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Elbow Stiffness
378 Plays1 month ago
Miranda and Josh dive into the challenges of elbow stiffness, discussing common pitfalls and effective treatment strategies.
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Transcript
Introduction to Elbow Stiffness
00:00:06
josh MacDonald
Hi, I'm Josh McDonald.
00:00:07
Miranda Materi
and then random material. And we are Hand Therapy Academy.
00:00:10
josh MacDonald
Let's talk a little bit today about elbow stiffness.
Causes and Prevention of Elbow Stiffness
00:00:14
josh MacDonald
Elbow stiffness can be really stubborn. So let's talk about ways to maybe prevent it. And if you didn't get to prevent it, maybe what to do afterwards.
00:00:22
Miranda Materi
Right, and so when we're talking about this, it's usually post, I would say post injury or post surgery.
Orthopedic Injuries and Elbow Stiffness
00:00:29
Miranda Materi
And we're not talking about like ulnar nerve transpositions or anything like that, but more things that really affect or involve the joint.
00:00:36
josh MacDonald
Yeah, yeah, those orthopedic injuries, usually pretty high velocity, high energy traumas that cause fractures. Even if it's a fall um at ground from ground level, it's something that causes some joint dysfunction within that elbow.
00:00:51
Miranda Materi
Right, right.
Strategies to Avoid Stiffness
00:00:52
Miranda Materi
So what are what are some of your things that you try to do to avoid stiffness, right? We know once the elbow gets stiff, we're working, it's such a hard hill to climb, right? And sometimes you're like, gosh, this is probably how it's going to be for this patient. But what are some things you do to try to prevent that from occurring? Or once it has started occurring, what are you doing?
Importance of Early Movement
00:01:13
josh MacDonald
First off, um all the research I'm seeing, everything is get that elbow moving as soon as possible. um you know Obviously, we have to follow fracture precautions. If it's a highly comminuted fracture, that's different. But um as early as you can, even if it's short arc motion, even if it's just active assisted with no passive range of motion,
00:01:31
josh MacDonald
just to keep that joint lubricated and keep all of those joint capsule structures, keep all of those big, strong muscles, tendons from tightening and shortening, um get them moving early. We see patients who are told like, oh, you know, you got to wait for six weeks, don't move it for six weeks. This is a big, hardy joint. This is not the same as a PAP joint. We've got all these small structures and delicate things. It's a big, hardy joint. You can do light, early stuff to keep it from tightening up. It's early motion is highly
Protocols and Approaches for Elbow Injuries
00:01:58
josh MacDonald
recommended.
00:01:58
Miranda Materi
Yeah, I think the other thing too, like some of the elbows we get is there's, there will be like the lateral collateral ligament damage and things like that. And those protocols want you to wait, right? Like there's some of those conservative protocols that want you to wait. But when there's other trauma associated with it, are you still waiting or are you going, are you just going to push those patients a little bit quicker than what you otherwise would?
00:02:21
josh MacDonald
I'm going to get the moving I hesitate to use the word push because I'm not literally going to push right like we're going to challenge them we're going to like advance but I think you can do like LCL stuff I can do things in that pronated position in supine and I can get them doing that active um against gravity extension and gravity assisted flexion that's still elbow range of motion and that's still well within those precautions sometimes the more diagnoses we see the more cautious we are and like slow it down slow it down let's just do other joints and and edema but
00:02:53
josh MacDonald
Sometimes the more diagnosis we see, the more we need to be proactive about early short arc protected range of motion, but active assist, um, maybe some, some light mobility if there's no major fractures in there. But yeah, sometimes the more diagnosis, the more we need to that early active stuff.
00:03:10
Miranda Materi
Right. And I want to clarify. So one thing you're saying short arc, which just is being basically you go within the range, um that they are comfortable, usually, or at least that's what I'm assuming you
Stretching Techniques and Precautions
00:03:21
Miranda Materi
mean is okay, however much you know, you can push it to come in as much as you can and go out as far as you can.
00:03:21
josh MacDonald
Yeah. yeah
00:03:26
Miranda Materi
from what I've read in studies and even I think in rehab of the hand, it says if you're just doing these little tiny motions at the elbow, you know, where you're just going back and forth, maybe 15, 20 degrees, it actually doesn't really do as much as if you can go to within their tolerance to fully extend and then fully flex. Of course, if there's precautions, like they had a tendon repair or something like that, and they can't, then you're not going to do that. But go within the range of motion that is somewhat comfortable, but starting them to move early.
00:03:54
josh MacDonald
Yeah. And so like I'll explain to staff or students or even patients going to the end of what you have available today, knowing that that will get further and further out without having to challenge end range without overpressure. So I'm telling them, I don't want you to fight for more degrees. Just take it to where you are today and come for extension inflection and mastering that mid range will improve your end range without having to apply overpressure either actively or passively.
