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DUTTON’S ORTHOPAEDIC
EXAMINATION, EVALUATION,
AND INTERVENTION
Dutton FM_pi-xiv.indd 1 11/07/19 10:15 AM

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DUTTON’S ORTHOPAEDIC
EXAMINATION, EVALUATION,
AND INTERVENTION
FIFTH EDITION
Mark Dutton, PT
New York Chicago San Francisco Athens London Madrid Mexico City

Milan New Delhi Singapore Sydney Toronto

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cause whatsoever whether such claim or cause arises in contract, tort or otherwise.
For my parents,
Ron and Brenda, who have always helped, guided, and inspired me
and to my two daughters, Leah and Lauren, who provide me with such joy.

Your Legacy
Will you have earned the respect of your peers and the admiration of your critics?
Will you have acted humbly during success and gracefully in the face of adversity?
Will you be remembered for how often you brought smiles to the hearts of others?
Will you have looked for the very best, and done your utmost to build worth, in others?
Will you have left this world a better place by the life you have lived?
Modified from The Legacy You Leave ©2000 by Rick Beneteau

Contents
Preface ix
SECTION IV
Acknowledgments xi
Introduction xiii THE EXTREMITIES
16 The Shoulder 555
17 Elbow Complex 676
SECTION I 18 The Forearm, Wrist, and Hand 739
ANATOMY 19 Hip Joint Complex 824
1 The Musculoskeletal System 3 20 The Knee Joint Complex 922
2 Tissue Behavior, Injury, Healing, and Treatment 28 21 Lower Leg, Ankle, and Foot 1024
3 The Nervous System 61
SECTION V
SECTION II THE SPINE AND TMJ
EXAMINATION AND EVALUATION 22 Vertebral Column 1123
4 Patient/Client Management 163 23 The Craniovertebral Region 1141
5 Differential Diagnosis 214 24 Vertebral Artery 1175
6 Gait and Posture Analysis 279 25 The Cervical Spine 1183
7 Imaging Studies in Orthopaedics 329 26 The Temporomandibular Joint 1259
27 The Thoracic Spine 1295
28 Lumbar Spine 1335
SECTION III 29 The Sacroiliac Joint 1417
INTERVENTION
8 The Intervention 353 SECTION VI
9 Pharmacology for the Orthopaedic
Physical Therapist 380 SPECIAL CONSIDERATIONS
10 Manual Techniques 398 30 Special Populations 1453
11 Neurodynamic Mobility and Mobilizations 423
12 Improving Muscle Performance 440 Index 1501
13 Improving Mobility 498
14 Improving Neuromuscular Control 533
15 Improving Cardiovascular Endurance 544
vii

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Preface
The fifth edition of this book is an update of information and highlights the fact that the “physical therapy profession will
bibliography provided in the previous versions together with define and promote the movement system as the foundation
a reorganization of various chapters. for optimizing movement to improve the health of society.”2
The 2017 Global Burden of Disease study revealed that To that end, this book aims to provide the reader with a
musculoskeletal disorders are the second biggest contributor systematic and evidence-based approach to the examination
to disability worldwide.1 The United States currently spends and intervention of the orthopaedic patient from the viewpoint
more money on healthcare per person than any other country of an expert on the movement system. Such an approach must
in the world, with current projections indicating that the be eclectic because no single method works all of the time.
United States will spend 20% of the gross domestic product Thus, this book attempts to incorporate the most reliable
on healthcare by the year 2019.1 As the population continues concepts currently available.
to age, the treatment of musculoskeletal conditions, and their I hope that this book will be the best available textbook,
subsequent expenses, will also increase. This financial burden guide, review, and reference for healthcare students and
will place an increasing pressure on the orthopaedic clinician clinicians involved in the care of the orthopaedic population.
to provide value for money—the achievement of a health
outcome relative to the costs incurred. Gone are the days Mark Dutton, PT
when a clinician can rely on an expensive shotgun approach
to treatment. Instead, the emphasis must now be placed on
outcomes such as patient satisfaction and accurate measures REFERENCES
of clinical outcomes, for it is the consistent measurement and 1. Disease GBD, Injury I, Prevalence C. Global, regional, and national
reporting of clinical outcomes that are the most powerful incidence, prevalence, and years lived with disability for 328 diseases and
tools in moving toward a value-based system.2 injuries for 195 countries, 1990-2016: a systematic analysis for the Global
Burden of Disease Study 2016. Lancet. 2017;390:1211–1259.
The APTA’s current vision statement, “Transforming society
2. Sahrmann SA. The human movement system: our professional identity.
by optimizing movement to improve the human experience,” Phys Ther. 2014;94:1034–1042.
Comments about this book may be sent to me at pt@mcgraw-hill.com.
ix


Acknowledgments
From inception to completion, the various editions span to Michael Weitz for his advice and support and to other
almost 15 years. Such an endeavor cannot be completed members of the team.
without the help of many. I would like to take this opportunity ▶▶ To the production crew at Cenveo, especially the project
to thank the following: manager, Radhika Jolly.
▶▶ The faculty of the North American Institute of Manual ▶▶ Bob Davis for his creative eye and the excellent
and Manipulative Therapy (NAIOMT)—especially, photography.
Jim Meadows, Erl Pettman, Cliff Fowler, Diane Lee, and
▶▶ Leah for agreeing to be the photographic model.
the late Dave Lamb.
▶▶ To the countless clinicians throughout the world who
▶▶ The exceptional team at McGraw-Hill, for their superb
continually strive to improve their knowledge and
guidance throughout this object. Thank you especially
clinical skills.
xi


Introduction
“The very first step towards success in any occupation is combining clinical expertise with the best available external
to become interested in it.” clinical evidence, clinicians can make informed decisions
regarding patient management, including the selection and
—Sir William Osler (1849–1919) interpretation of the most appropriate evaluation procedures.
Also, intervention strategies based on the best available
Until the beginning of the last century, knowledge about the evidence will have a greater likelihood of success with the
mechanism of healing and the methods to decrease pain and least associated risk.
suffering were extremely limited. Although we may scoff at The goal of every clinician should be to enhance patient/
many of the interventions used in the distant past, many of client satisfaction, increase efficiency, and decrease unproven
the interventions we use today, albeit less radical, have still to treatment approaches. The management of the patient/client
demonstrate much more in the way of effectiveness. That may is a complex process involving an intricate blend of experience,
soon change with the recent emphasis within many healthcare knowledge, and interpersonal skills. Obtaining an accurate
professions on evidence-based clinical practice. The process diagnosis requires a systematic and logical approach. Such
of evidence-based practice is outlined in Table I-1. When an approach should be eclectic because no single method
works all of the time. For any intervention to be successful,
an accurate diagnosis must be followed by a carefully planned
TABLE I-1 The Process of Evidence-Based Practice
and specific rehabilitation program to both the affected area
1. Identify the patient problem. Derive a specific question. and its related structures. In this book, great emphasis is placed
2. Search the literature. on the appropriate use of manual techniques and therapeutic
3. Appraise the literature. exercise based on these considerations. Electrotherapeutic
4. Integrate the appraisal of literature with your clinical expertise, and thermal/cryotherapeutic modalities should be viewed
experience, patient values, and unique circumstances. as adjuncts to the rehabilitative process. Please go to www
5. Implement the findings. .accessphysiotherapy.com, for numerous video clips of manual
6. Assess outcome and reappraise. techniques and therapeutic exercises, which the reader is
encouraged to view. The following icon is used throughout
Data from Sackett DL, Strauss SE, Richardson WS, et al. Evidence Based
Medicine: How to Practice and Teach EBM. 2nd ed. Edinburgh, Scotland: the text to indicate when such clips are available. [VIDEO]
Churchill Livingstone; 2000.
xiii


SECTION I ANATOMY
Dutton_Ch01_p0001-p0027.indd 1 10/07/19 11:25 AM


The
CHAPTER 1 Musculoskeletal
System
CHAPTER OBJECTIVES OVERVIEW

At the completion of this chapter, the reader will be The correct embryonic development of the musculoskeletal
able to: system requires a coordinated morphogenesis of the fun-
damental tissues of the body. Throughout the human body,
1. Describe the various types of biological tissue of the there are four major types of tissues:
musculoskeletal system. ▶▶ Epithelial. Epithelial tissue covers all internal and
2. Describe the tissue mechanics and structural differences external body surfaces and includes structures
and similarities between muscle, tendons, fascia, and such as the skin and the inner lining of the blood
ligaments. vessels.
▶▶ Connective. Connective tissue (CT) includes four
3. Describe the different types of joints and their various
different classes: CT proper, bone, cartilage, and blood
characteristics.
tissue. In the embryo, muscle tissue and its fascia form
4. Define the various terminologies used to describe the as a differentiation of the paraxial mesoderm that
joint position, movements, and relationships. divides into somites on either side of the neural tube
and notochord. The cartilage and bone of the vertebral
5. Give definitions for commonly used biomechanical terms.
column and ribs develop from the sclerotome, which
6. Describe the different planes of the body. is the anterior (ventral) part of the somite.1,2 The
dermomyotome, which is the posterior (dorsal) part of the
7. Define the body’s center of gravity and its location.
somite, gives rise to the overlying dermis of the back and
8. Describe the different axes of the body and the motions the skeletal muscles of the body and limbs.2 CT provides
that occur around them. structural and metabolic support for other tissues and
organs of the body.
9. Define the terms osteokinematic motion and
▶▶ Muscle. Muscles are classified functionally as either
arthrokinematic motion.
voluntary or involuntary, and structurally as either
10. Differentiate between the different types of motion that smooth, striated (skeletal), or cardiac. There are
can occur at the joint surfaces. approximately 430 skeletal muscles in the body, each of
11. Describe the basic biomechanics of joint motion in which can be considered anatomically as a separate organ.
terms of their concave–convex relationships. Of these 430 muscles, about 75 pairs provide the majority
of body movements and postures.2
12. List the different types of levers found within the body
▶▶ Nervous. Nervous tissue provides a two-way
and provide examples of each.
communication system between the central
13. Describe the difference between a closed kinematic nervous system (brain and spinal cord) and muscles,
chain and an open kinematic chain and how each can sensory organs, and various systems
influence an exercise prescription. (see Chapter 3).
14. Define the terms close-packed and open-packed and the
significance of each.

