Elbow Forearm Lab 2021

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PT 518 – Biomechanics and Kinesiology Week 3

Laboratory Activities

Elbow and Forearm Complex

Readings:
 Neumann: chapter 6
 Daniels and Worthingham: chapter 5, pp 138-155.

PowerPoints:
 Elbow & Forearm Complex: Anatomy Review
 Elbow & Forearm Complex: Biomechanics

For more information:


Biel A. Trail Guide to the Body, 4th ed. Boulder, CO: Books of Discovery; 2010.
Hoppenfeld S. Physical Examination of the Spine and Extremities. Norwalk, CT:
Appleton & Lange; 1976.
Kendall FP, McCreary EK, Provance PG, et al. Muscles: Testing and Function, 5th ed.
Baltimore, MD: Lippincott Williams & Wilkins; 2005. chapter 6, pp 286-294.
Houglum PA. Brunnstromm’s Clinical Kinesiology, 6th ed. Philadelphia: FA Davis
Company; 2011.

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PT 518 – Biomechanics and Kinesiology Week 3
Laboratory Activities

Elbow Bony Anatomy

Part I – Bony Anatomy of the Elbow

A. Humerus Bony Landmark Identification


Identify the following bony landmarks of the humerus, first on Figure 1 and Figure 2 below and then on the
skeleton.

1. medial supracondylar ridge (crest)


2. medial epicondyle
3. cubital tunnel
4. trochlea
5. coronoid fossa
6. olecranon fossa
7. lateral supracondylar ridge (crest)
8. lateral epicondyle
9. capitulum
10. radial fossa

medial supracondylar ridge (crest)

lateral supracondylar ridge (crest)


coronoid fossa
radial fossa

lateral epicondyle medial epicondyle

capitulum trochlea

radial head coronoid process


radial neck radial notch (on ulna; articulates with
radial head)
bicipital or radial tuberosity
ulnar tuberosity

Figure 1 – Elbow Bony Anatomy


Anterior view

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PT 518 – Biomechanics and Kinesiology Week 3
Laboratory Activities

olecranon fossa

lateral epicondyle
medial epicondyle
olecranon process

radial head
cubital tunnel
radial neck

ulnar ridge (crest) bicipital tuberosity

Figure 2 – Elbow Bony Anatomy


Posterior view

B. Radius and Ulna Bony Landmark Identification


Identify the following bony landmarks of the radius and ulna, first on Figure 1 and Figure 2 above and then on
the skeleton.

1. coronoid process
2. radial head
3. radial neck
4. radial or bicipital tuberosity
5. radial notch (on ulna)
6. ulnar tuberosity
7. olecranon process
8. ulnar ridge (crest)

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PT 518 – Biomechanics and Kinesiology Week 3
Laboratory Activities

C. Elbow Bony Landmark Palpation


Using the diagrams and the skeleton, identify and palpate the following bony landmarks on your lab partner:

humerus
-start on the medial side of the humerus above the elbow and move inferiorly
1. medial supracondylar ridge or crest
2. medial epicondyle
3. cubital tunnel

-then move to the lateral side of the humerus


4. lateral supracondylar ridge or crest
5. lateral epicondyle

-then move to the posterior elbow


6. olecranon fossa – with the elbow flexed palpate the opening in the posterior distal humerus
7. olecranon process – with the elbow extended palpate the point of the elbow
8. ulnar ridge or crest – move inferiorly from the olecranon process on to the ulnar ridge or crest – the
“shin” bone of the forearm

-then move to the proximal foream


9. radial head – with the elbow bent, palpate distal to the lateral epicondyle to the next prominent bony
bump; pronate and supinate and feel the radial head rotate under your fingers; then try to grasp the radial
head between your fingers dorsally and your thumb ventrally
10. radial neck – move distal from the radial head on to the narrow radial neck

Part II – Joints of the Elbow


The elbow is considered to be a compound joint because it consists of 3 separate articulations enclosed within
one joint capsule: 1) humero-ulnar joint, 2) humero-radial joint, 3) proximal radio-ulnar joint.

Identify the 3 joints on the skeleton:


1. humero-ulnar joint – trochlea and trochlear notch
2. humero-radial joint – capitulum and radial head
3. proximal radio-ulnar joint – periphery of radial head and radial notch

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PT 518 – Biomechanics and Kinesiology Week 3
Laboratory Activities

Part III – Alignment


Examine the elbow joint on a skeleton. Notice the configuration of the elbow axis created by the trochlea and
capitulum.
A. With your partner in the anatomic position, does the forearm appear to be abducted (valgus) or adducted
(varus) relative to the humerus?

