Arthrokinematics PDF

MPTY03 – Articular Kinematics: arthrokinematics & Osteokinematic Michael PHILIPPE, MSc. PT, OMT Context Revisiting something you already know Revision of previously acquired knowledge Deepening the concept and creating a bridge with applied Manual Therapy 15/11/2024 MPTY03 – Art...

MPTY03 – Articular Kinematics: arthrokinematics & Osteokinematic Michael PHILIPPE, MSc. PT, OMT Context Revisiting something you already know Revision of previously acquired knowledge Deepening the concept and creating a bridge with applied Manual Therapy 15/11/2024 MPTY03 – Articular kinematics 2 Before leaving Why revisiting joint kinematics Interpretation of joint movements; Interpretation of symptoms Application of manual therapy techniques; Administration of therapeutic exercise. 15/11/2024 MPTY03 – Articular kinematics 3 Lecture outline Topics Definitions Osteokinematics and arthrokinematics Capsular patterns Implications and practical examp les 15/11/2024 MPTY03 – Articular kinematics 4 Joint kinematics Definition “Biomechanics is traditionally divided into the areas of kinematics and kinetics. Kinematics is the branch of mechanics that deals with the geometry of the motion of objects, including displacement, velocity, and acceleration, without taking into account the forces that produce the motion.” Generally, movements are divided into: 1. Rotation Movement that takes place through a circular pattern or pattern around a pivot (axis of rotation) 2. Translation Linear motion that can occur in a straight or curvilinear line 15/11/2024 MPTY03 – Articular kinematics 5 Osteokinematics Definition and practical example “Describes the angular motions of the bone segments in the three planes of space and which are "visible".” Practical example Glenohumeral joint: 3 axes of rotation perpendicular to each plane, passing through the convex pattern (humeral head) Anatomical position Movement Flexion/extension AB/ADduction Rotation Plane Sagittal Frontal Transverse Axis Transverse Sagittal Vertical 15/11/2024 MPTY03 – Articular kinematics 6 Degrees of freedom Osteokinematics “Number of direction of angular motion allowed in a joint. ” Articulation Degrees of Freedom Glenohumeral 3 : Sagittal ; frontal ; horizontal planes Wrist 2 : Sagittal and frontal planes Elbow 1 : Sagittal 15/11/2024 MPTY03 – Articular kinematics 7 Degrees of freedom Biomechanics Engineering-wise : concept also applies to translational movement. Typically restricted by the joint capsule, ligament and surrounding structures. Antero-posterior (AP) X-axis Medial-Lateral (decoaptation-compression) Y-Axis Superior-inferior (cranial-caudad) Z-axis Functional importance : Joint stability : Slight translational adjustments help maintain joint congruency during motion. Shock absorption : Small translations dissipate forces during impact. Pathological assessment : Excessive or restricted translation can indicate injury (e.g., ligament tears in the knee) 15/11/2024 MPTY03 – Articular kinematics 8 Degrees of freedom Example : Knee joint The knee joint (tibiofemoral joint) has: Rotational DOF: Flexion/extension, internal/external rotation. Translational DOF: Anterior-posterior gliding (controlled by ACL/PCL). Medial-lateral translation (limited by collateral ligaments). Superior-inferior translation (minimal, influenced by compressive forces). 15/11/2024 MPTY03 – Articular kinematics 9 Arthrokinematics Definition “Movement occurring between joint surfaces: the Accessory "displacements" between joint heads in relation to each other that occur during body movements” 1) Three are the main movements: Roll, Slide, Spin 2) Concave-convex relationship: - Geometry of joint surfaces varies from flat to curved - In most cases: at least curvilinear → convex profile and profile concave) 15/11/2024 MPTY03 – Articular kinematics 10 Arthrokinematics Concave – convex rule Convex on Concave Concave on Convex 15/11/2024 MPTY03 – Articular kinematics 11 