Mr. E. J. Krass, SoH

Just Call Me - Galileo II/Founder of the Unified College of MedicineSpokesperson for THE TRUTH BASED FREE Society and Its Realm

RE: Distribution of my withheld thesis paper through public domain

To Everyone:

In March 2001, I first distributed my thesis paper founded upon self evident Truth,

observations of comparative x-ray images and application of centripetal mechanics.

In May 2004, under Full Disclosure, the appeals commission for the WCB alberta affirmed

that it has always acted as a “devil’s advocate” in my matters just as the WCB administration has

done since November 1, 1998 several months before I was injured: Exhibit “K” on File No.

PO-001 with The Defender of The Faith.

In Exhibit “Q” on File No. PO-001 with The Defender of The Faith, it was

discovered that the administration was the source of “devil’s advocacy” across Canada since 1982

and the corruption is contained in all “quasi-judicial tribunal” decisions since April 17, 1982.

Canada’s Charter of Rights and Freedoms is “devil’s advocacy” because s. 3 exists in

defiance of The Supremacy of God and Rule: Petition to The Defender of The Faith - formerly

Petition to the monarch when BAD FAITH is acknowledged: administration has NO RIGHT to

exist under The Rule of The Supremacy of God and its Petition to The Defender of The Faith!.

With the release of Exhibit “K” on File No. PO-001 with The Defender of The

Faith, the reality of Mr. Smith Goes To Washington was revealed concerning administration. The

correction of corruption was not though because changing the system to THE FREE Society of

Equals and Its Realm as dictated by objectively supported Truth through dismissal of administration

once and for all and forevermore could not have been presented as it is the embodiment of The Holy

Spirit.

Once a false step is taken away from The Truth, the administration MUST maintain the

corruption through lies, deceit and deception - the role of “devil’s advocate.” All administration is

PO Box 1041 STN MAIN, DAWSON CREEK BC V1G 4H9

Mr. E. J. Krass, SoH

Just Call Me - Galileo II/Founder of the Unified College of MedicineSpokesperson for THE TRUTH BASED FREE Society and Its Realm

a lie as my thesis paper confirms because tennis elbow is a serious and significant PHYSICAL injury

that can be easily prevented but not if everyone is devoted to mammon and the pursuit of wealth.

Deuteronomy 22:19 reads as follows: Thou shalt not lend upon usury - mammon - from the

era of Jesus Christ/the pursuit of wealth for today and since the 1200's AD. (The beast that was and

is, yet is not is exposed.)

Those choosing to Do Right including existentialists or those following moral conscience can

only find THE FREE Society of Equals and Its Divine Existence through dismissal of

usury/mammon/the pursuit of wealth which is a belief system or religion based on corruption.

As my thesis paper and the path that I was ordered to follow based upon “devil’s

advocacy”/administration is beyond dispute by anyone reading these documents, I am now releasing

my 2000 thesis paper entitled The Krass Realities™ of Upper Extremity Rotation and Rotatory

Instability as a public domain document along with the Preamble to it as written for The Defender

of The Faith and as wholly unified document that they truly are.

Review the x-ray images and centripetal mechanics and you will realize that I was not wrong

but the system hid this document from public consumption and my legal documents through the

application of the corrupt constitutional questions act because my documents are imbued with The

Truth/The Holy Spirit and they ultimately throw out everything that mankind has done for millennia -

build civilizations built upon false gods and false promises of administration and their ideals.

Fortunately, God showed me how to dismiss everything under Rule: Petition to The Defender

of The Faith.

Take care and leave those cities for living with God now that you know that your civilizations

are about to be dismissed and replaced with the 4 Primary Laws of THE FREE Society of Equals

contained on pages 168 through 191 of The August 2009 Peremptory Order.

In this universe, there is Doing Right as supported by the objectively supported

Truth/The Holy Spirit with all else being wrong!

PO Box 1041 STN MAIN, DAWSON CREEK BC V1G 4H9

Mr. E. J. Krass, SoH

Just Call Me - Galileo II/Founder of the Unified College of MedicineSpokesperson for THE TRUTH BASED FREE Society and Its Realm

Sincerely,

Mr. E. J. Krass, SoH

Author of The Treatise on The Petition to the Court Due Legal Process

Galileo II/Spokesperson for THE TRUTH BASED FREE SOCIETY

Founder of the Unified College of Medicine

Petitioner on File No. PO-001 with The Defender of The Faith

For The Record: the term radiocapitellar joint is the same as the radiohumeral joint in Gray’sAnatomy and my thesis paper. The newer term is reflective of the fact that thehidden part of medicine accepts that the radiocapitellar joint is the primary jointof the elbow but without the political ramifications of this change inunderstanding.

To understand everything easily, just note that there can be only one mature,healthy standard for the upper extremity. But, there are only 2 option to sortthrough: radiocapitellar joint centric or ulno-humeral joint centric. The medicalcommunity in 1901 went with the latter and has refused to correct its standardsbecause it rewrites everything pertaining to human anatomy.

T h e x - r a y i m a g e s p r o v i d e d a thttps://skydrive.live.com/self.aspx/Public/Objective%20x-ray%20evidence%20for%20MANDAMUS?cid=76d01868d933a2ac&sc=documents make it clearthat the medical standards for human anatomy is 100% wrong as the armupper extremity complies fully with the engineering standards of centripetalmechanics along with torsion along solid objects which defines the lateral/sideligaments of ginglymus joints as load bearing and unifier of the arm for forcedistribution up and down the arm.

The answer was always the fact that the upper extremity is radiocapitellar jointcentric but, once a path that is wrong is taken by administration, it is impossibleto correct simply as the entire understanding of medicine must now be dismissedas IT IS WRONG!

The medical community has made that point abundantly clear as it hid myfactually supported thesis paper for no other reason than it repudiated the currentapproach to medicine.

PO Box 1041 STN MAIN, DAWSON CREEK BC V1G 4H9

UppEn ExrnEMrrY Rorl.uoNAI.{D Ror^LroRY lxsrannrrY

(Mt E. J. KraR)

TrtE Knass RnzurtnS" oF

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THE Knas^s Rn,qLITIES" oF

UppER ExrREMrrY RorATrof{AND RoTAToRY IxsrABrLrrY

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Copyright O 2000 by E. J. KraB

All rights reserved. No parl of this publication may be reproduced, translated,stored in a retrieval system, or transmitted, in any form or by any means electronic,mechanical, photocopying, recording or otherwise, without the prior written permis-sion of the author and copyright holder.

Requests forpermissionto make copies of any paft of the work should be mailed to:

PermissionsE. J. KrassPO Box 654POUCE COUPE BC VOC zCO

CANADA

Printed in Canada

Contents

Sucrrox I: Trre Kuss Rnlr,rry or Uppnn Exrnrnrrry Rornrron

1. Rlrronlr,n FoR Nnw TnnoRrEs oN Suprnlrrox lxn Pnoxnrrox

2. Tnn Nnw TnnonrEs FoR Sr;prxarrox lxo Pnoxlrrox

3. Uppnn Extnomrry Mootrrrns Enpr,rclrno

SuprN,rrrnn Fr,rxrox lNo Suprxlrno ExrnnsronSupinated FlexionSupinated Extension

*ExrrNonn Anrvr SurmATroN uvo PnoNlrron*Extended Upper Extremity Pronation

. Extended Upper Exhemity Supination

Pnoxlrnn Fr,nxron luo Pnoxlrno ExrnxsronPronated FlexionPronated Extension

90 Dncnns Ft,exno Elsow SuprnerroN lNo Pnonlrrox90 Degree Flexed Elbow Pronation90 Degree Flexed Elbow Supination

4. Coxcr,usrou

Appnxurx: Su*rrrlany

SrcrroN If: Tno Knlss REALrry oF LATERAL

Uppnn Exrnnurry RouroRy INsrABrLrry

1. Basrcs or Larnur, Uprnn Exrnnrrtry Rorlrony fxsrlnrr,rry

2. Trrn Tnurq ABour Llrnnlr, Uppnn Exrnnurry Rorarony lxsrumr,rry

Er,row BAsED Lrrnnc.L Urrnn Exrnrnnrry Rourony fxsu,nn-rry

3. PlrnourcrrANrcs or Er,now BAsED L,lrnrur, Rourony lxsrlmr.rryInstability Due To Tiaumas To An Outstretched Upper ExtremityRepetitive Moderate Trauma: the Cumulative EffectRepetitive Overuse Syndromes

Gender Based Lateral Rotatory InstabilityOld Age (Men more so than Women) Lateral Rotatory Instability

4. Svuprouor,ocy or L.lrurur, Rourony Ixsmmr,rry

Elbow Symptoms

Wrist and Lower Forearm Symptoms

Long Term Complications

-f,

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T4

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5. DUcNosTICS FoR Larnml RoruroRy Insmrnrry r

Knass PnoxarroN Tnsr

6. TnnATMENT FoR L,rrgRAl RornroRy fnsrnBrlrryPhysiotherapyReconstructive Lateral Epicondylar SurgeryPost Operative TreatmentIneffective and Compliment ary (Current) Tfeatments

7. PnEvENTToN oF LATSRAT, RomroRy lNsmBrt,rry

8. CoNCLUSToN

'AppEttDIX: ScruNTrFrc Pnoor FoR Ersow Baspn Lnrnnnl

SrcrroN III: THr KnAss Runlrry oF SHouLDER Blssnf]rpnn ExrREMrry RornroRy lNsraBrr,rry

RorEroRY fNsrnBrlrry l-lil

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1. Snoulosn Blssn Uppnn Exrnnrr,rrry Romrony lNsrlnrr,rry

2. PrrsomncHANrcs or Sgour,nnR BASED RornroRy Insrlnrr,rrrns

Instability Due To Anterior Rotator CuffInsufficiencyInstability Due To Superior Rotator CuffInsufficiency

3. Svurrouor,ocy oF Snour,orn BASED Rourony Ixsrlnrr,rry

Anterior Shoulder Rotatory Instability SymptomsSuperior Shoulder Rotatory Instability Symptoms

4. Drlcxosrrcs FoR Snoulonn BAsED Romronv lNsrnenrry

Anterior Shoulder Rotatory InstabilitySuperior Shoulder Rotatory Instability

5. TnnrtrvrnNT FoR Snour,onn Ixsunnrcroxcm,s

PhysiotherapyReconstructive SurgeriesPost Operative Treatment

6. PnrvrxrloN oF Ssour,prn BAsED Rouronv fxsumury

Exonore & BrsrrocRAPrrY

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SncrroN I:Trm Kness RntuN" oF

LIpPER ExrREMrrY RoTATIoN

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N.Elr TnEoruns ow

Since 1989, I have been suffering from an injury to my right elbow and wrist that the medical profes-

sionals in westem Canada could not diagnose and fieat. Emly in I99l,T encountered another patien! -

referred to as Joe, with a similar symptomolory. In 1997,I finally discovered a nzrme for Joe's medical

condition -posterolateral rotatory instability (PLRI). Over the yearc, since I first met this individual, Ihad the good fortune - for the advancement of the lateral upper extremity rotatory instability condition

that is - ofbeing able to study 47 individuals with similar symtomology to Joe and myself. However, not

all of the 47 cases arose from the same cause but acfually arose from 5 different causes. The unique

feature to all these causes was the long-term symptomology which eventually became EXACTLY the

same after several years of attempted arm usage. To me, this fact meant that lateral epicondylitis was

more of a symptomto some uniform an4 asyet, understood cause.

Atpresent, PLRIisdefined as an insufficiency ofthe elbow's lateral collateral ligamentand its

widely known cause is limited to a trauma to the hand similm to one trying to brace one's fall with your

arm after sltpping on some ice. However, the Kerlan-Jobe fttropaedic Clinic in Los Angeles teats

patients, mainly basebalt pitchers, whose common etctensor tendon is tom right down the middle of the

tendon from the patient's activity, which obviously is repetitive overhand throwing. Although this latter

cause of PIRI is known to the orthopaedic surgeons at the pre-eminent clinics studying the causes of

lateral epicondylitis, it is not seen as a viable second cause amongst the general orthopaedic surgical

community as the thorough medical explanation for repetitive overuse has not been determined meaning

that there are no definitive medical papers on it. Both forms of lateral upper extremity rotatory instabil-

fp, though, do exhibit the same early symptom - lateral epicondylitis.

This begs the question: What exactly is lateral epicondylitis which, as yet, no medical professional

has fully explained? Simply, lateral epicondytitis is merely strain on the common extensor tendon fuom

repetitive forced pronation or strain on this tendon due to an under$ing insufficiency of the radial collat-

eral ligament determining lateral epicondylitis to be just a symptom ofthese conditions. This definition

though does not conform to the prese,nt medical paradign conceming supination and pronation demon-

strating exactly why this thesis is being written - to CHANGE the present medical understanding of

pronation and supination so that it is brought into alignment with physical reality.

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In the infancy of the medical profession, a couple of centuries ago, doctors created theses based on

cadavers and how the musculature looked as well as how they interpreted the activity. For supination and

pronation, the doctors saw that there was a muscle Soup which crisscrossed the anterior forearm and

attached to the medial epicondyle. The male doctors looked at their own anns pronated them and mistak-

enly determined that this activrty involved just the forearm and that the radius was being pulled over by

this muscle group. Thus, the narne of pronator teres was given to it. This mistaken interpretation of

pronation is why the medical community has been unable to confirm that lateral epicondylitis represelts

an abnormal stain being placed on the common extensor tendon and the radial collateral ligament.

In the present medical paradigm conceming pronation" the pronator teres is actually supposed to

contact and stengthen from repetitive pronation which means that there has to be some movement ofthe

radius at the lateral epicondyle as it is mistakenly assumed to be pulled over the ulna. This false conclu-

sion led to the mistaken medical belief that there normally is a natural laxity at the lateralepicondyle in

order to facilitate the present medical interpretation of pronation

Unfortunately, there was a complimentary set of muscle groups attachedto the lateral side ofthe

radius which are also connected to the lateral epicondyle and which led to the mistaken assumption that

the radius is rotated back across the ulna through supinatiorq i.e. the changing ofthe position of the hand

from palm down to palm up. These muscle groups were labeled the supinator longus and supinator

brevis. However, there was a slight glitch even at the inception ofthe supination axiom as another very

small muscle group was discovered at the lateral epicondyle whose purpose the medical community could

not explain but summarily concluded was of little importance as the physicians had suffrcient muscles to

conclude their theory. Consequently, this medically misunderstood muscle was not glven a supinator

tabel instead being labeled the anconeus and whose functionality remained a mystery until the compila-

tion of this book.

Regardless of all these labels, the medical community's axioms concerning supination andpronaiion

are utterly incorrect and were anived at illogically given science's present level of knowledge and diag-

nostic imagery. The error in logic arose from the original doctors using DEAD human bodies to formu-

late a theory and then not having the diagnostic means available to determine from a live human being

EXACTLY what happens internally d*i"g pronation and supination. There were no radiographic

machines, CT scanners or MRI machines available to the initial doctors and the present medical commu-

nity never thought that these axioms needed to be re-confirmed even though not all the muscle groups

conformedto these axioms orthat lateral epicondylitis remains to this day undefmd unexplained and,

now very common.

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Suqwarleu ANn Pnowarlor*r

Instead of starting my exploration of supination and pronation from the present medical axioms, I started

from the fact that I hqd a confirmed common extensor tendon injury which had been caused from excessive

and exfremely heavy pronation. Basically, in order to explain the resulq I had to reverse engineertheprocess

in order to determine how repetitive and heavy pronation caused my common extensor tendonto become torn

longitudinally from its insertion at the lateral epicondyle almost all the way down my right arm's upper fore-

arm. So, I had to determine how a process that could not conceivably cause the injury, pronation, had actually

done it. To do this, I postulated thatthe pronator teres wasnot pronating and that the supfuntors were not

supinating and I devised a simple experiment which would either confirm this axiom or refute it.

To my surprise, the results of this simple experiment did just what I expected and confirmed, without a

shadow of a doubq that the supinator andprorntor muscle groups of the forearm are actually improperly

labeled. This experiment also exposed that supination and pronation are not actions limited to the forearm but

actually include the upper arm bong the humerus. Essentially, the experiment exposed the fact that supination

and pronation are actually a set of very complex processes comprised of a sequence of muscle contractions

extending from the shoulder down through the forearm muscle groups as far as thepalmaris brevis.

Trying to explain how the forearm muscle groups contract to perform supination and pronation though

was complicated because, as I had discovered earlier this year, biceps and triceps confiactions were not the

only muscle contractions utilized to raise and lower the forearm. So, before the supination and pronation

processes can even be explained, understanding, which muscle groups acfually have to contract in order for

the upper extremity, i.e. the long drive train to the wrist from the shoulder, to pronate and supinate, has to be

determined generally to start.

The way in which I leamed how pronation and supination were performed was by fully extending my arm

in front ofme while it was perpendicular to my body. Then I studied the medial epicondyle of the humerus to

determine how the upper exffemity moved as the arm went slowly from fully supinated to fully pronated with

stop points being at the vertical and horizontal positions. (In a circulm description, the left hand's thumb

would be at the 10 o'clock position, to start, with stop points being at the 12 and 3 o'clock positions or, on the

right hand the start position would be at the 2 o'clock position with the stop positions being 12 and 9

o'clock.)

The best way to view the rotation of the medial epiconfle though is not &om the anterior but from the

posterior or backside. To get this view, it is best to place a large mirror behind the anq being studied so that,

when you look over the upper ann and into the minor as the arm slowly rotates from supination to full prona-

tion, you get the best view of the bone sfuctures through this motion.

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From this visual experiment, henceforth referred to as the ,1"' Krass experiment, it became evident that

indeed the humerus was moving through supination and pronation determining that these activities me not

forearm activities at all but rather full arm activities. Also, from the motion of the humerus through pronation

as well as the principle that bones move towmds the force that arises from muscle conkaction, it is clear that itis impossible for the pronator teres ot pronator quadratus to be confracting through pronation as the humerus

is rotating in a direction completely contrary to what the muscle contraction principle drdlrztes. Ergo, the

lateral and posterior muscles of the upper extremity must be contracting through pronation instead of the

pronators.

Another experiment that I recently devisd to be referred to as the F Krass experiment, confirms that,

from a fully supinated position through pronation, the humerus is part of the motion. This corroborating test is

fm more definitive because it involves a basic set of elbow radiographs which clemly define the initial and

ending bone positions and their motion through pronation from a fully supinated starting position or vice

versa,'depending on which radiograph one looks at first.

Normally, when a set of elbow radiographs are taken, it consists of 3 fikns: one where the arm is fully

extended and supinated; another where the fi.rlly extended arm is pronated to the horizontal position of the

hand; the final one being where the arm is flexed at the elbow to about 90 degrees from extension and the x-

ray taken from the lateral side of the arm. As can be seen, the first two radiographic images correspond rather

well with my second experiment and these films clearly demonstrate that the humerus is following the rotation

of the hand and forearm confirming that the upper exhemity pronates and supinates as a "full unif' or like a

drive train found on rear wheel drive vehicles.

The coordinated rotation of the humerus with the hand directly confradicts the present medical theory that

supination and pronation are shictly forearm activities arising from rotation of the radial head at the capitel-

lum. The x-ray films also corroborate that the direction of the upper exhemity through both supination and

pronation is completely opposite to the medically assumed muscle contractions which led to the present

muscle labels, i.e. the pronator teres and pronator Etadratus cannot be contracting through pronation and the

supinotor brevis and longus cannot, as well, be confiacting through supination. With the medical axioms that

supination and pronation is a forearm activity caused by contraction of the like named muscle groups utterly

obliterated by the two experiments and the fact that the upper extemity is moving clockwise in the left arm

and counterclockwise in the right arm, it is now possible to postulated accurately the roles of the upper ex-

tremity muscle groups from the shoulder down to the hand. However, before this discussion can be started,

how the elbow exactly works through flexion and extension has to be determined.

From my injury and the 1992 intemet paper on PLRI, it is clear that the anterior and radial eollateral

Iigaments of the elbow actually form a set of pins for the'tinge'motion of the elbow. This realrty e4plains

the role of the radiohwneral joint quite easily because these pins actuirlly allow the radial head to arc over the

humeral capitellum through flexion and extension. This process is confirmed when one actually attempts to

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flex the arm when it is nearly fully extended with the forearm pronated. During this process, the radiohurneral

portion of the arm acfirally rotates backward to the point where the radial head can glide in a natural arc over

the capitellum. This motion is similar to drawing a large circle with a string which is tied tightly to the center

of the circle where the radial head's medial and lateral pins function like the string, the humeral attachments as

the center and the radial head is the pencil.

Another more correct analogy is a "modified pulley" where, instead of a wheel rotating freely around a

centerpoint established by two stationary and isolated arrs, the wheel is stationary, the humeral capitellur4

and the rope, muscles, attached to the top and bot0om of an objecg the radial hea4 and it is pulled up by the

top muscle and down by the back muscle. To keep the force going on this same plane are two pins which

attach at either side of this plane, i.e. at the medial and lateral sides of the radiohurneral joint wherr looking

from overtop ofthe joint..

The discovery that the radiohurneral jornl is solid and pinned atthe radial collateral and anterior liga-

ments has serious ramifications for more present false medical theories. The most notable ones being that the

ulno-humeral joinl is solid" which it isn't and which will be proven when supination is discussed in this paper,

and that the radius is dependent on the ulrn-hurneral jointwhich is quite conftary to the truth. In fact, the ulna

is dependent on the solid nature of the rdiohurneral joint and its functionality arises from the latter explaining

why I wilt be referring to the joint formed by the radius and the ulna as Ihe ulno-radial joint-it is an accurate

portrayal ofthe structure rather than vice versa as is the present inaccurate medical designation.

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From my two tests and the position of the of the humerus through pronated flexiorl it is demonstrated that

there are 8 motions, excluding the raising and lowering of the humerus and its circular motion, that need to be

accounted for when defining the role of muscle contactions in the upper extremity: supinated flexion and

supinated extension motions; extended arm supination and pronation; pronated flexion and pronated exten-

sion; forearm pronation and supination motions with the elbow bent to 90 degrees.

Imnortant Note: the soft tissue labels used in this book are taken fuom Gray's Anatomy, 1901 edition

SupnqA,rED Frsruot\ AND SupmrarnD E>rrnNSroN

Supinated Flexion

This motion seems straight forward: the biceps muscle contracts causing the forearrn bones to arc towmds

the humerus. This understanding is incomplete because, if supinated flexion were this simply, you would find

that the ligament sheath across the anterior aspect of the tochlea and the medial arc pins would be severely

and easily stressed causing inflammation. This process does not mise often because supinated upper exhemity

flexion is considerably more complex-when you place a small weight, say 10 lbs. in your hand and flex the

biceps, the firll extent of muscle contractions is exposed.

Looking at the radial biceps attachmentposition, it is clearthat, when the biceps contacts, the radial head

should rotate upwards mound the humeral capitellum. Such rotation does not occur though which means that

this contractive force has to be mitigated. The first possible mitigating muscle contactionto biceps contrac-

tion has to be the supinator brevis which attiaches to the ulna and radius in a manner that surrounds the Bicipi-

tal Tuberosity. However, contraction ofthis muscles which does occur during both types of upper exfemity

flexion, supinated or pronated hand, cannot mitigate the rotative force created by the biceps because the

wpirntor brevis does not attach to the humerus at the anterior hochlea or the medial epicondyle. Actually, the

wpinator brevis attaches to the humerus at the lateral epicondyle so confoaction of it actually augments the

upward rotation of the biceps confaction while aiding in the raising of the radius and ulna and the unification

ofthe forearm as a unil the supinator brevis attaches to both aspects of the ulna on either side ofthe radius so

confaction of this muscle causes the ulna to remain tight to the radius while its latnral attachment applies a

complimentary forearm raising force to the biceps contraction over the radial collateral ligament - one of the

radial head's lateral arc pins. Thus, the theory that contraction ofthe supinator brevis contradicts the upward

rotative force created by confaction of the biceps is eliminated.

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The next muscle groups attached to the radius but slightly further down that could mitigate the anterior

rotative force ofttre biceps isthepronator teres andflexor sublfunis digitorum. Both of these muscle groups

attach to the medial epicondyle but the former attaches to the top of the radius just beyond its superior line

while the latter attaches to the medial side ofthe radius. Withbiceps contraction, contaction ofthe 2 afore-

mentioned muscles is clemly defined by radial attachment to colmteftrct naturally the rotative force generated

upwmd over the medial arc pin. So, the reason for a lack of swelling along the anterior tochlea line and in

the radial head's anterior ligament with biceps contraction has been discovered as well as the reason, the

anterior angle remains constant though flexion.

So, basic muscle contraction for upper exfemity flexion consists of biceps, supirmtor brevis, pronator

teres andJlexor sublimis digitonnn confactions over the radius which balance themselves out rotatively and

side-to-side causing the main fwce of biceps and, ntpinator brevis confactions to be applied upwmds and over

the radial head's medial and lateral arc pins. The complimentary basic forearm lifting force applied to the

ulna ii created by the brachialis antictts. This contraction augments the contraction of the supirator brevis

which raises the ulna in unison with the radius, thus eliminating any potential for swelling within this muscle -not over working. The brachialis anticus is itself mitigatedby the pronator teres andflacor sublimis

digitorum contractions as they reside in the line of the ulna causing the ulna o'to hinge" at the anterior of the

trochlea throughout upper exfemity flexion.

In flexion of a supinated forearm, these basic muscle contractions are augmented by contractions within

the palmaris longts, flexor carpi radialis, supinator longus and extensor carpi radialis longior. The first two

muscle groups add to the function ofthe medial arc pin while the final two's force adds to the stability of the

lateral arc pin allowing for large weights to be lifted when the hands and forearms are supinated. During the

latter stages of supinated flexion, though, the clavicle portion of the pectoralis major and subscapularis

contract to counterbalance the natural anterior rotation of the humerus that arises wheia the biceps, supinator

brevis, brachialis anticus, tlexor carpi radialis andpalmaris longrc contractions become too strong to be

controlled by the contractions of the pronator teres andflexor sublimis digitorum affecting the medial hu-

merus'position.

Note for weight lifters: using a sfraight bar for flexion is not recommended because it places an abnormalstain on the radial collateral ligament and common extensor tendon throughout the motionbecause the arm does not usually'lvorlC'with the anterior trochlear line remaining at thehorizontal line. This portion of the humerus usually remains around the 4 o'clock positionon the left and 8 o'clock on the right - angled down by at least 30 degrees from the horizon-tal plane. If you do feel that a straight bar works best for you through flexion, then youeither have naturally la:< joints or are suffering from an insufficie'ncy of the radial head'slateral arcpins.

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Supinated Extension

Extension of the arm while the forearm is supinated utilizes the internal triceps head nthe upper arm

withthe pectoralis major contacting to courterbalance the natural posterolateral rotational force created by

the original contractions. The forearm muscle contactions that make the force uniform throughout the upper

extremity me the exteraor ossis metacarpi pollieis, extensor carpi radialis brevior, extensor communis

digitorum, extensor minimi digiti and exterxor indicis. These contractions are necessary to keep the Greater

Sigmoid Cavity tight up to the radial head and trochlea while extending the elbow to 180 degrees and sucking

it of the ulna into the olecranon depression at the posterior of the humerus - the endpoint of extension. (Th"

ligaments pertaining ta the ulno-humeral joint are not tight which will be fully exposed in the explanation of

the supination and pronation motions. Also, the arrconeus does not conftact through supinated extension.)

The contractions ofthe aforementionedextensormtrccle groups comprise a shong and complimentary

force to the intemal triceps head's contaction. However, in the new realrty of elbow functionality, the

posterior force has to be placed almost directly over the medial and lateral arc pins of the radial head. The

ONLY muscle capable of doing this is the supinator brevis which does not confiact through supinated exten-

sion. Fortunately though, in order for this muscle group to provide this direct downward force to these pins it

doesn't have to be conhacted. Normally, the supinator brevis is never subjected to any force that causes it to

become weak or lax in any way so, as the ulna is rotated downward by contraction ofthe 5 aforementioned

extensor muscle groups, the supirntor brevis and the annular ligament act like a tight strap placed over the

radius and right over top of the radial head's arc pin. Naturally, this muscle's and ligament's placement

transfers the posterior confactive force produced to the superior, medial and lateral aspects of the radius

uniformly. Now, it is exposed how the radius is lowered in unison with the ulna through supinated extension.

Upper extremity extension with a supinated hand isn't half as complicated as upper extremif llexion

with the hand being supinated mainly due to the fact that the motion is merely a reversal of the flexion proccss

which is very complicated indeed. The only necessary information to remember though is that both motions

are actually performed throughout the upper exfemity like a drive train and that almost all upper exffemity

motions impact on the shoulder via the o'solid" radiohumeral joint andthe radial head's lateral andmedial arc

pr'ns. Now, the more interesting actions ofpronation and supination can be explored.

*E:<rgNDnu ARM Supnslrrox lrro PnoNlrrox*

The motions ofpronation and supination are the most significantly altered by the discovery that the

radiohumeral joint isthe most solid unit within the upper extremity and especially the elbow. It is important

to reiterate that the ulno-hwneral jolnr is significantly less solid than previously thought by the medical

community and that it actually facilitates the motions by moving between the trochlea and the lateral epi-

CopJ # ou for Rt,iiDIKRASS I2

condyle depending on the motion. The motion of the ulna is proven tnre because, with the concrete evidence

that the radius does not rotate through extended supination and pronation, there is no other conclusion that can

be derived based on the reality that the wrist and hand is changing position through pronation and supination.

Confirming this logical conclusion is easily done when one thinks about it for a second.

ln both Krass experiments, it was easily determined that both supination and pronation undeniably

involve the upper ann or humerus. Now, flexion of a supinated arm confirms that the anterior of the ulno-

humeralioinf is made functionalh stationary through this activity. Through simple geometry, with the elbow

hinged at its anterior and the arm at 90 degrees, this means that the posterior of the ulna must be displaced

relative to the humerus, i.e. a wedge shaped gap forms between the ulna and humerus with the larger portion

being at the most posterior point of both bones. This reality allows the displacement to be accurately calcu-

lated when dissected from a side view ofthe arm.

Using geometic a:<ioms, the 90 degrees of bend at the anterior of the hinge can be hansferred to the

posterior or opposite angle: opposite angles are always equal. Also, the thickness ofthe ffochlea and the ulna

are almost identical. (The Greater Sigmoid Cavity has little impact on the calculations because the ligament

line is above it on the olecranon.) With these figures, it is easy to calculate the circular distance at the poste-

rior of the ulno-humeral joint: thethickness of the tochlea and the ulna is the radius of the circle, r, and so all

that needs to be done is to plug this number into the formula for the circumference of a circle, 2nr, anddivide

it by 4 (360190:4). The numerical result from this is the arc distance taveled by the Greater Sigmoid Cavity

and the posterior ulna relative to the trochlea or humerus.

This figure can be translated into a linem distance by applying the Pythagorean theory which is

permissible given the fact that the hinge angle is 90 degrees. So, with the thickness ofthe ulna and the troch-

lea known to be equal, the need to determine the angles is eliminated: actually, the angles at the posterior of

the trochlea and the ulna relative to the hypotenuse is 45 degrees as the triangle that is formed within the

posterior of the "hinge" joint is an isosceles triangle meaning that the angles formed at the ends of the hypot-

enuse have to be equal or 45 degrees. Now, just plug the thickness of the bones, x, into the Sthagorean

theory and the numeric result will be the linear distance that the Greater Sigmoid Cavity and posterior ulna has

to travel from the frochlea during supinated flexion.

Both numeric calculations confirm, without any doubt, that the ligaments at the posterior of the ulrn-

humeral joints are naturally lax which means that these joints cannot be as solid as the present medical para-

digms for the elbow state. This fact was also used by the medical community to determine the erroneous

supposition that the radius rotates around the capitellum instead of how the radiohumeral joint actually

functions - the elbow's radial collateral and anterior ligaments act as radii pins fbr the natural arc of the

forearm through upper extremity flexion and extension causing the radial head to'oglide" up and down the

humeral capitellum from frontto back.

Both Krass experiments also demonshate that the humerus is involved with supination and pronation

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of the upper extnemity but they do NOT clearly demonstrate the fact that the ulna moves around the radius

through these actions. The true value of the Krass experiments wasn'ttn determine the ulna's motion relative

to the radius but to present an accurate means of analyzing how supination and pronation is actually performed

relative to the humerus----conJirmation that the ulna moves mound the radial head at the elbow will be pre-

sented in the discussion ofpronated flexion and extension.

