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ports and medical history. For example, Raynaud disease tends
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to aect the ngers in the upper extremity and has a characteristic blanching of the digits together with reports of intolerance
to cold temperatures. While some of the signs and symptoms,
when taken in isolation, could be associated with the remaining diagnoses on the list, when all ndings are combined with
the patient history, MRI, autonomic signs, mild to moderate
swelling, and laboratory results, CRPS is the only one associated with all signs and symptoms.
3.
In fact, 1 week later, the diagnosis of CRPS Type 1 is conrmed by a rheumatologist, and further physical therapy is
prescribed. Based on an evidence-based approach, which of
the following would be the most appropriate introductory
intervention for this patient?
a.
Progressive upper extremity strengthening program.
b. Aerobic conditioning using an upper-body ergometer.
c. AAROM of the right upper extremity.
Aqua therapy.
d.
e correct answer is c. AAROM of the right upper ex-
tremity. While it is vital to promote movement within the involved extremity at the earliest opportunity, the movement must
minimize pain and not aggravate the problem. While the other
options promote upper extremity motion, they would likely
be too aggressive at this relatively early stage in the treatment.
Over the next 3 weeks, the clinician progresses the patient from
AAROM to AROM and then to weight-bearing exercises using
a careful sequence of functional activities and exercises combined with several modalities, including uidotherapy, transcutaneous electrical nerve stimulation (TENS), and ice immersion. e patient is discharged from physical therapy to a home
exercise program at the end of the eighth week (10 visits) after
demonstrating full and pain-free AROM of the involved extremity.
Case Scenario 2
A 56-year-old female presents 7 weeks status-postsurgery
for a displaced proximal radial fracture on the right and subsequent immobilization. e patient’s chief complaint is one of
elbow stiness, pain with active motion, and overall weakness
of the right upper extremity. e physical examination reveals
mild to moderate swelling around the elbow complex. When
compared with the left upper extremity, ROM testing reveals
normal shoulder and wrist motions, but a 50° loss of elbow extension and a 30° loss of elbow exion (total available elbow
ROM is approximately 50°). ere is also a loss of 25° of both
pronation and supination (available combined pronation and
supination motion is approximately 120°). All motions produce
complaints of end-range pain scored at 6/10. e neurologic
and vascular examinations are both unremarkable. e clinician decides to prioritize pain management and the lack of joint
mobility.
1. Based on the clinician’s priorities, which of the following
manual techniques would best help decrease the patient’s
pain and address elbow stiness?
a.
Contract-relax technique to increase elbow exion.
Humeroulnar joint distraction.
b.
c.
Sustained stretching of the elbow exors.
d.
Gentle massage.
e correct answer is b. Humeroulnar joint distraction.
Humeroulnar joint distraction techniques would be more appropriate to help decrease pain. Gentle massage is a passive technique aimed at the supercial tissues. While the other manual
techniques would address the motion limitations, they would
likely increase the patient’s discomfort.
2.
At the next visit, the patient rates her pain at 2/10. Based
on this report, the clinician decides to switch the focus from
pain control to increasing joint ROM. Which of the following joint mobilization techniques should be employed to
help increase elbow exion?
Humeroulnar joint compression.
a.
b.
Humeroradial joint anterior glide.
Humeroradial joint posterior glide.
c.
d.
Proximal radioulnar joint posterior glide.
e correct answer is b. Humeroradial joint anterior
glide. All other techniques would have no impact on increasing
elbow exion.
3. Continuing with the focus of techniques to increase joint
motion, which of the following joint mobilization tech-
niques should be employed to increase forearm supination?
a. Proximal radioulnar joint anterior glide (radius on ulna).
b.
Proximal radioulnar joint posterior glide (radius on ulna).
Distal radioulnar joint anterior glide (radius on ulna).
c.
d.
Humeroradial joint posterior glide (radius on humerus).
e correct answer is a. Proximal radioulnar joint ante-
rior glide (radius on ulna). It is worth noting that, given the
various joints involved with forearm motion, the distal radioulnar joint would also have to be mobilized to help increase joint
supination.
4. Based on the previous statement about the need to mobi-
lize the distal radioulnar joint, which of the following joint
mobilization techniques should be employed at the distal radioulnar joint to increase forearm supination when moving
the radius on the ulna?
a. Posterior glide.
b. Anterior glide.
c. Lateral glide.
d. Medial glide.
