Professional Documents
Culture Documents
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MA:RG
VICTO,lI,,"',-.i,""
'.
BASIC BIOMECHANICS
of the
MUSCULOSKELETAL
SYSTEM
..._-4
foreword
Mechanics and biology have always fascinated dents in orthopaedics Ihal during the past 10 years have
humankind, The irnportance or understanding the llsed the texl. This book is written for stu-dents and
biomechanics of the musculoskeletal system cannot be with a major input from students and will hopefully be
underestimated, Much a([entian has been paid in recent used to edunHe students and res-idents for many ~Iears
years to genetic and biomo-leClilar research, but the to come. Although the basic information contained in
stlld~' of the mechanics of structure and of the whole the book remains largely unchanged, a considerable
body s}'stcm is still of immense importance. amount of extra infor-mation has been provided
Musculoskeletal ail-ments arc among the most throughoul. ~Ve have also made a special point to
prevalent disorders in the wodd and will continue to document with the key references any significant
grow as the pop-ulation ages. changes in the field of biomechanics and rehabilitation.
Since the days when I first studied biome-chanics in It has always been m)'interest lO bridge the gap
Sweden with Carl Hirsch, through my years as an between engineering knowledge and clinical carc and
orthopaedic surgeon, teacher, and re-searcher, I have praclice, This book is written primarily for clinicians
alway's emphasized combining basic and applied such as orthopaedists, physical and occupational
research with clinical experi-encc, This text represents therapists, clinical ergono-misls, chiropractors, and
my fifth effort to inte-grate biomechanical knowledge olher health profes-sionals who arc acquil-ing a
into clinical training for patient carc. It is not a simple working knowledge of biomechanical principles for use
task but by relating the basic concepts of biomechan-ics in the evalu-ation and treatment of musculoskeletal
to everyday life, rehabilitation. orthopaedics. dysfunc-tion. We only hope that if you find this book
traumatology, and patient care are greatly en-hanced. in-t~resting. you will seek more in-depth study in the
Biomechanics is a multidisciplinary spe-cialty, and so field of biomechanics. Enjo\' it. discuss it, and become
we have made a special effort to in-vite contributors a beller clinician and/or researchcl:
from many disciplines so that individuals from
dilTerent fields may feel com-Fortable reading this Vve are extremely proud that Basic Biome-
book. clUluics oj" the !\tlllscliioskeic/lli Sysle111 has been
designated "A Classic" by the publishers, Lippincott
Together with an invaluable team, Margareta Nordin Williams & Wilkins. We Ihank the readers, students,
and I have produced Ihis third edition of professors, and all who ac-quire thc tcxt and lise it.
Basic Biol1lechanics oFthe A'lusclt!o.\'keletal Systelll,
The new edition is shall1cncc! and improved thanks to
the input from the students and resi· VielO,. H. Frallkel, M.D., Ph.D., KNO
vii
.,
Preface
Biomechanics uses physics and engineering con-cepts ever possible. We retained the selected examples to
to describe the motion undergone by the various body illustrate lhe concepts needed for basic knowl-edge of
segments and forces acting on these body parts during the musculoskeletal biomechanics; we also have kept
normal activities. The inter-relationship of force and the important engineering con-cepts throughout the
motion is impor-tant and must be understood if rational volume. We have added four chapters on applied
treat-ment programs are to be applied to muscu- biomechanics topics. Patient case studies ancl
loskeletal disorders. Deleterious effects may be calculation bo:'\cs have been added to each chapter. \Ne
produced if the forces acting on the areas with incorporated flowcharts throughout the book as
disorders rise 10 high levels during exercise or other teaching tools.
activities of daily living. The text will serve as guide to a deeper under-
standing of musculoskeletal biomcchanics gained
The purpose of this text is to acquaint the read-ers through funher reading and independent research. The
with the force-motion relationship \vithin the information presented should also guide the rt.'ader in
musculoskeletal system and the various tech~ niqucs assessing the literature on biomechanics. "Vc have
llsed to understand these relationships. The third edition attemptcd to provide therapcutic exam-ples but it was
of Basic Biol1/eclwllics of rite iHllScliloskeleral not our purpose to cover this area; instead, \ve have
System is intended for use as a textbook either in described the undel'lying basis for rational therapcutic
conjunction with an introduc-tory biomechanics course or exercise programs.
or for independent study. The third edition has been An introductory chapter describes the inlpor-lance of
changed in many ways, but it is still a book that is the study of biomechanics, and an ap-pendix on the
designed for use by students who are interested in and international system of measure-ments serves as an
want to learn about biomechanics. It is primarily written introduction to the physical measurements used
for students who do not have an engi-neering throughout the book. The reader needs no more (han
background but who want to understand the most basic basic knowledge of mathematics to fully comprehend
concepts in biomechanics and physics and how these the material in the book, but it is important to review
apply to the human body the ap-pendix on the Sl System and its application to
biomechanics.
Input from students has greatly improved this third
edition. We have used the book for 10 years in the The body of the third edition is then divided into
Program of Ergonomics and Biomechanics at New three sections. The first section is the Bio-mechanics of
York University', and it is the students and residents Tissues and Stnlcturcs of the Mus-culoskeletal System
who have suggested the changes and who have and covers the basic biome-chanics of bone, ligaments,
continuously shown an interest in de-veloping and cartilage. tendons, muscles, and nenres. The second
irnproving this book. This edition has been further section covers the Biomechanics-of Joints, including
strengthened by the contribu-tion or the students over every joint system in the human body. Chapters range
the past year. \Vc formed focus groups to understand from the foot and ankle through the cervical spine, and
better what thc stu-dents wanted and applied their co\'er eve I:" joint in between. The third sec-
suggestions wher-
e .-.. ---~-_.-- .._--.-._.._------- .-.- ..----..-.-.... -'------------~--- ... ,~".-- ...-.. ..- ...-.--..-------..
~.~ ~ -.,,"------~----- -",,--.-.---.------
Ox .PREfACE
tion cover~ some topics in Applied Biomechan-ics, oFthe kluscu/oskelela/ Syslel1l will bring about an
including chapters on fracture fixation; arthroplasty; increased awareness of the imparlance of bio-mechanics.
silting, standing and lying; and gait. These arc basic II has never been our intention to complL'tely cover the
chapters that sl:l\re to intra· c1uce topics in applied subject, but instead provide a basic introduction to the
biomechanics: they arc not in-depth explorations of the field that will lead to further study or this important lopic.
subject.
Finally. we hope that the revision and expan-sion of
this third edition of" Basic 13io11leclulJIics Margarela NOf(!;11 alld Viclor H. Frankel
Acknowledgments
---------~ _---
..
This book was made possible through the out-standing JUlian boxes. Angela look this book to her heart, and
contributions of many individuals. The chapter authors' \ve arc all the bettcr for her passion and attention to
knowledge and understanding of the basic concepts of detail.
biomechanics and their wealth of experience have The illustrator: Kajsa Forssen. has now worked on
brought both breadth and depth to this work. Over the all three editions of this text. Her never-failing grasp of
past 10 years. questions raised by students and residents hiomechanical illustrations, her simpli. city and
have made this book a better teaching tool. The Third exactness of figures, is always appre-ciated. In drawing
Edition could not have been done without the students all the figures and graphs, she considers how they would
who have shared their cornmen(s and really sCnItinizcd translate into a slide or into a computer-generated
thc Second Edition. There arc too many names LO list presentation. Kajsa Forssen is one of the top iIIustralOrs
here, but we thank each student who asked a question that we have ever worked wilh, and she has been an
or made a sug-gestion during the course of his or her important member of the publication (cam.
studies. Special thanks to the students who panicipated
in several focus groups. whose input was in-valuable in This book was also made when publication
finalizing the contents and design of the text. companies I11ergcd and merged again, and in the end
we are deeply grateful to Ulila Lushnycky, who has
with her team at Lippincott \·Villiams & Wilkins been
responsible ror the production. She has worked with
Vve are honored and grateful for the contri-butions of tremendous energy and posilive thinking, put the book
everyone who has worked to prepare this new edition. together in record spced, and we fonvard our sincerest
'vVecan honestly say that this third edition is written gratitude to her. \Ne are also thankful for a development
ror the sludent and by students and residents who leave grant provided by Lippincott Williams & Wilkins to
the classroom with the knowledge to enhance our life finance this effort.
and existence.
Our colleagues al the Occupational and Industrial
A book of this size with its large number of figures, Orthopaedic Cenler and the Depart-ment or
legends, and references cannot be pro-duced without a Orthopaedics of the Hospital ror Joint Diseases
strong editorial team. As project editor, Dawn Leger's Orthopaedic Institule functioned as critical reviewers
continuous effort and perseverance and thoughtfulness and contributors to the chapters. Special thanks is
shines through the entire book. She has contributed not extended to David Goldsheydcl" for assislance in
just to the editing but also to logistics, and as a stylist, reviewing lhe biomechanical calculation boxes. to
as an innovator, and a friend. Our editorial assistant, Marco Campello as a contributor and reviewer, and to
Angela Lis, is a physical thcrapisl and recent recipient Shira Schccter-vVeiner for contributing to the spine
of the MA degree in Ergonomics and Biomechanics chapteI: Much thanks to Dr. Mark Pitman 1'01' supplying
from NYU. As a recent grad-uate, Angela was also a vital x-rays ror the new edition. \,Ve are parlicularly
recent USCI' of the book, and she devoted several months grateful to DI: Markus Pielrek for contributing with the
to help finalize this edition. She created the flowcharts latcst on intra-abdominal pressure. to Dr. Ali
and scru-tinized all the figures, patient cases, and caku- Sheikhzadeh ror reviewing chapters and contributing
new
references, to Dr. Tobias Lorenz for his work on the iHuscllloskeletal System was supported through-out its
first section, and to all other staff at the Occupational production by the Research and Develop-ment
and Industrial Orthopaedic Center who have been Foundation of the Hospital for Joint Diseases
managing the center while we are absorbed wilh the Orthopaedic Institute and the hospital administration, to
book. whom we forward our sincere gratitude.
\'\Fe arc most grateful to Drs. Bejjani, Lindh,
Pitman, Peterson, and Stuchin for their COI1l1·j· bUlions To all who helped, we say' again, thank yOLi and
to the second cdition which sen'cd as a framework for TACK SA MYCKET.
the updated third edition.
The third edition of Basic Biomechallics orEiIe klargareta Nordin and Victor fl. Frankel
Contributors
Contents
Appendix 1: The System International (11) Biomechanics of the Lumbar Spine 256
d'Unites(SI) 18 Margareta Nordin, Shira Schecter Weiner,
Dennis R. Carter adapted from Margareta Lindh
xviL
BASIC BIOMECHANICS
of the
MUSCULOSKELETAL
SYSTEM
1
Introduction to
Biomechanics:
Basic Terminology
and Concepts
Nihat OZkaya, Dawn Leger
Introduction
Basic Concepts
Scalars, VeCtors, and Tensors
Force Vector
Torque and Moment Vectors
Newton '$ l.aws
Free-Body Diagrams
Conditions for Equilibrium
Statics
Modes of Deformation
Normal and Shear Stresses
Normal and Shear Strains
Shl?ar·5train Diagrams
Elastic and Plastic Deformations
Viscoelasticity
Material Properties Based 011 Stress-Strain Diagrams
Principal Stresses
Fatigue and Endurance
Basic Biomechanics of the Musculoskeletal System
Part I: Biomechanics of Tissues and Structures
Part 11: Biomechanics of Joints
Part III: Applied Biomechanics
Summary
Suggested Reading
Introduction manual work conforms more closely to rhe physical
limitations of the human body and to natural body
Biomechanics is considered a branch of bioengi-neering rnO\'cmCnlS, these injuries rnay be combatlcd.
and biomedical engineering. Bioengineer-ing is an
interdisciplinary field in which the princi-ples and methods
from engineering. basic sciences. and technology arc Basic Concepts
applied to design. test, and man-ufacture equipment for use
in medicine and to un-derstand, define, and solve problems Biomechanics of the musculoskeletal system re-quires a
in physiology and biology!. Bioengineering is one of good understanding of basic mechanics. The basic
several spe-cialty areas that corne under the general field terminology and concepts from mechan-ics and physics arc
of bio-medical engineering. utilized to clcscribe intcrnal forces of the human body. The
objective of studying thcs~ forces is to understand the
Biomechanics considers the applications of clas-sical loading condition of soft tissues and their mechanical
mechanics 10 the analysis of biological and physiological responses. The purpose of this section is to rC\'jew the
svstems. Different aspects of biome-chanics utilize basic con-cepts of applied mechanics that are used in
different parts or applied mechanics. For example, the biome-chanical literature and throughout this book.
principles of statics havc been ap-plied to analyze the
magnitude and nature of forces involved in various joints
and muscles of the nUls-culoskeletal system. The principles
SCALARS, VECTORS, AND TENSORS
of dynamics have been utilized for motion description, gait
analysis, and segmental motion analysis and have many Most of the concepts in mechanics arc either scalar or
applications in sports mechanics. Thc mc~ chanics of solids vector. A scalar quanlity has a magnitude only. Concepts
provides the necessary tools for developing the field such as mass, energy', power, mechanical work, and
constitutive equations For bio-logical systems that are used temperalure are scalar quantities. For ex~ ample, it is
to evaluate their func-tional behavior under dilTerent load suffkicnt to say that an object has 80 kilograms (kg) of
conditions. The principles of fluid mechanics have been mass. A vector quanlity, con-versely, has both a magnitude
used to in-vestigate blood flow in the circulatory system, and a direction asso-ciated \vith it. Force, moment,
air flow in the lung, and joint lubl'ication. velOcity, and acceler-ation arc exall'lples of vector
quanlities. To describe a force fully. one must state how
much force is ap-plied and in which direction it is applied.
Research in biomechanics is aimed at improving our The mag-nitude of a vector is also a scalar quantity. The
knowledge of a vcry complex structure-the hu-man body. mag-nitude of any quanlity (scalar or vector) is always a
Research activities in biomechanics can be divided into positi\'c number corresponding to the numerical measure of
three areas: experimcntal studies, model analyscs, and that quantity_
applied research. Experimental studies in biomechanics arc
done to determine the mechanical properties of biological Graphically, a vector is represented by an arrow. The
materials, in~ eluding the bone, cartilage, muscle, tendon, orientation of the alTow indicates the line of ac~ tion and
liga-ment. skin, and blood as a whole or as parts the arrowhead denotes the direction and sensc of the vectm:
constituting them. Theoretical studies involving 'If1110re than one vector must be shown in a single
mathematical model analy1ses have also been an im~ drawing, the length of each arrow must be proportional to
ponant component of research in biomechanics. In general, the Inagnitude of the vector it represents. Both scalars and
a model that is based on experimental find-ings can be used vectors arc special forms of a more general category of all
to predict the efrect of environ-mental and operational quantities in mechanics called tensors. Scalars arc also
factors without resorting to laboratory experiments. known as "zero-01"(Ic1· tensors," whereas vectors aJ'e
"first· order tensors." Concepts such as stress and strain,
conversely, are "second-order tensors."
Applied research in biomechanics is the applica-tion of
scientific knowledge to bcnefit human bc-ings. vVe know
that musculoskeletal injury and ill-ness is one of the
FORCE VECTOR
primary occupational hazards in industrialized countries.
By learning how the mus-culoskeletal system adjusts to Force can be defined as· mechanical disturbance 01-load.
common work concli-tions and by developing guidelines to Whcn an object is pushed or pulled, a force is applied on it.
assure that A force is also applied when a ball is
3
Or!~jJ'i,bSH/"I'TER 1.',;'JTRODUCTION TO BIOMECHANICS: BASIC TERMINOLOGy AND CONCEPTS
thrown or kicked. A force <:\Cling on an object may deform TORQUE AND MOMENT VECTORS
the objecl, change its slale of m~lion, 0"1'
The effect of a roree on the object it is applied upon
both. Forces may be c1assif-lcd in variolls ways ac-cording
depends on how the rorce is applied and how the object is
to their effects on the objects to \vhicf'l they arc applied or
suppo!"ted. For example, when pulled. an open door will
according to their orientation as con~- pared with one swing about the edge along which it is hinged lO the wall.
another. For example, a force may be internal or external,
normal (perpendicular) 0'1' tangential; tensile. compressive.
cJ
\-Vh'll eallses the door 10 swin is the torque generated
01" shear; gravita-tional (weight); or frictional. Any two or
by the applied force abou~ an axis that passes through
more forces acting on (\ single body 111ay be coplanar
the hinges of the door. If one stands on the free-end of a
(acting on a lwo~dimcnsional plane surface); collinear (have a
diving board, the hoard will bend, What bends the board is
common line of action); concurrent (lines of action
intersecting at a single point); or parallel. Note that weight is a
the mo-mel1l of the body weight about the fixed end of the
special form of Force. The weight of an object on Earth is the board. In general. torque is associated with the ro~ tnlional
gravitational force exerted bv and twisting action of applied forces, while moment is
related to the bending action. However, the mathematical
Earlh on the mass of that object. Thc magnitude ~'r the defmition of moment and torque is the same.
wcighl of an object on Ea~·t11 is equal the masst; Torque and moment arc vector quantities. The
of the object times the magnitude of the gravita-
tional acceleration, \vhich is approximately 9.8 mt> ters pCI' second magnitude of the tonlue Of rnoment of a force about a point
1 is equal to the mannitude of the force times the length of
squared (111/s ). For exampl~,a 10-k<J
the shortc:t distance be-tween the point and the line of
object weighs approximately 98 newtons (N) o~ Earth.
action of the force which is known as the lever or moment
The direction of weight is always vertically do\vl1\vard.
arm. Con~
W) - _ - I
Definition of torque. Reprinred with permission from DZkaya, N. (998). Biomechanics. In w.N. Rom,
Environmental and Occupationa( Medicine (3rd ed., pp, 1437~1454), New
York: Lippincott·Raven,
CHAPTER 1 • INTRODUCTiON TO BIOMECHAN1CS: BASIC TERMrNOLOc;Y'AN()'CO~C;.~e~~[;D
sider a person on an exercise apparatLls who is lion. Th~ larger the inertia of an object, the more
holding a handle that is attached to a cable (Fig. difficult it is to sel in motion or to SlOp if it is ai-
I-I), The cable is wrapped around a pulley and at- rend)'in motion.
tached to a weight pan. The weight in the \veight Newlon's third law states that to every action
pan stretches the cable such that the magnitude F there is a reaction and that the forces of action and
of the tensile force in the cable is equal 10 thc reaction between interacting objects are equal in
weight of the weight pan. This force is transmitted magnitude, oppositc in direction, and have the
to the person's hand through the handle, At this in- same line of action. This law has important applica-
stant, if the cable allached to the handle makes an tions in constructing free· body diagrams.
angle 0 with the horizontal. then the force E ex-
erted by the cable on the person's hand also makes
FREE·BODY DIAGRAMS
an angle 0 with the horizontal. Let 0 be a point on
the axis of rolation of the elbow joint. To dcter- Free-body diagrams are constructed to help identify
mine the magnitude of the moment due to force f the forces and moments acting on individual parts
about 0, extend the line of action of force f and of a system and to ensure the correct use of the
drop a line from 0 that cuts the line of action of F equations of mechanics La analyze the system. For
at right angles. If the point of intersection or the this purpose. the parts constituting a system are iso-
twO lines is Q, then the dbtance d between 0 and lated from their surroundings and the effects of sur-
Q is the lever arm, and thc magnitude of the rno~ roundings arc replaced by proper forces and mo-
ment M of force E about the clbow joint is M = dE ments.
The direction of the moment ,·cctor is perpendicu- The human musculoskeletal system consists of
lar to thc plane defined by the line of action of E many parts that are connected to one another
and line 00, or for thb two-dimensional case, it is through a cornplcx tendon. Iigamcnt, muscle, and
counterclockwise. joint SU·uctUfC. In somc analyses, the objective may
be to investigate the forces involved at and around
val'ious joints of the human body for different pos-
NEWTON'SLAWS
tural and load conditions. Such analyses can be car-
Relatively few basic laws govern the relationship ried out by separating the body into two parts althe
betwcen applied forces and corresponding mo- joint of interest and drawing the free-body diagram
tions, Among these, the laws of mechanics intro- of one of the parts. For example, consider the arn1
duced by Sir Isaac Newton (1642-1727) are the illustrated ill Figure I ~2. Assume thal the forces in-
most important. NeWLOn's first law states that an volved at the elbow joint arc to be analyzed. As il-
object at rest will remain at rest 01'an object in mo- lustrated in Figure 1-2, lhe entire body is separated
tion will move in a straight line with constant ve- into two at the elbow joint and the free-body dia-
locity if the net force acting on the object is zero. gram of the forearm is drawn (Fig. 1-2B). Here,
Newton's second law states that an object with a E is the force applied to the hand by the handle of
nonzero net force acting on it will accelerate in the the cable attached to the weight in the weight pan,
direction of the net force and that the magnitude of \V is the total wcight of thc lower arm acting at
the acceleration will be proportional to the magni- the center of gravity of the lower arm,
tude of the net force. Newton's sccond law can be £,\\1 is the force excrted by'the biceps on the ra-
formulated as E = m ;), Here, E is the applied force. dius,
m is the mass of the object, and i! is the linear £.,,; is the force exerted bv the brachioradialis
(translational) accelcration of the object on which muscles on the radius.
the force is applied. If more than one force is acting £.\l~ is the force exerted by the brachialis musclcs
on the object. then E represcnts the net or the re- on the ulna, and
sultant force (the vector sum of all forces), Another f1 is the resultarll reaction force at the humero-
way of stating Newton's second law of motion is ulnar and humeroradial joints of the elbow. Note
M = I Q., where M is the net or resultant moment of that the muscle and joint reaction forces represent
all forces acting on the objcct, I is thc mass moment the mechanical effects of the upper ann on the
of inertia of the object, and ~ is the angular (rota- , lower arm. Also note that as illustrated in Figure
tional) acceleration of the object. The mass m and 1-2;\ (which is not a complete free-body diagram).
mass moment of incrtia I in these equations of mo- equal magnitudc but opposite muscle and joint re-
tion arc measures of resistance to changes in 1110- action forces act on the upper arm as wcll.
dum implies that the body of concern is either at rest or
moving with constant velocity. For a body to be in a slate
of equilibrium, it has to be both in translational and
rotational cquilibl-iul11. A body is in translational
cquilibriun1 if the net force (vector sum of all forces)
acting on it is zero. If the Ilt:t force is zero, then the linear
acceleration (time rate of change of linear velocity) of the
body is zero, or the linear velocity of the bod,Y is either
constant or zero. A body is in rotational equilibrium if the
net mo-ment (vector sum of the moments of all forces) act·
ing on it is zero. If the net moment is zero, then the angular
acceleration (time rate of change of angular velocity) of the
body is zero, or the angulal· yelocily of the body is either
constant or zero. Therefore, for a body in a state of
equilibrium, the equations of motion (Newton's second law)
take the following special forms:
A ~E = 0 and ~rvl = 0
rt is important to remember that force and mo-ment arc
E vector quantities. For example, with re-spect to a
rectangular (Cartesian) coordinate sys-tem, force and
moment vectors may have components in the .'\. y, and z
directions. Therefore, if the net force acting on an object is
zero, then the sum of forces acting in each direction must
be equal lo zero (IF, = 0, IF, = 0, IF, = 0). Similarly, if the
net moment on an object is zero. then the sum of moments
in each direction must also be equal to zero (lM, = 0, lM,. =
B
0, lM, = 0). Thel'efore, for three-dimension force systems
w there arc six cOl1cii-lions of equilibrium. For two-
dimensional force sys-[ems in lhe xy-plane, onl~: three of
these conditions (IF, = 0, ~F, = 0, and ~M, = 0) need to be
checked.
Forces involved at and around the elbow joint and the
free-body diagram of the lower arm.
Reprinted with permission from dzkaya. N. (7998).
Biomechanics. In W.N. Rom, Environmen-tal and STATICS
Occupational Medicine (31d ed., pp.
1437-1454). New York: Lippincott-Raven.
The principles of slatics (equations of equilibrium) can be
applied to investigate the muscle and joint forces involved
at and around the joints for various postural positions of
the human body and its seg-ments. The immediate purpose
of static analysis is to provide answers to questions such as:
CONDITIONS FOR EQUILIBRIUM
What ten-sion must the neck extensor muscles exert on the
Statics is an area within applied mechanics that is head to support the head in a specined position? \OVhen a
concerned with the anal~:sis of forces on rigid bod-ies in person bends, what would be the force ex~ ertcd by the
equilibrium. A rigid body is one that is as-sumed to erector spinae on the fifth lumbar ver-tebra? Ho\\'" does the
undergo no deformations. [n reality, evcr)' object or con1pression at the elbow, knee, and ankle joints vmy with
matcrial may undergo deformat ion to an extent when acted externally applied forces and with different segmental
on by forces. (n some cases, the amount of deformation arrangements? How docs the force on the femoral head
may be so smalllhal il may not affect the desired analysis vary with loads carried in the hand? \,Vhat arc the forces
and the object is as-sumed to be rigid. In mechanics, the in~
term cquilib-
volved in various muscle groups and joints during to call tensile and compressive forces normal or ax-ial
different exercise conditions? forces: shearing forces are tangential forces. Ob-jects
In general. the unknowns in static problems in-volving also deform when they are subjecled to forces that cause
the musculoskeletal s:'stcm arc thc magni-tudes of joint bending and torsion, which are related to the moment
reaction forces and muscle tensions. The mechanical and torque actions of applied forces.
analysis of a skelclal joint requires that we know the vector A matel"ial nwv respond differently to different
characteristics of tensions in the muscles, the proper loading configurations. For a given material. there may
locations of muscle at-tachments, the weights of body be different physical properties that must be considered
segmcnts, and the locations of the centers of gravity of the while analyzing the response of that ma-terial to tensile
body seg-mems. Mechanical models are obviously simple loading as compared with compres-sive or sheai'
representations of c0l11plex systems. Many models are loading, The mechanical properties of mnterials are
limited by the assumptions that must be made to reduce the established through stress analysis by subjecting them to
system under considcration to a st.ati- various experiments such as uni-axial tension and
compression, torsion, and bend-ing tests.
cally determinate one. Anv model can be improved by
~onsidering the comril)utions of other muscles,
but (hat will increase the number of unknowns and make
the model a statically indeterminate one. To analyze the NORMAL AND SHEAR STRESSES
improved model. the researcher would need additional
information related to the muscle forces. This Consider the whole bone in Figure \-3;,\ that is sub-
inforrrlalion can be gathered through electromyography jected to a pair of tensile forces of magnitude F. The
measurements of muscle signals or by applying certain bone is in static equilibriulll. To analyze the forces
optirnization techniques. A similar analysis can be made induced within the bone, the method of sections can be
to investigate forces involved at and around other major applied by hypothetically cutting the bone into two
joints of the musculoskeletal system. pieces through a plane perpendicular to the long axis or
the bone. Because the bone as a whole is in equilibrium,
the two pieces must individually be in equilibrium as
MODES OF DEFORMATION well. This requires that at the cut sec-tion of each piece
When acted on by externally applied forces. objects may there is an internal force that is equal in magnitude but
translate in the direction of the net force and rotate in the opposite in direction to the externally applied force (Fig.
direction of the net torque acting on them. If an object is 1-38). The internal force is distributed over the entire
subjected to externally applied forces but is in stalic cross-sectional area of the cut section. and E represents
equilibrium. then it is most likely that there is some the resultant of the distributed force (Fig. 1-3C). The
local shape change within the objec!. Local shape intensity of this distributed force (force per unit area) is
change under the effect of applied forces is known as known as stress. For the case shown in Figure 1-3.
deformation. The extent of deformation an object may because the force resultant at the cut section is
undergo depends on many' factors, including the perpendicular to the plane of the cut. the cOITesponciing
material properties. size, and shape of the object; stress .is called a normal or axial stress. It is customar:y to
environmental factors such as heat and humidity; and usc the symbol (T (sigma) to refer to normal stresses. As-
the nlagnitudc, di-rection, and duration of applied suming that the intensity of the distributed force at the Cllt
forces. section is uniform over the cross-sectional area A of the
bone, then u::::: FlA. Normal stresses that are caused by
One way of distinguishing forces is by observing their
forces that tend to stretch (elongate) matcl"ials aJ"C marc
tendencv to deform the object they are applied upon. For
specincally known as tensile stresses; those that tend to
example. the object is said to be in ten-sion if the body
shrink them are known as compressive stresses. According
tends to elongate and in compres-sion if it tends to shrink to the Standard In-ternational (SO unit system (see
in the direction of the ap-plied forces. Shear loading Appendix), stresses are measured in newton per square
differs from tension and compression in that it is caused meter (N/m~), which is also known as pascal (Pa).
b:! forces acting in directions tangent to the area resisting
the forces ~ causing shear, whereas both tension and
compres-sion are caused by collinear forces applied There is another form of stress, shear stress, which is
perpen-dicular to the areas on which they act. It is a measure of the intensity of internal forces acting
common tangent (parallel) to a plane of cut. For
a~1·~~j.jMTE~· 1 • INTRODUCTION TO BIOMECHANICS: BASIC TERMINOlOGY AND CONCEPTS
F .....~--I -
,..-__..J-_=-
~- ..
F
A
A
B
F ...... ~-G?- ='~,
c
Definition of normal stress. Reprinted wirh permission from OZkaya. N. (1998j. Biome-
chanics. In W.N. Rom, Environmental and Occupatiol1<11 r..,ledicine (3rd ed., pp. i437-
145r+). New York: Lippincorr·RiNen.
example. consider the whole bone in Figure 1-4A. The Assuming that the intensity of the force tangent to the cut
bone is subject to a number of parallel forces that act in section is uniform over the cross-sectional area A of the
planes perpendicular to the long a,is of the bone. Assume bone, then T = FlA.
that the bone is cut into two parts through a plane
perpendicular to the long axis of the bone (Fig. 1-48). If the
NORMAL AND SHEAR STRAINS
bone as a whole is in equilibrium, its individual parts must
be in equilib-rillm as well. This requires that there must be Strain is a measure of the degree of deformation. As in the
an in-ternal force at the cut section that ,lets in a direction case of stress, two types of strains can be dis-tinguished. A
tangent to the cut surFace. If the magnitudes of the external norm~l'l strain is deflnecl as the ratio of the change (increase
forces arc known, then the magnitude F of the internal or decrease) in length to the original (undeformed) length,
force can be calculated by considering the translational and and is commonly de-noted with the symbol € (epsilon).
rotational equilibrium of onc of the parts constituting the Consider the whole bone in Figure \-5. The total length of
bone. The intensity of the internal force tangent to the Clit the bone is I. If the bone is subjected to a pair of tensile
section is known as the shear stress. It is customary to usc forces. the length of the -bone may increase to I' or by an
the symbol T (tau) to refer to shear stresses (Fig. 1-4C). amount .1i\ = I' -I. The normal strain is the ratio of the
amount of elongation to the original
CHAPTER 1 • INTRODUCTION TO BIOMECHANICS: BASIC TERMINOLOGY AND CONc~~i~~-: i:D
Shear strains are related to distortions caused by
shear stresses and arc cornmonly denoted with the
symbol y (gamma). Consider the rectangle (ABCD)
shown in Figure 1-6 thm is acted on by a pair of tan-
gential forces that deform the rectangle into a par-
allelogram (AB'C '0). 'Ifthe relative horizontal dis-
placement of the top and the bOllom of the
rectangle is d and the height of the rectangle is h,
then the average shear strain is the ratio of d and h.
which is equal to the tangent of angle y. The angle y
is lIsllall~" vcry small. For small angles. the tangent
F, F.,
of the angle is approximately equal to the angle it-
self measured in radians. Therefore, the average
shear strain is "y = cllh.
Strains arc calculated by dividing two quantities
measured in units of length. For most applications,
the deformations and consequently the strains in-
A volved may be very small (c,g" 0,001), Strains can
also be gi\'en in percemages (e.g .. O.l%).
STRESS-STRAIN DIAGRAMS
Different I11mcrials may demonstrate different stress-
strain relationships. Consid(~r the stress-strain diagrarn
B F, shown in Figure 1-7. There arc six distinct points on the
curve, which arc labeled as O. P, E, Y, U, and R. Point 0 is
the origin of the Sli'ess-strain diagram, which corresponds
to the initial (no load, no deformation) state. Point P
represents the proportionality limit. Between 0 and P. stress
and strain are linearly proportional and the stress-strain
diagram is a straight line. Point E represents the clastic
limit. Point Y is the .\"ield point, and the stress (T..
corresponding to the yield point is called the yield slrength
of the material. At this Slress level, considerable elongation
(yielding) can occur without a corresponding increase of
load. U is the highest stress point on the stress-strain
diagram. The stress (r is the ultimate strength of the mater-
ll
I'
~
.; .:.\
F
~
"'"
,
I
-- - ):
I
...... F
' . l/ -.
1
Definition of normal strain. Reprinted with permission from 6zkaya. N. (/998). Biome-chanics. In W.N.
Rom, Environmental (1nd Occupational !v1edione (lrd ed., pp.
/437-1454). New York: Lippi(lCOfl-R(l~'efl.
•
Note that a given material may behave dilTcr~ ently under ELASTIC AND PLASTIC DEFORMATIONS
different load and environmental con~ ditions. If the curve
shown in F'igurc 1~7 repre-sents the stress"strain relationship
Elasticit:-.· is defined as lhe ability or
a material to resume
for a material under tensile loading, there ma).o' be a similar its original (stress-free) size and shape on removal of applied
but different curve representing the stress-strain rela-
loads. 1n other words, if a load
tionship for the same material under compressive or shear
loading. Also. temperature is known 10411-leI' the relationship
between stress and strain. For some materials, the stress-
strain relationship may also depend on the rate at which the
load is ap-plied on the material.
u
A
I_ d 'I
B S'~C
C'
/ --------- 7
/ /
h r1.t / /
/
/ / ,l - ,
/ /
AL----;-.------- ';0
F
•
is applied on a material such that the Stress gener-ated in
the material is equal to or less than th~ elastic limit, the
deformations that took place in the material will be G
cOlllpletcl.v recovered once the
applied lands arc removed. An elastic material \vhose
stress·strain diagram is a straight line is called a
linearly clastic material. For such a matc-the stress is
linearly proportional to strain. slope of the stress-strain
diagram in the e1as-region is called the elastic or
Young's rnodulus of the material. which is commonly
denoted by E. E
,Therefore, the relationship between stress and strain for
linearly elastic materials is a := E€. This equation that
relates normal stress and strain is called a material
function. For a given material. different material functions
may exist for different modes or derormation. For example,
SOme materi-als may exhibit linearly elastic belHwior under
shear loading. For such materials, the shear stress T is
linearly proportional to the shear strain y, and the constant of linearly elastic material behavior. Reprinted wirh permission
proportionality is called the shear modulus, or the modulus of from OZkclycl, N. (1998)_ Biomecll<lflics. In
rigidity. If G repre-sents the modulus of rigidity, then ,. = Gy. W.N. Rom. Environmental and Occupattonal MecH-cme
Combi-nations of all possible material functions for a given (3rd cd., pp J437-1Li54.J. Ne ....,; York: Lippincott-
material form the constitutive equations for that material. Raven
'U
constant strain while observing the stress re-sponse of the
material. Under a stress-relaxation lcst, an elastic mater-ial
will respond with a stress developed insw.ndy and maintained
at a consWnl level (Fig. I-II B). That is, an elastic malcrial
will not exhibit a stress-relaxation behavior. t\ viscoelas-lie
material. conversely', will respond with an initial high stress A '0
level that will decrease over time. If the m;terial is a cr
viscoelastic solid, the stress level will nevcr rcduce to zcro
(Fig, I-lie), As illuSlrated in
B
o·u to
0"0 = E,
ON STRESS-STRAIN DIAGRAMS a
U:
The stress-strain diagrams of two or Il"wrc materials can
be compared to determine \vhich m<:ucrial is rei· atively
stiffer, l1C:lrdcl~ tougher, more ductile, or more brittle. For
example, the slope of the stress-strain di~ agram in the
clastic region represents the clastic modulus that is a
10
measure of the relative stiffness of materials. The higher C
the elastic modulus, the stiffer the material and the higher G
l1-
its resistance to defor-mation. A ductile material is one that
exhibits a large plastic deformation prior to failure. A
britlie mater-ial, such as glass, shows a sudden failure
(rupture) without undergoing a considerable plastic
deforma-tion. Toughness is a measure of the capacity of a
10
ma-terial to sustain permanent defonllation. The tough-ness D
of a matedal is measured b~: considering the total area
under its stress-strain diagram. The larger this area, the
tougher the malerial. The ability of a material to store or
absorb energy without perma-nent deformation is called lhe Stress-relaxation experiment. Reprinted with per-mission
resilience of the ma-terial. The resilience of a material is from Ozkaya, N. (1998). Biomechanics. In
measured by its modulus of resilience, which. is equal to the WN. Rom. Environmental and Occupational Medicine
area un-der the stress-strain curve in the elastic region. (Jrd ed.• P.o. 1437-1454). Ne~··1 York: Lippincott-Raven.
maximum shear stress. The maximum shear SlI-es$ occurs o max - - ..... "7" - - ] - - - - .......- - - - - - -
riod of vears. a weight-bearing prosthetic dc\·icc or b~"clinicians (Q provide an introducLor~: level of knowh:dge
a'fi;.;:ati~n device can be subjected to a consiclerabk about each joint s~'stem.
number of cycles of stress reversals as a result or noHnal
daily activity. This cyclic loading and un-~~.•l;"N can cause
PART III: APPLIED BIOMECHANICS
faLigue failure of the device.
A new section in the third edition of this book in~ troduces
important issues in applied biomechanics. These include
Biomechanics the biomechanics of fracture fixation; arlhroplasty; sitting,
standing. and lying; and gait. It is important for the
the Musculoskeletal System beginning studenl to under-stand the application or
biomechanical principles in clirfcrcnt clinical areas.
even a simple task c.'\ecuted b.v the musculoskeletal svstcm
requires a broad. in-depth :~;' knowledge of various fields
that ma~' include 1110-
tor control, neurophysiology, physiology. physics. and Summarv
biomechanics. For example, based on the pur-pose ancl
intention or a task and the sensOl'~' infor-mation gathered 1 Biomechanics is a young and dynamic fidd of study
from the ph~'sical cndronmcnl based on the recognition thaI conventional cllginccl'ing
~;
and orielllatioll of tilL' body and joints, the central thcorks and methods can be useful for understanding and
nervous system plans a strategy for a task execu-:;.: lion. solving problems in physiology and medicine.
According to the strategy adoptc:d. Illuscles Biomcclwnics considers the applica-tions of classical
..' .,' will be recruited lO provide Lh<..' forces and 1110-mcnts rncchanics to biological problems. The flcld of
required for the movement and I.Jalance of the s.)'slem. biomechanil:s flourishes from the coop-eration among life
Consequently, the internal forces will be changed and soft scientists, physicians, engineers. and basic scientists. Such
tissues will experience differ-ent load conditions. cooperation requires a certain amount of common
vocabulary: an engineer must learn some anatom~:and
The purpose or this book is to present a \\'cll~ balanced ph)'siology, nnclmed-ical personnel need to understand
synthesis of information gatllCred frorn various some basic con-cepts of physics and mathematics.
disciplines. pro\'iding a basic understanding of
biomechanics of the musculoskeletal system. The material 2 The information presented throughout this textbook is
presented here is organized (0 cover three areas of
drawn from a large scholarship. The au-thors aim to
musculoskeletal biomechanics.
introduce some of the basic concepts of biolllechanics
related to biological tissues and joints. The book does nOl
PART I: BIOMECHANICS OF TISSUES intend to provide a com-prehensive review of the literature,
AND STRUCTURES and readers are encouraged to consult the list of suggcsted
reading below to supplcmcnt theil' knowledge. Some basic
The material presented throughout this textbook provides textbooks arc listed here, and studcnts should con-sult
an introduction to basic biolllechanics of the peer-revicwed journals for in-depth presenta-Lions of the
musculoskeletal system. Part I includes chap-ters on the latest research in specialty arcas,
biomechanics of bone. articular carti-lage, tendons and
ligaments, periphcral nerves, and skeletal muscle. These
are augmcnted wilh case studies to illustrate the imponarll
concepts for un-derstanding the biomechanics of biological SUGGESTED READING
tissues. Black. J. (19SS). Onhop'lcdic Bionmleriuls in R,'sl,.'ardl and Prac-til:c.
New York: Churchill Li\·in!!stonc.
Brollzino. J.D. (Ed.) (1995). The -Biom(.'dic<ll Engincl.'ring H.lIld*
PART II: BIOMECHANICS OF JOINTS book. 80(:01 R:llOn. rL: CRC Press.
B(lrst('in,A.H., & \Vright. T.~'I.( 1993). Fundamellt;lls of Or1hop<ll'dic
Part II of this textbook covers the major joiots of the Biolllc:dmnics. Ballirnorl': Williams & Wilkins.
human body, from the spine to the ankle. Each chapter Chaffin. 0.8 .. & All{krsson. G.B.J. (1991). O<::cupational Bioll1c-
ch~lllics (2nd l'<'I.). Nl'\\' York: John Wiley & Sons.
contains information about the structure and functioning of
Fung. Y.c. (1981). Biolllec!wnics: Mechanical Properties of Living
the joint. along with case studies illuminating the clinical Tissul.·s. New York: Springl.'r·\\:rJag.
di~lgnosisand management of joint injlll)' and illness. The FUll!!. yc. (1990). Biomcch~l1lics: ;\·Iotioll, Flo\\" Slrcss, :llld Growth.
chnpters are written New York: Springl'r,Vl'rlOIg.
a;1"~;;i~IfEi;'" 1 -.'1NTR6()UCTION TO BIOMECHANICS: BASIC TERMINOLOGY AND CONCEPTS
H~l\'. J.G .. 6:.. RI..'id. J.G. (1988). .'\nalOllw.'\lcchanil:s .md Human Mo- OZk:IY;\. N.. & Nordin. M. (1999). Fundamelltals of Biolll<.'ch'lllics:
-lioll (2nd cd.). Englewood Cliffs, NJ: Pn:llIkc-Hall. Equilihrium, :\lotioll. <lnd Dcfonlwtioll (2nd I..'d,). Nt:\\" York
Kelly, O.L. (1971). Kinl.'siology: FLllldaml.'llWlsof \Iolion D~·StTip· lion. Sprin!.!(,I~Vl.'rlag.
En!.:.lcw()od Cliffs, NJ: Prelltice-Hall. Schmid.Schonbl'i;l, G.\\'., \\'00. 5.1...·).... & Z\\"eifach. B.\V. (Eds.).
\Iow, Vc.. &: Hayes, w.e. (1997). Basic Orthopaedic Biorncch.mics (1985). Frontiers in Biomechanics. ~·h.'\\" York: Springer.Verlag:,
(2nd cd.). New York: Raven Press. Skal<:lk, R" & Chkn, S. (Eds.). (!98i). Hllndbonk or BiOi..'ngincering.
,\low. \I.e., Ratdiff, A".& Woo. S.L.·Y. (Eds.). (1990). BicHlll.:chanics or New York: McGraw·Hill.
{)i~tl"(llrodialJoinls. Nr.:\\' York: Sp.-jnga-Verlag. Thompsoll. C. W. (1989). :\·tanu'll of Stlllt'lur<ll Kinl~si()log~' (11th
NahulIl. A.M .. &. Md\'in. J. (Etls.). (19S5). The BiOlllcch:lI1il:s of cd,). 51. Louis. MO: ·fill1l..'sMirror/:\·Iosbv.
TI'UUll'lNorwalk.. CT: l\ppl('ton-Ct:llhll~'.Crofts. Williams. M., & lissner, H.R. (1992). Bion;l.'chanics of !·luman ;\'to-lion
Nordin, M .. Andersson. G.B.J., & Po\X", M.H. (Eds.). (1997). ~plllSCll- (3r<l cd.). Phibddphin: Sallll(k:rs,
1()sk..:k'IJI Disonk'J1; in the \VorkpbcL'. Philadclphin: :\'1osby,Ycilr Wintcl'. D.!\. (1990). Biol1lcchnnics :Illd ~:lolor Control or Hum"n
Book. Behavior (2nd I..'d.). New York: John Wiky &: Sons.
Nordin. ~L & Franb,:1. \l.H. (Eds.l. (1989). Basit- OiolUl.'chanics of lhe Willlel'S. J,!lil.. &. Woo. S.L-Y. (Eds.), (1990). Multiple Muscle Sys-Il'IHS.
:\hlst.:uloskdctal S,\':o;'lClll (2nd t:d,), Philaddphi:l: 1...:<.\ & New York: Springcr.verktg.
F.:bi"'.:r
OzkaYil,eN.·( 1998). Bi(Hn~d1iJnics. III W.N. Rom, EnvirorH1H:nlal and
OCCllp<:lliollal :\kdicill~' Ord cd., pp. 1437-1454). New York:
Li ppi m:olt -RaVCll.
The System
International
d'Unites(51)
Dennis R. Carter
MOMENT FORCE
OF FOACE newIon 2
ACCELERATION qp ,----.... N/m
kg m/s 2 PRESSURE & STRESS
pascal
speED
~\ \l/~ Nm
ENERGY & WORK
. \'Il/' ~r;)
;~:::::<':~:~~J JIS
joule
DENSITY ~,I //'/~'" POWER
radian (fad)
PLANE ANGLE
------
SUPPLEMENTARY UNIT
BASE UNITS
Specially Nanzeel Units The 51 unit of pressure, the pascal, is therefore defined in
the base 51 units as:
terms of
Other dedved units are similarl.v established from the base I Pa = I N I I 111"
units but have been given special names (Fig App-I and
Allhough the S[ base llnil of temperature is the kc.:lvin, the
Table App-I). These units are defined through the lise of
derived unit of degree Celsius (OC 01' c) is much marc
fundarnental equations or physi-cal laws in conjunction commonly used. The degree Celsius is equivalent to the kelvin
with the arbitrarily defined Sf base units. For example, in magnitude. but the ab~ solute value of the Celsius scale
Newton's second law of motion states that when a body differs frol11 that of the Kelvin scale such that °C = K - 273.15.
that is free to Il10vC is subjected to a force. it will experience
~m ~lCcelcr- alion proportional to thai force and inversely pro-
,",Vhen the 51 s~'stcm is used in a wide variely of
portional to its own mass. i\Jlathcmatically, this prin-ciple can measurements, the quantities expressed in terms of the
be expressed as: base. supplemental. or derived units ma~t be either very
large or very small. For example, the arca on the head of a
force = Illass X acceleration pin is an extremely small number when expressed in terms
of square meters. Conversely, the weight of a whale is an
The Sf unit of force, the newton (Nl, is lherefore defined
extremely large number when expressed in terms of
in terms of the base SI units as:
newtons. To accomrnodate the convenient representation of
1 N = 1 kg X I I11/S:! small or large quantities, a system of prefixes has been
incorporated into the SI system (Table App-2), Each prefix has
The Sf unit or pressure and stress is the pascal (Pa). a fixed meaning and can be used with all 5Iunils. \!\Then
Pressure is defined in hydroslaties as the force divided by
the area of force application. Mathem4ll-icall~l, this can be
used with the name or the unit, the prefb: indicates that the
expressed as: quanti!}! described is being expressed in some multiple or
pressure = force/area
..__ .._ __.__._.__.. _
I
; Definitions of Sl Units
Base 51 Units
meter (01) The meIer is the length eqllal to 1,650,763.73 wavelengths in vacuum of the radiation
corresponding to the transition belween the levels 2PHi and Sd" of the krypton-86
atom.
kilogram (kg) The kilogram is Ihe unit of mass and is equallO the mass of the international proto·
type of the kilogram.
second (s) The second is the duration of 9.192,631,770 periods of Ihe radiation corresponding to
the transition between the two hyperfine levels of the ground state of the cesium-133
atom.
kelvin (k) The kelvin. a unit of thermodynamic temperature, is the fraction 1/273.16 of the ther-
modynamic temperature of the triple point of water.
Supplementary SI Unit
radian (rad) The radian is the plane angle between two radii of a circle that subtend on the circum~
ference of an arc equal in length to the radills.
Derived SI Units With Special Names
newton (N) The newton is that force \tvhich, when applied to a rpass of 1 kilogram, gives it an aC-
/
celeration of 1 meter per second squared. 1 N= 1 kg rn/s .
pascal (Pa) The pascal is the pressure produced by a force of 1 newton applied. with uniform dis-
tribution, over an area of 1 square meter. 1 Pa = 1 N/m~.
joule (J) The joule is the work done when the point of application of a force of 1 newton is
displaced through a dist~nce of 1 meter in the direction of the force. 1 J = 1 Nm.
wall (W) The watt is the power that in 1 second gives rise to the energy of 1 joule. 1 W ::: 1 J/s.
degree Celsius (C) The degree Celsius is a unit of thermodynamic temperature and is equivalent to K -
273.15.
Standard Units Nmned
Factors and Prefixes for Scientists
SI Prefix
SI Symbol
giga G One of the more interesting aspects of the SI system is its
mega Iv1
lise of the names of famous scientists as st«n~ dard units. In
each case, the lInit was named after a scientist in recognition
kilo k
of his contribution La the
hecla h Geld in which that unit plays a major role. Table App-3
deka da lists a number of Slullits and the scientist for which each
deci d was named.
centi c For example. the unit of force. the neWlon, was named
in honor of the English scientist Sir Isaac Ncwlon (1624-
rniJli rn
1717). Hc wa' cducalcd 'II Trinil)' College at Cambridge
micro I' nana n
and later rclurned to Trinity College as a professor or
mathematics. Early in his career, Newton made
pica p fundamental contributions to malhcmalics Ihat formcd Ihc
Reprinred wirh permission from Ozkaya. N.. & Nord,-n. M. basis of diffcrcntial and integral calculus. His other major
(1999). Fundamentals oi Blomechani(!>: Equilibrium. Mo· tion. and discoveries were in the fields of optics. astronomy.
Deiormatlon (2nd ed.) New York: Springer·lJer/ag. p, iO. gravitation. and mechanics. His work in gravitation was
pur-portedly spurred by being hit on the head by an ap-ple
falling from a tree. It is perhaps poetic justice that the SI
unit of one newton is approximately equivalent to the weight
ten times the unit used. For example. the millime· 'tel' (mm) of a medium-sized apple. Newton W~lS knighted in t 705 by
is used to represent one thousandth (10"·1) of a meter and a Qucen i\ltary fot" his monumental contributions to science.
gigapascal (Gpa) is uscd to denotc one billion (10') pascals.
---_._--------
, SI Units Named After Scientists
Symbol Unit Quantity Scientist Country of Birth Oates
A ampere electric current Amphere, Andre·tvtarie France 1775-1836
( coulomb electric charge Coulomb, Charles Augustin de France 1736-1806
O( degree celsius temperature (elsius. Anders Sweden 1701-1744
F farad electric capacity Faraday, Michael England 1791-1867
H henry inductive resistance Henry, Joseph United States 1797-1867
Hz hertz frequency Hertz, Heinrich Rudolph Germany 1857-1894
J joule energy Joule. James Prescott England 1818-1889
K kelvin temperature Thomson, William (lord Kelvin) England 1824-1907
N newton force Newton, Sir Isaac England 1642-1727
fl ohm eleclrlc resistance Ohm. Georg Simon Germany 1787-1854
Pa pascal pressure/stress Pascal, Blaise France 1623-1662
5 siemens electric conductance Siemens, Karl Wilhelm (Sir William) Germany (England) 1823-1883
T testa magnetic flux density Testa. Nikola (roatia (US) 1856-1943
V volt electrical potential Volta, (ount Alessandro Italy 1745-1827
W walt power Watt, James Scotland 1736-1819,
Wb weber magnetic flux Weber, Wilhelm Eduard Germany 1804-189}.;;};'
Conversion of Units
1 pound mass (1 brn) = 0.4536 kilogr~lm (kg) 1 revolution (rev) :=: 360"
Force Temperature
1 kilogram force (kgf) = 9.807 Nevvton (f\J) <>( '""r~ ~ 273.2
The unit of pressure and stress. the pascal. was named ucated at the Universit.\· of Glasgo\\" and at Cam-bridge
after the French physicist, mathematician, and philosopher University. Early in his career, Thol11son in-vcstigated the
Blaise Pascal (1623-1662). Pascal conducted important thermal propcnies of steam at a sci-entific laboratory in
investigations on the <.:harnc-teristics of vacuums and Paris. At thc age of 32, he returned to Glasgo\\" 10 accept
barometers and also in-vented a machine that would make the chair of Nalural Philosophy. His meeting with James
mathematical calculations. His work in the area of JOllie in 1847 stimulated interesting discussions on the
hydrostatics helped lay the foundation for the later nature of heat, which eventually lecl to the establishment of
developmenl of these scientific ficlds_ In addition to his Thomson's absolute scale of temperature, the Kelvin scale.
scicntific pursuits, Pascal was passionalely interested in In recognition of Thomson'scontributions Lo the field of
reli-gion and philosophy and tllllS wrote extensively on a thermodynamics, King Edward VIl con-fen-cd on him the
wide range of subjects. title of Lord Kelvin.
The base unit of temperature, the kelvin. was named in The commonly llsed unit of temperature, the de-gree
honor of Lord Vv'illiam Thomson Kelvin (1824-1907). Celsius, \\ as named aftcr the Swedish as-lronomcl and
Named William Thomson, he was cd· lmenlO! Anders CelsiLl' (1701-1744).
APPENDIX 1 • THE SYSTEM 'M'·'.'''T,r",
Celsius was appointed professor or astronomy at the Inii"p- (slich as the English system). the units of length, time, and
",i,\'of Uppsala at the age of 29 and remained the university force arc arbitrarily' defined, and other units (including
until his death 14 years latec [n mass) are derived from these base
1742, he described the centigrade thermometcl- in a paper units. Because lhe units of force in gravitational svs-tems
prepared for the Swedish Academ!' of Sci- are in fact the It'eights of stan(~"\rd masses. c~n~
The name of the centigrade temperature waS version to 51 is dependent on the acceleration of mass due
officially changed to Celsius in 1948. to the Earth's gravity, By' international agreement. the
acceleration due to gravity is
9.806650 m/s'. This \'aille has been lIseel in establish-ing
to Sf From Other some of the conversion factors in Box App-I.
of'Measurement
REFERENCES
Box App·t contains the formulae for the conversion ~f J.L. (19i7). SI .\leu;£' /-land/wok. Nt'w York: Charks StTibll('r'S
F~ircr,
measurements expressed in English and non-Sl units into Sons.
Sf units. One fundamental source of connJSlon in converting Ozbva, N., ~ Nordin, ~'l. (1999). FWlfl(llllell1o!s orBirmlt:-c/;(wics:
from one system to another is that (wo basic t~'Pes of EquilihriulJI, .\lotioll, (lut! DejtmJ/(//ioll (2nd (:d.}
Illeasun:menl systems exist. N<:w York: 5pringcr-Vl·r1ag.
Pennychuick, C.J. {1974l. lIulldy .\!tllrif:l's oj" VI/il Crntl't'n;UIl Pi/oon
In the "ph\'sical" system (such as SI). the units of length.
(or Riolof!..\' amI .\lcclulJI;cs. New York: John Wiley
time, and nUlSS arc arbitrarily defined, and other units &: Son~.
(including force) are derived fron1 these \Vorld Health Org~lnizalion. (19i7). The SI /01' t!le fha/til Pro-jt's$iol1s.
,. base units. In "technical" or "gravitational" systems Gl.'llt'\"C WHO.
I
Biomechanics
of Tissue and
Structures of the
Musculoskeletal
System
Biomechanics of
Bone
Victor H. Frankel, Margareta Nordin
Introduction
Bone Composition and Structure
Biomechanical Properties of Bone
Biomechanical Behavior of Bone
Bone Behavior Under Various loading Modes
Tension
Compression
Shear
Bending
Torsion
Combined l.oading
Influence of Muscle Activity on Stress Distribution in Bone
Strain Rate Dependency in Bone
Fatigue of Bone Under RepetitivE: Loading
!nfluence of Bone Geometry on Biomechanical Behavior
Bone Remodeling
Degenerative Changes in Bone Associated With Aging
Summary
References
Flow Charts
of the tissue. Bone scn·cs <.lS a rcsen/Oir for essential
lJitijoduction minerals in the bod~·. particularly calcium.
TbJ:i~~rpose or the skeletal system is to protect in- Bone minend is embedded in variousl~« oriented fibers of
te.r~.~V:"organs, provide rigid kinematic links and
the protein collagen, the fibrous ponion of the extracellular
~~ls:ctEtattachmcntsites, and facilitate Illuscle ac· matrix-the inorganic matrix. Collagen ribers (type l) are tough
:·:::;:~"pJ:tf91iYli~9,bodymovement .. Bone has unique stl·UC· '- and pliable, yet they resist strelching ~lnd have lillie
:/:::"'{:<'Y~lit~I.-.rI1d mechanical properties that allow it to L'xtensibility. CollagL'1l composes ~\PPJ'().\.irnatdy 9(YYo of
,,:~,<,:;;::,/,):',si;(rrY()llt;these roles. Bone is among the body's the ex~ tracellular matrix and accounts for approximately 25 lO
,::)},:;;ll~lrci~~tstrllctllres;onl)' dentin and enamel in the 3W>'r' of the dr~! wl'ight of bone. A universal building block
'./t~¢th.>qreharder. It is one of the most dynamic and
:,:;:::';:,:::':i:,..
of the body, collagen also is the chie!" fibrous component of
::",';;::;.~/'i,1;i',.~t..?9Pp'.cally active tissues in the body and re· other skddal struc-tures. (A detailed descriplion 01" the
>.";'\1.lAiri,S::~\ctiv0throughollt life. A highl~; vascular tis- microstnlcturc and mechanical behavior of collagen is
s~e'.-.ithas an excellent capacity for self-repair and tan provided in Chapters 3 and 4.)
~lter its properties and configuration in rc-
. spOI~~e" to changes in mechanical demand. For ex-ample,
changes in bone dcnsit~1 arc commonly obsei~·ed after The gelatinous ground substance slIlTounding thc
pL:riods of disuse and of greatly in-creased use; changes in mineralized collagcn fibers consists mainly of protein
bone shapL' are noted dur· iog fracture healing and after polysaccharides, or gl~"cosarninoglycans (GAGs), primarily in
certain operations. the form of cOlllplt:x macro· molecules called
.;: Thus, bone adapts Lo the mechanical demands placed on i l. protcoglycans (PGs). The GAGs s~rvc as a cementing
substance between layers of mineralized collagen fibers. Thcs~
This chapter (iL'scribcs the composition and structure of GAGs, along wit.h various noncollagcI1ous glycoprotcins,
bone tissue, the mechanical properties of bone, and the consti-tute approximately 5% of the extracellular rnatrix. (The
behavior or bone under different loading conditions. structure or PG:-:, whi,:h arc vital components of artie,
Various factors that affect the mechanical behavior of bone i:il''_·;l~·{iL\gt·. is described in delail in Chap·
in vitro and in vivo also are disclissed.
kr .) ..1
\Vater is fairl~: abundant in live bone. accounting for up
Bone Composition and Structure to 25% of its total weight. Approximately 85°10 of the
walt.'r is found in the organic matrix, around the collagen
fibers and ground sllbstance, and in the h.vdl·ation shells
Bone tissue is a specialized connective tissue whose solid
surrounding the bone crysl~ds. The other 15% is localed in the
composition suits it for its supportive and pro-teclive roles.
canals and cavities that house bone cells and carry nutrienls to
Like other connective tissues, it con· sisrs of cells and an
t h~ bone tissuc.
organic extraccllular matrix of fibers and ground substance
produced by the cells. The distinguishing reature of bone is
At the microscopic level, the fllndamcmal StI11C-
its high con· tent of inorganic materials, ill the form of
lllralunit of bone is the osteon, or haversian system (Fig.
mineral salts, that combine intimately with the organic ma-
2·1). At the center of each osteon is a small channel, called
trix (Buckwalter et al., 1995). The inorganic compo· nent
a haversian canal, lIlat conlains blood vessels and nerVe
of bone makes the tissue hard and rigid, while the organic
fibers. The osteon itself con-sists of a concentric series of
component giv~s bone its flexil)ility and resilience. The
layers (lamellae) of mineralized rnatrLx surrounding the
composition of bone dirrers depend-ing on site, animal
central canal, a configuration similar to growth ring~ in a
age. dietar:.y histol)', and the pres· ence or disease (Kaplan
tree trunk.
et aI., 1993).
Along the bOllndflries of each layel: or lamella, are
In normal human bone, the mineral or inorganic portion
small cavities known as lacunae, each cOl1laining 011(.' bone
of bone consists primarily of calcium and phosphate,
cell. or ostcocyte (Fig. 2-1 C). Numerous small channels,
mainly in the form of small crystals rc· sembling synthetic
called canaliculi, radiate from each lacuna, connecling the
hydroxyapatite crystals \vith the composition
lacunae or adjacent lamellae and ultimately reaching the
Ca",(PO,)o(OI-l),. These minerals, which a~count for 60 to
haversian canal. Cell processes extend from the osteocytes
70% of ilS dry weight, give bone its solid consistency.
into the canali-culi, allowing nutrients '[Tom the blood vessels
"Vatcr nccounts for 5 to SOk and the organic matrix makes
in the haversian canal to reach the osteocyles.
tip the J'cmainder
27
a~~l~¥!T r: BIOIV1ECl-lANICS OF TISSUES AND STRUCTURES OF THE MUSCULOSKELETAL SYSTEM
Lamellae
OsteocYle~
Lacuna-----
A. The fine structure of bone is illustrated schematically haversian canal. Adapled irom Torrora G.J.. & Anagnos-takas. N.P.
in a section of the shaft of a long bone depicted with-out inner (198:1). Principles of Anatomy and Physiology (4th edJ. Ne~·v York:
marrow. The osteom. or haversian systems. are apparent as the Harper gRow. C, Along the boundaries of the lamellae are small
structural units of bone. The haver- cavities known as lacunae, each of which contains a single bone cell,
sian canals are in the center of the osteons, which form the main or osteocyte. Radi-ating from the lacunae are tiny canals, or
branches of the circulatory network in bone. canaliculi, into which the cytoplasmic processes of the osteocytes
Each osteon is bounded by a cement line. One osteon is shown extend. Adapted from Torrora G.;.. & AOclgflosrak05. N.P.
extending from the bone (20x). Adapted from Basset!, CAL. (1965).
£/ecrrical effects in bone. SCI Am, (1984). Principles of AnalOmy and Physiology (4th edJ. New
213.18. B, Each osteon consists of lamellae. concentric rings York: Harper & Ro~"/.
composed of a mineral matrix surrounding the
At the pcriphcl)! of each osteon is a cement line, a A typical osteon is approximately 200 micronle-tcrs
nrtrrow area of cement-like ground SubSlrtllCe composed (J..l) in (lin·rnctcr. Hence, evclY point in the os-teon is no
primarily of GAGs. The canaliculi of Ihc osteon do not pass more than 100 J..llll from the centrally 10-catcd blood
this cement line. Like the canali-culi, the collagen fibers in supply. In Ihe long bones, the osteons usually run
the bOl1e matrix intercon-nect from one larndla to another longitudinally. but they branch [I'c-quelltly and anaslOmose
within an osteon but do not cross the cement line. This extensively with each othcl:
intertwining of collagen fibers within the osteon undoubtedly
in-, creases the bone's resistance to mechanical stress and Jnterstitial lamellac span the regions between complete
probably explains _~vhy the cement line is the weakest O!"h:ons (Fig: 2-1..1). They arc continuous with the ostcons
portion of the bonc's microstructure. and consist of the same material in a difTerent geol11ctric
configuralion. As in the os-
Frontal longitudinal section through the head. neck, greater
trochanter, and proximal shaft of an adult fe-mur. Cancellous
bone, with its trabeculae oriented in a lattice, lies within the
shell of cortical bone.
! Reprinted with permission from Gray, H. (T 985). Anatomy of the Human Body.
(73(h American ed.J. Philadelphia:
activelv replaces woven bon~. Lamellar bone is therC'-for~ and ,'cRail'. (ostcoblasls). The periosteum covers th~cnli~
a "marc" l11all~'c bOlle.--- -b0I1::' except for the - joint-'Slld"a-ces,
All bones are §urrounded by a dC.llse __ U_bJ~olls which m":Cco\;'cr'ccT'witTl arlicufm- cartilage. InThe
membrane called the periosteulll (Fig. 2-1.-\). Its ouler long borles, 'a- thin'llcr "nl'e'moi~a-ne:llle-cndostcum,
fa)~ei: (~ -pe-i::nl-eat-e-(Ch~);-'-GToodvessels (Fig. v:,\'
line";; t heee n1ral (;;;";;clujIaty j ~,,",;il Ii icll;~Jmed \VilTl'-
2-5) and nerve fibers that pass into the cortex via y~cfl~~~~;~ fall'; -iiuirio\\':~ The'endostcum co.n-.--
Volk,llunn's cH"nalS: c()r\-i1c-EUn·g~\\;i.t~-1 thc--rl~i\.;e,:sian eLl m\ls tai,'ls~~~s:l'~~;~l;ia~t; ,~,~d . alse),. giant n~-~,fli"'l-ll1-c'le:'l:t'~'a'
'\Il'(Cc',~,~~,6~,lir~~Lt(?tll~-,s,a.·!1·~,~,1..1('-li~,I)one .. f\ n i n l.ioli"-e"lisctlTfec! osteoela-sfs: both of which play-
I'~<;-l~" o~_~,~~?g,~n.i..~,J,_~ver C()ll,t,,~1.'i Ils '" l?5)Il~ ~t:llsIY~ i m pOI:f~li1i'I~(;fc's"'Ttl-dlc'l~cmodc ling aMi1~ir"(:csoI'P t i 611
spo"nsible '(or ~(;nen~ting nc\v Gc;'n-c'''du'i-ing gro\Vtl~, of bone .
.....", ,5:_".". . .",.. "" •. '-""'-"""~""""""" -- """
. - - -
--
•
•
-
- ' --
- -" -
Lamellar
l
~.f v~~, J
/'i .\ } ,
,~. \. \ \) '("'1::.;,
.~
Woven
Schematic drawing and photomicrographs of lamellar and woven bone, Adapted from Kaplan,
F.5., Hayes, We., Keaveny. T.M., er a/. (1994). Form and funcrion of bone. In S.R. Simon (Ed.).
Orthopaedic Basic Science (pp. 129, 130). Rosemonr, fL: AAOS.
CHAPTER 2 • BIOMECHANICS OF '~S~J~"0: ~D
FS .. Nayes, w,e.. Keaven}~ rA1 .. et M (1994). Form and function of bone. In 5.R, Simon (Ed.).
Orthopaedic Basic Science (p. /3i}. Rosemon£, It: AAOS.
•
Biomechanical Properties strength, stiflness, and other mechanical properties of
of Bone the structure can be gained b~' examining this curve.
C
C' .•• ---- -••• -------- •••• •••• ••••
PlastiC region
B'
A B" C"
•
.~~;t;Trb~f~fJIP~lECHANICS OF TISSUES AND STRUCTURES OF THE IvlU$CUI.OSKEI.UM SYSTEM
~ :::1
~
CortIcal . bone
- - . 0.90 glee
-- 1.85 glee
as indicalC'd b~' a long plastic region on the ClitYC. Bone also
deforms before failing but to a rnuch lesser extent than metal.
The difference in the plastic behavior of metal and bone is the
l"e-suit or differences in microlllcchanical events at yield.
~ 100 Yielding in melal (tested in tension, or pulled) is caused b~'
iii plastic rIow and the fonrwtion of plaslic slip lines; slip lines
50
/ -------------- art: formed when the molecules of lhe latticc structurc of
/
/
Trabecular bone mctal dislo-cate. Yielding in bone (tested in tcnsion) is caused
o.j.........,=.:...:..:".+"....::.."...::..:.:..:".:." -'<":..:.":....::...:..:... :..cc.;.,:..:.":•...c.;":..•:.:.":...".f.:.c.;".:.":..".:.." ---<
o 5 10 15 20 25
Strain (%)
Metal
Example of stress-strain curves of cortical and trabec-ular bone
with different apparent densities, Testing was performed in
compression. The figure depicts the difference in mechanical
behavior for the two bone structures. Reprinted with permission
from Ke,1'.'eny.
T M., & Hc1yes, \tV. C. (1993). Mechanical properri(;.ls of cor- Glass
tical ancl rfDoecular bone, Bone. 7, 28S·]t]4,
After the yield point is reached, glass deforms very little before
Ceramic
Alumina 300 350 <2
Biological
Cortical bone 100-150 10-15 1-3
Trabecular bone 8-50 2-4
Tendon, ligament 20-35 2.0-4,0 10-25
1t --------
I
I
i
Ductile fracture
I
I
I Brittle fracture
I
~ ,urface' of sample, of a ductile and a br;ttle
material. The broken Jines on the ductile material in-dicate Scanning electron photomicrograph of a human cor-tical
the original length of the sample. before it deformed. The bone specimen tested in compression (30X). Ar-rows indicate
brittle material deformed very little before fracture. oblique cracking of the osteons. Courtesy 0;
Dennis R. Carter, Ph.D.
•
.;;~~iY~C?;;ART 1 • BIOMECHANICS Of TISSUES AND STRUCTURES Of THE MUSCULOSKELETAL SYSTEM
200
MPa
----
Strain
Anisotropic behavior of cortical bone specimens from a the neutral axis of the bone, tilted 60", and transverse
human femoral shaft tested in tension (pulled) in four (T). Data from Frankel, V.H., & Burstein, A.H. (1970). Or-
directions: longitudinal (L). tilted 30" with respect to lhopaedic Biomech<1nlcs. Philadelphia: Lea & Febiger.
•
10
f·7jgure 2-14 shows the variations in strength and stiffness
for cortical bone samples from a human remoral shah,
tested in tension in four directions (Frankel & Burstein c
1970; Carterc 1978). The values for both parameters are B
highest for the samples loaded in the longitudinal direction.
Figures 2·9 and 2·15 show trabecular bone slI-cngth and
stiffness tesled in two directions: compression and tension.
6
Trabecular or cancellous bone is approximately 25% as
dense, 5 to look; as stiff, and five times as ductile as conical
bone.
4
Although lhe relationship bel ween loading pat-lerns and
the mechanical properties of bone throughout the skeleton
is extremely complex, it generally can be said that bone
strength and stiff-ness are greatest in the dircction in which 2
daily loads arc most commonly imposed.
• Tension .. Ii
Bending
Compression
•
are applied toward the surface of the structure aI1d
eli compressive stress and strain. result inside the stI~IC- ture.
Compressive stress can be thought of as man yl small forces
directed into the surface of the stlucture. Maximal
compressive stress occurs on a plane per-pendicular to the
C..J applied load (Fig. 2-19). Under com-pressive loading, the
Shear Torsion Combined structure shortens and widens.
loading
Clinically, COin pression fractures are commonly found
~L.-.- _
in the vertebrae. which are subjected to high compressive
loads. These fractures are most often seen in the elderly
with osteoporotic bone tissue. Figure 2-20 shows the
Tension
During tensile loading, equal and opposite loads are
applied olltward from the surface of the structure,
ancCtensile stress and strai"n result inside the struc-ture.
Ten'sile stress can be thought of as manv small forces
Tensile loading.
directed· <.nva:v from the -;'urface of th~ stlJIC-lure.
Maximal tensile stress occurs on a plane per-
TISSUES A~JD STRUCTURES OF THE MUSCULOSI~ELETAL SYSTEM
Shear
L
Before loading Under shear loading
o
ues for ultimate stress uncleI' compressive, tensile,
and shear loading. Cortical bone can withstand
greater stress in compression (approximately 190
Mpa) than in tension (approximately 130 !\Ilpa) and
greater stress in tension than in shear (70 r\'lpa). The
D CJ
<>
<> 0 1
***
I ~ Unloaded Under
lensile
Under
compressive
loading loading
F- ' ---------
The presence of shear strain in a structure loaded in
tension and in compres.sion is indicated by angular
.... 1/
.... neutral axis, the higher their magnitude. Because a bone
structure is asymmetrical, the stresses may not be equally
distributed.
•
proximal tibia as the skier fell forward over the top of the
ski boot. An equal moment, pro-duced by the fixed foot
and ski, acted on thc distal tibia. As the proximal tibia was
bent fonvard, tensile stresses and strains acted on the
posterior side of the bone and compressive stresses and A
strains acted on the anterior side. The tibia and fibula
fractured at the top of the boot. Because adult bone is
weaker in tension than in compression, failure begins on A, During manipulation of a stiff knee joint during fracture
rehabilitation, four-point bending caused the femur to
the side subjected to tension. Because immature hone is refracture at its weakest point, the original fracture site. B,
n10r~ ductile, it nUl)' fail first in compres- Lateral radiograph of the fractured femur. Courtesy of Kaj
Lundborg, M.D.
sion, and a buckle fracture may result on the com-pressive
side (Flowchart 2~ I).
Cross-section of a cylinder loaded in torsion, showing the
distribution of shear stresses around the neutral axis. The
magnitude of the stresses is highest at the periphery of the
cylinder and lowest near the neutral axis.
Experimentally produced torsional fracture of a ca· nine
femur. The short crack (arrow) parallel to the neutral axis
represents shear failure; the fracture line at a 30'"angle to the
neutral axis represents the plane of maximal tensile stress.
61
<J)
,
I
,! ,i<?
i
,. ,:
@.- Shear
Compression
tensile stress. Such a pattern can be seen in the
experimentally produced torsional fracture of n canine
femur shown in Fig-ure 2-31.
, '
, ' '-.-'
.......1
Tension Combined loading,
I Allhough each loading mode has been considered
separately, living bone is seldom loaded in one mode only.
Loading of bone in vivo is complex for two principal
Schematic representation of a small segment of bone loaded
reasons: bones .~.re ~onstantlysubjected to multiple
in torsion. Maximal shear stresses act on planes parallel and indeterminate loads and their geomelric
perpendicular to the neutral axis. structure is irregulm: In vivo mcasurement of the strains on
Maximal tensile and compressive stresses act on the antcrol11cdial surface of a human adull tibia during
planes diagonal to this axis. walking and jogging dcmon-
.:
SlrateS the comph.:.xil.V 01" the loading patterns dur-ing crcas~d both the str~ss and the strain Oil the libia (Lan.'·on ct
these cOl11mon ph.'·siological activities (Lanyon aI., 1975). This increase in strain with grt,,:atcr speed was
el aI., 1975). Stress values calculated from these strain confirmed in studies or locomo~ lion in sheep, which
measurel~lentsby Carter (1978) showed thal ckmonslratcd a fivefold in-crcase in slrain values from siD\\"
during normal walking, the strc.i.~es wcre COlllP.I"CS-s.ivc walking to fast lrotting (Lanyon & Bourn, 1979).
dllring heel strike, tensile during- thc--s_t-~!.nce
ph~y~·,·,indi1¥aill--c()il·~prcssive-~Iu'ri,~,lg.-pLlsl.1~off(Fig.
2-3"2A). VaI"ucs for shear stress \\'cn.:.~ relatively high in
INFLUENCE OF MUSCLE ACTIVITY ON STRESS
the later portion of the gait c)ldc, denoting sig-nificant
DISTRIBUTION IN BONE
torsional loading. This torsional loading
\vas associated with external rotation of the tibia during When bone is loaded in vivo, the contraction of tbe
stance ancl push-ofr. muscles attached to the bone alters dlC stress distri-bution
Dul"ing jogging. the stress pattern was quite dif-rerent in [he bone. This muscle contraction de-cr<.:ases 01·
(Fi-g. 2:328). The COlJlP.~·.~~.~~c_slrcssPFcdom- eliminates [ensile stress on the bone by producing
inatin!! at lac strike was followed bv high tensile compressi\'c SlI-CSS thal neutralizes it ei-ther partially or
stress~di.iring r>ll-sh-ofr. The sllenr slrcss~:vi~~--'o\V totall~·.
tfil'oughout 'tlle strich:\ denoting 111ini;lwl torsional The effect of muscle contraction can be illus~ trated in a
loadhig"pl~o(lllcedby slight e~'\tern~" and inlcrm~l 1'0- tibia subjected to three-point bending. Figure 2~33A
tatiOll or-the tibia in an-ahernating pallcrn. The in-crease--fll represents Lhe leg of a skier who is falling: forward,
specd from slow walking LO jogging in- subjecting the tibia Lo a bending
10
Tensile
Walking (1.4 m/sec) 8 Compressive
4
Stress Shear (external rotation)
Tensile Shear (internal rotation)
3 6
Compressive rn
2 Shear (external rotation) a.
~1 I ~
~
~ 4
~
z 1 iii
;;; 0 +''<,--+-!----o:...-.--+,__+ __.-;~'c...,...+-
2
~"' ;i •••••••• '
- ', ..j ...i
{jj \. ! -~'.. .:;
\ .....;, ... i
O' , i ................
i
\·······1··..//
\ .. i "
"' i
2· "' i
"' i
3
4· h. l,\ r \i
\i
HS FF HO s 1\
4 .l---=-E--=~'-:':::------
A HO TO B TS TS·TO
A. Calculated stresses on the anterolateral cortex of a human tibia 8, Calculated stresses on the anterolateral cortex of a human tibia
during walking. HS, heel strike; FF, foot flat; HO, heel-off; TO. toe during jogging. T5, toe strike; TO, toe off.
off; S, swing. Calwlated from Calwfared [rom Lanyon. L.E.. Hampson. W.G.)., Goodship.
Lanyon, L.E.. Hampson. W'.G.J., Goodship. A.E.. et af. AE., et al. (1975). Bone deformation recorded in vivo from strain
(1975). Bone deformation recorded in vivo (rom srrain gauges gaoges aClacIJed ro the human tibial Shaft. Acta Orthop 5cand. 46.
c1tr<elched to the human tibial sharr. ACla Orlhop Scand, 46. 256. Figure courtesy 01 Dennis R. Carter, Pll.D.
256. Figure coortesy of Dennis R. Carler, Ph.D
OF TISSUES AND STRUCTURES OF THE MUSCULOSKELETAL SYSTEM
,, - ,,
," bone is loaded (Le., the rate at which the load is ap-plied
•
and removed). Bone is stifTer and sustains a higher load to
failure when loads are applied at higher rates. Bone also
stores more energy before failure at higher loading rates,
r:~ ,, " provided that these rates are within the physiological
range.
,,: ''I The in vivo claily' strain can vary considerably.'. The
calculated strain rate for slow walking is 0.00 1 per second,
\vhile slow running displays a strain rate of 0.03 per
second.
In general, when activities become more strenu-ous, the
strain rate increases (Keaveny & Hay'es, 1993). Figure 2-35
shows cortical bone behavior in tensile testing at different
physiological strain rates. As can be seen from the figure,
B the same change in strain rate produces a larger change in
ultimate stress (strength) than in elasticit.\' (Young's modu-
lus). The data indicates that the bone is approxi-mately
30(/0 stronger for brisk walking than for slow
A. Distribution of compressive and tensile stresses in a tibia
subjected to three-point bending. B, Contrac-tion of the triceps
surae muscle produces high com-pressive stress on the
posterior aspect, neutralizing the high tensile stress.
walking. At very high strain rates (> I per second) proaches its yield strength; that is, the number or
representing impact trauma, the bone becomes more repetitions needed to produce a Fracture dimin-ishes
brittle. In a full range of cxperimentaltesting for rapidly.
ultimate tensile strength and elasticity of corti- In repetitive loading of living bone, the fatigue
, cal bone, the strength increases by a factor of three and process is affected not only by the amount of load and
the modulus by a faclor of two (Keaveny & the number of repetitions but also bv the number of
Hayes, 1993). applications of the load within a given time (frequency
The loading rale is clinically significant because it of loading). Because living bone is self-repairing. a
innuences both the fracture paUern and the amount of fatigue fracture results only when the remodeling
soft tissue damage at fracture. \Vhen a bone frac-tures. process is outpaced by the fatigue process-that is, when
the stored energy is released. At a low loading rate, the loading is so Frequent that it precludes the remodeling
energy can dissipate through the formation of a single necessary to prevent failure.
crack; the bone and soft tissues remain relatively intact,
with little or no displacement of the ,. bone fragments. At Fatigue fractures are llsually sustained during
a high loading rate, however, the continuous strenuous physical activity, which causes the
;'·',greater energy stored cannOt dissipate rapidly :~ muscles to become fatigued and reduces
enough through a single crack, and comminution of bone and .' their ability to contracl. As a result, the.v are less able to
extensive soft tissue damage resull. Figure store energy aI~d thus to neutralize the stresses imposed
. 2-36 shows a human tibia tested in vitro in torsion at a on the bone, The resulling alter-ation of the stress
high loading 1'4ue; numerou:j bone fragments distribution in the bone causes
;;J'
OF TISSUES A~ID STRUCTURES Of THE MUSCULOSKELETAL SYSTEM
Human tibia experimentally tested to failure in torsion at a high loading rate. Dis-
placement of the numerous fragments was pronounced.
B"ne Overloading vent failure. iVluscie fatigue occurred as a result of the abnor-
mal loading pattern and the intensive uaining, It affected the
23-year-old military recruit was exposed to an intensive
muscle function in the neutralization of the stress imposed,
A ",'heavy physical training regime that included repetitive
continuous crawling in an awkward position for several weeks
leading to abnormal loading and altered stress distribution
(Case Study Fig. 2-1-1 B).
(Case Study Fig. 2-1-1 A). The repeated application of loads (high
repetitions) and the number of applications of a load during a short After 4 \-veeks of strenuous physical activity, the damage
period of time (high frequency of loading) surpassed the time for accumulation from fatigue at the femoral shaft lead to an
the bone remodeling process to pre-
oblique fracture.
Case Study Figure 2-1-1A. Abnormal loads at the femoral shaft occurred.
duced more slowl~'; the remodeling is Icss casily out-paced
by the fatiguc process and the bone may not proceed to
complete fracture.
,'. This theol)1 of muscle fatigue as a cau~e of fa-tigue
"m Injury fracture in the lower extremities is outlined in the schema
.3 in Flowchart 2-1 on p. 41.
Figure 2-38 shows typical strain ranges for hu-man
femoral cortical bone during different activi-tics and
distances. Resistance to fatiguc behavior is great.er in
Repetition compression than in tension (Keaveny & Hayes, 1993). On
average, approximately 5,000 cy-clcs of experimental
loading correspond to the number of steps in to miles of
The interplay of load and repetition is represented on a running. One mil-lion cycles corresponds to approximately
fatigue curve. 1,000 miles. A total distance of less than 1,000 miles could
cause a fracture of the cortical bone tissue . This is
• consistent with stress fractures reported among military
recruits undergoing strenuous training of up to 1,000 miles
abnormally high loads to be imposed, and n fatigue of nll1ning over a short period of timc (6 weeks). Fracturcs
damage accumulation occurs that Illav lead to a fracture. of indi-vidual trabeculae in cancellous bone have been ob-
Bone may fail on the tensil~ side, on served in postmortem hUlllan specimens and Illay be caused
the compressive side, or on both sides. Failure on the by fatigue accumulation. Common sites arc the lumbar
tensile side resulls in a transverse crack, and the bone vcnebrae, the femoral head, and the proximal tibia. It has
proceeds rapidly to complete fracture. Fatigue fnlctures on been suggested that these fractures may playa role in bone
the compressive side appear to be pro- remodeling as well as in age-related fractures, collapse of
sub-chondral bone, degeneraLive joint diseases, and other
I I
• • !
0006
l~
INFLUENCE OF BONE GEOMETRY ON
I~ 0 004 vlgorous,-:":::!::::""~~S~'b-'<:::::::-;:;-~ BIOMECHANICAL BEHAVIOR
I~ exercise
ig 0.002Running -----------===--:::- The geometrv of a bone greatl\' influences its mc-chanical
· tI) Walking
bel~avior. In Le~lsion' and compression.
0.0001+0-0--1---+---+----+---!------I
I 1~ 1~ 1~
the load to failure and the stiffness arc propor-tional to the
Number 01 Cycles cross-sectional area of the bone. The larger the area, the
stronger and stiffer the bone. In bending, both the cross-
lam
"i
J.-----------------
0: 48 "~i~~r'l i BIOIviECHANICS OF TISSUES AND STRUCTURES OF THE MUSCULOSKELETAL SYSTEIvi
- - - - ----,1--
:
4 ){ 1 2x2 1x4
I II III
Three beams of equal area but different shapes subjected to bending. The area moment
of inertia for beam I is 4/12; for beam II, 16112; and for beam
111,64/12. Adapted hom Franke', VH .. & Burstein, AH. (970). Orthopaedic Bio-
mechanics. Philadelphia: Lea & Febiger.
inertia is the width (8) multiplied by the cube of the height The factors that affect bone strength and stiffness in
(1-1') divided by 12: torsion are the same that operate in bending: the cross-
sectional area and the distribution of bone tis-sue around a
B· H'
ncutral axis. The quantity that takes into account these two
12 factol's In torsional loading is the polar moment of inertia.
Because of its large area moment of inertia. bean"'! III can The larger the polar moment of inertia. the stronger LInd
withstand four times more load in bending limn can beam stiffer the bone.
I. Figure 2-41 shows distal LInd pl'oximnl cross-sections
A third factor, the length of the bone, influences the of a tibia subjected to torsional loading. Al-though the
strength and stillness in bending. The longer the bone, the proximal section has a slightly smaller bony area thun docs
greater the magnitude of the bending mo-ment caused by the distal section, it has a much higher polar moment of
the application of a force. ,In a rec-tangular structure, the inertia because much of the bone tissue is distributed at a
magniwde of the stresses produced al the point of distance from the neu-tral axis. The distal section, while it
application of Ihe bending moment is proponional to lhe has a largel" bony area. is subjected to much higher shear
length of the StI1.IC-lure. Figure 2-40 depicts the forces stress bccause much of the bone tissue is distributed close
acting on two beams with the same width and height but to the neutral axis. The magnitude of the shear stress in the
different lengths: beam B is twice as long as beam A. The distal section is approximately double that in the proximal
bending moment for the longer beatn is twice that for the section. Clinically, torsional fractures of the tibia
shorter beam; consequently, the stress mag~ nitudc commonly occur distnlly.
throughout the beam is twice as high. Be-cause of their
length, the long bones of the skeleton are subjected to high When bone begills to heal after fracture, blood vessels
bending moments and. there-fore, to high tensile and and connective tissue from the periosteum migrate into the
c01npressive stresses. Their tubular shape gives them the region of the fracture. forming a cuff of dense fibrous
ability to resist bend-ing moments in all directions. These lissue, or callus (woven bone), around the fracture site.
bones have a large area moment of inertia because much of stabilizing that area (Fig. 2-42A). The callus significantly
the bone tissue is distributed at a distance from the neu-tral increases the area and polar moments of inertia. thereby
axis. increasing the strength and stiffness of the bone in bending
and torsion during the healing period. As the rrac~
CHAPTEI{ 2 • BIC'ME.CHANICS
Stress
~-"'~~-<:;magnilude S
I
-r-_I-L---... -L
Stress
•
magnitude =, 25
2L _____
------ 2L
----. I
as as
bending moment. Hence, the stress magnitude
throughout beam B is twice as high. Adapted from VH., &
Burstein, A.H. (7970), Orthopaedic Bio·
mechanics. Philadelphia: Lea & Febiger.
A, Early callus formation in a femoral fracture fixed with an
intramedullary nail. B, Nine months after in-jury, the fracture has
healed and most of the callus cuff has been resorbed. Courtesy of
Robert A. vVinquist,
MD
c-::-<........) Empty screw hole raiser effect produced by the screws and by the hol('s
125 _ -+-... Screw in place without screws had disappeared completely because the
bone had ren1odclcd: bone had been laid down around the
_:.~rew removed ~l_te~..-
100 screws to stabilize them, and the empty screw holes had
been filled in with bone. In femora from which the screws
~
,2 75 / _.::....--- had heen re-moved immediately before testing, however,
[;;
~-- the energy storage capacity of the bone decreased b)' 500hi,
~ 50
0>
<;; .,..---'y .
25 <I"
Control
Burstein and associates (1972) showed the effect of
stress rabel's produced by' screws and by empty screw
holes on the energy storage capacity of rab-bit bones tested
in torsion at a high loading rate. The irnmediatc effect or
drilling a hole and insert-ing a screw in a rabbit femur was
a 74% decrease in energy stOl'age capacily. After 8 weeks,
the stress
Open section
Deformation
Bone Remodeling
Bone has the ability to remodel, b)' altering its size, shape,
and structure, to meet the mechanical de-mands placed on
it (Buckwalter et aI., 1995). This phenomenon, in which
bone gains or loses cancel-lous and/or cortical bone in
response to the level of stress sustained, is summarized as
\'VqJJr's law, which states that the, remodeling of bone is
influ-enced and modulated by mechanical stresses (Wolff,
1892): .
~'------- Normal
I A patient sustained a tibial fracture through a surgi-cally produced open section
defect when she tripped
Bone Remodeling
30-year-old man who had a surgical removal of an
o0
nn
UW!
.... c
nl II
' -------------------
'- ." Vertebral cross-sections from autopsy specimens of
, (top) is subjected to absorption (shaded area) during the aging
young (A) and old (8) bone show a marked reduction in cancellous process, the longitudinal trabeculae become thinner and some
bone in the latter. Reprinted with permission transverse trabeculae disappear (bot-tom). Adapted from Sifter!,
,I
from Nordin. B,E.e. (1973). Metabolic Bone and Stone Dis- R.S .. & Levy. R.N. (J98/j. Tra-becular pacteffls and the internal
architecture of bone. ivlt.
lI__ease. Edinburgh:
9 9
Churchill Livingstone. C. Bone reduction
P
W_i'_h_a__i_n__i'_'_'_h_e_m_a_t_i,_a_'_'Y_d_e__i'_t_e_d_._A_,_n_o_,_m_a_1_b_o_n_e S_i_"_"_i_J_rv_lo_d_,_";_.S_,_2_2_'_. _
mined by the geometry and n1mcrial properties of each around scrcws is illustrated in Figure 2-49. A nail plate was
structure (Case Stud)' 2-2). A large plate, car-rying high applied to a femoral neck fracture and the bone
loads, unloads the bone to a great ex-tent; the bone then hypcrtrophied around the scrcws in responsc to the
atrophies in response to this di-minished load, (The bone increased load at thesc sites. H.~lpertrophy may also result if
may hypertrophy at the bone-screw interface in an altcmpt bone is repeatcdly subjected to high mechanical stresses
to reduce the rnicrol1lotion of the screws.) within the normal physio-logical range. Hypertrophy of
normal adult bone in response to strenuous exercise has
Bone resorption under a plate is illustrated in been observed (Dalen & Olsson, 1974; Huddleston et aI.,
Figure 2-48. A compression plate made of a mater-ial 1980; Jones et aI., 1977), as has an increase in bone den-
approximately 10 times stifTer than the bone \Vas applied to a sity (Nilsson & Wesllin, 1971),
fractured ulna and remained after the fracture had healed,
The bone under the plate ear-ried a lower land than normal;
it was partially re-sorbed, and the diameter of the diaphysis
became markedly smaller. A reduction in the size of the
bone diameter greatly decreases bone strength. par-ticularly
Degenerative Changes in Bone
in bending and torsion, as it reduces the area and polar Associated With Aging
moments of inertia. A 20(M, decrease in bone diameter may
reduce the strength in tor-sion by 60%. Changes in bone size A progressive loss of bone density has been ob-sCI·veci as
and shape illus-trated in Figure 2-48 suggest that rigid plates part of the normal aging process. The lon-gitudinal
should be removed shortly after a fraeture has healed and trabeculae become thinner, and some of the transverse
before the bone has markedly dimin-ished in size. Such a trabeculae arc resorbed (SifTert & Levy, 1981) (Fig. 2-50).
decrea.sc in bone size is usu-ally accompanied by secondary The result is a marked re-duction in the amount of
osteoporosis, which' further weakens the bone (SI'itis et a!., cancellous bone and a thinning of conical bone. The
1980), relationship between bone mass, age. and gender is shown
in Figure 2-51. The decrease ill bone Lissuc and the slight
decrease in the size or the bone reduce bone strength and
An implant may cause bone hypertrophy at its at- stillness.
tachment sites. An example of bone hypertrophy
BICHvlIECI,ANIC:S OF TISSUES AND STRUCTURES or THE MUSCUlOSKElET"l SYSTEM
1000
shown in Figure 2~52. The ultimate stress was
o
approximately the sarne for the .young and the old bone.
E
'"w The old bone specimen could withstand only half the strain
w
m that the young bone could, indicating greater brittleness
:;; 500
ID and a reduction in energy storage capacit},. The reduction
C
o
tIl
in bone density', strength, and stiffness results in increased
bone fragility!. Age~related bone loss depends on a number
of factors, including genclel: age, post-menopause,
20 40 60 BO endocrine abnormality, inactivity, dis-use, and calcium
Age (years) deficiency. Over several decades, the skeletal mass ma.y be
~OWlngbone mass,
the relatIOnship between
age, and gender. On the top of the figure, a cross-
section of the diaphysis of the femur and the bone mass
reduced to 5000 of original trabecular and 25°/(; of cortical
mass. In the fourth decade, women lose approximately 1.5
to 2(10 a year while men lose only approximately half that
rate (0.5 to 0.75(-/0) yearly. Regular physical activity and
configuration is shown. Reprinted ('lith permission from Kaplan,
F.S., rlayes, W.c., Keaveny, T.M., er al (7994), Form and function exercise (Zetterbarg et aI., 1990), calcium, and pos~ sibly
of bone. In S.R. Simon (edJ
estrogen intake may decrease the rate of bone mineral loss
Orthopaedic Basic Science (.0, 767). Rosemont, IL:AAOS
during aging.
Summarv
1i Bone is a complex two-phase composite mate~ rial.
One phase is composed of inorganic mineral salts and the
other is an organic matrix of collagen and ground
substance. The inorganic component makes bone hard and
rigid, whereas the organic component gives bone its
flexibility and resilience.
2 tVlicroscopically, the fundamental structural unit of
bone is the osteon, or haversian system, composed of
concentric layers of a mineralized ma~ trix surrounding a
central canal containing blood vessels and nellie fibers.
or totall).' neutralizcs thc tcnsilc stress acting on the Frankel, VH., &: Burslein. A.H. (1970). Ort/lOpacdic Biol/li.'clulllics.
Philadelphia: Lea 0.: Febigel:
bone. f-Iuddbaoll, A.t.. Rockwell, D.. Kulund, D.N., et a1. (1980). Bone
Bone is stiffer, sustains higher loads before fail- mass in lifetime tennis athletes, hUlA, N4, 1107.
ing, and stores more energy whcn loaded at higher !nternaLional Societv of Biomechanics (1987). QII{/lIlitics alld lillits oj"
J1easllfi.'IIiCIIlS· iI/ Bio/lltxhal/ics (unpublished).
physiological strain rates.
Jenkins. D.P.. 0.: Cochran, T.H. (1969). Osteoporosis: The dramatic
~i Living bone fatigues when the frequcnc y.' of loading effecl of disuse of an extremity. Clill On/lOp, 64, 128.
precludes the remodeling necessary to pre-vent failure. Jones, H., Priest . ./.. Hayes, \V.. et a1. (1977). f-lu!11l.'ral
hYPl.'nrophy in response to exercise. J BOlle Joill/ SIiI;!5. 59:\, 204.
Kaplan. ES .. Hayes. We., Kea\'eny. T.iVI., l'l al. (1994). Form and
The mechanical behavior of a bone is influ-enced funcLion of bone. In S.R. SiTllon (Ed.). Orlhopacdic Basic Scicllce
by its geometry (length, cross-sectional area, and (pp.I27-184). Rosemont. IL: AAOS.
distribution of bone tissue around the neutral Kazarian, L.L., & \.lon Gil.'r'ke, I-I.E. (1969) Bone loss as a result of
immobilization and chelation. Preliminary ri:sults in :\1<:IC,K<l
lllubtla. Clill Orthop. 65. 67.
Bone remodels in response to the mechanical Ke.weny, T.M .. &: Hayes, \V.e. (1993). Mechanical propertil.'s of
demands placed on it; it is laid down \vhere needed and cor-tical and trabecular bone. BOIIC, i, 285-344.
Krolner, B.. 0.: Toft. B. (1983). Vertebral bone loss: An unheeded
resorbed where not needed. side effecL of bedrest. C!ill Sci, 6e+. 537-540.
vVith aging comes a marked reduction in the Kummer, J.K. (1999). Implant Biomatl:.'rials. In: L\1. Sph'ak, P.E.
amount of cancellous bone and a decrease in the DiCesare, D.S. Feldman, KJ. Ko\·al. A.S. Rokito. & J.D. Zucker-
man (Eds.). Or/hop(i('dics:"\ S/Ildy Gllidc (pp. 45-48). New York:
thickness of cortical bone. These changes diminish bone \IcGraw-I-lill.
strength and stiffness. Lanyon. LE .. &. Bourn. S. (1979). The inlluence or lllechanicd
func-Lion on the dc\'elopmcrH and remodeling of the tibia: An
exp('ri· mental study in sh('ep . .1 BOlle Joinl SI/rg. 6/.4. 263.
REFERENCES Lanyon, L.E., H.unpson. \\I.GJ .. Goodship, A.E., et al. (1975). Bonl:
deformaLion recorded in vin) from sLrain g'lllgl.'S attached to lhe
Bassett. C.A.L. (1965). Electrical effects in bone. Sci .-\111,2/3. 18. human tibial shaft. ..lew Onhop Sct/lul, "'6~ 256.
BClIldicld, W.. 0.: Lt, e.H. (1967). AnisoLropy of nonelastic llow in Nilsson. B.E., & \\btlin, N.E. (1971). Bone density in athletes. Clill
bone. J App{ Physics, 38, 2450. On/lOp. 77, l79.
Buckwaltcl~ lA .. Glimcher, \U., Coopel: R.R., et al. (1995). Bone bi-
ology. Part I: Stnlcture. blood supply, cells, matrix and mineral-
6zkaya, N., & Nordin, M. (1999). Fllndall/ell/tlls or Biolllcc!ulllic:>:
EquilibriulII, ,HOlioll. alld Del(lnllatioll (2nd cd.) Ncw 'York:
ization. Pan II: Formation, form, remodelling and regubtion of cdl Springer-Verlag.
funcLion. ((nstructional Course Lectlln:). J BOlle JoiJl! Sllrg. Rarnballl~ P.c., 0.: ~Johnston. R.S. (1979). Prolonged
77A, 1256-1289. weighLlessness and calcium loss in man. Ac!a ASll'ollal/lica, 6, 1113.
Burskin, A.H., Reilly, D.T.. 0.: \bnens, M. (1976). Aging of bone tis- Siffen, R.S .• & Levy, R.N. (1981). Tnlbccular patterns and the inter-
sue: :vlechanical properties. J BOllI..' Joilll SI/1~!i. 58:\, 82 nal architecture of bonl.'. ;\fl. Sinai J lIed, 48. 221.
Burstein, A.H., L't al. (1972). Bone strength: The effecl of scre\\" SltiLis, P., Paa\"{llainell, P., Karaharju, E.. ct al. (1980). Structural and
holes. J BOlle Joillt Slil~!i, 54:\, 1143. biolllechanical changes in bOl~e aher rigid plate fixation. Call J
n.R. (1978). Anisotropic analysis of strain roselle informa- SlIIp., 23, 247.
tion from cortical bone. J BiolJlcch, II, 199. \Vhedon, G.D. (1984') Disuse osteoporosis: Physiological aspects.
D.R.. 0.: I-!ayes, W.e. (1977). Compact bone fatigue damage: Cab!" 'fissile lilt, 36, 146-150.
microscopic examination. Clill Of/hop, /27,265. Wolff, J. (1892). Dlls Gt:set::. der halls!(JrlII(ltiOiI der Kllochcll. Berlin: I-
N.. 0.: Olsson, K.E. (1974). Bone mineral content .md physi- lirschwald.
activity. Acla Orthop Scall(/, 45, 170. Zetterberg e., Nordin. :\'1., Sko\Ton. M.L.. et al. (1990). SkeleLal ef-
G.U., et al. (1979). Bone densitometry using computed to- feClS of physical activity. Geri-7bpics. /3(4). 17-24.
mography. Part I: Selective determination of trabecular bone
and oLher bone mineral paraml'lers. Normal values in
children and adults. BrJ Radiol, 52, 14.
~
C VASCULAR FACTO,RS J MECHANICAL FACTORS ~
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Collagen Proteins 1 ;,N~~coliag~n'Proteln~; Cry,Olh of
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attachment proteins ~
m
Calcium, Phosphate
PG', s:
FLOW CHART 2·2 Bone composition. structure, and functions.· (PG's, proteoglycans)
~This flow chart is dl?~igncd for classroom or group discussion. Flow chart is not meant to be exhaustive.
