Elbow, wrist, hand

Musculoskeletal overview

Authors

Affiliations

Nate Yomogida, B.S., SPT

Doctor of Physical Therapy

B.S. in Kinesiology

Chloë Kerstein, B.S., SPT

Doctor of Physical Therapy

B.A. in Neuroscience

Reading list

• Clinical Considerations of Elbow, Wrist, and Hand Pain¹
• Kinesiology / biomech
  • Elbow and forearm²
  • wrist²
  • Hand²
• MMT
  • wrist flex MMT³
  • wrist ext MMT³
  • wrist abduction (Radial dev) MMT³
  • Wrist adduction MMT³
  • Hand MMT
    • MMT³
• General
  • Ch17 elbow⁴
  • Ch 18⁴
• Examination
  • Ch19 Screening the Shoulder and Upper Extremity⁵
• Pathology
  • Elite Athlete’s Hand and Wrist Injury, an Issue of Hand Clinics⁶
  • Tendon disorders of the hand and wrist: IFSSH/FESSH instructional course book 2022⁷
• Manual tx
  • ch23 Orthopaedic Manual Physical Therapy of the Elbow and Forearm⁸
  • Ch24 Orthopaedic Manual Physical Therapy of the Wrist and Hand⁸
• Surgery
  • Management of Hand Fractures^{chungGrabbSmithPlastic2020?}
  • Management of Wrist Fractures^{chungGrabbSmithPlastic2020?}
  • Flexor Tendon Repair and Reconstruction^{chungGrabbSmithPlastic2020?}
  • Extensor Tendon Repair and Reconstruction^{chungGrabbSmithPlastic2020?}
  • Tenosynovitis Disorders of the Upper Extremity^{chungGrabbSmithPlastic2020?}
  • Principles and Applications of Tendon Transfers^{chungGrabbSmithPlastic2020?}
  • Ligament Injuries of the Hand^{chungGrabbSmithPlastic2020?}
  • Ligament Injuries of the Wrist^{chungGrabbSmithPlastic2020?}
  • Management of Mutilating Upper Extremity Injuries^{chungGrabbSmithPlastic2020?}
  • Replantation Strategies of the Hand and Upper Extremity^{chungGrabbSmithPlastic2020?}
  • Thumb Reconstruction^{chungGrabbSmithPlastic2020?}
  • Dupuytren Disease^{chungGrabbSmithPlastic2020?}
  • Hand Tumors^{chungGrabbSmithPlastic2020?}
  • Treatment of Vascular Disorders of the Hand^{chungGrabbSmithPlastic2020?}
  • Comprehensive Management of the Burned Hand^{chungGrabbSmithPlastic2020?}
  • Compartment Syndrome of the Upper Extremity^{chungGrabbSmithPlastic2020?}
  • Common Congenital Hand Anomalies^{chungGrabbSmithPlastic2020?}
  • Upper Limb Amputations and Prosthetics^{chungGrabbSmithPlastic2020?}
  • Rheumatoid Arthritis and Inflammatory Arthropathies^{chungGrabbSmithPlastic2020?}
  • Osteoarthritis^{chungGrabbSmithPlastic2020?}

Elbow Overview

3 bones:

1. Humerus
2. Radius
3. Ulna

Humerus

Medial epicondyle

Table 1: Muscles originating from the Medial Epicondyle

Muscle	Origin	Insertion	Innervation	Action
Flexor carpi radialis	Medial epicondyle	Base of 2nd Metacarpal (Sometimes base of 3rd Met)	Median n. C6 - C7	Wrist: Flexion, Radial deviation
Flexor carpi ulnaris	Medial epicondyle Olecranon	Hook of Hamate Base of 5th metacarpal	Ulnar n. C7 - T1	Wrist: Flexion, Ulnar deviation
Flexor digitorum superficialis	Medial epicondyle Coronoid process Anterior proximal half of Radius	Sides of middle phalanges 2-5	Median n. C8 - T1	Elbow: Weak flexion Wrist: Flexion 2-5 MCP & PIP: Flexion, Flexion
Palmaris longus	Medial epicondyle	Palmar aponeurosis	Median n. C6 - C7	Elbow: Weak flexion Wrist: Tightens aponeurosis
Pronator teres	Medial epicondyle Coronoid process	L:ateral radius distal to supinator	Median n. C6 - C7	Elbow: Weak flexion, Pronation