B. This position is the carrying angle. The carrying angle varies between males and females and within
individuals. On average, the carrying angle for males ranges from 5-15 degrees (mean 10 degrees) and for
females 10-25 degrees (mean 18 degrees) of valgus or an abducted position. Does your partner fall within these
values? Use a goniometer to measure the angle. Place one end of the goniometer along the longitudinal axis of
the humerus and the opposite end over the longitudinal axis of the forearm. Place the goniometer axis in the
middle of the anterior elbow. Remember > 20 degrees is considered excessive cubital valgus.

C. Compare the carrying angle of your partner with a member of the opposite sex. Do you notice this
difference?

Part IV – Muscle Attachment Review

A. Elbow Flexors
Review the proximal and distal attachments of the 3 primary elbow flexors on Figures 3 and 4:
1. biceps brachii – has no humeral attachment; refer to shoulder lab for proximal attachments; note distal
attachment on bicipital tuberosity
2. brachialis brachii – note attachments on anterior humerus and ulnar tuberosity
3. brachioradialis – note attachments on lateral humerus and lateral distal radius

B. Forearm Pronators
Review the proximal and distal attachments of the 2 pronators on Figures 3 and 4:
1. pronator teres – also serves as a secondary elbow flexor; note attachments by medial epicondyle and
ulna and then mid radius
2. pronator quadratus – note attachments on distal radius and ulna

C. Elbow Extensors
Review the proximal and distal attachments of the 3 heads of the triceps on Figures 5 and 6:
1. triceps long head – has no humeral attachment; refer to shoulder lab for proximal attachment; note distal
attachment on olecranon process
2. triceps lateral head – note attachment on lateral posterior humerus
3. triceps medial head – covered by long head through much of its course; note attachments through large
part of posterior humerus
4. anconeus – note attachments by lateral epicondyle and proximal lateral ulna

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PT 518 – Biomechanics and Kinesiology Week 3
Laboratory Activities

D. Forearm Supinators
Review the proximal and distal attachments of the 2 pronators on Figures 5 and 6:
3. supinator – note attachments on proximal radius and ulna
4. biceps brachii – was discussed under elbow flexors

Figure 3 – Humerus Muscle Attachments Figure 4 – Radius and Ulna Muscle Attachments
Anterior view Anterior view

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PT 518 – Biomechanics and Kinesiology Week 3
Laboratory Activities

Figure 5 – Humerus Muscle Attachments Figure 6 – Radius and Ulna Muscle Attachments
Posterior view Posterior view

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PT 518 – Biomechanics and Kinesiology Week 3
Laboratory Activities

Part V – Soft Tissue Palpations


Identify the following soft tissue structures and palpate them on your lab partner:

A. anterior elbow – cubital fossa


-cubital fossa is a triangle bordered laterally by brachioradialis, medially by pronator teres, and proximally by a
line connecting the epicondyles
-palpate these structures from lateral to medial within the cubital fossa radial head
1. radial head
2. biceps tendon
3. lacertus fibrosus – medial expansion of biceps tendon
4. brachial artery – medial to biceps tendon

B. medial elbow
1. ulnar nerve in cubital tunnel
2. area of attachment of ulnar collateral ligament – attaches from medial epicondyle to coronoid and
olecranon

C. posterior elbow
1. olecranon bursa
2. fat pad in olecranon fossa

D. lateral elbow
1. area of attachment of radial collateral ligament
2. area of attachment of annular ligament

Part VI – Muscle Palpations


Identify the following muscles and palpate them on your lab partner. Review the origin, insertion, action, and
innervation of each muscle. Demonstrate how you can elicit a contraction of each muscle in your lab partner:

A. elbow flexors
1. brachialis – attaches to (P) distal half of anterior aspect of humerus and then to (D) tuberosity of
ulna and coronoid process; palpate medial and lateral to biceps tendon and distal biceps; palpate
contraction with resisted elbow flexion with forearm pronated
2. biceps – no humeral attachment; (P) short head attaches to coracoid process and long head to
supraglenoid tubercle; 2 heads combine and attach to (D) tuberosity of radius and bicipital
aponeurosis; palpate short head as it attaches to coracoid; long head in bicipital groove; palpate
biceps tendon inserting into radial tuberosity and bicipital aponeurosis as it crosses forearm; resist
elbow flexion in supination; can grasp and pick up biceps and separate it from brachialis
3. brachioradialis – attaches to (P) proximal 2/3rd of lateral supracondylar ridge and then to (D) radial
styloid; palpate over lateral forearm; palpate contraction with elbow flexion with forearm in neutral
pronation/supination
4. pronator teres – attaches to (P) medial epicondyle and medial aspect of coronoid process and then
to (D) middle 1/3rd of lateral aspect of radius; palpate medial forearm; palpate contraction by
resisting maximum pronation

