Figures
Why is the Elbow Prone to Stiffness?
High joint congruency with limited joint volume
Tight capsular structures
Clinical Relevance
Stiffness is not defined by a fixed angle
Functional limitation varies between patients
Factors affecting functional demand:
Occupation
Sports activity
Daily living requirements
Etiology
Post-traumatic (Most common)
Arthrofibrosis
Post-traumatic arthritis
Mechanical Causes
Osteophytes
Loose bodies
Malunion
Osteochondral defects
Non-traumatic Causes
Primary osteoarthritis
Inflammatory arthritis
Burns
Hemophilia (hemarthrosis)
Neurological injury
Pathophysiology
Arthrofibrosis
Increased myofibroblast activity
Increased collagen cross-linking
Increased TGF-β expression
Leads to capsular contracture
Heterotopic Ossification (HO)
Bone formation within soft tissues
Causes mechanical block
Increased BMP activity
Post-traumatic Stiffness
Very common
Main causes:
Arthrofibrosis
Post-traumatic arthritis
Additional contributors:
Malunion
Osteophytes
Loose bodies
Clinical presentation:
Pain
Impingement
Primary Osteoarthritis
Mechanical block is dominant
Symptoms typically occur at terminal range
Common findings:
Osteophytes
Loose bodies
Arthrofibrosis is usually secondary
Classification (Morrey)
Intrinsic (Intra-articular)
Cartilage loss
Loose bodies
Deformity
Implants
Extrinsic (Extra-articular)
Capsule
Ligaments
Heterotopic ossification
Skin
Nerve adhesions
Combined (Most common)
Clinical Evaluation
History
Trauma or surgical history
Onset and progression
Pain characteristics
Occupation and activity level
Previous treatments
Physical Examination
Measure active and passive ROM
Evaluate previous scars or incisions
Identify pain arc
Assess ulnar nerve:
Palpation
Tinel sign
Subluxation
Check muscle atrophy
Examine forearm rotation and wrist
Imaging
X-ray (First-line)
Osteoarthritis
Osteophytes
Heterotopic ossification
Deformity
Nonunion
CT (3D)
Surgical planning
Osteophyte localization
Extent of HO
MRI
Rarely required
Ultrasound
Ulnar nerve evaluation
Injection guidance
EMG
When neuropathy is suspected
Nonoperative Management
Indications
Early stiffness (< 6 months)
No bony block
Options
Physiotherapy
Static or dynamic splinting
NSAIDs (for HO prevention)
Most effective in early stages
Principles
Prevention is the best treatment
Avoid prolonged immobilization
Start early controlled motion
Physiotherapy
Core treatment in both conservative and postoperative care
First 6 months are critical
Initial goals:
Edema control
Pain control
Later:
Active and passive mobilization
Avoid forceful stretching if mechanical block is present
Splinting
Types:
Static
Static progressive
Dynamic
Improves ROM
Consider:
Ulnar nerve symptoms
Duration:
6–12 months
Manipulation Under Anesthesia (MUA)
Can be used in early phase
Improves ROM
Risks:
Fracture
Soft tissue injury
Limited benefit in advanced stiffness
Continuous Passive Motion (CPM)
Useful especially postoperatively
May reduce pain and improve recovery
Pharmacologic Treatment
NSAIDs
Used for HO prophylaxis
Neuropathic Agents
Gabapentin / pregabalin
For neuropathic pain
Surgical Indications
No improvement after 3–6 months of conservative treatment
Functional limitation persists
Immediate consideration if:
Bony block
Significant HO
Malunion
Surgical Options
Arthroscopic Release
Mild to moderate stiffness
Minimal bony pathology
Open Release
Severe stiffness
HO
Bony block
HO Excision
When mature (typically after 6–12 months)
Arthroscopic Arthrolysis
Debridement
Synovectomy
Adhesion release
Osteophyte removal
Capsular release
Loose body removal
Advantages
Smaller incisions
Less soft tissue damage
Lower infection risk
Less pain and swelling
Faster rehabilitation
Disadvantages
Limited working space
Risk of nerve injury
Steep learning curve
Relative Contraindications
Extensive HO
Severe deformity
Advanced inflammatory arthritis
Inability to assess ulnar nerve
Extra-articular pathology
Open Arthrolysis
Indications
Extensive HO
Bony block
Need for ulnar nerve decompression
Severe contracture
Approaches
Lateral
Often sufficient
Ligament-preserving
Does not cause instability
Medial
Allows ulnar nerve decompression
Posterior MCL release
Anterior band should be preserved
Combined / Posterior
For extensive pathology
Postoperative Management
Early mobilization is critical
CPM in selected cases
Aggressive physiotherapy
Ulnar Nerve Management
Intervention should be considered in:
Preoperative neuropathy
Flexion < 90°
Compression on imaging (HO / osteophytes)
Subluxation or snapping triceps
Otherwise:
Risk of delayed neuropathy increases
Complications
Nerve injury (most commonly ulnar)
Infection
Recurrent stiffness
New HO formation
Fracture (especially after aggressive manipulation)
Neuroma
Prognosis
Better outcomes with:
Early intervention
Minimal articular damage
Worse outcomes with:
Long-standing stiffness
Severe trauma
Pits and Pearls
Early mobilization prevents stiffness
Extension loss is more common than flexion loss
Always distinguish between bony block and soft tissue limitation
Ulnar nerve must be carefully evaluated
Pitfalls
Delayed physiotherapy
Prolonged immobilization
Ignoring heterotopic ossification
Delayed surgery in severe contracture