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Intrinsic sources of elbow stiffness include articular incongruitie and space-occupying lesions such as heterotopic ossification (HO), scar tissue, osteophytes, and loose bodies.
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Extrinsic sources of elbow stiffness include adaptive shortening of the joint capsule, musculotendinous units that cross the elbow, and ulnar or lateral ligament complexes.
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The elbow is prone to stiffness for many anatomic reasons, and ectopic bone formation occurs frequently.
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Therapeutic interventions should focus on enhancing tissue extensibility to restore elbow range of motion (ROM). Skills in orthotic fabrication are essential for treating this patient population.
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Therapists should monitor for the “gelling” phenomenon that occurs 2 to 3 weeks following open contracture release.
Basic to the treatment of a stiff elbow is a thorough understanding of the anatomy and biomechanics of the normal elbow as well as of the history of injury, management thus far, and details specific to the individual patient. Management of the post-traumatic stiff elbow and elbow contracture releases frequently prove challenging to the hand therapist. The incidence of these cases outside the tertiary hand center model is low; therefore, the hand therapist may have limited experience with the advanced custom orthotic fabrication skills needed to resolve limited elbow ROM.
Elbows are required to provide stability for both power and precision tasks in both open and closed kinetic chain activities. To provide this function the elbow must have ample motion, stability, comfort, and strength. Our elbows permit hand placement almost anywhere within a large sphere whose boundaries are defined by shoulder motion. Limited elbow motion may prevent access to the center of the sphere (our face, ears, and mouth) and to the outer layer of the sphere (our feet and high shelves). Limited elbow motion may translate into significant functional deficits. The functional capacity of the entire upper limb should be viewed as the sum of the multiple articulations. Combined reductions in arcs of motion (e.g., elbow extension and forearm supination) profoundly impact function. In the context of full ROM at the other joints of the upper extremity, it has been determined that a 100-degree arc of elbow flexion-extension from 30 degrees to 130 degrees and a 100-degree arc of forearm rotation from 50 degrees of pronation to 50 degrees of supination is adequate for the performance of most activities of daily living. Unsatisfactory elbow ROM can be the result of arthritis, orthopedic trauma, burns, head trauma, and congenital abnormalities. This chapter will focus primarily on the therapeutic management of two stiff elbow populations: patients with post-traumatic elbow stiffness and patients who have undergone a surgical contracture release. The goal of this chapter is to facilitate a comprehensive understanding of elbow joint stiffness and to present recommendations for treatment and clinical reasoning. The goal of rehabilitation for the stiff elbow is to give the patient a pain-free, functional, and stable elbow.
History
The orthopedic literature of the 20th century is pessimistic about the surgical management of the stiff elbow. The early literature often reported on a single surgical approach used on a group of stiff elbows with dissimilar pathoanatomic concerns. The subtleties and complexities of management were missed, and the results were unconvincing and unenthusiastic. Although our understanding of the basic science of elbow stiffness has not progressed significantly, the introduction of effective surgical options and the collection and publication of successful outcomes have resulted in a more positive outlook on the management of the stiff elbow. The surgical procedures are still considered technically challenging, but expertise in the area is growing and the risks of complications are dropping. Sustainable improvements in motion and function are now realistically attainable goals.
Etiology of the Stiff Elbow
Mohan reported that in a group of 200 stiff elbows, 38% were fracture dislocations, 20% were dislocations, and 30% were isolated fractures. However, duration of immobilization following injury appears to be highly correlated with the development of an elbow contracture. Elbow joint motion is restricted by “blocks” and “tethers.” A block is analogous to a doorstop, a tether to a shortened leash. In a given stiff elbow there can be one (rare) or a combination of a few of each. The mix of blocks and tethers may change as the elbow progresses through its phases of injury, surgery, and rehabilitation. To aid in the treatment of contractures, classification systems have been developed based on etiology, pathology, and location of stiffness within the arc of motion.
