2
BIOMECHANICS OF THE ELBOW
INCLUDING ELECTROMYOGRAPHIC
ANALYSIS
FRANK K. NOOJIN
LARRY D. FIELD
FELIX H. SAVOIE, III
Normal elbow function is vital to the appropriate use of
the upper extremity in sports and daily activities. The elbow
is a complex joint that serves to position the hand in space,
to transmit load between the forearm and shoulder, and to
function as a fulcrum for the forearm lever. The complexity
of its bony articulations and stabilizing capsuloligamentous
structures render it one of the most stabile joints in the
body. As the anatomic link between the shoulder and fore-
arm, the elbow is subjected to extreme compressive, tensile,
and shear forces that culminate in various pathological con-
ditions, particularly in the overhead athlete. Loss of stability
or motion of the elbow severely compromises function of
the upper extremity.
A number of anatomic and biomechanical studies have
emerged recently to increase our understanding of elbow
function in normal and pathological states. Awareness of
these recent advances may have a direct impact on the ability
to diagnose and treat elbow disorders with particular appli-
cation to techniques of reconstruction. With the public’s
increasing participation in overhead and racquet sports,
knowledge of the biomechanical function of the anatomic
structures of the elbow becomes increasingly important for
the treating physicians.
The purpose of this chapter is to review the biomechani-
cal function of the stabilizing structures of the elbow with
emphasis on commonly encountered pathological condi-
tions in athletes and electromyographic (EMG) analysis.
This section includes a review of the elbow with regard to
its kinematics, stabilizing structures, force transmission, and
EMG analysis as they pertain to clinical diagnosis, tech-
Mississippi Sports Medicine and Orthopaedic Center, Jackson, Mississippi
39202.
niques for surgical reconstruction, and direction for future
research.
ELBOW ANATOMY
The elbow is comprised of three articulations: the humer-
oulnar, the humeroradial, and the radioulnar. The humer-
oulnar and humeroradial articulations function as gingly-
mus (hinge) and trochoid (pivot) joints, respectively. The
humeroulnar portion is the primary determinant of os-
seous stability. The guiding ridge of the sigmoid notch
of the ulna articulates with the central portion of the
trochlear groove, creating a congruent, v-shaped articula-
tion (Fig. 2.1). As the elbow extends, the tip of the
olecranon enters the olecranon fossa of the distal humerus,
enhancing elbow stability. Similarly, during flexion the
coronoid process enters the coronoid fossa and the radial
head enters the radial fossa. The radial head is a concave,
elliptical dish that functions as a secondary stabilizer to
valgus stress and an intermediary for force transmission
between the arm and forearm. Because of these osseous
configurations, the elbow is more biomechanically stable
in the positions of extreme elbow flexion and extension
than the middle range of motion (1).
The static stabilizers of the elbow are the bony articula-
tion, capsule, the medial collateral ligament (MCL) com-
plex, and the lateral collateral ligament (LCL) complex. The
anterior capsule inserts an average of 6 mm distal to the
coronoid and is taut in extension. The posterior capsule is
more lax in extension and becomes taut in flexion. The
MCL is comprised of the anterior bundle (the AMCL) and
the posterior bundle (the PMCL), which have a reciprocal
relationship with regard to tension during flexion and exten-
sion (Figs. 2.2 and 2.3). The LCL is comprised of the radial
 30 The Athlete’s Elbow
Guiding ridge
Transverse groove
or greater sigmoid
notch
Sigmoid
Tubercle
Radial notch
Greater sigmoid
notch
Ulnar
tuberosity
Olecranon
A B
collateral ligament (RCL), the annular ligament (AL), and
the lateral ulnar collateral ligament (LUCL) (Fig. 2.4).
ELBOW KINEMATICS
Center of Rotation
The normal elbow has 0 degrees extension, 145 degrees of
flexion, 80 degrees pronation, and 75 degrees supination.
The axis of motion during elbow flexion and extension has
been studied by numerous authors with variable findings
(2,3). Yuom et al. (2) demonstrated that the center of rota-
tion of the elbow does not change with flexion and exten-
sion, indicating that the elbow functions as a simple hinge
joint. An and Morrey (3) discovered up to 8 degrees of
variability between subjects. They determined that the flex-
ion-extension axis is represented in the sagittal plane by a
line drawn between the center of the capitellum and the
center of the trochlear sulcus, exiting medially just anterior
and inferior to the medial epicondyle (Fig. 2.5). In the coro-
nal plane, this axis creates an angle of 4 to 8 degrees of
valgus with respect to the longitudinal axis of the humerus
and is internally rotated 3 to 5 degrees relative to the transe-
picondylar plane. The flexion-extension axis is not the same
as the carrying angle. The humeroulnar axis angle changes
from valgus in extension to varus in flexion, which has led
some authors to describe elbow motion as helical due to
the obliquity of the trochlear groove relative to the long
axis of the humerus. Given this change in axis angle, the
elbow joint may be more complex than a simple hinge joint,
which may explain the success of semiconstrained total
elbow arthroplasty compared to constrained total elbow
arthroplasty. However, from a clinical standpoint, the vari-
Supinator crest FIGURE 2.1. A: Anterior aspect of the
and tuberosity proximal ulna demonstrating the guid-
ing ridge. B: Lateral view of the medial
aspect of the proximal ulna showing su-
pinator crest and tuberosity and the in-
sertion of the anterior bundle of the
medial collateral ligament. (Modified
from An KN, Morrey BF. Biomechanics
of the elbow. In: Morrey BF, ed. The
elbow and its disorders. Philadelphia:
WB Saunders, 1993:53–72, with permis-
sion.)
ability in the center of rotation of the elbow is minimal,
likely secondary to experimental design, and has little im-
pact on the treatment of elbow disorders (3). It generally
can be assumed that the humeroulnar articulation is uniaxial
except at the extremes of flexion and extension.
Carrying Angle
The carrying angle of the elbow is defined as the angle
between the longitudinal axis of the ulna and humerus with
the elbow in full extension. This angle averages 5 to 10
degrees and is generally 5 degrees greater in women than
men. The measurement of the carrying angle is dependent
on the position of the elbow with smaller values reported
with flexion (Fig. 2.6) (4). An and Morrey (3) illustrated
that the carrying angle may be defined three different ways:
(a) the angle between the long axis of the humerus and ulna
with the ulna as the fixed reference system, (b) the angle
between the long axis of the humerus and ulna with the
humerus as the fixed reference system, and (c) the abduc-
tion–adduction Euler angle of the ulna with respect to the
humerus. The latter definition accounts for the decrease in
carrying angle with flexion and the differences reported in
the literature. Therefore, the carrying angle of the elbow
should be measured with the elbow in full extension.
Pronation/Supination
The longitudinal axis of pronation and supination in the
forearm is described to pass from the distal end of the ulna
to the center of the radial head. This biomechanical axis is
oblique relative to the longitudinal anatomic axes of the
 2. Biomechanics of the Elbow 31

Anterior
bundle (MCL)
90º
120º ME

Posterior
bundle

Sublimis tubercle

60º
30º

FIGURE 2.2. Illustrations of the anatomy of the medial collateral ligament (MCL) at 30, 60, 90,
and 120 degrees of elbow flexion. The anterior bundle of the MCL (the AMCL) originates from
the inferior aspect of the medial epicondyle (ME) and inserts into the sublimis tubercle of the
proximal ulna. The AMCL is divided into anterior and posterior bands that tighten in reciprocal
fashion as the elbow is flexed and extended. The isometric fibers of the AMCL are demonstrated
by the black arrows. The PMCL originates from the inferior and posterior portion of the ME,
broadens distally, inserts on the olecranon process, and blends into the joint capsule. It tightens
with increased elbow flexion angles. (Modified from Callaway GH, Field LD, Deng XH, et al. Bio-
mechanical evaluation of the medial collateral ligament of the elbow. J Bone Joint Surg Am 1997;
79A:1223–1231, with permission.)
32 The Athlete’s Elbow
Anterior bundle
Posterior
bundle
Transverse
ligament
FIGURE 2.3. Artist rendition of the medial collateral ligament
complex of the elbow demonstrating the anterior bundle, poste-
rior bundle, and inferior transverse ligament. (Modified from An
KN, Morrey BF. Biomechanics of the elbow. In: Morrey BF,
ed. The elbow and its disorders. Philadelphia: WB Saunders,
1993:53–72, with permission.)
radius and the ulna (Fig. 2.7) (3). The axis of forearm rota-
tion has been demonstrated to pass through the interosseous
membrane at the level of the distal fourth of the ulna (5).
With pronation, the radius migrates proximally and the lat-
eral aspect of the humeroulnar articulation closes. O’Dris-
coll and associates (6) demonstrated that the ulna externally
rotates with supination and internally rotates with prona-
Radial collateral ligament
Annular ligament
Lateral
ulnar
collateral
ligament
FIGURE 2.4. Artist rendition of the lateral collateral ligament
complex of the elbow demonstrating the lateral ulnar collateral
ligament, the radial collateral ligament, and the annular liga-
ment. (Modified from An KN, Morrey BF. Biomechanics of the
elbow. In: Morrey BF, ed. The elbow and its disorders. Philadel-
phia: WB Saunders, 1993:53–72, with permission.)
