conservative management and rehabilitation of lateral

AVANTHI MANDALESON MBBS( H O N S ) , BMEDSCI, FRACS, FAORTHA HAND AND UPPER LIMB SURGEON Provider No.: 261873AA Level 7, Martin Street Heidelberg 3084 T: (03) 9456 9077 F: (03) 9456 9177 [email protected] [email protected] Conservative Management and Rehabilitation of Lateral Elbow Instability (1) Phase I: Day 1-4 weeks LCL deficiencies are best splinted with elbow at 90° of flexion and forearm in pronation (See Fig. 1). This position approximates the radial head to the coronoid and reduces the stress on the lateral soft tissue structures. Supine exercises allow gravity to aid in ulnohumeral reduction whilst maintaining motion. The need for splinting and rate of progression from active assisted to resisted exercises is dependent on the degree of instability whether the elbow dislocation has been conservatively managed or surgically stabilised. Figure 1: Posterior elbow splint with elbow at 90° and pronated forearm position • The splint is worn continuously for 3-4 weeks except for exercises and skin care unless the LCL has been surgically stabilised in which case a sling should be used for 3-4 weeks • Exercises commence within 1 week following reduction of the elbow • Introduce active assisted or overhead exercises 15x every 2hrs (See Figure 2) • Progress to active and then resisted exercises • Forearm rotation exercises only performed with elbow flexion 90° or greater • Shoulder, wrist and finger active motion exercises throughout program

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Page 1: Conservative Management and Rehabilitation of Lateral

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

Page 2: Conservative Management and Rehabilitation of Lateral

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

Page 3: Conservative Management and Rehabilitation of Lateral

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

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