Elbow instability Jill Thomas NWULG may 2018

Jill Thomas
Elbow and Shoulder Clinical Specialist Physiotherapist
Wrightington Hospital
Elbow Instability 
Rehabilitation 
 
North West Upper Limb Group, May 2018

www.wrightington.com
Considerations for Rehabilitation
Acute
! Compensatory patterns
! Established apprehension
! Mechanical signs
Risk of Stiffness
Protection in a sling
Time off work for rehab’
Pain and swelling
Associated effects of trauma
Risk of H.O
Protective period

Considerations for Rehabilitation
Acute
! Compensatory patterns
! Established apprehension
! Mechanical signs
Risk of Stiffness
Protection in a sling
Time off work for rehab’
Pain and swelling
Associated effects of trauma
Risk of H.O
Protective period
Chronic
Absence of acute post-op pain
No need for sling/protective period
Continue with normal bilateral function
" Mechanical signs
" Established stiffness
" Established compensatory patterns
é Proprioceptive deficit
Apprehension

Team Work
Stable fracture/ligament repair
Full ROM on the table
Post-operative instructions: Early active ROM

Proprioception
The proprioceptive deficient relative!

Proprioception – The Elbow
Limited capsular mechanoreceptors & articular
proprioception Goodwin et al, 1972; Khabiev et al, 1998, JSES; Petrie et al,
2006, J Hand Surg; Fuentes and Bastian, 2010, J Neurophysiology
Proprioceptive drift into flexion Tsay et al, 2014, J Physiology
Limited higher level processing Walsh et al, 2013, J Physiology
2 Joint muscles - compromises muscle spindle
proprioception Sturnieks et al, 2007

Biceps and Brachialis
Increased activity in biceps and brachialis on EMG
in stiff elbows Page et al 2003

Overhead Extension
45 Degrees 35 Degrees

Stability and Control
Osseous constraints greatest in full extension or
full flexion Morrey 1985; Karbach and Elfar, 2017
Only one uni-segmental muscle

It’s not all doom and gloom

The Good News
Cutaneous receptors Collins et al, 2005, J Neurology; Proske and Gandevia, 2009, J. Physiology
Muscle spindles Proske and Gandevia, 2009, J. Physiology; Tsay et al, 2014,J of Physiology
Vision and imagery Fuentes and Bastian, 2010, J Neurophysiology; Tsay et al, 2014,J of
Physiology; Wang et al. 2013, J Rehabil Med
Functional multi-joint movements Tillery et al,1996, J. Neurophysiology
Bilateral activities Tsay et al, 2014,J of Physiology
Kinetic chain recruitment Sciascia and Cromwell, 2012, Rehabil Research and
Practice

The Elbow & the Upper Limb
The Hand
• UL Compensates to achieve hand placement
Bland et al, 2008; Karduna and Sainburg, 2012
• Elbow restriction affects hand functionBland et al, 2008 J Hand
Therapy
• Visual pro/supination improves hand functionBland et al, 2008 J Hand Therapy
• Hand leads UL function van Andel et al., 2008 Gait & Posture

The Elbow & the Upper Limb
Function
• Functionally pro and supination occur in
conjunction with humeral rotation
van Andel et al., 2008 Gait & Posture

Dynamic Stability
Compressive Forces
Varus Stability
Valgus Stability
PLR Stability
Morrey, 1985;
Udall et al., 2009; Vollans & van Riet,
2016; Karbach & Elfar, 2017

Dynamic Stability
Compressive Forces
Biceps
Brachialis
Triceps
Varus Stability
ECU, EDC,
ECRB, ECRL
Anconeus
Valgus Stability
FDS
PT, FDP, FCU
PLR Stability
Anconeus
Morrey, 1985;
Udall et al., 2009; Vollans & van Riet,
2016; Karbach & Elfar, 2017

Dynamic Stability
Translation into Exercise?