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39
e correct answer is a. Posterior glide. When moving the
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radius on the ulna, a posterior glide would help to improve supination, whereas an anterior glide would help restore pronation.
is is because the concave sigmoid notch of the radius rotates
around the stationary convex ulnar head so that the arthrokinematic glide occurs in the same direction as the osteokinematic
motion. Conversely, if you were to mobilize the ulna on the
radius, the ulnar head would have to be moved posteriorly for
pronation and anteriorly for supination.
Case Scenario 3
A 32-year-old male presents with right posterior elbow
pain of gradual onset and occasional pins and needles in the
ring and little nger of the right hand, the latter of which tends
to be worse at night. e patient reports being a keen cyclist and
that he has recently started increasing his training to compete
in an upcoming cycling endurance event. e patient states that
he has not had any prior episodes of these symptoms, and his
medical record is unremarkable, apart from a right distal humerus fracture and a concussion about 8 months ago following
a fall from his bike.
A posture analysis shows a forward head carriage, slightly forward rolled shoulders, and a more prominent sternocleidomastoid on the right side. e physical examination reveals
normal AROM of the right shoulder and elbow, except for
end-range elbow exion, which reproduces some of the right
elbow pain. Gross strength testing is within normal limits at the
right and left shoulder, elbow/forearm, and hand except for grip
strength, which is noticeably weaker in the right hand. e patient’s paresthesia is reproduced by placing the elbow in a exed
position, and the ulnar nerve is palpably enlarged and tender in
the groove, 1 inch below the medial epicondyle. Reex and sensory testing are unremarkable except for the ulnar-sided digits
(little nger and ring nger) of the right hand, where 2-point
discrimination is diminished. ere is no evidence of sensory
disturbance in the forearm. e Tinel sign performed over the
ulnar nerve is positive at the elbow but negative at the wrist.
1.
At this stage of the examination, what would be the best
hypothesis for this patient’s condition?
a. Carpal tunnel syndrome.
b. Cervical radiculopathy.
c. Cubital tunnel syndrome (CTS).
d. Elbow instability.
Answer: c. Cubital tunnel syndrome (CTS). is would
be the most reasonable hypothesis at this stage given the specific location of the pain (posterior elbow), neurologic symptom
distribution, positive Tinel sign at the elbow, and the palpable
swelling of the ulnar nerve 1 inch below the medial epicondyle.
Technically speaking, the term CTS properly denotes compression of the ulnar nerve under the humeral–ulnar aponeurosis
(HUA), but in this context, it is used to indicate an ulnar nerve
lesion around the elbow until further conrmation can be provided. Although cervical radiculopathy cannot be completely
ruled out, the signs and symptoms mentioned above give a
stronger indication that the patient is presenting with CTS.
e C8–T1 nerve roots innervate the abductor and exor pollicis brevis, opponens pollicis, and lateral 2 lumbricals via the
median nerve entering the hand through the carpal tunnel. e
mnemonic AbOF the Law may be useful—the abductor (Ab)
and exor (F) pollicis brevis, opponens pollicis (O), and lateral
lumbricals (Law) are above the law that intrinsic hand muscles
262
are ulnar-innervated.
Also, C8 and T1 supply the medial antebrachial cutaneous nerve via the medial cord of the brachial
plexus, arising between the neck and proximal upper extremity.
In this case, there is no evidence of any sensory disturbance
in the forearm. Carpal tunnel syndrome is less likely because
the Tinel sign at the wrist was negative, and the distribution of
hand symptoms has more of an ulnar bias. An intra-articular
pathology at the elbow would not necessarily be associated with
neurologic symptoms and would likely present with a history
of locking or catching, so it is not the most likely candidate at
this point.
