Basic Concepts

Why Study Biomechanics & Biomaterials?

1. The basis of all implants & devices we use.
2. The basis for most trauma that we see.
3. The basis for most of our interventions.

❖ Basic Definitions:
➢ Kinesiology: it is the scientific study of human movement (Kinematics, Kinetics, Anatomy,
Physiology & Motor control).
➢ Mechanical Kinesiology: it is the study of mechanical factors affecting human body at rest or in
motion.
➢ Biomechanics: it is the study of biological systems by the application of the laws of physics
"mechanical principles" or it is the science of the action of forces (internal or external) on the
living body.
➢ Statics: it is the study of the action of forces on bodies at rest.
➢ Dynamics: it is the study of the motion of bodies & the forces that produce the motion:
1. Kinematics: descriptive analysis of mechanical components of motion (displacement &
velocity & acceleration) without referring to the forces causing the motion:
a. Qualitative analysis: naming & evaluating movement components.
b. Quantitative analysis: counting & measuring movement components.
2. Kinetics: causal analysis of motion which describes motion with referring to the forces
causing the motion.

 Joint kinematics helps in understanding an articulation which is important for the design
of prosthetic implants to restore function and to understand joint wear & stability &
degeneration.
 Kinematics & kinetics involve categorizing motion into translational components or
rotational components or both.

❖ Principle Quantities:
 Basic Quantities: (described by International System of Units "SI"; metric system)
• Length: meters "m".
• Time: seconds "sec".
• Mass "quantity of matter": kilograms "kg".
 Derived Quantities:(derived from basic quantities):
• Velocity(length/time):
o time rate of change of displacement (m/sec).

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 • Types:
1. Linear velocity: rate of translational displacement.

2. Angular velocity: rate of rotational displacement.

• Acceleration (length/time²).
• Time rate of change of velocity (m/sec²).
• It can also be linear or angular.
𝑀𝑎𝑠𝑠 𝑥 𝐿𝑒𝑛𝑔𝑡ℎ
• Force. 𝐹 = 𝑇𝑖𝑚𝑒 2
• Action causing acceleration of a mass (body) in a certain direction.
𝑀
• Unit of measure: newton; 𝑁 = (𝐾𝐺)(𝑠𝑒𝑐 2 )

❖ Scalar & Vector Quantities:

 Scalar quantities:
➢ have magnitude but no direction "Length, Time, mass, volume & speed (not velocity) ".
 Vector quantities:
➢ Have magnitude & direction "Velocity, Acceleration, Force &
Weight".
➢ Vectors have 4 characteristics.
➢ (represented as an Arrow):
1. Point of application (tail of the arrow).
2. Magnitude (length of the arrow).
3. Direction (head of the arrow).
4. Line of action (orientation of the arrow).
➢ Vectors can be subtracted or resolved (i.e. split into components) for analysis or added to
form a new vector by adding their components or graphically by the parallelogram of forces.
➢ Weight is vector quantity that is equal to the force of gravity "9.81 m/S2" acting on a mass.
➢ Velocity: amount of displacement per unit of time in certain direction;
(i.e. velocity = speed + direction).
 Tensors:
➢ Definition: arrays of numbers that represent the physical properties of a system.
➢ Scalars (e.g., mass): are tensors of rank 0.
➢ Vectors (e.g., force): are tensors of rank 1.
➢ Stress (force per unit area):
o It is an example of tensors of rank 2.
o Stress has magnitude & direction & is determined over a plane (surface) rather than
a line.
o Higher order tensors represent properties more complex than can be represented by
vectors.

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Newton’s Laws: (Basic Laws of Mechanics)
First Law (Low of Inertia):
➢ An object at rest will remain at rest and an object in motion will continue in motion with a
constant velocity (Mechanical Equilibrium) unless it experiences a change in external force.
➢ This law used in static analysis: ΣF = 0 (sum of external forces equals zero).
➢ Inertia: it is the tendency of an object to either remain at rest or to maintain uniform motion in
a straight line.
❖ Second law (Low of Acceleration):
➢ Acceleration (a) of a body is directly proportional to the magnitude of force (F) applied to it &
inversely proportional to the mass (m) of the body (𝐹 = 𝑚𝑥𝑎).
➢ This law is used in dynamic analysis.
➢ By combining the 1st & 2nd laws: the sum of the forces & moments that acting on a body must be
equal to zero "ΣF = 0" for equilibrium to occur.
❖ Third law (Low of Reaction):
➢ For every action (force) there is reaction (force) which is equal in magnitude & opposite in
direction.
➢ This law is used in free-body analysis & assists in the study of interacting bodies.

Levers:
➢ Consists of a rigid body with two externally applied forces & a point of rotation.
➢ In the musculoskeletal joints: one of the forces is produced by a muscle while the other is
provided by contact with the environment (or by gravity) & the center of rotation "COR" is the
joint.
➢ Types:
• First class: if the forces are on different sides of the COR.
• Second class: if the forces are on the same side of the COR and the external force is closer to
the COR than the muscle force.
• Third class: if the forces are on the same side of the COR and the muscle force is closer to the
COR than the external force.
N.B Most joints in the human body behave as third-class levers while second class levers are almost
never observed within the body.

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Free body analysis:
 General roles:
➢ It means forces & moments & free-body diagrams to analyze the action of forces on bodies.
➢ Mechanical Equilibrium:
• A system is considered in mechanical equilibrium when the sums of all forces "ΣF" &
moments "ΣM" acting on it are zero.
• A body in mechanical equilibrium is undergoing neither linear nor rotational acceleration;
however, it could be translating or rotating at a constant velocity (dynamic equilibrium).
• Static equilibrium is a special case of mechanical equilibrium of an object that is at rest.
➢ The following steps are used in the analysis:
• Identify the system (objective, known quantities, assumptions).

• Select a coordinate system.

• Isolate free bodies (free-body diagram).

• Apply Newton’s laws to establish equilibrium (ΣF = 0 and ΣM= 0).

• Solve for unknown quantities.

➢ Assumptions:
• No change in motion.

• No deformation.

• No friction.

❖ Force (F):
➢ Definition: physical quantity (Load) that changes the state of rest or state of uniform motion of
a body "external effect" and/or deforms its shape (Strain) "internal effect".
➢ The SI unit for measure: Newton (N).
❖ Motion:
➢ Definition: it is a change of position or place of object or subject in relation to a fixed point or a
reference point.

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 ➢ Types:
1. Linear (rectilinear or curvilinear).
2. Angular (rotatory).
3. General (combined of both).
➢ Properties of force:
1. Forces exist as a result of interaction & not necessarily associated with motion; for example,
a person sitting on chair exerts force on the chair but the chair doesn't move.
2. Force is a vector quantity:
• Has both magnitude & direction.
• Represented as an arrow (4 characters).
• Can be split into independent components for analysis:
a Usually in the x and y directions (Fx), (Fy).
b With angle (θ) between (Fx) & (Fy).
" If more than one force is applied to a body, the resultant force will be the vector sum of all the forces”.

❖ Types of Forces:
◆ Internal forces:
a. Muscle force.
b. Ligament & Tendon force.
c. Joint reaction force.
◆ External forces:
a. Gravitational force: pull the body downwards.
b. Ground reaction force: exerted on the body by the ground.
c. Friction: between contact surfaces.
d. Pressure: exerted over the area of contact between two bodies.
e. Resistance: may be air or water resistance.
 Muscle force:
➢ Size & structure of muscle affect the magnitude of the force exerted by this muscle.
➢ The maximum muscle strength (magnitude of muscle force) is affected by the physiological
cross section "PCS".
➢ The PCS is a perpendicular section which cuts all muscle fibers at its thickest part while the
muscle is in midway between complete contraction & complete stretch.
➢ The section changes according to the muscle shape: strap, fusiform, tricipital, triangular,
unipennate, bipinnate or multipennate.
➢ The 4 components of muscle force are: "Arrow"
1. Point of application of muscle force.
2. Magnitude of muscle force.
3. Direction of muscle force.

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 4. Line of application of muscle force.
➢ Magnitude of muscle force (muscle strength):
• It changes according to the PCS of this muscle.
➢ The factors that affect the magnitude of the muscle force are:
1. Arrangement of muscle fibers.
2. Width of the muscle.
3. Sex.
4. Age.
➢ Muscle strength: it is the maximum ability of the muscle to lift weight for one time or it is the
maximum force which the muscle can produce per unit cm "PCS".
➢ Types of muscle contraction:
A. Isotonic contraction:
• Concentric: shortening contraction.
• Eccentric: lengthening contraction.
B. Isometric contraction.

• Force System:
➢ Definition: it is a system which describes the relation between two or more forces.
➢ Classification:
A. Colinear:
• acting along same action line (Linear force system).
• To make a body in equilibrium in this system the two forces must be equal in
magnitude & opposite in direction.
• If the two forces are acting in the same line & direction: the resultant force "R"
will equal the sum of both forces.
• If the forces are acting in the same line & opposite direction: the resultant force
will be the subtraction of the two forces.
B. Coplanar:
• acting in the same plane (Parallel force system).
• Application of two forces or more acting at the same plane at two different
points & don't share the same action line.
• The forces act at a distance from each other & parallel to each other producing
rotatory effect.
C. Concurrent:
• acting at same point (Concurrent force system).
• Often forces acing on a body don't lie along the same line of action as in linear
force system but form an angle with each other i.e. concurrent force system like
sternal & clavicular heads of pectoralis major muscle.
• To calculate the resultant force:
o Parallelogram method.

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 o Trigonometric method.

 Moment (M):
➢ Definition: it is the rotational (angular) effect of a force (turning force) about a point.
➢ Important terms:
• Torque: is a moment from a force perpendicular to the long axis of a body.
• Bending moment: is a moment from a force parallel to the long axis of a body.
• Moment arm (Lever arm) "d": the perpendicular distance "shortest distance" from point of
rotation & the point of load application.
• Mass moment of inertia (I): it is the resistance to rotation:
o It equals mass times "multiplied by" the square of the moment arm
(𝐼 = 𝑚𝑥𝑑2 ).
It affects angular acceleration.
• Couple: pair of equal & opposite parallel forces applied at different points on the body which
produce a moment proportional to perpendicular distance between the line of action of
forces.
➢ Moment = magnitude of the force (F) times its moment arm (d) (𝑀 = 𝐹𝑥𝐷).
➢ The SI unit for measure: newton X meter (Nm).

◆ Free-body diagram:
➢ Definition: it is a drawing used to show the location & direction of all known forces & moments
acting upon an object in a given situation.
➢ For example, the forces acting on the forearm while at 90° of flexion & holding a weight in the
hand are:
• The total weight of the forearm.
• The weight of the object in the hand.
• The magnitude of the force exerted by the biceps muscle on the forearm. - The magnitude of
the joint reaction force at the elbow.
➢ They are useful in identifying and evaluating the unknown forces & moments acting on
individual parts of a system in equilibrium.
➢ The weight of each object acts through its center of gravity.

◆ Center of Gravity "COG":

➢ Definition: it is an imaginary balancing point at which all the body weight can be thought to be
concentrated & equally distributed.
➢ The summation of all forces & moments at this point equal zero.
➢ The gravitational force is one of the external forces that affect the human body.
➢ Location of "COG":
• It depends on the body shape & position & distribution of its mass.

