1. Carrying Angle controversies
Dr S L Yadav, MD
Department of Physical Medicine & Rehabilitation
AIIMS, New Delhi- 110029

2. Introduction
• Acts as a lever arm when positioning the hand
• Functions as a fulcrum for forearm lever
• In patients using crutches, it functions as a
weight bearing joint.
• During throwing, there is transfer of energy
between the shoulder and elbow
• It is crucial for activities of daily living

3. Carrying Angle
• Long axis of the humerus & ulna
• Average angle: Females 13.6/ Males 6.7
• Length of FA and carrying angle has significant relation
among girls; the elbow carrying angle higher who have
short FA/ulna
• Dominant hand > Non-dominant hand (ligamentous laxity
at the medial elbow or asymmetrical bone growth)
• Unilateral aseptic necrosis of humeral trochlea lead to loss
of carrying angle
• Bony remodeling to adapt stress among professional base
ball pitchers

4. Definition
The carrying angle has been defined as the angle between:
• the longitudinal axes of the arm and forearm (Amis and
Miller 1982), see figure 1(a);
• the longitudinal axes of the humerus and the ulna,
determined on X-rays (Keats et al. 1966, Steindler 1973);
the corresponding anatomical reference lines are
considered in figure 1(b);
• the longitudinal axes of the humerus and the ulna
determined on X-rays by means of the construction of two
mid-points at both the distal humerus and the proximal
ulna (Beals 1976); the corresponding anatomical reference
lines are considered in figure 1(c).

5. Measurement of Carrying Angle

6. Importance
• The carrying angle values increases
progressively from childhood until 16 years
when stabilization noticed.
• Useful in management in elbow displacement
and fractures
• Epicondylar disease
• Surgical planning for elbow reconstruction
• Walking, swinging and carrying objects

7. Abnormality of carrying Angle
Any variation of the angle that is more than 15°is known as cubitus valgus and
less than 5°are called cubitus varus.

8. Physiological conditions
The parameter varies according to
Age
Gender,
Hyperextension of the elbow,
Dominant upper limb,
Anthropometric characteristics such as height and
intertrochanteric distance and can be measured by simple
clinical and radiographic techniques.

9. Factors influencing carrying angle
• Elbow musculature/ligaments
• Forearm rotation
• Elbow flexion (changes when elbow flexed)
• Anatomical factors:
– Medial flange of trochlea 6mm below the lateral flange
– Superior articular surface of the coronoid process of the ulna
is placed obliquely to the long axis of the ulna

10. Factors……
• In most cases, the increased carrying angle is due to
muscle weakness or ligament injury, inefficient
alignment/ hypo-mobility of the bones or soft tissue
tightness lead to abnormal biomechanics
• The patient had an increased carrying angle of 20
degree and pain with throwing; after 6 weeks of
treatment (joint/ soft tissue mobilization and exercise
program) able to throw and play continuously for
more than 20 innings without pain and his carrying
angle has decreased to 12 degrees!

11. Abnormal carrying angle of elbow in
children
• Cardiofaciocutaneous syndrome
• Cohen syndrome
• Condylar fracture at the elbow
• Noonan syndrome
• Turner syndrome: Cubitus valgus is caused by
developmental abnormalities in the trochlea of the
humerus. Alteration in the shape of the trochlea changes
the angle of articulation with the ulna, resulting in
increased elbow angulation.

12. Elbow Observation
• Anatomical
– Carrying Angle
– Cubitum Varum
– Cubitum Valgum
– Cubitum Recurvatum

13. Anatomy Overview

14. Capsuloligamentous Complex
• Medial collateral ligament
• Lateral collateral ligament

15. Humeroulnar Joint
• A uniaxial hinge joint formed between the
trochlear notch of the proximal ulna and the
spool-shaped trochlea of the humerus
• The angulation of this joint forms the
“carrying angle”
• The carrying angle is approximately 11-14° in
males and 13-16° in females

16. Medial (Ulnar) Collateral Ligament
• The fan-shaped MCL is
functionally the most
important ligament in the
elbow for providing
stability against valgus
stress, particularly in the
range of 20-130° of
flexion and extension
• There are three distinct
components of the MCL:
– Anterior bundle
– Transverse bundle
– Posterior bundle
• Resists valgus stress
• Limits extension
• Taut throughout arch of
motion
– Anterior fibers most taut in
extension
– Posterior bundle is taut in
flexion
• Transverse fibers provide
valgus stability and help
with joint approximation

17. Medial (Ulnar) Collateral Ligament
• Anterior bundle
– Anterior band
• The strongest and stiffest
of the elbow collateral
ligaments
• Primarily stabilizes the
elbow against valgus
stress in the ranges of 20-
120° of flexion, and
becomes a secondary
restraint with further
flexion

