The rehabilitation of the elbow after dislocation should commence in a supine position to minimise the effect of gravity and allow the triceps to stabilise the elbow through range of motion.
First 3 weeks
• A custom thermoplastic splint is fabricated to immobilise the extremity in the following position:
1. Elbow flexion near 120 degrees to approximate the radial head to the coronoid process.
2. Forearm pronation to minimize lateral ligamentous stress.
3. Wrist inclusion in a neutral position to relax muscular attachments and optimise patient
4. The patient is instructed to wear the splint at all times except when performing overhead
exercises for the first three weeks.
Positioning for rehabilitation
• Exercises are performed in a supine position with the shoulder flexed to 90 degrees, adducted, and in a neutral to external rotation position. This position minimises the effect of gravity, decreases posteriorly directed forces, and allows the triceps to function as an elbow stabiliser. By avoiding abduction and internal rotation, the gravitational varus force is eliminated thereby allowing the lateral collateral ligament to heal in an isometric fashion.
• With the arm in the aforementioned position, three exercises are performed:
1. Active assisted forearm pronation and supination, with elbow in flexion.
2. Active and active assisted elbow flexion without limits.
3. Elbow extension tailored to the instability of the injury.
If posterolateral rotatory instability, extension limited to 30 degrees with forearm in
4 to 6 weeks
• By the third or fourth week, joint stability is typically achieved, and the second phase is
• The splint is remolded to 90 degrees of flexion with the forearm in neutral rotation.
• Active and active assisted elbow and forearm rotation ROM exercises are allowed in the
sitting or standing position.
• The arc of motion is dependent on the individual’s degree of stability.
• Shoulder internal rotation is avoided to minimise gravitational varus strain after 6 weeks.
• The third phase commences six weeks post-injury, and included maximum ROM
exercises, strength and endurance exercises, and resumption of normal activities.
• Capsular stretching and static progressive splinting is used if needed.
• This protocol has been adapted with thanks from Dr Eugene T Ek’s protocol and the Hand Therapy Department and Division of Hand and Upper Extremity Surgery, Hospital for Special Surgery, New York.
Wolff L, Hotchkiss RN. Lateral elbow instability: nonoperative, operative, and postoperative management. J Hand Ther.