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 • In symmetrically distributed mass as square block: "SOG" is at the center of the mass.
• In Asymmetrically distributed mass as human limb: "SOG" is nearer to the heavier end.
• The "SOG" of the adult human body in the anatomical standing position is located just anterior
to the second Sacral vertebra "S2" (N.B.: it was above the level of umbilicus in infants).
• Factors affecting location of "COG" in human body:
1. Age.
2. Sex.
3. Position of any segment in relation to total body segments.
4. Additional & subtraction of weight. Determination of total body "COG":
(𝑡𝑜𝑡𝑎𝑙 𝑏𝑜𝑑𝑦 ℎ𝑒𝑖𝑔ℎ𝑡 𝑥 55.7)+1.4
• Mathematically by Palmer formula: .
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• Determination of segmental body "COG":
The body consists of eight major segments: A. Axial
skeleton:
1. Head & Neck.
2. Trunk
B) Appendicular skeleton:
1. Arm.
2. Forearm.
3. Hand.
4. Thigh.
5. Leg.
6. Foot
➢ The "COG" of each body segment will be found towards its heavier end.
➢ This location is approximately 4/7 of the segment length measured from its distal end.

Segment Proximal End Distal end

Head & Neck Sternal Notch Vertex (top of head)

Trunk Sternal notch Midpoint between two hip joints
Arm Acromion Process Axis of Elbow joint
Forearm Axis of Elbow Joint Axis of Wrist joint
Hand Axis of Wrist Joint Middle finger tip
Thigh Greater Trochanter Axis of Knee joint
Leg Axis of Knee Joint Lateral malleolus
Foot Heel Tip of toes

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 ➢ Value of determination of "COG":
• Total body "COG": support the pelvis (which is the "COG") during weight bearing phase
after healing of fractures.
• Segmental "COG": it must be known in amputation because the distribution of the weight of
artificial limb must be equivalent to that of the amputated limb.
Other Important Basic Concepts:
◆ Work:
➢ Definition: the product of a force & the displacement produced by
the force.
➢ Work (w): (𝑊) = (𝐹𝑥𝐷). “F” is the force, “D” is the distance.
➢ Unit of measure: joule (J), ( 𝐽 = 𝑁𝑥𝑀)
◆ Energy:
➢ Definition: ability to perform work (unit of measure is also joule "J").
➢ Laws of conservation of energy:
• Energy is neither created nor destroyed.
• It is transferred from one state to another.
➢ Potential energy:
• Stored energy.
• Potential of a body to do work because of its position or configuration (e.g., strain energy).
➢ Kinetic energy: energy caused by motion (1/2 mv²).
◆ Piezoelectricity:
➢ It is an electrical charge when a force deforms a crystalline structure (e.g. bone).
➢ Convex (tension) side: charge is electropositive.
➢ Concave (compression) side: charge is electronegative.

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General Joint Biomechanics:
➢ How do joints maintain stability?
➢ What produces joint movement?
➢ What is the ROM?

◆ Joint Mechanics:
➢ Each joint provides various degrees of mobility & stability based on specific structural
considerations which acted on by internal & external loads.
➢ Joints are stabilized by the action of:
• Passive "Static" stabilizers: bony structure & ligaments.
• Active "Dynamic" stabilizers: muscles across the joint.
➢ The muscles are located at a distance from the joint.
➢ Muscle action produce moments about the joint center.

◆ Degrees of Freedom (DOF):

➢ Definition: the number of parameters that specify the position & movement of a body.
➢ The three-dimensional motion of a body segment is generally expressed using (X, Y, Z axes):
• Sagittal: divides the body into right & left sides.
• Coronal: divides the body into anterior & posterior parts.
• Transverse: divides the body into upper & lower parts.
➢ There are six DOF for a body moving in three-dimensional space:
• translational & 3 rotational (i.e. rotations & translations each occur in the X, Y &Z planes).
• There are three DOF for a body moving in two-dimensions: e.g. 2 translational & 1
rotational.
➢ Clinical examples:
• A ball & socket joint as the hip has 3 rotational DOF.
• A hinge joint as the elbow has 1 DOF: the geometric constraints of the joint permit only one
rotational motion about its axis of rotation.
• Translations may be relatively insignificant for many joints & often ignored in analyses.

◆ Joint Reaction Force "R":

➢ Definition: it is the force within a joint center in response to forces acting on it.
➢ The forces are both intrinsic & extrinsic.
➢ Muscle contraction about a joint: the major contributing factor.
➢ These reaction forces can be greater than the weight of the body segment or the entire body.
➢ When muscles & joint "R" are balanced: equilibrium occurs & the body segments don't
accelerate.
➢ When there is an imbalance of forces: acceleration (or deceleration) of the body segment occurs.
➢ "R" is correlated with predisposition to degenerative changes.

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➢ Joint contact pressure (Stress) can be minimized by:
• Decrease "R".
• Increase contact area.

◆ Coupled Forces:
➢ Rotation about one axis causes obligatory rotation about another axis in some joints.
➢ Such movements and associated forces are coupled.
➢ Example: lateral bending of the spine accompanied by axial rotation.

◆ Joint Congruence:
➢ It is related to the fit of two articular surfaces which is a necessary condition for joint motion.
➢ It can be evaluated radiographically.
➢ High congruence increases joint contact area while low congruence decreases joint contact
area.
➢ Movement out of a position of congruence:
• Increases stress in cartilage.
• Allows less contact area for distribution of joint reaction force.
• Predisposes the joint to degeneration.

◆ Instantaneous Axis of Rotation (IAR): (Instant Center of Rotation)

➢ It is the point about which a joint rotates.
➢ It normally lies on a line perpendicular to the tangent of the joint surface at all
points of contact.
➢ In some joints as the knee: the instant center changes during the arc of motion
following a curved path which is due to joint translation & morphologic features.

◆ Rolling & Sliding:

➢ Almost all joints roll & slide during motion to remain its congruence.
➢ Pure Rolling:
• Instant center of rotation is at the rolling surfaces.
• No translation or rotation change in position (just angulation).
• Contacting points have zero relative velocity (no “slipping” of one surface on the other).
➢ Pure Sliding:
• Occurs with pure translation or rotation about a stationary axis.
• No angular change in position (just translation or rotation).
• No instant center of rotation (“Slipping” of one surface on the other).

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◆ Friction & Lubrication:
❖ Friction:
➢ It is the resistance to motion between two solid objects as one slides over the other.
➢ Coefficient of friction for human joints: 0.002 to 0.04.
➢ Lubrication: decreases friction between surfaces.
➢ Articular surfaces have coefficient of friction 10 times better than the best synthetic system.
➢ Elasto-hydrodynamic lubrication: it is the primary lubrication mechanism for articular cartilage
during dynamic function.

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Regional Biomechanics

Hand
◆ Kinematics:
 Bony configurations:
➢ Each of the 4 medial fingers consists of metacarpal & 3 phalanges while thumb has only 2.
➢ MCPJ is synovial condylar joint formed by articulation between convex metacarpal head &
concave proximal end of proximal phalanx.
➢ IPJs are synovial hinge joints.
➢ ROM
• The 4 medial fingers:
I. MCP joint: universal joint has 2 degrees of freedom.
o Flexion: 100°.
o Abduction-Adduction: 60°.
II. PIP joints:
o Flexion:1100.
III. DIP joints:
o flexion 80°.
• The thumb:
I. Trapezio-metacarpal joint: (synovial saddle joint)
o Flexion: 70°.
o Abduction: 70°.
o Adduction: 30°
Opposition: it is a function of both Trapezio-metacarpal & MCP joints.
II. IP joint:
o Flexion: 90°.
o Extension: 20°.
o Arches:
o Two transverse arcs:
• Proximal through carpus.
• Distal through metacarpal heads.
o Five longitudinal arches: through each of the rays.
➢ Instant center of rotation of MCPJ present within the metacarpal head.
➢ There are 2 functional positions for the 4 medial fingers:
• 1st: formation of placement arc which occur at full MCPJ flexion & responsible for 75% of total
finger flexion.
• 2nd: when the fingers grasp an object "fine encompass" which occur from motion of PIPJ and
DIPJ & responsible for 25% of total finger flexion.
➢ Motion of MCPJ & PIPJ are interrelated because flexion of MCPJ leads to increase ROM of PIPJ.

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◆ Kinetics:
 Pinching:
➢ Joint loading with pinch mostly in MCP joins because they have large surface area however,
contact pressure (joint load/contact area) are lesser.
➢ DIP joints have the most contact pressure, so they develop the most degenerative changes with
time (Heberden’s nodes).
➢ Normal Pinch:
• For boys & men: 8 kg.
• For girls & women: 4 kg.
• Only 1 kg needed for daily activities.
➢ Compressive loads occur at the thumb with pinching:
• At Inter-phalangeal joint: 3 kg.
• At MCP joint: 5 kg.
• At Carpometacarpal joint: 12 kg (unstable joint leads to its degeneration).

 Grasping:
➢ Grasping contact pressures are lesser & focused on MCPJ (patients with MCPJ arthritis often
had occupations in which grasping was required).
➢ Normal Grasp:
• For boys & men: 50 kg.
• For girls & women: 25 kg.
• Only 4 kg needed for daily activities.

 Finger flexion:
➢ It is initiated by FDS & FDP & interossei &oblique retinacular ligaments.
➢ It occurs at PIPJ (by action of FDP) then at MCPJ then at DIPJ.
➢ FDP tensions the oblique retinacular ligament. so, prevents DIPJ flexion during PIPJ extension.

 Finger extension:
➢ Extensor tendons are divided into 6 compartments at wrist.
➢ Finger extensor mechanics "extensor expansion":
• Definition: it is a complex system responsible for extension of the 3 joints by a single
tendinous mechanism.
• Site: dorsum of proximal phalanx of medial 4 fingers.
• Formed by:
1. Extrinsic radial nerve innervated muscles: ED & EI & EDM.
2. Intrinsic ulnar nerve innervated muscles: interossei & 4th,5th lumbrical.
3. Intrinsic median nerve innervated muscles:2nd 3rd lumbricals.

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 ➢ Tendon excursions-moment arm:
• Definition: each tendon slides a certain distance when finger moves in which tendon of agonist
muscle displaces in one direction while tendon of antagonist muscle displaces in the opposite
direction.
• Importance:
1. Theoretical calculation of muscle forces.
2. Splinting of the hand after tendon repair.
3. Surgical procedures as tendon transfers.

 Muscle groups acting on thumb:

1. Extrinsic:
APL & EPL & EPB (absent in 15% of people) & FPL (strongest extensor).
2. Intrinsic: FPB & APB & AP & OP.

 Other concepts:
➢ Muscles of fingers are divided into flexors & extensors and both are intrinsic & extrinsic.
➢ Sagittal band:
• They are parts of extensor expansion surrounding the metacarpal heads.
• Function: they centralize the extensor tendons.
• There injury: subluxation of extensor tendons.
• Hand pulleys prevent bowstringing & decrease tendon excursion (bowstringing increases
moment arms).
• Sagittal bands allow MCPJ extension.
➢ With hyperextension of MCPJ: the intrinsic muscles must function to produce PIPJ extension
because the extension tendon is lax.