B
FIGURE 2.5. A: Lateral view of the distal humerus showing the
origins of the anterior bundle of the medial collateral ligament
(MCL), the posterior bundle of the MCL, and the radial collateral
ligament (RCL) relative to the flexion-extension axis of the el-
bow. B: Frontal view of the distal humerus showing the relation-
ship of the origins of the collateral ligaments to the joint axis of
rotation. More fibers from the RCL are located within the joint
axis of rotation than the MCL, thereby explaining the length-
tension relationship of the anterior and posterior bundles of the
MCL. (Modified from An KN, Morrey BF. Biomechanics of the
elbow. In: Morrey BF, ed. The elbow and its disorders. Philadel-
phia: WB Saunders, 1993:53–72, with permission.)
tion. An and Morrey (3) introduced a metal rod transversely
into the ulna and noted that in moving from pronation to
supination, the ulna extends, then flexes, and then laterally
rotates. Pronation and supination of the forearm alters the
position of the humeroulnar and radiocapitellar joints and
the patterns of force transmission from the forearm to the
elbow. The effects of forearm positioning on elbow bio-
mechanics will be further addressed later in this chapter.
FIGURE 2.6. The carrying angle of the elbow is dependent on the
degree of elbow flexion and should be defined with the elbow in
full extension. (Modified from Werner FW, An KN. Biomechanics
of the elbow and forearm. Hand Clin 1994;10:357–373, with per-
mission.)

Proximal radialulnar joint
Ulna
Radius
Distal radialulnar joint
FIGURE 2.7. The longitudinal axis of pronation and supination
travels obliquely through the forearm, beginning from the distal
end of the ulna to the center of the radial head. This axis is lo-
cated at the level of the ulnar cortex at the level of the distal third
of the ulna. (Modified from An KN, Morrey BF. Biomechanics
of the elbow. In: Morrey BF, ed. The elbow and its disorders.
Philadelphia: WB Saunders, 1993:53–72, with permission.)
Elbow Joint Capacity, Pressure, and
Compliance in Normal and Stiff Elbows
The intraarticular capacity of the elbow joint historically
has been estimated to be 10 to 15 mL based on experience
with arthrography procedures (7,8). O’Driscoll and associ-
ates (9) in 1990 investigated the compliance, capacity, and
position of minimum intraarticular pressure of the elbow
in 13 cadaver specimens. They reported that the average
capacity of the elbow joint was 23 Ⳳ4 mL with a range of
16 to 30 mL. The compliance of the capsule with increasing
pressures was found to exhibit viscoelastic behavior, with
the stiffness increasing with each capsular injection but
demonstrating ‘‘stress relaxation’’ between injections. The
position of minimum intraarticular pressure as measured by
pressure transducers was 80 degrees of elbow flexion with
a range of 65 to 90 degrees. This position correlates clini-
cally with patients with effusions holding their elbows in
flexion to minimize the intraarticular pressure and pain. The
pressure required to produce capsular rupture was variable,
averaging 80 mm Hg with a range of 32 to 170 mm Hg. The
findings in this study suggest that during elbow arthroscopy,
capsular leakage may occur at relatively low pressures lead-
ing to more postoperative periarticular swelling. These data
2. Biomechanics of the Elbow 33
also suggest that the resting position of 80 to 90 degrees of
elbow flexion allows the capsule to be the most lax, possibly
predisposing the elbow to posttraumatic capsular con-
tracture. This conclusion is supported by clinical reports
that state that the average arc of elbow motion for patients
undergoing surgery for elbow capsular contracture is 60 to
90 degrees (10).
In the arthrofibrotic elbow, both the capsular volume
and the compliance are diminished. Gallay et al. (11) stud-
ied the intraarticular capacity, compliance, and position of
minimum pressure for eight stiff elbows and ten normal
elbows prior to surgery for correction of posttraumatic cap-
sular contracture. The capacity of the normal elbow was 14
Ⳳ2 mL, compared to 6 Ⳳ3 mL for the stiff elbow. The
compliance for the stiff elbows as determined by the pres-
sure-volume curve was two to six times less than that of
the normal elbows. The position of minimum intraarticular
pressure was not significantly different for the stiff elbow
(85 degrees), compared to that of the normal elbow (70
degrees). This study concluded that the working elbow cap-
sular volume for elbow arthroscopy should be approxi-
mately 15 mL to minimize the risk of capsular rupture.
The stiff elbow not only has decreased capacity but also has
decreased compliance, indicating a change in the structural
properties of the capsule. Adequate capsular distension in
the stiff elbow may not be possible, increasing the risk of
neurological injury during arthroscopy (11).
Elbow Contact Area and Contact Pressure
A number of studies have analyzed the pressure distribution
of the articular surfaces of the elbow with and without load-
ing in varying degrees of flexion (12–17). The anatomy of
the articular side of the ulna consists of a rounded ridge
between the tips of the olecranon and coronoid process that
divides the trochlear notch into medial and lateral portions
(12). This articular geometry results in a bicentric loading
pattern that changes with flexion and extension of the
elbow. Goel et al. (12) in 1982 evaluated the contact area
of the elbow using a casting technique without loading.
They concluded that in full extension, the contact area was
more distal in the trochlear notch and concentrated on the
medial side. There was no contact in the radiocapitellar
joint in this position. At 90 degrees of flexion, the contact
area changed to a diagonal pattern crossing from the distal
medial portion of the trochlear notch to proximal lateral,
with slight contact observed between the radial head and
the capitellum. The stress distribution was similar at full
flexion with increased contact area seen at the radiocapitellar
joint. Eckstein et al. (13) used computed tomographic (CT)
absorptiometry to assess the subchondral mineralization dis-
tribution in 16 cadaver elbows. Their method evaluated the
physiologic stress distribution in elbow joints by measuring
the density of subchondral mineralization at different por-
tions of the joint surface. Their results indicated an in-
34 The Athlete’s Elbow

creased mineralization beneath the coronoid and olecranon

with a less heavily mineralized area intervening, reflecting
a ‘‘bicentric’’ pattern of loading. The central region of the
trochlear notch was less heavily mineralized. With increas-
ing load up to 1,280 N, the central region absorbed more
force. The contact area of the humeroulnar joint ranged
from 9% of the total articular surface at 10 N of load to
73% with 1,280 N of load. Their findings suggested an
articular incongruity that allows more peripheral loading
than a primarily congruous joint, potentially enhancing
stress distribution (13). In another study, Eckstein et al.
(14) also used CT absorptiometry to evaluate elbow joint
contact area in 36 specimens. Similarly, they found that
the humeroulnar joint had a bicentric loading pattern with
maximal mineralization beneath the anterior and posterior
portions of the articular surface. They also found that the
central fovea of the radial head consistently demonstrated
a central density maximum, reflecting a pattern of central
load transmission (14).
Eckstein et al. (17) demonstrated that the contact area
is dependent on degree of elbow flexion and amount of
load. In a cadaver study, they investigated joint space width
FIGURE 2.8. The contact area of the elbow is dependent on the
and contact area at 30, 60, 90, and 120 degrees of flexion degree of flexion and the amount of load. The humeroulnar joint
at 25 N and 500 N of load using a polyester casting material. demonstrates a bicentric loading pattern, as shown here. The
At low loads, the dorsal contact area was less than the ventral central region of the ulna is loaded at greater flexion angles and
contact area at 30 degrees of flexion. With increasing flex- with increasing amounts of force. (Modified from Eckstein F,
Lohe F, Hillebrand S, et al. Morphomechanics of the humero-
ion, the dorsal contact area increased and the ventral contact ulnar joint: joint space width and contact areas as a function of
area decreased (Fig. 2.8). At 500 N of load, the joint space load and flexion angle. Anat Rec 1995;243:318–326, with permis-
width (from the lateral view) diminished and the contact sion.)
area enlarged toward the center of the notch (Fig. 2.7). This
study again illustrates the bicentric loading pattern of the
humeroulnar joint and its concave incongruity. The contact
area of the elbow expands with increasing loads. further divided into two discrete bands referred to as the
Based on these studies (12–17), it appears that contact anterior and posterior bands of the AMCL. The AMCL
area of the elbow joint depends on the position of flexion originates from the inferior aspect of the medial epicondyle
and the degree of loading. There is an anatomic and physio- and inserts into the medial side of the coronoid process. The
logic incongruity of the humeroulnar joint that leads to a posterior bundle of the MCL originates from the posterior
bicentric loading pattern that affects different portions of aspect of the medial epicondyle and inserts in a fan-shaped
the articular surface depending on the degree of elbow flex- fashion into the medial olecranon (18). The PMCL has
ion. The articular incongruity may allow for better and more been described as more of a thickening of the capsule than
uniform stress distribution as well as possibly improve the a discrete ligament. The transverse ligament has not been
nutritional environment for the articular cartilage (13). The
shown to have significant biomechanical function in any
radiocapitellar joint is a flatter socket with a pattern reflect-
study (3). The MCL is the primary restraint to valgus load-
ing primarily central load transmission.
ing of the elbow and has been the subject of multiple biome-
chanical and anatomic studies (18–23). The role of the
STABILIZING STRUCTURES posterior band of the AMCL and the PMCL has recently
become more clearly defined. Subtle incompetence of the
Stability of the elbow is conferred primarily by the articular AMCL is frequently symptomatic and may require surgical
geometry and collateral ligaments. The contributions of the repair or reconstruction.
