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Managing the Stiff Elbow
393 Plays1 month ago
In this episode, Josh and Miranda discuss effective strategies for managing stiff elbows. They explore common causes of elbow stiffness, share personal experiences, and provide practical tips for improving mobility and reducing discomfort.
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Transcript
Introduction to Elbow Stiffness and Fractures
00:00:05
josh MacDonald
Hi, I'm Josh McDonald.
00:00:06
Miranda Materi
And I'm Miranda Materie and we are Hand Therapy Academy.
00:00:10
josh MacDonald
We had a bunch of people ask for us to cover the topic of elbow stiffness, fractures, all of that. So we're going to dive into that a little bit today. It's kind of a um ah harder topic to cover, a little bit more ambiguous, and not a lot of us cover elbows. So let's talk a little about what to
Factors Influencing Treatment Approaches
00:00:25
josh MacDonald
do when you get that. Maybe maybe let's start with elbow fractures um and talk about like how much are you comfortable pushing and challenging the range of motion of an elbow fracture?
00:00:34
josh MacDonald
What do you think, Miranda?
00:00:36
Miranda Materi
Yeah, I think this is, of course, one of those questions that really depends on the type of fracture, um the patient, and who you're working with, and how um some of those other factors, like
Case Study: Heterotopic Ossification
00:00:47
Miranda Materi
the anatomy, right? We know that they're higher risk for developing heterotropic ossification and How and also like, was it a major trauma, right? Like, so if they've had um like a car, I just thinking of patient I had where she was in a car accident. accident So it was a major high velocity trauma.
00:01:06
Miranda Materi
And she became extremely stiff and actually ended up developing HO. So I think, you know, you're like, well, do does pushing more lead to more inflammation markers that cause HO? And I think the studies say no, but I think intuitively we can kind of see when it's starting to happen and how much to push from there.
Preventing Stiffness: Early Movement Strategies
00:01:26
josh MacDonald
Yeah, yeah, you're right. HO is kind of a whole other category. I think like you talked about initially, it's good to know what kind of fracture, like it's high velocity, that's a difference, but also like where the fracture is. If it's an olecranon fracture, I can push maybe, ah wouldn't not not aggressively, but I can challenge elbow extension more because it's not loading that tricep.
00:01:44
josh MacDonald
If it's an electron fracture, I'm not going to load into flexion as much. And I really think an early active mindset is super helpful in those elbow stiffness patients. We have some of our referring referring sources wanting to lock these patients down because they're afraid of damage to the elbow. And it's a pretty hardy joint, um that so much that early active is not going to like put you in in harm's way. i think that can help Prevent some of those capsular tightnesses that can develop into HO or even just the soft tissue tightness around that joint capsule um that that's that early active is a
Effective Range of Motion Techniques
00:02:19
josh MacDonald
way to go. And you don't have to press aggressively, um especially if they've got something like HO already developed.
00:02:24
josh MacDonald
It doesn't really make things better. It just really hurts. So it may not cause HO, but it's also not making situation better. just Just absolutely crank on them.
00:02:34
Miranda Materi
Right. You're right. I think it's really important to move them as early as you can without causing, you know, too much trauma. And I think the other thing that sometimes we think with early active is you're doing it within a short arc and you're really not. You really want to go more to the end range of the joint. I read one study where they were saying just doing that short little range of motion is actually not helpful at all. You want to move them, you know, as far out you can, as far as you can to have a gentle stretch as opposed to just doing it, you know, within a short range.
00:03:04
josh MacDonald
Yeah, and that's kind of where the art of our job comes in is knowing where that line is, knowing the difference between a little bit of tension is healthy without overpressure.
Balancing Tension and Healing
00:03:14
josh MacDonald
Like, especially early on, we don't want to be be providing significant overpressure end range, but taking them to that endpoint and letting them maybe even just hang there letting it being a gravity assist or just an endpoint tension.
00:03:27
josh MacDonald
um That's a real low grade in our clinic. We just between providers, we say like, well, with that patient, I'm doing like a two out of 10 or three out of 10, just so we all have a common language. It's not standardized in any way, but, um but yeah, that's the art side of knowing how much at that end point.
00:03:41
Miranda Materi
Yeah, I think you're right. it is definitely an art. And I think that art comes in not only with our clinical experience, and ah it's also the patient too, right? Like knowing your patient really can be helpful in what they're able to tolerate and and and what is their pain tolerance?
00:03:59
Miranda Materi
Because sometimes people will be like, oh, I'm fine. I can do it. I can do it. And they want to push. And you're like, well, actually, we don't want you to down this one.
00:04:06
josh MacDonald
Yeah. Yeah.
Understanding Patient Cues and Needs
00:04:08
josh MacDonald
We talk so much about the person who's not tolerant to any load, but it's just as problematic to have the person who's stoic as all get out.
00:04:12
Miranda Materi
Thank you.