Contractures are grouped by direction of limitation. A flexion contracture describes an elbow that lacks extension. Elbow flexion contractures are more common than extension contractures and are generally easier to manage surgically. A lack of extension can be compensated for with trunk flexion and shoulder motion. An extension contracture describes an elbow that lacks flexion. Elbow extension contractures are less common and more difficult to manage surgically. Because neck flexion and wrist flexion are the only available compensatory motions, loss of elbow flexion is more functionally limiting. The posterior capsule is rarely the cause of extension contractures. More often it is adherence of the triceps to the posterior humerus and the joint capsule. A pronation contracture describes a forearm that lacks supination. It is seen more commonly than a supination contracture , which describes a forearm that lacks pronation. Pronation is required for many activities of daily living, such as keyboard use, but a deficit can be compensated for with shoulder abduction. Supination is needed for tasks such as extending the palm to receive change or holding a tray, but compensation for the lack of supination is very difficult.
Morrey developed a classification system based on the factors causing the contracture, whether intrinsic, extrinsic, or mixed ( Fig. 80-1 ) This system is designed to help with decision making about surgical and therapeutic interventions. Extrinsic factors include contracture of the soft tissues (joint capsule, collateral ligaments, muscles), extra-articular malunions, and HO. The pathology that is limiting the elbow motion exists outside the joint complex. Extrinsic causes of elbow contracture are treated with resection of the contracted structures. They typically respond well to therapy interventions including therapeutic exercise such as stretching and strengthening as well as the use of orthoses to restore motion. Intrinsic factors include intra-articular adhesions, articular misalignment, loss or destruction of articular cartilage, malunions of the distal humerus or proximal ulna and radius, osteophytes, and loose bodies. Changes within the joint complex are causing the loss of motion. A common cause of incongruity of the ulnohumeral joint is malunion of a T or Y condylar fracture of the humerus or a malunion of the olecranon. Surgical management of intrinsic causes of a stiff elbow require correction of the articular anatomy. Only after surgical restoration of the articular surfaces has occurred are rehabilitation interventions effective in regaining functional use of the elbow. Mixed contractures include both intrinsic and extrinsic factors. As a general rule, intrinsic contractures almost always have an extrinsic component. Damaged articular surfaces lead to decreased motion, which leads to adaptive shortening of the capsule, muscles, and ligaments. The elbow joint has several unique anatomic features that make it particularly prone to post-traumatic stiffness. First, the brachialis muscle belly lies right over the anterior joint capsule. Usually tendons, not muscle bellies, cross joints. When injury occurs, the brachialis muscle tears and bleeds. Scarring and adherence to the anterior joint capsule result. Second, the properties of the capsule make it sensitive to the chemical irritant of blood and to the effects of trauma. Fibrosis of the tissue results. In animal models, elevated numbers of myofibroblasts that have highly contractile properties are seen in the extracellular matrix of capsular and ligamentous tissue following trauma. The anterior capsule tends to tear with injury to the elbow joint, while the posterior capsule typically does not. Third, the ulnohumeral joint is highly congruent, and all three articulations exist in one capsule. Fourth, there is a close interrelationship among the joint capsule and the intracapsular ligaments. Finally, the elbow joint is prone to the development of HO.
Ectopic ossification is defined as the formation of pathologic bone. HO, MO (myositis ossificans), and periarticular calcification are types of ectopic ossification. There is an inappropriate and pathologic deposition of extra-articular bone with both HO and MO. MO forms in damaged muscle, and HO forms in nonosseous tissues. Periarticular calcification is the deposition of calcium pyrophosphates in soft tissues around joints, affecting primarily the capsule and collateral ligaments. While the structure of HO and MO are histologically identical to native bone, there are some distinct differences. Ectopic bone is not covered by a layer of periosteum; it has more osteoblasts than normal bone and almost double the number of osteoclasts. On a biochemical level, the events that promote its development are unclear or not known. Trauma appears to stimulate a cascade of events resulting in the differentiation of pluripotential mesenchymal cells into osteoblasts. It is thought that products of the torn muscle, soft tissue, and blood contain undifferentiated cells that differentiate to form bone when exposed to inductive agents such as growth factors and hormones.
