Kinesiology 2017#5: JOINT MOBILITY Joint Mobility of Upper Extremity Huei-Ming Chai, Ph.D., PT School of Physical Therapy National Taiwan University Functions of Synovial Joints Joint Mobility Osteokinematic movements physiological movements movements between 2 bony segments Arthrokinematic movements accessory movements movements between 2 articular surfaces Joint Stability 2 Osteokinematic Movements Swing: rotary movement around an axis Spin: rotation around longitudinal axis of distal segment 3 Description of Osteokinematic Movements joint(s) involved plane of motion axis of rotation degree of freedom range of motion / functional range open vs. closed chain motions concentric vs. eccentric contraction factors checking motions Arthrokinematic Movements Description of Arthrokinematic Movements joint morphology to establish concave-convex rule plane of motion direction of motion amplitude of motion Traction (distraction) Compression 1
Functions of Elbow The Elbow Complex to add mobility of hand in space by shortening and/or lengthening the arm, rotating the forearm, or combination of the above both to provide control and stability for skilled hand motions and forceful upper extremity motions Elbow Motions Joint involved in elbow motion humeroulnar joint humeroradial joint proximal radioulnar joint carrying angle Kinematics of the elbow Components of Elbow Complex 3 joints enclosed in ONLY one joint capsule humeroradial joint L proximal radioulnar joint radius humerus M humeroulnar joint ulna Joint Motions at Elbow Anterior View of Distal Humerus Humeroulnar joint primary joint for elbow flexion/ extension Humeroradial joint moves with flexion/extension but promarily affect pronation/supination Proximal radioulnar joint primary for forearm pronation/supination lateral epicondyle capitellum (small head) coronoid fossa (coronoid = like crown) medial epicondyle trochlea (= pulley) 2
Posterior View of Distal Humerus Lateral View of Humeroulnar Joint medial epicondyle olecranon fossa lateral epicondyle olecranon fossa humerus coronoid fossa coronoid process ulna trochlea capitellum olecranon process (funny bone) trochlear notch Humeroulnar Joint Proximal component: humerus hourglass-shaped trochlea (trochlea=pulley) olecranon fossa coronoid fossa (coronoid= like crown) Distal component: ulna saddle-shaped trochlear notch olecranon process coronoid process hourglass Bony Prominence of Elbow Bony prominence gives attachment to the muscle medial epicondyle: for wrist and hand flexors lateral epicondyle: for wrist and hand extensors olecranon process: for triceps brachii radial tuberosity: for biceps brachii anterior view posterior view Characteristics of Humeroulnar Joint joint type: hinged (ginglymus) elbow complex = HU + HR = trochleoginglymoid joint (Jazrawi LM et al., 2001) motions: concave on convex elbow flexion/extension with anterior/ posterior glide of trochlea notch of ulna on trochlea of humerus degree of freedom: 1 elbow complex DOF = 2 closed-packed position: full elbow extension resting position:70 of elbow flexion and 10 of forearm supination Humeroradial Joint Proximal component :humerus spherical (ball-shaped) capitulum radial fossa Distal component: radius cup-shaped radial head anterior view posterior view radial neck radial head 3
Characteristics of Humeroradial Joint joint type: ball-and-socket motions: concave on convex joint elbow flexion/extension with anterior/posterior glide of radial head on capitulum forearm pronation and supination with radial head spinning on capitulum degree of freedom: 2? 3? rest position: full elbow extension with forearm supination Proximal Radioulnar Joint Proximal component: ulna concave radial notch Distal component: radius convex rim of radial head Distal radioulnar joint structurally separate from elbow complex but moves with proximal radioulnar joint as a functional unit Characteristics of Proximal Radioulnar Joint joint type: pivot motions: convex on concave forearm pronation with posterior glide of radial head forearm supination with anterior glide of radial head degree of freedom: 1 rest position: 70º of elbow flexion and 35º of forearm supination Will be discussed in details on the session of "wrist complex". synonym: cubitus angle Carrying Angle 10-15º valgus angle when elbow extended and forearm supinated decreased when elbow flexed female > male trochlea more distally than capitellum inner lip of trochlea more distally than outer lip anomaly cubitus valgus: cubitus angle >15º cubitus varus 10-15º valgus Elbow Motions Joint involved in elbow motion Kinematics of the elbow Elbow flexion/ extension Forearm pronation/ supination Description of Joint Motions joint(s) involved plane of motion axis of rotation degree of freedom range of motion functional range open vs. closed kinematic chain arthrokinematic movements factors limited motion 4
