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Post-Traumatic Elbow Stiffness

Loss of elbow range of motion following trauma or surgery, the most common complication of elbow injuries. Morrey classification into 3 types: extrinsic (capsular), intrinsic (articular) and mixed. The elbow is the most stiffness-prone joint due to its thick capsule.

Characteristics

Post-traumatic elbow stiffness is defined as a loss of range of motion that limits functional activities, and is the most common complication of elbow injuries [1]. The elbow is the joint most prone to stiffening after trauma, due to its thick capsule, the tight congruence of three articulations, and the propensity for heterotopic ossification. Morrey's functional arc — the minimum range for most daily activities — is 30-130° of flexion and 50°-50° of pronation-supination. Any stiffness below this arc becomes functionally disabling.

The causes of stiffness are classified into three types: extrinsic (extra-articular: capsular contracture, collateral ligament shortening, heterotopic ossification, muscular fibrosis), intrinsic (intra-articular: articular incongruence, osteophytes, loose bodies, cartilage adhesions), and mixed (combination of both, most common after complex fractures) [2].

Treatment includes intensive physiotherapy with static progressive splinting (cornerstone of conservative treatment), arthroscopic or open arthrolysis (capsulectomy, osteophyte removal, HO excision), followed by immediate post-operative mobilization under regional anesthesia catheter. Results depend on the chronicity, type and severity of stiffness [3].

  • The elbow's predisposition to stiffness is explained by: 1) thick anterior capsule that retracts rapidly during immobilization, 2) tight bony congruence of three articulations (humeroulnar, humeroradial, proximal radioulnar), 3) tendency for heterotopic ossification, 4) brachialis muscle fibrosis (anterior capsule is adherent to brachialis), 5) collateral ligament contracture.
  • Morrey's functional arc: 30-130° flexion and 50°-50° pronation-supination. Loss of extension deficit beyond 30° and/or flexion below 130° progressively limits daily activities: eating (130° flexion needed), personal hygiene (reaching head requires 140° flexion), using a telephone (placing hand to ear requires 130° flexion), opening a door (forearm rotation needed).
  • Risk factors for post-traumatic stiffness: prolonged immobilization (> 3 weeks), complex fracture (distal humerus, terrible triad), high-energy trauma, associated head injury, burns, delayed surgery (> 48h), repeated surgery, aggressive passive mobilization, heterotopic ossification, complex regional pain syndrome.
  • Prevention: early mobilization (most important factor), stable surgical fixation allowing early ROM, NSAID prophylaxis (indomethacin) for HO prevention, avoidance of forced passive stretching, continuous passive motion (CPM) post-operatively, patient education on active self-mobilization.

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  1. Type 1 – Extrinsic

    Stiffness from extra-articular causes only: capsular contracture, collateral ligament shortening, muscular fibrosis (brachialis), heterotopic ossification. Normal articular surfaces. Best response to conservative treatment (static progressive splinting). Arthroscopic capsulectomy if conservative treatment fails. Best prognosis of the three types.

  2. Type 2 – Intrinsic

    Stiffness from intra-articular causes: articular incongruence, malunion, osteophytes filling the olecranon and coronoid fossae, loose bodies, cartilage adhesions, articular step-off. Requires surgical treatment to address the articular pathology (arthroscopic or open debridement, osteophyte removal, reconstruction). Prognosis depends on restoration of articular congruence.

  3. Type 3 – Mixed

    Combination of extrinsic and intrinsic components: capsular contracture AND articular obstacle. Most frequent form after complex articular fractures of the elbow. Surgical treatment often necessary to address the intrinsic component, followed by intensive rehabilitation for the extrinsic component. Prognosis depends on restoration of articular congruence.

