Carrying angles, snapping triceps, irritated ulnar nerves, and dislocated elbows

Posted on March 9, 2016

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The carrying angle is:

carrying angle 2

Don’t worry about all the terms in this picture:

carrying angle 1

We’re more concerned with the bright lines. Carrying angle is in yellow:

carrying angle 1 with outlines

There are two times when we concern ourselves with this term. When the angle is big- cubitus valgus. Fancy way of saying the elbow is pointed in:

You’ll often see this in throwing athletes, or those who grew up doing a lot of something throwing oriented. I haven’t thrown much of anything the last few years, yet here are my arms:

Large carrying angle Cubitus Valgus Throwing Arm Elbow

My throwing arm is the right (left in photo). The yellow line is bigger on that side than the other.

My throwing arm is the right (left in photo). The yellow line is bigger on that side than the other.

I threw a lot the other 25 years.

The other time is when the carrying angle is small- cubitus varus. The elbow points out:

cubitus varus

This can happen after something like breaking your arm, where things don’t heal properly.

Another easier way to think of this “Is the hand out (valgus) or is it in (varus) in relationship to the elbow?”

Why does it matter?

A larger carrying angle, elbow pointed in / hand pointed out, has been found as a risk factor in a few things:

  • Ulnar nerve neuropathy, including:
    • numbness,
    • tingling,
    • not as responsive,
    • inflammation (neuritis),
  • Increased risk of elbow dislocation,
  • Along with potential issues with overhead sports -think baseball / tennis / volleyball

A smaller carrying angle, elbow pointed out / hand pointed in, has been implicated with:

  • Snapping triceps and ulnar nerves

How does a larger carrying angle develop?

Women have greater carrying angles than men. They have more of this:

One line of thinking is women have wider hips. Because of these wide hips, their forearms move laterally, so the hands don’t hit the hips when walking.

Or say you spend a lot of time during development laying on your side.

Carrying Angle Laying On Side Carrying angle laying on side with line

With wider hips, maybe that pushes the hand out more, increasing the angle?

Or what if you grew up in the 90s, carrying around monstrosities for textbooks and boomboxes:

Credit: https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwilxKiLvqLLAhUN2WMKHaMUAHYQjBwIBA&url=https%3A%2F%2Fwww.colourbox.com%2Fpreview%2F2742674-school-boy-student-carrying-two-books-under-his-arm-and-smilingon-a-white-background.jpg&bvm=bv.115946447,d.cGc&psig=AFQjCNGxB71ufrkg8i_ff_ZmPC_Nt23EfQ&ust=1457024536628656

Credit: ColourBox.com

Well, actually that would put the elbow the other way. Plus, nobody holds a boombox like that.

Boombox old man eating

In a nice paper on this topic, this theory (the hips; not the boombox) was debunked by showing no relationship between hip width and carrying angle. What they did find, which has been replicated elsewhere, is the shorter your forearm, the greater your carrying angle tends to be.

In order to pronate the forearm -turn it inwards- the ulna angulates laterally.

Here is the ulna in the starting position:

Ulna forearm neutral

The forearm and hand turn in (pronates):

Ulna forearm pronated

And we can see the angulation- how much further the ulna has moved to the side:

Ulna comparison forearm neutral to pronated

(Hand has moved out in relationship to elbow => Greater carrying angle.)

Next we think of the ulna like a lever. Compared to a longer lever, a shorter lever needs a greater amount of muscle shortening in order to accomplish the same task. If you have shorter legs, you need more muscle shortening than someone with longer legs in order to go the same distance.

With women, they’re usually shorter than men, and subsequently have shorter levers all over. With a shorter ulna a woman has to shorten her pronating muscles more in order to get the same distance. (She has to shorten her muscles more in order to angulate the ulna the same amount.) Bones respond to the forces placed on them. Do this throughout development => Get an ulna to be more angulated => Greater carrying angle. “You get what you train.” Not only is it harder for a woman to be as strong as a man due to hormonal differences, not only is it harder for them to run as fast due to shorter legs, but it takes more muscle shortening to pronate their forearm due to shorter forearms.

