Management of Lateral Epicondylitis

Initial acute management focuses on resolving pain and swelling with the judicious use of ice massage directly over the affected area, phonophoresis or iontophoresis, physician-prescribed analgesics and nonsteroidal antiinflammatory drugs (NSAIDs), rest, and protection of the area from unwanted stress to allow for healing.8,23,28

Relative rest rather than strict immobilization is used. A wrist cock-up splint can be used in severe cases to minimize stress on the inflamed wrist extensor tendons. The patient is allowed to remove the splint as needed to participate in controlled motion exercises that do not produce pain. Long-term, rigid immobilization is not indicated, because treatment goals are to not only reduce pain and swelling but also to encourage proper collagen alignment and scar tissue maturation.²³ Without early protected motion, excessive tissue scarring and random collagen fiber alignment would severely limit normalized motion and function of the elbow and wrist.

During the initial healing stage, the PTA must encourage the patient to avoid any and all motions that may adversely affect healing. Short-term modifications in activities of daily living (ADLs), sports, and job-related activities must be addressed to provide a pain-free environment for healing. When this initial program fails to bring significant relief of symptoms, some physicians elect to inject the area with a steroid to reduce the inflammation.20,23

In addition, active gentle static stretching is advised for the wrist extensors to produce normalized, pain-free wrist flexion and extension (Fig. 22-2). Although specifically addressing treatment for the elbow, active motion and resistance exercises for the elbow and shoulder can be initiated if no wrist motion occurs to increase symptoms.

The PTA can enhance the effectiveness of low-load, long-duration static stretching by applying moist heat packs (provided the acute inflammatory process has ended) or ultrasound to the lateral epicondyle to stimulate local circulation and relieve congestion caused by metabolic waste products and relax soft tissues in preparation for stretching.

Resistance exercise can begin as pain is reduced with active motion exercises. Generally, submaximal isometrics are used for wrist extension, flexion, forearm pronation and supination, and radial and ulnar deviation.

The PTA must carefully instruct the patient to perform all exercises within a pain-free range of motion (ROM). Throughout all phases of recovery, the patient must avoid stressful, pain-producing activities to prevent the exacerbation of the inflammatory condition. Progressive motion exercises and increased resistance exercise are the foundation for a return to functional activities. Concentric and eccentric muscle contractions are added once the patient can demonstrate increased quality of multiangle isometric contractions. Care must be taken when initiating both concentric and eccentric resistance exercises because frequently these contractions produce symptoms. Light resistance is advocated when having patients perform these exercises for the first time. An important component for all resistance exercises used with lateral epicondylitis is the performance of slow, controlled eccentric contractions. Eccentric muscle contractions produce greater tension than either concentric or isometric exercise. In addition, energy use involving adenosine triphosphate (ATP) is less for eccentric exercise than for either concentric or isometric exercise. Eccentric muscle contractions are, in fact, advocated by Curwin and Stanish⁸ for the treatment of tennis elbow, and the rationale for the performance of eccentric exercise is described by Reid and Kushner²⁴ as, “Exercising the muscle eccentrically allows it to withstand greater resistance and prevent injury, which occurs by eccentrically loading an inflexible muscle.”²⁴

Resistive exercises emphasizing the eccentric phase are described in Figure 22-3, A-B. A hammer is an effective strengthening tool for the treatment of lateral epicondylitis. However, when instructing the patient to perform pronation and supination of the forearm for the first time, the PTA should have the patient hold the hammer close to its head (Fig. 22-3, C). As the patient gains strength and can control the resistance of the hammer eccentrically, the patient should gradually hold the hammer at the midshaft. As strength improves further, the patient should be allowed to hold the hammer at the end of the shaft, which requires greater eccentric muscle control, strength, and torque. In the same manner, strength can be gained for radial and ulnar deviation through use of the hammer. With a gradual return to functional activities, some physicians and therapists advocate the use of a counterforce brace to help dissipate the “overload forces” on the common origin of the wrist extensors (Fig. 22-3, D).^8,20,28

