The Elbow Complex

Functions of the Elbow Complex

Joint Structure of the Elbow Complex
Kinematics of the Elbow
Muscle Action at the Elbow
Stability of the Elbow Complex
Common Injuries at the Elbow

Objectives After studying this topic, the students will be able to

1. to identify the structures of the elbow and the forearm, including joint type,
articular shape, and the surrounding tissues
2. to describe joint motions occurring at the elbow, including physiological and
accessory movements, muscle actions, and factors checking elbow motions
3. to understand the stability mechanism of the elbow complex and the possible
mechanisms of injury

1. Neumann DA (2002). Elbow and Forearm Complex. In Neumann DA:

Kinesiology of the Musculoskeletal System: Foundations for Physical
Rehabilitation. Philadelphia: Mosby. Chapter 6, pp. 133-171
2. Smith LK et al., 1996. Chapter 5
3. Jazrawi LM et al. (2001). Biomechanics of the Elbow. In Nordin M & Frankel
VH: Basic Biomechanics of the Musculoskeletal System. Philadelphia:
Lippincott Williams & Wilkins. Chapter 13, pp.340-357

Functions of the Elbow Complex

Two major functions of the extremity joints are mobility and stability. The functions of
the elbow joints are

to add mobility of hand in space by

shortening and/or lengthening the arm
rotating the forearm
combination of the above both
to provide control and stability
for skilled hand motions
for forceful upper extremity motions
 1. Keep your arm straight and try to do any daily activities, e.g. eating, writing,
opening the door, throwing a ball, walking, etc. See which one is affected if
elbow motion is restricted and which one is not.
2. Try not to rotate your forearm and do any daily activities, e.g. eating, writing,
opening the door, throwing a ball, walking, etc. See which one is affected if
forearm motion is restricted and which one is not.

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Joint Structure of the Elbow Complex

Joints at elbow complex

humeroulnar joint (HUJ)

humeroradial joint (HRJ)
proximal radioulnar joint (prox. RUJ)
Note
The above three joints are enclosed in the same joint capsule

Humeroulnar joint

proximal component
humerus
hourglass-shaped
trochlea
trochlea =pulley
olecranon fossa
coronoid fossa
cornoid = like crown
distal componentulna
saddle-shaped
trochlear fossa
coronoid process
 olecranon process
joint type
hinged (ginglymus) or modified hinged (Morrey BF and Chao EY, 1976; Neumann
DA 2003, p.137)
Note The elbow complex, including both the humeroulnar and humeroradial joints,
is considered entirely and therefore is treated as a trochleoginglymoid joint. (Jazrawi LM
et al., 2001)

motion elbow flexion/ extension

elbow flexion with anterior glide of the trochlea notch of the ulna on
the trochlea of the humerus
elbow extension with posterior glide of the trochlea notch of the ulna
on the trochlea of the humerus
DOF = 1
Note Some scholars refer the elbow joint to the whole elbow complex so that
the degree of freedom of the elbow joint, they think, is equal to 2.
rest position 70 of elbow flexion and 10 of forearm supination
closed packed position full elbow extension

Joints at elbow complex

Elbow Flexion/ Extension

Humeroradial joint

proximal component humerus

radial fossa
ball-shaped capitulum
distal component cup-shaped superior aspect of the radial head (fovea)
joint type ball-and-socket joint
motion elbow flexion/ extension and forearm pronation/ supination
elbow flexion/ extension with anterior/ posterior glide of the radial
head on the capitulum of the humerus
forearm pronation/ supination with the radial head spinning medially/
laterally on the capitulum of the humerus
DOF = 2
rest position full elbow extension with forearm supination
 Joints at elbow complex
Elbow Flexion/ Extension
Forearm pronation/ supination

Proximal radioulnar joint

proximal component concave radial notch of the ulna

distal component convex rim of the radial head
joint type pivot joint
motion forearm pronation/ supination
forearm pronation with posterior glide of the radial head
forearm supination with anterior glide of the radial head
DOF = 1
rest position 70 of elbow flexion and 35 of forearm supination
Note The distal radioulnar joint structurally separate from the elbow
complex but moves with proximal radioulnar joint as a functional unit. Will be
discussed in details on the page of "wrist complex".

Joints at elbow complex

Forearm pronation/ supination

Carrying angle

synonym cubitus angle

10-15 valgus angle when the elbow is fully extended and
the forearm is fully supinated
disappear when the elbow is extended and the forearm is
pronated
decreased when the elbow is flexed
female > male
The trochlea of the humerus extends farther distally than
does the capitulum
The outer lip of the trochlea extends father distally than does
the inner lip
anomaly
cubitus valgus i.e. cubitus angle >15, resulting the
forearm deviating outwards
cubitus varus resulting the forearm deviating
towards the midline

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Kinematics of the Elbow

Elbow flexion and extension

joint involved
humeroulnar joint
(principal joint)
humeroradial joint
plane of motion sagittal
plane
axis of rotation
not a fixed point
close to a line
through the centers of
the trochlea and
capitulum
not perpendicular to the longitudinal axis of the humerus (4-8 of
valgus)
palpation slightly distal to the connecting line between the lateral
and medial epicondyles of the humerus
osteokinematic movements
range of motion (ROM)
elbow flexion 0-145
somewhat hyperextension, especially in female
functional range 30-130
closed kinematic chain motions motion occurs when the hand is
fixed and the elbow moves
pull-up ()
push-up ()
push and pull
elbow adduction with elbow flexion
6 adduction from full extension to full flexion (Morrey &
Chao, 1976)
< 1 from full extension to full flexion (London et al., 1981)
no clinical significance (An et al., 1984)
arthrokinematic movements (concave on convex joint)
distraction /compression of the ulna to the humerus
anterior glide of the ulna on the humerus with elbow flexion
especially in the last 5-10
posterior glide of the ulna on the humerus with elbow extension,
especially in the last 5-10
 1. Use your left thumb and index to palpate the olecranon and coronoid processes of
your right ulnar bone. Try to bend your right elbow and feel the the motions of
both processes.
2. Do the above trial on your friend's.
3. Place one hand on the medial aspect of your friend's upper arm as close to his/her
elbow as possible. Place the other hand on the lateral aspect of your friend's
forearm. Similarly, as close to the elbow joint as possible. Push the forearm
medially and feel the medial gliding of the forearm. DO NOT push too hard!!