The various types of CT, as they relate to the musculoskel-
CONNECTIVE TISSUE etal system, are described in the following sections.
CT proper has a loose, flexible matrix, called ground sub-
stance. The most common cell within CT proper is the fibro-
Fascia
blast. Fibroblasts produce collagen, elastin, and reticular Fascia, for example, the thoracolumbar fascia and the plan-
fibers: tar fascia, is viewed as a loose CT that provides support and
protection to a joint, and acts as an interconnection between
▶▶ Collagen is a group of naturally occurring proteins. The
tendons, aponeuroses, ligaments, capsules, nerves, and the
collagens are a family of extracellular matrix (ECM)
intrinsic components of muscle.2 Fascia may be categorized
proteins that play a dominant role in maintaining the
as fibrous or nonfibrous, with the fibrous components con-
structural integrity of various tissues and in providing
sisting mainly of collagen and elastin fibers, and the nonfi-
tensile strength to tissues. The ECM is formed from
ANATOMY
brous portion consisting of amorphous ground substance.2

glycosaminoglycan (GAG) subunits that are long
Three different types of fascia have been identified, namely,
polysaccharide chains containing amino sugars and
superficial, deep, and visceral. Various three-dimensional
are strongly hydrophilic to allow rapid diffusion of
biomechanical models of the human fascial system have been
water-soluble molecules and the easy migration of
developed, which correlate dysfunctional movement with
cells. Proteoglycans, which are a major component of
various interrelated abnormal amounts of tension through-
the ECM, are macromolecules that consist of a protein
out the network of fascia. In particular, deep fascia has been
backbone to which the GAGs are attached. There are two
implicated in being involved with the deep venous return, in
types of GAGs: chondroitin sulfate and keratin sulfate.2
having a possible role in proprioception, and responding to
Glycoproteins, another component of the ECM, consist of
mechanical traction induced by muscular activity in different
fibronectin and thrombospondin and function as adhesive
regions.5 However, there is still little evidence to justify such
structures for repair and regeneration.2,3
claims. Histological studies of deep fascia in the limbs show
▶▶ Elastic fibers, as their name suggests, are composed of a
that it consists of elastic fibers and undulated collagen fibers
protein called elastin, which provides elastic properties arranged in layers.6 Each collagen layer is aligned in a differ-
to the tissues in which it is situated.4 Elastin fibers can ent direction, and this permits a certain degree of stretch as
stretch, but they normally return to their original length well as a capacity to recoil.
when the tension is released. Thus, the elastic fibers of
elastin determine the patterns of distention and recoil in Tendons
most organs, including the skin and lungs, blood vessels,
and CT. Bundles of collagen and elastin combine to form a Tendons are dense, regularly arranged CTs that attach muscle
matrix of CT fascicles. This matrix is organized within the to the bone at each end of the muscle. At first glance, tendons
primary collagen bundles as well as between the bundles appear to be very simple rope-like structures. However, closer
that surround them.2 inspection reveals that the structure and material properties
▶▶ Reticular fibers are composed of a type of collagen that
of tendons are not universal, and therefore, each tendon can-
is secreted by reticular cells. These fibers crosslink to not be treated in the same manner as another. Medical imag-
form a fine meshwork, called reticulin, which acts as a ing today allows clinicians and researchers to more precisely
supporting mesh in bone marrow, the tissues and organs characterize the tendon structures that provide the tendon
of the lymphatic system, and the liver. with its physiological capacity. The predominant cell type
found in a tendon is the tenocyte, a structure that is sensi-
The various characteristics of collagen differ depending on tive to the mechanical loading environment and is capable of
whether it is loose or dense collagen. The anatomic and func- controlling tendon structure.7
tional characteristics of loose and dense collagen are summa- The collagen-forming triple helices (tropocollagen) of the
rized in Table 1-1. Collagenous and elastic fibers are sparse tendon pack together to form microfibrils, which interdigi-
and irregularly arranged in loose CT but are tightly packed tate to form fibrils, which coalesce to form fibers, which com-
in dense CT. bine to form fascicles, which in turn are bundled together to
TABLE 1-1 Loose and Dense Collagen

Joint Type Anatomic Location Fiber Orientation Mechanical Specialization
Dense irregular Composes the external fibrous layer of Parallel, tightly aligned Ligament: binds bones together and restrains
connective the joint capsule, forms ligaments, fibers unwanted movement at the joints; resists
tissue bone, aponeuroses, and tendons tension in several directions
Tendon: attaches muscle to bone
Loose irregular Found in capsules, muscles, nerves, fascia, Random fiber orientation Provides structural support
connective and skin
tissue

form a tendon.8 Tendon accommodates a high-tensile loading mechanical properties that confer time- and rate-dependent
environment through a multiscale structural design: polypep- effects on the tissue. Specifically, tendons are more elastic at
tide hydrogen bonds create the strong triple-helical structure lower strain rates and stiffer at higher rates of tensile loading
of a single collagen molecule; covalent bonds cross-linking (see Chapter 2). Tendons deform less than ligaments under
between collagen molecules (fibrils) allow collagen fibers an applied load and are thus able to transmit the load from
to withstand enormous forces; collagen fibers are bundled muscle to bone.7
together within an ECM (fascicles) that limits the extent of
neurovascular infiltration and maximizes mechanical integ-
rity; and bundling of fascicles into primary, secondary, and CLINICAL PEARL
tertiary fiber bundles reduces the impact of local fibril fail- ▶▶ At low rates of loading, tendons are more viscous or
ure on the whole tissue.9,10 The position and length of ten- ductile and, consequently, can absorb more energy
dons enable the muscle belly to be an optimal distance from compared to high loading rates.13
The Musculoskeletal System

the joint upon which it is acting. This creates space, but also ▶▶ At high rates of loading, tendons become more brittle
allows the tendon to work like a lever arm (see Levers later), and absorb less energy, but they are more effective at
moving the point of action away from the center of rotation transferring loads.13
(COR), thereby reducing the forces required for movement.7
Also, due to their design, tendons provide a graduated change Therefore, tendon load can be increased in one of two
in material characteristics, which minimizes the development ways when prescribing exercise: by the external load or by
of areas of stress concentration where failure would likely the speed of movement.13
occur.
Tendons must be sufficiently stiff to enable efficient force Patients with tendinopathy display tendons that are thicker,
transfer from the muscles to produce joint motion, but they but with reduced energy-storing capacity, meaning that for
must also incorporate a degree of elasticity to enable them to the same load, their tendons exhibit higher strains than those
stretch and store elastic energy.7 Other tendons must modu- of healthy individuals.14 Material and structural properties of
late muscle contraction with extreme precision to allow it to the tendon increase from birth through maturity and then
perform intricate activities such as writing.7 The thickness of decrease from maturity through old age.8 Although tendons
each tendon varies but is proportional to the size of the mus- withstand strong tensile forces well, they resist shear forces
cle from which it originates. Vascularity within the tendon is less well and provide little resistance to a compression force
relatively sparse, but the extent of vascularity is not univer- (see Chapter 2). In addition to the primary load-bearing
sally the same, and those tendons with less vascularity may part of the tendon, there is an extensive network of sep-
be more vulnerable to both progressive degeneration and a tae (endotendon), where the nerves and vessels are mainly
reduced healing potential.11 Within the fascicles of tendons, located.14
which are held together by loose CT called endotenon, the A tendon can be divided into the following three main
collagen components are oriented in a unidirectional way. sections15:
Endotenon contains blood vessels, lymphatics, and nerves,
and permits longitudinal movements of individual fascicles ▶▶ The bone–tendon junction. At most tendon–bone
when tensile forces are applied to the structure. The CT sur- interfaces, the collagen fibers insert directly into the bone
rounding groups of fascicles, or the entire structure, is called in a gradual transition of material composition. The
the epitenon. The epitenon contains the vascular, lymphatic, physical junction of tendon and bone is referred to as an
and nerve supplies to the tendon. A peritendinous sheath enthesis16 and is an interface that is vulnerable to acute
(paratenon), which is composed of loose areolar CT in addi- and chronic injury.7,17 One role of the enthesis is to absorb
tion to sensory and autonomic nerve fibers, surrounds the and distribute the stress concentration that occurs at the
entire tendon.12 This sheath consists of two layers: an inner junction over a broader area.
(visceral) layer and an outer (parietal) layer with occasional ▶▶ The tendon midsubstance. Overuse tendon injuries can
connecting bridges (mesotenon). The paratenon is richly vas- occur in the midsubstance of the tendon, but not as
cularized and is responsible for a significant portion of the frequently as at the enthesis.
blood supply to the tendon via a series of transverse vincula, ▶▶ MTJ. The MTJ is the site where the muscle and tendon
which function as passageways for blood vessels to reach the meet. The MTJ comprises numerous interdigitations
tendon. In addition, the blood supply to the tendon comes between muscle cells and tendon tissue, resembling
from two other sources: the musculotendinous junction interlocked fingers.
(MTJ) and the osseous insertion.
Ligaments
CLINICAL PEARL
Skeletal ligaments are fibrous bands of dense CT that connect
Paratenon lined with synovial cells of a variable structure is bones across joints. Ligaments can be named for the bones
called tenosynovium, while one with a double layer sheath into which they insert (coracohumeral), their shape (deltoid
without synovial cells is known as tenovagium.2 of the ankle), or their relationships to each other (cruciate).18
The gross structure of a ligament varies according to location
The mechanical properties of tendon come from its highly (intra-articular or extra-articular, capsular) and function.19
oriented structure. Normal tendons display viscoelastic Ligaments, which appear as dense white bands or cords of 5

CT, are composed primarily of water (approximately 66%) and nerves.2 Most of the bones of the body form first
and collagen (largely type I collagen [85%], but with small as hyaline cartilage, and later become bone in a process
amounts of type III) making up most of the dry weight.2 The called endochondral ossification. Articular cartilage
collagen in ligaments has a less unidirectional organization functions to distribute the joint forces over a large
than it does in tendons, but its structural framework still pro- contact area, thereby dissipating the forces associated
vides stiffness (resistance to deformation—see Chapter 2). with the load. This distribution of forces allows the
Small amounts of elastin (1% of the dry weight) are present articular cartilage to remain healthy and fully functional
in ligaments, with the exception of the ligamentum flavum throughout decades of life. The normal thickness of
and the nuchal ligament of the spine, which contain more. articular cartilage is determined by the contact pressures
The cellular organization of ligaments makes them ideal across the joint—the higher the peak pressures, the
for sustaining tensile loads and for tightening or loosening thicker the cartilage.19 For example, the patellar has the
in different joint positions. At the microscopic level, closely thickest articular cartilage in the body.
ANATOMY
spaced collagen fibers (fascicles) are aligned along the long ▶▶ Articular cartilage may be grossly subdivided into
axis of the ligament and are arranged into a series of bundles
four distinct zones with differing cellular morphology,
that are delineated by a cellular layer, the endoligament, and
biomechanical composition, collagen orientation, and
the entire ligament is encased in a neurovascular biocellular
structural properties, as follows:
layer referred to as the epiligament.18 Ligaments contribute to
■■ The superficial zone. The superficial zone, which lies
the stability of joint function by preventing excessive motion,
acting as guides or checkreins to direct motion, and provid- adjacent to the joint cavity, comprises approximately
ing proprioceptive information for joint function through 10–20% of the articular cartilage thickness and
sensory nerve endings (see Chapter 3) and as attachments functions to protect deeper layers from shear stresses.
to the joint capsule.2 Many ligaments share functions. For The collagen fibers within this zone are packed tightly
example, while the anterior cruciate ligament of the knee is and aligned parallel to the articular surface. This zone
considered to be the primary restraint to anterior translation is in contact with the synovial fluid and handles most of
of the tibia relative to the femur, the collateral ligaments and the tensile properties of cartilage.
the posterior capsule of the knee also help in this function ■■ The middle (transitional) zone. In the middle zone,
(see Chapter 20).18 The vascular and nerve distribution to which provides an anatomic and functional bridge
ligaments is not homogenous. For example, the middle of the between the superficial and deep zones, the collagen
ligament is typically avascular, while the proximal and dis- fibril orientation is obliquely organized. This zone
tal ends enjoy a rich blood supply. Similarly, the insertional comprises 40–60% of the total cartilage volume.
ends of the ligaments are more highly innervated than the Functionally, the middle zone is the first line of
midsubstance. resistance to compressive forces.
■■ The deep or radial layer. The deep layer comprises 30%
Cartilage of the matrix volume. It is characterized by radially
aligned collagen fibers that are perpendicular to the
Cartilage tissue exists in three forms: hyaline, elastic, and
surface of the joint and have a high proteoglycan
fibrocartilage.
content. Functionally the deep zone is responsible for
▶▶ Hyaline cartilage, also referred to as articular cartilage, providing the greatest resistance to compressive forces.
covers the ends of long bones and permits almost ■■ The tidemark. The tidemark distinguishes the deep
frictionless motion to occur between the articular surfaces zone from the calcified cartilage, the area that prevents
of a diarthrodial (synovial) joint. Articular cartilage is the diffusion of nutrients from the bone tissue into the
a highly organized viscoelastic material composed of cartilage.
cartilage cells called chondrocytes, water, and an ECM.
▶▶ Elastic (yellow) cartilage is a very specialized CT,
primarily found in locations such as the outer ear and
CLINICAL PEARL portions of the larynx.
Chondrocytes are specialized cells that are responsible for ▶▶ Fibrocartilage, also referred to as white cartilage,
the development of cartilage and the maintenance of the functions as a shock absorber in both weight-bearing
ECM. Chondrocytes produce aggrecan, link protein, and and non–weight-bearing joints. Its large fiber content,
hyaluronan, all of which are extruded into the ECM, where reinforced with numerous collagen fibers, makes it ideal
they aggregate spontaneously.2 The aggrecan forms a for bearing large stresses in all directions. Fibrocartilage
strong, porous-permeable, fiber-reinforced composite is an avascular, alymphatic, and aneural tissue and derives
material with collagen. The chondrocytes sense mechani- its nutrition by a double-diffusion system.2 Examples
cal changes in their surrounding matrix through intracy- of fibrocartilage include the symphysis pubis, the
toplasmic filaments and short cilia on the surface of the intervertebral disk, and the menisci of the knee.
cells.19
Bone
▶▶ Articular cartilage, the most abundant cartilage within Bone is a highly vascular form of CT, composed of collagen,
6 the body, is devoid of any blood vessels, lymphatics, calcium phosphate, water, amorphous proteins, and cells. It is

