Journal of Biomechanics 48 (2015) 449455

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Journal of Biomechanics
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Biomechanical risk factors and exor tendon frictional work in the

cadaveric carpal tunnel
Aaron M. Kociolek, Jimmy Tat, Peter J. Keir n
Department of Kinesiology, McMaster University, Hamilton, Ontario, Canada

art ic l e i nf o a b s t r a c t

Article history: Pathological changes in carpal tunnel syndrome patients include brosis and thickening of the
Accepted 8 December 2014 subsynovial connective tissue (SSCT) adjacent to the exor tendons in the carpal tunnel. These clinical
ndings suggest an etiology of excessive shear-strain force between the tendon and SSCT, underscoring
Keywords: the need to assess tendon gliding characteristics representative of repetitive and forceful work. A
Carpal tunnel mechanical actuator moved the middle nger exor digitorum supercialis tendon proximally and
Tendon distally in eight fresh frozen cadaver arms. Eighteen experimental conditions tested the effects of three
Subsynovial connective tissue well-established biomechanical predictors of injury, including a combination of two wrist postures (01
Gliding resistance and 301 exion), three tendon velocities (50, 100, 150 mm/sec), and three forces (10, 20, 40 N). Tendon
Viscoelastic
gliding resistance was determined with two light-weight load cells, and integrated over tendon
displacement to represent tendon frictional work. During proximal tendon displacement, frictional
work increased with tendon velocity (58.0% from 50150 mm/sec). There was a signicant interaction
between wrist posture and tendon force. In wrist exion, frictional work increased 93.0% between
tendon forces of 10 and 40 N. In the neutral wrist posture, frictional work only increased 33.5% (from
1040 N). During distal tendon displacement, there was a similar multiplicative interaction on tendon
frictional work. Concurrent exposure to multiple biomechanical work factors markedly increased tendon
frictional work, thus providing a plausible link to the pathogenesis of work-related carpal tunnel
syndrome. Additionally, our study provides the conceptual basis to evaluate injury risk, including the
multiplicative repercussions of combined physical exposures.
& 2014 Elsevier Ltd. All rights reserved.

1. Introduction exacerbated in SSCT layers adjacent to exor tendon (Ettema

et al., 2006; Schuind et al., 1990).
Carpal tunnel syndrome (CTS) is a peripheral entrapment Moore et al. (1991) used 12 biomechanical measures to model
neuropathy due to compression of the median nerve at the wrist. tissue loads in the wrist/hand and found that exor tendon frictional
While the etiology of CTS is multi-factorial (Staal et al., 2007), work was the best predictor of injury. Tanaka and McGlothlin (1993)
common histopathologic changes include brosis and thickening also developed a heuristic model of the wrist using frictional energy
of the subsynovial connective tissue (SSCT) surrounding the exor to predict work-related CTS. Both of these methods utilized the well-
tendons in the carpal tunnel (Barr et al., 2004; Ettema et al., 2006; established belt-pulley model that likens a tendon gliding over a
Jinrok et al., 2004). The SSCT loosely attaches the exor tendons to curved surface, such as the transverse carpal ligament in wrist
the visceral synovium, and is comprised of collagen bundles that exion, to a belt around a pulley (Armstrong and Chafn, 1979). Keir
form adjacent layers interconnected by small perpendicular brils. and Wells (1999) determined the radius of tendon curvature in the
During exor tendon displacement, the SSCT is strained, with deep carpal tunnel decreased with both wrist exion angle and tendon
layers close to tendon moving before supercial layers near the force magnitude thereby increasing normal stress on the median
visceral synovium (Guimberteau et al., 2010). Repetitive tendon nerve in addition to the effect of tendon tension on contact stress.
motion is thought to promote shear damage at the tendon- More recently, exor tendon gliding resistance was experimentally
SSCT interface, which is supported by the nding that brosis is measured (in vitro) within the carpal tunnel (Filius et al., 2014; Zhao
et al., 2007). Zhao et al. (2007) found that tendon gliding resistance
n
increased exponentially with tendon displacement, primarily due to
Correspondence to: Department of Kinesiology, McMaster University, 1280
the viscoelastic SSCT. The researchers also quantied the effect of wrist
Main Street West, Hamilton, Ontario, Canada L8S 4K1. Tel.: 905 525 9140 x23543;
fax: 905 523 6011. exion angle on tendon gliding resistance; however, the slow test
E-mail address: [email protected] (P.J. Keir). velocity of 2 mm/sec likely diminished viscoelastic shear-strain. There

