Elbow dislocation..

[BobbySports]

Hi all

I have just recently graduated & dont have much experience so I thought I would get some thoughts & opinions on this case....

Male 21yrs
Posterior elbow dislocation (occured during basketball)- was in cast for 4 weeks
No fracture was present
Did not get MRI scan so exact extent of damage to ligaments is unkown
Now 1 week out of cast
Elbow extension at approx 160-170 degrees (which I think is good @ this stage?)
Minor atrophy of extensors/flexors & bicep

Just had 1st treatment session which consisted of:

Deep tissue massage to the level of tolerence of muscles & attachments (extensors, flexors, bicep & tricep)
Gentle passive elbow ROM & PNF work
Followed with 20min ice

Exercises prescribed
- Wrist curls (2kg 3x15)
- Elbow ROM (2kg 3x15)
- Bouncing basketball against wall 30sec x 3 (endurance..)
- Extensor stretch 3 x 30sec

Told him to perform exercises every 2nd day & ice following sessions.

Does this all sound okay?
I know its still very early but I am worried we wont get full extension back..? are there specific methods to regain full extension?
I know it differs from case to case but how long is it once the cast comes off till return to sport? approx 5-6 weeks?

Any other ideas regarding treatment modalities, prescribed exercises etc would be greatly appriciated

Thanks in advance

Bobby
SPORTS THERAPIST

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[gcoe]

Hey Bobby

Just a couple of general comments:

• On the postive side you are really thinking through a range of therapy to treat the various impairments. Sounds like he is getting his money's worth.
• Potential negative - it is a lot in the first session. I would be concerned that if you did stir the healing tissue you would not know what was the offending mob or exercise. I think I would start off a bit more conservatively, tackling a prioritised list of problems and adding in mobs and exercises when I know he is going to tolerate them. Your patient might be fine but I even so recommend being oriened to assessing any potiential irritable response,particularly in the first 2-3 sessions. I would be inclined to do less and get him back soon to determine the response. I know you are tackling this with ice which may or may not control irritation - not sure if you can solely rely on the ice to counter irritability.
• the ROM is good - I don't think you are likely to have major poblems with restoring full extension. Just keep working at it
• with your strengthening exs are you using overload principle? - obviously need to go easy on this to start with but is this a true 15 RM (can't do any more or close to it ?) or is it a bit of number plucked out of the ether?
• Is he otherwise keeping fit? or does he need a bit of help with this - may not have been doing much so getting deconditioned?

Hope that is of help

[BobbySports]

Hey Gcoe

Thanks for you're response! You make some good points.

Following the first treatment my patient was fine with no soreness after the session or the following day which is good news I guess.

I think you are right in regards to starting off a bit more conservatively and tackling a prioritised list of problems. The patient still has a little bit of swelling on the medial aspect of his elbow so I probably should focus a bit more towards resolving that (contrast therapy?)

I was def planning on utilizing the overload principle. No its not a true 15RM, I just thought 3 x 15 with 2kg weights was a good place to start with the flexor/exentsor strengthening as the patient was able to complete 15 repetitions with relative ease. Then I was gradually going to progress to 2.5kg, 3kg, 4kg etc.. Do you think that is okay?

Also following the prescribed exercises I provided, the patient had no soreness during, after or the following day.

Once swelling was resolved and full elbow ROM was present I was going to begin with some bicep/tricep etc strengthening...

I have suggested to the patient that he is still able to maintain his cardiovascular fitness with running, cycling, lower limb exercises etc. Any other ideas?

I appriciate you're comments and look forward to you're response

Bobby

[gcoe]

Hey Bobby

Sounds like you have it all under control so well done! Good that he wasn't stirred up. But just for future it is probably best just to introduce things and see the response. Do you know of Geoffrey Maitland - the Manipulative physio who died recently. He was really picky about only introducing one thing at a time and assessing the effect each technique has. that way you can really assess the relative benefit or harm of each technique.