The.trirass experiments clearly demonstrate beyond their original mandate though that when the

upper exfemity is fully extended it becomes a "solid unif' from the shoulder down to the hand. This fact is

easily proven because the Greater Sigmoid Cavity of the ulna locks into the olecranon depression at the

posterior humenrs. From this final interlocking of the forearm structures to the humen:s, it can be determined

that the elbow when the arm is extended then functions like a'bniversal joint" on the drive tain of a front

urgine rear-wheel drive vehicle. This functionality of the elbow, i.e. universal joint, when the arm

is extended through the last 30 degrees which becomes very important when applied to pronated extension and

rotatory instability.

From the Krass experimenls,l also discovered that there me 3 main positions through both pronation

and supination motions which account for a change in muscle contractions. The positions are full supination,

the neutral position (12 o'clock or vertical), and the fully pronated hand position (5 o'clock for the left arm

and 7 o'clock for the right arm) with the thumb representing the reference point to these clock or degree

position. To better understand pronation and supination, it is better to discuss the full process with breaks at

these positions rather than discuss both processes simultaneously from position to position.

Extended Upper Extremity Pronation

Starting with pronation from extreme supination to the neutral, 12 o'clock, position, there is very little

contraction because supination beyond the neutral position is mainly a forced or abnormal activity when the

arm is firlly extended. So, when the contractions for supination are stopped, the arm instinctively seeks to

eliminate this trnnatural state. To do this, the subseapulmis and the clavicular portion of the pectoralis major

snap back to their normal s2e: a good analog, would be like stretching these two muscle groups like an

elastic band whiclr, when the force applied to stretch them is removed, they revert to their normal size.

This assessment of muscle activity it easily confirmed. It is known that the radiohumeral stuctures

forms a natural angle along the anterior side of the elbow of about 120 degrees which, from physical observa-

tion and the x-ray films, has been determined to remain static. When supination beyond the upper exremity's

neutral position occrlrs, it has to be done through an abnormal rotational force applied to the humerus' oppos-

ing muscle groups through supination or pro,nation. This means tha! during the final portions of pronation or

supination, the humeral rotation noted is occuning not just through muscle contraction but also a strong

stetching activity in the muscle groups those that are relaned and attach to the upper humerus and its head.

Corroboration of this assessment of the final stages of both supination and pronation is deterrnined by extemal

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observation of the medial epicondyle: the supination example of this principle is that the left arm's medial

epicondyle leaves its normal position of around the 4 o'clock to rise up to the 3 o'clockposition or approxi-

mately 30 degrees circularly through the latter portion of rotational motion. Furthermore, the anterior portion

of the shoulder demonstrates some discomfort mourd the Coracoid Process which indicates that the muscles

at this part of the shoulder are being subjected to a stretching proc€ss.

Anottrer way of confirming that the subscapularis and the clavicular porti on of the pectoralis major

are merely "reflectively contracting" through to the neutral position from extreme supination is the reality that

the radius in the forearm merely retums to its normal position, 12 o'clock" and the medial epicondyle reverts to

its normal position of 4 o'clock. The positional changes of the radius and medial epicondyle are consistent

with the natural and static angulation of the anterior radiohumeral joint line when the humerus is not rotated

beyond its natural position - the lateral epicondyle is at it proper position across from the medial arc pin. This

position revercal of the upper exffemity not only once again confirms that the radiohtmteral jor'nt is the pivot

for supinateO flexion but also affirms that the radius is definitely not rotating around the capitellum.

This medical theory was actually derived from the humeral head which rotates relatively circulmly at

the shoulder. This motion resulted in the general theory that atl circularparts of bones are rotated about by the

adjoining bone or rotate within the adjoining bone. Proof that this approach is mistaken is: if the radius were

rotating around the capitellum, then the anterior radiohumeral jointlnewould not reside permane'ntly at 120

degrees and the radial head would ALWAYS separate from the capitellum when subjected to pronation forces

which it does not. Unforhrnately, this incorrect theory about rounded bone endings was never challenged

since the advent of radiography and radiolory and this means that many medical problems conceming non-

rotating circular portions of the anatomy have remained undiagnosed and completely misunderstood by the

medical community- case in poinl lateral epicondylitis.

Retuming to the pronation motion, from the neuffal position to the fully pronated position is actually a

combination of actions: using the left as my reference, the medial epicondyle is seen to be rotating posteriorly,

cloclorise on the reference atm or counterclochrise on the right while the arm goes to either 2 o'clock or 10

o'clock, respectively; then, the dorsal part of the reference arm is seen to rotate clockwise, counterclockwise

on the right; with full pronation being completed by the lateral portion of the back of the hand rotating upward

on both sides. This motion from the neuhal position to full pronation is best exposed when you look at your

arm from the back in a mirror.

So, the muscle conhactions for pronation from the neuffal position has to be thus: upper arm poste-

rior and anterior shoulder with rotation of the hand at the wrist so ttrat its back and lateral portion goes from

the vertical position to facing upwards; then, anterior shoulder confractions continue through to the point

where the anterior side ofhumeral head rotates downward and is stopped by the coraco-humeral ligcnnent.

The muscles that correspond to these actions, respectively , ate: the subscapularis and teres major which

rotate the elbow's medial epicondyle downwmd through to its final position; then, the ulna in the lower

CopJ # oal fioTRUDIKRASS t5

portion ofthe forearm is rotated around the radial by contaction of the anconeus, extensor carpi ulnaris,

extensar minimi digiti, flexor carpi radialis, palmaris longus, qctensor longus pollicis and extensor indicis.

The motion of the ulna is facilitated by the Lesser Sigmoid Cnitybeing curved which facilitates the ulna's

positional rotation around the radial and which is expressed by the handos rotation to an horizontal line.

With the hand now horizontal, i.e. parallel to the floor beneath i! and palm dowq the subscapularis,

teres major, the claviculm portion of the pectoralis major andthe external triceps head c,ontact in conjunc-

tion with the anconerc, the portion of the extensor o.ssl:s metacarpi pol&bis between its radial and ulnm

attachments, the extensor carpi ulnaris, extensor minimi digiti, extensor commwis digitorurn, flexor carpi

radialis and, finally the palmaris longus and brevis. The first 4 muscle conhactions anteriorly rotate the

humeral head so that it ends up below its normal position in the shoulder and at the point where the coraco-

humeral ligamentbecomes taunt ceasing any further anterior humeral rotation. The contraction of the 4lateral

forearm extensor muscle groups rotates the ulnm side of the wrist and hand upwards mound the radius. The 2

medial side forearm contractions plusthe palmaris brevis contraction pull the anterior radial side of the hand

around the thumb, downward complimenting the rise in the ulnar side of the lower forearm and hand.

The ulnar rotation around the radial head isn't large in nature because the Greater Sigmoid Cavity

remains snugly in the olecranon depression throughout pronation of a fully extended arm. However, this

interaction of the ulna and humerus creates a pivot point for the rotational motion of the lower forearm portion

of the ulna which is observed to occur from the neutral position of pronation to the raising of the back of the

hand to the horizontal line.

Extended Upper Extremify Supination

With pronation of a fully extended upper extremity fully explained, the discussion pertaining to

supination can begin. Similar to the initial 60 degrees ofpronation, to the neutral positio4 the humerus is

slightly over rotated due to the exffeme contractions of the teres major and subscapularis, so any relaxing of

these muscle groups allows the coraco brachialis, and teres minor, which are stretched like an

elastic ban4 to conffact autonomically and rotate the humerus so that the medial epicondyle moves back to the

6 o'clock position and the lateral epicondyle posteriorly, backwards, to its natural 'heutral" position.

Following the initial and natural reverse humeral rotation from full pronation, the next portion of the

upper extremity to supinate from its pronated position is the hand and lower forearm. This motion is accom-

plished by the ulnarportion of the lower forearm and hand being rotated anteriorly downwmd undemeath the

radius through conftaction of the prorntor quadratus, Jlexor carpi uln4ris, flexor longus pollicis and palmaris

brevis. (Ihese contractions and the fact that the ulna normally rotates underneath the radius at the

wrist becomes invaluable in explaining carpal tunnel syndrome oro as I refer to this mistaken condition,

carpal tunnel complications of lateral upper &remity rotatory instabitity.) The final position of the hand

CopJ # aol for RUDI KRASS t6

from these contractions is at the vertical midpoint of supination, i.e. it lies in a line running from the 12

o'clock position of the thumb sfizight down through the 6 o'clock position - the forearm's basic neuftal

lowerportion of theflexor sublimis digitorum.

Now, the lower forearm and hand portion of the upper extremity is at its locked position for supina-

tion but also their neutral positions which means that, if all contractions were stoppe4 there would be no

autonomic muscle contractions and, if the arm remained in this position and were used" there would be no

negative effects on the tendons, ligarnents, nerves and blood flow. The next 30 degrees of supination is simple

and occurs due to coraco brachialis contraction. This fact is easily proven and results directly from the reality- that the anterior radiohumeral line ALWAYS remains at a constant 120 degrees. By observation, it is noticed

that, as the hand rotates to 30 degrees behind its neutual position, 1l o'clock for the left or 1 o'clock for the

right the medial epicondyle rotates from 5 o'clock to its normal position of 4 o'clock on the left or 7 to 8

o'cloik on the right uniformly with the lower forearm and hand motion making it an expression of the medial

epicondyle or humeral rotation.

The next 45-60 degrees though is exFemely complicated as a plethora of muscles conhact to cause

this frnal upper exfremity, or drive tain, backward rotation. From 11 o'clock on my reference arm, left, or 1

o'clock on the right, to full supination, the medial epicondyle is fist raised to the horizontal line, i.e. 3 o'clock

on the left or 9 o'clock on the right. This is followed by a further rotation of the lateral portion of the humerus

downward and then supination is completed with a further posterior rotation of the radial portion of the

forearm/trand and upward rotation of the hypotlrcrnr cleft. The first portion of the motion is accomplished by

{irttrer contraction of the coraco brachialis, teres minor and infraspinahn This humeral rotation is also

expressed at the posterior side of the humeral head which posteriorly reduces and the top ofthe anterior rises

to the point where the coraco-humeral ligament resides in a vertical line above the Coracoid Process.

The forearmfrand completion of supination is just as interesting mainly because it's a rotation of the

hand at the wris! scaphoid and semilunm, within the wist end of the radius which the medical community

never thought possible until now when it is confirmed to be occurring . Tlne lrypothenar clefi'srise, ulnar hand

rotation upwards, is accomplished by continued contraction of the lower portion of theflexor sublimis

digitorum, pronator quadratus, flexor carpi ulnnris, flexor longus pollicis and palmaris brevis which also

observed complimentary posterior thumb rotation results &om the contraction of the lower portion of the

extensor ossis metacarpi potticis andthe extensor brevis pollicis muscles. This rotation of the posterior ofthe

thumb backwards is, in turr4 complimented by conffaction of the extensor longus pollicls and the extensor

indicis--these contractions don't conhadict the anterior muscles contractions because they use them as a

foundation for the thumb's posterior rotation.

CopJ # ool for RUDI KRASS I7

PnoxarnD FrE:aoN Ar[D Pnoxarnr] E>rrsNSroN

Before the discussion on these two motions can be initiated how the upper extremity bones move

through these actions has to be determined through observation. While looking directly into a minor-not over the anrl place your fully extended arm into a pronated position so that the hand is fully pronated.

Without any sfenuous confactions, flexthe armtowards the shoulder while keeping the hand pronated.

You will immediately notice that the humerus rotates quickly backwards to the normal position for

flexion, i.e. back to where the medial epicondyle resides 30 degrees below the pin plane established by

the anterior andradial collateral ligammts.

As the humerus rotates backwmds, it is also observed that the radial and ulnm sides of the hand

do not just follow the backward motion of the radiohumeral joinl but also reflects the anterior motion ofthe trochlea and medial epicondyle. This hand and medial epicondylm motion once again clearly demon-

strate that the radiohumeralioint is solid with no rotation around the capitellum as is presently theorized

by the medical community: the ulna portion of the hand and forearm motion is only caused by the hu-

merus and the radiohumeral joint rctatrngaround a cenfal axis which affects both the medial and lateral

epicondyles equally. At the shoulder, the humeral head is advancrng to its anterior midpoint ofrotatiorq

i.e. the coraco-humeral ligamml goes from its downward vertical position to the horizontal position.

Now, you will notice that through the process ofpronated flexiorq your left forearm actually

flexes inward at about 70 degrrees from the horizontal in the upper right quadranf when the radiohumeral

pins, i.e, the anterior and radial collateral ligaments,are used as a horizontal reference line and the

vertical being the middle of the radial head. This line of motion is the normal line of flexion not just in

pronated flexion but also supinated flexion: remernber, theradiohumeral joint is solid and creates a

permanent anterior angle for the trochlea and the medial radial line. This fact is subsequently corrobo-

rated by the fact that, once the initial humeral rotation of pronated flexion occurs, the medial epicondyle

and the radius are in the exact satne location as those presented in supinated flexion-the only difference

is the position of the ulna relative to the radius and the position of the pakn" down or up.

Qt is possible to make the forearm rise through flefon at 90 degrees rather than 70 degrees but

this really isn't natural. As can be deduce4 with the reality that the radiohumeral joint plane is the basis

for all motion within the upper exhemity, this abnormal flexion line is facilitated by the humerus rotating

even firther anteriorly around its cental axis at the start of the motion causing the pronated or supinated

forearm to flex upwmd while the anterior fochlear line resides perfect$ horizontal. Such action and the

body's response has already been addressed in the previous Note to weight hrters.)

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Pronated Flexion

Pronated flexion is easily broken down into processes, or stages, for muscle conffaction because of

the previous observations. Using the fact that the humerus rotates anteriorly to the point where the medial

epicondyle resides at 4 o'clock and the radiohtmeral pins are horizontal, pronated flexion is broken down into

two distinct ranges of motion: going from the fully pronated and fully extended position to the point where

the humerus is at ie normal position; the other is flexion ofthe upper exhemity and how the forearm is moved

through this motion.

To accomplish the initial stage is actually quite simple once one thinks about it. Initially, the humerus

must be rotated with muscle contractions along both the posterior and medial aspects of the humerus as it is

rotated around the center of the (lower) humerus. This humeral rotation naturally brings the radial portion of

the forearm backwards relative to the ulna whiclr, in tum, shifts forward as the trochle4 medial epicondyle,

advances in this same direction relative to the cenfial anis and the radiohurneral joint . It is important to note

that the humenrs also drifu noticeably laterally from its initial fully pronated and extended position. In

muscular terms, pronated flexion is initiated with coraco brachialis contuaction which shifu the medial

epicondyle anteriorly 60 degrees to its normal position. Then, the humerus is rotated baclavards with confrac-

tion of the ffiaspinafin and teres minor at the posterior humeral head which accounts for backward move-

ment ofthe radiohwneral joint,the forearm's radial side and the humerus.

Often, the initial stage of pronated flexion, as observed and explained, isn't norrnally observed

because pronated flexion is usually started after the hand has been pronated just to its horizontal position and

not from its fullypronated position where the thumb resides 60 degrees below the horizontal line which is the

approximate point where the initial stage ends. Then, people drop their elbows causing them to miss the fact

that the coraco brachialis contracts to maintain the medial epicondyle's position as the posterior ofthe hu-

merus is rotated backwmds by contraction of fhe infraspirntus utdteres mirnr. So, the general population

and the medical community miss the important facts that the shifting ofthe elbow downward is actually a

shoulder based action and that the radiolrumeral joint's rotation and position change is actually an effect of

this shoulder rotation allowing the elbow motion to be inaccuratel), described as rotation of the radial head

around the humeral capitellum.

Furttrer conclusive proof that the present understanding about radiohwneral joint firnctionality

through ttre initial stage of flexion with a pronated hand is the effects on the hand as the elbow of a semi-

pronated hand is dropped down when at shoulder height. By observation of this activity, the radial portion of

the hand moves upwards and back as the elbow falls. Using physics, the thumbs motion clearly is a represen-

tation of the posterior humeral rotation at the shoulder: when you place a board over a small straight object

such that one end of the board is significantly closer to the fulcrum and you step down on the shorter end of

the board, the opposite and longer end rises by the same degree of circulm rotation even though the distance

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traveled by the longer end ofthe board is noticeably greater-the distance traveled can be calculated using a

simple physics equation.

The motion of the ulnar side of the hand also indicates that the ulna is not as solid asthe radio-

humeral side ofthe elbow and forearm because it remains stationary as the elbow and upperportion ofthe arm

is lowered relative the hand. This lac.k of motion by the ulnar side ofthe hand demonstrates that there has to

be some compensation at the frochlea which accounts for it not moving upwards and backwards in unison

with the radial side of the hand asthe radiohumeral joint and humerus rotate posteriorly. Upon inspection of

the trochlea and the uln4 it is quite easy to determine that the Coronoid Process and the Greater Sigmoid

Cavity of the ulna are capable of sliding within the ftochlear notch. This "sliding'o is how the ulna compen-

sates for the humeral position change through the initial stage of upper extremity flexion with a pronated hand.

Rotation of the humerus and consequently the radiohumeral jointfromthe arm's initial FULLY

pronated and extended position facilitates the raising of the forearm through pronated flexion - final stage of

pronated flexion - in almost the same manner as flexion of the arm with a supinated forearm. This reality

arises from the fact that the humerus and the radiohwneral joint now reside in the same position that is used

by the arm in supinated flexion. The only difference is that the hand is now palm down rather than palm up

which impacts on what muscle contractions occur beyond the basic muscles used in supinated flexion-as a

reminder, these muscles are the biceps, supirntor brevis, pronotor teres, Jlexor sublimis digitorum and

brachialis anticus.

. The secondary contactions that are different than those of supinated flexion occur in the supinator

Iongus, extensor carpi radialis longiar and/lexor carpi radialiswhich do confact through pronated flexion

even though such actions seem to be counter productive, i.e. rotate the thumb backwards, due to their new

position. This backwards rotation though is eliminated due to muscle contracts along the lateral side ofthe

ulna. The muscles that contract to eliminate the backward rotation of the hand at the thumb and which either

bind the forearm into a pronated unit or raise the ulna are: the extensor carpi ulnaris; extensor minimi digiti;

extensor indicis; extensor longus pollicis; extensor ossis metacarpi pollicis. All these muscle groups attach to

the majority portion ofthe lateral side ofthe ulnawhich means that contraction of them has to raise not just

the forearm but also the ulnar side ofthe forearm and hand.

The extensor brevis which is attached to the lateral side of the radius andthe palmaris longus do not

conffact through pronated flexion. Also, the clavicle portion of thepectoralis major and the subscapularis do

not contract towards the end of pronated flexion. The reason for the latter two muscle groups not confracting

is because the contactions within the brachialis antictn, flexor carpi radialis and supirntor longus arc

significantly less than those produced in flexion of a supinated hand. Furthermorg the lateral conffactions

impact over top of the radial collateral ligamentwhich increases the lateral stability ofthe humerus eliminat-

ing need for contracti on of the pectomlis major and subscapularis, i.e. the natural anterior rotation of the

humerus that occurs only in supinated flexion.

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(It is important to note that, for pronated flexion to be done through its latter stage, one's fingers must

NOT be wrapped around the weight or an attachment to the object being moved as this forces theflexor

profundus digitorwn andflexor longus potticis to contract. These forces directly conftadict the muscle con-

tractions at the dorsal aspect and anterior side of the forearm making the process extremely difficult but still

possible. Doing so, thougtr, reduces the effectiveness ofthe biceps and brachialis antictts conftactions signifi-

cantly.)

Thus, the discussion for the final, or normally observed stage of pronated flexion is complete'

Pronated Extension

With this upper extremity activity being the reverse of the pronated flexion, there has to be just two

stages to this action that need to be analyzed: pronated flexion to the start ofthe humerus being rotated

clockwise for the left arm or counterclockwise for the right; the rotation process of the humerus through to its

original fully pronated and extended state. The frst part of pronated extension is quite sftaight forward but the

latter is considerably more complicated and needs to be included even though most people don't do it regu-

larly when extending apronated arm.

In the initiat stage of pronated extension, the starting position for the arm is just past the 90 degree

point of pronated flexion which indicates ilrat, in order to extend the upper extremity at the elbow, the muscle

groups connected to the hypothenar dert arc4the base of the palm of the hand, and the medial epicondyle,

those along the anterior and medial sides of the radius and the posterior of the upper exftemity must confract.

The major difference between pronated extension and supinated extension is the pronated position of the hand

around the radius which diminishes the conftactive force generated over the medial epicondyle that lowers the

forearm. To compensate for this, the external triceps head contacts along with the internal triceps headto

produce the main extensive force in the upper extremity.

To compliment these upper arm contractions through the initial stage of pronated extension and to

ensure that this force is transferred uniformly to the forearm thereby reducing the possibility of soft tissue

ftauma at the elbow and in the forearm, theflexor carpi ulraris, flexor profurtdus digitorurn, extensor carpi

uhnris and extersor minimi digiti contract The first two muscle groups' contractions,theflexors, directly

correlates to the linear extensive force being applied to the ulna by confraction of the aforementioned triceps

heafu. As in supinated exiension, the supfuator brevis and'annular ligament ftnctions like a tight strap placed

over the radius and tied to both sides of the ulna causing the radial head to arc downward over the humeral

capitellum.

The conffaction ofthe latter2muscle groups, the qcternors, acts more like a counterbalance to the 2

flexar mvscle contractions which normally cause downward and anterior ulna rotation around the radius-

obviously, this does not occur through pronated extension. However, the contraction of the two aforemen-

Copy # ou for RUDIKRASS 2t

tioned extensor muscles do perform a significant function through pronated extension which is to keep the arc

motion ofthe radius along its normal line. (If the flexor muscle conffactions were not counterbalanced beyond

the lateral line of the radius, then the radius would be subjected, at the wrist, to medial force throughout

pronated extension which would be significant enough to bring the radius inward and cause weakness in the

extensor muscle groups allowing for the radial head's lateral pins, the radial collateral ligament and the

comrnon extensor tendon,to become damaged and/or weakened through normal usage.)

Contraction ofthe 2 triceps heads, the 2 aforementionedflexor muscles and the 2 aforementioned

extensor muscles persist until the forearm and upper arm create a 150 degree angle at which point the second

stage ofpronated flexion starts. Through physical observation ofthe pronated hand and upper exfremity as the

ann goes to full or 180 degree extension from the 150 degree position, it is observed that the humerus is

subjected to an anterior rotative force as the thumb moves significantly downward from its initial position.

Again, as in pronated flexioq the hand motion is really an effect of the humeral rotation at its head which

meaffi that it doesn't need to be explained beyond the fact that its motion is permitted by cessation of any

forearm contractions along the medial side ofthe forearm.

To accomplish the observed anterior humeral rotation of the final stage of pronated extension, the

teres major, subscapularis and the clavicular portion of thepectoralis major contract together and in conjunc-

tion with the still confracting interrnl andexternal triceps heads andthe now confracting anconeus. The first

three muscle contractions along the upper and anterior aspect ofthe humerus perform the anterior rotation of

the humerus and the radiohurneral joinl causing the radial portion of the hand and forearm to surge forward in

equal proportion to the humerus. The contraction of the 2 triceps heads mdthe anconeuscause the ulna to

extend downward until the Greater Sigmoid Cavity resides in the olecranon depression ofthe humerus.

These conffactions are not the only ones applicable to the last 15 degrees of extension because ulnm

motion has to be complimented at the posterior ofthe ulnar side of the forearm and hand so as to eliminate the

possibility of soft tissue trauma in this region of the body. The muscles that contract to perform this compli

mentary duty are the ertensor ossis metacarpi pollicis, the extensor minimi digiti and the extensor carpi

ulrnris. These conkactions are confirmed by feeling the top ofthe ulnar side of the forearm especially in

men-this part of the forearm is solid indicating muscle contraction. The entire ertensor ossis metacarpi

pollicis does not contract though as only the portion residing between this rnuscles radial and ulnar attach-

ments is exposed to stimulation. (The fact that the extensor ossis metacarpi pollicis is able to function like

two muscles astheJlexor sublimis digitorum does will become invaluable in the next section.)

Now, all muscle contractions for upper exhemity exteirsion with a pronated hand are defined allowing

the discussion of upper exfemity mobility to move on to the next set of complimentary actions.

CopJ # ool for RTIDI KRASS 22

90 Dncnrn Flumo Elnow SupnvarroFr axo PRoNlrroN

Supination and pronation of the forearm while the elbow resides at a flexed position of 90 degrees are

easily examined and explained. When the upper extremity is flexed to about the 90 degrees and the hand is

rotated so that your palm is down at its exfreme without rotating the humerus to make it go finttrer - this is 90

degree pronation or the starting position for flexed arm supination. Maintaining the humeral position while

reversing the hand positiorq so that your palm faces up, changes the position of the forearm and hand from the

initial supinated position, pakn face down and thumb 60 degrees below the horizontal plane, to the end point

of supination where the hand and forearm me rotated 180 degrees from the start.

Employing the reverse mirror observation method and focusing on the posterior of the olecranon and

lower humerus tlrrough this supination process and it reverse process, one notices that the area around the

posterior humerus bulges towards the e,nd point of supination and that this bulge dissipates through pronation.

This posterior bulging and conftacting of the ulrc-humeral joint atitsposterior can actually be felt when you

place your fingers at the back of the humerus around the olecranon depression and then supinate and pronate

the hand. This visual observation and tactile test fully confirm that the ulna is moving within the trochlea not

only reaffnming that the posterior ligaments of the ulno-humeral joint are naturally la:i but also confirming

that the anterior ligaments ofthis joint lax as well.

This reality about the ligaments on both sides of the ulrn-hwneral joinl is consistent with the realrty

that the radiohumeral joinl is the primary joint of the upper extremity with NO la:<ity within its medial and

lateral pins which allows them to perform as the radii for the forearm arc through upper extremity flexion and

extension. The rigidity of the radial head's medial and lateral ligament pins also leads to the conclusion that a

portion of the 90 degree supination and pronation has to be accomplished with slight humeral rotations that, in

this instance, compliment the hand and wrist rotation around the radius. This assumption is reflected in the

fact that there is never a cross over ofthe forearm bones at any point throughout either supination or pronation

of the forearm while the elbow is flexed to 90 degrees.

(Take a look at the ulna and you will find that the bone is built so ttrai it can be rotated around and

within the radius: the outward bow in the bone; the shape of the Lesser Sigmoid Cavity;the spinal rise in the

Greater Sigmoid Cavity; the ulnar head. All these factors combine to account for 90 degrees of supination and

pronation when the ulna is rotated around the radius at the forearm or pulled from one face side of the Greater

Sigmoid Cafity to the other, at the elbow, which coordinates respectively with the rotation of the ulna within

the radius at the wrist.

To prove this reality, follow the instructions of this 3il Krass experiment closely: put an old ulna bone

tight into its radius correlate and rotate the formerwhile holding the radius steady. As you rotate the ulnar

head within the lower end of the radius, you will notice that the Lesser Sigmoid Cavity rotates nicely around

the radial head. When the radius is placed in its normal vertical positiorl it will be noticed that the ulna rotates

CopJ # ou for R[/DI KRASS 23

to the neutral and horizontal hand stop positions ofpronation and supination, noted earlier. As indicate4 the

remaining portion of these actions, posteriorly beyond the neutral position through supination or anterior$

beyond the horizontal position, occur in either the wrist or at the humeral head. This perfect alignment of

these facs lead to the conclusion that the flnctionality presented in this book is inefutable.)

90 Degree Flexed Elbow Pronation

From the end position of supination, one notices that the fuipothenar dert, the portion of the palm just

above the ulna, falls backwards to the neuffal - 6 o'clock - position which is the initial 30 to 45 degrees of

forearm pronation. The remaining 120 degrees ofpronation, to the 4 o'clock position on the left or 8 o'clock

on the right is caused by the ulna being further rotated mound the radius along the entire forearm and into the

elbow until the hand is horizontal and then the remainder of the hand motion is a reflection of a minor rotation

ofthe.humerus at the capitellum.

So, the initial45 degrees ofpronation is not caused by any forearm muscle contactions as the hand

and the ulnar portion of the wrist fall downward due to the previously mentioned elastic principle of the

forearm muscle groups which were strekhed due to the exfeme muscle contractions that took the thumb

beyond the vertical line. The remainder of 90 degree bent elbow pronation must therefore result from the

contractions within the rnuscles attached to the posterolateral portion of the ulna and attached to either the

lateral portion of the back of the hand or the lateral epicondyle. The muscles that fulfill these requirements

and which cause the ulna portion of the hand to rise so that it resides along a horizontal plwrc arethe an-

coneus,the portion of the ertensor ossis metacarpi pollicis thattesides between this muscles radial and ulnar

at&achments, the exteruor carpi ulnaris and extensor minimi digiti.

The latter stage of pronation - from the horizontal plane upwards tbr the ulna portion of the forearm

and hand - is caused by continued strong confaction of the aforementioned posterolateral muscle groups as

well as contraction of the palmaris brevis, supirntor longts and extensor catpi radialis longior. The first

muscle combines with the extensor mrJscle contactions to rotate the thumb downwards. This downwmd

motion of the radial side of the hand causes the supinator longus andextensor carpi radialk to contract in

order to rotate the radiohumeral joint sliglrtly medially thus avoiding the transference of any rotative force

from the hand to the radial head's lateral pins. All these muscle conffactions actually define ttrat the lateral

portions of the hand and wrist don't really rise during the latter part of 90 ddgree pronation so much as the

thumb is brought downwards with sufficient complimentary muscle contractions to bring the lateral side of the

humerus forwmd which the structure of lhe radiohumeralioint demands.

The process of90 degree flexed elbow forearm pronation finally ceases at about the 5 o'clock posi-

tion for the left or 7 o'clock for the right.

CoW # ool IoTRUDIKRASS 24

90 Degree Flexed Elbow Supination

With the forearm now at its end position for pronation of the hand, the discussion for the revefiie

action" 90 degree flexed elbow supination, can begin. Be wamed though that although pronafion ofthe

forearm on an elbow that resides flexed at 90 degrees was rather staight forward, its reverse motion,

supination ofthe hand and forearm on an arm flexed to 90 degrees is very complex as you will soon

discover. The first stage of this type of supination brings the ulna portion ofthe hand back to the horizon-

tal, then, the fue process offorearm supination with muscle confraction begins. This process occurs in

two significant stages: the first is moving the lower forearm and handto the vertical line or its neuftal

position of 12 o'clock; the second being rotation ofthe hand and forearm to the exheme supinated posi-

tion or end point ofthe process which is about 60 degrees posteriorly beyond the vertical line.

lnitially, flexed elbow supination is a process caused by the elastic contraction principle, de-

scribed tnthe Extended Arm Supination And Pronation section of this book, which shifts the hand to the

horizontal line. From this new position, flexed elbow supination proceeds through trvo stages: the first

stage takes the hypothenar clefi fromits horizontal position down to the 6 o'clock or vertical position; the

second stage, pulls the thumb posteriorly and the palm and hypothenar clefi upwafis. The first stage is

rather straight forward and is performed by contractionof the pronator quadratus which rotates the ulnm

head anteriorly within the radius. This initial 90 degrees of supination is complimented with confactions

of theflacor longus pollicis,flacor carpi ulnaris, the lowerportion of thefletcor sublimis digitorum and

the palmaris brevis which create a solid unit ofthe wrist and hand as it rotates anteriorly in unison with

the uln4 bringing the palm to the vertical line and raising the thumb along with it. To bring the ulna

around the radius at the elboq the upper portion of theflaor sublimis digitorum contracts but to a lesser

degree which nafurally brings the Greater Sigmoid Cavity around from behind the radius to below it.

The final stage of flexed elbow supination occurs over approximately 60 degrees anteriorly for

the palm and posteriorly for the thumb from the vertical line-it is this portion ofthis type of supination

that is the most complicated. Such a large rotation though may not seem possible by the natural position

of the humerus which is at 4 o'clock on the left or 8 o'clock on the right and this bone remains fixed

throughout flexed elbow supination - including exfrerne supination. Furlher hindering the process though

is the structure of the radius just below the elbow * the Bicipital Tuberosity. This part ofthe radius in

conjunction with the fochlea jams the force applied to the ulna bringrng it into full contact with them -stopping the upper ulnar rotation abruptly at 30 degrees anteriorly Ueyon9 the neufral position or vertical

line. In sho( the final portion of flexed elbow supination cannot include rotation ofthe humerus beyond

30 degrees from the vertical line. Fortunately, wrist rotation within the end ofthe radius can be used to

explain the discrepancy between the final flexed elbow position and the anterior rotational limit of hu-

merus.