http://dx.doi.org/10.1016/j.jbiomech.2014.12.029
0021-9290/& 2014 Elsevier Ltd. All rights reserved.
450 A.M. Kociolek et al. / Journal of Biomechanics 48 (2015) 449455

remains a need to quantify tendon gliding characteristics representa-

tive of repetitive and forceful work to better understand the interplay 5
between contact shear with other anatomical structures and tenosy-
novial resistance on overall friction in the carpal tunnel.
The purpose of this study was to quantify exor tendon gliding
resistance and frictional work in two wrist postures (01 and 301
1
exion), three tendon velocities (50 mm/sec, 100 mm/sec, 150 mm/
sec), and three tendon forces (10 N, 20 N, 40 N). We hypothesized
4
that greater physical exposure, including higher tendon velocity and
force, would increase exor tendon frictional work, especially with
wrist exion.
3
2
CT
2. Methods

2.1. Cadaveric specimens Fig. 1. A cadaver specimen in the testing apparatus. Gliding characteristics of the
middle nger FDS tendon were evaluated as a motor moved the tendon proximally
Eight unmatched fresh frozen human cadaver upper limbs were amputated at (nger exion) and distally (nger extension). The apparatus includes the (1) con-
the mid-humerus (age 56.6 7 15.5 yr, height 178.4 7 8.8 cm, mass 99.7 7 26.2 kg). stant force spring, (2) distal load cell, (3) proximal load cell, (4) rotary potenti-
Exclusion criteria included a known history of wrist tendinopathy, peripheral nerve ometer, and (5) linear actuator. Note: the remaining exor tendons and median
disease, and CTS. This study was approved by the Hamilton Integrated Research nerve are not yet connected so that all the components of the apparatus are clearly
Ethics Board. visible.
Specimens were thawed at 5 1C for approximately 12 h prior to dissection. The
exor digitorum profundus (FDP) and exor digitorum supercialis (FDS) tendons
were exposed on both proximal and distal sides of the transverse carpal ligament. Table 1
Passive nger exion/extension movements were used to identify all four tendons Mean ( 7 standard error of mean) distal tendon force measurements from the
of FDP and FDS. The exor pollicis longus (FPL) tendon and median nerve were also constant force springs during proximal and distal tendon displacement.
identied. The nger and thumb exor tendons and median nerve were excised
from the proximal and distal attachments. The carpal tunnel was left undisturbed Manufactured rating (N) Prox disp (N) Dist disp (N)
and the mid-humeral amputation ensured that the ulna and radius remained intact
to preserve anatomic delity of the wrist complex. 10 N 9.52 7 0.12 6.39 7 0.11
20 N 21.93 7 0.28 16.007 0.20
40 N 39.127 0.62 30.247 0.37
2.2. Testing apparatus

