles: In general, muscles produce optimal forces at mid ranges. Function depends on the position of the hip and knee. *Flexors: There are 9, and the primary movers are: iliopsoas, r. femoris, TFL & sartorius. The iliopsoas is the most important and consists of the iliacus and the psoas major. If tight, they increase lumbar lordosis by pulling the lumbar spine

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(LS) forward. The rectus femoris flexes the hip and extends the knee. It is a 2 joint hip flexor, and so the position of the knee during hip flexion affects the force generating capability at the hip. Simultaneous hip flexion and knee extension shortens the ms & causes active insufficiency, therefore this ms works best with knee flexion. The sartorius flexes, externally rotates and abducts the hip, and flexes and internally rotates the knee. Even though it is a 2 joint ms, it is not affected much by the position of the knee due to the small change in length with increased knee flexion. It is active in knee flexion or extension. The TFL flexes, abducts and internally rotates the hip. It helps maintain tension in the ITB & decreases the tensile stresses on the femur during WB. Accessory ms are the pectineus, adductor longus, magnus and gracilis depending on the position of the hip. *Extensors: The prime movers are the gluteus maximus and hamstrings. Accessories are the posterior fibers of the gluteus medius, superior fibers of the adductor magnus and the piriformis. The gluteus maximus also does ER, and can reverse this function in the extremes of ranges. The 3 hams are 2 joint ms that flex the knee and extend the hip. The biceps does ER of the knee and the long head laterally rotates the hip. The other 2 hams do IR of the knee. The hams increase their moment arm as the hip flexes to 35. The moment arm of the gluteus maximus decreases with hip flexion. *Abductors: They are considered the deltoid of the hip and work best when in neutral. The prime movers are the gluteus medius and minimus. The superior fibers of the maximus and the sartorius assist when the hip is abducted against strong resistance. The TFL abducts only with hip flexion. The anterior fibers of the gluteus medius do hip flexion and IR and the posterior fibers do extension and ER. The gluteus medius and minimus act together to either abduct the femur in an open kinetic chain or to stabilize the pelvis in unilateral stance, preventing a pelvic drop. *Adductors: They are the pectineus, adductor brevis, longus, magnus and gracilis. The latter is the only 2 joint ms in this group, and is active as a hip flexor when the knee is extended, but not flexed. It is believed that they function not as prime movers, but by reflex response to WB. They are stronger than abductors. If they are posterior to the frontal plane, they extend the hip, and if anterior, they assist with flexion. *External Rotators: They are joint compressors since their combined action line parallels the head and neck of the femur (similar to the rotator cuff). They are obturator internus, obturator externus, gemellus superior and inferior, quadratus femoris, piriformis and gluteus maximus. The posterior fibers of the gluteus medius and minimus assist. *Internal Rotators: Prime movers are the anterior portion of the gluteus minimus and the TFL. Accessories are glut med, semimemb and semitendinosus.

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Muscle function in stance: When standing straight, the hips are neutral or slightly hyperextended. The LOG is just posterior to the axis, causing an extension moment that tends to tilt the pelvis posteriorly and is checked by passive tension in the ligs and capsule, which are taut in full extension. There is little ms activity needed to maintain balance while the LOG stays behind the axis, but if it falls anteriorly, there is a flexion moment and the hams and gluteus maximus prevent hip flexion via anterior pelvic and trunk tilting. If stance is asymmetrical, ms activity is needed for equilibrium. If standing on 1 leg, stability is given by the abductors. This posture increases the joint reaction forces through the standing hip by 2.5-3 times the body weight (and 7 times in stair climbing). To counter this, there is an abductor moment to stop the pelvis from dropping. It is also important to decrease weight; losing 1# decreases the joint reaction force by 3#. Other methods to decrease ms forces in unilateral stance and thus hip pain include leaning the trunk above the pelvis toward the side of pain or weakness, which brings the LOG closer to the supporting hip decreasing the moment arm. If this leaning is seen during gait its called gluteus medius gait and is due to hip abductor weakness; if due to hip pain its antalgic gait. If the leaning comes with a pelvic drop, its trendelenburg. Pushing down on a cane that is on the side of the pain decreases the body weight by the amount of the downward pressure and this is good because it decreases energy expenditure and stresses, but it is no good for reducing hip compression. So, using the cane on the opposite side, decreases the body weight (latissimus) by 15% and it creates a countertorque to the torque of gravity, decreasing the need to use the hip abductors, relieving the hip joint of 60% of its load. If a patient carries something while standing on one leg, it results in a shift of the LOG toward the painful hip if held on the bad side or away from the hip if held on the good side. A shift of the LOG to the bad side results in decreased WB torque, while carrying a load on the opposite side of the pain increases the torque requiring increased hip abductor activity. Using a cane contralaterally and carrying something ipsilaterally decreases the need for abductor force and joint reaction force to the hip. The force of the hip is the sum of the vertical forces down, minus the vertical forces up on the cane (JBJS 38A:695-708, 1956). THE KNEE COMPLEX It is one of the largest joints, located between the 2 longest levers & thus subject to great torque. It is composed of 2 articulations within 1 capsule: tibio-femoral and patellofemoral joints. The superior tibio-fibular joint is not considered part of