Surgery is rarely necessary for this condition because physical therapy management frequently is effective. In rare instances when conservative means fail to reduce pain and improve function, the surgeon may elect to surgically excise the “angiofibroblastic tissue at the origin of the extensor carpi radialis brevis muscle.”²⁹

Medial Epicondylitis

Medial epicondylitis, an overuse condition, affects the origin of the pronator teres, flexor carpi radialis, flexor digitorum sublimis, and flexor carpi ulnaris at the medial epicondyle of the elbow.²³ Although it occurs less often than lateral epicondylitis (the ratio of lateral epicondylitis to medial epicondylitis is 7:1),²⁸ it is no less incapacitating to the patient. Again the dominant feature is pain with palpation over the medial epicondyle, active motion, and particularly with resisted wrist flexion and full passive wrist extension (Fig. 22-4).^23,24

Medial Valgus Stress Overload

Injuries to the elbow often occur in the overhead athlete. The repetitive overhead motion involved in throwing is responsible for unique and sport-specific patterns of injuries to the elbow. These are caused by chronic stress overload or repetitive micro-traumatic stress observed during the overhead pitching motion as the elbow extends at over 2300°/s, producing a medial shear force of 300 N and lateral compressive force of 900 N.11,32 In addition, the valgus stress applied to the elbow during the acceleration phase of throwing is 64 N·m,^11,32 which exceeds the ultimate tensile strength of the ulnar collateral ligament.¹⁰ Thus the medial aspect of the elbow undergoes tremendous tensile (distraction) forces and the lateral aspect is forcefully compressed during the throwing motion.

Medial valgus stress overload, also known as valgus extension overload (VEO) occurs commonly among patients who participate in repetitive throwing and racquet sports such as javelin throwing, baseball, racquetball, and tennis.9,21,23 The overhead athlete is susceptible to these specific elbow injuries. A number of forces act on the elbow during the act of throwing,^11,32 including valgus stress with tension across the medial aspect of the elbow. These forces are maximal during the acceleration phase of throwing. Compression forces are also applied to the lateral aspect of the elbow during the throwing motion. The posterior compartment is subject to tensile, compressive, and torsional forces during acceleration and deceleration phases. This may result in valgus extension overload within the posterior compartment, leading to osteophyte formation, stress fractures of the olecranon, or physeal injury.^1,35 These stresses approach the ultimate failure load of the ligament with each throw. The repetitive nature of overhead throwing activities such as baseball pitching, javelin throwing, and football passing further increase the susceptibility of medial elbow injuries including ulnar collateral ligament (UCL) injuries, by exposing the ligament to repetitive micro-traumatic forces. Clinical differences exist between medial valgus stress overload and medial epicondylitis. Although medial epicondylitis represents a chronic overuse syndrome affecting the soft-tissue musculotendinous origin of the wrist flexors and pronators, medial valgus stress overload occurs to the capsuloligamentous structures (medial [ulnar] collateral ligament) as a result of repetitive valgus stress to the elbow (Fig. 22-5).^9,21,23

Patients usually complain of pain over the medial aspect of the elbow and the posterior aspect of the olecranon.21,23 During the physical therapist’s (PT) initial evaluation, the PTA may observe the performance of ligament stability tests to confirm the presence of UCL laxity. The affected arm is held in 20° to 30° of flexion while the humerus is held in full external rotation to unlock the olecranon process from the olecranon fossa. A medial or valgus stress then is applied to the elbow to assess the stability of the UCL (Fig. 22-6).^21,23

Management of Medial Valgus Stress Overload

Management of valgus stress injuries must take into account the healing constraints of ligaments. The patient may receive physician-prescribed NSAIDs, analgesics, ice massage, phonophoresis, or iontophoresis to reduce pain and swelling. Rest and protection of the injured medial ligamentous structures, while avoiding valgus stress, are the hallmarks of management. Because most of these injuries occur to active sports enthusiasts, the patient must omit activities that produce medial valgus stress. To ensure compliance, it may be necessary to suggest short-term rest from the activity, during which the patient should participate in running, cycling, and strength training and should perform flexibility exercises as long as no valgus load is applied to the elbow joint. In addition, the wrist, hand, and shoulder of the affected limb must be exercised during each phase of recovery.