Delving deeper into the physical examination, a more specic examination of strength revealed 4/5 strength for the exor carpi ulnaris (FCU), the ulnar-innervated exor digitorum
profundus (FDP), nger abduction, and nger adduction of
the right forearm and hand. ere is no apparent weakness of
the abductor and exor pollicis brevis, opponens pollicis, and
lateral 2 lumbricals. Joint stress testing of the elbow proves negative. A more detailed sensory examination reveals diminished
2-point discrimination in the distributions of the posterior cutaneous branch and the anterior main sensory branch of the
ulnar nerve of the right hand. Also, there is a positive Froment
sign (overt exion of the thumb interphalangeal joint while attempting resisted pinch) and Wartenburg sign (persistent abduction posture of the small nger due to unopposed action of
the radial-innervated extensor digiti minimi) of the right hand.
e physical examination continues with an investigation
for the presence of proximal dysfunction. Further questioning
of the patient about the presence of any neck and/or shoulder pain reveals that the patient reported having had some
right-sided neck pain that he attributes to the fall from his bicycle but has not mentioned it previously because he feels that it
is unrelated to the elbow and hand symptoms. e other aspects
of the physical examination of proximal structures includes thoracic outlet syndrome (TOS) provocation testing, including an
examination for the presence of an elevated rst rib using the
cervical rotation lateral exion (CRLF) test (the cervical spine is
passively and maximally rotated away from the side being tested before introducing cervical exion). Although the individual
TOS tests (Roos, Adson, hyperabduction, and costoclavicular)
were inconclusive (some were positive initially but became negative with repeated testing), the CRLF test proved positive with
40
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a 50% reduction in cervical exion compared to the other side.
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e CRLF test has a reliability of kappa = 1.0 for detecting any
restriction of the movement of the rst rib during expiration
and inspiration by using the rst rib to block the transverse pro-
263
cess of C7.
2. Given the latest ndings from the patient’s history and physical examination, which of the following diagnoses could be
ruled out for this patient?
a. Cubital tunnel syndrome (CTS).
b. Double crush syndrome (DCS).
c. oracic outlet syndrome (TOS).
d. Lower motor neuron lesion.
Answer: a. Cubital tunnel syndrome (CTS). Despite the
earlier hypothesis, the new information from the physical examination indicates a high probability that an isolated CTS is
unlikely. More probable is that a more proximal structure is involved. Although the standard TOS tests were inconclusive, this
is not uncommon; it appears best to interpret the TOS tests in
264
combination with each other.
Also, repetitive testing runs the
risk of stretching certain tissues, thereby alleviating some of the
signs and symptoms. However, the CRLF test was clearly positive. A cervical rib, which only tends to occur in approximately
0.5% to 1% of the population, commonly attaches to the sev-
265
enth cervical vertebra.
ey vary in size, shape, attachment
sites and can occur unilaterally or bilaterally. Most cervical ribs
go unnoticed throughout life and are clinically irrelevant, but,
in some cases, they can cause localized pain and compress surrounding structures. Although the presence of a cervical rib may
not always be meaningful, it is commonly found in individuals
266
with true neurogenic TOS.
Using current knowledge of neural lesions, one can theorize that a proximal neural lesion may have contributed to a
DCS involving the cubital tunnel, creating the lower motor
neuron lesion symptoms.
is patient was treated with a combination of postural
correction exercises, manual therapy techniques to increase the
mobility of the sternoclavicular and acromioclavicular joints,
and the rst and second ribs. Soft tissue techniques and stretches were applied to the scalenes, shoulder girdle musculature, and
cervical and upper thoracic spine musculature. After 10 therapy sessions and a home exercise program, the patient reported
signicant improvement in his overall symptomatology and reported no regression in his condition 6 months later.
One can hypothesize as to how these symptoms manifested
themselves in this patient. Perhaps the DCS remained dormant
until he sustained the distal humerus fracture. At that time, the
ulnar nerve lesion could also have occurred during the accident,
which created adhesions of the ulnar nerve, increasing tension
in the ulnar nerve, which then provoked the DCS.
Interestingly, a 2008 study found DCS to be a common
occurrence in cyclists with a diagnosis of ulnar nerve neuropa-
267
Several factors increase the risk of developing CTS in the
thy.
general population, including bone spurs/arthritis of the elbow
and swelling of the elbow joint, but 2 other common causes
include a prior fracture or dislocation of the elbow and repetitive or prolonged activities that require the elbow to be exed,
both of which pertain to this patient. Furthermore, a high incidence of TOS concurrent with carpal tunnel (30%) or cubital
tunnel (10%) syndrome/compression has also been reported.
