Professional Documents
Culture Documents
Basic Biomechanics of The Musculoskeletal System
Basic Biomechanics of The Musculoskeletal System
~ a i
MA:RG
VICTO,lI,,"',-.i,""
'.
BASIC BIOMECHANICS
of the
MUSCULOSKELETAL
SYSTEM
1
..._-4>
foreword
Mechanics and biology have always fascinated dents in orthopaedics Ihal during the past 10 years
humankind, The irnportance or understanding have llsed the texl. This book is written for stu-
the biomechanics of the musculoskeletal system dents and with a major input from students and
cannot be underestimated, Much a([entian has will hopefully be used to edunHe students and res-
been paid in recent years to genetic and biomo- idents for many ~Iears to come. Although the basic
leClilar research, but the stlld~' of the mechanics information contained in the book remains largely
of structure and of the whole body s}'stcm is still unchanged, a considerable amount of extra infor-
of immense importance. Musculoskeletal ail- mation has been provided throughoul. ~Ve have
ments arc among the most prevalent disorders in also made a special point to document with the
the wodd and will continue to grow as the pop- key references any significant changes in the field
ulation ages. of biomechanics and rehabilitation.
Since the days when I first studied biome- It has always been m)' interest lO bridge the
chanics in Sweden with Carl Hirsch, through my gap between engineering knowledge and clinical
years as an orthopaedic surgeon, teacher, and re- carc and praclice, This book is written primarily
searcher, I have alway's emphasized combining for clinicians such as orthopaedists, physical
basic and applied research with clinical experi- and occupational therapists, clinical ergono-
encc, This text represents my fifth effort to inte- misls, chiropractors, and olher health profes-
grate biomechanical knowledge into clinical sionals who arc acquil-ing a working knowledge
training for patient carc. It is not a simple task of biomechanical principles for use in the evalu-
but by relating the basic concepts of biomechan- ation and treatment of musculoskeletal dysfunc-
ics to everyday life, rehabilitation. orthopaedics. tion. We only hope that if you find this book in-
traumatology, and patient care are greatly en- t~resting. you will seek more in-depth study in
hanced. Biomechanics is a multidisciplinary spe- the field of biomechanics. Enjo\' it. discuss it,
cialty, and so we have made a special effort to in- and become a beller clinician and/or researchcl:
vite contributors from many disciplines so that Vve are extremely proud that Basic Biome-
individuals from dilTerent fields may feel com- clUluics oj" the !\tlllscliioskeic/lli Sysle111 has
Fortable reading this book. been designated "A Classic" by the publishers,
Together with an invaluable team, Margareta Lippincott Williams & Wilkins. We Ihank the
Nordin and I have produced Ihis third edition of readers, students, professors, and all who ac-
Basic Biol1lechanics oFthe A'lusclt!o.\'keletal Systelll, quire thc tcxt and lise it.
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
.,
l'~ e"!,-g,! !,•.-~--~"".'!~~~.""~"""c""',:::~::""'-'''''''';'-:'''"''''.''''''·'''''--'''''--''''''''''':~'''i~!1'···"'-"-"'·E"'.r,;>d"._"".""
.....,. ~"-h_,,:_/>;:~B:>~'¥,,..'13iA:s"' *w.c-:;·_!l , _~_iIl~!il i.iIl=i1!~i1!i!i!lWl;41.4~l'l!~$~rm!1il·, ~·" "'1l i&~.l\l.l!l~t!%_"t81; .0{t0r~:;:; ;:;,.f . ,.,;.:~ ~
.,
Preface
Biomechanics uses physics and engineering con- ever possible. We retained the selected examples
cepts to describe the motion undergone by the to illustrate lhe concepts needed for basic knowl-
various body segments and forces acting on edge of the musculoskeletal biomechanics; we
these body parts during normal activities. The also have kept the important engineering con-
inter-relationship of force and motion is impor- cepts throughout the volume. We have added
tant and must be understood if rational treat- four chapters on applied biomechanics topics.
ment programs are to be applied to muscu- Patient case studies ancl calculation bo:'\cs have
loskeletal disorders. Deleterious effects may be been added to each chapter. \Ne incorporated
produced if the forces acting on the areas with flowcharts throughout the book as teaching tools.
disorders rise 10 high levels during exercise or The text will serve as guide to a deeper under-
other activities of daily living. standing of musculoskeletal biomcchanics gained
The purpose of this text is to acquaint the read- through funher reading and independent research.
ers with the force-motion relationship \vithin the The information presented should also guide the
musculoskeletal system and the various tech~ rt.'ader in assessing the literature on biomechanics.
niqucs llsed to understand these relationships. "Vc have attemptcd to provide therapcutic exam-
The third edition of Basic Biol1/eclwllics of rite ples but it was not our purpose to cover this area;
iHllScliloskeleral System is intended for use as a instead, \ve have described the undel'lying basis for
textbook either in conjunction with an introduc- rational therapcutic or exercise programs.
tory biomechanics course or for independent An introductory chapter describes the inlpor-
study. The third edition has been changed in lance of the study of biomechanics, and an ap-
many ways, but it is still a book that is designed pendix on the international system of measure-
for use by students who are interested in and ments serves as an introduction to the physical
want to learn about biomechanics. It is primarily measurements used throughout the book. The
written for students who do not have an engi- reader needs no more (han basic knowledge of
neering background but who want to understand mathematics to fully comprehend the material
the most basic concepts in biomechanics and in the book, but it is important to review the ap-
physics and how these apply to the human body pendix on the Sl System and its application to
Input from students has greatly improved this biomechanics.
third edition. We have used the book for 10 years The body of the third edition is then divided
in the Program of Ergonomics and Biomechanics into three sections. The first section is the Bio-
at New York University', and it is the students and mechanics of Tissues and Stnlcturcs of the Mus-
residents who have suggested the changes and culoskeletal System and covers the basic biome-
who have continuously shown an interest in de- chanics of bone, ligaments, cartilage. tendons,
veloping and irnproving this book. This edition muscles, and nenres. The second section covers
has been further strengthened by the contribu- the Biomechanics-of Joints, including every joint
tion or the students over the past year. \Vc formed system in the human body. Chapters range from
focus groups to understand better what thc stu- the foot and ankle through the cervical spine,
dents wanted and applied their suggestions wher- and co\'er eve I:" joint in between. The third sec-
e .-.. ---~-_.-- . _--.-._.. _------- .-.- . ----.. -.-.... -'------------~--- .. ,~".-- . . -.. ..- ...-.--..-------..
~.~ ~ -.,,"------~----- -",,--.-.---.------
Ox .PREfACE
tion cover~ some topics in Applied Biomechan- oFthe kluscu/oskelela/ Syslel1l will bring about an
ics, including chapters on fracture fixation; increased awareness of the imparlance of bio-
arthroplasty; silting, standing and lying; and mechanics. II has never been our intention to
gait. These arc basic chapters that sl:l\r e to intra· complL'tely cover the subject, but instead provide
c1uce topics in applied biomechanics: they arc a basic introduction to the field that will lead to
not in-depth explorations of the subject. further study or this important lopic.
Finally. we hope that the revision and expan-
sion of this third edition of" Basic 13io11leclulJIics Margarela NOf(!;11 alld Viclor H. Frankel
~
""at ~.,,;,~~~~ :,,~,~t,
Acknowledgments
_---
---------~ ..
I
i
!
!Ii This book was made possible through the out- JUlian boxes. Angela look this book to her heart,
standing contributions of many individuals. The and \ve arc all the bettcr for her passion and
chapter authors' knowledge and understanding of attention to detail.
I
the basic concepts of biomechanics and their The illustrator: Kajsa Forssen. has now worked
wealth of experience have brought both breadth on all three editions of this text. Her never-failing
and depth to this work. Over the past 10 years. grasp of hiomechanical illustrations, her simpli.
questions raised by students and residents have city and exactness of figures, is always appre-
! made this book a better teaching tool. The Third ciated. In drawing all the figures and graphs, she
!
I
really sCnItinizcd thc Second Edition. There arc Forssen is one of the top iIIustralOrs that we have
too many names LO list here, but we thank each ever worked wilh, and she has been an important
student who asked a question or made a sug- member of the publication (cam.
gestion during the course of his or her studies. This book was also made when publication
;
Special thanks to the students who panicipated companies I11ergcd and merged again, and in the
in several focus groups. whose input was in- end we are deeply grateful to Ulila Lushnycky,
valuable in finalizing the contents and design of who has with her team at Lippincott \·Villiams &
the text. Wilkins been responsible ror the production. She
Vve are honored and grateful for the contri- has worked with tremendous energy and posilive
butions of everyone who has worked to prepare thinking, put the book together in record spced,
this new edition. 'vVe can honestly say that this and we fonvard our sincerest gratitude to her.
third edition is written ror the sludent and by \Ne are also thankful for a development grant
students and residents who leave the classroom provided by Lippincott Williams & Wilkins to
with the knowledge to enhance our life and finance this effort.
existence. Our colleagues al the Occupational and
A book of this size with its large number of Industrial Orthopaedic Cenler and the Depart-
figures, legends, and references cannot be pro- ment or Orthopaedics of the Hospital ror Joint
duced without a strong editorial team. As project Diseases Orthopaedic Institule functioned as
editor, Dawn Leger's continuous effort and critical reviewers and contributors to the
perseverance and thoughtfulness shines through chapters. Special thanks is extended to David
the entire book. She has contributed not just to Goldsheydcl" for assislance in reviewing lhe
the editing but also to logistics, and as a stylist, biomechanical calculation boxes. to Marco
as an innovator, and a friend. Our editorial Campello as a contributor and reviewer, and to
assistant, Angela Lis, is a physical thcrapisl and Shira Schccter-vVeiner for contributing to the
recent recipient of the MA degree in Ergonomics spine chapteI: Much thanks to Dr. Mark Pitman
and Biomechanics from NYU. As a recent grad- 1'01' supplying vital x-rays ror the new edition. \,Ve
uate, Angela was also a recent USCI' of the book, are parlicularly grateful to DI: Markus Pielrek
and she devoted several months to help finalize for contributing with the latcst on intra-
this edition. She created the flowcharts and scru- abdominal pressure. to Dr. Ali Sheikhzadeh ror
tinized all the figures, patient cases, and caku- reviewing chapters and contributing new
I
·fJ
-1.'- •
•
references, to Dr. Tobias Lorenz for his work on iHuscllloskeletal System was supported through-
the first section, and to all other staff at the out its production by the Research and Develop-
Occupational and Industrial Orthopaedic Center ment Foundation of the Hospital for Joint
who have been managing the center while we are Diseases Orthopaedic Institute and the hospital
absorbed wilh the book. administration, to whom we forward our sincere
\'\Fe arc most grateful to Drs. Bejjani, Lindh, gratitude.
Pitman, Peterson, and Stuchin for their COI1l1·j· To all who helped, we say' again, thank yOLi
bUlions to the second cdition which sen'cd as a and TACK SA MYCKET.
framework for the updated third edition.
The third edition of Basic Biomechallics orEiIe klargareta Nordin and Victor fl. Frankel
Contributors
xiii
Dawn Leger, Ph.D. Robert R. Myers, Ph.D.
Adjunct Assistant Professor Associate Professor
NYU-HJD Department of Orthopaedics Department of Anesthesiology
School of Medicine University of California San Diego
New York University La Jolla, CA
New York, NY
Margareta Nordin, P.T., Dr. Sci.
Jane Bear-Lehman, Ph.D., OTR, FAOTA Director, Occupational and Industrial Orthopaedic Center
Assistant Professor of Clinical Occupational Therapy (OIOC)
Department of Occupational Therapy Hospital for Joint Diseases Orthopaedic Institute
Columbia University College of Physicians and Surgeons !vlt. Sinal NYU Health
New York. NY Program of Ergonomics and Biomechanics
New York University
Margareta Lindh, M.D., Ph.D.
Research Professor
Associate Professor Department of Orthopaedics and Environmental Health
Department of Physical MeeJicine and Rehabilitation Science
Sahlgren Hospital School of Medicine, New York University
Gothenburg University New York, NY
Gothenburg, Sweden
Kjell Olmarker, M.D., Ph.D.
Angela Lis, M.A., P.T.
Associate Professor
Research Physical Therapist Department of Orthopaedics
Occupational and Industrial Orthopaedic Center Sahlgren Hospital
Hospital for Joint DiseasesiMt. Sinai NYU Health Gothenburg University
New York, NY Gothenburg, Sweden
Associate Professor
Physical Therapy Program Nihat bzkaya (deceased)
(orporacion Universitaria Iberoamericana Associate Professor
Bogota, COLOMBIA Occupational and Industrial Orthopaedic Center
Hospital for Joint Diseases
Tobias Lorenz, M.D.
Research Associate Professor
Fellow Department of Environmental Medicine
Occupational and Industrial Orthopaedic Center New York University
Hospital for Joint Diseases/Me Sinai NYU Health NelN York, NY
New York, NY
Lars Peterson, M.D., Ph.D.
Goran Lundborg, M.D.
Gruvgat 6
Professor Vastra Frolunda
Department of Hand Surgery Sweden
Lunds University
Malmo Allmanna Sjukhus Mark I. Pitman, M.D.
Malmo, Sweden Clinical Associate Professor
NYU-HJD Department of Orthopaedic Surgery
Ronald Moskovich, M.D.
School of lvIedicine
Associate Chief New York University
Spine Surgery New York, NY
NYU-HJD Department oj Orthopaedic Surgery
Hospital for Joint Diseases Andrew S. Rokito, M.D.
School of Medicine Associate Chief. Spons Medicine Service
New York University ASSistant Professor
New York, NY NYU-HJD Department 'Of Ortllopaedic Surgery
School of Medicine
Van C. Mow, Ph.D.
New York University
Director New York, NY
Orthopaedic Research Laboratory
Department of Orthopaedic Surgery
Columbia University
New York, NY
CONTRI~uioRS,;:,' ~V.
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
-~
'" I
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
I
\. 'l
\
thrown or kicked. A force <:\Cling on an object may TORQUE AND MOMENT VECTORS
deform 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-
depends on how the rorce is applied and how the
cording to their effects on the objects to \vhicf'l they
object is suppo!"ted. For example, when pulled. an
arc applied or according to their orientation as con~
open door will swing about the edge along which it
pared with one another. For example, a force may
is hinged lO the wall. \-Vh'll eallses the door 10 swin cJ
be internal or external, normal (perpendicular) 0'1'
is the torque generated by the applied force abou~
tangential; tensile. compressive. 01" shear; gravita-
an axis that passes through the hinges of the door. If
tional (weight); or frictional. Any two or more forces
one stands on the free-end of a diving board, the
acting on (\ single body 111ay be coplanar (acting on
hoard will bend, What bends the board is the mo-
a lwo~dimcnsional plane surface); collinear (have a
mel1l of the body weight about the fixed end of the
common line of action); concurrent (lines of action
board. In general. torque is associated with the ro~
intersecting at a single point); or parallel. Note that
tnlional and twisting action of applied forces, while
weight is a special form of Force. The weight of an
moment is related to the bending action. However,
object on Earth is the gravitational force exerted bv
the mathematical defmition of moment and torque
Earlh on the mass of that object. Thc magnitude ~'r
is the same.
the wcighl of an object on Ea~·t11 is equal t;
the mass
Torque and moment arc vector quantities. The
of the object times the magnitude of the gravita-
magnitude of the tonlue Of rnoment of a force
tional acceleration, \vhich is approximately 9.8 mt>
about a point is equal to the mannitude of the
ters pCI' second squared (111/s 1). For exampl~, a 10-k<J
object weighs approximately 98 newtons (N) o~
force times the length of the shortc:t distance be-
tween the point and the line of action of the force
Earth. The direction of weight is always vertically
which is known as the lever or moment arm. Con~
do\vl1\vard.
W)-_-I
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'S LAWS
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-
(i
-, ' .~ ...
"
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-
E ment arc 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
B moments in each direction must also be equal to
w zero (lM, = 0, lM,. = 0, lM, = 0). Thel'efore, for
three-dimension force systems there arc six cOl1cii-
lions of equilibrium. For two-dimensional force sys-
[ems in lhe xy-plane, onl~: three of these conditions
Forces involved at and around the elbow joint (IF, = 0, ~F, = 0, and ~M, = 0) need to be checked.
and the free-body diagram of the lower arm.
Reprinted with permission from dzkaya. N.
(7998). Biomechanics. In W.N. Rom, Environmen- STATICS
tal and 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
CONDITIONS FOR EQUILIBRIUM
to provide answers to questions such as: What ten-
Statics is an area within applied mechanics that is sion must the neck extensor muscles exert on the
concerned with the anal~:sis of forces on rigid bod- head to support the head in a specined position?
ies in equilibrium. A rigid body is one that is as- \OVhen a person bends, what would be the force ex~
sumed to undergo no deformations. [n reality, evcr)' ertcd by the erector spinae on the fifth lumbar ver-
object or matcrial may undergo deformat ion to an tebra? Ho\\'" does the con1pression at the elbow,
extent when acted on by forces. (n some cases, the knee, and ankle joints vmy with externally applied
amount of deformation may be so smalllhal il may forces and with different segmental arrangements?
not affect the desired analysis and the object is as- How docs the force on the femoral head vary with
sumed to be rigid. In mechanics, the term cquilib- loads carried in the hand? \,Vhat arc the forces in~
volved in various muscle groups and joints during to call tensile and compressive forces normal or ax-
different exercise conditions? ial forces: shearing forces are tangential forces. Ob-
In general. the unknowns in static problems in- jects also deform when they are subjecled to forces
volving the musculoskeletal s:'stcm arc thc magni- that cause bending and torsion, which are related to
tudes of joint reaction forces and muscle tensions. the moment and torque actions of applied forces.
The mechanical analysis of a skelclal joint requires A matel"ial nwv respond differently to different
that we know the vector characteristics of tensions loading configurations. For a given material. there
in the muscles, the proper locations of muscle at- may be different physical properties that must be
tachments, the weights of body segmcnts, and the considered while analyzing the response of that ma-
locations of the centers of gravity of the body seg- terial to tensile loading as compared with compres-
mems. Mechanical models are obviously simple sive or sheai' loading, The mechanical properties of
representations of c0l11plex systems. Many models mnterials are established through stress analysis by
are limited by the assumptions that must be made subjecting them to various experiments such as uni-
to reduce the system under considcration to a st.ati- axial tension and compression, torsion, and bend-
cally determinate one. Anv model can be improved ing tests.
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
NORMAL AND SHEAR STRESSES
analyze the improved model. the researcher would
need additional information related to the muscle Consider the whole bone in Figure \-3;,\ that is sub-
forces. This inforrrlalion can be gathered through jected to a pair of tensile forces of magnitude F. The
electromyography measurements of muscle signals bone is in static equilibriulll. To analyze the forces
or by applying certain optirnization techniques. A induced within the bone, the method of sections can
similar analysis can be made to investigate forces be applied by hypothetically cutting the bone into
involved at and around other major joints of the two pieces through a plane perpendicular to the long
musculoskeletal system. axis or the bone. Because the bone as a whole is in
equilibrium, the two pieces must individually be in
equilibrium as well. This requires that at the cut sec-
MODES OF DEFORMATION
tion of each piece there is an internal force that is
When acted on by externally applied forces. objects equal in magnitude but opposite in direction to the
may translate in the direction of the net force and externally applied force (Fig. 1-38). The internal
rotate in the direction of the net torque acting on force is distributed over the entire cross-sectional
them. If an object is subjected to externally applied area of the cut section. and E represents the resultant
forces but is in stalic equilibrium. then it is most of the distributed force (Fig. 1-3C). The intensity of
likely that there is some local shape change within this distributed force (force per unit area) is known
the objec!. Local shape change under the effect of as stress. For the case shown in Figure 1-3. because
applied forces is known as deformation. The extent the force resultant at the cut section is perpendicular
of deformation an object may undergo depends on to the plane of the cut. the cOITesponciing stress .is
many' factors, including the material properties. called a normal or axial stress. It is customar:y to usc
size, and shape of the object; environmental factors the symbol (T (sigma) to refer to normal stresses. As-
such as heat and humidity; and the nlagnitudc, di- suming that the intensity of the distributed force at
rection, and duration of applied forces. the Cllt section is uniform over the cross-sectional
One way of distinguishing forces is by observing area A of the bone, then u::::: FlA. Normal stresses that
their tendencv to deform the object they are applied are caused by forces that tend to stretch (elongate)
upon. For example. the object is said to be in ten- matcl"ials aJ"C marc specincally known as tensile
sion if the body tends to elongate and in compres- stresses; those that tend to shrink them are known as
sion if it tends to shrink in the direction of the ap- compressive stresses. According to the Standard In-
plied forces. Shear loading differs from tension and ternational (SO unit system (see Appendix), stresses
compression in that it is caused b:! forces acting in are measured in newton per square meter (N/m~),
directions tangent to the area resisting the forces ~ which is also known as pascal (Pa).
causing shear, whereas both tension and compres- There is another form of stress, shear stress,
sion are caused by collinear forces applied perpen- which is a measure of the intensity of internal forces
dicular to the areas on which they act. It is common acting tangent (parallel) to a plane of cut. For
':,
"r
F.
it
f!
a~1·~~j.jMTE~· 1 • INTRODUCTION TO BIOMECHANICS: BASIC TERMINOlOGY AND CONCEPTS
~i
H'
r
'.i~
F .....~--I
,..-__..J-_=-
- ~- .. F
A
A
B
~-G?-
F ...... =' ~,
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. Assuming that the intensity of the force tangent to
The bone is subject to a number of parallel forces the cut section is uniform over the cross-sectional
that act in planes perpendicular to the long a,is of area A of the bone, then T = FlA.
the bone. Assume that the bone is cut into two parts
through a plane perpendicular to the long axis of
NORMAL AND SHEAR STRAINS
the bone (Fig. 1-48). If the bone as a whole is in
equilibrium, its individual parts must be in equilib- Strain is a measure of the degree of deformation. As
rillm as well. This requires that there must be an in- in the case of stress, two types of strains can be dis-
ternal force at the cut section that ,lets in a direction tinguished. A norm~l'l strain is deflnecl as the ratio of
tangent to the cut surFace. If the magnitudes of the the change (increase or decrease) in length to the
external forces arc known, then the magnitude F of original (undeformed) length, and is commonly de-
the internal force can be calculated by considering noted with the symbol € (epsilon). Consider the
, the translational and rotational equilibrium of onc whole bone in Figure \-5. The total length of the
d; of the parts constituting the bone. The intensity of bone is I. If the bone is subjected to a pair of tensile
!:
the internal force tangent to the Clit section is forces. the length of the -bone may increase to I' or
known as the shear stress. It is customary to usc the by an amount .1i\ = I' -I. The normal strain is the
symbol T (tau) to refer to shear stresses (Fig. 1-4C). 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). 'If the 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-
B F, strain diagrarn 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
Definition of shear stress. Reprintecl with permis- ial. The last point on the stress-strain diagram is R,
sion {rom Ozkaya, N, (I 99B). Biomechanics. /11 W.N. \vhich represents the nq)ture or failure poinl. The
Rom, Environmenlal and Occupational Medicine stress at which lhe failure occurs is called the rup-
(3rd ed" pp. 1437-/454). New York: Lippincorr- ture strength of the material. For some materials, it
Raven. may not be easy to distinguish the elastic limit and
the yield point. The yield strength of sLieh materials
is determined by the offset method, which is ap-
plied b.y drawing a line parallel to the linear section
length, or E = c,11 1. If the length of the bone in- of the stress-strain diagram that passes through a
creases in the direction in which the strain is cal- strain level or approximately 0.2 % • The intersection
I
culated. then the strain is tensile and positive. If of this line with the stress-strain ClWVC is taken to
the length of the bone decreases in the direction be the vielel point, and the stress corresponding to
in which the strain is calculated, then the strain is this po-int is called the ~\pparent yield strength of
compressive and negative. the material.
"nfj
,
----,-
r
.~:,qi~sEgEXE~?l"NTHODUCTION TO SIOlvlECHANICS SASIC TERMINOLOGY AND CONCEPTS
I' ~ .; .:.\
F
~
"'"
,
I
'.l/
-- - -.
):
I
...... F
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~ ELASTIC AND PLASTIC DEFORMATIONS
ently under different load and environmental con~
ditions. If the curve shown in F'igurc 1~7 repre-
Elasticit:-.· is defined as lhe ability or
a material to
resume its original (stress-free) size and shape on
sents the stress"strain relationship for a material
under tensile loading, there ma).o' be a similar but removal of applied loads. 1n other words, if a load
different curve representing the stress-strain rela-
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- u
A
plied on the material.
y
I_ d 'I
B S' ~C
/ - - - - - - - - - 7 C'
/ /
/
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 G
the material will be 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 linearly elastic material behavior. Reprinted wirh
T is linearly proportional to the shear strain y, and
permission from OZkclycl, N. (1998)_ Biomecll<lflics. In
the constant of proportionality is called the shear W.N. Rom. Environmental and Occupattonal MecH-
modulus, or the modulus of rigidity. If G repre- cme (3rd cd., pp J437-1Li54.J. Ne....,; York: Lippincott-
sents the modulus of rigidity, then ,. = Gy. Combi- Raven
nations of all possible material functions for a
given material form the constitutive equations for
that material.
Plnsticity implies permanent deformations. Ma-
VISCOELASTICITY
terials may undergo plastic deformations follo\ving
elastic deformations when they are loaded beyond \·Vhcn they are subjected to relatively low stress lev-
their elastic limits. Consider the stress-strain dia- els, many materials such as metals exhibit elastic
gram of a material under tensile loading (Fig.I-7). material behavior. They undergo plastic deforma-
Assume that the stresses in the specimen arc tions at high stress levels. Elastic materials deform
brought to a level greater than the yield strength of instantaneously when they are subjected to exter-
the material. On removal of lhe applied load. lhe nally applied loads and resume their original shapes
material will recover the elastic deformation that almost instantly when the applied loads are re-
had taken place by following an unloading path par- mo\·cd. For an elastic material, stress is a function of
allel to the initial linearly elastic region. The point strain only, and the strcss-strain relationship is
where this path cuts the strain axis is called the unique (Fig. 1-8). Elastic materials clo not exhibit
plastic strain. which signifies the extent of perrl1a~ time-dependent behavior. A different gl'OUp of mate-
nent (unrecoverable) shape change that has taken rials, such as polymer plastics, metals at high tem-
place in the material. peratures, and almost all biological materials, ex-
Viscoelasticity is the characteristic of a material hibits gradual deformation and recovery when
that has both fluid and solid properties. Most ma- subjected to loading: and unloading. Such materials
terials arc classified as eilher fluid or solid. A solid are called viscoelastic. The response of viscoelastic
material will deform to a ccrLain extent when an materials is dependent on how quickly (he load is
exlernal force is applied. A continuously applied applied or removed. The extent of deformation that
force on a Ouid body will cause a continuous de- viscoelastic materials undergo is dependent all the
formation (also known as flow). Viscosity is n fluid rate at which the deformation-causing loads are ap-
property thut is a quantitative measure of rcsis· plied. The stress-strain relationship for a viscoelastic
tance to flow. Viscoelasticity is an example of how material is not unique but is a f1.lI1ction of time or the
areas in applied mechanics can overlap, because it rate at which the stresse.s and strains are developed
ulilizes the principles of both fluid and solid me- in the material (Fig. 1·9). The word "viscoelastic" is
chanics. made of two words, Viscosity is a fluid property and
II".·
" with an instantaneous strain that would remain at
a constant level until the load is removed (Fig.
I-lOB). At the instant when the load is removecl, the
deformation will instantl)' and completely recover.
Increasing To the same constant loading condition, a vis-
suain rale
-~
CHAPTER 1 • INTRODUCTION TO BIOMECHANICS. BASIC TERMINOLOGI< AN:D,:8:8:~2;g.~f~~~~~O
'U
the 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- A '0
lie material. conversely', will respond with an initial cr
high stress level that will decrease over time. If the
m;terial is a viscoelastic solid, the stress level will
nevcr rcduce to zcro (Fig, I-lie), As illuSlrated in
Fiourc
o I-II D, the stress will evct11uallv
zero for a viscoelastic nuid.
. reduce to
B
o·u to
0"0 = E,
a
MATERIAL PROPERTIES BASED
U:
ON STRESS-STRAIN DIAGRAMS
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~ 10
C
agram in the clastic region represents the clastic G
modulus that is a measure of the relative stiffness of
l1-
materials. The higher the elastic modulus, the stiffer
the material and the higher 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) 10
without undergoing a considerable plastic deforma- D
tion. Toughness is a measure of the capacity of a ma-
terial to sustain permanent defonllation. The tough-
ness of a matedal is measured b~: considering the Stress-relaxation experiment. Reprinted with per-
total area under its stress-strain diagram. The larger mission from Ozkaya, N. (1998). Biomechanics. In
this area, the tougher the malerial. The ability of a WN. Rom. Environmental and Occupational Medicine
material to store or absorb energy without perma- (Jrd ed.• P.o. 1437-1454). Ne~··1 York: Lippincott-Raven.
nent deformation is called lhe resilience of the ma-
terial. The resilience of a material is measured by its
modulus of resilience, which. is equal to the area un-
der the stress-strain curve in the elastic region. one: element for which the normal stresses are
Although thcy arc not directl\' rclated to the maximum and minimum. These maxin1lrm and
stress-strain diagrams, other important concepls minimum normal stresses arc called the principal
are used to describe material properties. For cxam~ stresses, and the planes whose normals are in the
pie, a material is called homogeneous if its proper- directions of the maximum and minimum stJ"esses
ties do not vary from location to location within the are called the principal plancs, On a principal
material. A material is called isotropic if its proper- plane, (he normal stress is either maximum or
lies are independent of direction. A material is minimum. and the sheal" stress is zero. It is known
called incompressible if it has a constant denSity. that fracture or material failure occurs along the
planes of maximum stresses, and structures must
be designed by taking into consideration the max-
PRINCIPAL STRESSES
/ imulll stresses involved. Failure by yielding (ex-
There are infinitely many possibilities of con- cessive deformation) n.lay occur whenever the
structing elements around a given point wilhin a largest principal stress is equal to the yield
structure. Among these possibilities, there may be strength of the material or failure by rupture may
o·
,
1f~[[HAPTER}1 • INTRODUCTION TO BIOMECHANICS: BASIC TERMINOLOGY AND CONCEPTS
II
occur whenever the largest principal stress ,is p
equal to the ultimate strength of the material. For
a given structure and loading condition. the prin- A a
cipal stresses ma~" be within the limits of opera-
I
tional safely. However, the structure must also be
checked for critical shearing stress. called the
maximum shear stress. The maximum shear SlI-es$
:· · . . .
o max - - ..... "7" - - ] -
(j"
- - - .......-
: ..'
-
•••••
- -
Tension
- - -
•••••
••
•••••
lime
1 cycle Compression
FATIGUE AND ENDURANCE
Principal and maximum shear stresses are useful in
predicting the response of materials (0 static load-
B
ing configurations. Loads that Illay not cause the
failure of a structure in a single application may
cause fracture when applied repeatedly. Failure may
occur aher a few or many cycles of loading and un-
loading, depending on factors such as the amplitude
of the applied load, mechanical properties of the
material, sIze of the structlire, and operational con-
ditions. Fracture resulting from repeated loading is
called fatigue.
Several experimental techniques have been de-
veloped to understand the fatIgue behavior of ma-
terials. Consider the bar shown in Figure 1-12;:1.
Assume that the bar is made of a material whose °0- - - - - - - - - - - - - -
ultimate strength is U'w This bar is first stressed to
a mean stress level (1m and then subjected to a L-_,---'---,---,--N
stress fluctuating over time, sometimes tensile 10' 10' 10'
and other times compressive (Fig. 1-128). The c
amplitude (T:, of the stress is such that the bar is
subjected to a maxImum tensile stress less than
the ultimate strength of the material. This reo
versible and periodic stress is applied until the Fatigue and endurance. Reprinred with permission
bar fractures and the number of cycles N to frac- from Olkaya, N. (1998). Biomechanics. In W.N. Rom,
ture is recorded. This experiment is repeated all Environmeniat and Occupational Medicine (3rd ed.,
pp. 1437-1454). New York: Lippincou-Raven.
specimens having the same material properties by
applying stresses or varying amplitude. A typical
result of a fatigue test is plotted in Figure 1-12C
on a diagram showing stress amplitude versus The fatiguc behavior or a material depends on
numbct· of cycles to failure. For a given N. the cor- several factors. The higher the temperature in
responding stress value is called the fatigue which the material is used, thc lower the fatigue
strength of the material at that nun1ber of cycles. strength. The fatigue behavior is sensitive to surface
For a given stress level, N represents the fatigue imperfections nnd the presence of discontinuities
life of the material. For some matel"ials, the stress within the material that can cause stress concentra-
amplitude versus number or cycles curve levels tions. The fatigue failure starts \vith the creation of
off. The stress CT, at which the fatigue curve levels a small crack on the surface of the material. which
off is called the endurance limit of the material. can propagate under the effect of repeated loads, re-
Below the endurance limit, the material has a sulting in [he rupture of [he material.
high probability of not failing in fatigue, regard- Orlhopaedic devices lII)dergo repeated loading
less of how many cycles of stress are imposed on and unloading as a result of the activities of the pa-
the material. tients and the actions of their 111uscles. Over a pe-
CHAPTER 1 • lNTRODUCTION TO BIOMECHANICS: BASIC TERlvllNOLOGy'.""rj'§;f9:~~~~TS,!~
I, .r
, .~.'
... :':.
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.'llWls of \Iolion D~·StTip· Sprin!.!(,I~Vl.'rlag.
lion. 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 New York: McGraw·Hill.
or {)i~tl"(llrodial Joinls. 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..'s Mirror/:\·Iosbv.
TI'UUll'l. Norwalk. CT: l\ppl('ton-Ct:llhll~'.Crofts. Williams. M., & lissner, H.R. (1992). Bion;l.'chanics of !·luman ;\'to-
Nordin, M .. Andersson. G.B.J., & Po\X", M.H. (Eds.). (1997). ~plllSCll lion (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 Willlel'S. J,!lil.. &. Woo. S.L-Y. (Eds.), (1990). Multiple Muscle Sys-
lhe :\hlst.:uloskdctal S,\':o;'lClll (2nd t:d,), Philaddphi:l: 1...:<.\ & Il'IHS. 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.
I
The System
International
d'Unites (51)
Dennis R. Carter
MOMENT FORCE
OF FOACE new Ion
qp ,- - . .
kg m/s 2 PRESSURE & STRESS
pascal
ACCELERATION N/m 2
speED
~\ . \l/~
ENERGY & WORK
~
\' Il/' _~r;)
joule
Nm
DENSITY
~~ ~,I //'/~'" POWER
VOLUME
;~:::::<':~:~~J" J , ,~/~,:'!j watt
JIS
~DERIVED~
,~m'?I~~'TS i~
TEMPERATURE
AREA degree Celsius
K'- 273.15
radian (fad)
PLANE ANGLE
- -----
SUPPLEMENTARY UNIT
BASE UNITS
19
O;;~ji':;<A~PENOIX l' • THE SYSTEM INTERNATIONAL O'UNITES (51)
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 sub tend 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 lise of the names of famous scientists as st«n~
mega Iv1
dard units. In each case, the lInit was named after a
kilo k
scientist in recognition of his contribution La the
hecla h Geld in which that unit plays a major role. Table
deka da App-3 lists a number of Slullits and the scientist for
deci d which each was named.
centi c For example. the unit of force. the neWlon, was
named in honor of the English scientist Sir Isaac
rniJli rn
Ncwlon (1624-1717). Hc wa' cducalcd 'II Trinil)'
micro I' College at Cambridge and later rclurned to Trinity
nana n College as a professor or mathematics. Early in his
pica p career, Newton made fundamental contributions to
malhcmalics Ihat formcd Ihc basis of diffcrcntial
Reprinred wirh permission from Ozkaya. N.. & Nord,-n. M.
(1999). Fundamentals oi Blomechani(!>: Equilibrium. Mo·
and integral calculus. His other major discoveries
tion. and Deiormatlon (2nd ed.) New York: Springer·lJer/ag. were in the fields of optics. astronomy. gravitation.
p, iO. 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
ten times the unit used. For example. the millime· that the SI unit of one newton is approximately
'tel' (mm) is used to represent one thousandth (10"·1) equivalent to the weight of a medium-sized apple.
of a meter and a gigapascal (Gpa) is uscd to denotc Newton W~lS knighted in t 705 by Qucen i\ltary fot"
one billion (10') pascals. his monumental contributions to science.
---_._--------
, 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
1 pound iorce IIbO = 4448 N
I dyn / em' = O. I Pa
Reprinted with pefFnisslon from OZkaya. 1'1., & No~dJn. l'1i. (1999). Fundamentals oi Biomechanics: EqUllib·
rium. Motion. and DeformatIon (2nd ed.) New York: Spnnger-verlag. p. 11.
The unit of pressure and stress. the pascal. was ucated at the Universit.\· of Glasgo\\" and at Cam-
named after the French physicist, mathematician, bridge University. Early in his career, Thol11son in-
and philosopher Blaise Pascal (1623-1662). Pascal vcstigated the thermal propcnies of steam at a sci-
conducted important investigations on the <.:harnc- entific laboratory in Paris. At thc age of 32, he
teristics of vacuums and barometers and also in- returned to Glasgo\\" 10 accept the chair of Nalural
vented a machine that would make mathematical Philosophy. His meeting with James JOllie in 1847
calculations. His work in the area of hydrostatics stimulated interesting discussions on the nature of
helped lay the foundation for the later developmenl heat, which eventually lecl to the establishment of
of these scientific ficlds_ In addition to his scicntific Thomson's absolute scale of temperature, the Kelvin
pursuits, Pascal was passionalely interested in reli- scale. In recognition of Thomson's contributions Lo
gion and philosophy and tllllS wrote extensively on the field of thermodynamics, King Edward VIl con-
a wide range of subjects. fen-cd on him the title of Lord Kelvin.
The base unit of temperature, the kelvin. was The commonly llsed unit of temperature, the de-
named in honor of Lord Vv'illiam Thomson Kelvin gree Celsius, \\ as named aftcr the Swedish as-
(1824-1907). Named William Thomson, he was cd· lronomcl and lmenlO! Anders CelsiLl' (1701-1744).
APPENDIX 1 • THE SYSTEM 'M'·'.'''T,r",
Celsius was appointed professor or astronomy at the (slich as the English system). the units of length,
Inii"p-",i,\' of Uppsala at the age of 29 and remained time, and force arc arbitrarily' defined, and other
the university until his death 14 years latec [n units (including mass) are derived from these base
1742, he described the centigrade thermometcl- in a units. Because lhe units of force in gravitational svs-
paper prepared for the Swedish Academ!' of Sci- tems are in fact the It'eights of stan(~"\rd masses. c~n~
The name of the centigrade temperature version to 51 is dependent on the acceleration of
waS officially changed to Celsius in 1948. mass due 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-
to Sf From Other ing some of the conversion factors in Box App-I.
of'Measurement
REFERENCES
Box App·t contains the formulae for the conversion
F~ircr, J.L. (19i7). SI .\leu;£' /-land/wok. Nt'w York: Charks
~f measurements expressed in English and non-Sl StTibll('r'S Sons.
units into Sf units. One fundamental source of Ozbva, N., ~ Nordin, ~'l. (1999). FWlfl(llllell1o!s or
Birmlt:-
connJSlon in converting from one system to another c/;(wics: EquilihriulJI, .\lotioll, (lut! DejtmJ/(//ioll (2nd (:d.}
is that (wo basic t~'Pes of 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
In the "ph\'sical" system (such as SI). the units of
Pi/oon (or Riolof!..\' amI .\lcclulJI;cs. New York: John Wiley
length. time, and nUlSS arc arbitrarily defined, and &: Son~.
other units (including force) are derived fron1 these \Vorld Health Org~lnizalion. (19i7). The SI /01' t!le fha/til Pro-
,. base units. In "technical" or "gravitational" systems jt's$iol1s. 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
l
""''''''----------.--.:~.",-----
_
of the tissue. Bone scn·cs <.lS a rcsen/Oir for essential
lJitijoduction minerals in the bod~·. particularly calcium.
Bone minend is embedded in variousl~« oriented
TbJ:i~~rpose or the skeletal system is to protect in-
fibers of the protein collagen, the fibrous ponion
te.r~.~V:"organs, provide rigid kinematic links and
~~ls:ctEtattachmcnt sites, and facilitate Illuscle ac·
of the extracellular matrix-the inorganic matrix.
Collagen ribers (type l) are tough and pliable, yet
:·:::;:~"pJ:tf91iYli~9,body movement .. Bone has unique stl·UC·
they resist strelching ~lnd have lillie L'xtensibility.
'-:/:::"'{:<'Y~lit~I.-.rI1d mechanical properties that allow it to
,,:~,<,:;;::,/,):',si;(rrY()llt;these roles. Bone is among the body's
CollagL'1l composes ~\PPJ'().\.irnatdy 9(YYo of the ex~
tracellular matrix and accounts for approximately
,::)},:;;ll~lrci~~tstrllctllres; onl)' dentin and enamel in the
25 lO 3W>'r' of the dr~! wl'ight of bone. A universal
:,:;:::';:,:::':i:,..'./t~¢th.>qreharder. It is one of the most dynamic and
::",';;::;.~/'i,1;i',.~t. ?9Pp'.cally active tissues in the body and re· building block of the body, collagen also is the
>.";'\1.lAiri,S::~\ctiv0 throughollt life. A highl~; vascular tis- chie!" fibrous component of other skddal struc-
s~e'.-.it has an excellent capacity for self-repair and tures. (A detailed descriplion 01" the microstnlcturc
tan ~lter its properties and configuration in rc- and mechanical behavior of collagen is provided in
. spOI~~e" to changes in mechanical demand. For ex- Chapters 3 and 4.)
ample, changes in bone dcnsit~1 arc commonly The gelatinous ground substance slIlTounding
obsei~·ed after pL:riods of disuse and of greatly in-
thc mineralized collagcn fibers consists mainly of
creased use; changes in bone shapL' are noted dur· protein polysaccharides, or gl~"cosarninoglycans
iog fracture healing and after certain operations. (GAGs), primarily in the form of cOlllplt:x macro·
·-'1
.;: Thus, bone adapts Lo the mechanical demands molecules called protcoglycans (PGs). The GAGs
s~rvc as a cementing substance between layers of
placed on i l.
This chapter (iL'scribcs the composition and mineralized collagen fibers. Thcs~ GAGs, along
structure of bone tissue, the mechanical properties wit.h various noncollagcI1ous glycoprotcins, consti-
of bone, and the behavior or bone under different tute approximately 5% of the extracellular rnatrix.
loading conditions. Various factors that affect the (The structure or PG:-:, whi,:h arc vital components
mechanical behavior of bone in vitro and in vivo of artie, i:il' '_·;l~·{iL\gt·. is described in delail in Chap·
kr .) ..1
also are disclissed.
\Vater is fairl~: abundant in live bone. accounting
for up to 25% of its total weight. Approximately
Bone Composition and Structure 85°10 of the walt.'r is found in the organic matrix,
around the collagen fibers and ground sllbstance,
Bone tissue is a specialized connective tissue whose and in the h.vdl·ation shells surrounding the bone
solid composition suits it for its supportive and pro- crysl~ds. The other 15% is localed in the canals and
teclive roles. Like other connective tissues, it con· cavities that house bone cells and carry nutrienls to
sisrs of cells and an organic extraccllular matrix of t h~ bone tissuc.
fibers and ground substance produced by the cells. At the microscopic level, the fllndamcmal StI11C-
The distinguishing reature of bone is its high con· lllralunit of bone is the osteon, or haversian system
tent of inorganic materials, ill the form of mineral (Fig. 2·1). At the center of each osteon is a small
salts, that combine intimately with the organic ma- channel, called a haversian canal, lIlat conlains
trix (Buckwalter et al., 1995). The inorganic compo· blood vessels and nerVe fibers. The osteon itself con-
nent of bone makes the tissue hard and rigid, while sists of a concentric series of layers (lamellae) of
the organic component giv~s bone its flexil)ility and mineralized rnatrLx surrounding the central canal, a
resilience. The composition of bone dirrers depend- configuration similar to growth ring~ in a tree
ing on site, animal age. dietar:.y histol)', and the pres· trunk.
ence or disease (Kaplan et aI., 1993). Along the bOllndflries of each layel: or lamella, are
In normal human bone, the mineral or inorganic small cavities known as lacunae, each cOl1laining
portion of bone consists primarily of calcium and 011(.' bone cell. or ostcocyte (Fig. 2-1 C). Numerous
phosphate, mainly in the form of small crystals rc· small channels, called canaliculi, radiate from each
sembling synthetic hydroxyapatite crystals \vith lacuna, connecling the lacunae or adjacent lamellae
the composition Ca",(PO,)o(OI-l),. These minerals, and ultimately reaching the haversian canal. Cell
which a~count for 60 to 70% of ilS dry weight, give processes extend from the osteocytes into the canali-
bone its solid consistency. "Vatcr nccounts for 5 to culi, allowing nutrients '[Tom the blood vessels in the
SOk and the organic matrix makes tip the J'cmainder haversian canal to reach the osteocyles.
27
.. , ..~l.'
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-
in a section of the shaft of a long bone depicted with- takas. N.P. (198:1). Principles of Anatomy and Physiology (4th
out inner marrow. The osteom. or haversian systems. edJ. Ne~·v York: Harper gRow. C, Along the boundaries of
are apparent as the structural units of bone. The haver- the lamellae are small cavities known as lacunae, each
sian canals are in the center of the osteons, which form of which contains a single bone cell, or osteocyte. Radi-
the main branches of the circulatory network in bone. ating from the lacunae are tiny canals, or canaliculi,
Each osteon is bounded by a cement line. One osteon is into which the cytoplasmic processes of the osteocytes
shown extending from the bone (20x). Adapted from extend. Adapted from Torrora G.;.. & AOclgflosrak05. N.P.
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 York: Harper & Ro~"/.
rings composed of a mineral matrix surrounding the
•
At the pcriphcl)! of each osteon is a cement line, A typical osteon is approximately 200 micronle-
a nrtrrow area of cement-like ground SubSlrtllCe tcrs (J..l) in (lin·rnctcr. Hence, evclY point in the os-
composed primarily of GAGs. The canaliculi of Ihc teon is no more than 100 J..llll from the centrally 10-
osteon do not pass this cement line. Like the canali- catcd blood supply. In Ihe long bones, the osteons
culi, the collagen fibers in the bOl1e matrix intercon- usually run longitudinally. but they branch [I'c-
nect from one larndla to another within an osteon quelltly and anaslOmose extensively with each
but do not cross the cement line. This intertwining othcl:
of collagen fibers within the osteon undoubtedly in-, Jnterstitial lamellac span the regions between
creases the bone's resistance to mechanical stress complete O!"h:ons (Fig: 2-1..1). They arc continuous
and probably explains _~vhy the cement line is the with the ostcons and consist of the same material in
weakest portion of the bonc's microstructure. 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:
1
Lea & Febiger.
activelv replaces woven bon~. Lamellar bone is therC'- and ,'cRail'. (ostcoblasls). The periosteum covers
for~ a "marc" l11all~'c bOlle.--- th~cnli~ -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 long borles, 'a- thin'llcr "nl'e'moi~a-ne:llle-cndostcum,
ouler fa)~ei: (~ -pe-i::nl-eat-e-(Ch~);-'-GTood vessels (Fig. line";; t heee n 1 ral (;;;";;clujIaty j ~,,",;il v:,\'
Ii icll;~Jmed
2-5) and nerve fibers that pass into the cortex via \VilTl'-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 tai,'ls~~~s:l'~~;~l;ia~t; ,~,~d .alse),. giant n~-~,fli"'l-ll1-c'le:'l:t'~'a'
eLl m\ls '\Il'(Cc',~,~~,6~,lir~~Lt(? tll~-,s,a.·!1·~,~,1..1('-li~ ,I)one .. f\ n l.ioli"-e"lisctlTfec! osteoela-sfs: both of which play-
i n 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~cm odc ling aMi1~ir"(:cso I'P t i 611
~(;nen~ting
spo"nsible.....",'(or ,5:_".". . .",..
nc\v"" •.Gc;'n-c'''du'i-ing
'-""'-"""~"""""""
gro\Vtl~,
-- """
of bone .
.
- -
- --
•
•
- '--
-
-
- " -
Lamellar
~ .f v~~, J
l
/'i .\ } ,
,~. \. \ \) '("'1::.;,
.~
Woven
•
Biomechanical Properties strength, stiflness, and other mechanical properties
of Bone of the structure can be gained b~' examining this
curve.
Biomechanically, bone tissue may be regUl~ded a~ a A hypothetical load-deformation curve for a
t\v9~ph~,lse (biphasic) c01JlposiL(;~ I1),aterial;" with the somewhat pliable fibrous structure, such as a long
mineral as onCjJhase and the collagen and ground bone, is shown in Figure 2·6, The i1~~lial (straight
substance as_.the o~her. In such matcl"'ials (n nonbio~ line) portion of the curve, the c1asticJ'cgion. reveals
logic-al exal,'lple is fiberglass) in which a strong. brit- the elasticity bf the structure, th:u is, its capacity for
tle material is embedded in a w~akcc more Oexible returning io its original shape after the load is re-
one, the combined substances ;:tre stronger for their moved, As· the load is applied, deformati911 occurs
weight than is either substance alone (Bassett, btll is not permanent; th-e structure recovers its orig-
1965), inal sllape \\'hen unloaded. As loading c·ontinues. the
Functionally, the most important mechanical outcrni"ost fibers of the struCture begin to yield at
properties of bone are its strength and stiffness. some point. This yidd poinl signals the elastic limit
These and other characteristics can best be under- of the structure, As, the load exceeds this limit, the
stood for bone, or any other structure, by e:'\amin- structure exhibits plastic behavior, I'cflecl~d in the
ing its behavior under .loading, that is, under the in- second (curved) portion of the eurvc, the p!as,tic rc-
nuence of externally applied forces. Loading causes gion. The structure \\~i11 no longer return to its origi-
a deformation, or a change in the dimensions, of 11al dimensions when the load has been released;
the~-strllctllre. \·Vhen a load in a known direction is some residual deformation will be permanent. If
imposed on a structure, the deformation 01" that loading-is progressively increased, the structure will
structure can be rncasurcd and ploued 011 a load- fail at'somc point (bonc' will fracturc), This point is
deformation curve. I\lluch information about the indic~-iled by the ultimate failure point on the CUI've,
BIC'ty"EClciAr<".' OF TISSUES AND STRUCTURES Of THE MUSCULOSKELETAL SYSTEM
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
before failing, 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-
100
~ suit or differences in microlllcchanical events at
iii yield. Yielding in melal (tested in tension, or
50
/
/ -------------- pulled) is caused b~' plastic rIow and the fonrwtion
of plaslic slip lines; slip lines art: formed when the
Trabecular bone
/
o.j.........,=.:...:..:".+"..:..:. ".:....:..:.:. :".:."
-'<":..:.":..:..:. :.c •.c.;":..:•.:.":...".f.:.c.;".:.":..".:.."---<
..c.;.,:..:.":..
. .:..:... molecules of lhe latticc structurc of mctal dislo-
o 5 10 15 20 25 cate. Yielding in bone (tested in tcnsion) is caused
-.~
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,
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 - - - - - - - -
II
i
Ductile fracture
I
I
Brittle fracture
-. I
~
I
,urface' of sample, of a ductile and a br;ttle
material. The broken Jines on the ductile material in- Scanning electron photomicrograph of a human cor-
dicate the original length of the sample. before it tical bone specimen tested in compression (30X). Ar-
deformed. The brittle material deformed very little rows indicate oblique cracking of the osteons. Courtesy 0;
before fracture. 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 B
for both parameters are highest for the samples
loaded in the longitudinal direction. Figures 2·9 and
2·15 show trabecular bone slI-cngth and stiffness
6
tesled in two directions: compression and tension.
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- 2
ness are greatest in the dircction in which daily
loads arc most commonly imposed.
0-1----1----1----1---+--"'"-1
o 2 4 6 B 10
..
of the pe-roneus brevis tendon and fractt,lres of
the calcaneus adjacent to the attachment of the
AchUlqs tendon. Figure 2-18 shows a tensile fracture
through the calcaneus; intense contraction of the
triceps surae muscle produces abnormall,Y high ten-
Tension Compression Bending
sile loads on the bone.
• I'~.
Compression
DUling compressive loading, equal ~nd opposite lOi:lds
I are applied toward the surface of the structure aI1d
•
I i compressive stress and strain. result inside the stI~IC
eli
C..J
ture. Compressive stress can be thought of as many l
1
Schematic representation of various loading modes.
Figure 2-20 shows the shortening and widening
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 directed· <.nva:v from the -;'urface of th~ stlJIC- Tensile loading.
that takes place in a human vertebra subjected to a Compression fracture of a human first lumbar verte-
high compressive load. In a joint, compressive load- bra. The vertebra has shortened and widened.
ing to failure can be produced by abnormally
strong contraction of the surrounding muscles. An •
example of this effect is presented in Figure 2-2 t;
bilateral subcapilal fractures of the Femoral neck
were sustained by a patient undergoing electrocon-
vulsive therapy; strong contractions of the muscles
around the hip joint compressed the femoral head
against the acetabulum.
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 <>
***
Unloaded Under Under
~
lensile compressive
loading loading
I
F-
.
The presence of shear strain in a structure loaded in
'---------
tension and in compres.sion is indicated by angular
_ Shear loading. deformation.
1
-~
OF TISSUES AND STRUCTURES OF THE MUSCULOSKELE!N SYSTEM
..
1_/_ _
..
B_-----.JO
stresses may not be equally distributed.
Bending may be produced by thl'qe forces (three-
point bendiilg) Ol:.Xour forces (roUI'~point bending)
(Fig. 2-26). Fractures produced b)' both types of
bending are commonly observed clinically, partiClI-
lady in the long bones.
Three-point bendirlgtakesplace when three
forces acting on a structure pn)c!uce two equal mo-
mcnts, each being the product of one of the t\\'o pc-
ripfle!~;;liforces and its perpcndicular distance. from
the axis of rotation (the point at which the middle
Two types of bending. A, Three-point bending. Forceis applied) (Fig. 2-26;\). IF loading continues
B, Four-point bending.
to the )-'iele! point, the structure, if homogeneous,
symmetrical, and with no structural or tissue de-
CHAPTER 2 • BIOMECHANICS
61, .
@.-
,:
Shear
Compression
formation of an initial crack parallel to the neutral
axis of the bone. A second crack usually forms
along the plane or maximal tensile stress. Such a
pattern can be seen in the experimentally produced
<J) I
, i'
,i<? torsional fracture of n canine femur shown in Fig-
ure 2-31.
,,, ,!
' ....... 1
Tension
'-.-'
I Combined loading,
Allhough each loading mode has been considered
separately, living bone is seldom loaded in one mode
Schematic representation of a small segment of bone only. Loading of bone in vivo is complex for two
,;
loaded in torsion. Maximal shear stresses act on principal reasons: bones .~.re ~onstantly subjected to
planes parallel and perpendicular to the neutral axis. multiple indeterminate loads and their geomelric
Maximal tensile and compressive stresses act on structure is irregulm: In vivo mcasurement of the
planes diagonal to this axis.
strains on the antcrol11cdial surface of a human
adull tibia during walking and jogging dcmon-
'.:
SlrateS the comph.:.xil.V 01" the loading patterns dur- crcas~d both the str~ss and the strain Oil the libia
ing these cOl11mon ph.'·siological activities (Lanyon (Lan.'·on ct aI., 1975). This increase in strain with
el aI., 1975). Stress values calculated from these grt,,:atcr speed was confirmed in studies or locomo~
strain measurel~lents by Carter (1978) showed thal lion in sheep, which ckmonslratcd a fivefold in-
during normal walking, the strc.i.~es wcre COlllP.I"CS- crcase in slrain values from siD\\" walking to fast
s.ivc dllring heel strike, tensile during- thc--s_t-~!.nce lrotting (Lanyon & Bourn, 1979).
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
INFLUENCE OF MUSCLE ACTIVITY ON STRESS
in the later portion of the gait c)ldc, denoting sig-
DISTRIBUTION IN BONE
nificant torsional loading. This torsional loading
\vas associated with external rotation of the tibia When bone is loaded in vivo, the contraction of tbe
during stance ancl push-ofr. muscles attached to the bone alters dlC stress distri-
Dul"ing jogging. the stress pattern was quite dif- bution in [he bone. This muscle contraction de-
rerent (Fi-g. 2:328). The COlJlP.~·.~~.~~c_slrcssPFcdom- cr<.:ases 01· eliminates [ensile stress on the bone by
inatin!! at lac strike was followed bv high tensile producing compressi\'c SlI-CSS thal neutralizes it ei-
stress~di.iring r>ll-sh-ofr. The sllenr slrcss~:vi~~--'o\V ther partially or totall~·.
tfil'oughout 'tlle strich:\ denoting 111ini;lwl torsional The effect of muscle contraction can be illus~
loadhig"pl~o(lllced by slight e~'\tern~" and inlcrm~l 1'0- trated in a tibia subjected to three-point bending.
tatiOll or-the tibia in an-ahernating pallcrn. The in- Figure 2~33A represents Lhe leg of a skier who is
crease--fll specd from slow walking LO jogging in- falling: forward, 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
Compressive 6
2 Shear (external rotation) rn
a.
~
~
z
1 I1
~
~
~
iii
4
4·
h.
HS
i
l,\
FF
r
HO s
2· "'\ ii
\i
1\
HO TO 4 .l---=-E--=~'-:':::------
TS TS·TO
A B
A. Calculated stresses on the anterolateral cortex of a 8, Calculated stresses on the anterolateral cortex of a
human tibia during walking. HS, heel strike; FF, foot human tibia during jogging. T5, toe strike; TO, toe off.
flat; HO, heel-off; TO. toe 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
(1975). Bone deformation recorded in vivo (rom srrain strain gaoges aClacIJed ro the human tibial Shaft. Acta
gauges c1tr<elched to the human tibial sharr. ACla Orlhop Orthop 5cand. 46. 256. Figure courtesy 01 Dennis R. Carter,
Scand, 46. 256. Figure coortesy of Dennis R. Carler, Ph.D Pll.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
r:~
, , failure at higher loading rates, provided that these
,, ''
: I
rates are within the physiological range.
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.
B As can be seen from the figure, 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-
A. Distribution of compressive and tensile stresses in mately 30(/0 stronger for brisk walking than for slow
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.
:
'
'
ma.y fail in compression. ,
Muscle contraction produces a similar effect in "
the hip joint (Fig. 2-34). During locomotion, bend-
ing moments are applied to the femoral neck and
tensile stress is produced on the superior cortex.
Contraction of the gluteus medius muscle pro-
duces compressive stress that neutralizes this ten-
sile stress, with the net result that neither com-
pressive nor tensile stress acts on the superior
cortex. Thus, the muscle contraction allows the
femoral neck to sustain higher loads than would Stress distribution in a femoral neck subjected to
otherwise be possible. bending. When the gluteus medius muscle is relaxed
(top), tensile stress acts on the superior cortex and
compressive stress acts on the inferior cortex. Con-
STRAIN RATE DEPENDENCY IN BONE
traction of this muscle (bottom) neutralizes the ten-
Because bone is a viscoelastic material, its biome- sile stress.
chanical behavior varies with the rate at which the
'~".
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
A
" , ' heavy physical training regime that included repetitive
continuous crawling in an awkward position for several
muscle function in the neutralization of the stress imposed,
leading to abnormal loading and altered stress distribution
(Case Study Fig. 2-1-1 B).
weeks (Case Study Fig. 2-1-1 A). The repeated application of
After 4 \-veeks of strenuous physical activity, the damage
loads (high repetitions) and the number of applications of a
accumulation from fatigue at the femoral shaft lead to an
load during a short period of time (high frequency of loading)
oblique fracture.
surpassed the time for the bone remodeling process to pre-
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-
".3
m Injury tigue fracture in the lower extremities is outlined
in the schema 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
Repetition great.er in 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 running. One mil-
The interplay of load and repetition is represented
on a fatigue curve.
lion cycles corresponds to approximately 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
abnormally high loads to be imposed, and n fatigue among military recruits undergoing strenuous
damage accumulation occurs that Illav lead to training of up to 1,000 miles of nll1ning over a
a fracture. Bone may fail on the tensil~ side, on short period of timc (6 weeks). Fracturcs of indi-
the compressive side, or on both sides. Failure on vidual trabeculae in cancellous bone have been ob-
the tensile side resulls in a transverse crack, and the served in postmortem hUlllan specimens and Illay
bone proceeds rapidly to complete fracture. Fatigue be caused by fatigue accumulation. Common sites
fnlctures on the compressive side appear to be pro- arc the lumbar vcnebrae, the femoral head, and
the proximal tibia. It has been suggested that these
o Compression fractures may playa role in bone remodeling as
Miles
II ::1
• TenSion well as in age-related fractures, collapse of sub-
10 100 1000 chondral bone, degeneraLive joint diseases, and
I I !
• • other bone disorders.
'E 0006
l~
INFLUENCE OF BONE GEOMETRY ON
I~ 0 004 vlgorous,-:":::!::::""~~S~'b-'<:::::::-;:;-~ BIOMECHANICAL BEHAVIOR
Ii g~ 0.002
exercise
Running -----------===--:::- The geometrv of a bone greatl\' influences its mc-
· tI) Walking chanical bel~avior. In Le~lsion' and compression.
I 0.0001+0-0--1---+---+----+---!------I
1~ 1~ 1~ the load to failure and the stiffness arc propor-
Number 01 Cycles tional to the cross-sectional area of the bone. The
"i larger the area, the stronger and stiffer the bone.
lam
I -------- In bending, both the cross-sectional arca and the
distribution of bone tissue around a neutral axis
Fatigue testing showing the number of cycles (x-axis) affcct the bone's mechanical behavior. The quan-
and strain range (y-axis) expressed as stress rangel tity that takes inLO account these two factors in
modulus in human cortical bone specimens loaded in
bending is called the area moment of inertia. A
tension and compression. Typical strain ranges are
larger moment of inertia results in a stronge.·
shown for walking, running. and vigorous exercises.
and stiffer bone. Figure 2-39 shows the influ-
. Note that resistance to fatigue fracture is greater in
ence of the arc,) moment of inenia on the load
I compressive loading. Ten miles represent approxj·
to failure and the stiffness of three rectangular
I mately 5,000 cycles, corresponding to the number of
steps running during that distance. Aclapared from Slruclures thal have the same area but different
I
'
,i
Carrer. D.R., Cater. W.E., Spengler, O.M.. Frankel, \l.H.
(J 98 1). Fatigue behavior of adtilt cortical bone: the influ-
shapes. In bending, beam III is thc stillest of the
lhree and call withstand the highest load because
i ence of mean srrc1ilJ anel strain range. Acra Orthop Seane!. the greatest amount of material is distribuLed at a
i 52.48/-490. distance from the neulral axis. For rectangular
~ ;>1
.;.
- - - - ----,1--
:; 1
4 ){ 1 2x2 1x 4
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 factors that affect bone strength and stiffness
the height (1-1') divided by 12: in torsion are the same that operate in bending: the
cross-sectional area and the distribution of bone tis-
B· H'
sue around a ncutral axis. The quantity that takes
12 into account these two factol's In torsional loading
Because of its large area moment of inertia. bean"'! is the polar moment of inertia. The larger the polar
III can withstand four times more load in bending moment of inertia. the stronger LInd stiffer the bone.
limn can beam I. Figure 2-41 shows distal LInd pl'oximnl cross-
A third factor, the length of the bone, influences sections of a tibia subjected to torsional loading. Al-
the strength and stillness in bending. The longer the though the proximal section has a slightly smaller
bone, the greater the magnitude of the bending mo- bony area thun docs the distal section, it has a much
ment caused by the application of a force. ,In a rec- higher polar moment of inertia because much of the
tangular structure, the magniwde of the stresses bone tissue is distributed at a distance from the neu-
produced al the point of application of Ihe bending tral axis. The distal section, while it has a largel"
moment is proponional to lhe length of the StI1.IC- bony area. is subjected to much higher shear stress
lure. Figure 2-40 depicts the forces acting on two bccause much of the bone tissue is distributed close
beams with the same width and height but different to the neutral axis. The magnitude of the shear
lengths: beam B is twice as long as beam A. The stress in the distal section is approximately double
bending moment for the longer beatn is twice that that in the proximal section. Clinically, torsional
for the shorter beam; consequently, the stress mag~ fractures of the tibia commonly occur distnlly.
nitudc throughout the beam is twice as high. Be- When bone begills to heal after fracture, blood
cause of their length, the long bones of the skeleton vessels and connective tissue from the periosteum
are subjected to high bending moments and. there- migrate into the region of the fracture. forming a
fore, to high tensile and c01npressive stresses. Their cuff of dense fibrous lissue, or callus (woven bone),
tubular shape gives them the ability to resist bend- around the fracture site. stabilizing that area (Fig.
ing moments in all directions. These bones have a 2-42A). The callus significantly increases the area
large area moment of inertia because much of the and polar moments of inertia. thereby increasing
--~
bone tissue is distributed at a distance from the neu- the strength and stiffness of the bone in bending
tral axis. and torsion during the healing period. As the rrac~
l
CHAPTEI{ 2 • BIC'ME.CHANICS
Stress
~-"'~~-<:;magnilude S
-r-_I-L---... -L • I
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
125 _ -+-... Screw in place hol('s without screws had disappeared completely
_:.~rew removed ~l_te~..- because the bone had ren1odclcd: bone had been
100 laid down around the screws to stabilize them, and
the empty screw holes had been filled in with bone.
~
,2
[;;
75 / _.::....--- In femora from which the screws had heen re-
moved immediately before testing, however, the
~ ~-- energy storage capacity of the bone decreased b)'
0>
<;; 50 .,..---'y .
.
c
w /'
50 0hi, mainly because the bone tissue around the
25 <I" screw sustained microdamage during sere\\' re-
moval (Fig, 2-43),
An open seclion defect is a discontinuity in the
a 2 345 6 7 B bone caused by the surgical removal of a piece of
Weeks bone longer than the bone's diameter (e.g.• by the
clilling of a slot during a bone biopsy). Because the
ollter surface of the bonc's cross-section is no longer
Effect of ~crews and of empty screw holes on the en- continuous. its abilit!1 to resist loads is allered, par-
ergy storage capacity of rabbit femora. The energy ticularly in torsion.
storage for experimental animals is expressed as a In a normal bone subjected to tOl'sion, the shear
percentage of the total energy storage capacity for stress is distributed throughout the bone and acts La
control animals. When screws were removed immedi- resist the torque. This stress pattcl-n is illustrated in
ately before testing, the energy storage capacity de 4
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): .
Load on the~,keleton can b~,,,~lc.l.:(?I""l~plished by ei-
tht:;,I.:,IX1~~_?(.:lc,activily or gravity. A positive correlation
exists b~twcen bOI1e mass and body we-ight. A gr~ater
body weight has been associated \vitha larger bone
mass (Exner et al., 1979). Conversely, a prolonged
condition ohveightlcssness, such as that expedenced
during space travel, has been found to result in de-
creased bone mass in weight-bearing bones. Astro-
nauts experience a fast loss of calcium and con-
sequent bone loss (Rambaut & Johnston, 1979;
\Vhedon, 1984). These changes are not completely
reversible.
~'------- Normal
A patient sustained a tibial fracture through a surgi-
I cally produced open section defect when she tripped
I a few weeks after the biopsy.
I
..-----------------
open section defect, only the shear stress at the pe-
riphery of the bone resists the applied torque. As the
shear stress encounters the discontinuity, it is
forced to change direction (Fig. 2-44B), Throughout
the interior of the bone, the stress nms parallel to Deformation
the applied torque, and the amount of bone tissue
resisting the load is greatly decreased.
In torsion tests in vitro of human adult tibiae, an Load-deformation curves for vertebral segments L5
open section defect reduced the load to failure and to L7 from normal and immobilized Rhesus monkeys.
energy storage to failure h,v as much as 90'10. The de- Note the extensive loss of strength and stiffness in
formation to failure was diminished by! approxi- the immobilized specimens. Adapted from Kazarian,
mately 70% (Frankel & Burstein, 1970) (Fig. 2-45). L.L.. g Von Gierke, H.E. (1969) Bone loss as a result of
Clinically, the surgical removal of a piece of bone immobilization and chelation, Preliminary results in
can greatly \veaken the bone, particularly in torsion. ivlacaca mulatta. (lin Orthop. 65. 67.
Bone Remodeling
30-year-old man who had a surgical removal of an
A.. ulna plate after stabilization of a displaced ulnar
fracture, Figure 2-48 shows anteroposterior (A) and lateral
(8) roentgenograms of the ulna after late plate removal.
The implant is used to stabilize the fracture for rapid
healing. However, in situations such as this, the late plate
removal decreased the amount of mechanical stresses
necessary for bone remodeling. It is of concern when the
plate carries most or all of the mechanical load and re·
mains after fracture healing. Thus, according to Wolff's
law, it will promote localized osseous resorption as a re-
sult of decreased mechanical stress and stimulus of the
bone under the plate, resulting in a decrease in strength
and stiffness of the bone.
UW!
nl II
.... '-------------------
,'- ." Vertebral cross-sections from autopsy specimens of
young (A) and old (8) bone show a marked reduction in
c
S_i_"_"_i_J_rv_lo_d_,_";_.S_,_2_2_'_. _
mined by the geometry and n1mcrial properties of around scrcws is illustrated in Figure 2-49. A nail
each structure (Case Stud)' 2-2). A large plate, car- plate was applied to a femoral neck fracture and the
rying high loads, unloads the bone to a great ex- bone hypcrtrophied around the scrcws in responsc
tent; the bone then atrophies in response to this di- to the increased load at thesc sites. H.~lpertrophy
minished load, (The bone may hypertrophy at the may also result if bone is repeatcdly subjected to
bone-screw interface in an altcmpt to reduce the high mechanical stresses within the normal physio-
rnicrol1lotion of the screws.) logical range. Hypertrophy of normal adult bone in
Bone resorption under a plate is illustrated in response to strenuous exercise has been observed
Figure 2-48. A compression plate made of a mater- (Dalen & Olsson, 1974; Huddleston et aI., 1980;
ial approximately 10 times stifTer than the bone \Vas Jones et aI., 1977), as has an increase in bone den-
applied to a fractured ulna and remained after the sity (Nilsson & Wesllin, 1971),
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 Degenerative Changes in Bone
bone diameter greatly decreases bone strength. par- Associated With Aging
ticularly in bending and torsion, as it reduces the
area and polar moments of inertia. A 20(M, decrease A progressive loss of bone density has been ob-
in bone diameter may reduce the strength in tor- sCI·veci as part of the normal aging process. The lon-
sion by 60%. Changes in bone size and shape illus- gitudinal trabeculae become thinner, and some of
trated in Figure 2-48 suggest that rigid plates the transverse trabeculae arc resorbed (SifTert &
should be removed shortly after a fraeture has Levy, 1981) (Fig. 2-50). The result is a marked re-
healed and before the bone has markedly dimin- duction in the amount of cancellous bone and a
ished in size. Such a decrea.sc in bone size is usu- thinning of conical bone. The relationship between
ally accompanied by secondary osteoporosis, which' bone mass, age. and gender is shown in Figure 2-51.
further weakens the bone (SI'itis et a!., 1980), The decrease ill bone Lissuc and the slight decrease
An implant may cause bone hypertrophy at its at- in the size or the bone reduce bone strength and
tachment sites. An example of bone hypertrophy stillness.
BICHvlIECI,ANIC:S OF TISSUES AND STRUCTURES or THE MUSCUlOSKElET"l SYSTEM
~OWlng
use, and calcium deficiency. Over several decades,
the skeletal mass ma.y be reduced to 5000 of original
trabecular and 25°/(; of cortical mass. In the fourth
the relatIOnship between bone mass,
age, and gender. On the top of the figure, a cross-
decade, women lose approximately 1.5 to 2(10 a year
section of the diaphysis of the femur and the bone while men lose only approximately half that rate
mass configuration is shown. Reprinted ('lith permission (0.5 to 0.75(-/0) yearly. Regular physical activity and
from Kaplan, F.S., rlayes, W.c., Keaveny, T.M., er al exercise (Zetterbarg et aI., 1990), calcium, and pos~
(7994), Form and function of bone. In S.R. Simon (edJ sibly estrogen intake may decrease the rate of bone
Orthopaedic Basic Science (.0, 767). Rosemont, IL:AAOS mineral loss 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.
3· rv(acroscopicall.\" the skeleton is composed of
cortical and cancellous (trabecular) bone. Cortical
bone has high density' while trabecular bone varies
in density over a wide range.
Strain
Bone is an anisotropic material, exhibiting diF-
ferent mechanical properties \vhen loaded in differ-
ent directions. iVlature bone is strongest and stiffest
Stress-strain curves for samples of adult young and in compression.
old human tibiae tested in tension, Note that the
bone strength is comparable but that the old bone is S Bone is subjected to complex loading patterns
more brittle and has lost its ability to deform. during common physiological activities such as
Adapted from Burs rein, A.H., Reilly, D. T, & Alartens, M. walking and jogging. Most bone fractures are pro-
(976). Aging of bone tissue' Mechanical properties. duced by a con1bination of several loading modes.
Bone Joint Surg, 58A, 82.
6 Ivluscle contraction affects stress patterns in
bone by producing compressive stress that partially
CHAPTER 2 , BlClMECHANIC:S
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 effecl of disuse of an extremity. Clill On/lOp, 64, 128.
loading precludes the remodeling necessary to pre- 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.
vent failure.
Kaplan. ES .. Hayes. We., Kea\'eny. T.iVI., l'l al. (1994). Form and
The mechanical behavior of a bone is influ- funcLion of bone. In S.R. SiTllon (Ed.). Orlhopacdic Basic Scicllce
enced by its geometry (length, cross-sectional area, (pp.I27-184). Rosemont. IL: AAOS.
and 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 cor-
demands placed on it; it is laid down \vhere needed tical and trabecular bone. BOIIC, i, 285-344.
Krolner, B.. 0.: Toft. B. (1983). Vertebral bone loss: An unheeded side
and resorbed where not needed. 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 \IcGraw-I-lill.
bone 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
Springer-Verlag.
cdl funcLion. ((nstructional Course Lectlln:). J BOlle JoiJl! Sllrg.
Rarnballl~ P.c., 0.: ~Johnston. R.S. (1979). Prolonged weighLlessness
77A, 1256-1289.
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:
N.. 0.: Olsson, K.E. (1974). Bone mineral content .md physi-
I-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
I
VASCULAR FACTO,RS JI
MECHANICAL FACTORS
~
. ;~::
to
6
s:
'm
()
I
}>
Z
n
'"
o~
-;
Vi
i '"
C
m
'"
~
i' Function SlruCturc
o
'"-<
,ilJ '"
C
()
-;
"
;j C
'"
m
w '"
o
~
Protection, suppOrt. kinCffiJtic links -;
I
m
~
~~ Organic Component \1 Inorganic Component '"
()
C
r
o
"'"
m
r'
m
i
~1
Collagen Proteins
Type I )
1 ;,N~~coliag~n'Proteln~;
Growth factor cell
Cry,Olh of
HYDROXYAPATITE '
~
r
'"-<
~
1 attachment proteins Calcium, Phosphate m
PG', s:
1
1
:
FLOW CHART 2·2 Bone composition. structure, and functions.· (PG's, proteoglycans)
.j ~This flow chart is dl?~igncd for classroom or group discussion. Flow chart is not meant to be exhaustive.
.1
'1
I
fJ, ,,1'.j2ij4if@_~\M¥i"I:IIi:i ;:H%J! dl 'I);; )'MltII: i)() 1tWC' !~
',~.
•~
~
a.
"
>
"a0
0
E £
m "
.'"
x
.".s
0
0
.0
B
cm
V 0
E
'"'m"
E
<;
c
.-
m
V em
'"c
0
{;
~
.0 0
u:
"'
.~
v
C
0
":;:
E
m ~
·u 'i3
0 0
~ 0
m 2
§
~
'"5
u E
.:" 0
u
.;;;
C
~
m
"5 u
x
w .e
"0
.,'"c
•
". -
;;;
"'
~
0
'"
~
,.
r'' ' .
~1Jf!i' .ii"'em " " ""~ '¥,."". ,.."" ,."
]
I
hco,j(
I j
!U':\",(,'p[{
q>'~!"",>i;~
fr~'~
t";;Ud
.
~i~
::'$..
"0'
)
s:
m
{\
J:
?<
1'\
v-
o
~
-<
·(11 v;
v-
C
m
v-
Blood Flow Gcnedc DIsturbance Tumoral DIsturbance
<.;,\' :..\;.:, \,.::,;:.\- ,~":
?<
" o
v-
-<
J .;',: 'i.~,:('erjm"ry Ii'"-<
:j c
'"
m
v-
,j
o
i :\f~pvcloping'
~
-<
I
\i ,;,:::';;'Skclc~on m
s:c
1 J
\:<·",-':::::::Y",
I
, "';; .'
~
IJ ,::
m
v-
-<
';:1
~,i s:
:j;
1/<1
.'~,
ri PATHOLOGICAL OR FRAGILITY FRACTURE
ij
~
t~: FLOW CHART 2-4 Intrinsic factors associated with bone damage. Clinical examples.*
i~
o
I'" "This flow chart is designed for d<lssroom or group discussion. Flow chart is not meant to be cxhamtivc.
:,i,¥
,:
Biomechanics of
Articular Cartilage
Van C. Mow, Clark T Hung
Introduction
Composition and Structure of Articular Cartilage
Collagen
Proteoglycan
WatE'r
Structural and PhysicallniE'raction Among Cartilage Components
Biomechanical Behavior of Articular Cartilage
Nature of Articular Cartilage Viscoelasticity
Confined Compression Explant Loading Configuration
Biphasic Creep Response of Articular Cartilage in Compression
Biphasic Stress-Relaxation ResponsE' of Articular Cartilage in
Compression
Permeability of Articular Cartilage
Behavior of Articular Cartilage Under Uniaxial Tension
Behavior of Articular Cartilage in Pure Shear
Swelling Behavior of Articular Cartilage
Lubrication of Articular Cartilage
Fluid-Film Lubrication
Boundary Lubrication
Mixed Lubrication
Role of Interstitial Fluid Pressurization in Joint Lubrication
Wear of Articular Cartilage
Hypotheses on Biomechanics of Cartilage Degeneration
Role of Biomechanical Factors
Implications on Chondrocyle Function
Summary
Acknowledgments
References
Flow Charts
J
Introduction Composition and Structure of
Articular Cartilage
Three types of joints exist in the human body: fi-
b'ro~ls, cartilagin,olls. and synovial. Onl.y one of' Chondrocytcs, the sparsely distributed cells in artic-
these,;-,ollle syn.ovial. or diarthrodial, jo.int, allows a lllarc~\I:tiL\ge, account for less than 10% of the tis-
large degree of motion. In Y~_L1ng normal joints, the sue's volume (Stoekwell. 1979). Schematically. Ihe
,-~llticulalingJ)onecn~ls of diartl~~'odiaIj9_inls,!.re cov- zonal arrangement of chondrocytcs is shown in Fig-
}--ered by a-thin (1-6 mill), den~c, tram~JJlcc_nt,~:-,'hile ure 3-1. Despite their sparse distribution, chondro-
,~~c6nnective-i.i.ssllc called hyaline arliCltlar. cartilage cytcs manufacture, secrete, on!anil',---c, and rnainlain
iCBox-3:!). Articul'IU~f\rtilage-;"s a highly s-p·ecia·lized tile on!anicco'n;-I;~I~l-~f the~ extracellular matrix
. tissue precisely suited for withstanding the highly (ECM) (Fos'lIlg & Hardingham, 1996; ·M~lir, 1983).
i~adcd joint environment without failure during an The org~nic ma~rix,is compo~~5:L~~[.:~,,(I(:nscp9.J~\'ork
a\lerage individual's lifetime. PhXti.t~~l.Qgically, how- of fin:"-§?·I-(..1¥8~,,,(~'bril~ (n10stly t'ype-Jl~c-olh;~gen.,with
ever, ,il is v51~~~I'.lIly an isolated li,ssuc, devQ.id of blood miii6i' amounts .,;1' types V, VI, IX, and XI) that "~reo
\;essds, 1).~-mphalic channels, and nelyrol.ogical inncr- enrneshcd..Jn. a cOnCC.tl.traled ~olu.~i().n. of proteogly-
~alion~'-Flll'lllermoJ'c,its .c~l.llliar density is less than cans (pcs) (l3ate;;'an et aI., I996;Eyre, 1980; Mloir,
.·tK"t of any other tissue (Stoek\~c·il. 1979). -~1983)_ 1n nOITn,)1 arLiculaL_cartilage the collagen
[n (liartll-i'o(Ti~;fioints, articular cartilage has two cOlllent ranges from 15 to 22% by wet weight and
- p-rimar'yfl~nctions': (1) to distl-ibute jo.int loads over the PG con-tent fronl4to 7% bv wet wei(Tht· the re-
.' :::::> '
,a wiele al-ea, thus decreasing lhe strc:)ses sllst~!.!ned maining 60 to 85 % is walCI: inorganic salts. and
by the contacting join.t..~.sl~rraccs (Atcshian ct aI., small amounts of other matrix proteins, glycopro-
1995; Helminen et aI., 1987) and (2) to allow rel"tive teins. and lipids (Mow & Ratcliffe, 1997). Collagen
movementoft!1cu:m,posing joinl surfaces \~:·,i.t"I,l""I~lin flbrils and PGs, each being capablc of forming
imal ft:'iction and wear (iVlow & Alcshian, 1997). In structural nctworks of significant strength (Broom
thi's"ch~l'I)iel','wc w'Hi describe how the biomcchani- & Silyn-Roberts, 1990; Kempson et aI., 1976;
cal pl'openics of articular cartilage, as determined Schmidt el aI., 1990; Zhu et aI., 1991, 1993), arc Ihe
by its composition and structure, allow for the opti- structural components supporting the internal me-
mal performance or these functions. chanical stresses that result rrom loads being ap-
plied to the articular 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
,
I A notable exception to the definition of hyaline articu-
COLLAGEN
Collagen is the mosl abundant protein in the body
lar G'lrtilage is the temporomandibular joint, a synovial
joint in which fibrocartilage is found covering the bone (Bateman et aI., 1996; Eyre, 1980). In articular carti-
ends. Fibrocartilage and a third type of cartilage, elastic lage. collagen has a high level of structural organiza-
cartilage. are closely related to hyaline cartilage embry- tion that providcs a fibrous ultrastructure (Clm-k,
ologically and histologically but .'lre vastly different in 1985; Clarke, 1971; Mow & Ratcliffe, 1997). The ba-
mechanical and biochemical properties. Fibrocartilage sic biological unit of collagen is tropocollagen. a
represents a transitional cartilage found at the margins Sln.lcture composed of three procollagen polypeptide
of some joint cavities, in the joint capsules, and at the chains (alpha chains) coiled into left-handed helixes
insertions of ligaments and tendons into bone. (Fig. 3-2;\) thaI are furthcr coiled abollt each other
Fibrocartilage also forms the menisci interposed be- inlO a right-handed triple helix (Fig. 3-28). These
tween the articular cartilage of some joints and com- rod-like tropocollagen molecules. 1.4 nanOJlletcl-s
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
ear, in the cartilage of the eustachian tube, in the ct al.. 1996; Eyre, 1980), In articular cartilage, these
epiglouis. and in certain pans of the larynx. fibrils have an 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%)
," '.
,~.-r
•
Scanning electron microscopic studies, for instance, lying bone (Bullough & Jagannath, 1983; Redler et
have described fibers with diameters ranging up to aI., 1975). This anisotropic fiber orientation is mir-
200 nm (Clarke, 1971). Covalent cross-links form be- rored by the inhomogeneous zonal variations in the
tween these tropocollagen molecules, adding to the collagen content, which is highest at the surface and
flbrils high tensile strength (Bateman et aI., 1996). then remains relatively constant throughout the
The collagen in articular cartilage is inhomoge- deeper zones (Lipshitz et aI., 1975). This composi-
neously distributed, giving the tissue a layered char- tionalla.vering appears to provide an important bio-
acter (Lane & Weiss, 1975; Mow & Ratc1iITc, 1997). mechanical function by' distributing the stress more
Numerous investigations Llsing light. transn1ission uniformly across the loaded regions the joint tis- or
electron, and scanning electron microscopy have sue (Selton et aI., 1995).
identifled three separate structural zones. For ex- Cartilage is composed primarily of type II colla-
ample, Mow et al. (1974) proposed a zonal arrange- gen. [n addition, an array of difFerent collagen
ment for the collagen network sho\vn schematically' (t)'Pes V, VI. IX, Xl) can be found in quantitatively
in Figure 3-3A. In the superficial tangential zone, minor amounts within articular cartilage. Tvpe II
which represents 10 to 20()0 of the total thickness, collagen is present primarily in articular cm·tilage,
are sheets of fine, densely packed fibers randomly the nasal septum, and sternal cartilage, as well as in
\voven in planes parallel to the articular surface
(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 Differences in Coliagen Types
randomly oriented and homogeneousl::.. dispersed
fibers. Below this, in the deep zone (approximatel.v Differences in tropocollagen alpha chains in various
30% of the total thickness), the fibers come together, body tissues give rise to specific molecular species, or
forming larger, radially oriented fiber bundles types of collagen. The collagen type in hyaline cartilage,
(Redler et aI., 1975). These bundles then cross the type II collagen, differs from type I collagen found in
tidemark, the interface between articular cartilage bone, ligament, and tendon. Type II collagen forms a
and the calcified cartilage beneath it, to enter the thinner fibril than that of type I, permitting maximum
calcified cartilage, thus forming an interlocking dispersion of collagen throughout the cartilage tissue.
"root" sj'stem anchoring the cartilage to the uncler-
(r chain
A
I Triple helix
1.4 nm
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 because their large slendcnlcss ratio, the ratio of
meniscus. For reference, type I is the most abun- length to thickness, makes it easy for them to buckle
dant collagen in the human body and can be found under cotl1prcssive loads (Fig. 3-48).
in bone and soft tissues such as intervertebral discs Like bone, articular canilage is anisotropic; its
(rnainl.y in the annulus fibrosis), skin. meniscus, ten- material properties differ with the direction of loacl~
dons, and ligaments. The most important mechani- ing (Akizuki et aI., 1986; Kempson, 1979; Mow &
cal properties of collagen fibers nrc their tensile RalclifTc, 1997; Roth & Mow, 1980; Woo el al ..
stiffness and their strength (Fig. 3-4;\). Although a 1987). Oft is thought that this anisotropy is related to
Single collagen fibril has'-not be~n tested in len;ion. the varying collagen fiber arrangements within the
the tensile slI'ength of collagen can be inferred from planes parallel to the articular surface. It is also
tests on structures with high collagen contenl. Ten- thought, however, that variations in collagen f-iber
dons, for example, are about 80% collagen (dry cross~link density, as well as variations in collagen-
weight) and have a tensile stiffness of 10.1 !\'1Pa and PG interactions. also contribute to articular carti-
a tensile strength of SO MPa (Akizuki et aI., 1986; lage tensile anisotrop~", In tension, this anisotropy
Kempson, 1976, 1979; Wooet aI., 1987, 1997).Stec1, is llsually described with respect to the direction
by comparison, has a tensile stillness of approxi- of the articular surface split lines. These split lines
mately 220 x 10" MPa. Although strong in tension. arc elongated fissures Jj·roduced by piercing the ar-
collagen fibrils offer little resis(ance lo ~olllpression ticular surface with a small round awl (Fig. 3-5;
O'TMW"PAMH;. EiiqMEcf-iANICS OF TISSUES AND STRUCTURES OF THE MUSCULOSKELETAL SYSTEM
ii'~
'1
'1 ';;;
"
~.;;
:;<,
.J
.'
'k
.'.
f
"
'4, "i
..'./.
~
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-
cartilages. A scanning electron microscopy sludy and a theoretical ter, The collagen fibrils of the deep zone form larger radially
mode! for the dynamic interaction of synovial fluid and articular car· oriented fiber bundles that cross the tidemark, enter the calci·
tilage. J Bionll?{hanics, 7, 449), B. Photomicrographs (x3000; fied zone, and anchor the tissue to the underlying bone. Note
provided through the courtesy of Dr. T. Takei, Nagano. Japan) the correspondence between this collagen fiber architecture
of the ultrastructural arrangement of the collagen network and the spatial arrangement of the chondrocytes shown in
throughout the depth of articular cartilage. In the superficial Figure 3-1. In the above photomicrographs (B), the STZ is
tangential zone (STZ), collagen fibrils are tightly woven into shown under compressive loading while the middle and deep
sheets arranged parallel to the articular surface. In the middle zones are unloaded.
Collagen Fibril
B
Uttle resistance to compression
Human femoral condyles
Hultkrantz, 1898). The origin of the pattcrn is re- binding region in c.:anilagc. iVlore recently, the other
lated to the directional variation 01" the tensile stilT- two globular regions have been extensively studied
ness and strength characteristics of articular can i- (Fosang & Hanlingham. 1996), but their functional
lage described above. To dale. ho\Vevel~ the exact significance has notycl been elucidated. Figure 3-68
rc;sons as to why articular canilage exhibits slIch is lhe accepted molecular confonnation of a PG ag-
pronounced anisolropies in tension is not known, gregate; Rosenberg Gt al. (1975) were the first to
nor is the functional significance or this tensile obtain an electron micrograph 01" this molecule
anisotrop)'. (Fig. 3-6C).
In native cartilage, most aggrccans arc associated
withHA to form the large PG aggregates (Fig. 3-6C).
PROTEOGLYCAN
These aggregates may have up to several hundred
l\llany types of PGs arc round in cartilage. Funda- aggrecans noncovalenliy uuached to a central HA
mentally, it is a large protein-polysaccharide mole- core via their HABR, and each sile is stabilized by
cule composed of a protein core to which one or an LP. The filamentous HA core molecule is a non-
more glycosaminoglycans (GAGs) are attached sulfated disaccharide chain that may be as long as 4
(Fosang & Hardingham, 1996; Muir, 1983; Ratcliffe fJ.m ill Icngth. PG biochcmists have dubbed thc HA
& Mow, 1996). Even the smallest of these molecules, an "honorary" PG, as it is so intimately involved in
high'Can and deem-in, are quite large (approxi- the structure of the PG aggregate in articular carti-
m;t~ly I X 10'\ 111\\'). but they comprise less than lage. The stability afforded by the PG aggregates has
10~~ of all PGs present in the tissue. Aggrccans are a rl"wjor functional significance. It is accepted now
much larger (1-4 X 10" mw), and they have the rc- thut PG aggregation promotes immobilization of
markable capability to attach to a hyaluronan mol· the PGs within the nne collagen meshwork, adding
ccule (HA: 5 X 10' I11W) via a specific 1·-1A-binding rc- structural stability and rigidity to thc ECM (Mow ct
gion (HABR). This binding is stabilized by a link aI., 1989b; Muir, 1983; Ratcliffc et aI., 1986). Fur-
protein (LP) (40-48 X 10" mw). Stabilization is cru- thermore, two additional forms of c!crmatan sulfate
cial 10 the function of normal cartilage; without it, PG have been idcntif"led in the ECM of articular car-
the components of the PG molecule would rapidly tilage (Rosenberg et aI., 1985). In tendon, c1ermatan
escape from the tissue (Hardingham & IVluir, 1974; sulfate PGs have been shown to bind noncovalently
H<lscall, 1977; Muil; 1983). to the surfaces of collagen fibrils (Scott & Orford,
Two types of GAGs comprise aggrecan: chon- 1981); however, the role of derma tan sulfatc in ar-
droitin sulfatc (CS) and kcmtan sulfate (KS). Each ticular cartilage is unknown, biologically and func~
CS chain contains 25 to 30 disaccharide units, while tionally.
the shorter KS chain contains 13 disaccharide units Although aggrecans generally have the basic
(MuiJ~ 1983). Aggrecans (previously rererred to as structure as described abovc, they arc not struc-
subunits in the American literature or as monomers turally identical (Fosang & Hardingham, 1996). Ag-
in the UK and European literature) consist of an ap- grecans vary in length. molecular weight, and com-
proximately 200.nanol11ctcr..long protein core to position in a variety of ways; in other words, they
which approximately 150 GAG chains, and both 0- arc polydisperse. Studies have demonstrated two
linked and N-linked oligosaccharides, are covalently distinct populations of aggrecans (Buckwalter et aI.,
attached (Fosang & Hardingham, 1996; Muir, 1983). 1985; Heincgard ct aI., 1985). The first population is
Furthermore, the distribution of GAGs along the present throughout life and is rich in CS; the second
protein core is heterogeneous; there is a region rich contains PGs rich in KS and is present only in adult
in KS and O-linked oligosaccharides and a rcgion cartilage. As articular cartilage matures, other agc-
rich in CS (Fig. 3-6M. Figure 3-611 dcpicts the fa- related changes in PG composition and structure
mous "boule-brush" model for an aggrecan (j\lluir, occur. vVith canilage maluration, the watcr content
1983j. Also shown in Figurc 3-6/\ is the hctcrogcne- (Armstrong & Mow, 1982; Bollet & Nancc, 1965;
ity of the protein core that contains three globular Linn & Sokoloff, 1965; Maroudas, 1979; Venn,
regions: GIl the HABR located at the N-terminus that 1978) and the carbohydrate/protein ratio progres-
contains a small amount of KS (Poole, 1986) and a sively decrease (Garg & Swann, 1981; Roughley &
few N-Iinked oligosaccharidcs, G., located between White, 1980). This dccrcase is mirrored by a de-
the HABR- and the KS-rich regio·n (Hardingham et crease in the CS content. Conversely, KS. which is
aI., 1987), and G" the corc protcin C-tenninus. A I: I present only in small ,imounts at birth, increases
stoichiomelly C:dslS between the LP and the GI throughollt development and aging. Thus, the
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 non covalently 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.
,',.
>
f.
i \~
1
If "~.,
CS/KS ratio, which is approximately 10: 1 at birth, is proximately 70(;r; of the water may be moved, This
only approxirnatel:v 2: I in adult cartilage (Roughlcy interstitial fluid movement is important in control-
& "Vhile, 1980: Sweet et al" 1979; Thonar et al" ling cartilage mechanical behavior and joint lubri-
1986). Furthermore, sulfation of the CS molecules, cation (Ateshian et aI., 1997, 1998; Hlavacek, 1995;
\vhich can occlir at either the 6 or the 4 position, Hou et aI., 1992; Mow et aI., 1980; Mow & Ateshian,
also undergoes age-related changes. In utero, chon- 1997).
droitin-6-sulfate and chondroitin-4-sulfate are pres-
ent in equal molar amounts; however, by maturity,
STRUCTURAL AND PHYSICAL INTERACTION
the chondroitin-6-sulfate:chonclroitin-4-sulfatc ra-
AMONG CARTILAGE COMPONENTS
tio has increaseel to approximately 25: I (Roughley
et a1., 1981). Other studies have also documented an The chemical structure and physical interactions
age-related decrease in the hydrodynamic size of of the PG aggregates influence the properties of the
tf~e aggrecan. Many' of these early changes seen in ECM (Ratcliffe & Mow, 1996). The closely spaced
articular cartilage may reflect cartilage maturation, (5-15 angstroms) sulfate and carboxyl charge
possibly as a result of increased functional demand groups on the CS and KS chains dissociate in solu-
\vith increased \vcight-bcaring. Ho\vever, the func- tion at physiological pH (Fig. 3-7), leaving a high
tional significance of these changes, as well as those concentration of fixed negative charges that create
occurring later in life, is as .\'ct undetermined. strong intramolecular and intermolecular charge-
charge repulsive forces; the colligative sum of
these forces (when the tissue is immerscd in a
WATER
physiological saline solution) is equivalent to the
\Valel~ the most abundant component of articular Donnan osmotic pressure (Buschmann & Grodzin-
cartilage, is n10st concentrated ncar the anicular sky, 1995; Donnan, 1924; Gu et aI., 1998; Lai et aI.,
surface (_80°;(j) and decreases in a near-linear fash- 1991). Structurally, these charge-charge repulsive
ion with increasing depth to a concentration of ap- forces tend to extend and stiffen the PG macro-
proximately 65% in the deep zone (Lipshitz et al., molecules into the interfibrillar space formed by
1976: Maroudas, 1979). This Iluid contains many the surrounding collagen network, To apprcciate
free mobile cations (e.g., Nu', K', and Cal.) that the magnitude of this force, according to Stephen
greatly! influence the mechanical and physicochem- Hawkings (1988), this electrical repulsion is one
ical behaviors of cartilage (Gu et aI., 1998; Lai et aI., million, million, million, million, million, million,
1991; Linn & Sokoloff, 1965; Maroudas, 1979). The million times (42 zeros) greater than gravitational
fluid component of articular cartilage is also essen- forces.
tial to the health of this avascular tissue because it In nature, a charged body cannot persist long
permits gas, nutrient, and waste product movement without discharging or attracting counter-ions to
back and forth between chondrocytes and the sur- maintain electroneutrality, Thus, the charged sulfate
rounding nutrient-rich synovial fluid (Bollet & and carboxyl groups flxed along the PGs in articular
Nance, 1965; Linn & Sokoloff, 1965; Mankin & cartilage must attract various counter-ions and co-
Thrashel; 1975; Maroudas, 1975, 1979). ions (mainly Na', Cal., and C I") into the tissue to
A small percentage of the \vater in cartilage re- maintain electroneutrality. The total concentration
sides intracellularl y', and approximately 30% is of these counter-ions and co-ions is given by the
strongly associated with the collagen fibrils well-known Donnan equilibrium ion distribution
(Maroudas et aI., 1991; Torzilli et aI., 1982). The in- law (Donnan, 1924). Inside the tissue, the mobile
teraction between collagen, PG, and water, via Don- counter-ions and co-ions form a cloud surrounding
nan osmotic pressure, is believcd to have an im- the fixed sulfate and carboxyl charges, thus shielding
portant function in regulating the structural these charges from each othet: This charge shielding
organization of the ECM and its s\velling properties acts to diminish the very large electrical repulsive
(Donnan, 1924; Maroudas, 1968, 1975). Most of the forces that otherwisc would exist. The net result is a
\vater thus occupies the interfIbrillar space of the swelling pressure given by the Donnan osmotic pres-
ECM and is free to move whcn a load or pressure sure law (Buschmann & Grodzinsky, 1995; Donnan,
gradient or other electrochemical motive forces are 1924; Gu et aI., 1998; Lai et aI., 1991; Schubert &
applied to the tissue (Gu et aI., 1998; Maroudas, Hamerman, 1968). The. Donnan osmotic pressure
1979). When loaded by a compressive force, ap- theory' has been extensivel:v used to calculate the
a1~~,V/P~'RT1 • BIOMECHANtCS OF TISSUES AND STRUCTURES OF THE !vlUSCUlOSKEl.ETAl SYSTEM
mechanical propcnies, in the prc.:SCnl context. arti<,:. Creep and strc~s rL,lnxalion phenomcna ll1a~' be
lIlar cartilage may be considered as a Ouid-filled caused b~' differenl Illcchani:sms, For single-phase
porous-permeable (uncharged) biphasic medium, solid pol~'lTh:ric materials, these phenomena are the
with each constituent playing a role in the functional result of iJHcrnal friction caused b.\' the mOl ion or the
behavior of cartilage. long polymL'ric chains sliding over ('ach olher \\'ithin
During joint arlicuhllion, forces at the joint sur- the stressed lll~lIcrial (Fling, 1981), The viscocl"stic
face may vary" from alnl0S1 zero to more than ten bdmvior of tendons and ligamt::IHs is primarily'
times body weight (Alldriacchi et ai., 1997; Paul, eauscd bv this mechanism (Woo et aI., 1987, 1997).
1976). The contact arcas also vary in a cOll1plcx For bone, the long-term viscoelastic lK'hador is
manner and typically they arc only or the order of thought to ilL' caused h.\' a rdati\'c slip uf lamellae
several square centimeters (Ahmed & Burke. 1983; within the osteons along with the Ilow of the inlL'rsti~
Ateshian et al .. 1994). It is estimated that the peak tial Iluid (Lakcs & Saha, 1979). For articul,,,' carti-
contact stress may reach 20 MPa in the hip while hlgC. the compressive \'iscoelastic bdHl\'ior is prilllar~
rising from a chair and to IVIPa during stair climb- i1~' caused h~' the Jlo\\' of tilL' interstitial lillie! and lhe
ing (Hodge et aI., 1986; Newberrv et aI., 1997). Thus, frictional drag associated with this lIow (Ateshian cl
articular cartilage, under physiologicallonding con- aI., 1997; Mow (,t aI., 1980, 1984). In shear, as in
ditions, is a highly stressed malcrial. To understand single-phase viscoelastic pol.vmers. it is primarily
how this tissue responds LInder these high physio- c<.lusL·d b~' tilt:' motion of 10l1g pol~!J1lL'r chains such as
logical loading conditions. its intl"insic mechanical collagen and PGs (Zhu d aI., 1993, 1996). Thc com-
properties in compression, tension, and shear must ponent or anicu[;.\r cartilage dscoclasticit~,caused by
be determined. From these properties, one can un· interstitial lluid !low is known as the hi phasic vis-
dcrstand the load-can~ying mechanisms within the cot.,lastic behavior (i'VlO\\' et a!., 1980), ~lI1d the COI11-
ECM. Accordingly, the following subsections \\"ill ponent of dscoebslicil~' caused b~' macromolecular
characterize tht: tisslIC' behavior under these loading motion is known as til(' l1ow-indepl'ndelll (Ha,\'cs '*
Il'lOclalities. Bc)dinc, 1(78) or the intrinsic visc()elastic behavior or
Ihe collagen-PG solid matrix.
Although the deformational bdwyior has been
described in terms of n lillem' elastic solid (Hirsch,
NATURE OF ARTICULAR CARTILAGE
1944) or viscoclastic solid (I-laves & Mockros, 1971),
VISCOELASTICITY
lhes~ modcls fail to recognii'.e the role or water in
If a material is subjected to the action of a constant the \'iscoelastic behavior or and thc significant con-
(time-independent) load or a constant deforrnation tribution lilal lIuid pressurizalion pla.vs in joint load
and its response varies with time, then the mechan- support and canilage lubrication (Ateshian L't aI.,
ical behavior of the material is said to be viscoelas- 1998; Elmol'c et aI., 1963, Mow & Ratcliffe, 1997;
tic. (n general, the response of slich a material can SokolofL 1963). Recentlv, experimental measure-
be theoretically modeled as a cornbination of the re- ments ha\'c deh:nnined that interstitial fluid pres-
sponse of a viscolls Ouid (dashpot) and an elastic surization supports mort' than YOOk of the applied
solid (spring), hence viscoelastic. load to the canilage surface (Solt/. & Ateshian.