TABLE 1-2 General Structure of Bone
Site Comment Conditions Result
Epiphysis Mainly develops under pressure Epiphyseal dysplasias Distorted joints
Apophysis forms under traction Joint surface trauma Degenerative changes
Forms bone ends Overuse injury Fragmented development
Supports articular surface Damaged blood supply Avascular necrosis
Physis Epiphyseal or growth plate Physeal dysplasia Short stature

Responsive to growth and sex hormones Trauma Deformed or angulated growth or
Vulnerable prior to growth spurt Slipped epiphysis growth arrest
Mechanically weak

Metaphysis Remodeling expanded bone end Osteomyelitis Sequestrum formation
Cancellous bone heals rapidly Tumors Altered bone shape
Vulnerable to osteomyelitis Metaphyseal dysplasia Distorted growth
Affords ligament attachment
Diaphysis Forms shaft of bone Fractures Able to remodel angulation

Large surface for muscle origin Diaphyseal dysplasias Cannot remodel rotation
Significant compact cortical bone Healing slower than at metaphysis Involucrum with infection
Strong in compression Dysplasia gives altered density and shape
Reproduced with permission from Reid DC. Sports Injury Assessment and Rehabilitation. New York, NY: Churchill Livingstone; 1991.
the most rigid of the CTs (Table 1-2). Despite its rigidity, bone within the bone. The exact mechanism of chondrocyte hyper-
is a dynamic tissue that undergoes constant metabolism and trophy and apoptosis is currently unknown. The hypertro-
remodeling. The collagen of bone is produced in the same phic chondrocytes (before apoptosis) also secrete a substance
manner as that of ligament and tendon but by a different cell, called vascular endothelial cell growth factor that induces the
the osteoblast. At the gross anatomical level, each bone has a sprouting of blood vessels from the perichondrium. Blood
distinct morphology comprising both cortical bone and can- vessels forming the periosteal bud invade the cavity left by
cellous bone. Cortical bone is found in the outer shell. Can- the chondrocytes and branch in opposite directions along
cellous bone is found within the epiphyseal and metaphyseal the length of the shaft. The blood vessels carry osteoprogeni-
regions of long bones, as well as throughout the interior of tor cells and hemopoietic cells inside the cavity, the latter of
short bones. Skeletal development occurs in one of two ways: which later form the bone marrow. Osteoblasts, differentiated
▶▶ Intramembranous ossification. Mesenchymal stem cells from the osteoprogenitor cells that enter the cavity via the
periosteal bud, use the calcified matrix as a scaffold and begin
within the mesenchyme or the medullary cavity of a bone
to secrete osteoid, which forms the trabecular bone. Osteo-
initiate the process of intramembranous ossification. This
clasts, formed from macrophages, break down the spongy
type of ossification occurs in the cranium and facial bones
bone to form the medullary cavity (bone marrow).
and, in part, the ribs, clavicle, and mandible.
The function of bone is to provide support, enhance lever-
▶▶ Endochondral ossification. The first site of ossification
age, protect vital structures, provide attachments for both
occurs in the primary center of ossification, which is in tendons and ligaments, and store minerals, particularly cal-
the middle of the diaphysis (shaft). About the time of cium. Bones also may serve as useful landmarks during the
birth, a secondary ossification center appears in each palpation phase of the examination. The strength of bone is
epiphysis (end) of long bones. Between the bone formed related directly to its density. Of importance to the clinician is
by the primary and secondary ossification centers, the difference between maturing bone and mature bone. The
cartilage persists as the epiphyseal (growth) plates epiphyseal plate or growth plate of a maturing bone can be
between the diaphysis and the epiphysis of a long bone. divided into the following four distinct zones20:
This type of ossification occurs in the appendicular and
axial bones. ▶▶ Reserve zone: It produces and stores matrix.
The periosteum is formed when the perichondrium, which ▶▶ Proliferative zone: It produces matrix and is the site for
surrounds the cartilage, becomes the periosteum. Chon- longitudinal bone cell growth.
drocytes in the primary center of ossification begin to grow ▶▶ Hypertrophic zone: It is subdivided into the maturation
(hypertrophy) and begin secreting alkaline phosphatase, an zone, degenerative zone, and the zone of provisional
enzyme essential for mineral deposition. Calcification of the calcification. It is within the hypertrophic zone that the
matrix follows, and apoptosis (a type of cell death involving a matrix is prepared for calcification and is here that the
programmed sequence of events that eliminates certain cells) matrix is ultimately calcified. The hypertrophic zone is
of the hypertrophic chondrocytes occurs. This creates cavities the most susceptible of the zones to injury because of 7

the low volume of bone matrix and the high amounts of eccentric-induced muscle damage, ischemia, and others (see
developing immature cells in this region.2 Chapter 2).21 Because the nuclei of the myofibers are termi-
▶▶ Bone metaphysis: It is the part of the bone that grows nally postmitotic (i.e., they cannot divide anymore), muscle
during childhood. regeneration is ensured by a population of adult muscle stem
cells, named satellite cells.21,23
Skeletal Muscle Tissue CLINICAL PEARL

Skeletal muscles constitute approximately 30–40% of total Satellite cells are essential to muscle regeneration post
body mass and have many vital roles such as generation of injury, and they also contribute to muscle hypertrophy.21
movement, protection, breathing, thermal regulation, and
metabolism.21 The microstructure and composition of skel-
ANATOMY
etal muscle have been studied extensively. The class of tis- All muscles, depending on their size, are made up of thou-
sue labeled skeletal muscle consists of individual muscle cells sands and, in some cases, hundreds of thousands of muscle
that work together to produce the movement of bony levers. fibers, which are wrapped in a CT sheath called epimysium
A single muscle cell is long and cylindrical and is called a (Fig. 1-1). As muscle cells differentiate within the mesoderm,
muscle fiber or myofiber. The myofiber is the most impor- individual myofibers are wrapped in a CT envelope called
tant part of skeletal muscle composition,22 and the integrity endomysium. Bundles of myofibers, which form a whole
and function of a myofiber can be affected by different trau- muscle (fasciculus), are encased in the perimysium (Fig. 1-1).
mas such as strain, contusion, laceration, immobilization, The perimysium is continuous with the deep fascia. This
Epimysium
Perimysium
Fasciculus
Capillary
Nucleus
Mitochondrion
Endomysium
Myofibril
Sarcolemma
FIGURE 1-1 Microscopic structure of the muscle.

8

relationship allows the fascia to unite all of the fibers of a One of the most important roles of CT is to mechanically
single motor unit and, therefore, adapt to variations in form transmit the forces generated by the skeletal muscle cells to
and volume of each muscle according to muscular contrac- provide movement. Each of the myofibrils contains many
tion and intramuscular modifications induced by joint move- fibers called myofilaments, which run parallel to the myofibril
ment.6 Under an electron microscope, it can be seen that each axis. The myofilaments are made up of two different proteins:
of the myofibers consists of thousands of myofibrils (Fig. 1-1), actin (thin myofilaments) and myosin (thick myofilaments)
which extend throughout its length. Myofibrils are composed that give skeletal muscle fibers their striated (striped) appear-
of sarcomeres arranged in series.2 ance (Fig. 1-2). The striations are produced by alternating
dark (A) and light (I) bands that appear to span the width of
the muscle fiber. The A bands are composed of myosin fila-
CLINICAL PEARL ments, whereas the I bands are composed of actin filaments.
The actin filaments of the I band overlap into the A band,

The sarcomere (Fig. 1-2) is the contractile machinery of
giving the edges of the A band a darker appearance than the
the muscle. The graded contractions of a whole muscle
central region (H band), which contains only myosin. At
occur because the number of fibers participating in the
the center of each I band is a thin, dark Z line. A sarcomere
contraction varies. Increasing the force of movement is
(Fig. 1-2) represents the distance between each Z line. Each
achieved by recruiting more cells into cooperative action.
muscle fiber is limited by a cell membrane called a sarcolemma
(Fig. 1-1). The protein dystrophin plays an essential role in the
All skeletal muscles exhibit four characteristics: mechanical strength and stability of the sarcolemma and is
lacking in patients with Duchenne muscular dystrophy.21
1. Excitability, the ability to respond to stimulation from the
nervous system.
2. Elasticity, the ability to change in length or stretch. The
CLINICAL PEARL
tension developed in skeletal muscle can occur passively
(stretch) or actively (contraction). When an activated The sarcoplasm is the specialized cytoplasm of a muscle
muscle develops tension, the amount of tension present cell that contains the usual subcellular elements along
is constant throughout the length of the muscle, in the with the Golgi apparatus, abundant myofibrils, a modi-
tendons, and at the sites of the musculotendinous attach- fied endoplasmic reticulum known as the sarcoplasmic
ments to bone. The tensile force produced by the muscle reticulum (SR), myoglobin, and mitochondria. Transverse-
pulls on the attached bones and creates torque at the joints tubules (T-tubules) invaginate the sarcolemma, allowing
crossed by the muscle. The magnitude of the tensile force impulses to penetrate the cell and activate the SR.
is dependent on a number of factors.
3. Extensibility, the ability to shorten and return to normal
length. Structures called cross-bridges serve to connect the actin
4. Contractility, the ability to shorten and contract in and myosin filaments. Increased synthesis of actin and myo-
response to some neural command. sin stimulates new myofibrils that are added to the external
layers of the preexisting myofibrils.24 The myosin filaments
contain two flexible, hinge-like regions, which allow the
cross-bridges to attach and detach from the actin filament.
Myofibril During contraction, the cross-bridges attach and undergo
power strokes, which provide the contractile force. Dur-
ing relaxation, the cross-bridges detach. This attaching and
detaching is asynchronous, so that some are attaching while
re others are detaching. Thus, at each moment, some of the
me
rco cross-bridges are pulling, while others are releasing.
Sa
The regulation of cross-bridge attachment and detachment
is a function of two proteins found in the actin filaments:
tropomyosin and troponin (Fig. 1-2). Tropomyosin attaches
Myosin directly to the actin filament, whereas troponin is attached
(thick filament)
to the tropomyosin rather than directly to the actin filament.
Actin
(thin filament)
CLINICAL PEARL
Tropomyosin and troponin function as the switch for mus-
Tropomyosin cle contraction and relaxation. In a relaxed state, the tropo-
Troponin complex myosin physically blocks the cross-bridges from binding to
the actin. For contraction to take place, the tropomyosin
FIGURE 1-2 Troponin and tropomyosin action during a muscle must be moved.
contraction.
9

At the level of voluntary control, the smallest functional TABLE 1-3 Comparison of Muscle Fiber Types
unit that can be activated is the motor unit. A motor unit
Characteristics Type I Type IIa Type IIx
consists of a single α-motor neuron. The α-motor neurons of
the spinal cord (anterior horn cells) are located in the ante- Size (diameter) Small Intermediate Very large
rior gray matter. When a contraction is initiated in the motor Resistance to High Fairly high Low
cortex of the brain, a depolarizing electrical current (action fatigue
potential) is transmitted along the axon of the motor neuron
and its branches, and at the neuromuscular junction (NMJ), Capillary density High High Low
a neurotransmitter (acetylcholine) is released resulting in the Glycogen Low Intermediate High
propagation of the action potential along the muscle fiber.25 content
Twitch rate Slow Fast Fast

