Complex Elbow Contracture: Prioritising a Limited Number of Visits
A 58-year-old retired teacher is 14 weeks after a conservatively managed radial head fracture with an associated elbow dislocation. She has 30-100 degrees of elbow flexion/extension, forearm pronation 40 degrees, supination 20 degrees, and reports end-range pain. She has 6 funded therapy visits remaining and cannot afford more. She wants to regain full motion and return to gardening and playing piano. She is frustrated that progress feels slow and asks for daily intense stretching at home. There is no heterotopic ossification on recent imaging and the joint is stable.
1. Given only 6 visits, set treatment priorities and justify what you will and will not target.
Read the worked answer
Prioritise function over full ROM, and supination over terminal extension.
Reasoning:
- Supination (20 degrees) is the most functionally limiting deficit for piano playing and many gardening tasks (turning tools, opening jars); it has the greatest functional return on investment.
- Elbow extension loss is common after this injury pattern and often the hardest to recover; chasing full extension with intense daily stretching risks pain flare and lost visits.
- End-range pain signals that forcing range may be counterproductive; the limited visit budget should go to skilled, targeted mobilisation, exercise progression, and self-management training, not passive stretching volume.
Plan: allocate visits to supination/pronation mobilisation and functional task practice, teach a graded home programme, and set realistic functional goals (e.g., piano repertoire tolerance, garden task tolerance) rather than a ROM target. Explain the evidence that intensive stretching does not reliably restore end-range motion and can increase symptoms.
2. The patient insists on daily aggressive end-range stretching. How do you respond, and what home programme do you prescribe?
Read the worked answer
Response: Acknowledge her frustration and goal, then explain the rationale: at 14 weeks with end-range pain and a stable joint, high-intensity daily end-range stretching is more likely to provoke pain and reduce her ability to participate than to add range. Frame the home programme as the engine of progress, with therapy visits as tune-ups.
Home programme:
- Frequency: 2-3 short sessions daily rather than one long aggressive session.
- Content: active-assisted supination/pronation with a cane or stick to a stretch, not pain threshold (mild discomfort only, settling within minutes); low-load prolonged stretch at end-range held briefly and frequently; functional tasks (turning a doorknob, jar lids) as disguised ROM work.
- Monitoring rule: if pain persists >30 minutes after exercise or increases next-day stiffness, reduce intensity.
Review at each remaining visit and adjust. This preserves her engagement while protecting the joint and her limited funded sessions.