Post-traumatic elbow stiffness: An overview

Let’s face it, the elbow is complicated. There’s a lot going on in a small area, which means trauma can have a unique impact on the functionality of the elbow complex as a whole. Management of post traumatic elbows can be tough; the lack of best-practice guidelines leaves us contemplating what the best way forward will be. Decision making in treatment is a balancing act between ensuring the integrity of the joint and honouring healing time frames, while also mitigating the risk of post-traumatic complications.

Before we get into it, check out this Masterclass HERE by Val Jones, which will take your assessment and treatments of elbow issues to the next level.

The elbow problem

Post Traumatic Elbow Stiffness (PTES) is a common complication with elbow injuries. Trauma is the most common cause of elbow stiffness, and approximately 10-15% of patients experience reduction in range of motion, and do not recover (1).

Stiffness can be caused by a range of things such as joint contracture, heterotopic ossification, or arthritic degeneration. The elbow is particularly prone to becoming stiff compared to other joints for a range of additional reasons. Firstly, there are three joints which share a synovial space, and there is a close relationship between the capsule, ligaments and muscles, so if one area is affected it is likely to affect the complex as a whole.

Secondly, the elbow lacks proprioceptive input compared to other joints – it is awful at knowing where it is in space, which makes rehabilitation all the more difficult.

Thirdly, the lack of understanding and consensus around the best management for injuries such as dislocations can cause patients to become fear avoidant – being worried the elbow will not heal or will become unstable if they move it too much too early has the potential to significantly impact rehabilitation.

PTES is not just an issue for the sporting population, stiffness can affect everyday tasks such as putting make up on, holding a mobile phone to your ear and feeding yourself with a fork – all of these things can be taken away from a patient if they don’t have the a functional range of motion in the elbow.

Look out for the stiff patient

As clinicians we need to identify those who are at risk of developing a stiff elbow. While the evidence is limited regarding risk factors for developing PTSE, below are some risk factors suggested by the research:

• High energy injury (2, 3)
• Time from injury to surgery >1week for terrible triad injury (2)
• Immobilisation time > 2 weeks for terrible triad injury (2)
• Increased cast immobilisation for conservative population (4)
• Multiple surgeries (4)

In her Masterclass ‘The Elbow Demystified’, Val Jones suggests people with a higher risk of developing stiffness are those who experience higher levels of pain, or concurrent nerve injury. Interestingly, she also notes high levels of anxiety causing fear avoidance as a potential contributor to the development of elbow stiffness.

The elbow solution

We need to counteract the effect PTES is having on the ability of our patients to recover and live their daily lives. It is important to note here that we are not even asking for a full pain-free pre-injury range of motion. We can settle for a functional range; that is, 100 degrees of flexion-extension, and 50 degrees each of pronation and supination (5).

So we know the goal – there seems to be a disconnect about how to go about achieving this goal. Traditionally, patients have been immobilised immediately post injury to protect the integrity of the elbow; while this may be appropriate in some cases, there are others in which it may be detrimental to their recovery. For example, the FuncSie trial compared immediate mobilisation with plaster immobilisation after elbow dislocation and found similar rates of complications among groups, with the early mobilisation group able to return to sport and activities quicker (6).

In her Masterclass HERE, Val Jones outlines the Sheffield regime for immediate mobilisation in order to gain the best outcomes for patients. Val notes the importance of specialist-physiotherapist communication to figure out a safe mobilisation plan for each individual patient, as well as the use of overhead mobilisation in the management of contractures.

Treatment should address the inherent lack of proprioceptive input the elbow has – it can be useful to use tactile feedback such as a tubigrip around the elbow during exercise. Additionally, graded mirror imagery has recently been applied to improve function, elbow AROM, pain, fear of movement and muscle strength (7).

Lastly, recent research has found that people with PTES may experience significant depression and anxiety symptoms (8) – therefore, identifying and addressing these symptoms may be important in the holistic management of the post-traumatic elbow patient.

Wrapping up

There are a range of factors which need to be considered when managing a post-traumatic elbow. It is important to keep in mind the prevalence of stiffness and the level of impact it can have on a patient’s function and participation in life. While we need to respect healing time frames, multidisciplinary communication seems to be the key to enhancing early mobilisation and providing improved outcomes for people.

If you found this useful, check out the Masterclass by Val Jones HERE to improve your assessment and management of elbow issues.