collateral ligaments, the joint capsule, and the bony articula- The anatomic dimensions of the MCL and its relation-
tion are reviewed in this section. ship with the elbow flexion axis have been reported in several
cadaver studies (19–21). Morrey and An (20) found the
The Medial Collateral Ligament Complex average length of the AMCL to be 27 mm and the average
The MCL complex is comprised of the AMCL, the PMCL, width 24 mm. The PMCL was slightly smaller with mea-
and the transverse ligament (Fig. 2.3). The AMCL may be surements of 24 mm and 5.3 mm for length and width,

FIGURE 2.9. By 60 degrees of elbow flexion, the tension within
the anterior medial collateral ligament (MCL) begins to equili-
brate and the tension in the posterior MCL increases. (Modified
from An KN, Morrey BF. Biomechanics of the elbow. In: Morrey
BF, ed. The elbow and its disorders. Philadelphia: WB Saunders,
1993:53–72, with permission.)
respectively. They described the humeral origin of the MCL
to rest posterior to the axis of elbow flexion, creating a cam
effect resulting in variable ligament tension depending on
the degree of elbow flexion. The distance between the
AMCL and the flexion axis increased slightly with increasing
flexion to 60 degrees and remained constant thereafter (Fig.
2.9). This study led to the concept that the MCL was not
isometric, which has implications for surgical reconstruction
(20). Ochi et al. (19) microscopically dissected ten cadaver
elbows to more clearly determine the proximal attachment
of the MCL and its relationship to the humeroulnar joint
axis. They marked the anterior and posterior bundles of
the AMCL with fine-setting pins, took axial images, and
performed computer-aided measurements of the distance
between the origins and insertions of the anterior and poste-
rior portions of the AMCL at elbow flexion angles of 0, 30,
60, 90, and 120 degrees. In their dissection of the elbows,
they discovered that the deep fibers did not course parallel
with the superficial fibers but obliquely toward the center
of trochlea. The axial images revealed that the pin marking
the deep fibers of the AMCL was located at the centerline
of the trochlea. Their results contradict those of Morrey et
al. (20) and Regan et al. (21) and indicate that the deep
fibers of the AMCL do in fact originate from the isometric
point at the center of the trochlea. If viewed as a three-
dimensional structure, the proximal attachment of the MCL
may not be eccentric to the rotation axis.
Selective ligament sectioning studies have further defined
the role of the anterior and posterior bands of the AMCL,
the PMCL, and the transverse ligament (21–25). Sojbjerg
et al. (22) found that elbow stability was independent of
the collateral ligaments with flexion of less than 20 degrees
or more than 120 degrees. From 20 to 120 degrees, the
AMCL was the primary stabilizer to valgus load. After tran-
section of the AMCL, PMCL, and capsule, maximum val-
gus instability and internal rotatory instability was 20.2 de-
grees and 21.0 degrees, respectively, at 60 to 70 degrees of
2. Biomechanics of the Elbow 35
flexion. No significant instability was created with section-
ing of the capsule and PMCL if the AMCL was intact.
Cutting the AMCL caused an average valgus instability of
11.8 degrees at 70 degrees of flexion. Transection of the
PMCL in addition to cutting the AMCL did not increase
the instability until the capsule was also sectioned, which
increased the instability to 24.2 degrees at 60 degrees of
flexion. This study further delineated the importance of the
AMCL and the relative unimportance of the PMCL and
capsule if the AMCL is intact. The AMCL was determined
to be important to resisting valgus load and internal rotation
within the functional range of elbow motion but not at the
extremes of flexion and extension (22).
Further studies have better delineated the function of
each portion of the MCL depending on the position of
elbow flexion (21, 23–25). Regan et al. (21) performed a
cadaver study using olecranon osteotomies to isolate the
collateral ligaments of the elbow to determine their mechan-
ical properties and at what angles of elbow flexion tension
develops in the AMCL and PMCL. They found that the
AMCL was the strongest and stiffest of the collateral liga-
ments with an average failure load of 260 N. The AMCL is
taut throughout flexion and extension and is in a reciprocal
relationship with the PMCL. Specifically, the anterior fibers
of the AMCL are taut from 0 to 85 degrees under valgus
load, 0 to 30 degrees under varus load, and 0 to 50 degrees
with no load. The middle fibers are taut from 20 to 135
degrees with no load and throughout the full arc of motion
with valgus load. With regard to the PMCL, the fibers are
taut from 90 to 150 degrees without loading. The anterior
fibers of the PMCL become taut at 65 degrees of flexion
with valgus loading and the posterior fibers progressively
tighten with increasing flexion angles. It may be concluded
from this study that generally speaking, the fibers of the
MCL progressively and sequentially tighten from anterior
to posterior as elbow flexion increases.
Floris et al. (18) performed three-dimensional kinematic
analysis of 18 cadaver elbow specimens to delineate the
function of the MCL complex throughout the entire flexion
range. Sectioning of the anterior band of the AMCL resulted
in a mean maximal laxity of 11.7 degrees at 30 degrees of
flexion with increased laxity from 10 to 80 degrees. When
the posterior band of the AMCL was cut first and the ante-
rior band intact, no increased laxity resulted at any flexion
angle compared to the intact joint. Release of the PMCL
alone did not yield increased instability either. Sectioning
the anterior and posterior bands of the AMCL yielded sig-
nificant valgus laxity with maximal values of 14.2 degrees
at 70 degrees of flexion. Further release of the PMCL with
the anterior band of the AMCL did not increase instability
in this study. However, when the PMCL was sectioned after
the AMCL the elbow was completely unstable. Releasing
the PMCL and the posterior band of the AMCL did not
result in any detectable increase in instability as long as the
36 The Athlete’s Elbow
anterior band of the AMCL was intact. Also, sectioning the
anterior band of the AMCL caused significant increases in
the internal rotatory laxity of the elbow, with a maximal
value of 11.2 degrees at 40 degrees of flexion. Cutting the
posterior band resulted in 2.4 degrees of internal rotation
laxity at 120 degrees of flexion. Cutting the PMCL after
the AMCL did not increase laxity in internal rotation. These
authors concluded that the anterior band of the AMCL is
the primary stabilizer to valgus loads and internal rotation
and that the posterior band of the AMCL is a secondary
stabilizer with no primary stabilizing function. The poste-
rior band is the primary stabilizer to internal rotation with
greater degrees of flexion. In the fully extended and maxi-
mally flexed positions, the collateral ligaments confer no
additional stability (18).
Callaway et al. (23) performed anatomic dissections and
biomechanical testing on 28 cadaver elbows to determine
the role of the MCL complex under valgus loading. The
hypothesis before testing was that different patterns of in-
jury to the MCL occur at different elbow flexion angles. In
all specimens, the anterior and posterior bands of the AMCL
were separate, definable structures. The anterior and poste-
rior bands of the AMCL and the PMCL were sectioned in
four sequences and biomechanically tested at 30, 60, 90,
and 120 degrees of flexion. In intact specimens, the angle
of flexion did not impact valgus rotation. Also, the anterior
bundle was found to originate inferiorly on the medial epi-
condyle and not anteriorly, as described by others (22, 26).
Upon visual inspection, the anterior and posterior bands of
the AMCL tightened in reciprocal fashion as the elbow was
taken from full extension to flexion. These authors con-
cluded that the anterior band is the primary stabilizer at
30, 60, and 90 degrees of flexion, that both bands are the
coprimary stabilizers at 120 degrees of flexion, and that the
posterior band was a secondary restraint at 30 and 90 de-
grees of flexion. The PMCL did not restrict valgus rotation
except at 30 degrees where it functioned as a secondary
restraint with the posterior band. At 2 Nm of valgus load,
sectioning of the PMCL alone showed no effects. No signifi-
cant increase in valgus rotation occurred with sectioning of
other bundles if the AMCL was intact. At 60 degrees of
flexion, sectioning the anterior band of the AMCL increased
valgus rotation by 1.7 degrees. When the posterior band
and the PMCL were also cut, no changes were noted. At
90 degrees of flexion, sectioning the anterior band increased
valgus rotation by 1.0 degree, which was increased further
to 2.3 degrees with cutting of the posterior band of the
AMCL. Loss of the PMCL did not increase valgus rotation
at this position, indicating that it is a secondary restraint.
The results of this study suggest that the anterior band may
be injured in isolation with the elbow between 90 degrees
of flexion and full extension. Injury to the posterior and
anterior bands of the AMCL occurs at greater degrees of
flexion and injury to the PMCL is unlikely unless there is
complete disruption of the AMCL (23).
MCL Biomechanics—Implications for
Reconstruction
The MCL is the primary restraint to valgus stability of the
elbow (27). Selective sectioning cadaver studies have shown
the radial head to be a secondary stabilizer to valgus stress
that does not appreciably contribute to valgus stability in
the otherwise normal joint. The anterior band of the AMCL
is the primary restraint to valgus loading up to 120 degrees
of flexion, at which point the posterior band of the AMCL
is the coprimary constraint (28). Recent evidence suggests
that the capsule, PMCL, and posterior band of the AMCL
have less impact on resisting valgus instability if the anterior
band of the AMCL is intact. After sectioning of the anterior
band of the AMCL, additional release of these structures
will increase valgus rotation and forced internal rotation.
