COMMON ELBOW
INJECTIONS AND BASIC REHABILITATION
Injections or aspirations
about the elbow, regardless of location, should always be performed under
sterile conditions. The needle site should be appropriately prepped with
povidone-iodine (Betadine) or another antiseptic before injection or
aspiration. Larger-gauge needles work best for aspirations (18-gauge), whereas
smaller-gauge needles can be used for injections.
Injections or aspirations of
the elbow joint are commonly performed through the lateral “soft spot.” The
“soft spot” is a normal depression in the posterolateral aspect of the elbow
that is defined by the lateral epicondyle, the tip of the olecranon, and the
radial head. If a joint effusion is present, this sulcus will develop a
fullness to it and the fluid that is present in the joint can be aspirated.
Typically, injection or aspiration is easiest with the elbow in a flexed
position, because this is the position of maximal joint capacity. Other common
sites for aspiration or injection around the elbow include the olecranon bursa
for olecranon bursitis and the common extensor origin for lateral
epicondylitis. The needle for an olecranon bursa injection or aspiration should
be inserted into the fluctuant portion of the bursa for maximal effectiveness.
For injections for lateral epicondylitis, the elbow is flexed to 90 degrees and
the point of maximal tenderness along the common extensor origin is located.
Ideally, the injection is fanned out from this point as the fluid goes in,
because the origin of these tendons is broad.
The goal of elbow
rehabilitation is to restore full, pain-free function. The elbow is prone to
the development of stiffness; therefore, early range of motion is a component
of most rehabilitation protocols. Rehabilitation after trauma or surgery may
require the use of braces or splints to protect healing tissues, while still
allowing range-of-motion exercises. Four types of range of motion are typically
used during elbow rehabilitation, in the following order: active-assisted,
active, passive, and resisted. Exercises should include both the
flexion-extension arc and the pronation-supination arc of the elbow.
Active-assisted range of motion (AAROM) is typically started first after trauma
or surgery, during the inflammatory phase of healing. These exercises maintain
low levels of voluntary muscle activation that minimize elbow joint compression
and shear forces. Active range of motion (AROM) has similar benefits to AAROM but
with more voluntary muscle activation to stimulate early neuromuscular control.
AROM exercises should first be performed with gravity eliminated and then
transitioned to antigravity positions. Passive range of motion (PROM) is best
initiated during the remodeling phase of healing to gain permanent tissue
length and motion by stretching and/or splinting. Finally, resisted range of
motion (RROM) should be implemented last as healing allows, typically 8 to 12
weeks after surgery or injury. The primary goal of RROM is to restore
neuromuscular control. Neuro-muscular control includes strength, endurance, and
coordinated muscle contractions.