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PT 518 – Biomechanics and Kinesiology Week 3
Laboratory Activities

B. elbow extensors
1. triceps long head – no humeral attachment; attaches to (P) infraglenoid tubercle and then to (D)
posterior aspect of olecranon through a common tendon; palpate under lower fibers of posterior
deltoid near inferior glenoid; palpate contraction by resisting elbow extension overhead; OR palpate
over medial humerus while subject attempts to do a seated push up; covers most of medial head
except distally
2. triceps lateral head – attaches to proximal 2/3rd of posterolateral humerus and then to (D) posterior
aspect of olecranon through a common tendon; palpate distal to the posterior deltoid along lateral
aspect of humerus while patient performs a seated push up
3. triceps tendon – broad flat area between lateral and long heads; lateral and long head insertion
4. triceps medial head – attaches to distal 1/3rd of posteromedial humerus and then to (D) posterior
aspect of olecranon through a common tendon; covered proximally by long head; palpate medial
arm superior to medial epicondyle; palpate medial distal forearm while patient performs a seated
push up; look for groove separating medial head from long head
5. anconeus – attaches to (P) dorsal aspect of lateral epicondyle and then to (D) lateral aspect of
olecranon and proximal ¼ dorsolateral aspect of ulna; palpate lateral proximal forearm; place finger
on lateral epicondyle and thumb on olecranon; anconeus is triangular structure with base on line
between those landmarks; palpate contraction with strong elbow extension

C. supinators
1. biceps (see above)
2. supinator – attaches to (P) lateral epicondyle, radial collateral ligament, dorsolateral aspect of ulna
distal to radial notch and then to (D) proximal ¼ of radius dorsal aspect; difficult to palpate; deep to
anconeus, ECRL, brachioradialis; grasp above muscles with thumb medial and fingers lateral; pull
muscles medially; palpate supinator as forearm slowly moves from pronation to supination (see
section E)

D. pronators
1. pronator teres (see above)
2. pronator quadratus – attaches to (P) distal ¼ of anterior ulna and then to (D) distal ¼ of
anterolateral radius; lies deep to finger and wrist flexors; difficult to palpate; travels across volar
surface of distal radius, interosseous membrane, and ulna

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PT 518 – Biomechanics and Kinesiology Week 3
Laboratory Activities

E. forearm muscles – You’re trying to identify the 3 main groups of forearm muscles that attach at the
epicondyle level:  1) radial muscles, 2) dorso-ulnar muscles, and 3) volar-ulnar muscles.  The first two groups
make up the lateral epicondyle muscles.  The third group makes up the medial epicondyle muscles.  Palpate
your right arm and use your left hand to do the palpating. 
1.  radial muscles: Begin by identifying the brachioradialis.  Flex your elbow against resistance with
the forearm in a neutral position.  You'll see the brachioradialis pop up.  Place your left thumb just
medial to the brachioradialis at the level of the cubital fossa or the elbow joint line.  Then extend
your right wrist with the fingers in a relaxed flexed position.  You'll feel the ECRL and ECRB pop
up.  If you place the fingers of your left hand just lateral to the ECRB, you'll be holding the radial
group.  If you dig your fingers down deep on the lateral side of the ECRB, you should feel the
supinator.  If you forcefully supinate your forearm, you should feel it contracting.
2. dorso-ulnar muscles:  If you now move your thumb to where your fingers were resting on the
supinator, and move your fingers to the crest of the ulna close to the olecranon process, you'll be
holding the dorso-ulnar muscles.  That includes the extensor digitorum (EDC), the extensor digiti
minimi or quinti (EDQ), the ECU and the anconeus.  Extend your fingers and feel the EDC and EDQ
contracting. Extend your wrist and fell the ECU contracting.  The extensor indicis, EPB, EPL and
APL are part of that group but they originate more distal. 
3. volar-ulnar muscles:  Now pronate vigorously to feel the pronator teres contracting.  Place your
left thumb just medial to the pronator teres at the level of the cubital fossa or elbow joint line.  Wrap
your fingers around the medial muscles to rest on the ulna.  You will now be grasping the volar-
ulnar group.  That includes the pronator teres, FCR, FCU, FDS, FDP, and the PL.  You'll feel them
contracting with pronation, wrist flexion, and finger flexion.