◆ Stability:
 Stabilizers:
a. Bony congruity of articulation.
b. Soft tissue:
1. MCPJ: capsule & volar plate & collateral and accessory collateral ligaments & sagittal band
& deep transverse ligament.
2. IPJ: capsule & volar plate & collateral and palmar ligaments.
3. Trapezio-metacarpal joint stabilizers:
i. Anterior oblique ligament (mainly).
ii. Posterior oblique ligament.
iii. Dorsal radial facet.

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 ➢ Main stabilizers of MCP joint:
1. Volar plate.
2. Collateral ligaments which are taught in flexion & lax in extension.
➢ Main stabilizers of PIP joints & DIP joints:
1. Joint bony congruity.
2. Large ratio of ligament to articular surface.
➢ Arthrodesis: recommended positions of flexion for arthrodesis of hand joints:
• Metacarpophalangeal "MCP": 20°.
• Proximal Interphalangeal "PIP": 40°.
• Distal Interphalangeal "DIP": 20°.
• Thumb MCP: 20° & Metacarpal in opposition.
• Thumb IP: 20°

Wrist
◆ Kinematics:
➢ Wrist 2 Rows of bones: (from lateral to medial) A. Proximal row:
• Scaphoid(boat): articulates with distal radius proximally while distally with trapezium &
trapezoid.
• Lunate(crescent): articulates with lunate fossa of distal radius & with capitate.
• Triquetrum(pyramidal): articulates proximally with triangular fibrocartilage "TFC" while
anteriorly with pisiform & hamate.
• Pisiform (pea-shaped): articulates with palmar surface of triquetrum (flexor carpi-ulnaris
"FCU" sesamoid).
B. Distal row:
• Trapezium (quadrangular):
o Articulates proximally with scaphoid while distally with the base of 1 st
MC.
o Its palmar surface is grooved for FCU tendon with a crest lateral to the
groove.
• Trapezoid (irregular): articulates proximally with scaphoid while distally with the base
of 2nd MC.
• Capitate (headed): articulates with the Scaphoid & lunate & 3rd MC.
• Hamate (hooked):
o Articulates proximally with triquetrum & capitate while distally with the base
of 4th & 5th MC.
o Hook of hamate fracture may encroach on ulnar nerve medial to it.
o Bipartite Hook = Hamuli Proprium.
➢ Wrist has 3 Columns:

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 I. Lateral column, (Mobile):
• Consist of: Scaphoid.
• Function: mobile column specially Abduction - Adduction & Axial loading.
II. Central column (Flex-Ext):
• Consists of: distal carpal row & lunate (Link system).
• Function: Flexion-Extension.
• Centre of rotation: capitate.
III. Medial column (Rotation):
• Consists of: Triquetrum.
• Function: carpus rotates around triquetrum independent of forearm rotation.
◆ ROM:
➢ Normal ROM:
➔ Sagittal plane (Flexion: 90°, Extension: 80°).
• Flexion is more than extension due to palmer tilt distal radial plate.
• Flex-Ext: Two-thirds radiocarpal while One-third intercarpal (midcarpal).
➔ Frontal plane (Radial deviation: 20°, Ulnar deviation: 30°).
• Radial deviation or extension: primarily intercarpal movement.
• Ulnar deviation or flexion: combined radiocarpal & intercarpal motion.
• With radial deviation: proximal carpal row moves ulnar while distal row moves radially.
➢ Instant center is difficult to be estimated due to multiple joint articulations but it usually the
head of the capitate.

 Interaction between wrist & hand motion:

➢ Wrist extension: increases the length of finger flexors leading to finger flexion.
➢ Wrist flexion: increases the length of finger extensors leading to finger extension.
➢ Normal radiographic relationships of distal radius:
• Radial length (height): averages 11 mm.
• Radial inclination (angle): medial tilt averages 23 degrees.
• Radial (palmar or volar) tilt: averages 11 degrees & loss or reversal of the normal palmar tilt
results in load transfer onto ulna & TFCC.
◆ Kinetic:
➢ Main kinetic function of wrist is to transmit compressive loads from hand to forearm & vice
versa.
➢ When applying compressive loads across the proximal carpal raw the resultant line of action
will pass through head of capitate to scapholunate to distal radial & ulnar surfaces.
➢ Distal radius normally bears about 80% of distal radioulnar joint load while distal ulna bears
20%:
• Ulnar load bearing increases with ulnar lengthening & decreases with ulnar shortening.

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 • TFC decreases compressive loads across the wrist joint & its excision will decrease load
borne by ulna to 0%.
➢ There is physiological mild flexion & ulnar deviation at rest which results from the
summation of all muscle forces across the joint.
➢ Relationships:
• Carpal collapse: ratio of carpal height to 3rd metacarpal height (normally 0.5).
• Ulnar translation: ratio of ulna to capitate length to 3rd metacarpal height (normally 0.3).
➢ Tendon shift mechanism:
• The wrist joint rebalances its flexion-extension forces by controlling their moment arms.
• With radial deviation & extension: scaphoid flexion so the distal pole acts as a pulley so
increase moment arm of wrist flexor tendons.
• With ulnar deviation & flexion: scaphoid extension so acts as a convex pulley with distal
radius so increases moment arm of wrist extensor tendons.
• Tendon shift mechanism is disturbed by:
1. Limited carpal fusions.
2. Proximal raw carpectomy.
◆ Stability:
Contributors of stability:
1. Articular congruity.
2. Soft tissue: capsule & ligaments & muscles.
Double "V" system:
➢ Definition: it is the system through which the palmer & dorsal intrinsic and extrinsic
ligaments provide wrist stability.
➢ Description:
• Distal V consists of: radio-scapho-capitate & ulno-capitate ligaments.
• Proximal V consists of: radio-ulno-triquetral & radio-scaphoid & ulno-lunate &
ulno- triquetral ligaments.
• Ulnar deviation: changes proximal "V" to "L" configuration & also changes distal
"V" to "L" configuration but in opposite direction.
• Radial deviation: the opposite occurs.
Link system:
➢ A system of 3 links in a “chain”: radius & lunate & capitate.
➢ Less motion is required at each link however it adds to instability of the chain.
➢ Stability is enhanced by strong volar ligaments & by scaphoid which bridges both carpal rows.
Arthrodesis:
➢ Relatively common.
➢ Unilateral fusion: 10° of dorsiflexion.
➢ Bilateral fusion: avoid it if possible but if necessary fuse the other wrist at 10° of palmar flexion.

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Elbow
◆ Kinematics:
➢ Functions:
1. A component joint of the lever arm when the hand is positioned.
2. Fulcrum for the forearm lever.
3. Weight-bearing joint in patients using crutches.
4. Activities of daily living.
➢ The 3 separate articulations of the elbow are:
1. Ulno-humeral (hinge).
2. Radio-humeral (rotation).
3. Proximal radioulnar (rotation).
◆ ROM:
➔ Flexion & Extension:
• 0° to 150°.
• Functional ROM: 30° to 130° (100° arc).
• Axis of rotation: the center of the trochlea.
➔ Pronation & Supination:
• Pronation: 80°.
• Supination: 85°.
• 90% of it occurs in forearm while 10% occurs in radiocarpal & intercarpal joints.
• Functional pronation & supination: 50°.
• Axis of rotation: runs from capitulum through radial head to ulnar head (forms a cone).

Carrying Angle:
➢ Valgus angle at the elbow in extension due to the special orientation of trochlea.
➢ It decreases with elbow flexion till the forearm comes at the same line of the arm.
➢ For boys & men: 7°.
➢ For girls & women: 15° (to accommodate for wider pelvis in females).

◆ Kinetics:
➢ Forces at the elbow have short lever arms:
• Results in large joint reaction forces.
• Subject the joint to degenerative changes.
➢ Static loads approach body weight & dynamic loads exceed it.
➢ About 15 % only of the axial load through forearm is transmitted by the ulna.
➢ Muscle forces:
• Flexion: brachialis & biceps.
• Extension: triceps & anconeus.

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 • Pronation: pronators (teres & quadratus).
• Supination: biceps & supinator.

◆ Stability:
➢ The elbow is a "modified hinge" joint with a high degree of intrinsic stability due to:
• Articular bony congruity.
• Opposing tension of elbow flexor & extensor muscles.
• Ligamentous constraints (the anterior band of the MCL is the most important for stability).
➢ Primary stabilizers (the 3 necessary & sufficient constraints for stability):
1. Anterior band of the medial collateral ligament (MCL):
o The most important part is the anterior oblique fibers.
o It is the primary medial stabilizer (valgus stability) of elbow.
o It also stabilizes against distraction force at 90°.
o Resection of the anterior band will cause gross instability except in extension.
2. Lateral (ulnar) collateral ligament (LCL):
o "specially the medial band of LCL", It acts with anconeus muscle as the lateral
stabilizer (Varus stability) of elbow.
o They prevent posterolateral rotatory instability i.e. prevent posterior
subluxation & rotation of the ulna away from the humerus in position of
forearm supination.
3. Coronoid.
➢ Secondary stabilizers:
1. Radial head is the most important secondary stabilizer against valgus stress:
o About 30% of valgus stability.
o Important at 0° to 30° of flexion & pronation.
➢ Joint capsule is the primary restraint to distraction forces in extension.
➢ Lateral stability is provided by lateral collateral ligament & anconeus & joint capsule.
➢ Specific elbow stabilizers:
o Anteroposterior stability:
• During extension: trochlea & olecranon fossa.
• During flexion: coronoid fossa, radio-capitellar joint, & (biceps /brachialis/triceps) muscles.
o Valgus stability:
• During both flexion & extension: MCL complex (specially the anterior band).
• During extension: anterior capsule & radio-capitellar joint.
o Varus stability:
• Static: Ulno-humeral articulation & lateral ulnar collateral ligament.
• Dynamic: anconeus muscle.
➢ Extension & pronation are the positions of relative instability.

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 ◆ Arthrodesis:
➢ It is difficult to perform and (fortunately) rarely required.
➢ Unilateral arthrodesis: 90° of flexion.
➢ Bilateral Arthrodesis:
• One elbow at 110° of flexion for the hand to reach the mouth.
• Other at 65° of flexion for perineal hygiene.

Shoulder
◆ Kinematics:
• Abduction: 1800.
• Adduction: 450.
• Flexion: 1800.
• Extension:450.
• Internal rotation: 900.
• External rotation: 900.

◆ Bony Configuration:
➔ The 5 Articulations of Shoulder girdle:
1. Glenohumeral.
2. Acromioclavicular.
3. Sternoclavicular.
4. Scapulothoracic articulation.
5. Pseudo joint between the head and coracoacromial ligament.
➔ Glenoid inclination & retroversion:
• Retroverted: 5o.
• Inclined superiorly: 5o
• Scapular anteversion: 300.
➔ The articular surface of the humeral head is about three times that of the glenoid fossa
which is ideal to accommodate a wide range of movement.
➔ Scapular plane:
• The plane of scapula is 20° anterior to the coronal plane.
• It is the preferred reference plane for assessment of ROM.

 Abduction Kinematics:
➢ First 30o abduction:
• Mainly occurs at Glenohumeral joint.
• Little motion at sternoclavicular joint occurs.

