ELBOW COMPLEX Sagar Naik, PT

ELBOW COMPLEX
Sagar Naik, PT

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The elbow complex consists of the elbow joint (humeroulnar &
humeroradial articulations) and the proximal and distal radioulnar joints.

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U Elbow Joint:
™ Articulation: This occurs between the trochlea and capitulum of the humerus
and the trochlear notch of the ulna and the head of the radius. The articular
surfaces are covered with hyaline cartilage.
Articulation between the ulna and humerus at the humeroulnar joint
occurs primarily as a sliding motion of the trochlear notch of the ulna on the
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trochlea. In extension, sliding continues until the olecranon process enters the
olecranon fossa. In flexion, the trochlear ridge of the ulna slides along the
trochlear groove until the coronoid process reaches the floor of the coronoid
fossa in full flexion.
Articulation between the radial head and the capitulum at the
humeroradial joint involves sliding of the shallow concave radial head over the
relatively large convex surface of the capitulum. In full extension, no contact
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occurs between the articulating surfaces. In flexion, the rim of the radial
head slides in the capitulotrochlear groove and enters the radial fossa as the
end of the flexion range is reached.
™ Type: Synovial hinge joint.
™ Capsule: Anteriorly it is attached above to the humerus along the upper margins
of the coronoid and radial fossae and to the front of the medial and lateral
epicondyles and below to the margin of the coracoid process of the ulna and to
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the annular ligament, which surrounds the head of the radius. Posteriorly it is
attached above to the margins of the olecranon fossa of the humerus and below
to the upper margin and sides of the olecranon process of the ulna and to the
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annular ligament.
™ Ligaments: Collateral ligaments are located on the medial and lateral sides of
hinge joints to provide medial/lateral stability to the joint and to keep joint
surfaces in apposition. The two main ligaments associated with the elbow joints
are the medial (ulnar) and lateral (radial) collateral ligaments.
The medial (ulnar) collateral ligament (MCL) is triangular and consists
principally of three strong bands:
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(1) The anterior band, which passes from the medial epicondyle of the humerus
to the medial margin of the coronoid process.
(2) The posterior band, which passes from the medial epicondyle of the
humerus to the medial side of the olecranon.
(3) The transverse band, which passes between the ulnar attachments of the two

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preceding bands.
Scientist have identified three components in the anterior portion of the

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ligament: a) fibres that arise from the anterior surface of the medial condyle that
are taut in full extension; b) fibres that arise from below the tip of the medial
epicondyle that are taut from 90° of flexion to full flexion; and c) fibres that
arise from the inferior edge of the medial epicondyle that are always taut
throughout the full range of motion and limit the extremes of extension. The
third group of fibres is known as “guiding bundle.” The posterior MCL limits
elbow extension but plays a less significant role than the anterior MCL in
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providing valgus stability for the elbow. The transverse MCL assists in
providing valgus stability and helps to keep the joint surfaces in approximation.
The lateral (radial) collateral ligament (LCL) is triangular and is
attached by its apex to the lateral epicondyle of the humerus and by its base to
the upper margin of the annular ligament. The LCL provides reinforcement for
the humeroradial articulation, offers some protection against varus stress in
some positions of the elbow, and assists in providing resistance to distraction of
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the joint surfaces. Some fibres of the LCL remain taut throughout the flexion
ROM with either a varus or valgus moment applied.
™ Synovial Membrane: This lines the capsule and covers fatty pads in the floors
of the coronoid, radial, and olecranon fossae; it is continuous below with the
synovial membrane of the proximal radioulnar joint.
™ Nerve Supply: Branches from the median, ulnar, musculocutaneous, and radial
nerves.
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Ö Axis of Motion:
The axis for flexion and extension is relatively fixed and passes through
the center of the trochlea and capitulum bisecting the longitudinal axis of the
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shaft of the humerus. When the upper extremity is in the anatomic position,
the long axis of the humerus, and the long axis of the forearm form an acute
angle medially when they meet at the elbow. The angulation is due to the
configuration of the articulating surfaces and results in a normal valgus
angulation of the forearm in relation to the humerus. This angle is called the
carrying angle and is slightly greater in women than men. The average angle
in men is about 5°, whereas in women it is about 10° to 15°. An increase in the
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carrying angle is considered to be abnormal, especially if it occurs

unilaterally. When the angle is increased beyond the average, it is called
cubitus valgus. Normally, the carrying angle disappears when the forearm is
pronated and the elbow is in full extension and when the forearm is flexed
against the humerus in full elbow flexion. The configuration of the trochlear

