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In order to make sound clinical decisions when treating patients with elbow and forearm disorders, it is necessary to understand the various pathologies, surgical procedures, and associated precautions and to identify presenting structural and functional impairments, activity limitations, and participation restrictions (functional limitations and possible disabilities). In this section, pathologies and surgical procedures are presented and related to the corresponding preferred practice patterns (groupings of impairments) described in the Guide to Physical Therapist Practice3 (Table 18.1). Conservative and postoperative guidelines for managing these conditions are described in this section.
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Joint Hypomobility: Nonoperative Management
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Related Pathologies and Etiology of Symptoms
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Pathologies, such as rheumatoid arthritis (RA), juvenile rheumatoid arthritis (JRA), and degenerative joint disease (DJD), as well as acute joint reactions after trauma, dislocations, or fractures affect this joint complex. Postimmobilization contractures and adhesions develop in the joint capsule and surrounding tissues any time the joint is immobilized in a cast or splint. This typically occurs after dislocations and fractures of the humerus, radius, or ulna. The reader is referred to Chapter 11 for background information on arthritis and fractures.
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Common Structural and Functional Impairments
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Acute stage. When symptoms are acute, joint effusion, muscle guarding, and pain restrict elbow flexion and extension, and there usually is pain at rest. If pronation and/or supination are restricted after an acute injury, other conditions, such as fracture, subluxation, or dislocation, may be present.23 These conditions require medical intervention.
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Subacute and chronic stages. A capsular pattern usually exists in the subacute or chronic stages of tissue healing. Elbow flexion is more restricted than extension. There is a firm end-feel and decreased joint play. In long-standing arthritis of the elbow, pronation and supination also become restricted with a firm end-feel and decreased joint play in the proximal RU joint.23 Arthritis of the distal RU joint results in pain on overpressure.
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Common Activity Limitations and Participation Restrictions (Functional Limitations/Disabilities)
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Difficulty turning a doorknob or key in the ignition
Difficulty or pain with pushing and pulling activities, such as opening and closing doors
Restricted hand-to-mouth activities for eating and drinking and hand-to-head activities for personal grooming and using a telephone
Difficulty or pain when pushing up from a chair
Inability to carry objects with a straight arm
Limited reach
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Joint Hypomobility: Management—Protection Phase
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See 'Guidelines for Management Related to the Stages of Tissue Healing' in Chapter 10, Box 10.1.
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Inform the patient regarding the anticipated length of acute symptoms and teach methods of joint protection and how to modify activities of daily living. For example, the patient should avoid activities that involve lifting or pushing off with the involved upper extremity.
Instruct the patient to avoid excessive fatigue by performing exercises frequently during the day but limiting the number of repetitions during each bout (set) of exercises.
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Reduce Effects of Inflammation or Synovial Effusion and Protect the Area
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Immobilization in a sling provides rest to the part, but complete immobilization can lead to joint hypomobility, contractures, and limited motion; therefore, frequent periods of controlled movement within a pain-free range should be performed.
Gentle grade I or II joint distraction and oscillation techniques in the resting position may inhibit pain and move synovial fluid for nutrition in the involved joints (see Chapter 5 for principles of application and techniques).
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CLINICAL TIP
When immobilizing the elbow, position in relative extension (20° to 30° flexion) and use a posterior splint bubbled out around the cubital tunnel to prevent or treat ulnar neuropathy. Splinting in this position is used to minimize pressure on the ulnar nerve, which may be at risk from joint swelling in the cubital tunnel.12
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Maintain Soft Tissue and Joint Mobility
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Passive or active-assistive ROM within limits of pain, including flexion/extension and pronation/supination
Multiple-angle muscle setting of elbow flexors, extensors, pronators, supinators, and wrist flexors and extensors in pain-free positions
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Maintain Integrity and Function of Related Areas
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Shoulder, wrist, and hand ROM and activities should be encouraged within the tolerance of the individual.
If edema develops in the hand, the arm should be elevated whenever possible. Apply massage as described in Chapter 25.
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Joint Hypomobility: Management—Controlled Motion Phase
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If joint hypomobility exists, ROM is increased by utilizing joint mobilization techniques as well as passive stretching and muscle inhibition techniques following the principles described in Chapters 4 and 5. Box 18.2 highlights several important precautions if joint restrictions are related to trauma.
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BOX 18.2 Precautions Following Traumatic Injury to the Elbow
If the brachialis muscle is injured, ossification of the injured tissue is a potential complication, and stretching is contraindicated.
After healing of fractures in the forearm, malunion is not unusual, preventing full range of pronation or supination. A boney block end-feel or an abnormal appearance of the forearm should alert the therapist to the cause of this impairment. Radiographical imaging is helpful in verifying the problem. No amount of stretching or mobilizing changes the patient's range. Indiscriminate stretching may lead to hypermobility of related joints, which could cause additional trauma and pain.
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Increase Soft Tissue and Joint Mobility
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Initiate stretching cautiously and note the joint and tissue response. Vigorous stretching should not be undertaken until the chronic stage of healing. As noted in Box 18.2, high-intensity stretching of the elbow flexors is contraindicated following trauma because of the potential for development of heterotopic bone formation.
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Passive joint mobilization techniques. Because several articulations are involved with each motion at the elbow, it is important to identify which of the articulations have reduced joint play prior to applying grade III sustained or grade IV oscillation techniques. For specific techniques to use, see Figures 5.28, 5.29, 5.30, 5.31,5.32, 5.33 and their descriptions in Chapter 5. Progress each technique by positioning the joint at the end of its available range before applying the mobilization technique.
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CLINICAL TIP
To progress joint mobility in the terminal ranges of flexion and extension, it may be necessary to emphasize the accessory motions of varus and valgus, respectively. This is accomplished with medial and lateral gliding techniques or with a varus or valgus physiological stretch at the elbow.
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Manipulation to reduce a "pushed elbow." Proximal subluxation of the radius may result from falling on an outstretched hand. The radial head is pushed proximally in the annular ligament and impinges against the capitulum. This injury sometimes accompanies a fracture of the distal radius (Colles' fracture) or scaphoid and is not identified as an impairment until after the fracture has healed and the cast is removed. It is often overlooked because there is considerable soft tissue and joint restriction caused by the period of immobilization. Bilateral palpation of the joint spaces reveals the decreased space on the involved side. There may be limited flexion or extension of the elbow, limited wrist flexion, and limited pronation.
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CLINICAL TIP
For an acute "pushed elbow" (and no fracture), apply a distal traction to the radius to reposition the radial head. If chronic, repetitive stretching with sustained grade III distal traction to the radius is necessary (see Fig. 5.29) in addition to the soft tissue stretching and strengthening techniques needed for increasing motion.
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Manipulation to reduce a "pulled elbow." Distal subluxation of the radius is usually seen as an acute injury in children and is sometimes labeled "tennis elbow" when it occurs in adults. It occurs as a result of a forceful pull on the hand such as would occur when a child jerks away from a parent or caregiver or a person tries to pick up a heavy object with a jerking motion on the handle. The force causes the radius to move distalward with respect to the ulna. The head of the radius is unable to slide proximally in the annular ligament when supination is attempted, resulting in the person holding the forearm in pronation. Either supination is restricted, or the patient guards against the motion.
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CLINICAL TIP
A quick, compressive manipulation (high-velocity thrust) with supination is applied to the radius (see Fig. 5.31) to reposition the radial head when there is a "pulled elbow." If it is an initial injury, there may be soft tissue trauma from the injury, which is treated with cold and compression.
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Manual stretching and self-stretching. Use manual stretching and inhibition techniques to increase the flexibility of any periarticular tissues that are restricting mobility. Use of a cuff weight placed around the distal forearm with the patient carefully positioned for an effective stretch provides a low-intensity, long-duration stretch and is an alternative to manual passive stretching (see Fig. 18.7 in the exercise section). If elbow ROM does not steadily improve after acute symptoms have subsided, the patient may need to begin wearing an adjustable, dynamic splint that applies a low-intensity stretch force over an extended period of time. These stretching interventions are described in Chapter 4.
Home instructions. Teach the patient self-stretching maneuvers followed by active exercise that utilizes the new range. Suggestions are provided in the last section of this chapter.
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Improve Joint Tracking of the Elbow
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A mobilization with movement (MWM) technique consisting of a lateral glide combined with the active movement of flexion or extension and pain-free passive overpressure may improve articular surface tracking by allowing the muscles to move the joint in a pain-free manner.66 (Refer to the principles of MWM in Chapter 5.)