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➢ 30°-900 abduction:
• 2/3 of motion occurs at Glenohumeral joint.
• 1/3 occurs at scapulothoracic motion i.e. with ratio 2: 1.
➢ 90°-1800 elevation:
• Mainly scapulothoracic.
➢ Associated Glenohumeral external rotation occurs to prevent greater tuberosity impingement
against acromion so abduction limited to 120° in case of internal rotation contractures.
➢ Acromioclavicular joint moves during the last 60o.
➢ Sternoclavicular joint moves during shrugging & protraction & during the later portion with
clavicular rotation along its long axis.

 Individual joint motion:

A. Glenohumeral joint:
• Rotation.
• Translation (gliding).
• Rolling: combination of rotation & translation.
B. Acromioclavicular joint: (synovial joint with meniscus)
• Forward rotation constrained by: Conoid ligament.
• Backward rotation constrained by: the trapezoid ligament.
• Axial rotation constrained by: both ligaments.
C. Sternoclavicular joint: (synovial joint with meniscus)
• Protraction/retraction: constrained by coracoclavicular & sternoclavicular ligaments.
• Elevation/depression: constrained by subclavius muscle.
• Rotation: constrained by both.
D. Scapulothoracic articulation:
• Protraction/retraction.
• Elevation/depression.
• Rotation.
➢ Coordinated motion involves: Glenohumeral & Scapulothoracic & SC & AC motion.
➢ Glenohumeral joint surface motion is combination of rotation & rolling & translation.

◆ Kinetics:
➔ Muscle forces:
➢ Glenohumeral:
• Abduction: deltoid & supraspinatus.
• Adduction: latissimus dorsi & pectoralis major & teres major.
• Flexion: pectoralis major & deltoid (anterior) & biceps.
• Extension: latissimus dorsi.
• Internal rotation: subscapularis & teres major.
• External rotation: infraspinatus & teres minor & deltoid (posterior).

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 ➢ Scapular:
• Rotation: upper and lower trapezius & levator scapulae (anterior) & serratus anterior.
• Adduction: trapezius & rhomboid & latissimus dorsi.
• Abduction: serratus anterior & pectoralis minor.

➔ Zero Position:
➢ Abduction of 165° in the scapular plane.
➢ At which there are minimal deforming forces about the shoulder.
➢ It is the ideal position for reducing shoulder dislocations & fractures with traction.

◆ Stability:
➢ Glenohumeral joint stability is limited and depends on various passive & active mechanisms:
A. Passive:
1. Joint conformity: synovial and ball & socket.
2. Bony restrictions: acromion & coracoid & glenoid fossa.
3. Joint capsule.
4. Glenoid labrum.
5. Glenohumeral ligaments: superior & middle & inferior.
B. Active:
➢ long head of Biceps & tendons of rotator cuff muscles blending with capsule as follows:
• Supraspinatus tendon superiorly.
• Infraspinatus & teres minor tendons posteriorly.
• Subscapularis tendon anteriorly.
➢ Bony stability is limited due to:
1. Humeral head inclination (125°) & retroversion (25°).
2. Slight glenoid retro-tilt "retroversion".
3. Humeral head surface area larger than glenoid area: 48 x 45 versus 35 x 25 mm.
➢ Specific stabilizers:
• Inferior Glenohumeral ligament (superior band) is the most important static stabilizer while
superior & middle Glenohumeral ligaments are secondary stabilizers to anterior humeral
translation.
• Inferior subluxation prevented by negative intra-articular pressure.
• Rotator cuff muscles are the dynamic contributors to stability.
➢ Causes of Shoulder Instability:
• Big head of humerus.
• Shallow glenoid cavity.
• Wide range of movement.
• Lax capsule specially below.
• Lack of muscle or ligament support especially below.

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◆ Arthrodesis:
➢ 20° abduction & 20° forward flexion & 40° of internal rotation.

 Other Joints:
➔ Acromio-clavicular joint "AC":
• Scapular rotation occurs through the conoid & trapezoid ligaments.
• Scapular motion occurs through the joint itself.
➔ Sternoclavicular joint "SC":
• Clavicular protraction/retraction in a transverse plane through the coracoclavicular
ligament.
• Clavicular elevation & depression in the frontal plane (also through coracoclavicular
ligament).
• Clavicular rotation around its longitudinal axis.

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Spine
◆ Kinematics:
ROM by anatomic segment:
Level Flexion/Extension Lateral Bending Rotation Instantaneous axis of rotation (IAR)

Occiput "C0-C1” 15 10 0 Skull, 1 inch above dens

C1-C2 10 0 45 Waist of odontoid

C2-C7 15 10 10 Vertebral body below

Thoracic spine 5 5 5 Vertebra below/disc nucleus

Lumber spine 15 5 5 Disc annulus

➢ Analysis based on the functional unit (Motion segment): 2 vertebrae & intervening soft tissues.
➢ About 50% of cervical flexion-extension occurs at base of skull "C0-C1” (Atlanto-Occipital joint)
➢ About 50% of cervical axial rotation occurs at C1-C2 (Atlanto-Axial)
➢ Cup & ball type of articulation between C0-C1 allows coronal & sagittal rotation.
➢ The mobile cervical & lumbar segments are separated by the rigid thoracic vertebral segment which
creates stress risers at cervico-thoracic & thoraco-lumbar junctions.
➢ Six degrees of freedom exist about all three axes.

 Coupled Motion:
➢ Simultaneous rotation & lateral bending & flexion or extension occurs in harmony in the 4 curves
of the spine.
➢ Especially axial rotation with lateral bending.

 Normal sagittal alignment: (4 Curvatures)

1. In cervical spine: 25° of lordosis.
2. In thoracic spine: 35° of kyphosis.
3. In lumbar spine: 50° of lordosis:
• The lordosis exists because of the disc spaces (not the vertebrae).
• Most lordosis occurs between L4 & S1.
• Loss of disc space height can cause loss of normal lumbar lordosis.
• Iatrogenic flat back syndrome of the lumbar spine: result of a distraction force.
4. Sacro-coccygeal spine: kyphosis.

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 Instantaneous axis of rotation (IAR) of Spine:
➢ It isn't necessary to be contained in the vertebral body.
➢ Its position is affected by:
• Degenerative Changes.
• Loss of anatomic Stabilizers or anatomic destruction.
➢ The previous causes lead to IAR shifting towards uninjured segment but within certain
limits.
➢ IAR is important to know to put any construct in mechanically favorable position.
➢ Lumber IAR for rotation is located near the posterior annulus which if destroyed, the IAR
migrates posteriorly which if also destroyed, the IAR migrates anteriorly.
➢ Lumber IAR for flexion is located within the nucleus pulposus & anterior column is
destroyed, the IAR migrates inferiorly & posteriorly.
◆ Kinetics:
 Disc:
➢ Behaves viscoelasticity.
➢ Demonstrates hysteresis:
• Absorbs energy with repeated axial loads.
• Later decreases in function.
➢ Demonstrates creep & deforms with time.
➢ Higher loads increase deformation & creep rate.
➢ Compressive stresses highest in the nucleus pulposus while tensile stresses highest in the
annulus fibrosus.
➢ Stiffness increases with compressive load.
➢ Loads increase with bending & torsional stresses.
➢ Repeated torsional loading (shear forces):
• Such repeated loading may separate the nucleus pulposus from the annulus & end plate.
• This in turn may force nuclear material through an annular tear.
➢ After subtotal discectomy: extension is the most stable loading mode.
➢ Disc pressures: are lowest with lying supine & higher with standing & highest with sitting.
➢ Carrying loads: disc pressures are lowest when the load is close to the body.
➢ Annulus is thick anteriorly & laterally but thin posteriorly & postero-laterally so it is the site of

stress risers leading to disc herniation.

 Vertebrae:
➢ Strength is related to bone mineral content & vertebrae size (increased in lumbar spine).
➢ Fatigue loading may lead to pars fractures.
➢ Compression fractures occur at the end plate.
➢ Vertebral body stiffness is decreased in osteoporosis due to loss of horizontal trabeculae.

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➢ Centre of gravity passes through cervical vertebral bodies & anterior to thoracic vertebrae &

intersecting anterior corner of sacrum so most of spinal column experience compressive forces

anteriorly & tensile posteriorly except in lumbar lordosis in which this fact is reversed.

◆ Stability & Supporting Structures:

➢ Stability comes mainly from ligamentous structures because of the unstable osseous
anatomy of spine that permits wide range of motion.
o Anterior supporting structures:
a. Anterior longitudinal ligament.
b.Posterior longitudinal ligament.
c. Intervertebral disc.
o Posterior supporting structures:
a. Capsular ligaments & facets.
b.Ligamentum flavum (yellow ligament).
c. Inter-transverse ligaments.
➢ Outer layer of annulus is important for rotational stability & if anterior column is injured it
will lead to rotational instability.
➢ Halo vest is the most effective device for controlling cervical motion because of pin purchase

in skull.

 Apophyseal "Facet" joints:

➢ Resist torsion during axial loading
➢ Attached capsular ligaments resist flexion.
➢ They guide the motion segment.
➢ Direction of motion determined by orientation of the facets of the apophyseal joint which
varies with each level:
• Cervical spine facet orientation:
o 45° to the transverse plane.
o Parallel to the frontal plane.
• Thoracic spine facet orientation:
o 60° to the transverse plane.
o 20° to the frontal plane.
• Lumbar spine facet orientation:
o 90° to the transverse plane.
o 45° to the frontal plane.
o They progressively tilt up (transverse) & inward (frontal).
➢ Motion at the facet joints is also complemented by concomitant motion between vertebral
bodies through the intervertebral disks.

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 ➢ Cervical facetectomy of more than 50% causes loss of stability in flexion & torsion.
➢ Torsional load resistance in the lumbar spine:
• Facets contribute 40%.
• Disc contributes 40%.
• Ligamentous structures contribute 20%.

◆ Spinal Arthrodesis:
➢ increasing implant stiffness is helpful in:
• Increases probability of successful fusion.
• Increases likelihood of lowering bone mineral content of the bridged

vertebrae.

Pelvis & Hip

◆ Kinematics:
❖ Range of Motion "ROM":
➢ Flexion: 115° (functional: 90°, squat: 120°)
➢ Extension: 30°.
➢ Abduction: 50° (functional: 20°).
➢ Adduction: 30°.
➢ Internal rotation: 45°.
➢ External rotation: 45° (functional: 20°).
➢ Instant center:
➢ Simultaneous triplanara motion for this ball & socket joint makes analysis impossible.

❖ Normal anatomical considerations:

➢ Acetabulum is a bony cavity faces obliquely:
• Outward& forward (10o from sagittal plane).
• Downward (60o from horizontal plane but labrum make it 500).
➢ Angles of proximal femur:
• Neck shaft angle is 130°±7° (if increased=coxa valga & if decreased= coxa vara).
• Femoral anteversion (torsion) angle is 10° ± 7°.
• Femoral offset: distance between center of head to the long axis of the shaft of femur.
➢ Calcar femoral:
• Definition: intra-osseous vertical plate of dense bone located postero-medially at the
neck-shaft junction & not part of the neck.
• Function: buttress at the medial neck & proximal shaft to absorb weight compressive and
bending forces.