Arthrokinematics Slide / Glide Glide : Translatory motion given by sliding of joint surfaces Slide : Occurs when a single point on the surface of the bone end makes contact with multiple points on the opposite end 15/11/2024 MPTY03 – Articular kinematics 12 Arthrokinematics Roll / Swing Roll : Occurs when multiple points of the joint end make contact with multiple points of the opposite end Swing : Angular motion occurring in the same direction of movement of the segment under consideration 15/11/2024 MPTY03 – Articular kinematics 13 Arthrokinematics Spin Occurs when one point of the joint end makes contact with one and only one point of the opposite end Rotary motion that occurs when the segment bone under consideration rotates around its own axis 15/11/2024 MPTY03 – Articular kinematics 14 Arthrokinematics Combined movement ROLL & SLIDE SWING & GLIDE They are associated with each They are associated with each other during physiological other during physiological movements in planes of movements in planes of motion motion when a convex when a concave surface moves surface moves over a over a convex one concave one 15/11/2024 MPTY03 – Articular kinematics 15 Arthrokinematics Combined movement ROLL & SLIDE SWING & GLIDE Glide Swing 15/11/2024 MPTY03 – Articular kinematics 16 Considerations Geometry – Displacement of axis – Kinetic chain Geometry of extremities Changes in location and Kinetic chain and joint profiles Of the orientation of the Which b ones ar e moving over which CON CAVE, CONVEX OR FLAT? center of rotation one? HOW DOES IT CHANGE DURING MOVEMENT? 15/11/2024 MPTY03 – Articular kinematics 17 Arthrokinematics CONCAVE-CONVEX RULES Alw ays at the foundation for guiding clinicians in making choices related to to the execution of manual therapy techniques Over time, several authors have questioned the veracity of the concave-convex rule (Ludewig PM, 2002; Poppen NK, 1976; Matsuki K 2012; Howell SM, 1988) Studies conducted on the shoulder (glenohumeral) joint have shown that: Humerus is relatively fixed or translates superiorly during abduction between 90° and 120°; Humeral head translates posteriorly by a few mm with respect to the glenoid during external rotation 15/11/2024 MPTY03 – Articular kinematics 18 Arthrokinematics CONCAVE-CONVEX RULES : NEUMANN’s answer 1. 16 cm circumference of the humeral head 2. If 90° of abduction occurred only with a "pure" and unique roll (without lower slide), the head Of the humerus should roll cranially 4 cm 3. Plus. acromial space about 1cm high. → Necessary lower slide ! 15/11/2024 MPTY03 – Articular kinematics 19 Arthrokinematics CONCAVE-CONVEX RULES : NEUMANN’s answer 1. If 75° of external rotation occurred with the sole and exclusive roll of the humeral head (without anterior slide), the latter would move 38 mm posteriorly and "disarticulate" it (transverse diameter of the glenoid fossa is only 22 mm) → Necessary anterior slide ! 15/11/2024 MPTY03 – Articular kinematics 20 Arthrokinematics CONCAVE-CONVEX PATTERN "[...] the convex-concave rule was never intended to establish the direction of a manual glide [...] the convex-concave rules of arthrokinematics, on their own merit, were not intended to serve as the unequivocal justification for deciding on the direction of the application of a manual glide maneuver. However, the rules can be a reasonable starting point for making such decisions, as long as factors such as the joint's resting position and local tensions within muscles, ligaments, or other connective tissues are considered" 15/11/2024 MPTY03 – Articular kinematics 21 Manual therapy Looking beyond the joint Joint position Capsular pattern 15/11/2024 MPTY03 – Articular kinematics 22 Manual therapy Joint position Joint congruence is not perfect The contact area between the joints at different points in the RO M is Minimum compared to the total available joint surface area Contact area 15/11/2024 MPTY03 – Articular kinematics 23 Joint position Closed