Deeper fibers of the MCL may be more isometric than
previously reported (3). Based on current biomechanical
data, reconstructions of the MCL should include the recrea-
tion of the anterior band of the AMCL and tightening at
90 degrees of flexion.
The Lateral Collateral Ligament Complex
The LCL is comprised of the AL, the RCL, and the LUCL.
The LCL originates from the lateral epicondyle at the center
of rotation of the elbow and is therefore under uniform
tension throughout flexion and extension (Fig. 2.10) (21).
The AL attaches to the anterior and posterior portions of
the sigmoid notch and stabilizes the proximal radius during
pronation and supination. The RCL blends into the AL
and stabilizes the radial head. The LUCL arises from the
lateral epicondyle and inserts into the crista supinatoris of
the ulna (21). This portion of the LCL complex is responsi-
ble for varus stability after radial head excision. It is an
important stabilizer to varus loading of the elbow and has
been implicated in posterolateral rotatory instability and
recurrent elbow dislocations (29).
FIGURE 2.10. Because the radial collateral ligament arises from
the joint center of rotation, it shows little variation regarding the
length-tension relationship with elbow flexion and exten-
sion. (Modified from An KN, Morrey BF. Biomechanics of the el-
bow. In: Morrey BF, ed. The elbow and its disorders. Philadel-
phia: WB Saunders, 1993:53–72, with permission.)
 2. Biomechanics of the Elbow 37

In a cadaver and biomechanical study by Regan and asso- stability should be secured at 90 degrees of joint flexion
ciates (21), the LCL was found to be a poorly demarcated because of the increased posterolateral laxity biomechani-
structure that blends into the lateral joint capsule deeply cally demonstrated at this position.
and the common extensor tendons superficially. These au-
thors also identified the LUCL as a discrete, structural com-
ponent of the RCL complex, being present in 90% of speci- Elbow Joint Capsule
mens dissected. Biomechanical testing revealed that the
Original studies indicated that the elbow joint capsule con-
middle fibers of the LCL complex were taut throughout
tributed significantly to elbow stability. As previously men-
elbow flexion and extension and the anterior and posterior
tioned, the collateral ligaments are intimately associated
fibers taut at all positions if varus or valgus loads were ap-
with the capsule in most anatomic dissections. Using an
plied. The LUCL was found to be taut at 110 degrees of
MTS machine, Morrey and An (25) demonstrated in 1983
flexion with valgus or no load applied to the elbow joint
that with the elbow extended, the capsule imparted 70%
and taut throughout all angles if varus loads were applied.
of the resistance to distraction, 32% of the resistance to
The ultimate failure load and stiffness of the LCL were
varus, and 38% of the resistance to valgus. This stability
reported to be less than those of the AMCL but more than
was reduced to 8% to 13% with the elbow flexed 90 degrees
those of the PMCL in this study.
(25). King et al. (35) in 1993 confirmed these findings by
Posterolateral rotatory instability of the elbow has re-
showing the capsule to have significant contributions to
cently been described by O’Driscoll et al. (31) and Bell et
stability with the elbow in extension. In a recent cadaver
al. (30). This entity involves a rotatory humeroulnar sublux-
study by Nielsen and Olsen (36), a three-dimensional test
ation followed by posterolateral subluxation or dislocation
apparatus using strain gauges and potentiometers was em-
of the radiohumeral joint. In a cadaver study, posterolateral
ployed to determine the stability afforded by the elbow cap-
rotatory instability was created by sectioning the LUCL in
sule during varus and valgus loading with the elbow flexed
eight of eight specimens tested and was eliminated with
and extended. Testing involved specimens with a puncture
suture repair of the ligament (29). The posterolateral rota-
in the capsule, complete transection of the anterior capsule,
tory instability test was described in 1991 and involves the
and complete transection of the posterior capsule with the
application of a valgus, compressive load as the elbow is
collateral ligaments spared. From full extension to full flex-
flexed from full extension with the forearm supinated (31).
ion, no laxity changes were noted for varus and valgus load-
Good clinical results have been obtained with an isometric
ing, internal or external rotation, or lateral pivot shift test-
reconstruction of the LUCL with free tendon grafts or tri-
ing. These results indicate that an elbow with intact bony
ceps fascia (31).
articulations and collateral ligaments does not acquire any
Recent reports have challenged the contention that the
increase in elbow instability with transection of the entire
LUCL is the primary stabilizer of the LCL complex to forced
capsule. However, the stabilizing effect of the capsule in the
varus and external rotation (32–34). In a study of 35 ca-
face of collateral ligament injury was not investigated in this
daver elbows, Olsen and associates (34) performed selective
study. The conclusions of this study suggest that reconstruc-
ligament sectioning of the LCL complex followed by pivot
tion of the joint capsule for purposes of increasing elbow
shift testing and LCL reconstruction with heavy suture. Iso-
stability is not warranted as long as the collateral ligaments
lated division of the AL and LUCL did not produce any
are intact or appropriately reconstructed.
significant valgus movement, external rotation, or radial
head translation during pivot shift testing. Cutting the RCL
resulted in 4 degrees of valgus laxity at 90 degrees of joint
The Impact of Radial Head Excision upon
flexion, which was not increased by combined cutting of
Elbow Kinematics
the RCL and LUCL. Isolated sectioning of the AL and the
LUCL did not increase radial head translation, but isolated The radial head contributes to elbow stability, load trans-
cutting of the RCL produced 14.2 mm of translation at 90 mission, and motion. The radial head stabilizes the forearm
degrees joint flexion. Once again, combined cutting of the and elbow by resisting valgus forces and by radiocapitellar
LCL and LUCL did not increase radial head translation. contact during gripping as load is transmitted from the wrist
Sectioning of more than half of the LCL complex was neces- to the elbow (1). An and Morrey (3) have shown that if
sary to produce any increase in external rotation. The au- the MCL and LCL are sectioned, the elbow becomes grossly
thors concluded that maximal posterolateral instability was unstable even with the radial head intact, proving that the
detected between 70 and 110 degrees of flexion and that radial head acts as a secondary stabilizer of elbow stability
the LCL was the primary constraint of the LCL complex and particularly to valgus load. However, there is minimal
with the LUCL and AL functioning as secondary con- evidence to suggest that in an otherwise normal elbow loss
straints. Isometric reconstructions of the LCL complex of the radial head has any significant impact clinically over
eliminated posterolateral instability in this study. This study the long term. Another function of the radial head is in load
suggests that surgical reconstructions for posterolateral in- transmission. As previously mentioned, the radiocapitellar
38 The Athlete’s Elbow
FIGURE 2.11. Graph illustrating that the radial head assumes
a stabilizing role in resisting valgus stress only after the medial
collateral ligament is released, defining it as a secondary stabilizer
to valgus stress. (Modified from Morrey BF, Tanaka S, An
KN. Valgus stability of the elbow: a definition of primary and
secondary constraints. Clin Orthop 1991;265:187–195, with per-
mission.)
joint also transmits up to 60% of the axial force from the
forearm to the arm, depending on position of the forearm,
elbow, and wrist (1). Lastly, the radial head governs forearm
rotation through its articulation with the proximal ulna.
The importance of the MCL as the primary stabilizer to
valgus load and the radial head as the secondary stabilizer
is widely known (Fig. 2.11) (27). Cadaver studies have
shown that the radial head is responsible for 28% to 30%
of total valgus stability and excising it compromises the
capability of the elbow joint to resist valgus forces but does
not increase laxity to valgus stress (25,48,49). Mathematical
models using physiologic cross-sectional area of muscles,
moment arms, and muscle fiber length have shown that
forces of up to 5.4 kN are concentrated in the coronoid
process after radial head excision, as the ulna must transmit
the humeroradial load (50). Sojbjerg et al. (51) found in
an experimental model that excision of the radial head cre-
ates laxity of the elbow in forced varus and forced external
rotation. These findings were confirmed in a recent biome-
chanical study investigating the effect of radial head excision
upon elbow kinematics using a three-dimensional kinematic
testing apparatus by Jensen et al. (52). Seven osteoligamen-
tous elbow specimens were tested during loaded and un-
loaded flexion and extension of the elbow after radial head
excision. In unloaded specimens, radial head excision re-
sulted in a 1.6-degree maximum varus displacement at 20
degrees of elbow flexion and a maximum external rotation
of 3.2 degrees at 110 degrees of flexion. After 0.75 Nm of
load, a maximum laxity of 3.3 degrees of forced varus at
20 degrees of flexion and a maximum laxity of 8.9 degrees of
forced external rotation at 10 degrees of flexion was created.
Excision of the radial head did not increase laxity to valgus
loading or forced internal rotation and forearm pronation
and supination had no effect in this model. This model
differed from that of other studies in that the forearm was
allowed to freely rotate during testing. The radial head was
shown to act as a stabilizer to forced varus and forced exter-
nal rotation, similar to the LUCL reported in other studies
(53), but to a lesser degree. It was also observed that excision
of the radial head created laxity in the LCL complex, which
may be responsible for the noted increase in laxity in forced
varus and external rotation. These results suggest that radial
head excision does alter the basic kinematics of the elbow
even with intact collateral ligaments.