CopJ # ou IoTRUDIKRASS 25

To complete the first 30 degrees of flexed elbow supination beyond the vertical line,the prorntor

quadratus, flexor carpi ulnaris,the lower portionof fheflacor sublimis digitorum,theflacor tongus

pollicis wrd palmaris brevis continue to contract pulling the ulna forward to its anterior limit. Through

the final 30 degrees of flexed elbow supination, these confiactions are complimented with conhaction of

the a,ctensor brevis pollicfs, the lower portion of the actensor ossis metacarpi pollicis,the extensor longus

pollicis and actensor indicis. The first two qteraor muscle groups provide the primary posterior rotative

force applied to the thumb due to their attachment to the lateral side ofthe radius. The other 2 extensor

muscle groups compliment this force which is permitted given the fact that they are conhacting against

the shonger muscle contactions on the anterior side of the wrist in order to created a posterior rotative

force on the hand. Thus, the posterior rotation ofthe wrist and thumb is fully explained concluding the

discussion of supinafion and pronation of the forearm while the elbow is flexed to 90 degrees. This also

completes the analysis of all the major upper exkemity articulations and defining how the muscles actu-

ally conhact to perform these articulations based on the reality that the radiohumeral joint is achaally

o'solid" and does not rotate through either supination or pronation.

CopJ # ool for RUDIKRASS 26

Coxcrustonr

From this understanding of supination and pronation, it is easy to produce a firll thesis on rotatory

instability: the second part of this document whictr" to date, the medical community has been unable to do. The

main reason for this is now fully exposed: the physicians have adheredo without question, to the illogical and

unscientific stance that their theories conceming pronation and supination of the upper exfemity are beyond

reproach--if it ain't broke, don't fix it. The medical stance is unacceptable for the millions of patients suffering

from carpal tunnel syndrome, wrist tendinitis, anterior rotator cuffswelling or subluxations within the shoulder,

bicipital and lateral epicondylitis and, in the long term, osteoarthritis in the elbow and shoulder.

With the sheer number of unexplained and unfieated cases of these medical problems that arise from

repetitive overuse of the upper extremity and lower forearm in fashions that they were not meant to be used,

according to my findings, comes the question: At what point will the medical community finally admit that their

theories about upper extremity functionality and its rotations are broke and therefore change them so that the

previously mentioned conditions canbe fullyundentood allowing themto be resolved quickly andwithout a

long hard battle with our physicians?

It is imperative that the medical community move quickly to accept that the majority of hand and

forearm rotations are actually conducted like a drive fiain on a rear car meaning that the majority of rotation

occurs at the shoulder and not at the humeral capitellum. From this realtty, the functionality of the elbow and

forearms also have to change in order to understand flrlly upper exfrcmity and extremity functionality. At

presen! it is falsely presumed that the elbow is a "hinge" joint with the ulno-humeral jointberngthe "hinge."

Well, 200 years agq I could see this being accepted, however, in this day and age with vector mechanics and a

complete knowledge of rotational force in physics, the centuries old simplistic approach to extremity motion can

no longer be supported especially with the massive amounts of misunderstood upper exffemity medical prob-

lerns.

This book's first Section firlly elaborated on how the muscle confactions ofthe forearm and upper arm

work with the new skeletal and ligamentous sftuctures of the elbowo wrist and shoulder. As I wrote this Section,

it was eerie how well the muscle contactions fit into the articulations of the wrisf elbow and shoulder without a

shaggler here or there as exists presently in the medical axioms, i.e. the anconeus. In my opiniorl the way that

the muscle contractions adhere to the joint and ligament structures alone should lead to the acceptance of the fact

that the elbow is basically like a'trniversal joint" tansfening force between the forearm/trand and the shoulder

and vice versa as well as making the upper extremity a'lvhole unit." The elbowos basic functionality is based

on the length of the medial and lateral ligament arc pins, i.e. the anterior andradial collateral ligaments respec-

tively.

Shoulder rotation is created not so much by the rotator cuffmuscles either, as the medical community

presently assumes. The rotator cuffmuscles along the anterior and posterior sides of the humeral head do play a

Copy # ou for RUDIKRASS 27

significant role in upper extremity pronation but in a far more engineered fashion than is assumed by the medical

community. As either side of the rotator cuff muscles confact and the other muscles rela& the rotative motion

has to caused by a fulcrum , the Glenoid Cavity,and a limiter to this contraction so that the opposing muscle

groups can conilact without sfain, the coraco-hwneral ligament. This ligament also contols the humeral

rotation, noticed at the medial and lateral epicondyles, x the Coracoid Process is represented in the circular

motion of the humerus - it is the 'benter point." This realrty determines that the arc of the coraca-humeral

ligament is actually represented in the humeral rotation of its lower portion by its circular rotation around this

center point the Coracoid Process. (All the circular humeral references are determined from a slice though the

elbow like those produced by a MRI or CT scan on film or computer monitor.)

Not to be forgotten, though, is the wrist and hand. These parts of the upper entremity rotate around the

now determined non-moving radial head to complete extreme pronation and supination. Also, the entire fore-

amr, from the tips of the frngers thtough to the humeral portion of the ulno- andradiohurneral joints, form a

cohesive unit or subsystem of the lower humeral end.

Interestingly enough, much of what I discovered about the radiohumeral joint, i.e. that it fimctions like

a '?nodified pulley" where, instead of a wheel rotating freely around a center point established by two stationary

and isolated arms or radii, the wheel itself is stationary, the humeral capitellum, and the rope, opposing muscles,

attaches to the top and bottom of an object, the radial hea4 and it is pulled up by the top muscle and down by the

back muscle, arose fuamreverse engineering. This'tnodifiedpulley''keeps the force stable on avertical plane

down plane with trvo pins which attach at either side of this plane, i.e. at the medial and lateral sides of the

radiohurneral jointwhen looking from overtop ofthe joint.

This functionality can be applied to the knuckles of the hands and toes as well as the knee. All of these

joints are '?nodified pulleys" bul instead of a stop point made out of bone - the Greater Sigtnoid Cavity,the

capitellums are actually formed in such a manner that the arc of motion occurs towards the range of flexion.

This reality means that, when the bones are firlly extended, the medial and lateral arc pins and the side of the

capitellum away from the bend no longer facilitate any firther extensive motion. (The knee actually finctions

almost the sarne as the elbow through flexion, i.e. with a few basic confuactive rrurscle towards the upper poste-

rior ofthe lower leg. This reality is reflected inthe "cramping'that linemen inAmerican style football suffer

from towards the latter skges of the games.)

lrcalue that the axioms are rather complex and may be difficult to follow with the muscle contoactions

being totally different than their present labels. However, when first reading this boolq don't dally tying to

understand wholly the motion and muscular contactions presented in this section at first brush because the basis

for this section is clearly established in the following sections: elbow problems like lateral epicondylitis fully

understood, at last. This section is the culmination of this undersknding which arose fromreverse engineering

this condition's main cause in society overthe last few decades-repetitive overuse syndrome. So, move on and

come back to e4pand fully your understanding of elbow functionality and upper extremity motion!

Copy # ool for RUDI KRASS 28

T

AppENpxt Suulwnnv

A simple e4periment confirme{ without a shadow of a doubt that the supinator urdpronator muscle

groups of the forearm are actually improperly labeled and also e4posed that supination and pronation are not

actions limited to the forearm but actually include the upper arm boneo the humerus. Essentially, the experi-

ment concretely exposed the fact that supination and pronation are actually a set of very complex processes

comprised of a sequence of muscle contractions extending from the shoulder down through the forearm

muscle groups as far as base of the palm of the hand making the upper exhemity function fundamentally like a

drive frain on a rear wheel car.

Tlre anterior and radial collateral ligaments actually form a set of mc pins for the raising and lower-

ing motion of the elbow explaining the role of the radiohwneral joint quitn easily because these pins actually

allow the radial head to arc over the humeral capitellum through flexion and extension. This motion is similarto drawing a large circle with a sring which is tied tightly to the midpoint of the circle where the radial head's

medial and lateral pins function like the sting, the humeral attachments as the midpoints and ttre radial head is

the pencil.Another more correct analogy is a'?nodified pulley" where, instead of a wheel rotating freely around

a centir point established by two stationary and isolated arms, the wheel is stationary, the humeral capitellurn,

and the ropeo muscles, attach to the top and bottom of an object the radial head, and it is pulled up by the topmuscles and down by the back muscles. To keep the force going on this same plane are two pins which atafrh

at either side of this moving object, the radial head - i.e. at the medial and lateral sides of the radiohwneraljoint when looking from over top of the joint.

Both analogies determine that the radiohumeral joizr is solid and pinned atthe radial collateral and

anterior ligaments. The drive train principle determines that the irfraspirntus, teres mfuror, subscapularis,

teres major and pectoralis major play a significant role in supination and pronation. This also determines that

the Glenoid Cavrty acts like a the fulcrum for humeral rotation through supination and pronation with the

coraco-huneral ligamenl functioning as the limiter of humeral rotation.

It is important to note that the muscle names were taken from the 1901 edition of Gray's Anatorny,

6P printing, but the functionality does not comply with what is presented in this book because the elbow and

upper exhemity do not function as the medical community presumes, i.e. hand rotation is strictly a forearm

activrty and that the radial head rotates around the humeral capitellum.

SupnqArnn FrE)iloN At\D SupnurEn E>rrnNSIoN

Supinated Flexion

Basic muscle confiaction for upper extremity flexion:

-> biceps, supinator brevis, brachialis antictn, pronator teres,flexor sublimis digitorum

In flexion of a supinated foreanrl basic muscles augme,lrted with contactions in:

-> palmaris longus,Jlexor carpi radialis, nryinator longus, extensor carpi radialis longior

Latter stages of supinated flexion add:

-> claviculm portion of the pctoralis maior, subscaprtlaris

CoW # ool for RUDIKRASS

Supinated Extension

Initial and main muscle contactions for lowering a supinated forearrn:

-> internal triceps ltead,pectoralis maior

Complimentary forearm muscle contractions:

-) extensor ossis metacarpt pollicis, extensor earpi radialis brevior, extensor commtmis digitorurn,

ertensor minimi digiti, qctensor indicis

Supinated flexion is merely a reversal of the supinated flexion process, the primary motion like all bending

motions ofjoints. The only necessary information to remember is that both motions are actually performed

throughout the upper extremity like a drive train and that almost all upper extremity motions impact on the

shoulder via ttre "solido' radiohwneral joint and the radial head's lateral and medial arc pins.

*E>rrBnonu ARN,I Supnraflox nvo horurnox*

Important Note: the ulno-hwneral joint is considerably less solid than previously thought by the medical

community especially since it actually facilitates extended supination and pronation byallowing the olecranon to move easily between the frochlea and the lateral epicondyle.

There are 3 main positions ttrough both pronation and supination motions which account for a change inmuscle conftactions: full supination; the neufral (12 o'clock or vertical) position; the fully pronated hand

position (5 o'clock for the left ann and 7 o'clock for the right ann) with the thumb representing the reference

point forthese clock or degree positions.

Extended Upper Extremity Pronation

Pronation from extrerne supination to the neutral

there is no contaction, elastic bandprinciple---> subscapularis, clavicular portion of the pctoralis major act as stretched elastic bands

From the neutral position to the fully pronated position:

downward rotation of the medial epicondyle

-> subscapulctris, teres rnajor

ulna rotated around the radial in the lower forearm

-> arrconeus, extensor carpi ulnaris, ertensor minimi digiti, flacor carpi radialis, palmaris longn,extensor longts pollicis, etctensor indicis

Withthe handnow horizontal andpalm down

-> subscapularis, teres major, clavicularportion ofthepeetoralis major, extennl triceps head

-> anconeas, portion of the extensor ossis metacwpi pollicisbetweenits radial and ulnm attash-

ments, extensor carpi ulrnris, extensor minimi digiti, extensor communis digitorurn,flexor carpiradialk, palmaris longus and brevis

uCoW # ou for RUDIKRASS

Extended Upper Extremity Supination

Supination from the final position to the horizontal line:

there is no contraction, elastic band principle

-> corcrco brachialis, infraspirntus, teres minor act as stretched elastic bands

Rotation of the ulna taking the palm from its horizontal line to the vertical and neutal position:

-> prorwtor quadrahn, flexor caryi ulruris, flexor longts pollicis, palmaris brevis, the lowerportion of the/lacor sublimis digitorum

The next 30 degrees ofsupination:

-> coraco brachialis

The final 60 degrees:

The frst portion of the motion:

furtlrer confiaction of the coraco brachialis, teres rninor, infraspirnhx

The forearm/hand completion of supination - rotation of the scaphoid and semilunar within the wristend of the radius:

-> the lower portion of theflexor sublimis digitorum, trtronator quadrattu, flexor carpi ubaris,

flexor longw pollicis, palrnaris brevis - replaces the improperly assumed contraction of the

pronator quadrafus

complimentary posterior thumb rotation

-> the lower portion of the extensor ossis metacarpi pollicis, extensor brevis pollicis, ertensor

longw pollicis, extensor fudicis

hoNlrEn FLn>iloN ANp holvarnn E)ffExsrou

Pronated Flexion

Pronated flexion is broken down into two distinct ranges of motion:

going from the fully pronated and fully extended position to the point where the humerus is at its

normal position

the other is flexion ofthe upper exfemity

The initial stage ofpronated flexion:

-) g6vqs6 brachialis, infraspirntus, teres minor

Rotation of the humerus and consequently the radiohumeral joint from the arm's initial FULLY pronated and

extended position facilitates the raising of the forearm through pronated flexion - final stage of pronated

flexion - in almost the same manner as flexion of the arm with a supinated forearm. The major difference is

that the hand is now palm down rather than palm up which impacts on what muscle conhactions occtr beyond

the basic muscles used in supinated flexion.

mCopy # ou for RUDIKMSS

Basic muscle contraction for upper exftemity flexion:

-> biceps, npirwtor brevis, brachialis antictu, pronator teres, flexor sublimis digitorum

Secondary contractions:

-> supirator longw, ertensor carpi radialis longior,flexor carpi radialis, actensor carpiulrwris, extensor ninimi digiti, extensor indicis, extensor longus pollicis, extensor ossis meta-

carpi pollicis

Pronated Extension

There are equally two stages to this action:

pronated flexion to the start of the humenrs being rotated

the rotation process of the humerus ttrough to its original fu!! pronated and extended state

The initial stage ofpronated extension:

*> /Iexor carpi uharis, flexor profun&* exteraor catpi ulnaris, extensor minimi digitiproduce complimentary forearm contactions

As in supinated extension" the supinntor brevis and the anrurlar ligarnent fwrctions like a tight stap placed

over the radius and tied to both sides of the ulna which causes the radial head to mc downward over the

humeral capitellum due to the extensive force applied to the ulna.

The final stage ofpronated extension:

anterior humeral rotation*> teres major, mbscapularis, clavicular portion of frrc pectoralis major, lmcorletlt, internal and

actenal heads of the triceps

fmal hand and forearmpronation

-) extensor minimi digiti, extensor carpi ulruris, portion of the actensor ossis metacarpi pollicisbetween its radial and ulnar attachmeirts (the extensor ossis metacarpi pollicis is able to fiurctionlike two muscles just lketheflexor sublimis digitorum does)

90 Dncnnn Fr,nrmo Er,sow SupNATroN ANp PRoxlfloN

Looking at the ulna you will find that the bone is built so that it can be rotated around the radius at the wristbut within the radius a third the way down from the elbow: the outwmd bow in the bone; the shape of the

Lesser Sigmoid Cavrty; the spinal rise in the Greater Sigmoid Cavrty; the ulnar head. All these factors com-

bine to account for 90 degrees of supination and pronation whe,n the ulna is rotated around the radius at the

forearm or pulled from one face side of the Greater Sigmoid Cavrty to the other, at the elbow, which coordi-

nates respectively with the rotation of the ulnar head within the radius at the wrist.

CoW # ou for RUDIKRASS iv

90 Degree Flexed Elbow Pronation

The initial 45 degrees of pronation:

there is no contaction, elastic band principle

90 degree pronation to the horizontal:

attachments, extensor carpi ubaris, extensor minimi digiti

The latter stage ofpronation:Complimentary contractions to the previous ones which continue me:

-> palmaris brevis, supirwtor longn, extensor carpi radialis longior

90 Degree Flexed Elbow Supination

This process occurs in truo significant stages:

moving the lower forearm and hand to the vertical line or its neutral position

then, rotation of the hand and forearm to the end point of the process

Initial flexed elbow supination:

there is no conffaction, elastic band pririciple

Supination of the lrypotlrcnar ckrt from its horizontal position down to the vertical position;

-> pronator quadrahn, flexor longus pollicis, flexor carpi ulrwris, the lower portion of theflexorsublimis digitonnn, palmaris brevis

The next 30 degrees of flexed elbow supination beyond the vertical line:

-> pronntor quadratus,flexor carpi ulrwris, the lowerportion ofthe flexor sublimis digitorutn,

flacor longus pollicis, palmaris brevis

The final 30 degrees offlexed elbow supination:

the previous muscle contactions are complimented with contractions of:

-) actensor brevis pollicis, the lowerportion of the extensor ossls metacarpi pollicis, extensor

longus pollicis, extensor indicis

All this restructuring of muscular contractions within the upper extremity did not mise out ofthin air but from

the discovery that lateral epicondylitis should not occur given the present medical a<ioms for upper exfemityfi.rnctionality yet it does occur and quite often over the last 10-12 years. Through reverse engineering, I was

able to decipher the process cause of lateraal epicondylitis and then reconfigure how the upper extremity

rotates while being faithful to the physics of the radiohurneral joint. lnaedibly, everything fit with no loose

ends like presently exist within the medical axioms. Thus, I know that these modalities and several compli-

mentary theories which adhere to physics are the actual way in which the hand becomes pronated.

CopJ # ou IoTRUDIKRASS

SncrroN II:TnE Kmss Rn,auN" oF

LITERAL IIpPER ExrREMrrYRoTAToRY IxsTABrLrrY

CoW # ool for RUDI KRASS

Basrcs qF

L+rrRar UpprR ExrnrurryRoTArpnv IxsrAsrl.rTY

As I stated early on in the preceding thesis, my discovery that the upper exhemity was radiohurneral

joint md coraco-hwneral ligamenl centric mose primarily from my having reverse engineeredmy nitial

tnj*ies and their cause. This process also led me to the realization that supination and pronation are not

forearm specific actions but rather whole arm activities. I knew that my initial wrist and elbow injuries arose

from activities that required repetitive hand pronation with high torque as well as constant elbow flexion with

high weight. I also knew that I had suffered a sharp sudden pain at my right or dominant elbow's lateral

epicondyle prior to the onset of lack of sensation within my ring and middle fingers and extensive swelling ofmy lower foreanrl wrist and hand. These symptoms arose quickly after the initial elbow injury - a8 hours -which resulted from my having continued to perform the same activities that caused the lateral epicondylitis

and then activities requiring more extensive use of my arm with flexion and extension. From pre- and post

elbow pain activities, I could only deduce that pronation of the forearm had caused the problems in my wrist

Essentially, I discovered" from reverse engineering, that repetitive high weight use of my right affn

through pronation was strengthening my pronator teres catasingwrist tendinitis as well as lateral epicondylitis.

So, I could only conclud etlntthe pronator teresdoes not confract at all atany point throughout pronation

which, in turq means that the radiohwneral joinl does not rotak around the capitellum as the medical theories

about supination and pronation present$ and falsely contend. This conclusion led to the present medical

thesis about upper exfemity rotation, i.e. basically that the ulna rotates around the radius throughout both

supination and rotation and that the ulno-humeral joinr is solid and the basis for the entire upper extremity.

Knowing this, I devised a simple experiment the 1o Krass experiment, which would confirm not only

that the radiohuneral joint was in fact solid throughout supination and pronation but also tha! what the

medical community was claiming in its theories about supination and pronation, was utterly wrong. This

realrty is confirmed by so many ofthe upper extremity's injuries being highly misunderstood and especially

their causes. The experiment that I devised was prese,nted in the preceding thesis but I knew that in order for

the medical community to accept this thesis, I would have to re-confirm this with some form of film images.

The images I needed were simply deduced to be a sequence of radiographs of a health elbow that demon-

strated the initial and ending position of all the bones within the upper extremity, fully supinated and f,rlly

pronated-the P Krass experimmt.

Both Krass experiments confirmed that supination and pronation are a whole exffemity activity and

that tlrc radial head does not rotate around the capitellum. These tests also proved that when the radius acted

CoW # ool IoTRUDIKMSS 35

in the mannerpresentlyprescribedby the medical communitythat it actually was performing in an incorrect

fashion. Further confirmation of both facts were the 47 other individuals that I knew were suffering with

cluonic lateral epicondylitis and carpal tunnel syndrome. Although the causes of these cases varied widely,

the long term symptoms were remarkably similar including shoulder crepitus and, when I applied my theories

about lateral rotatory instability, LM, to the causes, it was confirmed that atl the cases, to which I had been

exposd arose from the inalienable facts that I had discovered about how the upper exftemity actually rotates

and reverse rotates, i.e. pronates and supinates, and that these activities revolve around a solid radiohwneral

joint and coraco-hwneral ligament.

ALL the cases of soft tissue insuffrciency at the lateral epicondyle that I stumbled onto over the last

I I years arose from either forced pronation with weight beyond Ore han4 from repetitive use of the forearrn

while it was pronated to the horizontal plane or from a trauma to the hand while the ann was extended e.g.

use of the arm in an attempt to stop a fall from shpping on a patch of ice. The frst two causes clearly demon-

sfrat€d that the problem was due to the pronator teres contactingin order to bring the radius over the ulna

rather than the conect way which is to rotate the humerus posteriorly and the ulna under the radius. The third

and most medically known cause is more complicated bul under scrutiny, can be determined to have the same

affect on the forearm and upper elftemity.

This book's section will, by its end, demonstrate how all the causes are actually different

pathomechanics to a comnon soft tissue insufficiency at the lateral epicondyle - either tendinous, ligamentous

or both.

CoW # ou for RUDIKRASS 36

LaTEnar. [Jppnn Exrnnruury

Before this discussion can be started it has to be disclosed that there are basically two distinct types

of lateral upper extremity rotatory instability: cases arising from a soft tissue insufficiency at the lateral

epicondyle; cases arising from a soft tissue insufficiency at the anterior rotator cuff. The latter case thouglq

with repetitive pronation, actually cauies the large volume of cases among female workers of lateral rotatory

tustability, LN. It is important to start the discussion aboutZR/with the first t5ipe, elbow based - leaving the

discussion about the second type, shoulder based, for last.

Laruml IJppEn ExTnrr*nrrv

Rou,rony INsrAgtrlT.Y

The following section will indicate the causes of elbow based ZRlof the upper exremity as well as

how it causes the soft tissue insufificiency at the lateral epicondyle. Basically, all the causes of lateral upper

extremity rotatory instability adheres to the reality that the radius and the anterior medial epicondyle are pulled

together by contraction of the pronator teres when it naturally is meant to be relar<ed and when the medial

aspect ofthe humerus remains stationary due to contraction of the brachialis anticus and coraco brachialis

muscles.

The reduction ofthe natwal anterior angle ofthe radiohtnneral joint,120 degrees, is what causes

lateral epicondylitis or the sftetching to the point of tearing of the common extensor tendon. (The 120 degrees

is demonstrated when one adds the degrees from the natural horizontal line that is create4 when looking at the

front of the humeral capitellum, by drawing a line that passes through the humeral attachments of the anterior

and radial collateral ligaments, i.e. the base of the radial arc ligamentous pins, and by drawing a perpendicu-

lm line to this natural horizontal line at the midpoint of the capitellum. So, with the 90 degrees established,

the remaining 30 degrees of the 120 degrees is accounted for by the position of the anterior trochlear line

which is 30 or so degrees downward from the aforementioned horizontal. As has bee,n demonshated" the

natural position for the medial epicondyle (men) is at approximately 4 o'clock on the left or 8 o'clock on the

right which confirms that the humerus is naturally rotated downward some 30 degrees from the horizontal for

CoW # ool for RUDIKRASS 37

women. Thus, the natural anterior angle of the radiohwneral joint is I20 degree.)

The fact about the anterior angle of the radiolnnneral joinl is unknown to the medical community

because, when an x-ray of an extended arm is takerU the medial epicondyle or ftochlear line is raised to the

horizontal line. So, when the film is processd all that is seen is the natural valgus alignment of the radio-

humeral joint which is consistent with looking at the joint which has been rotated backwards 30 degrees. In

short, the film is not a true example of the natural alignment of the forearm and humeral bones because it is

not taken from directly on top of the radiohwneral joint, i.e. it is not taken along the perpendicular line

established earlier. The information about the position of the radius to the humerus will become very impor-

tant when devising techniques for diagnosing cases of lateral elbow based soft tissue insuffrciencies.

Once the radial collateral ligament and cotnmon extensor tendonhave been comrpted this 120

degree angle will continue to be reduced by improper contraction of the pronator teres andupper portion of

theJlexor sublimis digitonnn. So, once epicondylitis has been detected in individuals (men) who work with

high torque values at the hand or (women) who use their hands in a pronated position religiously - day-in and

day-out the living nightnare has begun.

CoW # ou for RUDIKRASS 38

Over the past 9 years, I have come across numerous individuals with an ide,ntical upper extremity

symptomology as myself. HowweE due to the varied causes, I was unable to collate them until I knew exactly

how epicondylitis, carpal tunnel and wrist tendinitis were caused. Once this was done, I was further able to

include anterior rotator cuff problems.

The causes of elbow based lateral rotatory instability, LN, to which I've been exposed are: taumas

to a nearly but not fully extended arm at the elbow; repetitive and moderate traumas like hockey players being

constantly bunped in the comers or boxers - basically a cumulative effect on ttre radiohumeral joint similu to

the more violent trauma cases; repetitive overuse syndrome, which includes pitchers and labourers in one sub-

group and then computer users and race car drivers in the other sub-group; old age; gender.

Instability Due To Traumas To An Outstretched Upper Extremify

This cause is unique even though most orttropaedic surgeons are aware ofthe relationship between

this cause and the resulting radial collateral ligament insuffrciency. The problem is that a trauma like bracing

your fall with an outsffetched arm can also result in several other medical outcomes: broken or crushed radial

head or wrist; strained or sprained wrist; lateral epicondylitis; damaged anterior rotator cuff So, how can the

same causalgia result in these ditrerent medical problems and is there any way to determine exactly the differ-

ent results? When the bracing upper extemity is partially extended that is when soft tissue taumas to the

wrist, elbow and shoulder occur. When this arm is fully extended, then damage to the bones at either the

elbow, wrist orhand occurs. Before the mechanics ofthese individual actions can be exposed" the relationship

between the lower forearm, hand and wrist has to be discussed.

Atpresent the medical community sees the han4 wrist, lower forearm as a separate entity aside from

the elbow even though the entire forearm down tlrough the finger tips from the hume,rus, i.e. the tuochlea and

capitellum, can easily be shown to be a complete unit by the results of the force applied to the hand. This

force often cau{ies problems in the elbow and shoulder- conclusivelyproven since the development of mag-

netic resonance imagery - which contradicts the medical thesis ofthe lower forearm through the finger tips

being a distinct and "sepmate entity'within the upper extremity and from the elbow joint and the upper arm.

The present medical thesis conceming the lower forearm and hand leads to the conclusion that all resulting

problems of the force at the hand would have to be limited to the lower forearm, wrist and hand. The fact that

a considerable sum ofproblems that arise from a hand based force are not located within the aforementioned

CoW # ou for RUDIKMSS 39

medically defined'tmif' demonsfrates that the basis for this designation is utterly wrong. The medical

community didn't catch this break in their logic, though.

In reality, the unit that exists is from the capitellum and tochlea down through the tips of the fingers.

This is a natural unit because the bones in the hand and forearm run perpendicular to the lower face of the

humenrs with the wrist being a conglomeration of small bones weakly held together with a single lo< ligament

which allows for its articulations and rotation within the lower exfemity ofthe radius. So, when force is

applied to the base of the palm and the hand is bent baclavards, the sfiuchres of the wrist and forearm act just

like a nail - in fact, when one isolates the bones of the forearm and places the wrist on top, the separate

structures bare a remarkable resemblance to a dull upside down nail.

As we all know, when a nail is hit cleanly upon its head, the whole nail goes into the wood or soft

stnrcture beneath. This transference of force is exactly what happens to the force applied to the hand: it ends

up being transfened to the elbow via the radius and ulna. However, there are different results mainly due to

what is happening with the hand and wrist. When the wrist and hand is held together either by taping or

sfrong contractions within the muscles attached to the te,ndons that surround and support the wrist the force

applied to the elbow is greater and, when the wrist and hand is not solidifie4 then the effects of the force may

be limited to the hand and wrist. With the knowledge that the natural forearm unit ends at the elbow and more

specifically the radiohumeral joint as it is the foundation for the remaining elbow joints, ubn-hwneral wrd

ulrn-radial,the discussion of how a significant and sudden force received at the hand causes soft tissue

problems at the elbow and shoulder can be initiated.

Soft tissue frauma at the lower face of the humerus occrlrs when the elbow is pmtially flexed because

all the bones at the elbow are not locked together. When the elbow is flexed and a sudden significant force is

applied to the upper exhemity at the han4 the lack of rigidity at the elbow allows for the force to be applied to

the radial collateral ligament. Essentially, this force revenie rotates the humerus, i.e. it rotates the lateral

epicondyle area bachvards, and becaus e the anterior ligament renains soli{ a 'livot point" is created at the

medial side of the radial head. So, the greater the sudden force applied to the arm at the hand the greater the

damage to both the radial collateral ligament and common extensor tendon. Now, these structures are insuffi-

cient to act as the lateral pin for not just the radial arcing motion utilized through flexion and extension but

also to pin the radiohnneral joinl through supination and pronation, i.e. keep the upper exffemity's 'hniversal

joint" tight.

The lack of proper lateral pins for the radial head will not however show up when one applies the

present standardized medical examinations for ranges of motion in the elbow because the soft tissue insuffr-

ciencies at the lateral pin do not ffibit these motions. All, the lack of lateral pins does, is force the humerus

to rotate frrttrer posteriorly before the elbow flexes and causes the radial head to rotate instead of the ulna

through supination and pronation. It is quite clear then that the medical examinations of the elbow to deter-

mine whether or not the joint is dysftrnctional have to be changed--{ris will be address nthe Diagnostic

CopJ # ou for RUDIKRASS 40

chapter ofthis section ofthis book.

With it now understood that when the elbow is not in its locked position, i.e. when the arm is flexed

beyond 30 degrees from the fully extended arm position, the sudden force applied to the hand actually causes

posterior displacemeirt of the radiolrumeral joint at the lateral epicondyle as well as rotates the humerus

clockwise for the right arm or countercloclarise for the left, i.e. contrary to the upper arm's normal rotation in

general. This sudden contrary humeral rotation places stain on the anterior rotator culf of the shoulder which

is manifest as swelling while the elbow problem is manifest as lateral epicondylitis. Wrist Strain or sprained

wrist results from the radius being thrust into tlre wrist as the abnormal radial displacement at the lateral

epicondyle in a typically solid and unmoving area has to go downward especially when the ulna is capable of

"sliding" backwards in the trochlea. The rotator cuffswelling is caused by the coraco-humeral ligament and

supporting coracoid tendons stopping the abnormal posterior humeral rotation which arises in a complimen-

tary fashion to the radial head's advancement in the wrist due to the radial head's medial arc pins acting as a

pivot ioint. This reality means thag when either wrist strain/sprain or swelling at the anterior of the

shoulder around the Coracoid Process are presented to a physician, regmdless of their cause, the lateral

epicondyle soft tissues must be assessed: the Bresence of either of these sJmptoms demonstrates that an

undiagnosed insufficiency of either the radial collateral ligament or common extensor tendanmay be present.

With it known that bracing a fall with your hand with a partially exte,nded elbow causes soft tissue

traumas throughout the upper extuemity, then obviously, bracing your fall with a futly extended elbow causes

skeletal damage within the foreann, wrist, hand or at the radial head. These resul8 arise because the force is

kept linear and when the arm is straighl the shoulder joint is strong enough to withstand this type of force and

its amount. But, the shoulder isn't capable of stopping rotatory force mainly because this process is soft

tissue based whereas linear force is skeletal in nahrre.