Elbow Flexion/ Extension joint involved humeroulnar joint humeroradial joint plane of motion sagittal plane axis of rotation not a fixed point a line through centers of trochlea and capitullum palpation: both epicondyles not perpendicular to the longitudinal axis of the humerus (4-8º of valgus) Osteokinematic Movements DOF = 1? or 2? (saddle joint) range of motion (ROM) 0-145º of elbow flexion some hyperextension functional range: 30-130º closed kinematic chain motion pull-up press-up ( 伏地挺身 ) push a heavy object Elbow Adduction 6 adduction from full extension to full flexion (Morrey & Chao, 1976) < 1 from full extension to full flexion (London et al., 1981) no clinical significance (An et al., 1984) Arthrokinematic Movements concave on convex joint anterior glide of ulna on humerus with elbow flexion posterior glide of ulna on humerus with elbow extension distraction/ compression of ulna on humerus Factors Limiting Elbow Flexion Factors Limiting Elbow Extension soft tissue approximation at anterior humerus coronoid process into coronoid fossa radial head into radial fossa passive tension of triceps and posterior capsule Olecranon process into olecranon fossa (most important) passive tension of elbow flexors, collateral ligaments, and anterior capsule 5
Forearm Pronation/ Supination joint involved proximal radioulnar joint distal radioulnar joint humeroradial joint 1 degree of freedom transverse plane motion axis of rotation: a line through radial and ulnar heads Osteokinematic Movements range of motion pronation: 0-70º supination: 0-85º functional range 50º of pronation and 50º of supination Arthrokinematic Movements Factors Limiting Forearm Pronation anteromedial glide with forearm supination posterolateral glide with forearm pronation radius hitting on ulna quadrate ligament posterior radioulnar ligament oblique cord Factors Limiting Forearm Supination anterior radioulnar ligament quadrate ligament oblique cord interosseous membrane The Wrist Complex 6
Functions of Wrist To argument fine hand and finger function To control length/ tension of finger long flexors and extensors To provide stability for skilled or forceful hand movements Wrist Motions Joint involved in wrist motions radiocarpal joint midcarpal joint intercarpal joints distal radioulnar joint Kinematics of the wrist Components of Wrist Complex No muscle attaches onto proximal row. trapezoid trapezium scaphoid radiocarpal joint distal radioulnar joint capitate radius ulna hamate distal row proximal row midcarpal joint pisiform triquetrum lunate Joints at Wrist Radiocarpal joint primary joint for wrist extension Midcarpal joint primary joint for wrist flexion Intercarpal joint Distal radioulnar joint primary for forearm pronation/supination Radiocarpal Joint Characteristics of RC Joint Proximal component -- radius biconcave distal radius triangular fibrocartilage complex (TFCC) Note: only articulate with radius Distal component -- proximal row biconvex scaphoid, lunate, and triquetrum S R L U T articular disc (TFCC) joint type: biconvex degree of freedom: 2 motions wrist flexion/ extension wrist radial/ ulnar deviation closed-packed position full wrist extension 7
trapezii on scaphoid capitate on lunate capitate on triquetrum hemate on triquetrum Midcarpal Joint trapezoid on capitate hamate on capitate pisiform on triquetrum Intercarpal Joints Distal Radioulnar Joint Proximal component -- ulna convex ulna head Distal component -- radius concave ulnar notch of radius moves with proximal radioulnar joint as a functional unit joint type: pivot Characteristics of Distal Radioulnar Joint degree of freedom: 1 concave on convex joint forearm pronation with anterior glide of radius forearm supination with posterior glide of radius 15 of extension Functional Position 10 of ulnar deviation flexion 10 ulnar deviation 15 functional range for daily activities extension 35 Carpal Tunnel proximal transverse arch covered with flexor retinaculum All extrinsic finger long flexors and median nerve passes through carpal tunnel except flexor carpi ulnaris carpal tunnel syndrome increase intratunnel pressure compression of median nerve median nerve radial deviation 10 8
fovea radialis Anatomic Snuff Box area bounded by tendons of extensor pollicis longus extensor pollicis brevis Wrist Motions Joint involved in wrist motions Kinematics of wrist Wrist flexion/ extension Wrist radial/ ulnar deviation Forearm pronation/ supination Osteokinematic Movements biconvex joint 2 degrees of freedom flexion/ extension radial/ ulnar deviation circumduction cone-like motion F-RD-E-UD F-UD-E-RD R L C sagittal view anterior view Wrist Flexion/ Extension joint involved radiocarpal joint midcarpal joint sagittal plane motion normal range 85-90º of flexion 75-80º of extension dorsal side flexion 40% 67% extension palmar side 60% 34% Axis of Wrist Flexion/ Extension Osteokinematic Movements -- closed chain motions a frontal axis through capitate palpation both styloid processes axis styloid process capitate styloid process press-up ( 伏地挺身 ) push and pull a heavy object radius ulna 9