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Improve Muscle Performance and Functional Abilities
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Initiate active and low-load resistance exercises in open- and closed-chain positions to develop control, muscular endurance, and strength in the muscles of the elbow and forearm. As the patient improves, adapt the exercises to progress toward functional activities. Specific exercises are described in the exercise section of this chapter. Include the shoulder girdle, wrist, and hand in the exercise program as their flexibility and strength has an influence on the recovery of elbow function.
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Joint Hypomobility: Management—Return to Function Phase
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Improve Muscle Performance
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Progress strengthening exercises as the joint tissue tolerates. Teach the patient safe progressions and exercise strategies that promote return to function. To prepare the joints and muscles for specific tasks, use exercises that replicate the repetitions and demands of daily activities, such as pushing, pulling, lifting, carrying, and gripping.
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Restore Functional Mobility of Joints and Soft Tissues
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If restrictions remain, use vigorous manual or mechanical stretching and joint mobilization techniques.
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Promote Joint Protection
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Chronic arthritic conditions may require modification of high-load activities to minimize deforming stresses on the involved joints.
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Joint Surgery and Postoperative Management
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Intra-articular or extra-articular surgical intervention is often necessary for management of severe fractures or dislocations that affect the joints of the elbow and surrounding soft tissues. These injuries may require open reduction with internal fixation or arthroscopic or open excision of bone fragments. In adults, the most common fracture in the elbow region is a fracture of the head and neck of the radius. This type of fracture accounts for approximately one-third of all elbow fractures.9,71 This injury usually occurs when a person falls on an outstretched hand when the elbow is extended, causing a posterior dislocation and fracture of the radial head coupled with injury of elbow ligaments.31
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If the proximal radius is displaced and the radial head fracture is comminuted, either open or occasionally arthroscopically assisted reduction with internal fixation or a radial head excision (resection) with or without prosthetic implant are surgical options.31,59,60,71 It has been suggested that rigid internal fixation (screws or plate fixation) of radial head fractures is indicated in the young, active adult, whereas excision of the radial head is more appropriate for the low-demand patient or if the fracture is severely comminuted and fixation is not possible.40 Box 18.3 summarizes the advantages and disadvantages of surgical options for management of displaced fractures of the radial head. Radial head fractures in children, however, are relatively uncommon. When they do occur, closed reduction is preferred.78
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BOX 18.3 Surgical Options for Displaced Fractures of the Radial Head Open Reduction and Internal Fixation
Advantages: Achieves stabilization and fixation of multiple fracture fragments with normal or near-normal alignment; ability to repair significant ligamentous damage; early postoperative motion permissible unless reconstruction of ligaments required
Disadvantages: Extensive soft tissue disruption and arthrotomy required; not amenable to nonreconstructible fractures and less practical than radial head excision for severely comminuted fractures
Arthroscopic or Arthroscopically Assisted Reduction and Internal Fixation Advantages: Allows arthroscopic evaluation of the joint and débridement of fracture debris; if fully arthroscopic, no arthrotomy, less soft tissue disturbance, less postoperative pain, better cosmetic outcome
Disadvantages: Limited to reduction and fixation of no more than two-part displaced fractures; not appropriate for radial neck fractures; if fully arthroscopic, fixation techniques more technically difficult (e.g., use of percutaneous screw fixation) than open procedure
Excision of the Radial Head Advantages: Only option for severely comminuted, nonreconstructible fractures; no potential for mechanical blockage of joint motion from malalignment of fracture fragments or internal fixation; early ROM permissible
Disadvantages: Requires arthrotomy; may compromise joint stability if a prosthetic implant is not used
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Small osteochondral defects of one or more of the articular surfaces of the elbow complex occur in the skeletally mature and immature individual (often in the throwing athlete) as the result of repetitive trauma. Such defects, depending on their size, characteristics, and location, may require surgical intervention, such as removal or internal fixation of a fragment, microfracture, or autologous osteochondral or chondrocyte implantation, if nonoperative measures have been ineffective.72
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Early-stage or long-standing joint disease (RA, JRA, post-traumatic arthritis) associated with synovial proliferation and destruction of articular surfaces of the elbow joints and leading to pain, limitation of motion, and impaired upper extremity function also may need to be managed with extra-articular or intra-articular surgery. For example, with early-stage RA in which synovial proliferation is present but joint surfaces are still in good condition, arthroscopic or open synovectomy is the procedure of choice for relief of pain if medications have not controlled the disease.14,32,43,47 Occasionally, advanced arthritis is managed surgically by interposition arthroplasty (only in the young patient on a selective basis),21,32,73 resection of the radial head with or without prosthetic implant and concomitant synovectomy,20,28,56,60 or arthrodesis (as a salvage procedure).73 However, today, the most common surgical procedure used to manage severe destruction of the elbow joint is total elbow arthroplasty.14,20,21,32,48,61,73 Table 18.2 summarizes how the severity of joint disease and the extent of soft tissue involvement influence the choice of surgical procedure for the elbow complex.14,21,28,32
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The goals of surgery of the elbow joint complex and postoperative rehabilitation include21,73: (1) relief of pain, (2) restoration of boney alignment and joint stability, and (3) sufficient strength and ROM to allow functional use of the elbow and upper extremity. Surgical procedures done to relieve pain and improve elbow stability tend to be more successful than procedures done solely to increase ROM. Heterotopic bone formation, which leads to joint stiffness, is often a complication of elbow fractures, dislocations, and elbow joint surgery.57 Therefore, the single goal of improving ROM is rarely an indication for surgery.21
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Radial Head Excision or Arthroplasty
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Indications for Surgery
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The following are frequently cited indications for radial head excision or arthroplasty.
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Severely comminuted fracture or fracture-dislocations of the head or neck of the radius that cannot be reconstructed and stabilized with internal fixation54,56,59,71
Chronic synovitis and mild deterioration of the articular surfaces associated with arthritis of the HR and proximal RU joints resulting in joint pain at rest or with motion, possible subluxation of the head of the radius, and significant loss of upper extremity function21,28,60
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CONTRAINDICATIONS: Radial head excision is contraindicated in the growing child.78 Excision without replacement of the radial head is not an appropriate option in the presence of a damaged lateral ulnar collateral ligament complex.56 As with other joints, arthroplasty also is contraindicated with active infection.
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Selection of procedure. Depending on the integrity of the ligaments and stability of the elbow complex, a radial head excision may be selected or implant arthroplasty may be the better choice. The use of a prosthetic implant is indicated when there is clinical instability of the elbow as the result of disruption of the supporting ligaments.49,56,60
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Implant designs, materials, and fixation. Radial head implants originally were flexible and made of silicone (Silastic® material).21,60 However, this material is no longer used because it has been associated with fatigue failure, particulate debris, and the development of adverse biological reactions, specifically inflammatory arthrosis (synovitis) of the HU joint.84 Currently used implants are one-piece or two-piece (modular) designs that more closely replicate the normal biomechanics of the elbow and are made of metal (cobalt-chrome and titanium), ceramics, or ultra-high molecular weight polyethylene.36,56,59,60 The use of pyrolytic carbon as an implant material also is being investigated.56 However, the optimal radial head implant has yet to be designed and fabricated. Cemented or cementless fixation is an option with total elbow arthroplasty (TEA).
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Overview of Operative Procedure
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A lateral or posterolateral triceps-sparing incision at the elbow and forearm is made into the joint (arthrotomy) just anterior to the lateral collateral ligament. The radial head is exposed, and a radial osteotomy is performed at the level of the annular ligament to resect the head. For a severe fracture, some of the neck of the radius also may need to be excised. When exposing the operative field, effort is made not to detach intact ligaments. A concomitant synovectomy is done if proliferative synovitis is present (typically seen in RA and JRA).
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If an implant is to be inserted, the medullary canal of the radius is prepared to accept the stem of the prosthesis. If the elbow is unstable, ligamentous structures are repaired. If the lateral ulnar collateral ligament (LUCL) is insufficient, it may be reinforced with a palmaris longus autograft or allograft. To prevent injury to the ulnar nerve or if symptoms of compression are present, ulnar nerve transposition is also performed.28,56,59,60
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Intraoperative complications. Damage to the posterior interosseous nerve is a concern during surgical excision of the radial head regardless of whether a radial head replacement is included in the procedure.56 If an implant is inserted, malpositioning or inaccurate sizing can cause postoperative pain and HR instability, compromise ROM, and eventually contribute to premature implant wear.