The prevalence of clinically significant HO at the elbow is not known. Estimates as low as 3% have been observed. There is a very high incidence when there is neurologic involvement (head trauma) or thermal burns. HO seems to form in predictable patterns about the elbow. Common sites include the posterolateral aspect of the elbow, the lateral and ulnar collateral ligaments (LCL, UCL), the coronoid process, and the formation of a bony bridge anteriorly between the humerus and the radius/ulna that locks the elbow at 90 degrees of flexion ( Fig. 80-2 ). Typically the onset of HO is about 2 weeks after trauma or surgery. Clinically, there is a direct correlation between the severity of the injury and the magnitude of ectopic bone formation. Symptoms include localized swelling, erythema, hyperemia, warmth, tenderness, pain, and a progressive loss of motion. Differential diagnosis includes infection, thrombophlebitis, and complex regional pain syndrome. HO can be seen on plain radiograph at about 6 weeks after development. Prophylactic treatment of HO includes two pharmacologic interventions (diphosphonates and indomethacin) and low-dose external beam radiation. Diphosphonates inhibit osteoid cells from calcifying, and indomethacin (a nonsteroidal anti-inflammatory medication) inhibits undifferentiated cells from differentiating into osteoblasts. The use of indomethacin for the first 3 weeks postoperatively is described in the literature, but research on its efficacy is inconclusive. A dosage of low-dose external beam radiation within the first 72 hours of surgery is used to prevent bone cell proliferation. HO is not excised until it has matured. Maturity is described as the presence of defined cortical margins and trabecular markings. This occurs by about 6 months. It is important to note that the belief that passive ROM (PROM) and stretching promotes the formation of HO has not been proven.
Relevant Anatomic and Kinematic Concepts
The concepts included below either contribute to the development of the stiff elbow or may influence rehabilitation.
Joint Stability
The three primary static constraints of the elbow are the ulnohumeral articulation, the anterior bundle of the UCL, and the LCL complex. The UCL is also known as the medial collateral ligament . It is estimated that 50% of the stability of the elbow is provided by the ulnohumeral articulation alone. Every effort is made to preserve these components during contracture release operations. Secondary constraints include the radiocapitellar articulation, the common flexor and extensor tendons, and the joint capsule. The muscles that cross the elbow provide dynamic stability by compressing the joint when they contract. Interestingly, the anconeus muscle is considered a dynamic constraint to both varus and posterolateral rotatory forces rather than a contributing elbow extensor.
Contraction of the biceps and the brachialis generates a force that posteriorly translates the ulna off the distal humerus. If it were not for the buttress effect of the coronoid process, the ulna would slip off the end of the humerus posteriorly, taking the radial head (and radius) with it. If the latter does occur, this is referred to as posterolateral rotatory instability. Awareness of the status of coronoid and radial head of one’s patient is important with respect to lateral elbow stability. Was the coronoid adequately restored? Was the radial head replaced with an appropriately sized prosthesis? The lateral ulnar collateral ligament (LUCL) of the LCL complex travels from the lateral epicondyle of the humerus to the ulna, enveloping and securing the radial head. It resists varus forces at the ulnohumeral joint, prevents external rotation of the ulna off the distal humerus, and supports the position of the radial head. The elbow experiences varus forces in almost every activity involving upper extremity reach. The elbow rarely experiences valgus forces except during handstands and overhead throwing. The medial facet of the coronoid also plays a role in resisting varus forces.
The UCL-deficient elbow on the medial side is most stable in flexion with supination. The LCL-deficient elbow is most stable in flexion with pronation. For coronoid fractures that involve more than 50% of the coronoid (with or without the UCL), the elbow is more stable in supination than pronation.
The radial head is responsible for 30% of the elbow’s ability to resist valgus forces. Its role becomes increasingly important in the context of UCL injury or deficiency. In the presence of an intact UCL, the radial head can be excised without compromising stability. In elbow extension, the radial head has no contact with the capitellum. During flexion, the radial head moves proximally and contact increases. So, if a radial head implant is too big (the radiocapitellar joint is “overstuffed”), the prosthesis may block flexion. Radiocapitellar contact increases with pronation and decreases with supination.