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FLOW CHART 2-4 Intrinsic factors associated with bone damage. Clinical examples.*
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Biomechanics of
Articular Cartilage
Van C. Mow, Clark T Hung
Introduction
Composition and Structure of Articular Cartilage
Collagen
Proteoglycan
WatE'r
Structural and PhysicallniE'ractionAmong Cartilage Components
,a wiele al-ea, thus decreasing lhe strc:)ses sllst~!.!ned by maining 60 to 85% is walCI: inorganic salts. and small
the contacting join.t..~.sl~rraccs (Atcshian ct aI., amounts of other matrix proteins, glycopro-teins. and lipids
1995; Helminen et aI., 1987) and (2) to allow rel"tive (Mow & Ratcliffe, 1997). Collagen flbrils and PGs, each
movementoft!1cu:m,posing joinl surfaces \~:·,i.t"I,l""I~lin- being capablc of forming structural nctworks of significant
imal ft:'iction and wear (iVlow & Alcshian, 1997). In strength (Broom & Silyn-Roberts, 1990; Kempson et aI.,
thi's"ch~l'I)iel','wcw'Hi describe how the biomcchani- 1976; Schmidt el aI., 1990; Zhu et aI., 1991, 1993), arc Ihe
cal pl'openics of articular cartilage, as determined by its structural components supporting the internal me-chanical
composition and structure, allow for the opti-mal stresses that result rrom loads being ap-plied to the articular
performance or these functions. canilage, Moreover, these structural components, together
with water, deter-mine the biomcchanical bchavior of this
tissue (Ateshian et aI., 1997; Maroudas, 1979; Mow et aI.,
1980, 1984; Mow & Aleshian, 1997).
,~rticular Cartilage
COLLAGEN
I A notable exception to the definition of hyaline articu-lar
Collagen is the mosl abundant protein in the body
G'lrtilageis the temporomandibular joint, a synovial joint in (Bateman et aI., 1996; Eyre, 1980). In articular carti-lage.
which fibrocartilage is found covering the bone ends. collagen has a high level of structural organiza-tion that
Fibrocartilage and a third type of cartilage, elastic cartilage. providcs a fibrous ultrastructure (Clm-k, 1985; Clarke,
are closely related to hyaline cartilage embry-ologically and 1971; Mow & Ratcliffe, 1997). The ba-sic biological unit of
histologically but .'lrevastly different in mechanical and
collagen is tropocollagen. a Sln.lcture composed of three
biochemical properties. Fibrocartilage represents a
procollagen polypeptide chains (alpha chains) coiled into
transitional cartilage found at the margins of some joint
cavities, in the joint capsules, and at the insertions of
left-handed helixes (Fig. 3-2;\) thaI are furthcr coiled abollt
ligaments and tendons into bone. each other inlO a right-handed triple helix (Fig. 3-28).
Fibrocartilage also forms the menisci interposed be- These rod-like tropocollagen molecules. 1.4 nanOJlletcl-s
tween the articular cartilage of some joints and com-
poses the outer covering of the interverlebral discs. the (nm) in diameter and 300 nm long (Fig. 3-2, C & 0),
anulus fibrosus. Elastic cartilage is found in the external polymerize into larger collagen fibrils (Bateman ct al.. 1996;
ear, in the cartilage of the eustachian tube, in the Eyre, 1980), In articular cartilage, these fibrils have an
epiglouis. and in certain pans of the larynx. average' diamcter of 25 to 40 nm (Fig.3-2E, Box 3-2);
howevec this is highly variable.
61
OF TISSUES AND STRUCTURES OF THE MUSCULOSKELETAL SYSTEM
Articular surface
...... ,,,,'• .,,• .,0' STZ (10.20%)
'. ~{~:f2jJ.~
,~.-r ,'-'
Photomicrograph (A) and schematic representation (8) of the chondrocyte arrangement throughout the
depth of noncalcified articular cartilage. In the superficial tangential zone, chondrocytes are oblong
with their long axes aligned parallel to the articular surface. In the middle zone, the chondrocytes are
"round" and randomly distributed. Chondrocytes in the deep zone are arranged in a columnar fashion
oriented perpendicular to the tidemark, the demarcation between the calcified and noncalcified tissue .
•
Scanning electron microscopic studies, for instance, have lying bone (Bullough & Jagannath, 1983; Redler et aI.,
described fibers with diameters ranging up to 200 nm 1975). This anisotropic fiber orientation is mir-rored by the
(Clarke, 1971). Covalent cross-links form be-tween these inhomogeneous zonal variations in the collagen content,
tropocollagen molecules, adding to the flbrils high tensile which is highest at the surface and then remains relatively
strength (Bateman et aI., 1996). constant throughout the deeper zones (Lipshitz et aI.,
The collagen in articular cartilage is inhomoge-neously 1975). This composi-tionalla.vering appears to provide an
distributed, giving the tissue a layered char-acter (Lane & important bio-mechanical function by' distributing the
Weiss, 1975; Mow & Ratc1iITc, 1997). Numerous stress more uniformly across the loaded regions or the
investigations Llsing light. transn1ission electron, and joint tis-sue (Selton et aI., 1995).
scanning electron microscopy have identifled three
separate structural zones. For ex-ample, Mow et al. (1974) Cartilage is composed primarily of type II colla-gen. [n
proposed a zonal arrange-ment for the collagen network addition, an array of difFerent collagen (t)'Pes V, VI. IX,
sho\vn schematically' in Figure 3-3A. In the superficial Xl) can be found in quantitatively minor amounts within
tangential zone, which represents 10 to 20()0 of the total articular cartilage. Tvpe II collagen is present primarily in
thickness, are sheets of fine, densely packed fibers articular cm·tilage, the nasal septum, and sternal cartilage,
randomly \voven in planes parallel to the articular surface as well as in
(Clarke, 1971; Redler & Zimny, 1970; Weiss et aI., 1968).
In the middle zone (40 to 60% of the total thickness), there
are greater distances between the randomly oriented and
homogeneousl::... dispersed fibers. Below this, in the deep Differences in Coliagen Types
zone (approximatel.v 30% of the total thickness), the fibers
come together, forming larger, radially oriented fiber Differences in tropocollagen alpha chains in various body
bundles (Redler et aI., 1975). These bundles then cross the tissues give rise to specific molecular species, or types of
tidemark, the interface between articular cartilage and the collagen. The collagen type in hyaline cartilage, type II
calcified cartilage beneath it, to enter the calcified collagen, differs from type I collagen found in bone, ligament,
cartilage, thus forming an interlocking "root" sj'stem and tendon. Type II collagen forms a thinner fibril than that of
anchoring the cartilage to the uncler- type I, permitting maximum dispersion of collagen throughout
the cartilage tissue.
(r chain
A
I
1.4 nm Triple helix
B l
Tropocollagen
molecule
Molecular features of collagen structure from the alpha chain ((I) to the fibril. The flexible amino acid
sequence in the alpha chain (A) allows these chains to wind tightly into a right-handed triple helix
configuration (8), thus forming the tropocollagen molecule (C). This tight triple helical arrangement of
the chains contributes to the high tensile strength of the collagen fibril. The parallel alignment of the
individual tropocollagen molecules, in which each molecule overlaps the other by about one quarter of
its length (0), results in a repeating banded pattern of the collagen fibril seen by eledron microscopy
(x20,OOO) (E).
Reprinted wirh permission from Donohue, It'l1., Buss. D., Oegema. IR., et al. (19831- The effects of
indireCl blunt trauma Oil adult canine arricuhu cartilage. J Bone Joint Surg, GSA. 948.
•
the inner regions of the intervertebral disc and meniscus. because their large slendcnlcss ratio, the ratio of length to
For reference, type I is the most abun-dant collagen in the thickness, makes it easy for them to buckle under
human body and can be found in bone and soft tissues such cotl1prcssive loads (Fig. 3-48).
as intervertebral discs (rnainl.y in the annulus fibrosis), Like bone, articular canilage is anisotropic; its material
skin. meniscus, ten-dons, and ligaments. The most properties differ with the direction of loacl~ ing (Akizuki et
important mechani-cal properties of collagen fibers nrc aI., 1986; Kempson, 1979; Mow & RalclifTc, 1997; Roth &
their tensile stiffness and their strength (Fig. 3-4;\). Mow, 1980; Woo el al .. 1987). Oft is thought that this
Although a Single collagen fibril has'-not be~n tested in anisotropy is related to the varying collagen fiber
len;ion. the tensile slI'ength of collagen can be inferred arrangements within the planes parallel to the articular
from tests on structures with high collagen contenl. Ten- surface. It is also thought, however, that variations in
dons, for example, are about 80% collagen (dry weight) collagen f-iber cross~link density, as well as variations in
and have a tensile stiffness of 10.1 !\'1Pa and a tensile collagen-PG interactions. also contribute to articular carti-
strength of SO MPa (Akizuki et aI., 1986; Kempson, 1976, lage tensile anisotrop~", In tension, this anisotropy is llsually
1979; Wooet aI., 1987, 1997).Stec1, by comparison, has a described with respect to the direction of the articular
tensile stillness of approxi- surface split lines. These split lines arc elongated fissures
Jj·roduced by piercing the ar-ticular surface with a small
mately 220 x 10" MPa. Although strong in tension. round awl (Fig. 3-5;
collagen fibrils offer little resis(ance lo ~olllpression
O'TMW"PAMH;. EiiqMEcf-iANICS OF TISSUES AND STRUCTURES OF THE MUSCULOSKELETAL SYSTEM
A. Schematic representation, (Repriflleej \·virh permission from zone, randomly arrayed fibrils are less densely packed to ac-
Mow v.c. el al. j1974j. Some surface dJc1riJcteristics of arriculaf commodate the high concentration of proteoglycans and wa-ter,
cartilages. A scanning electron microscopy sludy and a theoretical The collagen fibrils of the deep zone form larger radially oriented
mode! for the dynamic interaction of synovial fluid and articular car· fiber bundles that cross the tidemark, enter the calci· fied zone,
tilage. J Bionll?{hanics, 7, 449), B. Photomicrographs (x3000; and anchor the tissue to the underlying bone. Note the
provided through the courtesy of Dr. T. Takei, Nagano. Japan) of correspondence between this collagen fiber architecture and the
the ultrastructural arrangement of the collagen network throughout spatial arrangement of the chondrocytes shown in Figure 3-1. In
the depth of articular cartilage. In the superficial tangential zone the above photomicrographs (B), the STZ is shown under
(STZ), collagen fibrils are tightly woven into sheets arranged compressive loading while the middle and deep zones are
parallel to the articular surface. In the middle unloaded.
Collagen Fibril
B
Uttle resistance to compression
Human femoral condyles
Hultkrantz, 1898). The origin of the pattcrn is re-lated to binding region in c.:anilagc. iVlore recently, the other two
the directional variation 01" the tensile stilT-ness and globular regions have been extensively studied (Fosang &
strength characteristics of articular can i-lage described Hanlingham. 1996), but their functional significance has
above. To dale. ho\Vevel~ the exact rc;sons as to why notycl been elucidated. Figure 3-68 is lhe accepted
articular canilage exhibits slIch pronounced anisolropies in molecular confonnation of a PG ag-gregate; Rosenberg Gt
tension is not known, nor is the functional significance or al. (1975) were the first to obtain an electron micrograph
this tensile 01" this molecule (Fig. 3-6C).
anisotrop)'.
In native cartilage, most aggrccans arc associated
withHA to form the large PG aggregates (Fig. 3-6C). These
PROTEOGLYCAN
aggregates may have up to several hundred aggrecans
l\llany types of PGs arc round in cartilage. Funda-mentally, noncovalenliy uuached to a central HA core via their
it is a large protein-polysaccharide mole-cule composed of HABR, and each sile is stabilized by an LP. The
a protein core to which one or more glycosaminoglycans filamentous HA core molecule is a non-sulfated
(GAGs) are attached (Fosang & Hardingham, 1996; Muir, disaccharide chain that may be as long as 4 fJ.m ill Icngth.
1983; Ratcliffe & Mow, 1996). Even the smallest of these PG biochcmists have dubbed thc HA an "honorary" PG, as
molecules, it is so intimately involved in the structure of the PG
high'Can and deem-in, are quite large (approxi-m;t~ly I X aggregate in articular carti-lage. The stability afforded by
10'\ 111\\'). but they comprise less than the PG aggregates has a rl"wjor functional significance. It is
10~~ of all PGs present in the tissue. Aggrccans are much accepted now thut PG aggregation promotes
larger (1-4 X 10" mw), and they have the rc-markable immobilization of the PGs within the nne collagen
capability to attach to a hyaluronan mol· ccule (HA: 5 X meshwork, adding structural stability and rigidity to thc
10' I11W) via a specific 1·-1A-binding rc-gion (HABR). ECM (Mow ct aI., 1989b; Muir, 1983; Ratcliffc et aI.,
This binding is stabilized by a link protein (LP) (40-48 X 1986). Fur-thermore, two additional forms of c!crmatan
10" mw). Stabilization is cru-cial 10 the function of normal sulfate PG have been idcntif"led in the ECM of articular
cartilage; without it, the components of the PG molecule car-tilage (Rosenberg et aI., 1985). In tendon, c1ermatan
would rapidly escape from the tissue (Hardingham & sulfate PGs have been shown to bind noncovalently to the
IVluir, 1974; H<lscall, 1977; Muil; 1983). surfaces of collagen fibrils (Scott & Orford, 1981);
however, the role of derma tan sulfatc in ar-ticular cartilage
Two types of GAGs comprise aggrecan: chon-droitin is unknown, biologically and func~ tionally.
sulfatc (CS) and kcmtan sulfate (KS). Each CS chain
contains 25 to 30 disaccharide units, while the shorter KS
chain contains 13 disaccharide units (MuiJ~ 1983). Although aggrecans generally have the basic structure as
Aggrecans (previously rererred to as subunits in the described abovc, they arc not struc-turally identical (Fosang
American literature or as monomers in the UK and & Hardingham, 1996). Ag-grecans vary in length.
European literature) consist of an ap-proximately molecular weight, and com-position in a variety of ways; in
200.nanol11ctcr.. long protein core to which other words, they arc polydisperse. Studies have
approximately 150 GAG chains, and both 0-linked and N- demonstrated two distinct populations of aggrecans
linked oligosaccharides, are covalently attached (Fosang & (Buckwalter et aI., 1985; Heincgard ct aI., 1985). The first
Hardingham, 1996; Muir, 1983). Furthermore, the population is present throughout life and is rich in CS; the
distribution of GAGs along the protein core is second contains PGs rich in KS and is present only in adult
heterogeneous; there is a region rich in KS and O-linked cartilage. As articular cartilage matures, other agc-related
oligosaccharides and a rcgion rich in CS (Fig. 3-6M. changes in PG composition and structure occur. vVith
Figure 3-611 dcpicts the fa-mous "boule-brush" model for canilage maluration, the watcr content (Armstrong & Mow,
an aggrecan (j\lluir, 1983j. Also shown in Figurc 3-6/\ is 1982; Bollet & Nancc, 1965; Linn & Sokoloff, 1965;
the hctcrogcne-ity of the protein core that contains three Maroudas, 1979; Venn, 1978) and the carbohydrate/protein
globular regions: GIl the HABR located at the N-terminus ratio progres-sively decrease (Garg & Swann, 1981;
that contains a small amount of KS (Poole, 1986) and a Roughley & White, 1980). This dccrcase is mirrored by a
few N-Iinked oligosaccharidcs, G., located between the
de-crease in the CS content. Conversely, KS. which is
HABR- and the KS-rich regio·n (Hardingham et aI., present only in small ,imounts at birth, increases
1987), and G" the corc protcin C-tenninus. A I: I throughollt development and aging. Thus, the
stoichiomelly C:dslS between the LP and the GI
Link prolein
I Glycosaminoglycan (GAG)
chains (KS. CS)
Chondroitin Sulfate
(CS) chains f
C-terminal
globular
domain (G 3)
1200 nm
Hyaluronan (HA)
1DI1I'---- _
A. Schematic depiction of aggrecan, which is composed of
keratan sulfate and chondroitin sulfate chains bound cova-
lently to a protein core molecule. The proteoglycan protein
core has three globular regions as well as keratan sulfate-rich
and chondroitin sulfate-rich regions. B. Schematic rep-
resentation of a proteoglycan macromolecule. In the ma-trix,
aggrecan noncovalently binds to HA to form a macromolecule
with a molecular weight of approximately 200:<. 106. Link
protein stabilizes this interaction between the binding region of
the aggrecan and the HA core mole-cule. C. Dark field electron
micrograph of a proteoglycan aggregate from bovine humeral
articular cartilage (>:120,000). Horizontal fine at lower right
represents O,SlAm.
Reprinted with permission from Rosenberg, C, Hellmann, W, &
Klein5chmidr. AX (975). Electron microscopic studies 0; proteD-
gfycan aggregates (rom bovine articular cartifage. J Bioi Chem,
250. 1877.
CHAPTER 3 • BIOMECHANICS Of
CS/KS ratio, which is approximately 10: 1 at birth, is only proximately 70(;r; of the water may be moved, This
approxirnatel:v 2: I in adult cartilage (Roughlcy & "Vhile, interstitial fluid movement is important in control-ling
1980: Sweet et al" 1979; Thonar et al" 1986). Furthermore, cartilage mechanical behavior and joint lubri-cation
sulfation of the CS molecules, \vhich can occlir at either the 6 (Ateshian et aI., 1997, 1998; Hlavacek, 1995; Hou et aI.,
or the 4 position, also undergoes age-related changes. In 1992; Mow et aI., 1980; Mow & Ateshian,
utero, chon-droitin-6-sulfate and chondroitin-4-sulfate are 1997).
pres-ent in equal molar amounts; however, by maturity, the
chondroitin-6-sulfate:chonclroitin-4-sulfatc ra-tio has
STRUCTURAL AND PHYSICAL INTERACTION
increaseel to approximately 25: I (Roughley et a1., 1981).
AMONG CARTILAGE COMPONENTS
Other studies have also documented an age-related decrease
in the hydrodynamic size of tf~e aggrecan. Many' of these The chemical structure and physical interactions of the PG
early changes seen in articular cartilage may reflect cartilage aggregates influence the properties of the ECM (Ratcliffe &
maturation, possibly as a result of increased functional Mow, 1996). The closely spaced (5-15 angstroms) sulfate
demand \vith increased \vcight-bcaring. Ho\vever, the func- and carboxyl charge groups on the CS and KS chains
tional significance of these changes, as well as those occurring dissociate in solu-tion at physiological pH (Fig. 3-7), leaving a
later in life, is as .\'ct undetermined. high concentration of fixed negative charges that create strong
intramolecular and intermolecular charge-charge repulsive
forces; the colligative sum of these forces (when the tissue is
immerscd in a physiological saline solution) is equivalent to
the Donnan osmotic pressure (Buschmann & Grodzin-sky,
WATER
1995; Donnan, 1924; Gu et aI., 1998; Lai et aI., 1991).
\Valel~ the most abundant component of articular cartilage, is Structurally, these charge-charge repulsive forces tend to
n10st concentrated ncar the anicular surface (_80°;(j) and extend and stiffen the PG macro-molecules into the
decreases in a near-linear fash-ion with increasing depth to a interfibrillar space formed by the surrounding collagen
concentration of ap-proximately 65% in the deep zone network, To apprcciate the magnitude of this force, according
(Lipshitz et al., 1976: Maroudas, 1979). This Iluid contains to Stephen Hawkings (1988), this electrical repulsion is one
many free mobile cations (e.g., Nu',K', and Cal.) that greatly! million, million, million, million, million, million, million
influence the mechanical and physicochem-ical behaviors of times (42 zeros) greater than gravitational forces.
cartilage (Gu et aI., 1998; Lai et aI., 1991; Linn & Sokoloff,
1965; Maroudas, 1979). The fluid component of articular
cartilage is also essen-tial to the health of this avascular tissue
because it permits gas, nutrient, and waste product movement
back and forth between chondrocytes and the sur-rounding In nature, a charged body cannot persist long without
nutrient-rich synovial fluid (Bollet & Nance, 1965; Linn & discharging or attracting counter-ions to maintain
Sokoloff, 1965; Mankin & Thrashel; 1975; Maroudas, 1975, electroneutrality, Thus, the charged sulfate and carboxyl
1979). groups flxed along the PGs in articular cartilage must
attract various counter-ions and co-ions (mainly Na',Cal.,
and C I") into the tissue to maintain electroneutrality. The
A small percentage of the \vater in cartilage re-sides total concentration of these counter-ions and co-ions is
intracellularl y', and approximately 30% is strongly given by the well-known Donnan equilibrium ion
associated with the collagen fibrils (Maroudas et aI., 1991; distribution law (Donnan, 1924). Inside the tissue, the
Torzilli et aI., 1982). The in-teraction between collagen, mobile counter-ions and co-ions form a cloud surrounding
PG, and water, via Don-nan osmotic pressure, is believcd the fixed sulfate and carboxyl charges, thus shielding these
to have an im-portant function in regulating the structural charges from each othet: This charge shielding acts to
organization of the ECM and its s\velling properties diminish the very large electrical repulsive forces that
(Donnan, 1924; Maroudas, 1968, 1975). Most of the \vater otherwisc would exist. The net result is a swelling pressure
thus occupies the interfIbrillar space of the ECM and is given by the Donnan osmotic pres-sure law (Buschmann &
free to move whcn a load or pressure gradient or other Grodzinsky, 1995; Donnan, 1924; Gu et aI., 1998; Lai et aI.,
electrochemical motive forces are applied to the tissue (Gu 1991; Schubert & Hamerman, 1968). The. Donnan osmotic
et aI., 1998; Maroudas, 1979). When loaded by a pressure theory' has been extensivel:v used to calculate the
compressive force, ap-
a1~~,V/P~'RT1 • BIOMECHANtCS OF TISSUES AND STRUCTURES OF THE !vlUSCUlOSKEl.ETAl SYSTEM
swelling pressures of anicular cartilage and the Il is now apparenl that collagen and PGs also interact and
intervertebral disc (Maroudas, 1979; Urban & McMullin, thal these interactions m'e of great functional imponance. A
1985), By Starling's law, this swclling pressure is, in llll'n. small portion or the PGs have been shown to be closely
resisted and balanced by tension developed in the collagen associated with col-lagen and may serve as a bonding agent
network, confining the PCs to only 20% of their fTee bel ween lhe collagen fibrils. spanning distnnccs thLit ::H'C
Solulion domain (Maroudas, 1976; Mow & Ratcliffe. 1997; too great for collagen cJ."oss·links to develop (Bateman ~t
Sellow eL aI., 1995). Consequently. this swelling pressure al.. 1996; Mow & Ratcliffe, 1997; Muir, 1983).
subjects the collagen network to a "pre-stress" of sig·
CHAPTER 3 • BIOMECHANICS OF
mechanical propcnies, in the prc.:SCnl context. arti<,:. lIlar Creep and strc~s rL,lnxalion phenomcna ll1a~' be caused
cartilage may be considered as a Ouid-filled porous- differenl Illcchani:sms, For single-phase solid pol~'lTh:ric
b~'
permeable (uncharged) biphasic medium, with each materials, these phenomena are the result of iJHcrnal
constituent playing a role in the functional behavior of friction caused b.\' the mOl ion or the long polymL'ric
cartilage. chains sliding over ('ach olher \\'ithin the stressed lll~lIcrial
During joint arlicuhllion, forces at the joint sur-face (Fling, 1981), The viscocl"stic bdmvior of tendons and
may vary" from alnl0S1 zero to more than ten times body ligamt::IHs is primarily' eauscd bv this mechanism (Woo et
weight (Alldriacchi et ai., 1997; Paul, 1976). The contact aI., 1987, 1997). For bone, the long-term viscoelastic
arcas also vary in a cOll1plcx manner and typically they arc lK'hador is thought to ilL' caused h.\' a rdati\'c slip uf
only or the order of several square centimeters (Ahmed & lamellae within the osteons along with the Ilow of the
Burke. 1983; Ateshian et al .. 1994). It is estimated that the inlL'rsti~ tial Iluid (Lakcs & Saha, 1979). For articul,,,' carti-
peak contact stress may reach 20 MPa in the hip while hlgC. the compressive \'iscoelastic bdHl\'ior is prilllar~ i1~'
rising from a chair and to IVIPa during stair climb-ing caused h~' the Jlo\\' of tilL'interstitial lillie! and lhe frictional
drag associated with this lIow (Ateshian cl aI., 1997; Mow (,t
(Hodge et aI., 1986; Newberrv et aI., 1997). Thus, articular
aI., 1980, 1984). In shear, as in single-phase viscoelastic
cartilage, under physiologicallonding con-ditions, is a
pol.vmers. it is primarily c<.lusL·d b~' tilt:' motion of 10l1g
highly stressed malcrial. To understand how this tissue
pol~!J1lL'r chains such as collagen and PGs (Zhu d aI., 1993,
responds LInder these high physio-logical loading conditions. 1996). Thc com-ponent or anicu[;.\r cartilage
its intl"insic mechanical properties in compression, tension,
dscoclasticit~,caused by interstitial lluid !low is known as the hi
and shear must be determined. From these properties, one phasic vis-cot.,lastic behavior (i'VlO\\'et a!., 1980), ~lI1d the COI11-
can un· dcrstand the load-can~ying mechanisms within the ponent of dscoebslicil~'caused b~' macromolecular motion is
ECM. Accordingly, the following subsections \\"ill
characterize tht: tisslIC' behavior under these loading known as til('l1ow-indepl'ndelll (Ha,\'cs '* Bc)dinc, 1(78) or
Il'lOclalities.
the intrinsic visc()elastic behavior or Ihe collagen-PG solid
matrix.
compression (lvlow et aL, 1980) has been adopted by rapid initially', as evidenced by the early rapid rate of
researchers. In this configuration, a cylindrical car-tilage increased deformation, and it diminishes grad-ually until
specimen is fitted snugly il1to a cylindrical, srnZoth- flow cessation occurs. During creep, the load applied at the
walled (ideally frictionless) confining ring that prohibits surface is balanced by the compressive stress developed
motion and fluid loss in the radial di-rection. Under an within the collagen-PG solid matrix and the frictional drag
axial loading condition via a rigid p~rol1s-permeable loading generated by the flow of the interstitial fluid during exuda-
platen (Fig. 3-9;1), fluid will flo\v from the tissue into the tion. Creep ceases when the compressive stress developed
porous-permeable platen, and, as this occurs, ~he cartilage within the solid matrix is sufficient to balance the applied
samp~e will compress in creep_ At any tIme the amount 01 stress alone; at this point no fluid flows and the equilibrium
com-pression equals the volume of nuid loss because both the strain EX is reached.
watcr and theECM arc each intrinsicall:v incompressible
(Bachrach et aI., 1998). The advan-
Typically, for relatively thick human and bovine
tage of the confined compression tcst is that it cre-ates a articular cartilages, 2 to 4 mm, it takes 4 to 16 hours to
uniaxial, one-dimensional flow and def()rma~ reach creep equilibrium. For rabbit car~ tilage, which is
tional J1eld within the tissue, which does not depend on generally less than 1.0 111m thick, it takes approximately' I
tissue anisotropy.' or properties in the radial diN recLion. hour to reach creep equi-librium. Theoretically, it can be
This greatly simplir-Ies the mathematics needed to solve shown that the time it takes to reach creep equilibrium
the problem. varies inversely with the square or the thickness of the
It should be emphasized that the stress-strain, pressure, tissue (Mow et aI., 1980). Under relatively high loading
fluid, and ion flow fields generated within the tissue during conditions, > 1.0 J\ilPa, 50 0/() of the total fluid content may
loading can only be calculated; ho\VevcI~ these calculations be squeezed From the tissue (Echvards, 1967).
are of idealized models and testing conditions. There are Furthermore, in vitro studies demonstrate that if the tissue
man:\' confound-ing factors, such as the time~dependentnature is immersed in physiological saline, this exuded fluid is
and magnitude of loading and alterations in the natural state of fully re-coverable when the load is removed (Elmore et aI.,
prc~strcss (acting \vithin the tissue), that arise from disruption 1963; Sokoloff, 1963).
of the collagen network dur~ ing specimen harvesting. Despite
limitations in de~ terrnining the natural physiological states of
stress and strain within the tissue in vivo, a number of re N Because the rate of creep is governed b.y the rate of
searchers have made gains to\\'ard an understand~ ing of fluid exudation, it can be used to determine the
potential mechanosignal transduction I11ech~ anisms in permeability coefficient of the tissue (Mow et al., 1980,
cartilage through the use of explant loading studies (Bachrach 1989a). This is known as the indirect mea-surement for
et aI., 1995; Buschmann et aI., 1992; Kim et aI., 1994; tissue permeability (k). Average values of normal hun1an,
Valhmu et aI., 1998) based on the biphasic constitutive law bovine, and canine patellar groove articular cartilage
For soft hy'-drated tissues (Mow et aI., 1980). permeability k obtained in this manner arc 2.17 X 10. 15
M·'/N·s, 1.42 x 10'" M'/N·s, and 0.9342 x 10. 15 M4/N·s,
respectively (Athanasiou et aI., 1991). At equilibrium, no
fluid flow occurs and thus the equilibrium deformation can
be used to measure the intrinsic compressive modulus (H,\)
01' the collagen-PG solid matrix (Armstrong & Mow, 1982;
BlPHAS1C CREEP RESPONSE OF ARTICULAR Mow et aI., 1980). Average values of normal human, bovine,
CARTILAGE IN COMPRESSION and canine patellar groove articular cartilage compressive
modulus H,.\ are 0.53, 0.47, and 0.55 megapascal (MPa; note
The biphasic creep response of articular cartilage in a 1.0 MPa = 145 Ib/in 2 ), respectively. Because these
oneNdimensional confined compression ex-periment is coefficients are a measure of the intrinsic material properties
depicted in Figure 3-9. In this case, a constant of the solid matrix, it is therefore meaningful to determine
compressive stress (To) is applied to the tissue at tinlC to ho\v they vary \vith matrix composition. It was de-termined
(point A in Fig. 3-98) and the tis~ Slie is allo\ved to creep that k varies directly, while He' varies in-versely with water
to its final equilibrium strain (EX). For articular cartilage, content and varies directly with PG content (Mow & Ratcliffe,
as illustrated in the top diagrams, creep is caused by the 1997),
exuN dation of the interstitial fluid. Exudation is most
Porous filter
Confining ring
Impermeable platen
A
~
oJ 1 o
a
.~ E-'
E
-
No exudation C
- =-.........._----...-
i
"0w
>
.~ c a
0; 6
B o Equilibrium
rU_A_·_ •__• • •__•
0-
w Copious deformation
:e> fluid
exudation 1
Time
Time
B
A. A schematic of the confined compression loading configu-ration. drawings of a block of tissue above the curves illustrate that creep is
A cylindrical tissue specimen is positioned tightly into an accompanied by copious exudation of fluid from the sample and that
impermeable confining ring that does not permit defor-mation (or the rate of exudation decreases over time from points A to B to C. At
fluid flow) in the radial direction. Under loading, fluid exudation equilibrium (EO'-'), fluid flow ceases and the load is borne entirely by
occurs through the porous platen in the ver-tical direction. B. A the solid matrix (point C).
constant stress (T" applied to a sample of articular cartilage (bottom Adapted from MOH~ VC, Kuei, S,C, Lai, Wl'vl., f:.'( af. (1980).
left) and creep response of the sample under the constant applied Biphasic creep and stress relaxation of articular cartilage in com-
stress (bottom right). The pression: Theory and experiments. J Siomech Eng, 102, 73-8fl
CHAPTER 3 • BIOMECHANICS Of
STRESS-RELAXATION RESPONSE 1984). During the compression phase, the stress rises
CARTILAGE IN COMPRESSION continuously until (To is reached, COITC-sponding to lI o,
while during the stress-relaxation phase, the stress
viscoelustic stress-relaxation response F,,,,,.t,r,"a, continuously decays along the cun!c
cartilage in a I D compression experi-depi,ek'ci in X
B-C-D-E until the equilibrium stress (U ) is reached.
Figure 3-10. In this case, a con-,·,,,,,,rtression rate (line The mechanisms responsible for the stress rise and
t,,-A-B or lower left fig-to the tissue until lin is reached; stress relaxation are depicted in the lower por-tion of
Figure 3-10. As illustrated in the top dia-grams, the stress
b¢ypncl point B, the deformation Uo is maintained. rise in the compression phase is as-sociated with fluid
cartilage, the t.ypical stress response this imposed exudation, while stress relaxation is associated with fluid
deformation is sho\\'11in the flgurc (Holmes et aI., t 985; redistribution within the porous solid matrix. During the
Mow ct aL, compressive phase,
Copious
fluid exudation
Fluid redistribution
(no exudation)
t 1I t I I
III Equilibrium
deformation
A B c D E
I---"'L-o-a-d-in-g---ll jf------"S-tr-e-ss-'e-Ia-x-a-'i-o-n------
c B
w
E
w
~
a . B C D E
6 uo- - - - - - - ;-~----....- ...---
I
Controlled ramp displacement curve imposed on a cartilage and then decreases during the relaxation phase (points B to D) until
specimen commencing at to (bottom left) and the stress-response an equilibrium is reached (point E). Above these two curves,
curve of the cartilage in this uniaxial confined-compression schematics illustrate interstitial fluid flow (repre-sented by arrows)
experiment (bottom right). The sample is com-pressed to point B and solid matrix deformation during this compressive process. Fluid
and maintained over time (points B to E). The history of the stress e~udation gives rise to the peak stress (point B), and fluid
and response shows a characteristic stress that rises during the redistribution gives rise to the stress-relaxation phenomena.
compressive phase (points to to B)
G:.Z,1,;;,;rfttr}, ')i1PiylECHANICS Of TISSUES AND STRUCTURES Of THE MUSCULOSKELETAL SYSTEM
the hi!:!h stress is generated bv forced exudation of the by the relationship k ~ W/K (Lai & Mo\\', 1980), Ar-{j'cular
in~crstilial fluid and the c~mpaclionof the solid cartilage has a \'(.'1:-'low !kTlllcabilily and
matrix 11('<\1- the surface. Stress relaxation is in turn thus hi~h frictional l"I....sistin= I"oret's arc g('n~ratecl when
causcd bv the relicf 0" rebound of the high COIll-paction n~,id is caused tn flo\\" through the porous
r~gi(}n ncar the surface or the solid matrix. solid matrix.
This stress-relaxation process will cease when the compressive In the previous sections on c;:\rtilage \·iscoclastic~ ity \\·e
stress developed within the solid ll1alrix reaches the stress discw;st.'d the process of lluid !low through articular
generated by the intrinsic COIll-pressive modulus of the solid cartihH.!e induced bv solid matrix compres-sion and how
matrix corresponding to U o (Holmcs ct 'II.,1985; Mow ct aL, ll~is process i;lfluences lI1L' viscodas-tic behavior or the
1980, 1984), tissuC'. This process ;:l1so provides an indirect method to
Analysis of this stress-relaxation process leads to lhe dctcrmine the permeability of the tissuc. In this section, we
conc"!usion that under physiological loading cOl1cli-lions. discuss the cxpcri-mCJ1t~11 method uscd to direct I.\' measure
excessive stress levels arc difficult (() maintain because stress the perme-
relaxation will rapidly a(lenuat~ the stress developed within the ability codTicknt. Such an L'xperim(:nt is depicted in Fi~urL'
tissue; this must ncces~ sarily lead to the rapid spreading of the 3-1 I.·\. Here, a specimen or the tissue is
contact area in tht:: joint during articulation (Atcshian el aI., held fixed in ~\ chamber subjected to the action or a pressure
1995, 1998; tvlow & Atcshian, 1997), gradicl1l: tilL' imposed upstrt.'al11 pl\:ssure
PI is greater than the dOwJ1slrt.:;:\Il1 pressure P2'The
Rcccntlv, much focus has been on the inholllo-gencitv o(I- thick~css 01" tlte specimen is denoted by hand
IA with carLilagc depth (Schinagl ct aI., 1996, '1997), Bascd the cross-sectional an..-a 01" pt.'nneatiol1 is ddined b\· A.
on thi~ data, from an analysis of the stress-relaxation Darcy's law, L1sed to determine the perme~\bil- it'\" k fron~ this
experiment it was round that an inhornogencous tissue would simple t.'xpcrimental St.'ltlp, ~·idds k'= Qh/A(Pi-P2). where Q
relax at a faster rate than would the unirorlll tissue (\Vang & is the \'olumelric dis~
1\110\V, 1998). iVloreovcr, the stress, strain, pressure, and chargL' per unit time through the specimen whose area 01"
Ouid flow fields within the tissue were signif-icanllv altered permcm ion is A ([\llo\\' & R;:ltcl irr(" 1997). Us-
as well. Thus it seems thal the vari-ation~' in biochemical ing low pressures, approxiJ11atel~' 0_1 ivlPa. this mClhod was
and structural composition in the layel"s of cartilage pl"ovide f1rslused to determine the permeability of articular cartilage
anothet- challenge to understanding the environn1ent of (Edwards, 1967; lVlnroudas, 1975). The value ~I" k obtained
chondro-c.vtes in situ. in this manner
ram!ccl from 1.1 x 10. 1 < m·l/N·s10 7.6 ;:.< 10.1 ' m·:/N·s. In
~~ddition, using a uniform straight tube model.
the ;:\\IL'rage "pore diameter" has been estimatt.:d at 6 11111
PERMEABILITY OF ARTICULAR CARTILAGE (Maroudas. 1979), Thus. the "pores" within ar-tinllar cartilage
are of mokcular size.:',
Fluid-filled porous materials ma~' or may not be per-mcablc, The pL'nnt.'abilit~'or Hnicular cartibgc under com-pressive
Thc ratio of nuid volumc (VI) to thc total volume (\IT) of the strain and at high physiological pressures (3 MPa) was first
porous material is known as the porosity (f3 :;;;: ViI VT); obtained b~' j\Aansour and lV'1c)W (1976) and later analvzed by
thus, porosity is a geOJ1lclric concept. Articular cartilage is Lai and ,Vlo\\' (1980),
therefore a material of high porosity (approximately 80%), If The high pressure and compressh"e strain conditions
the pores are int~rconnected, th.; porous material is perme-able. examined in these studies more c1osd~' resemble those
PermeabilHv is a measure of the ease with which fluid can conditions found in dianhrodial joint loading. In these
f1(~W through a porous material. and it is inversely l.'xperimcnts, k was measured as a function or two variables:
proportional to the frictional drag ex~ ened by the fluid the pressure gradient across the specimen and the axial
flowing through thc porous, permeable material. Thus, compressive strain applied to the sample. Tht.· results from
permeability is a physi-cal concept; il is a meaSure of the these experiments arc shown in Figure 3-11 B. Permeabilit~·
decreased expo-
resistive force that is required to cause the fluid to Ilow at a
given speed through lhe porous-permeable material. Thb fric~ nentially ~lS a function of both increasing compres-sive
tional resistive force is ~enerated bv rhe inleraction of the slr~lin and increasing applied Iluid pressure, It
intcrstitial fluid-and the p;'rc walls of the porous-permeable was hlter shown, however, that. the dependence of k Ion the
material. The permeability coeffi-cient k is related to the applied fluid pressurt.: derives from com-paction of the solid
frictional drng coefficient K matdx that. in lurn, results from the frictional drag ("used by
rhe permeating nuid (Lai & MO\\', 1980), From the point
of view of pore
····,·;
CHAPTER 3 • 810MECHANICS OF ARTICUlI\RCb,RT~~J&1~'1)
Applied
Fluid , , ,
"~ 16
pressure difference
(P,-P,)
pressure ,- '- Fluid flow "e 14 r .0.069 MPa
P, I i I I
-'-- 0
~ 12 .0.172 MPa
Rigid ~
C><I;:, ,;.;.;+:.:.:. :.:.:-: .;.:.:.... h 10 r ... 0.342 MPa
00.689 MPa
porous { ..
x ~ 1.034 MPa
J , L ~ ~
0 8 16 24 32 40
A. Experimental configuration used in measuring the perme· parhologic caail,1ge (Juring function. I. The formulation. J Bio-
ability of articular cartilage, involving the application of a meeh. 9(8), 5:11-552, a, Experimental curves for articular car-
pressure gradient {P,-Pl)/h across a sample of the tissue (h =:: tilage permeability show its strong dependence on compres-
tissue thickness). Became the fluid pressure (PI) above the sive strain and applied pressure. Measurements were taken
sample is greater than that beneath it (PJ, fluid will flow at applied pressure differential (p\-p)) and applied strains.
through the tissue. The permeability coefficient k in this ex- The permeability decreased in an exponential manner as a
periment is given by the expression Qh/A(PI-P/), where Q is function of both increasing applied compressive strain and
the volumetric discharge per unit time and A is the area of increasing applied pressure. Adapted from L,1i, 1,1I/,'\11.. & MoV'-/,
permeation. Adapted from Torzilli. PA, & MoJ.v, VC (976). On II C. (/980). Drag-induced compre5sion of ,1rtiwlar (,milage dur-
. ,1rhe fundamental fluid cranspon mechafllsms rhrough normaJ and ing a pe-rmeaiion experimenr. J Btorheology, 17. J 11 .
•. ~---------------------------------
';S,n~IC[lIre, compaction or the solid matdx decreases 9j~ specimens h"rvested in the direction parallel to the split line
porosity' and hence the average "pore diameter" pattern than those harvested perpendicu-lar to the split line
" \\Iithin the solid matrix; lhus, solid matrix compac-tion pattern) and strongly inhomoge-neous (for mature anirnals.
increases fTictional resistance (MOWCl aI., 1984). being stiffer and stronger fOl'specimens harvested from the
... >",:1'he nonlinear permeability of articular cartilage superfi-cial regions (han those harvested deeper in the tis-
'X de.monstrated in Figure 3-11 B suggests that the lis- sue) (Kempson. 1979: Roth & Mow, 1980), Intercst-ingly,
<~/!7:9~ has a mechanical feedback sYSlem that may articular cartilage rrom immature bovine knee joints does
.J;s,e~'ve important purposes under physiological con- not exhibit these layered inhomoge-neous variations;
:'o'ditions. When subjecled 10 high lo"els through the however, the superficial zones of both ITlature and
\mechanism of incrcnsed frictional drag against in-:)~rslitial immature bovine cartilage appear to h"ve the ,,,me tcnsile
l1uiel 110w. the tissue will "ppear sLirfer "nel :';L'hwill be stiffness (ROLh & Mow, 1980). These anisotropic and
more difficult to cause fluid exudation. Re· (cent analyses of inhomogeneous char-acteristics in mature joints arc
articular cartilage compressive believed to be caused by the vaI)'ing collagen and PG
/,',/ ':,s,trcss-relaxation behavior have validated this con- stnlctural organiza-tion of the joinl surface and the layering
;C:"'c'ept and its importance in the capacity of the inter- structural arrangements found within the tissue_ Thus, the
g, stili,,1 Ouid La support load (Ateshian eL al.. 1998: col-lagerH'ich superficial zone appears to provide the joint
;'::;',":,~oltz & Ateshian, 1998). Moreover, this mechanism cartilage with a tough wear-resistant protective skin (Sellon
;< /al~o is important in joint lubrication, et "I.. 1993) (Fig. 3-3;\),
-
I
one mllst perform slow, low strain-rate experiments (/\kizuki et
aI., 1986; Roth & Mow, 1980; Woo et aI., 1987) or perform an ~~~
incremental strain experiment in which stress relaxation is al-
lowed to progress IowaI'd equilibration at each incre-menl
of strain (Akiwki et aI., 1986). Tvpically, in a low strain-rate
~
'=-
c
I Failure
negate the ef~ feet of interstitial Ollid now also negates the I
Illanires~ tation of the intrinsic viscoelastic behavior of the solid
matrix. Thus, only the equilibrium intrinsic me-chanical I . ------- ~~~~r-.r
propenies of the solid matrix ma~r be deter-mined from these
tensile tests. The intrinsic vis-coelastic properties of the solid
L ,=------------~ Toe region
Unloaded
..AIf--+ Collagen
+--f-water
Proleoglycan
E.R., Lal: V:l.M.• & Mow V.C (1984). A continuum rheory and an
experiment for the ion-induced swelling behavior cartirage. J Bio-
mech Eng, 106(2), 15/-158
to decreased corripresstve stiffness and increased per- subjected to uniaxial tension or compression. This
rneability of arti~ularcartilage. volumetric change causes interstitia) nuid now and induces
biphasic viscoelastic effects within the tis-sue. H, however,
articular cartilage is tested in pure shear under infinitesinlal
BEHAVIOR OF ARTICULAR CARTILAGE
strain conditions. no pressure gradients or volumetric
IN PURE SHEAR
changes will be 'produced within the material; hence, no
In tension and cOIllpression. only the equilibrium intrinsic interstitial
properties of the collagen-PG solid malri~ can be fluid flow will occur (Hayes & Bodine, 1978; Zhu et aJ.
determined. This is because a volumetric change always 1993) (Fig. 3-15). Thus, a stead v dynamic pure shear
occurs within a material when it is expct'iment C£ln be used [0 assess the
.lil!~~RT';" . BIOMECl:ll':r-IiCS OF TISSUES AND STRUCTURES OF THE MUSCULOSKELETAL SYSTEM
Tension 0%
•
501 n=203
40 1 x = 52.0' " 23.0'
C ;
30
~ 1
£ 20-i
1 ~lmmJlLill.IILillilllllLffi,.
o 45 90
Degrees
A
Tension 30%
•
50 i n = 145
I
lOi In,m_r!L~
0-' __,.
o 45 90
Degrees
Direction of Load
B
Collagen fibril alignment is dearly demonstrated by the scanning electron micrographs (X10.000)
(right) of cartilage blocks under 0% stretch (A) and 30% stretch (8). The his-tograms (left),
calculated from the micrographs. represent the percent of collagen fibers oriented in the direction of
the applied tension. At 0% stretch the fibers have a random orientation; however. at 30% they are
aligned in the direction of the applied tension.
Reprinred with permission (rom Wada, T.. & Akizuki, S. (1987). An ulcrasuucllIral sllIdy of solid ma-
trix in articular cartilage under uniaxial tensile stress. J Jpn Orthop Assn. 61.
intrinsic viscoelastic propcrLics or the collagen-PG solid viscoelastic propcnies arc equival~nl1y defined by the elastic
matrix. storage modulus G'; the viscous loss modulus G" of the
In a steady dynamic shear experiment. the vis-coelastic collagen-PG solid matrix may be determined as a runction
properties of the collagcn-PG solid matrix are detenl1ined of frequency (Fling, 1981: Zhu et aI., 1993).
by subjecting a thin circular wafer of tissue to a steady
sinusoidal torsional shear, shown in Figure 3-16. 1n an Sometimes it is morc convenient to determine the
experiment of this type, the tissue specimen is held by a magnitude of the dynamic shear modulus IG"i given by:
precise amount of compression between two rough porous
platens.
IG*I'= (G')'+ (G")'
The lower platen is attached to a sensitive torque transducer
and the upper platen is attached to a precision mechanical and the phase shifl angle given by:
spectrometer with a senro-controlled de mot01: A
l) = tan' (G"/G')
sinusoidal excitation signal may be provided by the motor
in a frequency of ex-citation range of 0.01 to 20 hertz (Hz). The magnitude or lh~ d~'namic shear modulus is a measure
For shear strain magnitudes ranging from 0.2 to 2.0°10, the of the tala I resistance offered bv the vis-coelastic material.
The value of 0, lhe angl~between
Unloaded Pure shear
I
Collagen
+----fWater
Proteoglycan
Schematic depiction of unloaded cartilage (A), and cartilage subjected to pure shear (8). When cartilage is tested in pure shear under
infinitesimal strain conditions. no volumetric changes or pressure gradients are produced; hence, no interstitial fluid flow occurs. This
figure also demonstrates the functional rote of collagen fibrils in resisting shear deformation.
','the steady applied sinusoidal strain and the steady modulus 10 bc of thc order of 10 Pa and phase shifl angle
~ipusoidallorqllcresponse, is a measure of the total ranging up to 70" (Mow et aI... 1989b; Zhu ct aI., 1991,
':";Edctional energy dissipation within the ll1aterial. EoI' a pure 1996), Therefore, it appcars that the mag-nitude of the shear
elastic material with no internal fric-,:'ti'onal dissipation, the modulus of concentrated PG so-
phase shift angle 8 is zero; for :iijJurc viscous fluid, the phase
shih angle 8 is 90t )/;·Themagnitude of the dynamic shear
'.
Typical stress-relaxation curve after a step change in shear strain. this 11'ipkl....ic Ilk'or,\"pl'<l\'i(\(' ~\ ",\..-'1 ur I!lLTln(ldYIl~IJllicalh'
expressed in terms of the mean of ten cycles of stress relaxation Ik·rllli...... ihk COlblitll-li\'\..·law .... to dl''''lTibllit\..-' till'lL'-
normalized by the initial stress. The solid line represents the dL'[k'lllk'llIph\'sicn-l·lll..'lllic~d, Ill\..-'Cll~lnil·;d, :IIHI
theoretical prediction of the quasi lin· ear viscoelasticity theory, L'k'l'lriL"alpI'OpLTtiL''''of cll<:II'gL'd-!lH!ralL'dso!'ttiSSlll ;\'11.
1I'L'O\·\..-'1',Ill\..-, tripk\-
Adapted from lilu, WB .. Lai. WA1.,
& Mav/, Vc. (/986). Intrinsic quasi .. /inear viscoelasric beflMior of
."ic 11lulti"ek'ctrol\'!L'tlwol',\'h<l h l 'L'1'lshown to he l.'I1-
the extracellular matrix of cartilage. Trans Orthop Res SoC, tirl·l.\'l'on... istl'11{ \\'ith thl' ",pl'ci<tlih·dclas ... ical 0:-:>-nWlic
11,407. PI'I..'SSUl'L'thL'(llyfut'ch'll'~l'(.1 POIYnll.'1'ic...o]L1-ti011S,
plh.'llOllll·llologic;,,1 {1'~lnSpol't II1L'oriL's,and tilL' hiphask theor.\·
(DOIlIl .. IIl, 192-l: I(;'ltch~llsk.\· &
Curran. 1973: .\'Io\\'1..'1 ..11 .. 19~O: On ...a~L'r. 1931), all of
\\'hkh In\\'''''bL'I...·1lfrL'lI11L'ntlyllsL·d 10 slud.\· :-:>pecific
IUlion is one hundred thousand times less and the phase f..lcl..'ls(II' aniCllbl'clrlilagL·.
angle is six to seven times grcmcr than lhat of anicular Th...'Iriphasic IhL'or~' has bl...·I...·!1used sliccl...·ssrllll~·to
cartilage solid matrix. This suggests lhat describe lll .. tny clf till..'1l1L'l'll"111(I-l'kcII'Oclll..'lllicalbl..-ha\·ior:-.
PGs do nOl function in situ to provide shear stiffness for or articubr cartilage. Tl1l..'s...·include tlli..'prl...·-diclion or
articular carlilage. The shear stiffness of arLicLI-lar frl..·e S\\·L·lIinglIIHk'rc1l1..'lllicalload:nonlin-L'a!'
cmotilage Illust lherefore derive (Tom its collagen content, or dCIK·IH.k·IlCL·or h.nlr"llllic pl·rnll..·i.lhilil.\·\\"illl FeD;
from the collagen-PG interaction (Mow llo!llirH.·;11'depcn(k'llCCor stl'L'alllingpOIL'lltialswith FeD:
& Ralcliffe. 1997). From Ihis interpretation, an in-crease in cLll'lingor Glnil ..lg,l· l"l.\·LT:-: pn.'-qrl'ss:osmotic
collagen, which is a much more clastic ele-ment than PC ..Inc! Ilcgatin'osmotic flows: s\\'clling..Ind l'leclric~tl responses or
and the predominant load-carrying el-ement of the tissue in cells 10 11SIlH>lic SIH)(.:k IO<lding; :lIld Ihl..' inlllll'lln:.'or
shear. would decrease the frictional dissipation and hence inhomog,('IlL'OUSfi.'\l·ddl<:lr~c d('nsil~'
the observed phase angle. (CUd al.. 1993. 1997. 1<.)%; Lai ,'1 "i.. 1<,)<,)1; VI,,,, d al.. J
998; Sellon L·t al... 1Y9t':SUIl ('IaI., 199:{). 1'1'0-
\'idillgIllorl..'\·I..'rsalilit.\·Ih....• triphasic Ih...·ol:·h<ls bel..·n
SWELLING BEHAVIOR OF ARTICULAR gcneralizcd to indlldl'lllulti-dcCII'OI.\·ICSin Ihe tissue (Gil L'Ial..
CARTILAGE 1Y9~).
From analysis llsin~ !l1l' triphasic theor.\·. it be-cOllles clear
The Donnan osmotic swelling pressure, associated with the thai thl'swelling hdw\'loror lhe tissw.: (:an hI..' I'L'sponsibiLfor-
densely packed fixed anionic groups (SO,. and COO·) on the ..I sigllific<IlH fraction or the compn,:ssi\'c IOi.ld-bL.'~lriJlg
GAG chains as well as the bulk compressive stillness of the Ci.lp~\i.:it~' or articular car-
PG aggregates entangled
CHAPTER 3 • BIOMECHANICS OF
0.1
IT = RT[<[,(2c+c')-2<!,*c*j + p=
where c is the interstitial ion concentration, c'" is the
external ion concentration, c" is the FeD, R is the universal o 0.15 0.5 1.0 1.5
gas constant, T is the absolute tempera-ture, (t) and 4)'"
Bathing Solution Concentration c'(M)
are osmotic coefficients. and peo is the osmotic pressure
caused by the concentration of PG particles in the tissue,
usually assumed to be
negligible (La! et aI., 1991). For a lightly loaded tis-Sll~, Swelling pressure of articular cartilage versus bathing solu-tion
~he s\vclling pressure ma:v co~~tribule signifi- concentration (c*). At equilibrium, the interstitial fluid pressure is
cantly to the load support. But for highly loaded tis-sues, equal to the swelling pressure, which is defined by the tissue
such as those found under physiological conditions and Donnan osmotic pressure (IT).
certainly.' for dynamically loaded tis-sues, the interstitial
fluid pressurization (Jtlllid) \vould dominate; the contribution
of this swelling pressure to load support would be less than
5(jf; (Soltz & Ateshian, 1998).
Lubrication or Articular
As with the biphasic theory, the triphasic n1echano~ Cartilage
electrochemical theory can be used to elucidate potential
mechanosignal transduction mecha-nisms in cartilage. For As alread.y discussed, synovial joints are subjected to an
example. because of their potential effects on chondrocyte enormous range of loading conditions, and under normal
function, it is im-portant to describe and predict circumstances the cartilage surface sustains little weac The
electrokinetic phe-nomena such as streaming potentials minimal wear of normal cartilage associated with such
and stream~ ing currents (Gu et aI., 1993, 1998; Katchalsky varied loads indicates that sophisticated lubrication
& Curran, 1975; Kim et al" 1994) that arise from ion processes are at work within the joint and within and on the
movement caused by the convection or interstitial fluid surface of the tissue. These processes have been attributed
flow past the FCD of the solid matrix. As a second to a lu~ bricating fluid-film forming between the articular
example, the pressure produced in the in-terstitial fluid by cartilage surface and to an adsorbed boundary lu-bricant on
polyethylene glycol-induced os-motic loading of cartilage the surface during motion and loading. The variety or joint
explants (Schneiderman et aI., 1986) was recently shown demands also suggests that a number of mechanisms are
to be theoretically nonequivalent to the pressure produced responsible for di-arthrodial joint lubrication, To
in any understand diarthro-dial joint lubrication, one should use
basic engi-neering lubrication concepts,
other common Iv used mechanicallv loaded ex-plant
experime~t or by hydrostatic -loading (Lai
et aI., ] 998). In light of this finding, earlier inter-pretations From an engineering perspective, there are two
of biological data from studies making such an assumption fundamental types of lubrication. One is boundary
of equivalency should be re-Visited. lubrication, which involves a single monolayer of lu-
bricant molecules adsorbed on each bearing surface.
a'!~:~~;r~Ji1 • BIOMECHANICS OF TISSUES AND STRUCTURES OF THE MUSCULOSKELETAL SYSTEM
Subchondral bone
Articular cartilage
~ Load
Articular cartilage
A
Subchondral bone Hydrodynamic
•
+f -o p
•
B
Squeeze-Film c Boosted o Weeping
A, In hydrodynamic lubrication, viscous fluid is dragged into a pacity depends on the size of the surfaces. velocity of ap-
convergent channel. causing a pressure field to be generated in proach, and fluid viscosity. C. The direction of fluid flow under
the lubricant. Fluid viscosity. gap geometry, and relative sliding squeeze-film lubrication in the boosted mode for joint lubrication.
speed determine the load-bearing ca-pacity. B. As the bearing D. Depicts the Weeping lubrication hy-pothesis for the uniform
surfaces are squeezed together, the viscous fluid is forced from exudation of interstitial fluid from the cartilage. The driving
the gap into the transverse direction. This squeeze action mechanism is a self-pressurization of the interstitial fluid when
generates a hydrodynamic pressure in the fluid for load support. the tissue is compressed.
The load-bearing (a-
The other is fluid-film lubrication, in which a thin fluid- 0.02 (Dowson. 196611967; Linn. 1968; McCutchen. 1962;
filn1 provides greater sllrrace-to~sllrracesepara-tion (Bowden Mow & Atcshian. 1997). Boundary-lubricated sllIfaces
& Tabor; 1967). Both lubrication types appear to occur in typically have a coefficient of friction one or two orders of
articular canilage under vaJying circulllstances. Intact magnitude. higher Lhan surfaces lubri-cated by a fluid-
synovial joints have an ex-tremely low cocrf!cicnl or 111m, suggesting LhaL synovial joints are lubricated. al
friclion, approximately Icast in part. by the fluid-film
\/,..:.': :t'ni~~Aanism. It is quite possible that synovial joints stead determined by the lubricant's properties, such as its
;{',.~..::.'\i~.{tihe:;mechanism that will most effectively provide rheological properties, viscosity and elasticity, the film
;ft\:. fU$rica~ion at a given loading condition. Unresolved, geometry, the shape of the gap between the two bearing
~:;' ~23:Jnc}Y:fllFjS the manner by which synovial joints gcn- surfaces, and the speed of the relative surFace motion.
;%.;0;;:~~;>tethefluid lubricant film.
;/:; '
;:';..c;.
;,~Z ~~r
""''',.'.
Cartilage is unlike any man-made material with respect
-iN,., Fti.JIP-fILM LUBRICATION to its near Frictionless properties. Classical theories
;.;;iir$Jdi~i!ri]m lubrication utilizes a thin film of lubl'i- developed to explain lubrication of rigid and impermeable
H:~'~'.> c~nt that causes a bearing surface separation. The bearings (e.g., steel) cannot fully explain Ihe mechanisms
'6.·Jld.~a on the bearing is then supported by the pres- responsible for lubrica-tion of the natural diarthrodial joint.
;j~\.tt·~that is developed in this fluid-film. The nuid-:' A variation of the hydrodynamic and squeeze-film modes
,..~';dihn';thickness associated with engineering bearings of fluid-film lubrication. for example, occurs \vhen the
C/. 'isitsually less than 20 f.l.m. Fluid-film lubrication re-' ... bearing material is not rigid but instead rela-tively soft,
q"jres a minimum nuid-fllm thickness (as predicted slich as with the articular cartilage cov-ering the joint
,i':i>Y/a"speciflc lubrication theOIy) to exceed three surface. This type of lubrication, termed
~f~;tioles'the combined statistical surface roughness of elastohydrodynarnic, operates when the relatively soft
cahUage (e.g., 4 to 25 f.l.m; Clarke, 1971; Walker et bearing surfaccs undergo either a sliding (hydrodynamic)
,al:;)970). If fluid-film lubrication is unachievable , or squceze-film action and the pressure generated in the
',;':,b~C~lllse of heavy.. and prolonged loading, incongru- fluid-film substan-tiallv deforms the surfaces (Fig. 3-19, A
'e'nL'gapgeomclI)', slow reciprocating-grinding 1110-tion, & B). These deformations tcnd to increase the surface area
or low synovial fluid viscosity, boundary lubri- and congnlcl1cy. thus beneficially altering film geomCli)'.
cation must exiSl (Mo\\' & Ateshian, 1997). By increasing the bearing contact area, the lubricant is less
The two classical modes of fluid-film lub"ication able to escape from be-tween the bearing surfaces. [t
" defined in engineering are hydrodynamic and squeeze-film longer-lasting lubri-cant film is generated. and the stress of
lubrication (Fig. 3-19, A & B). These modes apply to rigid articula-tion is lower and 1110re sustainable. Elastohydro-
bearings composed of rela-tively undeFormable material dynamic lubrication enables bearings to greatly increase
such as stainless steel. l-lydrodynamic lubrication occurs their load-carrying capacity (Dowson, 196611967,1990).
when nonparallel rigid bearing surfaces lubricated by a
nuid-film move tangentially with respect to each other (i.e.,
slide on each other), forming a converging wedge of Ouie!.
A lifting pressure is generated in Ihis wedge by the fluid
viscosity as the bearing motion drags the fluid into the gap Note that several studies have shown that hyaluronidase
betwcen lhe surfaccs, as shown in Figure 3~ 19A. In treatment of synovial fluid, which de-creases its viscosity
contrast, squeezc-f-Ilm lubrication Occurs when the (to that or saline) b~; causing de· polymerization of HA,
bearing surfaces 1110\'e perpendicu-lad.''''- toward each has lillie effect on lubrication (Linn, 1968; Linn & Radin,
other. A pressure is generated in the fluid-film as a result of 1968). Because nuid-fllm lubrication is highly dependent
the viscous resistance of the fluid that acts to impede its on lubricant viscos-ity, thcse results strongly suggest that
escape from the gap (Fig. 3-19B). The squeeze-film an alternative 1110de of lubrication is the primary
mechanism is suffJ-cientto cany high loads for short mechanism re· sponsible for the low frictional coefficient
durations. Even-tually, however, the fluid-film becomes so of joints.
thin that contact between the asperities (peaks) on the two
bearing surfaces occurs.
BOUNDARY LUBRICATION
During diarthrodial joint function. relative motion of the
Calculations of the relative thickness of the fluid-film articulaling surfaces occurs. In boundary lu-brication. lhe
layer and the surface roughness are valuable in establishing surfaces are protected by an ad-sorbed layer of boundary
when hy'drodynarnic lubrication may exist. In lubricant, which prevents direct. surface-to-surface contact
hydrodynamic and squeeze-film lubrica-tion, the thickness and eliminates most of the surface wear. Boundarv
and extent of the nuid-fllm, as well as its load-carrying lubrication is
capacity, are characteristics independent of the (rigid) .' essentially independent of the phy~ical properties of either
bearing surface material properties. Thcse lubrication the lubricant (e.g .. its viscosit~,) or the bearing material
characteristics are in- (c.g., its stiffness). instead de-pending almost entirely on
the chemical properties
O,I~:~,:;:i;~.g~r:,L".BlgMECHANICS OF TISSUES AND STRUCTURES OF THf: tv1USCUtOS~<EL[Tr:..1. sysn::r'Jl
. ------------------
Articular surface
• are possible.
Solute and
small particle Articular Hi ;'cW) :i:r'
flow surface ri,;;Cfor-r!O:C:CL:ic::-',
I 1
T -=-- -=. ,., - -- -- '---- -=-- "-
0.02-1 urn..
ilmlEL ""
Ultrafiltration of the synovial fluid into a highly viscous gel. edU"\:, of their'"ile',afe \H1i]bir:, tu C'~(ilP(" TlH.'seHi, nhH:rc"
As the articular surfaces come together. the small solute mol- rnoluui(,s forrn d ((mu:,n\r,',ted ~;e! ic'""th"Hl i l,r11 thick
r ecules escape into the articular cartilage and into the lateral lubricate'sthe "nicul.Jr'surfi'l(OS,This hypothc,,,iled
ti'~"H
IL;bric,:;tion
I joint space, leaving the large HA macromolecules that, be- moclc'is lC'ln:(~d "i)()o51cci lubriCdtion "
ing impact, the fluid-film Ina)'be clilninatcd, allo\ving :\III](lll~~lt i\J:li.,! i:-- p~lrlili(IIl!..:d h,:l\\l'l'llllll'"olid :llH,lllllid pll~l:-'l'" o!
sllrface~to-sllrracecontact, The sur-faces, however, will ~\ hipll~l"il' Ill~\llTi~d (\10\\ l'l~d" jl.lSOJ, .'\ll',,!JI~lll 1]l)l)7)
probabl.\' still be pro-tected, either b.\' a thin la)'Cl" of lkri\l'd~llll'\Pl\'""i(l!l lor the l'lkl'li\\:~or 1\1l'~\"\1I'l'd) l'(ll'llll'il'lll(II'friction
ultrafiltratccl s....·novial fluid gel (boosted lubrication) that
or by" the adsorbed lubricin monolayer (boundmy \\~l" lkpl'lldl'lll:-.okh OIl thl'proportioll or 1Ill'load :-'lIpplll'1l'dh\ thl':--olid
lubrication). In~ltl'i\ (c',~.. lhl'dilll'I\:IlCC hl'I\\l'l'lltOI~tl 1(l~\l1 ;\11(.1 tll;\l "lIpj1ol'll'dh\
h.\dl'o:-:;\a-
Ii ....'j11\',":-;[II\'ill llll'l]lIidl. Till'ilnplil';llion01 "lIch an l'\j1I'l'",,,i(llli" lilal
Ihl'!I'il'li(l]l;tl!1),Opl'l'til'"(d c\ni-
ROLE OF INTERSTITIAL FLUID PRESSURIZATION IN
L\~:'-l' \';1]'\ \\ilh lillll'dlll'ill~: ;\ppli,'d1(1;ldill~, ~l 1\'lkc~ 1101l
JOINT LUBRICATION ollhl'IllllT"llli~d l]lIid ;llld \.'(dl;l~:l'll-P(; I1I~ltrix illll'I'~\l'll(lIl" 111;\1 ~i\\'
During joint articulation, loads transmitted across a jointma.\' ri"l'to thl'1]0\\ "lkpl'lldl'111\'I~- <..'(ll,Lt:--lic Pl'(lPlTlil'"01 111l' li","lIl'lk:-
be supported by the opposing joint sur-faces via solid-to-solid ,crilwd \..';\rlier ~\Ild "ll(l\\ll in l:i~',Ul\'" ,;_l) ;llld 3" 1O.
contact, through a fluid-film la,\'er, or b.\' a mixturc of both,
Although rIuid-film lubrication is achievable, its contribution To \'alidall'Ili:-, l1lodl'!.;\ll':-,lli~\ll dl'\'l'lopl'd~\IHl\'el
to joint lubrication is transient, a C()J1sequcnce of the rapid IU;ldill,~ l'\j1o,.'l'illll'llllkll "lllkTilllpU:-'l'd~l I'ri....-tl(jl1al lorqlll'10~ld 011;\
dissipation of the fluid-filrn thickness by joint loads, Witb tbis ""';ll'til;\~:'-l' l'\pLllli111H,hT~~oill~:'-l'J'l'CP
caveat, Atesbian (1997), adopting the theoretical framc\vork 1();HJin~, ill ;1 Ulillill,'d l'()lllp)'l'S"ioll.'ollligl1r~\lion (Fig, .~-~-L\l ("\tl',,hi~lll
of the biphasic theory (Mow et aL, 1980), proposed a l'l ;11, ll)l)Sl. \lnrl'Spl'l'iii-
mathemati-cal formulation of a boundary friction model of L'all.\,;1 \.'\lilldril';J1hip!J;l."il'l·;ll'lil~l!.-',l' plug \\'~l:-' l'OIll-pl'l':-""l'dill ;\
articular cartilage to describe the underlying mechanism l'()lJ1illingrillg k,~2.., prohihiling r~ldial lllolion ;\lll! nuil! l'\ud~\tion)
behind diarthrodial joint lubrication, in particular, the time- 1l1ll!lT ~\ l'onstalllap-plil'dIO;ld ~_',l'lllT~lll'd h\ ~lfl illlPl'ITlll'~\hk'rigid
dependcnce of the friction coefficient for cartilage reported pLltcn llwl \\~l" r()lalill~,:'- ;11 ;\ prl':-:;\.'I'illl'l! ~lll!--,-lllar :-'jk'l'd,The
during creep and stress-relaxation experiments (1\'lalcolm,
1976; McCutchen, 1962), :-'lIrr~\l>l' or thl'plllg oppO:-,itl'till'pl~\ll'll \\~l~ prl's~cd
;lg;\ilbl ;\ li\l'dri~2.id PO]'OU:-IIIll'\'\\lllTl'h.\tIll'int('r~
di::,-it~\ti(lll or Ihe l';\)'liL\!2.\\'lll1lhl'rOIl!l'..'.ll:-'lll'!;\i.Xof
tll~,' POI'lI\!:-'liltL'!'prl:\'l:l~tcd it I'n)llln)t:ltill~!:. III lhis
CHAPTER 3 • BIOMECHANICS OF ARTICULAff~~\t~~~~.:i:~:O
, w
Confining
chamber -- / -- 7+H --- + -- Impermeable
rigid platen
A i ~ Fluid
exudaricn
I 0.15
0.13
0.10
~ 0.08
0.05
0.03
manner, a frictional torque was developed in the lis~ Sue. which closely match expel"imcntal results, show that
Because the application or a torque load that yields pure during initial loading, when interstitial pres-surization is
shear, under inflnitc~imaldeformations, induces no volume high, the friction coefficient' can be very low (Fig. 3-
change in the tissue or associ-ated nuid exudation, the load 2413). As creep equilibrium is reached and the load is
generated by the fric-tional torque is independent of the transferred to the solid ma-trix, the friction cocrficient
biphasic creep behaviOl" of the tissue. Theoretical becomes high (e.g.. 0.15). The time constant for [his
predictions, transient response
is in excellent agreement with observed experimen-tal Iv,:l '1111~h'\"II""lld;k't"\11111;11,:1 ])vl\\l'l'lltil", ~1"i)\.Ti- til"~ (d I Ill'1\\1)
results (Malcolm, 1976; J\l1cCutchcn, 1962), An-other l'~II'lil;l~l' '111'1;ll'I..I~ill"..·h lll..'l..lll'\hra._
imponant resull or this work is that nuid pres-surization can "j\t,.. \\l·;lr ill dh,,"V ","\pl..·rillh:l1h, 111'\\l'\<.·I"\\.. 1' Ilot rukd (Jill. Tltl..· lI11tllipk·
function in joint lubrication without concomitant fluid 11111<,11.·,..... fli dkt,.·lih·luh:;\.:a~ 1Il!ll \\l!llill!~ ill
exudation to the lubricating boundary as is proposed for ,,'(I1II..'l·rl;ll'l'Illl'1111'I..,ll:llli'JII'tn;t1,ing iIlIVr!;ll·i:d \'"1.::11' pi
weeping lubrication (McCutchen, 1962) (Fig. 3-190). :lrlit"IILII',::llliLI.!-'-\." IlllJik ...·k \ ,,-"v-<.·nl1<.'k...........- ;ldh<.",j\l·;lIld
Equally significant, this lubrication theory is capable of :d)r~l..... i\<.· \\l·:lr111:,\ \:11"1..· pbce ill :111 illqxtirl·d Ill" ...
explaining the obscl\'cd decrease of the effective friction k·~! ...·It",·r:ll<."d '.\llll\i:d jllill\. ()nce'-
coeffi-cient with increasing rolling and sliding joint veloc- [)h.' l·;II'liLI.!-'-:l·-'lll'I;ll'l''ll,t:lill'11111';I'll'll\.:lllJ':tldvkc{s
ities and with increasing joint load (Linn, 1968). :llHI'll!" dl'I..Tl·:I'V'ill 111:1". il hl·;,,:Ollh."':-'Idil'l:llld 111ur<.'rk·nlJl·;lhk·L\ki/ilki
1,:1 :11. !lJSh: :\nn"'ln'lI~ &.
Recently. the inlcl'Stilial fiuid pressurization within \1t,I.I.. 19~~: Sl·tloll 1:1 :d. I(jl..)-ll. Thu,.... lItJid Irc>!ll lhe
cm·tilage during uniaxial creep and stress re-laxation Illhl'il';llll!dlll 'l'p:lr;llil'I~: dll'hl';lrill~~ ,111'I:ll'l'"Ina\, Il,__;d~ :1\\;1\ I11UI\.' L·:l...
experiments was sliccessfully measured (Soltz & Aleshian. IhrClll~1i lil .... i.:anil:lgc 'lid:tC~.
ih
1998). As predicted by the bipha-sic theOly, they found Tlli~ 10:-....01 11lhri...:;Llill~ Illiid ll'IHIIhd\\l'l'l1 111\: ~ur- f;li.x, inlTl·;l'\.'"I
that interstitial Ouiet pressur-ization supported more that hI..· prllhahilil\'III dil\·t,.·1 i.-"Cllll;ll'l he-
90'/0 of the load for sev-eral hundred seconds following !\\ .... ·I..'ll 11lL' ;1:-'PlTilil" ;llld V\;ll'I'J"h;lk,tIll' ;lhl';\"ion
loading in confined compression (Ateshian & Wang. 1995). pl"! 't,.·l'~:-'.
The close agreement or their measurements with biphasic Ll\i~\II..' \\\,';\1" ld hl·;ll·;ll.;! '1lI'Lt<.·l·~ I"l·... IIII,... Illl!
,"'UI"I~ll"...:-\l'·:-'llrl~iI.,."L" ,.:lllll:tci !lUI Ii-tllli 1111..· ;H,:L"lIi;lIda~ ti('ll(d
from
the-oretical predictions represents n rnajor advance-ment in
the understanding of diarthrodial joint lu-brication and l1'li,Tl""'i..'iJpL,:d;ll)I;I.:,~L· \\ililin tIll: hV;II'illl,~ ma-kri:d until·' l"l·p,:lili\L· ...
(rL·......... ill~. Bl·;lrill;;: ,,!:'I:ICC
provides compelling evidence for the role of interstitial Ollid
L.illlrl',ll;t-' 11 ... '\.'111· \\illl Illl" rl'pl":t1nl,lpplil':lltl.nof
pressurization as a funda-mental mechanism underlying the
load-bearing ca-pacity in cartilage. It is emphasized that lli~1i l('~ld... O\er;l !"c!;tli\l"h :-hl.n lhTi(ld (II'\\t11l the"
1\'PI..'1jI illil I d'It 1\\ j( );Id ... (1\l'1";111 l'\I\.'lldl"dj1l"l'ilIi.! V\'cn
while the collagen-PG matrix is subjected to hydrostatic pres~
sure in the surrounding interstitial Ouid, it does not expose lh(lll~h lilt· 11l~1[.!llillllk· til'thll ... I..' 1(,;((../ ... l1la\ Ik· much
the solid matrix (nor encased chondrocytcs) to 1IJ\\l..'l' 1!J;11l !lJl" lll:lll"l"i;d":-. lilt i1ll;11l" ....11\·11,;2111. lh!~ fa-;. lii~tll·
deformation, presumably causing no mechanical damage. \\l':11". r...:'.... l!ltill~ il"ll!lll..·\l·lil':llhI"l·Pl';\II.·ddl.'lor-· Ill:lli(1I1 nldll·hl':lrill~
111;1ll'1'i;t!..... L';ll11:1 hi..'pl:tl'('L'\'cn ill \\cll·lllbril..":lIl'dlk·;ll'ill~:-'.
'Ncar is the unwanted removal of material from solid :\11ll (llil" 01 Ill\,· !lJ;ld ... ,d l'olll;\i,:I ;\I·l':I.!\'pl"titi\\,']y ~tl"l·:-...;ill~ 11l;ll
surfaces by mechanical action. There are two components aniL'u!:tr1\'gilliL l,(';ld~ iIIlPl):-l·d on :lrliL'uL,lrL"'lrlil~I~I..· a 1'1..'~11PPIll"!I.."d
of wear: interfacial wear resulting from Lhe interaction of In' 1111..' l'ullagl'll-PG 1ll;lIl"i,\ ~1lh.1 h.\· IIll· rL·",i~I;:1l1(l' gt,.·lllT~llcd 1)\ lhlid
bearing surfaces and fatigue wear resulLing from bearing ., Ill()\·l·IIII..'nlt1tl"(Jll~lllllll [Ili..' Ill;ll!"i\. '1'1111" I\·p..·tilive joint Illtl\ ...'IlIL"111 ;IIHI
deformation under load. ll';ldill~ \\ill 1..__ ~\Il"'L' 1\'Pdili\'c.
lnterfacial wear occurs when bearing surfaces come into
direct conLact with no lubricanL film (boundary 01' Iluid) SI1,,-',,:-.ingtil" I hI..'...;11Ii<l Ill:!l!"i\ :IIH.II'\..'IW:I1l"d""\lId:lllon and
separating them. This type or wear can Lake place in either irllhihilioll (JI 1111..' lis:-'llL'·:illl\,"l"-'.... lili;d llllid L\low l\: ;\tl'shiall,Il)')/l.TIII..,
of two ways: adhesion or abrasion. Adhesive wear arises ...;\" P1'l)l'l'~:"l'S ~'.i\'"," Ii...;\,.' III 1\\'0 ptl:-.:-.ihk· 1l11,(!l'llli:--llIsh.\ \dti\:h
when, as the bear-ings come into contact, surface f:Jli~ll"'· d;:lln:I~~l' lllay ,It,.·L·lllllll!:lll'ill ;lrlil..'ld;ll·1..";ll'lil;l~l·: disnlpliot'! (If
fragments adhere to each other and are torn off from the lhe
surface during sliding. Abrasive wear, conversely, occurs C(JlI'l~l·II-PG~(llid 11l:llri\ :lIld PC '\\';\~h Uti!.··
when a soft material is scraped by a harder one; the harder First. !\"Pl'tili\\'l·tdl:t~~l·ll-PC; Illalri\ :-'tl\.':,,:,-ing ",'(luldd I:-ru pi
material can be either an opposing bearing or loose ti'L·\."(JII;I~L·1l Ii IlLT:-.. I hl" PC 1ll:llT(JIIIOI~
particles bc(ween the bearings. The low rates or in- l'l'lIk:-:11)(1'01'Iltl'illll'd;:Ii....·I..hl'I\\n"l1Ii\l·~l' 1\\11 d,lll~ PUllL·"t",.:\ PU\llt!:ll'Il-
terracial wear observed in articular cartilage tested in vitro ,polhl",is i.... 111.,\ t,.·;lI"ti\;,~',:,,' fa-
(Lipshitz & Glimcher, 1979) suggest that di- li~lIL' i ..... Ihl'l"L·...;ltll ld';lIt.'lbiJ...·I':lihll\'PI'I hI.'l·'lii:I!.2CI1 lii~",'l"
111.,:1\\0,"1, (FrL'I..·lll;lll.1075)" ;\Isu. :IS di:-ldl:--:-ltxl
CHAPTER 3 • BIOMECHANICS OF ARTICULAR CARTIJ(~~!;;:,;',89 •
~bove pronounced changes in the articular cani- and Paul (1971) found dramatic articular cartilage damage
(-~e-':l;G population have been obscn'cd with age with repeated impact loads.
:ric\i_lisease (Buckwalter et aI., 1985; iVluil~ 1983; These mechanisms of wear and damage may be the
\R<Juahlev et at. 1980; Sweet et aI., 1979). These PG cause of the commonly obser'ved large range of structural
';.chal~ges "could be considered as part of the aCCUl11l1- defects observed in anicular canilage (BlIliollgh &
idrcd,tissue damage. These molcculaJ- stnlclural :- Goodfellow, 1968; Meachim & Fergie, 1975) (Fig. 3-25, A-
'~ha'nges would result in lower PG-PG irHcraction ;~ites C). One such defect is the split-ting of the cartilage surface.
and thus lower network strength (Mow et aI., 1989b; Zhu Ven ieal sections of car-tilage e:\hibiting these lesions,
et aI., 1991, 1996). Second, repetitive :and massive known as fibrillation, show that they eventually cxtend
exudation and imbibition of the intcr-<~iitii:d fluid may through thc full depth of the articular cartilage. (n other
cause the degradcd PGs to "wash specimcns. the cartilage layer appears to be eroded rather
, ollt~~;::from the ECM, with a resultant decrease in stff0e~s; than split. This erosion is known as smooth-surfaced de-
and increase in permeability of the tissue structive thinning.
tha('jp::lurn defeats the stress-shielding mechanism
oUnierstitial fluid-load support and establishes a vi-
Considering the variety of defects noted in artic-ular
dous/cycle of cartilage degeneration.
cartilage, it is unlikely that a single wear mech-anism is
A third mechanism of damage and resultant ar-ticular responsible for all of them. At any given site, the stress
wear is associated with s~'novialjoint impact loading-that histor:v may be such that fatigue is [he initiating failure
is, the rapid application of a high l8"ad. \,vith normal mechanism. At another, the lu-brication conditions may be
physiological loading, articular cartilage undergoes so unfavorable that in-terfacial wear dominates the
surface compaction during the compression with the
progression of carti-lage failure. As yet. there is little
lubricating fluid being exuded lhi'ough t.his compacted
experimental information on the type of defect produced by
region, as shown in Figure 3..:10::';\5 described above,
any given wear mechanism.
however, fluid redistl'ibu-tiol}.',\vithin the articular
cartilage occurs over time,
Once the collagen-PG matrix of cartilage is dis-rupted,
which relieves the stress in this compacted region.
damage resulling froll1 any of the three wear mechanisms
Thi~'processof stress relaxation takes place quickly;
mentioned becomes possible: (I) fur-ther disruption of the
the stress may decrease by 630/0 within 2 to 5 sec-onds
collagen-PG matrix as a result of repetitive matrix
(Ateshian et aI., 1998; ""lo\\' et aI., 1980). If, howevel~
stressing; (2) an increased "washing out" of the PGs as a
loads arc supplied so quickly that there is insufficient time
result of violent nuid movement and thus impairment of
for internal Iluid redistribution to reHeve the compacted
articular carti-lage's interstitial Ollid load SUppOrl
region, the high stresses pro-dliccd in the collagen-PG
capacity; and
matrix may induce dam-age (Newberry et aI., 1997,
(3) gross alteration of the normal load carriage mechanism
Thompson et aI., 1991). This' phenomenon could well
in cartilage, thus increasing frictional shear loading on the
explain why Radin
articular surface.
I
I
I
Photomicrographs of vertical sections through the surface of of the articular surface that will eventually extend through
articular cartilage showing a normal intact surface (A), an the full depth of the cartilage (C). Phocomicrographs provided
eroded articular surface (8), and a vertical split or fibrillation chrough che courcesy of Dr. S. Akizuki. Nagano. Japan
059":-~?ir~iil~:~810MECHA:NlCS OF TISSUES AND STRUCTURES OF THE I'J1USCUlOSKELETA.. SYSTEM
All these processes will accelerate the rale of in-terfacial ~i<: IlK'chanicalprop<..Tt~· 01" the tissue. Tht: nH)SI im-ponam
and fatigue wear of the already disrupted cartilage I"ailure-inilialillg rac((1l' appears I(J he Ihl:
microstructure. "loost..'ning:" of tile c()lla~cn nctwork tllal al!c,ws ab-normal PC
c.\pansiclIl and thus tissue :-,weJ[ing
(:\ilaroudas, 1976; McDL'vilt &: Muir, 1976). Associ-alL'dwilll
Hypotheses on the Biomechanics of Ihis Chi.U1gc is a dL'Cn:i.ISL' in canibg.1.: stilT-Ill:SS and an
Cartilage Degeneration incrl.:ase in canilage pi..'rI1lL'abilil~'
(Allman el aI., 19S-l; Armstrong &. Mow, 1982; Guilak L"l aI.,
ROLE OF BIOMECHANICAL FACTORS 1994. SL"lton el aI., 1994). h,,'h of which aller canilagL'
fUllction ill ~\ diunhrodialjoinl during joilll mOlion, as showll in
Articular cartilage has only a limited capacity for re-pair Figure 3-27 (!vlo\\'
and regeneration, and if subjected lO an abnor-mal range of
'" Atcshian, 1997).
slress~s can quickly undergo total fail-ure (Fig. 3-26). It has
ThL'magnitude of the stress sustained b,\' lhe ar-ticular
been hypothesized that failure progression relates to the
cartilage is dctennined b,\'both the toti.llload on the joint and
following: (1) the magni-tude of the imposed stresses; (2) the
how tlwt kli.\d is distributed ()\'er the i.\1·ticul~ir surface
total numbe,· of sustained stress peaks; (3) 1I1C changes in
conl~lCt arca (Allmed 6.: Burke,
the intrin-sic molecular and microscopic structure of the
19i'3; Annslrong L'I aI., 1979; Paul. 1976). :\n.\· in-h,:nsl..'stress
col-lagen-PG Illalri.'\;and (4) the changes in the intrin-
COllcL'nlration in Ilk' l'ont~\Ct i.lrea will pla,\'i.1 pl·imi.llY roIL, in
tissu<..'(k'gL'Ilt.'ration,A large Ilumb<..'ror well-knowll condilions
GillSi...' L'.\cL'ssi\'c stress conccnlrations in anicular canilage alld
re-sult in caniJage failure. Most of Illese stress L'oncen-II':Hiolls
are C~ltISI,:d h.\· joint :,urfacL' irH...'ongruit.\', re-sulting in i.lll
Cartilage Structure h. Mechanical....- Joint
Propenies Loading
i.\hnornwtly small conti.lCt area.
t
Biochemical Composition Spatial and+Temporal
E.xi.lmplcs or conditions causing stich joint incon-gruilil.:s
include 0:\ subscqllL'fl( to congeniwl ac-
L"!i.lbular dysplasia, a slipped cnpilal femoral <.:piph~
t Slress-Slrain, Pressure
and Fluid Fields .,"sis. and intra-articular fractures. Two fUriher eXi.\mpk-s arL'
1
knet: joint l1lcnisct.:uoll1~·,\\'hich elim-inak's the load·dislributing
CaliagenlPG ECM
function of the lll~nis- ellS ([vlow Cl aI., 1992), and ligi.llllCnl
I"llpllll"<"', which allows cxccssi\·<..'mo\"t:'1lll'1lI and the
Cartilage Function
iVIHcroscopiG\II~', stress IOGlJiz<.ltion and cOllcen-
Physical Activities
tration at the joint surfaces li~I\'L' i.\ I"url!ler dlt.'CL High COntact
pressures bctW('L'nIhe anicular sur-faces decrease Ill<..'
pr()babilit~· of fluid-fIlm lubrica-tion (Mow &. Aleshian, 1997).
Flow diagram of the events mediating the structure and Subscqllcnl <.lelLlal surl'''lI.:e-lo-surracc contacl or
function of articular cartilage, Physical activities result in joint i.\Slx.'rities will cause microscopic stress concentrations that
loads that are transmitted to the chondrocyte via the arc rt.'SI)(>nsi~ ble for further tissue damage (Atcshian et aI.,
extracellular matrix (ECM). The chondrocyte varies its cellu- 1995,
lar activities in response to the mechano-electrochemical 1998; !\leshian '" Wan!'. 1995) (Case Study 3-1). The high
stimuli generated by loading of its environment. The etiol-ogy
incidencL" or speciiic joint dcgerlt'ration
of osteoarthritis is unclear but may be traced to intrin-sic
in indiddllals with certain occupmions. such as football
changes to the chondrocyte or to an altered ECM (e.g"
pl<.l~·L'rs' knccs and ballet danccrs' i.lnklcs,
resulting from injury or gradual wear) that leads to abnor-mal
chondrocyte stimuli and cell activities.
can bL'<,,'xplainL'd b\ tilL'incn:i.lsL' in high i.lI1d i.lbnor-
Illi.llioad rn:.·qllcnt:~· and magnitude sllslainc:d b~' the joinls or
Ihese: individuals. II has becn suggL'slt.:d
CHAPTER 3• BIOMECHANICS OF ARTICULA~;S1[fJ~!tGf:lili.
thiLin some cases, OA mav be caused by deficicn- small contact area will suf-
fer hign.c9_ntact pressure. decreasing the probability of
'<eie'~3~' the mechanisms th~t act to Il1ini~llizc peak
fluid-film lubrication, and thus the actual surface~lo~
'~'ff6rc,~s~onthe joints. Examples of these mechanisms
surface contact will cause microscopic stress concentra-
~jh~~l~(le the ~clive processes of joint nexion and
tions that lead to damage.
_~:~,q~e, lengthening and the passive absol"ption of
':;k,,,by the subehondral bone (Radin, 1976) and ciscus
(Mow el al" 1992),
~generativc changes to the structure and com-
~gion of articular cartilage could lead to abnor-kti:ssue
swelling and funZtionally inferior biome~
;;,iji8<11 properties. In this weakened state, the '~-
,:J~ge ultrastruclure will then be gradually de-
.-g.t~d by stresses of normal joinl articulalion (Fig.
~m)j7;OAmay also arise sec~ndarilyfrom insult ~o
:' ':- ~~i~tIinsic molecular and microscopic structure of
/;f.~tfi~2so;qagen-PGmatrix. Manv conditions may pro-:\-
.Iil<?!~:~,l!ch a brea~down in .~latrix .integrity;· the~e
-;111~e degeneratIon assoclatcd wllh rheumalOId --
·.1isJ joint space hemorrhage associated with
'p.pilia. various collagen metabolism disorders.
}~S§.tl..e degradation by proteolytic enzymes. The
_,'l1C:c': of soluble mediators such as cytokincs Case Study Figure 3-1-1,
~ ------ .._-----~
... t1I........ 10\\ j1l..'l'Illt.,<thilit.\·,thl..· n(lnll~tI em il"UIlIIll..·IH ell
illl..· ChllJJdrlil:.\·!I..·i df)lIlill~lil..'d h.\· h.nlrli:-'I~ltic 1'1'1.....-
Osteoarthritis :-'111"1..' illthe illtL·r tili~d lluid. \'~tl·i(jth phl..'lI(lllIL·II~t origil1;llitl2:-'IrOll1
inIL'I"slili~t111uid Ilo\\'l',\ist~IS \\l·11. llJ)plil'~\kd ill I..'nh;lIll..·ill~ Illitril...'llt
eventy.year-OJd woman, overweight, with OA of the
dilfliSioll, illlL'!"~ :-.{iti~d lIuid 11<1\\- (i.I.,:.. or
unhoulld \\'~tlL'rJ ~i\'L'~
S right hip joint with associated symptoms of pain, limi-tation of
motion. joint deformity, and abnormal gait (Fig.
ri"L' 10 l'1..'J111I~\1' ....lillHlii Ill' ~lll 1..·ll..'cll'k,d1l~lllll"L', n~lnwl.\' ...
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Biomechanics of
Tendons and
ligaments
Margareta Nordin, Tobias Lorenz, Marco Campello
Introduction
Composition and Structure of Tendons and Ligaments
Collagen
Elastin
Ground Substance
Vascularization
Outer Structure and Insertion Into Bone
•
tutes a large portion of the organic matrix of bone and
Introduction ~artilageand has a unique mechanical support-ive function
in other connective tissues such as blood vessels, heart,
The three principal structures that c10selv surround, connect
ureters, kidneys, skin, and liver. The great mechanical
and stabilize the joints of the ~keletal svs-t~Il1are
stability of collagen gives the tendons and ligaments their
tendons, ligaments, and joint capsules. ~\l-
characteristic strength and flexibility.C
103
al!~~ii4~PART1 • BIOMECHANICS OF TISSUES AND STRUCTURF', ()f "!l ;,L/.( '" 0'., , L f ;;.,. '"""r.:
En(l0!0f!On
f:1l1nd!e
ProcoHagen
Collagen
Fibroblasl molecules
------------- _ . _..._._---- - _ _-
...... ----._.--.~--- ._--._-----------
Schematic representation of wllagen fibrils. fibers. and bun-dles f'xtrac('lIuiarlll<1!rl)( ill cl PiHt111e-! ilflangelll('llt {o form m;· crofibrils
in tendons and collagenous ligaments (not drawn to clnd then fibrils, The staggered array of the mole·
scale). Collagen molecules. triple helices of coiled polypep- (tIles, in which each overlaps the other, gives .1 banded ap-
tide chains. are synthesized and secreted by the fibroblasts. pcarancE' ,0 the Coll<1gen iibri!s under the electron llIicro,:>wpe.
These molecules (depicted with "heads" and "tails" to repre-sent Tilt:'hb!!l ... <)~J9rcgate further into hbers, ~"... I1l<:h
positive and negative polar charges) aggregate in the (omc together into dcn<,cly piicked bundles.
type I collagen. This Il101eculc consists of three lihril k'\'l'lIL.i...; till.'I,.'I'{):-;:,,-!illkl,ddl~II·~h.:[l'I'ur Llll'l'ol
polypeptide chains (ex chains), each coiled in a left-handed 1~lgl'll lihrib ikll I~h'l'~ ,"'II'l'll~lh [0 thl'li:--:-il.l('.'"IIlL'y
helix wilh approximately 100 amino acids, which give it a C( lmpOSl'and <:t1I< I\\':--I hl.':--l'I b:"Ul'SI( I l"tl1"ll.·1il III under
total molecular weight or approxi. mately 340,000 daltons 1ll1.'("II<tllic~d :--lrl':":--.\\'illlill111(' lihril:-., !Ill.'mulecules <:tl"t'
(Rich & Crick, 1961) (Fig. 4-2). Two or the peptide chains ;Jppar('Il!I~' tTUss-lillked h.y "hl'<:\(.I·I(l-i~lil" illter-<:ll:tiulb (Fi~_ -l~ I L
(called ,,·1 chains) are identical. and one differs slightly hUI inlcrlihrilbr IT(I:-..... -linkill~ of a rnOl"L'complL'\n~llllr(' <:d~(l rn~l.'"
(the 0:-2 chain). The three a-chains are c0l11binccl in a on·lll'.
right-handed triple helix. which gives the collagen III 111..'\\-1\- fcwlllt:d ,,:(lll~l~l'l1. thl'CI'(l:-.:--·lillk:--~\1\':' rd-
molecule a rod-like shape. The length or the molecule is :lli\"\,.,h- k\\' :lnd ~lrt' rl.~dlll.'ihl\:: 1111.'l.'(llb~l.'l1 b :,>olllble ill
approxi. mately 280 nanOllleters (nIT}), and its diameter is rJt'lIlralsail :"ohlliol"l:'<:!llll ill ~Icid :"(IIUliull:--, alld
ap-proximately 1.5 nm. 1Ilt'i.:ro:--~-Ii111..:-; a I"l'hI i rI., t'a~i I.,'dL'Il~llll rt'dhy hl.'at.As
t.:olla~t'n a~L':-', lilt'1111<:11 rlullIhtT nl rl'lilldhk'tTOSS' link:-. dl'LTl'a:-
Almost two thirds of the collagen molecule con-sists of 'L':lei-'~l tllinilllurn ~b ~l 1~lr~l' lllllllhl'rof
three amino acids: glycine (33%), proline (15%), and :--(~lhk', nonrl,dul'ihk·lTCls:"-lird,:,, ~lrl' fOI"t'lll'd\bIUI'C. l'<"lI~l~t'n i~ nul
hydroxyproline (15°/(;) (Ramachandran, 1963). Every third sU[lIhk, ill Ilt'lllral:"i.dl ~(lIt1ti(Jll:" 01' in ~ldd solulio1\:", and il :-illlyi\'l'~:\
amino acid in each 0: chain is glycine, and this repetitive hi~llL'l' dl'I1;,lllll'~ltion tl'l1IjWl':lllll'l',(1"-"0[' ~\ I\~\'il'\\' or lTo:"s-link:\1!l'ill ~'()Ila-
sequence is essential for the proper rormation of the triple
helix. The small size 01' this amino acid allows the tight 12l'll,Sl.'l'Viidik, D~lllil'lsl'll, t~ Chlulld, 10~2,l
helical pack· ing of the collagen molecule. C'vlorco\'cr. .:\ lihril is !"(Irllll,d h," till' a~~I·q.!.ali(l1l or Sl'\'t'l" l,'olla~l'1l
glycine en-hances the stability of the molecule by forming lllolL'ctlk'sill ;1 qU<lltTn~lIY Slrtlc!url.'.This strllclllrl.', in \\·Ilh.:h t"ach
hy-drogen bonds among the three chains of the superhelix. Illnkndt'O\'t'!·bp:-Ihe. otht'r, is I\'spollsihk for 1I1l' J'L'lk'alillt! IXIII((:-;
Hydroxyproline and proline form hydro-gen bonds, or ob-:':'t'J"Yl,dOil thl'lihril", lllH..kT till't,k-l'II'OIllllilTOS(Ope (Fi~, --l-2: ~l'l'
hydrogen-bonded wal~r bridges. within each chain, The :ds(l Fig, "''''')Till'qll,llt'l'll:II.-,"Slrll ...:lure or l.T)lIa~cn rdalt'S10 till.'
intra- and inlcrchain bond-ing. or cross-linking. between or~~1I1i:t<:lli(l1l III l.·ollagl.:'11
specific groups on the chains is essential (0 the stability of lllolt'ClIll'sil110 :l :"l~lbk. 10\\' l.'lll'r~i,:lic bi(llo!!icaJ unit ha:--
the molecule, t'd011 :J rq:!.ul<:\1·a:':"(ll"ialiOll (~r~\(,.l.iaCt'lll';1101·
t'''.'lIks'h~ISil' <:llId ~lcidil' :llIlino ~ll·ids. B., :In:ll1ging
Cross-links are also formed between collagen ~\d.iacl'lll col1at!.I.'l't1I1pk'l:uks in a qLl~lnl'l'-st~lg1:-~t'r. or·
molecules and are essential to aggregation at the
64 om arrangcn)cnt, which cquips the tendons to handle lhe high
unidirectional (uni4lxial) lensile loads to which they are
Fibril
000 , 0
subjected during activity (Fig. 4-4A). The Iigamenls
or;: Overlap zone gencrally sLisrain tensile loads in one predominant
010
direction but may also bear smaller (cnsile loads in other
;:r:r Hole zone II
Micrafibrils directions; their fibers may not be completely parallel but
Packing of
~~~~=~'~'~'~~~~~~~~~ arc closely interiaccd with one another (Fig. 4-48). The
specific orienta-tion of the fiber bundles varies to some
'molecules I I
..-",/ ................. cxtent among the ligaments and is dcpendcnl on the func-
~~/
/
... tion of the ligament (Arnie! et al .. 1984),
-' ...........
r Collagen r'.'='='=====:2~80~nm~======):J~
i'
molecule !... I ,
The metabolic tUI'nover of collagen may be stud-ied by
J ..................
!
Fibroblasts
Crimp
Fascicular membrane
•
weight PC aggregate like Lhm found in Lhc ground
substance of anicular cartilage (set.:' Fig. 3-6).
•
The PC aggregates bind most of the extracellular water
of the ligament and tendon. making the ma-trix a highl~'
structured gel-like material rather than an amorphous
solution. Furthermore. by acting as a ccment-likc substance
betwcen the coHagen mi-croflbrils. they ma),' help stabilize
Parallel bundles of
Nearly parallel the collagenous skeleton of tendons and ligaments and
bundles of contribute to the o\'crall strength of these composite structures.
collagen fibers collagen fibers Only' a small number of these molecules exist in ten-dons.
~
Fibroblasts
VASCULARIZATION
Tendons and ligaments have a Iimitcd vasculariza-tion.
Tendon ligament
which alTeets dircctl~' their healing process [lnd metabolic
A B activit~;. Tendons receive their blood sup-ply dircctly from
\'cssels in the perim.vsiulll. the periosteal insertion. and the
surrounding tissuc via vessels in the para tenon or mesotenon.
Schematic diagram of the structural orientation of the fibers of
Tendons sur-rounded b~) paratenon have been referred to as
tendon (A) and ligament (8); insets show longitu-dinal sections. In
vas-cular tendons. and those sllrround~d by a tendon sheath as
both structures the fibroblasts are elon-gated along an axis in the avascular tendons, In tendons surrounded by' a paratcnon,
direction of function. Adapted from Snell, R.5. (984), Cfinical and vessels enter rrom many points on the pcripher.v and
F~ln(tional Histology for anastomose with a longitudinal svstem or capilbries (Fig, 4-
Medical Stuejents. Boston: Liule. Brown 5),
The vascular pattern for tendons surrounded by a
tendon sheath is different. Here the meso tenons are
reduced to vincula (Fig. 4-6). This avascuJar region led
a variety of researchers to propose a dual path-way for
tendon nutrition: a vascular pathway, and, for the
avascular regions, a synovial (diffusion) pathway. The
concept of diffusional nutrition is of primary clinical
significance in that it implies that tendon healing and
repair can occur in the absence of adhesions (i.e" a
blood supply). Conversely, liga-ments in comparison
with surrounding tissue ap-pear to be hypovascular.
