Elbow Contracture: Causes, Symptoms, Diagnosis, and Treatment

What is elbow contracture?

Elbow contracture is a condition characterized by a significant loss of the normal range of motion in the elbow joint, making it difficult or impossible to fully straighten (extend) or bend (flex) the arm. This limitation arises from the shortening or stiffening of soft tissues and/or bone around the joint.

Understanding Elbow Contracture

The elbow joint, a complex hinge joint, primarily allows for flexion and extension, with a smaller degree of pronation and supination (rotation of the forearm). Its normal range of motion is crucial for countless daily activities, from lifting objects to self-care. An elbow contracture occurs when there is a pathological restriction of this motion, meaning the joint can no longer move through its full anatomical arc. This restriction can be due to changes in the joint capsule, ligaments, muscles, tendons, or even bone, leading to a fixed position or a severely limited ability to move.

Types of Elbow Contracture

Elbow contractures are typically categorized by the direction of the lost motion:

• Flexion Contracture: The elbow cannot be fully straightened, remaining in a partially bent position. This is the more common type.
• Extension Contracture: The elbow cannot be fully bent, meaning the arm cannot be brought closer to the shoulder. This is less common but can be equally debilitating.

In some severe cases, a contracture can involve both flexion and extension limitations.

Causes and Risk Factors

Elbow contractures can arise from a variety of factors, often involving trauma or prolonged immobility:

• Trauma and Injury:
  • Fractures: Especially those involving the humerus (upper arm bone) near the elbow, the ulna, or radius.
  • Dislocations: When the bones forming the joint are forced out of alignment.
  • Ligamentous Injuries: Damage to the strong bands of tissue that connect bones.
  • Myositis Ossificans: A condition where bone forms within muscle or other soft tissue after trauma, often severely limiting motion.
• Post-Surgical Complications: Following elbow surgery, scar tissue formation can restrict movement.
• Burns: Severe burns around the elbow can lead to scar tissue contractures of the skin and underlying tissues.
• Prolonged Immobilization: Extended periods in a cast or sling can cause the joint capsule and surrounding tissues to stiffen and shorten.
• Inflammatory Conditions:
  • Arthritis: Conditions like osteoarthritis, rheumatoid arthritis, or post-traumatic arthritis can cause joint damage and stiffness.
  • Capsulitis: Inflammation of the joint capsule.
• Neurological Conditions:
  • Stroke: Muscle spasticity and weakness can lead to contractures.
  • Cerebral Palsy: Can cause muscle imbalances and stiffness.
  • Traumatic Brain Injury: Similar to stroke, can lead to spasticity.
• Congenital Conditions: Some individuals are born with conditions that predispose them to joint contractures.
• Infection: Severe infections within or around the joint can lead to tissue damage and scarring.

Signs and Symptoms

The primary symptom of an elbow contracture is a noticeable reduction in the range of motion. Other signs and symptoms may include:

• Inability to fully straighten or bend the arm: This is the hallmark sign.
• Stiffness: A feeling of resistance or tightness when attempting to move the joint.
• Pain: Often experienced when attempting to push the joint beyond its limited range, or during daily activities.
• Functional Limitations: Difficulty performing everyday tasks such as:
  • Reaching overhead or behind the back.
  • Eating or drinking (flexion contracture).
  • Pushing off a surface (extension contracture).
  • Dressing or grooming.
• Swelling: May be present, especially if there's an underlying inflammatory process or recent injury.
• Visible Deformity: In severe or long-standing cases, the arm may appear visibly bent or unable to fully extend.

Diagnosis

Diagnosing an elbow contracture typically involves a thorough clinical evaluation:

• Medical History: The doctor will ask about previous injuries, surgeries, medical conditions, and the onset and progression of symptoms.
• Physical Examination:
  • Range of Motion Assessment: Using a goniometer, the clinician will precisely measure the active (patient's own movement) and passive (clinician moving the arm) range of motion to quantify the degree of contracture.
  • Palpation: Checking for tenderness, swelling, or abnormal bone formation.
  • Neurological Assessment: To rule out nerve involvement.
• Imaging Studies:
  • X-rays: To visualize bone structure, identify fractures, dislocations, arthritis, or heterotopic ossification (abnormal bone growth in soft tissues).
  • MRI (Magnetic Resonance Imaging): Provides detailed images of soft tissues, including ligaments, tendons, muscles, and joint capsule, helping to identify the specific structures causing the contracture.
  • CT Scan (Computed Tomography): Can offer more detailed bone imaging, particularly useful for complex fractures or bony blocks.