268
is case emphasizes the importance of always including the
entire upper kinetic chain, including the cervical spine, when
examining the elbow complex. It also highlights the fact that a
diagnostic hypothesis can change as more clinical ndings are
discovered.
oracic outlet syndrome (TOS) and DCS are frequently
overlooked causes of peripheral nerve compression, which creates diculties for the clinician regarding their diagnosis and
management. Indeed, both conditions have emerged as somewhat controversial topics in musculoskeletal medicine and rehabilitation. e disagreement regarding the denition of TOS
and DCS makes the overall incidence of either condition dicult to determine and validate.
Case Scenario 4
A 23-year-old male right-handed baseball pitcher and
outelder presents with a chief complaint of right elbow and
forearm pain and paresthesia. e patient describes a burning,
tingling sensation over the whole elbow and lateral portion of
the right forearm and occasional pins and needles in the ngers that have been present for the previous 6 weeks. Initially,
the symptoms only occurred with excessive throwing and upper
extremity exercise. Eventually, the symptoms became constant,
and decreasing the duration and intensity of his workouts and
taking over-the-counter anti-inammatories had no positive
impact, so the patient sought medical advice approximately 2
weeks ago.
At the initial physical therapy visit, the symptoms are now
occurring in the weight room and even occasionally at rest. e
physical exam reveals no sign of skin color changes, warmth,
or erythema in the right upper extremity. ere is hypersensitivity with palpation over the right lateral forearm, tenderness
over the lateral epicondyle, and slight tenderness over the medial epicondyle. e patient reports that the pins and needles
in his right hand occur in all 5 digits when present but are not
present at this time. e patient demonstrates full ROM in all
directions at the cervical spine, shoulder, elbow, and wrist with
no provocation of pins and needles in the patient’s right hand or
increased in the right forearm symptoms with any of the movements.
1.
Based on the limited ndings at this early stage of the examination, which of the following diagnoses could you tentatively rule out?
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41
a. Cervical nerve root impingement.
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b. oracic outlet syndrome.
c. Lateral elbow tendinopathy.
d. Peripheral nerve entrapment.
e correct answer is a. Cervical nerve root impingement.
Although there are occasional pins and needles in the hand, hypersensitivity with palpation over the right lateral forearm, tenderness over the lateral epicondyle, and slight tenderness over
the medial epicondyle are not consistent with nerve root impingement. Also, there is full and symptom-free cervical ROM
– a cervical nerve root impingement would likely demonstrate
a reproduction of symptoms with cervical sidebending toward
the involved upper extremity and/or with cervical extension,
and a reproduction of symptoms with cervical exion in the
presence of disk pathology. However, the symptoms do not rule
out a non-cervical neurologic or vascular cause or tendinopathy.
2.
Continuing with the physical examination and to further
investigate the cause for the patient’s symptoms, gross and
specic manual muscle tests of the elbow, forearm, and wrist
are performed. e results are normal, except for some slight
reproduction of the lateral forearm pain with resisted wrist
exion and resisted wrist extension, and testing does not
indicate fatigable weakness. e muscle stretch reexes (biceps, triceps) are normal. e Cozen, Maudsley, and Mill
tests are all negative. Also, thoracic outlet syndrome is provisionally ruled out because the Adson, Allen, costoclavicular,
and Roos tests are all negative. In addition to thoracic outlet
syndrome, which of the following diagnoses could you now
also tentatively rule out?
Compartment syndrome.
a.
b. Lateral elbow tendinopathy.
Radial tunnel syndrome.
c.
d. Cubital tunnel syndrome.
e correct answer is b. Lateral elbow tendinopathy. Although there is pain with resisted wrist extension, there is also
pain with resisted wrist exion. Also, the complaints of pins
and needles in the hand and the fact that 3 of the special tests
for lateral elbow tendinopathy (Cozen, Maudsley, and Mill) are
all negative decreases the likelihood of tendinopathy as the diagnosis.
3. e clinician now feels that the patient’s symptoms have a
systemic, vascular, or distal neurologic cause. e following
special tests are negative: crossed nger and scratch collapse.
ere is also no posterior elbow swelling and the Tinel sign
at the elbow is negative. ese ndings would tend to rule
out cubital tunnel syndrome. e remainder of the physical
examination, including a thorough hand examination and
special tests for carpal tunnel syndrome, prove negative. e
clinician now decides to attempt to provoke the patient’s
symptoms. e patient is instructed to perform burpees,
push-ups, and medicine ball tosses until the forearm’s pain
and tightness are felt (which occurs after approximately 10
minutes). e patient is asked to continue the exercises for
an additional 5 minutes. Following the exercises, the clinician notes discoloration of the right forearm, tenderness to
touch over both epicondyles, and pain in the exor and extensor compartments. e patient also reports stiness and a
feeling of heavy pressure within the right forearm. Which of
the following diagnoses do you suspect causing the patient’s
symptoms?
a.