00:04:15
josh MacDonald
And you know, like I'm doing as much as I really need to. I don't need to do more. I have to learn what tissues can handle. And they're saying like, nope, go for it. And only happy when there's a little tear coming their eye, but that's just as problematic. So it's, yeah, it's, it's important to learn not, you got to respond to the patient, but what are the tissues need in order to remodel?
00:04:35
Miranda Materi
Yeah, definitely. Okay. So with the lecranon fractures, you're doing more in extension, a little
Managing Olecranon Fractures Safely
00:04:41
Miranda Materi
bit less in flexion, right?
00:04:41
josh MacDonald
Yeah.
00:04:42
Miranda Materi
Depending upon exactly where it's at on lecranon.
00:04:43
josh MacDonald
yeah
00:04:44
Miranda Materi
And, you know, I think, like you said, the elbow joint is very stable. The lecranon cups, you know, the humerus really well. So if it's, if you have stable fixation or a good plate on there too, I think you can push even more.
00:04:56
josh MacDonald
Yeah, yeah. And while it's not a true simple hinge joint, it really does just hinge. So you're not putting lateral load on it. you're not I'm not doing traction if there's a fracture, right? So it's a simple uniplanar motion. So it's not something I have to get super complex about. It's just time and repetitions, end point to end point.
00:05:16
josh MacDonald
Yeah, so it doesn't need to be super complicated.
00:05:19
Miranda Materi
Yeah, and then another thing for all elbow patients, I would say, have your patient laid down.
Patient Positioning for Optimal Therapy
00:05:24
Miranda Materi
I think as hand therapists, we like them to sit up at the table. And I see this a lot with new guys. I'm like, go lay that patient down because you know you take the stress off their shoulder. You prevent some of that lateral loading that you do inadvertently when you're stretching them when they're sitting.
00:05:37
Miranda Materi
It's just so much more comfortable.
00:05:37
josh MacDonald
Yeah.
00:05:39
Miranda Materi
And I think so much better in terms of biomechanics for the patient.
00:05:44
josh MacDonald
That's a great point. All of our elbow patients, we we lay down. Sometimes even some of our like tennis elbow forearm patients, we lay down. um it They guard less because they can be relaxed, their head supported.
00:05:56
josh MacDonald
We like to take like rolled towels that are maybe like, depends on the size of the patient, six inches in diameter of a rolled towel under their elbow so they're not in a closed pack shoulder position. And it brings it up, gives me a simple leverage point, but it's soft. And so, yeah, positioning is a big deal to being effective with the elbow motion.
00:06:13
Miranda Materi
Yeah.
00:06:13
josh MacDonald
Yeah, yeah. So let's say you've got a patient, whether they came to you late or just the way they developed, they are stiff.
Splinting and Movement for Flexibility
00:06:21
josh MacDonald
Maybe not HO, they're just really stiff. They have still soft end range, so it's not HO.
00:06:26
josh MacDonald
How do you, what are your some of your favorite tricks?
00:06:30
Miranda Materi
Yeah. And so it depends on if they're stiff and i'm good I'm assuming you're saying stiff and elbow extension and flexion.
00:06:35
josh MacDonald
Yeah, yeah.
00:06:36
Miranda Materi
big A big one for me is static nighttime extension splinting. I think it's like comfortable up and yeah I'll put them in as much extensions they tolerate and then have them bring the splint back a week later and I'll put them in a little bit more extension. So That's one of my favorite for achieving extension. And then for achieving flexion, it's mostly a asking them to do a lot of functional things throughout the day. Like I'll definitely have them do some self-stretching, but I think like if you're using that arm, I'm going to say, you know, even if you're not, if it's your left arm and you're not left hand dominant, I want you to be using it to do things like feed yourself, brush your hair, scratch your head, like really start to use it if they can. And if they're not within that super protected um area, but I'm guessing if they're coming to me and they're that stiff,
00:07:20
Miranda Materi
They're already self splinting, right? So usually at that point, you're like, well, just want you to move it
00:07:24
josh MacDonald
Yeah,
Exploring Opposite Range of Motion
00:07:25
josh MacDonald
yeah. That you're right.
00:07:25
Miranda Materi
What about you?
00:07:27
josh MacDonald
That stiffness kind of prevents provides its own support that we got to work past. So um i I agree. I think doing like if they're only tight into one plane or into one direction, flexion or extension, I really feel like working the opposite direction well can give you gains in the direction they're tight. So if they're tight into flexion, but not as much into extension, I'm still working extension because that still gets those tissues mobile.
00:07:51
josh MacDonald
Um, i agree with all that. I definitely do all that stuff. I would add to it that if they are tight into both directions, it's tough for us to do like daytime dynamic splinting stuff that goes both directions.
00:08:02
josh MacDonald
Um, so I can do a flexion.
Tools for Managing Stiffness
00:08:04
josh MacDonald
I can do an extension at nighttime, but for both, I'll go with a Dynas splint or a jazz or, um, a statadine from Lance Medical, if their insurance covers it, that's something that can be really useful for them to find both directions.
