Mobility involves joint structures, their surrounding

connective tissues and activity of the nervous system.

The term in question is used frequently in biomechanics
and is essentially the same as joint flexibility. Flexibility
refers to the extent at which a given joint can move in
different directions and is greatly dependent on the
function of the neuromuscular system. A decrease in joint
flexibility, or resistance caused by the surrounding soft
tissue of a joint, is referred to as stiffness and results in
both active and passive restriction of joint mobility. Once
again, restriction is of a biomechanical nature. The term
'stiffness' is often used to describe any type of difficulty
in achieving normal movement, and may involve only
the individual's subjective impression of the tense state
of bodily tissues, yet may not actually involve any
physical restriction in mobility.
Dynamic flexibility refers to the ability to self-actively
move a joint using those muscles surrounding it. In this
situation, the agonist muscles contract to produce
movement in the same direction, while the opposing
Figure 1.5 Knee joint with normal structure.
muscles or antagonists relax to allow movement yet
remain active enough to preserve joint integrity. Dynamic
movement, therefore, does not only depend on potential
joint mobility and limitations of muscle tension, but also,
and more importantly, on the ability of the assisting
mus c1es to achieve movement regardless of tissue
resistance. Static flexibility refers to the extent of stretch
attainable, passively, while muscles are fully relaxed;
muscle force in this case has no bearing on the results.
Joint stability is equally important in joint function, as
is flexibility. For example, walking and running would
not be possible if the joints of the lower extremities were
unable to support the movement. Flexibility and stability
do not work against each other, but are both normal
characteristics of joint function. Healthy joint function
requires both good flexibility and adequate stability to
withstand load. Passive stability involves joint surface
anatomy, as well as joint capsule and ligament structure,
strength and tightness. Passive stability depends usually
on jOint positioning and the load involved. Active stability
involves the combined forces of both the movers and the
stabilizers of the muscle-tendon system of a joint.
Functional joint stability essentially depends on function
of the neuromuscular system. Many injuries and
disorders of the central nervous system involve
symptoms of increased muscle tone known as spasticity_
In healthy people, stiff muscles are often wrongly
referred to as spastic. However, spasticity is a condition
directly related to nerve damage or nerve diseases
involving the upper motor neuron system. Damage will
be loca ted in the pyramidal corticospinal nerve
pathways: the spinal cord, brain stem or the cerebral
cortex. Minor damage will appear as minimal spasticity
towards the middle phase of a given action while
extremities are moved quickly back and forth while in a
relaxed state. More severe spasticity will involve the
entire joint area. Intense stretching may suddenly release
spasticity and is known as the clasp-knife effect.
Spasticity wi ll affect either the muscles of extension or
flexion depending upon which area of the nervous
system has been damaged. Hyper- reflex is the term used
to describe the over-active nature of spasticity. In the
clinical examina tion, the muscle-tendon system is
stretched with minimal force to check if the reflex
response is exaggerated. Repetition of reflex response
contractions often leads to lesser jerking movements,
known as clonus. Damage to the pyramidal corticospinal
nerve pathways may also involve a change in the
Babinski reflex from negative to positive. Applying pressure
to the heel with a blwlt object and drawing it swiftly along
the outer edge of the foot towards the toes will cause the big
toe to flex. Violent extension of the big toe is an indicator
of pyramidal pathway damage. This reaction, however, is
normal in children under the age of 7 years.
Damage to the extrapyramidal nerve pathways of the
central nervous system will result in rigidity. It affects the
entire joint area involving both the flexor and extensor
muscles. Stiffness is felt with slow movements and does
not depend to the same degree on the speed of movement
as it would with spasticity. Reflexes are not oversensitive
and the Babinski reflex is negative. During passive
flexion and extension of a joint, muscle tension
repeatedly increases and decreases rapidly, causing jerky
movements. The degree of resistance depends on how
quickly the joint is bent and the muscles are stretched.
Mild rigidity, for example in the early stages of
Parkinson's disease, may be undetectable except as a
stuttered resistance to fast movements.
Disease of the central nervous system may only involve
spasticity of certain muscles and involuntary movement
known as dyskinesia. Spasmodic torticollis is an example of
spas ticity that often affects the muscles on only one side
of the neck, resulting in exaggerated rotation that can be
temporarily relieved with stretching for a few seconds
but the neck will then quickly return to the same position.
GENERAL JOINT PHYSIOLOGY
Tension with spasticity and rigidi ty is not always
entirely the result of nerve damage. Changes in muscles
will appear, as use will concentrate on slow motor
neurons. The rapid motor cells are not activated and they
will tend to shorten, atrophy and become less frequent.
Minimal use of joint range will lead to shortening of joint
connective tissue as well as in muscles. The changes
become gradually permanent, as normally elastic fibres
will be replaced by tougher fibrous tissue. Care should be
taken to preserve mobility with regular active and
passive exercises at the onset of disease in order to minimize
the extent of movement limitation.
Spontaneous activati0{l of individual motor neurons
may cause a twit~hing effect, fasciculation, but may not
produce actual mov~ment. This OCCurS most often with
partial paralysis and in spastic muscles. A mild form of a
similar phenomenon occurring in healthy people is
commonly called a twitch or myokymia. The most typical
form of twitching occurs in the upper eyelid, but it may
appear in any muscle and the affected muscle may vary.
Damage to lower motor neurons, i.e. those nerves
ex iting the spinal cord, will result in flaccidity. Muscles
will become partly or completely paralyzed. Limb
muscles also have reduced tone, i.e. they are hypotonic.
This suggests that these patients should have good range
of movement in the affected joint. However, mobility
often becomes restricted in joints, because they may not
have been moved regularly throughout whole ROM.
Instability refers to the occurrence of abnormal joint
mobility due to lack of support normally supplied by the
surrounding tissues to maintain the integrity of the joint;
testing can reveal laxity of joint ligaments. Hypennobility
refers to an exaggerated mobility in ROM but movement
remains in the normal line of joint action (Figure 1.10).
Hypermobility may appear in one or more joints, and
may indicate hypermobility syndrome. Instability and
hypermobility are often confused with one another. Hypermobility
involves exaggerated ROM within the normal
function of a joint. Instability, on the other hand, can be
classified as a symptom of disease involving the pathology
in the joint stabilizing system. A hypermobile joint is
more vulnerable to trauma and thus hypermobility may
lead to joint instability more readily, compared with a
joint with normal ROM and stability.
Instability may also appear in joints with normal
ROM, and/ or even limited ROM. Hypermobility and
instability have also been defined according to type of
movement (Figure 1.9). Arthritis and rheumatism, over
SECTION 1 STRETCHING THEORY
Figure 1.6 Instability of the knee due to inward
deviation: valgus deformity.
Figure 1.7 Instability of the knee due to outward
deviation: varus deformity.
time, may cause degeneration, which can lead to
restricted angular movement, which may considerably
limit both flexion and extension. Despite this, there may
be additional translatory movement at the joint surface,
Figure 1.8 Instability of the knee due to exaggerated
bending of the back: hyperextension.
Direction of motion