Functional Range of Motion 10º of wrist flexion 35º of wrist extension Loss of wrist function does not seriously impede performance of daily activities Arthrokinematic Movements -- Wrist Flexion/ Extension convex on concave joint articular surface moves in the opposite direction as the moving bone volar glide (anterior glide) with wrist extension dorsal glide (posterior glide) with wrist flexion distraction Volar/ Dorsal Glide of Wrist Factors Checking Motions dorsal side palmar side wrist flexion with dorsal glide dorsal side palmar side wrist extension with volar glide limiting wrist flexion dorsal radiocarpal lig radiolunate radiotriquetral radioscaphoid limiting wrist extension dorsal surface of the radius palmar ligaments: stronger than the dorsal ligaments dorsal palmar Wrist Radial/ Ulnar Deviation joint involved radiocarpal joint midcarpal joint frontal plane motion normal range 15-25º of radial deviation 30-45º of ulnar deviation Axis of Radial/ Ulnar Deviation a line between capitate and lunate perpendicular to the palm capitate palpation axis lunate radius ulna 10
Arthrokinematic Movements -- Wrist Radial/ Ulnar Deviation convex on concave joint articular surface moves in the opposite direction as the moving bone radial glide (lateral glide) with wrist ulnar deviation ulnar glide (medial glide) with wrist radial deviation Radial vs. Ulnar Glides double V system of ligament med. and lat. palmar intercarpal lig palmar ulnocarpal lig palmar radiocarpal lig radial deviation radial glide ulnar deviation compression stress for stability ulnar glide Forearm Pronation/ Supination joint involved proximal radioulnar joint distal radioulnar joint humeroradial joint 1 degree of freedom transverse plane motion axis of rotation: a line through radial and ulnar heads Physiological Movements -- Forearm Motions range of motion pronation: 0-70º supination: 0-85º functional range 50º of pronation and 50º of supination Arthrokinematic Movements proximal radioulnar joint anteromedial glide with forearm supination posterolateral glide with forearm pronation Arthrokinematic Movements Distal Radioulnar Joint posterior glide with forearm supination anterior glide with forearm pronation 11
Factors Limiting Forearm Supination posterior radioulnar ligament quadrate ligament oblique cord interosseous membrane The Shoulder Complex Functions of Shoulder Complex To link the upper extremity to the trunk dependent arm position: the arm is hanging down by the side of the trunk control of rotator cuff muscles To provide extensive mobility of the arm in space To provide stability for elbow and hand skillful or forceful movements Shoulder Motions Joint Invovled in shoulder motions glenohumeral joint sternoclavicular joint acromioclavicular joint scapulothoracic articulation plane of scapula Kinematics of the shoulder Components of Shoulder Complex ST: muscle-bone articulation acromioclavicular (AC) joint glenohumeral (GH) joint scapulthoracic (ST) articulation sternoclavicular (SC) joint Joints in Shoulder Complex -- Smith, Weiss, and Don Lehmkuhl, 1996 bony articulations gelnohumeral joint sternoclavicular joint acromioclavicular joint functional joints scapulothoracic articulation suprahumeral articulation (subacromial) bicipital groove 12
Glenohumeral Joint (GH Joint) proximal component -- scapula concave glenoid cavity covered with glenoid labrum distal component -- humerus convex humeral head glenoid labrum fibrocartilage deepens glenoid cavity lateral view gelnoid labrum scapula humerus anterior view Characteristics of GH Joint joint type: ball and socket (not a real socket) DOF = 3 convex on concave joint shoulder flexion/extension with post./ ant. glide shoulder abduction/ adduction with inf./ sup. glide shoulder external/ internal rotation with ant./ post. glide close-packed position 90º of shoulder abduction and full external rotation resting position 70º of shoulder abduction and 30º of flexion (horizontal adduction) Retroversion of Humeral Head humeral head rotated ~ 30º posterior to the frontal axis of the elbow joint A humeral head acromion sternum 20º Plane of Scapula the plane at the angle of 30º anterior to the frontal plane Not parallel to the frontal plane capsules in rest position no impingement in suprahumeral joint P 30º 30-35º H plane of scapula superior view S frontal plane Sternoclavicular (SC) Joint proximal component -- sternum saddle-shaped sternal manubrium distal component -- clavicle saddle-shaped medial end of clavicle interclavicular ligament S anterior and posterior SC ligament C costoclavicular ligament Rib1 articular disc Clavicle convex forward medially and concave forward laterally quadripedal animals do not have clavicles isokinetic strength of shoulder flexor and abductor decreases 50% if the clavicle is removed A C S superior view 13