18. Medial (Ulnar) Collateral Ligament
• Anterior bundle
– The posterior band
• Taut beyond 55° of elbow
flexion
• A secondary restraint to
valgus stress at lesser
degrees of flexion
• An equal co-restraint with
the anterior band at
terminal elbow flexion
• A primary restraint to
passive elbow extension

19. Medial (Ulnar) Collateral Ligament
• The transverse bundle
– Also known as Cooper’s
ligament
– Fibers both originate and
insert on the ulna and
therefore have little role
in elbow stability

20. Medial (Ulnar) Collateral Ligament
• Posterior bundle
– Appears to be a
thickening of the
posterior elbow capsule
– Provides only secondary
restraint to valgus stress
at flexion beyond 90°.

21. Electromagnetic tracking system
Clinical Protractor Goniometer
and with an Electromagnetic
tracking system.

22. Why to measure
• Knowledge of the measurement of the elbow
carrying angle and of its variations is important
when evaluating traumatic elbow injuries and
other elbow disorders that require reconstruction
or arthroplasties (surface and semiconstrained)
• This parameter shows a gradual increase from
childhood up to the age of 16 years when the
skeletal maturity is attained and demonstrated by
its stabilization.

23. Methods
• In vitro using mechanical instrumentations,
Hinged boards, or
Goniometers rigidly attached to the humerus;
Kinematics or geometrical computations; or
Radiographs,
thus obtaining results not always in agreement.
The main reasons for this are differences
in the definition of the angle and variations
• Van Roy et al adopted a protractor goniometer and an
electromagnetic tracking device to estimate the carrying
angle in full extension and also during flexion of the elbow
joint.

24. Over-use risk factors
• Heavy training loads
• Early sport specific training
• Year-round throwing
• Participation in multiple sports
• Training errors-unqualified coaching &
supervisory practices
• Muscle tendon strength & extensibility
deficiencies
• Faulty equipments

25. What about the ulnar collateral
ligament?
• The Throwing or Overhead motion

26. Throwing Motion
• Early cocking
– Abduction/ER - Supraspinatus very active
• Late Cocking
– Anterior shld. Stretched/medial elbow valgus
– Scapula must be stable
– Valgus stress on elbow
• Acceleration
– Stable scapula/Large muscle groups to IR
– Valgus stress on elbow
• Deceleration - ECCENTRIC
– Teres Minor/Infraspinatus espec. active to slow down
– Biceps Brachii to slow elbow extension
• Follow-Through
– Scapula protracts(abducts) - Serratus anterior
– LHB tendon stabilizes

27. Acceleration:
Extension occurs at a rate of up to 25º
per second and continues to 20º of
flexion. Forearm lags behind the upper
arm and generates valgus stress (> 60
Nm), The valgus force can overcome
the tensile strength of the UCL and
cause either chronic microscopic tears
or acute rupture.
Tensile stress

28. Ulnar (Medial) Collateral
• At 90º of flexion, it provides 55% of the resistance to
valgus stress at the elbow.
– UCL is composed of 3 bands: anterior, posterior, and
transverse
• Etiology
– Injured as the result of a valgus force from repetitive
trauma
– Can also result in ulnar nerve inflammation, or wrist flexor
tendinitis; overuse flexor/pronator strain, ligamentous
sprains; elbow flexion contractures or increased instability

29. TCI v/s Bauman’s Angle
• Trochaleocapitellar Index (TCI): The ratio between the
smaller trochanter and larger capitelar angles of the
measured elbow, not influenced by radiographic technique
(elbow position/rotation of the distal fragement)
– Post SC # reduction, determines the adequacy of reduction
– Coronal plane angulation prevention indicates accurate
reduction of #
• Bauman’s Angle: intersection of a line drawn the humeral
axis and a line drawn along the growth plate of the
capitulum of the elbow
TCI > Bauman’s angle

30. Study Of Carrying Angle And Its Correlation
With Various Parameters
Dr. Srushti Ruparelia, Dr. Shailesh Patel, Dr. Ankur Zalawadia, Dr. Shaival Shah,
Dr. S. V. Patel. NJIRM 2010; Vol. 1(3). July-Sept. pg 28-32.
There is no difference in the carrying angle in male &
female up to the puberty. But in the female, it is increased after puberty.
• The result of the study showed that the average carrying angle was
13.6 degrees for females and 6.7 degrees for males. The length of the
forearm and the carrying angle showed significant relation.
• Conclusion: The result of the study could be useful in the
management of elbow displacement, fractures, epicondylar disease
and surgical planning for elbow reconstruction.