- Angular Translatory ~
l Hypermobility J[ Instability J
Figure 1.9 Instability in relation to type of motion.
which may stretch the stabilizing joint capsule and ligaments,
causing pain and dysfunction (Figures 1.6-1.8).
Some consider hypermobility as excessive angular movement,
and instability as excessive translatory movement,
at the jOint surface.
Subluxatiol! refers to par tial joint separation from its
normal position, but a part of joint surfaces are still in
contact with each other (Figure 1.11). Luxation involves
complete displacement of joint surfaces. A decrease in
joint mobility is referred to as restriction, and anchylosis
is complete stiffening of a joint with no or very li ttle
movement at all. In this case, decreased mobility will
involve structural changes in the joint and surrounding
tissues.
Luxation
Hypermobility
Ankylosis
Figure 1.10 Function in relation to range of motion.
A
GENERAL JOINT PHYSIOLOGY
Different movemen ts requ ire different ran ges in
flexibility, which means optimal flexibility cannot be
standardized. What is considered normal mobility relates
to the average mobility of the population. Accuracy can
be improved by dividing result tables into categories of
age and sex. Professionals sh ould keep in mind that such
tables do not necessarily imply good mobility but, rather,
average mobility. In the older population, limited
mobility is COlnmon and because th ere is seldom much
attention paid to joint upkeep, a lot of joint problems exist
because of restricted ROM. However, there are exceptions
of elderly people with very good mobility.
Although instability is clearly a mechanical term, some
consider joint instability to be a defect in activation and
coordination, in which pain or hyperactive mechanoreceptors
inhibit synchronous function of support muscles.
Figure 1.11
A: Shoulder joint in tack, joint surfaces in opposition
to each other and joint shows maximal stability, which
depends on muscle activity and support of other
connective tissues.
B: Subluxation of shoulder joint with joint surfaces
only partially opposite each other. Orthopaedic
instability, this may often correct itself with the active
movement of the upper arm.
e: Dislocation of shoulder joint; joint surfaces without
any contact to one another. Manipulative
repositioning is commonly needed to correct the
displacement.
SECTION 1 STRETCHING THEORY
/ Impaired circulation