Compartment syndrome.
b. Motor neuron disease.
c. Systemic referral.
d. Peripheral vascular disease.
e correct answer is a. Compartment syndrome. As a
result of these ndings and a high suspicion of compartment
syndrome, the patient’s physician is contacted, and the patient
undergoes a bilateral pre-exercise and post-exercise MRI with
the left forearm as the control. e post-exercise MRI nds abnormal muscle edema within the exor and extensor compart-
259
ments of the right forearm.
In the exor compartment, there
is edema within the exor carpi radialis, exor digitorum supercialis, and exor carpi ulnaris muscles. Although the extensor
edema is less noticeable, it extends within the muscle belly of
the extensor carpi radialis brevis and longus.
42
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Appendix A.
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Osteology of the Elbow and Forearm
Structure Description
Humerus e distal humerus has 2 fossae that enable maximal exion and extension. Anteriorly,
the coronoid fossa accommodates the coronoid process of the humerus during terminal
exion. Posteriorly, the olecranon fossa accommodates the olecranon process of the ulna
during terminal extension. e non-articulating portions of the humerus include the
medial supracondylar ridge, the medial and lateral epicondyles, and radial, coronoid,
and olecranon fossae.
e medial supracondylar ridge forms the medial border of the humerus.
1.
2.
e medial epicondyle, which is prominent and easily palpable (especially with elbow
exion), serves as the proximal attachment of the ulnar (medial) collateral ligament of
the elbow in addition to the forearm pronators and wrist exor muscles.
e lateral epicondyle (less prominent than its medial counterpart) forms the distal
3.
end of the condyle ridge. It has an impression on its anterolateral surface for the
origin of the forearm extensor muscles, the radial (lateral) collateral ligament of the
elbow, and the forearm supinator muscle.
4. e radial fossa is located just above the capitulum; the coronoid fossa is located
just above the trochlea. e radial fossa accommodates the margin of the radial head
when the elbow is in full exion.
e distal end of the shaft of the humerus terminates medially as the trochlea, which
5.
resembles an empty spool of thread.
Radius Shorter and more lateral than its ulnar counterpart.
e radial head, located at the extreme proximal end of the radius, is discoid in shape
and articulates with the capitulum (the name capitellum is technically supposed to be
only used for non-human tetrapods, but appears to be interchangeable in the literature)
on the humerus and the radial notch on the ulna.
e radial tuberosity, which is distal and medial relative to the radial neck, serves as the
distal attachment for the biceps brachii.
Ulna e ulna’s proximal tip is formed by the olecranon process, while the posterior surface
receives the attachment of the triceps brachii.
e supinator crest serves as the distal attachments for a portion of the RCL and the
supinator muscle.
e ulnar tuberosity, a roughened structure just distal to the coronoid process, serves as
the brachialis muscle’s attachment.
e proximal ulna forms a 190° arc about the trochlea known as the trochlear notch.
e olecranon forms the posterior portion of this notch while the coronoid process
forms the anterior portion. e opening of this arc is directed 30° posteriorly and
corresponds with the 30° anterior rotation of the articular portion of the distal humerus
(relative to the longitudinal axis of the humerus).
e coronoid functions as a bony buttress to posterior ulnar displacement, receiving
much of the elbow’s axial load between 60° and 105° of exion.
e coronoid process is also a pivotal stabilizer to varus stress, likely contributing more
to stability in extension than in exion.
Clinical
Signicance
e anterior and
posterior surfaces
of the mid to
distal humerus
provide proximal
attachments for
the brachialis and
the medial head of
the triceps brachii.
e superior surface of the radial
head, known as
the fovea, forms
the humeroradial
joint by articulating with the
capitulum of the
humerus.
e trochlear
notch forms the
primary articulation with the
humeral trochlea
(humeroulnar
joint). During
elbow exion, the
trochlear notch
slides over and
articulates with
the anterior trochlea, exposing the
trochlea posteriorly and making
it vulnerable to
trauma from falls
or blows.