28
 • It has 3 extensions (Harty 1957):
1. Proximally: to postero-inferior neck.
2. Laterally: to posterior greater trochanter.
3. Distally: extend anterior to lesser trochanter to fuse with the shaft posteromedially.
➢ Blood supply of femoral head:
1. Medial circumflex femoral artery (the most important).
2. Lateral circumflex femoral artery.
3. Artery of the ligamentum teres.

◆ Kinetics:
➢ Femoral Head:
➢ Forms 2/3 of a sphere.
➢ Articular surface is thicker on the medio-central part and thinnest on the periphery.
➢ The Joint reaction force usually acts on the superior quadrant.
➢ Hip & Pelvis motion during gait: see gait.

➢ Joint Reaction Force (R) in the hip:

➢ It can reach 3 to 6 times body weight "W" mainly due to contraction of muscles crossing the hip.
➢ If the lateral moment (abductor muscles moment) from the point of rotation of hip joint is "A"
while the medial moment (body weight "W" moment) is "B".
➢ An increase in the ratio of "A/B" decreases "R" for example, medialization of the acetabulum or
long neck prosthesis or lateralization of the greater trochanter.
➢ Both "R" & abductor moment are reduced by shifting body weight over hip ➔(Trendelenburg
gait).
➢ A cane in the contralateral hand produces additional moment which can reduce "R" up to 60%.
➢ Carrying a load in the ipsilateral hand also decreases "R" at the hip.
➢ Energy expenditure is 250% of normal with a resection arthroplasty of the hip.
➢ The hip & trunk generate 50% of the force during a tennis serve.
➢ Hip is affected by 3 forces:
1. The Body Weight “BW” in front of S2.
2. The Abductor force = 2 times BW.
3. The Total Femoral Head force = 3 times BW in stance.

N.B.: These forces affect the hip joint through 2 lever arms (the abductor & BW lever arms) which meet

in the Hip center of rotation which is nearly the center of the femoral head.

➢ Forces acting across the hip joint:

1. Two-legged stance: 0.5X body weight.
2. One legged stance: 3X body weight.
3. Walking: 3X body weight.
4. Stairs or Running: 5 to 7X body weight.

29
◆ 3. Stability:
➢ Stability: deep-seated “ball & socket” joint is intrinsically stable.
➢ Sourcil:
• Condensation of subchondral bone under superomedial acetabulum.
• "R" is maximal at this point.
➢ Gothic Arch:
• Remodeled bone supporting the acetabular roof.
• Sourcil at its base.
➢ Neck-Shaft Angle:
A. Varus Angulation:
1. Decreases "R".
2. Increases shear across the neck.
3. Leads to shortening of the lower extremity.
4. Alters muscle tension resting length of the abductors.
5. May cause a persistent limp.
B. Valgus Angulation:
1. Increases "R".
2. Decreases shear across the neck.
C. Neutral or valgus angulation:
o better for THA.

◆ Arthrodesis:
➢ Position: 25° of flexion.
➢ 0° of abduction & neutral rotation:
• External rotation (about 5°) is better than internal rotation.
• If the implant is fused in abduction, the patient will lurch over the affected lower extremity
with an excessive trunk shift which will later result in lower back pain.
➢ Effects:
• Increases oxygen consumption.
• Decreases gait efficiency to approximately 50% of normal.
• Increases trans-pelvic rotation of the contralateral hip.

◆ Pelvic Stability:
➢ Based on ligamentous structures which divided into 2 groups according to their attachments:
A. Sacrum to ilium:
a. the strongest & most important ligamentous structures present in the posterior aspectof
the pelvis connecting the sacrum to the innominate bones.
b. Consists of 3 groups:

30
 i. Sacroiliac ligamentous complex:
▪ Divided into posterior (short & long) and anterior ligaments.
▪ Posterior ligaments provide most of the stability.
ii. Sacrotuberous ligament:
▪ It runs from the posterolateral aspect of the sacrum and the dorsal aspect of the
posterior iliac spine to insert on the ischial tuberosity.
▪ his ligament in association with the posterior sacroiliac ligaments are important in
maintaining vertical stability of the pelvis.
iii. Sacrospinous ligament:
▪ It is triangular ligament running from the lateral margins of sacrum & coccyx
to insert on the ischial spine.
▪ It is more important in maintaining rotational control of the pelvis if the
posterior sacroiliac ligaments are intact.
B. Pubis to pubis:
This is the symphysis pubis "Symphysial ligaments".
C. Additional stability:
by ligamentous attachments between lumbar spine & pelvic ring:
i. Iliolumbar ligaments: originate from transverse processes of L4 & L5 and insert
on the posterior iliac crest.
ii. Lumbosacral ligaments: originate from transverse process of L5 and insert on the
ala of sacrum.

The transversely placed ligaments:

➢ Include: short posterior sacroiliac & anterior sacroiliac & iliolumbar & sacrospinous.
➢ They resist rotational forces.
The vertically placed ligaments:
➢ Include: long posterior sacroiliac, Sacrotuberous & lateral lumbosacral.
➢ They resist vertical shear.

Assessment of pelvic stability after trauma:

➢ Stable injury:
• Definition: can withstand normal physiological forces without abnormal deformation.
• Penetrating trauma usually not results in pelvic ring destabilization.
➢ Unstable injury:
• It is characterized by the type of displacement:
a. Rotationally unstable:
open & externally rotated OR compressed & internally rotated.
b. Vertically unstable.

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Bony equivalents to ligamentous disruptions:
➢ Symphysis alone: pubic diastasis < 2.5 cm.
➢ Symphysis & sacrospinous ligaments: > 2.5 cm of pubic diastasis (these are rotational
movements and not vertical or posterior displacements).
➢ Symphysis & sacrospinous & Sacrotuberous & posterior sacroiliac: unstable vertically &
posteriorly & rotationally.

Knee
◆ Kinematics:
❖ ROM:
➢ Extension & Flexion:
• 10° of extension (Reccurvatum) to 130° of flexion.
• Functional ROM is nearly full extension to about 90° of flexion:
▪ 120°: required for squatting & lifting.
▪ 110°: required for rising from a chair after TKA.
➢ Rotation varies with flexion:
• At full extension: rotation is minimal.A
• t 90° of flexion: ROM is 45° of external rotation & 30° of internal rotation.
➢ Amount of abduction or adduction is essentially 0 degrees (a few degrees of passive motion is
possible at 30° of flexion).
➢ Knee motion is complex about a changing instant center of rotation (Polycentric rotation).
➢ Excursions of 5 mm for the medial meniscus & 11 mm for the lateral meniscus are possible
during 120° arc of motion.
❖ Joint Motion:
➢ The tibial plateau slopes anterior to posterior 10°.
➢ Instant center traces a J-shaped curve about the femoral condyle (moves posteriorly with
flexion).
➢ Flexion & extension involve both rolling & sliding.
➢ Screw home mechanism:
▪ Femur internally rotates (external tibial rotation) during the last 15 degrees of extension locks
the knee in the position of maximal stability (close packed "locking" position).
▪ It is related to difference in radii of curvature for the medial and lateral femoral condyles &
the musculature.
▪ Function: provide stability of the knee during extension.
➢ Posterior rollback increases maximum knee flexion.
▪ Tibiofemoral contact point moves posteriorly.
▪ Normal rollback is compromised by PCL sacrifice as in some TKAs.
➢ Axis of rotation of the intact knee is in the medial femoral condyle.
➢ Knee motion during gait: see gait.

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➢ Patello-femoral joint has sliding articulation:
• Patella slides 7 cm caudally (distally) with full flexion.
• Instant center is near the posterior cortex above the condyles.

◆ Kinetics:
 Joint Forces:
I. Tibiofemoral joint:
➔ Knee joint surface loads:
• times body weight during level walking.
• 4 times body weight during rising from a chair.
• 6 times body weight during stairs ascent.
• 8 times body weight during stairs descent.
➔ Menisci:
• Help with load transmission.
• Bear one-third to half body weight.
• Removal increases contact stresses up to 3 times the load transfer to bone.
• Quadriceps produces maximum anterior force on tibia at 0 to 60 degrees of knee flexion.
II. Patellofemoral joint:
➔ Functions of Patella:
1. Aids in knee extension by displacing the quadriceps tendon anteriorly away from the axis
of knee joint so increases the moment arm of quadriceps & its force.
2. Centralize the divergent forces of the 4 heads of quadriceps muscle.
3. Provide cartilage on cartilage articulation so decreasing coefficient of friction & increase
efficiency of quadriceps.
4. Protect the knee from direct trauma.
5. Provide good cosmetic appearance to the anterior part of knee joint.
➢ Patella has the thickest cartilage in the entire body (about 5 mm):
• Bears the greatest load.
• Loads proportional to ratio of quadriceps force to knee flexion.
• Bears compressive forces equals half the body weight during normal walking Which may
reach 3 times body weight during descending stairs & reach 7 times the body weight during
squatting (deep knee bend).
➢ Patellectomy:
• Length of moment arm is decreased by the width of the patella (30% reduction).
• Power of extension is decreased by 30%.
➢ During TKA, the following enhance patella tracking:
• External rotation of the femoral component.
• Avoidance of malrotation of the tibial component.
• Lateral placement of the femoral & tibial components.

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 • Medial placement of the patellar component.
➢ The previous actions avoid internal rotation.
➢ Three essential actions occur at the knee.
a. Flexion to decrease the impact of initial contact.
b. Extension for weight-bearing stability.
c. Flexion for toe clearance during swing.
➢ Axes of the lower extremity:
I. Vertical axis: from the center of gravity to the ground.
II. Mechanical axes:
a. Mechanical axis of the femur: from center of the femoral head to center of the knee.
b. Mechanical axis of the tibia: from center of the tibial plateau to center of the ankle.
c. Mechanical axis of the lower extremity: from center of femoral head to center of ankle
in the radiograph which is normally passes through the medial part of femoral notch
& just medial to the medial tibial spine.
III. Anatomic axes:
a. Anatomic axis of Femur: along the shafts of the femur in the radiograph.
b. Anatomic axis of Tibia: along the shafts of the tibia in the radiograph.
c. Anatomic axis of knee: where these 2 axes intersect at knee which is angle of 9° valgus.

Relationships:
➢ Mechanical axis of lower extremity is in 3° of valgus angulation from vertical axis.
➢ Anatomic axis of femur is in 6° of valgus angulation from mechanical axis of lower limb & 9° of
valgus angulation from the vertical axis.
➢ Anatomic axis of tibia is in 3° of Varus angulation from the mechanical axis of lower limb.

 Function of ligaments & cartilage (including mechanical properties):

➔ Anterior cruciate ligament "ACL":
• It is composed of anteromedial & posterolateral bundles.
• It is the primary restraint to anterior tibial translation & a secondary restraint to varus and
valgus angulation.
• Anteromedial bundle is the stronger and stiffer component & tightens with knee flexion.
• Posterolateral bundle tightens with knee extension.
• The normal ACL isn't isometric i.e. tension increases with knee extension.
• Typically subjected to peak loads of 170 N during walking & up to 500 N with running.
• Ultimate strength in young patients: about 1750 N.
• Failures by serial tearing at 15% elongation.