The humerus is not usually damaged from a ftauma to an outstretched arm mainly because it is the

largest and most solid bone within the upper extremity. The wrist and hand - carpal and metacarpal, respec-

tively - bones are the more likely to be shattered or broken as they are the smallest within the upper extremity:

wrist when the force is taken at the base of the palm of the hand; hand bones when force is received with a

loosely clenched fist. Damage to the bones of the hand and wrist mainly occur when the upper extremity is

within 10 degrees or less of the exfeme locked or extendedposition of the elbow. From 10 to 20 degrees

from the exteme locked elbow position, the arm has to be considered fully extended not just because the

bones of the elbow are still within their interlocked stage but because this means that the musculaflre neces-

sary to combat the lateral displacement of the radial head, i.e. the muscles that conftact during the final stages

ofelbow extension in the forearm and the internal triceps, are still tense enough to stop the lateral radial head

displacement with the aid of the slightly interlocked elbow bones.

Nowo all aspects of trauma to an outstretched arm have been examined and the reason for soft tissue

damage as opposed to damaged bones have been correlated respectively.

Copy # ou for RUDIKRASS 4I

Repetitive Moderate Trauma: the Cumulative Effect

The same ultimate effect on the radial collateral ligarnent and comrnon exteraor tendon -tn insuffi-

ciency of both - occurs with repetitive mild to moderate force on the elbows. This type of force occurs mainly

when the force to the partially outsfetched arm is mitigated. This occurs most often in sports especially those

where the individual is often put in a position where he has to stop himself from hitting a solid object, i.e. the

boards in hockey, indoor soccer, indoor football, indoor tack events like the 60 meters or tripping suddenly

from a pereonos normal height especially tall basketball playen during a garne - this time their height worla

against them. The athlete often sees the event a sudden stop, before it occurs and sfretches out his ann to

brace for the impact.

To mitigate the force of suddenly stopping with the outstretched anru this person flexes the elbow

upon impact which merely reduces the negative humeral rotation before the radial head's natural arc motion

takes over allowing the forearm to come in towards the humerus. This process isn't harmfirl, per say, if and

only if this occurs once or twice and then the arm isn't used significantly for several days following the event

as often happens in the 60 meter events at indoor track meets. (This process is firther helped along by thick

and soft mats being placed in front of the wall at the impact areas.) This break in usage often allows any

damage to the soft tissue structures at the lateral epicondyle to be repaired by natural healing and the training

techniques used by these athletes.

With hockey, indoor soccer, indoor football, squash, racquetball and sports in confined spaces, the

walls are not padded and the arms are used more significantly without diagnosis of lateral upper actremity

rotatory instability and proper treatne,nt. This lack of diagnosis and featnent results in a repetitive force

being applied to the participant's lateral soft tissue elbow structures which leads to a net result of increased

lateral torque tothe radiohumeral joint: torque : force x distance, where the distance increases following a

significant force that created an initial nominal stretch tothe radial collateral ligarnent and common extensor

tendon, thus, allowing the lateral radiohurneral gap to grow in these athletes. Although participants of these

sports may not notice the lateral elbow problem initially, they often complain of soreness of the shoulder -anterior rotator cuff, elbow, forearm and wrist stiffiress and soreness later on down the season or tlrc next

morning when the high adrenaline effects wear off. (All of these non-elbow problems will be proven to be

symptoms of an insuffrciency of either the common extermor tendon or radial collateral ligament rnthe

Symptomologt chapter of this section of this book.) If the mild permanent insufficiency at the lateral epi-

condyle grows to a moderate level and" in some cases, ultimately an exfreme level without being diagnosed,

the problems no longer remain limited to just the ligament and tendon of the lateral elbow but will also include

the cartilage at either or both the shoulder and elbow, depending on how long the elbow has been used and

how forcefully following the onset of a moderate level ofZRl.

An interesting group of athletes whose radial collateral ligatnent and/or cornrnon extensor tendon is

CopJ # ou for RUDIKRASS 42

damaged is boxers. In the early days ofpugilism, there was a large number ofparticipants who ended up

b,reaking ttre bones of their hands which is consistent with the principles of fully extended and outsfretched

arms receiving force. The short-sighted solution adopted by the boxing community was to tape the hands so

that the sudden stopping of the significant force behind the hard punches no longer broke the bones in the

hand. The unforeseen consequences of this taping for the boxers were that the wrists now began becoming

swerely sore and/or swollen with the occasional broken bone at the lower exfremity of the radius. These new

sypmtoms resulted in ttre taping being extended further upwards from the hand through to the lower forearm.

This incteased taping of the wrist and surrounding forearm however only really stopped the forces being

applied to the bones of the wrist and the inferior ulno-radial joint - the portion of the two forearm bones that

connect to the wrist. The force of the blow on the hand is thus better ftansferred to the elbow an4 in particu-

lar, the radiohumeral joint. However,the full force ofthe punch is mitigated although not by flexion ofthe

arm and elbow as in sports performed within an enclosed environmen! but by the fact that the boxer isn't

punching a solid object: essentially, the opponent's body receives the force ofthe punches by either compres-

sion of his soft tissues like the muscles ofthe stomach, moving ofthe head backrvards with the punch or

breaking of the bones in the area of the body receiving the punch * usually the ribs or face.

It is usually punches to the ribs which results in damage to the lateral soft tissues of the elbow as the

force is now contained in the puncher's arm especially when the ribs don't break-this is predictable given the

assessment of force previously preseirted in the discussion of partially extended arms. One hard punch doesn't

cause the full problem of LRI, but repetitive use of someone else's body to stop suddenly your arm's force

will, at some point cause a mild ligamentous and tendinous insuffrciency at the lateral epicondyle. When this

lateral insufficiency occuts, continued use of the arm in such a forceful manner will have more of a negative

effect on the puncher than on the recipient. In this scenario, towards the latter rounds of a fight, the small

lateral radiohumeral gapwill have grown significantly as the full force of the punches cause continued

outward torque atthe radial colhteral ligament in the same nunner as presented emlier, i.e. once a mild

insuffrciency appears and remains untreated, the next bout or round will cause a further expansion of this

insufficiency due to the calculation of torque and momentum.

(Interestingly, Karate and other forms of martial arts repetitiously train their students to complete a

punch once the elbow's extension process has started, i.e. less than 30 degrees from full extension and going

in this direction. This means thag even though the punch may land while the upper exffemity is partially

extende4 the martial arts ftainee is capable of completely extending and properly pronating the striking

exnemity due to repetitive practice. Such repetitve training makes the extension process of the upper exfern-

ity exfremely autonomic in nature and has already strengthened the proper upper exftemity muscle groups to

complete the punch. Such training often causes students of the martial arts to suffer more knuckle problems

with liule or no lateral radial head displacement problems like boxers if they wer apply their knowledge to

hand-to-hand combat in a toumament setting or the breaking of boards or solid objects.)

CopJ # au for RUDIKRASS 43

The effects of repetitive mild to moderate tauma to an outstretched arm is not limited to sports-it

can be applied to work case sceriarios or hobbies beyond this. An example of this, of which there are many, is

by carpenters. Often carpenters complain of soreness in the shoulder, wrists or elbows on the

hammering arm and many are forced to attempt changing ttreir profession due to chronic pains in these joints.

Now, the physics of ZRl and the knowledge of how the radiolnmteral joint frluly functions allow us to deter-

mine the rationale behind the pain. The lateral ligament pin and the tendon above it can only take so much

strain before they become unable to function normally and keep the radial head tight to the capitellum. When

the problem isn't detected or understood, as presently is the case, the individual with the problem continues

doing the same activities that qeated the initial mild soft tissue insufficiencies and some soreness and stiftress

in the shoulders, elbow or wrists. The continuation of these offending activities, in turn, exacerbates the mild

insuffrciencies at the lateral epicondyle. Unfortunately, thougfu the damage to the soft tissue at ttre lateral

epicondyle is often missed because the insufficiencies arises not from a complete dislocation as at the shoulder

or hip. The other main problem to diagnosing the problems at the early stages is the present inaccurate medi-

cal theories concerning elbow and upper extremity firnctionality and the diagnostic techniques built around

this misleading knowledge base.

Repetitive Oyeruse Syndromes

This portion of the Patlnmechsnics chapter deals with actions which should be eliminated because

they lead to serious complications within both gender's upper extremities. Repetitive overuse deals with two

distinct classes of actions with the more strenuous type afflicting men and the less sftenuous afflicting women.

There are legitimate reasons for these unique effects which will be dealt wittr simultaneously in this section.

Strenuous overuse occurs in actions used by pitchers or a labourer doing undisturbed long term

shoveling. In these two examples, the upper extremity is exposed to be an unharmonious action: the anterior

muscle groups of the arm are strengthened without cessation causing the lateralmuscle groups to be substan-

tially weakened, thus eliminating their ability to counteract the opposing improper level of force applied to the

elbow. This reality is corroborated by examining the processes used in the following two example activities.

When an overhand (major league type) pitch is thrown, the shoulder has to bring the arm around

which means that the cardco brachialis continuously. Then, the forearm is brought forward and

over the upper portion of the arm which is accomplished by contaction of the brachialis anticas, ptorntor

teres and upper portion of theflexor sublimis digitorwn around the elbow. This is followed by the radial

portion of the hand being brought over with confraction of theflexor carpi radialis andpalmaris longw.

From this examination of the overhand pirching motion, it is clear that the radius is being brought over the

ulna and the medial epicondyle is either stationary in an abnormal position or is advancing in the opposite

direction to the normal motion ofpronation which is actually caused by contraction of ttre lateral muscles of

the upper exfiemity.

CopJ # ou for RUDIKRASS 44

In shoveling, the hand closer to the head of the shovel is used to raise the high torque load-the

torque on the elbow has to be calculated by using the distance from the load to the elbow and not the length of

the forearm. So, the brachialis anticus and coraco brachialis are contracted while moving the load. To shed

the load from the shovel, the forearm rotates against the confracted upper ann muscle groups which means that

the radius is once again being brought over the locked in ulna and anterior tochlear line by contraction of the

upperportion of theflexor sublimis digitorwn, tlrc pronator teres,flexor carpi radialis andpalmaris longw.

As is known from Sectionl of this book, dealing with upper exfremity rotation, some of these contractions and

the radius motion are improper.

When this muscle contraction examination technique is applied to tennis, squash or racquetball

players suffering from tennis elbow or sawmill labourers suffering from clronic lateral epicondylitis whose

job was to ensure that the cut boards didn't become jammed along the conveyer line, it becomes clear that all

these sftenuous actions, which cause the numerous cases of lateral epicondylitis, result from the medial

epicoridyle remaining locked throughout the forced and repetitive pronation, i.e. ultimafely rising 30 degrees

to the 3 o'clock position on the left arm or 9 o'clock position on the right. Normally, this locking occtlls

following an initial sharp pain at the lateral epicondyle and then, the person continues using the afflicted arm.

This connection amongst the various actions, noticed by me, means that the medically theorized process of

pronation is actually the cause of lateral epicondylitis and which unequivocally confirms that there is abso-

lutel]'no way for the normal process of pronation to be caused by confraction of the pronator teres and

prorwtor Erdratus.

The sharp pain which occuts from long and continuous use of the arm doing these activities arises

from the lateral portion of the radial head being pushed through the soft tissue sfuctures at the lateral epi-

condyle, resulting in a tom cotnmon extensor tendon and tom radial collateral ligament It is important to

remernber that the shength in the lateral muscle groups has been diminished throughout this proc€ss which

actually allows the radial head to sublux instantaneously once the radial collateral ligarnent and the common

extensar tendonare made insufficient to perform their normal functions. As stated earher, these activities

actually occur more often amongst males which is partially due to men actually doing these abnormal activities

but also because of the nature of the upper attachments of the shoulder - they are tighter in men than women,

generally speaking. This fact will become important in the discussion of less strenuous repetitive oven$e

syndromes as well as ZRlarising from an insufficiency at the anterior rotator cuff.

Gender Based Lateral Rotatory Instability

This grouping of activities cotrld also be labeled the less strenuous forms of repetitive overuse of the

upper extremity or forearm. Basically, gender based instability arises from using the hand in vihat can best be

described as a serni-pronated position, i.e. where the hand remains at or around the horizontal line with the pakn

down.

CopJ # au IoTRUDIKMSS 4s

As I stated earlier, all Zfilcases arise from the 120 degree angle formed by the medial radial line and

the kochlear line along the humeral face - visible in CT or MRI slices of the elbow - being reduced. In the

preceding sectiono it was inffoduced how the body causes the reduction of Ihe radio-trochlear angulation:

conffaction of theflexor sublimis digitorum, pronator teres, flexor carpi radialis andpalmaris longus muscles at

the wrong times which causes the radius to be pulled over the ulna and towards the medial epicondyle, the

attachment of the contracting forearm muscle groups. It was also shov,'n how the lateral soft tissue sftuctures

become damaged from the sfenuous overuse of this abnormal activity especially when the offending activity is

performed continuously.

This section looks at how mild improper conhaction of the anterior forearm muscle goups causes ZRI

without the radial collateral ligament and cornmon actelwor tendon showing that they were damaged and which

can only be e4posed presenfly through enhanced diagnostic images, like a Gadolinium enhanced STIR MRI or

ar.ttroscopy. The activities that constitute mild overuse syndromes and which cause the soft tissue insufficien-

cies described are tSping whether it be data enby at a large corporation or that done by a cashier at your favourite

grocer or departrnent store - its all the sarne as the hand is pronated to the horizontal line.

At first, one would assume that women suffer most from these activities because they do these activities

in far greater numbers. This is not the truth though whictr can be proven by examination of statistics which

show that men who do these same activities show lesser arnounts per capita ofthe symptomologr of repetitive

overuse at the wrist, i.e. tendinitis or carpal tunnel. This fact means that there are unique features within women

that would account for the higher instances of overuse complications within the wrists. It has to be reiterated

that the activities which cause soft tissue insufficiencies at the elbow, that, at present are not easily detected,

arise from abnormal activities for the upper exfernf an4 as suctr" they should be abolished regardless of the

initial complications.

There are two causes that account for gender based lateral rotatory instability frommild and improper

overuse of the forearm. The first is that the ligament structues within women are prone to stretching without

teming when exposed to force-4ris best example of this unique feature is child birth. The other unique feature

for women is the natural length of their ligaments which is represented by the natural rotational position of the

humerus. The length of the coraco-hurneral ligament is longer in women than in men so, as this ligament is the

basis for the neunal position for the humerus, a woman's anteriorly rotated resting position for the medial

epicondyle, while the arm is extended" compared to a man's clearly confirms that the femaleos coraco-hurneral

ligament is nahrally longer than a man's. Demonstrating this exha length in the real terms is easily done simply

by pulling baclanmds on an arm along the shoulder height plane. In women, the range of posterior motion for

the upper exremity is significantly larger than that of a men confirming that the coraco-humeral ligament,i.e.

the center point for humeral rotation, is longer among women - greater arc at the humeral head creates greater

lateral humeral rotation at the elbow.

The result of these differences is that, when women use their arms in a semi-pronated position, the

Copl # ooL for RUDI KRASS 46

humerus resides at this rmnatural position without causing the swelling or pain at the lateral epicondyle that

normally occurs in men. This lack of soft tissue fiauma at the lateral epicondyle is not a good thing though

because, the aforementioned anterior muscles are allowed to confract and create insufficiencies in the radial

head's lateral soft tissue pins without all the waming signs. These abnormal mild forearm pronation activities

do, over the long terrn though, cause problems which can now be deemed as bonafide symptoms ofZR/. These

medical complications are wrist tendinitis and carpal tunnel complications. (LN lrnmen tends to be more

typically anterior rotator cuffand/or medial, bicipital and lateral epicondylitis problems with wrist sprains and

sfrains: the difference in symptomolory arises not just from the types of activities producing the problem which

are mostly split down gender activity lines but also the anterior ligament stuctures at, surprise, the shoulders.)

In short when the forearm is abnormally pronated by women, the radial collateral ligament and

comrnon extensor tendon stetch rather than snap when subjected to the mild lateral displaceme'nt of the radial

head at the lateral epicondyle explaining why this elbow problem has never discovered until now. This fact is

confirined because the resulting wrist tendinitis is due in part to the mimicked lengthening of the radius as its

new improper position becomes more and more advanced within the wris! i.e. the radial head rides firther and

finther up the surface ofthe humeral capitellum. This displacement ofthe radius at the radiohumeral joint

causes a fleeting misalignme,nt ofthe carpal bones sunounding the radius at the wrist naturally impacting

negatively on the tendons of the wrist sunounding the lower extremity of the radius as well as its ligaments.

Also, the wrist and hand articulations are negatively affected by the fact that the central focus for

supination and pronation of the hand and wrist now suddenly starts moving due to the contractions at the medial

epicondyle. This rotation of the radius throws offthe normal contractions for supination and pronation which

are radial centic. Now, all the forearm muscle but especially those that overlap the radius start to contact

improperly causing fauma which surfaces as swelling in the lower wrist, forearm and hand. The swelling from

improper supination and pronation and the mimicked le,ngthening of the radius which have just been proven to

be caused by elbow problems bring into question the need for lnnd specialists within the orttropaedic commu-

nity as most hand problems arise from arc pin damage at the elbow.

Carpal tunnel as a complication is a little more complicated but it arises mainly from the lack of proper

articulations within the wrist as well as the improper contraction of the pronator qrcdratus. As the ulna is no

longer being pulled backwards during pronation by contaction of the forearm extensor mvscle groups, as

defined tn Section I of this boolg the role of the pronator qrndrahn changes and starts confiacting to compli-

ment the impropet flmor muscle contractions. With no prop et extensor mlrscle confactions to weaken this

contaction, thepronator qrndratus remains contracted, the ffirior ulrc-radial joifi becomes anteriorly

subluxed and remains so until thepronator qrnfuatta conmction abates which usually means rest and anti-

inflammatories. Now, it is already knor,vn that the carpal bones of the wrist are being subjected to radial dis-

placement from the elbow bu! withthe pronator quadrarras connacting in a fashion which will only compress

the carpal tunnel, it appears that the causes of this complication have been firlly discovered and e4lained.

Copy # ou IoTRUDIKRASS 47

However, when thepronator qutdratus remains stongly and improperly confracted the thickness ofthis muscle

group also impinges on the carpal tunnel passage through the wrist which adds another cause to the problem.

So, the impingement of the median nerve through the carpal firnnel, presently referred to as carpal

funnel syndrome, has to be atEibuted to downward radial displacement created at the elbow, a collapsing of the

natnral linear alignment of the carpal bones due to improper pronator quadratw conhaction as well as this

muscle's mass, during its improper conhactio4 compressing internally onto the displaced carpal tunnel. (It is

interesting to note that none of this can be seen with a present day mdiograph of the wrist because they are onl5r

take,n when the hand is fully supinated and from above it-there are nonnally no side view x-mys taken of the

wrist and ffirior ulno-radial joint.) Ttre complimentary posterior radial nerve impingemenf tingling ofthe

thumb, then has to be due to the fiapezium bone being slightly displaced posterior$ by the improper pronator

qtndrafin conhactions as well as the lateral extensor muscles running over the radial nerve at the wrist being

pulled abnormally taunt over it as it passes beireath these muscle on its way down to the thumb..

Old Age (Men more so than WomeQ Lateral Rotatory Instability

This is an interesting cause ofZRl amongst the male population. It arises from the reduced levels of

testosterone found in men over 50. The results of lower testost€rone levels, however, does not immediately

impact on the individual but, over several years, the humerus becomes anteriorly rotated at the medial epi-

condyle. This humeral rotation arises fromthe Wctoralis major, teres major andsubscapularis no longerbeing

capable of maintaining the humerus rotated to 30 degrees below the horizontal line, or the 4 o'clock position on

the left arm and the 8 o'clock position on the right, with the high strength levels attained tltrough a man's youth.

Consistently, using the arm at this stage in life like men did in their youth causes many of the wrist problems

noted earlier in the forearm with possible rotator cuffproblems.

At present though, many of the latter stage problems among men, I suspect mose from the long term

improper use of their upper exfemities in constuction positions or blue collar jobs which, until the early 1990s,

were dominated by males. With the reduced testosterone level of advanced age, the effects become readily

apparent in the upper exhemities. Fortunately, most lafier stage middle-aged merl older than say 45, no longer

push their bodies as strongly and unwisely as they did in their youth: the cause of all the youthfirl and early stage

middle-aged upper exfemity aches and pains in men has been disclosed in this book.

Unfortunately, by using their upper extremities recklessly in youtlU men pay the price with their health

in old age.

CopJ # ou fioTRUDIKRASS 48

LlTrnAr Romlonv INsrasLgY

Most ofthe symptoms have already been discussed as well as its rationale for existence as prese,lrted

in the preceding Patlnmeclwnics chapter. It is important though for these problerns to be collected into one

area as well as other complications that mise from a lifetime of living with an insufficiency of the soft tissue

stnrctures at the lateral epicondyle * radial collateral ligament utd common aclensor tendon.

Starting at the shoulder, all rotator cuff problems that cannot be attributed to a frauma direct$

impacting on the shoulder, i.e. all force applied to the shoulder via an outstnetched arm or the sudden impact of

the body being stopped by the clavicle, when it is not broken, and the arm flails forward uncontrollably like

when a snowmobiler is thrown from his machine and lands head first in a semi-solid snow bank, should be

viewed as a complication ofZRL As forthe rationale ofthe aforementioned shoulder exceptions, referto the

Instability Due To Trawna section of Section III of this book.

Elbow Symptoms

Moving down the arm, Iateral epicondytitis has already been discussed in both the Traurna and

Repetitive Trauma sections of the preceding chaper. Medial epicondylitis arises from the patient attempting

to use his arm even though it is suffering from ZRlwithout him wen knowing that he has a dysfunctional

elbow. In this instance, the brachialis anticas over strengthens in the body's attempt to create a stable "hing-

ing" process bu! because this action is abnormal and the anterior trochlear ligaments me not soli4 as is

presently and incorrectly presumed by the medical community, these ligaments are exposed to forces that they

are incapable of supporting so they become swollen as the ulna is repetitively brought anteriorly through the

hochlearnotch of the humerus. Thus, medial epicondylitis is fully explained. (With insufficiencies inthe

radial head's lateral pins, the radius can rotate both ways e4pecially when the biceps are stengthened more so

than the muscles that created the insufficiencies - see bicipital epicondylitis later in this section)

Abnormal anterior advancement of the Cororcid Process in the hochlea also causes decreased blood

flow beyond the elbow down into the forearm and hand. A result of this is that the hand becomes cold easily

and is dfficult to warm up once it becomes cold. The problem of abnormally cold hands and forearm

usually only occurs in patients who are attempting to use the arm at amildly moderate to high activity level

which uses a lot of flexion. As the artery is impacted at the anterior hochlear region due ta Coronoid Process

advancement and subsequent ligament and tendinous swelling it stands to reason that the patient may also be

suffering from decreased nerve sensation in the forearm because the median nerve p:tsses through this same

passage. (A byproduct of this problems is just getting a median nerve reading :rcross the anterior of the elbow

Copy # ool for RUDI KRASS 4e

which is made diffrcult from the median nerve sheath being displaced by the anterior Corornid Process

advancement and by it being swollen.

During the initial physical examination of the entire upper exfemity, one may also encounter a

throbbing or spasming common &ensot tendon. \\is symptom arises mainly in men who have been doing

exceedingly heavy pronation activities on the job and is due to the person at0empting to work through the

lateral epicondylitis. The spasm within the common extelaor tendon is due to it having been split longitudi-

nally from its attachment downward. The tear can be any length from I cm. up to thg point where the ertensor

carpi ulnaris and extensor minimi digiti joninto *re common extensor tendon. The bause of this tear is the

lateral portion of the radius being pulled beyond the radial collateral ligarnent's natural boundary from the

unnatural contraction of the upper portion of theflacor sublimis digitorum andpronator teresowlichkeep the

radial head displaced when they remain conhacted. The continued use ofthe arm, doing the same activities

that caused the problem, only exacerbates the tem as the unnatural anterior upper forearm contractions remain

unopiosed increasing the strength and permanency of the improper contactions. lnterestingly, the subluxa-

tion of the radius at the lateral epicondyle is also represeirted by a complimentary reduction of the elbow's

natural anterior angle.

Once the initial diagnosis of lateral epicondylitis is made and cessation ofthe offending activities is

undertake4 the radial head's anterior ligarnent may also become traumatized due to the biceps contuactions no

longer being held in check by the srryinator brevis which is now being subjected to abnormal forces that

weaken it. So, whan biceps contraction is initiated in the treatnent prograr& the anterior ligament is exposed

to anterior rotatory force as the position of the biceps attachment is located on the lower medial aspect of the

radius. This anterior rotatory force results rnthe anterior ligarnentbecoming swollen from it being fauma-

tiznd,i.e. exposed to the significant and abnormal radial rotation. Bicipital epicondylitis is the medical term

applied to this swelling of the anterior ligament of the radius.

All of the lateral soft tissue ailments, swelling nthe radial collateral ligament andthe comrnon

extensor tendon, arise from the lateral displacement of the radius at the elbow which causies fxations within

the ranges of motion of the radius-this often occurs in chiropractors and physiotherapists that practice re-

alignment ofjoints throughout the body. The ffeafinent is usually a chiropractic adjustnent to the radius to

push it anteriorly while also rotating the humerus, medial epicondyle, bachroards and the forearm valgusly.

Although the adjustment is productive, it doe not address the root problenr-for this, read fhe Prqention

chapter in this section of this book.

The improper contraction of theflacor carpi ubaris, which becomes more permanent with increased

use ofthe afflicted arm especially at higher activity levels, explains the varus alignpslf, inward pointing

positioning of the forearm bones at the elbow in a radiograph film of individuals suffering from ZRL This

complication of the forearm bones is already known to the orthopaedic surgeons stu$yngpsterolateral

rotatory instability - initial physician's label for insufficiency of the lateral collateral ligament complex due to

CoW # ou for RUDIKRASS 50

significant applied force to an outstretched arm. (The varusly aligned forearm bones in a radiograph of a

person having an insuffrciency of the lateral pins is contary to the natural valgus alignment outward pointing

positioning, of the forearm bones at the elbow noticed in a radiograph of a healthy man's arm. (This fact will

be more thoroughly discussed nthe Diagrnsfics chapter.)

A symptom arising from the improperly varus alignment of the forearm bones - particularly the ulna -is ulnar nerve impairment at the ulnar notch. The amount of the vanrs shift determines the amount of nerve

sheath trauma. With the ulna being forced to flex as the main pivot rather than in relation to the radial arc, the

underlying nerve sheath is exposed to abnormal force. By the forearm bones residing inward to their normal

positions, the olecrarnn and Greater Sigmoid Cnity actually move outward or towards the lateral epicondyle

by an equal axnount. So, when the varusly aligned arm is flexed, the ulna nerve sheath and posterior ligament

become exposed to abnormal force as the distance taveled by the aforementioned portion of the upper ulna is

actually significantly greater than when the forearm resides in its normal valgus alignment. This swelling of

the nei.nre sheath results in ulna nerve impingement.

Once an insufficiency of the lateral pins of the radius exists, using the arm while it is fully extended

creates the real elbow pains that have baffled all my specialists - most notably the orthopaedic surgeons of

westem Canada. The pains that arise at the lateral epicondyle, commonly referred to as lateral epicondylitis,

me caused by gavtty and the loss of normal valgus forearm alignment as a result. In reality, when the arm is

by one's side and fully extended with the insufficiencies at the lateral epicondyle present the arm in fact

becomes nothing more than a'flumb bob" that carpenters use: the hand and lower forearm musculature and

skeletal structures act like the heavy bob or weight at the end of the string but, in this instance, on the arm at

the elbow. Examples of this'llumb bob" sce,nario are simply walking or even worse carrying something as

innocuous as a 5 pound bag of groceries home from your neighbourhood store. In the first example, the elbow

loses its normal valgus alignment from the force of gravrty on the hand and lower forearm which causes the

radius to sublux laterally which produces discomfort at the elbow and shoulder. This discomfort is easily

eliminated by forced extension of the arrn with posterior rotation of the medial epicondyle which should

produce a'!op" at the lateral epicondyle. Unfortunately, this process is often necessary over a half hour wallg

every 5 minutes or less.

In the second example - carrying a weight when the afflicted arm is fully extended, the problems

become even wonrc. In the first example, the arm is merely subluxed to the point where elbow pain is felt and

rectified by the sufferer. This second example takes the subluxation to its ma:<imum and, if the amount of

lateral pin insufficiency is to the point where the radius can dislocate or even just reside on top of the humeral

capitellum, the radius will either dislocate or reach the point of maximum subluxation prior to dislocation and

remain there. Either way, the arm is no longer capable of bending at the elbow without severe pain. As I had

this happen to me several times before I made changes in how I bought my groceries, I discovered that, by

leaving the arm for several minutes and then pushing on my medial epicondyle stongly with my good arm

CopJ # ooL for RUDI KRASS 5l

while I attempted to bend my arm, I discovered that the elbow lock could be eliminated and ttrat the high lwel

of elbow pain associated with this mo<imal subluxation would dissipate over several minutes. A dislocation

cannot be resolved in this manner as it requires either a chiropractic adjusfinent or a resetting ofthejoint, as

the physicians describe the process. Resetting the joint often by a medical professional or oneself has to be

followed up with the reconstructive surgical heatneirt, discussed tnthe Treatment clnpter, for the lateral soft

tissue insufficiencies which permiued the lateral radial head subluxation or full dislocation.

If a comparative grip strength test is done on a fully extended upper extremrty having insufficiencies

at the lateral epicondyle and prior to any ptrysiotherapy being applied to the elbow and upper extremity, not

only will the grip strength be significantly weaker on the afflicted arm than the healthy arm but, dwing the

gnp test, the arm will begin to shake violently. This response to the test arises because the muscular con-

tractions have not yet been modified from the nonn so as to compensate somew.hat for the lack of lateral pins

at the elbow

* An interesting discovery ofmine is tha! when the afflicted arm is flexed from full extension while the

hand is pronated, there is a noticeable clunk towards the middle portion of flexion inthe radiohumeral joint.

The aforementioned clunking occurs wery time the process is repeated without cessation. This noise is

described x noticeable because it can be heard easily by any individual within 6 to 9 feet, when the afflicted

flexes his ann as described given that the process is done in a quiet examination room. To date, not one

medical offrcer has been able to explain this clunb but, with this book and especially Section I, the explana-

tion for it becomes quite clem easily: with the loss of the lateral pins to the 'tnodified pulley'' system em-

ployed in the elbow, the radial head is subluxed laterally through flexion. Also, remernber that the otnterior

Iigamenf is acting like a 'livot poinf' tnL/d,,but don't forget that the lateral radial head is surrounded by soft

tissue structures. So, the clunk that is heard has to be due to the radial head frnally and suddenly being re-

tumed to its normal position from its subluxed state once the lateral soft tissue structures become sufficiently

shetched to counterbalance the abnormal radiohumeral gap.

The explanation of the clunk has another bonus though as it is useful in undentanding the long term

symptom in the elbow of osteoarthritis - the constant abnormal motion of the radial head over the capitellum

naturally wears down the cartilage which ultimately results in the bones rubbing against each other once the

cartilage is gone. This is a problem that often occuni in the ball joints of cars which are improperly maintained

or the seal fails allowing the greasg lubricant, to squeeze out. The resulting lack of lubricant allows the metal

parts to rub against each other which they are not meant to do creating the need for them to be replaced.

There is also far more crepitus, clicking and cracking in the elbow reported by individuals suffer-

ing from a lack of a lateral arc pin and often there doesn't have to be any pain associated with it. The clicking

or cracking will be reported to occur following the patient having written or typed for a long period of time -at most, l0 to 15 minutes. This activity will cause a sufferer ofZRIto begin to feel discomfort in the lateral

side of the arm around the elbow as well as the wrist prior to the person extending the afflicted arm. This

CoW # ou for RUDIKRASS 52

motion should result in a loud crack or snapping sound which is followed by the discomfort subsiding. If the

activity is resumed then obviously the cycle of discomfort-and-release will need to be repeated.

The discomfort in the arm arises from the position of the forearm as well as the lack of the lateral pins

of the radial head. The forearm position - pronated - is caused by mild improper confaction of the pronator

teres andvpper portion of theflexor sublimis digitorum muscles. As the 10-15 minute time frame elapses,

these improper muscle contractions continue but, due to the position of the forearm, it is impossible to rotate

the radial head any furttrer. So, the improper muscle contractions actually raise the medial epicondyle due to

anterior humeral rotation which causes the lateral subluxation of the radial head and the iritation of the soft

tissue surrounding the area. This mild and fixated subluxation then requires release which is done by extend-

ing the arm which produces the sharp and loud snap or crack at the lateral epicondyle. The discomfort and

snap/crack pattern from using the arm in a semi-flexed position with the hand and wrist pronated is ex-

plained.

