Highlights
- •First study with simulated active overhead motion in elbow dislocation.
- •Overhead extension after elbow dislocation replicates intact elbow kinematics.
- •Muscle activation and forearm rotation have minimal effect in the overhead position.
- •Overhead exercise may allow early motion to reduce elbow stiffness.
Abstract
Study Design
In vitro biomechanical study.
Introduction
Elbow stiffness is a common complication following elbow dislocation. Overhead exercises
have been proposed to initiate early motion to reduce stiffness through employing
gravity to stabilize the elbow. The implications of this position with regard to elbow
kinematics after dislocation have not been reported.
Purpose of the Study
To determine the influence of the overhead position on elbow stability following combined
medial and lateral collateral ligament (MCL and LCL) injuries.
Methods
Passive and simulated active extension were performed on 11 cadaveric elbows with
the arm in the overhead, dependent, and horizontal positions and with the forearm
in pronation, neutral, and supination. Internal-external rotation (IER) and varus-valgus
angulation (VVA) of the ulnohumeral joint were assessed for the intact elbow and after
simulated MCL-LCL injury. Repeated-measures analyses of variance were conducted to
analyze the effects of elbow state, arm position, forearm rotation, and extension
angle.
Results
During passive extension with the arm overhead, the pronated position resulted in
more internal rotation than supination (-2.6 ± 0.7°, P = .03). There was no effect of forearm rotation on VVA. The overhead position increased
internal rotation relative to the dependent position when the forearm was neutral
(-8.5 ± 2.5°, P = .04) and relative to the horizontal position when the forearm was supinated (-12.7
± 2.2°, P= .02). During active extension, pronation increased valgus angle compared to the
neutral (+1.2 ± 0.3°, P= .04) and supinated (+1.5 ± 0.4°, P= .03) positions, but did not affect IER. There was no difference between active and
passive motion with the arm overhead (P > .05).
Discussion
Movement of the injured elbow in the overhead position most closely replicated kinematics
of the intact elbow compared to the other arm positions.
Conclusions
Overhead elbow extension results in similar kinematics between an intact elbow and
an elbow with MCL and LCL tears. As such, therapists might consider early motion in
this position to reduce the risk of elbow stiffness after dislocation.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of Hand TherapyAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Simple dislocations of the elbow: evaluation and treatment.Hand Clin. 2004; 20: 389-404
- Incidence of elbow dislocations in the United States population.J Bone Jt Surg. 2012; 94: 240-245
- Ligamentous injuries in dislocations of the elbow joint.Clin Orthop Relat Res. 1987; 221: 221-225
- Elbow instability, mechanism and management.Curr Orthop. 2008; 22: 90-103
- Acute elbow dislocations: simple and complex.Orthop Clin North Am. 1999; 30: 63-79
- Rehabilitation of the medial and lateral collateral ligament-deficient elbow: an in vitro biomechanical study.J Hand Ther. 2012; 25: 363-373
- Optimizing elbow rehabilitation after instability.Hand Clin. 2008; 24: 27-38
- Optimizing the rehabilitation of elbow lateral collateral ligament injuries.Electron Thesis Diss Repos. 2016;
- Acute elbow dislocation: evaluation and management.J Am Acad Orthop Surg. 1998; 6: 15-23
- How controlled stress affects healing tissues.J Hand Ther. 1998; 11: 125-130https://doi.org/10.1016/S0894-1130(98)80009-4
- Rehabilitation considerations in the management of terrible triad injury to the elbow.Tech Hand Up Extrem Surg. 2011; 15: 198-208
- Optimizing the rehabilitation of elbow lateral collateral ligament injuries: a biomechanical study.J Shoulder Elb Surg. 2017; 26: 596-603
- Rehabilitation of the medial collateral ligament-deficient elbow: an in vitro biomechanical study.J Hand Surg Am. 2000; 25: 1051-1057
