Introduction

Elbow stiffness and contractures of the elbow result in loss of motion and difficulty performing activities of daily living. Morrey et al.1 found the functional arc of elbow motion during activities of daily living to be 100° for both flexion–extension (30° to 130°) and pronation–supination (50° in either direction). Although functional limitations can be seen with less severe loss of motion, a stiff elbow has been defined as one with loss of extension of greater than 30° and flexion of less than 120°.2 Elbow stiffness results from perturbations of bone, soft tissue, or a combination of both that may or may not follow a traumatic event, elbow surgery of a congenital condition. 

Etiology

Causes

Causes of elbow stiffness and contractures are diverse and can be categorized as traumatic, atraumatic, congenital, or acquired. Traumatic causes include fractures, burns, and injuries such as traumatic brain injury, which often result in stiffness proportional to the severity of the trauma. Surgical interventions on the elbow, while sometimes necessary, may also lead to postoperative stiffness. Atraumatic causes encompass conditions like osteoarthritis, prolonged immobilization, and inflammatory arthritis. Congenital conditions such as arthrogryposis and congenital radial head dislocation can also result in elbow stiffness. Additionally, neurological disorders like cerebral palsy and complications following burns further contribute to this condition.3

Pathoanatomy

Intrinsic Causes

Elbow stiffness and contractures can result from intrinsic, extrinsic, or mixed causes. Intrinsic causes originate within the joint and include joint incongruity, synovitis, loose bodies, intra-articular fractures, malunions, osteochondritis dissecans, post-traumatic arthritis, coronoid osteophytes, olecranon tip osteophytes, and radiocapitellar joint space narrowing.1 Atraumatic causes can also include rheumatoid arthritis, septic arthritis, and hemophilia.

Extrinsic Causes

Extrinsic causes are external to the joint and involve the formation of eschar following burns, heterotopic ossification, adhesions or contraction of the capsule, ligament contractures, and scarring of the posterior oblique portion of the medial ulnar collateral ligament. Mixed causes combine intrinsic and extrinsic factors; for instance, late effects of intrinsic conditions can lead to extrinsic stiffness by causing secondary soft tissue contractures or adhesions.1 

The majority of elbow stiffness and contractures is a mixed cause that can be the late effects of intrinsic conditions that can lead to extrinsic stiffness.

Block to Flexion

Causes of elbow stiffness and contractures that can lead to a block in flexion include involvement of the posterior capsule, the triceps muscle, and the posterior bundle of the medial collateral ligament (MCL). Additionally, mechanical obstructions such as osteophytes in the coronoid or radial fossa can contribute to this limitation. These factors collectively restrict the range of motion by creating structural or functional barriers to elbow flexion.

Block to Extension

Causes of elbow stiffness and contractures that can lead to a block in extension include issues with the anterior capsule and the presence of osteophytes at the posterior olecranon tip or within the olecranon fossa.

Clinical Presentation

History

It is important to understand what the functional demands are for the patient in front of you. Are they a high-level athlete or sedentary elderly individual? Do they require a great range of motion for their job or activities of daily living? Often decreased range of motion can limit a patient's activities of daily living.  

It is also important to understand if pain is the main driver for the patient to seek care or is it stiffness? Pain in mid-arc of motion may indicate intra-articular pathology. Extrinsic soft tissue contractures are typically painful at the extremes of flexion and extension where bone impingement and soft tissue stretching may occur. 

We also need to understand if there are any comorbidities that may affect patient outcomes, whether managed conservatively or operatively. 

Physical Exam

The physical examination of the elbow begins with inspection, focusing on the skin around the joint to identify scars from previous surgeries, signs of inflammation, or other abnormalities. The range of motion is then assessed, measuring elbow flexion and extension using tools like a goniometer. Normal flexion typically ranges from 130° to 154°, and extension from -6° to 11°. If flexion is less than 90°-100°, it may indicate contraction of the posterior band of the medial collateral ligament (MCL), which might require release. Pronation and supination are also evaluated, with normal ranges being approximately 75° to 85° for pronation and 80° to 90° for supination. Neurological assessment is crucial, examining the function of the median, radial, and ulnar nerves to identify any deficits or abnormalities. For ulnar nerve function it is important to check if there is intrinsic muscle atrophy in the hand and numbness or tingling along the ulnar nerve distribution. This is important because if the ulnar nerve is affected it can be addressed at the time of surgery. Posterior band of the MCL is the floor of the cubital tunnel. Excess scarring of the MCL can lead to compression symptoms. 