*10 N, 20 N, and 40 N Expected force magnitude of the constant force springs

Upper limb specimens were secured to the testing apparatus at the proximal from manufacturer specications.
forearm with an adjustable clamp as well as the distal forearm (proximal to the
wrist crease), hand (3rd metacarpal), and middle nger (3rd distal phalanx) with Four proximal-distal tendon displacement cycles were tested in each experi-
plastic fasteners (Fig. 1). The testing apparatus was hinged at the wrist to change mental condition, for a total of 72 cycles (18 conditions  4 cycles/condition). A
the joint angle in the experiment. The middle nger FDS tendon was attached balanced design mitigated order effects for wrist posture (i.e. four cadavers started
proximally to a cable, connected to a linear actuator (ERC3, IAI America Inc., in the neutral posture, four cadavers started in the exed posture). Tendon force
Torrance, CA) through a series of mechanical pulleys. Distally, the tendon was xed was randomized for each wrist posture, and tendon velocity was block randomized
to a cable that curved around a pulley and attached to a constant force spring (N- within each force level. The specimens were lightly sprayed with saline solution
series, Vulcan Spring Co, Telford, PA). Both sides of the tendon were attached before starting each wrist posture block. While this represents minimal spraying,
directly to cable ends with 6 mm aluminum crimping sleeves. Two light-weight the potential for confounded results due to changes in lubrication were minimized
load cells (LCM-200, Futek Inc., Irvine, CA) were connected in series with the (Uchiyama et al., 1997).
tendon proximal and distal to the carpal tunnel. A pulley on the proximal side of Tendon velocities and forces in this study were similar to previous in vivo
the carpal tunnel was also instrumented with a rotary potentiometer (6370 Series, studies. Tendons have been shown to reach velocities up to 150 mm/sec during full
State Electronics Corp., East Hanover, NJ) to calculate displacement of the tendon nger exion (Tat et al., 2013). Unrestricted dynamic nger tapping produces
via the motor. tendon force between 817 N, with higher magnitudes during forceful exertions
The proximal ends of the remaining nger exor tendons (3 FDS and 4 FDP) (Dennerlein, 2005). The impact of wrist posture on tendon friction is well
were connected to an adjustable plate on the testing apparatus. Distally, the established (Armstrong and Chafn, 1979; Tanaka and McGlothlin, 1993; Zhao
tendons were xed to extension springs to maintain a tension of 250 g. The et al., 2007). Representing wrist exion in vitro required meticulous care since the
extension springs connected to another adjustable plate to preserve the tendon tendons were detached on both sides of the carpal tunnel. During wrist exion
lines of action through the carpal tunnel. Since the FPL was only exposed and trials, the exor tendons were displaced 10 mm in the proximal direction to
excised from the origin site, the tendon was xed to an extension spring on the represent the position of the tendon for an intact musculotendon unit (Armstrong
proximal side of the carpal tunnel while the thumb was secured to the testing and Chafn, 1978).
apparatus. The distal median nerve branches throughout the hand; thus, tension
was provided with an extension spring on the proximal side of the testing
2.4. Data collection and analysis
apparatus.

Middle nger FDS tendon forces and displacements were collected at 120 Hz
2.3. Experimental protocol
(LabView 8.5, National Instruments Corp., Austin, TX). Load cell and potentiometer
data were smoothed with a dual second-order low pass Butterworth lter
FDS tendon displacements of the middle nger were produced with the linear (fc 6 Hz). Tendon gliding resistance was dened as the difference between
actuator. The motor was programmed to move 30 mm proximally and distally to proximal and distal tendon forces (Fp Fd). Positive gliding resistance represented
represent tendon displacements for full nger exion and extension, respectively resistance to proximal tendon displacement while negative gliding resistance
(Kociolek and Keir, 2013). Each specimen was preconditioned with twenty-four represented resistance to distal tendon displacement. Tendon frictional work was
continuous tendon displacement cycles (velocity 50 mm/sec; force 10 N). Tendon calculated by integrating tendon gliding resistance over tendon displacement in
displacements were tested in eighteen conditions using combinations of two wrist both the proximal and distal displacement phase of each cycle.
postures (01 and 301 exion), three tendon velocities (50, 100, 150 mm/sec), and
three tendon forces supplied by constant force springs (  10, 20, 40 N). While the
springs produce constant force with greater deections, we anticipated different 2.5. Statistical analysis
magnitudes for proximal versus distal tendon displacements, due to friction of the
mounting axle (Williams et al., 2013). Spring forces were 25.4% lower for distal Due to acceleration and deceleration of the motor, the rst 5 mm and last 5 mm
deections compared to proximal deections (Table 1). Note: from herein we will of proximal tendon displacement were removed to ensure constant velocity. Thus,
refer to the tendon forces based on the spring specications for ease of reading (10, we determined tendon gliding resistance for 20 mm of displacement (525 mm). A
20, 40 N). smaller displacement interval was used for return distal tendon displacement,
 A.M. Kociolek et al. / Journal of Biomechanics 48 (2015) 449455 451

Table 2
Mean (in N7 standard error of mean) exor tendon gliding resistance during
proximal tendon displacement (simulated nger exion).

