Musculoskelet Surg (2014) 98 (Suppl 1):S95–S102
DOI 10.1007/s12306-014-0328-x
REVIEW
Elbow rehabilitation in traumatic pathology
I. Fusaro • S. Orsini • S. Stignani Kantar •
T. Sforza • M. G. Benedetti • G. Bettelli •
R. Rotini
Received: 31 December 2013 / Accepted: 27 February 2014 / Published online: 25 March 2014
Ó Istituto Ortopedico Rizzoli 2014
Abstract The elbow, intermediate joint of the upper
limb, frequently undergoes to pathological events and is
especially prone to stiffness. Rehabilitation plays an
important role in recovering functional activities. For the
rehabilitation team, this goal always represents a challenge,
as the treatment has to be continuously modeled and cali-
brated on the needs of the individual patient, even many
times during the same rehabilitation cycle. Containing the
effects of immobilization, avoiding to excessively stress
the healing tissues, satisfying specific clinical criteria
before moving to the next rehabilitation stage, basing the
rehabilitation plan on up-to-date clinical and scientific data
that can be adapted to each patient and to his/her needs are
the basic principles of the rehabilitation plan, which can be
chronologically grouped into four rehabilitation stages.
After summarizing the general principles of elbow treat-
ment, the specific principles of rehabilitation after elbow
fractures and elbow instability are presented, and then the
rehabilitative approach to the most frequent and feared
I. Fusaro (&)
S. Orsini
T. Sforza
M. G. Benedetti
Physical Therapy and Rehabilitation Unit, Istituto Ortopedico
Rizzoli, Via Pupilli 1, Bologna, Italy
e-mail: ifusaro@ior.it
S. Stignani Kantar
Physical Therapy and Rehabilitation Unit, Terme di S.Petronio-
Antalgik, Bologna, Italy
S. Stignani Kantar
PhysioMedica Faenza Italy, Faenza, Italy
S. Stignani Kantar
Shouldertech Forlı̀ Italy, Forlı̀, Italy
G. Bettelli
R. Rotini
Shoulder and Elbow Surgery Unit, Istituto Ortopedico Rizzoli,
Via Pupilli 1, Bologna, Italy
pathological conditions of the elbow, namely stiffness, is
described.
Keywords Elbow rehabilitation
Elbow trauma

Physical therapy
Introduction
The elbow is the intermediate joint of the upper limb
which, in Juppiter’s words, allows the hand to reach every
position inside the volume of a hypothetical sphere of
space. Therefore, even a mild functional limitation of the
elbow can significantly reduce the ability of the hand to
reach its objectives [1].
At the present time, there are in the literature no
guidelines or randomized clinical trials (RCTs) about
elbow rehabilitation in traumatic conditions. Moreover, in
the clinical studies, the rehabilitation protocols are poorly
described and thus not reproducible. The rehabilitation
treatment proposed in this article originates from a study of
the available literature from the main data banks and from
the opinion of leading experts of the main national and
international centers dealing with elbow pathology.
In a Cochrane literature revision in 2012 by Taylor
et al. about treatments after acute elbow dislocations in
adults, two small randomized controlled trials were
included, involving a total of 80 participants with simple
elbow dislocations. Both trials were methodologically
flawed and potentially biased. In one trial, involving 50
participants were compared early mobilization at 3 days
post-reduction with self-rehabilitation at 3 times a day
for 10 min increasing range of mobilization overtime
versus cast immobilization. At 1-year follow-up, the
recovery of range of motion (ROM) appeared better in
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the early mobilization group. However, the results were

not statistically significant. There were no reports of
instability or recurrence [2].
According to Wilk, the basic principles of a rehabilita-
tion program are as follows: containing the drawbacks of
immobilization, avoiding to stress the healing tissues over a
certain limit, fulfilling some defined clinical criteria before
moving from one rehabilitation stage to the following and
basing the rehabilitation plan on up-to-date clinical and
scientific data that should be adapted to each patient and to
his or her specific needs [3].