Medical and Surgical Management

  • Static progressive splinting: reference conservative treatment. Custom-molded thermoplastic splints with adjustable turnbuckles. Alternating extension (day, 3×30 min) and flexion (night) posturing. Low-load prolonged stretch principle. Progressive weekly adjustment. 3-6 months of compliant splinting required.
  • Arthroscopic arthrolysis: capsulectomy (anterior and posterior), osteophyte removal, loose body extraction, heterotopic ossification excision if accessible. Advantages: less invasive, faster recovery, reduced HO recurrence risk. Combined with immediate post-operative mobilization under continuous regional anesthesia.
  • Open arthrolysis (column procedure): complete capsulectomy via medial and/or lateral approach (lateral column procedure of Mansat). Indicated for complex mixed stiffness, extensive HO, or failed arthroscopic arthrolysis. Ulnar nerve decompression/transposition if medial approach. Immediate post-operative CPM and intensive mobilization.

Physiotherapy treatment

  • Static progressive splinting program: alternating extension and flexion postures with custom turnbuckle orthoses. Low-load prolonged stretch (15-30 minutes per posture, 3-6 times daily). Weekly progressive tightening. Minimum 3-6 months of compliance required for results.
  • Active mobilization: flexion-extension and pronation-supination active exercises multiple times daily. Active-assisted exercises with the contralateral hand. Self-mobilization techniques taught to the patient. Emphasis on end-range sustained holds.
  • Post-arthrolysis rehabilitation: immediate mobilization under continuous regional anesthesia (interscalene or supraclavicular catheter for 3-5 days). CPM 6-8 hours daily. Maximum ROM gain in the first 4 weeks post-arthrolysis. Intensive physiotherapy twice daily initially.
  • Adjunctive modalities: cryotherapy after each session, scar mobilization (post-surgical), soft tissue mobilization, joint mobilization techniques (Maitland grades III-IV at end-range), hydrotherapy in warm water to facilitate mobilization. HO prophylaxis (indomethacin ± radiation) if excision performed.

After the session

You may feel slight fatigue or tightness: this is normal. Continue the exercises taught at home to maintain session benefits.

Questions About Elbow Rehabilitation

When should I start physiotherapy after elbow surgery?

Rehabilitation generally begins between 3 and 21 days after the operation, depending on the type of procedure and the stability of the surgical fixation. For fractures treated with stable internal fixation (screw plate), early mobilization is often authorized from D+3 to D+5 to prevent joint stiffness. In cases of elbow replacement or complex ligament repair, the delay may be extended to 2-3 weeks with initial immobilization in a splint. A systematic review published in the Journal of Shoulder and Elbow Surgery confirms that early mobilization after elbow surgery significantly improves final range of motion without increasing the risk of complications [Hackl et al., 2023] . Your surgeon will advise the optimal timing based on your specific procedure.

What are the goals of elbow rehabilitation?

Elbow rehabilitation pursues several complementary goals, adapted to each phase of recovery. In the initial phase (0-6 weeks), the priority is to restore range of motion in flexion-extension (goal: 30°-130° minimum for daily activities) and in pronation-supination (50° in each direction minimum). In the intermediate phase (6-12 weeks), the focus is on progressive muscle strengthening of the flexors, extensors and rotators of the forearm, as well as restoring joint stability through proprioceptive exercises. In the advanced phase (3-6 months), the emphasis is on functional reintegration: daily activities, work tasks and return to sports. Scientific literature highlights that the minimum functional arc of the elbow (30°-130° of flexion-extension, 50° of pronation and 50° of supination) is necessary to perform 90% of daily activities [Mofidi et al., 2020] . Scar treatment and adhesion prevention complete this comprehensive care approach.

Is elbow rehabilitation painful?

The techniques used are progressive and adapted to your tolerance. The elbow is a joint particularly prone to stiffness and inflammatory reactions: overly aggressive rehabilitation can paradoxically worsen the situation by causing heterotopic ossifications (abnormal bone formations in soft tissues). Exercises must be regular but never forced . The physiotherapist always adapts the intensity to stay below the pain threshold, following the "no pain, more gain" rule specific to the elbow. Gentle, regular active mobilization spread across the day in short sequences is generally preferred to prevent stiffness, with early active mobilization recommended after an elbow injury [Akhtar et al., 2021] . Complementary techniques such as cryotherapy , microcurrents and Novafon vibration therapy also help control pain during sessions.

Scientific sources

Average duration

3 to 12 months of intensive rehabilitation, optimal gains in first 6 months

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