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43
Appendix B.
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Joints of the Elbow Complex
Joint Articulating surfaces
Humeroulnar Trochlea of the humerus
and the trochlear notch
of the proximal ulna.
Cadaveric modeling has
demonstrated that approximately 40% of axial
loading is distributed
across the humeroulnar
joint when the elbow is
extended.
Humeroradial
(also known
as radiocapi-
Capitulum of the humerus and the fovea of
the radial head.
tellar)
e shape of the articu-
lating surfaces
e convex trochlea of
the humerus articulates
with the concave trochlear notch of the ulna.
e convex capitulum
articulates with the concave fovea.
us, there is a posterior
roll and a posterior slide
at the radial joint surface
during elbow extension.
Available passive range
of motion
5° of hyperextension.
145° to 150° of exion.
Involved in all motions
at the elbow and forearm
complex. us, any limitation of motion at the
humeroradial joint can
disrupt both exion and
extension and pronation
and supination.
End feel
Flexion: soft tissue
approximation.
Flexion combined with
supination: capsular.
Extension: bony/hard.
Excessive ectopic bone
formation around the
olecranon fossa can limit
full passive extension.
In full extension, with
the elbow joint at rest,
little if any physical
contact exists at the
humeroradial joint.
It provides minimal
structural stability to the
elbow, apart from providing bony resistance
against a valgus force.
Proximal
radioulnar
e radial head, which is
held against the proximal ulna by a bro-osseous ring formed by the
radial notch of the ulna
(25%) and the annular
ligament (75%).
e convex radial head
articulates with the concave radial notch.
us, as the radial head
forms the convex partner, there is a propensity
for the radial head to
move posterolaterally
during pronation and
anteromedially during
supination, but these
movements are sharply
curbed by the annular
ligament and the interosseous membrane.
90° of supination.
Structures that can restrict supination include,
but are not limited to,
adaptive shortening of
the pronator teres and
pronator quadratus, a
joint restriction of the
ulnocarpal complex, and
scarring of the interosseous membrane and
quadrate ligament.
80° to 85° of pronation.
Structures that can restrict pronation include,
but are not limited to,
an adaptive shortening
of the biceps or supinator muscles.
Supination: capsular.
Pronation: capsular.
44
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Appendix C.
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Elbow Motions and their Clinical Signicance
Elbow Motion Biomechanics Clinical Signicance
FlexionExtension
ese motions occur about a nonstationary
medial-lateral axis of rotation due to the
obliquity of the trochlear groove. is axis
causes the ulna to deviate laterally relative
to the humerus creating a frontal plane angle in the extended elbow position referred
to as cubitus valgus or carrying angle.
Flexion involves an anterior roll and a
Due to the nonstationary axis of rotation, exion and
extension occur as impure or combined motions at the
beginning and end of elbow exion. us, elbow exion
occurs with pronation at the onset of exion, and, at the
end of elbow exion, it occurs with supination.
Full supination is necessary for end range elbow exion,
and full pronation is necessary for end range elbow exten-
sion.
distal/anterior slide of the concave trochlear notch of the ulna about the convex
trochlea of the humerus.
Extension involves a posterior roll and a
proximal/posterior slide of the concave
trochlear notch of the ulna about the convex trochlea of the humerus.
PronationSupination
Involves the combined action of the PRUJ
and DRUJ as the radius rotates around
the ulna about a longitudinal axis of the
forearm, which runs from the facet on the
head of the radius to the styloid process
of the ulna. During pronation, the distal
segment of the radius and the hand rotate
and cross over a fundamentally xed ulna
with only a very slight motion occurring in
the ulna.
Pronation-supination can be performed independently of
shoulder motion or elbow exion/extension.
OKC pronation occurs with activities requiring the palm
to be turned down, such as pushing up from a chair or
using a cane.
Shoulder internal rotation often occurs naturally with
OKC pronation. us, if pronation is limited, an indi-
vidual will often compensate by internally rotating the
shoulder to achieve the desired motion.
Some supination and pronation also occur
at the humeroradial joint due to a spinning
of the radial head.
e amount of involvement of the humeroulnar joint during pronation-supination
remains controversial, with some proposing no involvement and others suggesting
OKC supination occurs in many functional activities that
require the palm to be turned up, such as holding a bowl,
drinking from cupped hands, and washing the face.