factors checking elbow flexion

soft tissue approximation at anterior humerus (most important)
coronoid process into coronoid fossa
radial head into radial fossa
passive tension of the triceps
tightness of the posterior joint capsule
factors checking elbow extension
olecranon process into olecranon fossa (most important)
passive tension of the elbow flexors
passive tension of the collateral ligaments
tightness of the anterior capsule

Humeroulnar Joint

Forearm Pronation/ Supination

 joint involved
proximal
radioulnar joint
distal radioulnar
joint
humeroradial
joint
plane of motion
transverse plane
axis of rotation
passing through
the center of the
radial head and the
distal ulnar head
not parallel to
the longitudinal axis
of the forearm
osteokinematic movements
motions the radial head rotates within the annular ligament and spins
on the capitulum of the humerus
range of motion (ROM)
pronation 0-70
supination 0-85
Note: Pure motions occur as the elbow is held in the 90 of
flexion. If the elbow is extended, shoulder rotation occurs
simultaneously with forearm rotation.
functional range 50 of pronation to 50 of supination
closed kinematic chain motions
open the door knob
open the can
arthrokinematic movements (convex on concave)
anteromedial gliding of radius on ulna with forearm supination
posterolateral gliding of radius on ulna with forearm pronation
 1. Use your left thumb and index to palpate the head of the radius of your right arm.
Try to rotate your right forearm and feel the the motion of the radial head.

2. Try the above trial on your friend's.

factors checking forearm pronation
ulna on radius
quadrate ligaments
posterior radioulnar ligament
oblique cord
factors checking forearm supination
anterior radioulnar ligament
quadrate ligament
oblique cord
interosseous membrane

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Muscle Action at the Elbow

Elbow flexors

brachialis
single joint muscle
not affected by position of forearm or shoulder
participates all flexion activities

biceps brachii
long head two-joint muscle
most effective when shoulder extended and forearm supinated
short head single-joint muscle
muscle actions
 effective as a flexor between 80-100 of elbow flexion or
forearm supinated
forearm supination
shoulder flexion as shoulder extended
factors affecting the strength of the biceps brachii
elbow position moment arm and muscle length
shoulder position long head only

brachioradialis activates when

joint stability is needed
speed of flexion motion increases
forearm is pronated
elbow flexion strength
generates maximum isometric force at 65 of flexion
force of flexion as forearm supinated > in neutral > pronated

Elbow extensors

triceps brachii
long head from lateral border of scapula
two joint muscle
most effective as shoulder flexed
medial and lateral heads
one joint muscle from posterior surface of humerus
insertion olecranon
factors affecting the strength of the triceps brachii
elbow position moment arm and muscle length
shoulder position long head only
 anconeus
acts as elbow extensor
stabilize elbow during forearm pronation and supination
against valgus stress
elbow extension strength generates maximum isometric force at 90 of
elbow flexion

Forearm pronators

pronator quadratus: most important

activates during all pronation activities
pronator teres
to be active during fast pronation or pronation against resistance
to stabilize proximal radioulnar joint
to approximate humeroradial joint
elbow position does not affect the activity of pronators

Forearm supinators

supinator most important

biceps brachiiactive during fast supination with elbow flexed or supination
against resistance regardless of elbow position
elbow position does not affect the activity of pronators

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Stability of the Elbow Complex



Factors Affecting Elbow Stability

bony configuration
coronoid process prevents anterior displacement
olecranon process prevents posterior displacement
humeroradial joint provides resistance to valgus stress

tension of ligaments
medial collateral ligament
from the medial epicondyle of the humerus to the coronoid
process (anterior fibers, the strongest) and to the olecranon process
of the ulna (posterior fibers) as well as from the olecranon process
to the coronoid process of the ulna (transverse fibers)
against valgus stress
taut at full extension (anterior fibers) or full flexion (posterior
fibers)
lateral collateral ligament
against varus stress
taut at full flexion
anterior oblique ligament
preventing hyperextension
taut at extension
posterior oblique ligament
taut at flexion flexion
less functional because its insertion is attached at the annular
ligament
muscle contraction (dynamic stability)
anconeus against varus stress
cocontraction of antagonists to increase compression forceand
produce joint approximation
What if
a varus stress happens?
a valgus stress happens?
an anterior stress happens?
a posterior stress happens?

Factors affecting the stability of the proximal radioulnar joint

What is the instability?

bony configuration is no help
tension of ligament
annular ligament against distraction of the radius and preventing
dislocation of radial head
 inerosseous membrane: prevents separation or longitudinal shift of
radius and ulna

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Common Injuries at the Elbow

Direct stress

longitudinal compression stress fracture of radial head, coronoid or

olecranon process and supracondylar fracture
distraction stress nurse maids elbow (pulled elbow)
posterior stress posterior dislocation of the elbow

Repeated stresses

repeated wrist motions as forearm pronated repeated tensile stress on

extensor carpi radilais brevis tennis elbow (lateral epicondylitis)
repeated wrist motions as forearm supinated repeated tensile stress on
pronator teres, flexor carpi radialis golfers elbow