However, histological stud-ies reveal that throughollt
the ligament substance there is a uniform
multivascularit)', which origi-nates from the insertion
sites of the ligament. De-spite the small size and limited
blood flow of this vascular s)'stem, it is of prima(y
India ink-injected (Spalteholz technique) into the calcaneal
importance in the
tendon of a rabbit, illustrating the vasculature of a paratenon-
maintenance of the ligament. Specifically, by pro-viding
covered tendon. Vessels enter from many points on the
periphery and anastomose with a longitudinal system of
nutrition for the cellular population. this vas-cular
capillaries. Reprinted wirh permission from Woo, S.L. Y, An, system maintains the continued process of matrix
K.N., Amoczky, D.V.M., et at. (1994). And!Om}~ biology. and bio- synthesis and repair. In its absence, damage fTom
mechanics of rhe iendon, ligament, and meniscus. In S.R. Simon normal activities accumulates (fatigue) and the ligament
(Ed) Orthopaedic Basic Science (p. 52). Rosemont, Ii: MOS. is at risk for rupture (Woo et aI., 1994).
•
ligaments and tendons and consists of four zones; Figure 4-
7 illustrates these zones in a tendon. At the end of the
tendon (zone 1), the collagen fibers intermesh with
fibrocartilage (zone 2). This fibro-cartilage gradually strong enough to sustain the high tensile forces that result
becon1es Inineralized fibrocarti-lage (zone 3) and then from muscle contraction during joint motion yet are
merges into cortical bone (zone 4). The change from more sufficiently' flexible to angulate around bone surfaces and
tendinous to more bony n1aterial produces a gradual to deflect beneath retinacula to change the flnal direction of
alteration in the mechanical properties of the tissue (i.e., muscle pull. The ligaments are pliant and Oexible, allowing
increased stiffness), which results in a decreased stress natural movements of the bones to which they attach, but
con-centration effect at the insertion of the tendon into the are strong and inextensible so as to ofTel' suitable
stiffer bone (Cooper & Misol, 1970). resistance to ap~ plied forces.
VIVI~,-."MI."."'L PROPERTIES
4
3
I Elongation (%»)
strains arc increased (strain values of between 1.5 and 4% elastic deformation that they endure under tensile strain
[Viidik, 1973]), a linear region will follow the toe region. and the storage and loss of energy. During loading and
This sudden increase in slope repre-sents the second region unloading of a ligament between two limits of elongation,
in the diagram and con"c-sponds to the response of Ihe the elastic fibers allow the ma-tcrial to return to its original
tissue to further elon-gation (Diamant et al.. 1972). shape and size after being deformed. Meanwhile, part of
the enel-gy spent is stOt"cd; what is left will represent lhe
Following the linear region. at large strains the stress- energy loss during Ihe cycle and is called hysteresis. The
strain ClIlve can end abruptly or curve down-ward as a area enclosed by the loop represents the energy loss (Fig.
result of irreversible changes (failure) (Woo et aI., 1994). 4-1 I).
Where the curve levels off toward the strain axis, the load
value is designated as Plin , The point at which this value is
reached is the yield point [or the tissue. The energy uptake
PHYSIOLOGICAL LOADING OF TENDONS
to PHn is rep-resented by the area under the ClIl·ve lip [0 the
AND LIGAMENTS
end of the linear region.
The ultimate tensile strength (P,,,:..,,) of ligaments and
\Vhen the linear region is surpassed, major fail-ure of tendons is of limited interest from a functional standpoint
fiber bundles occurs in an unpredictable l11anne1'. \Vith because under normal physiological conditions in vivo
the attainment of maximum load that reflects the uhimatc these structures are subjected to a stress magnitude that is
tensile strength of the speci-men, complete Failure occurs only approxirnately one third of this value. The upper limit
rapidly, and the load-supporting ability of the tendon or for physiological strain in tendons and ligaments (when
ligament is sub-stantially reduced. running and jumping, for example) is from 2 to 5% (Fung,
1981).
The modulus of elasticity for tendons and liga~ ments has
been determined in several investigations (Fung, 1967,
1972; Viidik, 1968). This parameter is based all a linear
relationship between load and de-formation (elongation), or
stress and strain; that is, the stress (force per unit area) is
proportional to the strain:
E = rIlE
where E = modulus of elasticity
(T = stress E
= strain
Load relaxation
"
'"
(length held constant)
o
--'
Ligal1zel1t Failure and Tendon
Injury Mechanisms
Injury mechanisms arc similar for ligaments and
Time tendons, therefore the following description of liga-ment
A injury and failure is gencrall~1 applicable La tendons. \Vhen
a ligament in vivo is subjected to
loading that exceeds the physiological range. micro-failure
Creep phenomenon takes place even before the yield point (P",.) is reached.
(load held constant)
\"'hen Ph" is exceeded, the ligament be-gins to undergo
gross failure and simultaneollsly the joint begins to
c
o displace abnormally. This dis-placement can also result in
.~
Time
B
Ligament injuries arc categorized clinically in three ways thus the greater the tensile loads transmitlcc! through the
according to degree of severity. Injuries in the first tendon. Similarly, rhe larger the cross-sectional area of the
category produce negligible clinical symptoms. Some pain tendon, the greater the loads it can bear. Although the
is felt, but no joint instability can be detected clinically, CYCI1 maximal stress to failure for a muscle has been difficult LO
though microfaillire of the collagen fibers may have compute accurately, such measurements ha\'c shown that the
occurred. tensile strength or a healthy tendon 111<1)-.' be mon: than
Injuries in the second category produce severe pain and
t\Vice that or its Illuscle (Elliot, 1967), This finding is
some joint instability can be detected clin-ically.
supponed clinically by the fact that muscle fUp-lures are
Progressive failure of the collagen fibers has taken place.
more common than are ruptures through a tendon.
resulting in parlial ligament nlplure. The strength and
stiffness of the ligament may have decreased by 50% or
more, mainly because the amount of undamaged tissue has Large muscles usually' have tendons with larg~ cross-
been reduced. The joint instability produced by the partial sectional areas. Examples arc the quadriceps
rupture or a ligament is oflen masked by muscle activity,
and thus the clinical test for joint stability is usually
performed with the patient under anesthesia.
Injuries in the third categOlY produce severe pain during --- -------- <0
the course of trauma with less pain after injury Clinically,
the joint is founelto be completely unstable. Most collagen -rend on Injuries: Achilles Tendon Injuries in
fibers have ruptured, but a few Illay still be intact, giving Runners. Which Result From a High Strain
the ligament the ap-pearance of continuity even though it is Rate
unable to SUppOrl any loads.
.·.. middle-aged male marathoner engaged in a strenuous
Loading of a joint that is unstable as a result of ligament A running activity expenenced pain and a popping
in his posterior calf. An overuse injury is diagnosed.
sensa~ tion
or joint capsule rupture produces abnor-mally high stresses
on the articular cartilage. This abnormal loading of the The first region of the load-deformation curve ShQ\.V5 a
articular cartilage in the knee has been correlated with normal physiological toe-loading response. In the linear
carl~,' osteoarthritis in humans and in animals. region, high load is producing a higher deformation within
the tendon structure. When the Achilles tendon is
Although injury mechanisms are generally com-parable subjected to higher strain rates during frequent loading ;_
in ligaments and tendons, two additional factors become ~yclesand insufficient time is allowed for the healing
important in tendons because of their attachment to process, the result is an overuse injury. Histological studies
muscles: the amount of force produced by contraction of ot',these injuries reveal a pathological pattern described as
the muscle to which the tendon is attached and the cross- ~'angiofibrotjc hyperplasia," which suggests a degenera-
sectional area of the tendon in relation to lhat of its muscle. " tive process. This failure in tendon remodeling frequently
,.occurs before the abrupt ruplure of the tendon. Relative aydscu!arity,
A tendon is subjected to increasing stress as its muscle con-
inflammatory disease, and other local factors also contribute to
tracls (see Fig, 6-10), When the Illuscle is maximally
contracted, the tensile stress on the tendon reaches high midsubstance ruptures (Case Study 4·2-1),
muscle with its patellar lendon and the triceps Slifac muscle did nOl differ signillcanLi~1(Kaspcrczyk et aI., 1991). This
with its Achilles tendon. Some small mus-cles have may be due 10 the fact lhal only lhe ACL was taken from
tendons with large cross-sectional areas; such as the donors in \I,,1hom no vascular or car-diopulmonary disease
plantaris. which is a liny muscle with a large tendon. and no ostcoanhritis of the knee was found on autopsy.
significanlly less stitT than the control spcc..:imens ments (Fig. 4-1 SA). Woo et "I. (1987) found that the
(Fig, 4-158), stress-strain characteristics after rcmobilization re-turn to
Amid and coworkers (1982) showed a similar de-crease normal but that the energy-absorbing capa-bilities or the
in the strength ancl stiffness or lateral collat-eral ligaments bone-ligament complex improved but did not return to
in rabbits immobilized for 9 weeks. As the cross-sectional normal.
area of the specimens did 110t change Significantly, the
degeneration of mechani-cal properties was altributed to DIABETES MELLITUS
changes in the liga-ment substance itself. The tissue
metabolism was noted to increase, leading to The term diabetes rcfcrs to disorders characterized by
proportionally more immature collagen with a decrease in excessive urine excretion. Diabetes mellitus is a metabolic
the amount and quality of the cross-links between collagen disorder in which the ability to oxidize carbohydrates is
mol-ecules. Newton et al. (1995) reported that the cross- more or less completely lost. This is usually caused by
sectional area of ligaments in immobilized n1bbit knees pancreas insufficiency and a disturbance of the normal
waS 740/0 of the control valuc. insulin mechanism, rc-sulting in hyperglycemia,
glycosuria, and polyuria. Diabetes mellitus is known to
In Noves' (I977a) experiment, assessment of the effects cause musculoskele-tal disorders. Diabetics compared with
of a reconditioning program initiated di-rectly aftcr the 8- nondiabetics show higher rates of tendon contracture (29
\\'cek immobilization pel"iod demonstraLcd that \IS. 9%), tenosynovitis (59 vs. 7%), joint stillness (40 vs.
considerable time was needed 1'01' the immobilized 9%), and capsulitis (16 \'s. 1%). Diabetes also causes os-
ligaments to regain their for-mer strength and stiffncss. teoporosis (Calvallo et aI., 1991; Lancaster et aI., 1994).
After 5 months, the re-conditioned ligaments still showed
considerably less stiffness and 20% less strength than did
liga-ments from control animals. At 12 months, the re- Duquette (1996) examined the effects of diabetes on the
conditioned ligaments had strength and stiffness values properties of the collateral knee ligament in rats. The tissue
comparable to those of control group liga- elastic properties did not differ be-tween the diabetic and
the control group. The vis-
100
60
-0,2"
" E
~~ 60 A' .------- --~8 weeks)
l'lE Immobilized
c
"
~
40
~·x
"'" " I
Q..E
""
20 o -- ,.- " \\
\
A, Maximal load to failure and energy stored to failure for primate program for 12 months. 8. Compared with controls. liga-ments
anterior cruciate ligaments tested in tension to faH-ure. Values are immobilized for 8 weeks were significantly less stiff (as indicated
shown as a percentage of control values for three groups of by the slope of the curve) and underwent greater elongation.
experimental animals: (1) those immobilized in body casts for 8 Adapred from Noyes. FR. 0977(1). Functional proper~
weeks; (2) those immobilized for 8 weeks and given a I ties of knee ligaments and alterations induced by immobilization.
reconditioning program for 5 months; and (lin Onhop, 123,2/0-242.
(3) those immobilized for 8 weeks and given a reconditioning
CHAPTER 4 • BIOMECHANICS OF
COllS component of the tissue response, however, \vas (1997) reports that physiological levels of estrogen reduce
increased in the hy'perglycemic group. Insulin therapy the collagen production by 40(;1(; and at phar-macological
seems to lessen such alterations. Lancaster, ct al. (1994) levels of estrogen, collagen production is decreased by'
examined the changes in the mechani~ cal properties of the more than 50%, Estrogen fluctua-tions may alter ligament
patellar tendon in diabetic dogs. The results showed the metabolism and may change the composition of ligament,
stiffness of the canine patel-lar tendon-tibia complex in a rendering it more susceptible to injury.
phy'sioiogical range of loading was 13% greater than in the
control group. There was no difference in the strength of
the tendon between the groups, but the mode of failure was
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
dif~ ferent. In the control group, failure was caused by
substance and avulsion failure, whereas failure of the NSAIDs (which include aspirin, acetaminophen, and
tendon in the diabetic group was caused by ten-sile indomethacin) are frequently used in the treatment of
fractures of the patella (Lancaster et al" 1994). various painful conditions of the musculoskeletal
system. NSAIDs are also widely used in the treat-ment
of soft tissue injuries such as inflammatOl)' dis-orders
and partial ruptures of tendons and liga~ ments. Vogel
STEROIDS
(1977) found that treatment with indomethacin resulted
Corticosteroids, when applied immediately after in-jury, in increased tensile strength in rat tail tendons. An
may' cause significant impairment of the bio~ mechanical increase in the proportion of insoluble collagen and in
and histological properties in liga~ ments. Corticosteroids the total collagen content also was observed. Ohkawa
also are known to inhibit collagen synthesis in vitro (1982) found increased tensile strength in the
(\'Valsh et aL, 1995). \Vig-gins et a!. (1994) described periodontium of rats after in-domethacin treatment.
these results in rabbits and implied that an acute injured Carlstedt and associates (1986a, 1986b) found that
ligament treated with corticosteroid injections may not indomethacin treatment increased the tensile strength in
\vithstand the mechanical loads of an earl)!, vigorous developing and healing plantaris longus tendons in the
rehabili-tation. Noyes et a!. (1977b) reported decreased rabbit and noted that the mechanism for this increase
liga-ment stiffness, failure load, and energy absorption was probably an increased cross-linkage of collagen
in monkey ligaments after injection of long-acting mol-ecules. These animal studies suggest that short~tern1
corticosteroids. These findings were tin1e- and dosage- administration of NSAlDs would not be deleterious for
dependent. After application of a dosage that was tendon healing but instead \vould increase the rate of
approximately 10 times an equivalent hu-man dose. biomechanical restoration of the tissue.
only! minimal changes were found after 6 \veeks, but
after IS weeks the maximum failure load (20%), energy
absorption prior to failure (11%), and HEMODIALYSIS
stiffness (11 %) decreased significantly. After Tendinous failure resulting from chronic renal failure
application of a dosage equivalent to the human dose, does occur, \vith tendon rupture reaching 36% among
the maximum failure load (9%) and the en- individuals receiving hemodialysis. Hyperlaxity of
absorption (8%) decreased significantly. Campbell tendons and ligaments \vas found in 74%, patellar tendon
ct al. (1996), however, showed that a elongation in 49%, and articular hypermobil~ ity in 51 % of
single injection of long-acting corticosteroid does not individuals receiving long-term he-modialysis (Rillo et
cause histological differences in rats with acute injured a!., 1991). Dialysis-related amy-loidosis may cause the
ligaments as compared \vith rats with acute ligament deposition of amyloid in the synovium of tendons. The
injury and no injection of corticosteroids. lv1cchanical major constituent of the amyloid fibrils is the beta 2-
testing showed no significant difference in ultimate load microglobulin (Morita et a!., 1995; Honda et a!., 1990;
or ultimate stress in the two groups. Oxlund et a!. Bardin et a!., 1985).
(1980) reports that local injec-tions of corticosteroids
every 3 days for 24 days in-crease the tensile strength
GRAFTS
and maxin1um load stiff~ ness of muscle tendons but
decrease the strength of the bone attachments of Reconstruction of torn ligaments, especially or the
ligaments. anterior and posterior cruciate ligament, is now a
Laborator).' investigations established the pres-ence frequent procedure. The need for reconstruction is
of estrogen receptors in hun1an ACLs. Liu et al. related to age, activity level, and associated injuries.
.~l~~,!-::;-:-B'OMECHA~'CS OF TISSUES AND STRUCTURES Of THE MUSCULOSKELETAL SYSTEM
Grafts derived from different individuals of the same species substantial proportion of elastin. which lends these
ar~ called allografts; grafts derived from the same structures their great elasticity.
individual are called aUlograhs. Allo-grafr tissue 2 The arrangement of the collagen fibers is nearly
preservation is done through freezc-drying and low·dose parallel in tendons. equipping them to with-stand high
irrndiation to reduce rales of rejection ancl infection and to unidirectional loads_ The less parallel arrangement of the
limit effects on the structural properties. Bone-patellar. collagen fibers in ligaments al~ lows these structures to
tendon-bone, and Achilles tendon are llsually L1sed as sustain predominant tensile stresses in one direction and
allograft tis-sue, whereas the central tissue of the patellar smaller stresses in other directions.
ten-don is commonly llsed as autograft tisslie.
Shino ct al. (1995) L1sed fresh-frozen allogenic ,;:~~)':At the insertion of ligament and tendon into stiffer
bone. the gradual change from a morc fibrous [0 a morc bony
Achilles, tibialis anterior or posterior. and peroneus longus
or brevis tendons for ACL reconstruction in humans. rnaterial results in a dccreased stress concentration effect.
Specimens were procured during second-look anhroscop~'. ~ ~ Tendons and ligaments undergo deformation before
Several years after reconstruction. the allografts had failure. ,,""hen the ultimate tensile strength of these
collagen fibril profiles that did not resemble normal tendon structures is surpassed. complete failure DC·
grafts or normal ACL. curs rapidl~!. and their load~bearing ability is sub~
Strocchi et al. (1992) L1sed patellar tendons that had been stantially decreased.
autograftcd to reconstn1C[ [onl ACLs. Follow-up biopsies 5. Studies suggest that during nonllal activity. a tendon
were performed 6, 12. and 24 months after surgel}'. During in vivo is subjected [0 less than one fourth of its ultimate
this time, the aUlOgraft underwent considerable changes. stress.
and after 24 months the auto-graft had the appearance of
normal ligament tissue. Strocchi suggested that the patellar '/'~:(: Injul"\! mechanisms in a tendon are influenced
tendon autograft is a valid functional ACL substitution for by"{he ~lm~unt of force produced by the contraction
patients who desire to perform normal mechanical activity. or the muscle to which the tendon is attached and the
cross-sectional area or the tendon in relation to that of ilS
Corselli el al. (1996) reports thal replacement tis-sue muscle.
undergoes extensive biological remodeling and 7 i The biomechanical behavior of ligaments and tendons is
incorporation. However. even a fully incorporated graft viscoelastic. or rate·dependent. so thal these structures
will never duplicate the native ACL but works instead as a display an increase in strength and stiffness with an
check reign that increases the knee function_ Tohayama et increased loading rate.
al. (1996) stated that the graft elongation at the time of
S An additional effect of rate dependency is the slow
implantation influ-ences the long-term outcome of ACL
rcconstruc· tions. at least in the canine model. They deformation, or creep. that occurs when ten-dons and
compared those cases where the graft elongation behavior ligamcnts are subjected to a constant low load over an
was within the 95% confidence limit of normal ACL extended period; stress relaxation takes place when these
structures sustain a constant elon-gation over time.
(group 1) with those cases where the graft elonga-tion
/{gi,::': Anina results in a decline in the mechanical
behavior was more than lhe 95(1'0 confidence limit of the ,/),,, :;;. b
normal ACL (group 2). Group 2 had sig-nificantly less inner properties of tendons and ligaments, th~1t is, their strength,
stiffness of the graft than did group 1. Group 2 showed a stiffness, and abilily to withsland defor-mation.
significantly increased anteroposterior laxity. but there was
no difference in ultimate failure load and absorbed energy. 10 Pregnancy, immobilization. diabetes. steroids.
NSAlD Lise, and hemodialysis affect the biomechan-ical
properties of ligaments and tendons.
Prockop. D.J .. Ii: Guz.man, N...\. (1977). Collagl.:1l dist.'asi,.'s ;\ltd the Viidik, A., D'lllidscn, C.e.. Oxlund, H. (1982). Fourlh tnlem,l-tional
bios,\'lllhcsis of collagen. /-Iosp Prw.:t, Dec, 61-68. Congress of Biorhl'oJogy Symposiulll on Mcc.:hHnical Propcnics of
Rarnachalldr<\ll. G.N. (1963). Molecular strllC!lln: of collagen. lilt Rev Living Tisslles: On fundamental and plll:llOnl-cnological models,
COllllcet TisslU' Uc.~·, /, 127. SlrllC(llrc and mcch:lJlical properties of collagen, elastic and
Rich, A., Crick, F.H.C. (1961), The molecuhll' structure of col· lagen. glycosaminoglyc'1I1 complexes. Bio-rll/:o!o,~y. 19,437.
J .Hol Bioi, 3. 483.
Rillo. D.L. Babini. S.M., B<lsn;lk. A., Wrlincr. E., BaHwclwl1. Vogel. 1·1.e. (I 97i). ~'kcll<:lnh.:al and chl'mic:d properties of nil'· iOlls
E.. Cocco. J.:\. (1991). Tendinous .md Iig:Ulll'lltoliS hyper-laxity in conneclive lissue org.tns in rats as iniluenced by non-sleroidaJ
patients reechoing long-Icrm hemodialysis. J anlirheum:ltic drugs. COI11/l!ct Tisslle! Res. 5, 91.
Rht'lIl1ullof. /8(8), 1227-1231. Walsh, W.R., Wiggins. r-,·1.E .. Fadak P.O., Ehrlich, !\·I.G.
Runc.lgrcn, A. (1974). Physical properties of conncctin: Lissuc as (1995). Errc:cts of dd;tyed steroid injection on ligamenl healing using
influenced by single and n::pc<I!L.'d pr~gn;\ncics ill thl.' r;IL .·kltl a rabbit medial colialen,1 ligament model.
Pilysiol Scam!, Sl/ppl.. 417. BilJllwt..:,-;a!s. 16( I 1), 905-910.
Shino, K., Oakt-s, B.W.• I-Ioribe. S.. Nnkaw, K.. Nakamurn. N. Walsh,S .. Fr'lIlk. c.. Shrive. N., Han, D. (1993). Knee immo-biliz;Hion
(1995). Collagen fibril popuhltions in human ;:Ulterior cru· ciate inhibits biolllcchanic<llmatllnHioll of the r:\bbit medinl collateral
lig;unent allografts. Electron micfoscopic analysis. lig:ll11l:111. Clill Orrhop. 297, 253-261.
A/1/ } Sport.~· Mal, 23(2), 203-208. \Vhite, A., H;:lndler, P., & Smith, E.L. (1964). Prillciples o{Bio.
Simon, S.R. (1994). Orthopedic Basic SciclI"'~. Rosemont, IL: MDS, cI/!:/IIistry. Ncw York: McGraw-Hill.
\Viggir\,o;, [VI. E., Fadale, P.O., B<lITach, H., Ehrilich, ,,"I.G., Walsh.
Snell. R.S. (198-1). Clillicld al/{! FI/Ilctiomd Histology {or ,\It,d· icaf W.R. (1994). Healing ch<lr;tClcrislics of a type I col· Iag('1l01lS
SIUt/CIIIS. Boslon: Lillk" Brown. SlnlClUre treJh:d wilh corticosteroids . .-\1/1 j SPOI"/S ,\kd, 22(2), 279-
Stfocchi, R., Dl' P<lsquale. v., Facchini. ,\ .. Rnsp,ulli, M .. Zaffagnini, 5 188.
.. ~'larcacci, ~1. t 1996). Agc:·rcbted changes in human anterior Woo, S.L.Y.....\n, K.N., Arnoczky, D.\I.\1.. Fithian, D., & ~ly('rs B. (1994).
cruciatt: ligament (ACL) collagen fibrils. Anatomy, biology, and biomechanics of the len-don, ligaml'nl, ;Iud
Ira! ..lWI/ E",bryui. /01(-1).213-120. m..:niscus. In S.R. Simon (Ed.). Or· rJ/Of/at'die Basic SCit'IICt' (p.
Slrocchi, R.. DePasqu:lIL', V.. Guizzardi, S., ~I:lrcacci, M.. Ruggeri. A. 51). Ros\,'monl. Il: .-\AOS.
(1992). Ultr.\slructural modificalions of patd-lar tendon fibres lIscd as Woo, S.L.Y., Gomez, \-1.,.\.. Siles, T.J., Cl :11. (1987). Thc bin·
'Ulterior cruci.\te ligament (ACI..) repbcclllcnL/uJ! } Allat EII/bryo!, mechanical .llld morphological clwngcs in the Illcdi:d (01-latcr,tl
97(4). 221-228. ligamelll of the rabbit after imlT1obilization (lnd rc-[T\obiliz;llion. )
Tipton, C. =\<1. , James, S.L., Mcrgner, W., Cl al. (1970). Influ· encc of !3lme )0;1// SlIrg, 69..1(8),1200-1211.
e-xcn::ise on slrl.:ngth of medial (ollatcralliganH:nls of dogs. Alii) \Von, S.L.Y., Gomez, M.A., Amid, D., Ritl('r, ~·l.A., Gdbt.'rman,
Physio!, 2/8. 894. R.I,!.. Akcson, W.H. (1981). The effects of e.\crcise on the
Tohayama. 1-1 .• Beynnon. B. D.. Johnson, R.J., Renstrom, P.A .. Arms biomcchanical and biochemical propcnies of swine digiwl flc:.\or
S.W. (1996). The effect of <lnlerior cruciate Jig.lInent graft leudons. } B;ol1l~!c.:h Ellg, 103, 51.
c1ong'llion at the lime of implantation on the biollle-chanical behavior Woo. S.L.Y. (1988). Lig;\mellt, tendon. :HH.l join! capsule in-sertions tu
of the graft and knee. ,.\/1/ j Sports .\lcd, bone. In S.L.Y. Woo, & J. Buckwalter(Eds.), Ill-jllly (II/(/ Repair of th~
24(5),608-614, ,HlISCU!oskduli So{t Ti...... uc:s (pp.
Viidik, A. (1968). EJ<lslicil)' <IIul lensile strenglh of Ihe antl.'· rior 133-166). Park Ridge. II. :\meric.w Academy of Or· Ihop<:ledi(..·
cruci<llc ligament in rabbils :lS influcnced by Iraining. Surgeons.
Acta Ph\'sio! Scallll, 7~, 372.
Viidik, A. '(1973). Functional propertics or collagenous tis-sues. IlIr
Rei' COllllcct Tissue Res, 6. 127.
;1:
~~~
:.~:,
,,\',
" ST~UC,;,UR~ ,~
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',,'-
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n
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m
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<D
-\ STRONG AND (5
"" EXTRACEllltLAR ." ;;:
FlEXIBlES, m
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The mcc~anjcal response I»
is dependent on the high tensile
z
-Ground $ubsL.,ncc rate at which thl! loads forces with R
limited elongation v>
Gel.like matcrialfSt.abilizc arc applied o
~
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;;i
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o
o
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FLOW CHA~T 4-1 Common structure and mechanical properties of tendons and ligaments. *
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"
Q:~Ir~Rr'tl.FI?MECHANICS OF TISSUES AND STRUCTURES OF THE MUSCULOSKELETAL SYSTEM
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~2
VI
RUPTURE
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FLOW CHART 4·4 Ligaments structure and mechanical properties.* (PG, Proteoglycan)
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The Cell and/or cxtracellular matrix componcnts
n
I
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Diabetes Mellitus
RUPTURE
Tot~I/PJrtial
Biomechanics of
Peripheral Nerves and
Spinal Nerve Roots
Bjorn Rydevik, Goran Lundborg, Kje/l O/marker. Robert R Myers
Introduction
• _ -...
._~.. _-~
Introduction pression. In this chapter, the basic microanatomy of the
peripheral nentes and the spinal nCIYC roots arc revicwed
The nervouS s)'stcm scn'cs as the bod.:,/s control cen-ter \vith special reference to thesc built-in mechanisms of
and communications nct\vork. As slIch, it has three broad protection. The mechanical behavior of peripheral nen'es
that are subjected to tension and compression is also
roles: it senses changes in the bod)! and in the external
described in some detail.
environment, it interprets these changes, and it responds to
this interpretation b)· initiating action in the form of muscle
contraction or gland secretion.
Anatomy and Physiology of
For descriptive purposes, the nen'OllS s)'stem can be divided Peripheral Nerves
into two parts: the central nervous sys-tem, consisting of
the brain and spinal cord, and the peripheral nervous The peripheral nervcs are complcx composite struc-tures
system, composed of the various processes that extend consisting of nen'e fibers, connective tissuc. and blood
from the brain and spinal corel. These peripheral nerve vessels. Because the three tissue clements that make up
processes pro-input to the central nervous system from these nen'es react to trauma in differ-ent ways and may
sen-receptors in skin, joints, muscles, tendons, vis- each pia)' distinct roles in the functional deterioration of
the nerve after injury, each element is described separatel)'.
cera, and sense organs and provide output from it to
effectors (muscles and glands). The peripheral ner-vous
system includes 12 pairs of cranial nen'es and branches
THE NERVE FIBERS: STRUCTURE AND
and 31 pairs of spinal nerves and their branches (Fig.
FUNCTION
5- lil). These branches arc
called peripheral nerveS. The term nerve fiber refers to the elongated pn)cess (axon)
Each spinal nerve is connected to the spinal cord a extending from the nerve cell bod)' along with its myelin
posterior (dorsal) root and an anterior root, which sheath and Schwann cells (Figs. 5~2 and 5-3). The nerve
unite to form the spinal nerve intervertebral foramen fibers of sensory neurons conduct impulses frolll the skin,
(Fig. 5-1, B-D). The skeletal I11uscles, and joints to the central nervous svstem.
noste,ric)r roots contain fibers of sensory' neurons The nerve fibers of the motor neurons conve)' impulses
conducting sensory information from recep-in the skin, from the central nen'ous system to the skeletal muscles,
muscles, tendons, and joints to the causing mus-cle contraction. (A detailed description of the
celHr.al nervous system) and the anterior roots con~ mainly me-chanics of muscle contraction is given in Chapter 6.)
fibers of motor neurons (those that con-impulses from
the central nen'ous system to The nen'e fibers not only transmit impulses but also
targets such as muscle fibers). sen'e as an anatomical connection between the nerve cell
Sh,ortlv after the spinal nerves leave their inter- body' and its end organs. This connection is maintained by
foramina, they divide into two main the dorsal axonal transport systems, through which various
rami, which innervate the mus- substances synthesized within the cell body (e.g., proteins)
and skin of the head, neck, and back. and the are transported from the cell body to the periphel)' and in
generally.' larger and more important ventral rami, the opposite direc-tion. The axonal transport takes place at
innervate the ventral and lateral parts of structures as speeds that Vat)' from approxilnatcly 1 to approximatel)" 400
well as the upper and lower ex~ ,,.,'m;t;,>< Except in the mm per day.
thoracic region, the ventral do not run directly to the
structures that they' innervate but first form interlacing Most aXO!lS of the peripheral nervous system are
networks, or surrounded by multilayered, segmented coverings known
with adjacent nen·'es (Fig. 5-1A). as myelin sheaths (Fig. 5-3). Fibers with this covering are
This chapter focuses on both the peripheral nerves spinal said to be myelinated, whereas those without it (mainly
nerve roots, which cOlltain not only nerve fibers but also small sensol)' fibers conducting impulses for pain from the
connective tissue elements and vascu-lar structures that skin) are unmyelinated. The myelin sheath of the axons of
encompass the nerve fibers. The possess some special the peripheral nerves is produced b).' flattened cells called
anatomical properties that may sen/e to protect the nente Schwann cells arranged along the axon (Fig. 5-3). A sheath
from mechanical is formed as the Schwann cell encircles the axon and
damage, for instance, stretching (tension) and com-
127
~:3,~Jf;A,~j)';liiOMECHANICS OF TISSUES AND STRUCTURES OF THE MUSCULOSKELETAL SYSTEM
Vertebral
body Ventral
Intervertebral
foramen
Cl-::>"_--.,
C2
C3
C4
Cervical
nerves
Vertebral
B arch Dorsal
Ventral
Thoracic nerves
Lumbar
plexus
Spinal nerve
Cauda
equina
~~ MOlor
~~ _ -->"",,--,-,'00'
I---~' ~
Dorsal root -~-
ganglion Sensory
Coccygeal rOOI
nerve
A o
A, Schematic drawing of the spinal cord and the spinal nerves is depicted. Adapted from rorrord, GJ & Anllgnostako5. N.fl.
(posterior view). The spinal nerves emerge from the spinal canal (J 984). Principles oj Anatomy and PhySiology (.1lh ed.J. New York:
through the intervertebral foramina. There are 8 pairs of cervi<al Harper & Row. B, Cross-section of the cervi<al spine showing the
nerves, 12 pairs of thoracic nerves,S pairs of lumbar nerves, 5 spinal cord in the spinal canal and the nerve roots exiting through the
pairs of sacral nerves, and 1 pair of coc-cygeal nerves. Except in intervertebral foramina. C, Cross-section of the lumbar spine
the region of the 2nd to the 11 th thoraci< vertebrae (T2-T11), shOWing the nerve roots of the cauda equina in the spinal canal. 0,
the nerves form complex net-works called plexuses after exiting Each exiting nerve root complex in the in-tervertebral foramen
the intervertebral forClm-ina. Only the main branch of each consists of a motor root, a sensory root, and a dorsal root ganglion.
nerve, the ventral ramus,
•
\vinds around it many times, pushing its cytoplasm and unmyelinated nerve fibers in a slow, continuous way,
nucleus to the outside layer. Unmyelinated gaps called whereas in the myelinaled nerve fibers the impulses
nodes of Ranvier lie between the segments of the myelin "jump" al a higher speed from one node of Ranvicr to the
sheath at approximately I to 2 I11Ill apart. next in a process called saltatOl)" conduction. The
The myelin sheath increases the speed of the con- conduction velocity of a myelinated nerve is di-rectly
duction of nerve impulses, and insulates and main-tains proportional to the diameter of the fiber, which lIsually
the aXOIl. Impulses arc propagated along the ranges [Tom 2 La 20 J-l111. MOlar f-ibers
CHAPTER 5 • BIOlvlECHA~JICS OF PERIPHERAL NERVES ANI)
innervate skeletal muscle have large diameters, do tive tissue la)rers is essential becausc nerve flbcrs arc
sensor~y'fibers that relay impulses associated touch, extremely susceptible to stretching and compres-sion.
pressure, heat, cold, and kinesthetic such as skeletal
muscle tension and joint po-Sensory fibers that conduct The outcnTlOst layer, the epineurium, is located
impulses for dull, between the fascicles and superficially in the nerve. This
diffuse pain (as opposed to sharp, immediate pain) the rather loose connective tissue layer serves as a cushion
smallest diameters. Nerve fibers are packed closely in during movements of the nel\'e, protecting the fascicles
fascicles, \vhieh are further arranged into bUIl1(II·es that from external trauma and maintaining the oxygen supply
make lip the nen'c itself. The fascicles sy'stem via the epineural blood vessels. The amount of
arc the functional subunits of the nCI-ve. epineural connective tissue varies among nerves and at
different levels within the same nerve. \!Vhere the nerves
INTRANEURAL CONNECTIVE TISSUE lie close to bone or pass joints, the epineurium is often more
abun~ c1ant than e1scwhere, as the need for protection may be
OF PERIPHERAL NERVES
greater in these locations. The spinal nerve roots are devoid of
Successive layers of connective tissue surround the nerve both epineuriurn and perincurium, and the ncrvc fibcrs in the
fibers-called the endoneurium, perineuriUl11, ,'mel nel\'e root may thercfore bc morc susceptible to trauma
epineurium-and protect the fibers' continuity (Fig. SA). The (Rydevik et aI., 1984).
protective function of these connec-
The perineurium is a lamellar sheath that en-compasses
each fascicle. This sheath has great me-chanical strength as
Sensory nerve root well as a specific biochemical barrier. Its strength is
Sensory cell Motor cell body demonstrated by the fact that the fascicles can be inflated
body in dorsal in anterior horn by fluid to a pressure of approximately! 1000 mm of
rool ganglion of spinal cord
mercury (I-Ig) beFore the perineuI'ium ruptuI·es.
!
Dorsal
Spinal nerve \
\ \
The barrier function or the perineurium chemi-cally
Dorsal ./ isolates the l1el\'e fibers From their surround-ings, thus
ramus / preserving an ionic environment of the in-terior of the
Ventral fascicles, a special milieu interieur. The endoneurium, the
Peripheral nerve ... '- connective tissuc inside the fasci-cles, is composed
Motor nerve rool
principally of fibroblasts and col-lagen.
~'-----------
1.5 ± 0.7 mm Hg [Myers & Powell, 1981]) comparecl \\'ith
the pressure in surrounding tissues sLIch as subcutaneous
tissue (-4.7 ± 0.8 mn1 Hg) and muscle tissue (~2 ± 2 mm Hg).
The elevated endoneurial fluid pressure is illustrated by the
phe~ nomenon whereby' incision of the perineurium re-sults in
Schematic representation of the arrangement of a typical herniation of nerve fibers. The endoneurial fluid pressure may
spinal nerve as it emerges from its dorsal and ventral nerve increase further as a result of trauma to the nerve, with
roots. The peripheral nerve begins after the dorsal ramus subsequent edema. Such a pressure increase ma.y affect the
branches off. (For the sake of simplicity, the nerve is not microcirculation and the function of the nerve.
shown entering a plexus.) Spinal nerves and most periph-eral
nerves are mixed nerves: they contain both sensory (afferent)
and motor (efferent) nerve fibers. The cell body and its nerve
fibers make up the neuron. The cell bodies of the motor
neurons are located in the anterior horn of the spinal cord, THE MICROVASCULAR SYSTEM OF
and those of the sensory neurons are found in the dorsal root
PERIPHERAL NERVES
ganglia. Here, a motor nerve fiber is shown innervating
muscle and a sensory nerve fiber is depicted innervating skin. The peripheral nerve is a well-vascularized structure
Adapted from Rydevik, B., Brown, MD., & containing vascular networks in the epineurium, the
Lundborg, G. (/98·4). Pathoanatomy and pathophysiology of perineurium, and the endoneurium. Because both inlpulse
nerve root compression. Spine, 9, 7. propagation and axonal transport depend
~y,l!R1:J![~2MECHAN;<:S OF TISSUES AND STRUCTURES OF THE MUSCULOSKELETAL SYSTEM
Node of Ranvier
Schwann cell
Myelin \ sheath
Axon
Node of Ranvier
Schematic drawings of the structural features of a myelinated nerve fiber. Ad(1fJted from
Sunderland 5. 0978j. Nerves and Nerve Injuries (2nd ed.). Edinburgh: Churchill Livings/one.
In an ex- •
CHAPTER 5 • BIOMECHANICS OF PERIPHERAL NERVES AND SPINAL N~RvE~bgr:if;;;:;)):1¥~
;,; ..'.... ,.. , .. :..,_"/:',.:..,"'.•..:.,.... ,,'.,:,,,.1"")/,.::c:.::.'·,;~
peri mental animal in vivo model, it is extremely dif-ficuh to "swdling" of the most caudal part of the respective dorsal
induce complete ischemia to a nerve by 10-surgical neryc root, called the dorsal rOOl ganglion. The dorsal root
procedures. For example, if the whole sciatic··til."'1i nerve ganglia arc locatcd in or close to the intervertebral Foramen.
complex of a rabbit (15 em long) is surgically Sepal"aled from Unlike the nCn!c roots, the dorsal root ganglia arc not
its surrounding struc-tures and the region"11 nutrient vessels enclosed by cerc brospinal fluid and the meninges. Instead.
w
arc ClIt. there is no detectable reduction in the they are enclosed by both a multilayc:rcd connective tissue
intrafascicular blood flow as studied by intravital microscopic sheath, similar lo the perineurium of the peripheral
tcch· Y"iGucs. Even if such a mobilized nerve is ellt distally or
proximall~'. the intraneural longiwdinal vascular systems cnn
maintain the microcirculation at least 7 l~ 8 ern rTom the clil
end. If a non mobilized nerve is cut, there is still perfect
microcirculation even at the vcr")' tip of the nerve; this
phenomenon demon-strates the sufficiency of the
intraneural vascular collalcrals. Howevcr~ othcr sllldies in rats
indicate
4
.that stripping the epineural circulation rronl nerve bundles
causes demyelination of subpel'ineural nerve fibers.
2 2
Anatomy and Physiology of ..
3 3
Spinal Nerve Roots
In the earl~' embryological developmental stages, the spinal
7
cord has the same length as the spinal column. However, in
the full~: grown individual, the spinal cord ends as the COIlUS
8
mcdullaris, approxi-mately at the level of the fit'st lumbar 5
vertebra. A nerve root that leaves the spinal canal through an
intervertebral foramen in lhe lumbar or sacral spine therefore
has to pass from the point where it leaves the spinal corel.
which is in the lower thoracic spine. lO the point of exit li'om
the spine (Fig. 5-5). Be-cause the spinal cord is not present
be.low the first lumbar vertebra, dte nervous content of the
6
spinal canal is only comprised of the lumbosacral nerve roots.
This "bundle" of nerve roots within the IUI11-bar and sacral
pan of the spinal canal has been sug-gested to resemble the
tail of a horse and is therefore often called the cauda equina,
that is, lail of horse.
afferent) axons and reach lhe spinal cord at the dorsal region O/marker. K. (J 99/ J. Spinal nerve rOOI compression. ACt/Ie
of the spinal cord. The cell bodies of the sensory axons are compression of the cauda equina sludied in pigs. Acta Orthop
located in a Scand. 62. Suppf 242.
•
O,~:3~J:Ei~T\ '. BIOMECHANICS OF TISSUES AND STRUCTURES OF THE MUSCULOSKELETAL SYSTEM
nerve, and a loose connective tissue layer called outer layers of the root sheath arc similar to the pia cells of
epineurium. the spinal cord, and the cells in the distal part are more
""Vhen the ncnlC root approaches the interverte-bral similar to the arachnoid cells of the spinal dura. The inner
foramen. the root sleeve gradually encloses the nerve tissue layers of the rOOl sheath are comprised of cells that show
more lighLly. The subarachnoid space and the amount of similarities to the cells of the perineurium of peripheral
cerebrospinal fluid surrounding each nen'c root pair will nerves. An in-lerrupted basement membrane encloses these
thus become gradually re-duced in the caudal direction. cells separately. The inner layers of the root sheath
Compression injury of a nerve root may induce an increase constitute a diffusion barrier bet\veen the cl1do~ neurium of
in the per-meability of the endoneurial capillaries. resulting the nerve roots and the cerebrospinal fluid, This barrier is
in edema formation (Olmarker et aI., 1989b; Rydevik & considered to be relatively weak and may only prevent the
Lundborg, 1977), This can lead to an increase of the passage or macro-molecules.
imraneural fluid and subsequent impairment of the
nutritional transport to the nerve (Myers & Powell. 1981;
Myers, 1998), Such a mechanism might be particularly The spinal dura encloses the nerve roots and the
important at locations where the nerve roots are tightly cerebrospinal fluid, When the two layers of the cra-nial
enclosed by connective tissue. Thus there is a more dura enter the spinal canal. the outcr layer blends with the
pronounced risk for an "entrapment syndrornc" within the periosteum of the pan of the lami-nae of the cervical
nerve roots at the intcrvene-bral foramen than more central vertebrae facing the spinal canal. The inner layers join the
in the cauda equina (Rydevik et aI., 1984), The dorsal root arachnoid and become the spinal dura. [n contrast to the
ganglion, with its content of sensory nCt've cell bodies, rooL sheath, the spinal dura is an effective difTusion
tighlly en-closed by meninges, might be panicularly barrier: The bar-rier properties are located in a connective
suscepti-ble to edema formation. tissue sheath between the dura and the arachnoid called the
neurotheliunl. Sirnilar to the inner layer or the root sheath,
this ncurothclium resembles the perineurium of the
pel'iphcral nen'es. It is suggested thal these t\VO layers in
facl form the perincuriulll when the nerve rooL is
MICROSCOPIC ANATOMY OF SPINAL NERVE
transformed to a peripheral nerve upon leaving the spinal.
ROOTS
There are two microscopically different rc.:::gions of the
ncnlC roots. Closest to the spinal cord is a cen-tral glial
segment comprised of glial cells and there-fore resembles
THE MICROVASCULAR SYSTEM OF SPINAL
the microscopic organization of cen-tral nervous structures
NERVE ROOTS
at the spinal cord or the brain. This glial segment is
transferred to a nonglial segment in a "dome-shaped" Information about the vascular anatomy of the nerve roots
junction a few mil-limeters from the spinal cord. This has mainly been derived from studies on the
nonglial segment is organized in the same manner as the vascularization of the spinal corel. Therefore. the
en-doneurium of the peripheral nerves, that is, with nomenclature of the various vessels has been somewhat
Schwann cells instead of glia cells. However, some small confusing. A SLlllllTIat·y of the existing knowledge on nerve
islets of glia cells also are found in this other-wise root vasculature will be pre-senteel below,
"peripherally" organized endoncurium.
The segnlental arteries generally divide into three
branches when approaching the intervertebral fora-men: (1)
an anterior branch that supplies the poste-rior abdominal
MEMBRANOUS COVERINGS OF SPINAL NERVE
wall and lumbar plexus. (2) a poste-rior branch that
ROOTS
supplies the paraspinal muscles and facet joints, and (3) an
The axons in the endoneurium are separated from the intermediate branch that supplies the contents of the spinal
cerebrospinal fluid by a thin layer of connective tissue canal. A branch of the intermediate branch joins the nCI"ve
called the root sheath, This root sheath is the structural root at the level of the dorsal root ganglion, There are usu-
analogue to the pia mater that covers the spinal cord. There ally three branches from this vessel: one La the ven-tcal
are usually 2 to 5 cellular layers in the root sheath, but as root, one to the dorsal root, and one to the vasa corona of
many as 12 layers have been identified, The cells of the the spinal corel.
proximal part of the
CHAPTER 5 • BIOMECHANICS Of PERIPHERAL NERVE5 AND 5Pl~%~..N.ERVE-59~lia~O
.:
STRETCHING (TENSILE) INJURIES ties, and the nerve behaves 1110re !ike a plastic ma-terial
OF PERIPHERAL NERVES (I.e., its response to the release of loads is in-complete
recovery).
Nerves arc strong structures with considerable ten-sile Although variations exist in the tensile strength of
strength. The maximal load that call be SlIS-tained b~/ the various nerves, the maximal elongation at the elastic limit
median and ulnar nerves is in the rangc of 70 to 220 newtons is approximately 20(~fi, and complete structural failure
(N) and 60 to 150 N, rc-spectively. These f-igurcs afC of seen1S to occur at a maximum elongation of approximately
academic interest only because severe intraneural tissue 25 to 30(k;. These val-ues are for normal nerves; injury to a
damage is produced b:v tension long before a nerve breaks. nell/e may in-duce changes in its mechanical properties,
namely increased stiffness and decreased elasticit\'.
A discussion of the elasticity and biomcchanical
properties of nerves is complicated by the fact that nerves Stretching, or tensile, injuries of peripheral nerves are
are not homogeneous isotropic I11aterials but, instead, usually' associated with severe accidents, such as when
composite structures, \vith each tissue com-ponent having its high-energ.\' tension is applied to the brachial plexus in
O\VI1 biomechanical properties. association with a birth~related injur.\'. as a result of high-
The connective tissues of the epineurium and per-ineurium speed vehicular co!lision, or after a fall from a height. Such
arc primarily longitudinal structures. plexus injuries may result in partial or total functional loss
\,Vhen tension is applied to a nen'e, initial elon-gation of some or all of the nerves in the upper extremity, and the
of the nerve under a ver.v small load is fol-lowed by! an consequent functional deficits represent a consider-able
interval in \vhich stress and elongation show a linear disability in terms of sensory and motor loss. The outcorne
relationship characteristic of an elas-tic material (Fig. 5-7). depends on which tissue components of the nerves are
As the limit of the linear re~ gion is approached, the nerve damaged as well as on the extent of the tissue injury'. Of
fibers start to rupture inside the endoneurial tubes and clinical importance is the ob-servation that there can be
inside the intact perineurium. The perineurial sheaths considerable structural damage (perineurial sheath injuries)
rupture at ap-proximately 25 to 30i?-c elongation (ultimate induced by stretching with no visible injury' on the surface
strain) above in vivo length (Rydevik et aI., 1990). Aftcr of the nerve (Case Study 5-1).
this point, there is a disintegration of the elastic proper-
12
11
10
9
"
(L
8
In-situ strain: 11.0 :!:. 1.5%
7 In-situ stress: 0.05 :c: 0.3 MPa
~
~
6
~
~ 5
iii 4
3
2 Ultimate stress: 11.7 :.:: 7 MPa
1 Ultimate strain: 38.5 :::: 2.0'%
0
0 4 8 12 16 20 24 28 32 36 40
Strain ('%)
The stress-strain behavior of a rabbit tibial nerve. The nerve K\·van, M.K., Myers, R.R., et al. (1990). An in. vitro mechanical and
exhibits a low stiffness toe region of approximately 15 % and histological study of acute stretching on rabbit tibial nerve. J Or-thop
begins to retain significant tension as the strain increases Res, 8, 694-707.
beyond 20%. Reproduced with permission from Rydevik. 8.L.,
CHAPTER S • BIOMECHANICS OF PERIPHERAL NERVES AND SPI~~~'~E~~%~~f~1[~~.
:'.'~·ilnd·.s.en.sory) neural
functions, mainly the muscles respon-·",-
slbh~,'for the
scapulohumeral rhythm (see Chapter 12).
.1' ;:\)'AHE.rb's palsy is diagnosed. The sudden elongation COMPRESSION INJURIES OF
J7;r~uHer~~dduring the traction can lead to structural dam- PERIPHERAL NERVES
~;.~ge an9 reduction in the transverse fascicular cross-sec-
It hns long been known that compression of a nerve can
{ftio.f1~(area, producing impairment of the intraneural
:~",,:vascu.larflow and impulse transmission .
induce symploms stich as numbness, pain, and muscle
~.
1', ·.In less severe cases, functional restoration may occur weakness. Thc biological basis for the func-tional changes
t.- within·weeks or months. In more severe cases, healing may has been investigatcd eXlensively (Rvdevik & Lundborg,
"i·i:~~X~k(place during the first 2 to 3 years, but if the structural 1977; Rydevik et aL, 1981), In these investigations (Fig. 5-
:~r~erveJnjury is severe, considerable long-term functional 9), even mild compres-sion was observed lo induce
:s<'disability can result, If structural derangement of the nerve
structural and func-lion'll changes, and the significance of
:i·::i.trunk has taken place, nerve grafting may be required.
):i:', " mechanical
Critical Pressure Levels The pressure level is not the only faclOr that influ-ences the
severity of nerve injlll)' brought about by compression,
Experimental and clinical observations have re· vealed Experimental and clinical evidence indicates that the mode
some data on the critical pressure levels at which of pressure application is also of major signiflcance. "Its
disturbances occur in intraneural blood flow, axonal importance is illus-trated by the fact that direct
transport, and nerve function. Certain pres-sure levels seem compression of a nerve at 400 mm Hg by means of a small
to be well defined with respect to structural and functional inflatable cuff around the nCI've induces a more severe
changes induced in the nerve, The duration of the nerve injury than does indirect compression of the nerve at
compression also influ-ences the development of these 1000 mrn Hg via a tourniquet applied around the extrem-
changes, ity. Even though the hydrostatic pressure acting on the
At 30 mm Hg of local compression, functional changes nerve in the former situation is less than half that in the
may occur in the nerve, and its viability may be jeopardized latter, the nerve lesion is more severe. probably because
during prolonged compression (4 to 6 hours) at this direct compression causes a more pronounced deformation
pressure level (Lundborg et aI., 1982), Such changes of the nerve (especially at its edges) than does indirect
appear to be caused by im-pairment of the blood flow in compression, in which the tissue layers between the
the compressed part of the nerve (Rydevik et aI., 1981), compression device and the nerve "bolster" the nerve, One
Corresponding pressure levels (approximately 32 111111 nlay also con-clude that the nerve injllly caused by
Hg) were recorded close to the median nen.re in the carpal compression is not directly related to the high hycfrostatic
tunnel in patients with carpal tunnel syndrome, while in a pl'essure in the center of the conipressed nerve segment but
group of control subjects the pressure in the carpal tunnel instead is more dependent on the specific mechani-cal
averaged onl~,.. 2 mm Hg. Long-standing or intermittent deformation induced by the applied pressure,
compression at lo\\' pres-
CHAPTER 5 • BIOlVlECHANICS Of PERIPHERAL NERVES AND SPINAL NERVE ROOJ,~:{'f, 137~O
Mechanical Aspects of Nerve Compression ing bone_ h may also occur when a spinal nerve is
compressed by a herniated elisc (Case Study 5·2).
Electron microscopic analysis of the deformation of the
The details of the deformation or a nerve may be quite
nerve fibers in the peroneal nerve or the baboon hind .limb
difTerent in these two cases of loading. In uni-form
induced b~,' tourniquet compression demonstrated the so- circumferential compression like that applied
called edge effect; that is. a specific lesion was induced in
the nerve fibers at both edges of the compressed nerve
segment: the nodes of Ranvicr were displaced toward the
non-compressed parts of the nct·ve. The nerve fibers in the
center of the compressed segment, where the hydrostatic Sciatic Pain
pressllt·c is highest. generally were nOl affected acutely. Tht.: 35-year-old male construction worker has chronic
large-diameter nerve fibers were usually affected, but the
thinner fibers were spared. This finding confirms theoretical
calcula-tions that indicate larger nerve fibers undergo a rd-
A low back pain radiating below the- Ie-f! knee that is more
severe with lifting activities and prolonged posi, tions. After a
atively greater deformation than do thinner fibers at a given careful examination. certain neurological signs were found.
Positive straight leg raising and L5 motor and sensory
pressure. It is also known clinically that a compression lesion functions were affected.
of a nCI-vc IIrst affects the large fibers (e.g., those that can)' A MRI shows a herniated disc at level L4-L5 with
molOr function). while the thin fibers (e.g .. those that mediate
posterolateral protrusion. which laterally compresses (he
pain sensa-lion) arc often preserved. The intraneural blood
left L5 nerve root. Compression of !he nerve deforms it
ves-sels have also been shown to be injured at the cdges of the
toward a more elliptical shape. increasing strain and stress
compressed segment (Rydevik & Lundborg, 1977), Basically,
loads_ The effects of the pressure and mechanical
the lesions of nerve libers and blood vessels seem to be
deformation resultant from the load affects the nerve
consequences of the pres-sllre gradient. which is maximal just
tissue, its nutrition, and the transmission function. in·
al the edges of the compressed segment.
flammation of the nerve root, induced by the nucleus
pu!posus, may sensitize the nerve rOOt so that mechani-
cal ne-rve root deformation causes SCiatic pain (Case
Study Fig 5·2·1),
Pressure
I irreversible damage [0 the nCI"e (Lundborg CI aI., 1982;
Rydevik el aI., 1981),
;.:,, ",..
"/':
,-", dislribution ..--, ---c___
I':'
'/,:,".:," '.'f;:-i::;:
" ';,';""
"
..." '
----
.. " :',:'
information indicalcs that Cn:n hiuh - pressure has to "acl"
for a certain period of lime for injur.v to occur. These data
also give some informa-lion about the viscoelastic (time-
dependent) proper-ties of" peripheral nCI"\'t:tissue. Sufficient
B' C' time OJ! f!51 elapse for permanent deformation to develop.
E E'
F F'
'"
,' . . ,.,. G G' x
Biol17echal1ical Behavior (Jf
Spinal Nerve Roots
I , The nerve roots in the thee;:d sac lack epinei"fl-tl:lw and
,
perin~uril1m, but under tensile loading they ex-hibit both
•
inrr4lthecal portion of human SI
nel'VC rOOIS at the S I level is appro:"\imatcl~; 13 N,
and thal 1'01' the roraminal portion is approximately 73 N.
For human nCI'vcroots at the L5 level. the cor-responding
that this kind or deformation can trigger r-iring of nerves, values arc 16 Nand 71 N, respectively
resulting in a sensation or pain when the ne"'e Gbers are (Fig. 5-12). Thus, the "allles ror ultimate load are
laterallv compressed. The details or such deformation of approxil11«lel~" five times higher ror the foraminal segment
nerves and their functional con-sequences have not been of the spinal ner'vc roots than for the in-trathecal pan ion of
studied extensively and re-quire further research for their the same nClVC roots under ten-sile loading. However, the
elucidation.
cross-sectional area of the nerve root in the intervertebral
fOI'(llllcn is sie:nifi-
-
cantlv larger than that of the same nerve root in lhe
Duration of Pressure Versus Pressure Level .
thecal sac; thus, the ultimate tensile stress was more comparable
Knowledge is limited regarding the relalive impor-tance o[
pressure and time, rcspectively, in the pro-duction of nerve
compression lesions. Mechanical faclors seenl to be
for the two locations. The ultimate strain LInder tensile loading is
13 La 19% for the human ne,Ye root at the L5-S I level (Fig. 5-13),
-
rehllively more imporlant al higher than at lo\ver pressures. The nerve roots in the spine arc nol static slruc-lures:
Time is a significant they 1110\'C relati\'e to the surrounding tissues
.~f~f1 • BIOMECHANICS OF TISSUES AND STRUCTURES OF THE MUSCULOSKELETAL SYSTEM
Ultimate load: Human sinal nerve roots roots normally' adhere lo the surrounding tissues
above and below the intervertebral disc they tra-
n:rsc, compression may give rise to intraneural ten-
sion, Spencer and associates (1984) measured the
contact force between a simulated disc herniation
u and a dclcwmed nerve 1'001 in cadavers. Taking the
'" area of contact into aeCOUlll, they assumed a contact
2
S
rn'" pressure of approximately 400 mm Hg. \<\'ith re-
§ duced disc height. the contact force and pressure be-
5 tween the experimental disc herniation and the
nerve root was reduced, They suggested that these
findings may explain in pan why sciatic pain is re-
lieved after chcmol1ucleolysis, and as disc degenera-
o'--_-'-_-';:-=----'-'-_-'-_-';-;:"'-_-'-_..J
Sl LS tion progresses over time and the disc height thereby
N"4 N~4 decreases,
[n central spinal stenosis, the mechanics or nerve
root compression arc completely diFferent. Under
these conditions, the pressure is applied circumfcr-
Diagram illustrating values for ultimate load obtained for
cntially around the nerve roots in the cauda cquina
human spinal nerve roots under tensile loading. INR, in-
at a slow, gradual rate, These different deformation
trathecal nerve roots; FNR, foraminal nerve root. Note the
marked difference in ultimate load for the intrathecal and factors, together with the fact that the nerve roots
the foraminal portions of the nerve roots. Error bars indi- centrally within the cauda equina differ completely
cate standard deviation. Reproduced with permission from from the nerve roots located more laterally, close to
Weinstein, IN., Latviotte, R.. Rydevik, B., er al. (1989), Nerve. In the discs, ma.y explain some of the dillcrcnt syrmpM
J, \IV, Frymoyer & S.L. Gordon (Eds.). NevI Perspectives on Low toms found in spinal stenosis and disc herniation.
Back Pain (Chapter 4, pp. 35-130). Park Ridge. IL: MOS. {Based on a
workshop arranged by the National Institutes of Hea/rh (NIH) in Airlie,
Virginia, USA, May 1988.} Ultimate strain: Human spinal nerve roots
_ 1S
with every spinal motion. To allow for such motion the l
c
nerve roots in the intervertebral foramina, for example. .~
spinal stenosis and resulting in radiating pain. In disc arranged by the NatioTlallnstitut.es of Health (NIH) in Air/ie, Vir· ginia,
USA, May /988.J
herniation, only one nerve root is usually compressed,
Because individual nerve
CHAPTER 5·BIOMECHANICS Of PERIPHERAL NERVES AND SPINAL NERVE ROOIs'"~~a'141:D
COMPRESSION OF SPINAL
balloon using a vilal microscope. The average occlusion Rydevik. 8., & Holm. S. (1989a). Edema (ormation in spina/
nerve roars inducecl by experimental. graded compression. An
pressure for the arterioles was !"ound to be slightly below experimental srudy on the pig cauda eq'Jina ~'.Jirh special refer-
and directly related to the systolic blood pressure. and the ence co differences in effects between rapid and slow onsec of
blood Ilow in the capillary net-works was intimately
depcndent on the blood flow of the adjacent venulcs. This 1 compression. Spine. ld. 579.
corroborates the as-sumption that venular stasis may induce > -------
capillary stasis and thus changes in the microcirculation of the
nerve tissue and is in accordance with previ-ous studies in
which such a mechanism has been suggested as involved in Howevcc with this protocol a full restoration or the blood
carpal tunnel syndrome. The mean occlusion pressures for the flow did not occur until thc compression was lowcred from
venules demonstrated large val"iations. However, a pres-sure 5 to 0 mill Hg. This observation 1111-- ther supports the
of 5 to 10 mOl Hg was found to be sufficient for inducing previous hypothesis that vascular impairment is present
venular occlusion. Because of retro-grade stasis, it is not even at low pressure levels.
unlikely to assume that the capillary blood flow will bc A cornpression-induced impairmenl of the vas-culature
affected as well in slIch situations. may thus be one mechanism for nerve root dysfunction
because the nutrition of the nerve root will be affected.
However, the nerve rools will also derive a considerable
nutritional supply via diffu-sion from the cerebrospinal nuicl.
To assess the compression-induced eFfects on the tolal
conlribu-tion to the nerve rools. an experiment was designed
In the same experimental SCt-lIp. the effects of gradual in which jH-labelcd melhyl-glucose was allowed to be
decompression, after initial acute compres-sion was transported to the nen/c tissue in the com-pressed segment via
maintained for only a short while. were studied. The both the blood vessels and the cerebrospinal fluid diffusion
average pressure for starting the blood lIow was slightly aflcI- systemic injec-tion. The results showed that no
lower at decompression than at comprcssion For artcrioles. compensatory
capillaries. and vcnulcs.
a~~i,{~~~l .BIOME(HANICS OF TISSUES AND STRUCTURES OF THE MUSCULOSKELETAL SYSTEM
mechanism from cerebrospinal fluid diffusion ONSET RATE OF COMPRESSION could be expeclr:d at
the low pressure levels. On the
COil Lntl)·, to 111m Hg compression was sufficient to induce a One faclor that has not been fully recognized in compr-
20 to 300/0 reduction of the transport or mClhyl·glucosc to ession trauma of nerve tissue is the onset rate of the
the nerve r001S, as compared with the control. compression. The onset rate, that is. the time from start to full
compression. may vnry clinically rrom fractions of seconds in
\·Ve know 1"1'0111 experimental studies on peri ph-end lraUI11atic conditions to months or years in association with
nen!cs that compression Illay also induce an increase in the degenerative processes. Even in the clinically' rapid-onset
vascular permeability, leading to an intraneural edema rates, there ma:v be a wide variation or onset rales. \Vith the
formation. Such edema may' in-crease the cndoncuriul Fluid presented model. it was possible to vary the on-set time of the
pressure, which in turn may impair the endoneurial capillary applied compression, Two onset rates have been investigated,
blood flow and jeopardize the nutrition of the ner'vc rOOls. Either the pressure is pre-sent and compression is started by
Because the edema Llsually persists for some lime after the flipping the switch of the compressed-air system used to
rClllo\'al of a compressive agenl. edema may negativel~r affect inllate the balloon or the compression pressure level is slowl~1
the nerve root for n longer period than the compression itself. increased during 20 seconds. The first onset rate was measured
The presence of intraneural edema is also related to the at 0.05 to 0.1 seconds. thus pro-viding a rapid inflation of the
subsequent formation of intraneural fibrosis and may therefore balloon and a rapid compression onset.
contribute to the slow recaVCI)" seen in some patients with
nellie compression disor-ders. To assess if' intraneural edema
also may form in nerve roots as the result of cornprcssion, the
dis-tribution of Evan's blue-labeled albumin in the nerve tissue Such a rapid-onset rate has been found to induce more
\vas analyzed after compression at var-ious pressures and at pronounced effects on eden1a formation, mcth~ll-
various durations (Olmarker el aI., 1989b). The study showed glucose transport. and impulse propagation lhan the slow-onser
thal edema was formed even at low pressure levels. The rale (Olmarker, 199 I). Regard-ing methyl-glucose transport,
predomi· nant location was at the edges of the compression the results show that the levels within the compression zone
zone. arc more pronounced at the rapid than at the slow onSd rate at
corresponding pressure levels. There was also a striking
difference between the two onset rates when considering the
segments ourside the com-pression zones. 1n the slow-onset
series, the levels approached baseline values closer to the
The function of the nelYC roots has been studied by compres-sion zone than in the rapid-onsel series. This ma.y
direct electrical stimulation and recordings ei-ther on the nenie indicate the presence of a more pronounced edge-zone edema
itself or in the corresponding muscular segments. During a 2- in the rapid-onset sel"ics, with a subse-quent reduction of the
hour compression period, a critical pressure level for inducing nutritional transport in the nerve tissue adjacent to the
a re-duction uf MAP-amplitude seems to be located be-tween compression zone.
50 and 75 111m Hg. Higher pressure levels (100-200 mm Hg)
may induce a tOlal conduction block \vith var.ying degrees of
recovery after com-pression release. To stud)! the effect's of For the rapid-onset compression, which is likely lo be
compres-sion on sensory nerve fibers, electrodes in the sacrum more closely related to spine trauma or disc herniation than
were used to record a compound nerve ac-tion potential after to spinal stenosis, a pressure of 600 mill Hg maintained for
stimulating the senso(v nerves in the lail, that is, distal to the only 1 second is surflcient to induce a gradual impairment
compression zone. The resuhs showed thaI the sensory fibers of nc,'ve conduction during the 2 hours studied aftcr the
are slightly more susceptible to compression than are the cornpression was ended. Overall, the mechanisms for these
motor fibers. Also, the nerve roots are more susceptible to pro-nounced differences between the different onset rates
compression injury if the blood pressure is lowered arc not clear but may be related to dilTerences in the
pharmacologically. This fur-ther indicates the importance of displacement rates of the compressed nerve tissue toward
the blood supply to maintain the functional properties of the the uncompressed parts, as a result of the viscoelastic
nerve roots. propcnics of the nellie tissue, Such phenomena may ICfld
nOl only ro structural damage to the nerve fibers but also
to stn.lcturfll changes in the blood vcssels with subsequcnt
edema formation.
CHAPTER S • BIOMECHANICS Of PERIPHERAL NERVES AND SPINAl;r(;E.R.•·.:• V..•-.".~.'r«g¢~~
.'"''''"'''''.M_;;(=~~~
The gradual formation or intraneural edema may also be segment itself is ullcomprcssed. Regarding nerve
closely" related to observations of a graduall.\' increasing conduction, the effects were much enhanced if the distance
dilTcrcncc in nerve conduction impair-ment between the between the compression balloons was in-creased frorn one
two onset rates (Olmar-ker et al.. 1989b). \'cn~bral segment La two verte-bral segments (Olmarker &
Rydevik. 1992). This in-dicates that the functional
impairment may be directl:v related to the distance
between the two compression sites.
MULTIPLE LEVELS OF SPINAL NERVE
ROOT COMPRESSION
!'atients with double or multiple levcls of spinal stenosis
CHRONIC NERVE ROOT COMPRESSION
seem to have morc pronounced symptoms than do patients
IN EXPERIMENTAL MODELS
with stenosis only at one level. The presented model was
modified to address this inter-esting clinical question. Th~ discLlssion of compression-induced effects on nerve
Using two balloons at two adjacent disc levels. which roots has deall primarily wiLh acute com-pression, that is,
resulted in a 10-mm un-compressed nerve segment compression that lasts for some hours and with no survival
bctwcen the balloons, induced a much more pronounced of [he animal. To better mimic various clinical situations,
impairment of nerve impulse conduction than previollsl~'had compression must be applied over longer periods of time.
been round at corresponding pressure levels (Olmarker & There arc probably man." changes in the nerve Lissue, such
Rydevik. 1992). For instancc. a pressurc of 10 mm I-1g in as adaptation ofaxons and vasculature, that will occur in
two balloons induced a 60% reduction of nerve impulse patients but cannot be studied in ex-perimental models
amplitude during 2 hours of COIll-pression, whereas 50 111m using only I to 6 hours of com-pression, Another important
I-Ig in one balloon showed no reduction. factor in this conlext is the onset rale that was discllssed
previousl)'. In clinical syndromes with nerve root
compression, lhe onset time may in many cases be quite
The mechanism ror the diFrerence between single and slo\\'. For instance, a gradual remodeling of the verte-brae
double compression may not simply be based on the fact to induce a spinal stenosis probably leads to an onset lime
thal the nerve impulses have lo pass more than one of many years. Jt will of course be dirficult to mimic such a
compression zone at double-level compression. There may situation in an experi-mental modcl. It will also be
also be a mechanism based on the local vascular anatomy impossible to have control over the pressure acting on the
of the nerve roots. Unlike for peripheral nerves, there are nerve roots in chronic models because or the remodeling
no re· gional nutritive arteries from the surrounding and adaptation or the nerve tissue to the applied pres-sure.
structures to the intraneural vascular system in spinal nerve However, knowledge of the exact pressures is probably of
roots. Compression at two levels might therefore induce a less importance in chronic than in acute compression
nutritionally impaired region be-twcen the two situations. Instead, chronic models should induce a
compression sites. In this way. the conLrolled compression with a slow onset time that is
easily reproducible. Such models may be well suited for
:.~: segmentnffected by the compression would be "', studies on pathophysiological events as well as
widened from one b,~lIoondiarneter (10 mm) to two inlcrvention b~' surgery or drugs. Some attempts have been
balloon diameters including the inLCrjacent nerve segment made to induce such compression.
(30 mm). This hypothesis was partly con-firmed in an
experiment on continuous analyses of the total blood flow
in the ul1compresscd nerve scg· ment located bet ween two
compression balloons (Takahashi et al.. 1993). The results
showed that a 64% reduction of total blood now in the Dclamarlcr and collaborators (1990) presentcd a model
uncoll1-pressed segment was induced when both balloons on dog cauda equina in which they applied a constricting
were inflated to 10 mm Hg. At a pressure close to the plastic band. The band was tightened nrollnd the thecal sac
systemic blood pressure lhere was complete is-chemia in to induce a 25, 50, or 750/0 re-duction of the cross-sectional
the nerve segment. Thus, experimental evidence shows that area. The band was left in place for various limes. Analyses
the blood supply to the nerve segment located between two were per-~forl1led and showed both stnlctural.and functional
compression sites in changes that were proportional to the degree of con-
••1.
striction.
nerve roots is severely impaired although this Tlel'VC
OF TISSUES AND STRUCTURES OF THE MUSCULOSKELETAL SYSTEM
Experimental study to analyze the effects on nerve conduc· from Cornefjord, 1''11., 5ato, K., O/marker, K., et 011. (1997), A
tion velocity of nucleus pulposus (1), the combination of morJe! for chronic nerve root compression studies. Presentation
nucleus pulposus and compression (2), and compression of a porcine mode! (or controlled slow-onset compression '<'lith
only (3). The nucleus pulposus and the constrictor were ap- analyses of anatomic aspects, compression onser rate, and mar·
plied to the first sacral nerve root in pigs. The contralateral phologic and neurophysiologic effects. Spine, 22. 946-957.
nerve root served as a control. Reproduced with permission
To induce a s!c)\ver onset and more controlled in the nen'(' root and the dorsal root ganglion fol-lowing
compression, Cornefjord and collaborators (1997) used a such compression also has been found. Substance P is a
constrictor to compress the nerve roots in the pig (Fig. 5- neurotransmitter that is related to pain transmission. The
15). The constrictor was initially! in-tended for inducing study may thus provide experimental evidence that
vascular occlusion in experi-mental ischemic conditions in compression of nerve roots produces pain.
dogs. The constric-tor consists of an outer metal' shell that
on the inside is covered with a material called amaroid that The constrictor model has also been used to stud.\' blood
expands when in contact with fluids. Because of the metal flow changes in the nerve root vascu-lature. It could then
shell, the amaroid expands inwards with a maximum be observed that the blood Flow is not reduced just outside
expansion after 2 weeks, result-ing in compression of a the compression zone but significantly reduced in parts of
nerve root placed in the central opening of the constrictor. the nerve roots located inside the constrictor. In this
Compression of the first sacral nerve root in the pig context, note that in case of disc herniation, the nerve root
resulted in a significant reduction of nerve conduction may become sensitized by substances from the disc tissue
velocity and axonal injuries using a constrictor with a de- (nucleus pulposus) so that mechanical root deformation can
fined original diameter. An increase in substance P induce pro-nounced sciatic pain.
CHAPTER 5 • BIOMECHANICS Of PERIPHERAL NERVES AND SPINALNE~\jEJCi;8i;8'{;W*~~~D
Myc:rs. R.R .. ~Itlrabmi, H., .& "(}WI:I!. H.C. (1986), Reduced uel"\'l'
hlood flow in l.'delllatous nCllropathics-A biom(,'· chanica I
lIle(,:h.lOism . .11;LTol'tlscu!al' Ues. 32. 145-151.
',:",f;1>Thc peripheral nerves arc composed of nerve Myi.'rs, R.R" 8.: Powell, H.e. (1981). Endoncuri,d fluid pres-sure in
}t;,,:rs, layers or connective tissue, and blood vessels. peripheral neuropathies. In A.R. Hargens (Ed.).
Ti..;SIIC flilid PreSSl/re tlml C01lllJOsithm (p. 193). Baltimore:
;~{2 The nCIYC f'ibers
arc extremely susceptible 10 ruuma but Willi.II11S &. Wilkins.
because they arc surrounded by slicces- Olillarkl"', K., Rydc\·ik. B., &: Holm. S. (1989a). Edema r(lrlll~l- lion in
sive layers of connective tissue (the epineuriulll and spin£llnl'l'\'l' roots induced by experimelltal. gra<kd compression, An
1?~rinc·urillm)Jthey arc 111cchanically protected. experirnenud Sllld~' on lhe: pig cauda equina with special reference 10
dilTerences in effects be-1\\,(.'(.'11 rapid ..Iud slow onset of compression.
;:.'$§';}Strctching induces changes in intraneural bl~~d Spiw:, I..J, 579.
noll' m~d nerve Iiber S[;'llctllre before the Olmarkcr. K., Rydc\'ik. B.. Holm. S .. 1..'1 ill. (l9&9b). EffcC1S of
trunk ruptures. CXpl'l'illlental graded compression on blood flow in spinal nl,.·l'vc
roms. r\ vilal microscopic study 011 Ihe porl~ine caudn equinll. J Orthop
Comrression of a nerve can cause ItlJury to nerve Res, 7,8Ii.
fibers and blood vessels in the nerve, 'mail,lv at the Olmarkcl'. K. {1991l. Spinal nerve rOOl compression. Acute compression
edges of the compressed nerve seg- of dle cauda equina studied in pigs . .. IeUl Or-f/mp Scallll, 62. Suppl
V>:ment. but also by ischemic mechanisms. 2·n.
Ollllarker. K. 6.: Rydc\·ik. B. (1992). Single: \'('rstls doubk· kH·1
5- Pressure level, duration of compression. and mode of COllllll·l,.·ssion. '\n experimental slud.... un till..'porcine cauda
preSSllre application arc signillcant vari- l'qUill,1 with 'lll.t1ySl'S of nen·c impulse condu<:lion proper· lies.
ables in the development of nen'c injury, Cfill On/lOp. 279, 3539.
j" . "'j Olmarker. K. & Hasuc, :\1. (1995). Classificalion and patho· physiology
6... Spinal nerve roots arc anatomically different from of spinal pain syndromes. III J.1'$. \\\:inSll'in & B. Rydl'\'ik (Eds.),
peripheral nerves and therefore react differ-ently to
mechanical defonnalion,
Essc/llial... or Ihe Spillt'. RJ\'l'n Prl'ss, !\l,.·w York. NY.
B.L., Kw~n, \I.K., ;-"'Iyel's, R.R .. l'l al. (1990). :\11 in vitro
R~·(!l'\'ik.
T: Spinal nerve roots arc morc susceptible than peripheral mechanical and histological study of <ll..:lHe stretching on r;,hbit tibial
ncrves to mechanical dcformation, mainly because of the lack nerve . .I Onhop Ucs. B, 694-701.
of protective connective tissue layers in nerve roots. Ryd(·\·ik. B. & Lundborg. G. (1977). Pl:rIllt.'ahilily of intr'l-ncur:ll
micl'U\'l'ssels :lnd perineurium following :ICUll', gradl,.·d
cxpl'l'illlenlal ncrn: cOlllprcs~ion.SC(/Iu} J Na:>t Re·
COI1Slr Sl/".~. II. 179.
REFERENCES Rydc\'ik, B., Lundborg. G., &. Bagge, U. (1981). Eff(,.,c(s or gra<k·d
CorndjonJ. lVi., Saw. K.. Olmarkcr. K.. ci :d. (1997). A nHldcl ror compr('ssion nn inlr,1I1cural blood flow. An in \·i\'{) sllld.... 011 rabbil
tihi.tl ner\'e. J flawl Sure;. 6. 3.
chronic n('IT":" roOI compression studies. PrCSi..'IlI~llion of a porcine
Ryd":"\'ik, B.. Bro\\'ll, :\I.D .. &: Lundborg, G. (1984). P<llhoanatolll~' and
model for contrnllt·d slow-onset comprl'ssion \\"ith an.tlyscs of
pathoph ....siolog.\· of nel'\'e root com· pression. Sp;Ilt.'. 9. 7.
anatomic ::lSPCCIS. comprl,.·ssion onSel r~lle, and morphologic and
neurophysiologic crfeels. SpilIC, 22. 946-957,
Ryd(.·\'ik. B.L.. Kw<tn, M.K .. Myers R.R., et :11. (1990). An in
vitro mechanical :\n(\ histological study of ,H:llle strelching on r .. hbil
[hillin. L.B .. Ry(kvik, B.. &: Lundborg. G. (1986). Thc p.IIIHI'
physiology of nelTe eHtrapmellis and nervi..' cOlllpr":"ssion injuries. In tibi:ll nen·l'. J Orrhop U,·.... 8. 694.
A.R. Hargens (Ed.). E!l;'cIS or .\kclwllic:al Stress 011 Tisslle
Spencer. D.L.. ~'lillcr. J.I\., .& BCriolini. J.E. (198·.J). The (.'f· fects of
intervertebral disc space narrO\\"ing nil the contact force bl·twcen the
Viability. New York: Springer-Verlag.
Ill'rn' rOOt and a simlll:llcd disc protnl' sion. Spille 9, 422.
Delamartcr, R.B" Bohlman. I-U-I., Dodge, L.D" el a!. (1990).
Experimental lumbar spinal SlCllosis. Analysis of the cor-tic~d evoked
SUl1ckrbnd. S. (1978). Nen'c.>: alld Nave III;tlri(~s (2nd cd.). Edinburgh:
potentials, microvasculature and histop<1thCII·
Churchill Livingslone.
ogy. J BOIlt: JOillf SI/r:.:, 72:\. 110-120.
Takah;lshi, K.. Olm:-.rkc.·r. K., Holm, S .. cl £II. (1993). Double·
Lundbor!!, G., &: Rvdcvik, B. (1973), Effecls of strctchin!! Ihe libial
I('velcauda ('quina cqmprcssion. An experimenlal stud\" wilh
~\cl"\"eof lill,.· rabbic: :\ prdimin.ary slUdy of tilt: i;llra-
conlinuous monitoring of intraneural blood flow. j
neural cin:ul~lliol1 and Ihe b.uTicr funclion of Ihe per· inelll'iul11. J
Onhop Res, II, 104,
BOllI: JOill1 SlIrg, 558, 390.
TOrlora, GJ., & Anagnoslakos. N.r. (1984). Prillci"les of
Lundborg. G. (1975). Structure :\Jld flllll:tioll of the inlra· ncural
AlUlIOI1lY (/ltd Physio}ogl' (41h cd.). N(.·w York: Harper & Ro\\'. Wall. E.J
micrO\'essl,:ls as related lO Iraum:l. edcma formation and nerve
.. M:ISSic, J.B.. Kwan. M.K .. CI 011. (1992). Experi-lllcnta!
fUllclion.) !JOIII.' )oim Surg. 57..1. 938.
stretch neurop'lthy. Changcs in nerve conduclion
Lundborg, G., e{ .11, (1982). Median nel'\'e compression ill the C,I1'p,ll
under tension,) BOllt' .foitlf Stl,.~, N-B. 126,
tunnel: The fUllclion:l1 respons(.· 10 cxpcrillH.'nlally induced
controlll·d pressure . .f f-/mu} SlIrg, 7, 152. Weinstein. J.N" L.li\lotll'. R.. Rydcdk, B. el 011., (1989). N1..Tn·. In
J.W. Frymoyer 8.: S.L. Gordon (Eds.)_ Nell' 1'('I"spcctiws 0/1 1.0\1'
Myers, R.R. (1998). :\Iorphology or the peripheral nervous
Back Paill (Chapll'r 4, pp, 3S-130). Park Ridg(·. 11.: '\AOS. [Based 011
System nnd its relntiollship to neuropathic pain. In T.L ';aksh. C.
a workshop ,IIT,lngcu by Ihe N:llion;ll In· stiwtes of Health (NIH) in
Lynch III. W.M. Zapol.:-"-1. ~'1azc, J.E Bicbuyck . .&
AirJil'_ Virginia, USA. May 1988.1
L.J. Saidman (Eds."J. Aw:...tht'S;u: Bio}o~ic FouI/datiolls (pp.
483-514). Phil'lCldphia: LippiIKOll·R~I\,l,.'n.
Nerve
structure
o
~
-;
Ui
'"C
m
'"
l>
Z
o
Structural
composition
Protects -Biochemical 'Axon's Delivery Local Returned Tl<lnsmission of Of importJ.nce Myelin '"-;
;D
from barrier protector of blood oxygen supply blood flow impulses; (or impulse production and C
and function n
external properties -Nutrition intl<lcellular transmission synthesis of -;
affected C
trauma 'Preserves ionic tl<lnspon of trophic factors ;D
environment material m
'"
o
~
..
-;
I
m
<:
c
n'"
D ,
o
c
'"
,"m
Illness or injury m
'",-<
'"-;
m
<:
"This flow (hart is designed for classroom or group discussion. Flow chart is not meant to be exhaustive.
Biomechanics of
Skeletal Muscle
Tobias Lorenz, Marco Campel/o adapred from
Mark I. Pieman, Lars Peterson
Introduction
Composition and Structure of Skeletal Muscle
Structure and Organization of Muscle
Molecular Basis of Muscle Contraction
The MOtor Unit
The Musculotendinous Unit
Mechanics of Muscle Contraction
Summation and Tetanic Contraction
Types of Muscle Contraction
Force Production in Muscle
Length-Tension Relationship
Load-Velocity Relationship
Force·TimeReJ(ltionship
Effect of Skeletal lvIuscie Architecture
Effect of Prestretching
Effect of Temperature
Effect of Fatigue
Muscle Fiber Differentiation
Muscle Injuries
Muscle Remodeling
Effects of Disuse and Immobilization
Effects of Physical Training
Summary
References
Flow Charts
Introduction ton. The myofibril is made lip of several sarcomeres that
contain thin (actin), thick (myosin), clastic (titin), and
The muscular sYSlCll1 consists of three III usc Ie.:: l.ypes: the inelastic (ncbulin) filaments. Actin and myosin are the
cardiac muscle, which composes the hc[trt; the contractile part of the myofibrils. whereas titin and nebulin
nrc part of the intramyo-fibrillar cytoskelcton (Stromer et
Sl1100th (nonstriated or involuntary) muscle, which lines the
aI., 1998). The myof-ibrils are the basic unit of contraction.
hollow internal organs; and the skeletal (striated or voluntary)
muscle, which auaches to the skeleton via the tendons. The Each fiber is encompassed b:y a loose connective tissue
focus of this chapter is the role and function of skeletal called the endomysium and the fibers arc or-ganized into
muscle. various-sized bundles, or Fascicles (Fig. 6·1, A & B), which
Skeletal muscle is the most abundant tissue in the human arc in (urn encased in a dense connective tissue sheath known
body, accounting for 40 to 45% of the to-lal body weighL. as the perimysium. The muscle is composed of several
The human body has morc than 430 skeletal !TIuscles, found fascicles sur-rounded by a fascia of fibrous connective tissue
in pairs on the right and left sides of the body. The most called the epimysium.
vigorolls movements are produced by fewer than 80 pairs.
The muscles provide strength and protection to the skeleton In general, each end of a muscle is attached to bone by
by distributing loads and absorbing shock; they enable Ihe tendons, which have no active contractile properties. The
bones to move at the joints and provide the maintenance or muscles form the contractile com-ponent and the tendons the
series clastic compo-nent. The collagen fibers in the
body posture against force. Such abilities usuall~' represent the
action of muscle groups, not of individurll mllscles. perimysium and epimysium are continuous with those in the
ten-dons: together these fibers act as a stnlctural fr,\Il1c~ work
for the attachment of bones and muscle fibers. The
perim)'sium, endomysium, epimysium, and sar-colemma act as
The skeletal muscles perform both dynamic and static
parallel elastic components. The forces produced by the
work. Dynamic work permits locomotion and the
contracting muscles arc transmitted to bone through these
positioning of the body segments in space. Sta-tic work
connective tis-sucs and tendons (Kassel'. 1996).
maintains body posture or position. In this chapter we
describe the composition and structure of skeletal muscle.
the mechanics of muscle con-traction. force production in
muscle. Illuscle fiber differentiation, and muscle remade-ling. Each muscle fiber is composed of a lal'ge num-ber of
delicate strands, thc mvol'ibrils. These are the contractile
clements of muscle. Their structure and function have been
studied cxhausti\'c1y b:v Iighl and eleclron microscopy,
Composition and Structure o( and [heir histo~ chemistr~' and biochclllistry have been
Skeletal Muscle explained elsewhel'c (Alvidson et aI., 1984; Guvton, 1986).
Approximately I p.m in c1iamctcl: the myofibrils lie parallel to
An understanding of the biorncchanics of Illuscle function each other within the cytoplasm (sar-coplasm) of the muscle
requires knowledge of the gross anatomi-cal structure and fiber and extend through-out its length. They vary in number
function of the musculotendinous unit and the basic from a few to several thousand depending on the diameter of
microscopic structure and chem-ical composition of the the ll1uscle fibel~ which depcnds in turn on thc type of ll1usclc
fiber.
muscle fiber.
149
G,a,SO' P~RT 1 • BIOMECHANICS Of TISSUES AND STRUCTURES Of THE MUSCULOSKELETAL SYSTEM
Livingstone.
Each sarcomere is composed of the Following: 3, The elastic filaments composed of the protein titin
(Fig, 6-2)
I, The thin filaments (approximately 5 nm in di-ameter)
A, The inelastic filaments composedof the pro-teins
composed of the protein actin
nebulin and tilin
2, The thick filaments (approximately 15 nm in
diameter) conlposed of the protein myosin (Fig, 6- Aetin, the chief component or the thin filament, has
1, D & E) the shape of a double helix and appears as two
strands of beads spiraling around t.:ach othcl: Two with a globular "head" projecting from a long shaft or
additional proteins, troponin and tropomyosin, are "tail." Several hundred slIch molecules are packed tail to
important constituents of the actin helix because tail in a sheaf with their heads pointed in one direction
thev appear to regulate the making and breaking of along half of the filament and in the oppo-site dircction
cOI~taclS between the actin and myosin filamel1ls along the other half, leaving a hcad-free region (the H zone)
during contraction. Tropomyosin is a long polypep-tide in between. The globular heads spiral about the myosin
chain that lies in the grooves between the he-iices of actin. filament in the region where actin and myosin ovcrlap (the A
Troponin is a globular molecule at-laehed at regular band) and ex-tcnd as cross-bridges to interdigitate with sites
intcr'vals to the tropomyosin (Fig. on the actin filaments, thus forming the structural and
6-1, D & E). I'unctionallink between the two filament types.
The thick filaments are located in the central re-gion of
the sarcomere, where their ordcrl.y, parallcl arrangemcl1l The intramyofibrilh.,r cvtoskeleton includes in-elastic
gives rise to dark bands known as A bands because they arc nebulin filaments, which span from the Z line to the actin
strongly anisotropic. Thc thin filaments arc atlachcd at filaments. Ncbulin might also act as a template for the thin
either end of the sar-comere to a structurL' known as the Z filament assembly.
line, which consists of shon elements that link the thin fila- Titin is I j.1m long. It is the largest polypeptide and spans
ments of adjacent sarcomcres. defining the limits of each from the Z line to the IVI line. Titin is an clastic filament. The
sarcomere. The thin filaments cxtcnd From the Z line part between the Z linc and myosin has a string-likL'
toward the center of the sarcomere, where they overlap appearance. Titin has been suggested to contdbutc greatly to
with the thick fibmcnts. Re-cently it was shown thal there the passh'c force development of muscle during stretch (Fig.
is a third set or n1YO-fibril filaments in the vertebrate 6·2). II also might act as a template for the thick filament
striated Illuscles. This connecting filament, named titin, assembly (Linke et aI., 1998; Squire et al., 1997; Stromer et
links the thick Filaments with the Z line (elastic I band re- aI., 1998),
gion of titin) and is part of the thick filaments (A band
region o[ titin). This filament maintains the central position The I bane! is bisected by the Z lines, which contain the
of the A band throughout contrac-tion and relaxation and portion of the thin filaments that does not overlap with the
might act as a template during myosin ~,sselllbly. thick filaments and the clastic part of tit in. In the center of
the A ballet. in the gap between the ends or the thin
filaments, is the H zone, a light band con-taining only thick
filaments and that part of tilin that is integrated in the thick
Myosin, the thicker filament, is composed of indi-vidual filaments. A narrow, dark area in the center of the H zone is
molecules, each of which resembles a lollipop the M line, 1'1'0-
M-line
A-band
part
01 titin
Extent of one
!!lin molecule
The arrangement of titin molecules within the sarcomere. Adapted from Craig. R.(J994). The
stftJ(ture of the contract filaments. In A.G. Engel & Fraflzini·Armscrong (eds.). !vlyology (2nd ed.•
p. 150). New York: McGr<)w-Hill, Inc.
.'f~~ P.o.,RTl ,BIOMECHANICS OF TISSUES AND STRUCTURES OF THE MUSCULOSKELETAL SYSTEM
duced by transversely and longitudinally oriented proteins allel to the myofibrils and lend to enlarge and fuse at the
that link adjacent thick filaments, maintain-ing their parallel level of the junctions between the A and I bands, forming
Hrrangclllel1L The various areas of the banding patlern arc transverse sacs, or the terminal cis-ternae, that surround the
apparent in the photomicro-graph of human skeletal muscle individual myofibril completely,
shown in Figure 6-3.
Closely correlated with the rcpealing pattern or the The terminal cisternae enclose a smaller tubule tha1 is
sarcomcrcs is an organized network of tubules and sacs scpanllcd from them by its own membrane. The smaller
known as the sarcoplasmic reticulum. tubule and the terminal cisternae above and below it are
The tubules of the sarcoplasmic reticulum lie par- known as a triad. The enclosed
---- Sarcomere
"'....
r _--~""
_~ } Sarcoplasmic
reticulum
Mitochondrion {
I~M t
z
--- Line Line
H
Zone
B
A. Single muscle fiber with three protruding myofibrils. B. Electron photomicrograph of a cross·sectionof human skeletal mus· c1e.
The sarcomeres are apparent along the myofibrils. Characteristic regions of the sarcomere ar~ indicated.
CHAPTER 6 • BIOMECHANICS OF ''',LCIALMLI>L.Lt
~
ill
E
0
Band
A
'l These cross-bridges swivel in an arc around their fixed
positions on the surface of the m,vosin filament, much like
the oars of a boat. This movement of the cross-bridges in
contact with the actin filaments pro-duces the sliding of the
actin filaments tc)\vard the center of the sarcomere, A
u Band
m muscle fiber contracts \vhen all sarcomere shorten
If)
simultaneously in an all-or-nothing fashion, which is called
a twitch,
I
Band I z· Because a single movement of a cross-bridge pro-duces
Triad only' a small displacement of the actin flla-ment relative to
! \j the myosin filament, each individ-ual cross-bridge detaches
itself from one receptor site on the actin filament and
Sarcotubule Terminal I
cisternae reattaches itself to an-other site further along, repeating the
DD-------- process five or six tirnes, "with an action similar to a man
pulling on a rope hand over hand" (Wilkie, 1968). The
Diagram of a portion of a skeletal muscle fiber illustrating the cross-bridges do not act in a s)-'nchronized manner; each
sarcoplasmic reticulum that surrounds each myofibril. The acts independently, Thus, at any given moment (mly
various regions of the sarcomere are indicated on the left approximately half of the cross-bridges actively generate
myofibril to show the correlation of these regions with the force and displacement, and when these detach, others take
sarcoplasmic reticulum, shown surrounding the middle and
up the task so that shortening is maintained, The shortening
right myofibrils. The transverse tubules represent an infolding
of the sarcolemma, the plasma membrane that encompasses
is reflected in the sar-comere as a decrease in the I band
the entire muscle fiber. Two transverse tubules supply each and a decrease in the H zone as the Z lines move closer
sarcomere at the level of the junctions of the A band and I together; the width of the A band remains constant.
bands. Terminal cisternae are located on each side of the
transverse tubule, and together these structures constitute a
triad. The terminal cisternae con-nect with a longitudinal A key..' to the sliding mechanism is the calcium ion
network of sarcotubules spanning the region of the A band. (Ca~'),which turns the contractile activity on and off.
Adapted from Ham, A.W & Cor-
Muscle contraction is iniliated \vhen calcium is made
available to the contractile elements and ceases when
Molecular Basis of Muscle \Vhen the motor neuron stimulates the muscle at the
neuromuscular junction (Fig, 6-5A) and the propagated
Contraction action potential depolarizes the mus-cle cell membrane
(sarcolemma), there is an in-\vard spread of the action
The most widely..' held theory of muscle contraction is the potential along the T system. (Details of this process arc
sliding filament theory, proposed simultane-ously by A.F. given in Figure 6-5, A-C and in Box 6-1, which summarizes
Huxley and H.E. Huxley in 1964 and subsequently refined the events during the excitation, contraction, and re-
(Huxley, 1974). According to this theory, active shortening laxation of muscle, Figure 6-5D shows the struc-
of the sarcomere, and
Molor
end
plate
(1 )
Synaptic
vesicles
(3)
c o
Schematic representation of the innervation of muscle fibers. A, An area in this section is shown in detail in C. C. Ultrastructure of
axon of a motor neuron (originating from the cell body in the anterior the junction of an axon terminal and the sarcolemma. The in·
horn of the spinal cord) branches near its end to innervate several vagination of the sarcolemma forms the synaptic trough into which the
skeletal muscle fibers, forming a neuro-muscular junction with each axon terminal protrudes. The invaginated sar-
fiber. The region of the muscle membrane (sarcolemma) lying colemma has many folds, or subneural clefts, which greatly in-crease
directly under the terminal branches of the axon has special its surface area. Acetylcholine is stored in synaptic vesi-
properties and is known as the motor end plate, or motor end plate cles in the axon terminal. Band C. adapted from Brobeck, IR. (Ed.)
membrane. The rec-tangular area is shown in detail in B. B, The fine (/979). Best and Taylor'sPhysiological Basis of Medical Practice
terminal branches of the nerve (axon terminals), devoid of myelin (10(h ed., pp. 59-1/3). Baltimore: Williams & Wilkins. D. Cross-
sheaths, lie in grooves on the sarcolemma. The rectangular bridge cycle of muscle contraction.
CHAPTER 6 • BIOMECHANICS OF ~"ccc,"."
1. An action potential is initiated and propagated in a mo-tor 11. Actin activates the myosin ATPase found on the myosin
axon. cfOss-bridge, enabling ATP to be split (hydrolyzed.) This
2. This action potential causes the release of acetylcholine process releaSES energy used to produce movement 01
irom the axon terminals at the neuromuscular junction. the myosin cross~br;dges:
3. Acetylcholine is bound to receptor sites on the motor end
A, I'll 'ATP --; A ' Iv1 + ADP + P,
plate membrane.
4. Acetylcholine increases the permeability of the motor end 12. Oar-like movements of the cross bridges produce rela-tive
4
plate to sodium and potassium ions. producing an end-plate sliding of the thick and thin filaments past each
potential. other.
S. The end-plate potential depolarizes the muscle mem- 13. Fresh AT? binds to the myosin cross-bridge, breaking the
brane (sarcolemma), generating a muscle action pOlen- actin-myosin bond and allowing the cross-bridge to
tiallhat is propagated over the membrane suriaee. dissociate from aGin:
6. Acetylcholine is rapidly destroyed by acetylcholinesterclse
A . rv1 .;-. ATP -) A + tvl . ATP
on the end plate membrclne.
7. The muscle aGion potential depolarize')the transverse 14. The ATPase hydrolyzes the myosin ATP complex to rhe M .
tubules. AlP complex, which represents rhe relaxed state of the
8. Depolarization of the transverse tubules leads to the re- sarcomere:
lease of calcium Ions from the terminal cisternae of the
M' ATP -) Iv1 'ATP
sarcoplasmic reticulum surrounding the myofibrils.
These ions are released imo the sarcoplasm in the direct 15. Cycles of binding and unbinding of actin with the myosin
vicinitY of the regulatory proteins tropomyosin and tro-ponin. cross-bridges at successive sites along the actin filament
(steps 11, 12, 13, CH'\d 14) continue as long as ii)e
9. Calcium ions bind to troponin, allowing movement of the concentration of calcium remains high enough to inhibit the
tropomyosin molecule away from the myosin recep-tor sites action of the troponin-rropomyosin system.
on the actin filament that it had been blocking and releasing 16. Concentration of calcium ions falls as they are pumped into the
the inhibition tilat had prevented actin from combining with terminal cisternae of the sarcoplasmic reticulum' by an energy-
myosin. requiring process that splits ATP,
10. Actin (A) combines with myosin ATP (M-ATP). In this state, 17. Calcium diSSOCIates from troponin. restoring the in-hibitory
ATP has been hydrolyzed to ADP and phosphate bUt the action of troponin-tropomyosin. The actin fila-ment slides back
products are still attached to myosin (receptor sites on the and rhe muscle lengthens. In the pr~s-, ence of ATp, actin and
myosin cross-bridges bind to receptor sites on the actin myosin remain in tll~ dissociated;, relaxed stale.
chain):
(,l.,!odiiied from Luciano er ,l!. (I 978j, In HUIl1"n FuncliOn <1nd Structure (Fig 5,5D/ New York: ,\,'1cGril~·/·Hi,ll: and
,jdiJpted from (I'dlg. R. 099.:1). Myology (2nd ed.. p. 162) New York: McGra:'1·;·/iIl.)
lural features between actin and the cross-bridges of tract independently. \Vhcn stimulated, all muscle fibers in
mvosin.) the mOlor unit respond as one. The fibers of a Illotor unit
arc said to show an all-or·none re-sponse to stimulation:
the),..' contract either maxi-mally or not at aIL
THE MOTOR UNIT
The functional unit of skeletal 111uscle is the mOlor unit. The number of muscle fibers forming a -motor unit is
which includes a single motor neuron and all of the muscle closely I"elated to the degree of control I"C-quirccl of the
rlbers innervated by it. This unit is the smallest part of the muscle, In small muscles thal perform vcr~' fine movements,
muscle that can be made to CO!l4 such as the extraocular I11U$-
~l~JART l';~{~Of',ilECHANICS OF TISSUES AND STRUCTURES OF THE MUSCULOSKELETAL SYSTEM
des, each motor unit may contain less than a dozen muscle
fibers; in large n'lUscies that perform coarse movements.
such as the gastrocnemius, the motor unil may contain 1,000 PEC
,OOOOOH
to 2,000 muscle fibers.
The fibers or each motor unit arc not contiguous but
SEC
dispersed throughout the muscle with fibers of other units.
Thus. if a single motor unit is stimu-latex!. a large ponion
CC
or the muscle appears to con· (rae£. If additional motor
units of the nerve inner· vating the muscle are stimulated, I
the muscle corHracls with greater force. The calling in of I
adeli· tional motor units in response to greater stimula-tion
of the motor nClvc is called recruitment.
rapidity of stimulation olltstrips the contraction~relaxation tion and Structure (pp. J J3-(36). New York: McGraw,Hill.
!>f()f'-'IEClHAN.IC:SOF TISSUES AN.D STRUCTURES Of THE MUSCULOSKEl.ETAL SySTEM
c
0
'iii
c 2
<l>
>--
<l>
>
'g
0;
a:
0
i t I i i i Jumnmrnmmnnrrmnnm
s s s s s s ssssssssssssssssssssssssssssssssssss
100 200 300 400 500 600 700 800 900 1000
Time (msec)
Generation of muscle tetanus. As the frequency of stimula- becomes maximal and the muscle contracts tetanically, exert-
tion (5) increases (Le., the intervals shorten from 200 to 100 ing sustained peak tension. Adapled from Luciano, OS. Vander,
msec), the muscle tension rises as a result of summation. AI, 8 Sherman, IN (978). Human Function and Structure (p.o.