' As a follow-up to the previous paragaph, continued use of the arm through this pain pattem over

an extended period of time but intermittentty, e.g. typing every second day for 2 hours over several weeks,

will result in full blown epicondylitis. The reason for this is the cumulative effect. By typing for several hotrs

and having released a fixated subluxation 6-7 times per how, the soft tissues at the lateral epicondyle have

been mildly traumatizd, i.e. exposed to forces that they are not meant to be repetitively. Continuously doing

this every second day is insufficient time for the tissues to reverse the trauma to them especially since all other

daily activities will continue to cause subluxations. So, in reality, the tauma accumulates without cessation

causing the soft tissues to swell without control and without any relief from anti-inflammatories or very short

term relief, 2.3 days, from a cortisone shot. So, chronic epicondylitis and uncontrolled epicondylitis has to

be declared merely another symptom of the lack of lateral pins for the radial head or LN.

Another problem mising &om an insufficiency ofthe radial head's lateral pins is the immediate

impact on the mnges of motion through which the upper exremity remains pain free when used. An early

restriction placed on all sufferers of this medical problem is to stop using the arm at shoulder height or

higher. The reason for this is all the force is directed strictly to the now improperly functioning radiohwneral

joint wfuchcauses the force to remain within the elbow's subsystem. During normal use for me,n and when

there is no insuffrciency to the radial head's lateral pins, this hand based force is transferred up to the shoulder

joint as the upper exfremity is a fully functional single unit - explaining the large shoulder and upper arm

musculature on men who do a lot of lifting varied with other heavy labourer work.

With an insuffrciency ofthe radial head's lateral pins, thougft the torque created by, say, lifting a full

2 litre bottle of pop offof a shelf overhead is no longer transferred all the way up the arm to the deltoid and

posterior rotator cuffmuscles. Instea4 the torque ends up being stopped at the elbow especially the radial

head an4 due to the lack of a lateral pin, a sudden and sharp pain occurs at the lateral epicondyle. This result

is predictable, given the principle of "a chain or drive ffain is a strong as its weakest link " which infers that

CoW # aol for RUDI KRASS 53

the lack of lateral pins, which normally cause the torque, generated at the hand by the full bottle of pop, to

be transferred to the shoulder, suddenly become the end point of the torque facilitating the forearm bones to

move suddenly into the improper yarus alignment position mentioned earlier as well as subluxed for the

radial head: for future reference, varus alignmeirt: radial head subluxation. The resulting sudden and intense

level of pain at the lateral epicondyle has to be resolved by cessation of any use of the arm and ifpossible,

release of the subluxation by the sufferer or by a medical practitioner like a doctor, chiropractor or physi-

otherapist. The pain will subside gradually over the next several minutes.

Prolonged use of the arm in this manner causes chronic and often permanent crcpitus to rise

quickly not just in the elbow but also in the shoulder. To demonstate the grinding that mises in the shoulder

from usage of an arm without latorl,lpins, place the patient's tm at 60 degrees sideways from the body and

have the patient rotate his thumb side of the hand downwards while bringing his arm slightly forwmd. (The

ginding atthe shoulder can also be demonsftated by movingthe upper efremity backwmds from a slightly

anteribr position whilst the forearm is in a fully pronated position and least 60 degrees laterally from the

body.) This crepitus in the shoulder will also lead to osteoarthritis in the shoulder as well - to be discussed

nthe Long Term Complications section of this chapter.

Wrist and Lower Forearm Symptoms

All the symptoms in the lower portion of the upper extremity arise from the fact that iL all the way

down to the tips of the fingers, is a subsystem of the elbow - actually of the humeral face of the elbow. This

realrty is reflected in the results of the subsystem being used with an insufficiency of the lateral pins of the

radius: when the arm is used even through sedentary activities, this subsystem's skeletal and soft tissues

structures are being subjected to abnormal forces solely because it is being improperly pronated-initially

performed by improper conftaction of the upper portion of theflexor sublimis digitorurn and pronator teres

and their subsequently followed by contraction of the lowerportion of theflacor sublimis digitonnn,the

pronator quadratw and the qetensot muscles that terminate with a tendon in the thumb.

The result of improper pronation in the lower forearm/trand was touched on tnthe Patlnmechanics

section vnder Gender Based Interal Rotatory Instability. To summarize, though, wrist/trand complications

include: wrist tendinitis; significant wealaness in the lateral actensor forearm complex as well as in the grip

stength; carpal tunnel syndrome; radial nerye impinge at the wrist, i.e. tingling in the thumb; soreness and

crepitus within the hand and wrist. These problems will be further elaborated on in this section and others will

be innoduced.

The initial improper muscle contractions used by the body to pronate the lower forearm/hand cause

the radial head to ride up the humeral capitellum which mimics a lengthening of the radius. This added radial

length from the shape of the humeral capitellum pushes the radius into the wrist infrastructure causing a mild

CopJ # ou IoTRUDIKRASS s4

trauma to the soft tissues at the lower end of the radial head - represented with mild swelling of the tendons

sad ligaments of the wrist. This mild displacernent of the radius also weakens the soft tissue structwes

which normally stop the prorwtor qtndratus ftom contracting at the wrong time. This weakening of soft

tissue wrist sfuctures without resolution of the root cause results in laxities in the wrist and hand.

The body's initial response to the improper contraction of the pronntor grndratus is further swelling

throughout the wrist as the carpal bones are now being displaced posteriorly causing the anterior portion of the

wrist to collapse like an accordian as the normally stationary radius now begins to be pulled medially through

pronation. This improper "accordion like" motion at the anterior wrist and inferior ulrc-radial joint then

leads to mild to severe neural impingement at the carpal funnel depending on the amount that the forearm is

pronated post-rqiury and the diffrculty of this wrisffrand usage. When improper pronation is performed

sfrongly, i.e. with aheavy load in the hand, the caxpal tunnel totally collapses at the anterior wrist which is

confirmed by a total loss of sensation in the fingers and hand as happened with me. At this poinl the

prorntor qrndratus and'Jlexor sublimis digitonnn are permanently and improperly contracted which results in

a subluxed inferior ulno-radial joint. this condition remains as long as the aforementioned muscle remain

locked or until intervention to relax the improperly conftacted muscles is initiated, i.e. cessation of all activity

and antlinflammatorieso as well as the fixation or subluxation is adjusted. Also, a neural impingement oftheradial nerve which runs down the posterior of the thumb from the posterior of the wrist results from the carpal

bones being shifted posteriorly into the radial nerve due to the anterior inferior ulrn-radial joint foldng-carpal tunnel syndrome, radial nerve impingement andinferior utnuradiat jointsubluxations deline-

ated.

The improper functionality of the elbow's subsystem through pronation also leads to a reduced size

of the hypothenar clefr,themea of the palrn directly above the ulna. The reason for the lack of muscle mass

is not disuse but rather a reflection of the improper contractions now used to supinate and pronate the fore-

arm. The size ofthe muscles of the lgtpothenar clefi asll.nl$ arise from the latter stages ofproper forearnr/

hand supination andpronation. Bu! with insuffrciencies in the radial head's lateral pins, these muscles are no

longer used properly and as forcefirlly so their muscle mass drops to the appropriate size for their new usage.

This results tnthe palmus brevis and ab&rctor minimi digitibe,comiirg significantly smaller in size which can

actually be measured as well as visually discemed.

The weakening effects onthe forearm muscle groups can be overcome with physiotherapy heaftnents

that focus on strengthening these muscle groups through limited rulges ofmotions for the upper extremity,s

joints so as to accept the improper usage: the brain will restructure its contraction impulses in order to adjust

ot evolve to the present dysfunctional condition of the forearm. In reality though, the best that physiotherapy,

strength training and'!ain managemenfo can produce is limited by the degree of insufficiency within the

radial head's lateral pins and the dedication of the patient to the treatnent program. Ultimately though, the

increases in forearm activity will reverse themselves quickly - 10-14 days - following discontinuation of the

CopJ # ou IoTRUDIKRASS 55

strength training program and any other treatnents applied to mitigate a legitimate pain caused by an untreated

and misunderstood patholory.

Long Term Complications

As was already indicate4 osteoarthritis arises in both the radiohumeral and glenrhumeral joinE,

over 5 or more years. This long term complication is due to the radiohwneral joint notremaining in proper

contact throughout flexion and pronation and then the radial head and humerus re-aligning themselves through

the latter 30 degrees of extension as well as supination. These processes mean that the cartilage on both the

bones but mainly the capitellum is subjected to forces ttrat it was not meant to receive---explaining why the

cartilage breals down and then bone-on-bone rubbing begins. The degree of radiohumeral osteoarthritis

depends on the types of activities that the sufferer performs post injury: those that require a lot of repetitive

pronation and use of the hand in a semi-pronated positioq i.e. at the horizontal plane position to 70 degrees

above it for both hands, cause significant repetitive improper bone rubbing atthe radiohuneral joint resulting

in vmious degrees of osteoarthritis-4epending on the amount of time from the initial rqiury that the afflicted

arm has been used.

Osteoarthritis at the shoulder occurs because, without the lateral pins of the radial head the hu-

menxi is allowed to rotate posteriorly, counterclockwise on the left arrn and clockwise for the right, and reside

in this improper position. With the humerus being rotated posteriorly, the soft tissues of the Coracoid Process

are subjected to improper forces when the shoulder muscles c,ontract to raise, lower, bring forward or pull

baclnvmds the upper exfemity. Essentially, the humeral head remains posteriorly rotated over the Glercid

Cntty causing the former to move in a severely restricted range of motion which nafurally causes the cartilage

towearsawaytothepointwherethehumeralheadandthe GlenoidCavity starttorubtogether-

osteoafthrtfis. Ifthe insufficiency of the radial head's lateral pins is not caught early enough and surgically

treate4 this is the inevitable outcome.

The improper posterior position for the humerus results in another symptom in the arm just above the

radiohwneral joint. this humeral rotation places an abnormal force on the supinator longus and the extensor

carpi radialis longior tendons at the lower humerus. Normally, these muscles work in unison with the radio-

Iumeral joint in order to rotate the humerus through the various extension and flexion motions - see Section Iof this book. However, since the radius is no longer working in conjunction with the rotational forces gener-

ated at the humeral head n Lkl, the muscles of the lateral portion of the lower humerus are forced to attempt

to pull it over through pronation. As the anterior angle of the elbow has been significantly reduced with

improper contaction of the coraco-brachialis, brachialis anticus,the upperpoftionof fheflexor sublimis

digitorwn,the/lexor catpi radialis andprorwtor teres,the two lateral upper:ilm muscle groups are attempting

to do the impossible which results in trauma tothe supinator longus' and esdensor carpi radialis longus'

CoW # ool for RUDIKRASS 56

tendons, i.e. swelling and soreness to touch. (This problems is most cornmon in basketball players and young

pirchers but not exclusive to them.)

Osteoarthritis in the hands has not been discussed to this point because it is such a long term

condition and also because it aJflicts mainly women especially those in their elder years. The main reason for

such a selective group of sufferers is due to the reality that women have joints that me more lax relative to men

which is ge,netic in nature. The otlrer reason for elderly women suffering from this condition" more so than

merq is that women have traditionally done copious amounts of activities like crocheting, knitting and other

handicrafls which require a lot of repetitive pronation/supination and flexion of the fingers and thumbs with

minimal extension.

The most important factor for osteoarthritis in the hands being more prevalent in women is the

longstanding missed diagnosis of insufficiency at the radial head's lateral pins and Coracoid Process. These

natural laxities facilitate the subluxation of radiohwneral joint and often tendinitis of the wrist (women) when

the foiearm is usedredomiUgntly inpronatedpositions and they also cause the natural and noticeable weak-

ness in the extensormuscle groups and grp strength that most young women and womerl in general, endure

atl their lives relative to most men**explaining a man's ability to open tightly sealed jars which women

cannot open without the use of an aid or a special technique.

Prior to a women's weakness inher erctensormuscles causing osteoarthritis in the hands, it leads to

hags hands disease or permanent flexion of the fingers. This complaint, also far more common in elderly

females, arises from all the pronation and finger flexion that these women have done in their lives. With little

sftength in the forearm and hands qcterlsor muscles, the effects on the fngerflexors is that the unbalanced

contactions of frteflacors ultimately shortens their tendons within the fingers themselves: don't forget that

this process takes more thanjust a few years--it actually accumulates over several decades. (Women have

been referenced mainly due to the fact thar they make up the largest portion of suffers of this condition.

Permanent partial flesion of the furgers does occur in men but mainly in those who have joints which are laner

than most males. In these case, this condition occurs in much the same way as it does in women or as a result

of their work place activities which probably demanded repetitive pronation and/or use of the forearms in

semi-pronated position for long durations as well as repetitive sfrong grpping of heavy objects like sledge

hammers.) The resolutions to this condition will be discussed in the Treatrnent and Prevention sections that

follow.

With the finger flexors now beginning to shorten due to perpetual finger flexion without pgqBer

extension, the cartilage in the knuckles of the fingers shrinks in thickness due to disuse as the portion of the

fnger beyond that knuckle is actually moving over less and less of the joint cartilage. Consequently, the

knuckle's cartilage reduces to the point where the knuckle bones end up rubbing against each other. Unfortu-

nately, by the time osteoartltritis is detecte4 the use ofthe fingers, tlrumb and hand will already have been

impaired beyond the point of recovery and not because of the arthritis. Rather, theflexor tendons running

Copy # ou for RUDIKRASS s7

down through the fingers will have shrunk to the point where any surgical attempt to eliminate the insuffi-

ciency in the radial head's lateral pins will be far too diffrcult on the patient----remember by this poing

osteoarthritis should not only be present in the elbow and shoulder but be at such a severe state that the

body's natural recuperative ability is incapable of reversing the effect. (Ponder this bold type for awhile!)

Cop) # ool for RUDI KRASS 58

Llrnnal Rqrarpny lxqrnsntTY

In March 1991, a team of orlhopaedic specialists introduced the lateral pivot-shifi test, /psr, into the

medical world in order to confirm the existence of the medical condition that the team designated as pstero-

lateral rotatory instability, PLRI asthe medical commurity now refers to it. I was able to access an internet

report on PLN, that I discovered late in 1997 , inwhich the lateral pivot-shifi test was very well explained by

the report's author as well a^sthe PLN condition and its immediate effects on the elbow and forearm - see the

Bibliograplry. To date, this /psr has been seen as an excellent diagnostic technique amongst orthopaedic

surgeons who suspect insuffrciencies of the radial head's lateral pins in their patieirts.

The lpst is a very exacting and conclusive test that made the patholog of PLRI easy to confirm so the

condition was easily accept by the medical community. But wen though the test is a good starting point for

the discussion of insufficiencies ofthe radial collateral ligament, it has been strictly applied to person's who

adhered to the designated cause ofPZR.I, i.e. patients having received a trauma to an outstretched arm. As a

consequenc€ of this limited application of the lpst, PLNhas been declared an uncommon condition and the

test is not normally applied to the predominantly male patients suffering from lateral epicondylitis whose

condition's origin could not be fraced back to a tauma to an outstretched arm. So, the discussion of PLN and

any possible flaws with the /psf was prematurely ended by the medical profession including the founders of

PLN andthe lpst.

Fortunately thougtr, the Kerlan-Jobe facility was researching the other cause for epicondylitis in men:

pirchers which are a sub-group of cases originating from a repetitive oven$e syndrome ofthe elbow or, as I

have designated this cause, Repetitive Impropr Pronation or NP,my designation. This facility's diagnostic

technique though is not limited to the /psf but rather a Gadolinium enhanced STIR MRI which this facility has

used extensively in diagnosing the cause of a patient's lateral epicondylitis since prior to the lpst's inception in

March 1991. This MRI diagnostic test makes use of a special dye injected into ttre person as well as a special

elbow brace.

There have been diagnosed cases of PLN or more aptly described as cases where the symptomolory

for PZRlwas present - anterior$ rotated humerus, varus misalignmeirt of the forearm bones at the elbow,

damaged common ertensor tendon,damaged radial collateral ligament and the presence of significant disor-

galrtizrd scar tissue within the joint capsule and also beneath the common extensor tendon - but the result of

the/psfwasnegativeaswellasthecausebeingdeterminedtoberepetitiveovenrse orNP andnotatraumato

an outstretched arm. These positive results from the Gadolinium enhanced STIR MRI confary to the medical

understanding of PLN andthe /pst results means that both conditions needed to be more comprehensively

researched and explained and that a better test for insufficiencies in the radial head's lateral pins needs to be

59CoW # au IoTRUDIKMSS

developed-both the test and the explanation me obviously intrinsically interlinked. As I have already ex-

plained the processes causing ZRI, it seems that it is time for the new test to be disclosed.

Prior to ttre introduction of the new test to dekrmine insufficiencies in the radial head's lateral pins

though, it is necessary to establish the faulB in the lpst and how these relate to the bigger picture of diagnosing

ALL cases of this problem accurately and quickly-this means cases from 25-30 years ago as well as newly

developed cases. As was written earlier, the lpstwas only applied to cases of epicondylitis that could be

determined to have arisen from a trauma or significant force to an outstretched arm. This approach by the

medical community was tenable even though the more sound approach should have been to apply the test to

all cases of lateral epicondylitis as the original orttropaedic surgeons had declared :rl.1992 that (chronic)

epicondylitis should be treated with some form of reconstructive lateral surgery (regardless of

cause).

(It sounds ridiculous but, even today, most orthopaedic surgeons declare that there are two distinct

types 0f (chronic) lateral epicondylitis: one, caused by a trauma to the arm, which means that the problem

receives surgical resolution; the other not being caused by a trauma which means pain management and living

the remainder of your life with worsening and debilitating upper exhemity pain is the recommended treaffnent

rather than the surgical solution. I know the latter to be factual because it is the main reason that I was forced

to write this book.

The surgeons that I have seen in western Canada between June 1989 to date have been unable to

relate my medicallyrecorded and confirmed case ofZR/to my NP injuries of June 1989 as all cases of lateral

epicondylitis and severe forearm problems are not yet seen as being symptoms of insufficiencies of the radial

collateral ligament and the common extensor tendorc-matnly because these symptoms, shangely enough,

don't adhere to the PZ,Rlparadigm. However, the Kerlan-Jobe orttropaedic surgeon that I have seen twice

since 1997 - once to recommend the Gadolinium enhanced STIR MRI which unequivocally confirmed the

existence of PLKI type problems and then the second time to recommend a surgical resolution to my problems

- has seen this condition numerous times among the pitchers that he and the other elbow specialists at this

facility freat. Unfortunately, the Kerlan-Jobe Clinic has been unable to understand the correlation ofrepetitive

overuse (elbow) syndrome to lateral epicondylitis and also PLRI - explaining my findings and thus this book.

(For the scientific proof of correlation see the Scientific Proof appendix at the end of this section.))

Applying the /psr Uictly to cases of late,ral epicondylitis that arose from a trauma demonstrates

conclusively exactly what types of lateral elbow soft tissue insuffrciencies, it was developed to confirm -extreme or substantial cases. These cases are exactly what the lpst determnes today because almost all ortho-

paedic surgeons no longer make an x-ray film of the arm at about 30 degrees of flexion: the rationale for this

change tothe lpst is understandable given that, if a radiograph were taken for wery case of lateral epicondyli-

tis, then the surgeons would be subjected to numerous low levels of radiation over a year let alone a career.

Another problem which was exposed by my enhanced STIR MRI is that the lpt c,omes back negative when

CopJ # ou for RUDIKRASS 60

there is significant scar tissue present in the joint capsule at the lateral epicondyle.

So, the 3 main problems with the lpt as it is presently performed have now been exposed: the need

for assisted and stressed radiographs; when these x-ray films are not made, the lpst only detects cases where

the lateral soft tissue insuffrciencies are significant in size, not the smaller cases; when there is scartissue

within the joint capsule at the lateral epicondyle, the result of the lpst is a false negative. Knowing the failings

of the lpst aids in the development of the new diagnostic techniques conceming insufficiencies of the radial

head's lateral pins by defining exactly what these new diagnostics need to determine better than the previous

test.

As has already been stipulats4 there is a superior test for diagnosing insufficiencies in the radial

head's lateral pins and it is a Gadolinium enhanced STIR MRI. This test though has some serious limitations,

as well, but these are not in the results of the images. The problems with either a Gadolinium enhanced or

basic STIR MRI, which uses an elbow rotation brace, is the present level of availability world wide for this

diagnostic imagery considering that, in many parts of the world, x-ray technolory is seen as a luxury given that

these areas don't even have running water let alone electricity.

If either a Gadolinium enhanced or basic STIR MRI is available then by all means use it, but there are

cheaper and equally competent diagnostic images possible and they only require an x-ray machine. Before

these new imaging techniques can be infroduced, it is necessary to understand the positive aspects of the lpt.

This test was effect because it reversed the body's means of absorbing the soft tissue insufficiencies at the

lateral epicondyle: i.e. the first step to was reveftie the humeral rotation and then reverse the varus positioning

of the forearm structwes which, of courseo isolated the insuffrciencies back to their point of origin, the lateral

epicondylar area ofthe radial head.

From this understanding of the lpst, whenever an image captures either a rotated humerus or

forearm bones residing varusly to the elbow, i.e. residing close to a line directly downward from the

humerus, then the image demonstates conclusively the presence of insufficiencies of the radial head's lateral

pins as both ofthese bone positions demonstrate how the upper exfremity nahrally absorbs the damage to the

soft tissue at the lateral epicondyle. This reality though has been overlooked by the medical community

because physicians do not see the position of bones on x-ray filns to be highly relevant or pertinent to the

discussion of disease or injury: only bone structure - broken, damaged by osteoarttritis or fully dislocated *in an x-ray film are grounds for the x-ray to be declared anomalous. (As a result, the medical community still

clings to the belief that the main joint of the elbow isthe ulrn-humeralwhichhas resulted in the elbow being

erroneously defined as a'hingeoo join! the ulna at the ffochle4 and that the radial head rotates around the

humeral capitellum.)

So, using the fact that varus alignment of the elbow is a clear sign that the radial head's lateral pins

are suffering from an insuffrciency, all that is needed is a radiograph which demonsftates that the forearm

bones are residing in this position relative to the humerus. Such an image is easily obtained with a slight

6ICopy # aol for RUDI KRASS

modification of the present overhead x-ray. The change to this type of x-ray is that the forearm bones be

placed under shess applied at the lateral side of a supinated wrist by either a second technician, a physician or

a strap across the plate table which must also immobilizes the forearm on the lateral side while the patie,nt

pushes against this stop either at the body or just above the elbow on the humerus with his other hand. (Be

warne4 this force can cause significant pain!)

Now, because the x-ray image is actually taken from 30 degrees medially from the vertical line ofthe

joint, the film will clearly show a separation of the ulna and the radius around the biceps attaclnnent onthe

latter. This gap will be eve,n more evident when the patiurt has been using the arm at a moderate level espe-

cially through the improper pronation technique used by an arm suffering from insufficiencies at the lateral

epicondyle. This widening of the ulrn-radial joint gap is due to the pronator teres andthe upper portion of

tkeflexor sublimis digitorwn being strengthened to the point where they are actually able to rotate the radius'

Bicipital Tuberosity further baclarards through the ulno-radial joint. T,llirs rotation of the radius, which

normrilly does not occur through prop€r pronation, forces the ulna medially from its normal alignment as well

as rotates the ulna's medial portion baclavards - just like an accordion with one strap attached. Thus, it is

proven that the abnormal radial rotation causes not onlythe impropervmus alignment demonstrated in the film

but also a slight rotation in the ulna as well.

With the knowledge that radial rotation causes ulno-radial joinl separation and that greater use of the

arm through pronation causes incneased separation, it is easy to produce a conclusive result in all cases of LN:

prior to having the x-ray done, have the patient do stictly forearm pronation strengthening exercises for an

aftemoon or day which, in cases of LN,will cause an easily noticeable ulrn-radial joint gap. These two facts

also lead to the conclusion tha! with prolonged e4posure to LV,the forearm bone positions should demon-

strate some of these effects in a normal overhead x-ray film.

As I was fortunate enough to have a ohormal" or unafflicted joint on my body, I rcalircdemly on that

I would be able to do a proper comparison betwee'n both an upper extremity suffering from insufficiencies to

the radial head's lateral pins and one without. From my images - CT scan both arms pronated and compara-

tive x-ray films, I found that it is easier to understand the bone positioning in these films when one has a

comparative joint to use as it creates an individual standard for the bone positions at the elbow.

The most notable change and easiest to see in a standard overhead x-ray film of an pronated elbow is\

that the overlap of the ulna and the radius is noticeable reduced-the intense white where the two bones

overlap is significantly smaller in thickness on upper extremities suffering from LM. Also, from the radial

rotation, an abnormal gap appears just beyond the Bicipital Tuberosity towrds the wrist and the radial head is

noticeably thicker in compmison with a fihn of a normal forearm/elbow: the latter is due to the fact that the

radius has rotated posteriorly making its representation in the film image thicker by fact.

The most notable changes for comparative CT scans ofpronated forearms are the musculature is

thicker around the unstable elbow and it is oval or circular in shape whereas a normal elbow's musculature is

CopJ # ool foTRUDIKRASS 62

very rectangular in shape and noticeably reduced in size when compared to an unstable elbow's image.

Interestingly, due to the pronated position of the forearms over the patient's head for the images, a small but

noticeable gap arises at the lateral portion of the rodiohumeral joint. This gap should persist over two or more

slice images and is demonstrated by a gradually increasing radial head image that finally becomes circular like

its counterpart on the healthy arm which should remain circular through all the images slices of it. (If a

comparative and healthy limb is not presented, then take a radiographic image of the elbow while under varus

stess, as outlined earlier.)

If the diagnosing physician does not have available an x-ray machine to create any of these diagnostic

images, the problem of insufficiencies of the radial head's lateral pins can still be diagnosed relatively easily.

To do this though, it is important to remember that the presqrt range of motion tests that medical practitioners

use today are oufinoded as their results come back as negative even though the upper exfremity is pronating in

a manner which is abnormal. The reason present basic physical testing does not expose the fact that the elbow

is dysfunctional is that there are actually two ways of performing forearm pronation: the erroneous and

medically accepted way, i.e. by rotation of the radius around the humeral capitellum making it strictly a

forearm activity, and the proper physical way, i.e. rotation of the entire upper extremrty through both pronation

and supination with the radiohwneral jointbengsolid and the main joint making the upper exfremity a single

unit and rotation of the wrist/hand within the lower exhemity of the radius possible without swelling and

tendinitis. (As has been presented, repetitively and through numerous images and tests, the rotational process,

presented in the frst section of this boolg is the true way of obtaining rotation ofthe hand!)

The new non-imagery means of determining whether or not the patient is capable of pronating the

arn as a unit is srmply by placing the forearm in a supinated position and at 30 degrees of flexion from full

extension. With the tester standing face to face with the subject place the same ann as is being tested on the

inside of the humerus just above the elbow. Now, with the tester's free hand placed on the lateral side of the

radius at the wrist and lightly gripping the forearmo push inward on the forearm and pull back while using the

arm placed on the humerus to keep this portion ofthe arm stationary. I am calling this physical examination

the Krass pronation test, Kpt.

A positive result will be the fact that the forearm is capable of moving back and forth - inward and

then back to its normal valgus alignment position - along the 30 degree of flexion plane. This forearm motion

along the horizontal plane is a clear indication that the lateral radial head's pins are insufficient to keep the

radial head's canilage tight against the capitellum's.

With the Krass pronation test,fhe radiograph analysis presented as well as the STIR MRI results, the

diffrcult lateral pivot-shirt /est, which is not always accurate in determining insufficiencies in the radial head's

lateral pins, can be replaced with these far more accurate tests. So, diagnosing insufficiencies within the radial

head's lateral pins can easily be done with a positive result produced by the Krass pronation /esf and then, ifx-ray technologr is available, this test can be confirmed with either avmusly stressed radiographic image

CoW # ou for RUDIKMSS 63

demonsfiating an unusually small overlap of the radius and ulna as well as a possible "gap" between the ulno-

radial jointbones at the elbow. A more e4pensive mqms of diagnosing lateral rotation instability is a set of

comparative CT films where the forearms are pronated in which the radial head demonsfrates a smallbut

confirmable gap at the lateral portion of the radiohumeral joint The most expe,nsive but very reliable diag-

nostic image is either a basic STIR MRI or Gadolinium enhanced STIR MRI - both use the posterolateral

rotational elbow brace.

It is importantto addthat a simple MRI of the armwithout abrace is NO LONGER acceptable as it

does not produces humeral as well as radial rotation. Also, if the patient has a healthy joint on his other anrL

then the quickest way to diagnose the problem is a comparotive Kruss prunation test.

CopJ # ou fioTRUDIKRASS 64

TnnlrurNr ronLlrEnAr Romronv INsrasr.rTY

Contrary to current medical practices, there me only 3 proper fteatrnents for lateral rotatory instabil-

ity, LN, due to insuffrciencies of the radial head's lateral pins: physiotherapy, adjusted to the new reality of

how the upper exkemity actually functions through all its motions; reductive surgery to both the lateral pins,

the radial collderal ligament and the common efrensor tendon;prevention, changes to the way in which

human beings use their upper extemities. The first two freatnents will be examined in this chapter while the

final foeatnent will be presented in its own chapter, Preventiono so as to try and present some semblance of the

enormity of this process which will be massive.

Physiotherapy

The key to determining the tneafnent counie depends on how quickly IRl is diagnosed from ttre injury

and the type of activity that caused this condition. In cases where women and some times men are suffering

from mild to moderate levels of wrist tendinitis and carpal hrnnel complications from repetitive activities like

typing, data input, cutting hair in a busy salon or standing at a grocnry store cash register not just for long

periods of time but for short time frames repetitiously over the work weeks, the recommended fteatrnent has to

be physiotherapy. In men and occasionally women, when lateral epicondylitis is present as well as some form

of wrist complication BUT these cases ofZR/complications were not preceded by a sudden and shaqp pain at

the lateral side ofthe elbow, fhen once again physiotherapy must be the treatnent rendered.

As the understanding of how the elbow joint system works has to change, so does the nature and types

of treafinent to recover the proper functionality. The type of trednent that remains is obviously reducing the

swelling at the wrist and elbow with ice and heat accordingly. The types of exercises to stengthen the muscles

that interact with the joint are different initially as they must be focused on those that reside on the lateral side of

the arm above the lateral epicondyle. Also, once these muscles ate strong, given their size, the manner in which

the upper extemity is use4 rotating at the shoulder rather than the elbow, has to be re-enforced not just in the

ann usage, but in the brain.

This repetitive practice fraining is accomplished initially with the patient grpping a wooden dowel

with his lateral 3 fingers and swinging the dowel up laterally from the 6 o'clock position---rcounterclockwise for

the right arm and clockwise for the left. This exercise should be done 3 times in repetitions of 30 and repeated

34 times a day for several days. From there, the patient should be moved onto light shengthening of the

pectoralis major, actually the clavicular portion, with dumbbells using the standard sfrengthening regime of 30

repetitions in sets of 3. This pectoral exercise should be done twice a day minimum until the patient reaches

about 15-20 pounds per ann and is capable of doing this weight without sfain from start to finish.

Copy # ou for RUDIKRASS 65

Once this activity level is reache{ then sfrengthening of the biceps, deltoid and supraspinatus muscle

groups should be initiated. This activity must be done with light dumbbell weights and progressing to moder-

ate weights as well as continuing the rotation exercises with a weight bar and exhemely light weight-l

pound of weight at 12 inches from the fulcrum creates quite the torque which means the force necessary to

move that 1 pound weight is much lmger than suspected and realized. Once moderate weight for the shoulder

muscle groups is attained" the rotational exercise is no longer necessary if the patient continues to work out

with moderate to sfrong weight naining.

All this teatnent will be for naught if the patient returns to a work environment which is designed

around the illusion that hand and forearm rotation occurs at the elbow and not the shoulder. Without changes

to the way in which society demands we use are arms, the patient will be back time and again but the amount

of patients being treated will continue to grow without end unless the changes outlined tn Prevention are not

undertaken - immediately !

Reconstructive Laterol Epicondylar Surgery

I{ at any point the physiotherapy treatnents, the lateral epicondylitis or wrist complica-

tions return or are not diminishe4 then the only way to teat the patientis reconstructive lateral epiconfulo,

surgeryto the radial head's lateral pins.

If, initially, the complications at the wrist are sevetre, both carpal tunnel and tendinitis, and which may

include soreness and crepitus at the shoulder, then reconstnrctive lateral epicondylar surgery is required to

resolve the underlying pathologr causing these problems.