The two fundamental responses of a viscoelaslic 1998) immediately following loading. This ('lfcCl
material arc creep and stress relaxation, Creep oc- can persist for more than 1,000 scconds and thus
curs when a viscoelastic solid is subjected to the ac- shields til(.' EC1VI and chondroc.\'tcs from the crllsh-
tion of a constant load, Typically. a viscoelastic solid ing defonnations or the high stresses (20 MPa) re-
responds with a rapid initial deforrnation followed sulting frollljoilll loading.
by a slow (time-dependent), progressivel)' increas-
ing deformation known as creep until an equilib-
rium state is reached. Stress relaxation occurs when
CONFINED COMPRESSION EXPLANT
a viscoelastic solid is subjected to the action of a
LOADING CONFIGURATION
constant deformation, l~ypically. a dscoelastic solid
responds with a rapid, high initial stress followed by The loading of cartilage in vivo is cxtr('mel~" com-
a slow (time~dependent). progressively decreasing plex. To achic\'C' a better understanding of the de-
stress required to maintain the deformation; this formational behavior or the tissue under load, an
phenomenon is known as stress relaxation. explant loading conliguration known as confined
CHAPTER 3 • BIOMECHANICS Of
compression (lvlow et aL, 1980) has been adopted by rapid initially', as evidenced by the early rapid rate
researchers. In this configuration, a cylindrical car- of increased deformation, and it diminishes grad-
tilage specimen is fitted snugly il1to a cylindrical, ually until flow cessation occurs. During creep,
srnZoth-walled (ideally frictionless) confining ring the load applied at the surface is balanced by the
that prohibits motion and fluid loss in the radial di- compressive stress developed within the collagen-
rection. Under an axial loading condition via a rigid PG solid matrix and the frictional drag generated
p~rol1s-permeable loading platen (Fig. 3-9;1), fluid by the flow of the interstitial fluid during exuda-
will flo\v from the tissue into the porous-permeable tion. Creep ceases when the compressive stress
platen, and, as this occurs, ~he cartilage samp~e will developed within the solid matrix is sufficient to
compress in creep_ At any tIme the amount 01 com- balance the applied stress alone; at this point no
pression equals the volume of nuid loss because fluid flows and the equilibrium strain EX is
both the watcr and theECM arc each intrinsicall:v reached.
incompressible (Bachrach et aI., 1998). The advan- Typically, for relatively thick human and bovine
tage of the confined compression tcst is that it cre- articular cartilages, 2 to 4 mm, it takes 4 to 16
ates a uniaxial, one-dimensional flow and def()rma~ hours to reach creep equilibrium. For rabbit car~
tional J1eld within the tissue, which does not depend tilage, which is generally less than 1.0 111m thick,
on tissue anisotropy.' or properties in the radial diN it takes approximately' I hour to reach creep equi-
recLion. This greatly simplir-Ies the mathematics librium. Theoretically, it can be shown that the
needed to solve the problem. time it takes to reach creep equilibrium varies
It should be emphasized that the stress-strain, inversely with the square or the thickness of the
pressure, fluid, and ion flow fields generated within tissue (Mow et aI., 1980). Under relatively high
the tissue during loading can only be calculated; loading conditions, > 1.0 J\ilPa, 50 0/() of the total
ho\VevcI~ these calculations are of idealized models fluid content may be squeezed From the tissue
and testing conditions. There are man:\' confound- (Echvards, 1967). Furthermore, in vitro studies
ing factors, such as the time~dependent nature and demonstrate that if the tissue is immersed in
magnitude of loading and alterations in the natural physiological saline, this exuded fluid is fully re-
state of prc~strcss (acting \vithin the tissue), that coverable when the load is removed (Elmore et
arise from disruption of the collagen network dur~ aI., 1963; Sokoloff, 1963).
ing specimen harvesting. Despite limitations in de~ Because the rate of creep is governed b.y the rate
terrnining the natural physiological states of stress of fluid exudation, it can be used to determine the
and strain within the tissue in vivo, a number of re N
permeability coefficient of the tissue (Mow et al.,
searchers have made gains to\\'ard an understand~ 1980, 1989a). This is known as the indirect mea-
ing of potential mechanosignal transduction I11ech~ surement for tissue permeability (k). Average values
anisms in cartilage through the use of explant of normal hun1an, bovine, and canine patellar
loading studies (Bachrach et aI., 1995; Buschmann groove articular cartilage permeability k obtained in
et aI., 1992; Kim et aI., 1994; Valhmu et aI., 1998) this manner arc 2.17 X 10. 15 M·'/N·s, 1.42 x 10'" M'/N·s,
based on the biphasic constitutive law For soft hy'- and 0.9342 x 10. 15 M4/N·s, respectively (Athanasiou
drated tissues (Mow et aI., 1980). 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,
BlPHAS1C CREEP RESPONSE OF ARTICULAR
1982; Mow et aI., 1980). Average values of normal
CARTILAGE IN COMPRESSION
human, bovine, and canine patellar groove articular
The biphasic creep response of articular cartilage cartilage compressive modulus H,.\ are 0.53, 0.47,
in a oneNdimensional confined compression ex- and 0.55 megapascal (MPa; note 1.0 MPa = 145
periment is depicted in Figure 3-9. In this case, a Ib/in 2 ), respectively. Because these coefficients are a
constant compressive stress (To) is applied to the measure of the intrinsic material properties of the
tissue at tinlC to (point A in Fig. 3-98) and the tis~ solid matrix, it is therefore meaningful to determine
Slie is allo\ved to creep to its final equilibrium ho\v they vary \vith matrix composition. It was de-
strain (EX). For articular cartilage, as illustrated termined that k varies directly, while He' varies in-
in the top diagrams, creep is caused by the exuN versely with water content and varies directly with
dation of the interstitial fluid. Exudation is most PG content (Mow & Ratcliffe, 1997),
Porous filter
Confining ring
Impermeable platen
A
~
oJ
"0
w 1 o
a
.~ E-'
No exudation C
- - =-.........._----...-
>
.~ c E
a i
r
0;
o 6
B Equilibrium
0-
w Copious deformation
U_A_·___•__• • •__• :e> fluid
Time
o exudation
Time
1
B
A. A schematic of the confined compression loading configu- drawings of a block of tissue above the curves illustrate that
ration. A cylindrical tissue specimen is positioned tightly into creep is accompanied by copious exudation of fluid from the
an impermeable confining ring that does not permit defor- sample and that the rate of exudation decreases over time
mation (or fluid flow) in the radial direction. Under loading, from points A to B to C. At equilibrium (EO'-'), fluid flow ceases
fluid exudation occurs through the porous platen in the ver- and the load is borne entirely by the solid matrix (point C).
tical direction. B. A constant stress (T" applied to a sample of Adapted from MOH~ VC, Kuei, S,C, Lai, Wl'vl., f:.'( af. (1980).
articular cartilage (bottom left) and creep response of the Biphasic creep and stress relaxation of articular cartilage in com-
sample under the constant applied stress (bottom right). The pression: Theory and experiments. J Siomech Eng, 102, 73-8fl
CHAPTER 3 • BIOMECHANICS Of
Copious
fluid exudation
Fluid redistribution
(no exudation)
t 1I t I I
A B
III c D
I---"'L-o-a-d-in-g---ll jf------"S-tr-e-ss-'e-Ia-x-a-'i-o-n------
E
Equilibrium
deformation
cw B
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
specimen commencing at to (bottom left) and the stress- D) until an equilibrium is reached (point E). Above these two
response curve of the cartilage in this uniaxial confined- curves, schematics illustrate interstitial fluid flow (repre-
compression experiment (bottom right). The sample is com- sented by arrows) and solid matrix deformation during this
pressed to point B and maintained over time (points B to E). compressive process. Fluid e~udation gives rise to the peak
The history of the stress and response shows a characteristic stress (point B), and fluid redistribution gives rise to the
stress that rises during the compressive phase (points to to B) stress-relaxation phenomena.
G:.Z,1,;;,;rfttr}, ')i1PiylECHANICS Of TISSUES AND STRUCTURES Of THE MUSCULOSKELETAL SYSTEM
the hi!:!h stress is generated bv forced exudation of by the relationship k ~ W/K (Lai & Mo\\', 1980), Ar-
the in~crstilial fluid and the c~mpaclion of the solid {j'cular 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
causcd bv the relicf 0" rebound of the high COIll- when n~,id is caused tn flo\\" through the porous
paction r~gi(}n ncar the surface or the solid matrix. solid matrix.
This stress-relaxation process will cease when the In the previous sections on c;:\rtilage \·iscoclastic~
compressive stress developed within the solid ll1alrix ity \\·e discw;st.'d the process of lluid !low through
reaches the stress generated by the intrinsic COIll- articular cartihH.!e induced bv solid matrix compres-
pressive modulus of the solid matrix corresponding sion and how ll~is process i;lfluences lI1L' viscodas-
to U o (Holmcs ct 'II., 1985; Mow ct aL, 1980, 1984), tic behavior or the tissuC'. This process ;:l1so provides
Analysis of this stress-relaxation process leads to lhe an indirect method to dctcrmine the permeability of
conc"!usion that under physiological loading cOl1cli- the tissuc. In this section, we discuss the cxpcri-
lions. excessive stress levels arc difficult (() maintain mCJ1t~11 method uscd to direct I.\' measure the perme-
because stress relaxation will rapidly a(lenuat~ the ability codTicknt. Such an L'xperim(:nt is depicted
stress developed within the tissue; this must ncces~ in Fi~urL' 3-1 I.·\. Here, a specimen or the tissue is
sarily lead to the rapid spreading of the contact area held fixed in ~\ chamber subjected to the action or a
in tht:: joint during articulation (Atcshian el aI., 1995, pressure gradicl1l: tilL' imposed upstrt.'al11 pl\:ssure
1998; tvlow & Atcshian, 1997), PI is greater than the dOwJ1slrt.:;:\Il1 pressure P2' The
Rcccntlv, much focus has been on the inholllo- thick~css 01" tlte specimen is denoted by hand
gencitv o(I-IA with carLilagc depth (Schinagl ct aI., the cross-sectional an..-a 01" pt.'nneatiol1 is ddined
1996, '1997), Bascd on thi~ data, from an analysis b\· A. Darcy's law, L1sed to determine the perme~\bil
of the stress-relaxation experiment it was round it'\" k fron~ this simple t.'xpcrimental St.'ltlp, ~·idds
that an inhornogencous tissue would relax at a k' = Qh/A(Pi-P2). where Q is the \'olumelric dis~
faster rate than would the unirorlll tissue (\Vang & chargL' per unit time through the specimen whose
1\110\V, 1998). iVloreovcr, the stress, strain, pressure, area 01" permcm ion is A ([\llo\\' & R;:ltcl irr(" 1997). Us-
and Ouid flow fields within the tissue were signif- ing low pressures, approxiJ11atel~' 0_1 ivlPa. this
icanllv altered as well. Thus it seems thal the vari- mClhod was f1rslused to determine the permeability
ation~' in biochemical and structural composition of articular cartilage (Edwards, 1967; lVlnroudas,
in the layel"s of cartilage pl"ovide anothet- challenge 1975). The value ~I" k obtained in this manner
to understanding the environn1ent of chondro- ram!ccl from 1.1 x 10. 1 < m·l/N·s 10 7.6 ;:.< 10. 1 ' m·:/N·s.
c.vtes in situ. In ~~ddition, using a uniform straight tube model.
the ;:\\IL'rage "pore diameter" has been estimatt.:d at 6
11111 (Maroudas. 1979), Thus. the "pores" within ar-
PERMEABILITY OF ARTICULAR CARTILAGE
tinllar cartilage are of mokcular size.:',
Fluid-filled porous materials ma~' or may not be per- The pL'nnt.'abilit~'or Hnicular cartibgc under com-
mcablc, Thc ratio of nuid volumc (VI) to thc total pressive strain and at high physiological pressures
volume (\IT) of the porous material is known as the (3 MPa) was first obtained b~' j\Aansour and lV'1c)W
porosity (f3 :; ;: ViI VT); thus, porosity is a geOJ1lclric (1976) and later analvzed by Lai and ,Vlo\\' (1980),
concept. Articular cartilage is therefore a material The high pressure and compressh"e strain conditions
of high porosity (approximately 80%), If the pores examined in these studies more c1osd~' resemble
are int~rconnected, th.; porous material is perme- those conditions found in dianhrodial joint loading.
able. PermeabilHv is a measure of the ease with In these l.'xperimcnts, k was measured as a function
which fluid can f1(~W through a porous material. and or two variables: the pressure gradient across the
it is inversely proportional to the frictional drag ex~ specimen and the axial compressive strain applied to
ened by the fluid flowing through thc porous, the sample. Tht.· results from these experiments arc
permeable material. Thus, permeability is a physi- shown in Figure 3-11 B. Permeabilit~· decreased expo-
cal concept; il is a meaSure of the resistive force that nentially ~lS a function of both increasing compres-
is required to cause the fluid to Ilow at a given speed sive slr~lin and increasing applied Iluid pressure, It
through lhe porous-permeable material. Thb fric~ was hlter shown, however, that. the dependence of k
tional resistive force is ~enerated bv rhe inleraction Ion the applied fluid pressurt.: derives from com-
of the intcrstitial fluid-and the p;'rc walls of the paction of the solid matdx that. in lurn, results from
porous-permeable material. The permeability coeffi- the frictional drag ("used by rhe permeating nuid
cient k is related to the frictional drng coefficient K (Lai & MO\\', 1980), From the point of view of pore
.'
r.··.'·····,·;
CHAPTER 3 • 810MECHANICS OF ARTICUlI\RCb,RT~~J&1~'1)
Applied
pressure difference
Fluid
,- , , , "~
"e
16
r
(P,-P,)
pressure
P ,
'-
I i
Fluid flow
I ~
14
12
.0.069 MPa
.0.172 MPa
I
... 0.342 MPa
Rigid ~
.. ,;.;.;+:.:.:. :.:.:-: .;.:.:.... -'-- 0
r
porous { C><I;:, h
x
10 00.689 MPa
~ 1.034 MPa
blocks '-
J , L ~ ~
:c
8
01.723 MPa
- I, 1Fluid1flow
Fluid Articular 6
pressure - cartilage '" 4
P2 §'"
• • ! !
I I a.'" 2 r
o[
-UIlIU
..I B
0 8 16 24 32
Applied Compressive Slrain {%}
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-
rhe fundamental fluid cranspon mechafllsms rhrough normaJ and ing a pe-rmeaiion experimenr. J Btorheology, 17. J 11 .
. ,1
•. ~---------------------------------
';S,n~IC[lIre, compaction or the solid matdxdecreases specimens h"rvested in the direction parallel to the
9j~ porosity' and hence the average "pore diameter" split line pattern than those harvested perpendicu-
" \\Iithin the solid matrix; lhus, solid matrix compac- lar to the split line pattern) and strongly inhomoge-
tion increases fTictional resistance (MOWCl aI., 1984). neous (for mature anirnals. being stiffer and
... >",:1'he nonlinear permeability of articular cartilage stronger fOl' specimens harvested from the superfi-
'X de.monstrated in Figure 3-11 B suggests that the lis- cial regions (han those harvested deeper in the tis-
<~/!7:9~ has a mechanical feedback sYSlem that may sue) (Kempson. 1979: Roth & Mow, 1980), Intercst-
.J;s,e~'ve important purposes under physiological con- ingly, articular cartilage rrom immature bovine knee
:'o'ditions. When subjecled 10 high lo"els through the joints does not exhibit these layered inhomoge-
\mechanism of incrcnsed frictional drag against in- neous variations; however, the superficial zones of
:)~rslitial l1uiel 110w. the tissue will "ppear sLirfer "nel both ITlature and immature bovine cartilage appear
:';L'h will be more difficult to cause fluid exudation. Re· to h"ve the ,,,me tcnsile stiffness (ROLh & Mow,
(cent analyses of articular cartilage compressive 1980). These anisotropic and inhomogeneous char-
/,',/ ':,s,trcss-relaxation behavior have validated this con- acteristics in mature joints arc believed to be caused
;C:"'c'ept and its importance in the capacity of the inter- by the vaI)'ing collagen and PG stnlctural organiza-
g, stili,,1 Ouid La support load (Ateshian eL al.. 1998: tion of the joinl surface and the layering structural
;'::;',":,~oltz & Ateshian, 1998). Moreover, this mechanism arrangements found within the tissue_ Thus, the col-
;< /al~o is important in joint lubrication, lagerH'ich superficial zone appears to provide the
joint cartilage with a tough wear-resistant protective
skin (Sellon et "I.. 1993) (Fig. 3-3;\),
/9BEHAVIOR OF ARTICULAR CARTILAGE
§;&,UNDER UNIAXIAL TENSION
Articular cartilage also exhibits viscoelastic behav-
ior in tension (\-Voo ct "I.. 1987). This viscoelastic be-
~~?''.::~:;rhe mechanical behavior of articular canilage in havior is allributable to both the internal friction as-
3~~;'{enSion is highly complex. In tension, the liss~le is sociated with polymeric motion and the flow of the
,:~.~; strongly anisotropic (being stiffer and stronger for interstitial fluid. To examine the intrinsic mechanical
A ;'::;;--"
'i";
'.C:; ".'.,
-i· response of the collagen-PC solid matrix in tension,
it is necessary to negate the biphasic fluid now ef-
+i TenSIle modulus. E Ci!t
-
I
fects. To do this, 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-
~
'=-
c
I Failure
2 .!---- ~~~
~--\
-------------
delermined from tilL' ~cnnnil1g dcctron micrograpll
single Young's modulus. Rather, a tangent modulus,
defined by the tangent to the stress-strain CUI'\'C. pkltln..: s (h.'h). Ch.'arl.\· it can he seen lhal ll1l.' c()lla-
must be used to descl'ibe the tensile stiffness of the gcn lletwork within c~lrlil~\gL.' l"L'sponds to lensile
tissue_ This fundamental result has given rise to the sll\.. s~ and strain (\Vada 1..'\:. Akizuki, 19~7l.
wide range of Young's modulus. 3 to 100 ,\lIPa, re- If the mok'ctll~lr st!1H.:(urc or L'(Jllag('~Il, Ilk' organiz,l-
poned for anicular cartilage in tension (Akizuki et lion of thL' collagen fibers within the collagcllolls IWI-
aI., 1986; Kempson, 1979; Roth & Mow, 1980; Woo \\"01''', or tilL' collngl'1l IiIK'!' lToss-lillking is altlTl~d
et aI., 1987). At physiological strain levels, however, (such ~lS tin\! OcclIlTing in mild fibrillation or OA), the
;.: less than 15% (Armslrong et aI., 1979) of the linear tensile prolKTlies of the I1L'I\\'ork \\'ill ch~lIlge. Schmidl
Young's modulus of anicular cartilage ranges be- l't al. (1990) ha\'c shown a definitive' t\:.-btionship be-
tween 5 and 10 MPa (Akiwki et aI., 1986). 1\\"C'I.'11 collag.. . n hydroxypyridinillm cn)ss-linking ~llld
Morphologically, the cause for the shape of the lensik' stilflk.'SS ~II)(I stn.. ,lgtll of nOI'mal h(wirH.~ carli-
tensile stress-strain curve for large strains is de- hlg(·. Aki/.uki et al. (1086) showcd lhat pr()grcssi\'(~
picted in the diagrams on the right or Figure 3-12. dcgr~\dnlion or lUI man kllL"C joint cartilag:(.', from mild
The initial toe region is caused by collagen fiber librillation 10Of\. ~'iclds n progn..:'ssin· (k'krioratio!l or
pull-out and realignn'lCnt during the initial pan ion Ilk' illl rinsic Icnsik' propl".'1'liL'S IJI" Ihe collagcn-PG :->()Iid
of the tensile experimel1l, and the final linear region matrix. Similar rl.'sults 11<.1\'(' bccll obsen'\..-d n.. .c\..'nll\ ill
is caused by the stretching of the straightcned- 'lI1ill1"lll1odcls of O!\ (Guil", l't ,Ii.. 1004; SCt!(Hl ct aI.,
aligned collagen fibers. Failure occurs when all the It)t).t). l()g\..,tllcr, lhese obSCI·V~llioJls sllpporl tll'..' belief
collagen fibers contained within the specimen are that disruptioll of tilL' colbgcn IlL'lwork is ~\ kL'~' factor
ruptured. Figure 3- I 3/\ depicts an ullslretched artic- ill thL' initial CH'IHS iL'adillg 10 11K' dC\'L'lopmcllt of ot\.
ular cartilage specimen, while Figure 3-138 depicts Also. loosening of til\.' collagen network is gCI1\..'rall:v he-
a stretched specimen. Figure 3-14, A & B shows' licved to h(' responsible for tlte incrcased swclling,
scanning eleclron micrographs or carlilage blocks hCllci..' W~Il\..T COI1H.'nl. or ostL'oartlll'ilic cartilage
;;.
under 0 and 30% sU'elch (right) and the COlTe- (Mankin &: Thrasher, 1973: iVlaroudas. 1979). \,Vc.: han~
sponding histograms of collagen fiber orientation ;:d]"L'ad~' discussed htl\\" iJ1cl"L'asl'd walcr cOlllClll le~lds
CHAPTER 3 • BIOMECHANICS OF ARTICULAR C,~RTlLAGytff;!??"1)
Unloaded
..AIf--+ Collagen
+--f-water
Proleoglycan
i '
E.R., Lal: V:l.M.• & Mow V.C (1984). A continuum rheory and an
experiment for the ion-induced swelling behaviorcartirage. 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~ular cartilage. volumetric change causes interstitia) nuid now and
induces biphasic viscoelastic effects within the tis-
sue. H, however, articular cartilage is tested in pure
BEHAVIOR OF ARTICULAR CARTILAGE
shear under infinitesinlal strain conditions. no
IN PURE SHEAR
pressure gradients or volumetric changes will be
In tension and cOIllpression. only the equilibrium 'produced within the material; hence, no interstitial
intrinsic properties of the collagen-PG solid malri~ fluid flow will occur (Hayes & Bodine, 1978; Zhu
can be determined. This is because a volumetric et aJ. 1993) (Fig. 3-15). Thus, a stead v dynamic
change always occurs within a material when it is pure shear 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
J:::~! '8.9~
'km= :: 17.6':>
intrinsic viscoelastic propcrLics or the collagen-PG viscoelastic propcnies arc equival~nl1y defined by
solid matrix. the elastic storage modulus G'; the viscous loss
In a steady dynamic shear experiment. the vis- modulus G" of the collagen-PG solid matrix may be
coelastic properties of the collagcn-PG solid matrix determined as a runction of frequency (Fling, 1981:
are detenl1ined by subjecting a thin circular wafer Zhu et aI., 1993).
of tissue to a steady sinusoidal torsional shear, Sometimes it is morc convenient to determine
shown in Figure 3-16. 1n an experiment of this type, the magnitude of the dynamic shear modulus IG"i
the tissue specimen is held by a precise amount of given by:
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 and the phase shifl angle given by:
precision mechanical spectrometer with a senro-
l) = tan' (G"/G')
controlled de mot01: A sinusoidal excitation signal
may be provided by the motor in a frequency of ex- The magnitude or lh~ d~'namic shear modulus is
citation range of 0.01 to 20 hertz (Hz). For shear a measure of the tala I resistance offered bv the vis-
strain magnitudes ranging from 0.2 to 2.0°10, the coelastic material. The value of 0, lhe angl~ between
1-,-----
!<::,::':,
~
r
f'
[
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
~ipusoidallorqllcresponse, is a measure of the total angle ranging up to 70" (Mow et aI... 1989b; Zhu ct
':";Edctional energy dissipation within the ll1aterial. aI., 1991, 1996), Therefore, it appcars that the mag-
EoI' a pure elastic material with no internal fric- nitude of the shear modulus of concentrated PG so-
-.0,"
,,
,:'ti'onal dissipation, the phase shift angle 8 is zero; for
:iijJurc viscous fluid, the phase shih angle 8 is 90t '.
)/;·The magnitude of the dynamic shear modulus for
'i':t1()rmal bovine articular cartilage has been mea-
sw\:d to range from I to 3 ~llPa, while the phase SIN (f n
'r shift angle has been measured to range from 9 to
20' (Hayes & Bodine, 1978; Zhu Cl aL. 1993), Thc in-
irinsk transient shear stress-relaxation behavior of
I
::':tI1t~ collaucn-PG solid matrix along with the steadv 'd
'\Iynamic . . .s hear properties also ha; been llleasUl'e~1
;',:. (Zhu el aI., 1986), Wilh bOlh lhc sleady dynamic and
'::'thc. transient results, the laller investi'gators showed I
. ~at the quasilinear viscoelasticity th~ory proposed
I
'?;:'.py Fung (198l) for biological materials provides an
I
<"accurale dcscription of the flow-independent vis-
i; coelaSlic behavior of lhe colla!!cn-PG solid malrix, .. 111 ~I
'.:':/,}<'jgure 3-17 depicts a comparis--on of the theoretical
'prediction of the transient stress-relaxation phe- Time
;[lomenon in shear with the results from Fung's t 981
'quasilinear viscoelasticity theory.
/:.. From lhese shear sluciies. it is possible to obrain
SOme insight as to how the collagen-PG soHd matrix Steady sinusoidal torsional shear imposed on a specimen in
functions. First, we note that measurements of PG pure shear. The fluctuating strain in the form of a sine
>:. SOlutions at concentrations similar to those found in wave with a strain amplitude filand frequency f.
':>a. nicular cartila(Tceo in Silu .'vidd a ma~miLudc of shear
0:;"
ill Iht: ullla~I..·1l 111..'1\\1 Irk. 1')I,.·rJllib till..' PC ~I..'I ill the
1.0 cc.,II"I~l:1I Ill't\\"ork to rl..':--.i:--t c{JlI1l)rl..·.... ~ion (DOIlIl" U1 .
11 '= 0.. 0004 192-l: Marolld.. I:--'. 1~79: ,'vl0\\·I..\: Rall.:lilll', 19971. TCI ;\C~
i5' 12"" 36.2 cOlllll for :--.tH.'h Fix('d Char~l..· DI..'I1:--.ily (FeD, 1...·lfech in
C 0.8 c = 0.13 cartila1!l'. a lriplla~i(.· Ilk,dlancl-l..·kdnl\,:llelTlical. llHdli-
·uc0 1..·!L·I...·ln,I.\·k· Ihcor,\' \\":I~ d ...·\·t.. !opl..·d [kit rJl(ldd~ cartibge
~
U.
c
"l~ a mi'\tlIrl...· (lr Ihn..·\,· misdhk' pklsl..·s: a cklr~l..·d s(Jlid
.Q pkhl..· rl..'j)rL·SI..·llIill~ IhL' \.:(jIl"I~I..·n.PC IlL'I\Ulik a fluid
1ii
x
~
phasL' rl..'l.,rL·~I..'llling th\,o inll..'rstiti .. d \\·<llI..'r, <llld an inn
a; ! j ! j ! ! ph"lse cOlllpri~illg tlk' llltlnO\·i.lk'llt L'alillil ' a - .. \1"1<.1 ~ln~
c: 0.'
'0
~ ion CI a~ \\"1..,11 as Dllk'l' 1l111llh·.. dl..·1l1 Slk'l..:iL's such ;IS
U
~ C"I' (ClI L'I <II., llJlJ:{: l.'li 1..'1 al..llJ01 ). I Il I hi~ I hl'olY. I he
.,
'0
IOlal slrl..·s~ i:- ~in'll h.\· IIIL' slim or 1\\'0 1I..'rllls: CT"~": :::.:
a: 0.2
CT,,,h.1 .~. Ulh"'i. \\"hel·I..' (T,,·"·I .llId (T,:',,·I "Irl' Ihl' ~()Iid Ill:l-
Subchondral bone
Articular cartilage
~ Load
Articular cartilage
• p
+f-o
•
A, In hydrodynamic lubrication, viscous fluid is dragged pacity depends on the size of the surfaces. velocity of ap-
into a convergent channel. causing a pressure field to be proach, and fluid viscosity. C. The direction of fluid flow
generated in the lubricant. Fluid viscosity. gap geometry, under squeeze-film lubrication in the boosted mode for
and relative sliding speed determine the load-bearing ca- joint lubrication. D. Depicts the Weeping lubrication hy-
pacity. B. As the bearing surfaces are squeezed together, pothesis for the uniform exudation of interstitial fluid from
the viscous fluid is forced from the gap into the transverse the cartilage. The driving mechanism is a self-pressurization
direction. This squeeze action generates a hydrodynamic of the interstitial fluid when the tissue is compressed.
pressure in the fluid for load support. The load-bearing (a-
The other is fluid-film lubrication, in which a thin 0.02 (Dowson. 196611967; Linn. 1968; McCutchen.
fluid-filn1 provides greater sllrrace-to~sllrracesepara- 1962; Mow & Atcshian. 1997). Boundary-lubricated
tion (Bowden & Tabor; 1967). Both lubrication types sllIfaces typically have a coefficient of friction one or
appear to occur in articular canilage under vaJying two orders of magnitude. higher Lhan surfaces lubri-
circulllstances. Intact synovial joints have an ex- cated by a fluid-111m, suggesting LhaL synovial joints
tremely low cocrf!cicnl or friclion, approximately are lubricated. al 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
;;{',.~. ::.'\i~.{tihe:;mechanism that will most effectively provide as its rheological properties, viscosity and elasticity,
;ft\:. fU$rica~ion at a given loading condition. Unresolved, the film geometry, the shape of the gap between the
.;~:;' ~23:Jnc}Y:fllFjS the manner by which synovial joints gcn- two bearing surfaces, and the speed of the relative
';%.;0;;:~~;>tethe fluid lubricant film. surFace motion.
;/:; Cartilage is unlike any man-made material with
;:';..c;.
;,~Z
""''',.'.
~~r ' respect to its near Frictionless properties. Classical
}-iN,., Fti.JIP-fILM LUBRICATION theories developed to explain lubrication of rigid
;;;.;;iir$Jdi~i!ri]m lubrication utilizes a thin film of lubl'i- and impermeable bearings (e.g., steel) cannot fully
"H:~'~'.> c~nt that causes a bearing surface separation. The explain Ihe mechanisms responsible for lubrica-
'6.·Jld.~a on the bearing is then supported by the pres- tion of the natural diarthrodial joint. A variation
";j~\.tt·~that is developed in this fluid-film. The nuid- of the hydrodynamic and squeeze-film modes of
.'";:' ,..~';dihn';thickness associated with engineering bearings fluid-film lubrication. for example, occurs \vhen
C/. 'isitsually less than 20 f.l.m. Fluid-film lubrication re- the bearing material is not rigid but instead rela-
' ... q"jres a minimum nuid-fllm thickness (as predicted tively soft, slich as with the articular cartilage cov-
,i':i>Y/a"speciflc lubrication theOIy) to exceed three ering the joint surface. This type of lubrication,
~f~;tioles' the combined statistical surface roughness of termed elastohydrodynarnic, operates when the
cahUage (e.g., 4 to 25 f.l.m; Clarke, 1971; Walker et relatively soft bearing surfaccs undergo either a
,al:;)970). If fluid-film lubrication is unachievable sliding (hydrodynamic) or squceze-film action and
, ',;':,b~C~lllse of heavy.. and prolonged loading, incongru- the pressure generated in the fluid-film substan-
'e'nL'gap geomclI)', slow reciprocating-grinding 1110- tiallv deforms the surfaces (Fig. 3-19, A & B).
tion, or low synovial fluid viscosity, boundary lubri- These deformations tcnd to increase the surface
cation must exiSl (Mo\\' & Ateshian, 1997). area and congnlcl1cy. thus beneficially altering
The two classical modes of fluid-film lub"ication film geomCli)'. By increasing the bearing contact
" defined in engineering are hydrodynamic and area, the lubricant is less able to escape from be-
squeeze-film lubrication (Fig. 3-19, A & B). These tween the bearing surfaces. [t longer-lasting lubri-
modes apply to rigid bearings composed of rela- cant film is generated. and the stress of articula-
tively undeFormable material such as stainless steel. tion is lower and 1110re sustainable. Elastohydro-
l-lydrodynamic lubrication occurs when nonparallel dynamic lubrication enables bearings to greatly
rigid bearing surfaces lubricated by a nuid-film increase their load-carrying capacity (Dowson,
move tangentially with respect to each other (i.e., 196611967,1990).
slide on each other), forming a converging wedge of Note that several studies have shown that
Ouie!. A lifting pressure is generated in Ihis wedge by hyaluronidase treatment of synovial fluid, which de-
the fluid viscosity as the bearing motion drags the creases its viscosity (to that or saline) b~; causing de·
fluid into the gap betwcen lhe surfaccs, as shown in polymerization of HA, has lillie effect on lubrication
Figure 3~ 19A. In contrast, squeezc-f-Ilm lubrication (Linn, 1968; Linn & Radin, 1968). Because nuid-fllm
Occurs when the bearing surfaces 1110\'e perpendicu- lubrication is highly dependent on lubricant viscos-
lad.''''- toward each other. A pressure is generated in ity, thcse results strongly suggest that an alternative
the fluid-film as a result of the viscous resistance of 1110de of lubrication is the primary mechanism re·
the fluid that acts to impede its escape from the gap sponsible for the low frictional coefficient of joints.
(Fig. 3-19B). The squeeze-film mechanism is suffJ-
cientto cany high loads for short durations. Even-
BOUNDARY LUBRICATION
tually, however, the fluid-film becomes so thin that
contact between the asperities (peaks) on the two During diarthrodial joint function. relative motion
bearing surfaces occurs. of the articulaling surfaces occurs. In boundary lu-
Calculations of the relative thickness of the fluid- brication. lhe surfaces are protected by an ad-
film layer and the surface roughness are valuable in sorbed layer of boundary lubricant, which prevents
establishing when hy'drodynarnic lubrication may direct. surface-to-surface contact and eliminates
exist. In hydrodynamic and squeeze-film lubrica- most of the surface wear. Boundarv lubrication is
tion, the thickness and extent of the nuid-fllm, as .' essentially independent of the phy~ical properties
well as its load-carrying capacity, are characteristics of either the lubricant (e.g .. its viscosit~,) or the
independent of the (rigid) bearing surface material bearing material (c.g., its stiffness). instead de-
properties. Thcse lubrication characteristics are in- 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
~n~1\\l~lf2t±-
shirl or 1111id-film lo bOl1ndar~-" luhrication with lim.:
0\'(.'1' the same loc'-llion (\Valkcr I.'l aI., \070).
The articular cartilagl...' :-;urf<'KL~. like all surfaces. is
not pL'rfCCtl.v smooth; as(k'ritics project out from tll(~
surface (Clarke, 1971; Gardner oS: McGillivray. 1971;
Lubricating glycoprotein Articular surface
Rc(IIl..~r& Zimn~', 1970) (Fi~s" 3-3/3 and 3·21). In syn M
-o~m'x;\;~,'~;
To summarize, in any bearing, the effective mode
of lubrication depcnds on thc applicd loads and on
the relative velocit~' (speed and direction of motion)
Boundary Articular of the bearing surfaces. Adsorption of the synovial
lubricated surface fluid glycoprotein, lubricin, to articular surfaces
asperity seems to be most important under severe loading
contact
conditions, that is, contact surfaces with high loads,
low relative speeds, and long duration. Under these
conditions, as the surfaces arc pressed together, the
Schematic depiction of mixed lubrication operating in ar· boundary lubricant monolayers interact to prevent
ticular cartilage. Boundary lubrication occurs when the direct contact between the articular Stll·races. Con-
thickness of the fluid~film is on the same order as the versely, Ouid-mm lubrication operates under less se-
roughness of the bearing surfaces_ Fluid-film lubrication vere conditions. when loads arc low and/or oscillate
takes place in areas with more widely separated surfaces. in magnitude and when the conlacting surfaces are
I Adapred from Armstrong, e.G" & Mo~-v. Ve. (1980), Friccion. Iv-
br;(Miofl clod wear of synovial joints. In: R. Owen, 1. GoocH(!lIow,
moving at high relative speeds. In light of the varied
demands on diarthrodial joints during normal func-
ilnd P. Bullot/gll (Eds). Scientific Foundations of Orthopaedics
tion, it is unlikely that only a single mode of lubri-
(lnd TraumMology (pp_ 223-232), London: William Heinemwnn.
calion exists. As )/ct. it is ,impossible lO slate dell-
I
:~
HA gel in joint lubrication·' remains unclear, ho\\'- during an extended period of standing follow-
i
~'.''.'._--~~"~,-,.,,"'''',!,,,_,_,_----~,.....= ,.,.,,"'"<" "- " ', ,",'!'='-' ' r-'- - - - -~"=,., , ,.7' ' '"' ' ' ,) :~ , "'---"'-"~'~-'"
"r
• BIOMECHAI'JlCS OF TISSUES AND STRUCTUH!
Solute and
small particle Articular Hi ;'cW) :i:r'
flow surface ri,;;Cfor-r!O:C:CL:ic::-',
T-=--
I
-=. ,., - -- -- ' -- --
1-=-- "-
0.02-1 urn ..
I SUrf;:iCC
ilmlEL ""
Ultrafiltration of the synovial fluid into a highly viscous gel. edU"\:, of their' "ile', afe \H1i]bir:, tu C'~(ilP(" TlH.'se Hi, 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 ti'~"H
rI ecules escape into the articular cartilage and into the lateral
joint space, leaving the large HA macromolecules that, be-
lubricate's the "nicul.Jr' surfi'l(OS, This hypothc,,,iled IL;bric,:;tion
moclc' is lC'ln:(~d "i)()o51cci lubriCdtion "
ing impact, the fluid-film Ina)' be clilninatcd, :\III](lll~~lt i\J:li.,! i:-- p~lrlili(IIl!..:d h,:l\\l'l'll llll' "olid
allo\ving sllrface~to-sllrracecontact, The sur- :llH,lllllid pll~l:-'l'" o! ~\ hipll~l"il' Ill~\llTi~d (\10\\ l'l ~d"
faces, however, will probabl.\' still be pro- jl.lSOJ, .'\ll',,!JI~lll 1]l)l)7) lkri\l'd ~llll'\Pl\'""i(l!l lor the
tected, either b.\' a thin la)'Cl" of ultrafiltratccl l'lkl'li\\: ~or 1\1l'~\"\1I'l'd) l'(ll'llll'il'lll (II' friction that
s.. . ·novial fluid gel (boosted lubrication) or by" \\~l" lkpl'lldl'lll :-.okh OIl load
thl' proportioll or 1Ill'
the adsorbed lubricin monolayer (boundmy :-'lIpplll'1l'd h\ thl' :--olid In~ltl'i\ (c',~ .. lhl' dilll'I\:IlCC
lubrication). hl'I\\l'l'll tOI~tl 1(l~\l1 ;\11(.1 tll;\l "lIpj1ol'll'd h\ h.\dl'o:-:;\a-
Ii . . ' j11\',":-;[II\' ill llll' l]lIidl. Till' ilnplil';llion 01 "lIch an
l'\j1I'l'",,,i(lll i" lilal Ihl' !I'il'li(l]l;tl !1),Opl'l'til'" (d c\ni-
ROLE OF INTERSTITIAL FLUID PRESSURIZATION
L\~:'-l' \';1]'\ \\ilh lillll' dlll'ill~: ;\ppli,'d 1(1;ldill~, ~l 1\'lkc~
IN JOINT LUBRICATION
1101l ollhl' IllllT"llli~d l]lIid ;llld \.'(dl;l~:l'll-P(; I1I~ltrix
During joint articulation, loads transmitted across illll'I'~\l'll(lIl" 111;\1 ~i\\' ri"l' to thl' 1]0\\ "lkpl'lldl'111 \'I~
a jointma.\' be supported by the opposing joint sur- <..'(ll,Lt:--lic Pl'(lPlTlil'" 01 111l' li","lIl' lk:-,crilwd \..';\rlier
faces via solid-to-solid contact, through a fluid- ~\Ild "ll(l\\ll in l:i~',Ul\'" ,;_l) ;llld 3" 1O.
film la,\'er, or b.\' a mixturc of both, Although rIuid- To \'alidall' Ili:-, l1lodl'!. ;\ll':-,lli~\ll dl'\'l'lopl'd ~\ IHl\'el
film lubrication is achievable, its contribution IU;ldill,~ l'\j1o,.'l'illll'lll lkll "lllkTilllpU:-'l'd ~l I'ri....-tl(jl1al
to joint lubrication is transient, a C()J1sequcnce of lorqlll' 10~ld 011;\ ""';ll'til;\~:'-l' l'\pLllli 111H,hT~~oill~:'- l'J'l'CP
the rapid dissipation of the fluid-filrn thickness 1();HJin~, ill ;1 Ulillill,'d l'()lllp)'l'S"ioll l.'ollligl1r~\lion
by joint loads, Witb tbis caveat, Atesbian (1997), (Fig, .~-~-L\l ("\tl',,hi~lll l'l ;11, ll)l)Sl. \lnrl' Spl'l'iii-
adopting the theoretical framc\vork of the biphasic L'all.\, ;1 \.'\lilldril';J1 hip!J;l."il' l·;ll'lil~l!.-',l' plug \\'~l:-' l'OIll-
theory (Mow et aL, 1980), proposed a mathemati- pl'l':-""l'd ill ;\ l'()lJ1illing rillg k,~2.., prohihiling r~ldial
cal formulation of a boundary friction model of lllolion ;\lll! nuil! l'\ud~\tion) 1l1ll!lT ~\ l'onstalll ap-
articular cartilage to describe the underlying plil'd IO;ld ~_',l'lllT~lll'd h\ ~lfl illlPl'ITlll'~\hk' rigid pLltcn
mechanism behind diarthrodial joint lubrication, llwl \\~l" r()lalill~,:'- ;11 ;\ prl':-:;\.'I'illl'l! ~lll!--,-lllar :-'jk'l'd,
The
in particular, the time-dependcnce of the friction :-'lIrr~\l>l' or thl' plllg oppO:-,itl' till' pl~\ll'll \\~l~ prl's~cd
coefficient for cartilage reported during creep ;lg;\ilbl ;\ li\l'd ri~2.id PO]'OU:-' IIIll'\' \\lllTl'h.\ tIll' int('r~
and stress-relaxation experiments (1\'lalcolm, 1976; di::,-it~\ti(lll or Ihe l';\)'liL\!2.l' \\'lll1 lhl' rOIl!..'.ll :-'lll'!;\i.X of
McCutchen, 1962), tll~,' POI'lI\!:-' liltL'!' prl:\'l:l~tcd it I'n)lll n)t:ltill~!:. III lhis
CHAPTER 3 • BIOMECHANICS OF ARTICULAff~~\t~~~~.:i:~:O
, w
Confining
chamber - - / - - 7+H---+-- Impermeable
rigid platen
Cartilage --/-----11--
Porous
filter --l---+':~:',,-:~.:.; :::'::l~::..\":.~:~~~.;:
I•
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~ which closely match expel"imcntal results, show
Sue. Because the application or a torque load that that during initial loading, when interstitial pres-
yields pure shear, under inflnitc~imal deformations, surization is high, the friction coefficient' can be
induces no volume change in the tissue or associ- very low (Fig. 3-2413). As creep equilibrium is
ated nuid exudation, the load generated by the fric- reached and the load is transferred to the solid ma-
tional torque is independent of the biphasic creep trix, the friction cocrficient becomes high (e.g..
behaviOl" of the tissue. Theoretical predictions, 0.15). The time constant for [his transient response
is in excellent agreement with observed experimen- Iv,:l '1111~h'\"II""lld;k't" \11111;11,:1 ])vl\\l'l'll til", ~1"i)\.Ti
tal results (Malcolm, 1976; J\l1cCutchcn, 1962), An- til"~ (d I Ill' 1\\1) l'~II'lil;l~l' '111'1;ll'I.." I~ill..·h lll..'l..lll'. \hra_
other imponant resull or this work is that nuid pres- "j\t,.. \\l·;lr ill dh,,"V ","\pl..·rillh:l1h, 111'\\l'\<.·I". \\.1' Ilot
surization can function in joint lubrication without rukd (Jill. Tltl..· lI11tllipk· 11111<,11.·,. . . fli dkt,.·lih· luh:;\.:a~
concomitant fluid exudation to the lubricating 1Il!ll \\l!llill!~ ill ,,'(I1II..'l·rl ;ll'l' Illl' 1111'I..,ll:llli'JII' tn;t1,ing
boundary as is proposed for weeping lubrication iIlIVr!;ll·i:d \'"1.::11' pi :lrlit"IILII' ,::llliLI.!-'-\." IlllJik ... ·k \ ,,-"v-
(McCutchen, 1962) (Fig. 3-190). Equally significant, <.·nl1<.'k- ........... ;ldh<.",j\l· ;lIld :d)r~l..... i\<.· \\l·:lr 111:,\ \:11"1..· pbce
this lubrication theory is capable of explaining the ill :111 illqxtirl·d Ill" . . k·~! . . ·It",·r:ll<."d '.\llll\i:d jllill\. ()nce'-
obscl\'cd decrease of the effective friction coeffi- [)h.' l·;II'liLI.!-'-l· :-'lll'I;ll'l' 'll,t:lill' 11111';I'll'll\.:lllJ':tl dvkc{s
cient with increasing rolling and sliding joint veloc- :llHI'll!" dl'I..Tl·:I'V' ill 111:1". il hl·;,,:Ollh."' :-'Idil'l :llld
ities and with increasing joint load (Linn, 1968). 111ur<.' rk·nlJl·;lhk· L\ki/ilki 1,:1 :11. !lJSh: :\nn"'ln'lI~ &.
Recently. the inlcl'Stilial fiuid pressurization \1t,I.I.. 19~~: Sl·tloll 1:1 :d. I(jl..)-ll. Thu,.... lItJid Irc>!ll lhe
within cm·tilage during uniaxial creep and stress re- Illhl'il';llll !dlll 'l'p:lr;llil'I~: dll' hl';lrill~~ ,111'I:ll'l'" Ina\,
laxation experiments was sliccessfully measured Il,__ ;d~ :1\\;1\ I11UI\.' L·:l ... ih IhrClll~1i lil .... i.:anil:lgc 'lid:tC~.
(Soltz & Aleshian. 1998). As predicted by the bipha- Tlli~ 10:-.... 01 11lhri...:;Llill~ Illiid ll'IHII hd\\l'l'l1 111\: ~ur
sic theOly, they found that interstitial Ouiet pressur- f;li.x, inlTl·;l'\.'" I hI..· prllhahilil\' III dil\·t,.·1 i.-"Cllll;ll'l he-
ization supported more that 90'/0 of the load for sev- !\\ .... ·I..'ll 11lL' ;1:-'PlTilil" ;llld V\;ll'I'J"h;lk, tIll' ;lhl';\"ion
eral hundred seconds following loading in confined pl"! 't,.·l'~:-'.
compression (Ateshian & Wang. 1995). The close Ll\i~\II..' \\\,';\1" ld hl·;ll·;ll.;! '1lI'Lt<.·l·~ I"l· ... IIII,... Illl! from
agreement or their measurements with biphasic the- ,"'UI"I~ll"... :-\l'·:-'llrl~iI.,."L" ,.:lllll:tci !lUI Ii-tllli 1111..· ;H,:L"lIi;lIda~
oretical predictions represents n rnajor advance- ti('ll (d l1'li,Tl""'i..'iJpL,: d;ll)I;I.:,~L· \\ililin tIll: hV;II'illl,~ ma-
ment in the understanding of diarthrodial joint lu- kri:d until·' l"l·p,:lili\L· ... (rL· ......... ill~. Bl·;lrill;;: ,,!:'I:ICC
brication and provides compelling evidence for the L.illlrl' ,ll;t-' 11 ... '\.'111· \\illl Illl" rl'pl":t1nl ,lpplil':lltl.n of
role of interstitial Ollid pressurization as a funda- lli~1i l('~ld ... O\er;l !"c!;tli\l"h :-hl.n lhTi(ld (II' \\t11l the"
mental mechanism underlying the load-bearing ca- 1\'PI..'1 j I illil I d' It 1\\ j( );Id ... (1\l'1" ;111 l'\ I \.'lldl"d j1l"l'il Ii.! V\'cn
pacity in cartilage. It is emphasized that while the lh(lll~h lilt· 11l~1[.!llillllk· til' thll ... I..' 1(,;((../ ... l1la\ Ik· much
collagen-PG matrix is subjected to hydrostatic pres~ 1IJ\\l..'l' 1!J;11l !lJl" lll:lll"l"i;d":-. lilt i1ll;11l" .... 11\·11,;2111. lh!~ fa-;.
sure in the surrounding interstitial Ouid, it does not lii~tll· \\l':11". r...:' .... l!ltill~ il"ll!lll..·\l·lil':llh I"l·Pl';\II.·d dl.'lor-·
expose the solid matrix (nor encased chondrocytcs) Ill:lli(1I1 nldll· hl':lrill~ 111;1ll'1'i;t! ..... L';ll1 1:1 hi..' pl:tl'(' L'\'cn
to deformation, presumably causing no mechanical ill \\cll·lllbril..":lIl'd lk·;ll'ill~:-'.
damage. III :-\lll,\'j~d jllilH ..... IhL· ..:\I..'lil.·~d \:Iri:llillll ill lotal
joinl Ill~ld dlll"ill~" 11111,t l)h\,i(ll()~il·:t1 :ll'll\ ilics
...':111.-.1..':- I"l'pl'lili\l' ;lrti ...: ll!:tr \:;:It"lil;l~~l.' ~lr""~~il1~,~ !i,klnr-"
Wear of Articular Cartilage 1ll:1IiullJ. III :u..ldi!ltlll. dUrill~~ rU!:llioll ;tllt.! ,liding, a
~pl.·\.·ilil..' I"l"giflll 01 IItL· ;ll"ll,,:u!:tr :-'Url~H:l· ·'1111;\\::-- in
'Ncar is the unwanted removal of material from :\11ll (llil" 01 Ill\,· !lJ;ld ... ,d l'olll;\i,:I ;\I·l':I. !\'pl"titi\\,']y
solid surfaces by mechanical action. There are two ~tl"l·:-...;ill~ 11l;ll aniL'u!:tr 1\'gilliL l,(';ld~ iIIlPl):-l·d on
components of wear: interfacial wear resulting from :lrliL'uL,lr L"'lrlil~I~I..· a 1'1..' ~11PPIll"!I.."d In' 1111..' l'ullagl'll-PG
Lhe interaction of bearing surfaces and fatigue wear 1ll;lIl"i,\ ~1lh.1 h.\· IIll· rL·",i~I;:1l1(l' gt,.·lllT~llcd 1)\ lhlid .,
resulLing from bearing deformation under load. Ill()\·l·IIII..'nl t1tl"(Jll~lllllll [Ili..' Ill;ll!"i\. '1'1111" I\·p..·tilive
lnterfacial wear occurs when bearing surfaces joint Illtl\ ...'IlIL"111 ;IIHI ll';ldill~ \\ill 1..__ ~\Il"'L' 1\'Pdili\'c.'
come into direct conLact with no lubricanL film SI1,,-',,:-.ing til" I hI..' ...;11Ii<l Ill:!l!"i\ :IIH.II'\..'IW:I1l"d ""\lId:lllon
(boundary 01' Iluid) separating them. This type or and irllhihilioll (JI 1111..' lis:-'llL'·:-' illl\,"l".... lili;d llllid L\low
wear can Lake place in either of two ways: adhesion l\: ;\tl'shiall, Il)')/l. TIII.., ...;\" P1'l)l'l'~:"l'S ~'.i\'"," Ii...;\,.' III 1\\'0
or abrasion. Adhesive wear arises when, as the bear- ptl:-.:-.ihk· 1l11,(!l'llli:--llIs h.\ \dti\:h f:Jli~ll"'· d;:lln:I~~l' lllay
ings come into contact, surface fragments adhere to ,It,.·L·lllllll!:lll' ill ;lrlil..'ld;ll· 1..";ll'lil;l~l·: disnlpliot'! (If lhe
each other and are torn off from the surface during C(JlI'l~l·II-PG ~(llid 11l:llri\ :lIld PC '\\';\~h Uti!.··
sliding. Abrasive wear, conversely, occurs when a First. !\"Pl'tili\\' l·tdl:t~~l·ll-PC; Illalri\ :-'tl\.':,,:,-ing
soft material is scraped by a harder one; the harder ",'(luld d I:-ru pi ti'L· \."(JII;I~L·1l Ii IlLT:-.. I hl" PC 1ll:llT(JIIIOI~
material can be either an opposing bearing or loose l'l'lIk:-.. :11)(1'01' Iltl' illll'd;:Ii..·I..' hl'I\\n"l1 Ii\l·~l' 1\\11 d,lll~
particles bc(ween the bearings. The low rates or in- PUllL·"t",.:\ PU\llt!:ll' Il-,polhl",is t,.·;lI"ti\;,~',:,,' fa-
i.. . 111.,\
terracial wear observed in articular cartilage tested li~lIL' i ..... Ihl' l"L· . ..;ltll ld';l It.'lbiJ...· I':lihll\' PI' I hI.' l·'lii:I!.2CI1
in vitro (Lipshitz & Glimcher, 1979) suggest that di- 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
(-~e-':l;G population have been obscn'cd with age damage with repeated impact loads.
:ric\i_lisease (Buckwalter et aI., 1985; iVluil~ 1983; These mechanisms of wear and damage may be
\R<Juahlev et at. 1980; Sweet et aI., 1979). These PG the cause of the commonly obser'ved large range of
';. chal~ges "could be considered as part of the aCCUl11l1- structural defects observed in anicular canilage
idrcd,tissue damage. These molcculaJ- stnlclural (BlIliollgh & Goodfellow, 1968; Meachim & Fergie,
:-'~ha'nges would result in lower PG-PG irHcraction 1975) (Fig. 3-25, A-C). One such defect is the split-
;~ites and thus lower network strength (Mow et aI., ting of the cartilage surface. Ven ieal sections of car-
1989b; Zhu et aI., 1991, 1996). Second, repetitive tilage e:\hibiting these lesions, known as fibrillation,
:and massive exudation and imbibition of the intcr- show that they eventually cxtend through thc full
<~iitii:d fluid may cause the degradcd PGs to "wash depth of the articular cartilage. (n other specimcns.
, ollt~~;::from the ECM, with a resultant decrease in the cartilage layer appears to be eroded rather than
stff0e~s; and increase in permeability of the tissue split. This erosion is known as smooth-surfaced de-
tha('jp::lurn defeats the stress-shielding mechanism structive thinning.
oUnierstitial fluid-load support and establishes a vi- Considering the variety of defects noted in artic-
dous/cycle of cartilage degeneration. ular cartilage, it is unlikely that a single wear mech-
A third mechanism of damage and resultant ar- anism is responsible for all of them. At any given
ticular wear is associated with s~'novial joint impact site, the stress histor:v may be such that fatigue is
loading-that is, the rapid application of a high [he initiating failure mechanism. At another, the lu-
l8"ad. \,vith normal physiological loading, articular brication conditions may be so unfavorable that in-
cartilage undergoes surface compaction during the terfacial wear dominates the progression of carti-
compression with the lubricating fluid being exuded lage failure. As yet. there is little experimental
lhi'ough t.his compacted region, as shown in Figure information on the type of defect produced by any
3..:10::';\5 described above, however, fluid redistl'ibu- given wear mechanism.
tiol}.',\vithin the articular cartilage occurs over time, Once the collagen-PG matrix of cartilage is dis-
which relieves the stress in this compacted region. rupted, damage resulling froll1 any of the three wear
Thi~'process of stress relaxation takes place quickly; mechanisms mentioned becomes possible: (I) fur-
the stress may decrease by 630/0 within 2 to 5 sec- ther disruption of the collagen-PG matrix as a result
onds (Ateshian et aI., 1998; ""lo\\' et aI., 1980). If, of repetitive matrix stressing; (2) an increased
howevel~ loads arc supplied so quickly that there is "washing out" of the PGs as a result of violent nuid
insufficient time for internal Iluid redistribution to movement and thus impairment of articular carti-
reHeve the compacted region, the high stresses pro- lage's interstitial Ollid load SUppOrl capacity; and
dliccd in the collagen-PG matrix may induce dam- (3) gross alteration of the normal load carriage
age (Newberry et aI., 1997, Thompson et aI., 1991). mechanism in cartilage, thus increasing frictional
This' phenomenon could well explain why Radin shear loading on the 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- ~i<: IlK'chanical prop<..Tt~· 01" the tissue. Tht: nH)SI im-
terfacial and fatigue wear of the already disrupted ponam I"ailure-inilialillg rac((1l' appears I(J he Ihl:
cartilage 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-
Hypotheses on the Biomechanics alL'd willl Ihis Chi.U1gc is a dL'Cn:i.ISL' in canibg.1.: stilT-
of Cartilage Degeneration Ill:SS and an incrl.:ase in canilage pi..'rI1lL'abilil~'
(Allman el aI., 19S-l; Armstrong &. Mow, 1982;
Guilak L"l aI., 1994. SL"lton el aI., 1994). h,,'h of
ROLE OF BIOMECHANICAL FACTORS
which aller canilagL' fUllction ill ~\ diunhrodialjoinl
Articular cartilage has only a limited capacity for re- during joilll mOlion, as showll in Figure 3-27 (!vlo\\'
pair and regeneration, and if subjected lO an abnor- '" Atcshian, 1997).
mal range of slress~s can quickly undergo total fail- ThL' magnitude of the stress sustained b,\' lhe ar-
ure (Fig. 3-26). It has been hypothesized that failure ticular cartilage is dctennined b,\' both the toti.llload
progression relates to the following: (1) the magni- on the joint and how tlwt kli.\d is distributed ()\'er
tude of the imposed stresses; (2) the total numbe,· of the i.\1·ticul~ir surface conl~lCt arca (Allmed 6.: Burke,
sustained stress peaks; (3) 1I1C changes in the intrin- 19i'3; Annslrong L'I aI., 1979; Paul. 1976). :\n.\· in-
sic molecular and microscopic structure of the col- h,:nsl..' stress COllcL'nlration in Ilk' l'ont~\Ct i.lrea will
lagen-PG Illalri.'\; and (4) the changes in the intrin- pla,\' i.1 pl·imi.llY roIL, in tissu<..' (k'gL'Ilt.'ration, A large
Ilumb<..'r or 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-
t
Biochemical Composition
+
Spatial and Temporal
Slress-Slrain, Pressure
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~
figure illustrating how osteoarthritic changes to the col- F ago in his right knee. Currently, he is sufiering pain as-
sociated with movement, swelling, and lirnilaiions of knee
'aqen·PG network can compromise the ability of articular
ca'til'lOe to maintain interstitial fluid pressurization, which motion (Fig. 3-1-1),
""'~"'''o< the tissue's load-bearing and joint lubrication ca· The history of knee meniscectomy not only implies an
Loss of PG and damage to the collagen fibers result alteration in joint surface congruence but also the elimi·
an increased hydraulic permeability (decreased resis- nation of the load-distribution function of the meniscus.
!'c!"""e to fluid flow) and supra-normal loads and strains on The effect is an abnormal joint. characterized by an in-
solid matrix (and chondrocyte). crease in the stress acting on the joint surface that results
in cartilage failure. Most of these stress concentralions are
pre-stress established by the balance between ten- 'Ii'lL' factors that g()\·1..'1'1l c!londnlC\[<.' f"llIKlion,
sion in the collagen flbers and the Donnan osmotic L'arlil<lgL' s[ruclllr...' <lnd l'UI'H,:lioll, ~\IH.l lhc diology
pressure. During joint loading. by vit·tue or the lis- or 0:-\ I..·an hI..' obtain..:d,
,
~.,t,--. ....'.~ ., .. "
~;
REFERENCES
SumrlzalY
!\hllh:d, i\"\1.. (\: Burkt.:, D.L. (1983). In vilro mcnSlirement of
st:llil: pressure distribution in synovial joints-P,lrl 1: lib-
The function of anicular cartilage in clianhro- i:1I surface of the knee. J Biolllech Ell.!!,. 105, 216.
joints is to increase the area of load distribution Akizuki. 5., \lo\\'. v.e., "-,lulieI'. F.. (.'t a1. (1986). Tensih.: prop-
"nies of knel." joint cartilage: 1. Influence of ionic: condi-
;'.(thereby reducing the stress) and provide a smooth, tion. wcighl bearing. and fibrillalion on the tCllsill." modu-
(\,vear-resistant bearing surface. IllS. J Orr/lOp U/.:.\', 4. 379.
i;~(2) Biomechanically, articular cartilage should Ahm~ln, R.D., Tt:nl'baum, J., Lilla, L. l'l "I. (1984). Biome-
Ch~1I1ic.:l1 <lnd bioc:ht:mical propenh:s of dog cartilage in I."X-
!J~~viewed as a multiphasic material. In tcrrns or a peri mentally induced oSlcoarthritis. All/I Rhl!/lI11 Dis. 43, 83.
}biphasic material. articular cartilage is comprised :\ndri~u.:chi, T.P.. Natar~lj'tn, R.N., ~ Hurwitz. D.E. (1997) .
.of ,i' porous-permeable collagen-PG solid matrix Musculoskclc·t~d dyn,llllics, locomolion, anti dink'll ~lprli
l.:;llioll. In V.C. Mo\\' & \V.e. H<'lyl'S (Eds.). Bw;;c 0,.·
(approximately 25% by wei weight) filled by the
I!wpw:dic BiViIlt.'dlllllics (2nd l."d.) (pp. 31-68). Philadel-
fl'e'~ly, movable interstitial fluid (approximately
phia: Lippincott-RHvcn.
i5r~',:bY wet weight). In addition to solid and Fluid Armstrong, CG .. Balmllli, A.S., ~\: Bardner. 0.1.. (1979). In
:tIlel,~e', (~xists an additional ion phase when CO!1- \'itl'o measurement of articular c;lrlilage deformations in
si~f~r'ing articular cartilage as a triphasic medium. lh~ intacl human hip joinl und"r load. J B(m" loi/a Sllrg.
/;:The ion phase is nccessa'"y to describe the swcl- 61,1.744.
:\rmslrong. CG., & Mow, V_e. (J980). Friclion, lubricil1ion and
>~cling and other electromechanical behaviors of the
w,,'ar or syno\'i,al join Is, III Owen, R.. Goodf...!low, J. (\: Bul-
:'~~/tissue. lough, P. (Eds.). Sci~'IlIiric FOlll1dt/tions or OrtJ/(JI'l/~'tlic:s (llld
'lH~:-'{~' lmporlanl biomcchanical properties of articular 7iwf/lllUO/Ogy (pp 213-232). London: William 1-ldncnn<'Hln.
ArmSIr<)IH!. e.G., & l\.fo\\'. V.e. (1982). Varialions in dll." in-
;:',c~rlilage are the intrinsic material properties of the
Irinsic-mcchank<.tl propt:r1ies of hum'lll anil:ulrtr ci.lnilagc
soli~1 matri:\ and the frictional "csistance to the flow Wilh agL', degencr;ltion. and w:lI..:'r COrllenl. } 8(111~' Joillt
9f/':,~nterstitial fluid through the porous-permeable Sltff::, 64..1, 88.
:spHcl,';',JTlatrix (n parameter inversely proportional to Ateshian, G.A. (1997'). Theoretical formulation for boundary
,~h8i+issue permeability). Together, -these parameters rrktion in articular cartilage. J !3iOll/cc), ElIg, 119, Sl.
:\LL'shi~tn, G.A., K\\'~tk, S.D.. Soslowsk.\', LJ., et al. (199-0. r\
,;~;~,~efine the level of interstitial fluid pressurization, a
n..:'w sll:n:ophotogr:lInmctry lll..:'lhod for dctermining in
:"'-};£6ajor detenninant of the load-bearing and lubrica- situ conlact are;\s in dianhrodinl joinls: A comparison
/iZ.J!ibn capacity of the tissue, which can be generated in sludy. J Biol1/~'dlallics, 2i, III.
)s:cartilage. Atc:shian. G.A., Lai, W.M., Zllli. \V.B., (:t a!' (1995). An :lsymp·
'~,ti!i-~t;Damage to articular cartilage, from whatcver totic solution for the contact of twO biphasic c~nibgc lay-
\.'1':;. J Biol1lccJulIIics. 27, 1301 i.
/~%g~use. can disrupt the normal interstitial fluid load- Ateshi:lll, G.A., & W'\Ilg. H. (1995). ;\ thl'oH:tical solution for
f;"9~~ring capacity of the tissue and thus the normal til(.' friclionless rolling contact of cylindrical biphasic .\1'-
"IH§n,fation process operating within the joint. ticular cartibge layers. J BiolIlCC/HlIlics, 28,1341.
Att:'shian, G.A., \Vallg, H., & Lai. W,M. (1998). Thl..' roll.' of In-
~n~tTf()re, lubrication insufficiency may be a pd-
tcr::;titi,d fluid in pressurization ilnd surface porosities on
:m~~;y':(aclor in the etiology of OA. the boundary friction of articular cartilage. 1 hi};ology,
/i?~@;,- :.'
;"G~hr~J'Nhen describing articular cartilage in the con- 120.241.
.-\Ieshian. G.:\., Warden. W.H., Kim. J.J .. d al. (1997). Finit"-,
,:D'Jexl ()f a rigorous theOl-etical framework such as the
("-,formation biplwsic malerial properties of bovine ,Irlinl-
J~.Jjlphasic. triphasic. or multiphasic theories. it is !;Ir cartilage from confined compr..:ssion experimellts. 1
':ltnqssible 10 accurately predict Ihe biomechanical be- BiulI/t.'c/UlIlics. 3D, 1157.
?:~}i~viors of anicular cartilage under loading and to Athan<lsioll, K.:\ .• Ros('llwasser, i\·I.P., Buckwallt.'r. J.:\., et al.
,. W~1,~!:;lJ~idate the underlying mechanisms that govern (1991). Inlerspecies comparison of in sill! Illcdmnical
propl."rlies or diswl rcrnor,ll cartil:tgc. J art/lOp Ik.., 9, 330.
';r1M,01oad-bearing and lubrication function. Further-
Bachrach, N.M., VlIlhmu, We., Stazzonc, E.J., et 'II. (1995).
'~?,r~',:')nsights into the temporal and spatial nature Chang~s in protcoglycan synthesis rutes of chondrocytes
'?Rr.\p·?'phy;ical stimuli that may affect chondrocyte in articular cartilage arc associ~lted with the time depen-
·;flinction in situ can be gained. dCllt changes in lilt: lllC'chanie<d environment. 1 13iolJu:-
(~j'r!;: - ch(lIlic~, 28, 1561.
Bachr'Kh. j\!'~C Mow. \i.C, & Guilak. F. (1998). Incompress-
ibility or the solid matrix of articular cartilage under high
4?£1.CKNOWLEDGMENTS
(~~'i::;';"-'
hydrostatic pressure. J BioJ11£'cluwics, 3/, 4015.
Bateman, J.E, Lamanue, S.R., & R,II11SIw,w, J.A.~'1. (1996). Col-
-f~~O;:his'wark \vas sponsored bv theatianal [nstitutes lagen sllpcrbmily. In W.D~ Comper (Ed.). Extracellular Ma-
}iitiR+lealth grants AR41913 ,{nd AR42850. Irix (Vol. 2. p. 226i). :\lIlsll'rdam: Harwood Academil: Pubs.
,:~:<ii~BX~(/
~. ;;,::/';:;<,-,
Bollet. A.1., &: Nance. J.L. (1963). Bio<:hcmical findillg~ in G:trdlll·r. 5.1.. ...\: .\-kGjllin;ty. D.C. (1971). Li\"ing :lrticul:II'
normal and oSh:oarthritic <:tnit:ubr canibgc, II: Chon· l';lrtilagl' i:- nOI SlIllll__llh. Till..' :-trth,:tl1l"l' (,t 1ll:lIll!ll;di;lll and
droitin suJf~\IC concl.'lltralion and ch'lin length. and W;:lt('l' a\"i;lll joint :-Ilrbl.:l':- dCllHJIl:·dr:lll..'d in \'i\"o b~ inlflli:r~i(li1
,.\[1<1 ash content. J Clill l'II't'St, oJ). 11 iO. indd('llt light miu(Js("op,\". ..1111/ Rhl:/1l1l Ois, 30, 3.
Bowden, F.P.. & T~lbor. D. (1967). rfiction /llId Lllbrictlli()J/. Garg.II.G., & Swann. n.:\. (1981). :\g,:-rdatct! ch:tng,·s lllthl..'
London: \lC1hucn Pubs. chl..'lllicd l:omposition (Jf h(I\'inl' :Inil'ld~\r ,;;anilagt".
Broom, N. D" &. Sil~·n-R()bens. H. (1990). Collagl'n·collagcn Hiot.:ht'lll J. 193, ·!.';9.
\'crsus collagen.prolCoglyc:w interaclions in the de!l:rmi- Gll, \\'.Y., Lai. \\'.\1. l..\: .\11)\\", v.e. !,1993J. Tr,-lll:-pon of fILlid
n;:ltion of c.lt·til~lgc stn..'ngth . .·Irthrilis 101i.'1II11, 33, 13[2. and ion:' lhrough ,\ POr<HIS-Pl'l"llll..·;lbll' ch;lrgl·d·h.nlrall'd
Buckwa!l\:'r, J.,\., KucHner, K,E., &: Thonar. E.J.-M.:\. (1985), ti:-SliC. and slrl'~llnilig p(lll'llti;1! d'lla on nnrllwl h()\"inc ;11'-
,\g('-rl"l<lted changl's in articuhlr c:lnilage proleoglycans: licltlar Glnilagl..·. .Il3iol//<,clllll/;("S, 1r;. iU9.
Eleclron Illicroscopit: sllIdics. J Orr/lOt' Re:., 3, 251. Cll, "·,Y.. La;' W..\1. . .:i.: .'1 ow. V.c. (1997). ,\ triph:l"ic allaly:-.is
Bullough, P.G .. &: Goodf,.'!low, J. (1968). The significance of or l1l'g,lli\'l: Olillloti<.· flo\\':" lhrough chMgL'd hydr,lll'd soft
th{' fillc structures of ~lrticllbr cartilage, J BOllI.' Join/ Surg li:-SllCS. J BiOlIl,·c!Wllic.....W. i I.
50B, 852. CII. \\'.Y., Lti. \\'..\I.,..\: .\Io\\". \'.c. {199S).:\ llli\tllrL' thl·ory {or
Bullough, P.G .. &. Jag,-Illnalh, A. (1983). The lI\orphoJog~' of dl'trgl..'d h.nll';llCd sott lisSl!l..·s (ont;lil\ill~ lllultl-eIN:-
the calcific'ltion front in articul:lr l.:anilagc . .I Bouc Joiut trolYll'S: PaSSI\'l' tr:lllspon and s\\'dling lll'h,,\·iors. J J3io-
SlIrg, 65B. 72. I1ICc!t EII~, 102. 169.
Buschm'llln. l\I.D .. Gluzband. Y.,\., Grodzinsky, A.1., L't :\1. Gujbk. F.. R:lIcliffL' . .-\ .. L:tlll·. :\ .....·1 ;t!. (1994)..\kch:1I1ic;d
(1992). Chondrocylt'S in agnrosl' culture s~'nthcsize a Ille- and bindlcmil';d l·hallgn ill lhl' Slllh·rlil.:ial ZUlll..' of ;-\rtil..·u-
chanic,lIly functional i.'xtracdltll;'lr m:ltrix . .I Or/hop Res. 1;11' canil:lgl' in a ~'~lnil1(' Illo(kl or nSll..'o:lrthrilis. J Orr/wi>
10. 745. Rt's. 12, .ti-L
Buschmann, :\-1.0.. &: Grodzinsk...... '\.J. (1995). A lIlolc~lllar flardillgh:llll. T. .\1.. l..\: .\Iull', H. (197-+1. IlYllluroni( :H.'id ill car-
modd of protL"()gl . . . can-nssoci~\{cd ckctrostatk forcl.'s ill lilagl' and prokogl~'C:1l1 :lggn..'~~l\ion. Hiu(·/tt·//t.l. 1.39. 56S.
l,;arti!:l~(' mechanics. } BhlllH'ch Ell!!" 117, I iO. 1·lardilJ.~dlall1. T.E .. !.h:ardrn(Jrl'·G;lrt~. \1., ~ Dunklill. D.G,
Clark, J.~,i.·(1985). The organization ~f coll:lgl'll in cr.. . ofr;lc- (llJ8iL Pn,Il'in d(lll"lain Stl"lll"llll"e of Ih ...· aggrq~~l!illg pl'O-
tun:d rabbit ~niclllar cartilage: A s'::lnning l'll'.:troll mi- teogl.\T;11l frolllc\rti1:lgl·. Tnm., On/t{J!, Rt'." ,)0('.11,61.
croscopy stud...... J Or/hop lk~, 3. li_ Ibsc;dl. V.C. (l<Jill. 11I11..·r~lC(i(JllS (If l'anilag...· pro(('oglycitlls
Clarke. I.e. (19il). Articldar cartilage: A re\'ie\\, and scanning with h,\';duronil' acid . .1 S/lpl"iul!l!i SII'I!ClIll"t·. 7. 101.
l']cctron microscope study-I. The inll'r1crritorial fibrillar Ib~·l·':-. W.c.. & Bodilh', :\.1. (1978). Flo\\'-indi..'peIHknt \'i;:;-
'.l!"chitccltIl'c. J BClIIl' Joim Surf;. 538. 732. cOl:l:!stir propl·nil..'s of articul;l], <.:ani!:lgl' m;\lri.". J Bitt/IIt·-
Donohue. J.M .. Buss, D.. Oegcma, T.R .. (.'t al. (1983). The d- c/ulIIics. II. 407,
fects of indirect blunt trauma 011 adult canine articular 1[;1.\·('S. W.C .. l..\: \Iockros, I...F. ([971 Oi.Viscoi..'!astic propl'rlii..'s
c;\l·tibge. J BOlle JoiJl/ SlIrg. 65A. 948. of human anit:ubr canil;lgl'.) :\PI'I Phy.~i(Jj, 31.562_
Donnan, F.G. (1924). The theory of membrane equilibria. 1I~I\\'killgs. S.\\'. (19SSI.:\ Brid l1ililor.,· of Tillie.' Frolll tilt: Bi~
Ch.:mical RCl';C\\', J, 73. Ba/l~ 10 l3!ack 110/n. Xl ·\\· York: B:IIlI<lm Book::..
Dowson, D. (1966/1967). Modes of lubricalion in human Hcinl'gard. 0 .. \\'it:slall(kr. J,. Shl'dlan. J., l'l ;d. (1983). S('p-
joints. Proc IlIs{ Mt!ch ElIg, IBIJ. 45. :tration ;'tlld . . haral·ll.'riz,llinn (If 1\\'0 poplll;ltions of ;1g.grL'·
Dowson, D, (1990). Bio·tribology of natural and rcp!accIlH:nt g:lllng proll..'ogl~"l';ln:- from i.':lnib~l'. Bif,d/"III J. 215. 95,
joints. In V,C. :"'Io\\', A. Ralcliffe, S-L.Y. Woo (Eds.l Biollll.'- Hdminl'n. H.1,. Ki\'ir:llll;l, J.. T;lI11l1li . .\1.. L'l :.1. (Eds.) (19~i),
('''(/Ilks orf)ial'thmdia! .foill/S (pp. 305-345). New York: ./oil// l.orldill,!.:: Biology (lild 11(.'111111 (>1" ..\I"/iclilal' Sll"/Iel((1""".
Spri ng~r- Verlag. Bristal, V.K: Wright &: Sons. Pubs.
Edwards. J. (196i), PhysiGII charach:risti(:s of <lnicubr cani- lIill:-. B.A. (1989), Oligolallll'llar luhri\:alion of join\:- hy sur-
lage. Proi' IIl.H :\ft:dl Ellg, ISIl. 16. fan' ~H:li\'c phnsphlJlipid. J Rlll'lIlJI. I-b. S2-91.
Elmorc, S.~·I., Sokoloff, L., ~orris, G.. et al. (1963L Nature of Hirsch. C, (19-+4). TIll' p;lIhngL'!ll'sis of l'llOndronwlacia of 11It'
"imperfect" clasticity of anicLll'lr CarLil~lgc. J :\pplid Phys- p~lli..'lb . .-\0(1 Chi)" Sl.'{/!ul. 83 lSuppl), I.
iol, 18. 393. 111:1\·a<:l,k. :\-1. (1995). Till' rnll' of s~--n('\'ial fluid fillr;llioll hy
Eyr('. D.R. (1980). Collagl'll: Molecular di\'ersity in lhe body's l·~lI"lilag ..., in luhril':llion of s~-Il(J\"i:1I join Is: IV. Squl.'l.'1....· .film
prol('in scaffold. Scicl/n:, 207, 131 S. lubrkatlo11 for :t.\ial ;,.nnllll·lr'.\ Linder high !o;,ding condi-
Fos~Hlg, :\.1., & Hardingh:lln. T.E. (1996). ;\\;.Hrix protcogly- tiOIl~,.1 BioIlH·C!z(/uic.', 28. 1199.
cans, In W.O. Comper (Ed.) Ex/racdlulur .\lll/rix (Vol. 2. Hodge. \\'...\ .. Fij:lll. R.S .. Clrlson,. 1\. .. 1.'1 al. (1%61. Conl.let
pp. 200-229). Amsl(:rd~II11: Harwood ;\c;ldcmic Pubs. prl':-iSllrl' in till' human hip joinl Illl·~I:-illrl'd in yi\·o. Prot:
Frank. E.H .. &: Grodzinsky. A.J. (198ia). Cartilage dcclro- Na/f :lclIe! Sci. US.--\. 83. 28i9.
mechanics-I. Ekclrokint:tic transduction nnd dfects of Holmcs, ~1.H .. L.li, W.M .. l\: !\lo\\". V.C, (1985). Singular p~'r
pH .1lHI ionic strength. J Biol1lec!ulIlics, 30. 615_ tllrb:ition ~Inalysis (Ill the nonlinear. f10\\".dqll'lldenl, COIll-
Frank, E.H., & Grodzinsky, A.J. (1987b). Cartilnge electro- prL'ssi\'c slrl'ss-rl'laxalion bdl;wior of ~1I'lkul;lr (~lnihlgL'. J
llll'chnnics-ii. " continuulll model of l·;:u·tilagc declroki- Biollll'ch I.:I/~, Wi. 206.
netics and corn:l<:ltion with L'xperiments. J BiOlltt:chol1ics. HOll. J.S., .\'Io\\". V.C .. L:ti. \\".\1 .. ('I al. (1992). :\n :In;d.\'sis of
20, 629. till' SqIH.'l'i'.L'-fillll lubrication llll'ch~llllsm for :1I·tleul:H· c~lr
Freeman. M.A.R. (19i5). The fatiguc or
c;lrtilage in the patho- tilagl·. J Riollll'dul1Iic.... 15, 147.
genesis of ostcoanhro$is. :\cw OrtllOfJ Scal/d. 46, 313. Huhkr;llllZ. W. (I S9S). L'dwr dil' Spaltrichlllngl'll lkr Ge-
Fung, Y.C. (1981). Ouasi-Iinear \'iscch:lasticity oj" sol'ttisslles. lellkknorp..::J. \'~~l"lliIlldl/lll~ell dl'l' :llIrI/olI/iscln'lI C:;csdlsc!za/i,
In Biolllcdlllllics: JleclulI1;cal Properlics of Lil'illg Tissues 12. 1-+8.
(p, 226). New York: Springl'r·Veriag.
~
I;~;::~~~{:;IA~. :"i &ill Curran. P.F. (1975). NOI1t.'qllilibriIUJI Tha-
Biophyjics (4th l.'d.L Camhridgl': Han'anl
Maroud'IS. A. (1975.1. Biophysical chcmislr~' of cartilaginous
ti~Slh:S with sllI.:cial refen::l1cC' 10 solute ~ll\d fluid transport.
Prl.'ss. Biorhco!ogy. 12,233.
G.£.. Tuke, M_A .• Dingle. J.T.. ct al. (1976). The d- "taroud~ls. ..\. lI976). 8;1blll.:e bC(\\'l.'l.'1l swelling pn:ssun: and
of proteolytic enZYllll's on thl.' Illl"chanical propt:.'l"ties coll~lg"n tension in n(lrl1l~a1 alld ,k·gelll.'ratc c3nilage. Na-
hunHlfl 'll·ticuIOlr canilagl.'. Biocltl!/IJ 13iopll,\'... :\cra, IIItc.', 260. 80$.
I. i\larou,!:Ls, A. (1979). Ph~'sicochcmkal propenies of anicular
G.E. (1979). Mechanil.:i.ll propl.'rtics of <Inicular cHrtilnge.ln M.A.R. Frl.'C'man (Ed.). Ildlill ,.\riiCl1ltu· Carti-
In ~'I.A.R. Frl.'cman (E,L), .4t/lIlt :\aicillar C(lai· la;:c: (2nd cd .. pro 215-290). Tunhridge Wdls. EnghllHI: Pit-
cd .. pr. 333--t.l-1). Tunbridge Wells. U.K.: Pitman mall '\h:dical.
:\broud:\s, A.. \bchteL L, Grushkn, G.. \..'t al. (1991). Th\..' d-
v.J., Sah. R.I..., Grodzinsky. A.J .. ct al. (1994). :Vh:chani- fecI of osmotil.: ~llld Ilh:ch;wical preSSllrl:S Oil Wi.ller pani·
1'C!;ulalion of cartil;lge biosyllthetic b\:h~l\'ior: Ph~'sical tioning in ~lJ'lit-lIl<lr (,:Hrtibgl·. Biocltt'l1I Biophys ..lettl,
Arch Biocln'/It Biophy,,,', 311, 1. 10i3. 285.
Gu, W,Y.. & Mo\\', \!.e. (1998). On the conditional \lcCutchcn, C.\\'. (19621. The frictional propi..·nies of :Inima[
<Qui"""",,·" of chemic:11 loading and ml'ch;lllical loading joints. it-'eM.5, 1.
articular C;lrt ilagc. 1 Biol/1('c:/wllics 3 I (111. 1181-11 $5. ,\kDevitt, C.A .. '*Xluir. H. (1976). Biochemical chall~es in
W.:'\'I., & Mow, \I.e. (1978). Ultrafiltr,ltiol1 of synodal th,' cartilage of ill(' knce in eXpl.'rilll('nt~d <llld lIatul;d os·
'';'?:'"'''' by canilagc_ J Ellg .tlt:clt Dil· ..I8CI":.:. /0./. 79. h:o'lI·(hritis in Iht: do~. j BOIlt! 10ill/ S/lr~. 588. 9.J. .
& Mo\\', r.e. (1980). Dnlg-induccd t'ompression of .\-kachilll. G., & Ft:rgie. I~..\. (1975). Morph~logic~d patterns of
,,''''ulal' cartil;\gt: during a permeation c.xpl,'rimenl. J Bio- articular cartilage fibrillation. J Pm/lal, 115, 231.
17. III. \'\(1\\', V.C .. AlllO~zky, S.P., &. Jadson, D.\V. {1992L Knec.'
W.M .. I-lOll, J.S .. &. Mo\\', V.C. (1991). A triphasic theory Jlt'lIis('/ls: Basic ami Clillical F(J/(II(huiol/.~. N(,'\\, 'York:
the s\\'dling .lIld deformation beh~l\'iors of anicular Ra\'en Press.
canil'a.". 1 Bicn/It'cll EII~. 1/3. 2-t.5. ,\10\\', V.e.. & Ateshian, G...\. (1997). Lnbrit~llion and \\"(,';11' of
& Saha. S. (1979). Cemenl line motion in bone. Sci- dianhrodial joints. [n V.e. Mo\\' &. W.e. Ha~'t's (Eds.), Ba-
204. 50 I. sic BiOUlt'c/wuics (2nd l'd .. pp. 175-315). Phibddphia:
,\'t., & \-Vt~iss, C. (1975). Rl'\'iew of nnicubr t·;\rtil;lgc Lippincot t-R~l\"l'n.
resl.'arch. Anhrilis Rhett/II, 18. 553. \lo\\', v.e" Atcshi'Hl, G.A .. Lai, W.M .. i..'l a1. (1998). Effl.'cts of
(1968). Lubrication of animal joints: l. The mech- fixed charges on the sll'ess-r(,'laXlltion bdl:l\"ior of h~'dratl.'d
J BilJllli'Challics. ,. 193. soft lissues in a confint'd compression pl'Obkm. /Ill J
EC.. is: Radin. E.L. (1968). Lubric<llioll of :-lnimal joints; Solid... & SIT/tc!/lres. 35, ~9.J.5-4961.
III. The eHcc! of certain chtmic~\1 altnations of thl' cart i- :\low, V.C., Gibbs. ,\I.e., LaL \\'.\1.. l.'t Ill. (1989a). Biphnsic in-
Iag~ rind lubricant. .. \f/hi/is Rlh·UII/. J 1. 674. dentation of ~Il·ticular Glrlibge-Part II. A llurlh:ric:11 algo·
F.C.. & Sokoloff. L. (1965). MO\·l.'IlH:nt and composition rithm ;\Ild an l'xpt.:riml.'U1;'ll stlld~'. 1 Bi()UI~'(:I/(l/1ic..;. 22, 833.
of inlt:'rslitial fluid of cartilage. Arthritis Rhc.'ll!ll, S, 481. '\'lo\\', V.C., Holmes, ;\1.1-1 .. &. LaL \\'.\'L (198"+). Fhlid tl'i.ll1spon
H.. Ethcredgl', R.. &. Glimcher, M.J. (1975). In vitro and mechanical propl.'nies of articular c,lrtilage: A review.
of articular c~ll"Iilage. I: I-Iydl'o'\~<prolinc, h(,'.'\- J Hiol/lt'cha /lies. I?, 377.
and amino acid composition or bO\'inl: i.\rticular \lo\\". \I.e.. Kuei, S.c.. LaL W.'\-1.. ('t al. (1980). Biphash: crCl'p
c<l.nibge as It function of depth from thl.' surface: hydrox- and stress rdaxOIlion of anicul;ll' L·'lrtilage ill comprcssion:
yproline cont"nl of the lubric;II11 and the weur debris as a Thl'ory and cxpl.'rimellts. J Biol1lt'dl EJlg. 102. 73.
1ll~;lsure of wear. 1 B01l1! 10i1l1 Slfrg. 5i..t. 527. Mow. V.c.. LaL W.;\I. . ..\: Rt.'dlcr. I. {197-H. Some surface char-
Lipshiti'., H., Etheredge, R.. is: Glimcher, ~1.J. (1976). Changes aCIl.'ristics of articular cartilag~s. A SC;-\lliling electron mi-
ill the he.'\os:lJlllne contt:nt and swelling ratio of articular croscopy study and a th~'orl'\ic~d model ror the d.vnamic
(:'Il·tibge as r11l1~lioll:; of depth from Ih" Sur!";,lC\..'. J BOlle inli,:ractioll of synovial fluid and articular cilrtilage. J Bio-
loilll Surg. 58..\. 11-t.9. IIleclumics. 7. -t.-I9.
Lipshitl.. 1-1., &. Glimchcr. \1.J. (1979). In \'itro stud it'S of the Mow, V.e. . ..\: R:llcliffi..'. :\. (1997). Structure :Hld funclion of
wenr of articular cartila!.!e. 1I'cm: 52, 297. articular c::Irtili1gc and menisclls. In v.e. ;"low l\! W.e.
Malcolm. L.l. (1976) . ..t/l ~t'xpt:rill1ollal illl't':,tigatioll of 1111: Hayi..'s (Eds.), B(I.'ii~· Ori"o!'(/I:dic: Biollll.·chal/ics (2nd l"d ..
{i'jet/vllal al/{l d,,{or1lltlliOlUl! I'espOIIScs o( or/iclllar cartilage pp. lI3-11i). Philadelphia: LippincOIl-Ra\"l.'ll.
illwrt,u:es 10 .wl/ic (lI/(/ dYl/(lIllic loadillg. Doctoral thesis. \!o\\', V.e., Zhll, W.B., Lai, W.M., ct al. (1989b). The influ-
Universitv of California. San Diego. ence of link protein stabilization on 1h..: viscoelastic prop'
:\lankin. 1-1.:\., & Thrasher, A.Z. (1975). Water conlent and ertici' of protcoglYC<1I1 aggregates. Bioclt':lll Biophys .-lela,
bindin~ in normal and osteonrthritic human cartil:-lgc. J 992, 201.
BOlle J~i/II Sun.:, 5i:\, i6. :'I·luil". H. (1983). Proteogl~'cans as org:lnizl.'rs of the extracel·
Mansour. J.,\'I..& ~to\\", v.e. (19i6). The permeability or artic- lular matrix. Bim.:ht'JIl Soc TraJJs, I 1.613.
u!;\r canilag..: ulU!l'r comprt'ssin:' str,lin lind at high pres- Myers. E.R .. Lai, \V.M .. &. ~·Iow. V.C. (1984). A continuulll the-
sures. J BOlle lohn SlIl',!;, 58;\, 509. ory ;Illd an expcriment for the iOIl-inducl'd swelling behav-
:\laroudas, A. (196611967). Hyaluronl( acid films. Proc IllS! ior canila£c. 1 Biol1wdl r.II!.'" 106(21, 151-15S.
Jkch Ell!;. 1.011£1011,1811. 122:. N\..'\\·b..:rry, W.N.. Zukosky, D.K:, & Hau!. R.C. (1997). Subfrac-
Maroudas, A. (1968). Physicochl.'llIical properties of c~\l·tilage tllrc insult to a knt:.·c joint causes alter~l(ions in the bone
in Ii£ht of ion-exchangL' theory. Biophy,'; J. S. 575. :-lnd in the rUflctional stiffness of o\'erlying cartilage. 1 01'-
Ihop Rc:s, 15. -t.50.
61(ltviECHANIC:S OF TISSUES AND STRUCTURES or THE tvlUSCULOSKEl.ETAl. SYSTUv1
Onsagcr. L. (1931J. Reciproc:l1 relations in irn.'vcrsible SCtlUIL L.A .. \leJ\\', V.e. \Iuller, F..J .. L'l :d. (199..+1. :\lcch<Hlic;d
processL's. I. Phys ReI' 37, "+05. pnq)l:l'liL's of c:lninL' :lnictllar c;lrlil:tgL' :11"L' signil'kanLly :11-
Pau!. J.P. (1976). Force actions transmilted b~' joints in the Il'rL'd following tr:lflSacliofl or IbL' ;lI'llL'l'ior l"l"tlCiak lig:l'
human bod\'. Proc Ror Soc Loud, /92B. 163. nh:nl. 1 Of/!zop Res. /2.451,
Poole. A.R. (1986). Pr~)[coglycans in health and diseasc: SL'llon. L.A., Toll.\':lIl1a. fl .. l\: \10\\'. V.e. (1998). S\\'L'lling :Ind
StrucLure and function. Hinchem J. 236. 1. curling bl'ha\'ior oi aniL'ular canibge. J BiuJllt'c1/ r:lIg,
Radin. E.L.. and Paul, 1.1.. (1971), RespollSc of joints to im- /10.355.
pact loading. l. In vitro wear. Arthritis Rhellill. 14, 356. Setton. L.A .. Zllli. \\'.13.. & :..,,10\\-. V.e. (19931. Thl' biphasic
Radin. E.L. (1976). Aetiology of osteoarthrosis. CIiIl RhculJI poro\'iscol'l:lstic lk'h:l\'ior 01' anlcular cartib1:!c in COIH-
Dis. 2, 509. prL'ssion: Role or thl' surracc zone. J Biollleclwl/ics. 26,
Ratcliffe. A.. &. ~'Iow, \f.e. (1996), Articular cartilage. In \V.D. 581.
Compel' (Ed.), Extrace/llIlar Alatrix (Vol. 1, pp. 234~302). Sokoloff. 1.. (1063). ElasliciL,V of articular cartilagL': Ei'fcct ol
AmsLcrdam: Harwood Academic Pubs. iOllS :lIld \'iscOlls solutions. Sci(l/ce. /4/. 1055.
Ratcliffc. A.. 'I\ler. J.. &: I-Iardingham. TE. (1986). Articuhlr Soltz, \1.A .. & A(l'shi:1I1. G.A. (1998). ExpnilllL'nlal \'nific:t-
cartilage culture with inlerlcukin I: lncreascd releasc of tion and Ihl'()]"L'lic,d prediction of canil:lgL' inkrsliti,d
link pr~)tein. hyaluronate-binding region and other proteo- r1uid pressurizalion al an impl'rmL'able cont:lct intcrhce
glycan fragments. BiochclII J, 238, 571. in conl'inl'd corTlpn:ssion . .I Bio!!/cchanics. OCt 31 (10),
Redler, I.. &. Zimny. M.L. (1970). Scanning electron mi- 927-934
croscopy of normal and abnormal artlcuhll' curtilagc and StoL:kWL'lI, R.S. (1979). Biolo.!!.y or COJ"/i!o!.!.c Cd/so Cambridge:
synovium. J BOl/c Joint SlIrg. 52/\. 1395. C:\lllbridgl' Uni\'crsit.\' Prcss.
Rcdlcr. L, Zimny. :'.'1.L., \Ianscl!, J .. et al. (1975). Thc ultra- Sun, D.N .. Gu. \\'.1'.. Guo. X.E .. L·t al. (199S1. ThL' infhll'llcL' cd'
structure and hiol11cchanical significancc of the tidemark inhomogelleous fixed charge dL'l1sitv on canil,q!l' nlcchano-
of articular canilagc. Clill Or/hop Rei Res, / /2.357. L'leetrochclllical belw\'iors. '!i'mls On/lUp Res Soc. 23. 4t;4.
Rosenberg. L.. Choi. H.U .. Tang. 1..-H .. et a!. (1985), Isolation Swann. I).A .. Radin, E.L .. & Hcndn:lL R.B. (1979). Thl·lubri-
of dennatan sulf.ltc proteoglycans from mature bovine ar- c:ltion of :lrliclIbr cartilage b~' syn(wial I'luid gl,\'copro-
tindar cartilage. J Bio! Cht'lJl, 260, 6304. tL'ins. Arthriris Rhein. 12, 665.
Roscnberg, L.. Hellmann, \V., &. Kleinschmidt, A.K. (1975). SW:\l1Il. fL\ .. Sih'L'r, F.H., Sla~'lL'r. H.S .. ct :d. {1%5L ThL' mol-
Electron microscopic studiL's or proteoglycan aggregatL'S t'cubr structure ~lnd lubricating :lcti\'it,\' of lubricin frorn
from bo\'ine articular cartilage. ./ Bio! Chew. 250, 1877. bo\"inc and human s~'nO\'ial fluids. BiucltoJl J. 225. 195.
Roth, V.. &: Mow. V.c. (1980). The intrinsic tensile bchavior of S\\'cL'l. \l.B.E .. Thonar. E../.-\1.A., & \1:lrsh . .I. (1979). AgL'-
the nl<\trix of bovine articular canilagc and its variation rL'lated ch,lngcs in protcoglYC:1I1 structurL'. Arch Hiochc!II
with age . ./ BOHi.' ./oilu SlIrg, 62A, 1102. Biopltys. / 98. 439~448.
Roughlev. P.J.. &. Whitc, R.J. (1980). Age-related changes in Thompson, R.C .. Ocgcma. TR .. Lcwis . .1.1" L'l al. (1991 L Os-
t';e structure of thc proteoglycan sub~lnits from hum7'1ll ar- tcoanhrotic changcs al'tcr anHe Iransarticular load. An
ticular cartilage. J BioI Choll. 255, 2!i. animal model. J BOHL' lohll Slirfi. 73:\. 990.
Roughley. P.l .. \Vhite. R.l., & Santcr. V. (198 I). Comparison Thonar. E..I.-\L·\ .. Bjornsson, S., & KueHner. K.E. (1986).
of proteoglycans extracted from high- and low-weight Age.related changcs in canil:lge proteoglycans. In K,
bearing human articular cartilage, with particular refer- Ku,-'ltner. R.S .. SclJle~'crbach. &. V. C. Hascall (Eds.). Arric-
encc to sialic acid content. J BioI Che/1/, 256, 12699. 1111/1' Clirrilllg.c Biochcl!/islJY (pp. 273,-287). Nl'\\' York:
Schinagl. R.M .. Gurskis. D., Chen, A.C., et a1. (!997). Depth- Ra\'en Prcss.
dependent confined compression modulus of full- Torzilli. P.A .. &: \Iow. V.e. (19761. On the t'lInd:lI11elltal fluid
thickness bovine articular cartilage. J Ort/lOp Res. /5,499. Iransport lllechanisms through normal and palhologic car-
Schinagl. R.M., Ting. M.K .. Pricc. J.H .. el a1. (1996). Video tilage during function. 1. The formulation . ./ Biolllcch, 9(8).
microscopy to quantitate the inhomogeneolls equilibrium 541-552.
strain within articular cartilage during confined compres- Torzilli. P.A .. Rose. D.!:., & Dethl'mcrs, S.A. (I9821. Equilib-
sion. illIll Biolllt'd Eng. 24. 500. rium watn partition in articular cartilage. Biorhw/ogy, /9.
Schmidt, :\-;1.B., Mow, V.C .. ChUll. L.E., et al. (1990). Effects of 519.
proteoglycan extraction on the tcnsile behavior of artiClI- Urban . .l.P.G .. & \-lc\luliin . .I.F. (1985). Swclling prcssure 01
Jar canilage . ./ Or/hop Rcs, 8. 353. thc intervertcbral disc: Influcnce of collagcn and proteo-
Schneiderman. R., Keret, D., &. Maroudas, A. (1986). Effects glycan content. Biorhc%gy, 22. 145.
of mechanical and osmotic pressure on thc rate of gly- Valhlllll. W.B .. StazmDc. E.J .. Bachrach. N.;vl . L'l a!. (1998).
cosaminoglycan synthesis in adult femoral head cartilage: LO<ld-controlkd compression of articular cartilagL' in-
An in vitro study. J Orthop Res. 4, 393. duces a transicllt stimulation of aggn:can gene cxprcssion.
Schubert, i\'1.. &. Hamerman, D. (1968). A Primer 011 COIIlICC- Arch Biocltc/!/ Biophys 353, 29.
tive Tisslle Biochelllistry. Philadelphia: Lea &: Fcbiger. Venn, \'I.F. (1978). Variation of chemical compOSition with
Scott . .I.E.. & Orford, C.R. (1981). Dennatan sulphate-rich age in hllman remora I head cartilagc. Ann RheulII Dis, 37,
protcoglycan associates with rat tail-tendon collagen at 168.
the d band in the gap region. BiochelJl J, /97,113. \Vada. T. & Akiwki. S. (1987). An ultrastructural study of
Selton, L.A., Gu, \V.Y., Lai, \V.M .. et a1. (1995), Predictions of solid matrix in articular cartilagc under uniaxial tensile
the swelling induced pre-stress in articular cartilage. In stress. J .Ifill On//tJfJ Assn. 61.
A.P.S. Selvadurai (Ed.), .lleclulllics of Porous Atcdia (pp. \Valker. P.S .. Dowson. D.. Longfeild. \I.D .. et al. (1968).
299-311). Kluwer Academic Pubs. Dordrecht. the Nether- "Boosted lubrication" in syno\'ial joints b~' rluid entrap-
lands. lllent and enrichment. :Inn !VIC/IIII Dis, 27, 511.
Walka. P.S .. Unswonh, :\ .. Dowson, D.. I,:t a!. (1970). ~-lod(.' of Woo, S.L.Y.. LL'wsay G.A., Runco, 1.1., ct:ll. (199;). Structure
ag!!rcgation of hyaluronic acid prntdn cOll1pk:x on tilL' aml function of (t:ndolls and ligalllt:nts. In V.C. ~·1ow &
sll~facc of articular cartilage. .. \/11I Wlt'lflll Dis. 29. 591. W.e. Hayes (Eds.), Basic Orthopaedic BiollleclUlllics (2nd
\V;JOg. C.B., &. Mow, V.C. (199S). Inhomogendty of aggreg,HL' cd., pp. 109-2.5 I). Phibddphia: Lippincolt-Raven.
n;odulus affects c~rtil:tgL' cornpn.:ssi\·I..' strcss-n:la:Xi1tion Zhu, \V.B .. Iatridis, J.e.. Hlibczjk. V.. Cl al. (1996). DClermi·
behavior. 1i'alls Or/hop Uc:s Soc, 13( I). 481. n;ltioll of collagen-prot('oglycan interactions in vitro. 1
Weiss. c.. Roscnbl.:rg. L., & J-1e1fL'1. A.J. (1968). Alluhraslrllc- BioJl1cclwnics. 29, 7i3.
tural study of !lumlal young adllli hum;11l anicular cani· Zhu, \-V.B., Lli, \V.~-I., &: J'I·low. v.e. (1986). Intrinsic quasi-
lage. J BO//(: 10illl SlIrg, 50A, 663. linl..'ar viscoebstic bL'havior of thc c.\tracelllllut' m;:Hrl.\ of
\Villiams, P.F., j1owdl. G.l.., &: Laberge, M. (1993). Sliding cartilagL'. 7i'tIIIS OrthofJ Res Soc, 1/, 407.
friction analysis of phosphatidylcholinl: as a boundary Zllu, \V.B., Lai. W.i\1., &. I\\OW, V.e. (1991). TIl(: dl.'nsity and
lubricant for anicul<"lr cartilage. Prot Ills 1 l/ech EIl.!jI'S, sll"L'ngth of proteoglycan-proli..'oglycan interaction sites in
l07, 59. C(IIlCenlrakd solutions. J Biolllt'C!liIllics, ],1, 1007.
Woo. S.L.-Y., Mow, V.c., &: Lai, W.~,t. (1987). l3iorncchanical Zhll, W.B., ,\In\\', V.C .. Koob. '1'.1 .. ct al. (1993). Viscoelastic
propcnics of ;Irticubr cartilage. In /-IllIu/book of Bioengi- shl.."u· propi..'rtil..'s of articular cartilagL' and the <:ffcc!:.> of
neering (pp. 4.1-.....·H. New York: McGrmv-Hill. glycosidase treatments. 1 Ortlwp Res, I J. 771.
increase area or load distribution to'dec..easeme
AIRTI'CULARCARTILAGE ,streSses sustlllned by cont::ict joint surfaces
".",.'.::~::~><,,:,>~'
-".<1
,~\Qt
;',\'CXM
~~!~
." '.' '"
'.•···HI.,hlvSpeclalizedTlssu'e
~
To provldoa smoothwear·reSistantbearing
;' 'I
s'urfac~ecrease b1ction~' '~:,',
I
1 \~
CELlULAR COMPONENTS
,-'/,.,'-'
EXTRACELLULAR COMPONENTS
Extracellular M3trix-ECM-
~
•
CD
(5
;:: 'i
m
":r
~
R'
'"o
POROUS PERMEABLE SOUD PHASE .! ;~TERS~IT.I~]f3~!·[)rHASE ,:;;; ~
....
v;
~!ceir'~~~~!%!~i;'1f'~~~&!,i~'>
"
-Qrganlt Component--: i
'"
C
m
.A
'"l>
z
o
'"....
0,
'"
C
:":1 ".C...
'"
m
'"
o
~
....
:r
m
S
C
'"
"5c
V'
"
m
~
m
;;
~ ~
V'
-<
j '"....m
:1 Biph;uic Str'uc(urc ;::
II
:,:,'1 BIOMECHANICAL PROPERTIES
\!
Animtropy,Viscocl;micity. Swelling Bchavior-ColllprCHivc lo~d bearing c~pJcity-
.~, FLOW, CHART 3·1 Articular cartilage structure and biomechanicaJ properties. ~
'~\j
"Thh How ChMl is d~si9ncd fOI das>room or group disCLl~~io". Flow than i~ not mCi'lr'lt \0 be cxh<lustive.
'lh::·, ,10';.1 ti\"'~ lC' "'-><'j'" "
n
I
»
:'1
m
'"w
co
is
$:
m
n
I
Results in
»Z
n
'"
om
Disruption of collagen-PG solid matrix
PG "wash out"
"This flow chart is designed for c1assroorn or group discussion. Flow ch.Jr1 is not meant to be exhaustive.
~
;;;
E
~
-"!
.2
-.;
v
~x
~
~'
\J
'"C'
~
0
v >
>- 't;;
'"
0
~
0
.0
0
0
0
Ci .0
ei 8
~ E
0
0
E
5
.;0 g
~
~ .-
c :;
~
'"
~
."
,
.,;
~
!1.
'"
~
.;0 g
.~
~
~
v
£ '0
.~ ~
." ~
~
~
·v
~
"'6
E
0
~ e
~
E •
v
0
V
~
."
e:;; ~
~
." 0
iii §
0
~
"0
C
,
." 0
-S
.~
's
1;' <;
0
."-
:E ,J.' t
,
0
.,;
~
i=
•
! .';".'i~'-
.;.
!j
'.:
./ !
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
Introduction and ~artilage and has a unique mechanical support-
The three principal structures that c10selv surround, ive function in other connective tissues such as
connect and stabilize the joints of the ~keletal svs- blood vessels, heart, ureters, kidneys, skin, and liver.
t~Il1are tendons, ligaments, and joint capsules. ~\l The great mechanical stability of collagen gives the
tIlollgh these structures arc passive (i.e., thev do not
tendons and ligaments their characteristic strength
and flexibility. C
103
al!~~ii4~PART 1 • 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- f'xtrac('lIuiar lll<1!rl)( ill cl PiHt111e-! ilflangelll('llt {o form m;·
dles in tendons and collagenous ligaments (not drawn to crofibrils 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
These molecules (depicted with "heads" and "tails" to repre- llIicro,:>wpe. Tilt:' hb!!l ... <)~J9rcgate further into hbers, ~"... I1l<:h
sent 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'l. IL i...; till.' I,.'I'{):-;:,,-!illkl,d dl~II·~h.:[l'I' ur Llll'l'ol-
polypeptide chains (ex chains), each coiled in a left- 1~lgl'll lihrib ikll I~h'l'~ ,"'II'l'll~lh [0 thl' li:--:-il.l('.'" IIlL'y
handed helix wilh approximately 100 amino acids, C( lmpOSl' and <:t1I< I\\':-- I hl.':--l' I b:"Ul'S I( I l"tl1"ll.·1 il III under
which give it a total molecular weight or approxi. 1ll1.'("II<tllic~d :--lrl':":--. \\'illlill 111(' lihril:-., !Ill.' mulecules
mately 340,000 daltons (Rich & Crick, 1961) (Fig. <:tl"t' ;Jppar('Il!I~' tTUss-lillked h.y "hl'<:\(.I·I(l-i~lil" illter-
4-2). Two or the peptide chains (called ,,·1 chains) <:ll:tiulb (Fi~_ -l~ I L hUI inlcrlihrilbr IT(I:-..... -linkill~ of a
,
are identical. and one differs slightly (the 0:-2 chain). rnOl"L' complL'\ n~llllr(' <:d~(l rn~l.'" on·lll'.
The three a-chains are c0l11binccl in a right-handed III 111..'\\-1\- fcwlllt:d ,,:(lll~l~l'l1. thl' CI'(l:-.:--·lillk:-- ~\1\':' rd-
triple helix. which gives the collagen molecule a rod- :lli\"\,.,h- k\\' :lnd ~lrt' rl.~dlll.'ihl\:: 1111.' l.'(llb~l.'l1 b :,>olllble
like shape. The length or the molecule is approxi. ill rJt'lIlral sail :"ohlliol"l:' <:!llll ill ~Icid :"(IIUliull:--, alld
mately 280 nanOllleters (nIT}), and its diameter is ap- 1Ilt' i.:ro:--~-Ii111..:-; a I"l' hI i rI., t'a~i I.,' dL'Il~llll rt'd hy hl.'at. As
proximately 1.5 nm. t.:olla~t'n a~L':-', lilt' 1111<:11 rlullIhtT nl rl'lilldhk' tTOSS'
Almost two thirds of the collagen molecule con- link:-. dl'LTl'a:-'L':-' lei ~l tllinilllurn ~b ~l 1~lr~l' lllllllhl'r of
sists of three amino acids: glycine (33%), proline :--(~lhk', nonrl,dul'ihk· lTCls:"-lird,:,, ~lrl' fOI"t'lll'd. \bIUI'C
(15%), and hydroxyproline (15°/(;) (Ramachandran, l'<"lI~l~t'n i~ nul sU[lIhk, ill Ilt'lllral :"i.dl ~(lIt1ti(Jll:" 01' in
1963). Every third amino acid in each 0: chain is ~ldd solulio1\:", and il :-illlyi\'l'~:\ hi~llL'l' dl'I1;,lllll'~ltion
glycine, and this repetitive sequence is essential for tl'l1IjWl':lllll'l', (1"-"0[' ~\ I\~\'il'\\' or lTo:"s-link:\1!l' ill ~'()Ila
the proper rormation of the triple helix. The small 12l'll, Sl.'l' Viidik, D~lllil'lsl'll, t~ Chlulld, 10~2,l
size 01' this amino acid allows the tight helical pack· .:\ lihril is !"(Irllll,d h," till' a~~I·q.!.ali(l1l or
Sl'\'t'l"al
ing of the collagen molecule. C'vlorco\'cr. glycine en- l,'olla~l'1l lllolL'ctlk's ill ;1 qU<lltTn~lIY Slrtlc!url.'. This
hances the stability of the molecule by forming hy- strllclllrl.', in \\·Ilh.:h t"ach Illnkndt' O\'t'!·bp:-. Ihe
drogen bonds among the three chains of the otht'r, is I\'spollsihk for 1I1l' J'L'lk'alillt! IXIII((:-; ob-
superhelix. Hydroxyproline and proline form hydro- :':'t'J"Yl,d Oil thl' lihril", lllH..kT till' t,k-l'II'OIl lllilTOS(Ope
gen bonds, or hydrogen-bonded wal~r bridges. (Fi~, --l-2: ~l'l' :ds(l Fig, "'''''). Till' qll,llt'l'll:II-," Slrll...: lure
within each chain, The intra- and inlcrchain bond- or l.T)lIa~cn rdalt'S 10 till.' or~~1I1i:t<:lli(l1l III l.·ollagl.:'11
ing. or cross-linking. between specific groups on the lllolt'ClIll's il110 :l :"l~lbk. 10\\' l.'lll'r~i,:lic bi(llo!!icaJ
chains is essential (0 the stability of the molecule, unit ha:--t'd 011 :J rq:!.ul<:\1· a:':"(ll"ial iOll (~r ~\(,.l.iaCt'lll ';1101·
Cross-links are also formed between collagen t'''.'lIks' h~ISil' <:llId ~lcidil' :llIlino ~ll·ids. B., :In:ll1ging
molecules and are essential to aggregation at the ~\d.iacl'lll col1at!.I.'l't 1I1pk'l:uks in a qLl~lnl'l'-st~lg1:-~t'r. or·
64 om arrangcn)cnt, which cquips the tendons to handle
lhe high unidirectional (uni4lxial) lensile loads to
Fibril
000
which they are subjected during activity (Fig. 4-4A).