5 mm 10 mm 15 mm 20 mm 25 mm

Neutral Wrist (01)

10 N
50 mm/sec 0.43 70.13 0.63 7 0.18 0.81 7 0.21 1.20 7 0.27 2.687 0.65
100 mm/sec 0.52 70.13 0.777 0.21 1.077 0.25 1.81 7 0.32 3.337 0.74
150 mm/sec 0.53 70.13 0.92 7 0.20 1.497 0.25 2.40 7 0.41 3.65 7 0.79
20 N
50 mm/sec 0.55 70.19 0.75 7 0.25 0.95 7 0.28 1.38 7 0.32 3.247 0.89
100 mm/sec 0.66 70.19 0.89 7 0.28 1.20 7 0.32 2.09 7 0.41 4.047 0.98
150 mm/sec 0.64 70.18 1.047 0.25 1.62 7 0.27 2.667 0.48 4.23 7 0.95
40 N
50 mm/sec 0.60 70.22 0.82 7 0.32 1.05 7 0.37 1.59 7 0.42 3.79 7 0.95
Fig. 2. FDS tendon forces recorded during proximal tendon displacement (black 100 mm/sec 0.73 70.22 1.007 0.33 1.377 0.36 2.43 7 0.42 4.737 0.96
lines) and distal tendon displacement (gray lines) for one cycle. The difference 150 mm/sec 0.74 70.21 1.217 0.30 1.89 7 0.34 3.107 0.50 4.84 7 0.95
between the proximal tendon force (Fp) and distal tendon force (Fd) represent Flexed Wrist (301)
tendon gliding resistance. During proximal tendon displacement, the proximal 10 N
force is greater than the distal force (Fp 4Fd). During distal tendon displacement, 50 mm/sec 0.38 70.10 0.63 7 0.15 0.94 7 0.22 1.497 0.32 3.167 0.64
the distal force is greater than the proximal force (Fd 4Fp). Note that the proximal 100 mm/sec 0.46 70.11 0.84 7 0.19 1.30 7 0.28 2.23 7 0.41 3.83 7 0.72
tendon force is greater than the distal tendon force near the beginning of distal 150 mm/sec 0.51 70.12 1.067 0.22 1.79 7 0.34 2.90 7 0.52 4.277 0.79
tendon displacement (  510 mm), which was excluded from analysis since this is 20 N
not representative of tendon gliding resistance. 50 mm/sec 0.69 70.18 1.03 7 0.26 1.42 7 0.36 2.107 0.47 4.007 0.75
100 mm/sec 0.82 70.19 1.357 0.34 1.917 0.47 2.977 0.59 4.83 7 0.86
150 mm/sec 0.82 70.20 1.55 7 0.34 2.43 7 0.49 3.687 0.66 5.20 7 0.91
since a positive artifact persisted for the rst 510 mm of distal tendon displace-
40 N
ment (Fig. 2). Thus, tendon gliding resistance was determined for a displacement
50 mm/sec 1.16 70.33 1.667 0.48 2.30 7 0.65 3.22 7 0.79 5.117 1.04
range of 15 mm (1025 mm). This interval ensured only gliding resistance was
100 mm/sec 1.23 70.31 1.96 7 0.52 2.717 0.67 4.017 0.82 5.89 7 1.04
included for analysis during return distal tendon displacement. FDS tendon gliding
150 mm/sec 1.3570.36 2.34 7 0.59 3.42 7 0.76 4.84 7 0.91 6.497 1.14
resistance was t with an exponential curve during proximal tendon displacement
and a logarithmic curve during distal tendon displacement, based on pilot work of
*10 N, 20 N, and 40 N Magnitude of tendon force (via constant force springs);
seven specimens and conrmed in a previous study (Zhao et al., 2007). Extensive
**50 mm/sec, 100 mm/sec, and 150 mm/sec Magnitude of tendon velocity (from
pilot work also determined that tendon frictional work increased exponentially
motor).
with proximal tendon displacement and linearly with distal tendon displacement,
and were also characterized with least-squares curve ts.
Three-way repeated measures analysis of variance statistical models were used
(Fig. 4). For distal tendon displacement, there was a three-way
to test the effects of wrist posture (01, 301 exion), tendon velocity (50, 100,
150 mm/sec), and tendon force (10, 20, 40 N) on tendon frictional work over the wrist posture  tendon velocity  tendon force interaction on fric-
reduced range of tendon motion. Proximal and distal tendon displacements were tional work (F4,28 3.1, p 0.032). In a neutral wrist posture,
tested in separate analyses since different intervals were considered in each tendon force had very little effect on frictional work (Fig. 6), but