Use of Splints in Treatment
00:04:20
Miranda Materi
Right, and then you can hold it at that end range right like just do like a little prolonged gentle stretch.
00:04:26
josh MacDonald
Yeah, yeah. um And then soft tissue work too to bicep and bicep tendon, tricep and tricep tendon, just ah whether it's iced in or soft tissue massage, just to keep those fibers from tightening as long as those fibers, like you said, aren't involved in a tendon injury. If it's a capsular thing, if it's a, um ah you know, radial head fracture, I can work on bicep and bicep tendon to keep those from tightening up. And that will slow down the advancement of that stiffness.
00:04:53
Miranda Materi
Yeah, definitely.
00:04:54
josh MacDonald
yeah
00:04:54
Miranda Materi
I know once it gets stiff, it's so hard. um I know we've had where patients will come in and they'll be doing great. You're like, wow, you're doing really, really well. And then it starts getting painful and they start losing range of motion.
00:05:09
Miranda Materi
And what are you doing in those cases? And what are you thinking when that happens?
00:05:12
josh MacDonald
Yeah. Yeah. It's usually their first appointment of the week because over the weekend, something like it started to be uncomfortable. So they took a day or two off a home program. And then you're like, all right, week four, we just lost it, right? They were doing great. Sometimes it can happen with the flexor tendon too. Like we're doing great. We're doing great. And then your body just scarred it just instantly. So that can be tough.
00:05:32
josh MacDonald
um Honestly, when I see that happen, I send requests to the doctor for um like a static or dynamic elbow splint, flexion or extension. um And sometimes I'll send the script to be signed with a sticky note on it and set and with the question so they don't have to worry about negating or signing the script with that question. I'm not saying when are we approved to use this, but I want to start the order process. So by the time it comes in, if I'm ordering like from Lance, my other daughter, Dinah Splint, we're ready for it. i want I don't want to wait until we're ready and then order it. So I'm starting the ball rolling on that a little early. That's not my only approach, but um that's early in my thought process because that's something that takes a while for insurance approval and fitting and delivery and all that.
Imaging and Diagnosis of HO
00:06:15
Miranda Materi
Right, I know a lot, sometimes I'll even send them back to the doctor just to be like, hey, can you get x-rays again and we'll see what we're working with. Because sometimes it's HO, right? Or a lot of times.
00:06:25
josh MacDonald
Yeah. Yeah. And we're sometimes the first ones to pick up on that because we see them more frequently and more, uh, and earlier than the doctors, you know, six weeks follow up or whatever. So you're right, sending them back for more imaging x-rays so the doctor can even get a read on like, Oh, what's the position this. And then if they say go for it on range of motion, all right, then I know I have the clearance explicitly without guessing at that.
00:06:45
Miranda Materi
Right, because I know what well long this is a long time ago, but when we spoke with some doctors, if they had HO, they would want you to back off a little bit. I don't think that's the case. It doesn't happen as often, but I still think there's probably some old school doctors that would want you to proceed differently.
00:07:01
josh MacDonald
Yeah, yeah. So if it's a diagnosis of HO, which we shouldn't make clinically, we can we can discuss it. we can you know We can consider that. But without an x-ray, we shouldn't make that clinically because there can be other things. What is your approach for a patient who's diagnosed via x-ray with HO?
Therapeutic Approaches for HO
00:07:19
Miranda Materi
ah Yeah, usually, you know, I make sure the doctor has talked to them first, right? Like, I'm fine to go back in and do other education with them, but I always like for the doctor to say that and diagnose them first. And then after the diagnosis has been made, I'm usually starting static progressive as soon as I can. And then sometimes, i'll think well, are we losing more in extension or flexion?
00:07:40
Miranda Materi
what's more important for function to this patient, right? Based on their ADLs or their work work status, like what what really matters to this patient? And then we'll either focus on both flexion and extension or maybe just flexion if they need that motion more, depending on the case. um And then just lots of education and gentle stretching. And then if it's a doctor I know who's going to go in and do surgery again, we'll start kind of prepping through that process too.
00:08:07
josh MacDonald
Yeah, yeah. We used to have the the guideline that said like HO stretching makes it worse, don't push, don't push because it makes it worse. They're realizing now it doesn't make it better.
00:08:18
josh MacDonald
It's just uncomfortable to really, really force end range.
Challenges in Treating HO
00:08:21
josh MacDonald
um So at this point, we're trying to not lose any more range than we have and maybe gain a little bit through some other tissues that we can address. But that deposit of the ossification is not going anywhere. We're just trying to maintain or maybe gain a little bit because maybe biceps can loosen or whatever.
00:08:38
josh MacDonald
um But yeah, I'm, I like static progressive for those, but sometimes if they need both, it's hard for us to fabricate that. So I like the, the Dyna splints or the Lance medicals because while they're dynamic, they at least can work on both, at both extension and flexion at the same time.