When the frequency is increased to lOO/second, summation I i 3-136). New York: McGraw-Hi//.
activity' of their motor units, in both stimulation fre- Although no motion is accomplished and no me-
quency' and the number of units activated. The repetitive chanical \vork is performed during an isomctric
twitching of all recruited motor units of a muscle in an contraction, muscle work (physiological work) is
as:vnchronous manner results in brief summations or more performed: energy is expended and is Illostly dissi-paled as
prolonged subtetanic or tetanic contractions of the muscle heat, which is also called the isornetric heat production. All
as a whole and is a principal Factor responsible for the dynamic contractions involve what ma.y be considered an
smooth move-ments produced by the skeletal muscles. initial static (isometric) phasc as the muscle first develops
tension equal to the load it is expected to overcome.
Dynamic work: Mechanical work is performed and joint mo- 4. Iseinenial (iso, constant; inertial, resistance) contraction: ;'"
tion is produced through the following forms of muscle con- This is a type of dynamic muscle work wherein the resis-
traction: tance against which the muscle must contract remains
1. Concentric (con, together; cemrum, center) contrac- constant. If the moment (torque) produced by the muscle is
tion: When muscles develop sufficient tension to over- equal to or less than the resistance to be overcome,
come the resistance of the body segment, the mus-cles the mllscle length remains unchanged and the muscle
shorten and cause joint movement. The net moment contracts isomelfically. If the moment is greater than the
generated by the muscle is in the same di· rection as resistance, the muscle shortens (contracts concentrically)
the change in joint angle. An example of a concentric and causes acceleration of the body part. Isoinertial con~'
contraction is the action of the quadriceps in extending traction occurs, for example, when a constant external
the knee when ascending stairs. load is lifted. At the extremes of motion, the inertia of the
2. Eccentric (e.g., out of-, centrum, center) contraction: load must be overcome; the involved muscles con-tract
When a muscle cannot develop sufficient tension and isometrically and muscle torque is maximal. In the midrange
is overcome by the external load, it progressively of the motion, with the inenia overcome, the mU'jclescontract
lengthens instead of shortening. The net muscle mo- concentrically and the torque is sub-maximal.
ment is in the opposite direclion irom the change in joint
angle. One purpose of eccenlric contraction is to 5. Isotonic (iso, constant; tonic, iorce) contraction: This term
decelerate the motion oi a joint. For example, when is commonly used to define muscle contraction in which the
one descends stairs, the quadriceps works eccentri- tension is constant throughout a range of joint m()~' tion.
cally to decelerate flexion of the knee, thus decelerat- This term does not take into aCCOLlnt the leverage'"" eilects
ing the limb. The tension that il applies is less than the at the joint. Ho\,vever, because the muscle force moment
force of gravity pulling the body downward, but it is arm changes throughout the range oi joint mo-··;: lion, the
sufficient to allow controlled lowering of the body. muscle tension must also change. Thus, isotonic muscle
3. Isokinetic (iso, constant; kinetic, motion) contraction: contraction in the truest sense does not exist in
This is a type of dynamic muscle work in which move- the production of joint motion (Kroll, 1987).
ment of the joint is kept at a constanI velocity. and Static work: No mechanical work is performed and posture or
hence rhe velocity of shortening or lengthening of the joint position is maintained through the following form of
muscle is constant. Because velocity is held constant, muscle contraction: '\'
muscle energy cannot be dissipated through accelera- 1. Isometric (iso, constant; metric, length) contra(ti()~,;,..:~~s.r.:· c1es
lion of the body part and is entirely converted to a re- are not always directly involved in the prod~qi~~:-Pr.'.:..: ,>
sisting moment. The muscle force varies with changes joint movements. They may exercise either a rest'ra(ning',"
in its lever arm throughout the range of joint motion or a holding action, such as that needed t~ ~aint~i~ the:"
(Hislop & Perrine. 1967). The muscle contracts con- body in an upright position in opposing the force of
centrically and eccentrically with different directions of gravity. In this case the muscle attempts to shorten (i.e.,
joint motion. For example, the i1exor muscles of a joint the myofibrils shorten and in doing so stretch the series ---::::-
contract concentrically during flexion and eccen-trically elastic componenr. thereby producing tension), but it
during extension, acting as decelerators during the does not overcome the load and cause movement; in-stead.
latter. it produces a moment that supports the load in a iixed
position (e.g., maintains posture) because no ,", change
takes place in the distance between the mlJsc!le's' points of
attachment.
•
occur alone in normal human movement. Instead, one type
of contraction or load is preceded by a dif-ferent type. An c
.2m '.0 I
example is the eccentric loading prior to the concentric c "
II
Most rnuscles that cross only one joint normally are not
stretched enough fOl- the passive tension 10 play an o ..
important role, but the case is different for lwo-joint Velocity
muscles. in which the extremes of the
L Length
length-tension relationship may be functioning (Crawford
& James, 1980). For example, the ham-strings shorten so
much when the knee is fully Hexed that the tension they
can exert decreases con-siderably. Conversely, when the
~------ hip is nexed and the knee extended. the Illuscles arc so
The active and passive tension exerted by a whole muscle
stretched that it is the magnitude of their passive tension
that pre-vents flirt her elongation and causes the knee to
I contracting isometrically and tetanically is plotted against the
muscle'slength. The active tension is produced by the con· tractile
flex if hip flexion is increased.
I greater the amount of stretching, the larger the contribution of the elastic
component to the total tension. The shape of the active curve is
The relationship between the velocity of shOl·lening or
eccentric lengthening of a muscle and different constant
generally the same in different muscles. but the passive curve, and loads can be determined by plolLing the ve-locil)' of
hence the total curve, varies de-pending on how much connective
tissue (elastic component) the muscle contains. Adapted from Crawford. motion of the muscle lever arm a1 various external loads.
CN.C & James.
N. T. (1980). Tile design of muscles. III R. Owen. 1. Goodfel/o;,t~ & p.
thereby generating a load-velocity curve (Fig. 6-11). The
Bulfough (£els.), Scientific Foundations of Orthopaedics and velocity of shortening of a muscle contracting
TraurnJ· tology (pp. 67-74). London: William Heinemann. concentrically' is inversely re-lated to the external load
I applied (Guyton, 1986). The velocity' of shortening is
~~~·_----_·_-------T
tcrnalload is zero, but as the load increases the mus~ ele
shortens morc and more slowly. \Vhcn the cxter4 nul load
Gastrocnemius Muscie Tear equals the mnximal force that the muscle can exen, the
---..·. 22·year-oldmale professional athlete tears his ga5- velocity of shortening becomes zero and the muscle
A trocnemius during a race (Fig. (56-1-1). The tensile
contracts isometrically. \,\fllen the load is increased still
further, th~ muscle contracts eccel1Lrically: it elongates
overload that happens during strenuous eccentric and
c6n~entric contractions increases the risk of injury. espe- during contraction. The load~velocity relationship is reversed
ciallywhen the forces involve bj-articular muscles such from that of the concentri-cally contracting rnuscle; the
:asthe gastrocnemius. This indirect trauma is associated muscle eccentrically lengthens more quickl)! with
:wi!~ 111gh tensile forces during rapid contraction (high increasing load (Kroll. 1987) (Case Study 6-1).
v~l_()~ity) and continued changes in muscle length. The status
of muscle contracrion at the time of overload is uS!Jally
eccentric, and failure most often occurs at or near the FORCE-TIME RElATIONSHIP
myotendinous junction unless the muscle has
Q.eef1. previously injured (Kasser, 1996). Swelling from The force, or tension, generated by a muscle is pl'O-portional
·h~~{br'rh~geoccurs initially in the inflammatory phase. to the contraction time: the longer the contraction lime, the
,The cellu.lar response is more rapid and repair is (rlore greater is the force developed, lip to the point of maximurn
complete'ifthe vascular channels are not disrupted and tension. In Figure 6-12, this relationship is illustrated by a
·thenutritioo.of ihe tissue is not disturbed. The degree
force-lime CUl\rc for a whole muscle contl"acting
of injury from a tensile overload will dictate the poten· isometrically. Slower contraction leads to greaLcr force
tia/hos< r~sponseand the time needed iar repair.
produc-lion because time is allowed for the tension pro4
duced b.y thL' cornractilc clements to be transmined
through the parallel clastic components to the ten-don.
AltlH)Ugh tension production in the contractile component
can reach a maximum in as little as to mscc. lip to 300
ITlSeC ma~' be needed for that ten-sion to be transferred to
the clastic components. The tension in the tendon will reach
the maximulll tension developed by the contractile element
only if the aClive contraction process is of sufficient dura-
lion (Olloson, 1983).
EFFEa OF PRESTRETCHING 10 15 20 25
It has been demonstrated in amphibians and in hu-mans Muscle Length (cm)
(Cuillo & Zarins, 1983) that a muscle per-forms more B 100
work when it shortens inlmediatcly af-ter being stl'etched
in the concentrically contracted state than when it shortens 80
from a state of isomet-ric contraction. This phenomenon is ~
not entirely ac-counted for by the elastic energ~' stored in ~ 60
the series clastic component during stretching but must also o
u.
be caused by energy stored in the contractile com· ~
'0 40
~
::;"
20
5 10 15 20 25
Muscle Velocity (cm/s)
•
0F -----------
pon~nl. 'Ithas been suggested [hat changes in the in-trinsic
mechanical properties of l11)'oflbrils are im-ponant in the
stretch-induced enhancement of work production
Time (Takarada et aI., 1997),
IBm
i L- _ EFFECT OF TEMPERATURE
muscle aconty is intense, Finally, myosin ATPase Jvlany methods of classifying muscle fibers have
may break down AT? faster than even glycolysis can been devised. As early' as 1678, Lorenzini observed
r~p'lace it, and fatigue occurs rapidly as AT? con- anatomically the gross dilTcrence bel\\,Icen red and
centrations drop. white muscle. and in 1873 Ranvier typed muscle on the
After a period of intense exercise, creatine phos- basis of speed of contractility and fatigability. Although
phate levels have become low and much of the mus-cle considerable confusion has existed con~ cCl'ning the
glycogen may have been convened to lactic acid. For the method and terminology for classifying skeletal muscle,
muscle to be returned to its original state, creatine recenl histological and histochemi-cal observations have
phosphate must be resynthesized and the led to the identification of three distinct typcs or muscle
u1vcofLcn stores must be replaced. Because both fibers on the basis of differing contractile and metabolic
pl:oce~ses require energy, the muscle will continue properties (Brandstater & Lambert, 1969; Buchtah! &
to consumc oxygen at a rapid rate cven though it has Soh mal-burch, 1980) (Table 6-1).
stopped contracting. This sustained high oxy-
uptake is demonstrated by the fact that a person
!:rell The fiber t~'pes are distinguished mainly by the
~ontinues to breathe heavily and rapidly aher a pe- metabolic pathways by which they can generate AT?
riod of strenuous exercise. and the rate at which its energy is made avail-able to the
v"hen the energy necessary to return glycogen and conrractilc system of the sarcomere, which determines
creatine phosphate to their original levels is taken into the speed of contraction. The three fiber types are
account, the ef(-icienc~... with which mus-cle coovens termed type I, slow-twitch ox-idative (SO) fibers; type
chemical energy to work (movement) is usually no more lIA, fast-twilCh oxidative-glycolvtic (FOG) fibers; and
than 20 to 250/0, the majority of the energy being type liB, fast-twitch gly-colytic (FG) fibers.
dissipated as heat. Even when Illuscle is operating in its
most efficient stnte, a maximum ()f only approxinwtel)! Typc I (SO) fibers are characterized by a low ac-tivity
45{>~ of
the energy is used for contraction (Arvidson ct 'II., of my'osin ATPase in the muscle fiber and, thcrefore, a
1984; Guyton, !986). relatively slow contraction time. The glycolytic
In growth biomechanics, muscle fatigue is flrst (anaerobic) aClivity is low in this fiber lype, but a high
observed by the lack of coorclinalion or movement and content of mitochondria produces a high potential for
its effect in the increasing of loads in tissue. Re- oxidative (aerobic) activity. Type I fibers are difficult to
searchers including Bates et al. (1977) have indi-cated fatigue because the high rate of blood now to these
that the skill of the person in performing a given action fibers delivers oxygen and nutri-ents at a sufficient rate
is affected by fatigue, They studied the fatigue effect on to keep up with the relatively slow rate of ATP
runners and absented that runners decrease their knee breakdown by myosin ATPase. Thus, the fibers are well
extension when fatigue occurs (Bates et aI., 1977). suited for prolonged, low-intensity work. These fibers
Parnianpour (1988) studied the motion coupling of the are relatively small in diameter and so produce
spine at exhaustive extension Oexion. This study relatively little tension. The high myoglobin content of
showed that when an individual became fatigued, the type I fibers gives the muscle a red color,
coupled motion increased and therefore the spinaltorquc
increased. The most dele-terious component of the Type II muscle fibers arc divided into two nlain
ncurornuscular adaptation to the fatiguc state was the subgroups, IIA and IlB, on the basis of differing sus-
reduction in accuracy control and speed of contraction, ceptibility to treatment with different buffers prior to
\vhich may predis-pose an individual to injury if muscle incubation (Brooke & Kaiser, 1970). A third sub-group,
fatigue occurs. the typc lIe fibers, are rare, undifferentiated fibers,
which are usually seen before the 30th week of
gestalion. This fiber type is infrequent in human muscle
Muscle Fiber Differentiation. (Banker, 1994). Tvpe IIA and 11 B fibers are
characterized by a high activity of myosin ATPase,
In the preceding section, we described the major ractors which results in relatively fast contraction.
that determine the total tension developed b.v the whole Type lIA (FOG) fibers are considered intermedi-ate
rnuscle when it COlllracts. Individual muscle fibers also between type 1 and type lIB because their fast contt-
display distinct differences in their rates of contraction, action time is combined with a moderately well-
development of tension. and susceptibility to fatigue. developed capacity for both aerobic (oxida-tive) and
anaerobic (glycolytic) activity. These
a~!~EiIJj;i,;~iS0ESH/'NICS Of TISSUES AND STRUCTURES Of THE MUSCULOSKELETAL SVSTEtvl
fiber's also have a well-developed blood supply. They can tractile and histochemical properties and the fast-twitch
maintain their contractile activity for rel-<Hively long fibers became slow.
periods; ho\vevcr, at high rates of ac-tivity. the high rate of The fiber composition of a given muscle de-pends on the
ATP splitting exceeds the ca-pacity of both oxidative function 01" that muscle. Some mus-cles perform
phosphorylation and glycolysis to supply ATP, and these predominantly one form of contrac-tile activity' and arc
fibers thus eventually fatigue. Because the myoglobin often composed mostly of one muscle fiber t}'pc.An
conlCIH 01" this muscle type is high, the muscle is oflen example is the soleus muscle in the calf, which prirnarily
cat-egorized as red III lIscl e. maintains posture and is composed of a high percentage of
type I fibers. More commonly', however, a muscle is
T:vpe liB (FG) libers rely primarily on glycolvtic reqllir'cd to perform endurance-type activity unde)' some
(anaerobic) activity for ATP production. Few capil-laries cirClllTlstances and high-intensity strength activity under
are found in the vicinity of these fibers and be-cause they others. These muscles generally contain a mixture of the
contain little myoglobin (hey are ohen referred to as white three muscle fiber types.
muscle. Although Lype liB fibers are able to producc ATP
rapidly, they fatigue easily because their high rate of ATP
splitting quickly de-pletes the glycogen needed for (n a typical mixed muscle exerting low tension, some of
glycolysis. These fibers generally are of large diameter and the small motor units, composed of type I fibers, contract.
are thus able to produce great tension, but only for short As the muscle force increases, more motor units are
pe-riods before they fatigue. recruited and their fre· quency of stimulation increases. As
the frequency becomes maximal. greater muscle force is
It has been well demonstrated that the nerve in- achieved by recruitment of larger motor units composed of
nervating the muscle fibcr determines its t.ypc (Burke el type 11;\ (FOG) fibers ancl eventually type lIB (FG) fibers.
aI., 1971); thus, the muscle fibers of each motor unit are of As the peak muscle force de-creases, the larger units are the
a single type. In humans and other species, electrical first to cease ac-tivity (Guyton. 1986; Luciano, Vander. &
stimulation was found to change the fiber type (Munsal, Sherman, 1978).
McNeal, & Waters, 1976). In animal studies, transecting
the nerves that inner-vate slow twitch and fast-twitch
8
muscle fibers and then crossing these nen;es was noted to It is generally, but not universally, accepted that fiber
reverse the fiber types. After recovery from the cross- types are genetically det~rmined (Costill ct aI., 1976;
innerva-tion, the slow-twitch fibers became fast in their Gollnick, 1982). In the average popula-tion,
con- approximatel.'Y' 50 to 55% of muscle fibers
CHAPTER 6 • BICIMI,C
brace. In this case, dynamic exercises can be per-formed. stood (Gollnick, 1982; Guyton, 1986). It appears that these
evcnts arc controlled or modified by both the intrafusal
Human muscle biopsy studies have shown that it is muscle spindles, located in par-allel with the extrafusal
mainly' the type I fibers that atrophy with im-mobilization; fibers of the muscle belly, and the Go!gi tendon organs,
their cross-sectional area decreases and their potential for located in series with
oxidative enzyme activity is reduced (Kannus et aI., 1998b).
Earl)' motion may' prevent this atrophy. It appears that if
the muscle is placed under tension when the body segment
moves, afferent (sensory) impulses from the intra-fusal
muscle spindles will increase, leading to in-creased Ruptured Left Anterior eruciate Ligament
stimulation of the type I fiber. Although in-termittent 25-year-old male, status postsurgical repair of the
isometric exercise may be sufficient to maintain the
metabolic capacity of the t.vpe II fibel~ the type I fiber (the
A - ruptured left anterior cruciale ligament, had torque
measurements taken from the involved and uninvolved
postural fiber) requires a more continuous impulse. limb 10 weeks after the surgical procedure (Fig. (56-2-1 A)
Evidence also suggests that electric stimulation may and repeated 6 weeks after the training began (Fig. (56-
prevent the de-crease in type I fiber size and the decline in 2-1 B). An increase of muscle torque is shown in the re-
its oxi-dative enzyme activity caused b:v immobilization peated isokinetic test. The initial deficit of the involved
(Eriksson et ai., 1981). side was approximately 63~o when compared with the
uninvolved side. After 6 '.Neeksof trainin~J. the deficit of
the involved side compared with tho uninvolved side de-
In elite athletes, inactivity following injury, surgery, or creased to 43%.
immobilization rapidly decreases the size and aerobic
capability of muscle fibers, partic-ularly in the fiber type 187, -------------- ,
affected bv the chosen sport. Tn endurance athletes, type I 163
fibers are af-fected, while in athletes engaged in an 140
E 116
explosive activity such as sprinting, type II fibers are af- <n
c 93 / -----
;:
fected. o 47
" 69
z 23
o J-~c_-----__:-~:-''''-'-----J
EFFECTS OF PHYSICAL TRAINING o 16 32 48 64 80 96 112 128
Knee motion degrees
Physical training increases the cross-sectional area of all
muscle fibers, accounting for the increase in muscle bulk A
and strength. Some evidence suggests that the relative 294
percentage of fiber types compos-ing a person's muscles 239
rna:v also change with phys-ical training (Arvidson, ~ 204
" " "-
c 192 .< /.
Eriksson, & Pitman, 1984). The cross-sectional area of the 0
;: 136
108
3 The myofibrils arc composed or thin filaments of the 12 The energy for muscle contraction and its re-lease is
protein actin and thick filaments of the pro- provided by the hydrolytic splitting of ATP. Muscle
tein myosin, and the intramyofibrillar cytoskeleton is fatigue occurs \\'!hen the ability of the mus-cle to
composed 01" the clastic filaments titin and the in-elastic synthesize ATP is insufficient to keep lip with the rate of
filarnents ncbulin. ATP breakdown during contrac-tion.
RelllI!JiUtarioll or the "ljlt/wl I\."m'c (pp. 210-234). SI. Louis: n Sec. 8160. -433.
Kannus. P., JOI.5", L.. K\·j:.;1. ,\1., Jarvinen, T" J;lnincll, M. (1998aL
C. V. Mosby.
EHeus of immobilizaLion and sllbseqm'nl low-and high. intensity
B;:lnkcr, B.O. (1994). Basic reaction of 1ll1lSt:!t:. In A.G. ErH!cl & C.
excrcise on morphology of I'~\t tall' mus-cles. Scal/t! J ,\Jed Sci Sports.
Franzini-Al'fllstrong (Eds.), Myology (2nd cel.). N~\\' )'ork: McGraw-
8(3), 160-171.
HilI. Inc.
Kant1us. P., Jozsa, L.. Jar\'int'n, T.L., K\'ist. 1\'1.. Vieno 1'. Jilrvinen,
Baratta R.V., Solornono\\',\1., Z!lOtl, S.H. (1998), Frequency
domain-based llwdds of skeletal llluscle. J ElcclroJllyogr ~\'t. (1998b). Fn:e mobilization ,11ld low- to h'i!..dl~ intensity
Kilu:siol, 8(1}, 79·91. exercise ill immobili/.ation-indllccd muscle at~·o- phy. J ..\ppl
P/I\'s;ol, 8-1(4), 1418-1424.
Billes. B.T.. Ostl,.'l'lling. L.R., James. S,L. (1977). Fati!!uc ef· feels in
Kassel', l.R. (1996). Celleral Knowledge. III J.R. Ka5sI..'r (Ed.)
running. ) MOlor Be/ull'. 9. 203-107. -
Onltop{lcdic Kllou·l....d~i! lIpt/tltf! 5: I-Ioml.' Sr/flh- S\'Ilalms.
Brobeck, J. R. (Ed.) (1979). Bes/ lIml Ttl.do,.:, Physiological Bt/· sis of
Illinois: American :\cad('my of Orthopaedic Su;·!!c(;ns. Kedc. C.r\ .•
:\let/iclIl Practice (10th cd., pp. 59-113). B~llimore:
Nl.'il. E., ..\: Jock N, (1982). \Iusch: a,;d Ihe ner-
\\'illinms &. Wilkins.
vous system. In StllJl:WI/ W,.ighl~ Applied Phrsiolo"\" (13th cd .. pp. 248-
Brooke. ;\'1.1-1. &. K~iscr, K.K. (1970). Thn:e lllyosin adenosine
259). Oxford: O.xford Unin.'l'siL\: Pres~~'
Iriphosphat~sl: systcms: The nature of t1~cir pH liability Komi, P. V. (1986). Tbl,.' slrl,.'tch-shorti.'nin~ t:v~le and human
and sulfhydryl depi.'nd"llce. J l-listodl/!JIl Cy/oclli:lll. 18, power OUlpUt. In N.L. JOllCS, N. McCan·!lt.'\·,~ A.J ..\k-
670.
Con~s (Eds.) I-ItlIIltlJl "'//SciI.' POII'a(PI'. 2'7-39). Cham· paign. IL: 1-
Blll;ht~lhJ. F & Sohl1li.\lburch, H. (1980). Motor unilS of Ill;llll-
lull1an Kin .... tics Publishers.
11l;llian Illusdt.'. Phniol Ret'. 60. 90.
r\.I'Oellll,.'l', I\..H.E., Marr:ls. \V.M., McGlothlin, J.D., et aL (1990). On
Burh-, R.E .. Levinc, D.N.. Z~lj~~C. F.E. (1971). M~lnlllwlinnmo· the IlH::ISUl'l..'lllent of hllm~\ll stf'I..'Il!.nh. III! J /11-elliS!
tor unils: Physiological hislochemic~ll corrckltion in Ihrce types of motor [;'/",!!,OIlOlllics, 6, 199-21 O. ~
units in cal gastrocllemius. Seicllct.', 17-1, 709. Kroll. P.G. (1987). The <fjfi:Cl oFpl"t.'l'iolls co!//rac/ioll cOIli!itioll
011 SU!lS(,({IIl'11I l..'cn'Jllric PO\\'('I" production iu dhol\' flexor
Cost ill, D.L.. Coyle, E.F., Fink. W.F., l.. eslllcs, G.R .. Wilzmann. EA.
IIIIISC!CS. Unpllbli~lwd doctoral dissertaLioll, New York
(1979). Adapt.uioll in skeletal llluscles following
University. Nt::\\· York.
strengLh Lraining. J .-Ippl Pln'siol, 46.96·9, ~ Craig. R. (199-4), The
Lkbcr, RL. &. Bodine·Fowler, S.c. (1993). Sh'Il,.,t~d 1ll1lSdc me-
structur~ of (he contract filaments. In
~hanics. ImpliGllions for n.'hahilit<ltion.l'h.l's Tho: 73(11),
A.~. ~ngd ,&. C. Fr<lnzini-Annstrong (Eds.), ,\(mlogy (2nd t.'cI.). New
844-856.
)ork: i\1cGraw·Hill, Inc
Linke, W.A .• In:·l1lcyl,.'l', ~L '\-llInde!. P., Stockm,·icl'. \LR .•
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R. O""..'n, J. Goodfellow, ~ fl. Bullollgh (Eds.) Sci· Kolml,.·rL'r, B. (1998). N~lturl,.· of PEVK-titill e1aslicil\' in skclet~ll
muscle. PJ'(l(: NIlt! '-\1.:lId Sci liS..\. 95(14),
~1!.lilie FOtllldaliOll.' or
Onltopacdics (lIId Tnl1lll/tllO!ogy (pp. 8052-8057.
0/-74). London: Willi.lm Heinemann.
Luciano, D.S., Vander, :\.1 .. .& Sherman, J.H. (1978). I-II/II/(III I-'Il.I/clio/1
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2. 71.
\'lul1s.al. TL. NcNl.'al. D.. & Wat(-rs. R. (1976). Effecls of lll,.'l"\,e
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stimulation on human must-Ie. :lrcll N<'lI.rol, 33, 608.
dectrie:ll slimulation on human skelt.-Ial musde.
Ohir~l. Y.. Y~\slli, w., Roy, R.R., Edgerlon, \f.R. (199;). Effccts of mllscl\:
1m Sports :lIed. 2, IS.
ll:ngLh on 1111: r('spons\: to unloadirH2. ..le!a Allat
Galler, S.. Hilbcr. K. (1998). Tension/stirrncl-is ratio of skinned rat
([Jasen. 159(2-3), 90-98. -
skelcLallllllsde fibn.' types at v:\l'iolls lCl11pCratllrt's. Ac/
Ottoson, D. (1983). I'hysio!o.!,:y of lhi' NO"l'IllIS 8"SI<,1II (pp.
Physio! Sctlml, 162(2), 119-126.
78-116), New York: Oxford Univcrsitv Press. . Parnianpou[", ~...I..
Gollnick, P.O. (1982). Ri..'lationship or strcngth and cndllr<lIlce with
Nordin, M .. Kahano\"iLz. N.. "'I al. (1988).
skeletal muscle structure and llll,.·tabolic potential. lilt
The triaxial collpling torque generation of trunk muscles
J Spons ,\1t:tI (SliP!'!]. 3, 26.
during isometric I..'xl,.'nioI1S and tlti.' l,.'fb.:1 of fati!!uin!! isoinerlial
Gordon, A.M., Huxley, A.F.!., &. Julian, FJ. (1966). The varia-tion in
mOH'ltIents on the molor output <lnd mOH~ment
isol1\l,.'tric 1i..'nsiOll with s;trC<llllt.'rt.' kngth in \'I:.'rte-bratc Illuscle
pallcrns. Spillt.', 13(9).
fibers. J Physiol, 18-1, 170.
Pate, E., Bhimani, i\l., Fnmks-Skib'l, K., Cook. R. (1995). Re-duced ('ffCCI
Guylon, A.C. (1986). Tex/book
Philndelphia: \V.B. Saunders. .
or ,\ledieal Pltysiolog\' (7th e(l.). of pH on skinned r~lhbit jlSO:lS muscle me· chanics at high
temperatures: Implications for f"ligue. J
Hnm,. A.W. &. Corm:lck, D.H. (I979). Nis{olo~y (Sth cd.). Phl1adclphia: J.B.
P!lysiol (Loud), -I86(Pt 3), 689-694. -
Lippincott.
Phillips, C.,x. &. Pctrofsky, 1.5. (1983) . .\lrchfUlics of Skeletal alltl
Hill, A. V. (1970). Firsl (//Ill L{lsi £'\"/1(:ri1l11:11/:; ;11 ,\fl/sell! ,lh'· e(mliut.' ,\fuse/e. Springfield; Charles C. Thon1<ls.
dUlllies. Cambridgl..': C;imbridgl: Uni\'cl"sitv Press.
S"ltin. B.• el al. (1977). Fiber types and I1K'tabolk polt.'nti~lls of skdelal
Hill, O.K. (1968), Tl.:nsion due 10 interaction bt.~lween lhe slid-ing
Illuscles in sedcntal"}' m;m and endurance run-n(;rs. :11111 NV ..lead
filal1lt.'nts of resting $lriatcd museit.-. Thl,.' dft.'cr of stimulatinn.
Sd, 301. 3.
Pltysio! (LOllll], /99,637.
Snndm<tnn, ~I.E.. Shoemanll. J.A .. Thompson. L. V, (1998). Th..:- T:lbrad~l, Y.,(wnll\oto, 1-1., Sugi. 1-1 .. Hir~ln(), Y.. Ishii, N. (1997).
fib1.'r·typ ... ·spccific effcct of inactivity and intcrmillellt Strctch-ilH.luccd l'nhanCCIllc.'Jll of m':"chanical work production in
wci2ht·henring on the !!aslroc!lcmius of 30'lllollth-old rats~ Arch long frog single fihers and hUIll<ln muscle. J
PI/\'~ ,lied UCllllb;/, 79(6), 658-662. App! Physio!, 83(5),1741-17-4$.
Squire. J.~1. (1997). Architecture and fUllction in thl.: muscl~ Wilkie. D.R. (J956). The mechanical propenies of llluscle. Br
s~lI·comcrl·. e/ln Opill Stl'llCI Bio!. 7(2). 247-257. .\It'd BIIII, /2, 177.
Strom~r, M.H. (1998). Thc cytoskelelon in skckt;-.l. c:lI'di:1C Wilkie, D.R. (1968) . .\lusc/c. london: Edward Arnold. Williams, P. &.
:lIId smooth muscl~ (dis. His/o! f/islOpa/llOl, / 3( I). Warwick. R. (1980). Gray:.; rlJlll/om." 06tl1 cd.,
283-291. pp. 506-5(5). Edinburgh: Churchill Livingstone.
i.:
• 810MEC):IANICS OF TISSUES AND STRUCTURES OF THE MUSCULOSKELETAL SySTEM
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*This flow chart is designed for classroom or group discussion. Flow chart is not meant to be exhaustive.
Biomechanics
of Joints
7
Biomechanics
of the Knee
Margareta Nordin, Victor H. Frankel
Introduction
Kinematics
Range of Motion
Surface Joint ~J1otion
Tibiofemoral Joint
Patellofemoral Joint
Kinetics
Statics of the Tibiofemoral Joint
Dynamics of the Tibiofemoral Joint
Stability of the Knee JOint
Function of the Patella
Statics and Dynamics of the Patellofemoral Joint
Summary
References
Introduction The knce is particularl...... \vell suited for demon-
strating biomechanical anal.vscs of joints because these
The knee transmits loads, part III pales in motion, aids in anal ....,scs can be simplified in the knee and still yield
conservation of momentum, and provides a force couple useful data. Although knee motion occurs si-multancous!y"
for activities involving the leg. The hu-man knee, the in three planes, thc motion in onc planc is so great that it
largest and perhaps 1110st complex joint in the bod)!, is a accounts for nearly all of thc motion. Also, although many
two-joint structure composed muscles producc forces on the knee, at any particular
'of the tibiofemoral joint and the patellofcmoral joint (Fig. instant one muscle group predominates, generating a force
7-1). The knee sustains high forces and moments and is so great that it accounts for most of the muscle force acting
situated between the body's two longest lever arms (the on the knee. Thus, basic biomedwnical analyscs can be
femur and the tibia), making it particularly' susceptible to limited to motion in one plane and to the force produced by a
injury. This d18ptcr uti-lizes the knee to introduce the basic single muscle group and still give an understanding of kncc
terms, explain the methods, and demonstrate the calculations mc)tion and an estimation of the magnitude of the principal
nec-essary for analyzing joint motion and the forces and forces and moments on the knee. Advanced bioIllcchanical
moments acting on a joint. This information is np· plied to d.\'namic anal,\'ses of thc knee joint that include all
other joints in subsequcnt chaptcrs.
Anterior cruclate
ligament
Medial
collateral
Popliteus ligament
tendon
Fibular
collateral Semimembranosus
ligament
Biceps
femoris
tendon Superficial
medial collateral
ligament (cut)
Iliotibial
Transverse
band (cut) ligament
Two-joint structure of the knee. A, Lateral view of a knee joint with open growth plates.
B, Anterior view without patella.
177
Cllilil~KT n • BIO~ECHANICS OF JOINTS
soft tissue structures are complex and still under in- Kinematics
vestigation.
Analysis or motion in any joint requires the lise of Kinematics defines thl..' range of motion and de-scribes the
kinematic daw. Kinematics is the branch of mc-crlanics sw-facc motion of a joint in three planes: frontal (coronal
thal deals with Illotion of a body without reference to force or longitudinal), sagittal, and trans-verse (horizonlal) (Fig. 7
or mass. Anal:vsis of the forces and momenl~ acting on a H 2, A & B). Clinical mea-surements of joint range 01"
joint necessitates the usc of both kinematic and kinetic motion define the anatomical position as a zero position for
data. Kinetics is the branch of mechanics that deals with mcasure-ment. This laxonomy will be uscd for joint motion
the motion of a body under the action of given forces throughout this book. Other taxonomies and reFcr-ence
and/or moments. systems exist (Ant!riacchi et aI., 1979; Groot! &
Proximal/
dislal
!j"~~;;:~i~1..k~~~i===::::=Fronlal
plane
•..,
I. -Sagittal
~ ~ plane
o ;,.j
Internal/external
k'.
)1
~
Varus!
valgus
A B
A, Frontal (coronal or longitudinal), sagittal. and transverse tion and proximal distal translation, flexion-extension rota-tion,
(horizontal) planes in the human body performed easily for both internal-external rotation, varus-valgus rotation. Adapted from
the tibiofemoral and the patellofemoral joint. B, Depic-tion and Wilson, S.A., Vigorita, V.J., & Scott, W.N.
nomenclature of the six degrees of freedom of knee motion: (1994). Anacomy. In N. Scott (Ed.), The Knee (p. 17). Philadelphia:
anterior posterior translation, medial/lateral transla- Mosby- Year Book.
Sun tal' 1983; Kroemer ct aL. 1990; bzkaya & Nordin,
1999), but the anatomical reference system bv far is the
mOSl commonlv lIsed among clinicians. O'r the two joints
composing the kne'; the tibio-femoral joint lends itself
particularly well to an analysis of range orjoinl motion.
Analysis of surface joint motion can be performed easily For
both the tibiofemoral and the P<'11cllofcmoral joint. An~' im-
pediment of range of motion or surface joint 'motion will
disturb the normal loading pattern of' a joint a.nd bear
consequences.
Percentage of Cycle
The range or motion of any joint can be measured in any
plane. Gross measurements can be made with a goniometer,
but more specific measurements re-quire the lise or more Range of motion of the tibiofemoral joint in the sagittal
precise methods such as elcc-lrogoniomelr~·. roenlgenogJ"aphy. plane during level walking in one gait cycle. The shaded dred
stcreopllologralll-metr)'. or photographic and video indicates variation among 60 subjects (age range 20 to 65
techniques using skeletal pins, years). Adapted {rom MtJ((a}~ M.P., Drought, A.B., Kor}~
R. C. (1964j. I/o/alking patterns of norma! men. J Bone Joint Surg,
In the tibiofcmoral jail'll. nlOtion takes place in all three 46A,335,
planes, but the range of motion is greatest by far in the
sagittal plane. Motion in this plane from full extcnsion to
Fulillexion of the knee is from 0' to approximately 140°.
Motion in the transverse plane. intel-nnl and ex-ternal in this joint during walking has been measured in all
rotation. is inOuenced by the position of the joint in the planes. The range of motion in the sagittal plane during
sagittal plane, With the knee in Full ex-tension. rOHHion is level walking was measured with an e1ectro-goniometer
almost completely restl'ictcd b~f the interlocking of the by Lamoreaux (1971) and MUlTay et al. (1964). Full or
femoral and tibial condyles. which occurs mainly because the nearly Full extension was noted at the beginning of the stance
medial femoral condyle is longer than the lateral condyle. The phase (0% of cycle) at heel strike, and at the end of the stance
range of rotation increases as the knee is flexed, reaching a phase before LOe-off (around 60% of cycle) (Fig, 7-3),
maximum at 90° of nexion; with the knee in this Maximum flex-ion (approximately 60°) was observed during
the middle of the swing phase (sec Chapter 18, Biome-chanics
:- position. external rotation ranges from 0° to ap- of Gait. For more detailed inFormation), These measurements
proximately 45° and internal rotation ranges from 0' to are velocit.y-c1ependent and must be interpreted with caution.
appmximatcly 3D'. Beyond 90' of Ilexion. the range of
internal and external rotation decreases, primarily because
~"lotion in the transverse plane during walking has been
the soft tissues restrict rOlation.
Motion in the frontal plane. abduction and ad-duction. measured by several investigators. Using a pho-lOgraphic
is similarly aFfected by the amount of joint flexion, Full technique involving the placement of skeletal pins through the
extension of the knee precludes almost all motion in the femur and tibia, Levens and associates (1948) Found that total
frontal plane. Passive abduction and adduction increase rotation of the tibia with respect to the fernur ranged from
with knee Oexion up to 30°. but each reaches a maximum approx-imately 4 to 13' in 12 subjects (mean 8,6'). Greate,-
of only a few degrees. rotation (mean 133') was noted by Kettclkamp and coworkers
With the knee flexed beyond 3D'. motion in the frontal (1970). who used electrogoniollletry on 22 subjects. In both
plane again c1ecre~lses because of the limit- studies, external rotation began during knee extension in the
ing function of the sol't tissues. stance phase and reached a peak value at the end of th~ swing
The range of tibiofernoral joint motion required For the phase just before heel strike. Internal rotation was noted
performance of various physical activities can be during Ilexion in the swing: phase.
determined from kinematic anal~lsis. MOlion
DDIII-~ callsc lhese mcthods ~lre highly technical and com-plex, a
simpler method evolved in the nineteenth ccnL'It'\, Is sLillus~d
Range of Tiblofemoral Joint Motion In the Sagittal (Reuleau,\, 1876), This m~,h()d, called the installt cl.?nter
Plane During Common Activities techniqul.', allows surface joinl 1l1Olion lO be analyzed in the
sagiual and froolal planes but not in the transverse plane. The
I Activity
Range of Motion
from Knee Extension
to Knee Flexion (Degrees)
instant center l~chniqLle pl{)vides a description of the rch'tive
uniplanar motion of two adjacent seg-ments or n body and
---------------- ,
Walking 0-67" the direction of displacement or the contact points bct\\'L~cn
""I
Climbing stairs
these segmcnts,
Descending stairs 0-90
The skeldal portion 01" a body segment is called a
Sitting down 0-93 link. As one link rotaLes ~il){H1l the other. al any in- ,
Tying a shoe 0-106 stum then.... is a point that docs nOl mov(:, that is, a
lifting an object 0-117 point thal has h'ro velocil.V. This point conslitllies
an instantaneous cenLer of motion, or instant cell-
';Dillillrom Kel1clkamp el al. (1970i. fvlean for 22 subjects. A slight tel: The instant center is found b.\' identirying the
ddiercncc was found bel'.'.'eenr19ht "nc! lei! knees (mean for right
knee 68.1°, nW,ln for left knee 66,r). displacen1cnt (If two points on a link as the link
"These and sub:.equerH date' from lauberllhal Cl al. (1972). Mean for moves from one position to another in relation to an
30 subjects. adjacl.?nt link, which is considered to he stalionary,
The points on thl.'moving link in its original posi-
tion and in its displaced position arc designated on
a graph and lines an.' drawn connecling the two sets
of points. The pCl-pcndicular bisectors or these two
Kcltclkamp's group (1970) also mcasurcd motion in the
frontal plane during walking. In nearly all of the 22 subjects, lines are then drawn. The intersection or the per-
maximal abduction of the tibia was observed during extension pendicular bisectors is thc instant ccntcl:
Clinir::'lll~', a path\\'a~' of the instant center for a
at heel slrike and at the beginning of the stance phase;
joint call be determined b\' takinQ- successive roenl-
maximal adduction occurred as the knee \Vas flexed during ~ ~
W(llking
Slow 0-6
SURFACE JOINT MOTION Free 6-12
SUrract~ joint motion. which is the Illation between the Fast 12-18
articulating surfaces of a joint. can be described 1'01' any joint Running 18-30
in any plane with the lise of stcrcopho-Logrammetric mcthods
Data itom Perry ct al. (1977). Range for seven subjects.
(Sclvik, 1978, 1983)~ Bc~
the instant center [() the contact point. A second line drawn simultaneously but is considerably less in the trans-verse
at right angles to this line indicates the di-reclion of and frontal planes. Surface motion in the
displacement of the contact points. The direction of patellofcmoraljoint takes place in two planes simul·
displacement of these points through-out the range of tancoLisly, the frontal and transverse, but is far greater in
motion describes the surface mo-tion in the joint. In most the frontal plane.
joints, the instant centers lie at a distance from the joint
surface, and the line indicating the direction of c1isplaccrncnt
o!" the con-wct points is tangential to the load-bearing Tibiofemoral Joint
surface, demonstrating thm one joint surFace is gliding on the
other (load-bcaring) surface. In the casc in which the instant An example will illustrate the lise of the instant cen-ter
center is found on the sudace. the joint has a rolling motion tcchniquc to describe the surface motion of the
and there is no gliding function. Because the instant center tibiofemoraljoint in the sagittal plane. To determine the
technique al-lows a description of motion in one plane only, it pathway of the instant center of this joint during flexion, a
is not useful for describing the surface joint motion if more lateral roentgenogram is taken of the knee in full extension
than I5° of motion takes place in any plane other than the one and successive films arc Laken at 10° intervals of increased
being rneasured. nexion. Care is taken to kcep the tibia parallel to the ,-ray table
and to pre-vent rotation about the femur. \Vhcn a patient has
limited knee motion, the knee is Ilc,ed or e'tendcd only as far
In the knee, surface joint motion occurs between the tibial as the patient can tolerate.
and fcmoral condyles and between the fcmoral condylcs and
the patella. In thc tibiofemoral joint, surface motion takes Two points on the femur that arc easily identi~ ned on all
place in all three planes roentgenograms are selecled and desig-
Locating the instant center. A, Two easily identifiable points on the femur are designated on a
roentgenogram of a knee flexed 80°. B. This roentgenogram is compared with a roentgenogram
of the knee flexed 90°, on which the same two points have been indi~ cated. The images of the
tibiae are superimposed, and lines are drawn connecting each set of points. The perpendicular
bisectors of these two lines are then drawn. The point at which these perpendicular bisectors
intersect is the instant center of the tibiofemoral joint . for the motion between 80 and 90° of
flexion. Courtesy of Ian Goldie, M.D. Univ~rsity of
Gothenburg, Gothenburg, Sweden.
natcd on each roentgenogram (Fig. 7.4..4). The films are
then compared in pairs, with the images of the tibiae supcl-
imposed on each othcl: Roentgenograms with marked
differences in tibial alignrncnt arc not used. Lines are
drawn between the points on thc felllur in the two
positions, and the perpendicular bisectors of these lines arc
then drawn. The point at which these perpendicular bi-
sectors intersect is the instant center or the tibiofemoral
joint for each 10° interval of motion (Fig. 7-4B). The
instant center pathway throughout the entire range or knee
Oexion and extension can then be ploued. In a normal
knee, the instant cen-ter pathway for the tibiofemoral joint
is semicircu-lar (Fig. 7-5).
I
D
1mIlI'------- _
A. In a normal knee, a line drawn from the instant center of I the tibiofemoral
joint to the tibiofemoral contact point
(line A) forms a right angle with a line tangential to the tib-ial
surface (line B). The arrow indicates the direction of dis-
placement of the contact points. Line B is tangential to the
tibial surface, indicating that the femur glides on the tibial
condyles during the measured interval of motion. B. Pure
sliding of the femur on the tibia with knee extension. Note that
the contact point of the tibia does not change as the femur
slides over it. Eventually impingement would occur if all
surface motion was restricted to sliding. Round points
delineate contact points at the femur and triangles delin-eate
Abnormal instant center pathway for a 35-year-old man with a
contact points at the tibia. C. Pure rolling of the femur on the
bucket-handle derangement. The instant center jumps at full
tibia with knee flexion. Note that both the tibia and the femoral
extension of the knee. Adapted from Frankel, VH., Burstein, A.H.,
contact points change as the femur rolls on the tibia. Also
&- Brooks, D.B. (1971). Biomechanics of in-ternal derangement of the
note that with moderate flexion, the femur will be~ gin to roll off
knee, Parhomechanics as determined by analysis of the instant
the tibia if surface motion was restricted to rol-ling. D, Actual
centers of motion. J Bone Joint Surg,
knee motion including both sliding and rolling.
53A, 945.
of knee flexion. The tibial rotation increased rapidly as the
knee flexion angle increased and reached a ma:dmunl of 31
0
at 30 0 of knee flexion.
IL then decreased again with additional flexion (Fig 7-10).
~-L'-JI Extension
The location of the longitudinal rota-tional axis was close
to the insenion of the ante-rior cruciate ligament (ACL) at
0° of flexion. At continuous flexion up to 60°, the
I'otational axis moved toward the insertion of the posterior
cru-ciale ligament. Belween 60 and 90° of flexion, the \'1
rotational axis moved anteriorly again (Fig 7-11). This '.,
study showcd thaI lhc rolational axis remains ... External
rotalion during
approximately in the area between the two cruciate extension
ligaments. Any change of direction and tension of the
cruciate ligaments and sur-rounding soft tissue may affect
the movement and the 'location of the longitudinal tibia axis
of rotation and thcrcby affccl joint load distri-bution. Screw·homemechanism of the tibiofemoral joint. During knee
extension. the tibia rotates externally. This motion is reversed
as the knee is flexed. A. Oblique view of the fe-mur and tibia.
The shaded area indicates the tibial plateau. solid line axis for
knee flexion and extension, dotted lines internal and external
A clinical tcst. the Helfet test, is often useel to de- rotation axis of the tibia during flex-ion and extension.
termine whether external rotation of the tibio- AcJapred from Helier. A.J. (1974j. Anatomy
and mechanics of movement of rite knee Joinr. In A. Heffer (EdJ.
Disorders of the Knee fpp. i -17). Philadelphia.- J B. LippincoH.
•
femoral joint takes place during knee eXlension, thereby
indicating whether the screw-home mecha-nism is illlact.
This clinical tcst is performed with the patient sitting with the
kn~e and hip flexed 90° ancl the leg hanging free. The medial
and lateral borders of the patella are marked on the skin. The
tibial tuberosity and the midline of the patella arc then
designated, and the alignment of the tibial tuberosity with
the patella is checked. In a normal knee Hexed 90°, the tibial
tuberosily aligns with the medial half or the patcll" (Fig. 7-
121\). The knee is then extended fully and the movement of
Distraction Compression the tibial tuberosity is obsel\:cd. [n a normal knee. the tibial
A B tuberosity moves laterally during extension and "Iigns with
the latent! h"lf or the patella at I'ull ex-tension (Fig. 7-128).
RotatOl')'motion in a nOl'mal knee may be as great as hair
Surface motion in two tibiofemoral joints with displaced instant
the width or the patella. In a deranged knee, the tibia may
centers. In both joints, the arrowed line at right an· gles to the not rotate externally during extension. Because of the altered
line between the instant center and the tibiofemoral contact surface motion in such a knee, the tibiofemoral joint will be
point indicates the direction of dis-placement of the contact abnormally compressed if the knee is forced into extension,
points. A. The small arrow indi-cates that with further fIeldon. and the joint surfaces may be d.amaged.
the tibiofemoral joint will be distracted. B, With increased
flexion, this joint will be compressed.
CHAPTER 7 • 8IC'ME:crlA~IIC5
Helfet test. A, In a normal knee flexed 90°, the tibial tuberosity aligns with the medial half of the
patella. B, When the knee is fUlly extended. the tibial tuberosity aligns with the lat· eral half of
the patella .
•
Superior
Lateral Medial
Lateral Medial
,~. - - - -30'-90"
I
(U '\ I
Inferior
20' 45' 90'
Lateral Medial
I
Inferior
135'
IA B
iR'm _
A, The position of the patella at different ranges of knee flexion Functional anatomy of the patellofemaral joint. J 80ne Joint Surg,
motion. a, Contact areas during different degrees of flexion. Beyond 58B. 287; and from Helme. H.I (1990). Biomechanics of the
900 of flexion, the patella rotates slightly outwards. Adapted from parellofemoral joint and its clinical relevance. Clin Onhop. 258.
GoodfelJo'J'l, I. Hvngerford, D.5., & lin· 73-85,
rotates around an axis perpendicular to the plane of the In this and subsequent chapters. the discussion of
fOl'ces producing the moments. Kinetic analysis allows stalics and dynamics of the joints of the skelelal sys-tem
one to determine the magnitude of the moments and concerns the magnitude of the forces and mo-ments acting
forces on a joint produced by body weight, muscle action, to move a joint about an axis or to maintain its position. It
soft tissue resistance, and externally applied loads in any does not lake into account Ihe deforming effect of Ihese
situation, ei-ther static or dynamic, and to identify those forces and moments
situ-ations that produce excessively high moments or on the joint structures. This effect is indeed present, but
forces. the discussion is not within the s~opeof this text.
STATICS OF THE TIBIOFEMORAL JOINT distinct from the rest of the bod.". <'lIlt! a diagram of this free-
bod." in tilt..' stair-climbing situation is drawn (Calculation
Static analysis may be lIsed to determine the forces and Bo,,,; 7-1). I":'nlrn all rorces acting on thl..: I"rct..··body. the
moments acling on a joint when no motion takes place or at three main coplanal- I"o('(,:(:s an; idenlified a~ the ground
one instant in time during a dy-namic activity such n5 rL'action force (equal to body weight I), the tensile force
walking, running, or lifting an objecl. 1t can be performed for through the patellar tcndon exel"ted h.v llw quadriceps
any joint in any position and under any loading configuration. Illust..:ll' , and th\.~ joint reaction force on the tibial plateau.
In such analyses, eHher graphic or mathematical methods may The ground n.:action force (\rV) has a known m<'lgnitude
be lIsed to solve for the unknown forces or moments. (L'qu;;llto body wt..'iglu). S~IlS('. line or <'lpplicalion. and
poinl or application (poii'll or contact between the foot and
the ground). The palellnr tendol1 force (P) has a known
A complete static analysis involving all moments and all SC'IlSL' (awa.'; from the knee joint), lint..' of ap· plicaliun
forces imposed on a joint in three dimensions is complicated. (along lhe patellar t('ndon). and point or
application (point or
For this reason. a simplified tech-nique is oflen lIsed. The
insertion of thc patellar tendoll on till'tibial tulx.·rosit."), but an
technique utilizes a frec-body diagrarn and limits the analysis unknown l1lagni~ tude. The joint n:action force (J) has a known
lo one plane, to the three main coplanar forces acting on the poilU of application OJl the slIrl"acL' or the tibia (the COJ1lact
frcc-body. and ro the main moments ~cting about the joint point of tilL' joint surfaces betw(.'en the tibial and femora!
under consideration. The minimum magni-tudes of the forces cond,vlc:s, estimated from a roelllgenogram or the joint in the
and moments arc obtained. pn)!x~r loading configuration), but an unknown magnitude,
sense. and line of applica-tion. Using \'L'ctors cakuh\lions
When the simplified Free-body technique is used to <:\11('\ triangles laws the joint rL'action force (.1) and thl'
analyze coplanar forces, one portion of the body is considered pall.'lIar tendon force (P) call be c,dculated (Calcul"tion Bo\ 7-
as distinct rrom the entire bod.\', and all forces acting on this 1)
free-body arc identified. A diagram is drawn of the free-body
in the loading sit-uation (0 be analyzed. The three principal
coplanar forces acting on the free-body are identified and It call bt..· seen thaI the main musck forct..' has a llluch
designaLcd on the free-body diagram. gre<.ltL'1' inlhICIll:L' on the magnitude of" the
~
!
, Free-Body Diagram of the Knee Joint
Force P ..~, The three main coplanar forces acting on the lower leg: Ground
... Force J
I \.\ .<
,.. ;':" Known: Point of applicalion
reaction iorce (W). patellar tendon force (P), and joint reaction force
(J) afe designaled on a free-body diagram of the lower leg while
Known: \Q', UnknO'.·',n:Magnitude
Sense climbing stairs (Calculation Box Fig 7-1·1),
Sense •~ \ Line of application
Line of application \\
Point of application .,•..,-..__ ....\
Unknown: Magnitude ". -'.\.
<\.
', \-".-\
I '.
I :i~ /\J
· ~-
o:__ ~~ /'
I
---==~-r"'iKnown:
Magnilude
Force W Sense
Line of application
!Point of application
.'Force J Because the 100\'crleg is in equilibriulll, the lines of application for all
" v~ .:.~ three forces intersect at one point. Because the linesof application for
"'i l~~:\Tibialemoral [I,.VO forces (Wand P) are known, the line of ap· plication for the third
Force P \( \ ..... i ... contact point force (;) can be determined. The lines of application for forces Wand
\~, \.'. P are extended until they jnter~ sect. The line or application for J Gill
, '.
. then be drawn from its point of application on the tibial surface
\\........ ,
'. \ through the intersec· tion point (Calculation Box Fig. 7-1-2).
\:;.... \
Intersection ~\ pOint~
-----·-·-~·=::::·:"~~W-1J.-·'""'---~----
I
_ .
'
......... J Force W
P and J, respectively. In this case, force P is 3.2 times body weight,
and force J is 4.1 times body weight.
{,
Free-Body Diagram of the Lower Leg During Stair Climbing
The two main mornents acting around tt1e center of motion of the
tibioiemoral JOlfH (solid dOl) are designated on the free· body
diagram of the lower leg during stair climbing (Calcula· tion Box Fig.
( 7-2-1).
b
W>:a=Pxb
!Again the welghl of the lower leg IS disregarded because it is
p=W xa lESS ,han Oile \Cntil of body vveight
b
DYNAMICS OF THE TIBIOFEMORAL JOINT analysis must be taken into account: the accelera-tion of the
body part under consideration and the mass moment of
Although estimations of the magnitude of the forces and inertia of the body part. (The mass moment of inertia is the
moments imposed on a joint in static situations are llseful. unit used to express the amount of torque needed to
most of Ollr activities are of a dynamic nature. Analysis of accelerate a body and depends on the shape of the body.)
the forces and mo-ments acting on a joint during motion (For more in-depth studies of dynamics, sec Ozkaya &
requires the use of a different technique for solving dynam,ic Nordin, 1999.)
problems.
The steps for calculating the minimum magni-tudes of
As in static analysis, the main forces considered in the forces acting on a joint at a particular in-stant in time
dynamic analysis arc those produced by body weight, during a dynamic aClivity arc as follows:
muscles, other soft tissues, and externally applied loads.
Friction forces arc negligible in a nor-mal joint and thus not I. The anatomical structures arc identified: defi-nitions of
considered here. In dynamic analysis. two factors in addition structures. anatomical landmarks, point of contact of
to those in static articular surface. and lever
4\rl11s involved in the production of forces for Th..: torque is not only a product or the mass mo-ment
the biol11cchanical analyses. of inertia and the angular acceleration of the body part
2. The angular acceleration or the moving body part but also a product or the main Illuscle force accelerating
is determined. the body part and the perpendic-ular distance of the
3. The mass monlent of inenia of the moving force from the center of motion of the joint (level' arm).
bod~" part is determined. Thus.
4. The torque (moment) acting abollt the joint is
T = Fe!
calculated.
5. The magnitude of the main muscle force ac-
where
celerating the body pan is calculated.
6. The magnitude of the joint reaction force at a F is the force expressed in newtons (N)
particular instant in time is calculated by sta-tic d is the perpendicular distance expressed in me~ leI'S
analysis. (01).
' ....
•
extension moments during the stance phnse are ap-
proximately 20 to 30 tilTICS larger than the moment produced
in the frontal (abduction-adduction) and transverse (intcrnal-
extcl-nal) planes.
An increase in knee joint flexion-extension mo-ment A_ Flexion-Exlension
amplitude has been reported at increased walking speeds Moment Pallerns
(Exlernal)
(Andriacchi & Strickland. 1985; Holden et aL. 1997). An
increase in the production of adduction knee joint moment It Pattern 1
during stair climb-ing compared with level walking was 3.0 I
reported b.\' Yu et al. (1997). ¥ ac 2.0 I
>~ 'x I
ID
;!: u:: 1.0
During the gait cycle, the joint reaction force shifts from "'
rL
0
the medial to the lateral tibial plateau. In the stance phase, .s c
1.0
I
a
when the force I'caches its peak value, it is sustained mainly ,
0
c
'00 I
2.0 I
by the medial plateau '"c
ID
wX'" I
in vitro the load-compressive transmission of the knee joint ;!: ;;; 0.5
OJ E
and the role of menbci and articular cartilage. The load l,
simulated was stalic and d).'namic impact load-ing. The c ;;; I
'0 c
testing was done in neutral. varus, and val-gus alignment of , ;;; 0.5 I
ID x
the knee joints in 40 fresh-frozen pig knee speclmens. The '"
c
w I
compressive stress on the medial subchondral bone was lip to 1.0 ..- Stance - .. I'-Swing-"
five times higher with the menisci removed. This study points '"
to the importance of the menisci as a structure to absorb load
and protect the canilage and subchon-dral bone under dynamic
Flexion-extension (A), abduction-adduction (8), and internal-
conditions.
external rotation (C) moments produced during one gait cycle
in normal subjects. The moments are nor· malized to each
individual body weight X height and ex-pressed as a
percentage. Reprinted with permission from Andriacch( IP. &.
In a normal human knee, stresses are distributed over a Strickland. A.B. (1985). Gaie analysis as a tool to assess joint
wide area of lhe tibial plateau. If the menisci are removed. lhe kinetics. In N. Berme, A.E. Etlgin. O.A. Correis,
stresses are no longer disll"ibutcd Over such a wide area but et al. (Eds.). Biomech(lnics of Normal and Pathological Human
instead arc limited to a contact area in the Center of lhe Articulating Joints. (NATO ASI series. Va/93. 'pp. 83-I02)'
plaleau (Fig. 7-17). Thus, removal of' the menisci not only Orodrechr. Netherlands: Marr;nus Nijhoff.
increases the
Force Force thought to carry lip to 70<}(; of the load across the knee.
II I • ...
III
\\\
\
• ...
,Vlovcmcnt during knee Ilcxion of the menisci would
therefore protect the articulating surfaces while avoiding
l \\ III tIl
I
~tttt
injury to it.
Vedi et al. (1999) studied menisci movement in 16
young football players with normal knees with MRI. The knee
flexion movement was scanned from full knee extension lo
Normal Menisci removed
90° of knee flexion. The imag· ing technique allowed for both
standing (weight-bearing) and sitting (non-weight-bearing)
and was performed simultancollsl~tin the sagittal and trans-verse
Stress distribution in a normal knee and in a knee with the plane. Figure 7-18 shows the movements in the transverse
menisci removed, Removal of the menisci increases the plane of the medial and lateral meni-sci expressed in
magnitude of stresses on the cartilage of the tibial plateau and millimeters (mean) from full exten-sion to 90° Ocxion of knee
changes the size and location of the tibiofemoral con· tact area. joint motion. Movement was significantly greater in weight-
With the menisci intact, the contact area encom-passes nearly the bearing than in non-\Veigllt~bearing for both lateral and medial
entire surface of the tibial plateau. With the menisci removed, the
menisci. The contributions of the menisci art: lhel-e-fore not
contact area is limited to the center of the tibial plateau.
only to protect the articular cartilage and subchondral bone but
also to contribute aClively to
"-
, ,
I f \
Flexion i
I
3.3r 1
, 3 .4
3.6 N \
\
-J_- ,
\
\ , . I
90
\
, , 3.9
-L_-
5.6
"-
3.8 ,
-~-
4.0 -- I
I
•
"-. , ,/
-4-
Post Post
Medial Lateral Medial Lateral
menisci menisci menisci menisci
A B
Simplified diagrams showing the mean movements of the with permission (rom Vedl, V. WiJjiams. A., Tennant. S.J.. el aJ.
medial and lateral menisci from full knee extension to 90° (1999). Menisca! movemenr. An In-vivo srudy u~in9 dynamic MRI. J
knee flexion during two conditions. A. Erect and weight~ Bone Join! Swg, 818(1), 37-41.
bearing. B. Sitting, relaxed. and bearing no weight. Adapted
.ACL Injury injuries. meniscal injuries. and possible cartilage degenera· lion.
i. A
J;_
30·year-oldmale suffered an external rotation trauma
in his right knee while downhill skiing. Following the
In this case. the patient firs! completed a course of conservative
treatment with physical therapy. After 6 months. the subjective
inS(clbilily was present during SPOrts and daily activities such
~~;,: trauma, he experienced sharp pain, progressive joint effu-
as gail and stair climbing. To com· pensate for the ACL
,~,iqn,_and subjective instability. ,During careful examination Ii'
deficiency, the patient altered his gait patterns, presenting
,by a specialist, an anterior positive drawer test was dlag-
quadriceps avoidance gait to prevent the anterior translation of
<";'n,osed,and the Lachman test and pivot shift test were
tl1e tibia when the quadriceps contracts at the midstance phase
': found positive. An MRI confirmed the ACL rupture (Case j'
of the gait (Andriacchi &
Si~dy Fig 7-1-1)
Birac, 1993: Berchuck et aI., 1990).
-,. The rupture of the primary stabilizer of the knee joint (ACl) leads to
The patient went for surgical treatment. The MRI below
a progressive structural alteration of the knee. A pri-mary objective of
(Case Study Fig. 7-1-2) shows the ACL status after patella
the treatment is the prevention of fe-injury of the knee in the hope of
bone-tendon-bone autograft was performed 10 months post-
preventing additional ligamentous
trauma.
of these structures arc malfunctioning or disturbed, knee approximately 55% of the applied load at full exten-
joint instability will occur. The ligaments arc t.he sion. The role of the lateral collateral ligament in-creases
primm)' stabilizer for anterior ancl posterior translation, with joint flexion as the posterior structures become lax.
varus and valgus angulation, and inter-nal and external The 1l1edial collateral ligament (superfl-cial portion) is
rotation of the knee joint (Case Study 7-1), the primary restraint to valgus (ad-duction) angulation
and resists 500/0 or the external valgus load. The
F,;
et aL (1994) sUlllmarized the functions of the knee capsule. the anterior and posterior cruciatc ligaments,
ligaments, The ACL is the predolllinant re-straint to share the remaining valgus load. Internal rotational
anterior tibial displacement. The ligament accepts 75% or laxity seen in the 20 to 40° range of knee nexion is
the anterior force at full extension and an additional 10% restrained bv the medial collateral ligament and the ACL
(up to 90") of knee nexion, The posterior crudate ligament Finally, external rotation lax-ity seen in the 30 to 40°
1S the primary re-straint to posterior tibial translation: il range of knee flexion is re· strained by the posterior
slIstains 85 to 100% of the posterior force at both 30 and cruciate ligaJllcnt at 90° of knee Ilexion,
90" of knee flexion. The latera) collateral ligament is the
primary restraint to varus angulation and it resists In vivo measurement or the normal ACL has been
performed by Beynnon et aL (1992), They placed a
."1'~~:irkRf:ti'810MECHANICS OF JOINTS
strain transducer arthroscopic'll)y in the ACL. The results tendon and it contributes the least to the length of the
showed that strain in the ACL was related to knee Oexion quadriceps muscle force lever arm (approxi. mately 10% of
(with the most strain occurring ncar full extension) and the total length). As the knee is ex-tended. the patella rises
increased with quadriceps con-traction. Less strain occurred from the intercondylar groove, producing significant
with co~conlraclions of both the quadriceps and the hamstring anterior displacement of thc tcndon. Thc length of thc
muscle groups and at greater degrees of knee flexion. This quadriccps force lever arm rapidly increases with extension
indicates that muscle contraction and co-contraction up to 45°, at which point the patella lengthens lhe lever ann
contribute to the stabilitv of the knee joint bv in-crcasing by approximately 300/0.
thc stiffncss of the joint. Kwak et al. (2000) studied in vitro
the effect of hamstrings and iliotib-ial band forces on the With knee extension bc"ond 45°, thc Icngth of thc lever
kinematics of the knee. At var-ious knee Oexion angles, arm is diminished slightly. \,Vith this decrease in its lever
human knee specimens were tested with different muscle- arlll, the quadric.:cps muscle force must increase for the
loading patterns. The quadriceps muscle force was always torquc about the knee to rcrnain the same. In an in vitro
present, and the test was performed with and withollt han)- study of normal knees. Licb and Perry (1968) showcd that
string muscle force and with and without iliotibial band thc quadriccps muselc force required to extend the knee (he
force. \AJith loading of simultaneous quach·i. eeps and last 15° in-creased by approximately 60% (Fig. 7-19).
hamstring muscle force. the tibia trans-latcd posteriorly and
rotatcd externally. The effecI If thc patella is removed from a knec, the I)atelhu-
tendon lies closer to the center of motion of the
tibiofemoral joint (Fig. 7·20). Acting with a shorter lever
""" similar for thc iliotibial band simulated forces but thc arm, the quadriceps llluscle must produce even more force
cffcct was smallcr. than is normnlly required for a cer~ tain torque about the
Many in vitro studies suggest that the ham-strings are knee to be maintained during
important anterior and rotational stab.i-lizers of the tibia. In
vivo studies have shown that co-contractions of the
quadriceps and hamstring muscles arc highly present in
75
normal knee joints and dail.'", activities (Baratta et a1.,
1988; Solomonow & D'Ambrosia, 1994). Thc co-
contraction mcchanisms also increase the knee joint
stability in vivo (Aagaard ct al .. 2000; Markholf et al ..
1978; Solomonow & D'Ambrosia, 1994). Howevel~ the
complex mecha-nism in vivo of muscle activity as a knee
stabilizer, the extent of protection, and the biomechanical
and clinical imparlance needs futther research (Grabiner &
Wcikcl', 1993).
3000
1 ...... Palellofemoral joinl
reaction force
the last 45° of eXlen~ion. Full active extension of such a --- Quadriceps muscle force
knee may require as much as 30% more quach'iceps
force than is normally required (Kaufer. 1971). This 2000J
increase in force may be beyond the ca-pacity of the
quadriceps muscle in some patients, particularly those
:s
!! "
who have intra~articular disease or are advanced in age. 0
"-
1000
In the patellofemoral joint. the quadriceps mus-cle Patellofemoral joint reaction force and quadriceps muscle force
force increases with knee Oexion. During re~ (axed during knee bend to 90° (three subjects). Adapted from Reilly, D.
upright standing, minimal quadriceps muscle forces are T. g. Martens, M. (1972). Experim.ental analysis of
required to counterbalance the small nexion l1lornents the quadriceps muscle force and patello/emaral joint reaction
about the patcllofemoral joint be-cause the center or force for various activities. Acta Orthop Scand. 43. 126
o
,,/
p //
,,'"
P------------/
1000 N J ~ 601.409
J2 '" Q2 .... p2 _~ 2PQ. cos 35~
Tibio femoral flexion 5"
J = )361695
J ~ 601.41
o
1000 N I
!---J--""-'r: 80" I
I
I
I
p I
I
I
I
I
10;0 N ---------j·::-;285_61
Summarv
1 The knee is a two-joint structure that is com-posed of
the tibiofel11oral joint and the patel1o-femoral joint.
points is tangential to the surface of the tibia, indi eating w Dra!!,\nich. L.D .. Andriacchi, T.P.. & Andersson, G.B.J. (19871.
gliding throughollt the range o[ motion. I~nlcraction betwccn intrinsic knec mechanism and tlH~
knee extensor mech'lllislll. ) OnhoJ} Res. 5, 539-547. Drillis, R.,
The scrc\v-homc mechanism of the tibio-femoral joint Conlini. R., & Bluestein, \1. (1964). Bod~' seglllellt
adds stability to the joint in full exten-sion. Additional passive par'lmc[(·rs. A stln'ey of 1l1l..'<lStll"elllent tec!miqut.'s. ill"/i{
stability' to the knee is given by the ligamentous structure and Lil/lbs, 8. 44.
menisci and the dynamic stability by'the muscles around the Frankel. V.H. & Burstl'in, A.I-I. (19701. OnJlOptldic Biol/l e-cfUlllics.
Philadelphia: 1.t.'a &- Fcbigcr.
knee. Fr'Hlkel, V.H., Burstein, A.H., l\c Brooks, D.B. (1971). Biome-
chanics of internal dl'rangeTw:nt of Lht.' knee. PatholTll'-chanics
S The tibiofemoral and patellofemoral joints are
as dl'tcrmincd b.v an~d~'sis of the instant ccnters or motion. J
subjected to great forces. Muscle forces have the greatest BOlle Joillt SlIrg. 53..\, 945.
influence on the magnitude of the joint rc action force, w
Fu, ElL Harner, CD., Johnsoll, D,I.., ct <11. (1994). Biome-chanics
which can reach several times body weight in both joints. of the kncl' ligamenLs: Basic concl'pts and clinica! application. II/Sfr
Tn the patcllofcmoral joint, knee flexion also affects the COllrsi' Lt.'ell/re, -t3, 137-148.
joint reaction force, with greater knee flexion resulting in a Fukuda, 'I{., Takai. 5., Yoshino, N., et al. (2000). Impact load
higher joint reaction force. Lransmission of the kncc joint~infltlenceof leg alignment and the role
01" IllL'niscus and articular carlilage. Clillical Bioll/L'ch, 15, SI6-
S2l.
Although the tibial plateaus arc the main load- Gardner. T.R .. Ateshian, G.A .. Grclsarner, R.P., et al. (1994). A 6
bearing structures in the knee, the cartilage. DOF knec testing de\'ice to d~termine patellar tracking and
menisci, and ligaments also bear loads. The menisci aid in patellofellloral joint contact area \'ia stereopho-lOQramrnl'trv. :Idl'
distribt~ting the stresses and reducing the Bio('II'.,; :IS.\1E BED. 28, 279-280
Gr)(ldl"dlow, .I.', llungcrl"o'rd, D.S., & Zindd, \1. (1976).
load imposed on the tibial plateaus. Patl'llofenloral joillt llH.'chanics and paLhology. I. FUllC-tional
The patella aids knee extension by lengthening the ,uwtorn.v of the patellofL'lllO!';t1 joint. J Bonc Joinl Surg. 5813,
287.
lever arm of the quadriceps muscle force throughout the
Grabine!', .\-I.D. & Weiker, G.G. (1993). :\ntl.'rior cruciate liga-ment
entire range of motion and allows a wider distribution of injury and hamstring CO-<lcli\'ation. elillical Bin-IIlt'ch, 8. 216-
compressive stress on the femur. 119.
Grood, E.S. l\: Suntav. \V.J. (1983). A coordinate svstelll for clinical
descriptio;l of three dimensional motion~ Applica-tion to the
knee. J Biollll!ch Ellg. 105, 136-144.
He!llIL', 1-1.1. (1990). Biomechanics of lhc patellol"emor.d joint and
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CHAPTER 7 • BIOMECHANICS OF.T~V~Nrg511it~gl{.
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1535. Pro" SP/E (36/) (pp. li8-18S).
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ll'::l'nS of l1orl11:d men. 1 130111..' Joillt S!l!·.~, -I6A, 335. Fchig('l'.
N. & Nordin. rio'\. (1999). FlIlId(/I!U'IIUJ!S oj' 13iOlllt'- Wilson. S.A., Vigorila, V.J., &. SCf.HL. WN. (1994). Anatomy. In
Eqllilihl'illlll, JIOlio/l, (/lId lJeji>rlllatioll (2nd cd.). N. SCOIt (Ed.), The Kllee (po 17). Philadelphia: ~'Iosby.
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~crr.v, 1.. Norwood, L., & House. K. (1977). Klll'C po.o;tUl'\.' ,llld
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(an EMG study). hailS Ortlwl) UL'S S(lC 2, 258. Yu, B., Stuart, 1\-1.1 .• Kicnb;ll'chcr, T., et .d. (1997). Valgus-\·'II·US
Ramsi..'y, O.K. & Wn.'tl'llhcrg, P.E (1999). Biolllcchallit,:-; of tht:' kn~c: motion of the knee ill norm.1I lc"d w;dking [lnd stair climbing.
Melhodological consid('r;ltions in Ihl' in \'i\'o kinl'-matic an:dysis (~f Clillical Biolllcch, 12(5), 2S6-293.
II\(' tibiofl'moral and patellofclIlor;d joint. RC\'i(:w pnp('r. Clillical Zcrnickc, R.E, G;lrhammer. J., & Jobe. FW. (1977). Human pntdlar
Biomecll. 1-1, 595-611. Icndon rupture. 1 801lt' loillt S1Irg, 59;\, 179-183.
Biomechanics
of the Hip
Margareta Nordin, Victor H. Frankel
Introduction
Anatomical Considerations
The Acetabulum
The Femoral Head
The Femoral Neck
Kinematics
Range of Motion
, /f
Surface Joint Motion
Kinetics
Statics
Dynamics
Effect of External Support on Hip JOll1l Reaction Force
Summary
References
Ie
Introduction
The hip joint is one of the largest and most SLable joints in
the body. In contrast to the knee, the hip joint has intrinsic
stability provided by its relatively rigid bali-unci-socket
configuration. (t also has a great deal or mobility, which
allows normallocomo-lion in the performance of daily
activities. Derange-ments of the hip Can produce altered
stress distri-butions in the joint cartilage and bone, leading
to degenerative arlhritis. Such damage is further po~
tcntiated by the large forces borne by the joint.
Anatomical Considerations
The hip joint is composed of the head of the femur and the
acetabulum of the pelvis (Fig. 8-1). This ar-ticulation has a
loose joint capsule and is sur-rounded by large. strong
muscles. The construction of this stable joint allows for the
wide range of 1110-tion required for normal daily activities
such as walking, sitting, and squatting. Such a joint must
be precisely' aligned and controlled,
THE ACETABULUM
The acetabulum is the concave component of the ball-and-
socket configuration of the hip joint. The acetabular
surface is covered with articular carti-lage that thickens
peripherally (Kempson et aI., 1971) and predominantly
laterally (Rushfeld et aI., 1979). The cavity of the
acetabulum faces obliquely forward, olitwarcL and
downward. The osseous ac-etabululll in the hip is deep and
provides substantial static stability to the hip. A plane
through the cir-cumference of the acetabulum at its The hip joint (front view) 1. External iliac artery. 2. Psoas
opening would intersect with the sagittal plane at an angle major muscle. 3. Iliacus muscle. 4. Iliac crest. S. Gluteus
of 40~ opening posteriorly and with the transverse plane at medius muscle. 6. Gluteus minimus muscle. 7. Greater
an angle of 60~ opening laterally. The acetabular cavity is trochanter. 8. Vastus lateralis muscle. 9. Shaft of femur. 10.
deepened by the labrum, a flat rim of fibro~ cartilage, and Vastus medialis muscle. 11. Profunda femoris vessels.
12. Adductor longus muscle. 13. Pectineus muscle. 14. Medial
the transverse acetabular ligament (Fig. 8-2). The labrum
circumflex femoral vessels. 15. Capsule of the hip joint.
contains free nenle endings and sensory end organs in its
16. Neck of femur. 17. Zona orbicularis of capsule.
superficial layer, which may participate in nociceptive and
18. Head of femur. 19. Acetabular labrum. 20. Rim of ac-
proprio-ceptive mechanisms (Kim & Azuma, 1995). etabulum. Reprinted with permission (rom McMinn, R.H. &
Huchings. R.H.R. (988). Color Atlas of Human Anatomy (2nd ed.,
p. 302). Chicago: Year Book Medical Publishers, Inc.
The unloaded acetabulum has a smaller diameter than
the femoral head (Greenwald & Haynes, 1972) (Fig. 8-3).
The acetabulum deforms about the femoral head when the
hip joint is loaded. It under-goes elastic deformation to
become congruous
with the femoral head, and contact is made abollt the
periphery of the anterior, sllperi()l~ and posterior
203
arLicular surface of the acetabulum (Konrath et al.. 1998). Superior
Load distribution of the acetabulum was studied in vitro in
human specimens (Greenwald & I-(aynes, 1972; Konrath et
'II.,1998). Joint reaction forces were simulated to
physiological levels. The loading pattern of the acetabulum
is shown in Fig-ure 8-3. Removal of the transverse Anterior
acetabular liga-ment and labrum sequentially did not affect
the loading pattern of the acetabulum significantly
(Konrath et 'II.,1998).
Intact
THE FEMORAL HEAD
The femoral head is the convex component of the ball-and-
socket configuration of the hip joint and forms two-thirds of loading pattern of a human acetabulum in vitro with in-tact
a sphere. The articular carti-lage covering the femoral head labrum and transverse acetabular ligament. Note: This
is thickest on the medi,al-central surface and thinnest toward pattern was grossly unchanged after removal of the trans-
the pe-riphery. The variations in the cartilage thickness verse acetabular ligament. or the labrum, or both, and
therefore those patterns are not displayed. Adapled from
result in a different strength and stiffness in vari-ous regions
Konrath. GA.. Hamel. A.I.. Olson. S.A.. et elf. {l998). The role of
of the femoral head (Kempson et 'II.,
the acetabular labrum and the trdnSverse clCeiabtJ/dr ligamefl! in
load transmission of tilt, hlp. J Bone Joint Surg. 80/'.,(12),
.I 1781-1788
--- .
---------- @
RANGE OF MOTION
Hip motion takes place in all three planes: sagittal
The radiograph illustrates a right femoral in-
(flexion-extension), frontal (abduction-adduction), and
tertrochanteric unstable fracture with separation of the
transverse (internal-external rotation) (Fig. 8·7). Motion
lesser trochanter. The image shovvs osteoporOlie changes
is greatest in thc sagittal plane, where the range of
characteristic of the aging process. The decrease in the
ncxion is from 0 to approximatcly 140" and the range of
bone mass at the femoral neck leads (0 reduced bone
extcnsion is from 0 to 15~. The range or abduction is strength and stiffness as a result of diminution in the
fTom 0 to 30", whereas that of adduction is somewhat amount of cancellous bone and thinning of conical bone. It
less, from 0 to 25'. External rotation ranges from 0 to increases the likelihood of a fracture at the weakest level.
9W degrees and internal ro-tation from 0 to 70' when the During the fall. the magnitude of the compressive
hip joint is flexed. Less rotation occurs when the hip
forces at the femoral neck overcame its stiffness and
joint is extended be-cause of the restricting function of
strength. In addition. the tensile forces produced by pro-
the soft tissues.
tective contraction of muscles such as the iliopsoas gener-
The range of motion of the hip joint during gail has
ated a traction fracture at the lesser trochanter level.
been measured e1ectrogoniometrically in all
Extension Abduction Adduction External Internal
rotation rotation
B c D E
allows a comparison of this motion with that of the knee the tracking limb; they also showed reduced dorsi-
and ankle. nexion of the ankle and diminished elevation of the toe
Motion in the frontal plane (abduction-adduc-tion) of the forward limb,
and transverse plane (internal-external rota-tion) during The range of motion in three planes during com-mon
gait (Johnslon & Smidt. 1969) is illus-trated in Figure 8-8B. daily activities such as tying a shoe, sitting down on a
Abduction occurred during swing phase, reaching its chair, rising [Torn it, picking lip an object from the floor,
maximum just after toe-olT; at heel strike, the hip joint and climbing stairs \vas measurcd electrogoniomctrically
reversed into addue-tion, which continued until late stance in 33 normalmcn by Johnston and Smidt (1970), The
phase. The hip joint was externally rotated throughout the mean motion during these activities is shown in Table 8-
swing phase, rotating internally just before heel st.-ike, The 1. Maximal Illation in the sagittal plane (hip flexion)
joint .-emained internally rotated until late stance phase, was needed for tying the shoe and bending down to
when it again rotated externally. The average ranges of sqUal to pick lip an object rrom the noor. The greatest
motion recorded for the 33 normal men in this study' \vere motion in the frontal and transverse planes was recorded
12' for the frontal plane and 13' For the transverse plane. during squatting and during shoe tying with the foot
across the opposite thigh, The values obtained for these
As people age, they use a progressively smaller common activities indicate that hip flexion of at least
portion of the range of motion of the lower extrem~ ity 120 abduction and external rotation of atleasl 20" are
G
joints during ambulation. Murray and co\\,/orkers (1969) necessary for caITying out daily activities in a normal
studied the walking pallerns of 67 normal men of similar manner.
weight and height ranging in age from 20 to 87 years and
compared the gait patterns of o.lder and younger men.
The diffcrences in the sagittal body positions of the two SURFACE JOINT MOTION
groups at the in-stant of heel strike are illustrated in Figure
8-9. The older mcn had shorter strides, a decreased nmge Surface Illotion in the hip joint can be considered as
of hip flexion and extension, decreased plantar flexion of gliding of the femoral head on the a<;etabulum. The
the ankle. and a decreased heel-to-noOJ" angle of pivoting of the ball and socket in three planes around
the center of rotation in the femoral head (estimated at
the center of the femoral head) produces this glid-
JOINTS
,-
70
--Hip joint
----. Knee joint
, ',
, , Abduction
60~ ........... Ankle joint ,, .,
. 5 ........
I: \
50 ,• o i==""1--~
'" 40~ ,
1 , •, , (j) 5 Adduction
. w
w
~ 1 \
w
C>
w
c
30~ ,1 Q,
w
.
:s / I \
0
20 :s
c 'x " I' \
c
,2 w ,
Q
;; u: 'I" .\,
10 ./ ;; Internal
~ "
'0
C
0
, ' ., ~ rotation
51:::::=~....1 --.l
.••.... Q.
~
..,/ ...... £ 04
c
10 ...
..... ...-
5 "'i ---' I
0
'"
External
c 20 ................ rotation
.'!l 100 60 100
x 30 Stance Swing
LU 100 60, 100
Stance phase Swmg phase phase phase
Percentage of Cycle Percentage of Cycle
A B
A. Range of hip joint motion in the sagittal plane for 30 nor-mal men range of motion in the frontal plane (top) and transverse
during level walking, one gait cycle. The ranges of motion for the plane (bottom) during level walking, one gait cycle. Addpt, cf
knee and ankle joints are shown for compari-son. Adapted from from Johnston, Pl. C. S Smiclt, G.L. (J 969). /vleasuremcn[ of hi,l.'·
ivlurray, ~J1.p. (1967). Gait as a tolal pattern of joinr morion during waf.l-:.ing_ EvaluMion of an electrogoliiomCir:c
movement. Am) Phys iVIed, 46, 290. B, A typical pattern for method J Bone Joint Sur~J, 51 A 1083
weight, the reaction force on each hip joint will be one half
of the remaining two thirds, or one third of body weight;
Mean Values for Maximum Hip Motion in fhree however, if the muscles surround-ing the hip joint contract
Planes During Common Activities to prevent swa,ying and to maintain an upright position of
Plane Recorded Value the body (e.g., during prolonged standing), this force
Activity of Motion (Degrees)
increases in proportion to the amount of muscle activity.
Tying shoe with Sagittal 124
foot on floor Frontal 19 vVhen a person changes from a two-leg to a single-leg
Transverse 1 stance, the line of gravit:v of the superincumbent body
Tying shoe with Sagittal 1 shifts in all three planes, producing moments around the
foot across Frontal 23 hip joint that must be counteracted by muscle forces and
opposite thigh Transverse 33 thus increasing the joint reaction force. The magnitude of
Sitting down Sagittal 104 the moments, and hence the magnitude of the joint rcaction
on chair and Frontal 20 force, depcnds on the posture of the spine, the position of
rising from sitting Transverse
the non-wcight-bearing leg and upper extremities, and the
Stooping to obtain Sagittal 117
inclina-tion of the pelvis (McLeish & Chamley, 1970).
object from floor Frontal 21
Transverse Figure 8-10 demonstrates how the line of gravity in the
Squatting Sagittal 122 frontal plane shifts with four different positions of the
Frontal 28 upper body and inclinations of the pelvis: stand-ing with
Transverse 26 the pelvis in a ncutral position, standing with a maximum
J'>.scendingstairs Sagittal 67 tilt of the upper bod)' over the sup-porting hip joint,
Frontal 16 sianding with the upper body tilt-ing away from the
Transverse 18 supporting hip joint, and standing with the pelvis sagging
Descending stairs Sagittal 36 away' from the supporting hip joint (Trendelenburg's test).
The shift in the gravity line, and hence in the length of the
i'.ile,)1lfor 33 normal men. Data hom Johnston, R.C. & Smidt. G.L. lever arm of the gravitational force (the peq)endicular
i.i970), Hip motion measurements for selected activities of daily living;
(lin Orrhop, 72, 205
distance be-tween the gravity line and the center of rotation
in the fernoral head), influences the magnitude of the
moments about the hip joint and, consequently, the joint
reaction force. The gravitational forcc lever arm and the
joint reaction force are minimized when the trunk is tilted
over the hip joint (Fig. 8-108).
developed for patients with pathological conditions of the
hip. The abductor muscle group (the glutcus medius and
minimus muscles) is the main stabilizer during one-legged Two methods arc used for deriving the magnitude of the
stance (Kumagai et aI., 1997; University of California, joint reaction force acting on the femoral head: the
1953) simplified free-body technique for copla-nar forces and a
mathematical method utilizing equilibrium equations. The
simplified free~body technique for coplanar forces was
STATICS
described in de-tail in Chapter 7, in Calculation Box 7.1.
During a two-leg stance, the line of gravity of the This tech-nique is used in the hip to cstimatc the joint reac-
superincumbent bod:v passes posterior to thc pu~ bic tion force in the frontal plane acting on the femoral head
s)'mphysis, and, because the hip joint is stable, an erect during a single-leg stance with the pelvis in a neutral
stance can be achieved \vithout muscle contraction through position (Calculation Box 8-1). The second method is a
the stabilizing effect of the joint capsule and capsular mathematical calculation of the joint reaction force on the
ligaments. With no muscle activity to produce moments femoral head using equilib-rium equations for a single-leg
around the hip joint, calculation of the joint reaction force stance with the pelvis level (Calculation Box 8-2).
be-comes simple: the magnitude of this force on each
femoral head during upright two-legged stance is one half
the weight of the superincumbent body. Because each To understand and solve the equations it is nec-essaI)' to
lower extremity is one sixth of body indicate first the location of the external forces acting on
the body during the single-leg
a:2~:g,:;r:ART)(~ BIOMECHANICS OF JOINTS
Roentgenograms utilizing a plumb line (black line) show supporting hip joint_ Again the gravity line has shifted to-ward the
that the line of gravity shifts in the frontal plane with differ· ent supporting hip, thus decreasing the joint reaction force. D. The pelvis
positions of the upper body and inclinations of the pelvis. A, The sags away from the supporting hip joint (Trendelenburg'stest). The
pelvis is in a neutral position. The gravity line faUs approximately shift in the gravity line is similar to that in C. (Courtes}' of 10hn C
through the pubic symphysis. The lever arm for the force produced by Baker. IvI.D., Case vVesrem Re-serve Unive(sir}~ Cleveland, OhiO} Note:
body weight (the perpendicu· lar distance between the gravity line In B, the antalgic gait is illustrated, which lowers the load on the head
and the center of rota-tion in the femoral head) influences the of the femur but alters the load line to a more vertical position.
moment about the hip joint and hence the joint reaction force. B, The Following arthroplasty for arthritis, the abductor muscles are weak
shoulders are maximally tilted over the supporting hip joint. The grav· and atrophic as a result of the disease process and the surgery.
ity line has shifted and is now nearest the supporting hip. Because External support such as a cane should be used until the ab-ductor
this shift minimizes the lever arm, the moment about the hip joint and muscles are rehabilitated. The best indication for a rehabilitated
the joint reaction force are also min-imized. C, The shoulders are abductor muscle is the lack of limping.
maximally tilted away from the
on a free·body diagram (Calculation Box Fig. 1)_ required for stability. The moment arising from the
Because the body is in equilibrium (i.e" the of the superincumbent body weight (equal to % 'IN) must be
11''lOmenlsand the sum of the forces both zero), the balanced by a moment arising from the force of the
ground l'eactionforce is equal to the abductor muscles_ The rorce produced by the su-
'Q:l-,witatwllal force of the body, which can be divided perincumbent hody weight (% W) acts al a diSlance or b
1WO components, the gravitational force of the leg (equal to rrom the center of rotation of the hip (Q), thus producing a
one-sixth body weight) and the moment of % Vt/ times b. The force pro-duced by the
force (equal to five-sixths body weight). body principal abductor, the gluteus medius, designated as A,
is divided at the hip joint into two acts at a distance of c from the center of rotation, producing
h-"e-DC)(lIeS- The main coplanar forces and moments on a counterbalanc-ing rnomcnt of A limes c. For the body to
these free-bodies must be determined. upper free-body remain in moment equilibrium. the sum of the moments
is considered first (Calculalion must equal zero. In this example, the moments acting
;1j~IJOX Fig. 8-2-2). In this free-body, t\\'o moments are
------------------
Force J
Intersection
point
J'
Force A //
2W/ I
I
/ I Force J
2_75 W
,
1
t
Force W
,._wt/ I
The internal forces acting on the hip joint are founel by sepa-
rating the joint into an upper and lower free-body; the Lipper
5/6 W :
free-body is considered first. In this free-body, two moments are
b :
required for stability. Moment equilibrium is attained by the -_._"
prOduction of two equal moments. A moment arising from the
Calculation Box
force of the abductor muscle (A) times abductor force lever arm (e) Figure 8-2·2.
counterbalances the moment arising from the gravitational force of
the superincumbent body (5/6 W) times gravitational force lever
arm (b), which tends to tilt the pelvis away from the supporting
lower extremity. Q, center of rotation of the hip joint.
A = 2W
Ax =: A ·sin30~
Ax = O.5A ~ W
Ay := A·cos30'"
Ay = 0.8 A = 1.7 W
y
A 30"
Calculation Box
Force A is equal to two times body weight and has a direction Figure 8-2-3.
,
clockwise arc arbilraril~' considered to be positive and lhe Fig. 8-2-2). This is particularly important in pros-thetic
counterclockwise moments arc considered replacements of the hip joint (Delp & Maloney. 1993; Free
be negative. Thus, & Dell', 1996; Lim et al .. 1999; Sutherland et 'II.,1999;
(Y.,W x b) - (A x c) = 0 Vasavada et 'II.,1994). The center of motion can be altered
by the prosthctic de-sign and the lever arm for the abductor
YoW x b
A = - ' ---- muscles can be slightly changed by slu-get)! techniqucs. A
c change of the center of location of the hip joint can de-
To solve for A it is necessary to find the values of and c. The crease the abduction force by more than 40(1'0 and thereby
gravitational force lever ann (b) is roentgenographically. the generated abduclor moment b~} almost 50% (Dell' &
Because the cenler of gravity must lie over the base of Maloney, 1993), Figure 8-11 illustrates the relationship of
sUppOrl, a plumb line intersecting the heel can be extended this ratio to the joint reaction force. ;\ low ratio (i.e., a
upward; a line drawn from the center of rota- small muscle force lever ann and a large gravitational force
lever arm) yields a greater joint reaction force than docs a high
in the femoral head (Q) to the line represents ratio.
"""'\IlOe b. The muscle force lever arm (c) is simi-larl~!
found by identifying the glutcus medius mus-cle on a A short lever arm of the nbduc(ol- musclc force, as in coxa
roentgenogram (Nemeth & Ohlsen, 1985, 1989) and drawing valga (Fig. 8-4), rcsults in a sTllall ratio and lInls a sornewhat
a perpendicular line from the center of rotation 01" the e1cvated joint reaction force. Mo\'-ing thc greater lrochanter
femoral head to a line ap-proximating the gluteus mcdius latcrally during lata! hip replacement lowers the joint reaction
muscle tendon. force. as it in-creases the lever arm ratio by increasing the
In this example, a value for A of two times body weight muscle force lever arm (Free & Delp, 1996). Inserting a
was derived from thc static free-body diagram and prosthetic CLIp deeper in the acetabulum reduces the
confil'med by instll.llnentcd in vivo measure-ments gravitational force lever ann, thereby increasing the ratio and
(English & Kilvington, 1979; Rydell, 1966). The direction decreasing the joint rcaction force. It is difficult. howc\'cl: to
of force A is found from a roentgenogrnrn to be 30 0 from change the lever an11 ratio in such a way as to reduce the joint
the vertical. The hOI'izontal and vcrtical components of rcaction force sig-nificantly been use the curve formed from
this force are found by vector analysis (Calculation Box plouing the ratios becomes asymptotic when the ratio of c to b
Fig. 8-2-3). The hOl-izonlal compo-nent (AJ is equal to approaches 0.8 (Fig, 8-1 I).
body" weight; the vertical compo-nent (A y ) is
approximately 1.7 times body \veight.
Attention is then directed to the lower free-body
(Calculation Box Fig 8-3-1). The gravitational forces DYNAMICS
(Wand II. W) are known. The joint reaction force (force J)
has an unknown magnitude and direction but originates The loads on the hip joint during dynamic activi-ties have
from the most narrow joint space in the radiograph and been studied by several investigators (Andriacchi ct aI.,
musl pass through the esti-mated center of rotation in the 1980; Draganich c{ al.. 1980; English & Kilvington. 1979:
femoral head. The magnitude of force J is determined by Rydell, 1966). Using a force plate system and kinematic
finding the horizontal and vertical force components and data for the nOI"-Illal hip, J. P. Paul, 1967. (Forces at the
adding them (Calculation Box Fig. 8-3-2). human hip joint. Unpublished doctoral theses, University of
Chicago) examined the joint reaction force on the femoral
The value of J is found by vector addition (Calcu-lation head in normal men and women during gait and correlated
Box Fig. 8-3~3), and its direction is measured on the the peak magnitudes with spe· cine muscle activity
parallelogram of forces. The joint reaction force on the recorded electromyograph i-cally. In the men, two peak
femoral head in a single-leg stance with the pelvis leveled forces were produced during the stance phase when the
in the horizontal plane is found to be approximately 2.7 abductor mus~ cles contracted to stabilize the pelvis. One
times body weight, and its di-rection is 69· fTom the peak of approximately four times body weight occurred just
horizontal (Calculation Box Fig, 8-3-4). nfter heel strike, and a large peak of approxi-matel:v seven
times body weight was. reached just before toe-ofr (Fig. 8-
A key factor influencing the magnitude of the joint 12A). During foot flat, the joint reaction force decreased to
reaction force on the femoral head is the ratio of the approximately
abductor muscle rorce lever ann (c) to the gravitational
force lever arm (b) (Calculation Box
OF JOINTS
~.
A,~W
A
w w
Calculation Box
Calculation Box
Figure 8~3~1. Figure 8-3-2.
CHAPTER 8 • BIC)Ivl:ECI·j"'N.I~;~IJF
Men
7.0
7
6.0
6
:c
'l a>
'ffi
5
a>
'ffi 5.0 ;; 4
~ >-
>- 1S
0
" @. 3
e ~
4.0
~
~
~ a
0 2 u.
u.
3.0
Upper and 60 100
lower
limits of Percentage of CyCle
10< >angle of
2.0 ~..,._.,......,_..,.._.--..,._.,.......;5,,0:..'.., inclination Women
o 0:2 0:4 0:6 0.8 i of abductor
! Ratio of c to b
muscle
force line
1Bm _
The value of the ratio of the abductor muscle force lever
arm (e) to the gravitational force lever arm (b) is plotted
I against the joint reaction force on the femoral head in , units of body weight.
Because the line of application of I the abductor muscle force (its angle of
inclination in the 60 100
frontal plane) has finite upper and lower limits (10 and
Percentage of Cycle
50°), the force envelope is plotted. The curve can be uti·
lized to determine the minimal force acting on the
Muscle AClivity During Slance Phase of Gait
I femoral head during a one-leg stance if the ratio of ( to b Gll/leus ma~,mus
r
"======
Sem:teM'llOSUS E~tellsors
I is known. AdiJpced from Frankel. VH. (960). In The Femoral Neck: Function, Semimem!)r,lllOSUS !------- 1
Fracture Mechanisms, Internal fixation. Spring- Biceps tomor,s
IIi",,",Gr,lc,bs
8 ---------------- Reclus femoris
Gluteus med,us Abductols
Gluleus minimus
.\dduc!or magous .-==:==~AddUCIOIS
Adductor IOr1(Jus
Adductor brevis
100 60
Percentage of Cycle
body weight because of the rapid deceleration of
c
the bodv's centcr of gravilv. Durin lT the swing
.' ~.' t> ~
~
..
1200
1000
200
800
t\ plwse or gail compared with external mcnsuremcnts and
calculations (Rydell, 1965) (Fig. 8-13;\). At a faster
cadence. the forces •.\Cling on the prosthesis grcatl~' increased
because of an increase in muscle ac(ivi(~' (Fig. 8-138). At both
e
0
lL
600 cadences, the magnitude or the forces during swing phase
400 was arproxirnatel~:half that during stance phase.
1400
1200
~ 1000
'"e
0
lL
800
600
,ImI!DJI
Range of Typical Reported Peak Hip Joint Forces
400 From Selected Studies
Reported
200 or,1-, i i i Activity
Peak Force
BW Instrumentation
-_.,-.'....'_-_._---_..._--_.,.._,._--
Reference
~--------'--'---'-"---'------"'-----r
of a femoral neck fracture allowed a subsequent
determination of the forces acting on the implant during
Fatigue Fracture of the Hip
activilies or daily living (Fig. 8-14) (Frankel el aI., 1971).
'1\.", 64-year-old, very active retired man experienced a Although the device measured forces on the implant and
·Mfemoral neck fracture after changing his training not on the hip joint, it was pos-sible to determine the
,'regimeto prepare for a marathon. The fracture was proportion of the load transmitted L1nough the device and
'.>classified as a faligue fracture caused by overload of -, to calculate the total load acting on the hip joint by means
the hip joint. of static analysis. In the case illustrated in Figure 8-14. the
nail plate transmitted one fOllrth of the lOtalload.
A, When the patient used elbows and heels to elevate the hips
while being placed on a bedpan, the force on the tip of the
instrumented nail was 670 N. With a spica cast, the force on the
tip of the nail was 190 N. B, The use of a trapeze and assistance
EFFECT OF EXTERNAL SUPPORT ON
from an attendant reduced the force to 190 N without a cast and
THE HIP JOINT REACTION FORCE
to 70 N with a spica cast.
Reprinted "vith permission from Frankel, VH. (7973). Biome- Static anal.\·sis of the joint reaction force on the femoral
chanics of the hip. In R. G. Tronzo (feU Surgery of the Hip Joint head during walking with a cane demon-strates that the
(.0,0. 105-125). Philadelphia: Lea & Febiger cane should be used on the side op-posite the painful or
operated hip. Neumann (1998)
High and low load on the hip joint during daily activities. Raising from a low chair produces
approximately 8 times body weight (A). Walking with a cane on the ipsilateral side of the
affected hip produces approximately 3.4 times body weight (B), and walking with a cane on the
contralateral side of the affected hip reduces hip joint load substantially to 2.2 times body weight
(C). This figure illustrates how load on the hip joint can be manipulated by simple means (X
denotes affected hip).
-
I :i:::~C::I::J::r:S:~t:~::r::e~h:i::~re:~~o<~OintRea~:~::e:::C:uSCle force (E) was then found from the
momenl relationship
I faKe acting on the femoral head in Ihe late swing phase of i the gait cycle for an 8·year- T ::::: Fd,
oldboy INeighing 24 kg and
where F is the extensor muscle force and d is the perpendicu~,
I wearing a )ong-Ieg brace. The main muscle force was pro-duced
lar distance from the center of rotation of the femur to the middle
by contraction of the gluteus maximus muscle and identified
through electromyography. The torque about the hip joint \ivas of the gluteus maxim us muscle. Distance d was mea., sureej
calculated according to the formula from a roentgenogram and found to be 3.2 em, From
H'eequation E;::;: TId, the muscle force on the normal Side',
T ~ la,
...."as calculated to be 338 N, and on the braced side, 600 N. The
where
joint reanion force on the femoral head (J) is equal to the muscle
T is the torque expressed in newton meters (Nm)
force (E) minus the gravitational force produced by Ihe weight of
I is the mass moment of inertia expressed in newton meters
the limb (W,). In this example, W L \·\las esti-mated to be 40 N.
times seconds squared (Nm sec!)
is the angular acceleration in late swing phase, expressed in
radians per second squared (rlsec 1). On the normal side, On the braced side,
J = E-\iV, J = E -\iV,
In the case of (he braced side. I = I , .;. I;; where is
J = 338 N - 40 N J=600N-40N
the mass moment of inertia of the leg
J = 298 N. J = 560 N.
is the mass moment of inertia of the brace.