These principles can be chronologically grouped in 4
stages: stage of early mobilization, intermediate stage of
recovery, stage of advanced strengthening and stage of
return to working/sports activity. In each stage, however, it
should be kept in mind that, different from other joints, in
the elbow aggressiveness of the rehabilitation treatment is
not synonym of efficacy and that the objectives to pursue
always should be identified according to the specific needs
of the patient.
The stage of early mobilization of the elbow (active-
assisted or passive) improves the articular homeostasis,
reduces the edema and hematoma and progressively
improves the ROM. The elbow joint is especially prone to
flexion contracture; therefore, it is necessary to start as soon
as possible the passive recovery of ROM as well as
instructing the patient about the techniques of self-assisted
joint motion recovery (Fig. 1a, b) or gravity-assisted
recovery (Fig. 2). As described by Wolff in his work ‘‘Lat-
eral elbow instability: non operative, operative, and post- Fig. 1 a, b Self-assisted mobilization in extension and flexion
operative management,’’ gravity-assisted flexion exercises
should be performed in supine position, with no pillow under
the head and the shoulders in 90° abduction. The hand of the
healthy limb should bring the opposite hand toward the
mouth in supination, or pronation, or intermediate position
depending on the capsular–ligamentous compartment that
needs to be protected [4]. Gravity-assisted extension exer-
cises are performed in supine position or while sitting,
leaving the elbow progressively extends (Fig. 3). If the
pathological condition allows, it is advisable to start also an
active joint recovery in one or more planes. In fact, according
to Nirschl, early active mobilization should start as soon as
the inflammatory process is under control and as allowed by
the healing stage [5]. It is important always to treat both the
humero-radial and the radio-ulnar joints. Also, the so-called
low-load prolonged stretching techniques are useful in
recovering the missing joint mobility. Each maneuver that
provokes pain has to be avoided. As suggested by O’Driscoll, Fig. 2 Gravity-assisted mobilization in flexion with 90° shoulder
continuous passive motion (CPM) in flexion–extension abduction and forearm in neutral position at the mouth level
prevents tissues swelling by a squeezing effect, it should be
performed slowly in the widest possible safe ROM and in Regional analgesia represents in our experience a useful
post-surgery cases, in case of stable fixation and no ligament aid. Together with the search of an early motion, it is
lesion, it allows to avoid the risk of axial stresses [6]. necessary to obtain the control of edema and pain through

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rest, cryotherapy, compression and functional taping, joint
unloading and drugs. Additional useful tools can be vas-
cular gymnastic, isometric contractions of the whole upper
limb, lymph drainage, also exploiting techniques such as
kinesiotaping (Fig. 4) with a draining action and mobili-
zation of the adjacent joints. Among instrumental tech-
niques, one of the most used is tecar therapy which proves
especially useful in preparing tissues to the following
stretching. With the same aim, ultrasounds can be
Fig. 3 Gravity-assisted mobilization in extension in sitting position,
with forearm in neutral position or in pronation, depending on the
capsular–ligamentous structures to protect
Fig. 4 Kinesiotaping with lymph-draining action
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employed. High-power laser therapy, such as Nd-YAG
laser, has an anti-inflammatory, anti-edema and biostimu-
lating action as well as an analgesic effect. Also, the pos-
sibility to act on the nervous pathways of pain by TENS
should be remembered. In this first rehabilitation stage, it is
important to contrast and contain muscle atrophy. This can
be obtained by simply asking to the patient to voluntarily
contract the elbow muscular units. Isometric sub-maximal
contractions below the pain threshold are initially required
for elbow and wrist flexor and extensor muscles. Stimula-
tion of the shoulder muscles should not be neglected, but
paying attention to the exercises for the rotator muscles in
case these are painful. If possible, already in the early stage
rhythmic stabilization, exercises for the shoulder and elbow
can be started with the aim to restore as soon as possible
proprioception and correct neuromuscular control of the
whole upper limb and specifically of the elbow.
