Elbow Pain: Stiffness
Reduced elbow motion can make it difficult to perform simple tasks. It may be difficult to bend or straighten your elbow. You may also have difficulty turning your palm up (e.g., to wash your face) or turning your palm down (e.g., to type on a keyboard).
Many patients with elbow stiffness also experience cubital tunnel syndrome, which is the compression of the ulnar nerve at the elbow. This manifests as numbness and tingling in the ring and small fingers. There can also be pain on the inside of the elbow. There can also be weakness in grip or pinch. Clumsiness and dropping objects can occur.
Causes
Elbow stiffness is usually the result of an injury. Arthritis can also cause stiffness in some people. After injury or surgery, a biologic reaction can occur. It is called heterotopic ossification. This is more common at the elbow than other joints. This reaction results in bone formation in the soft tissues. The bone should not be forming within soft tissue because the bone may block elbow motion depending on where it is located. It usually takes some time to form after injury or surgery. Once the process starts, the patient and doctor must wait several months until it stops. X-rays can be used to judge when the new bone formation stops. Sometimes motion loss occurs from the extra bone. If this stiffness is bad, the bone can be removed by another surgery. There are some risk factors for forming the bone. There are also some treatments that may decrease the risk of extra bone formation.
Pain and swelling can cause stiffness. Patient education on what type of pain to expect is important. Pain education can reassure the patient that gently and slowly increasing elbow motion is safe if the pain is mild. Swelling control with elevation can be helpful. Ice can reduce swelling and pain. Compression sleeves or dressings can be critical to minimize swelling. Finally, a range of motion of the fingers and wrist can increase the venous and lymphatic return to the area to decrease swelling. Range of motion at the elbow in terms of flexion and extension (bending and straightening) may be difficult due to muscles that act “shocked.” By moving fingers frequently, they can pump blood flow out of the arm.
Sometimes after injury, the muscles don’t contract well. This is when the patient tries to move the elbow and not much happens. Co-contraction can occur, as well. Co-contraction is when both straightening and bending muscles contract at the same time. This can lead to spasm, pain, and poor motion.
In response to injury or surgery, an effusion can occur. An effusion is where fluid, usually from bleeding, develops rapidly. Sometimes, draining the fluid can be helpful. Also, the elbow capsule, which is a fluid-filled sac that surrounds and lubricates the joint, often thickens after injury or surgery. The thick capsule also shortens, and this tissue is often not elastic and does not stretch easily. Thus, if motion doesn’t improve rapidly, the thick capsule may prevent motion. Even with therapy and splinting, the capsule changes might stop motion. If this occurs, surgical removal of the capsule may be necessary.
Signs and Symptoms
Symptoms to discuss with your surgeon include the following:
- Is your elbow bothered by pain, stiffness, or both?
- Which daily activities are difficult due to your elbow?
- Do you ever experience catching or locking of the elbow?
- Do you have any numbness or tingling in the elbow, forearm, or hand?
- What was the timing of the stiffness? Did it occur suddenly or gradually? Did it occur right after an injury or surgery, or was it delayed?
Treatment
The assessment of the stiff elbow includes a physical exam and x-rays. Advanced imaging such as a CT scan or MRI may be required. Reasons to get advanced imaging include identifying loose bodies or finding a ligament tear, which often do not show up on an x-ray.
Treatment for elbow stiffness often starts with exercises, stretching, and splinting (see Figure 1). Exercises are usually guided by a physical or occupational therapist. Many patients find low-impact exercises such as swimming to be beneficial because the underwater movement can help elbow motion. If therapy does not help enough, then surgery can be performed. Removal of tight structures such as the joint capsule can improve elbow motion.
Surgery can be performed through an open incision or with arthroscopy. Arthroscopy uses a small camera to look inside the elbow joint. Arthroscopy also uses several additional small incisions to place instruments in the joint. You should discuss these options with your surgeon; there are pros and cons with each approach. Patients occasionally need to stay in the hospital after surgery. Other times, the patient can return home the same day as surgery. Patients usually require extensive physical or occupational therapy after surgery. If needed, cubital tunnel syndrome can be treated at the same time as the stiff elbow.
Prognosis
The prevention of stiffness provides the best outcome. It is important to have early discussions with your doctor, therapist, and other team members because they can help the patient understand the injury and the treatment plan. It is also important to understand the risks of too much or too little motion.
The timeline for various changes in treatment should also be clearly understood, and setting expectations early can also be helpful.
Some injuries are stable, making early motion is possible. Other injuries require protection and a slower rehabilitation. Some stiffness may be expected. Stiffness may happen even if everyone does everything they can at the right times. Most patients who have surgery to reduce stiffness get better. They can often return to most activities. However, surgery carries some risks, including continued stiffness. Your surgeon will discuss these risks with you.
To prevent extra bone formation, your doctor may prescribe a one-time small dose of radiation. Other times, the doctor may place you on a strong anti-inflammatory medication for several weeks. Research is being performed to understand stiffness better. Early evidence suggests some medication treatments may improve outcomes. A short course of steroids may decrease stiffness. Mast cell stabilizing medications may also reduce stiffness.
© 2022 American Society for Surgery of the Hand
This content is written, edited and updated by hand surgeon members of the American Society for Surgery of the Hand. Find a hand surgeon near you.