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➔ Posterior cruciate ligament "PCL":
• It is comprised of anterolateral & posteromedial bundles.
• It is the primary restraint to posterior tibial translation & a secondary restraint to varus and
valgus angulation.
• Anterolateral bundle is the stronger and stiffer component & tightens with knee flexion.
• Posteromedial bundle tightens with knee extension.
• Its sectioning increases contact pressures in the medial compartment & patellofemoral joint.

➔ Medial collateral ligament complex "MCL":

• It is the primary restraint to valgus angulation.
• It is a secondary restraint to anterior & posterior tibial translation.

➔ Lateral collateral ligament/Posterolateral corner "LCL/PL":

• It is the primary restraint to Varus angulation & also resists external rotation.
• It is a secondary restraint to anterior & posterior translation.
➔ Meniscus:
• Tensile properties of menisci are nonlinear & anisotropic & vary by region of meniscus.
• Primary mechanical function of the menisci is to distribute loads across the knee joint.
• 50% of the compressive load of the knee joint is transmitted through the menisci in extension
which increases to 90% at 90° of flexion.
• The menisci enhance the shock-absorbing capacity of the knee.
• The medial meniscus is considered a secondary restraint to anterior tibial translation in the
ACL-deficient knee.
• Partial meniscectomy results in increased articular cartilage contact pressure which is
proportional to the amount of meniscus excised.
• Total meniscectomy results in 3 times increase in mean peak articular cartilage contact
pressures.
• Size-matched allograft meniscus transplantation results in a 50% decrease in mean peak
articular cartilage contact pressures (these values are 50% higher than normal).
• As the knee is moved from 0° to 120° of flexion:
o Mean AP displacement of the medial meniscus is 5 mm.
o Mean AP displacement of the lateral meniscus is 11mm.
o This is due to better bony conformity in the medial compartment & the medial
meniscus is well fixed to the capsule while lateral meniscus is less well constrained.

➔ Articular cartilage:
• Normal articular cartilage is soft & porous & permeable:
o Water constitutes 70% of the total weight of articular cartilage & fills the pores of articular
cartilage & flow out as a result of pressure.

35
 o The proteoglycans form a strong durable matrix with mechanical properties that allow it
to withstand repetitive high stresses & strains of normal use.
o So articular cartilage is best viewed as a biphasic material composed of solid phase &
fluid phase.
• Joint motion & loading are required to maintain normal articular cartilage nutrition &
structure & function.
• Increased joint loading as the result of injury or excessive loading may result in catabolism
of articular cartilage with resultant loss of mechanical properties.
• Prolonged decreased joint use as a result of injury or surgery lead to alteration in matrix
composition & loss of mechanical properties.
◆ Stability:
➔ Knee stabilizers: ligaments (passive) & muscles (active) play the major stabilizing role.
➔ Knee restraints:
1. Medial (Valgus): MCL complex (primary), joint capsule, medial meniscus & ACL/PCL.
2. Lateral (Varus): Joint capsule, Iliotibial band, LCL complex (middle), lateral meniscus &
ACL/PCL (90°).
3. Anterior: ACL (primary) & joint capsule.
4. Posterior: PCL (primary), joint capsule & PCL tightens with internal rotation.
5. Internal rotation: ACL.
6. External rotation: MCL complex.
➔ Screw home mechanism: can be tested by (Helfet) test.
➔ Arthrodesis position: 7° of valgus angulation & 15° of flexion.

Ankle & Foot

Foot & Ankle are regarded as one functional unit for weight bearing & gait propulsion.

Ankle:
◆ Kinematics:
➢ Ankle Mortise is a uniplanar hinge joint with its axis of rotation present within the Talus just distal
to the palpated malleolar tips & change slightly with movement.
➢ Talus described as a cone: body and trochlea are wider anteriorly & laterally so the talus & fibula
slightly rotate externally with dorsiflexion.
➢ Dorsiflexion & abduction are coupled.
➢ Ankle dorsiflexion results in external rotation & proximal translation of the fibula.
➢ Ankle mortise is maintained by 3 ligament complexes:
1. Deltoid (medial).
2. Lateral collateral ligament.

36
 3. Interosseous ligaments.

❖ ROM:
➢ Dorsiflexion: 20°.
➢ Plantar flexion: 40°.
➢ Rotation (at distal Tibio-fibular joint): 5°Also contributes to inversion & eversion.

❖ Kinetics:
➢ Ankle has a larger weight bearing surface area than hip & knee which decreases joint stress.
➢ Tibiotalar Articulation:
• It is the major weight-bearing surface of the ankle.
• Supports compressive forces up to 5 times body weight.
• Shear (backward to forward) forces up to Weight.
➢ Fibulotalar Articulation:
• It transmits about one sixth only of the force.
• The distal fibula is pulled distally about 2.4 mm by the contraction of foot flexors during
change from non-weight bearing to weight bearing position which increase ankle stability
by:
1. Deepening the mortise.
2. Tightening the interosseous membrane.
3. Pulling the fibula medially.
• Highest net muscle moment occurs during terminal stance phase of gait.
• Ankle & Foot motion during gait: see gait.
• Surface contact:
o Lateral Talar shift of only 1mm will decrease surface contact by 40%.
o Lateral Talar shift of 3 mm will decrease surface contact by 60%.
o Further lateral Talar shift implies medial compromise.
• Syndesmotic disruption associated with fibula fracture is associated with 3 mm lateral Talar
shift even with intact deep deltoid ligament.
• Disruption of the syndesmotic ligaments will result in decreased tibiofibular overlap.

❖ Stability:
 Ankle stabilizers:
A. Static:
1. Bony conformity: with the malleoli act as buttress for talus.
2. Talar shape: narrows posteriorly i.e. anterior width > posterior width which provides stability
together with ligamentous tautness in case of Planter flexion.
3. Interosseous membrane.
4. Ankle joint capsule.

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 5. Lateral collateral ligament complex: anterior, posterior talo-fibular ligaments &
calcaneofibular ligament.
6. Deltoid ligament complex: the main stabilizer of the ankle during stance & consists of
superficial (3 parts) & deep (two bands) parts.
7. Tibiofibular articulation (Syndesmosis): consists of anterior inferior tibiofibular ligament
(AITFL) & interosseous ligament & posterior tibiofibular ligament.

B. Dynamic:
1. Fibular distal movement during weight bearing.
2. Proprioception.
3. Muscle tone.
➢ N.B.
• Stability is greatest in dorsiflexion.
• Tibial & talar articular surfaces contribute most to stability during weight bearing.
• A Syndesmosis screw limits external rotation.
➢ Windlass Action:
• Full dorsiflexion is limited by the plantar aponeurosis.
• Further tension on the aponeurosis (toe dorsiflexion) raises the arch.

❖ Arthrodesis:
➢ Position: neutral dorsiflexion, 5 degrees of external rotation & 5 degrees of hindfoot valgus
angulation.
➢ Effect: leads to 70% loss of sagittal plane motion of foot.

Subtalar Joint (Talus-Calcaneus-Navicular):

➢ Axis of Rotation:
• In the sagittal plane: 40 degrees.
• In the transverse plane: 15 degrees.
➢ Functions as an oblique hinge:
• Pronation coupled with: dorsiflexion & abduction & eversion.
• Supination coupled with: plantar flexion & adduction & inversion.
❖ ROM:
➢ Pronation: 5 degrees.
➢ Supination: 20 degrees.
➢ Functional ROM: 5 degrees.

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Transverse Tarsal Joint (Chopart’s joint or Mid-tarsal)
➢ It comprises: Talo-Navicular & Calcaneo-Cuboid joints.
➢ The joint has two axes of rotation (talo-navicular & calcaneo-cuboid) which intersect during
external rotation of the leg.
➢ Motion based on foot position:
• During heel strike (early stance):
o Leg internally rotated, Ankle neutral & Heel eversion (subtalar valgus).
o Chopart axes are parallel & the joint is unlocked (ROM is allowed).
o Forefoot pronates to absorb energy.
• During terminal stance & pre-swing:
o Leg externally rotated, Ankle planter flexion & Heel inversion (subtalar varus).
o Chopart axes intersect & the joint is locked in forefoot supination (motion is limited).
o Subtalar valgus:
 Heel eversion.
 Abduction.
o Subtalar varus:
 Heel inversion.
 Adduction.
o Supination:
 Heel inversion + Ankle plantar flexion + Forefoot varus.
o Pronation:
 Heel eversion + Ankle dorsiflexion + Forefoot valgus.

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Foot:
❖ Kinematics:
➢ The 3 arches of foot:

➢ Hallux MTP joint "1st" ROM is:

o 30° PF – 90° DF (120° arc).
➢ The foot positions:
1. Equines/calcaneus (ankle).
2. Varus/valgus (hindfoot).
3. Abduction/adduction (midfoot).
➢ Motions of the Ankle & Foot:
1. Sagittal plane (X axis): Dorsiflexion OR Plantar flexion.
2. Frontal (coronal) plane (Z axis): Inversion OR Eversion.
3. Transverse plane (Y axis):
➢ Forefoot/midfoot (Adduction OR Abduction).
➢ Ankle/hindfoot (Internal rotation OR External rotation).
❖ Triplanar motion:
➢ Supination: Adduction & Inversion & Plantar flexion.
➢ Pronation: Abduction & Eversion & Dorsiflexion.

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❖ Kinetics:
➢ Foot transmits 1.2 times body weight with walking & 3 times body weight with running.
➢ Second metatarsal (Lisfranc) joint is “keylike”:
o Stabilizes the second metatarsal.
o Allows it to bear the most load during gait.
o The second metatarsal is more commonly involved in stress fractures. N.B.: First
metatarsal bears the most load during standing.
➢ Load distribution of foot:
➔ Load distribution during stance:
o 50% through heel & 50% through metatarsal heads.
o Load on 1st metatarsal head is twice load on each of lateral 4 metatarsal heads.
➔ Load distribution when muscles are relaxed: 80% through heel & 20% through metatarsal
heads.
➔ Load distribution during standing: over center of foot anterior to ankle.
➢ If the heel is in a neutral position (subtalar neutral): the forefoot should be parallel with the
floor to meet the ground flush (plantigrade).
➢ If the first ray is elevated the forefoot is in varus position while if it is flexed the forefoot is in
valgus position (this should not be confused with hindfoot varus or valgus).
➢ In a long-standing flatfoot deformity, the heel is valgus & the forefoot has compensated by
going into varus or supinating to keep the flat to the ground.
❖ Stability:
➢ Stability of foot arches is provided by a combination of the bony architecture & ligamentous
attachments & muscle forces.
➢ The primary stabilizer of the longitudinal arch is the interosseous ligaments while the plantar
fascia is a secondary stabilizer.
➢ Expected life of Plastazote shoe (silicon) insert in active adults is less than 1 month:
• Fatigues rapidly in compression & shear.
• Should be replaced frequently or supported with other materials as SpinCo or PPT foam.