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the knee because it lies outside the capsule and is functionally related to the ankle. Tibiofemoral joint: it is a condyloid joint with 2 of freedom. The femoral shaft is angled obliquely so the condyles do not lie directly under the HOF, but medially, so the lateral condyle is more in line with the shaft than the medial condyle. The articular surface of the medial femoral condyle is longer and extends further distally. The medial tibial condyle is then 50% larger than the lateral, and its cartilage is 3 times thicker. The lateral femoral condyle is flatter & more prominent anteriorly to decrease lateral patellar dislocations. Some authors consider the knee joint to have 6 mechanical degrees of freedom (3 rotations and 3 translations): prox-dist translation, med-lat translation and anterior-posterior translation; internal-external rotation, flexion-extension rotation and varus-valgus rotation. The axis of the tibia is almost vertical, so with the femur, a medial angle of 5-10 is formed which constitutes a normal valgus angle at the knee. Because GRF (ground reaction forces) follow the mechanical rather than anatomical axes, the WB stresses are equally distributed between the condyles, so the lateral meniscus is not more stressed than the medial one except when standing on 1 leg. The menisci are asymmetric fibrocartilaginous disks placed on the tibial condyles, and function to decrease friction, increase stability and absorb forces. They are unattached at the internal edge, allowing increased mobility. They are well vascularized up to the age of 10, and during adulthood, they are vascularized only on the periphery from the capsule and synovial membrane. This is probably why they can only regenerate in the periphery and why kids have such few tears. The horns are fully vascularized throughout life. Both, the horns and the periphery are innervated. The menisci can assume about 50% of the load during activities, so if they are removed, the magnitude of the load increases, leading to further damage. With varus of 5, the medial meniscus can be compressed by 25% more than normal. Both move (distort) with the femoral condyles during ROM. The medial meniscus is a semicircle. It is thick on the periphery and thin centrally and ends in horns. The function is to decrease WB force and friction and to improve joint congruency. It is connected to the periphery by the coronary ligs and is attached to the patella through the patellotibial ligs (anterior capsular thickenings). The anterior horns are connected to each other via the transverse lig. The medial meniscus is attached to the MCL & semi-membranosus through its capsular connections. This results in posterior displacement with flexion. Because it is attached more firmly, it is more prone to tears. It moves forward with IR and backwards with ER.

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The lateral meniscus is 4/5 of a ring. It is attached to the PCL & the popliteus ms via coronary ligs and posterior capsule, but is loser than the medial one. It displaces posteriorly during flexion up to 1 cm & moves forward with ER. The capsule is large and lax having several recesses. It is reinforced posteriorly by ms, by the oblique popliteal (expansion of the semimembranosus) and by the arcuate lig. The sides are reinforced by the collateral ligs and the front by the patella, & the quad and patellar tendons. The anterior-medial (A/M) and anterior-lateral (A/L) sides have expansions from the VM and VL. These portions of the capsule are called the extensor retinaculum and connect the capsule anteriorly to the menisci and tibia via the coronary ligs. The patellar plica is a synovial recess that can be present in 20-60% of adults and is formed of elastic loose fibrous connective tissue that moves over the femoral condyle during flexion and ext. It can get irritated and cause pain. Ligaments: Their function depends on the position of the joint and how the stresses are applied. The MCL & LCL provide rotatory stability. *MCL: it resists valgus, especially in extension when it is taut, but also in slight flexion. It also resists ER of the tibia and anterior and posterior displacement of the tibia. It functions also as a backup to anterior translation when the ACL is deficient. *LCL: it resists varus stresses, limits ER especially at 35 of flexion, and ER with posterior displacement of the tibia. It is also taut in full extension and resists hyperextension, but it does not attach to the capsule or meniscus. *ITB: It is a passive structure that is consistently taut. It helps the ACL to limit posterior displacement of the femur when the tibia is fixed and mostly extended. It sends fibers to the patella forming the iliopatellar band. *ACL: It is divided into an anterior-medial band (AMB), taut in flexion, and a posteriorlateral band (PLB). (Some authors state that the ACL & PCL also have an intermediate band). The ACL is the primary restraint to anterior displacement and IR of the tibia on the femur and to extension. It has a slip that attaches to the anterior horn of lateral meniscus. Basically, it is taut in extension, when it is almost vertical. It causes the femoral condyles to slide anteriorly and roll posteriorly with flexion. *PCL: Its fibers are also divided into AMB and PLB. The PLC is the primary restraint for posterior displacement of the tibia, and for flexion where it is taut. It

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also helps restrict IR, varus and valgus stresses. It causes the femoral condyles to slide posteriorly and roll anteriorly with extension. Its AMB is also taut in flexion. Both ligs twist on each other and lie outside of the synovial cavity but in the capsule: intraarticular but extracapsular. In general, external rotation is checked by the collaterals, while internal rotation is checked by the cruciates. *Oblique popliteal lig: this is the tendinous expansion of the semimembranosus, and is taut in extension and resists hyperextension and valgus stresses. It reinforces the posterior capsule. *Arcuate lig: also reinforces the posterior capsule, is taut in extension and resists varus stresses. *Posterior oblique lig: is part of the posterior medial capsule and stabilizes the joint against AM instability and valgus and prevents excessive tibial ER. There are also meniscofemoral ligaments from the lateral meniscus to the medial condyle, and meniscopatellar ligs, from the patella to the tibia and meniscus. Pes anserine: functions to prevent abnormal ER, and anterior displacement of the tibia, assisting the ACL and MCL, & stabilize the medial aspect of the knee. Bursae: There are more than 20. The most important ones are: suprapatellar, subpopliteal and gastroc bursae, and they communicate within the capsule so they are not totally separated. The other bursae do not communicate with the synovial cavity; some are the prepatellar (between skin and patella), infrapatellar (between patellar lig and the skin). Stability: The supporting structures of the knee are the medial and lateral compartment structures. The former includes AM, medial and PM aspects of the knee, and the latter includes its respective structures. So basically almost all the knee structures help with stability. Stability increases with extension (CPP). Flexion usually is the position for ligamentous injuries, and extension for fractures and ligament tears. Motion: *Flexion & extension: Hip position influences knee motion. Passive flexion = 140 but can be reduced when the hip is simultaneously hyperextended and the rectus femoris gets passively insufficient. Conversely, flexion can increase to 160 when the hip is flexed, as in squatting, with weight added.