Who else pronates their forearms a good deal during development?

Notice the hand turning downward:

Baseball players actually get more turning-their-palm-up movement (supination) when throwing, like with a curveball, but they get so much lateral movement of the forearm (valgus stress), that’s more than enough to cause this adaptation of an increased carrying angle:

External rotation pitchingchad bradford submarine valgus stress baseballCredit: http://2.bp.blogspot.com/-tfhaWDBaEvw/Ug3OHIg_ojI/AAAAAAAAAlk/Uu5O9Mlki5M/s1600/CUBITUS.jpg

-> It’s important to note when we say adaptation here we’re talking during childhood and adolescence. With these types of things, the bones, which start primarily as cartilage, literally morph into these different positions. However, once they’re set, they’re basically set. We’ll come back to the importance of this.

How a large carrying angle can cause issues

We’ve already been introduced to our ulna, now let’s meet the ulnar nerve.

Notice the nerve goes behind the inside of the elbow, then comes to the front of the hand.

Therefore, if we were to bend the elbow, we’d stretch the nerve.

Because it comes to the front of the hand, if we extend the hand, we’d also stretch the nerve.

Wrist movements

Now for the last way of stretching the nerve, which may be a little tough to visualize at first. If we move the forearm laterally, we tense the inside of the elbow by stretching it. If we move the hand in, we slacken the ulnar nerve. Notice the space which occurs between the simulated nerve and forearm as the hand moves in and out:

This is why we had to spend so much time on carrying angles. When we displace the forearm laterally, like throwing an object, we tense the hell out of the inside of the elbow, including the ulnar nerve. In someone who has a positive carrying angle, they’re already tensing this area.

-> This is why Tommy John surgery, the major injury involving the elbow in throwers, involves the ulnar collateral ligament. This little ligament has to deal with all that tensile stress:

That doesn’t mean one can’t be perfectly fine having a larger carrying angle. It does mean you might need to be more careful with this type of stress. The harder you can throw an object, the more you need to worry about this, as the more of this stress which will occur. This is where monitoring pitch counts comes in, as well as making sure other areas, like the shoulder, aren’t restricted. If the shoulder is restricted when moving the arm back, the elbow may compensate.

-> This is where those of us who get into some overhead activity like this later in life, tennis being the most common example, need to be careful. The problem goes the other way: You didn’t acquire the laxity for the elbow to lay back like this.

tennis serve various frames Roddick serve valgus stress elbow

And odds are you can’t acquire it past a certain age. Where your serve ends up looking like this:

tennis serve lack of laying back

If in your 20s, 30s, 40s or greater, and you start asking for your elbow to do something it should have started being able to do at five years old, you may need to be careful. For most, they’re unlikely to move fast enough / hit hard enough this becomes a problem, but it’s something to consider if the inside of your elbow starts bothering you. The other avenue here is to adapt your motion e.g. get less bend at the elbow.

Initially, one might think there isn’t really much which stresses this area besides throwing or overhead activities. But think a barbell curl with a wider grip:

Barbell Curl Wide Grip 1

When performing a curl with no weight (elbow flexion), even in someone with valgus going on, they should end up with some varus at the top of the curl. In other words, this should happen:

Elbow valgus curl 1 Elbow varus curl 2

Notice the hand went from outside the shoulder to inside the shoulder.

Notice the hand went from outside the shoulder to inside the shoulder.

