Arthroscopic elbow contracture release helps optimize sports performance

Most people who lose terminal elbow extension carry on with daily activities fairly well without interventions such as surgical contracture release. However, in some high-level athletes, a functional elbow arc of motion considered adequate for most adults (30 to 130 degrees of extension to flexion) is insufficient for full intensity and performance in their sport.

"High-level athletes need full, pain-free extension to perform certain sports such as gymnastics and weightlifting. Even minor loss of extension, if it is associated with pain at the endpoint, will limit an athlete's intensity of training and/or performance," explains Shawn W. O'Driscoll, M.D., Ph.D., an orthopedic surgeon with the Mayo Clinic Sports Medicine Center in Rochester, Minn.

Swimmers, goalkeepers in soccer and boxers are also among those who are especially vulnerable to overuse injuries of the elbow that can lead to loss of elbow extension, often with pain. Dr. O'Driscoll explains further, "The overuse causes minor degenerative changes in the elbow, with one of the earliest being the formation of small osteophytes in typical locations around the elbow. Posterior osteophytes impinge in extension, and as they grow, they limit terminal extension. These osteophytes have a propensity to stress fracture from repeated impingement. When they do, they may progress to a painful nonunion. It's become what I refer to as a 'telephone diagnosis.' "

From 1997 to 2007, Mayo Clinic orthopedic surgeons investigated the possibility that the traditional functional arc of motion as defined by Morrey and others in the July 1981 issue of The Journal of Bone & Joint Surgery may be insufficient for some elite athletes. Dr. O'Driscoll's collaborator James S. Fitzsimmons explains it this way: "We hypothesized that arthroscopic contracture release is effective in restoring terminal elbow extension in high-level athletes whose loss of terminal extension impairs their intensities and/or levels of performance in sport."

Optimizing the arc of motion

The Mayo team studied the results of arthroscopic capsulectomy or osteocapsular arthroplasty on 24 elite athletes, including five at the Olympic or professional level whose primary complaint was lack of terminal elbow extension, with or without pain. Each already possessed an arc of elbow motion considered functional — but not optimal. The study was also designed to help predict return to unimpaired sports performance.

Results appeared in the December 2010 issue of The American Journal of Sports Medicine and showed surgery improved all elbows (n = 26 in 24 patients), both by subjective and objective measures. All gained extension, with average loss of extension improving from 27 degrees to 6 degrees. Twenty-two of 24 patients returned to the same level of training intensity and sports performance as practiced before the onset of problems. At final follow-up review, 13 of 24 patients considered the elbow normal, or almost normal.

Standardizing surgical technique

Arthroscopic capsular release and osteocapsular arthroplasty are complex procedures. For safety and effectiveness, they are best performed by experienced teams. While developing and refining his approach, Dr. O'Driscoll devised a standardized, four-step sequence that he believes is fundamental to excellent outcomes.

He recommends beginning posteriorly; proceeding to the medial and then the lateral gutters; then doing the work anteriorly, including the anterior capsulectomy. In each compartment four sequential steps are to be performed:

  1. Get in and establish a view
  2. Create a space in which to work
  3. Remove bone
  4. Perform capsulectomy

"Through standardization, both safety and efficacy have become highly reproducible," Dr. O'Driscoll says. "The medical community has learned that invasive procedures, from cardiac catheterizations to total joint arthroplasties, have the best results and lowest complication rates when performed using standardized methodologies."

Indications and contraindications

Indications that a patient is a candidate for arthroscopic contracture release or osteocapsular arthroplasty to restore pain-free terminal extension include evidence showing:

  • The patient is an athlete — disciplined, committed and established in a long-term and high level of sports performance
  • The patient perceives lack of terminal elbow extension, with or without pain, that impairs intensity of training or performance
  • The contracture has been present for 6 months or more

Contraindications include minor loss of extension that does not cause pain or impairment of training intensity or performance in the patient's sport.

For high-level athletes, these complex elbow surgeries when performed by experienced practitioners can help the recovery of peak performance.

At a glance: Arthroscopic release of elbow contracture study

In the Mayo study, the underlying diagnosis for elbow contracture was hypertrophic osteoarthritis in 19 elbows, post-traumatic elbow contracture in six; and arthritis and contracture secondary to osteochondritis dissecans in one elbow.

The study involved:

  • 24 high-level athletes for a total of 26 elbows
  • Patients with an average age at surgery of 38 years
  • 22 males and two females
  • 20 patients whose dominant arm was affected
  • Median time from onset of contracture to arthroscopic release of two years
  • Five professional or Olympic athletes, two semiprofessional athletes and 17 amateur athletes