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The axis for flex/ext is oblique like the elbow, so the tibia moves medially in full flexion. The axis however, is not fixed and moves through the ROM superiorly and posteriorly on the femoral condyles with flexion (like a J). Normal walking requires 60, stairs needs 80, sitting needs 90 and donning and doffing 105. If the ankle is fused in DF, the knee cannot extend or flex without lifting part of the foot. *Rotation: This is automatic, and can only be done with the knee flexed, as the tibial tubercles are lodged in the intercondylar notch in the CPP (extension). When the knee is extended, the foot is externally rotated, and when flexed, it is internally rotated. The axis for rotation is on the medial condyles, but lateral motion is greater than medial motion. With ER, the medial tibial condyle moves slightly anteriorly on the femoral condyles while the lateral tibial condyle moves posteriorly much more. Synergies: 1. knee and hip extension: seen with rising, going up stairs & gait, controlled at the hip by the hams, and at the knee by the quads. Hip extension facilitates knee extension. 2. knee with hip flexion: seen going up stairs. Arthrokinemetics: During flexion in the open chain, the tibia rolls & glides posteriorly on the femoral condyles in the direction of the limb motion. The opposite happens in CKC: the femoral condyles roll back and slide forwards on the tibia to bend the knee. The menisci move slightly (distort) with the femoral condyles because the horns are fixed. There is pure rolling of the femoral condyles on a fixed tibia during the first 25 of flexion. This can lead to shear forces, but the menisci move posteriorly with the condyles in flexion and so shear decreases due to the semimembranosus & popliteus expansion tension. With extension, the meninsci go forward because of the meniscopatellar fibers. The LPP = 25 of flexion. ER during the last 30extension = screw home mechanism or locking or CPP, due to the larger medial component and the tibial tubercle lodging in the femoral notch. Unlocking is initiated by IR of the tibia on the femur before flexion can take place and is done by popliteus and tension of the PCL. Muscles: *Flexors: 7, all of which are biarticular except for the short head and the popliteus. The other 5 are the semis, sartorius, gracilis and gastrocs. They are influenced by the position of the 2 joints. (except for the sartorius). The popliteus, gracilis, and semis also do IR of the tibia, and the biceps does ER and stabilizes the PL aspect of the joint. TFL extends in flexion, flexes in extension. During prone flexion, the hams have to shorten over the 2 joints, so they weaken as flexion increases due to active insufficiency and need to overcome tension in the rectus femoris which is becoming passive insufficient. The gastrocs help prevent hyperextension; the popliteus helps with unlocking.

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*Extensors: they are twice as strong as the flexors. Only the rectus femoris is biarticular. The ms. fibers are slightly angulated, with the VM being angulated 15 medially on its upper fibers, and 50 medially on its lower fibers. Hence the name VMO and VML (longus). The ITB as an extension of the TFL is an extensor until 30 of flex, and a flexor beyond 40. Most of the literature supports that terminal extension is accomplished by the VMO.

Patellofemoral joint: Mechanically, the presence of the patella affects the quads by lengthening the moment arm of the ms by increasing the distance of the quad tendon and patellar lig. from the axis. The patella functions as an anatomic pulley and thus deflects the line of action away from the joint, increasing the angle of pull and torque production. During flexion the patella no longer works as a pulley. The maximum torque of the extensors occurs between 45 and 60 and the least torque occurs in the last 15 of extension due to decreased length-tension and length of MA. Patellectomy is thus bad. The patella functions to do the following: It increases the leverage, mechanical advantage or torque of the quads by increasing the distance from the axis. This improves extension by displacing the quad tendon anteriorly. If there is no patella, the quads need 30% more force due to short lever arm, and they have a 50% decreased strength. It gives bony protection to the distal part of the knee during flexion. It provides a wider distribution of compressive stress on the femur by increasing the contact area between the pat tend and the femur especially with knee flexion (squats). It protects the quad tendon from friction forces. In full knee extension, the patella sits on the anterior surface of the distal femur on the suprapatellar fat pad and synovium, while in flexion it slides down into the intercondylar notch. It travels 8 cm from full ext. to full flex. Patellar articular surface: The PFJ is the least congruent joint in the body; the medial and lateral facets on the posterior aspect are flat to slightly convex. It has the thickest cartilage in the body: 4-5 mm. The retropatellar surface is divided by a vertical ridge and 30% of patellas have an additional ridge closer to the medial side, which is the odd facet. Tracking: This is important because it is related to proper function and to the magnitude of forces acting on the PFJ. As the patella tracks or travels down the femur, it accommodates to the shape of the condyles. From 90 of flexion to 0 of extension, the patella undergoes a medial shift of 14 mm, a medial tilt of 12 (rotation on vertical axis) and medially rotates 6 to accommodate to the condylar asymmetries. (Reider, B: Clin Ortho Rel Res 157: 143-8 1981).