, 0
or;: Overlap zone The Iigamenls gencrally sLisrain tensile loads in one
010
r Hole zone predominant direction but may also bear smaller "
;:r:I I
Micrafibrils (cnsile loads in other directions; their fibers may not 1
~~~~=~'~'~'~~~~~~~~~
Packing of
be completely parallel but arc closely interiaccd
'molecules I I
with one another (Fig. 4-48). The specific orienta-
..-",/ ................. tion of the fiber bundles varies to some cxtent
~~/
/
... among the ligaments and is dcpendcnl on the func-
-' ........... tion of the ligament (Arnie! et al .. 1984),
rCollagen r'.'='='=====:2~80~nm~======):J~
i' molecule !... I
........ .J
,
..................
!
The metabolic tUI'nover of collagen may be stud-
ied by tritium labeling of h)-!droxyprolinc or glycine
. ,. - "
.......................
.......... i
and by autoradiographic methods, Studics in ani-
mals have shown that the half-life of collagen in ma-
, lure animals is very long: the same collagen mole-
a.2~~~t 1.5 nm
cules may exist throughout the animal's adult lire;
however, in young animals and in physically altered
~, 1 (e.g., injured or immobilized) tissue, the turnover is
acceleratcd. Rabbit studies have shown melabolic
activity to be somewhat greater in ligaments than in
tendons, probably because of different stress pat-
Schematic drawing of collagen microstructure. The colla- terns (Amie! et al .. 1984).
gen molecule consists of three alpha chains in a triple helix
(bonom). Several collagen molecules are aggregated into
a staggered parallel array. This staggering, which creates ELASTIN
hole zones and overlap zones, causes the cross-striation
The mechanical properties of tendons and liga-
(banding pattern) visible in the collagen fibril under the
electron microscope. Adapled from Prockop, 0.1.. & Guzman,
ments are dependent not only on the architecture
;\! A. (1977). Col/agen dise,)ses and the biosynthesis of collagen
and properties of the collagen fibers but also on the
" proportion of elastin that these su'uctures contain.
Hasp Pract. Dec. 61-68.
The protein elastin is scarcely present in tendons
and extrcrnily ligaments, but in elastic ligamcnts
such as the Iigamenlum Oavum, the proportion of
positely charged amino acids are aligned. This sta- elastic fibers is substantial. Nachemson and Evans
bl.c structure will require a great amount of energy (1968) found a 2 to I ratio of clastic to collagen
,':~ri,d force to separate its molecules, thus contribut- fibers in the ligaments flava. These ligamcnls, which
:.ipg to the strength of the structurc. In this way, or- connect the laminae of adjacent vertebrae, appear
gU)lizcd collagen molecules (five) form units of mi- to have a specialized role, which is to protect the
crofibrils, subfib"ils, and fibrils (Fig. 4·3) (Simon, spinal nerve roots from mechanical impingement,
1994). The fibrils aggregate f'urther to form collagen to pre·stress (preload) the motion segment (the
fibers, which are visible under the light microscope. functional unit of the spine), and to provide some
;;./(~hese fibers, which range from I to 20 J.L111 in cliam- intrinsic stability to the spine.
''.;:,'',¢ter, do not branch and l11av be many centimeters
"j<lI1g. They reflect a 64-nm periodicity of the fibrils
.:!: GROUND SUBSTANCE
and have a characteristic undulated form. The fibers
aggregate further into bundles. Fibroblasts are The ground substance in ligaments and tendons con-
aligned in rows between these bundles and arc elon- sists of proteoglycans (PGs) (ur> to approximately
gated along an axis in the direction of ligament or 20% of the solids) along with stnlctlll,JI glycoprotcins,
;'i':. ~.enclon function (Fig, 4-4). plasma proteins, and a variety of srnall n1olcculcs.
';/: The arrangement of the collagen j-ibers differs The PG units, macromolecules composed of various
somewhat in the tendons and ligarncnls and is sulfated polysaccharidc chains (glycos<lminoglycans)
Suited to the function of each stru~ture. The fibers bonded to a corc protein, -bind to a long hyaluronic
composing the tcndons have an orderl.y, parallel acid (HA) chain La form an cxtremely high molecular
G:ilR€1gf:'~~"~l ,.,SiOMECHANICS OF TISSUES AND STRUCTURES OF THE r,IUSCULOSKELETAL SYSTEM
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-
•
Parallel bundles of
collagen fibers
Nearly parallel
bundles of
collagen fibers
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 the collagenous
skeleton of tendons and ligaments and contribute to
the o\'crall strength of these composite structures.
I~=
Only' a small number of these molecules exist in ten-
dons. however, and their imporlance for its biorne-
~
chanical properties has been questioned,
VASCULARIZATION
Fibroblasts
Tendons and ligaments have a Iimitcd vasculariza-
Tendon ligament
tion. which alTeets dircctl~' their healing process [lnd
A B metabolic activit~;. Tendons receive their blood sup-
ply dircctly from \'cssels in the perim.vsiulll. the
periosteal insertion. and the surrounding tissuc via
Schematic diagram of the structural orientation of the vessels in the para tenon or mesotenon. Tendons sur-
fibers of tendon (A) and ligament (8); insets show longitu- rounded b~) paratenon have been referred to as vas-
dinal sections. In both structures the fibroblasts are elon- cular tendons. and those sllrround~d by a tendon
gated along an axis in the direction of function. Adapted sheath as avascular tendons, In tendons surrounded
from Snell, R.5. (984), Cfinical and F~ln(tional Histology for by' a paratcnon, vessels enter rrom many points on
Medical Stuejents. Boston: Liule. Brown the pcripher.v and anastomose with a longitudinal
svstem or capilbries (Fig, 4-5),
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
India ink-injected (Spalteholz technique) into the calcaneal
vascular s)'stem, it is of prima(y importance in the
··f tendon of a rabbit, illustrating the vasculature of a
" maintenance of the ligament. Specifically, by pro-
paratenon-covered tendon. Vessels enter from many points
on the periphery and anastomose with a longitudinal system
viding nutrition for the cellular population. this vas-
of capillaries. Reprinted wirh permission from Woo, S.L. Y, An, cular system maintains the continued process of
K.N., Amoczky, D.V.M., et at. (1994). And!Om}~ biology. and bio- matrix synthesis and repair. In its absence, damage
mechanics of rhe iendon, ligament, and meniscus. In S.R. Simon fTom normal activities accumulates (fatigue) and
(Ed) Orthopaedic Basic Science (p. 52). Rosemont, Ii: MOS. the ligament is at risk for rupture (Woo et aI., 1994).
Ligaments and tendons have been shown in both
• human and animal studies to have a variety of spe-
cialized nervc endings and mcchanorcceptors, They
play an important role in proprioception and noci-
ception, which are directly related to the function-
ality of joints.
VIVI~,-."MI."."'L PROPERTIES
means of analyzing the biomechanical proper-
of tendons and ligaments is to subject specimens
tensile deformation lIsing a constant rate of elon-
The tissue is elongated until it ruptures, and
resulting force, or load (P), is plolted. The result-
load-elongation Clll-ve has several regions that
the behavior of the tissue (Fig. 4-8).
The first region of the load-elongation cuniC is
the "toe" region. The elongation reflected in
region is believed to be the result of a change
the wavy pattern of the relaxed collagen fibers. In
region, the tissue stretches easily, without much
and the collagen fibers become straight and
their \vavy appearance as the loading pro-
a",:sSl:s(Hirscb, 1974; Woo et a!., 1994) (Fig. 4-9, A
B). Some data suggest, however, that this elonga-
may' be caused mainly by' interfibrillar sliding
4
3
I Elongation (%»)
strains arc increased (strain values of between 1.5 elastic deformation that they endure under tensile
and 4% [Viidik, 1973]), a linear region will follow strain and the storage and loss of energy. During
the toe region. This sudden increase in slope repre- loading and unloading of a ligament between two
sents the second region in the diagram and con"c- limits of elongation, the elastic fibers allow the ma-
sponds to the response of Ihe tissue to further elon- tcrial to return to its original shape and size after
gation (Diamant et al.. 1972). being deformed. Meanwhile, part of the enel-gy
Following the linear region. at large strains the spent is stOt"cd; what is left will represent lhe energy
stress-strain ClIlve can end abruptly or curve down- loss during Ihe cycle and is called hysteresis. The
ward as a result of irreversible changes (failure) area enclosed by the loop represents the energy loss
(Woo et aI., 1994). Where the curve levels off toward (Fig. 4-1 I).
the strain axis, the load value is designated as Plin ,
The point at which this value is reached is the yield
PHYSIOLOGICAL LOADING OF TENDONS
point [or the tissue. The energy uptake to PHn is rep-
AND LIGAMENTS
resented by the area under the ClIl·ve lip [0 the end
of the linear region. The ultimate tensile strength (P,,,:..,,) of ligaments
\Vhen the linear region is surpassed, major fail- and tendons is of limited interest from a functional
ure of fiber bundles occurs in an unpredictable standpoint because under normal physiological
l11anne1'. \Vith the attainment of maximum load that conditions in vivo these structures are subjected to
reflects the uhimatc tensile strength of the speci- a stress magnitude that is only approxirnately one
men, complete Failure occurs rapidly, and the load- third of this value. The upper limit for physiological
supporting ability of the tendon or ligament is sub- strain in tendons and ligaments (when running and
stantially reduced. 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
In the toe portion of the load-elongation curve (or
stress~slrain curve), the modulus of elasticity is not
constant but increases gradually. The modulus sta-
bilizes in the fairly linear secondary region of the
curve.
The load-elongation CUPie depicted in Figure 4-8 o -70
generally applies to tendons and extremity liga- Elongation (~o)
~1.'· ,--? .
~Peakload store more energy, require marc force to I1.lpture,
1 cycle ~
and undergo greater elongation (Kenncd.", Hawkins,
Willis, & Danylchuk, 1976).
Dw-ing cyclic testing of ligaments and tendons,
where loads are applied and released al specific in-
tenmls, the stress-strain curve is displaced to the
riglll along the deformation (strain) axis with each
loading cycle, revealing the presence of a nonelas-
tic (plastic) cOlllponcnt; thc amount 01" perma-
nent (nonrecoverable) deformation is progressively
greater with every loading cycle. As cyclic loading
progresses, the specimcn also shows an increase in
clastic stiffness as a result of plastic dcfonnation
(molecular displacement). IVlicrofailure can occur
within the physiological range if frequcnt loading is
imposed on an already damaged struclUrc where
Elongation
lhe stiffness has decreased.
Two standard tests that reveal the viscoelasticity
or ligaments and tendons are the stress-relaxation
test and the creep test (Fig, 4~12). During a stress-
Typical loading (top) and unloading curves (bottom) from relaxation test, loading is hailed safely below the
tensile testing of knee ligaments. The two nonlinear curves linear region of the stress-strain curve and the strain
form a hysteresis loop. The area between the curves, called is kept constant over an extended period. The stress
the area of hysteresis, represents the energy losses within decreases rapidly at first and then more sl()\vly.
the tissue. \Vhen the stress-relaxation test is repeated cycli-
cally, the decrease in stress gradually becomes less
pronou need.
During a creep lcst,loading is halted saFely below
'0 ,Few studies or loading of tendons or Ii!!aments in the linear region of the stress-strain curve and the
\:ivo have been perrorm~d. Kear and Smith (1975), stress is kept constanl over an extended period. The
using the strain gauge method, measured the rnaxi- strain increases relatively quickly at first and then
nUll strain in the latcral digital extensor tendons of more and more slowl.':. \Vhen this tcst is performed
sheep. The strain reached 2_6t}~ while the shl:cp cyclically. the increase in strain gradually becomes
were trolling rapidly and decreased when the trol- less pronounced,
ting speed decreased. This maximal strain occurred The clinical application or a constant low load 10
for only 0.1 second during each stride. The maximal the soft tissues over a prolonged period, which takes
load imposed on the entire tendon was approxi- advantage of the creep response. is a llseful treat-
mately 45 newtons (N). These results suggest that ment for several types of deformities. One example
during normal activity, a tendon in vivo is subjected is the manipulation of a child's clubfoot by subject-
LO less than one fourth of its ultimate stress. ing it to constant loads by means of a plaster cast.
Another example is the treatment of idiopathic sco-
liosis with a brace, whereby constant loads are ap-
VISCOELASTIC BEHAVIOR (RATE
plied to the spinal area to elongate the soft tissues
DEPENDENCY) IN TENDONS AND LIGAMENTS
surrounding the abnormally curved spine,
Ligaments and tendons exhibit viscoelastic, or rate- More complex viscoelastic beh41vior is observed in
dependent (time-dependent), behavior under load- the entire bone-ligament-bone complex_ Antel'ior
ing; their mechanical propelties change with differ- cnlciate ligaments (ACLs) in knee specimens taken
ent rates of 1041ding. v"hen ligament and tendon from 30 primates were tested in tension to failure at
specimens are subjected to increased strain rates a slow and a fast loading rale (Noyes el aI., 1976). At
(loading rates), the linear portion of the stress-strain , the slow loading rate (60 seconds), much slower than
curve becomes steeper, indicating greater stiffness that of an injury mechanism in vivo, the bony inser-
of the tissue at higher strain rates. v\lith higher tion of the ligament was 'the weakest component of
strain rates, ligaments and tendons in isolation the bone-ligament-bone complex.. and a tibial spine
c',,"
.~t~~ji~~Ji:,B~OMECC~ANICS OF TISSUES AND STRUCTURES OF THE MUSCULOSKELETAL SYSTEM
Ligament injuries arc categorized clinically in thus the greater the tensile loads transmitlcc!
three ways according to degree of severity. Injuries through the tendon. Similarly, rhe larger the cross-
in the first category produce negligible clinical sectional area of the tendon, the greater the loads it
symptoms. Some pain is felt, but no joint instability can bear. Although the maximal stress to failure for
can be detected clinically, CYCI1 though microfaillire a muscle has been difficult LO compute accurately,
of the collagen fibers may have occurred. such measurements ha\'c shown that the tensile
Injuries in the second category produce severe strength or a healthy tendon 111<1)-.' be mon: than
pain and some joint instability can be detected clin- t\Vice that or its Illuscle (Elliot, 1967), This finding
ically. Progressive failure of the collagen fibers has is supponed clinically by the fact that muscle fUp-
taken place. resulting in parlial ligament nlplure. lures are more common than are ruptures through
The strength and stiffness of the ligament may have a tendon.
decreased by 50% or more, mainly because the Large muscles usually' have tendons with larg~
amount of undamaged tissue has been reduced. The cross-sectional areas. Examples arc the quadriceps
joint instability produced by the partial 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 - - - --------<0
during the course of trauma with less pain after
injury Clinically, the joint is founelto be completely -rend on Injuries: Achilles Tendon Injuries in
unstable. Most collagen fibers have ruptured, but a Runners. Which Result From a High Strain
few Illay still be intact, giving the ligament the ap- Rate
pearance of continuity even though it is unable to
SUppOrl any loads. .·.. middle-aged male marathoner engaged in a strenuous
Loading of a joint that is unstable as a result of A running activity expenenced pain and a popping sensa~
ligament or joint capsule rupture produces abnor- tion in his posterior calf. An overuse injury is diagnosed.
mally high stresses on the articular cartilage. This The first region of the load-deformation curve ShQ\.V5 a
abnormal loading of the articular cartilage in the normal physiological toe-loading response. In the linear
knee has been correlated with carl~,' osteoarthritis in region, high load is producing a higher deformation
humans and in animals. within the tendon structure. When the Achilles tendon is
Although injury mechanisms are generally com- subjected to higher strain rates during frequent loading
parable in ligaments and tendons, two additional ;_ ~ycles and insufficient time is allowed for the healing
factors become important in tendons because of process, the result is an overuse injury. Histological studies
their attachment to muscles: the amount of force ot',these injuries reveal a pathological pattern described as
produced by contraction of the muscle to which the ~'angiofibrotjc hyperplasia," which suggests a degenera-
tendon is attached and the cross-sectional area of " tive process. This failure in tendon remodeling frequently
the tendon in relation to lhat of its muscle. A tendon ,. occurs before the abrupt ruplure of the tendon. Relative
is subjected to increasing stress as its muscle con- aydscu!arity, inflammatory disease, and other local factors
tracls (see Fig, 6-10), When the Illuscle is maximally also contribute to midsubstance ruptures (Case Study 4·2-1),
contracted, the tensile stress on the tendon reaches
250,00
high levels. This slress can be increased fl.lrlher if OVERUSE ~ RUPTURE
rapid eccentric contraction of the muscle takes Toe Linear yield and
200,00 region region failure region
place; for example, rapid dorsiflexion of the ankle,
which does not allow for reflex relaxation of the gas- ~ 150,00
trocnemius and soleus muscles, increases the ten- u
sion on lhe Achilles tendon, The load imposed on .3 100.00
the tendon under these circumstances may exceed
the yield point. causing Achilles tendon rupture 50,00
(Case Study 4-21-
The strength of a muscle depends on ilS physio-
1,00 2,00 3,00 4,00 5,00 6,00 7,00
logical cross-sectional area. The larger the cross-
Def9rmation (mm)
·1'-_-1
sectional area of the muscle, the higher the magni;:'
lude of the foree produced by the contraction and Case Study Figure 4·2·1.
CHAPTER 4•BIOMECHANICS OF TENDONS A~9t~t{'Jg~:f1iJi~D
muscle with its patellar lendon and the triceps Slifac did nOl differ signillcanLi~1 (Kaspcrczyk et aI., 1991).
muscle with its Achilles tendon. Some small mus- This may be due 10 the fact lhal only lhe ACL was
cles have tendons with large cross-sectional areas; taken from donors in \I,,1hom no vascular or car-
such as the plantaris. which is a liny muscle with a diopulmonary disease and no ostcoanhritis of the
large tendon. knee was found on autopsy.
oF"'-';- ,
QI~'fE'=::f!6~,T l\SIO'MECrIANICS Of TISSUES AND STRUCTURES Of THE MUSCULOSKELETAL SYSTEM
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-
Amid and coworkers (1982) showed a similar de- turn to normal but that the energy-absorbing capa-
crease in the strength ancl stiffness or lateral collat- bilities or the bone-ligament complex improved but
eral ligaments in rabbits immobilized for 9 weeks. did not return to normal.
As the cross-sectional area of the specimens did 110t
change Significantly, the degeneration of mechani-
DIABETES MELLITUS
cal properties was altributed to changes in the liga-
ment substance itself. The tissue metabolism was The term diabetes rcfcrs to disorders characterized
noted to increase, leading to proportionally more by excessive urine excretion. Diabetes mellitus is a
immature collagen with a decrease in the amount metabolic disorder in which the ability to oxidize
and quality of the cross-links between collagen mol- carbohydrates is more or less completely lost. This
ecules. Newton et al. (1995) reported that the cross- is usually caused by pancreas insufficiency and a
sectional area of ligaments in immobilized n1bbit disturbance of the normal insulin mechanism, rc-
knees waS 740/0 of the control valuc. sulting in hyperglycemia, glycosuria, and polyuria.
In Noves' (I977a) experiment, assessment of the Diabetes mellitus is known to cause musculoskele-
effects of a reconditioning program initiated di- tal disorders. Diabetics compared with nondiabetics
rectly aftcr the 8-\\'cek immobilization pel"iod show higher rates of tendon contracture (29 \IS. 9%),
demonstraLcd that considerable time was needed tenosynovitis (59 vs. 7%), joint stillness (40 vs. 9%),
1'01' the immobilized ligaments to regain their for- and capsulitis (16 \'s. 1%). Diabetes also causes os-
mer strength and stiffncss. After 5 months, the re- teoporosis (Calvallo et aI., 1991; Lancaster et aI.,
conditioned ligaments still showed considerably 1994).
less stiffness and 20% less strength than did liga- Duquette (1996) examined the effects of diabetes
ments from control animals. At 12 months, the re- on the properties of the collateral knee ligament in t:i:
conditioned ligaments had strength and stiffness rats. The tissue elastic properties did not differ be-
values comparable to those of control group liga- tween the diabetic and the control group. The vis-
100
60
-"
0,2
~~ 60
l'l E
c ~
"~·x
E A' .------- Immobilized
--~8 weeks)
"'"
Q..E
40
" " I
A, Maximal load to failure and energy stored to failure for program for 12 months. 8. Compared with controls. liga-
primate anterior cruciate ligaments tested in tension to faH- ments immobilized for 8 weeks were significantly less stiff (as
ure. Values are shown as a percentage of control values for indicated by the slope of the curve) and underwent greater
three groups of experimental animals: (1) those immobilized elongation. Adapred from Noyes. FR. 0977(1). Functional proper~
in body casts for 8 weeks; (2) those immobilized for 8 weeks I ties of knee ligaments and alterations induced by immobilization.
and given a 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, (1997) reports that physiological levels of estrogen
\vas increased in the hy'perglycemic group. Insulin reduce the collagen production by 40(;1(; and at phar-
therapy seems to lessen such alterations. Lancaster, macological levels of estrogen, collagen production
ct al. (1994) examined the changes in the mechani~ is decreased by' more than 50%, Estrogen fluctua-
cal properties of the patellar tendon in diabetic dogs. tions may alter ligament metabolism and may
The results showed the stiffness of the canine patel- change the composition of ligament, rendering it
lar tendon-tibia complex in a phy'sioiogical range of more susceptible to injury.
loading was 13% greater than in the control group.
There was no difference in the strength of the tendon
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
between the groups, but the mode of failure was dif~
ferent. In the control group, failure was caused by NSAIDs (which include aspirin, acetaminophen, and
substance and avulsion failure, whereas failure of indomethacin) are frequently used in the treatment
the tendon in the diabetic group was caused by ten- of various painful conditions of the musculoskeletal
sile fractures of the patella (Lancaster et al" 1994). 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~
STEROIDS
ments. Vogel (1977) found that treatment with
Corticosteroids, when applied immediately after in- indomethacin resulted in increased tensile strength
jury, may' cause significant impairment of the bio~ in rat tail tendons. An increase in the proportion of
mechanical and histological properties in liga~ insoluble collagen and in the total collagen content
ments. Corticosteroids also are known to inhibit also was observed. Ohkawa (1982) found increased
collagen synthesis in vitro (\'Valsh et aL, 1995). \Vig- tensile strength in the periodontium of rats after in-
gins et a!. (1994) described these results in rabbits domethacin treatment. Carlstedt and associates
and implied that an acute injured ligament treated (1986a, 1986b) found that indomethacin treatment
with corticosteroid injections may not \vithstand increased the tensile strength in developing and
the mechanical loads of an earl)!, vigorous rehabili- healing plantaris longus tendons in the rabbit and
tation. Noyes et a!. (1977b) reported decreased liga- noted that the mechanism for this increase was
ment stiffness, failure load, and energy absorption probably an increased cross-linkage of collagen mol-
in monkey ligaments after injection of long-acting ecules. These animal studies suggest that short~tern1
corticosteroids. These findings were tin1e- and administration of NSAlDs would not be deleterious
dosage-dependent. After application of a dosage for tendon healing but instead \vould increase the
that was approximately 10 times an equivalent hu- rate of biomechanical restoration of the tissue.
man dose. only! minimal changes were found after 6
\veeks, but after IS weeks the maximum failure load
HEMODIALYSIS
(20%), energy absorption prior to failure (11%), and
stiffness (11 %) decreased significantly. After Tendinous failure resulting from chronic renal failure 1
application of a dosage equivalent to the human does occur, \vith tendon rupture reaching 36% among i
dose, the maximum failure load (9%) and the en-
absorption (8%) decreased significantly.
individuals receiving hemodialysis. Hyperlaxity of
tendons and ligaments \vas found in 74%, patellar i
Campbell ct al. (1996), however, showed that a tendon elongation in 49%, and articular hypermobil~ I
single injection of long-acting corticosteroid does
not cause histological differences in rats with acute
ity in 51 % of individuals receiving long-term he-
modialysis (Rillo et a!., 1991). Dialysis-related amy- I
injured ligaments as compared \vith rats with acute
ligament injury and no injection of corticosteroids.
loidosis may cause the deposition of amyloid in the
synovium of tendons. The major constituent of the
I
lv1cchanical testing showed no significant difference
in ultimate load or ultimate stress in the two
amyloid fibrils is the beta 2-microglobulin (Morita et
a!., 1995; Honda et a!., 1990; Bardin et a!., 1985).
I
groups. Oxlund et a!. (1980) reports that local injec-
tions of corticosteroids every 3 days for 24 days in-
GRAFTS
crease the tensile strength and maxin1um load stiff~
ness of muscle tendons but decrease the strength of Reconstruction of torn ligaments, especially or the
the bone attachments of ligaments. anterior and posterior cruciate ligament, is now a
Laborator).' investigations established the pres- frequent procedure. The need for reconstruction is
ence 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 substantial proportion of elastin. which lends these
same species ar~ called allografts; grafts derived structures their great elasticity.
from the same individual are called aUlograhs. Allo- 2 The arrangement of the collagen fibers is
grafr tissue preservation is done through freezc- nearly parallel in tendons. equipping them to with-
drying and low·dose irrndiation to reduce rales of stand high unidirectional loads_ The less parallel
rejection ancl infection and to limit effects on the arrangement of the collagen fibers in ligaments al~
structural properties. Bone-patellar. tendon-bone, lows these structures to sustain predominant tensile
and Achilles tendon are llsually L1sed as allograft tis- stresses in one direction and smaller stresses in
sue, whereas the central tissue of the patellar ten- other directions.
don is commonly llsed as autograft tisslie.
Shino ct al. (1995) L1sed fresh-frozen allogenic ,;:~~)': At the insertion of ligament and tendon into
Achilles, tibialis anterior or posterior. and peroneus stiffer bone. the gradual change from a morc fibrous
[0 a morc bony rnaterial results in a dccreased stress
longus or brevis tendons for ACL reconstruction in
humans. Specimens were procured during second- concentration effect.
look anhroscop~'. Several years after reconstruction. ~ ~ Tendons and ligaments undergo deformation
the allografts had collagen fibril profiles that did not before failure. ,,""hen the ultimate tensile strength of
resemble normal tendon grafts or normal ACL. these structures is surpassed. complete failure DC·
Strocchi et al. (1992) L1sed patellar tendons that had curs rapidl~!. and their load~bearing ability is sub~
been autograftcd to reconstn1C[ [onl ACLs. Follow-up stantially decreased.
biopsies were performed 6, 12. and 24 months after
5. Studies suggest that during nonllal activity. a
surgel}'. During this time, the aUlOgraft underwent tendon in vivo is subjected [0 less than one fourth of
considerable changes. and after 24 months the auto- its ultimate stress.
graft had the appearance of normal ligament tissue.
Strocchi suggested that the patellar tendon autograft '/'~:(: Injul"\! mechanisms in a tendon are influenced
is a valid functional ACL substitution for patients who by"{he ~lm~unt of force produced by the contraction
desire to perform normal mechanical activity. or the muscle to which the tendon is attached and
Corselli el al. (1996) reports thal replacement tis- the cross-sectional area or the tendon in relation to
sue undergoes extensive biological remodeling and that of ilS muscle.
incorporation. However. even a fully incorporated 7 i The biomechanical behavior of ligaments and
graft will never duplicate the native ACL but works tendons is viscoelastic. or rate·dependent. so thal
instead as a check reign that increases the knee these structures display an increase in strength and
function_ Tohayama et al. (1996) stated that the stiffness with an increased loading rate.
graft elongation at the time of implantation influ-
S An additional effect of rate dependency is the
ences the long-term outcome of ACL rcconstruc·
slow deformation, or creep. that occurs when ten-
tions. at least in the canine model. They compared
dons and ligamcnts are subjected to a constant low
those cases where the graft elongation behavior was
load over an extended period; stress relaxation takes
within the 95% confidence limit of normal ACL
place when these structures sustain a constant elon-
(group 1) with those cases where the graft elonga-
gation over time.
tion behavior was more than lhe 95(1'0 confidence
limit of the normal ACL (group 2). Group 2 had sig- /{gi,::':
,/),,,
Anina
:;;. b
results in a decline in the mechanical
nificantly less inner stiffness of the graft than did properties of tendons and ligaments, th~1t is, their
group 1. Group 2 showed a significantly increased strength, stiffness, and abilily to withsland defor-
anteroposterior laxity. but there was no difference mation.
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.
Summary
11
Allografts and autografts are useful in ligament
f~1-~Tendons and extremity ligaments are composed reconstruction but material propenies do not re-
largely of collagen, whose mechanical stability gives 'turn completel~" to normal levels.
lhese structures their characteristic strength and 12) Ligaments and tendons remodel in response to
flexibility. The ligaments flava of the spine have a the mechanical demands placed on them_
REFERENCES Honda. K.. I-lara. M., Ogura, Y.. Nilll.:i. 1-1 •• i\lirnura, N. (I990).
~~t<l-~-microgl()hulin ~llnyloidosis in hemodialysis pa-
:\micl. D.. Kuipl'l'. S.D.. \\'all"C('. C.D .. Harwood. E V'lndl'-
t~l·ntS: An autopsy study of intcrH·rtt:hr.t1 disks and POSlC-
berg. J.S. (1991). :\gt:.rdall'd properties of llledi.d (;olbt·
nor hg<lOll·lltS . ..\eUl Patlwl lpII . .JO( II). S20-826.
l.:ral Iig~lIncnt and anterior cruciall' ligament: ..\ morpho·
Kaspl'I"czyk. W. J.. Rosoch:l. S .. BO$t:h. U .. Ocsh~rn. J.1.. Tsch-
logic :lnd coll'lgen maturation study in thl' r'lbbit. J
crnl·. I-I. (1991). Ag(' .\CtiviIY .Hld stl'<.'ngth of knee.: li!:.!.a-
Gerem/ol. 46(.J). BI56-BI65.
ments. U,,{alkhimrr,. 94(7).372-375. -
Amid. D•• Fr,lIlk, c.. I-Iar\\'ood. E. l.'1 OIL (198-1). Tendou~ and
Kassel". J. (Ed.) (19961. Onlwp/li.'dic I\lI00dccly,i.' Update 5:
ligaments: A morphological and biochl'lllical comp~l'ison.
f/?IIll! S{lfdy Syllal}f/,~, P'.ll'k Ridgl'. IL: American Acadl'IllY
lOt/hop nt's. 1.157.
ot Onhopatdic Slll"~c.:ons. -
:\mit'1. D., Woo. S.L.Y.. Harwood. F.L.. l't a!. (1982). Thl' dfl.'ct
Kcar, i\l.. & Smith. R.N. (1975), A flll'thnd for l'l'corJin u Wn-
of immobilization on colbgen lUl'IlO\"l'J" in t:onlll,,'cli\'c tis·
don stnlin in sheep during locomotioll, Aew On/lOp S:fllld
suc. i\ biochl..'rnical-biomechanical C01Tl'btion. Ac/o Or.
-16. 896. '
!hop Scalld, 53, 323.
Kl'llIll'dy, J.C., l-bwkins. RJ .. Willis. R.B .. d :.1. (1976). Ten-
Bardin. T.. Kuntz, S., Zingr.d"f, J.. Voisin. ~'I'I.C., ZelmaI', A.
sion Sllu.!i(·S of humall knec ligaments. Yield point, ulti-
(1985). Syno\'ial amyloidosis in patients undergoing long:.
matc failure, and disruption of thl.: cl'tlciatc and tibbl col-
terlll hl..'lllodialysis . .·\J'/l1l"it;., Rheum, 28(9}. 1052-1058.
"Heral ligaments. 1 BOlle.' loillT S/f/'~. 58:\. 350.
Campbell, R.B .. Wiggins. \-1. E.. Cannislra. L.;\L F"dalc. P.P..
Lancaster. R.L., Haut. R.C.. DeCamp. C.E. (199.J). Chan2es in
Akclm.m, E. (1996). Influencc of stcroid injc(:tion in li~:l-
thl' lllech:luic,,1 propenil's of p.ltdl.ll· tl'lldOll pr..:par.~tions
ment hc~t1ing in thl..' r.lI. Cli" OnllOp. 332. i.J1-253. -
of spolHancously dii:lbl'lic do,gs tIIH!l'r 10nll·tC'I"1ll insulin
Carlstcdl, C.:\. (1987). Mt:chanical and cht.'f1li(~11 f:u;tors in
th~rapy. J Biomf!cil. 27(8). 110.1-1108. -
[('ndon healing: Effects of indolTlcthacin and sun.!cn· in
Lill. S.H .. AI-Shaikh. R...\., Panossi~lll. \1.. Fil1{·rman. G.A.,
th..: 1'00hbil. Aew On/WI' Scawl SIIPI,I, IN. ~ .
Lane, J.M. (1997). Estrogen ;tlTccts l!Ie cellular Illctabo-
, Carlstcdt, C.:\ .. Madson. K.. &. Wn:dmark. T. (l9Soa). The ill-
lisll.l of .lh(.' .aolt'rior t:l'l1ciall' ligaml'lll. ,\ potential expla-
flllencc of indolTlethacin on collagen synthi.'sis durin!! lell'
n:tllnn lor lemalL' ~llhlt.'lic injury..'\111 1 Sports ,I/i.'d. 25(5).
([cm healing in lhi.' rnbhit. Pros/ag!(/I/{!i,ls. 32. 353. -
71J4-709.
C~Il'lstcdl, C.A .. ~bdsOTl. K" & W!'cdrnark. 1". (1986b). Till' in-
:\-lorita. H.. Shinzaalo. T.. Cai. Z.. Dadd. G.. i\lizulani A
Habuchi, H.. Ito, :\1.. Asai, J. 1.'1 ;d. (1995). Basic fibrol;la~~
fluent:l.: of indtlllll.'thacin on lendon hl'aling. A biolJlcchall'
itnl nnd biochcmical sllJd~'. ..lFell OrtllOl~1 7i'allll/{/ So!'!.;.
growth faClor-hepatin sulphate complex in the human
105. 332. '
dia1:o'sis-relalcd amyloidosis, Vir"hol\'s Arch. ';27(4).
(:11'\,(\110. A.. Ordonez. M.A .. Garcia. H.. T;tpia. J.C .. Bcbv:\c,
395-400.
1.. V:tlC:.'llCi;l. J., r..lorl'ira. ~','l. (1991). Adult llon·insll1in-dt:-
Nachclllson. A.L .. & E\'ans, J.I-I. (1968), Some mechanical
pcndl'lll diahetic: Limitation of <lJ'licular Illobi1itv ~\lld soft
propertit:s of tht: third hUl1wn lumb;\[' intcrlaminar liga·
tissue involvcment. Rev lIed Chil,119(9). 10Io-1()2l.
men! (ligalll(.'ntllm lhvlllll). J BicHIIIN,:". I. 211-220. -
Cooper. R.R .. ~ Misol. S. (1970). Tendon .Ind lig:lIllCIH inser- Nl·wton. P.O., \Voo. S.L.. ~ladenrw, D.A .. Akeson. \V.H.
lion. ;\ light and electron microscopic sllLdv. J B{J!/~' Joiul
(1995). Immohilization of tli..: knee:.: joint alters Ihl' me-
SU,,!;. 52;\, I. .
dwnic~d and uilrastrucllll',ll propenil's of the r.lhbit anle-
Corsl.'tti. J.R .. J'lckson. D.W. (1996). Fnilul'c of :lIl1Crior nud·
rior crucialC Iigaml'llt. J Orthop UI.:.... 13(2). 191-200.
~IlC Iig<lll1l'llt rl'conslruction: The biologic basis. Clill Or.
Noyl's. F.R .. t:l al. (l977a). Funt:lional propl'nics of knee li2-
fhop. 325. .J2--t9.
:1I11,;:-Uls and alterations induced b\' immobilization. Cl~,
Diamant. J .. Kdlcr. r\ .• Bael', ..\., Lill, M.. :\lTid~l'. R.G. (1972).
On/lOp. 123, 210-1-12. .
Colhlgen: Ultraslructure and its relations ~ 10 mechanic,,1
Noyes. F.R .. Grood. E.S.. Nussbaum N.S .. Cooper. S.M
propl..'ni<.'s as a function of aging. Prot· R Soc Loud
(1977b). Effect of intra<lrlicuhlr corticosleroids on li!:.!.a-
iBio/}, /80, 293.
mCIH properties: A biollll'chiHlic;1! and hislOlo!'!ical stl~dv
DuquclIc. J.J .. Grigg, P.. &. Hoffman. A.H. (1996). The effect
in Rhesus knees. Clill art/lOp. 123. 197-209. ~ -
(If diabetes on the viscoelastic propcrtil's of r~\[ kncl' li!'!H·
No)'l's. F.R .. and Grood, E.S. (1976). Tht: sm:ngth of the antl'-
ments. J Biolllt.!ch Ellg. 118(·0. 557-56.J. -
riot' cruciate ligament in hUIlIi.111S and Rhl'SllS monkl'\'s.
Elliot!. O.H. (1967). Tht: biomcchanical propl'rties of ll~lldoll
r\gc-rdaled and specil's.rl'lated chan!!,:;.. J BOlli: loint SI/·,o
in relation 10 muscular strcn"lh . .-\111/ PIn's ,\led 9 1 58..\, 1074-1082. ~ ."
Fillon·Jne.:kson, S. (1965), Antc~cdcnt pha~cs'in ;lla'tJ"i~ for-
Ohkawa, S. (1982). £ffl'ns of orthodolltic forces and anti· in-
malion. In 5tl'/lt"lll1"1..' alld PI/llelioll OJ"COIIIIt:ctiw {jllll Skele-
n<lmn~a(or~' drugs on the !llct:hallical sll'l:~ngth of the peri·
wi Tis.~lIes (p. 277). London: ButtCl'worth.
odoll II II III 111 Ihl' ral mandibular first molar. ..\/1/ J arthod.
Fun~, .Y.C.~. (1981). Biomeclumics: ;\kcllflllical Propr:f,i.:s o{
8/, 498-502.
Llvl1Ig T,ssue.'s (p. 222). Nc\\' York: Springer· Veri:.!!.
Oxlund, H. (1980). The influence of a lot:~ll injt:t:lion of corti-
Fung..r.C.B. (967). Elasticity of soft lissucs in sim-pk don·
solon the Illcchanic,,1 prolll'nies of tendons ;lnd lit!amelHs
g'lllon. :Im J Phvsiol, 213. 1532.
and thl.' indirect effeci 011 skin . ..\eta Or//top St:tllld, 51(2).
Fung. Y.C.B. (1971). Strl.'ss-str.lin-hislo/,v rdations of sof! lis·
231-138_
sues in simplc elongation. In Y.C_ Fu·ng. N. PelTOnl', & t\'1.
P.llTY, D.:\.D., Barnes. G.R.G ..•lIlel Cr;Ii!!, :\.5. (1978).:\ com-
l~nlikcr (Eds.). Biolllechallics: Its FOlll/dations awl Ob;ec-
p"rison of the size distribution of 1.'~lI;l!.!cn fibrils in con- 1
. IlvcS (pp. 181-20$). Englewood CliiTs. NJ: Prentice-Hall.
nective tissucs as a function of age anl possible rdation
HIrsch, C. (1974). Tensile properties during tendon healinl!.
between fibril size ;\Ild llll'chanicO'1 propcrlil's. Proc R Soc
..lCla Or/hop Scellld. SIIPl'l 153. -
Lrmd. 203. 305-321.
.i2'jrF'AI;:r"12t~IOMECHANICS OF TISSUES AND STRUCTURES OF THE MUSCULOSKELETAL SYSTEM
Prockop. D.J .. Ii: Guz.man, N...\. (1977). Collagl.:1l dist.'asi,.'s ;\ltd Viidik, A., D'lllidscn, C.e.. Oxlund, H. (1982). Fourlh tnlem,l-
the bios,\'lllhcsis of collagen. /-Iosp Prw.:t, Dec, 61-68. tional Congress of Biorhl'oJogy Symposiulll on Mcc.:hHnical
Rarnachalldr<\ll. G.N. (1963). Molecular strllC!lln: of collagen. Propcnics of Living Tisslles: On fundamental and plll:llOnl-
lilt Rev COllllcet TisslU' Uc.~·, /, 127. cnological models, SlrllC(llrc and mcch:lJlical properties of
Rich, A., Crick, F.H.C. (1961), The molecuhll' structure of col· collagen, elastic and glycosaminoglyc'1I1 complexes. Bio-
lagen. J .Hol Bioi, 3. 483. rll/:o!o,~y. 19,437.
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'·
E.. Cocco. J.:\. (1991). Tendinous .md Iig:Ulll'lltoliS hyper- iOlls conneclive lissue org.tns in rats as iniluenced by non-
laxity in patients reechoing long-Icrm hemodialysis. J sleroidaJ 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 (1995). Errc:cts of dd;tyed steroid injection on ligamenl
as influenced by single and n::pc<I!L.'d pr~gn;\ncics ill thl.' healing using a rabbit medial colialen,1 ligament model.
r;IL .·kltl 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-
(1995). Collagen fibril popuhltions in human ;:Ulterior cru· biliz;Hion inhibits biolllcchanic<llmatllnHioll of the r:\bbit
ciate lig;unent allografts. Electron micfoscopic analysis. medinl collateral 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: cI/!:/IIistry. Ncw York: McGraw-Hill.
MDS, \Viggir\,o;, [VI. E., Fadale, P.O., B<lITach, H., Ehrilich, ,,"I.G.,
Snell. R.S. (198-1). Clillicld al/{! FI/Ilctiomd Histology {or ,\It,d· Walsh. W.R. (1994). Healing ch<lr;tClcrislics of a type I col·
icaf SIUt/CIIIS. Boslon: Lillk" Brown. Iag('1l01lS SlnlClUre treJh:d wilh corticosteroids. .-\1/1 j
Stfocchi, R., Dl' P<lsquale. v., Facchini. ,\ .. Rnsp,ulli, M .. SPOI"/S ,\kd, 22(2), 279-188.
Zaffagnini, 5 .. ~'larcacci, ~1. t 1996). Agc:·rcbted changes in Woo, S.L.Y.....\n, K.N., Arnoczky, D.\I.\1.. Fithian, D., & ~ly('rs
human anterior cruciatt: ligament (ACL) collagen fibrils. B. (1994). Anatomy, biology, and biomechanics of the len-
Ira! ..lWI/ E",bryui. /01(-1).213-120. don, ligaml'nl, ;Iud m..:niscus. In S.R. Simon (Ed.). Or·
Slrocchi, R.. DePasqu:lIL', V.. Guizzardi, S., ~I:lrcacci, M.. rJ/Of/at'die Basic SCit'IICt' (p. 51). Ros\,'monl. Il: .-\AOS.
Ruggeri. A. (1992). Ultr.\slructural modificalions of patd- Woo, S.L.Y., Gomez, \-1.,.\.. Siles, T.J., Cl :11. (1987). Thc bin·
lar tendon fibres lIscd as 'Ulterior cruci.\te ligament (ACI..) mechanical .llld morphological clwngcs in the Illcdi:d (01-
repbcclllcnL/uJ! } Allat EII/bryo!, 97(4). 221-228. latcr,tl ligamelll of the rabbit after imlT1obilization (lnd rc-
Tipton, C. =\<1. , James, S.L., Mcrgner, W., Cl al. (1970). Influ· [T\obiliz;llion. ) !3lme )0;1// SlIrg, 69..1(8),1200-1211.
encc of e-xcn::ise on slrl.:ngth of medial (ollatcralliganH:nls \Von, S.L.Y., Gomez, M.A., Amid, D., Ritl('r, ~·l.A., Gdbt.'rman,
of dogs. Alii) 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 .. biomcchanical and biochemical propcnies of swine digiwl
Arms S.W. (1996). The effect of <lnlerior cruciate Jig.lInent flc:.\or leudons. } B;ol1l~!c.:h Ellg, 103, 51.
graft c1ong'llion at the lime of implantation on the biollle- Woo. S.L.Y. (1988). Lig;\mellt, tendon. :HH.l join! capsule in-
chanical behavior of the graft and knee. ,.\/1/ j Sports .\lcd, sertions tu bone. In S.L.Y. Woo, & J. Buckwalter(Eds.), Ill-
24(5),608-614, jllly (II/(/ Repair of th~ ,HlISCU!oskduli So{t Ti...... uc:s (pp.
Viidik, A. (1968). EJ<lslicil)' <IIul lensile strenglh of Ihe antl.'· 133-166). Park Ridge. II. :\meric.w Academy of Or·
rior cruci<llc ligament in rabbils :lS influcnced by Iraining. Ihop<:ledi(..· Surgeons.
Acta Ph\'sio! Scallll, 7~, 372.
Viidik, A. '(1973). Functional propertics or
collagenous tis-
sues. IlIr Rei' COllllcct Tissue Res, 6. 127.
", ,,:, ;','<:", '",1"',,,; '·;';'iY.:":""\'.':';'·)'~·':~ ':,',' ,v" i;;';i,"
;1:
~~~
:.~:,
,,\',
',,'-
Nutrition. mct.'lbolism
CEL(:FIBROBJ-ST't;\, !
.~, ~'\.\, \},o'
n
I
Synthesize »
Ex(r!:lcclJuI3r Mmix m
""
~
'"
81 '"
<D
l
-{
"" EXTRACEllltLAR ."
-\ STRONG AND
FlEXIBlES,
(5
;;:
m
n
The mcc~anjcal response Resistance of I
-Collagen type J: suPPOrt tensile loads high tensile »
is dependent on the z
-Ground $ubsL.,ncc rate at which thl! loads forces with R
limited elongation v>
Gel.like matcrialfSt.abilizc arc applied o~
collagenous skclC!ton
;;i
'El:min Z
o
o
z
'v>
'J>
pS;.;~"NEUAAl Nm:ORK'
z'
:D-
, :.~\:' ,- M~chjlnoreccp[ors
·Proprioception
;fi
:$:Z-'0
~;~~
·Sensorimotor Mechanism
'- '~\,
f;~~¥
',;:'-c:,,;,,' R§N,:j
R;'.~>'i
FLOW CHA~T 4-1 Common structure and mechanical properties of tendons and ligaments. *
*This flow chart is designed for classroom Of group di~cussion. Flow chart is not meant to be exhaustive. "
..
..~.~."" ,~,."""".~~ ..•""",,,,,,,,,,,,,,,,,,'",,"_~,_,,~,,,,.,,-"",",,,,,,,,,,,~,_,,,,,!.'<=J ••""......""""..............._.
Q:~Ir~Rr' tl.FI?MECHANICS OF TISSUES AND STRUCTURES OF THE MUSCULOSKELETAL SYSTEM
~.
;~
;.'
,(
ci y,
,~
"•
x0
0
~
9
•~
"
0
0
E ,~:<t
<5 ;;i
.~ c
to .- ~;;
w ';~
"- to
0 0
Ci -5
;;;
u
·c
•
~.
m C
.c
u
0
.~
w
E ~
"0 'C
c c.
m 0
~ 0
0
10 '<;"
~ E
0
, ~ ~
0
"0
:::
u
c
~ .2
'\:z:: ~
):Sf C•
,,:,;iO{:';
i,;vi ."m
0
-"~/,< ~
';:>'i',·o- .-
;:{;y;, to
, 0
-5
/ •
0
;0
i'o
~
s;;:e 6
~
.~l . '<.~.~,.. 't."';"'O>;_<:' c'"'.>"",-,.,.. . . '~0'~i'" "•.".;".?/.::~~ <,'",C<' ~~. ;';'-"",,>
I'
'r."
I
t'
'{ Mechanical Caused InjurJes
;,
i{
~:
:{I
'"
~I C1
... _._- :r
j l>
)l
Microtr.lumJS that
t Stre5s +- Str:lin J l exceed the reparative
procc5S
t Stress
J '"m-<
'"'".
-Thermal injuries Tendon 'Gun injurie5
'"
is
;::
'Inherit injuries 'Paratcnonilis m
·L1cer3.tions C1
'Corticosleroids ·Tcndinosis 'Bone fr.lCIUre5
:r
l>
'Endocrinologic and -Tendinitis 2
metabolic discases:
'Colli5iol1s n
diabetes Tendon's Jtuchment '"0
~
-Rheumatoid arthritis 'ApophY5it is -<
m
),I! -Congenital diseases -EnthcsopJtics '2,
:~O
'Inf~ctions 0"
~2
VI
\)
i
RUPTURE
, TOlal/PJrti;a1
"1
:l);
,if
"This flow chart is designed fOf cla5sroom Of group discussion. Flow chart is not meant to be exhaustive.
'/01
. .".._.
-'--~---'-'-=-- '" ",
Function
Structure
o
~
-<
Vi
'"
C
m
'"»
z
o
'"
-<
'"
c
n
c-<
'"
m
'"
o
~
-<
I
m
~
'"
n
c
r
o
'"
T
m
r
m
'i"
r
'"
-(
'"
-<
m
ViSCOElASTIC. S
MECHANICAC
PROPERTY
FLOW CHART 4·4 Ligaments structure and mechanical properties.* (PG, Proteoglycan)
~This flow chart is designed for classroom or group discussion. Flow chart is not meant to be exhaustive.
-~";-";- ';:"»'~-::.' <'-;i'.;~<'_-;;":::i'<,, ;';~-'>"e:"l-;,': ·'<li:;;<".;;;.'i-" ,,:. -;;';,;
*' -«:,.,~,'0._ ~>JC.-,
,""'~'<0;~:i--Z:-~' ,~c .>.:.'
"."
.:;
*1 n
I
I
''.t.,."I
RUPTURE
Tot~I/PJrtial
-This flow chart is designed for classroom or group discussion. Flow chart is not meant to be exhaustive.
'1 I
·····5' ':/
Biomechanics of
Peripheral Nerves and
Spinal Nerve Roots
Bjorn Rydevik, Goran Lundborg, Kje/l O/marker. Robert R Myers
Introduction
127
~:3,~J f;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
Sensory
Coccygeal ganglion
rOOI
nerve
A o
A, Schematic drawing of the spinal cord and the spinal is depicted. Adapted from rorrord, GJ & Anllgnostako5. N.fl.
nerves (posterior view). The spinal nerves emerge from the (J 984). Principles oj Anatomy and PhySiology (.1lh ed.J. New York:
spinal canal through the intervertebral foramina. There are 8 Harper & Row. B, Cross-section of the cervi<al spine showing
pairs of cervi<al nerves, 12 pairs of thoracic nerves,S pairs of the spinal cord in the spinal canal and the nerve roots exiting
lumbar nerves, 5 pairs of sacral nerves, and 1 pair of coc- through the intervertebral foramina. C, Cross-section of the
cygeal nerves. Except in the region of the 2nd to the 11 th lumbar spine shOWing the nerve roots of the cauda equina in
thoraci< vertebrae (T2-T11), the nerves form complex net- the spinal canal. 0, Each exiting nerve root complex in the in-
works called plexuses after exiting the intervertebral forClm- tervertebral foramen consists of a motor root, a sensory root,
ina. Only the main branch of each nerve, the ventral ramus, and a dorsal root ganglion.
•
\vinds around it many times, pushing its cytoplasm unmyelinated nerve fibers in a slow, continuous way,
and nucleus to the outside layer. Unmyelinated gaps whereas in the myelinaled nerve fibers the impulses
called nodes of Ranvier lie between the segments of "jump" al a higher speed from one node of Ranvicr
the myelin sheath at approximately I to 2 I11Ill apart. to the next in a process called saltatOl)" conduction.
The myelin sheath increases the speed of the con- The conduction velocity of a myelinated nerve is di-
duction of nerve impulses, and insulates and main- rectly proportional to the diameter of the fiber,
tains the aXOIl. Impulses arc propagated along the which lIsually ranges [Tom 2 La 20 J-l111. MOlar f-ibers
-. f:
CHAPTER 5 • BIOlvlECHA~JICS OF PERIPHERAL NERVES ANI)
innervate skeletal muscle have large diameters, tive tissue la)rers is essential becausc nerve flbcrs arc
do sensor~y' fibers that relay impulses associated extremely susceptible to stretching and compres-
touch, pressure, heat, cold, and kinesthetic sion.
such as skeletal muscle tension and joint po- The outcnTlOst layer, the epineurium, is located
Sensory fibers that conduct impulses for dull, between the fascicles and superficially in the nerve.
diffuse pain (as opposed to sharp, immediate pain) This rather loose connective tissue layer serves as a
the smallest diameters. Nerve fibers are packed cushion during movements of the nel\'e, protecting
closely in fascicles, \vhieh are further arranged into the fascicles from external trauma and maintaining
bUIl1(II·es that make lip the nen'c itself. The fascicles the oxygen supply sy'stem via the epineural blood
arc the functional subunits of the nCI-ve. vessels. The amount of epineural connective tissue
varies among nerves and at different levels within
the same nerve. \!Vhere the nerves lie close to bone
INTRANEURAL CONNECTIVE TISSUE OF
or pass joints, the epineurium is often more abun~
PERIPHERAL NERVES
c1ant than e1scwhere, as the need for protection may
Successive layers of connective tissue surround the be greater in these locations. The spinal nerve roots
nerve fibers-called the endoneurium, perineuriUl11, are devoid of both epineuriurn and perincurium,
,'mel epineurium-and protect the fibers' continuity and the ncrvc fibcrs in the nel\'e root may thercfore
(Fig. SA). The protective function of these connec- bc morc susceptible to trauma (Rydevik et aI., 1984).
The perineurium is a lamellar sheath that en-
compasses each fascicle. This sheath has great me-
Sensory nerve root chanical strength as well as a specific biochemical
Sensory cell Motor cell body barrier. Its strength is demonstrated by the fact that
body in dorsal in anterior horn the fascicles can be inflated by fluid to a pressure of
rool ganglion of spinal cord
approximately! 1000 mm of mercury (I-Ig) beFore the
! Dorsal perineuI'ium ruptuI·es.
Spinal nerve \
\ \
The barrier function or the perineurium chemi-
Dorsal ./ cally isolates the l1el\'e fibers From their surround-
ramus / ings, thus preserving an ionic environment of the in-
Ventral terior of the fascicles, a special milieu interieur. The
Peripheral nerve ... '- endoneurium, the connective tissuc inside the fasci-
Motor nerve rool
cles, is composed principally of fibroblasts and col-
lagen.
I nerve The interstitial tissue pressure in the fascicles,
1 fiber the endoneurial fluid pressure, is normally slightly
~'-----------
elevated (+ 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~
Schematic representation of the arrangement of a typical nomenon whereby' incision of the perineurium re-
spinal nerve as it emerges from its dorsal and ventral nerve sults in herniation of nerve fibers. The endoneurial
roots. The peripheral nerve begins after the dorsal ramus fluid pressure may increase further as a result of
branches off. (For the sake of simplicity, the nerve is not
trauma to the nerve, with subsequent edema. Such
shown entering a plexus.) Spinal nerves and most periph-
a pressure increase ma.y affect the microcirculation
eral nerves are mixed nerves: they contain both sensory
and the function of the nerve.
(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
THE MICROVASCULAR SYSTEM OF
spinal cord, and those of the sensory neurons are found in
PERIPHERAL NERVES
the dorsal root ganglia. Here, a motor nerve fiber is shown
innervating muscle and a sensory nerve fiber is depicted The peripheral nerve is a well-vascularized structure
innervating skin. 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
nerve root compression. Spine, 9, 7.
inlpulse 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.
• :1-
peri mental animal in vivo model, it is extremely dif- "swdling" of the most caudal part of the respective
ficuh to induce complete ischemia to a nerve by 10- dorsal neryc root, called the dorsal rOOl ganglion.
surgical procedures. For example, if the whole The dorsal root ganglia arc locatcd in or close to the
sciatic··til."'1i nerve complex of a rabbit (15 em long) intervertebral Foramen. Unlike the nCn!c roots, the
is surgically Sepal"aled from its surrounding struc- dorsal root ganglia arc not enclosed by cerc w
tures and the region"11 nutrient vessels arc ClIt. there brospinal fluid and the meninges. Instead. they are
is no detectable reduction in the intrafascicular enclosed by both a multilayc:rcd connective tissue I.
blood flow as studied by intravital microscopic tcch· sheath, similar lo the perineurium of the peripheral I.
1i
Y"iGucs. Even if such a mobilized nerve is ellt distally 1'·
or proximall~'. the intraneural longiwdinal vascular
systems cnn maintain the microcirculation at least 7
i·! f
l~ 8 ern rTom the clil end. If a non mobilized nerve is
0"'.,'" 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
Spinal Nerve Roots
3
.. 3
~
the spinal cord has the same length as the spinal
column. However, in the full~: grown individual, the
t spinal cord ends as the COIlUS mcdullaris, approxi- 5
8
I
mately at the level of the fit'st lumbar vertebra. A
nerve root that leaves the spinal canal through an
intervertebral foramen in lhe lumbar or sacral spine
I
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-
6
cause the spinal cord is not present be.low the first
lumbar vertebra, dte nervous content of the spinal
canal is only comprised of the lumbosacral nerve
f 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. The intraspinal nervous structures as seen from behind.
The vertebral arches are removed by cutting the pedicles
Two different lypes of nerve roots are ("ound
(1). A ventral (2) and a dorsal (3) nerve root leave the
within the lumbosacral spine, ventral/motor roots
spinal cord as small rootlets (4). Before leaving the spinal
and dorsal/sensory roots. The cell bodies of (he mo- canal, the dorsal root forms a swelling called the dorsal
tor axons are located in the anterior horns of the
gray malleI' in the spinal cord, and because these
root ganglion (5), which contains the sensory cell bodies.
before forming the spinal nerve (6) together with the
i
nerve roots leave the spinal cord from the ventral as- ventral nerve root. The nerve roots are covered by a cen· 1
II
pect, they are also called ventral roots. The other tral dural sac (7) or with extensions of this sac called
type of nelVC root is the SenSOl)', or dorsal root: As nerve root sleeves (B). ReprodtlCec/ with permission ;,om
the name suggests, these nerve roots mainly COll1 w O/marker. K. (J 99/ J. Spinal nerve rOOI compression. ACt/Ie
prise sensory (Le., afferent) axons and reach lhe compression of the cauda equina sludied in pigs. Acta Orthop
spinal cord at the dorsal region of the spinal cord. Scand. 62. Suppf 242.
The cell bodies of the sensory axons are located in a
•
,.".j
;1
1
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
epineurium. cells of the spinal cord, and the cells in the distal
""Vhen the ncnlC root approaches the interverte- part are more similar to the arachnoid cells of the
bral foramen. the root sleeve gradually encloses the spinal dura. The inner layers of the rOOl sheath are
nerve tissue more lighLly. The subarachnoid space comprised of cells that show similarities to the cells
and the amount of cerebrospinal fluid surrounding of the perineurium of peripheral nerves. An in-
each nen'c root pair will thus become gradually re- lerrupted basement membrane encloses these
duced in the caudal direction. Compression injury cells separately. The inner layers of the root sheath
of a nerve root may induce an increase in the per- constitute a diffusion barrier bet\veen the cl1do~
meability of the endoneurial capillaries. resulting in neurium of the nerve roots and the cerebrospinal
edema formation (Olmarker et aI., 1989b; Rydevik & fluid, This barrier is considered to be relatively
Lundborg, 1977), This can lead to an increase of the weak and may only prevent the passage or macro-
imraneural fluid and subsequent impairment of the molecules.
nutritional transport to the nerve (Myers & Powell. The spinal dura encloses the nerve roots and the
1981; Myers, 1998), Such a mechanism might be cerebrospinal fluid, When the two layers of the cra-
particularly important at locations where the nerve nial dura enter the spinal canal. the outcr layer
roots are tightly enclosed by connective tissue. Thus blends with the periosteum of the pan of the lami-
there is a more pronounced risk for an "entrapment nae of the cervical vertebrae facing the spinal canal.
syndrornc" within the nerve roots at the intcrvene- The inner layers join the arachnoid and become the
bral foramen than more central in the cauda equina spinal dura. [n contrast to the rooL sheath, the
(Rydevik et aI., 1984), The dorsal root ganglion, with spinal dura is an effective difTusion barrier: The bar-
its content of sensory nCt've cell bodies, tighlly en- rier properties are located in a connective tissue
closed by meninges, might be panicularly suscepti- sheath between the dura and the arachnoid called
ble to edema formation. 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
MICROSCOPIC ANATOMY OF SPINAL NERVE
thal these t\VO layers in facl form the perincuriulll
ROOTS
when the nerve rooL is transformed to a peripheral
There are two microscopically different rc.:::gions of nerve upon leaving the spinal.
the ncnlC roots. Closest to the spinal cord is a cen-
tral glial segment comprised of glial cells and there-
THE MICROVASCULAR SYSTEM OF SPINAL
fore resembles the microscopic organization of cen-
NERVE ROOTS
tral nervous structures at the spinal cord or the
brain. This glial segment is transferred to a nonglial Information about the vascular anatomy of the
segment in a "dome-shaped" junction a few mil- nerve roots has mainly been derived from studies
limeters from the spinal cord. This nonglial segment on the vascularization of the spinal corel. Therefore.
is organized in the same manner as the en- the nomenclature of the various vessels has been
doneurium of the peripheral nerves, that is, with somewhat confusing. A SLlllllTIat·y of the existing
Schwann cells instead of glia cells. However, some knowledge on nerve root vasculature will be pre-
small islets of glia cells also are found in this other- senteel below,
wise "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-
MEMBRANOUS COVERINGS OF SPINAL NERVE
rior abdominal wall and lumbar plexus. (2) a poste-
ROOTS
rior branch that supplies the paraspinal muscles
The axons in the endoneurium are separated from and facet joints, and (3) an intermediate branch that
the cerebrospinal fluid by a thin layer of connective supplies the contents of the spinal canal. A branch
tissue called the root sheath, This root sheath is the of the intermediate branch joins the nCI"ve root at
structural analogue to the pia mater that covers the the level of the dorsal root ganglion, There are usu-
spinal cord. There are usually 2 to 5 cellular layers ally three branches from this vessel: one La the ven-
in the root sheath, but as many as 12 layers have tcal root, one to the dorsal root, and one to the vasa
been identified, The cells of the proximal part of the corona of the spinal corel.
CHAPTER 5 • BIOMECHANICS Of PERIPHERAL NERVE5 AND 5Pl~%~..N.ERVE-59~lia~O
.:
STRETCHING (TENSILE) INJURIES OF ties, and the nerve behaves 1110re !ike a plastic ma-
PERIPHERAL NERVES terial (I.e., its response to the release of loads is in-
complete recovery).
Nerves arc strong structures with considerable ten- Although variations exist in the tensile strength
sile strength. The maximal load that call be SlIS- of various nerves, the maximal elongation at the
tained b~/ the median and ulnar nerves is in the elastic limit is approximately 20(~fi, and complete
rangc of 70 to 220 newtons (N) and 60 to 150 N, rc- structural failure seen1S to occur at a maximum
spectively. These f-igurcs afC of academic interest elongation of approximately 25 to 30(k;. These val-
only because severe intraneural tissue damage is ues are for normal nerves; injury to a nell/e may in-
produced b:v tension long before a nerve breaks. duce changes in its mechanical properties, namely
A discussion of the elasticity and biomcchanical increased stiffness and decreased elasticit\'.
properties of nerves is complicated by the fact that Stretching, or tensile, injuries of peripheral
nerves are not homogeneous isotropic I11aterials but, nerves are usually' associated with severe accidents,
instead, composite structures, \vith each tissue com- such as when high-energ.\' tension is applied to the
ponent having its O\VI1 biomechanical properties. brachial plexus in association with a birth~related
The connective tissues of the epineurium and per- injur.\'. as a result of high-speed vehicular co!lision,
ineurium arc primarily longitudinal structures. or after a fall from a height. Such plexus injuries
\,Vhen tension is applied to a nen'e, initial elon- may result in partial or total functional loss of some
gation of the nerve under a ver.v small load is fol- or all of the nerves in the upper extremity, and the
lowed by! an interval in \vhich stress and elongation consequent functional deficits represent a consider-
show a linear relationship characteristic of an elas- able disability in terms of sensory and motor loss.
tic material (Fig. 5-7). As the limit of the linear re~ The outcorne depends on which tissue components
gion is approached, the nerve fibers start to rupture of the nerves are damaged as well as on the extent
inside the endoneurial tubes and inside the intact of the tissue injury'. Of clinical importance is the ob-
perineurium. The perineurial sheaths rupture at ap- servation that there can be considerable structural
proximately 25 to 30i?-c elongation (ultimate strain) damage (perineurial sheath injuries) induced by
above in vivo length (Rydevik et aI., 1990). Aftcr this stretching with no visible injury' on the surface of
point, there is a disintegration of the elastic proper- the nerve (Case Study 5-1).
12
11
10
9
8
In-situ strain: 11.0 :!:. 1.5%
"
(L
~
~
6
7 In-situ stress: 0.05 :c: 0.3 MPa
~ 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 % histological study of acute stretching on rabbit tibial nerve. J Or-
and begins to retain significant tension as the strain increases thop Res, 8, 694-707.
beyond 20%. Reproduced with permission from Rydevik. 8.L.,
J,
CHAPTER S • BIOMECHANICS OF PERIPHERAL NERVES AND SPI~~~'~E~~%~~f~1[~~.
,-""
"--
. B~ichial Plexus Palsy
"ri.~.i-ipg
----0
.-0'.>
.1' ;:\)'AHE.rb's palsy is diagnosed. The sudden elongation COMPRESSION INJURIES OF PERIPHERAL
J7;r~uHer~~d during the traction can lead to structural dam- NERVES
~;.~ge an9 reduction in the transverse fascicular cross-sec-
{ftio.f1~(area, producing impairment of the intraneural It hns long been known that compression of a nerve
:~",,:vascu.lar flow and impulse transmission. can induce symploms stich as numbness, pain, and
.1,: ~.
1', ·.In less severe cases, functional restoration may occur muscle weakness. Thc biological basis for the func-
t.- within·weeks or months. In more severe cases, healing may tional changes has been investigatcd eXlensively
"i·i:~~X~k(place during the first 2 to 3 years, but if the structural (Rvdevik & Lundborg, 1977; Rydevik et aL, 1981), In
:~r~erveJnjury is severe, considerable long-term functional these investigations (Fig. 5-9), even mild compres-
:s<'disability can result, If structural derangement of the nerve sion was observed lo induce structural and func-
:i·::i.trunk has taken place, nerve grafting may be required. lion'll changes, and the significance of mechanical
):i:' , "
L
' ,"
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 details of the deformation or a nerve may be
the nerve fibers in the peroneal nerve or the baboon
quite difTerent in these two cases of loading. In uni-
hind .limb induced b~,' tourniquet compression
form circumferential compression like that applied
demonstrated the so-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-
;!: I
compressed parts of the nct·ve. The nerve fibers in Sciatic Pain
the center of the compressed segment, where the
35-year-old male construction worker has chronic
hydrostatic pressllt·c is highest. generally were nOl
affected acutely. Tht.: large-diameter nerve fibers
A low back pain radiating below the- Ie-f! knee that is
more severe with lifting activities and prolonged posi,
were usually affected, but the thinner fibers were
tions. After a careful examination. certain neurological
spared. This finding confirms theoretical calcula-
signs were found. Positive straight leg raising and L5
tions that indicate larger nerve fibers undergo a rd-
motor and sensory functions were affected.
atively greater deformation than do thinner fibers at
A MRI shows a herniated disc at level L4-L5 with
a given pressure. It is also known clinically that a
posterolateral protrusion. which laterally compresses (he
compression lesion of a nCI-vc IIrst affects the large
left L5 nerve root. Compression of !he nerve deforms it
fibers (e.g., those that can)' molOr function). while
toward a more elliptical shape. increasing strain and
the thin fibers (e.g.. those that mediate pain sensa-
stress loads_ The effects of the pressure and mechanical
lion) arc often preserved. The intraneural blood ves-
deformation resultant from the load affects the nerve
sels have also been shown to be injured at the cdges
tissue, its nutrition, and the transmission function. in·
of the compressed segment (Rydevik & Lundborg,
flammation of the nerve root, induced by the nucleus
1977), Basically, the lesions of nerve libers and
pu!posus, may sensitize the nerve rOOt so that mechani-
blood vessels seem to be consequences of the pres-
cal ne-rve root deformation causes SCiatic pain (Case
sllre gradient. which is maximal just al the edges of
Study Fig 5·2·1),
the compressed segment.
In considering the mechanical effects on nCI-ve
compression, keep in mind that the effect of a given
pressure depends on the way in which it is applied,
ils magnitude and duration. Although pressure may
be applied with a variety of spatial distributions.
two basic types of pressure applications arc gener-
ally encountered in experimental settings and in
pathological conditions. One type is uniform pres-
sure applied around the entire circumference of a
longitudinal segment or a nerve or exu'emity. This
is Ihe kind of purely radial pressure thai is applied
by the common pneumatic tourniquet. It has also
been used in miniature apparatlls to produce con-
trolled compression of individual nerves (Rydevik
& Lundborg, 1977) (Fig, 5-9). Clinically, Ihis Iype of
loading on a nerve probably occurs when the pres-
sure on the rnedian nenre is elevated in the carpal
tunnel. producing a characteristic syndrome.
Another type or mechanical action takes place
when the nerve is compressed laterally_ This is the
kind of defol-mation that occurs if a nelve or ex-
tremity is placed between two parallel nat rigid sur R
.:.-- ~I
y factor at both high and low pressures, but ischemia
i pl[t~·s a dominant role in longer-dunHion compres-
sion. This phenomcnon is illustraled b\' the fact that
,
direct ncr'vc compression at 30 111111 Fig for ) to 4
,'.' . .-:
I
--I------1I-- X
hours produces reversible changes, whereas pro·
longed compression a(}()\'c this time period at this
, -,'
.... Pressure
I pressure level ma~' cause irreversible damage [0 the
nCI"e (Lundborg CI aI., 1982; Rydevik el aI., 1981),
";.:,, ..
", ,-",
"/':
dislribution ..--, ---c___
• I' :' " '; ,';""
'/,:,". :," '.: 'f;-i::;: Corn pression at 400 I11Ill Hg causes a much more se-
A vere nervc injur~1 arter 2 hours than after 15 min-
, . ules. Such 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 time OJ! f!51
B' elapse for permanent deformation to develop.
C'
E E'
F F'
G G'
i,' . . '",.,. 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-
B hibit both elasticity and tensile strength. The ulti-
l11,tle load rnr ventral spinal nelye roots from the
thecal sac is belween 2 and 22 ! , and 1'01' dorsal
"iG, 5-11 nerve roots from the thecal sac the load is between
5 and 33 N. The length of the nerve roots I'rorn the
A, Theoretical displacement field under lateral compres-
spinal corel to the foramina \'aries From appro:d-
sion as a result of uniform clamping pressure. B, The origi,
I11ntely 60 mm at the L I level to approxilmllely 170
nal and deformed cross-sections are shown for maximum
elongation in the x direction of 10. 30, and 50%. The vec-
mm at the S I level. The mechanical propertics of
tors shown from A to fJ:, B to a', and so forth, indicate the
human spinal nerve roots arc c1ifferelll for an~1 given
paths followed by the particular points A, B, and so forth nerve roOl at its location in the cenlral spinal canal
during the deformation. ancl in the lateral intel'vertebral foramina. The ulti-
nwtc load for the inrr4lthecal portion of human SI
I • 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'vc roots at the L5 level. the cor-
that this kind or
deformation can trigger r-iring of
responding values arc 16 Nand 71 N, respectively
nerves, resulting in a sensation or pain when the
(Fig. 5-12). Thus, the "allles ror ultimate load are
ne"'e Gbers are laterallv compressed. The details or
approxil11«lel~" five times higher ror the foraminal
such deformation of nerves and their functional con-
segment of the spinal ner'vc roots than for the in-
sequences have not been studied extensively and re-
trathecal pan ion of the same nClVC roots under ten-
quire further research for their elucidation.
sile loading. However, the cross-sectional area of the
nerve root in the intervertebral fOI'(llllcn is sie:nifi-
Duration of Pressure Versus Pressure Level
cantlv . -
larger than that of the same nerve root in lhe
thecal sac; thus, the ultimate tensile stress was more
Knowledge is limited regarding the relalive impor- comparable for the two locations. The ultimate
tance o[ pressure and time, rcspectively, in the pro-
duction of nerve compression lesions. Mechanical -
strain LInder tensile loading is 13 La 19% for the
human ne,Ye root at the L5-S I level (Fig. 5-13),
faclors seenl to be rehllively more imporlant al The nerve roots in the spine arc nol static slruc-
higher than at lo\ver pressures. Time is a significant lures: they 1110\'C relati\'e to the surrounding tissues
.~f~f 1 • 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
'" S
2 area of contact into aeCOUlll, they assumed a contact
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-
o'--_-'-_-';:-=----'-'-_-'-_-';-;:"'-_-'-_..J lieved after chcmol1ucleolysis, and as disc degenera-
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 l
c
the nerve roots in the intervertebral foramina, for .~
COMPRESSION OF SPINAL
pressure for the arterioles was !"ound to be slightly ence co differences in effects between rapid and slow onsec of
>-------
_ . . . .'--->-->---
a~~i,{~~~l . BIOME(HANICS OF TISSUES AND STRUCTURES OF THE MUSCULOSKELETAL SYSTEM
The gradual formation or intraneural edema may segment itself is ullcomprcssed. Regarding nerve
also be closely" related to observations of a graduall.\' conduction, the effects were much enhanced if the
increasing dilTcrcncc in nerve conduction impair- distance between the compression balloons was in-
ment between the two onset rates (Olmar-ker et al.. creased frorn one \'cn~bral segment La two verte-
1989b). bral segments (Olmarker & Rydevik. 1992). This in-
dicates that the functional impairment may be
directl:v related to the distance between the two
MULTIPLE LEVELS OF SPINAL NERVE ROOT
compression sites.
COMPRESSION
!'atients with double or multiple levcls of spinal
CHRONIC NERVE ROOT COMPRESSION IN
stenosis seem to have morc pronounced symptoms
EXPERIMENTAL MODELS
than do patients with stenosis only at one level. The
presented model was modified to address this inter- Th~ discLlssion of compression-induced effects on
esting clinical question. Using two balloons at two nerve roots has deall primarily wiLh acute com-
adjacent disc levels. which resulted in a 10-mm un- pression, that is, compression that lasts for some
compressed nerve segment bctwcen the balloons, hours and with no survival of [he animal. To better
induced a much more pronounced impairment of mimic various clinical situations, compression
nerve impulse conduction than previollsl~' had been must be applied over longer periods of time. There
round at corresponding pressure levels (Olmarker & arc probably man." changes in the nerve Lissue,
Rydevik. 1992). For instancc. a pressurc of 10 mm such as adaptation ofaxons and vasculature, that
I-1g in two balloons induced a 60% reduction of will occur in patients but cannot be studied in ex-
nerve impulse amplitude during 2 hours of COIll- perimental models using only I to 6 hours of com-
pression, whereas 50 111m I-Ig in one balloon showed pression, Another important factor in this conlext
no reduction. is the onset rale that was discllssed previousl)'. In
The mechanism ror the diFrerence between single clinical syndromes with nerve root compression,
and double compression may not simply be based lhe onset time may in many cases be quite slo\\'.
on the fact thal the nerve impulses have lo pass For instance, a gradual remodeling of the verte-
more than one compression zone at double-level brae to induce a spinal stenosis probably leads to
.' . compression. There may also be a mechanism an onset lime of many years. Jt will of course be
based on the local vascular anatomy of the nerve dirficult to mimic such a situation in an experi-
roots. Unlike for peripheral nerves, there are no re· mental modcl. It will also be impossible to have
gional nutritive arteries from the surrounding control over the pressure acting on the nerve roots
structures to the intraneural vascular system in in chronic models because or the remodeling and
spinal nerve roots. Compression at two levels might adaptation or the nerve tissue to the applied pres-
therefore induce a nutritionally impaired region be- sure. However, knowledge of the exact pressures is
twcen the two compression sites. In this way. the probably of less importance in chronic than in
:.~: segment nffected by the compression would be acute compression situations. Instead, chronic
"', widened from one b,~lIoon diarneter (10 mm) to two models should induce a conLrolled compression
balloon diameters including the inLCrjacent nerve with a slow onset time that is easily reproducible.
segment (30 mm). This hypothesis was partly con- Such models may be well suited for studies on
firmed in an experiment on continuous analyses of pathophysiological events as well as inlcrvention
the total blood flow in the ul1compresscd nerve scg· b~' surgery or drugs. Some attempts have been
ment located bet ween two compression balloons made to induce such compression.
(Takahashi et al.. 1993). The results showed that a Dclamarlcr and collaborators (1990) presentcd a
64% reduction of total blood now in the uncoll1- model on dog cauda equina in which they applied a
pressed segment was induced when both balloons constricting plastic band. The band was tightened
were inflated to 10 mm Hg. At a pressure close to nrollnd the thecal sac to induce a 25, 50, or 750/0 re-
the systemic blood pressure lhere was complete is- duction of the cross-sectional area. The band was
chemia in the nerve segment. Thus, experimental left in place for various limes. Analyses were per-
evidence shows that the blood supply to the nerve ~forl1led and showed both stnlctural.and functional
segment located between two compression sites in changes that were proportional to the degree of con-
••1.
nerve roots is severely impaired although this Tlel'VC striction.
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-
compression, Cornefjord and collaborators (1997) lowing such compression also has been found.
used a constrictor to compress the nerve roots in Substance P is a neurotransmitter that is related
the pig (Fig. 5-15). The constrictor was initially! in- to pain transmission. The study may thus provide
tended for inducing vascular occlusion in experi- experimental evidence that compression of nerve
mental ischemic conditions in dogs. The constric- roots produces pain.
tor consists of an outer metal' shell that on the The constrictor model has also been used to
inside is covered with a material called amaroid stud.\' blood flow changes in the nerve root vascu-
that expands when in contact with fluids. Because lature. It could then be observed that the blood
of the metal shell, the amaroid expands inwards Flow is not reduced just outside the compression
with a maximum expansion after 2 weeks, result- zone but significantly reduced in parts of the
ing in compression of a nerve root placed in the nerve roots located inside the constrictor. In this
central opening of the constrictor. Compression of context, note that in case of disc herniation, the
the first sacral nerve root in the pig resulted in a nerve root may become sensitized by substances
significant reduction of nerve conduction velocity from the disc tissue (nucleus pulposus) so that
and axonal injuries using a constrictor with a de- mechanical root deformation can induce pro-
fined original diameter. An increase in substance P nounced sciatic pain.
CHAPTER 5 • BIOMECHANICS Of PERIPHERAL NERVES AND SPINALNE~\jEJCi;8i;8'{;W*~~~D
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 external properties intl<lcellular transmission n
-Nutrition synthesis of -;
affected trauma 'Preserves ionic tl<lnspon of C
trophic factors ;D
environment material m
'"
..
o
~
-;
I
m
D <:
c
'"
n
,c
o
'"
Illness or injury
,"m
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·Time ReJ(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
IJ~S'.r'
Introduction ton. The myofibril is made lip of several sarcomeres
that contain thin (actin), thick (myosin), clastic
The muscular sYSlCll1 consists of three III usc Ie.:: l.ypes: (titin), and inelastic (ncbulin) filaments. Actin and ,
the cardiac muscle, which composes the hc[trt; the myosin are the contractile part of the myofibrils. ,j
Sl1100th (nonstriated or involuntary) muscle, which
whereas titin and nebulin nrc part of the intramyo- ,.t
lines the hollow internal organs; and the skeletal fibrillar cytoskelcton (Stromer et aI., 1998). The
(striated or voluntary) muscle, which auaches to the myof-ibrils are the basic unit of contraction.
skeleton via the tendons. The focus of this chapter is Each fiber is encompassed b:y a loose connective
the role and function of skeletal muscle. tissue called the endomysium and the fibers arc or-
Skeletal muscle is the most abundant tissue in ganized into various-sized bundles, or Fascicles (Fig.
the human body, accounting for 40 to 45% of the to- 6·1, A & B), which arc in (urn encased in a dense
lal body weighL. The human body has morc than connective tissue sheath known as the perimysium.
430 skeletal !TIuscles, found in pairs on the right and The muscle is composed of several fascicles sur-
left sides of the body. The most vigorolls movements rounded by a fascia of fibrous connective tissue
are produced by fewer than 80 pairs. The muscles called the epimysium.
provide strength and protection to the skeleton by In general, each end of a muscle is attached to
distributing loads and absorbing shock; they enable bone by tendons, which have no active contractile
Ihe bones to move at the joints and provide the properties. The muscles form the contractile com-
maintenance or body posture against force. Such ponent and the tendons the series clastic compo-
abilities usuall~' represent the action of muscle nent. The collagen fibers in the perimysium and
groups, not of individurll mllscles. epimysium are continuous with those in the ten-
The skeletal muscles perform both dynamic and dons: together these fibers act as a stnlctural fr,\Il1c~
static work. Dynamic work permits locomotion and work for the attachment of bones and muscle fibers.
the positioning of the body segments in space. Sta- The perim)'sium, endomysium, epimysium, and sar-
tic work maintains body posture or position. In this colemma act as parallel elastic components. The
chapter we describe the composition and structure forces produced by the contracting muscles arc
of skeletal muscle. the mechanics of muscle con- transmitted to bone through these connective tis-
traction. force production in muscle. Illuscle fiber sucs and tendons (Kassel'. 1996).
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
Composition and Structure and function have been studied cxhausti\'c1y b:v
Iighl and eleclron microscopy, and [heir histo~
o( Skeletal Muscle chemistr~' and biochclllistry have been explained
elsewhel'c (Alvidson et aI., 1984; Guvton, 1986).
An understanding of the biorncchanics of Illuscle
Approximately I p.m in c1iamctcl: the myofibrils lie
function requires knowledge of the gross anatomi-
parallel to each other within the cytoplasm (sar-
cal structure and function of the musculotendinous
coplasm) of the muscle fiber and extend through-
unit and the basic microscopic structure and chem-
out its length. They vary in number from a few to
ical composition of the muscle fiber.
several thousand depending on the diameter of the
ll1uscle fibel~ which depcnds in turn on thc type of
STRUCTURE AND ORGANIZATION
ll1usclc fiber.
OF MUSClE
The transverse banding pattern in striated mus-
The slructuralunit of skeletal muscle is thc muscle cles repeats itself along (he length of (he muscle
fiber, a long cylindrical cell with many hundreds of fiber. each repeat being known as a sal'comerc (Fig.
nuclei. Muscle fibers range in thickness from ap- 6-IC). These striations are caused by thc individual
proximately 10 to 100 fim and in Icngth from ap- myofibrils, which are aligned continuously through-
proximately 1 to 30 cm. A muscle fiber consists of Ollt the muscle fiber. The sarcomere is the func-
many myofibrils, which are invested by a delicate tional unit of the contractile syslem in muscle. and
plasma membl·ane called the sarcolemma. The sar- the events that take place in one sarcomere arc du-
colemma is connected via vinculin- and dystrophin- plicated in the others. Various sarcomere build a
rich costameres with the sarcon1ctric Z lines, which myofibril, various myof"ibrils build the muscle fibel~
represent a pan of the cxtramyofibrillar cytoskcle- and various muscle fibers build the muscle.
149
G,a,SO' P~RT 1 • BIOMECHANICS Of TISSUES AND STRUCTURES Of THE MUSCULOSKELETAL SYSTEM
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-
A, The inelastic filaments composedof the pro-
ameter) composed of the protein actin
teins nebulin and tilin
2, The thick filaments (approximately 15 nm in
diameter) conlposed of the protein myosin Aetin, the chief component or the thin filament,
(Fig, 6-1, D & E) has 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
additional proteins, troponin and tropomyosin, are or "tail." Several hundred slIch molecules are packed
important constituents of the actin helix because tail to tail in a sheaf with their heads pointed in one
thev appear to regulate the making and breaking of direction along half of the filament and in the oppo- Il
cOI~taclS between the actin and myosin filamel1ls site dircction along the other half, leaving a hcad- I
during contraction. Tropomyosin is a long polypep- free region (the H zone) in between. The globular j
tide chain that lies in the grooves between the he- heads spiral about the myosin filament in the region h
~.~
iices of actin. Troponin is a globular molecule at- where actin and myosin ovcrlap (the A band) and ex-
laehed at regular intcr'vals to the tropomyosin (Fig. tcnd as cross-bridges to interdigitate with sites on
6-1, D & E). the actin filaments, thus forming the structural and
The thick filaments are located in the central re- I'unctionallink between the two filament types.
gion of the sarcomere, where their ordcrl.y, parallcl The intramyofibrilh.,r cvtoskeleton includes in-
arrangemcl1l gives rise to dark bands known as A elastic nebulin filaments, which span from the Z
bands because they arc strongly anisotropic. Thc line to the actin filaments. Ncbulin might also act as
thin filaments arc atlachcd at either end of the sar- a template for the thin filament assembly.
comere to a structurL' known as the Z line, which Titin is I j.1m long. It is the largest polypeptide
consists of shon elements that link the thin fila- and spans from the Z line to the IVI line. Titin is an
ments of adjacent sarcomcres. defining the limits clastic filament. The part between the Z linc and
of each sarcomere. The thin filaments cxtcnd From myosin has a string-likL' appearance. Titin has been
the Z line toward the center of the sarcomere, suggested to contdbutc greatly to the passh'c force
where they overlap with the thick fibmcnts. Re- development of muscle during stretch (Fig. 6·2). II
cently it was shown thal there is a third set or n1YO- also might act as a template for the thick filament
fibril filaments in the vertebrate striated Illuscles. assembly (Linke et aI., 1998; Squire et al., 1997;
This connecting filament, named titin, links the Stromer et aI., 1998),
thick Filaments with the Z line (elastic I band re- The I bane! is bisected by the Z lines, which contain
gion of titin) and is part of the thick filaments (A the portion of the thin filaments that does not overlap
band region o[ titin). This filament maintains the with the thick filaments and the clastic part of tit in. In
central position of the A band throughout contrac- the center of the A ballet. in the gap between the ends
tion and relaxation and might act as a template or the thin filaments, is the H zone, a light band con-
during myosin ~,sselllbly. taining only thick filaments and that part of tilin that
Myosin, the thicker filament, is composed of indi- is integrated in the thick filaments. A narrow, dark
vidual molecules, each of which resembles a lollipop area in the center of the H zone is 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.
duced by transversely and longitudinally oriented allel to the myofibrils and lend to enlarge and fuse
proteins that link adjacent thick filaments, maintain- at the level of the junctions between the A and I
ing their parallel Hrrangclllel1L The various areas of bands, forming transverse sacs, or the terminal cis-
the banding patlern arc apparent in the photomicro- ternae, that surround the individual myofibril
graph of human skeletal muscle shown in Figure 6-3. completely,
Closely correlated with the rcpealing pattern or The terminal cisternae enclose a smaller tubule
the sarcomcrcs is an organized network of tubules tha1 is scpanllcd from them by its own membrane.
and sacs known as the sarcoplasmic reticulum. The smaller tubule and the terminal cisternae above
The tubules of the sarcoplasmic reticulum lie par- and below it are known as a triad. The enclosed
r ----"'....
Sarcomere
_--~""
_~ } Sarcoplasmic
reticulum
Mitochondrion {
I~M
--- Line
t
z
Line
H
Zone
B
A. Single muscle fiber with three protruding myofibrils. B. Electron photomicrograph of a cross·section of human skeletal mus·
c1e. The sarcomeres are apparent along the myofibrils. Characteristic regions of the sarcomere ar~ indicated.
CHAPTER 6 • BIOMECHANICS OF ''',LCIAL MLI>L.Lt
~
ill
E A
'l
Band
tween actin and myosin (the A band), 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-
0
u Band
m duces the sliding of the actin filaments tc)\vard the
If)
center of the sarcomere, A muscle fiber contracts
\vhen all sarcomere shorten simultaneously in an
I
all-or-nothing fashion, which is called a twitch,
Band I z· Because a single movement of a cross-bridge pro-
Triad duces only' a small displacement of the actin flla-
! \j ment relative to the myosin filament, each individ-
Sarcotubule Terminal ual cross-bridge detaches itself from one receptor
I cisternae site on the actin filament and reattaches itself to an-
1
mack, D.H, (7979). Histology (8th ed.J. PiJifadefphia: IS, Lippincott made available to the contractile elements and
ceases when calcium is removed, The mechanisms
that regulate the availability of calcium ions to the
contractile machinery are coupled to electric events
tubule is part or the transverse tubule system, or T occurring in the muscle membrane (sarcolemma),
system, which are invaginatio!1s of the surface An action potential in the sarcolemma provides the
membrane of the fiber. This membrane, the sar- electric signal for the initiation of contractile activ-
colemma, is a plasma membrane that invests every it,v. The mechanism by which the electric signal trig-
striated muscle (Fig. 6-4). gel'S the chemical events of contraction is known as
excitationNcontraction coupling.
Molecular Basis of Muscle \Vhen the motor neuron stimulates the muscle
at the neuromuscular junction (Fig, 6-5A) and the
Contraction propagated action potential depolarizes the mus-
cle cell membrane (sarcolemma), there is an in-
The most widely..' held theory of muscle contraction \vard spread of the action potential along the T
is the sliding filament theory, proposed simultane- system. (Details of this process arc given in Figure
ously by A.F. Huxley and H.E. Huxley in 1964 and 6-5, A-C and in Box 6-1, which summarizes the
subsequently refined (Huxley, 1974). According to events during the excitation, contraction, and re-
this theory, active shortening of the sarcomere, and laxation of muscle, Figure 6-5D shows the struc-
Molor
end
plate
(1 )
Synaptic
vesicles
(3)
c o
Schematic representation of the innervation of muscle fibers. area in this section is shown in detail in C. C. Ultrastructure of
A, An axon of a motor neuron (originating from the cell body the junction of an axon terminal and the sarcolemma. The in·
in the anterior horn of the spinal cord) branches near its end vagination of the sarcolemma forms the synaptic trough into
to innervate several skeletal muscle fibers, forming a neuro- which the axon terminal protrudes. The invaginated sar-
muscular junction with each fiber. The region of the muscle colemma has many folds, or subneural clefts, which greatly in-
membrane (sarcolemma) lying directly under the terminal crease its surface area. Acetylcholine is stored in synaptic vesi-
branches of the axon has special properties and is known as cles in the axon terminal. Band C. adapted from Brobeck, IR.
the motor end plate, or motor end plate membrane. The rec- (Ed.) (/979). Best and Taylor's Physiological Basis of Medical Practice
tangular area is shown in detail in B. B, The fine terminal (10(h ed., pp. 59-1/3). Baltimore: Williams & Wilkins. D. Cross-
branches of the nerve (axon terminals), devoid of myelin bridge cycle of muscle contraction.
sheaths, lie in grooves on the sarcolemma. The rectangular
CHAPTER 6 • BIOMECHANICS OF ~"ccc,"."
1. An action potential is initiated and propagated in a mo- 1 1. Actin activates the myosin ATPase found on the myosin
tor 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:
end plate to sodium and potassium ions. producing an tive sliding of the thick and thin filaments past each
end-plate potential. other.
S. The end-plate potential depolarizes the muscle mem- 13. Fresh AT? binds to the myosin cross-bridge, breaking
brane (sarcolemma), generating a muscle action pOlen- the 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
tubules. M . AlP complex, which represents rhe relaxed state of
8. Depolarization of the transverse tubules leads to the re- the 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
vicinitY of the regulatory proteins tropomyosin and tro- myosin cross-bridges at successive sites along the actin
ponin. filament (steps 11, 12, 13, CH'\d 14) continue as long as
9. Calcium ions bind to troponin, allowing movement of ii)e concentration of calcium remains high enough to
the tropomyosin molecule away from the myosin recep- inhibit the action of the troponin-rropomyosin system.
tor sites on the actin filament that it had been blocking 16. Concentration of calcium ions falls as they are pumped
and releasing the inhibition tilat had prevented actin into the terminal cisternae of the sarcoplasmic reticulum'
from combining with myosin. by an energy-requiring process that splits ATP,
10. Actin (A) combines with myosin ATP (M-ATP). In this 17. Calcium diSSOCIates from troponin. restoring the in-
state, ATP has been hydrolyzed to ADP and phosphate hibitory action of troponin-tropomyosin. The actin fila-
bUt the products are still attached to myosin (receptor ment slides back and rhe muscle lengthens. In the pr~s-,
sites on the myosin cross-bridges bind to receptor sites ence of ATp, actin and myosin remain in tll~ dissociated;,
on the actin chain): relaxed stale.
(,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 tract independently. \Vhcn stimulated, all muscle
of mvosin.) fibers in 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-
THE MOTOR UNIT
mally or not at aIL
The functional unit of skeletal 111uscle is the mOlor The number of muscle fibers forming a -motor
unit. which includes a single motor neuron and all unit is closely I"elated to the degree of control I"C-
of the muscle rlbers innervated by it. This unit is the quirccl of the muscle, In small muscles thal perform
smallest part of the muscle that can be made to CO!l4 vcr~' fine movements, such as the extraocular I11U$-
~l~JART l';~{~Of',ilECHANICS OF TISSUES AND STRUCTURES OF THE MUSCULOSKELETAL SYSTEM
!I~ ,~
depending largely on the muscle fibcr makeup (de·
scribed below). Some muscle fibers contracl with
a speed of only 10 mscc; others ma~; take 100 Illsec
or longer.
I
An action potential lasts only approximately I to 100 400
0 200 300 500
2 msec. This is n small fraction of the time taken for
the subsequent mechanical response, or twitch, t
S,
..tI.-
5,S3
even in muscles that contract quickly; thus it is pos- Time (msec)
sible for a series of action potentials to be initiated
C
f ' before the first twitch is completed if the activity of
the motor axon is maintained. \'\Then mechanical re-
sponses to successive stimuli arc added to an initial
response, the result is knc)\vn as summation (Fig. Summation of contractions in a muscle held at a constant
6-7). If a second stimulus occurs during the latencyl length. A, An initial stimulus (51) is applied to the muscle,
period of the first muscle twitch, it produces no ad- and the resulting twitch lasts 150 msec. The second (51) and
third (5 J ) stimuli are applied to the muscle after 200-msec
ditional response and the muscle is said to be com-
intervals when the muscle has relaxed completely, thus no
pletely refractory.
summation occurs. 8.5 1 is applied 60 msec after 51, when
The frequency of stimulation is variable and is
the mechanical response from 5.. is beginning to decrease.
modulated by individual motor units. The greater The resulting peak tension is greater than that of the sin-
the frequency of stimulation of the muscle fibers. gle twitch. C. The interval between 5.. and 5J is further re-
the greater the tension produced in the muscle as duced to 10 msec. The resulting peak tension is even
a whole. However, a maximal frequency will be greater than in S, and the increase in tension produces a
reached beyond which the tension of the muscle no smooth curve. The mechanical response evoked by 5J ap-
longer increases. \"'hen this maximallension is sus- pears as a continuation of that evoked .by 51' Adapted from
tained as a result or summation, the muscle is said Luciano, 0.5., Vander. AJ.• & Sherman. J.H. (1978). Human Func-
to contract tetanically. In this case, the rapidity of tion and Structure (pp. J J3-(36). New York: McGraw,Hill.
stimulation olltstrips the contraction~relaxation
!>f()f'-'IEClHAN.IC:SOF TISSUES AN.D STRUCTURES Of THE MUSCULOSKEl.ETAL SySTEM
c
0
'iii 2
c
<l>
>--
<l>
>
'g
0;
a:
0
is ts Is is is is Jumnmrnmmnnrrmnnm
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 chanical \vork is performed during an isomctric
repetitive twitching of all recruited motor units of a contraction, muscle work (physiological work) is
muscle in an as:vnchronous manner results in brief performed: energy is expended and is Illostly dissi-
summations or more prolonged subtetanic or paled as heat, which is also called the isornetric heat
tetanic contractions of the muscle as a whole and is production. All dynamic contractions involve what
a principal Factor responsible for the smooth move- ma.y be considered an initial static (isometric) phasc
ments produced by the skeletal muscles. as the muscle first develops tension equal to the load
it is expected to overcome.
The tension in a muscle varies with the t.ype of
TYPES OF MUSCLE CONTRACTION
contraction. Isometric contractions produce
During contraction, the force exerted by a contract- greater tension than do conccntric contractions.
ing muscle on the bony lever(s) to which it is at- Studies suggest that the tension developed in an
tached is known as the muscle tension, and the ex- eccentric contractIon may even exceed that devel-
ternal force exerted on the muscle is known as the oped during an isometric contraction. These dif-
resistance, or load. As the muscle exerts its force, it ferences arc thought to be due in large part to the
generates a turning erFect, or moment (torque), on vat'ying amounts of supplemental tension pro-
the involved joint because the line of application of duced in the series clastic component of the mus-
the muscle force usually lies at a distance from the cle and to diFferences in contraction time. The
center of motion of the joint. The moment is calcu- longer contraction time of the isometric and ec-
lated as the product of the muscle force and the per~ centric contractions allows greater cross~bridge
pendicular distance between its point of application formation by the contractile components, thus per-
and the center of motion (this distance is known as mitting greater tension to be generated (Kroll,
the lever arm, or moment arm, of the force), 1987). More time is also available for this tension
Muscle contractions and the resulting muscle to be transmitted to the series elastic component
work can be classified according to the relationship as the muscle-tendon unit is stretched. The longer
bet\veen either the muscle tension and the resis- contraction time allo\vs the recruitment of aclcli-
tance to be overcome or the muscle moment gener- tional nlotor units.
ated and the resistance to be overcome, as shown in Komi (1986) has pointed oul that concentric, iso-
Box 6-2 (Krocmcr e! 'II., 1990), metric, and eccentric muscle contractions seldom
_ Types of Muscle Work and Contraction
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
tion: When muscles develop sufficient tension to over- is equal to or less than the resistance to be overcome,
come the resistance of the body segment, the mus- the mllscle length remains unchanged and the muscle
cles shorten and cause joint movement. The net contracts isomelfically. If the moment is greater than the
moment generated by the muscle is in the same di· resistance, the muscle shortens (contracts concentrically)
rection as the change in joint angle. An example of a and causes acceleration of the body part. Isoinertial con~'
concentric contraction is the action of the quadriceps traction occurs, for example, when a constant external
in extending the knee when ascending stairs. load is lifted. At the extremes of motion, the inertia of
2. Eccentric (e.g., out of-, centrum, center) contraction: the load must be overcome; the involved muscles con-
When a muscle cannot develop sufficient tension and tract isometrically and muscle torque is maximal. In the
is overcome by the external load, it progressively midrange of the motion, with the inenia overcome, the
lengthens instead of shortening. The net muscle mo- mU'jcles contract concentrically and the torque is sub-
ment is in the opposite direclion irom the change in maximal.
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
one descends stairs, the quadriceps works eccentri- the tension is constant throughout a range of joint m()~'
cally to decelerate flexion of the knee, thus decelerat- tion. This term does not take into aCCOLlnt the leverage'""
ing the limb. The tension that il applies is less than eilects at the joint. Ho\,vever, because the muscle force
the force of gravity pulling the body downward, but it moment arm changes throughout the range oi joint mo-··;:
is sufficient to allow controlled lowering of the body. lion, the muscle tension must also change. Thus, isotonic
3. Isokinetic (iso, constant; kinetic, motion) contraction: muscle 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 constan I velocity. and Static work: No mechanical work is performed and posture
hence rhe velocity of shortening or lengthening of the or 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.:·
lion of the body part and is entirely converted to a re- c1es 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 the myofibrils shorten and in doing so stretch the series ---::::-
joint contract concentrically during flexion and eccen- elastic componenr. thereby producing tension), but it
trically during extension, acting as decelerators during does not overcome the load and cause movement; in-
the latter. stead. 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- c
.2 '.0
ferent type. An example is the eccentric loading m I
c I
prior to the concentric contraction that occurs at " I
~,
f-
I
the ankle frolll miclstance to toe-off during gait. "
.~
<i
0.5
I
I
Because muscles normally' shorten or lengthen at 0; I
I ", .
a:
"at)!ing velocities and with valying amoullls of tcnsion, I
I I
perfolll1ance and measurement of isokinetic work re- 1.27 1.65 2.0 2.25 3.6
quire the lise of an isokinetic dynamon1ctcl: This device
provides constant velocity of joint motion and maxi- Sarcomere Length (JIm)
mum cxtcIllal resistance throughout the range of 010- 2.25-3.6 I'm c==:jr=z=J~\:~::\g;
::~;::~:::~\ ==i/i==
lion of the involved joint. thereby requiJing maximal
muscle torque. The use of the isokinctic dynamometer
z M A Z
provides a method of selective training and measure- 20-225"m=9! i':::": :::!::~ Ir==
ment, but physiological movement is not simulated.
<1.65"m==j~F=
Force Production in Muscle
Tension·length curve from part of an isolated muscle fiber
The total force that a muscle can produce is influ-
stimulated at different lengths. The isometric tetanic ten-
enced by its mechanical properties, which can be sion is dosely related to the number of cross-bridges on
described by examining the length-tension. load- the myosin filament overlapped by the actin filament. The
velocity, and force-time relationships of the muscle tension is maximal at the slack length, or resting length, of
and the skeletal muscle architecture. Other princi- the sarcomere (2 p.m), where overlap is greatest, and falls
pal factors in force production arc muscle tempera- to zero at the length where overlap no longer occurs (3.6
ture, muscle fatigue, and prestrclching. ,....m). The tension also decreases when the sarcomere
length is reduced below the resting length. falling sharply
at 1.6S IJ.m and reaching zero at 1.27 IJ.ffi as the extensive
LENGTH-TENSION RELATIONSHIP overlap interferes with cross-bridge formation. The struc-
The force, or tension, that a muscle exerts varies tural relationship of the actin and myosin filaments at vari-
ous stages of sarcomere shortening and lengthening is
with the length at which it is held when stimulated.
portrayed below the curve. A. actin filaments; M. myosin
This relationship can be observed in a single fiber filaments; Z, Z lines. Adapted from CriJ....,;ord. CN.C & J~lmes.
contracting isometrically and tetanically, as illus- N. T. (1980). The design of muscfes. In R. Owen, J. Goodfelfo'l'l, &
trated by the length-tension curve in Figure 6-9. P. Buffough (Eds.), Scientific Foundations of Orthopaedics and
Maximal tension is produced when the muscle fiber Trmilllalology (pp. 67·-74). London.' William Heinemann;')5
is approximately at its "slack," or resting, length. ,If modified from Gordon, A.M., rluxley, A.F.I., & JlIlian, F.l. (1966).
the fiber is held at shorter lengths. the tension falls Tile variation in isometric tension with SMcomere length in ver- / ..
off slowly at first and then rapidly. If the fiber is tebr~lre muscle fibers. J Physiol, 184, 170.
lengthened beyond the resting length, tension pro-
gressively decreases.
The changes in tension when the fiber is
stretched or shortened primarily are caused by sian because it allows ovedapping of the thin fila-
structural alterations in the sarcomere. Maximal ments at opposite ends of the sarcomere, which are
isometric tension can be exerted when the sarcom- functionally polarized in opposile directions. At a
eres arc at their resting length (2.0-2.25 /J.m), be- sarcomere length of less than 1.65 fJ.m. the thick fil-
cause the actin and myosin fllamcnts overlap along aments on the Z line and the tension diminish
their entire length and the number of cross-bridges sharply.
is maximal. If the sareo meres arc lengthened. there Thc length-tension relationship illustrated in Fig-
are fewer junctions between the marnents and the ure 6-9 is for an individual muscle fiber. If this rela-
active tension decreases. At a Sarcomere length of ,lionship is measured in a whole mus.de contracting
approximately 3.6 J.Lm, there is no overlap and isometrically and tetanically, the tension produced
hence no active tension. Sarcomcl·e shortening to by both active components and passive components
less than its resting length decreases the acLive ten- must be taken into account (Fig. 6-10).
The cun/e labeled "active tension" in Figure
6-10 represents the tension developed by the con-
tractile elements of the muscle. and it resembles Eccenlric Concentric
--~
the curve for the individual fiber. The curve labeled
"passive tension" reflects the tension developed
when the muscle surpasses its resting length and
the noncontractile muscle belly is stretched. This
u
passive tension is mainly developed in the parallel '"o
-'
and series elastic components (Fig. 6-6). When the
belly contracts, the combined active and passive
tensions produce the total tension excrled. The
curve demonstrates that as a muscle is progl'cs·
sivdy stretched beyond its resting length, the pas·
sive tension rises and the active tension decreases.
Most rnuscles that cross only one joint normally
are not stretched enough fOl- the passive tension 10 o ..
play an important role, but the case is different for Velocity
lwo-joint muscles. in which the extremes of the
L Length
(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
The active and passive tension exerted by a whole muscle
knee extended. the Illuscles arc so stretched that it
is the magnitude of their passive tension that pre-
I contracting isometrically and tetanically is plotted against the
muscle's length. The active tension is produced by the con· vents flirt her elongation and causes the knee to flex
tractile muscle components and the passive tension by the se- if hip flexion is increased.
ries and parallel elastic components, which develop stress
when the muscle is stretched beyond its resting length. The
~~~·_----_·_-------T
tcrnalload is zero, but as the load increases the mus~
ele shortens morc and more slowly. \Vhcn the cxter4
Gastrocnemius Muscie Tear nul load equals the mnximal force that the muscle
- -. ·.