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Postoperative complications. Postoperatively complications of excision with or without implant may include delayed wound closure, infection, limited ROM of the elbow and/or forearm, cubital laxity, persistent pain, and a sense of instability. Slight proximal migration of the radius may occur if resection does not include implantation of a prosthetic radial head. This complication may or may not be associated with elbow or wrist pain. Following excision for a severe radial head fracture, osteoarthritis of the HR joint also may develop over time.56,59
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As with all types of implant arthroplasty, aseptic loosing or long-term implant wear and breakage are complications that may occur, necessitating revision arthroplasty. Although not unique to elbow surgery, complex regional pain syndrome may develop in rare instances.
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Postoperative Management
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The goals and interventions, the rate of progression, and the length of the rehabilitation program, as well as final outcomes, are highly dependent on the extent of damage to soft tissues from injury or chronic inflammation, the integrity of repaired soft tissues particularly the supporting ligaments of the elbow complex, the philosophy of the surgeon, and the patient's expectations of the surgery and response to treatment.
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The elbow is immobilized continuously in a well-padded posterior resting splint in a position of 90° of flexion and mid-position of the forearm after surgery.59,60 When elbow motion is permissible (often as early as 1 to 3 days after surgery or longer if significant reconstruction of ligaments was necessary), the splint is removed for exercise but is replaced after exercise and worn at night for an extended period of time to protect healing tissues. If the stability of the elbow is in question, the patient may need to wear a dynamic (hinged) splint for ROM exercises.
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Exercise: Maximum Protection Phase
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Goals and interventions. The first phase of rehabilitation, which extends for about the first 6 weeks after surgery, focuses on patient education that emphasizes wound care, control of pain and peripheral edema, and exercises to offset the adverse effects of immobilization while protecting repaired soft tissues that maintain the stability of the elbow. The arm is elevated for comfort and to control edema distally. The following goals and exercise-related interventions typically are included in this initial phase.9,51,59,60,91
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Maintain mobility of unoperated joints. Active ROM exercises of the shoulder, wrist, and hand immediately after surgery.
Maintain mobility of the elbow and forearm. When permitted, have the patient remove the splint several times daily for self-ROM (passive or active-assisted) of the elbow and forearm within pain-free ranges. Active ROM is allowed within a week after exercises are initiated. As noted previously, some patients must wear a hinged splint for additional stability during ROM exercises.
Minimize muscle atrophy. Submaximal, pain-free, multiple-angle setting exercises of elbow and forearm musculature.
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CLINICAL TIP
Some specific motions initially may need to be restricted to prevent excessive stress on reconstructed ligaments. Restrictions vary depending on the extent of ligament disruption and which ligaments were repaired. For example, if the lateral collateral complex was repaired, supination is limited to 20° during the early weeks of rehabilitation.31
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Exercise: Moderate and Minimum Protection Phases
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Goals and interventions. The intermediate phase of rehabilitation begins when wound healing is satisfactory and active movements of the elbow are relatively pain-free. This phase and the final phase of rehabilitation are characterized by continued efforts to restore nearly full or at least sufficient ROM for functional activities while maintaining stability of the elbow. Exercises to improve upper extremity strength and muscular endurance and use of the involved elbow for light functional activities are introduced and progressed.9
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NOTE: It is important to note that some surgeons and therapists prefer to improve strength and muscular endurance solely through ADL without the use of specific resistance exercises.51,59,60
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CONTRAINDICATION: When applying joint mobilization techniques, do not perform valgus/varus stretches in terminal extension/flexion, particularly if the radial head was not replaced with a prosthetic implant or if the integrity of the supporting ligaments and stability of joints are questionable.
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• Improve functional strength and muscular endurance.
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Low-load resistance exercises (maximum 1 to 2 lb), emphasizing high repetitions
Use of the operated upper extremity for light ADL
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Resumption of recreational and work-related activities. Patient education is a key element of helping the patient return safely to physical activities. Following excision of the radial head with or without a prosthetic implant, a patient must permanently refrain from high-demand or high-impact, work-related or recreational activities regardless of the underlying pathology that necessitated surgery.51 Be certain the patient knows to avoid using the involved upper extremity for moving or holding heavy objects or refrain from participating in recreational activities that impose significant stress across the elbow complex, such as racquet sports.
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Outcomes
The anticipated outcomes after resection of the radial head for a severely displaced and comminuted fracture or advanced arthritis are a stable elbow and pain-free movement (flexion/extension and pronation/supination) within functional ranges.31,59,60 Short-term, postoperative outcomes of excision arthroplasty with and without implant are similar with regard to relief of pain and functional motion. However, patients with preoperative instability necessitating an implant and those with a tenuous repair of ligamentous structures have less satisfactory results than those with a stable elbow. If preexisting contractures exist, ROM does not necessarily improve.
Some patients may develop a slight increase (about 5° to 10°) in valgus laxity of the elbow, without complaints of instability during functional activities if ligaments are intact prior to surgery or repaired at the time of surgery. Others may experience pain and instability associated with the increased laxity, thus compromising outcomes. In a study by Hall and co-investigators,37 posterolateral rotary instability associated with a deficient lateral ulnar collateral ligament was identified at a mean of 44 months in only 16.6% of patients (7 of 42) who reported lateral elbow pain and a sense of instability or weakness after radial head resection (without implant).
Many of the long-term studies of excision with prosthetic implant have evaluated the results of procedures using flexible components made of silicone, which as previously noted, have been shown to be associated with material fatigue or inflammatory responses and have led to premature failure.60 Short-term and a few long-term outcomes after current-day procedures, using rigid implants but involving relatively small numbers of participants, are gradually being reported in the literature.56 Results of these studies are promising including pain relief, stability, and sufficient elbow and forearm ROM for functional activities leading to relatively high patient satisfaction.
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Total Elbow Arthroplasty
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When nonoperative management or previous surgical procedures have been unsuccessful, total elbow arthroplasty (TEA) has been considered a treatment option primarily for the older individual (over 60 to 65 years of age) with debilitating, late-stage elbow arthritis whose physical demands are relatively low.11,73 However, since the first cemented TEA was introduced several decades ago,24 the indications for this procedure have broadened considerably as the design of prosthetic implants and surgical techniques have evolved.88 TEA is now considered for the younger patient. One resource, for example, has suggested that any individual, older than age 30, might be an appropriate candidate for TEA depending on their expected postoperative demands.32 A long-term followup of patients, who had undergone TEA at or before the age of 40 for various types of elbow arthritis, showed that 93% continued to have good to excellent outcomes at a mean duration of 91 months after surgery.16
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In addition to management of advanced arthritis, TEA now is considered a preferred surgical alternative to open reduction and internal fixation for management of severely comminuted, intra-articular distal humeral fractures sustained by elderly patients.53,75
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Indications for Surgery
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The following are currently accepted indications for TEA.
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Debilitating pain and loss of functional use of the upper extremity as the result of moderate to severe joint pain and articular destruction of the HU and HR joints.11,21,32,73,75 Underlying diseases managed with TEA include RA (by far the most common pathology),28,34,61,63 JRA,20 and post-traumatic degenerative arthritis or primary OA.32,62,77
Gross instability of the elbow11,31,41,74,75
Acute comminuted, intra-articular fracture18,53 and nonunion fracture of the distal humerus58,64
Failed interposition arthroplasty or radial head resection76
Marked bilateral limitation of motion of the elbows21,22,58
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CONTRAINDICATIONS: Absolute and relative contraindications for TEA are identified in Box 18.4.11,22,32,48,61,75 It is important to note, however, with the exception of active infection, there is lack of agreement as to which contraindications are absolute versus relative.