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Going into flexion, it follows a concave lateral curve that starts laterally. During the first 20 of flexion the tibia internally rotates and the patella is drawn into the notch decreasing the Q angle. After 90, the patella tilts slightly laterally and moves laterally over the lateral condyle and as flexion increases, the medial condyle is exposed. Normal alignment has 3 components: tilt, glide and rot. The patella should be parallel with the long axis of the femur, and sitting midway between the 2 condyles (McConnell). Tracking and patellar position are influenced by: VMO, medial retinaculum, medial patellofemoral ligaments, patellar shape (deep is better), height of the patella, VL strg, lateral retinaculum tightness, lateral tibial tubercle which increases the Q angle, external tibial torsion, Q angle, hip anteversion, which causes inward squinting, foot pronation, and LE position, flexibility, strength and endurance. During IR of the tibia, the patella also moves into IR as the inferior pole is attached to the tibia. This occurs at all angles. The patella will move laterally with ER during flexion. Patellar index: The ratio of the length of the tendon to the length of the patella is ~ 1:1. The lig should not exceed the patella in length by more than 20%. A long tendon causes an abnormally high patellar position called patella alta. In full extension there is no contact on the femur. At most, there is minimal contact at the inferior pole and the notch. Normally, the patella should sit between the femoral notch. Normal patellar contact in extension is minimal. At 20 of flexion, the first contact takes place at the inferior border, across the medial and lateral facets. At 45 degrees contact increases from distal to proximal and at 90, contact is at the superior pole of the patella. After 90 the medial facet goes in the notch. The odd facet comes in contact at 135 while the medial facet is out of contact. So the medial facet has the most consistent contact with the femur, where most of the cartilaginous changes are noted with degeneration, along with the odd facet, because it has the least amount of compression. Q Angle: is measured between the ASIS to the midpatella and between the tibial tuberosity and the midpatella, in extension. Normal: 15, more in women due to anteversion, wider pelvis and valgus. If this angle increases, it increases the lateral forces and predisposes the joint to pathology. It decreases with tibial internal rotation. Stability: Static and dynamic stability is determined by patellar position. There are 2 types of stabilizers: transverse and longitudinal. The transverse ones are the medial and lateral retinacula joining the VM and VL respectively. The

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longitudinal stabilizers are the patella tendon inferiorly and the quad tendon superiorly. These influence tracking and positioning. In full extension, the patella can move half its width medially or laterally. Forces are usually stronger on the lateral aspect. The pull of the VL and VML is ~15 lateral to the femurs long axis. Weakness on the VMO or tightness in the VL or retinaculum can increase these lateral forces and lateral compression. Valgus can increase the obliquity of the femur and the pull of the quads. PFJRF: Because there is little to no contact between the patella and the femur in extension, even if the quad does a strong contraction, there is minimal compression. This is why SLR exercises increase strength without increasing stresses at the knee. As flexion increases, the pull of the quad tendon and patellar ligament become oblique increasing compressive forces, whether the quads are active or not, as the COG shifts farther away from the axis, increasing the flexion moment to be counterbalanced by quad forces, so as force increases, so does JRF. (The LOG of the knee is anterior to the axis). The JRF with walking when the foot first touches the ground at 15 flexion, is 50% of body weight. With stair climbing or running, it is 3 times body weight at 60 and with squatting it is 8 times. Between 70-90 the quad tendon contacts the femoral condyle dissipating some compression. Cartilage changes on the medial patellar facet are more common, but changes on the lateral facet can progress to osteoarthritis (OA) more commonly.

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ANKLE & FOOT COMPLEX The foot and ankle provide a stable BOS. The foot works as a shock absorber and allows the foot to conform to the shape of the ground. It functions as a rigid lever for proper push-off during gait, when the ankle provides most of the propulsive power. The complex also helps dampen the rotations from the proximal LE joints. The complex is divided into 3 sections: rearfoot, midfoot and forefoot, which function as a unit in stance. Changes in any structure will alter the function of the entire foot, as motion in one joint will influence motion in another, and this can be transmitted up the LE especially in WB. The joints include: proximal & distal tib-fib joints, TCJ, STJ, TNJ, CCJ, 5 TMT, 5MTP and 9 IPs. A normal foot is one in which there is no pain, there is normal muscle balance, a central heel and straight and mobile toes. Development: the foot develops in a supinated position, and is corrected by changes in the rearfoot, where as ER of the head of the talus occurs, forefoot varus decreases. In infancy, the varus angle = 36 and in the adult it is 3.6, (and the talar-neck-calcaneal angle decreases from 42 to 23 in the adult). The foot in an infant is pronated because the medial arch is occupied by a fat pad. The foot has also increased ROM. From the ages of about 5-12, the foot grows about 1cm a year ending at about the age of 15. Its adult shape however, is formed between the ages of 6 to 8. The adult gait pattern develops by the age of 5. At about one year of age, the foot equals half its adult size. REARFOOT: It consists of the talus and calcaneus and functions to convert the torque of the LE as well as to influence the function of the mid and forefoot. Prox tib-fib joint: plane synovial joint, surrounded by a capsule and reinforced by anterior and posterior ligs. It is not part of the knee. Motion is minimal and consists of superior and inferior gliding, and of rotation of the fibula. The fibula at this level is considered to be concave. The joint has a capsule and is supported by the anterior and posterior tib-fib ligaments. Distal tib-fib: is a syndesmosis without articular cartilage that does not really touch as it is separated by fibroadipose tissue. It has no joint capsule but several ligs. that restrict motion to keep the mortise stable. The strongest lig is the crural tibfib interosseous lig, which also functions as a fulcrum for fibular motion. Other ligs include the anterior & posterior tibfib ligs and the inter-osseous membrane, the latter stabilizing both tibfib joints. The fibula at this level is convex and moves more than the medial malleolus (superior/inferior, IR/ER). With DF, the fibula internally rotates, the malleoli separate, the inter-osseos membrane becomes more horizontal and the lateral malleolus migrates superiorly.

