Elbow Stiffness: Rehabilitation Management

Abstract

Elbow stiffness due to elbow or shoulder trauma is a difficult condition to treat. Unlike idiopathic and secondary shoulder stiffness, which are often amenable to appropriate manual physiotherapy, this form seldom benefits from physical therapy, especially if it is severe or very severe. Yet it is quite frequent, arising both in patients managed conservatively and in those treated by surgery.

1 Rehabilitation Management

Elbow stiffness due to elbow or shoulder trauma is a difficult condition to treat. Unlike idiopathic and secondary shoulder stiffness, which are often amenable to appropriate manual physiotherapy, this form seldom benefits from physical therapy, especially if it is severe or very severe (Charalambous and Morrey 2012; Giannicola et al. 2014). Yet it is quite frequent, arising both in patients managed conservatively and in those treated by surgery.

Management of wrist or shoulder joint injury often involves elbow immobilization with braces that hold it in 90° of flexion. Wearing such braces for longer than a week has the potential to induce elbow stiffness; if the patient has an especially anxious disposition and moves very slowly and carefully, even a week may give rise to stiffness (King et al. 1993; O’Driscoll and Giori 2000). Moreover, in case of a shoulder fracture, fracture bleeding combined with elbow immobilization in 90° of flexion will result in blood collection and oedema at the level of the elbow, similar to the way water stagnates in the L pipe of a sink (Carli and Di Giacomo 2013), further promoting stiffness (Fig. 31.1). These haematomas may evolve into a calcification that can then be managed only by surgery.

Fig. 31.1

Humeral fracture with the elbow held in 90° of flexion. Illustration of bleeding and fluid collection predisposing to stiffness development

This is why over the past few years replacing plaster casts with removable braces has proved a winning strategy also in the case of elbow rehabilitation, because they enable passive mobilization of the joints adjacent to the injured area even during the phase when absolute immobility is required. Immobilization has the potential to induce stiffness also in patients with direct elbow trauma. Here, too, dynamic orthoses are preferred to static ones (Merolla et al. 2014) (Fig. 31.2) also in patients with radial head fracture, medial or lateral ligament lesion, dislocation, and elbow surgery. The brace will be removed by the therapist at the time of the first rehabilitation session, to mobilize the wrist, shoulder, and upper thoracic outlet 2–3 times weekly, which will also promote tissue drainage and vascularization (Brach and Goitz 2006). Immediate passive mobilization is the first, key step to ensure a satisfactory outcome and full recovery.

Fig. 31.2

A patient with osteochondritis dissecans wearing a dynamic orthosis after implantation of an autologous rib graft (pictured 1 week from surgery)

Elbow stiffness may be induced by all elbow conditions, be they secondary to trauma or to surgery (King and Faber 2000; Timmerman and Andrews 1994). In these situations, risk of stiffness is even higher if the elbow is not early and appropriately mobilized in relation to the underlying injury; stiffness may arise as a complication.

Whether the elbow trauma has been managed conservatively or surgically, the rehabilitation programme during the early stage of mobilization (Wu et al. 2014) will be determined by the injury:

• In patients with radial head fracture treated conservatively, pronation-supination will be avoided, and mobilization in flexion-extension will be extremely gentle (0–40° of flexion; 0–40° of extension starting from 0°, with the hand in neutral position); in patients with simple dislocation and a ligament injury treated conservatively, rest is essential over the first week; passive mobilization of adjacent joints and—if the pain permits — of the elbow is initiated on the second week; special care is devoted to forearm position, to favour healing of the injured ligament;

• In patients treated surgically, the rehabilitation therapist will follow the surgeon’s prescriptions; in cases where extended immobilization is recommended, at least the wrist and shoulder should be mobilized to avoid the onset of stiffness. Skeletal fractures stabilized surgically should also be mobilized early, with timing and exercises based on the type of procedure. In his diagram, Protzmann (1980) highlighted that immobility exceeding a week is associated with a greater functional impairment.

Stiffness is not necessarily commensurate to trauma severity, be the injury treated conservatively or surgically (Fusaro et al. 2014b). Small bony lesions that are almost invisible radiographically may involve severe tissue stiffness that is not amenable to manual physiotherapy, whereas patients with severe lesions treated by surgery may recover satisfactory passive and active limb range of movement (ROM). (Figs. 31.3, 31.4, and 31.5).