22·year-old male professional athlete tears his ga5- can exen, the velocity of shortening becomes zero
A ___ trocnemius during a race (Fig. (56-1-1). The tensile and the muscle contracts isometrically. \,\fllen the
load is increased still further, th~ muscle contracts
overload that happens during strenuous eccentric and
c6n~entric contractions increases the risk of injury. espe- eccel1Lrically: it elongates during contraction. The
ciallywhen the forces involve bj-articular muscles such load~velocity relationship is reversed from that of
:asthe gastrocnemius. This indirect trauma is associated the concentri-cally contracting rnuscle; the muscle
:wi!~ 111gh tensile forces during rapid contraction (high eccentrically lengthens more quickl)! with increasing
v~l_()~ity) and continued changes in muscle length. The load (Kroll. 1987) (Case Study 6-1).
status of muscle contracrion at the time of overload is
uS!Jally eccentric, and failure most often occurs at or FORCE-TIME RElATIONSHIP
near the 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-
·h~~{br'rh~ge occurs initially in the inflammatory phase.
portional to the contraction time: the longer the
,The cellu.lar response is more rapid and repair is (rlore
contraction lime, the greater is the force developed,
complete'if the vascular channels are not disrupted and
lip to the point of maximurn tension. In Figure 6-12,
·thenutritioo.of ihe tissue is not disturbed. The degree
this relationship is illustrated by a force-lime CUl\rc
of injury from a tensile overload will dictate the poten·
for a whole muscle contl"acting isometrically.
tia/hos< r~sponse and the time needed iar repair.
Slower contraction leads to greaLcr force 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- Muscle Length (cm)
mans (Cuillo & Zarins, 1983) that a muscle per- B 100
forms more work when it shortens inlmediatcly af-
ter being stl'etched in the concentrically contracted :!
80
state than when it shortens from a state of isomet-
ric contraction. This phenomenon is not entirely ac- ~
~ 60
counted for by the elastic energ~' stored in the series o
u.
clastic component during stretching but must also ~
'0 40
be caused by energy stored in the contractile com· ~
"
::;
20
5 10 15 20 25
Muscle Velocity (cm/s)
•
0F-----------
pon~nl. 'It has been suggested [hat changes in the in-
trinsic mechanical properties of l11)'oflbrils are im-
ponant in the stretch-induced enhancement of
Time work production (Takarada et aI., 1997),
IBm
i L- _
EFFECT OF TEMPERATURE
Force-time curve for a whole muscle contracting isometri· A rise in muscle temperature causes an increase
cally. The force exerted by the muscle is greater when the
in conduction velocity across the sarcolemma
contraction time is longer because time is required for the
tension created by the contractile components to be trans-
(Phillips & PeLrorsky, 1983), increasing the rre-
ferred to the parallel elastic component and then to series quency of stimulntion and hence tbe production
elastic component as the musculotendinous unit is of muscle force. Rising of the muscle temperature
stretched. from 6 La 34 u C results in an almost linear increase
or the tension/stirrness raLio (Callcr et al" 1998).
•
01~1,;P:kRT:,,;;-., BIOMECHANICS OF TISSUES AND STRUCTURES OF THE MUSCULOSKELETAL SYSTEM
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
After a period of intense exercise, creatine phos- the basis of speed of contractility and fatigability.
phate levels have become low and much of the mus- Although considerable confusion has existed con~
cle glycogen may have been convened to lactic acid. cCl'ning the method and terminology for classifying
For the muscle to be returned to its original state, skeletal muscle, recenl histological and histochemi-
creatine phosphate must be resynthesized and the cal observations have led to the identification of
u1vcofLcn stores must be replaced. Because both three distinct typcs or muscle fibers on the basis of
pl:oce~ses require energy, the muscle will continue differing contractile and metabolic properties
to consumc oxygen at a rapid rate cven though it (Brandstater & Lambert, 1969; Buchtah! & Soh mal-
has stopped contracting. This sustained high oxy- burch, 1980) (Table 6-1).
!:rell uptake is demonstrated by the fact that a person 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
riod of strenuous exercise. AT? and the rate at which its energy is made avail-
v"hen the energy necessary to return glycogen able to the conrractilc system of the sarcomere,
and creatine phosphate to their original levels is which determines the speed of contraction. The
taken into account, the ef(-icienc~. . with which mus- three fiber types are termed type I, slow-twitch ox-
cle coovens chemical energy to work (movement) is idative (SO) fibers; type lIA, fast-twilCh oxidative-
usually no more than 20 to 250/0, the majority of the glycolvtic (FOG) fibers; and type liB, fast-twitch gly-
energy being dissipated as heat. Even when Illuscle colytic (FG) fibers.
is operating in its most efficient stnte, a maximum Typc I (SO) fibers are characterized by a low ac-
()f only approxinwtel)! 45{>~ of the energy is used for tivity of my'osin ATPase in the muscle fiber and,
contraction (Arvidson ct 'II., 1984; Guyton, !986). thcrefore, a relatively slow contraction time. The
In growth biomechanics, muscle fatigue is flrst glycolytic (anaerobic) aClivity is low in this fiber
observed by the lack of coorclinalion or movement lype, but a high content of mitochondria produces a
and its effect in the increasing of loads in tissue. Re- high potential for oxidative (aerobic) activity. Type I
searchers including Bates et al. (1977) have indi- fibers are difficult to fatigue because the high rate of
cated that the skill of the person in performing a blood now to these fibers delivers oxygen and nutri-
given action is affected by fatigue, They studied the ents at a sufficient rate to keep up with the relatively
fatigue effect on runners and absented that runners slow rate of ATP breakdown by myosin ATPase.
decrease their knee extension when fatigue occurs Thus, the fibers are well suited for prolonged, low-
(Bates et aI., 1977). Parnianpour (1988) studied the intensity work. These fibers are relatively small in
motion coupling of the spine at exhaustive extension diameter and so produce relatively little tension.
Oexion. This study showed that when an individual The high myoglobin content of type I fibers gives the
became fatigued, the coupled motion increased and muscle a red color,
therefore the spinaltorquc increased. The most dele- Type II muscle fibers arc divided into two nlain
terious component of the ncurornuscular adaptation subgroups, IIA and IlB, on the basis of differing sus-
to the fatiguc state was the reduction in accuracy ceptibility to treatment with different buffers prior
control and speed of contraction, \vhich may predis- to incubation (Brooke & Kaiser, 1970). A third sub-
pose an individual to injury if muscle fatigue occurs. group, 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 Fiber Differentiation. muscle (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 which results in relatively fast contraction.
ractors that determine the total tension developed Type lIA (FOG) fibers are considered intermedi-
b.v the whole rnuscle when it COlllracts. Individual ate between type 1 and type lIB because their fast
muscle fibers also display distinct differences in contt-action time is combined with a moderately
their rates of contraction, development of tension. well-developed capacity for both aerobic (oxida-
and susceptibility to fatigue. 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. tractile and histochemical properties and the fast-
They can maintain their contractile activity for rel- twitch fibers became slow.
<Hively long periods; ho\vevcr, at high rates of ac- The fiber composition of a given muscle de-
tivity. the high rate of ATP splitting exceeds the ca- pends on the function 01" that muscle. Some mus-
pacity of both oxidative phosphorylation and cles perform predominantly one form of contrac-
glycolysis to supply ATP, and these fibers thus tile activity' and arc often composed mostly of
eventually fatigue. Because the myoglobin conlCIH one muscle fiber t}'pc. An example is the soleus
01" this muscle type is high, the muscle is of len cat- muscle in the calf, which prirnarily maintains
egorized as red III lIscl e. posture and is composed of a high percentage of
T:vpe liB (FG) libers rely primarily on glycolvtic type I fibers. More commonly', however, a muscle
(anaerobic) activity for ATP production. Few capil- is reqllir'cd to perform endurance-type activity
laries are found in the vicinity of these fibers and be- unde)' some cirClllTlstances and high-intensity
cause they contain little myoglobin (hey are ohen strength activity under others. These muscles
referred to as white muscle. Although Lype liB fibers generally contain a mixture of the three muscle
are able to producc ATP rapidly, they fatigue easily fiber types.
because their high rate of ATP splitting quickly de- (n a typical mixed muscle exerting low tension,
pletes the glycogen needed for glycolysis. These some of the small motor units, composed of type I
fibers generally are of large diameter and are thus fibers, contract. As the muscle force increases,
able to produce great tension, but only for short pe- more motor units are recruited and their fre·
riods before they fatigue. quency of stimulation increases. As the frequency
It has been well demonstrated that the nerve in- becomes maximal. greater muscle force is
nervating the muscle fibcr determines its t.ypc achieved by recruitment of larger motor units
(Burke el aI., 1971); thus, the muscle fibers of each composed of type 11;\ (FOG) fibers ancl eventually
motor unit are of a single type. In humans and other type lIB (FG) fibers. As the peak muscle force de-
species, electrical stimulation was found to change creases, the larger units are the first to cease ac-
the fiber type (Munsal, McNeal, & Waters, 1976). In tivity (Guyton. 1986; Luciano, Vander. & Sherman,
animal studies, transecting the nerves that inner- 1978).
vate slow twitch and fast-twitch muscle fibers and
8
It is generally, but not universally, accepted that
then crossing these nen;es was noted to reverse the fiber types are genetically det~rmined (Costill ct
fiber types. After recovery from the cross-innerva- aI., 1976; Gollnick, 1982). In the average popula-
tion, the slow-twitch fibers became fast in their con- tion, approximatel.'Y' 50 to 55% of muscle fibers
CHAPTER 6 • BICIMI,C
are type I, approximately 30 to 35 Cj(; are type IrA, physical constraint of the surrounding tissues, the
and approximately' 15 rJr; are t.\'Pe lIB, but these extent and condition of extracellular matrices, and
percentages vary greatly among individuals. the development of repair cells. Muscle injuries are
In elite athletes, the relative percentage of fiber important but the topic is not \vithin the scope of
types differs from that in the general population and this chapter. Injuries should be investigated care-
appears to depend on whether the athlete's principal fully if suspicion arises that a patient has muscle
activit)' requires a short, explosive, maximal effort damage.
or involves submaximal endurance. Sprinters and
shot putters, for example, have a high percentage of
tvpe II flbers, whereas distance runners and cross- Muscle Remodeling
~ountry skiers have a higher percentage of type I
fibers. Endurance athletes may have as man.v as The remodeling of muscle tissue is similar to that of
80% t.ype I fibers, and those engaged in short, ex- other skeletal tissues such as bone, articular carti~
plosive efforts as few as 30 0/e of these fibers (Saltin lage, and ligaments. Asin these other tissues, mus~
et 'II., 1977). cle atrophies in response to disuse and immobiliza-
The genetically determined fiber typing may be tion and hypertrophies when subjected to greater
responsible for the natural selective process by use than usual.
which athletes are drawn to the type of sport for
which they are most suited. Because fiber types are
EFFECTS OF DISUSE AND
determined by the nerve that innervates the muscle
IMMOBILIZATION
fiber, there may be some cortical control of this in-
nervation that influences an athlete to choose the Disuse and immobilization have detrimental effects
sport in which he or she is genetical I)' able to excel. on muscle ftbers. These effects include loss of en-
durance and strength and muscle atrophies on a mi-
crostructural and macrostructural level, such as de-
Muscle Injuries creased numbers and size of fiber. Biochemical
changes occur and affect aerobic and anaerobic en-
iVluscle injuries comprise contusion, laceration, erg}' production. These effects are dependent on
ruptures, ischemia, compartment syndromes, and fiber type and muscle length during immobilization.
denervation. These injuries weaken the muscles and Immobilization in a lengthened position has a less
can cause significant disability'. Blunt trauma can deletet-ious effect (Appell, 1997; Kassel', 1996; Ohira
diminish muscle strength, limit joint motion, and fl- et 'II.. 1997; Sandmann, et 'II., 1998).
nally lead to myositis ossiflcans. lVlusclc laceration, Clinical and laboratory studies of human and an-
surgical incisions, and traumatic lesion to muscle imal muscle tissue suggest that a program of im-
tissue and denervation weaken the ITmsclcs, some- mediate or early motion may prevent Illuscle atro-
times significantly. Ruptures in muscles also can phy after injury or surgery. In a study of cnlsh
cause weakness. Like the other injuries, they rnay injuries to rat muscle, the effect of immobilization
result from direct trauma, but muscle contractions of the crushed limb was compared with that of im-
against resistance also can lead to tears in muscle mediate motion. The muscle fibers \vere found to
tissue. regenerate in a more parallel orientation in the mo-
Acute muscle ischemia and compartment syn- bilized animal than in the immobilized animal,
dromes can cause extensive muscle necrosis. The capillarization occurred more rapidly, and tensile
many potential causes of compartment s}'ndrome strength returned more quickly. Similar results
all result in increased pressure \vithin a confined were found in a later study on the effect of immo~
muscle compartment. In this case, failure to relieve bilization on the IT'lOrphology of rat calf muscles
the pressure rapidl.y ma}' cause complications that (Kannus et aI., 1998a).
range from weakness and decreased motion to loss It has been found clinically that atrophy of the
of an entire limb. quadriceps muscle that develops while the limb is
Studies have shown that healthy skeletal muscle immobilized in a rigid plaster cast cannot be re-
has a substantial capacity to repair itself. This re- v'ersed through the use of isometric exercises. At-
pair process following a specific injury is inferred rophy may be limited by allowing early motion
by the prior innovation pattern, vascularization, such as that permitted by a partly mobile cast
OF TISSUES AND STRUCTURES OF THE MUSCUI.OSKEI.ETAL SYSTEM
brace. In this case, dynamic exercises can be per- stood (Gollnick, 1982; Guyton, 1986). It appears
formed. that these evcnts arc controlled or modified by
Human muscle biopsy studies have shown that both the intrafusal muscle spindles, located in par-
it is mainly' the type I fibers that atrophy with im- allel with the extrafusal fibers of the muscle belly,
mobilization; their cross-sectional area decreases and the Go!gi tendon organs, located in series with
and their potential for 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- Ruptured Left Anterior eruciate Ligament
fusal muscle spindles will increase, leading to in- 25-year-old male, status postsurgical repair of the
creased stimulation of the type I fiber. Although in-
termittent isometric exercise may be sufficient to
A - ruptured left anterior cruciale ligament, had torque
measurements taken from the involved and uninvolved
maintain the metabolic capacity of the t.vpe II limb 10 weeks after the surgical procedure (Fig. (56-2-1 A)
fibel~ the type I fiber (the postural fiber) requires a and repeated 6 weeks after the training began (Fig. (56-
more continuous impulse. Evidence also suggests 2-1 B). An increase of muscle torque is shown in the re-
that electric stimulation may prevent the de- peated isokinetic test. The initial deficit of the involved
crease in type I fiber size and the decline in its oxi- side was approximately 63~o when compared with the
dative enzyme activity caused b:v immobilization uninvolved side. After 6 '.Neeks of trainin~J. the deficit of
(Eriksson et ai., 1981). the involved side compared with tho uninvolved side de-
In elite athletes, inactivity following injury, creased to 43%.
surgery, or immobilization rapidly decreases the
size and aerobic capability of muscle fibers, partic- 187,--------------,
ularly in the fiber type affected bv the chosen 163
sport. Tn endurance athletes, type I fibers are af- 140
E 116
fected, while in athletes engaged in an explosive <n
c 93
activity such as sprinting, type II fibers are af-
fected.
;:o 47
" 69
/ -----
z 23
o J-~c_-----__:-~:-''''-'-----J
EFFECTS OF PHYSICAL TRAINING o 16 32 48 64 80 96 112 128
Physical training increases the cross-sectional area Knee motion degrees
3 The myofibrils arc composed or thin filaments 12 The energy for muscle contraction and its re-
of the protein actin and thick filaments of the pro- lease is provided by the hydrolytic splitting of ATP.
tein myosin, and the intramyofibrillar cytoskeleton Muscle fatigue occurs \\'!hen the ability of the mus-
is composed 01" the clastic filaments titin and the in-
cle to synthesize ATP is insufficient to keep lip
elastic filarnents ncbulin. with the rate of ATP breakdown during contrac-
tion.
4· According to the sliding filament theOl)" active
shortening of the muscle results from the reiativL' 13 Three main fiber types have been identified:
movement of the actin and myosin filaments past type I, slow-twitch oxidative; type IIA, fast-twitch
one anothel: The force of contnlClion is developed oxidative-glycolytic; and type liB. fast-twitch gly-
by movement of the myosin heads, or cross-bridges, colytic fibers. Most muscles contain a mixture of
in contact with the aclin filaments. Troponin and these types.
tropomyosin, two proteins in the actin helix, regu- .,14 Muscle atrophies occur under disuse and im-
Iatc the making and breaking of the contacts be- mobilization; muscle trophism can' be restored
tween r-ilamenls. through early and active rcmobilization.
.f '
Cllz&:t'1:AIlT 1 :;BIOMECHANICS OF TISSUES AND STRUCTURES OF THE MUSCULOSKELETAL SYSTEM
'-'"
i.:
",' '''"
• 810MEC):IANICS OF TISSUES AND STRUCTURES OF THE MUSCULOSKELETAL SySTEM
:----.
z
0
;=
--:----- ---------1 ~
e-
Z o
0 .~
u
1< ~
>!'
z "
0
0
:>
~
0
"9
>
~ "
v "=
~
'" <;
, ....
E
<;;
0; -=
~
~I
,.' 0;
.,;
~
6
'"
(;
c
'g"
.~
.2
:;; .~
.~
c "=-
- ',." ,.
,·_------·1·----------1'
. . ~
'"
<;
c
:,
-0 <;
C
=
,
'"
l'
<;
e
~ <
t ~
. 2
~ §
··
~
"=
0
·--
~ .~
"
.~
",
-5
g
;::
........ - ..
f
~
..:.
?
,.
'3
~,
I!
1
I,
.
s"
~ .~
,~:':,i$;\')
c.
E
",:tt:./ ~ .2X
;1~&
X
~ 0
;;; 0
.a
v
:s £
c
.:)~;;;: 0 0
0
'"'"
,.', u....
'.;'x. E
~
j,t-:;:". E -0c
. e2?
ij <~-
~
." .-
~
v
~
"
0
.;;
~
E 3
0
;;:
-S
.~
."
.!!i
"
.~
.,
.
~ ~
'5
0
~
,
0.
~ 0
~
c,
§v i;
E
.e
v
0
e~
:~ 0
v
x
w 2
."
0
C
'"
.~
."
:". .~
.;;"
0
3
.g
.0
.a
'"
-,~, . "., ~.
-<
Vi
co
C
m
co
:l>
z
o
':')
c'"
n
-<
c
'"
m
co
~
-<
I
m
S
C
co
n
c
r
oco
"
m
r
m
~
r
co
.' f •.
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
The knce is particularl.. . . \vell suited for demon-
Introduction strating biomechanical anal.vscs of joints because
The knee transmits loads, part III pales in motion, these anal.. .,scs can be simplified in the knee and still
aids in conservation of momentum, and provides a yield useful data. Although knee motion occurs si-
force couple for activities involving the leg. The hu- multancous!y" in three planes, thc motion in onc
man knee, the largest and perhaps 1110st complex planc is so great that it accounts for nearly all of thc
joint in the bod)!, is a two-joint structure composed motion. Also, although many muscles producc
'of the tibiofemoral joint and the patellofcmoral forces on the knee, at any particular instant one
joint (Fig. 7-1). The knee sustains high forces and muscle group predominates, generating a force so
moments and is situated between the body's two great that it accounts for most of the muscle force
longest lever arms (the femur and the tibia), making acting on the knee. Thus, basic biomedwnical
it particularly' susceptible to injury. This d18ptcr uti- analyscs can be limited to motion in one plane and
lizes the knee to introduce the basic terms, explain to the force produced by a single muscle group and
the methods, and demonstrate the calculations nec- still give an understanding of kncc mc)tion and an
essary for analyzing joint motion and the forces and estimation of the magnitude of the principal forces
moments acting on a joint. This information is np· and moments on the knee. Advanced bioIllcchanical
plied to other joints in subsequcnt chaptcrs. d.\'namic anal,\'ses of thc knee joint that include all
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-
kinematic daw. Kinematics is the branch of mc- scribes the sw-facc motion of a joint in three planes:
crlanics thal deals with Illotion of a body without frontal (coronal or longitudinal), sagittal, and trans-
reference to force or mass. Anal:vsis of the forces verse (horizonlal) (Fig. 7 2, A & B). Clinical mea-
H
and momenl~ acting on a joint necessitates the surements of joint range 01" motion define the
usc of both kinematic and kinetic data. Kinetics is anatomical position as a zero position for mcasure-
the branch of mechanics that deals with the motion ment. This laxonomy will be uscd for joint motion
of a body under the action of given forces and/or throughout this book. Other taxonomies and reFcr-
moments. ence systems exist (Ant!riacchi et aI., 1979; Groot! &
Proximal/
dislal
!j"~~;;:~i..k~~~i===::::=Fronlal
~1 plane
•., -Sagittal
I~. ~ plane
o ;,.j
k'. )1
~
Internal/external
Varus!
valgus
A B
A, Frontal (coronal or longitudinal), sagittal. and transverse tion and proximal distal translation, flexion-extension rota-
(horizontal) planes in the human body performed easily for tion, internal-external rotation, varus-valgus rotation.
both the tibiofemoral and the patellofemoral joint. B, Depic- Adapted from Wilson, S.A., Vigorita, V.J., & Scott, W.N.
tion and nomenclature of the six degrees of freedom of knee (1994). Anacomy. In N. Scott (Ed.), The Knee (p. 17). Philadelphia:
motion: anterior posterior translation, medial/lateral transla- Mosby- Year Book.
.,. . .<:,
";'~'
,
I?:A
r
t
"m'Jh' ,
<"'J!!!::l~"
metr)'. or photographic and video techniques using to 65 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,
skeletal pins,
46A,335,
In the tibiofcmoral jail'll. nlOtion takes place in all
three 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°. in this joint during walking has been measured in
Motion in the transverse plane. intel-nnl and ex- all planes. The range of motion in the sagittal plane
ternal rotation. is inOuenced by the position of the during level walking was measured with an e1ectro-
joint in the sagittal plane, With the knee in Full ex- goniometer by Lamoreaux (1971) and MUlTay et al.
tension. rOHHion is almost completely restl'ictcd b~f (1964). Full or nearly Full extension was noted at the
the interlocking of the femoral and tibial condyles. beginning of the stance phase (0% of cycle) at heel
which occurs mainly because the medial femoral strike, and at the end of the stance phase before LOe-
condyle is longer than the lateral condyle. The range off (around 60% of cycle) (Fig, 7-3), Maximum flex-
of rotation increases as the knee is flexed, reaching ion (approximately 60°) was observed during the
a maximum at 90° of nexion; with the knee in this middle of the swing phase (sec Chapter 18, Biome-
:- position. external rotation ranges from 0° to ap- chanics of Gait. For more detailed inFormation),
proximately 45° and internal rotation ranges from These measurements are velocit.y-c1ependent and
0' to appmximatcly 3D'. Beyond 90' of Ilexion. the must be interpreted with caution.
range of internal and external rotation decreases, ~"lotion in the transverse plane during walking has
primarily because the soft tissues restrict rOlation. been measured by several investigators. Using a pho-
Motion in the frontal plane. abduction and ad- lOgraphic technique involving the placement of
duction. is similarly aFfected by the amount of joint skeletal pins through the femur and tibia, Levens
flexion, Full extension of the knee precludes almost and associates (1948) Found that total rotation of the
all motion in the frontal plane. Passive abduction tibia with respect to the fernur ranged from approx-
and adduction increase with knee Oexion up to 30°. imately 4 to 13' in 12 subjects (mean 8,6'). Greate,-
but each reaches a maximum of only a few degrees. rotation (mean 133') was noted by Kettclkamp and
With the knee flexed beyond 3D'. motion in the coworkers (1970). who used electrogoniollletry on
frontal plane again c1ecre~lses because of the limit- 22 subjects. In both studies, external rotation began
ing function of the sol't tissues. during knee extension in the stance phase and
The range of tibiofernoral joint motion required reached a peak value at the end of th~ swing phase
For the performance of various physical activities just before heel strike. Internal rotation was noted
can be determined from kinematic anal~lsis. MOlion during Ilexion in the swing: phase.
DDIII-~ callsc lhese mcthods ~lre highly technical and com-
plex, a simpler method evolved in the nineteenth
Range of Tiblofemoral Joint Motion In the ccnL'It'\, Is sLillus~d (Reuleau,\, 1876), This m~,h()d,
Sagittal Plane During Common Activities called the installt cl.?nter techniqul.', allows surface
I Range of Motion
from Knee Extension
joinl 1l1Olion lO be analyzed in the sagiual and
froolal planes but not in the transverse plane. The
Activity to Knee Flexion (Degrees)
- - - - - - - - - -0-67"
Walking
------, instant center l~chniqLle pl{)vides a description of
the rch'tive uniplanar motion of two adjacent seg-
""I
occurred as the knee \Vas flexed during the swing genograms of the joint in dilTcrent positions (usually
phase. The total amount of abduction and adduc- 10° apart) throughout the range of motion in one
tion averaged 11°. plane and applying the Rculcaux melhod for localing
Values for the rangc of motion o!" the tibiofemoral the inslanl center 1'01' each intcrv[ll or motion.
joint in the sagittal plane during several comn101l \Vhcn the instant center palhway has been deter-
activities arc presented in Table 7-1. l'vlaximal knee mined 1'01' joint motion in one plane, the surface
flexion occurs during lifting. A range of motion joint mol ion C[ln be described, For each intel'val or
I'rol11 full extcnsion to at least II r 01' flcxion ap- motion, the point at which the joint surfaces make
pears to be required for an individual to carry out contact is located on the roentgenograms lIsed fCH'
the activities of daily living in a normal manner. Any the instant center analysis, and a line is drawn frol11
restriction of knee motion can be compensated for
by increased motion in other joints. In studying the
range of libiofcmoral joint motion during various 1Imtl!JIJI--~ -~~-,-~----~
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
-'i<
then be ploued. In a normal knee, the instant cen-
ter pathway for the tibiofemoral joint is semicircu-
lar (Fig. 7-5).
After the instant center padnvay has been de-
termined for the tibiofemoral joint. the surface
motion can be described. On each set of superim-
posed roent-gcnograms the point of contact of the
tibiorcmoral joint surfaces (the narrowest point in
the joint space) is determined and a line is drawn
connecting this point with the instanl centet: A
second line drawn at right angles to this line incli- Semicircular instant center pathway for the tibiofemoral
cates the direction of displacement of the contact joint in a 19-year-old man with a normal knee.
points. In a normal knee, lhis line is tangential to
the surFace of the tibia for each interval of motion
from full extension to full flexion, demonstrating
that the femur is gliding on the tibial condyles
(Frankel et aI., 1971) (Fig. 7-6). During normal
knee motion in the sagittal plane from full exten- tel' pathway for one subject, a 35-~"ear-old man
sion to full flexion. the instant center pathway with a bucket-handle derangement. is shown in
moves posteriody, forcing a combination of Figure 7-7.
rolling and sliding to occur between the articular If the knee is extended and Hexed aboul an ab-
surface (Fig 7-6. A & B). The unique mechanism normal instant center pathway, the libiofemoral
prevents the femur from rolling off the posterior joint surfaces do not glide tangentially through-
aspect of the tibia plateau as the knee goes into in- out the range of motion but become cither dis-
creased flexion (Draganich et aI., 1987; Fu et aI., tracted or compressed (Fig. 7-8). Such a knee is
1994; Kapandji, 1970). The mechanism that pre- annlogous to a door with a bent hinge that no
vents this roll-off is the link formed between the longer fits into the door jarnb. If the knee is con-
tibial and Femoral attachment sites of the anterior tinually forced to move about a displaced instant
and posterior cruciate ligaments and the osseous center, a gradual adjustment to the situation will
geometry of the femoral condyles (Fu el aI., 1994) be reflected either b~: stretching of the ligaments
(Fig. 7-6, B-D). and other supporting soft tissues or by the impo-
Frankel and associates (1971) determined the in- sition of abnormall~' high pressure on the articu-
stant center pathway and analyzed the surface mo- lar surfaces.
tion of the tibiofemoral joint from 90· of Ilexion to Internal derangements of the libiofcmoraljoint
Full extension in 25 normal knees; tangential glid- may interfere with the so-called screw-home
ing was noted in all cases. They also determined the mechanism, which is external rotation during ex-
instant center pathway for the tibioFemoral joint in tension of the tibia (Fig. 7-9). The tibiofemoral
30 knees with internal derangement and found ~ioint is not a simple hinge joint; il has a spiral, or
that, in all cases, the instant center was displaced helicoid, motion. The spiral motion or the tibia
from the normal position during some portion of about the femur during flexion and extension re-
the motion examined. The abnormal instant cen- sults from the anatomical configuration of the
CHAPTER 7 •
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- Abnormal instant center pathway for a 35-year-old man
eate contact points at the tibia. C. Pure rolling of the femur with a bucket-handle derangement. The instant center
on the tibia with knee flexion. Note that both the tibia and jumps at full extension of the knee. Adapted from Frankel,
the femoral contact points change as the femur rolls on the VH., Burstein, A.H., &- Brooks, D.B. (1971). Biomechanics of in-
tibia. Also note that with moderate flexion, the femur will be~ ternal derangement of the knee, Parhomechanics as determined
gin to roll off the tibia if surface motion was restricted to rol- by analysis of the instant centers of motion. J Bone Joint Surg,
ling. D, Actual 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
~-L'-JI Extension
(Fig 7-10). 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- \'1
ciale ligament. Belween 60 and 90° of flexion, '.,
the rotational axis moved anteriorly again (Fig ... External
rotalion during
7-11). This study showcd thaI lhc rolational axis extension
remains approximately in the area between the
two cruciate ligaments. Any change of direction
and tension of the cruciate ligaments and sur-
rounding soft tissue may affect the movement Screw·home mechanism of the tibiofemoral joint. During
and the 'location of the longitudinal tibia axis knee extension. the tibia rotates externally. This motion is
of rotation and thcrcby affccl joint load distri- reversed as the knee is flexed. A. Oblique view of the fe-
mur and tibia. The shaded area indicates the tibial plateau.
bution.
solid line axis for knee flexion and extension, dotted lines
A clinical tcst. the Helfet test, is often useel to de-
internal and external rotation axis of the tibia during flex-
termine whether external rotation of the tibio- ion and extension. 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
Distraction Compression medial half or the patcll" (Fig. 7-121\). The knee is
A B then extended fully and the movement of the tibial
tuberosity is obsel\:cd. [n a normal knee. the tibial
tuberosity moves laterally during extension and
Surface motion in two tibiofemoral joints with displaced "Iigns with the latent! h"lf or the patella at I'ull ex-
instant centers. In both joints, the arrowed line at right an· tension (Fig. 7-128). RotatOl')' motion in a nOl'mal
gles to the line between the instant center and the knee may be as great as hair the width or the
tibiofemoral contact point indicates the direction of dis- patella. In a deranged knee, the tibia may not rotate
placement of the contact points. A. The small arrow indi- externally during extension. Because of the altered
cates that with further fIeldon. the tibiofemoral joint will surface motion in such a knee, the tibiofemoral
be distracted. B, With increased flexion, this joint will be joint will be abnormally compressed if the knee is
compressed. forced into extension, and the joint surfaces may be
d.amaged.
CHAPTER 7 • 8IC'ME:crlA~IIC5
ro
·x 20
'r"o
:0
i=
ro 10
-0
>- Kinetics
!
o o 15 30 45 60 75 . 90
Kinetics involves both static and d,vnamic analy-
sis of the forces and moments acting on a joint.
IL - Knee Flexion Angle
Statics is the stud~/ of the forces and moments act-
ing on a body in equilibrium (a body' at rest or
jIBm'------- moving at a constant speed). For a bod)' to be in
The total tibial axial rotation (y-axis) plotted against the equilibrium. two equilibrium conditions must be
magnitude of knee flexion (x-axis) in fresh-frozen speci- met: force (translator:v) equilibrium, in which the
mens tested under unloaded axial conditions, The magni- sum of the forces is zero, and moment (rotatory')
tude of tibial rotation was below 9" at A" of knee flexion. equilibrium, in which the sum of the moments is
Maximum rotation (31.]0) was measured between 30 to 45" zero. Dynamics is the study of the moments and
of knee flexion. Reprinted with permission from Matsumoto, forces acting on a body in motion (an accelerating
H., Seedhom, B.B., Suda, Y, et al. (2000), Axis of tibial rotation or decelerating body), In this case, .the forces do
and its change vi/ith flexion angle. Clin Orlhop, 371, 778-182.
not add up to zero, and the body displaces and/or
the moments do not add up to zero and the bod:v
Knee flexed 90c Knee lully extended
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
.,~
~
(U '\
- - - -30'-90"
I
I
Inferior
20' 45' 90'
Superior
---120" ,
Lateral Medial
I
Inferior
135'
IiR'm A B
_
;0..
A, The position of the patella at different ranges of knee Functional anatomy of the patellofemaral joint. J 80ne Joint Surg,
flexion motion. a, Contact areas during different degrees of 58B. 287; and from Helme. H.I (1990). Biomechanics of the
flexion. Beyond 900 of flexion, the patella rotates slightly parellofemoral joint and its clinical relevance. Clin Onhop. 258.
outwards. Adapted from GoodfelJo'J'l, I. Hvngerford, D.5., & lin· 73-85,
I
•
del, M (1976), PateJlofemoral joint mechanics and pathology. I.
rotates around an axis perpendicular to the plane In this and subsequent chapters. the discussion of
of the fOl'ces producing the moments. Kinetic stalics and dynamics of the joints of the skelelal sys-
analysis allows one to determine the magnitude of tem concerns the magnitude of the forces and mo-
the moments and forces on a joint produced by ments acting to move a joint about an axis or to
body weight, muscle action, soft tissue resistance, maintain its position. It does not lake into account
and externally applied loads in any situation, ei- Ihe deforming effect of Ihese forces and moments
ther static or dynamic, and to identify those situ- on the joint structures. This effect is indeed present,
ations that produce excessively high moments or but the discussion is not within the s~ope of this text.
forces.
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
Static analysis may be lIsed to determine the forces drawn (Calculation Bo,,,; 7-1). I":'nlrn all rorces acting
and moments acling on a joint when no motion on thl..: I"rct..··body. the three main coplanal- I"o('(,:(:s an;
takes place or at one instant in time during a dy- idenlified a~ the ground rL'action force (equal to
namic activity such n5 walking, running, or lifting body weight I), the tensile force through the patellar
an objecl. 1t can be performed for any joint in any tcndon exel"ted h.v llw quadriceps Illust..:ll' , and th\.~
position and under any loading configuration. In joint reaction force on the tibial plateau. The ground
such analyses, eHher graphic or mathematical n.:action force (\rV) has a known m<'lgnitude (L'qu;;llto
methods may be lIsed to solve for the unknown body wt..'iglu). S~IlS('. line or <'lpplicalion. and poinl or
forces or moments. application (poii'll or contact between the foot and
A complete static analysis involving all moments the ground). The palellnr tendol1 force (P) has a
and all forces imposed on a joint in three dimensions known SC'IlSL' (awa.'; from the knee joint), lint..' of ap·
is complicated. For this reason. a simplified tech- plicaliun (along lhe patellar t('ndon). and point or
nique is oflen lIsed. The technique utilizes a frec- application (point or insertion of thc patellar tendoll
body diagrarn and limits the analysis lo one plane, to on till' tibial tulx.·rosit."), but an unknown l1lagni~
the three main coplanar forces acting on the frcc- tude. The joint n:action force (J) has a known poilU
body. and ro the main moments ~cting about the of application OJl the slIrl"acL' or the tibia (the COJ1lact
joint under consideration. The minimum magni- point of tilL' joint surfaces betw(.'en the tibial and
tudes of the forces and moments arc obtained. femora! cond,vlc:s, estimated from a roelllgenogram
When the simplified Free-body technique is used or the joint in the pn)!x~r loading configuration), but
to analyze coplanar forces, one portion of the body an unknown magnitude, sense. and line of applica-
is considered as distinct rrom the entire bod.\', and tion. Using \'L'ctors cakuh\lions <:\11('\ triangles laws
all forces acting on this free-body arc identified. A the joint rL'action force (.1) and thl' pall.'lIar tendon
diagram is drawn of the free-body in the loading sit- force (P) call be c,dculated (Calcul"tion Bo\ 7-1)
uation (0 be analyzed. The three principal coplanar It call bt..· seen thaI the main musck forct..' has a
forces acting on the free-body are identified and llluch gre<.ltL'1' inlhICIll:L' on the magnitude of" the
designaLcd on the free-body diagram. .joint reaction force than dot..·s the -~round !"(.'action
These forces afC designated as vectors if four force produced b." bod~· \vcight. Note lhat, in this ex-
characteristics are kno\vn: magnitude, sense. line of amplc (Calculation Box 7·1), only til(' minimum
application, and point of application. (The tcrm '"di- magnitude of the joint rt..'~lction force has been
rection" includes line of application and sense.) If calculated. If other muscle I"oret-'s arc considered.
the points of application for allthrec forces and thc such as tht..' foret..' produced b~' tht..' contraction of th~
directions for two forces arc kno\vn, all remaining halllslring Inusc!es in stabilizing the knee, the jClint
characteristics can be obtained for a force equilib- reaction force inCl·cast..·s_
rium situation. \Vhen the free-body is in equilib- Th\.' ne:'.;t Slt.·p in the static analysis is ~\I1;:d."sis of
rium, the three pl-incipal coplanar forces are con- the moments acting around the centcI- of motion 01"
current; that is. they intersect at a common point. In the libiofcrnoral joint with the knee in the same po-
other words, these forces form a closed system with sition and lht..' loading. configuralion shown in Cal·
no resultant (i.e., their vector sum is zero). For this culation Bo:'.; Figure 7·1-1. The 1ll01llL'11I <'lIlal.\·sis is
reason. the line of application for one force can be Llsed to cstimak' the minimulll ll1agnitudL' of the
determined if the lines of application for the other mOIl1L'nt produced through the patellar h:ndon.
two forces arc known. Once the lines of application which counterbalances the 1l10ll1Cnt on the lowcr leg
for all IIwee forces are known, a triangle of forces produced b.'; the weight or the hod." as the subject
can be constructed and the magnitudes of all three ascends stairs (Calculation Box 7·2).
forces can be scaled from this triangle.
An example will illustrate the application of the
simplified Ii'ee-body techniquc for coplanar forccs to
the knee, In this case, the technique is lIsed to esti-
mate the minimum magnitude of the joint reaction lin C:lSl', the ground I"l'~ll"lillll rurn' is ;u.::lu;t1ly L'qllallo hody
lhi:,
force acting on the tibiorcmoral joint of the weight- \\"L'idltmintl:- (he \\"..::i!..:hl of till' IO\\"L'r k·t:. BL'l";III:-l' tit...· \widll of
the 'it'Hwr k~ is lllillilT~;ll {1L'SS (hall Olli.' 1:'l1(h or Ihl' bOtl\-), i( CIII
bearing leg when the other leg is lifted during stair l.k' di,.. rl·~aranl. ;llld the li~url' for tlll:tl hod\- \\"l'i!.!hl l\\·U bl' tui-
climbing. The lower leg is considered as a free-body. lizL'd ill Illl' l·akul:lIion. . .-
CHAPTER 7 • BIOMECHANICS OF T~~:~,~E~~Y;;!~~iO
~
!, Free-Body Diagram of the Knee Joint
Force P .., The three main coplanar forces acting on the lower leg:
~ ... Force J
I ,..
\.\ .<
;':" Known: Point of applicalion
Ground reaction iorce (W). patellar tendon force (P), and joint
Known:
Sense
\Q', • ~ \
UnknO'.·',n: Magnitude
Sense
Line of application
reaction force (J) afe designaled on a free-body diagram of the
lower leg while climbing stairs (Calculation Box Fig 7-1·1),
Line of application \\
Point of application .,•..,-..__ ....\ "
Unknown: Magnitude ". -'. \.
<\.
',-.\ "-
I
'. \
I /\J
:i~
· o:__ ~~
I---==~-r"'iKnown: ~- /'
Magnilude :1
Force W Sense
Line of application
;1
!Point of application
.
I
.' Force J Because the 100\'cr leg is in equilibriulll, the lines of application
" "'i
v~ .:.~
l~~:\
T ibialemoral
for all three forces intersect at one point. Because the linesof
application for [I,.VO forces (Wand P) are known, the line of ap·
II
j
Force P \ ( \ ..... i contact point plication for the third force (;) can be determined. The lines of
\~ \. application for forces Wand P are extended until they jnter~
,, '.'.
II
.\:;....
\\........
'.
,
\
\
sect. The line or application for J Gill then be drawn from its
point of application on the tibial surface through the intersec· j
!
tion point (Calculation Box Fig. 7-1-2).
Intersection ~\
pOint~
I
!
I -----·-·-~·=::::·:"~~W-1J.-·'""'---~---- I
Now that the line of application for J has been determined, it
I
is possible (0 constru([ a triangle of forces (Calculation Box Fig.
7-1 ~3). First, a ve([or representing W is drawn. Next. P is
I
I
i
I \'.,, Force P
drawn from the head of ve([or W. Then, to close the triangle, I
!
'.
'. ,, 3.2W force J is drawn from rhe head of vector W. The point at which
Force J
'.
'. . ,,
....
'.
\,
,,
forces P and J intersect defines the length of these vectors.
Now that the length of all three vectors is known, the magni· IiI,
4.1W '.
'. ,, tude of forces P and J can be scaled from force W, which is
'.
, equal to body weight. It is determining the number of limes
. . .J
'.
the length of force W can be aligned along the' force P and J,
Force W 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).
The fleXing moment on the lower leg is the product of the
\\ weIght of the body:- (W, the ground reaction force) and its
\/\
\ fever arm (a), 'Nhich is the perpendicular distance of the force
Force P \ W to the center 0; motion aT the tibiofemoral joint. The coun-
terbalanCIng extending moment IS the product of the quadri-
ceps muscle force through the patellar tendon (P) and its lever
arm (b), Because tile lo""er leg is in equilibrium. the sum of
these two moments must equal zero (~M = 0).
In this example. the counterclockwise moment is arbitrarily
designated as positive (W x a - P ~< b = 0). Values for lever
arms a and b can be measured from anatomical specimens or
on soft tissue imaging or fluoroscopy (Kellis & Baltzopoulos.
').
1999; Wretenberg et aI., 1996), and the magnitude of W can
be determined from the body weigt1t of the individual. The
magnitude of P can then bE' found from the moment equilib·
:::M = 0
num equation:
p~_.-
W;.: a
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
Although estimations of the magnitude of the mass moment of inertia of the body part. (The mass
forces and moments imposed on a joint in static moment of inertia is the unit used to express the
situations are llseful. most of Ollr activities are of a amount of torque needed to accelerate a body and
dynamic nature. Analysis of the forces and mo- depends on the shape of the body.) (For more in-
ments acting on a joint during motion requires the depth studies of dynamics, sec Ozkaya & Nordin,
use of a different technique for solving dynam,ic 1999.)
problems. The steps for calculating the minimum magni-
As in static analysis, the main forces considered tudes of the forces acting on a joint at a particular in-
in dynamic analysis arc those produced by body stant in time during a dynamic aClivity arc as follows:
weight, muscles, other soft tissues, and externally
applied loads. Friction forces arc negligible in a nor- I. The anatomical structures arc identified: defi-
mal joint and thus not considered here. In dynamic nitions of structures. anatomical landmarks,
analysis. two factors in addition to those in static point of contact of articular surface. and lever
4\rl11s involved in the production of forces for Th..: torque is not only a product or the mass mo-
the biol11cchanical analyses. ment of inertia and the angular acceleration of the
2. The angular acceleration or the moving body body part but also a product or the main Illuscle
part is determined. force accelerating the body part and the perpendic-
3. The mass monlent of inenia of the moving ular distance of the force from the center of motion
bod~" part is determined. of the joint (level' arm). 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- d is the perpendicular distance expressed in me~
tic analysis. leI'S (01).
Because T is known and d can be measured on
In the first step, the structures of the body in-
the body part from the line of application o[ the
volved in producing forces on the joint are identi-
force to the center of motion of the joint, the equa-
fied. These are the moving body part and the main
tion can be solved fOl" F. vVhcn F has been calcu-
muscles in that body part that arc involved in the
lated, the remaining problem can be solved like a
production of the motion. Great care must be taken
static problem lIsing the simplified free-body tech-
in applying this first step. For example, the lever
nique to determine the l11inirnum magnitude of the
arms for all rnajor knee muscles change according
joint reaction force acting on the joint at a certain
to the degree of knee Ilexion and gender (\Vreten-
instant in time.
berg et aI., 1996).
A classic example will illustrate the usc of dy~
In joints of the extremities. acceleration of the
narnic analysis in calculating the joint reaction force
body part involves a change in joint angle. To
on the libiofemoral joint at a particular instant
determine this angular acceleration of the moving
:f during a dynamic activity (c.g., kicking a football)
body part, the entire movement of the body part
(Frankel & Burstein, 1970). A stroboscopic film of
is recorded photographically. Recording can be
the knee and lower leg was taken, and the angular
done with a stroboscopic light and movie camera.
acceleration was found £0 be maximal at the instant
with video photogrummetry, with Selspot systems,
the foot struck the ball: the lower leg was almost ver-
with stereophotogrammctry, or with other methods
tical at this instant. From the film. the maximal an·
(Gardner et aI., 1994; Ramsey & Wretenberg, 1999;
gular acceleration was computed to be 453 !"/sec!..
\Vintel~ 1990). The maximal angular acceleration for
From anthropometric data tables (Drillis et aI.,
a particular motion is calculated.
1964), the mass momenl of inertia for the lo\ver leg
Next, the mass moment of inertia for the moving
was determined to be 0.35 Nm sec~. The torque
body part is determined. Anthropometric data on
about the tibiofemoral joint was calculated accord-
the body parl can be used for this determination.
ing to the equation; torque equals mass moment of
As calculating these data is a complicated pro-
inertia times angular acceleration (T = (0),
cedure, tables are commonly used (Drillis et aI.,
1964). 0.35 Nm sec' x 453 rlsec' = 158.5 Nm
The torque about the joint can now be calculated
After the torque had been determined to be 158.5
using Newton's second law of motion, which stales
Nm and the perpendicular distance fran) the sub~
that when motion is angulat~ the torque is a product
ject's patellar tendon to the instant center for the
of the mass moment of inenia of the body part and
tibiofemoraljoint had been found to be 0.05 m, the
the angular acceleration of that part:
muscle force aCling on the joint through the patellar
T = Ie< , tendon was calculated using the equation torque
where equals force times distance (1' = Fd),
T is the torque expressed in newton meters (Nm) 158.5 Nm = F x 0.05 m
I is the mass Illoment of inertia expressed in 158.5 Nm
newton meters x seconds squared ( m sec~) F .= -=--=--
0.05 m
a is the angular acceleration expressed in radians
per second squared (rlsec'). F = 3170 N
,
'i; :
.. , .'"
Thus, 3,170 N was the maximal force exerted by late s(;Jncc phase just before loe-ofr. This force
the quadriceps muscle during the kicking motion. ranged from two to four times body weight. varying
Static analysis can now bt: performed to deter- among the subjects tesled, and was <:Issociatcd with
mine the minimum magnitude of the joint reaction contraction of the gastrocnemius muscle. In the late
force 011 the tibiofcrnoraI joint. The main forces on swing phase, contraction of the hamstring muscles
this joint arc id':lltificd as the patellar tendon force resulted in a joint reaction force approximately
(P). Ihe gravilaliomtl force of Ihe lower leg en, and equal to bod)' weight. No significant dilTcrcnce was
the joint reaction force (J). P and T arc known vec- found between the joint reaction force magnitudes
tors. J has an unknown magnitude. sense, and line for men ancl women when the values were normal~
of application. The free-body technique for three izcd by dividing them by body weight.
coplanar forces is L1sed to solve for J, which is found Andriacchi & Sirickiand (1985) sludied Ihe normal
10 be only slighrly lower Ihan P. moment patterns around the knee joint during level
As is evident from the calculations, the two main walking for 29 healthy volunteers (15 women and 14
factors that influence the magnitude of the forces on men wilh an average age of 39 years). Figure 7-16
a joint in d)'namic situations are the acceleration of depicts the flexion-extension, abduction~adduction,
the body part and its mass moment of inertia. An in- and internal-external moments during the stance
crease in angular acceleration of the body part will and swing phase of level walking. The moments are
produce a proportional increase in the torque about normalized (0 the individual's body weight and
the joint. Although in the body the mass moment of height and are presented as a percentage. The flexion~
inertia is anatomically set, it can be manipulated ex-
tenl~l)Jy. For example. it is incrc.:ascd whcn a weight
boot is applied (0 the foot during rehabilitative ex- 4
en en
ercises of the extensor muscles 01" the knee. Nor- I I
./\ ,/\
times greater than it would be without the bool. u.
Dynamic analysis has been L1sed to investigate
the peak magnitudes of the joint reaction forces, .' /-..., l \
muscle forces, and ligament forces on the tibio~
femoral joint during walking. Morrison (1970) cal-
culated the magnitude of the joint reaction force
\/ \! \V,..' ' ' 1\
' ' ., . .,-.
transmiucd through the tibial plateau in male and o1~O:::O-c.._-'-'..J·~---~"'6~O~--'-"'------'~--:1-:'OO
female subjects during level walking. He simultane~ Percentage of cycle
ously recorded muscle activity elcctromyographi~
- Joint reaclion force
cally to determine which muscles produced the
..... Hamslrings
peak magnitudes of this force on the tibial plateau
HS =. Heel strike . - -- Quadriceps lemoris
during various stages of the gait cycle (Fig. 7-15).
TO =.: Toe-ofl -- .. Gastrocnemius
Just after heel strike, the joint reaction force
ranged from two to three times body weight and
\vas associated with contraction of the Iwmstring
muscles, which have a decelerating and stabilizing Joint reaction forces expressed as body weight transmitted
effect on the knee. During knee llexion in the begin- through the tibial plateau during walking. one gait cycle
ning of the stance phase. the joint reaction force (12 subjects). The muscle forces producing the peak magni-
waS approximately lWO rimes body weight and was tudes of this force are also designated .. Adapted from
associated with the contraction of the quadriceps Morrison, lB. (1970). The mechanics of the knee joinr in re/a-
rion lO normal w<lfking. J Biomech, 3, 51.
muscle, which acts 10 prevent buckling of the knee.
The peak joint reaction force occUlTed during the
•
.. '!'·_V.-.c__
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- A_ Flexion-Exlension
ment amplitude has been reported at increased Moment Pallerns
(Exlernal)
walking speeds (Andriacchi & Strickland. 1985;
Holden et aL. 1997). An increase in the production It Pattern 1
3.0 I
of adduction knee joint moment during stair climb-
ing compared with level walking was reported b.\' Yu
¥ c
a 2.0 I
>~ 'xID I
et al. (1997). ;!: u:: 1.0
During the gait cycle, the joint reaction force "'
rL 0
shifts from the medial to the lateral tibial plateau. In c I
.s0 a 1.0
the stance phase, when the force I'caches its peak , '00
c
I
2.0 I
value, it is sustained mainly by the medial plateau '"c w'"
ID X
3.0
I
(adduction moment); in the swing phase, when the
i. force is 111inimal. it is sustained primarily by the lat·
'" - Stance --l-Swing--
~
II I \\\ would therefore protect the articulating surfaces
l \\
...
III
III
Normal
tIl
I tt tt
...
Menisci removed
while avoiding 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 90° of knee flexion. The imag·
ing technique allowed for both standing (weight-
bearing) and sitting (non-weight-bearing) and was
Stress distribution in a normal knee and in a knee with the performed simultancollsl~t in the sagittal and trans-
menisci removed, Removal of the menisci increases the verse plane. Figure 7-18 shows the movements in
magnitude of stresses on the cartilage of the tibial plateau the transverse plane of the medial and lateral meni-
and changes the size and location of the tibiofemoral con· sci expressed in millimeters (mean) from full exten-
tact area. With the menisci intact, the contact area encom-
sion to 90° Ocxion of knee joint motion. Movement
passes nearly the entire surface of the tibial plateau. With
was significantly greater in weight-bearing than in
the menisci removed, the contact area is limited to the
non-\Veigllt~bearing for both lateral and medial
center of the tibial plateau.
menisci. The contributions of the menisci art: lhel-e-
fore not only to protect the articular cartilage and
subchondral bone but also to contribute aClively to
knee joint slabilit~:.
magniwde of the stresses on the cartilage and sub-
chondral bone at the ceiller of the tibial pl~llcau but
STABILITY OF THE KNEE JOINT
also diminishes the size and changes the location or
the contact area. Over the long term, th~ high The key to a healthy knee joint is joint slability. The
stresses placed on this smaller contact area may be osseous configuration, the menisci, the ligaments.
harmful to the exposed cartilage, which is usually the cnpsulc, and the muscles surrounding the knee
soft and fibrillated in that area. The menisci are joint produce joint slability (Fig. 7-1, A & B). If any
9.5 6.3
0
, "-
,
I f
\
3.3r
Flexion
3.6
I
N
i
\
\
\
,
1 3 .4
I
,, \
,
90
\
-J_- ., . I
•
3.9
Post
"-
-L_-
5.6
"- , -4-
3.8
Post
,
-~-
4.0 -- ,/
I
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·
i. A
J;_
30·year-old male suffered an external rotation trauma
in his right knee while downhill skiing. Following the
lion. 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
~~;,: trauma, he experienced sharp pain, progressive joint effu-
and daily activities such as gail and stair climbing. To com·
,~,iqn,_and subjective instability. ,During careful examination pensate for the ACL deficiency, the patient altered his gait )1
Ii' ,by a specialist, an anterior positive drawer test was dlag-
patterns, presenting quadriceps avoidance gait to prevent
<";'n,osed, and the Lachman test and pivot shift test were I
': found positive. An MRI confirmed the ACL rupture (Case
the anterior translation of tl1e tibia when the quadriceps j
,,1~
contracts at the midstance phase of the gait (Andriacchi &
j' 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 a progressive structural alteration of the knee. A pri-
The patient went for surgical treatment. The MRI below .,
(Case Study Fig. 7-1-2) shows the ACL status after patella
mary objective of the treatment is the prevention of fe-injury of
bone-tendon-bone autograft was performed 10 months
the knee in the hope of preventing additional ligamentous
post-trauma.
of these structures arc malfunctioning or disturbed, approximately 55% of the applied load at full exten-
knee joint instability will occur. The ligaments arc sion. The role of the lateral collateral ligament in-
t.he primm)' stabilizer for anterior ancl posterior creases with joint flexion as the posterior structures
translation, varus and valgus angulation, and inter- become lax. The 1l1edial collateral ligament (superfl-
nal and external rotation of the knee joint (Case cial portion) is the primary restraint to valgus (ad-
Study 7-1), duction) angulation and resists 500/0 or the external
F,; et aL (1994) sUlllmarized the functions of the valgus load. The capsule. the anterior and posterior
knee ligaments, The ACL is the predolllinant re- cruciatc ligaments, share the remaining valgus load.
straint to anterior tibial displacement. The ligament Internal rotational laxity seen in the 20 to 40° range
accepts 75% or the anterior force at full extension of knee nexion is restrained bv the medial collateral
and an additional 10% (up to 90") of knee nexion, ligament and the ACL Finally, external rotation lax-
The posterior crudate ligament 1S the primary re- ity seen in the 30 to 40° range of knee flexion is re·
straint to posterior tibial translation: il slIstains 85 strained by the posterior cruciate ligaJllcnt at 90° of
to 100% of the posterior force at both 30 and 90" of knee Ilexion,
knee flexion. The latera) collateral ligament is the In vivo measurement or the normal ACL has been
primary restraint to varus angulation and it resists performed by Beynnon et aL (1992), They placed a
."1'~~:irkRf:ti'810MECHANICS OF JOINTS
strain transducer arthroscopic'll)y in the ACL. The tendon and it contributes the least to the length of
results showed that strain in the ACL was related to the quadriceps muscle force lever arm (approxi.
knee Oexion (with the most strain occurring ncar mately 10% of the total length). As the knee is ex-
full extension) and increased with quadriceps con- tended. the patella rises from the intercondylar
traction. Less strain occurred with co~conlraclions groove, producing significant anterior displacement
of both the quadriceps and the hamstring muscle of thc tcndon. Thc length of thc quadriccps force
groups and at greater degrees of knee flexion. This lever arm rapidly increases with extension up to 45°,
indicates that muscle contraction and co-contraction at which point the patella lengthens lhe lever ann .;;; .
contribute to the stabilitv of the knee joint bv in- by approximately 300/0.
crcasing thc stiffncss of the joint. Kwak et al. (2000) With knee extension bc"ond 45°, thc Icngth of thc
studied in vitro the effect of hamstrings and iliotib- lever arm is diminished slightly. \,Vith this decrease
ial band forces on the kinematics of the knee. At var- in its lever arlll, the quadric.:cps muscle force must
ious knee Oexion angles, human knee specimens increase for the torquc about the knee to rcrnain the
were tested with different muscle-loading patterns. same. In an in vitro study of normal knees. Licb and
The quadriceps muscle force was always present, Perry (1968) showcd that thc quadriccps muselc
and the test was performed with and withollt han)- force required to extend the knee (he last 15° in-
string muscle force and with and without iliotibial creased by approximately 60% (Fig. 7-19).
band force. \AJith loading of simultaneous quach·i. If thc patella is removed from a knec, the I)atelhu-
eeps and hamstring muscle force. the tibia trans- tendon lies closer to the center of motion of the
latcd posteriorly and rotatcd externally. The effecI tibiofemoral joint (Fig. 7·20). Acting with a shorter
""" similar for thc iliotibial band simulated forces lever arm, the quadriceps llluscle must produce
but thc cffcct was smallcr. even more force than is normnlly required for a cer~
Many in vitro studies suggest that the ham- tain torque about the knee to be maintained during
strings are important anterior and rotational stab.i-
lizers of the tibia. In vivo studies have shown that
co-contractions of the quadriceps and hamstring
75
muscles arc highly present in 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).
""','
, ,.
~~=====
knee is almost directly above the center of rotation
------------- "- \\
\
~-
---------
Instant center
of tho patellofemoral joint. As knee Oexion in-
creases, the center of gravity shifts further away
from the center of rotation. thcrcb.y greatly increas~
1
1"
ing the Ilexion moments to be counterbalanced by
the quadriceps musclc force. As the quadriceps I:"
Normal muscle force rises. so docs the patellofemoral joint ~,
-L=--
don force. The angle of these two force compo-
nents becolTlCs more acute with knee flexion, in-
creasing the magnitude of the patellofemoral joint
reaction force (Calculation Box 7-3). Reilly and
Martens (1972) dctcrmincd the magnitude of the
After Patellectomy
patellofcmoral joint reaction force during several
dynarnic activities involving val·ying amounts of
knee flexion. During IC\'e1 walking, which requires
Quadriceps muscle lever arm (represented by the broken relatively little knee flexion, the reaction force was
line) in a normal knee and in a knee in which the patella low. The pcak valuc. ill the middle of the stance
has been removed. The lever arm is the perpendicular dis- phasc when flexion was greatest, was one-half
tance between the force exerted by the quadriceps muscle body weight.
through the patellar tendon and the instant center of the
The joint reaction forcc was much greater during
tibiofemoral joint for the last two degrees of extension.
activities that require greater flexion. During knee
The patellar tendon lies closer to the instant center in the
knee without a patella. Adapted from Kaufer. H. (1911). Me-
bends to 90'. this force reached 2.5 to 3 times body
chanical function of the parella. J Bone Join! Surg. 53A. 1551.
wcight with the knee Oexed 90' (Fig. 7-21). Through-
3000
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
I
p I
I
I
I
10;0 N ---------j·::-;285_61
J ~ 11652703
I Tibio femoral flexion 90"
J ~ 1285_57
Calculation Box Figure 7·3·1A. Calculation Box Figure 7·3-1B.
-------_._---- --------_..._------_._--- --_._.--- -._-----------
contact surface area increases in size somewhat
(Goodfellow et aI., 1976). To some extent, this in-
'" Extensor Mechanism Injury crease in the contact surface with knee nexion com·
pensates for the larger patellofemoral joint reaction
30-year-old basketball player had a forceful knee flex-
force, 11' a tight iliotibial band is present, the
ion while coming down from a jump. A strong eccen-
patcllofemoral joint force may shih laterally, caus-
of the quadriceps produced abnormally high
ing abnormal patellar kinen1atics and load-bearing
" ,0n",lp loads in the patella, leading to a fracture at the infe-
(Kwak et aI., 2000),
In this case, the patella fracture occurred because
The quadriceps muscle force and the torque
forces of the quadriceps overcame the osseous
around the patellofemoral joint can be extremely
of the patella. The weakest link was the patella.
high under certain circumstances, particularly
picture shows a fracture at the patella accompa-
when the knee is flexed-for instance. when a
f)ied by a significant fracture separation that resulted from
basketball plaver suffers a patella fracture as a
the quadriceps traction force.
result of indirect forces played by an eccentric
Because of the fracture. the extensor mechanism is un-
contraction of the quadriceps (Case Study 7-2).
=;'. able to function and extend the knee. It will directly affect
Another extreme situation was observed during a
the stability of the pate!lofemoral joint and the distribu-
stud~; of the external torque on the knee pro-
Co;
Summarv
1 The knee is a two-joint structure that is com-
posed of the tibiofel11oral joint and the patel1o-
femoral joint.
?:>: In the tibiofemoral joint, surface motion oc-
curs in three planes simultaneously but is greatest
out knee bend, the patellofemoral joint reaction by far in the sagillal plane. In the patellofemoral
force remained higher than the quadriceps Illuscle joint, surface Illotion occurs simultaneously in two
force. During stair climbing and descent, at the point planes, the frontal and the ll-ansverse, and is greater
when knee flexion reached a maximum of approxi- in the frontal plane.
mately 600, the peak value equaled 3.3 times body 3 The surface joint motion can be described with
weight. the use of an inslant center technique. vVhen per-
When the knee is extended, the lower part of the formed on a non11al knee, the technique reveals the
patella rests against the femur. As the knee is flexed following: the instant center for sllccessive intervals
to 90°, the contact surrace between the patella and of motion of the tibiofcmoral joint in the sagittal
femur shifts cranially in vivo and under weight- plane follows a semicircular pathway, and the direc-
bearing conditions (Komistek et aI., 2000). The tion 01" displacement of the tibiofemoral contact
BICIME:CHANICS OF JOINTS
Kroelller. K.I-I .. M;llTas. \V.S ...\1cGlothin. J.D .. 1..'1 al. (1990). Reilly, 0.1'. &. "'Iancus. ,\'1. (19i2). E.\:pel'imclll;.'I1 ;Inalysis of
On the IlH.'ilsun:nh.'nts of human stn:ngth. 11111 Imll/strial thl' qlwdriceps musclc force and patcllof"moral joint reac-
rr"OIUl111ic!I·. 6. 199-210. tion force for variolls 'lctivitic-s. :\ew Orrhop Scalld. 43.
Kwak~ 5.0.. ,\hmad, C.S .. Gardner. T.R .. 1..'1 al. (2000). Ham· 126.
Sirings and iliotihial forces affect knee ligamellts and con- Reulc;1ux. r. (1876). In The KillCl1lalio uf Jlachillc:ry: OutlillC
tact palh:rn.l O,.,ltop ReS. IS, 101-IOS. of II Theory of .'-1achillcs. London: ~l[lcmi lIan.
LaTllorc;IU.\:. L.. (1971). Kinematic IllC:lsurt:TllcnIS in Ihl.· stlldy Sccdhom. B.s.. Do\\'son, D., &. Wright. V. (19i4). The 10;1d-
of hurn:tll w;:lIking. Biomcch;lnics Lah. Uni\'t.'rsiIY of (;tli- bl:'aring function of Ihl' menisci: r\ prdiminary study. III
forni:l, S'lll rr~ncisco. B//II Prostlteth' Res, Sp1971, 10-15. 0.5. lngwl'rsl'n, ct :II. (Eds.), Thc h//CC loill/: f?en.'1/t .'lel-
L:ltlbenth;d. !\..N .. Smidt, G.L., & !\.ctLdkamp, D.B. (1971)."\ \'(l/ICC.~· ill Basic Research (wd Clinica! .'lsp(~rlS (I'p. 37-42).
quantitative analysis of knee motion during activities of r\mS!l:rdam: Exccrpta Medica.
dail\' living. I'II\'S Til!!,., 52. 3-L Seh'ik. G. (1978). Roentgcn slC'l'cophotogr.lllllllclry in Lund,
LC\'I.·ns: '\,S"Yllll1l~lI1. V.T., & Blosser. J.'\. (1948). Trans\'crsc Sweden. In .-\.M. Coble!l'l. & R.E. j·Jl'lTon (Eds.), Applica-
rot;ltion of the seglll"fHs of the lower cXlr('mity in locomo- /jolls or flUlIltll1 Biosten:mJII..' lru:s. fIroe 81'/£ (166) (pp.
tion, 1 BOlli! 10iut Sur..!.:. 30A. S59. 184-189).
Licb. FJ. ~ I)erry. J. (I968). Quadriceps function. An ;UHllOI1l- Sdvik, G. (1983). Roentgen stcrl.'ophotogramllleiry in 01'-
ical ;lnd mcch:lllical sludy using ;lIl1putaled limbs. 1 Bmw thop;:ledics. In R.E. HelTon (Ed.), BioslereOluetric:s 'S?_
loil/t Surg, 50~\, 1535. Pro" SP/E (36/) (pp. li8-18S).
LiIH.bhl, 0 . .& Mm·in,.-\. (1967). TIJ(,' 1lH.'chanil':-; of l'xt...'nsion Smidt. G.L. (1973). Biomechanical :-nnlysis of knee nexion
of the kncc joint. .·\eta 01'1/1011 Scaml, 38, 226. ;lUd c.\:wnsioll_ 1 Bioll/celt, 6. 79.
~;:;II'kholr. K., Gr:lff-R;l<lford, f\., &. Amstul'I.. H. (19iS). In \'i\'O Solomonow, M. &. D'r\mbrosia. R. (1994). Nellr:!1 l'1'f1ex ;Ircs
knce slllbility. 1 BOlli' 10ill/ SlIl'g. 60.'1. 664-674. ;tnd muscle control of knl'c sl;\bilil~' :lIld motion. In W.N.
~laISllmot(), 1-1.. Si..'i..'dholll, B.B.. Suda. Y., C"t <:II. (2000). Axis of Scott (Ed.), The Knce (pp. 107-120). New York: Moshy. .,
;.J
tibial rot.Hioll and its change with flcxion angle, C/ill Or· Vl'di, V., Williams, A" Tennant, S.L ('I :II. (1999). Mcniscal .j
. '),Op, 371. 178-182.
',\l<1ltl1(:\\,s, L.S .. Sonstc:gard. D.A .. &. I-lenke, .I.A. (1977). Lond
rnon::mcnt. An ill-vivo study llsing dynamic i\-lRL J BO/lc
loim SlIrf:!.. 8IB(J), 37-41.
.,1
h"arillg characterislics of lhe palellofemor;d joint. ,·\era Winll'l', D.A. (1990). In Bio!llee/ullIics flud Motor CO/ltrol or ,I
i
Onhop S,·a//(I. 48.311. 1'11111/1111 Be!wviour (2nd ed.). Ncw York: John Will'Y &.
M'HTis('n.J.B. (1970). The mechanics of the kIWi..' joint in re-
lation [0 nonn:'l! walking. J Bicol/cch. 3. 51.
SOilS.
Wiktorin. C.v.H. &. Nordin, ~\l. (1986). 1,II/,o(//I(:t;OI/ [() Prohll..'/II
i
.j
!'\i1.P., Droughl, :\.B .. !\.ory. R.C. (1964). \Valking 1':11- So/l'illg ill Biollll..'challics (Pl'. 87-129). PhihlClclphia: Lea &:: :J
ll'::l'nS of l1orl11:d men. 1 130111..' Joillt S!l!·.~, -I6A, 335. Fchig('l'. I
N. & Nordin. rio'\. (1999). FlIlId(/I!U'IIUJ!S oj' 13iOlllt'-
Eqllilihl'illlll, JIOlio/l, (/lId lJeji>rlllatioll (2nd cd.).
Wilson. S.A., Vigorila, V.J., &. SCf.HL. WN. (1994). Anatomy. In
N. SCOIt (Ed.), The Kllee (po 17). Philadelphia: ~'Iosby.
I
1
Wrclenberg, P., Nemeth. G., Lamontagne. M.. ct <II. (1996).
Ncw York: Springcr-V"r1ag.
~crr.v, 1.. Norwood, L., & House. K. (1977). Klll'C po.o;tUl'\.' ,llld
biceps and semimembranosus muscle action in fUllning
P;lssivc knee muscle momcnt <trillS meas.ured in vivo with
MRI. Clilliea! Biol1lcclt, I 1(8}, 439-446.
I
.,
1
<'Ind cutting (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- :1
Ramsi..'y, O.K. & Wn.'tl'llhcrg, P.E (1999). Biolllcchallit,:-; of tht:' \·'II·US motion of the knee ill norm.1I lc"d w;dking [lnd stair j
kn~c: Melhodological consid('r;ltions in Ihl' in \'i\'o kinl'- climbing. Clillical Biolllcch, 12(5), 2S6-293. .~
matic an:dysis (~f II\(' tibiofl'moral and patellofclIlor;d Zcrnickc, R.E, G;lrhammer. J., & Jobe. FW. (1977). Human I
joint. RC\'i(:w pnp('r. Clillical Biomecll. 1-1, 595-611. pntdlar Icndon rupture. 1 801lt' loillt S1Irg, 59;\, 179-183. 1
ij
J.,
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- The hip joint (front view) 1. External iliac artery. 2. Psoas
cumference of the acetabulum at its opening would major muscle. 3. Iliacus muscle. 4. Iliac crest. S. Gluteus
intersect with the sagittal plane at an angle of 40~ medius muscle. 6. Gluteus minimus muscle. 7. Greater
opening posteriorly and with the transverse plane at trochanter. 8. Vastus lateralis muscle. 9. Shaft of femur.
an angle of 60~ opening laterally. The acetabular 10. Vastus medialis muscle. 11. Profunda femoris vessels.
12. Adductor longus muscle. 13. Pectineus muscle. 14. Medial
cavity is deepened by the labrum, a flat rim of fibro~
circumflex femoral vessels. 15. Capsule of the hip joint.
cartilage, and the transverse acetabular ligament
16. Neck of femur. 17. Zona orbicularis of capsule.
(Fig. 8-2). The labrum contains free nenle endings 18. Head of femur. 19. Acetabular labrum. 20. Rim of ac-
and sensory end organs in its superficial layer, etabulum. Reprinted with permission (rom McMinn, R.H. &
which may participate in nociceptive and proprio- Huchings. R.H.R. (988). Color Atlas of Human Anatomy (2nd
ceptive mechanisms (Kim & Azuma, 1995). 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.. Superior
1998). 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- Anterior
ure 8-3. Removal of the transverse 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 loading pattern of a human acetabulum in vitro with in-
forms two-thirds of a sphere. The articular carti- tact labrum and transverse acetabular ligament. Note: This
lage covering the femoral head is thickest on the pattern was grossly unchanged after removal of the trans-
medi,al-central surface and thinnest toward the pe- verse acetabular ligament. or the labrum, or both, and
therefore those patterns are not displayed. Adapled from
riphery. The variations in the cartilage thickness
Konrath. GA.. Hamel. A.I.. Olson. S.A.. et elf. {l998). The role of
result in a different strength and stiffness in vari-
the acetabular labrum and the trdnSverse clCeiabtJ/dr ligamefl! in
ous regions of the femoral head (Kempson et 'II., load transmission of tilt, hlp. J Bone Joint Surg. 80/'.,(12),
.---
I
1781-1788.
125~, but it can vary' from 90 to 135 . An angle ex- Neck Head
ceeding 125' produces a condition known as coxa
valga; an angle less than 125'" results in coxa vara
(Fig. 8-4). Deviation of the femoral shaft in either Greater
trochanter
\vay alters the Force relationships about the hip joint
and has a nontrivial effect on the lever arms to mus-
cle force and line of gravity'.
The angle of anteversion is formed as a projec~
l.ion of the long axis of the femoral head and the
transverse axis of the femoral condyles (Fig. 8~5).
In adults, this angle averages approximately 12"',
but it varies a great deal. Anteversion of more than
12" causes a portion of the femoral head to be un-
covered and creates a tendency tc}\vard internal ro- Lateral
condyle Medial
tation of the leg during gait to keep the femoral condyle
head in the acetabular cavity. An angle of less than
12" (rclroversion) produces a tendency toward ex~
ternal rotation of the leg during gail. Both antever-
Top view of the proximal end of the left femur showing
sion and retroversion arc fairly common in chil-
the angle of anteversion, formed by the intersection of the
dren but arc usually outgrown. long axis of the femoral head and the transverse axis of
The interior of the femoral neck is composed of the femoral condyles. This angle averages approximately
cancellous bone \vith trabeculae organized into 12' in adults.
medial and lateral trabecular systems (Fig. 8-1, 8-
6), The fact that the joint reaction force on the
femoral head parallels the trabeculae of the medial
----------@
RANGE OF MOTION
Hip motion takes place in all three planes: sagittal
The radiograph illustrates a right femoral in-
(flexion-extension), frontal (abduction-adduction),
tertrochanteric unstable fracture with separation of the
and transverse (internal-external rotation) (Fig.
lesser trochanter. The image shovvs osteoporOlie changes
8·7). Motion is greatest in thc sagittal plane, where
characteristic of the aging process. The decrease in the
the range of ncxion is from 0 to approximatcly 140"
bone mass at the femoral neck leads (0 reduced bone
and the range of extcnsion is from 0 to 15~. The
strength and stiffness as a result of diminution in the
range or abduction is fTom 0 to 30", whereas that of
amount of cancellous bone and thinning of conical bone. It
adduction is somewhat less, from 0 to 25'. External
increases the likelihood of a fracture at the weakest level.
rotation ranges from 0 to 9W degrees and internal ro-
During the fall. the magnitude of the compressive
tation from 0 to 70' when the hip joint is flexed. Less
forces at the femoral neck overcame its stiffness and
rotation occurs when the hip joint is extended be-
strength. In addition. the tensile forces produced by pro-
cause of the restricting function of the soft tissues.
tective contraction of muscles such as the iliopsoas gener-
The range of motion of the hip joint during gail
ated a traction fracture at the lesser trochanter level.
has been measured e1ectrogoniometrically in all
;'
_~o_,
~:,,;:h-
:t: ./
i;:
"
allows a comparison of this motion with that of the the tracking limb; they also showed reduced dorsi-
knee and ankle. nexion of the ankle and diminished elevation of the
Motion in the frontal plane (abduction-adduc- toe of the forward limb,
tion) and transverse plane (internal-external rota- The range of motion in three planes during com-
tion) during gait (Johnslon & Smidt. 1969) is illus- mon daily activities such as tying a shoe, sitting
trated in Figure 8-8B. Abduction occurred during down on a chair, rising [Torn it, picking lip an object
swing phase, reaching its maximum just after toe- from the floor, and climbing stairs \vas measurcd
olT; at heel strike, the hip joint reversed into addue- electrogoniomctrically in 33 normalmcn by Johnston
tion, which continued until late stance phase. The and Smidt (1970), The mean motion during these
't. hip joint was externally rotated throughout the activities is shown in Table 8-1. Maximal Illation in
swing phase, rotating internally just before heel the sagittal plane (hip flexion) was needed for tying
st.-ike, The joint .-emained internally rotated until the shoe and bending down to sqUal to pick lip an
late stance phase, when it again rotated externally. object rrom the noor. The greatest motion in the
The average ranges of motion recorded for the 33 frontal and transverse planes was recorded during
normal men in this study' \vere 12' for the frontal squatting and during shoe tying with the foot across
plane and 13' For the transverse plane. the opposite thigh, The values obtained for these
As people age, they use a progressively smaller common activities indicate that hip flexion of at
portion of the range of motion of the lower extrem~ G
'T·- .. , '-. ,.
JOINTS
.
--Hip joint
70 ,,-',,
,,, ,
----. Knee joint
60~ ........... Ankle joint
I . , 5
Abduction
........
50 o i==""1--~
: \
,,• •,
'"
w
~
C>
40~
,,
1
1 \
.
,
(j)
w
w
5 Adduction
w 30~ Q,
..
1
:s c
0
/ I \ w
:s
c 'x
,2 20 , " I' \
c
;;
w
u: "
.
'I , Q
;; Internal
~ 10 ./ \ ~ rotation
C , '" ,
'0
~
0 .••....
......
51:::::=~....1
£Q. 04 --.l
.., /
c 10 ...
..... ...-
5 "'i...---' I
0 External
'.'!l"
c
x
20
30
................
100 60
rotation
100
LU Stance Swing
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- range of motion in the frontal plane (top) and transverse
mal men during level walking, one gait cycle. The ranges of plane (bottom) during level walking, one gait cycle. Addpt, cf
motion for the knee and ankle joints are shown for compari- from Johnston, Pl. C. S Smiclt, G.L. (J 969). /vleasuremcn[ of hi,l.'·
son. Adapted from 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
Roentgenograms utilizing a plumb line (black line) show supporting hip joint_ Again the gravity line has shifted to-
that the line of gravity shifts in the frontal plane with differ· ward the supporting hip, thus decreasing the joint reaction
ent positions of the upper body and inclinations of the force. D. The pelvis sags away from the supporting hip joint
pelvis. A, The pelvis is in a neutral position. The gravity line (Trendelenburg's test). The shift in the gravity line is similar
faUs approximately through the pubic symphysis. The lever to that in C. (Courtes}' of 10hn C Baker. IvI.D., Case vVesrem Re-
arm for the force produced by body weight (the perpendicu· serve Unive(sir}~ Cleveland, OhiO} Note: In B, the antalgic gait is
lar distance between the gravity line and the center of rota- illustrated, which lowers the load on the head of the femur
tion in the femoral head) influences the moment about the but alters the load line to a more vertical position. Following
hip joint and hence the joint reaction force. B, The shoulders arthroplasty for arthritis, the abductor muscles are weak and
are maximally tilted over the supporting hip joint. The grav· atrophic as a result of the disease process and the surgery.
ity line has shifted and is now nearest the supporting hip. External support such as a cane should be used until the ab-
Because this shift minimizes the lever arm, the moment ductor muscles are rehabilitated. The best indication for a
about the hip joint and the joint reaction force are also min- rehabilitated abductor muscle is the lack of limping.
imized. C, The shoulders are maximally tilted away from the
on a free·body diagram (Calculation Box Fig. required for stability. The moment arising from the
1)_ Because the body is in equilibrium (i.e" the superincumbent body weight (equal to % 'IN) must
of the 11''lOmenls and the sum of the forces both be balanced by a moment arising from the force of
zero), the ground l'eaction force is equal to the 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
1WO components, the gravitational force of the or b rrom the center of rotation of the hip (Q), thus
leg (equal to one-sixth body weight) and the producing a moment of % Vt/ times b. The force pro-
force (equal to five-sixths body weight). duced by the principal abductor, the gluteus
body is divided at the hip joint into two medius, designated as A, acts at a distance of c from
h-"e-DC)(lIeS- The main coplanar forces and moments the center of rotation, producing a counterbalanc-
on these free-bodies must be determined. ing rnomcnt of A limes c. For the body to remain in
upper free-body is considered first (Calculalion moment equilibrium. the sum of the moments must
;1j~IJOX Fig. 8-2-2). In this free-body, t\\'o moments are equal zero. In this example, the moments acting
------------------
Force J
Intersection
point
J'
Force A //
2W/ I
I
I Force J
/
,._wt/
I 2_75 W
,
1
t
Force W
! Calculation Box Figure 8-1-1. Calculation Box Figure 8·'-2.
&--------------------------------------~---------- ------------------------------------ -------
,.- . , -:-.-_ ..
External Forces Acting on the Body in
Equilibrium During a Single-Leg Stance
Calculation Box Figure 8-2-1 shows external fOKes acting on
the body in equilibrium during a single-leg Slance. The ground
reaction force is equal to body weight (W). The gravi!ational
force of the stance leg is equal to one-sixth of body weight;
Calculation Box
the remaining force is equal to five-sixths of body weight. Figure 8-2·1.
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
b :
are required for stability. Moment equilibrium is attained by -_._"
the prOduction of two equal moments. A moment arising
Calculation Box
from the force of the abductor muscle (A) times abductor Figure 8-2·2.
force lever arm (e) 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'"
A y = 0.8 A = 1.7 W
Ay 30"
Calculation Box
Force A is equal to two times body weight and has a direction Figure 8-2-3.
of 30' from the vertical. The magnitudes of its horizontal (A,)
and vertical (A) components are found by vector analysis.
Perpendiculars are drawn from the tail of A to a horizomal
and a vertical line representing A. and A" respectively. A, and
A, can then be scaled off. Allernatively. trigonometry is used
to find the magnitudes of the components. Ax
._--~._._-_._-_ .._--------._-
,
clockwise arc arbilraril~' considered to be positive Fig. 8-2-2). This is particularly important in pros-
and lhe counterclockwise moments arc considered thetic replacements of the hip joint (Delp &
be negative. Thus, Maloney. 1993; Free & Dell', 1996; Lim et al .. 1999;
(Y.,W x b) - (A x c) = 0 Sutherland et 'II., 1999; Vasavada et 'II., 1994). The
center of motion can be altered by the prosthctic de-
YoW x b sign and the lever arm for the abductor muscles can
A= -'----
c be slightly changed by slu-get)! techniqucs. A change
To solve for A it is necessary to find the values of of the center of location of the hip joint can de-
and c. The gravitational force lever ann (b) is crease the abduction force by more than 40(1'0 and
roentgenographically. Because the cenler of thereby the generated abduclor moment b~} almost
gravity must lie over the base of sUppOrl, a plumb 50% (Dell' & Maloney, 1993), Figure 8-11 illustrates
line intersecting the heel can be extended upward; a the relationship of this ratio to the joint reaction
line drawn from the center of rota- force. ;\ low ratio (i.e., a small muscle force lever
in the femoral head (Q) to the line represents ann and a large gravitational force lever arm) yields
"""'\IlOe b. The muscle force lever arm (c) is simi- a greater joint reaction force than docs a high ratio.
.~.' larl~! found by identifying the glutcus medius mus- A short lever arm of the nbduc(ol- musclc force, as
cle on a roentgenogram (Nemeth & Ohlsen, 1985, in coxa valga (Fig. 8-4), rcsults in a sTllall ratio and
1989) and drawing a perpendicular line from the lInls a sornewhat e1cvated joint reaction force. Mo\'-
center of rotation 01" the femoral head to a line ap- ing thc greater lrochanter latcrally during lata! hip
proximating the gluteus mcdius muscle tendon. replacement lowers the joint reaction force. as it in-
In this example, a value for A of two times body creases the lever arm ratio by increasing the muscle
weight was derived from thc static free-body diagram force lever arm (Free & Delp, 1996). Inserting a
and confil'med by instll.llnentcd in vivo measure- prosthetic CLIp deeper in the acetabulum reduces
ments (English & Kilvington, 1979; Rydell, 1966). The the gravitational force lever ann, thereby increasing
direction of force A is found from a roentgenogrnrn to the ratio and decreasing the joint rcaction force. It
0
be 30 from the vertical. The hOI'izontal and vcrtical is difficult. howc\'cl: to change the lever an11 ratio in
components of this force are found by vector analysis such a way as to reduce the joint rcaction force sig-
(Calculation Box Fig. 8-2-3). The hOl-izonlal compo- nificantly been use the curve formed from plouing
nent (AJ is equal to body" weight; the vertical compo- the ratios becomes asymptotic when the ratio of c to
nent (A y ) is approximately 1.7 times body \veight. b approaches 0.8 (Fig, 8-1 I).
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 The loads on the hip joint during dynamic activi-
but originates from the most narrow joint space in ties have been studied by several investigators
the radiograph and musl pass through the esti- (Andriacchi ct aI., 1980; Draganich c{ al.. 1980;
mated center of rotation in the femoral head. The English & Kilvington. 1979: Rydell, 1966). Using a
magnitude of force J is determined by finding the force plate system and kinematic data for the nOI"-
horizontal and vertical force components and Illal hip, J. P. Paul, 1967. (Forces at the human hip
adding them (Calculation Box Fig. 8-3-2). joint. Unpublished doctoral theses, University of
The value of J is found by vector addition (Calcu- Chicago) examined the joint reaction force on the
lation Box Fig. 8-3~3), and its direction is measured femoral head in normal men and women during
on the parallelogram of forces. The joint reaction gait and correlated the peak magnitudes with spe·
force on the femoral head in a single-leg stance with cine muscle activity recorded electromyograph i-
the pelvis leveled in the horizontal plane is found to cally. In the men, two peak forces were produced
be approximately 2.7 times body weight, and its di- during the stance phase when the abductor mus~
rection is 69· fTom the horizontal (Calculation Box cles contracted to stabilize the pelvis. One peak of
Fig, 8-3-4). approximately four times body weight occurred
A key factor influencing the magnitude of the just nfter heel strike, and a large peak of approxi-
joint reaction force on the femoral head is the ratio matel:v seven times body weight was. reached just
of the abductor muscle rorce lever ann (c) to the before toe-ofr (Fig. 8-12A). During foot flat, the
I gravitational force lever arm (b) (Calculation Box joint reaction force decreased to approximately
I \J
L I
j
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
:ca>
'la> 'ffi
5
'ffi 5.0 ;;
~ >- 4
>- 1S
"e0 @. 3
~
~ 4.0 ~
~ a 2
0
u.
u.
2.0
10< >
~..,._.,......,_..,.._.--..,._.,.......;5,,0:..'..,
limits of
angle of
inclination Women
o 0:2 0:4 0:6 0.8 i of abductor
muscle
_
The value of the ratio of the abductor muscle force lever
arm (e) to the gravitational force lever arm (b) is plotted
~~~~~~~F1'"''
field: Charles C. Thomas,
I ----------------
8
Tensor [osciac
S,lrtOri.us _
IIi",,",
Gr,lc,bs
Reclus femoris
Gluteus med,us Abductols
Gluleus minimus
.\dduc!or magous
Adductor IOr1(Jus
.-==:==~AddUCIOIS
Adductor brevis
100 60
Percentage of Cycle
body weight because of the rapid deceleration of c
the bodv's.'
centcr of ~ gravilv.
.'
Durin t>lT the swing~
phase, the joint reaction force was influenced by
contraction of the extcnsor muscles in decelerat-
Hip joint reaction force in units of body weight during
ing the thigh. and the magnitude remained rela-
walking, one gait cycle. The shaded area indicates varia-
tively low. approximately equal to body weight. tions among subjects. A. Force pattern for normal men.
In the women, the force pattern was the same but 8, Force pattern for normal women. Adapted from Paul, IP
the magnitude was sorncwhat loweI~ reaching a max- (1967). Forces at the human hip joint. Unpublished doctoral the·
imum of only approximalely four times body weight sis. University of Chicago. C, Muscle activity during stance
at late sfance phase (Fig. 8-128). The lower magni- phase of gait. The first peak corresponds mainly for the ex-
tude of thc joint reaction force in the women may tensor and abductor muscles. The last peak. is for the flexors
have been the result of several factors: a wider female and adductor muscles. Adapted from the University of Califor-
pelvis. a difference in rhe inclination of the fcmoral nia. (1953). The pattern of muscular acrivity in rhe lower excrem·
neck-to-shaft angle, a difference in footwear. and dif- i!'/ during ,·valking. Univ Cal Prosthet Dev Res Rep, 2(25). 1--4/.
t\
8-13;\). At a faster cadence. the forces •.\Cling on the
~
..e
0
800
600
prosthesis grcatl~' increased because of an increase
in muscle ac(ivi(~' (Fig. 8-138). At both cadences,
lL
400 the magnitude or the forces during swing phase was
arproxirnatel~: half that during stance phase.
200
l~lble 8·2 summarizes the typical peak joint forces
1200
~ 1000
'"e
, ,ImI!DJI
0 800
lL
or-,
,1
SlanceDphase
i
1
i
2
i
3
Activity
Walking
Reported
Peak Force
BW
-_.,-.'.'..._-_._---_
2.7-4.3
2.7-3.6
Instrumentation
... _--_.,.._,._--
Insirurnented
implants
Instrumented
Reference
Bergmann et aI.,
1993, 1995
~--------'--'---'-"---'------"'-----r
of a femoral neck fracture allowed a subsequent
determination of the forces acting on the implant
Fatigue Fracture of the Hip during activilies or daily living (Fig. 8-14) (Frankel
'1\.", 64-year-old, very active retired man experienced a el aI., 1971). Although the device measured forces
·M femoral neck fracture after changing his training on the implant and not on the hip joint, it was pos-
,'regime to prepare for a marathon. The fracture was sible to determine the proportion of the load
~.
'.> classified as a faligue fracture caused by overload of transmitted L1nough the device and to calculate
-, the hip joint. the total load acting on the hip joint by means of
;~
static analysis. In the case illustrated in Figure
8-14. the nail plate transmitted one fOllrth of the
lOtalload.
Strong forces aCling on the nail plate were en-
countered during such diverse activities as moving
onto a bedpan, transferring to a wheelchair, and
walking. The magnitude of the forces was greatl)'
modified by skillful assistance frol11 lhe nurse or
therapist to control the patient's movement. Forces
of lip to fOllr limes boely weight acted on the hip
joint when the patient used the elbows and heels to
elevate the hips while being placed on a bedpan
(Fig. 8-15), but these forces were greatly reduced
through the lise of a Lrapeze and assistance from an
attendant (Fig. 8-158). A 5-kg ex.tension traction on
the hip had little effect in modifying the forces act-
ing on the hip joint. Exercises of the foot and ankle
increased these forces.
Case Study Figure 8-2-1.
.., ...,: ..
BIOME'::HI,NI':S Of JOINTS
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<~Oint Rea~:~::e:::C:uSCle force (E) was then found from the
I the
i
faKe acting on the femoral head in Ihe late swing phase of
gait cycle for an 8·year-old boy INeighing 24 kg and
momenl relationship
T ::::: Fd,
I wearing a )ong-Ieg brace. The main muscle force was pro- where F is the extensor muscle force and d is the perpendicu~,
duced by contraction of the gluteus maximus muscle and lar distance from the center of rotation of the femur to the
identified through electromyography. The torque about the middle of the gluteus maxim us muscle. Distance d was mea.,
hip joint \ivas calculated according to the formula sureej from a roentgenogram and found to be 3.2 em, From
H'e equation E;::;: TId, the muscle force on the normal Side',
T ~ la,
. . " as calculated to be 338 N, and on the braced side, 600 N.
where
The joint reanion force on the femoral head (J) is equal to
T is the torque expressed in newton meters (Nm)
the muscle force (E) minus the gravitational force produced
I is the mass moment of inertia expressed in newton meters
by Ihe weight of the limb (W,). In this example, W L \·\las esti-
times seconds squared (Nm sec!)
mated to be 40 N.
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
J = 338 N - 40 N J=600N-40N
is 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 0.45 Nm sec; + 0.35 Ntn sec'
;.cc
Thus, Thus,
I = 0.45 Nm sec:' T = (.45 Nm sec) + 35 Nm sec!)
.: ~
x 24 rlsec~ x 24 rlsec~
studied the effects of cane use in 24 subjects with a a large push may not be possible because of a lack
,;:: mean age of 63 years. During walking, the e1ec- of strength in the upper extremities.
tromyographic activity of the hip abductor muscles The use of a brace on the leg may aller the forces
was measured, Neumann found that usc of a cane on the hip joint but may not always reduce the joint
on the contralateral side of the affected hip joint, reaction force on the femoral head. An ischial long~
with careful instructions to use with near maximal leg brace used in the treatment of Perthes' disease
effort, could reduce the muscle activity by 42% (Fig. raises the joint reaction force during late swing phase
8-16). This calculates to a reduction of approxi- because the large mass moment of inert ia of the
mately one times bod~; \veight from 2.2 body weight brace results in a higher extensor muscle force dur-
with a cane, compared with 3.4 body weight with- ing this part of 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 1'; The hip JOll1t is a ball-and-socket joint com-
body position. A cane used on the side of the painful posed of the acetabulum and femoral head,
hip works through a shoner levcr arm and thus an 2 The thickness and mechanical properties of the
even greater push on the cane is needed to decrease cartilageon the femoral head and acetabulum vary
the joint reaction force. For the olcler patient, such from point to poinl.
-_.~,
Fl·ss.\', ~1.I-1.. ;\'Diaye, A.. CalTd. J.P.. et :II. (1999)_ Locilting
3 Hip llexion of at lca~·a 120", abduction of at tht..· l·{.·lltl-r or rOlation of IIII.' hip. Sl/r.g nmliol A//at, 21(4),
least 20", and extenwl rOl<.l.lion of at least 20" are 24;-250.
necessary for can}'ing out daily activities in a nor- FI'~lnkd, V.H. (19;3). Biollll'challil:s or the hip. In R.G. Tronzo
mal manner. (Ed.), Slll'.~t:ry o( I!lt' Hip }Oil/l (pp. 105-125). Phil~ldl..'lphi::\:
lea &. Fdlif!l'r.
\4 A joint reaction force of apprOXill'latc1y three Frankd. V.H. (1960). In nUt FI.'J/ulI"iI} Nt'd: {-'Wlclioll. Frtldlfre
timcs body weight acts on the hip joint during a sin- .\-1f.'(:IUllli:'/II.\, "/lenla! FixaTioll. Springfidd: Charles C.
gle-leg stance with the pelvis in a neutral position; TlwllWS.
its m;gnitudc varies as the position of the upper Fr'lnkd. V.H .. BurSil'in. A.H .. L~·grl·. L., l't al. (1971). The Idl·
L.lil: nail. ) BOIH' 10illl SIII"~. 53:1. 1232.
body changes. Free, S.A. & Oelp, S.L. (1996). Trochantt.'rll.: transfer in IOlal
_~'> The magnitude of the hip joint reaction force is hip n:pJal:i.:IlIl.:nl: Effecls on Ilit' lTlOfllL'llt arms nnd force-
gellt..'ralillg c'lpadtic:;s of Ihe hip abductors. J Onlwl' Rt',,'.
infiuenced by the ratio of Ihe abductor muscle force
1-I{2L 1-15-250.
and gravitational force lever anns. A low ratio yields Gn.·em\'~a1d. A.S. & 1-I<I\'llI,:S, D.W. (1972). Weight-hcaring an.'as
a greater joint reaction force than does a high ratio_ ill lhe human hip j{~Jinl..! BOIlt' .!Oilll Siltg. 5-1B( I), 157-163.
Hurwitz. D.E. & Andri.tt:("hi. '1'.1>. (1998). Biomechanics of the
;;_~ The hip ,joint reaction force during gail reaches
hip. III J.J. Cdbgh'111. A.G. Rosl'nberg. &. I-I.E. Rub':Jsh
levels of three to six limes body weight or more in (Eds.1. The: Adult flip (pp. 73-85). Philaddphia: Lippillcol!'
stance phase and is approximately equal to body Raven Publishers.
weight during swing phase. Hllr",it;',. D.E. & Andri~\(:("hi. T.P. (1997). Biolllcl:hanks of the
hip .tlld the knl'l'. In ~'1. Nordin, G.B.J .•\ndnsson. &. ,\I.B.
j.7 An incrense in gait velocity increases the mag- POPl' (Eds.) . .\lusculoskclewl Disorders ill {Itt' Irorkf-'lau.
nitude of the hip joint reaction force in both swing Principles (Jud Prauice (pp. -186--196). Phila(k']phia: Mosby-
and stance phase. Year Book.
Inrn;lIl. V.T. (19-47). Flll1l:lional aspects of t!ll' abductOr mllS-
,'8 The forces acting on an internal fixation device c1es of thl' hip. J BOllI.' loim Sll"~. 29:\. 607.
during the ~\ctivitie; of daily living vary greatly' JohnslOn, R.C., Br~Hl(I, R.A .. &. Crowninshicld. R.D. (1979).
depending on the nursing carc and the therapeutic Re('onslnH:lioll of tht' hip. } BOI/t' Join, Smg. 61:\(5),
activities undertaken by the patient. 646-652.
Johnston. R.C. & Smidt. C.L. (1969). !\leasur(,llll'nt of hip-
/9 The lise of a cane or a brace on the leg can al- join! motion during walking. Evaluation of 'tll I'll'ctrogo·
tcrthe magnitude of the hip joint reaction force. niOllll'tric Illt.'lhod. 1 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.
REFERENCES 72. 105.
Kcmpson, G.E., Spin.'y. c.J .. Swanson. S.A.V.. cl at. (1971).
Andriacl:hi. T.P.. Andersson. G.B .. Famil:r. R.W., Stern. D.. Patk'rns of C<lrtila~1' stiffnt..'ss on normal and dC~Clll'riltc
G,t!anil', J.O. (1980). r\ study of to\\'er-limb medlanics dur- human femoral he;ds, J liiO/IIt'ch, -I, 59;. -
ing stair·dimhing. J BOllI.' Johu Surg, 62.-1. 749. Kim, Y.T. &: Azurll.l, H. (1995). The lH.'I'\'e t,;ndings of I lit' ac·
Bergmann, G., Graichl'll. E, & Rohlm=lIl1l. A. (1993). Hip joint etabular "tbrum. CfiJl Or/hop, 320, 1;6-181.
1~'H.ling during \V,lIking i.lIld running llh..· .ISurcd in IWo pa· Konrath, G.A., Hamel. A.1 .. Olson, S.r\ .. d .d. (19981. The role
tknts. 1 Bio/lw:h, 26(8),969-990. of the aCI'I.dHlbr labrum and the (r~\IlS,'e..SI' :lcL'(ablll~lr lig-
Bergmann. G.. Graichen. E. & Rohlmann, A. (t995). ts slair.. ;l11lt.:lIt in load transmission of the !lip. J (JOllt~ loilll SI/r:;,
cast: walking a risk for tht: fi.X<lli(lll of hip implants?} 13io- 80A(I2I. t781-1788.
IlIe,''', 28(5), 535-553. Kotzar. G.~L Davy. O.T.. Goldberg. V.;\1., cI al. (1991).
Catani, F.. Hod!!(', r\ .. ~'talln. R.W.. et ::d. (1995). The 1"011.; of TcJemilriZL'd in "j\'o hip joint forcc dilta. A report on IwO
museul"r co:eontr<lClion of the hip during mon.·men!. Chi,. ll<ltit.:IHS aftcr 10iai hip sllrgery. 1 Ort/wp Nt's, 9. 621-633.
Orgalli ;\1ov, 80(2), 227-236. Kumagai. iv1.. Sliiba, N., Higuchi, F.. et a!. (19971. FUllction,1!
Crowllinshidd, R.D .. Johnston, R.C.. Br<lnd. R.t\. (1978). The t.:\'aIU:llion of hip abductor mllSC!<;S with llSI' of m.lgnctk
eHccts of walking no'locity and agl' on hip kint:m<ltics and resonance imaging. 1 Orlhop Rt,S, 15(6),888-893.
kinetics. Clill Or/hop Rd Ues, 132,140-14-\. lilli. l.A .. CIl"mi(;h;lel, S.W.. &. C<lbancla, M.E. (19991. Bio·
Ddp, S.L. &. Maloney, \V. (1993l. Effects of hip Centcr loca- llH:chanics of lOUt! hip ;lrlhroplnsly. AI/ot UI:C, 257(3),
tioll on the momcnl-generating cilpacity of the l1luscks.) t 10-t 16.
8'0mi'd,. 26(5). 485-499. j\'kLl'ish, R.D. & Chilrnh:y. J. (1970). Abduuion forct's ill the
Drng::lllil·h. L.F.. Andrincchi. T.P.. Strongw::llcr. :\.1\'1.. ct ~\1. one-!l.'ggcd st~lnc('. J B;oll/cch. 3, 191.
(l980). Electronic tlll.:aSLlrcrnent or instantaneous fOOL-
floor conl;:\ct paltl'rns during gait. 1 BiOlIICdl. 13. S75.
;\'ld,linn, ~R.H. &: Huchil1!.;s, R.H.R. (1988). In C%}" Illlas or
HI/lllml AWIlO11/Y (2Il1.! cd., p. 302). Chic,lgO: )\:.11' Book
English. T.A. & Kilvington, M. (1979). In \'ivo re('ord~ of hip ,\-kdic<ll Publishl'rs, Inc
IO:.lds using ::1 fl'llloral impblll with lelemetric output (a MlllT~I\'. ~LP. (1967).. G.dt <lS ,I lOt~t1 pattern of movement. :1m
preliminary l't:ponl. 1 Biollled ElIg, 1(2), 111. 1 pjlYs .lled, -16, 290.
CHAPTER 8 • "'C'ME,crlA~J1C5
\-!urray, i'",1.P., Kor.\', R.C., &: Clarkson, 13.11. (1969). Walking Re!uh'd Bio-LII~il/ecrilig Topics (pp. 351-357). Oxford:
patterns in he:dthy old nH:n. } Geroll/ol, 2-1, 169-178. f\:rgamon Press.
Nemeth, G. &: Ohlsen, I-l. (1985). In vivo moment arm lengths Sutherland, A.G., D'Arcy, S .. Srn:lrt, D., et al. (1999). Abduc~
for hip extensor muscles at difTerent angles of hip fle\ion. tor muscle weakness and stress around acetabu!:lr compo-
} Biolllech, 18, 129-149. nents of total hip arthroplasty: A finite dement analysis.
Nemeth, G. & Ohlsen, H. (1989). rvlolTlel1t arms or hip abduc- 1111 Orthop. 23(5), 275-278.
tor and adductor muscles in vivo by computed tomogra· University of California. (1953), The pattern of muscular ac"
phy. Cfill 13iolllccll, 4, 133~136. tivity in tht: lo\\'er extremity during walking, (jllll' Cal
Neumann, D,A, (1998). Hip abductor JllLlscle activity as sub- Pros/hd DcI' Rcs Rep, 2(25). 1-41.
jects with hip prostheses walk with dirrerL~nt methods of van den Bogert, A.J., Read, L., &. Nigg, B.rv1. (1999). An ;:Hlal~'.
'using a cane. Pllys Ther, 78(5),490-501. sis of hip joint loading during walking, running and ski-
IWhrle, H., Scholten R., Sigolo!to, C., et al. (1984). Joint ing . .lIed Sci Sports, 31(l), 131-142.
forces in the human pelvis-leg skeleton during walking. } Vas:lvada, A.N., Delp, S.L., \.laloney. \V.J., et a!' (1994). Com-
Biolllcch, 17, 409-424. pens;:lling (or changes in Illuscle length in total hip <lrthro-
Rushfcld, P.D., \tann, R.\V., &: Harris, W.H. (1979). Influence pbst~,. Effects on tllL' llHHTll'nl gt:nt:rating capacity of the
of cartilage geometry on the pressure distribution in the muscles. Cfill OnllOp. 302. 121-·133.
human hip joint. Sciellce, April 27, 204(4391), 413-415. VonF.isenhart-Rotht:, R.. Eckstein, r.. ~luller-Gerbl. rlit., et al.
Rydell, N.W. (1966). Forces acting on the remoral head pros- (1997). Direct comparison or contact <.In:as, contact stress
thesis: A study on strain gauge supplied prostheses in liv- and subchondral mineralization in Illunan hip joint spcci·
ing persons. Acta Orr/lOp S("(lIld, SlIppl88. 1-132. mens . .. \I/IJ{ f:'lIlbryol ([kr/), 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 '''C
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-
The biomechanics of the fool and ankle arc complex lation of alterations in biomechanical Function is
and intricately associated with each olher. The fOOl presented in case studies. Footwear in \Vestern so-
is an integral mechanical part of the lower cxtrcrn- ciety may VaJ'y from a rigid ski boot to a soft moc-
ity necessary 1'01' a smooth and stable gaiL The an- casin. These externally restrictive materials may al-
kle transfers load frolll the lower extremity to the ter normal foot and ankle biomechanics and
foal and closely inllucnccs foot orientation with the ultimately innucncc the development or some
ground. pathological conditions, slich as hallux valgus.
The fOOL is comprised of 28 bones (including
scsamoids) whose motions arc closely inlcn-c1alcd
(Fig. 9-1). Besides acting as a structural sllpponing Growth of the Foot
platform capable of withstanding repetitive loads or
mulliples of body weighl. the fOOL/ankle complex The foot is formcd when the limb buds develop dur-
also must be able to adjust to different ground sur- ing the eighth week of gestation. Foot length and
faces and vat)'ing speeds of IOCOl11CHion. The unique width increases linearly from age 3 to 12 in girls
qualities of the 1'001 allow it to be rigid when ncccs- and age 3 to 15 in boys at an average of 8 to 10 mm
Sal)', as in ballet dancing on point, or quile flexible, per year, followed by a plateau in growth (Cheng et
as in walking barefoot on the sand. The transition al.. 1997). Blais and associales (1956) showcd lhal
from shock-absorbing platform to rigid lever capa- the foot appe«rs to be closer to the adult size at all
ble of forward propulsion occurs wilh cach slep of times during normal development of the child than
lhe gail cycle. arc other parts or the limb. On average, at age I
The ankle is compriscd of lhrec boncs Ihal form )'ear in girls and 18 months in boys, the length of
the ankle mortise. This joint complex consists of the the foot is one half the length of the respective adult
libiotalar, flbulotalar, and tibiofibular joints (Fig. foot (Fig. 9-3). This situation contrasts with that in
9-2). The ankle is a hinge joint whose stability de- the femur and tibia, which do not attain their ma-
pends on joint congruency and the medial. lateral, ture length unlil 3 years later in both boys and girls.
and syndesmotic ligaments. The relativel.\' large size or the fool, then, is impor-
This chapter discusses the motions that occur in tant for providing a broad base on which the child's
the foot and ankle during the various phases of gait body is supported. and Lhis base may at tilTlCS corn-
as well as during extremes or motion. The close in- pensate for the child's lack of muscle strength and
terplay between lower extremity rotation and Fore- coordination.
foot orientation is explained. The ground (foot-to-
floor) reaclion force and dislribulion of forccs on
lhe planlar aspeci of the fOOL are explored. The 10- Kinematics of the Foot
calion of forces as they pass from the tibiofibular
complex into the dome of the talus and then into the Gross motion of the foot is complex and occurs
foot is disclissed. Vve also discuss the roles of liga- m'ound three axes and on three planes (Fig. 9-4).
ments and muscles in the support of the medial lon- Flexion-extension occurs in Lhe sagittal plane,
gitudinal arch. Finally, ankle motion and ligamen- abduction-adduction occurs in Lhe horizontal or
tous stability is outlined. transverse plane, and inversion-eversion occurs in
A discussion of sophislicated electromyographic the coronal or frontal plane. Supination and
activity during walking is not within lhe scope of pronation are terms commonly used to describe
this chapter; however, the activity of certain extrin- positioning of the plantar surface of the foot and
sic and intrinsic muscles is by necessity presented to occur primarily at the subtalar (talocalcaneal)
allow a beller understanding of foot and ankle con- joint. During supination the sale faces medially,
trol during gait. The moments produced about and during pronation the sole faces lnterally.
joints by muscle action and resultant effects on foot Supination is a combination of inversion, flexion,
and ankle position are detailed. Joint axes and in- and adduction. Pronation is a combination of
stant centers of joint motion are described. Refer Lo eversion, extension, and abduction (Fig. 9-5). Toe
Chapler 18 for information aboul the application of motion includes Oexion, extension: adduction. and
biomechanics to gail. abduclion.