The elbow is predisposed to flexion contractures due to the intimate congruency of the joint articulations, the tightness of the joint capsule, and the tendency of the anterior capsule to develop adhesions following injury.³³ The brachialis muscle also attaches to the capsule and crosses the elbow joint before becoming a tendinous structure. Injury to the elbow may cause excessive scar tissue formation of the brachialis muscle as well as functional splinting of the elbow.³³ Gentle low-load static stretching begins as soon as pain allows. Therefore the stretching regimen focuses on all wrist motions, forearm pronation and supination, and elbow flexion and extension as long as no symptoms of pain occur with these activities. If the patient continues to have difficulty achieving full extension using ROM and mobilization techniques, a low-load, long duration (LLLD) stretch may be performed to produce a deformation (creep) of the collagen tissue, resulting in tissue elongation.^12,27,30,31 This technique is extremely beneficial for regaining full elbow extension. The patient lies supine with a towel roll or foam placed under the distal brachium to act as a cushion and fulcrum. Light resistance exercise tubing is applied to the wrist of the patient and secured to the table or a dumbbell on the ground (Fig. 22-7). The patient is instructed to relax as much as possible for 10 to 15 minutes per treatment. The amount of resistance applied should be of low magnitude to enable the patient to perform the stretch for the entire duration without pain or muscle spasm. This technique should impart a LLLD over a prolonged period of time to achieve maximal benefits. Patients are instructed to perform this stretch technique several times per day, equaling 60 minutes of total end range time. Patients may perform a 15 minute stretch, 4 times per day.¹⁶ This program has been extremely beneficial for patients with a stiff elbow.

The strengthening component of recovery must be modified to prevent any valgus stress or pain at end range extension. This ensures that the healing ligament is not receiving any additional tensile forces that may affect the healing capacity. Full ROM (flexion-extension) concentric and eccentric resistance exercise is allowed with light weights as motion and pain dictate. Wrist and hand exercises are encouraged early and pose no threat to the healing ligament. In addition, forearm pronation and supination with use of a hammer (as outlined) is employed as the patient is able to demonstrate improved motion without pain.

With time, the PT reassesses the stability of the medial collateral ligaments. If these structures demonstrate improved stability without pain, a gradual return to throwing can begin.

Surgery is considered if conservative treatment fails to restore function and eliminate pain. Degenerative changes, which are usually present in the adult, must be addressed surgically.21,24 In general, an osteotomy is performed to remove osteophytes (bone spurs) and fibrotic, degenerated tissue.^21,24

Acute rupture (grade III ligament rupture) of the medial (ulnar) collateral ligament can occur in skeletally mature adults if valgus stress is applied suddenly with sufficient force (Fig. 22-8).

First, these patients are managed conservatively with ice, NSAIDs, analgesics, and, most important, rest and protection. The progression from the acute, maximum-protection phase to return-to-normal function parallels treatment outlined for valgus stress injuries. However, because the ligament has been ruptured, a longer period of recovery is needed and rest and joint protection from valgus stress will last longer. Normal elbow function, which means flexion, extension, pronation, and supination, should be encouraged as early as pain and motion allow.

If early active protected joint motion and progressive resistance exercise have been used, authorities suggest that the injured patient can resume throwing activities approximately 3 months after injury.²¹ However, surgery may be necessary to stabilize the joint if the patient does not demonstrate improved valgus stability and continues to have dysfunction.