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BOX 18.4 Contraindications to Total Elbow Arthroplasty Absolute
The presence of active (acute or subacute) infection
Neurological dysfunction leading to paralysis and inadequate control of elbow musculature, particularly the elbow flexors
Relative History of previous elbow infection
Irreparable supporting ligaments
Inadequate control of elbow extensors
Heterotopic ossification or pain-free ankylosis
Insufficient bone stock
The younger patient, particularly one who must lift heavy loads (>10 lb) after TEA
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The complex structural relationships among the HU, HR, and proximal RU joints have made developing a prosthetic elbow joint a challenging task. Following introduction and use of early cemented elbow replacements,24 incremental improvements in design, materials, fixation, and surgical technique have contributed to increasingly predictable and successful outcomes.21,73 Elbow replacement systems include a humeral and an ulnar implant (Fig. 18.4), and some designs also include replacement of the head of the radius.48,58,61
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Implant design and selection considerations. Early designs were hinged (linked, articulated) and fully constrained metal-to-metal humeral and ulnar implants that allowed only flexion and extension of the elbow joint.21,32,73 These designs made no allowances for normal varus and valgus and rotational movements, and hence, the implants rapidly loosened at the bone-cement interface. Metal fatigue at the linkage of the prosthetic components and joint dislocation also were common complications.7,35 As more accurate information about the biomechanical characteristics of the elbow joint became known, the design of prosthetic replacements evolved. In addition to an arc of flexion and extension, contemporary designs provide 5° to 10° of varus and valgus and a small degree of rotation (Fig. 18.5).61
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The designs of total elbow replacement can be classified into two broad categories: linked (articulated) and unlinked (nonarticulated).7 Rather than being fully constrained, as the early components were, linked humeral and ulnar implants are now loosely constrained and, as such, are referred to as semiconstrained designs.34,58,61,77 Designs classified as unlinked are composed of two separate, nonarticulated implants and are often called resurfacing replacements.7,22,32,48 The most recent advance in implant design is the hybrid prosthesis, which can be inserted as either a linked or unlinked replacement system. Use of a hybrid replacement enables the surgeon to determine the more appropriate design based on intraoperative observations and evaluation.7
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The criteria for use of a linked or unlinked TEA are based in part on the characteristics of these designs with respect to stability. Linked designs derive inherent stability from one or two pins, which couple the humeral and ulnar components.58 In addition, some semiconstrained designs have an anterior flange to enhance joint stability and decrease the risk of posterior dislocation.61 Unlinked implant systems, although sometimes referred to as nonconstrained,32 actually have varying degrees of constraint built into their designs based on the degree of congruency of the articulating surfaces.22,48 The less constraining the articular surfaces of the implants, the more reliant the replacement system is on the surrounding soft tissues, particularly the collateral ligaments, for joint stability.
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Overall, linked designs, because of their inherent stability, are considered appropriate for use with a broader spectrum of patients, including those with unstable elbows, than unlinked designs.32 Although both linked and unlinked designs derive some degree of stability from the supporting capsuloligamentous structures and elbow musculature, the integrity of these soft tissues is far more critical for successful use of unlinked than linked designs.7,58
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In addition to considerations related to stability, the etiology and extent of joint destruction, the degree of deformity, the quality of the available bone stock, and the training and experience of the surgeon are factors that influence the type of replacement system used.
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Materials and fixation. A stemmed titanium humeral component that has a cobalt-chrome alloy articulating surface interfaces with a high-density polyethylene articulating surface of a stemmed ulnar component.7,21 Currently, prosthetic components are cemented in place with polymethyl methacrylate, an acrylic cement. Some designs also have a porouscoated extramedullary flange for osseous ingrowth. To date, all-cementless fixation has not yet been developed for total elbow arthroplasty.21,73
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The following is a brief overview of typical elements involved in a TEA.11,22,32,48,58,61,77 A longitudinal incision is made at the posterior aspect of the elbow, either slightly lateral or medial to the olecranon process. The ulnar nerve is isolated, temporarily displaced, and protected throughout the procedure. The distal attachment of the triceps is detached and reflected laterally with a triceps-reflecting approach or split longitudinally and retracted along the midline with a triceps-splitting approach.22,61 The more recently developed triceps-sparing (triceps-preserving) approach is also an option. It involves incisions on the medial and lateral aspects of the elbow joint. This approach preserves the attachment of the triceps tendon on the olecranon but makes insertion of the implants more technically challenging.8,32
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As the procedure progresses, ligaments and other soft tissues are released as necessary; the posterior aspect of the capsule is incised and retracted; and the joint is dislocated. In preparation for the implants, small portions of the distal humerus and proximal ulna are resected. Depending on the status of the radial head, the integrity of the collateral ligaments, and the design of the prosthesis, the head of the radius may or may not be excised. Then the intramedullary canals of the humerus and ulna and possibly the radius are prepared, and trial components are inserted. The available ROM and stability of the prosthetic joint are checked intraoperatively and x-rays are taken to confirm proper alignment of the implants. The components are then cemented in place, and the capsule and any ligaments that had ruptured prior to surgery or were released during the procedure are repaired to the extent possible or necessary based on the design of the prosthesis and the quality of the structures. If detached or split, the extensor mechanism is securely reattached or meticulously repaired. Following possible anterior transposition and careful placement of the ulnar nerve in a subcutaneous pocket, the incision is closed, and a sterile compressive dressing and posterior and/or anterior splint are applied to immobilize the elbow and forearm. The arm is elevated to control peripheral edema.
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Although the incidence of complications has declined steadily over the past few decades as selection of patients, prosthetic design, and surgical technique have improved, complications after TEA continue to occur more frequently than after total hip, knee, or shoulder arthroplasty.8,88
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FOCUS ON EVIDENCE
In the mid-1990s,35 a comprehensive review of the literature indicated that the overall rates of complications following TEA ranged from 20% to 45%. A recent systematic review of the results of subsequent studies (published from 1993 to 2009), however, indicated that the mean overall rate of complications after contemporary, primary TEA (semiconstrained and nonconstrained designs) was 24.3% (±5.8%).88
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Complications are categorized as intraoperative and postoperative—early or late (before or after 6 weeks).70
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Intraoperative complications. Intraoperative complications, such as fracture and component malpositioning, can significantly affect short- and long-term outcomes. Ulnar damage or irritation, either transient or permanent, also can occur intraoperatively from handling or during the early weeks after surgery from compression as well,8,35,70,88 typically causing paresthesia but not weakness.32,75
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Postoperative complications. Deep infection, a concern after any surgery, is reported to occur in an average of 3.3% (±2.9%) of cases following current-day TEA.88 This rate is higher for TEA than large joint arthroplasties, owing to the thin layer of soft tissues covering the elbow joint and because the majority of patients undergoing TEA have inflammatory arthritis and a compromised immune system due to medication.75,88
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Other postoperative complications, including joint instability, wound healing problems, and triceps insufficiency, are of particular concern during the early and intermediate phases of rehabilitation. Despite continuing improvements in implant design and fixation and surgical techniques, some complications develop several months or even years after surgery. These complications include aseptic (biomechanical) loosening of the prosthetic implants over time at the bone-cement interface (the most common long-term complication and reason for revision arthroplasty), periprosthetic fracture, and mechanical failure or premature wear of the components.8,30,32,75,88
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It is important for a therapist to be familiar with the incidence and possible causes of complications after TEA in order to effectively structure and progress a postoperative rehabilitation program that decreases at least some of the risk factors associated with these complications. The incidence and characteristics of selected postoperative complications (joint instability, triceps insufficiency, prosthetic loosening) after TEA and factors that contribute to these complications are summarized in Box 18.5.8,35,70,74,75,88 Precautions to reduce the risk of these and other complications are addressed in the following section on postoperative management.
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BOX 18.5 Analysis of Three Potential Complications after Total Elbow Arthroplasty Joint Instability
Incidence. One of the more common complications after TEA; predominantly a problem in unlinked arthroplasty;8,88 overall rate of dislocation and symptomatic instability of contemporary TEA, an average of 3.3% (± 2.9%).88
Higher incidence with prior radial head resection76
Higher rate in unlinked implants (reported at 4% to 15%, mean 8%)48 than in linked implants (reported at 0% to 14%, mean 3.5%).34,45,77
Characteristics. Early or late onset; associated with pain and loss of function.
Disruption of a repaired LCL complex → posterolateral, rotary, and varus instability; disruption of a repaired MCL complex → posteromedial and valgus instability.
Disruption of triceps mechanism → diminished dynamic compressive forces across the joint.
Contributing factors. Excessive release or inadequate or failed soft tissue repair → deficient static or dynamic stabilizers (possibly due to inadequate postoperative immobilization and excessive postoperative stresses across the elbow, particularly during the early postoperative period before soft tissue repairs have healed), malpositioning of implants, and long-term polyethylene wear of the ulnar component increase the risk of instability.8,48,70
Triceps Insufficiency Incidence. Primarily occurs after surgical approaches that disrupt the triceps mechanism; occurs in both linked and unlinked arthroplasty, usually during the first postoperative year.75 Examples of rates of occurrence reported in separate retrospective studies: 1.8% of 887 elbows,15 4% of 78 elbows,34 and 11% of 28 elbows45 and 2.4% (± 2.4%) of 2,938 elbows reported in a recent systematic literature review of contemporary TEA.88
Characteristics. Partial or complete rupture, or avulsion, of the extensor mechanism (during the early or late postoperative period) → weakness (particularly in terminal extension), often posterior elbow pain, and difficulty with pushing activities and overhead functions, such as combing one's hair.