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groove determines the pathway of the forearm during flexion and extension.
Ö Range of Motion:

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A number of factors determine the amount of motion that is available at
the elbow joint. These factors include
y The type of motion (active or passive).
y The position of the forearm (pronation or supination).
y The position of the shoulder.
The range of active flexion at the elbow is usually less than the range of
passive motion, because the bulk of the contracting flexors on the anterior
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surface of the humerus interfere with the approximation of the forearm with
the humerus.
The position of the forearm also affects the flexion ROM. When the
forearm is in either pronation or midway between supination and pronation,
the ROM is less than it is when the forearm is supinated.
The position of the shoulder may affect the ROM available to the elbow.
Two joint muscles, such as the biceps brachii and the triceps, that cross both
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the shoulder and elbow joints may become actively or passively insufficient
when a full ROM is attempted at both joints. Passive tension in the triceps may
limit elbow flexion when the shoulder is simultaneously moved into full flexion.
Concomitantly, the biceps brachii, if active, may lose tension as it attempts to
shorten over both the joints. Passive tension created in the long head of the
biceps by shoulder hypertension may limit full elbow extension. If the triceps is
producing the elbow extension, the long head may become actively insufficient.
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Other factors that limit the ROM and help to provide stability for the
elbow are the configuration of the joint surfaces, the ligaments, and joint
capsule. The elbow has inherent articular stability at the extremes of extension
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and flexion. In full extension the humeroulnar joint is in a close-packed

position. In this position, bony contact of the olecranon process in the olecranon
fossa limits the end of the extension range and the configuration of the joint
structures help to provide valgus and varus stability. The bony components,
medial collateral ligament, and anterior joint capsule contribute equally to resist
valgus stress in full extension. Approximation of the coronoid process with the
coronoid fossa and of the rim of the radial head in the radial fossa limits
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extremes of flexion. If the anterior portion of the medial collateral ligament

becomes lax through overstretching, medial instability will result when the
elbow is in flexed positions. Also, the carrying angle will increase. Co-
contractions of the flexor and extensor muscles of the elbow, wrist, and hand
help to provide stability for the elbow during forceful motions of the wrist and

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fingers and in activities in which the arms are used to support the body weight.
Ö Flexors Muscle Action:

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The role that the three-flexor muscles play in motion at the elbow is
determined by a number of factors, including
y The location of the muscles.
y Position of the elbow and adjacent joints.
y Position of the forearm.
y The magnitude of the applied load.
y The type of muscle contraction.
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y The speed of motion.
< Brachialis:
The brachialis is inserted close to the joint axis and therefore is considered
to be a mobility muscle.
The moment arm (MA) of the brachialis is greatest at slightly more than
100° of elbow flexion, and, therefore, its ability to produce torque is
greatest at that particular elbow position.
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The brachialis is inserted on the ulna and, therefore, is unaffected by
changes in the forearm position brought about by rotation of the radius.
 As a one-joint muscle, the brachialis is not affected by the position of the
shoulder.
According to electromyography (EMG) studies, the brachialis muscle
works in flexion of the elbow in all positions of the forearm, with and
without resistance. It is also active in all types of contractions during
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slow and fast motions.

< Biceps Brachii:
The biceps brachii is considered to be a mobility muscle because of its
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insertion close to the joint axis.

The moment arm (MA) of the biceps is largest between 80° and 100° of
elbow flexion and, therefore, the biceps is capable of producing its
greatest torque in this range.
The biceps is active during unresisted elbow flexion with the forearm
supinated and when the forearm is midway between supination and

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pronation in both concentric and eccentric contractions, but it tends not

to be active when the forearm is pronated.
When the magnitude of the resistance increases much beyond limb
weight, the biceps is active in all positions of the forearm.
The biceps with both heads crossing two joints may become actively

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insufficient when full flexion of the elbow is attempted with the
shoulder in full flexion especially when the forearm is supinated.