Considering the recent biomechanical data, excision of
the radial head obviously alters elbow kinematics and distri-
bution of load transmission. The results of primary radial
head excision for comminuted radial head fractures with or
without combined elbow dislocation are good with up to
70% of patients being satisfied, free of pain, and having no
restrictions in work and daily activities (54). However, the
rigorous forces that throwing places on the elbow have not
been investigated biomechanically with regard to partial or
complete radial head excision and its impact on elbow kine-
matics. Every effort should still be used to salvage the radial
head in all patients and particularly throwing athletes to
maintain optimal elbow kinematics.
The Effect of the Proximal Ulna upon
Elbow Stability
Historically it has been clinically acceptable to treat some
fractures of the olecranon with excision of the fracture frag-
ments and triceps tendon advancement. In clinical studies,
up to 80% of the olecranon has been excised with good
clinical results and no resultant instability as long as the
coronoid process and semilunar notch of the ulna remain
intact (55). An et al. (56) investigated the effect of the hu-
meroulnar joint upon static elbow stability in a biomechani-
cal study of eight cadaver specimens. After testing at full
extension and 90 degrees of flexion with four different load-
ing modes, they concluded that the constraint of the humer-
oulnar articulation was linearly proportional to the amount
of remaining olecranon. The proximal olecranon effectively
contributed resistance to varus loading, joint distraction,
volar displacement, and external and internal rotational dis-
placement (56). Recent unpublished data suggest that re-
moval of very small amounts of the olecranon process may
increase strain in the anterior band of the MCL. In a study
of five cadaver specimens, serial resections of the posterome-
dial surface of the olecranon at 0, 3, 6, and 9 mm were
performed. The strain patterns in both the anterior and the
posterior bands of the AMCL increased with progressive
resections, with the greatest increase occurring between 3
and 6 mm. In intact specimens, strain was transferred from
the posterior portion of the AMCL to the anterior portion
between 90 and 60 degrees of flexion. The study shows that
resection of normal bone and cartilage of the posteromedial
olecranon of more than 3 mm will increase the strain in
the MCL. These data provide new insight into the treatment
of posterior elbow impingement in throwing athletes. Pos-

teromedial olecranon resection may worsen symptoms in
patients with MCL insufficiency (ElAttrache NS, Rosen JE,
Morrey BF, et al. The effects of posteromedial olecranon
resection on motion of the elbow and ulnar collateral liga-
ment strain. Presented at the Closed Meeting of the Ameri-
can Shoulder and Elbow Surgeons, Philadelphia, 1999).
The proximal ulna has significant influence on elbow
stability and should be maintained in fractures of the olecra-
non if possible. One explanation as to why some patients
do well with olecranon excision and triceps advancement
is the triceps may dynamically increase the stability of the
elbow when portions of the olecranon are missing. Recent
evidence indicates that posterior olecranon spur excision
and debridement during elbow arthroscopy may increase
stresses in the MCL, which may be undesirable in throwing
athletes with posterior elbow impingement and MCL insuf-
ficiency.
FORCE TRANSMISSION
Load transmission from the wrist across the elbow has been
extensively studied. The variable results reported in the liter-
ature are likely secondary to limitations in experimental de-
signs. As experimental models continue to evolve, more in-
formation is being ascertained to expand current
understanding of how forces are transmitted in the forearm
and elbow in static and dynamic states.
Radioulnar Load Sharing in the Forearm
In 1860, Lopes (37) introduced the classic concept that
force transmission between the radius and ulna occurred
through the interosseous membrane. This view is further
corroborated by the anatomic observation of the downward
and medially directed fibers of the interosseous membrane.
Palmer and Werner (38) in 1984 studied 16 specimens with
the forearm in neutral rotation and reported that 82% of
the load sharing was through the radius and 18% through
the ulna. The importance of forearm rotation and degree
of elbow flexion during loading was reported by Ekenstam
et al. (39); they concluded that elbow flexion and forearm
pronation reduced the load transmitted to the radiocapi-
tellar joint. The position of the wrist has also been demon-
strated to influence patterns of loading. Trumble et al. (40)
in a cadaver study of ten elbows reported that 17% of the
axial forearm load was borne by the ulna in neutral wrist
position. Wrist extension and ulnar deviation increased the
amount of load transmitted through the ulna and wrist flex-
ion and radial deviation decreased it. It has also been shown
that lengthening the ulna by 2.5 mm increases the load
borne by the ulna from 18.4% to 41.9% and shortening it
decreases the load to 4.3% (38). These studies indicate that
multiple factors help determine the degree of measured load
2. Biomechanics of the Elbow 39
transmitted to and across the elbow, including position of
elbow flexion, degree of pronation or supination, ulnar
length, wrist position, and technique of measurement.
The importance of the integrity of the interosseous mem-
brane has a significant clinical impact in managing fractures
of the radial head. Proximal migration of the radius may
occur with primary and delayed radial head excision. The
central portion of the interosseous membrane has been dem-
onstrated to make up most of its stiffness and is three to
four times thicker than the peripheral attachments. In an
anatomic and mechanical study, Hotchkiss et al. (41) re-
ported that the central band of the interosseous membrane
was responsible for 71% of its stiffness after radial head
excision, and the triangular fibrocartilage complex 8%. The
average stiffness of the interosseous membrane was 116 N/
mm and was more in supination than pronation. The in
vitro stiffness of the silicone radial head prosthesis in the
same model was 18.2 N/mm to longitudinal compression.
These authors concluded that as the forearm supinates, the
interosseous membrane assumes a configuration that is stif-
fer, which may reflect greater accommodation of load trans-
mission in this position. They also concluded that silicone
prosthetic replacement has insufficient stiffness to axial
compression to prevent proximal radial migration. Markolf
et al. (42) demonstrated that the interosseous membrane
plays a minimal role in load transmission with the elbow
in the valgus position but assumes more importance with
elbow flexion and varus. Dynamic gripping activities and
forearm supination may place more force across the interos-
seous membrane than biomechanical models that test the
elbow in only the valgus, extended position.
Force Transmission through the
Radiocapitellar and Humeroulnar Joints
Force transmission across the elbow joint is a complex, dy-
namic process most certainly dependent on elbow, forearm,
and wrist position as well as the degree of muscular contrac-
tion. Most current knowledge stems from cadaver biome-
chanical studies using various models and techniques to
measure force distribution. In 1964, Halls and Travill (43)
performed a cadaver biomechanical study investigating the
distribution of force across the elbow joint using pressure-
sensitive transducers. They observed that 57% of a 147-
N load applied to the hand was transmitted through the
humeroulnar joint and 43% through the radiocapitellar
joint, not accounting for elbow and hand position. Morrey
et al. (44) studied force transmission through the radial
head in three cadaver specimens using force transducers and
reported that the greatest force transmission occurred from
0 to 30 degrees of flexion and when the forearm was pro-
nated. The load transmitted across the humeroulnar joint
increased with greater degrees of elbow flexion. The line of
pull of the brachialis muscle created a more medially di-
40 The Athlete’s Elbow
rected vector that projected over the lateral portion of the
trochlea (44). This force vector may account partially for
the decrease in loading of the radiocapitellar joint with in-
creasing elbow flexion.
In an excellent, recent cadaver study, Markolf et al. (42)
studied the effects of elbow position, forearm position, and
ulnar shortening upon force transmission from the wrist to
the elbow. To determine the pattern of force transmission,
they inserted custom-designed miniature load cells into the
distal end of the ulna and the proximal end of the radius
in ten cadavers. A servohydraulic testing machine (MTS)
was used to deliver a constant load of 134 N with the elbow
valgus and varus alignment and varying degrees of flexion
with the forearm ranged from 60 degrees of pronation to
60 degrees of supination. With the elbow in valgus align-
ment, the average force in the distal ulna did not change
with any degree of pronation or supination or at any angle
of elbow flexion. The mean force at the distal end of the
ulna in neutral forearm rotation, valgus elbow alignment,
and 45 degrees of flexion was 2.8% of the total load applied
to the wrist. This value did not change significantly with
forearm rotation. The proximal end of the ulna had a mean
force of 11.8% with 20 degrees of supination that decreased
to 0% with 60 degrees of pronation. During testing with
the elbow in varus alignment and 45 degrees of flexion, the
mean force in the distal ulna increased to 7% in neutral
rotation and to greater values with pronation and supina-
tion. The mean force in the proximal ulna was 93% in this
position. The authors concluded that the load transmitted
through the interosseous membrane was significantly
greater in varus elbow alignment than valgus alignment,
regardless of forearm position and elbow flexion. With the
elbow in valgus alignment, the force transmitted through
the interosseous membrane decreased with forearm prona-
tion, because most of the load was maintained within the
radius and crossed the radiocapitellar joint. The mean force
in the distal ulna progressively increased and the mean force
in the proximal radius progressively decreased with incre-
mental shortening of the distal radius (as seen after a Colles
fracture). Increased radial shortening of 2, 4, and 6 mm
each resulted in a significant increase in force transmission
through the interosseous membrane. This study demon-
strates that if there is radiocapitellar contact, the interos-
seous membrane has little load-bearing function. If there is
no radiocapitellar contact, as in varus elbow alignment, the
load-bearing function of the interosseous membrane be-
comes increasingly important. Little load is borne by the
distal ulna in any position.