In the intermediate stage of recovery, when the elbow
ROM becomes broad, with pain and swelling, markedly
reduced or absent and muscular strength is satisfactory
(at least 4/5 under manual testing), then it becomes
possible to effectively work on the recovery of neuro-
muscular control and on the improvement in muscular
strength and resistance. When the elbow has recovered a
wide motion, proprioceptive rehabilitation can also be
started (Fig. 5) in order to obtain fast reflex responses to
external stresses. The exercises should be progressively
performed in traction, suspension and compression, both
in closed and in open kinetic chain, gradually increasing
difficulty and tools instability. Since the fibroblastic stage
has begun, stretching techniques can become more
aggressive in order to prevent stiffness. The strength of
Fig. 5 Proprioceptive reahabilitation
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the manual technique, stretching and mobilization is

adjusted based on the therapist’s sensation of ‘‘end point’’
and on the pain referred by the patient. Recovery of
elbow extension and of forearm pronation proves in fact
essential, as well as the recovery of a complete shoulder
external rotation at 90° abduction. The exercises for
recovering the muscular power begin with concentric and
progressively eccentric strengthening. Recovery of elbow
and wrist power in flexion and extension and of forearm
pronation–supination will receive special attention. Also,
the muscles of the scapulohumeral and scapulothoracic
girdle will undergo a program of progressive strength-
ening, mainly concentrated on the shoulder external
rotators and on the scapula retractors.
The stage of advanced strengthening begins when the
ROM is complete and painless, swelling has definitively
subsided, and power has reached at least 70 % of the
contralateral limb. During this stage, special attention is
paid to exercises for recovering eccentric power with
the elbow in flexion. These strengthening exercises are
performed with rubber bands having gradually increas-
ing tension and at different speeds of concentric and
eccentric contraction. Moreover, it is possible to add Fig. 6 Hydrotherapy
manual resistance during flexion and rhythmic stabili-
zations. Also, exercises for the neuromuscular control
are enhanced until reaching the true plyometrics. A Elbow fractures: principles of rehabilitation treatment
plyometric exercise-specific of the elbow joint is the
lateral throw of the medical ball on the rubber mat. The As reported by MacDermid in his article ‘‘A survey of
aim is to teach the patient to perform the lengthening– practice patterns for rehabilitation post elbow fracture,’’
shortening sequence of the elbow flexor–supinator practice patterns in elbow fracture rehabilitation have not
muscles when the upper limb makes an external rotation been defined. The author in his work aims at describing
movement to control the valgus stress of the elbow current elbow fracture rehabilitation practices and com-
produced by the ball weight. Postural realignment, if paring those to the existing evidence base. From the results
needed, is recovered by global methods associated with of this study, it is possible to conclude that exercise, edu-
respiratory control. cation and functional activity have high consensus as
The last stage of the elbow rehabilitation program is components of elbow fracture rehabilitation. Future
the resumption of working and sporting activity formerly research should focus on defining the optimal dosage and
practiced. The exercises in this stage will therefore be type of exercise/activity and establish core measures to
selected according to the specific sport and work. When monitor outcomes of these interventions [8].
possible, it is useful to perform an isokinetic test to Shrikant suggests to perform the rehabilitation treatment
accurately evaluate the muscular recovery obtained. for elbow fractures according to five steps: an accurate
Inside a rehabilitation program, it has to be remembered diagnosis, control of pain and inflammation, early pro-
the importance of hydrotherapy and to be performed in a tected mobilization, neuromuscular control and integration
dedicated therapeutic pool with the aim to improve the of gesture in the kinetic chain [9]. An accurate diagnosis is
function of the neuromuscular-skeletal system (Fig. 6). done based on the anatomo-physiologic picture considering
Bender et al. stress how necessary it is that work inside stability, joint motion under protection, prognosis and the
water is taught and supervised by specific and qualified phase of histological healing. Control of edema and pain is
personnel. Inside the water, motion is easier and wider, performed according to the same methods described above.
requires lower muscle effort and takes place with reduced Early mobilization opposes to the effects of immobilization
or absent pain [7]. Moreover, the changes in proprio- on the capsular, ligamentous, osteochondral and muscular
ception related to immersion allow to obtain a significant tissues. Mobilization has to be protected and thus per-
reduction in muscular tone; therefore, muscle relaxation formed in respect of the soft tissues and based on the
is enhanced. presence of a specific ligamentous lesion [8]. Active work

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Fig. 7 Stretching in flexion
founds indication in the early rehabilitation stages, since
muscular contraction improves articular congruency.