Rehab’ Principles
Short lever/overhead Gain ROM
Long lever Gain control
Weight bearing Stability and function
Time

Early Overhead Mobilisation
Alolabi et al., 2012;
Schreiber et al., 2015;
Manocha et al., 2017

✓Reduce biceps/
brachialis activity
✓Promotes extension
✓ Spindle stretch
✓Visual feedback
✓Cutaneous feedback
✓Protecting ligament
repair

✓Reduce biceps/
brachialis activity
✓Promotes extension
✓ Spindle stretch
✓Visual feedback
✓ Kinetic chain
✓ Protecting ligament
repair

Functional Movement Pattern
✓ Reduce biceps/
brachialis activity
✓ Promotes extension
✓ Visual feedback - mirror
✓ Cutaneous feedback
✓ Bilateral Activity
✓ Kinetic chain
✓ UL function: hand leads
✓ Multi-jt proprioception
✓ Forearm supported

Progression
✓ Adequate soft tissue and fracture healing
✓ No compensatory patterns
✓ Good extension <20-25 degrees from 0
✓ Good awareness of elbow movement
✓ ‘Functional’ flexion
✓ No significant mechanical signs

Trouble shooting: Early
? Lack of AROM
• Do they know they’re stiff
• Compensatory patterns
• Muscle tone

Trouble shooting: Early
? Lack of AROM
• Do they know they’re stiff
• Compensatory patterns
• Muscle tone
Visual
Functional
Reduce tone

Mirror Therapy ✓ Reduce biceps/
brachialis activity
✓ Visual feedback - mirror
✓ Cutaneous feedback
✓ Bilateral Activity
✓ Kinetic chain
✓ Upper limb function
✓ Multi – joint
proprioception
✓ Forearm supported

Visual Pro/Supination

‘Punching’ Forwards Lunge
✓ Reduce biceps/
brachialis activity
✓ Visual feedback –
mirror
✓ Kinetic chain
✓ Multi-joint
proprioception
✓ Joint compression
✓ Hand function
✓ Minimal valgus/varus
stress

Reverse Row
✓ Reduce biceps/
brachialis activity
✓ Visual feedback –
mirror
✓ Kinetic chain
✓ Multi-joint
proprioception
✓ Hand function
✓ Compression
✓ Isometric wrist/
fingers & common
extensor activity
✓ Minimal Valgus/Varus
stress

Get Up and Go
✓ Reduce biceps/
brachialis activity
✓ Visual feedback
✓ Kinetic chain
✓ Multi-joint
proprioception
✓ Strengthening
✓ Control
✓ Joint compression
✓ Hand function
✓ Valgus/Varus control

Slide Outs ✓ Promotes extension
✓ Kinetic chain
✓ Multi-joint
proprioception
✓ Weight-bearing, joint
compression
✓ Control
✓ Hand function
✓ Varus/PLRI control

Kneeling slide out
✓ Joint compression proprioception
✓ Multi-joint functional movement
✓ Kinetic chain
✓ Control
✓ Strengthening
✓ Varus/PLRI control

Flexor/Pronators
✓ Kinetic chain
✓ Multi-joint proprioception
✓ Control
✓ Hand function
✓ Flexor/pronator activity

Functional Pro/Supination
✓ Combined humeral rotation
✓ Functional
✓ Visual
✓ Hand function
✓ Kinetic chain

Troubleshooting: Mid-late
? Mechanical signs
? Apprehension

Troubleshooting: Mid-late
? Mechanical signs
? Apprehension
Support valgus/varus
Gain confidence/control
Concentrate on dynamic
control
Assess stability
?Consider imaging

Anconeus Loading
✓ Kinetic chain
✓ Multi-joint proprioception
✓ Control
✓ Hand function
✓ Anconeus activity
✓ Common extensor activity
✓ Varus control

Push Offs
✓ Kinetic chain
✓ Multi-joint
functional
movement
✓ Joint
compression
proprioception
✓ Uneven surface
✓ Plyometrics
✓ Varus/PLR
control

Functional: Floor fitter

Target Practice

Rehabilitation Summary
Controlled
Appropriate for tissue/fracture healing
Relevant to direction of instability
Include dynamic control
Functional
Individualised

Elbow instability Jill Thomas NWULG may 2018

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