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Gait
❖ General Principles:
 Definitions:
➢ Walking: it is the repetitive process of sequential lower limb motion to move the body from one
location to another while maintaining upright stability.
➢ Walking is a cyclic & energy-efficient activity i.e. one foot must always be in contact with the
ground (single-limb support) with a period when both limbs are in contact with the ground
(double-limb support).
➢ Step: the distance between initial swing & initial contact of the same limb (i.e. The advancement
of a single foot) OR it is the distance between the initial contacts of alternating feet.
➢ Stride: it is the period from initial contact to initial contact of the same foot (i.e. each stride
comprises two steps, one step by each side of the body).
➢ Step Length: longitudinal distance between 2 feet.
➢ Stride Length: distance covered during 1 cycle i.e. 2 step lengths.
➢ Stride width: horizontal distance between the 2 feet at double support 2.4 inch.
➢ Gait Velocity: steps per unit of time (stride length / cycle time) m/s.
➢ Cadence: steps /minute.
➢ Running: the periods of "double-limb support" are replaced by "double float periods" i.e. neither
limb is in contact with the ground.
➢ Double Support: both feet on ground.
➢ Float Phase: neither foot is on the ground (running).
➢ Limping: abnormality of the gait pattern.

◆ Prerequisites for normal gait:

1. Maintenance of the upright posture & balance.
2. Maintenance of body weight support against gravity.
3. Stance-phase stability.
4. Swing-phase ground clearance.
5. Correct position of the foot before initial contact.
6. Energy-efficient step length & speed.

◆ Three tasks are required during gait:

1st & 2nd: During stance the leg must accept body weight & provide single-limb support.
3rd: During swing the limb must be advanced.

◆ Important Characteristics of gait cycle:

 Stance phase occupies 60% of single Stride duration & divided into 3 intervals:
1. Initial double limb support (double stance) interval:
• 10% "parts: 1 & 2".
• This interval comprises part 5 of the contralateral limb.

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 2. Single limb support interval:
• 40% "parts: 3 & 4".
• This interval comprises parts 6 & 7 & 8 of the contralateral limb.
3. Terminal double limb support (double stance) interval:
• 10% “part: 5”.
• This interval comprises parts 1 & 2 of the contralateral limb.
➢ 2/3 the duration of the stance phase, the other foot is in swing (single limb support).
➢ 1/3 the duration of the stance phase, the other foot is also in stance (double limb support) at these
times the body's center of gravity is at its lowest.
➢ All the duration of swing phase is a single-limb support of the contralateral side.
➢ During running both limbs are momentary off the ground (Float period) & heel strikes periods
are more forceful.
➢ The percentage relationship between stance & swing periods is velocity dependent.
➢ Initial contact & limb loading response parts are called weight acceptance phase.
➢ Swing phase is called limb advancement phase.
➢ The combined phases of gait contribute to an energy-efficient process by lessening excursion of
the center of body mass.
➢ Ground reaction forces are approximately 1.5 times body weight during walking & 3 - 4 times
body weight during running due to the increased load after the float phase of running.
➢ As the speed of gait increases the stance phase decreases.

◆ Windlass mechanism "effect" & function of the plantar fascia:

➢ When the foot is at rest: there is some mobility between the bones of the midfoot allowing
flexibility.
➢ During the push-off phase of gait the plantar fascia is tightened & the longitudinal arch is
accentuated because the MTP joints extend (the toes are dorsiflexed) which pulls the tarsal bones
together & locks them into a rigid column.
➢ This effect has been likened to a windlass which is a rope or chain extending over a drum used
to raise & lower sails and anchors on ships.

◆ Body Center of Gravity "COG" during gait cycle:

➢ Body COG is anterior to S2 which provides a reference for the moment arm to the center of the
joint under consideration & the resulting gait pattern resembles a sinusoidal curve.
➢ The head & neck & trunk & arms account for 70% of total body weight.
➢ The trunk center of gravity of its mass is located just anterior to T10 which is 33 cm above the
hip joints in an individual of average height (184 cm).
➢ The body’s center of gravity "center of mass" is subject to vertical & lateral displacement during
gait follows a sinusoidal curve with amplitude of about 5 cm for each direction.

43
 ➢ The speed of movement of body COG decreases at mid-stance & the peak of vertical
displacement is achieved.
➢ The COG displaces laterally with forward movement.

◆ Phases of Gait Cycle (Stride Pattern):

➢ Definition: the complete sequence of all the functions of a single limb during normal
walking from initial contact to initial contact.

I. Stance Phase:
Occupies 60% (5 parts) "The foot is in contact with the ground"
i. Initial Contact (Heal strike):
➢ Starts at Heal strike (contact) & Ends at start of double support.
➢ Initial contact of the foot with the ground at the heel (start of initial double-limb stance).
➢ Hip is flexed & Knee starts to flex to dampen impact of initial loading.
➢ Hip extensors contract to stabilize the hip because the body’s mass is behind the hip joint.
➢ The opposite limb progress through stance phase (start pre-swing phase).
➢ Compensatory mechanisms in initial contact:
(4 shock-absorbing reactions to ground contact):
1. Free ankle plantar flexion before the pretibial muscle action catches it.
2. Leg internal rotation everts the heel & unlock mid-tarsal joint leading to forefoot
pronation.
3. Knee flexion restrained by the quadriceps.
4. Contralateral pelvic drop decelerated by the hip abductors which occurs as weight
is rapidly dropped onto the loading limb as the other limb is being lifted.
ii. Loading Response: (Foot flat)
➢ Starts at Start of double support & Ends at Contra-lateral toe off.
➢ It marks the initial double-limb stance interval.
➢ Body weight is transferred onto the supporting leg.
➢ The ankle dorsiflexor muscles are active with an eccentric (lengthening) contraction to
control the plantar flexion moment to make the forefoot also in contact with the ground.
➢ Quadriceps contracts to counteract the flexion moment & stabilize the hip and knee.
➢ The opposite limb ends stance phase.
iii. Mid-Stance:
➢ Starts at Contra-lateral toe off & Ends at "COG" aligned over reference foot.
➢ It is the initial period of single-limb support.
➢ Gluteus Medius contracts to prevent swing side of pelvis from dropping.
➢ The opposite limb starts swing phase.
iv. Terminal Stance (Heel off):
➢ Starts at "COG" over reference foot & Ends at Contra-lateral foot contact.

44
 ➢ Gastrocnemius & soleus contracts producing planter flexion leading to heel off.
➢ Subtalar inversion occurs.
➢ The Foot locks "becomes rigid" to provide a rigid lever arm for heel off & subsequent toe off.
➢ The opposite limb ends swing phase.
v. Pre-Swing (Toe off):
➢ Starts at Contra-lateral foot initial contact & Ends at Reference toe off.
➢ It marks the terminal double-limb stance interval.
➢ Body weight is transferred to the opposite limb.
➢ Iliopsoas contracts leading to hip flexion.
➢ The knee flexes to raise the forefoot also off the ground.
➢ Toes dorsiflex at MTPJ.
➢ The opposite limb starts stance phase (comprises both initial contact & loading parts).
II. Swing Phase:
Occupies 40% (3 parts) "The foot is off the ground & the leg is moving forward"
vi. Initial Swing (Acceleration):
➢ Starts at reference toe off & Ends at maximal knee flexion.
➢ Start of single-limb support for the opposite limb.
➢ Knee flexion with accelerated forward leg swing & heal high rise.
➢ The opposite limb progress through stance phase.
vii. Mid-Swing:
➢ Starts at Maximal knee flexion & Ends at Tibia is vertical.
➢ Dorsiflexion of the ankle by the action of tibialis anterior.
➢ The opposite limb progress through stance phase.
viii. Terminal Swing (Deceleration):
➢ Starts at Tibia is vertical & Ends at Heal strike.
➢ Contraction of hamstring & gluteus maximus to decelerate the forward leg swing before heel
strike.
➢ The opposite limb progress through stance phase.

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❖ Gait Dynamics & Analysis:

◆ Kinematics (analysis of the motion):

A. Distance & Time variable (Visual analysis):

a. Distance:
1. Stride length.
2. Stride width.
3. Step length.
b. 2. Time:
1. Step time.
2. Stride time.
3. Stance time.
4. Swing time.
5. Cadence.
6. Speed.
7. Single limb support time.
8. Double limb support time.
B. Measurement of joints angles

➔ (Hip Knee Ankle Foot):

a. Stance Phase:
1. Initial Contact 30° F 00 00 Int. Rotation.
2. Loading Response 25° 150 150 PF Ex. Rot.
3. Mid-stance 0° 00 00Ex. Rot.
4. Terminal Stance 10° E 0° 10° DF Int. Rot. beginning
5. Pre-swing 0° 30° 20° PF Int. Rot.
b. Swing Phase:
6. Initial Swing 20° F 60° 10° PF Int. Rot.
7. Mid-swing 30° F 30° 0° Int. Rot.
8. Terminal Swing 30° F 0° 0° Int. Rot.

➔ Head & Neck & Trunk: moves as a unit.

➔ Shoulder (flexion & extension) & Elbow (flexion) movement.
➔ Pelvis arc of motion: minor.

46
❖ Determinants of Gait (Descriptive components):

➢ Definition: the 6 independent degrees of freedom in gait cycle for body adjustment to keep
movement of "COG" minimum.
1. Pelvic rotation (transverse plane):
➢ The pelvis rotates horizontally about a vertical axis of the line of progression:
• Stance phase: pelvis of ipsilateral side rotates 4° posteriorly.
• Swing phase: pelvis of ipsilateral side rotates 4° anteriorly.
➢ It is lessening the center-of-mass deviation in the horizontal plane & reducing the impact at
initial floor contact.
2. Pelvic tilt (frontal plane):
➢ The non-weight-bearing (Swing) contralateral side drops 5° so reducing superior deviation.
3. Lateral pelvic displacement (lateral shift):
➢ This relates to the transfer of body weight onto the limb.
➢ The length of motion is 5 cm over the weight-bearing limb leading to narrowing the base of
support & increasing stance-phase stability.
4. Knee flexion at loading:
➢ knee is flexed 15° to dampen impact of initial loading of stance-phase.
5. Knee & Ankle & Foot interaction:
➢ The knee works together with the foot & ankle to decrease necessary limb motion (the knee
flexes at initial contact & extends at mid-stance).
6. Physiological valgus:
➢ foot & ankle motion lead to damping of the loading response occurs through the subtalar
joint by " Physiological valgus " leading to stability during midstance & efficiency of
propulsion at push-off.

❖ Functions of gait determinants:

1. Decrease up and down (vertical) & side to side (lateral) movement of "COG" & keep it within
2 inches.
2. Smooth the curve of "COG" movement.
3. Decrease energy expenditure to minimum.
4. Pelvic tilt prevents "COG" drop.
5. Determinants number 2 & 3 & 4 & 5 decrease vertical rise of "COG".
6. Physiological valgus prevents side to side movement.

47
◆ Kinetics (analysis of forces producing motion):

A. External forces:

1. Line of Gravity "LOG": anterior or posterior.

2. Ground Reaction Force "GRF": anterior or posterior.
B. Internal forces (Muscles & Tendons):

➢ Agonist & antagonist muscle groups work in concert during the gait cycle to effectively
advance the limb through space.
➢ Types of muscle activity:
i. Eccentric: the muscle lengthening while it contracts.
ii. Isocentric: the muscle length remains constant while it contracts as hip abductors
during midstance.
iii. Concentric: the muscle shortens while it contracts.
➢ Most muscle activity is eccentric & allowing antagonist muscle to dampen the activity of an
agonist and act as “Shock absorber” while some muscle activity is concentric to move a joint
through space.
➢ The hip flexors advance the limb forward during the swing phase & are opposed during
terminal swing before initial contact by the decelerating action of the hip extensors.
➢ Dynamic polyelectromyography: assess the activity of multiple muscles during gait.