movement phase (20 mm for proximal tendon displacement and 15 mm for distal frictional work increased with tendon velocity by 29.0% between
tendon displacement) and different force levels were exhibited by the constant
force springs (Table 1). Signicant main effects and interactions were followed up
50 mm/sec and 100 mm/sec, and 14.5% from 100 mm/s to
(post-hoc) with Tukeys HSD ( 0.05). 150 mm/s (averaged over all three forces). In wrist exion, tendon
frictional work increased with tendon force between 1040 N
(Fig. 6). Frictional work also increased with velocity, more so at
3. Results higher forces. At 10 N, frictional work increased 26.1% from
50 mm/sec to 100 mm/sec and another 11.6% from 100 mm/sec
Tendon gliding resistance for all eighteen experimental condi- to 150 mm/sec (total increase of 37.7%). At 40 N, frictional work
tions is provided in Table 2 (proximal tendon displacement) and increased 37.1% from 50 mm/sec to 100 mm/sec and 11.8% from
Table 3 (distal tendon displacement). FDS tendon gliding resistance 100 mm/sec to 150 mm/sec (total increase of 48.9%).
increased exponentially throughout proximal tendon displacement
(Fig. 3). An exponential model accounted for 97.670.8% of the total
variance in gliding resistance versus proximal displacement over all 4. Discussion
eighteen experimental conditions. For distal tendon displacement, a
logarithmic relationship explained 90.7%72.1% of the total variance We evaluated the combined effects of wrist posture, tendon
in tendon gliding resistance (Fig. 3). velocity, and force on tendon frictional work in cadaveric carpal
Tendon frictional work also increased exponentially versus prox- tunnels. Concurrent exposure to several occupational risk factors
imal tendon displacement. An exponential relationship explained multiplicatively increased tendon frictional work. During proximal
98.670.2% of the total variance in proximally directed tendon tendon displacement (simulated nger exion), wrist posture
frictional work over all experimental conditions (Fig. 4). For proximal interacted with tendon force, while tendon velocity independently
tendon displacement, there was a wrist posture  tendon force increased frictional work. During distal tendon displacement (simu-
interaction on frictional work (F2,14 11.0, p0.01). In wrist exion, lated nger extension), there was an interaction between wrist
tendon frictional work increased 93.0% from a tendon force of 10 N posture, tendon velocity, and force, with frictional work being
(31.476.0 mJ) to 40 N (60.6713.0 mJ). In the neutral wrist posture, disproportionately greater for high magnitudes of all three biome-
tendon frictional work only increased 33.5% between 1040 N, from chanical variables simultaneously. This was the rst study to
26.674.9 mJ to 35.577.0 mJ (Fig. 5). During proximal tendon measure tendon gliding characteristics representative of repetitive
displacement, tendon frictional work increased with tendon velocity and forceful work. Furthermore, our experiment included contact
(F2,14 92.8, po0.001). A frictional work increase of 58.0% was found shear with adjacent anatomical structures and the viscoelastic SSCT.
between 50 and 150 mm/sec (Fig. 5). Zhao et al. (2007) previously suggested that viscoelastic shear-
A linear relationship accounted for 95.57 0.6% of the total strain was the largest component of tendon gliding resistance,
variance in frictional work against distal tendon displacement even for a non-physiological tendon velocity of 2 mm/sec and
452 A.M. Kociolek et al. / Journal of Biomechanics 48 (2015) 449455

