Elbow Dislocation Rehabilitation Protocol

This protocol outlines a progressive physical therapy rehabilitation program following an elbow dislocation. It is crucial to tailor this protocol to the individual patient, considering the severity of the injury, surgical intervention (if any), and patient’s pain levels and functional goals. Regular communication with the referring physician is essential.

I. Pathophysiology

Elbow dislocations are typically caused by a fall onto an outstretched hand, often with a rotational component. The ulnohumeral joint is most commonly dislocated posteriorly, but anterior, medial, and lateral dislocations can occur. Associated injuries are common, including fractures of the radial head, coronoid process, and medial epicondyle. Ligamentous damage, including the medial collateral ligament (MCL) and lateral collateral ligament complex (LCL), is also frequently present. The extent of these associated injuries significantly impacts the prognosis and rehabilitation timeline.Neurovascular compromise, though rare, must be immediately addressed.

II. Phase I: Protection (0-4 Weeks Post-Injury)

Goals:

• Control pain and inflammation.
• Protect healing tissues.
• Initiate gentle range of motion (ROM) exercises.

Interventions:

• Immobilization: Typically, the elbow is immobilized in a long arm splint or cast at 90 degrees of flexion for 1-3 weeks, depending on the severity and stability of the joint. This allows for ligamentous healing and reduces the risk of re-dislocation.
• Pain Management: Employ modalities such as ice packs (20 minutes every 2-3 hours), electrical stimulation (TENS), and pharmacological interventions (as prescribed by the physician) to manage pain.
• Edema Control: Elevate the arm above the heart, encourage gentle hand and wrist exercises (making a fist and extending the fingers), and consider gentle retrograde massage to reduce swelling.
• Gentle Active ROM (AROM): Focus on AROM of the wrist, hand, and shoulder to prevent stiffness and maintain circulation.
• Protected Early ROM: After splint removal, initiate gentle active-assisted ROM (AAROM) and AROM exercises of the elbow. Focus on achieving flexion and extension, avoiding pronation/supination early if there is ligamentous instability.
• Specific Exercises:
• Pendulum exercises for the shoulder
• Wrist flexion/extension
• Finger flexion/extension

Precautions:

• Avoid forceful stretching or movements that cause pain.
• Monitor for signs of neurovascular compromise (numbness, tingling, changes in color or temperature).
• Adhere strictly to the physician’s immobilization guidelines.

Progression Criteria:

• Decreased pain and swelling.
• Demonstrates understanding of precautions.
• Initiates AAROM and AROM with minimal pain.

III. Phase II: Loading (4-8 Weeks Post-Injury)

Goals:

• Increase ROM.
• Improve muscle strength and endurance.
• Begin functional activities.

Interventions:

• ROM Exercises: Continue AAROM and AROM exercises, gradually increasing the range and frequency. Introduce static progressive stretching (holding stretches at end range for 30 seconds) to address any limitations. Consider using a dynamic elbow splint for persistent stiffness.
• Strengthening Exercises: Begin with isometric exercises (holding contractions without movement) for the biceps, triceps, and wrist musculature. Progress to isotonic exercises (using resistance bands or light weights) as tolerated. Focus on controlled movements and proper form.
• Proprioceptive Exercises: Introduce exercises to improve proprioception (awareness of joint position), such as weight shifting on the hand and balance board exercises.
• Functional Activities: Gradually reintroduce functional activities such as reaching, lifting light objects, and performing ADLs.
• Specific Exercises:
• Bicep curls with light weight
• Triceps extensions with light weight
• Wrist curls
• Pronation/supination exercises with light resistance

Precautions:

• Avoid activities that cause pain or swelling.
• Progress exercises gradually to avoid overstressing healing tissues.
• Monitor for signs of instability or re-dislocation.

Progression Criteria:

• Improved ROM.
• Increased strength.
• Ability to perform functional activities with minimal pain.

IV. Phase III: Return to Function (8+ Weeks Post-Injury)

Goals:

• Restore full ROM and strength.
• Return to pre-injury activity level.
• Prevent re-injury.

Interventions:

• Advanced Strengthening Exercises: Progress to higher-intensity strengthening exercises, including resistance training with heavier weights and plyometric exercises (e.g., medicine ball throws).
• Sport-Specific Training (if applicable): Begin sport-specific drills to prepare for return to athletics. This may include throwing progressions for overhead athletes or simulated work activities for manual laborers.
• Functional Training: Focus on activities that replicate the demands of the patient’s job or sport.
• Endurance Training: Incorporate exercises to improve muscular endurance, such as high-repetition resistance training or sustained grip activities.
• Maintenance Program: Develop a home exercise program to maintain strength, ROM, and flexibility and to prevent re-injury.
• Specific Exercises:
• Progressive resisted bicep curls and triceps extensions
• Plyometric push-ups
• Rotator cuff strengthening for overhead athletes

Precautions:

• Avoid activities that cause pain or swelling.
• Progress exercises gradually to avoid overstressing healing tissues.
• Monitor for signs of instability or re-dislocation.
• Use proper technique during all activities.

Return to Activity Criteria:

• Full, pain-free ROM.
• Strength equal to at least 80% of the uninvolved arm.
• Successful completion of functional testing.
• Physician clearance.

V. Common Special Tests

• Valgus Stress Test: Assesses the integrity of the MCL.
• Varus Stress Test: Assesses the integrity of the LCL.
• Moving Valgus Stress Test: More sensitive test for MCL injury, especially in throwing athletes.
• Posterolateral Rotatory Instability Test (Pivot Shift Test): Assesses for LCL complex injury and posterolateral rotatory instability.
• Cozen's Test: Assesses for lateral epicondylitis (tennis elbow).
• Mill's Test: Assesses for lateral epicondylitis (tennis elbow).
• Golfer's Elbow Test: Assesses for medial epicondylitis (golfer's elbow).

Disclaimer: This protocol is a general guideline and should not be used as a substitute for professional medical advice. Always consult with a qualified healthcare provider for diagnosis and treatment of any medical condition.