Introduction
- Michael Levinson, PT, CSCS
- David Altchek, MD
Anatomy
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The elbow is a typical hinge type of joint, and has a normal motion of 0° (extension) to 145° (flexion), although the amount of motion that is required for activities of daily living is approximately 30° to 130°.
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Patients may also have hyperextension beyond 0° of extension in hyperlaxity or other soft tissue disorders.
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The pronation and supination are approximately 80° to 85°. Loss of extension is tolerated less than loss of flexion as patients like to have near full extension (or at least 30° for ADLs).
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Elbow stiffness can affect all aspects of elbow motion, including flexion, extension, supination and pronation.
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There are multiple causes of loss of motion of the elbow and are noted as both intrinsic and extrinsic factors in the following section. These typically cause stiffness of the elbow capsule and loss of volume of the elbow joint, and there are areas of bony overgrowth and osteophytes that may be due to overload or be posttraumatic in nature.
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The capsule and ligaments may also be abnormal, contracted, and thickened.
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The anatomy of the elbow is depicted in Figures 12-1 to 12-3 .
FIGURE 12-1
A, Anterior lateral, anterior medial oblique, and anterior transverse bands of the anterior capsule. B, Anterior and posterior view of a painted specimen with the capsule excised, demonstrating the area covered by the capsule.
(From Reichel LM, Morales OA: Gross anatomy of the elbow capsule: A cadaveric study. J Hand Surg. 2013;38:110–116.)
FIGURE 12-2
Anterior view of the elbow.
(Redrawn from Rogachefsky RA, Frey ME, Salcedo V, Santiago FH: The elbow: anatomy, pathology and diagnosis. In O’Young BJ, Young MA, Stiens SA, editors. Physical medicine and rehabilitation secrets, ed 3, 2008, Mosby, pp 352–357.)
FIGURE 12-3
( A ) Medial and ( B ) lateral views of the ligaments about the elbow.
(From Miller MD: Core knowledge in orthopaedics: sports medicine, Philadelphia, 2006, Mosby, pp 350–362.)
Pathophysiology
Intrinsic Factors
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Articular deformities
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Articular surface malalignment
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Fibrosis of the flexor-pronator group
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Contracture of the thin anterior capsule
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Adhesions
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Hemarthrosis resulting from injury to the triceps or brachialis
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Impinging osteophytes
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Loose bodies
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Ulnar nerve entrapment
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Articular degeneration
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Highly congruent elbow joint
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Traversed elbow joint (by muscle rather than tendons)
Traumatic Factors
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Elbow dislocation: hyperextension, axial compression, valgus stress
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Concomitant fractures of the radial head, capitellum or coronoid
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Associated tears of the ulnar or lateral collateral ligaments
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Ischemia and soft tissue swelling
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Extension limited by contracture of the biceps tendon
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Repetitive extension activities (such as throwing or playing tennis) that lead to scarring of the anterior capsule or fibrosis of the flexor-pronator group
Classic Pathological Findings
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Thickened anterior and posterior capsule
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Osteophytes and/or loose bodies
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Loss of range of motion (ROM)
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Loss of upper extremity function
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Gradual increase of elbow pain
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Parasthesia
Clinical Presentation
History
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Significant trauma to the elbow (e.g., dislocation, fractures)
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Repetitive extension in sports (e.g., throwing, tennis)
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Gradual loss of ROM with increased pain
Physical Examination
Abnormal Findings
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Progressive loss of range of motion: extension more often than flexion (often ulnohumeral pathology)
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Possible loss of pronation and supination: often radiocapitellar or proximal radial ulnar joint pathology
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Increased pain with progressive ROM loss
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Swelling
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Bony end-feel
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Crepitus
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Muscular spasm
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Mild to moderate pain
Pertinent Normal Findings
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Flexion is limited by the mass of the biceps, tension in the triceps, and articulation of the radius and coronoid.
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Extension is limited by tension of the biceps, anterior band of the UCL, and the olecranon into the olecranon fossa.
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Anterior capsule becomes taut in extension and the posterior capsule becomes taut in flexion.
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Elbow ROM: Extension-Flexion: 0° to 146°; Pronation: 71°; Supination: 84° (AAOS).
Imaging
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Radiographs: reactive osteophytes on the olecranon and olecranon fossa, osteophytes that may fracture and form loose bodies, heterotrophic ossification, degenerative joint disease, heterotrophic ossification, fractures
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MRI: thickened anterior or posterior capsule
Differential Diagnosis
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Ulnar neuritis: parasthesia and/or weakness in fourth and fifth fingers
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Septic arthritis
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Hemophilia
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Spastic neuropathy
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Complex regional pain syndrome
Treatment
Nonoperative Management
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Active and active assistive range of motion
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Low intensity, long duration stretch for extension
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Joint mobilization techniques
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NSAIDS
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Dynamic splinting at night
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Continuous passive motion (CPM)
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Custom molded orthoses
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Activity modification
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Modalities as needed
Guidelines for Choosing among Nonoperative Treatments
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Poor patient motivation
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Patient will not withstand postoperative rehabilitation
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Medical complications
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Symptoms do not interfere with athletic activities or activities of daily living
Surgical Indications
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Failure of nonoperative treatment to return an athlete to a pre-injury competitive level
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Loss of functional ROM
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Significant pain
Factors That Affect Choice of Treatment
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Functional demands of the patient
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Elbow ROM limiting sport- or work-related activities
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Chronic contracture for up to 1 year
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Loss of functional ROM: 30° to 130°
Aspects of Clinical Decision-Making When Surgery Is Indicated
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Radiographic findings
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Failure of conservative treatment
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Postoperative stiffness
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Posttraumatic stiffness
Evidence
Multiple-Choice Questions
- QUESTION 1:
All of these are considered effective clinical options for restoring range of motion in the contracted elbow except:
- A.