Beyond this symptomolory, if the patient mostly men, suffered a sudden and severe pain at the onset

of lateral epicondylitis othenrecorutnrctive lateral epicondylar surgery is necessary to resolve the patient's

condition. Surgical treatnent is easily diagnoseable because the cause of the sudden pain at the lateral epi-

condyle ofthe elbow is usually due to intense repetitive strairl i.e. like shoveling large amounts of dirt inces-

santly, pitching a baseball, excessive training to pitch orplay tennis, repetitive high intensity ratchet use by

mechanics, administering chiropractic adjustnents orphysiotherapy requiring resistance force orjoint manipu'

lation by the physiotherapis! etc. In these exanrples, the actions cause a sudden improper strengthening of

both theprorntion teres andupper portion of theflacor sublimis digitonnn. As a resull patients whose lateral

pins are of normal lengttr to keep the radiolrumeral jornl tight through extension and flexion have a sudden

tearing of the radial head's lateral pins - accounting for the suddsn and sharp pain at the lateral side of the

elbow.

Ifthere me fixations, initially within the wrist and elbow and initial teatment includes, or included,

an adjustnent to the elbow, meaning that the radiohumeral joint wasput into proper alignmen! then

reconstntctive lateral epicondylar surgery is the only means to correct the damage to the radial head's lateral

CopJ # ou for RUDIKRASS 66

pins without question. This quick prognosis arises from the fact that the fixations can only be due to continu-

ing to work at a high arm activity level following a sudden and severe pain at the lateral epicondyle or a

trauma to an outstretched arm. In either case, the radial head's lateral pins are damaged far beyond the body's

natural recuperative ability-a fact ttlat will be borne out by the failure of ANY physiotherapy or chiropractic

treaftnent to resolve completely or pennanently the effects in the upper extemity that arise from LN.

Unfortunately, I can only outline the objectives ofthe reconstrtrctive lateral epicondylar surgery. As

to the exact surgical processes that will accomplish the surgical objectives, I will leave that in the capable

hands of the Mayo Clinic's Head of OrtlCIpaedic Swgery and his team as well as the orthopaedic surgeon's at

the Kerlan-Jobe Orttropaedic Clinic in Los Angeles that specialize in elbow and upper exfremity surgeries.

The following is just my insights into ttre objectives of recowtnrctive lateral epicondylar surgery.

The main objectives of this reconstructive surgery will be to reduce the length of the radial head's

lateral pins, i.g the damaged radial collateral ligament AND the common exteraor tendon. In cases where the

tendoir seerns fme but the ligament is damaged" the tendon has been damaged as well and needs to be short-

ened. The rationale behind this assessment is the fact that the tendon supports or works together with the

radial collateral ligament in adults - more so in men than women - to reduce the vulnerability ofthe lateral

pin. (This fact about tendons supporting the ligament pins ofjoint arcs also applies to the finger and toe

knuckles and the knee explaining the most common cause of dislocations and ligament damage in these joints

- a frauma to the joint from the side.)

About the actual surgical process, I do know that reconstructive lateral epicondylar surgery is only

possible by actually opening up the skin over the lateral epicondyle for about 6-8 inches and not with the use

of arthroscopic surgery. This fact means that there will be a sizeable scm at the outside of the arm upon

completion of the surgery. Reduction in the visibility of the scar and healing of the skin can be done by using

the Montreal protocol of incision closing, i.e. using medical tape with porous glue to close and formulate a

connect between the incised skin.

Once the joint and common extension tendon are exposed following the skin incision and separation,

the tendon has to be cut across it and not longitudinally along it. Cutting the kndon lengthwise orre-opening

a previously healed tongitudinal tear, usually occuning in pitchers but not exclusive to thenU is the worst

means of exposing the lateral portion of the radiohwneral joint and the dorsal portion of the lateral epi

condyle. The explanation for eliminating a longitudinal cut ofthe common acterwor tendonto e4pose the

radial collateral ligament is that a torn tendon only occurs when the radius has been exposed to a stong and

sudden IMPROPER rotatory force so, replicating this alfect on a healthy or previously healed common exten-

sor tendononly weakens or re-weakens it. Ergo, creating a flap of the cornrnon qctensor tendonand the

forearm muscles that attach to it is the only means to expose the joint with minimal negative affect on the soft

tissues requiring reconstruction. (This fact has already been borne out by the success rates for the respective

surgical procedures when used to remove scar tissue from undemeath the tendon.)

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The most intriguing part of the surgical discussion is the fact that, when the radial collateral ligament

is exposed, the lateral piwt-shifi motion, lpsm, should be used to determine, the amount of ligament insufft-

ciency that is present through a visual inspection of the fully exposed joint as this motion is applied. The

intriguing part is that the result of ttris tesf performed on an exposed joinq will be the foundation for the new

reductive ligament surg€ry which will supplant the strgical procedure recommended by the /psr's founder: in

effect, the body's response tnthe lpsm, i.e. the /psf less flexion, actually demonstrates the exact amount of

ligament insufficiency that needs to be removed by reversing the body's meaffr of absorbing these insufficien-

cies.

Presently, once the radial collateral ligament is e4posed, a graft of the palmaris longn ta the dorsal

aspect of the lateral epicondyle is performed. When this tendon graft is examined with physics, it becomes

evident that it actually mimics the reversal effects of the lpsm or a proper reduction of the radial head's lateral

pins. Instead of mimicking the effects with such an invasive procedure, the benefits of actually performing a

propef reduction of the radial head's insuffrciencies demonstrates the rationalizaionfor it over the preseirt

tendon release surgery especially when it conforms completely with the realrty of how the elbow and upper

exfemity really firnction. Prior to performing the lpsrn andsurgical reduction of the radial head's lateral pins

though, all disorgani z.ed or clumped scm tissue inside the joint capsule and that between the common extensor

tendon and radial collateral ligarnent mtstbe removed. lf the radial collateral ligament istom, it would be

advantageous to use that point to gain enty to the scar tissue--I adhere to the policy of keeping the amount of

cutsto aminimum.

Once scm tissue removal has been completed, the elbow can be prepared for reduction nthe radial

collateral ligamentby implementing the lateral pivot-shirt mofion: the /psf minus forced flexion which rotates

the humerus poskriorly, counterclockwise for the right arm and clockwise for the left, and then pulls the

lateral portion of the radial head back into position over the capitellum and lateral epicondyle. This arm

position must be maintained throughout the ligament reconstnrction which dernands either a brace be devel-

oped which will allow easy and unimpeded access to the joint stuctures or, initially, two surgeons or a surgi-

cal asssistant will have to be present-*one person to manipulate and hold the arm while the other performs the

surgical reduction of the ligament.

With the lpsm appliedto the arm, in cases where the ligament was torn, the radial collateral ligament

area can be cleaned up and then sealed so that it is retumed to a normal or near normal size. To achieve the

same effect on a stretched but not torn radial collateral ligament, it should be cut and shortened at the radial

head attachment and not at the humeral attachment. With the radial collateral ligament now being the proper

lengttr, the ligament can be re-attached to the radial head with porous glue first being placed on the radial head

attachment.

To test the strength of the attachmen! the lpsm should be released. Using a mild force with the Krass

pronation test,thereshould, once again, be no discemable medial forearm motion confirming that the liga-

CoW # ou for RUDIKRASS 68

ment surgery was a success. Obviously, motion within the forearm sfructures during the.fi?ass pronation test

would mean that the ligament needs further reduction. This motion will once again be visible at the lateral

epicondyle as the radial head will still lose its alignment to the capitellum and the lateral epicondyle.

With the radial collateral ligament reduced to its normal or near normal size and its attachment soli4

the common extensor tendon can be reduced by several millimetres and then re-attached in the same manner as

the radial collateral ligament-porous glue placed on the epicondylar attachment and then the shortened

common extensor tendonre-placed over its humeral attachmen! i.e. the lateral epicondyle.

Then, to close the incision, put porous glue on one side of the cut and then use strategically placed

pieces of medical tape to close the wound nicely and strengthen the incision seal with porous glue over both

the incision and medical tape. It is important to determine which medical tapes the patient may or may not be

allergic to as the medical tape remains attached until cellular regeneration causes the skin to shed the tape.

With the surgery completed, the patient should remain in a secondary post operative bed until the glue

dries fnaking certain that ABSOLUTELY nothing comes in contact with the glued area due to the incredible

stickiness and bond strength ofporous glue. Also, acupuncture can be used to neutralize the neural stimula-

tion of the upper exffemity instead of a local anaesthetic throughout the surgical procedure.

Post Operative Treatment

Post operative care will require NO use of the upper extremity for 4-6 weeks. This means that the

elbow needs to be placed in a cast which will keep the arm FULLY extended and which extends from the

finger tips to the midpoint of the humerus. This cast length is necessary to ensure that there will be NO

BENDING OF THE ELBOW and no contractions in any forearm muscle groups which naturally impact on

the healing radial collateral ligament. This time frame permis the ligament and tendon time to establish an

actual cellular bond as well as grving the body time to reduce any post-operative swelling - anti-

inflammatories may be used reduce this effec! but I don't recommend this.

Following removal of the cast, physiotherapy with no weight for l-2 months will need to follow.

During this time, the arm cannot be used for almost everything in order to allow the radial head's lateral pins

to bond fully with cellulm regeneration of the attachments. At the end of these months, the elbow can now be

bent but WITHOUT any significant weight in the hand or in the forearm as the soft tissue stuctures at the

lateral epicondyle should be fully healed but very weak. Now, the treafrnent process described nthe Pfusi-

otherapy section can be initiated.

It is important to realize that the treatnent has to be tailoredta the patient. This means that the

weights will not be increased until the patient demonstrates COMPLETE competence with the weight and the

weights should start at 1 pound per arm and very gradually increase to moderate weights per arm/shoulder-

making certain to focus on correct use of the arm throughout all the exercises rather than rush to increase the

Copy # ool for RUDI KRASS 69

weight especially towards the end of the treabnent. Also, a rule of thumb that should be used to d*ermine

whether or not to include ffeatneirts for the shoulder: when shoulder crepitus c€ases, if it existed at all, then

ttre joint is ready for inclusion in the fteatnentprogram.

Tailoring the physiotherapy treatnents also means being prepared to use up to 2.5 years to treat not

just the wound and all physical upper extremity rotatory complications but also the mental aspects of this

condition. Don't forget that, in long term cases, the autonomic portion of the mind has been'qfained" for

decades, in some cases, to rrse one or both arms that are improperly rotating which makes the nzural feedback

and extremity inputs convoluted and improper. Essentially the brain has tried to work around the pain in the

arm and, in so doing, has created an improper ner.ral connectivity to this extrenrity which makes having a fully

functional upper exfiemity with ppg neural inputs from it a distant memory or myth for the brain.

From personal e4perience, I can say that it is diffrcult for me, a l2year sufferer of LRI, even to

remernberhow my right arm felt during the years when I used my dominant arm freely and without fearof

causirtg a debilitating pain in it, often requiring rest and relocation of the forearm bones to resolve these

problems. For persons suffering with this syndrome longer than myself, I beliwe that they've given up all

hope of ever having'!ain free" upper exffernities especially after having been constantly bombarded by

medical specialists' opinions indicating permanent impairment and impossible to cure or, possibly, being sent

to a pain management clinic. A surgical solution finally being presented for all cases ofZRl, decades after the

fact, is going to seem like a miracle.

I hope that, if, after the orthopaedic surgeons at both the Mayo Clinic and the KerlanJobe Clinic have

read this boolq they present and distribute their constructive changes to the surgical process quickly and have

,Rl instituted as a serious medical syndrome of epidemic proportions dating back to at least the 1960s. Such

action will make reviewing cases of previously undiagnosed upper extremrty pains from 1960 to today manda-

to{v. In tum, the surgical community will be inundated with tens of millions of prwiously undiagnosed cases

requiring surgical resolution because cases of lateral npper extremity rotatory iratabilitytnve actually in-

creased exponentially since 1960 due to the massive growth in the global economy and especially the North

American economy.

Ineffective and Complimentary (Cunent) Treatments

Before moving onto Prevention of LN, it is important to discuss teatnents for epicondylitis and

forearm complications that need to be eliminated and the rationale for this. The heatnents that need to be

eliminated are: res! proliferent injection, cortico-steroid injections, sfraps and prolonged use of nothing but

anti-inflammatories.

Rest needs to be eliminated as a fteatnent because all this does is allows the pronator teres andupper

portion of theflacor sublimis digitorum to weaken through a lack of improper contaction. This lack of

activity reduces the strain on the radial head's lateral pins which causes the lateral epicondylitis to reduce.

CoW # ou IoTRUDIKRASS 70

However, without refaining the mind to pronate and supinate the upper exfremity atthe shoulder, the

symptomolory is bound to re-occur when the upper exfemity is e4posed to activities that require repetitive

pronation of the forearm and/or anterior humeral rotation.

An occasionally used freafrnent for lateral epicondylitis is prolifereirt injection. However, this line of

treatnent can clearly be seen as inelevant because lateral epicondylitis can no longer be deemed a viral or

bacterial infection or even responsive swelling to either of these problems. As has already beer-r indicated, the

soft tissue ftaumas that occur in the wrist, hand and elbow are intrinsically linked and arise from the upper

extremity being used in fashions which causethe pronator teres tocontract at the wrong time, i.e. make it

function according to its present and improper medical designation causing a biomechanical breakdown in the

radiohumeral joint effectrngforce distribution at the radial head's lateral pins.

A nastv treatnent, if ever there was one, is cortico-steroid injections into the radial head's lateral pins.

Not only can this treafrnent be seen to be ineffective given the nature of lateral epicondylitis, but it has a

negative long term effect on the soft tissue stuctures--it weakens them at the cellular level. If the patient

received numerous rounds of cortisone injections prior to a surgical resolution to his lateral epicondylitis, this

will impact negatively on the probability of success because both the ligament and tendons will be prone to

stretch rather than sfrengthen during the latt€r stages of physiotherapy.

Bracing of the elbow, forearm straps and wrist splints or taping which aid in many sports to reduce

the amount of lateral epicondylitis will be unnecessary once preventative steps, i.e. changes to the use of the

upper exhemities, are forced upon and undertaken by commercial enterprises that presently demand vigorous

improper shengthening of the pronator teres and the upper portion of theflacor sublimis digitonnn muscles.

Proper reconstruetive lateral epicondylar surgerywillbe useless in cases where the patients decide to con-

tinue or retum to using their arms improperly due to their own frnancial benefits, highly paid professional

athletes, after the surgical freabnent has been rendered.

Forearm straps do provide some benefit by partially binding the forearm bones together which mimics

an healthy elbow where the radiohwneral jointis solid causing the upper extrernity to rotate at the shoulder

rather than the wrist through supination and pronation. The limiting factor to a sfap is the fact that it is

applied to the outside of the arm rather than at the actual skeletal level, so the musculature inhibits or limis the

effectiveness of the strap considerably.

Treating chronic and repetitive cases of lateral epicondylitis with nothing more than anti-

inflammatories is useless. All this t51pe of treatrnent does is reduce the swelling while doing nothing to combat

the underlying biomechanical dysfunction caused by repetitive improper strain placed on the radial head's

lateral pins. In artt;erliy, this teatnent is counterproductive because it may actually eliminate the swelling

with high enough doses bul once the use of anti-inflammatories is stopped, the radial collateral ligament and

the common extensor tendon will be stretched to the point where the lateral epicondylitis and any wrist com-

plications cannot be treated with physiotherapy but rather reconstntctive lateral epiconfular surgery.

CopJ # ool for RUDI KRASS 7I

Three treatments that are ofvalue as complimentar.v treatnents during physiotherapy are

electostimulatioq acupuncture and ultrasound. The first will be very effective when, during physiotherapy,

light weights me infoduced to the treabnent program. The benefits though will be best achieved when the

pads are placed over the lateral forearm muscle groups and the ENTIRE upper exfremity is either FULLY

pronated i.e. aposition beyond the horizontal line - 3 o'clock on the left and 9 o'clock on the righl or in the

supinated position, i.e. paln up. This upper exfemity position will focus the muscle contractions and

strengthening effects on the forearm muscles when there is no natual counter conffactive force applied to the

humerus.

Acupuncture has not only benefits for reduction of the lateral soft tissue swelling bu! for patients with

some minor neural complications especially at the lateral epicondyle, this freatnent would be better than anti-

inflammatories to reduce post operative swelling because acupuncture has some neurological benefits that

have yet to be understood. So, two birds can be killed with one stone.

' Ulhasound has been proven to be invaluable in reducing scm tissue build up around incisions. In

some cases, like mine, 3 incisions will be made and closed almost on top of each other so reducing the amount

of scm tissue buildup through recover will be a priority.

Copy # ool foTRUDIKRASS 72

Llrnnar Reraronv IxsrnBntw

The frst image that many will create at this point when prevention of lateral rotatory instabilily, LN,

is mentioned will be reconstructive lateral epicondylar surgery and mainly for the large portion of undiag-

nosed cases - women. I would like to dispel this notion right offthe bat because I do NOT want to be seen as

recommending this approach. Although it is certainly true that women make up the larger body of sufferers

from this condition strictly due to the reality that ligaments within women are set by genetics, to be laxer than

their male counterpmts-this has a lot to do with the female's body ability to bem children. (f female liga-

ments were as tight as males, then children would be brought into this world by cesarian section rather than

through the cervix as it would not be able to expand to facilitate the passing of a child through it.)

' It is exactly this child birthing and nursing ability which demands that the use of reconstnrctive

lateral epicondylar surgery as a pfg14g4tali\iilUga$Ag be eliminated for pre-menopausal women. It will

obviously be necessary for women who fall within this age group and who are suffering from severe wrist

tendinitis and carpal tunnel complications from ZRl to be treated wifh reconstnrctive lateral epicondylar

surgery. However, these women must also be informed that this ffeatnent has the likelihood of effecting their

ability to have a natural childbirttr and their ability to nurse the child following its birth. So, a{i you can see,

txe of reconstructive lateral epicondylar surgery as a preventative measure in pre-menopausal women NOT

demonsfiating ZRl complications must not be considered.

Now, certain segments of North American society will attenryttn take the preceding paragraphs out of

context and say that I am discriminating against women and presenting an outdated view of a woman's role.

Although my body defines me as male, this false interpretation of the preceding paragraphs was never my

intention. The real objective of this section is to demonsfate the pervasive improper upper exfremity use that

ALL human beings are exposed to through their work, play and everyday survival activities.

The reality concerning female health issues having arisen at a greater rate than men's over the past 3

decades is due to the medical community's failure to acknowledge or even suspect that joints play a greater

role in body functionality than bones do. This fact will be proven in my next book because, as it presently

stands, I am physically incapable of presenting all the theories and correlating data which confirm that men

suffered a great deal more from ZRlthan was previously thought and" by becoming a part of this malicious

work environment, women were exposed to these same deleterious effects however women's injuries surfaced

quicker because their joints me laxer-you have to wait for this boolq though.

As I mentioned, all aspects of human life, i.e. worlg play and basic survival activities, involve a

degree of improperuse of the upper extremity. This means ttntthepronator teres andupperportion ofthe

Jlexor sublimis digitorwn are exposed to different degrees of improper contractive force activities as well as

CopJ # au for RUDIKRASS 73

improper and unnecessary anterior medial humeral rotation. Examples of improper usage of the anffi are

easily found now that how the upper extremity ac'tualty works is known - like a'rmodified pulley" at-

tached at the radiohumeral joint rather tlnn a "hinge" joint specific to the ulno-humeral

Possibly the earliest example of human training that contradicts the fundamental and natural function-

ality of the elbow and upper extremity is teaching our children to write or pgnt. These actions are performed

with a slightly pronated forearm which can only be achieved witli slight improper contaction of the pronntor

teres andupper portion of theflexor sublinis digitonnn. To achieve beuer writing and printing skills, contol

of these improper muscle contractions is increased ttrough continuous and repetitive practice. Due to the

female body having larer joints, better writing and printing skills are achieved faster and in a greater percent-

age of female students-its little wonder that male children find learning basic writing and printing difficult

and the large majority end up with diffrcult to read sctibbles on paper. These mild improper contractions used

to write or print are exposed through hand cramping up during long periods of writing-improper bone

alignrnent in the wrist caused by mild radial bone advancement witttin the forearm subsystem. (Solution:

redesign pens and pencils so that the hand does not pronate beyond 10-15 degrees from its neuhal position.)

Improper pronation is taken to its limit, thougtL in qping on current keyboard designs. By pronating

at least 60 degrees beyond the hand and forearm's neutral position - the 12 o'clock position for both hands,

the improper contractive force of the pronator teres and upper portion of theflexor sublimis digitorwn is

increased significantly. These improper contractions are complimented by contractions within the ir{raspina-

tus and teres minor muscle groups that attach at the back of the humenrs at the shoulder. These secondary

contractions arise after the radial head's lateral pins have been stretched significantly in meir but are already

resident in women due to thetr coraco-hnneral ligamentbernglonger than men's. As a result of this facf

typing will produce wrist tendinitis and mild carpal tunnel more quickly in women but merely soreness over

the lateral epicondyle, at the anterior of the shoulder and in the hands of men. Following permanent damage

to the radial head's lateral pins in men, the symptoms will then be the same as those found in womeq i.e.

carpal tunnel and wrist tendinitis, but with the additional elbow symptom of lateral epicondylitis.

Work activities that actually cause tearing of the lateral pins, are mainly dominated by men and

include professions like mechanics, labowers that do excessive shoveling or manual jack harnmering heavy

equipment operator, sawmill lineman, caq)enters, etc. All these positions require use ofthe upper extremities

wherethe forearms and hands are pronated with extreme force especiallywhenthe distance fromthe elbow is

lengthened with a shovel, piclq ratche! screwdriver or hammer. Most of these types oflRlcases will mise

with either a sudden sharp pain, a sudden bout of severe lateral epicondylitis or a severe case of wrist tetdini-

tis and carpal tunnel ifthe bout of epicondylitis does not cause immediate cessation of all arm activity. (From

this paper, lateral epicondylitis must now be seen as a very serious medical injury requiring immediate treat-

ment rather than an inconvenience that should be worked through which is still the medical line in some

jurisdictions worldwide. The latter represents the attitude that I held in 1989 which was common for that time

Copy # ool for RUDI KRASS 74

and still is in the misinformed.)

Zftldoes not arise solely from work activities, thougtq as improper muscular conhaction and humeral

rotation is not limited to just these activities but also includes humanity's leisure activities - sports and arts

come to mind right away. Most of the sports activities rwolve around throwing a ball with a bent arm, like

handball, baseball (male hardball) and football. The most detrimental of these activities for the soft tissues of

the lateral epicondyle is baseball, especially pitching, because the objective is to throw the ball the hardest and

with the greatest accuracy. To do this, a pitcher practices daily while starting out and as the improper contac-

tions become more controllable, the individual starts tluowing hmder which leads to an even greater improper

muscular contractions at the anterior of the elbow. Although teming of the radial head's lateral pins, espe-

cially the common extensor tendano was recently discovered to be a common medical problem among pitchers,

thanks to better diagrrostic imagery of the elbow, professional baseball made changes quickly and started to

count pitches thrown rather than innings pitched in order to reduce the amount of torn cornrnon extensor

tendotts amongst its pitchers. The phenomena remained misunderstood though.

From the reality of how the upper extremity and elbow really worlg it is easy to elplain the injuries,

now. Prior to a game, a pitcher has ONLY so many pitches within his arm and this amount actually varies

depending on the amount of rest and taining that the pitcher undertook since the last game that he pitched.

So, every time a pitch is thrown, the pitcher reduces his number of remaining pirches until the effects of

improper pronstor teres andJlexor sublimis digitorum confaction is no longer counterbalanced by the

strength of his posterolateral muscles. Once this point is reached, the common actensor tendore and sometimes

the radial collateral ligamentwill suddenly snap allowing the radial bone to sublux or even dislocate

posterolaterally. Unfortunately, the damage is done which requires reconstnrctive lateral epicondylar sur-

gery.

A similar situation exists with racquet sports that include balls like tennis, squash and racquet ball. In

these sports, unwittingly, a participant uses an extension which automatically increases the torque force at the

top of the elbow subsystem. But, with improper contractions of the muscles located at the anterior of the

elbow, the participant leams that he can generate "ball spin" causing the ball to bounce differently than

anticipated by his opponent and usually resulting in a point. With practice, the pmticipants forearm contrac-

tions become stronger and sfionger until lateral epicondylitis occurs. Fortunately, the contractive force is

usually less significant than that of a pitcher which means that, in many cases, treafrnent includes re-training

for tennis players so that the raquet and hand rotation used to retum a ball is generated at the shoulder which,

until now, is exactly how the upper extremity naturally works. In other cases, if the epicondylitis is sudden

and severe, the patient actually needs surgery prior to leaming to use the upper extremity properly again.

Sports me not the only activity which causes LRl among our recreational activities. It is easily

deduced how long periods of crocheting, knitting and similar handicrafts or repetitive periods of these activi-

ties over long time frames cause the complications of LN a arise in people who partake of these activities-

CoW # ou for RUDIKRASS 75

these activities may relax the mind, but at a severe cost to the soft tissue structures in the upper exffernity. LRI

in these cases is due to improper and incessant confractions of the pronator teres andthe upper portion of the

flexor sublimis digitonnn with mild force. Treannent, then, for these cases, if they are caught early enough is

simply physiotherapy, retraining of the arm to its proper functionality, and buying a machine to produce the

endproduct, i.e. stop the activities or redesign the needles so that the hands are not pronated beyond the

neuftal position.

Other recreational and possible cmeer activities are leaming to play and playing certain instruments

for long time frames. The easiest example to discern has to be playrng apiano as this activity uses the hands

in a 60 degree pronation position just like typing at a keyboard. A not so easily discernable example is playing

a guitar and this is mainly for professional artists. The easy pmt to understand is the picking hand which does

a lot of mild pronation for all songs. The not so easily understood part is how the hand at the neck of the

guitm suffers from "tRl complications like wrist tendinitis. This realrty is easily disclosed by watching when a

bare armed player first puts on a shoulder strapped guitar if they me standing. At this point, the cord hand is

brought to the neck of the guitar with an anterior rotation of the humerus - the medial epicondyle rotates

forward. This improper humeral rotation is the activity which causes ZRlcomplications in the cord hand.

To demonstate exact$ how pervasive improper uppper exnemity rotation is, one need only look at

the earliest form of human training which contradicts the upper extremity's natural functionality - table

manners. As a child I was always taught to keep my elbow tucked in by my sides while eating. I'm sorry but

this position breaches the neutral or resting position for the humerus relative to the body which is actually at

30 degree laterally from the body like a tepee, roo{ etc. Now, the child is taught to use his knife and fork with

a pronated hand and so the process of taining an individual to use his arm in a manner that is contrary to its

natural rotational processes has begun.

All that these examples do is demonsfrate how pervasive improper arm rotation actually is. As has

been showr\ improper pronation techniques are taught to us as children and then the problem becomes pro-

gressively worse as geater and greater demands are placed on us to increase the amount of productivity from

our anns that are being improperly used. Eventually, the human body fails whether it be with the ZRl compli-

cations exposed in this book or with other more insidious complications which I just am too physically incapa-

ble ofpresenting at this time. (If I were to present just the complication without its scientific proof and

experiments, the medical community would have gounds to dismiss this book because too many statsments

would be uncorroborated. This is not what society and its individuals need at this point: we need concrete

and undisputable theories which will demand changes in the medical community without hesitation! By the

end of the booh this objective will be fulfilled concerning proper upper extremity and elbow functionality and

the symptoms of their intrinsic opposite, rotatory instability or a dysfunctional upper extremity.)

So, when whoever looks at all upper afin activities and not just the aforementioned ones, they will

have the job of determining whether or not the activity can be modified to the human body's natural upper

CoW # ou for RUDIKRASS 76

extremity functionality, not vice versa as presently exists with keyboards. If the activity cannot be altered to

eliminate improper contraction of the pronator teres andupper portion of theflexor sublimis digitonnn and

anterior humeral rotation prior to forearm pronation, then it must be abolished and, if possible, replaced with

an activity that actually results in the same objective but with sit having been accomplished in a totally ditrer-

ent manner ttrat won't cause ZR.L

To explain this process of activity evolution, some examples have to be presented and explained. I

have chosen table manners, engineered rac,e car cockpits and typing at keyboards. As indicated earlier, the

main problem with table manners is the pulling of the elbow inwards to the side of the body. By allowing the

arms to reside at their natural state, at an angle of approximately 30 degrees outward, the amount ofhand

pronation is reduced to the point where the muscle contractions within the prorator /eres and the upper

portion of theflexor sublimis digitorum become negligible. These contractions can be firttrer reduced by

modifications to either the shape of utensils or the nranner in which the utensils are held: the result of these

changbs will be to ensure that the hand position does not go beyond 30 degrees from its vertical position.

A couple ofyears ago, it was publicly disclosed that many of the engineered race car drivers experi-

enced carpal tunnel complications atthe end of a race which subsided over time once the driver was removed

from the restrictions of the car's cockpit. I added the latter clause as I have reviewed the size of the cockpit

and the restrictions placed upon an engineered race cm drivers' arms. In this instance, the cocllpit forces the

driver to rotate his humeral bone anteriorly - improperly timed coraco brachialis contraction, whiclr, as is

already known, is an improper motiorq prior to the pronation of his forearms and hands as he goes to grip the

steering wheel. Due to the first action, the second can only be accomplished with a significant conftaction of

the pronator teres andupper portion of theJlexor sublimis digitonnn an4 as this position is maintained

throughout a race of more than2 hours, the forearm, wrist and hand lose bone alignment SLOWLY: attempt

to relocate these posterolaterally subluxed radiohumeral joints andthe driver will indicate an immediate relief

following the adjustnent.

To resolve the LNthatarises from working in an engineered race car cockpit, resize the portion of

the cockpit that forces the arms inward to the point where it allows the upper portion of the driver's arm to

reside at its natural neutral position - toed outward beyond the shoulder. Then, redesign the steering wheel so

that the driver's hands remain in their natural neutral position - the vertical line. (Actually the whole steering

apparatus has to change so that comering is obtained not from rotating a steering wheel but from either

contuaction of the biceps or triceps.)

The final example is typing. In this day and age, typing means at a keyboard not the old standard of a

typewdter but the same principles apply to this design. As I indicated earlier, carpal tunnel and wrist tendinitis

arise mainly from the improper contractive force of the pronator teres and upper porti on of the flexor sublimis

digitonnn and complimentary improper secondary contractions within the infraspinatus and teres minor

muscles. So, naturally, these confractions need to be eliminated which is accomplished by retuming the upper

CoW # ou for RUDIKRASS 77

arm's position to its neutral position as well as the hand to its neutral (vertical) position throughout the typing

process. In order to accomplish this though, new keyboardos need to be designed that adhere to the rule that

the machine has to be adjustable to the operator and not the current rule which is causing all the prob-

lems---the operator has to adjust to the position of the computer's components, i.e. height and position of the

monitor relative to the seated position of the typis! the absolutely improper FDGD desrgn of the present

generation ofkeyboards and the poorly adjustable chair.

Due to the unique nature of all human bodies, all keyboard's should be specific to the user which

means that they should be independent of the computer and the possession of the user as it needs to be fitted to

the individual. If this recommendation is not adhered to, then I fem for the childre,lr who are being more

significantly exposed, during their bodies' formative school years, to the most detrimental of all forces, far

worse that writing typing. Be very aware of this fact as the consequences of today will be felt 20 years into

the future when almost everyone in North America adults who were the children of today, will be suffering

from dny or all of the aforementioned ZRl complications.

From my own life experience, I discovered that for exercise, the more structwed forms of martial

arts, like T'ai Chi, Qi Gong Karate, Judo, etc., stress perfect functionality ofjoints in all their motions. It

wasn't until now, when I learned how the joints of the extremities worlg that I was able to see this. The only

explanation for the structured martial arts being so advanced has to have arisen from the masters always

stressing that, during the learning process, the student or even the master tying to perfect his art respect pain

and not just work through it like in western sports. To the master, this ideal meant tha! if a motion caused

chronic pain or bouts of pain in himself or the students, then the motion was being done wrong and the proc-

ess had to be altered so that it could be performed without causing pain. Pain from haining to a martial artist

should not occur----only mild muscle pain should occur initially because the body is adapting to this perfect use

of the body whereas, until 7 years ago, the mantra for Westem athletics was "No pain, No gain!"

