Elbow Osteoarthritis
Elbow
osteoarthritis (OA) is relatively rare compared to OA in weight-bearing joints
such as the knees and hips. However, its impact on function can be significant,
especially in individuals with a history of trauma to the elbow. The elbow is
susceptible to injuries such as fractures and dislocations, which can disrupt
normal joint mechanics, increasing the risk of post-traumatic OA. Over time,
these changes lead to pain, inflammation, stiffness, and difficulty performing
daily tasks.
Clinically Relevant Anatomy
The elbow is
a synovial hinge joint that allows flexion, extension, pronation, and
supination. It comprises the following:
Bones Involved:
- Distal humerus
- Proximal radius
- Ulna
Articular Surfaces:
The trochlea
of the humerus and trochlear notch of the ulna form an articulation that is
angled at approximately 45°, allowing smooth and extensive flexion.
Carrying Angle:
It is the
angle formed between the upper arm (humerus) and the forearm (ulna and radius)
when the arm is fully extended and the palm is facing forward (supinated).
- Males: 10°–15°
- Females: 20°–25°
Pathophysiology
There are
two main types of elbow OA:
1. Primary Osteoarthritis
- Rare and typically seen in individuals involved in heavy manual labor or sports.
- Begins at the olecranon and coronoid processes.
- Early stage - pain is mainly at the end range of motion.
- Later stage - pain becomes more generalized due to osteophyte formation and capsular tightness.
2. Post-Traumatic Osteoarthritis
- More common form of elbow OA.
- Caused by malunion of fractures or instability after dislocations or trauma
- Clinical features include - pain, crepitus (crackling) during flexion-extension or rotation and progressive joint degeneration
Clinical Presentation
- Pain - initially at end range, later throughout the range of motion.
- Range of Motion Loss - especially extension in post-traumatic cases.
- Ulnar Neuropathy - weakness or numbness in the hand, particularly in the 4th and 5th fingers.
- Functional Impairments - difficulty with activities like lifting, pushing, or gripping.
- Trauma History - essential to determine past elbow injuries.
- Red Flags - consider post-surgical infections or septic arthritis if systemic signs are present.
Diagnosing Elbow Osteoarthritis
Differential Diagnosis
- Ligament injuries (sprains, tears)
- Lateral epicondylitis (Tennis elbow)
- Medial epicondylitis (Golfer’s elbow)
- Ulnar neuropathy
- Unrecognized fractures
- Cervical spine referred pain
Physiotherapy Management of Elbow Osteoarthritis
1. Goals of Physiotherapy
- Alleviate pain and inflammation
- Maintain or restore elbow ROM
- Improve strength in the upper limb and related regions
- Enhance functional performance and joint protection
- Delay surgical need in younger individuals
2. Non-Operative Physiotherapy Management
2.1. Education & Activity Modification
- Teach joint protection strategies:
- Avoid heavy lifting
- Use forearm cuffs/braces for support
- Ergonomic adjustments for writing, computer work, lifting
2.2. Pain and Swelling Management
- Hot pack or warm towel: 10–15 minutes before exercise
- Cryotherapy: After exercise or during flare-ups
- TENS or Therapeutic Ultrasound: If available, for adjunctive relief
2.3. Range of Motion (ROM) Exercises
It is performed
dailywithin pain-free range.
Examples:
- Elbow Flexion-Extension AAROM - slide forearm on table or use opposite hand to assist
- Forearm Supination-Pronation with Wand or Hammer - hold a stick and rotate forearm side to side
- Wall Slide (Flexion Stretch) - slide hand up wall to improve elbow flexion range
- Towel Stretch for Extension - use towel around wrist, gently pull to straighten elbow
2.4. Strengthening Exercises
Start
with isometrics → progress to dynamic resistance
Phase 1 – Isometric Strengthening (Hold for 5–10 sec, repeat 10x):
- Elbow Flexor Isometrics (Biceps) - push against immovable surface without actual movement
- Elbow Extensor Isometrics (Triceps) - press back of arm against wall
- Forearm Isometrics - resisted pronation and supination using hand pressure
Phase 2 – Dynamic Strengthening (Theraband or 0.5–1 kg weight):
- Biceps Curls (Theraband or Dumbbell)
- Triceps Kickbacks
- Wrist Flexion/Extension
- Radial/Ulnar Deviation with Light Dumbbell
- Supination/Pronation with Hammer or Weighted Stick
Phase 3 – Functional & Proximal Strengthening:
- Push-Ups (progress to table or modified knee push-ups)
- Wall Scapular Retractions using resistance bands
- Shoulder Abduction/Flexion with Theraband
- Core Stability Exercises (e.g., dead bug, bridges)
2.5. Manual Therapy Techniques
- Soft tissue release: Biceps, triceps, forearm flexors/extensors
- Maitland Mobilizations: Grade I–II for pain, Grade III–IV for stiffness
- MWM (Mobilization with Movement): For functional movement patterns
3. Post-Surgical Rehabilitation (e.g., after TEA, debridement, arthroplasty)
3.1. Immediate Post-Op Phase (Week 0–2)
- Pain/swelling control (ice, elevation, gentle compression)
- Splinting for joint prot
- Initiate passive elbow ROM if allowedection
- Gentle active ROM of wrist, hand, shoulder
3.2. Intermediate Phase (Week 2–6)
- Gradual restoration of elbow ROM (pain-free range)
- Light resistance exercises as tolerated
- Begin proprioception training
3.3. Advanced Phase (Week 6–12+)
- Functional strengthening (elbow, wrist, shoulder)
- Introduce closed kinetic chain (CKC) exercises
- Retraining for work/sport-related movements
- Emphasize compliance to movement precautions (e.g., weight restrictions after TEA)
4. Adjunct & Emerging Therapies
4.1. Platelet-Rich Plasma (PRP)
- It can be used alongside physiotherapy to help relieve pain
- Physiotherapy should follow a structured progression post-injection
4.2. Partial Denervation
- Post-denervation rehab focuses on preserving motion and strength while monitoring for neuropathic symptoms
4.3. Regenerative Medicine (Stem Cell Therapy)
- If used, focus on gentle ROM and unloading strategies to support cartilage repair
4.4. Osteochondral Autografts
- Customized rehab focusing on localized joint protection and progressive loading
Progress in elbow osteoarthritis is tracked using tools like the Mayo Elbow Performance Score (MEPS) and DASH Questionnaire to assess function and daily activity limitations. Pain levels are measured using the Visual Analog Scale (VAS). Range of motion is assessed with a goniometer, while muscle strength is evaluated through Manual Muscle Testing (MMT) or a dynamometer. These tools guide treatment and track recovery.
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