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Ankle or talocrural joint: is the most congruent joint in the body, being a synovial hinge joint with 1 degree of freedom: DF & PF. The talocrural joint is formed by the distal tibia and superior surface of the talus. This mortise is adjustable and functions as a weight distributor. The ankle is controlled by the proximal and distal tib-fib joints, but they do not add any degrees of freedom of motion; if fused, however, function decreases. The fibula bears only a maximum of 10% of weight. Because of the large surface area, the load transmission across the ankle is less than that across the hip or knee. The articular surface of talus, which is wedge-shaped, and wider anteriorly than posteriorly, is divided into 3 facets: lateral, medial and superior. It is called the caged bone or relay station as no muscles insert on it, but is surrounded by ligs. The stability of the TCJ is provided by its bony congruency and the ligaments. Ligaments: the capsule is thin and weak, but its ligs are strong, especially the MCM. In addition to the ones mentioned earlier, the collaterals are important as they provide medial and lateral reinforcement and check extreme ROM. *The MCL or deltoid lig, is divided into 3 bands and controls valgus stress and lateral talar shift. This lig. is important for the integrity of the syndesmosis. *The LCL is also divided into 3 bands: anterior & posterior talofibular and calcaneofibular ligs. The posterior talofibular is the strongest of the 3, and the calcaneofibular is the most important stabilizer. The LCL function depends on the position of the ankle, whereby it can resist DF, PF, talar tilt and rotation. PF is resisted by the ATF lig, DF by the calcaneofibular lig and posterior tib-fib, and pure inversion by the calcaneofibular lig, so at least one band is tense throughout the ROM. The posterior talo-fibular lig limits posterior shifting of the talus or anterior shifting of the tib-fib, and ER of the talus, or IR of the fibula. The ATF lig does the opposite. Muscles: Stability is also provided by the ms. The triceps surae checks DF, which is limited more during knee extension. Tension in the anterior tib, EHL and EDL check PF. The posterior tib, FHL and FDL protect the medial side of the joint, and the peroneus longus and brevis protect the lat side. The posterior tib keeps the malleoli pincer together and pulls the navicular back. The peroneus longus is important in foot dynamics and acts on all the arches. It also flexes the 1st MT. The FHL stabilizes the talus and calcaneus and keeps them forward. The last 2 muscles are 7-joint muscles. Motion: There is DF and PF, which do not take place exclusively in the sagittal plane but cross 3 planes with an oblique joint axis. Mobility is thus described as a triplanar motion, which is mov't in all 3 planes at the same time. These mov'ts are

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called pronation & supination. The 1st consists of abduction (trans), DF (sagittal) and eversion (frontal). Supination is a combination of adduction, PF and inversion. Pure DF entails a synergistic contraction of the EHL and anterior tib along with the EDL and peroneus tertius, which are also antagonistic ms. Pure PF results from balanced activity of the peroneus longus and brevis with the posterior tib, FDL and FHL medially. These are also antagonists and synergists, all of which are accessory PFs and weak compared to the triceps surae, which is the only ms that causes tip-toeing. The PL is stronger than the PB. The CPP = DF. Arthrokinamatics: The talus can rotate or twist within the mortise in the frontal and transverse planes, with 7 of IR and 10 of ER. It can also tilt about 5. The fibula can glide anteriorly on the lateral facet of the talus in DF, and posteriorly with PF. The fibula and tibia separate 1 mm during DF. The talus is convex, so PG will increase DF. It can be distracted & moved passively anterior and posterior about 2-3 mm. Talar rotation is driven by tibial rotation while calcaneal rotation is driven by muscles and GRF. Axis: The axis goes through the medial & lateral malleolus and the body of the talus. The axis is rotated laterally 20-30 in the transverse plane thus DF = foot up and out and PF = foot down and in. Torsion of the tibia is similar to that of the femur only in opposite direction, hence the toe-out position. Subtalar or talocalcaneal joint has 1 of freedom and is a very stable joint. It functions as a torque converter of the leg in WB, so that forces can be attenuated. It transfers axial rotation of the leg to pronation and supination of the foot during gait. Anatomically, the surface of the inferior aspect of the talus has posterior, anterior and middle articulations, with the posterior articulation being larger and forming a concave facet on the talus and convex facet on the calcaneus. It has its own capsule and the other 2 share one with the talonavicular joint. These articulations are divided by the tarsal canal. Motion and axis: Motion that occurs here are also composite: supination and pronation around an oblique axis which extends anteriormedialy from the neck of the talus to the posterior lateral side of the calcaneus, measuring 42 from the horizontal and 16 from the midline. Because the axis is oblique, mov't here is also triplanar, as its component motions cannot occur independently. Subtalar joint neutral is the midposition of the joint. Average subtalar joint motion from maximum inversion to maximum eversion = 30. Supination at this level occurs when the posterior tibialis pulls the navicular, which drags the cuboid that pulls the calcaneus opening the sinus tarsi. Pronation occurs when the peroneus brevis pulls the cuboid that draws the navicular and calcaneus. Both of these motions are limited by bones and ligs.

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Ligaments: they are the interosseous talocalcaneal or axial lig within the tarsal canal (sinus tarsi), which limits eversion, and the posterior and lateral talocalc ligs. which keep the joint together. The cervical lig. joins the necks of the talus and calcaneus. The MCL and LCL also work here. Arthrokinematics: The alternating concave-convex relationship at this joint restricts its motion, but the calcaneus is considered convex and talus concave as the posterior compartment of the joint is larger, so a MG increases eversion and LG inversion. Motion is like twisting. When the subtalar joint is NWB, its motion and that of the leg are independent and do not influence each other. The CPP is supination. In NWB (supination), the calcaneus does inversion, adduction & PF. Soft tissue: The heel pad consists of specialized fat cells in the shape of a comma or a U forming vertical columns reinforcing elastic fibers to produce a honeycomb effect to absorb and dissipate forces. MIDFOOT: It transmits motion from the rear-foot to the forefoot and provides stability. It depends on the mechanics of the rear-foot. Its joints orient the forefoot and can alter the arches to accommodate to the shape of the ground and assist with shock absortion. Talocalcaneonavicular joint: The midtarsal, transverse tarsal and Chopart's joint are the calcaneocuboid and talonavicular joints, but since the talus moves at the same time with the navicular and the calcaneus in WB, the complex is termed TCNJ. It is considered a transitional link between the rear-foot and forefoot in order to provide supination and pronation and to compensate the forefoot for rear-foot position. This TCN complex is considered to have 2 axes of triplanar motion with 1 of freedom for supination and pronation. At the longitudinal axis inversion and eversion predominate, and for the oblique axis there is combined DF & abduction and PF & adduction. Compensation is defined as the ability of the forefoot to remain flat in WB while the rear-foot is in varus or valgus. Calcaneocuboid joint is a saddle joint with its own capsule, where only rotation can occur, like a pivot, allowing the forefoot to twist on the rear-foot about 5. The cuboid acts like a fulcrum for the peroneus longus during push-off, plantarflexing the 1st ray. This pivotal motion is done by supination of the subtalar joint. The ligs of the CCJ help support the longitudinal arch: calcaneocuboid ligs and short and long plantar ligs. The navicular and cuboid joint has little motion and move as a unit with the anterior part of the foot. They unlock at heel contact during gait and are basically immobile with WB as they are fixed.