❖ Specific Muscle Action & Function:

Muscle Action Function

Gluteus medius Eccentric Controls pelvic tilt (mid-stance).
Gluteus maximus Concentric Powers hip extension.
Iliopsoas Concentric Powers hip flexion.
Hip adductors Eccentric Control lateral sway (late-stance).
Hip Abductors Eccentric Control pelvic tilt (mid-stance).
Quadriceps Eccentric Stabilizes knee at heel-strike.
Hamstrings Eccentric Control rate of knee extension (stance).
Tibialis anterior Concentric Dorsiflexes ankle at swing.
Eccentric (Predominant) Slows plantar flexion rate (heel-strike).
Gastrocnemius-soleus Eccentric Slows dorsiflexion rate (stance).

48
◆ Stability:

➢ Definition: it is the ability to maintain subject's balance in both static & dynamic situations
without use of mechanical devices.
 Factors affecting stability:
1. Center of Gravity Height:
• The lower the "COG" the greater will be the body's stability if other factors are constant.
• Example: standing is less stable than kneeling as in kneeling the COG height is lower
than standing.
2. Base of Support "BOS":
➢ Definition: it is the supporting area under the body (it includes the points of contact with the
supporting surface & the area between them (these points may be body parts or sticks or
crutches).
➢ Effect of "BOS":
• An increase in the "BOS" will be associated with an increase in the stability.
• An increase in the "BOS" during walking should be within limit because the angle of the step
determines the stability.
• The increase in the shape of the "BOS" (as after using a cane) occurs in the same direction of
force being applied to the body.

 Relationship between line of gravity "LOG" & "BOS":

➢ "LOG": it is a vertical line that passes through the "COG" & falls within the "BOS".
➢ The nearer the "LOG" to the center of "BOS", the greater the stability.

 Characteristics of the supporting surface:

➢ Friction: when the other factors are constant; the greater the friction between the supporting
surface & the parts of the body which are in contact with it, the more stable will be but within
limit otherwise it will be disturbing factor.
➢ Softness of the supporting surface: during lifting up exercises, more energy will be wasted in case
of using soft mattress.
➢ Inclination of the supporting surface:
• The inclination of the surface is the angle which the supporting surface makes in relation to
the horizontal (angle of friction).
• The greater the inclination, the less the stability.
➢ Segmentation principles: if there is deviation of a part of the body to certain direction, there is
another compensatory deviation of another part of the body to the opposite direction to
maintain balance during this position.

49
➢ Subject's state:
• Mass: the greater the mass of the body, the greater will be its stability.
• Vision: a person has a greater balance & stability in locomotion when he focuses his vision
on a stationary object.
• Speed: it is easier to balance on a bicycle when it is moving fast than when moving slowly.
• Physical & Emotional state.
• Age.

◆ Pathological Gait "Limping":

Abnormal gait patterns are caused by the following factors:

 Antalgic Gait: (the commonest cause)
➢ Definition: abnormal gait due to pain in the limb.
➢ Causes of antalgic gait: trauma or osteoarthritis or septic arthritis or SCFE.
➢ General abnormalities:
• Shortens of stance phase to lessen the time that painful limb is loaded (weight bearing).
• Gentler heel-strike in painful limb.
• The contralateral swing phase is more rapid.
➢ If Hip pain: leaning of the trunk laterally over the painful leg during stance to bring the COM
"COG" over the joint.
➢ If knee pain:
• The knee is maintained in slight flexion throughout the gait cycle especially if there is
effusion to reduces tension on the joint capsule.
• Compensation for knee flexion by toe walking on the affected side.
• Forces across the knee in arthritis may be 4 to 7 times those of body weight (70% of the load
across the knee occurs through the medial compartment).
➢ If Ankle & Foot pain: normal heel-to-toe motion is absent.
➢ If hind foot pain: the patient ambulates on the toes & avoid heel strike at initial contact.
➢ If forefoot pain: flatfoot gait with avoidance of weight bearing on the metatarsal heads.

 Hysterical Gait:
➢ Diagnosis by exclusion & history of emotional upset.
➢ Usually bizarre & inconsistent with CP.

➢ Muscle weakness or paralysis: It decreases the ability to normally move a joint through
space.
➢ A walking pattern develops on the basis of the specific muscle or muscle group involved &
the ability of the individual to acquire a compensatory pattern to replace that muscle’s action.

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 ❖ Gait abnormalities caused by muscle weakness:
Week muscle Phase Direction Type of gate treatment
Gluteus Medius. Stance Lateral lurch Abductor gait in unilateral. cane
Trendelenburg in Bilateral.
Gluteus Maximus. Stance Backward lurch Hip extension
Quadriceps Stance Forward lurch Back knee gate Ankle-foot orthosis
Swing Forward lurch Abnormal hip rotation
Gastrocnemius, Soleus. Stance Forward lurch Flatfoot (calcaneal) gait. Ankle-foot orthosis
Swing Forward lurch Delayed heel rise
Tibialis anterior Stance Forward lurch Foot drop/slap Ankle-foot orthosis
Swing Forward lurch Steppage gait

 Weakness of Hip flexors:

•
limits limb advancement during swing results in shortened step length.
 Moderate weakness of Hip extensors:
• Compensated by forward trunk flexion because assuming posture of hip flexion during
walking places the hip extensor muscles in a position of greater mechanical advantage.
 Severe weakness of Hip extensors:
• results in the need for upper limb assistive devices to maintain the erect posture.
 Quadriceps weakness (Back Knee Gait):
• Makes the patient susceptible to falls at initial contact so it is compensated by leaning the
trunk forward to keep COG anterior to the knee.
• Gastrocnemius muscle contracts more vigorously to maintain the knee locking in
hyperextension during stance phase.
• Patient may place hand on thigh to push knee into extension with initial weight bearing.
• Difficulty with stairs.
• Lurching more marked if also weakness of gluteus maximus present.

 Tibialis anterior weakness "weakness of pre-tibial muscles":

• Increased flexion of hip & knee to allow ground clearance leading to increase heel rise.
• Leads to High steppage gait or Drop foot gait.

 Calf weakness (Calcaneus Gait):

• Poor push-off due to calf weakness.
• "Hitch" at each step.

 Ankle plantar flexors weakness:

It causes:
• Instability of the tibia & knee as the COG moves anterior to the knee.
• Quadriceps activity increases to keep the knee extended.

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 • This compensation limits step length which predisposes to painful overuse syndromes of the
patella & quadriceps.

 Combined quadriceps & ankle plantar flexors weakness:

• leads to knee hyperextension for stability at initial contact which results in genu
reccurvatum deformity over time.
 Trendelenburg Gait:
• Causes of (Unstable Hip Limp):
o Fulcrum problem: DDH.
o Lever problem: short neck.
o Motor problem: gluteus medius weakness.

❖ Neurological conditions:
➢ It alters gait by producing:
1. Muscle weakness.
2. Loss of balance.
3. Joint contracture.
4. Reduced coordination between agonist & antagonist muscle groups (i.e. spasticity).
➢ Examples:
 Hip Scissoring:
• Is associated with overactive adductors and knee flexion contracture may be caused by
hamstring spasticity.
 Equinus deformity of the foot & ankle:
• May result in Steppage gait & backwards setting of the knee.
 Hemiplegic Gait:
• Characterized by prolongation of stance & double-limb support.
• Gait impairment may be excessive plantar flexion & weakness & balance problems.
• Associated problems are ankle equinus & limitation of knee flexion & increased hip
flexion.
• Equinus deformity is surgically corrected 1 year after onset.

 Spastic Gait (Cerebral Palsy):

• Many patterns as hemiplegia & diplegia.
• Short step & unsteady & failure of foot clearance at swing.

 Shuffling Gait:
• In Parkinsonism in which gait is short without lifting feet.

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  Stamping Gait (Double Tap):
• Proprioception or dorsal column affection: DM & Tabes Dorsalis.
• Patient doesn't feel the ground leading to increase heel rise and strike & wide base &
looks at the ground.
• +ve Rombergism (Romberg maneuver).

Romberg maneuver:
➢ It is based on that a person requires at least two of the three following senses to maintain balance
while standing:
1. Proprioception.
2. Vestibular function.
3. Vision.
➢ It is also used in testing drunken drivers.

 Ataxic Gait (Cerebellar Ataxia):

• Wide base (Feet apart).
• Tremors & Nystagmus.
• –ve Rombergism.

❖ Short Leg Limp:

➢ Difficult to be noticed at maturity if discrepancy is less than 2cm.
➢ There is pelvic tilt with short leg ankle equinus.
➢ Hip & knee of long leg are flexed.

❖ Joint Contracture Gait "Stiff joint gait":

 Flexion contracture of Hip:

➢ The contracture is compensated by increased lumbar lordosis & knee flexion to maintain the
COG over the feet for stability.
➢ Increased motion of pelvis on lumbar spine during swing.
➢ The crouched posture is energy inefficient and results in shorter overall walking distances.
➢ limp is minimal if hip stiff (fused) in 25° flexion.

 Flexion contracture of knee:

➢ It causes a relative limb-length discrepancy with toe walking on the affected side.
➢ Pelvic raising with increased hip & knee flexion of the opposite limb (Steppage gait) may be
required during swing phase to clear the foot because the affected limb is relatively too long.
➢ Contractures of less than 30° become more pronounced only with faster walking speeds while
those of greater than 30° are apparent even at normal walking speeds.

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 Plantar flexion contracture of Ankle:
➢ Results in knee extension moment (knee extension thrust) at initial contact of the forefoot with
the floor.
➢ Hip & knee flexion of the affected limb (Steppage gait) must be increased during swing phase
to clear the foot because the affected limb is relatively too long.

❖ Joint Instability:

◆ Knee instability:
➢ Result in variable gait presentations depending on the ligament involved (type of instability).

 Knee reccurvatum:
• Results from weakness of the ankle plantar flexors & quadriceps.
• The patient compensates during stance by leaning the trunk forward to place the COG
anterior to the knee which leads to degenerative changes of joint over time.

 Injuries of posterolateral corner:

• It comprises injury of posterior cruciate ligament, lateral collateral ligament, posterior
joint capsule & the popliteus tendon.
• It results in varus thrust gait pattern during stance.

 Quadriceps avoidance gait:

• It occurs in ACL deficient knee in which the tibia is prone to anterior subluxation because
quadriceps contraction provides anterior force to the tibia.
• Attempts to decrease the load response phase on the affected limb.
• Made by decreasing stride length & avoiding knee flexion during mid-portion of stance.

◆ Ankle instability:
➢ It results in difficulty with supporting body weight during initial contact.
➢ An unstable ankle often buckles resulting in antalgic gait which limits the load response
phase on the affected side.
➢ Joint abnormalities alter gait by changing range of motion of that joint or producing pain.

❖ Crutches & Canes:

➢ Devices that ameliorate instability & pain respectively:

• Crutches increase stability by providing two additional loading points.
• Canes helps shift the center of gravity to the affected side when the cane is used in the
opposite hand which decreases the joint reaction forces of the lower limb & reduces pain.
❖ Water walking:

➢ There is a significant decrease in joint & total joint contact forces as a result of the effect of
buoyancy.

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