Contributing factors. Occasionally postoperative trauma but most commonly a failed surgical reattachment or repair of a poor quality tendon; premature or excessive ROM or loads on the extensor mechanism during early rehabilitation or during long-term functional use of the arm.48
Implant Loosening Incidence. The most common postoperative complication, occurring in linked (semiconstrained) more than unlinked (nonconstrained) implants. Overall rates are lower with contemporary TEA designs (mean, 5.1%, ± 3.4%)88 than earlier designs35 but remain higher than after hip, knee, and shoulder arthroplasty.70 The more constrained the design, the greater the risk of loosening.
Rate of clinical loosening reported in individual studies of contemporary implants up to a 6-year follow-up has been reported to range from 0% to 6%.35,45,63,77
Rates of 0% reported in patients with RA over a mean followup of 3.8 years63 and in patients with posttraumatic arthritis with a mean follow-up of 5 years.77
The incidence of radiological loosening is consistently higher than clinical loosening (when the patient becomes symptomatic).
Characteristics. Aseptic (biomechanical) loosening, a late complication, occurs at the bone–cement interface typically of the ulnar component;32 clinical loosening is associated with pain. Excludes loosening caused by infection.8
Contributing factors. Inadequate cementing technique, implant malpositioning, and lack of adherence to postoperative activity modification. High-load, high-impact activities place patient at higher risk of loosening.
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Postoperative Management
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The overall goal of rehabilitation after TEA is to achieve pain-free ROM of the elbow joints as well as strength of the upper extremity sufficient for functional activities while minimizing the risk of early or late postoperative complications. This goal is best achieved with an individualized rehabilitation program based on a thorough examination of each patient's postoperative status.
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As noted previously, a soft compression dressing is applied at the close of surgery. A well padded posterior or anterior splint is used to immobilize the elbow and maintain stability and protect structures as they heal. Recommendations for the positions and duration of immobilization vary.
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Position. The position of immobilization is based on a number of factors, including the surgical approach, the implant design, and which soft tissues were repaired and require protection.6,22,28,51 If, for example, a triceps-reflecting approach was used for a linked TEA, full or almost full elbow extension typically will be selected to protect the reattached triceps tendon and a neutral position of the forearm.6,22,58,61 In contrast, with an unlinked TEA, which typically requires repair of the lateral ligament complex because of preoperative damage or release for operative exposure of the joint, the position of immobilization is a moderate degree of flexion with limitation of full forearm supination to lessen stress on the repaired ligaments.6,70 If a patient had a significant preoperative elbow flexion contracture that was surgically released, an anterior splint may be selected with the elbow placed in the available amount of extension. An extended position is also indicated if symptoms of ulnar neuropathy are present to alleviate pressure in the cubital tunnel.58,61,70
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Duration. The period of continuous immobilization after surgery, which is kept as short as possible to avoid stiffness, also varies widely, ranging from 1 to 2 days to several weeks. This time period depends on the design of the prosthesis, the surgical approach, the integrity of ligamentous structures, intraoperative observations by the surgeon, and the integrity of the skin and subsequent wound healing. In general, unlinked/resurfacing designs, which have little inherent stability, require a longer period of immobilization than linked/semiconstrained designs.8,28,51
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If there is increased risk of delayed wound healing because of poor skin quality or a patient's history of diabetes, smoking, or use of steroids, the elbow may be continuously maintained in extension for 10 to 14 days postoperatively to limit stress on the posterior incision.58,61,70 Even after it is permissible to remove the splint for exercise or self-care, the patient is advised to continue to wear the splint at night for protection for up to 6 weeks.6,51 If there was a preoperative flexion contracture, an adjustable splint that maintains the elbow in extension is worn periodically during the day for a prolonged stretch, and a static (resting) splint is worn at night to hold the arm in a comfortably extended position. This regimen may be followed for 8 to 12 weeks postoperatively to prevent recurrence of the contracture.51,58,61
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The progression of a postoperative exercise program after TEA varies considerably based on many factors. Key factors and their impact on postoperative rehabilitation are identified in Table 18.3.6,22,51,91 The rehabilitation process proceeds most rapidly when a triceps-sparing approach is used to insert a linked replacement in a patient whose incision is healing well. On the other end of the spectrum, in which rehabilitation must progress most cautiously, is the use of a triceps-reflecting approach for an unlinked replacement, requiring release and repair of the lateral ligament complex in a patient with poor skin quality.
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Just as the progression of exercise is based on the unique features of each patient's surgery, precautions are determined in a similar manner. It is particularly important for the therapist to know the status of repaired soft tissues to incorporate the necessary precautions into the exercise program. Information in the operative report and close communication with the surgeon are the best sources for these details. Specific precautions for exercise and functional use of the operated upper extremity are summarized in Box 18.6.6,11,51,58,75,91 Patient education about these precautions should occur throughout the rehabilitation program. A patient's adherence to precautions ensures more positive outcomes and lessens the likelihood of short- or long-term postoperative complications related to exercise and use of the operated arm for functional activities.
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BOX 18.6 Specific Precautions After Total Elbow Arthroplasty ROM Exercise
Perform ROM exercises only within the arc of motion achieved during surgery.
To reduce postoperative stress on a repaired triceps mechanism, avoid end-range flexion during assisted ROM and active, antigravity elbow extension for 3 to 4 weeks.
If elbow stability is questionable after an unlinked TEA, limit full extension of the elbow and rotation of the forearm, particularly supination past neutral, to avoid overload on repaired lateral ligaments for 4 weeks. With an unlinked replacement, the greatest risk of instability is when the elbow is extended beyond 40° to 50°.6
If symptoms of ulnar nerve compression are noted, avoid prolonged positioning or stretching into end-range flexion.2,12
Strengthening Exercises Postpone resisted elbow extension for 6 weeks (or as long as 12 weeks) if a triceps-reflecting approach was used.
When strengthening the shoulder, apply resistance above the elbow to eliminate stresses across the elbow joint.
Weight training using moderate and high-loads is not appropriate after TEA.
Functional Activities Avoid lifting or carrying any objects with the operated extremity for 6 weeks or objects greater than 1 lb for 3 months.
If the triceps mechanism was detached and repaired, avoid pushing motions, including propelling a wheelchair, pushing up from a chair, and using a walker, crutches (other than forearm platform design), or a cane, for at least 6 weeks or as long as 3 months.
If an unlinked replacement was implanted, do not lift weighted objects during daily tasks with the elbow extended to avoid shear forces across the lateral ligament repair, which could contribute to posterolateral instability.
Limit repetitive lifting to 1 lb for the first 3 months, 2 lb for the first 6 months, and no more than 5 lb thereafter. Never lift more than 10 to 15 lb in a single lift.6,22,48,51,61
Do not participate in recreational activities, such as golf, volleyball, and racquet sports, that place high-loads or impact across the elbow.
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Exercise: Maximum Protection Phase
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The focus during the first phase of rehabilitation, which extends approximately over a 4-week period, includes control of inflammation, pain, and edema with use of medication as needed, application of cold and regular elevation of the operated arm. Emphasis is also placed on careful inspection of the wound, protection of repaired soft tissues as they begin to heal, and early ROM exercises to offset the adverse effects of immobilization without jeopardizing the stability of the prosthetic joint. Assisted ROM as tolerated and within the ranges achieved intraoperatively typically is initiated 2 to 3 days after linked TEA and a few days later after unlinked TEA if the elbow is stable.6,51,91
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CLINICAL TIP
If there was significant preoperative instability of the elbow or if the repair of ligaments released during surgery is in question, elbow ROM typically is delayed for more than a week. When motion is initiated, the patient may need to wear a hinged splint for 4 to 5 weeks that allows only flexion and extension and restricts rotation of the forearm.6,51
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Goals and interventions. The goals and exercise interventions during this first phase include the following.6,19,25,48,51,58,61,91
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Maintain mobility of the shoulder, wrist, and hand.
Regain motion of the elbow and forearm.
After a linked TEA or if the elbow is stable after an unlinked TEA, start with gentle self-assisted elbow flexion/extension and pronation/supination with the elbow comfortably flexed and the forearm in mid-position, progressing to active ROM as tolerated. As acute symptoms subside, have the patient maintain the end-range position to apply a very low-intensity stretch.