Kinematics
The axis of rotation for elbow flexion and extension passes through the centers of the trochlea and capitellum. It can be approximated by a line connecting the lateral and medial epicondyles of the distal humerus. The fact that the axis of flexion and extension is close to fixed through the arc of motion permits hinged external fixation-distraction devices to work. Such devices are used in distraction arthroplasties (with or without interposition) to maintain a constant 3-mm gap between the distal humerus and the proximal ulna throughout the arc of flexion-extension motion. The axis of rotation for forearm rotation passes through the fovea of the radial head and the head of the ulna. It travels obliquely through the forearm, reflecting the path that the radius takes as it rotates around and crosses the relatively stable ulna during pronation.
The interosseous ligament (IOL) links the radius and the ulna in the forearm. The fibers of the ligament run obliquely, which facilitates the transmission of force moving proximally from the radiocarpal joint to the ulna and ultimately to the humerus as it travels to the axial skeleton. If the IOL is damaged, forces will not be effectively transmitted to the ulna and increased forces will be experienced at the radiocapitellar joint. The IOL is slack in forearm pronation and taut in supination. So, when a person falls on a pronated forearm (a common occurrence), the radial head is less protected from fracture-generating forces.
During closed-chain activities such as pushing a door open, using a screwdriver, or walking with crutches, the elbow is maintained in a fixed position and forces from proximal muscles or body weight are transmitted through the elbow to the hand. During open-chain activities, the elbow is moving within a sphere around the body to place the hand in the most appropriate place for task performance: bringing a fork to your mouth, throwing an object.
The close-packed position of a joint is the end-range position in which the joint is maximally congruent and the tension in the supporting connective tissues is the greatest. The close-packed position of the ulnohumeral joint is extension because of the wedge effect of the olecranon in the olecranon fossa. The close-packed position of the radiohumeral joint is flexion, because the radius is pulled proximally into the humerus during flexion. The close-packed position of the proximal radioulnar joint is supination due to tension in the IOL. Understanding these mechanical concepts helps us understand the biomechanical basis of ROM activities.
Joint Capsule
The elbow joint capsule provides most of its stabilizing effects when the joint is fully extended. The volume or capacity of the capsule is 25 to 30 mL. Intra-articular pressure is lowest at 70 to 80 degrees of flexion. This is why patients prefer to keep their injured elbow at about 80 degrees of flexion. When the elbow spends prolonged periods of time in this acutely flexed position, the anterior capsule shortens, the brachialis and biceps shorten, and the collateral ligaments adapt to this position, which results in difficulty regaining extension of the elbow.
Nonoperative Management of the Stiff Elbow
Patients who have sustained closed trauma to the elbow such as a dislocation that was reduced or a nondisplaced fracture that did not require surgery are likely to develop elbow stiffness, along with patients who have undergone open reduction and internal fixation of a fracture of the distal humerus, proximal ulna, or radial head, with or without dislocation. Often it is not entirely clear why they have gone on to develop a post-traumatic stiff elbow. In some cases it is because the patient is not referred for therapy until 6 to 8 weeks following injury, after the stiffness and limitation of motion have become established.
Examination
Therapeutic intervention begins with and is based upon a thorough history and musculoskeletal examination. The history should include a review of medical reports, operative reports (if any), radiographs or other imaging studies, and the patient’s account of the mechanism of injury or onset. The goal of the physical examination is to systematically examine all the structures that potentially contribute to elbow stiffness.
Range of Motion
Active (AROM) and PROM measurements of the elbow and forearm are required with screening of the scapulothoracic, shoulder, wrist, and digit ROM. Motion limitations present in the “uninvolved” joints of the involved upper extremity tend to compound the effects of the elbow joint limitations.
Pain
Generally, post-traumatic elbow stiffness is not painful at rest or during motion through the available range. Pain through the range can be indicative of intra-articular pathology such as arthritis, articular incongruity, articular cartilage damage, or HO. Complaints of pain at the end-ranges of motion are quite common. A stretching pain (feels like a very tight rubber band) is expected. Complaints of paresthesias or sharp, “electric” pain at end-range flexion are red flags for ulnar nerve adherence, irritation, or compression.