Generally if the ulnar collateral ligament is ruptured midsubstance, a direct repair is carried out and a reconstructive procedure is performed. The palmaris longus or gracilis graft source is taken and passed in a figure-of-eight pattern through drill holes in the sublime tubercle of the ulna and the medial epicondyle.² A subcutaneous ulnar nerve transposition is performed at the time of reconstruction. Some surgeons are presently performing UCL reconstruction utilizing the docking procedure, as described by Rohrbough and colleagues.²⁶

Postoperative rehabilitation begins immediately, with the patient’s affected limb immobilized in a brace to protect against valgus stress. Instructions are given to perform hand, wrist, and shoulder exercises to maintain motion. Usually by the third week postoperatively, ROM should approach at least 20° of extension while slowly progressing to 110° of elbow flexion.⁹ The continuous use of ice and therapeutic agents (e.g., ultrasound, transcutaneous electrical nerve stimulation, and galvanic stimulation)²⁴ are prescribed as necessary. Progressive resistance concentric and eccentric contractions are used for the wrist of the involved limb, whereas submaximal isometrics can begin for elbow flexion and extension.

Shoulder strengthening and flexibility exercises also can begin during the third week of recovery.⁹ However, care must be taken to avoid external shoulder rotation exercises because this motion produces valgus stress on the elbow.⁹

Usually by 4 to 6 weeks after surgery, ROM should be 0° to 130°.⁹ In addition, concentric and eccentric resistance exercises for elbow flexion and extension are added progressively as tolerated. Gentle forearm pronation and supination exercises also can be made more challenging. From 2 to 4 months after surgery, functional training can begin with an emphasis on shoulder, elbow, and wrist strengthening, motion exercises, and plyometrics. Plyometric drills can be an extremely beneficial form of functional exercise for training the elbow in overhead athletes.^33,34 Plyometric exercises are performed using a weighted medicine ball during the latter stages of this phase to train the shoulder and elbow to develop and withstand high levels of stress (Fig. 22-9). Plyometric exercises are initially performed with two hands performing a chest pass, a side-to-side throw, and an overhead soccer throw. These may be progressed to include one hand activities such as 90/90 throws, and wall dribbles. For patients returning to sports that involve the upper extremity, such as golf, tennis, javelin, baseball, and softball, these patients are placed on an interval sport program as described by Reinold and colleagues.²⁵ Ultimately, it takes 10 to 12 months after elbow reconstruction and rehabilitation for valgus instability before a functional return to overhead, competitive sports is allowed.²¹

Lateral Collateral Ligament Injury

Stability of the elbow occurs mainly through the osseous configuration but secondarily through the medial and lateral collateral ligaments (LCLs). In particular, the lateral ligament complex prevents rotational instability between the distal humerus and the proximal radius and ulna. However, disrupting the soft-tissue constraints through a traumatic onset often results in subluxation or dislocation. The elbow is the second most commonly dislocated large joint after the shoulder.14,15 In children younger than the age of 10 years, elbows are the most commonly dislocated joint.

In general, there are two main mechanisms of dislocation that have been suggested. Elbow dislocations are thought to result from hyperextension, in which the olecranon process is forced into the olecranon fossa and the trochlea is then levered over the coronoid process. Most elbow dislocations occur in a directly posterior or posterolateral direction. Very rarely will an anterior dislocation occur (~1% to 2%). Another proposed mechanism of injury is posterolateral rotation, in which combined forces of axial compression, elbow flexion, valgus stress, and forearm supination create a rotational displacement of the ulna on the distal humerus.

