Clinical Review

5 Points on Stiff Elbow

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Take-Home Points

  • Proper patient selection is critical as extensive postoperative rehabilitation is required to obtain an excellent outcome.
  • Open and arthroscopic approaches are effective treatment options for elbow contractures.
  • Elbow stability must be restored to obtain a successful outcome.
  • Knowledge of neurovascular anatomy is essential to prevent neurologic complications.
  • Prophylactic ulnar nerve release should be considered, especially in patients with limited flexion.

Elbow stiffness has several etiologies, posttraumatic being the most common. Elbow stiffness can have debilitating functional effects necessitating treatment. In a biomechanical study of normal elbow function, Morrey and colleagues 1 determined that a flexion extension arc of 100° (30 °-130°) and a forearm rotation arc of 100° (50 ° pronation-50 ° supination) are required in 90% of activities of daily living. Similarly, elbow flexion of <105° was poorly tolerated, whereas patients could easier adapt to flexion contractures up to 40°. 2

The goal of initial evaluation should be to establish the cause of the contracture and the patient’s functional demands and ability to cooperate in the extensive postoperative rehabilitation that is essential in achieving an excellent functional outcome. In a thorough clinical examination, the clinician must note skin, range of motion (ROM), ligamentous stability, and neurovascular structures and give special attention to ulnar nerve function and symptoms. Mid-arc pain suggests additional intra-articular pathology, as stiffness typically causes pain only at the limits of motion as osteophytes impinge and soft tissue is under maximal tension. Routine elbow radiographs are required in all cases, and computed tomography (CT) can be useful in evaluating osseous sources of contracture. Suspected ligamentous instability and cartilaginous defects particularly in the setting of mid-arc pain are best evaluated with magnetic resonance imaging. 3

In this 5-point review, we evaluate treatment options as well as rehabilitation protocols in the management of elbow stiffness.

1 Anatomy of Contracture: The Usual Suspects

The cause of elbow stiffness is incompletely understood. Several posited contributing factors include biology, complex intra-articular anatomy, capsular distention favoring a flexed position, and tenuous postoperative fixation necessitating prolonged immobilization. Identifying intrinsic and extrinsic anatomical sources of stiffness can help guide treatment. 4 Intrinsic pathology includes intra-articular malunion, osteophytes, loose bodies, and adhesions; extrinsic pathology includes soft-tissue contracture, heterotopic ossification, and extra-articular malunion.

Compared with the normal elbow, the capsule becomes thickened and fibrotic and thereby prevents motion. Severe contractures, and extension contractures in particular, may require release of the posterior medial capsule and the posterior medial collateral ligament (MCL) to regain motion. In a series of 42 patients with flexion <100°, Park and colleagues 5 noted that all patients required release of the posterior band of the MCL to regain flexion. Other muscular impediments to motion include contracture of the brachialis and scarring of the triceps to the posterior humerus. Scarring of the triceps to the humerus can limit flexion.

In the posttrauma setting, intra-articular and extra-articular malunion must be considered. Extension malunion of the distal humerus can reduce flexion, 6 and shortening with compromise of the olecranon and coronoid fossae can limit both flexion and extension.

Last, heterotopic ossification and osteophytes should be assessed as potential causes of limited ROM. Both the coronoid process and the olecranon can develop osteophytes, and their respective fossae should be assessed with CT. Posterior impingement is rare at the tip of the olecranon; it occurs because of "widening" of the olecranon by "Mickey Mouse ear" osteophytes and bony encroachment along the medial and lateral columns. Thus, the olecranon must be narrowed and the fossa widened and deepened.

In case of concomitant ligament instability, we prefer to reconstruct the ligament first, and then perform contracture release as a staged procedure. We favor a staged approach because the rehabilitation regimens for instability and contracture release are diametrically opposed: Instability requires immobilization, and contracture release requires immediate motion. Last, incision placement and ulnar nerve management are crucial in minimizing the potential complications of the second procedure.

2 Nonoperative Treatment

In the absence of significant bony impediments to motion—such as heterotopic ossification or malunion—initial treatment should commence with nonoperative therapy. Therapy should be initiated as soon as concern for stiffness arises in order to prevent contracture. Initial nonoperative treatment can also serve as an important litmus test of postoperative adherence. Adequate patient relaxation is crucial in avoiding co-contracture resisting stretching forces. Passive ROM exercises use sustained force to allow time-dependent stress relaxation to increase tissue length as well as fatigue antagonist muscles. In addition, hold-and-relax techniques apply isometric resistance to induce relaxation of antagonist muscles. 7 Active ROM


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