(Seemingly impenetrable) elbow stiffness after ORIF surgery

[mdh]

Hello Everyone,

After reading and considering the ideas in the pinned forum topics (including "What gets stretched;" "Pain, placebo and nocebo, and changing experience;" and Olivia's thread on "relaxation vs. ROM") I think this might be a huge topic that I am attempting to distill into a small one in order to ask a  couple of questions about traumatic injury and recovery.

I was traveling for work and I fell and shattered my radius and ulna in December of last year (2022). I had to wait 5 days for an Open Reduction Internal Fixation (ORIF-pins and plates installed) surgery, then another 6 before I could get home and see a doctor in town who told me I should be moving my arm. So, that's 11+ days of complete immobility.

Now, 3.5 months later, I still do not have anything close to full ROM. I can extend to about 150 degrees (if fully straight is 180 degrees) and I bend to ~80 degrees. My orthopedic surgeon is quite concerned about this, even though to me it seems like it's just going to take a lot longer to get my motion back. I've also read alarming articles by orthopedic surgeons about scar tissue formation and how elbows stiffen up permanently if you don't start moving immediately after injury. 

I've been working with a PT who understands (older, lifelong) female athletes and that's been going well. My arm has been steadily growing stronger with progressive movement, stretches, and strength training. The strength training has helped with ROM more than any other single thing I've tried, including deep tissue massage, acupuncture, a gentle yoga practice, and daily attempts to tense/relax/stretch my arm. So far it seems as though the weighted efforts help me gain movement better than passive ones. 

I recognize there are factors in play here with elbow mobility likely best addressed through a more wholistic approach to "ease of movement" in general: my own personal high-tension set point, the stress of dealing with medical bureaucracy (I'm in the U.S.), physical and psychological splinting in response to injury, age (I'm 50), and so on. 

But putting this aside for the moment, my questions: 

Is that even a thing, that one has to "break" through scar tissue in order to regain movement? I recovered full ROM after a shoulder surgery-took 3 years-and never had any sense that this is what happens. To me it just seems like a long slow process. My doctor insisting I should be fully bendy by now is stressing me out. 

Is there something peculiar to elbow stiffness that precludes ever regaining full ROM? 

Any finally, does anyone have any specific suggestions for elbow movements/stretches? It may be that you suggest something I've tried, but it'd still be good to hear ideas. 

Thank you for reading!

 

 

 

[Kit_L]

3 hours ago, mdh said:

Is there something peculiar to elbow stiffness that precludes ever regaining full ROM? 

Assuming the surgery was successful, no. And by "successful", I mean that the component parts were put back in the anatomically correct places, such that there is no bony impediment to the desirable amount of hyperextension that the non-injured arm demonstrates. IOW, 180° is not quite enough; we need a bit more (5–7°, or thereabouts).

Your experience with your shoulder may be a better guide to how your own body recovers than your doctor's insistence that you 'should be fully bendy', I feel. And I think your understanding of the factors that are working against a more rapid recovery of full ROM are likely accurate.

We do have an exercise that is designed to recover the desirable hyperextension, but it is probably too early in your recovery to try; for the future, here it is:

https://www.youtube.com/watch?v=Xajg71NUg6s&

The standard biceps and brachialis exercise is this one:

https://www.youtube.com/watch?v=Q_BhX4qwwiw

Try this one, but with a rolled towel or similar filling the space between the biceps and the floor, so you can feel a deformable support when you try this. But, at 150°, this might not be possible just yet either.

Perhaps you can expand on what your PT is doing WRT strengthening and stretching exercises, and others can comment. I would like to suggest hanging from a bar, or rings, and even holding a heavy dumbbell in the hand of the effected elbow, and doing micro-contractions in the extended position, and using triceps to gently straighten the arm further. Consider using a strap around the handle so the exercise is not dependent ultimately on grip strength. Finally, and this likely will help, please read this:

https://stretchtherapy.net/relaxation-wiki/

Really learning how to relax, and to experience the suite of sensations that are deep relaxation will help to mitigate the factors that create the high-tension set point you mention. Tension is a habit, and a way of presenting oneself in the world; relaxation is another habit, and long experience tells us it can be learned.

 

[mdh]

1 hour ago, Kit_L said:

Really learning how to relax, and to experience the suite of sensations that are deep relaxation will help to mitigate the factors that create the high-tension set point you mention. Tension is a habit, and a way of presenting oneself in the world; relaxation is another habit, and long experience tells us it can be learned.

Oh my goodness, yes. This seems like the hardest piece of all of this for me to engage with and focus on with enough commitment to actually make progress. Which probably means this is an area that needs a lot of attention!