Thus, tile Joint reaction force on the femoral head in the
On the normal side, On the braced side.
br~1Ced limb v"as over 80% higher than the force in the non~
I "" 0.45 Nm se(' 1 ;.cc 0.45 Nm sec; + 0.35 Ntn sec'
braced limb, reaching more than two times body weight.
n=: 24 rlsec'. n = 24 rlsee"
Thus, Thus,
I = 0.45 Nm sec:' T = (.45 Nm sec) + 35 Nm sec!)
.: ~
x 24 rlsec~ x 24 rlsec~
T ~ 10.8 Nm. T ~ 19.2 Nm.
I
0~---
studied the effects of cane use in 24 subjects with a ,;:: mean a large push may not be possible because of a lack of
age of 63 years. During walking, the e1ec- strength in the upper extremities.
tromyographic activity of the hip abductor muscles The use of a brace on the leg may aller the forces on the
was measured, Neumann found that usc of a cane on the hip joint but may not always reduce the joint reaction force on
contralateral side of the affected hip joint, with careful the femoral head. An ischial long~
instructions to use with near maximal effort, could reduce leg brace used in the treatment of Perthes'disease raises the joint
the muscle activity by 42% (Fig. 8-16). This calculates to a reaction force during late swing phase
reduction of approxi-mately one times bod~; \veight from because the large mass moment of inert ia of the brace
2.2 body weight with a cane, compared with 3.4 body weight results in a higher extensor muscle force dur-ing this part of
with- the gait cycle (Calculation Box 8~4).
Out a cane. These studies give important inforllla~
lion to the clinician about ways to moderate the load for the
patient with hip problems. SUl1lmary
Such use reduces the force on the femoral head of the painf-
ul joint without necessitating an anlalgic body position. A cane
1';The hip JOll1t is a ball-and-socket joint com-posed of
used on the side of the painful hip works through a shoner levcr the acetabulum and femoral head,
arm and thus an even greater push on the cane is needed to 2 The thickness and mechanical properties of the
decrease the joint reaction force. For the olcler patient, such cartilage on the femoral
head and acetabulum vary
from point to poinl.
Fl·ss.\', ~1.I-1.. ;\'Diaye, A.. CalTd. J.P.. et :II. (1999)_ Locilting tht..·
3 Hip llexion of at lca~·a 120", abduction of at least 20", l·{.·lltl-r or rOlation of IIII.' hip. Sl/r.g nmliol A//at, 21(4),
and extenwl rOl<.l.lion of at least 20" are necessary for 24;-250.
can}'ing out daily activities in a nor-mal manner. FI'~lnkd, V.H. (19;3). Biollll'challil:s or
the hip. In R.G. Tronzo (Ed.),
105-125). Phil~ldl..'lphi::\: lea &. Fdlif!l'r.
Slll'.~t:ry o( I!lt' Hip }Oil/l (pp.
\4 A joint reaction force of apprOXill'latc1y three timcs Frankd. V.H. (1960). In nUt FI.'J/ulI"iI} Nt'd: {-'Wlclioll. Frtldlfre
body weight acts on the hip joint during a sin-gle-leg .\-1f.'(:IUllli:'/II.\, "/lenla! FixaTioll. Springfidd: Charles C.
TlwllWS.
stance with the pelvis in a neutral position; its m;gnitudc Fr'lnkd. V.H .. BurSil'in. A.H .. L~·grl·. L., l't al. (1971). The Idl· L.lil: nail.
varies as the position of the upper body changes. ) BOIH' 10illl SIII"~. 53:1. 1232.
Free, S.A. & Oelp, S.L. (1996). Trochantt.'rll.: transfer in IOlal hip
_~'> The magnitude of the hip joint reaction force is n:pJal:i.:IlIl.:nl: Effecls on Ilit' lTlOfllL'llt arms nnd force-gellt..'ralillg
infiuenced by the ratio of Ihe abductor muscle force and c'lpadtic:;s of Ihe hip abductors. J Onlwl' Rt',,'.
gravitational force lever anns. A low ratio yields a greater 1-I{2L 1-15-250.
joint reaction force than does a high ratio_ Gn.·em\'~a1d. A.S. & 1-I<I\'llI,:S, D.W. (1972). Weight-hcaring an.'as ill lhe
human hip j{~Jinl..! BOIlt' .!Oilll Siltg. 5-1B( I), 157-163.
;;_~ The hip ,joint reaction force during gail reaches levels Hurwitz. D.E. & Andri.tt:("hi. '1'.1>. (1998). Biomechanics of the hip.
of three to six limes body weight or more in stance phase and III J.J. Cdbgh'111. A.G. Rosl'nberg. &. I-I.E. Rub':Jsh (Eds.1. The: Adult
is approximately equal to body weight during swing phase. flip (pp. 73-85). Philaddphia: Lippillcol!'
Raven Publishers.
Hllr",it;',. D.E. & Andri~\(:("hi. T.P. (1997). Biolllcl:hanks of the hip .tlld the
j.7 An incrense in gait velocity increases the mag-nitude knl'l'. In ~'1. Nordin, G.B.J .•\ndnsson. &. ,\I.B.
of the hip joint reaction force in both swing and stance POPl' (Eds.) . .\lusculoskclewl Disorders ill {Itt' Irorkf-'lau. Principles
(Jud Prauice (pp. -186--196). Phila(k']phia: Mosby-
phase. Year Book.
,'8 The forces acting on an internal fixation device during Inrn;lIl. V.T. (19-47). Flll1l:lional aspects of t!ll' abductOr mllS-c1es
the ~\ctivitie; of daily living vary greatly' of thl' hip. J BOllI.' loim Sll"~. 29:\. 607.
JohnslOn, R.C., Br~Hl(I, R.A .. &. Crowninshicld. R.D. (1979).
depending on the nursing carc and the therapeutic activities Re('onslnH:lioll of tht' hip. } BOI/t' Join, Smg. 61:\(5),
undertaken by the patient. 646-652.
/9 The lise of a cane or a brace on the leg can al-tcrthe Johnston. R.C. & Smidt. C.L. (1969). !\leasur(,llll'nt of hip-join! motion
during walking. Evaluation of 'tll I'll'ctrogo· niOllll'tric Illt.'lhod. 1
magnitude of the hip joint reaction force. BOll ...' loiJ/! Sll}".~.. 51:\, 1083.
Johnston, R.C. & Smidl. C.L. (1970). Hip motion tlll"\Sllrt:-m('Il{S for
sell-tted .\Ctidties of daily li,·ing. efill Or/flOp. 72. 105.
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Rydell, N.W. (1966). Forces acting on the remoral head pros-thesis: A Direct comparison or contact <.In:as, contact stress and subchondral
study on strain gauge supplied prostheses in liv-ing persons. Acta mineralization in Illunan hip joint spcci· mens . ..\I/IJ{ f:'lIlbryol ([kr/),
Orr/lOp S("(lIld, SlIppl88. 1-132. 195(3), 279-288.
Rvdell, N. (1965). Forces in the hip-joint. Part If: Intravital
. measurements. In R.rvl. Kenedi (i~d.), l3iolllt'cllilUics (jlld
Biomechanics of the
Foot and Ankle
G, James Sammarco, Ross Todd Hockenbury
Introduction
Growth of the Foot
Kinematics of the Foot
Foot and Ankle Motion During Gait
Causes of leg Rotation During the Gait Cyde
Muscle Action During Gait
MotIon of the Tarsal Bones
Sublalar Joint Motion
Transverse Tarsal Joint Motion
Tarsometatarsal and Intertarsal Motion
Motion of the Hallux
Motion of the Lesser Toes
The Medial longitudinal Arch
Muscle Control of the Foot
Kinetics of the Foot
Soft Tissues of the Foot
Ankle Joint Biomechanics
Kinemaiics
Range of Motion
Surface Joint Motion
Ankle Joint Stability
Kinetics of the Ankle Joint
Statics
Ankle load Distribution
Dynamics
Effects of Shoewear on Foot/Ankle Biomechanics
Summary
References
Introduction found impact on the foot and ankle's shock-absorb-ing,
propulsive, and stabiliZing roles. Clinical corre-lation of
The biomechanics of the fool and ankle arc complex and alterations in biomechanical Function is presented in case
intricately associated with each olher. The fOOl is an studies. Footwear in \Vestern so-ciety may VaJ'y from a
integral mechanical part of the lower cxtrcrn-ity necessary rigid ski boot to a soft moc-casin. These externally
1'01'a smooth and stable gaiL The an-kle transfers load restrictive materials may al-ter normal foot and ankle
frolll the lower extremity to the foal and closely inllucnccs biomechanics and ultimately innucncc the development or
foot orientation with the ground. some pathological conditions, slich as hallux valgus.
Any pathological change in root or ankle struc-ture or For practical purposes. foot motion can be con-sidered
motion, however subtle, may have a pro- to be of two distinct types; non-weight-
223
join! (01 eMparl)
Tarsometalarsal join! BOdy
(01 Lislrane) Navicular
~ Cuneiforms \,
Base\'" Os trigonum
\ KJ'"'R,..
Head Calcaneus
Phalanges
\
Sesamoids
Tuberosity
MEDIAL VIEW
Trochlea
Os Metatarsals trigonum
Tuberosity
calcan~-~~"""""'''~
Point or insenion
01 the carcaneolibular -.;...·..><'·:hlea ('ubercle) / .
TuberOSIty
ligament Head
Groove lor
peroneus longus TU!)fHc!e
LATERAL VIEW
Calcaneus
Latera! process
Talus -"'~~,-.
Medial
malleolus
lateral
Cuneilorms { Middle
Medial Lateral malleolus
HaUul(
-Great 100-
DORSAL VIEW
Top, View of the medial aspect of the foot. Middle. View of the lateral aspect of the foot.
Bottom left, Superior view of the foot. Bottom right, Anterior view of the ankle mortise,
La!. Med. beal"ing and weight-bearing. Passive. nOI1-wdght-bearing
Interosseous Illotion may be tested with the patient seated and the foot
membrane -~-'-.- 0~, Ii I and ankle hanging free. Subtalar motion is evaluated by
(~¥J~Tjbia
Fibula 0 f&t~~:
.....: grasping the tibia with one hand and inverting and cvcrting
.< ;:;if4~. Tibiotalar joint the heel with the other hane!. Abduction and adduction of
. . ~istal z:f, ...-;&"4.~
llbloflbular ....z.. ::~.,-:"~r-7: • . •
the fore-foot can be tested if the heel is held immobile.
Supination and pronation of the forefoot may also be tested
with the heel fixed, as may flexion and ex-tension of the
tarsometatarsal joints and [Des.
26 +-+--+--+-+-+-++'-+--1
24\ V ·· 24+-+1 +1-+1--h-t-:·,pv';l"/~····--4
1
\
o 2 4 6 8 10 12 14 16 18 0 2 4 6 8 10 12 14 1618
Age (years) Age (years)
lengths of normal girls'and boys'feet derived from serial measures of 512 children aged 1 to 18
years. Left, Foot length versus age in girls. Note plateau in growth after age 12. Right, Foot
length versus age in boys. Note plateau in growth after age 15. Adapted with permission from Blais.
M.M.• Green. W T.. & Anderson. M. (1956). Lengths of the growing (oot. J
Bone Joint Surg. 38A. 988.
thlllst on the subwlar joill!. In the middle or sWnce
phase and at push-ofr. the entire lower cxtrclllit:' be-
Dorsiflexionl ~i~lS t(~ reverse and ,:otatc L·.'(t:nlall~'as ..1he. ~ubu~lur
Eversion!
planlarflexion JOint Sll1lllltancollsl~'II1vcrts (Fig. 9-9). \\illh IIlVerSlon
inversion
of the subtalar joint and supination 01" the foot. the foot is
transformed into a rigid stntclurc capable of propulsion.
Olerud and Rosendahl (1987) and Lund-
berg Cl al. (1989a-d) Im"e experiml'ntallv measured lhe
coupling 01 tibial rot~lliOIl to subtalar motion. They h<:\ve shown
that lhe foot supimues I" for every
0.2 to 0.44" 01" libial external rotation.
Ill~l/~
I
1~lf~1 /1 II////II!
Stance Phase
I
~I2J~]~~
Double Double
limb Single limb limb
support support support
<1-+ ~ ~ <1-+
SWing Phase I
IAcceleration [Toe c1em""e IDecelemtion iH~e~ .. 62 100
IIBII _ '--~~~~~-
62% of the normal gait cycle is spent in stance phase and Stance phase consists of two periods of double limb sup-
38% is spent in swing phase. port and one period of single limb support.
I
& ------------------
A Ji A A A
Walking
A
: ;
Stance ~65'
If: II :' ,
:
j SWina(?5~o)
o 10 20 30 40 50 60 70 80 90 100
Right heel Mid Left heel
I.osl"rt~k_e ,-st-a.L:c-eT--T--,-,-F-O-'t-O-'-t'---S-1lr~ke
Q • + + 'I''I'+ ~
RighI twel Mid Toe Double limb ~:~tl Mid Double limb Right heel
slrike slance off unsupported strike stance unsupported slnke
Running
Stance (40%) Swing (30'%)
o 10 20 30 40 50 60 70 80 90 100
i
I
{ ~ftJz~~~~
IBDI'-- _
i Comparison of walking and running cycles. In the running cycle, stance phase decreases,
p
•1 __ float
9
S W in__phaseasedevelops:incraseS_'_d_O_U_b_l_e_l_im_b_S_U_P_P_O_rl_d_iS_a_p_p_e_a_rs_,_a_n_d_a_d_o_U_b_l_e_l_im_b_U_n_s_u_p_p_o_r_te_d_o_r _
air~ PARi". 810MECHANICS OF JOINTS
..
Heel contacl
..
Toe-off
..
Heel contact
Ankle _.
rotation
i
! '
!.......-:-- Stance phase _:
,6~T : ,I
.:t; .... FOOl immobile ....:
Subiala, ~_.'-_..__
A B
rolation :-
f,'
I
° ,._L_~_~..-----,----;c;;~' -----' ._~
m ~ W
Percent of Walking Cycle
W 100 I
I
II l I
• c o
joint axis, the leg internally rotates with ankle dorsi~ flexion Mitered hinge model of leg, ankle, and subtalar motion. A.
and externally rotates with ankle plal1larflex-ion. Outward rotation of the upper stick causes inward rota-tion of the
Additional mechanisms by which leg external ro-tation lower stick. 8. Inward rotation of the upper stick causes outward
occurs during late stance include the swing of the opposite rotation of the lower stick. C. exter-nal tibial rotation causes
leg that causes external rotation of the planted leg and the supination of the foot. O. Internal tibial rotation causes pronation of
obliquity of the metatarsal break (Fig. 9- I 2). The the foot.
metatarsal break is an oblique axis of 50 to 70" with respect
to the long axis of the [oat formed by the centers of rotation
of the metatar-sophalangeal joints. With push-off. the foot
and lower extremity externally rotate with respect to the
sagittal plane because of this oblique axis.
Number of
specimens
MUSCLE ACTION DURING GAIT 20
r
Although the motions of the foot and ankle during the 15 r
walking cycle OCClIr primarily as a result of the passive I
constraints of joints and ligaments. elec-trom.yography has
shown that rnuscle activity does occur during normal gait
(Fig. 9-13). At heel strike, the pretibial musculature fires
eccentrically to slow down the descent of the forefoot and
10' { 74 78 82 86 90 94
prevent a [oat slap. At midstance, the calf musculature
Angle (degrees)
contracls to slow down the Fonvard movement of the body
over the foot and prevent a crouch gait. The intrin-sics also
contract during midstance to toe-off to aid in rigidity of the
forefoot. Toe-off is primarily a pas-sive event. The Variations in the angle between the midline of the tibia and the
pretibial musculature again con-tracts during swing phase empirical axis of the ankle. The axis is angled obliquely and
to ensure (hat the fOOl inferoJaterally 82°. The histogram shows variability among
specimens.
clears the Ooor during swing~lhrough.
CHAPTER 9 • BIOMECHANICS OF THE F03,)T~ND ¥~i;~~i';::.
I I I
I
$
Muscle activity
1 __ Slance -.1.,Sw;n9....1
I phase I phase I
I 1 I
I I
The muscles of the lower extremity are more ac-live Pretibial muscle -NjWl~---- .......INlVNm'fM/'lir
dudng nmning. The gluteus maximus and ham-strings
arc active in midstance through toe-off and increase
Triceps (calf) .L--../MlWWJW'J,IIlWil,J----...L
I
their activity 30 to 500/0 1O decelerate the 1
.: stance phase limb. Dorsillexors of the foot and an-kle are Foot I I
'"""-1li Jl
active in 700/0 of the running cycle. The in-trinsics,
plantar flexors, and peroneals are impor-tant stabilizers
of the plantar surface and hindfoot during the foot nat
phase (Aclelaar, 1986).
/'
/ /.'\.
,
,
:,
,,,
transverse tarsal joint: a longitudinal axis and an oblique
axis. The longitudinal axis is oriented lSo up-ward from the
horizontal and go medially frolll the longitudinal axis of the
foot. Inversion and eversion occur about thc longitudinal
axis (Fig. 9-16). The oblique axis is oriented 52° upward
from the hori-zontal and 57(> anlcromcdially. Flexion and
extension OCClIr primarily aboLit this axis (Fig. 9-17).
Ouzonian and Shereff (1989) determined in vitro talonavicular
motion to be 7° in nexion-extension and 17u in prona-tion-
supination. Calcaneocuboid motion is 2{'flexion-extension and
7° pronation-supination.
~d - Lat.
9;t~'---
..-:--- Navicular
Calcaneus
B
Normal Varus
bar.
& l\IIasquelel, 1994), Mizcl (1993) described the plantar
first metatarsocuneiform ligament as the major restraint to
dorsal angulation ancl sllbse~ quent dorsal displacement of
!------------------- the distal first metatarsal head.
Oblique axis of the transverse tarsal joint. Flexion and ex~
tension occur about this axis. A. lateral view. B, Top view.
Reprinted wirh permission from Manter. 1. T. (1941). Movemenrs
Motion of the Hallux
of the subta/r1r and transverse tarsal foints, Anat Ree. 80, 397.
The hallux must accommodate a \vide range of mo· lion
of the foot to perform a great variety of tasks.
Dorsal
Phalanx
Plantar Medial
Llslranc'sJOInt
Dorsal
Melatarsal
Medial
A B Plantar Lateral
A, Top view of the tarsometatarsal joints, known as Lis· Contact distribution of the first metatarsophalangeal joint
franc'sjoint. Note the recessed second metatarsal base. B, ! in 0<> (neutral), 40° of extension. and 70<> of extension. Top, !
Cross-sectional view of lisfranc'sjoint seen on computed Joint contact of the proximal phalanx. Bottom, Joint con-tact of the
tomography scan. Note the arch-like structure. metatarsal head. With increasing extension,
1 .i_o_in_'_'_U_rf_a_,_e_,_o_n _,a_'_ls_'h_i_f'_d_o_, _,a_1_IY_O_n_'_h_e_m_e_,_a_'d_,_,a_l_h _e_a_d.
. tension .
------------------ A view of the plantar surface of the foot of a patient with severe
hallux valgus. Note calluses underlying the second and third
metatarsal heads (transfer lesions), which indi-cate a transfer of
The great toe provides stability to the medial as-pect of
plantar forces away from the first metatarsal head to the lesser
the foot through the \vindlass mechanism of the plantar
metatarsal heads.
aponeurosis (sec The Medial Longitudi-nal Arch). As the
body passes ovcr the foot in toe-off. the proximal phalanx
passes over the metatarsal head and depresses it. This has
been conflrmcd by force plate analysis in the lutc sLancc The altered joint mechanics produced by hallux valgus is
phase, which shows thai pressure under the first metatarsal evident in analysis of instant centers of rotation, which demonstrate
head increases in this phase of gait (Clark, 1980). In hal-lux joint distraction and jamming where gliding nor-
valgus, the proximal phalanx shiFts laterally ancl pronates on mally occurs (Fig. 9-24).
the first metatarsal head. Thb abnOl-· Illal position of the
proximal phalanx decreases its ability to depress the Abnormal Weighl Bearing
(Bunion)
metatarsal head during toe-off. Any clinical situation that
affects the normal de-pression of the metatarsal head may
t1'ansfer plan-tar forces laterally to the second and third
metatarsal heads and rcsulL in the formation of painful plantar
calluses called transfer lesions (Case Study 9-1 and Figs. 9-23
and 9-24).
and intrinsic muscles contribute to the toc extensor hood. points corresponds to a similarly numbered in· stant center. The
which controls motion of the metatarsophalangeal and arc indicates the range of motion of the hallux, which is more
interphalangeal joints limited than that in a normal foot.
Extensor digilorum longus relaxed
!
Extensor digitorum
Flexor digilorum
Interosseous I
longus tendon Extensor longus tendon
muscle Sling hood insertion site
Extensor sling
Extensor digitorum
longus contracted
Flexor 1
tendon
Lumbrical
tendon sheath
Deep transverse
ligament Flexor digitorum brevis Sling traction
tendon
(Fig. 9-2S). The e'trinsics consist of the long toe nexors and
extensors. The lumbricals and interos-sei are the main
intrinsic contributors to the ex-tensor hood. The intrinsics affect the intrinsiL: muscles or the fOOl and result in an
act to l1ex the meta-tarsophalangeal joints and extend the intrinsic minus condition. The extrinsiL'llluscles overpower
inter~ phalangeal joints (Fig. 9-26). The long toe cxten~ sors the intrinsics and a claw !C)C dcformit.\· is produced with
extend the metatarsophalangeal joint through the action of extension of the mt.:tatarsopha-langeal joint and flexion of the
the sagittal bands by lifting the pmx-imal phalanges into interphalangeal joints (Fig. 9-28).
e'tension (Fig. 9-27). The flexor digilorum brevis is rhe
primary Oexor of the proximal interphalangeal joint. The
ne,or digito-rum longus is the primary flexor of the distal
in-terphalangeal joint.
Interossei Extensors
I
- Extensors
Flexor
digitorum Lumbricals
Flexor
I longus digitorum
~brev!s
Interossei
Lumbricals
I ---------------
A claw toe deformity is produced by an imbalance of the
extrinsic and intrinsic muscles. Relative weakness of the in-
terossei and lumbricals with overpull of the extrinsic toe
The intrinsic muscles (interossei and lumbricals) act to flex extensors and flexors produces an intrinsic minus defor-mity
the metatarsophalangeal joint and extend the interpha- of metatarsophalangeal extension and interpha-langeal joint
langeal joints. flexion.
tic rod. The SlI-uts arc under compression and thc tie rod is
under tension (Fig. 9-30). BOlh models h(:t\·c validity and
c
can be demonstrated clinically.
The structure analogous to the tic rod in the truss model
is the plantar fascia. The plantar fascia originates on the
mediallubcrosily of the calcaneus and spans the transverse
tarsal, tarsometatarsal, and metatarsophalangeal joints to
insert on the metatarsophalangeal plantar plates and
W W collateral ligaments as well as the hallucal sesamoids.
2 2 Dorsi-nexion of the metatarsophalangeal joints places
traction on the plantar fascia and causes elevation of the
GE '------------ arch through a mechanism known as the "windlass effect"
(Hicks, 1954) (Fig. 9-31). During toe-off in lhe gail cycle,
The beam model of the longitudinal arch. The arch is a curved lhe loes are dorsiflexed pas-sively as the body passes over
beam consisting of interconnecting joints and sup-porting the foot and the plan-tar fascia lightens and aels to shorten
plantar ligaments. Tensile forces are concentrated on the inferior
the distance between the metatarsal heads and the heel,
beam surface; compressive forces are gen-erated at the superior
surface.
thus elevating the arch. The traction on the plantar fas-cia
I also assists in inverting the calcaneus lhrough its
e ---------------- altachment on the medial plantar aspect of the calcaneus.
o
B
Electromyography of the musculature of the foot and ankle during one normal gait cycle (heel
strike to heel strike) .
•
The strongest extensor of the ankle is lhe tibialis The primary evertcrs of thc foot and ankle arc the
anterior, which is 1110st active during stance phase peroneals. The peroneus longus inserts on the base of
from heel strike 10 foot nat. The ankle and toe ex-tensors the first metatarsal and Illcdial cuneiform and acls to
fire eccentrically to slow the descent of the foot and depress the metatarsal head. Injury or paral-ysis of this
prevent foot slap. They also are necessary to allow fOOl muscle may allow elevation of the first metatarsal head
clearance fTom lhe noor during the swi ng phase. and decrease loads borne by thc first metatarsals and can
rcsult in the development of a dorsal bunion. Thc
The strongest inverter of the foot ancl ankle is the peroneus brevis stabilizes the forefoot laterally by
posterior tibialis muscle. The postcrior tibialis is a resisting inversion and was found by Hinlermann and
dynamic supporter of the medial longitudinal arch. Il associates (1994) 10 be the strongest everter of the foot.
flmctions to invert the subtalar joint during mid-and latc Loss or peroneal muscle strength can result in varus of
stance, thereby locking the tranSVel'se tal'Sal joint and the hindfool (Sammarco, 1995).
ensuring rigidity of the foot during toe-all Loss of this
muscle results in acquit'cd pes planus with Ilattcning of The interosseus muscles are active during late stance
the arch, abduction of thc forefoot. and evcrsion of thc and are thought to aid in stabilizing the fore-foot during
heel (Fig. 9-35). Patients with posterior tibialis tcndon toe-olT. An imbalance between the in-Irinsics and
dysfunction usually are un-able to activcly invert their extrinsics will lead to toe deformities such as hammer
heel while attcn1pting a single toe rise. They have toes, claw toes, or mallei toes.
difficulty performing a sin· gle toe rise because of their ,Both intrinsic and extrinsic muscles; mediate the
inability to form a rigid platform on which to support positional control of the great toe. A cross·section of the
their weight. proximal phalanx shows the relative position of
Longitudinal
Sublalar • axis
II .
axis I
I
EHL I
I EDL
I
I
I
I
Ankle axis I
TP .
Loss of the medial longitudinal arch in an acquired adult
FDL.
. flatfoot secondary to posterior tibial tendon deficiency.
' --------------------
-'---------- 4.5
x
80
·
Med 70
60
<l
~
" . 50
~
5 40
x "' "'~ 30
Lat Ii:
20
10
0
0% Lal 1000;/" Med
Foot Width
A B
Metatarsal head pressure distribution during standing. A. A line The distribution of pressure along the metatarsal head line
(XX')drawn in the contour plot between the approxi-mate (XX')indicating maximum pressure under the second
locations of the first and fifth metatarsal heads. B. metatarsal head.
CHAPTER 9 • BIOMECHANICS OF THe f08I~N~A~~Slt~1EO
heel strike spike, The first peak follows heel strike in early A
stance and the second peak occurs in IDle stance prior lo Midfoot
strikers n=5
toe-olT. The fore and aft shear forces dcmonstt'atc initial
braking by the foot as the foot places a fonvard shear force
on the ground. followed by a backward shear on the ground
as it pushes off in late Slance. Most of the medial-lateral
shear is directed laterally because the body's center of o
(~r:J(_~~)t x- -.
x -i.,-"
Percenlage of Cycle
o 15 30 60
(0, ot bOdy
Force wDi('hn HS FF HO TO
-
I - -/" I'\.
\
Vertical 10060
20 \ ,
1\0.
0 --
Fore
t 20
,- ....
Shear 0
.........
AFT j 20 V
Medial 10
t IA
Lateral
Stlear
j
10
0
......... I I
I i
Torque (Nm) HS FF HO TO
9
Medial t 0
j
Lateral 9
Ground reactive forces acting on the foot during the gait cycle. HS, heel strike; FF, foot flat;
HO, heel-off; TO, toe-off. Reprinted ~vitfJ permission from Mann, R.A (7982). Biomechan-ics of running. In
AAOS Symposium on the Foot and Leg in Running Sports (.0.0.30-44). St. Louis:
C V Mosby Co .
•
tic transverse and diagonal fibers to produce a spi-ral anteriorly than posteriorly (Sarrafian, 1993a,b). A
honeycomb effect (Fig. 9-44). The multiple small closed single ankle joi.llt axis has been described as pass-ing
cells arc arranged to most effectively absorb and just distal to the mcdi,il malleolus and just dis-tal and
dissipate force. \,Vith age, septal degeneration and fat anterior to the lateral malleolus (Inman, 1976). This
atrophy occur, which predispose the calca-neus and foot empirical "general" ankle axis can be estimated by
to injury (Jahss et a!., 1992a,b). palpating the tips of the malleoli
(Fig. 9-45). The single ankle axis is angulated pos-
terolaterall y'in the transverse plane and inferolat-
Ankle Joint Biomechanics erally in the coronal plane. Several authors have
KINEMATICS disputed the theory of a single axis of ankle mo-tion
and have described multiple axes of motion as the ankle
The ankle mortise forms a simple hinge consisting of the moves from dorsiflexion to plantarflex-ion (Barnett &
talus, medial malleolus, tibial pia fond, and lateral Napier, 1952; Hicks, 1953; Hinter-mann & Nigg, 1995;
malleolus. The talus is shaped like a trun-cated cone, or Lundberg et aI., 1989a-d;
frustunl, with the apex directed me-dially (tnman, 1976). Sammarco et a!., 1973). Barnett and Napier (1952)
The talus is 4.2 mm wider describe a dorsiflexion axis inclined downward
CHAPTER 9 • HIC'M,.CHANIC,
Structure of a normal heel pad as seen on magnetic resonance imaging (MRI), A, Lateral view. Note
vertically oriented fat-filled columns. B, Top view of the heel pad demonstrat-ing the spiral structure
of the septae, which separate the fat-filled cells .
•
and laterall.\' and a plantarflexion axis angled downward
and medially (Fig. 9-46). The ankle joint axes for
dorsillexion and plantarflcxion cliffeI' by'20 to 3D" in the
coronal plane but remain par-allel in the transverse plane.
Y ~-~Y
,~ ~Z'
Iam _ Ankle joint axis variation. Top, In dorsiflexion (DF) the axis of
motion XX' is inclined downward and I~terally. Middle, In neutral the
The empirical axis of the ankle joint estimated through palpation axis of motion YY'is almost horizontal. Bot-tom, In plantarflexion
of the malleoli. The axis angles downward and the axis ZZ'is inclined downward and medially.
posteriorly, moving from medial to lateral.
Q 2!l'i ?ARJill. BIOMECHANICS Of JOINTS
0 10
the talus internally 1'0-tatcd 1.4", followed by external
rotation of 0.61> at 30" planlarllexion (Fig. 9-47). An in 0
vilro slud~' of loaded ankles demonstrated 2.5<" external
rotation in c
0 10
·x
25(0 dorsiflexion, and < I" internal rotation at 3Y' ~
plantarllexion (Michelson & Helgemo, 1995.) ~ 20 100 60 100
C
a:" Percentage of Cycle
RANGE OF MOTION
Ankle mol ion occurs primarily in the sagittal plane and is
rDm'-- _
described as planlarflexion (flexion) and dor-siflexion Range of ankle joint motion in the sagittal plane during level
(extension). A wide range of normal mo-lion for Ihe ankle walking in one gait cycle. The shaded area indicates variation
has been reported and depends on whether the Illotion is among 60 subjects (age 20 to 65 years). Rr:primed
measured clinically with a goniOll1cter or whether it is '..viti! permiSSion from Stiluffer. P. N.. Chao. E- YS., S Brew5:er. RL
measured radi-ographically. Goniomctric mCasurements yield {1971i. Force (Jocl molion analySIS 01 the norma!. d,seased
,
"
determined. Be- I
\
,,~ ginning in full plantarncx-ion. the ankle joint I
" ' I
/ 'I
f
and jamming of the Anterior I \ 1 I Posterior
, -- _ .J
,
Groove lor ,:-'-
Tibialis Posterior
- Tendo calcaneus
_ Groove for
FI. Halfucis Longus
n- Bursa
/f.J
- Calcaneus
Top, Lateral side of the foot and ankle. Bottom, Medial side
of the foot and ankle_ From Anderson, 1. (Ed.) (1978). Gram's
Atlas of Anatomy. Baltimore, MD. Lippincott, Williams & Wilkins.
20
D
ro
"E
~
c
10
Interosseous "E
'u
membrane
"c.
~
"0
Anterior tibiofibular ci
ligament z
%I!P--\t-lnterosseous 0
ligament I I
80 100 120 140
Posterior Degrees
tibiofibular
ligament
Inferior transverse
(tibiofibular) ligament
Average angle between the cafcaneofibular and talofibu-lar
ligaments in the sagittal plane. The average angle is 105° with
considerable variation from 70 to 1400 among measured
Components of the ankle syndesmosis. subjects.
ATF o Sprain Injury
i
basketball player with an injury that results from a
IR
Abrupt rupture
Microtears [ .j.
associa~e~ ~vilh
..
139 N
sprain InJury
A
~------B
I Function of the posterior talofibular ligament (PH). A, The PTF
limits posterior shift (PS) of the talus or anterior shift (AS) of the
tibia·fibula. B, The PTF limits external rotation (ER) of the talus or
internal rotation (lR) of the fibula, ATF, anterior talofibular Elongation of the Antero Talofibular Ligament
ligament; D, deltoid ligament.
(:ase Study Figure 9-2-2.
TI14'"
(Medial talar lill) LS 1.9 mm
AS 5.6 mm
IT 0
and Settles (1994) performed CT scans of loaded ca- 5ubtalar joint and ankle joilll inversion are oflen difficult
daveric ankles in an apparatlls that did not constrain to separate clinically. The calcaneoribular lig-ament provides
rotation and demonstrated that talar lilt or an average 201 )
stability to inversion and torsional stresses to both the ankle
still occllITcd in loaded ankles aftcr sectioning both and sublalar joints. Stephens and Sarnmarco (1992) provided
anterior talofibular and calcaneonbular liga-ments. They an inversion stress
did not feel thal the articular surfaces prevented inversion (0 cadaveric ankles and sequentially sectioned the anterior
instability during ankle loading. Most studies agree that talofibular and calcnncofibular ligaments. They found that lip
loading of the ankle results in increased stability as a result to 500/0 of the inversion observed clinically was coming from
of articular surface con· grueney. especially in ankle the subwlar joint. The structures that contribute to stability of
dorsiflexion. the subialar joint afC the calcancofibular ligament, the
Syndesmotic stability is dependent on the in-tegrity or cervical ligament. the interosseous ligament, the lateral talo~
calcaneal ligament, the ligament of ROtlvicrc, and the
both malleoli. the syndesmotic ligaments, and the deltoid
extensor retinaculum (Harpel: 1991) (Fig. 9-58).
ligamentous complex. During ankle dorsinexion. there is
approximately I rnm of mor-tise widening and 2" of
external rotation of the fibula (Close, 1956). The normal
distal fibular mi-gration with loading is I rnm (\'\fang et aI.,
t 996). This distal fibular mignllion serves to deepen the
Kinetics of the Ankle Joint
ankle mortise for addcd bony stability (Scranton, The reaction forces on the ankle joint dudng gail arc equal
McMaster, & Kelly, 1976). With disruption of the mortisc to or greater than the hip and knee joints, respectively. The
in an external rotation injury, the s~'n- desmotic ligaments and following static and dynamic analyses give an estimate of
deltoid ligaments are tOI'n, the distal fibula fmclures, and the the magnitude of the re-action forces acting on the ankle
talus displaces laterally. A study of cadaveric ankles by joint during stand-ing, walking, and running.
Olgivie-Harris et al. (1994) deflI1ed the conlribution to re-
sistance to lateral talar displacenlcnt by the syn-desmotic
ligaments to be 350/0 for the anterior tibiofibular ligament,
40% for the postcrior tibiofibu-lar ligan1cnt, 22% for the
interosseous ligarncnt, anel less than t00/0 for the interosscous
membrane.
"
100 20 40 60
A under the metatarsal heads and mav also con-tribute to
0.4
interdigital neuroma formation. Eleva-tion of thc heel also
:E i" 0.2 Illa}' ovcr time result in Achilles contracture, limited ankle
C> 0 ""..,...•"..,.
'Q5 lL. 0 dorsiflexion, and an altered gait. The amount 01" ankle
~
>.
D
joint mo-tion in the gait cycle decreases as heel height in-
0 0.2
£ '" creases (Murray ct aI., 1970).
'"0 t;: 0.4 '"
<;;
'0
u. 0.6 'iD
"«
'"
0.8
I Summarv
100 60
Percentage of Cycle 1 The I"oot alternates in form and function be-t\veen
(stance phase)
shock-absorbing flexible platform and rigid propulsive
B lever during different phases of the gait cvcle.
"4 The Lisfranc's joint (tarsornctt\tarsal joints) is 15 The deltoid ligament prevents ankle ever-sion, extcTnal
intrinsically stable and relatively immobile as a re-sult of its rotation, and lateral talar shift. It is kc~" in maintaining the
arch-like configuration and the key-like structure of the integl-it,Y of the syndes-mosis.
second tarsometatarsal joint.
,~ The first metatarsophalangeal joint exhibits a wiele range 16 The fibula bears approximately one sixth of the force
of motion, with gliding throughout Illost or its range and exerted through the lower extremity.
jamming at full extension.
JZ The distal syndesmotic ligaments prevent separation of
<,§:,('The medial longitudinal arch acts like both a beam the distal fibula and tibia and help lransmit force through the
and a truss. The arch is elevated through the windlass distal fibula on wcight-bearing.
mechanism of the plantar fascia. The pos-terior tibial tendon
provides c1ynarnic support to the arch.
18 Ankle joint centroid (cenler of pressure) posi-tion
changes wiLh ankle flexion-cxtension and inver-sion-
? Foot muscle action during standing is rela-tively silent, eversion. TalaI' surface contact is maximized and joint
but sequential firing of both extrinsic and intrinsic muscles is pressure is minimized in dorsiOexion.
necessary to produce a nor-mal gait patlcrn. The anterior tibial
19 The rorces acting on the ankle can rise to levels
musculature fires during early stance to slow fOOL
exceeding five tin1es body weight during walking and
plantarOexion and prevent fOOl slap. The posterior cnlf
muscula-ture fires during mid- and late stance to control pro~
thirteen times body weight dudng running.
grcssion of the body over the foot. 20 Narrow shoes and high heels can ad\'ersel~' af-fect foot
mechanics, leading to forefoot deformities, heel pain, and
~8 During barefoot standing, the heel bears 60% or the load
Achilles contracture.
and lhe forefoot bears 28(Yr!. Forefoot peak pressures occur
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Wanin:nhaus, A. & Pn:Llcrklieber, \1. (1989), First tar-sometatarsal joint:
Sal'l'afian, S.K. (1993a}. FUllctional anatomy of the foot and ankle. In Anatomical and biomeehanical study.
An(ltomy or the Foo! ami Anl:lc (pp. 474-602l. Philadelphia: Lippincott. FOOl Allkfe, 9, 153.
\Vaters, R.I.., Hislop, I-U., Perry, .I., et al. (1978). Energctics: Application of
Sarnlfian, S.K. (1993b). Retaining systems and compart-ments. In the study and m,Hl~lg('mcnt of locomotor disabilities. Orlhop Clill North
A/UlIOIllY
Lippincott.
or the Fool (lilt! Auk/e (pp. 137-149). Philadelphia: Am, 9, 351.
\Vright. D.G" Desai, S.\1.. 6: Henderson, \V.H. (19M), Action of the sublalar
Scranton, P.E., ;V\c,\'laster, J.I-I., &. Kelly, E. (1976). Dynamic fibular and ankle joilll comrle.'\ during the stance phase of walking . .1 130111.'
function: A new concept. Clill OrfflOp, 118,76-81. Joil/I Sur,!!" 46.'1, 361.
10
Biomechanics of the
lumbar Spine
Margareta Nordin, Shira Schecter Weiner adapted from
Margareta Lindh
Introduction
The Motion Segment: The Functional Unit of the Spine
The Anterior Portion of the Motion Segment
The Posterior Portion of the Motion Segment
The Ligaments of the Spine
Kinematics
Segmental Motion of the Spine
Range of lvIotion
Surface Joint Motion
Functional Motion of the Spine
The lvIuscles
Flexion and Extension
Lateral Flexion and Rotation
Pelvic Motion
Kinetics
Statics and Dynamics
Statics
Loading of the Spine Dunng Standing
Comparative loads on the Lumbar Spine During Standing, Sitting, and
Reclining
Static Loads on the Lumbar Spine During
Lifting Dynamics
Walking
Exercises
lvIechanical Stability of the Lumbar
Spine Intra·AbdominalPressure
Trunk Muscle Co-Contraction
External Stabilization
Summary
References
Introduction 11 12 13 14
2
The human spine is a complex structure whose principal
functions are to protect the spinal cord and transfer loads 3
10
from the head and tnmk to the pelvis. Each of the 24
vertebrae articulates with the adjacent ones to permit motion
in three planes. The spine gains stability from the 4
intervertebral discs and from the surrounding ligaments
and muscles; the discs and ligaments provide intrinsic
5
stability and the muscles provide extrinsie support,
Molion
segment
257
BICIMECHANICS Of JOINTS
.. _ ----------
prcssure in normal and slightl." degenerated cadavcr
lurnbar nuclei pulposi has shown an intrin-
The intervertebral disc, \vhich bears and distrib-utes Distribution of stress in a cross·section of a lumbar disc un-der
loads and restrains excessive motion, is of great compressive loading. The compressive stress is highest in the
mechanical and functional importance. It is well suited for nucleus pulposus, 1.5 times the externally applied load (F) per
its dual role because of its location be-tween the vertebrae unit area. By contrast, the compressive stress on the annulus
and because of the unique com-position of its inner and fibrosus is only approximately 0.5 times the externally applied
outer structures. The inner portion of the disc, the nucleus load. This part of the disc bears predom-inantly tensile stress,
which is four to five times greater than the externally applied load
pulposus, is a gelati-nous mass. Rich in hydrophilic (\vater-
per unit area. Adapted
binding) glycosaminoglycans in the young adult, it dimin-
,vith permission from Nachemson, A. (!975j, Tmvards a berrer
ishes in glycosaminoglycan content with age and becomes
understanding of back pain: A reviev'/ of the mechanicS of the
progressively less hydrated (Urban & McMullin, 1985). lumbar disc RheuI"T1illol Rehabi!, j'l.129
CHAPTER 10 • BIOMECHANICS m THg;~8.tv1Bj;'RS:~:[~;&l~O
sic pressure in the unloaded disc of approximately \0 N per stl·ess in the annulus fibroslis in the thoracic spine is less
square centimeter (Nachemson, 1960). This intrinsic than that in the lurnbar spine because of differ-ences in
pressure, or pre-stress, in the disc results from forces disc geometry. The higher rario or disc di-ameter to height
exerted by the longitudinal ligaments and the ligamentum in the thoracic discs reduces the cir-cumferential stress in
flavum. During loading of the spine. the nucleus pulposus these discs (Kulak et aI., 1975).
acts hydrostatically Degeneration of a disc reduces its protcoglycan content
(Nachemson. t 960), allowing a unifonn distribution of and thus its hydrophilic capacity (Fig. 10-5,
pressure throughout the disc; hence, the entire disc serves a A-C). As the disc becomes less hydrated, its elastic-ity and
hydrostatic function in the motion seg-ment, acting as a its ability to store energy and distribute loads gradually
clishion between the vertebral bod-ies to SLare energy and decrease; these changes make the disc(s) more vulnerable
distribute loads. to stl-csses.
In a disc loaded in compression. the pressure is
approximately 1.5 times the externallyay)plicd load per unit
THE POSTERIOR PORTION
area. Because the nuclear material is only slightly
OF THE MOTION SEGMENT
compressible, a compressive load makes the disc bulge
laterally; circumferential tensile stress is slIst"ined by the The posterior portion of the Illotion segment guides its
annular fibers. In the lumbar spine the tensile stress in the movement. The t~'pe of motion possible at any
posteriol- part of the annulus fibrosus has been estimated to IC\'e1 of the spine is determined b~" the oriental ion of the
be four LO five times the applied axial compressive load facets of the inlervenebral joints to the trans-verse and
(Galante, 1967; Nachemson, 1960, 1963) (Fig. 10-4). The frontal planes. This orientation changes throughollt the
tensile spine.
Except for the facets of the two uppermost cervi-cal a high collagen content, which limits tht.:ir extensi-bility
vertebrae (CI and C2), which arc parallel to the transverse during spine motion. The ligalllL'llllllll flavull1, which
plane, the facets of the cervical inten.1cr-tcbral joints are connects two adjaCL'1l1\'(,I"lcbralarches longi-
oriented at a 45° angle to the trans-verse plane and arc (lldinall~·, is an exception. having a lal'gc percentage of
parallel to the frontal plane (Fig. 10-6A). This alignment of dastin. The clasticit.Y of (his ligamclll <.lIlows it to
the joints of C3 to C7 al-lows flexion, extension, lateral contract during c.'\h..:nsion of the spine and 10 elon-gate
flexion, and rotation. The facets of the thoracic joints arc during nc.'\ion. Even when the spine is in a neu-tral
oriented at a 60 0 angle to the transverse plane and at a 20° position, the ligamentum flavul11 is uncleI' con-Slant
angle to the frontal plane (Fig. 10-68); this orientation tension as a result of its elastic properties. Because it is
allows lateral flexion, rotation, and some flexion and exten- located at a distance from the center or motion in the disc,
sion. In the lurnbar region. the facets arc oriented at right il pre-stresses the disc; that is, along with the longillldinal
angles to the transverse plane and at a 45° angle to the ligaments, it creates an irllradiscal pressure and thus helps
frontal plane (Fig. 10·6C) (White & Panjabi. 1978). This provide intl-insic support to the spine (Nachemson &.
alignment allows Oexion, exten-sion, and lateral Oexion, EV<.H1s, 1968; Rolander, 1966). Research suggests that with
but almost no rotation. The lumbosacral joints differ from degen-erative changes such as spond~"lolisthesis, traction
the other lumbar in-tervertebral joints in that the oblique spurs, and disc degeneration, which rna}' lead to in-
orientation of the facets allows appreciable rotation stability, altered mechanical stress \vill increasingly load
(Lumsden & Morris, 1968). The above-cited values for the ligamentum fluvul11 and callSt: hypertrophy
facet ori-entation are only approximations, as considerable (FlIkllyama el aI., 1995).
variation is found within and among individuals.
The amount of strain on the various ligaments differs
with the type of motion of the spine, During llc.'\ion, the
The facets guide movement of the Illotion segment and interspinous ligaments arc subjected to the greatest strain,
have a load-bearing function. Load-sharing be-tween the followed by' the capsular liga-ments and the ligamcnturn
facets and the disc varies with the position of the spine. The flavum. During exten-sion, the anterior longitudinal
loads on the facets arc greatest (ap-proximately 30% of the ligarnent bears the greatest strain. During latcral fle:don,
lotal load) when the spine is hyperextended (King et aI., the contralat-eral lransverse ligament sustains the highest
1975). Because the facets arc not the primary SUPPOI1 strains. followed by the ligament nuvulll and the capsular
structure in extension, if total compromise of these joints ligaments. The capsular ligaments of the facet joints bear
occurs, an alternate path of loading is established. This path the most strain during rotation (Panjabi et aI., 1982).
involves the transfer of axial loads to the annulus and
anterior longitudinal ligament as a way of supporting the
spine (Haher et aI., !994). High loading of the facels is also
present during forward bending, coupled with rotation (EI-
Bohy & King, 1986). The vertebral arches and Kinematics
intervertebral joints play an important role in resisting shear
forces. This function is demon-strated by the fact that AClive mol ion of the spine as in any joint is pro-duced b.'/
patients with deranged arches or defective joints (e.g., from the coordinated interaction of nerves and muscles.
spondylolysis and lis-thesis) are at increased risk for Agonistic n1uscles (prime movers) initiate and carry out
fOl'\vard displacement of tbe vertebral body (Adams & motion and antagonislic muscles control and modif." the
Hutton, 1983; Mi11er et aI., 1983) (Case Study 10·1). The motion, while COH contraction or both groups stabilizes the
transverse and spinolls processes seniC as sites of spine, The range of motion differs at various levels of the
attachment for the spinal muscles, whose activity initiates spine and depends on the orientation of the facels of the
spine motion and provides extrinsic stability. intervertebraljoinls (Fig. 10-6). Motion be-tween two
vertebrae is small and docs not occur independently; all
spine movements involve the combined action of several
motion segments. The skeletal structures that influence
THE LIGAMENTS OF THE SPINE motion of the lrunk are the rib cage, which limits thoracic
1110-lion. and the pelvis, which augments trunk move-ments
The ligamentous structures surrounding the spine by tilting.
contribute to its intrinsic stability (Fig. 10-2). All spine
ligaments except the ligamentum Ibvulll have
CHAPTER 10·BIOMECHANICS OF THE LUIl.1~1i~FJ~'F!·1~1iD
Cervical
(C3-C7)
Thoracic
Lumbar
c
Orientation of Orientation of
the facets to the facets to
the transverse plane the fronlal plane
Orientation of the facets of the intervertebral joints (ap- and are parallel to the frontal plane. B, The facets of the
proximate values). Reprinted with permission from White, A.A. thoracic spine are oriented at a 60° angle to the transverse
& Panjabi, M.N. (1978). Clinical Biomechanics of the Spine. plane and at a 20° angle to the frontal plane. C, The facets
Philadelphia: J,8. Lippincorr. A. In the lower cervical spine, the of the lumbar spine are oriented at a 90° angle to the trans-
facets are oriented at a 4S~ angle to the transverse plane verse plane and at a 45° angle to the frontal plane.
~
,'Sponaylolisthesis:Anterior Slippage of One Vertebra in Relation to the
Vertebra Below It
'- 30-year·old male gymnast complains of severe back pain interarticularis (aspect of the postenor arch of the vertebra that lies
A '''''..,with radiation to both legs. The pain is associated with periods of
betyveen the inferior and superior facets). This bilat· eral defect
leads to an (lnterior displacement of the vertebra lS onto S1. As the
strenuous training and the symptoms decrease
~ith rest or restriction of activity, After a careful examination l5 vertebra begins 10 slip forvllard, the cen-ter of gravity of the body
b'yaspecialist and MRI films. a diagnosis was made of is displaced anteriody. To compen-sate, the lumbar spine above the
spondylolisthesis at the level L5-S1 (Case Study Fig, 10-1-1), with lesion hyperextends and the upper pan of the trunk is displaced
concurrent bilateral pars interarticularis defects of L5 (Case Study backward. Because thi) is a disease continuum. the abnormal
Fig, 10-1-2),
forces placed on the inter· vertebral disc leads to herniation into the
-' Physiological loads during repeated flexion-extension mo-tiOn, neural foramina, producing moderate stenosis. of both l5-S I nerve
of the lumbar spine caused a fatigue fracture of the pars
rootS.
SEGMENTAL MOTION OF THE SPINE the relative amount of motion at different levels of the
spine. Representative values from \Vhite and Panjabi
The vertebrae have six degrees of freedom: rotation about
(1978) are presented in Figure 10-7 10 al-lc)\v a comparison
and translation along a transverse, a sagittal. and a
of motion at various levels of the thoracic and lumbar spine.
longitudinal axis. The motion produced dur-ing nexion. (Representative values for motion in the cendcal spine are
extension, lateral nexion, and axial rota-tion of the spine is included for comparison.)
a complex combined motion re-sulting fTom simultaneous
rotation and translation.
lnvestigations of the thoracic and lumbar spine show
that the range of l'lexion and extension is ap-proximately 4°
in each of the upper thonlcic motion segments,
Range of Motion
approximately 6° in the mid thoracic re-gion, and
Various investigations using autopsy material or approximately 12° in the two lower tho-racic segments.
radiographic measurements in vivo have shown di~ vergent This range progressively increases in the lumbar Illotion
values for the range of motion of indivi-dual motion segments. reaching a maxi-mum of 20' al Ihe lumbosacral
segments, but there is agreement on level.
CHAPTER 10. BICIIvIE.CHANICS
OC- Cl
Cl - 2 ' - '47'
2 -3
3-4
4 -5
5 -6
6-7
C7 - Tl
Tl - 2
2 -3
3-4
4-5
5-6
6-7
7-8
8-9
9 - 10
10 - 11
11 - 12
T12 - Ll
L1 - 2
2-3
3-4
4-5
L5 - 51
Flexion- Lateral Rotation extension flexion
A composite of representative values for type and range of motion at different levels of the spine.
Reprinted with permission from White, AA & Panjabi, M.N (978). Clinical Biome-chanics of the
Spine. Philadelphia: J.B. Lippincorr.
Lateral flexion shows the greatest range in each of the center of flexion-extension and lateral flexion in a motion
lower thoracic segments, reaching 8 to go. In the upper segment of the lumbar spine lies within the disc under
thoracic segments, the range is uniformly 6°. Six degrees normal conditions (Fig. 10-8A) (Cossette et aI., 1971;
of lateral flexion is also found in each of all lumbar Rolandel~ 1966). With abnormal concli-tions such as
segments except the lumbosacral seg-ment, \vhich pronounced disc degeneration, the instantaneous center
demonstrates only 3° of 111otion. pathway will be altered (Fig. 10-8B) (Gertzbein et aI.,
Rotation is greatest in the upper segments of the 1985; Reichmann et aI., 1972).
thoracic spine, \vhere the range is 9°, The range of rotation
progressively decreases caudally, reaching 2° in the lower
FUNCTIONAL MOTION OF THE SPINE
segments of the lumbar spine. It then increases to 5° in the
lumbosacral segment. Because of its complexity,') the motion of a single nl0~ tion
segment is difficult to measure clinically. Ap~ proximate
values for the normal functional range of motion of the
Surface Joint Motion
spine can be given. Variations among individuals are large
i\''Iotion between the surfaces of two adjacent verte-brae and show a Gaussian distribu~ lion in the three planes. The
during flexion-extension or lateral flexion may be analyzed range of motion is strongly age~dependent, decreasing ·b~v
b:v means of the instant center method of Reuleaux. The approxi-mately 30% from youth to old age, although \vith
procedure is essentially the sanle as that described for the ag-ing, loss of range of motion is noted in flexion and
cc,·vical spine in Chapter 11 (see Figs. 11-18 and 11-19). lateral bending while axial rotation motion is main-
The instantaneous
GIFttfi~~T \I • BIOMECHANICS OF JOINTS
G-J degeneration
~
J
ing-Sorensen, 1984; Moll & Wright, 1971). Loss of range of
motion in the lumbar and/or thoracic spine is compensated
for mainly by motion in the cervical spine and hips.
iJ
' "-'",7 THE MUSCLES
A
~ B
.( ~ L5
The spinal muscles can be divided into flexors and
extensors. The main flexors arc the abdominal mus-cles
(the reClus abdominis muscles, the intern,,) and external
oblique muscles. and the transverse ab-dominallllllsclc)
and the psoas muscles. In general, muscles anterior to the
vertebral column act as flex-ors. The main extensors arc
Instant center pathway for a normal cadaver spine (A) and a
cadaver spine with moderate disc degeneration (B). Instant
the ercCLOr spinae mus-cles. the multifidus muscles. and
centers were determined for 3~ intervals of motion from the intcnransver-sarii muscles auached to the posterior
maximum extension to maximum flexion. In the normal spine, elements. 1n general, the muscles posterior to the vertebral
all instant <enters fell within a small area in the disc. In the columns act as extensors (Fig. 10-9). The extensor
degenerated spine. the centers were displaced. and hence the
surface motion was abnormal. Reprinted wirh per· mission from
Gerr£bein, S.D., er al. (1985). Centrode patterns and
segmental instability in degenerative disc (Jisease. Spine, 10,257.
Anterior
Rectus abdominis muscle Transversalis fascia
Transversalis
Internal oblique Vertebral body
External oblique
Lumbar fascia:
Anterior
Middle
Posterior
Flexion is initiated by the abdominal muscles and the full flexion to upright positioning of the trunk, the pelvis
vertebral portion of the psoas muscle (Anders~ son & lavendel~ tilts backward and the spine then extends. The sequence of
1997; Basmajian & Deluca, 1985). The weight of the upper muscular activity is reversed. The gluteus maximus comes
body produces further flex-ion, which is controlled by the into action early together with the hamstrings and initiates
gradually increas-ing activity of the erector spinae muscles extension by pos-terior rotation of the pelvis. The
as the forward-bending moment acting on the spine in- paraspinal muscles then become activated and increase
creases. The posterior hip muscles are active in con~ trolling their activity until the movement is completed (Andersson
the forward tilting of the pelvis as the spine is flexed &
(Carls!j", 1961). It has long been accepted that in full Lavender~ 1997).
flexion, the erector spinae muscles be-come inactive once Some studies have shown that the concentric ex-ertion
they are fully stretched. In this position, the fonvard performed by the muscles involved in raising the trunk is
bending moment was coun-U:Tacted passively by these greater than the eccentric exertion per-formed by.' the
muscles and by the posterior ligaments, \vhich are initially muscles involved in lowering the trunk (de Looze et a!.,
slack but be-come taut at this point because the spine has 1993; Friedebolcl, 1958; Joseph, 1960). However, this
fully elongated (Farfan, 1975). This silencing of the erector finding has been con-tradicted in several studies (Reid &
spinae muscles is known as the flexion-relaxation Costigan, 1987; Marras & Mirka, 1992). Creswell ancl
phenomenon (Allen, 1948; Andersson & Lavender, 1997; Thortensson (1994) support the finding that less
Floyd & Silver, 1955; Morris et a!., electromyo-graphic (EMG) activity is noted during
eccentric ac-tivity, as in lowering, despite high levels of
force generated. The compressive load of the spine caused
962). However, Andersson et al. (1996), using wire by the muscle exertion produced by lower-ing the trunk
inserted in the trunk extensor muscles ~l1icl("cI by
CICCII'()('"'' with a load or resistance can approach the spinal tolerance
ultrasound or MRI, showed that in the flexed position limits, putting the back at greater risk for injury (Davis et
the superficial erector spinae muscles relax, while the aI., 1998).
quadratus lumborum and lateral lumbar erector spinae
muscles become When the trunk is hyperextended from the up-right
'''''V<lIeu (Fig. 10-10). In forced flexion, the superfi- position, the extensor rnuscles are active dur-ing the initial
extensor muscles become re~activated. From phase. This initial burst of activity de-
creases during funher extension, and the abdominal joints function mainlv as shock nbsorbers and are
muscles bccorne active to control and modify the important in protecting the intervertebral joints (Wilder
motion. In extreme or forced extension. extcnsor ac- et al.. 1980).
tivity is again required (Floyd & Silver. 1955). When loaded in vitro. the Sljoint exhibits th"ee-
dimensional movement with joint opening rotation
ranging from 0.5 to 1.2 0 and sacrum antcrior-
Lateral Flexion and Rotation
During lateral Oexion of the trunk, motion may pre-
dominate in either the thoracic or the lumbar spine. In
the thoracic spine, the facet orientation allows for Imeral
Oexion. but the rib cage rcstricts it (to vmying degrees
in different people); in the lumbar spine. the wedge-
shaped spaces between the intervertcbral joint surfaces
show variations during this motion (Reichmann. 1971).
The spinotransversal and trans-versospinal systems of
the erector spinae muscles and the abdominal muscles
arc active during lateral I1cxion; ipsilmeral
COnlractions of these muscles ini-tiate the motion and
contralateral contractions mod-ify it (Fig. 10-11)
(Andersson.& Lavender. 1997).
Significant axial rotation occurs at the thoracic and
lurnbosacral levels but is limited at other le\'els of the
lumbar spine, being restricted by the vertical orientation
of the facets (Fig. 10-6C). In the thoracic region, rotation Left
is consistently associated with lat· end flexion. During
lhis coupled motion. which is most marked in the upper
thoracic region, the ver-tebral bodies generally rotate 0
toward the concavity of the lateral curvc of the spine L3
FIG. 10-11
------
Pelvic Motion
Example of eleetromyographic activity of the erector spinae
Functional trunk movements not only involve a muscles collected with surface electrodes during side-bending
combined motion of different parts of the spine but also of the trunk. The figure illustrates trunk bending to the right
require the cooperation of the pelvis because pelvic and muscle activity at the ll, l3. and lS level of the lumbar
Inotion is essential for increasing the range of functional spine. Substantial contralateral mus-cle activity (left) of the
motion of the trunk. The relationship be-twecn pelvic erector spinae muscles is recorded when bending to the right
movements and spinal motion is gen-erally analyzed in to maintain equilibrium. Repro-
terms of motion of the lum-bosacral joints. the hip duced wirh permission from Andersson. G.BL Orrengren. R.• &
joints. Ol'both (Fig. 10-12). Load transfer From the spine Nachemson. A. (1977). fIHradiscaf pressure. intra-abdominal
to the pelvis occurs through the sacroiliac (SI) joint. pressure and myoelectric back muscle dcrivily related to poswre
Biomechanical analysis of the sacroiliac joints suggests and foading. Clin OrtllOp, 129. 156,
that these
lIsed. This involves measuring the m.voelectric aCliv~ it~,. of
the tnlllk muscles and correlating this activity with calculc:tlcd
values for muscle contraction forces. The values obtained
correlate well with those obtained through inLradiscal
pressure measurement and can thereFore be lIsed to predict the
loads on the spine (Andersson & Lavendcr, 1997; bnengren ct
aI., 1981; Schuhz et aI., 1982).
posterior rotation ranging from 0.3 to 0.6°; trans-lation STATICS AND DYNAMICS
ranged from 0.5 to 0.9 mm (\Vang & Dumas, 1998). In vivo
analysis of the 51 joint utilizing roentgen In the following section, static loads on the lumbar spine
slereophotogrammetr~!shows joint rota-tion mean at 2.5 0 and are examined for common postures such as standing and
translation mean at 0.7 mm with no differences between silting and also for Iif1ing. a common activity involving
symptomatic and asymptomatic joints (S,uresson et aI" 1989), external loads. [n the final section, the dynamic loads on
the lumbar spine during walk-ing and common
Muscle forces acting on the 51 joint have a stabi-liZing strengthening exercises for the back and abdominal
effect. helping to attenuate the high stress pelvic or muscles arc discllssed.
loading (Dalstra & Huiskes. 1995).
Statics
Kinetics The spine can be consich.:red as a modified elastic rod
because of the nexibility of thc spinal column. the
Loads on the spine are produced primarily by body weight. shock~absorbingbehavior of the discs and ver-tebrae. the
muscle activity, pre-stress exerted by the lig-aments, and stabilizing function of the longitudinal ligaments, and the
externally applied loads. Simplified cal-culations of the elasticity of the ligaments flavum. The two curvatures of
loads at various levels of the spine Can be made with the the spine in the sagit-tal plane-kyphosis and lordosis-also
usc of the [Tee-body technique for coplanar forces. Direct contribute to the spring-like capacity of the spine and allow
information regarding the vertebral column to withstand higher loads than if it
loads on the spinc.,(ll the level of individual interver-tebral were straight. A study of the capaci.ty of cadaver
discs can bq/~btainedby measuring the pres- thoracolumbar spines devoid of muscles to resist vertical
Sure within the d(scs both in vitro and in vivo. Be-cause loads showed lhat the critical load (the point at which
this mel~od is too complex for general buckling OCCUlTed) was approxi-
;
application. a semidircclmcasuring method is often
cles, the abdominal muscles an.: often intermittentlv ,-
lclive in maintaining tlte neutral upright poshio;, and
stabilizing the trunk (Cholc\\'icki el aI., 1997).
However, this activit~· is readily reduced by the COI11-mand to
stand relaxed (Hodges &. Richardson. 1997).
The venchr;:ll portion of the psoas muscles is also
invol\'ed ill producing postul'al s\\'a~' (Basmajian, 1958;
Nachemsoll, 1966). The level of aClivity in these muscles
varies considerably among individu-als and depends to some
extent on the shape of the spine, for eX<:\J11plc, on the
magnilllde of habitual kyphosis and lordosis.
/' .......
)i
((r'"
~
~:
mate!y 20 to 40 N (Gregersen & Lucas, 1967; Lucas &
Bresiel; 1961). The critical load is much higher in vivo and !\~\,
varies greatly among individuals. The ex· trinsic support '\. ;,;
provided by the trunk muscles helps stabilize and modify the \ i !
loads on the spine in both dynamic and static situations. 'J
.~
A B
LOADING OF THE SPINE DURING STANDING
When a person stands. the postural Illuscles are constantly o
active. This activity is minimized when the body segments
arc well aligned. During stand· ing, the line of gravity of
the trunk usually passes ventral to the center of the fourth
lumbar vertebral body (Asmussen & Klausen, 1962). Thus, it
falls ventral to the transverse axis of motion of the spine and
j -30
•
CHAPTER 10. BIOMECHANICS
. '" I
0 Nonspecific Low Back Pain '
Nachemson, 1975 .~
"
,S ~ 35-year-old male presents complaints of low back
400 0 Wilke, 1999
"(;9.-
en
c
A pain with radiation lO the posterior aspect of the leit
% thigh, not past the knee. His pain staned 3 weeks ago, af-ter
'5
300 ~
iii'"
c
'1" c!ll working a 12-hour shift, when he lifted \-vhile twisting an
i~
unusually large, yet lightweight box, During the iirst week of
]
;) ~
£ ' ,Z
,;I J.! pain, he visited his physician, who prescribed pain medication.
'C ~ ,.i
200 Currently, he is still in pain, panieufarly during sitting or
" ,~ ~, •
standing for loog periods. During a iollmv-up physician visi!, a
ro ~
,~
E
z
0
1
.~
% "~ #~ '1
,
careful examination showed the patient to be
someV'ihatovel\veight. ",vith weakness in his abdom· inaI and
100 ~ "
back muscles and poor flexibility in hiS ham-strings. psoas, and
~~~~ ~
c
;, ~
'1
back muscles. Neurological tests were normal and diagnostic x-
rays were normal as well, leading to a diagnosis of nonspecific
low back pain (Case Study
Fig.10-Z-1).
Tension
Compression
Dynamics
~Lw
Almost all mol ion in lhe body increases muscle rc-
<:r'=i~-A- =-::t= -=-i cl'uitmcnt and the loads on the spine. This increase
is modest during such aclivities as slow walking
or casy twisting but becomes morc marked during
450 N variou's exercises and the coqlplexity or dynamic
movement and dynamic loading (Nachclllson &
Elfstrom, 1970),
WALKING
In a study of normal walking at four speeds, the
compressive loads at the L3-L4 mOlion segmenl rangcd
200 N
from 0.2 to 2.5 limes body weight (Fig. 10-19) (Cappozzo,
1984), Thc loads were maximal around loe-off and
Talal fo"vard- Tolallorward- increased approximatel~1 lin-early with walking speed.
bending moment bending moment
= 69 Nm = 192,5 Nm
Muscle .action was mainly concentrated in the trunk
extensors. Incli-vidual walking trailS. parlicularly the
11 Calculation Box Calculation Box
Figure 10-2-1. figure 10-2-2. amount of forward flcxion of the trunk, influenced thc
$---------"-~---_.
loads,
The Technique Employed During Lifting Influences the Loads
on the Lumbar Spine
In the three situations shown in Calculation Box Figures 10-3-1, total forward·bending moment of 151 Nm(f200 N x 0.35 mJ
10-3-2. and 10-3-3, an identical object weighing 20 kg is lifted. + 1450 N x 0.18 m!).
Case 1 (upper body flexed forward) (Caleula- Case 3 (Cal(l,lIalion Box Fig. 10-3-3) shows that bem knees
tion Box Fig. 10-3-1) is identical to Case 2 in Calculation Box 10- per se do not decrease the forward-bending moments.
2, v~here ttle total fONJarcl-bending moment is 192.5 Nm. If the object lifted is held out in front of the knees, the lever arm of
In Case 2 (Calculation Box Fig. 10- 3-2), lifting with the knees the force produced by the weight of the object (l,.) in-creases to 50
bent and the back straight places the object closer to the trunk, ern. and [he lever arm of the ierce produced by the weight of the
decreasing the forwclrd-bending moments. The lever arms of the upper body (L..:) increases to 25 em. Thus, tile total forwarcj-
forces produced by the weight of the object (U and Lipper body IL,) bending moment created is 212.5 Nrn 1{200 N x 0.5 mj ... 1450 N
are shortened 10 35 and 18 em, re-spectively. at this point in the x 0.25m!).
lifting process. The result is a
200 N 200 N
The greater this flexion, the larger the muscle pressive jomt loading and EMG outpul with creased
forces and hcncc the compressive load. Callaghan lumbar spine motions. 1n conclusion. cause of low
et al. (1999) corroborated lhese findings and fur- tissue loaeling, walking is a safe a
ther showed that walking cadence affects lumbar perhaps ideal therapeutic exercise ror those w
loading, with increased anterior-posterior shear forces low back pain (Callaghan et al" 1999) while att tion to
noted as speed increased. Limiting arm swing during speed of walking can further moder spinal loads (Cheng
walking resulled in increased com- ct al" 1998)_
, "
loads on cl lumbar disc I,'iillbe calculilled for on,! point in tim[''t/hen a NUJ to be posit]>,'eand counterciochvis('moments are considered to
cer50n who weighs 70 kg lifts a 20 kg obj!'ctThe spin£'is flexed ilpprW.i. negeltl'/e.i
, 35 Q
In this example, the three priflclpdl forces ,Kling on the lurnl)ilf Thus,
allhe lurnbosilual le'leiilfe: (1) HK force produced by \1',(' ','ieight01
:::: r,il 0
upper body (Wi. Ciilculat.:d to be ':50N (approxin\ille!y 65",0 of the exerted
{\,V :< L<..J· (P >:U - iE >.: L) 0
by lhe IOtal body weigh!); (2) tile fOlce produced b~i the
(450 N ;.; 0,25 m) " (200 N >: DAm) \t ;.: 0.05 m) 0 E ;.: 0,05
of the object (Pl, 200 N; "neJ (3) trw force produced by contraction the
erector spinae muscles (El, which has a kno':mdirection anel point of rn 112.5 Nrn -;- 80 1~m
ap,al",,'''''' but an unknQl,W1 magnitude (Calculi1lion Box Fig. 1O·4A·l) Solving this equation for E yields 3.850 N
Because these three forces <let at a distance from the center of motion in Th!: to",1 compre~~!'/e force exe!led on the disc (Cl can now be calcu-lawd
the spine, they crcate moments in the lurntBr spille, Two fOPNard-ber:(j· in,) trigonof1,etricaliy (Calculation Box Fig. 10·cIA-2). in the example, C is lhe
moments (\iVl:,_ cl!ld PL,) are the products of (V{: and (Pi and the perpen- sum of lhe compressive forCi':s"cLng O'lel the disc. '.vhichis inclined to the
diculars from the instanl center of rOIMion to the lines of action of these fc,rces triirlSVelSe pldfle These forces are
(,heir lever Mms), The le'/erarm (L'J for (Pl is 0.<1 III and the !e'/erarm
(L,,) for (W) is 0.25 m. f\ counterbalanCing moment (ELi is the product of lEi and Its
The compressive force produced by the weight of the upper body
(V'/), \'ihichacts on the disc inclined 35'0(W:-: cos 35°).
lever arm, The lever elm: (l) is 0,05 m, TIl('fI1agnitude of (E) CiJll b~~ found tilrough
the use of the equilibriufI1 equa,ion for moments, For ,he kJdy to be in moment
2 The force producHJ by the '.veightof the object (Pl, which acts on the
disc inclined 35" (P '<cos 35"')
equilibrium, the sum of the moments aCiing on the ;u:nbar spine must be zeo (In ihis
3 Th;;,: fOlce produced by ,he erector spinae muscles (E), 'i,hichacts ap-
example. cloch'!isemorm,nts "re consid-
proxirn,w.:ly at il right angle to the diSC inclination.
The totdi compressive fOlce acting on the disc (C) has a known sense,
point of ilppliciltion, dnd line of iKlion but an unknown magnitude. The
n:dgnllude of C (an bt": ioundlflrough H\e use of the eq\Jiiibriurn 0quation for
forces For the body to be in force eqUilibrium, the sum of the forces must b(,
.-,qual to zero
Force W (450 N) Thus,
:::: forces a
Force C (v') :-: cos 35") ,. (P:· cos 35") .. E C °
(magnitUde Force P (200 N) (';501'-;1.: cos 3S~) .c. (200 N ;.: cos 35") -'. 3850 N ." C ;co 0
unknown) C 368.5 N .;. 163,8 N·· 3850 1'J Solving the
f I \, ~ equation for C yields 'U82 1'1
L-! Force S
\,\ \\ l' C '"4382 N (magnitude The shear component for the reaction force on the disc (S) is found in the
~P S373 N unknown) same'i/ay
Calculation Box
Figure 10·4A~1.
Calculation Box
Figure 10-4A-2.
{450 ~J '.,: sin 35") ;, {ZOO N :':sin 35") _. S ,'. °
373 N
~r-----------------------------------------
/ h) '"CJR
/ FOTeo E (tt) '" archsin (ClR) ;co 85" where (t,) is the angle belween lhe total vector force on the
disc and the disc inc!ina,ion
/ 35
The problem can be graphically solved by COlf5trUCling a v0ctor diagram
b"sed on the knQ'.'mvalues (Calcul,llion Box Fig, 10-48·2), A venicalline repre~
senting (V'l),-;. (P) is drawn first; (EJ is added at a right angle to the disc inclina~
Calculation Box Calculation Box tion, and (R) closes ,he triangle. The direction of (R) in relation to the disc termined
Figure 10-48-1. Figure 10~4B·2.
8IC'MECHANICSOF JOINTS
Walking Speed is recolllmended for c:\ercise that an initial position that h:eps
Slow (1.05 mfsec 1) the \"e["IL'hr~IL' in a 1l1Orc parallL'1 alignnlent is preferahle
l
Normal (1.38 m/sec' ) \"hen stn.:ngthcning e:\L'rcises for the LTector spinae
---------
l
IllLlscles ~\re performed (Fig. 10-2(13).
Fast (1.72 m/sec' )
The importance of the ahdorninal muscles in spinal
Very fast (2.16 mfsec 1) stahilit.'· and inlL'rpla.\" in the production of lAP reinforces
the need ror strong ahdorninal l1e.\-ors. Sit-ups arc a userul
exercisc ror ahdcllllinal rnusclc strengthening, wilh man."
:c
0> 2 vari:'\lions prac-ticed and cncOllraged by health
·ffi
;;: prol"cssionals, but cerlain vari:'l1ions arc viewed as hannflll
>- to the low back. Although the most common belief has heen
"0
In that sit-ups with the knees llexed and fed llnan~ chored will
<5 emphasize the abdominal contribution while minirnizing
~
E
~ psoas acti\"it." (.JukeI' et aI., 1998), this is not true. Both bent
f-
knee and straight leg sit-ups will producL' comparable le\"L'ls
.£
~ of PSO~\s and ab-domin~d aClivit.\", crealing c(lmpressivc spinal
~
0
LL
load-ing. Curl-ups, in which the head and shoulders arc raised
onl.\" to the point where the shoulder blades clear the l<.lble and
0 lumb<.lr spinL' motion is mini-
LHS RHS LHS
~l-L---:':--'-l.:-I-:'::-'-:!:::-''---
L
0 20 40 60
Percentage of Cycle
80 100
:Jmi!.ed (F'ig. 10·21) and ortell emphasized in rehabili-tation
programs, arc recommended for minimizing compressi\"L'
lumbar loading (A,der &. l\-!cGil!. 1997; Jukcr L't aI., I(98).
This modilic<'ltion of the exen:isc has been shown to be
Axial load on the L3~L4 motion segment in terms of body weight cl"fecti\'c in terms or Illotor unit recruitment in the muscles
for one subject during walking at four speeds. The horizontal line (F.kllOlm el aI., 1979; Flint, 1965; Partridge &. \\'alters,
(UBW) denotes the weight of the upper body, which represents 1959); all portkms 01' the external oblique and rcctus
the gravitational component of abdolninis rnuscles <.lre activated. Sit-ups with feet
this load. Loads were predicted using experimental data from unanchored, legs ele-vated, or tOI"SO twisting do not
photogrammetric measurements along with a biome-chanical significantl.v increase abdorninal muscle <.lclivit." (AxleI' &:
model of the trunk. LHS, left heel strike; RHS, J'dcGill, 1997), To lirnit the psoas activity, <.l reverse curl,
right heel strike. Adapted with permission from Cappozzo, A. wherein the knees arc brought t()\vard the chest and the
(1984), Compressive toads in the lumbar vertebral column dur-
buttocks <.lre raised I"rom the table, aetivalL's the internal
ing normal level walking. J Orthop Res, 1, 292.
:.mel external oblique rnuscles :.md the reclus abdominis
muscle (P<.\rtridge &: \Vahers, 1959), If the reverse curl is
perrormcd isometricall.v. the disc pressure is lower than that
produced during a sit-up, bUl the ex~ ercise is just as effective
EXERCISES
for strengthening the ab-dominal rnuscles (Fig. IO~22l. It can
During strengthening exercises for the erector spinae and he concluded that no single :.Ilxlominal exercise C<.m
abdominal muscles, the loads on the spine can be high. optimall.v train ~dl tnmk flexors while minimizing intervertebral
Although such exercises must be effective for joint loading. Instead, a \'aried program must he prc~ scribed,
strengthening the trunk muscles con~ cerned, they should be tailored to the training objectives of the in-dividual (;hler &
performed in such a wa:\' that the loads on the spine are McGill, 1997).
adjusted to suit the con-dition of the individual.
The erector spinae muscles are intensely activated by \Vhen designing a back strengthening cxercise progr:'llll,
arching the back in the prone position (Fig. the most import:.lnt consider:.ltion is the conclusion drmvn bv
IO-20A) (Pauly, 1966). Loading the spine in extreme positions the Paris Task Force (Abenh:.lim et al., 2(00). The guidelines
such as this one produces high stresses on spine structures, set forth in-clude recommendations that exercise is beneficial
in particular the spinous process for subacute and chronic low Inlck pain, No partic-ular group
(Adams et aI., 1988). Although intradiscal pressure in a or t~'pe of exercises has bcen shown to be most efTccti\·c.
prone position with upper bod)' support on the elbows is
halF that in standing (Wilke et aI., 1999), it
CHAPTER 10 • BIOMECHANICS OF THE LUM~i\R ~P(~§i~,;i~?l.
A, Arching the back in the prone position greatly activates the erector spinae muscles but also
produces high stresses on the lumbar discs, which are loaded in an extreme position. B,
Decreasing the arch of the back by placing a pillow under the abdomen allows the discs to better
resist stresses because the vertebrae are aligned with each other. Isometric exer-cise in this position
is preferable.
., ' .
200
150
100
50
Performing a curl to the point where only the shoulder A reverse curl, isometrically performed, provides efficient training
blades dear the table minimizes the lumbar motion and of the abdominal muscles and produces moderate stresses on the
hence the load on the lumbar spine is less than when a full lumbar discs. The relative loads on the third lumbar disc during a
sit-up is performed. A greater moment is produced if the full sit-up and an isometric curl are compared with the load during
arms are raised above the head or the hands are clasped upright standing, depicted as 100%. Adapted with permission from
behind the neck, as the center of gravity of the upper body Nachemson, A. (1975). Towards a better understanding of back
then shifts farther away from the center of motion in the pain: ~ review of the
spine. mechanics of the lumbar disc. Rheumatol Rehabil, 14. 129.
•
MECHANICAL STABILITY cles. [lS unloading mechanism was first proposed bv
OF THE LUMBAR SPINE Banelink in 1957 and I\-torris et al. in 1961. The)'
suggested that lAP serves as a "pressurized balloon"
i\tlechanical stability for the lumbar spine can be achieved
altempling lO separate the diaphragm and pelvic noor (Fig,
through several means: lAP, co·conlrac-lion of the tnlllk
10-23, A & B), This creates an extensor moment that decreases
muscles, external support, and surgery. Surgical procedures
lhe compl-essio!1 forces on lhe lumbar discs_ The extensor
for lumbar spine sta-bility will not be covered in this section.
moment produced by TAP has been calculaLCd in several
biomechanical models, with widely varying resulting
reductions in extensor moment from 10 to 400;' of the
extensor load (Anderson et at .. 1985; Chaffin, 1969; Eic,
Intra-Abdominal Pressure
1966; Lander et al .. 1986; Morris et aI" 1961).
lAP is one mechanism that may contribute to both
unloading and stabilization of the lumbar spine. Recent studies using fine-wire EMG of the deeper
.IAP is the pressure created within the abdominal cavity by abdominal muscles found that the transver-sus abdominis
a coordinated contraction of the di-aphragm and the is the primary abdominal muscle re-sponsible for lAP
abdominal and pelvic floor mus- generation (Cresswell, 1993;
Spine
160
140 Force."
120 ......
-lbs- --::._
" .
100
80 Respiratory flow
Abdominal Positive n:--~ Inlraabdominal
values = Inspiralion
cavity 60 Negalive
pressure
values=expiralion : -mmHg-
40
20 r \r- !
Ibs
mmHg
A B
A, Schematic illustration of the effect of intra-abdominal pres- values delineate expiration and positive values delineate inspi-
sure. An increased pressure will create an extension moment on ration). Note that the subject inspires before the lift and holds
the lumbar spine. B, Intra-abdominal pressure (lAP) (mea-sured the breath throughout the lift. lAP increases and peaks to-gether
by a nasogastric microtip transducer) and respiratory flow with the lifting force. helping to stabilize and unload the lumbar
(measured through a Pneumotach) during stoop lift of 120 lbs. spine. (ourtesy of Markus Pieuek, MD and Marshail Hagins PI:
(approximately 60 kg). Solid line, lAP; dotted line, force exerted in MA. Program of Ergonomics and Biomechanics, New York.
lbs; dashed line, respiratory flow (negative UniversiC'j and Hospital for Joint Diseases, New York, Ny' USA.
Cresswell el aI., 1994a; Cresswell eL aI., 1992; Hodges cl Loss of spine stabilit~... can be achieved through
aI., 1999). As the transversus abdominis is ho.-izontally repetitive loading. This can be achieved through repetitive
oriented. it creates compression and an incre,lSC in lAP continuous motions that fatigue the trunk muscles. l\tlusclc
withollt an accompanying flexor moment. A recent endurance is mechanically defined as the point at which
experimental study gave the.firsl direct evidence ror a fatigue of the mus-cles is observable. usually through a
trunk extensor moment pro-duced by eleva Led lAP change in movement pauern. Parnianpour ct al. (1988)
(Hodges el aI., 2000), used an isoinenial triaxial device to study force output and
It has been demonstrated that the lAP con-tributes LO the movement patterns when subjects performed a flexion and
mechanical stability of the spine through a co-activation extension rnovemcnt of the trunk un-til exhaustion. The
between the antagonistic lrunk lIexor and extensor muscles results showed that with fa-tigue, coupled motion increased
(Cholewicki et aI., 1997, 1999a,b; Gardner-Morse & in the coronal and transverse planes during the Oexion and
Stokes, 1998). As the abdominal musculature contracts, extension movement. In addition, torque. angular
JAP increases and converts the abdornen into a rigid excursion, and angular velocity of the motion decreased.
cylinder that greatly increases stability as compared with The reduction in the functional capacity of the f1exion-
the muhisegmenlcd spinal column (ivlcGiII & Norman. extcnsion muscles was compensated for by sec-ondary
1987; Morris et al.. 1961). Illuscle groups and led to an increascd cou-pIc motion
pattern that is morc injury prone. Figure 10-24, A & B
lAP increases during both stalic and dynamic conditions shows the increase in axial ro-tation (torque and position)
such as lifting and lowering, running Hncl jumping, and during flexion and ex-tension of the trunk until exhaustion.
unexpected trunk perturbations (Cresswell el aI., 1992;
Cresswell et aI., 1994b; Cress-well & Thorslcnsson, 1994;
Harman et aI., 1988). Current research suggests that the
transversus ab~ clominis muscle, together with the In an animal study, Solol11onow ct al. (1999) in-duced
diaphragm, plays an important role in stabilizing the spine laxity of the spine in the ligaments, discs, and joint capsule
in prepa-ralion for limb movement, regardless of the direc- by' cyclic repetitive loading of fc-line in vivo lumbar
tion in which n1QVement is anticipated. Transversus spines. The cyclic loading re-sulted in desensitization of
abdominis and diaphragmatic activity appear to oc-cur the mechanoreceptors with a significant decrease or
independently, prior to activity of the primary limb mover complete elilnina-tion of reflexive stabilizing contractions
or the other abdominal muscles (Hodges eL al.. 1997, of the multifidus muscle. This may lead to increased in-
1999). stability of the spine and a lack of protective mus-cular
activity even before muscular fatigue is ob-sen/cd. A IO-
minute rest period restored the mus-cular activity to
approximately 250/0.
Trunk Muscle Co-Contraction
To understand the phenomenon or co-contraction during
trunk loading, Krajcarski et al. (1999) stud-ied the in vivo
External Stabilization
muscular response to perturbations at two rates causing a
rapid flexion moment. The results of maximum trunk Restrict.ion of motion at any level of the spine may
flexion angles and re-sulting extensor moments were increase motion at another level. The usc of back belts as a
compared. The re-sults showed that with higher levels, co- means of preventing low back injury re-mains
contraction, spine compression. and trunk muscle stiffness controversial. Originally it was believed to assist in
in-crease. During unexpected loading, a 70% in-crease in increasing lAP as a way of unloading the spine during
muscle activity has been noted as com-pared with lifting; however, inconclusive evi-dence exists as to the
anticipated loading, which may lead to injury (Marras et biomechanical effectiveness of these devices (Perkins &
al.. 1987). Further investiga-tion into the loading response Bloswick, 1995). The National "Institute for Occupational
has revealed that an inverse relationship (i.e .. the shorter Safety and Health has advised against the use of back belts
the warn-ing time, the greater the peak trunk muscle re- Lo prevent low back injuries (NIOSH, 1994). As well. an
sponse) exists between peak muscle response and warning orthotic worn lo restrict lhoracic and lumbar motion may
time prior to loading (Lavender ct a\., 1989). result in compensatory motion at the lumbosacral level
(Lumsden & Morris, 1968; Norton & Brown, 1957; Tuong
et aI., 1998).
F1ex.-Exl. Torque and Posilion vs. Time
143.0 - , -- ... , . ---- , - , ------------------------------- ,
, 78.3
E
T~
7.9
J\I\I~I~\~I\ llmlm 1111111 Ill\/II\
~
!!
-·32.4
-127.1
!i~i I~i~
-'::======::;:======::;====================~
58.6,
40.9
2.3
E
, 2.3
z
,
" 1.1
~
!!
0
....
-0.6
-2.1
19.1
,
w 13.3
"~
co
"
7.0
'i'
c
.Q
.~
0
Q. 0.7
- 5. 1 -!--,----,-.-,.--...,--,-.,..--,----,-.-,.--...,--,-.,..--,----,-'-.-,.--...,--,,-.,..--,----,--I
0.1 9.3 18.4 27.5 36.6 45.7 54.7
B
Dynamic (isoinertial) flexion-extension trunk testing until Data for lateral flexion was similar to axial rotation and not
exhaustion for one subject. Torque and position data is de-picted shown here. Adapted with permission .from Parnianpour, M ..
for two planes, flexion-extension (A) and axial rota-tion (B). Note Nordin. M .. Kahclnovitz, N.. er al. (1988). The rriaxial coupling
that flexion-extension torque production is diminishing as is the 0; torque generarion of trunk muscles during isomet-ric
amount of performed extension of the trunk (A). Rotational exertions and the effect of fatiguing isoinercial movements on
torque and movement amplitude, increased accessory motion, the motor outpur and movemeor pc1tterns. Spine. 13(9).
and torque is shown in B. 982-992
CHAPTER 10· BIOMECHANICS OF THE LUMii!\R:g~i~E ·;'.28'f~
_c,,->:'7!!!II!ffJ
Investigation into the effect of back bells on muscle on the spine to bc minimized during lifting, the dis-tance
activity has revealed no significant EMG activity bL'lween the trunk and thc object lifted should be as short
differences in the back extensors during Iifling with or as possible.
withoul a back bell (Ciriello & Snook. 1995; Lee & Chen. 10 lAP and co-contraction of trunk musculature
1999), while McGill el al. (1990) showed slightly increased increases the slability of the spinal column.
EMG aClivily in the abdominal (except for the intel'l1al
oblique l11uscles) and erector spinae muscles. Thomas et 1/1' Trunk muscle fatigue may expose the spine to
'.11. (1999) have verified a slight increase in EMG ac- increased vulnerability as a result of loss of' motor control
tivity (2(10) in the erector spinae during symmetric lifting and thereby increased stress on the sur-rounding ligaments,
wilh a back belt. Back bells have not been shown to disc, and joint capsules.
significantly increase Iifling capacity (Reyna el aI., 1995). ,12 vValking is an excellent exercise thai poses a low
load on the lurnbal' spine.
REFERENCES
Summary Abt.:nhairn, L., Rossignol. ~'t., V~dal. J.P., l'ta1. (2000). Thc role of acti\'ily in
the tht.:r:q1clllic management of back pain. Report of thl: Inll:rn:l1ion~1
1 The lumbar spine is a highly intricate and com-plex Paris Task Force on Back Pain.
structure_ 5pinc. 25. IS.
Ad~lillS, M.A.• Dolan, P.. & 1·lutlon W.e. (1988). The lumbar spin\.' in
2 A vertebra-disc-vertebra unit constitutes a mo-lion b~tChnlrd bl·nding. Spille. 13. 1019
segment, the [unctionalunit of the spine. Atbms. ~L\. & Hulton, W.C. (19831. The 1lll.:ch;lIlicill func-tions of Ihe
lumbar apophyst.\ljoints. Spil/e. 8, 327.
, 3" The intervertebral disc scrves a hydrostatic function Alkn, C.E.L (1948). i\lusdc action potenlials used ill the sludy of dynamic
in the motion segmcnt, storing energy and analolll~', 13r J Phy.~ Jtcd, 11,66.
distributing loads. This function is reduced with disc Anders()Jl, C.K., Chaffin, D.B., Hcrrin, G.D .. ct :11. (1985). A
dcgeneration. biolllcchanical model of the lumbosacral joint during lift-ing ~\cli\'ities. J
BiollH'dllllll·I.:S. 18, 57.
~:"4 The primary function of the facet joint is to guide the :\lHkl'sson. E.A .. Oddsson, L.I.E .. Grundstrom, 1-1., ct al. (1996). E;\'lG
motion of the mOlion segment. The orien-tation of the acti\'ities or thl' qlladnHlIs lumborum erector spinae musdes
~llld
facets determines the type of motion possible al any level during flexion-relaxation and other motor lasks. CJinial!
Bio1llcdUlllics, J J, 392.
of the spine. The facels may also sustain compressive Andersson, G.B.J. & l:l\·cnd"r. S.A. (1997). Evalu;ltion of
loads, particularly during hyperextension. Muscle Function. In J.W. Frymoycr (Ed.). Tilt' A(/1I11 Spil/t',
Pril1c.:ip{es (lilt! Praclict: (2nd cd., pp. 341-3$0). New York:
Li ppi ncot t-Ra\·l:n.
S Motion between two venebrae is small and docs not Andersson. G.B.J .. Ortengrcn. R.. 0:: Nachcmson. r\. (1976). Quantitati\-
occur independentl~y in vivo. Thus, the functional motion of c studies or b~lck loads in lifting. Spillt:. I. 178.
the spine is always a combined action of sevel',,1 motion Andersson. G.B.J .. Oncngren. R., & Nachcmson. r\. (1977). lntr'ldiscal
segments. pressure. intr~\·... bdomin ...1 prl.'SSUrl' ilnd myo-det:tric bad lllusck
:ll:tivity rdated to pOSl\lrc <lnd load-ing. Clill OrtJlOp, 129, 156.
/6;- The instantaneous center of motion for the mo~ lion Andersson, G.B.J .. Onengl'cn, R., Nachclllson, A., et al. (1974).
segments of the lumbar spine lIsually lies within the lumbar Lumbardisc pressure and myoelectric b"H:k muscle
disc. ~\clidty during sitting. 1. Stu,dics 011 an experimental chair. SC(/I/d J
Rclwhil ,Ht.:d, 6, 104.
The trunk muscles play an important role in providing ,\sl11usscn, E. & Klauscn, K. (1961). Form and fUllction or the (.'rcc(
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CHAPTER 10. BIOMECHANICS OF THE LtJ'~1~5PI;-§rj;:i'83~
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annulus of the hurn'lllspinal disc due 10 l.:X' trcme loadilll.!. Pmc lifting bl.'l!:- Ol1 ll'unk Illusck :1l"lil':Lli()[l during a
Illst Jleclt Ef/J,!, (llJ. 204, 14l.
sudlk'111.\" appli<:d In.td. /l1t'WIII Faclo!"s. ·iI. 6iO.
Rcichm;t1Hl, S.~ (1971). Motion or thc lumbar anicular processes in
luong, N.H., {),lll:-l,.·r(,.·:HI. J .. \latlr~tis, G.. 1.'1 ~d. (199S.J. Three.
fh:xiull-cxtcnsion and lateral flexion of the spine. ~1c[(t .\!orp!lo/ dillll..'llsional I.·\·alu.ltion of lumhar urthosis dkcts on
Nt'crl SCfllld 8, 261. :-pinal bL'h;l\"i\11". J Uclwbil Il.·... Del'. 35. 3-1.
Reichmann, S., Bl.'rglllnd, E.,..\: Lundgr(,.·n, K. CJ972). Das B(,.·. lrb'lIl, J.P,G. & :\kMllllin, J.r. (1985). Swdlillg prl.';.;slIl"l' of thl'
wegungszcntrum in der LendenwirbclsAule bei Flc.xio[l lind Extension. inleJ"l.·crtd.u·al di!'L';Infllh:llc(,.' 01 pmIL'oglyc;1I1,lnd col.
Z A/llIl EIII\\·ickltlll;;';;;':I!.\·(.·h. /38,283. I:q;l'nCOlllt:'IlI:-. Bifl,.h.,o!o.t:..\·, 22. 1-45.
Reid, J.G. &. Costigan, P.A. (1987). Trunk llluscle balance and muscular \',111 Dici:n. l,tI., llUCt"l.I.'lllan:-, M.L\!.. &. TUllssainl, 1-1.:\1.
force. Spill/!, /2, 783. (1999J. SH,op or squal: ,.\ rl.'\·it'\\·of bilJlll(,.·<:hallil:al :-tudies on
Reyna, J.R. Jr., Leggdl, S.I-I., Kenney, ~., "I .d. (1995). The ef. feCi of lifling 1I.:(hniqu(,.'. CliJl Bifl/lft'c}wuic:•. /4. 6$5.
Ilimbar bells on isolated IlImb,lr musl'!e. Slrength and dynamic \bn~..\1. & DUlllHS. G.:\. (199S). \kdl;lIlh,:al hdl;l\'ior of th~ fl.~lllak
(;"padt)'. Spilll.', 20, 68. s:l(roilial.· joinl [llld inflllL'nCt' of t!l(,., :l1l11.·rior ,Ind
Rolandcr, S.D. (1966). ~'lotion of lhe lumb'lf spine wilh spe-cial reference poskrinr s:II.::roilia<: Iigamcnts under sagittal In'lds. Clill
to the stabilizing effect of posterior fusion. Hiw!lccltullio. /3, 193.
An experiment"l study 011 autopsy specimens . .'\elll Ortho}l \\'hi!l.', :\..-\. (1969). An:d.\"sis of thL' Illl'I'!l,lnit:- 01' lhoracic spint:' ill Illan.
8colld, .)11]1]11. 90, 1-144. An expl.·rillll.'llt,t1 stud.\' (II' :lllIOPS.\' spl'ci. mens . .·le/ll ()rt/wp ,"jcl/ud,
Sato, K., Kikuchi, S" & '{onez;Jwi1,1'. (1999). In vivo intradis. cal pressure SIIp/i! il7, 1-105.
llle'lsuremCllt in healthy individuals and in p<iticnts with ongoing back Whilt:, A.A. l\:. P:lnjahi. :\I.N. (19701. Cliniud HiulIlt'cI/(il/ics oj" Iht'Spilit'.
probll.'ll1S. Spille, 24, 2468. I'hil:ldl.'lphia: J.B. Lippincott.
Schuhz, A., ~l ~\1. (1982). Loads on lhe lumbar spine. Valida. ""ilkl.', "1.1., Ned. Po, C:lillli. :\1.. <'I al. (19991. ;\I.'W in \,i\"(1
lion of a biolllcchanicaJ analysis by mC<lsurenH.'IllS of in. ml.·asur(,.·IIK·nts of pr(,.'ssurl.'S in Ihl.' inl<.'l'\·(,,·rlChral disc in
Ir~ldisc.d prc:sslIn:s <1I1d myol.'!l.·ctric sign ... k J BOIlt' Joil/! Surg. dail~' life. Spill.·, 24. 755.
64.·\,713. Wilder. D.G., POpl.· ..\1.1-1 .. &. Fr.\"Ino~·L'r. J. W. (1980). ThL' func-
Shir4lzi-t\dl. ,.\. (1994). Biomt'ch4lnics of lhe lumbar spine in sagittalJlatcral tional lopogr,tphy of the s;Jcroiliac joint. Sp;/It'. 5, 575.
moments. Spi/h:, /9, 2407.
Biomechanics of the
Cervical Spine
Ronald Moskovich
Introduction
Component Anatomy and Biomechanics
Anatomy
Osseous Structures
Intervertebral Discs
Mechanical Pmperties
Vertebrae
Intervertebral Discs
Ligaments
Muscle
Neural Elements
Kinematics
Range of Motion
Surface JOint Motion
Coupled Motion of the Cervical Spine
Atlantoaxial Segment
Subaxial Spine
Abnormal Kinematics
Spinal Stability
Occipitoatlantoaxial Complex
$ubaxial Cervical Spine
Applied Biomechanics
Decompression
Arthrodesis
Cervical Spine Fixation
Biomechanics of Cervical Trauma
Airbag Injuries
Whiplash Syndrome
Summary
I· References
•
arc five t.'·pical cervical vertebrae, C3-C7, which arc
Introduction sirnilar in structure and function.
The spine has four curves when viewed in the sagiual
Knowledge of spinal biomechanics advanced expo-
nentially during the second half of the twentieth centlll)'. A plane. The celvical and lumbar regions arc convex
two-column model of the spine was de-scribcd by Sir anteriorly (lordotic), while the thoracic and sacra) regions
Frank HoldswOIth (1963) and, latel; a lhree-column model are convex posteriorly (k)iphotic). The lordotic curves
develop after birth as the in-fant's spine straightens out,
by Denis (1983), further refin-ing the principle or spinal which facilitates devel-opment of a bipedal posture.
stability. The computer age has produced powerful Although there is a
methods For modern hiomcchanical modeling, the promise
being the ability to assess the slnbility of n construct prior
to implantation. Today. the application of cendcal bio-
mechanical knowledge spans many inclustl'ies and
supports improved medical diagnoses and treaL-ment that is
more effective. Future technological and electronic
advances will continue to build on basic biomechanical Cl (atlas)
principles, many of \\:hich will be outlined in this chnpter.
C2 (axis)
Facet
joint
ANATOMY
A
The exquisite design of the cervical spine uniquely
contributes to the structure of the human body and
profoundly enhances its function. The cervical spine
supports the skull and acts as a shock ab-sorber for the
brain. It also facilitates the transfer of weights and bending
moments of the hend. It protects the brainstem, spinal cord,
Uncovertebral
and various neurovascular SU'UClures as they transit the
joint
neck nnd when they enter and exit the skull. The verte-bral
column also provides a multitude of muscle and Intervertebral
ligamentous attachments for complex move-ment and disc
stability. The neuromuscular control af-forded by the Tracheal air
muscle ntlnChmenls combined with the numerous shadOw
articulations of the cervical spine al-lows for a wide range
of physiological motion that maximizes the range of motion C7
of the head and neck and serves to integrate the head with
the rest of the body and the environment.
B
The spine consists of 33 vertebrae divided into five
regions: cervical (7) (Fig. II-I), thoracic (12), lumbar (5),
sncml (5 fused segments), nnd coccvgeal (approximately
4). The two most cranial vertebrae, Cl (atlas) and C2 (axis). A, lateral roentgenogram of the cervical spine. Note the
[Ire atypical. with a unique structural role in the lordosis. The facet joints are aligned obliquely only to the
articulation between the head and the cervical spine. The frontal or <oronal plane; hence, their excellent visualiza-tion in
atlanta-occipital joint, bel ween CI and the oecipital bone the lateral view. a, Anteroposterior view of the <er· vical spine.
of the skull, is also a functional part of [he cervical spine.
