CHAPTER 9 Principles of Elbow Rehabilitation

INTRODUCTION

The goal of elbow rehabilitation is to restore optimal, pain-free function within the anatomic and physiologic limitations of the patient. To achieve this goal, the clinician should adhere to several principles to guide the rehabilitation process: (1) establish a complete and accurate diagnosis, (2) control pain and inflammation, (3) implement early, atraumatic motion, (4) re-establish neuromuscular control about the elbow, and (5) rehabilitate the elbow in context of the kinetic chain. The purpose of this chapter is to review these principles as they apply to a wide variety of atraumatic and atraumatic elbow disorders. For more detailed discussion of specific rehabilitation protocols, readers are referred to the appropriate chapters in this text.

ESTABLISH A COMPLETE AND ACCURATE DIAGNOSIS

Successful rehabilitation is predicated on a complete understanding of the anatomic and physiologic factors pertaining to a particular elbow disorder. The elbow joints (humeroulnar, humeroradial, proximal radioulnar), nerves, vessels, capsule and ligaments, and muscles, as well as adjacent articulations (distal radioulnar and shoulder) should be considered. Anatomic alterations in these tissues will define initial motion restrictions as well as the potential for restoration of motion and stability. However, it is ultimately the patient’s physiologic age and biologic healing potential that will determine how much of this potential is realized. Some patients heal poorly and may be prone to ongoing instability, whereas others exhibit a propensity for scar formation and will develop stiffness despite the best efforts of the treatment team.³² From our perspective, this sometimes dramatic individual variation in the healing response assumes a dominant role in the recovery of some patients.

Throughout the rehabilitation process, the physiologic stage of healing directly affects the rehabilitation program.⁵⁰ During the inflammatory stage, the primary goals are pain and edema control and adherence to stable arcs of motion to protect tissues at risk. During the fibroblastic phase, controlled stresses may be increased to promote more normal collagen formation, and low-level strengthening is implemented to re-establish neuromuscular control. Finally, during the remodeling phase, stretching and strengthening exercises are advanced, and functional restoration is pursued. The clinician must be constantly aware of the physiologic status of the elbow. The elbow is an unforgiving articulation with significant bony congruity and a tendency to develop inflammation and stiffness.³² Overzealous rehabilitation efforts can quickly regress the elbow from the fibroblastic phase back into the inflammatory phase. Consequently, clinicians should constantly monitor the status of the elbow and modify the rehabilitation program accordingly. This process requires appropriate follow-up, patient education, and constant communication between members of the treatment team.

PATIENT PARTICIPATION

As with any successful program, but particularly at the elbow, the patient must be made to understand their role in the recovery process. The clinician and therapist must avoid having the patient become dependent on them, or on formal rehabilitation sessions. The key is to successfully transfer responsibility for improvements to the patient. They become their own therapists.

REDUCE PAIN AND INFLAMMATION

During the acute post-traumatic or postsurgical period, the primary goal is to control pain and inflammation. The elbow tends to get stiff as a result of adhesion formation and muscular cocontraction.^32,⁵⁰ PRRICEMM principles are applied to reduce pain, edema, and inflammation—Protection, relative Rest, Ice, Compression, Elevation, Medications, and Modalities.

Protection and Relative Rest

Appropriate protection and relative rest require balancing the need to protect healing tissues with the adverse effects of immobility. Total immobility can precipitate rapid deconditioning, whereas tenuous tissues can be easily damaged by aggressive motion.^2,^4,^21,⁵⁰ Diagnosis-specific safe elbow motion arcs guide early motion and are discussed in the next section. Bracing or splinting is often prescribed to protect healing tissues and are discussed in Chapter 11. Patients can immediately initiate general aerobic fitness programs (e.g., Exercycle) and exercises with their three unaffected limbs. With respect to the affected limb, patients may perform wrist-hand and shoulder motions while avoiding injurious elbow positions or loads. For example, shoulder abduction will produce a varus elbow stress and therefore is contra-indicated in the early post-traumatic/post-operative period after lateral collateral ligament complex injury/reconstruction.⁴¹

Ice

Physiologically, ice can reduce inflammation, modulate pain and control muscle spasm.¹⁰ Ice is applied regularly in the acute post-traumatic/postoperative period, and intermittently postexercise/postactivity in the later phases of healing.⁵⁰ Caution should be exercised when applying ice over traversing nerves, particularly those that have been surgically transposed.⁷

With respect to tennis elbow, iontophoresis appears to offer some short-term benefit,³⁸ the roles of acupuncture and shock wave therapy remain inconclusive,^8,¹¹ and pulsed electrical magnetic stimulation⁴⁷ and laser therapy⁸ appear to have no role.