Intercondylar T or Y Fractures

In addition to nondisplaced or displaced transverse supracondylar fractures, potentially more significant fracture patterns can occur with falls or direct trauma to the elbow. Intercondylar fractures describe injuries that extend between the condyles of the distal humerus and involve the articular surfaces of the elbow joint.7,17,18,29 According to Strege²⁹ and Miller,¹⁸ there are four classifications of intercondylar fractures that display a T or Y configuration^7,17,21:

 Type I: A nondisplaced fracture that extends between the two condyles (Fig. 22-12, A)

 Type II: A displaced fracture without rotation of the fracture fragments (Fig. 22-12, B)

 Type III: A displaced fracture with a rotational deformity (Fig. 22-12, C)

 Type IV: A severely comminuted fracture with significant separation between the two condyles (Fig. 22-12, D)

The type of fracture dictates a course of treatment that parallels the significance of the injury. With a type I nondisplaced fracture, treatment can be immobilization for approximately 3 weeks, followed by progressive, gentle active motion. Resistance exercises are deferred until secure bone union has been confirmed radiographically. With types II and III displaced fractures, the treatment is open reduction with internal fixation (ORIF) with the use of Kirschner wires, side plates, and lag screws to secure and stabilize the displaced fracture fragments (Fig. 22-13).^17,18,29 Type IV comminuted intercondylar fractures are treated differently for adults and elderly patients with poor bone quality (osteoporosis).^18,29 Adult patients are usually treated with an ORIF procedure to stabilize the fragments. However, in elderly patients with generally poor bone quality (osteopenic bone), a treatment procedure referred to as the bag of bones technique is used.^17,18,29 This technique calls for the use of a “collar and cuff” sling, with the affected elbow flexed as far as the limits of swelling and circulatory compromise allow.²⁹ With the elbow flexed and able to hang freely within the sling, gravity is used to help obtain possible reduction of the fracture fragments (Fig. 22-14).^18,29

With intercondylar fractures of the elbow, the patient is instructed in a general conditioning program during immobilization while close attention is paid to avoiding all stress to the affected arm. In addition, the wrist, hand, and shoulder of the affected limb may be exercised with active motion if prescribed by the physician and PT. With intercondylar fractures, the anatomic relationship of the elbow (being extremely compact, with significant bony stability) dictates that the restoration of purposeful, functional motion becomes paramount during recovery. Soft-tissue scarring and bone callus formation can lead to early joint stiffness, arthrosis, and contractures.

During the early postimmobilization period, no passive manipulation or passive stretching can be performed.²⁹ Strege²⁹ reports an appreciable risk of joint ankylosis when passive stretching and manipulation are performed during early postinjury elbow rehabilitation.

Once wound closure has occurred after an ORIF procedure, the use of a whirlpool bath may aid local circulation, removal of waste, reduction in soft-tissue congestion, and enhancement of soft-tissue relaxation in preparation for protected active motion. Elbow flexion and extension, as well as forearm pronation and supination, are encouraged as prescribed by the physician and directed by the PT. Stable union of the fracture signifies more active involvement with progressive motion exercises and the initiation of resistance exercise training to regain strength. If the patient demonstrates loss of motion, the physician and PT may decide to perform specific joint mobilization techniques once bone union is secure. This does not conflict with the mentioned contraindication for passive manipulation and stretching immediately after immobilization. Some patients ultimately may have residual loss of motion. However, functional activities can be performed with flexion and extension of 30° to 130° and pronation and supination of 50°.²⁹

Radial Head Fractures

Another common fracture that occurs as a result of a fall on an outstretched arm is a radial head fracture. These fractures represent approximately one third of all elbow fractures and nearly 20% of all elbow trauma.¹³

The definition of the “carrying angle” of the elbow and the difference noted between men and women are important in understanding radial head fractures. The carrying angle is formed between the intersection of the long axis of the humerus and the axis of the ulna, with the elbow joint in full extension.²⁹ A normal carrying angle for men is 10° of valgus; in women, it is 13° of valgus (Fig. 22-15).²⁹ The clinical relevance is that a fractured radial head can lead to an increased valgus deformity and the varus elbow malalignment called a gunstock deformity.¹³

Radial head fractures generally are classified into four types, as follows (Fig. 22-16):