However, in a barbell curl, the hands are fixed. You end up with this:

Barbell Curl Wide Grip 2

Notice the elbows pointed in / hands have to stay outside the shoulder (and the “Woo Sah” eyes close moment)

The mystical snapping tricep (and ulnar nerve)

Time to go the opposite way. Our starting position:

triceps brachii back posterior view

Let’s move the forearm in (medially) this time:

triceps brachii line of pull cubitus varus

What have we done to our line of pull with the tricep?

snapping triceps line of pull change 1

It’s been angled, to where now:

snapping triceps line of pull change 2

We’ve moved it inwards (medially). Notice above the purple line is more in the red on the right than on the left. Subsequently, it’s now more likely to rub, or rub over, the medial (epi)condyle.

snapping triceps medial epicondyle rubbing differenceThe tricep extends (straightens) your elbow. So when we flex the elbow (do the opposite), the tricep stretches. Think a rubber band, or your laptop or phone charger. Pull it to stretch it. It’ll get skinnier, right? Ok, but now push on it against a table or something. That will make it broader. When we bend our elbow and stretch our tricep, we make it skinnier, but because it gets pushed against the humeral condyle, it also broadens.

Here is an elbow in the resting position.

Let’s get our anatomy oriented:

ulnar nerve snapping and triceps with anatomy 1

We bend the elbow, and the ulnar nerve dislocates / subluxates first. Notice it’s now covering the bone:

ulnar nerve snapping and triceps 2

We bend the elbow some more, and we can see the tricep tendon broaden:

ulnar nerve snapping and triceps 3

Right before the tricep broadens; right after:

tricep tendon broadening over condyle

Look again at the right picture here:

snapping triceps medial epicondyle rubbing difference

Looking at that right picture, how close the green is already to falling over the epicondyle, and considering when we flex the elbow the tricep will broaden, we can see this makes for a nice understanding of why this elbow alignment can predispose snapping / dislocating / subluxating tricep and ulnar nerve issues.

Based on this, we’d expect snapping to be more likely with the elbow in varus than in valgus. We’d also expect it to be more common in males, because remember women have greater carrying angles than men (there elbows are more pointed in). Males who are doing activity which requires a good deal of tricep use, like manual labor or those into weightlifting or bodybuilding. And that’s what research shows. (Here and here.)

As I mentioned in the beginning, a varus alignment like this,

tends to be a concern in those after a broken arm, or perhaps a dislocated elbow. But this isn’t the only time. Valgus / varus is not a static thing. Elbow alignment, much like the knee, is dynamic. Let’s think back to our bicep curl. Maybe instead of a wide grip, you’re doing this:
Bicep Curl Varus Grip 1

Looks familiar!

Varus comparison with barbell curl

That is, elbow is pointed outside of hand.

Or when doing chin ups, you do a narrower grip because that’s often easier for people.

But pulling oriented exercises aren’t when most have their main problems. It’s more pushing, which is when the triceps have to contract. The stronger they contract, the more they compress against that epicondyle.

But let’s look at technique too. Think about a push-up. First, the wrists are extended:

Push ups wrists extended

That means our ulnar nerve has been tensioned.

Next, the forearm is pronated.

Push ups wrist pronated

Ulnar nerve even more stretched. Remember pronation angulates the ulna and subsequently stretches the nerve.

Next, this form is common:

Push ups elbows turned out

Meaning during a push-up our ulnar nerve is stretched due to the wrists, it becomes even more stretched because we’re flexing our elbows (when we come down), and then by turning the elbows out, we manipulate the line of pull of the triceps, all in all making something more likely to not sit as well in that cubital fossa. That is, we’ve compressed the ulnar nerve against the groove it’s in by stretching it. We’ve also put the triceps into a line of pull where it’s more likely to broaden outside the inside of the elbow.

The ulnar nerve is in front of the triceps:

ulnar nerve snapping and triceps with anatomy 1

First we’ve pulled the ulnar nerve against the bone more by stretching it. If we then give a big contraction of the tricep, like a push-up, bench press, or overhead press, we add even more compression and broadening of the tendon. Do this with the line of pull of the tricep getting moved inward? Boom => Push the ulnar nerve out of the groove => Eventually the tricep comes too.