Any pathological change in root or ankle struc- For practical purposes. foot motion can be con-
ture or motion, however subtle, may have a pro- sidered to be of two distinct types; non-weight-
223
Tarsometalarsal join!
(01 Lislrane) Navicular
i
Transverse mIdtarsal
join! (01 eMparl)
BOdy
~ Cuneiforms \ ,
Base\
\ 'KJ'"'R,..
" Os trigonum
Head Calcaneus
Phalanges \
Sesamoids Tuberosity
MEDIAL VIEW
Trochlea
Os Metatarsals
trigonum
calcan~-~~"""""'''~
Tuberosity
Point or insenion
01 the carcaneolibular -.;...·..><'·:hlea ('ubercle) / .
ligament TuberOSIty Head
Groove lor
peroneus longus TU!)fHc!e
LATERAL VIEW
Calcaneus
Latera! process
Medial
malleolus
lateral
Cuneilorms Middle
{ Medial Lateral malleolus
r"rsomelalarsal joint Tibiofibular articulation
(of Lisfranc)
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-
Interosseous bearing Illotion may be tested with the patient
L
membrane -~-'-.- 0~, Ii I
(~¥J~Tjbia
seated and the foot and ankle hanging free. Subtalar
Fibula .....: 0 f&t~~: motion is evaluated by grasping the tibia with one
.< ;:;if4~. Tibiotalar joint hand and inverting and cvcrting the heel with the
t . . ~istal
llbloflbular
z:f,
....z..
...-;&"4.~
::~.,-:"~r-7: •.• other hane!. Abduction and adduction of the fore-
•t foot can be tested if the heel is held immobile.
I
the patient to raise lip on his 01' her toes. Extel'nal ro-
Ankle joint complex composed of the tibiotalar, fibulotalar. tation of the leg while bearing weight on the foot
and distal tibiofibular joints. causes the hed to invert and the forefoot to pronate,
therefore raising rhe arch. Rotating the leg internally
has rhe opposite effect: it lowers the arch.
f
~'
F
~;:
g LENGTH OF NORMAL FOOT
i Girls
30 ,----,----,----,----,----,----,----,----,----, 30 ~
Boys
t 28 +-+-+-f-+-+-+-+-+--I
.1. !.!
26 +-+--+--+-+-+-++'-+--1
28
26
I I I I I I I I.! . l
I Iii ' I 0 / -
24\ V · 1 +1
24+- +1-+1--h-t-:·,pv';l"/~····--4
f E 22 W-+-~~·~····· 4+=1EE 22\ I .. i<;V i
::.~ 20 ./...' ::.:& 20 I
I I·l/;{.
0
f
;'
I~ § 18:/ § i lOX)· i
~
16 t-+--flfC'fJ+'-I-+--T.:-'-...L-j 18 \ all· I I
I 1,0
14l-l!f+-++-+--1·······..· · · ·
P.'cenmes
50
16\ i/.'./I/!· I 'I
14 +-fff!l+-+-+-+--l---'f---H
.f. I ... ~59~5 %' • I
i
~
12
o
·i
10'O±jjt±±t::±j lot,±l=l:±jj=±jj
2
\
4 6 8 10 12 14 16 18
12 H'l-+-+-+-+--l-f---H
0 2 4 6 8 10 12 14 1618
F
~'
Age (years) Age (years)
I.
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
1I
phase and at push-ofr. the entire lower cxtrclllit:' be- 7~
Dorsiflexionl Eversion! ~i~lS t(~reverse and ,:otatc L·.'(t:nlall~' as ..1he. ~ubu~lur ~I
planlarflexion inversion JOint Sll1lllltancollsl~' II1vcrts (Fig. 9-9). \\illh IIlVerSlon .~
of the subtalar joint and supination 01" the foot. the LI·~~
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 I."
lhe coupling 01 tibial rot~lliOIl to subtalar motion. ,J
They h<:\ve shown that lhe foot supimues I" for every S~
0.2 to 0.44" 01" libial external rotation. ./1:'
!~
Causes of Leg Rotation During the Gait Cycle
Malln (1993) has described the coordination or ankle
and subtalnr rl'lotion in an ekg::HH model called a
mitered hingL" (Fig. 9-10). As the tibia internally 1'0-
lales. the subtalar joint evens (pronatcs). COl1versdy,
external rotation or the tibia causes inversion
(supination) of the subtalar joint. He attributes [he
internal rotation or th(: lower cx.t1\:l11it~: in cady
stance to the obliquit.\' 01" a general ankk joint ax.is
(see Ankle Joint l\'totion). According [0 the "single"
Foot motion occurs around three axes.
axis model or the ankle joint, the ankle joint axis is
~~-------- angkd downward and postl.'riorly I'rorn Ilk·diallo lat-
eral (Fig. 9-1 I). Betau:-ic of the obUquily of the ankle
because the point or contact or the heel is lateral to ing foot pronation the sole faces laterally.
the center of the ankle joint, thus producing a valgus
•
CHAPTER 9 • BIOMECHM41CS
I Heel stnke
~=K\~ 7TTcr 5l~
Toe ot! Heel strike
I I
ll~l/~ 1~lf~1
! I Heel slnke : Fool flat
Stance Phase
l~~l-p-"-Sh-O-lI~'-T-o-e-o-I-,-1
/1 II////II!
<l~--------_~
Stance phase Swing phase
.~----_~
I L 0°" I 15~o I 30~'o I 45~'o 1 60~o
~I2J~]~~
Double Double
limb Single limb limb
support support support
<1-+ ~ ~ <1-+
SWing Phase I
IAcceleration [Toe c1em""e I Decelemtion iH~e~
I 70% _~~~~ l 100~,,
IIBII
62% of the normal gait cycle is spent in stance phase and
38% is spent in swing phase.
_ .. '--~~~~~-
62
Percent of Walk Cycle
I
&------------------
A
Walking
Ji AA A A
o
:
10 20
;
Stance ~65'
If:
30
II
40
:'
50
,
60
:
j 70
SWina(?5~o)
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
IBDI'--
{ ~ftJz~~~~ _
i Comparison of walking and running cycles. In the running cycle, stance phase decreases,
9p
•
1
float
S_W_in__phase
__
develops: _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
_h_a_se_in_c_r_e_a_se_S_' _
air~ PARi". 810MECHANICS OF JOINTS
..
Heel contacl
.. ..
Toe-off Heel contact
Ankle _.
rotation
i
! '
!.......-:-- Stance phase _:
,6~T
.:t;
:.... ,I
FOOl immobile ....:
l
I
-----'_._~
°,._L_~_~.. -----,----;c;;~'
m ~ W W 100
I
I
I
Percent of Walking Cycle I
I
• c o
joint axis, the leg internally rotates with ankle dorsi~ Mitered hinge model of leg, ankle, and subtalar motion.
flexion and externally rotates with ankle plal1larflex- A. Outward rotation of the upper stick causes inward rota-
ion. Additional mechanisms by which leg external ro- tion of the lower stick. 8. Inward rotation of the upper
tation occurs during late stance include the swing of stick causes outward rotation of the lower stick. C. exter-
the opposite leg that causes external rotation of the nal tibial rotation causes supination of the foot. O. Internal
planted leg and the obliquity of the metatarsal break tibial rotation causes pronation of the foot.
(Fig. 9- I 2). The 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
I I I
1__ Slance -.1.,Sw;n9....1
I
$
Muscle activity I phase I phase I
I 1 I
I I
The muscles of the lower extremity are more ac- Pretibial muscle -NjWl~---- .......INlVNm'fM/'lir
live dudng nmning. The gluteus maximus and ham-
strings arc active in midstance through toe-off and Triceps (calf) .L--../MlWWJW'J,IIlWil,J----...L
I
increase their activity 30 to 500/0 1O decelerate the 1
,;.: stance phase limb. Dorsillexors of the foot and an- Foot I I
kle are 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). '"""-1 li Jl Inilial
floor
Lift
off
Initial
floor
MOTION OF THE TARSAL BONES contact contact
Subtalar Joint Motion
The joint between the talus and calcaneus is
lermed the subtalar joinl. Its complex motion in Schematic phasic activity of leg and foot muscles during
three planes produces the motions of supination normal gait.
and pronation, c1inicnll.y referred to as subtalar in-
in it study enlailing eXlkTinh..'lllal sL'kClive fusion of
thl:sC joints. Sliblala,· joint arthrodesis redllcL'd talon-
~l\·iclilar Illolion to 26% or its normal mol ion and re-
duced calcaneocuboid mOlion lO 56~~ normal. Calca-
neocuboid arthrodesis n.:duccd sublala,· motion lo
92 % normal and talonavicular motion to 67':'/c nor-
mal. Selective fusion of the lalomwicuhu- joint had
A the most profound effect on the remaining joillls, re-
ducing their relT'laining Illotion to only 1" each. Beau-
doin (1991) showed thal "xperimelllal slIbtalar fu-
sion resulled in Significant reduction in talonavicular
joil1l contact and nlso reduced ankh.: joil1l contact.
9;t~'---
-
~d Lat.
..-:--- Navicular ~
Calcaneus
B ,I
I
Normal Varus
'.
Longitudinal axis of the transverse tarsal joint. Inversion
!
and eversion occur about this axis. A. lateral view. B. Top
Anteroposterior view of the transverse tarsal joint of the
view. Reprinted wirh permission from lv/anter. J. T. (194/).
right foot. The anterior articulations of the talar head and
Movements of the svbtalar dnd transverse tarsal joints. Anat
calcaneus are shown. The major axes of the talonavicular
Rec. 80, 397.
and calcaneocuboid joints are shown in the neutral posi·
Q~~---------------- tion (parallel) and with the heel in varus (convergent).
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's JOInt
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's joint. Note the recessed second metatarsal base. B, ! in 0<> (neutral), 40° of extension. and 70<> of extension. Top,
Cross-sectional view of lisfranc's joint seen on computed ! Joint contact of the proximal phalanx. Bottom, Joint con-
tomography scan. Note the arch-like structure. tact of the 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 .
proximatelv 90" eXlension to 50" flexion. The ex- contact points corresponds to a similarly numbered in·
trinsic and intrinsic muscles contribute to the toc stant center. The arc indicates the range of motion of the
extensor hood. which controls motion of the hallux, which is more limited than that in a normal foot.
metatarsophalangeal and interphalangeal joints
Extensor digilorum longus relaxed
!
Extensor digitorum
Flexor digilorum
Interosseous
muscle
I
longus tendon
Sling
Extensor
hood
longus tendon
insertion site
Extensor sling
Extensor digitorum
longus contracted
Flexor 1
Lumbrical tendon
tendon sheath
Deep transverse
ligament Flexor digitorum Sling traction
brevis tendon
Extensors
- Flexor
digitorum
Flexor
Lumbricals
longus
I 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-
the metatarsophalangeal joint and extend the interpha- mity of metatarsophalangeal extension and interpha-
langeal joints. langeal joint flexion.
tic rod. The SlI-uts arc under compression and thc
tie rod is under tension (Fig. 9-30). BOlh models
c
h(:t\·c validity and 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
W W metatarsophalangeal plantar plates and collateral
2 2 ligaments as well as the hallucal sesamoids. Dorsi-
nexion of the metatarsophalangeal joints places
GE'------------ traction on the plantar fascia and causes elevation
of the arch through a mechanism known as the
The beam model of the longitudinal arch. The arch is a
"windlass effect" (Hicks, 1954) (Fig. 9-31). During
curved beam consisting of interconnecting joints and sup-
porting plantar ligaments. Tensile forces are concentrated
toe-off in lhe gail cycle, lhe loes are dorsiflexed pas-
on the inferior beam surface; compressive forces are gen- sively as the body passes over the foot and the plan-
erated at the superior surface. tar fascia lightens and aels to shorten the distance
I ----------------
e
between the metatarsal heads and the heel, thus
elevating the arch. The traction on the plantar fas-
cia also assists in inverting the calcaneus lhrough
its altachment on the medial plantar aspect of the
THE MEDIAL LONGITUDINAL ARCH calcaneus.
The arch has both passive and active support.
models e~ist to describe the medial longitudi-
'[\1,10
I-luang et al. (1993) performed an in vitro study of
nal arch of the foot: the beam model and the truss the loaded fOOl and foundlhat division of the plan-
model (San-anan, 1987). The beam model slates tar fascia resulted in a 25°M decrease in arch stiff-
that the arch is a cun'cd beam made up of intercon- ness. They found the three most important static
necting joints whose structure is dependent on joint contributors to arch stability in order of impor-
and ligamentous interconnections for stability. Ten-
sile forces are produced on the inferior surface 01"
the beam and compressive forces are concentrated
on lhe superior surface of lhe beam (Fig. 9-29). The
truss model Slales that the arch has a triangular
structure wilh two slnlls connected at the base by a
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
from heel strike 10 foot nat. The ankle and toe ex- of the first metatarsal and Illcdial cuneiform and
tensors fire eccentrically to slow the descent of the acls to depress the metatarsal head. Injury or paral-
foot and prevent foot slap. They also are necessary ysis of this muscle may allow elevation of the first
to allow fOOl clearance fTom lhe noor during the metatarsal head and decrease loads borne by thc
swi ng phase. first metatarsals and can rcsult in the development
The strongest inverter of the foot ancl ankle is the of a dorsal bunion. Thc peroneus brevis stabilizes
posterior tibialis muscle. The postcrior tibialis is a the forefoot laterally by resisting inversion and was
dynamic supporter of the medial longitudinal arch. found by Hinlermann and associates (1994) 10 be
Il flmctions to invert the subtalar joint during mid- the strongest everter of the foot. Loss or peroneal
and latc stance, thereby locking the tranSVel'se tal'Sal muscle strength can result in varus of the hindfool
joint and ensuring rigidity of the foot during toe-all (Sammarco, 1995).
Loss of this muscle results in acquit'cd pes planus The interosseus muscles are active during late
with Ilattcning of the arch, abduction of thc forefoot. stance and are thought to aid in stabilizing the fore-
and evcrsion of thc heel (Fig. 9-35). Patients with foot during toe-olT. An imbalance between the in-
posterior tibialis tcndon dysfunction usually are un- Irinsics and extrinsics will lead to toe deformities
able to activcly invert their heel while attcn1pting a such as hammer toes, claw toes, or mallei toes.
single toe rise. They have difficulty performing a sin· ,Both intrinsic and extrinsic muscles; mediate the
gle toe rise because of their inability to form a rigid positional control of the great toe. A cross·section of
platform on which to support their weight. the proximal phalanx shows the relative position of
Longitudinal
axis
I
I.
Sublalar
axis I
I
EHL I
• I EDL
I
I
I
I
I
Ankle axis
I
TP.
Loss of the medial longitudinal arch in an acquired adult
FDL.
'--------------------
l
~matiC
Kin.etics Foot
The magnitude of loads experienced by the foot is as- cross·section of the proximal phalanx of the
tounding. Peak vertical forces reach 120°10 body hallux showing normal positions of the various tendons in
weight during walking, and they approach 275°10 dur- relation to the bone.
ing running. It is estimated that an average 150-lb
CHAPTER 9. BICIMECHANIC$
-'----------
i
4.5
80
x·
Med 70
60
"
<l.
~
~
50
5 40
x "'
~
"'
Lat Ii: 30
20
10
0
0% Lal 1000;/" Med
Foot Width
A B
Metatarsal head pressure distribution during standing. A. A The distribution of pressure along the metatarsal head line
line (XX') drawn in the contour plot between the approxi- (XX') indicating maximum pressure under the second
mate locations of the first and fifth metatarsal heads. B. metatarsal head.
",'jiI.
CHAPTER 9 • BIOMECHANICS OF THe f08I~N~ A~~Slt~1EO
l lached as is evident by the somctirncs dramatic dor-
sal foot swelling found during trauma or infection of
,!t
the foot or ankle. The plantar skin is firmly attached
to the underlying bones, joints, and tendon sheaths of
.. 55%
\50%
the heel and forefoot by specialized extensions of the
45o~,\40% plantar fascia, This function of the plantar fascia is es-
35'0 ,30% sential for traction between the floor and the foot's
weight-bearing skeletal structures to occur. During
25% ,,
,, extension of the metatarsophalangeal joints. these
, plantar fascial ligaments restl;ct the movement of
20% t, skin of the forefoot and pia mar metatarsal fat pad
,
,: (Bojsen-Moller & Lamoreux, 1979).
15% +, The heel pad is a highly specialized struclure de-
,, signed to absorb shock. The average heel pad area is
t 10% 23 cm~, For the average 70-kg man. the heel loading
: pressure is 3.3 kg/cm~. which increases to 6 kg/em!
r, 5"
,
10
with running, At a repetition rate of 1,160 heel im-
pacts per mile. the cumulative effect of running is
;2% impressive. These cumulative forces would nor-
I mally result in tissue necrosis in other pans or the
1mIIIIL-.- _ body (Perry, 1983). The heel pad consists of comma-
shaped or U-shaped fat-filled columns arrayed veni-
The progression of the center of pressure along the sale of the cally. The septae arc reinforced internally with clas-
foot during normal walking is expressed as a broken line. Each
I point on the sale corresponds to a percentage of the gait cy-
cle. Note the rapid progression across the heel and midfoot to
reach the forefoot. where most of stance phase is spent. It
then progresses rapidly along the plantar aspect of the hallux.
Percenlage of Cycle
o 15 30 60
(0, ot bOdy
Force wDi('hn HS FF HO TO
Vertical
100
60
20
I
- - -/" I'\.
\
,
\
1\0.
0 --
Fore t 20
,- ....
Shear 0
......... V
AFT j 20
Medial 10
t
Stlear
IA
j
0
.... ..... I I
Lateral 10
I i
Torque (Nm) HS FF HO TO
Medial 9
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- anteriorly than posteriorly (Sarrafian, 1993a,b). A
ral honeycomb effect (Fig. 9-44). The multiple small single ankle joi.llt axis has been described as pass-
closed cells arc arranged to most effectively absorb ing just distal to the mcdi,il malleolus and just dis-
and dissipate force. \,Vith age, septal degeneration tal and anterior to the lateral malleolus (Inman,
and fat atrophy occur, which predispose the calca- 1976). This empirical "general" ankle axis can be
neus and foot to injury (Jahss et a!., 1992a,b). estimated by 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 mortise forms a simple hinge consisting the ankle moves from dorsiflexion to plantarflex-
of the talus, medial malleolus, tibial pia fond, and ion (Barnett & Napier, 1952; Hicks, 1953; Hinter-
lateral malleolus. The talus is shaped like a trun- mann & Nigg, 1995; Lundberg et aI., 1989a-d;
cated cone, or frustunl, with the apex directed me- Sammarco et a!., 1973). Barnett and Napier (1952)
dially (tnman, 1976). 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.
A small amount of talnI' rotation occurs during
ankle motion, which varies with axial load. Lundberg
X'
~
Y-~Y
,~ ~Z'
Iam _ Ankle joint axis variation. Top, In dorsiflexion (DF) the axis
of motion XX' is inclined downward and I~terally. Middle,
The empirical axis of the ankle joint estimated through In neutral the axis of motion YY' is almost horizontal. Bot-
palpation of the malleoli. The axis angles downward and tom, In plantarflexion the axis ZZ' is inclined downward
posteriorly, moving from medial to lateral. and medially.
Q 2!l'i ?ARJill. BIOMECHANICS Of JOINTS
&.$
CHAPTER 9 • BIOMECHANICS OF THE FOOT ")NI?,A,~2~HJ2~~O
1 marie sWdy. OrttlOP Clin North Am, 4, 75. accessory functions of the anterior talofibular liga-
ment are resistance to anterior talar displacement
from the.: m()J"tisc, c1inicall.\' refclTt:d lO as anlcrior
drawel: and resistance LO int<:rmtl rotation of (he
talus within the mortise (Fig. 9-54). The calcnne-
ofibular ligament spnns both the lateral ankle joint
and lateral subtalar joint. thus conlributing lo sltt)la~
Jar joinl stabilitv (Stephens & S'lllll11arCO, 1992). The
posterior talo(lbular ligamenl is under greatest strain
in ankle dorsiflexion and aCls lo limit posterior (alar
displacement within the monise.: as \\'ell as limit talar
eXlernal rotation (Fig. 9-55) (Sarrafian, 1993a). In
vitro tesling of unloaded ankles subjected to alllcriol"
drawer testing del1lonstrated that the anterior
talofibular ligamcill was most important in plan-
tarnexion and that the calcancofibular and postel"inr
taloflbular ligaments were most important in ankle
dorsiflexion (l3l1ll1clI el aI., 1991 l.
Groove lor
,,:-'- Tibialis Posterior
- Tendo calcaneus
_ Groove for
FI. Halfucis Longus
n-
/f.J
Bursa
- 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
"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
Components of the ankle syndesmosis. measured subjects.
as £
<
ATF o Sprain Injury
A
basketball player with an injury that results from a
filII on a plantarflexed and inverted ankle position
i
during a game (Case Study fig. 9·2·1).
IR
Abrupt rupture
Microtears [ .j.
associa~e~ ~vilh
139 N
sprain InJury
..
I
A
~-----
B
f ~
k.."".......
,_..~ :00""" "",.. ",,,,L _I!!""'l'-""""
-~
-...:.<..
..._ ... _~...~~=. . . . . . . . . . . . . . ------,---~.~.~'-7.".7.=.',.c=,,--" l:.
,:,,:,.~.4,~,~~.
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
daveric ankles in an apparatlls that did not constrain difficult to separate clinically. The calcaneoribular lig-
rotation and demonstrated that talar lilt or an average ament provides stability to inversion and torsional
20 still occllITcd in loaded ankles aftcr sectioning
1
) stresses to both the ankle and sublalar joints. Stephens
both anterior talofibular and calcaneonbular liga- and Sarnmarco (1992) provided an inversion stress
ments. They did not feel thal the articular surfaces (0 cadaveric ankles and sequentially sectioned the
prevented inversion instability during ankle loading. anterior talofibular and calcnncofibular ligaments.
Most studies agree that loading of the ankle results in They found that lip to 500/0 of the inversion observed
increased stability as a result of articular surface con· clinically was coming from the subwlar joint. The
.:' grueney. especially in ankle dorsiflexion. structures that contribute to stability of the subialar
Syndesmotic stability is dependent on the in- joint afC the calcancofibular ligament, the cervical
tegrity or both malleoli. the syndesmotic ligaments, ligament. the interosseous ligament, the lateral talo~
and the deltoid ligamentous complex. During ankle calcaneal ligament, the ligament of ROtlvicrc, and
dorsinexion. there is approximately I rnm of mor- the extensor retinaculum (Harpel: 1991) (Fig. 9-58).
tise widening and 2" of external rotation of the
fibula (Close, 1956). The normal distal fibular mi-
/,'
r gration with loading is I rnm (\'\fang et aI., t 996). Kinetics of the Ankle Joint
This distal fibular mignllion serves to deepen the
The reaction forces on the ankle joint dudng gail
ankle mortise for addcd bony stability (Scranton,
arc equal to or greater than the hip and knee joints,
McMaster, & Kelly, 1976). With disruption of the
respectively. The following static and dynamic
mortisc in an external rotation injury, the s~'n
analyses give an estimate of the magnitude of the re-
desmotic ligaments and deltoid ligaments are tOI'n,
action forces acting on the ankle joint during stand-
the distal fibula fmclures, and the talus displaces
ing, walking, and running.
laterally. A study of cadaveric ankles by 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 t 00/0 for the interosscous membrane.
The deltoid ligament appears to be key in pre-
venting lateml talar shift. Burns et al. (1993) found
only minimaltalar shift in a loaded cadaveric ankle
study with sectioning or the syndesmotic ligaments
until the deltoid ligament was sectioned. Michelson
and colleagues (1990) simulated 4 mm of lateral
fibular displacement in a cadaver study and placed
the ankle under a 100-lb load. Lateral lalar shift
doubled from I to 2 mm following sectioning of the
deltoid ligament. Pereira et al. (1996) simulatcd a
laterally displaced fibular fracture of 4 mm and
placed cadavcric ankles under a 500-N load in vm"·
ious static positions of ankle dorsiflexion and plan-
tarnexion. Cutting the deltoid ligament in this
study did not result in significant lateral talar shift
or alteration in joint contact area or pressure. They Ligaments of the lateral ankle and subtalar joints: 1, ante-
hypothesized that under static loading the talus rior talofibular ligament; 2, posterior talofibular ligament;
moves to a position of maximum congruence 3. calcaneofibular ligament; 4, lateral talocalcaneal liga·
within the mortisc rather than displacing laterally ment; 5, fibulotalocalcanealligament, or ligament of Rou-
with the distal fibula. Most studies agree that the viere; 6, cervical ligament; 7, ligament of the anterior cap-
deltoid ligament and medial malleolus arc most im- sule of the posterior talocalcaneal joint; '8, interosseous
portant in resisting talar external rotation and lat- ligament,
cral talar shift.
STATICS
In a static analysis of the forces acting on the all w
t
these forces are found to be quite large. The joint
reactive force is approximately 2.1 times body
weight. and the Achilles tendon force reaches ap- ForceW
proximately 1.2 times body weight. The great force A
required for rising up on tiptoe explains why the
Calculation Box Figure 9~1-1.
patient with weak gastrocnemius and soleus mus-
cles has difficulty performing the exercise 10 times
in rapid succession. The magnitude of the ankle ~a
joint reaction force explains why a patient with de- '\
generative arthritis of thc ankle has pain while ris- :,\ \
ing on tiptoe.
An in vilro sludv bv Wang el al. (J 996) found lhal
~ " Force A
\
1.2 W
II
!
'--J- __ ."-_ .. /
'-:C J~-"-'.""
BIC'ME:Cl-IA~IICS OF JOINTS
0.8
I '" Summarv
100 60
Percentage of Cycle 1 The I"oot alternates in form and function be-
(stance phase)
t\veen shock-absorbing flexible platform and rigid
B
propulsive lever during different phases of the gait
cvcle.
2 The ankle and subtalar joint act like a mitered
A, The compressive component of the ankle joint reaction hinge. Ankle dorsiflexion and tibial internal rotation
force expressed in multiples of body weight during the are associated with subtalar eversion (pronation);
stance phase of normal walking for five normal subjects
ankle plantarllcxion and tibial external rotation are
and nine patients with joint disease before and after pros-
associated with subtalar inversion (supination).
thetic ankle replacement. B, The fore-aft shear component
produced in the ankle during the stance phase of walking 3 SlIbtalar motion is screw-like and influences
for the same subjects. Reprinted with permission from Stauf- the flexibility of the transverse tarsal joinl. Subta-
fer, R.N., Chao, E. Y5" & Brewster, R.L. (1977). Force and motion lar inversion locks the transverse joint and causes
analysis of the normal, diseased and prosthetic ankle joints. (fin the foot to become rigid; subtalar eversion lIn~
Orthop, 127, 789.
locks the transverse tarsal joint and allows foot
flexibility.
CHAPTER 9 • BIOMECHANICS OF THE ~o6J~©'B,t~~~~~13fiD
j
I
"4 The Lisfranc's joint (tarsornctt\tarsal joints) is 15 The deltoid ligament prevents ankle ever-
intrinsically stable and relatively immobile as a re- sion, extcTnal rotation, and lateral talar shift. It is
sult of its arch-like configuration and the key-like kc~" in maintaining the integl-it,Y of the syndes-
structure of the second tarsometatarsal joint. mosis.
,~ The first metatarsophalangeal joint exhibits a 16 The fibula bears approximately one sixth of the
wiele range of motion, with gliding throughout Illost force exerted through the lower extremity.
or its range and jamming at full extension. JZ The distal syndesmotic ligaments prevent
<,§:,(' The medial longitudinal arch acts like both a separation of the distal fibula and tibia and help
beam and a truss. The arch is elevated through the lransmit force through the distal fibula on wcight-
windlass mechanism of the plantar fascia. The pos- bearing.
terior tibial tendon provides c1ynarnic support to the 18 Ankle joint centroid (cenler of pressure) posi-
arch. tion changes wiLh ankle flexion-cxtension and inver-
? Foot muscle action during standing is rela- sion-eversion. TalaI' surface contact is maximized
tively silent, but sequential firing of both extrinsic and joint pressure is minimized in dorsiOexion.
and intrinsic muscles is necessary to produce a nor- 19 The rorces acting on the ankle can rise to levels
mal gait patlcrn. The anterior tibial musculature exceeding five tin1es body weight during walking
fires during early stance to slow fOOL plantarOexion and thirteen times body weight dudng running.
and prevent fOOl slap. The posterior cnlf muscula-
ture fires during mid- and late stance to control pro~ 20 Narrow shoes and high heels can ad\'ersel~' af-
grcssion of the body over the foot. fect foot mechanics, leading to forefoot deformities,
heel pain, and Achilles contracture.
~8 During barefoot standing, the heel bears 60%
or the load and lhe forefoot bears 28(Yr!. Forefoot
peak pressures occur under the second metatarsal REFERENCES
head. Adt::l:wr. R.S. (1986). Tht:' pr;ll.'tical biomechanics of running.
<,9 During walking, the ccnter of pressure moves :\111 J Sporls Jlcd. I -I. -197.
from the posterolateral heel rapidly across the mid- Ahu. T.K .. KilJoka. I·I.B .. 1..110, Z.I)., el at. (1997). KincmaLics
and Conl.acl c1lilracl(.'ristics of thL" first mCI:lI'.lrsopha-
foot to the forefoot with peak pressures under the langt';d joint. Foot AI/kit' 111/. 18. 170.
second 01· third metatarsal head. At toe-ofr. the hal- Astion, D.J., Debnd, J.T., Otis, J.e., l.'1 <II. (1997). Motion of
lux bears the most pressure. Ihe hindfool after simulated arthrodesis. J 8011t' Joil1t
S/lI'g. i9A. 241.
·10 The heel fat pad is specificallv designed to ab- Ataarian, D.E .. t\1cCrac:kin. 1·1.1.. De\·ito. D.P., CI ill. (1985).
sorb shock dUI'ing heel strike. The plantar fascia at- Bionll.'chanical char:ICIl.'ristics of human ankll.' lig<lItll.'llls.
taches the skin of the hecl and forefoot to Ihe un- Foot .·lllklc', 6. 54.
derlying bony and ligamcntous strUClures_
1:1 The ankle joint has muhiple axes that change
BaruNI. C.J. &. N<lpier, l.R. (1951). The axis of rol<llion at the
ankle joinl in Illall. Its influl.'llCe upon [hi.' form of Ihl.' wlus
:lIld the mobility of the fihula. J fhulf, 86, I.
1
during motion. Minimal talar rotation occurs dur- Basmaji<1Jl. J.V. &: Stedo, G. (1963). The role of flHI:>l:!l.'S in
ing dorsiflexion and plantarflexion. <\rch supporL of Iht:: fool. J BOllI: Joint Sllf~. 45..\. 1184.
;.'
..
'.•:1
',Tt: Ankle joint inslant centers of rotation fall
Beaudoin, A.J., Fiort::, S.~·l., Knillse. \V.R .. eL al. (1991) Effeci
of isolated talocalcaneal fusion on conlact ill Ihe :Inkle >
1
within the talus during range of motion. In 1ll0VC- and talonavicular joints. Foor AI/Uf, 12, 19.
rncnt from plantarnexion to dorsiflexion, joint sur- Bbis, i\'1.~'1.. Green, \V.T., I$.: . \IHll.'rson, M. (1956). Ll.,tlgths of
faces first distract, then glide and eventually jam at the growing fool. J BOllI: JOiHl S/lrg. 38:\. 988.
13ojsen-j\lolIl.'l'. F. &: LllllOI'<..'II.\:. l.. (1979). SignifiC:lIlCc of fr<..·c
the end of dorsiflexion. dorsifk'xion of 1!Jl.' IOt:'S in walking. ..tcUl 0,.11101' Sc:al/ll, 50.
13 Ankle joint stability is determined by joint con- 471.
6111111':U. C.. Thonl<ls, l\..A., Hakorson, T.L., l.'1 :11. (1991). Bio-
gruency and ligamentous integrity. Ankle stability
l1l('c1wnical ('\'31ualioll of the anlt..'rior drawer test: Till.'
increases and depends marc on articular surfacc contrihution of Ihe lah.'ral ankle ligamenLs. FOUl ..Il/kll'. I I.
congnlency during weight-bearing. 389.
Bunk,lt. R.G. (1982). Forces prl.'dicll..'d :tl Ihe :tllkle during
14 The anterior talofibular Hnd calcancofibular
rulllling . .\led Sci Sporls EXn"c, Iol, 30S-310.
ligaments synergistically provide stability againsl Bllrll:'i. W.e. II. Prakash. K., ,\debar. R.. l.'t al. (1993). Tihiola-
inversion during ankle motion. "II' j()inl dynamics: Indit.::ltions for lhl.' syndl.'Slllotil:
:'CI'<..'W-:\ l::ldaH'r study. FOOl .-I,,"-Ie, 14. 153-158.
!
,
Calhoun. J.I-I .. Eng. :\1 .. li. E. ('1 ;d. (199·0.:\ compr... hL'nsh·c Il.' Di_\orda\ (p. 41). O'\iord: BIa . : b'l'!1 Sd~·I1!i"il,.' Public,,_
study of !1t"l..'S:iUI"I.' dislribulion in th~' :lnkk joint with in- li(H1S.
n:rsion and cn:rsion. FOOl AJlk/~ 1111. 15. 123-[33. lnmall. \'.T. (19761. Til. JO;IH_' or dlt' AI/kit-. l1ultimort:
Cass, J.R. &. s~,tlh.':-. H. (199-0. Auld ... in stahility: In vitro Williams 6: \\·ilkin:!o.
kinL'nw.tics in r...sponsl· (0 :lxi:llioad. FoOl ..\Ilk/c II/I. 15(3). J~lhs:-- ..\1.1-1.. KUlllllh·r. F.. &. ,\lidldsoll. J.D. (199hJ. (ll\'L'Slj.
13~-I~O. g~ltion into lill' bt p:lds of Ih...· sok- of th~' foo!: H~d pre~·
C.l\·anagh, P.R .. Morng. E., BOU!lOIl, :\.J.I\-I.. L'I a!. (1997). Thl,,' sure s!lldi~·s. Fl)OI .. llIklt'. 13.22/.
rl'latiollship of SI;\lic foot :-tnll.:tUl"i· to dyn;ll1lic fOOl func· J;dlS~ . .\1.11 .. :\-1 ichd . . l.lI'l. J.D .. Desai. P.. r..'l :11. (1~91h). Im'esll-
lioll. J BioJ/ll.!t:I/(lIIic_.;, 30, 243-250. g:ltions into lhe bt p~lds of Illl' sole of I Ill' foot: :\IHllorny
Ca\"anagh. P.R .. Rodgi.:l's. rvl.\l.. &. lib()~hi. A. (1987). PressLln:.' and histulogy, FOOl .. II/Ide. 13.133.
distribulion undt.=r s,\"mptom . frcc !"L't:! during bardont Kil:\Oka. I'I.B .. Lun, 70.1'.. \,\: :\n. K.N. (1997), Efl'l· ... l oi posterior
standing. FOOl AI/kle. 7, 262. libia! I~'ndoll on th ... an.:h 01' the fOOL during sirnul:llcd weight-
Cawli-.'\', P.W. &. Fmncc, E.P. (1991). BiolllC'(:h:lnio; of thc lat- hearing: Bionl~'ch:tnk,d ;uwh'sis. FOil! .. \nk/,' 1111. 18,43.
era'i ligal1\('llls of lhl..' ankle: An e\"alll:llioll of thL' effects of l\..ial'r:-.ga:IHI-:\nd~·rsl.'n. P.. \Vdh ... lund. J.O .. I!('lmig. P.. d al.
<lxialload ;lIld single plane motion 011 Iig;UHI'IlI slr;lin p,lt- {19~9J. Stahilizing dfl'Ct (If the tibiOl:ak:lll ...· al bscick of
tcrns. FOOl ..\Ilkk 12. 92. thL' ddlOid on hindfoot joillt mO\'l'lll~'lltS: :\n ~·.·qwrilllcntal
Cheng. J.CY.. LL"ung. S.S.F.. lcung, .-\.K.l... et al. (1997). ~tml.'-". FOl!! .. Iukll'. /(), 30.
Ch'lllgt:.' of foot sizL' with wcighthe:lring. r\ sludy of 2829 "-hiliI..'. K.. H:IIlSI.'Il, S.T.. c.:. \Iasqlll·kl, ".c. (1994 L Clinical,
childr~'n 3 to 18 YC,lr~ of age. Clill OnJwp. 3-12. 123. quanlitali\"l;:' aSSn;Sllll'lll of firsl larsolll.... till,lrs.11 mobility
Clark. T.E. (19S0J. The Pn'Hllre lJi.";lrihl/licHl UI/{!cr fh .. FOOl (Ill Ihe s,lgitl;d p1;Il\~' ;lnd il~ r.. . lation 10 h.dlu.'\ ,·:dgus (It;;-
Duril/g 8(/1'4001 H'alki,l,li. Uni\'l'rsity Park. f'.... nnsyh'ania: formily. [-'OOf Allkll' 1111. 15( [J, 9-13.
Pcnn Sl.:lli.' Uni\'crsity. l.all1<lr~·all.\, L.\\·. (1971). Kin~'lIlatiL' ITh:;:lsurl'IlII,,'nb ill the
Close. J . R. (1956), SOIllI' applications of thi.' fUIH:tion;:tl ~tlldy of hlllll:1I1 w'ilking. Bilil Prosthl'f Rl·.,. 10. I.
,lnalomy of the <lnkk joint. J BOlle Jnillf Slfr~. 386, 761. Lundh...-rg, ..\ .. Goldil'. I .. K:ilin. B., ~'l :11. (19~9a). Kin~·lllatics
Daly, P.J., Kitaob, I·I.B .....\: Chao. E.Y.S. (1992). Pbnl:ir f:ts· (If IhL' :lnkkffolll ('(Illlpk-\: PI;llItarfll·,ion :Ind dl,rsifk·xioll.
ciotomy for intnlct:tblc planlar fasciillS: Clinical !'csults FOol .. InUt'. 9. 194-100.
and biomt.'dl:lnil.:~\1 c\'altmtion, FOOl AI/kIt'. 13. 188. l.undbl'l"g . ...\ .. S'·l'ns:-.l.ln. O.K .. B.\"Itllld. C.. ~'I :11. (1989b}.
D:t\'is, W.l-! .. Sobl:1, M .. Diarln, E.F. ..... t :tl. (1996). Gross. his . Kinel1latics of I Ill' :lnkldfoOI cOlllplc-x,--P:lrt ~: Pronation
tological. and mil.:nwascubr analolll~' ;lIld bioll1cchanicd :Illd slIpin:llio!l. rool ..\I/h!('. 9. 248.
tesling of the spring ligamt.·111 complex. FOOl ..II/kIt' IlIl. 17. l.undh(·r!! ...\ .. S\·.. ' llsfln. O.K .. N"'111('[1I. G.. (.[ :'d. (1%9i...'1. Kine-
95. lllati(~ 01' Ihe :lllkk,/foOI ~·()Jllpk·.\--Parl 3: lnfllll'IKe of kg
Earll. :\1., \Vaync. J.. Brodrick. C. ct 411. (1996). Contribution n:Il:llioll. roO! :llIkll'. V. 304.
of the ddlOid ligamellt to ankle joint cont,lct characteris· Lundherg, A., S\"('llS~lll. O.h .. N(:llli..'th, G., l'l :11. (1989£1). Thl:
tics: r\ GH!<IH'l' study, foot AIlk/e Illf. Ii, 317, axis of rotation of thc :llIkk .ioint. J BOlI l ' Joilll Sll"~, liB,
ElfllHan, H. (1960). The transverse tars.t! joint and its con- 94-Y9,
tro!. Clin OnllOp, 16. 41. .\l~lnn, R...\. (1982>. Biollll·t.:h:1I1ics of rUllllill~. In ..l,.\OS Syll1" ;,
rick, R. (191 I). J-/wulbuch dcr '-\/Hl{OJl/il , /fI1i! .\It'cJHlllik da Ct'.. plIsilllJl 011 Ihl' FO//l /llId I.l'~ ill R/IlIII;II~ Sp{/1'(S (pp. 30-4-0.
b,ke, Jena Fischer. SL Louis: C\· .\Iosh\" Co.
Frey. c.. Thompson, F.. Smith. J .. ~'I al. (1993). Am~'1"ican Or· '\!anll. R ..-\. lI97')). Bi~md:hJni\'·s of th ... rnO!. In ..\ ..\OS :\£ias
thopaedic Foot ;llld Ankle- Society wOlllen's ~hot: stirn:.... (It" Orr!lolit·s: Bioll1n:lltIlJint! PrillciJJk,; tllld :l{lp/iclItiol/ (pl'.
FOOf ..iI/kit:, 14. 7S-SI. 257-266). Sl. Louis: C\', .\Io:!ob.\' Co.
Fritz, G.R. & Pricskorn, D. (1993). Fina IIk'lat'lrsocunciform .\bnn. R..-\. (1993)' Biollk'l:h:lllics of thl' foot :Illd aukit-. In
motion: :\ radiographic and ~tatislical an~tlysis. FOOf Allklc SlIl";.!ay o{ llli: FpPI illld ..\/lk/t· (PP. 3-431. 51. L.ollis: C\'..
llIl, /6, 117. \Iosby Co.
Grecnwilld, S. (I 97i'). Unpllhlish~d d<ll;:t dtl'd in R.N. Stauf- :\lallkr. J.T. (19411. '\\()\"l'r1ll'IHS of thl' sllhwlar Hnd Ir;lIlS\"l:rSi:
fer, E.Y.S. Chao. ~\nd C. Brewster. F()l'c~' alld mOlion analy- lars;l! joinb..··1))111 Rl'(.'. 80. 397.
sis of the lIorll\;d. diseased, and pr(lslh~'lic ;Inkle joint. C!i!1 Mit.:helsnn. J.D .. Clal'h'. 1-1../ .. &. Jinnah. R.I-!. (1990). The ef-
Onhop. 127. [89. f~'cl 01' loading on libiol:dar alignlllent in (,;,Id;\\'er ankks.
Harper. ;\1. (1987). Deltoid ligamcllt: An t:Xpl.'l'illlClltal cvalua . fOOl .-\111:11.'. 10. 280.
tion of funclion. FOOl Allkle, 8. 19. \lidl~·lson. J.D. 6.: Hl.'lgl'Il\C'. S.L. Jr. (1995). Kill~'lllati(:s of the
Harpcr. '\'1. (1991). The lateral ligamentous support of tht.' ;l.\i:tll~· loaded :Inkk. rHiIl ..\l1klt' 1111, 16,577,
subtalar joint. FOOl Allklt', II, 334. :\tizl.:I. ,\I.S. (1993). Th~' role of the plallt~tr first melatarsal
Hil-ks, J,H. (1954). Thc mechanics of the foOl 11: The plantar l.·ul\~'ir()rll1 ligallwnt in w('iglllhearing 011 11ll" first
aponeurosis and the arch, ) ..lllal, 88. ~5. Illl'tatarsai. fOOl .-\lIkle. I-l, 82.
Hinterm<tnn. B, '* Nigg. B,M. (1993). In vitro kinem.. tics of
the .. xi .. lly loaded ankle cOJnple.'\ in r('sponsl' to dorsiflcx·
.\I()rlon, D,J. (l935L TlI(' /lumlill Fool. liS Emlmiol/. Physio/..
(1';:.'" 111111 FII//dio//al J)i...;on/as. ;'\('\\. York: COllllllhi:1 Uni\·L'r·
ion and pl:IIH:ll'flexion. fOOl AI/kl.: 1'11. 16. 514, Sil.\· Pr...· ss .
Huang, C.K .. Kitaoka, 1·1.8,. An. K,N .. et :11. (1993). Biom~'· .\ Illrra.,·. .\-J.P., Drought, .-\.11 .. &. Kor.\'. R.C (1964). Walking
chanical c\'aIUalion of longitudinal <In..-h sl~lhili[y. fool AIl- paul'rlls in nnnll:ll Ill~·n. J BOllt' JOill1 51/1':-:, ,lti.-\, 335-360.
k!c, I{ 333. ~\Iurray, ,\I.P., Knry, R.C, 6.: Sepie, S.B. (19;0). \V'llking. pal-
Hutton, W.C" SCUlL J.R.R" 6: Stokes, J.:\.F. (1973) The llll'- terns or normal woml'n . .-II'"h I'hys ,\fed Udwhil. 51. 637,
chanies of thl! fool. In L. Klentrlllan (Ed.). The FoOl tIIul
CHAPTER 9 • BIOMECHA~IICS OF THE
Nigg, B.:'V1., Skorran, G., Frank, e.8., l't .d. (1990), Elongation SherefT, ,\l.J., Ikjahi, F.J .. &. Kummer, F.J. (1986). Kinernatics
and forces of ankle ligamellts in a ph:,siological range 01 or the first met~llarsophabngeal joint. .I BOlle Joint SI/rg,
motion. Fool ..\/ll:Ie. I J, 30. 68..1, 392.
Okrud, C. &. Rosendahl. Y. (1987). Torsion-transmitting prop- Silver, R.I.., de la G~lrz~l, .I., l\: Rang, M. (1985). The myth of
erties of the hindfoo!. Cfill On/wI', 2/4, 285. llluscle balance: i\ stud~ of 1"t.'lati\'e strengths ~lnd excur·
Ohdrie-Harris, D.1 .. Reed, S.c.. &. Hedman, T.P. (1994), Dis- sions about the foot and ankle. J BOlle Joiu! Surg, 678,
~rllplion of the ankk syndesmosis: Biomechanical stud~' of 432.
ligamentous reslrainb. /\rlhroscopy, 10, 558~560. Snow, R.E., \Villiams, K.R., & Holmes, G.B. Jr (1992). The d-
Ouzoniall, T.1. & ShL'I'l'IT, \.Lf. (1989l. In \'tIro dClL'rrnination reets of wearing high heeled shoes on pedal pressures in
of midfool motion. 1"001 Allkte, !O, 140. women. Foo! Allkle, /3. 85-92.
Pereira, D.S .. Koral, K.J., Resnick, R.B .. ct al. (1996), libio- So~\nll's, R.\\'. (1985), Foot pressures during gait. J 13iomi.'ch
talar contact area and pressure distribution: Th(' effect of Eng, 7, 120-126.
mortise widening and syndesmosis fixation. FOOl AI/kle Stauffer, R.N., Chao, E.'{S., &: Brewster, R.I.. (1977). Force
11Il, 17, 269. and !'ll(Jti(lll ~lnal.\'sis of till: n()1'mal, disl'<lsl:d and pros-
Perry, J. (1983), Anatomy and biomechanics or the hindfoot. thetic ankle joints. Clin Orthop, /27, 189.
Cfill OrtflOP, 177, 9. Stephens, :\1.\1. & Sammarco, G.J. (1992). The stabilizing
Proctor, P. &: Paul. J.P. (1982). Ankle joint biomechanics. J role of the lateral ligalllt.'nt complex around the ankle and
Bio!llcch, /5, 627. subtalar joints. FOOl AI/klc, 13, 130.
Renstrom, P., \Venz, \1., Inc<l\'o, S., et aL (1988). Strain on Stiehl, J.B., Skrade, D.A., Needleman. R.I.., et al. ([ 993). Ef-
the lateral ligaments of the ankle. FOOl Ank/e, 9, 59. fect of a.'\i~ll load and ankle position on ankle stability. J
Sammarco, G.J. (1980). Biomechanics of the fool. In \'.1-1. Ort/lOp 7/"al/l1l(/, 7, 72-77.
Frankel &: \-1. Nordin (Eds.), Basic Biolllcchallics of Ihe Stormont. D.\I., :\10rrey, B.F.. An, K.N., et al. (1985). Stabil-
AllisclIloskdCf(/! Systelll (2nd ed., pp. 193-2(9). Philadel- ity of the loaded ankle. Relation between articular re-
phia: Lea &. Febiger. straint and prinwr.\' and sec()[ldar~' restrainis . ..1111 J Sports
Sammarco, G.J. (1995). Peroneus longus tendon tears: Acute Met!, 13, 295.
and chronic. Foot Ankh, lilt. /6(51,245-253. Thordarson, D.B.. Schmotzer, H . Chon, .I .. et al. (1995). Dy-
Sa tTl lTIan:o , G.J .. Burnstein, A.H., &. Frankel. V.I-I. (1973). Bio- namic support of the human longitudinal arch. Clill Or-
mechanics of the ankle: A kinematic study. O/"lhop Cli/I lhop. 316, 165.
Norlh Alii, -t, 75. Wang, O.W., Whiltle, .\1.. Cunningham . .I .. et al. (1996). Fibula
Sarrafian, S.K. (1987), Functional characteristics of the foot ~Hld its ligaments in load transmission and ankle joint sta-
and plantar aponeurosis under tibiotalar loading. FOOl .'111- bilit.\". Clill Ort/lOp. 330. 261.
l:lc, 8, 4. Wanin:nhaus, A. & Pn:Llcrklieber, \1. (1989), First tar-
Sal'l'afian, S.K. (1993a}. FUllctional anatomy of the foot and sometatarsal joint: Anatomical and biomeehanical study.
ankle. In An(ltomy or the Foo! ami Anl:lc (pp. 474-602l. FOOl Allkfe, 9, 153.
Philadelphia: Lippincott. \Vaters, R.I.., Hislop, I-U., Perry, .I., et al. (1978). Energctics:
Sarnlfian, S.K. (1993b). Retaining systems and compart- Application of the study and m,Hl~lg('mcnt of locomotor
ments. In A/UlIOIllY or the Fool (lilt! Auk/e (pp. 137-149). disabilities. Orlhop Clill North Am, 9, 351.
Philadelphia: Lippincott. \Vright. D.G" Desai, S.\1.. 6: Henderson, \V.H. (19M), Action
Scranton, P.E., ;V\c,\'laster, J.I-I., &. Kelly, E. (1976). Dynamic of the sublalar and ankle joilll comrle.'\ during the stance
fibular function: A new concept. Clill OrfflOp, 118,76-81. phase of walking . .1 130111.' 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·Abdominal Pressure
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 3
10
and transfer loads 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 4
spine gains stability from the intervertebral discs
and from the surrounding ligaments and muscles;
the discs and ligaments provide intrinsic stability 5
Molion
segment
~-----
tissues (Fig, 10- I). The anterior pOl,tion of the seg-
ment is C0111posed of two superimposed interverte-
bral bodies, the intervertebral disc. and the longitu-
I Anteroposterior (A) and lateral (B) roentgenograms of the dinal ligaments (Fig. 10-2). The c9ITcsponding
I lumbar spine. One motion segment, the functional unit of vertebral arches, the intervertebral joints formed by
1 the spine, is indicated. the facets, thc transverse and spinolls processes, and
I!l
various ligaments make up the postcrior portion. The
257
BICIMECHANICS Of JOINTS
sic pressure in the unloaded disc of approximately stl·ess in the annulus fibroslis in the thoracic spine is
\0 N per square centimeter (Nachemson, 1960). This less than that in the lurnbar spine because of differ-
intrinsic pressure, or pre-stress, in the disc results ences in disc geometry. The higher rario or disc di-
from forces exerted by the longitudinal ligaments ameter to height in the thoracic discs reduces the cir-
and the ligamentum flavum. During loading of the cumferential stress in these discs (Kulak et aI., 1975).
spine. the nucleus pulposus acts hydrostatically Degeneration of a disc reduces its protcoglycan
(Nachemson. t 960), allowing a unifonn distribution content and thus its hydrophilic capacity (Fig. 10-5,
of pressure throughout the disc; hence, the entire A-C). As the disc becomes less hydrated, its elastic-
disc serves a hydrostatic function in the motion seg- ity and its ability to store energy and distribute
ment, acting as a clishion between the vertebral bod- loads gradually decrease; these changes make the
ies to SLare energy and distribute loads. disc(s) more vulnerable to stl-csses.
In a disc loaded in compression. the pressure is
approximately 1.5 times the externallyay)plicd load
THE POSTERIOR PORTION
per unit area. Because the nuclear material is only '1
OF THE MOTION SEGMENT
slightly compressible, a compressive load makes the !
disc bulge laterally; circumferential tensile stress is The posterior portion of the Illotion segment guides
slIst"ined by the annular fibers. In the lumbar spine
the tensile stress in the posteriol- part of the annulus
fibrosus has been estimated to be four LO five times
its movement. The t~'pe of motion possible at any
IC\'e1 of the spine is determined b~" the oriental ion of
the facets of the inlervenebral joints to the trans-
II
the applied axial compressive load (Galante, 1967; verse and frontal planes. This orientation changes
Nachemson, 1960, 1963) (Fig. 10-4). The tensile throughollt the spine.
._J
"
H
d
1j
I,
!II
II
;-~
~!!II!JIIII!~~~~~~~~~~-----'---~~;~"_'.<"-'=.J
~ -~_.,__ ;- ... _~-<C-'t'"
OC~:~§,PI).RT !I • BIOMECHANICS OF JOINTS
Except for the facets of the two uppermost cervi- a high collagen content, which limits tht.:ir extensi-
cal vertebrae (CI and C2), which arc parallel to the bility during spine motion. The ligalllL'llllllll flavull1,
transverse plane, the facets of the cervical inten.1cr- which connects two adjaCL'1l1 \'(,I"lcbral arches longi-
tcbral joints are oriented at a 45° angle to the trans- (lldinall~·, is an exception. having a lal'gc percentage
verse plane and arc parallel to the frontal plane (Fig. of dastin. The clasticit.Y of (his ligamclll <.lIlows it to
10-6A). This alignment of the joints of C3 to C7 al- contract during c.'\h..:nsion of the spine and 10 elon-
lows flexion, extension, lateral flexion, and rotation. gate during nc.'\ion. Even when the spine is in a neu-
0
The facets of the thoracic joints arc oriented at a 60 tral position, the ligamentum flavul11 is uncleI' con-
angle to the transverse plane and at a 20° angle to Slant tension as a result of its elastic properties.
the frontal plane (Fig. 10-68); this orientation allows Because it is located at a distance from the center or
lateral flexion, rotation, and some flexion and exten- motion in the disc, il pre-stresses the disc; that is,
sion. In the lurnbar region. the facets arc oriented at along with the longillldinal ligaments, it creates an
right angles to the transverse plane and at a 45° irllradiscal pressure and thus helps provide intl-insic
angle to the frontal plane (Fig. 10·6C) (White & support to the spine (Nachemson &. EV<.H1s, 1968;
Panjabi. 1978). This alignment allows Oexion, exten- Rolander, 1966). Research suggests that with degen-
sion, and lateral Oexion, but almost no rotation. The erative changes such as spond~"lolisthesis, traction
lumbosacral joints differ from the other lumbar in- spurs, and disc degeneration, which rna}' lead to in-
tervertebral joints in that the oblique orientation of stability, altered mechanical stress \vill increasingly
the facets allows appreciable rotation (Lumsden & load the ligamentum fluvul11 and callSt: hypertrophy
Morris, 1968). The above-cited values for facet ori- (FlIkllyama el aI., 1995).
entation are only approximations, as considerable The amount of strain on the various ligaments
variation is found within and among individuals. differs with the type of motion of the spine, During
The facets guide movement of the Illotion segment llc.'\ion, the interspinous ligaments arc subjected to
and have a load-bearing function. Load-sharing be- the greatest strain, followed by' the capsular liga-
tween the facets and the disc varies with the position ments and the ligamcnturn flavum. During exten-
of the spine. The loads on the facets arc greatest (ap- sion, the anterior longitudinal ligarnent bears the
proximately 30% of the lotal load) when the spine is greatest strain. During latcral fle:don, the contralat-
hyperextended (King et aI., 1975). Because the facets eral lransverse ligament sustains the highest
arc not the primary SUPPOI1 structure in extension, if strains. followed by the ligament nuvulll and the
total compromise of these joints occurs, an alternate capsular ligaments. The capsular ligaments of the
path of loading is established. This path involves the facet joints bear the most strain during rotation
transfer of axial loads to the annulus and anterior (Panjabi et aI., 1982).
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 Kinematics
rotation (EI-Bohy & King, 1986). The vertebral
arches and intervertebral joints play an important AClive mol ion of the spine as in any joint is pro-
role in resisting shear forces. This function is demon- duced b.'/ the coordinated interaction of nerves
strated by the fact that patients with deranged arches and muscles. Agonistic n1uscles (prime movers)
or defective joints (e.g., from spondylolysis and lis- initiate and carry out motion and antagonislic
thesis) are at increased risk for fOl'\vard displacement muscles control and modif." the motion, while COH
of tbe vertebral body (Adams & Hutton, 1983; Mi11er contraction or both groups stabilizes the spine,
et aI., 1983) (Case Study 10·1). The transverse and The range of motion differs at various levels of the
spinolls processes seniC as sites of attachment for the spine and depends on the orientation of the facels
spinal muscles, whose activity initiates spine motion of the intervertebraljoinls (Fig. 10-6). Motion be-
and provides extrinsic stability. tween two vertebrae is small and docs not occur
independently; all spine movements involve the
combined action of several motion segments. The
,,- THE LIGAMENTS OF THE SPINE
skeletal structures that influence motion of the
The ligamentous structures surrounding the spine lrunk are the rib cage, which limits thoracic 1110-
contribute to its intrinsic stability (Fig. 10-2). All lion. and the pelvis, which augments trunk move-
spine ligaments except the ligamentum Ibvulll have ments by tilting.
;;;:
~_Q- ' .. ; -
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
,i;
•t"
~,.
Case Study Figure 10-1-1. Case Study Figure 10-1-2.
SEGMENTAL MOTION OF THE SPINE the relative amount of motion at different levels of
the spine. Representative values from \Vhite and
The vertebrae have six degrees of freedom: rotation
Panjabi (1978) are presented in Figure 10-7 10 al-
about and translation along a transverse, a sagittal.
lc)\v a comparison of motion at various levels of the
and a longitudinal axis. The motion produced dur-
thoracic and lumbar spine. (Representative values
ing nexion. extension, lateral nexion, and axial rota-
for motion in the cendcal spine are included for
tion of the spine is a complex combined motion re-
comparison.)
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
Range of Motion
~:" segments, approximately 6° in the mid thoracic re-
Various investigations using autopsy material or gion, and approximately 12° in the two lower tho-
radiographic measurements in vivo have shown di~ racic segments. This range progressively increases
vergent values for the range of motion of indivi- in the lumbar Illotion segments. reaching a maxi-
dual motion segments, but there is agreement on mum of 20' al Ihe lumbosacral 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 center of flexion-extension and lateral flexion in a
of the lower thoracic segments, reaching 8 to go. In motion segment of the lumbar spine lies within the
the upper thoracic segments, the range is uniformly disc under normal conditions (Fig. 10-8A) (Cossette
6°. Six degrees of lateral flexion is also found in each et aI., 1971; Rolandel~ 1966). With abnormal concli-
of all lumbar segments except the lumbosacral seg- tions such as pronounced disc degeneration, the
ment, \vhich demonstrates only 3° of 111otion. instantaneous center pathway will be altered (Fig.
Rotation is greatest in the upper segments of the 10-8B) (Gertzbein et aI., 1985; Reichmann et aI., 1972).
thoracic spine, \vhere the range is 9°, The range of
rotation progressively decreases caudally, reaching
FUNCTIONAL MOTION OF THE SPINE
2° in the lower 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
Surface Joint Motion
motion of the spine can be given. Variations among
i\''Iotion between the surfaces of two adjacent verte- individuals are large and show a Gaussian distribu~
brae during flexion-extension or lateral flexion may lion in the three planes. The range of motion is
be analyzed b:v means of the instant center method strongly age~dependent, decreasing ·b~v approxi-
of Reuleaux. The procedure is essentially the sanle mately 30% from youth to old age, although \vith ag-
as that described for the cc,·vical spine in Chapter ing, loss of range of motion is noted in flexion and
11 (see Figs. 11-18 and 11-19). The instantaneous lateral bending while axial rotation motion is main-
GIFttfi~~T \I • BIOMECHANICS OF JOINTS
G-J
iJ
~
noted between the sexes: men have greater mobility
in flexion and extension whereas women arc more
mobile in later,,1 Oexion (Bie.-ing-Sorensen, 1984;
Moll & Wright, 1971). Loss of range of motion in the
A
~ B
(. ' L5
mainly by motion in the cervical spine and hips.
THE MUSCLES
The spinal muscles can be divided into flexors and
extensors. The main flexors arc the abdominal mus-
Instant center pathway for a normal cadaver spine (A) and a
cles (the reClus abdominis muscles, the intern,,) and
cadaver spine with moderate disc degeneration (B). Instant external oblique muscles. and the transverse ab-
centers were determined for 3~ intervals of motion from dominallllllsclc) and the psoas muscles. In general,
maximum extension to maximum flexion. In the normal muscles anterior to the vertebral column act as flex-
spine, all instant <enters fell within a small area in the disc. ors. The main extensors arc the ercCLOr spinae mus-
In the degenerated spine. the centers were displaced. and cles. the multifidus muscles. and the intcnransver-
hence the surface motion was abnormal. Reprinted wirh per· sarii muscles auached to the posterior elements. 1n
mission from Gerr£bein, S.D., er al. (1985). Centrode patterns and general, the muscles posterior to the vertebral
segmental instability in degenerative disc (Jisease. Spine, 10,257. columns act as extensors (Fig. 10-9). The extensor
Anterior
Rectus abdominis muscle Transversalis fascia
, ..
Transversalis
Internal oblique Vertebral body
External oblique
Lumbar fascia:
Anterior
Middle
Posterior
Quadratus Erector
lumborum spinae muscle
muscle
Posterior
An MRI transverse cross-section of the body at the l4 level of a normal adult human spine. The major trunk ffius<les are shown
(R, right; l, left). By courtesy (rom Ali SfJeikzahed, PhD., Hospilal for Joint Diseases, Mr. Sinai, NYU Health, New York, NY, USA.
CHAPTER 10. BIOMECHANICS Of THE LUIIVIO'f.\K
\\
VFRA (pV)
\( 1\
abdominal muscles are active on both sides of
the spine, as both ipsilateral and contralateral mus-
5'
cles cooperate to produce this movement. High
coactivation has been measured for axial rotation
(Lavender et al.. 1992; Pope et aI., 1986).
FIG. 10-11
------
Pelvic Motion
Example of eleetromyographic activity of the erector
Functional trunk movements not only involve a
spinae muscles collected with surface electrodes during
combined motion of different parts of the spine but side-bending of the trunk. The figure illustrates trunk
also require the cooperation of the pelvis because bending to the right and muscle activity at the ll, l3. and
pelvic Inotion is essential for increasing the range of lS level of the lumbar spine. Substantial contralateral mus-
functional motion of the trunk. The relationship be- cle activity (left) of the erector spinae muscles is recorded
twecn pelvic movements and spinal motion is gen- when bending to the right to maintain equilibrium. Repro-
erally analyzed in terms of motion of the lum- duced wirh permission from Andersson. G.BL Orrengren. R.• &
bosacral joints. the hip joints. Ol' both (Fig. 10-12). Nachemson. A. (1977). fIHradiscaf pressure. intra-abdominal
Load transfer From the spine to the pelvis occurs pressure and myoelectric back muscle dcrivily related to poswre
through the sacroiliac (SI) joint. Biomechanical and foading. Clin OrtllOp, 129. 156,
,I,
arc the EiV1G-c1l'iven model based on c!cctromyo-
{ ',.
The pelvic ring with its linkage to the spine and the lower graphic trunk mllscle rccordings and the morc tra-
extremities. The antero-posterior view of these structures ditional biomcchanical model based on trunk mo-
on film gives a hint of the irregular shape of the sacroiliac mcnts and [OI'ces (Chaffin & Anderson, 1991;
joint 5urlaces. but an oblique projection is required for an Lavender et al.. 1992; Marras & Granata, 1995;
accurate view of the joints. Sheikhzadeh, [1997]. The eflixi or pllre alld COli/-
billed loading OIl the recruitment pattern or ten se-
lecled Intlll< IIlllscles, Unpublished doctoral thesis.
New York University. New York).
/' .......
)i
~
mate!y 20 to 40 N (Gregersen & Lucas, 1967; Lucas ~ : r'"
((
& 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 \ i !
stabilize and modify the loads on the spine in both 'J
dynamic and static situations.
.~
500
~ . '"
Nonspecific Low Back Pain
I
'
0 Nachemson, 1975 ".~
35-year-old male presents complaints of low back
"(;9.-
,S
400 0 Wilke, 1999
~ A pain with radiation lO the posterior aspect of the leit
en thigh, not past the knee. His pain staned 3 weeks ago, af-
c
'5 % ter working a 12-hour shift, when he lifted \-vhile twisting
300
c
'1" ~
'"
iii i~
',Z
c!ll an unusually large, yet lightweight box, During the iirst
£ ] week of pain, he visited his physician, who prescribed pain
;) ~
,;I J.!
'C
~
,.i
200 medication. Currently, he is still in pain, panieufarly during
ro"
;,
,~
~~~~
ina I and back muscles and poor flexibility in hiS ham-
~ '1 strings. psoas, and back muscles. Neurological tests were
c
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
.,. -~ .-;
I
I
conwct with the backrest. increasing the loads on the
lumbar spine (Andersson et aI., 1974) (Fig. 10-17).
Loads on the spine arc minimized when an incli-
assumes a supine position because the loads
b)' the bod;!s weight arc eliminated (Fig,
With the body supine and the knees ex-
>tenden, the pull of the vertebral ponion of the psoas
muscle produces some loads on the lumbar spine. !
'"-~--.~. ----,.
I
the hips and knees bent and supported, how-
the !umb4\r lordosis straightens out as the psoas
>'n'luscle relaxes and the loads decrease (Fig. 10-18). B
FiG."'10.18
STATIC LOADS ON THE LUMBAR SPINE
DURING LIFTING A, When a person assumes a supine position with legs
The highest loads on the spine are generally pro- straight, the pull of the vertebral portion of the psoas
!t~>;.,S7 duced by c:'\ternalloads, such as lifting a heavy ob- muscle produces some loads on the lumbar spine. B, When
ject. Just how mllch load can be sustained by the the hips and knees are bent and supported, the psoas mus-
spine before damage occurs continues to be inves- cle relaxes and the loads on the lumbar spine decrease.
tigated. Pioneering swdies by Eie (1966) of lumbar I
•
I~Di~sc1P;re~ss~u~re=========~;I:'===1~
were tolerated before conlplete disruption of mo-
tion segmel1l occurred. The flexion angle before
failure was recorded as 20° with 9 mm of horizon-
tal displacement bct\veen the two vertebrae (0$-
valder et aL, 1990). 80th age and degree of disc de-
Influence of backrest inclination and back support on generation innuence the range preceding failure.
loads of the lumbar spine. in terms of pressure in the third Although the vertebral body strength is relative to
lumbar disc, during supported sitting. A, Backrest inclina-
Ihe bone mass, with aging ~ the decline in bone
~ : tion is 90" and disc pressure is at a maximum. e, Addition
strength is more pronounced than is the decline in
of a lumbar support decreases the disc pressure. C, Back-
ward inclination of the backrest is 110", but with no lum-
bone mass (iVlosekildc, 1993).
bar support it produces less disc pressure. D. Addition of a Eie (1966) and Ranu (1990) observed that during
lumbar support with this degree of backrest inclination compressive testing the fracture point was reached
further decreases the pressure. E, Shifting the support to in the vertebral body, or end plate, before the inter-
the thoracic region pushes the upper body forward, mov- vertebral disc sustained damage. This finding shows
ing the lumbar spine toward kyphosis and increasing the that the bone is less capable of resisting compres~
disc pressure. Adapted with permission from Andersson, G.8.1.. sian than is an intact e1isc, During the testing, a yield
Ortengren, R.. Nc1CiJemson, A.. et at. (1974). Lumbar disc pres- point was reached before the vertebra or end plate
sure and myoelectric back muscle activity during sitting. 1. SHld-
fractured. \Vhen the load was removed at this point.
ies on cln experimental chair. Scand J Rehabil Med, 6. 104.
the vertebral body recovered but was morc suscep-
lible to damage when reloaded.
;,
BICIME:CHANICS OF JOINTS
!ji/! I ~:I~~;Cto~::haet~h~e:u~::r~;i~~on
load positioncd betwcen the feet and thcrcby reduc-
inn the lever arm of the extcrnal load (van Dieen ct
al~ 1999) (Calculafion Box 10-3),
lii}i!, I
~:
;:~ n~ ~O~; ,:;: dSehn~: ~1 i:b~:~~::;h~nBgO;~i~~r~s 10-
A literature review revealed no significant differ-
cnce in spinal compression and shear computed
forces betwcen SlOOp or squat lifting (van Dicenc ct
lifted, In Case 1 (Calculation Box fig. 10-2-1) (upright
at., 1999). However, it was suggestcd lhat loss or bal-
f standing), the lever arm of the force produced by the.- f
I weight of the objecr (lp) is 30 em. creating a forward-
ance is more likely during squat lifting. which in
turn m,,)' ,-,dd addilional stresses on the lumbar
r
i' '/
~',
bending moment of 60 Nm (200 N x 0.3 m), The
forward-bending moment created by the upper body is
9 Nm; the length of the lever arm (LW) is estimated to
"
spine.
In thc following examplc, thc frcc-body tech-
nique for coplanar forces will be used to make a
~ 2 em, and the force produced by the weight of the upper simplified calculation of the static loads on the
t',; body is 450 N. Thu5, the tolal forward-bending moment
J
~.'
spine as an object is lifted (Calculation Boxes 10-4;\
in Case 1 is equal to 69 Nm (60 Nm + 9 N(m). b d and 10-4B).
• In Case 2 (Calculation Box fig. 1O-2 -2J upper 0 y
Calculations made in this way for one point in
flexed forward), the lever arm of the force produced by
lime during lifting arc valuable for demonslrating
f the weight of the object (l..) is increased to 40 em, creat- how the lever arms of the forces produccd by the
I
Ii ing a fon,.vard·bending moment of 80 Nm (200 N x 0.4 m).
furthermore, ,he force of 450 N produced by the weight
of the upper body increases in importance as it acts with
wcight of the uppcr body and by the weight of the
obj;ct affect the loads i~,posed on the spine, The
usc or the salllc calculations to compule the loads
r a lever ann (L...) of 25 em, creating a forward-bending
I
produced when an 80 kg objcct is lifted (represent-
ff, moment of 112.5 Nm (450 N x 0.25 m), Thus, the total
ing a force of 800 N) yields an approximate load of
~: forward-bending moment in Case 2 is 192.5 Nm (1125
~'M""
10,000 N on the dise, which is likely to exceed thc
fracture point of the vertebra. Because athletes who
lift wcights can easilv reach such calculated loads
without sustaining fr~ctures, other factors, such as
intra-abdominal p~-essurc (lAP), may be .involved in
reducinrr thc loads on the spine in vivo (Krajcarski
t et aI., 1999),
I
I
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
J 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
,I
I
200 N
compressive loads at the L3-L4 mOlion segmenl
rangcd from 0.2 to 2.5 limes body weight (Fig.
10-19) (Cappozzo, 1984), Thc loads were maximal
Talal fo"vard- Tolallorward- around loe-off and increased approximatel~1 lin-
bending moment bending moment
I
= 69 Nm = 192,5 Nm early with walking speed. Muscle .action was
mainly concentrated in the trunk extensors. Incli-
11 Calculation Box Calculation Box
Figure 10-2-1. figure 10-2-2. vidual walking trailS. parlicularly the amount of
forward flcxion of the trunk, influenced thc loads,
i $---------"-~---_.
The Technique Employed During Lifting Influences the Loads
on the Lumbar Spine
In the three situations shown in Calculation Box Figures total forward· bending moment of 151 Nm(f200 N x 0.35 mJ
10-3-1, 10-3-2. and 10-3-3, an identical object weighing + 1450 N x 0.18 m!).
20 kg is lifted. Case 1 (upper body flexed forward) (Caleula- Case 3 (Cal(l,lIalion Box Fig. 10-3-3) shows that bem
tion Box Fig. 10-3-1) is identical to Case 2 in Calculation Box knees per se do not decrease the forward-bending moments.
10-2, 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
In Case 2 (Calculation Box Fig. 10- 3-2), lifting with the arm of the force produced by the weight of the object (l,.) in-
knees bent and the back straight places the object closer to creases to 50 ern. and [he lever arm of the ierce produced by
the trunk, decreasing the forwclrd-bending moments. The the weight of the upper body (L..:) increases to 25 em. Thus,
lever arms of the forces produced by the weight of the object tile total forwarcj-bending moment created is 212.5 Nrn
(U and Lipper body IL,) are shortened 10 35 and 18 em, re- 1{200 N x 0.5 mj ... 1450 N x 0.25m!).
spectively. at this point in the 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 d~M
forces and hcncc the compressive load. Callaghan creased lumbar spine motions. 1n conclusion. b~
et al. (1999) corroborated lhese findings and fur- cause of low tissue loaeling, walking is a safe and
ther showed that walking cadence affects lumbar perhaps ideal therapeutic exercise ror those with
loading, with increased anterior-posterior shear low back pain (Callaghan et al" 1999) while atten-
forces noted as speed increased. Limiting arm tion to speed of walking can further moderate
swing during walking resulled in increased com- spinal loads (Cheng ct al" 1998)_
,-
, "
loads on cl lumbar disc I,'iill be calculilled for on,! point in tim[' 't/hen a NUJ to be posit]>,'e and counterciochvis(' moments are considered to
cer50n who weighs 70 kg lifts a 20 kg obj!'ct The spin£' is flexed ilpprW.i. negeltl'/e.i
, 35 In this example, the three priflclpdl forces ,Kling on the lurnl)ilf
Q
Thus,
allhe lurnbosilual le'lei ilfe: (1) HK force produced by \1',(' ','ieight 01
:::: r,il 0
upper body (Wi. Ciilculat.:d to be ':50 N (approxin\ille!y 65",0 of the
{\,V :< L<..J· (P >:U - iE >.: L) 0
exerted by lhe IOtal body weigh!); (2) tile fOlce produced b~i the
of the object (Pl, 200 N; "neJ (3) trw force produced by contraction
(450 N ;.; 0,25 m) " (200 N >: DAm) \t ;.: 0.05 m) 0
E ;.: 0,05 rn 112.5 Nrn -;- 80 1~m
the erector spinae muscles (El, which has a kno':m direction anel point of
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 Th!: to",1 compre~~!'/e force exe!led on the disc (Cl can now be calcu-
in the spine, they crcate moments in the lurntBr spille, Two fOPNard-ber:(j· lawd trigonof1,etricaliy (Calculation Box Fig. 10·cIA-2). in the example, C is
in,) moments (\iVl:,_ cl!ld PL,) are the products of (V{: and (Pi and the perpen- lhe sum of lhe compressive forCi':s "cLng O'lel the disc. '.vhich is inclined
diculars from the instanl center of rOIMion to the lines of action of these to the triirlSVelSe pldfle These forces are
fc,rces (,heir lever Mms), The le'/er arm (L'J for (Pl is 0.<1 III and the !e'/er arm
The compressive force produced by the weight of the upper body
(L,,) for (W) is 0.25 m. f\ counterbalanCing moment (ELi is the product of
(W:-: cos 35°).
(V'/), \'ihich acts on the disc inclined 35'0
lEi and Its lever arm, The lever elm: (l) is 0,05 m, TIl(' fI1agnitude of (E) CiJll
2 The force producHJ by the '.veight of the object (Pl, which acts on
b~~ found tilrough the use of the equilibriufI1 equa,ion for moments, For ,he
the disc inclined 35" (P '< cos 35"')
kJdy to be in moment equilibrium, the sum of the moments aCiing on the
3 Th;;,: fOlce produced by ,he erector spinae muscles (E), 'i,hich acts ap-
;u:nbar spine must be zeo (In ihis example. cloch'!ise morm,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
C 368.5 N .;. 163,8 N·· 3850 1'J
f I \,
unknown)
~
L-! Force S Solving the equation for C yields 'U82 1'1
\, \ l'
\ \ C '" 4382 N (magnitude The shear component for the reaction force on the disc (S) is found in the
~P S 373 N unknown) same'i/ay
Calculation Box Calculation Box {450 ~J '.,: sin 35") ;, {ZOO N :': sin 35") _. S ,'. °
Figure 10·4A~1. Figure 10-4A-2. 373 N
~r-----------------------------------------
8ecause C and S form" right angle (Calculation 'Box Fig 10·48·1). the
Forco S 35 Pythagorean theorem can be used !O fin,J the towl reaction force on the disc (Rt
85 35 Forco W • Force P {R'I vc .;. s;'
j R 4398N
. ; ; Forco R
Forco The direction of (R) is determined by means of a trigonometric function:
Forco<;!/ .
/ 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
~0l-L---:':--'-l.:-I-:'::-'-:!:::-''---:JL
clear the l<.lble and lumb<.lr spinL' motion is mini-
mi!.ed (F'ig. 10·21) and ortell emphasized in rehabili-
20 40 60 80 100
tation programs, arc recommended for minimizing
Percentage of Cycle
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 cl"fecti\'c in terms or Illotor unit
Axial load on the L3~L4 motion segment in terms of body recruitment in the muscles (F.kllOlm el aI., 1979;
weight for one subject during walking at four speeds. The Flint, 1965; Partridge &. \\'alters, 1959); all portkms
horizontal line (UBW) denotes the weight of the upper 01' the external oblique and rcctus abdolninis rnuscles
body, which represents the gravitational component of <.lre activated. Sit-ups with feet unanchored, legs ele-
this load. Loads were predicted using experimental data vated, or tOI"SO twisting do not significantl.v increase
from photogrammetric measurements along with a biome-
abdorninal muscle <.lclivit." (AxleI' &: J'dcGill, 1997), To
chanical model of the trunk. LHS, left heel strike; RHS,
lirnit the psoas activity, <.l reverse curl, wherein the
right heel strike. Adapted with permission from Cappozzo, A.
(1984), Compressive toads in the lumbar vertebral column dur-
knees arc brought t()\vard the chest and the buttocks
ing normal level walking. J Orthop Res, 1, 292. <.lre raised I"rom the table, aetivalL's the internal :.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
EXERCISES lower than that produced during a sit-up, bUl the ex~
During strengthening exercises for the erector ercise is just as effective for strengthening the ab-
spinae and abdominal muscles, the loads on the dominal rnuscles (Fig. IO~22l. It can he concluded
spine can be high. Although such exercises must be that no single :.Ilxlominal exercise C<.m optimall.v train
effective for strengthening the trunk muscles con~ ~dl tnmk flexors while minimizing intervertebral joint
cerned, they should be performed in such a wa:\' that loading. Instead, a \'aried program must he prc~
the loads on the spine are adjusted to suit the con- scribed, tailored to the training objectives of the in-
dition of the individual. dividual (;hler & McGill, 1997).
The erector spinae muscles are intensely activated \Vhen designing a back strengthening cxercise
by arching the back in the prone position (Fig. progr:'llll, the most import:.lnt consider:.ltion is the
IO-20A) (Pauly, 1966). Loading the spine in extreme conclusion drmvn bv the Paris Task Force
positions such as this one produces high stresses on (Abenh:.lim et al., 2(00). The guidelines set forth in-
spine structures, in particular the spinous process clude recommendations that exercise is beneficial
(Adams et aI., 1988). Although intradiscal pressure for subacute and chronic low Inlck pain, No partic-
in a prone position with upper bod)' support on the ular group or t~'pe of exercises has bcen shown to be
elbows is halF that in standing (Wilke et aI., 1999), it most efTccti\·c.
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.
,?
.',. j
200
150
100
50
Performing a curl to the point where only the shoulder A reverse curl, isometrically performed, provides efficient
blades dear the table minimizes the lumbar motion and training of the abdominal muscles and produces moderate
hence the load on the lumbar spine is less than when a stresses on the lumbar discs. The relative loads on the third
full sit-up is performed. A greater moment is produced if lumbar disc during a full sit-up and an isometric curl are
the arms are raised above the head or the hands are compared with the load during upright standing, depicted
clasped behind the neck, as the center of gravity of the as 100%. Adapted with permission from Nachemson, A. (1975).
upper body then shifts farther away from the center of Towards a better understanding of back pain: ~ review of the
motion in the spine. mechanics of the lumbar disc. Rheumatol Rehabil, 14. 129.
Spine
160
80 Respiratory flow
Abdominal Positive n:--~ Inlraabdominal
cavity 60 values = Inspiralion pressure
Negalive
: -mmHg-
40 values=expiralion
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 ration). Note that the subject inspires before the lift and holds
on the lumbar spine. B, Intra-abdominal pressure (lAP) (mea- the breath throughout the lift. lAP increases and peaks to-
sured by a nasogastric microtip transducer) and respiratory gether with the lifting force. helping to stabilize and unload
flow (measured through a Pneumotach) during stoop lift of the lumbar spine. (ourtesy of Markus Pieuek, MD and Marshail
120 lbs. (approximately 60 kg). Solid line, lAP; dotted line, Hagins PI: MA. Program of Ergonomics and Biomechanics, New
force exerted in lbs; dashed line, respiratory flow (negative York. UniversiC'j and Hospital for Joint Diseases, New York, Ny' USA.
Cresswell el aI., 1994a; Cresswell eL aI., 1992; Loss of spine stabilit~. . can be achieved through
Hodges cl aI., 1999). As the transversus abdominis repetitive loading. This can be achieved through
is ho.-izontally oriented. it creates compression and repetitive continuous motions that fatigue the
an incre,lSC in lAP withollt an accompanying flexor trunk muscles. l\tlusclc endurance is mechanically
moment. A recent experimental study gave the.firsl defined as the point at which fatigue of the mus-
direct evidence ror a trunk extensor moment pro- cles is observable. usually through a change in
duced by eleva Led lAP (Hodges el aI., 2000), movement pauern. Parnianpour ct al. (1988) used
It has been demonstrated that the lAP con- an isoinenial triaxial device to study force output
tributes LO the mechanical stability of the spine and movement patterns when subjects performed
through a co-activation between the antagonistic a flexion and extension rnovemcnt of the trunk un-
lrunk lIexor and extensor muscles (Cholewicki et aI., til exhaustion. The results showed that with fa-
1997, 1999a,b; Gardner-Morse & Stokes, 1998). As tigue, coupled motion increased in the coronal and
the abdominal musculature contracts, JAP increases transverse planes during the Oexion and extension
and converts the abdornen into a rigid cylinder that movement. In addition, torque. angular excursion,
greatly increases stability as compared with the and angular velocity of the motion decreased. The
muhisegmenlcd spinal column (ivlcGiII & Norman. reduction in the functional capacity of the f1exion-
1987; Morris et al.. 1961). extcnsion muscles was compensated for by sec-
lAP increases during both stalic and dynamic ondary Illuscle groups and led to an increascd cou-
conditions such as lifting and lowering, running Hncl pIc motion pattern that is morc injury prone.
jumping, and unexpected trunk perturbations Figure 10-24, A & B shows the increase in axial ro-
(Cresswell el aI., 1992; Cresswell et aI., 1994b; Cress- tation (torque and position) during flexion and ex-
well & Thorslcnsson, 1994; Harman et aI., 1988). tension of the trunk until exhaustion.
Current research suggests that the transversus ab~ In an animal study, Solol11onow ct al. (1999) in-
clominis muscle, together with the diaphragm, plays duced laxity of the spine in the ligaments, discs,
an important role in stabilizing the spine in prepa- and joint capsule by' cyclic repetitive loading of fc-
ralion for limb movement, regardless of the direc- line in vivo lumbar spines. The cyclic loading re-
tion in which n1QVement is anticipated. Transversus sulted in desensitization of the mechanoreceptors
abdominis and diaphragmatic activity appear to oc- with a significant decrease or complete elilnina-
cur independently, prior to activity of the primary tion of reflexive stabilizing contractions of the
limb mover or the other abdominal muscles multifidus muscle. This may lead to increased in-
(Hodges eL al.. 1997, 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-
Trunk Muscle Co-Contraction cular activity to approximately 250/0.
To understand the phenomenon or co-contraction
during trunk loading, Krajcarski et al. (1999) stud-
External Stabilization
ied the in vivo muscular response to perturbations
at two rates causing a rapid flexion moment. The Restrict.ion of motion at any level of the spine may
results of maximum trunk flexion angles and re- increase motion at another level. The usc of back
sulting extensor moments were compared. The re- belts as a means of preventing low back injury re-
sults showed that with higher levels, co-contraction, mains controversial. Originally it was believed to
spine compression. and trunk muscle stiffness in- assist in increasing lAP as a way of unloading the
crease. During unexpected loading, a 70% in- spine during lifting; however, inconclusive evi-
crease in muscle activity has been noted as com- dence exists as to the biomechanical effectiveness
pared with anticipated loading, which may lead of these devices (Perkins & Bloswick, 1995). The
to injury (Marras et al.. 1987). Further investiga- National "Institute for Occupational Safety and
tion into the loading response has revealed that Health has advised against the use of back belts Lo
an inverse relationship (i.e .. the shorter the warn- prevent low back injuries (NIOSH, 1994). As well.
ing time, the greater the peak trunk muscle re- an orthotic worn lo restrict lhoracic and lumbar
sponse) exists between peak muscle response and motion may result in compensatory motion at the
warning time prior to loading (Lavender ct a\., lumbosacral level (Lumsden & Morris, 1968;
1989). Norton & Brown, 1957; Tuong et aI., 1998).
F1ex.-Exl. Torque and Posilion vs. Time
143.0 - , - - . . . , . - - - - , - , - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ,
, 78.3
E
!i~i I~i~
!!
T
~
-·32.4
-127.1
58.6, -'::======::;:======::;====================~
40.9
2.3
- 15.4 +--.,--
'''''1-'--,'--'1-r'-'
, 'I'-'I--''--'--Ir-,TI--...,--,-
- 1+-i-.....-r-1T,- ,I-"--""I-,rl
-
0.1 9.3 18.4 27.5 36.6 45.7 54.7
A
ROlation Torque and Position vs. Time
4.3,.-------------------------------,
2.3
,
E
z,
1.1
"~
!!
....0
-0.6
-2.1
19.1
w
, 13.3
"co~
'i'" 7.0
c
.Q
.~
0
Q. 0.7
- 5. 1 -!--,----,-.-,.--...,--,-.,..--,----,-.-,.--...,--,-.,..--,----,-'-.-,.--...,--,,-.,..--,----,--I
0.1 9.3 18.4 27.5 36.6 45.7 54.7
B
ij,
Dynamic (isoinertial) flexion-extension trunk testing until Data for lateral flexion was similar to axial rotation and
exhaustion for one subject. Torque and position data is de- not shown here. Adapted with permission .from Parnianpour,
picted for two planes, flexion-extension (A) and axial rota- M .. Nordin. M.. Kahclnovitz, N.. er al. (1988). The rriaxial
tion (B). Note that flexion-extension torque production is coupling 0; torque generarion of trunk muscles during isomet-
diminishing as is the amount of performed extension of ric exertions and the effect of fatiguing isoinercial movements
the trunk (A). Rotational torque and movement amplitude, on the motor outpur and movemeor pc1tterns. Spine. 13(9).
increased accessory motion, 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 on the spine to bc minimized during lifting, the dis-
muscle activity has revealed no significant EMG tance bL'lween the trunk and thc object lifted should
activity differences in the back extensors during be as short as possible.
Iifling with or withoul a back bell (Ciriello & 10 lAP and co-contraction of trunk musculature
Snook. 1995; Lee & Chen. 1999), while McGill el al. increases the slability of the spinal column.
(1990) showed slightly increased EMG aClivily in
the abdominal (except for the intel'l1al oblique 1/1' Trunk muscle fatigue may expose the spine to
l11uscles) and erector spinae muscles. Thomas et '.11. increased vulnerability as a result of loss of' motor
(1999) have verified a slight increase in EMG ac- control and thereby increased stress on the sur-
tivity (2(10) in the erector spinae during symmetric rounding ligaments, disc, and joint capsules.
lifting wilh a back belt. Back bells have not been ,12 vValking is an excellent exercise thai poses a
shown to significantly increase Iifling capacity low load on the lurnbal' spine.
(Reyna el aI., 1995).
REFERENCES
Summary Abt.:nhairn, L., Rossignol. ~'t., V~dal. J.P., l't a1. (2000). Thc role
of acti\'ily in the tht.:r:q1clllic management of back pain.
1 The lumbar spine is a highly intricate and com- Report of thl: Inll:rn:l1ion~1 Paris Task Force on Back Pain.
plex structure_ 5pinc. 25. IS.
Ad~lillS, M.A.• Dolan, P.. & 1·lutlon W.e. (1988). The lumbar
2 A vertebra-disc-vertebra unit constitutes a mo- spin\.' in b~tChnlrd bl·nding. Spille. 13. 1019
lion 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 Alkn, C.E.L (1948). i\lusdc action potenlials used ill the
function in the motion segmcnt, storing energy and sludy of dynamic analolll~', 13r J Phy.~ Jtcd, 11,66.
distributing loads. This function is reduced with Anders()Jl, C.K., Chaffin, D.B., Hcrrin, G.D .. ct :11. (1985). A
disc 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 :\lHkl'sson. E.A .. Oddsson, L.I.E .. Grundstrom, 1-1., ct al.
guide the motion of the mOlion segment. The orien- (1996). E;\'lG acti\'ities or thl' qlladnHlIs lumborum ~llld
tation of the facets determines the type of motion erector spinae musdes during flexion-relaxation and other
motor lasks. CJinial! Bio1llcdUlllics, J J, 392.
possible al any level of the spine. The facels may Andersson, G.B.J. & l:l\·cnd"r. S.A. (1997). Evalu;ltion of
also sustain compressive loads, particularly during Muscle Function. In J.W. Frymoycr (Ed.). Tilt' A(/1I11 Spil/t',
hyperextension. 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 Andersson. G.B.J .. Ortengrcn. R.. 0:: Nachcmson. r\. (1976).
docs not occur independentl~y in vivo. Thus, the Quantitati\-c studies or b~lck loads in lifting. Spillt:. I. 178.
functional motion of the spine is always a combined Andersson. G.B.J .. Oncngren. R., & Nachcmson. r\. (1977).
action of sevel',,1 motion segments. lntr'ldiscal pressure. intr~\·... bdomin ... 1 prl.'SSUrl' ilnd myo-
det:tric bad lllusck :ll:tivity rdated to pOSl\lrc <lnd load-
/6;- The instantaneous center of motion for the mo~ ing. Clill OrtJlOp, 129, 156.
lion segments of the lumbar spine lIsually lies Andersson, G.B.J .. Onengl'cn, R., Nachclllson, A., et al.
within the lumbar disc. (1974). Lumbardisc pressure and myoelectric b"H:k muscle
~\clidty during sitting. 1. Stu,dics 011 an experimental
The trunk muscles play an important role in chair. SC(/I/d J Rclwhil ,Ht.:d, 6, 104.
providing extrinsic stability to the spine; the liga- ,\sl11usscn, E. & Klauscn, K. (1961). Form and fUllction or the
ments and discs provide intrinsic stability. (.'rcc( human spinc. eJill OrlllOp, 25. 55.
Axlel". c.T. & McGill. S.M. (1997). Low back loads o\·cr'l \'ari-
8 Body position affecls the loads on the lumbar ...' tv of abdomin.;\1 e.'\en.:ises: SeillThing for th..., s;lfcst ab-
spine. Any deviation from upright relaxed standing d~l1lin;l1 challeng(·. .\lcdiefl/I: & Sciem"":c ill Sports & Exer-
increases the load. Forward flexion and simultane- cise. 29, 804
B:II·tclink, D.L. (1957). Thi.: role of i.lbouminal prC'ssure in re-
ous twisting of the trunk produce high stresses on lieving the pressure on thl.' lumbar inu:n'crlcbral discs. J
the lumbar spine. BOlle }oilll Slfr~, 39B. 718.
B:ISIlWji.lll. J. V. (t958). Electromyography of iliopso'ls. :ll/al
9 EXlernally applied loads lhal are produced. 1'01' Rcf.:, 131. 127.
example. by lihing or carrying objects Illay subject B~sl1laji~n. J.V. & DeLlll;;l, C.J. (1985). ;\1l1sdc:s Alive. Balli-
the lumbar spine to very high loads. For the loads mort: Williams &. Wilkins.
.~
'f
BicrilH!·SorenselJ. F. (1984). Plwsical nh.'<lsurcmenls as ri~k Eklwllll. J....\rhorelith. L·. F~lhlcr:Ill!I: ...\ .. l·t :11. (lYiYI. :\ni-
indlcalors for I()\\'-b~\ck lrol;bll.' over a on<:-yl.'ar period. \';lli(11I (If :,hd(llHin:lllllu:-clc:- during SOli\\,.' ph.\-sihl!ll,.·r:lp;::u_
Spill!.'. 9, 106. til,.' c\l,.'l"ci .. l,.·!-. SnlJld) I?dwhil.l1t:d. II. 7.~.
Callaghan. J.P.. P'IIla, .\..E .. & McGill, S.\\. (1999). Low back 101 U"hy. ,1.,.1, " K;n~, ..1.1. (1 'J~6j. Inlcn,'rlchr,d d;,c ,onel
·f. thrcc--dimellsional joinl forces. killl.'malics. and kinetics f:l("l'! l,.·ollta("\ prl,.·ssufl· in a:\i~tll(lr!-i(1l1. In S.:\. l.anlz '* :\.1.
during walking. Clill;cal BioIJlC(://(lllics, I';', 203. King (Ed:-.). /9SfJ :\d\'/I/H"".~ ill Uilh·lI:.;illt'I'l'ill.:: (pp. 26-27i.
Cappozzo, A. (1984). Compressive loads in the lumb'lr vent:- :\l,.'\\' York: . \!l1l'l"icall SOl,.·iL·\\ or \In:h:\lliL':d Ellginl:(·!'s.
..;.'
, br.1! column during llorlllal le\'el walking. J Or/hop Res, l, r:ad~ln.ll.F. (19751. \ltlsl,.·III~II' Jlh: .... h;llli .. 1lI fir the lUJ11kll' spin('
192. ~tl\d I Ill,.' P(,:>ilioll of Pfl\\"l'!" and dficil·/lL·..... On/Hip Clill
Carlsoo. S. (1961). Thl.' st .. tic muscle load in differelll work Xorth . \IlI. 6, 135.
posilions: All dL'ctromyographic study. Ergollolllic.,·. .J.. 193. Flinl . .\1..\1. (1965J. Ahdominal ll1u:>dL' in\'uln'l1ll'lll durin!::
Chaffin. D.B. (1969). r\ cornputcriz.cd biolllechanical modcl- thl' pl,.-rfnrm:lllt.·l,.· of \·.lriol1~ forms 01 :.it-up l,.·\l,.·n;i-.l,.·. ,.\~
Dc\'dopmcl11 of and usc in stud~'ing gross body <lctions. ) l,.·k('tr(Jm~·hgr'lphic :-llld~·. _'\1lI J Phys .\I,·d. ';'4. 114.
BiOiI/Cc!wl/ics, 2, 429. Fln\'d. \\'.F. <.\: Silv . . . r, P.fl.S. (193.:;). Thl' fUJll,.'linll (Ii llll,.· . . . ri.'c.
Chaffin, D.B. '* Andersson. G.BJ. (1991). Occup(1tiol/al Bio- lors spinal,.' Inllsl·k" in cnl~lill 111()\clll . . . n\S ~llld postu!'cs in
I/wcJ/(lIli<:s (2nd cd .. pp. 171-263". New York: 10hn Wile.\' 6.: man. J NI.niol. 129. 1$4.
Sons. Inc. Fri(·dd)old. G. (195~J. Dil,.· ..\kti\·iL'1 nOI·lIl.da Rih:h·n:-tn.:·ck-
Cheng. c.1\: .. Ch..:n. H.H .. Chen, C.S., et 31. (1998). Influcnces rnuskublur illl Ek,ktfom .... ogralllln ullll'r n'rschi . . . dl·IH:1l
of w~dking spce:d change' on the lumbosacral joint fon:c !·Iallllllgsik·dillgungl,.·n: l,.·illc Studil' wr
distribulion. BiOl1lt'd Mara £11::', S, 155. Skl·kllllltlskdnwchanik. I Of/hop. 90. I.
Choh:wicki. 1.. Juluru. K.. &: ~-IcGill, S.l\-l. (1999a). Intra-ab- rukll\:tlJl:t, S .. :\,tbmur:l, T. nl·d~l. T.. l't ,d. (1995). ThL' d-
dominal prt:ssun: ll1(.'chanisrn for stabilizing tll(.' lumbar k,(t of Itlc(!1:ulic.t! slrl's;,,; 011 hvpntroph\' o!" 11k hlillbar
spine.) Bio/lwch, 32. 1-13. li,\;;II11l'!lIUIll Il:l\'tllll. ) .')pilluIIJl'.-nn/. S. 126.
Cholcwicki, 1., luluru, K .. Radt:bold. :\., I:t <II. (1999b). Lum- Gatlilk. J.O. (1<)67). h'n:>ilc propl'nil's 01 11K hUIll;11l lumhar
b.ll· spinc stability (;'til be :lllgmcnted wilh an abdominal :lIl1lUIIlS fihrh:->II:-, .. lew O,.lIwJ' S,'lmd SII1'''!. 100, 1-91.
bcli and/or increased inlra-abdominal presslIrt:. f.:'llropcall G;lrdll~'r·.\I(.tr~l,.·. .\I.G. & S!('Kl,.· .... LA. (19%l. Till,.' dfl'({~ or ab-
SJlill~ )ollrJ/al. 8, 388. dominal lllu:-dl' CI,·;ll·ti\:ttic.n on lumbar :-pilll' :-t;tbility.
Choh.'wicki, J., P.mjnbi, ~L\L & f\.h;lChntr~·all. A. (199i). Sta· S/Iill... II::!,'), ~9.
bilizing function of trunk f1e.'l:or·('.'I:tcnsor llHlsch.. s around G(·rtl.lkill. S.D .. SI.·liglllt,IIl,.I. Hl.lltln, R....... l .d. (1%5). Cell.
<I neutral spine posture. Spine. 22(19), 1207. trndl' P~ltlL'l"llS :lnd sl'glllL'Il!,lI il1Sl~d)i1il.\ ill ,kgL'l1a:l\i\\:
Ciriello, \'_,\I....\: Snook, S.H. (1995). The dfl.-·Cl of b<lck belts di:,\.· disl':l:-e. S"i!/,·. 10. 257.
011 lumbar muscle fatiguc_ Spillt', 20, 1271. Granat'l. K.P. .i: Sanford. :\.1-1. (19991. LUll1har-pd\'k ((lordi-
COSSl.'ltc. J.W., Farfan, H.F.. Robertson, G.H., e[ at. (19il). n~tli(ln i:> influl'IH..·l,.·d b~ lifting l~\sk par~\nh.'kr:>. Spint',
The instant~1I1l.'OUS <:enttr of rot~l[ion of Iht.' third Illlllb,lf 25(111.1413.
inll.'ITl.'nebral joint. J Biol/m.:It . .;.( 149). 19i 1. Grl,.'gCl":>l,.'Il, G.G . .i Luc~t~. D.l3. (1967). An in \'inl slud.\· of Ihl,.·
Creswell, A.G. (1993). Rl.'sponses of intnl-abdorninal pressure lUlllbar a,xi:\1 rot;lliU!l (If thl' hlllll~\n Ilwrac(Jllllllb:\r spine.
and ,Ibdomin~ll muscle activity during dynamic trunk load- .l 8011,' .luil!! Sur:: . .,19:\. 2-+7-232.
ing in man.l::ur) Appi Physiol, 66,315. llaht.:r. T.IC. O·llrit:lI ..\1.. Dr.\·a, .1.\\'".. d 'II. (l\FHI. TIll' roil: oj
Crt.·sswcll. A.G .. Blakt.'. P.L.. &. Thofstcnsson. A. (1994<1). The till' IUlllb.\I· f,ll,."l,.'! joinl::- ill spinal :-tahilil~·. IllcntiliGtliOIl of
drect of an ahdomin.d muscle Iraining program 011 ill[ra- :illtTn:niH' palh~ of 1(1~\{lillg. Sl'ilh·. /9. 26-67.
abdominal pressure. Scant!) RC/Ulbil ;\ld. 26, 79. Hannan. E...\., Fr~"klll:lll. P.:\ .. Clagclt. E.R ....... t ~tl. (19SSl.ln[ra-
Cr~ss\\"dl. kG .. Grundstr6m. 1-1 .• 6.: Thorslcllsson. :\. (1992). ,.hd(llllinal ,tlld in!r:l·[hor~lL'ii.' prt'-,,~uro during lifting alld
Observations on intr<I-.llnlomillOlI preS$ur..: and p~lllcrns of jumping . .\led Sci S;10/"0 Erac 20. 195.
abdominal intra-muscular acti\'it~· in man . ..lcta Physiol Hasq:;\\\:l. K.. T~\bhashi. IU_:. "Og~l. Y.. l,.'1 :1I. (1993). \k-
Scaml, 1';'4. 409. Ch'Hlic:d propl,.,rti(·s or ostc'olwnic \,t:rtdn:d hodk's moni-
Crcsswdl. A.G .• Oddsson. L.. & Thorstcnsson. A. (1994h). Thl.' torl,.·d hy ;Il,.·ou:-;tie l.'llIb:-ioll. /Jeme. /-1-. 7.'ii.
influcnce of sudden perturbations on ll'unk muscle: aCli\'- l-laugh!oJl, \'. .\1.. Schmidt. T.A .. Kl,.·l,.-k, K .. l,.'1 ;.1. (200()). Flexi-
ity and intrn.- .. bdominal prcssU!"t' while: sl<\nding. EXJll'l' bility of lumbar spin:d motion :-l'gllll'lltS I..'orrd:lll'd llllq)l,.·
Brain Res, 98. 336. of 1.:.lrs in Ilk' ;lIl11ulus fihro:-llS. J .Vel/rosur.::. 92. S I.
Cresswell, A.G., & Thorstensson, A. (199-0. Chnngl.'s in intra- I-Iodgl,.·:-. P.\\'.. Crl,.·s:-\\dl. A.. l\: Thortl,.·l\:-~(JIl. :\. (1999).
abdominal pressure, Ll'llnk muscle acti\· ... tion and force Prl,.·p.\r:llor.\' [rullk lllUlioll ~ICc(lll1p:tnit:s r:lpid uppt:r lilllb
during isokinetic Iirting and lowering. Eur ] Appl Physiol. mO\·l,.'l1ll'l1l. 1:.\)1 Bmiu Ues. 12..+. 69.
68, 315. Hodgl.'s, P.W. l\: G.l1HII..'\·j,l. S.c. (2000-,...\.t.·ti\·:lliO!l of till,.' hu-
Dalstr~l. M. 6.: Huiskcs. R. (1995). Load lr.lnsfcr 'Kross the Ill,tn di:lphr~lgm during:l rt.·lk·tili\·l.' pOSIIlI';llt:lsk . .l P1Iy::;iol
pelvic bone. J Biollli:t:It. 28. i 15. fiJI/I.!) . .)22. 165.
Davis. K.G., M ... ITas, W.S .. & Waters, T.R. (1998). Evaluation I-Iodgl,.·$ P. W. ~ Richardson C.A. (199iL Fl,.·cdforw:ml (Onlrac-
of spinal IOildillg during lowering and lifting. CliJl Biolllt.'- lion of tranSH'rSllS ahdomini:-; is nOI infhll,.·lln-d ll\' Ihl.-· di-
dumics, /3, 141. l"l·...:lion of :lrm nW\·l,.·llH:nl. Ex!, U/"I/ill Ik~, 1/-1-. 36i.
de Looze, ~LP., Toussainl, 1·1.0.'1.. vall Dieen, J.H., et al. (1993). I'[utton. W.e. '*Adam::;, \-1.:\. (1982). Can tIll' lumklr -"pinc h.. .
Joint moments and llluscle activity in the lowel" e.'l:tremi- IT\lshcd in ht:a\'~' lifting"? Spill!!. 7. 5S6.
tics and lowcr ktck in lifting and lowering tasks. J 8io- 10s(·ph. J. 1.1960). "'flJI:': PO... ltll"t·: Ut!ClrolJl.'·fi~m/lhic Sltulil,....
l/I.:c/',26, 1067. Springfil,.·hl: Charll,.·s C Thollla~.
Eie. N. (1966). Load capacity of the low b ..d. J Oslo Cit.\" Jukn. D., .\!cGil\. S., l\.ropL P., ct ;11. ([ 99:n. OU:II11i[:tti\·I.-' in-
f1osp, /6. 73. tr:lllltl:-(lIbr llIyock·nril.' :H:ti\·it.\ of IlImb.lr porlioll.') of
CHAPTER 10. BIOMECHANICS OF THE LtJ'~1~5PI;-§rj;:i'83~
,~,~---~~,"",:,,,-~~
psoas and lhe abdominal wall during a wid\: \'ariel,v of ~Ioll. .I.M.H. &. Wright. V. (1971). Normal range of spin;.d mo-
lasks. }fed S,:i SporlS f.XCfC. 30. 30 I. bility. An objcclh'e clinic:l! study. AIlII UhClIIll Dis, 30, 381.
