Loss of range of motion after elbow surgery is common. The elbow is a very congruent and unforgiving joint.
It’s important to prevent loss of motion with early activities as much as possible. But what do you do when you have a loss of mobility in the elbow?
Here are our treatment strategies.
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#AskMikeReinold Episode 336: How to Deal with Stubborn Elbow Loss of Motion
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Show Notes
• Rehabilitation After UCL Repair with Internal Brace
• When to Push Range of Motion After Surgery
Transcript
Mikaela Meyer:
You’re lucky, it is me. Ed from Arizona says, “I’ve recently started working with more baseball players having elbow surgery. I have found that they tend to have issues with motion into both flexion and extension after surgery. What are some things you do to avoid this and deal with it when it occurs?”
Mike Reinold:
Awesome. Great question, Ed. Thank you, Mikaela. Really good question, right? I think we take this for granted. We see a lot of elbows at Champion, so I think we just know that elbows get tight. So I think we do a good job managing it ahead of time, but we take this a little bit like common sense to us, just because of the quantity that we see.
But man, the elbow is a very unforgiving joint. It is very congruent. You look at a cross-sectional anatomy. I love showing that in my presentations. It is so congruent that, man, you get any limitations or capsular scarring or any restrictions like anterior capsule types of things, you can get into a lot of loss of motion issues pretty easy with an elbow, right?
So why don’t we start it off, Len, Ed asked specifically about baseball. I don’t think we don’t have to keep this just to baseball, but I think baseball players get a lot. Len, what are your thoughts on loss of… Or what Ed wants to know is how do you actually deal with it once it is lost? So a stubborn elbow that has loss of motion, what are some of the things you do?
Lenny Macrina:
First off, we gotta get to the point where it doesn’t get stubborn… is the main thing, to avoid it. Now sometimes you can’t. I got a kid right now who had an ORI after the elbow, an avuls medial epicondyle, and the doctor immobilized him for four to six weeks I think, something like that. So he got stiff.
I can’t recall the last time I had a stiff elbow in a baseball player after a Tommy John. If you get them going early, which I think is going to be somewhat of the answer to the question, maybe there’s a protocol issue. Maybe the doctor is delaying sending them. Maybe he’s waiting or she’s waiting for two weeks to send them to PT instead of five days, and that can be a huge difference if they’re in a cast or a sling for two weeks.
So I think going a step backwards, let’s avoid the stiff elbows in baseball players because they’re avoidable, big time if you’re talking Tommy John because there’s not a lot of elbow. I guess you could do an ulnar nerve transposition, but they should be getting in early too.
So if you’re talking about an elbow in a baseball player, baseball players are hyper-relaxed in general. They should be relatively loose. They do get stiff elbows sometimes, but I cannot recall, personally for me, when the last time I had a stiff elbow because they just come in early enough and we get them mobilized and moving early enough. But if it does happen, which I do have that kid right now who’s not a baseball player, but I’m going to treat him the same. It’s motion. It’s a ton of motion throughout the day. So this kid’s like 14 years old. He does not care. Stiff elbow is cool right now. He just shows it off and is trying to get a girlfriend because of it.
So I’m trying to encourage him, get him to move it more, talk to the dad, talk to the parents, maybe some kind of bracing, like a Dynasplint or a JAS brace. I have him doing low load, long duration stretching. So a hot pack on his elbow. I tie a red TheraBand, a light TheraBand around his distal elbow, don’t include any blood vessels, and I have him lie there for about 10 minutes at the beginning of the session and get low load, long duration stretch and told him to do this at home numerous times a day. I have him doing wall slides down a wall where he’s coming down a wall and leaning into it and pushing it to create a little overpressure and deflection numerous times a day.
So the stiffness in the elbow needs motion, kind of like the knee. You need multiple bouts a day. It’s not like you go to PT for an hour and then you’re done for the day working on your motion. This is literally a full-time job for a 14-year-old or a 16-year-old, and they despise it. So you got to get the families involved.
But low load, long duration, multiple bouts of motion is going to be critical. Mobs, joint mobs, if it’s not contraindicated for any reason or whatever, the surgical procedures, wherever they are out of surgery, mobs, soft tissue work, triceps soft tissue work, biceps soft tissue work, you name it. We’re throwing everything at them that we can. But again, I can’t encourage enough, they have to be moving the elbow a ton more, probably more than you think.