Fig. 31.3

Radiography in a patient with large fracture. Reproduced with permission from Carli D, Di Giacomo S (2013), Preparazione atletica e riabilitazione. Edizioni Medico Scientifiche, Torino

Fig. 31.4

A patient with a large fracture managed with screws has recovered optimum ROM in extension. Reproduced with permission from Carli D, Di Giacomo S (2013), Preparazione atletica e riabilitazione. Edizioni Medico Scientifiche, Torino

Fig. 31.5

A patient with a large fracture managed with screws has recovered optimum ROM in flexion. Reproduced with permission from Carli D, Di Giacomo S (2013), Preparazione atletica e riabilitazione. Edizioni Medico Scientifiche, Torino

A narrow ROM in extension normally entails a predominantly aesthetic impairment, whereas a reduced ROM in flexion entails a functional impact on daily living activities (Figs. 31.6, 31.7, 31.8 and 31.9).

Fig. 31.6

A patient with severe extension limitations entailing disability in some activities of daily living but above all he has an aesthetic problem. Reproduced with permission from Carli D, Di Giacomo S (2013), Preparazione atletica e riabilitazione. Edizioni Medico Scientifiche, Torino

Fig. 31.7

A patient with severe flexion limitations can’t arrive to wash his face. Reproduced with permission from Carli D, Di Giacomo S (2013), Preparazione atletica e riabilitazione. Edizioni Medico Scientifiche, Torino

Fig. 31.8

A patient with severe flexion limitations entailing disability in some activities of daily living. Reproduced with permission from Carli D, Di Giacomo S (2013), Preparazione atletica e riabilitazione. Edizioni Medico Scientifiche, Torino

Fig. 31.9

A patient with severe flexion limitations can’t arrive to touch his ear. Reproduced with permission from Carli D, Di Giacomo S (2013), Preparazione atletica e riabilitazione. Edizioni Medico Scientifiche, Torino

ROM loss secondary to a surgical procedure may be induced by:

• Capsule thickening and loss of elasticity

• Capsular contracture

• Adhesions involving the capsule and articular cartilage surfaces

• Fibrosis

• Ossification of collateral ligaments and heterotopic ossification

• Muscle contracture

• Ossifying myositis

• Olecranon fossa oedema

In the post-operative (p.o.) period, after brace removal, physiotherapy sessions are scheduled at least twice weekly. At this stage tissue assessment is critical. Already at the time of the earliest movements, the expert therapist can predict whether the elbow is evolving to stiffness or mobility. If the tissue is becoming dense and passive movement is painful, mobilization will have to be performed three times weekly (Fusaro et al. 2014b; Takhashi et al. 2011). However, the joint should not be forced, to avoid the risk of augmenting the stiffness; since it is a complex joint with a limited ROM, mobilization shall have to be performed often but gently. In this phase the therapist’s experience and palpation sensitivity will guide them in establishing the appropriate exercise intensity that affords the best results with as little pain as possible (Takhashi et al. 2011). Before sessions, the joint should be warmed (for about 20 min) with a damp, lukewarm towel to prepare it for manipulation (Fig. 31.10).

Fig. 31.10

A patient warming the joint with a damp, lukewarm towel before passive mobilization

2 Long-Standing Stiffness

Some patients come to the attention of the rehabilitation therapist with long-standing stiffness. Their first question is will my elbow improve? Will I be able to move it as before? The key facts to be established are whether the stiffness is intrinsic, extrinsic, or mixed; whether it is poor, moderate, severe, or very severe; the time elapsed from the trauma/procedure and the current evaluation, patient age, and the type of physical therapy applied until then, if any.

In patients with severe or very severe stiffness, the therapist will have to determine whether manual rehabilitation can ameliorate the condition or whether a capsule release procedure is required (Bonutti et al. 1994; Michlovitz et al. 2004; Pignatti et al. 2000). The key criterion in such cases is the state of tissues. Over the past two decades, studies of glenohumeral injury management have found that retracted periarticular tissue (capsule, ligaments) generates intense pain that radiates along the limb. This also applies to the elbow. Painful passive mobilization is a significant symptom, encouraging the therapist to make a further attempt at manual rehabilitation even if the patient has been doing physiotherapy for months; this applies especially to operated joints. A patient with a stiff elbow, where passive mobilization elicits little or no pain in the joint or along the arm, may be with joint crepitus, has a stiff joint, not tissue stiffness, and the scope for ROM improvement is very limited.

Another factor that needs to be taken into account is whether the patient has been treated conservatively or surgically, since another surgical procedure must be avoided at all cost. The diagram reported below shows that functional recovery is enhanced if the variables on the two axes, i.e. time from trauma and healing process, form two adjacent curves, i.e. are themselves close. Since the repair process cannot be hurried, one parameter that can be affected is time to functional recovery, which can be reduced.