A.I .. Pr:\sad. P.. ~ Ewing. C,1.. (1975). ~·h·dl<lnism or Morri!'O. J.!"..l.. Bl:lllli:r. G., ~ Lucas. n.B. (1962). An dec-
spinal injur~" du(.' to l:<\udoCl.:phabd accderalion. Onlw/J tf(Jl1lyographic study of Ihe intrinsic muscles of the back
CIi" North :1m, 6, 19. in man. J :111t1l l.mul. 96. 509-520.
Kkin. J.A., Hickey, D.S., 0& Huskins. D.W. (I983). Radial ~-lorris. J.~L, Lucas. D.B .. &. Bn:sier, B. (1961). Role of the
bul!:!in!: of lhe annulus fibrosus and the fUlll.:lion and fail· trunk in st.:tbility of the spin<.'. } BUIIi: JOil1f Slll~~ . .:31\. 327.
llr~ -of ~he inlt:ITerlL'hr~t1 dbc. J Bi01llt'ch. 16. 211-217. :\-losekilck. L. (1993). Vertebral struclllr\.' :lIld strength in \'i\'o
~'1.H .. S~:mllssi, R.E., Wilder, D.G .. el ,d. (1987). Inh:r· and in vitro. Cah:i{Tissllc 1111.53.5121.
nal displacelll~nl dislribution from in vilro loading of hu· N;'lChl'llIson. A. (1960). Lumbar inlrndisc'll pn:SSllrl.' ..-k/a Or-
man lhoracic and lumb'll" spinal motion segments: Expl:r· [hop Sculld SlIp,.,l. n. 1-140.
ill1l:ntal results and lhl'orelical predictions. Spill/.', 12, Nachclllson, A. (1963). Thl' influence of spinal rno\'erni..'nts on
1001-1007. till.' lumbar intrndiscal pri.'SSUl'l.' and on till' tensile stresses
Krajc;Hski, S.R .. POI\'in, J.R .. & Chi;1I1g:, J. (1999). The in d\'O in IIIi.' ;tnlltllus fibrosus . ..lela Off/WI' SClIIul. 33, 183.
r~sponse to the pl.:rlttrbations c:lllsing rapid f1cxion: Ef· Nachcmson, :\. (1966). EIeCiromyographic studies Oil the n:r-
f~cts of pre-load and step inpul magnitude. Cii,l BiO/lll/- td}ral portion of the PSO:IS llluscl~. With special rcr~n:nce
dUlU;CS. 14, 54. to its stabilizing function of the lumbar spine. lkw OrrllOt'
Kuhlk. R.E. Schuhz. A.B .. BdYlschko. 1., el <II. (1975). Bin· Scalld, 37, Iii.
ll1echank;tl charactcristics of \'crICbral motion segments Nach<.:mson, A. (1975). Towards a beller understanding of
and intern:rtcbral discs. Or/hop Cfill North AI/I. 6, 121. back pain: A review or the mechanics of the lumbar disc.
L1nd~r. J.E .. B~ltes, B.T.. & Devita. P.(1986}. Biolllt.'chanics of RlJellllwlO! RelUlhi!. I.J, 129.
th\.' squat (.'xen:isc using. a modifil.'d Ci.'Ill(.'r of mass bar. Nach(.·m;.;on, A. & Elfstrom. G. (1970). IlIlravital [)\'I/(l/llic
.\lcd Sci Sports E.un:, IS. 469. Pre:ssure: .\lC(ISllrCJ1h.'lllS ill Llflllh(lr Dis,;:,: ,.\ Sllui.\' r.;{ CO/1/-
Ll\'cnder. $.:\., ;\lirka. G.:\ .. Schol.'I1ITI.lrklin. R.\\'., el al. IlIOIl .\IOl·i'J11CIlfS. :\Ialli:III'crs allll Exercises. Stockholm:
(1989). Thi.' l:rrCC1S of pre\'iew :lnd t<l.sk sym!lll:lry on trunk Almquisl & \\"iksc-lt.
mllscli.' response to sudden loading. lIwlIlm Fat-tors. J I, ~achelll;.;on, r\.L. .& E\':lns. J.H. (1968). Some mechanical
101. propcnies of the third human lumbar intalaminar lig;'l-
[.:\\'coder, S.A .. Tsuang. 1".1-1 .. AIH.li.'rsson, G.B .. ~t a1. (1992). ment (IigameJltulll flavum). J BiomcclulIIh's. I. 211.
Trunk nlusch.' co·contraction whitt: resisting applied mo· Nachclllson, A. & Morris, J.\l. (1964). In \'in) mCaSUri.'lllcnts
ments in a Iwisted poslure. Ergollolllics. 36, 1145. of inlradiscal pressure. Discolnl'lry. a mcthod iol' the de-
Lt.'c. Y.H. &. Ch('ll. C.Y. (1999). Lumbar vcrtebr.d angles and termination of presslll"i.' in the lower lumbar discs. J BOlli:
b.lck muscle loading with bells. Illd Health. 37, 390. 1ui1l/ SI/rg, -16:\, 1017.
Lucas. D.B. &. Brcsier.~B. (1961). SIal,ilil.'· of ,ht: Ligamt.'I1fOUS !\alional Institute for Occupational Safety .tnd Health (1994).
SpiltE.'. Biomechanics Laborator~', University of Cnliforni:\, WOl'kplclCe Use orS(lck Be/IS. DHHS (NIOSH), Number
San Francisco and Berkeley. Technical Repon 40. San 94-122.
Francisco: Th~ Ltbor.llor\,. Ndson, J.M .. \blmsky, R.P.. 6.: St(.'n:nsoll, J.,\'I. (1995).
Lumsden. R.M. & Morris. J.~'1. (1968), :\n in dvo study of ax- RcI'lti,·c IUlllbm' ;tnd pl.'!\·ic motion during londcd spinal
inl rotation and immobilization at the lumbos:\cral joint.} fk'\ion/extcllsion. Spinc, 20. 199.
Heme Joill/ SlIrg. 50A. 1591. Nemeth. G. (1984). On hip and lumbar biomechanics. A study
Manas, \V.S. & Granata. K.P. (1995). A biomechanical assess· of joint load and muscular ;lCtivity. SC(/l/(! J Uelwhil J/ed
ment and model of axial t\...· isling in the thoracolumbar Stlppl, 10.
spine. Spil1c? 20, 1440. Nonon, P.L. & Brown. T. (1957). The immobilizing c-fficiency
:\larras. \V.S. & Mirb. G.A. (1992). :\ comprehcllsivl.· c\'alll:\- of h'ICk braces. Their eHecl on th~ posture and motion of
lion of trunk respon$c 10 asymmL'tric trunk lllOlion. Spill/!. thl..' 11l1lloosacr;.\1 spine. 1 BOIIt' }oill1 S/lrg. 39:\. Ill.
17. 318 . Dncngrcn, R. And~rsson. G.B.l., & 1'\achcmson. A.L. (1981).
.\larras, \V.S .. Rang<lrajuili. S.L.. & Lan'nder. S.:\. (1987). SllIdies of rd:lliollships bel'\'cen lumb,lr disc pressure,
Trunk loading and ('xpectation. Erf,:ollolllics. 30, 351. myoelectric b<'H:k muscle acti\'it~,. and intra-abdominnl (in-
McGill, S.~vl. & Norman, R.\V. (1987). Reasscssm~nt of the trag;:\slric) pr~SSllre. Spille, 6. 98.
role of inlra·abdominal prcsstlrt.' in spinal compression. Osval<k'r. A.L.. Ncumann, P., Lo\"sund. P.. et a1. (1990). Ulti-
Ergollomics. 30, 1565. maII..' strength of the lumb.\r spine ill fle.xion-.1I1 in vitro
McGill. S.M .. NOrllmn. R.W., &. Sharratt. M.T. (1990). The d· study.} Bio1l1t.:clull/ics, 23, 453.
fret of an 'Ibdominal b~1t on trunk muscle acti\'ity and Panjabi. ,\13\-1., Gael, V.I-\. .. ..\: Tabtn, 1-\.. (1982). Ph~'siologic
intra·abdominal prl.'sslln..' Juring squal lifts. Er~ol/olllic.s. strains in the lumbar spinal ligamC'1l1s. An in vilro biolllC-
33, In. chanical slUdy. Spi1/i', 7. 192.
McGill, S.~1.. Yingling, V.R .. &. Pl..'ach, J.P. (1999). Tlm..'I..'- Parnianpour. M., Nordin, \1.. K<thnnol"iti'.. N., l.'t al. (1988).
dimcnsion:d kin~rnatics and trunk muscle my()d~ctric ac· The tri<.lxia! clHlpling or torque gcneration of trunk lllllS-
ti\'it~' in the ddcrly spinc-<l dawb,lse compared to young cles during isometric e.'\cnions and the effect of f:tliguing
people. CJiIl Biolllcclu/llics. 1'+. 389. isoincrtial mo\,emenlS on till.' motor output and 1ll0\'ement
,\'111es, M. & Sull ivan. W. E. ( 1961 ). L:lti:nd bi.'llding .11 Ihe hlln· p~IIt('rns. SpiJlt', 13(9). 982-991.
bar and lumbosacral joints. .·\11111 U~C, /39. 38i. Partridge. M.J. 6.: Walters, C.E. (1959). ~articip.llion of the
~liller. l.A.A., Hadersp\.'ck. K.:\., 6.: Schuhz, A.B. (1983). Pus- abdominal IlHlsdes in \'arious mOVt'lllc-lltS of Ih ..~ trunk in
tl'rior (.'lelllenl loads in lumbar motion segmcnts. Spille. S, IlWIl. An L'!cl::trol11yographic study. Phys Tll!'r Rei', 39, 791.
331.
Paul.\', J.E. (1966). :\n dcclromyographic '\llaly~is of cl:nain SIlI(ImOIlO\\" \\., ZIHIlI. B.-II.. Bar:llia. R.\'., 1.'1 itl. (1999). Bin_
nlO\'('Il1(:nls <lilt! ex('rcises. I. SOllle c!('cp muscles of Lhl' llh.'l'h:lnic. tlf incrl'a:-I.:d expUSlIl"(,.· to hlilihar injury C:lu~cd
back. All(/( Ret:. /55. 223. h.l.· l'~"l'lic loadillg: Pan I. lo;.;s of rdl,:.\i\·(,.· 1Il1l:,(,:ular st.tbi-
Perkins, ~I.S. & Bloswid. D.S. (1995). Th,· usc of h'ICk belts liz;llioll. Spillt'. 2·H23). 2-l26-243-l.
f 10 increase inlr~wbdominal pressure as a means of pn:- Sldkn. T., B;II·alllki. II.C .. Ruhin, R.. d :11. (19t.1~J_ LUlllb;u'
venting lo\\' back injuries: A survey of lhe lih:r.lIun:. 1m J inlradisl'al pr(,.'~:-.ur(,.· Ilh:a::-urcd in I hI.' :I11t(,.·riol" itlltl poslt.'ro_
OCCIlP EUl'imll rlt.:lllih, I, 326. bler:!l anllul;,r rcgi(l/IS during :i='.\"Inml.'lricll I(I;lding. Cfill
Pope, M.H., Andersson, G.B.J., Brolll.lIl, 1-1., L't .d. (1986). Biol/f(·clu/!/ic.\. 13, 495.
Electromyogr:q1hit studies of the ]lImb'H' trunk muscula. Sllln:ssoll, B" Sl'h·ik. Go, & L"dCIl, A. (1'J89). i\!on:mcllls of
tun: during thl: dcvelopmcnt of a.xi.1I torques. J (Julio!) thl.' s:lcroili:ll' joints. ,\ rt)I.'rllgt·ll sLerl'oplHllOgramrndric
Res, cJ, 288-297. :lIwlysis. Spi!lc, 1-1, 162.
Ranu, B.S. (1990). Measuremctlt of pr(.'SSllrcs in the nucleus Thomas, ./.5., Lavelltk'r, S.:\ .. Corcos, D.M., 1.'1 :t1. (1t.l99J, Ef-
and within the annulus of the hurn'lll spinal disc due 10 l.:X' fl'ct 01' lifting bl.'l!:- Ol1 ll'unk Illusck :1l"lil':Lli()[l during a
trcme loadilll.!. Pmc 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 luong, N.H., {),lll:-l,.·r(,.·:HI. J.. \latlr~tis, G.. 1.'1 ~d. (199S.J. Three.
processes in fh:xiull-cxtcnsion and lateral flexion of the dillll..'llsional I.·\·alu.ltion of lumhar urthosis dkcts on
spine. ~1c[(t .\!orp!lo/ 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
wegungszcntrum in der LendenwirbclsAule bei Flc.xio[l thl' inleJ"l.·crtd.u·al di!'L'; Infllh:llc(,.' 01 pmIL'oglyc;1I1 ,lnd col.
lind Extension. Z A/llIl EIII\\·ickltlll;;';;;':I!.\·(.·h. /38,283. I:q;l'n COlllt:'IlI:-. Bifl,.h.,o!o.t:..\·, 22. 1-45.
Reid, J.G. &. Costigan, P.A. (1987). Trunk llluscle balance and \',111 Dici:n. l,tI., llUCt"l.I.'lllan:-, M.L\!.. &. TUllssainl, 1-1.:\1.
muscular force. Spill/!, /2, 783. (1999J. SH,op or squal: ,.\ rl.'\·it'\\· of bilJlll(,.·<:hallil:al :-tudies
Reyna, J.R. Jr., Leggdl, S.I-I., Kenney, ~., "I .d. (1995). The ef. on lifling 1I.:(hniqu(,.'. CliJl Bifl/lft'c}wuic:•. /4. 6$5.
feCi of Ilimbar bells on isolated IlImb,lr musl'!e. Slrength \bn~..\1. & DUlllHS. G.:\. (199S). \kdl;lIlh,:al hdl;l\'ior of th~ .~.
and dynamic (;"padt)'. Spilll.', 20, 68. fl.~lllak 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- poskrinr s:II.::roilia<: Iigamcnts under sagittal In'lds. Clill
cial reference 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
8colld, .)11]1]11. 90, 1-144.
spint:' ill Illan. An expl.·rillll.'llt,t1 stud.\' (II' :lllIOPS.\' spl'ci.
Sato, K., Kikuchi, S" & '{onez;Jwi1, 1'. (1999). In vivo intradis. mens . .·le/ll ()rt/wp ,"jcl/ud, SIIp/i! il7, 1-105.
cal pressure llle'lsuremCllt in healthy individuals and in Whilt:, A.A. l\:. P:lnjahi. :\I.N. (19701. Cliniud HiulIlt'cI/(il/ics oj"
p<iticnts with ongoing back probll.'ll1S. Spille, 24, 2468. Iht'Spilit'. 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/! dail~' life. Spill.·, 24. 755.
Surg. 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 tional lopogr,tphy of the s;Jcroiliac joint. Sp;/It'. 5, 575.
sagittalJlatcral 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
:1(
il1Lh"'d,~.,%>. mLdi.
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
Knowledge of spinal biomechanics advanced expo-
sagiual plane. The celvical and lumbar regions arc
nentially during the second half of the twentieth
convex anteriorly (lordotic), while the thoracic and
centlll)'. A two-column model of the spine was de-
sacra) regions are convex posteriorly (k)iphotic).
scribcd by Sir Frank HoldswOIth (1963) and, latel; a
The lordotic curves develop after birth as the in-
lhree-column model by Denis (1983), further refin-
fant's spine straightens out, which facilitates devel-
ing the principle or spinal stability. The computer
opment of a bipedal posture. Although there is a
age has produced powerful 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 Cl (atlas)
and electronic advances will continue to build on
basic biomechanical principles, many of \\:hich will C2 (axis)
be outlined in this chnpter.
Facet
joint
:1
Component Anatomy and
Biomechanics C7
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, and various Uncovertebral
joint
neurovascular SU'UClures as they transit the neck
nnd when they enter and exit the skull. The verte- Intervertebral
bral column also provides a multitude of muscle disc
and ligamentous attachments for complex move- Tracheal
ment and stability. The neuromuscular control af- air shadOw
forded by the muscle ntlnChmenls combined with
the numerous articulations of the cervical spine al- C7
lows for a wide range of physiological motion that
maximizes the range of motion 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, A, lateral roentgenogram of the cervical spine. Note the
Cl (atlas) and C2 (axis). [Ire atypical. with a unique lordosis. The facet joints are aligned obliquely only to the
structural role in the articulation between the head frontal or <oronal plane; hence, their excellent visualiza-
and the cervical spine. The atlanta-occipital joint, tion in the lateral view. a, Anteroposterior view of the <er·
vical spine.
bel ween CI and the oecipital bone of the skull, is
also a functional part of [he cervical spine. There
287
•> QJ- ._
o 288 PART II • BIOMECHANICS OF JOINTS
harmonious progression of these curves from one to sagittal range of motion of the cervical spine. The
another, which may help distribute stresses and Cl-C2 articulation is the joint primaril.\-' responsible
strains, injuries occur more commonly at the jllnc~ for rotation in the cel'Vical spine.
tional areas because of differences in the relative The atlas, or C 1, is a bon.\-' ring consisting of an
stiffness of each anatomical segment of the spine. anterior ;:\lld posterior arch that is attached to the
The physical structure of the anatomical elements two !;:\terallnasses of the atlas (Fig. 11~2). The su~
modulates from the cervical to the sacral region in pcrior surfaces or the latent! rnasses, which face
relation to the segmental function. crani<:dly <:md inward, form an <:\rticulation with the
The lordosis in the cervical spine, like that in the caudally and clutward-facing occipital cond.\-'les of
lumbar spine, is maintained predoI1linantl:v b.v the skull (Fig. 11-3). E.xtension ()f the occipitocer~
slightl)' wedge-shaped intervertebral discs that arc vical joint is limited by' the bon.\-' <:uwt()!ll.v; flexion
larger anteriorly' than posteriorly. In contradistinc- is lirnited prirnaril.\-' by ligarneluous structures, the
tion, thoracic kyphosis is maintained largely.' by the tectorial mernbrane, and the longitudinal fibers of
vertebral bodies themselves; because the posterior the crucifonll ligarnent as well as by the posterior
portion of the thoracic vertebral body is larger than ligaments (Figs. 11 ~4 and 11 ~5). The anterior tu-
the anterior portion, there is a relative kyphosis of 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 conceptual biomechanical building block of The posterior arch of the atlas is a modified larnina
the spinal colunln is the Functional spinal unit or that is grooved on its superior surface for the pas-
motion segment. It consists of two adjacent verte- sage or the vertebral arteries as the.v enter into
brae and the intervening intervertebral discs and lig~ the fClrarnen magnum after piercing tile posterior
aments between the vertebrae. These ligaments arc ntlanto~(lccipital nlelllbl"ane.
the anterior and posterior longitudinal ligaments; Simi!;:\r to the occipitocel'Vical junction, there is
the intertransverse, interspinous, and supraspinous 11() intervertdJral disc betwecn Cl and C2. Stability
ligaments; and the facet capsular ligaments. As a re~ at this levcl is thus predicated on intact osscoliga-
suit of the different functional demands of the vari- l1lentclus structurcs. The articulation between Cl
ous parts of the spinal column, segmental variation and C2 is primaril.\-' specialized for rotation. The
is expressed by! changes in the size and shape of the bod.\-' of C2 projects superiorly to fOlTn the odontoid
vertebrae, the anatomy of the discoligamentous process, or dens (Fig. 11 ~6). The projection of the
structures, and the alignment and structure of the bod.\-' or C2 and the dens has a characteristic oblong
facet joints. appearance on lateral cervical radiographs and is
Biological structures behave differently than do
common engineering materials. Collagenous tissues Superior articular Facet for dens.
exhibit both viscoelastic and anisotropic behavior. facet on anterior arch
Viscoelastic properties are rate~dependent (time-
dependent) behaviors under loading that are seen in Origin of
both bone and soft tissues; mechanical strength in- transverse
creases \vith increased rates of loading. Anisotropy ligament
is the alteration in mechanical properties that is
seen \vhen bone is loaded along different axes.
Anisotropic behavior occurs as a result of the dis-
similar longitudinal and transverse microstructure.
Groove
Osseous Structures vertebral artery
1cm
The occipul-CI-C2 complex comprises the upper
cervical spine and is responsible for approxilnately on posterior arch
40% of cenrical flexion and 60% of cervical rotation. I
The occipital condyles articulate with the slightly DmI'---- " "__" ~~
concave lateral masses of the atlas. The primary
Illotion permitted by this articulation is flexion and
extension, accounting for a large portion of the 1 Bony architecture of the atlas. Bar 1 C111.
CHAPTER 11 • BIOMECHANICS OF THECER.\!C~~~~?l~IiztKO
Occipital
condyle ,r--__ Occiput·C1
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 .
--------------------------
Anterior Posterior
Superficial layer of
tectorial membrane
Apical
ligament Tectoria! membrane
I 01 dens
! Ant:~~~
I of alias ",,","u .
I ~-
-~
Dens of axis -t;~ffB~ll
Transverse
ligament ~~~~y.. . @0
Anterior ~~
)'., -.:,::(-'\ ~..
I atlantoaxial
I ligament
Flexion Extension
II interv~~:bral
fibrocartilage
Anlerior Tracings of lateral flexion and extension radiographs show-
1 longitudinal ing the occiput, el, (2. and (3. The substantial relative
ligament Posterior
longitudinal motion between the occiput, (1. and (2 can be seen.
Body of C3 ligament Large arrows indicate the direction of motion_ Small ar-
rows indicate that approximation of the posterior ele-
ments limit occipitocervical extension. In contradistinction,
maximum flexion is controlled by tautness of the Iiga·
Median sagittal section through the occipital bone and the ments. Reprinred with permission {rom MoskoviclJ, R. & Jones,
first three cervical vertebrae showing the articulations and D.A (1999). Upper (eNica/spine instrlJmellt<11ion, Spine: State
surrounding ligaments. of tIle Art Reviews. 13(2), 233-253.
07~EI1R;- II .Bi9~ECHA{\IICS OF JOINTS
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-
1. B. Lippiflcort bra. The facet joint alignment is fairly close to 45° from
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 1cm
to the intervertebral 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 Anterior view of a sixth cervical vertebra. The shorr arrows
when compressive forces arc rapidly applied based indicate the uncinate processes and the Ic;mg arrow indi-
on the biomechanical principles of viscoelasticity. cates the pathway of the sixth cervical nerve root. The
facet joints are located posteriorly. Bar = 1 em.
This propeny protects the disc /i'om catastrophic
failure until extremely high loads are applied.
~~~~~~~~?-I)
The nucleus puiposlis is centrally locmed within
( ,./ pulposus
the disc and consists of almost 90% water in young Nucleus
individuals. The water content is highest at birth
and decreases to approximately 700/0 as the disc de-
generates with age. The rest of the nucleus pulposus
consists of protcoglycan and collagen, which is ex-
clusively type II collagen. Type II collagen fibrils are A
thought to be able to absorb compressive forces bet-
ter than type I collagen fibrils.
Prolcoglycans consist of a protein core auached
to polysaccharide (glycosaminoglycan) chains. The Annular
pol.vsaccharicles are either keratin sulfate or chon-
I Disc - ' fibers
The annulus fibrosus is the OtHer portion of the Acf,;pred '.-Vlil! permission l,om W;uw, AA. 111 c~ Pan,iabl. M}vl
disc. Its water content is slighl1y less than that of the (l990} Clinical B!Drn~'dl,Hll(<' of the Sp:rl(' Pili/dcle/ph/a: III
nucleus, being only approximately 78£10 \vater in Lippincor[
younger individuals. \-\lith age, the water content !
falls to approsimalely 70%, like that of the nucleus •
pulposus in older persons. The annulus consists of
collagen that is arranged in approximately 90 con-
centric lamellar bands. The collagen fibers in these Cortical bone is stilll.'!" than cancellolls bone but
shccts nll1 at approximately 30 0 to the disc or 1200 can withstand greater stresses before failure. \Vhen
to each other in the adjacent bands. This unique ori- the strain in "h'o excl.;cds 2t:'(; of the originallengLh,
entation confers strength to the annulus while per- conic::d bone l"1"<.tclLtrcs, but c<.tllcdlous bone (<.ttl
milling some nesibility (Fig. I I-II). The composi- withSland somewhat greater strains before fractur-
tion of the collagen in the annulus is approximately ing. The gr('.. ltl.~r abilit~· to withstand strain is be-
60% type II collagen and approsimately 40% type I cause of" the stl"uctUrt: of cancellous bon ... : its poros-
collagen. As the disc ages, the collagen undergoes it,v varies from 30 t() 9CY>" compared with conical
irreducible cross-linking and the relative amount of bone with valuL's or 5 to 30%; (C~\rtcr & Hayes,
type 1 collagen increases, replacing type [[ collagen 1977). Vertebral corn pression strength increases
in the disc. from lhe upper cervical lo th(' lower lumbar k\'els.
Bone strength decreases with age as a result of
[he de\'c1oplllcnt of osteoporosis. The mineral con-
MECHANICAL PROPERTIES tenl (If' vertebr~\e decreases with increasing age at a
relatively con::'1ant rale (Hansson & RODS, 1986;
Vertebrae
Hansson et 411., 1980).;\ 25 cj{; «(..crease in osseous tis-
The mechanical properties of the bone and soft tis- suc results in a 1110re lhan a 500'0 tkcrcasc in [he
sues diffe!: Strength and stiffness and the relation of strength of the \"Crlchrac (Bell. 1967). BeC'lllSC the
stress to strain are the key IT'lCchanical properties. cortical shell of a venchra is responsible for on1.\' ap-
Stress-strain curves are used to determine the rela- proximatcl.v 1(Y;',; 01" its strength during compres-
tive loading behavior of bone. Stress is the load per 'sion, good quality c~lIlcellotis bone is criticall~" im-
unit area of a perpendicularly applied load. Strain is !Jorlant (McBroom e:t aI., 1985).
[he change in length per unit of original length, usu- \Vht,:.~n bone is loatk.'d in "h'o, contraction or the
ally expressed as a percenlage. musclt:s attached [0 the bone can alt0r [he stress
:lj
,
I
.ZiZY>_ .~" ). -~-"'>-- - ~." .
CHAPTER 11 • BIOMECHANICS OF [HE CERVIU\L
distribution in the bone. Bending moments are ap- in a neutral position or somewhat extended, and thus
plied to the vertebral bodies during motions. During pre-stresses the disc to some degree and provides
lie.""", tensile stresses are applied to the posterior some intrinsic support to the spine (Nachemson &
and compression to the anterior cortex of the Evans, 1968; Rolandcl~ 1966). The elastic properties
body. To perform lifting tasks, the back also assist in limiting the in\varcl buckling of these
are required to develop considerable forces ligaments during extension, which could potentially
IS"hltltz et aI., 1982). Stresses in a typical cClvical compress the neural clements.
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
Muscle
is weaker and fails earlier in tension than in
compression, posterior paraspinal muscle contrac- Muscular strength and control is imperative to
can decrease the tensile stress on bone by! pro- maintain head and neck balance. In the cervical
ducing a compressive stress that reduces or neutral- spine, muscle strength also has a role in reducing
izes the posterior cortical tensile stresses, allowing stresses on bones. Bending n10ments are applied to
the vertebrae to sustain higher loads than would the vertebral bodies during various motions. During
othenvise be possible. However, bone will often fail flexion, tensile stresses are applied to the posterior
prior to damage occurring to the intervertebral disc cortex and compression to the anterior cortex of the
under compressive loading. Finite element model- vertebral body. Substantial loads on the eel-vie'll
ing of the cervical spine indicates that the increase spine have been calculated during neck flexion, par-
in end plate stresses may be the initiating factor for ticularly! in the lower cenrical motion segments.
failure of this component under compressive loads 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-
Intervertebral Discs tions: full tlexion, slight flexion, neutraL head up-
right with the chin tucked in, and full extension.
Intenlertebral discs exhibit viscoelastic properties
The load on the junction between the occipital bone
(creep and relaxation) and hysteresis (Kazarian,
and C I was lowest during extreme extension (rang-
1975). Creep occurs more slowly in healthy discs
ing from an extension moment of 0.4 Nm to a flex-
than in degenerated or herniated discs, suggesting
ion moment of 0.3 Nm). It \vas highest during ex-
that degenerated discs are less viscoelastic in nature
treme flexion (0.9 to 1.8 Nm), but this was only a
(Kazarian, 1972).
slight increase 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-
Ligaments
tral position but bccame even lower when the head
Clinical stability of the spine depends primarily on \vas held upright with the chin tucked in (ranging
the soft tissue components, especially in the cervi- from an extension m0111cnt of 0.8 Nm to a flexion
cal spine. The spinal ligaments are functional moment of 0.9 Nm). The load increased somewhat
rnainly in distraction along the line of their fibers. during extreme extension (ranging from 1.1 to 2.4
Ligament strength and limited extensibility help Nm) and substantially during slight flexion (reach-
maintain stability, especially around the craniocer- ing 3.0 to 6.2 Nm). The greatest loads \vere pro-
vic'll junction. The alar ligaments have an in vitro duced during extreme extension, with moments
strength of 200 N, and the transverse ligaments ranging from 3.7 to 6.5 Nm.
have an in vitro strength of 350 N (Dvorak et aI., In the same study, surface electrode electromyog-
1988a). The strength of the ligaments is related to raphy was used to record activity over the erector
both the anatomical demands and the flexibility re~ spinae muscles of the cervical spine with the neck in
quired, \vhich is a classic example of form follow- the same five positions described above. Interest-
ing function. ingl}', the values obtained showed very low levels of
The ligaments all have high collagen content ex- muscle activity for all positions, even during ex-
cept for the ligamentum flavurn, which is exceptional treme flexion in which the flexion moment on the
in having a large percentage of elastin. The ligamen- C7-Tl motion segment increased n10re than three-
tum flavum is under tension even when the spine is fold over the neutral position. The fact that 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- lateral cervical radiograph of a 68-year·old 1Noman who
tively. Calculated moments and forces generally presented with severe torticollis. She denied any history of
correlated well with mean~ll1easured m:voelectric injury and did not have evidence of a suuctural vertebral
activities at eight sites around the perimeter of the abnormality, infection. tumor, or inflammatory disease.
neck al the C4 level. Pseudosubluxations (arrows) are evident subaxially as a
Muscles playa cr-iLical role in basic postural consequence of the marked kyphosis. Her neck was
twisted only because she had a severe cervical flexion de-
homeostasis, as can be observed in both historical Y$
formity. and she was unable to see forward except by
and present-day clinical settings. In unique obser-
turning her head to one side. She was neurologically in-
vational studies in lhe 1950s of severclv affecled po- tact. It was possible to extend her neck to a relatively neu-
liomyelitis patients, improvements in respiratory tral position using gentle traction. Following posterior fu-
assistance for those with respiratory paralysis led sion from (2 to (7, she returned to a normal independent
to higher survival rates and a large number of pa- life. Muscle biopsy was consistent with senile myopathy.
tients who sustained complete paralysis of the cer- Reprinred with permiSSion from tvioskovlCh. R. (1997). Cervical
, .
vical musculature. Patients with completely nail mSiabihw (rheumarold. d\·varfism, degeneraCtV£!. Oihers/ In X.H.
cervical spines were unable to support their heads Bridwell &- RL DeW,11d fEds), The Te;(lbook of Spln,ll Surgery
unless adequate support was provided and actually (D.o. 969- i009). Phdacie!pfJJd. Lippincorr-R,wfdl Publishers.
remained in bed despilc the good function of their
cxtrcmities (Perry & 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 edge base is growing. To date, certain basic para~
patients were found to have marked cenrical exten- meters have been established. The cervical spine
sor muscle weakness that has been attributed to se- undergoes significant changes in length during
nile cervical myopathy (Simmons & Bradley, 1988) f1cxion and extension (Breig el "I" 1966; Reill,
(Fig. 11-12). 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
Neural Elements
tolerance betwecn 2.75 and 3.44 kN is cstimated
Biomechanics of the neural elements have noL for the adult c~rvical spine before significant neu-
been as well studied as the biomechanics of the os- rological injury occurs (i'Vlyers &. \Vinkclstein,
teoligamentous vertebral column, but our know!- 1995).
CHAPTER 11 • BIOMECHANICS OF ii;E CE~CiS~~~f[[~~;~~;~"'D
9i
Spinal cord injuries can also result from extreme
or sudden flexion-c:\tcnsion movernCl1ts, especially N " C1
in the face of a $hallow spinal canal. I-lead Oexion ••
alone has been shown to result in significant in- 3.
II
0.. .___
male vertebrae (Moskovich el aI., 1996). This sludy
: ; ...t..-.
10 12 14 16 18 20 mm
used well-validated parametric statistical methods N C7
to determine that the mean sagittal diameter of the
81
spinal canal for C3-C7 was close to 14 mm (14.07 ±
1.63 mm; N ~ 272) (Figs. 11-13 and 11-14). The ot.
4'
_
mean ratio of the sagittal canal diameter to the ver-
10 12 14 16 18 20 mm
I
tebral body diameter (canal to body [cob] ralio) was I
86.68 ± 13.70. Thirly-one percent of subaxial verte-
brae would be diagnosed as having spinal stenosis if Histograms of the C1-(7 sagittal canal diameters. Apart I
a c-b ratio of less than 80% was considered abnor-
mal. Another study also found a high false-positive
error rate for the e-b ratio, with 49% of 80 asympto-
from the (1 plot, the same scale is used on all of the hori-
zontal axes so that the distributions of the diameters can
be compared, Reprinted with permission (rom Moskovich, R..
I,
1
1
et at. (996). Does rhe cervical canal [0 body rario predict spinal I
matic football players having a c-b ratio of less than
80O,b at one or morc cervical levels (Herzog et aI.,
stenosis? Bull Hasp Joint Dis, 55, 61-71. r
1991). Yet another group evaluated the reliability of I
the c-b ratio using plain lateral radiographs and CT
scans (Blackley el al., 1999). Results confirmed lhat
a poor con-elation exists between the true diameter
of the canal and the ratio of its sagittal diameter to
that of the vertebral body. The variab.ility in anatom-
especially in children (Dickman el aI., 1991; Osen-
bach & Menezes, 1989: Pang & Pollack, 1989). The
etiology of such injuries is unknown, but one mech-
anism may be longitudinal traction. The unusually
I
ical morphology means that the use of ratios h'om
anatomical measurements within the cervical spine
is not reliable in delermining the true diameter of
the cervical canal.
elastic biomechanics of the pediatric bony spine al-
lows deformation of the l11usculoskeletal structures
beyond physiological extremes, perm·itting direct
cord trauma followed by spontaneous reduction of
I
Spinal cord injul)' without radiographic abnor- the bony spine (Kriss & Kriss, 1996). The isolated
malities (SCIWORA) have also been described, spinal cord resists tension poorly; axial tensile
BICIMt:C1-IA~J1CS Of JOINTS
Posterior
longitudinal
ligament
Superior facet
l\v.-o-od{L Anterior
Capsular ligament,
Axial computerized tomographic scan of a sixth cervical . / longitudinal
vertebra, which was not part of the study detailed in the Spinous process ligament
text. The anteroposterior diameter of the spinal canal
measured 13.96 mm in this specimen. "'"
Interspinous II
Intervertebral
• and,
supraspinous J
disc
ligaments // I p I .
// . ostenor
forces to failure For three adult spinal cord speci- L' fl Inferior facet J longitudinal Intertransverse
Igamentum avum I ligament
mens arc reported to be 278 N ± 90 (Yoganandan et ligament
I
aI., 1996b). Lower forces may result in direct neural A Superior facet I
injury or vascular disruption. Interlransverse
I
Capsular ligament ligament
thogonal planes, for a total of six degrees of free- cal spifJ(l. (lin Orthop. \09,85··-96
.I,
the mobile vertebra. A. light-emitting diodes (LEOs); Band
C. Guide bars for application of tensile and compressive range of lateral motion of 3.0 mOl :!:: 0.3 mm, di-
fOfces. D. Pulley for application of torques. Weights are at· vided equally between right and left; tension results
tached to guide wires (w), which go around pulleys to pro- in 1.1 mm of distraction and compression, 0.7 mIll
duce torque on the upper vertebral body (v). n. interverte- of loss of vertical height (Panjabi et aI., 1986).
:
i
bral disc; 9. acrylic cement that attaches lower aluminum
plate (m) to test rig, which is rigidly bolted to the support
frame. The upper plate (p) and upper vertebral body (v)
are the moveable elements to which the loads and torques
are applied. LEOs are rigidly attached to the upper plate
The great Ilexibility of the eel'vical spine allows
the head to be positioned in a wide variety of ways,
;·Fy
I
c1
and their movement is recorded by two video cameras.
I Reprinted with permission {rom Raynor. R.• Moskovich. R.• Zide/,
l__
l1Y
I P. et a/. (1987). Alteration in primary and coupled neck motio1J5
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 radiographic studies or postmortem investiga- +Fz ~
0i---le.
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°
~Fx
(mean = 41°) (Dvorak et aI., 1987; Dvorak et aI.,
1988b; Penning & Wilmink, 1987). These measure-
ments account for approximately 50 r1'o of the lotal
cervical rotation. A vertebral body showing the three primary Cartesian
Another stereoradiographic study of neck motion axes, x, y. and z. Along each axis a positive force, ~ F. is de-
in adult men found a mcan of 105° axial rotation be- noted by the direction of the arrow. The curved arrows in-
tween the occiput and the C7 vertebra. Seventy per- dicate the direction of a positive torque. +..... Reprinted willJ
cent of the total axial rotation OCCUlTed between the permission from Raynor, R.• Moskovich. R., Zidel, P., el af.
occiput and the C2 vertcbra. Eaeh motion segment (/987). Alteration in primary and coupled neck motions aller
facete<:tomy. Neurosurgery. 21 (5). 681-687.
between the C2 and C7 vertcbrae avcraged fTom 4 to
8° rotation (Mimura et aI., 1989). Less well appreci-
i
l-",~~=~,...,.-.,-,~~-=-=-=--~;==;r.----,.--------:=,,~,
'.""'" .-.&f "" .. ",-"_",,,,,""£1 - .~"""'"- .-~- ~.~. •__ ' -,
.!~~~';-R1PBIOMEC8ANICSOF JOINTS
Post. AnI.
ment rnodeling indicate that the facet joints and un- I
covenebral joints are the major contributOl"S to cou-
pled motion in the lower cervical spine and thal the !
C5 uncinate processes effectively reduce motion cou-
pling and primal)1 cer'vical motion (in the same di-
rection as load application), especially in response
to axial roLation and lateral bending loads. Un-
covcrtcbral joints appear to increase primal)' cervi-
cal motion, showing an effect on cervical motion
Schematic drawing representative of a roentgenogram of opposite to that or the uncinate processes (Clausen
the C4-CS motion segment of a patient injured in a rear- et aI., 1997). Coupling or nexion-exLension with
end auto collision. The instant center of flexion·extension
transverse translation may be visualized roentgeno-
at this level (represented by the large solid dot) has been
graphically (Fig. 11-23). During flexion, the VCI-tc-
displaced from the anterior to the posterior part of (5 as a
result of the injury process, which impaired the ligaments
bral body normally shifts rorward: the racets glide
(compare with Fig. 11·18). The analysis of surface motion up and over one another with pseudosubluxalion.
shows compression and distraction of the facet joints with Changes in normal coupling patterns occur follo\\'-
I flexion and extension. iog palhological changes or surgical intervention.
Tensile load application to the cervical spine
• occurs in therapeutic traction, but more com-
monly so during trauma. Deployment of passive
COUPLED MOTION OF THE CERVICAL SPINE
Atlantoaxial Segment
The coupling characteristics of the atlantoaxial
spinal motion segments arc particularly important,
as this area of the neck is extremely' mobile. The [
dens is constrained within the osteoligamentous
ring of the atlas, causing the C l-C2 lateral masses
to articulate similarly to the condyles of the knee, ~'
\
with some sliding and rolling during Oexion and ex-
tension. The instant centers of both rotation and \
i:
n~xion-extension lie in the center of the dens itselr.
Rotation at CI-C2 is coupled with both vertical
\1'
translation along the Y axis (Fig. 11-20) and a de-
gree of anteroposterior disphlcenlent (\,Verne, 1957).
This implies that the CI-C2 joint is most stable in
the neutral position, and, if rotated, allempts should
be made to return it to the reduced position when A B
performing an arthrodesis.
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 as abnormal coupling or para-
Coupled motion during lateral bending is depicted
doxicalmotion. Par~\do.\icallllotionis seen when the
schematically. When the head and neck are flexed to the
left, the spinous processes shift to the right, indicating ro-
overall pattern of motion of one ~lSPCCI of the spine
tation. The converse is also illustrated. Adapted with permis- is in one direction while the local pattern is the op-
sion from White, AA 1// (~Panjabi, MM (1990). Clinical Bio- posite. For instancc, parado'\ical llc'\iol1 is seen
mechanics of the Spine. Philadelphia: 1.8. Lippincott. when llc'\iol1 occurs at a single functional spinal
unit, although the SpillL' as a whole is (''\tended.
A B
A, This diagram illustrates some of the other coupled mo- results in motion of the spinous processes to the right or the
tions, which occur in response to a torque (liZ) about the Z- left. B, The subject is bending to her right, demonstrating
axis (lateral bending). lateral translation (Rx) and vertical the large range of normal cervical motion possible (approxi-
motion (Ry) occur, as well as horizontal rotation (l!lY), which mately 50°).
Coupling of flexion-extension with transverse translation of (1-(2 articulation during flexion-extension; no translation is
the cervical spine is visible roentgenographically. A, Ouring evident in this example (black arrow). B, During extension
flexion the vertebral body shihs forward (small white ar- the reverse occurs, and the spinous processes limit motion as
row); the facets glide up and over one another with moder- they touch at full extension (arrow). The size of the interver-
I ate subluxation at full flexion (large white arrow). Up to 2.5 tebral foramina increases with flexion and decreases with
I mm of transverse translation may normally occur at the extension.
•
These types of abnormal motions describc a pattern logical loads to maintain its pattern of displacement
of mOVCIl'lCllt known as instability. so that there is no initial or additional ncurological
dcficit, no major defornlity,' and no incapacitating
pain (1990). Using this definition, physiological
Spinal Stability
loads are those incurred during normal activity, and
The concept of spinal stability is an intriguing and pain is not felt to be incapacitating if it can be con-
sometimes confusing notion. Medical practitioners trolled by non-narcotic drugs.
are frcqucnlly asked to look at a sel'ies of radi- Stability is detcrmined by many factors. There are
ographs and make a dctermination whether the different anatomical considerntions in different re-
spinc is stnblc. Exnclly what is stability, how is it de- gions or the spine. Certainly, ligamcntous anatomy
termincd, "'ld what happens if it is not present? The plays a large part in the stability or the spine, but the
term spinal stability has acquired diffcrent mcan~ muscular and bony clements of the ~pine also play
ings, depending on the setting in which it has been important roles.
used. White and Panjabi describe the term clinically Instability can be analyzed by considering kinematic
as the loss of the ability of the spine undcr 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 Motion increased
the functional spinalunil. In this type of instability, los..o:; lm.tantaneous ax(,>s of rotation altered
or alteration of various am.llomical portions detennines CDlipiing characteristics changed
the presence or instability (Box II-I). Parddo;O:I(d\ mOllon present
SAC
I
I
I
I
I
~
I L.-
space available for the spinal cord (SAC), which is denoted proprioception and correct functioning of the
I, by the dotted lines. Anterior atlantoaxial subluxation erector spinae muscles. Experimental section of
causes a reduction in the SAC. Normal measurements for the ligaments in sequence from either anterior to
the ADI are less than 3 mm in adults or 4 mm in children. posterior or posterior to anterior suggests L1lat if
Reprinted V'lirh permission from Moskovich, R. (1994). Atlanro-
a functional spinal unit has all or its anterior ele-
axial instability Spine: Stare of the Art Reviews. 8(3), 531-549.
ments plus one additional structure or all or its
posterior elements plus one anterior structure in-
'"1
"'7-~
11'1
.....
.~
..
'i;~
J
0l
:;'k~
,~
I
.~
j,*,
:;; i
~
,."
"1'
/.-;;
/'i,'
hl~~
iPi
ItM'~'"'~"~~M" .' A~_.~' ,~;;;Sk0. •.,••. ·W·,·_<· ,,,-- ',<>'< '. "..... .''''''~'
CHAPTER 11 • BIOMECHANICS OF THES~~VICAl-S~JI~I!i1r~
---=~ -~- - ~~
Dens
1
"3
•
I
I
I
Element
of Clinical Instability in the
Middle and Lower Cervical Spine
1!,
I,
I
rI!:
;~
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- tems have become available that can satisfactorily
sis also has an affect on adjacent motion segments. stabilize the cervicul spine from either approach..
Thcorcticall.',/, there is an increase in motion at \Vhen an anterior approach is used, a discectornv
nearby' unfused levels. Subsequent degeneration of or a vertebrectOlny at one or more levels is comm(H1I;,
other motion segments requiring additional levels performed, usuaIlv - followed bv. an anterior cervical
of arthrodesis has been demonstrated in multiple arthrodesis. The excised disc or bone must be re-
studies (Cherubinc) et aI., 1990; Hunter et aI., 1980). placed with a structural graft or prosthesis to restore
A recent study by Fuller ct al. (1998) evaluated the anterior column support to the spine. Osseous re-
distribution of motion across unfused cervical mo- placement ma:v be in the fm'm of autogenous or a!lo~
tion segments after a simulated segmental arthrode- genic bone, comrnonly from the iliac crest if autoge-
sis in cadaver cenrical spines. The authors simulated nous or from t.he fibula or iliac crest if allogenic (Fig,
01112-, t\\'o-, and three-level fusions in human cervical 11-30). The more cortical nature or flbula grafts rm;~
spines. They then moved the cervical spines through result in dela.yed incorporation compared"" with ilia~
a nondestructive 30° sagittal range of motion and crest grafts, which, therefore, are preferred clinically.
compared this range of motion with that of unfused The immediate postoperative strength of an.v of these
cervical spines. The findings of this study were inter- bone grafts under axial compression on a material
esting in that sagittal plane rotation was not in- testing machine reveals that they \\'ill adequately sup-
creased dispropc)J'tionatel)! at the cervical motion port the loads required in the cervical spine. The
segments immediately adjacent to a segmental ph.\'sical properlies of human bank bone seem to be
arthrodesis. Although the authors ackno\vledged preferable to autologous bone grafts, especially in
certain limitations of the study, they proposed that a
cenrical fusion causes a 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.
Another stud.y was performed descdbing the inci-
dence, prevalence. and radiographic progression of
symptomatic adjacent level disease after cervical
arthrodesis (Hilibrand et aI., 1999). Adjacent level
disease \vas defined as the development of a new
radiculopath,Y or myelopathy that was referable to a
motion segment adjacent to the site of a prior ante-
rior cervical arthrodesis. The findings revealed that
symptomatic adjacent level disease occurred at a
relatively constant incidence of 2.9 % per yeac A sur-
vivorship analysis revealed that approximately 26(Y£)
of patients \vha had an anterior cervical arthrodesis
would have new disease at an adjacent Icvel within
lO y"cars of the operation. The study also demon-
strated that more than two-thirds of the patients
who developed adjacent level cervical disease expe-
rienced failure of nonoperative treatment and
needed an additional procedure performed.
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 commonl:v performed after trauma but may also be
and its USe obviates the need to harvest autologous L1sed to treat degenerative, inflammatory, or neo-
bone from the iliac crest, sparing patients additional plastic conditions. Unlike anterior fixation devices,
surgical trauma and potential complications. which arc solel y lIsed in the subaxial cervical spine,
l
Calcium phosphate (bone) ceramics form a strong posterior fixation devices can extend up to the oc~
bond with host bone because of a zone of apatite mi- ciput (Fig. 11 ~32). Posterior fi.'\ntion has commonly
crocrystals deposited perpendicular to the hydroxy- consisted of various wiring methods, which arc
lapatite ceramic surface (Jarcho, 1981). Synthetic used as a tcnsion band posteriorly (Sutterlin et aI.,
hydroxylapatite blocks used for interbody cervical 1988). Within the past decade. however, techniques
arthrodesis in goalS produced similar fusion rates utilizing screws in both thc atlantoaxial and subax~
and biomechanical stifFness when compared with ial spine have become rnorc popular.
autogenous bone (Pintar et aI., 1994). 11 is interest- Techniques for aLiantoaxial fixation have evolved
ing to note that the goat holds its head creCl, and from onlay bone grafting alone to cver~more sophis-
thus loads the cervical spine similarly to human ticated methods of internal fixalion. Interlaminar
bipeds. Goat models for cervical spinebiologicallbio- clamp fixation is clinically reliable and safe
mechanical testing are, therefore. populal: (iVIoskovich & Crockard, 1992). Screw fixation tech-
A can inc thoracic anterior al1hrodcsis model niques may confer increased translational and axial
yielded contrary results when tested biomcchanically: rotational stability, but with greater surgical risks.
autogenolls iliac crest grafts were stiffer in all motions A biomechanical evaluation of four commonly used
than \\lcre ceramic graft substitutes (Emery et aI.. techniques for posterior atlantoaxial fixation was
1996). aturally grown coral is also a useful bone graft performed (Grob et aI., 1992\ Cadaver CI-C2 f,mc-
substitute once it has been processed. Jt is available tional spinal units were tested in nexion~cxtension,
con1rncl'cially in t\\-'o different porosities (200 ~m and lateral bending, and rotation, while intact as well as
500 lJ.m pore size). The grafls of lower porosity had a after a complete ligamel1lous injul)/. The fixation
compl"Cssive strength comparable \vith biconical iliac techniques used wcrc:
crest grafts, although they were much more briule.
They can therefore be considered appropriate for clini- I. Sublaminar wire with one median graft
cal lise with rcspect to their compressive strength (Gallie type)
(Table 11-1). An increasing variety of prosthctic intcr- 2. \Vire fixation with two bilateral grafts
body cages ~\re becoming available (Shono ct aL, 1993); (Brooks lype)
long-tellll clinical results arc eagerly awaited. Addi- 3. Transarticular screw fixation (Mager!)
tional anteJior (Fig. 11 ~31) or posterior intcI11al ft:-.:atio!l 4. Two bilateral posterior Halifax clamps (Fig.
using plates and screws for added support ma.\' be 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'1 instrlbilit\', 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
, ;" .. ,
' ,~
if ! 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.
:,~?;~
;7'''':;
lr -;.
j-
The palient presented with severe neck and shoulder pain
accompanied by sleep disturbance. The right sternocleido-
mastoid muscle was approximately twice as large as the left
t, sternocleidomastoid muscle. After muscle testing against re-
>.: ' f.. sjstance, the pain increased (Fig. cs 11-2-1).
..t. ~> 'To decelerate the posterior rotating head, a moment and
g>:a.force must be developed by active and passive stabilizers,
i.-?int surfaces, and the intervertebral disc. The moment and
force give rise to tension, compression, and shear stresses
.',: .find strains in various parts oi the neck Cdusing, damage.
fl., During the collision, rhe muscle tension increases with ihe
, velocity of lengthening. A tension inappropriate for the i
-i
length tension curve occurs and partial rupture of the sterno-
4
1
cleidomastoid muscle is produced. Reprinted with permission Case Study Figure 11-2-1.
'.- -..
I
I
I
I'IDIIDI B
~.
• 1~_H.a_nd_-_d_r.aw_n.c.e.I .,
(A) Before and (B).tr.a.c.ed_f'.o.m_t_w_o_f.r_am_e_'_o_f_a.C.in.e.-.m_o_V_ie_o.f.D.r_.I.rV.i_n9_T_u_e_lI_d.,.iV.in.9_h.i'.c.a.r-
aher bein9 rammed from behind by another car driven by hi, re,ident_ _
,;
.. ...
,.-
biomechanical responses for the various conditions plied, which protects the disc from catastrophic rail-
observed in normal driving (Viano & Gargan. 1996). lIrL' ulltil e . . . trl"lllcl~· high loads are applied.
Risk of injury was assumed to be proportional to 5 Vi".'I·lL"bl·al bod~' cUlllpr~ssioll str~ngth increases
neck extension. A low headrest position carries a from upper ct.'n:ical 10 IO\\'L'r lumbar lev-cis.
relative injl1r~' risk of 3.4 in rear-end crashes. com-
pared with 1.0 for the favorable condition. If all ad- 6 TIlL' mean sagillal diametL'r of the malt.- adult
justable headrests were placed in the up position, spinal canal for C3-C7 is close LO 14 Illm; the spinal
the relative risk would be lowered to 2.4, a 28.30/0 re- cord diameter is about 10 111 Ill.
duction in whiplash injury risk. 7 LigamclltuJ11 flavlIJ11 is undt..'1' tension even
Significantly more complex acceleration injuries when the spine is in a Ill:1Itral position or somewhat
ascribed to high G-force activities are now occurring. cxtended. prestressing the disc and pro\'iding some
There is a report in the Htel·ature of cervical injury in intrinsic support 10 tht..' spine.
pilots of F- t 6 fighter planes, citing a I-year preva-
lence of neck injury of 56.6% and a career prevalence
S iVlllscles pla~' a critical role in b~lsic postural
homeostasis. Patients with paral~'zL'd ct..'lyical mus-
of neck injury of 85.4% (Albano & Stanford. 1998).
cles arc unable to support thdr heads.
Maintenance of neurological homeostasis and
protection of the spinal cord. nerves. and vessels 9 The spinal cord has some longilUdinal c1astic-
and support and protection of the skull are the ulti- it.'· blll it tole-ratL's axial translation pond.". It is the
mate tasks of the cervical spine. An appreciation of translatolY forces {hat t.\'picall,\· rcsult in neurologi-
the principles presented should afford a greater un- cal injul·.\',
derstanding to physicians and allied health profes-
10 Instant c('ntl.'!' anal.\'sis indicates that tangential
sionals involved in the treatment of cervical spine
lnotion (gliding) wkcs placl.· bel\\,(.'c·]1 lltt::.' facet joints
pathology. 'vVith increasing technological advances
as lItc cervical spine is flexed alld extended. The size
in our society, \ve remain vulnerable not only to
or the intelTcrtebr~il !"()ramina inc.TeDscs with flexion
common types of cervical trauma but also to idio-
and deCl'l:ascs \\'ith extension,
syncratic methods of injury' related to these new
technologies. Acceleration injuries have been OCCUI'- 11 Kinematic instability' refl'rs to the quantity of
l'ing for decades but cervical spine injuries caused motion (too much or too little) or till.' quality of mo-
by airbags have only recently been described, and tion present (alterations in lile normal pattern), or
aliI' involvement in increasingly greater speeds and both. Component instahilil.\' addrcsses the clinical
higher risk activities places LIS in increasing jeop- biomechanic~ll role of till.' \'ariolls anatomic struc-
ardy, As our body' of knowledge expands, we con- tures of the functional spinal unit.
tinue to discover new methods of injury. It is critical 12 An." motion s~~glllent in which all of the ante-
to pursue rational treatments for these disorders rior ek'llkllts or all the posterior ekments m·e de-
based on sound biomechanical principles, stn>yed or are unabk' to function should be consid-
ered unstable.
5 11111111 a Iy 13 A significant incn:asc in annulus stresses and
scgrnclltal mobility' may' OCCUI' when bilateral focet
1 A functional spinal unit or motion segment resection exceeds 50(*;.
consists of t\\'o adjacent vcnebrae and the interven- 14 Appropriate use or internal fi:G1lion helps LO in-
ing intervertebral discs and ligaments between the (:reasc the fusion rate and maintain structural align-
vertebrae. ment.
_2 Whcn eithcr rotation or translation of a body 15 Front seat occupants are adcqLH.llcl~' protected
along one axis is consistently associated with a si- ~lgain.s{ frontal impact if scat belts arc worn in an
multaneous rotation or translation along another airbag equipped ,·chick. Passenger-side air bags
axis. the motions arc coupled. pose a lethal threat to children riding in the front '..
3,; Intervertebral disks cxhibit viscoelastic proper- scat 01" an automobile.
ties (creep and relaxation) and hysteresis. 16 \'Vhiplash s.\"ndrome is a complex set of s~'mp
(4;' Discs arc able to withstand greater than nor- tOI11S thal may present aher an (\("ccleration hyper-
l1l~r loads when compressive forces arc rapidly ap- extension injury.
CHAPTER 11 • BI()MECHA.NIC
Paniabi, ,\1.,\-1., \Vhile, A.A. III. & Johnson, R.,\1. (1973). Cer- Simmons, E.H. & Bradlev, D.D. (1988). Nturo-myorathic
\:ical spine mechanics ,IS a I"unction 01" transection of corn- flexion deformities (/ the cervical spine. Spille, 13,
pOneJllS. 1 HiOlllt'c!/(lIIics, 8, 327-336. 756-762.
Penning, L. & Wilmink, J.T. (1987). Rotation of the cCl'vical Steel. H.ll. (1968). Anatomical and mechanical considera~
spine. A study in normal people. Spille 12, 732-738. tions of atlanto-axial articulation. In Proceedings of tIll:
Perry, J. & Nickel. V.L. (1939). Total cervical-spine fusion for American Orthopaedic Association. J BOlle Joil/I SlIrg, 50A,
neck par,t1ysls. 1 BOIIt, loilll SIIJ'g, .Jl:\, 37-60. 1481-1482.
Pintar, FA., \himan, D.J., Hollowell. J.P., L't 'II. (1994). Fu- Sturzenegger, .\1., DiStel"ano, G.. Radano\', B.P., et a!' (1994).
sion rak and biorHechanical stillness of hydroxylapatite Presenting symptoms and signs after whiplash injury: The
versus autogenous bone grafts for antnior discectorny. An influence of accident lllechanisms. NCllrology, .J.J, 688-693.
in vivo animal study. Spille, 19, 2324-2328. Sutterlin, C.E., McAfee, P.e., \Vardell, K.E., ct al. (1988). A
Pintar, F.A., Yoganandan, N., Pesigan, ~'1., L'l a!' (1995). Cervi- biomechanical evaluation 01" celYlcal spinal stabilization
cal vertebra! strain llleasuremellts under axial and eccen- methods in a bovine model. Static and cyclical loading.
tric loading. 1 Bioll/cch Ellg, /17, 474--478. Spillt', 13, 793-802.
RapolT, A.J., O'Brien, T.J., Ghanayem, A.J., L'l al. (1999). An- Takebe, K" Vitti, :v1., & Basrnajian, J.\!. (1974). The functions
terior cervical graft and plate load sharing. J Spillill Dis, of semispinalis capitis and spli:nitls capitis muscles: An
12,45-49. electromyographic stud.v. Allat Rec, f79, 477-480.
Raynor, R.B., Moskovich, R., Zidel. P., et a!' (1987). Alteration Viano, D.e. &. Gargan, il,'l.F. (1996). Headrest position during
in primary and coupled neck motions after fncell.'ctomy. normal driving: Implication to neck injury risk in rear
NellnlslIl'.i.iery, 2l, 681-687. crashes. Accidellt Allal fln'I', 28, 663-674.
Ri:ill. J. (1960). Effects of flexion-exti:lIsion movement of thi: Yoo. I..M .. Kumar"san. S .. Yoganandan. N.. 01 at. (1997). Fi·
head and spine on the spinal cord and nerve roots . .I ,VCII- nite elemi:nt anal~'sis of ci:rvical facctectomy. Spille, 22,
ml ,VClII'OSlIr.i.i Psychi(/IJ', 23, 214-221. 964·-969.
Ripa, D.R., Kow,dl, \I.G., "'!eyer, P.R. Jr., et al. (1991). Series Wallis, B.J., Lord, S.M., Barnsky, L., et al. (1998J. The psy-
of ninety-t\\·o traumatic cervical spine injuries stabilized chological profiles of patiellts with whiplash-associated
with anterior ASIF pl,lte fusion technique. Spille, 16(3), headache. Cephalalgia, IS, 101-105.
46-55. WertH.', S. (1937), Studies in spontaneous alIas dislocation.
Rolander, S.D. (1966). \-lotion of the lumbar spine with spe- Acta Ort/lOp Sewld, 23 Suppl.
cial refi:rence to thi: stabilizing (.'ffect of posterior fusion. White, A.A. Ill, Johnson, R.~L Panjabi, :\1.M., et al. (1973).
An experimental study on autopsy specimcns. /lcw Orthop Biornechanical analvsis of clinical stabilitv in the cervical
Snllld,90, 1-144. spill(:. Clill Orl/top, l(N, 85-96. .
Roozmon, P., Gracovetsky, S.A., Gouw, G.J., ct a!' (1993). Ex- White, A.A. III & Panjabi. M.\1. (1990). Clillical Bio/llechal/ics
amining motion in the cervical spini:. I: Imaging systems oj' tlze Spille. Philadelphia: J.B. Lippincott.
and measurement ti:chniqui:s. 1 Bio/lled Ellg, 15,5-12. Wittenberg, R.l-I., i\loeller, J.. &. \Vhite, A.A. III. (1990). Com-
Saito, '1'., 't'amamuro, '1'., Shikata, J., et a!' (1991). Analysis pressive strength 01" autogenous and alJogenolls bone
and prevention of spinal column deformit.;.' following cer- grafts 1"01' thoracolumbar and cervical spine fusion. Spille,
vical laminectomy. I. Pathogenetic analysis of post- 15(101. 1073-1077.
lamini:ctomy deformitii:s. Spilll.', 16, 494-502. Yang, K.H., Latour. B.K., & King, A.1. (1992). Computer sim-
Schneider, R.e., Chi:rry, G., & Pantek, H. (1954). The syn- ulation of occupant neck rtsponse to airbag deployment in
drome of acute ci:ntral cervical spinal cord injury with I"rontal impacts. J J3io/llech Ellg, 11.J, 327-331.
special reference to the mechanism involved in hyperex- )'oganandan, N., Kumaresan, S.c., Voo, L., ct a!' (1996a). Fi-
tension injuries of the cervical spinto J /":I.'ZlroslIJ'j;, 11, nite dement modeling of dll: C4-C6 cervical spine unit.
546-577. lIed Ellg Phys, 18,569-574.
Schultz, A., Anderson, G., ()rtengri:n, R., et al. (1982). Loads Yoganandan, N., Pintar, EA., \Lliman, D.J., ct al. (1996bL
on the lumbar spine: Validation of a biol1ledwnical anal\'- I-Iuman head-neck biomechanics under axial tension. lIed
sis by measurements 01" intl'adiscal pressure and myoell'c- Ellg Pltys, 18,289-294.
tric signals. J BOllI.' .Ioillt SlIrg, 6",.1, 713-720. )'00, J.U., Zou, D.. Edwards, W.T., et al. (1992). Effect of cer-
Shono, Y., ivlcAI"ee, P.C., Cunningham, B.\V" et at. (1993), A vic,d spine motion on the netlroforaminal dimensions of
biomeclwnical analysis of decompression and reconstruc- human c('['vical spine. Spinc, 17{ 1131-1136.
tion methods in the cervical spine. Emphasis on a carbon-
fiber-compositc cagt. } BOllI.' .loilZI S/lrg, 7504, 1674-1684.
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 ----._------------------------~--------~._-._-~-------_._---
""" :;;;Cor
Introduction anatomy of the various aspeclS or the shoulder com-
plex and shows how their structure allows ror effi-
shoulder links the LIpper extremity to the trunk cient biotllcchanical function.
acts in 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-
12-J). An absence of bony constraints allo\I.'5 a wide n1al functioning of the shoulder complex, the four
range of motion at the expense of stability, which is pro- aniculations with their associated components act
for instead by the various ligamentous and mus- togcther in a way that produces mobility greater
stl1.!cturcs.
The biomechanics of the shoulder arc complex,
than that afforded by anyone individual aniClda-
tion, The ability of the shoulder complex to position
iii
and a complete discllssion necessitates an analysis the humerus and the remainder of the LIpper cx-
of the four aforementioned articulations that make trcmit~· in space is further augmented by movement
up the shoulc!eI- complex. This chapter describes the of the spine. A discussion follows of the t\'pcs 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
Acromion o f .
@ -~ /.
7'
/'
RANGE OF MOTION OF THE SHOULDER
COMPLEX
Shoulder range of motion is traditionally measured
in terms of flexion and extension (elevation or
scapula \ Clavicle
\ \ Sternum movcrncnt of the humenls away from the side of the
Scapula
, '\ thorax in the sagittal plane), abduction (elevation in
_ r the coronal plane), and intemal·external rotalion
I
,)" I ($
(axial rotation of the humerus with the arm held in
an aclducted position) (Fig, 12-2), Although during
I \ t?r functional activit.ies these pure motions are rarely
~,\ seen, we can better understand the complex mo-
i"-(l-- Humerus
,,
,
,
\
tions of the shoulder by anal~/zing the separate com-
ponents needed to achieve anyone position,
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· (Boone & Azen. 1979). These val·
I Scapulothoraclc
ues are Iimiled by capsular torsion. Abduction in
~0L-n _ the coronal plane is limited by bony impingement
of the greater tubcr()~ity on the acromion, Forward
I Schematic depiction of the bony structures of the shoulder elevation in thc plane or the scapula, thereFore, is
i and their four articulations. The circular insets show front considered to be more Functional because in this
, views of the three synovial joints-sternoclavicular, plane the inferior portion of the capsule is not
I
I acromioclavicular, and glenohumeral-and a lateral view
of the scapulothoracie joint, a bone-
twisted and the musculature of the shoulder is op-
timally aligned for elevation of the arlll (Fig. 12-3). "
,I muscle-bone articulation. Adapted with permis5ion from De Although shoulder range of motion !10nl1all~' de-
Palma, A.F. (1983). Biomechallin of the shoulder. In Surgery of
J.I the Shoulder (3rd 00.. pp.6S-85J. P!I;/adelp!l;d: J.8. Upp;ncorr
creases as part of the aging process, physical activ-
ity can counteract lhis process (Murray ct al.. I
1985).
";
,,j
,j
319 IJ
,I
"~ ~'~"~T" "'-_" "_' O' ' ' ' ' =' ' 'r. ....=" "~" ,.,. .,." ,- , ,_: " ' ' '-:' ' '-:' ' ~- ,' ' '., ,~, "'.=.". .- -". . . ,.-. .,.-"_"', ."'_,"', _J"'.;./"', ~. -7"+-r;" ':, :-o"'- :;'?"'~ _P ~"'"'~ ":'%="'~?"' ,~_' "' ' .~' ,U~ J
._--Ii!_'., _,.. •.=.. .. T":::;"': .. __ .
Of JOINTS
~ it
I ,
, lf
I
,,
:,,,
I
,
I
,
I
I
I
f
I
--c:+
cs. ..- _........"..'...........-=>1
,,
I I ,, Humerus
:, \\ at the
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-
The sternoclavicular joint consists 01" the enlarged
ticular disc or meniscus that divides it into two
medial end of the clavicle and the most superolat-
Cotlllxlrtmcnts.
eral aspect of the manubrium, linking the upper ex-
Although the joint itself has little intrinsic stabil-
tremity directly to the thorax. In addition, a small
ity, the articular disc in conjunction with anterior,
facet is present inFeriorly that articulates with the
posterior. C()stoclavicular, and intL't"clavicular liga-
ments maintains joint apposition (Fig. 12-4). The
Scapular plane elevation anterior and posterior sternocla\'icular ligaments
resist anterior ;:md posterior translatiolls (as well as
superior displacement), while the costoclm'icubr
Long axis Long axis
lig;:Hllenl, which rUIlS betwcen the undersurface 01"
c3~~
the medial end 01" the chlviclc and the first rib, re-
sists upward as Wi..'l1 as posterior displacement of
the clavicle (\'ia its anterior'portion) and is thought
to be the major constraint in limiting stcrnoclavicu-
br motion. The interclavicular ligament connects
the superollledial aspect or the clavicles ,:Hld assists
in restr;:lining the joint superiorl:v. '1'he posterior
portion 01" the interclavicular ligament also. assists
with anterior restraint of' the sternoclavicular joint.
Speciflcall)-', the interclavicular ligament tightens
Elevation in the scapular plane, which is midway between with arm depression and is lax when the ann is ele-
forward flexion and abduction. The humerus is in the vated (i\'lorrey & An, 1990). The disc prevents me-
plane of the scapula.
dial disphlcelnent or
the clavicle, which m<l!' occur
when C<\IT)-'ing objects at the side, ;:IS well as inferi<)!'
CHAPTER 12 • "IU'ME:U-IA~llC
Post.
Protraction-retraction
l:7==
.......
ACROMIOCLAVICULAR JOINT B
The acromioclavicular joint (Fig. 12·6) lies between
the lateral end of the clavicle and the acromion of Rotation
the scapula (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 c
\vithin the joint originating from the superior as-
pect. Both sides of the articular surface are covered
with fibrocartilage and the joint itself slopes infero-
Motion at the sternoclavicular joint. A, Top view showing
medially, causing the lateral end of the clavicle to
the clavicular protraction and retraction (anteroposterior
slightly override the acromion. 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
reinforced superiorly' by' the acromioclavicular lig- shown. Motion takes place between the sternum and the
ament. The acromioclavicular ligament acts pri- meniscus. B. Anterior view showing clavicular elevation
marily to restrain both axial rotation and posterior and depression (superoinferior gliding) in the frontal plane
translation of the clavicle. The majority of the around a sagittal axis (solid dot) through the costoclavicu-
joint's vertical stability is provided by the coraco- lar ligament. not shown. Motion occurs between the clavi-
clavicular ligaments that suspend the scapula cle and the meniscus. C, Anterior view depicting the clavic~
from the clavicle (Fukuda et aI., 1986). The cora- ular rotation around the longitudinal axis of the clavicle.
The coracoclavicular ligament complex consists of the larger arc and is CO\·cfL.,d with hyalin(' cartilag~ as is the
and heavier trapezoid ligament, which is oriented laterally, glenoid fossa. The hUllleral head is rctnwt..'rlcc! or
and the smaller coroid ligament, situated more medially. postt..'riorl.\' dirt..'ctcd 3D'" wilh rt..'speci 10 tilL> intcr-
Reproduced with permission from Hollinshead, WH. (/969). cond.\'lar plan..: of the distal hUlllerus and has an up-
Anatomy for Surgeons (Vol. 3), New York: Harper & RO'll, ward or llledial indination of 45°; this configuration
gives the humerus an o\'eral! more anterior and lat-
eral orienl~\liol\ (Fig. 12-7). The greater and lesser
tuberosities lie lateral to Ihe articular surface of Ihe
proximal hUIl1L'rus thal SCIY('S as tht.' all<:lchlllL'1ll site
coracoacromial ligament lies on the lateral side of
for IhL' rotator culT IllUsctdalUrc. The long head 01"
the acromioclavicular joint and runs rrom the
Lhe biceps lendon trii\vcrsL.'S till> bicipilal groove
most lateral aspect of the coracoid to the medial
aspect of the acromion.
Although clavicular rotation does occur with arm
elevation, Rockwood (1975) found little relative mo-
tion between the clavicle and acromion. This has
been attributed to synchronous clavicular and
scapular rotation with little resullant relative mo-
tion at the acromioclavicular joint: the majority of
scapulothoracic motion occurs via the stcnlOclavic-
ular joint. Thus, rigid fixation or fusion of the
acromioclavicular joint produces little loss or over-
all shoulder function while sternoclavicular fixation
leads to restricted motion or, more commonly. im-
plant failure.
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-
humeral ligament helps stabilize the biceps tendon in the nous rim that acts to deepen the glenoid, providing
groove. Reprinted with permission from Neer, C. (1990). Shoul- 50°;(; of the overall depth of the glenohumeral joint
der Reconstruction (p. 29), Philadelphia: WB. Saunders Co. (\Varner, 1993). It has a triangular configuration
\'.'hen viewed in cross-section and has firm attach-
a;'~~4XPART II • 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 when vie'Ned in cross·section and serves to effectively
glenoid and is confluent at its area with the long head of the deepen the glenoid, increasing the stability of the gleno-
biceps tendon. B. The labrum has a triangular configuration hllmeral joint.
I
The middle glenohumeral ligament originates in-
:~;~:;.:terotnferior1y) and beyond the glenoid labrum and
ferior to the superior glenohumeral ligament (at the
~~-- laterally it reaches [Q the anatomical neck of the
I o'clock to 3 o'clock position, right shoulder) and
;'~lh~humerlls. Superiorly, it is attached at the base of the
inserts fl.1rther laterally on the lesser tuberosity.
'itrtY:' coracoid. enveloping the long head of the biceps
Great variability in the anatomy of this structure !I
~'7F~;~tendon and mnking it an intl'n-articular structure
has been demonstrated, being absent in as many as
dfB"HFig, 12-1 I),
-!:%ihi The capsule nlso has a stabilizing role, tightening 30% of shoulders (Curl & Warren, 1996), It may
originate from the anterosuperior portion of the
II
,-._. with various arm positions. In adduction, the cap- 11
labrum, the supraglenoid lubercle, or the scapular 'I
sule is Lattl superiorly and lax inferiorly; with ab-
duction of the upper extremity, this relationship is
neck, Morphological variants have been descl'ibed.
including a cord-like variant (clearly distinct from
,I
,'ev'er<;ect and the inferior capsule tightens. As the I
the anterior band of the inferior glenohumeral liga-
is externally rotated, the anterior capsule tight-
while internal rotation induces tightening pas-
ment) and a sheet-like variant (blending with the j
;
anterior band of the lnferior glenohumeral liga-
teriOl'lv, The posterior capsule in particular has been
ment). Functionally, the middle glenohumeral liga- i
to be crucial in maintaining glenohumeral
ment acts as a secondary restraint to inferior trans-
I
stability, acting as a secondary restraint to anterior
lations of the glenohumeral joint with the arm in
!
dislocation (particularly! in positions of abduction)
the abducted and externally rotated position
as well as acting as a primar~y posterior stabilizing
(vVarner el aI., 1992). It also sen/cs as a restraint to
structure (Itoi, Hsu, & An, 1996),
anterior translation, having its maximal effect with
the arm abducted 45°.
The inferior glenohumeral ligament originates
Glenohumeral and Coracohumeral
from the inferior aspect of the labrum and inserts
ligaments
on the anatomical neck of the humerus. It has been
The three glenohumeral ligaments (SUPCriOI~ mid- shown to have three distinct components (O'Brien
dle, and inferior) are discrete extensions of the an- et ai., 1990): an anterior band originating from 2 to
terior glenohumeral joint capsule and al'e critical to 4 o'clock (right shoulder), a posterior component
shoulder stability and function (Fig, 12-12), The su- originating fTom 7 to 9 o'clock (right shoulder), and
perior glenohumeral ligament originates from the an axillat), pouch (Fig. 12-12), The inferiOl· gleno-
anterosupcrior labrum, just anterior to the long humeral ligament has the greatest rll11ctional signif-
head of the biceps, and inserts onto the lesser icance, acting as the primm)' anterio.' stabilizer of
tuberoSity. It is present in the majority of shoulders the shoulder with the arm in 90' of abduction, As
bllt only well developed in 50%, The superior gleno- the arm is abducted and externally rotated. the an-
humeral ligament acts as the main restraint to infe- terior band of the inferior glenohumeral ligament
rior translation with the arm in the resting or ad- tightens, resisting anterior tninslalion. \·Vith inter-
dllcted position (Warner el aI., 1992), nal rotation of the abducted arm, the posterior band
The coracohumeral ligament originates from the becomes taut and posterior translation is resisted.
lateral side of the base of the coracoid to insert on The inferior gleno·humeral ligament complex also
the anatomical neck of the humerus (Fig, 12-6) serves to resist inferior translation of the gleno-
(Cooper et aI., 1993). This structure lies anterior to humeral joint with the arm in the abducted posi-
the superior glenohumeral ligament and reinforces tion. Variability as to the size and attachnlent sites
the superior aspect of the joint capsule, These liga- of the gle-nohumeral ligaments has been demon-
ments span the rotator interval belween the sub- strated (Warner et aI., 1992); howe vet; the clinical
scapularis and supraspinatus, Some research incH- significance of this has yet to be fully elucidated al-
cates thal these strUClures have a secondary role in though it has been suggested thal absence of the
preventing 'inferior translation of the shoulder while middle glenohumeral ligament may predispose to
in the adducted, neutrall.v rotated posilion. The instability (Steinbeck et aI., 1998),
JOINTS
A-
A B
AS
c D
A, Schematic drawing of the shoulder capsule illustrating the humeral ligament complex remain lax, C, The anterior band
location and extent of the inferior glenohumeral ligament is the primary restraint resisting inferior translation of the
complex (IGHLC). A, anterior; P, posterior; B, biceps tendon; shoulder at 45<> abduction and neutral rotation, In this posi-
SGHL, superior glenohumeral ligament; MGHL, middle glenoo tion, the superior glenohumeral ligament, the middle gleno-
humeral ligament; AS, anterior band; Ap, axillary pouch; PS, humeral ligament, and posterior band are lax, D, At 90° ab-
posterior band; Pc, posterior capsule. Reprinted with pertnis· duction, the anterior and posterior bands of the inferior
sian from O'Brien, SJ, Neves, M.e, Amoczky, S.P, et at. (1990) glenohumeral ligament cradle the humeral head to prevent
The anatomy and histology of the inferior glenohumeral ligament inferior translation, The posterior band is more significant in
complex of the shoulder. Am J Sports Med. 18, 579-584. B. The external rotation, whereas the anterior band plays a greater
superior glenohumeral ligament is the primary restraint to role in internal rotation. Reprinted wirh permission from Warner;
inferior translation in the adducted shoulder at neutral rota- IP, Deng, X.H.. Warren, R,F., et al. (1992). Staric capsuloligamen-
tion. In this position, the middle glen?humeral ligament and taus restraints ro superior-inferior translations of rhe glenohumeral
the anterior and 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 . extremity, cauSing forceful abduction and external ro"
given anatomical structure to overall glenohumeral sta- tation. He noted acute pain in the arm and was unable to
bility (Curl & \JVarren, 1996). In this technique, cadav- IYlQveit Physical examination revealed loss of the normal
eric specimens are biomechanically tested before and contour of the shoulder and painful range of motion. Ra"
dlogr~phs showed an anterior dislocation with posterior
after selectively cutting sequential structures. A force is
then applied in a given arm position, and the transla- superi.()rhumeral head impaction fracture. The patient un-
tion that occurs is measured. From this information, the gerwent closed reduction. Postreduction radiographs con"
relative contribution that a given structure provides to firlYledreduction of the humeral head with a small bony
overall stability can be determined. When a particular ayulsion fracture of the anterior-inferior glenoid rim,
pattern of shoulder instability is then identified, the whichrepresents a detachment of the anterior labrum in
physician can infer which anatomical structures may be the area of the superior band of the glenohumeral liga-
deficient or disrupted so that a rational plan of physical ment insertion (Case Study Figure 12" 1" 1).
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
Additional Constraints to Glenohumeral translation of the humeral head, resulting in anterior dis-
Stability location. !n addition, a concomitant capsule lesion af-
fected the intra"articular negative pressure necessary to
Sy'l1ovial fluid acts via cohesion and adhesion to
pull the humeral head inward. After conservative man-
further stabilize the glenohumeral joint. Synovial
agement. the patient did well for 6 months until he sus"
fluid adheres to the articular cartila~e ovcrh;in cr the
tained a recurrent dislocation. The patient subsequently
glenoid and proximal humerus, c;using the b two
surfaces to slide along one another: Th~ synovial
opted for operative treatment that included repair of the
SCAPULOTHORACIC ARTICULATION
The scapula is a Flat, triangular bone that lies on
Case Study Figure 12-1"1.
the posterolateral aspect of the thorax between the
second and 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
r,.,
1)
,
!~
Kinetics
Numerous llluscll..'s aCI nn the \'arious components
Scapular orientation on the chest wall. Left. 30~ anterior, or the shoulder complex to provide both mobilit,v
Right. 3" upward, Reprinted with permission from Warner JJP: and d\'namic $t~lbilit.\·. Dynamic stabilization oc-
The gross anatomy of the joim surfaces, ligaments, labrum, and cllrs via sl.~\'cral possible lllcch:'lnisms (Molley &
capsule. In: Matsen. F.A., FtJ, F.H., Hawkins, R.I (Eds.) The Shoul- An, 1990), including p~lssi\'(' musch.' lension, or
der: A Balance of Mobility and Stability. Rosemont, IL: American via a b:,uTic:r effect of the contracted Illuscle, COIll-
Academy of Orthopaedic Surgeons, J 993.
prl..'ssi,·L' forces broughl ahout h~' llHISCU!:'U' con·
traction, .ioint lllotion that induces lightening or
CHAPTER 12 • BIOMECHANICS
"fmm'------
ular motions. It has a tendinous origin from the an-
teromedial aspect of the first rib and inserts on
I
tion the upper extremity. Reprinted with permission from
Pectoralis major
Rockwood, C. & Matsen, F (1990), The Shoulder (p. 2' 9).
Clavicular
Philadelphia: WB. Saunders Co.
Deltoid Sternal
Posterior
Middle
Anterior
the passive or ligamentous constraints, or via a
redirection of the joint force toward the center of
the glenoid.
To understand rnusclc function and force trans-
mission. one must consider a given muscle's orien-
tation, size, and activity. Given the multiple articu-
lations present in the shoulder complex, an:y given
muscle may" span several different joints, and de-
pending on the position of the upper extremity', its
relationship with regard to anyone articulation
may change, altering its effect on that joint and the
resultant forces or motions produced. Serratus
anterior
Anterior sheath Pectoralis
MUSCULAR ANATOMY of rectus minor
Deltoid
Anterior
~-'\-- InfraspInatus
Middle
'-=--+- Rhomboideus
major
Posterior
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 Forward Elevation
opposite direction. The relationship between two
such muscles is also referred 1O as a force couple TIll' most b~\~,dc motion (If thl.· shoukkr compk.'x in-
(Fig. 12-19). Around the glenohumeral joint. there \·oln.'s ck\'~lIioll of tIlL' arm ill the scapular plane.
is a force couple in the coronal plane (between the This motion has hel'n studiL'd in depth via both dcc-
deltoid and the infedor portion of the rotator ll'omyograph}' and stcrcopllOlogrammctl-.v. The
curf) and in the transverse plane between the sub- muscles of the shoulder girdk han: subsequent Iv
scapularis muscle anteriorly and the posterior ro- heen grouped according: to relatin.' illlponancL" witll
tator Cliff Illusculature (the infraspinatus and regard to this rnotion. TIll' first grouping includes
teres minor). the dcILoid <Spccificall~.. lhe anterior and middle
Relative Illotion is produced by an imbalance be- heads). lrapeziulll (inf..:rior ponion), supraspinatlls,
t\veen the agonist and antagonist that produces and serratus ~lJ)leri()r (Simon, 10(4), The second
torque. The degree of torque and the resultant an- grouping consists uf' the Iniddlc portion or the
gular velocity produced is determined by the rela- trapeziulll. the infraspinatus. and thl..' long head of
tive activation of two such muscles or muscle the biceps. r\ third group consists or Ilw posttrior
groups. Resultant muscular forces arc determined head or the ddlOid. thl.' c1~l\·iclilar Ill,:'~ld of tht.~ pec-
via an understanding of the cross-sectional area of toralis major, and lht.' slIpi.:rior ponion or the trapez-
the activated muscles involved and their orientation iUIll. The fourth and final group includes I hi.' stLTllal
at the time of activation. head or the pectoralis rnajor. the latissirnlls dorsi,
and t Itt.' long !It.'ad or the t ricL'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-
The deltoid and the oblique rotator cuff muscles (infraspina-
ever, is felt to h~l\'c 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
side, the 1ll0!llCI\t arm of till".' deltoid improvl.'s, n:-
(two forces equal in magnitude but opposite in direction).
suiting in a larger force in I\.'lation to thc supraspina-
With the arm at the side (A), the directional force of the del-
tus (Fig. 12-20), The p<.:rccllwge 01" shearing or verti-
toid is upward and outward with respect to the humerus
cal force created by the deltoid likewise ck'crt.-'<.lses
while the force of the oblique rOlator cuff muscles is down-
with increasing arnollllts or ahduction. The angle of
ward and inward, These two rotational forces can be re-
pull or the supraspinalUs'is more l'OIlSI~lJll at ap-
solved into their respective vertical and horizontal compo-
pro:dmalcl.,· 7,=,°, acting not onl.\· to elcvate or ahduct
nents. The horizontal force of the deltoid acting below the
the arm but also to compress the hurneral head
(enter of rotation of the glenohumeral joint is opposite in
within the glenoid. Thl.' remaining roW tor cull mus~
direction to the horizontal force of the oblique rotalOrs.
cles pull at approxil1latd~' -15°, which is din;(:ll".'d in-
which is applied above the center of rolation. These forces
{'edod}; (slightl,'· highcr in the ter('s minor at 55°), re-
acting in opposite directions on either side of the center of
sulting in forces lh~lt l.·quall}' compress ;:111(1 depress
rotation produce a powerful force couple. as illustrated by
the humeral head to maintain glcnohulllcral stabil-
the arm signal (B), The vertical forces offset each other,
ity (Fig. 12-21).
thereby stabilizing the humeral head on the glenoid and al-
Sl~\('ctive anesthetic block or tht' n:dllary nerve
lowing elevation to take place. Adapted with permission
(and resulting dcILoid paralysb) dcnlOnsll·atl.'s that
from Lucas, 0.8. (1973). Biomechanics of the shoulder joint.
forward elevation is possihle alb~it signincantl~.
Arch 5urg. 107.425.
weakencd. Lik.:,\·isc. a 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
External Rotation
The primary external rotator of the humerus is the The angle of pull of the subscapularis (top) is approximately
infraspinatus. with significant contributions made 45°. The angle of pull of the infraspinatus (bottom) is also
by the posterior head of the deltoid and the teres mi- approximately 45°, and the teres minor (bottom) is approxi-
nOI: With any given amount of shoulder abduction, mately 55°. These vectors result in nearly equal glenohu-
electromyography reveals the prime external rotator meral joint compression and humeral head depression. The
to be the infraspinatus. The subscapularis is simi- supraspinatus (center) is essentially horizontal in its orienta-
larly active but serves an antagonistic role as the tion, resulting in compression of the glenohumeral joint.
main stabilizer preventing anterior displacement of
•
----_._.__ ._----_._~~----~-_._._-----~- ----._--._-.
Subacromial Impingement Syndrome and Rotator Cuff Tear
·.
A 53-year-old right-hand-dominant woman who presents
right shoulder pain of 6 months' duration, The patient
still exert Its effects by Wc1Y of the "spans" of the bridge.
Thus. patients may have a "functional" rotator Cliff tear in
noted increasing pain at night and with overhead activities of \-vhich they are s!ill able to periorm overhead activities. Ii the
daily living such as putting on a shirt and brushing her hair. tearing force presem at the t\:'IO suppons is great enough.
The pain is unresponsive to pain killers. Physical examination howe'/er, worsening of the tear will occur.
revealed diffuse tenderness over the shoulder and deltoid
with.painful forward elevation above 60:3 and internal fOla-
tion limited to her ipsilateral greater trochanter. She had a
positive Neer sign (painful forward ele'l<ltion between 60 and
120°) and a positive Hawkins sign (pain with passive abduc-
tion and. internal rotation). A subacromial impingement test
was positive with near complete relief of pain and restoration
of fOl\lvard elevation to 1500 but persistent \;veakness on re-
sisted shoulder abduction. A diagnosis of subacromial im-
pingement syndrome is made. The patient was initially man-
aged with conservative treatment. At 5 weeks follow-up. the
patient had persistent pain and an MRI of her shoulder re-
vealed a full thickness tear or the supraspinatus tendon. The
patient opted for operative management (Case Study Fig, 12-1-1).
Biomechanically, rotator cuff tears have been likened to a
suspens.ion bridge, whereby the free margin of the tear corre·
sponds to the cable and the residual atlachrnents correspond
to the supports at each end of the cable's span. This coniigu-
ration allows the muscle that has been torn at its insertion to
forces) bet\veen the upper trapezium, levator humeral head. Three forces are then considered:
and upper serratus anterior with con- the deltoid muscle force (D), the weight of the
contraction of the lo\ver trapeziurn and arm (equivalent to 0.05 body weight [BW] acting
cP'T"llllS anterior leads to scapular rotation that is at the center of gravity of the limb, 3 cm), and
for full forward elevation (Fig. 12-23) 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 and are of equal but opposite
.u,","""o> AT THE GLENOHUMERAL JOINT
magnitude, The force on the glenohumeral joint
glenohumeral joint is considered to be a \vhen holding the arm at 90° of abduction can be
load-bearing joint. Although calculations estimated to be one-half of body weight (Calcula-
the exact forces acting on it are challenging tion Box 12-1, Case A). 11' a weight (W) of 2 kg is
thc large number of involved muscular added (equivalent to 0,025 body weight of an SO-kg
and possible positions attainablc, sev- male) to the hand of the outstretched extremity
sin1plifying assumptions allow an estima- held at 90° of abduction, a sirnilar calculation can
of the magnitude of these forces. A free- be made (Calculation Box 12-1, Case B).
diagram of a person holding the upper Experimentally, loads at the glenohumeral joint
held at 90' of abduction can be uti- and the forces necessary! for arm elevation have
as an example; it is assumed that only! the been detcrmined. These forces have been found to
ue"cm, muscle is active and that it acts at a dis- be greatcst at 90° of elevation, with the deltoid force
tance of 3 cm from the center of rotation of the equivalent to 8.2 times 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.
- - - - - - -
Rotation of the scapula is produced by the synergistic contractions of the lower portion
of the serratus anterior and the lower trapezius, with the upper trapezius, levator scapu-
lae, and upper serratus anterior. Reprinred with permission from Simon, 5.R. (Ed). (1994).
Orthopaedic Basic Science (p. 527-535). Rosemont. IL: AAOS
the joint reactive force equivalent to 10.2 times the musculature in the late cocking phase aCling both to
weight of the arm (Inman, Saunders, & Abbott, rotate the humerus and prevent anterior subluxa-
1944). More recent investigations of these same tion of the glenohumeral joint (Eames & Tullos,
forces utilizing the assumption that the muscular 1978). Specifically, the supraspinatus acts in the late
force is proportional to its area multiplied by its ac~ cocking phase to draw the hUllleral head loward the
tivity as determined by electromyography have glenoid, the infraspinatus and teres minor pull the
yielded similar values. with a maximal joint reactive humeral head posteriorly, and the subscapularis
force of 89% of body weight seen at 90 0 of elevation bOlh prevents excessive external rotation of the
in the scapular plane (Poppen, & Walke.; 1978). humerus ancl contracts eccentrically to relic\-c
stress on the anterior shoulder (Tibone et 'II., 1994).
The importance of scapular (and thus glenoid) sta-
THE BIOMECHANICS OF PITCHING
bilization has also been recognized, and the serratus
Pitching has been divided into five stages: wind up, anterior has been shown to nre actively in the late
earl.y cocking. late cocking, acceleration, and fol- cocking phase; this provides a stable platform for
low-through (Tibone et 'II., 1994). The deltoid has humeral motion. Thus. coordinated. sequential acti-
been found to be responsible for elevation and ab- vation of the shoulder musculature is needed to pre-
duction of the humerus in the carly phases. fol- vent anterior subluxation of the glenohumeral joint
lowed by increased activation of the ratmar cuff and the overuse tendinitis that can ensue.
CHAPTER 12 • BIOMECHANICS OF THt.:s~81~~~£¥;Z:O
~~,;;~
-/j
,0;"0" .Calculation of Reaction Forces
Estimates of the reaGlon force on the glenohumeral o is approximately one-half body weight. Because 0 and J i
joint are obtained with the use of simplifying assump- are almost paraUel but oppOSite. they form a force couple and !
:, lions (Poppen & Walker, 1978).
;;; Case A. In this example, the arm is in 90° of abduction,
;~(:and it is assumed
Ii
that only the deltoid muscle is active. The
force produced through the tendon of the deltoid muscle (0)
are of equal magnitude; thus, the joint reaction force is also
approximately one-half body weigll!.
Case B. Similar calculations can be made to determine the
value for 0 when a weight equal to 0,025 times body weight
I
:,~,acts at a distance of 3 em from the center of rotation of the is 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
(30 ern x .05 BW) + (60 em " .025 BW) -
\.veight (BvV) and acts at a distance of 30 cm from the center
(D x 3 em) ~ 0
of rotalion. The reaClion force on the glenohumeral joint 0)
may be calculated with the use of the equilibrium equation D = (30 em " .05 BW) + (60 em " .025 BW)
that states that for a body to be in moment equilibrium, the 30m
5;Jm of the moments must equal zero. In this example, the D = 1 BW
moments acting clockwise are 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
I
Force 0 ......... ----i""X'-
Force J ·········~)~~=----=t;;;;_;;:;---r
I
II I ,.ossw
! I, ,
30cm
;•
): ! 30cm
.~,----::------->
60 em
:/;' ~
L
• O>-~ '" "'"!'.,-_-.!'.!','!'.A__"'zg!,!,,,.,,!,!,,"""'_.","_!,,,~".B'" "'_........"_...,;"t.~".,,__,,,",_"_,·c"-, ___·,"'.", "_--",,---~. ·"",~c_,,,:-,-,,,,~,~,,_,,,,;;o..,,,,,,~,?,,_,,~,,,_--- __- __,,,,,,"7.2'}"'...!,,",,J.7!!J~'!;?3?WC'--"; _ ..!_".xa"'..", ;. ""'.."'""_,,~:<,",_-_,,"~,"'--"_7c_7.,""'~",:~"_$~,,.,.""'_._; ....- '
Biomechanics
of the Elbow
Laith M. Jazrawl~ Andrew 5. Rokito, Maureen Gallagher Birdzell,
Joseph D. Zuckerman
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
. ,
•
..
~
f~, ,,-
Introduction j
IX
~/ The elbow is a complex joint that functions as a ful-
!
·i
I
~•. ",.'
~
crUIll for the forearm lever system that is responsi-
. hie for positioning the hand in space. A detailed lin- I
t -Hi;:Xderstnnding of the biomechanics of elbow function \
Wi,
t,
J,;': ,is essential for the clinician to e1Tcctivcly treat
'pathological conditions affecting the elbow joint.
I
~"'"
~:'.•,.,· .;;'.A
''',J
~ Wi
I't: The elbow joint complex allows types of mo-
lion: nexion-extension and pronation-supination.
1\\10
rf
i,
trochlea and capitellum of the distal hUl11cnls arc
internally rotated 3 to 8' (Fig. 13-IC) and in 94 to 98'
of valgus with respect to the longitudinal axis of the
c
i
~ The distal humerus is divided into medial and lat-
.,. eml columns that terlllinate distally with the
, trochlea connecting the two columns (Fig. 13-3). The
~. medial column diverges [Tom the humeral shaft at a 4'
~ 45° angle and ends approximatel,Y 1 cm proximal to
I
::
the distal end of the trochlea. The dislal one third of
the medial column is composed of cancellous bone, I
$
ii;
is ovoid in shape, and represents the medial epi-
condyle. The lateral column of the distal humerus Ij
( diverges at a 20° angle from the humerus at the same
~.
~.. level as the medial column and ends \'.lith the capitel-
< IUlll. The trochlea is in the shape of a spool and is
I. comprised of medial and lateral lips with an inter-
l vening sulcus. This sulcus articulates with the semi- I
~ lunar notch of the proximal ulna. The articular sur-
I face of the trochlea is covered by hyaline cartilage in
il
~ an arc of 330°. The capitellum, comprising al0105t a A B
r: perfect hemisphere. is covered by hyaline cartilage
t
~
forming an arc of approximately 180°.
Tbe mticular surface of the ulna is rotated 30' poste·
"
'j
I Jiorly with respect to ilS long ax.is. This matches the 30° Angular orientation of the proximal ulna in the anteropos-
terior (A) and lateral (8) planes.
t anteIior angulation of the distal humerus. which helps
r pl"Ovide stability to the elbow joint in full extension
rt 341
t
~.,.
• I"
~._,',".~~.•."".....,,,,,..,~"".<~_..,.<.'o"O,..,_o""~'__,k"'.•~_,,__,,~,"_-."""",="~_".,,,,. . ._~.",-\~,,_ .,,,.c,,,.>_~-.----,--="_,,,, "'p"'......"'Q'.. . .----_~-"', ~r:'-'~.~77~3." :i-',\"" - .'"f:rr.C _O-'.,%__.",,~~"'~.
Lateral Medial \,,:Clllll"~ll·tl1n,,·s 01 tip to 30 which i ... C(Jfl:-.istl'lH with
column column Ilh: iUlll'tiollal r~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
fossa
I\"~ldl in 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'l 1'(11' Ik·,\ioll-I.'\1L'llsiull has been
s!\(l\\'[) h.\' Sl'\'l'l'~d illn..,'slig:I[OI"S lo Iw ~lt till· 1.·l. nler of
l
';
lP.!",,:;;.A !JC~~ .• "'"",":_ ",1'>-':-'" __ >~~,_: _" C
, r.
o 30 45 60 90 degrees
Function = Volume
V" 4/3 "r"
Diagram depicts the dramatic loss of effective reach area with flexion contractu res of the
elbow greater than 30"
~ .dl--------------------------------------
~
internal axial rotation of the ulna has been shown to flexion-extension occurs abollt a tight locus of
occur during early nexion and external axial rotation points measuring 2 to 3 mm in its broadest dimell M
during terminal tlexion. demonstrating that the el- sian and is in the center of the trochlea and capitel-
bow cannOl be truly represented as a simple hinge lum on the lateral view. It is approximated by a line
joint. -In conclusion. evidence suggests that the el- passing through the center of the lateral epicondyle
bow has a changing center of rotation during flex- and trochlea and then through the anteroinferior
ion-extension and functions in a more complex man- aspect of the medial epicondyle (Fig. 13-6) (Morrey
ner than would a simple uniaxial hinge. & Chao. 1976). These facLors should be Laken into
Despite variation in findings among investiga- account during joint replacement procedures of the
tors. Mon·ey. Tanaka. and An (199\) have slaled thal elbow as well as when placing hinged exlemaI fixa-
the deviation of the center of joint I'olation is mini- tors across the elbow joint (Figgie. rnglis. & i\flow.
mal and the reported variation is probably the 1986).
result of limitations in experimental design. There- Pronntion and supination take plac;e primarily at
fore. the ulnohullleral joint could be assumed to the humeroradial and proximal radioulnar joints
move as a uniaxial articulation except at the ex- with the forearm rotating about a longitudinal axis
tremes of nexion-extension. The axis of rotation of passing through the center of lhe capitellum and
.344 PA~I'g;'BIOMECHANICSOF JOINTS
y rotalion. Ray el al. (1951) demonstrated some varus_
valgus movemenl of the distal ulna with rotation On
an axis extending from the radial head through the
index finger (Fig. 13-7).
---
CHAPTER 13 • BtOMECHANtCS oFTBfiIBi);';;'~"Y345~
. ' - -'~~
Palmer et al. (1982) have demonslrated proxi- in adults and greater in females than in males, av-
mal radial migration with forearm pronalion. This eraging 10 and 13° of valgus, respectively, with a
finding has been supported by observations at el- wiele distribution in both (Atkinson & Elftman,
bow arthroscopy. In addition. as a result of the 1945; Mall, 1905). Steindler (1955) reported a
ovoid shape of the radial head. its axis is displaced gradual increase in the carrying angle with age
laterally in pronation by 2 mm to allow space for but found no statistical difference between men
medial rotation of the radial tuberosity (Ka- and women in this rate of increase or the c<'lITying
1982). 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
'ng Angle from the various references systems employed to
determine the carrying angle. They noted that
:'1 The valgus position of the elbow in full extension when the cCiITying angle is defined as either the
is commonly referred to as the c<'\ITying angle, angle ronned bet\veen the long axis of the hu-
The carrying angle is defined as the angle between merus and ulna on a plane containing the
the anatomical axis of the ulna and the humerus humerus or vice versa, the carrying angle changes
measured in the anteroposterior plane in exten- minimally with flexion. H the carrying angle is de-
sion or simply the orientation of the ulna with re- fined as the abduction-adduction angle of the
spect to the humerus. 01' vice versa, in full exten- ulna relative (0 the humerus Llsing Eulerian an-
sion (Fig. 13-8). The angle is less in children than gles to describe arm motion, the carrying angle
decreases with joint flexion changing to varus in
extreme flexion (Fig. 13-9).
I
Elbo'vv Stability
I
I
I
Valgus Forces at the elbow are resisted primarily
I by the anterior band of the medial collateral liga-
I
I ment (MCL) complex. The MCL complex consists
I
I
of an anterior bundle, a posterior bundle, and the
I , transverse ligament (Fig. 13-10). The anterior bun-
\I I' dle tightens in extension while the posterior bun-
I '
dle tightens in flexion. This occurs because the
I I
I
Mel complex docs not originate al the center of
I the axis of elbow rotation (Fig. 13-11). The ante-
I'
I rior band of the Mel complex originates frolll the
I inferior surface of the medial epicondyle of the
" distal humerus and inserts along the medial edge
'I
I I of the olecranon. vVith an intact anterior band, the
I I
, I radial head does not offer significant additional
,
I I
I
resistance to valgus stress'. However, with a trans-
acted or disrupted anterior band, the radial head
I I
,
,:.-...',
becomes the primary restraint to valgus stress,
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,
The carrying angle of the elbow, formed by the intercep· 1991) ""demonstrating the secondary valgus sta-
tion of the long axes of the humerus and the ulna with bilizing effect of the radial head, several investiga-
the elbow fully extended and the forearm supinated. Val- tors have noted increased valgus laxity after I'adial
gus angulation normally ranges from 10 to 15°,
head excision (Coleman, Blair, & Shurr, 1987;
• Gerard, Schernburg, & Nerot, 1984; Johnston,
A B
'I
,IJ
I
r Abduction/adduction
r
Humerus I
r
X4
Z1
Pronalionlsupinalion
X4
c
"
A. Carrying angle measured as the angle between the long the plane containing the humerus. C. Eulerian angle mea-
axis of the ulna and the long axis of projection of the surement of ulnar motion in reference to the humerus. Ab-
humerus on the plane containing the ulna. B. Carrying angle duction-adduction rotates about the axis orthogonal to both
measured as the angle formed between the long axis of the the Z and X4 axes; flexion-extension rotates about the Z1
humerus and the long axis of 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 restraint to varus stress
Anterior bundle
followed by the anterior capsule and the lateral col-
lateral ligament (LCL) complex, respectively, wilh
Posterior the LCL complex contributing only 9% (Table 13-1).
bundle Elbow extension is limited primarily by the anterior
capsule and anterior bundle of the MCL complex.
Transverse
Excision of the olecranon fossa fat pad has been
ligamem
shown to provide 5° of additional extension (\Valker,
1977). Furthermore, Morrey et al. (1991) have
demonstrated an almost linear decrease in ulno-
humeral joint stability with scrial removal of 15 to
Medial coHateralligament complex containing anterior 100% of the olecranon.
and posterior bundles as well as a transverse component. The LCL complex consists of the radial collateral
ligament that originates fTom the lateral epicondyle
and inserts on the annular ligament, the lateral ul-
nar collateral ligament that originates from the lat-
eral epicondyle and passes superficial to the annular
1962; Morrey, Chao, & Hui, 1979). However, this ligament inserting onto the supinator crest of the
does not seem to be clinicall.\' disabling ulna. and the accessory LCL complex (Fig. 13-12).
(Hotchkiss, 1997). The origin of the LCL con1plex lies at the center of
Selective ligament transection studies have the axis of elbow rotation, explaining its consistent
shown that in extension, resistance to valgus stress length throughout the flexion~extension arc (Fig.
is shared equally by the MCL complex. capsule. and 13-13). Although Mon'ey and An (1983) have
joint articulation. In flexion, the primary resistor to demonstrated only a minimal contribution of the
LCL complex to varus stability. others have shown
the LCL complex to be an important stabilizer of
2
Anterior
1 ~
0 Percent Contribution of Restraining
~
Force During Displacement (Rotational
2
P-MCl or Distractional)
1 Stabilizing
Position Element D~straction Varus Valgus:_"
0
o -
20 .:0 00 60 100 120 140 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 Capsule 8 13 10
in its length as a function of elbow flexion. The anterior Articulation 75 33
bundle. 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
.
Clinical stages of posterolateral rotatory instability of the
The lateral collateral ligament complex.
elbow.