Edema
Edema at the elbow, forearm, and hand can be significant after injury to the elbow and may persist with post-traumatic stiffness. Edema can be documented with measurements of circumference and volume.
Nerve Function
Sensory and motor function of the median, ulnar, and radial nerves is assessed with a screening examination of sensibility and targeted manual muscle testing of two key muscles for each nerve. If deficits are noted with screening, a more detailed neurologic examination is required.
Muscle Length
The biceps muscle is prone to adaptive shortening following elbow injury. This is secondary to prolonged posturing in acute elbow flexion and also the postinjury phenomenon of constant, reflex-like firing (spasm) of the biceps as the body attempts to splint or stabilize the joint. A pronated forearm position may relax the biceps and allow increased elbow extension. After injury, the biceps muscle contracts in response to the force that gravity exerts on the forearm. For this reason, the therapist should examine elbow extension ROM in a gravity-eliminated position. The triceps can also become tight with immobilization. It is important to remember that both the biceps and triceps are two-joint muscles and the position of the shoulder will impact their excursion at the elbow (see Figs. 80-3A,B and 80-4A,B online). Most of the extensor-supinator muscles and the flexor-pronator muscles cross both the elbow and wrist joints, so their excursion at the elbow will be impacted by wrist and forearm positions.
Capsular Tightness
By carefully positioning the shoulder, wrist, and digits to avoid stretch of the two-joint muscles, the impact of muscle tightness versus capsular tightness on elbow ROM can be assessed.
Muscle Inhibition
Following elbow injury, patients often have trouble recruiting and firing the triceps muscle. This may be due to reciprocal inhibition resulting from hyperactivity of the biceps. Examining and working the triceps with the patient in supine position and the shoulder at 90 degrees of forward flexion can be effective (see Fig. 79-3C ). The pull of gravity on the biceps is eliminated so that reciprocal inhibition of the triceps is decreased, and the therapist can easily assist extension if the patient is not able to fully overcome the force of gravity.
Scar
Scar adherence and/or hypersensitivity can limit elbow ROM and should be documented.
Blocks and Tethers
A careful assessment of the end-feel of elbow and forearm ROM is included in the initial assessment. Scar tissue filling the olecranon or coronoid fossae or osteophytes on the coronoid, olecranon processes are noted if present.
Tracking
Careful assessment of the tracking of the ulnohumeral joint as it moves through the arc of flexion and extension is conducted by placement of the examiner’s thumb and middle finger on the medial and lateral epicondyles and the index finger on the olecranon while moving the elbow through flexion and extension to determine congruency of the joint surfaces.
Function
A thorough assessment of the patient’s ability to perform basic activities of daily living as well as tasks unique to their work, leisure, and roles and responsibilities at home or in the community is necessary. Self-report measures discussed later in the chapter will assist the therapist in obtaining this information. Figure 80-5 illustrates a useful assessment of elbow function.
Treatment
Thermotherapy
Superficial heat applied at the end-range of motion is an effective way to prepare the soft tissue for active and passive range of motion exercises and stretching. Ultrasound may also be used for its deep heating effects.
Manual Therapy
Depending on the training and expertise of the therapist, a wide variety of soft tissue techniques can be effective for increasing elbow ROM. Some examples are soft tissue massage and mobilization, myofascial techniques, joint mobilization, contract-relax or hold-relax techniques, and muscle energy techniques. Aggressive, painful PROM or stretching is contraindicated, as it provokes episodes of repeated, involuntary muscle guarding. This type of aggressive stretching can cause tissue injury and inflammation, which lead to secondary fibrosis of the soft tissue and sabotage efforts to regain joint ROM. Coaxing, not coercing, joint ROM is recommended.