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The talonavicular joint is considered the key to foot function as it moves in response to the talus and calcaneus in a single unit. It is triplanar with 1of freedom for supination and pronation. Its axis is similar to that of the subtalar joint. It is deepened by the spring and deltoid ligs. The collaterals & inter-osseous talocalcaneal also reinforce the joint. Motion: Motion here is essentially similar to that of the subtalar joint. Supination at the TNJ restricts midfoot mobility increasing its stability, making the foot rigid. It is thus the CPP. Rotational movements at the midtarsal joint let the foot twist on the rearfoot. The forefoot moves on the talus & calcaneus via motion at the midtarsal joint. FOREFOOT: It is comprised of the tarsometatarsal or Lisfranc's joints, the MTTPJ and IPJs. It adapts to the ground as the terrain changes and also depends on the mechanics of the rear-foot. *The TMT joints are plane synovial joints between the distal tarsal row posteriorly and the MTT bases anteriorly. The first TMT is formed by the base of the first MTT and the medial cuneiform, having its own articular capsule. The second TMT joint is the joint between the base of the 2nd MTT and a mortise formed by the middle cuneiform and the sides of the medial and lateral cuneiforms. The 3rd TMTJ comprises the 3rd MTT and the lat cuneiform, sharing its capsule with the 2nd TMTJ. The 4th & 5th TMT bases go to the cuboid, and they share their capsule. The TMTJ functions as a continuation of the midfoot, regulating the position of the MTTs and phalanges to adapt to WB surfaces. The MTT heads tolerate WB forces and the toes stabilize the forefoot. Motion at these joints is normally small. The 2nd ray is the least mobile and the 1st is the most mobile. There is some motion available between the MTT bases. A ray is a functional unit formed by a MTT and its associated cuneiform if present. The first ray has the greatest ROM, with DF accompanied with inversion and adduction. It does not bear the greatest pressure in WB, which indicates that it has more of a dynamic function during push-off. Axis: The TMTJs have their own triplanar oblique axis, and allow flexion and extension with a bit of pronation and supination or axial rotation. Arches: The foot can become flexible or rigid thanks to the bony structure of the arches, lig and fascial support and ms activity. Body weight is distributed through the 3 arches, which do not collapse due to the aponeurosis, which is like a tie-rod or truss. They can be considered a single twisted osteoliga-mentous plate from the

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heel to the base of the proximal phalanx that untwist during WB, or considered to be divided into 3 arches, which is more common. The medial longitudinal arch goes form the calcaneus to the 1st MTT head. Its shape is kept by ms and ligs. Its the longest and highest. The lateral longitudinal arch comprises the 5th MTT head, the cuboid and the calcaneus. It is lower and more rigid than the longitudinal arch. Its keystone is the calcaneus. The transverse arch is formed by the cuboid and the cuneiforms posteriorly and by the 1st and 5th MTT heads anteriorly, with the medial cuneiform being the keystone. Ms. that support the arches are the adductor hallucis, PL and brevis, posterior tib. FHL, DL, abductor hallucis longus, triceps, anterior tib, FDL, EHL & B. Overall ligamentous support is provided by the spring lig, short and long plantar ligs, the fascia preventing flattening and the deep transverse MT ligament that resists splaying. Supination and pronation twists: If the first ray is extended (DF) and the fifth ray flexed (PF) there is a supination twist of the forefoot. A high medial arch in WB is caused by ER of the tibia, subtalar and midfoot supination and pronation of the forefoot, while a low arch is produced by tibial IR, pronation of the subtalar and midtarsal joints and supination twist of the forefoot. The PB and PL also function as pronators. Metatarsophalangeal joints: They are considered beams supporting the longitudinal arches. They are condyloid synovial joints with 2 of freedom, for flexion and extension and for abduction and adduction with the first 2 predominating. Toe extension is important because it makes the body pass over the foot while the toes balance the body weight in WB. MTP extension, unlike MCP extension, exceed flexion ranges. The head of the first MTT has a large joint surface having sesamoid bones providing the FHL with mechanical advantage to lessen joint forces as they protect the tendon. The sesamoids also serve as anatomic pulleys for FHB. Axis: There is a single oblique axis or MTT brake for MTP flexion & extension that runs through the 2 - 5th MTT heads helping to distribute the weight across the MTT heads with push-off as the foot becomes a rigid lever. It is like a hinge so the heel can rise. It is about 60 going med and anterior between 2 & 3 MTT heads. The first toe is normally adducted 15, which is a normal valgus angulation. If increased, it is called hallux valgus. Motion: DF across the NWB TMTs extends the 5 MTTs causing also inversion at the first 2 rays & eversion at the last 2 rays. The opposite occurs with PF. There is about 80-90extension and 15 flexion depending on the length of the MTTs, & whether motion is in WB or NWB.