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< Brachioradialis:
The brachioradialis is inserted at a distance from the joint axis and
therefore during muscle contraction, the largest component of muscle
force goes toward stability.
The peak moment arm (MA) for the brachioradialis occurs between 100°
and 120° of elbow flexion.
The brachioradialis shows no electrical activity during eccentric flexor
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activity when the motion is performed slowly with the forearm
supinated.
Activation of the brachioradialis during concentric contractions is greater
than during eccentric contractions particularly when the range of elbow
flexion is between 0° and 60°.
The brachioradialis shows no activity during slow, unresisted, concentric
elbow flexion.
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When the speed of the motion is increased, the brachioradialis shows
moderate activity if a load is applied and the forearm is in either a
position midway between supination and pronation or in full pronation.
The brachioradialis does not cross the shoulder and therefore is unaffected
by the position of the shoulder.
The pronator teres as well as the palmaris longus, flexor digitorum
superficialis, flexor carpi radialis, and flexor carpi ulnaris are weak elbow
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flexors.
Ö Extensors Muscle Action:
The effectiveness of the triceps as a whole is affected by changes in the
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position of the elbow but not by changes in position of the forearm because the
triceps attaches to the ulna and not the radius. The long head of the triceps
crosses two joints; therefore, activity of the long head is affected by changing
shoulder joint positions. The long head becomes actively insufficient when full
elbow extension is attempted with the shoulder in hyperextension. In this
instance the muscle is shortened over both the elbow and shoulder
simultaneously.
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The medial and lateral heads of the triceps are not affected by the position
of the shoulder. The medial head is active in unresisted active elbow extension.
All three heads are active when heavy resistance is given to extension or when
quick extension of the elbow is attempted in the gravity-assisted position. The
maximum isometric torque that the triceps can generate is at an elbow
position of 90° of elbow flexion. However, the total amount of extensor torque

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generated at 90° varies with the position of the shoulder and the body. The

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triceps is active eccentrically to control elbow flexion as the body is lowered to
the ground in a push-up. The triceps is active concentrically to extend the
elbow when the triceps acts in a closed kinematic chain such as in a push-up.
The triceps may be active during activities requiring stabilization of the elbow.
For example, it acts as a synergist to prevent flexion of the elbow when the
biceps is acting as a supinator. The other extensor of the elbow, the anconeus,
assists in elbow extension and apparently also as a stabilizer during supination
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and pronation.

U Superior Radioulnar Joints:

™ Articulation: Between the circumference of the head of the radius and the
annular ligament and the radial notch on the ulna.
™ Type: Synovial pivot joint.
™ Capsule: The capsule encloses the joint and is continuous with that of the elbow
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joint.
™ Ligaments: The three ligaments associated with the proximal radioulnar joint
are the annular and quadrate ligaments and the oblique cord.
The annular ligament is a strong band that forms four-fifths of a ring that
encircles the radial head. It is attached to the anterior and posterior margins of
the radial notch on the ulna and forms a collar around the head of the radius. It
is continuous above with the capsule of the elbow joint. It is not attached to the
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radius.
The quadrate ligament extends from the inferior edge of the ulna’s radial
notch to insert in the neck of the radius. The quadrate ligament reinforces the
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inferior aspect of the joint capsule and helps to maintain the radial head in
apposition to the radial notch. The quadrate ligament also limits the spin of
the radial head in supination and pronation.
The oblique cord is a flat fascial band on the ventral forearm that extends
from an attachment just inferior to the radial notch on the ulna to insert just
below the bicipital tuberosity on the radius. The fibres of the oblique cord are
at right angles to the fibres of the interosseous membrane.
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™ Synovial Membrane: This is continuous above with that of the elbow joint.
Below it is attached to the inferior margin of the articular surface of the radius
and the lower margin of the radial notch of the ulna.
™ Nerve Supply: Branches of the median, ulnar, musculocutaneous, and radial
nerves.