Active-assisted exercise is performed already in the
inflammatory stage, and it includes low recruitment levels
and therefore minor stress on the joint. Stretching (Fig. 7)
aimed at the recovery of the residual joint motion has to be
performed in the fibroblastic and remodeling stage: It
allows a permanent elongation of the soft tissues, stretching
has to be balanced, it should not cause pain that would
elicit an adverse reflex, and it should not be excessive in
order to avoid breakage of the healing structures and restart
of inflammation.
Together with stretching, mobilization braces are
employed and specifically static progressive braces that
allow to alternate stress and rest in order to avoid the return
to an inflammatory stage as stressed by Morrey et al. [10–
12].
In a review by Schwartz et al. in 2011 ‘‘Static pro-
gressive orthoses for the upper extremity: a comprehensive
literature review,’’ the authors report that static progressive
orthoses are commonly used in the treatment of stiff joints
or joint contractures of the upper extremity, but there are
few high-quality studies to support this intervention. In
addition, there has not been a recently published review of
the current literature describing this treatment technique
and the outcomes achieved. Although the overall level of
evidence is low, the inclusion of static progressive orthoses
as an intervention appears to result in positive outcomes,
including increased active ROM, increased grip strength,
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improved DASH scores and improved patient satisfaction
as well as reduced pain medications during orthotic inter-
vention. The current evidence supports static progressive
orthoses as an intervention for patients with upper
extremity joint stiffness or contractures due to orthopedic
conditions [13].
The recovery of muscular control is necessary in order
to make the joint motion obtained functional and in order
to stabilize the elbow. It is performed through recovery of
power, endurance and motor scheme. Power and endur-
ance are improved by isometric contractions which do not
place stress on the joint and at 8–12 weeks by contrasted
high-frequency and low-intensity exercises, always
respecting the flexor–extensor ratio, as indicated by
Nirschl et al. [14]. This is added to the specific
strengthening of the secondary stabilizers, especially if
the primary stabilizers are insufficient. The recovery of
the correct motor scheme is necessary since trauma and
the possible consequent surgery restrict the afferential
pool from the peripheral receptors. A cortical deafferen-
tation of the corresponding sensory-motor areas is con-
sequent, with disorders of the motor framework and
compensation mechanisms in order to perform adaptive
functions. It is performed by perceptive and propriocep-
tive rehabilitation, neuromuscular facilitations and plyo-
metric rehabilitation. The integration in the kinetic chain
is necessary, as the elbow is part of the kinetic–kinematic
chain of the upper limb: forces are transferred from the
elbow to the shoulder and to the hand through bi-articular
muscles.
Finally, it is necessary to search the elbow–shoulder
synergy that makes up the so-called strength elbow and is
organized around the synergic contraction of biceps and
triceps. Forceful gestures exploit extension in pronation to
push and flexion in supination to pull. The elbow–hand
synergy on the other side realizes the ‘‘relation elbow,’’
which is organized around the synergic contraction of the
epicondylar and epitrochlear muscles. Relation gestures
exploit flexion in pronation to take and extension in supi-
nation to give.
Finally, it is advisable to consider some cautions in
specific elbow fractures: Distal humerus fractures require a
posterior approach passing through the extensor apparatus
or an olecranon osteotomy, and it is therefore mandatory to
avoid an excessive degree of flexion until complete wound
healing and stresses which shorten the triceps muscle, in
order to protect the fixation. In case of radial head fracture
fixation, it is necessary to limit pronation and supination
until the fracture is stabilized. If a radial head prosthesis
has been implanted, then the only limit is pain and/or the
possible associated repair of the lateral collateral ligament.