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PT 518 – Biomechanics and Kinesiology Week 3
Laboratory Activities

Part VII – Manual Muscle Tests


Daniels & Worthingham pp 138-155.
Demonstrate patient and tester position and manual muscle test procedures for the following muscle actions.
Identify and confirm contraction of the muscles you are testing with each test.
A. elbow flexion
B. elbow extension
C. forearm supination
D. forearm pronation

We are using the break test during our manual muscle testing. In most cases the joint is moved close to end
range and then resistance is applied. The resistance attempts to “break” the muscle contracton.

Another type of manual muscle testing procedure is to use “strength through range.” In this case the
joint is allowed to move through full range, but the therapist applies the maximal amount of resistance that can
be applied and still allow movement to occur.

A. Retest the above movements but use strength through range instead of break testing.

B. What advantages and disadvantages do you see with strength through range testing?

Manual muscle testing has been criticized especially in the outpatient setting because most patients are able to
perform 4/5 or 5/5 grades. The reliability and objectivity of manual muscle testing decreases in this range. To
improve objectivity, hand held dynamometers may be used instead of manual resistance. With hand held
dynamometers the testing is often done using the “make test.” With a make test, the tester creates an
immovable object, and the subject pushes as hard as he/she can into the dynamometer.

A. Test elbow flexion using one of the hand held dynamometers. Have your subject sit with humerus by
his/her side and elbow flexed. Place the dynamometer over the volar surface of the distal forearm. Keep your
arms perpendicular to the forearm and lock your elbows over the dynamometer so that it cannot move. Have
your subject push against it with as much force as possible. (make test).

B. Alternatively, with stronger individuals, a belt can be looped over the dynamometer and down to the floor
where it is stood on by the tester. This makes a much more immovable resistance. Try this technique for elbow
flexion and extension. Test elbow flexion as above. For elbow extension have the subject lie prone on the table
with shoulder abducted 90 degrees and elbow extended. Loop the belt over the dynamometer over the distal
forearm. Then stand on the belt loop. Have the patient attempt to extend his/her elbow.

C. What are the advantages and disadvantages you see with “make” testing and the hand held dynamometer?

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PT 518 – Biomechanics and Kinesiology Week 3
Laboratory Activities

Part VIII – Elbow Lab Homework

1. Observe your partner move through full range of elbow flexion and extension.
A. Does the forearm stay in the sagittal plane with flexion and extension? How does the forearm move?
Why does this occur?
B. Does the amount of range of motion change when the joint is moved passively?

2. Observe your partner move to end range of elbow flexion.


A. What is normal elbow flexion range of motion?
B. Assess the end feel for elbow flexion by applying some overpressure at end range elbow flexion. What
kind of end feel do you observe with elbow flexion?

3. Observe your partner move to end range of elbow extension.


A. What is normal elbow extension range of motion? Do you notice any hyperextension?
B. Assess the end feel for elbow extension by applying some overpressure at end range. What kind of end
feel do you observe with elbow extension?

4. Observe your partner move to the extremes of supination and pronation.


A. What is normal range for pronation and supination?
B. What motions can be used to substitute for pronation and supination?
C. Assess the end feel for both pronation and supination. What kind of end feel do you observe?

5. In manual muscle testing, we test movements instead of muscles. However, joint positions can be changed
to emphasize different muscles.
A. In manual muscle testing supination, how can you position your subject to decrease the contribution of
the biceps?
B. Why is this not really a strength test for the supinator?

6. Palpate the biceps during elbow flexion with the forearm pronated and then with the forearm supinated.
A. Do you notice a change in biceps activity?
B. Palpate the biceps during elbow flexion with the forearm pronated with light resistance and then heavy
resistance. What do you notice now?
C. Palpate the biceps during elbow flexion with the forearm pronated with slow and quick movements.
What do you notice now?

7. Palpate the brachialis during elbow flexion with the forearm pronated and supinated.
A. Do you notice a change in brachialis activity? Why or why not?

8. The forearm position can be changed during manual muscle testing of the elbow flexors to emphasize
different muscles.
A. How would you change the forearm position to emphasize different muscles?
B. Consider a manual muscle test of the biceps. In a maximal manual muscle test, what result would you
get if the biceps is completely torn but the brachialis is normal strength?
C. What difficulties does manual muscle testing individual muscles create?

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PT 518 – Biomechanics and Kinesiology Week 3
Laboratory Activities

9. Palpate the triceps during elbow extension with the forearm pronated and supinated.
A. Do you notice a change in triceps activity? Why or why not?

10. Palpate the triceps and the biceps during the following activities. In which situations are the muscles
antagonists? Synergists?
A. pulling a rope toward you
B. lifting a load of wood from the ground
C. turning a screwdriver to put in a screw

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