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Overhead Protocol for Therapists - Left Unstable Elbow Recovery

It is important to coach the patient in proper exercise technique and to avoid positions that place varus directed stresses to the elbow. In the early stages, the overhead exercises should be active or active-assisted. The early therapy goal is not to achieve as much motion as possible, but rather to start early protected motion to promote healing and joint health.

Treatment sessions should focus on helping the patient perform the exercises independently, as well as education about how to perform ADLs safely. Cue the patient to avoid shoulder abduction when upright. If the patient is unable to independently remove the orthosis, then a family member or friend should be educated in how to do so safely so that the patient can perform the exercises at home. When the splint is placed back on, make sure that the elbow is seated all the way in the splint.

Tips and Tricks

  • Practice the steps of the overhead protocol on the uninvolved side first
  • Have a thin towel roll available to support distal humerus if appropriate
  • Heat and massage done with the elbow in a protected position can help with muscle guarding 

Getting Into the Overhead Position

  • Patient is supine, with the elbow in the protected position (flexion, pronation). Keep the glenohumeral joint in neutral rotation, forearm perpendicular to the surface of the plinth/bed. Do not allow the hand to rest on the abdomen (this puts varus stress on the elbow).
  • While maintaining the protected position, support the patient's distal humerus and the forearm at the wrist level, and forward flex the glenohumeral joint until the shoulder is at 90 degrees
  • With the shoulder at 90 degrees flexion, internally rotate the glenohumeral joint so that the wrist is positioned over the face
  • This video illustrates a patient moving into the overhead position independently

Support the Patient’s Arm Through the Range of Motion

  • It’s important for the therapist to support the arm in a protected position especially in the more acute stages of this injury. The patient feeling fully supported in the overhead position reduces apprehension and, therefore, pain and co-contraction.
  • The hand which is supporting the patient’s humerus can be placed with the thumb and middle finger at each epicondyle and the index finger on the olecranon. As the patient moves into extension (while pronated), this supporting hand can assess how well the elbow is tracking, as well as physically cue the patient into extension.
  • With the patient’s arm in a supported, protected position, the humerus can be supported against the body of the therapist (a pillow can be placed between patient and therapist). This is a comfortable position to work on gentle soft tissue mobilization and edema management.
  • While in overhead starting position, performing gentle elbow flexion/extension isometrics can be very helpful for enhancing joint proprioception and neuromuscular control. Fully supporting the forearm during isometrics is helpful and it is critical that the resistance is sub-maximal, as improving strength is not the purpose.
  • The patient's arm tires quickly when performing the overhead AROM program so therapist's assist and support through range is important. The goal is to offer just enough support to help, but not to push.

Early Goals of Therapy

End range extension should be avoided in the early stages. Early goals of therapy may include:

  • Protect healing structures
  • Gentle varus eliminated ROM to bring nutrition to articular surfaces via synovial diffusion
  • Edema management
  • Maintain ROM of unaffected joints. Shoulder external rotation can be performed with the patient supine, wearing the orthosis and the humerus adducted fully to side of body.

More information about posterior lateral elbow instability and the overhead protocol can be found in this article:
Wolfe AL and Hotchkiss RN. Lateral Elbow Instability: Nonoperative, Operative, and Postoperative Management. J Hand Ther 2006; 19(2):238-43. DOI: 10.1197/j.jht.2006.02.008.