----------------
the humeroulnar joint with forced varus and exter- dcrscl1, 1989). The latl.'raluilwr coll~t[eral is the pri-
nal rotation (Daria et aI., 1990; Dllrig et aI., 1979; llwr\ restraint to posl~r()latt..'r:.d l'OWlOr\ instabilit)'
Josefsson, Johnell, & Wenderberg, 1987; O'Driscoll. or the dl)()\\', followcd by lite radial collateral liga-
Morrey, & An, 1990a; Osborne & Cotterhill, 1966) . ment "nd capsule. O'Driscoll et al. (1990b) also
O'Driscoll and colleaglles( 1990a) described the noted a small but significant effect or the inherent
entity of posterolateral rotatory instability of the e1. negative intra-anicular pn.:.'ssurc of lhe elbow joint
bow in which the ulna supinates on the humerus to \'arus and rotation strcsses (C:'lse Stud.\' 13-1).
and the radial head dislocates in a posterolateral di- Slruclures Iimiling passh·.. .· lkxion include the
rection (Fig. 13-14). It has been shown that the el- capsule, lriceps, coronoid process, :.lnd radial head.
bow can dislocate postcrolatcrally or posteriorly Struclures limiting dbow exlt.'nsion include the ole-
with an intact Mel c0l11plex. This can occur with cranon process and Ihe anterior band or the Mel
combined valgus and e:\lernal rotation loads across complex. Passin:.' resistance 10 pronaLion-supination
the elbow joint (Sojbjerg, Helmig, & Jaersgaard-An- 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(railll to forearm
rotation (Spinner & Kaplan, 1970).
e c
Longitudinal stabilil~' 01" the f'orL'arm is pro\'ided
b~' both the interosseous 11lL'mbranc and the tri;:\11-
1n:,:::::1
a0
Z
0 20':0 60 80100 120 1.$0
''-:,'',-,','':',''1''''
CHAPTER 13· BIOMECHANICS OFTHE ELBOW 349 0
I
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 humerus and thL' prnximallaleral aspect of the ulna
resection when combined with TFCC transaction and insens into till: ~nl(:rior aspect of the supinated
caused 2,2 l1un of proximal radial migration, The proximal radius,
combination of radial head resection, interosseous Muscles in\"C)ln:d in pronation itH.:ltld~ the prona-
membrane transaction. and TFCC transaction led to {or qu()dratus and pronator teres, Thl,.' pronator
the greatest increase in proximal radius migration quadratus originates from the \-'olar asp~ct of the
of 16.8 mm. 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-
The primary nexor of the elbow is the brachialis. dius, The pronator quadratus is the primary prona-
which arises from the anterior aspect of the tor of the forearm reg~rdless of its position. The
humenJs and inserts on the anterior aspect of the pronator teres is a SCCOJ1c!4l1Y pronator when rapid
proximal ulna (Fig. 13-\5). The biceps arises via a pronation is required or during resish.'d pronation
long head tendon fTom the supraglenoid tubercle (Basmajian, 1969).
and a short head tcndon from the coracoid process In a sludy examining ('Ibn\\' strength in normal
of the scapula and inserts on the bicipital tuberosity' indi\'iduals, supination strength \\'as shown to be 20
of the radius, It is active in flexion when the forearm to 30%:: greater than pronalion strength (Askcw et
is supinated or in the neutral position. The brachio- al.. 1986), COllsish.'nt with muscle cross-sectional
radialis, which originates fTom the lateral two thirds area and moment arms, flexion strength w~s 30l }o
of the distal humerus and insens on the distal as- gre~ltcr than extension str('ngth, LastI~·, males were
pect of the radius near the radial styloid, is active consistcntl~' 40'j(i slronger than females in elbow
during rapid flexion movements of the elbow and strenglh testing.
when weight is lifted during a slow flexion move-
ment (Basmajian & Lalif, (957). The brachial is, bi-
ceps, brachioradialis, and extensor carpi radialis are Electromyography
Lhe major nexors of the elbow, the brachialis pos-
sessing the greatest work capacity (An et aI., (981), Elcctrom~'ogl'aph~' has been helpful in defining the
The primary eXLensor of the elbow, the triceps, contributions or elbo\\' musculature during activi-
is composed of three separate heads, The long ties of dail~' li\'ing and spcciflcall~' defined tasks.
head originates from the infraglenoid tubercle and TilL' biceps brachii is only l1linimall~' acth'L' during
the medial and lateral heads originate from the elbow Ilt'xion wh~n the forearm is pronated (Bas-
posleriol' aspecL of the humenls (Fig. 13-\5). The mujian '" LaLif, 1957: Funk el 'II., 1987: Malon &
three heads coalesce to form one tendon that in- BouisseL, 1977: SL~\'~ns ~L aI., 1973). Brachialis ac-
serts onto the olecranon process of the ulna, The th'it.v, howen.'r, is nOI affected b\ forearm rotation
medial head is the primary extensor and the lat- during flexion (Funk t't aI., 1987: St('\'L~ns et aI.,
eral and long heads act in reserve (Basmajian, 1973), The brachioradialis also is aClive during flex-
1969), The anconeus muscle. which arises from ion, This activit~" is enhanced wilen lh<.: forcarm is
the posterolateral aspect of the distal humerus and in a neutral or pronaled position (Basmajian &
inserts onto the posterolateral aspect of the proxi- Travill, 1961: DeSousa, DeMoraes, & DeMoracs,
mal ulna, is also active in extension, This muscle 196\: Funk el aI., 1987: Sle\"ens el al.. (973). Elee-
is active in initiating and rnaintaining extension, tromyographic dala demonstrates that (he medial
While the lriceps, anconeus, and Ilexol' carpi ul- head 01" the triceps "!lei anconeus is activc during e1-
naris are active in extension, the triceps has the bo\\' extension, with the lateral ~lIld long heads or
largest work capacity of all the elbow extensors the triceps sCI'ving as secondaJ'~' extensors, Morrey
(An et al., 198\). (1993) concluded the following from the elec-
,
I'; Muscles involved in supination of the forearm in- tromyographic data: (I) the biceps is gencrall~; less .. "
clude the supinator. biceps, and lateral epicondylar aClive in full pronation or Ihe forearm, s(;.'conelary to
'-~
extensors of the wrist and fingers. The primal)' mus- its role as a supinator: (2) lhe brachialis is acth'c
cle involved in supination is the biceps brachii. The throughollt flexion and i~ belic\'ed to be the work-
supinalor arises fTom the IaLent! epicondyle of the horse of flexion; (3) electrical activity or lhe triceps
CHAPTER 13. BIOMECHANIPS.. OFTHE
'
El~eta"1!'1,1D
=if~S--~Z~ ..-.,
Supraspinatus
Lev. scapulae
Rhomboid
'" Infraspinatus
Subscapularis ---'f-+ min.
Teres minor
Lat. dorsi - - \ - H
Infraspinalus
'I-\-Ir-t- Trieeps
Teres maj. ---t'~J (long head)
Rhomboid
Pectoralis maj. ----'R maj. '--'--'HHf- Teres minor
Coracobrachialis
Brachioradialis
I A B
~'------------------------
. Origin and insertions of muscles of the upper extremity. A. Anterior view. B. Posterior view.
JOINTS
i ,
Case A. No object is held in the hand. B is calculated with the 13cm
equilibrium equation for moments. Clockwise moments are
30 em
considered to be positive. whereas counterclockwise moments
Cal(Ul~ltjon Box Figure 13-1-1.
are considered to be negative.
~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. 260 t'Jcm _. 300 Non
8=
can now be calculated by means of the equilibrium equa- 5 ern
tion for forces. Gravitational forces are negative; forces in B 15 found to be 112 N.
the opposite 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- force is shorter than that for the flexor l'orec-3 ern
tions. The joint reaction force for the elbow in ex- as opposed to 5 em. Thus, a greater l1111scl~ I'orce
tension is 107 N. compared with 32 N in Ilexion. (87 N as opposed lo 52 N) is required for the fore-
,. This more than threefold increase can be explained arm Lo be 111ainlained in the extend~d position. and
by the fact that the lever arm for the elbow extensor as a r~sllit the joint reaction force is greater.
CHAPTER 13. BIOMECHANICS9Ff~,~i~~~~%~l~JD
?-
-
I Joint Reaction Force: Elbow Extension
i The joint reaClion force during elbow extension can be
calculated by means of the same method:
3cm
;....;.-- 13 em ~
Force T :
,
!
I ~rvl = 0 ,--+------'~~
(13 em x WI - (3 em x TI = 0
If W = 20 N
13 ern x 20 t'J
T= - - - - - - - -
3cm Force W
T is found to be 87 N.
:SF = 0
J-T-W=O
J= T+ W
J = 87 N + 20 N.
Foree J
J is found to be 107 N. Thus, in this example, the joint
reaction force during elbow extension is 75 N greater than
during elbow flexion. Calculation Box Figure 13·2·1.
Swnnuuy
A clear understanding of elbow mechanics and 5 The can}'ing angle of the elbow is defined as
function is critical to gain a broader understanding the angle betwcen the anatomical axis of the ulna
of problems affecting the elbow joint. This knowl- and humerus in the anteroposterior plane and in
edge will provide the basis for management of el- rull elbow extension. [t averages between 10 and IS"
bow disorders. of valgus.
6 The primary stabilizer to valgus stress at the el-
1 The elbow joint complex consists of three ar- bow is the anterior band of the MeL complex, with
ticulations: the humeroulnal: humeroradial. and the radial head acting as a secondul'Y stabilizel: The
proximal radioulnac It allows two types of motion, primary restraint to varus stress is the elbow articu-
nexion~extension and pronation~supination.
lation. The lateral ulnar collateral ligament is the
,;:,:Z> The functional range of elbow motion is 30 to main stabilizer to posterolateral rotatory instability
(30° of flexion-extension and 50 to 50 0 of pronation- of the elbow.
supination, with most activities of daily living ac- ,'i>The primary flexor or'the elbow is the bra-
complished within this range. There is a significant cl~ifdi$ while th~ prin"lury extender is the triceps.
and rapid loss of the ability to reach in space with The anconeus is acti\·e in initiating and maintain-
fl~xion contractul'es of the elbow greater than 30°.
ing Oexion ancl is considered to act as a dynamic
'3 The axis of rotation for Oexion-extension occurs joint stabilizel: The main source of supination is
about a tight locus of points measuring 2 to 3 mIll in the biceps brachii. The pronator quadratus is the
its broadest dimcnsion and is located in the center of primary pronator of the forearm regardless of posi-
the trochlea and capitellum in the lateral vie\\'. tion of the forearm or degree of elbow flexion.
'4...- The elbow has a changing center of rotation S· Force generated in the dbow has been shown
during fle:don·exlcnsion and cannot be trul.v repre- to be up to three times bod.v weight ,"vhen perform-
sented as a simple hinge joinl. ing nctivities of daily living.
O_~5~'J1~TII. BIOMECHANICS Of JOINTS
O·Drisl.:oll. S.W.. Morre)'. H.F., &. An. ".N. (1990:\). Thl.· Sowa, D.T.. Hotchkiss, R.N., '-': Wi.'ihUld, "\,J. (l993). Sympto-
p'I!lIO'lllalOllly aEld kinl:mati<.'s of postcrolaH:ral inst<l!lility m:.tic proximal tr,lIIslation of the radius following r<ldial
(pivot-shifl) of I hI.' ".'Ibo\\'. Orlhop Trem .... 1-1. 306. IH:ad resectioll. Clill Ortlwli. 317. 106-113.
Osborne. G. & Cotterill. P. (1966). Rl:l:urrelH disloc'llion or Spinner, M, &. Kaplan. E.B. (19iOJ. The quadrati.' Iigamcnt of
the dbo\\'. 1 Bom: 10i1/1 SlIrg ilr. 488. 340-3-16. lhe elbo\\': Its relationship to the st.lhility of the proximal
Palmer. A.K .. Glisson, R.R .. & \Vernl.·r. EW. (1982). Uln,II·\·<tri- radioulnar joint. ..kla Orlho!' Scaml. '+1. 632.
ane\.' 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
P"arson. J.R .. McGinley. D.R., & Blllzcl, L.M. (1963). ,\ dy- Norlllal awl Pathological COlI~i;ticJIIs. Springfield: 'Charles
namic 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
'the fOre;ll'lll. :\n e.xpel'inH.'lltal study of pronation and iSOIlH.'lric loading. [b:troll/yogl' Clill NI:/lroph.\'siol. /3.
supin'ltioll. J BOlle: 10illl Stir!::. 33:1. 993-996. 465.
Rc.lI·don. J.P., Larrcrty, ~'L, K'inwric, E.. ct 'II. (1991), SInH;- Stormonl. TJ., An, K.N .. ~'Iorr('.\·. B.F.. d nl. (1985). Elbow
turc:s innucncing :-axial st:-ability 10 Ihe forearm: The role of joint (Onta<:1 study: r\ t:omp~II'ison of techniqllt.'s. J Bio-
the radial he-tid. interosseous membrane. and distal rndio, 1I1('('h. /8(5). 319.
ulnnr joint. O,.,hop Trails. /5.436-437. Tullos. B.S.. Erwin. W.. Woods. G. W.. el 'II. (19i2). Unllsllnl
Sojhjl..'rg, J.O .. Helmig. P.. &. Jaersgat:lrd-:\ndcrscll, P. (19R9). lesions of the throwing ann. Clill Orl/WI'. 88. 169.
Disloc'ltion of Ihe dbow: An experimcntal slud)' of till: lig- r.s.
W.llki:.... (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
Interaction of Wrist and Hand Motion
Patterns of Prehensile Hand Function
Summary
References
~;
-s
Introduction it and the ligamentous strUCllires that connect the
carpal bones to each other ancl to the bonv clements
'-" The wrist. or carpus. is the collection of bones and 01" the hand and forearm. '"
soh tissue structures that connects the hand to the The eight carpal bones are divided into the prox-
iforearm. Thisjoint complex is capable of a substan- imal and distal rows. The bones of the distal I"OW
:~tial arc of motion that augments hand and finger from radial to ulnar are the trapezium. trapezoid,
/'function, .'vet it possesses a considerable degree~of
;~:':,
capitate, and hamate. The distal carpal row forms a
~";:";"stab.ility. The wrist functions kinematically by al- relatively immobile transverse unit that articulates
),lJowing for changes in the location and orientation \vith the metacarpals to form the carpometacarpal
(}"of the hand relative to the forearm and kinetically joints. All four bones in the distal row fit tightly
"""",/;-by transmitting loads from the hand to the rOrear~1 against each other and are held together by stout in-
jt~~;~14;'a~ld vice vcrsa~ terosseous ligaments. The more mobile proximal
/"/!<"" Although the function of all joints of the upper row consists of the scaphoid, lunate. and trique-
;;~;{ extremity is to position the hand in space so that it trum. This row articulates with the distal radius to
can perform the activities of daily living. the wrist form the radiocarpal joint (scaphoid fossa of radius.
appears to be the key to hand function. Stabilitv of 46 % ; lunate fossa of radius. 43 % ; ulnar soft tissue
the wrist is essential for proper functioning of the structures, 11%) (Simon et aI., 1994). The scaphoid
digital Oexor and extensor muscles. and wrist posi- spans both rows anatomically and functionally and
tion affects the ability of the fingers to flex and ex- articulates exclusively with the radius. The lunate
tend maximally and to grasp effectively during pre- articulates in part with the ulnar soft tissue struc-
hension. tures. The eighth carpal bone, the pisiform. is a
The hand is a highly complex and multifaceted sesamoid bone that mechanically enhances the
mobile organ. It is valued and judged for its perfor- wrist's most powerful motor, the Oexor carpi ulnaris,
mance and appearance in delicate prehensile tasks and forms its own small joint with the triquctrun1.
to powerful grasp patterns. It is remarkably mobile Between the proximal and distal rows of carpal
and adaptable as it conforms to the shape of objects bones is the midcarpal joint, and between adjacent
to be grasped or studied, emphasizes or gestures an bones of these rows are the intercarpal joints (Fig.
",;. idea to be expressed. or shows an aCl of love or af- 14-1). The palmar surface or the Cal"!'us as a whole
fection (Tubiana. 1984), is concave, constituting the Door and walls of the
The hand is the final link in the mechanical chain carpal tunnel (Fig. 14-2).
of levers that begins at the shoulder. The mobility The distal radius, lunate, and triquetrum articu-
and stabilitv of the shoulder, the elbow. and the late with the distal ulna through a ligamentous and
wrist, all operating in different planes. allows the cartilaginous structure. the ulnocarpal or triangular
hand to move within a large volume of space and to fibrocartilage complex (TFCC), The components of
reach all parts of the body with relative ease. The this complex are illustrated in Figure .14-3, and its
unique aITangement and mobilit.y of the 19 bones functional role will be discllssed in detail along with
and 14 joints of the hand provide the structural ligamentous [-unction.
foundation for the hand's extraordinary f"tlllclional
adaptability.
HAND ARTICULATIONS
The Hoger and thumb are the elementary compo-
AnatOlny of the Wrist nents of the hand (Fig. 14-4). Because each digital
and Hand unit extends into the middle of the hand, the term
digit ray is used (0 indicate the entire chain, com-
WRIST ARTICULATIONS posed of one metacarpal and three phalanges (two
in the thumb). The digital rays are numbered from
The wrist joint complex consists of the multiple ar- the radial \0 the ulnar side: [ (thumb). II (index fin-
ticulations of the eight carpal bones with the distal ger). III (middle finger). IV (ring finger), and V (Iit-
radius, the stn.lC(UreS within the ulnocarpal space, tie finger). Each finger ray articulates proximally
J
I,
the metacarpals, and each other (Fig. 14-1). The soft with a particular carpal bone in a carpometacarpal
tissue structures surrounding the carpal bones in- (CMC) joint. The next joint in each ray-the meta- ~l
elude the tendons that cross the carpus or attach to carpophalangeal (MCP) joint-links the metaca::: ~l
I __
,~,,,,,iI'.-~~~~'l""·"""'_.,-":.3!!!_""'''''"''''''?~~'''~'l:''''''''~--'''''''''-''''''''::'_''~'''''- ~'''~''''',e'''',_,'''__.='''''''_--- --- ' '7",'""··;,,c "~".>? '1,. 'J.
J
'-,;",~f,M"~,,,_ '~"'0?2:;,-~""mi~
, III
MelaCarpals II I
V
,
~
I)
J
H
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
'I
Radioulnar ligaments
I
·1
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
Proximal ~ :"
II
III
inlerphalangeal , IV
joint _ _ Distal
V phalanx
Middle
phalanx
Distal--
phalanx
Proximal if
phalanx !
,j,
A B '1
Schematic drawing of the skeleton of the hand. The finger joints are labeled. B. Dorsal (posterior) view of the right
rays are numbered from the radial (medial) to the ulnar (Iilt- hand. The bones are labeled.
era!) side. A, Palmar (anterior) view of the right hand. The
bone to the proximal phalanx. Bt:tw('cn the pha· r.t,'·s around thL' s~l'(JJld and third finger", .dlows the
langes of the fll1gcrs, a proximal (PIP) and a distal palm to IbttL'n or l.·up itself to acc(l1lllllodatc objects
(DTP) interphalangeal joint arc round; the thumb of \·arious sil.L'S and sh..qk's (Strickland. 19~7).
has only one intcrphalangeal (lP) joint. The thenar Although (hL" extrinsi<.: flexor and ('.'\!t..'nsOI· 1Il1lS.
eminence at the palmar side of the first mcwcarpal c!L·s arL' largc:l.\· rL'spollsihle for changing lhe shape
is formed by the intrinsic muscles of the thumb. Its of lhe '\'orking hand, 1I1L' intrinsic muscles of the
ulnar counterpart, the hypothenar eminence, is cre· hand an: prill1al"it~' responsible 1'01" Ilwifll<.dning the
alec! by' muscles of the littlc finger and an overlying configuration or tile thr('(' archcs (refer to Table
rat pad. 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
ARCHES OF THE HAND
injur~', rhclimatic disease, or paral.\'sis of the intrin-
The bones of the hand are arranged in three arches sic muscles call contribute (0 SC\'erl' disability and
(Fig. 14·5), two transverse and one longitudinal dL:rorlllil~'.
(Flatt, 1974; Tubiana, 1984). The proximal trans·
verse arch, with the capitate as its keystone, lies at
NERVE AND BLOOD SUPPLY OF THE
,. ~: the level or the distal carpus and is relati\'e!y fl.xed.
WRIST AND HAND
The distal transverse arch, with the head or the third
metacarpal as its kcystone, passes through all of the ThL' cO\'L'ring of the h~lnd is important Ik'c<.Hlsc or its
metacarpal heads and is more mobile. The two ph~'sical qualities, sensory propcl·tiL's, and microcir-
transverse arches arc connected by thc rigid portion cubtiull (Tubiana, 190-1). The skin on the dorsulll or
of the longitudinal arch, composed of lhe four digi· tilL' back orthi..' ktlH.l differs and is distinct frolll the
tal rays and lIle proximal carpus. The second and skin that CO\"i.'I"S tll(' palmar stlrr~\CL', Dorsal skin is
third metacarpal bones fonn the central pillar of mobile, Or!C!l rcg~\l'(k'd ~h \'('1"\ line, and highl.\· Ill'.\>
this arch (Flatl. 1974). The longitudinal arch is com- ihlL'. ~\llo\\'ing for a \\'ide arra~' or ~ll'tictllar 1ll0\'(>
pleted by the individual digital rays, and the mobil· menls. In cuntrast. palnwr skin is thick, glabrous,
ity of the thumb and fourth finger and fIfth fInger 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.
Distal I.k>aring.
transverse arch
Proximal
The wrist and tilL' hand are innl'lY~IlL'd for motor
transverse arch Longitudinal and SL'nsory function b~' tllrL'c pt:riphernlIlL'IYes (It.>
arch
seelKling from tht.' brachial plcxus: radial. median,
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 poll ids 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
proximal carpal 1'0\\'5 can be appreciated. The nat- Inelacarpals. Thl' intrinsic ligalllents originak and
ural tendency' of the scaphoid to extend is stabilized insert on the C~II'PUS.
at the midcarpal level; the trapezium and trapezoid The pallnar e:\trinsic ligaments include the r~ldial
articulate with the dorsal aspect of the scaphoid, collateral ligall'lcnt, the paillwr radiocarpal liga-
pushing its distal pole dc)\vn into flexion. Hence, the ments, and components of the Triangular fibn>ea;:ti_
scaphoid counteracts the extension tendency! of the lage complex crr"cc). The radial colhltl'r~l1liga[l'lC'nt
lunate, lending some stability! to the biarticular is aCluall~' more pallllar than lateral and is vicwcd
carpal complex (Fig. 14-7). as till.' most lateral of all palnwr radioGll'p~11 L.Isci-
This arrangement has an advantage over a sym- cles rather than as a ulilateral ligament per sc, be-
metrical biarticular s)'stem because instability is fo- cause the function or a true collatcral ligament is
cused in onl).' one direction and can be countered by not hlnctionall.\· ad\'~ll1tageous in the wrist.
a single force applied in the opposite direction or Thc palnwr radiocarpal ligarncnts a['c arranged
flexion (Kauer. 1980; Kauer & Landsmeer, 1981). in superficial and deep hl.\"ers, In thc superficial
This mechanism is consistent with the lISC of the fin- layer, most libel'S ~Issumc a V shape, providing re-
ger and wrist flexors during hand function. stl'~tint and supporl. The decp ligaments arc three
strong fascicles named according to their points of
()]'igin and insertion: the radioscaphocapitatc (or
Ligamentous Mechanisms radiocapitateJ ligarnent, which supports thc \\'aist
or thl.' scaphoid; the radiolutHllC liganlcllt, which
WRIST LIGAMENTS
supports the lunate; and the r;:ldic)scapholunatc lig-
As in other joints, the function of the \vrist liga-
ament, which connccts the sGlpholunate aniClda-
ments is to restrict joint motion and appose Jomt
tion with tll(' palmar portiCHl or the distal radius.
surfaces. In addition, the ligaments of the wrist are
This lig~\lncnt checks sC~lphoid lk.\ion ~lnd ex-
capable of inducing bOll y displacements and of
!
tension. SludiL's of the tensile strength of carpallig-
transmitting loads originating in proximal or distal
aments suggest that the \\'eakest link bL'tween
segments (Taleisnik, 1985). The palmar ligaments
the carpus anc! the forearm is through [he radio-
(Fig. 14-8.4) are thick and strong, whereas the dor-
scaphocapitate and radial collateral ligaments, both
sal ligaments (Fig. 14-88) are much thinner and
of which are on the radial sklL' ()f the wrist
fewer in number (Taleisnik, 1976, 1985).
(i\bdield ('I "I .. 19791.
The highly developed. complex ligaIllcntous sys-
The dorsal extrinsic lig~Hnents includt' the three
tem of the wrist can be divided into extrinsic and in-
bands of the dorsal mediocarpal ligament. Originat-
trinsic cOIllponents (Table 14-2). The extrinsic liga-
ing from the rim of the radius, these three fascicles
ments run from radius to carpus and from carpus to
insert hrllliv into the lunate, triquetrum, and
scaphoid, respecti\·c!.\'.
The intrinsic ligamcilts call be grcHlpcd into three
Dorsal
categories (shc)rl, klng, and intermediate) according
to their length and the rehltin: intercarpal move~
ment the~' ~dlow. Overall, the palmar intrinsic liga-
mellts are thicker and stronger than the dorsal (lIlCS.
The three short intrinsic ligaml'nts-palnwr, dor-
sal. and interosscous-;:\['l," stout, unyielding fibers
tlwt bind the ~ld,iacent c<:\rpal bones tightl~,. These
strong lig<:Hl'lents <:lre responsible for maintaining
the four bones or the distal carpal row as an immc)-
Schematic drawing of the trapezoid (T), scaphoid (5), lu- bile functional unit (Taleisnik, 1976; \Veber, 1984),
nate (L), and radius (R) in a sagittal view. The tendency of Three intermediate intrinsic ligaillcnts arc located
the wedge-shaped lunate (palmar pole larger than dorsal bct\\'ccn the lunate and triquetrum, the scaphoid
pole) to rotate into extension is counteracted by the and IUll<:lte, and the sC<:lphoid and tr<:lpezium.
scaphoid, which provides a palmar-flexing force induced Of the two long intrinsic ligaments-dorsal in-
by the trapezium and trapezoid. Adapted with permission tercarpal and palrnar intcrcarpal-the palmar is
from Ta/eisnik, J. (1985). The Wrist. New York: Churchill Living- the mc)re important. Also called the dcltclid, or V,
stone.
lig;:llnenl. it st~lbilizes the capitate because il at-
tacht:.'s to its neck and fans out proximally' to in-
SL
Med. Med.
...
I
I
------------------
A
1
ed., pp. 3--41). St. Louis: C. V Mosby.
IV
Proximal interphalangeal joint
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 120 0 (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~ f
Force F
ION
~<, r
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 R in the putley system equals 14 N. Therefore. R equals
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. rlexed, while the palmar porLions provide a restrain-
When the MCP joint was nexed from 0 to 80', the ing force during tvlCP extension, This study sup-
dorsal ponion of the ligaments lengthened 3 to 4 ports the rationale for positioning the Mep joint in
mOl, the middle portion elongated slightly, and the 50 to 70 of flexion to prevent extension contracture
Q
\/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
originate from the metacarpal and insert into the
~·tz
thick palmar fibrocartilaginous plate. This plate on
the volar surface of the MCP is firmly attached to
the base of the proximal phalanx and it is loosely
attached to the volar surface of the neck of the
~
_.:'"-.
"n'1(lt03)
i··,-·
. Palmar
interossei
metacarpal. It serves to reinforce the joint capsule
anteriorly and to prevent impingement of the Hexor
\ i· tendons during MCP flexion. This anatomical align-
-I
!s ment allows for the volar plate to slide proximally
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 connected by the transverse Jintermctacarpal liga-
left hand. B, Dorsal view of the left hand showing the four
ments that then connect each plate to its neighbor
dorsal interossei and the abductor digiti QuintL These mus-
(Strickland, 1987).
cles abduct the fingers (i.e., move them away from the
midline of the hand). C. Patmar view of the leh hand
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 DIGITAL EXTENSOR ASSEMBLY SYSTEM
Strickland. J. W (1987), Anatomy and kinesiology of the n,lnd. In The lang"extensor tendons are l1at structures lhat
fE. fess & c.A. Philips (Eds.), Hand Splinting. Principles and emerge from their synovial sheaths at the dorsal
Methods (2nd ed., pp. 3-41). Sr. Louis: C. V Mosby: and (ailler, siele of the carpus anel run over the M~P joint; they
R. (1982). HClnd Pain and Impairment (3rd edJ Philcldelphia: FA. are helel in this position by the sagittal banels. At the
Oc1Vis. dorsum of the proximal phalanx, thc~e extensor ten-
,i dons and parts or the interossei interweave so as to
e
Second dorsal form :1 tendinous cOnlplL,,'\, the ('xh:nsor aS~L'l1lbly
Transverse Junctura (also knO\\'11 as tilL' L'xkl\s(,r Ilh:chanisllll. whiLh ex-
interosseous muscle
inlermelacarpal tendinum
tl'l1ds 0\'(."1' hOlh I P joints (Fig. 14-141.
ligament
Triflln.:alion 01" (he long C:-':h,'nsor (cndon and r~ln
ning 01" inh.Tossl'Olis fihl'r:-. 1\.'SUIt in the formation or
Ollt: IllL'dial and two la1l.:ral hands. The Illcdial bnnd
(or cL'lltr~d slip) runs d()rs~dl,\' ovel' the trochka of the
pro.'\iJ1wl phalan.\ and insl'rts into the base or the
Extensor
digilorum
middle plwlaJl\, 'rIlL' two lalcml bands cours(' along-
communis ! r ' ~irst dorsal sidl..' the shouldL'l'S of tlH..' PI P joint. These bands pur~
InteroSseOl.
tendon --+1-\-\l..\l , 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'ndon is linkcd (0 the prox-
v tV 111 II
imal phalanx b.\' m{.'~lJ1s or I IlL' obliquc rctinacular lig-
Dorsal
~IIllL'nts, Thcsi..' Iigamcnts origin<lk' from the proxi-
A
mal phalanx and run la1L'rall,\' around tilL' I'll' joint,
,iust palm;'lr 10 the CL'nt!.,.'!' or motion of this joint in
tilL' L'\;ll...'IH.k-d posilion, to join Ihe tcrminal ti..'lld<JIl.
IlI1Istr;'lling thl.,.' aL'!ioll (If thL' i..'.'\lL'nsor assL'mbl.\· in
cnllplin~ PIP and DIP joinl motion, Landsl1lccr
Med. Lat
~
" ----.
'.'
/~(Fjl~\J···f----Collateral ligament
f.f!<:~.~~::~~ ~ccessory collateral
Palmar
./~ ~, ~."" ligament I.
B
~-palmarPtate
Proximal phalanx A
I .- Checkrein ligaments
1 PIP joinl Middle phalanx
A, Fibrous structures of the proximal transverse (MC?) arch j - \
~:'l.,
il
b_t~;~"""""""'=""-~""""""'-"--"''''''''''''''''~''=''=:-
,."",;.;;T ... ' " .6,. c.",~J2'':-'''_''_;'''''J>'-.> .. ~.'-= .. ",_,,,,,.' "J >~__ ""J-""'7.'-";'"-O'"~) '''''''''''''''=='r=-7~~.u
!" - .'"'.' :_~'_' ;';' ><-. _>:_;C'~~,. ~~ -~r % .p~ @..;;~)§~~
• . _. . ...'%",:&11'
to-tip pinch, a mechanism used in precision han- longus were assessed e1ectrornyographically during
dling such as needlework and active tactile explo- wrist flexion (Kauer, 1979, 1980). In addition to
ration. demonstrming their expected muscle actions, these
Sarrafian and coworkers (I 970) used strain muscles were found to function as a dynamic "ad-
gauges to measure the tension in different parts of justable collateral system" that acts as a true collat-
the extensor mechanism during finger flexion and eral support, the extensor carpi ulnaris for the ulnar
furthel' elaborated on this phenomenon. They found side of the wrist and the extensor pollicis brevis and
an increase in the central slip tension bevond 60· of abductor pollicis longus for the radial side. In this
PIP flexion; at 90° of flexion there \vas total relax- way, active control mechanisms serve to fltlfill the
ation of the lateral bands. void left by the lack of collateral ligamentous re-
strictions while still affording considerable posi-
tional variability for functional hand activities (Case
ACTIVE CONTROL MECHANISMS Study 14-2).
Muscular Mechanisms of the Wrist
The wrist joint complex is surrounded at its pe-
~-·--_·_···----~-_·------i
riphel)' by the 10 wrist tendons. whose muscles
and Lheir actions are listed in Table 14-1. The three
flexors and three extensors arc the motors of the de Quervain's Tenosynovitis
wrist, controlling radial and ulnar deviation as 50-year-old female school teacher complains of pain
well as wrist flexion and extension. Four addi-
tional muscles control pronation and supination
A on active radial abduction of the thumb afler per-
forming a prolonged, continuous paper CUlling task. The
of the forearm. Eight of the muscles originate pain extends proximally from the radial styloid along the
from the forearm, and two, the brachialis and ex- dorsoradial aspect of the wrist and increases with passive
tensor carpi radialis longus, originate above the el- stretch of the abductor pollicis longus (Finkelstein's test).
bow. Except for the flexor carpi ulnaris tendon, After a careful examination, de Quervain's tenosynovitis is
which attaches Lo the pisiform, all of the wrist confirmed.
muscle tendons traverse the carpal bones to insert In this case, overuse by performance of a repetitive,
on the metacarpals. forceful task involving abduction of the thumb while the
Each wrist tendon has a substantial amplitude of wrist is ulnar deviated contributed to the development of
excursion. The extensor carpi radialis brevis and the tenosynovitis. Another contributing factor is the
longus each have a maximal excursion of approxi- anatomical structure of Ihis first dorsal compartment of
mately 37 mm. The flexor carpi radialis excursion is the wrist. The restrictive volume of this compartment
approximately 40 mm, and that of the nexor carpi along with the multiaxial movements oi the thumb render
ulnaris is approximately 33 mm. The pronator teres the tendons of the abductor pollicis longus and the exten-
excursion is approximately 50 mm (Boyes, 1970). sor pollicis brevis susceptible to inflammation following
Impainncnt of the excursion of any of these tendons exposure to high frictional loads.
owing to adhesions after trauma or surgery can se-
riously limit wrist mOlion.
The anangemenl of digital and wrist extensor
and flexor systems around the wrist axis makes for
antagonist groupings of illataI' forces that afford
positional stability. The extensor digitorum C001-
munis and extensor indicis propius pair against the
flexor carpi radialis and flexor pollicis longus. The
extensor carpi ulnaris works against the extensor
poll ids brevis, and the abductor poll ids longus and
extensor carpi radialis longus pair against the
flexor carpi ulnaris and the flexor digitorum pollieis
.(Steindlet; 1955).
The contributions of the extensor carpi ulnaris,
Case Study Figure 14-2-1,
extensor pollicis brevis, ancl abductor pollicis
CHAPTER 14 • BICJMECHANIC:S
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 26
possible 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-
Flexion
stead from motion arising at the proxirnal and dis-
tal radioulnar and the radiohumeral joints (Volz ct
aI., 1980). Extension
-~,
1-
.'i.
LSi&. -_- , ~- .
CHAPTER 14. BIOMECHANICS OF
motion proper, pIa)' an intricate role in hand and the ulnar head of up to 9° in the direction oppo-
function. Average range of motion of site that of the distal radius has been demon-
pronation~supination is 150 (60-80° of prona-
0
strated during this motion (Ray et a1., 1951), and
tion and 60-85° of supination). In a biomechani- the ulnar head glides in the sigmoid notch 01' the
study, YOUlll et a!' (1979) found the axis of radius from a dorsal distal position to a palmar
pronation-supination to lie oblique to both the proximal position as the forearm moves from full
radius and the ulnar, passing through the center pronation into full supination (Bunnell, 1956;
of the humeral capitulum and the midpoint of Palmer & Wemer, 1984; Rose-Innes, 1990; Vesely,
the head of the ulna ..Modest lateral movement of 1967).
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 viation, the bones of the proximal row are extended. The
(A), in the neutral position (B), and in ulnar deviation (C). Ar- scaphoid appears elongated, the shape of the lunate appears
rows in the schematic drawings above roentgenograms A and trapezoidal, and the triquetrum is distal in relation to the ha-
C indicate general movement of the bones of the proximal mate. Tp, trapezium; TZ, trapezoid; C. capitate; H, hamate;
row with wrist motion. In radial deviation, the bones of the TQ, triquetrum; L, lunate; 5, scaphoid. Roentgenogram cour-
proximal row are flexed toward the palm. The scaphoid ap- tesy of Alex Norman, M.D.; drawings adapted ~vith permission
pears 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
ligament
Med, 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.
•.
---------------------~~-~-~-~--~~
!W~;j··it!
Fingers
I"."il\'.
The second and third metacarpals arc linked to the The PIP and disl~d joints or the fOLlI' digits arc bi-
trapezoid and capitate and to each other by' light~ cond~!lar hinge joints as a result of the LOnguc-and~
f'ltting joints that are basically immobile (Fig, groove fit or their articular surfaces (Figs. 14-10
14-19). As a result, these metacarpal and carpal and 14-19L TilL'SC surfaces are c1cJscl~' congrllenl
)y;;j
bones constitute the "immobile unit" of the hane!' throughollt the range or r!e:don-cxtcnsion, which is
The arlicliialions or Ihe [ollrlh and firlh melacarpals IhL' onl~-" motion possible in Ihese joints, Flexion is '11
with the hamate pel"mit a modest amount of mo- measured from thL' zero position wilh the finger in '~
tion: 10 to 15° of nexion-extcnsion at the fourth the plane or lhe hane!' The largest ,·allgc of flexion.
CMC joinl and 20 to 300 at Ihe fi[lh. Limilecl palmar I 10° or more. occurs in Ihe PI P joint (Fig. 1-t-20B). ,.
·''''1'
displacement, or descenl, of these metacarpals rna~' Flexion of approxillw(cl.\' 90" ulkes place in the DIP
take place. This mOlion allows Clipping or the hand joint (fig. 1..J.-20C). Extension bc~'ond the zero po~ "
and is essential ror gripping. sitioll. termed h,\"pL'l"extcnsion, is a I"L'gular feature
The I\'ICP joints or the fOUl" fingers are uniconety-
Iar dianhrodial joints (Figs. 14-10 and 14-19), al-
of Ihe DIP alld PIP joints. although il elL-pellets
largd~· on ligalllt'lltous laxily. eSlk'ciall~' in lhe PIP
j
lowing motion in three planes: fkxion-exlcnsion joinl.
'·,1
'"':'/)11~
:d
j
,,:\
··.·.131
"
E1
(HAPTER 14 •
,\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 OPPOSITION OF THE THUMB
Composite of Three Motions
wide range of 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 Zero starling
flexion and extension with respect to the t.humb are postion
' ....
'." ;'.
Man.\· attempts h~l\'L' hl..'L'!1 nwdc to Chlssif\ diller.
cnt patterns or prL'ht,:nsik~ hand function. !'\npier-~
(1956) idclllified two distinct rmtlcrns or prchcn-
;-;ilt...' lIlo"elllent in thL' n(Jlnwl hand: pOWL"r grip and
pr~cbion grip. I-k (:mplwsizcd thai the fundalllen_
tal requisile 10 prL"ilL"nsioll, :-;Iabilit,\', can bt,.." mel bv .~
eilher posture. -
Power grip. or POWL'1' grasp, is a rorerI'll l act pcr-
fnnncd with the finger lk'.'\cd at all three joints so
that the object is held bc!\\'een the finger and the
palm, with the thumb positio!1ed on the palnmJ' side
or lile obje('l to fore\! it sccllrL'I~' into tlw IXllm (Fig,
14~14.·l). It is lIsliall.\· performed wilh Ihe wrisl devi-
aiL'd ulnarl~-' and dorsillL'xed sljghll~' to <lugml'1H the
lL'llsinll in the flexor (L'ndons.
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
i,
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-
In E.E. h'ss & CA. Philips (£ds.), 1-/1IIul Splillfillg: Pritlci· joinl. J :\l1al, 63, 259.
pIes alld 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. Ed.). Philaddphia: J.B. lippincott.
J, 110. Weber, E.R. (198-.1). COllccpts governing [hI,.' rotational shift of
Talcisnik, J. (1985). Tlte WriSl. New York: Churchill L.iving- the intt.'rcal'ltcd S('glllCflt of the carpus, Onhol' eli" "-{Ofll,
stone, ..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
(Vol. I .. 9th cd.). Buenos Aires: 5,,1\,;'11 Editorcs. the wrist 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-
R. Tubi'ln;;t, J.·M. Thominc. & E. J\·lackin (Eds.), £XOI1l;I1(1- eh.mical amtlyses of forearm pronalion-supination and el-
rioll or
{fte Halld al/(l Upper i.i/llb (pro 1-97), Philaddphi<\: bow f1c.xion·e.xtensioll. J Biol/II.'ch 12, 1-.15.
W.B. Saunders. YOll III , Y.. ,\ldvlunry, R.Y., FhHI, A.E., el 411. (1978). Kinema[-
Vesely. D.G. (1967). The dist"l radioulnnr joint. eJin (JrtJlOp. ics of the wrist. J Bone Joi1/1 SlIrg, 60.-\(-0,423-31.
5/. 75. Youm, Y. & Yoon, '\'.5. (1979). Analytical dcn~loplllCn! in in-
Volz. R.G. (1976). The dcn:lopment of " tot,,1 wrist arthro- vcstigation of wriSI kincm~ltics. J Bhwle(.'h, /2,613.
pl<lSlY. Clill 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 Surgery (2nd cd., pp. 3-63). Philadclphi~l: J.B. Lippincott.
the wrist. ('/ill Orlimp, 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
.~'.
,
I
The study of fracture fixation biomechanics can be Currently, controversy exists about \vhether com-
divided into two main areas: (l) criteria for achiev- pletely rigid fixation is the optimal condition for
ing fracture stability and promotion of bone healing bone healing. Ivlicromotion has been shown to aid
and (2) the characterization of techniques and de- healing. Healing results even in cases of gross mo-
vices intended to mechanically stabilize a fracture. tion such as that seen in rib fractures. Rigid fixation
An understanding of the biomechanical principles may lead to delayed healing, bone atrophy, and a
involved in these areas will aid the engineer in im- lack of external stimuli necessary for the healing
plant design and enable the surgeon in selection of process.
the most effective technique and device to obtain Although gross motion between two or more
successful results in patients. 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
Fracture Stability and that stimulates the biological repair processes. The
Healing amount of local strain in the healing region (change
in length divided by the original length) seems to de-
The clinical goal of effective fracture treatment is termine the nature of the tissues formed (e.g., fibro-
rapid healing, withollt significant deformity or li1l1b cartilage or bone). The optimal frequency, \vave
shortening, to restore the patient to a pre-fracture form, and total number of cycles of this signal cur-
level of function. In the elderly. rapid mobilization is rently are being investigated. Several methods to
essential to prevent deleterious consequences of bed promote healing by externally stimulating a fTacture
stay. The first goal of treatlnent is fracture stabiliza- with ultrasound or electromagnetic fields are in
tion. This is determined by the location and type of clinical use (Case Study 15-1). Concern also exists
fnlcture, the muscle and body forces acting on it, and regarding the process of stress shielding that occurs
the various passive soft tissue constraints such as lig- when the fixation device carries most or all of the
aments and fascia. Some simple fractures are inher- mechanical load and thus, by Wolffs law, promotes
ently stable with low loading and thus require nlini- localized osseous resorption as a result of the resul-
mal treatment, such as sling (clavicle), while others, tant unloading of the bone around the device. This
such as midshaft comminuted femur fracture, require is often referred to as load bearing versus load shar-
major surgical intervention and insertion of an inter- ing. Much of the initial osteopenia seen beneath
nal fixation device for adequate fixation. Although an fracture plates, howevel~ is thought to be caused by
osteotomy (a surgically created fracture for correc- vascular disruption during their application.
tion of defonnity) allows close approximation of frac- Bone healing in the presence of a gap with lTIini-
ture ends, typical fractures are often fragmented and mal movement passes through several stages of re-
usually lack inherent stability. The interdigitation of pair \vith a concomitant increase in mechanical
the bone ends can facilitate stability, such as when a strength as mineralization increases: hematoma
tapered bone end is inserted into the nledullar:v cavity! and inflammation, callus formation, replacement by
(creating a displacement deformity, however). woven bone, and fmally remodeling into lamellar or
Traditional methods for the treatment of frac- trabecular bone. Callus can~form both periosteally
tures are externally applied and include traction, and endosteally and enlarges the diameter of the
cast, and braces. External forces or constraints ap- bone at the fracture site. Although callus is less
plied to the injured limb act to stabilize the fracture strong and stiff than nlature bone, this increased di-
(by limiting ITIuscle or soft tissue forces leading to ameter can increase stiffness in bending and torsion
deformity) and maintain alignnlent of the limb. at the fracture site as a result of the increased mo-
Howevel~ in many cases, as a result of the nature of ments of inertia. Direct bone apposition by com-
the fracture or the patient's condition, an internal or pression with rigid fixation, in which the initial re-
external fixation device attached directly to the bone pair stages are eliminated or minimized, heals by a
is required to achieve adequate fracture stabiliza- remodeling process and can take longer because
tion. The designs and use of these fixation devices vascularity must be re-established.
rely on an understanding of bone healing and the The other impOl·tant factor for healing is ade-
loads and forces to which the device is subjected. quate blood supply that necessitates the surgeon
391
o 392 PART III • APPLIED BIOMECHANICS
in December sustained a left tibiofihular lr<1Cwre treated man heanng. Its acoustIC raeJlCIllon, In the form of pres-
with external fixation. Case Study Fig. 15-1·1, In January, lo'.>\'- sure waves, provides rnICfOrnf.'chiH·\ICa! stress and force' to
intensity pulsed ultrasound (US) was mitiatecJ 10 promote frac- the bone ,me! surrounding tiSSUe>, ThiS rnedh1nI((ll stunu·
ture healing. Case Study Fig. 15-1-2, in March, 3 months lalion plays a major role in bone hedlll1g because bone:
postfracture and 2 months after mitiation of pulsed US appli- reacts to the amount and dir(;ction of force and remof.!·
cation, early healing is detected (arrow). Case Study Fig els to adapt to the applied suess "mel its elirf~c!i()n
15-1-3, in May, 5 months after injury and 1\ months follo\,..,mg ReprHlted V-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
riosteum) and providing conditions for early rcvas- which the fixation will he 'subjected and whether
cularization by; careful opcrative techniquc (e.g.! these forces will be cyclic, requiring ~\dditional
sort tissue presenTation). Numerous studies 1lave strength of fixation 10 ~\ccnunt for possible dC\'ice fa-
demonstrated a direct relationship between the tigue (Case S(ud~' 15-2). The second factor is the
quantity and quality of microvascular structures in bone quality', which delermines the strength a\'ail-
the healing region and the rate of ronn~llion and re- able to supporl the fi:..;atioll dc\·jcc. Other factors arc
sultant mechanical properties of" lhe new bone. related to surgical and ~lIlatomical considerations,
for example, the expOSllre (possible scarring and vas-
cular compromisc), wIlL,thcl- the devicc will fit ade-
SURGICAL FACTORS
quately within the soft tissuC's. and if nL'urovascular
Many factors determine the optimal fixation method structures are at risk. The nature of the original in-
for a specific fracture appliGltion. First arc mechan- .iur:v and the amount of soft tissue d~IIll~lgC also de-
ical considerations, specif-lcally the types (tension, tern1illC treatment l~chl1iques. ;.,.\1
.•
i~
:'1
)1
';
t"h.,_ '. , !
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
A the arm of a 25-year·old male who sustained a frac-
ture of the radius. The plate was fractured as a result of Fixation Devices
fatigue 20 years later. Repeated loading and unloading of
a material will cause it to fail, even if the loads are below
and iVlethods
-.: .the ultimate stress (Simon. 1994). Each loading cycle pro-
vVires, staples, pins, plates, and screws are the com-
duces a minute amount of microdamage that accumulates
mon implant devices used to achieve fracture fixa-
with repetitive loads until the material fails. Mechanical
tion. These are usually made of stainless steel
considerations as to the magnitude and repetition of the
(316L), sometimes of titanium alloy (Ti-6A l-4V), or
loads to which the fixation will be subjected should be
occasionally of cobalt-chromium alloy'. Each metal
considered, along-with the fatigue life of the material. This
has advantages and disadvantages such as strength,
is recorded on a curve of stress versus number of cycles.
modulus (stiffness), corrosion resistance, and case
T,hus, higher stresses produce failure in fewer cycles (load·
of imaging (MRf, CAT). Sometimes there is a "race"
ing to the ultimate stress produces failure in one cycle>.
between healing of the bone and fraclure, usually by
while lower stresses are tolerated for an extended period.
faligue, of the device. There is a recent interest in
the clinical application of biodegradable polymers
such as polylactic acid. Polymers are more Ocxible
than rnetals and would lead to greater load be:1l-ing
by the healing Ii·acture; biodegradable materials do
not have to be removed in a secondary' operation
and their mechanical properties gradually decrease
with time, thus avoiding stress shielding. Ho\Vevcl~
their mechanical strength is much less than that of
metal and some of the degradation products have
shown untoward biological responses. Research
continues into the use of various glues, cements,
and adhesives for fracture fixation, some of which
Case Study Figure 15-2-1. are also biodegl-adable.
Wire fixation lIsed as cerclage or a bone suture is
a common application; in both cases multiple wires
are required to provide stable, three-dimensional
Evaluation of fixation strength can be accolll- fixation. This requires achieving equal tension dur-
plished by laboratory testing of actual implants in ing tightening because loosening at one or more
cadaver bone. One difficulLy of such testing is in ad- sites can provide a locus for motion and possible
equately simulating in the test model the complex in nonunion or cause malpositioning. Problems with
vivo, cyclic forces on the device. Another difficulty is v.lire fracture fixation include the necessity and sur-
in simulating the biological repair processes that gical complexity of making a'bone hole and passing
would act to stabilize the fixation over time. Ca- the wire, breakage during tightening or later as a rc~
daver studies also can determine the anatomical suit of fatigue (cyclic loading), and cut-through of
structures at risk. Computer modeling such as finite the bone. For cerclage applications, there is concern
element analysis can be lIsed as an initial method to about compromise of the periosteal blood supply
evaluate fixation methods and device designs but re- and the resulting increased healing time required
quires quantified parameters of bone modulus and for revascularization.
strength, which may be lacking. for an exact solu- Some~recent developments are wire tensioning!
tion. twisting instruments and the usc of crimping sys-
Clinical trials is the other major method used to tems to avoid the problems with twisting or knot ty-
evaluate the efficacy of a particular fixation method. ing. There are also new oriented polymers (Spectra)
HOWe\lel~ care must be taken to adopt the appropri- that do not stretch as traditional suture malcrials do
ate techniques to quantify data and design the trial that can be Llsed with a suture anchor system to
eliminate the difficult.\' of looping a suture through
bone and suture abrasion against the bone.
Staples alone usually' do not provide sufficient
mechanical stability for permanent fixation and /------ ......
their use often requires pre-drilling holes for the sta~
pic legs; pneumatic-driven staples can be used to \ /
rapidly tack fragments prior to a more rigid fixation ~\ / I
but need careful control of the insertion driving \\ I
force to prevent untoward damage to the bone.
Some staple designs have been developed that can \ \ /1
effect compression during insertion, such as staple \ \ /1
fabrication from nitinol (an alloy.' that changes \ '1/
shape when heated to body temperature). y~
Kirschner \vires are normally used to hold frag-
nlents of bone prior to rigid fixation and for percu~ /
taneous pinning of small bone fractures but, in gen~ /1
eral, lack sufficient mechanical stability for their I--il- Tension band
/ I wire loop
use as a primary fixation in weight-bearing bones.
At least two wires should be Llsed for each bone / /
fragment, and they should not be inserted in a par- /
allel manner to prevent "pis toning" of the bone frag-
ment along the wires (Fig. 15-1). Threaded pins pro-
vide additional stability because they minimize
sliding of the bone fragments, but their rcmoval is
morc difficult. Occasionall'y', pinning is uscd in com-
bination with sutures looped and tightencd around
the pin ends or through loops in the pins. This "len-
sion band" techniquc provides significantly' in-
creased 111echanical stability of the fixation.
The major intrinsic factors that influence scrc\v-
holding po\ver are outer thrcad diameter, thread Tension band wiring of two K-wires; tightening the wire
loop applies compression to the fixation. K-wires are in-
configuration, and thread length; extrinsic factors
serted in a skewed configuration for stability,
are bone quality, typc, and screw insertion orienta-
tion and driving torque (Fig. 15-2). The two basic
types of screws are cortical and cancellous and are
distinguished by their thrcad design; cancellous
screws have a greater distance bct\veen adjacent
threads (pitch) and the ratio of outer thread diame- portant to prevent stripping of the bone or scre\v
ter to body diameter (Fig. 15-3). head torsional Failure.
The inherent holding power of a screw is a func- Because of anatomical constraints or surgical ex-
tion of the outer thread dianlcter times the length of posure, screws cannot <.lIways be inserted perpen-
its threads within the bone. When used to hold two dicular to the bone axis or the orientation of the
bone fragments together, scre\vs comnlonl:v are ends of thc bone fragments is not perpendicular to
used in a lag modality in which the proximal por- the screw axis. In this case, the holding power of the
tion of the screw remains free within one fragment screw is decreased and a shear component of the
(either b:v using a screw design having no proximal holding Force is created, which acts to destabilize
threads or b)' enlargement of the hole in the proxi- alignment. Pre-tapping of thc scrcws usually! is not
mal fragment, which should require thc use of a necessary and has been shown to have minimal ef-
washcr under the screw head for adequate support). fect on their holding ability; many' screws are sclf-
Insertion torque detcrmines the force with which tapping owing to a modification to the design of the
bone fragments are held togethel~ which, in turn, leading threads. Usually lwo or more screws are re-
crcates the friction that prevents their motion. Con- quired for functioning, although one screw has been
trol of torque (torque-limiting scre\vdrivcr) is im- suggested for some applications if sufficient inter-
Outer thread rragment approximation can be achieved to create
diameler
~I adequate friction between the bone surfaces for sta-
bility. The quality of bone also determines serew-
holding ability; cortical bone is approximately ten
times stronger than cancellous bonc. The thickness
of the cortex and the degree of osteopenia (bone
density) are thus critical for fixation strength and in-
nucnce the number of screws required for adequate
Length
Thread
stability. Using screws in a biconical manner appre-
of screw
in bone' pitch ciably increases the strength of fixation.
Anatomical constraints limit the number or size
of screws that can be applied in a given region. As a
result, screws are ohen combined with plates to
achieve adequate stability and increased strength of
,. fixation. The optimal site for a single plate applica-
tion is on the side of the bone subjected to tension;
lIsually two plates are applied to achieve better FIxa-
Lion stability (Fig. 15-4). Owing to anatomical COI1-
Screw parameter~. For ~crew pull-out the bone must shear strail1ls such as soh tissue thickness. sometimes
along the outer diameter (dotted line). thinner plates are used (such as for forearm fracture
stabilization), but these plates possess sufficient
stiffness (function of the width of the plate times its
thickness cubed) Lo prevent undesired fracture mo-
tion as a result of bending loads (Fig. 15-5).
Screws should be inserted with a torque driver
and the tightness of all screws rechecked; if this is
not done, one screw may bear most of the load and
possibly Fail. Some plates use a specially designed
scre\v hole slot, countersunk Lo accommodate the
Load Load
~ ~
Fracture
Gap_
Plate gap Plate
closes
ope~s -~'!lIlIJ'llm~
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.
J
'~
..... }
Posterior thl.'ir insertion and the possibilit.\" (II" compromising
bending force
p\.'riosh.';.11 blood stlppl.,· b.\· thL' l':\posure or pl;'11(' in-
I sert iOl1 (somi..' plati..' designs have inferior fed Or
Posterior
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
Lateral till." fracture:.: thai could 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
- bending is a 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,
Anterior
load sharing) 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-
Effect of loading direction on plate stiffness. The rigidity ing. lnt\..'rnal c!t:..'\"ic(':-; for fix~ltioll arc llsually in-
of the plate is EI, where E is the modulus of the plate mao traIl1L'dullal".\· nails (Ii\,1) alld in cOinparison with
terial and I is the moment of inertia of the plate. I == ('x (('1"1141 I dc\"iccs arL' SUhjL'ct to less loading fore\.' be~
bh 1/12 ( II = posterior bending; 11 = medial bending; II = C;;luse or their location being closer to t1h.. . Ileutral
0.5 x 1.8)/12 = 0.243; I~ = 1.8 x 0.5J /12 = 0.01875), where b
bending axis 01" the bon\..' (Fig. 15·6). Their size is
is the base dimension and h is its height. Thus, the plate is
critical bcc..wsc their ht..'nding and tor:-;ional stifTnL'ss
13 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
screw head, whose center is offset with respect to also important because the swbilit.\" of the fixation
the screw head to obtain interfragmentary compres- rL'lics on lond transfer to the bont.~: often, distal and
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.
Plates can also be used to span gaps created by
severe fractures or tumor surgel), and are frequently
used with bone grafts for this application. Unless
the graft is exactly sized. the plate will bear the en-
tire load across the defecl. The bending moment on
the plate-screw fixation linearly increases with c1e~
fect size and thus the plate requires adequate stabi-
lization, particularly at the morc highly loaded,
proximal end where at least three screws are
needed. Multiple-holed plates enable selection of
the best osseous sites 1'01" screw purchase and should
permit anchoring of the graft by at least two addi-
tional screws. Typical intermeduliary and extramedullary devices. Top,
The major surgical considerations I'm" the lise of Medoff sliding plate; bottom, intermedullary hip screw"
plates are the requirements of a large exposure for
•
proximal screws inserted through the bone and nail Type olframe and
connections
arc used to increase torsional stability (Fig. 15-7).
Bending of the nail as a result of insertion in a
curvcd medullary cavity can make inserlion of the
Size and
pin type
I
distal screws difficult.
External fixation devices are also used for fnK-
ture stabilization; multiple transcutaneous pins are
Ii
11
II
inserted into the bone and stabilized with an exter- Ii
1 1 11
nal bares) or ring(s). Factors that influence mechan- 1 Pin I Fracture I
distance spacing
ical stability and rigidity of these constructs are the
numbel~ diameter, orientation, and length of these
pins and their relation with respect to the fracture:
however, these factors arc subject to surgical con- Typical external fixator showing the variable that influ-
siderations for frame application. Large, short pins ences fixation stability.
located close to the fracture provide the most rigid
fixation (Fig. 15-8).
Spinal implants used for deforrnity correction or
fracture fixation consist of various combinations of
rods, wires, plates, and screws. The junctions be- tion of appropriate sites for device attachmenl to
tween these components are often the site of failure, th~ spine are IitrJi ted. This is imponanl because
such as fatigue or fretting as a result of cyclic load- lhese devices are subject to appreciable forces dur-
ing. A specific problem is that the size and the loc3- ing flexion and extension of the neck, and torso and
fixation failure can occur.
Summarv
Extramedullary Intermedullary
SUGGESTED READING
Burstein, A.H. & Wright, T.M. (1994). FItIll[all/i:J1/a[s of 0,.·
tltoflW.'dic Biol1lcc!ulIlic:s. Baltimore: Williams & Wilkins.
!;...
The extramedullary device is less rigid and when loaded Codlran. G.V.B. (1982).:1 Primer oJ' Orthoplledic lJiOIllCc!UlII-
it..'s. London: Churchill Li\·ingstonc.
has greater deflection, creating higher medial stresses in
DYi.:hc"IlI..'. P.. &. Hastings. G.W.-(Eds.) (l9S . l ). FllIlc:tiOlud Be-
the femur.
. hm;;or of Orlhop(ll'dl~· !J;omata;als. -Bot-'I Raton. FL: eRe
Press.
,
~""'===~====~===""'==~=---="""~".~",."."_"~",_""'~"--======""',"",,;r,--'0'J!'G'7,;- ;"c-~"'<,!",:" ' ' _ ..,-,'":'_ r"·· ,....."......,,:::s;-"'H-"~,_i"~>s""'-,_A~_!2__h_.k:r~
.. " " " ,
Fr~lnkd, V.H. {I 99S). Resldts or prescription or pulse ultra- Radin. E.L. (Ed.) (1992). "raniral BioJllecJlllllics (01' the 0,.-
sound therapy in rl'.u.:tun: management. In Z. Szabo, J. tJwfll.'liic Surgeol/. Nl:\\' York: Churchill Livingstone.
L~\\'is, G. F311tini. 0: R. Sa\·~tlgi (Eds.), 5111"gi('(// 7t:dlllology Sarmiento. A., McKdlop. '·I.A., Llinas. A., c[ al. (1996). Effecl
IUlc!t"/WliOlw{ VII. IJll~n/(/tiollal Dct'dlJIJllli.!lIls "11 SlIrg{.'(\· of IO<:lding Hnd fraclUn: motions on diaphyscaltibi.l! frac-
(//ul Surgical R,:s{.'(/J"l.'h. Snn Francisco: Universnl ~lcdical tureS. J OrtllOp Ues, /.+( I). 80-84.
Press. Inc. Surgical Technology Inlcrnationnl. Simon. S.R. (1994). OrrJwpcdic Basic S(.'iclln:. Rosemolll. IL:
Fun~, Y.c. (1981). BiomecJulllics: ,\-lcdulI/lt:a/ Properties of ,I,IOS.
L-it'illg TisSlil'S. Ncw York: Springcr-Vcl'bg. Sph'ak, J.~'l., Oi Cesarl:, P.E .. Feldman, O.S" ct til. (Eds.)
Ghista, D.N. (Ed.) (1981). BiolllecJUlllics o{ Medical Dn'ices. (1999). Orthopacdics-A Suu/y Gllidi.'. New York: McGraw-
Nt\\' )'ork: Dekkt:r. Hill.
Coma, E.R., Harrington, I.J., & Evans, D.C, (1982). Biollle- Tencer, A.F. & Johnson, K.D. (1994). 13iolllecllllllics ill Or/ho-
duwi"s or AJlIsclilo.d:dcUI{ 11I;llry. Baltimore: Williams & fl,'dic 7hlllllUI. London: M. Dunitz..
Wilkins. Uhthoff, H.K. (Ed.) (1980). C"rrclI! COl/cep!s or Jl1rcn/{l{ Fixa-
Kasscl', J.ll.. (Ed.) (1995). OrlJwpai'dic Knowledge Update .i. liol/ 0" Frac!ures. Berlin: Springcr-Vtrlag.
RoselJl<)lll, I L: AA05. Valcllw. J. (Ed.) ( 1993). 8iollle(.'I1(l1Iio. Amsterd,un: Elsevier.
Mow. V.e. 0: l'layes, W.e. (Eds.) (1991). Basic Orthopaedic White, A.A. &.: Panjabi, M.M. (£ds.) (1990). CliHical Biollle-
BiOllh'challics. Ncw York: Ravcn Prcss. cJWI1It.·s o{ the Spiltc. Phil;:lddphia: Lippincott.
Ozka\'a, N. & Nordin, M. (1998). Fllluhmll'ltrals o{ Biome- Wolff, J. (1986). Dos Geset:. tier Trtms{o1'l11l1tioll del" Knochen
d;aJlio (2nd .::d.). Nl'W York: Springer-Verlag. [The 1;:1\\' of bone l"enloddingJ. P. ,\,Iaqul:t & R. Fulon!:!
Pauwels, F. (1976). BivJIlt:clulllics o{ the NOI'I//(/i ami Dist:(LWd (Trans.). Berlin: Springcr.Vcr!;g. (Original work published
fljp. Berlin: Springl,.·r.Vcriag. in 1892).
Biomechanics of
Arth roplasty
Debra E. Hurwitz, Thomas P Andriacchi, Gunnar BJ Andersson
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
1,.
Introduction To meet one design objective, compromises with re- j
spect to another design objecLive must often be
;
,.,
As designs for total joint replacements evolve, there made. For example, the femoral stem of ccmcntless
is an increasing need to improve the understanding total hip replacements requires initial rotatory sta-
of the biomechanics of these joints. For instance, bility for bony ingrowth into the porous material to
reducing loads on a total joint replacement during occur. The rotational stability of early ccmentless
daily activities and designing implants to withstand total hip replacements was insufflcient and was in-
these loads will both increase the likelihood of nor- creased by designing implants with greater mcdul-
mal joint function and lower the probability of im- lary canal fill. Ho\vever, implants with increased
plant failure. As implants arc put into younger and medullary canal fill were stiffer because of their
more active patienls, the IO~lds placed on the illl~ larger size and were thll:) associated with greater
plants arc often several times greater, thereb.y in- stress shielding.
creasing the likelihood of mechanical failure. Me- Forces acting at the hip or knee joint arc depen-
chanical problems associated with lotal joint dent on the external forces aCLing on the limb and
replacements include issues related to wear of the the internal forces primarily generated by muscle
bearing surface, mechanical failure of the implant, contraction. Joint forces have been measured with
loosening of the implant from the bone, and dislo- implanted transducers or estimated using inverse
cation of the implant at the articulating surfaces. dynamics and analytical methods (Tables 16-1 and
Important biomechanical infOl-mation addressing 16-2). By measuring the external ground reaction
eHch of these issues has been obtained from in vitro forccs, approximating the limb segment inertial
cadaver testing, model simulation of the joint mo~ properties, and localing the three-dimensional posi-
tions and loads, and in vivo studies of human loco- tion of the joint centers during dynamic activities,
motion. the intersegmenLal hip forces and external moments
The overall goals of joint replacement are to pro- can be obtained using inverse dynamics. Even \\lith
vide long-term restoration of function and pain re- simplifications to the anatomy, solving For the mus-
lief. Several mechanical challenges must be met to cle and contact forces at the hip and knee remains
achieve these goals. For example, the control of an indeterminate problem. Thus, a unique solution
joint motion and stability in total knee replace- for individual muscle forces is not possible without
ments is achieved through an inLl'icate biomechani- further assumptions or simplifications.
cal interaction between the shapes 01" the replaced In general, two approaches have been used to
surfaces and the remaining ligaments and muscles. 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
VValkltlq 510""./ wltllOlll cane 3.4 endurclnce
vValkinD Cro'lojl)H1Sflleld 0t aI., 1978
Stair climbln~l
(hal( rising 3.3
Walkmg 5.S QuasI SIc1!IC-!llmm)lb2 muscle lorces Selreg & ArvJkar, i 975
Knee Force
VV,llklng 32 Re<.i~:ctlon method Harnng!Oo, 1983
Walking 4 Rt~uuctlon method i'-Aofflson, 1970
Walking 3 Op!imil<:tlon Sclllpp!eJn fit Andric1cchi, i991
W,11kin9 7 Optin11Z,ltl0n 5(>lr09 & ;\rvlkar, i 975
A Activities: Walking, Jogging. Stairs, Stumbling teria to determine the agonistic and antagonistic
muscle activity, and assuming norrnal function. Iden-
RESULTANT FORCE R
900 tifying how patients with total hip replacements alter
EBl EBR JB their function during gait could irnprove analytical
800
700 predictions of joint force. In vivo force measurements
600 have often been obtained during the early postopera-
~
<D 500 'u, tive period \vhen patients may still have compromised
t 400 AI function.
a: 300 I /.
I II II
200
100 ESJ Mmli<ln 6 Abs. max
0
"~ ,
0 Rotational Moments About
,~ .§" "
~ ~ ~
,~
% 0
% ~
6 'i 'i 0
~ w "
3
§ M
" ~' w
" ""
.§ M
.< "
2
~ the hnplant
~ ~
2 ~
"~ "~ E
w ~
Out-or-plane loads l11ay be detrimental to both ini-
B BENDING MOMENT Mf
18 tial and long-term implant stability, especially in
16 ullcemented stems (Berzins, Sumner, & Andriac-
14 chi, 1993; Phillips, Nguyen, & Munro, 1991). Ex-
1\
I 12 cessive bone-implant motion prevents bone in-
:i:<D 10
6 D growth into porous coatings and may lead to
1\ A
.0
8
o·
A ~ r 61 failure of the biological fixation (Pilliar, Lee, &
;; 6
d Pli )11 Maniatopoulus, 1986). The largest torsional mo-
4
2 ESJ MiJd'i1rl D. Abs. 01i1~ ments measured in vivo during activities of daily
a living (Bergmann, Graichen, & Rohlmann, t 995)
,
c g.
~ "~ ,:i
0 F 0
;:;
~
€ 0
% reach the average experimental strcngth of implant
~
0
f ,~ 0 11 "
~" "5 ~~ fixation (33.1 Nrn) as dctermined from in vitro
" M §
~
'0 M
~ ~
~ ~ ~ w
•" • ~
~ if",
~ ~ w
.0
~ ~ tests (Phillips, Nguyen, & Munro, 1991) (Fig. 16-1).
In vitro testing of prostheses implanted in human
c TORSIONAL MOMENT Ml
femurs indicate that the amount of initial bone-im-
7
6
plant motion is sensitive to the off-axis loading
A A A 6 that frequently! occurs during stair climbing and
I 5 A rising from a chair (Fig. 16-2) (Berzins, Sumnec &
:i:
<D
4 u, Andriacchi, 1993). Furthermore, resultant proxi-
6
e: 3
F,
A
mal translations were twice as high with a straight
;; 2 I 6
stcm as with a curved stem at load angles encoun-
!n I I
tered during these 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-
Murray, BreweI~ & Zuege, 1972; Stauffer, Smidt, &
ues (column height) and absolute maxima (triangle) are given.
Wadsworth, 1974; White, Yack, & Lesswing, 1992)
The resultant force is in the top graph (A) the bending mo- may be beneficial for iIllplant stability b,Y reducing
ment in the frontal plane is in the middle graph (B) and the the rotational moments about the implant stem. D:v-
torsional moment in the transverse plane is in the bottom namic hiii range of motion during gait in patients
graph (C). The gray bar indicates the fixation strength of ce- with uncemented total hip replacements has been
mentless implants (14). Reprinted ~vith permission from Bergmann related to the metaphyseal fill of the femoral stem
G., Graichen, F., & Roh/mann, A (1995). Is staircase walking a risk (Hurwitz et aI" 1992). It was concluded that a re-
for the fixation of hip implants? j Biomechanics, 28(5), 535-553. duction in the dynamic range of hip motion \vas an
adaptive response to decrease torsional micromo-
100 vantage of the ~lhductors (Fig. 16-3) (Delp, ":'om;:tttu,
&. \Vi:"son, 1994). Joint contact forces therefore
E should be minimized with sm~t11 1H..'ad-neck all!!les
.3
C 020" extension 0.3 ~ (Johnston, Brand, &. Crownillshicld, 1(79). 'De-
w 70 3
E [J] 20" flexion cre~\sed heml-IH_'ck angles also improve joint stability
~ 60 .34" flexion go
~ through increased congrucnce hv tUI-ning the
g.'"
50 1m 68° flexion 0.2 '"o
:D k'moral head del.~pt..'r into Iht..' aCt..'tabulul1l. j\/toving
is 40 the greater !rochalllL'r b{crall~' also increases the
w
c
!i!
~ 30 §f mechanical ad\'antagl..' of tilL' ahductors. Clinically.
0.1 " increased abdlll:lor/adducLOr stn:ngth has hC1..'1l asso-
E 20
'"
ijj 10 ciated with incl"easC'd neck length and a morc distal
greater trochantcr position (HuJ"\viti'. & i\ndriacchi.
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
Distal motions as a function of flexion angle (mean and
proximal felllur_ A varus hip or an illcrcasl.,d neck
standard deviation) There were significant differences be- length increases bending moments in the proximal
tween 20 and 34° and between 34 and 68° for the resul- felllur by inCrL'~ISillg. lill.' fllOllll.'nt arm or the forces
tant translation and the transverse rotation, but for the lransmitted along tile slwft or tilt.: felllur. Proslhc-
sagittal rotation only the difference between the 20 and S('S IllUSl be designed to resiSl these bending mu-
34° was significant. Reprinted with permission from Berzins, ments. Decreasing the neck k'ngth or increasing
A, Sumner. D.R., Andriacch!; T.P, et ell. (1993). Stem curvature !he ht.~ad-neck angle (yalgus) will decrcase the
and toad angle influence the initial relative bone implant motion bending 1l10mcnts in the steIn; howcver, these al-
of cemenrfess femoral srems. J Orthop Res. 11 (5), 758-769. terations compromise thc abductor function and
incrcas(' the joi nl react ion rorc(~ (Case 5t ud.v 16-1).
• The abductors art.' important during the singlc-
legged stnnec phase or gail because their contrac-
tion pulls the rim or till' pclds toward thL' grt..'ater
tion produced by out-of-plane loads when the hip trochanter and prl..'\1:nts tlK contralateral side of
reaches greater ranges of Oexion.
" ,',
the pelvis from dropping as a result of the weight Although the models can predict hip joint center po-
of the swinging leg and upper body. If changes in sitions that minimize the resultant force, these posi-
the neck angle, neck length. and joint center posi- tions may not be practical for the acetabular com-
tion decrease the abductor moment arm relative to ponent. Pathological conditions strongly inOuence
the body weight and no compensation in [unction the potential locations of the hip cente!: For in-
occurs, then an increase in the resultant force stance, osteoarthritis h-equently results in the
would be expected. Subjects may, however, adapt femoral head being displaced laterally, superiorly,
their gait to lessen the demand on these muscles and posteriorly.
when the moment-generating capacity of the ab- Large joint forces are analytically predicted for
ductors is compromised. hip centers that are located superiOl~ lateral. and
Alterations in hip center location have a large ef- posterior as compared with the original location
fect on the moment·generating capacity of the mus- (Johnston, Brand, & Crowninshield. 1979). High
cles and the resultant hip force (Doehring et aI., joint forces were obtained with superior latenll hip
1996; Johnston, Brand, & Crowninshield, 1979). Pre- centers in an experimental sel-up in which a loading
dicted joint forces are minimized when the joint fixture simulated the hip abductors, adductors, and
center is moved medial, inferior, and anterior (Fig. extensors during single-legged stance and stair
16-4). This position maximizes the moment-generat- climbing (Gore et aI., 1977). Superior displacements
ing capacity of the abductors and brings the hip cen- of the hip center reduce the moment~generatingca-
ter closer to the line of action of the foot floor reac- pacity of the abductors, adductors, flexors, and ex-
tion force, thus decreasing the external moment that tensors as a result of alterations in muscle lengths
needs to be balanced by muscle forces (Doehring et and moment arms (Doehring et aI., 1996). Increas-
aI., 1996; Johnston, Brand, & Crowninshield, 1979). ing the neck length or advancing lhe greater
,./0.,0' C, _w·.'·
trudl;:IIlICl' pani~III.\" compt'llsal('S for lhl..'se lusses
in rI1u:-.ck m()lIll·llI-gt,"lh.'r~lting l'aracitk-s (Delp,
KOlllattu. ~ \\'j.'\:-'Oll, 19lJ.i),
Prosthesis Moment
0.4
Sf eIII Po., if iOfl IIi fII ill f lie
r'e/110 m I Co iI {II
"o
fI)
pL'i.lk sll"l.'sscS lhall thosL' ill \'algLls or llL'lllr~d for Ih..--:
same loading condiliol1s (.-\lldrii.lccili l..'1 ;;11., 1476).
0.1 SubjL'l'IS with :'1 .\'hIL'IIL'I'"cL'lllcnlL'd Stl..'lll ill ~l ,'antS
positi()l1 \\'~llk \\'ilb 11101\.' ~d)[lorl"ll~l1itics thall those
\\'ilh a \'alglls sll'l'll tiL-spilL' thL' I':ll'l lhal :-'lIbjL'Cl~ in
hoth groups h~H.1 an L'xcdlL'IH clinical OlllL'(IIllC
A D A D A D (Hodg(', :\ndrii.lcchi. & Gal~llllL', 19tJl). Tltl..' gail ab-
llorllli.llitiL,:-; in till.' \';:II'lIS group may be sllggcsth'L' or
<l bi{ll11l.'chaniGII ~ldapl~lli(Hl 10 I.'illle!· nlicromolioll
ur ahnol'lnal SlI"L'S:-; patterns prL's\.'nt in \'i.I!"lIS stl'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
0=0: Pcripmst!wlic BOi!e Loss
and 0 = hip center 20 mm medial, 20 mm inferior, and 10
mm anterior. Peak forces were based on an optimization Pcriprosthetic bOlk' loss associ'lled wilh uncc-
approach that minimized muscle stresses. Reprinted with Il'lclltcd rL'rnoral slerns has bL'l'll \\TIl dOClllllCl1\l'd
permission from Johnston, R. c..
Brand, R,A., & (rownins!lield, (Br:-"i.l11 t'! al.. 1994: Engll & Boh,n1, I 088; En~h L'l
R.D. (979). Reconstruction of (he hip. J Bone Joint Surg, :.d., 1992L and concerns han:' lk'cn raisl.'d \\'itll rc-
6IAIS),646. gi.\nls to the long·lerm clinical impliG\linns or this
phL'nOllll.'llon. OSI('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
./0~; ;periprosthctic bolne loss"lvvearl dcb,:islhas (been im- have also shown that the lower the bone mineral
;,:,,::,'plicated in osten ysis ane imp ant lai lire Amstutz density or content 01" the contralateral femur, the
"i;, , et aI., 1992). Wear particles f!'Om the polyethylene greater the reductioll in peri prosthetic bone on the
and other implant materials are found in the joint affected side, which further implies that preopera-
Quid and adjacent tissues. Even small amounts of tive bone mineral density' influences the extent of
~vear can generate large numbers of polyethylene postoperative bone loss (Engh et aI., 1992; Maloney
particles that are as small as or smallcl- than a mi- el aI., 1996).
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
unexpectedly" undersized or unstable compo- stability while sustaining large joint reaction forces
have a higher incidence of osteolytic lesions at the tibiofemoral and patellofcllloral articulations.
than do those with stable fixation (Noble, 1995). The peak forces during walking predicted by the
Stress shielding results from a decrease in the analytical modcls (Morrison, 1970; Schipplein &
stress distribution in the fenloral bone as a result of Andriacchi. 1991; Seireg & Arvikar, 1975) val'ied
the presence of the implant stem thal has a greater from 3 to 7 bod~· weights and arc similar to those
or equivalent mechanical stiffness as compared measured in vivo (2.3 to 2.5 body weights) in a
with the femur. Changes in the loading environ- single patient with a distal femoral replacement and
ment rcsuh in bone remodeling. Once bone in- rotating knee hinge (Taylor et al.. 1997) (Tables
growth occurs in the cemcnllcss prosthesis, load 16-1 and 16-2). Thc magnitude and cyclic nature of
transfer can OCClIr through these areas of bony at- the compressive force in the tibiorelTlOnd joint are
tachment. However, bone remodeling docs not re- important considerations in the design of a total
sult in the restoration of normal cortical strain lev- knce replaccment, General chnracteristics of the
els (Engh et aI., (992). The fit of the prosthesis predicted forces at the knee joint show three peaks
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- Percent change in the strain energy density within the me-
lated to an as)'mmetry in the peak vertical interseg- dial and lateral regions of the medial and lateral cortex from
mental knee force during gait (Bryan et aI., 1996). a three-dimensional finite element model. The greatest re-
Preoperative gait mechanics of patients with hip OS~ duction in strain energy density was found for the femur
teoarthritis have been shown to be correlated with with the stiffest implant (CoCr). The femur with the most
the bone mineral density of the proximol femur- flexible implant (Composite 1) had the smallest reduction in
(Fig. 16-6) (Hurwitz el aI., 1997). The greater the strain energy density (Camp I and Comp2. composite materi-
bone loss preoperativelv, the less stilT the femur and als; Cocr, cobalt chromium; Ti. titanium) (Personal communica-
the more that likely stress shielding and associated tion. RN NariJrajan).
bone resol-ption will occur postopcratively (Engh &
• -.
during stance phase. Thus, failure as a result of rolling of the femur on the tibia as thL' knel' flexes. A
cyclic fatigue of both interfaces and implant materi- two·dimcnsionall1lodelusing input from gait analv-
als is an important consideration in lotal knee re- sis has demonstrated the presence and location ~f
placement designs (Ducheyne. Kagan. & Lacey. tractive forces on the tibial surface (\.ViIII l1ler & An~
1978; Kagan. 1977; Landy & Walkec 1988). In acldi- driacchi. 1997). The model shows that a ""versal of
tion. the portion of the tibial plateau that is loaded the tractive force occurred at the postcrior end of
varies with knee flexion angle (Fig. 16-7). In many the contact region, suggesting that the effect 01" trac~
designs of total knee replacements, a large contact live forces should be considered in the evaluation of
area only occurs for a limited portion of the knee damage mechanisms. Different types of gait can
range of motion with a I1luch smaller contact area cause different tractive forces on the tibial surface.
occurring at other flexion angles. The smaller the Thus, one of the importanl variables in the consid-
contact area, the larger the contact stresses. eration of factors leading (0 POI~:L·th.\·lenc d~lmage
One consideration in the Factors producing wear may be a variation in the tractive force associated
on the tibioFemoral articulation is the tractive with the gait of a particular patient.
• •
'"
'in
c
w • • •
0
rn
c
<;;
2
• 2
• 2
•
~
w
c
0
lD
• •
g
~
C
'" 0 0 0 • •
....e"
<;;
iii
i"
OJ
-0
w
.'rn" -2 -2 -2
• ••
E
• • •
0
Z
•
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- lady, the anterior fibers of the gluteus medius and minim us
nal rotation moments were significant predictors of the nor- are recognized as primary internal rotators. Thus, the de-
malized bone mineral density of the greater trochanter in creased external rotation moment in early stance may also be
the patients with hip osteoarthritis. The abductors are the reflective of decreased abductor muscle forces. Modifi~ wirh
primary structures responsible for balancing the adduction permission from Hurwitz. D.E.• Foucher. K.C Sumner: D.R.. et al.
moment. Because the abductors insert on the greater (1998). Hip motion dnd moments dtJring gail relMe clireCily 10
trochanter, a reduced adduction moment may reflect re- proximal femoral bone mineral density in pc1tieflls "''/Ith osteodfihri-
duced forces in this region and may result in bone loss. Simi- tis. J Biomechanics 3 I (lOj, 919-925
Posterior Adduction Moment During Gait
60 and
Medial - Lateral Joint Loading
ROIII~o .~90
70 5g 20
20
Roll 60 _'0
- .D
I<t
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
Heel
1 - -Slance
- - - 1Toe
much more during flexion (0-20°) than does the medial strike phase off
side 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.
-'l"~4.~.
ance, tibial component designs were modif-lcd to
have a mewl backing of the polyeth~'lcnc articulat- 100 * Abnormal
pattern
i.m!: surface, and surgical instrumentation was rnod-
ifi~d to allow for proper alignment or the mechani-
cal axis.
Loads
5.0
the incidence of tibial component loosening sub-
stantially decreased in the eady 1980s, patello-
fcmoral problems began to emerge as a primary is- -f
c
2.5
Non-anatomicallrochlea
sue in total knee replacement (ROI'abeck et aI., 1995; ""OlD
Es:
Rosenberg et aL. 1988), The magnitude of the rell'o- :i: ~ 0.0 --I''-------->,--~f_-1''''----
......= - - - -
patellar force as well as the contact area on the
retropatellar surface varies with knee Oexion angle
(Ahmed, Burke, & l-hder, 1987; Hubeni & Haves, 2,5
Swing
1984), Loads between two and three body weights
have been reponed at the putcllofcmoral joint for
, various activities of daily living. It was shown that
for walking, the loads arc relatively' low but because (Top) The moment tending to flex the knee during stair
the knee flexes beyond approximately 40" during ac- climbing demonstrated differences in stair climbing func-
tivities such as stair climbing, the loads can reach tion between the patients with nonanatomical femoral
trochlea and anatomical femoral trochlea designs.
levels of several body \veights. The high magnitude
Reprinted with permission from Andriacchi, T.P., Yoder. D.,
of these forces poses a great risk lO the mechanical
Conley, A., er 8/. (997). Parel/ofemaral design influences func-
integl"ity of the implant as well as the implant's fixa- tion following coral knee iJrihroplasty. j Anhroplasty. 12(3),
tion to bonc. 243-249. (Bottom) Patients with the nonanatomical
The external knee nexion moment as measured femoral trochlea had increased knee flexion in late stance
with gait anal~'sis is reflective of net quadriceps phase (shown by It). The increased knee flexion was bal-
muscle activity. Alterations in the external llexion anced by an increase in the flexion moment (balanced by
momenl during stair climbing have been related to net quadriceps contraction) during late stance phase.
both the curvature of the patellar nange (Anclriac- Reprinted with permission from AndriacclJi, T.P. & Hurvvitz, D.E.
chi & Hunvitz, 1997) and the height of the patella (1997). Gail biomechanics and total knee arrhroplasly. Am J
(Mat,tel et aI., 1990), Two groups of patients with Knee Surg. 10(4), 255-260.
• ~ •.. <
Interaction Between Tibiofemoral Joint Line Position
Joint Line Height and
Patellotemoral Mechanics
In some instances, the joint line is elevated following
total knee replacement, \vhich results in an inferior
movement of the position of the rctropatellar con~
tact on the femur: Elevated joint lines, which affect
patella function and patella subluxation, have been
correlated with wear patterns (vVasielcwski et al.,
I994), decreased longevity of the patellar component
(Rosenberg et aI., 1988), decreased clinical outcome
(Junnosuke et aI., 1993), and decreased range of mo-
tion (Rittel~ Faris, & Keating, 1988). The height of
the patella with respect to the joint line has been as-
sociated with signilkant changes in the flexion mo-
ment of the knee during stair climbing (Fig. 16-11).
vVhen the patellar position was changed IS mm in- Slair Climbing Knee Flexion Moment
ferior to its normal position, more than 50% reduc- and
Joint Line Change
tion in the flexion mornent during stair climbing was
. ..
noted (Martell et aI., 1990).
• • A
/' .
•/ ' ""-""":......-----
t-- - - . •
·A L-' •
can result in edge loading and high stresses if the im~ Stair Climbing in Patients Following Total Knee Replacement
plant is tilted. Observation Interpretation
Removal of the posterior cruciate ligament neces~
sitates that posterior stability no\v results from in~
I. 10.0
creased tibial-femoral constraint. In the absence of a PCl retained
posterior cruciate ligament, the posteriorly directed ~
shear force is instead sustained by the interfaces of ~ 4.0
the articulating surfaces (Andriacchi & Galante, C
Normal roll
1988). Although more constrained designs are inher- §'" 0.0 back increases
ently more stable, they may limit the passive range ;:;; quadriceps lever-
of motion by restricting the amount of rollback Stance arm (/) with flexion
needed lo achieve deep knee flexion (Fig. 16-12).
Substituting designs are also more constraining with PCl
removed
a cam mechanism used to maintain the posterior po-
sition of the femur relative to the tibia. PCl/
retained
Variations in the knee kinematics and moments
during stair climbing suggest that posterior cruci-
ate~retaining patients have more normal function
¢~~~ PCl removed roll
back constrained
\vhile ascending stairs than do patients with knees and leverarm (t)
reduced
in \vhich the posterior cruciate ligament is removed
(001'1' et 'II., 1988; Kelman el 'II., 1989). Patients with Patients with PCl
cruciate~sacrificing knee replacements had a ten- removed tend to lean
forward reducing the
dency to reduce the moment sustained by the net quadriceps moment
quadriceps by leaning 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 Patients with designs that remove or substitute for the
posterior cruciate ligament tend to reduce the knee flex-
finding was also consistent with a study in which
ion moment and thus the resulting demand on the quadri-
electro111yographic activity' was measured during
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
15,----------------, normal posterior 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-
"~iUS
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, ralio extension
~
The functional differences between the postel'ior
cn-'Ciate ligament-retaining and sacrificing designs
were associated with the normal posterior movemenl
of the femur on the tibia (rollback) with flexion, This
finding has been explained by the dynamic interac-
tion belween the posterior crudate ligament and
tibiofemoral rollback with flexion. The lever arm of
the quadriceps (Andriacchi, Stanwyck, & Galante,
1986) normally increases with knee nexion. The func-
tional adaptations seen among patients with cruci-
ate-sacrificing designs were likely associated with the
need to compensate for the lack of normal femoral
rollback in knees in which the cruciale ligament is re-
moved, Thus, rollback must occur in the early phases
of flexion to have an appropriate quadriceps lever The radius of the femoral component varies with knee
arm to sustain normal stair climbing. flexion angle. Thus, in the sagittal plane it is not possible
to achieve optimal conformity in both flexion and exten-
Conformity sion. Reprinted with permission from Andriacchi, T.P. &
Nararajan, R.N. (/993). Conformity allcl polyethylene damage
The degree of conformity between the femoral in lolal knee replacement (lnrerndJ Communication
component and the tibial component depends on 97-5110-206 3MZ). Zimmer, Inc.
the ratio or the radii of the two components. As the
•
CHAPTER 16' BIOMECHANICS ~F A~l~Wqf~~tt ::~~O
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 general, proper soft tissue balance is necessary for in the polyethylene serve as sites for crack initiation
a satisfactory outcome. In the presence of con;plex and propagation (Fig. 16-16). Increasing the poly-
bony defOl-mities such as a severe valgus deformitv ethylene thickness to at least 8to 10 mm will reduce
sati~factOl)' stability is often unobtain:,ble and co~~ contact stresses and should decrease the amount of
straint must be provided by the implant design. His- wear (Collier et aI., 1991). Metal backin2 was ini-
torically, a hinged prosthesis, which provides maxi- tially introduced to more evenIv distribut-;; the load
mum constraint. was advocated for those patients to the underlying cancellous b~ne of the proximal
with severe valgus deformities. Hinged prostheses, libia. Howcvc,', overall component thickness needed
however, have been associated with a poor clinical to be increased following the introduction of metal
outcome (Bargar, Cracchiolo, & Amstutz, 1980; Bui backing so that an adequate polyethylene thickness
& Fitzgerald, 1980; Rand, Chao, & Stauffer, 1987). A was maintained. The multivariate nature of the
more contemporary alternative to the hinged pros- causes of pol:vethylene damage makes it difficult to
thesis is a highly constrained but unlinked total knee draw definitive conclusions on failure mechanisms
replacement (constrained condylar knee). This de- from retrieval studies. Moreovec the diverse nature
sign eliminates the need for lio"ament balancin.
a bv of the contact stress distribution (compressive, ten-
0 0
providing medial lateral stability throuah a rectan- sile. and shear) may result in differenl damage
gular polyethylene tibial post.- This "highly con- modes. Deformation, pitting, cracking. and abra-
strained design has provided adequate outcome for sion are all examples of polyethylene damage
elderly low-demand patients with severe valgus de- modes.
formities (Bullek, Scuderi, & Insall, 1996).
Anterior Cruciate Ligament
, -
Polyethylene
During total knee replacement, the anterior crudale
Polyethylene damage has been closely related to its ligament is either already absent ~r usually re-
thickness (Collier et aI., 1991; Wright & Bartel, moved. In the case when only oTie compartment of
1986), the material properties, the presence of third- the knee requires replacement (unicompartmental
.,
knee arthroplasty), both cruciate ligaments are fre- :\Ildriacchi, TP. (1993). FUllclion;t! all;t1.\'sis or prL'- ;\Ild POst-
quentl.\' retained. Gait studies of total knee replace- knee surgL'lS: TOI;t! kllL'L' ,lrthropl,lStv ,tlld :\CL I'econstruc_
lion. J Diollll'c!IIiJlic." Lug, 115,575-5:)1.
ment patients (Andriacchi, Galante, & FermieI~
:\ndri:tcchi, T.P, 6.' C;\l'lnte. J.O. (19t:t:J. Relcnliull (ll' IhL' DOS-
1982; Chao, Laughman, & StauffeI~ 1980; Kelman et tl'rior nlll.:i;ill' lig,lIl1enl in tul;1I knee arthropl;\SI~'. J
aI., 1989; Simon et aI., 1983) show that normal func- Arthroplasty, SI3-,19.
tion is not achieved in the majorit y' of the patients .-\ndri'lcchi. TP.. Gabnll', J.O., Iklvlschko, TIL l't ,d. (1976).
despite improvements in stride lengths and knee ,.\ stress an;dysis 01' rl'[llOI';t! stelTI in lotal hip prustheses. J
HOlle Joilll "ill I)!" 58:\(Sl,61,s",62·1.
motion and clinical status. Numerous subsequent
Andrial'clli, TP., G;danlc. J.O .. 6.' FLTlllil'l', R.\V. (1982). The
studies demonstrated differences in the flexion- inl'hlL'ncl' or loul! knee rL'pl;tCeIllL'lll design on walking and
extension moment during level \valking. These vari- sl;\ir-clilllhing. .I !lout' .loiul Sill)!" 6-1:1, 132S.
ations in the flexion-extension moments at the knee Alldri;\cchi. TP. & Hurwit/, D,E. (1'107J. G;lil hiomeckmics
could not be related to an}' specific design but in- ;llld tillal knee arthruplasl,v. ·1!11 j I\I/(l' Sill',:!" 10(4),
255-260.
stead suggested the possibility that loss of joint pro-
.'\ndriacchi. T.P. & N:\laraj~ln, R.\:. (1993). Conl'ormil\' ~ll1d
prioception or the functionalit y of the anterior crll-
l
polyelh,\'lt:!lL' d;lIn;l):!l' in lutal knee replacelllelll (Internal
ciate ligament may have been a factor (\J\'einstein, Communication 97··S110-206 3\lZ). ZillllllL'l'. Inc.
Anclriacchi, & Galante, 1986). The removal of the :\ndriacchi, TP.. Stal1\\',vck, T.S., & Galanle. J.D. (1%6). Kne~:
anterior cruciate ligament was common to all total biolllech;lllics and tOlal knee repl;lct:JllL'llt. :Irlhro/dusty,
/(3),211-219.
knee replacement designs and may be one of the
:\ndriacclli, T.P" l·odl'r. D.. Conle\'. .'\ .. L't ~i1. (1997).
factors that limit a patient's recover)' of total normal Patelln!'ell1or;1! d('sign influL'nces funclion I'ollowing total
function. Similar patterns of abnormal flexion- knee 'lJ'lhroplaSI,\'. .I :lohruplosty. 12(3). 2..L ',·2-l9.
extension moments (Berchuck et aI., 1990) have Barg;II', \V.L., Cracchiolo . .'\., L\.: :\mstllll. H.e. I: 19801. Rt:sults
been reported in patients foll()\ving injury to the an- \\'ith constr~tlned IOlal knee proslhl'sis in lreating se\'L'l'('!Y
dis:thkd p,lliL'nb ;\Jld p:ltil'lItS \\illl 1',\iIL'd tot,li kIll:":' 1\>
terior cruciate ligament.
pl,tce!1lent, J BOJlt, Joint Surg. 62:\. 50..\-"512.
Ibrgren . .I.H" Blah;!. .l.D., & Fret:rn;lIl. \1.:\,R. (1983). .'\li~!Il
lTlL'nt in IOl,1I klll'e i\rthropl:lst.\', COlTL,I;ill'd ,tnd clinical ob-
Summar)! S(·l'\'iltions. Clin On!zO!I, /73. 17S,
lkrchuck, \1.. :\ndriacchi, TP., Bach, B.R. Jr.. el ;d. (1990).
Gait ;ld;tptalions hv p;\li(:nls \\'110 ha\'<.-' :1 deficienl :\CI.,.I
t The effect of forces on the stability of a total
BOlle Joini Sur,!.:. 72:1. 871-877.
joint replacement depends not only on its magni- Ikrgmann, G., Graichen. F., L\: Rohlmann, .'\. (1093J. !-lip joinl
tude but also on its orientation and point of appli- k':lding during \\',lIking ;lnd running measurwl in t\\'o pa-
cation. lil'nls. J BirJlncc!wuics, 26(8), 960 . ·990.
Ikrgnwnn, G.. Gr;lichell, F., & Rohlmann. A. (199S). Is slair-
Magnitude, orientation, and point of applica- case walking a risk ror the fi\;\lion or hip irnpl;lI11s?.1 Bin-
tion of the loads at joints influence the stresses, lI/c·c!liIuic.,-, 28(31. 335-333.
bending ITIOments, and rotational moments of the Berzins. :\., Sumner. D.R .. & Andriacchi. TP. (19931. Stem
implant, and are critical for the implant stability Clll'VatUl'l' and load angle influence thl' initial rel<:\li\e
ho!w·implallt ll10tiun of l'ernentk'ss kmoral slerns. J Or-
and longevity.
Ihop Nt's, 11(5). 758-·769.
3 Understanding the d.ynamic loads during daily' Bl'I'I,ins. A" Sumner, D.R .. i\ndriacchi, TP., L't a!. (10931. Stl.'1ll
activities provides critical information for address- Clll'\'alure ,\nd load an~le illfluellct the inili:d rel;1Ii\'e bonc
implanl motion of celllent1l'ss remoral SkillS. J Or/hop Nn'.
ing clinical problems such as ITIechanicalloosening
11(5!. 758-760.
of implants, amount of weac bone resorption, and Bo\, G. & Noble, P.e. (1993). TI1I,,' posilion of the joint Cl'l1lcr
the choice of rehabilitation and surgical protocols. and thl' l'ullclion;1! outcomc 01' tolal hip rl'placCIllClll. ONS
Trans. IS, 323.
4 The evolution of total joint replacement has
Br;lnd, R.A. &: CnJ\\'ninshicld, R.D. (1980). The ellcl't or C;tllC
been aided by information generated from biome- use 011 hip conlacl forcL'. CONI?, 1-17. 181 184.
chanical studies. Brand, R.:\., Pedersen. n.R .. & Fricdl'l"ich, .l.A. (1%6), Thl,,'
sensith'it.\, or lIluscle forcL' predictions to changes in ph.\·s-
iolngic cross-sectional area. J Hiolllec!lIIl1ic.,', IY(Sl,
S80-·396.
Brugioni. DJ .. :\ndriacchi. T.P.. &: GaLlIllc, .1.0. (1990). A
REFERENCES
funclioll,1! and r:Hliograpllic an;dysis of the toud condylar
Ahmed, A.M., Burke, D.L., & Hvc!l-r, A. (1987). Force analvsis kncc ;lrlhroplasty. .1 Arthroplasty. 5(2).173-1 SO.
of the patd!;:tr mechanism. j Orr/lOp Uus, 5, 69. . Bryan. J. 1\-'1. , Su111 IlL'r, n.R" Hurwitz, D.E., L'l al. (1996), A pos-
Amstutz, 1-I.C., Campbell. P., Kossovsky, N., Cl a1. (1992). sible confounding effccl or ;I!IL'rcd lo:\d histor.\' on thc :IS·
i\lechanism and clinical significance of wear dcbris- sesslllcnl or pcriprOSlhL'lic bOlle loss lell ,vcars I'ollowing
induced osteolysis. CORR. 276, 7-18. succcssl'ul CL'IllCllllcss tOlal hip arthropl:lsly: Assesslllcllt
CHAPTER 16 • BIClMECI-IANIC:S
by dual energy x-ray absorptiomelry and gait anal~'sis. J English, T.A. & Kih'ington, M. (1979). In vivo records of hin
OrtllOfJ Ncs, 14(5), 762-768. loads using a femoral implant with telemetric output (a
Bryan, J.\'1., Tompkins, G., Sumner, D.R., t:l al. (1994). Quan- preliminary report). J BiOll/t,d ElIg, 1(2),111-15.
tifying proximal femoral bone loss following cement!t:ss Foucht'r, K.C., Hurwitz, D.E., Andriacchi, T.P., et al. (1997).
lOtal hip arthropbsty using dual energy x-ray absorptiom- Reductions ill hip contact forces due to gait adapLations in
eLry. 7i"(//IS ORS, 19, 580. preoperative total hip replacement patients persist t'ven if
Bullek, D.D., Scuderi, G.R., & Ins;:dl J.N. (I996). The con- antagonistic muscle activity is incrt'ased. 21s! AII/Hlal
strained corldylar knee prosthesis: An alternative for the .lfeetillg or Alllerican Society ;J{ BiolllL'c1ulllics, 192-193.
valgus knee in the elderly. In J.N. [nsall. N.\V. Scott, & Galante, J.O., Rostoket", \V., & Doyle, J.M. (1975J. Failed
G.R. Scuderi (Eds.), Currcllt COllcCpts i1l Prill/ary (///(1 Rcvi- femoral stem in total hip prostht'ses. A report of six C'lses.
sion ](Jtal Knl.'/.' Arrhrop{(/sly (pp. 85~89). Philadelphia: J 130111.' Joi/lt SlIrg, 57A(2J, 230-236.
Lippincott-Raven Press, Ltd. Goethgen, C.B., Sumner, D.R., Platz, C, et al. (1991). Changes
Chao, E.Y., Laughman, ILK., & Stauffer, R.N. (1980). Biollle- in tibial bone mass after primary cementless and revision
chanical gait evaluation of pre- and p()stope['~lti\'e tot~ll knee ccmciltlcss tOlal hlp <lrthl'Oplasty in canif1t' models. ) 01'-
replacement patients. Arch OrtllOfJ Iimllllil SlIrg, 97, 309. t!/Op Res, 9, 820-827.
Cheal, EJ., Spector, \1., & Hayes, W.C. (1992). Role of loads Gort', D.R., Murray, M.P., Gardner, G.:\1., et al. (19ii).
and prosthesis material properties on the mechanics of the Roentgenognlphic measureillents aftt'r Muller total hip re-
proximal femur after total hip arthroplasty. ./ Orthop Res, placement. J Bone Joint SliJ"g, 59.4(7), 948-953.
10(4),5-22. Harrington, I.J. (1983)' Static and dynamic loading pattt'rIls
Collier, J.P., i\layor, \'1.B., McNamara, J.L., et al. (1991). in knee joints with deformities. J B(me Joil/t SlIrg, 65:\,
Analysis of the failure of 122 polyeth~'lene inserts from Ull- 247-259.
cemenIed tibial knt't' components. Clill Onhop, 273, Harvey, LA., Barry, K., Kirby, S.P., et al. (1993). Factors af-
232~242. fecting the range of movement of towl knee arthroplasty. J
Collis, D.K. & Oregon, E.. (1977). Femoral sLem failure in to- BOIIi~ Joil/t SlIrg, 7513(6),950-955.
tal hip replacelllenl../ BOlle Joillt SlIr.~, 59,\(8), 1033~1041. Hirsch, H.S., Lotke, P.A., & ivlorrison, L.D. (1994), The poste-
Crowninshield, R.D. & Brand, R.A. (1981). A physiologically rior cruciate ligament in total knee surgery: Save, sacri-
based criterion of muscle force prediction in locomotion. fice, or substitute? CORR, 309, 64-68.
J Bioll/ec1U1l1ics, J.J( II), 793-80 I. Hodge, W.A., Andriacchi, T.P., & Galante, J.O. (1991). A rela-
Cro\\'ninshit'ld, R.D., Johnston, R.C, Andre\\', J.G., et al. tionship between stern orien[;:\tion and function following
(1978), A biomt'chanical im"Cstigation of the human hip. J total hip arthroplasty. J Arthroplasty, 6(3). 229-235.
Bioll/cchallics, I I, 75-85. Hsieh, 1-1. & Walker, P.S. (1972). Stabilizing mechanisllls of
Davy, D.T., Kotzar, G.!\-!., Brown, R.H., et al. (1988). Telemet- the loaded and unloaded knee joint. J BOlle Joi/lt S/lrg,
ric force measHrt'menLs across the hip after total hip 58A, 87-93.
arthroplasty. J BOIIC Joill! SlII"g" 70A( I), 45-50. Huberti. ILH. & Hayes, \V.c. (1984). Patellofemoral contact
Dell', S.L, Komattu, A.V., & \Vixson, R.L (1994). Superior pressures. J BOlle Joillt SlIrg, 6611, 715-724.
displacemenL of the hip in total joint replacemenL: Effects I-lui, F.C & Fitzgerald, R.H. (1980). Hinged total knee arllll'o-
of proslhetic neck length, neck-stem angle, and antever- plasty. J Heme Joint SlIrg, 62A, 513-519.
sion angle on the moment-gellt'rating capacity of the mus- Hurwitz, D.E. & Andriacchi, T.P. (1997). Biomechanics of tht'
cles. J Orthop Res, I 2, 860~869. hip. In J. Callaghan, A. Rosenberg, & H. Rubash (Eds.).
Delp, S.L & i\.laloney, W. (1993). Efft'cts of hip center loca- The Adlilt Hip (pp. 75-89). New York: Raven Press, Ltd.
tion on the moment-generating capacity of the muscles . ./ Hurwitz, D.E., Chertack, CC., &: Andriacchi, T.P. (1992). How
Bioll/cchallics, 26(4,5l. 485-499. gait changes in preoperative and postoperative patients
Doehring, T.e., Rubash, I-I.E., Shelly, F.J., et ;:11. (1996). The with total hip replacements. Proceedillgs or NACOB 1/, The
effect of superior and superolater,d relocations of the hip Secol/(! North Americall COligress 01/ Bio/llechallics,
center on hip joint forces: An experimental and analytical 313-314.
analysis. J Arthroplasty, Sepl 11(6), 693-703. Hurwitz, D.E., Foucher, K.C, Stunner, D.R., t't al. (1998). Hip
DOlT, L.D., Ochsner, J.1.., Gronley, J., et al. (1988). Functional motion and moments during gait relate directly to proxi-
comparison of posterior cruciate·retained versus cruciate- mal femur bone mineral density in patients with hip os-
sacrificed total knee arthroplasty. Clill Or/hop, 236, 36. teoarthritis. J BioIllCC!Ulllics, 3 I( 10), 919-925.
Ducheyne, P., Kagan, A., & Lacey, J.A. (19i8). Failure of total Hurwitz, D.E., Guyton, J.A., Andriacchi, T.P., et a!. (1992).
knee arthroplasty due to loosening and deformation of the I-low can,d fill in uncemented total hip replacements af-
tibinl component. J 130111.' Joi/I! SlIrg, 60A, 384. fects the biomechanics of gait. 38th ..lIllI/wI ,Heetillg or the
Engh, CA. &: Bobyn, J.D. (1988). The influence of skill size OrillOpaedic Rcsearch Society, I 7( I), 281.
and extent of porous coating on femoral bone resorption Hurwitz, D.E., Stunner, D.R., Andri;:lCchi, T.P., et al. (1998).
after primary cernelltlcss hip arthroplasty. CORR, 231, Dynamic knee loads during gait predict proximal tibial
7~28. bont' distribution. J Biolllec!lallics, 31(5),423-30.
Engh, CA., McGovern, T.F., Bobyn, J.D., et al. (1992). A quan- Jast)", 7vI:, Bragon, C., Lee, K., et al. (1993). Wear of polycth-
titative evaluation of periprosLhetic bone remodeling after ~'lene in total joint <lrthroplasty. In B.f. Morrey (Ed.). Bio-
cementless total hip arthroplasty J BOlle Joint SlIrg, NA, logical ;\I(/teri(/l (/I/(! J/echallical COllsidi!J"(/tioIiS orJoil1! Re-
1009-1020. placeillellt (pp. 103-117). New York: Raven Press Ltd.
Engh, CA., O'Connor, D., Jasty, M., et al. (1992). Otl<lntifica- Jasty, M., O'Connor, D.O., Henshaw, R.M .. ~t al. (1994). Fit of
tion of implant micromotion, strain shielding and bone re· the uncemented femora! component and the use of cement
sorption with porous-coated anatomical medullary locking influence the strain Lransfer to the femol',d cortex. J Or-
femoral prosLheses. CORR, 285, 13-29. thop Res, 12, 648-656.
Johnston, R.C., Brand, R.A., &.: Crowninshield, R.D. (1979). illltllL'di~lIL' ri,\:llion wilh 1(t~Hling \'L'nical. fl'nlUr' horizon_
Reconstruction of the hip. J BOlli! Joillt Surg, 61..1(5), tal. j Bi<I!II('clu/IIics, 2-l( 1),37··48.