packed position 1. Position of maximum joint stability 2. Usually at end-range 3. Ligaments, capsular component, and other peri-articular tissues in moderate-to-maximum tension 4. Minimal or no accessory movements 5. Minimal intra-capsular space in the joint The Closed-Packed Position is: Effective for loading (static) but dangerous for movement (dynamic) A testing position (as in shoulder instability apprehension tests) 15/11/2024 MPTY03 – Articular kinematics 24 Joint position Open packed position 1. Position of minimum joint stability 2. Usually mid-range 3. Ligaments, capsular component, and other peri-articular tissues in minimal tension 4. Ancillary movements allowed 5. Maximum intra-capsular space in the joint The Loose-Packed Position is: A position that allows maximum joint play (useful for treatment) A resting position of the joint Ineffective for load (static) but safe for movement (dynamic) 15/11/2024 MPTY03 – Articular kinematics 25 Joint Open-Pack Position Closed-Pack Position Shoulder (Glenohumeral) 55° Abduction, 30° Horizontal Adduction (scapular plane) Full Abduction and External Rotation Acromioclavicular Arm resting by the side Arm abducted to 90° Sternoclavicular Arm resting by the side Full Arm Elevation Elbow (Humeroulnar) 70° Flexion, 10° Supination Full Extension Elbow (Humeroradial) Full Extension and Supination 90° Flexion, 5° Supination Forearm (Proximal Radioulnar) 70° Flexion, 35° Supination 5° Supination Forearm (Distal Radioulnar) 10° Supination 5° Supination Wrist (Radiocarpal) Neutral position with slight ulnar deviation Full Extension Midcarpal Neutral or slight flexion with ulnar deviation Full Extension Carpometacarpal (Thumb) Midway between Abduction/Adduction and Flexion/Extension Full Opposition Metacarpophalangeal (Fingers) Slight Flexion Full Flexion Metacarpophalangeal (Thumb) Slight Flexion Full Opposition Interphalangeal (Fingers and Thumb) Slight Flexion Full Extension Hip 30° Flexion, 30° Abduction, Slight External Rotation Full Extension, Internal Rotation Knee (Tibiofemoral) 25° Flexion Full Extension, Tibial External Rotation Ankle (Talocrural) 10° Plantarflexion, midway between inversion and eversion Full Dorsiflexion Subtalar (Rearfoot) Midway between inversion and eversion Full Inversion Midtarsal (Transverse Tarsal) Midway between inversion and eversion Full Supination Toes (Metatarsophalangeal) Neutral position Full Extension Toes (Interphalangeal) Slight Flexion Full Extension Cervical Spine Midway between flexion and extension Full Extension Thoracic Spine Midway between flexion and extension Full Extension Lumbar Spine Midway between flexion and extension Full Extension Temporomandibular Joint (TMJ) Mouth slightly open (freeway space) Teeth tightly clenched Capsular pattern Capsular obligated translation Concept that restrictions in the extensibility ("stiffness") of the joint capsule may cause early and/or excessive translations or accessory movements in the opposite direction of stiffness (Harryman 1990; Soslowsky, 1992) Features of a Capsular Pattern 1. Proportional Restriction: 1. Movement limitations occur in a specific and predictable order of severity. 2. Different movements are restricted in a proportional pattern, not necessarily equally. Example: In the shoulder joint, external rotation is typically more restricted than abduction, which is more restricted than internal rotation. 15/11/2024 MPTY03 – Articular kinematics 27 Capsular pattern Capsular obligated translation Concept that restrictions in the extensibility ("stiffness") of the joint capsule may cause early and/or excessive translations or accessory movements in the opposite direction of stiffness (Harryman 1990; Soslowsky, 1992) Cause: Capsular patterns are associated with pathology affecting the entire joint capsule, such as: Arthritis (e.g., osteoarthritis, rheumatoid arthritis). Capsulitis (e.g., adhesive capsulitis or "frozen shoulder"). Post-immobilization joint stiffness. Diagnostic Value: Recognizing a capsular pattern helps identify joint pathologies and differentiate them from other causes of movement restriction (e.g., muscle tightness, ligament sprains). 