If the triceps mechanism was reflected and repaired, limit assisted flexion to 90° to 100° for the first 3 to 4 weeks to avoid excessive stretch on the repaired triceps tendon. Perform active elbow flexion/extension in a seated or standing—rather than supine—position for the same time frame to avoid antigravity extension, which also could cause excessive stress to the reattached triceps mechanism and subsequent insufficiency.6,19,51 While sitting and standing, elbow extension is gravity-assisted; extension is controlled by an eccentric contraction of the elbow flexors.
If a linked replacement was implanted using a triceps-sparing approach, there is little to no risk of early postoperative instability or disruption of the triceps mechanism. Therefore, active ROM in all planes of motion is permissible immediately.
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NOTE: Some sources recommend that after linked arthroplasty involving a triceps-reflecting approach—and if secure reattachment of the triceps tendon was achieved—ROM exercises progress as tolerated without restriction.31,61
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Exercise: Moderate and Minimum Protection Phases
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By about 4 to 6 weeks postoperatively, soft tissues have healed sufficiently to withstand increasing stresses. By 12 weeks, barring complications, only minimum protection is necessary; therefore, a patient typically can resume most functional activities with some imposed restrictions (see Box 18.6). However, the recommended timeline for return to a reasonably full level of activity varies from 6 weeks22,48,58 to 3 to 4 months.6,25,51
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Goals and interventions. The focus of rehabilitation during the intermediate and final phases is to improve ROM to the extent achieved intraoperatively, regain strength and endurance of elbow musculature, and use the operated arm for gradually demanding functional activities. However, these goals must be reached without disrupting repaired soft tissues and compromising the stability of the prosthetic elbow. Strength and muscular endurance usually continue to improve up to 6 to 12 months postoperatively by cautious use of the operated arm for functional activities.
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Patient education, especially with regard to the resumption of functional activities, is ongoing until the patient is discharged from therapy. The following goals and interventions are added during the moderate and minimum protection phases of rehabilitation.6,25,51
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NOTE: It is the opinion of the authors that use of joint mobilization techniques to increase ROM of the elbow or forearm is inappropriate after TEA, particularly with linked implants or if the stability of the elbow is questionable. If selected as a stretching technique, it should be implemented only after specific consultation with the surgeon to determine its appropriateness. It is a more prudent choice to forego full elbow motion than to jeopardize the stability of the joint.
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Low-intensity, manual self-stretching.
Low-load, long-duration dynamic splinting,13,38,51,83 as described and illustrated in Chapter 4 (see Fig. 4.13), or alternating use of static splints, each fabricated in maximum but comfortable extension and flexion.
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PRECAUTIONS: Emphasize end-range extension before end-range flexion to protect the posterior capsule and the triceps mechanism. If symptoms of cubital tunnel syndrome are present (aching along the medial forearm and hand, paresthesia, or hyperesthesia due to compression or entrapment of the ulnar nerve), avoid prolonged or repeated end-range positioning or stretching to increase elbow flexion.2,11
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NOTE: Some sources advocate progressive use of the operated upper extremity to regain strength and muscular endurance rather than an exercise program.31,48,58,61
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Resisted, multiple-angle isometric exercises at 5 weeks if not initiated previously.
Light ADL (initially <1 lb of weight) performed with the arm positioned along the side of the trunk and the elbow flexed. If a triceps-reflecting approach was used, incorporate activities that require elbow flexion before elbow extension. Initially modify activities to avoid those that require lifting with the elbow extended and pushing motions, such as pushing up from a chair or using a walker, axillary crutches, or a cane.
Dynamic, open-chain resistance exercises no earlier than 6 weeks and often later using a light-weight (1 lb) or light-grade elastic resistance. Emphasize gradually increasing repetitions rather than resistance.
Repetitive lifting during exercise and functional activities limited to 1 lb for the first 3 months and 2 lb for the next 3 months. Permanently limit repetitive lifting to no more than 5 lb and a single lift to no more than 10 to 15 lb.6,22,48,51,58,61 (See Box 18.6 for additional restrictions to strengthening exercises and functional activities.)
Low-load, closed-chain activities, such as wall push-ups after 6 weeks or later (when the triceps mechanism and posterior capsule have healed).
Upper extremity ergometry.
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CONTRAINDICATIONS: High-load progressive resistive exercise (PRE), heavy lifting during home- and work-related activities, and recreational activities that place high-loads or impact on the upper extremities (e.g., racquet and throwing sports or golf) are not allowed after TEA. These activities must be permanently avoided to reduce the risk of complications, such as elbow instability, implant loosening, and polyethylene wear.6,17,25,48,51,61
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Outcomes
Although the results of the early use of TEA during the 1970s were unsatisfactory, improvements in prosthetic design and fixation, surgical techniques, postoperative management, and criteria for patient selection have made this procedure a reliable means for relieving pain, restoring joint stability, improving physical function, and preventing eventual disability.
The outcomes of TEA and postoperative rehabilitation typically are assessed by a combination of patient self-report instruments that address pain relief, function, and quality of life (e.g., the Patient Related Elbow Evaluation form or the Disabilities of the Arm, Shoulder, and Hand [DASH] questionnaire), and physician-administered tools (e.g., the American Shoulder and Elbow Surgeons Questionnaire or the Mayo Elbow Performance Score, which also include measurements of ROM, strength, and specific shoulder and elbow functions).5 Because of the variety of tools used, direct comparison among studies is often difficult.
Pain relief and patient satisfaction. Complete or nearly complete relief of pain is the most consistently positive and predictable outcome after elbow arthroplasty, occurring in more than 85% to 95% of patients.20,34,48
As noted at the beginning of this discussion on TEA, although the indications have broadened over the past four decades, elbow arthroplasty continues to be used most frequently in patients with RA followed by patients with post-traumatic arthritis. Follow-up studies of patients with these and other underlying pathologies who have undergone linked or unlinked TEA indicate an overall high rate of patient satisfaction, with 80% to 100% of patients reporting "good" or "excellent" results after linked16,34,45,74,77 and unlinked22,48 TEA.
ROM and functional use of the upper extremity. Improvements in elbow ROM after TEA are less significant than relief of pain. In addition, maintaining stability of the prosthetic elbow postoperatively is a higher priority than gaining full ROM. However, results of most studies of linked34,45,55,62 and unlinked81,82 arthroplasty indicate some increase in the arc of elbow extension/flexion and forearm rotation in patients with late-stage posttraumatic,62,77 rheumatoid,34,45,81,82 and juvenile17 arthritis. Anecdotal evidence suggests that most gains are achieved within 6 to 12 weeks but occasionally up to 6 months postoperatively. Patients with little active movement of the elbow because of preoperative instability have exhibited marked improvement of active motion postoperatively.41,74
Many resources suggest or report supporting preoperative and postoperative data to show that greater improvement occurs in elbow flexion than extension after TEA.22,45,48,77,81,82 Some examples of the arc of extension/flexion achieved after TEA are 26° to 131°,34 19° to 140°,45 and 27° to 131°.77 Remember that arcs of 100° (from 30° to 130° of extension/flexion and 50° each of pronation/supination) are necessary for most functional activities.65 Therefore, in all of these studies, functional ROM for extension and flexion was achieved.
It is important to note that, when reviewing the literature for this summary of outcomes, there were no studies found that compared outcomes after different approaches to rehabilitation.
TEA survival rates. "Survival rate" (the point at which revision arthroplasty is necessary) following current-day TEA appears to depend more on a patient's underlying pathology than on the type of prostheses implanted.32 Relatively recent long-term studies of patients with RA, for example, have indicated that the survival rate of implants is 94% at a mean of 7.6 years45 and 92.4% at a minimum of 10 years34 after linked (semiconstrained) arthroplasty and 87% at a mean of 12 years82 and 90% at 16 years81 after unlinked arthroplasty. Overall prosthetic survivorship rates tend to be lower and the risk of revision arthroplasty higher in patients with post-traumatic arthritis or primary OA than in patients with RA. This may be because of generally higher activity levels—and therefore, greater loads placed across the elbow—in those with posttraumatic arthritis than in those with inflammatory disease.30,88
Regardless of underlying pathology, the survival rates are dramatically better for contemporary designs than those for the early, constrained implants in which upward of 70% failed within 10 years and are even better than the 82% survival rate of 5.5 years reported in an analysis of studies published worldwide from 1986 to 1992.35 There is general consensus that for the best long-term results, a patient must be selective in the type of work-related or recreational activities performed, modifying some activities and eliminating those that impose high-loads and high impact on the elbow.