00:08:53
Miranda Materi
Yeah, definitely. I think that's really great. Or sometimes if they need flexion extension, I'll put them in a nighttime static progressive extension split because I think those are really comfortable and you could wear them while you're sleeping.
00:09:06
Miranda Materi
And then during the day, have them work on the flexion. And I think usually for those protocols, at least the rep will be like, do 30 minutes three times per day working on flexion.
00:09:15
josh MacDonald
Yeah, yeah, yeah.
00:09:15
Miranda Materi
Sometimes I have them do just a little bit more because I know the research says you usually need around like six hours. so
00:09:23
josh MacDonald
Yeah, yeah. Lots of time, lots of time. Really unrealistic time for so for a joint like an elbow. It's one thing if it's a PIP joint, but a joint like an elbow, you just can't live life if you're in this big bulky thing challenging your range.
Managing Patient Expectations
00:09:34
josh MacDonald
It's hard to do, you know, taking care of your kids and cleaning the house and doing your job.
00:09:38
Miranda Materi
Right, and those flints are huge, right?
00:09:39
josh MacDonald
yes Yeah, yeah.
00:09:39
Miranda Materi
like so what ah but How much time are you telling them to wear it?
00:09:45
josh MacDonald
I start, like I wean up and I say for tolerance, give me three times a day of I'd like to see 30 minutes. If you can't tolerate 30, give me 15 until we get to 30. And then from 30, that's our like, okay, we check the box, we've got a starting point. And then see if you can get to three times of an hour.
00:10:02
josh MacDonald
And then if you have some downtime in the evenings, try to build as much time as you can. I say our target is six. I realize that's a challenge. But if you can give me three times a 30 and then grow from that as you can, even if it's some days or more, some days or less, that's okay.
00:10:14
josh MacDonald
But three times a 30 is our baseline.
00:10:16
Miranda Materi
right yeah and they're yeah so difficult to wear
00:10:17
josh MacDonald
Yeah.
Therapist Tips for Elbow Treatment
00:10:20
josh MacDonald
Yeah, yeah. um Know that doctors and surgical outcomes are considered positive and and within tolerance and good outcomes if they have a negative 30 degrees of elbow extension and 130 degrees of elbow flexion. So that's not full range of motion, but that is full functional range of motions. They can do, um you know, hair care, they can do period care, they can do functional activities if they're minus 30 to 130 of elbow mobility. So that's kind of, I mean, patients want full range of motion, but if you've got a patient who's darn close to that or better than that, that may be just you you have a conversation and say like, these are good outcomes, this is this is what we're looking for.
00:11:01
Miranda Materi
And maybe you say that early on, you know, so you're managing those expectations or asking the surgeon, Hey, what do you expect to get?
00:11:04
josh MacDonald
Yeah, yeah.
00:11:10
josh MacDonald
Yeah. Yeah. And it's something that, yeah, like you said, we mentioned early on, if I see a patient where like that's going to be a tough get, i I tell them that early on. Like, listen, this is a pretty traumatic thing and no doctors, doctors aren't necessarily willing to tell that to patients. The hard news of how long it's going to take, how uncomfortable it's going to be and what the outcomes are. They aren't always telling patients out of the gate. So I may not tell them first visit, but early on we're having a discussion about what are reasonable outcomes.
00:11:38
Miranda Materi
Yeah. ah One other thing real quick. One tip is I like as hand therapists, a lot of time we're sitting at tables, right? where We don't have them on the plinth, but I definitely lay these patients down for stretching. So if you're not laying them down, you get so much more leverage. You have better biomechanics. It's better for the patient to when you're stretching because you're in a more natural alignment with their arm.
00:11:58
josh MacDonald
Absolutely. Absolutely. Um, a hundred percent. And if I have a patient that I'm laying on the mat working on anything that's not shoulder, I take like a decent size towel roll and put it under their elbow. Um, it keeps their shoulder in a more open pack, more comfortable position rather than it resting on a table that's kind of behind them. And that puts them in a little bit of shoulder extension. So yes, all of my elbow patients were doing supine on the mat table. Um, and then I'm putting a bit of a bolster roll, maybe like four inches in diameter, depending on the size of the patient under their elbow to support that shoulder.
00:12:27
Miranda Materi
Yeah, definitely.
00:12:28
josh MacDonald
Yeah. All right.
Conclusion and Contact Information
00:12:30
josh MacDonald
Tons of stuff. We'll do more on elbows because it's an area that's just not well covered in our in our field, but we do see patients with them often. And sometimes it's ah a secondary diagnosis, but um if you have more questions, shoot us a message. You can reach us on Instagram or social media at info at hand therapy academy and our email info at handtherapyacademy.com.