There
287
o 288 PART II • BIOMECHANICS OF JOINTS
harmonious progression of these curves from one to sagittal range of motion of the cervical spine. The Cl-C2
another, which may help distribute stresses and strains, articulation is the joint primaril.\-' responsible for rotation
injuries occur more commonly at the jllnc~ tional areas in the cel'Vical spine.
because of differences in the relative stiffness of each The atlas, or C 1, is a bon.\-' ring consisting of an
anatomical segment of the spine. anterior ;:\lld posterior arch that is attached to the two
The physical structure of the anatomical elements !;:\terallnasses of the atlas (Fig. 11~2). The su~ pcrior
modulates from the cervical to the sacral region in relation to surfaces or the latent! rnasses, which face crani<:dly <:md
the segmental function. inward, form an <:\rticulation with the caudally and
The lordosis in the cervical spine, like that in the lumbar clutward-facing occipital cond.\-'les of the skull (Fig. 11-3).
spine, is maintained predoI1linantl:v b.v slightl)' wedge- E.xtension ()f the occipitocer~ vical joint is limited by' the
shaped intervertebral discs that arc larger anteriorly' than bon.\-' <:uwt()!ll.v; flexion is lirnited prirnaril.\-' by
posteriorly. In contradistinc-tion, thoracic kyphosis is ligarneluous structures, the tectorial mernbrane, and the
maintained largely.' by the vertebral bodies themselves; longitudinal fibers of the crucifonll ligarnent as well as by
because the posterior portion of the thoracic vertebral body is the posterior ligaments (Figs. 11 ~4 and 11 ~5). The anterior
larger than the anterior portion, there is a relative kyphosis of tu-berek' on the <:llTh of C I serves <:lS <:In attachment
the thoracic spine. for the longus colli muscle, a flexor of the neck. The
posterior arch of the atlas is a modified larnina that is
The conceptual biomechanical building block of the grooved on its superior surface for the pas-sage or the
spinal colunln is the Functional spinal unit or motion vertebral arteries as the.v enter into the fClrarnen magnum
segment. It consists of two adjacent verte-brae and the after piercing tile posterior
intervening intervertebral discs and lig~ aments between the
vertebrae. These ligaments arc the anterior and posterior ntlanto~(lccipital nlelllbl"ane.
longitudinal ligaments; the intertransverse, interspinous, Simi!;:\r to the occipitocel'Vical junction, there is 11()
and supraspinous ligaments; and the facet capsular intervertdJral disc betwecn Cl and C2. Stability at this levcl is
ligaments. As a re~ suit of the different functional demands thus predicated on intact osscoliga-l1lentclus structurcs. The
of the vari-ous parts of the spinal column, segmental variation articulation between Cl and C2 is primaril.\-' specialized for
is expressed by! changes in the size and shape of the rotation. The bod.\-' of C2 projects superiorly to fOlTn the
vertebrae, the anatomy of the discoligamentous structures, and odontoid process, or dens (Fig. 11 ~6). The projection of the
the alignment and structure of the facet joints. bod.\-' or C2 and the dens has a characteristic oblong
appearance on lateral cervical radiographs and is
Occipital
Occiput·C1
condyle ,r--__ joint
Transverse Dens
process
Cl-C2
Lateral mass facel joint
of Cl
Lateral mass
ofC2
The open-mouth radiograph demonstrates the occiput-(l and the atlantoaxial articula-tions.
Note the symmetric spacing between the lateral masses of (1 and the dens. Asym-
.
metry or widening of these spaces may occur after rotatory disturbances or fractures of the (1 ring .
--------------------------
Median sagittal section through the occipital bone and
the first three cervical vertebrae showing the articulations
and surrounding ligaments.
Anterior Posterior
Superficial layer of
tectorial membrane
Apical
ligament Tectoria! membrane
I 01 dens
! Ant:~~~
I of alias
I
Dens of axis -t;~ffB~ll
Transverse
ligament ~~~~y..
Anterior
Iatlantoaxial
I ligament
interv~~:bral
I fibrocartilage
I Anlerior
1 longitudinal
ligament Posterior
longitudinal
Body of C3 ligament
",,","u .
~--~
. @0
)'~~.-,.:,::(-'\..
Flexion Extension
C4
CS
C6
C7
Orientation of the facets of a typical cervical vertebra in three
planes. The facets are oriented at a 45" angle to the
transverse plane and the frontal plane, and are at right angles
to the sagittal plane. Y indicates the craniocaudal axis. z the
anteroposterior axis. and x the mediolateral axis. Adapted
'.t'lieh permission from White, A.A. 111 & Panjabi,
M.M. (1990). Cfinical Biomechanics oi the Spine. Pili/adelphia: Lateral photograph of a fourth and seventh cervical verte-bra.
1.B. Lippiflcort The facet joint alignment is fairly close to 45° from the transverse
I plane. Note also the difference in size of the spinous processes,
e which are a reflection of the size and importance of the muscle
attachments_
Intervertebral Discs
The intervertebral discs are highly specialized st11.1C-
tures that contribute up to one-third of the height of the
vertebral column and fmm specialized joints be-tween
the cartilaginous end plates of the adjacent vertebral
bodies. Activities such as running and jumping apply
short-duration, high-amplitude loads to the intervertebral 1cm
discs, whereas normal physical activity and upright stance
resuh in the application of long-duration, low-magnitude
loads to the disc. Discs are able to withstand greater than
normal loads when compressive forces arc rapidly applied Anterior view of a sixth cervical vertebra. The shorr arrows
based on the biomechanical principles of viscoelasticity. indicate the uncinate processes and the Ic;mg arrow indi-cates the
This propeny protects the disc /i'om catastrophic failure pathway of the sixth cervical nerve root. The facet joints are
until extremely high loads are applied. located posteriorly. Bar = 1 em.
The nucleus puiposlis is centrally locmed within the disc
~~~~~~~~? -I) ( ,./ pulposus
distribution in the bone. Bending moments are ap-plied to in a neutral position or somewhat extended, and thus pre-
the vertebral bodies during motions. During lie.""", tensile stresses the disc to some degree and provides some
stresses are applied to the posterior intrinsic support to the spine (Nachemson & Evans, 1968;
and compression to the anterior cortex of the body. Rolandcl~ 1966). The elastic properties also assist in limiting
To perform lifting tasks, the back are required the in\varcl buckling of these ligaments during extension,
to develop considerable forces which could potentially compress the neural clements.
IS"hltltz et aI., 1982). Stresses in a typical cClvical
change from tensile to cornpressive in a re-gion
approximately 0.5 to I cn1 anterior to the pos-
~ longitudinal ligament (Pintar et al., 1995). As is
Muscle
weaker and fails earlier in tension than in compression,
posterior paraspinal muscle contrac-can decrease the Muscular strength and control is imperative to maintain
tensile stress on bone by! pro-ducing a compressive stress head and neck balance. In the cervical spine, muscle
that reduces or neutral-izes the posterior cortical tensile strength also has a role in reducing stresses on bones.
stresses, allowing the vertebrae to sustain higher loads Bending n10ments are applied to the vertebral bodies
than would othenvise be possible. However, bone will during various motions. During flexion, tensile stresses are
often fail prior to damage occurring to the intervertebral applied to the posterior cortex and compression to the
disc under compressive loading. Finite element model- anterior cortex of the vertebral body. Substantial loads on
ing of the cervical spine indicates that the increase in end the eel-vie'll spine have been calculated during neck
plate stresses may be the initiating factor for failure of this flexion, par-ticularly! in the lower cenrical motion
component under compressive loads segments.
Harms-Ringdahl (1986) calculated the bending
('loganandan et al., 1996a). moments generated around the axes of motion of the
atlanta-occipital joint and the C7-TI motion segment in
seven subjects with the neck in five posi-tions: full tlexion,
Intervertebral Discs slight flexion, neutraL head up-right with the chin tucked
in, and full extension. The load on the junction between the
Intenlertebral discs exhibit viscoelastic properties (creep
occipital bone and C I was lowest during extreme extension
and relaxation) and hysteresis (Kazarian, 1975). Creep
(rang-ing from an extension moment of 0.4 Nm to a flex-
occurs more slowly in healthy discs than in degenerated or
ion moment of 0.3 Nm). It \vas highest during ex-treme
herniated discs, suggesting that degenerated discs are less
flexion (0.9 to 1.8 Nm), but this was only a slight increase
viscoelastic in nature (Kazarian, 1972).
over that produced when the neck was in the neutral
position. The load on the C7-Tl motion segment was low
with the neck in the neu-tral position but bccame even
lower when the head \vas held upright with the chin tucked
Ligaments
in (ranging from an extension m0111cnt of 0.8 Nm to a
Clinical stability of the spine depends primarily on the soft flexion moment of 0.9 Nm). The load increased somewhat
tissue components, especially in the cervi-cal spine. The during extreme extension (ranging from 1.1 to 2.4 Nm) and
spinal ligaments are functional rnainly in distraction along substantially during slight flexion (reach-ing 3.0 to 6.2
the line of their fibers. Ligament strength and limited Nm). The greatest loads \vere pro-duced during extreme
extensibility help maintain stability, especially around the extension, with moments ranging from 3.7 to 6.5 Nm.
craniocer-vic'll junction. The alar ligaments have an in
vitro strength of 200 N, and the transverse ligaments have
an in vitro strength of 350 N (Dvorak et aI., 1988a). The
strength of the ligaments is related to both the anatomical In the same study, surface electrode electromyog-raphy
demands and the flexibility re~ quired, \vhich is a classic was used to record activity over the erector spinae muscles
example of form follow-ing function. of the cervical spine with the neck in the same five
positions described above. Interest-ingl}', the values
obtained showed very low levels of muscle activity for all
The ligaments all have high collagen content ex-cept for positions, even during ex-treme flexion in which the
the ligamentum flavurn, which is exceptional in having a flexion moment on the C7-Tl motion segment increased
large percentage of elastin. The ligamen-tum flavum is n10re than three-fold over the neutral position. The fact that
under tension even when the spine is the e1ec-
tromyographic levels over the neck extensors were low in
this and other studies (Founlain et aI., 1966; Takebe et aI.,
1974) suggests that the nexing mo-ment is balanced by
passive connective tissue SlILIC-tures, such as the joint
capsules and ligaments. This phenomenon is seen in many
other joints in which passive support is provided by the
ligaments.
The values for the moments computed by Harms-
Ringdahl (I986), howcvcr, are appmxi-mately 10% of the
maximal values measured by lvloroney and Schullz (1985)
in 14 malc subjccts who resisted maximal and submaximal
loads against the head while in an upright siuing posi-tion.
The mean maximal voluntary moments were 10 Nm
during axial rotation or the cervical spine, 12 to 14 Nm
during flexion and lateral bending, and 30 1m during
extension. Calculation of the maxi-mum (compressive)
reaction forces on the C4-C5 motion segment ranged from
500 to 700 N during flexion, rotation, and lateral bending.
and rose La 1,100 N during extension. AnteroposLerior
and lal-eral shear forces reached 260 Nand lION, respec-
tively. Calculated moments and forces generally correlated
well with mean~ll1easured m:voelectric activities at eight lateral cervical radiograph of a 68-year·old1Noman who
sites around the perimeter of the neck al the C4 level. presented with severe torticollis. She denied any history of injury
and did not have evidence of a suuctural vertebral abnormality,
infection. tumor, or inflammatory disease. Pseudosubluxations
(arrows) are evident subaxially as a consequence of the marked
Muscles playa cr-iLical role in basic postural kyphosis. Her neck was twisted only because she had a severe
cervical flexion de-formity. and she was unable to see forward
homeostasis, as can be observed in both historical and
except by turning her head to one side. She was neurologically
present-day clinical settings. In unique obser-vational
in-tact. It was possible to extend her neck to a relatively neu-tral
studies in lhe 1950s of severclv affecled po-liomyelitis position using gentle traction. Following posterior fu-sion from (2
patients, improvements in respiratory assistance for those to (7, she returned to a normal independent life. Muscle biopsy
with respiratory paralysis led to higher survival rates and a was consistent with senile myopathy.
large number of pa-tients who sustained complete paralysis
of the cer-vical musculature. Patients with completely nail Reprinred with permiSSion from tvioskovlCh. R. (1997). Cervical
cervical spines were unable to support their heads unless mSiabihw (rheumarold. d\·varfism, degeneraCtV£!. Oihers/ In X.H.
adequate support was provided and actually remained in Bridwell &- RL DeW,11d fEds), The Te;(lbook of Spln,ll Surgery
bed despilc the good function of their cxtrcmities (Perry & (D.o. 969- i009). Phdacie!pfJJd. Lippincorr-R,wfdl Publishers.
Nickel, 1959). Similarly, severc cervical kyphosis
occasionally is seen in elderly pa-tients \vho do not have an
obvious stntetural ctiol~ ogy when investigated
radiologically. Some of these patients were found to have
marked cenrical exten-sor muscle weakness that has been edge base is growing. To date, certain basic para~ meters
attributed to se-nile cervical myopathy (Simmons & have been established. The cervical spine undergoes
Bradley, 1988) (Fig. 11-12). significant changes in length during f1cxion and extension
(Breig el "I" 1966; Reill, 1960). Thus, while there is some
longitudinal elas-ticity to the spinal corel. it tolerates axial
transla-tion poorl~". It is the translator~' forces llwt t)-'pi-cally
result in neurological in.illr~·. A compressive tolerance
betwecn 2.75 and 3.44 kN is cstimated for the adult c~rvical
Neural Elements
spine before significant neu-rological injury occurs
Biomechanics of the neural elements have noL been as (i'Vlyers &. \Vinkclstein, 1995).
well studied as the biomechanics of the os-teoligamentous
vertebral column, but our know!-
CHAPTER 11 • BIOMECHANICS OF ii;E CE~CiS~~~f[[~~;~~;~"'D
e
"
...l2
corel and arc I110re common if the spinal is stenotic. -.
Flexion motions can result in in-when the spinal cord ::"':3
10 12 14 16 18 20 mm
makes contact with cer-vical osteophytes, and cxtcnsion
mOl ions may resull N
in a pincer-like compression of the cord between (anterior) e.
ostcophytes and (posterior) invaginated ligamentum 4;
0.__
Oavum. Anterior or central spinal cord injuries may ensue. 10 12 14 16 18 20 mm
N 16: C4
Although a diagnosis of spinal stenosis may be made ".Il____ ..
e·
based on the absolute size of the spinal canaL imaging of
the neuraxis itself may be of greater value. Contrast-
,.
O~.
10 12 1': 16 18 20 mm
enhanced computerized tomogra-phy, myelography, and
magnetic resonance imaging can demonstrate actual N 1. C5
impingement or distortion of the spinal corel. Studies ':.a . 0...
Posterior
longitudinal
ligament
Superior facet
l\v.-o-od{L Anterior
Capsular ligament,
Axial computerized tomographic scan of a sixth cervical . / longitudinal
ligament
vertebra, which was not part of the study detailed in the text. Spinous process
The anteroposterior diameter of the spinal canal
measured 13.96 mm in this specimen. "'" I Intervertebral
• Interspinous
and,
supraspinous
I
J
disc
ligaments // I I p .
// . ostenor
forces to failure For three adult spinal cord speci-mens arc L'
Igamentum
fl
avum
Inferior facet J longitudinal
I ligament Intertransverse
reported to be 278 N ± 90 (Yoganandan et aI., 1996b). ligament
I
Lower forces may result in direct neural injury or vascular A Superior facet I
disruption. Interlransverse
I
Capsular ligament ligament
c1
Reprinted with permission {rom Raynor. R.• Moskovich. R.• Zide/,
lI__ P. et a/. (1987). Alteration in primary and coupled neck motio1J5 l1Y
a_f_,e_'_fa_,_e_,e_,_,o_n_'Y_._N_,e_"_,o_S_"'_9_e_ry_,_2_1(_5_),_6_8_'_-_68_7_. _
RANGE OF MOTION
Measurements of cervical range or motion are based on +Fz 0i~---le.
radiographic studies or postmortem investiga-tions.
Inclinometers and various optoelectronic and
electromagnctic dcvices L1sed clinically for noninva-sive
evaluation of cervical spinc motion are not as accurate; in
particular, coupled motion is poorly quantified (Roozmon
et aI., 1993). The established range of active axial rotation
to one side at CI-C2 is 27 to 49° (mean = 39°); passive
rotation is 29 to 46° (mean = 41°) (Dvorak et aI., 1987; ~Fx
Dvorak et aI., 1988b; Penning & Wilmink, 1987). These
measure- r
ments account for approximately 50 of the lotal
1'o
cervical rotation. A vertebral body showing the three primary Cartesian axes, x, y.
Another stereoradiographic study of neck motion in and z. Along each axis a positive force, ~ F. is de-noted by the
adult men found a mcan of 105° axial rotation be-tween the direction of the arrow. The curved arrows in-dicate the direction of
occiput and the C7 vertebra. Seventy per-cent of the total a positive torque. +..... Reprinted willJ permission from Raynor, R.•
Moskovich. R., Zidel, P., el af.
axial rotation OCCUlTed between the occiput and the C2
(/987). Alteration in primary and coupled neck motions aller
vertcbra. Eaeh motion segment between the C2 and C7
facete<:tomy. Neurosurgery. 21 (5). 681-687.
vertcbrae avcraged fTom 4 to 8° rotation (Mimura et aI.,
1989). Less well appreci-
.!~~~';-R1PBIOMEC8ANICSOF JOINTS
.-,-~~~~~--~-~~-~~
Abnormal Kinematics
Left lateral Neutral Righi lateral
flexion flexion Abnonnal kinematics gCl1crall.\" refers to l'.'\ccssive motion
within rUl1etional spinal units; however, ab-norrnal
kinClnatics Ina....· also refer to at.\vical pat-terns of motion
such asabnormal coupling or para-doxicalmotion.
Coupled motion during lateral bending is depicted schematically.
Par~\do.\icallllotionis
seen when the overall pattern of motion of
When the head and neck are flexed to the left, the spinous
processes shift to the right, indicating ro-tation. The converse is
one ~lSPCCI of the spine is in one direction while the local
also illustrated. Adapted with permis-sion from White, AA 1// pattern is the op-posite. For instancc, parado'\ical llc'\iol1 is
(~Panjabi, MM (1990). Clinical Bio-mechanics of the Spine. seen when llc'\iol1 occurs at a single functional spinal unit,
Philadelphia: 1.8. Lippincott. although the SpillL' as a whole is (''\tended.
A B
A, This diagram illustrates some of the other coupled mo-tions, results in motion of the spinous processes to the right or the left. B,
which occur in response to a torque (liZ) about the Z-axis (lateral The subject is bending to her right, demonstrating the large range of
bending). lateral translation (Rx) and vertical motion (Ry) occur, as normal cervical motion possible (approxi-mately 50°).
well as horizontal rotation (l!lY), which
Coupling of flexion-extension with transverse translation of the (1-(2 articulation during flexion-extension; no translation is evident in
cervical spine is visible roentgenographically. A, Ouring flexion this example (black arrow). B, During extension the reverse occurs,
the vertebral body shihs forward (small white ar-row); the facets and the spinous processes limit motion as they touch at full
glide up and over one another with moder- extension (arrow). The size of the interver-tebral foramina increases
I ate subluxation at full flexion (large white arrow). Up to 2.5 I mm of transverse with flexion and decreases with extension .
translation may normally occur at the
•
These types of abnormal motions describc a pattern of logical loads to maintain its pattern of displacement so that
mOVCIl'lCllt known as instability. there is no initial or additional ncurological dcficit, no
major defornlity,' and no incapacitating pain (1990). Using
this definition, physiological loads are those incurred
Spinal Stability
during normal activity, and pain is not felt to be
The concept of spinal stability is an intriguing and incapacitating if it can be con-trolled by non-narcotic
sometimes confusing notion. Medical practitioners are drugs.
frcqucnlly asked to look at a sel'ies of radi-ographs and Stability is detcrmined by many factors. There are
make a dctermination whether the spinc is stnblc. Exnclly different anatomical considerntions in different re-gions or
what is stability, how is it de-termincd, "'ld what happens if the spine. Certainly, ligamcntous anatomy plays a large
it is not present? The term spinal stability has acquired part in the stability or the spine, but the muscular and bony
diffcrent mcan~ ings, depending on the setting in which it clements of the ~pine also play important roles.
has been used. White and Panjabi describe the term
clinically as the loss of the ability of the spine undcr Instability can be analyzed by considering kinematic
physio- instability and structural or component instabilit:'t,.
Kinematic instability focuses on either the quantity of _ Conceptual Types of Instability
motion (too much or too little) or the qualit..., of motion
present (alterations in the nOimal pattenl), or both.
Component instability addresses the clinical biome- Kinematic Instability
chanical role of the various anatomical components of the Motion increased
functional spinalunil. In this type of instability, los..o:; or lm.tantaneous ax(,>s of rotation altered
alteration of various am.llomical portions detennines the CDlipiing characteristics changed
presence or instability (Box II-I). Parddo;O:I(d\ mOllon present
spine: Surgery
Degenerative changes
The synal1hroscs bClwcen Ihe \'cl1cbral bodies rely for Developmental changes
theil' slabilit~, upon the immensely slrong annulus fi~ brosus.
Combined Instability
ThL: clim'lhrodial apophys(.';:d joints arc sla-bilised by the
K:nemiitK
capsule, by rhc interspinous and sllpraspinous Iigamenls
and the ligamcnta Ila\"a. This group of ligaments [ call the Cornponen!
'postedol' ligament com-plex.' It is upon this complex (hal
(he swbilily of lh~ spine largdy dq:>ends (Holdsworth,
1963).
SAC
I
I
~
I L.- _
-rease. Study' Figure 11-1·1. lateral radiograph demonstrating
. ,,~,?j}.n:~,~!~?sed atlantodental interval of 6 mm after trauma.
stabilization.
1 ,..terior
rotation is defined as 11 0 greater than the amount of extension ill~lI)Cll\'l'rS should Ilol be per-formed, a stretch
~Hl(1
rotation that exists at the mo-tion segment above or Lest l'~lll b~ d01l1:.' 10 assess cer-deal inlq.!rit~·. A la(I.'ral
below the functional spinal unit in question. The 3.5- CI.·ITiGll spine radi-ograph is taken al a standardized lube
mm value represents the radio-graphic measurement of distance of 180 em. ~\lld incrclll(,.'nud .i-kg weights nrc ap-
the maximum per-missible translation when the plied as traction \n lhe Sklllilisillg LT<.lllial longs (Fig. 11-
radiographic magni-fication is taken into account 28). RadiogT~\phs arc tak~n ark!" each addilion~d wcight has
(Panjabi et aI., 1986). been npplicd. An nbnor-
CHAPTER 11 • BIOMECHANICS OF THES~~VICAl-S~JI~I!i1r~
---=~ -~- - ~~
Dens
1
"3
neurological sy'mptoIlls such as racliculopath.v or A nUlllber of studies using three-dimensional fi~ nite
my'clopath)'. Other posterior decompressive proce-dures element models showed that f::\Cetectom.v has a greatcr
such as partial or full facctcctomics for visu-alization or errc'ct on annulus stress th<:ll1 (Hl intervcne. bral joint
decompression of nerve root pathology also arc comnlonly stillness. Based on these models, it was concluded that a
performed. Development of postlaminectol11)' kyphosis is signific<:lnt increase in annulus strcsses and
well known in chil-dren and may develop in 17 (Miyazaki et scgmentalrnobility nlaY ()ccur when bi-lateral facet
a!., 1989) to 25% of adults (Berkowitz, 1988). [,ostlaminec- resection c:\:ceeds S(Y'·'r (Kumal'esan ct a!., 1997; VClO et
tomy spinal deformity may..' occur in up to 50% of children a!., 1997), Deccnnpression b~' celvi-cal laminoplasty, in
who undergo laminectomies for spinal cord tumors (Lonstein, which the facet joints are not sacrificed and the laminae are
1977). Simulated finite ele-ment anal.'.'sis on cervical spines reconstructed, results in maintenance ()f fle:\:ic)n-
indicates that the primary cause of postlaminecto!l1 yr e:\:tension and lateral bending stability', \vith a nwrginal
deformity is re-section of one or more spinolls processes as increase in axial torsion. Iatrogenic injur.v is less likel:' to
well as the posterior ligamentous structures, such as the result if the capsules of the rernaining facet joints and
ligamentum flavulll or interspinous or supraspinous ligaments. ::\lllerinr elements remain intact.
The removal of these structures causes the tensile forces
normally present in the cervical spine to become unbalanced Cervical subluxations and dislocations resulting from
and place extra stress on the facet joints. Results indicate that injul':' may narrow the spinal canal and calise neurological
either a kyphotic or a hy'periordotic cervical defonnity' may' imp::lirmenl. In SOllle cases, adequate reduction and
ensue, depending on the center of balance of the head (Saito et re::dignment or the vertebrae, fol-lowed b~' stabilizatkm,
aI., 1991). may' decompress the neural elements without resecting
bone (Fig. 11-29).
ARTHRODESIS
Although reports exist of patients undergoing multiple-
level cervical laminectomy with no evi-dence of clinical Spin::d arthrodesis is indicated in man:' disease pro-cesses
instability or deformity' on long-term follow-up (Jenkins, such as spinal instability, neoplasm, post-traumatic and
1973), most biomechani-cal studies indicate some degree degcnerative conditions of the spine. Thc goa! of
of instability when the posterior elements arc resected. arthrodesis is to achicve a solid bon." fu-sion in which two
Multilevel cer-vical lan1inectom.v induces significant or more vcrtebrac solidi.'" unite. In 1l1an:' cases, internal
increases in total column flexibility associated with fixation is ust::.'d to achicvc initial st::\bilization as well as
increased segmental flexural sagittal rotations. In a to correct defclrmit.", if necessary.
cadaveric laminectomy model. the mean stiffness of the in-
tact ce,·vical column was significantly' greater than the An important principlc regarding vertebra! arthrodesis is
mean stiffness for the laminectomized speci-men, and there that the stabilit.\' established b." inter-nal fixation is a
were consistently greater rotations as compared with the prelude to the biological process of fusion. Although
intact specimen (3.6 versus 8.0°) at ever)' cendcal spine fusic)l\ can occur without internal fi:\ation, its appropriate
level (Cusick et al., 1995). USl' helps to increase the fu" sion rate and maintain
structur::ll alignment. I-lard· ware b:' no means supplants
the necd for the sur-gecm to perfol'ln a thorough and
The loss of facet joints alone causes a significant careful preparation of the vertebrae and add bone graft tCl
decrease in coupled motions that result from lateral achie\"c fu-sion. \Vith few exceptions, Imrdw::lre that is
bending. A moment about the anteroposterior axis results in not ulti~ matel.v supported and protected by a solid fusion
a significant reduction in lateral displace-ment, a decrease will fatigue and fail after a finite number of c.'"Cles. There
in vertical displacement, and a de-crease in rotation about is ~l race b." the body to achieve a solid fusion mass before
the vertical axis. Partial facetectomy «50% ) did not, a fatigue failure (If the implanted fixa-tion device occurs,
however, significantly alter flexion and extension
movements (Raynor et a!., 1987). Another anatomical
study demonstrated that progressive laminectomy with The choice of a surgical approach !() the cervical spine,
resection of more than 25% of the facet joints resulted in as well as whether an anterior, posterior, or a combined
signif~ icantly increased cervical flexion-extension, axial arthrodesis should be performed, is de· pendent on the
torsion, and lateral bending motion when compared \vith particular patholog." present. \Vhen performing a fusion, it
the intact spine (Nowinski et a!., 1993). is important for the surgeon to understand the
biomeclwnical properties of dif-
Unilateral facet dislocation in a 24-year-old woman who was involved in a motor vehicle
accident. The degree of vertebral subluxation is less than half the AP diameter of tbe vertebral
body. Her spinal cord was compressed and she presented with an incomplete spinal cord
injury. A, Computerized tomographic scans and reformatted images demon-strate the canal
compromise at (5-(6. An attempt to realign the spine was made using longitudinal traction of up
to approximately one-third of her body weight. B, The lateral radiograph with traction applied
shows persistent malalignment. An open reduction was performed using a posterior exposure
of the vertebra. Once the spine was realigned, the posterior tension band was recreated using
interspinous wiring, and autogenous bone graft was inserted. C, The radiograph taken after the
operation demonstrates restora-tion of normal vertebral relationships. The fixation provided
good stability and enabled the patient to mobilize early. She had a good clinical outcome.
Reprinced with permission
from Mos,l:ovich. R. (1997). Cervical instability (rheumatoid. dwarfism, degenerative. others). In
K.H. Bridwell & R.L. DeWc1/d (Eds.). The Textbook of Spinal Surgery (pp. 969-1009). Philadelphia:
Lippincott-Raven Publishers.
"'CIMI,UiM"L' Of JOINTS
fcrent t)'PCS of fusion constructs. Cervical arthrode-sis also tems have become available that can satisfactorily stabilize
has an affect on adjacent motion segments. the cervicul spine from either approach ..
Thcorcticall.',/, there is an increase in motion at \Vhen an anterior approach is used, a discectornv or a
nearby'unfused levels. Subsequent degeneration of other vertebrectOlny at one or more levels is comm(H1I;,
performed, usuaIlv followed bv an anterior cervical
motion segments requiring additional levels of arthrodesis - .
has been demonstrated in multiple studies (Cherubinc) et arthrodesis. The excised disc or bone must be re-placed
aI., 1990; Hunter et aI., 1980). with a structural graft or prosthesis to restore anterior
A recent study by Fuller ct al. (1998) evaluated the column support to the spine. Osseous re-placement ma:v
distribution of motion across unfused cervical mo-tion be in the fm'm of autogenous or a!lo~ genic bone,
segments after a simulated segmental arthrode-sis in comrnonly from the iliac crest if autoge-nous or from t.he
cadaver cenrical spines. The authors simulated 01112-, t\\'o-, fibula or iliac crest if allogenic (Fig, 11-30). The more
and three-level fusions in human cervical spines. They then cortical nature or flbula grafts rm;~ result in dela.yed
moved the cervical spines through a nondestructive 30° incorporation compared"" with ilia~ crest grafts, which,
sagittal range of motion and compared this range of motion therefore, are preferred clinically. The immediate
with that of unfused cervical spines. The findings of this postoperative strength of an.v of these bone grafts under
study were inter-esting in that sagittal plane rotation was axial compression on a material testing machine reveals
not in-creased dispropc)J'tionatel)! at the cervical motion that they \\'ill adequately sup-port the loads required in the
segments immediately adjacent to a segmental arthrodesis. cervical spine. The ph.\'sical properlies of human bank
Although the authors ackno\vledged certain limitations of bone seem to be preferable to autologous bone grafts,
the study, they proposed that a cenrical fusion causes a especially in
fairly.' uniform increase in motion across all remaining
open cervical motion segments; therefore, an increased
potential for de-generative change may exist at all cervical
levels.
Adapted with permission itQm Wittenberg, R.H.. Moeller. J., P. White, AA Ill. (1990). Compressive strenglh of
autogenous (lnd alfogenolls bone grafts for thOf.lcolurnb.lf and cervical spine fusion. Spine. 15(0),
1073-1077.
older patients (Wittenberg et aI., 1990). The biological Posterior arthrodeses of the ccndcal spine are
incOIvonuion or allograft appears to be satisfactory and commonl:v performed after trauma but may also be
its USe obviates the need to harvest autologous bone L1sed to treat degenerative, inflammatory, or neo-plastic
from the iliac crest, sparing patients additional surgical conditions. Unlike anterior fixation devices, which arc
trauma and potential complications. solely lIsed in the subaxial cervical spine, posterior fixation
l
Calcium phosphate (bone) ceramics form a strong devices can extend up to the oc~ ciput (Fig. 11 ~32).
bond with host bone because of a zone of apatite mi- Posterior fi.'\ntion has commonly consisted of various
crocrystals deposited perpendicular to the hydroxy- wiring methods, which arc used as a tcnsion band
lapatite ceramic surface (Jarcho, 1981). Synthetic posteriorly (Sutterlin et aI., 1988). Within the past decade.
hydroxylapatite blocks used for interbody cervical however, techniques utilizing screws in both thc
arthrodesis in goalS produced similar fusion rates and atlantoaxial and subax~ ial spine have become rnorc popular.
biomechanical stifFness when compared with
autogenous bone (Pintar et aI., 1994). 11 is interest-ing Techniques for aLiantoaxial fixation have evolved
to note that the goat holds its head creCl, and thus loads from onlay bone grafting alone to cver~more sophis-
the cervical spine similarly to human bipeds. Goat ticated methods of internal fixalion. Interlaminar clamp
models for cervical spinebiologicallbio-mechanical fixation is clinically reliable and safe (iVIoskovich &
testing are, therefore. populal: Crockard, 1992). Screw fixation tech-niques may confer
A can inc thoracic anterior al1hrodcsis model yielded increased translational and axial rotational stability, but
contrary results when tested biomcchanically: with greater surgical risks. A biomechanical evaluation
autogenolls iliac crest grafts were stiffer in all motions of four commonly used techniques for posterior
than \\lcre ceramic graft substitutes (Emery et aI.. 1996). atlantoaxial fixation was performed (Grob et aI., 1992\
aturally grown coral is also a useful bone graft substitute Cadaver CI-C2 f,mc-tional spinal units were tested in
once it has been processed. Jt is available con1rncl'cially in nexion~cxtension, lateral bending, and rotation, while intact
t\\-'o different porosities (200 ~m and 500 lJ.m pore size). as well as after a complete ligamel1lous injul)/. The
The grafls of lower porosity had a compl"Cssive strength fixation techniques used wcrc:
comparable \vith biconical iliac crest grafts, although they
were much more briule. They can therefore be considered
appropriate for clini-cal lise with rcspect to their I. Sublaminar wire with one median graft
compressive strength (Table 11-1). An increasing variety of (Gallie type)
prosthctic intcr-body cages ~\re becoming available (Shono 2. \Vire fixation with two bilateral grafts
ct aL, 1993); long-tellll clinical results arc eagerly awaited. (Brooks lype)
Addi-tional anteJior (Fig. 11 ~31) or posterior intcI11al ft:- 3. Transarticular screw fixation (Mager!)
.:atio!l using plates and screws for added support ma.\' be 4. Two bilateral posterior Halifax clamps (Fig.
lIsed. 11-33)
str<:ltcd similar 01' irnproved fusion rates compared with
stand-alolle bone grafts.
Anolher group <:lssl."s;ed lilt, biollH.:L·hallical siabil_ it~·
01" sen.'n different cervical n:construction meth-ods using 24
c(lif cClyieal spinl' segments (KotC:lfli et al.. 1994). Thl'~'
studied Ihn:\:.' posk'rior-nnl,\' lech-niques. anlcrior-onl.\'
u...·lyical platL·s. antcrior bone graft alone. and a combined
<:lIlterior plate wilh pos~ (erior triple wiring. The results
dcmollstnlled that for onL'-lc\"L'1instrlbilit\', the stiffncss
\"alues of rc-consllliciion with an a;1terior procedure alOlle
were si!.!nificanth- smaller than those of all the othL'r con-
st;ucts tcst~'d. Intcrl'slin!!lv, stiffness w<:\s n.:storcd 10 prc-
in,iul-y le\'cb in specin'1L'nS \\'itlt lwo-lc\'L'! inj1ll1' patterns
reconstrucled using an~' of the three <Jll!c-riot" 1l'lL,thocls.
TilL'findings do not SlIpport the use of C':\clusi\'L' ank'rior
methods in either posterior or
•
CHAPTER 11 • BIOMECHANICS
Nai;ional HighwayTraffic
BIOMECHANICS OF CERVICAL TRAUMA Safety Administration
.Guidelines Regarding
Airbag Injuries Airbags & Children
Motor vehicle accidents continue to be the leading cause of
injury-related deaths in the United States. [n 1984, the The back seat is the safest place for children of any age
National Highway Traffic Safety Ad-rninistration (NHTSA) to ride.
required that automatic oc-cupant protection devices Never put an infant (less than 1 year old) in the front of a
(airbags or automatic scat belts) be placed in all c"ar with a passenger-side airbag.
automobiles in the 1987-1990 model years. In 1993, the Infants must always ride in the back seat, facing the
passengelcside airbag was introduced. Studies generally' rear of the car.
concluded that front seat occupants are adequately! Make sure everyone is buckled up. Unbuckled occu-
protected against frontal impact if belts are worn in an pants can be hurt or killed by an airbag.
airbag-
1992). It was found lhal when the standard 20° an-gie elude inlerspinous ligamcllt tears, spinous process fractures.
steering wheel was used, neck joint torques were decreased by disc rupture. ligamcntum f1avulll nlplurc, facd joinl
22%. The resultant head acceleration increased 41% fTom the disruptiun, and stretching of 11K.' ~\IHcrior musdl's. The
baseline study when a ver-tical steering \vheel \\"las used. "If diagnosis and managcll1clH of whip-lash injuries an.... oflel1
the verlical (limen-sian of the airbag was reduced by 100/0, t.:ol1l"oUIl(!L·d b~r concomitant psychosoci;':il ,lilt!
neck joint torques were increased by l4%, while head acceler- IlH.'dicolcgal isSlIl..."S':IS well (\-Vallis et ,Ii., 1998j.
ation showed a slight decrease of 90/0. Although ideal
dimensions and inflation rates for airbags re-main elusive, One of the earlv (unpublishcd) biomcehanical studies or
their use has resulted in a significant reduction in head and whiplash injury was clone b.v the late Dc
neck injuries. Irving Tuell. nil orthopuedic surgeon in Seattle, \V~\shillgton. I-
h.: uscd a cinl' camenl to photograph himsdf driving as he was
rammed from behind by his surgical J'csidL'ntdriving
anothLT car. Frarnes drawn frolll Lhat movit.' ckarly
Whiplash Syndrome
demonstrate tilL' h~'- pen:xtension of his neck over the
Whiplash syndrome is a complex se' of symp,oms ,hal may sl.'alback of his CLl!" (Fig. 11-34). One C;:\l\ also scc thl' dlect
present after an acceleration hyperextension in-jury. These of inertial l"orces on tht.: mandible as his jaw snaps opt'n
injllIies typically occur when a Car is struck From behind, bUl while the Hcccicratioll forces his !lead backwards. This
may also be caused by lalcml or Fron'al collisions (Barnslev el mechanism Illi.l\ explain the tL'mporomandiblilar injuries thal
aI., 1994) (Case Study 11-2). The acceleration of the car seat (In,.' a COllllllon accompanilllL'nt of ccr~ \'ical \\'hipbsh
pushcs the torso of the occupant forward with the result that injuries_
the un-supp0l1ed head falls backward. resulting in an exten-
sion strain to the neck. A secondaJ)' Aexion injlll)' may occur r\ recent sLud~' of rcar·end collisions qualHiLa-
if the vehicle just struck then strikes another ve-hicle in front elucidated the m.:tllal neck movements that wke place
!i\'d~'
and just as suddenly decelerates again, throwing the occupant (Castro CI aI., 1997). A1kr being ramllled from behind, the
forward once more. Crowe coined the tellll 'whiplash' in 1928 Illcan accl'ler<:\tionor the target \'chicles was from 2.\ to 3_6
in a lecture on neck injllIies caused by rear-end automobile g. Maximal ex-tension was n.'ached when the head contacted
collisions in the United States but latcr reported that he the headrest; the angle b('!wt...·L·n the head and tipper bOth'
regretted using the term (Breck & Van Norman, 1971) because varied From 10 to 47" (meall = 20"). In the ab-SCIlCL' or a
il de-scribes only the manner in which a head was moved headrest, tht..., maximal r('cordcd exten-sion was 80". FollOW-
suddenly to produce a sprain in the neck and not a spe-cific LIp clinical and rvIRI cxamina-tions were pcrformt.:d_ The
injUl}' pattern. Therefore, we refer to this clinical entity as
concluded that the "limit or hannlessllcss" for stresses
sttlcl~!
whiplash syndrome, not as whiplash injllry.
arising from rear-end impacts with regard to the velocity
changes lies bd\\'cen 10 and 15 km/h, In studies, a
reproducible \\-hiplash trauma mode! using whole cervical
Allhough whiplash injuries are a common trau-matic spinc specimens 1ll00Jnh.:d on a belH.:h LOp sled was used to
event, the pathology is poorlv understood. 01'-len the severity simulate rear-end collision with increasing horizontal
of the whiplash trauma does not con-elate with the seriousness accderations applied to tht.: sled (Panjabi ct 'II" 1998a.b). Bo,h
or the dinical prob-lem, which can include neck and shoulder sled and hcad kinematics CHIl be measur'cd using
pain, dizziness, headache, and blurring of vision (Brault et al., potentiometers and acceleroll1l.~tcrs. Using this whiplash
1998; Ettlin Cl aI., 1992; Panjabi el aI., 1998a; Sturzenegger modt,l. an S-shapL'd cun:c was (kscrihed in whiplash injuries
el 'II., 1994). Apart Ii'om a frequently observed loss of in which the lowt.:'r cervical spinC' h.\'perextcnded ~JIld the
physiological lordosis, a radio-graphic examination of the upper cCITical spine flexed (Grauer ct <.11.. 19(7). The
cervical spine is often normal. Even newer technology such as invesLigators r~h that Ihe in.iur~' was in-currcd during the
MRI is not always able (0 I-eveal a soft tissue injul}'. MRI hyperextension phase in the knvcr cervical spinc,
exam-ination of the cerebrum and cervical spinal column
perrormed 2 days after a \vhiplash neck sprain in-JUI)'in 40
patients did not deli~cl an)' pathology con~ nected lO the injlll)',
nor was the MRI able '0
predicl symptom development or
outcome (Borchgre\fink d aI., 1997). Injuries thaI have been Correct positioning or adjustable headn..'sts bc-hind the
documented in- skull. not hehind the Ileck, is important. Tests using a H~'gc
sk~d and a Hybrid III dlllllm~' wcre pcrrorl11L:d by other
iJ1\'estigalOrs to determine
(HAPTER 11 • BIOMECHANICS OF THE CERVICAL SPIN1Jri1;~:O
..
' , ,~
f ! Whiplash Syndrome
,:'i::'/.::,';):
»::)/:,:'':-''P,}\ 32-year·old man was injured in a car accident. The trau- from Fr(1nkel, VH. (1972). Whiplash injuries to the neck. In
:~9>:~;:_~i~;~ matic event happened after being struck from behind. [n C. Hirsh & Y Zotterman (Eds.), Cervical Pain (pp. 97~111).
~~{~:d{t:ih.iS case. the inertia of the head and the flexible spine re- New York: Pergamon Press.
"?g;'sulted in marked hyperextension movement of the head. The
.¥a~celeration of the car seat pushed the torso of the occupant
$Jo~va{d with the result that the unsupported head fell back-
'ft~~ard, resulting in an extension strain to the neck.
~?;~ lr -;.
The palient presented with severe neck and shoulder pain
accompanied by sleep disturbance. The right sternocleido-
7'''':;j-
'.-..
I
I
I
I' B
IDIIDI _
1~_H.a_nd_-_d_r.aw_n.c.e.II., .traher..c.ed_f'.o.m_t_rammedwof.am_e_'_o_behindfa.C...em.-_o_Vanotherie.f.D.r_.I.rV.i_n9_T_u_e_lI_dhi,..iV.in.9_h.i'.c.a.r- _
• (A) Before and (B) bein9 from by car driven by re,ident_
biomechanical responses for the various conditions observed plied, which protects the disc from catastrophic rail-lIrL' ulltil
in normal driving (Viano & Gargan. 1996). Risk of injury was e ..... trl"lllcl~· high loads are applied.
assumed to be proportional to neck extension. A low headrest 5 Vi".'I·lL"bl·al bod~' cUlllpr~ssioll str~ngth increases
position carries a relative injl1r~' risk of 3.4 in rear-end crashes. from upper ct.'n:ical 10 IO\\'L'r lumbar lev-cis.
com-pared with 1.0 for the favorable condition. If all ad-
justable headrests were placed in the up position, the relative 6 TIlL' mean sagillal diametL'r of the malt.- adult
risk would be lowered to 2.4, a 28.30/0 re-duction in spinal canal for C3-C7 is close LO 14 Illm; the spinal cord
whiplash injury risk. diameter is about 10 111 Ill.
7 LigamclltuJ11 flavlIJ11 is undt..'1' tension even when the
Significantly more complex acceleration injuries ascribed spine is in a Ill:1Itral position or somewhat cxtended.
to high G-force activities are now occurring. There is a report prestressing the disc and pro\'iding some intrinsic support 10
in the Htel·ature of cervical injury in pilots of F- t 6 fighter tht..' spine.
planes, citing a I-year preva-lence of neck injury of 56.6%
and a career prevalence of neck injury of 85.4% (Albano & S iVlllscles pla~' a critical role in b~lsic postural
homeostasis. Patients with paral~'zL'd ct..'lyical mus-cles arc
Stanford. 1998).
unable to support thdr heads.
Maintenance of neurological homeostasis and protection of
the spinal cord. nerves. and vessels and support and protection 9 The spinal cord has some longilUdinal c1astic-it.'· blll it
of the skull are the ulti-mate tasks of the cervical spine. An tole-ratL's axial translation pond.". It is the translatolY forces
appreciation of the principles presented should afford a greater {hat t.\'picall,\· rcsult in neurologi-cal injul·.\',
un-derstanding to physicians and allied health profes-sionals
involved in the treatment of cervical spine pathology. 'vVith 10 Instant c('ntl.'!' anal.\'sis indicates that tangential lnotion
increasing technological advances in our society, \ve remain (gliding) wkcs placl.· bel\\,(.'c·]1 lltt::.' facet joints as lItc
vulnerable not only to common types of cervical trauma but cervical spine is flexed alld extended. The size or the
also to idio-syncratic methods of injury' related to these new intelTcrtebr~il!"()ramina inc.TeDscs with flexion and
technologies. Acceleration injuries have been OCCUI'-l'ing for deCl'l:ascs \\'ith extension,
decades but cervical spine injuries caused by airbags have only 11 Kinematic instability' refl'rs to the quantity of motion
recently been described, and aliI'involvement in increasingly (too much or too little) or till.' quality of mo-tion present
greater speeds and higher risk activities places LIS in increasing (alterations in lile normal pattern), or both. Component
jeop-ardy, As our body' of knowledge expands, we con-tinue instahilil.\' addrcsses the clinical biomechanic~ll role of till.'
to discover new methods of injury. It is critical to pursue \'ariolls anatomic struc-tures of the functional spinal unit.
rational treatments for these disorders based on sound
biomechanical principles,
12 An." motion s~~glllent in which all of the ante-rior
ek'llkllts or all the posterior ekments m·e de-stn>yed or are
unabk' to function should be consid-ered unstable.
_2 Whcn eithcr rotation or translation of a body along one 15 Front seat occupants are adcqLH.llcl~' protected ~lgain.s{
axis is consistently associated with a si-multaneous rotation or frontal impact if scat belts arc worn in an airbag equipped
translation along another axis. the motions arc coupled. ,·chick. Passenger-side air bags
pose a lethal threat to children riding in the front '. scat 01" an
automobile.
3,; Intervertebral disks cxhibit viscoelastic proper-ties
(creep and relaxation) and hysteresis. 16 \'Vhiplash s.\"ndrome is a complex set of s~'mp- tOI11S
thal may present aher an (\("ccleration hyper-extension injury.
(4;' Discs arc able to withstand greater than nor-l1l~r loads
when compressive forces arc rapidly ap-
CHAPTER 11 • BI()MECHA.NIC
Paniabi, ,\1.,\-1., \Vhile, A.A. III. & Johnson, R.,\1. (1973). Cer-\:ical spine Simmons, E.H. & Bradlev, D.D. (1988). Nturo-myorathic flexion
mechanics ,IS a I"unction 01" transection of corn-pOneJllS. 1 deformities (/ the cervical spine. Spille, 13, 756-762.
HiOlllt'c!/(lIIics, 8, 327-336.
Penning, L. & Wilmink, J.T. (1987). Rotation of the cCl'vical spine. A Steel. H.ll. (1968). Anatomical and mechanical considera~ tions of atlanto-
study in normal people. Spille 12, 732-738. axial articulation. In Proceedings of tIll: American Orthopaedic
Perry, J. & Nickel. V.L. (1939). Total cervical-spine fusion for neck Association. J BOlle Joil/I SlIrg, 50A, 1481-1482.
par,t1ysls. 1 BOIIt, loilll SIIJ'g, .Jl:\, 37-60.
Pintar, FA., \himan, D.J., Hollowell. J.P., L't 'II. (1994). Fu-sion rak and Sturzenegger, .\1., DiStel"ano, G.. Radano\', B.P., et a!' (1994). Presenting
biorHechanical stillness of hydroxylapatite versus autogenous bone symptoms and signs after whiplash injury: The influence of accident
grafts for antnior discectorny. An in vivo animal study. Spille, 19, lllechanisms. NCllrology, .J.J, 688-693.
2324-2328. Sutterlin, C.E., McAfee, P.e., \Vardell, K.E., ct al. (1988). A
Pintar, F.A., Yoganandan, N., Pesigan, ~'1., L'la!' (1995). Cervi-cal biomechanical evaluation 01" celYlcal spinal stabilization methods in
vertebra! strain llleasuremellts under axial and eccen-tric loading. 1 a bovine model. Static and cyclical loading. Spillt', 13, 793-802.
Bioll/cch Ellg, /17, 474--478.
RapolT, A.J., O'Brien, T.J., Ghanayem, A.J., L'l al. (1999). An-terior Takebe, K" Vitti, :v1., & Basrnajian, J.\!. (1974). The functions of
cervical graft and plate load sharing. J Spillill Dis, 12,45-49. semispinalis capitis and spli:nitls capitis muscles: An
electromyographic stud.v. Allat Rec, f79, 477-480.
Raynor, R.B., Moskovich, R., Zidel. P., et a!' (1987). Alteration in Viano, D.e. &. Gargan, il,'l.F. (1996). Headrest position during normal
primary and coupled neck motions after fncell.'ctomy. driving: Implication to neck injury risk in rear crashes. Accidellt Allal
NellnlslIl'.i.iery, 2l, 681-687. fln'I',28, 663-674.
Ri:ill. J. (1960). Effects of flexion-exti:lIsion movement of thi: head and Yoo. I..M .. Kumar"san. S .. Yoganandan. N.. 01 at. (1997). Fi· nite
spine on the spinal cord and nerve roots . .I ,VCII-ml ,VClII'OSlIr.i.i elemi:nt anal~'sis of ci:rvical facctectomy. Spille, 22, 964·-969.
Psychi(/IJ', 23, 214-221.
Ripa, D.R., Kow,dl, \I.G., "'!eyer, P.R. Jr., et al. (1991). Series of ninety- Wallis, B.J., Lord, S.M., Barnsky, L., et al. (1998J. The psy-chological
t\\·o traumatic cervical spine injuries stabilized with anterior ASIF profiles of patiellts with whiplash-associated headache. Cephalalgia,
pl,lte fusion technique. Spille, 16(3), 46-55. IS, 101-105.
WertH.', S. (1937), Studies in spontaneous alIas dislocation.
Rolander, S.D. (1966). \-lotion of the lumbar spine with spe-cial Acta Ort/lOp Sewld, 23 Suppl.
refi:rence to thi: stabilizing (.'ffect of posterior fusion. An White, A.A. Ill, Johnson, R.~L Panjabi, :\1.M., et al. (1973).
experimental study on autopsy specimcns. /lcw Orthop Snllld,90, 1- Biornechanical analvsis of clinical stabilitv in the cervical spill(:. Clill
144. Orl/top, l(N, 85-96. .
Roozmon, P., Gracovetsky, S.A., Gouw, G.J., ct a!' (1993). Ex-amining White, A.A. III & Panjabi. M.\1. (1990). Clillical Bio/llechal/ics oj' tlze
motion in the cervical spini:. I: Imaging systems and measurement Spille. Philadelphia: J.B. Lippincott.
ti:chniqui:s. 1 Bio/lled Ellg, 15,5-12. Wittenberg, R.l-I., i\loeller, J.. &. \Vhite, A.A. III. (1990). Com-pressive
Saito, '1'., 't'amamuro, '1'., Shikata, J., et a!' (1991). Analysis and strength 01" autogenous and alJogenolls bone grafts 1"01'
prevention of spinal column deformit.;.' following cer-vical thoracolumbar and cervical spine fusion. Spille,
laminectomy. I. Pathogenetic analysis of post-lamini:ctomy 15(101. 1073-1077.
deformitii:s. Spilll.', 16, 494-502. Yang, K.H., Latour. B.K., & King, A.1. (1992). Computer sim-ulation of
Schneider, R.e., Chi:rry, G., & Pantek, H. (1954). The syn-drome of acute occupant neck rtsponse to airbag deployment in I"rontal impacts. J
ci:ntral cervical spinal cord injury with special reference to the J3io/llech Ellg, 11.J, 327-331.
mechanism involved in hyperex-tension injuries of the cervical spinto )'oganandan, N., Kumaresan, S.c., Voo, L., ct a!' (1996a). Fi-nite dement
J /":I.'ZlroslIJ'j;, 11, 546-577. modeling of dll: C4-C6 cervical spine unit. lIed Ellg Phys, 18,569-574.
Schultz, A., Anderson, G., ()rtengri:n, R., et al. (1982). Loads on the Yoganandan, N., Pintar, EA., \Lliman, D.J., ct al. (1996bL I-Iuman head-
lumbar spine: Validation of a biol1ledwnical anal\'-sis by neck biomechanics under axial tension. lIed Ellg Pltys, 18,289-294.
measurements 01" intl'adiscal pressure and myoell'c-tric signals. J
BOllI.' .Ioillt SlIrg, 6",.1, 713-720. )'00, J.U., Zou, D.. Edwards, W.T., et al. (1992). Effect of cer-vic,d spine
Shono, Y., ivlcAI"ee, P.C., Cunningham, B.\V" et at. (1993), A motion on the netlroforaminal dimensions of human c('['vical spine. Spinc,
biomeclwnical analysis of decompression and reconstruc-tion methods 17{ 1131-1136.
in the cervical spine. Emphasis on a carbon-fiber-compositc cagt. }
BOllI.' .loilZI S/lrg, 7504, 1674-1684.
ik
~
~:
YJ,j
Biomechanics
of the Shoulder
i>'
f/,
Introduction
Kinematics and Anatomy
Range of Motion of the Shoulder Complex
Sternoclavicular Joint
Acromioclavicular Joint
Clavicle
Glenohumeral Joint and Related Structures
Glenoid labrum
Joint Capsule
Glenohumeral and Coracohumeral ligaments
Additional Constraints to Glenohumeral Stability
Scapulothoracic Articulation
Spinal Contribution to Shoulder Motion
Kinetics
Muscular Anatomy
Integrated Muscular Activity of the Shoulder Complex
Forward Elevation
External Rotation
Internal Rotation
EXiension
Scapulotr,oracic Motion
loads at the Glenohumeral Joint
The Biomechanics of Pitching
Summary
References
It
----._------------------------~--------~._-._-~-------_._---
Introduction anatomy of the various aspeclS or the shoulder com-plex
and shows how their structure allows ror effi-cient
shoulder links the LIpper extremity to the trunk acts in biotllcchanical function.
conjunction with the elbow to position hand in space for
crfkient function. [t consists of the glenohumeral.
acromioclavicular, stcrnoclav·
iculat: and scapulolhoracic articulations and the Kinematics and Anatomy
musculature structures that act on them La produce the
most dynamic and mobile joint in the bodv (Fig, To produce the intricate motions necessary for nor-n1al
12-J). An absence of bony constraints allo\I.'5a wide range functioning of the shoulder complex, the four aniculations
of motion at the expense of stability, which is pro-for with their associated components act togcther in a way that
instead by the various ligamentous and mus- produces mobility greater than that afforded by anyone
stl1.!cturcs. individual aniClda-tion, The ability of the shoulder
The biomechanics of the shoulder arc complex, and a complex to position the humerus and the remainder of the
complete discllssion necessitates an analysis of the four LIpper cx-trcmit~· in space is further augmented by
aforementioned articulations that make up the shoulc!eI- movement of the spine. A discussion follows of the t\'pcs
complex. This chapter describes the and ranges of motion for the shoulder complex as a whole,
with subsequent sections discussing the manner in which
motion is achieved at each of the articulat ions,
Acromioclavicular
iOin1 Stern1i~:~tCular
@
- /.
RANGE OF MOTION OF THE SHOULDER
COMPLEX
scapula
Acromion of ~
\ Clavicle
. 7'
/'
Shoulder range of motion is traditionally measured in
terms of flexion and extension (elevation or movcrncnt of
the humenls away from the side of the thorax in the sagittal
\, '
\ Sternum
plane), abduction (elevation in the coronal plane), and
\
Scapula _ r intemal·external rotalion (axial rotation of the humerus
I with the arm held in an aclducted position) (Fig, 12-2),
Although during functional activit.ies these pure motions
" I ($
I \ t?r
are rarely seen, we can better understand the complex mo-
~,\
tions of the shoulder by anal~/zing the separate com-ponents
needed to achieve anyone position,
i"-(l-- ,
,, , \ Although forward elevation of 180° is theOl'eti-cally
possible, the average value in men is 167° and in women it
is 171°. Extension or posterior eleva-lion averages 60·
Humerus
(Boone & Azen. 1979). These val· ues are Iimiled by
I Scapulothoraclc
capsular torsion. Abduction in the coronal plane is limited
~0L-n _
by bony impingement of the greater tubcr()~ityon the
acromion, Forward elevation in thc plane or the scapula,
I Schematic depiction of the bony structures of the shoulder thereFore, is considered to be more Functional because in
i this plane the inferior portion of the capsule is not twisted
, and their four articulations. The circular insets show front views of the three and the musculature of the shoulder is op-timally aligned
synovial joints-sternoclavicular,
for elevation of the arlll (Fig. 12-3). Although shoulder
I acromioclavicular, and glenohumeral-and a lateral view of the scapulothoracie
range of motion !10nl1all~' de-creases as part of the aging
joint, a bone-
319
Of JOINTS
, lf
I
,
I
,
I
I
, ~I I
I f cs . .. - ........".............'-= >1
--c:+
I ,
,I
: , ,I
,
, ,it at the
, Humerus
:, \\ side
":
'1,1
A B c D
A, Forward flexion. The humerus is in the sagittal plane. B, the humerus at the side, Internal rotation is shown with the
Extension. The humerus is in the sagittal plane. C, Abduction. arm behind the back, which is a functionally important form
The humerus is in the frontal plane. D, Rotation around the of this motion.
long axis of the humerus. External and internal rotation with
STERNOCLAVICULAR JOINT first rib. This is a truc s\TH)vial joint that has a sad-dle-like
shape and contains a fibrocartilaginous i.\r-ticular disc or
The sternoclavicular joint consists 01" the enlarged medial
meniscus that divides it into two
end of the clavicle and the most superolat-eral aspect of the
Cotlllxlrtmcnts.
manubrium, linking the upper ex-tremity directly to the
Although the joint itself has little intrinsic stabil-ity, the
thorax. In addition, a small facet is present inFeriorly that
articular disc in conjunction with anterior, posterior.
articulates with the
C()stoclavicular, and intL't"clavicular liga-ments maintains
joint apposition (Fig. 12-4). The anterior and posterior
Scapular plane elevation sternocla\'icular ligaments resist anterior ;:md posterior
translatiolls (as well as superior displacement), while the
costoclm'icubr lig;:Hllenl, which rUIlS betwcen the
Long axis Long axis
undersurface 01" the medial end 01" the chlviclc and the first
Post.
Protraction-retraction
l:7==
posterior translation (Fig. 12-5). .......
ACROMIOCLAVICULAR JOINT B
The acromioclavicular joint (Fig. 12·6) lies between the
lateral end of the clavicle and the acromion of the scapula Rotation
(the lateral and anterior extension of the scapular spine)
and is subject to the high loads transmitted from the chest
musculature to the up-per extremity. It too is a synovial
joint, but has a pla-nar configuration. A wedge-shaped
articular disc, whose function is poorly understood, is
found \vithin the joint originating from the superior as- c
pect. Both sides of the articular surface are covered with
fibrocartilage and the joint itself slopes infero-medially,
causing the lateral end of the clavicle to slightly override
Motion at the sternoclavicular joint. A, Top view showing the
the acromion.
clavicular protraction and retraction (anteroposterior gliding) in
the transverse plane around a longitudinal axis
A weak fibrous capsule encloses the joint and is (solid dot) through the costoclavicular ligament, not shown. Motion
reinforced superiorly' by' the acromioclavicular lig-ament. takes place between the sternum and the meniscus. B. Anterior
The acromioclavicular ligament acts pri-marily to restrain view showing clavicular elevation and depression (superoinferior
both axial rotation and posterior translation of the clavicle. gliding) in the frontal plane around a sagittal axis (solid dot)
through the costoclavicu-lar ligament. not shown. Motion occurs
The majority of the joint's vertical stability is provided by
between the clavi-cle and the meniscus. C, Anterior view depicting
the coraco-clavicular ligaments that suspend the scapula
from the clavicle (Fukuda et aI., 1986). The cora- the clavic~ ular rotation around the longitudinal axis of the clavicle.
coclavicular ligaments consist of the posteromedi-
•
Coroid ligament Trapezoid Coracoclavicular vasclll~ll' slrlH.:lllrl"S and SL'IYL'Sas an altachmcnt :-:;itc for
ligamenl Inan\ of Iht.' l1luscles dl41t ~Ict on tilL'shoulder Tht.' clavicle'
li)7ment
Acromioclavicular also pro\'ides for the normal appear-ance 4\[H.! contour or tIJL~
ligament llPP(~J' chest. Elevation of
IhL'upper extrcmil,\' is aCCOl11lXlnicd b.\· rotation as
- Acromion
wdl as ck'\-',<1lion or the c1a\'idL.', with approximatelv
-1-0 of c1m·icular dL.'\·ation for evcr~· 10'> of arm d~'-
Coracoacromial
\·~ltion, \\·ith the majorit.\, of this motion occurring at the
stL'I"llocla\'indar joint {Inman, Saunders, & Ahhot!. 1944 J.
CLAVICLE
Glenoid Labrum
The long head of the biceps goes in the bicipital groove
between the greater and lesser tuberosities. The transverse The glenoid labru111 (Fig. 12-10) is a fibrocartilagi-nous
humeral ligament helps stabilize the biceps tendon in the rim that acts to deepen the glenoid, providing 50°;(; of the
groove. Reprinted with permission from Neer, C. (1990). Shoul- overall depth of the glenohumeral joint (\Varner, 1993). It has
der Reconstruction (p. 29), Philadelphia: WB. Saunders Co. a triangular configuration \'.'hen viewed in cross-section and
has firm attach-
a;'~~4XPARTII • BIOMECHANICS OF JOINTS
Coracoacromial ligament
Glenoid --',--'\l;--i.
labrum
Coracoid
Glenoid --+--~: process
cavity Coracohumeral
ligamenl
Tendon of long head of
biceps brachii
Long head of
tTiceps brachll
A
A, The glenoid labrum is attached to the underlying bony glenoid and when vie'Nedin cross·section and serves to effectively deepen
is confluent at its area with the long head of the biceps tendon. B. the glenoid, increasing the stability of the gleno-hllmeral joint.
The labrum has a triangular configuration
A-
A B
AS
c D
A, Schematic drawing of the shoulder capsule illustrating the location humeral ligament complex remain lax, C, The anterior band is the
and extent of the inferior glenohumeral ligament complex (IGHLC). primary restraint resisting inferior translation of the shoulder at 45<>
A, anterior; P, posterior; B, biceps tendon; SGHL, superior abduction and neutral rotation, In this posi-tion, the superior
glenohumeral ligament; MGHL, middle glenoo humeral ligament; AS, glenohumeral ligament, the middle gleno-humeral ligament, and
anterior band; Ap, axillary pouch; PS, posterior band are lax, D, At 90° ab-duction, the anterior and
posterior band; Pc, posterior capsule. Reprinted with pertnis· sian posterior bands of the inferior glenohumeral ligament cradle the
from O'Brien, SJ, Neves, M.e, Amoczky, S.P, et at. (1990) The humeral head to prevent inferior translation, The posterior band is
anatomy and histology of the inferior glenohumeral ligament complex of more significant in external rotation, whereas the anterior band plays
the shoulder. Am J Sports Med. 18, 579-584. B. The a greater role in internal rotation. Reprinted wirh permission from
superior glenohumeral ligament is the primary restraint to inferior Warner;
translation in the adducted shoulder at neutral rota-tion. In this IP, Deng, X.H.. Warren, R,F., et al. (1992). Staric capsuloligamen-taus
position, the middle glen?humeral ligament and the anterior and restraints ro superior-inferior translations of rhe glenohumeral
posterior bands of the inferior gleno· joint. Am J Sports Med, 20, 675-678.
(HAPTER 12 • BI(>MI'(
Experimental Techniques:
Ligament Cutting Studies
Shoulder Instability
Ligament cutting studies have been instrumental in fur- A 21-yea:"0Id ma.n fell while skiing onto his right upper
thering our knowledge regarding the contribution of a given . extremity, cauSing forceful abduction and external ro" tation.
anatomical structure to overall glenohumeral sta-bility (Curl He noted acute pain in the arm and was unable to IYlQveit
& \JVarren, 1996). In this technique, cadav- Physical examination revealed loss of the normal contour of the
eric specimens are biomechanically tested before and shoulder and painful range of motion. Ra" dlogr~phs showed an
after selectively cutting sequential structures. A force is anterior dislocation with posterior superi.()rhumeral head
then applied in a given arm position, and the transla- impaction fracture. The patient un-gerwent closed reduction.
tion that occurs is measured. From this information, the Postreduction radiographs con" firlYledreduction of the humeral
relative contribution that a given structure provides to overall head with a small bony ayulsion fracture of the anterior-inferior
stability can be determined. When a particular pattern of glenoid rim, whichrepresents a detachment of the anterior
shoulder instability is then identified, the physician can infer labrum in the area of the superior band of the glenohumeral
which anatomical structures may be deficient or disrupted so liga-ment insertion (Case Study Figure 12" 1" 1).
that a rational plan of physical therapy or surgical repair can
be implemented. Structural alteration of bony geometry, ligaments, and
labrum resulted in shoulder instability. The detachment of the
• anterior labrum and the superior band of the liga-ment insertion
affected primarily the resistance to anterior translation of the
Additional Constraints to Glenohumeral humeral head, resulting in anterior dis-location. !n addition, a
Stability concomitant capsule lesion af-fected the intra"articular negative
pressure necessary to pull the humeral head inward. After
Sy'l1ovial fluid acts via cohesion and adhesion to
conservative man-agement. the patient did well for 6 months
further stabilize the glenohumeral joint. Synovial fluid
until he sus" tained a recurrent dislocation. The patient
adheres to the articular cartila~eovcrh;in cr the subsequently opted for operative treatment that included repair
glenoid and proximal humerus, c;using theb two surfaces to of the fracture and capsule and a complete period of rehabilita"
slide along one another: Th~ synovial fluid provides a tion~vithernphasis on joint stability and proprioception.
cohesive force bet\veen the~e two, making it difficult to
pull them apart (Simon, 1994). Under normal conditions,
the intra-articular pressure \vithin the gknohumeral joint is
negative, acting to pull the overlying capsule and gleno-
SCAPULOTHORACIC ARTICULATION
The scapula is a Flat, triangular bone that lies on the
posterolateral aspect of the thorax between the second and Case Study Figure 12-1"1.
seventh ribs. It is angled 30° anterior to the coronal plane
of the thOl;X and is rotated slightly toward the midline at
its superior end and tilted anteriorly with respect to the
sagittal plane
(Fig. 12-13) (Laumann. 1987). The spine of the scapula
gives rise laterally to the acromion process that articulates
with the distal clavicle at the acromioclavicular joint. The
coracoclavicular liga-ments and muscular attachments help
to suppon the scapula and stabilize it against the thorax
(Fig. 12-6). There is, however, no osseous connection with
the axial skeleton. This allows for a wide range or
scapular Illotion, including protraction,
Kinetics
Numerous llluscll..'s aCI nn the \'arious components or the
Scapular orientation on the chest wall. Left. 30~ anterior, shoulder complex to provide both mobilit,v and d\'namic
Right. 3" upward, Reprinted with permission from Warner JJP: The
$t~lbilit.\·. Dynamic stabilization oc-cllrs via sl.~\'cral possible
gross anatomy of the joim surfaces, ligaments, labrum, and capsule. In:
lllcch:'lnisms (Molley & An, 1990), including p~lssi\'(' musch.'
Matsen. F.A., FtJ, F.H., Hawkins, R.I (Eds.) The Shoul-der: A Balance
lension, or via a b:,uTic:r effect of the contracted Illuscle,
of Mobility and Stability. Rosemont, IL: American
COIll-prl..'ssi,·L' forces broughl ahout h~' llHISCU!:'U'con·
Academy of Orthopaedic Surgeons, J993.
traction, .ioint lllotion that induces lightening or
CHAPTER 12 • BIOMECHANICS
"fmm'------
the an-teromedial aspect of the first rib and inserts on
I tion the upper extremity. Reprinted with permission from Rockwood, C. & Matsen,
F (1990), The Shoulder (p. 2'9).
Pectoralis major
Clavicular
Philadelphia: WB. Saunders Co. Sternal
Deltoid
Posterior
Middle
Anterior
the passive or ligamentous constraints, or via a redirection
of the joint force toward the center of the glenoid.
Teres minor
Teres major
Latissimus
dorsi
Posterior view shoWing the superficial muscles (left shoulder) and underlying muscles
(right shoulder).
ium serves to elevate. retract, and rotate the tivity but does not directly indicate forces gener-
scapula. The latissimus dorsi covers the inferior ated. A complete understanding of the latter re-
portion of the back, inserting on the intertubercular quires knowledge of lhe moment arm (measured
groove of the humerus. It acts to extend. adduct, as the distance between the instantaneous ccntel'
and internally rotale the humerus. of rotation of thc joint and the distance of mus-
Below these muscles.lie the levator scapulae supe- cular pull) and the physiological cross~section of
riorly, which elevale and inferiorly rotate the scapula, the involvcd muscle ('measured as the muscular
and the rhomboid muscles below, \vhich retract and volume divided by its length). In the shoulder
rotate the scapula. Both of these muscle groups nctLO complex, each motion is associated with move-
assist the serratus anterior (which lies laterally on the ment at multiple articulations and the constantly
chest and intercostal muscles inserting onto the me~ changing relationships of the muscular origins
dial border of the anterior surface of the scapula) in and insertions.
keeping the scapula fixed to the trunk. Given the paucity of osseous stabilil~' at the
glenohumeral joint, force generated by one mus-
cle: (the primary agonist) requires the activation
INTEGRATED MUSCULAR ACTIVITY
of an antagonistic muscle 50 that a dislocating
OF THE SHOULDER COMPLEX
force does not result (Simon, 1994) .. The antago-
Electromyography allows for the quantification of nist usually accomplishes this via an eccentl'ic
:. muscular activity during dynamic conditions.contraction whereby the mU5cfe is lengthened
This permits insight into the level of muscular ac- while actively contracting or via the production of
a neutralizing force of equal magnitude but in the opposite Forward Elevation
direction. The relationship between two such muscles is also
referred 1O as a force couple (Fig. 12-19). Around the TIll'most b~\~,dc motion (If thl.· shoukkr compk.'x in-\·oln.'s
glenohumeral joint. there is a force couple in the coronal of tIlL' arm ill the scapular plane. This motion has
ck\'~lIioll
plane (between the deltoid and the infedor portion of the hel'n studiL'd in depth via both dcc-ll'omyograph}' and
rotator curf) and in the transverse plane between the sub- stcrcopllOlogrammctl-.v. The muscles of the shoulder girdk
scapularis muscle anteriorly and the posterior ro-tator Cliff han: subsequent Iv heen grouped according: to relatin.'
Illusculature (the infraspinatus and teres minor). illlponancL" witll regard to this rnotion. TIll'first grouping
includes the dcILoid <Spccificall~.. lhe anterior and middle
heads). lrapeziulll (inf..:rior ponion), supraspinatlls, and
Relative Illotion is produced by an imbalance be-t\veen serratus ~lJ)leri()r (Simon, 10(4), The second grouping consists
the agonist and antagonist that produces torque. The degree uf' the Iniddlc portion or the trapeziulll. the infraspinatus. and
of torque and the resultant an-gular velocity produced is thl..' long head of the biceps. r\ third group consists or Ilw
determined by the rela-tive activation of two such muscles posttrior
or muscle groups. Resultant muscular forces arc determined
via an understanding of the cross-sectional area of the head or the ddlOid. thl.' c1~l\·iclilar Ill,:'~ld of tht.~ pec-
activated muscles involved and their orientation at the time of toralis major, and lht.' slIpi.:rior ponion or the trapez-iUIll.
activation. The fourth and final group includes Ihi.' stLTllal head or the
pectoralis rnajor. the latissirnlls dorsi, and t Itt.' long !It.'ad or
the tricL'ps.
Thl.' inter-rt..'!i.lriol1ship bL'l\\·ct.'1l the muscular rorces
in\·oh'l.'d in shoulder dl.'\'~llion W<lS firsl stud-ied b,\' Inman,
who round that the deltoid and sllpr~ISpiJlatus \ulrk
s}·nergisticall.,· ,,·hile the rc-mainder of till".'rotator
cufllllusculalllrc provides a hUllleral dcpn:ssing forct.' 10
counter sllbluxation or lhl.:.' humeral !lead (Illll1~\I1. Saunders.
& Abbott,
19-1-1). Thus. the vertic'l1h· orien'ed pull o[ the del-
(oid is offset h~' a net inferior rorce crcat(:d b~' the in-
A B fraspinatlls, suhscapularis, anc! teres millOI'.
EIt.:.'ctrom.,'ographic studies have shown tlwt both lhe
supraspilwluS and deltoid ~\rc acti\'L' throughollt the nlllgt..'
of ann clev"ltioll. ThL' supraspinatus. how-ever, is felt to h~l\'c
The deltoid and the oblique rotator cuff muscles (infraspina-
a larger role in initiating abduc-
tus. subscapularis. and teres minor) combine 10 produce ele-
tion. As the arm is progrcs~i\'d}" dL'\'~\ted from the
vation of the upper extremity by means of <1 force couple (two
side, the 1ll0!llCI\t arm of till".'deltoid improvl.'s, n:-suiting in a
forces equal in magnitude but opposite in direction). With the
larger force in I\.'lation to thc supraspina-tus (Fig. 12-20), The
arm at the side (A), the directional force of the del-toid is
p<.:rccllwge 01" shearing or verti-cal force created by the
upward and outward with respect to the humerus while the
force of the oblique rOlator cuff muscles is down-ward and deltoid likewise ck'crt.-'<.lses with increasing arnollllts or
inward, These two rotational forces can be re-solved into their ahduction. The angle of pull or the supraspinalUs'is more
respective vertical and horizontal compo-nents. The horizontal l'OIlSI~lJll at ap-pro:dmalcl.,· 7,=,°, acting not onl.\· to elcvate or
force of the deltoid acting below the (enter of rotation of the ahduct the arm but also to compress the hurneral head within
glenohumeral joint is opposite in direction to the horizontal
the glenoid. Thl.' remaining roW tor cull mus~ cles pull at
approxil1latd~'-15°, which is din;(:ll".'din-{'edod}; (slightl,'·
force of the oblique rotalOrs. which is applied above the
highcr in the ter('s minor at 55°), re-sulting in forces lh~lt
center of rolation. These forces acting in opposite directions
l.·quall}' compress ;:111(1 depress the humeral head to
on either side of the center of rotation produce a powerful
maintain glcnohulllcral stabil-ity (Fig. 12-21).
force couple. as illustrated by the arm signal (B), The vertical
forces offset each other, thereby stabilizing the humeral head
on the glenoid and al-lowing elevation to take place. Adapted
Sl~\('ctive anesthetic
block or tht' n:dllary nerve
with permission from Lucas, 0.8. (1973). Biomechanics of the
(and resulting dcILoid paralysb) dcnlOnsll·atl.'s that forward
shoulder joint.
elevation is possihle alb~it signincantl~.. weakencd. Lik.:,\·isc. a
Arch 5urg. 107.425.
supr~lscaplilar nerve block
CHAPTER 12 • D""v",~n,,,,",~,
Supraspinatus Subscapularis
ff,o':::;7'1:_u..p",ra::-s-,-p_in_a-tIU.S \
I -~-------
As the arm is abducted to 90", the direction of pull of the deltoid
approximates that of the supraspinatus. There-fore, patients with
a large tear of the rotator cuff often
can actively maintain the arm abducted to 90° but may not be
capable of actively abducting to 90", Reprinted with
permission from Simon, S.R. (Ed). (/994) Orthopaedic Basic
Science (p. 527). Rosemont, IL: AAOS.
Supraspinatus --I-:~~~~~~~
I
9
Teres minor
External Rotation
The primary external rotator of the humerus is the The angle of pull of the subscapularis (top) is approximately 45°.
infraspinatus. with significant contributions made by the The angle of pull of the infraspinatus (bottom) is also
posterior head of the deltoid and the teres mi-nOI: With approximately 45°, and the teres minor (bottom) is approxi-mately
any given amount of shoulder abduction, 55°. These vectors result in nearly equal glenohu-meral joint
electromyography reveals the prime external rotator to be compression and humeral head depression. The supraspinatus
the infraspinatus. The subscapularis is simi-larly active but (center) is essentially horizontal in its orienta-tion, resulting in
serves an antagonistic role as the compression of the glenohumeral joint.
Internal Rotation
Internal rotation of the shoulder is accomplished by the
Scapulothoracic Motion
subscapularis. sternal head of the pectoralis ma-jor,
lHtissinlus dorsi, and teres major. The subscapu-laris is active Motion at the scapulothoracic articulation allows maintenance
during all phases of' internal rotation, with decreased relativc or deltoid tcnsion, allowing it to maintain optimal power
activity seen with cxtremes of abduction. 1n the samc \Va.v. regardless of arm posi~ lioll. \-Vith forward elevation at the
activity of the sternal head of the pectoralis major Hnd the arm, the scapula rotates, increasing stability at the gleno-
latissimus dorsi decreases with abduction. However. the humeral joint and decreasing the tendency 1'01' im-pingement
poste-rior and middle heads of the dehoid compensate with or the rOlator cufe bcncmh the acromion (Fig. 12-22). A
increased eccentric activity during internal ro-tation while the rotalional rorc~ COLI pIe
arm is abducted.
(two equal. noncollinear, parallel but oppositely di-
CHAPTER 12 • BICIMI,CI,AiNICS
forces) bet\veen the upper trapezium, levator and upper humeral head. Three forces are then considered: the deltoid
serratus anterior with con-contraction of the lo\ver muscle force (D), the weight of the arm (equivalent to 0.05
trapeziurn and cP'T"llllS anterior leads to scapular rotation body weight [BW] acting at the center of gravity of the
that is for full forward elevation (Fig. 12-23) limb, 3 cm), and the joint-reactive force at the
glenohuIl1eral joint
1994). (1). The joint reactive force and the force of the deltoid,
being nearly! parallel, are considered to be a force couple
.u,","""o> AT THE GLENOHUMERAL JOINT
and are of equal but opposite magnitude, The force on the
glenohumeral joint \vhen holding the arm at 90° of
glenohumeral joint is considered to be a load- abduction can be estimated to be one-half of body weight
bearing joint. Although calculations the exact forces (Calcula-tion Box 12-1, Case A). 11' a weight (W) of 2 kg
acting on it are challenging thc large number of is added (equivalent to 0,025 body weight of an SO-kg
involved muscular male) to the hand of the outstretched extremity held at 90°
and possible positions attainablc, sev- of abduction, a sirnilar calculation can be made
sin1plifying assumptions allow an estima-of the (Calculation Box 12-1, Case B).
magnitude of these forces. A free-diagram of a person
holding the upper held at 90' of abduction can be uti- Experimentally, loads at the glenohumeral joint and the
as an example; it is assumed that only! the forces necessary! for arm elevation have been detcrmined.
These forces have been found to be greatcst at 90° of
ue"cm, muscle is active and that it acts at a dis-tance of 3 elevation, with the deltoid force equivalent to 8.2 times the
cm from the center of rotation of the weight of the arm and
Forward elevation or abduction 0-120 o of the arm requires synchronous rotation of the
scapula. Reprinted "'lith permission {rom Simon, S.R. (Ed). (1994). Orthopaedic Basic Science (p.
the joint reactive force equivalent to 10.2 times the weight musculature in the late cocking phase aCling both to rotate
of the arm (Inman, Saunders, & Abbott, 1944). More recent the humerus and prevent anterior subluxa-tion of the
investigations of these same forces utilizing the assumption glenohumeral joint (Eames & Tullos, 1978). Specifically,
that the muscular force is proportional to its area multiplied the supraspinatus acts in the late cocking phase to draw the
by its ac~ tivity as determined by electromyography have hUllleral head loward the glenoid, the infraspinatus and
yielded similar values. with a maximal joint reactive force teres minor pull the humeral head posteriorly, and the
of 89% of body weight seen at 900 of elevation in the subscapularis bOlh prevents excessive external rotation of
scapular plane (Poppen, & Walke.; 1978). the humerus ancl contracts eccentrically to relic\-c stress on
the anterior shoulder (Tibone et 'II.,1994). The importance
of scapular (and thus glenoid) sta-bilization has also been
recognized, and the serratus anterior has been shown to nre
THE BIOMECHANICS OF PITCHING
actively in the late cocking phase; this provides a stable
Pitching has been divided into five stages: wind up, earl.y platform for humeral motion. Thus. coordinated. sequential
cocking. late cocking, acceleration, and fol-low-through acti-vation of the shoulder musculature is needed to pre-
(Tibone et 'II.,1994). The deltoid has been found to be vent anterior subluxation of the glenohumeral joint and the
responsible for elevation and ab-duction of the humerus in overuse tendinitis that can ensue.
the carly phases. fol-lowed by increased activation of the
ratmar cuff
CHAPTER 12 • BIOMECHANICS OF THt.:s~81~~~£¥;Z:O
j
0" .Calculation of Reaction Forces
Estimates of the reaGlon force on the glenohumeral joint o is approximately one-half body weight. Because 0 and J are
are obtained with the use of simplifying assump- almost paraUel but oppOSite. they form a force couple and are of
:, lions (Poppen & Walker, 1978). equal magnitude; thus, the joint reaction force is also approximately
;;; Case A. In this example, the arm is in 90° of abduction, one-half body weigll!.
;~(:and it is assumed that only the deltoid muscle is active. The Case B. Similar calculations can be made to determine the
Ii force produced through the tendon of the deltoid muscle (0) value for 0 when a weight equal to 0,025 times body weight is
:,~,acts at a distance of 3 em from the center of rotation of the held in the hand with the arm in 90" of abduction.
,,'joint(indicated by the hollow circle). The force produced by
~M = 0
~, the weight of the arm is estimated to be 0.05 times body \.veight
(30 ern x .05 BW) + (60 em " .025 BW) - (D x
(BvV) and acts at a distance of 30 cm from the center of rotalion.
3 em) ~ 0
The reaClion force on the glenohumeral joint 0) may be calculated
D = (30 em " .05 BW) + (60 em " .025 BW)
with the use of the equilibrium equation that states that for a body
30m
to be in moment equilibrium, the 5;Jm of the moments must equal
zero. In this example, the moments acting clockwise are D = 1 BW
considered to be positive and counterclockwise moments are
considered to be negative. Once again. 0 and J are essentially equal and opposite.
: forming a force couple. Thus. the joint reaction force is ap-
~M = 0
proximately equal to body weight.
(30 em x .05BW) - (D " 3 em) = 0
D = 30 em x .05 BW
3cm
D = 0.5 BW
3cm
3cm
I Force 0 ......... ----i""X'-
I Force J ·········~)~~=----=t;;;;_;;:;---r
I
I ,.ossw
I
!
I I,
,
30cm
•
;
): ! 30cm
.~,----::------->
60 em
Sumrnarv within the joint and the ligaments that surround it provide
stability while allowing for significant rota-tion of the
F The shoulder consists of the glenohumeral, clavicle. lillie relative motion is seen be-tween the clavicle
ncromioclavicular. stcrnoclaviculat: and scapulotho- and acromion at the acromio-clavicular joint.
racic articulations and the muscular structures that act on
them to produce the most mobile joint in the body. 3 The glenohumeral joint. while known to be a
precise articulation, is inherently unstable because the
2 The sternoclavicular joint, which connects the glenoid fossa is shallow and is abl.e to contain only
medial end of the clavicle to the manubrium. links the approximately onc third of the diameter of the humeral
uppe.· ex trernity to the thorax. The aniculnr disc head. Stability is instead provided by the
capsular, musculal~ Llnd ligamentous structures that Fukllda, K.. Cr;lig. E.\·.. All. K .. t·l ;d. 11{J~6i. Bihmt·ch<Lnical :-llId,- e,l
surround it. Illl· ligallll·lll('ll:' :-~:-tt·1ll (If thl' :lcnHnicH,:b"iclllar jllill!..1 HfJlil' .If/ill;
Sltr::. MS. ·t3.t-~.tO.
4 The three glenohumeral ligaments (superior, middle. Gihh. T.IL Sidle,. J.:\ .. lbn·~lll;tll. D.T.. d :11. (1991). The i..·f-ft...:! (d- l"~lp:-lIlar
and inferior) are discrete extensions of Ihe anterior \l·lIling oil gk·lIohllllkr:d 1:,'\iiY. Cliil Or.
!/f(ip. 268. 110-11i.
glenohumeral joint capsule and are critical to shoulder
l!ollillShl·"d. \\'.11.(IY6t)). ·\lIli//llllf /n,. Sllr.::OJl/\ (VoL 3i. Xc\\,
slability and function. York: Harp..·.. ...\: Ih,\\.
S" The inferior glenohumeral ligament has the most lIe,\,-dl. 5.:\1.. IIlHdlcr:-kg. :\ ..\\.. S..·ga, D.lI .. l:I :11. ,19$6).
Cbrifil:;ltion 01 till.· nd .., Io! Ih~· :-upr:l:-pill:IlU:- n1l\.'>,:le in
functional significance (particularly the anterior bane!),
:-houldl·r 11llKliclll. 1 H"'I/, 11'iHI Slfl~. 00:\. 3YS-·W ..L
acting as the primary anterior stabilizer of the shoulder [nm:\ll. V.T.. S;\Illllk·r:-. J.I3 .. & :\blwll. L.C. (19.t ..+.!. Obsl:lya .. lifl!\S
when the arm is 'lb· ducted 90'. nn Ihe llln;.:lillll III till· :-houldn jlllnl . .1 !JOI/(' luilll
SllJ·.~. 26..\. 1-30.
Iloi. E., I-bll. I-I.e.. l\: All. h.\. (199{\1. BiOlllt'ch:lnical ill'.·t:slj· g;llioll of
·6. The inlegrity of the shoulder capsule and the negative lhl: gkllohllllll:r;d join!.) SltlJ//lcla Uhow S/lr~, 5,
intra-articular force it maintains also plays an integral pan 40i- ..L~~.
in mainlaining shoulder stability. Iloi. E.. \lol/.kin. ~.E. .\IMr..·.\. B.F.. d :tl. {IY9-ii. SI~hilizing illlKlioll Ilf tht·
long hC:ld of Iht· hic..·p:- ill till· hanging ;"t!'m po:-,itilln. J Sltould..r
.)~ Elevation of the arm involves motion at both the FlblOw Sur;.!.. 3, 135-1-I:!.
glenohumeral joint and the scaplliothoracic ar-ticulation. hoi. E..\l(llzkin. \:.E. . .\1{)lTt·'. 13.17.. l'l ~tl. (1992). S;,:apular inclill:ltiol\
~ll\d illk·ri(lr :-1;lbilil, 1'\ lilt· ... huuldCl". .I Shulll-tit'/" r:1l}('1~' Sun.;. I.
131-1.,9.
?;S) Movements of the spine assist the shoulder in "-l1m;lr. \'.1'. & lbb:-uhr;ltll;tlli:llll, P. (1')S51. Tilt· rClk 01 ,1\' n\I,:,ph~·rjt·
positioning the UppCt'extrcmity in space. pr~·.... :-t1r~' ill :-1:lhili/ing lllv :-h(,tlllkr: i\n ~·\!h.. ri· ll\~·llt:d ~tltd\. J nUll<'
Jpiur Sill.!.:. (,iii. 71'L·711.
{g) The muscles around the shouldcr contribute lO
L'llilll'11HI. t'.i 1'J~7). Kin~·~i()I(I~'.\' (Ii I h\.· sil(llillkr joinL III R. K(,ih~·1. ~·t a!. i.
st~~'bility via a barricr effect by producing compres- E.d~.I. ,I,,;/inlildl'l'N'Pi!;Cl'iJl,'IIi. 1~~'l'1in:
sive forces on the glenohumeral joint and byeccen-tric Sprinl,'n·\"nl:q!. I 'J~ 7.
contraction. Lippitt. S,B .. \·"JHkrho()ft. .J.F. J[;\I'1'i~, S.L. ~·t ~i1. 11993l.
GICI1(lhllI11~'!":\1 :;t~lhijit' I"rllill ('(JJICI\'il.\·l:olllpr,,·:;:;ioll:A q\l'lnlil'lli\~·
~Q';Theglenohumeral joint is a major load-bearing joint :ll1;I!.,:;i:, . .1 SJIO/lldrJ' IJ;'II\\' Sur::, }, 27-·3.~.
with forces equivalent to one-half body weight produced [.tll·,t:'. I).B, (1973). Biolll(·Ch:ltli\.'s 01 tht· :;hntlltlt·r inint . ..\)';.,1:
when holding the arm in an outstretched position. Sw·:,;. 107. ~2~ .
.\bbC:l. E. Fl!. F.. \.\: 1[;1\\ kill:-. R. 1Fd ..... \ \ 19921. rh,· Slu;nld"t:
:1 J3a!IiIiC" iI! _\//Ohilizy rll/{; Stahility. RO:-Clllill1l. It: :\:\OS.
I\';II!. Colorado: \\'lIl"bhop Suppllrkd b., dl~· Ameri~';1l1
:\(adt'my (If Orth(Jp~lt·dic Sllr~"·{)I\:-. Ih..• X<llional Institu[i..: of r\nhrili:-
REFERENCES alld .\llI:-nllo~k~·k!:t1Skill I)i~t·a:-;..,:-. tht' :\ma· i t-:Ill ShouldtT ;1Ilt! ElbO\\
:\gur, A.M.R .. lee. \1., &. Grant. J.e. (1991). :lIla ... o":lwllomy Suq:!t·OII:-. Ih ..· On!lopat·uic R~· :-t·~lr\.>h and E.hIGII il'"F('lllltbi iOll.]
(9th NI.). Bahimorl..': Williams &. Wilkins.
Baml..'s, D.A. &. Tullos, H.S. (1978). An analysis of 100 symp-tom'llie .\lilffcy. B.F. & :\n. I\..\:. i 1990), Biolllt·dl:lllk:o, (If the sbouli..kr. III c.:\.
b<tsl..'ball playt.'fs ...\11/ J Sports Mel!. 6. 62-67. ROi..·k\\(I(,t! \'-. F.:\ . .\1~lt:-t·1l III {Elk). The S1Jolflda lpp. 10~-2.t:;L
Boonc. D.C. &. :\zcn. S.P. (1979). Nornwl range of Illotion of joints in rhibddphi~l: \\".B. S;illl1(lt-r:-.
male subjl.'cts. 1 Bow: loiHt S/frg. 61. 756-759. .\I(lor..·. h.L. (19t)\ji. Cliuh:{:lly O,-it'lth'd ..Ii/ili/IJllY 1-1-111 cd.).
Colaehis, S.C. Jr. &. Strohm, B.R. (1971). Effl..'ct of supras-capul;lr and l)hibtklphi"l: LippilKllti \\'illl,tlll:- & \\"ilkin:-.
axillary nervc blocks on muscle farer: in upper .\hUTt·'·. B.F. l\: :\11. "-.X. (1990). BiCll11t'I.:h:lllk:-. of lht' shotd· tit-I'. In
I..'.xtrl..'milv. Arch Phvs :\Jed RciUlbil. .12, 21-29. C:\. Ritt"kW(IOd l\: 17.:\. '\\;il:-t·1l 111 {Ed~.). rIJ ...'j!wlf{-d,·,: PhiliHk·lphia:
Cooper, D.E., O'Briel~, 5.1., Amol:Zk:". S.P., 1..'1 ;;d. (1993). The W.B. S:llln.kr....
structurc and function of the coraCOllllllll.'ral ligamcnt: An anatomic .\lurr:I\·. ;\-I.P.. GMt.. D.R .. Cardlll·r. C ..\I.. ('1 ,d. l19~51. Sluml .. tin'
and mil.:roscopic study. J Shoulder Elboll· SlIrg. 2, motion ;llld Illll:-r.:k :-lrt·ngth of normal mcil and
70-77. \\Olllt'll in Iwo ;l~e ~rollp:-,. Clill Onhflp. /92, 193.
Curl. L.A. &. Warrcn, R.F. (J 996). Glenohumeral joinl stabil· ity: :\cl..'r. C. (1990i. Shoulder UC·(·flll:'In/oiIlJl(p. ]9). PhilOldd-phi;t: W.B.
ScI",'ctin' culting studies on the slatic: c<\psubr re· siminis. Clill Saundns Co.
Onhop, 330, 54-65. O'Brit·n. Sol .. \ne:- . .\1.C. "l1Hli.:l.k~. 5.1'.. d al. (1990). Th~
Delee J. & Ora, D. (199.:1). Onhopac:l!ic Spons Mc:dicillt·. :lnalomy and hi:'lology 01 Ih ..· inkriof gknohullwral lig:l-lIh:nl cOlllpkx
Prillciplt:s awl 1)raelicc (p. 464). Phibdelphin: W.B. Saunders. of Ilit· shoulder. :\111 J Sports .\let!. IS. 579-3$4.
Introduction
Anatomy
Kinematics
Carrying Angle
Elbow Stability
Kinetics
Electromyography
Elbow Joint Forces
Artieular Surface Forces
Calculation of Joint Reaction Forces at the Elbow
Summary
References
.,
•
Introduction j
!
·i
The elbow is a complex joint that functions as a ful-crUIll I
for the forearm lever system that is responsi-hie for
positioning the hand in space. A detailed lin- I
;:Xderstnnding of the biomechanics of elbow function \
,is essential for the clinician to e1Tcctivcly treat 'pathological
conditions affecting the elbow joint.
I
"
341
Lateral Medial \,,:Clllll"~ll·tl1n,,·s 01 tip to 30 which i ... C(Jfl:-.istl'lH with
column column Ilh: iUlll'tiollalr~lllgl.· \alul.".... dl"SlTilk·d aho\·I.·. rlcx-i(Jll 1.·(llitractllrl."~
~rl'~lkr than 3(r~ ~U\· a:-'Mll'i~llCd
,,·ith 1.·(lJrlplailll:" {If ... iglliiicant In...:" or r1Hllion.
Olecranon i... ~l clInsidl'rahk ~1l1<..1 rapid loss Ill' thl" ahiiity I\"~ldl in
fossa
spal·l· \\ ilb Ik','\ion coniraclllrl~'" " ... "....>.-
Coronoid lh:lll 30" (Fi~. 13-':» U\n 8.: :\1 0 tTL".\'. 10Y 1).
fossa
Till.':l\is 01' I"OI:llil!l'l1'(11' Ik·,\ioll-I.'\1L'llsiullhas been
s!\(l\\'[)h.\'Sl'\'l'l'~d illn..,'slig:I[OI"Slo Iw ~lt till· 1.·l.nler of
till'lr()l,.:hk~l, SLlPPol'lingthl.'COIlCI.'ptLhal elhow ilL'.\:-iotl I.·~lll lk·
I"l'pll'sl"l'1ll'das a L1ni:l\i~l1 hingL'. F·:\\,ald ~1I1(.1 Ishizaki.
COIl\\'1''''l''ldi.....l'U'·L·n.,·,.a·ddl<'ltlgillgc:L\:is of rotatiun ,dill dho\\'
lIc:don (EwHld, 1975'
Ish i Zll ki. 1979). LOlldull <.k·!l1ollstra h...d t hill t he aXi~ or
Lateral rOlatioll passl.·... Ihrough Iht.'Cl.'fllL·r(If' CO Ill.:l· 111 ric arcs
epicondyle c>utlillcd Iw IhL'hOl!ull) of Ihl.' trnchk'ar sulcus ~\nd till'
A B pl...TiphL'I·.'·or t!tL'capilcllunl ((3111c!tlll. \981).
! k ~t1>'(1 noted lhat tilL'..... llrr~in.. joint mOl ion during
I!L-xioll-L'xtclbion\\'~I~ prilllaril.'·of thL· gliding 1.''P~ ~llld Ilwl
\\ilh tlk'L·,\(rl."I1lI.'S01 Ill.'xiun·I.''\IL'Il~i(l1l (the lillal :iIO ICY of bUlh
Anterior (A) and posterior (B) projections of the distal
humerus highlighting the medial and lateral (Olumns.
lk\ioll and L".'\lI.·ll~ion). I hI.'axis or rot:llioll dWllgl'd ;:lIld
tilL'gliding/sliding j<lim mo· lion cl1~lllgl'd to a rlJllitlg 1,"lll'
• mOlion. TIlt.'rolling oc-l:llrS al illL'l'.\lrclnl.'s of Ik\iOIl and I...'\lL'I'\.:-
:'iulIas lhe
(:OITl!1Clid process I.·CJIl'lL'Sinto I.'olltacl\\'ilhtill..' floor or 111L'
IUllllL"I'a! okcranon fossa and 1Ill' okcrallon
(FigI3-2). The arc of m1icular cartilage of the greater (.'(ll'ltacls 111L' l!(l(t!'of Illl' ()IL'c,·~u\On fossa. In addition,
sigmoid notch is 180°, but this is often not continuous in its
midportion. [n more than 90"m of individuals, this area is
complised of fally. fibrous tissue (Walkc); 1977). As Mon-
ey noted, this anatomical feature explains the propensity for 15
fractures to occur in this area, as this pOI1ion of the greater
sigmoid notch is not suppQl1ed by stronger subchondral
bone (MOITe)', 1986).
The radial neck is angulated 15° from the long axis in
the anterior-posterior plane away from the bicipital
tuberosity (Fig. 13-4). Four fifths of the ra-dial head is
covered by hyaline cartilage. The an-terolateral one fifth
lacks articular cartilage and strong subchondral bone,
explaining the increased propensity' For fractures to occur
in this region.
\
\
Kinematics I
Elbow flexion and extension take place at the humeroulnar \
and humeroradial articulation. The normal range of
Oexion-extension is from 0 to 146° with a functional range
I
of 30 to 130°. The normal range of forearm pronation-
~
supination averages from 71 ° of pronation to 81 0 of
Angulation of the r('ldialhead/neck in relation to the radial
supination (Mon-ey et al.. 198\). Most activities are
shaft.
accomplished within the hmctional range of SO° pronation
to 50° supination. Clinically, patients can tolerate flexion .--_._-------~~-~-
o 304560 90 degrees
Function = Volume
V" 4/3 "r"
Diagram depicts the dramatic loss of effective reach area with flexion contractures of the elbow
greater than 30"
. dl --------------------------------------
internal axial rotation of the ulna has been shown to occur flexion-extension occurs abollt a tight locus of points
during early nexion and external axial rotation during measuring 2 to 3 mm in its broadest dimell sian and is inM
terminal tlexion. demonstrating that the el-bow cannOl be the center of the trochlea and capitel-lum on the lateral
truly represented as a simple hinge joint. -In conclusion. view. It is approximated by a line passing through the
evidence suggests that the el-bow has a changing center of center of the lateral epicondyle and trochlea and then
rotation during flex-ion-extension and functions in a more through the anteroinferior aspect of the medial epicondyle
complex man-ner than would a simple uniaxial hinge. (Fig. 13-6) (Morrey & Chao. 1976). These facLors should be
Laken into account during joint replacement procedures of the
Despite variation in findings among investiga-tors. elbow as well as when placing hinged exlemaI fixa-tors across
Mon·ey. Tanaka. and An (199\) have slaled thal the the elbow joint (Figgie. rnglis. & i\flow. 1986).
deviation of the center of joint I'olation is mini-mal and the
reported variation is probably the result of limitations in
experimental design. There-fore. the ulnohullleral joint Pronntion and supination take plac;e primarily at the
could be assumed to move as a uniaxial articulation except humeroradial and proximal radioulnar joints with the
at the ex-tremes of nexion-extension. The axis of rotation forearm rotating about a longitudinal axis passing through the
of center of lhe capitellum and
.344 PA~I'g;'BIOMECHANICSOF JOINTS
radial head and the distal ulnar articular surface. This axis
is oblique in relation to the anatomical axis of the radius
and ulna. During pronation-supinat ion, the radial head I
I
rotates within the annular Iigan1Cnl and the distal radius I
rotates around the distal ulna in an arc outlining the shape I
of a cone. Carret ct al. (I976) studied the instant centers of \ \
rotation at the proximal and distal radioulnar joints with the \ \
fore-arm in varying degrees of pronation and supination. \ \
They found that the proximal instant center of rota-tion \ \
\ \
varied with differences in the cun1alure of the radial head \ \
among individuals. Chao and Morrey (I 978) investigated \ \
the effect of pronation and supination on the position of thc \ \
\ \
ulna and found no significant axial rotation or valgus \.J
deviation of this bone during forearm rotation when the
10' ~
elbow \vas fully extcnded. ODriscoll et al. (1991) has
demon-strated that internal axial rotation of the ulna occurs
with pronation while external axial rotation occurs with
supination. Kapandji (1982) has suggested that both the Diagram of semiconstrained total elbow replacement al-
distal radius and ulna rotate about the axis of pronation- lowing a variable amount of toggle in the varus/valgus and
supination. with the ulnar arc of rota- axial planes. The design takes into consideration the fact that
the motion of the elbow cannot.be purely repre-sented as a
simple hinge.