In coronoid fractures, excessive stresses in flexion and
extension should be avoided until bone healing.
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Elbow instability: principles of rehabilitation treatment
Posterolateral rotatory instability (PLRI) is the most fre-
quent elbow instability form that takes place as described
by O’Driscoll in trauma with fall on the outstretched hand
with the forearm in supination, with progressive lesion of
the lateral ulnar collateral ligament (stage I), of the capsule
(stage II) and of the medial collateral ligament (stage III).
In stages I and II lesions, treatment is conservative with a
brace. Surgical treatment with fixation, ligament recon-
struction or external fixator finds its indication in stage III
lesions and in complex elbow instabilities [15–17].
Posteromedial rotatory instability (PMRI) takes place
with a violent mechanism of hand pronation with the elbow
in varus and flexion of about 30°. The humerus externally
rotates, placing tension first on the medial collateral liga-
ment and then on the other capsular and ligamentous
structures. The rehabilitation treatment is tailored on the
pathological pattern, giving the forearm a posture such as
to stabilize the elbow and keep the muscles in proper
tension [18]. Thus, when the elbow is mobilized in
extension in case of lateral compartment lesion, as sug-
gested by Singleton, the forearm should be kept in prona-
tion, while in case of medial compartment lesion, the
forearm should be kept in supination [19].
Szekeres in his article ‘‘Optimizing elbow rehabilitation
after instability’’ describes the rehabilitation treatment
based on the three stages of histological healing: inflam-
matory stage, during which the aim is to control pain and
inflammation; fibroblastic stage, centered on the recovery
of ROM, elasticity and muscle power; and remodeling
stage, to recover function [20]. Nirschl stresses that the
progress of the rehabilitation treatment depends on stability
and evolution of the repair processes [5]. The goals of the
rehabilitation treatment are as follows: to preserve stability
while the injured structures heal and to prevent stiffness
through the control of edema and pain and to recover joint
motion and muscular power. Control and elimination of
edema and pain are necessary as they would make reha-
bilitation ineffective [21]. This objective is achieved by the
use of an open brace, unloading the limb, cryotherapy and
regional analgesia if the patient is in the postoperative
period, pain-killing drugs, vascular gymnastic and lymph
drainage. It has also been recently introduced the applica-
tion of kinesiotaping (Fig. 4), the effectiveness of which is
currently under investigation. If the elbow is stable, CPM
as suggested by O’Driscoll is associated [22]. The reha-
bilitation treatment of the simple posterolateral dislocation
follows the Mayo Clinic algorithm which includes the use
of a brace and early mobilization if the elbow is stable with
forearm in neutral position, otherwise in pronation and
even with extension stop at 30°. In the case of unstable
elbow, surgery finds its indication. The rehabilitation
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Musculoskelet Surg (2014) 98 (Suppl 1):S95–S102
treatment includes three stages. The first stage lasts
4 weeks, a half-cast or a hinged brace is used with the
forearm in stable position in order to minimize the stresses
on the ligaments and the intra-articular pressure. During
this stage, to recover joint motion and muscular power,
active-assisted movements in flexion and extension are
performed. The early start of mobilization, as suggested
also by Cohen in his work ‘‘Acute elbow dislocation:
evaluation e management,’’ allows to reduce the develop-
ment of adhesions, enhance cartilage healing and increase
blood circulation [23]. Mobilization should be repeated
every 2–3 h. The active-assisted mode promotes low
muscular recruiting levels and minor joint stress and is
performed in postures which do not put elbow stability at
risk. Then, active exercises are introduced, to activate
agonists and antagonists, to stimulate proprioception and to
inhibit pain. Exercises in pronation–supination with the
elbow at right angle, isometric contractions of elbow
flexors and extensors in brace, CPM, cryotherapy after the
exercises are associated. In case of lesion of the lateral
collateral ligament, it is useful to strengthen the wrist ex-
tensors, in case of lesion of the medial collateral ligament,
the flexor carpi ulnaris and the flexor communis digitorum
will be strengthened. Active shoulder mobilization should
be associated with elbow mobilization.