Shoulder external rotation often occurs naturally with
OKC supination. us, if supination is limited, an indi-
vidual will often compensate by externally rotating the
shoulder to achieve the desired motion.
some involvement. eoretically, given
that the completion of the end ranges of
elbow exion-extension motions requires
supination-pronation motions, respectively, there is likely to be some involvement of
the humeroulnar joint.
With closed kinetic chain pronation and supination,
which occur with weight-bearing through the wrist and
hand, the annular ligament and the radial notch of the
ulna spin around a xed radial head at the PRUJ, and the
convex ulnar head rolls and slides in opposite directions on
the concave ulnar notch of the radius at the DRUJ.
At the DRUJ, a space between the ulna’s
distal end and the medial side of the carpus
allows the carpal bones to rotate without
interference from the distal ulna.
As pronation and supination involve the humeroradial
joint and both the PRUJ and the DRUJ, mechanical
dysfunction of any of these joints may become apparent,
especially in the extremes of elbow exion or extension.
Abbreviations: DRUJ, distal radioulnar joint; OKC, open kinetic chain; PRUJ, proximal radioulnar joint
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Appendix D.
https://t.me/med1917
Major Stabilizing Structures of the Elbow Complex
Structure Anatomical Location Function
Humeroulnar joint e articulation between the trochlea and the
Provides most of the elbow’s structural stability.
trochlear notch.
Medial collateral
ligament complex
Traditionally described as having 3 components:
Anterior: a strong cord-like structure continuous
with the joint capsule on the medial aspect of
the humeroulnar joint, attaching to the coronoid
As a unit, the UCL provides valgus stability to
the elbow complex and resists internal rotation
stress, assisted by the radial head. e UCL has
also been noted to resist distraction of the elbow
joint.
process of the ulna. e anterior bundle can
be further divided into anterior and posterior
bands that have complementary functionality
– the anterior band acts as the chief restraint to
valgus stress from full extension to up to 90° of
exion, whereas the posterior band’s resistance to
valgus stress occurs between 60° of exion to full
Anterior: the strongest and stiest of the collateral ligaments. It is separated into 2 bands, which
are taught during dierent amount of elbow
exion/extension. e anterior band is the most
important static stabilizer of the elbow against
valgus and internal rotation.
exion.
Posterior: thinner and weaker than the anterior
Posterior: a triangular structure that attaches
to the medial margin of the olecranon. Forms
the oor of the cubital tunnel and thickens the
component. It provides only secondary restraint
to valgus stress at elbow exion beyond 90°,
becoming taut in the extremes of elbow exion.
posterior elbow capsule.
Transverse (oblique): has little role in elbow
Transverse (oblique): variably present. Originates
and inserts on the ulna. Often referred to as
Cooper’s ligament.
stability as it crosses from the olecranon to the
coronoid process of the ulna and, therefore, does
not cross the elbow joint.
Lateral collateral
ligament complex
e complex varies widely between individuals,
although it is generally comprised of 4 ligaments:
the RCL proper, the LUCL, the ALCL, and the
annular ligament.
RCL: a fan-shaped ligament that travels from the
lateral epicondyle to the annular ligament deep
to the common extensor tendon.
LUCL: travels from the lateral epicondyle to
the supinator crest on the ulna. Proximal to its
attachment on the humerus, this ligament is
normally indistinguishable from the RCL and
can be considered the posterior portion.
ALCL: present in only one-third of individuals,
it travels from the inferior margin of the annular
ligament to the supinator crest.
Annular ligament A thick circular band of connective tissue that
wraps around the anterior radial head originating
and inserting on the ulnar sigmoid notch.
As a group, the lateral collateral ligament com-
plex resists excessive varus and external rotation
stress.
e LUCL, often described as a thickening of
the capsule, stabilizes all 3 articulations of the el-
bow and contributes to resisting the rotary forces
of varus and external rotation.
e LUCL is considered to be the primary
stabilizer of the elbow joint against posterior
lateral rotary instability. It also prevents the ulna
from rotating around its long axis away from the
trochlea.
Primarily functions to stabilize the PRUJ. Its
inner surface is lined with cartilage to reduce
friction.