00:08:17
josh MacDonald
um It ends up being this big bulky thing that they have to figure out. um But i feel like that can be a ah useful tool if they can manage it.
00:08:25
Miranda Materi
Yeah, those are so big and so I can't like as a patient, I think, oh, gosh, this is terrible. But you want to, you know, throw everything at it that you can.
00:08:32
josh MacDonald
Yeah, yeah.
Realistic Range of Motion Goals
00:08:34
josh MacDonald
And, and It's also helpful to know what our goal is if they're a truly very stiff elbow. Our goal is not full range. It's minus 30 in extension and 130 in deflection.
00:08:45
josh MacDonald
That is considered good, both functional and within functional limits range of motion. So if they can get to minus 30 extension and they can get to 130 degrees of flexion, they can do all activities of daily living. They would like more range of motion. We certainly would, but that's kind of a reasonable goal for us to establish for the patient. And that helps them realize, okay, maybe this means I can, I can do my hair. I can do peri care. I can shower all the way. I can feed myself. Those are all necessary tasks you can do with 130 degrees of elbow flexion.
00:09:14
Miranda Materi
Yeah, I agree. I think we could have a lot of other topics more about the elbow joint, like we could do the proximal radial or joint forearm rotation. I think those are all things we can dive in. But for today, we're just talking about managing a stiff elbow and how much to really push the patient.
Tracking Progress with Measurements
00:09:30
Miranda Materi
um So do you have any last tips or tricks for, especially for that patient that's really painful? How much are you really performing passive range of motion and how much pressure are you doing?
00:09:42
josh MacDonald
I would like to be putting those tissues under enough tension to remodel them, but it may be in order to get there, I have to invest time, establishing trust with the patient. And I go based off of their response.
00:09:54
josh MacDonald
I go based on their um nonverbal cues and their verbals of like, Hey, that's about as much that feels like a stretch. And that's about as much I can tolerate with education to them saying like, Hey, it's like stretching your hamstrings. We got to be a little uncomfortable.
00:10:07
josh MacDonald
And so i work on within their tolerance and trying to push how much the tissues get loaded within their tolerance.
00:10:15
Miranda Materi
Yeah.
00:10:16
josh MacDonald
Yeah.
00:10:16
Miranda Materi
I think one thing too, since we have a lot of newer therapists that listen to our podcasts and um do our courses, one thing I would say is make sure you're taking range of motion measurements every week because then you know how much to push your patient and how little, like if you're having changes
00:10:27
josh MacDonald
Yeah.
00:10:34
Miranda Materi
you know, you're getting four to five degrees a week, that's great. I would stay there, you know, but if, if you're not gaining range of motion, you may need to push a little bit harder, right? So, and you don't know that unless you're doing measurements. So sometimes I'll like fill in for some of our therapists and i'm like, Oh, you haven't taken measurements in six weeks. Like, how do you know if your patient is progressing or not?
00:10:54
josh MacDonald
Yeah. Yeah. And, and patients always want to know, like, how does it look? How's it look? How's it look? Well, let's measure, let's be specific about it. And if it's not changing, then your plan isn't working after a couple of weeks. Let's do something different. Let's try something different if it's not making any differences.
00:11:08
Miranda Materi
Yeah, do we need to move to static progressive splinting?
00:11:08
josh MacDonald
Yeah.
00:11:11
Miranda Materi
Do we need to be more aggressive? Do you need to be doing more exercise at home? I think it's the only way to really know how in how you should really progress your patient.
00:11:19
josh MacDonald
Yeah. Yeah. I will say is maybe kind of a last note that the elbow progresses very
The Journey of Elbow Recovery
00:11:25
josh MacDonald
slowly. So it's okay if you're not seeing changes as quickly or as dramatically as maybe it just a distal radius fracture or PIP joint, it's not necessarily going to adjust as quickly as that, but you do still need to see slow progressive changes. Four to five degrees at a time is is is fine. as so long as you're getting good interrater reliability between your providers.
00:11:43
josh MacDonald
But it's not just not going to change us quite as fast.
00:11:45
Miranda Materi
Right. And I don't think you need to do it. If they're seeing them three times a week, you're not measuring them three times a week.
00:11:49
josh MacDonald
yeah
00:11:49
Miranda Materi
You're going to say, hey, we're going do measurement at this time.
00:11:50
josh MacDonald
Yeah. one is great
00:11:52
Miranda Materi
And we're doing it at the exact same time in the treatment. Like I'm always going to do it before they get in the hot pack and before we do stretching. Or just be consistent when you're measuring.
00:11:59
josh MacDonald
Yeah. Yeah. For sure. All right. Lots of information on the elbow. There's always more we can talk about, but maybe we'll do another one of these on the elbow and treatment ideas, that kind of stuff. So um let us know if you have any questions or any other great treatment ideas.
00:12:11
josh MacDonald
You can reach us on our Instagram at hand therapy Academy, or you can email us info at hand therapy Academy.com.