force of 2 N. We manipulated tendon velocity and tendon force in and force), which were modeled using least squares regression.
neutral and exed wrist postures, and found high-order interac- The model also includes interaction terms to represent the multi-
tions between these three well-established biomechanical vari- plicative effect of combined biomechanical risk factors, typical of
ables. Our results also suggest a linkage between contact and observation studies characterizing work-relatedness in CTS. Future
viscoelastic sources of friction (tendon velocity  tendon force research will assess the capability of the model to predict work-
interaction for distal tendon displacement). Overall, this study related musculoskeletal disorders of the wrist/hand.
connects biomechanical risk factors with underlying mechanics. Schweizer et al. (2003) indirectly quantied nger exor tendon
Our results provide mechanistic support for epidemiological friction via the difference between maximum eccentric and con-
studies, which indicate exposure to multiple physical work factors centric muscle contractions. Wrist and nger movements against a
disproportionately increases injury risk for CTS (Bernard, 1997; high load produced greater estimates than previous studies that
Punnett and Wegman, 2004). directly measured gliding resistance with low loads between the
To provide context and a better visual, we re-addressed the FDS tendon and A2 pulley (An et al., 1992; Uchiyama et al., 1995). In
main ndings in a scalable model to calculate FDS tendon gliding this study, friction in the carpal tunnel was greater with high load,
resistance (Fig. 7), which can be integrated to calculate tendon and this effect was magnied in wrist exion. While friction
frictional work. A generic curve characterizes tendon gliding between the nger exor tendons and digital pulleys may enable
resistance as a function of tendon displacement for both proximal higher ngertip forces than theoretically possible from musculoten-
tendon displacement (nger exion) and distal tendon displace- don force transmission alone (Schweizer et al., 2009; Vigouroux et
ment (nger extension). Gliding resistance is modulated by the al., 2006), the broader mechanical implications of carpal tunnel
biomechanical factors in this study (wrist posture, tendon velocity, friction are unknown. Anatomical characteristics of the digital pulley
system, including transverse chiasma (or ridges) of FDP tendon and
Table 3 the A2 pulley, are ideally suited for a tendon compression mechan-
Mean (in N7 standard error of mean) exor tendon gliding resistance in distal ism, thus providing a means to decrease muscular force contribu-
tendon displacement (nger extension). tions (Walbeehm and McGrouther, 1995). However, the smaller arc
10 mm 15 mm 20 mm 25 mm
of contact between exor tendon and the transverse carpal ligament
