Principles of Elbow Rehabilitation

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CHAPTER 9 Principles of Elbow Rehabilitation

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.

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

Medications

Medication use is determined by the specific diagnosis, healing stage, and physician preference. Narcotics, nonsteroidal anti-inflammatory drugs (NSAIDs), and acetaminophen are used based upon an individualized risk-benefit ratio analysis. Although NSAIDs may provide short-term analgesic benefits in lateral elbow tendinopathy (“tennis elbow”),20 they are typically used with more caution in the post-traumatic/postsurgical elbow. Some NSAIDs inhibit platelets and may result in hemorrhage, whereas others may actually inhibit the healing response.30,48 Nonetheless, controlling inflammation with medication is an important element of the postinjury/postoperative recovery period.

Patients with inflammatory arthropathies may benefit from rheumatologic consultation to optimize systemic medications. In tennis elbow, corticosteroid injections do provide reliable relief for 4 to 6 weeks in most cases but may not affect long-term outcome and often cause temporary symptom exacerbation.27,45 Further investigation is needed to clarify the initial positive results reported for topical nitric oxide,42 platelet-rich plasma injections,31 and botulinum toxin injections24 in tennis elbow. Interested readers are referred to Chapter 44 for a more in depth discussion.

Modalities

Other than ice, the role of modalities in the acute post-traumatic/postsurgical period remains poorly defined. During periods of muscle inhibition, high-voltage galvanic stimulation (HVGS)–induced muscle contractions have been used to reduce pain and edema.50 As elbow motion improves, electromyographic (EMG)-biofeedback can be used to reduce muscle co-contractions, initially inhibiting the antagonists and subsequently cuing on the agonists.13,50 These modalities should be applied carefully in conjunction with constant reassessment.

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.