15/11/2024 MPTY03 – Articular kinematics 28 Joint Capsular Pattern (Order of Restriction) Shoulder (Glenohumeral) External rotation > Abduction > Internal rotation Capsular pattern Elbow (Humeroulnar) Flexion > Extension Elbow (Humeroradial) Flexion > Extension > Supination > Pronation Capsular obligated translation Forearm (Proximal Radioulnar) Equal limitation of Supination and Pronation Wrist (Radiocarpal) Flexion = Extension Hip Internal rotation > Flexion > Abduction > Extension (slight limitation in adduction and external rotation) Knee (Tibiofemoral) Flexion > Extension Ankle (Talocrural) Plantarflexion > Dorsiflexion Subtalar (Rearfoot) Inversion (varus) > Eversion (valgus) Midfoot (Transverse Tarsal) Plantarflexion > Dorsiflexion, with associated inversion > eversion Toes (Metatarsophalangeal) Big toe: Extension > Flexion; Lesser toes: Flexion > Extension Cervical Spine Lateral flexion = Rotation > Extension Thoracic Spine Lateral flexion = Rotation > Extension Lumbar Spine 15/11/2024 MPTY03 – Articular kinematics Lateral flexion = Rotation > Extension 29 Temporomandibular Joint (TMJ) Limitation of mouth opening End-Feel ROM limitation and ROM recovery End feel refers to the sensation felt by the examiner at the end of a joint's passive range of motion (ROM). It provides information about the nature of the tissues limiting motion and helps identify normal or pathological conditions. Normal End Feels : These are expected sensations encountered in healthy joints and tissues: Type SOFT FIRM HARD Description A soft, yielding A firm, springy An abrupt, hard stop sensation due to soft resistance due to when bone contacts tissue approximation. capsular or bone. ligamentous stretching. Example Elbow flexion (biceps Shoulder external Elbow extension compressing against rotation (capsular (olecranon process forearm) stretch) meeting the olecranon fossa). Cause Compression of soft Tension in capsules, Bone-to-bone contact. tissues. ligaments, or muscles. 15/11/2024 MPTY03 – Articular kinematics 30 End-Feel ROM limitation and ROM recovery Abnormal End Feels : These occur when the end feel is inconsistent with the expected motion or occurs prematurely. Type SOFT FIRM HARD Empty SPASM SPRINGY Description A boggy, mushy Occurs earlier or An abrupt stop No mechanical A sudden, hard A rebound sensation, often later in ROM before normal resistance felt stop to motion sensation due to swelling than expected or ROM is reached. because the accompanied by indicating or synovial feels stiffer than patient stops the muscle spasm. internal joint inflammation. normal. motion due to derangement. pain. Example Knee effusion Frozen shoulder Osteoarthritis Acute bursitis, Cervical spine in Meniscal tear in after injury. (adhesive (osteophyte tumor, or severe whiplash injuries the knee. capsulitis) formation), loose inflammation. or protective body in a joint. spasms in fractures. Cause Edema or Muscle Bony block, joint Pain, guarding, Muscle guarding Loose body or synovitis. shortening, degeneration. or psychological due to injury, torn meniscus capsular factors. pain, or inside the joint. tightness, instability. ligament restriction. 15/11/2024 MPTY03 – Articular kinematics 31 Treatment ROM limitation and ROM recovery Pain + Reduced joint mobility = restriction in activity and participation = disability (ICF) ROM is one of the crucial aspects of musculoskeletal rehabilitation, and its restriction (hypomobility) is an impairment as important as pain is To treat efficiently, we need to know : 1. Type of musculoskeletal disorder; 2. Joint biomechanics; 3. Joint and muscle anatomy and physiology; 4. Movements between respective joint profiles (arthrokinematics) 15/11/2024 MPTY03 – Articular kinematics 32 Treatment Rationale PATIENT WITH TOTAL KNEE PATIENT WITH OUTCOME OF TIBIA ARTHROPLASTY FRACTURE AT 3 MONTHS Does it make sense to perform an Anterior translation of the tibia relative to anterior translation (glide) of the tibia the femur may be one of the techniques in a patient in whom one of the ("in PA") for treatment (along with other most important anterior translation manual techniques and therapeutic limiting factors (ACL) is no longer exercise) present? 