ANATOMY
CLINICAL PEARL
Energy system Aerobic Aerobic Anaerobic
The area of contact between a nerve and muscle fiber is
known as the motor end plate, or NMJ. Maximum muscle Slow Fast Fast
shortening
velocity
The release of a chemical acetylcholine from the axon ter- Major storage Triglycerides Creatine Creatine
minals at the NMJ causes electrical activation of the skeletal fuel phosphate phosphate
muscle fibers. Action potentials are the signals that relay glycogen glycogen
information along the axons from one structure to another
within the nervous system.2 An action potential arises from
the temporary reversal of the membrane potential due to
an increase in the permeability to sodium.2 When an action On the basis of their contractile properties, two major types
potential propagates into the transverse tubule system of muscle fiber have been recognized within skeletal muscle
(narrow membranous tunnels formed from and continuous based on their resistance to fatigue: type I (tonic, slow-twitch
with the sarcolemma), the voltage sensors on the transverse fibers) and type II (phasic fast-twitch fibers). Type II muscle
tubule membrane signal the release of Ca2+ from the terminal fibers are further divided into two additional classifications
cisternae portion of the SR (a series of interconnected sacs and (types IIa and IIx [formerly known as IIb and sometimes IId])
tubes that surround each myofibril).2 The released Ca2+ then (Table 1-3).
diffuses into the sarcomeres and binds to troponin, displacing Type I fibers are richly endowed with mitochondria (and have
the tropomyosin and allowing the actin to bind with the myo- a high capacity for oxygen uptake). Compared to type II fibers,
sin cross-bridges (Fig. 1-2). Whenever a somatic motor neu- type I fibers exhibit lower levels of isometric force produc-
ron is activated, all of the muscle fibers that it innervates are tion per unit area, demonstrate a longer time to contract and
stimulated and contract with all-or-none twitches. Although relax from a single electrical impulse, and have lower maxi-
the muscle fibers produce all-or-none contractions, muscles mal speeds of shortening but are more resistant to fatigue.
are capable of a wide variety of responses, ranging from activ- They are, therefore, suitable for activities of long duration or
ities requiring a high level of precision to activities requiring endurance (aerobic), including the maintenance of posture.
high tension. In contrast, fast-twitch fibers, which generate a great amount
At the end of the contraction (the neural activity and action of tension within a short period, are suited to quick, explo-
potentials cease), the SR actively accumulates Ca2+ and mus- sive actions (anaerobic), including such activities as sprinting.
cle relaxation occurs. The return of Ca2+ to the SR involves The type II (fast-twitch) fibers are separated based on mito-
active transport, requiring the degradation of adenosine tri- chondria content into those that have a high complement
phosphate (ATP) to adenosine diphosphate (ADP).*,2 Because of mitochondria (type IIa) and a high contractile speed and
SR function is closely associated with both contraction and those that are mitochondria-poor (type IIx) but are the fastest
relaxation, changes in its ability to release or sequester Ca2+ to contract. This results in type IIx fibers having a tendency to
markedly affect both the time course and magnitude of force fatigue more quickly than type IIa fibers (Table 1-3) but hav-
output by the muscle fiber.2,26 ing a higher potential for generating ATP through anaerobic
(glycotic) pathways.
CLINICAL PEARL
The SR forms a network around the myofibrils, storing and CLINICAL PEARL
providing the Ca2+ that is required for muscle contraction.
In fast-twitch fibers, the SR embraces every individual
myofibril. In slow-twitch fibers, it may contain multiple
myofibrils.
*
The most readily available energy for skeletal muscle cells is stored in the
form of ATP and phosphocreatine (PCr). Through the activity of the enzyme
ATPase, ATP promptly releases energy when required by the cell to perform Each muscle comprises a mixture of fiber types. Theory
any type of work, whether it is electrical, chemical, or mechanical. dictates that a muscle with a large percentage of the total
10

TABLE 1-4 Functional Division of Muscle Groups recruited; (4) an increase in motor unit firing rates; and
(5) a decrease in the level of coactivation of antagonistic
Movement Group Stabilization Group
muscles after training.
Primarily type IIa Primarily type I ▶▶ Endurance training produces (1) a decrease in the motor
Prone to adaptive shortening Prone to develop weakness
unit firing rate and (2) a lowering of the recruitment
Prone to develop hypertonicity Prone to muscle inhibition threshold, which improves fatigue resistance.
Dominate in fatigue and new Fatigue easily
movement situations Primarily cross one joint The effectiveness of muscle to produce movement depends
Generally cross two joints Examples
on some factors. These include the location and orientation
Examples of the muscle attachment relative to the joint, the limitations
Fibularis (peronei)
Gastrocnemius/Soleus or laxity present in the musculotendinous unit, the type of
Tibialis anterior
contraction, the point of application, and the actions of other

Tibialis posterior Vastus medialis and lateralis muscles that cross the joint.
Short hip adductors Gluteus maximus, medius, and
Hamstrings minimus
Rectus femoris Serratus anterior CLINICAL PEARL
Tensor fascia lata Rhomboids
Erector spinae Lower portion of trapezius Following the stimulation of muscle, a brief period elapses
Quadratus lumborum before a muscle begins to develop tension. The length of
Short/deep cervical flexors
Pectoralis major this period, the electromechanical delay (EMD), varies con-
Upper limb extensors
Upper portion of trapezius siderably among muscles. Fast-twitch fibers have shorter
Rectus abdominis
Levator scapulae
periods of EMD when compared with slow-twitch fibers.28
EMD is affected by muscle fatigue, muscle length, muscle
Sternocleidomastoid
training, passive muscle stretching, and the type of mus-
Scalenes
cle activation.28 Theoretically, a tissue injury may increase
Upper limb flexors the EMD and, therefore, increase the susceptibility to future
ata from Twomey LT, Taylor JR. Physical Therapy of the Low Back: Clinics in
D injury if full healing does not occur. One of the purposes of
Physical Therapy. New York, NY: Churchill Livingstone; 1987.
neuromuscular reeducation (see Chapter 14) is to return
the EMD to a normal level.
cross-sectional area occupied by slow-twitch type I fibers

Muscles serve a variety of roles depending on the required
should be more fatigue resistant than one in which the
movement:
fast-twitch type II fibers predominate. While there is little
evidence of change in the relative proportions of the two ▶▶ Prime mover (agonist). This is a muscle that is directly
fiber types, there is good evidence to show that there is responsible for producing a desired movement.
in fact a decrease in the number of type IIx fibers accom- ▶▶ Antagonist. This is a muscle that has an effect directly
panied by an increase in type IIa fibers with resistance opposite to that of the agonist.
training.25 ▶▶ Synergist (supporter). This is a muscle that performs
Different activities place differing demands on a muscle
a cooperative muscle function relative to the agonist.
(Table 1-4). For example, dynamic movement activities
Synergists can function as stabilizers, neutralizers, or
involve a predominance of fast-twitch fiber recruitment,
rotators.
whereas postural activities and those activities requiring sta-
■■ Stabilizers (fixators). Muscles that contract statically to
bilization entail more involvement of the slow-twitch fibers.
In humans, most limb muscles contain a relatively equal dis- steady or support some part of the body against the pull
tribution of each muscle fiber type, whereas the back and of the contracting muscles, against the pull of gravity,
trunk demonstrate a predominance of slow-twitch fibers. or against the effect of momentum and recoil in certain
Although it would seem possible that physical training may vigorous movements.
cause fibers to convert from slow twitch to fast twitch or the ■■ Neutralizers. Muscles that act to prevent an undesired
reverse, this has not been shown to be the case.25,27 However, action from one of the movers.
fiber conversion from type IIB to type IIA, and vice versa, has ■■ Rotators. A force couple is a pair of forces, equal in
been found to occur with training.25 magnitude, oppositely directed, and displaced by
In addition to structural changes during resistance and perpendicular distance or moment. The best example
endurance training, a number of neural adaptations also of a force couple that controls rotation occurs at the
occur25: scapula during arm elevation when the trapezius and
▶▶ Strength training produces (1) an enhanced drive from serratus anterior contract.
the higher centers of the brain after resistance training, The basic function of muscle is to contract. The word con-
resulting in the improvement in strength observed; (2) traction, used to describe the generation of tension within
an increased synchronization of the motor units; (3) a muscle fibers, conjures up an image of shortening of muscle
decrease in the force threshold at which motor units are fibers during a resistance exercise. However, a contraction
11

can produce shortening or lengthening of the muscle, or no throughout the whole range of its related lever. Isokinetic
change in the muscle length. Thus, three types of contraction contractions require the use of special equipment that
are commonly recognized: isometric, concentric, and eccen- produces an accommodating resistance. Both high-
tric (see Chapter 12). speed/low-resistance and low-speed/high-resistance
regimens result in excellent strength gains.30 The major
▶▶ Isometric contraction. Isometric exercises provide a
disadvantage of this type of exercise is its expense. Also,
static contraction with a variable and accommodating
there is the potential for impact loading and incorrect
resistance without producing any appreciable change
joint axis alignment. Isokinetic exercises may also have
in muscle length. The strength of a muscle is defined as
questionable functional carryover.
the force (or torque) generated about the joint during a
maximum isometric contraction. ▶▶ Econcentric contraction. This type of contraction,
▶▶ Concentric contraction. A concentric contraction
described by the Gray Institute (https://www.grayinstitute.
ANATOMY
com) and used in most functional movements, combines

produces a shortening of the muscle. This occurs when
both a controlled concentric and a simultaneous eccentric
the tension generated by the agonist muscle is sufficient
contraction of the same muscle over two separate joints.
to overcome an external resistance and to move the body
Examples of an econcentric contraction include the
segment of one attachment toward the segment of its
standing hamstring curl, in which the hamstrings work
other attachment. Power is the rate at which a muscle does
concentrically to flex the knee while the hip tends to flex
mechanical work and is determined by the product of the
eccentrically, lengthening the hamstrings. When rising
force of a contraction and velocity of shortening.
from a squat, the hamstrings work concentrically as the
▶▶ Eccentric contraction. An eccentric contraction occurs
hip extends and work eccentrically as the knee extends.
when a muscle slowly lengthens as it gives in to an Conversely, the rectus femoris work eccentrically as the
external force that is greater than the contractile force hip extends and work concentrically as the knee
it is exerting. In reality, the muscle does not lengthen, it extends.
merely returns from its shortened position to its normal
resting length. Eccentric muscle contractions, which are
▶▶ Isolytic contraction. An isolytic contraction is an
capable of generating greater forces than either isometric osteopathic term used to describe a type of eccentric
or concentric contractions,29 are involved in activities that contraction that makes use of a greater force than
the patient can overcome. The difference between an
require a deceleration to occur. Such activities include
eccentric contraction and an isolytic contraction is that,
slowing to a stop when running, lowering an object, or
in the former, the contraction is voluntary, whereas in the
sitting down. Because the load exceeds the bond between
latter, it is involuntary. The isolytic contraction can be
the actin and myosin filaments during an eccentric
used in certain manual techniques to stretch fibrotic tissue
contraction, some of the myosin filaments probably are
(see Chapter 10).
torn from the binding sites on the actin filament, while
the remainder are completing the contraction cycle. The As previously mentioned, depending on the type of mus-
resulting force is substantially larger for a torn cross- cular contraction, the length of a muscle can remain the same
bridge than for one being created during a normal cycle of (isometric), shorten (concentric), or “lengthen” (eccentric).
muscle contraction. Consequently, the combined increase The rate of muscle length change substantially affects the
in force per cross-bridge and the number of active cross- force that a muscle can develop during contraction.
bridges results in a maximum lengthening muscle tension
that is greater than the tension that could be created ▶▶ Concentric contractions. The velocity at which muscle
during a shortening muscle action.29 contracts significantly affects the tension that the muscle
produces and subsequently affects a muscle’s strength
and power. As the speed of a concentric contraction
CLINICAL PEARL increases, the force it is capable of producing decreases.
Both concentric and eccentric muscle actions comprise The slower speed of contraction is thought to produce
the type of exercise called isotonic. An isotonic contraction greater forces than can be produced by increasing the
is a contraction in which the tension within the muscle number of cross-bridges formed. This relationship is a
remains constant as the muscle shortens or lengthens. This continuum, with the optimum velocity for the muscle
state is very difficult to produce and measure. Although somewhere between the slowest and fastest rates. At
the term isotonic is used in many texts to describe concen- very slow speeds, the force that a muscle can resist
tric and eccentric contractions alike, its use in this context or overcome rises rapidly up to 50% greater than the
is erroneous because in most exercise forms the muscle maximum isometric contraction.
tension during exercise varies based upon the weight ▶▶ Eccentric contractions. During a maximum-effort
used, joint velocity, muscle length, and type of muscle eccentric contraction, as the velocity of active muscle
contraction. “lengthening” increases, force production in the muscle
initially increases, but then quickly levels off.31 The
The following three other contractions are worth following changes in force production occur during an
mentioning: eccentric contraction:
▶▶ Isokinetic contraction. An isokinetic contraction occurs ■■ Rapid eccentric contractions generate more force than
12 when a muscle is maximally contracting at the same speed do slow eccentric contractions.