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U Inferior Radioulnar Joint:

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™ Articulation: Between the rounded head of the ulna and the ulnar notch on the
radius.
™ Type: Synovial pivot joint.
™ Capsule: The capsule encloses the joint but is deficient superiorly.
™ Articular Disc: This is triangular and composed of fibrocartilage. It is attached
by its apex to the lateral side of the base of the styloid process of the ulna and
by its base to the lower border of the ulnar notch of the radius. It shuts off the
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distal radioulnar joint from the wrist and strongly unites the radius to the ulna.
™ Ligaments: The dorsal and palmar radioulnar ligaments, as well as the
interosseous membrane, which stabilizes both proximal and distal joints,
reinforce the distal radioulnar joint.
The dorsal and palmar ligaments are formed by longitudinally oriented
collagen fiber bundles originating from the dorsal and palmar aspects of the
ulnar notch of the radius. The two ligaments extend along the margins of the
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articular disc to insert on the ulnar fovea and base of ulnar styloid process.
The interosseous membrane is described simply as a broad collaginous
sheet that runs between the radius and ulna. The fibres of the central band run
distally and medially from the radius to the ulna. Maximum strain in the fibres
of the central band occurs when the forearm is in a neutral position (midway
between supination & pronation). The fibres in central band are relaxed in both
the supinated and pronated positions. The interosseous membrane provides
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stability for both the superior and inferior radioulnar joints. When under
tension, the membrane not only binds the joints together, but also provides for
the transmission of forces from the hand and distal end of the radius to the
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ulna.
™ Synovial Membrane: This lines the capsule passing from the edge of one
articular surface to that of the other.
™ Nerve Supply: Anterior interosseous nerve and posterior interosseous nerve.
Ö Axis of Motion:
The axis of motion for pronation and supination is a longitudinal axis
extending from the centre of the radial head to the centre of the ulnar head.
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In supination the radius and ulna lie parallel to one another, whereas in
pronation, the radius crosses over the ulna. There is very little motion of the
ulna during pronation and supination. The ulnar head moves distally and
dorsally in pronation and proximally and medially in supination. Therefore, at
the distal radioulnar joint, ulnar head glides in the ulnar notch of the radius from

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the dorsal lip of the ulnar notch in pronation to a position on the palmar aspect
of the ulnar notch in full supination.

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Ö Range of Motion:
A total ROM of 150° has been ascribed to the radioulnar joints. The
range of motion of pronation and supination is assessed with the elbow in 90° of
flexion. This position stabilizes the humerus so that radioulnar joint rotation
may be distinguished from rotation that is occurring at the shoulder joint.
Limitation of pronation when the elbow is extended may be caused by passive
tension in the biceps brachii. Pronation in all positions is limited by bony
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approximation of the radius and ulna and by tension in the dorsal radioulnar
ligament and the posterior fibres of the medial collateral ligament of the
elbow. Supination is limited by passive tension in the palmar radioulnar
ligament and the oblique cord. The quadrate ligament limits spin of the radial
head in both pronation and supination, and the annular ligament helps to
maintain stability of the proximal radioulnar joint by holding the radius in
close approximation to the radial notch.
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Ö Muscle Action:
The pronators produce pronation by exerting a pull on the radius, which
causes its shaft and distal end to turn over the ulna. The pronator teres is a two-
joint muscle that has a slight role in elbow flexion although its major action is at
radioulnar joints. As a two-joint muscle, the pronator teres may become
actively insufficient when a full range of pronation is attempted
simultaneously with the full range of shoulder flexion. The pronator teres
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contributes some of its force toward stabilization of the proximal radioulnar

joint. The translatory component of the force produced by the pronator teres
helps to maintain contact of the radial head with the capitulum. The pronator
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quadratus, a one-joint muscle, is unaffected by changing positions at the elbow.

The pronator quadratus is active in unresisted and resisted pronation and in
slow or fast pronation. The deep head of the pronator quadratus also acts to
maintain compression of the distal radioulnar joint.
The supinators, like pronators, acts by pulling the shaft and distal end of
the radius over the ulna. The supinator muscle acts alone during unresisted

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slow supination in all positions of the elbow or forearm. The supinator also
can act alone during unresisted fast supination when the elbow is extended.
However, activity of the biceps is always evident when supination is
performed against resistance and during fast supination when elbow is flexed
to 90°. Activity of the biceps is most evident when using a screwdriver to drive

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a screw into the wood. The anconeus muscle is active in supination and
pronation.

