Elbow Exercises
by Theresa Kelly (MS, PT)
and
June Zimmerman
By courtesy of Hemalog

Despite all the talk today about the enormous benefits of exercise, many people with haemophilia are not working out as much as they could be. This reluctance is partly a psychological throwback to a time when exercise was forbidden and PWHs came to realise inactivity and disability came as an inevitable part of their lives.

A case in point is the elbow. As one of the most vulnerable hinge joints for people with haemophilia, it is surprising that it is also one of the most neglected. Yes, though we are talking about the area of human anatomy that is also known as the "funny bone", the lack of exercise in this area has led to extremely painful and sad consequences. How did this happen? Ironically, perhaps, the elbow may be a victim of its own durability. Unlike the knee and the ankle, which immediately lose function after a bleed and compromise an individual's balance and ability to walk, the elbow can sustain a succession of bleeds and still be basically functional. In other words, though the bleeds gradually destroy joint mobility, it's still possible to eat a sandwich, get dressed for work or lift a small child with limited movement. Many people with haemophilia may actually have lost 20% of elbow extension, but as long as they can comfortably use their arms, they don't feel motivated to remedy the problem. In fact, many others ignore the effects of bleeds until more than 30% of movement is impaired and they can no longer accomplish certain tasks. Unfortunately, by this time, the damage may be irreversible.

In two other articles, we reviewed how a program of exercise can maintain and improve the health of your ankle and knee (see knee and ankle exercises). In this article we'll look more closely at the elbow - the various movements it controls and exercises that can help improve the joint's range of motion and strengthen the muscles surrounding it.

Three Joints in One

The elbow is made of three closely related synovial joints. These three joints are located where three bones meet: the humerus, or upper arm bone which runs from the shoulder to the elbow area, the ulna, the larger forearm bone and the radius, the smaller forearm bone. The humeroulnar joint is a simple hinge joint that enables the forearm to flex (bend) and extend. The radioulnar joint, a pivot joint, allows for rotational movements such as supination and pronation. (Imagine you are standing and that both your arms are at your side. If you turn your palm outward, that is supination; if you then turn your palm inward, that is pronation.) The third joint is the humeroradial joint, also a pivot-type joint that connects the radius and the humerus and also allows for pronation and supination.

These three joints work in concert with several muscle groups; the triceps, located in the back of the upper arm, extend the elbow; the biceps, located in the front of the upper arm, flex the elbow and supinate the arm; and the pronator muscles, located in the front of the forearm, pronate the arm. It is necessary to strengthen these muscle groups to keep the elbow strong and flexible.

Because the three joints are so closely interrelated, an injury to the area affects all of them. After a bleeding episode, the capsules around the humeroulnar, radioulnar and humeroradial joints swell, making it more difficult both to bend and to extend the arm. However, the arm generally goes to a bent position after a bleed because there is more room in the capsule for blood to enter. So the movement that generally becomes most limited is extension. The best way to maintain elbow function is through exercises that strengthen muscles and stretch the swelled capsule area, thereby allowing more room for such movements as extension.

The following exercises do just that. Designed to be done at home or at the gym, they focus on stretching the joint capsule and strengthening the muscles that control flexion, extension, supination and pronation. Remember, any joint bleed must have stopped completely before you attempt to perform any of these exercises. Also, never work for pain. To avoid injury, exercise should feel like a tolerable stretch. As you grow stronger, you may gradually increase the duration and/or repetitions of these exercises.

Regarding other activities, because the elbow is such a vulnerable joint, we recommend that those with haemophilia wear elbow pads when playing any kind of contact sport. The type of activity that is appropriate for you depends on the severity of your joint dysfunction and how easily bleeding occurs. If your elbow is a target joint, for example, you should probably avoid heavy lifting, and certainly aggressive upper body activity such as tennis and racquetball.

Theresa Kelly is the assistant chief physical therapist in the Department of Rehabilitation Medicine at the New York Hospital/Cornell Medical Centre.

June Zimmerman is a writer and specialises in medicine and healthcare.