Authors’ Conclusions—Force
Transmission
Although reported to bear anywhere from 3% to 43% of
axial load to the forearm (38,39,43,45,46), the distal ulna
probably has a minimal role in load bearing. The distal
Applied force
40% 60%
FIGURE 2.12. The majority of axial load is transmitted through
the radiocapitellar joint with the elbow in full extension and pro-
nated. (Modified from An KN, Morrey BF. Biomechanics of the
elbow. In: Morrey BF, ed. The elbow and its disorders. Philadel-
phia: WB Saunders, 1993:53–72, with permission.)
radius absorbs most of the axial load at the wrist and the
direction of force transmission afterward is a function of
radiocapitellar contact (Fig. 2.12). If the forearm is pronated
with the elbow in valgus alignment, most force transmission
is maintained within the radius and the interosseous mem-
brane has little load-bearing function. If the elbow is in
varus alignment with minimal or no radiocapitellar contact,
most of the axial load is transmitted from the distal radius
to the proximal ulna through the interosseous membrane.
ELECTROMYOGRAPHIC ANALYSIS
EMG analysis has evolved into a useful aid to increase our
understanding of elbow dynamics during throwing. Knowl-
edge of the joint reactive forces and muscle-activation pat-
terns during activities of daily living is helpful before exam-
ining those encountered during athletic activities.
Various methods have emerged to test the dynamic mus-
cular forces, joint reactive forces, and effects of the muscular
moment arms upon elbow biomechanics (57–62). Isomet-
ric elbow flexion strength in healthy individuals has been
studied (63). Askew et al. (63) determined that mean exten-
sion strength in their population of middle-aged subjects
was 61% of the mean flexion strength and pronation 86%
of supination. Men were approximately twice as strong as
women when testing elbow flexion, pronation and supina-
tion, and grip strength. The dominant extremity was 6%
stronger than the nondominant (63). Although frequently
considered a non–weight-bearing joint, elbow joint reaction
forces during normal activities range from 0.3 to 0.5 times
body weight and potentially up to two times body weight
with strenuous lifting (57). In a study by An et al. (57), the

magnitude and orientation of the joint reaction force was
dependent on which muscles were activated and the posi-
tion of elbow flexion. When the brachioradialis was used
for pronation and supination, the joint reaction force was
located toward the rim of the trochlear notch. When the
biceps or brachialis was used, the resultant joint force moved
from the outer rim to the center of the trochlear notch with
flexion of the elbow (57). These studies illustrate that the
elbow does experience significant forces in daily activities
and that multiple factors determine elbow stability at var-
ious positions. Much further study will be required to fully
understand the impact and pattern of muscle activation
about the elbow when in dynamic states.
Funk et al. (58) performed an EMG analysis in five sub-
jects to determine the pattern and degree of muscle activa-
tion with resistance to flexion, extension, adduction, and
abduction about the elbow. Bipolar wire electrodes were
inserted into the muscle bellies of the biceps brachia, brachi-
alis, brachioradialis, triceps, extensor carpi radialis, anco-
neus, extensor carpi ulnaris (ECU), and flexor carpi radialis
(FCR). They reported that with resisted elbow flexion, the
EMG activity in the biceps, brachialis, and brachioradialis
progressively increased with increasing load while the exten-
sor muscles were relatively quiet until greater loads. The
extensor carpi radialis and FCR showed moderate activity
at varying degrees of flexion. With resisted elbow extension,
the anconeus and triceps showed significant activity that
increased with greater resistance while the major flexor mus-
cles were relatively somnolent. Interestingly, when varus and
valgus loads were applied to the joint, most of the muscles
tested were not active except for the anconeus, which was
relatively active with resisted varus stress. These authors con-
cluded that the static articular and ligamentous restraints
were primarily responsible for resistance to varus and valgus
loading of the elbow. The level and degree of muscle activa-
tion is dependent on the relationship between the externally
applied load and its direction, the line of pull of the muscles,
and the constraint of the articular and ligamentous stabiliz-
ers. For the elbow joint, the magnitude of the resultant
muscle force to a given load is dependent on the degree of
external load and occurs about the flexion-extension joint
axis and not the varus-valgus axis due to the anatomic orien-
tation of the muscle line of pull. This has particular implica-
tions in understanding pathological elbow problems in the
throwing athlete because the muscles may not exert much
protective resistance to valgus loading. However, in a subse-
quent study, An and Morrey (3) demonstrated that contrac-
tion of the biceps, triceps, and brachialis to only 5% of
maximal force reduced valgus joint laxity significantly in
MCL-excised elbow specimens. It is probable that muscular
activation about the elbow increases stability by joint
compression and unloads the static stabilizers. In cases of
MCL insufficiency, the pattern of muscle activation may
be different, as most of these data were obtained in patients
with normal MCLs.
2. Biomechanics of the Elbow 41
EMG ANALYSIS: INDIVIDUAL MUSCLES
Most studies show a high degree of variability between sub-
jects during EMG testing (58,64–66). The degree to which
the muscles are activated, which muscles are activated, and
the movement or arm position that stimulates activation of
the muscles vary widely among individuals. The timing of
activation and relaxation of the specific muscles during a
given motion is also variable. The following section is a
summary of the findings of EMG research on individual
muscles about the elbow.
Biceps Brachii
The biceps muscle is generally active during flexion of the
supinated or semisupinated forearm. Both the long and
short heads have similar action, but the long head is gener-
ally more active in most movements. The biceps muscle
plays minimal role in flexion of the pronated forearm proba-
bly because of its tendency to supinate, which is reflexively
inhibited. It does not appear active during normal supina-
tion of the forearm but is recruited for resisted supination
when power is needed. The most effective forearm position,
however, for powerful elbow flexion is slight supination or
neutral, despite that the biceps muscle is a strong supinator
(66).
Brachialis
EMG analysis demonstrates that the brachialis is a flexor
of the arm with the forearm in the supinated, neutral, or
pronated position (64).
Brachioradialis
The brachioradialis is not appreciably active during elbow
flexion and extension in the unloaded state. If weight is
being lifted, it becomes moderately active with elbow flexion
with the forearm pronated or neutral and less active with
forearm supination. Other studies have shown the brachior-
adialis is least active with the forearm pronated (65). The
brachioradialis is a significant supinator with the arm pro-
nated and a significant pronator with the arm supinated
(62).
Anconeus
The anconeus is active during initial elbow extension and
continues through elbow extension until the triceps acti-
vates, at which time it decreases. It is responsible for fine
control and is more active in pronation than supination
(67). The anconeus also helps to generate a valgus load at
the elbow, which may help to unload the LCL complex
(62).
42 The Athlete’s Elbow
Triceps
The triceps muscle is active during elbow extension. It also
exerts a valgus moment at the elbow in full extension that
may resist varus stress and stress-shield the LCL complex
(62). It also functions as an adductor of the arm (67).
PITCHING AND ELBOW BIOMECHANICS
The art of pitching involves exact coordination of the entire
body with sequential activation of various body parts to
culminate in maximal velocity at the time of ball release.
Arm motion is rapid and violent, so elbow injuries in pitch-
ers are common. The peak angular velocities during throw-
ing have been found to be 6,180 degrees per second for
shoulder internal rotation and 4,595 degrees per second for
elbow extension (68). Peak elbow accelerations have ranged
from 225,000 to 500,000 degrees per second (68,69). The
elbow flexes from 90 to 120 degrees during the early acceler-
ation phase and rapidly extends to 25 degrees of flexion
at ball release (68). Stresses at the elbow occur during the
acceleration and follow-through phases, which lasts approxi-
mately 15 ms. During this period, the arm undergoes organ-
ized deceleration, which requires normal functioning elbow
musculature to prevent the articular and ligamentous stabi-
lizers from absorbing all of the force (68).
To better understand the biomechanics of the elbow dur-
ing pitching, we divide the pitch into five phases (Fig. 2.13).
During the windup and stride phases, the elbow is not sub-
jected to significant forces. In the arm-cocking phase, con-
traction of the wrist flexor-pronator group generates a varus
torque to counter the valgus extension loading of the MCL,
which is not strong enough to resist the torque by itself
(70). The anconeus and triceps are also active during this
phase to decrease the stress on the MCL by compressing the
Wind-up Early Late
cocking cocking
FIGURE 2.13. Illustration of the five phases of throwing. (Modified from Johnston J, Plancher
KD, Hawkins RJ. Elbow injuries in the throwing athlete. Clin Sports Med 1996;15:307–329, with
permission.)
joint and conferring dynamic stability. During acceleration,
triceps activity increases and biceps activity decreases. When
the arm reaches maximum internal rotation, the decelera-
tion phase begins with increased contraction seen in the
biceps, triceps, wrist flexors, and wrist extensors (to counter
wrist flexion). The trunk and legs help to dissipate forces
during the follow-through phase (70).