In the second stage, from the 4th through the 6th week,
active mobilization is increased keeping the stabilizing
position and active stabilizing muscles strengthening.
Flexion–extension is performed in neutral position and
pronation–supination in 90° flexion. In this stage, the
exercises can be preceded by thermotherapy in order to
increase soft tissues elasticity and it is possible to employ a
mobilization brace overnight, set at the desired angle, in
case of lack of extension. Performing light activities of
daily living is allowed, while it is forbidden to make
efforts, to place the limb in destabilizing positions such as
elbow extension with forearm in supination, shoulder
mobilization in abduction and internal rotation in case of
varus elbow or in adduction and external rotation in case of
valgus elbow.
The third stage goes from around the 6th to the 12th
week. It includes removing the brace, increasing joint
motion, strength, resistance and recovery of function.
Exercises against resistance are begun so as to make the
obtained ROM functional, keeping the forearm protected
during the first 2 weeks and then free. Weights and elastic
bands for movements at high frequency and low intensity
can be used respecting the flexors/extensors ratio. If a loss
of joint motion is persistent at 6–8 weeks, then low-load
long-acting stretching is performed, by hand or by low
weights or elastic bands. In this stage, both dynamic and
static mobilization braces can be used, as described by
Marinelli et al. [24].
Musculoskelet Surg (2014) 98 (Suppl 1):S95–S102
The rehabilitation treatment after bony and ligamen-
tous reconstruction includes after removal of the drain-
age, and for 3–4 weeks the use of a half-cast or hinged
brace allowing motion in the safe range, scar massage,
self-assisted mobilization and CPM, both in the pre-
scribed range. Recovering joint motion and muscular
power takes place according to a rehabilitation plan
tailored on the patient and based on the stages of his-
tological healing of the tissues. Stretching and mobili-
zation brace can be prescribed from the 6th to 8th week,
as reported by Cohen [23]. Strengthening by weights and
rubber bands can be started from the 8th to 10th week.
After surgically treated dislocations, it is important to
recover the motor scheme altered by the cortical deaf-
ferentation. This is done through perceptive rehabilitation
for recovering the perception of movement through the
solution of tasks and proprioceptive rehabilitation starting
from the 6th week, in order to recover fast reflex
responses after external stimulations when the elbow has
reached a wide ROM. During rehabilitation, it is possible
that an ulnar nerve irritation takes place due to post-
surgical fibrosis, with flexion contracture, pain in the
ulnar nerve territory and transient paresthesia. A positive
Tinel’s sign in the cubital tunnel confirms the diagnosis.
The treatment requires surgical debridement to make the
compressed nerve free.
The treatment of elbow instability by external fixator is
done mainly in chronic and post stiffness instability as
reported by Yu and after arthrolysis and biological
arthroplasty performed for elbow stiffness [25]. The
external fixator has two functions: to stabilize the joint and
keep it centered also during joint motion and to neutralize
stresses transferring them on the fixator and on bone. This
allows both motion-guided soft tissues healing and a more
adequate tension. The external fixator makes two basic but
opposite needs compatible: early motion while maintaining
joint stability. In the immediate postoperative stage, self-
assisted passive mobilization, made easier by regional
analgesia, and active mobilization respecting the pain
threshold without loads on the elbow are started. The
period of use of the external fixator lasts on average
6–10 weeks. After fixator removal, rehabilitation goes on
with exercises for recovering complete joint motion, power
and proprioception of the upper limb. The use of a hinged
brace is also associated to keep elbow stability until com-
plete healing.