This understanding of the martial arts explains the old adage often used by the masters who state that

being a true martial artist is a 'Way of Life.' This means seeking perfection in practice so that, only when it is

a true matter of life and deatlU the maximum amount of force and activity can be applied with total conviction

by the student that it is all that he has. The reason ttrat martial arts are so advanced though is the longevity of

this approach to body motion - several millennium makes for a high degree of reftnement! Now, the Westem

or scientific approach to motion can finally catch up to the Eastem world because now the functionality of the

exhemity joints are fully understood: '?nodified pulley" systems with the medial and lateral arc pirx provid-

ing the rigidity to our exfremities equal to, if not greater, than that of our skeletal stuctures so that our anns

and legs work as whole units from their nails all the way up to the tomo.

Copy # ool for RUDI KRASS 78

With this booh the tue functionality of the upper exfremity has been clearly establishe4 Section I,

while the main causes of lateral upper extremity rotatory instability,presented tn Section II, were demon-

shted to be intrinsically linked to this new reality ofupper extremity rotation unequivocally confirming the

new upper offemity functionality. In essence, these two sections demonstrate aperfectly enclosed functional

and dysfunctional system for the upper extremrty with no exffaneous facets as presently exist in the illusionary

medical theories concerning upper exffemity rotation and the copious amounts of unexplained medical prob-

lems in the upper exhemity. This reality begs the question: Why wasn't this functionality discovered sooner?

The only response to this question is that the medical community assumed, without question, that their

numerous theories pertaining to the upper exfemity actually reflected the milner in which it functioned. In

reality, though" the medical community built what is tantamount to a 'house of cardso' upon a poorly conceived

analysis of the extremities' and their joints' functionalities. The main problem, which I eluded to at the outset

of Section I, was that the medical community started its theoretical assessmer$ of muscle and joint functional-

ity from the outside inwards. To put it another way, the medical community started its assessment from

looking at the joints at the skin level which is when the elbow appears to function like a'hinge,o' a c,ommon

term and understood function used considerably 200 hundred yeffs ago. From this initial and dubious assess-

ment of the elbow, the surgeons dissected dead bodies to elpose the musculature whose functionality was

interpreted prior to dissection downward beyond this level to the joint level. This process gave rise to the false

labels that many of the muscles bear today. At this poing tlte joints were dissected an{ to my resent shock

when reading up on the term "hinge" joint in Gray's anatomy,t the soft tissues, whose true functionality I

theorized prior to reading this section of this book, were discovered but not properly interpreted as a'tnodified

pulley system:" hence, the present and inaccurate medical label of 'hinge joinf' forthe knuckles ofthe toes

and fingers, the knees and elbows. Unfortunately for the billions ofpatients worldwide and historically to date

over the last 200 years, the medical analysis from the outside in conducted 200 years ago and upheld today by

the medical community is illogical and without merit.

As this book proves and the burgeoning cases of misunderstood medical conditions particularly

within the upper exhemity over the 1990s to date, the analysis of the exhemities' fimctionality should have

started at the joint level and then have the muscles labeled according to their contractions once they were

determined relative to bone motion at the joints. This analysis was not possible up until about 100 years when

radiologr and radiography arose from the discovery of x-rays and the process of making radiographic images

on plate films. As a result, the'tnodified pulley system," employed in the knees, elbows, toes and fingers, was

mistakenly labeled as being a ohinge" when there was no evidence to confirm this assessment other than

society was unaware of any other way of understanding the firnctionality of the structures discovered from the

dissection ofthe human body.

Copy # ou IoTRUDIKRASS 79

Disheartingly, the medical community, since the advent ofradiography, never saw the need to con-

firm their theories pertaining to the extremities and their joints mainly because there was a seemingly good

consistency between top down analysis ofthe extremities and the underlying musculature. The false faith, that

the medical community had in its muscle contraction and joint functionality theories, did present suffrcient

inconsistencies though that a vigilant specialist should have perceived. From this realization, a more accurate

analysis of the medical theories pertaining to joint functionality would have been done discovering that the

tlrcories and the logic behind them were wrong. Unfortunately, not one specialist to date has noticed the lack

of correlation of motion of the bones and the present medical theories even thouglq over the last 13 or more

years, ailments within the upper extemity have risen exponentially as work and society have demanded

greater and greater improper use of the upper exhemity.

The rise in soft tissue upper sxtremity problems were never conclusively demonstrated by the medical

community to be the result of massive increased arm usage among the general work force so the medical

comrn"unity remained oblivious to the reality that, at the base level, their INVALID theories pertaining to the

exfemities are actually causing their patients to injure themselves without a valid means of resolution. The

reliance of society's constifuents, i.e. its citizens, on improper medical theories has led to the worst breakdown

in health since the Black Death plague of the Middle Ages if not even worse. As the number of worldwide

sufferers of repetitive ovenrse syndrome or repetitive stress injuries have arisen since the mid-1980s, the

medical community's response has been inconsistent with the principles of science and their own Hippocratic

Oath.

It is understandable that the medical community did not fathom what was going on beyond their

offrces until now since it mainly arose from a lack of vigilance. The keeping of a database of all cases of

repetitive stress injuries that arose from the early to mid-1980s, which the medical community did not do,

would have facilitated the correlation of the rise in upper extremrty rqjuries to the differing and shifting work

standards from previous work history over this time frame.

Over the years, many people have pointed out that typing was done by secretaries yet they did not

suffer from repetitive overuse syndrome or repetitive stress injuries. The reality as to why few secretaries

suffered from repetitive stress injtnies is due to several factorso but mainly the reality that a secretary had a

varied work load, like taking dictatioq making coffee, filing some typing, etc. Basically, these women did

not sit at a typewriter all day and every day like a data entry clerk or an operator in a call center which do. So,

the compmison between a secretary and present day office and clerical positions which have a high risk of

causing repetitive stress injuries just isn't feasible-it is like comparing apples to oranges.

In the 1950s to late 1970s, there was a position which did record the problems encountered by many

suffers of repetitive strain: this was a typist in a typing pool that remained there for many years. The individu-

al's who filled these positions were women as employment during this time was gender specific. However, not

many companies to 1970 had a typing pool so the condition was most definitely viewed as rare or uncornmon.

CoW # oot fioTRUDIKMSS 80

The factors that made the carpal tunnel syndrome and wrist tendinitis even more uncommon was the fact that,

ofterq the women did not remain in this position for long either due to advancement or marriage, at which

point, the women became stay at home motherso homemakers and wives.

Today though, women often do not advance in a company as easily because computers have reduced

significantly the amount of clerical and secretarial positions within most companies, do more with less, and

fewer and fewer working women are becoming housewives: present-day married women remain working in

orderto make ends meet as their spouse no longerbrings home sufficient income to support anon-working

wife let alone a child or trvo. So, any break from duties causing repetitive stress injuries that arose from

marriage in the past has dissipated over the last 25-30 years. The pressure for women to remain working in

our present work place environment takes its toll rapidly on women - with the results being those in the

Gender Based Lateral Rotatory Instability section.

Just as computers have led to significantly increased wor{doads and limikd the ability for advance-

ment out of data enty and typing positions for women, the increased consumer demand in all products has

lead to numerous positions which, prior to 10 years ago, did not exist. Often, the shifting of industries to mass

production of an atypically limited production indus@ has created numerous positions which breach upper

extremity functionality , see Sectionll/ as well. This shifting to mass production, especially in the United

States but also worldwide, has led to the weakest people being put into jobs which cause repetitive stress

injuries after just a few months in the pro-dominantly female work force-the best example of this is the

female line workers in the chicken factories ofDelawme and Maryland. In reality thougfi it is not female

physiolory which cause the debilitating arm problems in these employment positions but the constant pronated

forearm work which not even a man could do for long without tearing his elbow's latoal pins.

The medical community did not realize all this because all they knew was that there were injuries, on

mass, which could not be explained and therefore could not be properly teated. Instead of accurately deter-

mining the microcosmic cause-and-effect relationship, repetitive pronation of the han4 wrist, forearng elbow

and shoulder, and then reverse engineering the problems to determine the actual process, the medical conrmu-

nity responded by either: going straight to a phgmraceptica! response to eliminate the trauma within the arm's

soft tissue structures; declaring the patient's soft tissue arm problem to be permanent, still undiagnosed

though, and requiring'!ain managemenf' so that the patient could attempt to live and work with the debilitat-

ing lnjury; or treat the complications with unnecessary surgeries which had proven beneficial in some cases

but not permanently so. The first treatnent response was already negated as a viable teatnent due to the soft

tissue problems being caused by a biomechanical dysfunction of the lateral radiohumeral pins nthe Ineffie-

tive and Complimentary (Cwrent) Treatments section of theTreatment chaptsr of this book.

By ttre medical community deciding to create a new branch of medicine, psychonewoimmunologt,to

deal with the 'pain" aspects rather than scientifically source the problems out demonsffates the lengths to

which the medical community is willing to go in order to deiry that medicine's original founders were wrong

CoW # ou for RUDIKRASS 8I

in their analytical determination ofjoint, exfemity and muscle functionality. The institutionalization of '!ain

managemento' is vicious because the major thesis of this new branch of medicine is that ALL pain is psycho-

logical in nature rather than physiological. Essentially, this makes the problems of the suffers of repetitive

stress injuries psyclnlogical ones ralher than legitimate physiological ones.

This medical theory statement was freated as fact which resulted in all Workers Compensation Boards

and medical insurance companies ofNorth America as well as federal, provincial and state governments being

absolved of the legal responsibility conceming the continued cost of treaftnent for those suffering from repeti-

tive ovenrse and repetitive stress injuries. With this boolq though, the aforementioned entities will no longer

be able to hide behind improper medical opinions or even use them to asses the patient's until they have been

educated in the new and proper functionality of the extremities.

As I stated earlier in this chapter, the vast majority of medical information has been built upon the

present inaccurate medical understanding of the firnctionality of the upper extremities and the extremities, in

generirl. This fact means that the vast majority of medical knowledge has to be seen as invalid because its

under pinnings are no longer valid. Given this reality and the fact that this information was used to date means

that all medical cases of problems within the soft tissue and nerves of the upper extremity have to be reviewed

once the medical personnel have become educated in the new ftnctionality of the upper extremity, its muscles

and its joints. This massive review has to include cases where that suffererwas deemed permanently disabled

with soft tissue upper extremity problems and advised to change jobs. (IIow could this person change jobs

when all jobs require further improper pronation of the upper exremity? Obviously, this approach was

misguided.)

The other medical files that need to be reviewed me those in which the patient received what can only

be described as unnecessary and ill-advised medical treafinent for some of the complications of elbow based

lateral rotatory instability. Most certainly cases treated with carpal tunnel surgery, whether outlet surgery or

the new e4perimental surgery, radial nerve ftansference atthe elbow, biceps attachmenttransference surgery,

lateral epicondylar (release) surgeries, etc., have to be included in this review because improperly treating the

elbow causes numerous long term complications that were too complex to include in this book even though I

am acutely awme of them: don't forget that I'm one of the multitude being told that my elbow problems are

not a result of my activities because they don't as yet constitute a valid and documented cause within the

medical community of westem Canada, especially the orthopaedic surgical community. I also am the ONLY

penion who knows how the upper extremity and its joints properly work which also has given me a substantial

head start which will never be caught up by the medical community.

This book essentially conJirms that lateral epicondylitis is a very serious injury contadicting the

longstanding misconception in society and among policy makers. This realrty allows for lateral rotatory

instability of the upper extremity to declared a medical problem of epidemic prooortions at present. This

assessment will permit the full force of the medical community to be directed to the eradication of the problem

CoW # ool for RUDIKRASS 82

not just in the patients but in all environments, i.e. workplaceo leisureo self-employed professions like farming,

table manners, etc. The latter has to be done by retraining the entire medical profession, including

kinesiologists, physiotherapist, chiropractors, nurses, Occupational Safety and Health Agency inspectors,

policy makers, etc., to understand the new functionality and its correlate lateral upper extremity rotatory

fustability so that ALL environments and activities can be evaluated and corrected. This correction may take

the form of an elimination of the activity, a redesign of the machine used to perform the task or a minor

alteration of the activity.

I want to state that, even though the proposition of re-evaluation of all activities of our upper exfem-

rty usage to eliminate improper pronation may seem enoflnous and devastating to the present industrial

economies, it will be transitory. Aftff 25 to 30 years, the backlog should be eliminated with a minimal amount

of new cases occurring. So, the tens of trillions of currency spent to rectiS the upper exfemity problems,

which have been building for at least 40 years, will shrink to probably less than millions worldwide.

' The rwiew will have more benefits than permitting all citizens in the industrialized nations to live a

healthy life beyond 150 to 200 years-*imagine your children living to see2200 A.D. and possibly beyond, it

will cease the massive profit making worldwide offthe ill health of the workers as well as facilitating the now

older generations, i.e. beyond 45, getting the chance to see 125-150 years of age. (Once my next book is

published and all the symptoms of elbow based lateral rotatory instability are e4posd everyone will be able

to glimpse the vision of the future society that dominates my thoughts right now and keeps me going on even

though the complications are sever€ in me from the writing of this book.) Examples ofprofits being made off

the ill health of its workers are sawmill line, chicken factory and the new large scale beef and pork slaughter

house workers. In all cases, it was cheap enough to merely replace the workers because Workers Compensa-

tion Board benefits and costs were minimal once an individual was injured as the injured worker often had

total temporary benefie cut offafter 4-6 months even though the problem was never resolved. Actually, this

approach strould never have been tolerated by both the Worker Compensation Boards, their medical depan-

ments and rwiewing bodies including the govemment as these industries should have been forced a long time

ago to mechanize the line and the offending job duties that were causing the problems when a cause-and-

effect relationship was easily established-4re medical community failed the claimants, their families and

future employees. The policy of not penalizing the offending industy unduly wen though the amount of

injured works annually was unacceptable and staggering when you factor out the supervisory staffdriving up

the ratio of employees to injuries.

In Alberta n lgg2,the Workers Compensation Board was looking at an underfunded liabitity of

over (CDN) $722 million. Yet, within 18 months and following a change in its presidency, thrs underfinrded

liabilitylnd disappeared and the Workers Compensation Board was working with a surplus. This massive

turnaround was all due to a simple policy change which was to cut offall injured workers after 6 months from

total temporary benefits and force ttrem to work with whatever remaining unresolved medical conditions, they

Copy # ou for RUDIKMSS 83

had. This approach was established by the new President of the Alberta Workers Compensation Board and

was endorsed by the medical deparhnent of the Workers Compensation Board the policy i.e. the

Government of Alberta, and the Appeals Commission even though it is not ev€n a remotely valid medical and

societal approach to the problem of soft tissue tauma in the upper extremity and shoulder. Consequently, the

$722 million unresolved deficit will balloon to over (CDN) $10 billion in Alberta alone. Subsquent under

funded liabilities, i.e. skeletons, for Workers Compensation Boards and insurance companies that have been

hidden across North America since the late 1980s and emly 1990s, have to come out of the closets and finally

be dealt with now! The populous has to bc assured that there will be no more sacrificing of our bodies, long

term health and lives just so that we can earn a living make a life and keep the economy going.

Returning back to the medical domain, Section I of this book introduced the concep of most joints in

the exhemities functioning like'tnodified pulleys" whose lateral and medial pins contol the arc of the bones

beyond the upper bone of the specific joint. This section of the book also merely alluded to the reality that

these same ligaments also create the functioning unit of either the lower extremity, the legs, or the upper

extremity, the arms. This reality makes these particular ligaments invaluable in understanding the units

created as well as cartilage damage. When the joints are lax, i.e. permit motion along a plane perpendicular to

the arc ligaments in question, the principle of the Krass pronation test, the jonts ultimately will suffer from

asteoarthritis as has been demonstrated. Beyond this, these la:rjoints will suffer from significantly more torn

cartilage problems and ruptured ligaments from a hauma force rather that strains or sprainso which normally

occur in men. (Now, the medical community knows where to look to explain tom cartilage anilor a ruptured

ligaments.)

The difference in female ligaments which cause more stretching from mild repetitive strain then their

male counterparts is their estrogen levels. Estrogen acts like cortisone in its affects on the soft tissue struc-

tures, i.e. at a cellular level, which would subsequently facilitate child birthing. Testosterone does not permit

this sffiching explaining the more significant arnount of tom cornrnon extensor tendons rnelbow based

lateral rotatory fuwtability among men. Even though the musculm confractions me greater in males from the

testosterone, the ligaments normally do not stretch but rather they, the tendons and/or muscles tear. Essen-

tially, the estrogen /evels ofwomen and the naffial ladty that exists in some of theirjoints establish the fact

that male and female bodies are fundamentally distinct and not the same as has been accepted by and en-

hsnched in North American society over the last several decades.

There is a new equation in the medical mix as a result of this book Not only are male and female

extremities fundamentally different even though they share relatively the same bones, but this new medical

equation or reality has to factor in the fact that la,r joints can also exist in men as a small percentage of this

population which creates a similarity in some of their long term medical problems to those of women - most

notably of these conditions is osteoporosis. (The scientific proof is hidden in this book but will be presented

in my next book which will expound on the complication s of lateral upper extremity rotatory instability.)

CoW # ou for RUDIKRASS 84

This book will also car$e a significant change in society through the value structure of ig citizens

which has to be leamed with the change's rationale in childhood. People have been given a very serious

choice to make: use our bodies in less violent and abusive ways to preserve our health and increase our

longevity to 200 yearso at leasl without significant problerns in the later years OR continue to abuse our bodies

in ouryouthful leisure pursuits and work activities and continue to die prematurely. This means not just

changing sports but also developing non-abusive joint sports of which T'ai Chi and Qi Gong are a few. (I

believe that Jesus Christ foretold of this decision as Christian doctine claims that the meek slnll inherit the

earth - Matthew 5:5 of the New Testament.)

In making your decision, you can't depend on the medical community not just because their medical

knowledge base has been proven incorrect but also because ofthe thought processes eschewed by the present

system: it is very shallow and rather unscientific in its response to problems. (This process is changing

because viable and proper scientific research has started to lead the way in advances concerning many differ-

ent specialities like cancer, viral infections, bacterial infections, immuno-response, etc. All these advances

though are based mainly on a change in thinking from just obseruing a cause-and-effect relationship but

further to define the process, a stage in medical logic that has been missing for the longest time.) A

major example of the presentfa the problem quickly witlnut understanding the root cau.se approach to

injuries on a physical level was the broken ankle syndrome while skiing of the late 1970s.

Prior to present full ankle ski boots, downhill ski boots went up only as far as the top of the ankle and

were not solid like they are now. The new design of ski boots to resolve all the broken ankles of the late

1970s was not questioned by the orttropaedic surgical community in the early 1980s and still has not been

condemned to date. Instead, the sugical response was to devise better surgical techniques to treat the now

pro-dominantly tom anterior crucial ligament The medical response should have been a move to ban the

new design of ski boots because, wen though surgical techniques for the anterior cnrcial ligamenthave

advanced significanfly, one tear ofthis lieament is one too many as the surgical reconstruction doesnot come

close to making the joint function anywhere near an undamaged knee.

The long term complications from ski injuries to the knees, whose numbers will start to surge as the

skiers of the 1980s and 1990s tum 40 and 50 years old" me obviously osteoarthritis, possibly tom cartilage

problems and stiftress in ttre joint. The medical community did not rcalizp that a broken ankle is a rather mild

problem that the human body can deal with even in the long term due to the structure of the joint and its

functionality whereas ligament damage to the knees are truly not repairable. So, the appropriate medical

response for the new ski boot design was never been put forward allowing hundreds ofthousands of people to

suffer a tom anterior erucial ligament and be left with a future filled with pain in their 60s and 70s, if they are

lucky enough to live that long

Another improper medical response to a legitimate medical problem that I was exposed to, by way of

the klevision, is some psychoneuroimmunolgists' response to chronic elbow or upper exFemity pain in their

CopJ # oot for RUDI KRASS 85

patients. In the Canadian science program's 1999-2000 seasor\ the '!ain" doctor performed brain surgery and

implanted a device into the brain of a woman who, 20 years prior, had been hit by a car and had suffered

lateral epicondylitis ever since then. According to the information onposterolateral rotatory instability,this

wonmn was a classic case and, had the lateral pivot-shifi testbe.enprforme4 I'm certain that it would have

demonshated that the treatnent that this individual needed was reconstrtrctive lateral epicondylar wrgery not

having her head cut open in a vain attenrpt to eliminate the chronic pain she had. (If the lirass pronation test

were done now, the new reconstructive lateral epicondylar surgical treatnent contained in this book and

corrected by the Mayo and the Kerlan-Jobe Clinics could be applied meaning that the brain implants must be

rernoved and the brain surgery stopped.) I am confident that this woman's czne was not reviewed to see if it

fell within the guidelines of posterolateral rotatory instabilitythat were established in 1991, though, because

the medical community does not do this when new diagnoses me made especially when the person is being

helped by a different speciality, mainly pain managernent specialists.

' The ver.v political and unscientific approach to medicine that presently exists especially amongst the

specialists leads me to conclude, withotrt hesitation, that if this book were not produced today it could be

written 20 or 30 years down the road and still be as poignant and ground breaking in the future as it is

today. This is a very sad statement especially since it can be substantiated. At present, the orthopaedic,

radiological, kinesiolory and general medical community's theories about the physical body do not comply

with the very basic theories of physics: all present day knowledge of physics has never even been applied to

exfiemity functionality at the bone level including Sir Isaac Newton's basic theories of motion. This explains

why the joints were mislabeled as 'tringe" joints when they actually function like '?nodified pulleys." (The

ligamentous structures exposed centuries ago from dissection bare an incredible resernblance to pulleys rather

than a hinge - solid at either the anterior or posterior side while the other end opens with a gap and then closes

by eliminating this gap.)

Further corroboration of the statement that the findings in this book would never be discovered are all

the body's sigtts,langwge, wetre missed and/or misinterpreted: 'tnicro tears" can only exist in something that

is being exposed to improper force or force to which a solid and stationary object, i.e. radial collateral liga-

ment,isnot normally exposed; there is NO gap between the radial head and the humeral capitellum when the

arm is flexed as is demanded in a hinge. Then, when x-ray films continuously demonstated that the ulna

resided behind the Bicipital Tuberosity of the radius, had the principles of physics been employed, it would

have been realundthat it is impossible for the radius to rotate around the humeral capitellum through prona-

tion with the ulna residing directly in the way of the Bicipital Tuberosity's line of motion. These facts never

were understood or presented by any orthopaedic surgeon, radiologist, kinesiologist, chiropractor, or physician

in any speciality or in general practice and especially the founden of posterolateral rotatory instability n1991, the closest that the medical community ever came to understanding the proper functionality of the

extremities and their'lnodified pulley" joints.

CopJ # ou for RUDIKRASS 86

When I started this book in the spring of last year, it was to corroborate that the injuries recorded in

my 1998 Gadolinium enhanced MRI arose from my June 1990 injury so that I could finally get the surgical

resolution to my right elbow's confirmed problems. Basically, this book was meant to be a refutation of the

Albertan orttropaedic advice of January and April, 2000. However, as this book progressed, I was infioduced

to the fi,rll and accurate functionality ofthe upper exremity as well as it impact on society. This knowledge

dealt with the present for the longest time but recent$ it has expanded into the future something that the

medical community does not factor into its decision making processes. I am now firlly awme of the full

enormity of not just this book but my next one - the portion of the iceberg below the water line - on medicine,

society, in general, and its structures.

I hope that I have given enough information in the filst ffito Sections of this book to bring the frnc-

tionality of the upper extremity and its 'tnodified pulley'' joints concisely into focus. If you did as I requested

nthe Conclusion of Sectionland moved on quickly to this section of the boolg go on and read the next

sectioh as it is a short one. Therl re-read Section I aganas this should make the functionality much clearer as

its rationale has been fully introduced to your conscious mind.

Once you've done this and the new proper functionality of the upper extremity and its joints are

understood I hope that you will re-read this chapter so that you will realize that the changes that I've de-

sctibed will encompass the entire globe and all its citizens. When acknowledging this change, also realize

that this is a golden opportunity for all because new sports will have to be developed, new ways of doing

things will also be needed as will new devises to eliminate any improper pronation. With the right mind se!

anyone and everyone will benefit regmdless of where you live or your education level!

Note: This book does not mention medial upper extremity rotatory instabilitybecause it is such a small problem

relative to lateral upper qctremity rotatory instability and it is easily understood once the pfqper functionalityof the elbow is accepted. Wherr you golf, play broomball or polo, you strike an object with your arms fullyoutstretched and the force to the medial side of the arm. When this motion is not blocked, there is no problem.

When the full force of this motion is blocked at or beyond the bottom of the swing, by say an opponent inbroomball or the earth in polo or golf, then the force goes directly to the elbow's anterior ligcnnent cansngitto sftetch or tear. Tlte biceps tendon may also be tom or damaged in the process. Now, all that needs to be

done is defining reconsbuctive medial radial head pin surgery which is easy when the orthopaedic surgeons

think about it. (Don't forget that all wrist problems demonstrate an elbow rnjury due to the nature of theelbow's subsytem, the forearm and wrist/trand bones.

CoW # ou for RUDIKRASS 87

crEr{TrFrc PnooF roR

PLRI * x: lateral epicondyli-tis

(C ause -and-effect re lati onshipfor PLRI)

(C ause -and-effect re lationshipfor x)

PLRI: lateral epi. : rergo, PLM = x

I-gfn nar urpf n E>rrnnvrrryRa[A,Tq.Ry INs IAB r r=.rTv

When I started this medical joumey, Iwas nnive and falsely believedthat the medical comnnmity actually had a good grasp of how the upper extrem-ity worked. I now know that the msdical community knows absolutely nothingabout how the upper exftemity functions because the ann functions at its mostbasic level in a manner that completely contadicb the present medical commu-nity's theories conceming it.

Early in 1997,Iwas exposed viamy appoinfinent in Los Angeles tothe equation ofhow lateral epicondylitis arises according to the orthopaedic

surgical community. In Dece,rnber of that year, I was exposed to the abridged

but full medical theory pertaining to posterolateral rotatory instabilitythatwasand still is posted on the intemet http:/www.nmis.com/onm/trtnVets95 lateral_collateralelbow.hnn.

In the summer of 1998, I had the Gadolinium enhanced STIR MRIwhicb when finalized in October, confirmed that I had the same conditionswhich apply not just ta PLN butalso'litcher's elbod' - tarn radial collateralligatnent and cotwnon extensor tendon, This meant not only that the medicalequation relayedto me ftom the Los Angeles orthopaedic surgeon was correctbuttlnt PLN and repetitive oven$e are fundamentally the same.

Now, the medical community only does cause-and-effect research and

e4pends noresources to determine how the'tnicro-tears" of the common acten-

sor tendon and radial collateral ligament werc caused. So, as far as the medical

community was concemd its responsibilities had been fulfilled by merely

noting the causes of lateral epicondylitis.By applying the most medically written about cause of lateral epi-

condylitis to datl - PLN,I was no further along with the process of o<plaininghow the causes actually created the effect. But" by subjecting the repetitive

oven$e actions to scrutiny, I was able to determine that repetitive pronation was

the root cause of lateral epicondylitis.This discovery lsad to the conclusion that pronation was not caused by

confraction of the pronator teres and its compliment in the wrist, the prorator

Endrahn. With this theory, an e4periment and/or a diagnostic image would be

required to confirm that indeed the contractions of the pronator teres andprorutor quadraus werr misunderstood.

Knowing this, I viewed the oosterior of ttre elbow as it pronated and

supinated tlrc lil Krass eryrcriment,to determine exactly how the medial epi-

condyle moved and discovered that it moved posteriorly through pronation and

antoiorly ttnough supination. This motion confirmed that the prorator musclegroups were indeed not contacting through pronation.

I then confirmed this assessment on my radiographic films, the P Krass

experiment. I compared the location of the medial epicondyle and the position

of the humerus from a supinated to pronated x-ray film and confirmed that

indeed the humenrs was rotating through supination and pronation. This fact

about the hume,nrs not only confirmed that the pronator teres andprorwtor

Coyn # Nt foTRWIKMSS I

x -> lateral epicondylitisprocess explained and definedas repetitive improperpronetion, NP

Physical test, lo KrasseJcperiment,to confirmpronation is not performed bycontract ion of pr onatormuscles discovered

Radiographic test, ?dKras s qcperiment, confirm-ing pronation is notperformed by confiaction ofpr onstor muscles discov-ered

Radi ohumer al j oint estab-lished as primar,v joint of theelbow

Elbow demonsffated tofimction like a "modifiedpulley" with the opposingflexion and extension musclegroups acting like ropes tiedto the radial head

quadratus were not contracting as the medical community has theorized but also

that the radius was not rotating around the humeral capitellwn as was also

theorized.

The fikns from my improperly interpreted comparative CT scans from1996 demonstated that the radiohwneral jointwas actually the most importantand solid of the elbow's two humeral joints. This fact was also confirmed by thelateral pivot-shifi test for PLN which was fully described at the aforementionedinternet site and which indicated that the radial head dislocates/subluxes over thecapitellum and towmds the radial collateral ligament.

I was now able to present exactly how the elbow firnctions throughflexion and extension which was necessary because supination and pronation are

actually processes that extend from the hand up to the shoulder viathe elbow.Flexion and extension could only be performed if the radiohumeral jotnt func-tioned like a '?nodified pulley." In this instance, instead of the radius for themotion being attached to a solid objecl the radii would have to be attached tothe lateral and medial sides of the radial heod andthe base of the capitelhnn.These radii pins would then keep the radial head in constant contact with thecapitellum as the radius moved from full extension to full contraction. Thismeant that the extension and flexion muscles were like rope tied to the radius.

This new theory about elbow finctionality meant that lateral x-ray filmswould demonstrate that, atextensioq the radiohwneral line would be straightand this line would change much like the degree lines on a protractor as it wentfrom 180 degrees extension to anywhere up to 90 degrees flexion. Whenradiographic images are taken from the lateral side of a healthy elbow, thiscircular relationship is conclusively demonsfrated. (At this poinL the fullfunctionality ofthe elbow section ofthis book became apparent and was re-corded.)

With the elbow being proven to work like a'tnodified pulley" with themedial and lateral pins ofthe radial lreadprovento conffol the mc motion oftheforeamr through flexion, it was easy to deduce how lateral epicondylitis wascaused in cases which mose from repetitive improper pronation, i.e. pronating

the hand by strengthentngthe prorntor teres. Such activities had to be rotatingthe radial head at the capitellum which has now been proven to be

biomechanically inconect and which would explain the swelling of the radialhead's latsralpins, the radial collueral ligament and the common extensortendon.

This firnctionality had to be hansposed to cases where a frauma to an

outstretched ann was its cause in order for it to be vali4 though--te equationindicates that the two causes must be relatively the same in process. The proper

ftrnctionality of the elbow allowed for this fiansference because, when the elbowis subjected to force while it is slightly bent then the radial head pushes back-wards on the medial side of the radiohumeral joint'sbones, forming a pivot

ro1 and placing a sudden and abnormal force on the radial head's lateral pins.

Thus, a gap forms at the lateral side of the radiohwneral joint and expands

depending on the severity of the force transferred from the hand through the

elbow's subsystem to the medial pivot point, i.e. the medial side of the radio-humeral joint.

Now, both c:xes were in agreement with the new functionality of theelbow and" although the two causes seemed fundamentally differenq both were

Radiographic confirmation ofthis "modified pull ey' systemat work

Soft tissue radii pins, lateraland medial sides of therqdiohumeral joint, defined asforearm o'ate pins"

kIP + PLM - lateral epi.fullyexplained as is the reahty thatRIP and PLkl are caused thesame way although throughtwo seemingly differentcauses

fiCopJ # oot for RUDI KRASS

Muscle groups in forearmfunctionahty proven to be

misunderstood and mislabelled

demonstrated to be having the exact same effect on the radial head's lateral pins,the radial eollateral ligament andthe cornmon extensor tendon. This reality also

lead to the proper definition of '?nicro tearo'as athe body's way of demonstrat-

ing a biomechanical dysfunction at that joint.The final piece of the ptzzle for the immediate abolition of the present

medical theory of how the elbow and upper exfremity work came from theplacement of the Bicipital Tuberosity and the fact that the ulna resides sigrufi-cantly within this bone extension and the ulno-radial joint fits snugly together.

These facg indicak that the radius could not rotate inward without displacingthe ulna but this does not occur through pronation. This lack of 'toom to rotatfr"clearly confirms that the radial head does not rotate AT ALL around the hu-meral capitellum when the radial head's lateral pins are not damaged which isconsistent with the 'tnodified pulley systent" discovered by me as well as therealrty of ligament and tendon'tnisro-tears."