■■ During slow eccentric muscle actions, the work Although each muscle contains the contractile machin-
produced approximates that of an isometric ery to produce the forces for movement, it is the tendon that
contraction. transmits these forces to the bones to achieve movement or
stability of the body in space. The angle of insertion the ten-
don makes with a bone determines the line of pull, whereas
CLINICAL PEARL the tension generated by a muscle is a function of its angle of
insertion. A muscle generates the greatest amount of torque
The number of cross-bridges that can be formed is depen- when its line of pull is oriented at a 90-degree angle to the
dent on the extent of the overlap between the actin and bone, and it is attached anatomically as far from the joint cen-
myosin filaments. Thus, the force a muscle is capable of ter as possible.2
exerting depends on its length. For each muscle cell, there Just as there are optimal speeds of length change and opti-
is an optimum length, or range of lengths, at which the mal muscle lengths, there are optimal insertion angles for

contractile force is strongest. At the optimum length of each of the muscles. The angle of insertion of a muscle, and
the muscle, there is a near-optimal overlap of actin and therefore its line of pull, can change during dynamic move-
myosin, allowing for the generation of maximum tension ments. The angle of pennation is the angle created between the
at this length. fiber direction and the line of pull. When the fibers of a mus-
▶▶ If the muscle is in a shortened position, the overlap of cle lie parallel to the long axis of the muscle, there is no angle
actin and myosin reduces the number of sites available of pennation. The number of fibers within a fixed volume
for the cross-bridge formation. Active insufficiency of a of a muscle increases with the angle of pennation. Although
muscle occurs when the muscle is incapable of short- pennation can enhance the maximum tension, the range of
ening to the extent required to produce a full range of shortening of the muscle is reduced. Muscle fibers can con-
motion (ROM) at all joints crossed simultaneously. For tract to about 60% of their resting length. Since the muscle
example, the finger flexors cannot produce a closed fist fibers in pennate muscles are shorter than the non-pennate
when the wrist is fully flexed, as they can when it is in equivalent, the amount of contraction is similarly reduced.
neutral position. Muscles that need to have large changes in length without the
▶▶ If the muscle is in a lengthened position compared with need for very high tension, such as the sartorius muscle, do
its optimum length, the actin filaments are pulled away not have pennate muscle fibers. In contrast, pennate muscle
from the myosin heads such that they cannot create as fibers are found in those muscles in which the emphasis is on
many cross-bridges. Passive insufficiency of the muscle a high capacity for tension generation rather than ROM (e.g.,
occurs when the two-joint muscle cannot stretch to the gluteus maximus).
extent required for full ROM in the opposite direction
at all joints crossed. For example, when an individual
attempts to make a closed fist with the wrist fully flexed, CLINICAL PEARL
the active shortening of the finger and wrist flexors
Skeletal muscle blood flow increases 20-fold during
results in passive lengthening of the finger extensors.
muscle contractions.2 The muscle blood flow increases in
In this example, the length of the finger extensors is
proportion to the metabolic demands of the tissue, a rela-
insufficient to allow full ROM at both the wrist and the
tionship reflected by positive correlations between muscle
fingers.32
blood flow and exercise. As body temperature elevates,
the speeds of nerve and muscle functions increase, result-
ing in a higher value of maximum isometric tension and
The force and speed of a muscle contraction depend on a higher maximum velocity of shortening possible with
the requirements of the activity, which in turn, are dependent fewer motor units at any given load. Muscle function is
on the ability of the central nervous system to control the most efficient at 38.5°C (101°F).2
recruitment of motor units. The motor units of slow-twitch
fibers have lower thresholds and are easier to activate than
those of the fast-twitch motor units. Consequently, the slow- During physical exercise, energy turnover in skeletal
twitch fibers are recruited first, even when the resulting limb muscle may increase by 400 times compared with muscle at
movement is rapid.2 rest, and muscle oxygen consumption may increase by more
As the force requirement, speed requirement, or duration than 100 times.34 The hydrolysis of ATP to ADP and inor-
of activity increases, motor units with higher thresholds are ganic phosphate (Pi) provides the power for muscular activity.
recruited. Type IIa units are recruited before type IIb.2 Despite the large fluctuations in energy demand just men-
tioned, muscle ATP remains practically constant and demon-
strates a remarkable precision of the system in adjusting the
rate of the ATP-generating processes to the demand. There
CLINICAL PEARL
are three energy systems that contribute to the resynthesis of
The term temporal summation refers to the summation of ATP via ADP rephosphorylation. These energy systems are
individual contractile units. The summation can increase as follows:
the muscular force by increasing the muscle activation
▶▶ Phosphagen system. The phosphagen, or ATP-PCr,
frequency.33 13
system is an anaerobic process—it can proceed

without oxygen (O2). The skeletal muscle cell stores ▶▶ Oxidative system. As its name suggests, the oxidative
the phosphocreatine (PCr) and ADP, of which PCr system requires O2 and is consequently termed the
is the chemical fuel source. At the onset of muscular “aerobic” system. The fuel sources for this system are
contraction, PCr represents the most immediate reserve glycogen, fats, and proteins. This system is the primary
for the rephosphorylation of ATP. The phosphagen system source of ATP at rest and during low-intensity activities.
provides ATP primarily for short-term, high-intensity The ATP is resynthesized in the mitochondria of the
activities (i.e., sprinting), and it is the major source of muscle cell such that the ability to metabolize oxygen
energy during the first 30 seconds of intense exercise, but and other substrates is related to the number and
it is also active at the start of all exercises, regardless of concentration of the mitochondria in cells. It is worth
intensity.35 Once a muscle returns to rest, the supply of noting that at no time during either rest or exercise does
ATP-PCr is replenished. While the maximum power of any single energy system provide the complete supply
this system is great, one disadvantage of the phosphagen of energy. While being unable to produce ATP at an
ANATOMY
system is that because of its significant contribution to equivalent rate to that produced by PCr breakdown
the energy yield at the onset of near maximal exercise, and glycogenolysis, the oxidative system is capable of
the concentration of PCr can be reduced to less than 40% sustaining low-intensity exercise for several hours.35
of resting levels within 10 seconds of the start of intense However, because of increased complexity, the time
exercise, which translates into a small maximum capacity between the onset of exercise and when this system is
of the system. operating at its full potential is around 45 seconds.36
▶▶ Glycolytic system. The glycolytic system is an anaerobic
The relative contribution of these energy systems to ATP
process that involves the breakdown of carbohydrates— resynthesis has been shown to depend upon the intensity
either glycogen stored in the muscle or glucose delivered and duration of exercise, with the primary system used being
through the blood—into pyruvate to produce ATP in a based on the duration of the event37:
process called glycolysis. Pyruvate is then transformed
into lactic acid as a by-product of the anaerobic glycolysis. ▶▶ 0–10 seconds: ATP–PCr. These bursts of activity develop
Because this system relies on a series of nine different muscle strength and stronger tendons and ligaments, with
chemical reactions, it is slower to become fully active. the ATP being supplied by the phosphagen system.
However, glycogenolysis has a greater capacity to provide ▶▶ 10–30 seconds: ATP–PCr plus anaerobic glycolysis.
energy than does PCr, and therefore it supplements ▶▶ 30 seconds to 2 minutes: Anaerobic glycolysis. These
PCr during maximal exercise and continues to longer bursts of activity, if repeated after 4 minutes of
rephosphorylate ADP during maximal exercise after PCr rest or mild exercise, enhance anaerobic power with the
reserves have become essentially depleted.35 In essence, ATP being supplied by the phosphagen and anaerobic
this system is the major source of energy from the 30th to glycolytic system.
90th second of exercise. The process of glycolysis can be in ▶▶ 2–3 minutes: Anaerobic glycolysis plus oxidative system.
one of two ways, termed fast glycolysis and slow glycolysis,
▶▶ More than 3 minutes and rest: oxidative system. These
depending on the energy demands within the cell. If
energy must be supplied at a high rate, fast glycolysis periods of activity using less than maximum intensity may
is used primarily. If the energy demand is not so high, develop aerobic power and endurance capabilities, and the
slow glycolysis is activated. The main disadvantage of the phosphagen, anaerobic glycolytic, and anaerobic systems
fast glycolysis system is that during very high-intensity supply the ATP.
exercise, hydrogen ions dissociate from the glycogenolytic
end product of lactic acid. The accumulation of lactic Respiratory Muscles
acid in the contracting muscle is recognized in sports and
resistance training circles. An increase in hydrogen ion Although the respiratory muscles share some mechanical
concentration is believed to inhibit glycolytic reactions similarities with skeletal muscles, they are distinct from skel-
and directly interfere with muscle excitation–contraction etal muscles in several aspects as follows2:
and coupling, which can potentially impair contractile ▶▶ Whereas skeletal muscles of the limbs overcome inertial
force during an exercise.35 This inhibition occurs once loads, the respiratory muscles overcome primarily elastic
the muscle pH drops below a certain level, prompting and resistive loads.
the appearance of phosphofructokinase (PFK), resulting ▶▶ The respiratory muscles are under both voluntary and
in local energy production ceasing until replenished by involuntary control.
oxygen stores.
▶▶ The respiratory muscles are similar to the heart muscles,
in that they have to contract rhythmically and generate

the required forces for ventilation throughout the entire
CLINICAL PEARL lifespan of the individual. The respiratory muscles,
Lactic acid is the major energy source for providing the however, unlike the cardiac muscles, do not contain
muscle with ATP during exercise bouts that last 1–3 minutes pacemaker cells and are under the control of mechanical
(e.g., running 400–800 m). and chemical stimuli, requiring neural input from higher
centers to initiate and coordinate contraction.
14