- Muscle forces and pronation stabilize the lateral ligament deficient elbow.Clin Orthop Relat Res. 2001; 388: 118-124
- Elbow subluxation and dislocation: a spectrum of instability.Clin Orthop Relat Res. 1992; 280: 186-197
- An online video investigation into the mechanism of elbow dislocation.J Hand Surg Am. 2013; 38: 488-494
- The influence of gravity on the unstable elbow.J Shoulder Elb Surg. 2013; 22: 81-87
- Lateral collateral ligament repair restores the initial varus stability of the elbow: an in vitro biomechanical study.J Orthop Trauma. 2008; 22: 615-623
- In vitro kinematic assessment of a hinged elbow orthosis following lateral collateral ligament injury.J Hand Surg Am. 2018; 43: 123-132
- The effect of medial collateral ligament repair tension on elbow joint kinematics and stability.J Hand Surg Am. 2007; 32: 1210-1217
- Development of a motion-controlled in vitro elbow testing system.J Orthop Res. 2003; 21: 405-411
- Development of an active elbow flexion simulator to evaluate joint kinematics with the humerus in the horizontal position.J Biomech. 2010; 43: 2114-2119
- Simulation of elbow and forearm motion in vitro using a load controlled testing apparatus.J Biomech. 2000; 33: 635-639
- Dislocation of the elbow joint.Arch Orthop Trauma Surg. 1984; 102: 183-186
- Simple dislocation of the elbow in the adult: results after closed treatment.J Bone Jt Surg. 1988; 70: 244-249
- Conservative management of elbow dislocations with an overhead motion protocol.J Hand Surg Am. 2015; 40: 515-519
- Effects of elbow flexion and forearm rotation on valgus laxity of the elbow.J Bone Jt Surg. 2005; 87: 2065-2074
- The effect of forearm rotation on laxity and stability of the elbow.Clin Biomech. 2001; 16: 401-407
- The pathoanatomy of lateral ligamentous disruption in complex elbow instability.J Shoulder Elb Surg. 2003; 12: 391-396
- The effectiveness of a hinged elbow orthosis in medial collateral ligament injuries: an in vitro biomechanical study.Am J Sports Med. 2019; 47: 2827-2835
- Magnetic resonance imaging findings in acute elbow dislocation: insight into mechanism.J Hand Surg Am. 2014; 39: 199-205https://doi.org/10.1016/j.jhsa.2013.11.031
- Dislocation of the elbow: an experimental study of the ligamentous injuries.Orthopedics. 1989; 12: 461-463
- Elbow joint instability: a kinematic model.J Shoulder Elbow Surg. 1994; 3: 143-150https://doi.org/10.1016/S1058-2746(09)80093-1
JHT Read for Credit
Quiz: # 853
Record your answers on the Return Answer Form found on the tear-out coupon at the back of this issue or to complete online and use a credit card, go to JHTReadforCredit.com. There is only one best answer for each question.
- # 1.With active extension
- a.there was no effect on valgus stress
- b.supination increased valgus stress
- c.pronation reduced valgus stress
- d.pronation increased valgus stress
- a.
- # 2.PROM is generally withheld until _______ post-op
- a.4 weeks
- b.10 weeks
- c.6 weeks
- d.8 weeks
- a.
- # 3.The target population would be patients who sustain
- a.combined medial and lateral collateral ligament injuries
- b.posterior lateral instability
- c.Fx-dislocation of the distal humerus
- d.LUCL injury
- a.
- # 4.Elbow instability was determined at different angles of extension by
- a.neither VVA nor IER
- b.both c and d below
- c.VVA
- d.IER
- a.
- # 5.The advantage to performing extension overhead is that it more closely replicates the kinematics of the intact elbow
- a.not true
- b.true
- a.
When submitting to the HTCC for re-certification, please batch your JHT RFC certificates in groups of 3 or more to get full credit.
Article info
Publication history
Published online: February 25, 2022
Accepted:
January 24,
2022
Received in revised form:
November 29,
2021
Received:
March 9,
2020
Footnotes
Conflict of interest: Dr King has a patent from Wright Medical resulting in the receipt of royalty fees, unrelated to the content of this manuscript. The remaining authors hereby declare that they have no conflicts of interest to disclose.
Identification
Copyright
© 2022 Elsevier Inc. All rights reserved.