in wrist exion as well as SSCT viscoelastic strain may limit any
Neutral wrist (01) mechanical advantage of friction through the carpal tunnel.
10 N Peak tendon gliding resistance in this study was remarkably
50 mm/sec  0.59 7 0.16  0.74 70.19  0.917 0.24  1.09 7 0.27
high relative to the input force of 1040 N, ranging from
100 mm/sec  0.78 7 0.18  1.03 70.19  1.177 0.23  1.247 0.27
150 mm/sec  0.767 0.26  1.20 70.22  1.377 0.23  1.38 7 0.26 2.68 70.65 N to 6.49 71.14 N. During wrist exion, the nger
20 N exor tendons migrate palmarly, generating friction with the
50 mm/sec  0.667 0.21  0.81 70.25  0.98 7 0.31  1.197 0.35 transverse carpal ligament (Keir and Wells, 1999). Lee and
100 mm/sec  0.84 7 0.25  1.18 70.28  1.30 7 0.33  1.377 0.37 Kamper (2009) demonstrated the importance of digital pulleys
150 mm/sec  0.717 0.31  1.28 70.24  1.50 7 0.26  1.53 7 0.32
40 N
and passive joint characteristics on spatial coordination of nger
50 mm/sec  0.82 7 0.31  0.97 70.36  1.117 0.39  1.317 0.45 joint kinematics in a biomechanical model of the musculoskeletal
100 mm/sec  0.93 7 0.32  1.28 70.35  1.38 7 0.39  1.46 7 0.43 system. Tendon resistance in the carpal tunnel, including both
150 mm/sec  0.727 0.36  1.40 70.33  1.62 7 0.36  1.63 7 0.40 synovial and extrasynovial friction, represents another important
Flexed Wrist (301)
consideration in musculoskeletal models used to investigate motor
10 N
50 mm/sec  0.81 7 0.12  1.04 70.13  1.26 7 0.17  1.447 0.22 control, injury mechanisms, surgical procedures, and rehabilita-
100 mm/sec  0.98 7 0.18  1.38 70.17  1.58 7 0.21  1.677 0.25 tion protocols (Holzbaur et al., 2005; Sancho-Bru et al., 2001; Wu
150 mm/sec  0.917 0.16  1.51 70.18  1.78 7 0.22  1.82 7 0.25 et al., 2008; Valero-Cuevas, 2005).
20 N Using a similar setup, Zhao et al. (2007) found that peak tendon
50 mm/sec  1.147 0.23  1.44 70.30  1.737 0.39  2.077 0.50
gliding resistance increased from 1.15 N to 1.85 N from 01 to 301
100 mm/sec  1.42 7 0.32  1.94 70.39  2.25 7 0.49  2.45 7 0.58
150 mm/sec  1.317 0.34  2.15 70.40  2.55 7 0.49  2.65 7 0.56 wrist exion. We obtained higher peak gliding resistance with
40 N 3.847 0.85 N (01) to 4.75 70.85 N (301 wrist exion). While both
50 mm/sec  1.197 0.60  1.69 70.63  2.177 0.73  2.75 7 0.86 studies found similar trends, magnitude differences were antici-
100 mm/sec  1.87 7 0.46  2.50 70.56  2.917 0.69  3.197 0.81
pated due to the specic test conditions in each experiment,
150 mm/sec  1.767 0.56  2.75 70.70  3.247 0.81  3.38 7 0.89
including higher tendon velocities (50 mm/sec 150 mm/sec)
n10 N, 20 N, and 40 N Magnitude of tendon force (via constant force springs); and forces (10 N 40 N) in the current study to replicate in vivo
n50 mm/sec, 100 mm/sec, and 150 mm/sec Tendon velocity (from motor). conditions (Dennerlein, 2005; Tat et al., 2013). Smutz et al. (1994)