Lateral epicondyle

Table 2: Muscles originating from the Lateral Epicondyle

Muscle	Origin	Insertion	Innervation	Action
Anconeus	GHJ joint capsule	Olecranon of Ulna (radial surface)	Radial n. C6 - C8	Elbow: Extension, Tightens joint
Extensor carpi radialis brevis	Lateral epicondyle of Humerus	3rd metacarpal base	Radial n. C7 - C8	Elbow: Weak flexion Wrist: Extension, Radial deviation
Extensor carpi ulnaris	Lateral epicondyle of Humerus Ulnar head	5th metacarpal base	Radial n. C7 - C8	Wrist: Extension, Ulnar deviation
Extensory digiti minimi	Lateral epicondyle of Humerus	5th Dorsal digital expansion	Radial n. C7 - C8	Wrist: Extension, Ulnar deviation 5th MCP, PIP, DIP: Extension, Abduction
Extensor digitorum	Lateral epicondyle of Humerus	2-5th Dorsal digital expansion	Radial n. C7 - C8	Wrist: Extension 2-5 MCP, PIP, DIP: Extension
Supinator	Olecranon Lateral epicondyle Radial collateral lig. Annular lig.	Radius (between radial tuberosity and pronator teres)	Radial n. C6 - C7	Radioulnar joints: Supination

Elbow Ligaments

• Ulnar collateral ligament
• Radial collateral ligament

Radius bone

Head of Radius

Elbow Joint

Articular surfaces

Carrying Angle

Elbow Flexion & Extension

Elbow Flexion

Limits of active flexion: apposition of anterior arm and forearm muscles⁹

Limits of passive flexion with overpressure:

• Muscle compression⁹
• Bony block of radial head against radial fossa⁹
• Bony impact of coronoid process against coronoid fossa⁹
• Tension in posterior aspect of capsule⁹
• Triceps stretch tension⁹

Table 3: Elbow Flexor Muscles

Muscle	Origin	Insertion	Innervation	Action
Biceps brachii Long head	Supraglenoid tubercle of scapula Adjacent rim of Glenoid Labrum	Radial tuberosity Bicipital aponeurosis	Musculocutaneous n. C5 - C6	Elbow: Flexion, Supination GHJ: Flexion, Stabilization of humeral head during deltoid contraction, Abduction, IR
Biceps brachii Short head	Coracoid process	Radial tuberosity Bicipital aponeurosis	Musculocutaneous n. C5 - C6	Elbow: Flexion, Supination GHJ: Flexion, Stabilization of humeral head during deltoid contraction, Abduction, IR
Brachialis	Distal half of anterior Humerus	Ulnar tuberosity	Musculocutaneous n. Radial n. C5 - C7	Elbow: Flexion
Brachioradialis	Lateral distal humerus Lateral intermuscular septum	Styloid process of Radius	Radial n. C5 - C6	Elbow: Flexion, Semipronation (to 90°)
Extensor carpi radialis brevis	Lateral epicondyle of Humerus	3rd metacarpal base	Radial n. C7 - C8	Elbow: Weak flexion Wrist: Extension, Radial deviation
Extensor carpi radialis longus	Lateral supracondylar ridge Lateral intermuscular septum	2nd metacarpal base	Radial n. C6 - C7	Elbow: Weak flexion Wrist: Extension, Radial deviation
Flexor digitorum superficialis	Medial epicondyle Coronoid process Anterior proximal half of Radius	Sides of middle phalanges 2-5	Median n. C8 - T1	Elbow: Weak flexion Wrist: Flexion 2-5 MCP & PIP: Flexion, Flexion
Palmaris longus	Medial epicondyle	Palmar aponeurosis	Median n. C6 - C7	Elbow: Weak flexion Wrist: Tightens aponeurosis
Pronator teres	Medial epicondyle Coronoid process	L:ateral radius distal to supinator	Median n. C6 - C7	Elbow: Weak flexion, Pronation

Elbow Extension

Limits of extension:

• bony block of olecranon process in the olecranon fossa⁹
• Anterior ligament tensioning⁹
• Elbow flexor resistance

Table 4: Elbow Extensor Muscles

Muscle	Origin	Insertion	Innervation	Action
Anconeus	GHJ joint capsule	Olecranon of Ulna (radial surface)	Radial n. C6 - C8	Elbow: Extension, Tightens joint
Triceps brachii lateral head	Posterior humerus just *proximal* to radial groove Lateral intermuscular septum	Olecranon of Ulna	Radial n. C6 - C8	Elbow: Extension
Triceps brachii medial head	Posterior humerus just distal to radial groove Medial intermuscular septum	Olecranon of Ulna	Radial n. C6 - C8	Elbow: Extension

Hyperextension injuries

• Olecranon fracture⁹
• Capsule tear⁹
  • With or without posterior dislocation⁹
    • Circumflex humeral artery can be damaged⁹

Elbow Joint Stabilization

Longitudinal traction

Longitudinal traction is limited primarily through soft tissue structures:

• Medial and lateral collateral ligaments⁹
• Muscles:
  • Triceps
  • Biceps
  • Coracobrachialis
  • Forearm muscles: Brachioradialis
  • Medial epicondyle muscles
  • Lateral epicondyle muscles

In full extension the olecranon of the humerus hooks onto the humeral trochlea in the olecranon fossa which can provide resistance to elongation of the humeroulnar joint⁹.