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suicide in sane people. There is no danger of deliberate homicidal
acts in persons of good character. A criminally disposed person
would more readily commit murder in simple melancholia than if free
from that disease.
Simple melancholia may be the initial stage of almost all of the

mental diseases, especially acute mania, paralytic dementia, and the
severer forms of melancholia. It may be differentiated from the first
stage of mania only by waiting until other symptoms appear or not,
and the same is true with regard to distinguishing it from the forms of
melancholia involving danger to life. In the latter case, however,
there is much greater difficulty in diagnosis, inasmuch as insane
delusions may be concealed, and there may be so slight a change in
the patient's behavior when delusions appear in his mind that the
closest observation is needed to guard against them. The simple
melancholia marking the first stage of paralytic dementia is
characterized by noticeable although often slight mental impairment
—a distinctly diminished capacity for work, of which the individual
himself is not seldom conscious, whereas in the disease simple
melancholia the mind's usual power is exerted, provided its attention
can be withdrawn from morbid introspection and concentrated upon
any subject, as it commonly can be for a while.
Melancholia with delusions (acute melancholia) is commonly a

further development of simple melancholia, but sometimes its course
is so rapid that if there is a period of mental depression without
delusion it is overlooked. The earliest and most common delusion is
some form of causeless self-reproach with regard to some matter,
whether trivial or important, or of groundless self-accusation, of
impossible sins of omission or commission, but generally of some
vague, undefinable fault, as having irretrievably offended God or
committed the unpardonable sin, etc. Often this and an unfounded
belief in self-unworthiness are the only delusions present, and in that
case within narrowed limitations the mind acts soundly in other
matters. The feeling of personal fault or sin often expands to a sense
of the justice of punishment, and the consequent delusion that all
sorts of terrible things are to happen—poverty, the poorhouse, or
some great unknown dread, even involving family and friends; and
from personal sin or fault it is only a step to the belief that the world
is all wrong, and to the certainty that everything is going to worse
than ruin. Illusions of sight and hearing may magnify common fires
and locomotive whistles into general conflagrations of the world and
shrieks of tormented persons. Hallucinations of the special senses
may create visions of all sorts of imaginary horrors, sounds of voices
saying every possible dreadful thing, odors most disagreeable,
tastes most vile. Anæsthesia prompts the delusion of death, and
hyperæsthesia of burning, freezing, scalding, etc. Some mysterious
force within them, which they can neither explain nor understand,
drives them to automatic acts of all kinds—to obscenity, profanity,
verbigeration, intonation of sentences, wailing, screaming,
destructiveness, etc. In cases of exceptional severity the mind
seems deluded on almost every subject: the food is poisoned, the
atmosphere is deadly, the world loses all its reality, friends their
identity, things their substance. They are to be burned alive, starved,
quartered, suffocated, smothered, drowned. Every conceivable and
inconceivable thing is to happen. The delusions are nearly always of
the illogical or unsystematized kind, although systematized delusions
of persecution are met, for the most part, in incurable cases.
Deliberate plans of suicide are formed in most cases, and are to be
suspected in all. Homicidal attempts are apt to be made upon
persons whom it is desired to save from impending calamities.
Suicidal, and less often homicidal, impulses occur. Suicide and
homicide from deliberation need, to be successful, (1) the
opportunity, (2) lack of power of self-control, and (3) a strong
determination. Sometimes there is the will without the opportunity, or
the opportunity with self-control; and for this reason persons in
danger of killing themselves or others often for months escape any
acts of violence. Not seldom, too, they determine to kill themselves
or family in a particular way, and neglect other chances so long that
they are thought to be not meditating destruction of self or others.
When the determination or impulse to suicide or homicide is
persistent and desperate, no means are too horrible and no
opportunities too hopeless to be attempted. There is no reason for a
special name for these symptoms, but they have been called suicidal
melancholia and homicidal melancholia. No more is there any
justification of the term hypochondriacal melancholia for melancholia
with hypochondriacal symptoms.
In melancholia with delusions there is sooner or later, in the majority

of cases, refusal to eat, from lack of appetite, nausea, or disgust of
food, from disagreeable hallucinations of taste or smell, from
delusions that it is a sin to eat, that the stomach is full, that the
mouth is sealed or the throat obstructed, that the food is not and
cannot be paid for, that eating will do no good, etc., from a wish to
commit suicide by starving, or in the states of stupor (attonitäts-
zustände) from mental torpor or stupidity. Sometimes there is
resistance to the calls to eat, urinate, or defecate by virtue of
resistive melancholia—a condition to resist and oppose everything—
or from delusions that it will destroy the soul, etc. to follow the natural
inclinations. Refusal of food may be under certain conditions
instinctive and conservative. It is the exception for the bodily
functions to be well performed. Usually, there is obstinate
constipation, with headache, coated tongue, greater variation in daily
temperature than is usual in health, accelerated pulse, and rapid
wasting in flesh. The various anomalous sensations observed in
functional diseases of the nervous system are common.
Masturbation is a not infrequent symptom of loss of self-control in
both sexes.
Acute melancholia is sometimes confounded with delusional insanity

with mental depression. In the former the delusions are evolved from
the mental state; in the latter, the mental state from the delusions. In
the former the delusions are for the most part unsystematized: the
patient cannot state why he believes them to be true; in the latter
there is correct reasoning from false premises: the delusions are
logical or systematized and of a depressing character, so that a
belief in them naturally gives rise to sadness.
Before the courts the fact should be kept in mind that persons with
acute melancholia have diminished power of self-control by virtue of
their disease, and so yield more readily to temptation than in health.
They also may have imperative conceptions—ideas so strong that
they cannot, or can with difficulty, resist carrying them out even when
they know them to be wrong; and there may be sudden outbursts of
almost maniacal excitement. They are often able to make wills and
perform contracts, in form and in detail, as well as ever, when they
are so filled with insane delusions as to be on the point of killing
themselves and their families. There is impaired capacity, however,
of recognizing the relations of persons and things to one another, a
distinct moral perversion, and a diminished recognition of obligations
and sense of responsibility. In other words, they are not always fully
themselves on those points in which they seem to be so, and yet
patients in asylums with acute melancholia have been known to give
the best of advice to their business-partners.
Melancholia with stupor (melancholia attonita) appears like complete

dementia or a mindless state, but there are now and then evidences
of intelligence. The mind is filled with overwhelming and terrible
delusions, which paralyze the will and place mental and physical
activity for a while in abeyance. It arises commonly in the course of
the less profound form of melancholia, after some great mental
shock, and there is a condition of marked anæmia of the brain,
probably symptomatic rather than pathognomonic, which if not soon
relieved goes on rapidly to atrophy and degeneration. Except when
there are attacks of frenzy, which may occur at any time, there is
little danger of active violent acts except suicide, desperate refusal of
food, and determined resistance to any care or treatment. There are
the usual indications of physical exhaustion.
In melancholia agitata the mind is clear and active, the opposite of

the condition last described, and the distressing delusions produce
such a degree of motor excitement arising from the mental suffering
that the disease closely simulates acute mania. The mind not only
reacts as readily as in health to distressing ideas, but abandons itself
more fully to their domination through diminished will-power and lack
of self-control. Almost blind acts of desperation and fury are
committed from which the utmost vigilance can hardly save them.
The three severe forms of melancholia just described are
interchangeable in the same person during the course of his illness,
so that the states of frenzy and stupor are more properly called
symptoms than classes of disease.
Melancholia among children is more common than the books state it

to be, although rarely met in the asylums. Magnan has reported a
suicidal case in a child four years old, and it occurs up to the latest
years of life.
The DURATION of simple melancholia is from a few weeks to a dozen

years; of acute melancholia, from a month to two or three years,
after which it is apt to end in chronicity; melancholia stupida (with
stupor) is usually curable, if at all, in the first year, although relapses
are frequent, and in melancholia agitata from a year to three years is
the common limit of the possibility of a cure.
The PROGNOSIS in simple melancholia is favorable. Including cases

treated out of asylums, probably 90 per cent. recover; in acute
melancholia, uncomplicated with other diseases, not far from two-
thirds recover; in melancholia attonita less than half get well; and in
melancholia agitata nominal recovery occurs perhaps in a third of the
cases, although I doubt whether complete restoration to health is
seen often.
In chronic melancholia the process of mental deterioration is slow.

As the mind becomes impaired the delusions lose their activity and
the mind reacts less readily, so that a state of less suffering and
greater calm is reached, and the patients are often useful workers in
asylums for many years, or remain in their own homes a constant
source of anxiety to those who understand their condition. Many of
them commit suicide.
In treatment of melancholia the first indication is to protect society

and the individual against acts of violence. Homicidal acts are not to
be feared in simple melancholia, unless in persons of bad character
and ugly temper, or in those few cases with the symptoms, in
addition, of moral insanity or impulsive insanity. Suicide is so rare
that precautions will not often be needed against it, provided the
patient is so frank or so transparent that the appearance of distinct
delusions may be detected and then guarded against. In cases of
long standing, especially in persons beyond middle age, this is
extremely difficult, and their treatment outside of asylums must
always be attended with risk. In the other forms of melancholia the
fact should be taken for granted that the patient is suicidal, and he
may be also homicidal, so that he should be watched constantly and
efficiently, and never left alone or with weak or helpless persons, no
matter how free from suicidal determination or impulse he may have
appeared. The puerperal mother, especially, is a source of the
greatest danger to her child, even when she seems natural and fond.
The degree and kind of watching varies, according to the severity of
the case, from the constant presence or close proximity of some
responsible person, who may sleep in the same room with the usual
home-surroundings, to the most vigilant and wakeful personal care
every moment day and night, and removal of every source of
possible self-injury. In some few cases this can be well done only in
an asylum or in a padded room. Some form of restraint, either
personal or by confining or limiting the movements of the hands in
rare cases of exceptional desperation, will be found necessary.
Placing the patient in an entirely healthy atmosphere is next in

importance. In the very earliest stage quiet, recreation, change of
scene, and association with a pleasant and judicious companion are
often sufficient to effect a cure. If the disease is pronounced, rest
and removal from sources of irritation are more important until
convalescence, when travel may be tried. The question of removal
from home and commitment to an asylum should be decided upon
the grounds already stated in considering the general treatment of
mental diseases. The degree in which the patient should have
exercise, occupation, and recreation or be let alone will be
determined for each individual case. The fact should be borne in
mind that the disease is a debilitating one, and that it arises in
conditions of mental or physical exhaustion. Massage and a modified
rest-cure, without seclusion, are beneficial in some cases, especially
of elderly people. Baths and the cold pack should be used with
discrimination. Electricity, where it does not give rise or add to
delusions, is a useful tonic, especially in passive cases. There are
very few patients of such desperate frenzy as to require confinement
of the hands, and that should only be done with an attendant close at
hand. Whatever is done, nothing should be attempted which excites
delusions unless it be absolutely necessary. Fresh air, and an
abundance of it, are very important. Experience and careful study of
the particular case will be needed to know how far to press the
taking of food. But the necessary amount should be given by the
stomach-tube if ordinary means fail, and it is better to use it early
rather than tire the patient out with ineffectual attempts with spoons,
etc. Whether the nasal or œsophageal tube be used—of which I
prefer the latter—the greatest care should be taken not to inject food
into the lungs, the throat being so devoid of sensitiveness sometimes
that the tube may be passed into the trachea. Nutrient enemata may
be relied upon for a week or two if the patient is in bed, but no
longer.
Tonics are indicated—cod-liver oil with bark, the hypophosphites,

dilute phosphoric acid, malt. Strychnia, iron, and quinine should be
used with caution, as they often cause disagreeable headache with
indisposition to sleep. Fattening food will be found useful in most
cases. The few fat melancholies need nitrogenous food and
graduated exercise. Constipation will be corrected in many cases by
a full, laxative diet, cod-liver oil, malt, or it may be beer. Mineral
water or Sprudel salts are usually indicated. A pill containing aloin,
strychnia, belladonna, mastich, or even colocynth or podophyllin,
may be needed in obstinate constipation.
Medicines to control restlessness and sleeplessness should be

avoided if possible. Hydrate of chloral, opium, bromides, valerian,
sometimes increase the difficulty, and the objections to their
prolonged use are obvious, and yet they must sometimes be used
for a time. The bromides, with cannabis indica, valerianate of zinc,
camphor, and hyoscyamus, may serve an excellent purpose for a
time. Opium and its preparations, where they agree, act like magic in
producing mental calm and sleep. They may relieve constipation and
increase the desire for food, but the danger of the opium habit is so
great that their use should be decided upon only in extreme cases,
and the effect should be watched from dose to dose, each one of
which should be given under medical direction. Wilful masturbation,
one of the signs of loss of self-control which occurs in the best of
people, cannot be corrected by drugs or appliances, but only by
constant watching and by placing the individual where his self-
respect, as soon as it can be appealed to, will keep him from it. If it is
uncontrollable and symptomatic, fresh air and exercise, and, if
necessary, bromides or opiates in moderate doses, with a tonic (not
iron), should be used.
MANIA (Manie, Exaltation générale), according to Morel, meant, in the