The first 2 months of rehabilitation after a trauma/operation are critical (Fusaro et al. 2014b). Patients with severe or very severe stiffness who are referred to the therapist after this interval, especially young, sport-practising patients, will not achieve a satisfactory outcome without surgery (Figs. 31.11, 31.12, 31.13, 31.14, 31.15, and 31.16).

Fig. 31.11

A young basketball player during the match

Fig. 31.12

Brace after surgery

Fig. 31.13

A young basketball player suffered an elbow trauma and left ulnar collateral ligament (UCL) injury during a game; 2 months later he developed elbow stiffness in flexion despite rehabilitation three times weekly

Fig. 31.14

Residual elbow stiffness in extension after UCL reconstruction by the docking technique was followed by passive mobilization already on the first p.o. day, to avoid a recurrence

Fig. 31.15

The player 4 month from surgery, after daily physiotherapy in a rehabilitation pool, passive mobilization, and daily self-assisted exercises every 2 h

Fig. 31.16

ROM 4 months from the operation; this goal would never have been achieved without surgery and an intensive physiotherapy programme

How then should elbow stiffness be managed?

According to the literature, it should be managed with surgical approaches (Brach and Goitz 2006; Moro and King 2000; Morrey 1992), series of braces, passive mobilization, and day and night static braces (Veltman et al. 2015; Fusaro et al. 2014a; Jupiter et al. 2003; Schwartz 2012).

It should be noted that when managing stiffness, the principle of treating the patient as a whole is temporarily superseded by the need for addressing the local condition. Clearly, work on posture does provide benefits, but the decisive element is treatment of the elbow joint using specific grip techniques acting along the force lines of the different elbow movements:

• Grip technique for flexion (Figs. 31.17, 31.18, 31.19, and 31.20)

Fig. 31.17

Grip technique for flexion if there is shoulder compensation. the therapist’s support is on all forearm of the patient.

Fig. 31.18

Detail hand position during the flexion tecnique if we want to increase thrust intensity and avoid shoulder compensation

Fig. 31.19

Grip tecnique for flexion if there is not shoulder compensation

Fig. 31.20

Detail of the proximal grip

• Grip technique for extension (Figs. 31.21, 31.22, and 31.23)

Fig. 31.21

Grip technique for elbow extension

Fig. 31.22

Detail of the elbow extension grip

Fig. 31.23

Grip technique to improve the last degrees of elbow extension

• Grip technique for supination: the therapist’s hands form a pair of forces, thus avoiding making a lever only on the wrist by applying also a proximal grip (Fig. 31.24).

• Grip technique for pronation: the therapist’s hands form a pair of forces that avoid making a lever only on the wrist by applying also a proximal grip (Fig. 31.25).

Fig. 31.24

Elbow supination grip and grip technique for supination

Fig. 31.25

Elbow supination grip and grip technique for pronation

Flexion and extension may be executed with the patient’s hand in neutral position, pronated, or supinated. Combining two movements executed in different planes is recommended when trying to recover the last few ROM degrees, but may be painful in the early mobilization period.

Awareness of the procedure undergone by the patient is critical to select the most suitable grips.

Precautions to be taken during elbow mobilization include the following:

• If a plaque and screws or a prosthetic stem has been applied, the grip will be below the plaque, because making a lever above the plaque may result in bone fracture (Figs. 31.26, 31.27, 31.28, and 31.29).

Fig. 31.26

X-ray sequence in a elbow fracture before surgery. Reproduced with permission from Carli D, Di Giacomo S (2013), Preparazione atletica e riabilitazione. Edizioni Medico Scientifiche, Torino

Fig. 31.27

X-ray sequence after surgery. Reproduced with permission from Carli D, Di Giacomo S (2013), Preparazione atletica e riabilitazione. Edizioni Medico Scientifiche, Torino

Fig. 31.28

X-ray sequence of a lesion treated with plaque and screws where a fracture above the plaque was determined by an inappropriate grip during mobilization. Reproduced with permission from Carli D, Di Giacomo S (2013), Preparazione atletica e riabilitazione. Edizioni Medico Scientifiche, Torino

Fig. 31.29

The same fracture after 20 days of rest with bone callus. Reproduced with permission from Carli D, Di Giacomo S (2013), Preparazione atletica e riabilitazione. Edizioni Medico Scientifiche, Torino

• Passive mobilization of a painful, stiff elbow should avoid movements that involve different planes, i.e. flexion and supination or pronation, because they entail greater tissue pain that risks discouraging the patient; such movements are allowed after recovery of the intermediate ROM degrees, to achieve further gains. In the early phase, movements will therefore be confined to physiological planes, such as flexion, extension and — with the elbow in 90° of flexion — supination and pronation.