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Stability at the forefoot is given by the plantar plates (like in the hand), the small collateral ligaments, the deep transverse MT lig & plantar aponeurosis. Plantar aponeurosis: It is dense fascia, which courses almost the full length of the foot, starting at the medial aspect of the calcaneus and attaching to the proximal phalanx of each toe. It transmits forces and contributes to the medial longitudinal arch stability as it restricts passive flexion of toes, & serves as an attachment for intrinsic ms. of the foot. If the fascia is tight, it promotes inversion of the calcaneus & ST supination. It is taut with toe & MTP extension (resisting it if excessive), by producing a passive flexor force across the MTPJ. Some call it a windlass mechanism, which passively stabilizes the bones. It resists tensile and compressive forces and tightens with MTP extension supporting the rear and the midfoot. Weight distribution: During standing, loads are distributed equally on the heel and the ball of the foot, with the hallux bearing twice the load than the other MTTs, but during gait, most of the load is on the 2nd MTT as it tends to be longer and stiffer (index minus foot). Sixty percent of the WB load is carried by the rearfoot, 8% by the midfoot and 28% by the MTT heads during stance. Each talus bears 50% of the weight, while running can create 250% of body weight to the calcaneus. Forces acting on the ankle = 5 x body weight during ambulation, and up to 13 x with running. Muscles: Active control of the foot is provided by extrinsic ms. all of which act on more than one joint depending on the angle of pull. The anterior leg ms decelerate the foot at heel strike & posterior ms propel the foot toward toe-off.

Extrinsic: the triceps surae supinates the midfoot and elevates the arch. Its
function depends on the angle of knee flexion. The gastrocs are less efficient as flexion increases. The posterior tib also supinates the foot reversing pronation. The FHL and FDL flex the toes. The peroneus longus & brevis pronate the foot while the longus plantarflexes and pronates the 1st ray stabilizing it. It also supports the longitudinal arch. The anterior tib & EHL DF the ankle and may supinate the TCNJ. The EDL and peroneus tertius are weak DF and pronators of the foot. Supinators are stronger than pronators.

Intrinsic: they stabilize the toes and support the transverse and longitudinal
arches during gait. The rest are similar to the hand ms. Interphalangeal joints: They are synovial hinge joints with 1 of freedom for flexion and extension for 5 proximal IPJ and 4 distal IPJs. They stabilize the longitudinal arch and maintain contact against the ground. Approx 40% of the body weight is transmitted to the toes during push-off.

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CLOSED KINETIC CHAIN MECHANISCMS OF THE FOOT AND ANKLE

Heel contact to weight acceptance:


Rearfoot: Fast rearfoot varus, then Subtalar joint pronation Talocrural plantarflexion Tibial internal rotation Calcaneal eversion Talar adduction and PF Midfoot: Midtarsal (TCNJ) pronation Cuboid/navicular unlock Talus displaces forward Navicular rotates Forefoot: Supination twist-DF of 1st ray

Early midstance/ midtance/ late midstance:


Rearfoot: Early: tibia displaced forward over talus Midstance: subtalar joint neutral Late: talus begins to supinate and DF Midfoot: Midtarsal reversal of pronation Forefoot: FWB of MTT heads

Push-off and propulsion:


Rearfoot: Tibial external rotation Subtalar supination Calcaneus inverts Midfoot: Midtarsal supination Forefoot: Pronation twist-1st ray PF Sesamoids weight bearing

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Adapted from Donatelli R: The Biomechanics of the Foot and ankle. FA Davis, 1990. GAIT Gait is a style of walking. Each person has their own gait pattern, which may reflect their type of occupation, their personality, health, body structure, etc. The functions of locomotion are: propulsion, stance, stability, shock absortion and energy conservation. Gait is a translatory progression of the body, and should be rhythmic and coordinated. It is characterized by alternating propulsive and retropulsive motions of the lower limbs, and alternating swinging of the upper limbs, and is classified in phases, such as the stance phase and the swing phase. A gait cycle occurs from the time there is initial contact of the heel on the ground, to the point where the same heel hits the ground again. As the body assumes different positions, the COG changes in response to the new position. From a kinematic perspective, gait consists of 2 phases: 1) The stance phase occurs when the foot is in contact with the ground (60% of the time) and is comprised of heel strike (H-S), foot-flat, midstance (when body weight is directly over the supporting limb), heel-off and toe-off sub-phases. 2) The swing phase occurs when the foot is in the air, and consists of acceleration, midswing (when the limb passes directly beneath the body) and deceleration (the knee is extended in preparation for heel-strike). This takes place 40% of the time. These two phases occur in one gait cycle. Classic gait terminology is event-based, referring to what occurs in a single extremity, whereas the newer (RLA) gait terminology is phase-based and refers to phases and events occurring in both extremities: initial contact, loading response, midstance, terminal stance and preswing. Gait parameters:

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A. Temporal variables: 1. stance time 2. swing time 3. stride and step time 4. cadence (number of steps per minute, usually 90-120) 5. speed (distance walked per time, usually 81 m/minute) B. Distance variables: 1. stride length (or gait cycle: from heel of R to heel of R, 140-155cm) 2. step length (from heel of the R to heel of the L, 68-78cm) 3. width of walking BOS (5-10cm) 4. degree of toe out (7) Determinants of gait: In the kinematic analysis of gait, these components refer to the bodys' ability to keep the up-and-down and side-to-side mov't of the COG to a minimum (2 inch square box), and thus decrease energy expenditure. These determinants include: lateral pelvic tilt, knee flexion, knee and ankle interactions, pelvic rotation and knee valgus. Lateral pelvic tilt (5), knee flexion and knee and ankle interactions help keep the body from an excessive vertical displacement, (which normally varies between 2-5 cm), by relatively shortening the lower extremities to lower the COG. Pelvic rotation (apprx 4 of lateral displacement in each direction) helps decrease the side-to-side mov'ts, while knee valgus helps narrow the width of the BOS. There is a normal & slight anterior. pelvic tilt (3-5) throughout. Regarding ROM, the minimum angle needed for gait at the hip is 30 of flexion to 10 of hyperextension; at the knee, the minimum needed is 60 of flexion and 0 extension, while at the ankle, there should be at least 10 of DF and 20 of PF. The toes require going from neutral to MTP extension of ~ 70. In the kinetic analysis of gait, 2 basic factors come into play: * the energy requirements for walking refer to oxygen consumption. This is necessary for muscles to produce force, and averages 100 mL per Kg of body weight per minute when walking at about 5 km/h. Walking 3 mph averages an oxygen consumption of 12 ml per Kg per minute. Younger and older people tend to consume more oxygen when walking at a comfortable speed.

