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Overhead arm positioning in the rehabilitation of elbow dislocations: An in vitro biomechanical study

  • Ranita H.K. Manocha
    Correspondence
    Corresponding author. R.H.K. Manocha, Section of Physical Medicine and Rehabilitation, Foothills Medical Centre, AC144, Special Services Building, 1403 – 29 Street NW, Calgary, Alberta T2N 2T9, Canada Telephone:(403)944-5930; Fax:(403)283-2526.
    Affiliations
    Section of Physical Medicine and Rehabilitation, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada

    McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Alberta, Canada

    Roth-McFarlane Hand & Upper Limb Centre, St. Joseph's Health Care, London, Ontario, Canada

    Western University, London, Ontario, Canada
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  • Sara Banayan
    Affiliations
    Roth-McFarlane Hand & Upper Limb Centre, St. Joseph's Health Care, London, Ontario, Canada

    Western University, London, Ontario, Canada
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  • James A. Johnson
    Affiliations
    Roth-McFarlane Hand & Upper Limb Centre, St. Joseph's Health Care, London, Ontario, Canada

    Western University, London, Ontario, Canada
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  • Graham J.W. King
    Affiliations
    Roth-McFarlane Hand & Upper Limb Centre, St. Joseph's Health Care, London, Ontario, Canada

    Western University, London, Ontario, Canada
    Search for articles by this author
Published:February 25, 2022DOI:https://doi.org/10.1016/j.jht.2022.01.008

      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

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      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
      • # 2.
        PROM is generally withheld until _______ post-op
        • a.
          4 weeks
        • b.
          10 weeks
        • c.
          6 weeks
        • d.
          8 weeks
      • # 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
      • # 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
      • # 5.
        The advantage to performing extension overhead is that it more closely replicates the kinematics of the intact elbow
        • a.
          not true
        • b.
          true
      When submitting to the HTCC for re-certification, please batch your JHT RFC certificates in groups of 3 or more to get full credit.