5
FDS Gliding Resistance (N)

FDS Gliding Resistance (N)

FDS Displacement (mm)

0
4 5 10 15 20 25
25 20 15 10 5

3 -1

2
-2
1

0 -3
5 10 15 20 25
FDS Displacement (mm)
Fig. 3. FDS gliding resistance versus (a) proximal (simulated nger exion) and (b) distal (simulated nger extension) tendon displacement.
 A.M. Kociolek et al. / Journal of Biomechanics 48 (2015) 449455 453

50

FDS Frictional Work (mJ)

FDS Displacement (mm)

FDS Frictional Work (mJ)

40 0
5 10 15 20 25
30
-10

20
-20
10

0 -30
5 10 15 20 25
FDS Displacement (mm)
Fig. 4. FDS frictional work during (a) proximal (simulated nger exion) and (b) distal (simulated nger extension) tendon displacement.

Fig. 6. Mean ( 7 standard error of the mean) tendon frictional work for distal
Fig. 5. Mean ( 7 standard error of the mean) tendon frictional work for proximal tendon displacement in (a) 01 and (b) 301 wrist exion. Letters indicate signicant
tendon displacement in (a) 01 and (b) 301 wrist exion. Letters indicate signicant differences between the three tendon velocities (50, 100, 150 mm/sec) at each force
differences between the three tendon velocities (50, 100, 150 mm/sec) at each force (10, 20, 40 N).
(10, 20, 40 N).
observed in our study. FDS tendon velocity also inuenced
showed that friction increased over time using a high-repetition, frictional work during nger exion, presumably due to viscoe-
low-force cadaveric model; however, their in vivo protocol with lastic strain in adjacent layers of the SSCT (Osamura et al., 2007).
rhesus monkeys found no histological evidence of inammation or While strain rate in viscoelastic tissue is by denition velocity
brosis. Together these results further highlight the importance of dependent, gliding resistance between two adjacent structures
multiple biomechanical risk factors on nger exor tendon gliding (such as the nger exor tendon and transverse carpal ligament) is
resistance and frictional work. velocity independent (assuming constant velocity and force). Our
In the current study, the relationship between tendon force and results underscore the importance of accounting for both synovial
tendon frictional work was dependent on wrist posture during and extrasynovial sources of gliding resistance in the determina-
proximal tendon displacement. Changing tendon force from 10 N tion of exor tendon frictional work.
to 40 N increased tendon frictional work by 33.5% and 93.0% in the There were a few limitations to this study. We measured
neutral (01) and exed (301) wrist postures, respectively. Keir and tendon frictional work in fresh frozen cadavers, which required
Wells (1999) showed the radius of exor tendon curvature anatomical dissection proximal and distal to the carpal tunnel.
decreased with wrist exion and tendon force, and thus increased SSCT damage may arise due to the formation of ice crystals as well
contact stress on surrounding structures, including the median as repetitive cyclical loading during testing (Filius et al., 2014). To
nerve. Representing these geometrical changes in the belt-pulley minimize tissue damage, the cadavers were thawed slowly in a
wrist model qualitatively match the posture by force interaction cold room at 5 1C. We also pre-conditioned each specimen and
454 A.M. Kociolek et al. / Journal of Biomechanics 48 (2015) 449455

Fig. 7. Middle nger FDS tendon gliding resistance during (a) proximal tendon displacement (simulated nger exion) and (b) distal tendon displacement (simulated nger
extension). Gliding resistance is calculated with an exponential model for proximal tendon displacement and a logarithmic model for distal tendon displacement. Gliding
resistance computations are further scalable based on the biomechanical risk factors tested in this study, including wrist posture, tendon velocity, and force. R/R0 represents
scaling factors to modulate gliding resistance calculations. The model inputs P, V, and F are wrist posture (1), tendon velocity (mm/sec), and tendon force (N), respectively.
P0 151; V0 100 mm/sec; F0 20 N.

block-randomized the experimental conditions to mitigate poten- link between physical exposure and carpal tunnel mechanics, thus
tial order effects due to tissue degradation. We generated a providing further insight into the pathogenesis of wrist/hand
uniform tendon displacement of 30 mm without considering tendinopathies and CTS. Additionally, our study provides the basic
individual anthropometrics. However, it is unlikely that we framework for an etiological method to predict tendon frictional
exceeded the SSCT viscoelastic threshold, as tendon displacements work and injury risk during repetitive wrist and nger exion/
for combined wrist and nger exion are of considerably higher extension movements in the workplace.
magnitude (  5 to 8 mm). Finally, we did not validate the
regression equations due to the limited number of specimens
available for model development. However, our data showed a Conict of interest statement
multiplicative effect of combined biomechanical risk factors, in
general agreement with odds ratios from epidemiology (Bernard, There are no conicts of interest.
1997). Furthermore, additional research is planned to test the
predictive capabilities of the model in the workplace. Acknowledgments

This study was funded by NSERC (Discovery Grant # 217382-09).

5. Conclusions
Thanks to Bruce Wainman and Glen Oomen for accommodating this
research project in lab space for the Education Program in Anatomy.
Concurrent exposure to several biomechanical risk factors
including wrist posture, tendon velocity, and force, multiplica-
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