31. With the elbow extended, the carrying angle of the elbow should be reviewed, and
clinical comparison as well as radiograph comparison can be performed to assure an
adequate reduction.

32. Investigations - Ultrasound
• Controversial
• Medial elbow pain was associated with widening of the medial joint
space (p < 0.05) and with the presence of attenuation of the ulnar
collateral ligament (p < 0.01)
• Absolute difference 2.7mm vs. 1.6mm
Ultrasonographic assessment of the ulnar collateral ligament and medial elbow
laxity in college baseball players. Sasaki J, Takahara M,Ogino T, Kashiwa H,
Ishigaki D, Kanauchi Y. J Bone Joint Surg Am. 2002 Apr;84-A(4):525-31

33. EVOLUTION OF THE CARRYING ANGLE
OF THE ELBOW: A CLINICAL AND
RADIOGRAPHIC STUDY
Terra BB, Silva BCM, Carvalho HBF, Dobashi ET, Pinto JA, Ishida A. Acta Ortop
Bras. [online]. 2011;19(2):79-82.
CONCLUSION
This parameter shows a gradual increase from childhood up to the age of 16 years when
the skeletal maturity is attained and demonstrated by its stabilization. There was no
significant statistical difference between the clinical and radiographic measurements.

34. An evaluation of the carrying angle of the
elbow joint in adolescents
Rajesh B*, Reshma VR, Jaene RC, Somasekhar IT,
Vaithilingam A
Int J Med Biomed Res 2013;2(3):221 -225
Conclusion: The result of the study could be useful in the
management of elbow displacement, fractures, epicondylar
disease and surgical planning for elbow reconstruction

35. The Carrying Angle in Sex
Chromosome Anomalies
Fred A. Baughman Jr., MD; James V. Higgins, PhD;
Thomas G. Wadsworth, FRCS, FACS; Michael J.
Demaray, MD. JAMA. 1974;230(5):718-720.
Conclusions: The carrying angle is said to be
greater in the XO phenotype than in XX and
greater in XX than in XY.

36. The actions of bowlers with a large “carrying angle” or a hypermobile elbow often look
suspicious even though they are legal

37. The study of predictor’s
anthropometric parameters of
upper limb with elbow carrying
angle in athletes
Daneshmandi Hassan, Shahrokhi Hossein, Pegah Rahmani, Nazary Sharif
Hossein. Journal of Romanian Sports Medicine Society.Medicina Sportiva
(2014), vol. X, no 4, 2447-2451.
Conclusions
The results of regression showed that among the variables shoulder-elbow
length, elbow-wrist length and arm span, shoulder- elbow length was the
best predictors of carrying angle. According to results of this study athletes
who have greater forearm are more exposure carrying angle changes and
require special medical care in upper extremities to maintain normal elbow
alignment.

38. The role of the elbow musculature,
forearm rotation, and elbow flexion
in elbow stability: An in vitro study
Kenneth Seiber, MD, Ranjan Gupta, MD, Michelle H. McGarry, MS,
Marc R. Safran, MD, Thay Q Lee, PhD. J Shoulder Elbow Surg (2009)
18, 260-268
Conclusions
The medial elbow musculature mostly affects elbow stability with
the arm in supination and the lateral musculature in pronation,
where the passive tension in the respective muscles is increased.
Furthermore, the medial elbow musculature provided stability to
the elbow when the forearm was supinated even with a deficient
anterior bundle of the UCL, emphasizing its role as a secondary
stabilizer.

39. A protocol for clinical evaluation of the carrying
angle of the elbow by anatomic landmarks
Maria Luisa Zampagni, MSc, PhD, Daniela Casino, MSc, Sandra Martelli,
MSc, Andrea Visani, MD, and Maurilio Marcacci, MD, Bologna, Italy. J
Shoulder Elbow Surg 2008;17:106-112.
In conclusion, this study shows that the carrying angle evaluation by the FaroArm
and the Cardan algorithm provides more reliable results than other methods. The
setup is comfortable for the subject, and acquisition is fast and takes about a
minute, including software elaboration of the result.

40. Arthro-kinematics of the elbow: study
of the carrying angle
P. VAN ROY, J. P. BAEYENS, D. FAUVART, R. LANSSIERS and J. P. CLARIJS.
Ergonomics, Vol. 48, Nos. 11 – 14, 15 September – 15 November 2005,
1645–1656 .
The mean carrying angles at 0, 30, 60, 90 and 120 degree of flexion
revealed larger standard deviations in the male group than in the female
group.

41. Questions