Treatment options parallel the significance of the injury and dictate the course of rehabilitation. Patients with type I nondisplaced radial head fractures usually need a period of immobilization ranging from 5 to 7 days up to 3 to 4 weeks.17,29 Usually, early active motion is allowed as soon as pain subsides. Because these fractures generally are stable (nondisplaced), healing occurs with very good results.¹⁷ Terminal elbow extension may be recovered many months after type I radial head fractures.¹⁷

With a type II displaced fracture, the radial head can be excised or stabilized with an ORIF procedure. With a type III comminuted radial head fracture, the fractured area is excised.13,17,18,29

Rehabilitation after an ORIF or radial head excision usually calls for immobilization in a hinged splint to protect the healing bone and surrounding soft tissues. As noted, excision of the radial head can lead to increased varus or valgus deformity. In either case, migration of the radial shaft may occur after excision and place stress on the distal ligamentous radioulnar articulation.13,17,18 Therefore any discomfort expressed by the patient at the distal radioulnar joint after excision of the radial head usually results from added stress on this area created by the disrupted proximal radial segment.^13,17,18 When the patient is immobilized, the hand, wrist, and shoulder of the affected limb are exercised as tolerated. The patient also is encouraged to participate in a general conditioning program of aerobic exercise, strength training, and flexibility exercises. Pain and swelling usually are managed satisfactorily by placing ice packs directly over the painful area. Early active ROM exercises are advocated 3 to 5 days postoperatively by some or deferred for up to 3 weeks by others.^13,29 Restoration of motion is the cornerstone for recovery after radial head fractures. As noted, joint restrictions secondary to arthrofibrosis and contractures can occur, with pronation and supination most commonly affected after radial head fractures.

The PT may elect to perform specific joint mobilization techniques to enhance pronation and supination if secure fixation has occurred after an ORIF procedure. Once wound closure has occurred, a whirlpool bath can be an effective adjunct preceding motion exercises. After excision of the radial head, resistance exercises of elbow flexion and extension and forearm pronation and supination can begin as soon as pain and motion allow. These exercises may be deferred for longer periods if an ORIF procedure was used so that stable bone union and soft-tissue healing can occur.

Olecranon Fractures

Olecranon fractures commonly result after a fall on the point of the elbow (olecranon process) or indirectly from forceful contraction of the triceps.¹⁷ Generally, they are classified as either nondisplaced or displaced fractures. Displaced fractures of the olecranon have four subclassifications¹⁸:

The treatment for nondisplaced olecranon fractures requires immobilization for 6 to 8 weeks,7,17 although as little as 3 weeks or less is used in some cases (particularly in older patients).^18,29 The position in which nondisplaced olecranon fractures are immobilized is somewhat controversial, in that some authorities advocate placing the affected arm in extension or slight flexion,^5,7,13,17 whereas others recommend placing the affected arm in 45° to 90° of flexion.^18,29 The rationale for placing the elbow in 45° of flexion is the likelihood of the loss of flexion after immobilization.²⁹ In addition, Strege²⁹ suggests that immobilization should not exceed 45° because of the risk of displacing fracture fragments.

Usually, nondisplaced olecranon fractures are allowed gentle active ROM exercises after 3 weeks of immobilization. Flexion of the affected arm should not exceed 90° for the first 6 to 8 weeks after injury so that fracture fragments can heal.13,29

Displaced or comminuted fractures of the olecranon can be treated with an ORIF procedure to secure the fragments. With severely comminuted fractures, excision of as much as 80% of the olecranon can occur without loss of joint stability.18,29

Physical therapy can begin during the initial stages of immobilization. Active motion of the hand, wrist, forearm (pronation and supination), and shoulder can commence once acute pain has subsided. A general physical conditioning program is allowed as soon as tolerated by the patient. Active elbow flexion must not exceed 90° for the first 2 months after injury. Active resistance exercises for elbow extension must be minimized because the forceful contraction of the triceps can displace the fracture fragments before secure bone healing at 8 weeks. Resistance exercises for elbow flexion can begin earlier if motion is limited and the muscle contractions are submaximal. Submaximal isometric triceps extensions can proceed once bony union has been verified. Progressive concentric and eccentric loading is added as motion increases and secure fixation of the fragments has occurred.