15/11/2024 MPTY03 – Articular kinematics 33 Joint Movement Limited Capsule Involved Accessory Movement for Treatment Shoulder (Glenohumeral) External Rotation Anterior Capsule Anterior Glide Shoulder (Glenohumeral) Internal Rotation Posterior Capsule Posterior Glide Shoulder (Glenohumeral) Abduction Inferior Capsule Inferior Glide Shoulder (Glenohumeral) Flexion Posterior/Inferior Capsule Posterior Glide Elbow (Humeroulnar) Flexion Posterior Capsule Posterior Glide Elbow (Humeroulnar) Extension Anterior Capsule Anterior Glide Elbow (Humeroradial) Flexion Posterior Capsule Anterior Glide Elbow (Humeroradial) Extension Anterior Capsule Posterior Glide Forearm (Proximal Radioulnar) Supination Anterior Capsule Anterior Glide Forearm (Proximal Radioulnar) Pronation Posterior Capsule Posterior Glide Forearm (Distal Radioulnar) Supination Posterior Capsule Posterior Glide Forearm (Distal Radioulnar) Pronation Anterior Capsule Anterior Glide Wrist (Radiocarpal) Flexion Posterior Capsule Posterior Glide Wrist (Radiocarpal) Extension Anterior Capsule Anterior Glide Wrist (Radiocarpal) Radial Deviation Ulnar Capsule Ulnar Glide Wrist (Radiocarpal) Ulnar Deviation Radial Capsule Radial Glide MCP Joints (Fingers) Flexion Posterior Capsule Anterior (Volar) Glide MCP Joints (Fingers) Extension Anterior Capsule Posterior (Dorsal) Glide MCP Joints (Fingers) Abduction Opposite Side Capsule Medial/Lateral Glide MCP Joints (Fingers) Adduction Opposite Side Capsule Medial/Lateral Glide IP Joints (Fingers) Flexion Posterior Capsule Anterior (Volar) Glide IP Joints (Fingers) Extension Anterior Capsule Posterior (Dorsal) Glide CMC Joint (Thumb) Flexion Radial Capsule Medial Glide CMC Joint (Thumb) Extension Ulnar Capsule Lateral Glide CMC Joint (Thumb) Abduction Posterior Capsule Posterior Glide CMC Joint (Thumb) Adduction Anterior Capsule Anterior Glide MCP Joint (Thumb) Flexion Posterior Capsule Anterior (Volar) Glide MCP Joint (Thumb) Extension Anterior Capsule Posterior (Dorsal) Glide IP Joint (Thumb) Flexion Posterior Capsule Anterior (Volar) Glide IP Joint (Thumb) Extension Anterior Capsule Posterior (Dorsal) Glide Joint Movement Limited Capsule Involved Accessory Movement for Treatment Hip (Coxofemoral) Flexion Posterior/Inferior Capsule Posterior Glide Hip (Coxofemoral) Extension Anterior Capsule Anterior Glide Hip (Coxofemoral) Abduction Inferior Capsule Inferior Glide Hip (Coxofemoral) Adduction Superior Capsule Superior Glide Hip (Coxofemoral) Internal Rotation Posterior Capsule Posterior Glide Hip (Coxofemoral) External Rotation Anterior Capsule Anterior Glide Knee (Tibiofemoral) Flexion Posterior Capsule Posterior Glide Knee (Tibiofemoral) Extension Anterior Capsule Anterior Glide Ankle (Talocrural) Dorsiflexion Posterior Capsule Posterior Glide Ankle (Talocrural) Plantarflexion Anterior Capsule Anterior Glide Subtalar Joint Inversion Lateral Capsule Lateral Glide Subtalar Joint Eversion Medial Capsule Medial Glide MTP Joints (Toes) Flexion Posterior Capsule Anterior (Volar) Glide MTP Joints (Toes) Extension Anterior Capsule Posterior (Dorsal) Glide IP Joints (Toes) Flexion Posterior Capsule Anterior (Volar) Glide IP Joints (Toes) Extension Anterior Capsule Posterior (Dorsal) Glide Cervical Spine Flexion Posterior Capsule Posterior-Anterior Glide Cervical Spine Extension Anterior Capsule Anterior Glide Cervical Spine Rotation Opposite Side Capsule Posterior-Anterior Glide (Opposite Side) Thoracic Spine Flexion Posterior Capsule Posterior-Anterior Glide Thoracic