In a study by Werner et al. (70), video data and surface
EMG activity of the biceps, triceps, wrist flexor pronators,
wrist extensors, and anconeus were recorded for seven base-
ball pitchers during throwing. The elbow musculature was
fairly silent during the windup and stride phases. During
the arm-cocking phase, the elbow was subjected to a valgus
extension load that was resisted by the MCL and the wrist
flexor-pronator group primarily with assistance from the
triceps and anconeus to compress the joint and unload the
MCL. At maximal shoulder external rotation, the triceps
activity increased and the biceps activity decreased to allow
for rapid elbow extension. Other studies have shown that
with a paralyzed triceps muscle, up to 80% of normal ball
speed may be obtained, indicating that the triceps muscle
is not primarily responsible for generating elbow extension
velocity. Increased activity was again seen in the wrist flexor-
pronator muscles, triceps, and anconeus during accelera-
tion. At deceleration, biceps activity was required to gen-
erate and elbow flexion torque to decelerate the elbow
followed by contraction of all muscles to prevent joint dis-
traction and ligament strain at follow-through. This study
demonstrated the importance of proper throwing mechan-
ics, timing, and sufficient muscle strength and stamina to
prevent elbow ligament and joint injury during pitching.
EMG analysis has also been used to compare pitchers
with healthy elbows to those with MCL insufficiency (71).
In a study of 10 competitive baseball pitchers with MCL
insufficiency and 30 uninjured competitive pitchers, EMG
and high-speed film were used to study differences in mus-
Acceleration Follow-through

cle-activation patterns during throwing. Pitchers with MCL
insufficiency demonstrated a decrease in mean velocity with
65 mph for the fastball and 53 mph for the curveball com-
pared to 72 mph and 56 mph in healthy pitchers. The
extensor carpi radialis longus (ECRL) and extensor carpi
radialis brevis (ECRB) showed increased activity for both
types of pitches in the injured pitchers. The pronator teres,
triceps, and FCR all had less activity during the fastball
pitches while only the triceps during the curveball pitches.
These differences were noted mainly in the late cocking and
early acceleration phases when stresses are greatest on the
MCL. The activity of the pronator teres and FCR was para-
doxically decreased in the MCL-deficient elbows, predispos-
ing the joint to further injury with continued throwing.
The injured pitchers also demonstrated increased ECRB
and ECRL signal that was not statistically significant.
Healthy pitchers showed greater FCR activity for the fastball
than the curveball because the forearm was in greater prona-
tion for the fastball. The biceps was also studied and no
significant differences were found, implying that it does not
confer a protective or adaptive effect in MCL insufficiency.
The supinator, triceps, and brachioradialis muscles showed
some changes in injured pitchers, but those changes were
not thought to result from the MCL insufficiency or to be
instrumental in its prevention. The authors concluded that
all muscles monitored except the biceps showed altered ac-
tivity. Whether these changes were primary leading to injury
to the MCL or secondary because of incompetence of the
MCL was not determined. This study emphasized that reha-
bilitation programs should focus on strengthening of the
FCR and pronator teres (71).
Based on anatomic studies, the flexor digitorum superfi-
cialis, flexor carpi ulnaris, and FCR have close proximity
to the MCL and would be expected to contribute some
dynamic stability to valgus stress in throwing athletes (72).
In Fact, the flexor digitorum superficialis has some fibers
originating from the MCL. Hamilton et al. (73) used high-
speed video and EMG analysis to study muscle activity in
26 collegiate or professional baseball pitchers with MCL
insufficiency that was documented surgically and subse-
quently reconstructed. Their study demonstrated that pitch-
ers with healthy elbows and pitchers with valgus instability
had similar patterns of muscle activity on EMG analysis.
In injured pitchers, the FCR had decreased activity in late
cocking and early acceleration and the flexor carpi ulnaris
had decreased activity in all phases of throwing. A slight
increase in signal was noted in the ECRL and ECRB in
elbows with MCL insufficiency, but this was not statistically
significant. Again it was observed that the flexor digitorum
superficialis, flexor carpi ulnaris, and FCR had a paradoxical
decrease in activity in injured elbows, as these muscles seem
the most appropriate to provide compensatory stability. It
was postulated that these muscles may be injured as well,
preventing them from affording dynamic stability (73).
EMG analyses of anterior shoulder instability have shown
2. Biomechanics of the Elbow 43
the subscapularis to have decreased activity in throwing ath-
letes as well, indicating that the instability may induce re-
flexive inhibition of activity in stabilizing musculature about
the shoulder and elbow (74). Therefore, there is no evidence
to suggest the elbow musculature provides dynamic stabil-
ity in MCL insufficiency in any studies based on EMG
analyses.
BIOMECHANICS OF THE ELBOW IN TENNIS
During tennis playing, the elbow serves as a link in the
kinetic chain, allowing transfer of kinetic energy from the
body to the racquet. Efficient energy transfer and appropri-
ate stroke biomechanics minimize tensile stresses, eccentric
muscle contraction, and impact forces and help prevent in-
jury. High-speed video analysis studies demonstrate that
during the serve, the elbow moves from 116 degrees to 20
degrees of flexion within 0.21 seconds, with ball impact
occurring at approximately 35 degrees of flexion. During
ground strokes, observed flexion and extension is less with
11 degrees of elbow tension on the forehand (46 to 35
degrees) and 18 (48 to 30) on the backhand. Pronation and
supination range from 15 degrees of supination to 70 de-
grees of pronation at ball impact during the service motion
(75). The calculated angular velocity during the service mo-
tion is 982 degrees per second for elbow extension and 347
degrees per second for forearm pronation. These data reveal
the extreme forces that the elbow and other links of the
kinetic chain must absorb repetitively during tennis strokes.
These forces produce repetitive tensile stresses on the elbow
ligaments and supporting musculature as well as shear and
compressive loads on the bony articulations. Proper stroke
biomechanics have been shown to decrease elbow injury
(76–79).
BIOMECHANICS OF TENNIS ELBOW
Tennis elbow or lateral epicondylitis afflicts up to 40% to
50% of recreational tennis players. The backhand stroke
has been most commonly implicated, whereas the forehand
and serve usually cause medial epicondylitis (80). The etiol-
ogy of tennis elbow is likely the result of repetitive micro-
trauma and eccentric muscular contractions from tensile
stresses that occur at ball impact. Repetitive contraction of
the wrist extensors is required to stabilize the wrist and hold
the racquet. Most modern rackets continue to oscillate after
impact, transferring vibrations to the arm. With the racket
held in hand, the vibrations diminish within five to ten
cycles and a tighter grip of the racket hastens energy removal
from the frame. However, the tighter the grip, the greater
the magnitude of vibrations transmitted to the hand as well
as the duration of those oscillations (81). A stiffer racket
frame will deform less at ball impact, transmit less vibration
to the arm, and dampen out the vibrations more quickly
44 The Athlete’s Elbow
(82). Properly striking the ball also reduces the energy trans-
ferred to the wrist. A ball struck at the periphery of the
racket generates a twisting, angular momentum separate
from the linear momentum of the swing that necessitates
additional muscular contraction to counter, as well as di-
minishes ball speed (82).
Backhand technique has also been implicated in the gen-
esis of lateral epicondylitis (77). Players using a one-handed
backhand technique have a higher incidence of tennis elbow
than those using a two-handed technique. It has been deter-
mined that a one-handed backhand requires the use of five
body parts before ball impact. After stepping into the ball,
the hips turn, the trunk rotates, and the upper arm moves
about the shoulder. The upper arm movement is transferred
to the forearm and then to the hand for impact. Compara-
tively, the two-handed backhand requires only two body
parts. After the hips rotate, the trunk and arms rotate as a
unit, requiring no movement at the elbows or wrists until
impact (77). One-handed backhand players are subject to
easier disruptions in swing kinetics due to the greater com-
plexity of the swing and greater impact forces incurred due
to the lack of support from the other arm, both of which
may contribute to the increased incidence of lateral epicon-
dylitis.
Skill level is an important factor in the development of
tennis elbow in tennis players. Unskilled players have more
mishits at the racket periphery, less coordination of the ki-
netic chain, lack of strength and endurance, and improper
technique. Knudson and Blackwell (76) performed electro-
goniometer, strain gauge, and accelerometer analyses of one-
handed backhand strokes in three groups of players: profes-
sionals with no history of tennis elbow, intermediates with
no history of tennis elbow, and intermediates with tennis
elbow (76). They found that the intermediates with tennis
elbow had an angular wrist flexion velocity before impact,
compared to the professionals and intermediates without
tennis elbow who had a wrist extension velocity. The profes-
sionals continued to extend their wrists after impact,
whereas the intermediates with tennis elbow developed
more wrist flexion. Elbow goniometer data revealed that
this group was not using the ‘‘leading elbow’’ technique
common to many novices. This study suggests that wrist
position at ball impact and follow-through may be an im-
portant factor in the development of lateral epicondylitis.
Repetitive, eccentric contractions of the wrist extensors in-
crease the likelihood of tendon damage and subsequent de-
velopment of tennis elbow.