Imaging Studies for Elbow Septic Arthritis

Radiographic Evaluation

The recommended views for the elbow are AP, lateral and oblique views. Serial radiographs are recommended if heterotopic ossification is noted. The findings on x-ray can vary depending on the pathology causing stiffness/contractures. Radiographs are particularly effective at detecting osseous abnormalities like loose bodies, arthritis, osteophytes, and heterotopic ossification. 

CT Scan

Advanced management of the stiff elbow may require a CT scan. Indications include loose bodies within the joint, non-unions, joint incongruity or abnormal bony anatomy. CT scan can help the surgeon plan the surgery. 

Magnetic Resonance Imaging

Rarely indicated. 

Nonoperative Management

Prevention

Prevention of elbow stiffness can be achieved through several approaches.5 Physiotherapy plays a crucial role in maintaining joint mobility and reducing stiffness. Early mobilization of the elbow is essential to prevent the development of contractures and improve functional outcomes. Both active range of motion (AROM) and passive range of motion (PROM) exercises are beneficial in promoting flexibility and preventing rigidity. The use of a continuous passive motion machine can further aid in maintaining joint movement during the recovery process. 

Additionally, prophylaxis for heterotopic ossification is important, as nonsteroidal anti-inflammatory drugs (NSAIDs) such as indomethacin and ibuprofen have been shown to reduce the risk by 57–59% compared to placebo.6 

In some cases, radiation therapy may also be employed as a preventive measure against heterotopic ossification.7 Low-dose radiation therapy (e.g., 7–8 Gy) can be applied preoperatively (<4 hours before surgery) or postoperatively (<72 hours after surgery). Radiation therapy is effective in high-risk patients and prevents ectopic bone formation by targeting local factors involved in bone growth.

Treatment

Nonoperative treatment for elbow stiffness and contractures typically includes the use of non-steroidal anti-inflammatory drugs (NSAIDs) and physical therapy involving active and passive range of motion exercises.8 This approach is generally considered the first line of treatment, particularly for cases with contractures less than 40°. 

However, when physical therapy fails to yield sufficient improvement, static splinting is recommended.8 Static splinting is specifically indicated for patients with elbow flexion contractures exceeding 30° or those with elbow flexion less than 130°. These measures aim to improve mobility and prevent the need for surgical intervention.

Operative Management

Surgeries

Operative treatment for elbow stiffness and contractures involves several approaches tailored to the underlying pathology and patient factors. Below is a structured overview of key techniques, their indications, outcomes, and contraindications.

Capsular Release ± Release of Posterior Band of MCL

Indications: This procedure is indicated for extrinsic capsular contractures with normal joint surface congruency, particularly when stiffness results from thickened capsules, heterotopic ossification, or implants.1 It is most effective in patients without significant arthritis, as outcomes become less predictable with incongruous joint surfaces.8

Outcomes: Compliance with postoperative rehabilitation, including active motion exercises, is critical for success.1 Results are less predictable in cases of preoperative ankylosis.8 A lateral or medial approach is chosen based on pathology, with average improvements in elbow flexion ranging from 21° to 66°.1

Contraindications: Absolute contraindications include Charcot arthropathy, neurologic elbow disorders, and poor skin integrity. Poor skin may require rotational flap coverage as a relative contraindication.8

Osteophyte Excision

Indications: This is used for intrinsic contractures with arthritis confined to the olecranon fossa, often combined with capsular release to address bony blocks limiting terminal motion.10 Bone removal typically targets the coronoid, coronoid fossa, olecranon, and olecranon fossa.10

Technique: Arthroscopic osteotomes are preferred for precision, minimizing iatrogenic cartilage damage compared to burrs.10

Distraction Interpositional Arthroplasty

Indications: Recommended for intrinsic contractures with diffuse arthritis in high-demand younger patients seeking motion preservation.8 This technique avoids prosthetic constraints but requires viable soft tissues for interposition material.

Total Elbow Arthroplasty

Indications: Reserved for low-demand elderly patients with intrinsic contractures and diffuse arthritis.8

Outcomes: High failure rates occur in young, active patients due to mechanical demands. Permanent 5-lb lifting restrictions are typically imposed postoperatively.8

Musculocutaneous Neurectomy

Indications: Used for neurogenic contractures with flexion deformities <90°, often in cases of spasticity or irreversible nerve injury. This procedure reduces spastic flexion but does not address joint mechanics.