Spine Extension Anterior Capsule Anterior Glide Thoracic Spine Rotation Opposite Side Capsule Posterior-Anterior Glide (Opposite Side) Lumbar Spine Flexion Posterior Capsule Posterior-Anterior Glide Lumbar Spine Extension Anterior Capsule Anterior Glide Lumbar Spine Rotation Opposite Side Capsule Posterior-Anterior Glide (Opposite Side) Manual Therapy Application : combining accessory and physiological movement Purpose: Improve range of motion by integrating passive accessory glides with active or passive physiological movements. Technique: 1. Position the Joint: Place the joint in the starting position where the limitation occurs. 1. Example: For the shoulder, position in slight abduction for anterior glide (external rotation improvement). 2. Apply the Accessory Movement: Mobilize the joint along the glide direction (anterior, posterior, inferior, etc.) while maintaining the appropriate hand placement and force. 3. Add the Physiological Movement: 1. Passive: The therapist moves the joint through its range of motion while maintaining the glide. 2. Active: The patient actively performs the movement while the therapist applies the glide. 4. Reassess: Check for improvement in the range or reduction in symptoms. Example: To improve shoulder external rotation: Perform anterior glide of the humeral head while the patient actively rotates the shoulder externally. 15/11/2024 MPTY03 – Articular kinematics 36 Manual Therapy Application : Strain-Counterstrain (Positional Release Therapy) Purpose: Reduce muscle guarding and pain by positioning the joint in its most relaxed and least painful position. Technique: 1.Find the Tender Point: Identify a painful or tight area related to the joint or movement limitation. 2.Position for Comfort: Passively position the joint to shorten the involved tissue and relieve tension. Example: If there’s pain in the anterior capsule of the shoulder, position the arm in slight flexion and external rotation. 3.Hold the Position: Maintain the position for 90 seconds while monitoring the patient’s comfort and symptoms. 4.Reassess: Return the joint to neutral and test the range of motion or pain reduction. Example:For posterior capsule tightness in the shoulder, use a position of flexion and internal rotation to relieve tension before attempting mobilization. 15/11/2024 MPTY03 – Articular kinematics 37 Manual Therapy Application : Graded mobilizations (Maitland) Purpose: Gradually increase the joint's range of motion and reduce stiffness or pain. Grades: Grade I-II: Small-amplitude movements for pain relief and relaxation. Grade III-IV: Larger amplitude movements toward the end range to stretch the capsule. Grade V (Manipulation): High-velocity, low-amplitude thrusts used sparingly by trained professionals. Technique: Amplitude and Rhythm: Apply a smooth, rhythmic oscillation at the chosen grade. Typically, 2-3 oscillations per second for 30 seconds to 2 minutes. Start with Grades I-II to reduce pain and spasm. Progress to Grades III-IV to improve range of motion. 15/11/2024 MPTY03 – Articular kinematics 38 Conclusion Nuancing the model Osteokinematics aids understanding of the mutual behavior of joint profiles and to "visualize in mind" the behavior of joints in angular movements Arthrokinematics provides useful insights into the administration of joint techniques (e.g: Posterior translation of the talus for recovery of ROM in dorsal flexion) The "bare bones" study of joint kinematics alone is meaningless The concave-convex pattern is just one of the principles that guide our decision making clinical and will be integrated with new findings on pain-related neuroscience 15/11/2024 MPTY03 – Articular kinematics 39 Bibliography Kenneth Kirby, Chris Showalter, Chad Cook. Assessment of the importance of glenohumeral Peripheral mechanics by practicing physiotherapists. Physiother Res Int. 2007. Baeyens J-P, P Van Roy, J P Clarys. 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