conservative management and rehabilitation of lateral
TRANSCRIPT
A V A N T H I M A N D A L E S O N M B B S ( H O N S ) , B M E D S C I , F R A C S , F A O R T H A
H A N D A N D U P P E R L I M B S U R G E O N
Provider No.: 261873AA Level 7, Martin Street
Heidelberg 3084 T: (03) 9456 9077 F: (03) 9456 9177
[email protected] [email protected]
ConservativeManagementandRehabilitationofLateralElbow
Instability(1)PhaseI:Day1-4weeksLCLdeficienciesarebestsplintedwithelbowat90°offlexionandforearminpronation(SeeFig.1). This position approximates the radial head to the coronoid and reduces the stress on thelateral soft tissue structures. Supine exercises allow gravity to aid in ulnohumeral reductionwhilstmaintainingmotion.Theneedforsplintingandrateofprogressionfromactiveassistedtoresisted exercises is dependent on the degree of instabilitywhether the elbowdislocationhasbeenconservativelymanagedorsurgicallystabilised.
Figure1:Posteriorelbowsplintwithelbowat90°andpronatedforearmposition
• Thesplintisworncontinuouslyfor3-4weeksexceptforexercisesandskincareunless
theLCLhasbeensurgicallystabilisedinwhichcaseaslingshouldbeusedfor3-4weeks• Exercisescommencewithin1weekfollowingreductionoftheelbow• Introduceactiveassistedoroverheadexercises15xevery2hrs(SeeFigure2)• Progresstoactiveandthenresistedexercises• Forearmrotationexercisesonlyperformedwithelbowflexion90°orgreater• Shoulder,wristandfingeractivemotionexercisesthroughoutprogram
A V A N T H I M A N D A L E S O N M B B S ( H O N S ) , B M E D S C I , F R A C S , F A O R T H A
H A N D A N D U P P E R L I M B S U R G E O N
Provider No.: 261873AA Level 7, Martin Street
Heidelberg 3084 T: (03) 9456 9077 F: (03) 9456 9177
[email protected] [email protected]
Figure2:(A,B)Overheadflexionandextensioninsupinepositionwithshoulderflexedto90°andpronatedforearmpositionPhaseII:4to6weeksJointstabilityIsoftenachievedby4to6weeksfollowingtraumaorsurgery.Duringthisphaseofelbow rehabilitation, the goals are to maximise elbow and forearm range of motion whilstmaintainingelbowstabilityandmaximisingstrengthofthelateralmuscles.
• Discontinueposteriorelbowsplint• Collarandcufforslingtobewornwhenoutofthehouseorwhenactive,fracture
protection• Applyheatbeforeexercisetoincreasetissuecomplianceandgreaterarcofmotion• Flexion-Extensionexercisesperformedwithforearminneutralposition,25xeachhour
insupineorerectposition• Forearmrotationexercisescontinuesin90°ofelbowflexion• Wristanddigitalextensorstrengtheningincreasingresistance• Increasegripstrengtheningexercises• EncouragelightADL’savoidingthecombinedpositionofextensionandforearm
supination
A V A N T H I M A N D A L E S O N M B B S ( H O N S ) , B M E D S C I , F R A C S , F A O R T H A
H A N D A N D U P P E R L I M B S U R G E O N
Provider No.: 261873AA Level 7, Martin Street
Heidelberg 3084 T: (03) 9456 9077 F: (03) 9456 9177
[email protected] [email protected]
PhaseIII:6-12weeksRangeofmotion limitationsare liftedduring thisphase,as the jointshouldnowbestable.Thegoal of rehabilitation in this phase is to increasemobility, strength and endurance andoverallupperlimbfunction.
• Freeweightsandelasticbandscanbeincorporatedintotheprogramtoprogressstrength
• Strengtheningofelbowflexorswiththeforearminpronationforthefirst2weeksreducestheriskofrecurrentinstability
• Tricepsstrengthening• Shoulder,forearm,wristandhandstrengtheningmustbeincorporatedinthisphaseof
rehabilitation• Heatandstretch,passiverangeofmotionandstaticprogressivesplintingcanbehelpful
inrestoringflexioncontractures
References:
1. SzekeresM,ChinchalkarSJ,KingGJW.OptimizingElbowRehabilitationAfterInstability.HandClin.2008Feb;24(1):27–38.
2. ThisprotocolhasbeenadaptedwithpermissionfromAssocProfEugeneEkatMelbourneOrthopaedicGroupandtheHandtherapyDepartmentandDivisionofHandandUpperExtremitySurgery,HospitalforSpecialSurgery,NewYork