Mike Reinold:
I like how Lenny attacked that from multiple angles, like the soft tissue, the joint, different home exercises. I think the big takehome really from some of Lenny’s comments there for me though, is that if you have a stubborn joint with range of motion and you have a joint that tends to get a loss of motion, like the knee, the elbow, those sorts of places, it’s about the frequency of the motion. And if this person has that stubborn loss of motion, I can almost guarantee, I can almost bet that they’re not doing enough at home and it’s just about frequency of getting it going. So that’s interesting.
Mike, you probably deal with probably the second most Tommy Johns of everybody nowadays. We have so many at Champion nowadays. What are some of your thoughts?
Mike Scaduto:
Yeah, I get the stiffer ones. No, I’m just kidding.
Mike Reinold:
We send those to you. That’s why Lenny and I never see tight ones, we send them to you.
Mike Scaduto:
Like, “Oh, he’s lacking a little extension. Get him on Mike’s schedule.” No, I think every surgeon is different with the protocol that they use. I think even just a few years ago when I started six, seven years ago, they were all splinted with a posterior splint, 90 degrees for the first week. They’d go in for a follow-up, they’d take the splint off and then they would put the hinge brace on.
Starting around COVID, at least in the Northeast, I think some doctors started to get away from that. They would put them in the hinge brace immediately, locked at either 70 degrees or some doctors are at 90 degrees, and that’s kind of where they live for the first week. But every doctor is slightly different.
So I think have an understanding of the expectation from the surgeon that’s sending this person… Hopefully, you know this person beforehand, but if you don’t, get an idea of how that brace is going to be managed, because like Lenny said, an hour of PT, we can do a lot, but this is something we need to be working on. But if there are brace restrictions from the doctor, that can become a limitation.
I think also, and this isn’t the majority of cases, but I’ve seen probably a handful this year where they have Tommy John surgery for baseball player, but they’re also doing something in the back of the elbow and the posterior elbow, some kind of debridement or something like that. And that trauma to the back of the elbow does tend to make them a little bit stiff and it becomes maybe a little more difficult to get their motion back.
So I think, and this is something that I’ve worked with Lenny and Mike over the years, is like when do we reach out to the doc and try and get them on medicine like an Indocin or something like that?
Hopefully early, as soon as you start to recognize that they’re getting really stiff. The docs that we work with like to be aggressive, get them on medication, high-powered anti-inflammatory or steroid to get some of that inflammation out so you don’t end up being 12 weeks out of surgery and lacking like 40 degrees of extension, then you’re in a bad spot.
So I think early intervention. There are some tools that are non-physical therapy related. We can get them on some medicine through their doctor, obviously, right, prescription, but that’s something you have to reach out to the doc and see if they’re on board with.
Mike Reinold:
Awesome, good stuff. Before I get into it a little bit, because I have a couple of additional thoughts, I think from Lenny and Mike there with some of the baseball ones, I do want to throw it to Dave for a hot second.
Dave deals with some doozies of elbows, I’d like to call them. Now maybe this isn’t that exciting because gymnasts have a lot of mobility, but Dave’s seen some very traumatic high velocity, high-stress injuries of the elbow, which is common in other laborers, other sports, those types of things too.
So Dave, any thoughts from your experience on these more traumatic ones that obviously have more trauma, more damage, more surgical techniques? Any thoughts from you?
Dave Tilley:
Yeah, sometimes when gymnasts will fall on an outstretched arm, they’ll get a TJ, and they’ll dislocate but also have a fracture. So obviously the more trauma to the joint, the more local irritation, inflammation. And this is actually from something I learned from Lenny with knee stuff is I think oftentimes PTs or therapists, whoever, will panic a bit and they’ll try to push the motion harder and more and more and more and more. And you got to realize that, like you said, Mike, the joint’s so congruent that if there is some irritation or inflammation of the capsule, or a small amount of swelling, it significantly restricts the motion in the osteokinematics.
And so I personally find that taking a step back and just calming down a bit and saying like, “Hey, let’s not go crazy. Let’s not yank on this thing.” I think the biggest example is when someone ranges knee flexion, and they’re on their back and it’s puffy, it’s kind of angry, it’s kind of swollen and they just push and push and push and they’re just kind of gritting their teeth on the table and then they irritate the joint.
And this cycle comes back where a person’s fear avoiding it because it hurts, it gets a little bit more swollen and angry, then they don’t want to arrange themselves or they can’t tolerate ranging more.
