Elbow instability is excessive, painful mobility out of its range of motion rendering the joint vulnerable to dislocation. The range of motion varies between 0 and 140 degrees from full extension to flexion. It allows the forearm to rotate about its axis by 180 degrees.
Elbow instability may lead to repetitive injuries, which cause wear and tear of soft tissues. It may result in permanent damage to the arm and cause disability. Hence, early diagnosis, treatment, and management are crucial for a better quality of life.
While surgical intervention for any disease is a final resort, non-surgical treatment modalities are elementary for abnormalities in the mechanical aspects of the musculoskeletal system.
Non-Surgical Treatment for Elbow Instability
Physical Therapy:
Physical therapy is significant half of elbow instability treatment. Its goal is to restore the functions of tendons and ligaments that restrict the abnormal movement of the elbow beyond the range of motion.
- Exercises
Early exercises focus on restricting the movement of the elbow within the range of motion of 20 to 90 degrees without causing pain. These are either passive or actively assisted.
As the range of motion extends, therapists include stretching and strengthening exercises in the protocol. The aim is to extend the ligaments in a controlled fashion and strengthen the arm muscles.
With improvement in the control of the movement, therapists introduce isometric exercises.
They strengthen arm muscles without involving joint movement. In addition, they can incorporate isotonic exercises that involve wrists, biceps, triceps, and shoulders.
- Manual Therapy
Manual therapy involves the application of controlled and predetermined force on the elbow, usually using the hands. The aim is to restore the biomechanical and neurophysiological properties in the underlying tissues, including tendons, ligaments, bones, and muscles. The techniques of manual therapy are as follows.
Soft Tissue Techniques: These techniques involve mobilising tissues in and around the elbow without moving or rotating the joint. Massage is an example.
Distraction: It involves pulling the forearm in a controlled manner and directions that provide relief and correct ligament deformities.
Manipulations: involve applying force with low amplitude at high velocity to reposition one of the bones in the joint.
Bracing:
Bracing is immobilising the elbow partially or completely using elastic or rigid support. Three types of braces are discussed in detail below.
- Protective Braces
These protect the elbow by restricting its range of motion to zero to promote the repair of damaged ligaments and tendons. Therapists prescribe them during the inflammatory phase following an injury.
- Braces with Adjustable ROM
These braces permit elbow movement within a safe range of motion, wherein patients do not experience pain. Doctors prescribe them after one or two weeks of use of the protective brace to initiate elbow movement without causing damage.
- Joint Mobilisation Braces
These mobilisation braces are of two types: Static braces hold the joint at an angle out of the range of motion. In contrast, the dynamic type produces force intermittently, stimulating the ligaments to stretch.
However, the latter induces inflammation due to repetitive motion. Hence, static is the most preferable. A static brace alternates between the rest period, and the angle gradually increases toward the extreme.
Activity Modification:
- Rest
Overusing the elbow worsens the instability and increases the risk of repetitive dislocation. Hence, individuals with unstable elbows must understand and observe the indications for rest, allowing time for the joint to recover. Rest is necessary during physical therapy as the exercises produce excessive stress in the joint and the arm muscles.
- Avoiding Certain Activities
Abstinence from rigorous activities is one of the first recommendations for individuals diagnosed with an unstable elbow. They prevent the worsening of elbow instability symptoms and the biomechanical features of the joint. For example, basketball players with unstable elbows must avoid overhead ball-throwing movement.
Medications:
- Anti-inflammatory Drugs
The most commonly used medications are non-steroidal anti-inflammatory drugs, such as ibuprofen, naproxen, and aspirin. These are available as over-the-counter medications.
- Pain Medication
NSAIDs also exert an analgesic effect. However, doctors and therapists may prescribe corticosteroids, such as cortisone, to reverse inflammation and relieve pain.
Benefits and Risks of Non-Surgical Treatment Options
The advantages of non-surgical treatment are as follows.
- Non-surgical treatment does not cause side effects as medications.
- It rectifies physical and mechanical anomalies of the elbow and associated muscles. In addition, it alleviates pain and oedema.
- They do not involve exposing internal tissues, like surgical treatments. Hence, they do not offer complications, such as infection or sepsis.
- They strengthen arm muscles, in addition to stabilising the joint.
- They offer a long-term positive effect on elbow stability.
The limitation of non-surgical treatments for elbow instability is the failure to maintain the stability of the joint when nerve damage is involved.
When to Consider Surgery
The conservative method is the first-line treatment for elbow instability, as the integrity of elbow stabilisers depends on the mechanical aspects more than pharmacological activities.
However, when the pain and the damage are severe, conservative therapies fail to induce the required physiological changes in the tissue. Besides, physical therapies are not effective in patients with conditions such as diabetes.
The psychological involvement of the patient is a factor that influences the efficiency and the outcomes of conservative therapy. It prompts surgical intervention that alters the mechanical and biochemical aspects.
Types of Surgery:
- Open Surgery
Ligament reconstruction involves replacing the damaged ligament with a tissue graft, which acclimatises into the elbow. It is necessary in cases of tissue loss and severe grades of lateral instability.
- Arthroscopy
Arthroscopic ligament reconstruction is preferable for low-grade posterolateral instability. It allows reconstruction using a tube-like instrument inserted through small incisions instead cut opening the entire length of operative tissue. Surgeons employ small camera that assists them visually.
Risks and Benefits of Surgery:
Benefits of surgical treatment
- It provides case-specific solutions at the tissue level.
- It corrects structural deformities in a shorter period.
The risks of surgical interventions are as follows.
- Internal bleeding
- Infection
- Transmission of disease from tendon or ligament donor
- Delayed recovery
- Allergic reaction to anaesthesia
Conclusion
Elbow instability increases the risk of frequent dislocation, which causes repetitive wear and tear of tendons and ligaments. It is detrimental to the integrity and healing capacity of the tissues. Hence, individuals who experience persistent discomfort and incidents of dislocation should consult an orthopaedic professional.
Extensive research on conservative treatment modalities has led to a protocol devised for a specific group of ligaments and muscles involved. In other words, personalised therapies are available to achieve goals realised according to functional needs.