Longitudinal Compression

Unlike longitudinal traction, longitudinal compression is supported primarily through boney contacts⁹.

Compressive force is transmitted through the radius to the radial head⁹.

Compressive force is also abosrbed through the ulna to the coronoid process of the ulna⁹.

Overload

Excessive compressive load through the radius can result in a radial head fracture⁹. Likewise, excessive load through the ulna can result in a fracture or posterior dislocation⁹.

90° Flexion

At 90° of flexion, the ulna is “perfectly” stabilized, but the radius is unstable⁹.

The ulna is stabilized at the trochlear notch due to musculotendinous insertions on either side from the triceps common insertion and the coracobrachialis⁹. These two muscles insert on opposite sides of the trochlear notch and oppose eachother when contracting, resulting in joint approximation and stabilization⁹. The anconeus also plays a role in humeroulnar stability at 90° flexion⁹.

The radius has a large amount of freedom at 90° flexion, which results in decreased stability. When the biceps contract, the radius could dislocted “proximately”⁹, if the annular ligament did not prevent it⁹. Patients with annular ligament tears, commonly experience proximal and anterior radial dislocations during from the slightest degree of flexion following biceps contraction⁹.

Proximal Radioulnar Joint

The proximal RUJ refers to the articulation of the radial head on the radial notch of the ulna⁹.

The radial head is convex with a cartilage rim that widens anteromedially⁹.

Note

The cartilage extends to the superior articular facet of the radius which is concave and articulates with the humerus’ capitulum⁹.

The readial head is surrounded by a fibro-osseous ring

Read more about the proximal radioulnar joint here.

Distal Radio-ulnar Joint

Read more about the distal radioulnar joint here.

Pronation & Supination

Pronation and supination are important forearm mechanics that allow us to optimally position the hand for grasp, press, pull, or support objects⁹.

Pronation and supination are a compound movement that occurs through 2 joints:

1. Proximal radioulnar joint
2. Distal radioulnar joint

Range of motion

ROM for pronation and supination should be assessed with the elbow flexed to 90°⁹. When fully extended, the axis for pronation and supination is collinear with shoulder internal and external rotation, making it difficult to isolate⁹.

Complexity

Pronation

Table 5: Forearm Pronation Muscles

Muscle	Origin	Insertion	Innervation	Action
Brachioradialis	Lateral distal humerus Lateral intermuscular septum	Styloid process of Radius	Radial n. C5 - C6	Elbow: Flexion, Semipronation (to 90°)
Pronator quadratus	Distal 1/4 of anterior Ulna	Distal 1/4 of anterior Radius	Median n. C8 - T1	Elbow/Forearm: Pronation Distal RUJ: Stabilization
Pronator teres	Medial epicondyle Coronoid process	L:ateral radius distal to supinator	Median n. C6 - C7	Elbow: Weak flexion, Pronation

Note

Limited pronation will result in compensations, most notably excessive shoulder internal rotation.

Supination

Table 6: Forearm Supination Muscles

Muscle	Origin	Insertion	Innervation	Action
Biceps brachii Long head	Supraglenoid tubercle of scapula Adjacent rim of Glenoid Labrum	Radial tuberosity Bicipital aponeurosis	Musculocutaneous n. C5 - C6	Elbow: Flexion, Supination GHJ: Flexion, Stabilization of humeral head during deltoid contraction, Abduction, IR
Biceps brachii Short head	Coracoid process	Radial tuberosity Bicipital aponeurosis	Musculocutaneous n. C5 - C6	Elbow: Flexion, Supination GHJ: Flexion, Stabilization of humeral head during deltoid contraction, Abduction, IR
Supinator	Olecranon Lateral epicondyle Radial collateral lig. Annular lig.	Radius (between radial tuberosity and pronator teres)	Radial n. C6 - C7	Radioulnar joints: Supination

Note

Limited supinationwill result in compensations, most notably excessive shoulder external rotation.