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U Effects of Immobilization and Injury:
The joints and muscles of the elbow complex may be subjected to the
effects of immobilization and injury. Immobilization may cause decrease in
muscle strength. If the flexors happen to be weakened more than the extensors,
the flexors may not be able to counteract the pull of the extensors and the elbow
joint may hyperextended during extension. Also the flexor muscles contributions
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to joint compression would be decreased, and therefore joint stability would be
diminished. Prolonged immobilization of the elbow in 90° of flexion results in
adaptive shortening of the elbow flexors and lengthening of the elbow extensors.
Consequently the elbow ROM in extension is limited.
Injuries to the elbow are fairly frequent and these injuries usually disrupt
normal function.
Ö Compression Injury:
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Resistance to longitudinal compression forces at the elbow is provided for
mainly by the contact of bony components; therefore, excessive compression
forces at the elbow leads to bony failure. Falling on the hand when the elbow
is in a close-packed position may result in the transmission of forces through
the bones of the forearm to the elbow. If the forces are transmitted through
the radius as may happen with a concomitant valgus stress, a fracture of the
radial head may result from impact of the radial head on the capitulum. If the
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force from the fall is transmitted to the ulna, a fracture of either the coronoid
or olecranon processes may occur from impact of the ulna on the humerus. If
neither the radius nor the ulna absorbs the excessive force through a fracture,
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then the force may be transmitted to the humerus and may result in a fracture
of the supracondylar area.
Ö Distraction Injury:
Ligaments and muscles provide for resistance of the joints of the elbow
complex to longitudinal traction. A distraction force of sufficient magnitude
exerted on the radius may cause the radius to slip out of the annular
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ligament. Small children are particularly susceptible to this type of injury

because the radial head is not fully developed. Lifting a small child up into
the air by one or both hands or yanking a child by the hand is the usual
causative mechanism and therefore the injury is referred to as nursemaid’s
elbow. However, the distractive pull will rarely cause problems if the child is

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expecting the pull and has contracted the compressive elbow flexors. When the
pull is unexpected, the muscles are not ready to provide the appropriate

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stabilization.
Ö Varus/Valgus Injury:
The medial collateral ligament (MCL) and lateral collateral ligament
(LCL), articular configuration, and the joint capsule provide resistance to
medial and lateral stresses at the elbow. If either one of the ligaments is
overstretched, one aspect of the joint will be subjected to abnormal tensile
stresses and the other to abnormal compressive forces. The MCL is subjected
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to tensile stress during the backswing or “cock up” portion of throwing a ball. If
the stress on the MCL is repetitive, such as in baseball pitching, the ligament
may become lax and unable to reinforce the medial aspect of the joint. The
resulting medial instability may cause an increase in the normal carrying
angle and excessive compression of the radial head on the capitulum. If the
abnormal compression forces on the articular cartilage are prolonged, these
forces may interfere with the blood supply of the cartilage and result in
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avascular necrosis. Repetitive microtrauma from valgus stress can cause
epiphyseal plate fractures of the proximal radius.
Ö Overuse and Other Injuries:
The use of a racquet greatly increases the length of the forearm lever
(resistance arm) and subjects the elbow complex structures to great stresses.
The classic tennis elbow (epicondylitis of the lateral epicondyle) is caused by
repeated forceful contractions of the wrist extensors, primarily the extensor
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carpi radialis brevis. The tensile stress created at the origin of the extensor
carpi radialis brevis may cause microscopic tears that lead to inflammation of
the lateral epicondyle. Repeated tensile stress on the inelastic tendon may result
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in microscopic tears at the musculotendinous junction and result in tendinitis.

Repetitive microtrauma injury can lead to mucinoid degeneration of the
extensor origin and subsequent failure of the tendon.
Medial tendinitis or medial epicondylitis (Golfer’s Elbow) may be
caused by forceful repetitive contractions of the pronator teres, flexor carpi
radialis, and occasionally by the flexor carpi ulnaris. These muscles are

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involved in the tennis serve when the combined motion of the elbow extension,
pronation, and wrist flexion is used.
Other injuries to the elbow complex that may occur as a result of
muscular contraction include nerve compression and bony fracture or
dislocation. Repetitive forceful contraction of the flexor carpi ulnaris may

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compress the ulnar nerve as it passes through the cubital tunnel between the
medial epicondyle of the humerus and the olecranon process of the ulna. The

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resting injury, called cubital tunnel syndrome, results in impaired motion of
the thumb and fourth and fifth digits. Sudden forceful contractions of the
biceps brachii when the forearm is supinated and flexed at 90° may cause a
rupture of the biceps tendon, or fracture or dislocation of the radius.

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