I was def planning on utilizing the overload principle. No its not a true 15RM, I just thought 3 x 15 with 2kg weights was a good place to start with the flexor/exentsor strengthening as the patient was able to complete 15 repetitions with relative ease. Then I was gradually going to progress to 2.5kg, 3kg, 4kg etc.. Do you think that is okay?

It is probably is a safe way to proceed as you are just gradually increasing the load. However it isn't really following an exercise science approach. Ask yourself this: why are you doing the exs:

1. to strengthen the flexors and extensors
2. to improve the endurance of these muscles
3. exercise the muscles but avoiding overstressing the joint.

If it is point 1. then you are probably not being very effective. No overload no gain. And for a young male You need to be working him within the range of 8-12 reps near to fatigue. If you are going for 2. then that is probably what you are more likely to achieve - however even then you still need to be working near to overload. If 3. then you are being conservative and safe. If you are trying to strengthen but want to reduce the sharing forces across the joint One other factor to consider is the length of the lever arm. The closer the weight or resistance is to the joint (ie shorter the resistance arm) the less sharing forces across the joint. So heavier weight but more proximal eg wrist weight rather than holding a dumbell

[BobbySports]

Hey gcoe

Thanks for your response, you have been helpful

Just thought I would give a quick update...

Patient has now been out of cast for 4 weeks

We have essentially regained full elbow ROM

Atrophy of extensors/flexors has visually reduced.

I have been progressing the exercises- working on strength, endurance & proprioception (extensors/flexors, bicep, tricep)

Also introduced some sport specific rehab exercises.

Hoping to get patient back within 3 weeks so he is able to play basketball finals.

One thing I wanted to mention was the patient appears to still have minor swelling around medial elbow, however there is no pain or tenderness anywhere around the elbow and it does not fell like 'fluid' on palpation (so I know its not swelling due to inflammation). Have used contrast therapy and always icing post treatment/exercises. Will this just eventually resolve..? Is there something I should try to resolve it?

Thanks again for you're help

Bobby

[gcoe]

Hey Bobby

Well done! Sounds like things are going well.

RE: the swelling - is it firm it may be just tissue hyptertrophy - is it over the medial collateral ligament? Perhaps alot of fibrous tissue has been laid down where the ligament has been healing. If it is hard could it be a bit of callus where the bone may have got "bruised". Or perhaps a bit of heterotopic ossification. I take it isn't too large? Anyway most likely it may improve with remodelling over months. As it is asymptomatic perhaps it isn't much to worry about.

[BobbySports]

Hey gcoe

Thanks for the reply once again!

Yep the swelling is over the Ulnar Collateral Ligament and it is not too large at all.

It does not feel hard at all, so I guess it wouldnt be heterotopic ossification (can you explain what this is & how it occurs?) or a callus. I'm not sure if it would be tissue hypertrophy its basically been like that since the cast came off.

I'm thinking just some scar tissue that has been laid down but then again it feels too soft to be that..

[gcoe]

Hi Bobby

Yes that usually resolves - at least to a major extent - over time as the remodelling process continues to kick in

No your patient doesn't have Heterotopic ossification - HO is basically abnormal laying down of bone tissue in the surrounding soft tissues, usually following trauma. The trauma can be orthopaedic or soft tissue (in either case the subtype is called Traumatic myositis ossificans) and there is also a high incidence of HO after trauma CNS such as TBI or SCI. When it is orthopaedic in nature it is limited to tissues close to the traumatised joint. It can be quite concerning when it happens and needs to be watched. I don't have the figures on it but the elbow is prone to this type of HO - clinically you might see it forming in the bellies of the elbow flexors or triceps for instance. Diagnosis is by plain Xray. There is a contention that over vigorous passive movements may trigger it off or make it worse but I don't know if there is any evidence for this or if it is just clinical lore. If there is too much build up of bony tissue then it restricts ROM and can incapacitate a joint.

Have a read of this e article: Posttraumatic Heterotopic Ossification: eMedicine Physical Medicine and Rehabilitation if you want to know more.

Cheers