Range of Motion

Radio-ulnar complex

The radius and ulna stay together during pronation and supination due to:

• IO membrane
• Oblique cord: Reinforces connection between the superior radius and ulna⁹.
• Annular ligament
• Radial Collateral Ligament (of the forearm): Reinforces the annular ligament
• Ulnar collateral ligament (of the forearm) reinforces the annular lig.
• Radio-ulnar joint ligaments
  • Anterior Radio-ulnar joint ligament
  • Posterior Radio-ulnar joint ligament
  • Inferior Radio-ulnar joint ligament
• Articular disc
• Muscle limits
  • Medial epicondyle flexors
    • FDS
    • PL
    • FCR
  • Lateral epicondyle extensors
    • ED
    • ECRL
    • ECRB
    • ECU
  • Elbow joint:
    • Supinator
    • Pronator Teres
    • Brachioradialis

Interosseous membrane

Interosseous membrane (IO Membrane)

Ligaments

• Oblique cord
• Annular ligament
• Lateral Collateral Ligament (of the forearm)
• Medial collateral ligament (of the forearm)
• Radio-ulnar joint ligaments
  • Anterior Radio-ulnar joint ligament
  • Posterior Radio-ulnar joint ligament
  • Inferior Radio-ulnar joint ligament

Movement

MMT

See reading list

Elbow evaluation

• Palpate:
  • Olecranon
  • Medial epicondyle
  • lateral epicondyle

Wrist

Wrist Movements

• Flexion & Extension
• Radial (abduction) & Ulnar Deviation (adduction)
• Circumduction

Flexion

Extension

Radial Deviation

AKA wrist abduction

Ulnar deviation

AKA wrist adduction

Radiocarpal Joint

Wrist Ligaments

• Palmar radiocarpal ligaments
  • Radioscaphocapitate ligament
  • Long radiolunate ligament
  • Radioscapholunate ligament
  • Short radiolunate ligament
• Palmar ulnocarpal ligament
• Dorsal Radiocarpal ligament
• Collateral Carpal ligaments
  • Ulnar collateral carpal ligament
  • Radial collateral carpal ligament
• Radiocarpal Ligaments
  • Anterior radiocarpal ligament
  • Posterior radiocarpal ligament
• Interosseous ligaments (link the scaphoid, lunate, and triquetrum)
  • Scapholunate interosseous ligament (SLIL)
  • Lunotriquetral interosseous ligament (LTIL)
  • Trapezotrapezoidal interosseous ligament
  • Trapezoidocapitate interosseous ligament
  • Hamatocapitate interosseous ligament
• Lunatocapitate ligament
• Triquetrocapitate ligament
• Scaphotrapezial ligament
• Triquetrohamate ligament
• Pisohamate ligament
• Pisometacarpal ligaments

Radiocarpal and Midcarpal Joint ligaments

Triangular Fibrocartilage Complex (TFcC)

The Triangular Fibrocartilage Complex (TFcC)

Carpal Bones

• Scaphoid
• Lunate
• Triquetrum

Midcarpal Joint

Carpus

• Median pillar: Lunate and capitate
• Lateral pillar: Scaphoid, trapezium, trapezoid

Carpus Variability

Therex

Elbow Exercises

• Elbow CARs

Wrist Exercises

• ROM
  • Wrist CARs

Compound Movements

• Deadhangs
• Scap retraction deadhangs
• Grip variations
  • Lumbrical grip on ankle weight
  • Pronated grip
  • Neutral
  • Supinated grip
  • Suicide grip (no thumb)
• Shoulder I’s
• Shoulder T’s
• Shoulder Y’s

Recovery Movements

• ULTT1

Hand MMT

see reading list

References

1.

Donnelly JM, Simons DG, eds. Travell, Simons & Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual. Third edition. Wolters Kluwer Health; 2019.

2.

Neumann DA, Kelly ER, Kiefer CL, Martens K, Grosz CM. Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation. 3rd ed. Elsevier; 2017.

3.

Weinstock D. NeuroKinetic Therapy: An Innovative Approach to Manual Muscle Testing. North Atlantic Books; 2010.

4.

Dutton M. Dutton’s Orthopaedic Examination, Evaluation, and Intervention. 5th ed. McGraw Hill Education; 2020.

5.

Heick J, Lazaro RT. Goodman and Snyder’s Differential Diagnosis for Physical Therapists: Screening for Referral. 7th edition. Elsevier; 2023.

6.

Carlson M. Elite Athlete’s Hand and Wrist Injury, an Issue of Hand Clinics. 1st ed. Elsevier - Health Sciences Division; 2012.

7.

Federation of the European Societies for Surgery of the Hand, Shewring DJ, Giddins G, Boyce DE, International Federation of Societies for Surgery of the Hand, eds. Tendon Disorders of the Hand and Wrist: IFSSH/FESSH Instructional Course Book 2022. Thieme; 2022.

8.

Wise CH, ed. Orthopaedic Manual Physical Therapy: From Art to Evidence. F.A. Davis Company; 2015.

9.

Jones B. B Project Foundations. b Project; 2025.