1 hour ago, Kit_L said:

Perhaps you can expand on what your PT is doing WRT strengthening and stretching exercises, and others can comment. I would like to suggest hanging from a bar, or rings, and even holding a heavy dumbbell in the hand of the effected elbow, and doing micro-contractions in the extended position, and using triceps to gently straighten the arm further. Consider using a strap around the handle so the exercise is not dependent ultimately on grip strength.

These suggestions make me happy because they are very similar to what I've been doing! Before I got hurt, I had spent several months working up to sets of minute-long hangs from a pull-up bar (which, incidentally, made pull-ups pretty easy) so this is not an unfamiliar exercise for me. Now I can only hang for about 5 seconds unless I massively favor my uninjured (also my dominant) arm. I have also been holding progressively heavier kettle bells in my left hand (injured side), just trying to relax and let that stretch my arm-which feels pretty good. Or I do carries, back and forth across the gym. I've not tried the micro-contractions in the extended position so I'm looking forward to adding that. I have been trying to use my triceps to help, but this is challenging-figuring out how to use my triceps again is a real journey! Fortunately, I had developed a reasonably strong grip before I got hurt so even now, when I've built up to a 26kg bell, grip is not a limiting factor. 

I also do ring rows where I grab the rings and pull myself towards them-like a pull-up motion only I adjust the angle to make it easier. Same idea for push-ups against the wall. And I do just a basic dumbbell bicep curl with the injured arm, trying to get as much flexion as I can and then spotting myself with my other hand to try to increase total flexion. Same idea with variations of tricep extensions--these are really hard and I use very light weight, just trying to improve the extension motion. It hurts, too, but not a bad hurt. Although it's possible that sometimes I might curse out loud when I do these, if no one is around.

My PT and I share an enthusiasm for kettlebells, which I am very fortunate to have had years of excellent coaching with, so I've also been doing light kb swings, usually for sets of 10. And finally, my PT has had me doing bottom-up kettle bell holds with my left hand because I can't yet do a proper shoulder press. 

The solo bicep stretch you demonstrate in the video is currently out of reach for me, even with a rolled towel, mostly because when I lay on my stomach and try to extend my arm, the head of my humerus pops forward to compensate for my limited ROM. Does that make sense? Maybe I need to go with a bigger pad, like a blanket. 

And lastly: when I woke up from surgery, the surgeon had gone home and the nurse could tell me nothing about how the operation went. After a couple weeks and a lot more effort than you'd think necessary, I finally got a copy of the operative report, which said "full range of motion was restored," so that seems positive.

Much, much gratitude for your responses! I feel much more optimistic. 

[Kit_L]

On 3/31/2023 at 1:42 PM, mdh said:

Fortunately, I had developed a reasonably strong grip before I got hurt so even now, when I've built up to a 26kg bell, grip is not a limiting factor. 

Missing the point here, with respect: a strap (your PT will show you how to use one; tell him/her it's like how Olympic and powerlifters hold the bar when working really heavily. The goal here is not to go past the grip strength limit so much as to allow you to relax in the "relax" part of the Contract–Relax cycle. The lengthening happens then.

On 3/31/2023 at 1:42 PM, mdh said:

I have been trying to use my triceps to help, but this is challenging-figuring out how to use my triceps again is a real journey!

Concentrate of feeling the triceps exactly when doing any of the other exercises you mention that you are doing, rather than focusing on the exercise resistance or numbers. Once you can really feel them, use them in the biceps lengthening exercises. They (triceps) have atrophied too, and the connection has to be woken up, vividly.

On 3/31/2023 at 1:42 PM, mdh said:

Maybe I need to go with a bigger pad, like a blanket. 

Yes.

And I reiterate: the relaxation exercises are at least as important as the resistance ones. This will not be tangible to you right now, but if you practise them daily, with no thought to the outcome, or their utility, many useful changes will occur in the background.

[mdh]

Ah- yes, I follow you, on the use of straps. Thanks for clarifying.

I have this sense that my nervous system is almost waiting for me to let it let go before I can make further significant improvements in arm ROM. I believe you, on prioritizing relaxation. As an aside-I like the sleepy kitten and cat picture of the relaxation wiki page. I have an orange kitty, too! 

[Kit_L]

9 hours ago, mdh said:

I have this sense that my nervous system is almost waiting for me to let it let go before I can make further significant improvements in arm ROM.

Précisement. Concentrate on that—relaxation is the opposite of doing. It is not doing, and this is unexplored territory for most Westerners. You will love the results!