As with all types of total joint arthroplasty, TEA survival rates deteriorate over time regardless of underlying pathology, type of implant, and the extent of stress placed on the elbow. For example, in a large follow-up study of patients who underwent TEA between 1995–2005, the survival rates of the implants were 92% and 85% at 5 and 10 years respectively regardless of patient's underlying diagnosis or if a semiconstrained or nonconstrained prosthetic design was used.30
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The terms myositis ossificans and heterotopic or ectopic bone formation are often used interchangeably to describe the formation of bone in atypical locations of the body. Some resources39,54,57 use the term myositis ossificans to denote only ossification of muscle. More often, the term is used generally to characterize heterotopic bone formation in the muscle-tendon unit, capsule, or ligamentous structures. In this text, the terms myositis ossificans and heterotopic bone formation are used synonymously.
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Although not a common phenomenon, the sites most frequently involved are the elbow region and thigh. In the elbow, heterotopic bone formation most often develops in the brachialis muscle or joint capsule as the result of trauma, such as a comminuted fracture of the radial head, a fracture-dislocation (supracondylar or radial head fracture) of the elbow, or a tear of the brachialis tendon.23,39,57,59 Patients with neurological impairments, specifically traumatic brain injury or spinal cord injury, and patients with burns to the extremities are also prone to develop this complication.57 It also may develop as the result of aggressive stretching of the elbow flexors after injury and a period of immobilization.23
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Myositis ossificans is distinguished from traumatic arthritis of the HU joint in that passive extension is more limited than flexion; resisted elbow flexion causes pain; flexion is limited and painful when the inflamed muscle is pinched between the humerus and ulna; and resisted flexion in mid-range causes pain in the brachialis muscle. Palpation of the distal brachialis muscle is tender.23,39 After the acute inflammatory period, heterotopic bone formation is laid down in muscle between, not within, individual muscle fibers or around the joint capsule within a 2- to 4-week period. This makes the muscle extremely firm to touch. Although this condition can permanently restrict elbow motion, in most cases, the heterotopic bone, is largely reabsorbed over several months, and motion usually returns to near normal.54
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Massage, passive stretching, and resistive exercise are contraindicated if the brachialis muscle is implicated after trauma. The elbow should be kept at rest in a splint, which should be removed only periodically during the day for active, pain-free ROM. Rest should continue until the boney mass matures and then resorbs. If the capsule also is involved, surgical excision of heterotopic bone from muscle or TEA is necessary only in rare instances.54,57
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Overuse Syndromes: Repetitive Trauma Syndromes
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Overuse can occur in any musculotendinous structure in the elbow region, including the flexors and extensors of the elbow, but it most commonly occurs in the muscles attached to the lateral or medial epicondyles in response to repetitive stressful wrist motions. Problems anterior or posterior to the elbow frequently are caused by excessive extension or flexion strain in sporting activities.4 Discussion in the literature as to whether overuse syndromes have an inflammatory component or are primarily degenerative in response to repetitive trauma lead to questions on use of terminology.27,46,85
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Overuse of the medial and lateral musculotendinous structures causing microscopic tears and inflammation is commonly termed epicondylitis (medial and lateral epicondylitis), and overuse of the distal biceps and triceps tendons is called tendonitis.23,85 Tendinosis or tendinopathy refers to degenerative changes in the collagen tissue without signs of inflammation. These changes include immature fibroblastic and vascular elements and weakening of the tendinous structure.27,85
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Lateral Elbow Tendinopathy (Tennis Elbow)
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Tennis elbow is commonly called lateral epicondylitis, lateral epicondylalgia, or lateral epicondylosis depending on whether inflammation is present or not.79,85 Symptoms include pain in the common wrist extensor tendons along the lateral epicondyle and HR joint with gripping activities. Activities requiring firm wrist stability, such as the backhand stroke in tennis, or repetitive work tasks that require repeated wrist extension, such as computer keyboarding or pulling weeds in a garden, can stress the musculotendinous unit and cause symptoms. The most frequent location of involvement is in the musculotendinous junction of the extensor carpi radialis brevis,23,26,27,39,69,85 although the extensor communis is also involved in many patients.27 Symptoms also occur when the annular ligament is stressed.
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Positive tests of provocation include palpation tenderness on or near the lateral epicondyle, pain with resisted wrist extension performed with the elbow extended, pain with resisted middle finger extension performed with the elbow extended, and pain with passive wrist flexion with the elbow extended and forearm pronated.23,89
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NOTE: Pulled elbow, pushed elbow, rotated elbow, radial head fracture, pinched synovial fringe,68 meniscal lock, radial tunnel syndrome, tendinosis,46 and periosteal bruise are also possible sources of pain at the elbow and are sometimes erroneously called tennis elbow.49
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Medial Elbow Tendinopathy (Golfer's Elbow)
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Golfer's elbow, also known as medial epicondylitis, medial epicondylalgia, or medial epicondylosis, involves the common flexor/pronator tendon at the tenoperiosteal junction near the medial epicondyle. It is associated with repetitive movements into wrist flexion, such as swinging a golf club, pitching a ball, or work-related grasping, shuffling papers, and lifting heavy objects. Concomitant ulnar neuropathy is often an associated finding.33,39
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Positive tests of provocation include palpation tenderness on or near the medial epicondyle, pain with resisted wrist flexion performed with the elbow extended, and pain with passive wrist extension performed with the elbow extended.
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The most common cause of epicondylalgia is excessive repetitive use or eccentric strain of the wrist or forearm muscles. The result is microdamage and partial tears, usually near the musculotendinous junction when the strain exceeds the strength of the tissues and when the demand exceeds the repair process. Initially there may be signs of inflammation followed by the formation of granulation tissue and adhesions.69 With repetitive trauma, fibroblastic activity and collagen weakening occurs. Recurring problems are seen because the resulting immobile or immature scar is re-damaged when returning to activities before there is sufficient healing or mobility in the surrounding tissue.
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Hypersensitivity over the radial and ulnar nerves has been reported to occur in women with lateral epicondylalgia, indicating a possible link between mechanical irritation and nerve sensitization.29
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Common Structural and Functional Impairments
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Gradually increasing pain in the elbow region after excessive activity of the wrist and hand
Pain when the involved muscle is stretched or when it contracts against resistance
Decreased muscle strength and endurance for the demand
Decreased grip strength, limited by pain
Tenderness with palpation at the site of inflammation, such as over the lateral or medial epicondyle, head of the radius, or in the muscle belly
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Common Activity Limitations and Participation Restrictions (Functional Limitations/Disabilities)
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Inability to participate in provoking activities, such as racket sports, throwing, or golf.
Difficulty with repetitive forearm/wrist tasks, such as sorting or assembling small parts, typing on a keyboard or using a computer mouse, gripping activities, using a hammer, turning a screwdriver, shuffling papers, or playing a percussion instrument.
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Nonoperative Management of Overuse Syndromes: Protection Phase
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Utilize the following management guidelines and interventions when signs of acute or chronic inflammation are present.
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Decrease Pain, Inflammation, Edema, or Spasm
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Immobilization. Rest the muscles by immobilizing the wrist in a splint such as a cock-up splint in which the elbow and fingers are free to move.
Patient instruction. Instruct the patient to avoid all aggravating activities, such as strong or repetitive gripping actions.
Cryotherapy. Use ice to help control edema and swelling.
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Develop Soft Tissue and Joint Mobility
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Patient position and procedure: Sitting with the elbow flexed, forearm pronated and resting on a table, and the wrist in extension. Begin with gentle isometric contractions with the wrist extensors in the shortened position. Resist wrist extension, hold the contraction to the count of 6, relax, and repeat several times; then move the wrist toward flexion and repeat the isometric resistance. Do not move into the painful range or provide resistance that causes a painful contraction.
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When full wrist flexion is obtained without pain in the lateral epicondyle region, progress by placing the elbow in greater degrees of extension and repeat the isometric resistance sequence to the wrist extensors. Progress until gentle resistance can be applied to the wrist extensors in the position of elbow extension and wrist flexion. It may take several weeks to reach this position.