46
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Appendix D.
https://t.me/med1917
Continued
Structure Anatomical Location Function
Joint capsule Originates anteriorly around the coronoid and
radial fossa and inserts distally at the anterior
border of the coronoid and into the annular
Although the anterior aspect is thin, it does contribute to varus-valgus stability with the elbow in
extension.
ligament.
e capsule is reinforced both medially and
Posteriorly, the capsule attaches to the olecranon
laterally by the collateral ligaments.
fossa proximally and the olecranon distally.
e capsular pattern at the elbow is characterized
Encases the humeroulnar joint, the humeroradial
by the limitation of more exion than extension.
joint, and the PRUJ.
e capsule is reinforced anteriorly by oblique
bands of brous tissue and medially and laterally
by the UCL and RCL, respectively.
Bone Some static stability is provided by the osteoar-
ticular architecture of the elbow complex.
Approximately 50% of the coronoid is necessary
to maintain stability toward elbow extension.
Anterior-posterior stability depends on the
trochlea’s congruency and the integrity of the
trochlear notch of the ulna and the coronoid.
e radius and humeroradial joint sustain
impressive loads applied to the upper extremity,
and, in cases of UCL insuciency, the radial
head plays a signicant role as a secondary stabi-
e integrity of the olecranon inuences var-
lizer to valgus stresses.
us-valgus stability.
Interosseous membrane
Has several roles:
Has an essential role in stabilizing the distal
radioulnar joint, especially in supination.
Acts as a static longitudinal stabilizer of the forearm but less so as a rotational stabilizer.
As the IOM does not resist forces that pull on
the hand and wrist, individuals who carry heavy
Due to its ber orientation, the IOM works in
force transmission when weight bearing through
the forearm, allowing some of the compression
loads for extended periods may complain of a
deep aching in the forearm due to fatigue of the
muscles.
force to cross the elbow via the humeroulnar
joint.
Abbreviations: ALCL, accessory lateral collateral ligament; IOM, interosseous membrane; LUCL, lateral ulnar collateral ligament; PRUJ, proximal radioulnar
joint; RCL, radial collateral ligament; UCL, ulnar collateral ligament
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Appendix E.
https://t.me/med1917
Major Muscles of the Elbow and Forearm
Peripheral nerve
Muscles
supply and ap-
proximate nerve
root derivation
Triceps Radial
(C7, C8)
Action Clinical signicance
Elbow and shoulder
extension.
A 3-headed (long, lateral, and medial), 2-joint (shoulder
and elbow) muscle that has its maximal force in movements that combine both elbow extension and shoulder extension, thereby utilizing the long head (law of parsimony).
Anconeus Radial
(C7, C8, [T1])
Brachialis Musculocutane-
ous
(C5, C6, [C7])
Biceps brachii Musculocutane-
ous
(C5, C6, [C7])
Assists the triceps
with elbow extension.
Also helps stabilize
the elbow joint and
abducts the ulna
Appears to be a fourth head of the elbow extension mechanism, like the quadriceps of the knee extension mechanism.
Is involved with elbow extension during low-level force
demands.
during pronation.
Elbow exion. Because the brachialis inserts a long distance from the joint
axis, it has the highest mechanical advantage of any of the
elbow exors – it is the workhorse of the elbow, functioning to ex the elbow regardless of the amount of pronation
or supination of the forearm.
Elbow exion and
supination of the
forearm. e biceps is
also a weak shoulder
exor.
Distally, the separate bellies of the biceps brachii form a
common tendon that attaches, after it twists, to the posterior aspect of the radial tuberosity.
e bicipital aponeurosis is a broad medial expansion that
courses distally to blend with the deep fascia of the forearm
exors.
e elbow exion component of the biceps is weakest if
performed with the forearm held in pronation. In contrast,
the biceps brachii is at its most ecient when performing
both exion and supination simultaneously.
Brachioradialis Radial
(C5, C6)
Elbow exion and
forearm rotation.
e supination action of the biceps increases as the elbow
is exed, is maximal at 90°, and diminishes again when the
elbow is fully exed.
e brachioradialis, the longest of all elbow muscles, is
more supercial than the biceps brachii muscle and forms
the lateral border of the cubital fossa.
A primary elbow exor, especially during rapid movements
against high resistance or when the forearm is in a mid-position between supination and pronation.
In addition to its elbow exor function, it also functions
to bring a pronated or supinated forearm back into the
neutral position of pronation and supination.
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