It’s not a coincidence push-ups (and bench pressing) is one of the exercises people most often feel a snapping on. Nor is it a coincidence many will feel some relief by changing their hand position. Watch what happens to the elbows:

Elbows and pronation supination relationship front GIF

Elbows and pronation supination relationship back GIF

We’ve lessened the compression and tension on the ulnar nerve by not having the forearms as pronated, and manipulated our line of pull of the triceps by not having the elbows out so much. [1] (Some notes on distinguishing between the ulnar nerve and tricep are at the end.)

A more organized guide to help

The above can be a bit jumbled in terms of practical application for those unfamiliar with anatomy. I’ve put together a manual based on the above to help with ulnar nerve issues and snapping triceps. The above is our rationale; the guide is “Ok, I have some understanding, now what do I do? How do I avoid surgery?”

Here is what’s covered:

  • Activities to look out for during the day
    • Why how you type can make snapping more likely
    • Why how you hold your arms while standing / walking can have an impact
    • Be on the lookout for these common sitting positions
      • Some easy ways to piss off your ulnar nerve
    • The 8 hours we don’t think about: Taking care of the elbow while sleeping
  • Exercise
    • How to get back into pressing movements. More technique considerations, as well as changing up exercises.
      • Push-ups, bench pressing, DB pressing, overhead pressing, all discussed.
      • How your stiff lats can be making snapping more likely on overhead pressing
    • Why skull crushers are one of the most common exercises causing snapping tricep issues, how to make them friendlier, but why you should probably just get rid of them in favor of other tricep exercises
    • More specifics on bicep curls
    • Working on forearm flexibility
    • Holding the barbell when squatting
    • While there are plenty of notes on exercise modifications, there will also be rationale for giving the triceps a brief rest

Tons of pictures and some videos are provided for all the above. It comes in the form of a password protected link. You’ll be redirected to the specific link with the password, as well as have it emailed to you.

It’s 10 bucks:Add to CartBuy Now

If you’re unhappy with it for some reason, shoot me an email, b-reddy@hotmail.com, and I’ll refund you.

Or if you’re tired of trying to figure this out by yourself, check out the remote client process.

It’s worth reiterating here some will have issues which are exacerbated by structural things going on. We discussed cubitus varus from a broken arm. There are other structural considerations as well though. A simple one is those who have a deeper cubital fossa or groove for the ulnar nerve to sit in, are less likely for that ulnar nerve to slip out. This is something we can’t do anything about, but there is more than enough in the manual to hopefully get you to where you can understand how to avoid sensations, avoid an operation, and get back to pushing some weight around rather than the doctor saying “ice, rest, stop lifting.” We can’t do anything about the fact you may have broken your arm years ago, but we can likely do something about how you move your arm.

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Speaking of trauma…

The worst of them all- the elbow dislocation

Looking at the difference between a larger and smaller carrying angle again:

My throwing arm is the right (left in photo). The yellow line is bigger on that side than the other.

The yellow line is bigger on that side than the other.

Now think about falling to the ground in some fashion. Perhaps likes this:

Simulating Fall carrying angle

You’d rather the line of stress go straight than angle:

Simulating Fall carrying angle with lines

Notice on the right side the green width is a bit larger than the left. This is because the forearm is angled out more on that side. In other words, what we’d prefer is our forearm be as close to the light blue line as possible, so the stress of falling goes straight. Thinking of our arm like a stack of blocks, if the stack is angled, it’s more likely to collapse. With the elbow in this case, we’re saying it’s more likely to get pushed out of the joint, because rather than compress the joint in a straight line, we’re pushing the elbow up *and* to the side.

Simulating Fall carrying angle with line

I can tell you you really prefer the straight line, because as someone who has a bigger carrying angle, and someone who has dislocated their elbow, it SUCKS. (It’s extraordinarily painful. I’ve also torn my ACL, and that was nothing compared to the elbow.) Your elbow may end up looking like this:

Notice the forearm, the hooked part, has moved up / the humerus, the ball part, has moved down.

