What is Stiff Elbow?
Elbow stiffness, which is a fairly common condition, can significantly impact a person’s ability to move and perform daily activities. There are many reasons why someone might experience a decreased range of motion in their elbow. So, it’s really important to understand each person’s specific medical history to decide the best form of treatment, which could involve surgery or other non-surgical options.
What Causes Stiff Elbow?
Elbow stiffness can occur due to a variety of reasons, including joint trauma, formation of bone in unexpected places, soft tissue injuries around the elbow, or issues with healing fractures. There are three key factors when it comes to elbow stiffness: 1) complicated anatomy of the elbow, 2) the growth of bone in the anterior brachial muscle covering the anterior capsule, and 3) prolonged immobilization due to difficulties in stabilizing the elbow after complex fractures.
It’s usually the severity of the elbow injury that determines how stiff the elbow becomes. However, other factors like loss of periosteum (a layer that covers the bone) and extended periods of immobility can enhance this stiffness. These factors can also explain why elbow stiffness can still occur even after a fracture has healed properly or even in fractures that didn’t move out of place.
Other non-injury based reasons for stiffness include hemophilia (a rare disorder that prevents blood from clotting properly), after-effects of infections, rheumatoid arthritis (where the body’s immune system mistakenly attacks the joints), and osteoarthritis (a type of arthritis that affects the cartilage cushioning the ends of your bones). As for inborn causes, conditions such as arthrogryposis (a condition present at birth that leads to joint contractures) and dislocation of the radial head (a bone of the forearm) can also lead to elbow stiffness.
One common cause of elbow stiffness is Heterotopic Ossification (HO). HO is a condition where bone grows in places where it shouldn’t, like in your elbow joint. Even though the actual cause of HO is still unknown, it often presents with amorphous calcium deposits affecting the joint capsule and collateral ligaments, which may further solidify into calcifications around the joint. HO frequently shows up after a direct trauma to the elbow, with a 3% rise in incidence post dislocation and up to 20% in cases associated with fractures and complex dislocations. If we consider patients with isolated brain trauma, the occurrence is about 5% to 10% – usually the side affected by hemiplegia (paralysis of one side of the body) has a higher incidence. When brain trauma combines with elbow trauma, the frequency upticks dramatically to 75% to 90%. Certain surgical approaches have been also paired with HO. Since there is not a completely effective medical treatment for HO, preventing it is essential. Anti-inflammatory drugs like indomethacin, ibuprofen, naproxen, and aspirin have shown the most effectiveness, especially if taken within the first 3 to 5 days of its development.
Another leading cause for elbow stiffness are malunions and nonunions. These conditions arise as side effects of fractures that haven’t healed correctly, often disrupting the normal mechanics of the elbow. Nonunion of the distal humerus (the lower part of the upper arm bone) may lead to limitation of elbow motion due to pain and instability. If this happens, it may be necessary to consider treatment for nonunion and procedures like arthrolysis, a surgery that aims to restore the normal movement of a joint. It is important to evaluate the whole affected limb and deal with any associated injuries, such as burns, infections, and damage to nerves and blood vessels.
Risk Factors and Frequency for Stiff Elbow
About 5% of people experience loss of elbow movement after a traumatic event.
Signs and Symptoms of Stiff Elbow
For your joint to move without restriction, it needs to have a certain degree of flexibility. Normally, your joint can flex and extend up to 145 degrees, with about 75 to 85 degrees for a movement called pronosupination. But for most day-to-day activities, you only need between 30 and 130 degrees of flexion-extension and 50 degrees of pronosupination.
Keep in mind, the level of movement that you need may depend on the types of activities you do. For instance, athletes and musicians might require a larger range of motion than the average person.
If your joints are feeling stiff, you typically won’t feel pain. However, if it is due to arthritis, you might experience discomfort during the flexing and extending movement. If there’s an infection, you could feel pain even when you’re not moving.
In some cases, you could develop a condition called heterotopic ossifications. This can cause local inflammation, pain, and an increase in local temperature. But don’t confuse this with an infection. Pain may not always be present and if it is, it usually happens at the end moment of the joint movement.
Lab tests on heterotopic ossifications might show decreased calcium and increased phosphates. Serum alkaline phosphatase, a kind of enzyme, may rise about 2 to 4 weeks after the symptoms start and it could reach 3 to 4 times above normal limit after 3 to 10 months. Your doctor might use a test called a bone centellogram with TC 99 to show increased metabolic activity during the first week, and this can last for up to a year. X-rays are often the best way to track and study this condition. Whenever mature bone appears as well-defined, this usually occurs after 3 to 5 months, after which surgical approach can be taken.