Critical Considerations:

• Postoperative rehabilitation adherence significantly influences outcomes, particularly after capsular release.1
• Arthroscopic techniques are advantageous for osteophyte excision and limited capsular release but are less suitable for complex contractures requiring open approaches.9
• Preoperative evaluation of ulnar nerve function and stability is essential to guide surgical planning.4

Complications

Complications with surgery for a patient with elbow stiffness and contractures can include:

• Postoperative heterotopic ossification:12 These patients may be treated with low-dose radiation therapy or indomethacin. Low-dose radiation may be contra-indicated with acute fractures due to the risk of nonunion. 
• Transient ulnar neuropraxia:11 Transient ulnar neuropraxia after elbow surgery typically involves temporary nerve irritation or compression, often manifesting as numbness, tingling, or weakness in the ulnar nerve distribution (little and ring fingers). Neuropraxia represents a mild nerve injury (focal demyelination without axonal damage), which generally resolves with time as nerve conduction restores. Most patients experience symptom resolution within 6–12 weeks, with significant improvements often seen in the first 6 weeks. Prolonged cases: In older adults or those with preexisting nerve vulnerability, recovery may extend to 3–6 months. Persistent symptoms: If deficits persist beyond 6 months, further evaluation is warranted to rule out axonal damage or incomplete decompression.
• Ulnar nerve damage: Ulnar nerve transposition should be considered to reduce risk of ulnar nerve injury if preoperative flexion is less than 100 degrees.
• Recurrent contracture: Recurrence risk correlates with injury severity, surgical completeness, and adherence to rehabilitation. 

References

1. Morrey BF, Askew LJ, Chao EY. A biomechanical study of normal functional elbow motion. J Bone Joint Surg Am. 1981;63(6):872-877.
2. Søjbjerg JO. The stiff elbow. Acta Orthop Scand. 1996;67(6):626-631. doi:10.3109/17453679608997771
3. Nandi S, Maschke S, Evans PJ, Lawton JN. The stiff elbow. Hand (N Y). 2009;4(4):368-379. doi:10.1007/s11552-009-9181-z
4. Streubel PN, Cohen MS. Open surgical release for contractures of the elbow. J Am Acad Orthop Surg. 2015;23(6):328-338. doi:10.5435/JAAOS-D-14-00051
5. Evans PJ, Nandi S, Maschke S, Hoyen HA, Lawton JN. Prevention and treatment of elbow stiffness. J Hand Surg Am. 2009;34(4):769-778. doi:10.1016/j.jhsa.2009.02.020
6. Schneider, J., Maffulli, N., Eschweiler, J. et al. Efficacy of ibuprofen and indomethacin as prophylaxis of heterotopic ossification: a comparative study. Sci Rep 13, 20210 (2023). https://doi.org/10.1038/s41598-023-47508-8
7. Baird EO, Kang QK. Prophylaxis of heterotopic ossification - an updated review. J Orthop Surg Res. 2009;4:12. Published 2009 Apr 20. doi:10.1186/1749-799X-4-12
8. Siemensma MF, van der Windt AE, van Es EM, Colaris JW, Eygendaal D. Management of the stiff elbow: a literature review. EFORT Open Rev. 2023 May 9;8(5):351-360. doi: 10.1530/EOR-23-0039. PMID: 37158372; PMCID: PMC10233805.
9. Ring D, Jupiter JB. Operative Treatment of Elbow Stiffness. JBJS Essent Surg Tech. 2011;1(3):e18. Published 2011 Oct 26. doi:10.2106/JBJS.ST.K.00010
10. Savoie FH 3rd, O'Brien MJ, Field LD. Arthroscopy for arthritis of the elbow. Hand Clin. 2011;27(2):171-vi. doi:10.1016/j.hcl.2011.01.005
11. Giladi AM, Gaston RG, Haase SC, et al. Trend of recovery after simple decompression for treatment of ulnar neuropathy at the elbow. Plast Reconstr Surg. 2013;131(4):563e-573e. doi:10.1097/PRS.0b013e318282764f
12.  Hong CC, Nashi N, Hey HW, Chee YH, Murphy D. Clinically relevant heterotopic ossification after elbow fracture surgery: a risk factors study. Orthop Traumatol Surg Res. 2015;101(2):209-213. doi:10.1016/j.otsr.2014.10.021