So I think the opposite is true, which is try to calm the joint down with wearing an elbow sleeve and medicine like you guys said, is really important. Consistent five times a day, six times a day of 20 reps of motion to end range slightly is probably more effective than just wailing on yourself for 20 minutes and trying to go as hard as you can. If you combine that with low load stretching, soft tissue stuff, heat before, all that kind of stuff, I think makes things calm down quite a bit.
And I’ve had a lot of people who get 5, 10, 15, 20 degrees of motion over a couple of weeks by doing not less consistency, but just less overall intensity. Just relax, let it chill, get the swelling out, get the pain down a bit, and just barely poke the end ranges to each way. I think that’s way better. I think it’s way better to do that than versus go crazy on it.
So I would say not less is more in terms of how much you need to put into it, but “less is more” intensity overall sometimes makes quite a big difference.
Mike Reinold:
And especially if they’re gaining a small percentage of range of motion each week with that technique, that’s still a success in my mind, especially with those big traumatic ones. Right, Dave? So awesome.
I want to share a little bit about the history of elbows with Tommy Johns and stuff because I think that is kind of what Ed wanted to do. But back in the day when we first getting started this and the Tommy Johns were gaining more and more popularity, late ’90s, early 2000s, elbow extension was the big thing we were losing. We were losing that all the time. That was a big one.
So what did we do? Well, we updated the protocols. We just said we have to get elbow extension faster, and we updated that. That was a big one. Flexion tends to come on its own over time, but elbow extension, if we kept them locked in a brace or sprint like Mike was saying, and we didn’t get that range of motion going, we would have some pretty sticky loss of extension that wouldn’t come back ever on people. They would lose that terminal 10 degrees or whatever it was if we didn’t get it back. So we adjusted the protocol.
So then over time we did a lot better with elbow extension and then some of the newer techniques were coming out like the docking procedure, some other techniques now with internal brace and even more of the hybrids, I’m actually starting to see people with issues with flexion. So I’m actually seeing that more common now is that they have pain with flexion and they have a sensation over their medial elbow. I think we talked about this recently in an episode when we talked about the internal brace, but they have that.
So initially I was a little bit more cautious thinking that we were tugging on that joint a little bit. But I was fortunate enough, I sat next to Dr. Andrews a couple of months ago and just said like, “Hey, Dr. Andrews, what do you think we should do here? I’m seeing these sticky elbows in the flexion.” And he’s like, “Just push. Just push.” I was surprised he said that. I wasn’t thinking he was going to say that.
I think what we’ve learned over the years and over the course of my career is that with these sticky elbows, the goal is to just get them going faster. There’s no tension hopefully on the graft or on the elbow, or even if they do osteo work posteriorly, there’s no tension. There’s no surgical reasons to not necessarily do that. So push, and I think that’s the key that I think we found here.
Dr. Andrews’ protocol from when I first started to what it is today, we want full range of motion in three weeks, and that was probably more like six weeks 20 years ago. So we’re pushing a little bit here.
I think what we did is we learned from our mistakes to Lenny’s point, Mike’s point, Dave’s points, we learned from our mistakes and we let them get tight. I think this is just for you, it’s about prevention and then hopefully if you have it Ed, you use a bunch of the techniques that Lenny outlined for you and you kind of go from there.
Great question.
Lenny Macrina:
About 15 years ago, Dr. Andrews changed the protocol to fully open and embrace. He was sick of seeing stiff elbows after Tommy John when they’d come back for two weeks, six weeks out of surgery. And he changed the protocol and literally opened the brace all the way and said, “Just get the motion back right away.”
And there is a study in 2009 by Burness et al and AGSM that did show low stress on the elbow getting immediate extension. So there is research to support what we’re doing. So I invite Ed to read that and maybe have his surgeon read that and change the protocol. There are old protocols still out there that say limit for a certain period of time. I think that’s part of the issue too. People go by the old Andrews protocols and not the updated ones.
Mike Reinold:
That’s a good point. That’s actually a really good point. And I will say, I’ve seen people make the mistake, Len, of like, “Oh, you’re in a brace for that long, and well, you’re supposed to come out of that brace to do your range of motion. The brace is just protective when you’re not doing your therapy instead.” But some people, the first two weeks, keep them in that position and that’s a mistake. Don’t do that.
But anyway, awesome stuff. If you have a question like that, head to MikeReinold.com. Click on that podcast link and ask away. And please subscribe, rate, review on Apple Podcasts and Spotify. We’ll see you on the next episode. Thank you.