original Greek, folie or madness, while Esquirol derives it from the
Greek word meaning moon, making the words maniac and lunatic
equivalent. The word mania is still used in this loose way, even by
writers on mental disease, as a synonym of insanity. Its use is
properly restricted to conditions of mental exhilaration or excitement
with motor activity. The morbid anatomy of the disease is not yet
made out, and the indications of hyperæmia observed in the acute
stage after death are no greater than are found in diseases in which
mania is not a symptom. In its final stages atrophic, degenerative,
and inflammatory signs are abundant and well marked.
Simple mania18 (manie sans délire, manie raisonnante), an

exaltation of the mental faculties similar to the exhilaration produced
by too much wine, with an accelerated flow of ideas, impaired
judgment, and motor activity, without definite delusions, delirium, or
incoherence, has been called an insanity of action, affective insanity,
folie raisonnante, and even moral insanity, from which it differs in
being marked by constant mental elation and exaltation of the
physical functions, and not necessarily by striking moral perversion.
It is a mental erethism, an exaggerated gayety, an uncontrollable
exhilaration, an unbounded joy, an excessive anxiety, a perpetual
anger, unusually good spirits, increased intellectual and physical
energy, with such striking loss of self-control, diminished powers of
reflection, and so decided weakening of the judgment that all sorts of
unwonted errors of commission or omission may be performed.
Under its influence many fortunes have been lost, many reputations
have been ruined, and the happiness of many families has been
sacrificed before the existence of insanity was suspected, except
possibly by a very few persons. Indeed, the wit is usually so
sharpened, the flow of ideas often so clear and rapid, the capacity
for brain- and body-work without fatigue is generally so increased,
that not seldom the patient is remarked upon as being unusually
well. The most troublesome symptoms arise from the tendency to
squander property, to drink alcoholic liquors to excess, and,
especially in women, to allow the exalted sexual desires to get
control of the judgment and reason, thereby bringing about
unfortunate marriages or scandalous relations with the opposite sex.
In women there is commonly increased menstrual flow.
18 Also called by some writers moral insanity, folie morale, folie des actes, folie or
manie instinctive.
The course of the disease is without material change, and the

duration is from several weeks to a number of years. When it does
not constitute the initial stage of other types of mental disease,
especially severer forms of mania, circular insanity, general
paralysis, or (in the neuropathic constitutions and at the critical ages)
mental degeneration, the termination is in recovery in about 90 per
cent. of the cases, although sometimes some moral impairment or
deterioration in character remains for life. The recklessness incident
to the disease leads to unusual risks, now and then to fatal
accidents. Simple mania rarely becomes chronic.
TREATMENT involves the necessity of proper control to prevent

scandals, disasters, and perhaps crimes. The matter of the degree of
seclusion and control should be governed by the general
considerations already mentioned in the general treatment of
insanity, bearing in mind that repression of the motor energy, except
to prevent exhaustion, does harm. The demand for food is
enormous; its supply should be abundant and judiciously chosen
with reference to easy digestion. Frequent prolonged warm baths
and cool applications to the head are indicated, and the usual
palliatives for headache, sleeplessness, constipation, etc. The
surroundings should be such as to favor rest and undisturbed sleep,
and to dispel sources of excitement, whether they arise in certain
associations, localities, occupations, or persons.
Acute mania (Tobsucht) follows an incubative stage of simple

melancholia, often of simple mania, and rarely bursts out without
previous indications of disease. Delusions, unsystematized and
illogical, are abundant; the ideas flow so rapidly that the mechanism
of speech is not adequate to their expression; the motor excitement
is intense. In the most severe forms there is mental confusion,
delirium, incoherence of ideas, and furious muscular action, to the
point often of acts of destructiveness and self-injury. The clothing is
torn to shreds, and no act of violence is too wild not to be attempted
without warning. The skin is hot, the tongue heavily coated, the pulse
accelerated, the temperature elevated, more, probably, than would
be accounted for by the physical activity—from one to two or three
degrees—now and then, in conditions of exhaustion, a little below
the normal. Just as there is liable to be maniacal frenzy in the course
of severe melancholia, so in acute mania outbursts are seen of
desperately suicidal melancholic frenzy. Unless great care is used to
keep up the strength, and often in spite of it, exhaustion rapidly sets
in, under the influence of which the symptoms are very much
aggravated. The amenorrhœa in women in this condition is
conservative.
The COURSE AND DURATION of acute mania vary within wide limits, with
an average of not far from six months, with recoveries in about 60
per cent. of first cases uncomplicated by pneumonia, chronic
disease, or a marked neuropathic state: 5 or 6 per cent. die, chiefly
from pneumonia, phthisis, accidents, or exhaustion, seldom suicide.
Incurable cases drop slowly into dementia or into chronic delusional
insanity, the motor excitement subsiding. The delusional insanity
may be simply a stage in the process toward dementia.
In the DIAGNOSIS of acute mania, unless great care is used, the
physician sometimes finds that he has sent to the asylum a case of
acute, especially infectious disease, in the early stage and with
unusual manifestations of febrile delirium. The indications for
avoiding this unfortunate mistake are care and time in making
diagnoses.
In the TREATMENT of acute mania the matter of foremost importance is

that the physician should be able to sufficiently control his patient to
prevent harm, and that he should have him in such a place as to give
him an abundance of fresh air, unhampered by annoying and
irritating limitations of his free will, restrictions of his liberty, and
repression of his motor excitement. The risks of injury to others must
be reasonably provided against. It goes without saying that few
homes meet these indications: very few people can command a
house to be converted into a virtual hospital, with the care of trained
physicians to direct every little detail of treatment, and proper
nursing. The public asylum, therefore, or the private retreat must
usually be depended upon. In the case of quiet young people,
especially of young women whose illness may be of such a nature
as to justify their marrying after recovery, and in the acute mania
following childbirth, it is well worth the physician's while to make an
effort to keep the patient in a private house when the conditions are
such as to make such a course practicable. To the rest and quiet
which may be had under such circumstances, with all the goings on
of the house regulated to the patient's comfort and convenience, to
prolonged hot baths, a full simple diet, given with the stomach-tube if
necessary, as few medicines as can be got on with, the supervision
of the nurses by some judicious member of the family, and the
gentleness (combined, of course, with proper firmness) of home-
influences, I attach very great importance in properly selected cases.
But I attribute as much to the restful influence of keeping the patients
among familiar scenes, and where some familiar face and voice can
reassure them in their comparatively clear moments, instead of their
being agitated and distressed to know how to account for the strange
people and cell-like room of the insane ward to which they will
awaken from their delirium in the hospital. It is something to avoid
the excitement of commitment and removal to an asylum, with all
that they involve, as well as the sight of demented patients, whose
noise may make sleep impossible just when it is most needed. Acute
mania seems to me to arise much less often than other mental
diseases in definite associations which need to be escaped from for
successful treatment.
The term subacute mania is used by some writers for the milder
cases of acute mania, just as acute delirious mania is a term which
is applied to those violent cases of acute mania in which furious and
prolonged delirium marks the disease, and in which there is a high
death-rate and low proportion of recoveries.
In chronic mania the motor excitement, mental instability, and,

sooner or later, delusions, if not present at the beginning, as is usual,
continue. The progress to dementia is commonly slow, and there are
few cases which it is wise to treat away from an asylum or its
dependencies on account of the possible danger to others from
sudden exacerbations of the disease or through uncontrolled violent
impulses.
Although there is no pathological condition distinctive of mania in its

curable stage, conditions indicating hyperæmia are usually found,
whether as a result of the disease or its underlying cause, and
sometimes meningitis. In chronic mania there is in the terminal
stages evidence of atrophic and degenerative changes which do not
distinguish it from other forms of mental disease.
ACUTE DELIRIUM is the typhomania of Bell. Its prevailing mental state

is of mania oftener than of melancholia. It resembles the worst cases
of typhoid fever so closely, and it is so uncommon a form of disease,
that the mistake has often been made of sending typhoid-fever
patients to insane asylums. The mistake is unnecessary, as the
clinical features of typhoid fever are so well marked that with
sufficient care and delay they may be recognized if the physician
does not commit the common error in mania of being too much
afraid of his patient to examine him thoroughly. The tendency to
exhaustion in acute delirium is rarely successfully combated, as the
motor excitement is so intense and the delirium so furious that
nourishment to meet the tremendous demands of the system can
seldom be given, and death is the usual result. Recoveries are rare,
but less uncommon in the melancholic than in the maniacal form.
Little need be said in the way of TREATMENT, except that in so

speedily fatal a disease it is well to keep the patient at home, if he
can be properly cared for there.
TRANSITORY INSANITY is used by Krafft-Ebing19 (Transitorisches

Irresein) as indicating mental disease differing from other insanity
only in the fact that it is of short duration—namely, from two to six
days. If it is applied to sudden and transient outbursts of mania, with
delirium, loss of power of self-control, and inability to clearly recollect
the circumstances of the attack and what happened during its
continuance, it is a rare disease, occurring for the most part in
epileptics and in persons under the influence of alcohol or addicted
to its habitual use. It is sometimes, under the latter-named condition,
called alcoholic trance. It consists in an automatic state resembling
the epileptic delirium, which may occur also in sleep and resemble
somnambulism. The actions are guided by co-ordinated will without
conscious intelligence, and may consist in crimes and brutalities and
foolishness entirely inconsistent with the character in health. It
seldom lasts more than a few hours. When caused by alcohol or as
a symptom of epilepsy, it may occur without other marked inciting
cause; otherwise it is commonly due to mental shock. Several cases
happened during the mental excitement of the first battle in our civil
war. The most striking case within my own experience was that of a
man who under the strain of prolonged grief and the mental shock of
a great fire destroying a large part of the town in which he lived,
perhaps moderately affected by alcohol, suddenly grasped an axe
and cut off with one blow the head of a beloved child. He was found
in the street without knowing how he had got there or what he had
done.
19 Irrenfreund, 1883, p. 113.
One attack is the rule, although several, probably of an epileptic
nature, have been reported. It is an extremely difficult condition to
diagnosticate with certainty, and is therefore often the refuge of
criminals and a resource of criminal lawyers. The most likely honest
mistake liable to be made regarding it is to confound it with an
outburst of passion.
PRIMARY DEMENTIA (Acute dementia, Stuporous insanity, Anergic

stupor) is a disease chiefly of youth and early maturity in persons of
inherited weakness or under the influence of prolonged exhausting
conditions, to which some mental shock usually adds the immediate
cause. Although most of the cases are under the age of twenty-five,
it occurs up to forty-five. Masturbation is so common a symptom in
its course—and it may be one of the debilitating and enervating
factors constituting a predisposing cause—that most of the primary
dementia is classed in some asylums as insanity of masturbation.
There may be an initial stage of a number of days, marked by
moderate melancholia or by maniacal excitement, but there is
usually mental torpor advancing rapidly to pronounced dementia. In
rare cases there is marked chorea, and slight choreic movements
are often observed. The course of primary dementia may be
subacute and advance with extreme slowness.
There is no overwhelming delusion paralyzing the mind, so to speak,

as in melancholia attonita (melancholia with stupor). In acute cases
the brain quickly falls into a state of profound anæmia, precisely
such as is found post-mortem in starved dogs, and loses its power to
a greater or less extent of reacting to the stimulus of the senses.
There is little or no sensation of hunger, the sensory nerves are
nearly or quite paralyzed, the bladder and rectum become distended
until urine and feces are voided unconsciously or at least
uncontrolled, and voluntary movements almost cease, although the
muscles are capable of acting if directed: if led or pushed, the patient
walks; if placed in a chair or bed, remains there; and in the worst
cases lies on the floor quite inattentive to all the decencies of life
unless constantly looked after. There is always partial, and there
may be complete, anæsthesia, to such an extent that even the
involuntary muscles do not respond to the ordinary stimuli. There is
rapid loss of flesh, very sluggish circulation, and feeble heart-action.
After recovery the patient speaks of the stage of his greatest illness
as a blank in his memory.
This description of pronounced cases of primary dementia of the