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Patient position and procedure: Sitting with the elbow flexed, forearm resting on a table, and the wrist in flexion. Begin with gentle isometric contractions with the wrist flexors in the shortened position. Resist wrist flexion, hold the contraction to the count of 6, relax, and repeat several times; then move the wrist toward extension and repeat the isometric resistance. Do not move into the painful range or provide resistance that causes a painful contraction.
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When full wrist extension is obtained without pain in the medial epicondyle region, progress by placing the elbow in greater degrees of extension and supination and repeat the isometric resistance sequence to the wrist flexors. As stated above, it may take several weeks to reach the full range of elbow extension, forearm supination, and wrist extension and to be able to tolerate gentle resistance.
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Cross-fiber massage. Apply gentle cross-fiber massage within tolerance at the site of the lesion. Teach the patient to self-administer the submaximal isometric and cross-fiber massage techniques in a home exercise program.
Neuromobilization. If increased symptoms occur with nerve tension testing, use neuromobilization techniques as described in Chapter 13.
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Maintain Upper Extremity Function
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Active ROM. Have the patient perform ROM to joints not immobilized to maintain the integrity of the rest of the upper extremity.
Resistive exercises. Have the patient perform shoulder and scapular ROM and stabilization exercises with resistance applied proximal to the elbow.
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Nonoperative Management: Controlled Motion and Return to Function Phases
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Utilize the following management guidelines and interventions when there are no signs of inflammation.
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Increase Muscle Flexibility and Scar Mobility
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Manual stretching techniques. Use agonist contraction, hold-relax, and passive stretching techniques to elongate the tight muscle to the end of its range (principles for application of these techniques are described in Chapter 4). Use an intensity of muscle contraction and stretch that causes a stretching sensation but not increased pain.
For both the wrist flexors and wrist extensors, the elbow must be extended.
To stretch the wrist extensors, pronate the forearm, flex and ulnarly deviate the wrist, and flex the fingers.
To stretch the wrist flexors, supinate the forearm, extend and radially deviate the wrist, and extend the fingers.
Self-stretching techniques. The patient may use a wall (see Fig. 18.10) and slide the hand along the wall until a stretch force is experienced, or the patient may use the opposite hand to apply the stretch force. These techniques are described in the self-stretching section later in the chapter.
Cross-fiber (friction) massage. Palpate to localize the scar, and then apply pressure and cross-fiber massage. Increase the intensity of massage as tolerated.
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Restore Joint Tracking at the RU Joint
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Mobilization with movement (MWM). These techniques are used to restore normal tracking of the radius on the capitulum, so the forearm muscles can be strengthened without painful symptoms.66 Several researchers have reported decreased pain and increased grip strength during or shortly after MWM at the elbow.55,86,87 One researcher observed decreased shoulder rotation in patients with lateral epicondylalgia and demonstrated significant improvement in shoulder range after MWM at the elbow. He proposed that the mechanism was mediated neurophysiologically.1 Refer to Chapter 5 for principles of application. The following techniques are used if the patient experiences pain when making a fist or with resisted wrist extension.
Patient position and procedure: Supine with the forearm pronated. Place a mobilization belt around the patient's proximal forearm and across your shoulders and stabilize the distal humerus with one hand. Apply a lateral glide to the forearm through the belt and then have the patient do repeated wrist extension against manual resistance applied by your other hand (Fig. 18.6 A).
Alternative method: Apply the lateral glide force against the proximal forearm with your distal hand and have the patient do repeated gripping by squeezing a ball or inflatable bulb (Fig. 18.6 B). Both the lateral glide force and the muscle contraction must be pain-free.
Self-MWM. The patient stands with the humerus of the involved elbow stabilized against a doorframe and the forearm in the opening and then applies lateral glide force against the proximal forearm with the contralateral hand. The patient then does repetitive gripping or squeezing against a resistive force, such as a pneumatic bulb or squeezable ball (Fig. 18.6 C).
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Improve Muscle Performance and Function
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Counter force elbow sleeve or strap. Use an elbow orthosis to help reduce the load on the musculotendinous unit. This type of orthosis has been shown to have the immediate effect of improving pain-free grip strength in individuals with lateral epicondylosis.42
Isometrics. Progress the isometric exercises by applying resistance in various pain-free positions with emphasis on the lengthened position.
Dynamic resistance exercise. Progress to dynamic exercises against manual or elastic resistance or free weights through pain-free ranges. Initially, use low-intensity resistance with multiple repetitions for muscular endurance, then progress to more intense resistance to strengthen the muscles in preparation for functional demands.
Eccentric training: Incorporate a progression of eccentric contractions of the involved musculotendinous unit, first within a comfortable wrist ROM against a low-intensity load, at a slow speed, and preferably with the elbow in a relatively extended position.79 Use of an isokinetic dynamometer enables the patient to perform repetitive, eccentric-only contractions.19 If elastic resistance or a free weight is used, have the patient lift the weight or lengthen the elastic band with the sound hand when returning to the starting position of wrist extension.52
Progressions: Progress to faster speeds before increasing the resistance. When resistance is increased, return to a slow speed and then again work up to a faster speed before increasing the resistance and so on. Gradually perform the eccentric contractions through a full, pain-free ROM.
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FOCUS ON EVIDENCE
Eccentric resistance training (typically combined with a program of static stretching) often is recommended in the literature and implemented in the clinical setting to reduce pain associated with epicondylalgia/epicondylitis of the elbow, improve grip strength, and gradually restore physical functioning of the upper extremity. Although there is evidence demonstrating positive changes over time for patients participating in eccentric strengthening programs, these studies typically do not include control groups or direct comparisons of different treatment approaches.19,27 Furthermore, if provided, details about the eccentric training programs often are limited or vary considerably from study to study, making it difficult to replicate the training programs. Consequently, the results of a systematic literature review92 indicated that there is insufficient evidence from high-quality studies (prospective randomized trials) at this time to support the efficacy of eccentric exercise for management of elbow epicondylalgia compared with other active exercise interventions, such as a program of concentric training. The need for more well-designed studies is consistently emphasized.
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Functional patterns. As flexibility and strength improve and the pain is brought under control, incorporate functional training, utilizing functional patterns into the exercises. Emphasize control of the resistance through the pattern. If pain or deviation of the pattern with substitute motions occurs, have the patient rest before resuming additional repetitions. Exercises simulating the desired activity are progressed from slow, controlled motions to high speeds with low resistance to improve timing (see Fig. 18.22).
General strengthening and conditioning. Incorporate any unused or underused part of the extremity or trunk into the training program prior to returning to the stressful activity.27,90
Plyometric exercises. Add plyometrics to the program if the patient's goals include returning to sports or occupational activities that require elbow and forearm power. Suggestions include the following and are described and shown in Chapter 23.27,90
Dribbling a weighted ball against the wall or the floor
Flipping and catching a weighted ball
Bouncing a tennis ball on a short-handled racquet, progressing to a long-handled racquet
Rapid eccentric/concentric elbow and forearm motions against elastic resistance
Rapid chest passes or overhead passes using a weighted plyometric ball
Activity modification. It may be necessary to modify the patient's activity or technique before he or she returns to the repetitive or stressful activity. For example, it may require taking tennis lessons to correct improper tennis techniques, adapting use of a hammer or other equipment, or making ergonomic modifications of a computer workstation.26,27,39,69,89
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NOTE: Information on ergonomic recommendations for computer workstations are described in Chapter 14.
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Education includes advice and techniques on prevention, recognition of provoking factors, and identification of warning symptoms.
Teach the patient how to reduce the overload forces that caused the problem and retrain the patient in proper techniques.26,27,39
In addition to exercises, include home instructions on the application of friction massage and stretching the involved muscle prior to using it.
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FOCUS ON EVIDENCE
In a descriptive study of 60 subjects with lateral epicondylalgia who were followed for 6 months after initiating physical therapy intervention, Waugh and associates89 reported that 80% of the participants continued to improve, but only 33% had complete resolution of symptoms. The therapy intervention consisted of 8 weeks of ultrasound, deep transverse friction massage, and a stretching/strengthening program for the wrist extensor muscles; 37% of the participants also received treatment for the cervical spine or shoulder. Altogether, 50% continued with some form of therapeutic intervention after the initial 8 weeks. Those with poorer outcomes had repetitive work duties, with 92% of the repetitive duties involving computer work.
This study also reported that women who have positive cervical signs as well as repetitive job duties involving computer usage had a poorer prognosis. This was observed at both 8 weeks and 6 months. Ergonomic recommendations for postural adaptations when using a computer included having forearm support, smooth movements, and relaxed shoulders.89