* external and internal forces, such as inertia, gravity and ground reaction forces
(GRF), which represent the force of the ground on the foot, and is equal in magnitude but opposite in direction to the force that the body applies to the floor (Newton's third law). Internal forces are produced primarily by muscles.

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Knowing the location of the GRF helps us analyze muscle activity during gait, i.e., the type of contraction. For example, at heel-strike, the GRF is posterior to the axis of the ankle and thus causes a plantarflexor torque that is decelerated by the dorsiflexors. The same GRF passes through the knee and therefore creates no torque, while the GRF runs anteriorly to the hip and causes a flexion torque that is counterbalanced by the hip extensors. Generally speaking, there is a net extensor moment that occurs in the stance phase, and a net flexor moment that appears in the late stance to the early swing phase. What follows is the muscle activity that occurs during the stance phase (sagittal plane analysis): 1. The hamstrings and glutei maximi act in decelerating the swing limb through the last milliseconds prior to heel strike, and they continue their activity as hip stabilizers during the initial part of stance. 2. The quads stabilize the knee and absorb the shock by eccentrically contracting to allow the knee to flex under increasing loads. 3. The anterior leg muscles also contract eccentrically to absorb the shock at heel strike and thereafter, to lower the forefoot to foot-flat. 4. The trunk musculature balances the torso 5. The triceps surae act through most of the stance phase. 6. The hip adductors stabilize the pelvis throughout this phase. During the swing phase, the following muscle function takes place: 1. The hip flexors initiate acceleration of the stance limb and continue to give support throughout the swing phase. 2. The quads dampen knee flexion to prevent excessive heel strike after toe-off 3. The hamstrings aid in lifting the toe off the ground and decelerate knee extension and hip flexion. 4. The dorsiflexors elevate the forefoot during swing to prevent toe stubbing. 5. The hip extensors decelerate the swing limb prior to heel strike.

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HEEL-STRIKE Hip extensors: Quads: Dorsiflexors: FOOT-FLAT: Hip extensors: Quads: Plantarflexors: MIDSTANCE: Hip flexors: Knee ms: Plantarflexors: HEEL-OFF: Hip flexors: Quads: Plantarflexors:

eccentric concentric eccentric

ATTRIBUTES OF EFFECTIVE GAIT: 1. stability in stance 2. clearance in swing 3. foot orientation @ contact 4. adequate step length 5. energy conservation

concentric concentric eccentric

no activity no activity eccentric

concentric eccentric concentric

The eccentric contraction of the posterior tibialis during heel-strike is important because it decelerates pronation, helping the foot to adjust to the ground, while controlling internal rotation at the tibia and stabilizing the tarsal joints in supination in the late stance phase. The anterior tibialis, active at heel-strike, restrains eversion. The FDL and FHL contract after foot-flat and affect the longitudinal arch, while stabilizing the toes. The peroneals have a similar activity as the plantarflexors, being activated initially after foot-flat, and also help adjust the foot to the ground and provide mediolateral stability of the ankle through control of the arches. The 6 intrinsic foot muscles are active in the latter part of the stance phase, assisting the foot in becoming a rigid lever. The hip abductors stabilize the pelvis during unilateral stance, contracting eccentrically to decelerate and limit pelvic drop on the swinging limb. The hip adductors vary considerably in their action, but they are primarily active during stance, and eccentrically in preswing to restrain the lateral weight shift onto the contralateral limb. The trunk extensors are active during heel-strike, and they counterbalance the trunk flexor torque during deceleration. The trunk flexor activity varies according to the speed of gait, and their primary function is to limit horizontal accelerations of the head thus providing a stabile platform for the eyes.

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The motion of the arm during gait is due to gravity and muscle control, and it is believed that the posterior arm muscles decelerate the forward swing and accelerate the backward swing. During forward swing, internal rotators contract eccentrically to control ER, and the posterior deltoid acts eccentrically to control the forward swing. The lats, teres major and posterior delt function concentrically to cause the backward swing. The middle delt maintains the arm in slight abduction to allow it to clear the side of the body. During the swing phase, there are no GRF as the foot is in the air, but there is acceleration and deceleration in this phase, and this also requires ms activity. Initial acceleration takes place due to a concentric contraction of the hip and knee flexors, and ankle dorsiflexors, but during midswing and terminal swing, hip extensors are eccentric, knee extensors are concentric, knee flexors are eccentric and dorsiflexors are isometric. Hip flexors are inactive. Deceleration takes place basically by eccentric contraction of hip extensors and knee flexors, especially at terminal swing. All these demands increase w/ use of stairs, running, etc. Effect of age on walking. When infants begins to walk, from 11 to 15 months, they contact the floor with the foot flat, have a WBOS, a prolonged stance phase, lower extremity ER, high guarding position of the arms and fall frequently. By the time they reach the age of 2, heel-strike and slight knee flexion are evident during stance, the arms are not so elevated, reciprocal arm motion begins, there is less LE ER, and the BOS decreases. By the age of 4, most characteristics are similar to the adult in terms of ms activity and joint angles. The pattern of the GRF are similar from age 5 to the adult. By the time some individuals reach the age of 60 to 65, slight changes begin to emerge: gait is slower, joint motion and stride length decreases, the period of double support increases, all in order to attain a more stable gait.

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