Joint mobilization
- B.
Aggressive passive stretching
- C.
Low-intensity, long-duration stretch
- D.
Custom-molded orthoses
- A.
- QUESTION 2:
Which of the following would not be confused as differential diagnosis with the stiff elbow?
- A.
Septic arthritis
- B.
Spastic neuropathy
- C.
Lateral epicondylitis
- D.
Hemophilia
- A.
- QUESTION 3:
Which of these may be radiographic findings associated with the stiff elbow?
- A.
Osteophytes in the olecranon fossa
- B.
Heterotrophic ossification
- C.
Degenerative joint disease
- D.
All of the above
- A.
- QUESTION 4:
All of these are traumatic conditions that may result in elbow contractures except:
- A.
Elbow dislocation
- B.
Medial epicondylitis
- C.
Ulnar or lateral collateral ligament tears
- D.
Radial head or coronoid fracture
- A.
Answer Key
- QUESTION 1.
Correct answer: B (see Treatment )
- QUESTION 2.
Correct answer: C (see Differential Diagnosis )
- QUESTION 3.
Correct answer: D (see Pathophysiology )
- QUESTION 4.
Correct answer: B (see Traumatic Factors )
Postoperative Rehabilitation after Elbow Capsular Release
- Michael Levinson, PT, CSCS
- David Altchek, MD
Indications for Surgical Treatment
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Nonoperative treatment fails to return an athlete to a preinjury competitive level
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Loss of functional range of motion ( functional being approximately 30° to 130°)
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Significant pain that interferes with activities of daily living
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Radiographic evidence of osteophytes or loose bodies
Brief Summary of Surgical Treatment
Major Surgical Steps
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Regional anesthesia
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Patient is supine with upper extremity elevated in arm holder, elbow flexed
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Anterior, posterior and posterior lateral capsular release ( Figure 12-4 )
FIGURE 12-4
A, B, Anterior capsular release. Arthroscopic view of a right elbow joint after first obtaining scope entry into the proximal-medial portal, looking laterally. Debridement of synovitis is being performed with the shaver. There is a lack of concavity in the trochlea (T) and capitellum (C) area. (RH, radial head). B, Partially completed release. C–E, Posterior capsular release. Establish a posterior-central portal for the arthroscope (4 cm proximal to olecranon tip through triceps) C, and a posterolateral working portal D, (approximately 2 cm proximal to the midpoint between the tip of the olecranon laterally and the lateral epicondyle). Open these widely with a knife down into the olecranon fossa with the elbow extended (protecting the articular surface). The shaver is utilized to debride and open the space, and to remove loose bodies and osteophytes. Elevate the capsule from the distal humerus proximally with a shaver or elevator. Once a view and working space are created, perform all bone recontouring, removing any osteophytes from the olecranon and appropriately deepening the olecranon fossa if indicated. The posterior capsule is released with a basket cutter or arthroscopic elevator on the medial and lateral sides. The release is stopped before the medial aspect of the olecranon fossa (to avoid injury to the ulnar nerve). E, An arthroscopic view of the elbow joint after capsulectomy and deepening of the coronoid and radial fossa. The dissection is carried down to the fibers of the brachialis muscle. The posteromedial capsule should be resected in the setting of significant flexion loss (posterior band of the medial collateral ligament). However, this is extremely dangerous and places the ulnar nerve at greatest risk. Alternatively, this capsule can be released after the ulnar nerve has been dissected out through a limited open approach. The posteromedial capsule forms the floor of the cubital tunnel. Perform a final inspection from both portals to ensure adequate release.
(From Ghodadra N, et al: Arthroscopic treatment of elbow stiffness. In Reider B, Terry MA, Provencher MT (eds): Operative techniques: sports medicine surgery. Philadelphia, 2010, Elsevier (Saunders).)
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Any osteophytes or loose bodies are removed
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All contracted tissue must be addressed
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Care is taken to avoid the ulnar nerve and the posterior interosseous nerve
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Postoperative cortisone injection
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Immediate range of motion
Factors That May Affect Rehabilitation
Anesthetic
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Should not affect rehabilitation
Surgical
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The arthroscopic procedure should allow early rehabilitation intervention.
Other Surgical Techniques and Options
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Open contracture release ( Figure 12-5 ).