It is convenient to start the patient’s treatment in the supine position. Superficial heat (hot pack) is applied in a tolerable end-range position for 10 to 15 minutes. Ample layers of toweling, especially over bony prominences (e.g., olecranon process) should be used. Soft tissue mobilization techniques follow the thermotherapy. This sequence prepares the patient well for a session of active assistive ROM (AAROM) exercises. The therapist guides the patient through repetitions of flexion, extension, pronation, and supination, providing tactile and verbal cues for muscle recruitment. Slight overpressure at end-range can be applied if the patient does not respond with counterproductive muscle guarding. When working on flexion, grasping just the patient’s wrist should be avoided. A wide contact over the entire length of the ulnar aspect of the patient’s forearm with the therapist’s hand and forearm is better tolerated. When working on extension, the therapist’s superior elbow and forearm may be used to stabilize the patient’s shoulder and upper arm while the inferior arm guides the patient’s forearm movement. As stated previously, more extension may be obtained when the patient’s forearm is in pronation because the biceps is inhibited. After each motion has been addressed, combinations of flexion + supination and extension + pronation through a full arc of motion can be performed. The soft tissue mobilization and AAROM component of the patient’s therapy session is time-consuming and requires one-to-one time and focus.
Therapeutic Exercise
Activities and exercises that incorporate elbow motion into a functional task are recommended. An emphasis is placed on recruiting the triceps muscle. There are many creative ideas for these exercises: Placing cones on a high surface and then retrieving them, putting pegs in a pegboard that is mounted to a wall, turning pages in a magazine, etc. Pulleys and upper body ergometers are also useful for repetitive, cyclical elbow motion. Outside of therapy, patients may carry a bag with a light object (can of soup) during prolonged walking activities. Be sure to instruct them to let the bag lightly stretch the elbow. If they respond to the weight with biceps contraction, this is not a beneficial exercise for them. In general, deficits of flexion and pronation respond well to functional activities, and deficits of extension and supination require the use of long-arm orthoses to restore motion.
Orthoses to Increase Motion
The use of static and static progressive long-arm orthoses is an important component of treating the stiff elbow ( Fig. 80-6 online). It is particularly effective in patients whose contractures are not long-standing and who have little articular involvement. Orthosis wearing schedules vary widely in the literature. Each patient’s schedule will be based on tolerance, extent of motion loss, and logistical issues such as other demands on their time. Understanding the rationale behind orthosis use for post-traumatic and post–contracture release elbow stiffness will guide the therapist’s recommendations regarding orthotic fabrication and wearing schedules. Excessive use of orthoses may cause pain that does not resolve soon after orthosis removal. A static progressive orthosis is one that holds the elbow at an end-range, fixed position and imparts torque to the joint in that position. As the soft tissue and capsule elongate in response to the positioning, the force dissipates. The orthosis is then repositioned (usually by further tightening straps or extending a turnbuckle) to again apply torque to the joint. The soft tissue is progressively elongated through cycles of stretch and accommodation. Static orthoses hold the joint at its end-range for prolonged periods of time (typically overnight). Little or no force is imparted. Dynamic orthoses use a spring or elastic to exert a constant stretch. This unforgiving, constant stretch often provokes muscle spasm, which defeats the purpose of tissue elongation and is often poorly tolerated. The use of static progressive orthoses can begin as soon as the incision and the fixation can tolerate it. Immediate postoperative pain and swelling should be allowed to resolve. The orthoses can be used for 30- to 60-minute periods, four to six times per day. If the patient requires orthoses for both flexion and extension, the schedule is modified. At night patients usually wear an extension long-arm orthosis to position their elbow at end-range extension. Positioning the elbow in flexion during the night is poorly tolerated due to tensioning of the ulnar nerve if it has not been transposed. The critical points and tips about the use of orthoses are located in Boxes 80-1 through 80-5 .
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Prolonged positioning of the elbow at 90 degrees should be avoided.
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Frequent joint motion should be encouraged to glide the articular surfaces and reduce edema.
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Static progressive long-arm orthoses have been shown to be effective.
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A night extension orthosis prevents overnight posturing in a midrange joint position.
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Orthosis use is not effective in the presence of intrinsic pathology or bridging/blocking HO.
Orthotic fabrication tips: See Figure 80-6 (online) and Figures 80-7A–D, 80-8A–E, 80-9 , and 79-13 for examples of orthoses used in the treatment of the stiff elbow. Boxes 80-2 through 80-5 review important tips for each type of orthosis.