• Mobilization of the wrist in flexion, extension, and ulnar and radial deviation should always be included.

• The shoulder should consistently be mobilized in all planes of movement: protraction, retraction, and external and internal rotation at all angles.

• Only proximal grip techniques should be applied.

• The forearm should be hugged, not held in the hands, to reduce pain (allodynia). According to Melzack and Wall’s gate theory of pain, stimulation of joint and muscle elongation activates pain receptors, generating a nociceptive stimulus that is modulated by the central nervous system. Hand pressure on the painful area activates cutaneous sensory neurons that respond to the mechanical and pressure stimuli and inhibit the pain fibres stimulated by elongation, thus allaying pain in the area. This principle, which explains why we spontaneously compress painful areas of our body (e.g. our abdomen in case of abdominal pain), is exploited by the therapist, who holds the painful area with a hugging grip.

Beginning on the 30th day from the operation/trauma, careful instruction by the therapist enables patients to begin self-assisted passive mobilization exercises in flexion and extension every 2 h in a series of 10 (Figs. 31.30, 31.31, 31.32, and 31.33).

Fig. 31.30

Self-assisted mobilization exercises to be performed at home at 2 h intervals in the first period after surgery (about 50 days)

Fig. 31.31

Self assisted mobilization exercises for extension, to be performed at home at 2 h intervals, in the first period after surgery

Fig. 31.32

Self assisted mobilization exercises in flexion to be performed at home at 2 h intervals

Fig. 31.33

Strong self assisted mobilization exercises to be performed at home at 2 h intervals

Recovery of the last 20° of passive ROM, especially in young patients who still exhibit elbow stiffness 3 months from surgery/trauma, can be helped by night bracing. A tailor-made brace, worn at night after rehabilitation sessions and remodelled after a week, helps stabilize the gains of manual treatment. The approach has been found effective both for extension and flexion (Veltman et al. 2015; Fusaro et al. 2014a; Müller et al. 2013) (Figs. 31.34, 31.35, 31.36, 31.37, and 31.38) and can be adopted for 6 up to 16 months from surgery/trauma.

Fig. 31.34

Construction equipment for thermoplastic brace, custom-made immediately after the rehabilitation session to be worn by a patient with stiffness in extension. Reproduced with permission from Carli D, Di Giacomo S (2013), Preparazione atletica e riabilitazione. Edizioni Medico Scientifiche, Torino

Fig. 31.35

Thermoplastic brace, custom-made immediately after the rehabilitation session to be worn by a patient with stiffness in extension. Reproduced with permission from Carli D, Di Giacomo S (2013), Preparazione atletica e riabilitazione. Edizioni Medico Scientifiche, Torino

Fig. 31.36

Thermoplastic brace, custom-made immediately after the rehabilitation session to be worn by a patient with stiffness in extension. Reproduced with permission from Carli D, Di Giacomo S (2013), Preparazione atletica e riabilitazione. Edizioni Medico Scientifiche, Torino

Fig. 31.37

A patient with a stiff elbow in flexion is wearing a flexion brace with straps that prevent forearm extension

Fig. 31.38

Another vision of a patient with a flexion brace with straps that prevent foream extension

As soon as the patient achieves the ROM degrees that are indispensable for active movement (50° to 140° degree), they can follow a programme of active exercises with therapist supervision to recover normal fluid movement and strength (Figs. 31.39, 31.40, 31.41, 31.42, 31.43, 31.44, 31.45, 31.46, and 31.47).

Fig. 31.39

Exercises direct at recovering strenght in left elbow

Fig. 31.40

Exercises directed at recovering strenght using body weight

Fig. 31.41

Exercises directed at recovering the proprioception in the elbow after surgery

Fig. 31.42

Exercises directed at recovering normal fluid movemnt in extension

Fig. 31.43

Plyometric exercises for elbow after surgery

Fig. 31.44

Exercises directed at recovering fluid movement in flexion

Fig. 31.45

Exercises directed at recovering strenght in flexion

Fig. 31.46

Exercises directed at recovering strenght in extension

Fig. 31.47

Exercises dirested at recovering strenght in extension against gravity