Palmer et al. (1982) have demonslrated proxi-mal in adults and greater in females than in males, av-
radial migration with forearm pronalion. This finding eraging 10 and 13° of valgus, respectively, with a wiele
has been supported by observations at el-bow distribution in both (Atkinson & Elftman, 1945; Mall,
arthroscopy. In addition. as a result of the ovoid shape 1905). Steindler (1955) reported a gradual increase in
of the radial head. its axis is displaced laterally in the carrying angle with age but found no statistical
pronation by 2 mm to allow space for difference between men and women in this rate of
medial rotation of the radial tuberosity (Ka-1982). increase or the c<'lITying angle. Controversy exists
regarding the change in the carrying angle as the e1bo\v
is Flexed. An et al. (1984) have noted that this
controversy arises from the various references systems
'ng Angle employed to determine the carrying angle. They noted
that when the cCiITying angle is defined as either the
:'1 The valgus position of the elbow in full extension is angle ronned bet\veen the long axis of the hu-merus and
commonly referred to as the c<'\ITying angle, The carrying ulna on a plane containing the humerus or vice versa,
angle is defined as the angle between the anatomical axis the carrying angle changes minimally with flexion. H
of the ulna and the humerus measured in the the carrying angle is de-fined as the abduction-adduction
anteroposterior plane in exten-sion or simply the angle of the ulna relative (0 the humerus Llsing Eulerian
orientation of the ulna with re-spect to the humerus. 01'vice an-gles to describe arm motion, the carrying angle
versa, in full exten-sion (Fig. 13-8). The angle is less in decreases with joint flexion changing to varus in
children than extreme flexion (Fig. 13-9).
I
Elbo'vv Stability
I
I
I
Valgus Forces at the elbow are resisted primarily by the
I anterior band of the medial collateral liga-ment (MCL)
I
I complex. The MCL complex consists of an anterior
I
I bundle, a posterior bundle, and the transverse ligament
I , (Fig. 13-10). The anterior bun-dle tightens in extension
\ ' while the posterior bun-dle tightens in flexion. This
I I
I ' occurs because the Mel complex docs not originate al the
I I
I center of the axis of elbow rotation (Fig. 13-11). The ante-
I rior band of the Mel complex originates frolll the inferior
I'
I surface of the medial epicondyle of the distal humerus and
I inserts along the medial edge of the olecranon. vVith an
" intact anterior band, the radial head does not offer
'I I I
significant additional resistance to valgus stress'. However,
I I
, I with a trans-acted or disrupted anterior band, the radial
I I
, I head becomes the primary restraint to valgus stress,
I I , emphasizing its function as a secondary stabilizer in elbows
with an intact MCL (Palmer, Glisson, & Werner, 1982).
,:.-...', Despite studies by Mon'ey (Money, An, & Stormont, 1988;
Morrey, Tanaka, & An, 1991) ""demonstrating the
secondary valgus sta-bilizing effect of the radial head,
several investiga-tors have noted increased valgus laxity
The carrying angle of the elbow, formed by the intercep· tion after I'adial head excision (Coleman, Blair, & Shurr, 1987;
of the long axes of the humerus and the ulna with the elbow Gerard, Schernburg, & Nerot, 1984; Johnston,
fully extended and the forearm supinated. Val-gus angulation
normally ranges from 10 to 15°,
•
A B
'I
IJ
,
I
r Abductio n/ad ductio n
r
Humerus I
r
X4
Z1
Pronalionlsupinalion
X4
c
A. Carrying angle measured as the angle between the long axis the plane containing the humerus. C. Eulerian angle mea-surement
of the ulna and the long axis of projection of the humerus on the of ulnar motion in reference to the humerus. Ab-duction-adduction
plane containing the ulna. B. Carrying angle measured as the angle rotates about the axis orthogonal to both
formed between the long axis of the humerus and the long axis of the Z and X4 axes; flexion-extension rotates about the Z1
the projection of the ulna on axis; forearm axial rotation takes place about the X4 axis .
•
valgus stress is the MCL complex (I\ltorrey & An, 1983).
In extcnsion, the elbow articulation provides most of the
resistance to varus stress, followed by the alllcrior capsule.
In flexion. the elbow artiClda-tion remains the primary
Anterior bundle
restraint to varus stress followed by the anterior capsule
and the lateral col-lateral ligament (LCL) complex,
respectively, wilh the LCL complex contributing only 9%
Posterior (Table 13-1). Elbow extension is limited primarily by the
bundle anterior capsule and anterior bundle of the MCL complex.
Excision of the olecranon fossa fat pad has been shown to
Transverse
provide 5° of additional extension (\Valker, 1977).
ligamem
Furthermore, Morrey et al. (1991) have demonstrated an
almost linear decrease in ulno-humeral joint stability with
scrial removal of 15 to 100% of the olecranon.
2
Anterior
1 ~
0
Percent Contribution of Restraining Force
1
2
~ During Displacement (Rotational or
P-MCl Distractional)
Stabilizing
Position Element D~straction Varus Valgus:_"
0 00 60 100 120 140
o 20 .:0 - Extension MCl 12 31
Elbow joint flexion LCL 10 14
angle (degrees)
Capsule 70 32 38
":'rticulation 55
Flexion MeL 78 54
Origin of the anterior and posterior bundles of the medial
collateral ligament (MCL) complex. As the MCL does not LCL 10 9
originate on the axis of elbow rotation. there are changes in Capsule 8 13 10
its length as a function of elbow flexion. The anterior bundle. Articulation 75 33
which is closer to the axis of rotation, is the most isometric.
MeL. medial collater.11Iigamen, complex; LCL. lateral
collateral ligament complex
o 1 2 3
Reduced Posterolateral Perched Dislocaled rotatory
instability
Radial
collateral
ligament
----------------
the humeroulnar joint with forced varus and exter-nal dcrscl1, 1989). The latl.'raluilwr coll~t[eral is the pri-llwr\
rotation (Daria et aI., 1990; Dllrig et aI., 1979; Josefsson, restraint to posl~r()latt..'r:.d l'OWlOr\instabilit)' or the dl)()\\',
Johnell, & Wenderberg, 1987; O'Driscoll. Morrey, & An, followcd by lite radial collateral liga-ment "nd capsule.
1990a; Osborne & Cotterhill, 1966) . O'Driscoll et al. (1990b) also noted a small but significant
O'Driscoll and colleaglles( 1990a) described the entity effect or
the inherent negative intra-anicular pn.:.'ssurc of lhe
of posterolateral rotatory instability of the e1. bow in which elbow joint to \'arus and rotation strcsses (C:'lseStud.\' 13-1).
the ulna supinates on the humerus and the radial head
dislocates in a posterolateral di-rection (Fig. 13-14). It has Slruclures Iimiling passh·....· lkxion include the
been shown that the el-bow can dislocate postcrolatcrally or capsule, lriceps, coronoid process, :.lnd radial head.
posteriorly with an intact Mel c0l11plex. This can occur Struclures limiting dbow exlt.'nsion include the ole-cranon
with combined valgus and e:\lernal rotation loads across the process and Ihe anterior band or the Mel complex. Passin:.'
elbow joint (Sojbjerg, Helmig, & Jaersgaard-An- resistance 10 pronaLion-supination is provided in large pan
b~" (he ::lIltagonisl muscle gruup on slrdch, not b)' th ....,
ligal1lclHous structures
(Braune &. Flugd. 1842). Olll....'I's have shown {hat thL'
quadrate ligament proddes l'l.'s(railllto forearm rotation
(Spinner & Kaplan, 1970).
e c
Longitudinal stabilil~' 01" the f'orL'arm is pro\'ided b~'
both the interosseous 11lL'mbrancand the tri;:\11-gular
Elbow Fracture Dislocation Instability of the joint occurs in posterolateral dislocation. The
ulna supinates onto the humerus, the radial head dislocates in the
A 16-year old male gymnast falls onto an outstretched arm, x~ posterolateral direction, and the lateral ulnar collateral ligament is
producing abnormal loads in the elbow complex. The axial
injured, as is the radial collateral ligament and cap-sule. All these
loading during the fall onto the outstretched position caused a
abnormalities lead to an increase in stress within the joint and a loss
fracture on the radial head, altering the articular congruity of
of stability and congruency necessary for normal joint kinematics.
the radjocapitel!um joint and the stability of the elbow (Fig.
(513·1-1 ).
Case Study Figure 13-1-1. Figure A: Antera-posterior X-rays that confirms postero-Iateral elbow dislocation, Figure B: lateral radiography that fracture on the
radial head and capitellum, Figures C. D: Posterior and lateral vie,v, Post-operative x-rays. Congruence of the joint has been achieved.
radial migration increased to 4.4 mm, Radial head resection humerus and thL' prnximallaleral aspect of the ulna and
when combined with TFCC transaction caused 2,2 l1un of insens into till: ~nl(:rior aspect of the supinated proximal
proximal radial migration, The combination of radial head radius,
resection, interosseous membrane transaction. and TFCC Muscles in\"C)ln:d in pronation itH.:ltld~ the prona-{or
transaction led to the greatest increase in proximal radius qu()dratus and pronator teres, Thl,.' pronator quadratus
migration of 16.8 mm. originates from the \-'olarasp~ct of the distal ulna and inserts
onw the dislal and lateral as-pect or the supinated r~\dius,
The pronator teres is more proximall.\' located, arising
from the medial
Kinetics l'picond~'lc or the hLlm~l'us and inserting onto the
lal~ral aspect of the midshal't 01" the supinmed ra-dius, The
The primary nexor of the elbow is the brachialis. which pronator quadratus is the primary prona-tor of the forearm
arises from the anterior aspect of the humenJs and inserts reg~rdless of its position. The pronator teres is a SCCOJ1c!4l1Y
on the anterior aspect of the proximal ulna (Fig. 13-\5). The pronator when rapid pronation is required or during
biceps arises via a long head tendon fTom the supraglenoid resish.'d pronation (Basmajian, 1969).
tubercle and a short head tcndon from the coracoid process
of the scapula and inserts on the bicipital tuberosity' of the In a sludy examining ('Ibn\\' strength in normal
radius, It is active in flexion when the forearm is supinated indi\'iduals, supination strength \\'as shown to be 20 to
or in the neutral position. The brachio-radialis, which 30%:: greater than pronalion strength (Askcw et al.. 1986),
originates fTom the lateral two thirds of the distal humerus COllsish.'nt with muscle cross-sectional area and moment
and insens on the distal as-pect of the radius near the radial arms, flexion strength w~s 30l }o gre~ltcr than extension
styloid, is active during rapid flexion movements of the str('ngth, LastI~·, males were consistcntl~' 40'j(i slronger than
elbow and when weight is lifted during a slow flexion females in elbow strenglh testing.
move-ment (Basmajian & Lalif, (957). The brachial is, bi-
ceps, brachioradialis, and extensor carpi radialis are Lhe
major nexors of the elbow, the brachialis pos-sessing the
greatest work capacity (An et aI., (981), Electromyography
Elcctrom~'ogl'aph~' has been helpful in defining the
The primary eXLensor of the elbow, the triceps, is contributions or elbo\\' musculature during activi-ties of
composed of three separate heads, The long head originates dail~' li\'ing and spcciflcall~' defined tasks. TilL' biceps brachii
from the infraglenoid tubercle and the medial and lateral is only l1linimall~' acth'L' during elbow Ilt'xion wh~n the
heads originate from the posleriol' aspecL of the humenls forearm is pronated (Bas-mujian '" LaLif, 1957: Funk el
(Fig. 13-\5). The three heads coalesce to form one tendon 'II., 1987: Malon & BouisseL, 1977: SL~\'~ns ~L aI., 1973).
that in-serts onto the olecranon process of the ulna, The Brachialis ac-th'it.v, howen.'r, is nOI affected b\ forearm
medial head is the primary extensor and the lat-eral and rotation during flexion (Funk t't aI., 1987: St('\'L~ns et aI.,
long heads act in reserve (Basmajian, 1969), The anconeus 1973), The brachioradialis also is aClive during flex-ion,
muscle. which arises from the posterolateral aspect of the This activit~" is enhanced wilen lh<.: forcarm is in a neutral
distal humerus and inserts onto the posterolateral aspect of or pronaled position (Basmajian & Travill, 1961: DeSousa,
the proxi-mal ulna, is also active in extension, This muscle DeMoraes, & DeMoracs, 196\: Funk el aI., 1987: Sle\"ens
is active in initiating and rnaintaining extension, While the el al.. (973). Elee-tromyographic dala demonstrates that (he
lriceps, anconeus, and Ilexol' carpi ul-naris are active in medial head 01" the triceps "!lei anconeus is activc during
extension, the triceps has the largest work capacity of all e1-bo\\' extension, with the lateral ~lIld long heads or the
the elbow extensors triceps sCI'ving as secondaJ'~' extensors, Morrey (1993)
concluded the following from the elec-tromyographic data:
(I) the biceps is gencrall~; less aClive in full pronation or Ihe
(An et al., 198\). forearm, s(;.'conelary to its role as a supinator: (2) lhe
Muscles involved in supination of the forearm in-clude brachialis is acth'c throughollt flexion and i~ belic\'ed to be
the supinator. biceps, and lateral epicondylar extensors of the work-horse of flexion; (3) electrical activity or lhe
the wrist and fingers. The primal)' mus-cle involved in triceps
supination is the biceps brachii. The supinalor arises fTom
the IaLent! epicondyle of the
CHAPTER 13. BIOMECHANIPS.. OFTHE El~eta"1!'1,1D
' =if~S--~Z~ ..-.,
Supraspinatus
Subscapularis ---'f-+
Lev. scapulae
Rhomboid
'" Infraspinatus
min.
Teres minor
Lat. dorsi -- \ - H
Infraspinalus
'I-\-Ir-t- Trieeps
Teres maj. ---t'~J (long head)
Rhomboid
Pectoralis maj. ----'R maj. '--'--'HHfTeres- minor
Coracobrachialis
Brachioradialis
i Ext.
Ext. indicis
Flexor pollicis
digitorum
longus
Flexor dig. profundus
I A B
~'.------------------------
Origin and insertions of muscles of the upper extremity. A. Anterior view. B. Posterior view.
JOINTS
~M = O.
Case B. ;\n object of 1 k9 is hele! In the hand, producing a
113 em x WI ~ 130 cm x P) - (5 em x B) = 0
forcQ of 10 N Wi
If W = 20 Nand P = o.
13cm x 20N ~ivl = 0
B= 5 em
Ji W == 20 Nand P =:: 10 N.
B is calculated to be 52 N. (13 cm ;..-; 20N) - (30 eln x JON) - (5 cm x B) = 0
J. the reaction force on the trochlear fossa of the ulna. can 260 t'Jcm_. 300 Non
8=
now be calculated by means of the equilibrium equa-tion for 5 ern
forces. Gravitational forces are negative; forces in the opposite B 15 found to be 112 N.
direction are positive. The joint reaction force can om\'be calculated.
~F =0 ~f =0
B-J-W-P=O B-vV-P-J'='O
J = 52 N - 20 N - ON. J=8-VIJ-P
J is found to be 32 N. J = 1 12 N - 20 N - lON,
!.·
T and J are calculated with the equilibrium equa-tions. force is shorter than that for the flexor l'orec-3 ern as
The joint reaction force for the elbow in ex-tension is 107 opposed to 5 em. Thus, a greater l1111scl~ I'orce (87 N as
N. compared with 32 N in Ilexion. This more than opposed lo 52 N) is required for the fore-arm Lo be
threefold increase can be explained by the fact that the 111ainlained in the extend~d position. and as a r~sllit the joint
lever arm for the elbow extensor reaction force is greater.
CHAPTER 13. BIOMECHANICS9Ff~,~i~~~~%~l~JD
Swnnuuy
A clear understanding of elbow mechanics and function is 5 The can}'ing angle of the elbow is defined as the
critical to gain a broader understanding of problems angle betwcen the anatomical axis of the ulna and
affecting the elbow joint. This knowl-edge will provide the humerus in the anteroposterior plane and in rull elbow
basis for management of el-bow disorders. extension. [t averages between 10 and IS" of valgus.
O·Drisl.:oll. S.W.. Morre)'. H.F., &. An. ".N. (1990:\). Thl.· Sowa, D.T.. Hotchkiss, R.N., '-': Wi.'ihUld, "\,J. (l993). Sympto-m:.tic
p'I!lIO'lllalOllly aEld kinl:mati<.'s of postcrolaH:ral inst<l!lility (pivot- proximal tr,lIIslation of the radius following r<ldial IH:ad resectioll.
shifl) of I hI.' ".'Ibo\\'. Orlhop Trem .... 1-1. 306. Clill Ortlwli. 317. 106-113.
Osborne. G. & Cotterill. P. (1966). Rl:l:urrelH disloc'llion or the dbo\\'. 1 Spinner, M, &. Kaplan. E.B. (19iOJ. The quadrati.' Iigamcnt of lhe elbo\\':
Bom: 10i1/1 SlIrg ilr. 488. 340-3-16. Its relationship to the st.lhility of the proximal radioulnar joint. ..kla
Palmer. A.K .. Glisson, R.R .. & \Vernl.·r. EW. (1982). Uln,II·\·<tri-ane\.' Orlho!' Scaml. '+1. 632.
dl.'ll.·rmin'ltion. J /-Iuud Sur;.;, 7, 376. StC'indler. A. (1955). In KiIH'si(Jlo~\' of the f-1ll/tllll/ Bod\' UI/dcr Norlllal
P"arson. J.R .. McGinley. D.R., & Blllzcl, L.M. (1963). ,\ dy-namic awl Pathological COlI~i;ticJIIs. Springfield: 'Charles
analysis or the upper extrl.'rnity: PI.lllar motions. C. Thomas.
fl1l1lUl11 F{l(;wrs, 5. 59. Stevens, A., Stijns. H.. PI.·ybrouck. '1'., ~:t :\1. (1973). A poly-
R.i:l\', R.D., Johnson, R.J., &. Jameson. R.i\l. (1951). ROl<ltion of cll"ctrom)'ographical sludy of the arm muscles at gradunl iSOIlH.'lric
'the fOre;ll'lll. :\n e.xpel'inH.'lltal study of pronation and supin'ltioll. J loading. [b:troll/yogl' Clill NI:/lroph.\'siol. /3.
BOlle: 10illl Stir!::. 33:1. 993-996. 465.
Rc.lI·don. J.P., Larrcrty, ~'L, K'inwric, E.. ct 'II.(1991), SInH;-turc:s Stormonl. TJ., An, K.N .. ~'Iorr('.\·. B.F.. d nl. (1985). Elbow joint (Onta<:1
innucncing :-axial st:-ability 10 Ihe forearm: The role of the radial study: r\ t:omp~II'ison of techniqllt.'s. J Bio-1I1('('h. /8(5). 319.
he-tid. interosseous membrane. and distal rndio, ulnnr joint. O,.,hop
Trails. /5.436-437. Tullos. B.S.. Erwin. W.. Woods. G. W.. el 'II.(19i2). Unllsllnl lesions of
Sojhjl..'rg, J.O .. Helmig. P.. &. Jaersgat:lrd-:\ndcrscll, P. (19R9). the throwing ann. Clill Orl/WI'. 88. 169.
Disloc'ltion of Ihe dbow: An experimcntal slud)' of till: lig- W.llki:....r.s. (1977). In HUllum 1oillt:i alit! TJu.'ir ..Irtific:ial Re-
.unenWlIs injuries. Orthopedics. /2, 461--163. placelllel/l, Springfield. IL: Clwrles C. Thomas. I'ublishcl'.
Biomechanics
of the Wrist and
Hand
Ann E. Barr, Jane Bear-Lehman
adapted from Steven Stuchin, Fadi 1. Bejjani
Introduction
Anatomy of the Wrist and Hand
Wrist Articulations
Hand Articulations
Arches of the Hand
Nerve and Blood Supply of the Wrist and Hand
(ontrol of the Wrist and Hand
Passive (ontro! Mechanisms
Bony Mechanisms
ligamenious Mechanisms
Wrist Ligaments
Triangular Fibrocartilage
Complex Hand Ligaments
Digital flexor Tendon Sheath Pulley
System Digital (ollateralligaments
Volar Plate
Tendinous Mechanisms
Digital Extensor Assembly System
Active Control Mechanisms
Muscular Mechanisms of the Wrist
Muscular Mechanisms of the Hand
Kinematics
Wrist Range of Motion
Flexion and Extension
Radial and Ulnar Deviation
Forearm Pronation and Supination
Digital Range of Motion
Fingers
Thumb
Functional Wrist Motion
~";:";"stab.ility. The
wrist functions kinematically by al- immobile transverse unit that articulates \vith the
),lJowing for changes in the location and orientation metacarpals to form the carpometacarpal joints. All four
(}"of the hand relative to the forearm and kinetically bones in the distal row fit tightly against each other and
,/;-by transmitting loads from the hand to the rOrear~1 are held together by stout in-terosseous ligaments. The
14;'a~ld vice vcrsa~ more mobile proximal row consists of the scaphoid,
Although the function of all joints of the upper {
" lunate. and trique-trum. This row articulates with the
extremity is to position the hand in space so that it can distal radius to form the radiocarpal joint (scaphoid
perform the activities of daily living. the wrist appears to be fossa of radius. 46% ; lunate fossa of radius. 43 % ; ulnar
the key to hand function. Stabilitv of the wrist is essential soft tissue structures, 11%) (Simon et aI., 1994). The
for proper functioning of the digital Oexor and extensor scaphoid spans both rows anatomically and functionally
muscles. and wrist posi-tion affects the ability of the fingers and articulates exclusively with the radius. The lunate
to flex and ex-tend maximally and to grasp effectively during articulates in part with the ulnar soft tissue struc-tures. The
pre- eighth carpal bone, the pisiform. is a sesamoid bone that
hension. mechanically enhances the wrist's most powerful motor,
The hand is a highly complex and multifaceted the Oexor carpi ulnaris, and forms its own small joint with
mobile organ. It is valued and judged for its perfor- the triquctrun1. Between the proximal and distal rows of
mance and appearance in delicate prehensile tasks to carpal bones is the midcarpal joint, and between adjacent
powerful grasp patterns. It is remarkably mobile and bones of these rows are the intercarpal joints (Fig. 14-1).
adaptable as it conforms to the shape of objects The palmar surface or the Cal"!'us as a whole is concave,
to be grasped or studied, emphasizes or gestures an constituting the Door and walls of the carpal tunnel (Fig.
. idea to be expressed. or shows an aCl of love or af- 14-2).
fection (Tubiana. 1984),
The hand is the final link in the mechanical chain of
levers that begins at the shoulder. The mobility and The distal radius, lunate, and triquetrum articu-late
stabilitv of the shoulder, the elbow. and the wrist, all with the distal ulna through a ligamentous and
operating in different planes. allows the hand to move cartilaginous structure. the ulnocarpal or triangular
within a large volume of space and to reach all parts of fibrocartilage complex (TFCC), The components of this
the body with relative ease. The unique aITangement complex are illustrated in Figure .14-3, and its
and mobilit.y of the 19 bones and 14 joints of the hand functional role will be discllssed in detail along with
provide the structural foundation for the hand's ligamentous [-unction.
extraordinary f"tlllclional adaptability.
HAND ARTICULATIONS
The Hoger and thumb are the elementary compo-nents
AnatOlny of the Wrist of the hand (Fig. 14-4). Because each digital unit extends
and Hand into the middle of the hand, the term digit ray is used (0
indicate the entire chain, com-posed of one metacarpal
WRIST ARTICULATIONS and three phalanges (two in the thumb). The digital rays
are numbered from the radial \0 the ulnar side: [
The wrist joint complex consists of the multiple ar- (thumb). II (index fin-ger). III (middle finger). IV (ring
ticulations of the eight carpal bones with the distal finger), and V (Iit-tie finger). Each finger ray articulates
radius, the stn.lC(UreS within the ulnocarpal space, the proximally with a particular carpal bone in a
metacarpals, and each other (Fig. 14-1). The soft tissue carpometacarpal (CMC) joint. The next joint in each ray-
structures surrounding the carpal bones in-elude the the meta-carpophalangeal (MCP) joint-links the metaca:::
tendons that cross the carpus or attach to
, III
MelaCarpals II I
V
,
~
I)
J
Mod. e Mod.
TZ
TP
P
S
L
Sigmoid notch
Styloid of radius
process
Ulnar styloid
Radius
Ulna
Schematic drawings of the wrist joint complex showing the triquetrum; P, pisiform; L, lunate; S. scaphoid. The arrows
eight carpal bones and their articulations with the distal indicate the line of the midcarpal joint. Ad~lpred with per-
radius, the metacarpal bones of the hand, and each other. mission from Ta/eisnik, J. (J 985). The Wrist. New York: Chu{chifl
Palmar view (left) and dorsal view (right) of the right hand. Livingstone.
H, hamate; C, capitate; TZ, trapezoid; TP; trapezium; TO,
Oislal
TZ
Ulnar Radial
L
Proximal
Longitudinal view of the right hand from proximal to distal showing the palmar surface of the
bones. This concave surface constitutes the floor,· and walls of the carpal tunnel, through which the
median nerve and flexor tendons pass. The carpal tunnel is bordered laterally by the prominent
tubercle of the trapezium and medially by the hook of the ha-mate. The motor branch of the ulnar
nerve (not shown) winds around the base of the hook before entering the deep palmar compartment.
S, scaphoid; L, lunate; TQ, trio quetrum; P, pisiform; H, hamate; C, capitate; Tp, trapezium; TZ,
trapezoid. Adapted wit" per-mission from Taleisnik. 1. (1985). The Wrist. New York: Churchill Livingstone.
III
Ulnar collateral
ligament
Radioulnar ligaments
Longitudinal section (frontal plane) of the right wrist and hand viewed from the palmar
side. The components of the triangular fibrocartilage complex are visible between the dis-tal ulna and
the lunate and triquetrum. 5, scaphoid; L, lunate; TQ, triquetrum (the pisiform is not shown); H,
hamate; C, capitate; TZ, trapezoid. Tp, trapezium. Adapted with permission
{rom Parmer, AX & Werner. F,W (1981). The {[ianguld! fibrocartilage complex of the wrisr-
andtomy and function. J Hand Surg, 6. 153.
III
Distal IV II
interphalangeal
joint V
III
Proximal ~:" II
inlerphalangeal , IV
joint __ Distal
V phalanx
Middle
phalanx
Distal--
phalanx
Proximal
phalanx
A B
Schematic drawing of the skeleton of the hand. The finger rays are joints are labeled. B. Dorsal (posterior) view of the right hand.
numbered from the radial (medial) to the ulnar (Iilt-era!) side. A, The bones are labeled.
Palmar (anterior) view of the right hand. The
bone to the proximal phalanx. Bt:tw('cn the pha· langes of r.t,'·s around thL' s~l'(JJld and third finger", .dlows the palm to
the fll1gcrs, a proximal (PIP) and a distal IbttL'n or l.·up itself to acc(l1lllllodatc objects of \·arious
(DTP) interphalangeal joint arc round; the thumb has only sil.L'S and sh ..qk's (Strickland. 19~7).
one intcrphalangeal (lP) joint. The thenar eminence at the Although (hL" extrinsi<.: flexor and ('.'\!t..'nsOI· 1Il1lS. c!L·s
palmar side of the first mcwcarpal is formed by the intrinsic arL' largc:l.\· rL'spollsihle for changing lhe shape of lhe '\'orking
muscles of the thumb. Its ulnar counterpart, the hypothenar hand, 1I1L' intrinsic muscles of the hand an: prill1al"it~'
eminence, is cre· alec! by'muscles of the littlc finger and an responsible 1'01" Ilwifll<.dning the configuration or tile thr('('
overlying rat pad. archcs (refer to Table 14~1 ror a listing of the lnuscles or !he
wrisl and the hand ~\s well ~\S the cOITesponding TnllsL"lC
actions). A collapse in tilL' arch s~'st(,1ll resulting I"I"0rn bone
injur~', rhclimatic disease, or paral.\'sis of the intrin-sic muscles
ARCHES OF THE HAND
call contribute (0 SC\'erl' disability and dL:rorlllil~'.
The bones of the hand are arranged in three arches (Fig.
14·5), two transverse and one longitudinal (Flatt, 1974;
Tubiana, 1984). The proximal trans· verse arch, with the
capitate as its keystone, lies at the level or the distal carpus
NERVE AND BLOOD SUPPLY OF THE
and is relati\'e!y fl.xed. The distal transverse arch, with the
WRIST AND HAND
head or the third metacarpal as its kcystone, passes through all
of the metacarpal heads and is more mobile. The two ThL' cO\'L'ring of the h~lnd is important Ik'c<.Hlsc or its
transverse arches arc connected by thc rigid portion of the ph~'sical qualities, sensory propcl·tiL's, and microcir-cubtiull
longitudinal arch, composed of lhe four digi· tal rays and lIle (Tubiana, 190-1). The skin on the dorsulll or tilL'back orthi..'
proximal carpus. The second and third metacarpal bones fonn the ktlH.l differs and is distinct frolll the skin that CO\"i.'I"S tll(' palmar
central pillar of this arch (Flatl. 1974). The longitudinal arch stlrr~\CL', Dorsal skin is mobile, Or!C!l rcg~\l'(k'd ~h \'('1"\ line, and
is com-pleted by the individual digital rays, and the mobil· highl.\· Ill'.\> ihlL'. ~\llo\\'ing for a \\'ide arra~' or ~ll'tictllar 1ll0\'(>
ity of the thumb and fourth finger and fIfth fInger menls. In cuntrast. palnwr skin is thick, glabrous, and inelastic.
Palmar skin pla~'s a significant role in hand pcrccptibilit.\· or the
perception of touch, safety or (he uPlk'r limb through sensory
protection, and in prodding. stlppon for the limb as in weigill.
I.k>aring.
Distal
transverse arch
Proximal
The wrist and tilL' hand are innl'lY~IlL'd for motor and
transverse arch Longitudinal SL'nsory function b~' tllrL'c pt:riphernlIlL'IYes (It.> seelKling
arch
from tht.' brachial plcxus: radial. median, and ulnar (Fig. 14·6),
Muscle Action
Flexors
Flexor carpi ulnaris Flexion of wrist; ulnar deviation of hand
- Flexor carpi radialis Flexion of wrist; radial deviation of hand
Palmaris longus Tension of the palmar fascia
Extensors
Extensor carpi radialis longus and brevis Extension of wrist: radial deviation of hand
Extensor carpi ulnaris and brevis Extension of wrisl; ulnar deviation of hand
Pronacors-SUpifJdCOrS
Pronator teres Forearm pronation
Pronator qtJadratus Forearm pronation
Supinator Forearm supination
Brachioradialis Pronation or supination, depending on position of forearm
Muscle Action
Extrinsic Muscles
Flexors
Flexor digitorum 5uperficialis Flexion of PIP and MCP joints
Flexor digitorum profundus Flexion of DIP, PIp, and MCP joints
Flexor poJlicis longus Flexion of IP and MC P joints of thumb
Extensors
Extensor polticis longus Extension of IP and MC P joints of thumb; secondary adduction of the thumb
Extensor pollicis brevis Extension of Mep joint of thumb .:>
Abductor pollids longus Abduction of thumb
Extensor indicis proprius Extension of index finger
Extensor digitorum communis Extension of fingers
Extensor digiti quinti proprius Extension of V finger
Intrinsic Muscles
Jmerossei (a/I) Extension of PIP and DIP joints and flexion of MCP joints
Dorsal interossei Spread of index and ring fingers away from long finger
Palmar interossei Adduction of index, ring, and little fingers toward long fjnger
Lumbrica/s Extension of PIP and DID joints and flexion of MCP 2-5 finger
Thenar Muscles
Abductor pollids brevis Abduction of thumb
Flexor pollicis brevis Flexion and rotation of thumb
Opponens pollids Rotation of first metacarpal toward palm
HYPolhenc1f muscles
Abductor digiti quinti Abduction of little finger (extension of PIP and DIP joints)
Flexor digiti quinti brevis Flexion of proximal phalanx of little finger and forward rotation of fifth metacarpal
AdchJCtor pollieis Adduction of thumb
Modified from Strickland, l.W, (1987). Anatomy and kinesiology of the hand, In E.E. Fess & CA, Philips (Eds.),
Hanel Splinting: Principles and Methods (2nd ed., PI'. 3-41). St. LOLlis: C.v. Mosby.
OF JOINTS
highly specialized Pilary ridges with many types of segments, and intrinsic rnusculature, ongmating from the
sensory receptors and nerve fiber properties (Calma, 1954). cal'pal and hand segments, This muscular control fulfills
The sensory receptors change from free needs for both mobililY and stability dul'ing functional
nerve ending to encapsulated receptors or wrist and hand activities. The muscles of the wrist and
·:~:·01echanoreceplors.There are more receptors than fibers, hand are summarized in Table 14-1. No muscles are
and each fiber is connected to several intrinsic to the carpus; lhererore, passive mechanisms
,">C',"'Wl'S (Mount Castle, 1968). Furthermore, sen- derived from bony morphology, ligamentous function, and
information is transmitted over quickly or adapting nerve tendinous expansions play major roles in controlling carpal
fiber properties. It is also ))known that sensation docs not and digital movements during hand activities, In this sense,
have the same value the hand; certain zones or regions have the carpus acls as a bridge for muscle ac-tion and load
more receptivity 10 a stimulus than do olhers. For exam-the transmission between the hand and forearm segments.
sensOI)'acuity is considered to be of a more specialized
quality in the specific anatomical re-gions required for
very fine motor prehension: the ulnar half of the digital A number of anatomical features contributc to the
pulp of the thumb, the radial half of the digital pulp of both stabililY and control or the various articulations of the
the index and middle fingers. and the ulnar border of the hand. The coordinated actions 01" the extrin-sic and
lillie finger. It is essential to be aware of these specialized intrinsic muscles of the hand permit control of the digit
regions and their critical role in terms of the restoration of rays: a dorsallcndinolls complex known as the extensor
assemblv contl"iblltes to the control and stabilit); of the
jo'ints and a well-developed flexor tendon sheath pulley
';,' hand function following injLlly (Tubiana, 1984). Blood is system facilitates smooth and stable flexion of these joints.
dually supplied to the wrist and the hand The bony and ligamentous asymmetry of the Mep joints
by the ulnar and radial arteries, \vhieh join or com-municate lends the hand its functional versatility. The IP joints gain
together after each has individuall.'/ en-tered into the han,!. their stability' from the shape of their articular con-tours
The skin of the hand is supplied by both a deep and a and from special ligamentous restraints,
superficial plexus, The general ,'. p;\llern of the blood
supply to the wrist and the hand does not differ from
that which is found in other parts of the body. What differs PASSIVE CONTROL MECHANISMS
in terms of cu-taneous circulation relates to the hand's distal
loca-tion ft-om the heart and to its constant exposure to Bony Mechanisms
thermal and postural variations (Tubiana, 1984). Similar The PIP and midcm·pal joints in the wrist creale a double-
to the highly complex and varied sensory re-ceptors noted hinged system, This bimuscular, biarticular construction is
within the hanel, particularly within the palmar skin, the subject to collapse under compres-sive load (Landsmcer,
hand hosts a complex and dense capillmy system (Cauna, 1976), Because virtually no Illusclcs insert on the carpus to
1954). This dense provide dynalnic stability. the compressive forces of the
long Oexors and extensors tend to calise the carpus to
':' system allows [or more variation in capillal)! pres-sure than buckle at the PIP and midcarpal joints, intricate
in other parts of the body. Capillmy pres-sure depends on a ligamentous constraints and the precise opposition of
number of factors such as arteri-olar tone, venous return, multifac-eted articular surfaces counteract these tendencies
the position of the wrist and the hand, and temperature and afford stability.
(Cauna, 1954; Tubiana, 1984). Hand injuly or disease that
alters or threatens the cycle of vasodilatation-vasoconstric- In the sagittal plane or the wrist, both the sca-phoid and
tion can cause progressive wrist and hand edema that leads the lunate are wedge-shaped with the pal-mar aspect of
to stiffness or causalgia. both bones being wider than the dor-sal aspect (Kauer,
1980). Because compression tends to squeeze a wedge to
its narrowest portion, both the lunate and the scaphoid
Control of the Wrist would tend to be displaced palmward and rotate into
extension with contraction of the long flexors and
and Hand extensors,
As both the scaphoid and lunate lend to be forced into
Active control of the wrist and hand is achieved through extension. stabilization forces must be directed primarily
coordinated action of both extrinsic mus-culature, toward flexion. It is here that the COlltl'i-bUlion of the
originating from the forearm and humeral scaphoid spanning both distal and
JOINTS
proximal carpal 1'0\\'5 can be appreciated. The nat-ural Inelacarpals. Thl' intrinsic ligalllents originak and insert on
tendency' of the scaphoid to extend is stabilized at the the C~II'PUS.
midcarpal level; the trapezium and trapezoid articulate with The pallnar e:\trinsic ligaments include the r~ldial
the dorsal aspect of the scaphoid, pushing its distal pole dc)\vn collateral ligall'lcnt, the paillwr radiocarpal liga-ments, and
into flexion. Hence, the scaphoid counteracts the extension components of the Triangular fibn>ea;:ti_
tendency! of the lunate, lending some stability! to the lage complex crr"cc). The radial colhltl'r~l1liga[l'lC'nt
biarticular carpal complex (Fig. 14-7). is aCluall~' more pallllar than lateral and is vicwcd as till.'
most lateral of all palnwr radioGll'p~11 L.Isci-cles rather than
This arrangement has an advantage over a sym-metrical as a ulilateral ligament per sc, be-cause the function or a
biarticular s)'stem because instability is fo-cused in onl).' true collatcral ligament is not hlnctionall.\· ad\'~ll1tageous in
one direction and can be countered by a single force the wrist.
applied in the opposite direction or flexion (Kauer. 1980; Thc palnwr radiocarpal ligarncnts a['c arranged in
Kauer & Landsmeer, 1981). This mechanism is consistent superficial and deep hl.\"ers, In thc superficial layer, most
with the lISC of the fin-ger and wrist flexors during hand libel'S ~Issumc a V shape, providing re-stl'~tint and supporl.
function. The decp ligaments arc three strong fascicles named according
to their points of ()]'igin and insertion: the radioscaphocapitatc
(or radiocapitateJ ligarnent, which supports thc \\'aist or thl.'
Ligamentous Mechanisms scaphoid; the radiolutHllC liganlcllt, which supports the
lunate; and the r;:ldic)scapholunatc lig-ament, which connccts
WRIST LIGAMENTS
the sGlpholunate aniClda-tion with tll(' palmar portiCHl or the
As in other joints, the function of the \vrist liga-ments is to
distal radius.
restrict joint motion and appose Jomt surfaces. In addition,
the ligaments of the wrist are capable of inducing bOll y !
This lig~\lncnt checks sC~lphoid lk.\ion ~lnd ex-
displacements and of transmitting loads originating in
tension. SludiL's of the tensile strength of carpallig-aments
proximal or distal segments (Taleisnik, 1985). The palmar
suggest that the \\'eakest link bL'tween the carpus anc! the
ligaments (Fig. 14-8.4) are thick and strong, whereas the dor-
forearm is through [he radio-scaphocapitate and radial
sal ligaments (Fig. 14-88) are much thinner and fewer in
collateral ligaments, both of which are on the radial sklL' ()f
number (Taleisnik, 1976, 1985).
the wrist (i\bdield ('I "I .. 19791.
The highly developed. complex ligaIllcntous sys-tem of
The dorsal extrinsic lig~Hnents includt' the three bands of
the wrist can be divided into extrinsic and in-trinsic
the dorsal mediocarpal ligament. Originat-ing from the rim
cOIllponents (Table 14-2). The extrinsic liga-ments run
of the radius, these three fascicles insert hrllliv into the
from radius to carpus and from carpus to
lunate, triquetrum, and scaphoid, respecti\·c!.\'.
Med. Med.
I A B
... ------------------
The ligaments of the wrist. A. The palmar wrist ligaments ligament. The short palmar intrinsic!. are not shown. B. The
I (right hand). Extrinsic ligaments: RSC, radioscaphocapitate dorsal wrist ligaments of the right hand. Extrinsic ligaments:
ligament; Ret, radial collateral ligament; Rt radiolunate liga- RT, radiotriquetral; RL, radiolunate; and RS, radioscaphoid
ment: RSL, radioscapholunate ligament; UL, ulnolunate lIga- fascicles of the dorsal radiocarpal ligament. Intrinsic liga-
ment; M. meniscus homologue (radiotriquetral ligament); ments: OJ(, dorsal intercarpal; IT, trapeziotrapezoid; TC,
VCL, ulnar collateral ligament; the superficial palmar radio- trapeziocapitate; and CH, capitohamate fascicles of the short
carpal ligament and the triangular fibrocilrtilage are not intrinsic ligaments. The scaphotrapezium ligament is not
shown. Intrinsic ligaments: SL, scapholunate ligament; L1. shown. Adapred with permission from Taleisnik, 1. (1985). ihe
lunotriquetral ligament; V. palmar intercarpal (deltoid, or V) Wrist. New York: Churchill Livingstone.
which is filled with svnovium.. Dorsally.', the TFCe has a Most tendons in thL: hand are restrained 10 some C.\~ lent
h~' sheaths nnd retinacula tlwt keep them close to the
weak attachment to the carpus except where some of its
skeletal plane so that the,\' maintain a rela~ lively constant
fibers join the ten-don sheath of the flexor carpi ulnaris
moment arm, rather than bowstring~ ing across tilt joints. The
dorsolaterally, The ulnolunatc ligament connects the
palmar bor~ del' of the triangular fibrocartilage with the pulle,\' s~.'ste1'l1 of the flexor lendon she~lth in ilk'linger is
lunate. The ulnar collateral ligament arises from the ulnar the most highly devcl~ oped of these restraints.
styloid process and extends distally to the base of the fifth
metacarpal bone. As they eXh:nd fnllll their lllusc!L's, Ihe digital flexor
lendons pass through thL' carpal tunne!. along with
Volz et al. (1980) analyzed the pattern of contact til('tendon or the I'IL'x(Jr pnllicis longus
between the proximal carpal row and the distal ra-dial and ..1nd thL' Il1L'diannerve, before f<.\nning out toward t1h,'ir
ulnar surfaces while the radiocarpal joint complex was respect in,' digits. The flexor superficialis tendon inserts nn
subjected to compressive loads in a position of neutral wrist Ihe middle phalanx and the flexor profundus inscrls on the
nexioo and extension. "Vith small loads, the initial contact distal phalanx. In c<.H:h digit. these two tendons,
arca was between the scaphoid, lunate, and distal radial surrounded by tht:ir s~'I1()\'ial sheaths. arc held against thl..·
plate, but with in-creasing loads the contact area extended phalanges h,\' a fibrous sheath. At strategic locations along
to the TFCC. Removal of the TFCC diminished the contact the she~\th are five dense annular pulleys (desig~ n<.\ted as AI,
area between the lunate and the distal radial~ulnar surface, A2. 1\3, A4.'and A5) and three thinner crucil"o,..n !Julle.'·s
thus increasing the stress per unit area be-tween these (Cl. C2. and C3) (Fig. 14-9). ThL'se pulleys allo\\' for ~l
structures. smooth curve so that no sharp or <Jngular bends exist in til
....· coursc of the lendon. Local points of high pressur....·.
Volz's group (1980) concluded that compressive loads SlI·L'SS ntis-('rs. helw....·cll tcndon and sh ....·ath are therefore
are directed across the carpus along a vector force pattern mill i m iI,cd.
thaL passes through the head of the capitate to the
scapholunate junction and then to the distal radial-ulnar
triangular fibrocartilage sur-faces. They suggested that any At the point \\'hL~I'C lhe A3 pulk'y tra\'(TSCS the PIP joinl.
alteration in the alignment of the structures of the proximal the tension in tl1(' tendon gL'IK'r~\Icd b~' joint lJ...:xion either
and dis-tal carpal I-OW5 might provoke an increase in stress pulls the pulley a\\"a~· from its altach-Ilk'nl to the bone or
in localized areas, which would then accelerale ar-ticular pulls lhe hune a\\"a~· from the joint. This is no problcm in a
cartilage wear. normal. stable joint, but when the joint becomes unstable. as
in a patient
CHAPTER 14. BIOMECHANICS
Metacarpophalangeal joint
with rheumatoid arthritis, there could be a danger of severe
PIP subluxation.
To appreciate the magnitude of these subluxating forces
and how they increase with increased flexion, consider two
separate flexed positions of a PIP joint: 60° and then 90°.
At 60°, the two limbs of the nexor tendon form an angle of
1200 (Calculation Box Fig. 14-1-1). At that point, the
tension in the restraining pulley must equal the tension in
the tendon for the system to be in equilibrium. At 90' of
flexion, how-ever, the pulley n1us1 sustain 40% more
tension than the tendon (Calculation Box Fig. 14-1-2)
(Brand, 1985; Brand & Hollister, 1992).
10 N
lON
F
j~
~<
Force F
ION
10 N
Calculation Box Figure 14~1·1. lateral view, The PIP joint is flexed 60°, With the sys-tem in
equilibrium, the resultant force (R) in the pulley system is equal to the vector sum of the two
components of the tensile force (F) in the flexor tendon (i.e., 10 N). These three forces are
presented graphically in an equilateral triangle of forces.
\
\+-45' 14 N
I ... R
I ......
45'
_L
\
90'~'t=!r--
F Force F
10 N
Force F
ION Force A
14 N
ION
OR
R2::=:F2+F2
R'~ 100 N + 100 N
R'~ J200 ~ 14.1 N
Calculation Box Figure 14-'-2. lateral view. The PIP joint is flexed 90°. A triangle of
forces shows that the resultant force Rin the putley system equals 14 N. Therefore. Requals
1.4 F. The value for R is also found by use of the Pythagorean theorem, which states that in a
right triangle, the square of the hypotenuse equals the sum of the squares of the sides.
Adapted with permission from Brand. P.W. (1985). Clinical Mechanics of the Hand (pp.
30-60). SI. Louis: c.v. Mosby.
the index finger at various degrees of joint flexion. When rlexed, while the palmar porLions provide a restrain-ing
the MCP joint was nexed from 0 to 80', the dorsal ponion force during tvlCP extension, This study sup-ports the
of the ligaments lengthened 3 to 4 mOl, the middle portion rationale for positioning the Mep joint in 50 to 70 of Q
elongated slightly, and the palmar portion shortened I to 2 flexion to prevent extension contracture when
mm. When the MCP joinl moved inlO hyperextension, the immobilization is required.
dorsal ponion of the ligaments shortened 2 to 3 mm, the The collateral ligaments are found to be slack when the
MCP joints are held positioned in exten-sion and taut when
," middle third shOl,tened slightly, and Ihe palmar Ihird the MCPs are positioned in rlex-ion. By placing the MCPs
lengthened slightly. Thus, the dorsal ponions of both into full nexion, the cam configuration of the metacarpal
collateral ligaments appear to provide the principal head tightens the collateral ligaments and the lateral
restraining force when the MCP joint is mobility or "play" obse"ved when the MCPs were held into
ex-tension is limited (Strickland, 1987). Therefore, Ihe
fingers cannot be spread or abducted unless the hand is open,
or naltened (Agur, 1991).
\/b/ar Plate
In addition to the role of the collateral and acces-
sory collateral ligament, attention is brought to the
function of the palmar or volar plate (Fig. 14-13),
The accessor)' collateral ligaments arc just palmar
I
to the radial and ulnar collateral ligaments, which
~·tz originate from the metacarpal and insert into the
attached to the volar surface of the neck of the
.:'"-. . Palmar
"n' interossei metacarpal. It serves to reinforce the joint capsule
i··,-· 1(lt03) anteriorly and to prevent impingement of the Hexor
~\i· tendons during MCP flexion. This anatomical align-
ment allows for the volar plate to slide proximally
!s c like a moving visor during MCP flexion (Agur, 1991;
I ' --------------Strickland, 1987). The volar plate also limits hyper-
extension of the MCP joint. The volar plates are
! The intrinsic muscles of the hand. A, Palmar view of the
-
left hand. B, Dorsal view of the left hand showing the four connected by the transverse Jintermctacarpal liga-
(Strickland, 1987).
showing the three palmar interossei. These muscles adduct Tendinous Mechanisms
the second. fourth, and fifth fingers. flex the Mep joint.
and extend the PIP joint. Adapted wilh permission {rom Strickland. J. DIGITAL EXTENSOR ASSEMBLY SYSTEM
W (1987), Anatomy and kinesiology of the n,lnd. In fE. fess & c.A. The lang"extensor tendons are l1at structures lhat emerge
Philips (Eds.), Hand Splinting. Principles and from their synovial sheaths at the dorsal siele of the carpus
Methods (2nd ed., pp. 3-41). Sr. Louis: C. V Mosby: and (ailler, anel run over the M~P joint; they are helel in this position
R. (1982). HClnd Pain and Impairment (3rd edJ Philcldelphia: FA. by the sagittal banels. At the dorsum of the proximal
,i
Oc1Vis. phalanx, thc~e extensor ten-dons and parts or the interossei
e interweave so as to
Second dorsal form :1 tendinous cOnlplL,,'\, the ('xh:nsoraS~L'l1lbly (also
Junctura
Transverse interosseous muscle knO\\'11 as tilL'L'xkl\s(,rIlh:chanisllll. whiLh ex-
tendinum
inlermelacarpal tl'l1ds0\'(."1'hOlh I P joints (Fig. 14-141.
ligament
Triflln.:alion 01" (he long C:-':h,'nsor(cndon and r~ln- ning 01"
Extensor
phalan.\ and insl'rts into the base or the middle plwlaJl\,
digilorum 'rIlL'two lalcml bands cours(' along-sidl..' the shouldL'l'S of tlH..'
communis ! r'~irstdorsal PI P joint. These bands pur~
tendon --+1-\-\l..\l InteroSseOl.
, muscle
SllL' tlh.:ir \\'<1,\'distall.\' ~ll1d lllerge o\'er the doi'sUOl of the
middle phalanx, running the tcnninal tendon, \\·hidl inserts into
the dorsal tubercle or the dislal phalanx. This tcrminal lL'ndonis
v 111 II linkcd (0 the prox-imal phalanx b.\' m{.'~lJ1s or I IlL' obliquc
tV
rctinacular lig-
Dorsal
~IIllL'nts, Thcsi..' Iigamcnts origin<lk' from the proxi-mal phalanx
A and run la1L'rall,\' around tilL'I'll' joint, ,iust palm;'lr 10 the
or
CL'nt!.,.'!' motion of this joint in tilL'L'\;ll...'IH.k-d posilion, to
join Ihe tcrminal ti..'lld<JIl.
IlI1Istr;'llingthl.,.' aL'!ioll(If thL' i..'.'\lL'nsorassL'mbl.\·in cnllplin~
PIP and DIP joinl motion, Landsl1lccr
Med. Lat
" ----.
~ '.'
/~(Fjl~\J···f----Collateral ligament
..
f.f!<:~.~~::~~ ~ccessory collateral
Palmar /~ ~, ~."" I. ligament
B ~-ApalmarPtate
Proximal phalanx
I .- Checkrein ligaments
1 PIP joinl Middle phalanx
j - \
A, Fibrous structures of the proximal transverse (MC?) arch
(palmar view of the right hand), Adapted with permission from
Tubiana, R. (1984). Architecture and functions of the hand. In R.
Tubiana, J,-M. Thomine, & E. Mackin (Eds,), Ex-amination of the
Hand and Upper Limb (pp, 1-97). Collateral ligamenl
Philadelphia: w.e. Saunders. B, Capsuloligamentous struc-tures Clleckrein ligaments \\ .......,. Accessory collateral ligament
of the MCP joint (transverse view of the proximal phalangeal joint Palmar plate
surface, middle finger, left hand). 1, ex-tensor digitorum communis
tendon; 2, sagittal band; 3, collateral ligament; 4, accessory
collateral ligament; 5, volar plate; 6, flexor tendon sheath; 7, flexor
digitorum su-perficialis tendon; 8, flexor digitorum profundus Oblique (top) and mediolaterc11 (bottom) views of the PIP joint.
tendon; 9, lumbrical muscle; 10, dorsal interosseous muscle; 11, This joint gains stability from a string, three-sided ligamentous
dorsal interosseous muscle; 12, insertion of dorsal interosseous support system produced by the collateral lig-ament, the
muscle into base of phalanx; 13, transverse inter-metacarpal accessory collateral ligament, and the palmar fibrocMtilaginollS
ligament; 14, articular surface of proximal pha-lanx. Adapted with plate (volar plate), which is anchored to the proximal phalanx by
permission (rom Zancolli. E. (979). Struc-tural and Dynamic proximal and lateral extensions know as the checkrein ligaments.
Bases of Hand Surgery (2nd ed.. pp. 3-63). Phifadelphia: 1.8. ,:\dapteci ','Iith p~rf1lission
Lippincott hom S;nd/and. } W (987), AnMomy dnd kinf'siofogy of ;he
hand In E E Fess 8 C A Pill/ips (Ec/5). Hanel Spllllllflg PfFlloples
(mc! ivjc,thed) (2nd {'d., pp 3 1/1) St Louis.· C V Mos/)V
.I ---------- _-_.-
.... ----_._-----------------
..
CHAPTER 14. BIOMECHANICS OF THE wRlsrAr>i8ft!~~~i?:~3~'O
Data from Von Lanz, T & Wachsmuth. IN. (1970), Functional anatomy. in J,H, Boyes (Ed.), Bunnell's
Surgery of the Hand (5th Ed.). Philadelphia: J.B. Lippincott.
Although small amounts of axial rotation arc possible 26
and may' exist in some individual wrists, from a pracLical
standpoint such rotation docs not occur through the cm·pal
complex (Volz. 1976; Youm et al.. 1978). Axial rotation of
the hand. ex-pressed as pronation and supination, results
in-stead from motion arising at the proxirnal and dis-tal
Flexion
radioulnar and the radiohumeral joints (Volz ct aI., 1980).
Extension
Investigators have found various values ror the Approximately 60% of wrist flexion (top) oewrs at the
contribution of the pl'oximal and distal carpal rows to the midcarpal joint, whereas approximately two thirds of "vrist
extension (bottom) arises at the radiocarpal joint. Ai;l{>icd
tOlal arc of nexion and extension, Sar-rafian and
~·.f:;l pE':mi'i_~i{)fl from Sarrafl<lfi. 5,1-::, t3t.-'i,lf1lfXi. j L. ,-3- Gosi'9iJf-
coworkers (1977) noted that approxi-mately 60% of Rex
I,ln, G :~/; !9/'11 Srucfr Cd \',11:;', marion If} flE.·.-:lon an[f f.'xum~ian.
ion occurs at the midcarpal joinl and 40%, in the
Clin Onhcp. 126. T53
radiocarpal joint, while ap-proximately 67(Yo of extension
takes place at the radiocarpal joint and 33%· at the
midcarpal joint (Fig. 14-16).
motion proper, pIa)' an intricate role in hand and function. the ulnar head of up to 9° in the direction oppo-site that of
Average range of motion of pronation~supination is 150 0 the distal radius has been demon-strated during this motion
(60-80° of prona-tion and 60-85° of supination). In a (Ray et a1., 1951), and the ulnar head glides in the sigmoid
biomechani-study, YOUlll et a!' (1979) found the axis of notch 01' the radius from a dorsal distal position to a
pronation-supination to lie oblique to both the radius and palmar proximal position as the forearm moves from full
the ulnar, passing through the center of the humeral pronation into full supination (Bunnell, 1956; Palmer &
capitulum and the midpoint of the head of the ulna ..Modest Wemer, 1984; Rose-Innes, 1990; Vesely, 1967).
lateral movement of
I
lImIEIe-- _
Roentgenograms of the right wrist and hand (dorsal view) triquetrum is proximal in relation to the hamate. In ulnar de-
showing the position of the carpal bones in radial deviation (A), viation, the bones of the proximal row are extended. The
in the neutral position (B), and in ulnar deviation (C). Ar-rows in scaphoid appears elongated, the shape of the lunate appears
the schematic drawings above roentgenograms A and C trapezoidal, and the triquetrum is distal in relation to the ha-
indicate general movement of the bones of the proximal row with mate. Tp, trapezium; TZ, trapezoid; C. capitate; H, hamate; TQ,
wrist motion. In radial deviation, the bones of the proximal row triquetrum; L, lunate; 5, scaphoid. Roentgenogram cour-tesy of
are flexed toward the palm. The scaphoid ap-pears Alex Norman, M.D.; drawings adapted ~vith permission
foreshortened, the lunate appears triangular, and the {rom Taleisnik, 1. (1985). The Wrist. New York: Churchill Livingstone.
•
Capitate
Palmar intercarpal
(V) ligament
/scaPhoid
1 RadioJunate
Med, ligament La!.
Ulnolunate
ligament
Diagrammatic representation of the changes in alignment of and ulnar deviation (palmar view of right hand), Ada{Jl':.<J
the double-V system formed by the ulnolunate and radiolu- ~'.!I!h permission !rornl(l!':'ISflI,::,J f/935) T1:;::· VIrlS! Nc\~' York:
nate ligaments and the palmar intercarpal (V. or deltoid) lig- Churchill Llv;rlgswne
ament with the wrist in radial deviation, the neutral position.
•. ---------------------~~-~-~-~--~~
,\L"-'~L-- Carpometacarpal
joints
0".....-_;;_-===
Neutral Metacarpophalangeal joint
Thumb
At the UvlC level, the base of the thumb metacarpal forms
a saddle joint with the trapezium (Fig. 14-19), This
configuration allows the thurnb metacarpal a wide range of OPPOSITION OF THE THUMB
Composite of Three Motions
motion through a conical space ex-tending frolll the plane of
the hand palmarly to the radial direction. Motion of the first
metacarpal is described in degrees of abduction, either radial
or palmar, from the second metacarpal, thereby defin-ing the
plane in which this motion is carried out with respect to the
plane of the hane!' The terms flexion and extension with
respect to the t.humb are reserved for motions of the Me? and Zero starling
IP joints. postion
•
were accomplished by motion of 5° of flexion to 35° of
extension. Nearly all or these continuous tasks re~ quired only
extension. Rising from a chair em-ployed the gr~atest arc of
motion, nearly 63°. Volz and coworkcrs (1980) also found
that loss of wrist mobility did not seriously impede
performance of the activities of daily living, Volunteers with /
wrists immobilized in four different positions were asked [0
rate their performance on 10 activities, and per~ formance A
averages were then computed for each position of
immobilization. The results disclosed the least compromise
of hand function with wrists immobilized in 15° of extension
(88% of normal performance) and the greatest disability \vith
the wrists placed in 20° of ulnar deviation (71% of nor~ mal B
function).
When the wrist is flexed, the tip of the thumb is level with the
distal interphalangeal joint of the index finger. With the wrist in
extension, the pulps of the thumb and index finger come passively
into contact. Adapted with permission
from Tubiana, R. (1984). Architecture and functions of the
hand. In R. Tubiana, J. -M. Thomine, & E. Mackin (Eds). Exami-
nalion oi the Hand and Upper Limb (.oP. 1-97). PhIladelphia:
\IV B, Saunders.
A Tip pinch
B Palmar pinch B c
Strickl'lnd. J.W. (1987). An;ltomy and kinesiology of the hand. "on Bonin, G. (1929).'\ not~ on thl..' kinematics of the wriSI-joinl. J :\l1al,
In E.E. h'ss & CA. Philips (£ds.), 1-/1IIul Splillfillg: Pritlci· pIes alld 63, 259.
Jlethods (2nd cd., pp. 3-~1). $1. Louis: CV. Von La Ili',. T. & \VachsllHllh, W. (1970). Functional anatomy.
Mosby. In J.H. Boyes (Ed.), BlIIlII.'J!:;; SlIr!:ery oj" Iht' 1-/(/1/(/ (5th
Taleisnik, J. (1976). The ligaments of lhe wrist. J Ham! Stlrg. J, 110. Ed.). Philaddphia: J.B. lippincott.
Weber, E.R. (198-.1). COllccpts governing [hI,.' rotational shift of the
Talcisnik, J. (1985). Tlte WriSl. New York: Churchill L.iving-stone, intt.'rcal'ltcd S('glllCflt of the carpus, Onhol' eli" "-{Ofll,
..111I, J5, 193.
Tcstut, L. &. Lltarjcl, A. (1951). ]i-auulo de illla(om;a 111111/(/1/(/ Wright, R.D. (1935/36). A dctlliled sludy of thc movcment of the wrist
(Vol. I .. 9th cd.). Buenos Aires: 5,,1\,;'11 Editorcs. joint. J .·llIllt. 70, 137.
Tubi<lna, R. (198'0. Architecture and functions of the h.\nd. in You Ill, Y., Drya, R.F.. Thambyrajah, K., C[ al. (1979). Biolllc-eh.mical
R. Tubi'ln;;t, J.·M. Thominc. & E. J\·lackin (Eds.), £XOI1l;I1(1-rioll or {fte amtlyses of forearm pronalion-supination
f1c.xion·e.xtensioll. J Biol/II.'ch 12, 1-.15.
and el-bow
Halld al/(l Upper i.i/llb (pro 1-97), Philaddphi<\:
W.B. Saunders. YOll III , Y.. ,\ldvlunry, R.Y., FhHI, A.E., el 411. (1978). Kinema[-ics
Vesely. D.G. (1967). The dist"l radioulnnr joint. eJin (JrtJlOp. 5/. 75. of the wrist. J Bone Joi1/1 SlIrg, 60.-\(-0,423-31.
Youm, Y. & Yoon, '\'.5. (1979). Analytical dcn~loplllCn! in in-
Volz. R.G. (1976). The dcn:lopment of " tot,,1 wrist arthro-pl<lSlY. Clill vcstigation of wriSI kincm~ltics. J Bhwle(.'h, /2,613.
Ortlwp, /16, 209. Z:\ncoll~ E. (1979). StrlICfl/m! (II/d DYI/amic Bases of !lallll
Volz, R.G., Lieb, !\.I., & Benjamin, J. (1980). Biomechanics of the wrist. Surgery (2nd cd., pp. 3-63). Philadclphi~l: J.B. Lippincott.
('/illOrlimp, J49. 111.
III
Applied Biomechanics
~ -,~ l:<
"'''~~'. -)00..
Introduction
to the Biomechanics
of Fracture Fixation
Frederick 1. Kummer
Introduction
Fracture Stability and Healing
Fracture Healing
Surgical Factors
Fixation Devices and Methods
load
Summary
Suggested Reading
Introduction FRACTURE HEALING
The study of fracture fixation biomechanics can be divided Currently, controversy exists about \vhether com-pletely
into two main areas: (l) criteria for achiev-ing fracture rigid fixation is the optimal condition for bone healing.
stability and promotion of bone healing and (2) the Ivlicromotion has been shown to aid healing. Healing
characterization of techniques and de-vices intended to results even in cases of gross mo-tion such as that seen in
mechanically stabilize a fracture. An understanding of the rib fractures. Rigid fixation may lead to delayed healing,
biomechanical principles involved in these areas will aid bone atrophy, and a lack of external stimuli necessary for
the engineer in im-plant design and enable the surgeon in the healing process.
selection of the most effective technique and device to
obtain successful results in patients. Although gross motion between two or more bone
fragments usually leads to nonunion and fi-brocartilage
tissue formation, there is a low level of displacement
(microlllotion) that appears advanta-geous to healing by
providing a mechanical signal that stimulates the biological
Fracture Stability and repair processes. The amount of local strain in the healing
Healing region (change in length divided by the original length)
seems to de-termine the nature of the tissues formed (e.g.,
The clinical goal of effective fracture treatment is rapid fibro-cartilage or bone). The optimal frequency, \vave
healing, withollt significant deformity or li1l1b shortening, form, and total number of cycles of this signal cur-rently
to restore the patient to a pre-fracture level of function. In are being investigated. Several methods to promote healing
the elderly. rapid mobilization is essential to prevent by externally stimulating a fTacture with ultrasound or
deleterious consequences of bed stay. The first goal of electromagnetic fields are in clinical use (Case Study 15-
treatlnent is fracture stabiliza-tion. This is determined by 1). Concern also exists regarding the process of stress
the location and type of fnlcture, the muscle and body shielding that occurs when the fixation device carries most
forces acting on it, and the various passive soft tissue or all of the mechanical load and thus, by Wolffs law,
constraints such as lig-aments and fascia. Some simple promotes localized osseous resorption as a result of the
fractures are inher-ently stable with low loading and thus resul-tant unloading of the bone around the device. This is
require nlini-mal treatment, such as sling (clavicle), while often referred to as load bearing versus load shar-ing.
others, such as midshaft comminuted femur fracture, Much of the initial osteopenia seen beneath fracture plates,
require major surgical intervention and insertion of an howevel~ is thought to be caused by vascular disruption
inter-nal fixation device for adequate fixation. Although an during their application.
osteotomy (a surgically created fracture for correc-tion of
defonnity) allows close approximation of frac-ture ends,
typical fractures are often fragmented and usually lack Bone healing in the presence of a gap with lTIini-mal
inherent stability. The interdigitation of the bone ends can movement passes through several stages of re-pair \vith a
facilitate stability, such as when a tapered bone end is concomitant increase in mechanical strength as
inserted into the nledullar:v cavity! (creating a mineralization increases: hematoma and inflammation,
displacement deformity, however). callus formation, replacement by woven bone, and fmally
remodeling into lamellar or trabecular bone. Callus can~form
Traditional methods for the treatment of frac-tures are both periosteally and endosteally and enlarges the diameter
externally applied and include traction, cast, and braces. of the bone at the fracture site. Although callus is less
External forces or constraints ap-plied to the injured limb strong and stiff than nlature bone, this increased di-ameter
act to stabilize the fracture (by limiting ITIuscle or soft can increase stiffness in bending and torsion at the fracture
tissue forces leading to deformity) and maintain alignnlent site as a result of the increased mo-ments of inertia. Direct
of the limb. Howevel~ in many cases, as a result of the nature bone apposition by com-pression with rigid fixation, in
of the fracture or the patient's condition, an internal or which the initial re-pair stages are eliminated or
external fixation device attached directly to the bone is minimized, heals by a remodeling process and can take
required to achieve adequate fracture stabiliza-tion. The longer because vascularity must be re-established.
designs and use of these fixation devices rely on an
understanding of bone healing and the loads and forces to
which the device is subjected. The other impOl·tant factor for healing is ade-quate
blood supply that necessitates the surgeon
391
o 392 PART III • APPLIED BIOMECHANICS
A 40-year-old female involved in il mOlOr vehicle collision acoustIC rodiaHon at irequ€-nCles above the !lm!! of hu-
man heanng. Its acoustIC raeJlCIllon, In the form of pres-
§_ in December sustained a left tibiofihular lr<1Cwre treated with
external fixation. Case Study Fig. 15-1·1, In January, lo'.>\'-intensity sure waves, provides rnICfOrnf.'chiH·\ICa! stress and force'to
pulsed ultrasound (US) was mitiatecJ 10 promote frac-ture healing. the bone ,me! surrounding tiSSUe>, ThiS rnedh1nI((ll stunu·
Case Study Fig. 15-1-2, in March, 3 months postfracture and 2 lalion plays a major role in bone hedlll1g because bone:
months after mitiation of pulsed US appli-cation, early healing is reacts to the amount and dir(;ction of force and remof.!· els
detected (arrow). Case Study Fig to adapt to the applied suess "mel its elirf~c!i()n ReprHlted V-
15-1-3, in May, 5 months after injury and 1\ months follo\,..,mg 11th permission from v\lolH, J (1986). Das
initiation of US, the bone healing is successful. Geseu der Transformarion <ft.'r Knochen [The law oj
Pulsed low-intensity ultrasound has been succEssfully bone remodeling]. P. Milquet & R. Fulong (Trans.). Berlin:
used for fracture repair (Frankel. 1998). Ultrasound is an Springer-Verlag. (Oflglllal ..vork published in 1892).
presel·ving the vascular supply' of the bone (e.g., pe- b~nding! and/or torsion) and magnitude of forces to which the
riosteum) and providing conditions for early rcvas- fixation will he 'subjected and whether these forces will be
cularization by; careful opcrative techniquc (e.g.! sort cyclic, requiring ~\dditional strength of fixation 10 ~\ccnunt for
tissue presenTation). Numerous studies 1lave demonstrated possible dC\'ice fa-tigue (Case S(ud~' 15-2). The second factor
a direct relationship between the quantity and quality of is the bone quality', which delermines the strength a\'ail-able to
microvascular structures in the healing region and the rate supporl the fi:..;atioll dc\·jcc. Other factors arc related to
of ronn~llionand re-sultant mechanical properties of" lhe new surgical and ~lIlatomical considerations, for example, the
bone. expOSllre (possible scarring and vas-cular compromisc),
wIlL,thcl- the devicc will fit ade-quately within the soft
tissuC's. and if nL'urovascular structures are at risk. The
SURGICAL FACTORS
nature of the original in-
Many factors determine the optimal fixation method for a
specific fracture appliGltion. First arc mechan-ical .iur:v and the amount of soft tissue d~IIll~lgC also de-
considerations, specif-lcally the types (tension, tern1illC treatment l~chl1iques.
CHAPTER 15 • INTRODUCTION TO THE BIOMECHANiC5 OF FRACTURE FIXAr,J~f~~;~93 It
lillIiVIEf.1C-------·--··---·----- ··-·--r(number of patients, adequate follow-up) so that the
many vadables can be properly analyzed and
Fixation Plate Failure proper statistical significance determined.
.' n internal contemporary fixation plate inserted into
Load Load
~ ~
Fracture Gap_
Plate gap ope~s -~'!lIlIJ'llm~ Plate
closes
Plale on Plate on
tension side compression side
Types of bone screws, left to right: cortical, cancellous, Effect of plate placement. A plate located on the compres-
and cancellous lag. sion side causes the fracture to gap when loaded.
Posterior thl.'ir insertion and the possibilit.\" (II" compromising
bending force p\.'riosh.';.11 blood stlppl.,· b.\· thL' l':\posure or pl;'11(' in-
Posterior
I sert iOl1 (somi..' plati..' designs have inferior fed Or ridges (0
minilnize this possibilil:!). Therc is ;.tlso in-lCrest ill
pol:·tTlcric plales lhat would he tTlOrL~ flexi-ble 10 achicvc a
grealt:r degre\.' of Inicromoti(l!l at till." fracture:.: thai could
Lateral
he:.: advantageous 10 bone healing and minimiz\.' stress
shielding.
Hip fr.:Ictlire ck\'ices call be intt.·rnal orexlcl"nal in
1.8 em Medial -
thl.'ir application; lilt: most cornlTlon \.'xternal dt.:\'ice is a
bending side.: plate affixed to the felllur supponing an in-
force Icrn[ll. sliding hlg screw through the fleck across the
fmctlll"c.
The relationship uf biomt'chanical forces borne h,,· the
tk'\'ice ;'Hld borne b-,· the bone (load \.x'aring, load sharing)
Anterior
inllllt.'nces fracture hc;;ding ;'\lld device sun.'h·al. An important
ractor is the.: ability 01" the de-vice (0 slide 10 cOllsolidate the
rnlClurc during heal-ing. lnt\..'rnal c!t:..'\"ic(':-; for fix~ltioll arc
Effect of loading direction on plate stiffness. The rigidity of llsually in-traIl1L'dullal".\· nails (Ii\,1) alld in cOinparison with
the plate is EI, where E is the modulus of the plate mao terial
and I is the moment of inertia of the plate. I == ('x (('1"1141I dc\"iccs arL'SUhjL'ctto less loading fore\.' be~
bh1/12 ( II = posterior bending; 1 = medial bending; II =
1
C;;luse or their location being closer to t1h.... Ileutral bending
0.5 x 1.8)/12 = 0.243; I~ = 1.8 x 0.5J /12 = 0.01875), where b is
axis 01" the bon\..' (Fig. 15·6). Their size is critical bcc..wsc their
the base dimension and h is its height. Thus, the plate is 13
ht..'ndingand tor:-;ional stifTnL'ss
times more rigid in posterior bending than in medial bending.
;;lre proportional to the diameter to tile fourth power. This is
\\'11.\· (me large nail provides trwrc rigid (jxalion than docs
lllllltipk smaller rods. Size, <:lmoullt or ClilTaturc, and
amount 01" n:~;'lIning are also important because the swbilit.\" of
screw head, whose center is offset with respect to the the fixation rL'licson lond transfer to the bont.~: often, distal and
screw head to obtain interfragmentary compres-sion as
the scrc\v is tightened. An alternative method to achieve
compression is to pre-bend the plate before application
so that when the attach-ment screws are tightened, the
bone fragments are approximated as the plate
straightens. Some new plate designs use threaded holes
to engage the screw so that bicOl-tical screw insertion is
not as essential for maximum fixation stabilily.
Summarv
Introduction
Forces at the Hip Joint
Rotational Moments About the Implant
Reconstructed Joint Geometry
Stem Position Within the Femoral Canal
Periprosthetic Bone loss
Forces at the Knee Joint
Medial-lateral load Distribution
Patellofemoral Joint and loads
Joint line Height
Posterior Crucfate Ligament
Conformity
Constraint
Polyethylene
Anterior Cruciate Ligament
Summary
References
Introduction To meet one design objective, compromises with re-spect
to another design objecLive must often be made. For
As designs for total joint replacements evolve, there is an example, the femoral stem of ccmcntless total hip
increasing need to improve the understanding of the replacements requires initial rotatory sta-bility for bony
biomechanics of these joints. For instance, reducing loads ingrowth into the porous material to occur. The rotational
on a total joint replacement during daily activities and stability of early ccmentless total hip replacements was
designing implants to withstand these loads will both insufflcient and was in-creased by designing implants with
increase the likelihood of nor-mal joint function and lower greater mcdul-lary canal fill. Ho\vever, implants with
the probability of im-plant failure. As implants arc put into increased medullary canal fill were stiffer because of their
younger and more active patienls, the IO~lds placed on the larger size and were thll:) associated with greater stress
illl~ plants arc often several times greater, thereb.y in- shielding.
creasing the likelihood of mechanical failure. Me-chanical
problems associated with lotal joint replacements include Forces acting at the hip or knee joint arc depen-dent on
issues related to wear of the bearing surface, mechanical the external forces aCLing on the limb and the internal
failure of the implant, loosening of the implant from the forces primarily generated by muscle contraction. Joint
bone, and dislo-cation of the implant at the articulating forces have been measured with implanted transducers or
surfaces. Important biomechanical infOl-mation addressing estimated using inverse dynamics and analytical methods
eHch of these issues has been obtained from in vitro (Tables 16-1 and 16-2). By measuring the external ground
cadaver testing, model simulation of the joint mo~ tions and reaction forccs, approximating the limb segment inertial
loads, and in vivo studies of human loco-motion. properties, and localing the three-dimensional posi-tion of
the joint centers during dynamic activities, the
intersegmenLal hip forces and external moments can be
obtained using inverse dynamics. Even \\lith
The overall goals of joint replacement are to pro-vide simplifications to the anatomy, solving For the mus-cle
long-term restoration of function and pain re-lief. Several and contact forces at the hip and knee remains an
mechanical challenges must be met to achieve these goals. indeterminate problem. Thus, a unique solution for
For example, the control of joint motion and stability in individual muscle forces is not possible without further
total knee replace-ments is achieved through an inLl'icate assumptions or simplifications.
biomechani-cal interaction between the shapes 01" the
replaced surfaces and the remaining ligaments and muscles. In general, two approaches have been used to solve the
indeterminate problem. The first is a "rc-
Hip Force
Walking normal to fast speeds 2.7-3.6 2 1-2 Kotzar et aI., 1991
Stair climbing 2.6
Walking slow speed (crutches) 2.6 Davy et a\., 19B8
Ascending stairs 2.6
Walking 2.7-4.3 2 8-33 Bergmann et a\., 1993, 1995
Ascending stairs 3.4-5.5
Descending stairs 3.9-5.1
Walking 1.8-3.3 2 6 Rydell, 1966
Walking slow speed 2.7 1 t5 English & Kilvinglon, 1979
Knee Contact Force
Walking normal to fast speeds 2.3-2.5 12 Taylor el al . 1997
401
o 402 PART III • APPLIED BIOMECHAHICS
~------------
Hip Force
Walking 4.8 Reduction nlE.'thod P(1UI. 1976
Stair ascending 7.2 Reduction tneihod Pc)tJI, 1976
SI'lIr ciescendlllg 7. ,
VValking slow w!th cane 2.2 0plimILdtlon-maXlfniZe Brand & Crol"vnmshield, 1980
A Activities: Walking, Jogging. Stairs, Stumbling teria to determine the agonistic and antagonistic muscle
activity, and assuming norrnal function. Iden-tifying how
RESULTANT FORCE R
900 patients with total hip replacements alter their function
EBl EBR JB
800 during gait could irnprove analytical predictions of joint
700 force. In vivo force measurements have often been
obtained during the early postopera-tive period \vhen
~ 600
<D 500 'u, patients may still have compromised function.
t 400
a: I /. AI
300
200 I II II
100 ESJ Mmli<ln 6 Abs. max
0
%
0
~ ~ ~ %~ 0
,
Rotational Moments About
,
~ ~
.§
" 6 "
3
§
'i 'i ,~ " 0 "
"~
.< "
~
2
the hnplant
"
M
" "
.§ M
w w
~ 2 ~
" " ~' E
~
~ ~~ w
Out-or-plane loads l11ay be detrimental to both ini-tial and
B BENDING MOMENT Mf
18 long-term implant stability, especially in ullcemented stems
16 (Berzins, Sumner, & Andriac-chi, 1993; Phillips, Nguyen, &
14 Munro, 1991). Ex-cessive bone-implant motion prevents
1\
I 12 bone in-growth into porous coatings and may lead to failure
:i: 10 6 D
of the biological fixation (Pilliar, Lee, & Maniatopoulus,
<D 8 1\ A
.0
;; A ~ 61
6 d Pli )11
during activities of daily living (Bergmann, Graichen, &
4
Rohlmann, t 995) reach the average experimental strcngth
2 ESJ MiJd'i1rl D. Abs. 01i1~
a of implant fixation (33.1 Nrn) as dctermined from in vitro
f
0
F
~
,
c
;:;
0
0
0
~
~ "~ € :i
g. ~
0
11 % "
tests (Phillips, Nguyen, & Munro, 1991) (Fig. 16-1) .
, " ~ " , §
'0 ~ ~ M if", ~ ~ M
~
~
~
5 ~
" ~
.0 ~ ~ w
~ w •• ~ ~
"
In vitro testing of prostheses implanted in human femurs
c TORSIONAL MOMENT Ml indicate that the amount of initial bone-im-plant motion is
7
sensitive to the off-axis loading that frequently! occurs
6
6 during stair climbing and rising from a chair (Fig. 16-2)
A A A
I 5 A
(Berzins, Sumnec &
:i: 4
u, Andriacchi, 1993). Furthermore, resultant proxi-mal
<D
6
e:;; 3
I F, 6
A
translations were twice as high with a straight stcm as with
2 a curved stem at load angles encoun-tered during these
!n I I activities (Berzins, Surnner, &
o Meclian D. Abs, 01i1~ Andriacchi, 1993).
o \Valking with a decreased hip range of Illotion during
-- - - - - daily activities may minimize the out-of-plane force
components (anterior-posterior). Thus, decreased sagittal
plane motion during walking of-ten reported in patients
with total hip replace-
ments (Hurwitz, Chertack, & Andriacchi, 1992;
Joint loading during different activities for two patients, EB (EBL:
left hip and EBR: right hip) and JB. The median load val-ues
Murray, BreweI~ & Zuege, 1972; Stauffer, Smidt, &
(column height) and absolute maxima (triangle) are given. The Wadsworth, 1974; White, Yack, & Lesswing, 1992) may be
resultant force is in the top graph (A) the bending mo-ment in the beneficial for iIllplant stability b,Y reducing the rotational
frontal plane is in the middle graph (B) and the torsional moment in moments about the implant stem. D:v-namic hiii range of
the transverse plane is in the bottom graph (C). The gray bar motion during gait in patients with uncemented total hip
indicates the fixation strength of ce-mentless implants (14). replacements has been related to the metaphyseal fill of the
Reprinted ~vith permission from Bergmann G., Graichen, F., &
femoral stem (Hurwitz et aI" 1992). It was concluded that a
Roh/mann, A (1995). Is staircase walking a risk for the fixation of re-duction in the dynamic range of hip motion \vas an
hip implants? j Biomechanics, 28(5), 535-553. adaptive response to decrease torsional micromo-
100 vantage of the ~lhductors(Fig. 16-3) (Delp, ":'om;:tttu,
&. \Vi:"son, 1994). Joint contact forces therefore should be
E minimized with sm~t11 1H..'ad-neck all!!les (Johnston, Brand,
.3
C 70 020" extension 0.3 ~ &. Crownillshicld, 1(79). 'De-cre~\sed heml-IH_'ck angles also
w 3
E [J] 20" flexion improve joint stability through increased congrucnce hv tUI-
~ 60 .34" flexion go
ning the k'moral head del.~pt..'r into Iht..' aCt..'tabulul1l. j\/toving
'" 1m 68° flexion ~
g. 50 0.2
'"
:D
the greater !rochalllL'r b{crall~' also increases the mechanical
is 40 o
w !i! ad\'antagl..' of tilL' ahductors. Clinically. increased
c
~ 30 §f abdlll:lor/adducLOr stn:ngth has hC1..'1l asso-ciated with
E 20 0.1 " incl"easC'd neck length and a morc distal greater trochantcr
'" position (HuJ"\viti'. & i\ndriacchi.
ijj 10
o
Resultant Transverse 1997).
Translation Neck angle and neck length have an impact not olll~' on I he
~\bductor muscle force and resultallt hip force but also on the
bellding rnomenls in the proximal felllur_ A varus hip or an
illcrcasl.,d neck length increases bending moments in the
Distal motions as a function of flexion angle (mean and
standard deviation) There were significant differences be- proximal felllur by inCrL'~ISillg. lill.' fllOllll.'nt arm or the forces
tween 20 and 34° and between 34 and 68° for the resul-tant lransmitted along tile slwft or tilt.: felllur. Proslhc-S('S IllUSl
translation and the transverse rotation, but for the sagittal be designed to resiSl these bending mu-ments. Decreasing the
rotation only the difference between the 20 and neck k'ngth or increasing !he ht.~ad-neck angle (yalgus) will
34° was significant. Reprinted with permission from Berzins, decrcase the bending 1l10mcnts in the steIn; howcver, these
A, Sumner. D.R., Andriacch!; T.P, et ell. (1993). Stem curvature al-terations compromise thc abductor function and incrcas(' the
and toad angle influence the initial relative bone implant motion of joi nl react ion rorc(~ (Case 5t ud.v 16-1) .
cemenrfess femoral srems. J Orthop Res. 11 (5), 758-769.
the pelvis from dropping as a result of the weight of the Although the models can predict hip joint center po-
swinging leg and upper body. If changes in the neck sitions that minimize the resultant force, these posi-tions
angle, neck length. and joint center posi-tion decrease may not be practical for the acetabular com-ponent.
the abductor moment arm relative to the body weight Pathological conditions strongly inOuence the potential
and no compensation in [unction occurs, then an locations of the hip cente!: For in-stance, osteoarthritis
increase in the resultant force would be expected. h-equently results in the femoral head being displaced
Subjects may, however, adapt their gait to lessen the laterally, superiorly, and posteriorly.
demand on these muscles when the moment-generating
capacity of the ab-ductors is compromised. Large joint forces are analytically predicted for hip
centers that are located superiOl~ lateral. and posterior as
Alterations in hip center location have a large ef-fect compared with the original location (Johnston, Brand, &
on the moment·generating capacity of the mus-cles and Crowninshield. 1979). High joint forces were obtained
the resultant hip force (Doehring et aI., 1996; Johnston, with superior latenll hip centers in an experimental sel-
Brand, & Crowninshield, 1979). Pre-dicted joint forces are up in which a loading fixture simulated the hip
minimized when the joint center is moved medial, inferior, abductors, adductors, and extensors during single-legged
and anterior (Fig. 16-4). This position maximizes the stance and stair climbing (Gore et aI., 1977). Superior
moment-generat-ing capacity of the abductors and brings displacements of the hip center reduce the
the hip cen-ter closer to the line of action of the foot floor moment~generatingca-pacity of the abductors, adductors,
reac-tion force, thus decreasing the external moment that flexors, and ex-tensors as a result of alterations in
needs to be balanced by muscle forces (Doehring et aI., muscle lengths and moment arms (Doehring et aI.,
1996; Johnston, Brand, & Crowninshield, 1979). 1996). Increas-ing the neck length or advancing lhe
greater
trudl;:IIlICl' pani~III.\" compt'llsal('Sfor lhl..'se lusses in rI1u:-.ck
m()lIll·llI-gt,"lh.'r~lting l'aracitk-s (Delp,
KOlllattu. ~ \\'j.'\:-'Oll, 19lJ.i),
Joint Contact Force In general. Ilk' ;:1il .. t1.\,tical and \..·.\lk·'·in1l..'1H ..'t1 rc-slIlb on
8 ,ill.'d"fl..,\.:t
or juilll gL'(Jl1lclr.," {In hip ioint km..:cs al\:
l'OIlSisll'llt\\'ilhdinic;:l1 p;:\liL:llt stu'dies.
Stair CliniLal sllH.liL'S hau.: <.ISS(l(.:i;:\kd ink-riu!' functional lIulcOnlt.::-
- \\'jlh supcrior placl...·lllcl1l or till..' jnim CCn-
6 IL'r (Box "-\..: ;'\Clblc. 1093) and h~I\'L' assoCi;:lled dc-crt:;:tSCS
ill abductor stn:llgtll and I(ISS of p;:lssive hip ik'.\ioflI'l'lOliOIl \dlll
E sup1,.·rior pIaCt.:rlJCIlt:-. of the joint l'L'nlcrs l.llllL'sS COl1llk'llSall'd
·w'" \\'illl ;:111 illlTtased neck
SO 4 k'll!.!lh (Hurwitz ~ i\lldri;:\cchi. 1997). Hiohcr
~
u
fI)
0 fl..'n~()ral loo:-.cning ra1l..'sl1a\'L'Ik'l.'ll~lssoCi<llt'd~\'i{h
joint cL'l'lll'rsplacl.'dslqK'I'iur~llld lalL'r-aIas opposed lu 1!1osI.·
placed ill all anat(1Il1icd POSili(lll ("'{odel'et al.. 1988). ,,-hill.'
2
highl..'r \'o!ulnl..'lricp(,lyelhyk'llc
\\'t..'~l!' is :tssuciatl'd \\'itll dL'crl'~lsl'd k'llloral ollsds
~Hl(.l dClTL';\SL,dahductor (Robinson ('{ al..
1'll1l1l1l'1'lli.11"lllS
llnpllhlishL'd d~ll~1. ThL' cllckl uf illlpblll posi· lion in
D pul,h'th.\'k'lll\\\..'.'~Ir in IOl~11 hip anhroplasly).
Prosthesis Moment
0.4 Sf eIII Po., if iOfl IIifII ill f lie
r'e /110 m I Co iI {II
0.3 Stair
Both clinical L'.'\!kTit.:I1C!...;'lIl',1hi()mL'ch~lllic~ll stn..'ss an~ll.,:ses :-
>UggL'St that a \'algllsslt..'lll position pro-,'idl'shl.'tll.T rl..'slilts t1li.tll
E
z <.I(K'S ~l ,'ants position
1 (Alldri~\l'chi 1.'1 ~I1,. 1076: Culli:-; & o n.:,'l!.ull, 1977;
.c
,~ 0.2 Gi.lli.Ulk'. RoslOh'r. I.\: DO,de, 197)). Fillill..'I.'k'ml'nt !l1o(!L,ls
SO indic;.I!I.' thai ,'i.II·llS slt..'llb sustain grl.'i.lll.'!' pL'i.lksll"l.'sscS lhall
~
"fI)o thosL'ill \'algLls or llL'lllr~d for Ih..--: same loading condiliol1s (.-
\lldrii.lccili l..'1 ;;11., 1476).
0.1 SubjL'l'ISwith :'1 .\'hIL'IIL'I'"cL'lllcnlL'dStl.. ill ~l ,'antS positi()l1 \\'~llk
\\'ilb11101\.' ~d)[lorl"ll~l1itics thall those
\\'ilha \'algllssll'l'lltiL-spilL'thL'I':ll'llhal :-'lIbjL'Cl~ in hoth groups
h~H.1 an L'xcdlL'IHclinical OlllL'(IIllC
A D A D A D
(Hodg(',:\ndrii.lcchi. & Gal~llllL', 19tJl). Tltl..'gail ab-llorllli.llitiL,:-; in
till.'\';:II'lISgroup may be sllggcsth'L'or <l bi{ll11l.'chaniGII~ldapl~lli(Hl
10 I.'illle!·nlicromolioll ur ahnol'lnalSlI"L'S:-;patterns prL's\.'ntin
\'i.I!"lISstl'llb.
Peak contact forces at the hip and peak moments about the
neck-stem junction of the prosthesis during level walk-ing,
stair climbing, and rising from a chair under the fol-lowing
conditions: A normal location of the hip center and 0 = hip
0=0: Pcripmst!wlic BOi!e Loss
center 20 mm medial, 20 mm inferior, and 10 mm anterior.
Peak forces were based on an optimization approach that Pcriprosthetic bOlk' loss associ'lled wilh uncc-Il'lclltcd rL'rnoral
minimized muscle stresses. Reprinted with permission from
slerns has bL'l'll\\TIl dOClllllCl1\l'd
Johnston, R. c.. Brand, R,A., & (rownins!lield, (Br:-"i.l11 t'! al.. 1994: Engll & 088; En~h L'l
Boh,n1, I
R.D. (979). Reconstruction of (he hip. J Bone Joint Surg, :.d., 1992L and concerns han:'lk'cn raisl.'d \\'itll rc-gi.\nls to the
6IAIS),646. long·lerm clinical impliG\linns or this
phL'nOllll.'llonOSI('olysis,stress. shielding, and gL'Il-
CHAPTER t6' BIOMECHANICS OF·';:~THR~PLA'~~i%~.
eralized limb unloading all may play a role in Bobvn, 1988; Engh el al.. 1992). Au lOpS), studies have also
/0~; ;periprosthctic bolne loss"lvvearl dcb,:islhas (been im- shown that the lower the bone mineral density or content 01"
;,:,,::,'plicated in osten ysis ane imp ant lai lire Amstutz "i;, , et the contralateral femur, the greater the reductioll in peri
aI., 1992). Wear particles f!'Om the polyethylene and other prosthetic bone on the affected side, which further implies that
implant materials are found in the joint Quid and adjacent preopera-tive bone mineral density' influences the extent of
tissues. Even small amounts of postoperative bone loss (Engh et aI., 1992; Maloney el aI.,
~vear can generate large numbers of polyethylene particles 1996).
that are as small as or smallcl- than a mi-crometer.. These wear
particles resuh in a foreign-~'/ body· reaction with increased
macrophage activity and intercellular secretion of mediators that
slimu- Forces at the Knee Joint
" late osteoclasts and I'esult in periprosthetic bone loss
(Jasty et al.. 1993; Willert & Buchhorn, (993). The knee joint depends primarily on soft tissucs for stability
unexpectedly" undersized or unstable compo-have a higher while sustaining large joint reaction forces at the tibiofemoral
incidence of osteolytic lesions and patellofcllloral articulations. The peak forces during
than do those with stable fixation (Noble, 1995). walking predicted by the analytical modcls (Morrison, 1970;
Stress shielding results from a decrease in the Schipplein & Andriacchi. 1991; Seireg & Arvikar, 1975)
stress distribution in the fenloral bone as a result of the val'ied from 3 to 7 bod~· weights and arc similar to those
presence of the implant stem thal has a greater or measured in vivo (2.3 to 2.5 body weights) in a single patient
equivalent mechanical stiffness as compared with the femur. with a distal femoral replacement and rotating knee hinge
Changes in the loading environ- (Taylor et al.. 1997) (Tables 16-1 and 16-2). Thc magnitude
ment rcsuh in bone remodeling. Once bone in-growth and cyclic nature of the compressive force in the tibiorelTlOnd
occurs in the cemcnllcss prosthesis, load transfer can joint are important considerations in the design of a total knce
OCClIr through these areas of bony at-tachment. However, replaccment, General chnracteristics of the predicted forces at
bone remodeling docs not re-sult in the restoration of normal the knee joint show three peaks
cortical strain lev-els (Engh et aI., (992). The fit of the
prosthesis within Ihe femoral canal (JaslY et aI., 1994). as
well as the material properties (stiffness) of the stem (Cheal,
Spector. & Hayes, 1992; Weinans, Huiskes,
Latera! Medial
& Grootenboe,; 1992), affects the amount of stress- % change % change
shielding (Fig. 16-5).
Bone loss also can result from limb disuse
(Goethgen et aI., 1991). Postoperative subjccls with
total hip replacements continue to walk aSy'lllmctri-cally,
with decreased forces on the operated side as compared
with the contralateral side (Bl)'an et aI.,
1996; Long et al.. 1993). Tibial bone loss is unaf-fected by
implant characteristics and most likely re-sults from
generalized limb disuse associated with
asymmetries in joint loading conditions. A 160/0 de-crease in
proximal tibial bone n1ineral content has
been demonstrated in subjects with long-term total hip
replacements, and this decrease has been re-lated to an
Percent change in the strain energy density within the me-dial
as)'mmetry in the peak vertical interseg-mental knee force and lateral regions of the medial and lateral cortex from a
during gait (Bryan et aI., 1996). Preoperative gait mechanics three-dimensional finite element model. The greatest re-
of patients with hip OS~ teoarthritis have been shown to be duction in strain energy density was found for the femur with
correlated with the bone mineral density of the proximol the stiffest implant (CoCr). The femur with the most flexible
femur-(Fig. 16-6) (Hurwitz el aI., 1997). The greater the bone implant (Composite 1) had the smallest reduction in strain
loss preoperativelv, the less stilT the femur and energy density (Camp I and Comp2. composite materi-als;
Cocr, cobalt chromium; Ti. titanium) (Personal communica-
the more that likely stress shielding and associated bone tion. RN NariJrajan).
resol-ption will occur postopcratively (Engh & • -.
during stance phase. Thus, failure as a result of cyclic rolling of the femur on the tibia as thL' knel' flexes. A
fatigue of both interfaces and implant materi-als is an two·dimcnsionall1lodelusing input from gait analv-sis has
important consideration in lotal knee re-placement designs demonstrated the presence and location ~f tractive forces on
(Ducheyne. Kagan. & Lacey. 1978; Kagan. 1977; Landy & the tibial surface (\.ViIII l1ler & An~ driacchi. 1997). The
Walkec 1988). In acldi-tion. the portion of the tibial model shows that a ""versal of the tractive force occurred at
plateau that is loaded varies with knee flexion angle (Fig. the postcrior end of the contact region, suggesting that the
16-7). In many designs of total knee replacements, a large effect 01" trac~ live forces should be considered in the
contact area only occurs for a limited portion of the knee evaluation of damage mechanisms. Different types of gait
range of motion with a I1luch smaller contact area can cause different tractive forces on the tibial surface. Thus,
occurring at other flexion angles. The smaller the contact one of the importanl variables in the consid-eration of
area, the larger the contact stresses. factors leading (0 POI~:L·th.\·lenc d~lmage may be a variation in
the tractive force associated with the gait of a particular
One consideration in the Factors producing wear on the patient.
tibioFemoral articulation is the tractive
'in '"
• •
•• •
••
c
•
w
0
2 2
rn 2
<;;
c
•
~
w
c
0
lD
•
gC
'"
~
0 0 0 ••
e"
....
<;;
iii
i"
OJ
-0
w
.rn'"-2 •
Z
0
E
• •
-2
•
-2
• • •
5 10 15 20 25 30 0.0 0.2 0.4 0.6 0.8 1.0
0 2 3 4 5 6
Dynamic Hip Range of Motion External Rotation Moment Adduction Moment
(degrees) (% body weight· height) (o{;, body weight· height)
The hip range of motion and external adduction and exter-nal lady, the anterior fibers of the gluteus medius and minimus are
rotation moments were significant predictors of the nor-malized recognized as primary internal rotators. Thus, the de-creased
bone mineral density of the greater trochanter in the patients with external rotation moment in early stance may also be reflective of
hip osteoarthritis. The abductors are the primary structures decreased abductor muscle forces. Modifi~ wirh permission from
responsible for balancing the adduction moment. Because the Hurwitz. D.E.• Foucher. K.C Sumner: D.R.. et al. (1998). Hip motion dnd
abductors insert on the greater trochanter, a reduced adduction moments dtJring gail relMe clireCily 10 proximal femoral bone mineral
moment may reflect re-duced forces in this region and may result in density in pc1tieflls "''/Ith osteodfihri-
bone loss. Simi- tis. J Biomechanics 3 I (lOj, 919-925
Posterior Adduction Moment During Gait
60 and
Medial - Lateral Joint Loading
Roll 60 -
I<t
.D
10 0+ - 1 -------- .
c
c
40 30 20 10 0 10 20 30 40 "E
em ~ ~ 20
40
The tibial-femoral contact moves posteriorly with knee
flexion. The contact on the lateral side moves posteriorly
1 ----- 1
Heel Slance Toe
much more during flexion (0-20°) than does the medial side strike phase off
because the lateral femoral condyle is rolling on a larger
radius than is the medial femoral condyle. Beyond 20°,
sliding motion begins on both condyles. Reprinted with
permission from Andriacchi, T.P., Sran ...vyck, IS., & Galante, J.O (J
986). Knee biomechanics and (Oral knee rep/~Kement. ArttlrO-
plasty, 1(3),211-219.
. .
f -------- ..• "" -""":......-----
/'
/'
• • A
Posterior Cl'llciate Ligament
t---- . ·A• L - ' •
Differing opinions exist with regards to the benefits of
retaining, substituting for, or removing the pos-terior
cruciate ligament (Andriacchi & Galante, 1988; Li et aI.,
1995; Rorabcck et '11.,1993), with no definitive answers
with regard to which design re-sults in better wear rates, 15 10 5 a
clinical outcome, or range of motion. Sonle studies indicate Change in Patellar Contact
no substan-tial differences in loosening or radiolucent lines (mm)
(Ranawat et aL, 1993; Stern & Insall, 1992; Wright
can result in edge loading and high stresses if the im~ plant Stair Climbing in Patients Following Total Knee Replacement
is tilted.
Observation Interpretation
Removal of the posterior cruciate ligament neces~ sitates
that posterior stability no\v results from in~ creased tibial- I
femoral constraint. In the absence of a posterior cruciate . 10.0 PCl retained
ligament, the posteriorly directed shear force is instead ~
sustained by the interfaces of the articulating surfaces ~ 4.0
ligament is removed
(001'1' et 'II.,1988; Kelman el 'II.,1989). Patients with Patients with PCl
removed tend to lean
cruciate~sacrificing knee replacements had a ten-dency to
forward reducing the
reduce the moment sustained by the quadriceps by leaning net quadriceps moment
forward during the portion of the support phase of
ascending stairs when the quadriceps moment would reach
a peak value (Fig. 16-13) (Andriacchi, Galante, & Fermier,
1982). This finding was also consistent with a study in Patients with designs that remove or substitute for the
which electro111yographic activity' was measured during posterior cruciate ligament tend to reduce the knee flex-ion
moment and thus the resulting demand on the quadri-ceps.
The mechanism they use for the adaptation is a for-ward lean
of the torso. The biomechanical explanation for the adaptation
seen in these patients can be related to the normal posterior
15, ---------------- , movement of the tibiofemoral contact with flexion, which is
reduced when the posterior cruciate ligament is removed and
constraint is added to the articu-lar surface. Reprinted with
permission from Andriacchi, TP
(1993). Functional analysis of pre- and post-knee surgery.' Total
knee arthroplasty and ACL Reconstruction. J Biomechanics Eng,
115.575-587.
•
nexion moment during stair climbing between nor-mal
subjects and patients following LOlal knee re-placemenl. The
lack of a statistically significant dif-ference in that study may
have been associated with the small sample size or the test
population,
"~iUS ralio extension
Section through
metal femoral
component
Seclion Ihrough
plastic libial
DefeCIS componen1
in plastic
Time Cracks propagating
from defects
Surface wear
~ and deforma1ion
smallr::~r-:~~~=t--I~~::~~~"""'7
contacl Level of maximum shear
area and sUess moves downward
high slress as surface wear proceeds
A model of delamination wear in polyethylene with intergranular defects. The lower dia-gram
explains a possible reason why delamination does not occur if there are no defects in the
material. Reprinred with permission from Wdlker. AS. & Blunn, G.W (997). Keynote Lecture
1/: Modem design of tocal knee replacement. In S NiwiJ. X. Yoshino, M. Kurosdka. K. Shino, S. Ya-
mamoto (Eds.). Reconstruction oi ,he Knee Joint (p.o. 129-142). Tokyo: Springer· Verlag.