The stiff elbow: principles of treatment
The elbow is intrinsically prone to rigidity due to the strict
congruence of the ulno-humeral joint, the presence of three
joints in one synovial space, the strict relationship between
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joint capsule and intracapsular ligaments/surrounding
muscles. A great attention has especially to be paid to the
evaluation and treatment of the brachialis muscle that
overlays the capsule anteriorly and has a special tendency
to the development of heterotopic ossifications after trauma
[26]. There are several causes which can lead to a joint
motion restriction of the elbow and it is essential to identify
them in order to decide how to manage the patient. The
rationale of treatment depends on the mechanisms through
which a trauma can lead to joint stiffness. The first element
to consider is pain that causes intentional and unintentional
mechanisms to protect the elbow, which in time can lead to
a retraction of the capsule and sometimes of the brachialis
muscle too, which can develop a reflex co-contraction. It is
therefore necessary to get rid as soon as possible of pain
and inflammatory process, as well as to deal with the
brachialis muscle and the capsule with the aim to oppose to
their retraction. Trauma can also induce important changes
in the joint capsule, as described in Cohen’s paper, trans-
forming mainly its anterior thin and loose portion in a thick
and inhomogeneous fibrotic tissue [27]. This explains why
the most common complication after elbow trauma is a
flexion contracture, namely a progressive inability to obtain
extension. Thus, the main goal of the physical therapist is
to regain the complete elbow extension in the shortest
possible time. In doing this, great attention has to be paid in
balancing in the proper way the maneuvers, since the
rehabilitation itself, if badly managed, can become an
irritating mechanical stimulus. Also according to Nirschl,
an aggressive physical therapy in the management of a
post-traumatic stiffness is unsuccessful and often worsens
the contracture [5]. Thus, it is useful to associate the use of
mobilization braces to manual techniques. Moreover, pro-
longed joint immobilization also brings a fibroadipose
connective tissue growth which can override the capsule
and enter the joint space. This process takes about 2 weeks.
If immobilization goes on, this tissue can produce intra-
articular adhesions which contribute in limiting joint
motion. In the meantime, the muscles immobilized in
shortening lose both connective tissue and sarcomeres, the
latter in a much faster fashion. An increase in the propor-
tion of connective tissue relative to the elastic tissue
therefore occurs, and later abnormal cross-links can
develop among the connective fibers, which can lead to
muscle stiffness. The goal of therapy, for the above-men-
tioned reason, is to delay as much as possible muscular
hypotrophy.
Some studies seem to indicate that if electrical stimu-
lation is associated with immobilization, then the growth of
connective tissue does not take place, or it happens at a
lower rate. Thus, electric activity may be a primary factor
in conserving the normal proportion of connective tissue
inside the muscle, as stated by Farmer [28]. A direct
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capsular trauma or a lesion of the surrounding muscles can
cause a hemarthrosis, which also is a potential source of
stiffness due to progressive transformation of the synovial
tissue into a fibrotic scar tissue, leading to a flexion con-
tracture of the elbow because the flexed position is the one
of maximum capsular capacity and hence of minor intra-
articular pressure and minor pain for the patient. All this
explains why it is necessary to exploit all the therapeutic
resources which can rapidly contrast hemarthrosis. Finally,
a possible consequence of a direct elbow trauma can be the
development of heterotopic ossifications (HO) which can
act as a true mechanical block of elbow motion. HO rep-
resent the most frequent extrinsic cause of elbow stiffness.
Their incidence after simple trauma (e.g., dislocation) is
not very high (around 3 %), but dramatically increases with
the severity of injury. What the physical therapist can do in
such cases is to try to prevent them by abolishing the
inductive signal. The consciousness of HO existence by
physiatrist and physical therapist is therefore of paramount
importance as only in this case, their formation can be
suspected and hence therapy can be stopped in due time,
before it turns from a useful tool into a damage for the
patient.
Conflict of interest I. Fusaro, S. Orsini, S. Stignani Kantar, T.
Sforza, M. G. Benedetti, G. Bettelli, R. Rotini declare that they have
no conflict of interest.
Human and Animal Studies The study describe in this article does
not contain studies with human or animal subjects performed by any
of the authors.
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