EMG ANALYSIS OF TENNIS ELBOW
EMG studies have shown that the wrist extensors are heavily
involved in the serve, forehand, one-handed backhand, and
two-handed backhand (79,83,84). Morris et al. (83) used
indwelling wire electrodes in the extensor digitorum com-
munis (EDC), ECRL, ECRB, pronator teres, and FCR to
perform EMG analysis on nine professional and collegiate
tennis players. They found that the wrist extensors, particu-
larly the ECRB, were very active in the acceleration and
follow-through phases of the backhand. In the forehand,
the ECRB had significantly elevated activity in the prepara-
tory and acceleration phases. The wrist extensors were also
the predominant muscle activity during the cocking phase
of the serve and acceleration. These authors concluded that
the wrist extensors were very active in all tennis strokes,
predisposing them to overuse injury (83).
EMG analysis was also used to compare the differences
in muscle-activation patterns between the one-handed and
the two-handed backhand techniques in 25 college and
professional tennis players (79). There were no significant
differences with regard to wrist extensor activity between
the two groups. However, there was greater activity seen in
the FCR in the preparation phase and in the pronator teres
in the acceleration phase with the two-handed technique,
which the authors attributed to the relatively pronated grip.
These authors postulated that the pronated grip stabilizes
the elbow ligaments more readily, allowing impact forces
to be transmitted through the elbow rather than the extensor
tendons. The change in grip and swing biomechanics likely
explains the decrease of lateral epicondylitis in players using
the two-handed backhand. Changing the size of the grip
has not been shown to alter muscle-activation patterns dur-
ing the backhand by EMG analysis and likely will not allevi-
ate symptoms of tennis elbow (85).
Increased activity in the wrist extensors has also been
demonstrated in patients with tennis elbow. Kelley et al.
(84) performed an EMG analysis of the EDC, ECRL,
ECRB, FCR, and pronator teres in eight players with lateral
epicondylitis and 14 normal upper extremities. The back-
hand stroke was selected for study using high-speed film
and synchronized with the EMG signal. They discovered
a statistically significant increase in wrist extensor muscle
activity in four of the six phases of the backhand swing.
Video analysis demonstrated the injured players to strike
the ball with the ‘‘leading elbow’’ and the wrist flexed, leav-
ing the forearm and elbow in a less stable position to resist
impact forces. The ECRB showed less activity in early accel-
eration due to the flexed position of the wrist, further cor-
roborated by the significant increase in signal of the FCR
at the same time. The FCR signal was increased in the
injured group during the early acceleration and late follow-
through phases. The abnormal EMG findings were consis-
tent with the abnormal stroke biomechanics in players with
a leading elbow: wrist flexion and pronation at impact with
ball contact in the lower portion of the racket. This study
population was in the subacute clinical phase of lateral epi-
condylitis and did not have acute pain during backhand
stroke testing, suggesting that these findings may be reflec-
tive of the abnormal biomechanics that produced the ten-

don injury and not those that resulted from it. The unusual
EMG finding of increased activity in injured muscles may
be explained by the subacute clinical setting of the study.
These authors concluded that faulty mechanics are the likely
prerequisite to the development of tennis elbow.
CONCLUSIONS
The elbow is a complex joint primarily stabilized by the
collateral ligaments and bony articulations. Recent data
have demonstrated more clearly that force transmission
across the elbow is dependent on the position of the elbow,
forearm, and wrist. The anterior band of the MCL is the
primary stabilizer to valgus stress and should be the focus
of surgical reconstruction for MCL insufficiency. Although
current anatomic dissections have shown that the deeper
portions of the MCL are more isometric than previously
thought, they have reaffirmed that the AMCL and PMCL
have a reciprocal relationship with regard to tension during
flexion and extension of the elbow. The radial head and
proximal olecranon should be preserved if possible to main-
tain more normal biomechanics. EMG analysis has been
helpful in determining muscle-activation patterns in throw-
ing athletes but has failed to unveil which adaptations are
necessary to prevent symptomatic MCL insufficiency and
what should be the primary area of focus for rehabilitation
programs.
Advances in experimental designs and testing apparatuses
have contributed significantly to further elucidating the
complex relationship between the dynamic and static elbow
stabilizers and how they change with varying elbow posi-
tions during testing. Future research should focus on in-
creasing the understanding of dynamic elbow stability in
normal and pathological states.
References
1. King GJW, An K. Biomechanics and functional anatomy of the
elbow. In: Norris TR, ed. Orthopaedic knowledge update: shoulder
and elbow. Rosemont: American Academy of Orthopaedic Sur-
geons, 1997:301–310.
2. Youm Y, Dryer RF, Thambyrajah K, et al. Biomechanical analysis
of forearm pronation-supination and elbow flexion-extension. J
Biomech 1979;12:245–255.
3. An KN, Morrey BF. Biomechanics of the elbow. In: Morrey BF,
ed. The elbow and its disorders. Philadelphia: WB Saunders, 1993:
53–72.
4. London JT. Kinematics of the elbow. J Bone Joint Surg Am 1981;
63A:529–535.
5. Mori K. Experimental study on rotation of the forearm. J Jpn
Orthop Assoc 1985;59:611–622.
6. O’Driscoll SW, Bell DF, Morrey BF. Posterolateral rotatory in-
stability of the elbow. J Bone Joint Surg Am 1991;73A:440–446.
7. Johansson O. Capsular and ligament injuries of the elbow joint:
a clinical and arthrographic study. Acta Chir Scand 1962;[Suppl
287]:1–159.
2. Biomechanics of the Elbow 45
8. Hudson TM. Elbow arthrography. Orthop Clin North Am 1981;
19:227–241.
9. O’Driscoll SW, Morrey BF, An KN. Intraarticular pressure and
capacity of the elbow. Arthroscopy 1990;6:100–103.
10. Morrey BF. Post-traumatic contracture of the elbow. Operative
treatment, including distraction arthroplasty. J Bone Joint Surg
Am 1990;72A:601–618.
11. Gallay SH, Richards RR, O’Driscoll SW. Intraarticular capacity
and compliance of stiff and normal elbows. Arthroscopy 1993;9:
9–13.
12. Goel VK, Singh D, Bijlani V. Contact areas in human elbow
joints. J Biomech Eng 1982;104:169–175.
13. Eckstein F, Lohe F, Muller-Gerbl M, et al. Stress distribution in
the trochlear notch: a model of bicentric load transmission
through joints. J Bone Joint Surg Br 1994;76B:647–653.
14. Eckstein F, Muller-Gerbl M, Steinlechner M, et al. Subchondral
bone density in the human elbow assessed by computed tomogra-
phy osteoabsorptiometry: a reflection of the loading history of
joint surfaces. J Orthop Res 1995;13:268–278.
15. An KN, Himeno S, Tsumura T, et al. Pressure distribution on
articular surfaces: application to joint stability evaluation. J Bio-
mech 1990;23:1013–1020.
16. Eckstein F, Lohe F, Muller-Gerbl M, et al. Stress distribution in
the trochlear notch: a model of bicentric load transmission
through joints. J Bone Joint Surg Am 1994;76B:647–653.
17. Eckstein F, Lohe F, Hillebrand S, et al. Morphomechanics of
the humero-ulnar joint: joint space width and contact areas as a
function of load and flexion angle. Anat Rec 1995;243:318–326.
18. Floris S, Olsen BS, Dalstra M, et al. The medial collateral liga-
ment of the elbow joint: anatomy and kinematics. J Shoulder
Elbow Surg 1998;7:345–351.
19. Ochi N, Ogura T, Hashizume H, et al. Anatomic relation be-
tween the medial collateral ligament of the elbow and the hum-
ero-ulnar joint axis. J Shoulder Elbow Surg 1999;8:6–10.
20. Morrey BF, An KN. Functional anatomy of the ligaments of the
elbow. Clin Orthop 1985;201:84–90.
21. Regan WD, Korinek SL, Morrey BF, et al. Biomechanical study
of ligaments around the elbow joint. Clin Orthop 1991;271:
170–179.
22. Sojbjerg JO, Ovesen J, Nielsen S. Experimental elbow instability
after transection of the medial collateral ligament. Clin Orthop
1987;218:186–190.
23. Callaway GH, Field LD, Deng XH, et al. Biomechanical evalua-
tion of the medial collateral ligament of the elbow. J Bone Joint
Surg Am 1997;79A:1223–1231.
24. Pribyl CR, Wascher DC, Firoozbakhsh K, et al. Elbow ligament
strain under valgus load: a biomechanical study. Orthopedics
1999;22:607–612.
25. Morrey BF, An KN. Articular and ligamentous contributions to
stability of the elbow joint. Am J Sports Med 1983;11:315– 319.
26. Conway JE, Jobe FW, Glousman RE, et al. Medial instability
of the elbow in throwing athletes: treatment by repair or recon-
struction of the ulnar collateral ligament. J Bone Joint Surg Am
1992;74A:67–83.
27. Morrey BF, Tanaka S, An KN. Valgus stability of the elbow: a
definition of primary and secondary constraints. Clin Orthop
1991;265:187–195.
28. Fuss FK. The ulnar collateral ligament of the human elbow joint.
Anatomy, function, and biomechanics. J Anat 1991;175:
203–212.
29. O’Driscoll SW, Horii E, Morrey BF, et al. Anatomy of the ulnar
part of the lateral collateral ligament of the elbow. Clin Anat
1992;5:296–303.
30. Bell SN, Morrey BF, Bianco A. Chronic posterior subluxation
and dislocation of the radial head. J Bone Joint Surg Am 1991;
73A:392–396.