CoW # ou for RUDIKRASS ilI

t

SNCTION III:TrrE KR4ss Rn,auN" oF

SnotLDER BesnnL

UpPER ExTREN{rrY

RoTATORY IxSTABILITIE,S

Copy # ou for RUDIKMSS

Srtournnn BlsnpuppEn ExrnEl,urr

Although it has already been demonshated that a portion of this branch of rotatory instability results

from long term use of an arm suffering from insuffrciencies at the lateral epicondyle, there are several other

ways that shoulder based rotatory instability can be caused. This section will expand on this realrty by expos-

ing the other causes of anterior shoulder based upper exffemity rotatory instability, basically Coracoid Process

insufficiencies, and then rotator cuffinjuries to the cres! i.e. the supraspirntus, of the shoulder.

(It is important to note that using an arm with an insufftciency atthe Coracoid Process often leads to

insufficiencies within the radial head's lateral pfu, e.g. women initially do not have problems at their lateral

pins howwer using their arms in a pronated fashion creat€s these problems more insidiously than those of a

man. The main problem arising from a naturally lax Coracoid Process or a produced insuffrciency and

extended usage of the hand while it is pronated even at mild activities is that this arm configuration places an

inordinate amount of force on both the radial collateral ligament and the common extensor tendon. Theq the

disposition of women's ligaments to stretch allows the radial collateral ligament to do so creating all the

gender based symptomolory in the wrisf defined rn Section // of this boolq which me also reproduced in men

who damage their shoulders and do not get freatnent but then have to use their arms in sedentary pronated

fashions.)

CopJ # ooI for RUDI KRASS 92

Pnrupr,nEcHaNrcs orSHgurnnn sesun

Instability Due To Anterior Rotator CuffInsufficiency

Even though an injury to the anterior rotator cuff was prwiously discus sed tn Section.I/ of this booh

an equally common cause of insuffrciencies of the tendon and ligament at the anterior rotator cuffis tying to

lift a heavy load with a fully extended arm and the forearm subsystem in a supinated position. The reason, this

particulm arm and forearm position cause tendon and ligament insuffrciencies at the Coracoid Process,the

anterior rotator cuffas I refer to it, is because, when the weight is applied to the hand, it forces the e,ntire arm

to actiike a'!lum bob."

Now, it is known that the forearm bones me aligned toed outwar4 valgusly, due to the interior and

exterior radial mc pins. So, with the forearm fully supinated, the downward force on the hand by the heavy

object causes the humeral head and the humerus to rotate, clockwise on the right and counterclockwise on the

left when looking downwmds towards the hand as the forearm seeks a natural and gravity forced vertical

alignment. This sudden humeral rotation places abnormal force on the short biceps head's and coraco

brachialis' coracoid tendons and the coraco-humeral ligamenr-the latter being far more important than

previously thought.

When the downwmd force or reverse gravitational force, leg lifting of a heavy object is exceptionally

stong, the humeral head will dislocate or sublux to near dislocation in an anterior and downward direction.

Examples of activities that regularly cause this humeral dislocation or severe subluxation are heavy lifting

with the legs from a crouched or semi-crouched position while the supinated hands are holding onto an objecL

e.g. a gumey with a patient in i! a heavily weighted bar used in weight training but with hands mistakenly

supinated, carching a heavy object with a supinated hand or snagging the paln side of a work glove on a

gravity propelled object among others.

A similar means of causing severe damage tothe short biceps' and coraco brachialis' coracoid

tendons and the coraco-hurneral ligamenr is pulling on someone else's arm when, once again, his hand is

supinated bu! this time, the arm is over his head. This action causes the recipient of the force to have his

humerus, once agairl rotated anteriorly due to the force applied to the hand creating a "plumb bob" but this

time with the body and not at the hand. In this activity, the full weight ofthe body is applied downward at the

Coracoid Process causing the shoulder to separate as the upper extremity, humeruso once again rotates anteri-

orly beyond the tendons' and ligament's limits. An example of this activity is when someone comes to the aid

of someone else below them on stqls, over a ledge or in a hole and who needs a lift up. (The amount of

CoW # ool IaTRUDIKRASS 93

rotational force in these instances can be easily calculated with a simple gravitational physics equation because

the gravitational force is equal to the rotational force.)

It is important to state that the hand has to be supinated while the arm is also FULLY extended. The

latter point is pararnount because, in this positiorl it is impossible to counteract the rotational forces applied to

the CoracoidProcess through the humerus with muscle contraction. When the elbow is partially beirt, full

biceps conffaction and contraction of the posterior and superior forearrn muscles can counteract the plumb bob

effect and stabilize the humerus.

Anterior rotator cuffcomplications arising from either trauma or repetitive and untreated mild trau-

mas to an outstretched partially extended elbow - the causes of lqteral rotatory instability at the elbow - isagain similar to the 2 previous causes of direct improper force placed on the Coracoid Process. This fact is

confrnned by examination of these cases and how the force ends up being applied to the radiohumeral joint.

In both cases, once the radial head's lateral pins are damaged - either suddenly or gradually, upwardly directed

force is applied to the anterior side of the radiohumeral joint whichcauses the humenrs to rotate anteriorly.

(Although the force at the humeral capitellum is backwards, the real effect on the humerus is anterior rotation

which is seen by the medial epicondyle rotating forward.)

Now, all cases of anterior rotator cuffinjury are actually seen to be almost exactly the same in nature

on a microcosmic scale.

Instability Due To Stryraspinatzs fnsufficiency

Prior to discussing rotator cuffproblems based at the crest of the shoulder in a meaningful manner,

how the shoulder functions at shoulder height or above needs to be examined. Firstly, everyone knows thag

when the deltoid muscle contacts, the arm is raised. However, raising the humerus is a little more compli-

cated than thought because the deltotd conhaction only applies force to the mid-point ofthe humerus. This

reality means that the humeral head needs to be rotated upwmd in conjunction with the fultoid's contractive

force in order not to produce soft tissue trauma at the crest of the shoulder from any upwmd displacement of

the humerus. The muscle that works in conjunction with the deltoid isthe rupraspinatus which attaches to the

Greater Tuberosity of the humerus. Another important point about the shoulder that has not been calculated

into the incorrect motions which cause tearing and swelling nthe supraspinatus is the placement of fhe biceps

tendons not just at the elbow but at the shoulder.

The biceps muscle group is quite unique in that it does not attach to trry partof the humerus even

though all of its conffactions have an affect on this very important bone. So, when the arm is raised to shoul-

der height, the supraspinatus is confacted, and then the humerus is brought forward in a throwing or basic

swimming motion, the slnrt head of the biceps and coraco brachialis conract forcefully. This motion causes

a problem because the supraspirwtus does not relax af any point tluoughout the throwing motion and, towards

CopJ # ool for RUDI KRASS e4

the end of the forward arm motio4 the slnrt head of the biceps and the coraco brachialis ar€ now near full

contraction which places a posterior force on the fulb rotated humeral head. Now, you have two muscle

contactions fighting against one another----not complimenting each other ldr'e biceps andtriceps ar hamstrings

and quadriceps, etc. So, the smaller of the two muscles will nahnally be damaged because it is incapable of

maintaining its contraction against the opposing force. The muscle group that fails then has to be the suprasp

inatus which has been discovered through diagnostic imagerl,.

At fust, the stpraspirntus will suffer from swelling from some minortearing of its tendon fibres.

Without cessation ofthe activity and application ofknown non-surgical treatments, the swelling and pain in

the mpraspinatw will get worse and the te,ndon may begin to tear starting at the posterior of the crest of the

shoulder, i.e. the back part of the supraspinatus. If treafrnent is rendered and the activity is resumed follow-

ing a break in usage, and the swelling and pain returns, don't jump to the conclusion that surgery is necessary

to treat the injury! Before making this assessment and having an MRI done, ALWAYS check the radial

head'i lateral pins with the Krass prorntion test for insufficiencies!

In cases where srrgery has been determined to treat the superior rotator cuffinjury, still check the

elbow for insufficiencies in the lateral radial head's arc pins. From my information, when insufficiencies are

noted in the radial collateral ligament and common extensor tendon at the lateral epicondyle and ttre person

used the anrg especially pitching, without having the elbow problem diagnosed for quite some time, the

anterior shoulder pins - the coraco-humeral ligamert, the short head of the biceps' and the coraco brachialis'

coracoid tendors - have been lengthened as well. This added length to the anterior shoulder pins means that

the humeral head can be further displaced posteriorly by at least 50 percent which makes the sudden force on

the contracted, stpraspiratus far greater causing a more serious tear to its humeral tendon.

Once again, Iateral rotatory irxtability at the elbow is demonstrated to have a serious deleterious

effect on an adioining joint-tlrc wrist was conclusively demonstrated to be negatively affected by LRl in the

Section II ofthis book.

CopJ # au for RUDIKRASS 95

SvupTomelocv or

Anterior Shoulder Rotatory Instability Symptoms

The symptoms forproblems with the coraco-hurneral ligament,the coraco brachialis' andthe short

bicpes head's tendons are basically swelling and tendemess mound the Coracoid Process. Ifthe humeral head is

subluxed or dislocated, then obviously the shoulder will be deformed at the anterior side of shoulder and painful.

(If this deformity is detected and a radiographic film dernonsfates ttre anterior dislocation or subluxation, then it

will require a resetting ofthe shoulder joint.)

. Chronic or persistent swelling and soreness al the anterior portion of the shoulder will be present if there

is either a permanent insufficiency of the soft tissue attached lo the Coracoid Process, which usually occurs

following a dislocation or repetitively dislocating humeral head, or an insufficiency of the radial head's lateral arc

pins and the arm is being used or abused by ourpresent ann usage.

Both ofthese cases of upper extremity rotatory instability also produce palpable clicking and popping in

the shoulder when it is raised and lowered to its exfieme ranges of motion either by the patient or by a medical

profesSional manipulating the shoulder

Superior Shoulder Rotatory Instability Symptoms

Most ofthe symptoms pertaining to this form of instability, commonly referred to as either pitcher's

shoulder or swimmer's shoulder, revolve around the supraspinatus. So, the basic symptoms for superior shnul-

der rotatory instability are swelling or tearing of the supraspinnlers tendon over the humeral head. Exteriorly, the

shoulder may have a bump over the humerus at the top ofthe shoulder which arises from severe swelling witftin

the tendon beneafh the deltoid. These symptoms are usually accompanied by pain at the top of the shoulder when

attempting to raise the arm from the body's side. Also, when the arm is raised, it is painftl for the patient to

maintain the height of the arm and it begins to fall slowly and painfully after the medical practitioner releases it to

the effects of gravity. The shoulder pain elicits a response from the patient when mild pressure is applied to this

part ofthejoint.

For more information about this condition's symptoms and you have access to the interne! do a search

using the phases: pitcher's shoulder, swimmer's shoulder orjaveler's shoulder. Superior shoulderrotator cuff

injury is a well documented although highly misunderstood condition as knowledge ofthe cause-and-effect on

the body have been known to the orthopaedic surgical community since the mid-1980s. The main hindrance to

the medical community understanding the process was its lack of knowledge of how the upper extremity actually

rotates and it is this knowledge around which all subsequent upper extremity rotatory instability revolves.

Copy # ou for RUDIKRASS 96

*$HoUI.pER. snsrn

Anterior Shoulder Rotatory Instabilify

Diagnosing anterior shoulder rotatory instability should start with a physical examination of the

Coracoid Process which will demonstrate a palpable tendemess around the front side of the shoulder. As

indicated emlier in this section, the te,ndemess, pain and swelling at the anterior of the shoulder can be either a

complication of an undiagnosed elbow based lateral rotatory instability or directly attributed to an anterior

dislocation of the humeral head. So, determining the cause should be done with a review of the patient's

activities but this diagnosis should be confirmed with either a physical stress test of the shoulder and elbow, a

CT scan or MRI of the shoulder if the latter 2 diagnostics are available.

The.fiirass anteriar shoulder stress test, Kasst, will quickly establish whether or not the anterior

shoulder swelling and discomfo* is due to a dislocating or swerely subluxing humeral head or not. The Kasst

is performed with the physician standing behind the patient so that he is facing the back and afflicted shoulder

of the patient. With the arm attached to the patient's painful shoulder raised to shoulder height and the physi-

cian's lateral arm lightly grpped underneath the lower humerus mound the medial epicondyle and his other

hand lightly glpped over top of the humeral head are4 the physician pushes anteriorly and slightly downward

with his medial hand while pulling simultaneously backwmds on his lower humeral hand the physician's

lateral hand. This process creates a potential anterior dislocating force on the humeral head with the physi-

cian's medial hand actually functioning like a fulcrum.

For an anteriorly dislocating or severely subluxing shoulder, the humeral head will dislocate when

mild force isused in the Kass/ and the patient should not readily be able to eliminate the dislocation or severe

subluxatior-a radiographic image at this point will confirm the dislocation or severe subluxation. A positive

result from the Krass anterior shoulder stress /esf determines tltat reconstrtrctive coracoid surgery may need

to be applied to the shoulder buf only without a negative result on the Krass pronation test. Reconstructive

lateral epicondylar surgery to the radial head's lateral pins should not be ruled out which" if discovered to

exisl especially in men, must be performed prior to any shoulder surgery provided that a dislocation did not

originally occur.

Shoulder laxity in young men will most likely be naturally eliminated following the surgical elimina-

tion of the elbow problem, but women will most definitely not because thek cocaco-hwneral ligament is

longer to start with than a men's creating the following rules:

CopJ # ou IoTRUDIKMSS 97

Following an anterior dislocation in women and it is diagnosed forthwith, reconstructive coracoidsurgery must be performed;

If the dislocation has not been treated with reconstructive coracoid surgery, i.e. the shoulder is used

considerably prior to recgiving surgery and the shoulder has continued to dislocate over this timeframe, more than likely both reconstructive coracoid andreconstnrctive lateral epicondylar surgerywill be necessary - womeir mainly, but not exclusive to them. @oth r?ass diagnostic fesfs will bepositive.)

If the humeral head does not dislocate or sublux tluough the Krass anterior shoulder stress test,then

definitely the Krass pronation /esl needs to be performed. This test will probably confirm that the anterior

shoulder pain is actually a complication of insufficiencies in the radial head's lateral soft tissue pins. If the

Krass pronation test is positive, this means that reconstnrctive lateral epicondylar surgery should resolve the

shoulder problem without the need for reconstructive coracoid surgery.

. It is very important at this juncture in time NEVER to assume that the patient is not suffering from a

previously undiagnosed elbow based lateral rotatory instability rcgmdless of the Krass anterior slnulder

stress test.

Superior Shoulder Rotatory Instability

As this form of shoulder based rotatory instabitityis soft tissue based, it cannot be demonsfrated on a

radiographic film which makes the means of confirming the condition either a CT scan or preferably a MRL

Prior to either of these tests being done, the patient must express, as a problun" the ability to raise his arm

laterally upwards. The shoulder of a person suffering with this condition may also demonstrate a deformation

at the top of the shoulder over the supraspfumhn which is very sensitive to touch.

Once superior shoulder instability is suspected" the following physical tests should be used to confirm

the suspicions. First, have the patient raise his arm laterally, if possible, and have him tell you how it feels

when doing so. If the patient is actually able to raise the arm even though it is difficult, then there is no need

for surgery. But, ifthe MRI or CT scan confirms swelling tnthe supraspinatus,thenrepetitive improperuse

of the shoulder has to be diagnosed and the activity causing the problem stopped. Once again, the elbow has

to be tested with either a STIR MRI (brace) where available or the.trirass pronation test to detilfftine whether

the activities, which caused the swelling in the shoulder - mainly Westem based sports activities, had not

wknowingly damaged the radial head's lateral soft tissue pins prior to the onset of the dorsal shoulder prob-

lems. The reason for this test is that, following the creation of insufficiencies in the radial collateral ligament

and common extensor tendon, the humerus naturally rotates posteriorly at the lateral epicondyle and" following

usage of the damaged arm, the anterior soft tissues attached to the Coracoid Process from the upper exhemity

will become lax at their upper attachments allowing greater tearing force to be applied to the supraspinatus

while it may be contracted i.e. raising the arm.

CopJ # ou IoTRUDIKRASS 98

Interestingly enough, the complication at the superior of the shoulder is presently treated with cessa-

tion of the activity which does not resolve the elbow problem but it does eliminate the swelling at the shoulder

giving a false belief that the problem has been resolved. Instead, the weakness in the the supraspinatw

relative to the biceps will cause the swelling in the superior shoulder to retum once the offending activity is

resumed. However, this time, the patient will adjust his process motions slightly to account for the shoulder's

weakness. Consequently, the athlete will end up strengthening the coraco brachialis and the short biceps

headta keep the humerus improperly rotated when doing the initial offending activity. Now, when the athlete

resumes training at a high level, the humerus will suddenly snap posterolaterally at the top of its humeral head

but even further this time than before and significantly so. With the supraspinatus silongly contracted, this

muscle's humeral tendon does not just become swollen from'?nicro tears" due to a biomechanical dysfunction

but literally tears starting from the back and extending forwmd depending on the pain tolerance of the athlete

or the drugs administered to him allowing the patient to use his arm beyond the initial tear.

Confirming that the patient has a partially tom supraspinattn tendon is easily done with a CT scan or

preferably a Gadolinium enhanced MRI. As most cases of superior shoulder instability occur in athletes

competing in Westem athletics, like baseball, javelin, swimming, etc., so these types of diagnostic images will

be readily available to confirm the supraspinatus 'tom humeral tendon.

If these diagnostic tests are not available though, the following physical test will suffice. Ask the

patient to attempt to raise his arm from his side, if the person is unable to do so due to the pain and weakness,

then he is suffering from a partially tom supraspirntus (humeraD tendon. Another confirmation of this

diagnosis will be the patient's inability to maintain the arm laterally at shoulder height once you have released

it after having raised the arm. A patient zuffering liom a partially tam supraspinatw tendon will not be able

to maintain the arm at shoulder height and the arm will slowly fall to ttre patient's side as the patient complains

of severe pain at the top of the shoulder. Due to tltis tendon being torn, you should be able to detect an

involuntary spasm at the top of the shoulder after the test has been administered.

As superior shoulder instability requires either a CT scan or a MRI to provide an absolutely irrefiila-

ble confirmation of the problem, it is fortunate that the problem is rarely seen in the general population be-

cause many parts of dweloping countries or poorly populated areas in industrialized countries do not have

ready access to such diagnostics. Fortunately, the indigenous populations of these regions do not employ the

activities that cause the problem and most assuredly they do not overtrain in the intrinsically improper arm

activities that Western athletes do.

CopJ # au for RUDIKRASS 99

$HpurnFR lr.rsurFrqrnxcrEs

Physiotherapy

The role ofphysiotherapy conceming anterior and superior rotator cuff problems will be mainly

follow-up treat following reconstructive coracoid surgery. The other cases that will be treated by physi-

otherapy are cases where the supraspinatus is swollen but not torn.

In these non-surgical cases, physiotherapy has to be applied mainly to reduce the swelling of the

supraspinatus which means heat andlor ice packs. This freafrnent will be complimented by cessation of the

offending shoulder activity. Following the reduction of swelling at the top of the shoulder, PROPER and

progressive light weight training to strengthen the supraspiratus and the deltoid muscles should be added to

the treafrnent prograrn.

In cases of anterior rotator cuffswelling not following an anterior dislocation, i.e. cases where the

swelling mound fhe Coracoid Process is a complication of elbow based lateral rotatory irxtability, physi-

otherapy will not be beneficial until the reconstructive lateral epicondylar swgery is performed and its

treatment'is completed. Towards the end of the post operative elbow physiotherapy though, light weight

fuaining for the muscles that attach to the Coracoid Process will have to included into the treahnent program.

This simplistic approach should be sufficient to reduce the swelling and larity atthe Coracoid Process that

was created by the long term case of elbow based lateral rotatory instability.

At this poin! the concems presented inthe Prevention se,ction of this book's Section II, pertaining to

re-occurence of the problem with society's prevalent and improper upper exfremrty usage, apply and will

determine the next course of action.

Reconstructive Surgeries

Before the objectives of reconstrtrctive coracoid swgery are presented, it is important to understand

why evenjust one anterior shoulder dislocation is one too many. There are two main reasons which explain

why the humeral head must never dislocate anteriorly-gravity and the location of the humeral attachment of

the subscapularis. Both these factors make recovery from an anterior dislocation impossible. Conceming

gavl$, the arm and all its weight is held in ctreck by the upper arm muscle attachments to the Coracoid

Process as well as the coraco-hwneral ligarnent- So, once these soft tissue attachments are stretched, they

never regain their normal length because all day the gravitational force created by the weight of the arm while

we are standing is now placed on the damaged soft tissue upper extremity coracoid attachments-a sling only

temporarily and sliehtlv mitigates ttre gravitational force problem.

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Now, the subscapularis further complicates the matter of anterior rotator cuffrecovery from a dislo-

cation because the coraco-hwneral ligamentwas the soft tissue pivot point for contactions of the rotator cuff

muscles. So, when the soft tissue pirts determining humeral rotational force me damaged, the subscapularis

confraction becomes uncontrolled and uses the new length of the coraco-humeral ligament pnas its stop

point permanently. The contraction of fhe subscapularis is ofparticulm interest because it is the longest arc

segment traveled once the soft tissue pins of the Coracoid Processhave been lengthened. Thus, both Savlty

and continued rotation of the humerus me demonskated as the unconhollable forces that they are which makes

full recovery from a dislocation or sev€re subluxation impossible without recbnstructive coracoid surgery.

Quite frankly, it is impossible to provide and maintain an environment which will perrnit the body's recupera-

tive abilities to shrink the short biceps head's and coraco brachialis coracoid tendozs as well asthe coraco-

huneral ligament once the humeral head anteriorly dislocates or severely subluxes.

I must once again reiterate that I am not an orthopaedic ,*g"on which means that I cannot state

exactli' how reconstnrctive coracoid ntrgery willbe done. The true surgical outline will be presented by the

Mayo Clinic and the Kerlan-Jobe Orthopaedic Clinics following their review of this book. As I know more

about the proper functionality of the shoulder and elbow joints, I can make viable recommendations which

must be addressed in the forthcoming papers though.

Reconstructive coracoid surgery has to start with an incision from about 2 inches above the clavicle

and directly above the midpoint of the clavicular tendon of the deltoid going downward and toward the

Coracoid Process. The incision should stop far enough beyond the Coraeoid Process down the upper arm in

order to allow for the anterior portion of the deltoidmvscle to be released from the clavicle and folded out of

the way so as to expose the Caracoid Processto visual inspection. (Note: It is important that no muscle

groups or tendons ever be cut longitudinally in order to gain access to the deep muscle attachments and bones

beneath if another option is possible as muscles rarely bind themselves properly from these types ofwounds or

incisions.)

With the Coracoid Process and its soft tissue attachments now exposed,the slnrt biceps tendon can

also be cut which will be followed by the coraco brachialis tendon. As both tendons attach to the bottom of

the Coracoid Process, they should be incised so as to allow for re-attachment after 2-5 rilns., or so, of tendon

has been removed, depending on the patient. This reduction should be removed from the tendon portion that

is still attached to the slnrt biceps andcoraco brachialismuscles. This reduction can be done immediately

following the removal of these tendons from the Coracoid Process or just prior to their being re-attached.

Once the slnn biceps lrcad's and coraco brachiolis' tendon have been severed, these muscles can be

left to drop out of the way exposing the capsular ligament as well as the coraco-humeral ligatnent. Beforc

attempting to reduce the latter ligament, relocate the humeral head whileplacing the arm close to the body, no

further than 30 degrees from the body, and making certain that the medial epicondyle is at about 45 degrees

downwards from the horizontal line, both right and left arms. Now, the excess of coraco-humeral ligament

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will be exposed facilitating its removal either by stapling orpreferably by cutting and then re-attachment with

either sutures orporous glue.

When the ligament is finished being reconstructed, the tendon attachments for the short head of the

biceps and the coraco-brachialis canbe re-at0ached once they have been shortened if this was not done upon

removal from the Coracoid Process. My preference again is to use porous glue to form the bond for re-

attachment but sutures can be used as well. (Remember, sewing is an activity that uses the arms improperly

and will have to be ultimately eliminated!) Once the deep tendons are re-attachedrthe anterior dehoidflap

can be repositioned and re-attached to the clavicle and the skin can be sealed with the closing procedure

described tnthe Treatment section of Section II of this boolg i.e. the Montreal Protocol.

Torn srqraspindus tendon surgery can be done either with arthroscopic surgery or by gaining

access tothe supraspinntus by way of the aforementioned anterior deltoidflap technique and then fusing the

tendon with porous glue, sutures or laser. Both surgical techniques will fail ifthe humeral head is not rotated

posteriorly and raised slightly laterally during the re-attachment. This humeral motion facilitates the unifica-

tion of the tendon body by eliminating the separation of the two sides of the tom tendon which becomes

exposed when the humerus is brought forward--{tris separation is even more apparent when the arm is raised

laterally and brought forward.

There isn't much more to say about tom rotator cuffsurgery as this condition and its surgical treat-

ment have been known to the orthopaedic surgical community for over a decade. The only problem has been

understanding the process causing the injury. This book has provided this as well as dispels the present and

erroneous medical theories established to explain the condition.

It is important to re-iterate thaf, prior to an:y rotator cuff surgery the elbow has to be examined so as

to eliminate the presence of an undiagnosed elbow based lateral rotatory instabilitywhich can cause the torn

rotator cuffespecially if the arm is used for pitching or throwing.

Post Operative Treatment

For tom rotator cuffsurgery, ttrere really isn't anything more to be done than possibly diathermy and

cryo-therapy in conjunction with cessation of the offending activity. This treaftnent plan will reduce the

swelling prior to the start of a light weight ffeafrnent program. However, the offending activity has to be

permanently eliminated from the individual's lifestyle, see Prevention.

Fot reconstnrctive eoracoid surgetT,the arm has to be immobilized in a manner which does not place

any or minimal force on the anterior side ofthe shoulder for 6-8 weeks to allow the soft tissue struchres to

heal. Once the arm is removed from either the cast or brace which is to be wom24 hours per day, physi-

otherapy has to be initiated.

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At first, physiotherapy freatnent will consist of ultrasound, to reduce the amount of scartissue, and

heat and ice, to reduce the post casVbrace swelling that will occur with first use of the arm. Once the post

cast/brace swelling is gone, then light strength training of the deltoid and supraspinatus muscles will be

initiated. After these shoulder muscles have reached a light to moderate strength, the pronation strengthening

technique, described tnthe Treatment clnpter of Section IIof this book, needs to be added to the workout.

Once pronation reaches a plateau lwel - maybe 34 pounds for several days, light weight flexion and exten-

sion can be added to the workout. At the end of physiotherapy, the workout should consist of moderate to

light-high weights for lateral arm raiseso deltoid and supraspinatrc, a minimum of 5 pounds for the dowel type

pronation fraining technique and moderate weights for upper exremity extension and flexion, i.e. 15-20

pounds per ann ma:rimum.

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Ssourngn BlsunRoraroRy lx$rannrry

Coracoid based rotatory instability is easily eliminated by merely changing the position ofthe hand

and forearm when lifting is done. As it has been proven that fully supinated forearms in cor{unction with the

lifting or raising of heavy objects cause damage to the soft tissues that attach to the Coracoid Process and,

having the forearms in pronated positions through lifting can cause damage to the radial head's lateral pins,

the only logical position then for the hands and forearms through lifting must be the forearm's neutral position

or the 12 o'clock position

. Superior shoulder instability or supraspirwtw injuries can be eliminated by the cessation of strong

arm motions forward and above the shoulder. This means that overhead pitching as Norttr Americans pres-

ently performed in professional and amateur baseball must cease. (In reality, this book confirms that the

proper medical way of looking at pitching is not "if' a pitcher will suffer problems but ohhen." According to

my findings, it is only a matter of time before a pitcher sufilers either from elbow based lateral rotatory

instability, shoulder based rotatory instability or both.)

ALL overhead use of the arms must stop especially if the action is used to lift heavy objects. The

rationale for this is because heavy or repetitive lifting from over one's head is another major cause of superior

rotator cuffproblems and this section of the book explains the process that causes the problem-it is frmda-

mentally the sarne as a pitcher's shoulder. (To raise the armo the dehoid and supraspirwtus contract while a

heavy load is placed on the overhead arm. This added weight pushes the humeral head backwards against the

contracted supraspinatus causing it to either physically tear or '?nicro tear" depending on the extent of the

conilaction and the weight. Either way, the crest of the shoulder swells with either mild to extreme pain

present.)

By implementing all these changes, within 25 years, all cases of improper usage c{Nes leading to

damage to either the Coracoid Process and the supraspinatus will be eliminated making the reconsfructive

surgical techniques and diagnostics for these conditions almost totally irrelevant excryt for orthopaedic

specialists and the occasional rare case.

As advice, remember that both reconstructive lateral epicondylar surgery and reconstructive coracoid

surgery should only be applied in women who have demonstrated the need for them and not as preventitve

measure. Work has to be changed to adapt to the real truth ofupper exfemity functionality!

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EnJnote

1 Gray, Dr. Henry, The Unabridged Running Press Edition of the American Classic Gray's

Anatomy, Anatomy, Descriptive and Surgical, ed. Dr. T. Pickering Pick, Dr. Robert Howden, 1901

edition, 60th printing (Philadelphia: Courage Books, $7$ p.220

Fibli"e'eph]'

Morrey, Dr. Bemard F., Lateral Unar Collateral Ligament: Evaluatian & Treatment,

http://wwwnmis.com/onm/htnl/ets95 lateral_collateralelbow.htm

O'Driscoll, Dr. SW; Bell, Dr. DF; Morrey, Dr. Bemard F.: Posterolateral rotatory instability of the elbow

JBJS : 73 (3 ) : 440 -6, 1 99 1 . (http ://www.medmedia.com/lib7 / 50.htm\

Gray, Dr. Henry, The Unabridged Running Press Edition of the American Classic Gray's Anatomy,

Anatomy, Descriptive and Surgical, Ed. Pick, Dr. T. Pickering, Howden, Dr. Robert. 1901 edition

60th. printing Philadelphia: Courage Books, 1974

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Major Change to the thesis "Krass Realitie{M of Upper Extremity Rotation andRotatory Instahility:"

Treatment:

The most effective means of treatment for lateral upper extremity rotatory instability cases

where there are no torn radial collateral ligaments or disorganised scar tissue within the joint capsule

at the lateral epicondyle and signs of a healing/tearing radial collateral ligament is casting. The cast

has to be put on when the hand is fully supinated, thumb perpendicular to the hand and the radial head

has been re-aligned to its normal valgus position relative to the humerus - a common chiropractic

adjustrnent used today - and the arm is fully extended.

The process of casting has to start at the elbow and then move down to the wristhand with the

intervening forearm bone portion of the cast being done last. In the end, the cast will extend from

about the middle of the humerus on a fully extended ann down to the tips of the fingers on the

supinated hand with extended fingers and a thumb pointing outward from the hand.

In cases caught early, the cast should need to be on for 2-4 weeks. ln longer term cases,

where scar tissue is not detected within the elbow's joint capsule at the lateral epicondyle,

Gadolinium enhanced STIR MRI and the Krass pronation test is positive, the arm has to remain cast

for anywhere from 6-8-10 weeks. To determine whether or not the arm needs to be re-cast is the

Krass pronation test which, when negative, means that post operative physiotherapy can be initiated.

presenf the orthopaedic surgical community has become very reluctant to use casts

because they "reduce the ranges of motion at the joints." This assessment is a complete

misunderstanding of the effects of casting because the medical community does not yet realise that

It is true that casting reduces the ranges of motion of the joints, but the only ranges of motion

that is lost is the improperly ones that society has forced us from childhood to incorporate into our

lives - see the following Prevention chapter. This reality means that casting re-introduces the

individual to their extremities' normal functionality as this is what is re-established in the soft tissue

structures of the joints from the casting treatment.

(Physiotherapy and anti-inflammatories to reduce the soft tissue trauma in joints as well as

mitigate any neural and blood flow complications in the upper exhemity is no longer necessary.)

Copyright e 2001

Any treatment of lateral upper exhemity rotatory instability, that is not complimented with the

massive changes to the way in which we use our upper exffemities through all aspects of out lives,

will be futile because the true cause of the problem has not been resolved, i.e. elirnination of repetitive

improper pronation - see the Prevention chapter for an overview of this undertaking.

(The surgical information from the Mayo Clinic and the Kerlan-Jobe Orthopaedic Clinic areeffectly made almost obsolete and nearly irrelevant because the vast majonty of persons sufferingfrom lateral upper extremity rotatory instability will only need to be treated with casts rather thansurgery. Unfortunately, I just happen to be one of the minority that will need surgery.

Copyright @ 2001