Progressive flexion and extension movements must proceed cautiously and slowly to prevent displacement of the fragments. In addition, the patient must be carefully instructed to initially perform resistance exercises well within the limits of pain and motion restrictions to allow for proper bone healing. The strong contractions of the biceps during flexion and the triceps during extension activities are effective to gradually overcome most motion limitations observed early after injury or surgery. Full recovery after olecranon fractures may take 6 months to 1 year.¹³

Fracture-Dislocations

A fall on an extended outreaching arm causes isolated elbow dislocations and combined fracture-dislocations (Fig. 22-17).^{9,17,19,24,28} Conwell⁷ reports that “with the exception of the shoulder, the elbow is the most frequently dislocated joint in the body.” This injury occurs most often in men, with the nondominant arm representing about 60% of these injuries.¹⁹

Posterior elbow dislocations are the most common, whereas anterior dislocations represent 1% to 2% of all elbow dislocations.¹⁹ Associated fractures of the radial head occur in approximately 10% of elbow dislocations.^19,28 In addition, associated neurovascular injuries can occur with either isolated elbow dislocations or with fracture-dislocations.^17,19,28,29 Injuries involve the median, radial, and ulnar nerves, as well as the brachial artery with elbow dislocations.^19,29

Isolated posterior elbow dislocations are managed with closed reduction and immobilization.7,9,17–19,28 The elbow is placed in 90° of flexion in a splint for 3 to 6 weeks.^7,17,29 During this period, hand and shoulder motion is allowed if no offensive stress is applied to the elbow. Early active ROM exercises can begin during the first week after reduction.²⁹ However, no passive ROM or stretching is allowed because of the risk of myositis ossificans,^17,28 which results from aggressive passive stretching and mobilization. Active motion is not believed to cause this condition.²⁸ Therefore gentle active flexion and extension exercises are added as pain, swelling, and soft-tissue healing dictate. Because this injury represents a hyperextension trauma that significantly affects the joint capsule, muscle, tendon, and frequently ligamentous restraints, extensive soft-tissue healing is necessary for a stable, functional joint. The joint capsule of the elbow may require 8 to 10 weeks to heal satisfactorily.⁹ Restoration of elbow extension therefore must proceed cautiously because the mechanism of injury is usually elbow hyperextension. Resistance exercises can begin as soft-tissue healing progresses. Eccentric and concentric resistance exercises for the biceps can be emphasized to reduce hyperextension forces.⁹ Resistance-type exercises are deferred for at least 3 weeks to allow for acute symptoms to subside. However, aggressive elbow extension must be prevented until 8 to 10 weeks have elapsed.^9,19

The most common complication after elbow dislocation is loss of extension.19,28,29 Ten weeks after dislocation, a 30° flexion contracture is common, and a 10° flexion contracture is typically observed 2 years after injury.¹⁹ However unacceptable this loss of motion may be, it does not represent an “overwhelming functional deficit.”²⁹

The treatment of fracture-dislocations centers on the appropriate management of the fracture (most commonly the radial head) and reduction of the elbow. In most cases, radial head excision is performed to minimize the development of myositis ossificans.²⁸ Therefore with radial head excision, proximal migration of the radius can result in stress and pain to the distal radioulnar ligamentous articulation.^17,18,29

Rehabilitation after fracture-dislocation of the elbow focuses on early protected active motion. Passive stretching again is strictly avoided during the early recovery phases of healing. With radial head excision, a loss of 25° to 30° of pronation and supination can be expected if postoperative immobilization lasts longer than 4 weeks.²⁸ As with isolated dislocation, loss of full elbow extension is not uncommon.