Principles of Elbow Rehabilitation

Introduction

The goal of elbow rehabilitation is to restore optimal, pain-free function within the anatomic and physiologic limitations of the patient. To achieve this goal the clinician should adhere to several principles to guide the rehabilitation process: (1) establish a complete and accurate diagnosis, (2) control pain and inflammation, (3) implement early, atraumatic motion, (4) reestablish neuromuscular control (NMC) about the elbow, (5) rehabilitate the elbow in the context of the kinetic chain, and (6) facilitate return to the highest level of function, be it return to sport or simply activities of daily living. This chapter reviews these principles as they apply to a wide variety of traumatic and atraumatic elbow disorders. For more detailed discussion of specific rehabilitation protocols, readers are referred to the appropriate chapters in this text.

Establish a Complete and Accurate Diagnosis

Successful rehabilitation is predicated on a complete understanding of the anatomic and physiologic factors pertaining to a particular elbow disorder. Anatomic alterations in anatomic alterations in the soft tissues about the elbow will define initial motion restrictions as well as the potential for restoration of motion and stability. However, it is ultimately the patient's physiologic age and unique biologic healing potential that will determine how much of this potential is realized. Some patients heal poorly and may be prone to ongoing instability, whereas others exhibit a propensity for scar formation and will develop stiffness despite the best efforts of the treatment team. From our perspective, this sometimes dramatic individual variation in the healing response assumes a dominant role in the recovery of some patients. Furthermore, no two surgical procedures are alike, and surgical approach, initial diagnosis severity, and patient postoperative functional goals should be taken into consideration in the context of rehabilitation progression.

Throughout the rehabilitation process the physiologic stage of healing directly affects the rehabilitation program. During the inflammatory stage the primary goals are pain and edema control and adherence to stable arcs of motion to protect tissues at risk. During the proliferative or fibroblastic phase, controlled stresses may be increased to promote more normal collagen formation, and low-level strengthening is implemented to reestablish NMC. Finally, during the remodeling phase, stretching and strengthening exercises are advanced, and functional restoration is pursued. The clinician must be constantly aware of the physiologic status of the elbow. The elbow is an unforgiving articulation with significant bony congruity and a tendency to develop inflammation and stiffness. Overzealous rehabilitation efforts can quickly regress the elbow from the proliferative-fibroblastic phase into the inflammatory phase. Consequently, clinicians should constantly monitor the status of the elbow and modify the rehabilitation program accordingly. Consideration should also be given to joints above and below the level of injury, with the goal of rehabilitating the entire patient. Studies have demonstrated the critical role of the kinetic chain in optimizing upper limb and elbow function. The rehabilitation process requires appropriate follow-up, patient education and cooperation, and constant communication between members of the treatment team.

Patient Participation

As with any successful program, but particularly at the elbow, patients must be made to understand their role in the recovery process. The clinician and therapist must avoid having the patient become dependent on them or on formal rehabilitation sessions. The key is to successfully transfer responsibility for improvements to patients. They become their own therapists.

Reduce Pain and Inflammation

During the early posttraumatic or postsurgical period, the primary goal is to control pain and inflammation. The elbow tends to get stiff as a result of adhesion formation and muscular cocontraction. PRRICEMM principles (protection, relative rest, ice, compression, elevation, medications, and modalities) are applied to reduce pain, edema, and inflammation.