639-652. Pilli~lr. [(,M., Li.'i:. L\I ,& .\l~llliatop(l\dll:-', C. (1986). ObsL'rv<t_
Junnosukc, R., Saito. S., Yamamoto, K., ct .. L (1993). F~u.:tors lioll:> (In t!h: dfect of 1ll(J\·L·ml·nl Oil hl.lnl· ill~rfJ\\'lh into
influencing the po~toper.i.\Ii\'e r"Hlge of motion in IOI~d pnroll:-.slIrbcl·d i mrl"llH~. C/ill O,.t/IO/I. 208. 10$-113.
knee arthroplasty. Bull Hasp Joillt Di.'i, 53(3).35-·W. R~1I1:I\\'a!, C.S.. Fl,vl1n, \\".F.. S:llldlt,r. 5., \,:1 :I!. (1~93l. Long_
Kngan, ,\. (1977). ~..kch'lnical C<lllS~S of loosening in k!lei,.· ll.'rm fesult:- fJf !Ill' tot:t! cOlld~'I:lr Klll'l' <Irlhrnpl:lst~·. (,liJl
joint rcp1:"lcements. J Biol1lecJulIIics, 10, 387. OrihlJp. 286. 9.J-1 02.
Kelman. G.J., Biden, E.N .. &. ()hil. et al. (1989). Gait labora- Rand, J.A .. Chao. E.\'.S .. ,,\; St:lUffl.'r. R.W, (19$7). t\illl..'lll:11ic
tory analysis of a poslerior cruciate-sparing total knee rowtillg hillg<.: knl't.' ~lI·lhroplasty . .I !iOIl(' .Iuilll S/lI"g 69.-\,
arthroplasty in stair ascent and descent. Cfill Orrhop, 248, ~Sl)-497.
21. Riltl,.·r. M,A., F;u·is. P.\\.. & KL·.i.\lin~. E..\\. (198$). P()~ll'rior
Kotz,lr, G.~·L, D;:l\'Y. D:r., Goldbcrg, V.;\,l., tl nl. (1991). (TIH:i;11e lig:1l1lclll b:dantill~ durin!,: Itllal krli.:l,.· ..\nhro-
Trlcmch:rizcd in vivo hip joint fon:c data. ;\ rcp0rl on 1\\'0 pl~ISt~·_ 1 ..lrlllf(lp!llsty. 3. 313.
paticnts .Iftcr wt"l hip surgery. J OrtJlOp 1?l.'.,', 9, 621-633. R(,raht.'ck. C.II .. Bournl·. R.B .. Ll,.·\\"i:-. P,L.. d :11. (19<;3). The
Krnchow. K.A. (1993). Surgical principles in total knee .\lilkrfGalarlLl,.· klll'l' proslhl,.'si:- for I ilL' trl':\IIllL'1l1 of os-
i1rthroplasty: Alignmenl, deformity, appro:lches nnd bOlle Il'o:lrlhrosis: ..\ comparisoll of Ihl.: rL'slIhs of pal'li"ll fixa-
elliS. In J.J. Callag"ln, D.A. Dennis. \V.G. Paprosky. & A.G. tion with cellH:nt ..Inti fix:llinll without any Ct.·IlH:lll. 1 Bone
Rosenberg (Eds.), 0I'111o/){/rdic KI/CJIl'led!,;e Update Hip (Iml jO;IIT Sur;.:, 75. 402.
Kllee R(:(,.·OIlSIJ"llClioll (PP. 269-276). RoseffiOll1. IL: AAOS. Ror;'d~L·d. C.H., DOlT.I.D .. Hofnwnn, "\.:\ .. t.'l a!' (1995). Con·
Landy, :\'1.:\'1. &: Walker, P.S. (1988). Wear of u!tl';:\-high-molec· tnl\'l.:rsial issu('s in kn('L' ;ll"lhropl:lst~·. Onhofl CI'(,I$,"1I0"
uhlr weighl polycthyknc components of 90 rctficved knee /8(9). 905-91~.
prosthl,.·scs. 1 Arthroplasty (SlIpplJ. 73-85. Rosl,.·nhl·rg. A.G .. Andri.u:chi. T.P.. B"In.kn. R.. d .. d. (1988).
Li. E.. Rincr. :\1., :\Ioilancil. T.. 1.'1 .d. (1993). Point-cOllnlcr- P;ltdbr component bihlrL' in l"ellll,.·ntl ....ss lot:d kne....
point \Otnl km.'e arthroplasty. 1 Arthroplasty, 10(4), anhr{lpla~IY. Clill Onlt0fJ. 230. 106.
560-570. Rytldl. \:.\\'. (19(\61. F(ln:L'~ :Kling (In the fL'\llVr:1! h.. . ad-
Long, \V.T.. DOlT. L.D .. Healy. B.. l..'l ,,!. (1993). Functional rl,.·- prosthesis::\ Sltltl~· CHI ~Il':lin g;lUg.e supplkd prostht.·st.·s in
covcry of nonccmented total hip llnhroplast~'. CORR, 288. li\·ing. pnsons. An(/ Orrhol' SCi/1Il1 (SIrf'f,[J. S~. 37,
73-77. Schipplein. 0.0, ~ Andri:li.'I.·hi. T. (1991), Irlln:lcllOJl bClWl'Cn
~'lahoney, 0.:\>1., Noblt::, P.c., Rhoads, D.O., l..'l al. (1994). Pos- activl' ~lIHI p:lssi\'c kncl' SI:lhiliJ,er:-i during !L-\'l' I walking. J
terior crllci<lte function following lotal knee ~\rthroplasty. Ort/lOp Res, 9. 113-119.
A bionll.'chanicai study. J Arthroplasty. 9(6). 569-378. Sci reg. A. L'\: Ap,·ibr. R.J. (1973). Thl' pr,.-diction of Illuscular
Maloney, \V.1. &. Schunn<ln, OJ. (1992). The effecls or im- lo:uJ sharing ~Ind joint fol'!':l,.·s in the 10\\'l'r l,.-'xtl"l,.·lllilies dur-
planl design on range of nHHion after total knee anhro- ing: walking. J Bioll/f.:dlCllliL~. 8. $9-102.
plasty. Total condylar versus posterior stabilized tOlal Simon. S.R., Trit.'shmallll, H.W.. Bunit'll. R.G .. l·I.:"I1. (198.3).
condylar designs. CORR, 278. 147-132. QU:ll1titati\'e g:..lil allalysis ariel' 10lal klll..·..· i.lrthropb~t~- for
Maloney, \V.J" SychlCrz. C., Bragdon, C. et al. (1996). Th" fllOl\anicular dl'gl,.'lli.'rati\·e arthritis . .I H(lI/~' loilft SlIrg. 65.
Olto Aufn\l1c Award. Skeletal rcsponsl.' 10 well fixed 605.
fel1lornl components inserted with and without cement. Stallfrl,.'r, R.N .. Smidt. G.L. \Vatl:-iwonh ..1.13. (1974). Clinical
C!ill Orr/lOp, Dec(333). 15-26. 'l1H.I bioJl1l,.·c!wnical an'd.\'sb of g;\il I'ollowing Clwrnle.\· 10-
Manell. J.M .• Andriacchi. T.P., Rosenberg. A.G .. et nl. (1990). tal hip ri..'p!;U;l,.·Illl,.'1l1. CaRR. 99, 70-ii.
The rdationship b~t\\'een changes in pa!dl<lr heighl and St<'Tn. 5.1-1. &. Ins.a11, J.H. (1992). Postl..'rior :-Iahilizl,.·d proslh('-
function following total knee repl<lccment. Transcript of sis n.-sults "ft,-r follow·up of nine to l\\·t.·!n' .\"l,.·;II'S. 1 BOIU
the 36rh AIlI1IUlI Mecril/!;, of the OrtJIO!Jlwdic Rt'search Soci- 1oill/ SlIr!::, 7.,l:1. %0.
ely, 15(1).169. Swany. .\1.R. & 5";011. R.D. (1993). Posll..'rjor poIYl,.·thylcne
Morrison. J.B. (l9iO). The mechanics of the knee joint in rc- \\,('ar in postnior cruci:lll..' lig;lllk'nt rl'laining !Owl knee
lation to nOfmal walking. 1 Biolllt·dlilllics, 3. 51-61. an hrop1ast~'. J .. Inhrop!flsly. 8, ·B9~.J.J6.
Murray, i\'I.P.. Brewer, 8.1., &: Zuege. R.C. (1972). Kinesiologic Taylor, 5.1., Walkl.:r, P.S., LlIlnon, P.L 1.'1 a!' (1997), The
measurements of functional performance before and after ror<:l.:s in the dislal 1'l,.'Ill11r 'Illd knee during diffel\.'111 activ-
McKec-Farrnr total hip rcpbcemelll. 1 BOlle 10ill1 Sllr~, itil,.·s llll':!sur"d by klemetr,\·' Tmllsl/clioJlS or
lilt' ·UI"(I AI/-
54;\(2). 23i-256. lIt/al OUS .\lc?l'til1::'. 259.
Noble. P.C. (1995). The design of cCfllcnlless femoral proslh~ Walker, 1).5. & Blunn, G.\\'. (1997). Ke.\"IIOIC Lel,."hu·L' II: !\-\od-
scs. In J.J. Gallaghan, D.:\. Dennis, & A.G. Rosrnb(,'rg l'rll elL'sign of total kn('L' rt.'pl~ICl.:nll:lI!. In S. Niw::l, X.
(Eds.). Ol'1hopaedic Kllo\l'led~t! U,ulate: flip ((1Il1 Kllee Re:- Yoshino. ~l. KUfOS;lb. K. Shino. S. Y;lln:l/11oto (l~ds.). Rc-
cOllstructioll (pp. 12i-138). Rosemont. IL: AAOS. (,.·OllSffllctiOJ/ or lite KlIt't' .1oil1t (pp. 129-1.J2). Tokyo:
Noble, P.c., Helmke, H.W., & Paul, J.P. (1993). Femoral posi- Spri Il!!l'r- Vt.'rl:l!.!.
tion crilic;:t1ly affects the intl.'l'pretation of intra-vital hip \\"aside\\~ski, R.C.~ Galante, J.O .. Lcii,dlly, R.\I., cl al. (1994).
force dnta. TrailS ORS. 18(2),443. \\'(::11' patll'rns on rt.'trie\·"d pnlyclh.vkllC tibial ill.~CnS and
Paul. J.P. (1976). Approaches to design: Force ':Ictions Irans- lheir relationship 10 Icchnical col1sidt.'l"~lIiOllS during lCJI ..d
mitted by join Is in thc human body. Proc I?es Soc LOlldol1. knt.'l,.' anhropl'lsty. CORR. 299. 31-43.
192, 163-72. Wcin:\I1s. 1-1., I-Iuiskes. R.. .$: Groo!cnboer. H.J. (1992). Effects
Phillips, T.W" Nguyen. L.T.. & Mull1'o, S.D. (\991). Loosening of mate!"ial prol1L'l"lies of femoral hip cornpOlll'nlS on bone
of cemen(\css femoral stems: A biomcchanical nnalysis of rClllodeling. J Or/hop Rt's. 10. 8-15-53.
CHAPTER 16' BIOMECHMJICS
\V~instdn. J.N ..Andriacchi, T.P.. &. Galante. J.O. (1986). Fac- Wilson. S.A .. McCann. P.D .. Gollin. R.S .. et a1. (1996). COI11-
tors influencing walking and stairclirnbing following uni- prcherlsi\"(.' gait analysis in posterior-stabilized kne~
compartmental knee arthroplasty. J Arthropilisty. 1(2), anhroplasty. J ..\rthroplasty. 11{41.359-367.
109~115. Wimmer. ;\1.A. &.: Andriacchi. T.P. (1997), Tracth'e forces dur-
\Vhite, S.C., Yack, 1-1.1 .. &. Lesswing, A.L. (1992). Pre- and post ing rolling motion of the knt.'e: Implications for wear in to-
surgical gait of a total hip replacement p<:llielli. hilliS 71h tal knee replacement..1 Biol/lcclulllics. 30(21.131~37.
iI/lllual East Coast Gail ('olll('I"('II('c 1992; Session 11, Rich- \Vright, T.i\'1. &. Banel. D.L. (1986). The problem of surface
moml Virginia. damage in polycthylL'ne total knee components. Clill Or-
\Villert. H. &. Buchhorn. G.H. (1993). Particle disease due to {hop, 205, 67-74.
wear of ultrahigh molecular weight polyethylene. Findings )'oder, S.A., Brand, R.A .. Pedersen, D.R., et a!. (1988). Total
from retrieval studies. Wear of polyethylene in total joint hip acetabular component position affects component
arthroplasty. In B.F. ivlorrey (Ed), Biological ,lIa/erial alld loosening rates. CORR, 228, 79-87.
,1Ice/wl/ical 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_
D_ O_ Y ure 17-4, the angle is 40°. Recom~1ended angles a~
Ix 10 to 14", which translates to heel heights of 3 to 4
IX cm maximum.
Fg
In Figure 17-511, a chock is placed under a plaster
cast around the lower leg and foot. This position of
y the chock causes discomfort because it is placed in
front of the ankle joint and causes a counterclock-
F, wise moment, M = FI,.a. The foot and cast can be re~
garded as a single entity, so equilibrium is obtained
A B C 0 with a clock\vise moment from 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.
A, The resultant force between ground and feet {FJ equals
17-5). The heel of a shoe produces a lever arm with
body weight (F y ). B. Fv position (center of pressure path,
respect to the ankle joint (Fig. 17-5(') that is consid-
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 Fs
/
and y directions.
I
I
I •
condition of neuromuscular control. Consumption
of alcohol or certain 11lcelicines causes greater
swaying. Marksrnen, conversely, stand significantly
more stable. Most force plates have a rectangular
design with four force transducers uncleI' the cor- A B
ners. Such construction, however, has the disad-
vantage of static overdetermination. Because stand- 0.24 II
ing is not a pure static equilibrium as a result of I
accelerations and decelerations of body mass dur- I
F, I
ing swaying, the COP does not represent the exact I
position of the mass center of gravity' of the body. + •
Recordings show that the COP is always located in
front of the ankle axis at the site of the as navicu-
lads. Therefore, in standing, calf muscles are al- 0.42 (
ways active (Fig. 17-3, A & B). Figure 17-3, C & D 0.18 I 0.72 I Fill
presents the location of forces in relation to foot
geometry taken from different literature sources
(Snijders, 199\). 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 A, The foot-ground reaction force {F...} is always in front of
the ball of the foot, the sale must be thin to give the ankle axis (black circle). B, Therefore, the calf muscles
goodllexibility. It is beller to look at the inclination {FJ have to be constantly active. C, Mean values of lever
of the foot, not at the height of the heel, because the arms for calf muscles and foot ground reaction forces in
inclination determines the degree to which a person relation to foot length (t). The data is derived from differ~
loads the forefoot. With an)' given heel height, the ent sources. D, Lever arms for resultant forces on the heel
inclination of the foot depends on the length of the (Fr.) and the forefoot (Fin) in relation to foot length (I).
foot. vVith a certain heel height, the angle of incli-
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, A
-
which can be reduced by! cutting off the back edge D
~
B
of the heel (Fig. 17-5D). The laller produces a more ...---....
~
horizontal movement of the ankle. This provision is
relevant for normal, sport, and orthopaedic shoes.
+
Excessive I110bility' or play is characteristic of an
unstable joint, as compared with that of the healthy
joint. In the following, instability refers to a Sllscep-
tibility to tilting or falling as a result of interFering
0) \
Calculation Box
Figure 17-1-1.
a
l·tQ optimal because the)' are perpendicular to the
~~
longitudinal orienlation of the spine. However,
the sacroiliac (51) joint surfaces are parallel to the
largest forces and are not protected against dislo-
cation bv the closed form of a ball and socket
//11111111 1111/11111 joint. Thus. the 51 joints arc vulnerable to shear-
ing because of their predominant flat surfaces.
which arc almost parallel to the plane of maximal
load (Fig. 17-9), In a biomechanical model. Sni-
.iders et al. (1993) made the assumptiollthat in <ld-
dition to strong ligament support, muscle forces
B are always required for compression of the SI
~
but a more comfortable position, thanks to suitable support
of the pelvis. The lever arm a is reduced by 30%. and the
arms and eyes are in a better position. (F" = center of gravity
upper body; a = lever arm center of rotation spine to F".)
• F
\ 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.
Scherr,atic drawing illustrating that the sacroiliac joint is
vulnerable to shear when loaded in the sagittal plane (mo-
BIOMECHANICS OF THE PELVIS
ment M/Force F). Integrity of the joint reli~s on ligament
With reference to Figure 17-8, the largest forces support; joint compression by muscle force can raise fric-
always act in the longitudinal direction of the tion and prevent shear.
spine. The position of the intervertebral discs is
\1
i:':'
%,
~".~
~
U'.~ .... ly,=~""·,z':liC,::c:::c_*i?"~;::se ,.
JOInts to raise friction, which resists shearing.
This so~called self-bracing is also expected in sit-
ting with reference to ligament creep by the load II J/II
of upper body weight. -1---5
IIIIII
FLAT VERSUS BALL AND SOCKET JOINT 2 ---I--\--\ ~IIIW 6
The different joints in the human body have a wide
variety of often highly irregular forms. By compar-
ing a ball and socket joint (or cylindrical joint) 3
with completely flat joint surfaces, some main
principles of load transfer can be identified. If a
transverse force is applied to the bones in Figure 4--+..,..,.~
17-1011, shearing must occur to produce stress in
ligaments, which stops the movement. The bones
are no longer in line. A ball and socket joint (Fig.
17-10B) is better protected against transverse
forces. \"'hen a flat joint is loaded with a bending
moment (Fig. 17-IOC), the joint reaction force can
shift to the edge of the joint surface and can pro-
duce with ligament or muscle force F{ a couple
with moment M = F f .2c \Vhen a ball and socket
joint is loaded with a moment (Fig. 17·10D), the Transversely oriented muscle forces that cross the sacroiliac
joint reaction force cannot shift to the edge of the (51) joints can press the sacrum in between the hip bones.
joint surface. Here, F" and F 1 form a couple with Such forces caudal to the SI joints may contribute to the
moment M = Fi.r. This shows that a flat joint can mechanism of the pelvic arch by opposing lateral move-
ment of the hip bones. (1) linea alba, (2) external oblique
transfer a "factor two" larger bending moment
abdominal, (3) transverse abdominal, (4) piriformis, (5) rec-
than a spherical or cylindrical joint at the hip
I tus abdominis, (6) internal oblique abdominal, (7) ilioin-
joints. In Figure 17-10, C d.! D, the joint reaction
force is perpendicular to the tangent to the joint 1.-_9_u_i_na_I_I_i9_a_m_e_n_t,_a_n_d_l_8_)S_I_iO_i_n_t. ~~~_~~_
surfaces at the bone contact point. This holds
when friction can be neglected. At the spherical hip
joint the problem of a lesser moment of force has
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
Case Study Figure 17-1·1.
body 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-
The back rest provides stability for the vertically il~' perform this test. The fUllcticl!l of a lumbar sup-
erected trunk, analogous to Figure 17-8B. HoweveI~ port is to exert a firm force on the upper side of the
in prolonged sitting, the prevention of a lumbar pelvis ..md the lumbar area to prevent tilting of the
kyphosis seems to be the most important function of spine into kyphosis. This support should not reach
the back rest. The significance of a lumbar support higher than the lower edge of the scapulae. The tho-
can be illustrated with the so-called click-clack phe- racic spine is still enough (ribs) and a higher lnlCk
nomenon (Fig. 17-13) (Snijders, 1970, On the form rest pushes the shoulder blades rorward, which
of the human thorneD-lumbar spine and some as- "overrules" the lumbar support and hinders the
pects of its mechanical behavioc Thesis, Eindhover). shoulders to stretch and to turn to the lert and the
This can be experienced when one sits upright on right. The absence of a back rest, like sitting on a
the edge of a straight chait: Slow forward translation crutch. alwa~'s leads to a C-form of the spine.
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
o
tuberosities. This leads to a simple representation of
The lumbopelvic click-clack phenomenon. Lumbar lordosis nearly' perpendicular to the surface. There is a re-
is the result of a mass center of gravity of the trunk at the duced force component in the shear direction.
ventral side of the ischial tuberosities (right). The mass cen- \Vhcn the back rest is tilted further) the seal angle
ter of gravity of the trunk dorsal to the ischial-tuberosities must follow because F becomes more inclined. [n
I
forces the lumbar spine into kyphosis (left). The latter can Figure 17-15. the relation between back rest angle
be prevented by the exertion of lumbar support on the and scat angle is given for the condit.ion that Fric-
upper side of the pelvis and the lumbar spine. tion is absent (Goossens & Sni.iclers, 1995). This re-
lation was found with a 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)
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, A. The mass center of gravity (represented by a circle and
and therefore inclines backward. The horizontal compo- gravitational force F~) is behind the atlanto-occipital joint
nent (F h ) must come from friction acting on skin and un- axis A-{F t represents the joint reaction force). With sup-
derlying tissues. (-0, By tilting the seat slightly backwards port of a head rest, no muscle forces are needed for equi-
((\), the resultant seat force (f l ) becomes nearly perpendic- librium of the head (F'J = Fl ). B, The head rest is posi-
ular to the seat surface and friction on the ischial tioned too far forward and is useless. Muscle force F,
tuberosities is significantly reduced. remains needed for equilibrium andF, increases.
support when the mass center 01" gravity of the Upright Position Anteflexion Position
head is 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.
~
served. Problems arise when such extreme pos-
tures are mainrained for long periods of time. In
the relaxed posture according to Figure 17-17;\ the
Fj
direction of vision with the head upright is given
(dOlled line). However, reading with the trunk up-
right requires a sharp bend in the cervical spine, ',.
which cannot be sustained for a long time. Fur-
thermore, in this position the reading distance is Transverse
larger than 25 to 35 CI11 (the height of the table view
must coincide with approximately the level of the
elbows). Consequcntly, children and adults always
bend fonvard with a curved spine over the table
(Fig. 17-178) and urgings to sit up straight are
useless. / ..
In the past, inclined desks wcre common. The
fixed angle was approximately 12 0 because at a Anteflexion of the head leads to a larger lever arm of the
higher angle, paper will slip downward on paper be- weight force (F'l) with respect to the atlanta-occipital joint
axis (A) than in the upright position. For equilibrium,
greater neck muscle forces (FJ are needed. Forward indi-
nation also raises tension in the ligamentum transversum
atlantis (F 1) to transmit the force from the dens (F el ), which
,,--
,: is directed transversely to the cervical spine. This force fol-
lows from the equilibrium of the atlas, with joint reaction
forces F1 and Fl·
,
:'i
Pain
(
Tissue
\ Muscular
2 3 4
breakdown spasm
\ Poor
blood supply
J tLl5 i' ,l::!
~ • I •
6
Smooth 7 Rough
8
•
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- 16 17 18 19
cle spasm. Some biomechanical problems in sitting
arc illustrated in Figure 17-20.
I. The absence of an arm rest loads the loose
shoulder girdle, which hangs from the spine
with ligaments and muscles.
2. Sitting without a back rest always leads to a ~
C-form of the spine. 20 21 22 23
3. A back rest must leave space for the but-
tocks. \ViLh a straight back rest staning
from the seat, no proper support can be
given to the upper side of the pelvis and the
lumbar spine. A support that is too high
does not provide force on the lumbar area
and a C-fonn of the spine is the result. 24
4. If the back rest is too high (as it is in some
folding chairs), it gives no support to the
lumbar area and the back bends in a C-form.
Examples of poor chair design leading to poor posture.
5. A vertical, straight, and high back rest also molded lO the individual anatomy should be
promotes lumbar kyphosis. restricted La the severely handicapped.
6. On a horizontal slippery scat, the botlom 21. A head rest lh<:tt is placed too far forward
slides forward and the body sags in the hinders upright sitting.
chair because the [detion force (Fh in Fig. 22. Tall people experience hindrance from a
17-14A) is absent. head rest thm pushes against the shoulder
7. On a rough horizontal seat, the friction (analogous to 5).
force (F" in Fig. 17-14B) causes discomforl; 23. \,y'hen reading and writing at a horizontal
people avoid back support and adopt a pos~ desk, adults and children always show
tureasinFig.17-17B. flexion of the thoracolumbar spine. This
8, When silting on a horizontal cushion like on forward bending is independenl of the
a lounge chair, the cushion is moved by the chair.
horizontal force component at the ischial 24. Neck and shoulder complaints arc reponed
tuberosities (reaction force of F h in Fig. with visual display units. \.Vhen it is not nec-
17-14B) and mOves inlo Ihe room. essary Lo look at the kevboard all the time.
9. Further lilting of Ihe back rest must be cou- the optimal height of the screen is approxi-
pled to the same increase of scat inclination. mately al eye level (Snijders el aI., 1991;
In ailvlancs, ho\\'evel~ seats remain almost Wall el aI., 1992).
horizontal.
10. Broad persons are jammed by lateral sup-
LEG-CROSSING
pons. In common cars, such pronounced
lateral supports arc useless because curves The majority of people cross their legs often when
are not taken with more than 30 111/S1 (0.3 g sitting, alternating left over right and righl over left
centripetal acceleration). A back rcst with a (Fig. 17-21). There may be many' reasons to do this,
uniform moderate curvature flts everybody bUl in the literature th(~rc is no scientiflc proof
and provides sufficient lateral support. aboLlllhe benefit or demerit of leg-crossing. One e:\'-
1I. Elderly people do nol appreciale a low or
deep sinking seat.
12. The length of the seat in a chair for adults is
too large for children.
13. The lengths of scats in easy chairs or lounge
chairs arc often too large for adults.
14. Although the length of Ihis seal (2) seems to
be sufficient. Ihe effective seat length (t) is
fm" too small because of a useless elevation
at the dorsal side and a too large radius at
the foreside. A radius of approximately 30 to
50 mm is sufficient.
15. Pronounced lateral supports on seats have
no use, also common in cars. Broad people
experience painful jamming on the thighs.
16. A back support that is too low cannot give sta· A B c
bilily 10 the LJunk (analogous to Fig. 17-88).
17. Arm rests are even more important in easy
chairs than in straight chairs because the Even in sitting with the support of back rest and arm rests,
arms cannot rest on a table. the internal oblique abdominal muscles are significantly
18. Easy chairs exist with a pronounced C-form. more active as compared with when supine. Crossing the
19. A seat Ihal is 100 high causes pressure on legs (upper legs crossed or ankle on knee) lowers this activ-
the thighs. whlch promotes "sleeping legs." ity. Therefore, leg·crossing is assumed to be functional and
20. Seats must be straight in the anteroposterior should be allowed for in work places (except car seats and
cockpit seats).
direction. The curvature in the lateral direc-
tion should remain moderate. Forms
CHAPTER 17. ENGINEERING APPROACHES TO STANDING, SITTING,A;~.<O!Eil'~&;~~
_·-/:::'_':'c'c'o_~~,,,,lh;_".; ~..
ception is the observation that leg-crossing (upper thin people. But this may also hold for heavy peopiG
legs crossed or ankle on knee) may result in less ac- because with an increase of volume, the weight in-
tivity of the internal oblique abdominal muscles creases with the third power (m]) but the support
that have the same orientation as the transverse ab~ surface only with the second power of length (m').
dominal muscles (Fig. 17-11) (Snijders et al" 1995). The most unconstrained form of the lumbar
By crossing the legs, an ahernativc and less fatigu- spine is found when the angle bet\vcen the trunk
ing means is found for self-bracing of the Sl joints. and femur is 135" (Keegan, 1953). Furthermore, the
muscle running from the lumbar spine to the femur
(111. psoas major, part of the 111. iliopsoas) can be
Lying shortened, which raises tension in this muscle and
causes a hollow back in supine posture. This can be
A bed is a body support surface on which prolonged improved by exorotation of the legs and, if this is in~
"'. and complete rest must be found. It is a combina- sufficient, by lying on the side. When lying 011 the
tion of a mattress, a mattress carrier, and a bed side. the spine should not bend laterally. resembling
frame or bedstead. However. in many countries it is the scoliotic form. This occurs in persons with pro-
customary to sleep on a spread-out mat on the floor. nounced waists and little give of the mattress in the
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,
(2) remain nal, (3) have a pleasant spring action,
(4) have good ventilation, and (5) not be too warm
or too cold, Aspects I to 3 concern body support
that evenly spreads the pressure on protruding
(bony) parts. gives a straight spine when lying on
the side, and gives a natural S-shape to the spine in
the supine posture. Lying on a horizontal surface is
special because each body part receives separate
support with minimal pressure on skin, and under-
lying tissues and joints can be kepl in a relaxed po-
sition. The result must be that for static equilib-
rium, muscle action is superfluous.
For separate support of the head, a pillow is
needed. The thickness of the pillow is related to the
curvature of the spine: the more curved (especially
in older people), the thicker the pillow (Fig. 17-22).
II' the pillow is too thin, the head must be tilted
backward. A pillow that is too thick is inconvenient
because it causes a bend in the cervical spine. This
bend can also occur when the pillow is harel. Wilh
the shape of a coconut resulting in a concentrated
force on the head at the side of the crown. Pillows
must be pliable to also support the neck. Pillows must be pliable to also support the neck. The thick·
A bed that is too hard results in restless change of ness of the pillow is related to the curvature of the spine
posture to unload areas with disturbed blood flow. because hyperextension or a sharp bend of the cervical
spine should be avoided.
Normally. people change posture 20 times per night.
One can imagine that large pressure occurs with
~----------- r
Decubitus Skin Ulcerations I
90-year-old man. v,nth a pelvIC fraClure and cognitive lim-I
A itatians. In his second week ai hospiializatlon. the patient !
is spending 10.0% of h.is t1rl1e In. be~.
Prolonged pressure and Ii
15
SITTING IN BED
"
"-
~ 12
c
Sitting in bed is common, especially in hospitals in 0
.~
Study 17-2).
CHAPTER;7. E~IGINEERING APPROACHES TO
1
;
Solid material
A B
Fluid Gas
c o
A. Equilibrium of a body on a mattress of solid material. Re- mattress with a loose cover; less shear than in B. D. Equilib-
stricted support surface. a, Fluid mattress with an elastic en- rium of the body on gas. A favorable, uniform pressure distri-
velope. The highest pressure is at the deepest point. C, Fluid bution over almost the maximal available supporting surface.
cor-dance with Figure 17-14C. This folding princi- largest bod).' surface is involved in support when
ple is now applied in hospital beds and in beds for the body sinks deep in the maltress (Holscher et
home care. aI., 1994).
The medium for antidecubitus mattresses can
be divided in four groups: solid material. fluid,
gas, and a combination of these media. Solid ma- Swnmarv
terials are foam, sheepskin. woolen blankets, etc.
Deep impression of the material results in a larger Any deviation from the anatomical posture
force (Fig. 17-25A). The ideal material should have generates increased tension in soft tissue and in~
a horizontal (isotonic) and adjustable spring creased loading on the skeletal structures.
characteristic. For fluid, a good envelope is The design of hurnal{ tools should include
needed (Fig. 17-25B). Tensile forces in this enve- knowledge of biomechanics and its effect on hu-
lope contribute to bodS' support, but raise shear mans.
stresses. The supported surface is large but still
the largest stresses are at the deepest point. Gas al- Use and adaptation of supports, including arm
lows for the application of equal pressure along a rests, back rests, and adjustable desks or beds, will
large surface (Fig. t 7-25D). Chambers are neces- help to decrease the load on musculoskeletal struc-
sar.y to follow the contour of the body. Combina- tures.
tions of the foregoing are the "air-fluidized" beds, The most important factor to reducing load on
hammocks, etc. For home situations, gas support the lumbar spine during lifting is to keep the load
is preferred, with an adjustable spring characteris- close to the body. For engineering purposes, the goal
tic to accommodate bod)' weight. In all cases, the is to reduce the lever arm of the object.
Snijdc.:rs, C.J. (1991). Biolllc..:hani(,·s of fool gcnr. hallux \·.I!gllS
REfERENCES .1lH.I splay fool. In ,\tH. J.dlSS (Ed), TIlt, FoOl (jIul ifS 0;'::0,._
Goossens. R.I·Uvl. & Snijdc:rs. C.l. (1995). Dc:si!!.11 ,ritcri~l for lIt.'rs (2nd cd.). rhil.lddphia: W.B. S'llllldcrs.
the reduction of ShClll" forces in beds and S~~ltS. J 8i0I1I," Snijdcrs: CJ., :\?hi~n. J.c.r.M., Rid. ~"'ll.J.i\l.. d al. (1990).
dWl1ics. 28(2).225-230. Rcadlllg and IIldlned surf.lc..-s. L.al/al, 335(8692}, 802.
Goossens. R.H.M .. Zegers. R.• Hoek \'an Dijkc. G.A .. ct ~II. Snij~lers. C.l .• .Hoek V;Jll Dijkc, G.A., 6: Roosch. E.R. (1991).:\
(1994). Influellce of shear on skin oxygen !ellsion. J eJin ~101llt'~hanlcal model for the an.\lysis of Ihl.' cen'ica! spine
Ph)':;i"/, 14, 111-118. III stauc postures. J Biol1w..)ulIl;c:.... 2-1(9),783-792.
Hel Bcd. IIlSfi1l1l1l 1'oor fllfisllo/l{ltecJlllisdl Advic:s (lVI1A) \'(111 Snijde!'s, c.J., Slagter. A.H.E .. Strik. R.. ct at. (1995). Wh\' Ie!!·
dc Nctlahllulsc \'crclligillj; vall I-/lIiS\'rDI/II't!II. Tl!stn:pol'/ (in crossing? The influl.'llcc of common postures on abdomi-
Dutch). Gr:l\'cnhagc: 1979. nal muscle acth·ity. Spilll.'. 20( IS}, 1989-1993.
Holscher. T.G .. Goossens. R.IL"!., Snijdr.:rs, C.l., c:1 al. (1994). Snijdl:r~, C,J. & Verduin, ~'1. (1973). Stabilograph. all <lCCU·
A new low·cost anti·decubitus mattress for home care: Re- r~tl: Instrument for sciences inlcrrslcd in postural equilib-
qllirctlWrHS and development. J RehaIJ Sci, 7(2).53-58. rium . ..tgressologie. l-1C, 1520.
h.nda. V (1980). .\1l1skel{llJlkliollsdiagJloslik. Verlag {iiI' .\It:tJj· Snijdc-rs, c.J .. Vleeming. A., &. StOl.'Ck;II't, R. (1993). Trnnsfer
:';1/ Dr. EU'ald Fischer. LClI\'cn. AceD Valag; Heidelbcrg. of IUlllbosacr.1i IOi:ld to iliac bones and h:gs. P;lrl I: Biome-
Kecgnn, J. (1953). Aher'lIions of the 11Imb~r curH.' n:latc~1 10 d.l~llics of sdf.bracing of Ihe s'lcroiliac joints and its sig-
posture .md seating. J BOlle )0;111 SIl,.~elY. 35. 589-603. IlIflCanCe for treatmenl and c.xcrcise. Clill Biol1lc.'clulII;cs S
Moll v.m Chan:mte. A.W.• Snijdcrs. CJ .. & Mulder, P.C.H. 285-294. . .
(1991). Posture control and Ihe risk of industrial .lCcidcnt: Wall, !\..t., d.e Rid, \t.P.J.M., van ,\ghin.l, J.c.rJ\'I., l'l al. (1992).
A st.lbilographic invcstig'llion in u nU\'al shipy'll·d. Ami 0(.'- Impwnng the sil!ing posture of Cr\D/C,\~<t workers bv in·
ttlP l1y:;;<:IIe, 35(5),505-515. creasing VDU monitor working hcighl. Ergo/lomics, 35'(.4)
Snijdcrs, C,J. (1988). Biomcchanical analysis of s~illcd pos· 427-436. . .
tun:. IC..tART 88: hlfl.'l'/wtirmal COI1/'cn.'~,(.'l.' of lite Associ/I-
liOI/ for Ilti.' /\d\'allct:IlIClIlor
RelUlbilitafioll Tt:f.:llIlIllo""
i\'lontrcal. 472-473. e>.'
I
-j
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
Bipedal locomotion, or gait, is a functional task constraints of the talocr-ural joint, which permits
requiring complex interactions and coordination only plantarllexion (extension) and dorsillexion
among most of the major joints of the body, par- (Ilexion), Although frequently modeled in gait
ticularlv of the lower extremitv. This fundamental analysis as a rigid segment. the foot is required to
task ha~ been the subject of st;,dy by scientists for act as both a semirigid structure (as a spring during
several centuries, both with respect to description weight transfer and a lever arm during push-off)
of typical body movements and of pathological and a rigid structure that permits adequate stability
conditions and therapeutic intcl'"ventions. Gait to support body weight.
analysis and training in one form or another is a The movements of the ankle, subtalar, tarsal,
staple of physical therapy and rehabilitation mcdw metalHrsal, and phalangeal joints contribute to
icine practice. As technological advances become the smooth progression of the body's center of
both more sophisticated and affordable, detailed mass through space. Thcl-e are constant acljust-
biomechanical analyses of gait increasingly can be Illents in these joints in response to the charac-
performed in a clinical setting. This means that teristics of the supporting terrain and to the ac-
the biomechanics of gait need to be more broadly tions of the muscles that cross them, which
understood b)' both clinicians and researchers. In provides a smooth interaction between the body
the paragrapl~s that folio\\', the anatomical charac- and the wide variety of supporting surfaces en-
teristics of the major joints of the lower limb and countered when walking. The loss of normal mo-
trunk will be summarized and their behavior dur- tion or muscular function at these joints has a di-
ing level walking in healthy adults will be de· rect effect nOt only on the fOOl and ankle bUI also
scribed. More detailed anatomy of the relevant on the remainder or the joints of the lower ex-
joints and tissues can be found in other chapters tremity.
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
HIP rigid unit comprised of the head, arms, and trunk
During gait, motion abollt the coxofernoral, or hip, (pelvis + thorax), or HAT, segment, The upper
joint is~ triaxial: nexion-extension occurs about limbs and head have not received as much atten-
a mecliolateral axis; adduction-abduction occurs tion as the trunk and lower limbs in the literature.
about an anteroposterior axis: and internal-external Studies that do exist indicate that shoulder mo-
rOlation occurs about a longitudinal axis. Although tions occur pl-imarily as flexion-extension and
flexion-extension movements are of the highest am- internal·external rotation at the glenohumeral
plilude, motions in the other two planes are sub- joints. Elbow flexion-extension and forcarm prona-
stantial and consistent both within and between in· tion-supination oceUI: Cervical spine motion is pri~
clividuals. In addition, impairments in all three marily in flexion-extension and rotation to stabilize
movement planes can cause problematic deviations visual gaze or facilitate the vestibulo·ocular reflex
of the typical gail pattern althe hip and olher joints. as the body is propelled through 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 The information presented in this chapter is sum-
primary motion is knee nexion-extension about a marized from the scientific and clinical literature in
mediolateral axis. Knee internal-external rotation which various laboratory methods have been llsed
and adduction·abduction (varus-valgus) may also oc- to measure gait charactcristics, including stride
cut: but with less consistency and amplitude among analysis, angular kinematic anal~;sis, force plmc and
healthy individuals owing to soh tissue and bony foot pressure analysis, and electromyographic
constraints to these motions. (EMG) analysis, In stride analysis, the temporal se-
439
quence of stance and swing are quantified using ei- terns. and load bearing of the lower cxtremities and,
ther simple tools, slich as a stopwatch and ink and as a result, is cfflcicnt in translating the bod)/s cen-
paper, or electromechanical instruments. stich as ter of muss in the ovcrall direction 01" locomotion. A
pressure~sensitive switches imbedded in shoe in- full gait cycle is defin~d by the OCCllrrcnce 01" a ~e~
serts or applied to the bollom of the fool. Stride quential stance phase and swing phase by one limb,
analysis data arc used to calculate basic time- or a stride (Figs. 18-1 and 18-2). The limits of a
distance variables, which will be described in detail. stride can be demarcated by the occurrence of a
Angular kinematic analysis lIses c1ectrogoniome- specific gait event (e.g., initial COlll<:lct) on one limb
t!)', accelerometry, and optoelectronic techniques. to the next occurrence of that same event on the ip-
ElectrogoniOlllelers arc available in uniaxial and silateral limb.
multiaxial configurations and are attached directly Stancc phase occupies 60(7"0 of the stride and con-
to the body segments on either side of the joint or sists of two pel"iods of double limb support (initial
joints of interest for the direct measurement of an~ and tcrmillal), wh~n the contralateral foot is in con-
gular displacement. Accelerometers arc attached to tact with the ground, and an intermediate period of
the bodv .. sc cr ll1ents of interest for the direct mea-
~
single limb support. when the contralateral limb is
surement of segmental acceleration from which seg- engaged in swing phase. Stance can be decomposed
mental velocities and displacements arc then dc- into six events or period~. Initial contact or heel
rivcd. Optoelcctronic techniques involve the use of contact is ddlncd as the instant the foot makes con-
video cameras to capture images of an individual tact with the floor. Loading response is an interval
walking. Such systems llsually include the use 01' during which the sole of the foot comes into con-
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 Stride/cycle
careful calibration to locate anatomical markers
and are often permanently installed in a "gait labo- LTO LHC LTO LHC
ratory." Force plate and foot pressure analysis tech-
!
niques involve the recording of information at the L. swing I L. stance L. swing
foot~noOl' interface during the stance phase of gait.
Force plates measure the resultant ground reaction
I I
I
force beneath the foot and the location of its point " ,<",,·,'1' O,".,i . , I
of application in the plane of the supporting sur-
A. stance R. swing R. stance
face. Pressure plates or insoles measure the load
distribution beneath the foot during stance. Force 60'% I 40~G
and pressure plates are often combined with angu· RHC RTO RHC RTO
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
Comprehensive Study Gllide. New York: McGr~w-Hil!.
morc or less symmetrical with regard to angular
motions of the major joints. muscle activation pat-
CHAPTER 18· 810rvlECHANicP9v~gr~,;;i~.
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 Swing phase is demarcated by two events, TO and He, and
or stride showing stance phase on the right and swing phase broken into three periods, initial swing (from -60 to 70% of
on the left. He, heel/initial contact; TO, toe off, R, right; L, the stride), mid-swing (from -70 to 85% of the stride), and
left. Stance phase is demarcated by two events, HC and TO. terminal swing (from ... 85 to 100% of the stride). Reprinted
and broken into four periods, loading response (foot flat) with permission from Barr, A.E. (1998). Gait analysis. In I Spivak &
(from -0 to 10% of the stride), midstance (from -10 to 30% I Zuckerman (Eds.), Orthopaedics-A Comprehensive Study Guide.
of the stride), terminal stance (from -30 to 50%, of the New York: McGraw-Hili.
stride), and pre-swing (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
cepted onto the supporting limb. The loading re- the contralateral limb in preparation for swing
sponse period coincides with the end of initial dou- phase. The end of pre-swing corresponds to toe off
ble limb support at approximately 10 to 12% of the at which moment the foot breaks contact with the
stride. Ivlidstancc is the period during which the floor, thereby demarcating 'the beginning of swing
tibia rotates over the stationary fOOL in the direc- phase.
tion of locomotion. The beginning of midstance co- Swing phase occupies 40% of the gait cycle and
incides with single limb SuppOrl and lasts from ap- is decomposed into three periods. Initial swing
proximately 10 to 30% of the stride. Terminal lasts From approximately 60 to 73% of the stride
stance is the period during which the weight of the (approximately one third of swing phase), from toe
body is transferred fTom the hind and midfoot re- off until the swinging foot is opposite the stance
gions onto the forefoot. It occurs from 30 to 50% of [001. Mid-swing ends when the tibia of the swing-
the stride and coincides with the beginning of ter~ ing limb is vertically oriented and lasts from 73 to
minal double limb support. Pre·swing occurs si- 87% of the stride. Terminal swing lasts from 87 to
multaneously with terminal double limb support 100% of the stride and ends at the moment of ini-
and lasts from approximately 50 to 60% of the tial contact.
Time-Distance Variables
~ Normal Values
for Time-Distance Parameters ,.
Time-distance variables arc derived from the tem-
poral and spatial occurrence of the stance and
of Adult Gait at Free Walking Velocity swing phases. Normal values or these quantities are
Stride or cycle time 1.0 to 1.2 mlsect provided in Table 18·1.
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
Step length 0.56 to 1.1 m-''' . covered b.y a stride in the direction of locomolion.
Step width 7.7 to 9.6 em" '. Step is defined as the occurrence of an event on one
Cadence 90 to 140 steps!~jnuteo.. root until the ncxt occurrence or thai same evenl on
Velocity 0.9 to 1.8 m/sec:.> the opposite fool. It is most commonly delineated
by sequential contralateral initial contact. Laterality
Reprinred with permission (rom Barr. A.E. (1998). Gait analysis. In 1.
Spivak & 1. Zuckerman. (eds.), Orthopedics: A Comprehensive Study
is determined by the swinging limb; fOl' example,
Guide. New York: McGraw·Hill, right step is delineated by left initial contact to the
~Vafues adapted from multiple sources as summariled in Craik, R.t fit -"S subsequent right initial contact. Step length refers
Caris, CA. (1995). Gait Analysis: Theory dnd Application. Sr. Louis: -:~- to the distance covered by a step in the direction of
Mosby.
locomotion. Step width refers to the distance cov-
l"Values adapred from Whirr/e. M.W (1991). Gait Analysis: An lntro-
duC!ion. Oxford: Builen'lorth·Heitlemann ered by a step perpendicular to the direction or lo-
comotion as measured from the points of contact on
20 40 40
10 30 30
0;
~
E 0 20 20
\\
~
c -10
'.\ 10 10
'"
C -20
\\ O~· 0
'-.\
..,'0
-30
-40
0 20 40 60
".:.....
'
80
'.,
100
-10
-20 L::::J
0 20 40
::::=:-..,
60 80 100
-10
-20
0
::::::::::........ ~
20 40 60 80 100
1.2 1.2 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 0 0 0
c ""
..,'0 -0.3 :"/ ,/ -0.3 -0.3
..-'
,
Angular displacements and moments of the hip dur~ng level A (bottom). Hip extensor «0) and flexor (.>0) moment;
walking at freely chosen velocity among normal subjects (25 B (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)
scissa).. qashed Jines indicate 90% bootstrap confidence inter- position; C (bottom), Hip internal rotator «0) and external
vals. A (top), Hip flexion «0) and extension (>0) position; rotator (>0) moment.
the heels. Two sequential steps comprise a stride. Al-
though step variables may differ fTom right to left
within an individual, stride variables will remain Bootstrap Method for the Statistical ..
constant regardless of whether stride is delineated Calculation of Confidence Intervals
by right or left initial contacts, because stride con-
The boo ISHap method for the calculation of confidence,.:", '.;
sists of the SlIlllS of right and left steps. ;. ./':, -,
intervals is an iterative technique whereby a population of "
Cadence is a measure of step frequency that is de~
fined as the nUI11ber of steps taken per unit time and gait data time history curves (e.g., joint angular disp,la.c~~;':,,:>,"
ment or joint moment with respect to percent of the.. g~it:::;
is usually expressed in steps per minute. Velocity is
cycle) is sampled with replacement. This sampling is ,;',,:, '"
defined as the distance covered in the direction of
known as a bootstrap iteration.
locomotion per unit time and is usually expressed in
Each curve in the population of interest is first ana-;: .
meters per second.
Iyzed using a Fourier series representation, and a mean
. '.,
curve for the entire population is constructed by averag~
Angular Kinematics iog [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-
randomly selected with replacement and a mUltiplier is
ments about the motion axes of the major lower ,.
calculated for that iteration. b. using the following for-
limb and axial segments during level walking. Fig-
mula:
ures 18-3 through 18-7 show examples of angular
displacements at these motion segments over the
course of the stride in a healthy adult population
(Calculation Box \8-1).
where f\t),)! is the mean of all curves at point tj of.
gait CYCle, F(tJ)tF. is the mean of the bootstrap
HIP the same point of the gait cycle, and is (T(t)b~ ;t;h;;e:';;:;~~~;d
deviation of the bootstrap sample at the same poi!)t of
At initial contact, the hip is flexed approximately
the gait cycle (Lenhoff. et aI., t996; and personal c·,·,mrnu-
30' (Fig. 18-3A, top). Throughout terminal stance
nication).
phase, the hip extends until it reaches approxi-
Alier the final bootstrap iteration, the multipliers:":
mately IDa of extension. During pre-swing and
M!bJ. are sorted by magnitUde and an M value is selected
throughout the majority of swing phase, the hip
corresponding to the desired confidence limit at each
nexes to approximately 35°, and then begins to ex·
point in time. For example, if a 90% confidence interval is
tend just prior to the next initial contact as the
desired, the value for M is selected such that it is larger
lower limb is extended for placement of the foot on
than 90% of [he remaining M values at a given pOint in
the ground.
the gait cycle. The standard deviation of [he population
The hip is neutral with respect to adduction-
mean is then multiplied by the appropriate M value at
abduction at initial contact (Fig. 18-38, lOp). By the
each point in time of the gait cycle to obtain the confi-
end of initial double limb support 0'· early mid-
dence interval envelope.
stance, the hip achieves its maximum adduction po-
The stability of the confidence intervals obtained by
sition of approximately 5°. Throughout the remain-
the bootstrap method increases as .the population size
der of stance, the hip abducts to approximately 10'
creases and as the number of bootstrap iterations in-
at toe off, then steadily adducts throughout swing in
creases. The curves depicted in Figures 18·3 through
preparation for the next initial contact.
were analyzed using the bootstrap method. For more spe-
Hip rotational motions are more variable across
cific computational details. see Lenhoff et al. (1996).
individuals during gait (Fig. 18-3C, top). At initial
contact, the hip is externally rotated approximately
5° and remains so throughout loading response and
early midstance. It begins to internally rotate to swing, i(s hip internally rotates to within 3° of neu-
within 2 of neutral rotation by the middle of termi-
0
tral. then it oscillates between 3 and 5' or external
nal stance, then reverses direction and externally ro- rotation dudng terminal swing. Except for perhaps
tates, as the heel begins to rise, to its peak of 150 of a brief period during the middle of (erminal swing,
external rotation during initial swing. As the limb the hip never achieves an internally rotated position
swings past the opposite stance leg during mid- during gait.
;,~::-: .
!I'l?~ w" "_,. " "= _~",m=,.", ., ,Yo~',"~"_",", ?"." ","·':! !L" "-~, -_~," ' ~' '. ., _,. "_,~ ._ "'_: ", .:g, ,~o.~
!l_!lIf'l!!j!l'__ . __ .__>"
.,_-c" .....,...-.. ... .,- :,<"-_g'f!b:>n_jz,ri1dG", -'@,~'t 1.'FS0;._~ F' "' ,;>_".1§·.:~[0 ~;,~"}':; . 0i:!l, ~\'4-.:·;§'F j
--...,..,."...,.....,...".,,,.",.":,-",.·,. __ ... _<;--::;-;_,,,-m:,__
70,---------, 60 50,----------,
60 50 1 40
"
50 40 30
40 30 20
30 20 10
20 :--.. 10 o-l--~~-~-~-_.j
/,'"""-', o.~-=;---=--.=---=?--=;;;;~.d·;0;;~:::§::-~-- , .. ,---------- , .... ....
10,: ....:::- __ ). --10·
----··B' .-.
o-l-~---''-''r--_-.--'k:i1 -10 -20 "',
Angular displacements and moments of the knee during (>0) position; A (bottom), Flexor «0) and extensor (>0) mo-
level walking at freely chosen velocity among normal sub- ment; 8 (top). Knee abduction «O) and adduction (>0) posi~
jects (25 males. tI females; 15 to 35 years of age). Solid lines tion; B (bottom), Knee adductor «0) and abductor (>0) mo-
indicate mean values (ordinate) over the course of a single ment; C (top), Knee external rotation «0) and internal
stride (abscissa). Dashed lines indicate 90% bootstrap confi- rotation (>0) position; C (bottom), Knee internal rotator «0) I,!'
dence intervals. A (top), Knee extension «0) and flexion and external rotator (>0) moment.
mechanisms and is variable across individuals. In In the normal sample of predominantly males
addition, the placement of reference markers dur- (25 males/29 subjects) depicted in Figure 18-4C
ing optoelectronic gait anal~/sis may introduce spe- (top), the knee is maintained in an externally ro~
cific offsets into angular calculations. For example, tated position throughollt stance and fluctuates be-
in the data presented in Figure 18A, there was an tween 10 and 20°. Rotational motions about the
external rotation offset as a result of placement of knee are strongly coupled with flexion-extension
the ankle markers on the medial and lateral malle- motions. A comparison of Figure I8A, A-C (top) il-
oli. Such technical differences may result in slight lustrates that during periods when the knee is flex-
discrepancies bet\vcen the absolute value of joint ing, it also internally rotates; whereas during peri-
angular position at the knee as reported by differ- ods when the knee is extending, it also externally
ent laboratories, although the relative displace- rotates. This coupling is related to the bony mor·
ment range and overall patterns of motion should phology of the femoral condyles and tibial plateaus
be simihll: 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,-\
'"c
0, a At initial contact, the ankle joint is neutral or
« slightly plantarllexecl 3 to 5' (Fig. 18-5, top). From
C
-5
initial contact to loading response, the ankle plan w
,0 ···10
tarflexes (I.e., extends) to a maximulll of 7° as the
-15 foot is lowered to the supporting surface. Through-
-20 out midstance, the ankle dorsiflexes (i.e., flexes) to a
a 20 40 60 80 100
maximum of t 5° as the lower leg rotates anteriorly
and medially over the supporting foot. During ter-
0.5
minal stance and pre-swing, the ankle plantarflexes
0;
O·
to approximately 15° as body weight is transferred
~ onto the contralateral limb. Immediately following
;S toe off, the ankle rapidly dorsi flexes to the neutral
-0.5
C
position to attain toe clearance and then may plan-
'"0
E
·-1 "\ tarflex slightly during terminal swing in preparation
::::
c '-::'\'--' for initial contact.
,
'0 '1.5 '-'-'
-2
a 20 40 60 80 100 Subtalar Joint
A Gait Cycle (%) The subtalar joint rotates in, both stance and swing
(Fig. 18-6, bottom), but it is the motion during
stance that influences the weight-bearing alignment
Angular displacements and moments of the ankle during
of the entire lower extremity. Like the ankle joint, the
level walking at freely chosen velocity among normal sub· arc of n10tion at the subtalar joint is small compared
jects (25 males, 4 females; 15 to 35 years of age). Solid with the knee and the hip, but it is the motion pre-
lines indicate mean values (ordinate) over the course of a sent at this joint that permits the foot to adapt to a
single stride (abscissa). Dashed lines indicate 90% boot- varietY.Qf surfaces. The subtalar joint functions as a
strap confidence intervals. Top, ankle dorsiflexion (flexion) mitered hinge during gait to transmit internal and
«0) and plantarflexion (extension) (>0) position; bottom, external rotation from the tibia to rotations (ever-
ankle plantarflexor (extensor) «0) and dorsiflexor (flexor) sion and inversion) about the foot. The subtalar joint
(>0) moment. also transmits inversion and eversion from the foot
to external and internal rotation about the tibia.
Midtarsal joint
Heel contact
.. ..
Toe off Heel contact
.. Motion about lite.: transverse a:\is of the Inidtarsal
joint affects the longitudinal arch of the foot. Fol-
Ankle
rotation lowing forefoot contact during loading response,
the longitudinal arch n"ttcns during single limb
Stance phase j ; support. The restoration of the arch occurs wilh
Ii' heel rbe,
Foot immobile Midtarsal extension is another of the rnecha-
• nisms for shock absorption as body weight is low-
ered Onto the stance limb during loading response
Sublalar
rolation and carly midstance. This motion, which accompa-
nies forefoot contact at the onset of midstance, oc-
curs after subtalar eversion,
~_ .._ - - o ' : - . Finally, the interaction between the subtalar
o 20 40 60 80 100
joint and the midtarsal joint is such that if mo-
Percent of Walking Cycle
tion at the subtalar joint is limited, then motion
at the midtarsal joint will be limited. Similarl)',
when motion at the talonavicular joint is pre-
Ankle and subtalar rotations during normal walking in a \'cntcd, aimosl no motion is permitted at the sub-
single subject. Reprinted with permission from Wright, talar joint.
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
;1 c'
The toes then Oex to neulral after for-croat contact at
during pre-swing. During swing. the toes Oex
slightl~1 but rernain in extcnsion. Finall~', there is a
I
the end of loading response. A ncutral position is
minimal increase in toe extension in preparation for
maintained throughollt midstance. Olll-jog terminal
initial contacl. Little or no flexion occurs at the
stance, as the heel rises, the metatarsophalangeal
~14 joints (collectively known as the metatarsal break)
metatarsophalangeal joint during walking, although
some Illay be presenl during athlctic activities.
extend to approxirnately 21 0 while the tocs remain
!
Littie or no motion occurs al the interphalangeal
in contact with the ground and the hind fOOl lifts up
joints during gait wilh the exception that during
into the air. This metatarsophalangeal extension
pre-swing, slight rlexion is occasionally noted.
places tension on the plantar aponeurosis, which in
turn exens a passive hind foot (calcaneal) inversion
~~ force. Tightening of the plantar aponeurosis also re·
TRUNK AND PELVIS
suits in supination of the foot and accentuation, or
heightening, of 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 15
i
~;_-JI!i 10 10 10
c; Ii
"
?
5 5
I
5·
"
.,.-
"
"c
e;,
0~",1
"
0 0
?/""'~'~
«
-5
-10
-J '". ,' I
-10
--5
15 15 15
10 10 10
....',
c;
5 ...... .....
"
?
5 5
"
e;, ,- '-- ... '
c 0 0 0
«
-5 -5 -5
Angular rotation of the trunk and pelvis during level walking Trunk downward « O) and upward (>O) tilt with respect to
at freely chosen velocity among normal subjects (25 males, 4 the stance limb; B (bottom), Pelvis downward «0) and up-
females; 15 to 35 years of age). Solid lines indicate mean val- ward (>0) tilt with respect to the stance limb; C (top), Trunk
ues (ordinate) over the course of a single stride, (abscissa). backward « 0) and forward (>0) rotation with respect to
Dashed lines indicate 90% bootstrap confidence intervals. the stance limb; C (bottom), Pelvis backwar.d «0) and for~
A (top), Trunk posterior «0) and anterior (>0) lean; A (bot- ward (>O) rotation with respect to the stance limb.
tom), Pelvis posterior «0) and anterior (>0) tilt; B (top),
, "",.,..
\\~ardapproximately 5° (Fig. 18~7C. bOllom), and is trunk is rataled backward approximately 3° while
level from right to left. During the loading re· the pelvis is rotated forward approximately 5°. The
sponse, the pelvis tills upward on the stance limb anlpliludes of the angular displacemenls of the
side to a maximum of 5°, then it regains ncutrallilt trunk segment as rencctcd in the movement of the
at the nexl initial conlact of the swinging limb (Fig. shoulder girdle arc only slightly ullcnuated in com-
18·78, bOllom). During stance phase, the pelvis 1"0· parison with the pelvic movements, as can be easily
tates backward on the stance limb side and tilts an· appreciated by comparing the lOP (trunk) La bottom
teriorly (hollom of Fig. 18-7 C & B, respectively). (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·
CENTER OF MASS
proximately 10°. The body's center of mass remains located within the
Tnmk motion during gait is opposite in direction. pelvis anterior to the sacrum throughout the gait cy-
or out of phase, 10 the motions of Ihe pelvis (Fig. cle. It undergoes sinusoidal displacements in all three
18-7, A-C, lOp). For example, at initial conlaCl, the planes with peak to peak excursions of approximately·
"
,-,
j,,, '
~"
' \
,' ,
Joint , ""
,
rotation
, ",, , ,
,
Extension - 15 .- 15 ,.__..--." ,
Extensor
,
2.0 r·
Joint
,,
i
.- I ..
moment I ,',- . :........
Generation 3~ ,,
!
~ , ,
,
,, ,,
I'
,
I
JOin!
power
L'\
r" - "'",
,~
#
.
......
" ...., - -'
~--~
,- ,
l' '.. "',- . . . ---- "
"
"
1\
'
'
1-
-2 L __l _ _ ~~_ -L----' 1 ,_--'-, _~ ._--'----'--- - - '- - ;
Absorption
a 50 100 o 50 100 a 50 100
% Gait Cycle % Gait Cycle % Gait Cycle
..,-.
-.C·
Joint power profiles in watts/kg of body weight (bottom ments in Nm/kg body weight. Joint motions are in degrees.
row) of the hip (left column), knee (middle column), and an· Reprinredwilh permission from Gage. l.R. (1991). Gait Analysis in
kle (right column) for flexion-extension motions (top row) Cerebral Palsy (p. 31). LOlldon: Mac Keith Press.
during level walking. The middle row shows the joint mo·
CHAPTER 18 •
when the external moment tends to cause knee found gait deviations. One possible pathological gait pat-
flexion). Activation b,\' the knee cxtensors is re- tern is Trendelenburg gait, which results from the failure
quired to counterbalance the tendenc'y' for knee of the hip abductors to produce a sufficient abductor mo-
flexion caused by the external flexion n~oment. In- ment during loading response and terminal stance. This
ternal moments arc assumed to be generated b"" pattern is easily observed as a lateral drop of the pelvis on
the muscles, soft tissues, and joint contact rorce~ the side opposite the weakness during stance on the
acting on the joint and are inferred from inverse weak side. Another way of describing this pattern is ex-
dynamics calculations of external moments. As cessive adduction of the weak hip during stance phase.
such, the internal m0111ent is an expression of the Another pathological gait pattern seen with abductor
net effect of internal active and passive structures weakness or coxofemoral pain is the lateral lurch. In this
and is strictly accurate in the case where a muscle i pattern, the trunk is displaced toward the affected stance
group is contracting unopposed by antagonist ac- , limb during loading response, where it remains through-
tivation. At certain periods during normal gait and out terminal stance. This is observed as excessive lateral
for longer periods during gait in nlany pathologi- displacement of the trunk toward the affected side, The
cal conditions, agonist-antagonist coactivation result of this gait deviation is to reduce the required hip
may be present. In such cases, reported values for abductor moment by displacing the body's center of mass
net internal moments will underestimate the ac- closer to the hip adduction-abduction rotation axis.
tual muscular forces occurring. However, this ter- Both of these gait deviations effectively reduce com-
n1inology is prevalent in the literature and useful pressiori" across the coxofemoral joint by reducing contrac-
for the calculation of other kinetic variables. Plots ! tion force of the hip abductors, thereby alleviating joint
of the internal moments occurring about the hip, I pain. The Trendelenburg pattern is a simple mechanical
knee, and ankle joints during level walking in 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- Nm/kg occurs. During terminal stance, a second low
lernal rotator moment of appro.ximately 0.18 Nm/kg amplitude extensor moment of 0.2 Nm/kg occurs
is achic\'cd (Fig, 18-3C, bOllom), The eXlernal rota- (Case Slud" 18-1),
tor mOment gradually decreases until the middle of As \\'as the case with adduction-abduction about
terminal stance. Throughout the remainder of ter~ the knee, knee adduction-abduction moments arc
min'll stance and pre-swing, a slight hip internal ro- controlled primarily through bone and soft tissue
Lalor moment occurs, constraints. Therefore, the terminology for these
moments nt the knee refers to passive restraints, not
Knee to n1uscular control.
At initial contact, there is a small knee flexor mo- An abductor moment persists about the knee
ment (Fig, 18-4A, boltom), During early midstance, throughout stance with lwo peaks of approxi-
an extensor moment peak of approximately 0.6 mately 0.4 Nm/kg during loading response and ter-
80 50
70 40~ ...... --
"'"
~ 60 ---- Unalfected llexion
E
:s
._-- Unaffected
-Affected
'"'" 50
:;;
- Affected flexion C 30j
'"
E 20
..
c
C
'"
0> 40
'0 30
c
0
:;;
·0
~
1O~
~
'"'"c 0
'"'" ....
20 ,""
C
'" 10
-,
-- '" -10
0, -20j , ,
0 20 40 60 80 100 0 10 20 30 40 50 60
Gait Cycle ('%) 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
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. terminal stance; PSw, pre-swing; JSw, initial swing; MSw, mid-
Gray regions represent activation below 20% of maximum swing; and TSw; terminal swing. Adapted with permission from
voluntary contraction. Black regions represent activation Perry, 1. (1992). Gait Analysis: Normal and Pathological Function.
above 20% of maximum voluntary contraction. /C, initial con- Thorofare. NJ: SLACK Incorporated.
~"~fu~.!~'I'~"-I--ll-r-l--r~~[§';,~,:;' -~ Vaslus intermedius
~ ~- Vastus lateratis
~ Vaslus medialis longus
~
[f::'J~g]~':§"-
b~. -~~
t-,
~.wEl.~ VaSlu$ medialis oblique
Reclus femoris
~
:"i:i Semitendinosus
Semimembranosus
,,-2
c2(,~~;:~i!t&;~t:.: Popliteus
Gaslrocnemius
Gracilis
Sartorius
Stride events Ie TO Ie
Stride intervals LR MSt TSt PSw ISw MSw 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. Most of the harnstrings muscles are activated in late
The function of the muscles during such periods is mid-swing or terminal swing. Their function at the ! '
to control the acceleration of the rotating joints to knee is probably to control the angular acceleration
ensure the precise placcrnent of the fOOL on the sup· into knee extension. This is consistent with their pre-
port surface in anticipation of the upcoming stance sUllled action at the hip, or the control of hip flexion in
phase. This explains lhe hamstrings and adductor preparation for the upcoming stance phase. The short
magnus activity during 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 mid-swing. Ho\Vevel~ these muscles may very well be
limb support (Fig. 18-10). This muscle group is acti- acting as primary hip ncxors during this period.
vated during terminal swing and then acts eccentri-
cally during \veight acceptance as the knee rotates ANKLE AND FOOT
from the fully extended position at initial contact to
Talocrural Joint
its peak support phase flexion of approximately 20°
during loading response. Thereafter. the quadriceps From EMG sludies on the muscles that cross the an-
act concentrically to extend the knee through early kle, 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-
tically over the supporting 11mb and the anterior ori- ance and eccentrically during loading response to
entation of the ground reaction force vector pre- control the placement of the foot by ankle plan-
cludes the need for furlher Illuscular control of knee tarflexion (Fig. 18-1 1). The plantarflexors are con-
flexion. sistently firing eccentrically during stance to conrrol
~~
=:~- ~ i~--ll---II;:====:'~~_·~!=:-~c:.== ~~~~:O:n~:~li~~iS longus
Exlensor digitorum longus
h., ."T Soleus
Fx:;s~.
I I
01 I
I Gastrocnemius
--"''/»''"'J;O~~';.;..;.1'.:.!',',;1~~::>'J'S'';; Posterior tibialis
Flexor digitorum longus
Flexor halluc is longus
I
;:;;';,,"k"ir~'::JM:,-iA:';~(';'/i;; Peroneus longus
"'-: Peroneus brevis
Abductor digiti quint!
Abductor hallucis
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-
cles of the ankle and foot during level walking in healthy adults. tion is not shown. Ie, initial contact; TO, toe off; LR. loading re-
Gray regions represent activation below 20% of maximum vol- sponse; MSt, midstance; TSr, terminal stance; PSw, pre-swing;
untary contraction. Black regions represent activation above ISw, initial swing; MSw, mid·swing; and TSw, terminal swing.
20% of 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.
J
ues to contract to begin active ankle plantarflcxion. In summary. during the first arc of plantarflexion
During this phase. they provide a stable tibia over following initial contact, the dorsWexors arc fil"ing
,,·hich the felllur may advance. Peak electrical activ- eccentl'i~ally to decelerate the rate of plantarnexio~
ity is seen at 50% of the gail cycle. and footfall onto the ground. During the first arc of
Although both the soleus and gastrocnemius dorsiflexion, the plantarflcxors ar~ firing eccentri-
muscles share a common insertion. the role of the cally to control the rate of dorsiflexion and tibial
soleus is somewhat different from that of the gas- progression over the slationar~' fool. During the sec-
trocnemius because of the soleus' origin on the ond arc of plantarflexion, just prior to weight trans-
tibia. The soleus, as a one-joint muscle, provides a fer onto the opposite limb. the plantarflexors ar~ fir-
direct link between the tibia and the calcaneus and ing to maintain walking velocity and step length.
is thought to be the dominant decelerating plan- Finally, during the last arc orIllation, dorsiflexion
tarflexion force. The gastrocnemius, as a two-joint during swing. the dorsiflexors are firing concentri-
muscle, plays a direct role in knee flexion during cally to allow foot clearance.
midstance (Fig. 18-10).
The remaining five postelior muscles arc smaller
in size and as perimalleolar muscles lie closer to the
Subtalar Joint
ankle joint (Fig. IS-II). These five muscles are tib-
ialis posteriOJ~ flexor hallucis longus, flexor digito- As the fOOL makes contact with the floor, subtalar
rum longus, peroneus longus, and peroneus brevis. ev~rsion occurs as a shock·absorbing mechanism.
These muscles playa greater role at the subtalar The inverters fire to dcceleralc this ~\'ersion (Fig.
joint and the foot than at the ankle but still create a 18-11). The tibialis anterior acts to restrain the sub-
plantarOexion force at the ankle joint. talar joint during loading response. \Vith its greatest
The tibialis posterior begins firing at initial con~ activity seen during loading response, the tibialis
tact and remains active through single limb stance anterior is quiet by midstancc.
until opposite initial contact. The flexor digitorum Although the activation patterns of the tibialis pos~
longus begins firing next at opposite toe off and also terior have been reported with various patlcr·ns of ac-
continues until opposite initial contact. The flexor thrity by different investigators, there is agreement
hallucis longus is active from 25% of the gait cycle that it is a stance phase muscle. It becomes active
into pre-swing. Peroneus brevis and longus activity during loading response and remains active through-
begins early in stance and. continues into terminal out stance until early pre-swing, Pen)' (1992) pro-
stance or pre-swing. Note thal the activit)' in these posed that the activation during loading response
muscles is subject to considerable variation across provides early subtalar control. In addition. the vari-
individuals. ability of activity in this muscle may be indicative of
The posterior calf muscles f'mction as a group its function as a reserve force to supplement insuffi-
and cease functioning by 5000 of the gait cycle when cient vanls control by the ankle Illuscles.
opposite initial contact has occurred. The continua- Soleus activity is seen during midstance with pro-
tion of plantarflexion past this point probably serves gressively increasing activity in terminal stance. De-
to balance the body because the opposite foot has spite its major function as an ankle plantarllexor,
already accepted the body's weight. In a small group this muscle also has considerable il1\'crsion lever-
of healthy adults, Sutherland et al. (1980) used a age, especially as a resull of its large cross-sectional
nerve block to the tibial nerve to further describe area. B.y pre-swing there is a 'rapid decline in activ-
the role of the ankle plantarOexors, particularly the ity. and the muscle remains quiet during swing. The
gastrocnemius and soleus during gait. They con- long loe Ilexors are the last in\'cners to be activated.
cluded that these muscles did not sen.:e as a propul- The flexor c1igitoruTll longus and the ncxor hallucis
sion mechanism during pre-swing. Instead, they longus begin activation during midslancc and cease
concluded that these muscles should be thought of firing during pre-swing.
as maintaining fonvard progression, step length, The muscles that arc responsible for c\·ersion at
and gait symmetry. If the plantarnexors do not func- the subt<.llar joint are tht:: extensor digitorulll longus,
tion normally. an increase in ankle dorsiflexion is peroneus tertius, peroneus longus, and peroneus bre-
seen with a shortened step by the swinging limb. In vis. The first two lie anterior to the subtalarjoint axis,
addition, the swinging limb strikes the ground pre- while the last two lie posterior to the subtalar joint
maturely as a resuh of the lack of restraint of the axis. The extensor digitorul11 longus is active during
tibial movement of the stance limb. loading response and quiet with the onset of mid-
APPLIED BIOMECHANICS
I
1
iA
! A bands. 151. /52
,gail cyck muscle ;;Ictio\l (If. 228-229,
136, 23i, ~53--456
compOIll.'lHS cA. 61-67, 62
stIlIClllr:l! inh... r:IC:'lioll ~11ll0iH!. 67-69
1 anisotropy of. \5\ joints and Illolion of. 225. 245-149 in IO:tdl.'d :lnd \lnloadl.'d li~Sll(,.
! Abdominal musdc:s 'kinl.'malics of. 223.225 75-77, is
! in intra-nbdomin;d p[,~sslln:, 278-279 axes in. 226. 242-143 c('lnpn:ssion (If
in spinal mov~mcn!. 265-266. 266 !.!;Iit CVl.,:k and, 226-228 bipll~l:'lic rrL'ql l'c.::'POl1SI.' in. 71-7~
in spinal slabilit\'. 278-281 iig:,m~1ll ane! hone injllr\' in. biph:ISic stl'l·~s·n,"-I;t:.;ntioll n:sponsc
strcnglhcning.276-277 2-15-249 ,. in. 73-7~
lension of. and spinal loading. 268-269 r::tllge of mOl ion in. 24-1 confincd. 70-71
Abductor musch:.- group. hip slIrbce:: joinl motion in. 244-2-t5 stress propl.'nks ill, 6$-69
slabilization, 207 kinl,:lics of. 249-251 degi:lll.:ratioll of. 90
Abductor pollicis longus muscle. 374 lig:uth.'IlIS of. 245-249 ~h(llldrocvlc..' fUlH.:tion in, 91-92
Abrasive WC:\I-. 88 iUjUI;" of. 245-249 faclOr"!' I.·(;nsidcrl.'d ill. 00-91
Acccleromctrv.440 load disll'ihulion hi, 25\ malrix illtCgrilV in. 90-92
;\cct,abululll.203-204 musck :tclion of. in e.ail I.:H-Ie::. Ol>tW:ln Ilrilic, '()()-92
Inbrum of. 20-1 453-456 ~ . l'Xp!;llH loading l.'ollligurmioll of. 70-71
loading p,lltcrn (Jf, 20-1 ShOl·\\'I.'~lr nnd m~'ch;\Ilics of, 251-252 lluid (lo\\, in, 69-75, ~I-SS
transversc :Icc::tnblllar 1i£:ltllc::nl of. 20-1 spr:lin in,lury of. 245-149 fUllctions of. 61
Achilks tcndon, 236 - sl;,bilitv or. 245-249 hv:dirw.61
injury of. as~()ci<l{(,'d with high slrain sl:ltic ~illal\'sis or. 250 h;bricoHion of. 81-83
I';;UC (nlfll1('rs). 114 and subwl:tr ,join I 11'101ion, 226, bnostl..'d. 85. 86, 86
kincmntics of. 249-250 12t\. 230 bOtilldal\'. 83-H4, 8'+, 86
Acromioclnviclllnr joint, 319 joinl (.'oll'lIX'n~')li(Jn in. 446 I..'lasloh\"lrodvrwmir.:. $5
analOlllV/killcm;'I'tics of. 321-322 Ankk- Il'lOl'\isc. 223. 242 t\:udcd' fluid 'in. ~5
Actin fihllllents. 149-150 Annulus fibroslls, 258 !luid film. 82-83
arI1lngcmcnt in sarcomen:. 150. 150 of cervical illICI'\'Crldlr:'t1 disc. 292 intl.'f'Sliliallhlid pn::ssllriwtion in.
in musch:~ cormaclion. 153-155 tClIsioll in. 258 86-88
Adhesive wear. S8 Anll.'rior crlldal~ Jigalllclll (ACL) mLxl'd. S-I-86. 85
ADI (,:ltJalltode1114lJ intc['\,:tl). 302. fUtlClion of. 195-196 molecular organ;z:llion of. 61-69
303.303 g:lil :lc:l:lptaljon~ inddkicncy of, 450 PCI'Il1l.':lhililV of. 74-75
A~!lrccan(s) iujurvof. 1 13. 16S puq)OS('S (i. 61
-aging and i)1n.lctur~\1 \'al'iation of. '~ts~ol,:blc::d wilh tr<tum'l. 195 shl.':u'~Il\di(.'s of. 77-$.0
65.67 in km'~ :\nhroplasty, ... J S-416 SllllC1l1l:11 dcfc..·cls of, ('":lllsed
b\' \\'c::ac 89
bOllle-brush mock-I of. 66, 67 postsurgical rcp:tir of. 16S slrUClure :Ind c::omp(lsiti(Ht ol'. 61-69
molecular cOmposilion of. 65 Anlioecuhilis matll\.'SSI:!'. 434-l35 sUl'f:u.:r.: of. 804. 84-85
slnlctural variations of. 65. 67 Apical IigamclHs. 29{) swdlin!.! behavior of. SO-$I
Aging. <lnd biomr.:chanical prope::nic::s Arch«(.'s} ll.'nsik' ~(rl.'$s,sll':Lill curve for, 76
of arlicular cartibgc. 65. 67 of fOOl. 235-236 lripll:tsic bioltlCdl:lllic'll bl.'ll~IViol' of.
of bone. 53-5~ collapse of. 236 RO-Sl
of ligaments, 115 of h~lIld, 362 uniaxi:tltcnsion on. 7S-77
of tcndons. I 15 AI'\:<I It)OIll('nt of inertia, 47-4S viscoelaslic bdlil\'ior of. 70
Airbag injudcs, of ccr·Yil... nJ spinc, Armrest suppor!. 427 now-irl(h.:p~·tl("-·nt.70
311-312 Al'lllrodesis intrjn~ic. 70
Alar ligamems. 290 cClyical. 308-311 wr.::\!· of. 0$-90
Anconeus OlllSCh:. 350 spinal. 306. 30S colbgcn-nro1coglyC:11l rcslxII1SC 10.
activitv of. 351 AnhroplaslY. 401-402 SS-90
Angle or' ante\'crsion, of fcllloml head. arllcrior cl1.tdatt.: ligmnenl ill I\nl.'I.', dcfl.'cts :lIlcl. 89-90
204-205 415-416 iltlP~ICI lo:tding in. 89
Angular kincm:Hic analysis. 440 goals of. 40 I intcrr:\(:bl. SS
Anisotropy. 36 hip. 401--107 AtlalllO:\xial SCgmcnt. 2S8-290
Ankle joil1l. 223 knr.:r.:. -107--412 coupled motion of. 299
axis of. cmpidcal. 242-243 poslerior crudale ligament in knec.:. inst:lbilitv of. wilhout fr:lclun:. 303
ball-and-sockel.229-230 -112-414 r.lIl£,c o(motioll of. .297-29~
in biomcchanics of sianding. 4:22-H4 Articular ('al'lila~c Allmltodcnl:\l iIHt..'I'V:11 (/\DI). 301. 303. 303
boncs of. 223, 225. 245-249 :lIlisolrOpi(' plnpcnks of. 63. 6-("65 :\tlas n'r1I..'bnl. 287. 288-290
dynamic mwlysis of. 251 bioltlt.'chnnic::nl hch;;\\'iol'of. 69-81 Axis \'(,'I'Ic::br:l. 287. 290
gait cycle kincmalics of. 226-228. hiph;l~k C\'l..'l.'P response:: in. 71-72 :Uld dcn~. 288. 290
445-447 biphask Sil'l.'Ss-rc!a,xalioll rl.'sponsc in. Axonal 1r:IIl~pOn syslclns, 127
gait cycle kinetics of. 249-251, 451 73-74 Axons. 127
:
(I> ----------------------------------
459
B bi0l11cch;lllk;11 propcnil:s or. 31-36 C~lllalicuJi. 27-28
Ba~k belts. biolllcchankal l.:ff..:clin,'ucss anisOl.-opic.3-4, 36 C:.nct::llolls hOlll..·. 29
of. 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, 33-34 Cnpsular ligaments, spinal. 260
and loading of lumbar spine. 269, 271 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
Bcd(s) microscopic. 29-30 in. 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
activit\' of. 352 geometry of, 47-51 (<.:I11.:nl linc::, 28
Biceps lllllScI.... he<llin!? of Celltl:ror 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
330, 350 pCI·iproslht.:lk loss of. 406-407 gmft malerials in, 30S-309
Biulvcan 65 n.:modcling of. ~\lld biomechanic:ll indications for, 308
Bi~l;lcch·allic~. -' behavi<ll~ 51-53 poslc!"ior, 309-311
ddonn~Hion modes in. 7 slri.:nglh and stiffness of. 31-36 studies of, 309-31 I
c1:1stil".- ddonnation in, 10-11 nging t:fft.:cIs 011. 53-54 Cen:ic<lllamilll:ClOm\'. 305-306. 30i
cndurnncc in.m:ll..: .. ial. 14-15 bone Icn2th innucncc 011. 48 Ccrvk~ll plming systems. 310
('quilibrilllll conditions in. 6 (:aHus form~llion and incrc;:asl,.' in, CL'r"ic;t! spine
fatigue' in. material. 14-15 48-49 allalonw of. 2~7-292
force Vectors in, 3-t cross sectional an'a influence on. ;IIHcllcx'ion of. in silling position,
frcc-body di.tgrams in, 5-6. 6 47-48 430-431
ll1<l1crial propcnies based on sln:"$S- fatigue.: in, in l"e.:pctili\·I..·loading. ;tpplied biomechanics or. 305-311
slrain di:lgrams in. 13 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
tissut's and Slll.lctltfCS. 15 microscopic, 29-30 fllBclionallillil or. 296. 297
Newton's bws in. 5 \'ascukll' ~)'SICIll of. 30. 31 injury of. 311-314
nomlnl SU"~tin in. S-9. /0 Bone densilv. 33 instabilitv or. 301-305
norl11~ll stress in. 7-8. 8 and <lging·. 53-54 instan! C~IllCl" or Illotion or. 293
plastic ddolTIlation in, 10-11 [lolle mass illll.'r",:nL·br'll discs of, 288. 291-292
principal stn:ss in. 13-1~ 'I"C "cnd!"'r '\l1d 53 i.J medl;tllical projK'nies of, 293
scalars in. 3 ;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
she.lr stress in, 7-8, 9 BOlle rCllloddin2. 51. 52 coupled motion in, 299-301
s!<ltics in, 6-7 body weight :tl~d bone m:ISS in, 51. 51-52 l';lIl~C of 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 implanls ·<lnd. 52-53 ligaments of. 288
stresses 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 shoe wear and de\'Clopmcnt of. 251-252 \'i,'nebntc of, 288-291
combined loads nnd, 42-43 mechanical propl.'rtics of. 292-293
compressive loads and, 37-38, 39 llflcO\'L'l'lebnd joints of, 291
gcomt:tJ')' of bonc and, 47-51 C C!londrocvles, in articular cani1a!!.l.l, 61,62
llHISclc ,Jctidtv and stress 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
stn.:ss di,Sll·ibution in. and muscle injlll)' to, 245-249 Clavicle, 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 uoicondvl.w, 378 Epilcllon, lOS
of nrticulul' cnnilage. 61. 62 Digital Oc.\OI' tendon sheath pulk,.\· Equilibl"illHl condition.s, 6
distribution of, 62, 64 systcm, 368-369. 370 Erl1S palsy. 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
c:lrlilagc, 67-69 375.3751 loads on lumbar spine in, 276-277
response 10 weal- of. $8-90 mllscular mechanisms of. 375 Extcnsor digilOnlln longus. ..l55
in tendon ~machmcnl of muscle lO llumbcl"ing of. 359 Extensor mechanism injury. kllcc.199
bone, 149 l-::lIl!!C of n~otion of, 378-380 Extensor s\,sh.:m
of tendons nnd Iigamcnu'i Dist~\I-in(Crpll:llangcnl(DIP) join\S, 362 of digitai rays, 371-374, 375
mcwbolic turnover of. 105 range of motion of. 378-379 of toes, 455
molecular composition of, 103-104. tendinous mechanisms of, 371-374 of wrist. 350. 374
105 Donnan equilibrillll1 ion distribution Extraccllular matrix (ECi\l),
structural alignment of. in loaded law, 68 of aniClll,u" c<lnilage. 61
and 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!ar aggregates 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 D\"namic she.lf modulus. 78-79 F
Colla!!cn fibrils, 10-1-105 D;"namic tripod, 383 F'lcct capsular lig;:l11u::nts. 288
Compact bone, 29 Dynamics, 185 F:lccteclOmy, pani:\J, 306
Component inst,-\bility, 301-302 F~ICl.:tS
Computer workst<ltion, biomechanics of of ccrvical intcl'ycrlcbl"al joints, 290-291
sitting at, 427 E of 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
mcchanical properties of, 33, 35. EI'-lstin, of tendons and ligamellls.l 05 F'-ltigue 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~'c loading, -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
Crcep response forces on articular surface of. 353 of knee pmsthcscs. 407-10S
biphasic. in articubr l..'artilage, 71-72 fracture disloc'-ltion of. 3..l9 nwtcri.. I, 1-1,14-15
in tendons and ligamt.:nts, Ill. 112 injury of. 347-350 of prostheses, 392. 393. 402--103,
Cross-bridges. of myosin filaments, lateral epil.:ondylitis, 352 407-408
I 153-155
Cnlciate IigHmcnts, 195
kinematics of
carrvin" nn"le 345 346
Femoral head, 203, 204
Fcmoml intcnrocharlteric fracture, 206
II Cvelic faliuLle
.of hip p~osthcscs. 402-403
of knee prosl heses, -107--108
cent'er;r r07:ttion. 343, 34-1
f1exion·cxtcnsion, 3-12-3-t3
pmnation/supination. 343-345
stability.3-t5-350
valgus position, 345
remoral neck, 204
aging and ch"lIlgcs in. 205-207
in hip anhropbsty. -104-106
neck-to-shaft ..Hlgle of. 20-1-205
Fencing grip, 38..l
I
D kinctics of. 350-355 FG (f'lst twitch glycolytiC) fibers, 165-167
de Quc!"\'ain's Icnosyno\'itis. 374- muscular :malon1\' of. 350 Fibroblasls, '103.10-1
Dccodn,65 muscular mech;:ulics of. 350 Fibulolalm' joint. 223. 225
Decubitus. 434-435 clcctromyogm,phic an'-llysis or. 350 Fick's principle. 236
Ddormmioll. 7 reaction for<:c calculations for, 353-355 Fingers. 359, 362
ofbone,31-36 stability of. 345, 347-350 in prehensile hand function, 3~2-3S5
;1 clnstic and plastic, 10-11 Ekctrogoniol11etry, 440 range of motion of. 378-380
Deltoid ligaments, of ankle, 245-246 Ekctromyogrnphic (Ei'v1G) .analysis. 440 Fixation plate ['nihl!"c, 393
I function of. 249 Elel.:tromyography. 156 Flexion-relaxation phenomenon, 265-266
rI
injury lO, 249 End plalc, 258 Flexor digilOl1.lll1 lon!!us, -l55, 456
Deltoid muscle. 329-330 Endomysium. 149-150.150 Flexor hallucis I()ngu~. 455. 456
Dens, 288,290 Endoneudum. 129. 130 Fh:xOl" s\"stcm
Derivcd 51 units, 19 Endosteum, 28. 30 of digital r:lyS, 368-369, 370. 375
with spccial names, ddinitions. 201 Endotenon. 104. 108 of tocsJfordoot. 237-::238, 453-456
Devic(,.· f:-tti£!.uc, 392, 393 Endurance,material,I-I-15 of wlist. 350. 359. 374
I Diabetes nldlitlls. h,'ndons .md lig3mel\ls
in, 116-117
Enlrapmenl, nerve. 132. 133
Epimysium. 149-150,150
Flexor tendon sheath pulley syst,,·m.
368-369.370
I
~'-"""""""""""""'=-""""""~".,.-"---.-.."...",..=-"""",,,,,;==;r.-~~~~~~~~~~..J~.I
f!'!!%-1Jk=-~~,~_",-zt"'". £€{"--,..=~ _~cs. -."-0""_ ~~ "y(' '?cP5'~" ".' -,- ::'·~._'c>"'5
;<O.7'__ .... ];g,~~.±gA...1 ~'$--.-~.-",j@";....W;;:"::
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.:r in. 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~. 4-10~4 I 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..1 0-24 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 . 1 07-408 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~'moid joilll, 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.) 6
117 Intcl'osseous membl-:mc:.', of dbo\\'. conformity of femoral and tibial
Hinged joint. 3~ I 348-350 components in ...H4
bicondylar. 373 injury of. <"Ind r;lelia] migr;uion. 352 conslr~lillt <k'sign in. 415
Hip ill,th,:oplasty Interosst..'olls mllsd~s. 237 forcl.·s acting on, 401--402. 407-408. -109
bone n:moddin~ around. 52-53 Intcrphal::mgeal (lP) joints hinged proStheses in, ... 15
celllented tOI~1 hip rcph\CCmcnl . .:lOS of fim::ers, 362. 365-366, 378-379 joinl lint.: dc'·;ltion in. 412
forces ;:lctin~ on, 401-402 of 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 patcllofcmoral joint loading ill. 411
. of. 404-406 gait 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 cnpsuh:: of. 195 .
Hip joint. 203 11Hl.'lycl.. tcbml 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
anatonw of. 203 loading. 291 injury 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~mpositioll of. 258-259 gait cycle kin~lllatics of. 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
c-,tern;ll support, nnd dyn;\lnic~ of, in rniddlt: age, 259 menisci of. 193-194
218-219 prL'ssure on. 258-259 muscle action on. gait c~·de and,
btiglle fracture of. 2/i in \'OlI!h. 259 196. 453
femoral head of. 203. 204 lliechailical propL'nit::s of. 293 patella of. 196-197
femoral neck 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 :-;i.\ 'kgrees of freedom of motion, 178
fracturc of. 21 i in st~lbility
of lurnbal' spinc, 278-279 s(~lbilitv of. 194-196
kinenwtics of. 205-208. 209, Inlnlflls~,1muscle spineles. typl."s of. 169 statics ·of. 188-190, 197-199
mll~e of motion, 206-107 Intrinsic minimlls condition. 234 SIl'lICturc of, 177
surf.'1ce joint motion. 207-208 Intrinsic muscles. of foot, 233-23.... surf<lce joilH 1Tl00ion of. 180-187
kinetics of, 208-213. 2/5 237-238 ll.'ndons 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
muscle action in g;:lit cycle. -I52......t.53
in Slalics of standing, 26S
I
1I
Paraspinal muscles. 265-266
Par~ltenon. 108
Patella, 196-197
fracture of. 199
precision grip, 383
Principal stress, 13-14
Prominens, 290
Pronalor quadratus muscle. 350
Sciatic pain, 137
nucleus pulposLlsin, 144
SCIWORA (spinal cord injury without
radiognlphic abnorm,llilies),
I P:;\Iellofemoral joint. 185. /87
instant center of. /86
PronalOr teres muscle, 350
Pronator teres tendon. 3i4
295-296
Screw-horne mechanism. 182-183,
I loading in knec arthroplasty. 411
static and dynamic analysis of.
197-199
Proteoglycans (PGs). 27
in aggregate solution dom'lin. 67-68
in articular cartilage. 65
/84. 352
Seming angle, 429-430
Sensory nerve, t 27-129
surface joint motion of, 181-185 disruption of matl'i.x, 88-90 Sensol~' spinal nen'c roOtS, 131
!,
Pectoralis major muscles, 329-330 moleculnr composilion of. 65-67 Sharpcy's pelforating fibers, 108
Pcdiclcs. of cervical vertebrac. 290-291 stnlctural interaction of. 67-69. Shear slrain, 8-9, /0, 32
Pelvic tilt. and spinal statics. 268-269. 75-77 Shear stress, 7-8, 9
425-426 wash out of. 88, 89 Shocwcar. and biomechanics of
Pelvis in cen.. ical nucleus pulposus. 292 fool. 240. 251-232
gait cycle kinem.ltics of. 447-448 of tendons and lig:UllCntS. 105-106 Shouldcl: 319
i- kinematics of. 266-267 Proximal interphalang"'al (PIP) joints. injuries of. 323-324
f Pcrimalleobl" muscles, 455 362,374 rotator cuff lear. 334
Perimysium. 149-150 lkxor tendon sheath pulley system SLAP lesion. 324
Perineurium. 129. /30 of,370 subacromial impingement syndrome.
Periosteum. 28, 30 in passive control of wrist, 365-366 334
Peripheral nerves. 127. /28 range of motion of. 378-379 instability of. 327
biomechanical behavior of. 133-139 tendinous mechanisms of. 371-374 joint capsule of. 325-327
blood-nerve bmTicr in, 133 Psoas muscle. 265-266 joinls/articulations of. 319
compressive injury of, 135-136, /45 lens ion of, and spinal loading, acromioclavicular, 321-322
critical prcssure levels in. 136 269-271 glenohumeral. 322-327
mechanical aspects of. 137-139 scapulothoracic. 327-328
presstll-c application modes in. 136 stcmoclavicuI<\r. 320-321
pressure duration \·5 pl·cssure Icvel Q kinematics of. 319-328
in. 139 Quadralus lumbomnl muscle. 265-266 spinal conlIibution lO. 328
connective tissue of. 129, /30 Quadliceps kinelics of, 328-337
funclion of. 127-129 function of, in knee joint, 196. extension, 334
Illvdinaled, 127-129. /30 in gait cycle. 453 external rotation, 333-334
st;..lclure of. 127-129. /29. /30 in knee motion, 196-199 forward elevation. 332-333
tensile injtll)· of. 134-135 glenohumeral joint loads in.
\·asclilar svstcm of. 129-131 335-336
Peroneal ml;sc!cs. 237. 455-456 R internal rotation. 334
Pcs phll1us. 237. 238 Radial arter\" 365 pitching, 336
Phalanges, of fingers, 359.36/.362 Radial collaieralligament. 366 scapulolhoracic. 334-335
~
l!lo. .~~c
Shouldel'--coll 1i Hl ted tensile o\·el"1o<ld of. 161-163 St:.Iil- climbing, lower leg in. 190
ligaments of. 325-317 types of, 149 Sumcc phase, ..\-10-4-11
muscul<lture of, 329-331 work performed by, 149, ISg-160 londs on foot in. 239-240
mechanics of, 331-337 dynamic. 159-160 St:.\nding. biortlcch.lllics of
osseous .motom\' of. 319-328 static, 159 Celltel: of pressure (COPl in, 421-42.2
range of motion' of. 3! 9 Skeletal system, 27 eye and hand movemcnt in. 42.4-425
Sf metric system, 19 SLAP lesi~n, 324 flal joint \'S ball and socket joint in.
SI units Slip lines, 34 426-427
base. 19 Smooth mllsch.~. 149 foot and ankle joilll in. 422--U.t.
conversion of. 221. 23 SO (slow twitch oxidative) fibcl's.165-167 mass center of gravity in. 421-422
definitions of. 20t Soleus muscle . ..\5-1, 455, 456 peh·ic kinematics in, 425-426
derived. 19 Spinal anhrodesis, 306, 308 postural and phasic mllscles in, 421-422
multiplication factors and, Zit Spinal cord injury reaching while, -U5
named artci' scienlists, 21-23, 21t and cen'icnl mechanics, 294-296 stooped-posture while, -124
prefixes of, 21t without radiogl'aphic abnOlll1ulitics. Stmics.6-7. 185. 187
specially named, 20-21 295-296 free-bock dia~r~lIns in, 188-190
suppkmcntm}'. 19 Spinal implnnt li.'\ation dcvict:s. 397 Sttcrs Rlll~ of '[hirds, 303
svlllbois for, 211 Spinal n('",..e(s), 127, /28 Step, 442
Sitting, biomechanics of. 427-431 embryologic development of. 131 Step frequency, 443
amm::st support in. 427 peripheral, 127 SICP length, ..\42
backn..' st support in, ..\28 roots of. 127, 131 Step width, 442
in bcd, 434-435 Spinal nerve roOts. /28, /3/ S('modaviclll~u- joint. 3/9
at cOlllpUler workstation . ..\27 analOm'· of, 131-13.2 :'Ul<ltomv/kinematics of. 320-321
nnd decubitus ulcer dc,·c1opmcllt. -134 biomechanic:.ll behavior of. 139-144 Steroid ll~e. tendons and lignmcnts ill.
hei.ld :'llltcncxion in, -n0-431 blood-nCIYC barrit.'r in, 133 117
hend rcst angle in, .t.29-430 compression injury of. 132 Strain
leg-crossing in, 432-.03 compression of linc:'I1'.32
maximnl SUppOI-t in, -128-429 expedmelllai. 141-1..\2 nOll1131, 8-9. /0
neck pnin in. -130-431 expaimcntal chronic, 1-13-1-1-1 I:\tc depcndem:y of bone. 4-l--I5,-I6
problem arei.IS in. 431~32 multiplc k'\'ds of. 143 sh..:.ar. 8-9, /0. 32
seating :.lngle in, ..\28-431 onset raw of. 141-143 Strain gauge, 33
at tabk:, 430-..\31 connectivl: tissul: of. 131 Stress, 32
Skeletal muscle, 149-150 motor, 131 normal. 7-8
activity of. :.md sO'ess distribution in ph:,-'siology ()f.131-131 principal. 13-14
·bone, 43-..\4 sensory. 131 shc:.u·. 7-8, 9
.au3chment of. lO bone. 149 vascular system of. 132-133 units of measurClllent of. 31
banding pa[[em of. 149-153 Spin;ll slcnosis. 295 Strl.·ss r:.liser. 49-50
biomcchanical behavior of. 160- I65 Spine. 257-258 Siress-relaxation experiment, /3
composition of, muscle fiber, 149-153, Clllyature or, 267-268, 2$7 Slress-rdax:.uion response
165-167 fatigue fracturcs of. 271 of articular c.:artilallc. 73-7-1
contraction of fllnctionnlunit of. 257-260 of tendons and Iig;menls, III, // i
mechanics of. 156-160 (eSling, 296. 297 Stress-strain diagl.ll1ls, 9-10
molecul.u- basis of. 153-155 instnnt Center pathway of. 264 SU'ctch test, for subaxial instability,
Slllllmntion :.md tet:.mi<:. 157-158 intcrycrtebmi discs of. 258, 28S. 304.305
typt:s of. (58-160 291. 293 Stride. 442-443
work types and, 158-160 kinematics of. 260, 301-30.2 Stridc analysis, 439-440
force production in, 160 muscle <:letion in. 264-267 Stride length, 442
fatigue crfect in, 164-165 range of motion in, 262-163 Stridc time, 442
fOfc:c,timc relationship of. 162 surface joint motion in. 262-263 Subacromial impingement syndrome. 334
length-tension relationship of. kinematics of shouldel" and. 319-328 Subaxinl spine. 287. 290-291
160-161 kinetics of. 274-180 COli pled motion of, 299-300
10:ld-"elocil)' relationship of. 161-162 ligaments of. 257, 260. 293 inswbilit\' of. 303-305
muscle architecture cffLoct in, 162-163 loads on diagnosis checklist for, 3051
pn:stl'Ctching effect in, 163 dvnamic analvsis of. 273-280 stretch test for. 304, 305
temp<:falUrC effect in, 163-16-1 sianding, 268~269 fange of Illotion of. 297-298
function of. 149 st<:ltic annlvsis of. 268-273 Subtalar joint
functional unit of. 155-156 mechanic:.l! j>roperties of components !:!:'lit c\'cle kinematics of. 4-15-146
injurit.'s of. 167 of. 292-296 gtlit c)'c!c muscle :.lcti"ity of. 455-456
extrinsic factors in, /72 motion of. 263-.264 ligaments of. 249
intrinsic faclors in, /7/ motion segment of. 257-260, 288 motion of. 229-231
innervation of. /54 muscles in movement of, 264-267 ankle and, 226, 228, 230, 249,
motor unit of. 155-156 flexor and e.xtensor, 265-266 445-446
musculOlcndinous unit of. 156 lateral flexor and rotation. 266 Summation, 157
I rcmodeling. 167 pelvic motion and. 266-267':" Supin:.llor muscle. 350
disuse and immobilization in. neural dements of, 29-1-296 Supplemelllary SI units. 19
167-168 stability of, 301-302 definitions. lOt
j physicallraining in, 168-169
repair or. 167
structure of. 257-260
vertebrae of. 287, 291-293
Supraspinolls ligaments, 288
Surfact: joint motion, 180-181
II
structurc and organization of. 149-153. Spondylolisthesis, 262 Swing phase. 440--141
170 Spring ligaments. 235-236 Symbols, 51 units. 211
}
I
L,,· " " '-" =.5=~.=~5'~_~" '_=~,~_~= " , , " " "' ' ' ' ' ' >~,' ', =~" '" , " -=" ' ' ' ' ' ',", ,~=.,Z:; ' "~".' . ' .' ' ',,,...-..,....,...."'.);"'~.'P~:."':"~." ," ", ' ' ;' ' Jf" J,'l 'r2'.~,.-';·~[,:· : :". ,_", . {; ;,. ·{ . ;o ;, ~; .,"0V§._ ,."'~K<, ',;:J1~?:. ~='; ",'.;'~; 'l<",il';~; ~-,
1iJ,"4;'J. •.
Syndesmotic ligaments. 223 scn.'w·llOme mechanism of, V
. componenls ~)f. 245-246 182-183, /5,'4 \'eclOrs, 3
Svndeslllotir.: stabilitv. of ankle, 249 statics of. 188 fon:e, 3-4
S~·novial joims. 61 . surf'lee join[ motion of, 181-185 moment, 4-5
System Intemational d'Unites (SO, 19 Tibioflblll~u· joint, 223, 225 torque, 4-5
Tibiofibular ligaments, 245-248 Velocitv, 443
injun· to, 245-249 Ventrai/molor roots, /28, 131
T TibicHalar joint, 223, 225 Vertdmlc, 287
l' system, 153 Titin filaments, 149-150 failure of. loads causing, 271-273, 291,
l~)locrural joint. 245-246 arrangement in sarcomere, lSI 293
gait cycle kinematics of, 445 Toe(s) mechanical properties of, 292-293
gait cvcle muscle action of. 453-455 claw, 237 Vertebral arthrodesis, 306, 308
Talofil1lilar ligament(s), 245-248 extensor muscles of. 233-234 Vertebral bodies, 258
injury to, 245-249 cxtdnsic muscles of. 233-234 cervical. 290
Talonavicular joint, 229, 230 great, 231-233 Viscoelastic material behador,12
Talus. 241-242 hammer, 237 Viscoelasticitv, 11-13
load distribution on, 25/ intrinsic muscles of, 233-234 Volar plate, 3"71
Tarsal joint motion, transvcrse, 229-231 k'ssel~ joint motion of. 233-234 Volkmann's canals, 28, 30
Tarsometatarsal joint motion, 230-231, mallet: 237
233-234 Toeing, -in and -out, 446
Tendons Torque vcctors, 4-5 W
biomechanical behavior of. 108 Trabeculac, 28, 29 \Vear, 88
physiological loading and, 110-111 Trabecular bone, 29 \\'eight, and bone mass, 51-52
viscoelastic. 111-112 TransfCl" lesions, 233-234 \Vhi~plash s~·ndromc, 312-314
biomechanic;:1! properties of. 109-110 Transverse ligament \Vindlass effect, on arch of foot, 235-236
in aging, 115 of acetabul"um, 204 WollTs law, 51
in diabetcs mellitus, 116-117 of atlas, instabilit\" of. 302, 303 \Voven bone, 29-30
in grafts, 117-118 Transvcrse tarsal joint, axes of. 23/ Wrist joint. 359, 360
in hemodialysis, 117 Trans\"crsc tarsal :joint motion, articulations of. 359
in immobilization/cxercise, 229-231 blood supply of. 365
115-li6 Transversus abdominis muscle, control mechanisms of
in nonsteroidal anti-inflarmnatory 278-279 active. 374
drug use. 117 Trendclenburg gnit pallern, 449 bonv, 365-366
in pregnancy/postpanum period, liS Trendelcnburg's test. 209 ]jga;l1entous, 366-368
in steroid usc, 117 Triangular flb~·ocartilage complex n;llscular, 374
components of, 103-108, 103r (TFCC) passive, 365-368
diffusional nutl'ition of. 107 components of, 359,36/,366.368 functional motion of, 380-381
elasticitvof, 110 kinematics of wrist and, 368 hand motion and motion of, 381
functiOil of. 103 radial migration and, 348-350, 352 kinematics of. 375
injury and failure mechanisms of. Triceps muscle, 350, 352 flexion and extension, 376
112-115, /21 Triquctnlln, 359 forearm pronation and supination,
innervation of. 107 Tl"ochlcoginglymoid joint, 341 376-377
insertion of, into bone, 108 Tnlchoid joint, 341 radial and ulnar deviation, 376, 377
muscle attachment to bone, 149 Tropocollagen moleculcs, 61-62 kinetics of, 380-381
structural arrangement of Tropomyosin, in skeletal muscle, 150 ligaments of. 366-367, 367t
fiber, 104-105, /06 Troponin, in skeletal muscle, ISO ~d()rsal extrinsic, 366
outer, 108 Trunk intl·insic, 366, 368
tensilc strength of, compared to llexor and extensor muscles of, 279 palmar extrinsic, 366
muscle, 114-115 gait cvcle kinematics of. 447-448 palmar radiocarpal. 366
\"ascular svstem of, 106-107 ;nuscie co-contraction in, 279, 280 muscles of. 363r
viscoelasticitv of, 111-112 T"\ve I muscle fibers. 165-167 extrinsic and intrinsic, 350, 365
Tenosynovitis, ~le Ouen"ain's. 374 Type IlA muscle fibers, 165-167 Ilexor and extensor, 374-376
Tensors, 3 Type 1m musclc fIbers, 165-167 nelyeS of. 362, 364-365
Terminal cisternae, 152. /53 osscus slructUI"e of. 359, 360
Tetanic muscle contraction, 157-158 range of motion of, 375-377
Thumb U rep~titive motion injury of. 374
functional motion of, 380 Ulna, 341-342 tendons of. 374-376
in prehensile hand functions, 383-385 distaL articulation of, 359 tl'iangular fibrocanilage complex and,
Tibial plateau, stresses on, 193-194 Ulnar arter\", 365 368
Tibialis muscles, 237 Ulnar nen"~, 364
in gait cvcle, 455-456 Ulnocarpal complex, 359 y
Tibiol·emo;·al joint Ulnocarpal space, 359 Yield point, 34
derangel11e;1ts of. 182-185 Uncinate processes, of cervical \"ertebrae. Young's modulus, 33
dvnamics of, 190-194 291
I-ielfet test of. 184, /86 LJncovertebral joints, of cervical
instant ccnter pathway of. 181-182 vel"teb·rae, 291 z
range of motion of, 179-180 LJnicondylnr dianhroidal joints, 378 Z lille(s). 151, /52