Characteristics of SC Joint joint type: saddle joint degree of freedom = 3 motions clavicle elevation/ depression clavicle protraction/ retraction clavicle posterior rotation elevation depression Acromioclavicular (AC) Joint proximal component -- clavicle convex lateral end of the clavicle distal component -- scapula concave acromion process of the scapula coracoacromial ligament P retraction superior view A C A protraction posterior rotation acromioclavicular ligament Characteristics of AC Joint motion: convex on concave scapular winging: medial border moves backwards scapular tipping: inferior angle moves backwards scapular upward/downward rotation: inferior angle rotates upwards/downwards DOF = 3 spine of scapula superior border acromion process superior angle glenoid cavity medial border (vertebral border) inferior angle lateral border (axillary border) tipping winging rotation Motions at AC joint contribute 20º of scapular elevation and 20º of upward rotation during full arm elevation Neer and Rockward (1984) only 8º of motion at AC joint no loss in upward rotation if AC is fixed Scapulothoracic (ST) Articulation proximal component -- rib cage convex posterior aspect of rib cage distal component -- scapula concave anterior surface of scapula an articulation between bone and muscle; not a synovial joint Motions at ST Articulation degree of freedom: 3 concave on convex articulation abduction (protraction) elevation adduction (retraction) upward rotation depression downward rotation 14
Functions of ST Articulation to provide movement base for the humerus to maintain length-tension relationship for the deltoid muscle to function above 90º of arm elevation to provide stability of the GH joint working overhead to absorb the shock for forces applied to the outstretched arm to permit push-up during crutch walking short Shoulder Motions Jionts involved in shoulder motions Kinematics of the shoulder shoulder flexion/ extension shoulder abduction/ adduction shoulder external/ internal rotation shoulder horizontal adduction/ abduction shoulder girdle elevation/ depression shoulder girdle protraction/ retraction shoulder girdle upward/ downward rotation neutral neutral upward rotation Shoulder Flexion/ Extension joint involved: GH joint (principal joint) SC joint AC joint arthrokinematic movements? ST articulation plane of motion: sagittal plane axis: transverse axis thru center of humeral head range of motion shoulder flexion: 0-90º shoulder extension: 0-45 or 60º checking factors Shoulder Abduction/ Adduction joint involved: GH joint (principal joint) SC joint AC joint arthrokinematic movements? ST articulation plane of motion: frontal plane axis of rotation GH joint: sagittal axis thru center of humeral head SC joint: sagittal axis thru center of medial end of clavicle checking factors Shoulder External/ Internal Rotation shoulder external rotation 90º as the arm at 90º of abduction with anteomedial glide shoulder internal rotation 70º as the arm at 90º of abduction with posterolateral glide vertical axis through humeral head Scapulohumeral Rhythm Inman et al. (1944) measured frontal plane motion GH: ST = 2:1 after 30º of abduction Bagg and Forrest (1988) measured plane of scapula motion GH: at the beginning and the end ST: 80-140 º of abduction averaged ratio: 1.25:1 Codman s paradox: conjunct rotation occurs during sequential motion 15
Elevation of the Arm shoulder elevation (seldom used) joint involved GH joint: 120º SC and AC joints: 60-70º normal range 165-180º AC joint upward rotation humerus abduction 120º Arthrokinematic Movements Rotator cuff muscles provide inferior glide of the humeral head on the glenoid cavity deltoid acromion SIT supraspinatus SC joint elevation + post. rotation GH joint abduction scapula upward rotation force couple teres minor infraspinatus subscapularis Superior Glide at Extreme Abduction inferior capsule to support the humeral head to provide superior glide at terminal abduction Abduction inferior capsule Inferior glide Horizontal Abduction/ Adduction occurring at 90º of shoulder abduction definition: horizontal abduction: arm moves backwards horizontal adduction: arm moves forwards joint involved: GH, SC, and AC joints as well as ST articulation plane of motion: transverse plane axis of rotation: vertical axis through the center of the humeral head arthrokinematic movements? motion analysis using cardinal-plane motions? Cricumduction at SC joint A combination of elevation, protraction, depression, and retraction or in the reversed sequence SC joint as the pivot tip of shoulder moves in a circle path 16