most severe type needs modification as applied to milder cases,
which may exist in all degrees, down to a state of mental impairment
of very moderate extent.
The mental impairment may be progressive and quite incurable, but

also so slight in the beginning, and may make such slow progress,
as to entirely escape detection for several years, and then attract
attention at first by the lowered plane of character and loss of self-
control in little matters of daily life, rather than by the intellectual
deterioration, which by that time has become quite marked. This
subacute form of primary dementia in young people rarely finds its
way into the insane asylum until the second, third, or fourth year of
its course, and then its progress is slowly downward. It has none of
the eccentric or grotesque features of hebephrenia, and little of its
emotional disturbances.
Subacute primary dementia in the later years of maturity, just before

or several years before the climacteric, is of grave import, as it
indicates the development of an hereditary predisposition to insanity
in a form which not only offers no reasonable hope of recovery, but
also is quite certain to manifest a change of character which is even
more difficult to treat and properly control than the intellectual failure.
As it is most likely to arise under circumstances of wear and worry,
its symptoms may be for a long time attributed to disappointment or
bad temper. After the dementia becomes pronounced its downward
course is seldom otherwise than very rapid.
SECONDARY DEMENTIA is a convenient name for the curable dementia

which appears at the subsidence of acute symptoms occasionally in
mania, and rarely in melancholia—that is, just about the beginning of
the period of convalescence. It is also called secondary stupor.
In primary and secondary dementia, resulting in recovery, the
progress of the disease is rarely otherwise than very rapid, and
unless a cure takes place in a few months at the outside, secondary
changes occur in the brain and the tendency is to terminal or
incurable dementia. So many cases are treated outside of asylums
that it is difficult to estimate the cure-rate, but it is probably not less
than 60 or 70 per cent., although it is quite common in the apparent
cures for the brain to remain on a lower intellectual or moral plane
than if the disease had not occurred.
TREATMENT does not involve the necessity of removal from home in

the acute cases, except when that is demanded for convenience of
treatment. There is no melancholia to suggest the possibility of
suicide, and no mental exhilaration or motor excitement to make
restraint necessary. The most important indications are met by
abundant, easily-assimilated food, which must usually, for a time at
least, be given with a spoon or by the stomach-tube; fresh air,
attention to the processes of digestion, relief of the gastro-intestinal
catarrh by the usual remedies, stimulating baths, tonics, stimulants,
and general galvanism. Proper care in emptying the bladder and
rectum and entire cleanliness will suggest themselves.
In mild cases a tonic and stimulating regimen, including sea-bathing

and gymnastics, will often be sufficient.
In the subacute cases young people are easily depressed by the

asylum associations, but there is usually a time in the progress of the
disease when home-discipline is too weak for them, and they must
be sent away; older people have usually complications in their home-
life such as to make a change desirable for the comfort of the
household. Recoveries are extremely exceptional.
In all cases there is little to be gained in keeping up home-

associations for so disturbing, distressing a disease after there is
pronounced dementia.
Medicines, other than tonics, are of little use, except opiates to

control various distressing nervous symptoms, including
masturbation, but they should be used with great caution.
KATATONIA (Katatonie of Kahlbaum; Katatonische Verrücktheit of

Schüle) presents, with more or less regularity of appearance,
symptoms of (1) mild melancholia without the characteristic mental
pain; (2) mental excitation, sometimes ecstatic, with cataleptiform
conditions; (3) confusion and torpor or apathy. There is an underlying
well-marked intellectual impairment, slowly advancing in incurable
cases to pronounced dementia. Delusions, more of the
unsystematized than of the systematized character, but resembling
both, constitute a prominent part of the disease from the beginning.
Verbigeration and a curious sort of pomposity are usually found in
more or less pronounced degree. The delusions are mixed. They are
exalted, hypochondriacal, melancholic, with all sorts of self-
accusation, and may be full of suspicion, fears of poisoning, and
ideas of persecution. Hallucinations of the special senses and
illusions are not uncommon. If the term katatonia is not used, or at
least if a special place in the nosology were not given this disease, it
would be difficult to know whether to class these cases as primary
dementia, melancholia with delusions, delusional insanity, or
confusional insanity.
The verbigeration, when it exists, and the expression of delusions

are often associated with a manner on the part of the patient
suggesting disbelief in them, and sometimes the patient smiles or
laughs at the astonishing character of his statements. There is a self-
conscious element at times, suggesting mimicry or hysteria; a certain
pathos is universal; opposition and contradiction, even to refusal to
eat, leave the bed, dress, wash, are quite common; and nurse and
physician are tired out with the monotony of the mental and physical
state. Well-marked catalepsy is not common in my experience,
although it occurs; and in all cases I have seen the mental state and
physical atony suggesting that condition. Little attention has as yet
been given to katatonia in asylums in this country. Judging from my
own experience, it is not a common disease.
Its CAUSES apparently lie in prolonged mental exhaustion and
inattention to bodily health. I have been led to suspect syphilis as at
least a predisposing cause.
The COURSE AND DURATION of katatonia are tedious, and even if there
is apparent recovery from the first attack, the tendency is to relapses
and to slowly-advancing dementia and death from those causes of
which dements in hospitals die, especially phthisis. I have never
seen a complete and permanent recovery.
The MORBID ANATOMY of katatonia suggests a deep-seated neurosis,

the precise nature of which we do not understand. In terminal stages
there are atrophy and degeneration and all that goes with them.
The CLINICAL HISTORY of katatonia is so characteristic that it need be

confused with the other diseases already mentioned as simulating
features of it, and with the early stage of general paralysis, only
through insufficient observation or too hasty diagnosis.
It is difficult to treat katatonia without the conveniences of a hospital.
PRIMARY CONFUSIONAL INSANITY is a term recently introduced for a

form of mental disease of which the most marked features are
moderate fever rapidly developed, confusion, incoherence, and mild
delirium. The onset of the disease is rapid. In some of the cases
which I have seen the diagnosis was made of typhoid fever, although
the clinical marks of that disease were absent, the general
appearance of the patient in the two diseases being quite similar.
There is no real melancholia or exaltation, no rapid flow of ideas, and

no dementia. Hallucinations of the special senses are common;
there is a consciousness of illness; the delusions are
unsystematized, and the confusion of ideas frequently goes to the
point of not being able to recognize persons and places. The usual
signs of fever are present for a few days, but the temperature rarely
exceeds 102° F., and soon drops to nearly or quite the normal.
The COURSE of the disease is quite rapid, and if recovery does not
take place in several weeks or a few months, chronic insanity with
delusions or dementia of various degrees may be expected.
The MORBID ANATOMY is not distinctive of this condition in the early

stage, and we cannot yet differentiate it from simple fevers by the
post-mortem. If ending in incurability, the atrophic and degenerative
changes of chronic mental disease are found.
As regards removal from home, the considerations already referred

to should be the guide. It is a good rule to keep the patient at home if
a suitable one for the purpose, and to resort to the asylum in case of
chronicity or troublesome complications.
PRIMARY DELUSIONAL INSANITY (Folie systematisée, Verrücktheit20)

differs from secondary delusional insanity in the facts that the
disease arises primarily, and not secondarily to other mental
diseases; that there is little or no mental enfeeblement in the early
stage; and that the delusions, although fixed and systematized, are
limited. It has the advantage of allowing the avoidance of the
misleading terms monomanie of the French and monomania of
English and American writers, the narrower forms of which may be
included under the term primary insanity (primäre Verrücktheit),
including the further developments of the neuropathic constitution,
especially those with the physical marks of degeneration described
by Sander as originäre Verrücktheit, and those marked by imperative
conceptions and such delusions of self-importance, suspicion, etc.
as seem to some people evidence of insanity, while by others they
are considered as simply false beliefs not indicating mental disease.
Unlike primary insanity, which is one of the states of mental defect
and degeneration, and incurable, primary delusional insanity may
occur in persons of healthy mental organization, and may end in
recovery,21 although it is one of the most distinctly hereditary forms of
insanity, generally speaking.
20 Called also by some writers Wahnsinn, although they use the term for secondary
delusional insanity also.
21 Some writers include both diseases under the term monomania, and make both
incurable degenerative states, which is contrary to my experience. Clouston also has
seen cures in what he calls monomania (primary delusional insanity) without the
neuropathic taint.
There are several subdivisions of primary delusional insanity,

according to the character of the delusions: (1) with delusions of
unseen agency, suspicion, and persecution; (2) with delusions of
personal exaltation; (3) with delusions transformed from sensations.
Delusions of unseen agency, suspicion, and persecution appear

either acutely and expand very rapidly in a few weeks, or from a very
insidious beginning so gradually that they may exist for months or
years before they are detected. The general indications of illness
consist in impaired sleep, slight loss of flesh, some reserve or
shyness in relations with other people, and diminished ability to
concentrate the mind in the usual occupations. The mental
impairment at first is very slight, and shows itself (1) in the readiness
with which the absurd delusions are believed and the fixedness of
their hold on the mind, and (2) in the diminished general power of
judgment and self-control in the little matters of daily life, at first so
slight that it is not seen except in matters requiring some effort to
maintain the customary equilibrium. Hallucinations, especially of
hearing, appear. In the progress of the disease the mind loses power
of self-control more and more, the delusions become more fixed,
concealment is no longer possible, and the patient is so annoyed or
angered that he repeatedly seeks relief from the courts
(Querulantenwahnsinn) or commits some act of violence in self-
defence. The common delusions are of marital infidelity, attempts at
poisoning, mesmerism, electricity, influence through telegraphs,
telephones, poisoned air, etc., signs of which are evolved directly
from the consciousness or transformed from common sights and
sounds, such as ringing of bells, striking of clocks, simple ordinary
motions, etc. The delusions in time produce a state of mental
depression.

Duttons Orthopaedic Examination Evaluation and Intervention 5Th Edition Mark Dutton Full Chapter

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Dutton's orthopaedic examination,

evaluation, and intervention 5th Edition

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Comments about this book may be sent to me at pt@mcgraw-hill.com.

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CHAPTER OBJECTIVES OVERVIEW

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brous portion consisting of amorphous ground substance.2

TABLE 1-1 Loose and Dense Collagen

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The Musculoskeletal System

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Physis Epiphyseal or growth plate Physeal dysplasia Short stature

The Musculoskeletal System

Diaphysis Forms shaft of bone Fractures Able to remodel angulation

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Skeletal Muscle Tissue CLINICAL PEARL

FIGURE 1-1 Microscopic structure of the muscle.

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The Musculoskeletal System

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Twitch rate Slow Fast Fast

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The Musculoskeletal System

cross-sectional area occupied by slow-twitch type I fibers

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com) and used in most functional movements, combines

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The Musculoskeletal System

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in that they have to contract rhythmically and generate

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Simple melancholia may be the initial stage of almost all of the

Melancholia with delusions (acute melancholia) is commonly a

In melancholia with delusions there is sooner or later, in the majority

Acute melancholia is sometimes confounded with delusional insanity

Melancholia with stupor (melancholia attonita) appears like complete

In melancholia agitata the mind is clear and active, the opposite of

Melancholia among children is more common than the books state it

The DURATION of simple melancholia is from a few weeks to a dozen

The PROGNOSIS in simple melancholia is favorable. Including cases

In chronic melancholia the process of mental deterioration is slow.

In treatment of melancholia the first indication is to protect society

Placing the patient in an entirely healthy atmosphere is next in

Tonics are indicated—cod-liver oil with bark, the hypophosphites,

Medicines to control restlessness and sleeplessness should be