Treatment Approaches

Treatment for elbow contracture aims to restore functional range of motion and alleviate pain. The approach depends on the severity, cause, and duration of the contracture.

Conservative Management

Conservative treatment is typically the first line of defense, especially for less severe or more recent contractures.

• Physical Therapy (PT): This is the cornerstone of conservative management.
  • Manual Therapy: Techniques such as joint mobilizations and soft tissue massage to improve tissue extensibility.
  • Stretching Exercises: Targeted stretches to lengthen shortened muscles and connective tissues.
  • Strengthening Exercises: To improve muscle balance and support the newly gained range of motion.
  • Modalities: Heat, ice, or ultrasound may be used to reduce pain and facilitate tissue extensibility.
  • Static Progressive Splinting/Bracing: Custom or off-the-shelf splints worn for extended periods (e.g., overnight) to apply a prolonged, low-load stretch to the joint. Dynamic splints may also be used.
• Pain Management:
  • Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): To reduce pain and inflammation.
  • Corticosteroid Injections: May be used into the joint or surrounding tissues to reduce inflammation, though repeated injections are generally avoided due to potential tissue damage.

Surgical Intervention

When conservative measures fail to provide significant improvement, or in cases of severe bony blockages or heterotopic ossification, surgery may be considered.

• Arthroscopic Release: A minimally invasive procedure using small incisions and a camera to remove scar tissue, loose bodies, or bony spurs.
• Open Release: A more extensive procedure involving a larger incision to directly access and release contracted tissues (joint capsule, ligaments, muscles) or remove bone spurs.
• Osteotomy: In very rare and severe cases where bone deformity contributes significantly to the contracture, a wedge of bone may be removed or reshaped to improve alignment and motion.
• Removal of Heterotopic Ossification (HO): Surgical excision of abnormal bone growth, often followed by radiation or medication to prevent recurrence.

Rehabilitation and Physical Therapy

Post-operative rehabilitation is crucial for the success of surgical intervention and for maximizing conservative treatment outcomes.

• Immediate Mobilization: Often, rehabilitation begins very soon after surgery to prevent the reformation of scar tissue.
• Intensive Stretching and Strengthening: A structured program designed by a physical therapist to regain and maintain range of motion and build strength.
• Continuous Passive Motion (CPM) Machine: May be used in the early post-operative period to gently move the joint.
• Splinting/Bracing: Continued use of static progressive or dynamic splints to maintain gains in range of motion.
• Home Exercise Program: Essential for long-term success, requiring diligent adherence from the patient.

Prevention

While not all elbow contractures can be prevented, certain measures can reduce the risk:

• Early and Appropriate Mobilization: Following injuries or surgery, adhering to a prescribed rehabilitation program and starting gentle movement as soon as medically advised.
• Proper Burn Care: Aggressive physical therapy and splinting for burns around the elbow to prevent scar contractures.
• Management of Underlying Conditions: Effectively managing conditions like arthritis or neurological disorders that can contribute to stiffness.
• Adherence to Rehabilitation Protocols: For any elbow injury or surgery, diligently following the physical therapy plan is paramount.

Outlook and Prognosis

The prognosis for elbow contracture varies widely depending on the cause, severity, duration, and the patient's adherence to treatment and rehabilitation. Early intervention generally leads to better outcomes. While full restoration of motion may not always be possible, significant improvement in functional range of motion and reduction in pain are often achievable, allowing individuals to return to their daily activities and improve their quality of life.

When to Seek Medical Attention

If you experience any of the following, it is important to consult a healthcare professional:

• Progressive loss of elbow motion after an injury, surgery, or without a clear cause.
• Significant pain that limits your ability to move your elbow.
• Difficulty performing daily tasks due to elbow stiffness or limited movement.
• Any concerns about your elbow's function or appearance.