Testing for Stiff Elbow
X-rays are often very helpful for most cases involving a significant decrease in the range of motion – when you can’t move a joint as much or as freely as usual. However, if the limited motion extends to 45 degrees or more, getting a clear Anteroposterior (AP) x-ray, which is a head-to-toe picture, can be hard. In these cases, or when the injury involves complex fractures, a CT scan can be used, especially if there are uncertainties about the treatment.
Ideally, stiffness can be categorized into three types to help with treatment plans:
- Extrinsic stiffness, which doesn’t involve the joint but affects ligaments, muscle, and the capsule surrounding the joint.
- Intrinsic stiffness, which affects the joint surface due to factors like adhesions (scar tissue), bony growths (osteophytes), cartilage loss (chondrolysis), or trauma.
- Mixed stiffness, which involves both intrinsic and extrinsic factors. These are the most common, and usually, intrinsic causes lead to extrinsic stiffness as well.
Depending on how much you can bend and straighten the affected area, stiffness can also be classified as minor (less than 90 degrees range of motion), moderate (between 60 to 90 degrees), severe (between 30 to 60 degrees), and very severe (less than 30 degrees).
It’s also important to differentiate between simple and complex contractures, which are conditions that cause shortening and hardening of muscles, tendons, or other tissues. A simple contracture may include any of these traits:
- Mild or moderate contracture: you can move the joint 80 degrees or more.
- No previous surgery, or minor surgery.
- The ulnar nerve in your arm has not been moved before.
- No bone repair hardware inside your body, or minimal amounts.
- No abnormal bone growths (heterotopic ossifications), or minimal amounts.
- Your bone anatomy is normal.
If any one of these factors is not present, the contracture would be considered complex.
Treatment Options for Stiff Elbow
There are both surgical and non-surgical options to treat joint stiffness. The choice of treatment depends on several factors, such as the patient’s condition, level of disability, lifestyle, and expectations. Also considered are the length of time the stiffness has been going on and its cause. It’s vital to evaluate these factors carefully to come up with the best approach for each individual.
Non-surgical treatment usually involves supervised stretching exercises, the use of dynamic or static splints, plaster casts, and physical therapy. Generally, splints lead to better outcomes when the stiffness has not been present for an extended period and when there’s no severe joint conditions. Sometimes, doctors apply force to mobilize the stiff joint under anesthesia. Such non-surgical approaches often work well for joint stiffness caused by external factors.
Surgical treatment becomes necessary when non-surgical methods don’t bring about improvement, when the stiffness is severe, and when a condition like heterotopic ossification (abnormal bone growth within muscles, tendons, or other tissues) is present. Knowing the cause of the stiffness is important for planning the surgery. The right surgical approach and techniques are determined based on this information.
There are several surgical approaches available. The one to use depends on factors such as the positioning of previous scars, whether there’s a need to relieve pressure on a nerve, and the extent of any abnormal bone growth. The surgeon may choose from the medial approach (used for issues on the inside of the joint), lateral approach (used for conditions on the outside of the joint), posterior approach (used for issues at the back of the joint), and arthroscopic release approach (a minimally invasive procedure making small incisions to access the joint).
After surgery, the doctor checks for any neurological issues. To control swelling and bleeding, a padded bandage and a splint are used. Pain is managed with medication or nerve blocks. Soon after surgery, it’s recommended to start a movement therapy called continuous passive mobility. Once the patient can move without the aid of the continuous motion splint, this is often followed up with static splints. Sometimes, medication such as indomethacin is used to prevent abnormal bone growth.
After surgery, it’s common to see good results, with patients achieving an increased range of motion. Reviews of related medical literature suggest that up to 90% of patients will see an improvement of at least 10 degrees, and roughly 80% achieve a functional range. However, it’s worth noting that some patients may lose the gained mobility over time. More research is needed to compare the advantages of minimally invasive (arthroscopic) surgery over traditional open surgery.
Postoperative rehabilitation needs to be personalized, taking into account the cause of the stiffness and what the patient prefers. The main goals of rehabilitation are to restore functional movement, regain muscle strength, and help the patient re-incorporate the affected limb into their daily activities. The movement exercises often start two days after the surgery, provided the pain is well controlled. Certain cases, like when ligaments have been either repaired or replaced, need special care. The use of anti-inflammatory drugs or low-dose radiation therapy is recommended by some doctors to prevent abnormal bone growth.
What else can Stiff Elbow be?
There are several conditions that can be associated with joint issues, including:
- Arthrogryposis, a condition present at birth that causes joint contractures (stiffness)
- Congenital radial head dislocation, a condition where the radius (one of the bones in the forearm) dislocates from its normal position at the elbow
- Inflammatory arthritis, which is inflammation of the joints due to an overactive immune response
- Multiple joint bleeding events (hemarthroses) in people with hemophilia
- Osteoarthritis, a type of joint disease resulting from breakdown of joint cartilage and underlying bone
- Post-septic arthritis, a condition that occurs when a joint becomes infected, often after a bacterial or fungal infection