muscle stiffness
\ Nerve irritation [ Pain ] Increased

\ Increased load J
Figure 1.12 A vicious circle may develop as nerve
irritation caused by pain leads to muscle tension,
which leads to increased loading and impaired
circulation, which again increases muscle tension.
Typically in this case, stretching of the supporting connective
tissue in certain movements will induce flinching
and a strong painful reaction. If this is repeated several
times, it will become a constant painful condition (Figure
1.12). Joint instability, according to this definition, is more
a functional than a structural problem. Examinations
should not only include joint ROM but joint function in
various movements, because a joint may be found to be
unstable due to dysfunction of muscles, despite normal
or even reduced flexibility.
Self-assessment: concepts
During a bench press, the triceps (agonist)
muscle contraction withstands an increase in the
load with the increase in weight. How does this
affect the activity of the biceps (antagonist)
muscle?
Into which two functional parts is flexibility
divided?
What is the difference between hypermobility
and instability?
What methods are clinically used to differentiate
between pain caused by muscle tension, and
joint related pain?
What will happen to joint mobility in the
rehabilitation of patients suffering from severe
neurological spasticity, if regular treatments of
stretching are not given?
TYPES OF JOINTS
Flexibility of the locomotor system has specific characteristics
that vary, both between individuals and between
joints. Joint mobility depends on physical anatomy and
connechve tissue structure, which are greatly determined
by hereditary factors. The normal development of joints
is assisted with physical activity and load. Genetic defects,
deficiency disease, infection and toxins, especially during
the early growth phase, as well as prolonged immobility,
may cause pathologiC structural changes. Excessive loading,
trauma and/or inflammation of joints and their
surrounding soft tissues may cause structural changes,
resulting in permanent mobility limitations or instability.
Joint mobility is based on joint type that involves surface
shapes and structure of connective tissue.
Classification of joints according
to anatomical structure and degree
of motion
Osseus joints: no movement
Synostosis between the sacral vertebrae
Fibrous joints: little or no movement
Sutures of the skull
Sydesmosis, as in the distal tibiofibular joint
Gomphosis, as peg sutures in the roots of teeth in
alveolar process
Cartilaginous joints: little or no movement
Synchondroses, as in the epiphyseal plates (hyaline
cartilage)
Symphysis, as in the intervertebral discs and
symphysis pubis (fibrocartilage)
Free moving synovial joints
Ball and socket joints, as in the shoulder and hip
joints. Multiaxial movement
Saddle joint in which the structures of both surfaces
are reminiscent of saddles placed together, allowing
for movement in two directions. The first carpalmetacarpal
joint of the thumb is an example of a
saddle joint. Biaxial movement
Condyloid/ellipsoid joints, in which one surface is oval
shaped and convex. The second surface is concave
as in the radiohumeral and radiocarpal joints.
Biaxial movement
Hinge joint, in which movement remains along one
plane, as in the elbow, knee and superior ankle
joints. Monoaxial movement