The elbow joint is a type of hinge joint. It bends (flexion) and straightens (extension), as well as rotating to position your palm up or down. The normal range of flexion and extension is from 0 to 145 degrees, although the range of motion that we work within for daily activities is only from 30 to 130 degrees. This means that for most people a bit of loss of motion does not cause problems with function. However, with a reduction of extension greater than 30 degrees and or a flexion less than 130 degrees most people will complain of loss of function. Loss of extension is usually less disabling than loss of same degree of flexion.
When is Elbow Stiffness Surgery recommended?
The major symptoms of stiff elbow are pain and loss of motion. The onset of symptoms may be gradual or sudden, depending on the cause of the condition. In most cases, the elbow will become inflamed and produce pain upon movement which will gradually worsen over time and cause stiffness. When this occurs, the pain in the region will actually become less, however, movement will be very difficult.
What are the causes?
Factors that cause stiffness are divided into those that are within the elbow joint itself (intrinsic) and those in the tissues around the joint, such as the muscles and tendons (extrinsic).
Intrinsic / Intra-articular Causes
Extrinsic / Extra-articular Causes
congenital – arthrogryposis, congenital disloc radial head
The commonest cause of stiffness is after trauma and injury. In fact, some stiffness after an elbow injury is very common. Usually this improves, but sometimes it may not. The amount of stiffness isdirectly related to the degree of initial trauma and the degree of involvement of the joint surfaces is most important. The length of immobilisation after injury also leads to more long-term stiffness.
The ‘Simple’ Stiff Elbow is one that recovers well. The criteria are: Mild to moderate contracture (<80o)
No or minimal prior surgery. No prior ulnar nerve transposition. No or minimal internal fixation in place
No or minimal heterotopic ossification (bone in the muscles) Normal bony anatomy has been preserved
How is Elbow Stiffness diagnosed?
You should seek medical treatment when you sustain injuries to the elbow that results in severe pain and swelling. Often, seeking traditional forms of treatment without prior evaluation with x-rays to exclude fractures can lead to long term damage of the elbow joint, pain and stiffness.
If you experience spontaneous onset of elbow pain without any prior history of trauma, you should seek medical advice to rule out any serious elbow disease, as delays in treatment may lead to a poorer outcome.
What are the treatment options for Tennis Elbow?
Non operative treatment?
The goal of stiff elbow treatment is to restore pain-free motion that improves function. Non-operative measures to treat elbow stiffness include physiotherapy for range of motion exercises and stretching. Sometimes a splint can be made that will slowly help straighten or bend your arm over time.
Surgery may be necessary if the symptoms fail to improve with these conservative measures. The operation may require release of the joint capsule or covering, release of scarred muscle or ligaments, removal of abnormal bone or joint contents, and possibly release of nerves if they are tight or involved in scar. This will usually be performed using arthroscopic or minimally-invasive surgery in which small instruments are introduced into the elbow joint through the skin and a camera is used to guide the surgery. Recovery from this type of surgery is quicker, but patients who have had previous surgery or have extensive bone abnormality are not suitable for keyhole surgery.
Post operative physiotherapy is critical in the treatment of elbow stiffness. The elbow will usually fully straighten and flex at the end of the operation. However this must be maintained with agressive physiotherapy. If the elbow is allowed to rest for even a few days the soft tissues and scar tissue will return and the joint will once more become stiff. Regular pain killers should be taken so that the elbow can be stretched to its maximum range of movement possable. Dispite analgesia this can be painful, however it is safe to continue to stretch the joint as no harm is being done. Indeed imobility is the enemy!.
Sometimes after a major debridement for an arthritic elbow a continuous infusion of pain killer is fed through a cannula to the nerves which provide feeling to the elbow. This leaves the arm numb for 48 hours and facilitated early pain free range of motion.
What are the risk factors for Elbow Stiffness?
Prolonged immobilisation. Patients with prolonged immobilisation of the elbow joint due to injury or illness are at highest risk of developing elbow stiffness.
Damage to joint. Diseases like infection that lead to damage of the joint surface (also known as the articular cartilage) also predispose to elbow stiffness.
Can Elbow Stiffness be prevented?
In patients with elbow injury, stable fixation of fractures and early mobilisation is the best form of prevention of elbow stiffness. In diseases which can result in articular cartilage damage, early and effective treatment to control the disease and limit articular cartilage is needed to minimise long term elbow stiffness.
How fast can you recover?
To be shared by the doctor.
Following either Open or Arthroscopic Elbow Release, the elbow is splinted in full extension because full extension is the position that best keeps post-operative swelling out of the elbow. Therapy is begun within 2-3 days after surgery to maintain the motion gained during surgery. To maximize motion, therapy should be done 5 days a week for the first month. Therapy usually continues after the first month, but often less frequently.
A technique that helps maximize motion following elbow release, especially after open release, is a Manipulation Under Anesthesia. A Manipulation is routinely scheduled one week after Open Elbow Release, although it may not be required for those undergoing Arthroscopic Elbow Release for lesser degrees of stiffness. A Manipulation is not a surgery and no wound is made or reopened. A Manipulation is simply a special “therapy session” where the surgeon moves the elbow while the patient is asleep. After a quick anesthetic, the patient wakes up to go to regular therapy. Please note that a Manipulation will not regain motion except after surgical excision of the joint capsule. If a Manipulation is attempted in the presence of a stiff joint capsule, it will fail and the bones and/or cartilage of the elbow may be damaged. The reason that a Manipulation works the week following surgery is because the stiff joint capsule has been removed, and a new capsule has not yet reformed.
So, if elbow stiffness is a problem, it can be addressed by either an Arthroscopic or Open Elbow Release. Improved motion is the rule as long as the therapy and home stretching program are taken seriously.
What are the results of the surgery?
To be shared by the Doctor.
What are the complications?
The most common complication following any elbow surgery or injury is stiffness. It is also possible for excess bone to form in the soft tissues around the elbow, called heterotopic ossification. It is best to prevent a stiff elbow by moving the elbow as soon as practical.
The surgeon will balance soft tissue considerations, fracture stability and other patient factors when deciding whether to move the elbow early or not. If the elbow becomes stiff it can sometimes be splinted back to a functional range of motion. This is most effective in the first six months following injury or surgery. Typically this involves soft tissue stiffness only and will not overcome joint deformity.
If all non operative measures have failed, a surgical stiff elbow release can be performed. This is typically performed when patients are no longer able to put their hand to their mouth, or lose more than half of their straightening ability.
Stiffness can be:
Within the joint,
Because of the joint, or,
Outside the joint.
Your surgeon will discuss your particular problem and its treatment with you.
Cost of Surgery?
The cost of surgery for Elbow Stiffness depends on many factors. They include the cost of being in the hospital for several days. Unexpected events that result in an extended hospital stay will also increase the overall cost.
Costs also vary depending on the type of insurance coverage you have. Many insurance companies cover the cost of the surgery, the hospital stay, and the instruments to straighten the spine. You may owe a co-payment or you may be billed the balance of what your insurance does not cover.
Be sure to contact your insurance provider prior to surgery to discuss the extent of your coverage. Discuss with your surgeon, as well as the hospital billing department to make sure you understand all the costs involved.