•
Constraint body particles (cement), and areas of high contact stress
(Bargren, Blaha, & Freeman, 1983). Defects in the
In general, proper soft tissue balance is necessary for a polyethylene serve as sites for crack initiation and
satisfactory outcome. In the presence of con;plex propagation (Fig. 16-16). Increasing the poly-ethylene
bony defOl-mities such as a severe valgus deformitv thickness to at least 8to 10 mm will reduce contact
sati~factOl)'stability is often unobtain:,ble and co~~ stresses and should decrease the amount of wear (Collier
straint must be provided by the implant design. His- et aI., 1991). Metal backin2 was ini-tially introduced to
torically, a hinged prosthesis, which provides maxi-mum more evenIv distribut-;; the load to the underlying
constraint. was advocated for those patients with severe cancellous b~ne of the proximal libia. Howcvc,', overall
valgus deformities. Hinged prostheses, however, have component thickness needed to be increased following
been associated with a poor clinical outcome (Bargar, the introduction of metal backing so that an adequate
Cracchiolo, & Amstutz, 1980; Bui & Fitzgerald, 1980; polyethylene thickness was maintained. The multivariate
Rand, Chao, & Stauffer, 1987). A more contemporary nature of the causes of pol:vethylene damage makes it
alternative to the hinged pros-thesis is a highly constrained difficult to draw definitive conclusions on failure
but unlinked total knee replacement (constrained condylar mechanisms from retrieval studies. Moreovec the
knee). This de- diverse nature of the contact stress distribution
bv
sign eliminates the need for lio"ament balancin a (compressive, ten-sile. and shear) may result in differenl
00 .
providing medial lateral stability throuah a rectan-gular damage modes. Deformation, pitting, cracking. and
- " abra-sion are all examples of polyethylene damage
polyethylene tibial post. This highly con-strained design modes.
has provided adequate outcome for elderly low-demand
patients with severe valgus de-formities (Bullek, Scuderi, &
Insall, 1996).
Polyethylene
,
- Anterior Cruciate Ligament
During total knee replacement, the anterior crudale
Polyethylene damage has been closely related to its ligament is either already absent ~r usually re-moved. In
thickness (Collier et aI., 1991; Wright & Bartel, 1986), the case when only oTie compartment of the knee
the material properties, the presence of third- requires replacement (unicompartmental
knee arthroplasty), both cruciate ligaments are fre-quentl.\' :\Ildriacchi, TP. (1993). FUllclion;t! all;t1.\'sis or prL'- ;\Ild POst-knee
retained. Gait studies of total knee replace-ment patients surgL'lS: TOI;t! kllL'L' ,lrthropl,lStv ,tlld :\CL I'econstruc_ lion. J
Diollll'c!IIiJlic." Lug, 115,575-5:)1.
(Andriacchi, Galante, & FermieI~ 1982; Chao, Laughman, &
:\ndri:tcchi, T.P, 6.' C;\l'lnte. J.O. (19t:t:J. Relcnliull (ll' IhL' DOS-tl'rior nlll.:i;ill'
StauffeI~ 1980; Kelman et aI., 1989; Simon et aI., 1983) lig,lIl1enl in tul;1I knee arthropl;\SI~'. J
show that normal func-tion is not achieved in the Arthroplasty, SI3-,19.
majority'of the patients despite improvements in stride .-\ndri'lcchi. TP.. Gabnll', J.O., Iklvlschko, TIL l't,d. (1976). ,.\ stress an;dysis
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HOlle Joilll "ill I)!" 58:\(Sl,61,s",62·1.
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Andrial'clli, TP., G;danlc. J.O .. 6.' FLTlllil'l', R.\V. (1982). The inl'hlL'ncl' or
extension moment during level \valking. These vari-ations loul! knee rL'pl;tCeIllL'lll design on walking and sl;\ir-clilllhing . .I !lout'
in the flexion-extension moments at the knee could not be .loiul Sill)!" 6-1:1, 132S.
related to an}' specific design but in-stead suggested the Alldri;\cchi. TP. & Hurwit/, D,E. (1'107J. G;lil hiomeckmics ;llld tillal knee
possibility that loss of joint pro-prioception or the arthruplasl,v. ·1!11 j I\I/(l' Sill',:!" 10(4),
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l
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CHAPTER 16' BIOMECHMJICS
\V~instdn. J.N .. Andriacchi, T.P.. &. Galante. J.O. (1986). Fac-tors Wilson. S.A .. McCann. P.D .. Gollin. R.S .. et a1. (1996). COI11-
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109~115. Wimmer. ;\1.A. &.: Andriacchi. T.P. (1997), Tracth'e forces dur-ing
\Vhite, S.C., Yack, 1-1.1 .. &. Lesswing, A.L. (1992). Pre- and post rolling motion of the knt.'e: Implications for wear in to-tal knee
surgical gait of a total hip replacement p<:llielli. hilliS 71h iI/lllual East replacement..1 Biol/lcclulllics. 30(21.131~37.
Coast Gail ('olll('I"('II('c 1992; Session 11, Rich-moml Virginia. \Vright, T.i\'1. &. Banel. D.L. (1986). The problem of surface damage in
polycthylL'ne total knee components. Clill Or-
\Villert. H. &. Buchhorn. G.H. (1993). Particle disease due to wear of {hop, 205, 67-74.
ultrahigh molecular weight polyethylene. Findings from retrieval )'oder, S.A., Brand, R.A .. Pedersen, D.R., et a!. (1988). Total hip
studies. Wear of polyethylene in total joint arthroplasty. In B.F. acetabular component position affects component loosening rates.
ivlorrey (Ed), Biological ,lIa/erial alld ,1Ice/wl/ical CORR, 228, 79-87.
COllsideratiolls of Joillt Rcplacelllclit (pp.
87-102). New York: Raven Press Ltd.
Engineering
Approaches to
Standing, Sitting,
and lying
Chris 1. Snijders
Biomechanics of Standing
Reaching
Biomechanics of the Pelvis
Flat Versus Ball and Socket Joint
Sitting
Arm Rests
Back Rest
Seat
Chair and Table
Leg-Crossing
Lying
Sitting in Bed
Decubitus Ulcers
Summary
References
Biomechanics of Standing
Muscles extending from the neck to the ankle are
continually active to prevent collapse of the skele-toll. In
view or this function, these muscles are known as postural
muscles. ObvioLisly, these I1lLlS· des are comparatively
strong and do not tire easily.
In skeletal musculature, postural and phasic mus-cles-also
known as slow and fast muscles-are present (see Chapter
6). Thc mO"phological differ-ences arc particularly marked
in the Illuscles of birds, but in humans this distinction is less
evident because of the mixed composition of muscles. It is
assumed that the force proportion of postural to phasic
muscles is 3:2. Exercise, especially participa-tion in high-
level sports or athletic training, can change this proportion to
even 5; I. Selective training of postural (red) muscles is
ach-antageous because these muscles are stronger and
deliver more work than do phasic (white) muscles. The
neurologist and muscle physiologist Vladimir Janda (1980)
pointed to the following relationship between postural and
phasic muscles in agonist and nntagonist action:
421
nation of the smaller foot is greater than that of the larger
foot. In practice. however, it is often the
COP smallest \\'omen who wear the highest heels. In Ficr_ ure
D_ O_ Y 17-4, the angle is 40°. Recom~1ended angles a~
Ix 10 to 14", which translates to heel heights of 3 to 4 cm
IX
F maximum.
g In Figure 17-511, a chock is placed under a plaster cast
around the lower leg and foot. This position of the chock
y causes discomfort because it is placed in front of the ankle
joint and causes a counterclock-wise moment, M = FI,.a.
F, The foot and cast can be re~ garded as a single entity, so
equilibrium is obtained with a clock\vise moment from
A B C 0 force Fh exerted by the tibia on the cast. A moment about
the ankle joint in the opposite direction occurs when the
foot hits the ground with force F at heel strike (Fig. 17-5).
The heel of a shoe produces a lever arm with respect to the
A, The resultant force between ground and feet {FJ equals body ankle joint (Fig. 17-5(') that is consid-
weight (Fy ). B. Fv position (center of pressure path,
COP) can be measured with a force plate with force trans-
ducers under the corners depicting in a three-dimensional force
system (x, y, z). The person recorded in C rests more
on the left leg but has less sway than the person in D in x and y Fs
directions.
I
/
I •
C 0
Standing in shoes in general means standing on uneven
ground because a heel of elastic rubber has a certain height
for shock absorption and because at the ball of the foot, the A, The foot-ground reaction force {F...} is always in front of the
sale must be thin to give goodllexibility. It is beller to look ankle axis (black circle). B, Therefore, the calf muscles {FJ have
at the inclination of the foot, not at the height of the heel, to be constantly active. C, Mean values of lever arms for calf
because the inclination determines the degree to which a muscles and foot ground reaction forces in relation to foot length
person loads the forefoot. With an)' given heel height, the (t). The data is derived from differ~ ent sources. D, Lever arms for
inclination of the foot depends on the length of the foot. resultant forces on the heel (Fr.) and the forefoot (Fin) in relation
vVith a certain heel height, the angle of incli- to foot length (I).
CHAPTER 17. ENGINEERING APPROACHES TO STANDING,
A B c
•
erably larger than with a bare foot (Fig, 17-513), This
moment claps the forefoot down on the ground, which can
be reduced by! cutting off the back edge of the heel (Fig.
- B
A
D
~~
nlu:".cli:· to:C(·. F.,;:: f(',lellon !OfCE' of the wel9ht f()ru~; F. =kilCiOI1 iorw (!f
lhr bid',Inusc!e force: il = h:!'Jcr<1rlTl of upper budy '/,.'eiqht;b :::
1('',',:r.'l(l'nof!Jdd: tT~lJ:;(I(~ force.
Calculation Box
Figure 17-1-1.
Calculation Box
Body weight is carried by the arch of the fOOl, which Figure 17-1-2.
resembles the form of a Roman arch (Fig. 17-7A). The
arch mechanism relies on the firm con-nection between the
two ends. In the root, this func-tion is ascribed to the
plantar aponeurosis. Schematic free-body diagrams of parts
of the foot (Fig. 17-78) show the interesting feature of an
arch: the joint re-action forces in the hind foot arc Case B. In the fH'X; C.15[o. the- le'.if'f,,1m a is 11 COl• ..."h,(;1 fe-
perpendicular to the flat joint surfaces. Thus, shea,· loading Sll1tS lf1 b,lCk musclE- force'F.. ~., alb. F.: - 11/5;, 500 "., 1100 N.
that would tend to dislocate predominantly flat joints is ThiS reduction of 60°/0 oi muSC,IIM forc('illustrates lhClt keeping
avoided (Snijders et aI., 1993). lh(! Hunk more uprighl has c!rMrl,11ic mfluence on (still Ie) work IO~l(1.
wilh the le'/diHn1 11 ilS 1110 1110s1 irnponarll iilCtor. Thus, a mOfC'
uprighl pOSlure rcdtJn~s ll1usclo and disc load consicleraoly.
Stooped postures often occur because of the role of
the eyes in combination with the work of the hands. This
raises large muscle forces in the lower back as a result of
the large ratio of the lever arm (a) of upper body weight
(F,) and the lever mm (b) of back muscle force (F). A
cross-section at the level of L5-S 1 shows that the mass
center of gravity of the body part above this cross- Calculation Box
section is situated at the armpits (Calculation Box 17-1, Figure 17-1-3.
Case A). The equilib-rium of forces in the verlical
direction shows that the weight force (F~) equals its
reaction Corce in the spine (FI1:). It is assumed that this
reaction force acts in the middle of the intervertebral
disc (the axis of
L i
.I
CHAPTER 17 • ENGINEERING APPROACHES TO STANDING, SITT'ING, AND'f~~INGo/~r~E:O
a
l·tQ optimal because the)' are perpendicular to the longitudinal
REACHING
Conditions like those shown in Figure 17-81\ occur at work
when the person reaches as far as possible to a distant
object while the feet cannot be placed any further forward,
either because of the design of the machine involved or
because the tocs touch a tank with liquid. The provision of
a support for the pelvis as shown in Figure 17-88 allows
for the same I'cach but with greatly improved posture. This
mea~ sure reduces the lever arm by approximately 300/0
and the arms and eyes are in a much more suitable position.
In the workpl<lce, people often seek sup-port 1'01' the pelvis
or upper legs by using the edge of a tablc or bench.
·-u '-H ~
~lF,
comparison, it can be concluded that SI joints are
vulnerable to shear but can trans-fer large bending
Il - · n-· li:~F' moments and compression (Sni-jders el aI., 1993).
I. 2r I ~. r .I
, , rVlusc1e forces that cross'the 51 joint surfaces can
A B C 0 produce compression, in combination with Forces in
ligaments and fascia. This protective sys-tem requires the
concerted action of muscles in the back, pelvis, and legs.
A, Forces near and in the plane of a flat joint result in shearing Some muscles with the appropriate transverse direction arc
before this movement is stopped by ligaments. B, A ball and indicated in Figure 17-11. SI joint stabilit:, can also be
socket joint is well protected against shear. C, Because of the ascribed to the 111cchanism of the pelvic arch, which
greater lever arm, a pure bending mo-ment can be better relies on the protection against lateral movement of the hip
transferred by a flat joint than by a ball and socket joint (0) (F., bones. Figure 17-12 compares the arch of the fOOL and the
delineates joint reaction force, Fi is the ligament or muscle force, arch of the pelvis. The effect of a pelvic belt distal \0 the 51
r represents the lever arms). joints also can be seen (Snijders et aI., 1993). The pelvic
arch receives bi·
CHAPTER 17. ENGINEERING APPROACHES TO STANDING. SIFIN8•• }"~~.D,.~~'1~~\ir~m
arm rests. the arms arc placed on the table, crossed before
[he chest. or laid in the lap. 1n cars, arm rests arc ohen
absent or lOa low. Drivers tend to turn to the side of the
door and put their arm on the edge of the window. The
other arm rests on the lap or is put on the back rest of the
passenger seat. Because of the weight of the arms, the
driving wheel is often held at the lower side. A proper arm
rest must be placed be-low the mass centers of upper and
lowcr arm. A sup-pan at the wriSl is lherefore useless. In
cockpit sealS, arm rests arc adjustable in height but only by
tlu-ning about an axis adjusted to the back rest. This con-
stnlction is a logical error because in a high position the arm
rest only supports the wrist and leaves air be-low the elbow of
the tall pilot.
Analogy between the arch of the pelvis and the arch of the foot.
This shows analogy between the load on the sacroiliac joint and
the load on a tarsal joint. The (horizon-tal) line of action of a pelvic
belt distal to the sacroiliac joints is also seen. Reprinted with
permi.ssion (rom Snijders, C.J.. Vleeming. A., & Stoeckarr. R.
(1993). Transfer of lum-bosacral load to iliac bones iJnd legs. Part
I: Biomechanics of
j self-bracing of the sacroiliac joints and irs significance for ((eat-men( and
exercise. Clin Biomechanics. 8. 285-294. Postural Problems at VDT Workstations
female computer operator works at a VDT worksta-
ARM RESTS
The importance of arm rests is often underestimated. Arm
rests unload the shoulder girdle, which is a loose
construction hanging on the spine by means of liga..: ments
and muscles. The weight of the arms is 100/0 of body
Case Study Figure 17-1·1.
weight, which is considerable. In chairs without
BACK REST tion. (":'urther transhltion results in backward tilt of the
pelvis and lumbar k~·phosis. The reader can cas-il~' perform
The back rest provides stability for the vertically erected
this test. The fUllcticl!l of a lumbar sup-port is to exert a firm
trunk, analogous to Figure 17-8B. HoweveI~ in prolonged
force on the upper side of the pelvis ..md the lumbar area to
sitting, the prevention of a lumbar kyphosis seems to be the
prevent tilting of the spine into kyphosis. This support should
most important function of the back rest. The significance
not reach higher than the lower edge of the scapulae. The tho-
of a lumbar support can be illustrated with the so-called
racic spine is still enough (ribs) and a higher lnlCk rest pushes
click-clack phe-nomenon (Fig. 17-13) (Snijders, 1970, On
the shoulder blades rorward, which "overrules" the lumbar
the form of the human thorneD-lumbar spine and some as-
support and hinders the shoulders to stretch and to turn to the
pects of its mechanical behavioc Thesis, Eindhover). This lert and the right. The absence of a back rest, like sitting on a
can be experienced when one sits upright on the edge of a crutch. alwa~'s leads to a C-form of the spine.
straight chait: Slow forward translation of the trunk
increases lumbar lordosis, whereas slow backward
translation moves the center of gravity above the ischial
tuberosities into an unstable posi-
SEAT
The weight of the trunk, head, and (part 00 the arms is
alnH)st completcl~' carried b~' the ischial tuberosities. This
o o
leads to a simple representation of the static equilibriurn of
the upper bod\' in sitting. The aim of Figure 17-14 is to
illustrate that a hori-zontal seat always raises friction at the
ischial tuberosities, tl1<.\t friction can be completely elimi-
nated b~' means of a moderate seat angle. and that the angle
betwL'en seat and back rest is ()ptimal be-twcen 90 and
95°. which is met b~' the classical rock-ing chair (Snijders.
1988). In Figure 17-1413, a free-bodv diagrarn of the trunk
is given, with a cross-section at the upper legs and
SUppCl!'t forces at the seat and the back rest. The mass
center of grav-it}· of this part of the body is near the
~lnnpits. The line of action or the gravil<.ltional f()rce (FJ
and the back rest (Fb ) intersects at point S. The resultant
force exerted by the scat on the ischial tuberosities (FJ must
also intersect at point S for static equilib-rium. The
magnitude of the three forces is f()llnd b:v the composition
or the tri ..mgle of forces. It can be concluded from the
direction of Ft that a back rest force always raises a
hOI'izontal force component (Fh ) at the ischial tuberosities.
The consequence is friction on the skin and )undcrl~'ing
tissues that causes discolnt"ort.
The lumbopelvic click-clack phenomenon. Lumbar lordosis is There is a re-duced force component in the shear direction.
the result of a mass center of gravity of the trunk at the ventral \Vhcn the back rest is tilted further) the seal angle must
side of the ischial tuberosities (right). The mass cen-ter of gravity follow because FI becomes more inclined. [n Figure 17-15.
of the trunk dorsal to the ischial-tuberosities forces the lumbar the relation between back rest angle and scat angle is given
spine into kyphosis (left). The latter can be prevented by the for the condit.ion that Fric-tion is absent (Goossens &
exertion of lumbar support on the upper side of the pelvis and Sni.iclers, 1995). This re-lation was found with a
the lumbar spine. biomcchanical model of
CHAPTER 17. ENGINEERING APPROACHES TO
o Measured -- Calculated
20r ---------------- ,
1ii
(f) '"
o'--~......"O:_~___,~~,__.,;;,____;;,___;;.,____::':::_--'
70 72 74 76 78 80 82 84 86
Backresllnclination (degrees)
Relation between back rest angle and seat angle. No fric¥ tion
exists at the ischial tuberosities. The solid line is from a model
calculation. The vertical bars represent measure-ments (n 10), --0
A B
the total bod)-' divided in five links and \vas verified by
measurements on 10 healthy subjects with dif-ferent body
height. Back rest inclination is larger in auditoriums, cars,
and eas)-' chairs at home. This facilitates a horizontal
direction of looking and has the advantage that the back
rest contributes in car-rying the trunk. Head rests cannot
carry' the head when they are positioned too far fonvard.
Figure 17¥16A illustrates that the head rest can only give
F,
Fgr(
c
~"FIG:~17-14 ~
~~--~~
D
1:,
A B
A, Sitting with maximal support. B, Free-body diagram of
the trunk. Back rest force (Ft» and upper body weight force (F()
intersect in the point S. The resultant seat force at the ischial
tuberosities (f\) must intersect in 5 as well, and therefore inclines A. The mass center of gravity (represented by a circle and
backward. The horizontal compo-nent (Fh ) must come from gravitational force F~) is behind the atlanto-occipital joint axis A-{Ft
friction acting on skin and un-derlying tissues. (-0, By tilting the represents the joint reaction force). With sup-port of a head rest,
seat slightly backwards ((\), the resultant seat force (fl ) becomes no muscle forces are needed for equi-librium of the head (F'J= Fl ).
nearly perpendic-ular to the seat surface and friction on the B, The head rest is posi-tioned too far forward and is useless.
ischial tuberosities is significantly reduced. Muscle force F, remains needed for equilibrium andF, increases.
support when the mass center 01" gravity of the head is Upright Position Anteflexion Position
dorsal to the axis of the atlanto-occipital joint (A). In
Figure 17-168, the head rcst hinders movement because the
head cannot bc tilted back-ward. This design error can be
recognized in trains "nd buses in which people nod or rest
with the head sidewa.ys.
\
Pain
( 2 3 4
tl
Tissue Muscular
breakdown spasm
\ Poor
blood supply
J 5
L
i',l::!
~• I •
6
Smooth
7 Rough
•
9 11
longed, continuous contraction (above approxi-mately
20% of voluntary maximal contraction) causes a lack of
oxygen, accumulation of sour metabolites, and
intracellular shortage of potas-sium. Pain is the result,
which can lead to muscle spasm, which closes a vicious
circle (Fig. 17-19). ~~
Prolonged isometric contractions can even cause an ~
inflammation process with fibrosing; the result is a 12 13 14 15
passive shortening of the respective muscle. Enter-ing
this vicious circle is also ascribed to cold and stress.
Attempts to cut this circle are analgesia, mus-cle
relaxation, and improvement of circulation by massage
and heat radiation. These efrorts involve the treatment of
symptoms, while the improvement of the work posture
addresses the origin of the mus-cle spasm. Some 16 17 18 19
biomechanical problems in sitting arc illustrated in Figure
17-20.
ception is the observation that leg-crossing (upper legs thin people. But this may also hold for heavy peopiG
crossed or ankle on knee) may result in less ac-tivity of the because with an increase of volume, the weight in-creases
internal oblique abdominal muscles that have the same with the third power (m]) but the support surface only with
orientation as the transverse ab~ dominal muscles (Fig. 17- the second power of length (m').
11) (Snijders et al" 1995). By crossing the legs, an The most unconstrained form of the lumbar spine is
ahernativc and less fatigu-ing means is found for self- found when the angle bet\vcen the trunk and femur is 135"
bracing of the Sl joints. (Keegan, 1953). Furthermore, the muscle running from the
lumbar spine to the femur (111. psoas major, part of the
111. iliopsoas) can be shortened, which raises tension in
Lying this muscle and causes a hollow back in supine posture.
This can be improved by exorotation of the legs and, if this
A bed is a body support surface on which prolonged and is in~ sufficient, by lying on the side. When lying 011 the
complete rest must be found. It is a combina-tion of a side. the spine should not bend laterally. resembling the
mattress, a mattress carrier, and a bed frame or bedstead. scoliotic form. This occurs in persons with pro-nounced
However. in many countries it is customary to sleep on a waists and little give of the mattress in the
spread-out mat on the floor. Three types of mattresses can
be distinguished: polyethel; foam rubber, and internally
sprung. There are several kinds of mallress carriers, like the
wire-spiral mat, the hardboard boltom, lathes thar can tih,
the box spring. and a carrier simply made of planks with
distances of approximately 7 cm. Many combinations of
mattress and mattress carrier arc possible, but not every
combination is appropriate. A good bed should (1) adapt to
body curvatures,
15
SITTING IN BED "- 12
~
c
Sitting in bed is common, especially in hospitals in which .~
0
9
c
the head portion can be raised upwal'd. \Vith a horizontal
>'"-
mattress, the same biomechanical model holds as in Figure c 6
con-sequence, the pelvis moves little by little on the mat- (J) '" 0
Solid material
A B
Fluid Gas
c o
A. Equilibrium of a body on a mattress of solid material. Re-stricted mattress with a loose cover; less shear than in B. D. Equilib-rium of
support surface. a, Fluid mattress with an elastic en-velope. The the body on gas. A favorable, uniform pressure distri-bution over
highest pressure is at the deepest point. C, Fluid almost the maximal available supporting surface.
cor-dance with Figure 17-14C. This folding princi-ple is largest bod).' surface is involved in support when the
now applied in hospital beds and in beds for home care. body sinks deep in the maltress (Holscher et aI., 1994).
Introduction
Anatomical Considerations
Hip
Knee
Ankle and Foot
Upper Body
Methods of Gait Analysis
Gait Cycle
Time-Distance Variables
Angular Kinematics
Hip
Knee
Ankle and Foot
Talocrural Joint
Subtalar Joint
Midtarsal Joint
Forefoot and Interphalangeal Joints
Trunk and Pelvis
Center of Mass
Segmental Kinetics
Joint Moments
Hip
Knee
Ankle
Joint Power
Hip
Knee
Ankle
Work and Energy Transfer
Muscular Control
Hip
Knee
Ankle and Foot
Taloc(ural Joint
Subtalar Joint
Midtarsal Joint
Forefoot and Interphalangeal JOints
Summary
References
Introduction ANKLE AND FOOT
Ankle motion is restricted by the morphological constraints
Bipedal locomotion, or gait, is a functional task requiring of the talocr-ural joint, which permits only plantarllexion
complex interactions and coordination among most of the (extension) and dorsillexion (Ilexion), Although frequently
major joints of the body, par-ticularlv of the lower modeled in gait analysis as a rigid segment. the foot is
extremitv. This fundamental task ha~ been the subject of required to act as both a semirigid structure (as a spring
st;,dy by scientists for several centuries, both with respect during weight transfer and a lever arm during push-off) and
to description of typical body movements and of a rigid structure that permits adequate stability to support
pathological conditions and therapeutic intcl'"ventions. body weight.
Gait analysis and training in one form or another is a staple
of physical therapy and rehabilitation mcdw icine practice. The movements of the ankle, subtalar, tarsal,
As technological advances become both more sophisticated metalHrsal, and phalangeal joints contribute to the smooth
and affordable, detailed biomechanical analyses of gait progression of the body's center of mass through space.
increasingly can be performed in a clinical setting. This Thcl-e are constant acljust-Illents in these joints in
means that the biomechanics of gait need to be more response to the charac-teristics of the supporting terrain
broadly and to the ac-tions of the muscles that cross them, which
provides a smooth interaction between the body and the
understood b)'both clinicians and researchers. In the wide variety of supporting surfaces en-countered when
paragrapl~sthat folio\\', the anatomical charac- walking. The loss of normal mo-tion or muscular function
teristics of the major joints of the lower limb and trunk will at these joints has a di-rect effect nOt only on the fOOl and
be summarized and their behavior dur-ing level walking in ankle bUI also on the remainder or the joints of the lower
healthy adults will be de· scribed. More detailed anatomy ex-tremity.
of the relevant joints and tissues can be found in other
chapters of this book.
UPPER BODY
Anatomical Considerations The pelvis and thorax may be considered sepa-rately or, as
in many studies in the literature, as a rigid unit comprised
HIP of the head, arms, and trunk (pelvis + thorax), or HAT,
During gait, motion abollt the coxofernoral, or hip, joint segment, The upper limbs and head have not received as
is~ triaxial: nexion-extension occurs about a mecliolateral much atten-tion as the trunk and lower limbs in the
axis; adduction-abduction occurs about an anteroposterior literature. Studies that do exist indicate that shoulder mo-
axis: and internal-external rOlation occurs about a tions occur pl-imarily as flexion-extension and
longitudinal axis. Although flexion-extension movements internal·external rotation at the glenohumeral joints. Elbow
are of the highest am-plilude, motions in the other two flexion-extension and forcarm prona-tion-supination
planes are sub-stantial and consistent both within and oceUI: Cervical spine motion is pri~ marily in flexion-
between in· clividuals. In addition, impairments in all three extension and rotation to stabilize visual gaze or facilitate
movement planes can cause problematic deviations of the the vestibulo·ocular reflex as the body is propelled through
typical gail pattern althe hip and olher joints. the cnvironn1cnl.
KNEE
lVlethods of Gait Analysis
In the case of the knee, three degrees of fTeedom of
angular rotation are also possible during gait. The primary The information presented in this chapter is sum-marized
motion is knee nexion-extension about a mediolateral axis. from the scientific and clinical literature in which various
Knee internal-external rotation and adduction·abduction laboratory methods have been llsed to measure gait
(varus-valgus) may also oc-cut: but with less consistency charactcristics, including stride analysis, angular kinematic
and amplitude among healthy individuals owing to soh anal~;sis, force plmc and foot pressure analysis, and
tissue and bony constraints to these motions. electromyographic (EMG) analysis, In stride analysis, the
temporal se-
439
quence of stance and swing are quantified using ei-ther terns. and load bearing of the lower cxtremities and, as a
simple tools, slich as a stopwatch and ink and paper, or result, is cfflcicnt in translating the bod)/s cen-ter of
electromechanical instruments. stich as pressure~sensitive muss in the ovcrall direction 01" locomotion. A full gait
switches imbedded in shoe in-serts or applied to the bollom cycle is defin~d by the OCCllrrcnce 01" a ~e~ quential
of the fool. Stride analysis data arc used to calculate basic stance phase and swing phase by one limb, or a stride
time-distance variables, which will be described in detail. (Figs. 18-1 and 18-2). The limits of a stride can be
demarcated by the occurrence of a specific gait event
Angular kinematic analysis lIses c1ectrogoniome-t!)', (e.g., initial COlll<:lct) on one limb to the next
accelerometry, and optoelectronic techniques. occurrence of that same event on the ip-silateral limb.
ElectrogoniOlllelers arc available in uniaxial and multiaxial
configurations and are attached directly to the body Stancc phase occupies 60(7"0 of the stride and con-
segments on either side of the joint or joints of interest for sists of two pel"iods of double limb support (initial and
the direct measurement of an~ gular displacement. tcrmillal), wh~n the contralateral foot is in con-tact with
the ground, and an intermediate period of single limb
Accelerometers arc attached to the bodv .. sccr ll1ents of
~
support. when the contralateral limb is engaged in swing
phase. Stance can be decomposed into six events or
interest for the direct mea-surement of segmental period~. Initial contact or heel contact is ddlncd as the
acceleration from which seg-mental velocities and
instant the foot makes con-tact with the floor. Loading
displacements arc then dc-rivcd. Optoelcctronic techniques
response is an interval during which the sole of the foot
involve the use of video cameras to capture images of an
comes into con-
individual walking. Such systems llsually include the use
01' reference markers. which are attached to the sub-ject, to
estimate.: the location of joint axes and to as~ sist in
digitization. Such camera systems require careful Stride/cycle
calibration to locate anatomical markers and are often
permanently installed in a "gait labo-ratory." Force plate LTO LHC LTO LHC
and foot pressure analysis tech-niques involve the !
recording of information at the foot~noOl' interface during
the stance phase of gait. Force plates measure the resultant L. swing
II L. stance
L. swing I
ground reaction force beneath the foot and the location of I
its point of application in the plane of the supporting sur- .,I
" ,<",,·,'1' O,".,i
face. Pressure plates or insoles measure the load A. stance R. swing R. stance
distribution beneath the foot during stance. Force and
pressure plates are often combined with angu· lar kinematic 60'% I 40~G
methods for the calculation of kinetic variables, such as RHC RTO RHC RTO
joint moments.
Stride/cycle
EI\tIG is used to record muscle activation during
walking. Both surface and intramuscular sensing
techniques are used in gait analysis. EMG is typi· cally
combined with stride or angular kincmatic analysis to Schematic diagram of the temporal sequence of the gait
cycle or stride showing complete right (shaded bars) and left
provide information about phasic mus-cle activation
strides. HC, heel/initial contact; TO. toe off, R. right; L. left.
pallerns. EMG helps to explain the motor performance
The areas of overlap between HC and TO represent periods
underlying the kinematic and kinetic characteristics of
of double limb support, which coincide with the occurrence of
gait. pre-swing on the trailing limb and loading response on the
leading limb. In the case of the right stride, initial double limb
support (lasting -10% of the stride) occurs from RHC to LTO,
Gait Cycle and terminal double limb suppo~_~ (lasting -10% of the stride)
occurs from LHC to
Bipedal locomotion is a cyclic activity consisting 01" RTO. Reprinted with permission itom Bart; A.E. (998). Gair
two phases for each limb, stance and swing. Gait is analysis. III J. Spivak & J. Zuckerman (Eds.), Orthopaedics-A
morc or less symmetrical with regard to angular motions Comprehensive Study Gllide. New York: McGr~w-Hil!.
Fool Terminal
lIat Midslance stance Pre-swing
RHC RTO
lnilial swing Midswing Terminal swing
LHC
Schematic diagram of the spatial sequence of the gait cycle or Swing phase is demarcated by two events, TO and He, and
stride showing stance phase on the right and swing phase on broken into three periods, initial swing (from -60 to 70% of the
the left. He, heel/initial contact; TO, toe off, R, right; L, left. stride), mid-swing (from -70 to 85% of the stride), and terminal
Stance phase is demarcated by two events, HC and TO. and swing (from ... 85 to 100% of the stride). Reprinted with permission
broken into four periods, loading response (foot flat) (from -0 to from Barr, A.E. (1998). Gait analysis. In I Spivak &
10% of the stride), midstance (from -10 to 30% of the stride), I Zuckerman (Eds.), Orthopaedics-A Comprehensive Study Guide.
terminal stance (from -30 to 50%, of the stride), and pre-swing New York: McGraw-Hili.
(from -50 to 60 % of the stride).
tact with the noor and the weight of the body is ac- stride. During pre·swing, weight is transferred onto the
cepted onto the supporting limb. The loading re-sponse contralateral limb in preparation for swing phase. The
period coincides with the end of initial dou-ble limb end of pre-swing corresponds to toe off at which
support at approximately 10 to 12% of the stride. moment the foot breaks contact with the floor, thereby
Ivlidstancc is the period during which the tibia rotates demarcating 'the beginning of swing phase.
over the stationary fOOL in the direc-tion of locomotion.
The beginning of midstance co-incides with single limb Swing phase occupies 40% of the gait cycle and is
SuppOrl and lasts from ap-proximately 10 to 30% of the decomposed into three periods. Initial swing lasts From
stride. Terminal stance is the period during which the approximately 60 to 73% of the stride (approximately
weight of the body is transferred fTom the hind and one third of swing phase), from toe off until the
midfoot re-gions onto the forefoot. It occurs from 30 to swinging foot is opposite the stance [001. Mid-swing ends
50% of the stride and coincides with the beginning of when the tibia of the swing-ing limb is vertically oriented
ter~ minal double limb support. Pre·swing occurs si- and lasts from 73 to 87% of the stride. Terminal swing lasts
multaneously with terminal double limb support and from 87 to 100% of the stride and ends at the moment of
lasts from approximately 50 to 60% of the ini-tial contact.
Time-Distance Variables
~ Normal Values
Time-distance variables arc derived from the tem-poral and
for Time-Distance Parameters ,.
spatial occurrence of the stance and swing phases. Normal
of Adult Gait at Free Walking Velocity
values or these quantities are provided in Table 18·1.
Stride or cycle time 1.0 to 1.2 mlsect
Stride or cycle length 1.2 to 1.9 mil Stride time refers to the time it takes to perform a single
stride. Stride length refers to the distance covered b.y a
Step length 0.56 to 1.1 m-''' . stride in the direction of locomolion. Step is defined as the
Step width 7.7 to 9.6 em" '. occurrence of an event on one root until the ncxt
Cadence 90 to 140 steps!~jnuteo .. occurrence or thai same evenl on the opposite fool. It is
Velocity 0.9 to 1.8 m/sec:.> most commonly delineated by sequential contralateral
initial contact. Laterality is determined by the swinging
Reprinred with permission (rom Barr. A.E. (1998). Gait analysis. In 1.
limb; fOl' example, right step is delineated by left initial
Spivak & 1. Zuckerman. (eds.), Orthopedics: A Comprehensive Study
Guide. New York: McGraw·Hill, contact to the subsequent right initial contact. Step length
~Vafues adapted from multiple sources as summariled in Craik, R.t fit -"S refers to the distance covered by a step in the direction of
Caris, CA. (1995). Gait Analysis: Theory dnd Application. Sr. Louis: -:~-- locomotion. Step width refers to the distance cov-ered by a
Mosby.
step perpendicular to the direction or lo-comotion as
l"Values adapred from Whirr/e. M.W (1991). Gait Analysis: An lntro-
duC!ion. Oxford: Builen'lorth·Heitlemann measured from the points of contact on
20 40 40
10 30 30
0;
~
E 0 20 20
\\
~ -10
c
'.\ 10 10
C
'"-20 \\ '-.\
O~·
L::::J
0
..,
-40
-30
".: ' . ,
' .
-10
::::=:-..,
-20
-10
-20
::::::::::........ ~
'0
....
2
1.2 1.2 1. 1
0; 0.9 0.9 0.9
E
;;.'" 0.6 0.6 0.6
C 0.3 0.3 0.3
~
E
0 ....::::::._.:..
:2
c
0
" 0 0
Angular displacements and moments of the hip dur~ng level A (bottom). Hip extensor «0) and flexor (.>0) moment; B
walking at freely chosen velocity among normal subjects (25 (top), Hip abduction «0) and adduction (>0) position;
males, 4 females; 15 to 35 years of age). Solid Jines indicate B (bottom), Hip adductor «0) and abductor (>0) moment;
mean values (ordinate) over the course of a single stride (ab- ( (top). Hip external rotation «0) and internal rotation (>0) position; C
scissa).. qashed Jines indicate 90% bootstrap confidence inter- (bottom), Hip internal rotator «0) and external rotator (>0) moment.
vals. A (top), Hip flexion «0) and extension (>0) position;
the heels. Two sequential steps comprise a stride. Al-
though step variables may differ fTom right to left within Bootstrap Method for the Statistical ..
an individual, stride variables will remain constant
regardless of whether stride is delineated by right or left Calculation of Confidence Intervals
initial contacts, because stride con-sists of the SlIlllS of right The booISHap method for the calculation of confidence,.:", '.;
and left steps. ;. ./':,-,
intervals is an iterative technique whereby a population of " gait
Cadence is a measure of step frequency that is de~ fined
data time history curves (e.g., joint angular disp,la.c~~;':,,:>,"
as the nUI11ber of steps taken per unit time and is usually
ment or joint moment with respect to percent of the..
expressed in steps per minute. Velocity is defined as the
g~it:::; cycle) is sampled with replacement. This sampling
distance covered in the direction of locomotion per unit
is ,;',,:, '" known as a bootstrap iteration.
time and is usually expressed in meters per second.
Each curve in the population of interest is first ana-;: .
Iyzed using a Fourier series representation, and a mean
..'.,
curve for the entire population is constructed by averag~ iog
Angular Kinematics [he Fourier coefficients. Then. for each bootstrap iter-ation.
a sample of curves, equal in number to the popula-tion of
curves from which the sample is taken, is
This discussion will focus on joint angular displace-ments
randomly selected with replacement and a mUltiplier is
about the motion axes of the major lower limb and axial ,.
segments during level walking. Fig-ures 18-3 through 18-7 calculated for that iteration. b. using the following for-
mula:
show examples of angular displacements at these motion
segments over the course of the stride in a healthy adult
population (Calculation Box \8-1).
--30
- 10 - ' ----------- " o 20 40 60 80 100 - 20 - ' ------------- ' o 20 40 60 80 100
0 20 40 60 80 100
E
i'S 0.4 0.4 0.4
C
~ 0.2 0.2 0.2
E
:2
a
0 0 O. .:~
...,
c -0.2 -0.2 iV
'0 -0.2 '-'
Angular displacements and moments of the knee during level (>0) position; A (bottom), Flexor «0) and extensor (>0) mo-ment; 8
walking at freely chosen velocity among normal sub-jects (25 (top). Knee abduction «O) and adduction (>0) posi~ tion; B (bottom),
males. tI females; 15 to 35 years of age). Solid lines Knee adductor «0) and abductor (>0) mo-ment; C (top), Knee
indicate mean values (ordinate) over the course of a single stride external rotation «0) and internal rotation (>0) position; C (bottom),
(abscissa). Dashed lines indicate 90% bootstrap confi-dence Knee internal rotator «0) and external rotator (>0) moment.
intervals. A (top), Knee extension «0) and flexion
In the adduction-abduction plane of motion, the knee is Internal and external rotation about the knee during gait.
quite stable during stance phase because 01" the presence as in the case of adduction-abduction, is determined
of bony and ligamentous constraints primarily by bony and ligamentous
CHAPTER 18.
mechanisms and is variable across individuals. In addition, In the normal sample of predominantly males (25
the placement of reference markers dur-ing optoelectronic males/29 subjects) depicted in Figure 18-4C (top), the knee
gait anal~/sis may introduce spe-cific offsets into angular is maintained in an externally ro~ tated position throughollt
calculations. For example, in the data presented in Figure stance and fluctuates be-tween 10 and 20°. Rotational
18A, there was an external rotation offset as a result of motions about the knee are strongly coupled with flexion-
placement of the ankle markers on the medial and lateral extension motions. A comparison of Figure I8A, A-C (top)
malle-oli. Such technical differences may result in slight il-lustrates that during periods when the knee is flex-ing, it
discrepancies bet\vcen the absolute value of joint angular also internally rotates; whereas during peri-ods when the
position at the knee as reported by differ-ent laboratories, knee is extending, it also externally rotates. This coupling
although the relative displace-ment range and overall is related to the bony mor· phology of the femoral condyles
patterns of motion should be simihll: and tibial plateaus as well as the displacements induced in
this articu-lation by, especially, the anterior and posterior
cru-ciate Iigalllents.
20
15· ANKLE AND FOOT
0; 10
Talocrural Joint
:s'" 5,-\
'" a
0, At initial contact, the ankle joint is neutral or slightly
«c plantarllexecl 3 to 5' (Fig. 18-5, top). From initial contact
C -5
···1
to loading response, the ankle plan tarflexes (I.e., extends)
w
0
, 0 to a maximulll of 7° as the foot is lowered to the supporting
-15 surface. Through-out midstance, the ankle dorsiflexes (i.e.,
-20 flexes) to a maximum of t 5° as the lower leg rotates
a 20 40 60 80 100 anteriorly and medially over the supporting foot. During
ter-minal stance and pre-swing, the ankle plantarflexes to
0.5 approximately 15° as body weight is transferred onto the
0; contralateral limb. Immediately following toe off, the ankle
~ O· rapidly dorsi flexes to the neutral position to attain toe
;S clearance and then may plan-tarflex slightly during
-0.5
C terminal swing in preparation for initial contact.
E
0
'" ·-1 "\
::::
c '-::'\' --'
'0 '1.5
'-
, '-'
Subtalar Joint
-2
a 20 40 60 80 100 The subtalar joint rotates in, both stance and swing (Fig.
A Gait Cycle (%) 18-6, bottom), but it is the motion during stance that
influences the weight-bearing alignment of the entire lower
extremity. Like the ankle joint, the arc of n10tion at the
subtalar joint is small compared with the knee and the hip,
Angular displacements and moments of the ankle during level but it is the motion pre-sent at this joint that permits the
walking at freely chosen velocity among normal sub· jects (25
foot to adapt to a varietY.Qf surfaces. The subtalar joint
males, 4 females; 15 to 35 years of age). Solid lines indicate
functions as a mitered hinge during gait to transmit internal
mean values (ordinate) over the course of a single stride
(abscissa). Dashed lines indicate 90% boot-strap confidence
and external rotation from the tibia to rotations (ever-sion
intervals. Top, ankle dorsiflexion (flexion) «0) and plantarflexion and inversion) about the foot. The subtalar joint also
(extension) (>0) position; bottom, ankle plantarflexor (extensor) transmits inversion and eversion from the foot to external
«0) and dorsiflexor (flexor) (>0) moment. and internal rotation about the tibia.
.. .. ..
Midtarsal joint
Heel contact Toe off Heel contact
•
Midtarsal extension is another of the rnecha-nisms for
Foot immobile shock absorption as body weight is low-ered Onto the
stance limb during loading response and carly midstance.
Sublalar
rolation This motion, which accompa-nies forefoot contact at the
onset of midstance, oc-curs after subtalar eversion,
.._ -- o': - .
~_
Finally, the interaction between the subtalar joint and
o 20 40 60 80 100 the midtarsal joint is such that if mo-tion at the subtalar
Percent of Walking Cycle
joint is limited, then motion at the midtarsal joint will be
limited. Similarl)', when motion at the talonavicular joint is
pre-\'cntcd, aimosl no motion is permitted at the sub-talar
Ankle and subtalar rotations during normal walking in a joint.
single subject. Reprinted with permission from Wright, D.G.,
Desai, S.M., & Henderson, W.H. (1964). Action of the
sub[alar and ankle-joint complex during the stance phase of
walking. J Bone JOInt SlJrg. 46A(2), 36/-382
Joint Compensation: In- and
Out-Toeing
•
Forefoot and Interphalangeal Joints from the calcaneus to the metatarsal break imparts rigidity
to the entire foot and facilitates push-off.
AI initial contact, the LaCS are off the ground with the
A maximum of 58° of toe extension is reached during
metatarsophalangeal joints in 25° of extension. The toes
then Oex to neulral after for-croat contact at pre-swing. During swing. the toes Oex slightl~1 but rernain
c' in extcnsion. Finall~', there is a minimal increase in toe
the end of loading response. A ncutral position is extension in preparation for initial contacl. Little or no
maintained throughollt midstance. Olll-jog terminal stance, as flexion occurs at the metatarsophalangeal joint during
the heel rises, the metatarsophalangeal joints (collectively walking, although some Illay be presenl during athlctic
known as the metatarsal break) extend to approxirnately 21 0 activities.
while the tocs remain in contact with the ground and the hind
Littie or no motion occurs al the interphalangeal joints
fOOl lifts up into the air. This metatarsophalangeal
during gait wilh the exception that during pre-swing, slight
extension places tension on the plantar aponeurosis, which
rlexion is occasionally noted.
in turn exens a passive hind foot (calcaneal) inversion
force. Tightening of the plantar aponeurosis also re· suits in
supination of the foot and accentuation, or heightening, of
TRUNK AND PELVIS
the longitudinal arch of the fOOL
At initial contact, the pelvis is tilted anteriorly ap-
The subsequent stirrening of the intcrtarsal joints proximately 7° (Fig. 18-7A. bOLlom). rOlated for-
15 15 i 15
10 10 10
c; I
"
?
5 5 i
I
5·
" "
e;,
" 0 0~",1 .,.- "
c
« ?/""'~'~ 0
-5 -J '"..,' I --5
-10 -10
0 20 40 60 80 100 0 20 40 60 80 100 0 20 40 60 80 100
15 15 15
10 10 10
', ....
c; .....
? " 5 ...... 5 5
e;, ,- '-- ...'
" 0 0 0
c
«
-5 -5 -5
Angular rotation of the trunk and pelvis during level walking at Trunk downward « O) and upward (>O) tilt with respect to the
freely chosen velocity among normal subjects (25 males, 4 stance limb; B (bottom), Pelvis downward «0) and up-ward (>0)
females; 15 to 35 years of age). Solid lines indicate mean val- tilt with respect to the stance limb; C (top), Trunk backward « 0)
ues (ordinate) over the course of a single stride, (abscissa). and forward (>0) rotation with respect to the stance limb; C
Dashed lines indicate 90% bootstrap confidence intervals. A (bottom), Pelvis backwar.d «0) and for~ ward (>O) rotation with
(top), Trunk posterior «0) and anterior (>0) lean; A (bot-tom), respect to the stance limb.
Pelvis posterior «0) and anterior (>0) tilt; B (top),
\\~ard approximately 5° (Fig. 18~7C. bOllom), and is level trunk is rataled backward approximately 3° while the
from right to left. During the loading re· sponse, the pelvis pelvis is rotated forward approximately 5°. The anlpliludes
tills upward on the stance limb side to a maximum of 5°, of the angular displacemenls of the trunk segment as
then it regains ncutrallilt at the nexl initial conlact of the rencctcd in the movement of the shoulder girdle arc only
swinging limb (Fig. 18·78, bOllom). During stance phase, slightly ullcnuated in com-parison with the pelvic
the pelvis 1"0· tates backward on the stance limb side and movements, as can be easily appreciated by comparing the
tilts an· teriorly (hollom of Fig. 18-7 C & B, respectively). lOP (trunk) La bottom (pc)vis) plols in Figure 18-7.
The total excursion for anteroposterior tilt is ap-
proximately 5°; for lateral tilting, approximately 10°; and
for forward and backward rotation, ap· proximately 10°.
CENTER OF MASS
The body's center of mass remains located within the
Tnmk motion during gait is opposite in direction. or out pelvis anterior to the sacrum throughout the gait cy-cle. It
of phase, 10 the motions of Ihe pelvis (Fig. 18-7, A-C, undergoes sinusoidal displacements in all three planes with
lOp). For example, at initial conlaCl, the peak to peak excursions of approximately·
j ,,
,-,
" ~" '\
Joint , ,
", , ,',
Extension - 15 .- 15 ,. __..--." ,
,
Extensor 2.0 r·
,
i
Joint
,
.- I..
moment I ,',- .. : ........
3~
,,
Generation
! , ,
, ,, ,,
" ....
~
, I' I
L .. " 1\
'\
,~
, - -'
l''.."',-...... ---- " '
JOin! ~-- ~
Joint power profiles in watts/kg of body weight (bottom row) of ments in Nm/kg body weight. Joint motions are in degrees.
the hip (left column), knee (middle column), and an· kle (right Reprinredwilh permission from Gage. l.R. (1991). Gait Analysis in
column) for flexion-extension motions (top row) during level Cerebral Palsy (p. 31). LOlldon: Mac Keith Press.
walking. The middle row shows the joint mo·
CHAPTER 18 •
antagonist ac-tivation. At certain periods during normal , limb during loading response, where it remains through-out
gait and for longer periods during gait in nlany pathologi- terminal stance. This is observed as excessive lateral
cal conditions, agonist-antagonist coactivation may be displacement of the trunk toward the affected side, The
present. In such cases, reported values for net internal result of this gait deviation is to reduce the required hip
moments will underestimate the ac-tual muscular forces abductor moment by displacing the body'scenter of mass
occurring. However, this ter-n1inology is prevalent in the closer to the hip adduction-abduction rotation axis.
literature and useful for the calculation of other kinetic Both of these gait deviations effectively reduce com-
variables. Plots of the internal moments occurring about pressiori" across the coxofemoral joint by reducing contrac-
the hip, knee, and ankle joints during level walking in ! tion force of the hip abductors, thereby alleviating joint
healthy adults are depicted in Figures l8-3 through 18-5 I pain. The Trendelenburg pattern is a simple mechanical
and 18-8. I
._re_s_ultOf.hiP a_bd.. c.t_or weak_ness. The lateral_lurch is a. __
U.
e
By the end of loading response, the peak hip ex-lernal Nm/kg occurs. During terminal stance, a second low
rotator moment of appro.ximately 0.18 Nm/kg is achic\'cd amplitude extensor moment of 0.2 Nm/kg occurs (Case
(Fig, 18-3C, bOllom), The eXlernal rota-tor mOment Slud" 18-1),
gradually decreases until the middle of terminal stance. As \\'asthe case with adduction-abduction about the
Throughout the remainder of ter~ min'll stance and pre- knee, knee adduction-abduction moments arc controlled
swing, a slight hip internal ro-Lalor moment occurs, primarily through bone and soft tissue constraints.
Therefore, the terminology for these moments nt the knee
refers to passive restraints, not to n1uscular control.
Knee
At initial contact, there is a small knee flexor mo-ment An abductor moment persists about the knee throughout
(Fig, 18-4A, boltom), During early midstance, an extensor stance with lwo peaks of approxi-mately 0.4 Nm/kg during
moment peak of approximately 0.6 loading response and ter-
80
50
70
'" 60
"
~
:;;
..
5040 :s 30j
-Affected
C
c
'"
0>
E
0
'" 20
C :;;
'0 30 c
~ ·0 1O~
'"
,"" -,
'" 20 .... ~
'" 10
C
-- '"c
'"
0
0,
'"-10
0 20 40 60 80 100 -20j , ,
Gait Cycle ('%) 0 10 20 30 40 50 60
Gait Cycle (%)
Case Study Figure 18·1-1. Effect of anterior cruciate ligament injury on knee motion and moments about the flexion-extension axis.
Data were obtained during three trials of walking at freely chosen velocity and averaged. The figure (left) shows the difference
between the ACl-deficient knee (affected) and unaffected knee flexion angles. The figure (right) shows the corresponding knee
moments with values greater than zero representing knee extensor moments and values less than zero representing knee flexor
moments.
CHAPTER 18 .810M
min'll stance (Fig. 18-4B, bottom). During mid~ stance, the Knee
knee abductor moment decreases to approximately 0.2
During loading response, power absorption by the
Nm/kg. In individuals who achieve abduction (valgus)
eccentrically contracting quadriceps controls knee flexion
positions of the knee, the moment profile may' be shifted
(Fig. 18-8. bolloll1-llliddle). During early midstance,
toward adduc-tor moments, and midstance adductor
power generation b:v the con-centrically contracting
moments mayoccur.
quadriceps extends the knee while the contralateral limb is
engaged in swing. During pre-swing, power absorption by
A knee internal rotator moment peak of 0.18 Nm/kg
the eccentrically' contracting quadriceps controls knee
occurs at the transition between loading re-sponse and
flexion \\'hile the stance limb unloads in preparation for
midstance. The knee rotation moment then reverses
swing and the transfer of body weight onto the
direction during the latter portion of midstance, reaching an
contralateral limb. During termi-nal swing, power
external rotator moment peak of approximately' 0.15
absorption by the eccentrically contracting hamstrings
Nm/kg during terminal stance.
controls the forward ac-celeration of the swinging thigh,
leg, and foot segments.
Ankle
Immediately after initial contact, there is a slight
dorsiflexor (Le., flcxor) moment of approximately 0.2 Ankle
Nm/kg about the ankle that rapidly rcverses to a
During midstance, power absorption by the ec-centrically
plantarflexor (i.e., extensor) moment for the re-maindcr of
contracting plantarflexors controls the tibia as it rotates
stance (Fig. 18-5, bottom). The plan-tarflexor moment
over the stationary foot (Fig. 18-8, bottom right). During
peak is approximately 1.6 Nm/kg at 45°;0 of the stride, or
pre-swing, a high-magnitude power generation peak of 2 to
the latter portion or termi-nal stance.
3 \vatts/kg by' the concentrically contracting plan-tarflexors
represents approximately' two thirds of the total energy
generated during walking and is believed to contribute
JOINT POWER significantly to propulsion in gait.
Joint power is defined as the product of joint an-gular
velocity and the corresponding internal mo-ment at a given
point in time and is expressed in watts/kg of body weight.
It (luctuates continuously throughout the gait cyTle and can WORK AND ENERGY TRANSFER
be either nega-tive or positive in value. Joint po\ver
v\fork is defined as the integral of power with re-spect to
indicates the generation or absorption of mechanical
time and is expressed in Joules/kg of body weight. \Vork is
energy by muscle groups and other soft tissues. Profiles for
an estimate of the flow of mechanical energy from one
joint power about the Flexion-extension axes dur-ing level
bod)' segment to an-other and is used to determine overall
walking in healthy adults are depicted in Figure 18-8.
mechani-cal energy efficiency during gait. \Vhen work is
positive in value, the internal moment and joint angular
velocity are actirlg in the same direction, a concentric
muscle contraction is indicated, and mechanical energy' is
being generated. ,",Vhen work is negative in valuc, the
Hip internal moment and joint angular velocity are acting in
From initial contact through early' midstance, the opposite directions, an eccentric contraction is indicated,
concentrically contracting hip extensors generate power to and mechanical energy is being absorbed. Dur-ing p'eriods
a peak of approximately I watt/kg (Fig. 18-8, bottom left). of energy generation, the muscle is working on the limbs to
From midstance to terminal stance, po\ver absorption by' produce movement. During periods of energy absorption,
the eccentrically con-tracting hip flexors controls the the limbs are working on the muscles, which must then
backward accelera-tion of the thigh segment until contract to resist the tendency for muscle elon-gation.
approximately 50% of the stride. From pre-swing to mid-
swing, p()\ver generation by' the concentrically contracting
hip Oexors acts to pull off the swinging limb.
Muscular Control contact to the middle of loading response that ta-pers off
by the end loading response. The upper fibers of the
J\tluscle activation patterns are also cyclic during gait gluteus maximus and the gluteus mcdius (and probably
(Figs, 18-9 through 18-11), Muscle contraction type the gluteus minimus) in-crease activation intensity
varies between the eccentric control of joint an~ gular through loading re-sponse and taper olT by the end of
accelerations, such as in hamstrings activa~ tion during rnidstancc. The postcrior fibers of the tensor fascia lata arc
terminal swing, and the concentric ini-tiation of mocl~ crately activated at the onset of loading response
movement, such as in tibialis anterior activation in while the anterior fibers become activated later and persist
prc~swing. In normal individuals, ago-nist-antagonist
into terminal stance.
coactivation is of relatively short duration and occurs
during periods of kinematic transition (e.g., terminal During pre-swing and initial to mid-swing, the hip
s\ving to initial contact). The presence of prolonged or Ilcxors act to advance the limb. particularly when
out-or-phase agonist-antagonist coactivation during gait walking velocity is changing. The adductor longus is
in individuals with pathology may indicate skeletal activated earliest in terminal stance and persists the
instability as well as motor control deficiencies. longest to earl~' mid-swing. The rectus femoris is the
second hip Oexor activatcd during pre-swing and
remains activated a short time into early initial swing.
Thc iliaclls, sartorius, and gra-cilis have short periods of
HIP
activation predominantly during initial swing.
During early stance phase, the hip extensors act
concentrically while the hip abductors stabilize the The hip adducLOrs are activated during transi-tions
lateral aspect of lhe coxofemoral joint (Fig. 18-9). The between stance and swing, as are the ham-string muscle
lower fibers or the gluteus maximus show increasing group. This activation pattern can be interpreted as the
activation intensity from initial dynamic control of the swinging
'2,,'&
Gluteus maximus (upper)
.~
Semimembranosus
-,
;;C~ Semitendinosus
>' Adductor magnus
::@ Gluleus medius
%# :£a.-:= Tenser fascia lala
:'B Adductor longus
Rectus femoris
Gracilis
Sartorius
Iliacus
Stride evenlS IC TO IC
Slride inlelVals LR MSI TSI PSw ISw MSw TSw
Phasic pattern of electromyographic (EMG) activity of the tact; TO, toe off; LR, loading response; MSt. midstance; TSt,
muscles of the hip during level walking in healthy adults. Gray terminal stance; PSw, pre-swing; JSw, initial swing; MSw, mid-
regions represent activation below 20% of maximum voluntary swing; and TSw; terminal swing. Adapted with permission from
contraction. Black regions represent activation above 20% of Perry, 1. (1992). Gait Analysis: Normal and Pathological Function.
maximum voluntary contraction. /C, initial con- Thorofare. NJ: SLACK Incorporated.
~"~fu~.!~'I'~"-I--ll-r-l--r~~[§';,~,:;''-~~ Vaslus intermedius
~ ~- Vastus lateratis
~ Vaslus medialis longus
~.wEl.~ VaSlu$ medialis oblique
~ Reclus femoris
[f::'J~g]~':§"- Biceps femoris (long head)
t-,
b~. -~~ Biceps femoris (short head)
~:"i:i Semimembranosus
,,-2 Semitendinosus
c2(,~~;:~i!t&;~t:.: Popliteus
Gaslrocnemius
Gracilis
Sartorius
Stride events Ie TO Ie
Stride intervals LR MSt TSt PSw ISwMSw TSw
Phasic pattern of eleetromyographic (EMG) activity of the tact; TO, toe oft; LR, loading response; M5t, midstance; T5t,
muscles of the knee during level walking in healthy adults. terminal stance; P5w, pre-swing; 15w. initial swing; MSw, mid·
Gray regions represent activation below 20% of maximum swing; and TSv.I, terminal swing. Adapted with permission from
voluntary contraction. Black regions represent activation Perry, J. (992). Gail Analysis: Normal and PJ!hologlCill FunCtion.
above 20% of maximum voluntary contraction. fe, initial (00- Thorofare. NJ: SLACK.
limb that is tending to flex and abduct at the hip. The Most of the harnstrings muscles are activated in late
function of the muscles during such periods is to control mid-swing or terminal swing. Their function at the knee
the acceleration of the rotating joints to ensure the is probably to control the angular acceleration into knee
precise placcrnent of the fOOL on the sup· port surface in extension. This is consistent with their pre-sUllled
anticipation of the upcoming stance phase. This explains action at the hip, or the control of hip flexion in
lhe hamstrings and adductor magnus activity during preparation for the upcoming stance phase. The short
terminal swing. head of the biceps femoris is activated earlier than are
the other hamstrings muscles in early mid-swing and
probably assists in flexing the knee for foot c1ean:mcc.
KNEE
The gracilis and sarlorius muscles also may con-
During stance phase, the quadriceps muscle group tribute to swing phase knee flexion when they are ac-
(vasti) is relied on to control the tendency for knee tivated during late pre-swing, initial swing, and early
nexion collapse with weight acceptance and single limb mid-swing. Ho\Vevel~ these muscles may very well be
support (Fig. 18-10). This muscle group is acti-vated acting as primary hip ncxors during this period.
during terminal swing and then acts eccentri-cally
during \veight acceptance as the knee rotates from the ANKLE AND FOOT
fully extended position at initial contact to its peak Talocrural Joint
support phase flexion of approximately 20° during
loading response. Thereafter. the quadriceps act From EMG sludies on the muscles that cross the an-kle,
concentrically to extend the knee through early the dorsiflexor muscles are shown to be firing
midstance as the bod)/s center of mass is raised ver- concentrically during swing to allow for foot clear-ance
tically over the supporting 11mb and the anterior ori- and eccentrically during loading response to control the
entation of the ground reaction force vector pre-cludes placement of the foot by ankle plan-tarflexion (Fig. 18-1
the need for furlher Illuscular control of knee flexion. 1). The plantarflexors are con-sistently firing
eccentrically during stance to conrrol
·1~~.:}ART III • APPLIED BIOMECHANICS
~=:~~--~~i~--ll---II;:====:'~~_·~!=:-~c:.== ~~~~:O:n~:~li~~iSlongus
SUide events Ie TO Ie
Stride intervals LA MSI TSt PS...J ISw MSw TSw
Phasic pattern of electromyographic (EMG) activity of the mus- relative intensity as a percent of maximum voluntary contrac-tion is
cles of the ankle and foot during level walking in healthy adults. not shown. Ie, initial contact; TO, toe off; LR. loading re-sponse;
Gray regions represent activation below 20% of maximum vol- MSt, midstance; TSr, terminal stance; PSw, pre-swing;
untary contraction. Black regions represent activation above 20% of ISw, initial swing; MSw, mid·swing; and TSw, terminal swing.
maximum voluntary contraction. Whire bars for the in- Adapted wirh permission from Perry. 1. (1992). Gait Analysis: Normal
trinsic muscles of the foot indicate phasic data only for which and Pathological Function. Thorofare. Nt SLACK !ncorporared.
:
(I> ----------------------------------
459
B bi0l11cch;lllk;11 propcnil:s or. 31-36 C~lllalicuJi. 27-28
Ba~k belts. biolllcchankal l.:ff..:clin,'ucss of. anisOl.-opic.3-4, 36 C:.nct::llolls hOlll..·. 29
281 cotlljxlrcd to olher maled:tls ..13-34, rtlcchanienl properties of. 33, 292-293
Back muscles, in spin:l! rlIo~'clllcnL 266 35f stress-s!l"ain cun'c (If, 34
Back rcsl suppOrt diffcrcnc(,.·s 1.Jl.:twten bont:: typ('s, 33- Cnpsular ligaments, spinal. 260
and loading of lumbar spine. 269, 271 34 biphask propc::nit::s of, 27-29. 31 Cardiac 11ll1Sdc, 149
Backrest support, 428 composition and stJ'UClurl..' of. 27-31, C:u"I':d bones. 359
B~lsc Siunits. 19 55 C<ll'pal tunnel. 359
definitions. lOt lllacrosl.:opic.29 ClI'pal tunnel syndrome. fllcdian nerve in.
Bcd(s) microscopic. 29-30 36~
fcatures of good. 433-H4 damage of Caq)ol11l:tacarpal (Ci'vIC) jOilllS. 359. 379
lying in, biorncclwnics of. 433--434 extrinsic factol's, 56 of fing<:rs, 378-380
sitting in. biomechanics of. 434-B5 intrinsic bctors, 57 of thumb. 380
Biceps brachii. 350 fatigue or. in r("'pctitivc loading. ~5-47 C'II'PUS, 359
(<.:I11.:nl linc::, 28
activit\' of. 352 geometry of, 47-51
Biceps lllllScI.... he<llin!? of Celltl:r or pressure (COP), 421-422
in elbow kinetics, 350 inrn~c(Ul'(,fixation, 391-392 Cervical anhrodesis
in sholllder kinetics. 322-324, hypertrophy of, undt::r platt:, 52, 53 alllcrior approach in, 308 gmft
330, 350 pCI·iproslht.:lk loss of. 406-407 malerials in, 30S-309
Biulvcan 65 n.:modcling of. ~\lld biomechanic:ll indications for, 308 poslc!"ior,
Bi~l;lcch·allic~. -' behavi<ll~ 51-53 slri.:nglh 309-311
ddonn~Hion modes in. 7 c1:1stil".- and stiffness of. 31-36 studies of, 309-31 I
ddonnation in, 10-11 cndurnncc nging t:fft.:cIs 011. 53-54 Cen:ic<lllamilll:ClOm\'. 305-306. 30i
in.m:ll..: ..ial. 14-15 bone Icn2th innucncc 011. 48 (:aHus Ccrvk~ll plming systems. 310
('quilibrilllllconditions in. 6 form~llion and incrc;:asl,.' in, CL'r"ic;t! spine allalonw
fatigue' in. material. 14-15 force 48-49 of. 2~7-292
Vectors in, 3-t frcc-body cross sectional an'a influence on. 47- ;IIHcllcx'ion of. in silling position,
di.tgrams in, 5-6. 6 48 430-431
ll1<l1crial propcnies based on sln:"$S- fatigue.: in, in ;tpplied biomechanics or. 305-311
slrain di:lgrams in. 13 l"e.:pctili\·I..·loading. 45-·.:7 :lnhrodesis or. 306-311. 30S
mOllH:llt vectors in, 4-5 n.:modding ;\lld. 51-53 biomcchanical mOdt:lilH! of. 287
of rnusl.:llioskeleta! svstem, 15 surgical prex.'(.'(!ures thaI wcakL'n, 49-51 dl.'compression of. 305-306. 307
applied biollicchallics, 15 stlllcture ~Illd composition of. 27-31.55 fi,\,ltiol1 of. 308-311
joints. 15 macroscopic. 29 function of. 287 fllBclionallillil
tissut's and Slll.lctltfCS. 15 microscopic, 29-30 or. 296. 297 injury of. 311-314
Newton's bws in. 5 \'ascukll' ~)'SICIll of. 30. 31
nomlnl SU"~tin in. S-9. /0 norl11~ll Bone densilv. 33 instabilitv or. 301-305
stress in. 7-8. 8 plastic and <lging·. 53-54 instan! C~IllCl"or Illotion or. 293
ddolTIlation in, 10-11 principal [lolle mass illll.'r",:nL·br'll discs of, 288. 291-292
stn:ss in. 13-1~ scalars in. 3 'I"C "cnd!"'r '\l1d 53 i.J medl;tllical projK'nies of, 293
;t~(i~'dght.'51-52 .- kin(,Ol;tlics of. 296.297
shear· strain in. 8-9. /0 Bone milll:r;ll, 27 abnormal. 300-30 I coupled
she.lr stress in, 7-8, 9 BOlle rCllloddin2. 51. 52 motion in, 299-301 l';lIl~C of
s!<ltics in, 6-7 body weight :tl~d bone m:ISS in, 51. 51-52 motion, 297-298
strains in, normal and sheal~ 8-9. 10 C;lse stud\' of. 52 slllLce joilll llIolion, 298, 299
stresS'Slrain diagrams ill, 9-10,10 stresses implanls ·<lnd. 52-53 ligaments of. 288
in Boosted lubrication, 85. 86 mechanical properties of, 293
normnl and shear. 7-8 Bootstrap ilt.:ratioll, 4~3 motion of. 287, 288, 290
pdlldpal, 13-14 BoundalY lubl'ic;ltion. 81 ~\hnonnal. 300-301
tensors in. 3 of aniculal' c~\nib2c. 83-8.... $6 p;tradoxlc;tl. 300-301
IOrqlle \,('ctors in. 4-5 BI71chialis Illuscle. 350. 37... l1lotion scgmelH or. 288. 290-291
\'I..·clors ill, 3 ncti\'itv of. 352 llluscular medwnics of, 293-29-4
dscoebsticity in. 11-13 BI"::K:hio;'adialis llluscle, 350 l'lcur:1i lllc::chanics of. 294-296
Bone, 17.~7-48 activil)' of. 352 neurologic,injury in. 294-296
aging and changes in. 53-5~ Brooks type. cc,,'kal arthroc!L-:,is. 309-310 OSSl.:OllS SIlU(:tur~s of. 28H-291
anisolwpic propenks of. 3-1. 36 Bunched lisi. 38.. stabilit\' of. 301-305
biomcdwnicaJ beh:l\'ior of. 37 BUllions. 233 tl"::IUI1l~ 10. 311-314
bending !onds and, 40-~2 combined shoe wear and de\'Clopmcnt of. 251-252 \'i,'nebntc of, 288-291
loads nnd, 42-43 compressive loads mechanical propl.'rtics of. 292-293
and, 37-38, 39 gcomt:tJ')' of bonc and, llflcO\'L'l'lebnd joints of, 291
47-51 llHISclc ,Jctidtv and stress C C!londrocvles, in articular cani1a!!.l.l, 61,62
CJ-C7 vcrtebrnc. 297-298 degenel:al i\'i,~ clwnges and. 91':92
distl"ibulioll in. 43-~4 Cadence. 443 Chondroitin SlIlf<ll(:
n:pctili\"(:')onding and, .. 5....-17 Cnlcancocuboid joint. 229. 230 in aniculat' cal'lilagc. 65-69
sh"'~lI' londing ~lIld. 33-W Clkancofibular Jigaml.:lll. 245-2-16 in cerdcal nuclclls plilposus, 292-
sll71in mtc dependency of. ~4--45. -16 flillciioll or. 2-J9¥ Chopan's joilll motion, 230 Clavicle,
stn.:ss di,Sll·ibution in. and muscle injlll)' to, 245-249 322
"clivity.43-l4 Calf muscles. ~55 CI<lw loes, 237
tensik·lo<ldini!. and. 37. 38 Callus formation. <lnd incrense in bone Click-clack phenOIIl(·non. IUlllbopdvic. 428
lorsionallo;uiing and. 42 stl"l,,'ngth ...8-49 Co:tJ-hanllnl..'r grip. 3S-I
ColI~gcn Diarthrodinl joints, 61 Epincul"ium, 129, 130
anisotropic properties of. 288 of uoicondvl.w, 378 Epilcllon, lOS Equilibl"illHl
nrticulul'cnnilage. 61. 62 Digital Oc.\OI'tendon sheath pulk,.\· condition.s, 6 Erl1S palsy.
distribution of, 62, 64 systcm, 368-369. 370 135
mechanical properties of. 62-65, 288 Dil~ital rays. 362 Ercttor spinae lllllsck·s. 265-266
rnOlcCllkll" composition of, 61-62, 63 ~ollatel:al liganwnts of. 369, 371 in arched batk in prone position.
stl1.lctLlral alignment. in loaded and extc:nsor and flexor systems of. 375 276,277
unlo:ldcd tissue. 75-77.78 c.,tcnsor systellls of. "371-374 f()f"cCS of. in standing, 268-269
Sll1.lCIUrnl organization of. 61-63. 6..1- flexor tendons heath pulley systelll of. strengthcning c.,crdses fOl~ 276-277
65.67-69 368-369.370 EX"'rcisin"
type II. 62-63 joints of, 378-380, 379 ··Ioads o~ ankle joint in. 2-19-251
nnd prolCoglycan m:urix of :Irticubr muscles of. extrinsic and imrinsic, londs on fOOl in, 240-241, 2-12 loads
c:lrlilagc, 67-69 375.3751 on lumbar spine in, 276-277
response 10 weal- of. $8-90 mllscular mechanisms of. 375 Extcnsor digilOnlln longus. ..l55 Extensor
in tendon ~machmcnlof muscle lO bone, llumbcl"ing of. 359 mechanism injury. kllcc.199 Extensor
149 l-::lIl!!C of n~otion of, 378-380 s\,sh.:m
of tendons nnd Iigamcnu'i Dist~\I-in(Crpll:llangcnl(DIP) join\S, 362 of digitai rays, 371-374, 375 of
mcwbolic turnover of. 105 range of motion of. 378-379 tendinous toes, 455
molecular composition of, 103-104. mechanisms of, 371-374 of wrist. 350. 374
105 Donnan equilibrillll1 ion distribution law, Extraccllular matrix (ECi\l),
structural alignment of. in loaded and 68 of aniClll,u" c<lnilage. 61
unloaded tisslie. 109 Donnan osmotic pn:.'SSUI·C cqu'Hion. 81 in dc~t'ncl'::\li\'(,.' conditions, 90-92
Slll.lctlll~1 organizalion of. 104--105. 106 Donnan osmotic prcssufc Llleol)". 67, 68 Illole~u!araggregates and properties of.
type I. 103-10~ DOI'Sa! intcrcarp;:ll ligament. 368 67-69
type II, in cen'ical nucleus pulposus. 292 Dorsal root g"lIlglion. 128, 131 of tendons :\nd ligaments, 103, 10-1
types of. 62-63 Dorsal scnson' roots. 128. 131
visc:odastic properties of. 288 Dorsiflexion. 2-t-l, 453-454
Collagen fibers, 104. 105 Colla!!cn D\"namic she.lf modulus. 78-79 F
fibrils, 10-1-105 Compact bone, 29 D;"namic tripod, 383 Dynamics, F'lcct capsular lig;:l11u::nts. 288
185 F:lccteclOmy, pani:\J, 306
Component inst,-\bility, 301-302 Computer F~ICl.:tS
workst<ltion, biomechanics of of ccrvical intcl'ycrlcbl"al joints, 290-291 of
sitting at, 427 E intervcrtd>n:tl joints. 259-260, 261
Concentric muscle contraction, 159 Eccentric muscle contr:\ction, 159 F"lscicles
Conversions. 51 units, 221,23 Elastic deformation. 10-11 of muscle libcrs,I..l9-150
Coracohumeral lig'lments. 321,325-327 Elastic material bdlavior, I I of periphcral nerves, 129, 130
Conic..d bone. 29 Elasticitv. 33 F..lIiguc fractllr\.'s, 45--47 F'-ltigue
mcchanical properties of, 33, 35. EI'-lstin, of tendons and ligamellls.l 05 WCal", 88
292-293 Elbow joint. 3-t 1 of articular cartilage, 88-90
stress-strain curvc for, 33. 3-1 nnatom.,.· of. 3-11-342 of bone, in rcpt.'titi~'cloading, -t5-47
yidd points in, 34-36 articula"tions of. 3-11-3-12 evclic
Crecp and recovcry tCSt, 12 forccs gencratcd in. 352 . of hip jlmsthcscs. ..t02-W3 of
Crcep response forces on articular surface of. 353 knee pmsthcscs. 407-10S
biphasic. in articubr l..'artilage, 71-72 in fracture disloc'-ltion of. 3..l9 nwtcri.. I, 1-1,14-15
tendons and ligamt.:nts, Ill. 112 injury of. 347-350 lateral of prostheses, 392. 393. 402--103,
Cross-bridges. of myosin filaments, epil.:ondylitis, 352 407-408
153-155 kinematics of Femoral head, 203, 204
Cnlciate IigHmcnts, 195 carrvin" nn"le 345 346 cent'er;r Fcmoml intcnrocharlteric fracture, 206
Cvelic faliuLle r07:ttion. 343, 34-1 remoral neck, 204
.of hip p~osthcscs.402-403 f1exion·cxtcnsion, 3-12-3-t3 aging and ch"lIlgcs in. 205-207 in
of knee prosl heses, -107--108 pmnation/supination. 343-345 hip anhropbsty. -104-106 neck-to-
stability.3-t5-350 shaft ..Hlgle of. 20-1-205
valgus position, 345 kinctics Fencing grip, 38..l
D of. 350-355 muscular :malon1\' FG (f'lst twitch glycolytiC) fibers, 165-167
de Quc!"\'ain's Icnosyno\'itis. 374- of. 350 muscular mech;:ulics Fibroblasls, '103.10-1
Dccodn,65 of. 350 Fibulolalm' joint. 223. 225
Decubitus. 434-435 clcctromyogm,phic an'-llysis or. 350 Fick's principle. 236 Fingers.
Ddormmioll. 7 reaction for<:c calculations for, 353-355 359, 362
ofbone,31-36 stability of. 345, 347-350 in prehensile hand function, 3~2-3S5 range
clnstic and plastic, 10-11 Ekctrogoniol11etry, 440 Ekctromyogrnphic of motion of. 378-380
Deltoid ligaments, of ankle, 245-246 (Ei'v1G) .analysis. 440 Elel.:tromyography. Fixation plate ['nihl!"c, 393
function of. 249 156 Flexion-relaxation phenomenon, 265-266
injury lO, 249 End plalc, 258 Endomysium. Flexor digilOl1.lll1 lon!!us, -l55, 456
Deltoid muscle. 329-330 149-150.150 Endoneudum. 129. Flexor hallucis I()ngu~. 455. 456
Dens, 288,290 130 Endosteum, 28. 30 Fh:xOl" s\"stcm
Derivcd 51 units, 19 Endotenon. 104. 108 of digital r:lyS, 368-369, 370. 375 of
with spccial names, ddinitions. 201 Endurance,material,I-I-15 tocsJfordoot. 237-::238, 453-456 of
Devic(,.· f:-tti£!.uc, 392, 393 Enlrapmenl, nerve. 132. 133 wlist. 350. 359. 374
Diabetes nldlitlls. h,'ndons .md lig3mel\ls in, Epimysium. 149-150,150 Flexor tendon sheath pulley syst,,·m.
116-117 368-369.370
"""""""""""'=-""""""~".,.-"---.-.."...",..=-"""",,,,,;==;r.-~~~~~~~~
Fluid·(ilm lubril'illion. 82 Kil'sdllll.'r wire. 394 Gk'rlOhuflll,:rnl joinl, 3/9
of :lrticular c~ll·tibge. 82-83 ori';':IHcd polYrlll.'r. 393 -394 capsule of. 325. 326
FOCi (fasl twitch oxidali\"l.' glycolYlic) plate. 395-396 gk.·llOid bbnllll of. 323-324
Jibers. 165-167 scn.'\\·, 394-396 Inslabilil\' of. 327
Fool spin.1I impbnt. 3'17 kincmilli~.s of. 322-327
'In~llomy of. 223. 22-1 slapk 39-1 lig~lInenl CUlling sludies of. 327
in biomechanics of st:lndin!.!. 422---+24 wir..:-. 393 ligi\lllt:nls of. 325-317
extrinsic nluscks of. 233-2.34. 237-238 \\"in: lensiolli!l!!;twisli!H!.. 393-394 IO~Hls on, 335-336
fn.'c·body di;lgi41111 or. 250 fn:e bod.\' di;lgn~ll(s), 5-6. 6 I't::lclion force on. 337
gait cycle ground reaclive fon.:cs on. Frec-bod~' diagl,llllS Glenoid,323
240-24 I ill sialics, 18~-190 Glc.:noid bbnllH, 323-324
g.lil cycle kin(~n}[ltics or, 226-229, Free-body tcchniqul.:, for coplan.lr forces, injuries involving, 32~
445-447 18~-·190 Cil~'cosaminoglycans(GAGs), 27
g~\it cycle leg rot:nion ,Ind. 226. 228 simplified. 211-213 in artkulnr C:irtilnge, 65-67
gnil cycle mus(,:lc nelioH of. 22X-229, chondl"Oitin sulfal~. 65-69
236. 237. ~53-156 ker~lin sulfale. 65-69
!.!.r<l\\'!h of. 223, 225 G Gracilis. in 2:tit cvde. 453
Joints of. 223. 22-J Gail. ~39 Grafts - .
killcll1:llics of. 223. 225 an~IIOJllicnl Illolion in. 439 in cer\'ic:11 nnhrO(ksis. 308-309
anklL' :and suhtaku: 226. 228. 230 ~1l!~lIl~lr kincmalic:s of. 443-149 tcndons ~Ind lig;:lInl;.·nls in, 117-118
gait cycle and, 226-229 c\'~I(" of. 4"0-457
hallux. 231-234 ,fc\'i:ltions of. -149
lesser lOe, 233-234 join! killL'lllatics of, 443-449 H
111I.'lat'-\l"sal bn.::lk, 228. 229 joint moments in. 449 H zonc. 151. 152
prorwlion/supination. 223, 226 joint POWt:I' in. -151 1·1.llil'<:lx C!:llllpS, ccn'iC~11 ;:lnhrodcsis.
subml;u: 229-230. 23/ IHuscubr co1l11'o1 or, 452-156 309-310. 3//
!:\rsomctat.lr:-al and inlen;ll·sal. segml.:ntal kinclks of. 449-431 H:lllux
230-231, 232 w~rk and Clll'!'!!V tr~\nsfi.:rin. 451 joint 1I10tion of. 231-134. 233
trnnS\'i.·I"SL' l;lrS:ll, 229-231 G~dt ~Ul:d\'sis. mc~t'h()ds of. 439-4-10 'tendon posit ions in. 238
kin~lics of, 238-2-11 Gail c\·d~. 4-10~4I I-I;lilux dgidu:-,. ~32
g,til cyde and ground n::aeti\'c fore..::-. <lnkle killenwlics ill. 226-22~. 218. lbllux \';\Igus. 23 L 233
in. 2..10-24 I 445-447 shoew~.':lr and dcvclormL'nt of. 251-252
running ane!, 240-241 ankle kinctics in, 249-251. 45! in spntin injury. 2-J7
slJOcwc-ar and, 240 ankk: muscle ;Iclion in, 228-229. 236, Hammer tocs. 237
sol'ltissut:s lind, 241-242, 2..J3 237. 453-456 sho(,'wc:\!' ;\Ild development of. 251-252
medial longitudinal arch of. 235-236 bootstrap iwrmions of. .;)43 H;llllsirings, function in knec joint.
muscle aClion of. 236-238, 236/ c("utcr of mass in. hod\'. 4-18-149 196.453
g~it cycle and, ~53~56 cydil' btiguc of hip p,:osth..:-ses in. l·blle!.359
rnusdl..· injury :lna disorders or. 136-~3:$ 402-403 arches of. 362
shoewcar <lnd m....ch:mics or. 2..m. e~'c1ic bligu(' of kncc proslh~sl.'s in. articulations of. 359. 362
2S 1-252 ..107-408 blood supply of. 365
soft tissues of, 241-242.1';3 dorsilkxioll in, 453-454 capillal;" prcssurc within. 365
FoOl prcssure :Ill;,lysis, 4-10 fOOl kinematics in. 226-228, 4-15-447 control mcchanisms of. 365
Fon.:c: plalc an:dysis, 440 foot Illuscle action in. 228-229, 232, aCli\'e, 375
Force ,·cctOl'S. 3-4 236. 237. 453--456 ll1uscllhu: 375
For....ann. pron'llion and SUpill:ltioll. ground l'1.':tclin: forcl;.'s in. 240-241 passive. 368-37-\
376-377 hip kinemalics in. 4-'3 immobile unit of. 378
Forefoot aging alld, 206-207. 208 joints of. 36/.378,379
g.\it cycle kinematics of, 446~47 gcndL'r differcnces and. 215 H!!amenlS of. 371-374
g;til cyclc muscle :activity of. 456 hip kinclics in. 449-150. -1-19-151 -dieil~11 colbll'l"l!. 369..HI
Fnlcturl."{s) dt:g('neraliw p:lthology and. 449 digilal flexor lendon shl.":llh pulle."
hone healing in. 391-392 hip musd£: action in. 45~-453 SV$h:m of. 368-369. 370
brittlc, 35. 36 kn..:-I.~ kinemalics in, 179-180, 444-445 \'obl"phUL',371
,hlclite, 35,36 knl.'l: kindies in, 185-194,450-451 lI1uscies of. 363l
fmiguc,45-47 knee muscle action in, 453 t:.\lrinsic, 350. 362, 365, 375
Iwnlin!!. uhnlsolHld Irc;HI11\.'nl for. 392 leg rOl;ltion in. 226. 228 intrinsic. 350. 362, 365. 37/,375
yield ,;oint of hOlle. 35, 36 lo\\"er k'l! muscle action in. 232 nerVeS of. 362. 36-1-365
f"acturc fixation, 391 mllscllli~'acti\'~ltion in. 452-456 OSSt.'lIS sll1t<:lttrC of. 361. 362
boll\.' hcaling in, 391-392 p~:l\'ic kinc.:matics in, 4~7-148 prdlcnsik function patt(''I"llS, 382-3S5
hone 1110\'CIll\.'n! in. 39\ st~lllCt: phasl.~ of. 227 r.1ngc of Illotion of digital rays.
deviccs and Illl..'lhods of. 393-397 s\\'ing phase of. 227 378-3 $0
ev:t1uation of. 393 tillle·disl;lIlce \·ari.1bles of, 4-12-443 repelil!\'(: Ill(ltion injlll;" or. 37-1
goals of, 391-397 tnlnk kincmatlcs in. 447--I-iS s..:-nsOl)· specialization of palmar, 364-365
sllr!.!.ical factors in. 392-393 w:dking ~tnd mnning skirt of. 362
tl"<\<iitional methods of. 391 comparison of. 226, 227 tendons of, 371-374
Fr.H:lllfC fixation c!C\'iccs!mclhods, 393 forccs on ankli: in, 251 \\Tisl mOl ion nnd motion of. 381
cxtrmncdullm;:. 396-397 kne~: flexion in. 179-180 Ha\'cI-sian canal. 27
btiguc of. 392. 393 Gallic (~'p\.;'. ccrvicill anllrodcsis. 309-310 Havasi'lIl S\'SICIll, 27-28
hip, 396-397 Gastroclll'rnillS mU5ck 454~55 Hl."acl,·cst :l;lde, -129-130
intcnncdulhll;:, 396-397 Gill,gl~'moidjoilll, 34\ Heel pml, 2-1 i -242
Hdf~1 tl~st. 184.186 11lIerfacbl we;lr. 88 f(.nt..'l,.' :mhroplast.\·
i-kmodialysis, tendons and ligamems in. Interosseous ligamL'nt. of ankh,'. 245-246 :ITlh.'rior cnl<.·iatc ligan1L'll1 in, 415--4.)
117 Intcl'osseous membl-:mc:.', of dbo\\'. 6 conformity of femoral and tibial
Hinged joint. 3~ I 348-350 components in ...H4
bicondylar. 373 Hip injury of. <"Ind r;lelia] migr;uion. 352 conslr~lillt<k'sign in. 415
ill,th,:oplasty Interosst..'olls mllsd~s. 237 Intcrphal::mgeal forcl.·s acting on, 401--402. 407-408. -109
bone n:moddin~around. 52-53 celllented (lP) joints hinged proStheses in, ... 15
tOI~1 hip rcph\CCmcnl . .:lOS of fim::ers, 362. 365-366, 378-379 of joinl lint.: dc'·;ltion in. 412
forces ;:lctin~ on, 401-402 thl~mb. 380 ·1l1edial.laleralload disll'jbulioll in.
!!.ail and sttl~lics of forces 011, 402-403 of tocs, 233-234 409-411
joint recollstruction and biomechanics I:::~lit cvdL' kinematics of. 447 gait patcllofcmoral joint loading ill. 411
. of. 404-406 c;'c1e muscle activity of. 436 polyc(hy!cllL' cbmagc modes in. 415
peri prosthetic bont: loss in, 406-407 Ill1crspinous ligaments, 260. 288 posteriol' Cnlciate ligament in. 412-414
rot~\tional moments <Inc! bone Intcrstitial fluid pressuriziltion, in tihi:d component loosL'ning in. 409-411
in-growth in. 403. 404 ~lniClll<lr cnrtilage. 86-88 Knr.:,'(.'joint
stem position within femoral canal in. Intel't~II"Sal joilll mOl ion, 230-231, 233-234 bio;nl.·dwniGII analvsis of. 177-178
406 Intenransn:I'se ligamel1ts. 2SS 11Hl.'lycl..tcbml cnpsuh:: of. 195 .
Hip joint. 203 discs, 258 dcrangelllt:llts of. 182-1 t\5
::lcc(;lbulum of. 203-204 cervical. 288, 291 dynan~ics of. 190-19';, 197-199
"ging and changes in. 205-207. 208. 217 :.nnulus fibrosus of. 292 nc:don of injury
anatonw of. 203 loading. 291 in. 196
ball-and-socket configunltion of. 203, lllc:.'chaniC;l1 propt..'nics of. 293 rc:."lctiOll forcl"s in. 197-19$
204,205 nucleus puJpOStlS of. 292 in SlancL' phase of l1.mning/walking,
(knamics of Illmb~u' 179-180
- gait and gcndcr differences. 213. ~l~in~ of. 259 fn.:e·hod," dii:l2rmn of. /89
215-217 c~mpositiollof. 258-259 gait cycle kin~lllaticsof. 179-180. -
wilh instrumented o::lil pialI..'. 217-219 degC"l1cmtionnl changt..'s in. 259 t4.........t.45
wilh insI11.1mcillcd prosthesis. loading distribution in. 25S gnil cycle kincticsoL 185-194. 45Q-..-151
216-217 lo;:\(ling f;lilllrc of. 271-273 g<tit i.:yck muscle aClion of. ... 53 menisci
c-,tern;ll support, nnd dyn;\lnic~ of, 218- in rniddlt: age, 259 of. 193-194
219 prL'ssure on. 258-259 muscle action on. gait c~·de and, 196.
btiglle fracture of. 2/i femoral in \'OlI!h. 259 453
head of. 203. 204 femoral neck lliechailical propL'nit::s of. 293 patella of. 196-197
of. 204-205. 206 Imr:l·abdominal prL'ssul'e (lAP) l";:1l)2C of motion of. 179-180
rr~lcturc h.\atioll devices, 396-397 ,HlCl!oading of lumbar spinl.'. 272-273 in :-;i.\ 'kgrees of freedom of motion, 178
fracturc of. 21 i of lurnbal' spinc, 278-279
st~lbility s(~lbilitv of. 194-196
kinenwtics of. 205-208. 209, mll~e of Inlnlflls~,1 musclespineles. typl."s of. 169 statics ·of. 188-190, 197-199
motion, 206-107 surf.'1ce joint Intrinsic minimlls condition. 234 Intrinsic SIl'lICturc of, 177
motion. 207-208 muscles. of foot, 233-23.... surf<lce joilH 1Tl00ion of. 180-187 ll.'ndons
kinetics of, 208-213. 2/5 237-238 and ligamen(s of. 177. 19"'-196
ex lerna I forces on body in single-leg Isoinertial muscle contl-:lction, 159 Knee meniscectollw, 90, 9/
stance. 212 IsokinL'lic mllsclt: cOll(l'aclion, 159 Kyphosis. 267-268: 287-288
free-body diagr;llll of lower Isometric rnusclt: comnlction. 159 pathology of cervical. 29..J
cxtremity. 21~ Isotonic muscle conu71ction. 159 posturc and. 421-425
mm'Clllt:'nlS or:207 in Slalics of standing, 26S
muscle action in g;:lit cycle. -I52......t.53
muscles of, posterior. 265-266 J
and spin~t1 motion. 266-267 Joint Illomt.'nts. gait cycle. 449 L
static analysis of, 209-213 Joint power. g:.il c.velc. 451 Joinls Labrum, 203
HUlllcromdinl nniclll;ltion, 341-342 Laclln;:\C, 27. 28
kinematics of, 342-345 capsule of. 103 Lamellae. 27-29
HUllleroulnar aniculation. 341~342 dvnamic analvsis of. 185, 187 Lamclbr bOlle. 29-30. 30
kinematics of. 342-345 kinematics or". 178-179 Lnrnini.:clOmv. cervical. 305-306, 30i
Humerus. anicular slIrf;lcc r;:\nge of motion, 179-180 surface Lmcrnl c:ollaiL'ralligalllcllt (I.el.), 195
distal. 341-342 proximal. joint mot ion. 180-18! :IIHltOm)" of. 347, 3413
322-323 killL'tics of. 185.187 kinematics of. 347-348
Hyaline ;,rticular canilage. 6 i statics :malvsis of. 185. 187 Laler,,1 epicondylitis. 352
Hvaluronic articular c;:\rtilage. 65-67. 69 - types of. 6'· Lalt..'ml m~lsscs. 288
inhomogeneity of, with c<~"rtilagc 1.;I(t..'r"lit'.., 4.12
depth. 7-1 Ll'g.crossing. while silting, -t32......t.33
Hydrodynamic lubricmion, 82 K Lifting
Hysteresis, 110, III KCI";\tin sulfate bilCk belts in, drectiven~ssof. 2S1
in ;:mieu!;!.!" e;lrtila!!c. 65-69 b"ncling moment produced in. 272
in cer'deal nuelcus-pulposlls. 192 .lI1d c:m·ying, spinal loading in. 271-273
I Kint:nmtic inslability. 301-302 andlo\\' back paill. 269-271, 273 tumb'lr
I band. lSI. 152 Kinematics. 17S spinutloading in. 271-273
Immobiliz..'\tion/cxcrcisc, tendons and range of motion.179-ISO sud"aec tedllliqlle and. 272-275
ligaments in, 115-116 joint motion. 180-ISI l"L'pe;:lted. spinallonding in, 271-273
Instilllt center tcchlliquc, t80-181 Kinetic ;malysis. 185. lS7 stoop and squat.Jorce comp,lI'isons
Intercm-pal joinls, 359 Kinelics, 185, 187 in, 274
Li~aments muscle control of. 264-267 lkxor sllpplementm-y units of. 19
biornec!wnical bch;'lvior of, lOS and extensor, 265-266 Iawntl svmbols of. unit. 2IT
physiologicnl londing and. 110-111 nexor and rotation, 266 pelvic Midcarpal joint. 359, 365-366
viscoclnstic. I 11-1 12 motion and. 266-267 Midtarsal joint
hiofllcchanicnl pmpcnics of. 109-110 in st;-abilityof. 278-281 gait cycle kinem<ltics of. 4-16 gait
aging. J 15 external stabilization in, 279. 281 intra- cycle musclc activity of. 456
in diabetc:'s mellitlls, 116-117 in abdominal pressure in, 278-279 trunk Moment vectors. 4-5 Motion
gl1lfts. 117-1 J8 muscle co·contnlction in, 279 segment, 257-260
in hClllodial:ysis, 117 static analysis of landing, 268-273 anterior portion of. 258-259
in immobilization/exercise. ca1c:uh\tions in, 272-275 cervic.tl, 288, 290-291, 296 facets
115-116 companllive, in standing, sitting, of. louding, 259-260 ligamentum
in nonsteroidal anti·inf1<:Hllmatory reclining, 269-271 llavum of. 259 longitudinal
drug lise. 117 intra-abdominal pressure .md, 273 in ligaments of, 259 posterior
in pregnancy'!postpnrtum lifting, 271-273 portion of, 259-260 range of
period, 115 Lumbosacral joint, "nel spinal motion, motion of, 262-263 stnlctllres of.
in steroid lise. I 17 components 266-267 257-260
of. 103-108, \031 d~lsticit\' of. 110 Lunate, 359 surface joint motion of. 262-263
Luschka. joints of. 291 trans\,crse section of. 258
fUflctim; of, 103 Lying in bcd, biomechanics of crih:rion Motor cells, 127-128, /29 ,\110101'
injury ;-and failure mech"nisms of. of conformitv in, 434 and decubitus nerw, 127-128. /29 :\>10tor
. • 112-1IS, 123 ulcer de"elopment, neuron, 127-128. /29 ;\,10tor
cl.tssificntion of. 114 434--435 spinal nerve roots, 131
innervation of. 107 inscl·tion mattress support in, 433-434 ;\'1uhiplicalion factors, SI units, 21(
of. into bone. 108 pillow support in, 433 MllSclc(s)
stl1.lclural nIT;l.ngcmt:nt in postunll and phasic, 421-422
fiber, 104-105~ /06 types of, 149
OlllCl~ 108 M ~'Iusclc fali2uc, 279
v"sclllnr svstem of. 106-107 illt line, 151, 152 !\'1l1sclefibc;"$
viscoelasticity of. 11 1-112 M:lgerl type, cervical arthrodesis_ contrnction of. 153-155
in barle-ligaments complex, 111-112 309-310 cross section of. /52
Lig::ullcnlUl11 llavul11. 259 i\Jlalleoli, 242 cross sectional amltolllV of. /53 disuse
elasticit\' of. 110,260 Mallet wcs, 237 ..lnd immobilization effects on.
hypenn~)phyof. 260 ~'1alcrial propcnies, bascd on Slress~ strain 167-168
Line;.\!- strain, 32 diagrams. 13 lllvofibrils of. 149-154
Link. 180 M;.l\lress support, 433-434 p!~ysica.ltminingeffects on, 168-169
Lisfranc's joint motion, 230-231 and development of decubitus ulcers, stl1.lctmnl organization of.
Lisfranc's ·ligament. 231 Lond- 434-435 149-150, /52
defOlTIlalion curve Medial collateral ligament (MCL),195 types of. 165-167 dt:tcnnination
for fibl'Ous stl1.lcture, 31, 32 nnmomy of. 345, 347 of. 166-167
p"ramelcrs of. 32 usefulness kinematics of. 345, 347 MlIsclIloskclctnl system. 15
of. 32 Medi;-ao longitudinal nrch, 235-236 applied biomechanics of. 15
Loading patterns collapse of. 236 joints of. 15
and mechanical behavior secondary to posterior tibial 'tissues and stll.lctures of. 15
of articular c.milage, 70-80 of dcficicncv, 237, 238 Musculotendinous unit, 156
bone. 37-43 - models of. 235"':236 windlass Mvdin sheath. 127-128, /30
and mechanical pl'Operlies, 36 effect on, 235-236 M;·ofibrils. 149-150
Longitudinalligamcnls, spirml. 259, Mcdinn ncn'c, 362. 364 composition of. 149
260,288 Longus in carpaltunne1 syndrome. 364 contraction of. 153-155
colli muscle. 288 Mcnisccctomv, knee, 90. 9/ organii'.ation of. 149-150
Lordosis, 267-268, 287-288 Menisci, of kn~e, 193-194 sarcomeric, 149
posture and, 421-425 Met.lc;.trpal heads, 369 striated ~m-;,ulgeihcntof. 149-150
in S!<:llics of standing. 268 Metacarpals, 359 Mvosin filaments, 149-150
l.ow back pain Metac<'\l'Pophalangeal (iv1CP) joints. 359, 'in muscle contraction, 153-155
.md lifting, 269-271. 273 strengthening 362,369,370-371 sarcomeric alTangement of. /50. 151
exercises fol', 276-277 of fingers, 378-379
Lubrici7l, 84-85, 86 range of motion of. 378-379 of
I.umbal' spine thumb. 380 N
axial load on. in w~llkillg. 273-274, 275. and vohlr plate. 371 Nebulin filaments. 149-150 sarcomeric
276 Metmnfsal bl'eak motion, 228, 229 annogcment of, 151
back I-CSt SUppOl-t ;:lnd loading Metmarsophalangcal joillls, 232, 233-234 Neck-to-shaft angle. of femoral nc..'Ck.
of. 269.271 ~.'tetric syslem, 19 204-205
dynamic analysis of loading, 273-276 in b<lsC units of. 19 in hip arthroplasty, 404-406
exercises, 276-277 conversion of units of, 221, 23 Ncl'YC fibcl~ Sll1.lcture and function. 127
in walking, 273-274 definition of units of. 201 derived Ncl'YOUS s\,stt:m, 127
kinematics of. 260 units of, 19 mllltiplication faclOrs Newton's bws, 5
llluscle action, 264-267 in, 211 NodesofRan\'iel~ 127-128,/30
nmge of motion, 262-263 nnming of units after scientists, 21-23. 211 Nonsteroidal anti-innammatol)' drug usc.
surfnce joint motion, 262-263 tcndons and Iigamcnts in. 117
micro(bmage to, in cOlllpressiv~ prefixes used in. lInie 211 specially Normal strain, 8-9. /0
loading:, 272 named units of. 20-21 Nornwl stress. 7-8, 8