IMPLEMENT EARLY ATRAUMATIC MOTION

The elbow exhibits a marked tendency to rapidly develop intra-articular and periarticular adhesions, resulting in motion loss that may eventually compromise outcome.³² Early motion is desirable to minimize or prevent adhesion formation,^32,⁵¹ mitigate against the deleterious effects of immobility,^2,^4,^21,⁵⁰ facilitate lymphatic and venous drainage,¹³ and modulate pain through proprioceptive mechanisms.^4,^13,⁵² These benefits must be weighed against the risk of irritating healing tissues, thereby deleteriously affecting the rehabilitation program.

The long-term range-of-motion goals for the patient must be established, and the patient must have a clear understanding of this goal. The potential range of motion is defined by the specific diagnosis and any post-traumatic/postsurgical anatomic alterations. Whether this potential is achieved depends on the ability of the rehabilitation program to optimize the patient’s physiology, as well as the patient’s compliance with the program. Normal elbow range of motion is 0 to 5 degrees of hyperextension, 134 to 145 degrees of flexion, 75 degrees pronation, and 85 degrees supination.^28,³⁵ Most activities of daily living are performed within 30 to 130 degrees flexion, 50 degrees pronation, and 50 degrees supination.^28,³⁵ However, some daily activities (e.g., reaching to the opposite side of the head), as well as many recreational and vocational activities, may require greater motion.^17,³⁶ The patient and the treatment team must understand the expected limitations of the elbow in the context of the potential functional needs, thereby defining realistic functional expectations for “success.”

To implement early, atraumatic motion, the clinician must completely understand the patient’s anatomy and physiologic healing stage with respect to all tissues involved—joints, capsule, ligaments, muscle-tendon units, nerves, and vessels. In addition, the elbow must be constantly reassessed for increased pain, swelling, or motion loss, and the rehabilitation program modified accordingly. The initial arc of protected elbow motion is diagnosis specific. For example, a dislocated elbow with lateral ulnar collateral ligament (LUCL) insufficiency is most stable in flexion and pronation,^15,^33,⁴⁰ whereas a dislocation with bilateral ligament injuries (LUCL and medial ulnar collateral ligament [MUCL]) and a radial head fracture is kept in neutral pronation-supination to modulate humeroradial contact stress while balancing ligamentous tension.^13,³² A normally located ulnar nerve may be irritated by excessive or prolonged flexion, whereas a transposed ulnar nerve, particularly if adhered, may be irritated by excessive or prolonged extension.⁵⁰ Interested readers are referred to Chapters 28, 29, and 48 for more diagnoses-specific in-depth discussion.

As previously discussed, elbow bracing or splinting may be protective in the postoperative/post-traumatic period by controlling position and forces, as well as providing external stability.⁹ As healing progresses to the fibroblastic and remodeling phases, braces may be used to restore motion.⁹ Appropriate prescription, application, and compliance are the keys to success.^9,^18,²⁶ Specific applications are discussed in Chapter 11.

TIMING

Once safe motion arcs have been defined, motion can be prescribed based on the stage of tissue healing.^13,⁵⁰ A complete clinical examination is necessary to determine the healing stage, as well as the specific tissue or tissues responsible for the motion loss.³² Assessing both the quality and quantity of motion loss is necessary to accurately prescribe range of motion within the restrictions. Bony motion blocks will not respond to rehabilitation efforts, and well-established soft tissue contractures with a hard end-feel will not respond as reliably as those with a springier end-feel.⁵⁰ During the inflammatory phase, range of motion must not be aggressive, and must strictly adhere to restrictions while monitoring for regression. As the elbow enters the fibroblastic and eventually remodeling phases, range of motion may become more aggressive because tissues have healed sufficiently to absorb additional forces that will be beneficial to promote collagen reformation. During these latter phases, the clinician must constantly monitor for signs of inflammation and modify the program accordingly. Four types of range of motion are typically used during elbow rehabilitation: active assisted, active, passive, and resisted.

Regardless of each type, the role of the therapist must never be so aggressive as to aggravate pain or incite inflammation.

Active Assisted Range of Motion

Active assisted range of motion (AAROM) is typically implemented earliest, including during the inflammatory phase. Goals are prevention of intra-articular and periarticular adhesions, promotion of cartilage healing, edema control, and pain modulation.¹³ Maintaining low levels of voluntary muscle activation minimizes elbow joint compression and shear forces. Gravity-assisted motion is often used during this phase, as is continuous passive motion (CPM) (see Chapter 10). Although CPM is by definition “passive,” in the early post-traumatic/postoperative period, its benefits parallel those of AAROM.

During gravity-assisted flexion, the patient is positioned supine on the table, upper limb flexed to 90 degrees, and the elbow allowed to flex under the pull of gravity, as guided and assisted by the well arm.¹³ Gravity-assisted extension may be performed sitting with the upper limb supported, and the elbow allowed to extend under the influence of gravity, assisted by the well arm.¹³ Both exercises may be initiated during the inflammatory phase with diagnosis specific restrictions. As pain and edema subside, the amount of gravity and well arm assistance may be decreased, eventually transitioning to active range of motion.

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