Notice the forearm, the hooked part, has moved up while the humerus, the ball part, has moved down. (Credit: http://oftankonyv.reak.bme.hu/tiki-download_file.php?fileId=896&display )

This is where a major theme of this site rears its ugly head again: When you gain something, you lose something. Having a greater carrying angle allows one the laxity to lay back more when doing an overhead activity.

External rotation pitching

But it also makes your elbow inherently less stable. So when someone like me who threw a ton growing up, does well pitching as a youngster, but gives that up for football and gets moved to linebacker in college, I end up more likely to dislocate my elbow if trying to break a fall with my right arm. Which is exactly what happened to me. Fortunately I came back well from that injury, so a couple years later when I started playing dodgeball, I naturally threw harder than most. (Of course there are other reasons too, like how I’m taller.)

Context for an adaptation is crucial. The carrying angle was helpful with youth baseball, hurtful with college football, then helpful again with rec dodgeball.

[1] Thinking about the ulnar nerve vs the triceps

This is one potential way to distinguish between whether the ulnar nerve or tricep is snapping (it’s often both!): Turn your hands, but let the elbows still flare to the side.

Elbows Wide Push Ups with hands turned

If that makes things feel better, that’s a sign only the ulnar nerve is at play, because we’ve changed the tension in the nerve, but haven’t changed much with the tricep. If the snapping is still going on, it’s more likely the tricep and ulnar nerve.

-> Because the tricep is behind the ulnar nerve, if the tricep snaps, the ulnar nerve is more than likely also snapping. The tricep pushes the ulnar nerve out, then comes out itself. However, if the ulnar nerve snaps, that doesn’t mean the tricep will. But, it could simply mean the tricep is causing the ulnar nerve to snap, and just isn’t out of the groove itself. At least not yet.

In other words, be careful about obsessing over which it is. If something is snapping, that’s probably enough information in itself.

You could do this during a bicep curl as well. Keeping the elbows in tight, normal grip width, does a palms down grip feel worse on the inside of the elbow than a palms up grip?

Pronated grip barbell curl

Sometimes you don’t even need weight to assess this.

Then that’s probably the ulnar nerve, as we’re not negatively impacting the triceps line of pull in that case. (By the way, hands down curls are a bad choice for most anyways.)

-> This might be confusing. Remember when we turn the hands in, the ulna angulates laterally. That will stretch / compress the ulnar nerve, and to a lesser degree, the triceps into the groove they sit in. But because this pull is lateral, that will make the tricep less likely to snap. (Provided we’re not in a varus -elbows out / hands in- alignment.) It’s when the forearm is angulated inwards that snapping is much more a concern.

Said another way: Snapping issues are more a problem with varus alignment than valgus alignment. That is, with elbow alignment opposed to whether the hands are pronated or supinated. If snapping is a problem, this is what we want to be harping on.

Another way to differentiate between the two is if you can more easily get the snapping to occur, like just bending your arm up and down, give a decent tap to the out of place area. If it radiates down your arm, that’s the ulnar nerve. (That’s the “funny bone” area which can get hit, but it’s been dislocated for a moment.)

Lastly, if your issue is with throwing, 1) Double check it’s not something else like medial epicondylitis or golfer’s elbow (here for more info) 2) The tricep is not very involved in something like a baseball pitch.

Fun fact: In college we discussed this and here I was never thinking I’d bring it up again! The idea is the tricep just cannot keep up with the amount of force which comes with throwing, as such a great amount of that force comes from the lower body. The triceps brachii is paltry compared to the leg musculature. If you watch a slow motion pitch analysis, you’ll see the tricep flopping in the wind:

With throwing, because it’s valgus stress, the issue is more likely with the nerve, ulnar collateral ligament, something from grabbing so much, or a lack of shoulder mobility.

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Posted in: Elbow Pain, Pain